Anthony W Ashton1, Thi Yen Loan Le2, Mahidi Mardini3, Celso E. Gomez-Sanchez4 and Anastasia Susie Mihailidou*5
1The Kolling, Royal North Shore Hospital & University of Sydney, Sydney, Australia, 2The Kolling, Royal North Shore Hospital & University of Sydney, St Leonards NSW, Australia, 3The Kolling, Royal North Shore Hospital & University of Sydney, Australia, 4University of Mississippi Medical Center, Jackson, MS, 5The Kolling, Royal North Shore Hospital & University of Sydney, Sydney NSW, Australia

 

Increased levels of aldosterone (Aldo) lead to cardiac damage by pro-oxidant and pro-apoptotic action during myocardial infarction (MI). Free radical scavenger Tempol, prevents Aldo-induced cardiac damage during experimental MI to the same extent as mineralocorticoid receptor (MR) antagonists, suggesting a role for redox balance. Further, low dose MR antagonists alone prevented reperfusion injury by preventing apoptosis. Aim: Since activation of oxidative stress triggers apoptosis, we examined the role of redox balance in the cardioprotective action of low dose MR antagonists. Methods:We used our ex-vivo rat heart model of ischemia-reperfusion (I-R) with spironolactone (SPIRO, 10 nM), Tempol (100 μM) or Aldo (10 nM) perfused 15 mins. prior to ischemia (30 min) and throughout reperfusion (2.5hr) and apoptosis measured using in-situ nick end-labeling (TUNEL) assay. A membrane impermeable Aldo analogue, aldosterone-3-carboxymethoxylamine-TFP ester reacted with 8-branched PEG amine (Aldo-PEG) was used to determine contribution of non-genomic pathways. Redox balance was determined by measuring superoxide levels (lucigenin-enhanced chemiluminescence) and estimation of reduced glutathione (GSH)-to-oxidised glutathione (GSSG) ratio. In separate studies, cultured rat cardiomyocytes (H9c2) were treated with buthionine sulfoximine (BSO), a glutathione synthesis inhibitor, to simulate oxidative stress (±10 nM SPIRO) and Sgk-1 and PAI-1 transcripts used as a measure of MR activation. Results: I-R significantly increased superoxide levels [166 ± 10% (I-R, N=8) vs 100 ± 7% (sham I-R, N=8), P<0.05], while decreasing GSH:GSSG ratio [2 ± 0.3 (I-R, N=5) vs 4 ± 0.3 (sham I-R, N=5), P<0.05], indicating loss of antioxidant defence. This correlated with activation of apoptosis [8 ± 0.6% (I-R, N=8) vs 2 ± 0.5%, (sham I-R, N=5), P<0.05]. SPIRO alone restored redox balance (3 ± 0.1, N=8) and prevented I-R-induced apoptosis, whereas Tempol alone did not prevent I-R induced apoptosis, despite restoring redox balance. In contrast, Aldo potentiated I-R induced decrease in GSH levels (2 ± 0.4, N=7) and aggravated apoptosis (17 ± 1.2%, N=6). Activity of Aldo-PEG was similar to Aldo to increase superoxide production in H9c2 cells, whereas only Aldo aggravated cardiac damage. In separate studies, redox state was manipulated in H9c2 cells by BSO (20 μM) normalising the effect of SPIRO, confirmed by decreased GSH levels. BSO-induced oxidant stress increased both Sgk-1 and PAI-1 transcription (1.6 ± 0.18 and 1.2 ± 0.04 -fold change) indicating MR activation; SPIRO blocked these increases despite absence of anti-oxidant action. Conclusion: Our findings suggest that the cardioprotective actions of MR antagonists involve both maintaining redox balance as well as preventing MR activation.

 

Nothing to Disclose: AWA, TYLL, MM, CEG, ASM

PP06-1 12739 1.0000 SAT-0839 A Role of Genomic and Non-Genomic Pathways in the Cardioprotective Action of Mineralocorticoid Receptor Antagonists 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 11:30:00 AM PP06 4892 11:15:00 AM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension Poster Preview

Carmela Maniero*1, Junhua Zhou1, Elena AB Azizan1, Ian McFarlane2, Sudeshna G Neogi2, Cheryl A. Brighton1, Luis Galietta3, Paolo Scudieri3 and Morris J Brown1
1University of Cambridge, Cambridge, United Kingdom, 2Genomics CoreLab, Cambridge National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), Cambridge, United Kingdom, 3Istituto Giannina Gaslini, Genova, Italy

 

Somatic mutations in genes encoding Cav1.3 and Na+/K+-ATPase delineate a zona glomerulosa (ZG) subtype of aldosterone producing adenomas (APA).1 In order to identify molecules which are markers of a ZG-phenotype and may be influenced by gain-of-function mutations in an adrenal-selective Ca2+ channel, we compared the transcriptome of adjacent ZG and zona fasciculata (ZF), and investigated whether genes upregulated in ZG may influence aldosterone production.

1) RNA was isolated by laser capture microdissection from ZF, ZG and tumour (T) of 14 APA and 7 phaeochromocytoma patients.  An Affymetrix microarray analysis was performed comparing ZG, ZF and T. The expression of upregulated genes was validated by qPCR.  2) Putative Ca2+-sensitive genes were analysed for protein expression by immunohistochemistry ± western blotting. 3) Subcellular localisation of a putative Ca2+-activated chloride channel was determined by immunofluorescence microscopy of transfected HEK293 cells. 4) The channel’s role in regulating aldosterone production was studied by transfection of H295R cells. 5) We looked for mutations in these genes from whole exome sequencing of ten ZG-like APA.

Results are summerized as follow:  1) 28 genes were at least 5-fold over-expressed in ZG vs ZF. VSNL1 was 23.5-fold (p=3.6x10-23), and ANO4 19.9-fold higher (p=6.6x10-24) in ZG than ZF; although both were also increased in APAs, expression was 2- and 10-fold lower, respectively, than in ZG.  qPCR confirmed 168- and 54-fold upregulation, respectively, of VSNL1 and ANO4 in ZG vs. ZF. 2) IHC showed selective staining of both VSNL1and ANO4 in ZG adjacent to either phaeocromocytoma or APA. Western blot was consistent with IHC. 3) Aldosterone secretion from H295R cells was reduced from 27.3 to 11.8 pg/ml after transection with ANO4, and CYP11B2 mRNA expression fell 24-fold. 4) HA-tagged ANO4 was localized in the membrane.5) We found rare germline coding variant in VSNL1 (K153T), predicted to cause loss of function (SIFT=0) in one APA, but this not found on a further 56 patients during the replication sequencing.

In conclusion, two of the most ZG-selective genes are VSNL1, a Ca2+-sensor previously reported in APAs, whose transfection protects H295R cells from apoptosis2; and ANO4, a member of the anoctamin family including at least two Ca2+-activated chloride channels. Both VSNL1 and ANO4 may function to protect normal ZG cells from Ca2+ activation, and contribute to negative feedback of aldosterone from APAs. Relatively lower expression in APAs may augment the consequence of Ca2+ activation – by Cav1.3 and other mutations.

 

Nothing to Disclose: CM, JZ, EAA, IM, SGN, CAB, LG, PS, MJB

PP06-2 16199 2.0000 SAT-0840 A Putative Calcium-Sensitive Genes, VSNL1 and ANO4, ARE Upregulated in Human Zona Glomerulosa CELLS and MAY PLAY a Role in Regulation of Aldosterone Production 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 11:30:00 AM PP06 4892 11:15:00 AM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension Poster Preview

Andrew S Powlson*1, Olympia Koulouri1, Elena AB Azizan1, Carmela Maniero1, Kevin Taylor2, Franklin Aigbirhio1, Brendan Koo2, Heok K Cheow2, John Buscombe2, Mark Gurnell1 and Morris J Brown1
1University of Cambridge, Cambridge, United Kingdom, 2Addenbrooke's Hospital, Cambridge, United Kingdom

 

Adrenal vein sampling (AVS) is the current gold-standard for distinguishing unilateral and bilateral disease in primary aldosteronism (PA). However it is technically demanding and invasive, and in many centres is frequently unsuccessful or ambiguous. Metomidate (MTO), a potent ligand of CYP11B1 and CYP11B2, can be C11H3-labelled as a PET tracer (11C-MTO), offering a rapid non-invasive alternative to AVS for localising unilateral aldosterone-producing adenomas (APAs)1.

Here, we report a retrospective analysis of the 61 sequential patients with PA referred for 11C-MTO PET-CT in the three years since our formal comparison with AVS. All patients had a definite or possible adenoma on previous CT or MRI, or an AVS suggestive of lateralisation. 11C-MTO PET-CT was unequivocally positive, by our previously validated criteria, and led to a recommendation for surgery in 26 out of the 61 patients (42.6%). In all 12 cases operated to date following local surgical referral for unilateral adrenalectomy adrenocortical histology (including immunohistochemistry for CYP11B2) was positive, and there was biochemical cure of PA (normalisation of the aldosterone-to-renin ratio (ARR)); six local patients await adrenalectomy. In a further 8 ‘tertiary’ referrals from abroad, or another centre in the UK, lateralisation by 11C-MTO PET-CT led to a recommendation for adrenalectomy but further clinical outcome is currently unknown.

The 26 patients in whom unilateral disease was successfully confirmed fell into one of five indications for 11C-MTO PET-CT: [i] AVS technically unsuccessful with failure to cannulate one of the adrenal veins; [ii] technically adequate AVS, but without unequivocal lateralisation: [iii] AVS not possible (unable to safely withdraw spironolactone or epleronone); [iv] no clear cut abnormality on cross-sectional imaging; [v] patient choice not to undergo AVS. 11C-MTO PET-CT was also valuable in providing strong evidence against lateralisation, especially in patients with a definite unilateral adenoma on CT or MRI but no resolution by AVS.

Finally, where multiple nodules co-exist within a single or both glands, 11C-MTO PET-CT has accurately identified the causative tumour (confirmed by cell-culture, gene-expression and genotyping).  We speculate that this may facilitate non-surgical targeted nodule-specific ablation or selective surgical adenomectomy.

In conclusion, analysis of 11C-MTO PET-CT in 61 sequential patients supports its use as an adjunct to AVS in diagnostically challenging cases and, in addition, provides a non-invasive alternative.

 

Disclosure: MG: Principal Investigator, Ipsen, Advisory Group Member, Novartis Pharmaceuticals. Nothing to Disclose: ASP, OK, EAA, CM, KT, FA, BK, HKC, JB, MJB

PP06-3 16188 3.0000 SAT-0838 A 11C-Metomidate PET-CT Facilitates Definitive Diagnosis in Patients with Primary Aldosteronism and Ambiguous Previous Imaging: A Sequential Analysis of 61 Cases 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 11:30:00 AM PP06 4892 11:15:00 AM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension Poster Preview

Amalia Sertedaki*1, Athina Markou2, Gregory A Kaltsas3, Ioannis Androulakis4, Theodora Pappa2, Aggeliki Gouli2, Labrini Papanastasiou2, Achilles Zacharoulis2, Apostolos Karavidas2, Despoina Ragkou2, Dimitrios Vlachakis5, Sophia Kossida5, Emilie Campanac6, Dax A Hoffman6, Maria De La Luz7, Paraskevi Xekouki8, Constantine A Stratakis9, Evangelia Charmandari1, George P. Chrousos10 and Georgios P Piaditis2
1Athens University, School of Medicine, Athens, Greece, 2“G. Gennimatas” General Hospital, Athens, Greece, 3University of Athens School of Medicine, 4“G. Gennimatas” General Hospital, Athens, Greece, Greece, 5Biomedical Research Foundation of the Academy of Athens, Greece, 6National Institutes of Health, 7National Institute of Health, Bethesda, 8National Institute of Health, Bethesda, MD, 9National Institutes of Health (NIH), Bethesda, MD, 10University of Athens, School of Medicine, Athens, Greece

 

Background: Aldosterone secretion by the adrenal zona glomerulosa is regulated by angiotensin II, K+ and ACTH.  Somatic and germline mutations of the KCNJ5 gene expressed in the zona glomerulosa and encoding the Kir3.4 inward rectifying K+ channel have been identified in patients with Familial Hyperaldosteronism (FH) type III. FH type I, on the other hand, is due to a chimeric gene originating from the unequal crossing over between the CYP11B1 and CYP11B2 genes.

Objective and Hypotheses: The aim of this study was to investigate the presence of KCNJ5 gene mutations or the CYP11B1/CYP11B2 chimeric gene in patients with hypertension and an increased aldosterone response to ACTH stimulation, but no evidence of primary aldosteronism.

Patients and Methods: We studied 23 hypertensive patients aged 35-68 years with normal findings on adrenal computed tomography scan and increased aldosterone response to ACTH (0.03 μg, iv). Using the 97.5% of CI of aldosterone concentrations and the aldosterone/renin ratio (ARR) of a population of 61 healthy controls, we defined increased aldosterone response the presence of both aldosterone >1300 pmol/L and ARR > 77 pmol/mIU. Genomic DNA was isolated from peripheral blood leucocytes in all subjects. The coding region of KCNJ5 gene was PCR-amplified and sequenced. The chimeric gene CYP11B1/CYP11B2 was PCR amplified as previously described. Electrophysiological and structural biology studies were performed to determine the effect of the mutations identified.

Results: The chimeric gene CYP11B1/CYP11B2 was not detected in any of our patients. Two novel, heterozygous KCNJ5 mutations were detected: the p.V259M c.775G>A in exon 2 and the p.Y348N, c.1042T>A in exon 3. The in silico analysis showed that the mutations were deleterious and that the amino acids V259 and Υ348 are highly conserved among species. Electrophysiological studies revealed that the Y348N showed greater rectification and a significantly less negative reversal potential of -1.3 ± 11.8 mV than the wild-type. The V259M did not appear more rectified than the wild-type, given that the reversal potential was not significantly different (-18.7 ± 10.5 mV). Structural biology studies revealed that the amino acid positions 259 and 348 are very important to the overall 3D arrangement of the KCNJ5 protein.

Conclusions: Two novel mutations of the KCNJ5 gene were detected in two hypertensive patients with an increased aldosterone response to ACTH stimulation. These findings indicate that the K+ channel might be involved in the pathophysiology of idiopathic hypertension.

 

Nothing to Disclose: AS, AM, GAK, IA, TP, AG, LP, AZ, AK, DR, DV, SK, EC, DAH, MD, PX, CAS, EC, GPC, GPP

PP06-4 14614 4.0000 SAT-0837 A Mutations of the KCNJ5 Gene in Patients with Hypertension and Increased Aldosterone Response to ACTH 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 11:30:00 AM PP06 4892 11:15:00 AM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension Poster Preview

Sapna Sanjay Shah*, Claudia E Ramirez, Alvin C Powers, Cyndya Shibao and James M Luther
Vanderbilt University Medical Center, Nashville, TN

 

Impaired insulin secretion is an early indicator of type 2 diabetes risk but has not been completely investigated in association with the metabolic syndrome, another risk factor for type 2 diabetes.  We hypothesized the severity of the metabolic syndrome is associated with impaired insulin secretory response and insulin sensitivity.  A total of 109 hyperglycemic clamps in 96 individuals (mean age 45.3±1.2 years, 56% female, 22% African American) were performed at Vanderbilt University Medical Center.  Standardized glucose priming dose followed by a variable infusion rate was adjusted to maintain plasma glucose at 200mg/dL for 120 minutes.  The metabolic syndrome defined by ATP III criteria was present in 78% of the cohort: increased waist circumference (80.7%), elevated blood pressure (79%), decreased HDL (70%), elevated fasting glucose (50.5%), and elevated triglycerides (20%).  Outcomes included acute glucose stimulated insulin response (AIR = area under insulin curve from 0-10 minutes corrected for baseline insulin secretion), late phase insulin response (LIR = average of insulin values from 90-120 minutes), insulin sensitivity index (ISI = average glucose infusion rate/LIR), and disposition index (DI = AIR x ISI).  Outcome variables and metabolic syndrome components were analyzed using fixed effects models adjusted for age, gender, and race.  ISI declined nonlinearly when stratified by number of metabolic syndrome components.  ISI negatively correlated with age (-0.17 [95% CI -0.01 to -0.32] per year, p=0.040), waist circumference (-0.29 [95% CI -0.17 to -0.42] per cm, p<0.001), and male gender (-3.7 [95% CI -0.19 to -7.3] versus females, p=0.039) and positively correlated with HDL (0.18 [95% CI 0.04 to 0.32] per mg/dL, p=0.01).  ISI did not correlate with race, systolic blood pressure, triglycerides, or fasting glucose.  DI was assessed to adjust the insulin secretory response for insulin sensitivity.  DI correlated inversely with number of metabolic syndrome components (-511.1 [95% CI -215.3 to -806.8, p<0.001), age (-67.6 [95% CI -31.6 to -103.6] per year, p<0.001) and in Caucasians (-1391.9 [95% CI -498.4 to -2285.5] versus African Americans, p=0.003).  When individual metabolic syndrome components were analyzed as continuous variables, DI correlated inversely with waist circumference (-48.6 [95% CI -19.1 to -78.1] per cm, p=0.002) and fasting glucose (-41.6 [95% CI -12.5 to -70.7per mg/dL, p=0.06) and correlated positively with HDL (33.1 [95% CI 0.11 to 66.1] per mg/dL, p=0.049).  DI did not correlate with systolic blood pressure, triglycerides, or gender.  These data demonstrate a negative association between beta cell function and number of metabolic syndrome components adjusted using multivariate analysis.  Therefore, an insulin secretion defect is evident in individuals with the metabolic syndrome prior to progression to overt type 2 diabetes.

 

Disclosure: ACP: Ad Hoc Consultant, Boehringer Ingelheim Pharma GmbH & Co. KG, Ad Hoc Consultant, GNF/Novartis. Nothing to Disclose: SSS, CER, CS, JML

PP01-2 14932 2.0000 SAT-1052 A Beta Cell Function Is Negatively Associated with Metabolic Syndrome Severity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 11:30:00 AM PP01 4893 11:15:00 AM Basic Mechanisms of Glucose Homeostasis and Diabetic Complications Poster Preview

Xiaoyu Li*1, Mark A Clements1, K Kover1, Dara J Watkins1, Mengwei Zang2, Dan Heruth1, Wayne V Moore1 and Yun Yan1
1Children's Mercy Hospital and University of Missouri-Kansas City, Kansas City, MO, 2Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA

 

Background:  Chronic hyperglycemia in diabetes causes endothelial cell dysfunction and, eventually, macro- and microvascular diseases. Thioredoxin-interacting protein (TXNIP) has been recently described as a regulator of the cellular redox state. TXNIP over-expression induced by high glucose concentration decreases thioredoxin reductase activity and renders cells more susceptible to oxidative stress and apoptosis. Metformin is a first line therapy for type 2 diabetes and an antioxidant effect has been reported. The effect and the mechanism of modification of TXNIP expression by metformin in endothelial cells are unknown.

Objective:  To determine the impact of metformin on TXNIP over-expression induced by high glucose concentration in endothelial cells. 

Materials and Methods: The cells (a mouse aortic endothelial cell line) were maintained at 37 0C with 5% CO2. Metformin and Compound C, an AMP-activated protein kinase (AMPK) inhibitor, were purchased from Sigma and Millipore, respectively. The treated cells were harvested for qRT-PCR and western blot analyses. To study metformin effects on TXNIP promoter activity, we transfected cells with a construct containing a TXNIP promoter-driven luciferase or the pGL3 basic vector prior to the following treatments. Relative firefly luciferase activity was determined using the Dual Luciferase Assay Kit (Promega) after 24h incubation.

Results: The cells were divided into 5 groups: 1) normal glucose (5.5 mM), 2) high glucose (25 mM), 3) normal glucose with metformin (2 mM), 4) high glucose with metformin (2 mM), 5) 25 mM mannitol (osmotic control) and treated for 24 hours . TXNIP expression was significantly increased by high glucose after 24 h compared to normal glucose at both the mRNA level (10 fold, p<0.01) and the protein level (4 fold, p<0.05). The expression at the protein level was suppressed by metformin (2 fold, p<0.05).  Metformin also suppressed TXNIP promoter activity (3 fold, p<0.05).  The effect of metformin on suppressing TXNIP promoter activity is partially attenuated by pretreatment with Compound C (10 µM) under high glucose conditions (1.5 fold, p<0.05).

Conclusion:  High glucose concentration induces the pro-oxidant gene TXNIP.  Metformin suppresses high glucose concentration induced TXNIP over-expression through activation of AMPK activity.  Further delineation of the mechanisms of metformin action on TXNIP over-expression induced by high glucose concentration will provide evidence for using metformin as a potential adjunctive treatment for patients with type 1 diabetes.

 

Disclosure: MAC: Consultant, Medtronic Minimed. WVM: Investigator, Versartis, Inc. Nothing to Disclose: XL, KK, DJW, MZ, DH, YY

PP01-3 15585 3.0000 SAT-1058 A Metformin Suppresses Thioredoxin-Interacting Protein (TXNIP) over-Expression in Endothelial Cells: The Involvement of AMP-Activated Protein Kinase 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 11:30:00 AM PP01 4893 11:15:00 AM Basic Mechanisms of Glucose Homeostasis and Diabetic Complications Poster Preview

Sabyasachi Sen*1 and Nagendra Yadava2
1The George Washington University, Washington, DC, 2Pioneer Valley Life Science Institute

 

MSCs are multipotent cells that differentiate into fat, muscle, bone and cartilage cells. High Glucose (HG) exposure of bone marrow derived MSCs leads to: increased reactive superoxide (ROS) accumulation both in cytosol and mitochondria ( analysed by FACS using Mitosox Red dye) and increased intra-cellular lipid droplet accumulation. We hypothesized that intra-cellular antioxidant up-regulation specifically mitochondrial (super-oxide dismutase-2), may help reduce superoxide accumulation in mitochondria which will subsequently help reduce fat droplet accumulation and associated cellular inflammation.

 We exposed hMSCs to HG (25mM) and normal glucose (NG, 5.5 mM) and interrogated mitochondrial superoxide accumulation and cellular oxygen consumption rate (OCR using Seahorse) and interrogated response to mitochondrial complex I-IV 4 substrate addition. We used AdSOD2 to up-regulate SOD2 prior to HG exposure. HG exposure increased TNF α (Tumor Necrosis Factor, 4 fold) and IL6 (interleukin6, 6-fold) mRNA and increased lipid accumulation (2.5 fold) and led to impaired OCR on SeaHorse and impaired Mitochondrial Complex 1.

With prior SOD2 upregulation in MSCs, TNF α and IL6 mRNA expression was reduced in HG and improved Complex-1 function.

 Next we delivered the SOD2 upregulated MSC intra-peritoneally to obese diabetic (db/db) mice. We confirmed homing-in of eGFP labeled MSC, delivered IP, to different fat pockets. The mice that received MSC-SOD2 (experimental) showed reduced adipocyte and systemic inflammation (IL6 and TNF alpha levels) compared the mice that received MSC-Null (control). Interestingly the experimental group showed consistent reduction in fat mass (Echo-MRI), local adipocyte inflammation, systemic inflammation in serum and marked improvement in glucose tolerance tests (GTT).

 We conclude that local delivery of mitochondrial superoxide dismutase using stem cells as a gene delivery vehicle reduces inflammation and glucose tolerance tests in vivo. We plan to carry out further glucose clamp studies to consolidate our findings. In conclusion local rather than systemic up-regulation of a mitochondrial anti-oxidant helps in reducing local and systemic inflammation, total fat mass and improves glucose mediated insulin response in obese diabetic mouse models.

 

 

Nothing to Disclose: SS, NY

PP01-4 15951 4.0000 SAT-1063 A Genetically Modified Mesenchymal Stem Cells (MSCs) Help Reduce Inflammation and Glucose Mediated Insulin Response in Obese Diabetic Mouse Models 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 11:30:00 AM PP01 4893 11:15:00 AM Basic Mechanisms of Glucose Homeostasis and Diabetic Complications Poster Preview

Le Min*1, Min Nie2, Junping Wen2, Sekoni D. Noel3, Rona S. Carroll3 and Ursula B Kaiser4
1Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 2Brigham and Women's Hospital, Boston, MA, 3Brigham and Women's Hospital/Harvard Med School, Boston, MA, 4Brigham and Women's Hospital and Harvard Medical School, Division of Endocrinology/Diabetes, Boston, MA

 

The important roles of G protein-coupled receptors (GPCRs) in the central regulation of reproductive function have been well documented. These GPCRs include GnRHR, KISS1R, NK3R, and PROKR2. Many mutations in these GPCRs have been identified in patients with GnRH deficiency. GPCRs are integral membrane proteins that possess seven transmembrane domains connected by three extracellular and three intracellular loops. Alignment of GPCRs has identified many conserved amino acids across GPCRs. Mutations occurring in conserved residues are usually thought to cause loss of function, whereas mutations in non-conserved residues are regarded as more likely to be benign. We performed receptor alignment by CLUSTAL 2.0.12 Multiple Sequence Alignments and then ran BoxShade to identify non-conserved, conserved and highly conserved amino acids - defined as having no conservation at that position, 50% or more similar residues (i.e., sharing physicochemical properties), or 50% or more identical residues, respectively - in human GnRHR, KISS1R, NK3R and PROKR2. Notably, all of these receptors are primarily Gq-coupled. To specify conserved amino acids across GPCRs, we also included AT1a, a Gq-coupled receptor, and b2AR, a Gs-coupled receptor, in the alignment. Through detailed literature searches, we found a total of 51 reported naturally occurring missense mutations resulting in amino acid substitutions in GnRHR, KISS1R, NK3R, and PROKR2, identified in patients with GnRH deficiency. Among these, 26 mutations were in non-conserved amino acids, 11 in conserved amino acids, and 14 in highly conserved residues. Seventeen of the 26 mutations in non-conserved residues were reported to have undergone experimental testing for functional effects; 14/17 caused loss of function, whereas 3/17 displayed normal function. Nine of 11 mutations in conserved residues were tested experimentally; all caused loss of function. All 14 mutations in highly conserved residues were demonstrated to cause loss of function. In conclusion, as expected, all mutations tested that occurred in conserved and highly conserved amino acid residues are loss-of-function mutations. Surprisingly, most mutations in non-conserved amino acid residues are also loss-of-function mutations. It is, therefore, important to perform functional testing for mutations occurring in non-conserved amino acids to determine whether they are associated with loss of function or normal function.

 

Nothing to Disclose: LM, MN, JW, SDN, RSC, UBK

PP08-1 16461 1.0000 SAT-0346 A Predicting the Functional Effects of Mutations in GPCRs Involved in the Neuroendocrine Regulation of Reproduction By Sequence Alignment and Conservation Analysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, June 21st 11:30:00 AM PP08 4903 11:15:00 AM New Insights in GPCR Structure and Function Poster Preview

Shilpi Mahajan*1, Juan A Oses-Prieto2, Dimitris Grammatopoulos3, Alma L Burlingame2 and Aditi Bhargava1
1UCSF, San Francisco, CA, 2University of California San Francisco, 3Univ of Warwick Biomed Res Inst, Coventry, United Kingdom

 

The corticotropin-releasing factor (CRF) family mediates the classic “fight or flee” stress response by activating the HPA axis. The effectors and responders consist of the neuropeptides CRF, urocortins (Ucn1-3), and two GPCRs: CRF1 and CRF2. Two protein-coding variants of CRF2 have been reported (CRF2a and CRF2b). CRF1 and CRF2a-b contain putative N-terminal signaling peptide (NTSP) that is cleaved-off after mediating internalization and/or endoplasmic reticulum (ER) targeting. Usually the transmembrane domain 1 of the mature GPCRs mediates ER targeting and insertion, and the role of putative N-terminal signal peptide in ligand-mediated trafficking and signaling remains unclear. We hypothesized that the NTSP of CRF2b is key in determining its subcellular localization because it interacts with specific proteins and acts as a rheostat to respond differentially to its four distinct ligands in a context-dependent manner. We generated HEK cells stably expressing full-length CRF2b (FL-CRF2b) or deleted NTSP (ΔSP-CRF2b). FL-CRF2b HEK cells showed robust intracellular Ca2+ peak [Ca2+]i responses after stimulation with 10-100nM doses of Ucn3, but only at high (100nM) dose of Ucn1 or Ucn2. Surprisingly, and unlike CRF2a, FL-CRF2b also showed measurable [Ca2+]i after challenge with high doses (75-100nM) of CRF only. Unexpectedly, HEK cells expressing ΔSP-CRF2b displayed a left-shift in dose-response for kinetics of Ca2+ stimulation as activation of [Ca2+]i responses was seen even at 10-50nM of Ucn1-2 and showed a 50% increase in peak [Ca2+]i responses to 30-100nM CRF stimulation as compared with FL-CRF2b, suggesting increased receptor sensitivity. Next, we determined if this differential signaling was due to differential trafficking of the ΔSP-CRF2b and CRF1 to distinct subcellular organelles. Cell-surface labeling of epitope-tagged receptor showed that while CRF1 trafficked to early endosomes where it co-localized with EEA1 after stimulation with either CRF or Ucn1, CRF2b did not co-localize with EEA1 after stimulation with either CRF or Ucn1-3. Because deletion of the SP resulted is distinct receptor signaling and trafficking, we determined if the SP determines subcellular localization after ligand stimulation via interaction with other regulatory proteins. By co-immunoprecipitation and mass spectrometry analysis, we identified calnexin, a lectin and ER-targeting chaperone protein that is part of the CRF receptor complex, only after stimulation with CRF and/or Ucn2. We previously showed that CRF2-/- acinar cells have dramatic ER ultrastructure damage and activate ubiquitination of unfolded proteins in response to chemical stress that is more pronounced in males than females. Thus, we propose a novel mechanism by which the CRF2 receptor forms a complex with calnexin to regulate subcellular targeting of proteins and signaling at baseline and during stress.

 

Nothing to Disclose: SM, JAO, DG, ALB, AB

PP08-2 16590 2.0000 SAT-0347 A N-Terminal Signaling Peptide of CRF Receptor 2b Is a Key Mediator of Ligand-Dependent Trafficking and Signaling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, June 21st 11:30:00 AM PP08 4903 11:15:00 AM New Insights in GPCR Structure and Function Poster Preview

Juliane Dinter*1, Jessica Mühlhaus1, Carolin Leonie Piechowski1, Anne Müller1, Daniela Nürnberg2, Annette Grueters2, Josef Köhrle1, Chun-Xia Yi3, Matthias H. Tschöp3, Heiko Krude1, Gunnar Kleinau1 and Heike Biebermann1
1Charité - Universitätsmedizin Berlin Campus Virchow, Berlin, Germany, 2Charité - Universitätsmedizin Berlin Campus Virchow, Berlin, 3Helmholtz Center Munich, Garching, Germany

 

The thyroid hormone derivative 3-iodothyronamine (T1AM) is known to activate the GPCR trace amine-associated receptor 1 (TAAR1) via Gs/adenylate cyclase pathway. T1AM is more and more gaining medical interest as therapeutic target. Recent studies in rodents have shown that T1AM has cardio- and neuroprotective effects with treatment options in humans for intensive care patients such as infarct or stroke patients. Moreover, significantly higher T1AM concentrations were observed in diabetic patients. Prior to taking treatment options for humans into account all effects and functions of T1AM as well as species transferability need to be elucidated.

We speculated that T1AM affects other receptors than TAAR1 because T1AM injection produced similar effects in WT and Taar1 ko mice. A possible candidate could be Taar5 for T1AM as potential target for mediating T1AM effects which is from the same receptor class and moreover highly conserved across species.

In situ hybridization for Taar1 and Taar5 in mouse brains revealed overlapping expression profiles in the amygdala and ventromedial hypothalamus. Consequently, we functionally characterized the signaling properties of human and mouse TAAR5. We confirmed recent data that the volatile amine dimethylethylamine is an agonist for Gs activation at mTaar5, however, not at hTAAR5. Further investigations revealed elevated basal activity for ERK activation and inositoltriphosphate (IP3) accumulation at hTAAR5 and mTaar5 and additional basal Gs activity for mTaar5. In response to 3-T1AM, no signaling via Gs, Gq, Gi, G12/13 and ERK was observed at hTAAR5 and mTaar5, while T1AM acted as inverse agonist at hTAAR5 by decreasing its basal IP3 and ERK activity. In order to elucidate the particular determinants involved in the ascertained signaling differences between hTAAR5 and mTaar5 chimeric receptors were created, with the objective of transferring murine signaling properties to hTAAR5. We identified 6 amino acids in the ligand binding and G protein-coupling region to be involved.

Our data demonstrated that transferring signaling properties of Taar5 from mouse to human situation ought to be treated warily. The in vitro data suggest that hTAAR5 functions as a target for T1AM and exhibits inhibitory T1AM effects on Gq- and ERK signaling. In consequence, T1AM acts on distinct molecular components which their interaction with T1AM and each other need to be understood in order to use T1AM as pharmacological agent.

 

Nothing to Disclose: JD, JM, CLP, AM, DN, AG, JK, CXY, MHT, HK, GK, HB

PP08-3 13734 3.0000 SAT-0348 A Identification of a New Target for 3-Iodotyonamine (T1AM) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, June 21st 11:30:00 AM PP08 4903 11:15:00 AM New Insights in GPCR Structure and Function Poster Preview

Anne Müller*1, Franziska Meyer2, Gunnar Kleinau1, Heiko Krude1, Annette Grüters-Kieslich1 and Heike Biebermann1
1Charité - Universitätsmedizin Berlin Campus Virchow, Berlin, Germany, 2Charité Universitätsmedizin Berlin, Berlin, Germany

 

G-protein coupled receptors (GPCRs) play an important role in hypothalamic body weight regulation. Promoting orexigenic signals the ghrelin receptor (GHSR) and the melanocortin 3 receptor (MC3R), both expressed in the arcuate nucleus on Neuropeptide Y/Agouti-related peptide-neurons are key players in appetite control. Recently it was shown that both receptors function in a signaling network with other GPCRs. To elucidate deeper insights into the complex network of GPCR function in hypothalamic weight regulation we established a hypothalamic murine screening system based on bimolecular fluorescence complementation to detect further interactions of these GPCRs. With that screening procedure we identified a variety of different new interaction partners.

In the present study the impact of the screening hit Ring Finger Protein 11 (RNF11) was investigated. RNF11 is an ubiquitin ligase, part of the A20-complex and required to downregulate inflammatory NFκB-signaling, communicated by the Tumor Necrosis Factor α (TNFα) receptor for instance. In a first step we confirmed the RNF11/MC3R and the RNF11/GHSR-interaction. Next we demonstrated that RNF11 downregulates MC3R-signaling in response to α- and γ-Melanocyte-Stimulating Hormone. In contrast GHSR-signaling, basal and with ghrelin-stimulation was not affected by RNF11. In addition and in concordance with these findings we showed that the MC3R potentiates the cellular NFκB-signaling in response to TNFα, while the GHSR did not. RNF11 in coexpression with the MC3R decreased the TNFα-mediated NFκB-signaling, as expected. These data indicate a hint for a potential MC3R/TNFR-interaction in which RNF11 downregulates simultaneously TNFR and MC3R.

Recently it was shown that obesity is associated with low-grade inflammation of the hypothalamus. This is the first time that a molecular link between GPCRs, expressed in the arcuate nucleus of the hypothalamus and hypothalamic inflammation could be demonstrated indicating a huge spectrum of complexity in energy metabolism.

 

Nothing to Disclose: AM, FM, GK, HK, AG, HB

PP08-4 14616 4.0000 SAT-0345 A RNF11: A Potential Link Between Chronic Inflammation in Obesity, Hypothalamic GPCR-Signaling and Control of Energy Homeostasis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, June 21st 11:30:00 AM PP08 4903 11:15:00 AM New Insights in GPCR Structure and Function Poster Preview

Laura E. Dichtel*1, Kevin C.J. Yuen2, Miriam A. Bredella1, Anu V. Gerweck3, Brian M. Russell3, Ariana D. Riccio3, Michelle H. Gurel3, Stacy E. Legg2, Patrick M. Sluss3, Beverly MK Biller1 and Karen K. Miller1
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Oregon Health and Science University, Portland, OR, 3Massachusetts General Hospital, Boston, MA

 

Context: Obesity is associated with diminished GH secretion, which may result in the overdiagnosis of GHD in overweight/obese patients with pituitary disorders. Although BMI-appropriate peak GH cut-offs for the diagnosis of GHD have been established for the GHRH-arginine test, there are no BMI-specific peak GH cut-offs for the GST, which is currently the favored dynamic test for assessing GHD in the U.S.

Objective: To determine a peak GST GH cut-off value for the diagnosis of GHD in overweight/obese individuals.

Subjects and Methods:  Controls (n=47) were otherwise healthy young men with BMI ≥25 kg/m2 on no medications. Total pituitary deficiency (TPD) cases (n=20) were defined as BMI of ≥25 kg/m2 and ≥3 non-GH pituitary deficiencies. Diagnoses included pituitary adenoma (n=9), craniopharyngioma (n=5), and other pituitary disorders (n=6), while treatments included TSS (n=12) and cranial irradiation (n=6). A partial pituitary deficiency (PPD) group (n=41) was defined as men with BMI ≥25 kg/m2and 1-2 non-GH pituitary hormone deficits. IM glucagon 1 mg (<90 kg) or 1.5 mg (≥90 kg) was administered and serum GH (Immulite 2000, Siemens Medical) was measured every 30 min for 4 h. TPD cases were used as the gold standard for defining GHD in ROC analysis. Abdominal fat was measured by cross-sectional CT at L4 in controls.

Results: Mean BMI did not differ between TPD cases and controls (32±7 vs 34±3 kg/m2, p=0.1), while age of controls was lower than TPD cases, as expected (33±7 vs 45±14 y, p=0.004). Mean age (45±13 y) and BMI (33±7 kg/m2) of PPDs was not significantly different than TPD cases (p=0.8 and p=0.7, respectively). Median peak GH was 0.4 ng/ml (95% CI 0.4-4.1) in TPD cases and 3.0 ng/ml (95% CI 0.7-16.1) in controls. Using the standard peak GH cut-off of 3 ng/ml, 95% (19/20) of TPD cases and 45% (21/47) of controls were classified as GHD.  In ROC curve analysis of controls vs TPD cases, a value of 0.94 ng/ml provided the greatest sensitivity (94%) and specificity (90%) for diagnosing GHD in overweight/obese men. Using a cut-off of 1 ng/ml, 6% (3/47) of controls and 90% (18/20) of TPD cases would be classified as GHD. Additionally, 88% (18/21) of controls and 5% (1/19) of TPD cases who failed using the standard cut-off would be reclassified as GH sufficient. When the cut-off of 1 ng/ml was applied to the PPD group, 59% (24/41) were classified as GHD, as compared to 80% (33/41) using the standard cut-off. BMI (R= -0.35, p=0.02), visceral adipose tissue (R= -0.32, p=0.03) and waist circumference (R= -0.31, p=0.04) negatively correlated with peak GH levels in controls.

Conclusion: Nearly 50% of young, healthy men with a BMI of ≥25 kg/m2 failed a GST using the standard cut-off of 3 ng/ml. This suggests that overweight/obese men with pituitary disease are at significant risk of being misclassified as GHD by GST using this cut-off.  A GH cut-off of 1 ng/ml by GST may reduce the rate of overdiagnosis of GHD in these patients.

 

Disclosure: KCJY: Principal Investigator, Pfizer, Inc., Advisory Group Member, Pfizer, Inc., Investigator, Novo Nordisk, Advisory Group Member, Novo Nordisk. BMB: Consultant, Pfizer, Inc., Consultant, Novo Nordisk. Nothing to Disclose: LED, MAB, AVG, BMR, ADR, MHG, SEL, PMS, KKM

PP03-1 13147 1.0000 SAT-0676 A Overweight/Obese Adults with Pituitary Disorders Require Lower Peak Growth Hormone (GH) Cut-off Values on Glucagon Stimulation Testing (GST) to Avoid Overdiagnosis of Growth Hormone Deficiency (GHD) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 11:30:00 AM PP03 4906 11:15:00 AM GHRH, GH & IGF Biology Poster Preview

Yujun Gan*, Andrew J. Paterson, Yue Zhang, Ashiya Buckels, Jing Jiang and Stuart J Frank
University of Alabama at Birmingham, Birmingham, AL

 

Growth hormone (GH) is a powerful somatogenic and metabolic regulatory hormone that signals via the GH receptor (GHR) and the GHR-associated JAK2 tyrosine kinase. GH activates the STAT5 transcription factor and expression of the insulin-like growth factor-1 (IGF-1) gene and others. We previously demonstrated that GHR interacts physically and functionally with the IGF-1 receptor (IGF-1R), such that, even in the absence of IGF-1, IGF-1R’s presence augments GH-induced STAT5 phosphorylation and IGF-1 gene expression. Using IGF-1R-floxed mouse osteoblasts, our recent studies (1) showed that adenovirus (Ad)-mediated expression of IGF-1R, but not insulin receptor (IR), rescued the diminished GH-induced STAT5 phosphorylation observed in Ad-Cre-infected (IGF-1R-deficient) osteoblasts.  Further, reexpression of IGF-1R/IR chimeras with swaps of the related alpha chain extracellular domain L1, CR, and L2 regions indicated that the IGF-1R alpha chain CR-L2 region was required for functional collaboration with GHR signaling. We now report the effects of treatment of GH-responsive cells with conditioned medium (CM) from cells programmed to express soluble truncated fragments of either IGF-1R or IR alpha chain extracellular domains that include the L1-CR-L2 regions of each receptor. We first verified the presence of immunodetectable soluble (sol) IGF-1R and sol IR in the CM of HEK-293 cells infected with Ad-sol IGF-1R or Ad-sol IR, respectively. Pretreatment of each of three GH-responsive cells (mouse osteoblasts, mouse 3T3-F442A preadipocytes, and human LNCaP prostate cancer cells) with sol-IGF-1R CM, but not sol IR CM, resulted in substantial reduction of GH-induced acute STAT5 phosphorylation. Further, sol IGF-1R CM specifically inhibited GH-induced expression of IGF-1 mRNA, as assessed by RT-PCR, in osteoblasts. By immunoblotting, we observed a GH-dependent association of sol IGF-1R, but not sol IR with cells, suggesting that the inhibitory effect of the sol IGF-1R is related to interaction with GHR or a GHR-associated cell surface protein. Studies of the mechanism(s) of this inhibitory effect of sol IGF-1R on GH signaling are underway and may have therapeutic implications.

 

Nothing to Disclose: YG, AJP, YZ, AB, JJ, SJF

PP03-2 13299 2.0000 SAT-0673 A Effect of a Soluble IGF-1 Receptor Extracellular Domain Fragment on GH Signaling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 11:30:00 AM PP03 4906 11:15:00 AM GHRH, GH & IGF Biology Poster Preview

Jose Cordoba-Chacon*1, Neena Majumdar2, Edward O List3, John J Kopchick3 and Rhonda D. Kineman4
1University of Córdoba; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC); Hospital Universitario Reina Sofia, and CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn) / University of Illinois at Chicago, Córdoba, Spain, 2Jesse Brown VA Medical Center/University of Illinois at Chicago, Chicago, IL, 3Ohio University, Athens, OH, 4University of Illinois at Chicago/Jesse Brown VA Medical Center, Chicago, IL

 

The liver partitions nutrients for appropriate utilization/storage by other tissues. Defects in hepatic nutrient processing can lead to inappropriate fat accumulation (hepatosteatosis), insulin resistance, hyperglycemia, hyperlipidemia and associated pathologies. The liver is a major target of growth hormone (GH), where developmental-, gender- and disease-related changes in GH secretion/action are associated with alterations in hepatic nutrient processing. However, since GH receptors (GHR) are ubiquitously expressed and are required for normal structural growth, it has been difficult to tease apart the direct vs. indirect effects of experimental or disease-related changes in circulating GH levels on adult hepatic metabolism. In order to better define the primary actions of GH on hepatic metabolism in adults, we have knocked down the GH receptor (GHR) in the liver of mice (aLivGHRkd), by treating 10wk-old GHRfl/fl mice (1) with adeno-associated vectors expressing liver-specific, Cre recombinase. Specifically, 7d post-virus infection, hepatic GHR mRNA expression was reduced (<1.5% of controls) and hepatic GHR protein was undetectable by western-blot in aLivGHRkd mice. Hepatic glycogen and triglyceride (TG) content was dramatically increased in male, but not female mice. The increase in hepatic nutrient storage could not be attributed to changes in systemic or hepatic insulin sensitivity or GH-mediated increases in lipolysis. Interestingly, under both basal and fasted conditions, hepatic PPARγ mRNA and protein levels were increased and this was associated with consistent changes in expression of PPARγ target genes. The lack of an effect of aLivGHRkd in female mice may be in part mediated by estrogen, because livers of ovariectomized (OVX) aLivGHRkd mice accumulated TG and increased expression of lipogenic genes, which was blocked by estrogen replacement. Interestingly, an increase in lipogenesis was not evident in OVX-females with intact hepatic GHR, as compared to SHAM-operated controls. These results clearly demonstrate that the hepatic GHR, or estrogen alone, are sufficient to suppress lipogenesis. It is possible that estrogen may modify GHR through regulation of pStat5 (2). However, estrogen may also bypass the effects of hepatic GHR resistance and act directly to suppress the activity of lipogenic transcription factors. Studies are ongoing to differentiate between these possibilities.

 

Nothing to Disclose: JC, NM, EOL, JJK, RDK

PP03-3 14851 3.0000 SAT-0674 A Sexual Dimorphic Impact of Adult-Onset Hepatic GH Resistance on Glucose and Lipid Metabolism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 11:30:00 AM PP03 4906 11:15:00 AM GHRH, GH & IGF Biology Poster Preview

Andrew S Powlson*1, Anand K Annamalai1, Alison J Webb1, Samantha Moir2, John M Shneerson2 and Mark Gurnell1
1University of Cambridge, Cambridge, United Kingdom, 2Papworth Hospital, Cambridge, United Kingdom

 

Context:Sleep disordered breathing (SDB), including obstructive sleep apnoea (OSA), leads to excessive daytime somnolence, impaired quality of life, and predisposes to premature cardiovascular and metabolic disease. It is a common complication of acromegaly. In many centres, screening for SDB involves an initial questionnaire [e.g. Epworth Sleepiness Scale (ESS)], which then triggers overnight oximetry to measure desaturation index (DI). However, polysomnography (PSG) remains the gold-standard for confirming and defining the true extent of SDB. Since 1980, forty studies have reported sleep data in subjects with acromegaly, but PSG was performed in fewer than half, and many cohorts have included a predominance of previously treated patients, thus confounding attempts to dissect primary disease and secondary treatment effects.

Study aims:

(i) To determine the prevalence of SDB in the largest cohort of patients with newly-diagnosed, treatment naïve, acromegaly studied to date.

(ii)To investigate whether screening tools such as ESS and DI accurately capture the true extent of SDB in acromegaly.

(iii)To determine the extent to which sleep architecture is disrupted in acromegaly.

Study design:ESS, DI, and PSG were performed in 40 consecutive newly diagnosed patients (22 males, 18 females, mean age 55, range 23-78 yr) referred to our tertiary centre between 2004 and 2013.

Results: OSA, defined on PSG by the apnoea-hypopnoea index (AHI), was a common finding (78%)  (mild OSA n=12; moderate OSA n=5; severe OSA n=14). However, in contrast DI markedly underestimated the extent of SDB (mild OSA n=11; moderate OSA n=7; severe OSA n=3). ESS also failed to predict the presence of SDB in many patients (ESS>11, n=12). Consistent with the finding of a high rate of OSA, patients exhibited an increased arousal index, with consequent marked disruption of the normal sleep cycle, despite the majority (n=34) exhibiting normal sleep latency and sleep period time. Twenty-seven patients spent longer than predicted in stage 1 sleep, while the deeper sleep stages were dramatically attenuated in many patients (reduced stage 2, n=26; reduced slow wave sleep, n=26; reduced REM sleep, n=31).

Discussion: Our findings confirm that the majority of patients with acromegaly have SDB. Importantly, we have shown that in acromegaly this is associated with disrupted sleep architecture – specifically attenuation of the deeper sleep stages resulting from regular arousal. Moreover, we have found that ESS and DI are poor screening tools for SDB in acromegaly and, if used alone, may fail to diagnose this important complication. 

 

Disclosure: MG: Principal Investigator, Ipsen, Advisory Group Member, Novartis Pharmaceuticals. Nothing to Disclose: ASP, AKA, AJW, SM, JMS

PP03-4 15767 4.0000 SAT-0675 A Sleep Disordered Breathing in Acromegaly Revisited: Novel Insights from the Largest Study of Polysomnography in De Novo Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 11:30:00 AM PP03 4906 11:15:00 AM GHRH, GH & IGF Biology Poster Preview

Hidenori Fukuoka*1, Genzo Iguchi1, Ryusaku Matsumoto2, Hironori Bando2, Kentaro Suda2, Hitoshi Nishizawa1, Michiko Takahashi1, Naoko Inoshita3, Song-Guang Ren4, Shozo Yamada5 and Yutaka Takahashi2
1Kobe University Hospital, Kobe, Japan, 2Kobe University Graduate School of Medicine, Kobe, Japan, 3Toranomon Hospital, Tokyo, Japan, 4Cedars-Sinai Med Ctr/UCLA, West Hollywood, CA, 5Toranomon Hosp, Tokyo, Japan

 

Objectives: ACTH-producing tumors express ErbB receptors, and EGFR (ErbB1) has been shown to be a therapeutic target for these adenomas (1). To extend these observations, we now assessed other ErbB receptor family (ErbB2-4) molecules as potential anti-tumor therapeutic targets using the pan-ErbB receptor tyrosine kinase inhibitor (TKI), canertinib. 

Methods: We treated primary cultured cells derived from resected human ACTH-producing pituitary adenomas (n = 14) with canertinib or with gefitinib, an EGFR mono-TKI, and analyzed effects on POMC expression. We also determined whether expression levels (ranging from - to ++) of tumor ErbB receptor family members were determinants of TKI-responsiveness. 

Results:In three EGFR (+) tumors, POMC expression levels were suppressed by gefitinib treatment (42 ± 29 %, p < 0.01). In two EGFR (-) tumors POMC levels were not altered by gefitinib, but were suppressed by canertinib treatment (34 ± 9 %, p = 0.04). However, in normal human pituitary cells, POMC levels were not decreased by canertinib suggesting tumor specificity of the drug. In two ErbB3 (-) tumors, POMC levels were significantly suppressed by canertinib more effectively than in 5 ErbB3 (++), or 5 ErbB3 (+) tumors (p < 0.01, p < 0.01). ErbB4 was detected in all 14 tumors, and 7 ErbB4 (++) tumors showed the most profound reduction in POMC levels (mean reduction of 63 %) achieved by canertinib than 6 ErbB4 (+) tumors (p < 0.01), suggesting that canertinib specifically suppresses POMC expression via ErbB4. 

Conclusion:Canertinib suppresses POMC expression in human ACTH-producing pituitary adenomas. This effect was associated with high adenoma cell expression levels of ErbB4 and low expression of ErbB3. The pan-ErbB TKI canertinib could be a targeted drug for drug-naïve as well as for gefitinib-resistant ACTH-secreting tumors.

 

Nothing to Disclose: HF, GI, RM, HB, KS, HN, MT, NI, SGR, SY, YT

PP09-1 15873 1.0000 SAT-0639 A ErbB Mediate ACTH Suppression By Canertinib in Human Pituitary Corticotroph Adenoma Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 11:30:00 AM PP09 4908 11:15:00 AM Pituitary Tumors Poster Preview

Daniel Bengtsson*1, Marianne Andersen2, Dominique Maiter3, Katarina Berinder4, Ulla Feldt-Rasmussen5, Aase Krogh Rasmussen5, Gudmundur Johannsson6, Charlotte Hoybye4, Aart Jan van der Lely7, Maria Petersson8, Oskar Ragnarsson9, Henrik Daa Schroeder10 and Pia Burman1
1University Hospital, Malmö, Sweden, 2Odense Univ Hosp, Denmark, 3Univ of Louvain, Brussels, Belgium, 4Karolinska Univ Hospital, Stockholm, Sweden, 5National Univ Hosp, Copenhagen, Denmark, 6Sahlgrenska Univ Hosp, Gothenburg, Sweden, 7Erasmus MC, Rotterdam, Netherlands, 8Department of Endocrinology, Metabolism and Diabetology, Karolinska University Hospital, Stockholm, Sweden, 9Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden, 10Univ Hosp, Odense, Denmark

 

Atypical pituitary adenomas and pituitary carcinomas constitute a clinical challenge. The tumors usually progress in spite of radiotherapy, and respond poorly to conventional medical therapy and cytotoxic drugs. About 66% of carcinoma patients die within 12 months after diagnosis. Temozolomide (TMZ) is an oral alkylating drug with good tolerability, approved for medical treatment of malignant gliomas. The experience of its use in aggressive pituitary tumors is limited.

Here we report on 20 patients with aggressively growing pituitary tumors treated with TMZ for a median of 6 months (range 2-23) at 7 specialist centers in Europe. Hormone producing tumors were confirmed in 16 (80%) patients (ACTH n=3, GH 4, GH/PRL 2, PRL 7). Ki-67 levels ranged from 2-23% in atypical adenomas, and 5-90% in carcinomas. Time to metastases was shortest in ACTH producing carcinomas. Immunohistochemistry of tumor O6-methylguanine DNA methyltransferase (MGMT) was performed at a single laboratory.

Outcome:  Of 7 pituitary carcinomas, complete regression of metastases was observed in 2 (which persists after 3 and 7 yrs off TMZ), regression >50% followed by stable disease in 1, transient regression > 50% in 1, and progressive growth in 3. Four patients were alive at 1.2 -7 yrs after start of TMZ. In 13 patients with atypical pituitary tumors there was a clinically relevant decrease in size (by 25-80%) in 7, no change in 3, and progressive growth in 3. In 3 of the 20 patients where TMZ was paused after an initial response, a second treatment period was less effective. One patient developed liver metastases after cessation of TMZ. The MGMT staining tended to correlate with the clinical response.

In summary, TMZ improved outcome in about half of the patients with atypical pituitary adenomas and pituitary carcinomas. TMZ can thus be of benefit and a valuable treatment option in patients with uncontrolled pituitary tumors.

 

Nothing to Disclose: DB, MA, DM, KB, UF, AKR, GJ, CH, AJV, MP, OR, HD, PB

PP09-2 13403 2.0000 SAT-0638 A Treatment with Temozolomide in 20 Patients with Atypical Pituitary Tumors and Pituitary Carcinomas - the Experience of the North-European Neuroendocrine Network 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 11:30:00 AM PP09 4908 11:15:00 AM Pituitary Tumors Poster Preview

Kyohei Hayashi*1, Akira Takeshita1, Hisanori Suzuki1, Noriaki Fukuhara1, Naoko Inoshita2, Hiroshi Nishioka2, Shozo Yamada1 and Yasuhiro Takeuchi1
1Toranomon Hosp, Tokyo, Japan, 2Toranomon Hospital, Tokyo, Japan

 

Background: Crooke’s cell adenoma (CCA) is a rare histologic subtype of Cushing’s disease (CD), characterized by massive Crooke’s hyaline change in corticotroph adenoma. CCA is generally aggressive presenting as invasive macroadenomas, and resistant to both surgery and radiotherapy. Therefore, the patients with CCA often require additional postoperative medical therapies. Although the effectiveness of dopamine agonist cabergoline, somatostatin analog pasireotide, as well as alkylating agent temozolomide have been reported in some proportions of CD, whether such drugs would be valuable therapeutic options for the management of CCA is unknown. The aim of this study is to predict drug susceptibilities of CCA by comparison with those of other histological types of CD.

Methods: Tumor samples from 59 CD patients were collected during surgery at Toranomon Hospital between 2004-2013. Forty-three samples were non-CCAs and 16 samples including 3 boarder line cases were CCAs. Clinical features were compared between the two groups with respect to tumor size, cavernous sinus invasion, and radical resection rate. After extracting total RNA from the samples, the mRNA expressions of the proopiomelanocortin (POMC), dopamine receptor type 2 (D2R), somatostatin receptor subtype-2 (SSTR2), SSTR5, and O6-methylguanine-DNA methyltransferase (MGMT) were determined with quantitative reverse-transcription-PCR analysis (qRT-PCR) using SYBR green. Results were normalized with GAPDH and expressed relative to the mean expressions of 9 normal pituitary samples.

Results: In clinical features, rates of macroadenomas, cavernous sinus invasion and curative resection were 93.8% vs 30.2%, 87.5% vs 53.5% and 43.8% vs 78.3% in CCAs and non-CCAs, respectively, confirming aggressive clinical behaviors of CCAs compared with non-CCAs. In qRT-PCR analysis, the expressions of POMC, D2R, SSTR2, SSTR5, and MGMT were significantly (P<0.05) lower in CCAs as compared with non-CCAs (mean±SEM=131.7±122.2% vs 355.8%±363.9%, 2.9±3.5% vs 21.2±31.4%, 5.9±5.3% vs 10.8±12.8%, 8.4±13.4% vs 25.1±34.1%, 24.6±29.3% vs 65.6±57.9%, respectively).

Conclusion: Our study suggests that the patients with CCAs are resistant to cabergoline and pasireotide compared with those with non-CCAs because of lower expressions of their cognate receptors. On the other hand, lower MGMT expression in CCAs may predict a better response to temozolomide because MGMT proteins repair DNA damage induced by alkylating agents such as temozolomide.

 

Nothing to Disclose: KH, AT, HS, NF, NI, HN, SY, YT

PP09-3 13189 3.0000 SAT-0637 A Predicting Drug Susceptibilities of Crooke's Cell Adenoma, an Aggressive Variant of Cushing's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 11:30:00 AM PP09 4908 11:15:00 AM Pituitary Tumors Poster Preview

Marie Helene Schernthaner-Reiter*1, Giampaolo Trivellin1, Maria V Nesterova1, Laura C. Hernandez Ramirez2, Elena Daniela Aflorei3, Maria De La Luz Sierra1, Constantine A Stratakis1 and Márta Korbonits3
1National Institutes of Health (NIH), Bethesda, MD, 2Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom, 3William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom

 

M.H.S.-R. and G.T. share the first authorship; C.A.S. and M.K. share the senior authorship of this abstract.

Background: Germline mutations in the Aryl hydrocarbon receptor-interacting protein (AIP) gene cause mostly somatotropinomas (SM) in a subset of familial isolated pituitary adenomas (FIPA). AIP has been shown to interact with two phosphodiesterases (PDE), thereby suggesting a link to the cAMP-PKA pathway, which is involved in sporadic SMs that carry GNAS1 mutations and SMs in Carney complex that are due to PRKAR1A(R1a) mutations. R1a binds the PKA catalytic subunit Ca.

Aim of the study: To study possible interactions between AIP and the PKA pathway in pituitary tumors.

Methods: The SM (GH3) and HEK293 cell lines were used for experiments. AIP, R1a, and Ca overexpression and knockdown were performed by transient transfection with AIP-MYC, R1a-HA, and Ca-HA expression vectors or Aip siRNA, respectively. Both wild-type (wt) and p.R304* AIP, a mutation with a shorter half-life (1), were employed. cAMP levels and PDE activity were measured. Intracellular localization and levels of AIP and R1a were assessed by immunofluorescence (IF). Co-immunoprecipitation (Co-IP) was performed to assess whether AIP interacts with R1a or Ca.

Results: Aip knockdown in GH3 cells led to significantly increased cAMP levels, as shown previously (2), and increased PDE activity. Co-IP suggested direct interaction of AIP with R1a, but not with Ca. IF confirmed that AIP levels were lower in HEK293 overexpressing p.R304* compared to wt AIP. In addition, when p.R304* was co-transfected with R1a, R1a levels were lower than during co-transfection with wt AIP. In GH3 cells, endogenous R1a expression was reduced during AIP knockdown.

Conclusions: We show that AIP knockdown simultaneously leads to increased cellular cAMP levels and PDE activity, indicating that an overactive PKA pathway could be compensated by PDE-mediated cAMP degradation. Furthermore, these preliminary data provide evidence for a functional overlap of AIP with the PKA pathway, possibly through stabilization of R1a by direct interaction with AIP, suggesting a potential mechanism for the contribution of AIP to pituitary tumorigenesis.

 

Disclosure: MK: Researcher, Pfizer, Inc., Researcher, Novartis Pharmaceuticals, Researcher, Syntaxin, Consultant, Pfizer, Inc., Consultant, Chiasma, Consultant, Sanofi, Consultant, Syntaxin. Nothing to Disclose: MHS, GT, MVN, LCH, EDA, MDLLS, CAS

PP09-4 16714 4.0000 SAT-0640 A Interaction of AIP with the cAMP-Dependent Protein Kinase (PKA) Pathway and Its Role in Pituitary Tumor Formation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 11:30:00 AM PP09 4908 11:15:00 AM Pituitary Tumors Poster Preview

Zhixiao Wang*1 and Shaloo Gupta2
1Eisai, Inc., Woodcliff Lake, NJ, 2Kantar Health, Princeton, NJ

 

Background: Obesity has been associated with significant burden and can negatively affect patients’ quality of life. Different weight loss (WL) methods are available and may lead to different results. Treatment satisfaction is not only associated with the effectiveness of the WL method, but can be a driver for long-term compliance and commitment, which is essential in weight management. The objective of this study was to explore treatment satisfaction associated with different WL methods.

Methods: Data were obtained from the 2012 National Health and Wellness Survey (NHWS). The NHWS is an annual Internet-based survey, using stratified random sampling to ensure demographic representativeness of the adult U.S. population (N=71,157). Patients were categorized as had a WL procedure (e.g., gastric bypass, LAP-BAND@) or using a prescription medication for WL (Sur/Rx), vs. using self-modification WL techniques (e.g., diet, exercise, over-the-counter medication, weight management programs, and WL supplements). Sur/Rx patients were matched on demographics, comorbidities, insurance status, smoking and alcohol use, obesity class, and had non-WL surgery in the past 12 months to self-modification patients, via propensity scores (1:2). Overall satisfaction with current WL methods (1 [extremely dissatisfied] to 7 [extremely satisfied]) was assessed. Chi-square tests and ANOVAs were used to determine significant differences after matching.

Results: Of the 22,927 obese (BMI≥30) patients, 58.4% took no current action to lose weight, 2.3% were in the Sur/Rx group and 39.3% were in the self-modification group. The average age was 50.6 (SD=15.3), 50.0% were female. The Sur/Rx group reported being extremely/very satisfied more frequently than the self-modification group (39.3% vs. 20.2%, p<0.001). There was no difference in treatment satisfaction between those using Rx and those whom had a surgical procedure (p>0.05). Similar results were found in overweight and obese patients (BMI≥27) with ≥1 weight related comorbidity (type 2 diabetes, hypertension, or dyslipidemia). Satisfaction was higher for the Sur/Rx group vs. the self-modification group (44.4% vs. 19.7%, p<0.001).  

Conclusion: Almost 60% of the obese U.S. population did not take steps to lose weight, suggesting the need for more education on obesity awareness/prevention. Among those who took measures to lose weight, satisfaction with WL methods was greater for the Sur/Rx vs. the self-modification group.

 

Disclosure: ZW: Employee, Eisai. SG: Consultant, Eisai.

PP05-1 12522 1.0000 SAT-0926 A Satisfaction with Different Weight Loss Methods Among Obese Patients: An Analysis of the 2012 U.S. National Health and Wellness Survey 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 11:30:00 AM PP05 4912 11:15:00 AM Peripheral Regulation of Energy Homeostasis Poster Preview

Rachel K Crowley*1, Conor Woods2, Beverly Hughes3, Joanna Gray4, Theresa McCarthy4, Susan Hughes5, Cedric H Shackleton5, Nicola Crabtree5, Peter Nightingale4, Paul M Stewart5 and Jeremy W Tomlinson5
1Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, United Kingdom, 2St Vincent's University Hospital, Dublin, Ireland, 3Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, UK, 4Queen Elizabeth Hospital, Birmingham, United Kingdom, 5University of Birmingham, Birmingham, United Kingdom

 

Obesity is a major risk factor for hypertension and is associated with adverse cardiovascular outcomes. Excess mineralocorticoid production is associated with hypertension in Conn’s syndrome. The role of mineralocorticoid metabolism in hypertension associated with obesity remains unclear.

In order to investigate the role of corticosteroids in hypertension and obesity, we conducted a longitudinal observational study of 57 obese or overweight individuals over 5 years. The participants underwent yearly dual energy X-ray absorptiometry (DXA) scans, 24-hour urine collections for steroid metabolites, subcutaneous fat biopsy and measurement of blood pressure. Total body water (litres) was calculated by multiplication of free fat mass (grams) on DXA by the constant 0.732. Urinary steroids were measured by gas chromatography / mass spectrometry. Expression of the NR3C2 gene for the mineralocorticoid receptor was measured by real time PCR. Generalised estimating equations were used to analyse the change in variables over time. Linear regression was used to assess prediction of final visit systolic blood pressure. Statistical significance was accepted at p < 0.05.

Systolic blood pressure increased during the study (p = 0.01) at a rate of approximately 1mmHg / year. Serum sodium increased from 140 mmol/L to 142 mmol/L (p < 0.001) but the increase in calculated total body water did not reach significance (p = 0.06). The urinary mineralocorticoid metabolite tetrahydroaldosterone increased during the study (p < 0.001) as did urinary cortisol:cortisone (F/E) ratio (p = 0.003) which indicated the presence of increased circulating aldosterone, and reduced 11β- hydroxysteroid dehydrogenase type 2 activity in the kidney. Expression of NR3C2 in subcutaneous adipose tissue at baseline visit was predictive of final visit systolic blood pressure 4 or 5 years later (p = 0.03).

The increase in systolic blood pressure and in serum sodium during the study suggests increased mineralocorticoid activity. The MR could have been activated by either aldosterone or by cortisol, since inactivation of cortisol to cortisone by 11β-HSD2 was falling over time. These findings suggest a role for MR antagonists in this patient group. It is unclear what role the MR plays in adipose tissue and why MR gene expression in adipose tissue would be predictive of later systolic blood pressure. It is possible that an adipokine is secreted in response to MR activation that contributes to development of hypertension in obese and overweight patients.

 

Nothing to Disclose: RKC, CW, BH, JG, TM, SH, CHS, NC, PN, PMS, JWT

PP05-2 16975 2.0000 SAT-0927 A Systolic Blood Pressure Increases with Time in Obese Patients and Is Predicted By Adipose Expression of the Mineralocorticoid Receptor Gene 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 11:30:00 AM PP05 4912 11:15:00 AM Peripheral Regulation of Energy Homeostasis Poster Preview

Suman Srinivasa*1, Kathleen V Fitch1, Kimberly Wong1, Eva Petrow2 and Steven K. Grinspoon3
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Massachusetts General Hospital, Boston, MA, 3Mass General Hosp, Boston, MA

 

Metabolic abnormalities and body composition changes are common in HIV-infected patients on chronic antiretroviral therapy. We previously demonstrated that intervention with lifestyle modification (LSM) or metformin significantly improves metabolic indices in HIV-infected patients, and that HIV-infected patients have unique brown adipose tissue-like fat depots associated with improved resting energy expenditure (REE). In this study, we investigated whether irisin and FGF21, both known to play a role in “beiging” of white adipose tissue, increase after intervention with LSM or metformin, providing a potential mechanism by which metabolic indices improve in HIV-infected patients with fat redistribution. This is the first study to our knowledge investigating irisin in any HIV cohort and to assess changes in irisin and FGF21 in an HIV cohort in response to LSM or metformin. 50 HIV-infected patients with the metabolic syndrome were previously randomized to receive LSM and/or metformin over 12 months. Baseline comparisons were made to 50 healthy controls well-matched on age, gender, race, and waist circumference. Circulating levels of FGF21 and irisin were assessed at baseline and after 12 months of intervention in association with metabolic parameters. At baseline, HIV-infected patients demonstrated increased log FGF21 (2.13±0.06 vs. 1.98±0.05 pg/mL, P=0.05) and log irisin (0.33±0.02 vs. 0.17±0.04 mg/mL, P=0.003) levels compared to healthy controls. In a subset of HIV-infected patients with increased waist circumference (WC) per National Cholesterol Education Panel guidelines (n=32), FGF21 was positively associated with fasting insulin (ρ=0.42, P=0.02) and HOMA-IR (ρ=0.45, P=0.01), while irisin was negatively associated with fasting insulin (ρ=-0.37, P=0.04) and HOMA-IR (ρ=-0.38, P=0.03). There was no association to these glucose homeostasis parameters in controls with increased WC. After 12 months, HIV-infected patients randomized to LSM had a significant decrease in FGF21 compared to those not randomized to LSM (-10[-35, 22]) vs. 40[0, 94] % change, P =0.01), and the change in FGF21 was strongly associated with improved REE (ρ=-0.34, P=0.05), maximal oxygen consumption (ρ=-0.38, P=0.02), and respiratory quotient (ρ=0.40, P=0.02). Irisin levels were unaffected by LSM or metformin. These data may suggest that HIV-infected patients with the metabolic syndrome present with compensatory increases in FGF21 and/or an FGF21 resistant state. Our data suggest that LSM may help to overcome FGF21 resistance, reducing FGF21 levels and improving energy homeostasis. Irisin levels are elevated in HIV-infected patients, but not influenced by LSM or metformin.

 

Nothing to Disclose: SS, KVF, KW, EP, SKG

PP05-3 12178 3.0000 SAT-0924 A Effects of Lifestyle Modification and Metformin on Irisin and FGF21 Among HIV-Infected Patients with the Metabolic Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 11:30:00 AM PP05 4912 11:15:00 AM Peripheral Regulation of Energy Homeostasis Poster Preview

F Xavier Pi-Sunyer*1, Arne Astrup2, Ken Fujioka3, Frank Lyons Greenway III4, Alfredo Halpern5, Michel Krempf6, David C Lau7, Carel W Le Roux8, Rafael Violante Ortiz9, Christine Bjørn Jensen10 and John Wilding11
1St Luke's Roosevelt Hosp, New York, NY, 2University of Copenhagen, Frederiksberg C, Denmark, 3Scripps Clinic, La Jolla, CA, 4Pennington Biomed Res Ctr, Baton Rouge, LA, 5Universidade Sao Paulo, Sao Paulo, Brazil, 6Université de Nantes, Nantes, France, 7University of Calgary, Calgary, AB, Canada, 8University College Dublin, Dublin, Ireland, 9Instituto Mexicano del Seguro Social, Cuidad Madero, Tamaulipas, Mexico, 10Novo Nordisk A/S, Søborg, Denmark, 11University of Liverpool, Liverpool, United Kingdom

 

Obesity is associated with prediabetes, a significant risk factor for development of type 2 diabetes mellitus (T2DM) and its accompanying complications. This trial investigated the effects of liraglutide 3.0 mg, as adjunct to diet and exercise, on weight loss (primary endpoint), prediabetes prevalence and onset of T2DM (ADA 2010 criteria) over 56 weeks. The effects of liraglutide 3.0 mg cessation were investigated in a subsequent 12‑week re-randomized period.

Adults (BMI ≥27 kg/m2 with ≥1 comorbidity or ≥30 kg/m2) were advised on a 500 kcal/day deficit diet and exercise program and randomized 2:1 to once-daily s.c. liraglutide 3.0 mg or placebo. Randomization was stratified by prediabetes status (ADA 2010 criteria). At week 56, individuals without prediabetes and on liraglutide 3.0 mg were re-randomized 1:1 to liraglutide 3.0 mg or placebo (diet and exercise continued). The trial has an ongoing 2-year extension for individuals with prediabetes. Clinicaltrials.gov ID: NCT01272219.

Of 3731 randomized individuals (age 45.1 years, 78.5% female, body weight 106.2 kg, BMI 38.3 kg/m2, 61.2% with prediabetes), 71.9% on liraglutide 3.0 mg and 64.4% on placebo completed 56 weeks.

At week 56, individuals on liraglutide 3.0 mg (n=2432) had lost 8.0% (8.4 kg) of body weight compared to 2.6% (2.8 kg) on placebo (n=1220) (estimated treatment difference [ETD] 5.4% [5.6 kg], p<0.0001, LSmeans, full analysis set with LOCF, ANCOVA).

Liraglutide 3.0 mg improved fasting and post-load glycemia compared to placebo (ETD FPG ‑6.9 mg/dL, PG [OGTT, area under the curve] ‑36.4 h*mg/dL, HbA1c ‑0.23 %-points; p<0.0001 for all). Accordingly, of those with prediabetes at screening, more individuals had reverted to normoglycemia on liraglutide 3.0 mg (69.7%) than on placebo (32.1%) at week 56 (estimated odds ratio [OR] 4.85, p<0.0001, LSmeans, logistic regression). Likewise, of those with normoglycemia at screening, more individuals had progressed to prediabetes on placebo (19.9%) than on liraglutide 3.0 mg (6.9%) at week 56 (OR 3.3, p<0.0001). Few individuals developed T2DM during treatment, but more did so on placebo (14 individuals, 1.3 events/100 patient years of exposure [PYE]) than on liraglutide 3.0 mg (4 individuals, 0.2 events/100 PYE) (OR 0.12, p=0.0003).

From week 56 to 68, individuals re-randomized from liraglutide 3.0 mg to placebo regained more weight (2.9%) than individuals staying on liraglutide 3.0 mg (0.7%) (ETD 2.2%, p<0.0001), and more individuals progressed to prediabetes on placebo (from 8.0% to 22.4%, observed means) than on liraglutide 3.0 mg (from 9.1% to 8.6%) (p<0.0001). No individuals developed T2DM.

In conclusion, consistent with the combined effects on body weight and glycemia, liraglutide 3.0 mg, as adjunct to diet and exercise, was superior to placebo in reducing the prevalence of prediabetes and T2DM after 56 weeks of treatment. Continued treatment was required to sustain these effects.

 

Disclosure: FXP: Medical Advisory Board Member, Novo Nordisk, Medical Advisory Board Member, Weight Watchers, Medical Advisory Board Member, Johnson &Johnson, Medical Advisory Board Member, Vivus USA, Medical Advisory Board Member, Zafgen, Medical Advisory Board Member, Eisai. AA: Advisory Group Member, BioCare, Advisory Group Member, Pathway Genomics Corp, Advisory Group Member, Vivus USA, Board Member, Dentacom Aps, Shareholder, Dentacom Aps, Consultant, Arena Pharmaceuticals Inc, Consultant, Basic Research , Consultant, Boehringer Ingelheim Pharma GmbH & Co KG, Consultant, Gelesis, Consultant, Gerson Lehrman Group, Consultant, Novo Nordisk, Consultant, S-Biotek, Consultant, Twinlab. KF: Consultant, Eisai, Speaker Bureau Member, Eisai, Consultant, NPS, Speaker Bureau Member, NPS, Consultant, Vivus USA, Speaker Bureau Member, Vivus USA, Consultant, Isis, Consultant, NaZura, Consultant, Novo Nordisk, Consultant, Zafgen, Consultant, Orexigen, Speaker Bureau Member, Abbott Laboratories, Speaker Bureau Member, Takeda, Researcher, Eisai, Researcher, Novo Nordisk, Researcher, NPS, Researcher, Orexigen, Researcher, Enteromedics, Researcher, Shire, Speaker Bureau Member, WeightWatchers. FLG III: Patent holder, Patent holdings, Consultant, Align2Action, Consultant, BARONova, Consultant, Basic Research, Consultant, Citius Pharmaceutical, Editorial Board member, Diabetic Living, Consultant, Eisai, Consultant, General Nutrition Corp, Consultant, Medacorp, Consultant, Guidepoint Global, Consultant, Japan Tobacco Pharmaceutical Division, Medical Advisory Board Member, Jenny Craig, Consultant, Lithera Inc, Patents licencee and stockholder, NeuroQuest, Scientific Board Member, Novo Nordisk, Stockholder, NuMe Health, Scientific Board Member, Orexigen, Stockholder, Origin Biomed, Advisory Group Member, Pam Labs, Stockholder, PlenSat, Consultant, Thetis Pharmaceuticals, Consultant, Unigene Labs, Advisory Group Member, Zafgen, Researcher, Novo Nordisk, Researcher, Hanmi Pharmaceuticals. AH: Advisory Group Member, Novo Nordisk, Speaker Bureau Member, Novo Nordisk. MK: Medical Advisory Board Member, Astra Zeneca, Medical Advisory Board Member, Bristol-Myers Squibb, Medical Advisory Board Member, Novo Nordisk. DCL: Researcher, Astra Zeneca, Researcher, Boehringer Ingelheim, Researcher, Bristol-Myers Squibb, Researcher, Eli Lilly & Company, Researcher, Novo Nordisk, Medical Advisory Board Member, Amgen, Medical Advisory Board Member, Astra Zeneca, Medical Advisory Board Member, Boehringer Ingelheim, Medical Advisory Board Member, Bristol-Myers Squibb, Medical Advisory Board Member, Jansen Pharmaceuticals, Medical Advisory Board Member, Eli Lilly & Company, Medical Advisory Board Member, Novo Nordisk, Medical Advisory Board Member, Roche Pharmaceuticals, Medical Advisory Board Member, Valeant Pharmaceuticals, Speaker Bureau Member, Amgen, Speaker Bureau Member, Astra Zeneca, Speaker Bureau Member, Boehringer Ingelheim, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Eli Lilly & Company, Speaker Bureau Member, Merck & Co., Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Valeant Pharmaceuticals. CWL: Medical Advisory Board Member, Novo Nordisk. RV: Medical Advisory Board Member, Merck Sharp & Dohme, Medical Advisory Board Member, Boehringer Ingelheim, Medical Advisory Board Member, Novo Nordisk, Medical Advisory Board Member, Bristol-Myers Squibb, Medical Advisory Board Member, Astra Zeneca, Medical Advisory Board Member, Eli Lilly & Company, Researcher, Eli Lilly & Company, Researcher, Novo Nordisk, Speaker Bureau Member, Merck Sharp & Dohme, Speaker Bureau Member, Boehringer Ingelheim, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Astra Zeneca. CBJ: Employee, Novo Nordisk, Employee, Novo Nordisk. JW: Speaker Bureau Member, Novo Nordisk, Medical Advisory Board Member, Novo Nordisk, Speaker Bureau Member, Eli Lilly & Company, Speaker Bureau Member, Jansen Pharmaceuticals, Medical Advisory Board Member, Jansen Pharmaceuticals, Speaker Bureau Member, Bristol-Myers Squibb, Researcher, Bristol-Myers Squibb, Medical Advisory Board Member, Bristol-Myers Squibb, Speaker Bureau Member, Boehringer Ingelheim, Speaker Bureau Member, Astra Zeneca, Medical Advisory Board Member, Astra Zeneca, Medical Advisory Board Member, Astellas, Researcher, Novo Nordisk, Speaker Bureau Member, Merck & Co..

PP05-4 12489 4.0000 SAT-0925 A Liraglutide 3.0 Mg Reduces the Prevalence of Prediabetes and Delays Onset of Type 2 Diabetes in Overweight and Obese Adults: Results from Scale Obesity and Prediabetes, a Randomized, Double-Blind and Placebo-Controlled 56-Week Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 11:30:00 AM PP05 4912 11:15:00 AM Peripheral Regulation of Energy Homeostasis Poster Preview

Miyuki Shibata*1, Ryoichi Banno1, Takeshi Onoue1, Taku Tsunekawa1, Koichi Adachi1, Yoshihiro Ito1, Motomitsu Goto1, Hiroshi Arima1 and Yutaka Oiso2
1Nagoya University Graduate School of Medicine, Japan, 2Nagoya Univ Grad Schl of Med, Nagoya, Japan

 

Peripheral signals reflecting energy balance are integrated in the hypothalamic arcuate nucleus, and alter feeding behavior as well as energy expenditure. Two potent orexigenic neuropeptides, neuropeptide Y (NPY) and agouti-related protein (AgRP), are co-expressed in the same neurons in the arcuate nucleus. The central administration of these peptides was shown to increase food intake consumption, whereas the acute ablation of AgRP neurons reportedly caused severe anorexia and weight loss. In addition, it was reported that pharmacological activation of AgRP neurons markedly reduced energy expenditure.

Glucocorticoids are key hormones that regulate energy balance by affecting many peripheral neuroendocrine signals and metabolites. In rodents, genetic or diet-induced obesity is reportedly prevented by adrenalectomy, and restored by glucocorticoid replacement. An excess of glucocorticoids causes obesity, whereas their depletion leads to marked anorexia in humans. Our previous studies demonstrated that (1) glucocorticoids increased the expression of NPY and AgRP mRNA, (2) insulin inhibited NPY mRNA expression only in the presence of glucocorticoids, and (3) ghrelin increased NPY mRNA only in the presence of glucocorticoids. These data suggest that glucocorticoids are not only orexigenic but also play a permissive role in the energy balance.

In this study, we examined the effects of AgRP neuron-specific deletion of glucocorticoid receptors (GRs) (KO) on energy balance in mice. Female and male KO mice on high fat diet (HFD), which was started at the age of 3 weeks, showed mild decreases in body weight (BW) at the age of 6 weeks compared to control (WT) mice, and the differences in BW between KO and WT mice remained significant until 16 weeks old. On a chow diet, the female KO mice showed slightly but significantly attenuated weight gain compared to WT mice after 11 weeks, but there were no significant difference in BW in males between genotypes. The analysis of female mice on HFD showed that visceral fat pad weight and serum leptin levels were decreased in KO mice compared to WT mice, whereas no differences were detected in brown adipose tissue (BAT) weight. In addition, female KO mice on HFD showed increases in uncoupling protein-1 mRNA expression in the BAT as measured by RT-PCR.

Thus, it is demonstrated that the absence of GRs signaling in AgRP neurons resulted in decreased body weight and adiposity under HFD conditions, suggesting that GRs signaling in AgRP neurons is required for the homeostatic regulation of energy expenditure.

 

Nothing to Disclose: MS, RB, TO, TT, KA, YI, MG, HA, YO

PP07-1 13690 1.0000 SAT-0875 A Agrp Neuron-Specific Deletion of Glucocorticoid Receptor Leads to Decreased Body Weight and Adiposity in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 11:30:00 AM PP07 4913 11:15:00 AM Central Regulation of Energy Homeostasis Poster Preview

Elizabeth P. Bless*, Tejaswini Reddy, Kalpana D Acharya and Marc J Tetel
Wellesley College, Wellesley, MA

 

Perimenopausal women tend to gain fat weight, increasing the likelihood of related health concerns including heart disease, cancers and type 2 diabetes. While the drop in estradiol associated with menopause is a known factor in weight gain, the mechanism by which this occurs is not entirely understood, but is likely due to cross-talk between estrogens and leptin. Leptin and estradiol have overlapping functions in energy homeostasis and fertility, and receptors for these hormones are localized in the same regions in the hypothalamus which is considered the energy homeostasis center of the brain. Mammalian adult neurogenesis, the birth of new neurons, is well identified in the olfactory bulb and the hippocampus. More recently, new neurons have been discovered in the adult male rodent hypothalamus. Furthermore, some of these new neurons are leptin-sensitive and influenced by diet. Here, we tested the hypothesis that diet and hormonal status modulate hypothalamic neurogenesis in the adult female mouse. Adult mice were ovariectomized and implanted with capsules containing estradiol (E2) or oil (Veh). Within each group, mice were fed a high fat diet (HFD) or maintained on standard chow (STND). All animals were administered BrdU into the lateral ventricle of the brain for 9 days and sacrificed 34 days later after an injection of leptin to induce phosphorylation of signal transducer of activation and transcription 3 (pSTAT3). Areas of the hypothalamus involved in energy homeostasis: the arcuate, ventromedial hypothalamus and dorsomedial hypothalamus were immunohistochemically labeled for BrdU (newly born cells), Hu (neuronal marker) and pSTAT3 (leptin sensitive). As predicted, while mice on a HFD became obese, estradiol protected against obesity.  Interestingly, in all three brain regions, HFD increased the number of new cells while E2 inhibited this effect. Moreover, the number of new leptin-sensitive neurons (BrdU-Hu-pSTAT3) in the arcuate was increased by HFD, while E2 attenuated this induction. These results suggest that adult hypothalamic neurogenesis in the adult female mouse is modulated by diet and hormonal status and is related to energy homeostasis. We are currently exploring the possibility that a subpopulation of these new neurons is also estrogen-sensitive.

 

Nothing to Disclose: EPB, TR, KDA, MJT

PP07-2 14809 2.0000 SAT-0877 A Estradiol and Diet Modulate Energy Homeostasis and Hypothalamic Neurogenesis in the Adult Female Mouse 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 11:30:00 AM PP07 4913 11:15:00 AM Central Regulation of Energy Homeostasis Poster Preview

Shi-Bing Yang*1, Yuh Nung Jan2 and Lily Yeh Jan2
1University of California San Francisco, san francisco, CA, 2University of California San Francisco/HHMI, San Francisco, CA

 

Role of Hypothalamic KATP Channel in Developing Age-Dependent Diabetes in mice

Aging is important risk factor for diabetes, however, little is known about the mechanism for aging to increase diabetes risk. ATP-sensitive Potassium (KATP) channel in the hypothalamus has been proposed as a key molecule in regulating energy homeostasis, and interestingly, mice lacking Kir6.2, the pore-forming subunit of the KATP channel, develop diabetes in older age. As recent evidence reveals that the KATP channel activity in the hypothalamus is regulated in an age-dependent manner for midlife obesity, we hypothesize that this age-dependent regulation of KATP channel activity in the hypothalamus may also contribute to the development of diabetes in older mice. We found that pharmacological manipulation of the KATP channel in the brain is sufficient to recapitulate the age-dependent diabetes phenotype in the Kir6.2 knockout mice, as blocking central neuronal KATP channel by glibenclamide induces diabetes while opening KATP channel in the brain ameliorates diabetes in older mice but not in young adult mice. Furthermore, re-expressing Kir6.2 in the leptin receptor (lepR) expressing neurons in the hypothalamus reverses the age-dependent diabetes in older Kir6.2 knockout mice. Lastly, genetic activation of KATP channel in the pro-opiomelanocortin (POMC) neurons improves glucose tolerance and this glucose lowering effect is abolished in the Kir6.2 knockout background. Our study reveals that down-regulation of KATP channel in hypothalamic neurons contributes to age-dependent diabetes.

 

Nothing to Disclose: SBY, YNJ, LYJ

PP07-3 17037 3.0000 SAT-0878 A Role of Hypothalamic KATP Channel in Developing Age-Dependent Diabetes in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 11:30:00 AM PP07 4913 11:15:00 AM Central Regulation of Energy Homeostasis Poster Preview

Hillary Lauren Woodworth*, Hannah Marie Batchelor, Janaan Meyers, Raluca Bugescu, Juliette Anne Brown and Gina Marie Leinninger
Michigan State University, East Lansing, MI

 

The lateral hypothalamic area (LHA) acts in concert with midbrain dopamine (DA) neurons to modulate the motivation to move, drink or feed, and these adaptive behaviors regulate energy balance.  We hypothesized that LHA neurons expressing the neuropeptide neurotensin (Nts) regulate distinct DA-mediated circuits and behaviors to contribute to energy balance.  We previously demonstrated that LHA Nts neurons project into the midbrain and regulate DA neurons that co-express neurotensin receptor 1 (NtsR1).  We therefore examined the projections of midbrain NtsR1 neurons by injecting a cre-mediated anterograde tract tracer into the midbrain of transgenic NtsR1Cre mice.  We found that midbrain NtsR1 neurons synapse within the ventral striatum, including the nucleus accumbens and olfactory tubercle, which are important sites for modulating motivated intake and locomotor activity.  To determine if the LHA Nts neuronal circuit regulates DA-mediated behaviors we utilized the D3q Designer Receptor Activated Exclusively by Designer Drugs (DREADD) system to selectively activate LHA Nts neurons.  We injected an AAV that mediates the cre-dependent expression of the D3q-DREADD into the LHA of Ntscre mice, permitting the selective activation of LHA Nts neurons in response to the DREADD ligand, clozapine-N-oxide (CNO).  Acute activation of LHA Nts neurons with CNO increased water intake and locomotor activity, but not chow intake in sated animals.  Further, action via the LHA Nts neuronal circuit increased the expression of cFos (a marker of neuronal depolarization) in the ventral striatum.  Collectively, these data suggest that LHA Nts neurons modulate mesolimbic DA circuits to promote locomotor activity and water intake, and thus regulate adaptive behaviors that impact energy balance.

 

Nothing to Disclose: HLW, HMB, JM, RB, JAB, GML

PP07-4 13985 4.0000 SAT-0876 A Lateral Hypothalamic Neurotensin Neurons Regulate Locomotor Activity and Water Intake Via the Mesolimbic Dopamine System 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 11:30:00 AM PP07 4913 11:15:00 AM Central Regulation of Energy Homeostasis Poster Preview

Lucia Gagliardi*1, Marni A Nenke1, Tilenka Rosemary Jenni Thynne1, Jenny von der Borch1, Wayne A Rankin2, David Ernest Henley3, Jane Sorbello4, Warrick J Inder4 and David J Torpy1
1Royal Adelaide Hospital, Adelaide, Australia, 2SA Pathology, Adelaide, Australia, 3Sir Charles Gairdner Hospital, Guildford, WA, Australia, 4Princess Alexandra Hospital, Woolloongabba QLD, Australia

 

Background: Cortisol is a hormone essential for life; plasma levels reflect secretion by the adrenal zona fasciculata. Key regulators of cortisol production include the light-entrained circadian rhythm, ultradian pulsatility and stress.  Patients with Addison’s disease (AD) report impaired well-being [1, 2]. It has been postulated that this is due to an inability of standard release oral glucocorticoid to mimic the circadian variation in cortisol.  In contrast, continuous subcutaneous hydrocortisone infusion (CSHI) is able to produce circadian variation in cortisol levels and is feasible and safe [3].  Anecdotal data suggest CSHI therapy improves health status in patients with AD but no placebo-controlled trial has been performed [3].

Hypothesis: CSHI therapy improves health status relative to standard oral glucocorticoid therapy.

Methods: We undertook a multicentre, randomised, double-blind, placebo-controlled clinical trial (CTN080310). CSHI was administered using a proprietary insulin infusion pump.  Participants were randomly assigned to each of two 4 week treatment periods: (1) thrice daily oral hydrocortisone (HCT) with placebo subcutaneous infusion and (2) oral placebo with CSHI. Crossover followed a 2 week washout period. Participants took a prescribed bolus dose on waking, mimicking the cortisol-awakening response, and a bolus with lunch, to mimic the cortisol response to food.  In addition, they were asked to take a “stress” bolus on experience of a predefined psychic stress. CSHI rates were as previously described [3]. Health status questionnaires (Addison’s quality of life questionnaire [AddiQoL], Short Form-36 [SF-36], Chalder Fatigue Scale [CFS] and General Health Questionnaire-28 [GHQ-28]) were performed at the beginning and end of each treatment period. Between treatment differences were validated by salivary cortisol day profiles and 24hr urine cortisol, performed at baseline and twice during each treatment period. Treatment preference was recorded at the end of the study.

Results: Ten participants (2M, 8F) completed the study, mean age 49y (33-70). Baseline health status scores were consistent with mild impairment. Few stress boluses were administered. Questionnaire scores (mean±SD) with CSHI vs oral HCT were:  AddiQoL 100.3 ±9.6 vs 94.5±12.4, SF-36 physical component summary 51.4±6.7 vs 52.1±8.2 and mental component summary 52.5±8.3 vs 52.3±10.1, CFS 11.9±1.7 vs 12.9±4.6, GHQ-28 14.7±3.1 vs 13.2±3.1. No statistically or biologically significant differences were observed between the treatments. Five participants preferred CSHI, four preferred oral HCT and one was uncertain.

Conclusion: CSHI therapy did not improve health status in ten AD participants with mild deficits in well-being at baseline. Treatment preferences suggested non-superiority of CSHI therapy over standard oral glucocorticoid replacement.

 

Nothing to Disclose: LG, MAN, TRJT, JV, WAR, DEH, JS, WJI, DJT

PP02-1 14151 1.0000 SAT-0821 A Continuous Subcutaneous Hydrocortisone Infusion Therapy in Addison's Disease; Effects on Health Status in a Randomised Placebo-Controlled Clinical Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 11:30:00 AM PP02 4917 11:15:00 AM Hypothalamic-Pituitary-Adrenal Axis Poster Preview

Ribal Al Aridi*1, Katia El Sibai2, Laure Sayyed Kassem1, Nadine El Asmar3 and Baha M Arafah4
1University Hospitals,Case Medical Center, Cleveland, OH, 2University Hospitals Case Medical Center, Cleveland, OH, 3UH Case Medical Center/ Case Western Reserve University, Cleveland, 4Case Western Reserve Univ, Cleveland, OH

 

Background: Earlier studies from our institution demonstrated that HPA function is activated during critical illness as evident by the rise in serum free cortisol levels (1,2). In critically ill (CI) patients with low albumin, serum total cortisol was lower than that seen in others with near normal (near-NL) albumin even though the two groups had similar free cortisol levels. The impact of activation of HPA function during critical illness on secretion of other ACTH-dependent steroids (DHEA and DHEA-S) is not well studied. Some studies showed serum DHEA-S levels in CI patients to be low. In the current investigation, we studied alterations in serum DHEA, DHEA-S along with total and free cortisol levels in CI patients before and after cosyntropin stimulation. We calculated the molar ratio of cortisol to DHEA to investigate comparative alterations in secretion of the two steroids. We postulated that critical illness is associated with enhanced secretion of glucocorticoids more so than adrenal androgens, such that the molar ratio of total or free cortisol to DHEA would be higher than normal. In light of its binding to albumin in the circulation, we also postulated that serum DHEA-S would be normal or elevated in CI patients with near-NL albumin but low in those with low albumin.

Methods: Baseline and cosyntropin stimulated levels of cortisol, free cortisol, DHEA, and DHEA-S were measured in 51 CI subjects and 32 healthy subjects of similar ages and gender distribution. While 29/51 of the CI subjects had near-NL albumin (mean 3.2g/dL), the remaining 22/51 had albumin <2.5 (mean 1.9) g/dL.

Results: Although both groups of CI patients had higher than normal baseline serum total cortisol, the respective levels were lower in patients with low albumin (13.2±6.6mcg/dL) than those with near-NL albumin (20.9±11.4mcg/dL) and both groups had equally elevated serum free cortisol levels. Similar pattern was noted in the two CI groups after cosyntropin stimulation. Baseline and post-cosyntropin serum DHEA levels in both groups of CI were similar and not different from those of healthy subjects. In contrast, serum DHEA-S in patients with low albumin (51±28mcg/dL) were lower (p<0.005) than those observed in patients with Near-NL albumin (101±84 mcg/dL) and those of healthy subjects (105±70mcg/dL). The molar ratios of baseline free cortisol to DHEA in the two groups of CI patients (20.5±16.2 Vs 31±42) were higher (p <0.0001) than those of normal subjects (3.3±3.5) and these ratios did not change with cosyntropin stimulation.

Conclusion: Critical illness is associated with higher than normal ratio of cortisol to DHEA secretion that continues at equimolar concentration with cosyntropin stimulation. The persistence of normal DHEA secretion in this setting is yet another evidence against impaired adrenal function during critical illness. The low serum DHEA-S levels observed in some CI patients are due to decreased albumin.

 

Nothing to Disclose: RA, KE, LS, NE, BMA

PP02-2 14245 2.0000 SAT-0822 A Discordance Between Glucocorticoids and Adrenal Androgen Secretion during Critical Illness: The Impact of Alteration in Binding Proteins 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 11:30:00 AM PP02 4917 11:15:00 AM Hypothalamic-Pituitary-Adrenal Axis Poster Preview

Carmen A Carrasco*1, Alejandro Martínez-Aguayo1, Fidel Allende1, Sandra Solari1, Carmen Campino1, Carolina Mendoza2, Carolina A Loureiro2, Francisca Grob1, Rodrigo Bancalari1, Carolina Valdivia1, Cristobal A Fuentes1, Andrea Vecchiola1, Alejandra Tapia1, Hernan Garcia Bruce2 and Carlos E Fardella1
1Pontificia Universidad Catolica de Chile, Santiago, Chile, 2Pontificia Universidad Católica de Chile, Santiago, Chile

 

Introduction: Midnight salivary cortisol (MSC) is a reliable way to screen hypothalamic pituitary adrenal axis. Few data are available concerning normal value in children and adolescent and all of them used radioimmunoassay. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) has the advantage to eliminate interference from drugs and cortisol metabolites and recent publications demonstrate utility in adults.

Aim: To evaluate MSC measured by LC-MS/MS in children and compare to adult values.

Methods: We prospectively included 29 children (56% female, median of age 13 years [range 10-17] and 26% obese) and 50 adult volunteers (62% female, median of age 46 years [range 19-63] and 25% obese). Criteria for obesity was body mass index (BMI) > 95thpercentile for age and gender in children and BMI > 30 in adults. Interview and physical examination excluded symptoms of Cushing disease, drugs or pathologies known to interfere with cortisol axis. They collected two consecutive MSC (MSC1, MSC2) and 24 hours urinary free cortisol (UFC) at home; morning plasma cortisol (F) was measured at 9:00 am. F and UFC were measured by ECLIA (normal value UFC 13.6-106.7 µg/g creatinine). MSC was collected using polyester Salivette and measured by LC-MS/MS. The range of cortisol assay was 0.02-1 µg/dL, the detection limit was 0.02 µg/dL and the inter assay coefficient of variation was <5.6%, with minimum volume requirement of 500 µL. Normal values in adults < 0.1µg/dL were previously established by Mayo Medical Laboratories.

Results: Median of MSC1 and MSC2 in children were 0.02 µg/dL (range 0.02-0.08) and 0.02 µg/dL (range 0.02-0.06) respectively. No differences were found between children and adults in MSC1 (median 0.02 µg/dL vs.0.02 µg/dL, p 0.1), MSC2 (median 0.02 µg/dL vs. 0.02 µg/dL, p 0.1), UFC (median 45.1 µg/g creatinine vs. 42.4 µg/g creatinine, p 0.5) or F (median 12.2 µg/dL vs. 13.4 µg/dL, p 0.3). Regression analyses revealed no correlation between gender or BMI in MSC, UFC or F. MSC values below the assay lower limit of quantification were found in 87% of children and 76% of adult samples. Six children and ten adults were excluded of the analyses because of inadequate saliva volume.

Conclusion: Our results suggest that MSC measured by LC-MS/MS in children above 10 years had similar values than adults. Inadequate volume of saliva sample is one limitation. To the best of our knowledge, this is the first report of normal values of MSC measured by LC-MS/MS in children.

 

Nothing to Disclose: CAC, AM, FA, SS, CC, CM, CAL, FG, RB, CV, CAF, AV, AT, HG, CEF

PP02-3 12103 3.0000 SAT-0818 A Assessment of Midnight Salivary Cortisol in Children and Adolescents Measured By Liquid Chromatography-Tandem Mass Spectrometry 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 11:30:00 AM PP02 4917 11:15:00 AM Hypothalamic-Pituitary-Adrenal Axis Poster Preview

Katarzyna G Zarnecki*1, Nicole Kelly2, William Peppard3, David Herrmann4 and James W. Findling5
1Medical College of Wisconsin, Milwaukee, WI, 2University of Colorado Hospital, 3Froedert Memorial Lutheran Hospital, 4Froedtert Memorial Lutheran Hospital, 5Medical College of Wisconsin, Menomonee Falls, WI

 

Background

Cushing’s syndrome (CS) is a disorder of diverse etiologies leading to cortisol excess.  Etomidate (ET) is an anesthetic induction agent that suppresses adrenal steroidogenesis by inhibiting 11 beta hydroxylase with subhypnotic doses.  In patients where rapid control of prodigious hypercortisolism is required and oral therapy is problematic, a continuous intravenous therapy of etomidate has been shown to be an effective intervention.

Patients

We describe 6 patients with ACTH dependent CS in whom we employed a continuous intravenous etomidate infusion (iET) for control of severe hypercortisolism prior to more definitive medical or surgical therapy from January 2008 to January 2014.  Five cases involved an ectopic ACTH producing tumor and one patient had an  ACTH pituitary tumor and acute psychosis. The mean basal pre-treatment ACTH and cortisol were 419 pg/mL (range 93-1002) and 138 ug/dL (range 32-245).

Results

ET was initiated for preoperative management of hypercortisolism, except in one patient where ET was initiated to control hypercortisolemic metabolic derangements while awaiting metyrapone availability.  Goal cortisol level was 10-20 ug/dL.  Goal was achieved in all but one patient in whom iET was suspended due to the initiation of palliative care due to extensive tumor progression.  The average time to goal was 76 hrs (range 29-134 hrs).  All patients received a 5 mg ET bolus prior to a starting infusion rate of 0.02 mg/kg/hr.  The rates were increased by 0.01-0.02 mg/kg/hr every 4-6 hrs.  The mean rate of cortisol change was 1.93 ug/dL/hr.   The average infusion rate at goal was 0.07 mg/kg/hr with a maximum infusion rate of 0.1 mg/kg/hr.  Sedation was monitored by the Richmond Agitation Sedation Scale and the maximum infusion rate was below sedative doses in all patients.

Discussion

ET is commonly used as an induction anaesthetic agent, but its adrenostatic effects limit its infusion for prolonged maintenance of sedation.  However, subhypnotic doses by means of a continuous infusion may have desirable adrenal suppressive effects.  Studies have shown that normalization of cortisol at a dose of 0.1 mg/kg/hr or lower may be an effective strategy to control hypercortisolism.  Based on our experience, we have developed a standard iET protocol in our institution: an ET 5 mg bolus is followed by an infusion at 0.02 mg/kg/hr with dose titration in increments of 0.01-0.02 mg/kg/hr every 4 to 6 hrs based on serum cortisol changes.   A maximum dose of 0.3 mg/kg/hr is recommended based on previous studies showing a sedative effect at these rates.  

Conclusion

From our cumulative experience, we have now developed a standardized titrated iET protocol which should provide clinicians with a simple, safe and effective means to lower serum cortisol in patients with severe clinical, metabolic, and neuropsychiatric consequences of prodigious hypercortisolism as a bridge to more definitive medical or surgical therapy.

 

Nothing to Disclose: KGZ, NK, WP, DH, JWF

PP02-4 14311 4.0000 SAT-0819 A Continuous Etomidate Infusion for the Management of Severe Hypercortisolism in ACTH-Dependent Cushing's Syndrome: A Case Series 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 11:30:00 AM PP02 4917 11:15:00 AM Hypothalamic-Pituitary-Adrenal Axis Poster Preview

Amina M AL-Awadi*1, Layal Saleh2, Entissar S. Al-Zaman3, Naeema A. Mahmoud3, Fabiola Lisa Saldanha1 and Wassim Y Almawi4
1Arabian Gulf University, Manama, Bahrain, 2Pennsylvania State University, State College, PA, 3Salmaniya Medical Complex, Manama, Bahrain, 4Arabian Gulf Univ, Manama, Bahrain

 

Context: Adiponectin is an adipocyte-secreted insulin-sensitizing adipokine, with anti-diabetic and anti-atherosclerotic properties. Adiponectin exists in plasma as three oligomeric isoforms, of which the high molecular weight (HMW) is reported as the most biologically active form of adiponectin in regulating glucose homeostasis.

Objective: We investigated whether decreased total and HMW-adiponectin, and altered HMW/total adiponectin ratio are independent predictors of polycystic ovary syndrome (PCOS).

Subjects and Methods: Study subjects included 122 PCOS women and 89 control women. PCOS was evaluated according to 2003 Rotterdam criteria. Plasma total and HMW adiponectin were measured by ELISA.

Results: PCOS women had significantly reduced plasma total adiponectin (P = 0.031), HMW adiponectin (P = 0.026), and total/HMW adiponectin ratio (P = 0.002) compared to control women. Logistic regression analysis revealed that HMW adiponectin levels and HMW/total adiponectin ratio, more so than total adiponectin, were independently and negatively associated with PCOS, after adjusting for age, body mass index, waist-to-hip ratio, and HOMA-IR.  The receiver operator characteristic (ROC) area under the curve (AUC) for predicting PCOS for HMW adiponectin (0.679 ± 0.037), and HMW adiponectin/total adiponectin ratio (0.653 ± 0.039), were larger than that for total adiponectin (0.537 ± 0.041). Categorizing levels of total adiponectin, HMW adiponectin, and HMW/total adiponectin ratio in quartiles demonstrated that PCOS was positively associated with low quartiles in HMW adiponectin (P <0.001) and HMW/total adiponectin (P <0.001), but not total adiponectin (P = 0.178). Logistic regression analysis confirmed the association of low HMW adiponectin [OR(95% CI) = 5.42(2.31 – 12.72)] and HMW/total adiponectin ratio [OR(95% CI) = 7.11(2.66 – 18.97)] with PCOS. Serum HMW adiponectin and HMW/total adiponectin ratio were inversely correlated with age, BMI, hirsutism, fasting insulin, HOMA-IR, and positively correlated with serum LDL-cholesterol. On the other hand, total adiponectin was negatively correlated with waist-hip ratio and serum LH levels.

Conclusions: Reduction in adiponectin secretion is an independent risk factor for PCOS. Our results demonstrate that changes in HMW adiponectin serum levels and HMW/total adiponectin ratio are better better predictors for the presence of PCOS when compared with total adiponectin serum levels.

 

Nothing to Disclose: AMA, LS, ESA, NAM, FLS, WYA

PP04-2 16699 2.0000 SAT-0019 A High-Molecular Weight (HMW) Adiponectin and HMW/Total Adiponectin Ratio Are Better Predictors of Polycystic Ovary Syndrome (PCOS) Than Total Adiponectin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 11:30:00 AM PP04 4919 11:15:00 AM Female Reproductive Endocrinology Poster Preview

Pedro E Martinez*1, Peter John Schmidt1, Karla D Thompson1, Lynnette K. Nieman2, A Leslie Morrow3, Dahima Cintron4 and David R Rubinow5
1National Institute of Mental Health, Bethesda, MD, 2NIH, Bethesda, MD, 3UNC Schl of Med, Chapel Hill, NC, 4University of Puerto Rico-Medical Sciences Campus, 5Univ of North Carolina at Chaple, Chapel Hill, NC

 

Background: Evidence suggests that premenstrual dysphoric disorder (PMDD) represents an abnormal affective response to normal levels of progesterone (PROG). In rodents, the exposure to or withdrawal from a PROG metabolite, allopregnanolone (ALLO), modulates GABA-A receptor subunit conformation, brain excitability and anxiety-like behavior. Despite no clear evidence of abnormal plasma levels of ALLO in PMDD, the onset of PMDD symptoms could reflect sensitivity to changing levels of ALLO during the luteal phase.  We examined the effects on PMDD of  preventing the luteal phase increase in ALLO by administering dutasteride (DUT), a blocker of  5 alpha reductase  (type I&2)  critical for the conversion of PROG to ALLO.

Methods: Women with PMDD (n=16) and asymptomatic controls (ACs) (n=16) (mean [SD] ages = 41.8 [6.1], 41.5 [4.8] years, respectively) participated in a double-blind, placebo-controlled, cross-over trial of DUT, conducted over two menstrual cycles. Subject samples were further subdivided to receive one of two doses of DUT: a low dose (LD) 0.5mg/day and a high dose (HD) 2.5mg/day. Outcome measures included daily symptom self-ratings. In the HD group, plasma levels of sex steroids and the corresponding 5 alpha- and 5 beta-reduced metabolites were assayed by GC/MS-MS. Results were analyzed with ANOVA-R and Bonferroni t-tests.

Results: In women with PMDD on LD DUT (n=8), we observed no significant effects of DUT on luteal phase symptom appearance or severity compared with either baseline or PBO conditions – all women continued to meet criteria for PMDD. In contrast, HD DUT in women with PMDD (n=8) significantly decreased luteal phase symptom scores (i.e., irritability, anxiety, sadness, breast pain, bloating, and food cravings) compared with both baseline and PBO conditions (F6,36 [range]= 4.8-8.7; p[range]= .001-.03). Seven of these eight women no longer met criteria for PMDD. Luteal phase plasma PROG levels consistent with ovulation were observed and did not differ in women with PMDD on HD DUT compared with PBO.  In contrast, significant luteal phase increases in plasma ALLO levels were observed in all women on PBO but not on HD DUT (F1,13=10.1, p<.01). Both doses of DUT were well-tolerated in both PMDD and AC groups.     

Discussion: This pilot study suggests that DUT (2.5 mg per day) effectively treats both affective and physical symptoms in PMDD (without the induction of dysphoric symptoms in ACs) by preventing exposure to increased ALLO levels in the luteal phase.  These preliminary therapeutic results require replication in a larger RCT. Nonetheless, PMDD symptoms were eliminated in the context of “normal” ovulation and reduced luteal phase ALLO secretion despite the absence of differences in plasma PROG secretion between DUT and placebo. These data suggest that the mechanism underlying DUT’s effects in PMDD involves the prevention of a luteal phase increase in ring A-reduced metabolites of PROG.

 

Nothing to Disclose: PEM, PJS, KDT, LKN, ALM, DC, DRR

PP04-3 12177 3.0000 SAT-0020 A Effects of Dutasteride, a 5 Alpha-Reductase Type I Inhibitor, on Pmdd Symptoms: Results of a Pilot Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 11:30:00 AM PP04 4919 11:15:00 AM Female Reproductive Endocrinology Poster Preview

Clare A Flannery*1, Anne M Rowzee2, Farrah Saleh1, Gina Choe1, Pinar Kodaman1, Teresa L Wood3 and Hugh S Taylor1
1Yale University School of Medicine, New Haven, CT, 2New Jersey Medical School/Rutgers University, Newark, NJ, 3New Jersey Med Sch, Rutgers Biomedical & Health Sciences, Newark, NJ

 

Women with obesity, PCOS, or Type 2 Diabetes Mellitus are at risk for endometrial hyperplasia and adenocarcinoma. The expression of insulin-like growth factor 1 receptor (IGF-1R) is well-characterized in the endometrium during decidualization and is known to promote cancer growth. The insulin receptor has two splice variants, IR-A and IR-B, which have mitogenic and metabolic roles, respectively; IR-A and IR-B expression are not well characterized in the endometrium. We hypothesized that IR-A and IR-B mRNA expression in endometrial tissue vary differently across the menstrual cycle, suggesting distinct roles in the physiology of normal endometrium. In addition, we hypothesized that the mitogenic receptors IR-A and IGF-1R have higher expression in endometrial adenocarcinoma.

We developed a highly specific quantitative PCR assay to quantify and compare IR-A, IR-B, and IGF-1R expression. We determined receptor expression in endometrial tissue from cycling women using no hormonal medication (n=45, mean age 36+/-1, range 20-48 years) and women with endometrial adenocarcinoma, type 1 (n=10, mean age 58+/-4). Gene expression was normalized to actin, and analyzed for each phase of the menstrual cycle: early proliferative (EP, D1-7), late proliferative (LP, D8-14), early secretory (ES, D15-21), and late secretory (LS, D22-28).

IR-A increased dramatically during the early proliferative phase, with a mean mRNA expression 20 fold-higher than either IR-B or IGF-1R (p=0.002). IGF-1R was at its lowest expression during EP (p<0.03). During LP, IR-B and IGF-1R rose slowly, reaching their individual maximum expressions during ES (p<0.01). In LP and ES phases, the relative ratios of IR-A: IR-B: IGF-1R were 1:1:1, but then altered to 3:2:1 in LS phase due to an increase in IR-A and decrease in IGF1-R expression. In endometrial adenocarcinoma tissue, the mean relative expressions of IR-A: IR-B: IGF-1R were similar (1.5: 1.6: 1; p=NS), and most resembled the levels seen during ES phase. Receptor expression did not vary with either age or body mass index in normal tissue or histological grade in malignant tissue.

The dramatic rise of IR-A corresponds to the rapid increase in endometrial thickness seen during the early proliferative phase, indicating IR-A is likely the predominant isomer responsible for glandular proliferation in normal endometrial physiology. In contrast, IR-B and IGF-1R reached their maximum expressions during the early secretory phase, indicating a role in decidualization involving the differentiation of stromal cells and accumulation of glycogen in epithelial cells. Surprisingly, IR-B was equal in expression to the mitogenic receptors IR-A and IGF-1R in endometrial adenocarcinoma. This is distinct from that reported in prostate, breast, lung, and colon cancer and supports a role for metabolic IR signaling in endometrial adenocarcinoma.

 

Nothing to Disclose: CAF, AMR, FS, GC, PK, TLW, HST

PP04-4 15170 4.0000 SAT-0017 A Differential Expression of IR-a, IR-B and IGF-1R in Endometrium Reflects Physiology during the Menstrual Cycle and Demonstrates a Distinct Expression Signature in Endometrial Adenocarcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 11:30:00 AM PP04 4919 11:15:00 AM Female Reproductive Endocrinology Poster Preview

Juliette Abeillon - du Payrat*1, Karim Chikh2, Patricia Bretones3, Pascal Gaucherand4, Olivier Claris4, Anne Charrié5, Veronique Raverot6, Jacques Orgiazzi7, Francoise Borson-Chazot8 and Claire Bournaud9
1Hospices Civils de Lyon, Groupement hospitalier est, Bron, France, 2Hospices Civils de Lyon , Centre hospitalier Lyon Sud, Pierre-Bénite, France, 3Hospices Civils de Lyon, Groupement Hospitalier est, Bron, 4Hospices Civils de Lyon, Groupement Hospitalier Est, Bron, 5Hospices Civils de Lyon, Centre Hospitalier lyon Sud, Pierre - Bénite, 6Hospices Civils de Lyon, Lyon, France, 7Université Lyon 1, Pierre-Bénite, 8Hospices Civils de Lyon, Groupement Hospitalier est, Bron Cedex, France, 9Hospices Civils de Lyon, Lyon Cedex 03, France

 

Context: Hyperthyroidism occurs in 1% of neonates born of mothers with active or past Graves’ disease (GD). Recent guidelines for management of GD during pregnancy were edicted from studies conducted with first-generation Thyroid Binding Inhibitory Immunoglobulin (TBII) assays.

Objective: This retrospective study was conducted in order to specify second-generation TBII threshold predictive of fetal and neonatal hyperthyroidism, and to identify other factors that may be helpful in predicting neonatal hyperthyroidism.

Methods: We included 47 neonates born in the Lyon area from 45 mothers harboring measurable TBII during pregnancy. TBII measurements were performed in all mothers; bioassays in 18, and fetal thyroid ultrasonographies (US) in 21.

Results: Three neonates were born with hypothyroidism and 9 with hyperthyroidism, including 5 with severe hyperthyroidism requiring treatment. All hyperthyroid neonates were born of mothers with TBII > 5 IU/L in second trimester and TSH-receptor Stimulating Antibodies (TSAb, measured by bioassay)> 400%. These associated criteria identified at risk pregnancies with 100% sensitivity and 85% specificity. Fetal thyroid US was normal in 4 out of 5 hyperthyroid neonates. None of the mothers of hyperthyroid neonates that required antithyroid drug during pregnancy could stop treatment before delivery. Analysis of TBII evolution showed six unexpected cases of increasing TBII values during pregnancy.

Conclusion: TBII values above 5 IU/L require performing a bioassay. In such cases, TSAb values above 400% are strong predictors of neonatal hyperthyroidism. Fetal thyroid US, if not repeated, is not as sensitive as previously described

 

Nothing to Disclose: JA, KC, PB, PG, OC, AC, VR, JO, FB, CB

PP12-3 12961 2.0000 SAT-0528 A Predictive VALUE of Maternal Second Generation Tbii ASSAY for Neonatal Autoimmune Hyperthyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 11:30:00 AM PP12 4923 11:15:00 AM Thyroid Autoimmunity Poster Preview

jin-An Zhang*1, Qiu Qin2, Ronghua Song2, Ling Xiao2 and Wenjuan Jiang2
1Jinshan Hospital of Fudan University, Shanghai, China, 2Jinshan Hospital of Fudan University

 

Abnormal microRNAs (miRNAs) expression is found in many diseases including autoimmune diseases. However, little is known about the role of miRNA regulation in Graves’ disease (GD). Here, we simultaneously detected different expressions of miRNAs and mRNAs in thyroid tissues via a high-throughput genomics approach,  known as microarray. Totally 7 specimens of thyroid tissue from 4 GD patients and 3 controls were obtained by surgery for microarray analysis. Then, 30 thyroid specimens (18 GD and 12 controls) were also collected for further validation by qRT-PCR. Statistical analysis showed that the expressions of 5 specific miRNAs were increased significantly while those of other 18 miRNAs were decreased in thyroid tissue of GD patients (FC≥1.3 or≤0.77 and p<0.05). In addition, the transcription of 1271 mRNAs was up-regulated, while the expression of 777 mRNAs transcripts was down-regulated (FC≥2.0 or≤0.5 and p<0.05). Furthermore, integrated analysis of differentially expressed miRNAs and their target mRNAs demonstrated that 2 miRNAs (miR-22 and miR-183) were increased while their target mRNAs were decreased. 3 miRNAs (miR-101, miR-197 and miR-660) were decreased while their target mRNAs were increased. The above findings from microarray screening were confirmed by quantitative real-time PCR (qRT-PCR) in more samples. Thus, our study highlights the possibility that miRNA-target gene network may be involved in the pathogenesis of GD and could provide new insights into understanding the pathophysiological mechanisms of GD.

 

Nothing to Disclose: JAZ, QQ, RS, LX, WJ

PP12-4 16530 3.0000 SAT-0529 A Aberrant Expression of Micrornas and Target Genes in Lesioned Tissues of Graves' Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 11:30:00 AM PP12 4923 11:15:00 AM Thyroid Autoimmunity Poster Preview

Susmeeta T. Sharma*1, Jack A Yanovski2, Smita Baid Abraham1 and Lynnette K. Nieman3
1Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 2NIH, Bethesda, MD, 3National Institutes of Health, Bethesda, MD

 

Background: Dexamethasone (dex) suppression tests (DST) are used for screening and differential diagnosis of Cushing’s syndrome (CS). The 1mg overnight (LD) DST is used to diagnose CS, the dex-suppressed CRH stimulation (Dex-CRH) test to differentiate CS from pseudocushings (PCS) while the 8mg overnight (HD) DST is used to differentiate Cushing’s disease (CD) from ectopic ACTH syndrome (EAS). We assessed the utility of dex levels in improving the diagnostic accuracy of these tests.

Methods: Retrospective study of patients (pts) with CS, PCS and normal volunteers (NV) who had a dex level measured as part of LDDST, HDDST or Dex-CRH test (1-2). A post-dex cortisol (F) level ≥1.8mcg/dl in the LDDST and a 15min post-CRH F level ≥1.4 mcg/dl in the Dex-CRH test suggested CS (2-3). A ≥69% suppression of F levels in HDDST indicated CD (4). Dex levels <140 ng/dl for LDDST and <1600ng/dl for HDDST were considered low.

Results: LDDST (N=77): Post-dex F was abnormal in 44 pts, 37 of these did not have CS on follow-up. Proportion of pts with low dex levels was similar in those with incorrect or correct LDDST results (P=0.7). Three of five pts with an abnormal result and low dex levels (44-117ng/dl) had suppressed post-dex F levels after a 2mg overnight DST.

HDDST (N=56): Results were not consistent with the final diagnosis (CD or EAS) in 13 (23%) pts. Of these, five had low dex levels (400-1220 ng/dl). Proportion of pts with low dex levels was similar between those with correct and incorrect HDDST results (P=0.5). HDDST in one pt with ACTH-dependent CS suggested EAS (28% suppression) with low dex level. IPSS indicated CD. After a doubled dex dose (16mg), F levels suppressed by 76%, changing the HDDST result to CD.

Dex-CRH (N=139): Results were consistent with the final diagnosis in 133 pts (74 CS, 20 NV, 39 PCS). Six pts with an abnormal result had dex levels <500 (247-493) ng/dl. Of these, repeat testing with doubled dex dose (1mg every 6 hours) in two pts led to higher dex levels (610, 757 ng/dl) and normal F level in one. Two pts with abnormal result were on OCPs, one with a known high cortisol binding globulin (CBG) level. None had CS on follow-up.

There was no correlation between dex and post-dex F levels in LDDST, 15min post-CRH F levels in Dex-CRH test and % suppression of F post-dex in HDDST (P=NS).

Conclusion: Low dex and high CBG levels can account for false positive (FP) DST and Dex-CRH test results. Use of a higher dex dose in pts with low dex levels can help decrease FP results.

 

Nothing to Disclose: STS, JAY, SBA, LKN

OR02-1 16622 1.0000 A Utility of Measurement of Dexamethasone Levels in the Diagnostic Testing for Cushing's Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 1:00:00 PM OR02 4719 11:30:00 AM Diagnosing and Treating Cortisol Excess and Deficiency Oral

Ty Brian Carroll*, Bradley R Javorsky and James W. Findling
Medical College of Wisconsin, Milwaukee, WI

 

Background:

Transsphenoidal surgery (TSS) is first-line treatment for most patients with Cushing’s disease (CD); however, post-surgical recurrence is an ongoing concern that may arise years after initial remission. While there are currently no standardized guidelines for post-TSS follow-up in patients with CD, conventional tools for assessing recurrence include urinary free cortisol (UFC) and 1 mg overnight dexamethasone suppression testing (DST). More recently, late-night salivary cortisol (LNSC) has also gained recognition as a diagnostic tool for both de novo and recurrent CD. However, timely recognition and treatment may be delayed when biochemical results are discordant.

Methods:

To study this diagnostic difficulty more closely we retrospectively reviewed clinic records from 2/2006 to 7/2013 at our institution to identify patients with proven post-TSS CD recurrence and normal UFC.

Results:

We identified 10 female patients with recurrent CD who had normal UFC at time of recurrence. All patients underwent primary TSS; mean time to CD recurrence was 3.5 years (range 1–9) after initial clinical and biochemical remission. Five patients had evidence of tumor on MRI at time of recurrence. All patients had normal renal function and underwent testing with LNSC, DST, and UFC. All 10 patients had normal UFC; however, DST was abnormal in 8, and all 10 had ≥1 elevated LNSC measurement. All patients with available follow-up data (9/10) demonstrated significant improvement upon treatment. Two patients underwent repeat TSS; in both cases, pathology confirmed ACTH-staining pituitary adenoma and the patient achieved clinical and biochemical remission. Six patients received pharmacological therapy (5 with mifepristone, 1 with cabergoline) and all have shown clinical and/or biochemical improvement. One patient, who had normal UFC and DST with abnormal LNSC, underwent bilateral adrenalectomy and, among other clinical improvements, experienced a 55-kg weight loss and resolution of hypertension.

Conclusion:

While UFC is generally considered an accurate diagnostic tool for CD, our case series indicates that UFC is not a reliable marker of recurrence and supports the hypothesis that LNSC may be more sensitive than UFC or DST for detection of recurrent CD. Prompt intervention when LNSC is elevated, despite normal UFC, may yield significant clinical benefit for many patients with CD.

 

Disclosure: TBC: Consultant, Corcept. JWF: Consultant, Corcept, Consultant, Novartis Pharmaceuticals. Nothing to Disclose: BRJ

OR02-2 12799 2.0000 A Late-Night Salivary Cortisol for the Diagnosis of Recurrent Cushing's Disease: Evidence of Clinical Benefit from Early Detection 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 1:00:00 PM OR02 4719 11:30:00 AM Diagnosing and Treating Cortisol Excess and Deficiency Oral

Eleni Daniel*1, Simon J B Aylwin2, Stephen G Ball3, Kristien Boelaert4, Daniel Cuthbertson5, Christina Daousi5, Julian Richard Davis6, William Drake7, Ashley B. Grossman8, Mark Gurnell9, Niki Karavitaki10, Tara Kearney11, Karim Meeran12, Aled Rees13, P J Trainer14 and John Newell-Price15
1University of Sheffield, Sheffield, United Kingdom, 2King's College Hospital, London, United Kingdom, 3Newcastle University, Newcastle Upon Tyne, United Kingdom, 4University of Birmingham, Birmingham, 5University of Liverpool, Liverpool, United Kingdom, 6University of Manchester, Manchester, United Kingdom, 7St Bartholomew's Hospital, London, United Kingdom, 8University of Oxford, Oxford, United Kingdom, 9University of Cambridge & Addenbrooke's Hospital, Cambridge, United Kingdom, 10Oxford Center for Diabetes, Oxford, United Kingdom, 11Salfrod Royal NHS Foundation Trust, Salford, United Kingdom, 12Imperial College NHS Healthcare Trust, London, United Kingdom, 13Cardiff University, Cardiff, United Kingdom, 14Department of Endocrinology, Manchester, United Kingdom, 15University of Sheffield and Department of Endocrinology, Sheffield Teaching Hospitals, Sheffield, United Kingdom

 

Background: Metyrapone is widely used in the UK for the control of cortisol excess in Cushing’s syndrome, but its use is not standardised.  The few published reports on metyrapone use pertain to limited patient numbers.

Method:A retrospective survey was conducted across 13 tertiary centres in England and Wales. Using a standardised proforma, extensive data including monitoring and safety information were collected for patients with Cushing’s syndrome on metyrapone therapy between 1997 and 2013. Eucortisolemia was defined according to the monitoring test used as a mean cortisol ‘day curve’ value ≤300nmol/l, a urinary free cortisol bellow the upper limit of normal (ULN) or a 9am serum cortisol <ULN (but <600nmol/l).

Results: 195 patients received metyrapone (160 as monotherapy). Average age was 49.6 +/-15.7 years: 87.2% had metyrapone in conjunction with other interventions (surgery, radiotherapy or chemotherapy) while 12.8% had cortisol-lowering treatment alone. Dose-titration was used in 81% of patients, whereas 19% had a block-and-replace regimen.

A total of 138 patients received metyrapone monotherapy for a mean duration of 162 days before any other intervention took place. The etiology of Cushing’s syndrome in this subgroup was: pituitary-dependent disease [CD, 59% (macroadenoma 32% of CD)], ectopic ACTH syndrome (EAS, 17%), adrenocortical carcinoma (ACC, 4%), adrenal adenoma (AA, 17%) and other benign adrenal disease (3%). Hypokalemia was actively managed with potassium levels increasing during metyrapone therapy (3.90mmol/L Vs 3.68mmol/L, p=0.0026). In this subgroup, 74% achieved eucortisolemia on varying doses: CD 1370mg, EAS 2080mg, AA 1170mg, ACC 750mg daily in divided doses.

The preferred monitoring method was by cortisol ‘day-curves’, followed by 9am cortisol and urinary free cortisol. Overall, 25.3% of patients developed side effects, most commonly gastrointestinal upset and hypoadrenalism. 88% of adverse events were managed as outpatients; 36% of patients treated for more than one month had ≤2 monitoring assessments and insufficient dose titration.

Conclusion: This is the largest report of metyrapone use. Metyrapone was effective in achieving eucortisolemia in over 70% of patients without any other cortisol-lowering intervention, with a satisfactory safety profile. A variety of monitoring regimens were used, but greater standardisation of practice and more active dose titration is needed.

 

Disclosure: ED: Investigator, HRA Pharma. SJBA: Principal Investigator, HRA Pharma. SGB: Principal Investigator, HRA Pharma. KB: Principal Investigator, HRA Pharma. DC: Principal Investigator, HRA Pharma. CD: Principal Investigator, HRA Pharma. JRD: Principal Investigator, HRA Pharma. WD: Principal Investigator, HRA Pharma. ABG: Principal Investigator, HRA Pharma. MG: Principal Investigator, HRA Pharma. NK: Principal Investigator, HRA Pharma. TK: Principal Investigator, HRA Pharma. KM: Principal Investigator, HRA Pharma. AR: Principal Investigator, HRA Pharma. PJT: Principal Investigator, HRA Pharma. JN: Principal Investigator, HRA Pharma.

OR02-3 13753 3.0000 A Clinical Effectiveness of Metyrapone Monotherapy in 195 Patients with Cushing's Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 1:00:00 PM OR02 4719 11:30:00 AM Diagnosing and Treating Cortisol Excess and Deficiency Oral

Elena Valassi*1, Alicia Santos2, Romana T. Netea-Maier3, Richard A. Feelders4, Thierry Brue5, John A. Wass6, Philippe Chanson7, Maria Yaneva8, Stylianos Tsagarakis9, Kathrin Zopf10, Olivier Chabre11, Irina V Komerdus12, Miklos Toth13, Holger Franz14, C J Strasburger15, Steven W.J. Lamberts4, P J Trainer16 and Susan M Webb17
1IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, Universitat Autònoma de Barcelona (UAB), ISCIII; Barcelona, Spain, 2IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, Universitat Autònoma de Barcelona (UAB), 08193, Bellaterra, Cerdanyola del Vallès, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain, 3Radboud University Nijmegen Medical Center, Nijmegen, Netherlands, 4Erasmus Medical Center, Rotterdam, Netherlands, 5Centre de Recherche en Neurobiologie et Neurophysiologie de Marseille, France, 6University of Oxford, Churchill Hospital, Oxford, United Kingdom, 7Univ Paris-Sud, UMR-S693, Le Kremlin Bicêtre, France, Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Service d’Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, Paris, France, Le Kremlin-Bicêtre, France, 8Medical University of Sofia, 9Evangelisnos Hospital, Athens, Greece, 10Division of Clinical Endocrinology, Department of Medicine CCM, Charité- Universitätsmedizin, Berlin, Germany, 11Service d’Endocrinologie-Diabétologie-Nutrition, Grenoble Cedex, France, Grenoble, France, 12Moscow Regional Research Clinical Institute, Moscow, Russia, 13Semmelweis University, Budapest, Hungary, 14Lohmann and Birkner Health Care Consulting GmbH, Berlin, Germany, 15Division of Clinical Endocrinology, Department of Medicine CCM, Charité- Universitätsmedizin, Berlin, Germany, Berlin, Germany, 16Department of Endocrinology, Christie Hospital, Manchester, UK, 17IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, Universitat Autònoma de Barcelona (UAB) and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII; 08025 Barcelona, Spain

 

Background: Surgery is the treatment of choice for Cushing’s syndrome (CS) but preoperative medical therapy (PMT) may be used to lower circulating cortisol and improve patient’s condition. The most commonly used medications for CS include ketoconazole (KTZ), metyrapone (MTP) and cabergoline (CAB); mifepristone, mitotane, etoposide and aminogluthetimide may also be employed depending on etiology of CS and availability of drugs.

Objective: 1) To study the prevalence of PMT in CS patients throughout Europe; and 2) To evaluate any differences in surgical outcome between patients who received PMT vs. those who did not.

Methods/Design: In October 2013 ERCUSYN included 1023 patients (821 F, 202 M; mean age (+SD) 44.7±13.5 years) from 57 centers in 28 countries. It comprises 669 (65%) pituitary-dependent CS (PIT-CS), 249 (24%) adrenal-dependent CS (ADR-CS), and 105 (11%) from other etiologies, including ectopic (ECT-CS).

Results: Two hundred and twenty-eight CS patients of 930 (25%) with therapy data available took PMT vs. 634 who did not (68%). A subset of 65/930 (7%) was excluded from analysis because only medical treatment was given, but no subsequent surgery. More than half of CS patients who were medically treated before surgery were from the Netherlands, France and Spain. Patients with PIT-CS received PMT more frequently than the other etiologic groups (82% PIT-CS vs. 7% ADR-CS and 10% ECT-CS; p<0.01 for both comparisons). KTZ was the most commonly used medication, given to 171 of 228 patients (75%; alone or in combination) vs. MTP administered to 53 (23%), CAB to 18 (8%), and mifepristone to 10 (4%) patients. Mitotane and aminogluthetimide were taken by 2 and 1 patients, with PIT-CS. Median duration of PMT was 103 days (range:1-1155 days). Median cumulative dose of KTZ and MTP was 66 gr (range:1,6-1314gr) and 120gr, (range: 6-1838.5gr), respectively. Median cumulative dose of CAB was 0.06 gr (range: 0.015-8.6 gr). Of 471 PIT-CS patients in remission in the immediate postoperative period (within 2 weeks since surgery), 326 (69%) had not received any PMT vs. 144 (31%) who had been medically treated (p<0.01). Early hypoadrenalism was reported in significantly more patients without PMT (70%), as compared with those who had taken PMT (30%) (p<0.01). After a median follow-up of 975 days (range:181-8153 days), 319 PIT-CS were in remission, of whom 196 (61%) had not taken PMT vs. 123 (38%) who had been medically treated before surgery (p<0.01).        

Conclusions:

- PMT may be associated with lower prevalence of postoperative hypoadrenalism in PT-CS patients; this may be due to decreased negative feedback, leading to recovery of pituitary-adrenal axis function.

- PMT appears to be associated with lower prevalence of long-term remission in PIT-CS patients, although this may be determined by a more severe initial clinical presentation.

 


 

 

Disclosure: TB: Clinical Researcher, Pfizer, Inc., Clinical Researcher, Novo Nordisk, Clinical Researcher, Novartis Pharmaceuticals, Clinical Researcher, Ipsen, Clinical Researcher, Serono, Clinical Researcher, Sandoz. CJS: Advisory Group Member, Chiasma. PJT: Principal Investigator, HRA Pharma. Nothing to Disclose: EV, AS, RTN, RAF, JAW, PC, MY, ST, KZ, OC, IVK, MT, HF, SWJL, SMW

OR02-4 16669 4.0000 A Presurgical Medical Treatment in Patients with Cushing's Syndrome. Results from the European Registry on Cushing's Syndrome (ERCUSYN) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 1:00:00 PM OR02 4719 11:30:00 AM Diagnosing and Treating Cortisol Excess and Deficiency Oral

Ashwini Mallappa*1, Lori-Ann Daley2, Ninet Sinaii2, Carol Van Ryzin2, Hiep Huatan3, Dena Digweed3, David Eckland3, Martin J Whitaker3, Lynnette K. Nieman4, Richard J Ross5 and Deborah P. Merke2
1National Institutes of Health Clinical Center, Bethesda, MD, 2National Institutes of Health, Bethesda, MD, 3Diurnal Limited, 4NIH, Bethesda, MD, 5Univ of Sheffield, Sheffield, United Kingdom

 

Background: Classic congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is characterized by cortisol and aldosterone deficiency and androgen excess. Current conventional glucocorticoid therapy is suboptimal as it cannot replace the normal cortisol circadian rhythm and inadequate or inappropriate suppression of adrenal androgens are common. Here we present preliminary results of a phase 2 study of Chronocort®, a modified release hydrocortisone capsule formulation.

Methods: The study objectives were: (A) characterize pharmacokinetics and (B) examine disease control following 6 months dose titration. Serial profiling was obtained at baseline (conventional glucocorticoid) and every 2 months. Twice daily Chronocort® was initiated: 20mg at 2300h, 10mg at 0700h. Dose titration was based on clinical status and optimal hormonal ranges (17OHP 300-1200 ng/dL, normal androstenedione (males: 40-150, females: 30-200 ng/dL), with androstenedione prioritized. Chronocort® cortisol pharmacokinetic profile was the primary endpoint. Secondary endpoints included biomarkers of disease control.

Results: 16 adults (8 females; age 29 ±13 years) with classic CAH (12 salt-wasting, 4 simple virilizing) participated. Conventional therapy varied (5 dexamethasone, 7 prednisone, 4 hydrocortisone). Chronocort® cortisol pharmacokinetic profile approximated physiological cortisol secretion. 10 patients required Chronocort® dose adjustments (decrease in 8, increase in 2; mean hydrocortisone equivalent dose conventional vs. 6 months: 16.1 ± 6.4 vs. 14.7 ± 6.4mg/m2).

Serial androstenedione levels were in the normal range in 8 (50%) of patients on conventional therapy compared to 12 (75%) on Chronocort® at 6 months The majority of patients on Chronocort® achieved 17OHP levels within the normal range, rather than within the mildly elevated range currently used for management.

At 6 months, Chronocort® resulted in lower 24-hr (p=0.02), morning (0700-1500; p=0.008), and afternoon (1500-2300; p=0.03) area-under-the-curve androstenedione compared to conventional therapy.

No serious adverse events occurred. Common adverse events were headache, fatigue, early awakening, and anemia. 3 patients had unexpected carpal tunnel syndrome which resolved with wrist splints.

Conclusions:  Chronocort®, a novel modified release hydrocortisone capsule formulation, approximates physiological cortisol secretion, and improves biochemical control of CAH. Further analyses are underway. 

 

Disclosure: HH: Employee, Diurnal. DD: Employee, Diurnal. DE: Employee, Diurnal. MJW: Management Position, Diurnal. RJR: Other activities, please specify:, Asterion Ltd, Director, Diurnal Ltd. DPM: Investigator, Diurnal. Nothing to Disclose: AM, LAD, NS, CV, LKN

OR02-5 14644 5.0000 A A Phase 2 Study of Chronocort®, a Modified Release Formulation of Hydrocortisone, in the Treatment of Adults with Classic Congenital Adrenal Hyperplasia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 1:00:00 PM OR02 4719 11:30:00 AM Diagnosing and Treating Cortisol Excess and Deficiency Oral

Chiara Simeoli*1, Teresa Mannarino1, Maria Cristina De Martino1, Alessia Cozzolino1, Davide Iacuaniello1, Monica De Leo1, Renata Simona Auriemma1, Carolina Di Somma1, Annamaria Colao1 and Rosario Pivonello2
1Università Federico II, Naples, Italy, 2Federico II University, Naples, Italy

 

Life-long glucocorticoid (GC) treatment is needed in patients with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency in order to replace cortisol deficiency and to control ACTH and consequently androgen levels. Therefore, patients with CAH tend to have an increased risk of metabolic syndrome (MS), probably due to cortisol overexposure, caused by multiple daily doses of conventional GCs, unable to mimic cortisol circadian rhythm. The current study aimed at investigating the impact of the switch from twice or thrice daily conventional GCs to once daily dual release hydrocortisone formulation (DR-HC) on metabolic and hormonal profile in a cohort of patients with CAH. Twenty-three patients (15 F, 8 M, 19-29 years) with CAH, chronically treated with hydrocortisone (15-40 mg/day) or prednisone (6.25-12.5 mg/day) and switched to DR-HC (10-40 mg/day) entered the study. Metabolic and hormonal parameters were evaluated before and after short (3 months) and long-term (6 months) DR-HC treatment in the entire group of 23 and in a subgroup of 15 patients, respectively. The insulin resistance was evaluated by calculating the homeostasis model assessment of the insulin resistance index (HOMA-IR) whereas the MS was estimated in line with NCEP ATP III definition. At 3-month-follow-up, fasting plasma glucose (p=0.004) and HDL-cholesterol (p=0.027) levels significantly improved. At 6 month-follow up, fasting plasma glucose (p=0.004) significantly improved and a trend to a significant improvement was registered for fasting serum insulin (p=0.074). Moreover, HOMA-IR also significantly improved (p=0.041); a clear diagnosis of MS was performed in one patient at the baseline, but this was not confirmed after 6 months of DR-HC treatment. No significant change in morning plasma ACTH, 17-OH progesterone and androgens levels and no clinical worsening of symptoms and signs related to hyperandrogenism were observed, but a significant increase in morning serum cortisol levels was registered both after short and long-term follow-up. In conclusion, the switch from conventional GCs to DR-HC significantly improves metabolic parameters and insulin resistance, maintaining an optimal hormone control in patients with CAH due to 21-hydroxylase deficiency.

 

Disclosure: CS: Consultant, Viropharma. AC: Speaker, Novartis Pharmaceuticals. MD: Consultant, Viropharma. AC: Speaker, Novartis Pharmaceuticals, Consultant, Italfarmaco, Consultant, Pfizer, Inc., Consultant, Ipsen, Consultant, Novartis Pharmaceuticals, Study Investigator, Novo Nordisk, Study Investigator, Merck & Co., Study Investigator, Ferring Pharmaceuticals, Principal Investigator, Lilly USA, LLC, Principal Investigator, Pfizer, Inc., Principal Investigator, Ipsen, Principal Investigator, Novartis Pharmaceuticals, Speaker, Ipsen, Speaker, Pfizer, Inc.. RP: Coinvestigator, Viropharma, Coinvestigator, IBSA, Consultant, Novartis Pharmaceuticals, Consultant, Ipsen, Consultant, Pfizer, Inc., Consultant, Viropharma, Consultant, Ferring Pharmaceuticals, Consultant, Italfarmaco, Speaker, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Coinvestigator, Novartis Pharmaceuticals, Principal Investigator, Novartis Pharmaceuticals. Nothing to Disclose: TM, MCD, DI, RSA, CD

OR02-6 15038 6.0000 A The Treatment with Glucocorticoids in Congenital Adrenal Hyperplasia: Short and Long-Term Effects of the Switch from Conventional Glucocorticoids to "Dual Release" Hydrocortisone on Metabolic and Hormonal Profile 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 1:00:00 PM OR02 4719 11:30:00 AM Diagnosing and Treating Cortisol Excess and Deficiency Oral

Stephanie Sisley*1, Randy Seeley2 and Darleen Sandoval3
1Baylor College of Medicine, Houston, TX, 2Univ of Cincinnati, Cincinnati, OH, 3University of Cincinnati, Cincinnati, OH

 

Low vitamin D levels have been correlated to both obesity and the development of type 2 diabetes (T2DM) (1, 2), although no causative mechanisms have been established.  Vitamin D receptors are present in the hypothalamus (3), a region important in both weight and glucose regulation.  The role of these receptors, though, is unknown.  We tested the hypothesis that vitamin D can act in the brain to improve glucose tolerance and weight gain in diet-induced obese animals.  1,25-dihydroxyvitamin D3, the active form of vitamin D, improved glucose tolerance in DIO rats when given into the third cerebral ventricle (i3vt) 1 hour prior to an intraperitoneal glucose tolerance test.  During a hyperinsulinemic euglycemic clamp, i3vt 1,25-dihydroxyvitamin D3 acutely improved whole body insulin sensitivity, as demonstrated by an 8-fold higher glucose infusion rate in vitamin D treated animals compared to vehicle treated animals (13.19±0.96 vs. 1.55±0.62 mg/kg/min; P < 0.0001; n≥4 per group).  I3vt vitamin D3 suppressed hepatic glucose production to 50% of vehicle treated animals (7.36±1.98 vs. 16.40±2.82 mg/kg/min; P = 0.03).  This correlated with a 9-fold decrease in the expression of phosphoenolpyruvate carboxykinase (PEPCK), a key enzyme in hepatic gluconeogenesis, in vitamin D treated animals (12.67±6.86 vs. 118.3±66.61 ratio of PEPCK:L32; P = 0.009).  No changes occurred between groups in glucose clearance (13.59±0.97 vs. 9.96±1.67 mL/kg/min; P = 0.08).  Although i3vt 1,25-dihydroxyvitamin D3 did not change food intake when given acutely, chronic administration dramatically reduced food intake (179.71±11.27 vs. 484.29±28.84 g/28 days; P < 0.0001; n≥3 per group) and body weight (509.87±9.43 vs. 670.21±38.05 g; P = 0.014) of DIO animals on a high fat diet without changes in energy expenditure.  These results demonstrate the ability of vitamin D to act within the brain to dramatically alter glucose homeostasis and weight maintenance in DIO rats and suggest that vitamin D may play a large role in the onset of both obesity and T2DM. 

Results expressed as mean±SEM.

 

Nothing to Disclose: SS, RS, DS

OR13-1 16486 1.0000 A CNS Vitamin D Improves Glucose Tolerance, Hepatic Insulin Sensitivity, and Reverses Diet-Induced Obesity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 1:00:00 PM OR13 4721 11:30:00 AM Vitamin D Metabolism & Action Oral

Ken Batai*1, Adam B Murphy2, Ebony Shah3 and Rick A Kittles1
1University of Illinois at Chicago, Chicago, IL, 2Northwestern University, 3University of Illinois at Chicago

 

Vitamin D deficiency is more common among African Americans (AAs) than European Americans (EAs).  Epidemiologic evidence links to vitamin D status to many health outcomes, and differences in serum vitamin D [25(OH)D] concentration among racial/ethnic groups are suspected to be one of the sources of health disparities.  Two genome wide association studies (GWAS) meta-analyses in European populations identified vitamin D pathway gene Single Nucleotide Polymorphisms (SNPs) associated with serum vitamin D 25(OH)D levels, but a few of these SNPs have been replicated in AAs.  Here, we investigated the associations of 39 SNPs in vitamin D pathway genes, including 19 GWAS identified SNPs, with serum 25(OH)D concentrations in 652 AAs and 405 EAs.  Linear and logistic regression analyses were performed adjusting for environmental and biological factors which confound associations.  The pattern of SNP associations in AAs contrasted from EAs.  In AAs, six GWAS identified SNPs in GC, CYP2R1, and DHCR7/NADSYN1 were replicated, while nine GWAS SNPs in GC and CYP2R1 were replicated in EAs.  The CYP2R1 SNP, rs12794714, revealed the strongest signal of association in AAs (P=0.01).  In EAs, however, another CYP2R1 SNP, rs1993116, was the most strongly associated (P=0.006).  Additionally, although not significant after correcting for multiple testing, another GC SNPs, rs115316390, which is unlined to GWAS identified SNPs, was also associated in AAs (P=0.03), but not in EAs.  Our models, which take into account genetic variants and environmental variables, account for 20% and 28% of the variance in serum vitamin D levels in AAs and EAs, respectively.  Increased attention is focused on the role of vitamin D in many health conditions, and many of them are more common in AAs than other racial groups.  Our findings provide insights on the biological and environmental modifiers of serum vitamin D3 and will help guide future studies on the role of vitamin D in health disparities.

 

Nothing to Disclose: KB, ABM, ES, RAK

OR13-2 16451 2.0000 A Common Vitamin D Pathway Gene Variants Reveal Contrasting Effects on Serum Vitamin D Levels in African Americans and European Americans 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 1:00:00 PM OR13 4721 11:30:00 AM Vitamin D Metabolism & Action Oral

Julie Støy*1, Ulla Kampmann1, Lars Rejnmark2, Jørgen Rungby3, Ivan Brandslund4, Cramer Christensen4, Torben Hansen5, Oluf Pedersen5 and Niels Møller1
1Aarhus University Hospital, Aarhus C, Denmark, 2Aarhus University Hospital, Aarhus C, 3Rigshospitalet, Copenhagen, Denmark, 4Vejle Hospital, Vejle, Denmark, 5University of Copenhagen, Copenhagen, Denmark

 

The genetics of osteoporosis have been scrutinized in large-scale genome-wide association studies (GWAS) with a large number of common genetic variants identified, each of which exerts subtle effects on disease susceptibility. In a recent whole exome sequencing project of 2000 Danish individuals, a rare amino acid polymorphism in CD300LG was found to associate with low fasting HDL-cholesterol levels and high triglyceride levels. The rs72836561 CT polymorphism in CD300LG has not been detected in GWAS of osteoporosis, most likely due to its relatively low frequency, but a negative correlation between BMD and HDL-cholesterol has been suggested. Mice studies have shown changes in bone structure and quality in CD300LG knockout mice. We therefore performed a bone-related phenotype characterization of human carriers of the CD300LG risk-allele including an evaluation of BMD and a biochemical profile relevant to bone metabolism.

Methods: 20 healthy males with the CD300LG rs72836561 CT genotype were matched on age and BMI with 20 healthy males with the CC genotype. The 40 study subjects were examined by DEXA scan of the hip, lumbar spine, distal forearm, and whole body. The biochemical profile included markers of bone formation, bone reabsorption, vitamin D turn-over, and calcium homeostasis.  

Results: CT-carriers had a tendency to higher whole body BMD (1.19 g/cm2 (95 % confidence interval (CI), 1.15-1.24) versus 1.16 (1.11-1.20); p=0.24) and a higher BMD in the hip (0.99 g/cm2 (95 % CI, 0.93-1.05) versus 0.95 (0.91-0.99); p=0.21) compared to the CC-carriers. The differences in BMD were statistically significant or borderline significant after adjustment for vitamin D level (p=0.064 and p=0.045, respectively). The same trend was observed for BMD in the lumbar spine and in the forearm (adjusted p-values of 0.22 and 0.06, respectively). Vitamin D levels were higher in the CT-carriers 59.4 nmol/l (95 % CI, 51.7-67.1) compared to the CC-carriers (47.5 nmol/l (39.0-56.1)); p=0.037. Exclusion of two study subjects with daily intake of a vitamin D and calcium supplement, preserved a significant difference in BMD of the hip (p=0.023). A trend towards a higher level of the bone formation markers, osteocalcin and bone-specific alkaline phosphatase, among CC-carriers was observed (p=0.09 and p=0.07, respectively).  

Conclusion: The CD300LG rs72836561 CT-genotype may affect vitamin D and bone metabolism in healthy male carriers in terms of higher levels of Vitamin D and higher hip BMD. This points to CD300LG as a potential novel gene in the regulation of bone and vitamin D metabolism. The underlying mechanisms are currently unknown and future studies are warranted to test the possible association in a larger study cohort.

 

Nothing to Disclose: JS, UK, LR, JR, IB, CC, TH, OP, NM

OR13-3 13627 3.0000 A Hip Bone Mineral Density and Vitamin D Levels Are Increased in Healthy Male Carriers of Arg82Cys in CD300LG and Points to CD300LG As a Novel Gene in Bone and Vitamin D Metabolism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 1:00:00 PM OR13 4721 11:30:00 AM Vitamin D Metabolism & Action Oral

Klaus Badenhoop*1, Dimitra Bogdanou2, tje Lin Chung3, Firouzeh Shoghi4, Maria Sandler4, Claudia Brehm4, Sabine Huenecke4, Eva Herrmann3, Ulrike Koehl5 and Marissa Penna-Martinez2
1Goethe-University Hospital, Frankfurt, Germany, 2University Hospital, Goethe-University Frankfurt am Main, Germany, 3Goethe University Frankfurt am Main, Germany, 4University Hospital Frankfurt am Main, Germany, 5Institute for Molecular and Therapeutics (MHH), Hannover, Germany

 

Introduction: Autoimmune Addison’s disease (AAD) is mediated by adrenal infiltrating T-lymphocytes. The initiation and propagation of AAD is determined by both genetic and environmental factors. One candidate environmental risk factor is vitamin D deficiency. Based on the immunemodulatory effects of vitamin D on immune cells, the aim of this study was to investigate the influence of three months vitamin D therapy on T-cell subpopulations in patients with AAD.Methods: Thirteen patients (7 females, 6 males) with AAD were included in this randomised, placebo controlled, double blind cross-over trial (registered under EudraCT 201002267734). The patients received three months 4000 IU/d Vigantol oil followed by three months placebo oil (AB arm) or placebo/verum (BA arm). The 25(OH)D3 concentration and T-cell subpopulations were measured at baseline (V1), after three months (V3) and six months (V5). Hereby, EDTA-blood samples were stained by fluorochrome conjugated antibodies and flow cytometric analysis was performed to determine the following T cell phenotypes: T helper cells (=Th;CD3+CD4+,CD4+HLA-DR+,CD4+HLA-DR+[late active], CD4+CD25+CD127dim/neg) and T cytotoxic cells (=Tc; CD3+CD8+, CD8+HLA-DR+,CD8+HLA-DR+[late active]). In addition 25(OH)D3 plasma concentration were measured by radioimmunoassay. The influence of the vitamin D therapy was evaluated on the basis on within-subject differences between verum and placebo with regard to the investigated outcome variables. Median differences are given with the Hodges-Lehmann estimate and 95 % confidence interval (CI).Results:  Preliminary testing did not detect significant differences in carryover effects between the AB/BA arms. After three months of therapy with Vigantol, the 25(OH)D3 concentration was significantly elevated (median 20 ng/mL, CI 13-24; p < 10-3). An absolute percentage reduction of peripheral blood derived CD8+HLA-DR+ (median 0.75 %, CI 0.1-1.45) and CD8+HLA-DR+[late active] (median 4.05 %, CI 0.4-7.2) as well as CD4+HLA-DR+[late active] (median 1.6 %, CI 0.3-2.6) p ≤ 0.03, respectively was observed. In contrast, changes in the percentages of CD3+CD4+, CD4+HLA-DR+ and CD4+CD25+CD127dim/neg cell populations were not significant.Conclusion: Vitamin D therapy with 4000 IU/d Vigantol in AAD patients led to an elevation of 25(OH)D3 concentration. This was accompanied by a reduced autoimmune activity probably due to the inhibition of particular T cell subpopulations. It is important to note that the vitamin D therapy only had an influence on Tc cells and Th cells that expressed the activation marker HLA-DR on their surface but not on regulatory T cells (CD4+CD25+CD127dim/neg). A follow-up study with larger numbers is needed to confirm these findings and to extend functional analyses.

 

Nothing to Disclose: KB, DB, TLC, FS, MS, CB, SH, EH, UK, MP

OR13-4 14771 4.0000 A The Effect of Vitamin D Therapy on Peripheral HLA-DR Expressing T Cell Subpopulations in Patients with Autoimmune Addison's Disease: A Randomized Controlled Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 1:00:00 PM OR13 4721 11:30:00 AM Vitamin D Metabolism & Action Oral

Deep Dutta*1, Samim Ali Mondal2, Indira Maisnam2, Satinath Mukhopadhyay3 and Subhankar Chowdhury2
1Institute of Post Graduate Medical Education & Research (IPGMER) and Seth Sukhlal Karnani Memorial (SSKM) Hospital, Calcutta, West Bengal, India, 2Institute of Post Graduate Medical Education & Research (IPGMER) and Seth Sukhlal Karnani Memorial (SSKM) Hospital, Calcutta, India, 3Institute of Postgraduate Medical Education & Research (IPGMER) and Seth Sukhlal Karnani Memorial (SSKM) Hospital, Calcutta, India

 

Objective:

Indian individuals with prediabetes (IPD) have one of the highest rates of progression (≈18% per year) to type2 diabetes (T2DM). Since vitamin-D deficiency has been linked to prediabetes, we aimed to evaluate role of vitamin-D supplementation on progression to T2DM and/ or reversal to normoglycemia in IPD.

Methods:

IPD with persistent impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) over 2 oral glucose tolerance test (OGTT), without any severe co-morbid state or drug intake, having serum 25-OH-vitamin-D (25OHD) ≤30ng/ml were randomized into Group-A [received vitamin-D (cholecalciferol 60,000 U once weekly for 8 weeks then monthly) and calcium (1250mg of calcium carbonate/day equivalent to elemental calcium 500mg) supplementation] and Group-B (received calcium only). IPD with serum 25OHD>30ng/ml were also followed with calcium supplementation (Group-C). All received therapeutic lifestyle modification. OGTT, insulin, 25OHD, lipids, interleukin-6 (IL6), tumor necrosis factor-α (TNF-α) and hsCRP were done at baseline and annually. Data from IPD with at least 1-year follow up were analyzed.  The trial is registered with clinical trial registry of India at ctri.nic.in (CTRI/2011/091/000192).

Results:

1946 individuals were initially screened, of which 498 underwent OGTT-1 and 301 underwent OGTT-2. 125 out of 170 finally included IPD (73.52%) had 25OHD ≤30ng/ml. Mean follow-up in Group-A (n=55), B (n=49) and C (n=32) was 28.2±8.83, 29.15±7.69 and 27.51±7.8 months respectively. 25OHD had significant correlation with HOMA2-IR (r=-0.42; P=0.004), TNFα (r=-0.31; P=0.03) and hsCRP (r=-0.31; P=0.03), after adjusting for BMI.

At the end of study, Group-A IPD had significantly higher serum 25OHD (p<0.001), lower FBG (p=0.023), 2hPGBG (p<0.001), TNFα (p=0.002) and IL-6 (p=0.0005) as compared to Group-B and C. Group-A IPD as compared to Group-B had significantly lower progression to diabetes (6/55 vs. 13/49; P=0.04), and higher reversal to normoglycemia (23/55 vs. 10/49; P=0.02). Cox regression revealed baseline 25OHD [Exp(B)=0.921; P=0.049] and 2hPGBG [Exp(B)=1.033; P=0.014] independently predicted progression to diabetes. Hypertension [Exp(B)=0.416; P=0.043] and baseline 25OHD [Exp(B)=1.054; P=0.046] predicted reversal to normoglycemia.

Conclusion:

Vitamin-D supplementation in IPD decreased the rate of progression to diabetes and increased reversal to normoglycemia, presumably by an improvement in IR and systemic inflammation.

 

Nothing to Disclose: DD, SAM, IM, SM, SC

OR13-5 11046 5.0000 A Vitamin-D Supplementation in Prediabetes Reduced Progression to type2 Diabetes through Decreased Insulin Resistance and Systemic Inflammation: An Open Label Randomized Prospective Study from Eastern India 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 1:00:00 PM OR13 4721 11:30:00 AM Vitamin D Metabolism & Action Oral

Francesco Tona1, Elena Osto1, Giulia Famoso1, Sara Tellatin1, Sabino Iliceto1, Nadia Sorgato1, Mariarosa Pelizzo1, Andrea Rebellato2 and Francesco Fallo*1
1Univ of Padova, Italy, 2Padova University Hospital, Padova, Italy

 

Primary hyperparathyroidism (PHPT) is associated with high rate of cardiovascular events. We previously showed (Circulation, 2012) that high PTH levels correlate independently with coronary microvascular dysfunction as assessed by coronary flow reserve (CFR) measurement, suggesting a crucial role of PTH in the increased cardiovascular risk of PHPT. Hypovitaminosis D is considered an independent predictor of cardiovascular morbidity and mortality in the general population, and is commonly seen in PHPT. The aim of our study was to dissect in PHPT patients the potential impact of vitamin D deficiency, as determinant of coronary disease, from that of PTH. One-hundred eighteen consecutive patients with PHPT due to solitary parathyroid adenoma (98 female, aged 59±11 years) and without clinical evidence of ischemic heart disease, were studied. PHPT patients were subdivided into two groups according to the absence (n=77) or the presence (n=41) of vitamin D deficiency, as defined by serum 25(OH)D levels <20 ng/ml (50 nmol/L). Coronary flow velocity in the left anterior descending coronary artery was detected by transthoracic Doppler echocardiography at rest and during adenosine infusion. CFR was obtained as the ratio of hyperemic diastolic flow velocity (DFV) to resting DFV. The two PHPT groups had comparable age, sex distribution, prevalence of risk factors (including hypertension, diabetes and dyslipidemia) and time from diagnosis. No differences between the two groups were found in serum PTH, calcium as well in CFR values. PTH was inversely related to CFR both in all PHPT patients and in each PHPT group separately (P=0.03). A direct linear correlation between vitamin D and CFR was found in the vitamin D-sufficient PHPT patients (R=0.293, P=0.01), but not in the vitamin D–deficient PHPT group. At multivariable linear regression analysis, vitamin D was an independent determinant of CFR in the vitamin D-sufficient PHPT group (Beta=0.254, P=0.01), regardless PTH levels. Conclusions: In the vitamin D-sufficient PHPT patients, relative lowering of vitamin D concentration may have a negative impact on coronary microvascular function, representing an additional cardiovascular risk factor. The potential impact of vitamin D on CFR is lost in the vitamin D-deficient PHPT patients, due to the distribution within a very narrowed low-level range, and the deleterious effect of high PTH becomes predominant.

 

Nothing to Disclose: FT, EO, GF, ST, SI, NS, MP, AR, FF

OR13-6 12007 6.0000 A Vitamin D Deficiency and Coronary Microvascular Function in Primary Hyperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 1:00:00 PM OR13 4721 11:30:00 AM Vitamin D Metabolism & Action Oral

Mitsuhide Naruse*1, Mika Tsuiki1, Kanako Nakao1, Hironobu Umakoshi1, Yuichi Fujii2, Kohei Kamemura3, Tatsuya Kai4, Ryuichi Sakamoto5, Tetsuya Tagami6, Atsushi Ogo7, Yusuke Hirokawa8, Yuichi Matsuda9 and Tomikazu Fukuoka10
1National Hospital Organization Kyoto Medical Center, Kyoto, Japan, 2Hiroshima General Hospital of West Japan Railway Company, Hiroshima, Japan, 3Akashi Medical Center, Akashi, Japan, 4Saiseikai Tondabayashi Hospital, Japan, 5National Hospital Organization Kyushu Medical Center, Fukuoka, Japan, 6NHO Kyoto Medical Center, Kyoto, Japan, 7Kyushu Medical Center, Fukuoka, Japan, 8Kyoto Medical Center, Kyoto, Japan, 9Sanda City Hospital, Sanda, Japan, 10Matsuyama Red Cross Hospital, Matsuyama, Japan

 

Adrenal venous sampling (AVS) is recommended as a gold-standard for subtype testing in PA, if adrenal surgery is considered. Besides that AVS requires expertise staffs in the specialized centers, unstandardized method and criteria for subtype classification are another drawback. Aim of the study was to investigate the effects of ACTH loading and different criteria on the subtype classification by AVS. The study was conducted as the multi-center collaborative study in west Japan (WAVES-J). Methods: Seven hospitals participated into the study. AVS data from 288 patients were analyzed. ACTH loading was performed in 270 patients. Catheterization was judged to be successful if selectivity index was > 2 before and > 5 after ACTH loading. Four different criteria were used for subtype classification: 1) Lateralized ratio (LR) >2, 2) LR>2.6, 3) LR>4, and 4) Contralateral ratio (CR) <1.0 before ACTH loading and 1) LR>2.6, 2) LR>4, 3) PAC >14000pg/ml, and 4) CR <1.0 after ACTH loading. Success rate before and after ACTH loading was 60.0% and 85.2%, resulting in the overall success rate of 85.4%. Percentage of unilateral subtype before ACTH loading was 66.5% with LR>2 followed by 60.7% with LR>2.6, 45.1% with LR>4 and 42.8% with CR<1, respectively. Percentage of unilateral subtype after ACTH loading was 41.3% with PAC>14000pg/ml followed by 37.8% with LR>2.6, 30.7% with CR<1, and 29.6% with LR>4, respectively. LR before ACTH loading was increased in 12.7% and unchanged in 34.4%, but decreased in 52.9% after ACTH loading. Subtype classification before ACTH loading (LR>2.0) was unchanged in 55.4% even after ACTH loading (LR>4). By contrast, subtype classification was changed in 44.6% after ACTH loading: unilateral to bilateral in 41.4%, bilateral to unilateral in 1.9%, and unilateral to contra-unilateral in 1.3%. The present study clearly demonstrated that both ACTH loading and type of criteria have profound effects on the subtype classification by AVS. Since AVS is critical in determining treatment of choice, standardization of the methods and decision criteria of AVS is mandatory.

 

Nothing to Disclose: MN, MT, KN, HU, YF, KK, TK, RS, TT, AO, YH, YM, TF

OR06-1 14353 1.0000 A Effects of ACTH Loading and Different Criteria on the Subtype Classification By Adrenal Venous Sampling in Primary Aldosteronism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 1:00:00 PM OR06 4725 11:30:00 AM Hyperaldosteronism and Salt-Sensitive Hypertension Oral

Celso E. Gomez-Sanchez*1, Xin Qi2, Elise P Gomez-Sanchez3 and Max V Wisgerhof II4
1Univ of Mississippi Med Ctr, Madison, MS, 2University of Mississippi Medical Center, Jackson, MS, 3University of Missippi Medical Cener, Jackson, MS, 4Henry Ford Hosp, Detroit, MI

 

Immunohistochemical and immunofluorescence of CYP11B2, CYP11B1, KCNJ5 and 17Alpha-hydroxylase of the Adrenals in Familial Hyperaldosteronism type 3

Geller et al described family with a syndrome of severe hypertension, hypokalemia, low plasma renin activity and very high levels of aldosterone and 18-oxocortisol which he classified as familial hyperaldosteronism type 3 (FHA3)(1).  The hypertension and hypokalemia was resistant to high doses of spironolactone and bilateral adrenalectomy was required for control of the hyperaldosteronism, hypokalemia and hypertension.  Genetic analysis determined that this family had a germline mutation in the selectivity filter of the inward-rectifying potassium channel KCNJ5 (T158A). 

We performed immunohistochemical and immunofluorescent analysis of the adrenals from 2 of the original FHA3 patients using specific monoclonal antibodies against the CYP11B1 and CYP11B2 enzymes and polyclonal antibodies against the KCNJ5 and 17a-hydroxylase.  H & E staining demonstrated marked hyperplasia with distortion of the normal architecture of the adrenal glands with areas of cells resembling zona glomerulosa (ZG) embedded in areas with cells with zona fasciculata (ZF) characteristics.  Normally CYP11B2 and KCNJ5 are found in ZG cells, CYP11B1 and 17a-hydroxylase only in ZF.  Strongly CYP11B2-immunoreactive cells were found throughout the ZG and ZF.  Some of the cells were compact as expected of normal ZG cells, others looked more like lipid-ladened ZF cells.

Triple immunofluorescence confirmed wide distribution of CYP11B2-immunoreactive cells throughout the adrenal gland intercalated with CYP11B1 expressing cells.  Some cells co-expressed both the CYP11B2 and CYP11B1 enzymes.  CYP11B1 expressing cells co-expressed 17a-hydroxylase as in normal adrenals, but there were also cells that co-expressed CYP11B2 and 17a-hydroxylase, a distinctly abnormal situation.  KCNJ5 immunoreactivity was co-expressed with the CYP11B2 enzyme throughout the adrenal, with a few cells co-expressing CYP11B1 and KCNJ5.

In conclusion, adrenals from patients with a T158A germline mutation of the KCNJ5 gene exhibit gross hyperplasia with distorted architecture of the cortex.  Normal segregation of enzyme expression is also lost and some cells co-expressed enzymes of ZF cells, CYP11B2 and 17a-hydroxylase, with CYP11B2 normally found only in ZG cells.  The extremely high excretion rates of 18-oxocortisol in FHA3 occurs both by synthesis in cells co-expressing CYP11B2 and the 17a-hydroxylase and by commingling of normal ZF cells that co-express CYP11B1 and 17a-hydroxylase and provide substrate to ZG-type cells that express CYP11B2.  It is unclear how a mutation of the KCNJ5 gene would alter not only its pattern of expression, but that of the steroidogenic enzymes.

 

Nothing to Disclose: CEG, XQ, EPG, MVW II

OR06-2 15427 2.0000 A Immunohistochemical and Immunofluorescence of CYP11B2, CYP11B1, KCNJ5 and 17alpha-Hydroxylase of the Adrenals in Familial Hyperaldosteronism Type 3 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 1:00:00 PM OR06 4725 11:30:00 AM Hyperaldosteronism and Salt-Sensitive Hypertension Oral

Rene Baudrand*1, Nidhi Gupta2, Amanda Elizabeth Garza2, Anand Vaidya3, Jonathan S Williams4, Gail K. Adler5, Gordon H Williams5 and Luminita H Pojoga5
1Pontificia Universidad Catolica de Chile, Santiago, Chile, 2Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, 3Brigham and Women’s Hospital/Harvard Medical School, Boston, MA, 4Brigham & Women's Hospital, Harvard Medical School, Boston, MA, 5Brigham and Women's Hospital, Harvard Medical School, Boston, MA

 

Background/Aim: Excess activation of the aldosterone/mineralocorticoid receptor (MR) pathway is associated with impaired glucose metabolism, insulin resistance (IR) and dyslipidemia. Caveolin-1 (cav-1) is a plasma membrane protein involved in glucose and lipid homeostasis and has been proposed as a modulator of MR signaling. Herein - in a translational approach - we conducted 2 studies to investigate the interplay between cav-1 and aldosterone signaling in modulating IR and dyslipidemia. In study 1 we evaluated metabolic dysfunction and MR-mediated pathways in cav-1 null mice. Next in study 2 we assessed the relationship between a prevalent cav-1 variant and aldosterone levels in modulating cardiometabolic outcomes.

Methods/Results:  Cav-1 KO mice exhibited higher HOMA, cholesterol and resistin, and lower HDL/LDL ratio (all p <0.001 vs WT). Moreover, cav-1 KO mice displayed hypertriglyceridemia, as well as increased mRNA expression of resistin, retinol-binding protein 4 (RBP4), NADPH oxidase 4 (NOX4) and aldose reductase (AldoR) in liver and/or fat tissues. Further, MR blockade by eplerenone in the cav-1 KO significantly decreased glycemia (68.6±2.1 vs. 98.9±7.1 mg/dL, p <0.01), total cholesterol (p <0.05), plasma resistin (p <0.05) and transcript levels for RBP4, NOX4 and AldoR, but had no effect on insulin or triglyceride levels. Next, available cav-1 gene eQTL data revealed that the minor allele of rs926198 was associated with lower cav-1 expression. Then, we analyzed 556 Caucasians for the association between the cav-1 polymorphism and cardiometabolic outcomes using a dominant model. Fifty-eight percent of genotyped subjects were minor allele carriers of rs926198 and displayed higher odds for IR (HOMA-IR > 2.5, OR 2.26 [1.40 – 3.64]) and low HDL status (<35 mg/dL in men, <39 mg/dL in women, OR 1.54 [1.01 – 3.37]) despite similar baseline characteristics. Interestingly, aldosterone levels positively correlated with HOMA-IR, total cholesterol and resistin and negatively with HDL-C only in minor allele carriers, thus resembling the cav-1 null phenotype.

Conclusion: Our findings in mice and humans suggest that cav-1 may modulate the effect of aldosterone on IR, dyslipidemia and circulating resistin. Further, we show that blocking MR signaling improved glucose, cholesterol and resistin dysregulation in cav-1 deficient states, consistent with a role for MR overactivation in these metabolic pathways. In contrast, hyperinsulinemia and hypertriglyceridemia in cav-1 null mice were not corrected by eplerenone, suggesting that these abnormalities are likely mediated by MR-independent mechanisms.

 

Nothing to Disclose: RB, NG, AEG, AV, JSW, GKA, GHW, LHP

OR06-3 16030 3.0000 A Caveolin-1 Modulates Aldosterone-Mediated Pathways of Glucose Homeostasis and Lipid Profile 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 1:00:00 PM OR06 4725 11:30:00 AM Hyperaldosteronism and Salt-Sensitive Hypertension Oral

Amanda Elizabeth Garza*1, Chevon M Rariy2, Jonathan S Williams3, Rene Baudrand4, Jose R Romero1, Gail K. Adler1, Luminita H Pojoga1 and Gordon H Williams1
1Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 2Brigham and Women's Hospital, Boston, MA, 3Brigham & Women's Hospital, Harvard Medical School, Boston, MA, 4Pontificia Universidad Catolica de Chile, Santiago, Chile

 

Background: Numerous studies have demonstrated an association between dietary sodium intake and increases in blood pressure (BP). The underlying mechanism(s) resulting in salt sensitivity (SS) of BP in humans remain largely unknown.  Aldosterone (ALDO) through mineralocorticoid receptor (MR) activation is an important regulator of sodium and water homeostasis. We recently reported that dietary sodium restriction in mice was associated with increased striatin levels in aortas and kidneys. Furthermore, we demonstrated MR and striatin co-immunoprecipitate in cardiovascular tissues. Striatin is a highly conserved member of the WD-repeat family of proteins that functions as both a scaffolding protein and signal transducer. The aim of this study was to test the hypothesis that striatin modulates SS of BP.

Methods/Results: We examined the relationship between striatin gene polymorphisms and SS BP in 366 Caucasian, hypertensive subjects. Haplotype constructs from 19 SNPs were analyzed using a multivariate logistic model to predict BP response to a dietary salt intervention (High Sodium [HS] minus Low Sodium [LS] diet).  Block 1 was significantly associated with salt sensitive blood pressure (P=0.04), driven by two SNPs (rs2540923: OR, 6.25; 95% CI 1.7-20; P=0.01 adjusted) and (rs888083: OR 1.98; 95% CI 1.22-3.22;P=0.005 adjusted).

To further explore the relationship between SS of BP and striatin, we generated a striatin heterozygous knockout (Strn+/-) mouse model. Sixteen-week old male Strn+/- and aged-matched littermate wild-type (WT) mice were randomized in a crossover intervention to HS (1.6% NaCl) and LS (0.03% NaCl) diets for 7 days each. BP was measured by tail cuff plethysmography.  RT-PCR and western blot data demonstrate significantly decreased striatin mRNA and protein expression in heart, aorta, adrenal, and kidney tissue of Strn+/- as compared to WT mice.  Strn+/- mice had significantly higher BP on HS as compared with LS diet (LS 105 ± 3 vs HS 114 ± 3 mmHg, P=0.02),   whereas WT mice had no change (LS 104 ± 2 vs HS 109 ± 3 mmHg, p=NS).  BP response to salt intake was independent of ALDO or renin activity in both the human cohort and the mouse model.  MR genomic (ENaC and SGK1) targets were significantly increased, while non-genomic targets (pAkt/Akt) were significantly decreased  kidney and heart tissue of Strn+/- mice compared to WT mice.

Conclusion: Striatin is associated with salt sensitivity of BP in human gene association analysis and in a genetically altered mouse model. Observed reduced striatin expression with salt sensitivity of BP in the absence of RAAS modulation suggests impaired MR signaling.  This may implicate striatin in the pathogenesis of salt sensitive blood pressure.

 

Nothing to Disclose: AEG, CMR, JSW, RB, JRR, GKA, LHP, GHW

OR06-4 16056 4.0000 A Variation in Striatin Gene Is Associated with Salt Sensitive Blood Pressure 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 1:00:00 PM OR06 4725 11:30:00 AM Hyperaldosteronism and Salt-Sensitive Hypertension Oral

Masao Omura*1, Kohzoh Makita2, Seishi Matsui3, Maki Nagata3, Yoko Matsuzawa1, Jun Saito1 and Tetsuo Nishikawa1
1Yokohama Rosai Hosp, Yokohama, Japan, 2Hikarigaoka Hospital, Tokyo, 3Yokohama Rosai Hospital, Yokohama, Japan

 

Introduction:Unilateral total adrenalectomy (T-Adx) is worldwide performed for unilateral hyperaldosteronism, while normal adrenal tissue attaching to APA is removed even though it dose not cause primary aldosteronism (PA). Since 2010, we have treated CT-detectable APA by partially removing unilateral adrenal lesions containing CT-visible APA (P-Adx) to preserve normal adrenal tissue attaching to the APA based on the diagnosis of APA by selective segmental AVS (SSAVS). Then, we tried to analyze outcomes of clinical and laboratory findings after surgical treatment with P-Adx.

Methods: We performed SSAVS obtaining adrenal effluents at central and more than 2 tributary veins in each adrenal gland after ACTH stimulation to detect the lesions causing hyperaldosteronism in 300 cases with PA. Comparative study on subtype diagnosis of PA by regular AVS with that by SSAVS was performed, and we tried P-Adx according to the detailed localization of APA diagnosed by SSAVS.

Results: The regular AVS could diagnose 114 cases with unilateral PA, who were treated by unilateral T-Adx, and also 186 cases with bilateral PA, who were under medications. On the other hand, SSAVS diagnosed 98 unilateral APA and 39 with bilateral APAs, that could be treated by P-Adx when the adrenal lesions localized by SSAVS were detected as the same portion as APA detected by CT images. SSAVS also diagnosed 36 cases with CT-undetectable small APA and 12 with unilateral hyperplasia. We performed P-Adx in 76 cases with unilateral APA and 32 with bilateral APAs, resulting in complete and partial improvement in hyperaldosteronemia of unilateral APA and of bilateral APAs, respectively.

Conclusion: We can exactly localize the detailed portion of APA by SSAVS, and also differentiate bilateral APAs from IHA. CT-detectable APA is possible to be completely cured by minimally invasive P-Adx.

 

Nothing to Disclose: MO, KM, SM, MN, YM, JS, TN

OR06-5 14399 5.0000 A Minimally Invasive Surgery of Aldosterone-Producing Adenoma (APA) Detected By a New Adrenal Venous Sampling (AVS) Method 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 1:00:00 PM OR06 4725 11:30:00 AM Hyperaldosteronism and Salt-Sensitive Hypertension Oral

Hidekazu Nagano*1, Takashi Kouno1, Masanori Fujimoto1, Eri Komai1, Akina Shiga1, Akitoshi Nakayama1, Tomoko Takiguchi1, Seiichirou Higuchi1, Ikki Sakuma1, Sawako Suzuki1, Naoko Hashimoto1, Hisashi Koide1, Tomohiko Yoshida1, Ichiro Tatsuno2, Koutaro Yokote1 and Tomoaki Tanaka1
1Chiba University Graduate School of Medicine, Chiba, Japan, 2Toho University Sakura Medical C, Sakura-City, Japan

 

Primary aldosteronism (PA), characterized by the autonomous overproduction of aldosterone, is one of the most common form of secondary hypertension, with a prevalence of approximately 8 to 10% of hypertensive patients. While the two major PA subtypes are bilateral idiopathic hyperaldosteronism and aldosterone-producing adenomas (APA), APA can be cured by surgical resection. Importantly, recent exome sequencing of human APAs identified somatic mutations in K+ channel KCNJ5, P-type ATPase gene family, ATP1A1 and ATP2B3, additionally, CACNA1D encoding a voltage-gated calcium channel. However, a little is known about the frequency of these mutations as well as endocrinological pathogenesis in Japanese APA patients. Here, we have performed direct sequencing, RNA-sequence and RT-qPCR analysis using adrenal tumor tissues and examined the relationship between types of mutation, clinical features and molecular biological characteristics including gene expression in steroid hormone synthetic pathways. Gene mutation analysis of 71 APA cDNA samples revealed that KCNJ5 mutations were present in 48 cases (67.5%), ATP1A1 in two cases (2.8%), ATP2B3 in one case (1.4%), CACNA1D in one case (1.4%) and WT in 19 cases (26.7%). Consistent with previous reports, KCNJ5 mutations were more prevalent in female than male (female: 56.0% of KCNJ5mt). Aldosterone renin ratio (ARR), lateralization index of AVS, serum aldosterone levels after adrenocorticotropic hormone (ACTH)- or saline-infusion test were significantly elevated in APA group with mutations, while there was a variation in the presence or absence of mutations. Gene expression analysis using tumor-derived mRNA showed that CYP11B2 expression was correlated to total urine aldosterone and peak levels of serum aldosterone after ACTH stimulation in vivo whereas CYP17/HSD3B2 displayed inverse correlation to them. Furthermore, the expression of CYP11B2 and PCP4, a Ca2+ signal transducer, was upregulated in mutant groups with variation. Taken together, our results suggest that the reasonable expression profile of steroidogenic enzymes and Ca2+ signaling pathway for autonomous aldosterone production including CYP11B2 in APA represents aldosterone-secreting ability in vivo, with remarkable changes in tumors with somatic mutations of KCNJ5, ATP1A1, ATP2B3 and CACNA1D, concerning mutation frequency and pathogenesis of Japanese APA patients.

 

Nothing to Disclose: HN, TK, MF, EK, AS, AN, TT, SH, IS, SS, NH, HK, TY, IT, KY, TT

OR06-6 16373 6.0000 A Somatic KCNJ5, ATP1A1, ATP2B3 and CACNA1D Mutations, Its Clinical Features and Gene Expression Profile By RNA-Sequence in Japanese Aldosterone Producing Adenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 1:00:00 PM OR06 4725 11:30:00 AM Hyperaldosteronism and Salt-Sensitive Hypertension Oral

Kavaljit H Chhabra*1, Jessica M. Adams1, Daniel D Lam1, Marcelo Rubinstein2 and Malcolm James Low3
1University of Michigan, Ann Arbor, MI, 2INGEBI, CONICET, Buenos Aires, Argentina, 3University of Michigan Medical School, Ann Arbor, MI

 

Hypothalamic-derived POMC peptides regulate body weight (BW) by modulating food intake and energy expenditure. Consequently, arcuate nucleus-specific (Arc) POMC-deficient mice develop morbid obesity and insulin resistance (1). However, it is not clear if the insulin resistance is purely a secondary effect of obesity or a direct result of POMC-deficiency. Therefore, we determined the role of central POMC in maintaining glucose homeostasis independently of changes in BW by utilizing ArcPOMC-deficient mice that were weight-matched to wildtype (WT) controls by food restriction starting immediately after weaning. The daily allotment of standard low fat chow was provided once a day before lights out to singly housed mice. 8-10 wk old mice were fasted for 6 h on two occasions and blood glucose and plasma insulin were measured before performing insulin- or oral glucose-tolerance tests (ITT 0.5 units/kg BW i.p.; OGTT 2 g/kg BW by gavage). The mice were also challenged with 10% glucose in drinking water while housed in metabolic cages for collection of 24 hr urine samples. Weight-matched ArcPOMC-deficient mice (n = 6 or 7) exhibited hyperinsulinemia (Male: 1.6 ± 0.1 vs. 1.0 ± 0.2; Female: 1.3 ± 0.1 vs. 0.5 ± 0.2 ng/ml) and reduced insulin sensitivity (glucose AUC, Male: 13,610 ± 1,676 vs. 9,150 ± 311; Female: 14,920 ± 940 vs. 9,840 ± 414 mg/dl*min) compared to WT groups (unpaired, two-tailed t-tests, all P < 0.05). Paradoxically, the weight matched ArcPOMC-deficient mice showed improved glucose tolerance (glucose AUC, Male: 20,823 ± 1,774 vs. 25,500 ± 1,607, P < 0.05; Female: 17,266 ± 242 vs. 23,076 ± 2,485 mg/dl*min, P < 0.01) despite insulin resistance (HOMA-IR, Male: 13.1 ± 2.4 vs. 7.4 ± 1.8; Female: 11.9 ± 1.2 vs. 6.4 ± 1.3 mM*mU/L) (P < 0.01). We speculated that this unusual phenotype could be a consequence of reduced glucose reabsorption and thus increased excretion of glucose in urine. Hence, we measured urine glucose levels using Bayer Diastix test strips during OGTT. Indeed, ArcPOMC-deficient mice excreted more glucose than WT (urine glucose: 251-500 vs. 0 mg/dl at the 60 min time point) suggesting reduced renal glucose reabsorption in the mutant mice. The mice were then challenged with 10% glucose in their drinking water. In agreement with the screening results during OGTT, ArcPOMC-deficient mice exhibited profound glycosuria compared to WT mice (urine glucose, Male: 1,030 ± 548 vs. 18.0 ± 7.6; Female: 1,018 ± 818 vs. 15.5 ± 4.2 mg/dl) indicating the suppression of glucose reabsorption in mutant mice. By analogy to the relative protection against hypertension exhibited by obese melanocortin receptor 4-deficient rodents due to decreased sympathetic tone, we speculate that the glycosuria exhibited by weight-restricted ArcPOMC-deficient mice may be the result of decreased renal sympathetic nerve activity (2) leading to down-regulation of one or both of the renal glucose transporters, GLUT2 and SGLT2.

 

Nothing to Disclose: KHC, JMA, DDL, MR, MJL

OR01-1 11608 1.0000 A Elevated Glycosuria Improves Glucose Tolerance in Arcuate Nucleus-Specific Pomc Deficient Mice Despite the Presence of Insulin Resistance 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 1:00:00 PM OR01 4726 11:30:00 AM Basic Mechanisms of Glucose Homeostasis and Diabetic Complications Oral

Jennifer M. Rojas*1, Miles E. Matsen1, Gregory J. Morton1, Darko Stefanovski2, Richard N Bergman3 and Michael W. Schwartz1
1University of Washington, Seattle, WA, 2Cedars-Sinai Medical Center, West Hollywood, CA, 3Cedars-Sinai Medical Center, CA

 

Following a glucose challenge, glucose disposal occurs via both insulin-dependent and -independent mechanisms. The latter, referred to as glucose effectiveness (GE), is crucial for glucose homeostasis and, like insulin action, is impaired in obesity and type 2 diabetes mellitus. We recently reported that low-dose intracerebroventricular (icv) administration of the gut-derived hormone fibroblast growth factor-19 (FGF19) exerts anti-diabetic effects in genetically obese, leptin-deficient ob/ob mice by potently, rapidly and selectively increasing GE. This effect involves an action at central FGF receptors (FGFR), since glucose lowering (whether FGF19 is given centrally or peripherally) is strongly inhibited by icv pre-treatment with a non-selective FGFR inhibitor (FGFRi; PD173074). As the mechanism underlying increased GE in response to central FGF19 appears to involve increased metabolism of glucose to lactate, we sought to determine whether endogenous neuronal FGFR signaling plays a physiological role in glucose and/or lactate homeostasis and if so, whether the effect involves regulation of GE. To address these questions, we performed icv infusions of either PD173074 (150µg) or vehicle (Veh) in lean, overnight fasted Long-Evans rats 1 week following cannulation of the third ventricle. Thirty min after icv injection, glucose homeostasis was assessed with a frequently sampled intravenous glucose tolerance test (FSIGT) followed by Minimal Model analysis to quantify GE, insulin secretion (AIRg) and insulin sensitivity (Si). As predicted, treatment with icv FGFRi worsened glucose tolerance during the FSIGT (by ~28%; p<0.001) relative to Veh, despite a surprising 3-fold increase of Si (p<0.01). In contrast, GE was reduced (albeit non-significantly; p=0.174) and AIRg did not change. Treatment with icv FGFRi also markedly raised lactate levels at baseline (20 min post icv injection, 10 min before the FSIGT) relative to Veh (p<0.01), and this effect was partially ameliorated following iv glucose injection, suggesting a marked disruption of basal lactate homeostasis. Interestingly, basal glucose values were strongly positively correlated with GE in the Veh-treated controls (r=0.9; p=0.005), and this relationship was lost following icv injection of the FGFRi (r=-0.01; p=ns). A similar correlation was observed between basal lactate levels and GE in control rats, although it did not achieve statistical significance. In conclusion, endogenous central FGFR signaling appears to be required for normal glucose homeostasis, potentially via opposing effects on GE and Si. In addition, basal glucose is a strong predictor of GE measured during the FSIGT in normal rats. Since this relationship is blocked by central FGFR inhibition, we hypothesize that the link between basal glucose levels and GE is centrally mediated.

 

Nothing to Disclose: JMR, MEM, GJM, DS, RNB, MWS

OR01-2 13259 2.0000 A Central FGF Receptor Signaling Is Required for Normal Glucose Homeostasis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 1:00:00 PM OR01 4726 11:30:00 AM Basic Mechanisms of Glucose Homeostasis and Diabetic Complications Oral

Mengxi Jiang*, Meishu Xu and Wen Xie
University of Pittsburgh, Pittsburgh, PA

 

The steroid sulfatase (STS)-mediated de-sulfation is a critical metabolic mechanism that regulates the chemical and functional homeostasis of endogenous and exogenous molecules. In this report, we first showed that the liver expression of STS was induced in both the high-fat diet (HFD) and ob/ob models of obesity and type 2 diabetes and during the fed to fasting transition. In defining the functional relevance of STS induction in metabolic disease, we showed that over-expression of STS in the liver of transgenic mice alleviated HFD and ob/ob models of obesity and type 2 diabetes, including reduced body weight, improved insulin sensitivity, and decreased hepatic steatosis and inflammation. Interestingly, STS exerted its metabolic benefit through sex-specific mechanisms. In female mice, STS may have increased hepatic estrogen activity by converting biologically inactive estrogen sulfates to active estrogens and consequently improved the metabolic functions, whereas ovariectomy abolished this protective effect. In contrast, the metabolic benefit of STS in males may have been accounted for by the male-specific decreased inflammation in white adipose tissue and skeletal muscle, as well as a pattern of skeletal muscle gene expression that favors energy expenditure. The metabolic benefit in male STS transgenic mice was retained after castration. Treatment with the STS substrate estrone sulfate also improved metabolic functions in both the HFD and ob/ob models. Our results have uncovered a novel function of STS in energy metabolism and type 2 diabetes. Liver-specific STS induction or estrogen/estrogen sulfate delivery may represent novel management of metabolic syndrome.

 

Nothing to Disclose: MJ, MX, WX

OR01-3 11210 3.0000 A Hepatic over-Expression of Steroid Sulfatase Ameliorates Mouse Models of Obesity and Type 2 Diabetes through Sex-Specific Mechanisms 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 1:00:00 PM OR01 4726 11:30:00 AM Basic Mechanisms of Glucose Homeostasis and Diabetic Complications Oral

Laura Ann Maile*1, William Flowers2, Kara Stewart2, Nikhol Dysart2, Stefani Garbacik2, Timothy Nichols3, Dwight Bellinger3, David R Clemmons4, Katherine Gollahon5, Christine Wai6, Robin Raymer3, Elizabeth Merricks3 and Kent Passingham3
1Vasular Pharmaceuticals, Chapel Hill, NC, 2North Carolina State University, 3University of North Carolina at Chapel Hill, 4Univ of N Carolina Schl of Med, Chapel Hill, NC, 5Vascular Pharmaceuticals, 6University of North Carolina at Chapel Hill, Chapel Hill, NC

 

The aim of this study was to characterize the development of renal impairment in a pig model of streptozotocin (STZ) induced diabetes combined with high fat diet and to examine the effect of a novel anti αVβ3 antibody on the progression of the disease. The anti-C-loop β3 antibody (anti-C-loop) binds to a non-RGD binding region site on the β3 subunit of αVβ3 and is the mouse monoclonal precursor of VPI-2690B, which is currently in Phase 1 clinical trials. 

Twenty pigs were made hyperglycemic by the administration of STZ then placed on a high fat diet. 2 weeks later 10 pigs were treated with control F(ab)2 and 10 pigs were treated with anti-C-loop F(ab)2 every 72 hours for 20 weeks.

After 20 weeks of diabetes, the animals developed proteinuria and histological changes in the kidney.  Urinary protein was significantly lower in diabetic pigs that received anti-C-loop antibody compared to those that received control (218 ± 57 vs 115 ± 50 mg protein / gm creatinine, p<0.05).  The kidneys of untreated diabetic pigs were characterized by significant histopathology, including expansion of the mesangial matrix and glomerular basement membrane (GBM) and by an increase in podocyte foot width compared to nondiabetic pigs. In the diabetic animals treated with anti C-loop F(ab)2, the area of the mesangial matrix as a percentage of total glomerular area was reduced (35 ± 5.2% vs 27.4 ± 3.8%; p<0.02),GMB thickness decreased (169 ± 3.1 vs 159.9 ± 7.3 nm, p<0.01) and podocyte foot width decreased (503±15 nm vs. 359 ± 21.2, p<0.05) compared to diabetic animals treated with control F(ab)2. β3 phosphorylation, a marker of αVβ3 activation, was elevated in the diabetic animals compared to nondiabetic controls.  As expected, treatment with anti-C-loop significantly reduced β3 phosphorylation in these animals (13,934 ± 6437 vs 6,730 ± 1524 scanning units; p<0.01).

The results of this study show that, in this pig model of Type 2 diabetes, animals develop the early changes in loss of barrier function and histopathologic changes that are consistent with diabetic nephropathy.  The changes are accompanied by activation of the αVβ3 integrin as assessed by phosphorylation of the b3 subunit.  Blocking αVβ3 integrin with anti-C-loop antibody leads to prevention of albuminuria and of the early histologic changes of diabetic nephropathy.  The results suggest that this antibody may have efficacy in preventing the progression of diabetic nephropathy in patients.

 

Disclosure: LAM: Employee, Vascular Pharmaceuticals. DRC: Chief Scientific Officer, Vascular Pharmaceuticals. KG: Employee, Vascular Pharmaceuticals. Nothing to Disclose: WF, KS, ND, SG, TN, DB, CW, RR, EM, KP

OR01-4 11805 4.0000 A Targeting a Novel Site on the aphaVbeta3 Integrin Reduces Hyperglycemia-Induced Changes in the Kidney of Diabetic Pigs 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 1:00:00 PM OR01 4726 11:30:00 AM Basic Mechanisms of Glucose Homeostasis and Diabetic Complications Oral

Weiwei Zhao, Wei Gong, Bin Lu, Zhaoyun Zhang, Yiming Li, Yehong Yang* and Renming Hu
Huashan hospital, Shanghai, China

 

Although significant advances in the diagnosis and treatment of diabetic nephropathy (DN) have been achieved over the last two decades, the molecular pathogenesis is still unclear. In order to further understand the mechanisms of DN, patients with DN and non-DN were tested by SELDI-TOF-MS with the CM10 protein chip to get the protein spectra maps. Combined with RayBiotech high-throughput antibody microarray, we finally identified the elevated protein resistin-like molecule β (RELMβ), which may involved in the development of DN. High expression of the RELMβ protein was validated in both glomerular mesangium of Sprague Dawley rats with DN and cytoplasm of human mesangial cells (HMCs). High levels of circulating RELMβ were correlated with the development of diabetic albuminuria in community population. Glucose stimulated the production of RELMβ protein derived from HMCs. The overexpression of RELMβ in HMCs promoted the proliferation of mesangial cells and accelerated cell cycle progression, whereas the knockdown of RELMβ decreased cell proliferation and delayed cell cycle progression. However, RELMβ did not work on apoptosis of HMCs. Furthermore, RELMβ triggered HMC proliferation by phosphorylating MAPKs (JNK and p38 MAPK), while the activity of ERK1/2 MAPK was not altered. The proliferation could be reversed by a p38 MAPK inhibitor (SB 202190) in Lenti-RELMβ HMCs. In addition, PCR array analysis demonstrated that 8 signal transduction pathways involved in cell proliferation were modified upon RELMβ modulation. WISP1 gene, which is associated with proliferation, extracellular matrix production, as well as fibrosis (1), is significantly downregulated as 33.27 fold in Lenti-sh-RELMβ HMCs. These findings suggest that RELMβ accelerates the proliferative function of HMCs by targeting the MAPK pathway and cell cycle. RELMβ might be a candidate predictor for DN.

 

Nothing to Disclose: WZ, WG, BL, ZZ, YL, YY, RH

OR01-5 14757 5.0000 A Resistin-like Molecule β Promotes Renal Injury By Modulating Mesangial Cell Proliferation in the Development of Diabetic Nephropathy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 1:00:00 PM OR01 4726 11:30:00 AM Basic Mechanisms of Glucose Homeostasis and Diabetic Complications Oral

I George Fantus*1, Anu Shah2, Elodie AY Masson2, Rohan John3 and Mansoor Husain3
1Mount Sinai Hospital, Toronto, ON, Canada, 2Mount Sinai Hospital, 3University Health Network

 

Thioredoxin-interacting protein (TxNIP), a member of the α-arrestin domain family of proteins, binds and inhibits the thiol oxidoreductase, thioredoxin.  We previously reported that high glucose (HG) upregulated TxNIP in cultured mesangial cells (MC) which in turn, promoted oxidative stress, MAPK/p38 signaling and collagen synthesis.  However, the role of TxNIP in diabetic nephropathy (DN) in vivo is unknown.  Thus, TxNIP-WT (WT), TxNIP-/- (KO), TxNIP+/- (HET), C3H (Control) and Hcb-19 (Spontanous mutation lacking TxNIP) mice were rendered equally diabetic with low dose streptozotocin (STZ).  After 24 weeks of diabetes and equivalent hyperglycemia and BP, in contrast to WT, KO mice did not manifest albuminuria, proteinuria or elevation of serum cystatin C or creatinine.  EM studies showed thickened glomerular basement membranes and effacement of podocyte foot processes in diabetic WT mice, but not in KO.  Similarly, a loss of podocytes (WT-1 staining) and increased urinary nephrin was observed in diabetic WT but not in KO mice.  Mesangial expansion (PAS staining), collagen IV and TGFβ (immunohistochemistry, iHC), and renal interstitial fibrosis (Masson’s trichrome) revealed significant increases only in diabetic WT.  Consistent with a role of TxNIP in generating oxidative stress and inflammation, while WT diabetic mice showed significantly increased 24 h urinary 8-hydroxy-2-deoxyguanosine, glomerular nitrotyrosine and F4/80 iHC and augmented renal cortex Il-1β mRNA, these parameters were not altered in diabetic KO mice.  Furthermore, consistent with our results in MC, renal cortex Nox4 mRNA and glomerular Nox4 staining were increased in diabetic WT but not KO.  Diabetic Hcb-19 TxNIP-deficient mice also displayed protection from renal markers of DN in comparison to diabetic C3H controls, similar to KO versus WT.  In the presence of diabetes the TxNIP+/- HETS had a lesser but significantly increased TxNIP mRNA (~70% of WT) and showed only partial protection from DN.  Taken together, these data indicate that TxNIP plays a critical role in the development and progression of DN and may represent a promising therapeutic target.

 

Nothing to Disclose: IGF, AS, EAM, RJ, MH

OR01-6 12187 6.0000 A Thioredoxin-Interacting Protein (TxNIP) Deficiency Protects Against Diabetes-Induced Renal Oxidative Stress, Inflammation and Pathologic Characteristics of Diabetic Nephropathy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 1:00:00 PM OR01 4726 11:30:00 AM Basic Mechanisms of Glucose Homeostasis and Diabetic Complications Oral

Nora S Kayton*1, Greg Poffenberger1, Chunhua Dai1, Pedro L Herrera2, Dale L Greiner3, Lenny D Shultz4 and Alvin C Powers5
1Vanderbilt University Medical Center, Nashville, TN, 2Univ of Geneva Medical Sch, Geneva, Switzerland, 3University of Massachusetts Medical School, Worcester, MA, 4The Jackson Laboratory, Bar Harbor, ME, 5Vanderbilt Univ Med Ctr, Nashville, TN

 

Chronic hyperglycemia and resulting “glucotoxicity” are suspected to compromise beta cell function.  To examine the effect of hyperglycemia on human beta cells in vivo, we transplanted human islets into NOD-scid Il2rgammanull (NSG)–Rat Insulin Promoter-Diphtheria Toxin Receptor (RIP-DTR) mice.  In this new model, human islets engraft under normoglycemia, and subsequent injection of diphtheria toxin (DT) specifically ablates the pancreatic (mouse) beta cells.  In characterizing this model, following transplantation of 500 human islets under the kidney capsule of NSG or NSG-RIP-DTR mice, we found that injection of 5.0 ng DT in NSG-RIP-DTR mice reduced mouse pancreatic insulin content from 47,244 ± 14,905 μg/g of pancreas weight to below detectable levels but did not alter fasting (control 2.07 ± 0.26 vs. DT treated 2.10 ± 0.32 ng/mL, n=6, p>0.05) or glucose/arginine-stimulated human C-peptide  (control 3.17 ± 0.37 vs. DT treated 3.75 ± 0.46 ng/mL, n=6, p>0.05) or graft human insulin content (control 187.6 ± 30.31 vs. DT 156.0 ± 42.66 ng; n=5, p>0.05).  Engraftment of four thousand human islet equivalents (IEQ) maintained euglycemia after DT injection (mean fed blood glucose of 106.2 ± 3.0 vs. control of 123.0 ± 3.4 mg/dL; n=3, p>0.05), but 2000 human IEQ resulted in hyperglycemia (mean fed blood glucose of 353.2 ± 43.5 vs. control of 123.0 ± 3.4 mg/dL; n=3, p<0.01).  The divergence in blood glucose values began 3 days after DT injection and continued for 4 weeks, until the termination of the experiment.   We have discovered different consequences for human islets under euglycemic and hyperglycemic conditions.  At 2 weeks after DT injection, human insulin release in response to injection of a glucose-arginine bolus did not increase in 2000 IEQ + DT mice (1.13 ± 0.42 ng/mL) but did increase in 4000 IEQ + DT mice (6.19 ± 0.93 ng/mL), compared to controls, which had 2000 human IEQ but received no DT (2.63 ± 0.59ng/mL).  This resulted in a greater increase in blood glucose of 2000 IEQ + DT mice compared to the other groups (544.8 ± 23.6 vs. 265.3 ± 24.3 and 264.7 ± 48.1 mg/dL).  At 4 weeks after DT injection, human insulin content of grafts from 4000 IEQ + DT mice was significantly higher compared to controls (11409 ± 2244 ng vs. 1351 ± 253 ng, n=6, p<0.01), but 2000 IEQ + DT grafts were unchanged (973.7 ± 300.9, n=5 vs. 1351 ± 253 ng, n=5, p>0.05).  Mouse pancreatic insulin content in 4000 and 2000 IEQ DT-treated animals was reduced to 2.7% and 3.4%, respectively, of the content of controls (23.88 ± 5.9, n=5 and 18.90 ± 7.0, n=6 vs. 712.1 ± 60.22 ng, n=4, p<0.0001).  Beta cell proliferation and apoptosis are extremely low and not significantly different among the groups.  The NSG-RIP-DTR model enabled us to observe that glucose-stimulated insulin release and increases in insulin content are impaired in human beta cells exposed to 4 weeks of hyperglycemia in vivo, suggesting glucotoxic consequences, but does not induce beta cell proliferation or death.  

 

Disclosure: PLH: , Unknown (author has not provided this information. Information will be provided as soon as possible).. DLG: Speaker, Genzyme Corporation, Speaker, Pfizer, Inc., Speaker, Boehringer Ingelheim, Ad Hoc Consultant, Viacord, Ad Hoc Consultant, The Jackson Laboratory. LDS: Speaker, Boehringer Ingleheim, Speaker, Bristol-Myers Squibb, Speaker, Pfizer, Inc., Ad Hoc Consultant, Viacord. ACP: Ad Hoc Consultant, Boehringer Ingelheim Pharma GmbH & Co. KG, Ad Hoc Consultant, Novartis Pharmaceuticals. Nothing to Disclose: NSK, GP, CD

OR10-1 15030 1.0000 A Assessment of Glucotoxic Consequences for Human Beta Cells in Vivo Via the NOD-SCID Il2rgammanull –RIP-Dtr Mouse 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 1:00:00 PM OR10 4732 11:30:00 AM Nutrient-Insulin Interactions in the Pancreas and Periphery Oral

Ramya Embar Srinivasan*, Poonam R Sharma and Craig S Nunemaker
University of Virginia, Charlottesville, VA

 

Background: Type 2 diabetes (T2D) is characterized by insulin resistance and beta-cell failure. Several mechanisms underlying the causes of pancreatic beta-cell failure, which we term “stressors”, have been reported including glucotoxicity, lipotoxicity, endoplasmic reticulum (ER) stress, oxidative stress, and inflammation. We identified several iron-regulating genes in a gene microarray of beta-cell stress, of which Six-transmembrane epithelial antigen of the prostate 4 (STEAP4) was the most upregulated. STEAP-proteins allow cellular uptake of iron by reducing iron to its lower oxidative state. Epidemiological studies have reported a positive association between high body iron stores, increased dietary iron intake and the risk of T2D. We wished to examine whether STEAP4 and other iron-regulating genes participate in islet stress responses.

Objective: Determine how iron-regulating genes are regulated by 1) beta-cell stressors and 2) STEAP4 overexpression in islets.

Methods: Pancreatic islets of 8-12-week-old, male CD1 mice were isolated and cultured. Islets were exposed for 48-hrs to one of the following stressors representing models of beta-cell failure: 20nM rotenone (oxidative stress), 100nM thapsigargin (ER stress), 10pg/ml IL-1B + 20pg/ml IL-6 (low-grade inflammation), 28mM glucose (glucotoxicity), or 50pg/ml palmitate + 100pg/ml oleate + 50pg/ml linolate (lipotoxicity). Islets incubated in standard RPMI 1640 media were used as controls; n=4/condition. The expression of iron-regulating genes STEAP4, ferritin, ferroportin, and lipocalin-2 (LCN2) were measured in islets by RT-PCR. In a second study, islets were transduced with lentivirus for 24 hrs for overexpression of STEAP4. RNA was extracted from transduced islets 72 hrs post transduction to measure expression of various genes by RT-PCR.

Results: When treated with cytokines, thapsigargin and free fatty acids, respectively, fold increases in islet STEAP4 expression were 90.6+/-7.6-fold SEM (p<0.001), 4.1+/-1.0 (p<0.05), 3.4+/-0.9 (p<0.05) and LCN2 were 35.6+/-6.2 (p<0.01), 7.1+/-1.7 (p<0.05), 2.1+/-0.5 (p=0.11). Thapsigargin increased islet ferritin expression by 2.0+/-0.2 (p<0.01); no significant changes in ferroportin were observed. No iron genes were downregulated. Overexpression of STEAP4 (~15-fold) upregulated the iron-sequestering protein LCN2 by 7.9+/-1.7-fold, p<0.05, n=3. Ferritin and ferroportin were not significantly changed.

Conclusion: STEAP4 and LCN2 are linked in their expression and both exceptionally cytokine-sensitive, suggesting these iron-regulating proteins may play a central role in the low-grade chronic inflammation accompanying T2D.

 

Nothing to Disclose: RES, PRS, CSN

OR10-2 13940 2.0000 A Association of Iron-Regulating Genes and Islet Stress 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 1:00:00 PM OR10 4732 11:30:00 AM Nutrient-Insulin Interactions in the Pancreas and Periphery Oral

Riccarda Granata*1, Fabio Settanni1, Letizia Trovato1, Davide Gallo1, Iacopo Gesmundo1, Rita Nano2, Maria Pia Gallo1, Marina Taliano1, Loredana Bergandi1, Marco Volante1, Giuseppe Alloatti1, Lorenzo Piemonti2, Mauro Papotti1, Jérôme Leprince3, Hubert Vaudry3, Huy Ong4 and Ezio Ghigo1
1University of Turin, Turin, Italy, 2San Raffaele Scientific Institute, Milan, Italy, 3University of Rouen, Rouen, France, 4University of Montreal, Montreal, QC, Canada

 

The RFamide neuropeptides 43RFa and 26RFa were found to promote food intake and to exert a variety of peripheral actions through binding to the orphan receptor GPR103. In addition, 26RFa has been recently shown to inhibit pancreatic insulin secretion, whereas 43RFa effect on β-cell function is still unknown, as well as the role of both peptides on β-cell survival. In the present study we sought to investigate 43RFa and 26RFa effects on survival and apoptosis of pancreatic β-cells and human pancreatic islets. Furthermore, we determined the influence of these peptides on insulin secretion and the underlying signaling mechanisms. Our results show that in INS-1E β-cells and human pancreatic islets, both 43RFa and 26RFa prevented cell death and apoptosis induced by serum starvation, cytokine synergism and glucolipotoxicity, via PI3K/Akt- and ERK1/2-induced signaling. Moreover, 43RFa promoted, whereas 26RFa inhibited, glucose- and exendin-4-induced insulin secretion, through Gαs and Gαi/o proteins, respectively. The insulinotropic effect of 43RFa, but not the insulinostatic action of 26RFa, was blocked in β-cells knocked-down for GPR103. Finally, 43RFa, but not 26RFa, induced cAMP increase and glucose uptake. In conclusion, because of their survival effects along with the effects on insulin secretion, these findings suggest potential for 43RFa and 26RFa as therapeutic targets in diabetes and metabolic dysfunctions.

 

Nothing to Disclose: RG, FS, LT, DG, IG, RN, MPG, MT, LB, MV, GA, LP, MP, JL, HV, HO, EG

OR10-3 13684 3.0000 A Rfamide Peptides 43RFa and 26RFa Both Promote Survival of Pancreatic Β-Cells and Human Pancreatic Islets but Exert Opposite Effects on Insulin Secretion 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 1:00:00 PM OR10 4732 11:30:00 AM Nutrient-Insulin Interactions in the Pancreas and Periphery Oral

Rodolfo Guardado-Mendoza*1, Carla Perego2, Lilia Marisela Jiménez-Ceja3, Giovanna Finzi4, Carlo Capella4, Edward J. Dick Jr.5, Ma. de Lourdes Reyes-Escogido3, Stefano La Rosa4, Fausto Sessa4, Ralph DeFronzo6, Amalia Gastaldelli7, Alberto M Davalli8 and Franco Folli6
1University of Guanajuato, Department of Medicine and Nutrition, and Hospital Regional de Alta Especialidad del Bajío, Departamento de Investigación, León, Guanajuato, Mexico, 2Universitá degli Studi di Milano, 3University of Guanajuato, 4University of Insubria, 5Southwest National Primate Research Center, Texas Biomedical Research Institute, 6University of Texas Health Science Center, San Antonio, TX, 7CNR, Inst of Clinical Physiology, Pisa, Italy, 8San Raffaele Scient Inst, Milano, Italy

 

Background and Aims: The unique composition and architecture of the islet of Langerhans is essential to ensure its normal function (1-3).  Morphological and physiological abnormalities are both present in islets of subjects with type 2 diabetes but the relationship between islet cell composition with fasting plasma glucose (FPG) and other metabolic and biochemical parameters is presently unknown. Therefore, we explored the correlation between islet cell abnormalities and FPG and other metabolic markers.

Methods:We measured the relative α-, β- and δ-cell volumes and amyloid deposition with stereology techniques in the pancreas of 40 baboons stratified according to FPG in 4 groups (G1: FPG<80mg/dl n=10; G2: FPG=80-<95mg/dl n=9, G3: FPG=95-125mg/dl n=9, G4: FPG≥125mg/dl n=12) and examined the correlations between islet composition and various functional and metabolic parameters. We performed double and triple immunofluorescence staining to identify apoptotic islet cells as well as electron microscopy to identify the ultra-structural composition of different islet cells.

 Results: As compared to G1, G2 showed a significant increase in islet amyloid deposition which increased linearly up to G4.  Amyloidosis preceded the decrease in b-cell volume statistically significant only in G4.  α-cell volume increased of ~50% in G3 and G4 (p <0.05), while δ-cell volume decreased in these groups of 39 and 31%, respectively (both p<0.05).  In G4, glucagon, cholesterol and free fatty acid levels were higher, while insulin and HOMA-B were lower, than in the other groups.  Staining of G4 pancreatic sections with the apoptosis marker CCL3, insulin and somatostatin showed ongoing apoptosis of both b- and d-cells which was confirmed by immuno-electron-microscopy.  Ultra-structural analysis confirmed a normal structure in α-cells while β- and δ-cells showed multiple signs of cell suffering in baboons with the higher glucose levels.

Conclusions/interpretations: In baboons, the changes in islet composition that matches the increase in FPG concentration are in sequence: i. increased amyloid deposition; ii. increased a-cell- and decreased d-cell volumes; iii. decreased b-cell volume.  Timing and nature of these changes suggests a so far unrecognized role of d-cells in diabetes pathogenesis.

 

Nothing to Disclose: RG, CP, LMJ, GF, CC, EJD, MDLR, SL, FS, RD, AG, AMD, FF

OR10-4 15533 4.0000 A Islet Cell Paracrinopathy and the Relevance of Delta-, Alpha- and Beta-Cell Dysfunction in the Development of Hyperglycemia in Non-Human Primates 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 1:00:00 PM OR10 4732 11:30:00 AM Nutrient-Insulin Interactions in the Pancreas and Periphery Oral

Wenwei Zhang*1, So Young Bu2, Mara T Mashek2, Olga Ilkayeva3, Christopher B. Newgard3, Douglas Mashek2 and Terry G Unterman1
1University of Illinois at Chicago & Jesse Brown VAMC, Chicago, IL, 2University of Minnesota, St Paul, MN, 3Duke University Medical Center, Durham, NC

 

FoxO proteins are major targets of insulin action and regulate gluconeogenic, glycolytic and lipogenic gene expression in the liver (JBC 281:10105, 2006).  Adipose triacylglycerol lipase (ATGL) mediates the first step in triacylglycerol (TAG) hydrolysis and FoxO1 stimulates ATGL expression in adipose tissue. Based on gene array data, we asked whether FoxO1 also regulates hepatic expression of ATGL and its inhibitor, the G0/G1 switch gene protein 2 (G0S2) and examined their role in mediating effects of FoxO1 on gene expression and metabolism in the liver.  Studies in liver-specific transgenic and knockout mice show that FoxO proteins stimulate ATGL and suppress G0S2 expression, and studies in isolated hepatocytes with adenoviral vectors confirm that FoxO1 regulates ATGL and G0S2 expression in liver cells.  Metabolic labeling studies demonstrate that FoxO1 stimulates TAG turnover and fatty acid oxidation in isolated hepatocytes, and knocking down ATGL expression or expressing its inhibitor, G0S2, with adenoviral vectors disrupts the effect of FoxO1 on TAG catabolism.  FoxO1 also stimulates liver TAG turnover and fatty acid oxidation in vivo, based on serum beta hydroxybutyrate and intrahepatic fatty acylcarnitine levels, and knocking down ATGL in the liver with an  adenoviral vector expressing ATGL shRNA disrupts these effects of FoxO1.  In addition, post-prandial serum TAG levels are decreased in transgenic mice expressing constitutively active FoxO1 in the liver, reflecting reduced lipogenic and glycolytic gene expression, consistent with previous studies (ibid), and knocking down ATGL reverses these effects and increases glycolytic and lipogenic gene expression and hepatic TAG production and secretion.  Similarly, FoxO1 transgenic mice have impaired glucose  tolerance reflecting increased gluconeogenic gene expression (ibid), and suppressing ATGL in the liver restores normal glucose and pyruvate tolerance in transgenic mice.  Studies in isolated hepatocytes confirm that ATGL is required for the ability of FoxO1 to stimulate glucose production in liver cells. Together, these studies demonstrate that ATGL plays a critical role in mediating effects of FoxO1 on TAG turnover and fatty acid oxidation in the liver, and contributes to the ability of FoxO1 to suppress glycolytic and lipogenic gene expression  and stimulate hepatic glucose production.  These results indicate that ATGL-mediated TAG catabolism plays a critical role in the integrated regulation of both lipid and carbohydrate metabolism by FoxO proteins in the liver.

 

Nothing to Disclose: WZ, SYB, MTM, OI, CBN, DM, TGU

OR10-5 16294 5.0000 A Regulation of Hepatic Lipid and Glucose Metabolism By Fox0 Proteins Requires Atgl-Mediated Triacylglycerol Catabolism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 1:00:00 PM OR10 4732 11:30:00 AM Nutrient-Insulin Interactions in the Pancreas and Periphery Oral

Lucia Russo*1, Sumona Ghosh Lester2, Saja S Khuder1, Terry D Hinds2, Simon L Abdallah2, Simona S Ghanem2, Scott L Friedman3 and Sonia M Najjar2
1University of Toledo College of Medicine and Life Sciences, Toledo, OH, 2University of Toledo, College of Medicine, Toledo, OH, 3Icahn School of Medicine at Mount Sinai, New York, NY

 

Nonalcoholic fatty liver disease (NAFLD) and its progressive form, nonalcoholic steatohepatitis (NASH), are a global health concern. Whether insulin resistance, commonly associated with obesity, is an obligate metabolic manifestation of the disease is still debated. We have demonstrated that mice with transgenic liver-specific inactivation and with global null deletion of Ceacam1 (Cc1) gene are characterized by impaired insulin clearance in liver, which causes hyperinsulinemia followed by insulin resistance, liver steatosis and visceral obesity. These mice have spontaneous liver fibrosis with a NASH-characteristic chicken-wire collagen deposition pattern. Moreover, high-fat feeding provoked progression to the full spectrum of NASH in both Cc1 mutants. This prompted us to test whether liver-specific loss of CEACAM1 causes insulin resistance and NASH, both being driven by hyperinsulinemia. Clinically, this is bolstered by findings that hepatic CEACAM1 levels are markedly decreased in patients with NAFLD/NASH. Thus, we aimed to determine whether specific deletion of Ceacam1 gene (Cc1) in liver causes insulin resistance and the pathological abnormalities of NAFLD/NASH in L-Cc1fl/fl mice. Conversely, we tested whether exclusive rescuing of CEACAM1 in liver protects Cc1–/–xliver+ mice against NAFLD/NASH. L-Cc1fl/fl null mice exhibited a higher body weight beginning at 2 months of age that was associated with an increase in total fat mass and lower lean mass as compared to their littermate controls starting at 4 months of age. These mice also developed hyperinsulinemia and insulin resistance, as demonstrated by insulin intolerance testing. Conversely, liver-rescued Cc1–/–xliver+ mice (2 months old) exhibited lower body weight and total fat mass, a higher total lean mass and lower levels in almost all the metabolic parameters compared to Cc1–/– littermates. They also exhibited restored insulin sensitivity. We are currently feeding mice with a high fat diet to examine whether null mice are predisposed while rescued mice are protected against NASH-characteristic pathological abnormalities. Furthermore, lentiviral-mediated ShRNA loss of CEACAM1 in immortalized human LX2 stellate cells decreased cellular fat content with a parallel increase in its mobilization into the medium, associated with increased cell proliferation and expression of smooth muscle actin, all consistent with increased stellate cell activation. These data support a key role for CEACAM1 in attenuating hepatic steatosis and stellate cell activation. These findings uncover an important novel role for CEACAM1-dependent pathways in regulating key features of NASH.

 

Nothing to Disclose: LR, SG, SSK, TDH, SLA, SSG, SLF, SMN

OR10-6 16019 6.0000 A Loss of Liver Carcinoembryonic Antigen-Related Cell Adhesion Molecule 1 (CEACAM1) Causes Insulin Resistance and Nash Pathogenesis in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 1:00:00 PM OR10 4732 11:30:00 AM Nutrient-Insulin Interactions in the Pancreas and Periphery Oral

Han-Chuan Dai* and Ya-Xiong Tao
Auburn University, Auburn University, AL

 

The melanocortin-4 (MC4R) is a G protein-coupled receptor critically involved in regulating energy homeostasis, including both food intake and energy expenditure. More than 170 mutations in the MC4R gene have been identified in different populations of patients, causing early-onset severe obesity. In addition to the activation of the classical Gs-cAMP pathway, the MC4R also activates mitogen-activated protein kinases, especially extracellular signal-regulated kinases 1 and 2 (ERK1/2). We recently showed that in wild-type (WT) and six naturally occurring constitutively active (CAM) MC4Rs, including H76R, S127L, D146N, P230L, L250Q and F280L, the endogenous antagonist Agouti-related protein and three small molecule inverse agonists decrease basal signaling in cAMP pathway but are agonists in the ERK1/2 pathway. In the present study, we performed detailed pharmacological studies on two peptide antagonists (SHU9119 and Compound 10) derived from the endogenous agonist alpha-melanocyte stimulating hormone on these seven MC4Rs. In ligand binding experiments using iodinated NDP-MSH as the tracer, we showed that SHU9119 bound to the seven MC4Rs with high affinity, with IC50 ranging from 1.12 to 6.68 nM. However, Compound 10 could not displace iodinated NDP-MSH in any of the seven MC4Rs studied. In signaling experiments measuring cAMP generation, we showed that SHU9119 was a very weak agonist, increasing intracellular cAMP levels at very high concentrations whereas Compound 10 had negligible agonist activity. We then examined potential activation of MC4R in the ERK1/2 pathway by these ligands. We found that upon treatment with 1 nM SHU9119 (which did not increase cAMP levels), all seven MC4Rs had significantly increased pERK1/2 levels, ranging from 2.3 to 6.2-fold of vehicle-treated controls.  When treated with 1 nM Compound 10, WT and four mutants (H76R, D146N, P230L and F280L) had significantly increased pERK1/2 levels, ranging from 2.5 to 5.2-fold of vehicle-treated controls. In summary, our study showed SHU9119 and Compound 10, MC4R antagonists at the Gs-cAMP pathway, could serve as agonists in the MAPK pathway, suggesting that these ligands are biased ligands at the MC4R.

 

Nothing to Disclose: HCD, YXT

OR08-1 16932 1.0000 A SHU9119 and Compound 10 Are Biased Ligands at the Melanocortin-4 Receptor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, June 21st 1:00:00 PM OR08 4737 11:30:00 AM New Insights in GPCR Structure and Function Oral

William F Schwindinger*1 and Janet D Robishaw2
1Bloomsburg University of Pennsylvania, Bloomsburg, PA, 2Geisinger Health System, Danville, PA

 

Heterotrimeric G-proteins couple cell surface receptors for hundreds of different extracellular signals to a smaller number of intracellular effectors. Heterotrimeric G-proteins are assembled from the protein products of 16 genes encoding α-subunits, 5 genes encoding β-subunits and 12 genes encoding γ-subunits. Both the α-subunit and the βγ-dimer of a heterotrimeric G-protein may participate in signal transduction, sometimes regulating distinct intracellular effectors. Much of what is known about G-protein coupled signal transduction details which specific α-subunit couples a given receptor to a particular intracellular effector. For example Gαs couples receptors for a number of hormones (e.g. PTH, TSH, MSH, LH) to the stimulation of adenylyl cyclase. This knowledge has permitted a greater understanding of endocrine disorders caused by mutations in the gene encoding Gαs: pseudohypoparathyroidism and McCune-Albright syndrome. Much less is known about the specific roles of individual γ-subunits in signal transduction. We studied mice with targeted disruption of several γ-subunit genes: Gng3, Gng5, Gng7 and Gng11. Knockout of Gng7 disrupted stimulation of adenylyl cyclase by dopamine and adenosine in the striatum, but did not produce a locomotor phenotype. Knockout of Gng3 disrupted stimulation of potassium currents by a GABAB agonist, and produced phenotypes of seizure susceptibility and resistance to diet induced obesity. Knockout of Gng5 produced an embryonic lethal phenotype associated with abnormalities in heart and brain development. Knockout of Gng11 resulted in accelerated development of an inflammatory dermatitis. These results indicate that individual γ-subunits have unique roles in signal transduction. Elucidation of the signal transduction pathways for each of these γ-subunits may grant insights into the molecular basis of human diseases such as obesity, epilepsy, Parkinson’s disease, congenital defects and inflammatory conditions.

 

Nothing to Disclose: WFS, JDR

OR08-2 11190 2.0000 A Further Characterization of G-Protein Gamma-Subunit Knockout Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, June 21st 1:00:00 PM OR08 4737 11:30:00 AM New Insights in GPCR Structure and Function Oral

Mi Hye Lee*1, Kathryn M. Appleton2, Thomas A. Morinelli3, Josh Kwon4, Yuri K. Peterson2 and Louis M. Luttrell3
1College of Medicine, Medical University of South Carolina, Charleston, SC, 2College of Pharmacy, Medical University of South Carolina, Charleston, SC, 3Medical University of South Carolina, Charleston, SC, 4University of Pittsburgh, Pittsburgh, PA

 

The arrestins are a small family of G protein-coupled receptor (GPCR) binding proteins that interact with the vast majority of GPCRs.  Agonist-induced changes in GPCR conformation promote receptor phosphorylation by GPCR kinases (GRKs), leading to redistribution of arrestins from the cytosol to agonist-occupied receptors on the plasma membrane.  Arrestin-binding sterically uncouples GPCRs from their cognate heterotrimeric G proteins, producing receptor desensitization, and links receptors to the clathrin-dependent endocytic machinery to promote their sequestration.  Arrestins also function as signaling scaffolds, supporting the assembly of multi-protein signalsome complexes that confer novel G protein-independent signaling functions. In this study, we created a series of arrestin3 intramolecular fluorescent arsenical hairpin (FlAsH) bioluminescence resonance energy transfer (BRET) reporters that monitor changes in arrestin conformation in live cells based on the BRET between an N-terminal RLuc donor and a FlAsH acceptor fluorophore located at each of seven different positions within the protein.  We then determined the arrestin3 ‘conformational signature’ generated upon activation of six GPCRs that differ in their G protein-selectivity, trafficking pattern of GPCR-arrestin complexes, and capacity of the receptor to promote arrestin-dependent activation of ERK1/2.   We found that GPCRs that bind arrestin3 stably and traffic with it into early endosomes, i.e. angiotensin AT1, vasopressin V2, and parathyroid hormone PTH1, produce similar FlAsH1-7 signatures, whereas the signatures produced by GPCRs that form transient GPCR-arrestin complexes confined to the plasma membrane, i.e. β2 adrenergic, α1B adrenergic, and sphingosine 1-phosphate S1P1, were different and more heterogenous.  Receptors capable of arrestin-dependent ERK1/2 activation, i.e. AT1, V2, PTH1 and α1B, produced a characteristic decrease in the BRET signal detected by FlAsH acceptors in the C-terminal domain.  Comparing the FlAsH signatures of wild type V2 and β2 receptors with those of chimeric V2-β2ct and β2-V2ct receptors that exhibit reversal of the arrestin3-binding and trafficking patterns, demonstrated that stable arrestin binding and arrestin-dependent ERK1/2 activation correlate with characteristic changes in arrestin conformation.  These data suggest that upon GPCR binding, arrestin3 undergoes characteristic conformational rearrangements that relate to its downstream trafficking functions, and that a ‘conformational signature’ monitored by FlAsH BRET may be valuable for receptor and ligand classification.

 

Nothing to Disclose: MHL, KMA, TAM, JK, YKP, LML

OR08-3 16127 3.0000 A Arrestin3 Adopts GPCR-Specific Conformations That Correlate with Its Trafficking and Signaling Functions 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, June 21st 1:00:00 PM OR08 4737 11:30:00 AM New Insights in GPCR Structure and Function Oral

Rory Sleno*, Dominic Devost, Darlaine Pétrin, Marc-André Bourassa and Terry Hébert
McGill University, Montreal, QC, Canada

 

Recently, a large number of G protein-coupled receptor (GPCR) structures have provided a wealth of information about different inactive and active receptor conformations. Comparison of active- and inactive-state structures has suggested specific conformational rearrangements which occur during receptor activation. However, these static images only provide a glimpse of the complexity of receptor conformational dynamics and are limited in their utility for drug discovery due to technical challenges of protein crystallization and the loss of the physiological milieu associated with their purification. Here, we propose a system to capture conformational rearrangements induced by ligand binding to GPCRs in live cells and how these might be modulated by partner receptors.

We have designed two panels of conformation-sensitive biosensors to capture structural rearrangements in the receptor for PGF2α (FP) or angiotensin II (AT1R). Our system incorporates intramolecular bioluminescence resonance energy transfer (BRET) between a C-terminally fused Renilla luciferase moiety and a targeted small fluorescent molecule (FlAsH) with binding sites engineered or “walked” into different positions in the third intracellular loop. These biosensors were validated for cell surface localization and signalling competency in that they were capable of activating ERK1/2 mitogen-activated protein kinase when treated with PGF2α or angiotensin II, respectively. Our sensors generate distinct FlAsH tag position-dependent BRET signals in the absence of ligand reflecting their ability to report conformation from different vantage points. We also demonstrate varying degrees of position-dependent BRET following stimulation with either PGF2α or angiotensin II.

Using these conformation-sensitive biosensors, we have investigated conformational rearrangements which occur in the context of a recently identified FP/AT1R heterodimer. FP- or AT1R-based biosensors were co-expressed with WT AT1R or FP respectively. Interestingly, we identified conformational changes in the FP biosensor in the presence of agonist for untagged AT1R which could be blocked by an antagonist for the AT1R but not FP. Inhibition of Gαq by a small molecule inhibitor abolished the conformational change of the WT partner receptor. We have now begun to interrogate the possibility of feedback from downstream signalling as well as the role of specific G proteins on this transmitted conformational change. To our knowledge this is the first account of relayed conformational rearrangements between protomers of a heterodimer in intact cells.

 

Nothing to Disclose: RS, DD, DP, MAB, TH

OR08-4 13062 4.0000 A Monitoring Conformational Rearrangements of F Prostanoid-Angiotensin II Type 1 Receptor Heterodimers Using Bret-Based Biosensors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, June 21st 1:00:00 PM OR08 4737 11:30:00 AM New Insights in GPCR Structure and Function Oral

Ashutosh Trehan*1, Emmi Rotgers1, Eleanor Coffey2, Jorma Toppari3, Ilpo T. Huhtaniemi4 and Adolfo Rivero-Müller1
1Institute of Biomedicine, University of Turku, Turku, Finland, 2Biocity, Åbo Akademi University, Turku, Finland, 3University of Turku, Turku, Finland, 4Imperial College London, London, United Kingdom

 

G protein-coupled receptors (GPCRs) constitute a family of cell surface receptors that have been highly targeted by the current generation of drugs, mainly because of their ability to transduce signals from a wide variety of extracellular stimuli such as odor, light, neurotransmitters and hormones, among others.  Many GPCRs upon ligand activation, couple to Gαs leading to cyclic AMP (cAMP) production through adenylyl cyclase. Therefore, the development of assays to monitor cAMP production is crucial in studying signaling of GPCRs that couple via Gαs. Moreover, the use of primary cell cultures over established cell lines represent a better system to study the signaling properties of GPCRs, since they are physiologically more similar to their parent tissue. However, currently available methods for detecting cAMP, mainly from primary cell cultures, suffers from two major drawbacks (1) lack of kinetic measurements for cAMP production as the commonly used methods based on competitive ELISA require cell lysis and hence can only measure a single time point, and (2) high variability in measuring successive time points because of the use of different population of primary cells for different time points. Even though the use of fluorescent and luminescent cAMP sensors is becoming more common, their utility in primary cell cultures is limited due to poor transfection efficiency, requirement for extensive normalization controls and photobleaching. We have developed a cell-based bioassay to monitor the kinetics of cAMP production in primary cell cultures. The assay is based on co-culture of primary cells (donor cells) with a separate sensor cell line, which stably expresses a luminescent cAMP sensor (Glosensor 22F, Promega). The activation of GPCRs in primary cells causes cAMP production that is detected by the co-cultured sensor cells thereby causing a luminescent read-out of cAMP production. This co-culture setup leads to kinetic monitoring of cAMP production, reduces variability and also eliminates the need to transfect primary cells. The activation of GPCRs in primary cultures of rat cortical neurons and mouse granulosa cells was tested by this method. The optimization of assay for best signal-to-noise ratio was done by varying the number of sensor and primary cells, using phosphodiesterase inhibitors and by testing the necessity for cell-cell contact. The assay is robust, best performed at room temperature and does not require sophisticated humidified gas chambers for kinetic measurements up to 2 hours. The main utility of the assay lies in monitoring the kinetics of cAMP production in primary cell cultures and in comparing the kinetics of cAMP production from different treatment of the same cells as well as in testing cAMP production from cells of unknown origin.

 

Nothing to Disclose: AT, ER, EC, JT, ITH, AR

OR08-5 16819 5.0000 A Bioassay to Monitor cAMP Production in Primary Cell Cultures 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, June 21st 1:00:00 PM OR08 4737 11:30:00 AM New Insights in GPCR Structure and Function Oral

Kim Carol Jonas*1, Francesca Fanelli2, Ilpo T. Huhtaniemi3 and Aylin Hanyaloglu1
1Imperial College London, London, United Kingdom, 2Univ of Modena & Reggio Emilia, Modena, MO, Italy, 3Imperial Coll of London, London, United Kingdom

 

G protein-coupled receptors (GPCRs) are the largest family of mammalian receptors, modulating most aspects of endocrine homeostasis. In vitro studies have demonstrated that GPCRs can associate to form dimers and higher order oligomers, acting to diversify receptor functionality. Using the luteinizing hormone receptor (LHR), we have demonstrated the first in vivo relevance of Class A GPCR dimerization by transactivation; targeted co-expression of ligand-binding deficient (LHRB-), and signalling-defective (LHRS-) LHR restored the gonadal function and fertility of male LHR knockout mice, showing that dimerisation is a physiologically relevant form of GPCR-mediated signalling. As transactivation is a complex and multifaceted form of signaling, the aim of this study was to mechanistically resolve transactivation at the single molecule level. Using our previously described transactivating LHR mutants, we have developed a multi-color super-resolution imaging approach to detect individual GPCR molecules using photoactivatable dyes and localization microscopy, we term PD-PALM. PD-PALM resolved the molecular composition of wild type (WT) LHR, and transactivating heteromeric LHRB-/S- complexes to ~8nm. Both WT LHR and heteromeric LHRB-/S- formed dimers and oligomers, however, heteromeric LHRB-/S- favored association as oligomeric complexes. These hetero-oligomeric complexes were functionally affected by the ratiometric composition of LHRB-: LHRS-. Furthermore, these transactivating heteromers differentially signaled to Gαs and Gαq in a ligand-specific manner. Spatial analysis of individual LHRB-/S- oligomeric forms by PD-PALM revealed specific spatial arrangements of protomers within trimers and tetramers that interestingly favored excess LHRB- over LHRS-. Structural modeling of LHRB-/S- di/tri/tetramers strongly aligned with the spatial analysis by PD-PALM and identified TM interfaces within these specific arrangements. Combining both super-resolution and structural modeling, with functional analysis, provides an unprecedented molecular insight into how GPCR protomers communicate within individual di/oligomers to modulate their functionality, suggesting mechanisms of how one receptor subtype can fulfill multiple physiological requirements.

 

Nothing to Disclose: KCJ, FF, ITH, AH

OR08-6 16643 6.0000 A Single Molecule Analysis of GPCR Transactivation Via PD-PALM Reveals Oligomeric Complexes That Regulate Signal Sensitivity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, June 21st 1:00:00 PM OR08 4737 11:30:00 AM New Insights in GPCR Structure and Function Oral

Hana Vakili*, Yan Jin and Peter A Cattini
University of Manitoba, Winnipeg, MB, Canada

 

Growth hormone (GH) is a major metabolic homeostatic factor, and its levels are decreased in obese individuals. Exercise is a potent stimulus for GH secretion in healthy individuals and an effective physiological intervention in obesity to rescue the GH deficiency status. However GH levels decrease early in response to both excess caloric (food) intake and insulin release (hyperinsulinemia) before obesity occurs. The underlying mechanism responsible for this suppression of GH is not known. We used a ‘humanized’ transgenic mouse containing the intact human (h) GH gene locus (hGH/CS-TG) to examine whether a high caloric intake results in hyperinsulinemia and remodeling and down-regulation of the hGH gene promoter and synthesis. In addition, we assessed whether promotion of energy usage through physical activity interferes with the negative effect of excess caloric intake on hGH production. Four-week old male hGH/CS-TG mice were assigned to non-exercise and exercise (50 minutes swimming daily) groups and were fed either a high-fat (60 kcal%) or a low-fat (10 kcal%) diet for 3 days. Serum glucose, insulin, C-peptide and hGH levels were assessed by ELISA, and hGH RNA levels were assessed by quantitative polymerase chain reaction. Relative levels of histones H3/H4 hyperacetylation and recruitment of RNA polymerase II at the hGH promoter, were assessed as an indication of promoter accessibility/transcriptional status in pituitary cells by chromatin immunoprecipitation assay. The presence of a long-range interaction between the hGH promoter and a distal upstream enhancer required for efficient expression via ‘looping’ was assessed by Chromosome Conformation Capture (3C) assay. High fat diet for three days created a state of excess insulin but not hyperglycemia, without weight gain. Metabolic changes during excess caloric intake were associated with a decrease in both hGH synthesis and secretion. This was associated with decreases in histone H3/H4 hyperacetylation, RNA polymerase II occupancy and disruption of the chromatin ‘looping’, consistent with reduced hGH promoter function. ‘Exercise’ significantly muted the effect of excess caloric intake on insulin and C-peptide levels. There was also a corresponding blunting of the decrease in hGH promoter hyperacetylation, and gene expression/RNA levels seen in the absence of prescribed physical activity through preservation of ‘looping’. These observations provide the first evidence that metabolism and energy homeostasis target hGH synthesis through changes in the three-dimensional chromatin structure of the GH gene locus. A significant concept that may be derived from our study relates to the dynamic and flexible repression and reactivation of the hGH gene in response to the altered metabolic states, which may provide insight into the changes in GH availability as an early event in pathogenesis of obesity.

 

Nothing to Disclose: HV, YJ, PAC

OR03-1 11776 1.0000 A Dynamic Chromosomal Reconfiguration of the Human Growth Hormone Gene Locus in Response to Excess Caloric Intake and Physical Activity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 1:00:00 PM OR03 4740 11:30:00 AM Factors Regulating HPA Axis Function Oral

Rocío Leal-Campanario*1, Juan Francisco Martin-Rodriguez2, Ainara Madrazo-Atutxa2, Victor D Ramos-Herrero1, Eva Venegas-Moreno3, Agnès Gruart1, Jose Maria Delgado-Garcia1, David A Cano4 and Alfonso Leal-Cerro5
1Division of Neurosciences, Pablo de Olavide University, Seville, Spain, 2Instituto de Biomedicina de Sevilla (IBiS), Consejo Superior de Investigaciones Científicas, Endocrinology Unit of Virgen del Rocío University Hospital, University of Seville, Sevilla, Spain, 3Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla & Endocrinology and Nutrition Unit, Virgen del Rocio, Seville, Spain, 4Endocrinology and Nutrition Unit, Institute of Biomedicine of Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Seville, Spain, 5Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío Seville, Sevilla, Spain

 

Growth hormone (GH) and IGF-I play a significant role in the structure and function of the developmental and mature brain. Moreover, neuroprotective and regenerative effects have been attributed to GH, and particularly IGF-I, in vitro and in vivo experimental models. Interestingly, chronic GH/IGF-I hypersecretion has been suggested to underlie cognitive deficits in acromegaly patients. In this research we aimed to test the hypothesis that chronic GH/IGF-I hypersecretion can result in cognitive deficits by studying cognitive functions in an animal model of chronic GH/IGF-I hypersecretion. Wistar Furth rats were s.c. injected with GH-producing GC cells to induce a GH-secreting tumor. Control rats were injected with PBS. In a group of tumor-implanted rats, tumor was surgically extirpated either 3 or 8 weeks after cell injection. GH and IGF-I levels returned to normal levels upon removal of the tumor. Learning and memory functions were assessed with associative learning tasks 12 weeks after cells implantation. The tests included appetitive operant conditioning and fear learning with the passive avoidance task. Tumor-bearing rats displayed better learning performance than both tumor-resected and control rats. Interestingly, rats in which the tumor was resected at 8 weeks showed better learning and memory performance than both control rats as well as rats in which tumor was resected at 3 weeks. To determine whether increased neurogenesis could underlie improved learning and memory performance, cell proliferation was analyzed by injecting rats with a daily dose of 5-bromo-2'-deoxyuridine (BrdU) (150 mg/kg) for 3 consecutive days and their brains dissected the day after the last BrdU injection for immunohistochemical analysis. Increased neurogenesis (higher number of BrdU-positive cells) in the dentate gyrus of the hippocampus was observed in both tumor-bearing rats and rats in which tumor was resected at 8 weeks compared with control rats. These results were confirmed by quantification of cells positive for doublecortin in the subgranular zone of the dentate gyrus. Altogether, our results suggest that chronic exposure to GH/IGF-I hypersecretion enhances cognitive function and that this effect remains even after GH/IGF-I levels are restored to normal values. Increased adult hippocampal neurogenesis could mediate the cognitive effects of GH/IGF-I hypersecretion.

 

Nothing to Disclose: RL, JFM, AM, VDR, EV, AG, JMD, DAC, AL

OR03-2 14382 2.0000 A Chronic Growth Hormone/IGF-I Hypersecretion Enhances Learning and Memory and Promotes Neurogenesis in Adult Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 1:00:00 PM OR03 4740 11:30:00 AM Factors Regulating HPA Axis Function Oral

Joseph R Kurian*1, Ei Terasawa2 and Jon E Levine1
1University of Wisconsin-Madison, Madison, WI, 2Univ of Wisconsin, Madison, WI

 

Puberty and reproductive function depend on the elevation of gonadotropin releasing hormone (GnRH) neuron activity. We previously found that increased activity of GnRH neurons is accompanied by epigenetic changes (1). Specifically, during neuronal maturation, GnRH mRNA levels rise while cytosine residues within the GnRH gene promoter are actively demethylated. Whether active DNA demethylation itself has an impact on neuron development and consequently reproductive function remains unknown. In these studies we aimed to determine whether Tet enzymes, which initiate the process of active DNA demethylation, influence neuronal function and reproduction. First, examining two GnRH neuronal cell lines with immature (GN11) and mature (GT1-7) neuronal characteristics, we found that expression of Tet1 and Tet2 is drastically lower in GN11 compared to the GT1-7 cells. Overexpression of Tet2 in GN11 cells increased GnRH mRNA levels and elevated mean GnRH peptide release in dynamic cultures. While glutamate alone had no impact, exposure of GN11 cells overexpressing Tet2 to glutamate increased GnRH mRNA to levels consistent with mature GT1-7 cells. Second, to evaluate the impact of Tet2 in vivo, we generated two separate sets of mice with selective disruption of Tet2 activity in GnRH (gTKO mice) and kisspeptin (kTKO) neurons. We found minimal impact on the timing of puberty in gTKO mice, perhaps due to developmental activation of the GnRH gene prior to Tet2 disruption. Notably, plasma lutenizing hormone (LH) levels were significantly lower in both male and female adult gTKO compared to WT animals, suggesting Tet2 might be necessary for the maintenance of GnRH neuron function in adulthood. In contrast, disruption of Tet2 in kisspeptin neurons had a more distinguishable influence on pubertal timing in male and female mice. Vaginal opening and regular estrus cycling was significantly delayed in kTKO females and the pubertal rise in plasma LH lagged for both male and female mice compared to WT littermates. Abnormal fecundity was not observed in female kTKO mice; however, for male kTKO animals the interval between pairing with a fertile female and litter birth was significantly longer than for WT males. Together, these studies implicate Tet2 as a mediator of epigenetic control over neuronal maturation and reproductive function. They further suggest that Tet2 activity is necessary for the maintenance of neuroendocrine control of gonadotropin release.

 

Nothing to Disclose: JRK, ET, JEL

OR03-3 13869 3.0000 A The Methylcytosine Dioxygenase Ten-Eleven Translocase-2 (Tet2) Enables Elevated GnRH Gene Expression and the Typical Development and Maintenance of Reproductive Function 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 1:00:00 PM OR03 4740 11:30:00 AM Factors Regulating HPA Axis Function Oral

Louise Cheryl Gregory*1, Simon James Rhodes2, Khadija Nuzhat Humayun3, Miles Jonathan Levy4, James Greening5 and Mehul Tulsidas Dattani6
1UCL Institute of Child Health, London, United Kingdom, 2Indiana Univ.-Purdue Univ. Indianapolis, Indianapolis, IN, 3Aga Khan University, Karachi, Pakistan, 4Leicester Royal Infirmary, Leicestershire, United Kingdom, 5Leicester Royal Infirmary, Leicester, United Kingdom, 6UCL GOS Institute of Child Health, London, United Kingdom

 

Introduction: The LHX4 gene encodes the LIM/homeobox protein (LHX4), which is a member of the LIM-homeodomain transcription factor protein family. These genes possess two specialized zinc-fingers termed the LIM domains; unique cysteine-rich zinc-binding domains. LHX4 is found in the nucleus and acts as a transcriptional regulator where it is involved in controlling differentiation and development of the pituitary gland and nervous system. To date, only incompletely penetrant or de novo, heterozygous mutations in LHX4 have been described in patients with variable combined pituitary hormone deficiencies (CPHD). Mice homozygous for LHX4 die shortly after birth from immature lungs that fail to inflate.

Objective/hypothesis: To investigate a cohort of patients with congenital hypopituitarism for mutations in LHX4.

Method: We screened 150 patients with CPHD (the vast majority having an ectopic posterior pituitary (EPP)) using PCR and direct sequencing analysis. Upon identification of any variants, control databases (1000 genomes, dbSNP, Exome Variant Server) were consulted for the change.

Results: We identified a novel homozygous missense mutation (c.377C>T, p.T126M) in two deceased male patients of Pakistani origin, born to non-consanguineous parents, with panhypopituitarism. Both sons had low set crumpled ears, small upturned nose with depressed nasal bridge, mid-facial hypoplasia, micropenis and undescended testes. The parents also had a daughter with a depressed nasal bridge. In spite of rapid commencement of hydrocortisone and thyroxine, all three children died within the first week of life. DNA analysis confirmed the presence of a homozygous p.T126M mutation, located in the LIM zinc-finger binding domain 2, predicted to alter protein-protein interaction. Additionally, we identified a novel heterozygous missense mutation (c.1009A>C, p.N337H) in a Caucasian female patient with isolated GHD (peak GH: 1.47ug/L) learning difficulties, obesity and an EPP. The mutation is in the C-terminal domain, possibly affecting protein folding. Both mutations are absent from control databases and are located at highly conserved residues.

Functional studies are currently underway in the form of reporter assays.

Conclusion: We report for the first time to our knowledge a novel homozygous mutation in LHX4 associated with a lethal phenotype; recessive mutations in LHX4 may be incompatible with life.

 

Nothing to Disclose: LCG, SJR, KNH, MJL, JG, MTD

OR03-4 12164 4.0000 A Novel Lethal Form of Hypopituitarism Associated with the First Recessive LHX4 Mutation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 1:00:00 PM OR03 4740 11:30:00 AM Factors Regulating HPA Axis Function Oral

Jennifer Park1, Zhiqiang Cheng1, Jong Youl Kim2, Chia-Ling Tu1 and Wenhan Chang*1
1University of California San Francisco, San Francisco, CA, 2University of California San Francisco

 

Adequate balances between mineral, skeletal, and energy metabolism are required to maintain a normal body growth. The hypothalamus (Hyp) regulates growth, skeletal development, and energy homeostasis by controlling autonomic activities and secretion of hormones in the pituitary gland (Pit). We detected robust expression of the extracellular Ca2+-sensing receptor (CaSR) in Hyp neurons. To test whether the CaSR, a putative receptor sensing changes in Ca2+ homeostasis, modulates neuroendocrine signals to control growth, skeletal, and energy metabolism, we generated NeuronCaSR-/- mice with CaSR knockout (KO) targeted to neurons by breeding floxed-CaSR mice with transgenic Nestin-Cre mice. Genomic DNA, immunoblotting, and qPCR analyses confirmed ablation of CaSR gene, protein, and RNA, respectively, in Hyp, but not in Pit, liver, kidney, and bone. The KO mice were born in normal Mendelian ratios, but had smaller body sizes (by ≈25% in weights) and small undermineralized skeleton compared to floxed-CaSR control (Cont) mice at 2 weeks and 3 months of age. qPCR analyses of RNA from the bones of the KO mice showed reduced expression of IGF-1 (by 30%) and osteocalcin, a marker of mature osteoblast, and increased expression of early osteoblast marker, type I collagen, indicating a delay in skeletal development.  In the KO mice, serum growth hormone (GH) and IGF-1 levels were reduced to <10% of Cont mice along with reduced expression of GH and GH-releasing hormone RNA by >60% in the Pit and Hyp, respectively, suggesting that a dysregulated Hyp-Pit-GH/IGF1 axis might have contributed to stunned growth and skeletal phenotypes of the KO mice. Despite their smaller body sizes, the KO mice have (1) increased visceral fats by ≈60%, as determined by DEXA and weights; (2) increased serum leptin levels by 2 folds; and (3) profound glucose intolerance, indicating dysregulated energy metabolism. Despite the elevated serum leptin levels, the expression of agouti-related protein (AGRP) and neuropeptide Y, which enhance feeding and decrease energy expenditure, were increased by 70 and 25%, respectively, while pro-opiomelanocortin (POMC), which suppresses feeding and increases energy expenditure, was decreased by ≈30% in the KO Hyp, indicating reduced sensitivity of POMC and AGRP neurons to leptin. Immunohistochemistry confirmed the expression of CaSR in the POMC and AGRP neurons. Additionally, in the KO mice, RNA levels for thyrotropin-releasing hormone and gonadotropin-releasing hormone were reduced by 35-60% in the Hyp and the expression of thyrotropin, follicle-stimulating hormone, and luteinizing hormone, was reduced by 40-60% in the Pit, indicating dysregulated Hyp-Pit-thyroid/adrenal and Hyp-Pit-Gonadal axes. Together, our data support a central role for neuronal CaSRs as a critical integrator of mineral, skeletal, reproductive, and energy metabolism by controlling hypothalamic functions.

 

Nothing to Disclose: JP, ZC, JYK, CLT, WC

OR03-5 16592 5.0000 A Neuronal Ca2+-Sensing Receptors (CaSRs) Modulate Growth, Energy Metabolism, and Skeletal Development By Controlling Hypothalamic Functions 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 1:00:00 PM OR03 4740 11:30:00 AM Factors Regulating HPA Axis Function Oral

Nastaran Foyouzi*1, Sally A Camper1, Michele Moreira2, Marcela M Franca2, Aline P Otto2, Fernanda de Azevedo Correa2, Ivo J P Arnhold2, Berenice B Mendonca2, Qianyi Ma1, Jun Z. Li1, Qing Fang1 and Luciani R S Carvalho3
1University of Michigan, Ann Arbor, MI, 2Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo FMUSP, São Paulo, Brazil, 3University of São Paulo, Hospital das Clinicas, São Paulo, Brazil

 

Mutations in the homeodomain transcription factor OTX2 cause variable and incompletely penetrant effects on craniofacial development that can include the eyes, hypothalamus, and pituitary gland [1, 2].  Mouse studies demonstrate that genetic variation in multiple loci can suppress or enhance the features associated with OTX2 dysfunction, but the genes underlying these loci are unknown [3].  Multiple pieces of evidence support the idea that hypopituitarism results primarily from the critical role of OTX2 in development of the neural ectoderm that gives rise to the hypothalamus, pituitary stalk, and posterior lobe (neurohypophysis) [4].  A proband with hypopituitarism ((GH, TSH, LH/FSH and ACTH deficiency), polydactyly, and normal eyes was ascertained in a large Brazilian pedigree with 4 unaffected siblings, and Sanger sequencing of candidate genes revealed a novel heterozygous variant in OTX2 (p.H230L).  This histidine is conserved across all vertebrate species and some in silico analyses predict that the leucine substitution is deleterious.  To test this prediction we transfected heterologous (293T) and homologous GnRH neuronal cell lines (GT1-7) with expression vectors for OTX2 and/or the p.H230L variant and assessed transactivation of reporter genes with either a consensus OTX2 binding site or the GnRHR promoter.  In both cell lines normal OTX2 produced robust activation of each reporter gene, while mutant OTX2 had no activity.  Mixing experiments suggest that the OTX2 variant exerts a dominant negative effect on normal OTX2 function.  This is consistent with the idea that the OTX2 variant (p.H230L) causes CPHD in this patient.  The proband’s mother is a p.H230L carrier with short stature (-2.4 SD), and 2 unaffected siblings are carriers with normal stature (sister -1.7SD, brother -0.4 SD).  All of these individuals have normal basal pituitary hormone levels.  The presence of polydactyly in the father and the proband suggests the possibility of digenic disease.  No other patients with OTX2 mutations are reported to have digital abnormalities.  We carried out exome sequencing on several family members to identify variants in other genes that could contribute to the proband’s phenotype.  No deleterious variants were detected in obvious candidate genes for hypopituitarism.  Ongoing analysis may reveal candidate genes for polydactyly segregating in this family.  Exome sequencing of other large families with incompletely penetrant effects of OTX2 mutations could identify modifier loci that influence the effects of OTX2 variation on normal craniofacial development and function.  This study underlines the difficulty of predicting the clinical consequences of deleterious genetic variation.

 

Nothing to Disclose: NF, SAC, MM, MMF, APO, FDAC, IJPA, BBM, QM, JZL, QF, LRSC

OR03-6 16490 6.0000 A A Novel OTX2 Mutation, p.H230L, Causes Hypopituitarism with Incomplete Penetrance: Exome Sequencing to Identify Modifier Genes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 1:00:00 PM OR03 4740 11:30:00 AM Factors Regulating HPA Axis Function Oral

Sarah J. Larkin*1, Veronica Angela Preda2, Niki Karavitaki3, Ashley B Grossman4 and Olaf Ansorge1
1University of Oxford, Oxford, United Kingdom, 2Royal North Shore Hospital, Sydney, Australia, 3Oxford Center for Diabetes, Oxford, United Kingdom, 4Oxford Centre for Diabetes, Endocrinology & Metabolism

 

Mutations in BRAF and CTNNB1 genetically distinguish papillary and adamantinomatous craniopharyngiomas

Craniopharyngiomas are epithelial, sellar tumours comprising two subtypes: adamantinomatous (aCP) and papillary (pCP). The adamantinomatous form occurs predominantly during childhood whereas the papillary form is more common in adults. aCPs often contain mutations in CTNNB1, encoding β-catenin: a component of the adherens junction and mediator of Wnt signaling. The tumorigenic mechanism underlying pCPs is not well understood. In a large series of craniopharyngiomas (61 aCP, 25 pCP) we show that the adamantinomatous subtype harbours mutations in CTNNB1 in 44% of cases sequenced, while the papillary subtype has BRAF V600E mutations in 91% of cases sequenced, indicating that these lesions are genetically distinct with differing tumorigenic mechanisms, namely Wnt pathway (aCP) and MAPK pathway activation (pCP).  An antibody to the BRAF V600E mutation (clone VE1) proved less reliable than sequencing for detection of BRAF V600E mutation, but for specimens with little epithelium, immunohistochemistry may prove useful. While CTNNB1 mutation - when present - is found throughout aCPs, translocation of β-catenin from membrane to cytosol and nucleus is restricted to small cell clusters near the invading tumour front. We observed translocated β-catenin in 100% of aCPs, occurring not only in cell clusters but also in individual cells scattered throughout the tumour. There was no disruption of the adherens junction in these tumours indicating that loss of junction integrity is not associated with β-catenin translocation or mutation. Translocation of β-catenin from membrane to cytosol and nucleus in aCPs and mutation in V600E in pCPs offers a potential marker for differential diagnosis. Furthermore the availability and clinical efficacy of mutant BRAF inhibitors presents an opportunity for directed therapy in patients with pCPs. While mutations in CTNNB1 and BRAF underlie tumorigenesis in the majority of craniopharyngiomas, the tumorigenic event in the remaining population is unknown.

 

Disclosure: NK: Principal Investigator, HRA Pharma. Nothing to Disclose: SJL, VAP, ABG, OA

OR09-1 16970 1.0000 A Mutations in BRAF and CTNNB1 Genetically Distinguish Papillary and Adamantinomatous Craniopharyngiomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 1:00:00 PM OR09 4742 11:30:00 AM Non-Functioning Pituitary Tumors and Craniopharyngioma: Pathology and Survival Oral

Hiroshi Nishioka*1, Ozgur Mete2, Sylvia L. Asa3, Naoko Inoshita1, Noriaki Fukuhara4, Kentaro Horiguchi5 and Shozo Yamada4
1Toranomon Hospital, Tokyo, Japan, 2University Health Network, Toronto, ON, Canada, 3Univ Health Network, Toronto, ON, Canada, 4Toranomon Hosp, Tokyo, Japan, 5Chiba University Medical School, Chiba, Japan

 

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Objective

Clinically nonfunctioning pituitary adenomas (NFA) are histologically classified into null cell adenomas (NCA) and silent adenomas. NCA are considered to represent undifferentiated adenomas with no adenohypophysial hormone immunoreactivity and no specific adenohypophysial differentiation. In 2008, Asa et al proposed to add lack of transcription factors for each adenohypophysial cell lineage to the definition of NCA. The aim of the present study is to classify NFA using the new classification system and to detect clinicopathological features of each subtype.

Materials

Based on hormone immunostainings, 516 consecutive cases of NFA, operated on between 2008 and 2011, were initially classified as: 119 NCA, 300 silent gonadotroph adenomas (SGA), 51 silent corticotroph adenomas (SCA), and 46 other silent adenomas. In 119 cases of NCA, immunohistochemistry for transcription factors including SF-1, estrogen receptors (ER), Pit-1, and Tpit was performed.

Results

119 NCA showed lineage-specific differentiation as gonadotrophs (SF-1- and ER-positive), corticotrophs (Tpit-positive), or somatomammothyrotrophs (Pit-1-positive) in 78 cases, 36 cases, and 2 cases, respectively. Only three cases (0.6%) were true NCA, i.e. conventional NCA with no lineage-specific differentiation at the transcription factor level. The 36 ACTH-negative, Tpit-positive adenomas (7.0%) showed female preponderance (P<0.0001), were more frequently giant (P=0.0028) and were associated with cavernous sinus invasion (P<0.0001) compared with 378 SGA; these features were identical to those of the previously classified 51 cases SCA in this series.

Conclusions

Our results show that the use of pituitary transcription factors (SF-1, ER, Tpit, and Pit-1) prevents hormone-immunonegative adenomas from being mistakenly classified as NCA. Our data suggest that 30% of hormone-negative pituitary adenomas are SCA and share distinct clinicopathological features of ACTH-expressing SCA. This histological classification of NFA more accurately characterizes biological behavior and can predict postoperative prognosis.

 

Nothing to Disclose: HN, OM, SLA, NI, NF, KH, SY

OR09-2 11322 2.0000 A The Crucial Role of Pituitary Transcription Factors in the Accurate Classification of Hormone-Negative Nonfunctioning Pituitary Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 1:00:00 PM OR09 4742 11:30:00 AM Non-Functioning Pituitary Tumors and Craniopharyngioma: Pathology and Survival Oral

Laura C. Hernandez Ramirez*1, Plamena Gabrovska2, Judit Dénes1, Giampaolo Trivellin3, Serban Radian4, Daniel Tilley1, Francesco Ferraù2, Scott Alexander Akker5, Ashley B. Grossman6, Mônica Gadelha7, Márta Korbonits1 and The International FIPA Consortium2
1Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom, 2Barts and The London School of Medicine, London, United Kingdom, 3National Institutes of Health (NIH), Bethesda, MD, 4William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom, 5St Bartholomew's Hospital, London, United Kingdom, 6University of Oxford, Oxford, United Kingdom, 7Clementino Fraga Filho University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil

 

Introduction: The variable penetrance displayed by germline AIP mutations (AIPmut) could theoretically be explained by mutation-specific phenotypes or by other disease-modifying genes. Somatic GNAS1 mutations are frequent in sporadic somatotropinomas, and are associated with a relatively benign phenotype. In contrast, an apparent correlation between the germline FGFR4 G388R variant and somatotroph adenoma size and GH levels has been described. We evaluated the influence of the type of AIP mutations and these two disease-modifying genes on the clinical features of pituitary adenoma (PA) patients in a large cohort of familial isolated pituitary adenoma (FIPA) and simplex AIPmut positive patients.

Methods: We studied 37 AIPmut positive FIPA families, including 113 patients and their unaffected relatives, and 34 apparently sporadic young-onset (≤30 years) PA patients with AIPmut. DNA from 22 AIPmut positive paraffin-embedded somatotropinomas was screened for GNAS1 mutations. Additionally, 98 AIPmut positive patients and 108 unaffected AIPmut carriers were screened for FGFR4 G388R.

Results: Of the 31 different AIPmut detected (10 not previously published), 70.9% were predicted to produce a truncated protein. Patients with truncating mutations had a younger age at onset (median 16 [IQR15-25] vs. median 22 [IQR17.3-27.8], P<0.01), and at diagnosis (median 21 [IQR 16-30] vs. median 27 [IQR 20.8-37], P<0.01) than those with non-truncating mutations, concluding that AIPmut truncating mutations cause an earlier disease onset in FIPA. GNAS1 mutations were absent in all the tumors studied. The absence of GNAS1 mutations in AIPmut positive adenomas is concordant with the relative resistance to somatostatin analog therapy described in this setting. Ninety-four (45.6%) of the screened individuals were hetero- or homozygous for FGFR4 G388R; the genotype distribution was similar between patients and carriers. Age at onset/diagnosis, tumor size and extrasellar invasion were not significantly different between GG and GR/RR individuals. The FGFR4 G388R SNP does not seem to influence the disease penetrance or to confer additional features of aggressiveness in AIPmut positive FIPA.

Conclusions: Younger age of onset is characteristic in truncating AIPmut patients compared to those with non-truncating mutations. No somatic GNAS1 mutations are present in AIPmut somatotroph adenomas. The FGFR4 G388R variant does not influence the penetrance or clinical features of AIP-related pituitary adenomas.

 

Disclosure: ABG: Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Ipsen, Advisory Group Member, HRA Pharma, Advisory Group Member, Viropharma. MG: Collaborator, Novartis Pharmaceuticals, Medical Advisory Board Member, Novartis Pharmaceuticals, Collaborator, Ipsen, Collaborator, Pfizer, Inc., Principal Investigator, Novartis Pharmaceuticals, Researcher, Novartis Pharmaceuticals, Researcher, Pfizer, Inc.. MK: Researcher, Pfizer, Inc., Researcher, Novartis Pharmaceuticals, Researcher, Syntaxin, Consultant, Pfizer, Inc., Consultant, Chiasma, Consultant, Sanofi, Consultant, Syntaxin. Nothing to Disclose: LCH, PG, JD, GT, SR, DT, FF, SAA, TIF

OR09-3 13830 3.0000 A Pituitary Adenomas Harboring AIP Mutations Exhibit Phenotype-Genotype Correlation, but No Association with the Germline FGFR4 G388R Variant or Somatic GNAS1 Mutations 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 1:00:00 PM OR09 4742 11:30:00 AM Non-Functioning Pituitary Tumors and Craniopharyngioma: Pathology and Survival Oral

Mark J McCabe*1, Mark J Cowley1, Jiang Tao1, Kerith-Rae Dias1, Tanya Thompson1, Marcel E Dinger1 and Ann I McCormack2
1Garvan Institute of Medical Research, Sydney, Australia, 2St. Vincent's Hospital, Sydney, Australia

 

Background: In the past few years, new genes involved with familial predisposition to pituitary tumour development have been recognised, including AIP and SDHx. In routine clinical care, these genes are tested individually, guided by clinical presentation with significant cost and efficiency implications. These factors are likely to underestimate the occurrence of familial pituitary tumour predisposition, commonly thought to account for 5% of all pituitary tumours. Furthermore, the clinical management of aggressive pituitary tumours is challenging, particularly when tumours exhibit resistance to standard hormonal agents and temozolomide. 

Methods: We have developed a custom next generation sequencing (NGS) panel (Roche/Nimblegen) which contains the 8 known familial pituitary tumour genes (MEN1, AIP, PRKAR1A, p27, SDHA-D), plus 25 genes implicated in embryonic pituitary development and a further 267 genes that have been implicated in various cancers and cancer-related pathways (~0.9 Mb target sequence). Subjects recruited for testing include those under the age of 40 with a sporadic pituitary tumour, or patients with a family history of pituitary tumours or other endocrine neoplasia. DNA extracted from blood is interrogated using our 300-gene panel (Illumina HiSeq 2500 sequencing). Raw sequencing data was analysed by a custom bioinformatic pipeline, with mutations being functionally assessed in silico. In addition, whole exome and transcriptome sequencing was applied to DNA and RNA extracted from blood and tumour of a patient with a highly aggressive ACTH-secreting pituitary tumour, who had failed all standard treatments including temozolomide. 

Results: In this ongoing study, sequence analysis using our gene panel detected three patients from 12 tested, with germline mutations in AIP (p.F269F, p.A299V, p.R106C) and verified by Sanger sequencing. In addition, RNA from the aggressive pituitary tumour was found to have high expression of the VEGF signalling pathway which may indicate suitability for trial of Bevacizumab, an inhibitor of VEGF-A. 

Conclusions:   We have demonstrated the clinical utility of NGS in patients with pituitary tumours. Use of a comprehensive gene panel allows concurrent testing of multiple genes, and potentially exploration of new predisposition genes and otherwise unrecognised clinically significant parallel genomic variations. Whole exomic and RNA expression analyses may allow new treatment targets to be identified.

 

Nothing to Disclose: MJM, MJC, JT, KRD, TT, MED, AIM

OR09-4 15576 4.0000 A Next Generation Sequencing: Towards a New Clinical Frontier in the Diagnosis and Management of Pituitary Tumours 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 1:00:00 PM OR09 4742 11:30:00 AM Non-Functioning Pituitary Tumors and Craniopharyngioma: Pathology and Survival Oral

Daniel S Olsson*1, Eva Andersson2, Ing-Liss Bryngelsson3, Anna G Nilsson1 and Gudmundur Johannsson1
1Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden, 2Sahlgrenska University Hospital, Gothenburg, Sweden, 3Örebro University Hospital, Örebro, Sweden

 

Excess mortality has been described in adult patients with craniopharyngioma (CP) in small retrospective studies at tertiary care centers. Our aim was to investigate mortality, morbidity and incidence rate in CP patients and to examine the influence of age at diagnosis and hypopituitarism on the outcome in a nationwide register-based population study.

CP patients were identified and followed in national health registers in Sweden. Search criteria for CP were tested and validated in 28% of the total population where detailed patient records were accessible. Standardized mortality ratios (SMRs), standardized incidence ratios (SIRs) and annual incidence rates were calculated.

Included in the analysis were 307 CP patients (151 men, 156 women) diagnosed between 1987 and 2011. Mean follow-up time was 9 years (range 0-25). Patients with childhood-onset CP (COCP) and adult-onset CP (AOCP) were 106 and 201, respectively. Hypopituitarism was reported in 250 patients, 110 patients had diabetes insipidus (DI) and 54 patients had neither.

Mean annual incidence was 1.7/million inhabitants. The observed number of deaths during the study was 54 compared to the expected number of 14, resulting in an SMR of 3.8, 95% CI 2.9-5.0 (men: 3.2, CI 2.2-4.7: women: 4.9, CI 3.2-7.2). SMR for COCP of 17 (CI 6.3-37) was significantly higher than for AOCP, 3.5 (CI 2.6-4.6). SMR in patients with hypopituitarism was 4.3 (CI 3.1-5.8), with DI 6.1 (CI 3.5-9.7) as compared to 2.7 (CI 1.4-4.6) in patients without hypopituitarism and DI. SMR due to cerebrovascular diseases was increased, 5.1 (CI 1.7-12). The mortality was also increased in patients with prior radiation therapy (SMR 5.9, CI 2.9-11). Average years of life lost was 14.6 for all, 55 for COCP patients and 9.6 for AOCP patients. SIRs for all patients were increased for type 2 diabetes mellitus (6.3, CI 3.8-8.0), cerebral infarctions (7.1, CI 5.0-9.9), fractures (2.1, CI 1.4-3.0) and infections leading to hospitalization (5.9, CI 3.4-9.4). SIR for malignant tumors was not increased, 1.3 (CI 0.8-2.1).

This first population-based study of CP patients demonstrated an excess mortality ratio in CP patients that was markedly higher in COCP than in AOCP. Prior radiotherapy and anterior and posterior pituitary hormone deficiency had a negative impact on the prognosis. CP patients suffered from an increased disease burden of type 2 diabetes mellitus, cerebral infarctions, fractures and severe infections. These findings demand a substantial improvement in the treatment and follow-up of CP patients with the aim to prevent early death.

 

Disclosure: DSO: Speaker, Pfizer, Inc.. AGN: Consultant, Viropharma. GJ: Speaker, Pfizer, Inc., Speaker, Novo Nordisk, Speaker, Otsuka, Consultant, Viropharma, Consultant, Astra Zeneca. Nothing to Disclose: EA, ILB

OR09-5 13467 5.0000 A Mortality and Morbidity in 307 Patients with Craniopharyngioma – a Population Based Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 1:00:00 PM OR09 4742 11:30:00 AM Non-Functioning Pituitary Tumors and Craniopharyngioma: Pathology and Survival Oral

Daniel S Olsson*1, Gudmundur Johannsson2, Ing-Liss Bryngelsson3, Penelope Trimpou2, Anna G Nilsson1 and Eva Andersson2
1Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden, 2Sahlgrenska University Hospital, Gothenburg, Sweden, 3Örebro University Hospital, Örebro, Sweden

 

Adult hypopituitarism due to various causes, including non-functioning pituitary adenomas (NFPAs), has been associated with an excess risk of death. The aim was to investigate mortality in NFPA patients and to examine whether gender, hormonal deficiencies and other clinical characteristics influenced the outcome in a nationwide register-based population study.

NFPA patients were identified and followed in national health registers in Sweden. Search criteria for NFPA were tested and validated in 17% of the total population where detailed patient records were accessible. Standardized mortality ratios (SMRs) with 95% confidence intervals (CI) and annual incidence rates with means and 95% CIs were calculated.

Included in the analysis were 2795 patients (1502 men, 1293 women), diagnosed with NFPA between 1987 and 2011. Mean (±SD) age at diagnosis was 58±17 years (men 60±15; women 56±18; p-value <0.001). Hypopituitarism was reported in 1500 patients and diabetes insipidus (DI) in 145 patients. Mean follow-up time was 6 years (range 0-25) with 20 139 patient-years included in the analysis.

Mean annual incidence of NFPA in Sweden was 20.3 (CI 18.8-21.9) cases per million inhabitants. The incidence was significantly higher in men compared to women (21.8, CI 19.7-23.9 vs. 18.9, CI 17.8-19.9; p-value=0.03). The observed number of deaths during the study was 473 compared to the expected number of 431, resulting in a SMR of 1.10, CI 1.00-1.20 (men: 1.00, CI 0.88-1.12; women: 1.29, CI 1.11-1.48). SMR for patients with onset of NFPA ≤40 years of age was 2.68 (CI 1.23-5.09). SMR for patients with hypopituitarism was 1.06, CI 0.94-1.19 (men: 0.94, CI 0.81-1.08; women 1.38, CI 1.12-1.66) and for patients with DI 1.71, CI 1.07-2.58 (men: 1.26, CI 0.60-2.31; women 2.43, CI 1.26-4.25), respectively. SMRs due to cerebrovascular and infectious diseases were increased to 1.73 (CI 1.34-2.19) and 2.08 (CI 1.17-3.44), respectively, whereas death caused by ischemic heart disease was not increased (SMR 1.09, CI 0.88-1.34). SMR for malignant tumors was decreased to 0.76 (CI 0.61-0.94). Mortality in patients with one pituitary surgical treatment was normal (SMR 1.01, CI 0.84-1.20), but increased in patients treated with radiation therapy (2.67, CI 1.79-3.84).

This nationwide study of patients with NFPA demonstrated an excess mortality ratio, mainly due to increased deaths from cerebrovascular and infectious diseases. The worst prognosis was seen in women, patients with early onset of the disease, patients with DI and those who had received radiation therapy.

 

Disclosure: DSO: Speaker, Pfizer, Inc.. GJ: Consultant, Astra Zeneca, Consultant, Viropharma, Speaker, Otsuka, Speaker, Novo Nordisk, Speaker, Pfizer, Inc.. AGN: Consultant, Viropharma. Nothing to Disclose: ILB, PT, EA

OR09-6 13474 6.0000 A Women and Young Patients with Non-Functioning Pituitary Adenoma Have an Excess Mortality – a Nationwide Study Based on More Than 20 000 Patient-Years 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 1:00:00 PM OR09 4742 11:30:00 AM Non-Functioning Pituitary Tumors and Craniopharyngioma: Pathology and Survival Oral

Leon S Farhy*, Ralf Manfred Nass, Jianhua Liu, Suzan S Pezzoli, Bruce D Gaylinn and Michael O Thorner
University of Virginia Health System, Charlottesville, VA

 

Background.Ghrelin is a gut peptide that regulates GH, appetite and metabolism. Its primary source, the stomach X/A-cells, co-secrete two main forms:  acyl-ghrelin (AG) and desacyl-ghrelin (DG). Both increase before meals and at midnight on a typical fed day, AG decreases with long-term fasting [1], and AG and DG are inhibited by insulin [2]. AG regulation may depend also on the time elapsed from the last meal, since ghrelin acylation decreases with fasting [3]. Here, we test whether under low insulin conditions, total ghrelin (TG=AG+DG) is still controlled by insulin and also by a separate process of progressive secretion decline.

Methods.  Seven men, age (mean±SD) 21±2.9yr; BMI 22±2.9kg/m2 were studied twice on the Clinical Research Center. At 8 AM after an overnight fast, blood was sampled every 10 min for 26 hr for AG and DG using an in-house two-site sandwich assay. On one (fed) admission, 3 meals were served at 8 AM, 1 PM and 6 PM. No meals were served on the other (fasting) admission. Changes in circulating ghrelin were assessed during 6-hr periods: P1 (8 AM-2 PM); P2 (2 PM-8 PM); P3 (8 PM-2 AM); P4 (2 AM-8AM). To minimize the confounding effect of meals, periods P1 and P2 on the fed admission were not studied. Ghrelin regulation was analyzed by testing the ability of 3 mathematical models to describe the changes in TG. Model MI includes suppression by insulin and model MD assumes a secretion decline as time progresses. A combined model, MID, assumes suppression by insulin and separate gradual decline with time. Two information criteria (IC) were used to compare model performance.

Results. In the fed admission AG declined overnight (P3 vs. P4: 32.6±9.8 vs. 23.5±6.28 pg/mL; p=0.035).  DG and TG decreased, but not significantly (DG: 70.0±16.70 vs. 67.2±14.74 pg/mL, p=0.62; TG: 102.4±24.02 vs. 90.2±18.42 pg/mL, p=0.18). During the fasting admission, AG declined 3 fold:  28.2±9.67 (P1), 28.3±10.47 (P2), 18.9±6.98 (P3),  9.5±3.81 pg/mL (P4), p=0.002; DG declined 1.3 fold:  83.7±23.70 (P1), 80.3±22.76 (P2), 79.0±22.60 (P3), 65.2±17.56 pg/mL (P4), p=0.02; and TG decreased 1.5 fold: 112.4±27.58 (P1), 106.6±26.70 (P2), 96.41±25.55 (P3), 75.5±19.07 pg/mL (P4), p=0.0003.  Model MI was the worst performer with higher IC values than MD and MID (p<0.05). MD was outperformed by MID during the fasting admission (p=0.02) and had one of the two IC values lower during the fed admission (p=0.02). Overall, model MID was the best performer and explained 64.4% of the variance of TG.

Conclusions. Our findings support the hypothesis that the changes in circulating total ghrelin depend jointly on inhibition by insulin (even under low-insulin conditions) and on a separate process of progressive secretion decline. This process may depend on the time elapsed since the last meal and may be also influenced by the circadian clock.

 

Nothing to Disclose: LSF, RMN, JL, SSP, BDG, MOT

OR05-1 14874 1.0000 A Evidence for Joint Regulation of Circulating Total Ghrelin By Insulin Suppression and a Separate Process of Secretion Decline in Healthy Young Men 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 1:00:00 PM OR05 4749 11:30:00 AM Ghrelin and GHRH in Human Obesity Oral

Richard C Brown1, Anna L Hopkins1, Charlotte L Lewis1, Irina A Guschina1, Helen C Christian2, Jeffrey S Davies3 and Timothy Wells*1
1Cardiff University, Cardiff, United Kingdom, 2University of Oxford, Oxford, United Kingdom, 3Swansea University, Swansea, Wales, United Kingdom

 

Although unacylated ghrelin (UAG) does not activate the growth hormone secretagogue receptor (GHS-R) (1), it does exert a distinct spectrum of biological actions.   For example, unlike acylated ghrelin (AG), which promotes adipogenesis in most depots, UAG stimulates adipogenesis in bone marrow (2), but not in intra-abdominal white adipose tissue (WAT) (3).   Since a receptor mediating these actions of UAG has not been identified, we investigated the interaction of UAG with GHS-R in bone marrow in greater detail.

As previously shown in rats (2), intra-bone marrow (ibm) infusion of AG and UAG induced adipogenesis in wild-type (WT) mice, increasing the number of tibial marrow adipocytes by 90 and 68% respectively (p<0.001 & 0.05).   Surprisingly, these effects of AG and UAG were abolished in loxTB-GHS-R (GHS-R-null) littermates (4), AG- and UAG-treated mice having 100 and 88% of marrow adipocytes in vehicle-treated animals.   Since this suggested that UAG may be acylated in bone marrow, we used capillary gas chromatography with flame ionization detection to reveal that isolated tibial marrow adipocytes contain observable amounts of octanoic acid, the substrate used for activation.   In addition, fluorescence immunohistochemistry demonstrated that, unlike stomach (which expressed the activating enzyme, ghrelin O-acyl transferase (GOAT), but not the adipocyte-specific marker, PPARγ) and intra-abdominal WAT (which expressed PPARγ, but not GOAT), tibial marrow adipocytes show prominent co-expression of both PPARγ and GOAT.   Immunogold electron microscopy revealed that GOAT immunoreactivity was located in the membrane of the lipid trafficking vesicles and the plasma membrane of tibial marrow adipocytes.   Finally, although a tibial ibm infusion of UAG increased adipocyte number by 120% in WT littermates (p<0.05), this effect of UAG was completely abolished in GOAT-null mice (5).

Thus, our data demonstrate that the adipogenic effect of UAG in tibial marrow is dependent upon acylation by GOAT and subsequent activation of GHS-R.   This suggests not only that GOAT may acylate extracellular UAG, but implies that the local expression of the elements of this hormone activation system, together with the relative physico-chemical properties of AG and UAG, may determine the different activity spectra of these two hormones.

 

Nothing to Disclose: RCB, ALH, CLL, IAG, HCC, JSD, TW

OR05-2 14853 2.0000 A The Adipogenic Action of Unacylated Ghrelin in Murine Bone Marrow Is Mediated By Ghrelin O-Acyl Transferase and the Growth Hormone Secretagogue Receptor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 1:00:00 PM OR05 4749 11:30:00 AM Ghrelin and GHRH in Human Obesity Oral

Philippe Zizzari, Yacine Chebani, Khadidja Chettab, Marie Pastor, Marie Korostelev, Jacques P Epelbaum, Virginie Tolle and Jacques Pantel*
INSERM UMR-S 894, Université Paris Descartes, Paris, France

 

The deciphering of the physiological importance of the GH secretagogue receptor (Ghsr), a G protein-coupled receptor (GPCR) depicted as the sole receptor of the pleiotropic hormone ghrelin, was initially compromised by the modest phenotype observed in Ghsr-/- animals.  This lack of a robust response to total loss of Ghsr may result from developmental compensatory signals. Still, the description of rare mutations in the GHSR partially affecting receptor function in patients with short stature or partial GH-deficiency allowed us to ascertain its role in somatic growth (1-2). Thus, we hypothesized that a recently generated line of rats carrying a premature termination codon in the Ghsr gene (Q343X) might be an ideal model to explore Ghsr physiology. Prior to exploring the phenotype of these animals, we deciphered the mechanism of action of this specific mutation using HEK293 cells transfected with HA-tagged and/or eYFP- or rLuc-chimeras of the wild-type (WT) or mutant rat Ghsr. The Q343X mutation does not impair cell surface expression of Ghsr. The functional analysis of this GPCR in calcium flux experiments revealed that, compared to the WT isoform, the mutant isoform has an increased potency as well as a major increase of the maximal response in the presence of increasing concentrations of ghrelin (EC50= 1.5±0.5 nM and 0.5±0.2 nM; Emax= 25±0.6% and 37±0.8 %, respectively, Mean± sem, n=2). Similar patterns of response were also found in reporter gene assays depicting the serum-response elements (SRE) or cAMP-response elements (CRE) pathways. Of note, when subjected to a maximal dose of ghrelin, internalization of the mutated receptor is blunted compared to the WT receptor. Finally, bioluminescence resonance energy transfer (BRET) experiments suggest that this results from a severe impairment of the ligand-induced β-arrestin2 recruitment. Overall, these in vitro observations are supportive of a gain-of function associated to the Ghsr Q343X mutant allele. Interestingly, our very first in vivo data are consistent with an increased body weight and chow intake in adult rats carrying the mutated allele. To our knowledge, these mutant rats represent the first description in mammals of a functionally significant gain-of-function mutation in the Ghsr. This model therefore deserves an extensive phenotypic evaluation.

 

Nothing to Disclose: PZ, YC, KC, MP, MK, JPE, VT, JP

OR05-3 14364 3.0000 A Putative Gain-of-Function in Rats Carrying the Ghsr Q343X Mutation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 1:00:00 PM OR05 4749 11:30:00 AM Ghrelin and GHRH in Human Obesity Oral

Ralf Manfred Nass*1, Leon S Farhy1, Jianhua Liu1, James Patrie2, Suzan S Pezzoli1, Bruce D Gaylinn1 and Michael O Thorner1
1University of Virginia Health System, Charlottesville, VA, 2University of Virginia, School of Medicine, Charlottesville, VA

 

Background: Acyl-ghrelin is a 28-amino acid peptide released from the stomach. It has both orexigenic effects and stimulates growth hormone (GH) release. In-vitro, an increase in beta-1 adrenergic activity stimulates acyl-ghrelin release from cultured ghrelin cells (1). Similar studies in humans have not been reported. We tested the hypothesis that beta-1 adrenergic blockade suppresses circulating acyl-ghrelin concentrations.

Methods: Five healthy young men age (mean ± SD) 25.4 ± 5.1 yr; BMI 24.9 ± 2.6 kg/m2 were studied in a single-blind, placebo-controlled study during 4 outpatient admissions on the Clinical Research Unit. The volunteers received each of the following interventions on separate admissions in random order at 0900h: a) atenolol (100 mg) tablet and s.c. glucagon (1 mg); b) placebo tablet and s.c. glucagon; c) atenolol and s.c. saline; d) placebo tablet and s.c. saline. Subjects also took atenolol or placebo at 0900h for 2 days prior to admission. During the admission blood was drawn every 10 min for 7 hr (0800h-1500h) for measurement of acyl-ghrelin, insulin and blood glucose (BG) concentrations. A moving average was computed for each intervention and the fold change from baseline and nadir was analyzed. A Wilcoxon matched pair test was used for statistical analysis; p<0.05 was considered statistically significant.

Results:

  • There was no significant difference between the mean baseline acyl-ghrelin (pg/ml) concentrations between placebo and atenolol treatments.
  • In response to glucagon, BG and insulin peaked and then declined. Acyl-ghrelin levels tended to decrease in parallel with the glucagon-stimulated increase in BG and insulin (p=0.125).
  • Atenolol had no impact on the decrease in acyl-ghrelin (fold change from baseline).
  • Acyl-ghrelin concentrations rebounded on the decline of BG and insulin; the rebound (fold change from nadir) showed a trend to higher values with glucagon/atenolol when compared to glucagon/placebo (p=0.0625).

Conclusions: Blocking the beta-1 adrenergic receptor did not change baseline acyl-ghrelin levels. Administration of glucagon resulted (indirectly) in an initial decrease followed by a rebound-like increase in acyl-ghrelin levels. There was a trend for higher rebound acyl-ghrelin levels during beta-1 adrenergic receptor blockade.

 

Nothing to Disclose: RMN, LSF, JL, JP, SSP, BDG, MOT

OR05-4 13312 4.0000 A Effect of Beta-1 Adrenergic Blockade on Acyl-Ghrelin Release in Healthy Young Adults 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 1:00:00 PM OR05 4749 11:30:00 AM Ghrelin and GHRH in Human Obesity Oral

JI-an Chen1, Bobby O Guillory2 and Jose Manuel Garcia*3
1Third Military Medical University, 2Baylor College of Med, Houston, TX, 3MEDVAMC/ Baylor Coll of Med, Houston, TX

 

Cachexia and muscle atrophy are common and often lethal consequences of cancer and, paradoxically, of chemotherapy administration. The novel hormone ghrelin has been proposed as a treatment for cachexia. However its mechanisms of action are not well-understood. We characterized the molecular pathways involved in muscle atrophy induced by tumor implantation and by cisplatin administration. We also determined the effects of ghrelin in these settings and the mechanisms mediating these effects in muscle.

We show here how multiple pathways interact and are involved in the development of cachexia; either induced by a tumor or, paradoxically, by the chemotherapeutic agent cisplatin. Ghrelin prevented the anorexia, fat loss, muscle loss and weakness induced by cisplatin or tumor. Activation of p38/C/EBPβ, myostatin, and inflammatory cytokines (in tumor-bearing animals) and a decrease in akt and Myogenin/myoD ultimately leads to increased proteolysis, and decreased muscle mass and strength. Ghrelin prevents muscle atrophy by decreasing inflammation, and by downregulating the p38/C/EBPβ/myostatin pathway and increasing akt phosphorylation and activating myogenin and myoD. These changes appear, at least in part, to target muscle cells directly and to be GHSR1a-independent.

Experiments in GHSR-1a KO animals suggest that although this receptor is necessary for ghrelin’s effect on food intake and adipose tissue, it only partially mediates ghrelin’s effect on muscle. Ghrelin also decrease mortality in tumor bearing animals, highlighting the clinical relevance of these findings.

In summary, we characterize the effect of ghrelin in different models of cancer-related cachexia and show how multiple pathways are modulated leading to the prevention of muscle atrophy, weakness and ultimately death.

 

Disclosure: JMG: Consultant, Helsinn Therapeutics, Investigator, Aeterna Zentaris, Investigator, Helsinn Therapeutics. Nothing to Disclose: JAC, BOG

OR05-5 16096 5.0000 A Ghrelin Prevents Cancer-Related Muscle Wasting through a Combination of Ghsr-Dependent and Independent Mechanisms 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 1:00:00 PM OR05 4749 11:30:00 AM Ghrelin and GHRH in Human Obesity Oral

Takara L. Stanley*1, Meghan N. Feldpausch1, Jinhee Oh2, Karen L Branch3, Hang Lee2, Martin Torriani4 and Steven K. Grinspoon5
1Massachusetts General Hospital and Harvard Medical School, Boston, MA, 2Massachusetts General Hospital, Boston, MA, 3Massachusetts General Hospital, 4Massachusetts General Hospital/ Harvard Medical School, Boston, MA, 5Massachusetts General Hospital/Harvard Medical School, Boston, MA

 

Background:  Non-alcoholic fatty liver disease (NAFLD) is common in HIV-infected patients  and is strongly associated with increased visceral adiposity.  A growth hormone (GH) releasing hormone analogue, tesamorelin, increases endogenous pulsatile GH secretion and reduces visceral adiposity in HIV-infection, but its effects on liver fat are not known. 

Objective:  To determine the effects of tesamorelin on liver fat in HIV-infected individuals with increased visceral adiposity, with the hypothesis that tesamorelin will significantly reduce liver fat.

Methods:   50 HIV-infected, antiretroviral-treated men and women with abdominal fat accumulation were randomized in a 1:1 ratio to receive tesamorelin 2mg subcutaneously daily or identical placebo for 6 months in a double-blind trial.  Primary endpoints were changes in visceral fat and in liver fat as measured by 1H-magnetic resonance spectroscopy.  Secondary endpoints included glucose and insulin sensitivity.  Euglycemic hyperinsulinemic clamp was performed in 50% of randomly selected patients.

Results:  At baseline, visceral fat and liver fat were strongly positively associated (ρ = 0.42, P = 0.003), and both showed strong associations with measures of glucose homeostasis and lipids.  Both VAT (ρ =     -0.43, P = 0.003) and liver fat (ρ = -0.44, P = 0.003) were negatively associated with baseline overnight mean GH; neither was associated with baseline IGF-1.  Tesamorelin treatment increased endogenous GH secretion, as evidenced by significant increases in IGF-1 (Δ IGF-I Z score +1.1±0.3 vs. -0.1±0.2, tesamorelin (T) vs. placebo (P), p=0.004) and mean overnight GH (Δ +0.35 [0.15, 0.57] vs. -0.01 [-0.07, 0.06] ng/mL, T vs. P, p=0.0007).  Tesamorelin significantly reduced VAT (Δ -34±9 vs. +8±11 cm2, T vs. P, p=0.005) and liver fat (Δ -2.0 [-6.4, 0.1] vs. +0.9 [-0.6, 3.7] lipid-to-water %, T vs. P, p=0.004).  Change in liver fat was associated with change in VAT (ρ = 0.31, P = 0.047) and HOMA-IR (ρ = 0.50, P = 0.001). 

Fasting glucose increased in the tesamorelin group between baseline and two weeks (Δ 9±2 vs 2±3mg/dL; T vs. P, p=0.03) but was not different from baseline at 3 months (p=0.20) or 6 months (p=0.56).  Mixed effects modeling showed no significant effects of tesamorelin on fasting glucose (p=0.94), fasting insulin (p=0.76), or HOMA-IR (p=0.48) after 6 months. There was a modest but statistically significant increase in HbA1c from baseline to 6 months (Δ 0.20±0.08 vs. 0.02±0.04%; p=0.04, T vs. P).   In the clamp subgroup, insulin stimulated glucose uptake (M) significantly changed over the first three months in the tesamorelin group (ΔM -0.4±0.6 vs. +1.3±0.3 mg/kg/min, T vs. P, p=0.03), whereas the overall change from baseline was not significant at 6 months (0.5±0.8 vs. 0.7±0.6, T vs. P, p=0.78). 

Conclusion:  In HIV-infected individuals with visceral obesity, tesamorelin significantly reduces liver fat in conjunction with decreases in VAT.

 

Nothing to Disclose: TLS, MNF, JO, KLB, HL, MT, SKG

OR05-6 12198 6.0000 A Growth Hormone Releasing Hormone Analogue Reduces Liver Fat in HIV-Infected Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 1:00:00 PM OR05 4749 11:30:00 AM Ghrelin and GHRH in Human Obesity Oral

Nasreen Alfaris*1, Jesse Chittams2, Lisa Diewald2, Marion Vetter3 and Thomas Wadden1
1University of Pennsylvania, philadelphia, PA, 2University of Pennsylvania, Philadelphia, PA, 3Univ of Pennsylvania, Philadelphia, PA

 

Little is known about the effects of intentional weight loss on sleep quality or sleep duration in obese individuals not selected for obstructive sleep apnea. This study examined the issue in 390 subjects (M age=51.5±11.5 yr, BMI=38.5±4.7 kg/m2, 75.4% female) who participated in a 2-yr randomized trial of behavioral weight loss in primary care (POWER-UP study). As reported previously1, subjects were randomized to: 1) Usual Care; 2) Brief Lifestyle Counseling (LC); or 3) Enhanced Brief LC, all of which were delivered by physicians and medical assistants in the primary care practices. The three interventions provided subjects different amounts of support to achieve the prescribed diet (1200-1800 kcal/d) and activity (180 min/wk) goals. This study reports changes at months 6 and 24 in weight, sleep quality and duration (assessed by the Pittsburgh Sleep Quality Index questionnaire [PSQI]), and mood, measured by the Patient Health Questionnaire-8 (PHQ-8). Data were analyzed by mixed effects general linear models. Changes in sleep and mood also were compared in subjects who lost ≥5% vs <5% of initial weight, regardless of original group assignment. At month 6, subjects in the three groups lost a mean (SEM) of 2.0±0.5, 3.5±0.5, and 6.6±0.5 kg, respectively; all three groups differed significantly from each other (p<0.05). There were no significant differences between groups in sleep duration, PSQI scores, or mood, although the latter two values declined (favorably) over time (p<0.05). At month 24, subjects in Enhanced Brief LC lost more weight than Usual Care (-4.6±0.7 vs -2.0±0.5 kg, p<0.05) and reported more favorable changes in sleep duration (+13.8±9.0 vs -9.0±9.0 min; p<0.05).  There were no differences between groups on PSQI or mood scores, but both values declined (favorably) over time (p<0.05). When examining participants who lost ≥5% vs <5% of initial weight, regardless of original group assignment, at month 6 sleep increased by 21.6±7.2 min in the former group, compared with 1.2±6.0 min for those losing <5% (p<0.05). Similarly favorable changes, with greater weight loss, were observed on the PSQI (-1.6±0.2 vs -0.4±0.2, p < 0.001) and PHQ (-2.5±0.4 vs -0.1±0.3, p<0.0001). At month 24, however, only the differences between the two groups on mood (PHQ) remained significant (p<0.05), and at no time were significant differences observed between the two weight loss categories on sleep duration. The present findings indicate that losing ≥5% of initial weight is associated with significant short-term (6 month) self-reported improvements in sleep quality and mood. Further study is needed of the possible effects of weight regain, as observed in this study, in mitigating short-term improvements in sleep quality.

 

Nothing to Disclose: NA, JC, LD, MV, TW

OR07-1 13475 1.0000 A Effect of Behavioral Weight Loss on Sleep and Mood: Results from the POWER-up Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 1:00:00 PM OR07 4750 11:30:00 AM Neuroscience of Human Obesity Oral

Kristen Eckstrand1, Ronald Cowan1, Brian Welch1, Joel Kullberg2, Robert Kessler3, Heidi Silver1, Kevin Dean Niswender1 and Malcolm Avison*1
1Vanderbilt University Medical Center, Nashville, TN, 2Uppsala University Hospital, Uppsala, Sweden, 3University of Alabama Medical Center, Birmingham, AL

 

Increased BMI is associated with decreased availability of striatal dopamine (DA) D2 receptors (D2R).  This has led to the suggestion that obesity, like classical drug addiction, may be driven, at least in part, by impaired behavioral self-regulation, arising from disruptions in striatal DA tone.  The molecular and neural mechanisms underlying such a disruption, and their impacts on behavior remain poorly understood in the context of obesity, however.

We therefore used whole body fat-water (FW-MRI), functional MRI (fMRI), and F18-fallypride PET imaging to measure adipose tissue (AT) distribution, activation of neural circuitry subserving impulse control during a stop signal task (SST), and brain D2R availability respectively, in a cohort of right-handed obese (BMI=37.1 ± 0.7, range 30-39; n=48) volunteers (age 47.1 ± 1, range 30-39 yrs) with T2DM (HOMA-IR=7.8±0.8) who were otherwise healthy, and had no history of insulin therapy.

We hypothesized that increased adiposity, would be associated with decreased availability of striatal D2R, and/or altered activation of neural elements of impulse control in a stop signal task (SST) measured as the BOLD fMRI contrast between stop success and stop error (CON(SS>SE)), and that one or both of these contribute to increased impulsivity in obesity.

Increased visceral (VAT), but not total or subcutaneous, AT burden was associated with decreased striatal D2R availability (R2 = 0.50, p = 0.001), and decreased striatal activation during stopping (CON(SS>SE): R2 = 0.2, p = 0.07).  Both striatal D2R and CON(SS>SE) were significant predictors of more impulsive responding (i.e. shorter median Go Response Time - mGRT):  mGRT vs D2R, R2 = 0.43, p = 0.036; mGRT vs CON(SS>SE), R2 = 0.42, p = <0.001.  After accounting for an independent impact of insulin resistance (Eckstrand et al., abstract submitted), there was a significant association of increased VAT burden with decreased mGRT (increased impulsivity) that was mediated by the VAT-associated reductions in striatal D2R and activation.  Thus VAT, independent of total adiposity or insulin resistance, was a predictor of reduced striatal D2R availability and blunted striatal activation during response inhibition, associations that appeared to mediate a VAT-associated blunting of behavioral impulse control.

We believe these findings are the first to demonstrate a link between VAT burden and molecular and functional correlates of impulsivity in the human brain.  Furthermore the nature of the association suggests that increased visceral adiposity, independent of BMI, is associated with poorer impulse control.

 

Disclosure: RC: Investigator, Novo Nordisk. HS: Investigator, Novo Nordisk. KDN: Investigator, Novo Nordisk. MA: Investigator, Novo Nordisk. Nothing to Disclose: KE, BW, JK, RK

OR07-2 16983 2.0000 A Molecular and Neural Bases for Heightened Impulsivity with Visceral Adiposity in Obesity Associated T2DM 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 1:00:00 PM OR07 4750 11:30:00 AM Neuroscience of Human Obesity Oral

Erin C Hanlon*1, Rachel Leproult2, Esra Tasali3, Harriet de Wit2, Kara Stuhr4, Cecilia J Hillard4 and Eve Van Cauter2
1Univ of Chicago, Chicago, IL, 2University of Chicago, Chicago, IL, 3The University of Chicago, Chicago, IL, 4Medical College of Wisconsin, Milwaukee, WI

 

The endocannabinoid (EC) system, a pharmacotherapeutic target for obesity treatment, mediates the hedonic control of feeding, and modulates reward mechanisms.  Over activation of the EC system could be involved in excessive hedonically driven eating and the risk of overeating associated with obesity.  We examined the 24-h profile of (2-AG), and of its structural analog 2-oleoylglycerol (2-OG), which does not bind EC receptors, in healthy lean and obese subjects.

Sixteen healthy lean subjects, (5 women; age: 23 ±1yrs; BMI: 23.6±1.3kg/m2) and 11 obese but otherwise healthy subjects (7 women; age: 27 ±1yrs; BMI: 39.0±1.7kg/m2), were studied in the laboratory under controlled conditions of energy expenditure and caloric consumption.  Blood sampling was performed for 24-h following two nights of normal sleep (2300-0730).  Samples taken at 60-min intervals were assayed for levels of 2-AG and 2-OG by liquid chromatography-electrospray ionization-mass spectrometry (LC-ES-MS).

Both lean and obese individuals displayed circadian rhythms for 2-AG and 2-OG, with similar nadir and acrophase concentrations.  However, the timing of the nadir was significantly delayed from mid-sleep in lean subjects to early morning in obese individuals (lean 0353 ± 32min vs. obese 0621 ± 39min, p = 0.0065).  Moreover, the acrophase was also significantly delayed from early to late afternoon (lean 1223 ± 30min vs. obese 1805 ± 37min, p < 0.001).  There was a significant correlation between BMI and the timing of both the nadir and the acrophase, such that the higher the BMI the later the timing of the nadir and acrophase (n=27; p = 0.0006 and p = 0.0035, respectively).  When expressed as % of the 24-h mean, over the sleep period from 2300-0700 2-AG and 2-OG levels were higher in obese individuals than in the lean subjects (2-AG: obese 86.9 ± 5.2% vs lean 65.3 ± 4.3%, p = 0.004; 2-OG obese 95.8 ± 3.9% vs. lean 84.4 ± 3.3%, p = 0.035).

This study provides the first demonstration of a circadian rhythm of human plasma EC levels in obese individuals.  Moreover, the delay in timings of both 2-AG and 2-OG nadir and acrophase in obese compared to lean individuals reveals that obesity is associated with a circadian misalignment that may contribute to overeating in the later part of the day and adverse metabolic consequences known to be associated with obesity.

 

Nothing to Disclose: ECH, RL, ET, HD, KS, CJH, EV

OR07-3 17049 3.0000 A Alterations in the Circadian Rhythm of Circulating Levels of the Endocannabinoid (EC) Receptor Ligand, 2-Arachidonoylglycerol (2-AG), in Obese Individuals 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 1:00:00 PM OR07 4750 11:30:00 AM Neuroscience of Human Obesity Oral

Peter Kühnen*1, Daniela Handke1, Joachim Spranger2, Antje Fischer-Rosinsky2, Annette Grüters-Kieslich1 and Heiko Krude1
1Charité - Universitätsmedizin Berlin Campus Virchow, Berlin, Germany, 2Charité - Universitätsmedizin Berlin Campus Mitte, Berlin, Germany

 

Background: POMC plays a major role in central body weight regulation. Recently we have shown in a candidate gene approach, that a POMC hypermethylation variant at the border of the intron2- 3´CpG island in obese children is significantly associated with obesity in children and adolescents. We could also demonstrate that this variant was present before the onset of obesity, is linked to an Alu element that most likely triggers the hypermethylation and that the hypermethylation seems to interfere with an enhancer that binds p300 1. Here we extended our epigenetic studies in the POMC locus and analysed the POMC DNA methylation in a second childhood cohort now with another independent method (pyrosequencing) and tested the hypothesis that also adult obese individuals harbour the hypermethylation variant more often compared to normal weight controls.

Methods: We tested the POMC DNA methylation in obese adults (n=92) and in normal weight individuals (n=101). The DNA methylation was analysed in DNA extracted from peripheral blood cells with a sodium-bisulfite based protocol and pyrosequencing.

Results: We could show that - based on pyrosequencing - we could reproduce our initial findings and observed a highly significant enrichment of the POMC hypermethylation variant in obese children compared to normal weight individuals. Moreover we observed now for the first time also a significant higher rate POMC hypermethylation in obese adults compared to age-and sex matched normal weight adult individuals (30,3% variant in obese versus 15,3% variant in normal weight).

Conclusion: Our finding of a highly significant enrichment of the POMC hypermethylation variant in obese children and also in obese adults represent the strongest factor that explain the individual risk for obesity since all so far described genetic variants have shown to have a much lesser impact on the individual BMI compared to the here described POMC locus hypermethylation.

 

Nothing to Disclose: PK, DH, JS, AF, AG, HK

OR07-4 15908 4.0000 A Pomc DNA Hypermethylation Variant in Highly Associated with Obesity in Children and Adults 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 1:00:00 PM OR07 4750 11:30:00 AM Neuroscience of Human Obesity Oral

Belinda S Lennerz*1, Elke Fröhlich-Reiterer2, Ulrich Paetow3, Klaus-Michael Debatin4, Georgia Lahr5, Franziska Degenhardt6, Pamela Fischer-Posovszky7, Gudrun Weinhandel2, Hans-Josef Boehles3 and Martin Wabitsch7
1Ulm University, Ulm, Germany, 2University Hospital Graz, 3Johann Wolfgang von Goethe University, 4University Medical Center Ulm, 5University Hospital Ulm, 6University Bonn, 7University of Ulm, Ulm, Germany

 

Background: The prevalence of homozygous mutations in the leptin receptor (LEPR) gene was 3% in a cohort of patients with early onset extreme obesity1. 6 of the 8 affected children had consanguineous parents. Despite this report, LEPR mutations are not routinely tested for, and only 11 affected families are published in the literature.

Objective:Our aim is to raise awareness of this monogenetic form of obesity.

Methods:Over the past 12 months, three patients with early onset extreme obesity and mutations in the LEPR gene were presented to our pediatric obesity center and were gathered in a case series.

Results:

  1.     34 months old boy, BMI: 40 kg/m2 (+5.4 SDS). A new homozygous deletion with loss of function was identified: exon 3-20.
  2.     33 months old boy, BMI 30 kg/m2 (+4.4 SDS). Two published2,3 homozygous missense point mutations were identified: exon 8, c.946C>A and exon 14, c.1938G>T.
  3.     32 months old girl, BMI 45 kg/m2 (+5.5 SDS). A published1 homozygous mutation resulting in a deleterious frame shift was identified: Exon 5, c.461dupA (p.N154Kfs*3).

All three patients had in common:

  •     extreme hyperphagia
  •     dramatic weight gain in the first 6 months of life, surpassing the 97th weight percentile between 1 and 6 months of age
  •     extreme obesity at the time of presentation (BMI > +4SDS)
  •     normal-weight, consanguineous parents of Turkish ancestry

Conclusion: Together with the high reported prevalence rate1, this case series suggests that mutations in the LEPR gene are a common cause of early onset extreme obesity. If no other causes are identified, genetic testing of these patients should include sequencing of the LEPR Gene, especially when consanguinity is present.

This research was funded by the Federal Ministry for Education and Research (BMBF, 01GI1120A) and is integrated in the Competence Network Obesity (CNO).

 

Nothing to Disclose: BSL, EF, UP, KMD, GL, FD, PF, GW, HJB, MW

OR07-5 17059 5.0000 A Mutations in the Leptin Receptor (LEPR) Gene in Patients with Early Onset Extreme Obesity - a Case Series 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 1:00:00 PM OR07 4750 11:30:00 AM Neuroscience of Human Obesity Oral

Shan He* and Ya-Xiong Tao
Auburn University, Auburn University, AL

 

The melanocortin-4 receptor (MC4R) is a Family A G protein-coupled receptor that plays an essential role in regulating energy homeostasis, including both energy intake and expenditure. Defects in MC4R are the most common monogenic form of obesity, with more than 170 distinct mutations identified in humans. In addition to the conventional Gs-stimulated adenylyl cyclase pathway, it has been recently demonstrated that MC4R also activates mitogen-activated protein kinases, especially extracellular signal-regulated kinases 1 and 2 (ERK1/2). We also showed there is biased signaling in the two signaling pathways, with inverse agonists (negative antagonists) in the Gs-cAMP pathway acting as agonists for the ERK1/2 pathway. Herein, we investigated the constitutive and ligand-stimulated activation (pERK1/2) in wild type and 64 naturally occurring MC4R mutations, including Class IV (mutants that have normal cell surface expression and ligand binding but are defective in cAMP signaling) and V (mutants that have normal cell surface expression, binding and cAMP signaling) mutants. We showed that four mutants (P48S, G55V, I125K and M208V) had significantly decreased basal pERK1/2 level, and fifteen mutants (F51L, T112M, N240S, N274S and S295P in class V, N62S, P78L, D90N, L106P, S136F, T162I, R165W, R165Q, R165G and Y302F in class IV) had impaired ligand-stimulated pERK1/2 activation. Defective signaling in Class V mutants might be the cause of obesity observed in patients harboring these mutations. In summary, our studies demonstrated for the first time that the decreased basal or ligand-stimulated ERK1/2 signaling might contribute to obesity pathogenesis caused by mutations in the MC4R gene. We also observed biased signaling in these naturally occurring mutations in the Gs-cAMP-protein kinase A and ERK1/2 pathway.

 

Nothing to Disclose: SH, YXT

OR07-6 17016 6.0000 A Defect in MAPK Signaling As a Cause for Monogenic Obesity Caused By Inactivating Mutations in the Melanocortin-4 Receptor Gene 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 1:00:00 PM OR07 4750 11:30:00 AM Neuroscience of Human Obesity Oral

Angela Delaney*1, Francois M. Lalonde1, Jonathan D. Blumenthal1, Liv S. Clasen1, Rebecca L. Hicks1, Alexander H. Denker1, Jay N. Giedd1, William F Crowley Jr.2 and Ravikumar Balasubramanian2
1National Institutes of Health, Bethesda, MD, 2Massachusetts General Hospital, Boston, MA

 

BACKGROUND: Men with idiopathic hypogonadotropic hypogonadism (IHH) have impaired spatial ability compared to healthy controls or men whose hypogonadism was acquired after normal puberty1. This observation suggests that androgen exposure during puberty plays an important role in neurocognitive development. However, it is not known whether similar neurocognitive defects occur in females with a deficiency of pubertal sex steroids. In addition, the effect of sex-steroid deficiency on structural differences in the developing brain is yet to be directly quantified. Therefore, we hypothesized that the delayed exposure to sex hormones during puberty in both male and female patients with IHH results in neurocognitive deficits as well as structural differences in the developing brain.

METHODS: Neurocognitive testing, structural brain MRI and functional MRI (fMRI) were performed in subjects with IHH (n=16, mean age 24.2 y), including 11 with anosmia (Kallmann syndrome; 5M, 6F) and 5 normosmic subjects (all male), as well as 10 healthy controls (5M, 5F; mean age 30.3 y) matched for age, sex, socioeconomic status, and handedness. MRI scans were acquired using a GE 3 Tesla LX MR750 scanner. Cortical measurements such as thickness, area, and volume were analyzed using FreeSurfer2 with sex and mean-centered age at the time of the scan included as covariates. 

RESULTS: Complete sexual development did not occur in IHH patients unless treated with sex steroids (mean age at pubertal onset: 16.3 y, M; 14.8 y, F). Puberty onset was normal in controls (12.5 y, M; 9.8 y, F). Accounting for gender, the cortical area was negatively correlated with age in the IHH group and positively or uncorrelated with age in controls in the superior temporal (p < 0.01) and rostral middle frontal (p < 0.01) cortices. fMRI results available from a subset of subjects (11 IHH; 7 controls) showed that the magnitude and extent of blood oxygenation level dependent activation during a face recognition task was reduced bilaterally in occipital regions in the IHH subjects (P < 0.001). Neurocognitive testing in the same subset showed preserved verbal and overall IQ, but significant deficits in several neurocognitive domains in IHH patients (performance IQ (WASI, p=0.009); spatial vs. verbal short term working memory (WMS-III; P=0.047); cognitive flexibility/shift (Trail Making Test, P=0.004); processing speed (WAIS Symbol Search, P=0.022); verbal memory (WRAML2 Verbal Learning, P=0.05) and semantic verbal fluency (P=0.027)).  

CONCLUSIONS:  1. In both sexes, pubertal sex steroid deficiency contributes to persistent structural and functional brain differences as well as to neurocognitive deficits primarily involving spatial ability and recognition memory.

2. These findings provide further direct evidence in humans about the critical spatiotemporal role played by appropriately timed pubertal sex steroids during normal brain development.

 

Nothing to Disclose: AD, FML, JDB, LSC, RLH, AHD, JNG, WFC Jr., RB

OR11-1 16936 1.0000 A Delayed Sex Hormone Exposure during Puberty Is Associated with Differences in Brain Cortical Thickness, Spatial Ability, and Recognition Memory 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 1:00:00 PM OR11 4754 11:30:00 AM Puberty: From Bench to Bedside Oral

Ana Paula Abreu*1, Delanie B. Macedo2, Ana Claudia Silva Reis3, Luciana Ribeiro Montenegro4, Andrew Dauber5, Diane Beneduzzi2, Priscilla Cukier2, Leticia Gontijo Silveira6, Milena Gurgel Teles7, Rona S. Carroll8, Gil Guerra Jr.9, Guilherme Guaragna Filho10, Zoran Spasico Gucev11, Ivo J P Arnhold2, Margaret Castro12, Ayrton C. Moreira13, Carlos Eduardo Martinelli Jr.13, Joel N Hirschhorn14, Berenice Bilharinho Mendonça2, Vinicius N. Brito2, Sonir Roberto Antonini15, Ursula B Kaiser8 and Ana Claudia Latronico4
1Brigham and Women's Hospital/Harvard Medical School, Boston, MA, 2Disciplina de Endocrinologia e Metabologia, Laboratório de Hormônios e Genética Molecular/ LIM42, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 3Universidade de Sao Paulo, Ribeirao Preto, Brazil, 4Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 5Division of Endocrinology, Boston Children's Hospital and Program in Medical and Population Genetics, Broad Institute, Boston, MA, 6Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 7Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 8Brigham and Women's Hospital and Harvard Medical School, Division of Endocrinology/Diabetes, Boston, MA, 9Medical School, University of Campinas (FCM-UNICAMP), Brazil., São Paulo, Brazil, 10Medical School, University of Campinas (FCM-UNICAMP), Brazil., 11Univ Kiril & Metodij/Med Sch, Skopje Fyr, Macedonia, 12R, 13Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil, 14Division of Endocrinology, Boston Children's Hospital and Program in Medical and Population Genetics, Broad Institute, Harvard Medical School, Boston, MA, 15Ribeirão Preto Medical School - University of São Paulo, Ribeirão Preto, Brazil

 

Background: We recently identified loss-of-function mutations in the imprinted MKRN3 gene, encoding makorin ring finger protein 3, in patients with GnRH-dependent central precocious puberty (CPP) using whole exome sequencing. MKRN3 is a maternally imprinted gene located on chromosome 15q11.2, in the Prader Willi syndrome critical region. We showed that Mkrn3 is expressed at high levels in the hypothalamus of mice prepubertally and decreased immediately prior to puberty onset, suggesting that MKRN3 acts as a brake on GnRH secretion.

Objectives: To investigate potential MKRN3 sequence variations in patients with apparently sporadic CPP.

Methods: We studied 215 unrelated children (207 girls and 8 boys) with a diagnosis of CPP. All but two of these patients (213 cases) reported no family history of premature sexual development. First-degree relatives of patients with identified MKRN3 variants were included for genetic analysis. All 215 CPP patients were screened for MKRN3 mutations by automatic sequencing.

Results: We identified five novel heterozygous mutations in MKRN3 in eight unrelated girls with CPP. Four were frameshift mutations predicted to encode truncated proteins and one was a missense mutation, which was suggested to be deleterious by in silico analysis. All patients with MKRN3 mutations had classical features of CPP with a median age of onset at 6 years. No major signs of Prader Willi syndrome were detected in the patients with CPP and MKRN3 mutations. Segregation analysis was possible in 5 of the 8 girls with MKRN3 mutations; in all cases, the mutation was inherited on the paternal allele.

Conclusions: We have identified novel inherited MKRN3 defects in children with apparently sporadic CPP, supporting a role of MKRN3 in the control of puberty initiation. Because of the imprinting pattern of MKRN3, the CPP phenotype can be inherited from an apparently asymptomatic father, highlighting the importance of obtaining a detailed family history, especially from the paternal side, in children with apparently idiopathic CPP. MKRN3 gene analysis may provide an additional tool for the diagnosis of CPP, allowing early diagnosis and treatment of children with CPP.

 

Nothing to Disclose: APA, DBM, ACSR, LRM, AD, DB, PC, LGS, MGT, RSC, GG Jr., GG, ZSG, IJPA, MC, ACM, CEM Jr., JNH, BBM, VNB, SRA, UBK, ACL

OR11-2 16858 2.0000 A Apparently Sporadic Central Precocious Puberty Is Caused By Paternally Inherited Mutations in the Imprinted MKRN3 Gene 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 1:00:00 PM OR11 4754 11:30:00 AM Puberty: From Bench to Bedside Oral

Maria Bygdell, Liesbeth Vandenput, Claes Ohlsson and Jenny M Kindblom*
University of Gothenburg, Gothenburg, Sweden

 

A secular trend for the timing of menarche has been described in women, but for men, studies of pubertal timing are scarce. Both negative and positive associations between childhood obesity and pubertal timing in men have been reported.

 In Sweden, Child Health Care (CHC) centers follow all children regarding growth and general health. We have collected detailed CHC growth data (height and weight) from centrally archived records for all children born 1946 or later in Gothenburg and established a unique population-based cohort, the BMI Epidemiology STudy (BEST; n≈400 000). The overall aim of the well-powered BEST cohort is to determine the role of childhood obesity and pubertal timing for a variety of diseases later in life.

The aim with the present BEST sub-study was to investigate if there is a secular trend for male pubertal timing and if childhood BMI influences pubertal timing. Men born every five years from 1946 to 1991 were evaluated (n=200 for each birth year, n=2000 for the entire sub-cohort). The height measurements were curve-fitted according to the Infancy – Childhood – Puberty (ICP) model and age at Peak Height Velocity (PHV) was calculated. PHV is the maximum growth velocity and represents an established method to objectively determine age at pubertal timing (PHV ≈ 2 years after pubertal onset).

The mean age at PHV was 14.0± 1.1 years. Linear regression analyses revealed that age at PHV was 1.3 months earlier for every 10 year increase in birth year between 1946 and 1991 (p=5.3*10-12).  As expected, a secular trend of increased childhood BMI at eight years of age was observed (p=1.2*10-12). We next evaluated the impact of childhood BMI on age at PHV and found that age at PHV was 2.1 months earlier for every quintile increase in BMI at eight years of age (p=1.1*10-21). To determine the independent role of birth year and childhood BMI for age at PHV, both parameters were included in the same model, demonstrating that both birth year and childhood BMI were independently associated with age at PHV (standardized β; birth year β = -0.13, p=8.2*10-9; childhood BMI β =-0.21, p= 9.8*10-21).

In conclusion, we provide compelling statistical evidence of a secular trend for pubertal timing in Swedish men. The secular trend of earlier pubertal timing is partly explained by increased childhood BMI but also other factors, to be identified, contribute.

 

Nothing to Disclose: MB, LV, CO, JMK

OR11-3 14868 3.0000 A A Secular Trend for Pubertal Timing in Swedish Men Born 1946-1991 – the Best Cohort 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 1:00:00 PM OR11 4754 11:30:00 AM Puberty: From Bench to Bedside Oral

Casper P. Hagen*1, Kaspar Sørensen2, Lise Aksglaede1, Annette Mouritsen1, Mikkel Grunnet Mieritz2, Jeanette Tinggaard1, Christine Wohlfart-Veje1, Jørgen Holm Petersen1, Katharina M Main3, Ewa Rajpert-De Meyts1, Kristian Almstrup4 and Anders Juul1
1University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark, 2University of Copenhagen, Faculty of Health and Medical Sciences, Rigshospitalet, Department of Growth and Reproduction, Denmark, Copenhagen, Denmark, 3Rigshospitalet, Copenhagen, Denmark, 4University of Copenhagen, Faculty of Health and Medical Sciences, Rigshospitalet, Copenhagen, Denmark

 

Context: Follicle-stimulating hormone (FSH) stimulates ovarian follicle maturation and estradiol synthesis which is responsible for breast development. Age at pubertal onset varies substantially among healthy girls. Although more than half of the variation is heritable, only a small part has been attributed to specific genetic polymorphisms identified so far.

Objective:We assessed the effect on pubertal onset of three genetic polymorphisms affecting FSH action.

Design and Participants: Combined cross-sectional and longitudinal cohort study of 964 healthy girls, age 8-13 years.

Setting: General community.

Main Outcome Measures: Puberty was defined as Tanner breast stage ≥ 2 by palpation. DNA was isolated from blood and FSHB -211 G>T, FSHR -29 G>A, and FSHR 2039 A>G were genotyped by competitive allele-specific polymerase chain reaction.

Results: Girls homozygous for FSHR -29 AA (reduced FSH receptor expression) entered puberty 7.4 (2.5-12.4) months later than carriers of the common variants FSHR -29 GG+GA, p = 0.003. In a combined model, puberty occurred on average 8.0 months later in carriers of either FSHR -29 AA or FSHB -211 TT (reduced FSH production) compared with girls with at least one wild-type allele (10.63 vs. 9.96 years, p = 0.001). The number of minor alleles (FSHR -29 A and FSHB -211 T) was positively associated with age at pubertal onset (beta 1.9 months, p = 0.025).

Conclusions: For the first time we demonstrate that age at breast development is highly influenced by genetic variation in promoters affecting FSH action. To our knowledge, this is the strongest genetic effect on age at pubertal onset in girls published to date.

 

Nothing to Disclose: CPH, KS, LA, AM, MGM, JT, CW, JHP, KMM, ER, KA, AJ

OR11-4 15111 4.0000 A Pubertal Onset in Girls Is Strongly Influenced By Genetic Variation in Promoters Affecting FSH Action 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 1:00:00 PM OR11 4754 11:30:00 AM Puberty: From Bench to Bedside Oral

Felix Schreiner*1, Bettina Gohlke1, Michaela Hamm1, Eckhard Korsch2 and Joachim Woelfle1
1Children's Hospital, University of Bonn, Bonn, Germany, 2Children's Hospital Amsterdamer Straße, Cologne, Germany

 

Background: Loss-of-function-mutations in the gene encoding the makorin RING finger protein 3 (MKRN3) have recently been reported to underlie familial cases of central precocious puberty (CPP). The imprinted MKRN3 gene is expressed only from the paternal allele, and mutations inherited from the father affect boys and girls equally, which is in contrast to the known female preponderance in idiopathic CPP.

Patients and Methods: In order to select a series of individuals suspective of having monogenetically caused CPP, we searched our single-center database (in total, 47 new non-organic CPP cases between 2005 and 2013) for either idiopathic CPP with evidence of familial clustering (14 cases in six families) or idiopathic CPP in males (two sporadic cases, one of them lost for follow-up). The coding region of the intronless MKRN3 gene was analyzed by genomic sequencing.

Results: By sequencing MKRN3 in six families and one male patient with idiopathic CPP, we identified two further families carrying loss-of-function-mutations. In addition to the previously reported variant c.475_476insC (p.Ala162Glyfs*14), which was detected in two girls who entered puberty at ages 6.8 and 7.5 yrs, we identified a novel mutation, c.331G>T (p.Glu111*), detected in one girl (thelarche at age 6.1 yrs) and his brother (pubarche at age 9.0 yrs and unusually rapid testicular growth to >8.0 ml at age 10.0 yrs). In both families, the MKRN3 mutations were inherited from the fathers, both of them were of normal height and reported to have entered puberty at an “early-to-normal” age. Grandparental DNA was not available in these two families.

Conclusions: We conclude that MKRN3 mutations appear to be a frequent cause of familial CPP. Considering the imprinted mode of inheritance allowing the phenotype to skip one or more generations, MKRN3 mutations may also account for a certain proportion of isolated CPP cases. Remarkably, four out of five MKRN3 mutations described so far encode either a stop codon or a frameshift followed by a premature stop codon, suggesting that the clinical spectrum associated with MKRN3 mutations known to date might represent only the lowest tip of a broader phenotypical range related to functional variants of the MKRN3 gene. Mutation screening in larger cohorts is necessary in order to estimate the prevalence of MKRN3 mutations in idiopathic CPP.

 

Nothing to Disclose: FS, BG, MH, EK, JW

OR11-5 14772 5.0000 A MKRN3 Mutations in Familial Central Precocious Puberty 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 1:00:00 PM OR11 4754 11:30:00 AM Puberty: From Bench to Bedside Oral

Gerhard Binder*1, Roland Schweizer1, Gunnar Blumenstock2 and Regina Braun1
1University Children's Hospital, Tuebingen, Germany, 2University of Tuebingen, Tuebingen, Germany

 

Background

The clinical distinction between constitutional delay of growth and puberty (CDGP) and hypogonadotropic hypogonadism (HH) in girls with delayed puberty is sometimes difficult. Accurate endocrine tests would be helpful for counselling and treatment in time. As delayed puberty is rare in females, there is a big lack of studies.

Aim

We assessed the accuracy of inhibin B (INHB) and the GnRH agonist (GnRHa) test for diagnosing HH by retrospective analysis of our data collected during the last 5 years using a strict clinical protocol.

Patients

All prepubertal non-underweight girls (n=20) aged 13.1 to 17.5 years characterized by Tanner breast stage B1 or B2 and low E2 serum levels were tested. Re-examinations were performed every six months. CDGP was defined by spontaneous menarche, HH by no spontaneous progress of puberty during 30 months of follow-up. INHB was measured by ELISA (Beckman Coulter, Inc, U.S.A.), FSH and LH by CLIA (Siemens Health Care Systems, Germany). We assessed the test validity of INHB as well as of stimulated FSH and LH at 4h after a Triptorelin 0.1 mg challenge.

Results

The cohort comprised 12 girls with CDGP and 8 girls with HH. Causes of HH were septo-optic dysplasia, panhypopituitarism, Prader-Willi syndrome, chromosomal aberration, mental retardation syndrome with ataxia and idiopathic (n=3).

Each, basal INHB < 18 pg/mL or stimulated FSH(4h) < 11 IU/L had a sensitivity and a specificity for the detection of HH of 100%. Stimulated LH(4h) < 9 IU/L had a sensitivity of 100%, but a low specificity of 83%. The area under the curve of ROC plot analysis for diagnosing IHH was greatest for INHB < 18 pg/mL (100%) and for stimulated FSH(4h) < 11 IU/L (100%). Performance of stimulated LH(4h) < 9 IU/L was lower (97.4%; 95%-CI: 91.6%-100%).

Conclusions

Inhibin seems to be the ideal parameter to detect HH in girls. GnRHa test is the alternative, but more laborious. In contrast to males, in females with delayed puberty GnRHa stimulated FSH seems to be more specific than stimulated LH to distinguish HH from CDGP.

 

Nothing to Disclose: GB, RS, GB, RB

OR11-6 14866 6.0000 A Inhibin B and the GnRH Agonist Test for Distinguishing Constitutional Delay of Growth and Puberty from Hypogonadotropic Hypogonadism in Girls 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 1:00:00 PM OR11 4754 11:30:00 AM Puberty: From Bench to Bedside Oral

Alexander N Comninos*1, Channa N Jayasena2, Evi Stefanopoulou3, Adam Buckley4, Julianne Mogford2, Chioma Izzi-Engbeaya2, Risheka Ratnasabapathy2, Shakunthala Narayanaswamy2, Mohammad A Ghatei2, Stephen R Bloom4, Myra Hunter3 and Waljit S Dhillo1
1Imperial College NHS Healthcare Trust, London, United Kingdom, 2Imperial College London, London, United Kingdom, 3King's College London, United Kingdom, 4Imperial College London, United Kingdom

 

Hot flushes affect millions of women worldwide, yet their precise aetiology remains elusive. Furthermore, existing therapies such as HRT and clonidine are limited by side-effects and variable effectiveness.

Hypothalamic neurokinin B (NKB) expression is markedly increased in post-menopausal women. In addition, the NKB receptor is strongly expressed in hypothalamic thermoregulatory centres. In rodents, ovariectomy (as a model of menopause) results in thermoregulatory tail skin vasodilatation, while ablation of hypothalamic NKB receptor-expressing neurones blocks this effect. NKB is therefore a potential mediator of menopausal hot flushes; however animal studies are limited by their inability to detect symptoms. We investigated for the first time whether NKB could induce symptomatic hot flushes in healthy pre-menopausal women.

We performed a randomised, placebo-controlled, double-blinded, 2-way cross-over study in a temperature-controlled and humidity-controlled clinical research facility. Nine healthy pre-menopausal women (age 34±1.4y, BMI 22.9±1.3kg/m2), in the follicular phase of their menstrual cycle, received two 30min intravenous infusions during the same study visit separated by a 90min washout interval. Infusions were randomised to either NKB or vehicle. Symptoms, skin temperature (measure of cutaneous vasodilatation, determined by skin temperature probe and thermal imaging camera), skin conductance (measure of sweating), and heart rate were recorded minutely peri-infusion and every 10min at other times. BP and reproductive hormone levels were measured every 10min throughout the study visit.

Flushing was reported in 7/9 women during NKB administration, and 0/9 during vehicle administration (p<0.01 vs. vehicle). In total there were 12 episodes of flushing during NKB administration with a mean duration of 3.7±0.6min. Flushing symptoms were localised to the face and upper torso in all women who experienced flushing (7/7). During hot flush episodes, elevations in mean heart rate (+6.1±2.1bpm, p<0.01 vs. mean pre-symptoms), mean skin temperature (+0.2±0.080C, p<0.05 vs. mean pre-symptoms), and alterations in skin conductance suggestive of menopausal flushing were observed. There were no significant changes in BP or reproductive hormone levels (LH, FSH, estradiol) during NKB or vehicle administration.

We demonstrate for the first time that NKB administration to healthy pre-menopausal women results in symptoms and physiological changes analogous to those observed during menopausal hot flushes. These data have important implications for the better understanding of the elusive aetiology of menopausal flushing and for the future clinical development of improved targeted therapies for hot flushes.

 

Nothing to Disclose: ANC, CNJ, ES, AB, JM, CI, RR, SN, MAG, SRB, MH, WSD

OR04-1 14487 1.0000 A Neurokinin B Administration Induces Menopausal-like Hot Flushes in Healthy Young Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 1:00:00 PM OR04 4757 11:30:00 AM Female Reproductive Endocrinology Oral

Ali Abbara*1, Channa N Jayasena2, Chioma Izzi-Engbeaya2, Alexander N Comninos3, Richard A Harvey4, Juan Gonzalez Maffe5, Subair Sarang6, Zainab Ganiyu-Dada7, Ana Padilha8, Mandish Dhanjal8, Catherine Williamson9, Lesley Regan8, Mohammad A Ghatei2, Stephen R Bloom1 and Waljit S Dhillo3
1Imperial College London, United Kingdom, 2Imperial College London, London, United Kingdom, 3Imperial College NHS Healthcare Trust, London, United Kingdom, 4Imperial College NHS Trust, London, 5Imperial College London, London, 6Imperial College London, 7Imperial College London, london, United Kingdom, 8Imperial College NHS Trust, 9King’s College London, London, United Kingdom

 

BACKGROUND: The kisspeptins are a group of peptides encoded by the KISS1 gene, which is highly expressed in the placenta. Circulating levels of kisspeptin rise dramatically during normal human pregnancy, reaching levels several thousand-fold higher when compared with levels found outside of pregnancy. Plasma kisspeptin levels measured during early pregnancy may therefore represent a novel predictive marker for assessing the risk of subsequent pregnancy complications. Miscarriage (pregnancy loss prior to 24 weeks of gestation) is the most common complication of pregnancy, affecting 1 in 5 pregnancies. 

OBJECTIVE: To determine whether a single measurement of plasma kisspeptin in asymptomatic women attending their antenatal booking visit predicts miscarriage risk.

STUDY DESIGN: Prospective cohort study in single tertiary obstetric centre in London.

PARTICIPANTS: We recruited 993 asymptomatic pregnant women attending their routine antenatal booking visit (mean gestation of 11.2 weeks (range 5.9-29.0) between 2010 and 2012.

MAIN OUTCOME MEASURES: Plasma kisspeptin and serum hCG were measured during the routine booking antenatal visit and pregnancy outcome was prospectively recorded.

RESULTS: Plasma kisspeptin levels were highly correlated with the gestational week of pregnancy (r2=0.57; P<0.0001). Gestational age-corrected (multiples of median; MoM) plasma kisspeptin levels were 60.4% lower (P<0.001), and MoM hCG was 36.1% lower (P<0.001) in women who were later diagnosed with miscarriage when compared with women who did not miscarry. Plasma kisspeptin >1306 pmol/L was strongly associated with a reduced risk of miscarriage, even after adjusting for age, body mass index, gestational age, smoking and blood pressure (Odds Ratio 0.13 [CI 0.08-0.22],  P=0.0001). Plasma kisspeptin had a higher diagnostic performance for miscarriage when compared with hCG (ROC area under curve: 0.899±0.025, plasma kisspeptin; 0.775±0.040, serum hCG, P<0.01 vs. plasma kisspeptin).

CONCLUSION: This is the first study demonstrating that a single plasma kisspeptin measurement taken during early pregnancy provides a highly predictive marker for identifying asymptomatic pregnant women with subsequent miscarriage.

 

Nothing to Disclose: AA, CNJ, CI, ANC, RAH, JG, SS, ZG, AP, MD, CW, LR, MAG, SRB, WSD

OR04-2 14583 2.0000 A Plasma Kisspeptin Measurement during Early Pregnancy Is a Highly Predictive Marker of Subsequent Miscarriage 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 1:00:00 PM OR04 4757 11:30:00 AM Female Reproductive Endocrinology Oral

Ruchi Bhabhra*, Amy Denise Anderson, Christine M. Burt Solorzano, John C. Marshall and Christopher R. McCartney
University of Virginia, Charlottesville, VA

 

Background: Pulsatile LH (by inference GnRH) secretion is primarily nocturnal (sleep related) in early puberty; but by late puberty, daytime LH pulse frequency (awake) is higher than nighttime pulse frequency (sleep). Mechanisms regulating these changes are unknown. We reported differential sensitivity of the GnRH pulse generator to inhibition by progesterone (P) in early pubertal girls - supraphysiological P levels abolished daytime (awake) but did not suppress nighttime (sleep) pulse frequency. We have shown that the GnRH pulse generator is less sensitive to feedback inhibition by P in women/adolescent girls with hyperandrogenemia (HA). In normal puberty, mean free T gradually increases from 2.8 (Tanner I) to 12.7 pmol/L (Tanner V). We aimed to test the hypothesis that the ability of P to inhibit daytime GnRH secretion is impaired as T levels increase across normal puberty, allowing a gradual increase in daytime LH frequency.

Methods: We studied 49 normal weight girls (Tanner I-V) via q 10 min sampling from 1900 to 0700 h. Subjects were divided into groups based on AM free T (pmol/L): <5 (“low T”), 5-10 (“mid T”), and >10 (“high T”). 39 subjects (14 low T, 8 mid T, 17 high T) did not receive P, while 10 girls (5 low T, 3 mid T, 2 high T) received exogenous P in 2-3 divided doses (mean P = 5.33 ng/mL). LH pulses frequency was determined in two time blocks: 1900-2300 h (daytime/wake) and 2300-0700 h (nighttime/sleep).

Results: Girls with T < 5 had few daytime LH pulses (0.14 ± 0.06 pulses/h [mean ± SEM]), but LH frequency was higher in girls with higher T: 0.56 ± 0.11 (mid T) and 0.74 ± 0.05 (high T) (p = 0.005 for both vs. low T). Nighttime (sleep) LH frequency was similar in all 3 groups: 0.43 ± 0.06 (low T), 0.56 ± 0.07 (mid T), and 0.51 ± 0.04 (high T). In girls receiving exogenous P, daytime LH frequency was 0.10 ± 0.10 (low T), 0.08 ± 0.08 (mid T), and 0.63 ± 0.13 (high T). In each group receiving P, LH frequency during sleep was similar to that in corresponding groups not receiving P: 0.38 ± 0.07 (low T), 0.46 ± 0.08 (mid T), 0.69 ± 0.06 (high T).

Conclusion: These results indicate that P tends to suppress LH pulses during day time (awake) with no effect during the night (sleep). This effect is more prominent when T levels are lower. These data suggest that the progression of GnRH pulse secretion during pubertal maturation is regulated by the gradual increase of T. The physiological overnight increase in P may be adequate to suppress day time GnRH pulses in early pubertal (lower T) girls. However as T rises during pubertal maturation, this process is impaired, allowing a selective increase of daytime pulse frequency. This mechanism may regulate the gradual increase in GnRH pulse secretion during puberty which drives pubertal development.

 

Nothing to Disclose: RB, ADA, CMB, JCM, CRM

OR04-3 16713 3.0000 A Testosterone Regulates the Evolution of Daytime GnRH Pulse Secretion during Pubertal Maturation in Girls? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 1:00:00 PM OR04 4757 11:30:00 AM Female Reproductive Endocrinology Oral

Marcelle Cedars*1, Sunni Mumford2, Anne Z. Steiner3, Peter Raymond Casson4, Christos Coutifaris5, Michael P Diamond6, Gregory M Christman7, William D Schlaff8, Ruben Alvero9, Hao Huang10, Nanette Santoro11, Esther Eisenberg12, Richard S Legro13, Heping Zhang14 and The Reproductive Medicine Network15
1Univ of California San Francisco, San Francisco, CA, 2Eunice Kennedy Shirver National Institute of Child Health and Human Development, Rockville, MD, 3University of North Carolina, 4University of Vermont, Burlington, VT, 5Hosp of Univ of PA, Philadelphia, PA, 6Wayne State Univ, Grosse Pointe Shores, MI, 7Univ of Michigan, Ann Arbor, MI, 8Jefferson University, Philadelphia, PA, 9University of Colorado-Denver, Aurora, CO, 10Yale University School of Medicine, New Haven, CT, 11University of Colorado Anschutz Medical Campus, Aurora, CO, 12Vanderbilt Univ Med Ctr, Nashville, TN, 13Penn State University, Hershey, PA, 14Yale University, New Haven, CT, 15NICHD

 

AMH reduces sensitivity of the follicle to FSH stimulation and reduces aromatase activity suggesting a potential for resistance to ovulation even in response to ovulation induction.

Objective: To determine the association between AMH levels and ovulation among the Pregnancy in Polycystic Ovary Syndrome II (PPCOS II) participants.

Methods: This is a secondary analysis of a randomized clinical trial. 750 women with polycystic ovary syndrome (PCOS) were randomized to ovulation induction with either letrozole or clomiphene citrate (mean BMI 35.1 kg/m2). PCOS was defined by Rotterdam Criteria. Females were 18-40y, had at least 1 patent fallopian tube and normal uterine cavity and a male partner with sperm concentration of at least 14 million/mL who consented to regular intercourse. Couples were followed up to 5 treatment cycles to determine ovulation and pregnancy. 748 subjects had AMH measured at baseline. Geometric mean AMH levels were compared between women who ovulated during the trial and women who did not, after adjustment for age, BMI, testosterone, insulin and Ferriman-Gallwey score. Logistic regression was also used to evaluate the association between AMH and ovulation, after adjusting for the same factors.

Results: 619 women ovulated in response to treatment during the study. A lower mean AMH was associated with ovulation (geometric means 5.59 vs. 7.07, p=0.004; odds ratio 0.56, 95% confidence interval 0.42, 0.75). Significance remained when the comparison was adjusted for age, BMI, testosterone, insulin levels, and Ferriman-Gallwey scores (p=0.0001). Adjustment for antral follicle count, smoking, and treatment did not impact the findings. Both age and BMI were negatively associated with AMH levels, but absolute AMH levels still were relatively high (geometric mean 5.81). AMH was also positively associated with testosterone and negatively associated with insulin levels. The fully adjusted ratio of AMH/AFC was also lower (0.14 vs. 0.17, p=0.04) in women who ovulated compared to those who did not ovulate.

Conclusions:  In this large cohort of obese women with PCOS, AMH levels and AMH per follicle count were significantly lower among women who ovulated in response to treatment compared to women who never achieved an ovulatory cycle. There were no interactions between AMH levels and treatment (letrozole vs. clomiphene citrate). Lastly, among women with an ovulatory cycle, the AMH levels at baseline were lowest among women taking the smallest dose at their last ovulatory cycle. These results suggest that high AMH is associated with a decreased response to ovulation induction and women with higher AMH levels may require higher doses to achieve ovulation.

 

Disclosure: MC: Investigator, Ferring Pharmaceuticals. AZS: Consultant, Roche Diagnostics. CC: Board Member, NOVA Therapeutics . NS: Advisory Group Member, Menogenix, Principal Investigator, Bayer, Inc.. RSL: Speaker, Ferring Pharmaceuticals. HZ: Ad Hoc Consultant, Sun Yat-Sen University, Heilongjiang University of Chinese Medicine, Tsinghua University, and Shangdong University, Ad Hoc Consultant, Sun Yat-Sen University, Heilongjiang University of Chinese Medicine, Tsinghua University, and Shangdong University. Nothing to Disclose: SM, PRC, MPD, GMC, WDS, RA, HH, EE, TR

OR04-4 15532 4.0000 A Impact of AMH Level on Chances for Ovulation in Pregnancy in Polycystic Ovary Syndrome II, a Multi-Center Randomized Clinical Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 1:00:00 PM OR04 4757 11:30:00 AM Female Reproductive Endocrinology Oral

Mojca Jensterle*1, Tomaz Kocjan1 and Andrej Janez2
1Univ Med Ctr Ljubljana, Ljubljana, Slovenia, 2University Medical Center Ljubljana, Ljubljana, Slovenia

 

Context: Phosphodiesterase (PDE) enzymes, including members of PDE4, have been investigated in regulation of endocrine and reproductive functions of ovaries. In addition, selective inhibition of PDE4 enzyme has recently been implicated in the regulation of metabolism with positive effects on glucose homoeostasis and weight reduction.

Objective: The aim of this study was to evaluate whether the PDE4 inhibitor roflumilast affects body weight and hormonal and metabolic status in obese women with polycystic ovary syndrome (PCOS).

Design/Participants/Main Outcome Measure: A 12-week prospective randomized open-label study was conducted with 36 obese women with PCOS diagnosed by the National Institute of Child Health and Human Development criteria who had been pre-treated with metformin (MET). They were randomized to MET 1000 mg BID or combined treatment (COMBI) with MET 1000 mg BID and roflumilast 500 mcg QD. The primary outcome was change in anthropometric measures of obesity. Secondary outcomes included hormonal and metabolic changes.

Results: 31 patients (aged 33.8 ± 7.4 years, BMI 36.4 ± 5.1 kg/m2, mean ± SD) completed the study: 16 on MET and 15 on COMBI. Subjects treated with COMBI lost on average 4.2 ± 2.8 kg compared with a 0.9 ± 2.5 kg weight gain in MET group (p<0.001). BMI decreased for 1.6 ± 1.1 kg/m2 in COMBI arm compared to increase for 0.9 ± 2.4 kg/m2  in MET arm (p= 0.001). Visceral adipose tissue area as assessed by DXA decreased from 136.7 ± 37.8 to 121.2 ± 36.2 cm2 in COMBI arm compared to increase from 155.3 ± 61.9 to 166.7 ± 67.2 cm2 in MET arm (p=0.02). From baseline to study end both treatment interventions resulted in a significant reduction of androstenedione (p=0.013), free testosterone (p=0.002) and HOMA-IR score (p=0.027) and a significant increase in SHBG (p=0.024), although the between-treatment differences of the changes have not been statistically significant yet.

Conclusion: Roflumilast added to metformin reduced body weight in obese women with PCOS, primarily due to a loss of fat mass. These improvements were associated with beneficial effects on hormonal and metabolic status.

 

Nothing to Disclose: MJ, TK, AJ

OR04-5 12947 5.0000 A Phosphodiesterase 4 Inhibition As a Potential New Therapeutic Target in Obese Women with Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 1:00:00 PM OR04 4757 11:30:00 AM Female Reproductive Endocrinology Oral

Natalie D Shaw*1, Serene Srouji2, Corrine K. Welt3, Kimberly H Cox4, Janis H Fox5, Judith M. Adams6, Patrick M. Sluss4 and Janet E. Hall7
1Boston Children's Hospital, Boston, MA, 2Brigham and Wmn's Hosp, Boston, MA, 3The University of Utah, Salt Lake City, UT, 4Massachusetts General Hospital, Boston, MA, 5Brigham & Women's Hosp, Boston, MA, 6MA Gen Hosp, Boston, MA, 7Massachusetts General, Boston, MA

 

Context: Estradiol (E2) levels are maintained within or exceed the normal range in older reproductive-aged women with regular menstrual cycles, whereas levels of inhibin B and anti-mullerian hormone  (AMH) begin to decline and FSH levels begin to rise and fertility is decreased.  The mechanisms underlying preserved E2 synthesis in older reproductive–aged women in the face of other evidence of declining ovarian function are unknown. The current study was designed to determine if sustained E2 secretion with aging is due to increased granulosa cell aromatase mRNA expression and activity.

Methods:  Healthy, regularly cycling older (n=13; 36-45 yrs) and younger (n=14; 22-34 yrs) women were studied. Reproductive hormone and peptide levels were measured in peripheral blood samples throughout the follicular phase. Follicular fluid (FF) and granulosa cells were aspirated from dominant follicles in naturally occurring cycles. FF was assayed for androstenedione (AD), testosterone (T), estrone (E1) and E2 as indices of aromatase activity within the follicle. Inhibin A, inhibin B, and AMH were also measured in FF.  Aromatase mRNA expression was determined in granulosa cells using qRT-PCR.

Results: Older women had higher FSH levels (O vs Y: 13.5±0.9 vs. 11.3±0.5 IU/L, p=0.04) than younger women during the early follicular phase in the setting of similar E2 (54.6±5.0 vs. 52.0±2.9 pg/ml, p=0.7) but lower inhibin B (74.0±9.3 vs. 94.3±5.3 pg/ml, p=0.04) and AMH (1.0±0.3 vs. 3.1±0.5 ng/ml, p=0.006) levels.  Late follicular phase serum E2 levels were similar in the two groups but older women demonstrated an earlier pre-ovulatory rise in E2 (cycle day 7.4±0.5 vs. 9.9±0.8; p=0.02).  Aromatase mRNA expression was 3-fold higher in older compared with younger women (p< 0.001). Although aromatase expression per granulosa cell was higher in older women, there were no age-related differences in FF E2 (O vs. Y: 1169.8±183 vs. 1166.8±215 ng/ml, p=1) or E1 (40.0±7.7 vs. 54.8±14.2 ng/ml, p=0.3) or in aromatase substrate to product ratios (T to E2: 0.03±0.005 vs. 0.02±0.005, p=0.8; AD to E1: 15.8±4.1 vs. 10.6±3.2, p=0.3) after controlling for dominant follicle size.

Conclusions: These studies demonstrate an increase in ovarian aromatase mRNA in older compared with younger reproductive-aged women. Similar FF E2 levels in older and younger women are consistent with previous studies finding fewer granulosa cells in the dominant follicle in women with decreased ovarian reserve marked by increased FSH levels (1). These data suggest that estrogen synthesis is likely to be increased on a per cell basis in conjunction with ovarian aging in women.

 

Disclosure: CKW: Ad Hoc Consultant, Up To Date. Nothing to Disclose: NDS, SS, KHC, JHF, JMA, PMS, JEH

OR04-6 17075 6.0000 A Evidence That Ovarian Aromatase Action Is Preserved with Aging in Regularly Cycling Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 1:00:00 PM OR04 4757 11:30:00 AM Female Reproductive Endocrinology Oral

Sin-Gi Park1, Jong Bhak1, Jong-Soo Kim1, Tae-Hyung Kim1, Jee Hyun An2, Sang Youl Rhee3, Hee Kyung Kim4, Min Joo Kim5, Hyun Jeong Jeon6, Taekeun Oh6 and Hyung Jin Choi*7
1Theragen BiO Institute, TheragenEtex, Suwon, Korea, Republic of (South), 2College of Medicine, Korea University, Seoul, Korea, Republic of (South), 3Kyung Hee University School of Medicine, Seoul, Korea, Republic of (South), 4Chonnam National University College of Medicine, Gwangju, Korea, Republic of (South), 5Korea Cancer Center Hospital, Seoul, Korea, Republic of (South), 6Chungbuk National University College of Medicine, Cheongju, Korea, Republic of (South), 7Seoul National University College of Medicine, Seoul, Korea, Republic of (South)

 

Agranulocytosis is a rare but life-threatening side effect of antithyroid drugs. Several reports, including familial cases, suggested that susceptibility to antithyroid drug induced agranulocytosis has a genetic bases. These genetic components could be used to predict the risk of antithyroid drug induced agranulocytosis. However, no tests are currently available to predict the risk of antithyroid drug induced agranulocytosis. In this study, we performed whole-exome sequencing to comprehensively identify the genetic variations responsible for antithyroid drug induced agranulocytosis. For discovery stage 1, whole-exome sequencing was performed for seven antithyroid drug induced agranulocytosis cases. Variant based approach and gene based approach were performed to discover candidate variants or genes for antithyroid drug induced agranulocytosis. For HLA loci, HLA-sequence-based typing was performed. For validation stage 2, Sanger sequencing and HLA-sequence-based typing were performed for eight additional independent antithyroid drug induced agranulocytosis cases. Korean local healthy controls and public HLA database were used as control group. Discovery stage genome-wide association study results revealed strong signals in chromosome 6 (P=2.7×10-8) and chromosome 19 (P=1.7×10-14). HLA typing of seven discovery cases and eight validation cases revealed several HLA types, which showed strong association with antithyroid drug induced agranulocytosis (odds ratio=4.6-6.3, P=3×10-3-5×10-5). Gene based approach indicated several candidate genes for antithyroid drug induced agranulocytosis. In these genes, several loss of function variants were found, which were common among antithyroid drug induced agranulocytosis cases, but these variants were rare among controls (P=2.0×10-3-1.8×10-4). In conclusion, several strong genetic predictors of antithyroid drug induced agranulocytosis were discovered. To avoid the risk of life-threatening agranulocytosis side effect, these pharmacogenomics markers could be tested in clinic before initiation of antithyroid drugs.

 

Nothing to Disclose: SGP, JB, JSK, THK, JHA, SYR, HKK, MJK, HJJ, TO, HJC

OR12-1 14618 1.0000 A Whole-Exome Sequencing Reveals Strong Genetic Predictors of Antithyroid Drugs Induced Agranulocytosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 1:00:00 PM OR12 4764 11:30:00 AM Thyroid Autoimmunity Oral

Jing Li*1, Juan Qin1, Hongmei Zhang1, Zhongyan Shan2 and Weiping Teng3
1the First Affiliated Hospital of China Medical University, Shenyang, China, 2Institute of Endocrinology, China, 3The Endocrine Institute, Shenyang, China

 

Alpha-Enolase (ENO1) is a key glycolytic enzyme in the cytoplasm, and also expressed on the surface of immune cells, neurons, glial and endothelial cells (1). Anti-ENO1 autoantibody (ENO1Ab) was reported in several autoimmune disorders, such as autoimmune retinopathy. Aside from enzymatic function, the pathogenic roles of ENO1 have been implicated for its immunogenic capacity, DNA-binding ability and plasmin(ogen) receptor function. ENO1Ab has been found in the sera of patients with steroid responsive encephalopathy associated with autoimmune thyroiditis (2). However, it is not clear whether ENO1Ab develops directly from thyroid autoimmunity or due to other concurrent autoimmune diseases. In this study, we directly examined whether ENO1 was an autoantigen in the pathogenesis of autoimmune thyroiditis based on a classical experimental autoimmune thyroiditis (EAT) animal model induced by thyroglobulin (Tg) immunization. Seven-week-old female CBA/J mice were randomly assigned to two groups and kept in specific pathogen free facilities. One group was first immunized with murine Tg in complete Freund's adjuvant, and then challenged with Tg in incomplete Freund's adjuvant two weeks later. They were sacrificed 4 weeks after the second Tg challenge. The other group was injected only with Freund's adjuvant as control. Sera were collected for determination of TgAb and ENO1Ab by ELISA. Serum ENO1Ab were further identified by western blot using recombinant ENO1 protein and HRP-conjugated anti-mouse IgG. ENO1 expression in the thyroid from non-immunized intact CBA/J mice was detected through both western blot and immunohistochemical staining using rabbit anti-ENO1 IgG. After Tg immunization, the occurrence of EAT was confirmed by significantly elevated serum TgAb and intrathyroidal mononuclear cell infiltration. Serum anti-ENO1 total IgG level was significantly higher in EAT group induced by Tg immunization (OD450=0.4509±0.2643; n=17) as compared with that of control group injected only with Freund's adjuvant (OD450=0.2416±0.0875; P=0.024; n=10). In western blot experiments, the pooled sera from EAT mice (n=3) was found containing autoantibody against 47 kDa ENO1 protein, and there was a protein band migrating around 47 kDa on SDS-PAGE gel from pooled thyroid extract of non-immunized mice recognized by rabbit anti-ENO1 IgG (n=3). The above western blot experiments had been repeated three times with consistent findings. Immunohistochemical staining using rabbit anti-ENO1 IgG and UltraSensitive™ SP system confirmed ENO1 expression in thyroid follicular cells, which was mainly distributed in the cytoplasm (n=3). The above findings suggest that ENO1 expressed in thyroid follicular cells may act as one of autoantigens in thyroid autoimmunity. Reactions to this multifunctional protein might elicit immune attacks to some extrathyroidal tissues, such as brain, at the same time.

 

Nothing to Disclose: JL, JQ, HZ, ZS, WT

OR12-2 13218 2.0000 A Direct Identification of Alpha-Enolase As an Autoantigen in the Pathogenesis of Autoimmune Thyroiditis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 1:00:00 PM OR12 4764 11:30:00 AM Thyroid Autoimmunity Oral

Angela Lombardi*1, William B Inabnet III1, Randall Owen1 and Yaron Tomer2
1Icahn School of Medicine at Mount Sinai, New York, NY, 2Icahn School of Medicine at Mount Sinai and James J. Peters VA Medical Center, New York, NY

 

Background: Amiodarone (AMIO) is one of the most effective antiarrhythmic drugs available. However, its use is often limited by serious side-effects including thyroid dysfunction. Management of AMIO-induced thyrotoxicosis (AIT) remains a very challenging problem especially since the half life of AMIO is several weeks and merely stopping therapy does not result in resolution of thyrotoxicosis. Moreover, the molecular mechanisms underlying AIT are still unclear and therefore, specific therapy cannot be developed. Subtoxic doses of AMIO were recently reported to interfere with protein folding in the endoplasmic reticulum (ER) causing ER stress. Here we sought to evaluate the potential role of ER stress in the induction of AMIO-induced thyroiditis.

Results: To investigate the functional role of AMIO in ER stress, human thyroid cell line ML-1 was treated with increasing concentrations of AMIO (5, 10 or 20 µM); the classic ER stress inducer Thapsigargin (0.5 µM) was used as positive control. AMIO increased mRNA and protein levels of BiP, a typical marker of  ER stress, already at a concentration of 5 µM. Time course analysis with AMIO (5 µM) showed that BiP mRNA was significantly increased as early as 16 hours after treatment and remained elevated for up to 72 hours. To explore the contribution of iodine released from AMIO in BiP upregulation, we treated ML-1 cells with different concentrations of iodine (10, 100 or 1000 µM). Intriguingly, none of the concentrations used caused upregulation of BiP, tested both at the mRNA and protein levels. These data  demonstrated that AMIO did not induce BiP via iodine-mediated mechanisms. Confirming the BiP data, incubation of ML-1 with 5 µM AMIO for 24 hours significantly increased expression of other ER stress markers including phospho-eIF2α, Chop and spliced-XBP1. Human primary thyrocytes cultured in the same experimental settings, displayed a significant increase of BiP mRNA and protein, mirroring the results obtained in ML-1 cells. Remarkably, in both experimental systems AMIO downreguated thyroglobulin (Tg) protein levels but had no significant effect on Tg mRNA levels suggesting a mechanism involving Tg protein degradation. To test this hypothesis, we pretreated overnight both ML-1 cells and primary thyrocytes with 0.8 µM MG132, a proteasome-specific inhibitor, reversing the AMIO-induced downreguation of Tg protein. Moreover, pretreatment of both ML-1 cells and primary thyrocytes with the chemical chaperone 4-phenylbutyric acid (7.5 mM) for 24 hours completely prevented the effects of AMIO on ER stress induction and Tg downregulation, suggesting an ER stress-dependent proteasome activation.

Conclusions: We demonstrated for the first time that ER stress represents one of the molecular links between AMIO and AIT providing a new therapeutic target in the prevention and treatment of AMIO-induced thyroid dysfunction.

 

Nothing to Disclose: AL, WBI III, RO, YT

OR12-3 15305 3.0000 A A New Mechanism for Iodine Independent Amiodarone-Induced Thyroiditis with Translational Implications 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 1:00:00 PM OR12 4764 11:30:00 AM Thyroid Autoimmunity Oral

Liping Wu*1, Yuan Zhao1, Bingyin Shi2, Chuqi Gao1, Yue Wang1, Li Xu1, Hongjun Lv2, Jing Shi1, Peng Hou2 and Meiju Ji2
1The First Affiliated Hospital of Xi’an Jiaotong University Health Science Center, Xi'an, China, 2The First Affiliated Hospital of Xi’an Jiaotong University School of Medicine, Xi'an, China

 

Graves’ disease (GD) is more prevalent in females than males. This female preponderance for abnormal autoimmune function has largely gone unexplained. Androgen may be responsible for the decreased susceptibility of males to GD. The current study was designed to explore gender difference and response to androgen treatment in the mice model of GD induced by injection of adenovirus expressing thyrotropin receptor (TSHR) A-subunit. The incidence and the severity of GD were observed in male and female BALB/c mice, castrated males or androgen treated females. The total thyroxine (TT4) levels of males were decreased compared to females (98.71+19.08 nmol/l vs. 167.75+26.44 nmol/l, p=0.048; n=10 per group). However, the free thyroxine (FT4) levels were slightly, but not significantly, lower in males than females (p=0.368). Castration had no apparent influence on the induction of GD vs. sham-operation (TT4: p=0.59; FT4: p=0.81; n≥10 per group). As expected, both testosterone(T) and dihydrotestosterone(DHT) reduced the levels of TT4(T: 88.20+7.0 nmol/l vs. 160.24+24.15 nmol/l，p=0.047; DHT: 84.35+11.98 nmol/l vs.160.24+24.15 nmol/l , p=0.042; n≥10 per group), FT4(T: 13.07+1.46 pmol/l vs. 39.75+9.04 pmol/l, p=0.047; DHT: 13.11+2.57 pmol/l vs.39.75+9.04 pmol/l, p=0.0 47) and the degree of thyroid hyperplasia vs. controls. In addition, the incidence of Graves’ hyperthyroidism was decreased respectively 22% or 30% in androgen(T or DHT) treated females compared to controls. To help understand the androgen influence on the immune system, the immune response of Th1/Th2/Th17/Treg was analysis by measuring the percentage of CD4+INF-γ+, CD4+IL-4+, CD4+IL-17A+, CD4+CD25+, CD4+CD25+Foxp3+ in CD4+ T cells from spleen. The analysis of T cells flow cytometry showed that the expression of CD4+INF-γ+ among CD4+ T cells in males was decreased when compared to females(10.24±0.79 % vs. 12.45±0.68 %, p=0.048), and androgen depletion mildly decreased the percentage of CD4+CD25+ (6.79±0.28 % vs. 7.69±0.33 %, p=0.046) or CD4+CD25+Foxp3 (5.70±0.28 % vs. 6.60±0.33 %, p=0.047)in CD4+ T cells vs. sham-operation. Androgen treatment not only significantly inhibited the expression of CD4+INF-γ+(T: 9.85±0.59 % vs.12.67±0.85 %, p=0.07; DHT: 9.97±0.60 % vs.12.67±0.85 %, p=0.01), but also promoted the expansion of CD4+CD25+ (T: 8.67±0.43 % vs.7.23±0.35 %, p=0.011; DHT: 8.91±0.32 % vs 7.23±0.35 % ，p=0.003) and CD4+CD25+Foxp3(T: 7.74±0.41 % vs.6.17±0.32 %, p=0.005; DHT: 8.14±0.33 % vs.6.17±0.32 %，p=0.001) population within CD4+ T cells compared to controls. Our data suggested that endogenous androgen hasn’t evidently inhibited effect against GD in BALB/c mice. Supplemental exogenous androgen provided protection against Graves’ hyperthyroidism. Supressed Th1 immune response and extended Tregs population may be one mechanism responsible for protective role of androgen.

 

Nothing to Disclose: LW, YZ, BS, CG, YW, LX, HL, JS, PH, MJ

OR12-4 12999 4.0000 A Exogenous Androgen Is Protective in Experimental Graves' Hyperthyroidism in BALB/c Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 1:00:00 PM OR12 4764 11:30:00 AM Thyroid Autoimmunity Oral

Veitla S Rao*1, Allison Lea Galloway2, Hongliang LI1, Alexandria Benbrook1, Xichun Yu3 and David C Kem3
1OUHSC, Oklahoma City, OK, 2Freeman Heath System, Joplin, MO, 3Univ of Oklahoma and VAMC, Oklahoma City, OK

 

Objective: We examined the prevalence of activating autoantibodies (AAb) to beta (B) adrenergic and muscarinic (M) receptors in subjects with Graves’ hyperthyroidism (GH) and atrial tachyarrhythmias including atrial fibrillation (AF).

Methods: Sera from 81 patients including 31 with GH and AF, 36 with GH without AF, 9 with toxic multinodular goiter (TMNG), 5 subacute thyroiditis and 10 healthy control subjects were examined for autoantibodies to B1/2-adrenergic receptors (B1/2AR) and M2 muscarinic receptor (M2R) by ELISA. Some sera were examined for B1/2AR-AAb and M2R-AAb bioactivity using transfected cell-based bioassays.

Results: 45% of patients with GH and AF were ELISA positive for autoantibodies to B1AR and 65% of the patients were positive for autoantibodies to M2R. Seventy eight (78) % were positive for B2AR but these were equally distributed between those with and without AF. Twelve subjects harbored both B1AR and M2R autoantibodies. Using a sensitive receptor-specific cell-based cAMP assay in 20 subjects, 10 with AF and 10 without AF, mean B1AR-AAb activity was elevated in both groups but higher in those with AF than those without AF (P=0.01). Both suppressed toward baseline with the BAR blocker propranolol. Β2AR-AAb activity for both was elevated (P<0.0001) from baseline but equally (P=0.2); and suppressed (P<0.001) to baseline with the B2AR blocker ICI188531. M2R-AAb suppressed forskolin-induced cAMP production in both groups, but with significantly greater suppression (P<0.001) in AF subjects. This activity returned to nearly baseline with the muscarinic blocker atropine. All but one with AF were >45 years of age. Patients with TMNG or subacute thyroiditis had a low prevalence of autoantibodies.

Conclusions: B1AR, B2AR and M2R AAb are elevated in patients with GH and concurrent AF and to a lesser extent in those without AF. Orthosteric activation of these receptors with their normal ligands is known to facilitate AF especially in older subjects. Patients with TMNG have a relatively low prevalence of AAb compatible with the non-autoimmune pathogenesis of their hyperthyroidism. We conclude B1AR-AAb and M2R-AAb, often in combination, serve as allosteric agonists in the presence of excessive thyroid hormone to facilitate AF and tachycardia in older subjects with GH. The role for B2AR-AAb is less clear, but may add to the risk for AF when present with other AAb. Β2AR-AAb also may contribute to the sinus tachycardia so commonly observed with GH.

 

Nothing to Disclose: VSR, ALG, HL, AB, XY, DCK

OR12-5 15165 5.0000 A Activating Autoantibodies to Beta Adrenergic and Muscarinic Receptors Associate with Atrial Tachyarrhythmias in Patients with Graves' Hyperthyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 1:00:00 PM OR12 4764 11:30:00 AM Thyroid Autoimmunity Oral

Tania Pilli*, Silvia Cantara, Valeria Cenci, Sandro Cardinale, Fausta Sestini, Carla Fioravanti and Furio Pacini
University of Siena, Siena, Italy

 

Introduction: Over the past 10 years, several clinical studies have suggested that selenium supplementation may influence the natural history of AIT. Recently, IFNγ-inducible chemokines (CXCL9, CXCL10 and CXCL11) were shown to be elevated in the AIT patients. The aim of this prospective, randomized, controlled study was to evaluate the effect of two different doses of selenomethionine (80 or 160 µg) versus placebo in euthyroid women with AIT, in terms of reduction of anti-thyroid antibodies and improvement of thyroid hypoechogenicity, during 12 months. Serum levels of selenium, CXCL9, CXCL10 and CXCL11 and their regulators, TNF-α and INF-γ, thyroid functin and volume and the quality of life of AIT patients were also evaluated. Patients and Methods: 60 patients (age 21-65 years) were equally randomized into 3 groups according to the treatment modality: 80 µg of Semet (80-Semet), 160 µg of Semet (160-Semet) or placebo. The abovementioned parameters were measured at baseline and every 3 months. Results: Data available up to 9 months. Patients were moderately in selenium deficient at the baseline (m±SD: 81.78±14.55 µg/l). AbTg levels were significantly reduced in the 160-semet group, from a median of 181.5 to a median of 102.5 U/ml, starting at 3 months (p=0.0125) while they did not show any change in the placebo and 80-semet group; serum levels of CXCL9, CXCL10 and CXCL11, assessed at baseline and at 6 months, were significantly reduced in both 80-Semet (p = 0.008, 0.007 and 0.016 respectively) and 160-Semet (p = 0.001, 0.006 and 0.001 respectively) group, while they remained unchanged or increased in the placebo group. In parallel we observed a significant decrease of TNF-α and IFN-γ in both Semet groups (IFN-γ, p=0.015 in the 80-Semet group and p=0.072 in the 160-Semet group; TNF-α, p=0.013 in the 80-Semet and p=0.006 in the 160-Semet group). Semet supplementation had no effect on AbTPO levels, thyroid hypoechogenicity, function and volume and the quality of life of AIT patients. No side effects were reported. Conclusions: Both doses of Semet (80 and 160 µg) were able to decrease significantly circulating CXCL9, CXCL10 and CXCL11, maybe through TNF-α and IFN-γ reduction, suggesting a positive immune-modulatory effect in AIT patients , as confirmed by the decreased levels of AbTg in the 160-Semet group. However, we hypothesize that a longer Semet supplementation may be needed to achieve a more evident clinical effect.

 

Nothing to Disclose: TP, SC, VC, SC, FS, CF, FP

OR12-6 15147 6.0000 A IFNγ-Inducible Chemokines Are Down-Modulated By Selenomethionine (Semet) Supplementation in Women with Euthyroid Chronic Autoimmune Thyroiditis (AIT): Comparison Between 2 Doses of Semet (80 μg or 160 μg) Versus Placebo 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 1:00:00 PM OR12 4764 11:30:00 AM Thyroid Autoimmunity Oral

Dimitrios T Papadimitriou*1 and Anastasios Papadimitriou2
13rd Department of Pediatrics, Attikon University Hospital, Athens Greece, Athens, Greece, 2Attikon University Hospital, Athens, Greece

 

Background: Hormonal replacement in boys with congenital HH remains a challenge in pediatric endocrinology. Micropenis has been traditionally successfully treated, usually with 3 monthly injections of 25/50 mg of testosterone enanthate in the post-neonatal period or in early infancy, but in cases with bilateral cryptorchidism surgical intervention is required. Even after a successful surgery, the hypoplastic testes with the deficient proliferation of immature Sertoli cells before and during puberty, due mainly to the absence of the male neonatal surge in pulsatile gonadotropin secretion, are responsible for azoospermia and infertility later in life.

Objective: To investigate whether early postnatal daily injections of the commercially available recombinant LH plus FSH preparation (Pergoveris®) could mimic the physiological male mini puberty and successfully resolve bilateral cryptorchidism, result in penis enlargement and restore the responses of the Leydig and Sertoli cells to normal.

Design and Methods: Three neonates with bilateral cryptorchidism in intra-abdominal position and micropenis with absence of neonatal male mini-puberty were treated for 3 months with daily subcutaneous injections of Pergoveris® (recombinant LH 75 IU and FSH 150 IU), followed monthly. Parents were trained to perform the injections. Case 1 (born 36+6, AGA) had CHARGE syndrome had a penile length of 2.3 cm at 4 months of age. Case 2 (born 36+3, SGA) had Kallmann syndrome and a penile length of 2 cm at 1 month of age. Case 3 (born 37+1, AGA) had septo-optic dysplasia and panhypopituitarism diagnosed soon after borth beacause of symptomatic hypoglycemia and cholestatic jaundice with a penile length of 1.5 cm at 3 months of age.

Results: Mean LH reached high normal C1: 7.22, C2: 4.7, C3: 6.5 IU/L) and mean  FSH supranormal levels C1: 132, C2: 88, C3: 77.1 IU/L. Mean Inhibin b and AMH, from subnormal before treatment, reached high normal levels: 241 pg/ml and 1034 pmol/L respectively. Mean Testosterone increased from undetectable levels to C1: 2.22, C2: 3.33 and C3: 0.55 ng/ml. In all cases testes descended in scrotal position by the end of the 1st in C1, 2nd in C2 and 3rdmonth in C3 with a volume of 1.5, 2.5 ml and 2 ml respectively. In cases 1 and 2 who have now reached 3.5 and 4.5 years of age testes have regressed to 0.5 and 1 ml respectively but are still in scrotal position. Case 3 just completed therapy. Penile length increased to 4.5, 3.8 and 4 cm respectively. None presented any adverse events or reactions.

Conclusions: The present regimen mimics neonatal male mini puberty repairing micropenis and cryptorchidism and inducing high-normal activation of Leydig and Sertoli cells.

 

Nothing to Disclose: DTP, AP

LB-OR01-1 17971 1.0000 A Successful Treatment of Neonatal Micropenis and Bilateral Cryptorchidism Due to Hypogonadotropic Hypogonadism (HH) with 3-Month Daily Subcutaneous Injections of the Recombinant LH Plus FSH Preparation (Pergoveris®) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 1:00:00 PM LB-OR01 5225 11:30:00 AM Origins and Treatment of Reproductive Dysfunction Oral

Anu Bashamboo*1, Marie France Portnoi2, Marie-Charlotte Dumargne1, Joelle Bignon-Topalovic1, Hassan Rouba3, Sandra Rojo1, Celia Ravel4, Luca Persani5, John C Achermann6, Sophie Christin-Maitre7, Jean-Pierre Siffroi2 and Ken McElreavey1
1Institut Pasteur, Paris, France, 2Trousseau Hospital, Paris, France, 3Institut Pasteur of Morocco, Casablanca, France, 4Centre Hospitalier Universitaire de Rennes, Rennes, France, 5Istituto Auxologico Italiano, milan, Italy, 6UCL Inst of Child Health, London, United Kingdom, 7Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Paris, France

 

Sox8, a member of the SoxE gene family, is expressed in Sertoli cells during early testis development. The combined action of both Sox9 and Sox8 in murine Sertoli cells is essential for proper testis differentiation. Sox8 null mutants show normal embryonic and early postnatal testis development but develop infertility due to progressive spermatogenic failure. We identified a patient with 46,XY complete gonadal dysgenesis (CGD), who carried a paracentric inversion of the short arm of chromosome 16. The distal breakpoint mapped to 69 kb upstream of the SOX8 gene. Sequencing the SOX8 open reading frame in other cases of 46,XY gonadal dysgenesis revealed a heterozygote missense mutation in the HMG-box. Extending this analyses to unexplained cases of infertility revealed 7 heterozygous missense mutations associated with either azoo- or oligozoospermia (n=274, 2.5%) and 7 heterozygous missense or frameshift mutations associated with ovarian insufficiency (n=153, 4.75%). Sequencing of the SOX8 gene in ancestry-matched control samples (n=840) identified 10 rare or novel missense mutations (1.19%). However, when a subgroup of ancestry-matched control samples of known fertility status and/or with normal semen parameters were analysed, only 2 of 420 (0.047%) carried rare or novel SOX8 missense mutations. These two mutations were predicted to be benign by SIFT and PolyPhen analysis.  All of the mutations associated with infertility were located outside the HMG-box of the protein. In-vitro assays, showed that the mutations have a variable effect on the biological function of SOX8. Overall the data demonstrate that, similar to SF-1/NR5A1, heterozygous mutations involving the SOX8 gene contribute to a wide range of reproductive anomalies in both the male and the female.

 

Nothing to Disclose: AB, MFP, MCD, JB, HR, SR, CR, LP, JCA, SC, JPS, KM

LB-OR01-2 18002 2.0000 A Mutations Involving SOX8 Are Associated with a Spectrum of Human Reproductive Disorders 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 1:00:00 PM LB-OR01 5225 11:30:00 AM Origins and Treatment of Reproductive Dysfunction Oral

Andy Videsh Babwah*1, Michele Dawn Calder1, Yee-Ming Chan2, Renju Raj3, Adrienne Elbert4, Michelle Noonan4, Claudia Caligioni5, Nathalie Berube4, Moshmi Bhattacharya4 and Stephanie Beth Seminara5
1University of Western Ontario, London, ON, Canada, 2Massachusetts General Hospital, MA, 3University of Vermont College of Medicine, 4University of Western Ontario, 5Massachusetts General Hospital, Boston, MA

 

The hypothalamic kisspeptin signaling system is a major positive regulator of the reproductive neuroendocrine axis, and loss of Kiss1 in the mouse results in infertility; a condition generally attributed to its hypogonadotropic hypogonadism. We demonstrate that in Kiss1-/- female mice, acute replacement of gonadotropins and estradiol restores ovulation, mating and fertilization; however, these mice are still unable to achieve pregnancy because embryos fail to implant. Progesterone treatment did not overcome this defect. Kiss1+/- embryos transferred to a wild-type female mouse can successfully implant, demonstrating the defect is due to maternal factors. Kisspeptin and its receptor are expressed in the mouse uterus, and we suggest that it is the absence of uterine kisspeptin signaling that underlies implantation failure. This absence, however, does not prevent the closure of the uterine implantation chamber, proper alignment of the embryo and the ability of the uterus to undergo decidualization. Instead, the loss of Kiss1 expression specifically disrupts embryo attachment to the uterus. We observed that on the day of implantation, Lif, a cytokine that is absolutely required for implantation in mice, is weakly expressed in Kiss1-/- uterine glands and that the administration of exogenous Lif to hormone-primed Kiss1-/- female mice is sufficient to partially rescue implantation. Taken together, our study reveals that uterine kisspeptin signaling regulates glandular Lif levels, thereby identifying a novel and critical role for kisspeptin in regulating embryo implantation in the mouse. This study provides compelling reasons to explore this role in other species, particularly livestock and humans.   

 

Nothing to Disclose: AVB, MDC, YMC, RR, AE, MN, CC, NB, MB, SBS

LB-OR01-3 18027 3.0000 A Implantation Failure in Female Kiss1-/- Mice Is Independent of Their Hypogonadic State and Can be Partially Rescued By Leukemia Inhibitory Factor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 1:00:00 PM LB-OR01 5225 11:30:00 AM Origins and Treatment of Reproductive Dysfunction Oral

Jean-Pierre J Bourguignon*1, Delphine Franssen1, Arlette Gerard1, Benoit Hennuy2 and Anne-Simone M Parent1
1Developmental Neuroendocrinology Unit, GIGA Neurosciences, University of Liège, Liège, Belgium, 2transcriptomic platform, GIGA, University of Liège, Belgium

 

We recently reported that neonatal exposure of female rats to 1 or 10 µg/kg.day of diethylstilbestrol could respectively cause late or early puberty and consistent changes in maturation of pulsatile GnRH secretion (1).  Endocrine disrupting effects of low bisphenol A (BPA) doses in the µg range are a matter of controversy. We studied the effects of neonatal exposure to a very low dose of 25 ng/kg.day in comparison with 5mg/kg.day. Newborn female rats were exposed to vehicle (corn oil) or BPA injected subcutaneously from postnatal day 1 (PND 1) to 5 or from PND 1 to 15. The rats were followed for vaginal opening (VO) and estrous cyclicity. The GnRH interpulse interval that was known to decrease between PND 10 and 25 was studied ex vivo using hypothalamic explants obtained at PND 15, 20 or 25. Gene expression in the retrochiasmatic hypothalamus was assessed by whole exome RNA-sequencing on PND 20 (3 samples per condition). After neonatal exposure to 25 ng/kg.day of BPA for 15 days, the age at VO was delayed (35.3 ± 0.7 days vs 33.5 ± 0.5 days in controls) while advancement (32.1 ± 0.6 days) was observed using 5 mg/kg.day. The difference in pubertal timing between the two doses was significant. The late VO after exposure to 25 ng/kg.day of BPA was preceded by a significant increase in GnRH interpulse interval (52.5 ± 0.8 min vs 44.6 ± 0.7 min in controls) at PND 20. By contrast, early VO after exposure to 5 mg/kg/d was preceded by a significant decrease in GnRH interpulse interval (40.3 ± 0.1 min vs 42.8 ± 0.4 min). Similar dose-related changes in GnRH secretion were observed after BPA exposure from PND 1 to 5. At PND 20, after exposure from PND 1 to 15, RNA expression of 10 genes showed significant opposing changes in the high vs low BPA dose groups. Fourteen genes displayed an expression that was only affected by 25 ng/kg of BPA. The dose of 5 mg/kg resulted in modified expression level of 472 genes versus controls. A significant difference in level of RNA expression was observed for 1407 genes when comparing the two BPA dose conditions. In conclusion, neonatal exposure to a very low dose of BPA was followed by a delay in pubertal timing with consistent changes in pulsatile GnRH secretion. Changed hypothalamic RNA expression confirmed the effects of the two BPA doses with opposing changes of similar genes in relation to BPA dose and alteration of distinct genes by each of the two doses.

 

Nothing to Disclose: JPJB, DF, AG, BH, ASMP

LB-OR01-4 17984 4.0000 A Delayed Puberty, Slowed Down GnRH Secretion and Changed Hypothalamic RNA Expression after Neonatal Exposure to a Very Low Environmentally Relevant Dose of Bisphenol a 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 1:00:00 PM LB-OR01 5225 11:30:00 AM Origins and Treatment of Reproductive Dysfunction Oral

Almudena Veiga-Lopez*1, Sindhu Halubai1, Lixia Zeng2, Charles F Burant2, Kurunthachalam Kannan3, Subramaniam Pennathur2 and Vasantha Padmanabhan2
1Univ of Michigan Med Schl, Ann Arbor, MI, 2University of Michigan, Ann Arbor, MI, 3Wadsworth Center, Albany, NY

 

Human exposure to bisphenol A is a contentious public health issue. Developmental exposure to BPA leads to intrauterine growth restriction and adult metabolic diseases, including insulin resistance. Free fatty acid imbalance and oxidative stress are common traits of disorders manifesting insulin resistance and are thus potential targets for insult from BPA. We hypothesized that mothers exposed to higher levels of BPA will have metabolic imbalance reflected as systemic inflammation via the oxidative stress pathway. Pregnant women were recruited in the first trimester (8 to 14 weeks) and blood samples collected avoiding plastic contact. Unconjugated (uBPA) and glucuronidated BPA (gBPA) concentrations in plasma were quantified using HPLC and MS/MS by one of the laboratory validated through the Round Robin study [1]. Two subsets (n=12 each), one that had low uBPA (Blow:0.08±0.01 ng/ml, mean±SEM:) and another with high uBPA (Bhigh: 27.8±8.4 ng/ml) concentrations were selected to assess 1) the concentration of products of tyrosine oxidation (chlorotyrosine (CT), dityrosine (DT), and nitrotyrosine (NT)), markers for oxidative stress and 2) free fatty acids (FFA). Products of tyrosine oxidation and FFAs were measured using MS/MS and GC. Independent T-test revealed that pregnant mothers with high BPA levels had higher levels of NT (Bhigh: 0.38±0.06 vs. Blow: 0.09±0.008 mM/mol; P=0.001), but not CT or DT compared to those with low BPA. A significant Pearson correlation was found between gBPA and NT levels (r=0.440, P<0.05) and marginally significant between uBPA and NT (r=0.398, P=0.054). This is of relevance, as NT has been implicated in the pathogenesis of chronic diseases including diabetes-induced vascular dysfunction. Levels of 14:0, 14:1, 18:3 (n-3), 20:0, 20:5, 22:0, 22:1, 22:5, and 22:6 FFA were undetectable. FFA 18:3 (n-6), 20:1, and 22:4 levels were detected in £ 3 subjects and not analyzed. FFA 16:0 was higher in the Bhigh group (81.1±9.6nmol/ml) compared to the Blow group (52.7±5.3 nmol/ml; P=0.01). No differences were found in FFAs 16:1, 18:0, 18:1(n-7), 18:1(n-9), 18:2, 20:2, 20:3, and 20:4, between groups. A positive correlation was found between uBPA and 16:0 (palmitic acid; r=0.779, P<0.001) and between uBPA and total FFA (r=0.645, P<0.001), but not gBPA. The correlation between 16:0 and NT tended to be significant (r=0.396, P=0.062). The correlation between increased maternal BPA exposure and increased maternal NT suggests that BPA may play a role in the development of systemic inflammation via the nitrosative stress pathway. Higher palmitic acid and its correlation with increased NT are supportive of palmitate-induced oxidative stress, a mediator of cellular insulin resistance. Further studies are required to determine if palmitic acid and NT may ultimately serve as non-invasive biomarkers for assessing the degree of BPA toxicity and whether they impact offspring well being.

 

Nothing to Disclose: AV, SH, LZ, CFB, KK, SP, VP

LB-OR01-5 17927 5.0000 A First Trimester Maternal BPA Levels Correlate Positively with Systemic Oxidative Stress in Humans 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 1:00:00 PM LB-OR01 5225 11:30:00 AM Origins and Treatment of Reproductive Dysfunction Oral

Peter Laurberg* and Stine Linding Andersen
Aalborg University Hospital, Aalborg, Denmark

 

Objective: Birth defects might seriously hamper the life of the child and the parents. Increasing evidence suggests that Methimazole (MMI)/Carbimazole (CMZ) treatment of maternal hyperthyroidism in early pregnancy might lead to severe birth defects (e.g. aplasia cutis, choanal and esophageal atresia). On the other hand, it is less clear if treatment with Propylthiouracil (PTU) is teratogenic. 

Methods: Cohort study of all children live-born in Denmark, 1996-2008 (n=817,093). Information on maternal redeemed prescription of antithyroid drug (ATD) and diagnosis of birth defect in the child were obtained from nationwide registers. Logistic regression was used to estimated crude and adjusted odds ratio (OR) with 95% confidence interval (CI) for a diagnosis of birth defects before the age of 2 years (overall and within specific subgroups of birth defects) in children exposed to ATD (MMI/CMZ n=1,097, PTU n=564) in early pregnancy versus non-exposed children (no maternal ATD treatment (n=811,730)). To evaluate the PTU associated birth defects in detail, we subsequently focused on the two subgroups of birth defects which revealed a significant association with PTU (face and neck region and urinary system). As these birth defects might be less severe, the time of diagnosis could be later. Thus, we extended the follow-up period to a median age of 8 years and reviewed individual cases in detail.

Results: In line with previous studies, MMI/CMZ was associated with an increased risk of birth defects and a particular high risk of the previously described embryopathi with severe birth defects. Overall, additional 3.4% children had birth defects after MMI/CMZ exposure in early pregnancy. As a new finding, PTU was also associated with an increased risk of birth defects with additional 2.3% cases, and the risk was confined to two subgroups: the face and neck region and the urinary system. When follow-up was performed to the age of 8 years, a total of 14 cases (face and neck n=7 and urinary system n=7) were identified after PTU exposure and an increased risk was again observed (face and neck; adjusted OR 4.92 (95% CI 2.04-11.86), urinary system; 2.73 (1.22-6.07)) versus non-exposed children. In the face and neck region, the birth defects were dominated by preauricular and branchial sinus/fistula/cyst, and 6 of 7 cases had undergone surgery. In the urinary system, the birth defects were dominated by congenital hydronephrosis and renal cysts, and 3 of 7 cases had undergone surgery.

Conclusions: Both MMI/CMZ and PTU treatment in early pregnancy are associated with an increased risk of birth defects, but the spectrum of malformations is different. The MMI/CMZ associated birth defects are often severe. The PTU associated birth defects seemed less severe, but they did, however, often require surgery. The use of ATD should be restricted as much as possible in early pregnancy. If treatment is considered necessary, PTU should be used.

 

Nothing to Disclose: PL, SLA

LB-OR01-6 17798 6.0000 A Birth Defects after the Use of the Antithyroid Drugs Methimazole and Propylthiouracil in Early Pregnancy Are Common and May be Serious. a Danish Nationwide Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 1:00:00 PM LB-OR01 5225 11:30:00 AM Origins and Treatment of Reproductive Dysfunction Oral

Gabriela R V Sousa*1, Tamaya C Ribeiro1, Andre M Faria1, Beatriz M P Mariani2, Antonio M Lerario3, Maria Claudia N Zerbini2, Ibere C Soares4, Alda Wakamatsu2, Venancio A F Alves2, Berenice B Mendonca5, Maria Candida B V Fragoso6, Ana Claudia Latronico1 and Madson Q. Almeida7
1Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 2Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3ICESP/University of Sao Paulo, São Paulo, Brazil, 4Faculdade de Ciências da Saúde de Barretos Dr. Paulo Prata, Barretos, Brazil, 5Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular LIM/42, Disciplina de Endocrinologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, 6Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, 7Hospital das Clínicas & Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Introduction: A microRNA family, miR-103/107, attenuates miRNA biosynthesis by targeting Dicer, a key component of the miRNA processing machinery. In human breast cancer, high levels of miR-103 and miR-107 are associated with metastasis and poor outcome. Recently, DICER1 mutations in the RNase IIIb domain were found in 29% of nonepithelial ovarian tumors, predominantly in Sertoli–Leydig cell and embryonic tumors. These mutations were restricted to codons encoding metal-binding sites within the RNase IIIb catalytic center. Aim: Since adrenocortical tumors (ACTs) are also sterodoigenic lesions such as Leydig cell tumors and up to 12% of adrenocortical tumors are diagnosed before 1 yr, which suggests an embryonic origin, we investigated DICER1 mutations in metal biding sites located at the RNase IIIb domain, and studied DICER1 and miR-103 expression in pediatric and adult ACTs. Patients and methods: Four metal-binding sites (codons 1709 and 1705 in exon 24; codons 1810 and 1813 in exon 25) within the RNase IIIb catalytic center of DICER1 were sequenced in 86 ACTs (25 children and 61 adults). DICER1 expression was assessed in 80 ACTs from 23 children (17 clinically benign and 6 clinically malignant) and 57 adults (28 adenomas and 29 carcinomas) by quantitative real-time PCR. Expression of miR-103 was analyzed in a subgroup of this cohort (49 ACTs). Results: No variant was identified in the four metal binding sites within the RNase IIIb catalytic center of DICER1 in pediatric and adult ACTs. DICER1 mRNA levels in ACTs were 5.0 ± 0.8 (range, from 0 to 43.6) in comparison with the normal adrenal gland. DICER1 expression was not associated with overall and disease-free survival in both children and adults. DICER1 and miR-103 expression did not correlate in both children and adults with ACTs. Interestingly, miR-103 overexpression was associated with a reduced overall survival in pediatric ACTs (p= 0.02), but not with disease-free survival. Additionally, miR-103 expression levels were higher in clinically malignant than in clinically benign pediatric ACTs [median (range), 63.5 (30.8-188.6) vs. 31.4 (12.7-72.5), p= 0.08). miR-103 expression did not predict outcome in adult ACTs. Conclusion: DICER1 deregulation was not associated with pediatric and adult adrenocortical tumorigenesis, but miR-103 overexpression was a predictor of reduced overall survival in children with ACTs.

 

Nothing to Disclose: GRVS, TCR, AMF, BMPM, AML, MCNZ, ICS, AW, VAFA, BBM, MCBVF, ACL, MQA

14496 1.0000 SAT-0781 A Mutation and Expression Analysis of DICER1 and Mir-103 in Pediatric and Adult Adrenocortical Tumors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Kaori Sugawara1, Ken Matsuda2, Naotaka Kogure1, Akira Uruno3, Ikuko Sato1, Kyoko Shimizu1, Rehana Parvin1, Takeo Yoshikawa3, Masataka Kudo2, Akiko Saito-Hakoda1, Ryo Ito1, Atsushi Yokoyama1, Sadayoshi Ito2 and Akira Sugawara*4
1Tohoku Univ Grad School of Med, Sendai, Japan, 2Tohoku University Hospital, Sendai, Japan, 3Tohoku Univ Grad School of Med, 4Tohoku Univ Grad School of Med, Sendai Miyagi-Ken, Japan

 

11β-hydroxylase gene (CYP11B1) encodes the final step enzyme of adrenal cortisol production. In order to examine its transcriptional regulation, we generated a stable human adrenal H295R cell line expressing -1102/-2 of CYP11B1 promoter region fused upstream of liciferase cDNA. The cell line responded 3.0-fold to dbcAMP (1 mM), 2.8-fold to angiotensin II (100 nM), 1.5-fold to ACTH (10 μM), and 2.4-fold to KCl (10.4 mM), which was almost equivalent to the transient transfection study. We next examined the effect of high-glucose on CYP11B1 expression. The stable cell line and H295R cells were incubated with several concentrations of D-glucose. The cellular osmolarity was adjusted by L-glucose. mRNA expression of CYP11B1 was determined by real-time PCR. Interestingly, D-glucose dose- and time-dependently stimulated CYP11B1 transcription as well as CYP11B1 mRNA expression. The high-glucose stimulated CYP11B1 transcription was not affected by treatment with LY333531, a protein kinase (PK) C-β inhibitor, but was partially abrogated by treatment with H89, a PKA inhibitor. These data indicate that high-glucose mediated CYP11B1 transcription activation may at least in part be mediated via the cAMP-PKA pathway independent of PKC-β. It is therefore speculated that high-glucose-induced CYP11B1 expression may induce cortisol secretion, which may result in cortisol-induced hyperphagia and further increase of blood glucose.

 

Nothing to Disclose: KS, KM, NK, AU, IS, KS, RP, TY, MK, AS, RI, AY, SI, AS

16701 2.0000 SAT-0782 A Generation of a Stable H295R Cell Line Expressing 11beta-Hydroxylase Gene Promoter and the Effect of High-Glucose on Its Expression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Guillaume Assie*1, Eric Letouze2, Anne Jouinot3, Windy Luscap3, Olivia Barreau4, Hanin Omeiri5, Stéphanie Rodriguez5, Karine Perlemoine1, Martin Fassnacht6, Fernande rené-Corail7, Nabila Elarouci8, Silviu Sbiera9, Matthias Kroiss10, Bruno Allolio11, Jens Waldmann12, Marcus Quinkler13, Massimo Mannelli14, Franco Mantero15, Thomas Papathomas16, Ronald R de Krijger17, Antoine Tabarin18, Veronique Kerlan19, Eric Baudin20, Frederique Tissier5, Bertrand Dousset21, Lionel Groussin22, Laurence Amar23, Eric Laurent Clauser24, Xavier Bertagna1, Bruno Ragazzon1, Felix Beuschlein25, Rossella Libe1, Aurélien de Reynies26 and Jerome Yves Bertherat27
1INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, France, 2Ligue Nationale Contre Le Cancer, Paris, France, 3INSERM U1016, CNRS UMR 8104, Institut Cochin Université Paris Descartes, Paris, 4Inserm U1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, 5INSERM U1016, CNRS UMR 8104, Institut Cochin Université Paris Descartes, 6Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, University of Munich, Munich, Germany, 7INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, Paris, 8Ligue Nationale Contre Le Cancer, Paris, 9Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, 10University Hospital Wuerzburg, 11University of Wuerzburg, Wuerzburg, Germany, 12Visceral-, Thoracic and Vascular Surgery, University Hospital Giessen and Marburg, Marburg, Germany, 13Charité University Medicine Berlin, Campus Mitte, Berlin, Germany, 14Univ of Florence, Florence, Italy, 15University of Padova, Padova, Italy, 16Department of Pathology, Josephine Nefkens Institute, Erasmus MC-University Medical Center, Rotterdam, Netherlands, 17Erasmus MC, Rotterdam, Netherlands, 18Universite de Bordeaux II/Hopital Haut Leveque, Pessac, France, 19CHUBrest - Hopital De La Cavale Blanche, Brest, France, 20Institut Gustave-Roussy, Paris, France, 21Department of Digestive and Endocrine Surgery, Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France, 22INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, 23Hopital Europeen Georges Pompido, Paris, France, 24Assistance Publique Hôpitaux de Paris, Hôpital Cochin, Paris, France, Paris, France, 25University of Munich, Munich, Germany, 26Ligue Contre Le Cancer, Paris, 27INSERM U 1016, Cochin Institute, Paris Descartes University, Paris, France

 

Despite the overall poor prognosis, adrenocortical carcinoma (ACC) outcome is heterogeneous. The pathophysiological mechanisms are not well identified. The aim was to perform an integrated genomic analysis of these tumors, to identify the molecular alterations and a molecular classification with potential clinical impact.

130 ACC were included, with a discovery set of 53 ACC from French centers (COMETE network) and an independent validation set of 77 ACC from European centers (ENSAT network). ACCs from the discovery cohort were characterized by exome sequencing, transcriptome, mirnome, methylome and single nucleotide polymorphism (SNP) arrays.

Exome sequencing and SNP array analysis in the discovery cohort revealed recurrent alterations in known drivers (CTNNB1, TP53, CDKN2A, RB1, MEN1) and in genes not previously reported to be altered in ACC (ZNRF3, DAXX, TERT and MED12). These alterations were confirmed in the validation cohort.

MiRna expression identified three clusters of ACC: the Mi1 cluster was characterized by the up-regulation of 11 miRNA from the 506-514 miRNA cluster in Xq27.3, and the down-regulation of 38 miRNAs from the DLK1-MEG3 miRNA cluster in 14q32.2; the Mi2 cluster was characterized by the up-regulation of the 506-514 miRNA cluster; the third cluster (Mi3) presented none of these alterations.

Integration of the different unsupervised omics classifications defined molecular groups, associated with different outcomes. The C1A group of poor outcome was characterized by a specific transcriptome signature, by the accumulation of somatic mutations and by specific DNA methylation alterations. The C1B group of better outcome displayed a distinct transcriptome signature, and the specific deregulation of the two miRNA clusters Mi1 and Mi2.

In conclusion, aggressive and indolent ACC correspond to two distinct molecular entities, driven by different oncogenic alterations.

 

Disclosure: BA: Consultant, Boehringer-Ingelheim, Coinvestigator, HRA-Pharma, Committee Member, Ipsen. EB: Research Funding, HRA Pharma. Nothing to Disclose: GA, EL, AJ, WL, OB, HO, SR, KP, MF, FR, NE, SS, MK, JW, MQ, MM, FM, TP, RRD, AT, VK, FT, BD, LG, LA, ELC, XB, BR, FB, RL, AD, JYB

15185 3.0000 SAT-0783 A Integrated Genomic Characterization of Adrenocortical Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Akiko Saito-Hakoda1, Akira Uruno2, Kyoko Shimizu1, Naotaka Kogure1, Rehana Parvin1, Ikuko Sato1, Ikuma Fujiwara3, Hiroyuki Kagechika4, Yasumasa Iwasaki5, Atsushi Yokoyama1, Sadayoshi Ito6 and Akira Sugawara*1
1Tohoku Univ Grad School of Med, Sendai, Japan, 2Tohoku Univ Grad School of Med, 3Tohoku Univ Hosp, Sendai, Japan, 4Tokyo Med Dent Univ, 5Health Service Center, Kochi, Japan, 6Tohoku University Hospital, Sendai, Japan

 

Retinoids are possible candidates for the novel therapeutics against adrenocorticotropic hormone (ACTH)-dependent Cushing's syndrome. In ENDO 2011 and 2012, we demonstrated that RXR agonist HX630 inhibited ACTH secretion, proopiomelanocortin (Pomc) gene expression, and cell proliferation in AtT20 cells. In the present study, we examined the molecular mechanisms of HX630-mediated Pomc transcription suppression and the effects of HX630 on in vivo tumor formation. Using Pomc promoter deletion mutants, HX630 was demonstrated to suppress Pomc transcription via NurRE, to which Nurr1/Nur77 heterodimer binds. HX630 also decreased Nur77 and Nurr1 mRNA expression as well as Nur77/Nurr1 heterodimer binding to the region determined by ChIP assay. Overexpression of Nurr1 and Nur77 attenuated the HX630-mediated suppression. On the other hand, overexpression of RXR augmented the HX630-mediated suppression, while RXR siRNA attenuated the suppression. It is therefore indicated that HX630-mediated RXR activation may induce the decrease of Nur77 and Nurr1 mRNA expression, resulting in the suppression of Pomc transcription. Furthermore, HX630 inhibited tumor growth, and decreased Pomc mRNA expression in corticotroph tumor cells in female nude mice in vivo. These results therefore indicate that RXR agonist HX630 may be a novel therapeutic candidate for ACTH-dependent Cushing's syndrome.

 

Nothing to Disclose: AS, AU, KS, NK, RP, IS, IF, HK, YI, AY, SI, AS

16676 4.0000 SAT-0784 A Effects of RXR Agonist HX630 on Pomc Promoter Activity and in Vivo Tumor Formation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Segolene Hescot*1, Angelo Paci2, Atmane Seck2, Abdelhamid Slama3, Say Viengchareun4, Severine Trabado3, Sylvie Brailly3, Jacques Young5, Eric Baudin6 and Marc Lombes4
1INSERM U693, Le Kremlin Bicetre, France, 2Gustave Roussy Institute, Villejuif, France, 3APHP CHU Bicêtre, Le Kremlin Bicetre, France, 4Inserm U1185, Le Kremlin-Bicêtre, France, 5University Paris Sud, Department of Endocrinology, Bicetre Hospital, INSERM U693, Le Kremlin-Bicêtre, Fance, Le Kremlin Bicêtre, France, 6Institut Gustave-Roussy, Paris, France

 

Mitotane (o,p’DDD) is the most effective treatment of advanced adrenocortical carcinoma (ACC) but its molecular mechanism of action remains poorly understood. It has been suggested that o,p’DDD requires a metabolic transformation into o,p’DDA, carried out by an unknown cytochrome P450 enzyme in adrenal cells. To determine whether o,p’DDA was responsible for pharmacological effects of mitotane, we quantified o,p’DDD and o,p’DDA contents by UV-HPLC analysis with a threshold detection limits of 0.5 and 2.5 mg/l respectively, in human adrenocortical tissues and in subcellular fractions of H295R and SW13 adrenal cells. In both a ACC and a normal adrenal gland of mitotane-treated patients, o,p’DDA was undetectable unlike o’p’DDD, suggesting a lack of cellular uptake and/or in situ production. Furthermore, o,p’DDA was not detected in whole cell homogenates nor in the supernatant of cultured cells after 48 h exposure  to 50 µM of o,p’DDD, consistent with the absence of o,p’DDA production in these models. While o,p’DDD concentration was significantly reduced by 40% in the supernatant of H295R cells after 48h exposure, indicating a marked cellular uptake, o,p’DDA levels were not altered upon cell exposure suggesting that it was not efficiently transported  into H295R cells. Next, we investigated functional consequences of o,p’DDA compared to o,p’DDD exposure on proliferation, steroidogenesis and mitochondrial activity. Dose-dependent concentration curves (from 10 to 300 µM) showed that o,p’DDA did not inhibit proliferation of H295R and SW13 cells. At 50 µM, o,p’DDA was also unable to inhibit 17-hydroxyprogesterone secretion as opposed to the 70% reduction induced by o,p’DDD. Mitotane significantly decreased expression of genes encoding proteins involved in steroidogenesis whereas o,p’DDA had little or no effect on HSD3B2, CYP21, CYP11B, StAR and CYP11A1 expression. Moreover, o,p’DDA did not alter respiratory chain complex IV (cytochrome c oxidase) activity and gene expression nor induce mitochondrial biogenesis as previously demonstrated with o,p’DDD (1).

Collectively, our results indicate a lack of adrenal cell metabolism and uptake of o,p’DDA and provide in vitro evidence that o,p’DDA is not an effective metabolite of mitotane to control tumor proliferation, steroidogenesis and to impact mitochondrial activity. Better understanding of o,p’DDD pharmacology will enable identification of predictive factors of efficacy for ACC management.

 

Disclosure: SH: Researcher, HRA Pharma. EB: Research Funding, HRA Pharma. Nothing to Disclose: AP, AS, AS, SV, ST, SB, JY, ML

12996 5.0000 SAT-0785 A Lack of Adrenal Cell Metabolism and Uptake of o,P'dda Excludes Its Prominent Role As an Active Metabolite of Mitotane for Adrenocortical Carcinoma Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Mabrouka Doghman*1, Silviu Sbiera2, Veronica Granatiero3, Rosario Rizzuto3, Martin Fassnacht4 and Enzo Lalli1
1IPMC CNRS UMR 7275, Valbonne, France, 2Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, 3Padua University, Padua, Italy, 4Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, University of Munich, Munich, Germany

 

Steroidogenic Factor-1 dosage has a critical role in regulating the proliferation of human adrenocortical cells and to trigger adrenocortical tumorigenesis in mice. We identified FATE1 (Fetal and Adult Testis Expressed) as a new target gene for SF-1 (1).

The aim of this study was to elucidate the localization and the role of FATE1 in adrenocortical cells and also in normal and human adrenocortical tumoral tissue by using different biochemical and immunochemistry approaches.

We showed that FATE1 is an outer mitochondrial membrane protein. By performing immunoprecipitation experiments followed by MS/MS analysis, we identified FATE1-interacting proteins. We found that FATE1 is enriched in MAM (Mitochondrial Associated Membranes), specialized subdomains that play an important role in metabolism, cell survival and cell death as well as in intracellular calcium signaling. By using overexpression and knockdown approaches, we showed that FATE1 overexpression induces a change in mitochondrial morphology and calcium uptake and modulates steroidogenesis, prompting us to explore the impact of FATE1 in the response to chemotherapeutic drugs.

Furthermore, high FATE1 expression is associated with poor clinical outcome in adrenocortical cancer (ACC). A strong negative correlation exists between SF-1 and FATE1 expression with recurrence-free and overall survival in ACC patients.

Taken together, our findings reveal that FATE1 is a potential marker for poor prognosis in human adrenocortical tumors and highlight the novel role of FATE1 on mitochondrial and ER dynamics in adrenocortical cancer cells.



 

Nothing to Disclose: MD, SS, VG, RR, MF, EL

15704 6.0000 SAT-0786 A Role of FATE1, a Novel Steroidogenic Factor-1 Target, in the Regulation of Mitochondrial Morphology and Function in Human Adrenocortical Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Joakim Crona*1, Per Hellman2 and Peyman Björklund1
1Uppsala University, Uppsala, Sweden, 2Uppsala University, Sweden

 

Background: Pheochromocytomas are characterized by pronounced genetic heterogeneity with more than 14 disease causing genes described to date. Tumours are divided into 3 molecular clusters: 1a (SDHx), 1b (VHL) and cluster 2 (NF1, RET, TMEM127 and MAX). Previous studies suggested common genomic aberrations with sporadic tumours harbouring loss of chromosome 1p and 3q whereas VHL related tumours showed loss of 3p and 11p arms.

Methods: DNA from 103 tumours were investigated by targeted Next generation sequencing (NGS) and high resolution SNP array. Copy number events and allelic imbalances were determined. Relative clonal fractions were calculated from NGS allele frequencies as wells as SNP array B-allele frequencies and log ratios. Phylogenetic trees were determined among matched tumour samples.

Results: Novel and previously described mutation specific copy number alterations were discovered. Copy number neutral loss of heterozygosity were observed in 15/103 tumours, while 37/103 had regions with hemizygous copy number loss that showed variable allelic frequencies. Branched and linear modes of evolution were observed in paired tumours from patients with metastatic disease.

Conclusion: Pheochromocytoma tumours may exhibit inter and intra tumoural heterogeneity. Presence of multiple tumour cell clones should be further investigated for potential impact on patient management and adds additional levels of complexity to the understanding of the genomic landscape of these tumours.

 

Nothing to Disclose: JC, PH, PB

15050 7.0000 SAT-0787 A Integrative Genomics Reveal Branched Evolution and Clonal Heterogeneity in Pheochromocytoma Tumours 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Hannah Yi*1, Rita Keil1, Robert J Handa2 and Tao-Yiao J Wu1
1Uniformed Services University, Bethesda, MD, 2University of Arizona College of Medicine, Phoenix, AZ

 

The mPER2 gene is a `clock gene’ important for the regulation of circadian rhythms. Its deletion in mice results in impair diurnal rhythms. The goal of this study is to examine the effect of PER2 gene  deletion on depressive and anxiety behaviors in male mice by using the Porsolt’s forced swim tests (FST) and marble burying test (MBT). For MBT, 19 WT and 16 PER2-/- mice were placed in cages with 4 cm of sawdust bedding and 8 black marbles for 30 minutes. The MBT was scored by marking the time each marble was buried for the first time to examine the rate of burying. FST was performed with 12 WT and 12 PER2-/- mice (clear cylinder with 15 cm of water for 6 minutes). Time spent floating rather than swimming was measured.  Corticosterone (CORT) levels were enhanced in PER2-/- mice that were restrained.  There was no difference (p>0.10) in MCR2 mRNA and 11β-hydroxysteroid dehydrogenase mRNA levels in the adrenals. There was no difference between the rate of burying for WT and PER2-/- mice in the MBT. However, PER2-/- mice spent more time floating in the FST test, suggesting that they exhibited more (p<0.05) depression-like behavior than WT mice.  The results of the present study suggest that disruption of the circadian system via mPER2 gene knockout dysregulated the stress axis and is correlated with a depressive behavior.  (HY and RK have equal contributions to the work)

 

Nothing to Disclose: HY, RK, RJH, TYJW

15099 8.0000 SAT-0788 A mPER2 Mutant Mice Show Depressive Behavior 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Sofia Pereira*1, Valdemar Máximo2, Ricardo Coelho2, Paula Soares2, Manuel Sobrinho Simões2, Mariana Pereira Monteiro3 and Duarte Pignatelli4
1Instituto Ciências Biomédicas Abel Salazar - UP, Porto, Portugal, 2IPATIMUP, Porto, Portugal, 3Instituto Ciências Biomédicas Abel Salazar - UP, Matosinhos, Portugal, 4Hospital S João, Porto, Portugal

 

INTRODUCTION: Normal human somatic cells cannot divide indefinitely due to progressive telomeric DNA loss mainly attributed to the lack of TERT (telomerase reverse transcriptase) expression. Activating TERT mutations and expression is able to immortalize some cell types. In adrenocortical tumors, the state of TERT remains unknown.

AIM: The aim of this work was to search for TERT promoter mutations in adrenocortical tumors and hyperplasias and to evaluate the TERT expression in adrenocortical tumors and normal adrenal glands.

METHODS: The expression of TERT was evaluated by immunohistochemistry in adrenocortical carcinomas (n=12), adrenocortical hyperplasias (n=3), adenomas with Cushing syndrome (n=7), non-functioning adenomas (n=11) and adjacent normal adrenal gland (n=8). For the search of promoter TERT mutations in the non-adrenocortical normal tissues, the two hotspots positions located -124 and -146 bp upstream from the ATG start was identified by PCR followed by Sanger sequencing.

RESULTS: TERT promoter mutations were not identified in any of the adrenocortical tumors and hyperplasias. TERT was found to be expressed in the nucleus of 33% of adrenocortical carcinomas and 45% of non-functiong adenomas, while no nuclear TERT expression was observed in adrenal hyperplasias and adenomas with Cushing syndrome. In the normal adrenal gland, all of the cases presented expression of TERT in the nuclei of zona glomerulosa and zona reticularis cells and approx. 25% of the cases presented positive staining in the nuclei of zona fasciculata.

CONCLUSIONS: These results suggest that there are no TERT promoter mutations in adrenocortical tumors and adrenocortical hyperplasias. As to the TERT protein it seems to be expressed in only a few adrenocortical carcinomas and adenomas, while an intense nuclear expression occurs in the normal adrenal gland. This warrants further research in order to understand its role in adrenal physiology.

 

Nothing to Disclose: SP, VM, RC, PS, MS, MPM, DP

16770 9.0000 SAT-0789 A TERT Promoter Mutations and TERT Expression in Normal and Tumoral Adrenocortical Tissues 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Ping Li*, Xinjue Dai, Yan Hao, Shanmei Shen and Dalong Zhu
Drum Tower Hospital Affiliated to Nanjing University Medical School, Nanjing, P. R. China, China

 

Although primary aldosteronism (PA) is the most common cause of endocrine hypertension, histopathological methods to differentiate the aldosterone-producing adenoma (APA) with cortisol-producing adenoma (CPA) and non-functioning adenoma (NFA), have not been established. Disabled-2 (Dab2) is a mitogen-regulated phosphoprotein. Previous study demonstrated Dab2 is a specific marker of the zona glomerulosa (ZG) not only in rodents but also in humans. Whether Dab2 can be a powerful tool for histopathological diagnosis of APA remains to be investigated. The objective of this study was to determine the significance of dab2 in APA by investigating the expression of Dab2 in tissue of different adrenocortical adenomas. Real-time PCR and immunohistochemistry were used to detect Dab2 expression in 12 APA samples, 10 CPA samples, 8 NFA samples and 6 normal adrenal samples. In normal adrenal glands, Dab2 protein is expressed strongly in the zona glomerulosa, weakly in zona fasciculata-reticularis, and with no expression in medulla. In APAs, several clusters of cells with positive dab2 staining were detected in 4 out of 12 samples, others (8 out of 12 APA samples) showed extensively weak dab2 staining. In all the CPA and NFA tumors, weak dab2 staining was detected. According to the results of real-time PCR, Dab2 mRNA expression increased significantly in APAs compared with normal adrenal glands. There is no significant difference between normal adrenal glands, CPAs and NFAs in Dab2 mRNA expression. Compared to nontumor portions, APAs also showed higher Dab2 mRNA expression in the tumor. No significant difference was detected between nontumor portions and tumor in Dab2 mRNA expression in CPAs and NFAs. In conclusion, Dab2 was predominantly localized in zona glomerulosa in normal adrenal gland. Increased Dab2 mRNA expression was detected in APAs compared to CPAs, NFAs and normal adrenal glands. Whereas, just sporadically cluster of ZG cells expressing Dab2 were demonstrated in some of the APAs. Dab2 was not an ideal marker in differential diagnosis of APAs with other adrenocortical adenomas in histopathology.

 

Nothing to Disclose: PL, XD, YH, SS, DZ

11423 10.0000 SAT-0790 A The Expression of Dab2 in Adrenocortical Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Guilherme Asmar Alencar*1, Antonio M Lerario2, Mirian Y Nishi1, Beatriz M P Mariani3, Madson Q. Almeida4, Johanne Tremblay5, Pavel Hamet5, Isabelle Bourdeau6, Maria Claudia N Zerbini3, Maria Adelaide Albergaria Pereira1, Gilberto Carlos Gomes1, Manoel Souza Rocha1, Jose Luiz Chambo1, Andre Lacroix7, Berenice B Mendonca8 and Maria Candida Barisson Villares Fragoso1
1Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 2ICESP/University of Sao Paulo, São Paulo, Brazil, 3Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 4Hospital das Clínicas & Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 5Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Canada, 6Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, QC, Canada, 7Centre hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada, 8Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular LIM/42, Disciplina de Endocrinologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

 

Background: Primary macronodular adrenal hyperplasia (PMAH) is a rare cause of Cushing's syndrome (CS). Familial clustering of PMAH has been described, suggesting an inherited genetic cause for this condition. Objectives: Identify the gene responsible for PMAH and characterize the clinical aspects of the disease. Methods: Forty-seven individuals of a Brazilian family with PMAH underwent a clinical, laboratory and radiologic evaluation. A SNP-based genome-wide linkage analysis followed by whole-exome sequencing were then performed in selected family members. Additionally, 29 other patients with PMAH and 125 healthy individuals were studied to validate the genetic findings. Moreover, PMAH tissue was also analyzed. Results: Three candidate genomic regions (16p11.2, 16q13 and 16q21) were initially identified by linkage analysis. A heterozygous germline mutation (p.Leu365Pro) was then found by whole-exome sequencing in the armadillo repeat containing 5 (ARMC5) gene (16p11.2). The mutation was confirmed by conventional sequencing in all 16 affected family members and was predicted to be damaging by in silico methods. Pedigree analysis showed that PMAH was inherited in an autosomal dominant fashion, with incomplete penetrance and variable expressivity. Seven additional ARMC5 germline mutations were subsequently identified in five out of 21 patients with apparently sporadic PMAH and in two other families with the disease. Further molecular analysis also identified a somatic mutational event in the adrenal tissue. The 1 mg dexamethasone suppression test (DST) proved to be the best laboratory test for the diagnosis of PMAH (sensibility: 90%; specificity: 87%; NR ≤ 50 nmol/liter). In nearly 38% (6/16) of the patients with familial PMAH, radiological abnormalities were found in only one of the adrenal glands. Distinct responses among family members were observed throughout the in vivo studies for aberrant hormone receptors, favoring the hypothesis that these receptors might be a secondary phenomenon in the pathophysiology of the disease in this family. Conclusions: We demonstrate that germline ARMC5 mutations are a frequent cause of familial PMAH, which is in agreement with data recently published by Assié et al. (1). Biallelic inactivation of ARMC5 is consistent with its role as a potential tumor suppressor gene. Subclinical CS is the most common clinical presentation of familial PMAH and DST demonstrated the highest sensitivity for the detection of this condition. Asymmetry between adrenal glands is a fairly frequent finding in familial PMAH.

 

Nothing to Disclose: GAA, AML, MYN, BMPM, MQA, JT, PH, IB, MCNZ, MAAP, GCG, MSR, JLC, AL, BBM, MCBVF

11315 11.0000 SAT-0791 A Inherited Autosomal Dominant Mutations in ARMC5 Gene a Frequent Cause of Primary Macronodular Adrenal Hyperplasia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Christopher Ryan Lapensee*1, Gary D Hammer2, William E. Rainey1 and Stephen W Hunt III3
1University of Michigan, Ann Arbor, MI, 2Univ of Michigan, Ann Arbor, MI, 3Atterocor, Inc., Ann Arbor, MI

 

Adrenocortical Carcinoma (ACC) is a rare cancer of the adrenal cortex (~0.5-2 cases/million), accounting for 0.2% of cancer deaths annually. ACCs are highly aggressive with many patients presenting with metastases upon diagnosis due to difficulty of detection.  While mitotane and cytotoxic chemotherapy are often used to treat metastatic ACC, the efficacy of most regimens is extremely limited, toxic, and poorly tolerated, leaving an unmet need for new treatments for ACC. ATR-101 is a novel, oral drug candidate currently in development for the treatment of ACC. ATR-101 is an inhibitor of acyl-coenzyme A:cholesterol O-acyltransferase (ACAT) that catalyzes intracellular esterification of free cholesterol. The adrenal cortex is particularly reliant on the proper maintenance of cholesterol homeostasis, as cholesterol is the precursor of all steroid hormones. In a variety of preclinical studies, ATR-101 has been shown to have selective inhibitory effects on cells derived from the adrenal cortex from a number of species. We are investigating mechanisms by which ATR-101 specifically targets and induces death in cells of the adrenal cortex. In H295R human adrenocortical carcinoma cells, ATR-101 treatment decreases viability and increases cellular toxicity in a time- and dose-dependent manner. Caspase-3 levels are markedly increased by ATR-101 after 4 hours of treatment, indicating activation of apoptosis. ATR-101 does not act as mitochondrial toxin in H295R cells, or alter oxygen consumption in isolated mitochondria. Together, these studies indicate that ATR-101 causes H295R cell death by activating the apoptotic pathway. The inability of ATR-101 to alter oxygen consumption in vitro suggests that ATR-101 induced cell death either does not involve disruption of  mitochondrial activity, or an in vivo metabolite of ATR-101 present in the intact adrenocortical cell does indeed result in mitochondrial toxicity. Transcriptional profiling is being conducted to gain insight into genes and pathways altered by ATR-101 in H295R cells.

Disclosure: This work was supported in part by a sponsored research grant funded by Atterocor, Inc.  SWH is an employee of Atterocor.  WER is a consultant for Atterocor.  GDH is a co-founder of Atterocor.

 

Disclosure: GDH: Founder, Atterocor, Inc.. WER: Consultant, Atterocor Inc. SWH III: Chief Scientific Officer, Atterocor, Inc., Chief Scientific Officer, Atterocor. Nothing to Disclose: CRL

16835 12.0000 SAT-0792 A ATR-101, a Selective and Potent Inhibitor of ACAT1, Causes Apoptosis in H295R ACC Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Tamaya C Ribeiro*1, Alexander Augusto Lima Jorge2, Madson Q. Almeida3, Beatriz M P Mariani4, Mirian Y Nishi5, Berenice B Mendonca1, Maria Candida Barisson Villares Fragoso6 and Ana Claudia Latronico7
1Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 2Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 3Hospital das Clínicas & Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 4Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 5University of São Paulo, Hospital das Clinicas, Sao Paulo, Brazil, 6Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, 7Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Context: Insulin-like growth factor 1 receptor (IGF1R) overexpression is a prognostic biomarker of metastatic pediatric adrenocortical tumors. However, the molecular mechanisms that are implicated in its upregulation remain unknown.

Aim: To investigate the potential mechanisms involved in IGF1R overexpression in adrenocortical tumors.

Patients and methods: We studied 64 adrenocortical tumors that were diagnosed in 26 children and 38 adult patients. IGF1R expression was previously studied in 45 of these tumors, and overexpression was detected in 65% and 13% of pediatric and adult tumors, respectively. IGF1R copy number variation was determined using multiplex ligation-dependent probe amplification and confirmed using real time PCR. Automatic sequencing was used to identify IGF1R allelic variants. The expression of microRNAs involved in IGF1R regulation was determined using real time PCR.

Results: IGF1R amplification was detected in an adrenocortical carcinoma that was diagnosed in a 46-year-old woman with Cushing´s syndrome and virilization. IGF1R overexpression (5-times higher than the normal adrenal gland pool) was demonstrated in this case. In addition, gene amplification of other loci was identified in this adrenocortical malignant tumor, but no IGF1R copy number variation was evidenced in the remaining cases. Automatic sequencing revealed three known polymorphisms in the adrenocortical tumors, but they did not correlate with its expression. Expression of miR-100, 145, 375 and 126 did correlate with IGF1R expression.

Conclusion: We demonstrated the amplification and overexpression of the IGF1R gene in only one adrenocortical carcinoma, suggesting that these combined events are uncommon. In addition, IGF1R polymorphisms and abnormal microRNA expression did not correlate with IGF1R upregulation in adrenocortical tumors.

 

Nothing to Disclose: TCR, AALJ, MQA, BMPM, MYN, BBM, MCBVF, ACL

11331 13.0000 SAT-0793 A Amplification of the Insulin-like Growth Factor 1 Receptor Gene in an Adrenocortical Adenocarcinoma: Searching for Potential Mechanisms of Overexpression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Beatrice Rubin*1, Raffaele Pezzani1, Maria Verena Cicala1, Maurizio Iacobone2, Carla Maria Scaroni1, Marco Boscaro1 and Franco Mantero1
1University of Padua, Padova, Italy, 2University of Padova, Padova, Italy

 

Introduction: Adrenocortical tumors (ACT) are common diseases mostly benign, but among them, adrenocortical carcinomas (ACC) appear highly aggressive with metastatic potential. Wnt/β-catenin pathway is frequently switched on in ACT, with β-catenin greatly dephosphorylated and consequently activated. While IWR1 induces an increase in Axin2 protein levels, XAV939 inhibits tankyrase 1 and tankyrase 2 (thus stabilizing Axin), both stimulate β-catenin phosphorylation and degradation.

Aim: To investigate the role of IWR1 and XAV939 alone or in combination with Mitotane in adrenocortical cell lines and in primary adrenocortical tumor cells.

Methods: MTT test was performed on SW13 and H295R cells and 2 ACC and 2 cortisol producing adenomas (CPA) primary cell cultures. Western blot and Immunofluorescence analyzed the expression of IWR1 and XAV939 targets (Tankyrase1, Tankyrase2, Axin1 and Axin2) and β-catenin.

Results: MTT test at 72h revealed a concrete cell viability decrease using XAV939 (10 µM) of 52% for SW13 and 37% for H295R cells. Furthermore IWR1 at 72h (10 µM) induced a moderate cell viability reduction for SW13 cells of 57% and for H295R cells of 30%. In SW13 cells at 72h, combination of Mitotane (10 µM) and XAV939 (10 µM) resulted in cell viability decrement of 15% if compared to XAV939 alone. No appreciably alteration was found in combination regimen for H295R cells. Furthermore XAV939 alone at 24h was effective in 1 ACC primary cell culture, while IWR1 at 24h showed a weak cell viability decrease in 1 ACC and 1 CPA primary cell culture.

Discussion and conclusions: Our preliminary results demonstrated by Western blot the expressions of different IWR1 and XAV939 targets in ACT cells. Moreover IWR1 and XAV939 seem to effectively act on Wnt/β-catenin pathway, providing evidence for their potential role on ACT treatment. Further biomolecular analysis are in progress to substantiate these data.

 

Nothing to Disclose: BR, RP, MVC, MI, CMS, MB, FM

13775 14.0000 SAT-0794 A New Drugs Switching off Wnt/Beta-Catenin Signaling in Adrenocortical Tumor Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Ivan Casaburi*, Paola Avena, Adele Chimento, Arianna De Luca, Carmela Campana, Francesco Domanico, Emilia Martire, Rosa Sirianni and Vincenzo Pezzi
University of Calabria, Rende, Italy

 

ACC is a highly aggressive tumor extremely heterogeneous with limited therapeutic options and its pathogenesis involves integration of multiple signals. The study of ACC-associated syndromes has suggested that the IGF-II signaling pathway, p53, or Wnt/β-catenin signaling are currently the most attractive targets to fight ACC (1). Recently, we demonstrated the existence of a functional cross-talk between IGF-II signaling pathway and Estrogen Receptor α (ESR1), a gene overexpressed in ACC that drives estrogen-dependent proliferative effects (2,3). A useful strategy to develop an effective therapy for ACC is to identify a common downstream target of these multiple pathways. A good candidate could be ERRα, an orphan member of the superfamily of hormone nuclear receptors involved in the control of energy metabolism, mitochondrial biogenesis, and cancer progression. Several studies suggested that peroxisome proliferator-activated receptor γ coactivator-1 α and β (PGC-1α or PGC-1β) expression level and/or activity could regulate the transcriptional activity of ERRα and the ERRα/PGC-1 complex is a downstream target of multiple signaling pathways in hormone-dependent cancers (4). ERRα seems to be more expressed in ACC respect to adenoma and normal adrenal where it regulates steroidogenesis (5,6). In this study we investigated the role of ERRα in ACC by using the ERRα inverse agonist, XCT-790 and H295R cell line as experimental model for ACC. We revealed that XCT-790 cell treatment (1-10 µM) determined a dose dependent reduction of ERRα protein content concomitantly with a reduction of adrenocortical cancer H295R cells growth in vitro and in H295R xenograft model in vivo.  Flow cytometric analysis indicated that XCT-790 increases cell population within the G0/G1 phase of the cell cycle, without any detectable sub-G1 cells accumulation. Accordingly, XCT-790 treatment decreases cyclin D1, cyclin-dependent kinase-4 (cdk4) protein expression and the phosphorylation status of pRb. Furthermore, XCT-790 treatment increases autophagic vesicles, concomitant with a reduction of PGC1-α protein expression, which is key player in mitochondrial biogenesis. Indeed, the evaluation of c-cic carrier expression, here used as an index of mitochondrial function and mass, suggests that mithophagy could be involved in such inhibitory effect. In conclusion these results, suggest that ERRα depletion could be a new strategy to control ACC growth.

 

Nothing to Disclose: IC, PA, AC, AD, CC, FD, EM, RS, VP

13884 15.0000 SAT-0795 A Estrogen Related Receptorα (ERRα) As Potential Target for a New Adrenocortical Carcinoma (ACC) Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Mary Anne Pandy Calimon*1, Maria Katrina Malabanan Mallonga2, Oliver Allan Castillo Dampil3, Pauline Rizelle Toledo1 and Michael L Villa4
1St. Luke's Medical Center Quezon City, Philippines, 2St. Luke's Medical Center, Quezon City, Philippines, 3St. Luke,s Medical Center, Quezon City, Philippines, 4St Lukes Medical Center, San Juan, Philippines

 

INTRODUCTION: Most adrenal masses are lipid-rich cortical adenomas with low unenhanced attenuation value on CT. Size is one of the criteria used to determine if it should be resected. However, all subjects with an incidentally discovered adrenal mass should still be screened for both catecholamine and cortisol.

METHODOLOGY: This is a retrospective cohort study done at a private tertiary hospital from January 2009 to August 2012. This included 23 admitted patients with a total of 27 adrenal masses detected on CT with corresponding biochemical evaluation. Outcomes of the biochemical tests and the unenhanced attenuation value (Hounsfield units) on CT were correlated using ANOVA with a significant p value  < 0.05.

RESULTS: The total number of detected adrenal masses among the 23 patients was 27. Seven of the adrenal masses (25.9%) were functional, 9 (33.3%) were operated on. Urinary metanephrine were elevated in patients with an adrenal mass characterized by a high unenhanced attenuation value (HU 20.29 + 11.53) but this did not differ significantly compared to patients with normal urinary metanephrine (p value < 0.701).  No significant difference in size of the tumor as well as the Hounsfield unit in patients with normal or elevated cortisol, renin and aldosterone (p-value 0.664, 0.804 and 0.701, respectively).

CONCLUSION: The Hounsfield unit measurements of adrenal masses were not statistically different among those with normal and elevated biochemical tests. Biochemical screening may still be necessary to determine the functionality of the tumor that will help determine if the adrenal mass should be resected or can be closely monitored.

 

Nothing to Disclose: MAPC, MKMM, OACD, PRT, MLV

14536 16.0000 SAT-0796 A Correlation of the Biochemical Markers of Adrenal Masses and Their Unenhanced Attenuation Values on Computed Tomography: A Retrospective Cohort Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Yutaka Watanuki*1, Shinobu Takayasu2, Kazunori Kageyama3 and Makoto Daimon3
1Hirosaki University School of Medicine & Hospital, 2Hirosaki Univ Schl of Med, Hirosaki-Shi, Japan, 3Hirosaki University Graduate School of Medicine, Hirosaki Aomori, Japan

 

Ultraviolet radiation B (UVB) stimulates a-melanocyte-stimulating hormone (a-MSH) production in human keratinocytes and melanocytes. The melanosomal enzyme tyrosinase-related protein 1 (TRP1) is involved in modulation of pigment production in response to the stressor. Recent molecular and biochemical analyses have revealed the presence of corticotropin-releasing factor (CRF) and urocortins (Ucns), together with their corresponding receptors in mammalian skin. Although CRF and Ucns are thought to have potent effects on the skin system, their possible roles and regulation have yet to be fully determined. Our previous findings suggest that in human melanoma HMV-II cells both CRF and Ucn1 regulate TRP1 gene expression via Nurr-1/Nur77, transcription factors that constitute the nuclear receptor 4a subgroup of orphan nuclear receptors, production, independent of pro-opiomelanocortin or a-MSH stimulation.

This study aimed to explore the effects of UVB on Ucn1 gene expression and TRP1 protein levels using human melanoma HMV-II cells. HMV-II cells were found to express mainly Ucn1 mRNA, as well as CRF and Ucn2 mRNA at lower levels; no Ucn3 mRNA was evident. CRF receptor type 1, but not type 2, mRNA was also expressed. UVB stimulated Ucn1 mRNA expression levels, and increased both Nurr-1 and Nur77 mRNA expression levels. UVB also increased TRP1 protein levels. These data suggest that UVB-induced Ucn1 contributes to TRP1 production via the transcriptions, both Nurr-1 and Nur77. Ucn1 would be produced in melanocytes, and act on melanocytes themselves in an autocrine manner.

 

Nothing to Disclose: YW, ST, KK, MD

13565 17.0000 SAT-0797 A Ultraviolet Radiation B Stimulates Urocortin 1 Gene Expression and Tyrosinase-Related Protein 1 Protein Levels in Human Melanoma Hmv-II Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0781-0797 4771 1:00:00 PM Adrenal Tumors: ACC & Adrenal Incidentaloma Poster

Thomas Kerkhofs*1, Luc Derijks2, Hester Ettaieb2, Jan Den Hartigh3, Kees Neef4, Hans Gelderblom3, Henk-Jan Guchelaar3 and Harm Haak5
1Máxima Medical Center, Eindhoven, Netherlands, 2Máxima Medical Center, Eindhoven/Veldhoven, the Netherlands, 3Leiden University Medical Center, Leiden, the Netherlands, 4, Maastricht University Medical Center, Maastricht, the Netherlands, 5Maxima Medisch Centrum, Eindhoven, Netherlands

 

Context: Mitotane is the drug of choice in medical treatment of adrenocortical carcinoma. The anti-neoplastic effect appears to be correlated with a minimum plasma level of 14mg/L, but plasma concentration build-up is in general slow due to the long elimination half-life. Consequently, the therapeutic effect sets in after weeks or even months.

Objective: To develop a pharmacokinetic model that enables clinicians to adjust dosing based upon a target drug exposure, which facilitates personalized therapy.

Design and setting: Retrospective multicenter study.

Patients/Interventions: Data on dosing and plasma level measurements performed throughout mitotane therapy were collected in a population of 29 patients from two hospitals. A population pharmacokinetic model was constructed based on data from 20 patients using iterative two-stage Bayesian fitting (ITSB, MWPharm). The model was validated in an independent sample of 9 patients.

Main Outcome Measure: Goodness of fit was evaluated using the root mean squared error.

Results: The concentration-time data were best described by a three-compartment model. The model estimated mitotane clearance at 0.94±0.37L/h and volume of distribution in steady state at 161±68L/kg∙LBM. Mean prediction error was 2.2±0.5mg/L.

Conclusions: A pharmacokinetic model was developed which characterized mitotane by slow clearance and large volume of distribution. The model appears to be able to predict mitotane levels in individual patients with an error margin of 2.2mg/L. The model enables to adapt dosing based on individual plasma level measurements in prospective setting, which improves the prediction’s accuracy. We expect that individualization of mitotane dosing leads to anticipated and more rapid attainment of the therapeutic levels and potentially to improved clinical management of mitotane treatment.

 

Nothing to Disclose: TK, LD, HE, JD, KN, HG, HJG, HH

11458 1.0000 SAT-0798 A Development of a Pharmacokinetic Model of Mitotane: Towards Personalized Dosing in Adrenocortical Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Olga Martínez Colete*1 and Ivette Pereira Venereo2
1Hospital Clínico-Quirúrgico "Hermanos Ameijeiras", La Habana, Cuba, 2Hospital Clínico-Quirúrgico, La Habana, Cuba

 

Adrenal incidentalomas (AI) are mostly benign and non-functioning lesions, but it is important to detect the few cases with malignant or hyperfunctioning tumors for immediate resolution. OBJECTIVES: To analyze clinical and imaging characteristics, functional status, surgical criteria, pathological findings and etiological diagnosis in patients diagnosed for AI. METHODS: We performed a retrospective descriptive study in 65 patients diagnosed for AI that were referred to the Endocrinology Department of tertiary referral Hermanos Ameijeiras Hospital, Havana, Cuba, between July 2006 and March 2013. We reviewed data about patient history, clinical findings, hormonal tests results and Computed Tomography (CT) findings. Surgical criteria and pathological findings were analyzed. Kappa Index was calculated to establish the concordance between presumptive diagnosis and pathological findings in patients underwent surgery. We compared clinical and imaging characteristics by dividing patients according to the type of tumor in 5 groups: benign adenoma, (BA), adrenal carcinoma (AC), Mielolipoma/Cyst (M/C), pheocromocitoma (P), and miscellaneous (MISC). Statistical significance was set at p<0,05. RESULTS: 65 patients, mean age: 50,4 yr; female: 48 (73,8%). 12 patients (18,5%) showed hormonal adrenal hyperfunction . 34 patients (52,2%) were referred to the follow-up protocol. 31 patients (47,7%) underwent surgery (7 due to tumor size over 6cm, 12 due to presumptive malignancy in CT scans, 2 due to functioning status and 10 due to mixed criteria). Kappa Index was 0.85 (CI 95%: 0,65-1), meaning an almost perfect concordance between presumptive diagnosis and pathological results. The main diagnosis were: BA : 30 (49,2%, 2 of them cortisol-secreting adenomas); mielolipoma: 10 (15,5%), AC: 9 (13,8%, 5 of them functioning AC); P: 7 (10,8%, 5 of them with normal cathecolamines levels); cysts: 3 (4,7%); and hemangioma, nodular cortical hyperplasia, pseudocyst and ganglioneuroma: 1 (1,5%) each. Patients on AC group showed significant higher levels of DHEA-S (mean 433,1 µg/dl, p=0,001,normal range: 62-492µg/dl). Mean size tumor (cm) was: BA: 3,7; AC: 9,8; P: 8,8; M/C: 4,7; MISC: 6,6 (p<0,001). Mean attenuating values (UH) were: BA: 13,3; AC: 35,6; P: 40,9; M/Q: -7,6; MISC: 17,3 (p<0,001) . CONCLUSIONS: Benign and non-functioning lesions were the main causes for AI. This study showed that functional and malignant tumors can be detected in early stages by a correct interpretation of clinical, hormonal and imaging findings.

 

Nothing to Disclose: OM, IP

11569 2.0000 SAT-0799 A Adrenal Incidentaloma: A Study of 65 Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Anh Truong*, Diane Mary Biskobing and Amelia Grover
Virginia Commonwealth University, Richmond, VA

 

Background: Incidental adrenal lesions are discovered in between 4-10% of patients undergoing imaging scans. The American Association of Clinical Endocrinologists (AACE) and the American Association of Endocrine Surgeons advise that all patients with an adrenal incidentaloma be referred to an endocrinologist or endocrine surgeon for appropriate evaluation1.  AACE guidelines recommend biochemical evaluation to screen for a hormone secreting adenoma and a repeat CT scan within 6 to 12 months to evaluate for growth. This study was conducted to determine whether patients at an academic medical center with adrenal incidentalomas receive the suggested evaluation.

Methods: A list of subjects was generated by the radiology department. Reports between January 2012 and January 2013 were searched for the phrase ‘adrenal nodule’, but excluding the phrase ‘no adrenal nodule’. The initial list identified 885patients; however, 437 were excluded because of a history of cancer, multiple repeat scans outside of the time frame, or no adrenal nodule. A total of 448 remaining patients were reviewed for demographical information, nodule size, labs, and follow up CT scans.

Results: An analysis of the physicians ordering the CT/MRI scans found that the majority of scans were ordered by Emergency Medicine (EM) physicians (23.6%). Other groups ordering large numbers of scans included Internal Medicine and General Surgery. Upon review of the patients’ history, 304 patients had hypertension. Of the hypertensive patients, 71.7% had adrenal masses larger than 1 cm, but only 8.2% had at least one of the recommended labs drawn and only 2.96% of patients had a follow up scan done within 6-12 months of the initial scan. In the two patients with masses larger than 4 cm, neither had labs drawn nor scans ordered. The masses were also examined in the context of patients’ age, lab work, and follow up scans. Of the 448 masses reviewed, 311 had been identified in patients 65 y/o or younger. From this group of patients, 65.6% had masses larger than 1 cm. Only 2.2% of patients in this group had a full lab work up done and only 2.25% had scans ordered. The remaining 137 masses had been seen in patients older than 65 y/o, with 75.9% of these masses found to be larger than 1 cm. From this group of patients, only 2.2% had a full lab work done and 2.2% had follow up scans ordered within 6-12 months. 

Conclusion: The majority of patients with incidentalomas did not have any biochemical evaluation or a follow up scan within the 6-12 month timeframe. The largest number of these masses were discovered on scans ordered by the EM department. While guidelines are in place for the management of these patients, it is unclear as to why these guidelines are not followed. Further determination into the cause can be made by evaluating contributing factors such as discontinuity of care, oversight of secondary findings on imaging studies, or lack of awareness of these guidelines.

 

Nothing to Disclose: AT, DMB, AG

11677 3.0000 SAT-0800 A Evaluation of Adrenal Incidentaloma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Anand Vaidya*1, Rene Baudrand2, Linda Wiinberg3, Daniel T Ruan3, Paul Shyn4, Robert G Dluhy3, Rana McKay5, Toni Choueiri6 and Aymen Elfiky7
1Brigham and Women’s Hospital/Harvard Medical School, Boston, MA, 2Pontificia Universidad Catolica de Chile, Santiago, Chile, 3Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 4Brigham and Women's Hospital, Harvard Medical School, MA, 5Dana-Farber Cancer Institute, 6Dana-Farber Cancer Institute, Boston, MA, 7Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School

 

Context:Advanced adrenal cortical carcinoma (ACC) is a rapidly progressive, often hormonally active, malignancy with no effective medical therapies.

Hypothesis/Aims:We performed a retrospective review of our patients with stage IV ACC, hypothesizing that an aggressive approach to repeatedly reduce overall tumor volume, employing surgical and minimally invasive procedures, could improve outcomes and patient well-being when combined with medical therapy.

Methods:Patients with stage IV ACC presenting to our Center for Adrenal Disorders after 2012, when repeated minimally invasive interventions were routinely considered for all ACC patients, were treated when possible with repeated cytoreductions after initial debulking surgery with metastatectomies and thermal ablations to reduce overall tumor volume, in addition to medical therapy (REP-MED) (n=6). Age and gender matched patients in the prior 5 years who only had an initial extensive surgical debulking, followed by medical therapy, were categorized as “INI-MED” (n=8).  Patients were included in INI-MED even if they underwent 1-2 metastatectomies if indicated for pain palliation only.  Matched patients who received only maximal cytotoxic medical therapy because their disease was too severe to permit safe surgical debulking were categorized as “MED” (n=5). Patients completed validated quality of life (QoL) instruments every 3 months, including CDC-HRQoL, CARES, SF12, and PHQ9.  ANOVA and P-trend regressions were used to evaluate the influence of treatment category on outcomes (*P<0.05; **P<0.01; ***P<0.001).

Results:Mean follow-up time was 22 vs 29 vs 6 months for REP-MED vs INI-MED vs MED. During this time, the REP-MED group had the most cytoreductive procedures (4.2 vs 1.2 vs 0*), but there were no differences with respect to the types or number of cytotoxic medical therapies administered, anti-hormonal medical drugs used, or number of ACC specialists involved per patient.  During the course of their disease, the REP-MED group had fewer sites of metastases (1.8 vs 2.5 vs 2.4 organs) and fewer overactive adrenal hormonal lines, when compared to the MED group (1 vs 1 vs 2.8 adrenal hormone lines**).  While all 3 groups described poor overall mental and physical status, REP-MED had the best QoL scores (CARES: 85 vs 98 vs 122**;  SF12: 31 vs 27 vs 25*). During the follow-up time, the REP-MED group had the least progression of disease (50% vs 75% vs 100%*), the longest progression-free time after initial intervention (6 vs 2.6 vs 2.2 months***) and the lowest mortality (0% vs 25% vs 80%*).

Conclusion: This short and small observational study suggests that repeated interventions to reduce tumor volume, in combination with medical therapy, may delay the progression of advanced ACC and improve QoL.  Larger and longer studies are needed to validate our findings and assess the impact of this approach on overall survival and well-being.

 

Nothing to Disclose: AV, RB, LW, DTR, PS, RGD, RM, TC, AE

13091 4.0000 SAT-0801 A The Impact of Repeated Cytoreduction in Combination with Maximal Medical Therapy on Clinical Outcomes and Quality of Life in Advanced Adrenal Cortical Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Yuksel Altuntas*, Suna Avci, Sayid Shafi Zuhur and Feyza Yener Ozturk
Sisli Etfal Training and Research Hospital, Istanbul, Turkey

 

Introduction:Adrenal incidentalomas are frequently encountered in clinical practice on radiologic imaging done for unrelated reasons.

Aim:We aimed to evaluate the functional status and the growing rates of adrenal masses followed-up at our department.

Method:Our study included 137 patients (97 female, 40 male, age range: 27-80 years) who were evaluated for adrenal incidentaloma over 1 cm in diameter at Sisli Etfal Training and Research Hospital, Department of Endocrinology between years 2008 and 2013.  The archive records of the patients were analyzed retrospectively.  All the masses diagnosed with CT or USG had been reevaluated with MR imaging. Hormonal assessment for pheochromocytoma, subclinical Cushing’s syndrome, primary hyperaldosteronism (in hypertensive patients) and non-classic congenital adrenal hyperplasia were performed in all patients. Mean follow-up period was 20,2±19,86 months. The patients were reevaluated after six months and then yearly with MR imaging and biochemically.

Results:According to the hormonal assessment, the patients were classified as 99 (72,3%)  non-functional adenoma(NFA), 21 (15%) subclinical Cushing’s syndrome , 9 (6%) pheochromocytoma, 6 (4%) Conn’s syndrome, 2 (1%) congenital adrenal hyperplasia and 6 (4%) malignancy. The latter one consisted 2 patients (1%) with adrenocortical carsinoma and 4 patients (3%) with metastasis (2 lung cancer, 1 renal cell cancer, 1 Non Hodgkin Lenfoma). Patients with functioning adrenal adenomas were significantly younger than the patients with non-functioning tumours (p<0,05). The groups didn’t differ in regards to tumour size. During follow up, none of the patients with non-functional adrenal incidentaloma developed hormonal hyperfunction. Tumour enlargement was determined in 24 patients (17%). Growth rate of adenomas for males was significantly higher than that of females (5 male (12%) vs. 19 female (%19)) (p=0,031). During follow-up period, the enlargement was detected in 20/99 of NFAs (20%; 10,8±8,92 mm) and  4/38 of functional adenomas (10.5%; 10,75±4,35mm). However, the growing rates did not show significant difference between two groups .

Conclusion:Tumor enlargement may occur in a substantial number of adrenal incidentalomas during follow-up. Since the mass enlargement may be a sign of malignancy, long-term follow-up of these patients with imaging techniques is essential.

 

Nothing to Disclose: YA, SA, SSZ, FY

13374 5.0000 SAT-0802 A The Functional Assessment and Growth Rates of Adrenal Incidentalomas: A Single Center Experience 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Serkan Yener*1, Hamiyet Yilmaz2, Abdurrahman Comlekci1 and Tevfik Demir1
1Dokuz Eylul University Medical School, Izmir, Turkey, 2Tepecik Hospital, Izmir, Turkey

 

Subclinical Cushing's Syndrome (sCS) is defined as the mild hypercortisolemic state in subjects with an adrenal incidentaloma. The prevalence of sCS in individuals with an adrenal incidentaloma may vary due to the heterogenicity in diagnostic approach. The overnight dexamethasone suppression test (DST) with 1 mg dexamethasone is considered the most valuable test to screen for sCS. However, becasue of the limitations of any single test of the HPA axis, several additional tests like urinary free cortsiol, midnight serum cortsiol, CRH test or high dose DST have been recommended in previous studies.

As the concept of sCS is the ACTH independent cortsiol secretion of an adrenal adenoma, we aimed to demonstrate DHEAS levels in four different conditions; non functioning adrenal adenoma (NFA), sCS, overt Cushing Syndrome becasue of an adrenal adenoma (CS) and benign non-adenomatous tumors (cysts or myelolipomas) (NAT). In this study, data of consecutive 84 subjects with radiologically benign adrenal tumors with different functional status has been evalauted. All subjects referred to our divison becasue of an incidentally discovered adrenal mass were evalauted with radiological and laboratuary interventions as previously described by several associations. Hormonal evalaution was performed in accordance with the recent  guidelines. Breifly, subjects with post-DST cortsiol levels < 1.8 mcg/dl were defined as NFA group while subjects with post DST cortisol levels > 5 mcg/dl were defined as sCS group. Individuals with post DST cortsiol between 1.8-5 mcg/dl were defined as sCS if ACTH level was < 10 pg/ml.

Study group included 18 subjects with sCS, 49 subjects with NFA, 5 subjects with CS and 12 subjects with NAT. Mean age was comparable in NFA, sCS and CS groups (53, 54, 46 years respectively, p>0.05, One way ANOVA, Bonferoni correction). Mean age was lower in NAT group (38 yr. p<0.001 when compared to sCS and NFA groups. Mean DHEAS level was 17.0, 26.9, 98.8 and 170.4 mcg/dl in subjects with CS, sCS, NFA and NAT, respectively (p<0.001, One way ANOVA). DHEAS level was significantly reduced in subjects with CS and sCS when compared to subjects with NFA (p<0.001 for both comparisons, One way ANOVA, Bonferoni correction). Subjects with NAT had the highest DHEAS levels. DHEAS level was significantly and positively correlated with ACTH (r=0.370, p<0.005) and negatively correlated with age (r=-0.357, p<0.005) and post DST cortisol level (r=-0.374, p<0.001).

These results indicate that hypercortisolism related with adrenal adenomas was associated with lower DHEAS levels. The magnitude of DHEAS suppression was significantly associated with the extent of hypercortisolism. This was also clear and independent from the effect of age variations between NFA and sCS groups. Therefore, we suggest routine DHEAS testing in adrenal incidentaloma workup.

 

Nothing to Disclose: SY, HY, AC, TD

13599 6.0000 SAT-0803 A Pros and Cons of Dheas Testing for Adrenal Incidentaloma Workup 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Joana Menezes Nunes*1, Elisabete Rodrigues2, Elisabete Rios3, Catarina Eloy4, Isabel Carvalho5 and Davide Carvalho6
1Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar São João. Faculty of Medicine, University of Porto. Portugal, Porto, Portugal, 2Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar São João. Faculty of Medicine, University of Porto, Porto, Portugal, 3Pathology Department Centro Hospitalar S. João, Porto. Faculty of Medicine, Porto University. Institute of Molecular Pathology and Immunology at the University of Porto. Portugal, Porto, Portugal, 4Institute of Molecular Pathology and Immunology at the University of Porto. Portugal, Porto, 5Oncologic Registry, Centro Hospitalar S. João, Porto. Portugal, Porto, Portugal, 6Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João. Faculty of Medicine, Porto University. Portugal, Porto, Portugal

 

Introduction: Adrenocortical carcinoma (ACC) is an uncommon and aggressive malignancy, 30-85% presenting distant metastasis at the time of diagnosis. We aimed to investigate the clinical and pathological findings of ACC diagnosed / treated in our hospital from Jan/88 until Jan/13. Methods: Search of adult patients with ICD10-C74 diagnosis and selection of those with ACC for data collection: clinical presentation, imagiologic characteristics, histopathology review, staging according to ENSAT and survival. Results: We identified 31 ACC patients, mean age at diagnosis 54.6±12.6years, 51.6% women. Sixteen died, seven are alive and there was no information about the remaining patients. At diagnosis, 11.8% were asymptomatic, 23.5% presented back pain, 17.6% general malaise, 29.4% hypercortisolism and 17.6% hirsutism / virilization. The average size of the tumor was 11.7±6.6cm, 53.3% localized on the right side, 72.7% with local invasion, 25% inferior vena cava invasion and 63.7% distant metastasis. Two patients were submitted to exploratory laparotomy and ten to adrenalectomy. One patient refused surgery based on religious beliefs. Of the 10 histologies reviewed, 80% presented atypical mitosis, 20% diffuse architecture, 60% ≤25% clear cells, 90% necrosis, 70% venous invasion, 90% sinusoidal invasion, 60% capsule invasion, mean mitotic index 41.2/50HPF (±36.8). One patient was treated with adjuvant radiotherapy and four with mitotane therapy (two stopped because of side effects: rash and liver dysfunction). The remaining patients didn’t start adrenolytic treatment due to death and/or difficulties in acquiring the drug. Two patients, on stage II ENSAT, maintain follow up without mitotane. Three patients were submitted to cytotoxic therapy (cisplatin, etoposide and doxorubicin). Mean overall survival was 59.2±52.4 months for stages 1+2 and 6.2±6.8 months stages 3+4 (ENSAT) (p=0.004). Conclusion: Our series reinforces the importance of early diagnosis by demonstrating a worse prognosis of cases in more advanced stages and the need for a multidisciplinary approach in such a rare malignancy.

 

Nothing to Disclose: JMN, ER, ER, CE, IC, DC

13837 7.0000 SAT-0804 A Adrenocortical Carcinoma: What's Our Experience in the Past 25 Years? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Joana Menezes Nunes*1, Elisabete Rodrigues2, César Esteves3, Rui Cunha Guimarães4, Davide Carvalho3 and Isabel Ramos5
1Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar São João. Faculty of Medicine, University of Porto. Portugal, Porto, Portugal, 2Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar São João. Faculty of Medicine, University of Porto, Porto, Portugal, 3Centro Hospitalar São João, Faculty of Medicine, University of Porto, Portugal, 4Radiology Department, Centro Hospitalar São João. Faculty of Medicine, Porto University, Portugal, Porto, Portugal, 5Radiology Department, Centro Hospitalar São João, Faculty of Medicine, Porto University. Portugal, Porto, Portugal

 

Introduction: According to actual guidelines, adrenal incidentalomas should have imagiologic evaluation 3-6 months after diagnosis and annually for 2 years and hormonal evaluation annually for 5 years. However, the optimal frequency and duration of follow up are still uncertain issues. Methods: We retrospectively analyzed all patients with at least two imagiologic exams (CT/MR) performed in our hospital, from Jan/04 to Sep/13, whose reports referred adrenal nodule and selected those with incidental diagnosis. Results: Of 251 selected patients, 183 fitted our criteria: 58.6% were women, mean age at diagnosis 65±10.7years, 85 on left adrenal gland with average size 20±7.7mm, 60 on the right one with mean size of 23±10.4mm and 38 bilateral. Six patients didn’t have hormonal evaluation, two are waiting for results, two presented hypercortisolism, two 21-hydroxylase deficiency and two hormonal alterations compatible with pheocromocytoma. After the initial evaluation, adrenalectomy was undertaken in 6 patients: four for hyperfunction and two for size >40mm (<10HU, regular and homogeneous lesions, one of them with imaging features suggesting a myelolipoma). Histologies revealed four cortical adenomas, one oncocytoma and one pheocromocytoma. Of the remaining 177, 37 (20.9%) had imagiologic re-evaluations at 4±2 months (1st), 96 (54.2%) at 12±3 months (2nd), 48 (27.1%) at 24±3 months (3rd), 48 (21.7%) at 36±3 months (4th), 28 (15.8%) at 48±3 months (5th), 17 (9.6%) at 60±3 months (6th), 4 (2.6%) at 72±3 months (8th) and 8 (4.5%) at 84±3 months. The growth rate ≥5mm observed at the follow-up evaluations was 1st-10.8%, 2nd-9.4%, 3rd-10.4%, 4th-14.6%, 5th-0%, 6th-5.9%, 7th-0%, 8th-12.5%. Overall, the mean time of follow up was 43.5±23.4 months and the observed growth was 0.8±1.4 cm (main left incidentaloma) and 0.7±1.5 cm (main right incidentaloma).  Seven patients were submitted to adrenalectomy because of growth, which occurred, in four patients, 2y after diagnosis (histologies: adenomas). None of the incidentalomas became hyperfunctioning. Conclusion: As we observed growth of adrenal incidentalomas after the two initial years and in four cases with surgical indication, we propose that imagiologic follow up should be individualized according to the rate of growth and to the adrenal lesion size.

 

Nothing to Disclose: JMN, ER, CE, RCG, DC, IR

13889 8.0000 SAT-0805 A Adrenal Incidentalomas: From Diagnosis to Follow up 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Anna Kasperlik-Załuska*1, Andrzej Cichocki2, Maciej Otto3, Katarzyna Roszkowska2, Rafal Z Slapa3, Jadwiga Slowinska-Srzednicka4, Elzbieta Roslonowska4, Wojciech Jeske4, Piotr Zdunowski5 and Wojciech Zgliczynski6
1Medical Centre of Postgraduate Education, Warsaw, Poland, 2M. Sklodowskiej-Curie Memorial Center of Oncology, Warsaw, Poland, Warsaw, Poland, 3Medical University of Warsaw, Warsaw, Poland, 4The Medical Centre of Postgraduate Education, Warsaw, Poland, 5Bielanski Hospital, Warsaw, Poland, 6Medical Center of Postgraduate, Warsaw, Poland

 

Most of adrenal incidentalomas  (AI) are benign tumors. Malignancy in this group is frequently believed to be characteristic for elderly. We would like to revise this opinion basing on observation of our group of patients with AI.
Material: 2666 patients, 1953 women and 713 men, aged 11 - 87 years (only 4 patients below 18 years old).
Methods: clinical examination, imaging techniques, hormonal assays, histopathological and immunohistochemical studies in patients treated by surgery. Basing on the results of these studies we divided our material into 4 groups: 1/ probably benign tumors - 2377; 2/ adrenal carcinoma (ACC) - 194; 3/ metastatic lesions - 62; 4/ other malignant tumors - 17 (pheochromocytomas, lymphomas, sarcomas, ganglioneuroblastoma) - not evaluated, because of too small number for statistics.Three age compartments were distinguished: up to 30 years old, 31 - 60, over 60 years.
Results In the all group there were 109 patients (4%) up to 30 years old: in the group 1 - 74 (3%), group 2 - 34 (18%), group 3 - 0. Subset ranging  31 - 60 years: group 1 -1281 (54%); group 2 - 114 (59%); group 3 - 28 (45%). Subset over 60 years - group 1 - 1021 (43%); group 2 - 48 (23%); group 3 - 34 (55%).
Conclusions:
1. A domination of patients middle aged , 31 - 60 years, was found in the ACC group.
2. Similar trend was noted in the group with probably benign tumors.
3. A majority of patients over 60 years old was stated only in the group of patients with metastatic infiltrations in the adrenals.
4. Interestingly, the greatest percentage of young patients (18%) was found in the ACC group.
5. In the total group of 256 patients with malignant tumors (ACC and metastases) a majority (55%) was middle aged
 
The study was supported by 501-1-13/101 and 301-1-08-11/13 CMKP grants.

 

Nothing to Disclose: AK, AC, MO, KR, RZS, JS, ER, WJ, PZ, WZ

14366 9.0000 SAT-0806 A Malignant Adrenal Incidentaloma - Is It a Tumor of Old People? a Clinical Analysis of a Group of 2666 Patients Observed at a Single Endocrinological Unit 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Mehmet Calan1, Mine Sencan Eren1, Serkan Yener1, Ozhan Ozdogan2, Dilek Cimrin2, Ali Riza Sisman2, Mustafa Secil1, Hatice Durak3 and Abdurrahman Comlekci*1
1Dokuz Eylul University Medical School, Izmir, Turkey, 2Dokuz Eylul University, 3Dokuz Eylul University Medical School

 

Introduction: Incidentally-identified adrenal masses, are increasingly detected, due to the widespread clinical use of abdominal imaging. For differentiating between benign and malignant masses, positron emission tomography (PET/CT) imaging is useful with its qualitative analysis. The aim of the present study was to find out the optimum SUVmax cut-off for accurate characterization of adrenal tumors.

Design, methods:The research was designed as a cross-sectional study. Data was collected from subjects who underwent abdominal MRI. Hormonal evaluation included measurements of plasma ACTH and cortisol before and after 1-mg dst sup. test, midnight cortisol, and 24-h urinary-free cortisol; 24-h urinary catecholamine metabolites; and finally, plasma renin activity, and aldosterone. All subjects underwent PET-CT imaging for the assessment of SUVmax of the adrenal mass. 29 subjects who had high-risk lesions underwent surgical excision. Pathological examination of the resected specimens revealed malignant adrenal masses in 14 patients and benign adrenal adenoma in 15 subjects.

Results: A total of 145 subjects  (91 women and 54 men, mean age 58.11 ± 10.24) attended the study. The study population consisted of 116 subjects with non-functional and benign adrenal adenoma, 14 with subclinical Cushing’s syndrome, and 15 with malignant adrenal mass. 14.5% of subjects had bilateral adrenal masses. Median adrenal mass size was 26 (10-65) mm in subjects with benign adrenal adenoma, 27 (10-40) mm in subjects with subclinical Cushing’s syndrome, and 4.9 (2.9-6.3) mm in subjects with malignant adrenal mass. Adrenal mass size and SUVmax was significantly higher in subjects with malignant adrenal mass compared to those with non-functional incidentaloma and with subclinical Cushing’s sydrome (p<0.001). SUVmax was found to be 2.3 (1-4.9) in subjects with benign adrenal adenoma, 2.8 (1.6-5.1) in subjects with subclinical Cushing’s syndrome, and 4.9 (2.9-6.3) in subjects with malignant adrenal adenoma. In Pearson’s correlation analysis,  SUVmax was found out to be positively correlated with adrenal mass size (r=0.26, p=0.001) and with BMI (r=0.18, p=0.025). Multiple linear regression analysis showed that age, adrenal mass size, and BMI had no direct impact on SUVmax. Upon ROC curve analysis, a SUVmax value of 3.5 (sensitivity 87%; specificity 89%) was found to be the cut-off value for distinguishing between benign and malignant adrenal masses.

Conclusions: PET imaging may be of use if a lesion remains indeterminate in appropriate clinical setting. In the present study, SUV index was observed to be significantly higher in subjects with malignant adrenal mass compared to both subjects with non-functional incidentaloma and with subclinical Cushing’s syndrome and a SUV index of 3.5 was found to be optimal for differentiating between benign and malignant masses of the adrenal.

 

Nothing to Disclose: MC, MSE, SY, OO, DC, ARS, MS, HD, AC

15082 10.0000 SAT-0807 A Maximum Standardized Uptake Value: To Distinguish Between Benign and Malignant Adrenal Mass 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Joana Simoes-Pereira1, Daniel Macedo*2, Margarida Silva-Vieira3, Helena Vilar4, Maria Conceição Pereira4, Valeriano Leite1 and Maria João Bugalho1
1Portuguese Institute of Oncology, Lisbon, Portugal, 2Portuguese Institute of Oncology, Lisbon, Lisbon, Portugal, 3Portuguese Institute of Oncology of Lisbon, Lisbon, Portugal, 4Portuguese Cancer Centre of Lisbon, Lisbon, Portugal

 

Introduction

Adrenocortical Carcinoma (ACC) is a rare tumor, being the 2nd most aggressive endocrine malignancy (after anaplastic thyroid carcinoma). Herein, we describe the clinical features and outcomes in 27 cases.

Material & Methods

Retrospective analysis of clinical files of patients with histological features of ACC (Weiss criteria ≥ 3 or local invasion/distant metastases) diagnosed and/or followed at our institution between 1997-2013. Data were analyzed using SPSS 20.0.

Results
Mean age at diagnosis: 46 ± 19 years; 70% women; median follow-up: 35 months (mo). Hormonal profile: 33% produced glucocorticoids 15% androgens, 11% glucocorticoids + androgens; 22% were non-functioning; unknown in 19%. ACC was an adrenal incidentaloma in 22%. Hypertension was documented in 37% and secondary diabetes in 3%; pheochromocytoma was excluded in only 44%. Of those who underwent surgery (25), 60% were submitted to adrenalectomy, 24% adrenalectomy + nephrectomy, 12% en bloc resection (4% unknown procedure). Lymph node dissection was only performed in 12%. Resection status: R0 40%, R1 12%, 8% R2, Rx 40%. Type of resection had no impact in our sample’s survival (p=0.119). Average tumor’s size: 12 ± 4 cm. At diagnosis, 56% had adrenal confined disease, 19% infiltration of surrounding tissue, 6% invasion of adjacent organs and 18% distant metastasis. During follow-up, 88% were reclassified as stage IV (ENSAT); their median survival was 60 mo; 5-y survival was 48%. Compared with other imaging scans, FDG-PET: anticipated relapse in 4/10 patients; confirmed images obtained by conventional methods in 5/10; and turned out to be false-negative in 1/10. Mitotane was used in 74% patients; 35% of them reached therapeutic levels (median cumulative dose: 770 g). From these, after a mean time of 30 mo, 51% showed progression of disease. Main adverse event was adrenal insufficiency. Mitotane had no impact on survival (p=0.920); patients who achieved therapeutic levels didn’t show better progression free survival (p=0.687). Chemotherapy (QT) was performed in 33% (most used schemes: Streptozocin and /or Doxorubicin + Etoposide + Cisplatin). Radiotherapy (RT) in 41% (36% palliative, 64% adjuvant). Combined therapy (mitotane + QT) in 18.5%. Currently, 22% are alive with no disease, 15% with distant metastasis; 15% were lost to follow-up; 48% died from ACC. Most living patients were submitted to surgery + mitotane or surgery + mitotane + QT/RT. Median survival: 106 months; 5-y survival: 64%; median disease free survival: 28 mo.

Conclusion
Treatment options beyond surgery are limited making preoperative staging and definition of surgical protocols crucial in the management of these patients. Mitotane monotherapy might be indicated in patients with low tumor burden but requires close monitoring. Combined treatments are likely to improve survival.

 

Nothing to Disclose: JS, DM, MS, HV, MCP, VL, MJB

15188 11.0000 SAT-0808 A Adrenocortical Carcinoma: Retrospective Analysis of a Portuguese Cancer Centre 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Paolo Dalino Ciaramella*1, Maurizio Vertemati2, Duccio Petrella1, Erika Grossrubatscher1, Benedetta Zampetti1, Marco Boniardi1, Raffaele Pugliese1 and Paola Loli1
1Niguarda Ca Granda Hospital, Milan, Italy, 2University of Milan, Milan, Italy

 

High mitotic index and high nuclear grade are part of representative hallmarks of adrenocortical cancer (ACC), but the analysis of these parameters is known to be operator-dependent. A characteristic neutrophil/T-lymphocytes infiltrate ratio has been often implicated in carcinogenesis, progression and clinical outcome of several cancer types. However, its role in adrenal cortical tumors is unclear. Aim: to assess by computerized morphometry morphological features, vascular and inflammatory pattern in adrenocortical adenomas (ACAs) and carcinomas. Methods: A single Institution series of 11 ACAs and 18 ACCs samples was analyzed using a Kontron-Zeiss KS400 image analyzer. Four consecutive sections 4 µm thick were obtained with a total of 250–300 HPF examined for each case. Immunohistochemistry for Ki67 and CD8/CD15 was obtained to assess proliferation index and inflammatory infiltrate respectively. To minimize subjectivity, particularly relevant when quantitative results are expected, we generated a morphometric model based on analysis of volume fractions occupied by Ki67 positive and negative cells (nuclei, cytoplasm) and inflammatory compartments (CD15+ granulocytes, CD8+ lymphocytes). Lastly, the assessment of Ki-67 by computerized morphometry was compared with pathologist’s evaluation. Results: volume fraction of Ki-67+ cells was higher in ACCs (ACC .11951, ACA .06637; p<0.001); nuclei volume fraction resulted higher in ACCs, in both Ki-67- (ACC .11951, ACA .06637; p<0.001) and Ki-67+ cells (ACC .01293, ACA .00104; p<0.001). Nuclear/cytoplasmic ratio was higher in ACCs, both Ki-67- (ACC .20535, ACA .09260; p<0.001) and Ki-67+ cells (ACC .66141, ACA .27281; p<0.001). Volume fractions of CD15+ (ACC .00312, ACA .00098; p<0.001) and CD8+ cells (ACC .00731, ACA .00356; p<0.05) were also significantly higher in ACCs. Moreover, when comparing morphometric analysis of Ki67+ cells to pathologist’s scores, the data of the point grid analysis revealed significantly lower values compared to conventional histopathology. Conclusions: Our computerized morphometric model is simple, repeatable (lacking observer bias) and flexible, as it can be upgraded to include newly described histological or immunohistochemical features. This method could be integrated into a classification tool to complement conventional histological analysis to achieve quantification of morphological characteristics and histological biomarkers of adrenocortical tumors. In our experience, nuclear/cytoplasmic ratio differs mostly between ACCs and ACAs, both in Ki-67+ and Ki-67- cells. We speculate that neutrophils may play a role in ACC milieu and that the quantitative assessment of inflammatory infiltrate may find a place in the diagnostic algorithm of adrenal benign and malignant tumors.

 

Nothing to Disclose: PD, MV, DP, EG, BZ, MB, RP, PL

15214 12.0000 SAT-0809 A Quantitative Assessment By Computerized Morphometry of Ki-67 and Intratumoral Inflammatory Infiltrate in Benign and Malignant Adrenocortical Tumors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Thiago Machado Nogueira*1, Roy Lirov2, Antonio M Lerario3, Gary D Hammer4, Maria Candida B V Fragoso5, Elaine M Caoili2 and Tobias Else6
1Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 2University of Michigan Health System, Ann Arbor, MI, 3ICESP/University of Sao Paulo, São Paulo, Brazil, 4University of Michigan, Ann Arbor, MI, 5Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 6Univ of Michigan, Ann Arbor, MI

 

Benign adrenal tumors are common (5-10% of adult population) and often discovered incidentally. Adrenocortical carcinoma (ACC) in contrast is a markedly rare neoplasm (incidence 1/million/year). Concern for ACC is a leading cause for imaging follow-up of incidentally discovered adrenal tumors. However, taken the rarity of this malignancy, the benefits of serial imaging have not been established.

The goal of the current study is to define the imaging and clinical characteristics of adrenal lesions in patients later diagnosed with an ACC.

We identified a total of 11 patients (7F, 4M) within the Michigan Endocrine Oncology Repository (MEOR, total 410 patients) with an adrenal lesion <6cm diagnosed ≥5 months prior to ACC diagnoses.

The reason for initial imaging was unrelated to endocrine symptoms in all cases. Mean age at initial diagnosis was 42.4 ± 15.0 years and ACC was diagnosed at 46.8 ±14.5 years

The mean lead time to diagnosis of ACC was 54.2 ± 41.9 months (range: 5 to 126) with 4 ACCs being diagnosed within a 24 month period. The mean size of the initial lesion was 3cm (median 3cm, range 1.5 – 5.9) with 9 tumors < 4cm. In retrospective image review, signs not clearly suggestive of a benign lesion (heterogeneity, attenuation > 10HU, irregular margins, absence of signal drop in MRI, high signal in T2) were evident in all but one patient. Mean increase in the largest diameter was 1.6 ± 1.3cm (range 0.2 – 6.0) per year. However, in several cases a latent phase of stability or slow growth was followed by accelerated growth. 5 of 11 of the lesions had a growth rate (incidentaloma to ACC) lower than 1cm/year.

6 of 11 patients were initially followed with at least one additional imaging. 4 of these lesions were stable over 11, 11, 25 and 103 months and 2 ACCs were diagnosed at 5 and 8 months, with growth of 2.6 and 1.5 cm/year.

In summary, our data show that the time between an initial adrenal lesion and ACC diagnosis varies greatly. Imaging features of only one lesion were suggestive of a benign character; only 4 ACCs were diagnosed within a time frame of 24 months after initial incidentaloma diagnosis and 4 patients developed an ACC despite stability on initial follow-up imaging. These findings raise concerns on the usual recommendations for follow-up imaging. Taken the rarity of ACC, general follow-up imaging, particularly for benign appearing lesions, may not be justified considering patient radiation exposure and overall health care costs. Individualized risk stratification is needed.

 

Nothing to Disclose: TMN, RL, AML, GDH, MCBVF, EMC, TE

16215 13.0000 SAT-0810 A Radiographic Characteristics of Incidentalomas in Patients Later Diagnosed with Adrenocortical Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Aung Naing*1, Mouhammed Amir Habra2, Rashmi Chugh3, Marian Ijzerman4, Martin D Phillips5 and David C Smith6
1MDAnderson Cancer Center, Houston, TX, 2The University of Texas MD Anderson Cancer Center, Houston, TX, 3University Of Michigan, Ann Arbor, MI, 4Atterocor, Inc, Ann Arbor, MI, 5Atterocor, Inc., Ann Arbor, MI, 6University of Michigan, Ann Arbor, MI

 

ATR-101 (Atterocor, Inc., Ann Arbor, MI, USA) is a selective inhibitor of ACAT1 (acyl coenzyme A:cholesterol acyltransferase) in clinical development for the treatment of adrenocortical carcinoma (ACC).  ACAT1 catalyzes cholesterol ester formation from cholesterol and long-chain fatty acyl-CoA and, in the adrenals, is particularly important in creating a reservoir of substrate for steroid biosynthesis.  ATR-101 selectively distributes to the adrenals, inhibits steroidogenesis and causes apoptosis of cells of the adrenal cortex, as well as in H295R ACC cells.

ACC is an ultra-rare malignancy, occurring in about 2 per million population annually.  ACC is frequently discovered in Stage 4 and the overall disease survival is approximately 17 months.  Tumors often overproduce steroids normally produced in the adrenal cortex and cause therapy-resistant Cushing’s syndrome.  Current therapies are toxic, difficult to administer, and poorly effective. 

ATR-101-001 is a phase 1 study being conducted at two centers in the United States.  It is a “3+3” design: 3 subjects with advanced ACC who have failed or declined existing therapies are enrolled at each dose level for 28 days.  If no Dose Limiting Toxicity is observed, three additional subjects are enrolled at a higher dose.  Subjects who appear to be deriving benefit may stay on ATR-101 indefinitely.  The primary objective is to determine the safety and tolerability of ATR-101 in subjects with advanced ACC.  Secondary objectives include efficacy by RECIST, measurement of production of steroid hormones and intermediates, determination of pharmacokinetics and the Maximum Tolerated Dose.  The study is open to patients age 18 and over with advanced ACC.  Patient’s mitotane level must be 5 ng/ml or less; the QTcF 470 ms or less; and if present, CNS metastases must be treated and inactive.

Full study information is available on ClinicalTrials.gov, Identifier NCT01898715.

 

Disclosure: MAH: Investigator, Eisai. RC: Study Investigator, Atterocor, Inc. MI: Employee, Atterocor, Inc. MDP: Employee, Atterocor, Inc, Employee, Atterocor, Inc. Nothing to Disclose: AN, DCS

16240 14.0000 SAT-0811 A ATR-101 Phase 1 Clinical Study for Adrenocortical Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Lucyna Papierska*1, Jaroslaw B Cwikla2, Michal Rabijewski3, Piotr Glinicki4, Maciej Otto5 and Anna A Kasperlik-Zaluska1
1The Medical Centre of Postgraduate Education, Warsaw, Poland, 2University of Warmia and Mazury, The Faculty of Medical Sciences, Olsztyn, Poland, 3Medical University of Warsaw, Warsaw, Poland, Warsaw, Poland, 4The Medical Centre of Postgraduate Education,, Warsaw, Poland, 5Medical University of Warsaw, Warsaw, Poland

 

Objective

According to some authors a higher incidence of subclinical hypercortisolaemia is found among patients with bilateral adrenal tumors with benign phenotype than with unilateral ones. The question is whether all patients with bilateral adrenal tumors and subclinical hypercortisolemia should undergo surgery and, if yes, which of the tumors should be removed first.

Patients and methods

The group consisted of 50 patients with benign bilateral adrenal tumors: 25 with subclinical hypercortisolemia and 25 without hormonal activity. 24 patients with subclinical hypercortisolaemia were operated. The adrenal gland for removing was typed basing on scintigraphy or on tumor diameter. Patients with tumors without hormonal hyperfunction were only controlled every 6 months. Measurements of cortisol concentration at 0800, 2200 and the following morning after dexamethasone suppression were done. Blood morning levels of ACTH, DHEAS, 17OHPG, concentration of glycated hemoglobin and lipid fractions were determined. The measurements were repeated every 6 months. In 15 patients with subclinical hypercortisolaemia adrenal scintigraphy with iodometyl-19norcholesterol was conducted.

Results

In all operated patients the biochemical signs of hypercortisolaemia ceased after surgery. However only in 14 (58%) operated patients the clinical improvement was evident. A clinically significant decrease in blood pressure, glycemia or glycated hemoglobin and BMI was not observed in 10 operated patients with good-controlled arterial hypertension or diabetes despite of evident hypercortisolemia before surgery. Nobody in observed group without hypercortisolemia developed a hormonal hyperfunction or health status deterioration during long-term observation.

Conclusions

Even though unilateral adrenalectomy brought about a regression of subclinical hypercortisolemia in all operated patients with bilateral adrenal tumors, only persons with deteriorated control of diabetes, hypertension or a quick increment of body mass before surgery have experienced benefits from surgical treatment.

 

Nothing to Disclose: LP, JBC, MR, PG, MO, AAK

16276 15.0000 SAT-0812 A Subclinical Hypercortisolemia in Bilateral Adrenal Incidentalomas - Who Should be Operated? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Eun Ky Kim*, Ji Hyun Lee, Eun Roh, Jae Hyun Bae, Jung Hee Kim, Ji Won Yoon, Seong Yeon Kim and Sang Wan Kim
Seoul National University College of Medicine, Seoul, Korea, Republic of (South)

 

Diagnosis for adrenal metastasis in patients with adrenal incidentaloma is less than 1%. But, among the patients with cancers, upto 50-75% of adrenal mass are reported to be metastasis (1, 2). Hounsfield units (HU) and the size of tumor in CT may help to distinguish between benign and malignant lesions. We investigated radiological features of adrenal incidentaloma in patients with cancer. Among 1029 subjects with adrenal mass detected during 2000-2012, 181 patients had cancer (17.6%). Mean age was 58.6 ± 10.3 years, and 61.9% were male. Renal cell carcinoma is the most common in cancer patients with adrenal mass (17.1%), followed by gastric (13.3%), colorectal (12.7%), lung (11.0%) and breast (11.0%) cancer. Initial size of mass was 21.0 ± 13.6 mm, and 59.7% of tumors were in the left side. 6.6% of patients had bilateral adrenal tumors. Biochemically functioning tumors were in 9.4% of patients. Adrenalectomies were performed to rule out metastasis in 21 patients, which revealed metastasis in 11 patients (52.4%). We compared the cases of adrenal metastasis (M) to the cases of benign adrenal lesions (B). Tumor size was 31.6 ± 14.2 mm (M) versus 26.5 ± 8.0 mm (B) (p=0.338). HU was 37.8 ± 10.9 U (M) versus 16.7 ± 2.1 U (B) (p=0.011). Although statistically not significant, there were more metastatic adrenal tumors in patients with other distant metastasis than in patients without distant metastasis (7 of 10 patients versus 4 of 11 patients). The primary cancer were lung cancer (n=4), renal cell carcinoma (n=2), lymphoma (n=2), hepatocellular carcinoma (n=2), breast cancer (n=1) and others. The cases which had features of benign adrenal tumors in CT (no more than 40 mm mass size and 20 HU) with at least 6 months of follow-up period were also analyzed. Initial size of mass was 16.1 ± 5.8 mm and their change in size was 0.5 ± 1.7 mm. Mean HU was 14.5 ± 24.0 U. Using receiver operating characteristic (ROC) curve, we may suggest that tumor size of 16.5 mm (sensitivity 91%, specificity 57%) and HU of 26 U (sensitivity 99%, specificity 77%) can be used for reference to exclude metastasis in cancer patients with adrenal mass.

 

Nothing to Disclose: EKK, JHL, ER, JHB, JHK, JWY, SYK, SWK

16783 16.0000 SAT-0813 A Clinical Features of Incidentally Detected Adrenal Mass in Cancer Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Narin Nasiroglu Imga*1, Ozgul Ucar Elalmis2, Mazhar Muslum Tuna1, Bercem Aycicek Dogan1, Deniz Sahin1, Dilek Berker1 and Serdar Guler3
1Ankara Numune Education and Research Hospital, Ankara, Turkey, 2Ankara Numune Education and Research Hospital, Ankara, Turkey, 3Hitit University, Faculty of Medicine, Corum, Turkey

 

INTRODUCTION: Emerging evidences indicate that patients diagnosed with adrenal incidentaloma may present with cardiovascular complications. Epicardial fat is known to play a role in left ventricle changes. Whether epicardial fat can be associated with increased left ventricle mass (LVM), which is a strong predictor of adverse cardiac events, in patients with adrenal incidentaloma is unknown. We aimed to test the relationship between echocardiographic epicardial fat thickness and LVM in a group of subjects with adrenal incidentaloma.

METHODS: 51 consecutive patients (age 52.6  ± 10.2 years) with adrenal incidentaloma and 35 healthy controls (age 52.1  ± 7.75 years) underwent transthoracic echocardiogram for epicardial fat thickness and LVM measurement. Standard parasternal and apical echocardiographic views were obtained in the left lateral decubitis position. Epicardial fat thickness was measured in parasternal long axis at end-systole. LVM was calculated using the Penn equation. LVM values were divided to body surface area to calculate the LVM index. Non-functional incidentaloma was confirmed by endocrine tests in all subjects.

RESULTS: Epicardial fat thickness was significantly higher in patients with incidentaloma  when compared to controls (0.89 ± 0.32 vs 0.74±0.26 mm, p= 0.023). LVM index was also higher in subjects with adrenal incidentaloma than in controls (103.9 ± 29.1 vs 87.2 ± 22.4 g/m²; p=0.006). A multivariate regression analysis which included age, body mass index, epicardial fat tissue thickness, HbA1c, neutrophil/lymphocyte ratio and the Homeostasis Model Assessment insulin resistance (HOMA-IR) showed that epicardial fat thickness was the best correlate ( R²=0.146, beta=0.242, 95% CI=1.505-40.695, p =0.035) of LVM index in overall study patients.

CONCLUSION: In conclusion, we showed that epicardial fat thickness and LVM index are higher in subjects with adrenal incidentaloma. Therefore these patients should be closely followed for increased cardiovascular risk. In addition, epicardial fat thickness independently correlates with LVM index and epicardial fat may be related with earlier cardiac abnormalities in patients with adrenal incidentaloma.

 

Nothing to Disclose: NNI, OUE, MMT, BAD, DS, DB, SG

16828 17.0000 SAT-0814 A Epicardial Fat Thickness and Left Ventricular Mass in Subjects with Adrenal Incidentaloma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Maria Antonenko*1, Natalya Volkova2, Serguey Dimitriadi3, Ilia Davidenko4, Igor Reshetnikov5 and Irina Dzherieva6
1Rostov State Med Univ, Rostov-on-don, Russia, 2Rostov state medical university, Rostov on Don, 3Rostov Scientific Oncology Institute, Rostov on Don, Russia, 4Rostov State Medical University, Rostov-on-Don, Russia, 5Rostov State Medical University, Rostov-on-Don, Russia, 6Rostov State Medical University, Rostov on Don, Russia

 

Urologists are the specialists who often deal with adrenal pathology, in other words who operate adrenals frequently. Since there is increased prevalence of adrenal incidentalomas (AI) as well as about 20% of them are presented as conditions requiring an operation, the adherence to the diagnostic protocol for AI by urologists is absolutely urgent. The aim of the study was to inquire about adherence to diagnostic protocol for AI by urologists. There was performed a retrospective analysis of 25 case reports of the patients who had been presented with the diagnosis of AI at urology department. The following parameters were analyzed: carrying-out screen tests for pheochromocytoma, primary aldosteronism (PA) and subclinical Cushing syndrome (CS); primary endocrinologist consultation, interpretation the CT density in Hounsfield units (HU), indication for contrast CT if it was necessary, calculation of washout percentage, indications for adrenalectomy. According to the conducted analysis, there were received next results. General screening for pheochromocytoma was performed to 18 patients among 23. However, it was correctly done only at 4 patients.  Screening for PA was indicated to 16 of 23 patients as they had arterial hypertension. Nevertheless, it was executed correctly only in 3 patients. Screening for subclinical CS was carried out to 5 of 23 patients. However, it was done correctly only in 2 patients. It should be also referred that endocrinologist consultation did not preceded hormonal assessment in most cases. 17 patients among 23 had CT density lesion more than 10 HU, therefore, contrast CT should have been performed. However, it was done at 10 patients without calculating washout percentage. In all analysed case reports there were no interpretation of CT density in connection with indications for adrenalectomy. The most predominant indication for operation was the lesion size. The second was the presence of hormonal activity. In accordance with results received, it may be concluded that there is a dual adherence to diagnostic protocol for AI by urologists. On the one hand, hormonal and imaging assessment was preformed. However, on the other hand, it was not completely correct. In our opinion, it might indicate that AI is not being considered as urologic pathology. Since urologists operate many patients with AI, it might be useful to create combined clinical guidelines by endocrine and urologic associations in order to underline that AI are as endocrine as urologic pathology.

 

Nothing to Disclose: MA, NV, SD, ID, IR, ID

16833 18.0000 SAT-0815 A Adherence to the Diagnostic Protocol for Adrenal Incidentalomas By Urologists 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Christiane Gruetzmacher1, Marilena Nakaguma*2, Mirela Costa de Miranda3, Livia Mara Mermejo4, Margaret Castro5, Gabriela Resende6, Antonio M Lerario7, Berenice B Mendonca8, Ana Claudia Latronico9, Sonir Roberto Antonini10, Madson Q. Almeida11 and Maria Candida B V Fragoso12
1Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, São Paulo, Brazil, 2Hospital das Clinicas, University of São Paulo Medical School, São Paulo, SaoPaulo, 3Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Sao Paulo, Brazil, 4Centre hospitalier de l'Universite de Montreal, Montral, QC, Canada, 5R, 6Hospital das Clínicas, University of Sao Paulo Medical School, 7ICESP/University of Sao Paulo, São Paulo, Brazil, 8Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular LIM/42, Disciplina de Endocrinologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, 9Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 10Ribeirão Preto Medical School - University of São Paulo, Ribeirão Preto, Brazil, 11Hospital das Clínicas & Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 12University of Sao Paulo, Sao Paulo-SP, Brazil

 

The specific p.R337H TP53 germline mutation in adults with adrenocortical carcinoma

Christiane Gruetzmacher1 MD, Marilena Nakaguma1 MD, Mirela C de Miranda1 MD, Livia Mermejo2 MD PhD, Margaret de Castro2 MD PhD, Gabriela Resende1 MD PhD, Antonio M Lerario1 MD PhD, Berenice B Mendonca1 MD PhD, Ana Claudia Latronico1 MD PhD, Sonir R R Antonini2 MD PhD, Madson Q Almeida1 MD PhD, Maria Candida B V Fragoso1 MD PhD

Adrenal Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of Sao Paulo Medical School1,2, Sao Paulo1, Ribeirao Preto2, Brazil

Background: The incidence of pediatric adrenocortical tumors (ACTs) is notable in Southern Brazil, due to a high frequency of a specific germline mutation (p.R337H) of the TP53 gene. This specific mutation was identified in 78% of children with pediatric ACT. Aim: To evaluate the prevalence of p.R337H germline mutation in an adult cohort of ACC patients from southeastern Brazil, describing the clinical features and outcomes. Methods: A retrospective chart review of 51 ACC patients seen at São Paulo University in São Paulo and Ribeirão Preto from 1990-2013 was performed. We specifically reviewed information regarding personal and family history of cancer, age of diagnosis, tumor size, Weiss score, ENSAT stage and outcomes. Germline p.R337H TP53 mutations were studied in all these patients either by RFLP or by sequencing analysis. Results: Nine out of 51 patients (17.6%) harbored the p.R337H germline mutation. The median age at diagnosis was 26.7 years. The ENSAT stage was II (2/9); III (3/9); IV (4/9), and Weiss score 3 (1/9), 6 (1/9), 7 (2/9), 8 (2/9) and 9 (3/9). Tumor sizes ranged from 6.5-20 cm (mean 12.93 cm). The majority of patients presented Cushing’s syndrome isolated or associated to virilization except for one non-functioning tumor. All except one patient had no personal or family history of other cancers. This patient had a strong family history for breast cancer, consistent with Li Fraumeni-like syndrome. All patients who underwent a complete surgical resection presented a recurrence after 6 to 12 months. Seven patients died from progressive disease after a median time of 16.2 months. Conclusion: We identified a low frequency (17.6%) of p.R337H germline mutation in adult patients with ACC from Southeastern Brazil. The p.R337H mutation in this group was associated with a dismal prognosis.

 

Nothing to Disclose: CG, MN, MCDM, LMM, MC, GR, AML, BBM, ACL, SRA, MQA, MCBVF

16839 19.0000 SAT-0816 A The Specific p.R337H TP53 Germline Mutation in Adults with Adrenocortical Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Antonio M Lerario*1, Francis P Worden1, Carole Andrea Ramm1, Elizabeth A Hasseltine1, Walter M Stadler2, Manisha H Shah3, Edem Agamah4, Krishna Rao5 and Gary D Hammer1
1University of Michigan, Ann Arbor, MI, 2University of Chicago, 3The Ohio State University Comprehensive Cancer Center, Columbus, OH, 4Central Illinois Hematology Oncology Center, Springfield, IL, 5Southern Illinois University School of Medicine, Springfield, IL

 

Background: Adrenocortical carcinoma (ACC) is an aggressive malignancy, which lacks an effective systemic treatment. In recent years, molecular-targeted therapies have been proposed as therapeutic options for different types of cancer. In ACC, the activation of the IGF system is the most frequent molecular abnormality, suggesting that insulin-like growth factor receptor 1 (IGF1R) would be an interesting therapeutic target. Preclinical data have shown that pharmacological inhibition of IGF1R signaling in ACC cells significantly reduces proliferation and enhances apoptosis and also potentiates mitotane cytotoxic effects. A previous phase I trial with an IGF1R inhibitor has demonstrated biological activity against ACC. Aims: The aim of this study was to assess efficacy of the combination of IMC-A12, a monoclonal antibody that targets the IGF1R, in association with mitotane as a first-line treatment for advanced ACC. Methods. This study was designed as a randomized double-arm phase II trial and consisted of an initial single-arm phase for safety evaluation with IMC-A12 + mitotane, followed by the randomization phase, which included two treatment groups: IMC-A12 + mitotane and mitotane alone. IMC-A12 was dosed at 10mg/kg intravenously as a single one-hour infusion every two weeks. The starting dose for mitotane was 2 grams orally on a daily basis, either in single or divided doses. Dose adjustments were based on symptoms and serum levels (to attain a serum concentration of 14 to 20 mg/dL). The primary end-point was progression-free survival (PFS) according to Response Evaluation Criteria in Solid Tumors (RECIST) criteria. Results. This study was terminated before the randomization phase due to slow accrual and limited efficacy. Therapeutic effects were observed in 8/20 patients, including one partial response and 7 stable diseases (SD). The median for PFS was 6 weeks (range 6 – 48). The median duration of SD was 12 weeks (range 12 – 48). Toxic events included two grade 4 (hyperglycemia and hyponatremia) and one grade 5 (multiorgan failure). Conclusion. Although the regimen demonstrated activity in some patients, the relatively low therapeutic efficacy precluded further studies with this combination of drugs.

 

Nothing to Disclose: AML, FPW, CAR, EAH, WMS, MHS, EA, KR, GDH

16888 20.0000 SAT-0817 A The Combination of Insulin-like Growth-Factor Receptor 1 (IGF1R) Antibody Cixutumumab and Mitotane As a First-Line Therapy for Patients with Recurrent/Metastatic Adrenocortical Carcinoma: A Multi-Institutional NCI-Sponsored Phase II Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0798-0817 4775 1:00:00 PM Adrenal Tumors: ACC & Incidentaloma Poster

Perie Adorable-Wagan*
The Medical City, Pasig City, Philippines

 

Bilateral small adrenal glands in a patient with pulmonary tuberculosis

Perie Adorable-Wagan, MD, FPCP1, Mary Queen Villegas-Florencio, MD, FPSEM2 , Hilario Tamondong, MD,FPCCP3

Fellow in training1, Consultant Endocrinologist2, Section of Endocrinology and Metabolism,  Pulmonologist, Section of Adult Pulmonology3,  The Medical City Hospital, Ortigas Avenue, Pasig City, Philippines

Background

Usual  CT scan findings  of patients with acute PTB have enlarge adrenals with or without calcification, while chronic PTB have smaller adrenal glands, mostly unilateral and rarely bilateral. We report a  not so common finding of  PTB patient with primary adrenal insufficiency having bilateral small adrenal glands on CT scan.

 

Clinical case

A 47 year old male with Type 2 DM,  with a 5 year history of  Pulmonary tuberculosis,   presented with generalized body weakness,  vomiting and  progressive weight loss over 1 month.  Laboratory tests showed hyponatremia at Na 118 mmol/L and K 3.60 mmol/L. Thyroid function test were normal. His serum baseline cortisol level  was low at 0.7ug/dL, and elevated ACTH of 86 pg/ml. (0-46 pg/ml). ACTH stimulation using 250 mcg IV test showed inadequate cortisol response of  2.10 ug/dL and 2.20 ug/dL at 30 and 60 mins post ACTH respectively. A Chest xray showed   PTB with cavitary lesion. He was given Hydrocortisone 30mg/day and Fludrocortisone 0.1mg/day.

 Since test for adrenal autoantibodies are not available in the Philippines, information obtained by CT scan is important in the etiological diagnosis of Addison’s disease. A CT scan of the abdomen with IV contrast showed the adrenals are small   with the right measuring approximately 2cm in length and the left measuring 3 cm in length. No focal lesions, no abnormal enhancement or calcification seen.  Studies show that  patients with active pulmonary tuberculosis did not show evidence of adrenal cortical insufficiency (York, 1992, Barnes,1989). Kelestimur  evaluated  radiological findings of PTB  patients and the size of adrenal glands on CT scan. He observed that adrenal glands are enlarged on CT scan while small glands generally indicate either idiopathic atrophy or long-standing tuberculosis (Kelestimur, 1994).  Standard TB therapy includes Rifampicin a potent hepatic enzyme inducer that contribute to adrenal insufficiency by accelerating the catabolism of cortisol. (Venter, 2006).

Conclusion: While some of the studies showed normalization of the adrenal function following treatment of anti-TB drugs  others have contradicted it. In this case, both adrenal glands are small.  It is prudent to re-evaluate this patient if there is recovery of adrenal function upon completion of anti-TB treatment. Close follow up is required to prevent an adrenal crisis.

(1.)Kelestimur, F., Unlu, Yalcin. A hormonal and radiological evaluation of adrenal gland in patients with acute or chronic pulmonary tuberculosis. Clinical Endocrinology (1994) 41, 53-56.

 

Nothing to Disclose: PA

13260 1.0000 SAT-0747 A Bilateral Small Adrenal Glands in a Patient with Pulmonary Tuberculosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Mohammed Ahmed*
King Faisal Spec Hosp/Res Ctr, Riyadh, Saudi Arabia

 

Introduction

Adreanleukodystrophy(ALD) is X-linked disorder of peroxisomal fatty acid ß-oxidation resulting in abnormal accumulation of very long chain fatty acids (VLCFA). It is caused by mutations in ABCD1 gene, located at Xq28, that encodes ABC transporter. The  transporter helps transloate VLCFA into the peroxisome. ABCD1 mutations prevent normal transport of VLCFA into peroxisomes, thereby preventing  ß-oxidation. ALD is a heterogamous disorde.The most severely affected tissues are adrenal cortex , testicular Leydig cells & myelin in CNS. ACTH levels are often increased during early life. VLCFA levels are elevated in 99.9% males w/ ALD of all ages . The parameters analyzed are: concentration of C26:0,C 24:0, ratio of C26:0/C22:0 & C24:0/C22:0.

Objective:I present an asymptomatic familial case diagnosed early in life w/ adrenal insufficiency & early brain abnormalities detected on MRI. Definitive treatment using bone marrow transplant (BMT) was instituted. Long-term FU revealed arrest of disease process associated w/ substantial decline in levels of VLCFA , regression of abnormal brain MRI findings, & preserved testicular function.  

Case Report: A 2-yr. old asymptomatic male had lost 2 brothers from ALD. Pt. was 10th percentile for height & weight, had no history of seizure disorder, had normal  neurological, ophthamological, & audiolgy findings . Lab findings: Normal EEG, serum AM cortisol 239 nmol/l, (RR: 170-356), elevated serum AM ACTH 144 ng/l (RR: 5-60 ng/l), & abnormal synacthen test. GC/MS analysis repeated x2 revealed abnormally increased  VLCFA profile  (values expressed in ug/ml) C26:0 1.406 (RR: 0.256+/- 0.08), C24:0: 12.45:(RR:0.12+/- 0.01), an abnormal ratio for VLCFA/LCFA profile: C26/C22: 0.248 (RR: 0.019+/- 0.007), C24/C22: 2.196. MRI Brain: minimal increased signal intensity involving bilateral peritrigonal regions  consistent w/ early changes of ALD but findings had progressed a year later.

Clinical Course: Treatment consisted of Hormonal replacement using hydrocortisone & florinef, followed later using allogeneic BMT. Serum VLCFA improved w/ C26 declining to 0.544. MRI brain done 2 years post BMT showed substantial improvement & no additional lesions seen compared to previous year. At age 15 years pt. developed normal puberty w/ serum testosterone of 23.67 nmol/l (RR: 9.9-27.8), normal LH & FSH. However, pt. has developed Nelson’s syndrome, serum ACTH increased to 248, & MRI showed 7x 4 mm centrally located lesion. A progressive increase in ACTH level to 2594 warranted  increase in hyrdocortisone dose to 5 mg tid w/ a decline in ACTH to 29.   

Conclusions: A combination of classical clinical features coupled w/ abnormal plasma levels of VLCFA  is sufficient to establish the Dx of X-ALD. ACTH levels are often increased  during early life, & should alert to early Dx. Definitive treatment using bone marrow transplant offers a promising approach towards disease arrest.

 

Nothing to Disclose: MA

13711 2.0000 SAT-0748 A Inherited Neuroendocrine Peroxisomal Disorder Involving Abnormal Very Long Chain Fatty Acids Metabolism: Long-Term Follow up after Allogeneic Bone Marrow Transplant 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Alicia Algeciras-Schimnich*, Hemamalini Ketha, J Paul Theobald and Alice Y Chang
Mayo Clinic, Rochester, MN

 

Background: Interference in immunoassays is a rare event but a potentially clinically significant problem when it leads to additional diagnostic tests and inappropriate treatments. Previous reports identified falsely elevated ACTH concentrations due to heterophile antibodies and misdiagnosis of Cushing’s disease. We describe a case of misdiagnosed primary adrenal insufficiency that required evaluation beyond commercially available heterophile antibody blocking reagents.

Case: An 18 year old male, presented to the Endocrinology department for evaluation of primary adrenal insufficiency. Prior clinical history included growth hormone deficiency and delayed puberty in the context of secondary hypogonadism. During routine annual evaluation with his local endocrinologist, he was diagnosed with primary adrenal insufficiency based on a noon ACTH concentration of 156 pg/mL and a cortisol concentration of 3.9 μg/dL. The patient was treated with hydrocortisone (20 mg am, 10 mg pm). Patient presented for a second opinion because he was asymptomatic at the time of diagnosis. He denied any weight loss, nausea, fatigue and had no evidence of hyperpigmentation on exam. Baseline 8am cortisol (more than 24 hours from the last hydrocortisone dose) was 8.6 μg/dL (reference interval 7-25 μg/dL) and ACTH was 89 pg/mL (reference interval 10-60 pg/mL). Cortisol concentrations after cosyntropin stimulation were 19 and 22 μg/dL at 30 and 60 minutes, respectively. To investigate possible interference in the Siemens Immulite ACTH immunoassay, ACTH measurements were performed after serial dilutions. ACTH concentration was 83 pg/mL (non-diluted), 200 pg/mL (1:5), 280 pg/mL (1:10) and 420 pg/mL (1:20). This nonlinear response indicated an analytical interference affecting the Siemens Immulite ACTH immunoassay. The analytical interference could not be resolved using heterophile antibodies blocking reagents (Scantibodies Laboratories, Inc.).  ACTH concentration measured using the Roche Elecsys immunoassay was 8.9 pg/mL. With the clinical assessment otherwise arguing against adrenal insufficiency and evidence for a falsely-elevated ACTH, the patient was tapered off the hydrocortisone successfully without any difficulty.

Conclusion: In cases where the clinical presentation is inconsistent with the diagnosis of primary adrenal insufficiency, an analytical interference in the ACTH immunoassay should be considered and may need to be evaluated beyond standard heterophile antibody assessment.

 

Nothing to Disclose: AA, HK, JPT, AYC

15486 3.0000 SAT-0749 A Interference in the Siemens Immulite ACTH Immunoassay Leading to Misdiagnosis of Primary Adrenal Insufficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Fatima Al Kaabi*1, Nagi Mohammed2 and Muhammad Houri3
1AL Ain Hospital, Al Ain, United Arab Emirates, 2ICLDC, AlAin, 3Al Ain Hospital, Al Ain, United Arab Emirates

 

Introduction  

          The autoimmune polyglandular syndromes (APS) include a wide spectrum of autoimmune disorders involving multiple organs. Clinicians should suspect this diagnosis in patients who have multiple autoimmune disorders especially the rare ones like hypoparathyroidism. The time lag between different manifestations could be years. So follow up is crucial.

Case: 25-year-old female student had ( APS-1) diagnosed in adulthood. Her initial presentation was at age 7 with symptomatic hypocalcemia related to primary hypoparathyroidism, followed by alopecia and recurrent mucocutaneous candidiasis. Few years later, she developed primary hypothyroidism. Up to this point the diagnosis of APS was still not made.

She presented to our hospital in January 2012, with fatigue, nausea, vomiting hyperglycemia and dehydration. Physical exam was remarkable for signs of dehydration and chronic nail changes. She had no hyperpigmentation

Diabetic ketoacidosis was diagnosed and treatment initiated.

Because of past medical Hx, Adrenal insufficiency (AI) was suspected and confirmed by short Synachten test. Basal cortisol 10 nmol/l   (0.36 mcg/dl) after synacthen 250 mcg IV, cortisol was   256 nmol/L and   189 nmol/L at 30 and 60 minutes respectively. Baseline ACTH <0.03  ( normal range<= 14.0 Pmol/L) Pituitary MRI was unremarkable.

She was discharged in stable condition on  hyrodcotisone and insulin.

Few weeks later, a pulmonologist advised her-by error- to taper hydrocortisone down to 5 mg daily. Within days she presented with symptoms and signs of impending adrenal crisis, potassium was 5.3 mmol/l .Alsosterone  0.05 ( normal range 0.08-0.44 nmol/L)   Renin > 230.40 milli IU/L  (  normal range 7.00-42.60 )  and ACTH   was elevated at 25 pmol/l consistent with a diagnosis of primary AI.

Currently she is on  Prednisolone,Fludrocortisone, Levothyroxine and Aspart via insulin pump with HbA1c of 6.6 % .

Discussion:

Our patient presented with DKA and Addison’s disease to complete the spectrum of APS type I. The initially low ACTH, was likely a result of mishandled specimen . Even though she had four different manifestation of APS in childhood, APS was not suspected.

(APS1), also known as the autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) syndrome, is a rare autosomal recessive disorder and it is appears to be due to mutations in (AIRE) gene. Diagnosis of APS involves serological measurement of organ-specific autoantibodies and functional testing. Treatment is based on supplementation of the various deficiencies. Clinicians should have high level of suspicion of this disease when patient present with more than one autoimmune manifestation espicially rare ones. For Instance patients who have autoimmune hypoparathyroidism should be monitored for and counseled about the possibility of other endocrinopathies.

 

Nothing to Disclose: FA, NM, MH

17035 4.0000 SAT-0750 A Autoimmune Polyglandular Syndrome Diagnosed 18 Years after the Initial Presentation of Hypoparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Jamil bawerjan Alkhaddo*1, J. Bruce Redmon2, Ameer Khowaja3 and Asad Saeed4
1University of Minnesota, Minneapolis, MN, 2Univ of MN Med Sch, Minneapolis, MN, 3Hennepin County Medical Center, Minneapolis, MN, 4Univ of Minnesota, Minneapolis, MN

 

78 years old Male diagnosed with 46 XX Disorder of Sex Development (DSD) due to Congenital Adrenal Hyperplasia (CAH), presented with Adenocarcinoma of Cervix

Introduction

46 XX Disorder of Sex Development (DSD) due to congenital adrenal hyperplasia (CAH) is a rare condition with wide spectrum of phenotypic manifestation from ambiguous genitalia to complete virilization. It is usually diagnosed during childhood. We present a case of 46 XX DSD due to CAH diagnosed at age of 78 years in a phenotypic male.

Clinical Case

78 year old male presented with symptoms of hematuria, increase frequency and hesitancy. He was diagnosed with UTI and sepsis. He required mechanical ventilation and pressors for hemodynamic support. A transurethral urinary catheter placement was attempted but failed, a bed side cystoscopy showed obliterated bulbar urethra.  

He had been married but did not father any children. He subsequently underwent a CT and alter a MRI of abdomen and pelvis, that showed rudimentary vagina and a Uterus was visualized too, alongwith 11.3x17x13 cm pelvic mass causing mass effect.  A 4.2 cm heterogeneous cystic structure was found on left lateral aspect, consistent with cystic ovary. A bilateral adrenal masses seen too, measuring 8.2 cm on right and 14.5 cm on left.

Karyotype analysis was done using Fluorescent In Situ Hybridization (FISH) method, which showed 97 % cells with 46 XX Karyotype. SRY gene was not detected.

After his recovery, his adrenal hormonal profile showed ACTH: 189 pg/mL (10 – 47 pg/mL), 17 OH Progesterone: more than 9000 ng/dL (20 – 190 ng/dL), morning cortisol: 8.2 µg/dL (4 – 22 µg/dL), DHEA – sulfate: 583 µg/dL (80 – 560 µg/dL) and estradiol: 92 pg/mL (6 – 50 pg/mL).

He was diagnosed with 46 XX DSD due to CAH, 21 hydroxlase deficiency. He subsequently underwent resection of pelvic mass. Surgical pathology showed moderately differentiated cervical adenocarcinoma originating from endocervix. Bilateral ovaries and fallopian tubes were also resected. Intraoperative core needle biopsy of right adrenal gland did not show evidence of adrenal malignancy.

Currently he is undergoing radiation treatment with adjuvant chemotherapy with cisplatin followed by 5-fluorouracil.  

He wished to continue to live as a male.

Conclusion

This is a rare case 46 XX DSD due to CAH diagnosed at late age of 78 years. He had a diagnosis of cervical adenocarcinoma, non- HPV related. It is of paramount importance that individuals with 46 XX DSD due to CAH receive endocrine (for appropriate hormone replacement) and surgical cares (resection of internal genitalia considering the risk of malignancy). Psychological and social support is also crucial in order to maintain quality of life. If diagnosed early in life then issues related to gender assignment need to be addressed as well.

 

Nothing to Disclose: JBA, JBR, AK, AS

11928 5.0000 SAT-0751 A 78 Years Old Male Diagnosed with 46 XX Disorder of Sex Development (DSD) Due to Congenital Adrenal Hyperplasia (CAH), Presented with Adenocarcinoma of Cervix 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Mohammed Almehthel1, Ebtesam Qasem2 and Ali Saeed Alzahrani*2
1King Faisal Specialist Hosp & Research Centre, Riyadh, Saudi Arabia, 2King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia

 

Background: Congenital adrenal hyperplasia (CAH) due to 17-alpha-hydroylase (CYP17A1) deficiency is a rare autosomal recessive disorder.  Several CYP17A1 gene mutations have been reported (1, 2).  We report here a case of a young “female” who has this condition.

Case: An 19-year-old patient, raised as a female, presented with delayed puberty. She was a product of full term, spontaneous vaginal delivery without any complications; particularly there was no history of neonatal crisis. Her childhood and adolescence were uneventful. She presented with primary amenorrhea and lack of secondary sexual characteristics.  She has never been told to have hypertension of hypokalemia. Parents are first-degree relatives and she has 5 sisters who all achieved puberity by age 13 years. Physical examination was remarkable for BP of 136/99 mmHg and Tanner I breasts. She has scant axillary and pubic hair. Genital exam showed female external genitalia with small blind vaginal pouch. No clitromegaly and no palpable gonads in the pubic or inguinal areas. She has no alopecia or acne.  Laboratory investigations are remarkable for the following(normal values are presented between the brackets): K 2.3 mmol/L (3.5-5.0), CO2 33 mmol/L (22-30), ACTH 124 ng/L (5-60), AM cortisol 154 nmol/L (low normal), peak cortisol after ACTH stimulation was 225 nmol/L (expected >550 nmol/l), renin <0.5 mU/L, Aldosterone 384 pmol/L (normal), deoxycorticosterone 829 ng/dL (3.5-11.5) , 17-hydroxyprogesterone <0.4 nmol/L, DHEAS 0.13 µmol/L (1.8-8.3), testosterone < 0.08 nmol/L, DHT <50 pg/mL, 11-deoxycortisol <5 ng/dL, Estradio 25 pmol/L and progesterone 33 nmol/L. Karyotyping 46XY. MRI of pelvis showed no uterus, cervix or ovaries with distal vagina and bilateral inguinal oval-shaped structure which could represent bilateral undescended testes.

Molecular studies:DNA was extracted from peripheral leucocytes using Puregene DNA extraction kit.  Primers and PCR conditions to amplify the 8 exons and the exon-intron boundaries of the CYP17A1 gene were previously described (3). The PCR products were purified and directly sequenced. 

Results: A biallelic homozygous mutation changing guanine to adenine in exon 8 (c.G1247A) and changing the codon 416 from CGT to CAT resulting in a substitution of arginine with histidine (R416H).  This mutation was previously described in a patient with CYP17A1 deficiency in a heterozygous form as part of a compound heterozygous mutation with another heterozygous mutation in exon 2 (R125Q) but has never been described as an isolated homozygous mutation. It was previously functionally characterized and was shown to abolish the activity of the CYP17A1.    

Conclusion: We present a case of CAH with clinical and laboratory investigations consistent with 17-alpha-hydroxylase deficiency which was confirmed by genetic testing showing a mutation in CYP17A1 gene (R416H) that has never been described in a homozygous form.

 

Nothing to Disclose: MA, EQ, ASA

14913 6.0000 SAT-0752 A Congenital Adrenal Hyperplasia Due to a Previously Undescribed Homozygous Mutation in 17-Alpha-Hydroylase (CYP17A1) Gene 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Maria Sonia Baquedano*1, Sabrina Madjinca1, Paula Aliberti1, Nora Isabel Saraco2, Diana M. Warman3, Marco A. Rivarola1 and Alicia Belgorosky1
1Garrahan Pediatric Hospital, Buenos Aires, Argentina, 2Hospital de Pediatria Garrhan, Buenos Aires, Argentina, 3Hospital de Pediatria Garrahan, Buenos Aires, Argentina

 

17-Hydroxyprogesterone (17OHP) can be converted to DHT via the backdoor pathway without the intermediacy of testosterone. This is a major route to DHT in pathological states in which 17OHP accumulates, including 21-hydroxylase (21OH) and POR deficiencies. However, the relevance of the backdoor pathway to human adrenal physiology is unknown.

Adrenal tissue from a 7 year-old 21OH-deficient patient resistant to hydrocortisone replacement therapy (21OHD-Res), but responsive to high doses of dexamethasone, and normal human adrenal tissues (HAT) were collected from 3 postnatal age groups (Grs): Gr1: <3 months, n=9, fetal zone involution; Gr2: 3 months to 6yr, n=9, pre-adrenarche; and Gr3: >6 to 20yr, n=8, post-adrenarche period.

By quantitative real-time RT-PCR, Gr3 mRNA levels (mean±SD, arbitrary units) of AKR1C1 (1.86±0.64) and AKR1C2 (1.89±0.50) were similar to GR2 but higher (p<0.05) than in GR1 (1.14±0.39 and 1.13±0.32, respectively). AKR1C3 mRNA in Gr3 (3.06±0.78) was higher than in Gr1 (2.00±0.67) and Gr2 (1.24±0.54), p<0.05. SRDA1 and RoDH mRNAs were readily amplified from HAT without difference among age Grs. SRDA2 and AKR1C4 mRNA were undetectable in the three age Grs. In all cases, mRNA expression from 21OHD-Res (AKR1C1, 1.74±0.09; AKR1C2, 1.78±0.09; AKR1C3, 2.99±0.12; SRDA1, 2.47±0.16 and RoDH, 1.8±0.08) was within the ±2SD range of Gr3 HAT. Laser capture microdissection of zona reticularis (ZR) and zona fasciculata (ZF) from Gr3 HAT showed no differences in adrenal zone-specific backdoor enzyme expression, except for a higher ZR expression of AKR1C1 and AKR1C3.  

AR mRNA was expressed in micro-dissected ZR (1.22±0.11) and ZF (1.11±0.26) without differences among the 3 age Grs (Gr1, 1.70±0.32; Gr2, 2.12±0.22; Gr3, 2.02±0.21). AR protein expression was confirmed by immunofluorescence. Impaired 21OHD-Res AR mRNA expression (1.22±0.04), below -2SD of HAT Gr3 expression was observed.

These results indicate that postnatal HAT would express all enzymes needed to complete the steps in the backdoor pathway to DHT. The reported activation of the backdoor pathway in 21OHD seems not to be due to a transcriptional activation of the pathway enzymes, suggesting that it might only be related to an excess of the 17OHP substrate. These data support a physiological role of the backdoor pathway in the postnatal human adrenal cortex. Finally, our data might suggest that proper activation of AR signaling is required to control adrenal cortex sensitivity to ACTH in 21OHD. 

 

Nothing to Disclose: MSB, SM, PA, NIS, DMW, MAR, AB

15076 7.0000 SAT-0753 A Postnatal Expression of Androgen Receptor (AR) and the Alternative “Backdoor” Pathway to Dihydrotestosterone (DHT) in Normal and 21-Hydroxylase Deficient Human Adrenal Cortex 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Boonchai Boonyawat*1, Nawaporn Numbenjapon1, Piriya Chantrathammachart1 and Voraluck Phatarakijnirund2
1Phramongkutklao Hospital, Bangkok, Thailand, 2Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand

 

Background: Adrenal hypoplasia congenita (AHC) is a rare inherited disorder of adrenal development resulting in hypoplasia of adrenal gland and inability to produce glucocorticoids, mineralocorticoids and sex steroids.. The most prevalence form is an X-linked AHC caused by mutation of the DAX1 gene on chromosome Xp21. Most of X-linked AHC patients present with skin hyperpigmentation and salt losing crisis. To date, almost 200 mutations in the DAX1 have been identified but no data was available in Thailand. Here we report a case of 4-year-old Thai boy with X-linked AHC, the first case of genetically confirmed novel DAX1 mutation in Thailand.

Clinical case: A 4-year-old Thai boy presented with fever and vomiting for 3 days. He was the first child of unrelated parent. Birth history revealed an uneventful pregnancy and delivery. Birth weight was 3,200 gm. The past medical history was unremarkable except his skin progressively more pigmented since early infancy. Physical examination revealed normal vital signs, no dysmorphic feature with normal genital development and addisonian hyperpigmentation which prominent at skin crease, gum and knuckles. Laboratory investigations showed hyponatremia (Na 128 mmol/L), hyperkalemia (K 5.2 mmol/L), and hypochloremia (Cl 94 mmol/L).  Hormonal evaluation revealed low baseline cortisol level (0.89 mg/dL) which is not rising after 250 mg ACTH stimulation test. ACTH level was very high (13,270 pg/mL) as well as plasma renin activity (470 ng/dl/hr). Aldosterone and 17-hydroxyprogesterone levels were normal. The karyotype was 46,XY. A diagnosis of X-linked AHC was established. Glucocorticoid and mineralocorticoid replacement therapy were initiated.

Mutation analysis by direct DNA sequencing of all 2 coding exons and exon-intron junction of the DAX1 gene revealed a novel hemizygous GG deletion (c.1148_1149delGG; codon 383). This frameshift mutation resulted in a premature termination codon at the position 387 and was predicted to encode a truncated DAX1 protein missing a portion of ligand binding domain. Molecular analysis from all other family members revealed only a heterozygous for the same mutation in the mother, indicating that the mutation found in the index case was inherited from his carrier mother.

Conclusion: We report a case of X-linked adrenal hypoplasia congenita with established a novel hemizygous frameshift mutation in the DAX1 gene. Mutation analysis is important not only for diagnostic confirmation in the index case but also for carrier detection in his mother which provided a proper management and appropriate genetic counseling for this family.

 

Nothing to Disclose: BB, NN, PC, VP

15803 8.0000 SAT-0754 A Novel Dax-1 Mutation in a Thai Boy with X-Linked Adrenal Hypoplasia Congenita (AHC): A First Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Karla Cristina Borromeo Detoya*1, Daniela Ciltea2, Dylan Timberlake3 and Nairmeen A Haller4
1Akron General Medical Center, Cleveland Clinic Affiliate, Akron, OH, 2Akron Gen Prtnrs Physician Grp, Akron, OH, 3Northeast Ohio Medical University, 4Akron General Med Ctr, Akron, OH

 

Introduction: Autoimmune Polyglandular Syndrome (APS) is a rare condition involving multiple endocrinopathies and associated autoimmune disorders. It is preceded by adrenal failure in almost 50% of cases.  Takotsubo Cardiomyopathy (TCM) is a disorder with a poorly understood pathogenesis, leading to transient dysfunction of the middle segments/apex of the left ventricle and subsequent apical systolic dilatation.  We report a case of APS type II in a 65-year-old female with recent history of TCM. 

Clinical Case:  A 65-year-old female diagnosed with TCM based on cardiac catheterization consulted seven months later for progressive and chronic fatigue, hair loss, nail problems, insomnia, eczema and multiple hypopigmented patches.  She was being maintained on hormone replacement therapy for hypothyroidism (TSH at 33.3 uIU/mL, n 0.358- 3.74 uIU/mL; free T4 at 0.37 ng/dL, n 0.82-1.77 ng/dL).  Workup revealed thyroid peroxidase antibodies (51 IU/mL, n <35 IU/mL) present and was unremarkable for other autoimmune antibodies (anti-thyroglobulin, anti-tissue transglutaminase, anti-cardiolipin, anti-phosphatidylserine, anti-glutamic acid decarboxylase, anti-islet cell, and anti-21 alpha hydroxylase antibodies). ACTH (17 pg/mL, n 6-50 pg/mL) and DHEAS (75 ug/dL, n <146 ug/dL) were both normal. Despite the sensitivity of anti-21 alpha hydroxylase antibody testing, negative results have been documented in diagnosed cases of Addison’s disease. Thus, confirmatory cosyntropin stimulation test was performed and result suggested primary adrenal insufficiency (baseline cortisol at 1.7 ug/dL, 30 minute cortisol at 11.0 ug/dL, 60 minute cortisol at 13.6 ug/dL; n baseline cortisol at least 5 ug/dL, increase in 30 minute cortisol at least 7 ug/dL, 60 minute cortisol at least 18 ug/dL). Autoimmune Polyglandular Syndrome was  suspected based on symptomatology, laboratory findings of  hypothyroidism, primary adrenal insufficiency and recent clinical findings consistent with dermatomycosis.  The patient was then started on hydrocortisone, with good response to treatment.

Conclusion: This is a case of TCM with hypothyroidism,presenting with clinical and laboratory findings consistent with APS II.  Three other cases of APS with concomitant TCM have been reported.  While TCM is currently of unclear etiology, if related to APS it may be an early sign of the latter disease, as seen in this case.  One plausible theory argues that TCM may be triggered by potentiated catecholamine release in APS II due to ACTH stimulation.  Other authors cited possible hormonal preconditioning combined with the patient being in distress as factors contributing to the coexistence of these two diseases.  This case report supports the possibility that APS II and TCM may share common pathogenetic pathways which may include autoimmunity, hormonal factors, and genetic factors.  Further studies are recommended to establish correlation.

 

Nothing to Disclose: KCBD, DC, DT, NAH

16103 9.0000 SAT-0755 A Autoimmune Polyglandular Syndrome II in a Patient with Takotsubo's Cardiomyopathy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Mohamad Eid*1, Swathi Sridhar Sangli2, Erwyn Chua Ong3 and Adrienne M. Fleckman4
1Beth Israel Medical Center, 2Beth Israel Medical Center, New York, NY, 3Mount Sinai Beth Israel, New York, NY, 4Beth Israel Med Center, a Member of the Mount Sinai Health System, New York, NY

 

Introduction

Inhaled glucocorticoid (GC) is the mainstay of treatment for asthma and chronic obstructive pulmonary disease (COPD).  Although the development of iatrogenic Cushing’s syndrome is well known with the use of systemic (oral) GC, little is known with the use of inhaled GC, with the few case reports restricted only to fluticasone and budesonide.  Here we report a first adult case of iatrogenic Cushing’s syndrome due to adverse drug-drug interaction from inhaled mometasone and a concomitant cytochrome P-450 inhibitor.

Case

A 54-year old woman presented with acute kidney injury secondary to multiple medications and dehydration. She was a long-time smoker with COPD on mometasone/formoterol inhaler (Dulera®), and had HIV on tenofovir, raltegravir and darunavir/ritonavir for >10 years. She had developed multiple vertebral fractures, hypertension, impaired glucose tolerance, hyperlipidemia and a recent episode of herpes zoster. Examination was significant for BMI 32 with typical Cushingoid features of facial plethora, “moon facies”, central obesity, abdominal striae, thin arms and legs, bipedal edema with thin blistered skin and multiple bruises on both upper limbs. Laboratory values included a low morning cortisol level (2.9 mg/dL) with undetectable ACTH (< 5 pg/mL). During a prolonged ACTH stimulation test (250 mg Cosyntropin over 12 hours), cortisol rose from baseline 2.55 mg/dL to 28 mg/dL at 7 hours (27.6 mg/dL at 10 hours) consistent with adequate adrenal response. The patient was started on physiologic doses of the short-acting GC hydrocortisone in preparation for adjusting her medications to prevent further iatrogenic Cushing’s syndrome and permitting recovery of the pituitary-adrenal axis.

Discussion

Our patient developed severe unrecognized exogenous Cushing’s syndrome from the concomitant administration of the potent inhaled GC mometasone in conjunction with the Cyp3A4 inhibitor ritonavir. This case demonstrates that it is critical for clinicians (1) to recognize that exogenous glucocorticoids from any route of administration may cause Cushing’s syndrome, with possible adrenal insufficiency on sudden withdrawal; (2) to take detailed drug histories, evaluate the potential for drug-drug interactions when prescribing new medications, and to be aware of interactions with related compounds; (3) to monitor patients on exogenous GC for signs/symptoms of Cushing’s syndrome, and to be aware of the necessity to evaluate patients with COPD and other chronic illnesses who develop rapid/excessive weight gain; and (4) to inform families and take a multidisciplinary approach to prevent complications of systemic side effects.

 

Nothing to Disclose: ME, SSS, ECO, AMF

12119 10.0000 SAT-0756 A Severe Iatrogenic Cushing's Syndrome from Combined Mometasone and Ritonavir: First Adult Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Lauren Brian Hawkins*1 and Cynthia Anne Burns2
1Wake Forest University School of, Winston Salem, NC, 2Wake Forest Univ Hlth Sci, Winston Salem, NC

 

Background: Disseminated Cryptococcosis typically affects immunocompromised patients, most often affecting the CNS and lungs. Very rarely cryptococcus causes adrenal insufficiency. Adrenal disease without evidence of CNS and lung disease is rare.

Clinical Case:We present an atypical case of primary AI secondary to cryptococcal infection without evidence of CNS involvement.

The patient was admitted to the hospital with hypotension, weight loss, and N/V. A 250mcg cosyntropin stimulation test confirmed primary AI: baseline cortisol 1.4 mcg/dL (N 5.5-20.0 mcg/dL), cortisol at 30 minutes 1.8 mcg/dL, cortisol at 60 minutes 1.7 mcg/dL; ACTH 726 pg/mL (N 6.0-50.0 pg/mL). Treatment with hydrocortisone and fludrocortisone was begun.  Antibodies for 21-hydroxylase and adrenal tissue were negative.

Abdominal CT revealed symmetric, diffusely enlarged and thickened adrenal glands.  He was referred to ID for workup of adrenal infection. Serum cryptococcal Ag titer was positive at 1:64.  Testing for HIV was negative.  LP showed normal CSF protein (69 mg/dL, N 15-60 mg/dL), WBC (1/mm3, N 0-5/mm3), and glucose (44 mg/dL, N 50-75 mg/dL). CSF cryptococcal Ag was negative. Blood and CSF fungal cultures were negative. Chest CT showed a focus of lobular nodularity with surrounding groundglass attenuation in the RLL and numerous sub-4mm nodules in the right lung.  Induction therapy with liposomal amphotericin and flucytosine was given. He is currently taking fluconazole 200mg daily for maintenance therapy.

A low CD4 count at 150 (N 310-3,110) was found.  Immunoglobulins were also found to be low, likely secondary to poor T-cell stimulation: IgG 523 mg/dL (N 635-1741 mg/dL), IgA 30 mg/dL (N 70-350 mg/dL), IgM 26 mg/dL (N 70-210 mg/dL). He was referred to Immunology for further workup. He was prescribed weekly SC IG. No cause for his immunodeficiency has been found.

A follow up contrasted abdominal CT seven months after diagnosis showed unchanged adrenal enlargement. There was no contrast enhancement, suggesting no residual functioning tissue. Serum cryptococcal titer most recently is stable at 1:32 after eleven months of treatment

He is followed by Endocrinology, Infectious Disease, and Immunology. He continues hydrocortisone, fludrocortisone, fluconazole, weekly SC immunoglobulin, and PCP and HSV prophylaxis. The fluconazole will be continued indefinitely given his immune deficiency.

Conclusion: This patient’s case is atypical in that Cryptococcus rarely causes primary adrenal insufficiency, and when it does, it is typically associated with cryptococcal meningitis. We could only find three prior case reports of patients with adrenal insufficiency secondary to cryptococcosis without meningoencephalitis. This patient’s case is unique in that his diagnosis of cryptococcosis led to the finding of idiopathic T-cell deficiency and hypogammaglobulinemia, which up to this point had gone undiagnosed.

 

Nothing to Disclose: LBH, CAB

12590 11.0000 SAT-0757 A Disseminated Cryptococcosis Causing Primary Adrenal Insufficiency in a Patient with Idiopathic T-Cell Lymphopenia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Aqueel Usman1, Thanh Duc Hoang*2, Vinh Quang Mai1, Patrick W Clyde1 and K M Shakir1
1Walter Reed National Military Medical Center, Bethesda, MD, 2Naval Medical Center San Diego, San Diego, CA

 

Background: Bilateral adrenal nodules usually require a thorough investigation to rule out underlying disorders that can have significant adverse clinical implications.  Herein we report an elderly male presenting with calcified bilateral macronodules due to non-classic (late onset) congenital adrenal hyperplasia (CAH).

Clinical case: An 80-year-old male was referred for evaluation of adrenal nodules.  Patient had no signs or symptoms of Cushing’s syndrome, pheochromocytoma, or any malignancy.  Review of systems was essentially negative other than unsteadiness and vertigo.  Family history did not reveal any endocrine disorders.  Physical examination showed HR 58 bpm, BP 151/71 mmHg, BMI 20.8, no stigmata for Cushing’s syndrome and normal testicular examination. Laboratory tests: serum testosterone 398 ng/dL, androstenedione 58 ng/dL, DHEA 37 mcg/dL, DHEAS 79 mcg/dL, aldosterone/renin ratio 1.4, 17-OHP 187 ng/dL. Abdominal CT scan showed bilateral adrenal nodules with rim calcifications (right 5.5cm x 4.0cm with HU 20.5, left 2.7 cm x 3.5 cm HU 30). A previous CT scan in 2005 showed bilateral adrenal nodules, right 5.3cm x 4.0cm HU 26, left 5.4cm x 3.6 cm HU 24. Stimulation with 250 mcg of ACTH revealed elevated 17-hydroxyprogesterone 1495 ng/dL at 30 minutes and 1464 ng/dL at 60 mintues, confirming a diagnosis of CAH due to 21-hydroxylase deficiency.  11-deoxycortisol, 17-hydroxypregnenolone and cortisol responses were normal. Peripheral blood gene analysis confirmed heterozygous CYP21A2 mutation (Val281Leu).

Discussion: The differential diagnosis of bilateral adrenal nodules involves granulomatous disease, bilateral pheochromocytoma, bilateral primary aldosteronism, adrenal myelolipoma, adrenal metastases from malignancy elsewhere (1, 2).  Detailed evaluation did not confirm these disorders; and this patient was diagnosed with late onset heterozygous CAH.  It has been suggested that elevated CRH and ACTH may have contributed to adrenal hyperplasia and subsequent formation of adrenal nodules. Adrenal nodules are more common in homozygous than heterozygous patients with CAH although there are some overlaps in 17-OHP responses (2). 

Conclusions: Patients with bilateral adrenal nodules should be evaluated for CAH after excluding other underlying disorders. Additionally gene testing may be useful to confirm the diagnosis in patients with borderline response to ACTH stimulation test.

 

Nothing to Disclose: AU, TDH, VQM, PWC, KMS

11436 12.0000 SAT-0758 A Bilateral Calcified Macronodules in the Adrenal Glands As an Initial Presentation of Congenital Adrenal Hyperplasia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Hebatullah M Ismail*1, Fernanda Delgado2, Catherine Pihoker1 and Anita E Beck1
1Department of Pediatrics, University of Washington, Seattle, WA, 2University of Washington School of Medicine, Seattle, WA

 

Background: Congenital isolated adrenocorticotrophic hormone deficiency (IAD) is a rare disorder that can be difficult to diagnose, and missed diagnosis may result in infant mortality. IAD is caused by homozygous or compound heterozygous TBX19 gene mutations. TBX19 mutations can be uncovered by whole exome sequencing (WES), a relatively new diagnostic tool, even if the diagnosis is not suspected in advance.
Clinical Case: We present a 24-month-old Hispanic child with a lifelong history of multiple endocrine abnormalities without a unifying diagnosis. He was a full term infant with a history of feeding difficulties and hyperbilirubinemia, referred to endocrinology for congenital hypothyroidism identified on the newborn screen. He had been started on levothyroxine at 1 week of age, and was seen at 4 weeks. Physical exam was notable for icteric sclera, and he was found to have conjugated hyperbilirubinemia. Subsequent evaluation revealed low cortisol, and he was started on hydrocortisone. During an acute illness he was hypoglycemic, at which time stress doses of hydrocortisone were administered. He also had low serum growth hormone and elevated insulin levels, therefore growth hormone and diazoxide were prescribed. A comprehensive clinical evaluation was insufficient to explain his clinical findings. However, a single nucleotide polymorphism (SNP) microarray demonstrated long stretches of homozygosity representing about 23% of his genome and raised concern for possible consanguinity with recessive disorders. Subsequent WES revealed a homozygous TBX19 mutation that partially explains his presentation and conditions. The hypothyroidism appears to be transient, and his levothyroxine has been since stopped; growth hormone therapy and diazoxide are gradually being discontinued.
Conclusions: We report on a perplexing case of congenital IAD and highlight the utility of WES to establish a molecular diagnosis in endocrine practice. The use of WES in endocrinology has led to other major advances and discoveries: germline mutations in patients with pheochromocytomas, a de novo heterozygous nonsense mutation in a gene encoding thyroid hormone receptor alpha, an inactivating mutation in KISS1, as well as novel mutations in the imprinted gene MKRN3 that causes central precocious puberty in humans. With more widespread availability and advances in technology, WES will continue to serve as a valuable tool in endocrine research and clinical practice.

 

Nothing to Disclose: HMI, FD, CP, AEB

12511 13.0000 SAT-0759 A An Argument for Application of Whole Exome Sequencing in Puzzling Endocrine Cases 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Inderpreet K Dardi and Serge Jabbour*
Thomas Jefferson University, Philadelphia, PA

 

DAX-1 (NROB1) Mutation with Adrenal Hypoplasia Congenita & Hypogonadotropic Hypogonadism

Inderpreet K Dardi, MD & Serge A Jabbour, MD; Division of Endocrinology, Department of Medicine; Jefferson Medical College, Thomas Jefferson University , Philadelphia, Pennsylvania

Background: X-linked Adrenal Hypoplasia Congenita is a rare disorder in which the adrenal cortex doesn’t develop normally and manifests as primary adrenal failure in early infancy. It is caused by mutations or deletions in DAX-1 (NROB1) dosage sensitive sex reversal, adrenal hypoplasia gene located on short arm of Chromosome X that is Xp21.Tissues of DAX-1 expression are adrenals, gonads, hypothalamus and pituitary gland and is responsible for controlling development and function of these tissues. More than 100 DAX-1 mutations have been described occurring throughout the coding region. Heterozygous females with this DAX-1 mutation are asymptomatic.

 Clinical Case: Mr.KM presented at age 3 weeks when he was noticed to have poor feeding. His sodium was 115mmol/L (135-146 mmol/L) and his potassium was 8.9 mmol/L(3.5-5.3 mmol/L). Subsequent testing revealed an ACTH of 606 pg/ml (9-46 pg/ml), renin activity of 8.56 ng/ml/h (0.25-5.82 ng/ml/h) and undetectable serum cortisol and aldosterone levels. In addition, his 11-deoxycorticosterone and 17-OH-progesterone levels were undetectable. Ultrasound of the abdomen showed no evidence of adrenal tissue. He was started on replacement hydrocortisone and fludrocortisone.

At age 14, he was noted to have delayed puberty. Testing showed FSH of 0.99 mIU/ml (1.5-12.4mIU/ml), LH 0.15 mIU/ml (1.7-8.6 mIU/ml) and testosterone of 22ng/dl (348-1197 ng/dl) with normal prolactin and pituitary MRI, all consistent with hypogonadotropic hypogonadism. DAX-1 mutation was hypothesized and genetic testing was done showing a maternally inherited large deletion of Xp21.2 diagnostic of X-linked Adrenal Hypoplasia Congenita. The patient received androgen replacement with normal attainment of secondary sex characteristics.

Review of his family history indicated the death of his mother’s half-brother with adrenal crisis at age 13 days and death of his maternal grandmother’s brother in early infancy of uncertain etiology. Mr.KM has only one female sibling who tested negative for DAX-1 mutation.

Conclusion: DAX-1 mutation can cause congenital adrenal hypoplasia and usually manifest very early with primary adrenal insufficiency. Most individuals develop hypogonadotropic hypogonadism usually recognized at the time of puberty. Abnormal spermatogenesis with sertoli cell defects is also noted in some patients. Secretion of other pituitary hormones is not impaired.

 

Nothing to Disclose: IKD, SJ

11835 14.0000 SAT-0760 A Dax-1 (NROB1) Mutation with Adrenal Hypoplasia Congenita & Hypogonadotropic Hypogonadism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Tripti Joshi* and Shamasunder H Acharya
John Hunter Hospital, New Lambton, Australia

 

TITLE: A Giant Retroperitoneal Teratoma and Post-Operative Adrenal Insufficiency.

Background: Large retroperitoneal teratomas involving adrenal gland are exceedingly rare.

Clinical case: A 29 year old male with a background of schizophrenia was found to have a large right renal /adrenal mass on CT scan whilst being worked up for hypertension in 2004. He was lost to follow up and represented in 2012 with abdominal discomfort. A repeat CT scan, showed this large and complex mass arising from the right kidney measuring 23 × 23 × 26 cm, encasing the dual renal arteries, causing right urinary tract obstruction. An elective right nephrectomy and removal of the mass was performed through laparotomy and median sternotomy, after consulting multi-disciplinary team.  

The histology was suggestive of a mature teratoma with mucinous borderline proliferation with no secretory component arising from retroperitoneum. There was extensive perirenal fibrosis and necrosis. The right adrenal gland was compressed and trapped in the mass.

He had a complicated post-operative course and was hypotensive requiring vasopressors. Unexpectedly, he was found to have a low cortisol level of 276nmol/L at 0500 hrs. and 302nmol/L at 0800hrs on two separate occasions in the intensive care, which appears to be low for his critical illness.

He received hydrocortisone replacement from 3rdpost –operative day with improvement in his blood pressure.

Repeat cortisol was 205nmol/L with an ACTH level of 19.8pmol/L (RR 0-10). An outpatient short-synacthen test on two occasions found him to be glucocorticoid deficient. The 8 am cortisol was 102 nmol/L with an ACTH level of 5.6pmol/L (RR 0-10) at 0 min followed by a stimulated 60 min level of 206nmol/L. The adrenal antibodies were negative. The renin was 1.3ng/ml/hr. (1.2-2.8), Aldosterone 66 pmol/L (80-1040) with an aldosterone renin ratio of 1.8 (0-30). The 17-hydroxy progesterone was 10.2 nmol/L(<10.3) following synacthen stimulation making classic and non-classic congenital adrenal hyperplasia unlikely.

The tumor markers were negative: AFP 1IU/L (RR<8), HCG <2IU/L (RR <5).

Conclusion: We present a case of large retroperitoneal teratoma involving adrenal gland with post- operative persistent hypocortisolism. Teratomas are not known to be secretory to cause adrenal suppression.

Teratomas are a type of non-seminomatous germ cell neoplasms, arising from pluripotent cells that can differentiate into ectoderm, mesoderm, and endoderm (1). Retroperitoneal teratomas are the least common of the extra-gonadal tumors and involvement of adrenal gland is exceedingly rare. Majority of retroperitoneal teratomas involving adrenal gland are asymptomatic, benign and present as an incidental finding and 6% of retroperitoneal teratomas are malignant. Surgical excision is recommended for symptomatic relief and malignant potential (2).

 

Nothing to Disclose: TJ, SHA

11525 15.0000 SAT-0761 A A Giant Retroperitoneal Teratoma Post-Operative Adrenal Insufficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Melvin Kok Seng Lee* and Cherng Jye Seow
Tan Tock Seng Hospital, Singapore, Singapore

 

Introduction:

Licorice is a known cause of hypokalemia. There are reports of life-threatening cardiac arrhythmias secondary to hypokalemia arising from excessive licorice intake. Not many are aware that licorice is an ingredient in preserved plums, a popular local snack. We report a patient who presented with cardiovascular collapse secondary to ventricular fibrillation from severe hypokalemia. She was successfully resuscitated, and subsequent history- taking and detailed biochemical investigation point towards chronic licorice ingestion as the most likely aetiology.

Case report:

A 66 year-old Chinese lady with no significant medical history of note presented with poor oral intake and worsening muscle cramps over a few days. She subsequently had a cardiac arrest. Cardiopulmonary resuscitation and defibrillation was initiated rapidly when ventricular fibrillation was noted. She  had no history of hypertension. On examination, she did not look Cushingnoid. Biochemical results: Sodium 135 mmol/L (RI: 134-145), Potassium 1.6 mmol/L (RI: 3.5-5.0), Magnesium 0.6 mmol/L (RI:0.7-1.0) fT4 19 pmol/L (RI:8-21), TSH 2.55 mIU/L (RI: 0.34-5.60), HCO3 29 mmol/L (RI: 19-31). Her spot urinary potassium was 20.9 mmol/L suggesting renal loss.  Both aldosterone and renin were low at 217 pmol/L and 0.37 ng/ml/hr respectively. 8am cortisol was suppressed at 45 nmol/L after an overnight 1mg dexamethasone suppression test. The hypokalemia was aggressively corrected and she underwent urgent cardiac catheterisation. This revealed sub-total occlusion (TIMI 1 Flow) of the left anterior descending artery. The cardiologist deemed the occlusion as an unlikely root cause of the cardiovascular collapse. A detailed history was taken from the patient and it surfaced that she had been taking a large amount of preserved plums for the last few years. Her poor oral intake prior to admission had likely exacerbated the hypokalemia resulting in ventricular fibrillation. She was advised to stop intake of preserved plums. Serum potassium rapidly normalised in the ward.

A follow up serum potassium done 2 months after discharge was normal at 4.7mmol/L.

Discussion:

Licorice contains glycyrrhizic acid which inhibits 11-beta hydroxysteroid dehydrogenase Type 2 (an enzyme that inhibits cortisol conversion to cortisone). Excess cortisol accumulates stimulating mineralocorticoid receptors and inducing a state of pseudohyperaldosteronism. Enhanced renal excretion results in clinically significant hypokalemia.

People are unaware of the significant content of licorice in preserved fruit and its side effects. The most commonly reported complications are secondary hypertension and hypokalemic myopathy. Documented fatalities were linked to its arrthymogenic effects from hypokalemia.

We report this case to increase awareness of this often-overlooked cause of hypokalemia and its significant complications.

 

Nothing to Disclose: MKSL, CJS

13348 16.0000 SAT-0762 A Case Report of a Patient Who Experienced Cardiovascular Collapse Secondary to Severe Hypokalemia from Chronic Consumption of Licorice-Containing Preserved Plums 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Milay Luis Lam*1, Alan Scott Sacerdote2 and Gul Bahtiyar3
1woodhull Medical Center, Brooklyn, NY, 2Woodhull Med & Mental Hlth Ctr, Brooklyn, NY, 3Woodhull Medical & Mental Health Center, Brooklyn, NY

 

Background: We have previously reported that vitamin D replacement can ameliorate both classical and non-classical adrenal hyperplasia (NCAH) due to 11-hydroxylase deficiency much as it does with both polycystic ovarian syndrome, possibly due to a reduction in  insulin resistance. In this case report we show the biochemical benefit that a patient received from vitamin D replacement and GLP-1 agonist treatment in terms of his 11-deoxycortisol levels.

Clinical Case: Our patient is a 60 year old male being followed in Endocrinology clinic since March 2012, after being hospitalized for bowel obstruction and noticing that he was hyperglycemic.  His only past medical history was positive for seizure disorder, for which he was taking oxcarbazepine 300mg and phenobarbital 30mg both three times a day. The latter is known to cause Vitamin D deficiency/insufficiency via increased clearance.

At the time of his diabetes diagnosis he was not taking any insulin sensitizers. His BMI was 36 kg/m2 and has been stable in that range.  His initial HbA1c by immunoturbidimetry on 3/20/2012 was 11.4% (normal range 0-6.99%) so he was started on an insulin regimen with bedtime glargine and lispro before meals.  On 3/20/2012 his 25-OH-vitamin D by liquid chromatography tandem mass spectrometry [LC MS/MS] was 10ng/ml (normal range 30-100 ng/ml). He was started on replacement with ergocalciferol 50 000 IU weekly. The initial measurement of 11- deoxycortisol could not be done since the laboratory lost the corresponding  sample. 

On 5/22/2012 he had a follow-up visit in Endocrinology clinic where he was started on liraglutide,1.2mg SC, since his HbA1c from 5/3/2012 was still above target at 8.8%, 11 deoxycortisol by LC/MS/MS was found to be 79ng/dl (< 42ng/dl) with a 25-OH-Vitamin D level of 41ng/ml.  On 8/6/2012 his HbA1c was 5.8%, 11 Deoxycortisol level was 70ng/dl, 25–OH vitamin D level was 61ng/dl, so on his 8/15/2012 Endocrinology visit, liraglutide was increased to 1.8mg daily.

By 11/8/2012 his 11-deoxycortisol level was 49ng/dl, HbA1c 5.5% and on 2/13/13 11-deoxycortisol level was normal at 34 ng/dl, with a 25-OH-Vitamin D level of 62 ng/ml.

Conclusion: Our findings suggest that vitamin D replacement in combination with a GLP-1 agonist can help in the treatment of NCAH caused by 11- Hydroxylase deficiency by reducing insulin resistance through reductions in inappropriate glucagon secretion and glucose toxicity in addition to weight loss (when it occurs) as well as by a direct effect of Vitamin D, through binding to its adrenocortical receptors and increasing the synthesis of mRNA for 11-hydroxylase.

 

Nothing to Disclose: ML, ASS, GB

11634 17.0000 SAT-0763 A Normalization of Serum 11- Deoxycortisol in a Patient with Non-Classic Adrenal Hyperplasia Due to 11-Hydroxylase Deficiency Treated with Vitamin D and a Glucacon-like Peptide(GLP)-1 Agonist 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Muhammad A Mahmood*1 and Christine Irene Oakley2
1Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, 2Joan C. Edwards School of Medicine Marshall university, Huntington, WV

 

Objective: To describe an unusual case of adrenal insufficiency (AI) in pregnancy.

Clinical Case: A 26 year-old G1P0 female with microprolactinoma, currently off medical therapy, presented at 32 weeks gestation with sudden onset sharp right upper quadrant (RUQ) pain associated with malaise and vomiting. She was afebrile and normotensive, with mild RUQ tenderness. Laboratory evaluation was unremarkable except leukocytosis. Abdominal ultrasonography was normal. CT scan of abdomen showed a 4.2 x 3.1 cm right adrenal mass likely representing hemorrhage and normal left adrenal. Endocrinology was consulted. Patient recalled that her father underwent adrenalectomy for unknown reason.  Plasma metanephrines and normetanephrines were normal. MRI two days later demonstrated stability of adrenal mass and changes consistent with hemorrhage. Her hematocrit was stable. She was discharged, but readmitted four days later with recurrence of abdominal pain more so on left, associated with nausea and fatigue. Vitals were stable and laboratory evaluation unremarkable. Repeat MRI showed stability of right adrenal mass. A morning serum cortisol was 7.2ug/dL (>21ug/dL normal in 3rd trimester). Cosyntropin (250ug) stimulation showed baseline cortisol of 7.5ug/dL, 8.2ug/dL at 30 minutes, and 7.7ug/dL at 60 minutes indicative of AI. Serum ACTH was 286.4pg/mL (normal:7.2-63.3pg/mL). Twenty-one hydroxylase antibodies were ordered, but specimen lost. The patient started hydrocortisone 20mg in the morning and 10mg in the afternoon leading to resolution of her symptoms. She delivered a healthy baby at 37 weeks gestation via elective Cesarean section. She was lost to endocrine follow-up. 

Discussion/Conclusion: With a reported incidence of 1/3,000 (1), the diagnosis of AI in pregnancy should be entertained in those with significant malaise and emesis beyond the 1st trimester, or in those with symptoms of weight loss, salt craving, orthostatic hypotension, hypoglycemia, or electrolyte abnormalities. Primary AI manifests when more than 90% of each adrenal gland is destroyed (2) making primary AI from adrenal hemorrhage unlikely in our case, and autoimmune disease more likely.  As cortisol binding globulin levels rise in pregnancy, levels of serum cortisol should be higher, leading to higher diagnostic cutoffs (3). Recognition of AI is vital to prevent maternal adrenal crisis, IUGR and fetal demise (3).

 

Nothing to Disclose: MAM, CIO

11295 18.0000 SAT-0764 A “an Atypical Presentation of Adrenal Insufficiency in Pregnancy As Recurrent Abdominal Pain” 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Lauren Michelle Maiorini*1 and Lawrence E Shapiro2
1Winthrop University Hospital, Mineola, NY, 2Winthrop Univ Hosp, Garden City, NY

 

Introduction/background:

Adrenocortical insufficiency (AI) is a rare but potentially lethal disease. Compared to the prevalence of adrenal metastases in patients with malignancy, AI in these patients is very uncommon. A salient feature of AI due to adrenal metastases is normal levels of basal serum cortisol.

Clinical Case:

This is a 68 year old female referred for evaluation of hypotension and new onset hyperkalemia. Associated symptoms included severe bilateral flank pain, fatigue and dizziness. She has a history of ovarian carcinoma s/p TAH-BSO. During a chemotherapy treatment session, she became hypotensive and recent labs revealed a potassium level of 6.0 mEq/L. She was known on PET-CT imaging to have bilateral adrenal masses, suspicious for metastatic disease. Given her adrenal masses, hyperkalemia, and hypotension, she was referred to our office for suspected AI. A 250mcg cosyntropin stimulation test was performed. Her baseline serum cortisol level was normal, 15.4 mcg/dL, but the stimulated value was only 16.2 mcg/dL. Despite normal basal cortisol, other values were consistent with adrenal insufficiency: baseline ACTH level of 400 pg/mL, an aldosterone level of <1 ng/dL, and a renin level of 21.55 ng/mL/hour. She was started on Hydrocortisone and Fludrocortisone. Her symptoms of fatigue and orthostasis improved. She died a few months later from her progressive disease.

Discussion:

The adrenal glands are the 4th most common site of distant metastasis. However, adrenal metastases from gynecological neoplasms are relatively rare. AI is typically found in patients with 4cm or larger bilateral adrenal metastases. The features of AI which are treatable may be masked by the symptoms of end stage metastatic disease so the diagnosis can be missed. A literature review revealed that advanced cancer patients have increased levels of basal cortisol but can have biochemical and clinical features of AI. This elevation in cortisol may be due to an activated hypothalamic-pituitary-adrenal axis from increased physiologic stress & interactions between the tumor, the immune system, and the endocrine system. Thus, “normal” basal cortisol concentrations exist in patients with AI due to adrenal metastases. Hormonal replacement therapy may be life-saving and improve quality of life in patients suffering symptoms of adrenal insufficiency.

 

Conclusion:

This is a rare case of ovarian cancer metastasizing to the adrenal glands & causing symptoms and biochemical abnormalities consistent with AI. Evaluation of patients with bilateral adrenal metastases & suspected AI must account for the fact that the HPA axis is activated in patients with malignancy to avoid erroneous exclusion of AI by the presence of normal serum cortisol.

 

Nothing to Disclose: LMM, LES

12214 19.0000 SAT-0765 A Adrenal Insufficiency with Normal Morning Cortisol in a Patient with Metastatic Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Jamie M Olejarski*, Lavanya N Sendos, Kelly L Wirfel and Jeena Mary Varghese
The University of Texas Health Science Center at Houston

 

Introduction: Acute adrenal crisis is a potentially life threatening condition requiring rapid diagnosis and treatment.  We present a case of heparin induced thrombocytopenia associated bilateral adrenal hemorrhage resulting in primary adrenal insufficiency and acute adrenal crisis.

Clinical Case: A 64 year old woman was transferred to our hospital for surgical intervention after sustaining a traumatic T12 burst fracture.  She underwent an uncomplicated surgical repair.  Four days postoperatively, platelet counts were noted to have fallen from an initial value of 188 to 42 K/cmm.  Heparin administered for DVT prophylaxis was discontinued.  Later that evening, the patient developed acute neurological changes culminating in complete obtundation and respiratory failure requiring intubation.  CT scan of the head revealed acute bilateral posterior cerebral artery infarcts with a large intracranial hematoma with mass effect.  Heparin induced thrombocytopenia (HIT) was confirmed by HIT antibody testing.  Therapeutic plasma exchange was initiated.  Sodium values during this time were also noted to fall acutely from an initial level of 136 to 123 mEq/L with normal potassium levels. A baseline cortisol value was obtained with a level of 1.2 µg/dl.  Results of a cosyntropin stimulation test confirmed the diagnosis of acute adrenal insufficiency.  CT abdomen revealed acute bilateral adrenal hemorrhage.  Steroid therapy and fluid resuscitation were immediately initiated with the eventual addition of mineralocorticoid replacement.  Sodium values quickly trended to normal limits.  Platelet count slowly improved after discontinuation of heparin and treatment with fondaparinux.  The patient gradually made a full recovery and was discharged home on oral steroid replacement. 

Conclusion: Although isolated HIT is well documented, bilateral adrenal hemorrhage resulting in primary adrenal insufficiency secondary to heparin induced thrombocytopenia is rare.  The rapid clinical deterioration and potential for complete hemodynamic collapse from acute adrenal crisis requires a high degree of clinical suspicion regardless of confounding factors or the complexity of the case.

 

Nothing to Disclose: JMO, LNS, KLW, JMV

15287 20.0000 SAT-0767 A Bilateral Adrenal Hemorrhage: A Rare Complication of Heparin Induced Thrombocytopenia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Lara Paraskos*1 and Atil Yilmaz Kargi2
1University of Miami, Coral Gables, FL, 2University of Miami Miller School of Medicine, Miami, FL

 

INTRODUCTION: Congenital Adrenal Hyperplasia (CAH) is a known a cause of nonhyperfunctioning adrenal adenomas.  Non-classical CAH presents in late childhood or early adulthood and manifests itself in females as hyperandrogenism, anovulatory infertility and amenorrhea, in males excess androgen does not cause clinical signs and so diagnosis is usually not made.  Non-Classical CAH should be ruled out in patients suspected of PCOS as the phenotypes overlap significantly.  Elevated serum 17-hydroxyprogesterone (17OHP) has been observed in patients with adrenal adenomas both with and without CAH, suggesting that abnormal tumoral steroidogenesis, rather than CAH, may be the cause in some instances.

CASE PRESENTATION: We present a case of a 48-year-old man referred for evaluation of bilateral adrenal masses..  He initially presented with a  1.5 cm left adrenal adenoma with benign imaging characteristics found incidentally on CT scan of abdomen 10 years prior for evaluation of musculoskeletal pain  . Functional workup was negative and the nodule was followed annually for several years with minimal growth. 10 years after the initial diagnosis, MRI of the abdomen showed interval increase of left sided adenoma to 2.3cm and development of a right-sided 2.7cm adrenal adenoma.  Dedicated CT abdomen with adrenal mass protocol revealed bilateral adenomas with  precontrast density <10 HU.  To elucidate an etiology of these adenomas and prevent further testing and imaging, a baseline17OHP level was measured and found to be elevated at 657 ng/dL (33-195), and after ACTH stimulation increased to 3535 ng/dL (33-195).  This led to the diagnosis of non-classical CAH.

This diagnosis lead to questions regarding his children, and it was discovered that his 21 year old daughter was previously diagnosed with PCOS.  We performed baseline 17-hydroxyprogesterone level testing on the daughter and the levels were significantly elevated at 1127 ng/dL (33-195), confirming a diagnosis of non-classical CAH rather than PCOS.

In this case, elucidating the etiology of the bilateral adenomas as non-classical CAH does not affect the treatment course of the father, but has led to the diagnosis of non-classical CAH in the patient’s daughter who had been previously diagnosed with PCOS.  Both father and daughter have been referred to genetics for testing, as it will be useful to have pre-conception genetic counseling in the daughter.  Additionally, a diagnosis of non-classical CAH in the father will provide reassurance to treating physicians and eliminate the need for repeat adrenal imaging. 

CONCLUSION: We conclude that a diagnosis of non-classical CAH should be considered even in males with adrenal adenomas as this may have implications for family members.

 

Nothing to Disclose: LP, AYK

14647 21.0000 SAT-0768 A Adrenal Incidentaloma in Father Leads to Diagnosis of Congeital Adrenal Hyperplasia in Daughter 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Ursina A. Probst-Scheidegger*1, Christa E Flueck2, Dagmar l'Allemand3 and Nuria Camats4
1Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland, 2Pediatric Endocrinology and Diabetology, Bern, Switzerland, 3Children's Hospital of Eastern Switzerland, St.Gallen, Switzerland, 4University Children's Hospital Bern, Bern, Switzerland

 

Background: 3β-Hydroxysteroiddehydrogenase (3b-HSD) is a key enzyme in steroidogenesis, responsible for the conversion of Δ5- to Δ4-Steroids. Deficiency in 3b-HSD results in congenital adrenal hyperplasia (CAH) including glucocorticoid deficiency and a various degree of mineralocorticoid and sex steroid deficiency. The molecular etiology of 3b-HSD deficiency lies in a defect in HSD3B2gene, coding for the isoform II of the enzyme, present in adrenals and gonads. 

Clinical Case: A healthy full-term female baby, born to a non-consanguineous Swiss couple, was admitted on day of life (DOL) 8 due to increased 17-OH-progesterone (17OHP) in newborn screening. She was in no physical distress, feeding well, and gaining weight appropriately. External genitalia were female without virilisation nor palpable gonads.

Ultrasound revealed female internal genitalia with slightly stimulated uterus and normal ovaries with few follicles. Biochemical analysis revealed increased ACTH (549 ng/l) with low cortisol (92 nmol/l), increased 17OHP (124 nmol/l), normal DHEA and 11-desoxycortisol, and increased renin (116 pg/ml).

The patient was immediately started on hydrocortisone (HC). The following day, she developed salt loss (Na of 129 mmol/l, K of 6.1 mmol/l) and was therefore started on fludrocortisone (FC) and NaCl. On continuous HC and FC replacement psychomotor and physical development were normal.

At  7 months of age, the patient was further evaluated for steroidogenic function. Serum steroids were measured 36h after last dose of HC and FC. Results confirmed glucocorticoid and mineralocorticoid deficiency with large increase in ACTH and renin, low cortisol and aldosterone. There was no increase, whatsoever, in 17OHP, DHEA, androstendione, 11-desoxycortisol and testosterone.  

Molecular analysis discovered that the patient was compound heterozygote for 2 mutations in HSD3B2: a previously described c.512G>A (W171X) mutation in the paternal allele, and a novel frameshift mutation c.503delC (A168Vfs*6) in the maternal allele. Both mutations cause two shorter and aberrant gene products.

In retrospect, we interpreted the neonatally increased 17OHP as a product of the placental acitivity of 3β-HSD Type I activity. The absent increase in DHEA at 7 months is probably due to the immature zona reticularis at this age. 

Conclusion: Our patient is compound heterozygote for two mutations in HSD3B2 causing two shorter and aberrant peptides. This clinically causes a severe loss of 3β-HSD II activity, leading to a nearly complete deficiency in glucocorticoids, mineralocorticoids and sex steroids in our phenotypically non-virilized female CAH patient. One of the mutations is novel: c.503delC (A168Vfs*6).

 

Nothing to Disclose: UAP, CEF, DL, NC

12083 22.0000 SAT-0769 A Non-Virilizing Congenital Adrenal Hyperplasia in a Female Patient - Report of a Novel HSD3B2 Mutation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Maria Patricia Gamboa Puno*, Elizabeth P Pacheco, Adriano Dela Paz, Stephanie Mae O. Ang, Gregorio B. Cortez III and Elizabeth Ann S. Alcazaren
The Medical City, Pasig City, Philippines

 

Hemorrhage to the adrenal glands is a rare finding occurring more frequently in children than in adults.  It is classically associated with meningococcal septicemia (Waterhouse–Friderichsen syndrome).  In adults, it is mainly caused by trauma, surgical stress,  anticoagulation therapy, or a tumor; however, spontaneous or idiopathic adrenal hemorrhage is extremely rare.  

We report a case of a 72 year old male, hypertensive, diabetic, presenting with an a palpable soft, non-tender right lumbar mass. He had no history of trauma nor intake of anti-coagulants and was otherwise well with good functional capacity. A CT scan was done and revealed a large heterogeneous mass lesion with a central hypodense component (likely necrosis) centered in the right retroperitoneal region, with non-contrast Hounsfield units ranging from 15-40 HU. It measured 14.2 x 12.5 x 14.7 cm, with neovascularities and small calcific components.  A possible adrenal neoplasm was considered. A hormonal work-up was subsequently done revealing a non-functioning adrenal mass.  The results:  Plasma Aldosterone-RIA 23.77 ng/dl (NV: 3.0-35.5 ng/dl), Plasma Renin Activity 5.65 ng/ml/hr (0.5-1.9 ng/ml/hr supine; 1.9-6.0 ng/ml/hr upright), ARR:  4.207, Serum Cortisol (8am): 15.7 ug/dl (nv 4.2 – 38.4), 24h urine metanephrine: 1.21 mg/24hr (nv up to 1 mg metanephrine/24 hr ); DHEA-S: 69.5 ug/dl (nv 33.6-249); Progesterone: 0.26 ng/ml (nv 0.2-1.31); Testosterone: 3.31 ng/ml (nv 1.95 – 11.38); Estradiol: 29 pg/ml (nv 20-77).  A biopsy of the adrenal mass was then done however results were inconclusive.  Exploratory laparotomy and resection of the retroperitoneal mass was done with a histopathologic finding of a diffuse adrenal hemorrhage on the right. 

Adrenal hemorrhage is an uncommon condition and is difficult to diagnose because of its nonspecific presentation that the diagnosis is often made at autopsy. The value of imaging modalities with the use of CT scan or MRI allows one to determine certain characteristics of an adrenal mass that can point to a benign or malignant tumor. The size and characteristics of the adrenal mass of this patient on CT scan indicated a possibility of malignancy.  Further hormonal work-up was warranted and only on post surgical histopathology was the diagnosis of adrenal hemorrhage made.  This patient, with no known predisposing factors for bleeding, with no history of intake of anti-coagulant nor history of trauma suffered from an idiopathic adrenal hemorrhage without any hormonal disturbances.

 

Nothing to Disclose: MPGP, EPP, AD, SMOA, GBC III, EASA

13354 23.0000 SAT-0770 A Idiopathic Unilateral Adrenal Hemorrhage 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Anis Rehman*1, Michael Dominic Morocco2 and Vidhya Sabapathy3
1Akron General Medical Center, Cleveland Clinic Affiliate, Akron, OH, 2Endocrine Associates, Akron, OH, 3NorthEast Ohio Medical Univesity, Akron, OH

 

Introduction:

Anti-Phospholipid Syndrome (APLS) is a frequent accompaniment with Systemic Lupus Erythematosus (SLE). The condition predisposes to thrombosis, however adrenal hemorrhage in such population is exceptionally rare.

Case Report:

A 57-year-old Caucasian female, presented to the emergency room with altered mental status, shortness of breath and decreased urine output for 48 hours. Vital signs revealed hypotension (blood pressure 53/30), tachycardia (pulse 110/minute), and a temperature of  37.0 (°C).  Laboratory investigations were significant for decreased  sodium 125 mEq/L potassium 3.1 mEq/L, blood glucose (serum sugar 46 mg/dL) and elevated creatinine (Cr 5.23 mg/dL). Chest x-ray showed diffuse bilateral lower lobe infiltrates and VBGS were: pH 7.34, pCO2 43.2 mmHg, pO2 32.7 mmHg, HCO3- 22.9mEq/L, O2% Sat Venous 52.9%.

Thus a preliminary diagnosis of sepsis with acute respiratory failure secondary to pneumonia and acute kidney injury was made and the patient was intubated and shifted to the ICU. CT scan of abdomen and pelvis (without contrast) performed in ICU showed a 2.4 x 4cm right and 3 x 4 cm left adrenal gland abnormality that was consistent with adrenal hemorrhage. Patient had been on warfarin 5 mg daily for APLS with an INR being subtheraputic 1.33, she was switched to heparin drip at 20 units/kg/hour in the ICU. An endocrinology consultation was obtained and the dose of hydrocortisone 50 mg q24h was continued.

The patient initially received one time dose of Piperacillin/tazobactam 3.375 g and vancomycin 1g q12h, however after Infectious Disease consultation, the antibiotics were switched to ciprofloxacin 200 mg q12h IV and meropenum 0.5 gm q24h for highly resistant gram negative rod coverage.

Patient gradually responded over a period of 2-3 days. The patient was extubated on day 5 and was discharged on physiologic cortisol replacement, with hydrocortisone 20 mg qAM and 10 mg qPM.

Discussion:

Adrenal hemorrhage is a relatively uncommon condition with a non-specific presentation (typically flank, back or abdominal pain), but can also present through cardiovascular sequel. Without prompt management, the condition it could lead to adrenal crisis, shock and death with an overall mortality rate of 15%.

 Our case illustrates several risk factors for adrenal insufficiency such as sepsis, APLS and use of anti-coagulant therapy. Adrenal hemorrhage is a life threatening condition warranting prompt diagnosis and therapy. Clinicians should maintain a high index of suspicion while managing cases of hypotension in the setting of risk factors. A timely CT scan of abdomen and steroid administration could be life saving in such cases.

 

Nothing to Disclose: AR, MDM, VS

12393 24.0000 SAT-0771 A Adrenal Insufficiency Due to Bilateral Adrenal Hemorrhage in Anti-Phospholipid Syndrome (APLS) and Systemic Lupus Erythematosus (SLE) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Melissa Sawyer*1, Gauri Dhir2 and Marc J Laufgraben3
1Aria Health, Philadelphia, PA, 2Cooper University Hospital, Bala Cynwyd, PA, 3Cooper University Hospital, Camden, NJ

 

First report of large uterine myelolipoma  in a woman with 11-β hydroxylase deficiency

Sawyer ML,  Laufgraben MJ,   Dhir G.

Department of Endocrinology, Diabetes and Metabolism, Cooper Medical School of Rowan University, Camden, NJ

Department of Medicine, Aria Health, Langhorne, PA

Background: CAH patients are at increased risk of developing adrenal myelolipomas and testicular adrenal rest tumors, but uterine leiomyoma has only been reported in a single case of a woman with 21-hydroxylase deficiency .  We provide the first report of a large uterine  leiomyoma in a woman  with 11-β hydroxylase deficiency.

Case presentation: A 24 yo African American female with 11-β hydroxylase deficiency presented with increasing abdominal girth associated with abdominal pain, nausea and vomiting. She had been diagnosed with CAH due to 11-β hydroxylase deficiency shortly after being born with ambiguous genitalia. She had been treated with hydrocortisone and had corrective vaginal surgery at 7 months. At age 10, she developed HTN requiring treatment with multiple antihypertensive agents. She was nonadherent with her treatment and was lost to follow-up for many years prior to presenting with abdominal signs and symptoms. Abdominal exam revealed a large, soft and nontender pelvic mass extending to xiphisternum suggestive of a uterus at 36 weeks gestation.  However, a pregnancy test was negative. CT revealed bilaterally enlarged adrenal glands and a large tumor originating from the uterus measuring 19.5 x 17.0 x 20.5 cm.  She underwent total abdominal hysterectomy with bilateral salpingectomy. The resected mass measured 17 x 15 x 17 cm and weighed 3620 gm. Pathology demonstrated features of a typical benign leiomyoma.

Conclusion: We believe this is the first case report of a large uterine leiomyoma presenting in a woman with 11-β hydroxylase deficiency. Leiomyoma in women with CAH is exceedingly rare, with only one prior report of multiple uterine leiomyomas in a woman with 21-hydroxylase deficiency.  The growth of uterine leiomyoma is generally associated with stimulation by estrogen and progesterone, and would be expected to be inhibited in a high androgen environment as seen in 21-hydroxylase deficiency and 11-β hydroxylase deficiency. In vitro analysis of hormone receptors in the leiomyoma tissue from such unusual patients would be most illuminating.

 

Nothing to Disclose: MS, GD, MJL

15411 25.0000 SAT-0772 A First Report of Large Uterine Myelolipoma in a Woman with 11-Beta Hydroxylase Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

YunYing Shi* and Dorothy Santos Martinez
UCLA, Los Angeles, CA

 

Introduction: Addison’s disease is often difficult to diagnose due to non-specific presenting symptoms. Hypovolemic hypotension is a commonly associated cardiovascular complication. Rarely, cardiogenic shock can also occur during an Addisonian crisis. We report here a postpartum young woman with undiagnosed Addison’s disease who presented with acute biventricular systolic failure as the primary marker for a fulminate adrenal crisis.

Case: A 32-year-old Caucasian female was admitted from an outside hospital (OSH) for heart transplant evaluation with presumed postpartum cardiomyopathy. Patient’s pregnancy was complicated by hyperemesis gravidarum started 2 months into her pregnancy. She did not have any history of hypotension while pregnant and had an uneventful vaginal delivery of a healthy, full-term boy. Two weeks postpartum, her emesis worsened, accompanied by 30lb weight loss, dizziness, and low blood pressure (BP) requiring IV hydration. Six months postpartum, she presented at OSH due to hemodynamic collapse with left ventricular ejection fraction (LVEF) <10%, requiring intubation and pressor support. Hospital course was complicated by acute renal failure, sepsis, anemia, right lower extremity arterial thrombus, stroke and seizure. On admission, her TSH was 106 mcIU/mL (n: 0.3-4.7 mcIU/mL). Levothyroxine IV 50mcg daily and hydrocortisone 100mg IV q8h were started by OSH.  Repeat TFT after 5 days of therapy at our hospital showed elevated TSH (16 mcIU/mL, n: 0.3-4.7 mcIU/mL), borderline-low Free T4 (0.6 ng/dL, n: 0.6-1.7 ng/dL), low Free T3 (122 pg/dL, n: 222-383 pg/dL), and positive thyroid peroxidase antibody and thyroglobulin antibody. Liothyronine 5mcg twice daily was added. Despite rapid full recovery of ventricular function (LVEF 60-65%) in two weeks, she continues to have intermittent low BP on hydrocortisone IV 25mg daily. Further evaluation showed elevated ACTH (2150 pg/mL, n: 4-48 pg/mL), elevated prolactin (152 ng/mL, n: 3.0-23.1 ng/mL), elevated rennin (6.3 ng/mL/hr, n: 0.6-1.6 ng/mL/hr), and normal aldosterone (n<1.0 ng/dL). A diagnosis of Addison’s disease was made. Her 21-hydroxylase antibody was later confirmed to be positive. Patient’s BP improved with the addition of mineralocorticoid. She was eventually discharged in stable condition on oral levothyroxine, hydrocortisone, and fludrocortisone.

Conclusion: New onset Addison’s disease is rare in pregnancy. It has been suggested that during the pregnancy, free cortisol produced by the fetal adrenal cortex can offer some maternal protection. However, the withdrawal of the cortisol source after delivery can result in acute adrenal insufficiency, in our case, leading to the rare presentation of acute ventricular dysfunction. Therefore, a high index of suspicion for Addison’s disease is required in postpartum women presenting with hemodynamic instability with a history of hyperemesis gravidarum.  

 

Nothing to Disclose: YS, DSM

15508 26.0000 SAT-0773 A Addisonian Crisis Presenting As Acute Ventricular Failure in the Postpartum 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Vishnu Sundaresh*1, Kartik Anand2, Tania Rowland3, Michael Constantinescu3 and Sherry Lynn Ryan3
1Louisiana State University Health Sciences Center, Shreveport, LA, 2Louisiana State University health Sciences Center, Shreveport, LA, 3Overton Brooks VA Med Ctr, Shreveport, LA

 

Amyloidosis refers to the extracellular deposition of insoluble proteinaceous material affecting multiple organs in its systemic form. Endocrine involvement is infrequent with endocrine dysfunction being extremely rare. We report a case of Systemic Amyloidosis (SA) presenting with primary adrenal insufficiency (PAI) with poly-endocrine gland involvement.

A 63-year-old white male presented with a 3-month history of recurrent episodes of dizziness and syncope. He had cold sensations in the extremities, decreased libido, erectile dysfunction, dysphagia, early satiety, and unintentional 90-pound weight loss pounds in two years. Medical history included papillary thyroid cancer treated with total thyroidectomy and I-131 ablation, autoimmune and post-surgical hypothyroidism, focal gastric amyloidosis secondary to h. Pylori gastritis, and stage 3 kidney disease of unknown etiology. Exam revealed supine hypertension, orthostatic hypotension with inappropriate heart rate response and peripheral sensory neuropathy. Sodium was 133 mmol/L (136–145), potassium 3.8 mmol/L (3.3-5.1), and creatinine 1.8 mg/dL (0.6-1.3). EKG had low voltage complexes with fixed R-R interval. 2D ECHO showed normal systolic function with impaired diastolic relaxation. Gastric emptying study showed severe gastroparesis with T 1/2 855 minutes (normal <110). No obstruction was seen on EGD. A 250-µg cosyntropin stimulation test revealed baseline, 30- and 60-minute cortisol levels of 9.7, 20, and 21 µg/dL (AM 6.7-22.6 ug/dL), respectively. ACTH was 42 pg/mL (7.2-63.3), DHEA-S 38.9 µg/dL (48.9-344.2), aldosterone <1 ng/dL (0.0-30), and renin < 0.16 ng/ml/hr. (1.31-3.95 upright).  LH was 2.1 mIU/ml (1.2-8.6), FSH-7.7mIU/ml (1.3-19.3) and total testosterone was 1.1 (1.8-7.8). Repeat testing showed baseline cortisol of 15.9 which stimulated to 17.5 with a baseline ACTH of 14.7. Non-contrast CT of the adrenals and pituitary were normal. Free Lambda light chains were abnormally detected in both serum and urine along with nephrotic range proteinuria. Serum immunoelectrophoresis was normal with an absent M spike. Bone marrow biopsy revealed 4.6% plasma cells. 18-F PET scan ruled out a plasmacytoma. On careful re-examination of biopsies of the stomach, duodenum, bone marrow and previously excised thyroid tissue, all exhibited Congo red staining and apple green birefringence within small vessel walls, confirming SA. Mayo classification was stage II, AL type. Treatment with hydrocortisone and fludrocortisone for presumed PAI due to amyloid infiltration of the adrenals resulted in significant clinical improvement. He is currently receiving chemotherapy in preparation for autologous stem cell transplantation. 

Endocrine dysfunction secondary to SA is rare, with subtle presentation. Investigating glandular function may avoid potentially life-threatening consequences of glandular failure.

 

Nothing to Disclose: VS, KA, TR, MC, SLR

16479 27.0000 SAT-0774 A Amyloid Here, Amyloid There, Amyloid Everywhere! Primary Adrenal Insufficiency Due to Systemic Amyloidosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Sri Harsha Tella*1 and J Christopher Gallagher2
1Creighton University, Omaha, NE, 2Creighton University Medical Center, Omaha, NE

 

Background: Treatment with the benzodiazepines atypical antipsychotics is frequently associated with development of obesity, insulin resistance and drowsiness. Treatment-induced weight gain has been suggested to be the main contributing factor of diminished insulin sensitivity. Here we describe a case of benzodiazepine and antipsychotic medication induced hypocortisolism.

Case:We describe a case of 32 year old homeless Caucasian male with past medical history of anxiety, depression, bipolar disorder, obsessive compulsive disorder and opioid abuse (methadone) was brought into ER by squad as he overdosed himself with 15 pills of clonazepam 2 mg. Initial vital signs on presentation are Temp: 99.7 F, Pulse: 97/min, BP: 60-70/40-50 mm Hg, RR: 12/min. Chest X ray and CT head were unremarkable. He was transferred to the ICU for management of hypotension. He was given 8 liters of 0.9% normal saline over a period of 6 hours (including 3 liters of bolus) and blood pressure came up to 80-90/50-60 mm Hg. His laboratory evaluation showed normal electrolytes, creatinine and white count. Serum cortisol levels were tested which showed 1.7 mcg/dl at 04 50 AM and 0.6 mcg/dl at 06 00 AM. 250 mcg ACTH stimulation test was done which showed serum cortisol of 2.8 mcg/dl, 14.4 mcg/dl and 16.7 mcg/dl at 0, 30 and 60 minutes respectively. ACTH, testosterone, LH and TSH at baseline were 3.8 pg/ml, 979 ng/dl, 2.2 IU/l and 0.75 microIU/ml respectively. On further review of records, patient had normal blood pressures and serum cortisol in the past before the initiation of these medications. We discontinued clonazepam from his medication list and added prednisone 40 mg that has increased the blood pressures to normal range in our patient. He was discharged home on after fast taper with follow up in clinic which showed normal blood pressure in 1 month.

Discussion:Benzodiazepines and Opioids can cause endocraniopathy by acting on GABA receptors there by inhibiting the secretion of corticotrophin releasing hormone (CRH). In this patient, the acute drop in serum cortisol might be due to overdose of clonazepam that can inhibit CRH. This is interesting since CRF may have neurotropic effects related to the behavioral responses to stress, and the inhibitory effect thus may represent a mechanism of action for the anxiolytic effect of benzodiazepines. Surprisingly, this effect is dose dependent and can be seen as soon as 2 hours. So, in our patient this acute drop in blood pressures and cortisol levels are mostly likely related to more potent and efficacious benzodiazepine Clonazepam. 

Conclusion: Benzodiazepines can cause in acute lowering of serum cortisol levels and one should recognize this effect and treat accordingly to prevent the morbidity or mortality from acute drop in cortisol levels. Moreover, chronic use of opioids, antipsychotics and benzodiazepines can cause GABA induced suppression of CRH release leading to low cortisol levels.

 

Nothing to Disclose: SHT, JCG

12950 28.0000 SAT-0775 A Relationship of Benzodiazepines with Serum Cortisol Levels: A Hidden Fact 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Cesar Abuchaibe*1 and Omar Naeem Akhtar2
1The Jewish Hospital of Cincinnati - Mercy Health, Cincinnati, OH, 2Mercy Health, Mason, OH

 

Background

To present a case of exogenous Cushing’s syndrome after use of a OTC joint supplement from Cuba.

This case illustrates how difficult it can be demonstrate the presence of corticosteroids in OTC medications especially foreign medications. 

In this case the patient was not aware that the Herbal medication that she brought from Cuba was the one responsible for her clinical syndrome.  Therefore physicians should pay close attention on the history for asking new medications, even herbs or foreign medications. 

As we can illustrate in this case the label telling the composition of the medication never showed or mentioned the inclusion of steroids

Presentation

67 y/o Hispanic female who presented to the endocrine clinic for the management of Diabetes mellitus type 2, Hypertension and severe osteoporosis.  During the initial encounter the patient appeared clinically Cushingoid. Her physical examination exhibited obesity, round facies, supraclavicular fat, thin skin and lower extremity edema. 

She had been evaluated for Cushing’s Syndrome by previous  endocrinologist. Work up in the past for endogenous Cushing’s was negative on multiple occasions. 

She had also been tested for exogenous Cushing’s; having multiple positive screens for synthetic steroids. She had not had any steroids injections in the past and she denied the use of steroids orally. She did admit that she had been taking an OTC joint supplement from Cuba called ATRIN® for the past 3 to 4 years.

Having the suspicion that this foreign OTC joint medication could have been causing the exogenous Cushing’s’ resulting in adrenal suppression; she was advised in several visits to stop taking this medication.  The patient tried to stop taking the OTC medication but she had fatigue and joint pain after stopping it.

On our initial visit, we had the same suspicion of Exogenous Cushing’s, source being the OTC supplement.

A sample of the medication was sent to the Mayo Clinic to be analyzed

Composition was as follows:

            4 mg of prednisolone

            100 ug of hydrocortisone

            She was taking 5-6 pills a day.

Am cortisol was low (1.6mcg/dl) after holding the supplement, indicating secondary adrenal insufficiency. It was stopped and she was started on steroid replacement which was gradually tapered.

After stopping it, she lost 30lbs, insulin and oral hypoglycemic were stopped and osteoporosis improved.

Her Synthetic glucocorticoid screening was also negative for the first time

Conclusion

 Even though herbal medications appear to be harmless, caution should be taken in those from other countries.  Patient with Exogenous Cushing’s should be started on steroid replacement before stopping the supplement due to secondary adrenal insufficiency.

 

 

Nothing to Disclose: CA, ONA

14155 29.0000 SAT-0776 A Exogenous Cushing's Syndrome after Use of OTC Joint Supplement 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Vrinda Agrawal*1 and Ramaswami Nalini2
1Baylor College of Medicine, Houston, TX, 2Baylor Colg of Med, Houston, TX

 

Introduction:

Long term glucocorticoid therapy may result in suppression of hypothalamic-pituitary-adrenal function leading to significant morbidity. We report a case of a Cushingoid appearing male with adrenal insufficiency secondary to the use of ‘Rumoquin’ – an over the counter (OTC) pain medication from Mexico.

Clinical Case:

A 57 year old Hispanic male with coronary artery disease and uncontrolled hypertension was referred to endocrinology clinic for evaluation of suspected adrenal insufficiency after he was found to have undetectable morning cortisol levels on two separate occasions. Patient’s physical examination revealed a Cushingoid appearing male, rounded facies with central adiposity and marked skin bruising. This prompted the primary care physician to obtain a morning cortisol level. He was asymptomatic otherwise. Morning cortisol was <0.2 ug/dL (normal 3.09-22.4 ug/dL) along with an ACTH level of <1.1 pg/mL (normal 7.2-63.3 pg/mL). He failed a 1 mcg ACTH stimulation test with a baseline cortisol of 1.3 ug/dL, ACTH of 53.3 pg/mL (normal 7.2-63.3 pg/mL) and a peak cortisol of 2.0 ug/dL. With a suspicion for exogenous steroid use, detailed questioning revealed that the patient had been taking ‘Rumoquin’, an OTC Mexican pain medication for more than 5 years for arthritis related pain. Further review of this medication divulged that this contained 0.75mg of dexamethasone. Patient also reported symptoms of lightheadedness and increased lethargy upon missing a single pill of this medication. A diagnosis of adrenal insufficiency was made secondary to chronic exogenous corticosteroid use. He was advised to stop Rumoquin and was started on replacement doses of hydrocortisone with an aim to taper it off gradually.

Conclusion:

This case illustrates the importance of a detailed history taking including a complete medication history encompassing OTC medications, creams or supplements as quite often patients are unaware that these contain steroids. Physicians should be increasingly aware of such practice to recognize the potential effects of long term corticosteroid use in any form, and to educate the patients, thereby preventing any resulting morbidity and mortality.

 

Nothing to Disclose: VA, RN

16535 30.0000 SAT-0777 A Over the Counter Pain Medications from Mexico and Adrenal Suppression: Beware! 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Ravi Kant*1, Hillary Barnes Loper2, Kashif M. Munir2 and Rana Malek2
1AnMed Health and Medical University of South Carolina, 2University of Maryland School of Medicine, Baltimore, MD

 

Although fluticasone (FC) is a potent glucocorticoid, it has minimal systemic effects at recommended dosages due to rapid metabolism by cytochrome P450 3A4 (CYP3A4). We report the first case to our knowledge of iatrogenic Cushing's syndrome (CS) that was presumably caused by the inhibition of CYP3A4 metabolism of FC by duloxetine (DL).

A 52 year old man presented with a 10 week history of lower extremity weakness, extreme fatigue, night sweats, easy bruising and 45 lbs weight gain. Past medical history included allergic rhinitis and ulcerative colitis (UC) managed with FC (50 mcg/act) nasal spray 2 puffs/nostril for 5 years and intermittent mesalamine, respectively. DL had been started for depression several weeks prior to the onset of symptoms. Physical examination revealed severe facial plethora, central obesity and trace pedal edema. Laboratory investigations for CS were discordant with mildly elevated 24 hr urine cortisol [24 UFC (52.2-71.8; normal <50 mcg/24 hr)] but normal 1 mg dexamethasone suppression test [DST (0.5-0.6 mcg/dl)] and mid-night salivary cortisol levels (0.3-1.4; normal 0.3-4.3 mcg/dl). Additional evaluation to support the diagnosis of CS, including ACTH 50 (6-50 pg/ml), 24 hr urine 17-OH corticosteroids 1.7 (3.0-10.0 mg/24 hr), MRI-pituitary, and CT-chest, abdomen and pelvis, was unremarkable. Interestingly, urine FC 17-B carboxylic acid level (U-FCA) was elevated at 266 (normal <10 pg/mL), suggesting iatrogenic CS. Discontinuation of FC led to resolution of hypercortisolism within 4 weeks (1mg DST 0.7 and 24 UFC 32.2). Loss of steroid suppression from FC resulted in a UC flare, 12 lbs weight loss, and continued fatigue over the next 3 months. EMG and gastrocnemius muscle biopsy were performed for myopathy evaluation. Muscle biopsy showed many non-specific findings suggestive of myotonic dystrophy.

Clinically significant drug interactions in patients receiving concomitant FC and CYP3A4 inhibitors, such as ritonavir, are well known.1 DL has been shown to cause time dependent reversible inhibition of CYP3A4, which can potentially alter FC metabolism and lead to systemic corticosteroid effect although no such case has been reported.2 Our patient tolerated chronic FC therapy for 5 years, but developed clinical features consistent with iatrogenic CS shortly after initiating DL. This led us to suspect a significant drug interaction between DL and FC as a potential etiology for his symptoms. In addition to elevated U-FCA levels, resolution of hypercortisolism symptoms and development of UC exacerbation after discontinuation of FC further support our hypothesis. The patient’s myopathy is probably explained by another etiology as suggested by EMG and muscle biopsy, however, glucocorticoid-induced myopathy cannot be entirely excluded. FC should be cautiously administered to patients who are receiving DL and providers should be wary of clinical clues that may indicate CS.

 

Nothing to Disclose: RK, HBL, KMM, RM

14884 31.0000 SAT-0778 A Iatrogenic Cushing's Syndrome in a Patient Treated with Duloxetine and Fluticasone 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

César Esteves1, Celestino Neves*2, Maria João Matos1 and Davide Carvalho1
1Centro Hospitalar São João, Faculty of Medicine, University of Porto, Portugal, 2São João Hospital, Faculty of Medicine, University of Porto, Porto, Portugal

 

Introduction: Cases of iatrogenic Cushing syndrome or adrenal failure are usually the result of the administration of oral glucocorticoids for a long period. Inhaled or topic corticoids aren't usually considered to be responsible for significant abnormalities in the glucocorticoid axis. However, there are exceptions. Aims: To report a case of adrenal failure in a patient treated with itraconazole and inhaled budesonide therapy. Clinical case: Female, 63 years old, under follow-up in a Pulmonology consultation for allergic broncopulmonary aspergillosis. She was treated with itraconazole 400 mg od for 7 months until July 2011 and kept under therapy with budesonide/formoterol 160/4,5 µg / inhalation bid, tiotropium bromide 18 µg/inhalation od and mometasone furoate 50 µg/pulverization od. She was referred to the Endocrinology appointment due to skin hyperpigmentation and weight loss after initiation of therapy with itraconazole, and a morning serum cortisol of 0.05 µg/dL. At the time of the first Endocrinology appointment she complained of subsequent weight gain with centripetal fat deposition and moon face. She had an ACTH below the limit of detection, normal potassium and low aldosterone (0.9 ng/dL). After itraconazole therapy suspension, ACTH increased to 64.1 ng/L, cortisol 9.7 and 18.8 µg/dL before and after the administration of Synacthen, respectively, and aldosterone to 10.3 ng/dL. Due to worsening of aspergillosis, she initiated treatment with itraconazole, with reduction of cortisol levels to 4.0 and 9.3 µg/dL before and after the administration of Synacthen, respectively. Discussion: The present case is representative of itraconazole effects on the pituitary-adrenal axis, in individuals treated with budesonide, which is an inhaled glucocorticoid metabolized by the cytochrome P450 3A4. Mometasone furoate is also a glucocorticoid for nasal pulverization metabolized by the same cytochrome but its systemic absorption is minimal and its contribution in the present case is undetermined. Itraconazole can also induce abnormalities of mineralocorticoid metabolism. Conclusion: Itraconazole is an antifungal agent, considered safe in terms of its effects on the glucocorticoid axis. The occurrence of pituitary-adrenal axis suppression was previously described for the association of itraconazol and budesonide. There are no described cases associated with mometasone furoate. However, it might be considered as it shares the same metabolic pathways as budesonide.

 

Nothing to Disclose: CE, CN, MJM, DC

15978 32.0000 SAT-0779 A Hypothalamic-Pituitary-Adrenal Axis Suppression Related to Itraconazole and Budesonide Association Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0747-0780 4776 1:00:00 PM Adrenal Case Reports 1 - CAH and Adrenal Insufficiency Poster

Ashwini Mallappa1, Lori-Ann Daley2, Carol Van Ryzin2 and Deborah P. Merke*2
1National Institutes of Health Clinical Center, Bethesda, MD, 2National Institutes of Health, Bethesda, MD

 

Background: Heterogeneous quality-of-life (QoL) has been reported in patients with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. Patients with classic CAH require lifelong glucocorticoid therapy. Disease and treatment-related co-morbidities such as obesity, hyperandrogenism, metabolic syndrome, and the use of long-acting glucocorticoid therapy have been suggested to contribute to poor QoL outcomes.

Methods: Health related quality of life (QoL) was assessed by administering the Short Form Health Survey (SF-36) to adult patients with classic CAH enrolled in a Natural History Study at the National Institutes of Health Clinical Center in Bethesda, MD. This 36-item survey measures subjective physical and mental health within the past four weeks across eight domains:  physical functioning, role - physical, bodily pain, general health, vitality, social functioning, role- emotional and mental health. Scores in each domain range from 0 - 100 with higher scores indicating better health; a score of 50 represents the population mean with a standard deviation of plus or minus 10. 

Results: 48 patients (25 female; 29 ± 13 years) with classic CAH (33 salt-wasting, 15 simple-virilizing) participated in this study. Overall, patients reported an above average QoL (mean total SF36 score: females 65.1 ± 25.9; males 84.3 ± 14.6). QoL was significantly reduced in females compared to males in the physical functioning (p=.033), role-physical (p=.009), bodily pain (p=.014), general health (p=.003), vitality (p=.003), social functioning (p=.004), mental health (p=.003), physical health summary (p=.002), mental health summary (p=.005), and total SF-36 score (p=.003). Salt-wasting CAH females reported the lowest scores. Younger age and lower BMI significantly contributed to higher QoL, but only for females.  Total QoL and subgroup scores were not associated with glucocorticoid dose or type, marital/relationship status, or socioeconomic status.  

Conclusions: In a population of adult patients with classic CAH reporting overall good quality of life, female patients consistently report lower health status than males. Further studies are necessary to elucidate the factors contributing to impaired QoL in classic CAH females.

 

Disclosure: DPM: Investigator, Diurnal. Nothing to Disclose: AM, LAD, CV

14709 3.0000 SAT-0820 A Quality of Life in Adults with Classic Congenital Adrenal Hyperplasia: Females Have Reduced Quality of Life Compared to Males 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0818-0831 4780 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis 1 - CAH, AI & Cushing's Poster

Ribal Al Aridi*1, Katia El Sibai2, Nadine El Asmar3, Warren Selman4 and Baha M Arafah5
1University Hospitals,Case Medical Center, Cleveland, OH, 2University Hospitals Case Medical Center, Cleveland, OH, 3UH Case Medical Center/ Case Western Reserve University, Cleveland, 4UH Case Medical Center, Cleveland, OH, 5Case Western Reserve Univ, Cleveland, OH

 

Background: PRL has been proposed as a modulating factor in DHEA-S secretion.  Yet, studies in vivo and in vitro have yielded variable conclusions. The aim of this study is to assess the acute and chronic influence of changes in PRL levels on DHEA and DHEA-S secretion.

Materials: We examined changes in serum DHEA, DHEA-S and PRL levels during the first 48hrs after transphenoidal surgery (TSS) in 16 women with prolactinoma (group 1; mean age 26.9 ± 9.9yrs) and in a control group of 10 women who had resection of non-secreting pituitary adenomas (group 2; mean age 32.4 ± 6.8 yrs). Blood samples for measurements of PRL, ACTH, cortisol, DHEA and DHEA-S were taken at baseline and at 2-4, 6-8, 12-18, 24, 36 and 48hrs postop in both groups. In a separate investigation, we examined the effects of medical treatment of hyperprolactinemia (using dopamine agonists) on serum DHEA-S levels in 9 patients (5F, 4M) with prolactinoma (mean age 45.5 ± 9.2yrs). In the latter group, PRL and DHEA-S levels were measured before initiation of treatment and at 2-4 months (mo) intervals for the first year of therapy. All studied patients had NL-HPA function and were not on medications that affect HPA axis.

Results: In the surgically treated prolactinoma group, PRL levels decreased acutely during the first few postop hours reaching normal levels 6-8 hrs following TSS.  In both groups of patients who underwent TSS, plasma ACTH levels increased similarly reaching a peak during the first 2-4 postop hrs after which they decreased gradually to normal by 12-18hrs. Similar increases in serum cortisol levels were noted in both groups. Patients with prolactinoma had higher baseline DHEA levels than those with non functioning tumors (8 ±6 ng/ml Vs 3.8±2.5 ng/ml; p<0.05) even though the 2 groups were of similar age and gender. With the acute rise in ACTH at 2-4hrs, serum DHEA levels increased in both groups but were consistently higher in patients with prolactinoma in the first 24hrs. Serum DHEA-S levels in patients with prolactinoma were similar during the first 24hrs to those of non functioning tumors. However, DHEA-S levels in patients with prolactinoma decreased from their baseline values at 48hrs (171 to 131mcg/dL; P 0.009). In medically treated prolactinoma, PRL and DHEA-S decreased in a parallel manner at 2-4 mo post treatment and reached a plateau at 4-6 mo of continued therapy.

Conclusion: Patients with prolactinoma had higher serum DHEA and DHEA-S levels that decreased with surgical or medical treatment of the disease. In surgically treated prolactinomas, the effect of PRL was eliminated at 6-8 hrs postop once PRL levels normalized. The higher levels of DHEA at baseline and during the early postop period in patients with prolactinoma suggest potentiation of ACTH influence on DHEA secretion by hyperprolactinemia. In the absence of acute ACTH stimulation as observed in medically treated prolactinoma, PRL was noted to be a modest modulator of DHEA-S secretion.

 

Nothing to Disclose: RA, KE, NE, WS, BMA

14248 6.0000 SAT-0823 A Prolactin (PRL) Is a Modulator of DHEA and DHEA-S Secretion 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0818-0831 4780 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis 1 - CAH, AI & Cushing's Poster

Hideki Katakami*1, Seiichi Hashida2 and Isolated ACTH Deficiency Study Group3
1Teikyo Univ Chiba Medical Center, Ichihara, Japan, 2Tokushima Bunri University, Tokushima, Japan, 3IAD consortium, Japan

 

Isolated ACTH deficiency (IAD) is a rare disease. Our previous epidemiological study of IAD in a Japanese cohort, population size: 1.15-1.17 million-inhabitants, has shown that its prevalence and incidence were 19.1 cases/million and 0.9 cases/year/million, respectively, whereas 85.9 case/million and 5.3 cases/year/million, respectively, for acromegaly in the same cohort. There were both IAD of young onset (JIAD, 11-21yr, 4M+1F, n=5) and IAD of mature onset (MIAD, 36-96yr, 16M+4F, n=20) of acquired form and idiopathic etiology. Noted initial symptoms in JIAD and MIAD were hypoglycemia and weight loss, respectively. Thyroidal autoantibodies were positive in 1/4 of JIAD and 4/11 of MIAD. Pituitary atrophy on MRI or CT was found in 3/4 of JIAD and 4/18 of MIAD.

On the other hand, selectively impaired ACTH secretion causes secondary adrenal insufficiency. Conventional measurements for plasma ACTH levels (2.0/mL for ECLIA or 5.0pg/ml for IRMA) are not sensitive enough to characterize ACTH secretory dynamics in Px with IAD, or to make differential diagnosis among conditions or diseases which cause ACTH insufficiency. We have developed a novel ultrasensive EIA (immune complex transfer-EIA, ICT-EIA) for ACTH, LDV 0.1pg/mL (0.2attomole/assay). To characterize corticotroph function among acquired ACTH insufficiency, including acquired form of IAD (n=18), autoimmune hypophysitis (AH, n=6), CNS germ cell tumors (GT, n=16), post irradiation hypopituitarism (RH, n=6), pituitary tumors (PTm, n=24) and normal controls (CNT, n=28), we measured plasma ACTH levels before and after provocative tests. Despite low plasma ACTH levels in Px with GT or PTm, ACTH responded significantly to stimulatory (CRH or GHRP-2) tests. However, Px with IAD or AH showed no ACTH responses to stimulatory tests. Pharmacological doses of synthetic steroids acutely suppressed plasma ACTH levels to 1.5-4.0pg/ml in Px without pituitary diseases.

The present results show that the prevalence and incidence of IAD are about 1/5 of those of acromegaly, and there are two forms of IAD, i.e., JIAD and MIAD. The corticotroph function was most severely impaired in Px with IAD or AH (0.6-1.2pg/ml), followed by Cushing’ syndrome (1.2-3.5pg/ml), PTm (3.8-8.6pg/ml) and/or irradiation (3.8-8.6pg/ml) vs. CNT (7.8-43.0pg/ml). These results suggest that the novel ultrasensive ICT-EIA for ACTH is useful to establish the diagnosis of IAD or AH.

Sources of Research Support: Health and Labor Sciences Research Grant, Japan


 

Nothing to Disclose: HK, SH, IADS

16438 7.0000 SAT-0824 A Isolated ACTH Deficiency: Epidemiology, Clinical Features and Secretory Dynamics of Plasma ACTH By a Novel Ultrasensitive EIA 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0818-0831 4780 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis 1 - CAH, AI & Cushing's Poster

Yasin Simsek*1, Zuleyha Karaca2, Halit Diri1, Sulbiye Aribas1, Fatih Tanriverdi2, Kursad Unluhizarci2 and Fahrettin Kelestimur2
1Faculty of Medicine, Erciyes University, Kayseri, Turkey, 2Erciyes University Medical School, Kayseri, Turkey

 

Aim

Insulin tolerance test (ITT) is accepted as the gold standard test for the assessment of growth hormone (GH)–insulin like growth factor (IGF-1) axis and hypothalamic-pituitary-adrenal (HPA) axis. The goal is to achieve a blood glucose level ≤40 mg/dl during ITT for an effective test hence correct assessment of HPA and GH-IGF-1 axes. In this study, we aimed to compare GH and cortisol responses of patients who achieved biochemical hypoglycemia or not during ITT.

Material-Method

Eighty-six patients with pituitary disorders were included in the study. All patients had clear  symptoms of hypoglycemia during ITT and blood glucose levels were obtained during these symptoms at the beginning of ITT. Since the patients were clearly symptomatic The patients were divided into two groups according to their plasma glucose level was ≤ 40 mg/dl or >40 mg/dl during ITT.

Results

The mean age of the patients between 2 groups were found to be similar. The patients had similar body mass index and waist circumference in both groups. The mean blood glucose level was significantly lower in the hypoglycemic group (19.3±0.9) than in non-hypoglycemic group (52.0±2.3 mg/dl). Basal cortisol levels of the patients were similar in both groups. When two groups were compared in terms of peak cortisol and GH responses to insulin-induced hypoglycemia, no statistically significant differences were found.

Conclusion

Present data suggest that clinically symptomatic hypoglycemia is more important than biochemically confirmed glycemic level ≤40 mg/dl during ITT.

 

Nothing to Disclose: YS, ZK, HD, SA, FT, KU, FK

12788 8.0000 SAT-0825 A Is Biochemical Hypoglycemia Necessary during Insulin Tolerance Test? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0818-0831 4780 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis 1 - CAH, AI & Cushing's Poster

Peter Kamenický*1, Alban Redheuil2, Charles Roux3, Sylvie Salenave4, Jacques Young5, Elie Mousseaux6 and Philippe Chanson7
1Univ Paris-Sud, UMR-S693, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France, 2Université Pierre et Marie Curie, Département d’Imagerie Cardiovasculaire, Paris, France, 3AP-HP, Hôpital Européen George Pompidou, Service de Radiologie Cardiovasculaire, Paris, France, 4AP-HP, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, France, 5Université Paris-Sud, Faculté de Médecine Paris-Sud & AP-HP, Hôpital de Bicêtre, Service d’Endocrinologie et des Maladies de la Reproduction, Le Kremlin-Bicêtre, France, 6Université Paris Descartes, Faculté de Médecine & AP-HP, Hôpital Européen George Pompidou, Service de Radiologie Cardiovasculaire, Paris, France, 7Univ Paris-Sud, UMR-S693, Le Kremlin Bicêtre, France, Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Service d’Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, Paris, France, Le Kremlin-Bicêtre, France

 

Background Cardiac structure and function in Cushing’s syndrome has been evaluated in few echocardiographic studies that reported left ventricular (LV) hypertrophy with LV dysfunction. Echo-based measurements require assumptions about LV geometry, which may limit the accuracy of mass and volume measurements especially in obese patients. Little is known about right ventricular (RV) and left atrial (LA) size and function in this setting. The aim of this study was to evaluate LV, RV and LA structure and function by cardiac magnetic resonance (CMR), currently the reference modality in such assessment.

Methods and Results Eighteen patients with active Cushing’s syndrome and 18 normotensive volunteers matched for age, sex and body mass index were studied by CMR. In patients, imaging was repeated after normalization of cortisol secretion. Patients compared to controls had lower LV, RV and LA ejection fractions (P<0.001 for all) despite comparable end-diastolic volumes, ruling out pre-load differences. Patients had markedly increased end-diastolic LV segmental thickness in the basal (P<0.001), mid-LV (P<0.001) and apical (P<0.001) short axis planes associated with a trend towards increased LV mass. However, only one patient had LV hypertrophy according to the conventional CMR threshold. Treatment of hypercortisolism improved ventricular and atrial systolic performance, as reflected by a 15% increase in LV ejection fraction (P=0.029) and 45% increase in LA ejection fraction (P<0.001) with a trend for an 11% increase in RV ejection fraction. The end-diastolic segmental thickness decreased by 37% in the basal (P<0.001), 34% in the mid-LV (P<0.001) and 35% in the apical (P<0.001) short axis planes. LV mass index and end-diastolic LV mass/volume ratio decreased by 17% (P<0.001) and 10% (P=0.002) after treatment, pointing to more excentric LV geometry. The treatment-related decrease in LV mass was independently associated with changes in glucose metabolism (r2=0.82, P<0.001) and BMI (r2=0.61, P=0.017). Late-gadolinium enhancement was absent in all patients.

Conclusion Cushing’s syndrome is associated with subclinical biventricular and LA systolic dysfunction that are reversible after treatment in the absence of dense myocardial fibrosis. Despite skeletal muscle atrophy, Cushing’s syndrome patients have increased LV wall thickness and a tend to have increased LV mass, reversible upon normalization of cortisol excess.

 

Nothing to Disclose: PK, AR, CR, SS, JY, EM, PC

14742 9.0000 SAT-0826 A Cardiac Structure and Function in Cushing's Syndrome Assessed By Cardiac Magnetic Resonance Imaging 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0818-0831 4780 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis 1 - CAH, AI & Cushing's Poster

A Ram Hong*1, Jung Hee Kim1, Yoon Ji Kim1, Kyeong Seon Park1, Eun Ky Kim1, Sang Wan Kim2, Chan Soo Shin1 and Seong Yeon Kim1
1Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 2Seoul Metropolitan Government Boramae Medical Center, Seoul, Korea, Republic of (South)

 

Salivary cortisol has been used as a diagnostic test for Cushing’s syndrome. However, the diagnostic performance of morning salivary cortisol for adrenal insufficiency was less established. Furthermore, ACTH-stimulated salivary cortisol has rarely been evaluated in identifying adrenal insufficiency. We aimed to investigate the diagnostic utility of morning basal and ACTH-stimulated salivary cortisol in assessing adrenal insufficiency in Korean adults.

We prospectively included 120 subjects (female, n=70) in Seoul National University Hospital, who was subjected to the short Synacthen test (SST) to identify adrenal insufficiency. A peak serum cortisol level below 18 μg/dl during the SST was used to diagnose adrenal insufficiency. Saliva was collected by chewing a cotton swab and saliva-collecting device. Salivary cortisol levels were measured using an enzyme immunoassay kit. Serum and saliva sampling were taking from 0800 h to 0900 h in the morning.

Thirty-five patients were diagnosed with hypocortisolism according to the SST results. Age, gender, BMI, serum albumin, and serum creatinine were not different in between normal and adrenal insufficiency group. Basal and peak salivary cortisol levels were positively correlated with basal (r=0.538) and peak serum cortisol levels (r=0.750), respectively (all P <0.001). Basal salivary cortisol level in adrenal insufficiency group was significantly lower than that in normal group (0.130 ± 0.288 vs. 0.260 ± 0.195 μg/dl, P <0.001). Receiver-operating characteristic (ROC) analysis allowed that the cutoff levels with at least 95% sensitivity and specificity were 0.378 and 0.068 μg/dl, respectively (area under the curve (AUC), 0.815). The optimal cutoff value of peak salivary cortisol was 0.477 μg/dl (sensitivity, 91.8%; specificity, 94.3%; AUC, 0.960). Subjects with peak salivary cortisol level above 0.477 μg/dl but peak serum cortisol level below18 μg/dl (n=2) had lower serum albumin levels compared with those with concordant response. In addition, subjects with peak salivary cortisol level below 0.477 μg/dl but peak serum cortisol level above 18 μg/dl (n=7) had higher serum creatinine levels than those with concordant response.

Morning basal salivary cortisol measurement can be used as a noninvasive screening tool in assessing adrenal insufficiency. The diagnostic performance of peak salivary cortisol measurement after the SST was comparable with serum cortisol measurement.

 

Nothing to Disclose: ARH, JHK, YJK, KSP, EKK, SWK, CSS, SYK

16589 10.0000 SAT-0827 A Diagnostic Utility of Morning Basal and Stimulated Salivary Cortisol in Assessing Adrenal Insufficiency in Korean Adults 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0818-0831 4780 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis 1 - CAH, AI & Cushing's Poster

Luciane Carneiro de Carvalho*1, Regina Martin Matsunaga1, Aline Machado Zamboni1, Elaine M F Costa1, Sorahia Domenice1, Rosana Barbosa Silva1, Margaret de Castro2, Livia M Mermejo2, Fernanda B. Coeli-Lacchini3, Rosana Quezado4, Virginia Ribeiro Teixeira4, Fabricia Torres Gonçalves5, Alexandre Jose Faria Carrilho6, Kenny Yelena Del Toro Camargo7, Gabriela Paula Finkielstain8, Ignacio Bergada9, Giselle Fernandes Taboada10 and Berenice Bilharinho Mendonça1
1University of São Paulo, Hospital das Clinicas, São Paulo, Brazil, 2University of São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, Brazil, 3Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil, 4Federal University of Ceara, Fortaleza, Brazil, 5Federal University of Uberlândia, Uberlândia, Brazil, 6State University of Londrina, Londrina, Brazil, 7Unidad Médica Villa Country, Barranquilla, Colombia, 8Centro de Investigaciones Endocrinológicas (CEDIE); Hospital de Niños Dr. Ricardo Gutiérrez, Buenos Aires, Argentina, 9Centro de Investigaciones Endocrinológicas Dr. César Bergadá, Buenos Aires, Argentina, 10Federal University Fluminense, Niteroi, Brazil

 

Congenital adrenal hyperplasia due to P450c17 deficiency is a rarely reported in 46,XX patients. Report the clinical, laboratory, genetic and ovarian imaging in 46,XX patients. We evaluated 18 Brazilian patients belonging to 12 families, and reviewed 10 cohorts with deficiency of P450c17 activity, 7 due to CYP17 defects and 3 due to POR defects, 46 patients were 46,XX, and 13 patients had complete clinical, laboratory, genetic and ovarian evaluation. From our cases, most patients had primary amenorrhea (83%) and 17%  had secondary amenorrhea; 89% of the patients had blood hypertension at diagnosis. The ultrasound showed an increase of at least one of the ovaries in 75% of the patients before treatment and ovarian macrocists in 56%; three of them had previous surgery for twisting or ovarian rupture. The patients were treated with dexamethasone, estrogen and progesterone with ovarian volume reduction. Around 80% of patients in the literature also showed ovarian enlargement. We observed a high incidence of emotional disorders such as depression and anxiety (13/18) in our cohort but no reports were found in the literature. All patients showed basal elevated basal LH and progesterone levels, and decreased androgen levels. In our cases, the molecular study showed that 17 patients have inactivating mutation in the CYP17 gene and 1 in POR gene. Two novel mutations were identified in CYP17 gene, the p.R362H in exon 6 and p.G478S in exon 8. The most prevalent mutation in CYP17 was p.W406R, followed by p.P428L. In cases of literature, the clinical and laboratory data are similar to those of our patients, although psychological disorders were not reported. In literature review the patients came from the 5 continents and there was a predominance of Chinese and Brazilian with defects in CYP17 whereas defects in POR were most reported in European and American subjects. Mutations in the CYP17 found in Brazilian patients differ from those found in most patients already reported, but the mutation found in POR gene in one of our patient (p.A287P) is the most prevalent in the literature. In this review on thirty-one 46,XX patients with deficiency of P450c17 activity, we emphasize the importance of basal progesterone measurement for this diagnosis and the high prevalence of ovarian macrocists with risk of twisting and of psychiatric disorders.

 

Nothing to Disclose: LCD, RMM, AMZ, EMFC, SD, RBS, MD, LMM, FBC, RQ, VRT, FTG, AJFC, KYDTC, GPF, IB, GFT, BBM

15896 11.0000 SAT-0828 A Phenotype and Genetic Aspects of 46,XX Patients with Congenital Dysfunction of the P450c17 Activity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0818-0831 4780 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis 1 - CAH, AI & Cushing's Poster

Mary Ellen Vajravelu*1, Jared Tobolski2, Evanette Burrows3, Marianne Chilutti3, Vaneeta Bamba4, Steven Matthew Willi1 and Shana E. McCormack4
1Children's Hospital of Philadelphia, Philadelphia, PA, 2Drexel University College of Medicine, Philadelphia, PA, 3Children's Hospital of Philadelphia, 4The Children's Hospital of Philadelphia, Philadelphia, PA

 

Background: Corticotropin-releasing Hormone (CRH) stimulation testing is used to evaluate suspected adrenocorticotropic hormone (ACTH) deficiency in at-risk children, but the clinical factors that determine maximal cortisol response are not known. Previous studies have not systematically evaluated the effect of age and body surface area (BSA), particularly in young children (age < 6 years).

Objective: To determine the effect of age and BSA on peak cortisol response to CRH in children referred for clinical testing.

Subjects/Setting: 288 children, ages 30 days – 18 years, undergoing their first outpatient CRH stimulation testing at a tertiary referral center, 2007-2013

Design/Methods: Retrospective observational study. All subjects received 1mcg/kg corticorelin per testing protocol. Bioinformatics-based extraction of clinical and laboratory values, as well as manual record review, were performed to abstract variables of interest. Univariate and multivariate regression analyses were performed.

Results: Subjects were 70% male, with mean age (+/- SD) 8.8 +/- 4.6 years (154 days-17.8 years), 76% pre-pubertal. Peak cortisol was 21.2 mcg/dl +/- 8.0; 24% were <18 mcg/dL. Indications for testing included: short stature with concern for GH deficiency, divided into those found to be GH sufficient >10 ng/mL (n=39, group 1) or insufficient (n=38, group 2), anatomic and/or syndromic risk for pituitary insufficiency (n=62, group 3), neoplasm with treatments increasing risk for cortisol deficiency (n=56, group 4), previous steroid exposure (n=58, group 5), known hypopituitarism (n=23, group 6), and other (n=12, group 7). Subjects with incomplete anthropometric data (documentation within 3 months of testing) were excluded from subsequent analyses (n=31). Among all subjects with available data, peak cortisol was inversely correlated with age (r=-0.15, p=0.01) and BSA (r=-0.21, p=0.0009). The association between peak cortisol and BSA held in each of groups 1 and 3, with similar trends in groups 2 and 4 (r=-0.3,p=0.06; r=-0.22, p=0.11). In groups 1-4, peak cortisol was more likely to be >=18 mcg/dL (88%) than in groups 5 and 6 (43%; p<0.001). Multivariate regression analysis was performed to determine the independence of these physiologic effects, excluding groups 5 and 6 due to high failure rates (66% and 37%, respectively). When both age and BSA were included in the model, BSA remained negatively correlated with peak cortisol (p<0.001); after accounting for BSA, age was positively associated with peak cortisol (p=0.004). These results held even after sex, pubertal status, and indication for testing were included in the model.

Conclusions: Despite the use of a weight-based dosing protocol, peak cortisol response to CRH is independently negatively associated with BSA in children referred for clinical testing. The clinical implications of this finding will be the focus of additional study.

 

Nothing to Disclose: MEV, JT, EB, MC, VB, SMW, SEM

12144 12.0000 SAT-0829 A Peak Cortisol Response to Corticotropin-Releasing Hormone Is Related to Age and Size in Children Referred for Clinical Testing 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0818-0831 4780 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis 1 - CAH, AI & Cushing's Poster

Maya Beth Lodish*1, Yasaman Ardeshirpour2, Ali Afshari2, Evgenia Gourgari3, Margaret Farmar Keil4, Elena Belyavskaya4, Charalampos Lyssikatos5, Victor Chernomordik6, Amir Gandjbakhche6 and Constantine A Stratakis7
1National Institutes of Health, Bethesda, MD, 2NIH, 3Georgetown University Hospital, Washington, DC, 4Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH)., Bethesda, MD, 5Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 6NICHD, Bethesda, MD, 7National Institutes of Health (NIH), Bethesda, MD

 

In this study, we used non-invasive multi-spectral imaging (MSI) before and after surgery (transphenoidal surgery (TSS), bilateral adrenalectomy, or surgical resection of pulmonary carcinoid) to quantify changes of facial plethora in patients with Cushing’s syndrome (CS) as an early assessment of their cure. As a follow-up to our previous pilot study in 5 patients, we have expanded the use of this technology to a larger cohort. Twenty patients with CS (14 F, mean age 19.8 ± 12.3) were studied. Among these patients, 17 patients had ACTH secreting pituitary tumors (Cushing Disease, CD), 2 had ACTH-independent adrenocortical tumors and one had an ectopic ACTH-secreting pulmonary carcinoid. In the single case that required two surgical procedures to achieve cure of CD, MSI data after the first non-curative TSS considered “pre surgery” and the MSI after the re-operation was used to assess correlation with cure. Two patients with CD were excluded from the study, one secondary to severe facial acne and the second due to fever on the day of imaging. MSI was performed on the right cheek of the patients prior to TSS and a mean of 5.6 ± 3.9 days after surgery using 4 wavelengths (700,750, 800 and 850nm) with a Near Infrared CCD based multispectral imaging system. Spectral analysis, using the two-layer skin model along with a curvature correction algorithm, was applied to quantify the fraction of blood volume of the tissue (2). Data are presented as mean ± SD.  A two-tailed Fisher’s exact test was used to examine the association between cure of CS and change in MSI data. Fourteen of the 18 patients were surgically cured of disease with post-operative measurements of plasma cortisol < 2 μg/dl as previously described (1).  Pre-op AM cortisol values of patients were 23.9 ± 18.8 μg/dL. The post-op AM cortisol in the 14 cured patients reduced to 1.33 ± 0.62 μg/dL, whereas the AM cortisol level in the non-cured patients is decreased only to11.9 ± 2.9 μg/dL. In all patients, who entered remission for their CS, the mean value of tissue blood content (volume percentage), observed at the patient right cheek, is significantly reduced, after surgery, relative to one, measured before treatment, i.e., 17 ± 2.6 versus 14.7 ± 3 %. To the contrary, in all five patients, who were not surgically cured, blood volume percentage at their right cheeks, increased from pre- to post-operative measurements, %(18.6 ± 3.9 to 21.6 ± 4.3), p-value ≤0.0001. Clinical data, obtained from 18 patients, indicate that a decrease in facial plethora after surgery, evidenced by blood volume decrease, is well correlated with cure of CS. Thus, discussed novel technology is a promising early marker of cure of patients with Cushing’s syndrome after surgery, along with biochemical data

 

Nothing to Disclose: MBL, YA, AA, EG, MFK, EB, CL, VC, AG, CAS

12888 13.0000 SAT-0830 A Non-Invasive Multi-Spectral Imaging for Pre and Post-Operative Assessment of Patients with Cushing's Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0818-0831 4780 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis 1 - CAH, AI & Cushing's Poster

Oskar Ragnarsson*1, Anders F. Mattsson2, John Patrick Monson3, Helena Filipsson Nyström4, Gudmundur Johannsson1, Ann-Charlotte Akerblad5 and Maria Koltowska Häggström6
1Sahlgrenska University Hospital, Gothenburg, Sweden, 2Pfizer Health AB, Sollentuna, Sweden, 3London Clinic Ctr for Endo, London, United Kingdom, 4Sahlgrenska University Hospital, Gothenburg, 5Endocrine Care, Pfizer Health AB, Sollentuna, Sweden, 6Uppsala University, Uppsala, Sweden

 

Introduction

Adult hypopituitary patients have impaired quality of life (QoL). This study analyzed: a) the impact of glucocorticoid (GC) replacement on QoL, b) the impact of GC doses on QoL, and c) the influence of ACTH insufficiency on the effect of growth hormone (GH) replacement on QoL. The main hypothesis was that ACTH insufficient patients experience a dose dependent deterioration in QoL.

Patients and study design

This was a retrospective analysis of data from 2,737 hypopituitary patients obtained from KIMS (Pfizer International Metabolic Database).  All patients had GH deficiency. Data at baseline and after one year of GH replacement were analyzed.

Methods

Data on background characteristics were obtained from KIMS as reported by participating centres. QoL was assessed by the QoL-assessment of GH deficient adults (QoL-AGHDA). Higher scores (up to 25) denote poorer QoL. Total score and 5 dimensions (memory, tiredness, tenseness, social isolation and self-confidence) were analyzed with linear regression. P-values <0.05 were considered as statistically significant.

Results

Nine hundred eighty seven patients (36%) were ACTH sufficient and 1,750 (64%) were ACTH insufficient. The mean ± SD hydrocortisone (HC) dose was 22.3 ± 8.7 mg (median 20.0). After adjustment for age, gender, weight, etiology, KIMS entry year, country, onset of pituitary disease (childhood versus adult), TSH deficiency and serum IGF-I SDS, no difference in mean QoL score was observed between the ACTH sufficient [11.1 (95% CI 10.6-11.7)] and ACTH insufficient patients [11.0 (95% CI 10.5 – 11.5); P =0.81]. There was an association with increasing HC dose and worse QoL. Patients on HC ≤10 mg had the best and patients with doses ≥25 mg the poorest QoL. There were also statistically significant associations between increasing HC dose and problems with tiredness, tenseness and social isolation. At one year on GH replacement, QoL improved at a similar rate in ACTH sufficient and insufficient patients. No association was observed between HC dose and the improvement in QoL.

Conclusion

Hypopituitary patients with untreated GH deficiency on GC replacement have similar QoL as ACTH sufficient patients, however it should be noted that QoL-AGHDA is a GHD-sensitive measure. In patients with ACTH insufficiency, an adverse dose-dependent association with QoL was observed that may be explained by supraphysiological GC exposure or an empirical increase in GC dose in patients with negatively affected QoL.

 

Disclosure: OR: Speaker, Pfizer, Inc.. AFM: Employee, Pfizer, Inc.. GJ: Speaker, Pfizer, Inc., Speaker, Novo Nordisk, Speaker, Otsuka, Consultant, Viropharma, Consultant, Astra Zeneca. ACA: Employee, Pfizer, Inc.. MK: Employee, Pfizer, Inc.. Nothing to Disclose: JPM, HF

12975 14.0000 SAT-0831 A Glucocorticoid Replacement Therapy and Quality of Life: A Study in 2,737 Hypopituitary Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Saturday, June 21st 3:00:00 PM SAT 0818-0831 4780 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis 1 - CAH, AI & Cushing's Poster

Karin Amrein*1, Christian Schnedl2, Alexander Holl3, Regina Riedl4, Kenneth B. Christopher5, Tadeja Urbanic-Purkart4, Andrea Berghold4, Thomas R Pieber6, Christoph Pachler4, Andreas Waltensdorfer4, Andreas Münch4, Tatjana Stojakovic4, Egbert Bisping4, Wolfgang Toller4 and Harald Dobnig7
1Medical University of Graz, Graz, Austria, 2Medical University Graz, Graz, Austria, 3Department of Neurology, 4Medical University of Graz, 5Renal Division, Brigham and Women's Hospital, 6Medical University of Graz, Austria, 7Schilddruesen|Endokrinologie|Institut, Graz, Austria

 

Introduction

Observational studies have shown an association between low vitamin D status and poor outcomes including increased mortality in critically ill patients. Whether this relationship is causal remains unclear to date. 

 

Methods

In this randomized, double-blind, placebo-controlled single-center trial, five intensive care units assigned a mixed medical and surgical population of 480 adult patients with vitamin D deficiency (≤20 ng/ml) to either vitamin D or placebo. Vitamin D3 was given orally or via nasogastric tube once at a dose of 540,000 IU followed by 5 monthly maintenance doses of 90,000 IU.

 

Results

Vitamin D3 administration led to an immediate and sustained rise of mean 25-hydroxyvitamin D levels in the interventional vs. the placebo group: 13.0±4.0 vs.13.1±4.3 (baseline); 35.5±20.6 vs. 14.5±5.1 ng/ml (day 7; P<0.001). The primary endpoint, length of hospital stay, was comparable between groups (median 20.1 vs.  19.3 days, P=0.98). Hospital- and 6-month mortality rates in contrast, tended to be lower in the vitamin D group [HR 0.81 (95%CI 0.58-1.11), P=0.18 and HR 0.78 (0.58-1.04), P=0.09, respectively]. In the predefined subgroup analysis of patients with severe vitamin D deficiency (≤12 ng/ml, n=200), hospital- and 6-month mortality rates were significantly reduced [HR 0.56 (95%CI 0.35-0.90), P=0.01 and HR 0.60 (0.39-0.93), P=0.02, respectively]. At the 6-month follow up, patients with severe vitamin D deficiency at baseline did not show any significant changes in investigated parameters compared to the placebo group whereas patients with less severe vitamin D deficiency (baseline 25(OH)D level >12 and ≤20 ng/ml) showed significantly improved grip strength of the right hand as well as a higher physical component summary score of the SF-12 questionnaire. Adverse event rates including hypercalcemia, falls and fractures were similar in both groups.

Conclusions

High-dose vitamin D3 in critically ill patients did not change the length of hospital stay but tended to decrease hospital- and 6-month mortality. In patients with severe vitamin D deficiency, vitamin D3 reduced all cause mortality, as compared with placebo. (ClinicalTrials.gov number: NCT01130181)

 

Nothing to Disclose: KA, CS, AH, RR, KBC, TU, AB, TRP, CP, AW, AM, TS, EB, WT, HD

12989 1.0000 SAT-0229 A Correction of Vitamin D Deficiency in Critically Ill Patients: A Randomized Placebo-Controlled Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Shariq Rashid Masoodi*1, Khalid J Farooqui2, Abdul Hamid Zargar3, Arshad Iqbal Wani4, Mir Iftikhar Bashir4, Syed Mudassar4 and Mushtaq Siddiqi5
1Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India, 2Sher-i-Kashmir Institute of Medical Sciences, 3Center for Diabetes & Endocrine Care, Srinagar, India, 4Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India, 5Sher 1 Kashmir Institute of Medi, Srinagar, J&K, India

 

BACKGROUND: There is a worldwide epidemic of Vitamin D deficiency with Kashmir Valley (Northern India) being no exception. About 83% of apparently healthy adults in the Kashmir valley are reported to be vitamin D deficient despite adequate exposure to sunlight and adequate consumption of dairy products. A positive correlation between vitamin D deficiency, glucose intolerance and impaired insulin secretion has been demonstrated in subjects with PCOS. Serum levels of 25-hydroxyvitamin D [25(OH) D] are inversely correlated with insulin resistance (IR) in subjects with PCOS. Apart from vitamin D deficiency, PCOS is also very common in Kashmir Valley.

OBJECTIVE: To determine the association between vitamin D status and components of Metabolic Syndrome (Met-S) in women with PCOS and the effects of vitamin D supplementation on IR parameters.

STUDY DESIGN: In this randomized double-blind, placebo-controlled trial, 123 eligible enrolled subjects were randomly divided into three groups of 41 each: Group I: Active Vitamin D3 Tablets (1000U/tab), twice a day plus placebo sachets; Group II: Placebo Tablets plus Active Vitamin D3 sachets (60,000U/sachet); and Group III: Tablets: Placebo; sachets: Placebo. Effects of Vitamin D supplementation, 2,000 IU per day (Group I) or 60,000 IU per month (Group II) were compared with those of placebo (Group III) on measures of IR at 3 months.

METHODS: The fasting blood glucose, insulin, 25(OH) D, HOMA-IR and QUICKIE were measured at baseline and after treatment.

RESULTS:Hypovitaminosis D was present in 115 out of 123 PCOS women (93.4%). Of the 115 subjects with hypovitaminosis D, 98 (79.7%) had vitamin D deficiency (< 20 ng/ml). Using the IDF criteria Met-S was identified in 30 subjects (24.4%). Baseline 25(OH) D did not show any correlation with components of Met-S. The mean 25(OH) D levels increased from 13.76±10.60 ng/dl to 25.71±15.04 ng/dl after intervention (86.84% change).Post Vitamin D supplementation, 48(39%) subjects achieved vitamin D sufficiency as compared to 8(6.5%) at baseline. Similarly the number of subjects with severe, moderate and mild vitamin deficiency before intervention i.e. 55(44.7%), 43(35%) and 17(13.8%) respectively improved to 25(20.3%), 19(15.4%) and 31(25.2%) after intervention. The mean HOMAIR did not show any significant change overall (2.30±4.13 vs. 3.96±6.82), but in 53 subjects in whom Vitamin D levels increased by two-fold with a post-supplementation 25(OH)D level of ≥20 ng/ml, a statistically significant improvement in HOMA-IR was observed (P= 0.025).

CONCLUSIONS: Vitamin D3 supplementation equivalent to 2000 IU daily for 3 months normalises vitamin D status in around half of the predominantly Vitamin D deficient subjects with PCOS, but improves insulin resistance in only those with significant  increase in vitamin D levels (two-fold increase with a post-supplementation 25(OH)D level of 20 ng/ml or more)

 

Nothing to Disclose: SRM, KJF, AHZ, AIW, MIB, SM, MS

16938 2.0000 SAT-0230 A Polycystic Ovary Syndrome and Vitamin D Status - Impact of Vitamin D Supplementation on Insulin Resistance 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Kyu-jin Kim*1, Bo-Yeon Kim1, Chan-Hee Jung1, Chul-Hee Kim2, Sung-koo Kang2 and Jioh Mok1
1Soonchunhyang University School of Medicine, Bucheon hospital, Bucheon, Korea, Republic of (South), 2Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon city, Gyeonggi-do, Korea, Republic of (South)

 

Existing evidence suggests that vitamin D deficiency may contribute to the development of atherosclerosis. The aim of our cross-sectional study was to assess the association of circulating vitamin D metabolite concentrations with insulin resistance and subclinical atherosclerosis in patients with T2DM.

Two hundred thirty seven T2DM patients who were measured serum 25-hydroxyvitamin D(25(OH)D) at diabetes clinic, from January 2009 to September 2013 (89 males and 148 females, mean age 60 years, mean duration of DM 8.5 years) were enrolled. Viatamin D status was categorized into three groups, deficiency [25(OH)D < 10ng/mL], insufficiency [10ng/mL ≤ 25(OH)D < 20ng/mL] and sufficiency [20ng/mL ≤ 25(OH)D]. Then, basic characteristics, insulin resistance, subclinical atherosclerosis marker and diabetic microangio pathies were analyzed by intergroup differences according to vitamin D status. Carotid atherosclerosis was assessed by B-mode ultrasonography. In addition, the patients were evaluated diabetic microangiopathies and baPWV and ABI to evaluate atherosclerotic burden.

The prevalence of deficiency (<10 ng/ml) and sufficiency (≥20 ng/ml) of vitamin D in T2DM patients was 25.3% and 24.1%, respectively. In intergroup analysis of variance, vitamin D deficiency had positive correlation with hsCRP level (p=0.025), fasting insulin level (p=0.045), c-peptide level (p=0.004) and HOMA-IR level (p=0.021). And, there was significant difference in cIMT mean values by degrees(0.66±0.17 vs. 0.59±0.15 vs. 0.540± 0.16 mm; p=0.044) of subclinical atherosclerosis markers between groups. But, there was no significant difference in prevalence of retinopathy and nephropathy. In relation analysis of vitamin D status with insulin resistance, subclinical atherosclerosis and microangiopathies, vitamine D deficiency was related to fasting c-peptide level (r=-0.174, p=0.011) and HOMA-IR level(r=-0.144, p=0.047).

In this present study, vitamin D deficiency were associated with insulin resistance, inflammation and atherosclerosis. But, there was not a correlation between vitamin D deficiency and diabetic microangiopathies

 

Nothing to Disclose: KJK, BYK, CHJ, CHK, SKK, JM

13190 3.0000 SAT-0231 A Association Vitamin D Status with Subclinical Atherosclerosis in Patients with Type 2 Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Asma Javed*1, Adrian Vella1, Prabhakara P Balagopal2, Philip Fischer1, Amy Weaver1, Francesca Piccinini3, Chiara Dalla Man3, Claudio Cobelli3, Paula Giesler1, Jeanette Laugen1 and Seema Kumar1
1Mayo Clinic, Rochester, MN, 2Res Div, Jacksonville, FL, 3University of Padova, Padova, Italy

 

 

Effect of Vitamin D supplementation on Insulin Sensitivity and Beta Cell Function in Obese adolescents

Background: Despite the strong relationship between Vitamin D deficiency and obesity, ambiguity exists on its potential relationship with insulin sensitivity and β-cell function in obese adolescents.

Objective: To determine if Vitamin D supplementation has any impact on insulin sensitivity (Si)and pancreatic β-cell function as assessed by oral glucose tolerance test (OGTT) in obese adolescents.

Study Design and Methods: The study design was a 12 week double blinded, randomized, comparison of the effect of vitamin D supplementation on Si and β-cell function (Disposition Index or DI) in obese, Caucasian adolescents (BMI > 95th percentile) aged 12-18 years. The subjects were randomized to receive either 400 IU/ day of Vitamin D3 supplementation (n=23) or 2000 IU/day (n=24) for 12 weeks. Each subject underwent a 7-sample 75 g oral glucose tolerance test (OGTT) with glucose, insulin and C peptide used to calculate Siand DI using the oral minimal model before and after Vitamin D supplementation.

Results: A total of 47 subjects (age: 15.0±1.9 years) with mean BMI percentile 98.1±1.2 were randomized to 2000 IU/day (n=24) or to 400 IU/day (n=23) of Vitamin D supplementation. Mean 25(OH)D concentration was 24.0±8.1 ng/mL with 37 (78.7%) subjects having 25(OH)D level less than 30 ng/mL. There was no correlation between plasma 25(OH)D levels and insulin sensitivity or DI in the subjects at baseline.  There was a modest but statistically significant increase in the 25(OH)D level in the 2000 IU/day arm (3.1 ± 6.5 ng/mL, p=0.04) but not in the 400 IU/day group (0.8 ± 4.2 ng/mL, p=0.40). There was no significant change in the Si in either group, (-4.97 ± 15.94, p-value= 0.28) in the 2000 IU arm and (0.42 ± 4.29, p = 0.81) in the 400 IU group. The change in Sidid not differ between groups (p-value 0.12).

There was no significant change in DI in either group (2000 IU: 1865.2 ± 6833.7, p-value 0.22 and 400 IU: 274 ± 824.9, p-value 0.44). The change in DI also did not differ between groups (p-value 0.2).

Conclusions: Our study explores the relationship between Vitamin D status and dynamic measures of insulin sensitivity and β-cell function in obese Caucasian adolescents. Vitamin D supplementation at 2000 IU/day and 400 IU/day for 12 weeks in obese adolescents did not impact dynamic measures of insulin sensitivity and β-cell function. Given the modest increase in 25 (OH) D concentrations with these supplementation doses, further studies with higher doses of vitamin D and longer duration are warranted.

 

Disclosure: AV: Advisory Group Member, Sanofi. Nothing to Disclose: AJ, PPB, PF, AW, FP, CD, CC, PG, JL, SK

13291 4.0000 SAT-0232 A Effects of Vitamin D Supplementation on Insulin Sensitivity and Beta Cell Function in Obese Adolescents 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Angela Mojica*1, Kathleen Bethin2 and Lucy D Mastrandrea1
1University at Buffalo, Buffalo, NY, 2University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY

 

Higher rates of vitamin D deficiency have been found among obese children and adolescents. Several studies have shown an inverse relationship between 25(OH) D levels and fasting glucose levels as well as insulin resistance (1) (2). The outcome of treating vitamin D deficiency on glucose homeostasis in children hasn’t been examined in large randomized prospective controlled studies. The aims of this study are to examine the relationship between 25-OH D level and insulin resistance in obese/overweight children and the effect of vitamin D supplementation on insulin sensitivity in subjects with low vitamin D by measuring changes in Homeostasis Model of Assessment - Insulin Resistance (HOMA-IR). We also sought to compare the magnitude of this effect in relation to race and baseline vitamin D level (deficient vs. insufficient). Using a prospective clinical trial design, we recorded BMI, vitamin D intake, acanthosis nigricans, fasting glucose and insulin, and  25-OH D levels in obese/overweight children (age 10 – 18yr) seen at a subspecialty endocrine clinic and at a General Pediatric practice from January 2013 to January 2014.  These assessments were done at baseline and 6 months after vitamin D supplementation per the Endocrine Society Guidelines in subjects with low vitamin D levels. A total of 52 subjects (31 female) were recruited for the study.  92% of the subjects had 25-OH D levels below 30 ng/mL (52% had 25-OH D below 20 ng/mL and 40% 21-29 ng/mL). African American subjects were more likely to be diagnosed with Vit D deficiency (25OHD < 20 ng/ml; p = 0.01). Although there were no significant differences in HOMA-IR among the vitamin D deficient and insufficient groups, 51% and 43% of the subjects had HOMA-IR levels above 2.5 and 3.16 respectively. Vitamin D levels trended toward a negative correlation with insulin levels (r= -0.26; p=0.06), but this correlation was not significant for fasting glucose (r=-0.08; p=0.58) or HOMA-IR (r=-0.22; p=0.11). Odds ratio of having insulin resistance based on HOMA-IR >2.5 and >3.16 was 0.78 (p=0.0025) and 0.84 (p=0.0094) respectively. Analysis of 6 month follow-up data for 12 subjects demonstrated that BMI is a stronger predictor of HOMA-IR change than vitamin D level. Subjects with 25-OH D below 30 ng/mL tend to have elevated fasting insulin; however it is unclear whether vitamin D supplementation alone improves insulin resistance.

 

Nothing to Disclose: AM, KB, LDM

11123 5.0000 SAT-0233 A Effect of Vitamin D Deficiency/Insufficiency Treatment on Insulin Resistance in Obese and Overweight Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Mansi Mehta*1, Barbara Tommasulo1, Renee Pekmezaris2, Andrzej Kozikowski2, Meredith Akerman1, Nooshi Karim1, Judy Beizer2, Sidhu Jasdeep1, Stuart A Weinerman2 and Gisele Wolf-klein1
1North Shore LIJ Health System, Manhasset, NY, 2North Shore LIJ Health System

 

Background: Older adults and particularly nursing home residents are known to be at risk for Vitamin D deficiency.  Vitamin D deficiency has been implicated as a contributing factor in a multiplicity of diseases including Type 2 diabetes mellitus (DM). We proposed to assess the association of vitamin D deficiency and insufficiency and HbA1C (Haemoglobin A1C) levels in elderly patients with type 2 DM.

Methods: A retrospective chart review study was conducted in a nursing home, using electronic medical records of all patients over the age of 55 from 1/1/07 to 12/31/12. All diabetic residents met American Diabetes Association criteria for diagnosis of type 2 DM. Vitamin D levels, alkaline phosphatase levels, phosphorus, parathyroid hormone levels, calcium and albumin levels were recorded as well as demographics, co-morbidities, mobility, medications and supplements. Vitamin D deficiency was defined as <20 ng/dl, insufficiency as 20-29 ng/dl, and sufficiency >= 30 ng/dl. The Kruskal-Wallis test was used to compare the three groups for continuous variables. The chi-square test or Fisher’s exact test, as deemed appropriate, was used to compare the three groups for categorical variables.

Results: In the 120 patients analyzed, average age was 80 years (range: 56-97), with 71% female and 92% Caucasian. Average body weight was 73 kg (range: 40-149 kg) with BMI of 26 (range: 17-46). In this nursing home population, 37% of subjects were vitamin D deficient, 35% were insufficient and only 28% were sufficient. As expected, there was a significant difference among the three Vitamin D groups for alkaline phosphatase levels (p<0.002), with those subjects that were vitamin D deficient having the highest median levels. However, none of the other variables collected, namely subject age, weight, BMI, serum albumin, calcium levels, phosphorus, HbA1C levels and daily calcium and Vitamin D supplements, were significantly associated with Vitamin D serum levels.

Conclusions: Our study does not support the association between the severity of vitamin D deficiency or insufficiency and elevated HbA1C in elderly Type 2 diabetic patients residing in long term care institutions. 

 

 

Nothing to Disclose: MM, BT, RP, AK, MA, NK, JB, SJ, SAW, GW

11261 6.0000 SAT-0234 A Association Between Vitamin D Deficiency and HbA1C Levels in Elderly Patients with Type 2 Diabetes in Long Term Care Institutions 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Hwa Young Kim*1, Young Ah Lee1, Jung Hae Woon Jung1, Lee Gyung Min Lee1, Chung Seung Joon Chung1, Jieun Lee2, Yoon Ju Young Yoon3, Choong Ho Shin4 and Sei Won Yang1
1Seoul Natl Univ College of Med, Seoul, Korea, Republic of (South), 2Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, Republic of (South), 3National Cancer Center, Goyang, Korea, Republic of (South), 4Seoul National University Children's Hospital, Seoul, Korea, Republic of (South)

 

Many studies suggest that vitamin D deficiency is more common in individuals with type 1 diabetes (T1DM) compared to controls, but mechanisms contributing to the vitamin D deficiency in T1DM remains unclear. With increased urinary loss of vitamin D binding protein (VDBP), a major transport protein for vitamin D metabolites in plasma, the risk of vitamin D deficiency may also be increased as the recirculation of 25-hydroxyvitaminD (25-OHD) is impaired. In this study, we examined whether there was an increased urinary loss of VDBP in pediatric T1DM patients without microalbuminuria and examined for a correlation between VDBP and circulating 25-OHD levels. We also aimed to identify risk factors influencing low vitamin D levels in pediatric T1DM.

Subjects with T1DM without microalbuminuria (n=45) and age-matched healthy control subjects (n=29), aged 9–14 yr, residing in Seoul and the Gyeonggi-Do in Korea (37°N) were studied  during January and March 2013. Height, weight and pubertal stage were evaluated. The percentage of body fat was measured by bioelectrical impedance analysis (inbody). A questionnaire was used to assess the amount of daylight outdoor activity and vitamin D intake. Serum levels of calcium, phosphorus, intact parathyroid hormone, 25-OHD, 1,25 dihydroxyvitamin D and VDBP, as well as urinary levels of VDBP, microalbumin and creatinine (Cr) were measured. 25-OHD deficiency was defined as ≤20 ng/mL.

T1DM subjects were older and showed lower physical activity compared with the control group. However, the percentage of body fat and amount of vitamin D intake were not different between the two groups. There was no difference in the frequency of vitamin D deficiency between the T1DM (55.6%) and control group (44.8%) during the winter season. Serum 25-OHD and VDBP levels were not different. Whereas the urinary microalbumin to Cr ratio (mACR) was not different, the urinary VDBP to Cr ratio (VDBPCR) in T1DM patients was higher than in the control group (P=0.016). VDBPCR was positively correlated with mACR in both T1DM subjects and control groups (P=<0.001). In the univariate analysis, serum 25-OHD levels did not correlate with serum VDBP nor urinary VDBPCR. Age (P=0.050) and daylight outdoor hours (P=0.035) positively correlated with 25-OHD levels. Multivariate regression analysis including known risk factors for vitamin D deficiency such as age, gender, percentage of body fat, vitamin D intake, daylight outdoor hours and urinary VDBPCR showed that the factors affecting 25-OHD level in T1DM patients were daylight outdoor hours (β = 2.881, P = 0.009) and vitamin D intake (β = 2.342, P = 0.050).

In pediatric T1DM patients without microalbuminuria, urinary loss of VDBP was increased in proportion to urinary mACR. However, urinary VDBPCR was not correlated with serum 25-OHD levels. The factors associated with 25-OHD level during winter period were daylight outdoor hours and vitamin D intake.

 

Nothing to Disclose: HYK, YAL, JHWJ, LGML, CSJC, JL, YJYY, CHS, SWY

11293 7.0000 SAT-0235 A A Lack of Association Between Vitamin D-Binding Protein and 25-Hydroxyvitamin D Concentrations in Pediatric Type 1 Diabetes without Microalbuminuria 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Asma Javed*, Ravinder J. Singh, Aida N Lteif and Seema Kumar
Mayo Clinic, Rochester, MN

 

BACKGROUND:Vitamin D deficiency is prevalent worldwide, particularly in the obese.  In this patient population, higher doses of vitamin D are needed to treat vitamin D deficiency. There is insufficient data on the safety or efficacy of high dose once monthly vitamin D supplementation in obese adolescents. Poor compliance is often a concern in adolescence which makes once monthly dosing regimens a suitable option. We conducted a prospective study to determine the short term safety and efficacy of once monthly 100,000 IU vitamin D3 in obese adolescents.

METHODS: 19 obese adolescents (BMI > 95thpercentile) aged 13-18 years with vitamin D deficiency  or insufficiency (serum 25 (OH)D concentration less than 30 ng/ml) received Vitamin D3 100,000 IU orally once a month for three months. Each subject completed a short calcium questionnaire (SCQ) before and after vitamin D supplementation to assess daily calcium intake. Serum calcium, urine calcium and 25(OH)D levels were measured at baseline and 1, 2 and 3 months after starting vitamin D supplementation.  Parathyroid hormone (PTH) levels were obtained at baseline and 3 months.  Changes in 25 (OH)D levels and other biochemical variables were assessed using paired t-tests. Linear regression analyses were used to assess associations between change in 25 (OH) D and various biochemical variables.

RESULTS:Mean age was 15.8 ± 1.7 years, mean BMI was 36.1 ± 6.04 kg/m2 and BMI z score was 2.35 ± 0.56. Mean 25(OH)D concentrations increased from 22.4 ± 4.9 to 34.8 ± 6.7 (ng/ml) (P < 0.01). 25(OH)D levels increased to above 30 ng/mL in 15/19 (79%) of subjects by 3 months. Serum calcium increased by a mean of 0.23 ± 0.01 mg/dL (p < 0.01) but none of the patients were noted to have serum calcium above the reference range. Serum phosphorus concentrations did not change. There was no significant change in urine calcium to creatinine ratio following vitamin D supplementation (P = 0.32). There was a significant decline in PTH (pg/ml) (-7.4 ± 0.6 P=0.01) but none of the subjects had a suppressed PTH. There was no change in calcium intake as assessed by SCQ (P = 0.12).

CONCLUSION: In obese adolescents with inadequate levels of 25(OH)D, vitamin D (3) at a dose of 100,000 IU orally once a month for 3 months appears to be effective in achieving 25(OH)D levels above 30 ng/mL. Hypercalcemia, hypercalciuria and PTH suppression were not found in this short term study. Long term studies are warranted to study the safety and efficacy of this regimen in obese adolescents.

 

Nothing to Disclose: AJ, RJS, ANL, SK

13535 8.0000 SAT-0236 A Short Term Safety and Efficacy of High Dose Vitamin D Supplementation in Obese Adolescents with Vitamin D Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Michael Yuri Torchinsky* and Xu Zhang
University of Mississippi Medical Center, Jackson, MS

 

Background: Low serum 25-OH vitamin D levels are more common in obese children; however, the clinical significance of these findings has been unclear (1-3).

Objectives: The objective was to determine the prevalence of secondary hyperparathyroidism in obese children with serum 25-OH vitamin D <20 ng/ml.       

Methods: We reviewed medical records from the Pediatric Endocrine Clinic over a period of one year and identified forty children aged 3 to 18 years with BMI >95 percentile, who had serum 25-OH vitamin D, intact parathyroid hormone (PTH), serum calcium, phosphorus, albumin, alkaline phosphatase, blood urea nitrogen, creatinine, and urine calcium-to-creatinine ratio measured. Spearman rank correlation coefficient was evaluated to measure association between continuous variables. Fisher’s exact test was used to assess association between categorical variables.

Results: Vitamin D deficiency, defined as serum 25-OH vitamin D level <20 ng/ml, was found in twenty eight out of forty obese children, including six out of eleven children aged 3 to 10 years (54%), and twenty two out of twenty nine children aged 11 to 18 years (76%). The mean 25-OH vitamin D level decreased with age (r=-0.52, p<0.001). Only fifteen out of twenty eight obese children with vitamin D deficiency had secondary hyperparathyroidism, defined as serum PTH >65 pg/ml, including four out of six children aged 3 to 10 years (66%), and eleven out of twenty two children aged 11 to 18 years (50%). Secondary hyperparathyroidism was seen in six out of seven patients with serum 25-OH vitamin D level <15 ng/ml (86%), and only in nine out of twenty one patients with 25-OH vitamin D between 15 and 20 ng/ml (43%). All twelve obese patients with serum 25-OH vitamin D >20 ng/ml had serum PTH within the normal range 10 to 65 ng/ml. There was significant negative association between serum 25-OH vitamin D concentration and incidence of secondary hyperparathyroidism (p<0.001). Urine calcium-to-creatinine ratio inversely correlated with serum PTH levels (r=-0.44, p=0.004).

Conclusions: Obese children with serum 25-OH vitamin D levels <20 ng/ml include patients who have vitamin D deficiency that adversely affects bone metabolism through secondary hyperparathyroidism and those who are vitamin D sufficient based on normal serum PTH and have low 25-OH vitamin D levels presumably due to high volume of distribution of vitamin D in excessive body fat. Measuring serum PTH in conjunction with 25-OH vitamin D may be useful for identifying those obese children who can benefit most from vitamin D replacement. Increase in severity of vitamin D deficiency with age underscores the need for early screening.

 

Nothing to Disclose: MYT, XZ

11104 9.0000 SAT-0237 A Decreased Serum 25-OH Vitamin D Levels Are Not Always Associated with Secondary Hyperparathyroidism in Obese Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Preneet Cheema Brar*1, Bonita H Franklin2 and Nipapat Visavachaipan3
1New York University School of Medicine, New York, NY, 2NYU School of Medicine, NY, 3Bumrungrad International Hospital, Thailand

 

Background: The childhood obesity epidemic had led to an exponential rise in the prevalence of pre diabetes and /or Type 2 diabetes. Vitamin D deficiency results in decreased insulin sensitivity (ability of insulin to promote peripheral glucose uptake) and fasting hyperglycemia has been correlated with Vitamin D deficiency in obese adolescents and children.1,2

Aims: To study insulin sensitivity and secretory indices derived from an oral glucose tolerance test (OGTT) in obese adolescents with vitamin D deficiency before and immediately after normalization of serum 25(OH) vitamin D levels. 

Methods: In a single blinded randomized placebo controlled study (cross over design with planned sample size= 20) obese adolescents with vitamin D deficiency; 25 (OH) vitamin D ≤ 20 ng/dl (50 nmol/L) were recruited. Adolescents were assigned to receive 50,000 IU of ergocalciferol (group A) once weekly or placebo (group B) for 6 weeks. At week 7, subjects were  reassigned to receive vitamin D if they were in group B or placebo if they were in Group A. Study subjects had an OGTT and screening labs (25 (OH) Vitamin D, PTH, CMP, calcium, phosphorous and urine calcium/ creatinine ratio) at baseline, week 7 and then again at week 12 on the completion of study.

Indices derived from OGTT were:

1) Whole body sensitivity index (WBISI):10,000/√(fasting glucose(mg/dL)x fasting insulin(uIU/mL)x(mean glucose (mg/dL)  x mean insulin (uIU/mL)

2) Insulinogenic index: 30 min insulin- fasting insulin (uIU/mL) ⁄ 30 min glucose- fasting glucose (mg/dL)

Results: To date four subjects have completed the study: Hispanic females (mean ± SD) age 16.1± 1years, BMI 34.5± 4.5. Baseline labs were: HbA1c 5.3± 0.2, fasting glucose 81± 5.1, and fasting insulin 16.5± 5.3uIU/ml. PTH 48.5± 13.8 ng/dl (15- 75), calcium 9.1± 0.1 mg/dl (8.3- 10.3), phosphorous 4.3± 0.2mg/dl ( 2.7- 4.5), alkaline phosphatase 95± 19 mg/dl (39-390) and urine calcium/creatinine were normal at baseline and on completion as we monitored for hypercalcemia.

Mean 25 (OH) Vit D was 19.4± 1.4 ng/dl before treatment. In 3 of 4 subjects vit D did not normalize to ≥ 30 ng/dl (23± 6.7 mg/dl) on completion of the study, while it did in one patient (30.2 ng/dl). The mean insulin during OGTT (total of six levels during OGTT) decreased by 57% from 88± 36 to 51± 10 IU/L from start to completion of the study, while mean glucose values and HbA1c remained unchanged. WBISI improved significantly from 2.2± 0.3 to 4.3± 0.6, a 51% increase in this sensitivity index.

Conclusions: These results, though preliminary, suggest that even marginal increases in the Vitamin D levels in deficient insulin resistant obese adolescents appears to improve their hyperinsulinemia. More intriguing is that insulin sensitivity index WBISI improved after 6 weeks of vitamin D treatment, which if confirmed at study completion could have important therapeutic implications for insulin resistance.

 

Nothing to Disclose: PCB, BHF, NV

13978 10.0000 SAT-0238 A Efficacy of Vitamin D on Glucose Homeostasis in Obese Adolescents 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Gonca Tamer*1, Ilkay Kartal1, Ismet Tamer2, Ayse Kubat Uzum3, Banu Mesci1, Gül Sagun1, Damla Coksert Kilic1, Safiye Arik1 and Meral Mert4
1Medeniyet University, Göztepe Training and Research Hospital, Istanbul, Turkey, 2Kartal Training and Research Hospital, Istanbul, Turkey, 3Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey, 4Bakirköy Training and Research Hospital, Istanbul, Turkey

 

Objective: Vitamin D deficiency is suggested to be a risk factor for atherosclerosis. Since high lipid levels have important roles in the pathogenesis of atherosclerosis, the aim of our study is to compare fasting lipid concentrations of vitamin D sufficient subjects with those of vitamin D insufficient subjects.

Materials and Methods: Three hundred and fifteen non-smoking premenopausal female volunteers without diabetes mellitus were included in the study. According to their serum 25(OH)D vitamin levels, subjects were divided into 2 subgroups as 195 subjects (61.90%) with vitamin D insufficiency (VDIS Group) and 120 vitamin D sufficient subjects (38.10%) (VDS Group). Total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglyceride, and non-HDL-C levels of two groups were compared.

Results: Serum mean HDL-C level of VDIS Group was significantly lower (p=0.002) and means of LDL-C, triglyceride and non-HDL-C levels of VDIS Group were significantly higher (p=0.01, p=0.02, p=0.004, respectively) than those of VDS group. There were no significant differences between serum parathormone, calcium and phosphorus levels of VDIS and  VDS groups (p=0.78, p=0.11, p=0.76, respectively). No significant difference was found between obese and nonobese subjects with vitamin D insufficiency in serum TC, LDL-C, TG, HDL-C and non-HDL-C levels (p=0.399, p=0.471, p=0.198, p=0.271,p=0.215, respectively).   

Conclusion: Dyslipidemia may be more common in  vitamin D insufficiency independent of diabetes mellitus and hyperparathyroidism. Further studies are needed to determine whether vitamin D insufficiency is a casual factor for dyslipidemia.

 

Nothing to Disclose: GT, IK, IT, AKU, BM, GS, DCK, SA, MM

11610 11.0000 SAT-0239 A Vitamin D Insufficiency May be a Casual Factor for Dyslipidemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Anthony Chinedu Anyanwu*1, Olufemi Adetola Fasanmade2, Herbert Babatunde Coker3 and Augustine E Ohwovoriole4
1Division of EDM, Dept of Medicine, Lagos University Teaching Hospital, Lagos, Nigeria, 2Lagos University Teaching Hospital, Lagos, Nigeria, 3Faculty of Pharmaceutical Sciences, University of Lagos, Lagos, Nigeria, 4University of Lagos, Yaba Lagos, Nigeria

 

BACKGROUND

Diabetes Mellitus (DM) is a progressive disease associated with multiple complications.  Improvement of glycaemic control reduces the risk of complications. Reports suggest that vitamin D supplementation improves glycaemia. However, there are no data on the vitamin D status or its relationship to glycaemic control in diabetic Nigerians.

RESEARCH QUESTION AND OBJECTIVE

Does vitamin D supplementation improve glycaemic control in Type 2 diabetes mellitus (T2DM) Nigerians with vitamin D deficiency?

The objective of this study was to determine the effect of vitamin D supplementation on glycaemic control in type 2 DM participants with vitamin D deficiency.

METHODOLOGY

 A prospective randomized placebo controlled trial, involving type 2 DM participants attending the Diabetes Clinic of the Lagos University Teaching Hospital, Lagos, Nigeria. We studied 42 T2DM participants with poor glycaemic control and vitamin D deficiency. Participants were randomized into one of two treatment groups i.e. treatment and placebo arms. Levels of serum vitamin D, fasting plasma glucose (FPG), HbA1c, calcium, phosphate and albumin were determined. Daily doses of 3000 IU vitamin D3 were given to the participants in the treatment arm while placebo was given to the placebo arm. Glycaemic status was determined at baseline and after 12 weeks of treatment. Results were expressed as Mean±SD and percentages. Comparisons between treatment groups were made using Wilcoxon, Chi square and Z-tests. P values < 0.05 were considered statistically significant.

 RESULTS

The mean age of the participants was 52.5 ± 2.2 years in the treatment group and 51.1 ± 1.9 years in the placebo group (p > 0.05). There were 10 (58.8%) females and 7 (41.2%) males in the treatment group and 9 (56.3%) females and 7 (43.7%) males in the placebo group (χ2 = 0.02, p = 0.88). The Mean±SD baseline HbA1c was 8.1±0.5% in the treatment arm and 7.7±0.5% in the placebo arm (p > 0.05). The mean (95%CI) baseline FPG was 156(130-181) mg/dl in the treatment arm and 150(121-180) mg/dl in placebo arm (p>0.05). Vitamin D3 supplementation resulted in a significant increase in serum vitamin D level, serum calcium and decrease in FPG in the treatment arm compared to placebo. There was a 0.7% reduction in the mean HbA1c level in the treatment group, while the mean HbA1c increased by 0.4% in the placebo arm after 12 weeks of treatment. The number of participants with good glycaemic control increased by 33% in the treatment arm but reduced by 9% in the placebo arm (p< 0.05)

CONCLUSION

Vitamin D3 supplementation in persons with T2DM and vitamin D deficiency results in a significant improvement in glycaemic control. Diabetic patients with vitamin D deficiency will benefit from vitamin D supplementation. However, optimal dose of vitamin D, duration of supplementation and the underlying mechanism for glycaemic control need to be determined.

 

Nothing to Disclose: ACA, OAF, HBC, AEO

14693 12.0000 SAT-0240 A Vitamin D Supplementation Improves Glycaemia in Vitamin D Deficient Nigerians with Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Jinny Cai*1, Morri Markowitz2 and Ping Zhou3
1University of Southern California, 2Albert Einstein College of Medicine, Bronx, NY, 3Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY

 

Background

There is evidence that thyroid hormone levels may be regulated by vitamin D (1-3). For example, low vitamin D and slightly elevated TSH levels have been described together in obese populations, a state now considered pro-inflammatory. As an immune modulator, vitamin D may affect thyroid functioning in patients with autoimmune thyroiditis. However, population based studies supporting this relationship are lacking.

The purpose of this study is to examine the relationship between serum 25-hydroxyvitamin D levels (25(OH)D) and thyroid related measures in people with and without evidence of autoimmune thyroid activity.

Data, Design, Method, and Analysis

This is a retrospective cross-sectional study using NHANES data collected between 2001-2002.  Data on anthropomorphic measures, 25(OH) D, TSH, FT4, anti-thyroglobulin and anti-thyroid peroxidase antibodies levels are abstracted.

Pearson correlations are calculated.  To examine the role of autoimmunity, we divided the data into two groups based on thyroid antibody positivity.  Means of 25(OH) D levels of the two groups were calculated and compared.

We further analyzed the data in the available pediatric subset (ages 12-20 years). For these analyses we divided this group into four subgroups: lean, normal, overweight, and obese (<4.9%, 5-84.9%, 85-94.9%, and =>95% respectively) based on BMI percentile for age and sex. Group means of 25(OH) D, TSH, and FT4 were compared.

Results

In the original data set (N=2006), 25(OH) D levels show a strong correlation with BMI (-0.18, p<0.0001, weight (-0.12, p< 0.0001) and height (0.08, p<0.0001). TSH shows a strong positive correlation with both anti-thyroglobulin antibody (0.097 p<0.0001) and anti-thyroid peroxidase antibody (0.31, p<0.0001).  It also shows a negative correlation with FT4 (-0.16, p<0.0001).  However, 25(OH) D levels were not significantly correlated with any of the thyroid related measures.

Similarly, the difference between mean 25(OH) D levels in the groups stratified by antibody status was not statistically significant (22.2 Vs. 21.4).

In the thyroid antibody negative group (N=611), 25(OH) D shows no correlation with either TSH or FT4, but has a strong negative correlation with BMI (-0.18, p<0.0001).

In the pediatric analyses, compared to the BMI normal group, the mean 25(OH) D levels of all three other groups are significantly lower. The mean of the FT4 is slightly lower in the overweight group; however, differences between groups were small and may not have biological meaning. For TSH, the mean value in the obese group is statistically significantly higher than the normal BMI group, but the mean values for both groups are in the normal range.

Conclusion

No relationship was found between thyroid function (TSH, and Free T4 levels) and 25(OH) D levels regardless of thyroid antibody or weight status.

 

Nothing to Disclose: JC, MM, PZ

11516 13.0000 SAT-0241 A Relationship Between Thyroid Hormones and Vitamin D 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Amra Osmancevic*1, Taye Demeke2, Anne Lene Krogstad3, Håkan Sinclair4, Eva Angesjö5, Gamal El-Gawad6 and Kerstin Landin-Wilhelmsen7
1Department of Dermatology, Gothenburg, Sweden, 2Lärjedalen Primary Health Care, Gothenburg, Sweden, 3Section for Climate Therapy, Oslo, Norway, 4Department of Geriatric Medicine, Borås, Sweden, 5Brämhult Primary Health Care, Alingsås, Sweden, 6Gamlestadens Primary Health care, Gothenburg, Sweden, 7Section for Endocrinology, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

 

Background: Sun exposure is the strongest factor affecting vitamin D status in man. Vitamin D deficiency is a common health problem among immigrants with dark skin and with reduced sun exposure. There is limited information about how common and how serious vitamin D deficiency is in this population.

Aim: The aim was to compare the effect of two doses of oral vitamin D intake/placebo on serum 25(OH)D levels in healthy Somalian women (latitude 0-10°N)  in Sweden (latitude 57° North).

Subjects: A total of 102 women from Somalia (mean age 34.2 years, 0.95CI: 32.3 - 36.0) living in Sweden >2 years participated.

Methods: A randomized, double-blind, placebo-controlled study was performed  with two doses of vitamin D. Oral drops containing 800 IU, 1600 IU cholecalciferol and similar amounts of placebo were given during 12 weeks. Blood tests including 25-hydroxyvitamin D (25(OH)D) were monitored before and every 6thweek throughout 6 months, i.e. 3 months follow-up after the treatment.

Results: The majority of women (n=71; 70%) were vitamin D deficient, 25(OH)D < 10 ng/ml (25 nmol/l) at the start of the study.

After six weeks of treatment only 50 subjects (49%) entered the first study visit. The mean increase in serum 25(OH)D after six weeks in subjects treated with 800 IU (n=14) was 6.0 ng/ml (14.9 nmol/l) (0.95CI: 9.0 - 20.8.) and the mean increase for subjects treated with 1600 IU (n=17) was 8.7 ng/ml (21.8 nmol/l) (0.95CI: 11.3 - 32.2.) The subjects in the placebo group (n=19) had no increase in 25(OH)D. There was a dose dependent increase in serum 25(OH)D levels (P=0.024).

After twelve weeks only 35 patients (34%) remained in the study. The mean increase in serum 25(OH)D after twelve weeks in patients treated with 800 IU (n=13) was 7.1 ng/ml (17.8 nmol/l) (0.95CI: 6.2 - 29.3.) and the mean increase for patients treated with 1600 IU (n=12) was 12.0 ng/ml (29.9 nmol/l) (0.95CI: 17.5 - 42.4.) There was no significant difference between serum 25(OH)D increase in the groups treated with 800 IU and 1600 IU, probably due to the low number of remaining participants.

During the follow-up period, after the per-oral vitamin D treatment was terminated, the serum 25(OH)D levels decreased but were still above baseline levels in the treatment groups. The placebo group remained unchanged in 25(OH)D levels throughout the study.

Conclusions: Vitamin D deficiency is a very common problem in immigrants living at higher latitudes. Treatment with Vitamin D in Somalian women living in Sweden increased the serum 25(OH)D levels dose dependently compared with placebo during 3 months. The effect was maintained for another 3 months. One third of the subjects dropped out from the study for unknown reasons indicating that this study group was hard to reach and, by that, difficult to treat.

 

Nothing to Disclose: AO, TD, ALK, HS, EA, GE, KL

16090 14.0000 SAT-0242 A Vitamin D Treatment in Somalian Women Living in Sweden - a Randomized, Double-Blind, Placebo-Controlled Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Nasser Mohmmed Al-Daghri*1, Majed S Alokail1, Antigoni Manousopoulou2, Omar Al-Attas3, Khalid Alkharfy4, Yousef Al-Saleh5, Sobhy Yakout3, Shaun Sabico3, Harvey Johnston6, Theodoros I Roumeliotis6, Akul Singhania6, Christopher Woelk6, Paul Townsend7, George P. Chrousos8 and Spiro D Garbis6
1King Saud University, Riyadh, Saudi Arabia, 2University of Southampton, United Kingdom, 3King Saud University, Riyadh, 4King Saud University, 5King Saud University for Applied Health Sciences, 6Southampton University, 7University of Manchester, Manchester, United Kingdom, 8First Department of Pediatrics, Athens, Greece

 

Low vitamin D status or hypovitaminosis D has been associated with a plethora of adverse extra-skeletal health consequences, including obesity, metabolic syndrome, cardiovascular disease and cancer. However, a causal molecular link at the serological protein level remains to be established. This proof-of-principle study compared the proteomic profiles of age-matched non-diabetic, overweight and obese females (n=22) and males (n=20) that attained a Vitamin D sufficient status after a 12-month intervention compared to those in women (n=17) and men (n=20) that participated in the same intervention but did not achieve vitamin D sufficiency. The intervention protocol was based on the increased consumption of vitamin D-rich foods and sun exposure. Non-targeted, depletion-free quantitative proteomics with bioinformatics in silico interpretations were used to analyze the whole serum specimens. This novel method profiles more than double the number of proteins otherwise captured by other proteomic methods to date. Over 2500 proteins were profiled of which ~14% changed positively or negatively with vitamin D status correction (p<0.05). The change ranged from negative 2.2 to positive 3.6 on a log2 ratio, included novel and known proteins, and showed marked sexual dimorphism. These data, thus, provide a sexually dimorphic signature of vitamin D repletion. The known proteins identified are involved in the canonical pathways of intermediary metabolism, blood coagulation, tumorigenesis and apoptosis.  These multiple, mildly modulated proteins and their potentially epistatic functions may on the one hand explain the beneficial effects of vitamin D and on the other the elusive and frequently controversial mainstream clinico-pathological indicators. The identified previously unknown proteins could serve as novel vitamin-D status correction molecular signatures and help create testable hypotheses on its potential metabolic, cardioprotective and anti-cancer effects in men and women.

 

Nothing to Disclose: NMA, MSA, AM, OA, KA, YA, SY, SS, HJ, TIR, AS, CW, PT, GPC, SDG

11291 15.0000 SAT-0243 A The Effect of Vitamin D Status Correction on the Human Milieu Intérieur Proteome: A Year-Long Prospective Interventional Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Jo Eun Kim*1, Yong-ho Lee2, Yun Ho Roh3, Yumie Rhee1, Dae Ryong Kang3 and Sung-Kil Lim1
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 3Yonsei University College of Medicine

 

Although mild-to-moderate chronic kidney disease (CKD) and vitamin D insufficiency are prevalent in the elderly population worldwide and are closely associated with sarcopenia, their influence on bone mineral density (BMD) has not been determined. We aimed to assess the effects of vitamin D insufficiency and CKD on BMDs in the elderly population and their relationships with sarcopenia and parathyroid hormone levels. We designed a cross-sectional study with nationally representative samples of 6949 subjects aged≥55 years from the Korea National Health and Nutrition Examination Surveys (KNHANES) conducted between 2008 and 2011. Appendicular skeletal muscle mass and BMD were examined by dual energy X-ray absorptiometry; serum 25-hydroxyvitamin D [25(OH)D] was determined, and glomerular filtration rate was estimated using the CKD-EPI equation. The study population was divided into four groups according to vitamin D and CKD status. BMDs in the total hip and femoral neck as well as femoral bone geometry were markedly deteriorated in stage 3 and 4 CKD subjects with vitamin D insufficiency [25(OH)D <20 ng/ml] compared to other groups, regardless of gender. The prevalence of osteopenia, osteoporosis and sarcopenia were significantly higher in CKD subjects with vitamin D insufficiency. Multivariable logistic regression analyses demonstrated that CKD subjects with vitamin D insufficiency showed a significantly increased risk of osteoporosis or osteopenia, which was mainly mediated by elevated levels of parathyroid hormone and sarcopenia in these groups. In conclusion, the combination of mild-to-moderate CKD and vitamin D insufficiency was more closely associated with deteriorated BMDs in a geriatric population, linked with hyperparathyroidism and sarcopenia.

 

Nothing to Disclose: JEK, YHL, YHR, YR, DRK, SKL

12460 16.0000 SAT-0244 A The Combination of Vitamin D Insufficiency and Mild-to-Moderate Chronic Kidney Disease Is Significantly Associated with Deterioration of Bone Mineral Density and Bone Geometry Via Hyperparathyroidism and Sarcopenia-the Korea National Health and Nutrition Examination Surveys 2008-2011 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Yanzhi Cai1, Chandrama Shrestha1, Shangli Ji1, Lingyun Liang1, Xiangbing Wang2 and Zhongjian Xie*1
1The Second Xiangya Hospital, Central South University, Changsha, China, 2Rutgers University-RWJMS, New Brunswick, NJ

 

Graves’ disease (GD) is one of the commonly encountered endocrine diseases in China. Studies over the past few years have suggested the association of vitamin D deficiency in myriad autoimmune diseases, including GD. However, it is unclear whether the vitamin D binding protein (DBP) plays a role in altering vitamin D levels in patients with GD. To address this issue, forty female patients of GD without remission after antithyroid drugs (ATD) therapy [23 patients on methimazole (MMI), 6 patients on propylthiouracil (PTU) and 9 on MMI and PTU alternately] and 40 age- and body mass index (BMI)-matched female control subjects were included in the study. Levels of total calcium, albumin, triiodothyronine (FT3), free thyroxine (FT4), thyroid-stimulating hormone (TSH), thyroid stimulating hormone receptor antibody (TRAb), total 25OHD, intact parathyroid hormone (iPTH), and DBP were measured. The results showed that both total and free 25OHD levels in GD patients were higher than that in controls (p<0.05). Levels of iPTH were increased in GD patients compared with controls (P<0.05). There was, however, no significant difference in DBP levels between the two groups. A positive correlation of DBP levels with total 25OHD levels (r=0.423, p<0.01) and a negative correlation of DBP levels with free 25OHD levels (r=-0.587, p<0.01) or bioavailable 25OHD levels (r=-0.573, p<0.01) were observed. There was no correlation of DBP levels with levels of FT3, FT4, TSH, iPTH, calcium, or albumin, age, or BMI. The level of iPTH was negatively correlated (r=-0.466; p<0.01) with the level of calcium. No correlation of 25OHD levels with FT3, FT4, TSH and TRAb levels was observed. The level of total 25OHD in patients on MMI was higher than those on PTU (p<0.05). There was no significant difference in levels of free 25OHD, bioavailable 25OHD, iPTH, DBP, and calcium between patients on MMI and patients on PTU. Therefore, we conclude that although DBP levels are not changed in GD patients, DBP levels are negatively associated with free 25OHD. Therefore, DBP may play a role in altering bioavailable 25OHD levels in patients with GD. Measuring DBP and calculating the bioavailable 25OHD in patients with GD might be useful for assessing true vitamin D status in such patients.

 

Nothing to Disclose: YC, CS, SJ, LL, XW, ZX

12580 17.0000 SAT-0245 A The Vitamin D-Binding Protein Level Is Associated with Vitamin D Status in Graves' Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

William Wilkison*1, Benjamin M Buehrer2, Bentley Cheatham3, Susan Walker3, Shigeru Nakano4, Kenji Katsuno4 and Masayuki Isaji4
1Islet Sciences, RALEIGH, NC, 2Zen-Bio, Inc., RTP, NC, 3BHV Pharma, RTP, NC, 4Kissei Pharmaceuticals, Matsumoto City, Japan

 

The worldwide increase in obesity has fostered a corresponding increase in the incidence of non-alcoholic fatty liver disease (NAFLD).  NAFLD is a key risk factor in the development of non-alcoholic steatohepatitis (NASH), a serious condition that can lead to hepatic failure.  The etiology of NASH is not certain but the combination of insulin resistance and oxidative stress has been shown to be important.  Remogliflozin etabonate (RE), the prodrug of remogliflozin, is an inhibitor of the sodium glucose-dependent renal transporter 2 (SGLT2). RE has been shown to reduce HbA1C and also improve insulin sensitivity.  In the current study, we examined the effects of a 4-week RE treatment in a diet-induced mouse model of hepatic steatosis. Compared to obese untreated animals, RE caused reductions of liver triglycerides (40% decrease) and liver weight (50% decrease).  In addition, reductions in ALT (80% decrease) and AST (35% decrease) were observed.  Finally, thiobarbituric acid (TBARS), a surrogate marker of the oxidative stress levels, was significantly decreased (30%) in plasma and liver homogenates from RE treated animals.  The TBAR results suggested that RE may have intrinsic antioxidant activity.  We directly measured the oxygen radical antioxidant capacity (ORAC) in three different SGLT2 inhibitors: RE, canagliflozin and dapagliflozin.  Interestingly, only remogliflozin, the active species derived from RE, had any significant ORAC activity.  In summary, Remo suppressed the increase in both AST and ALT, reduced hepatic triglyceride content and weight, and reduced markers of oxidative stress in both plasma and liver. Based on these observations, we propose that RE may be an ideal compound for the treatment of NASH and NAFLD due to its insulin-sensitizing and anti-oxidant properties.

 

Disclosure: WW: Management Position, Islet Sciences, Inc., Founder, BHV Pharma. BC: Management Position, BHV Pharma. SW: Collaborator, BHV Pharma. Nothing to Disclose: BMB, SN, KK, MI

13979 18.0000 SAT-0246 A Remogliflozin Etabonate Improves Non-Alcoholic Steatohepatitis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Manoj Kumar*1, Deep Dutta2, Samim Ali Mondal3, Shivaprasad K S4, Abu hena hesanoor Reza4 and Satinath Mukhopadhyay5
1Institute of Post Graduate Medical Education And Research and SSKM Hospital, Kolkata, India, 2Institute of Post Graduate Medical Education & Research (IPGMER) and Seth Sukhlal Karnani Memorial (SSKM) Hospital, Calcutta, West Bengal, India, 3Institute of Post Graduate Medical Education & Research (IPGMER) and Seth Sukhlal Karnani Memorial (SSKM) Hospital, Calcutta, India, 4Institute of Post Graduate Medical Education And Research and SSKM Hospital, 5Institute of Postgraduate Medical Education & Research (IPGMER) and Seth Sukhlal Karnani Memorial (SSKM) Hospital, Calcutta, India

 

Abstract

Background and aims:Vitamin-D is believed to modulate glucose homeostasis and cytokines. Fetuin-A (FetA) secreted predominantly from liver is believed to modulate insulin resistance (IR) and inflammation, by being the principle ligand for free fatty acid induced activation of toll like receptor-4 (TLR-4) and nuclear factor‑κB (NF‑κB). Tumor necrosis factor-α (TNF-α), interleukin-1beta (IL1β) and interleukin-6 (IL6) are the principle cytokines implicated in IR. Interleukin-1 receptor antagonist (IL1ra) is the predominantly anti-inflammatory cytokine. This study aimed to evaluate the relation between Vitamin-D, FetA, cytokines and IR in normal individuals (NI), individuals with prediabetes (IPD) and newly diagnosed treatment naïve type-2 diabetes (T2DM) patients.

Material and methods:30 NI (Group-I), 57 IPD (Group-II) and 37 T2DM (Group-III) who had persistent normoglycemia, IFG and/or IGT and blood glucose in diabetic range respectively, over 2 OGTTs over a week, underwent estimation of insulin 25-hydroxyvitamin-d (25OHD) (Architect, Abbott, USA), TNF-α, IL6, IL1β, IL1ra and FetA (ELISA, Ray Biotech, USA).

Results: 75% and 41.1% individuals had 25OHD ≤30 and ≤20 ng/ml respectively. Mean age of NI, IPD and T2DM was 39.7±7.7, 42.4±8.8 and 42.2±6.7 years (P-value 0.18) respectively. Significantly increased FetA (489.2±103.7 vs 443.8±116.6 ng/ml; p=0.02), IL1β (7.9±7.7 vs 6.1±2.9 pg/ml; p=0.03), fasting glucose (112.4±22.4 vs 105.5±22.8 mg/dl; p=0.04) and IR (HOMA2-IR 1.5±0.99 vs 1.1±0.8; p=0.01) were observed in individuals with metabolic syndrome (MetS; IDF Criteria; n=46) compared to those without MetS (n=78).

In NI HOMA2-IR had positive correlation with BMI (r=0.57; p=0.02), IL1β (r=0.52; p=0.02), and FetA (r=0.49; p=0.04). Serum 25OHD had inverse correlation with IL-6 (r= -0.47; p=0.006), IL1β(r= -0.56; p=0.01) and positive correlation with IL1ra (r=0.42; p=0.02). BMI positively correlated with IL1ra (r=0.45; p=0.01).

Among IPD HOMA2-IR had positive correlation with BMI (r=0.39; p<0.001) and TNFα (r=0.23; p=0.03). Serum 25OHD had inverse correlation with HOMA2IR (r= -0.31; p=0.001), TNFα (r= -0.28; p=0.003), IL6 (r= -0.26; p=0.006), Ilβ (r= -0.27; p=0.02), FetA (r=0.31; p=0.01) and positive correlation with IL1ra (r=0.33; p=0.006). IL1ra was inversely correlated with TNFα (r= -0.3; p=0.01) and IL6 (r= -0.28; p=0.03).

In T2DM, 25OHD had positive correlation with IL1ra (r=0.36; p=0.02) and negative correlation with FetA (r=0.35; p=0.03).

Conclusion: The inverse correlation of vitamin-D with inflammatory cytokines along with positive correlation with IL1ra supports anti-inflammatory role of vitamin-D. It may be hypothesized that vitamin-D may exert its beneficial effects on IR through decreased inflammation and modulation of FetA, as evidenced by significant inverse correlation of 25OHD with FetA in IPD and T2DM.

 

Nothing to Disclose: MK, DD, SAM, SK, AHHR, SM

12286 19.0000 SAT-0247 A Serum Vitamin-D May Modulate Fetuin-a, Cytokines and Insulin Resistance Across the Spectrum of Glycemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Anne E Sumner1, Caroline K Thoreson1, Michelle Y O' Connor2, James C Reynolds3, Madia Ricks2 and Stephanie T Chung*1
1NIDDK, NIH, Bethesda, MD, 2NIDDK/NIH, Bethesda, MD, 3National Institutes of Health, Bethesda, MD

 

The Institute of Medicine (IOM) defines vitamin D insufficiency as 25(OH)D <20 ng/mL, while the Endocrine Society uses the threshold <30 ng/mL. By either standard, African descent populations have a high prevalence of low 25(OH)D. The significance and etiology of low 25(OH)D levels in African descent populations are unknown. Therefore, in 82 Africans living in America (74% male; age 39±1y (mean±SE), range 22-63y; BMI 28±0.5 kg/m2, range 20-41 kg/m2), we measured 25(OH)D, parathyroid hormone (PTH), ionized calcium, phosphorous, and whole body bone mineral density (BMD) by dual-energy X-ray absorptiometry scan. Africans with 25(OH)D <20 ng/mL were compared to Africans with 25(OH)D ≥20 ng/mL. Then Africans with 25(OH)D <30 ng/mL were compared to Africans with 25(OH)D ≥30 ng/mL. In the entire cohort, 25(OH)D levels were 21±1 ng/mL, range 10-36 ng/mL. Most importantly, 50% had 25(OH)D <20 ng/mL and 83% had 25(OH)D <30 ng/mL. Ionized calcium levels were 1.2±0.01 mmol/L, range 1.1-1.3 mmol/L. Phosphorous levels were 3.3±0.1 mg/dL, range 2.5-4.4 mg/dL. Nine percent had T-scores defined as osteopenic (-1.0 to -2.5) and no one had T-scores defined as osteoporotic (<-2.5). PTH levels were 44±2 pg/mL, range 20-93 pg/mL, but 10% had PTH levels above the upper limit of normal. Adjusting for age and sex, and using the 25(OH)D cutoff of above and below 20 ng/mL, there was no difference by group in PTH, ionized calcium, phosphorous or whole body BMD. Using the threshold of 30 ng/mL, the results were similar. Overall, 50% of Africans are vitamin D insufficient by IOM thresholds, and >80% of Africans are vitamin D insufficient by Endocrine Society thresholds. Yet, less than 10% of Africans have any evidence of vitamin D insufficiency such as secondary hyperparathyroidism or decreased bone density. Therefore, the level of vitamin D which indicates insufficiency in Africans needs fresh evaluation.

 

Nothing to Disclose: AES, CKT, MYO, JCR, MR, STC

12862 20.0000 SAT-0248 A Vitamin D Levels Defined As Insufficient By the Institute of Medicine and the Endocrine Society May be Adequate in Africans 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Mohammad Nabil Soliman Atta, Samir Naim Assaad*, Aliaa Ali El-Aghoury, Hassan El-Prince, Mohammad Ibrahim Sayed Ahmed and Manal Ahmad Aboulfadl Aboulela
University of Alexandria, Alexandria, Egypt

 

Recent studies have linked low vitamin D to atherosclerosis and cardiovascular events. Hypovitaminosis D and hypoadiponectinemia have been reported in metabolic syndrome, a collection of risk factors that increases chance of developing heart disease and stroke. Sunny areas as middle eastern countries are not immune against vitamin D deficiency. The aim of this study was to determine the relation of vitamin D status and adiponectin to serum endothelin (an index of endothelial dysfunction) and carotid intima media thickness (CIMT)(a surrogate marker for atherosclerosis) in subjects with metabolic syndrome.

SUBJECTS & METHODS: The study included  forty male patients with metabolic syndrome (Met S), aged between 25-35 years,  and selected according to the new IDF definition (2006). Twenty healthy men of matched age served as a control group. BMI, waist circumference (WC), and skin fold thickness (triceps, subscapular) were measured. Fasting plasma glucose (FPG) was determined. Serum was used for the estimation of calcium, phosphorus, LDL-cholesterol, HDL-cholesterol, triglycerides, 25 OH cholecalciferol (25 OH Vit D3) (by Elisa), adiponectin (by Elisa), and endothelin-1 (by Elisa). Carotid intima media thickness (CIMT) was assessed using duplex ultrasonography (7.5-10 MHz transducer).

RESULTS: The mean serum 25 OH Vit D3 was 27.6 ± 19.6 ng/ml in Met S patients versus 33.7 ± 17.9 ng/ml in controls. The difference was not statistically significant (P=0.111). However, 77.5% of Met S patients were vitamin D insufficient (serum 25 OH Vit D3 <30 ng/mL) versus 55% in controls. A negative correlation was observed between serum 25 OH Vit D3  and both BMI and WC in Met S (p=0.038 and p=0.006, respectively). There was no correlation between serum 25 OH Vit D3 and serum LDL-cholesterol, HDL-cholesterol, triglycerides, FPG, or blood pressure. Mean serum endothelin-1 was higher while mean serum adiponectin was lower in Met S subjects versus healthy controls (62.7 ± 32.9 pg/ml vs 17.6 ± 5.7 pg/ml, 0.50 ± 0.19 ng/ml vs 1.56 ±0.56 ng/ml, respectively, p<0.001). CIMT was greater in Met S patients versus controls (0.67 ± 0.14 mm and  0.54 ± 0.05 mm, p<0.001). In Met S subjects, serum 25 OH Vit D3 correlated negatively  with serum endothelin-1 and CIMT (p=0.01 and p=0.03, respectively); and directly with serum adiponectin (p=0.034). An inverse relation was observed between serum adiponectin and endothelin-1 (p<0.001).

CONCLUSIONS: In patients with Met S, serum vitamin D is inversely correlated with measures of whole body (BMI) and central (WC) adiposity. In these subjects, low vitamin D status is associated with hypoadiponectinemia. The increased serum endothelin-1 and CIMT observed in Met S is related to vitamin D insufficiency.

 

Nothing to Disclose: MNSA, SNA, AAE, HE, MISA, MAAA

13442 21.0000 SAT-0249 A Hypovitaminosis D and Hypoadiponectinemia in Metabolic Syndrome: Relation to Endothelin and Carotid Intima-Media Thickness 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Anuradha Khadilkar*1, Vivek Patwardhan2, Shashi Chiplonkar2, Zulf M Mughal3 and Vaman Khadilkar2
1Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India, 2Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India, 3Royal Manchester Children’s Hospital, Manchester, United Kingdom

 

Vitamin D status as assessed by serum 25(OH)D concentrations is influenced by sunlight exposure and dietary intake. In tropical countries such as India, abundance of sunlight along with dietary inadequacy of vitamin D coupled with higher prevalence of metabolic syndrome may have varying impact on  Vitamin D status and lipid concentrations.   In the skin, Cholecalciferol (Vitamin D3) and cholesterol are synthesized from the common substrate dehydrocholesterol where sunlight and DHCR compete for the same substrate.  Those with high serum DHCR concentrations may have less efficient Vitamin D synthesis for given exposure of sunlight.

To explore these associations, a cross sectional study was performed in apparently healthy adult men.   A random sample of 200 men (40-60 yrs)  were selected from people undergoing   preventive health checks. Exclusion criteria were i) fasting blood sugar level (FBSL) >125 mg/dl, ii) abnormal glutamic pyruvic transaminase (SGPT >65 IU/ L ), iii) abnormal creatinine ( 1.2 mg/dl), iv) on treatment with statins or v) on Vitamin D supplements. Eligible 172 subjects (mean age 48 ± 6 yrs ) were included in the study with a written informed consent. Sunlight exposure was assessed using validated sunlight exposure questionnaire. Lipid profile, serum 25(OH)D, blood sugar and serum DHCR were estimated on a fasting blood sample using standardize procedures.

Vitamin D deficiency (25(OH)D < 20ng/ml) was found in 56% of cases. Sunlight exposure per day was less than 60 minutes in 28%, between 60-120 minutes in 52% and more than 120 minutes in 20% cases. 25(OH)D was positively associated with sunlight exposure (r=0.47,  p=0.0001) and negatively  with DHCR (r=  -0.30, p=0.013).   At lower sunlight exposure (< 60 minutes/day) 25(OH)D  was positively associated with High Density Lipoprotein cholesterol  (r=0.36, p=0.011) and  HDL-C:LDL-C ratio (r=0.216, p=0.145). With increasing sunlight exposure ( > 120 min/day)  relationship  turned to a negative association with HDL-C ( r= -0.386, p=0.022) and HDL-C:LDL-C ratio (r = -0.338, p=0.047). Generalized linear model analysis adjusted for DHCR showed that HDL-C is influenced positively by serum 25(OH)D  (beta=0.143, p=0001) and triglyceride is negatively influenced by serum 25(OH)D (beta=0. 814, p=0.0001). 

Interrelationship of vitamin D, HDL-C and DHCR appear to vary for a given level of DHCR or sunlight exposure.

 

Nothing to Disclose: AK, VP, SC, ZMM, VK

14440 22.0000 SAT-0250 A Duration of Sunlight Exposure and Levels of Dehydrocholesterol Reductase (DHCR) Affect Relationship Between Vitamin D and Lipids 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Nigel J. Clarke*1, Mildred Goldman1, Patrick William Mason2, Khan Viec1, Michael Phillip Caulfield3, Michael John McPhaul4 and Richard E Reitz5
1Quest Diagnostics Nichols Inst, San Juan Capistrano, CA, 2Quest Diagnostics, Chantilly, VA, 3Quest Diagnostics Nichols Institute, San Juan Capistrano, CA, 4Quest Diagnostic, San Juan Capistrano, CA, 5Quest Diagnostic Inc, San Juan Capistrano, CA

 

Background

Vitamin D is derived from dietary sources or from the action of ultraviolet light on 7-dehydrocholesterol and undergoes a number of enzymatic modifications that lead to the synthesis of active Vitamin D metabolites or metabolites with reduced biological activity. Among these, epimerization at the 3-hydroxyl group leads to the synthesis of 3-epi 25-hydroxy vitamin D (3EVD). Described first in biological systems experiments employing in vitro incubation of vitamin D in cell culture, this molecule has been reported as having distinct activities when compared to 25-hydroxy vitamin D (25OHVD). Measurements of vitamin D have been conducted using a variety of methodologies and have led to conflicting assessments of the quantities of 3EVD D3 that are measured.

 Method

The present manuscript describes the development and use of a simple, CLIA validated, LC/MS/MS method to quantitate 3EVD3 in 3528 subjects, including 309 children (162 less than 2 years of age) and 232 pregnant women.

 Results

Our findings demonstrate that although 3EVD3 constitutes a significant proportion of measureable 25OHVD3 in subjects less than 1 year of age, 3EVD3 levels are negligible in most subjects older than one year of age.

 Conclusions

It is important to choose the correct 25-OH Vitamin D assay dependent on the age of the patient. Patients under 1 year of age should be run on an LC-MS/MS assay proven to not have potential contributions from any 3-Epi 25-OH Vitamin D present in the sample.

 

Disclosure: NJC: Employee, Quest Diagnostics. MG: Employee, Quest Diagnostics. PWM: Employee, Quest Diagnostics. KV: Employee, Quest Diagnostics. MPC: Employee, Quest Diagnostics. MJM: Employee, Quest Diagnostics. RER: Employee, Quest Diagnostics.

11603 23.0000 SAT-0251 A The Measurement of 3-Epi-25-Hydroxyvitamin D By Mass Spectrometry in Clinical Specimens Detects Inconsequential Levels in Adult Subjects 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Gülay Karagüzel*1, Nil Palanci1, Sevgi Bahadir1 and Selçuk Yaman2
1Karadeniz Technical University, School of Medicine, Trabzon, Turkey, 2Karadeniz Technical University, School Of Medicine, Trabzon, Turkey

 

Background and Objectives: Alopesia areata (AA) is an inflammatory hair loss and there is a role of the immune system in the pathogenesis of the disease. It has been reported that vitamin D plays an important role in cutaneous immune modulation as well as calcium regulation. We investigated serum 25-hydroxyvitamin D [25(OH)D] levels in children with AA and evaluated the efficacy of oral vitamin D treatment in addition to topical treatment on the hair regrowth of AA patients.

Methods: Thirty (10 boys, 20 gils) newly-diagnosed AA (mean age 10.5±2.9 years) patients without systemic autoimmune diseases and 30 sex- and age-matched healthy children as controls were included in the study. Lesion sizes and levels of 25(OH)D, PTH, calcium, phosphorus, alkaline phosphatase were measured at baseline and sixth month. Vitamin D deficiency was defined as 25(OH)D  level <20 ng/ml. Both patients and controls who diagnosed vitamin D deficiency were treated with oral vitamin D for six months. All the patients were also treated with topical ointment.

Results: Serum 25(OH)D levels of the patients with AA and controls were 25.3±19.4 ng/ml and 21.3±12.5 ng/ml, respectively (p >0.05). The frequency of vitamin D deficiency was similar in patients and controls (p >0.05). Serum levels of 25(OH)D and calcium were increased and PTH levels were decreased significantly after six months of the treatment in children with vitamin D deficieny (p <0.05). In patients with AA who received oral vitamin D treatment in addition to topical ointment (n= 15), lesion size decreased from 59.9±58.3 cm2 to 14.0±20.1 cm2 after 6 months of treatment (p <0.005). In patients who received only topical ointment (n= 15), lesion size increased from 29.5±33.6 cm2 to 38.9±41.7 cm2 (p >0.05).

Conclusions: This is the first prospective study in childhood and our results showed that there was no statistically significant difference in  25(OH)D levels between the patients with AA and controls. However, we found a marked reduction in lesion size in AA patients who received vitamin D treatment in addition to topical ointment. Therefore, we suggest that vitamin D treatment besides topical ointments could be successful on the hair regrowth of AA patients.

*This study was supported Karadeniz Technical University Research Project Unit under protocol No: 2010.114.003.08.

 

Nothing to Disclose: GK, NP, SB, SY

13693 24.0000 SAT-0252 A Vitamin D Status and the Effects of Vitamin D Treatment in Children with Alopesia Areata 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Goknur Yorulmaz*1, Aysen Akalin2, Narguler Tomus3, Murat Senol3, Pınar Yildirim4 and Muzaffer Bilgin4
1Eskisehir State Hospital, Eskisehir, Turkey, 2OGUTF, Eskisehir, Turkey, 3Eskisehir State Hospital, 4Eskisehir Osmangazi University

 

Introduction: Gestational transient thyrotoxicosis (GTT), nonautoimmune hyperthyroidism results from the direct stimulatory effects of hCG on the thyroid and is most often present as subclinical hyperthyroidism observed transiently in the first half of gestation. Although hyperthyroidism arising from primary thyroid disease is rare in pregnancy, transient gestational hyperthyroidism is not uncommon. The prevalence of low vitamin D levels may be increasing globally.

Objectives: Our aim in this study was to evaluate the vitamin D levels in pregnants with gestational thyrotoxicosis.

Methods: Sixteen pregnants with thyrotoxicosis and 9 age matched non-pregnant healthy women were included in study. The ages, thyroid function tests, gestational weeks, β- Hcg levels, thyroid ultrasound, 25 hydroxyvitamin D and 1,25 hydroxyvitamin D levels were evaluated.  Vitamin D levels were evaluated in pregnants and healthy women who referred in november and december.

Results: None of the individuals in both groups had thyroid disease in the past. Anti TPO, antithyroglobulin, TSH receptor antibodies were negative. Three of the pregnant women had nodules in ultrasound, there was no nodule and thyroid sizes were normal in the remaining patients. All pregnants had hyperemesis.

There was a positive correlation between Hcg levels and free T4 levels. There was no relation between gestational week and free T4 levels.

The vitamin D levels of both patients and control group were low and the difference was not considered significant statistically. 1,25 hydroxyvitamin D levels were higher in pregnants compared with control group and the difference was significant. 

Results: The low levels of vitamin D in both groups were considered as a seasonal effect. The high levels of 1,25 dihydroxyvitamin D in pregnants may be due to increased maternal renal 1α-hydroxylase activity and the synthesis and secretion of calcitriol by the placenta.

 

Nothing to Disclose: GY, AA, NT, MS, PY, MB

13420 25.0000 SAT-0253 A Vitamin D Levels in Pregnants with Gestational Thyrotoxicosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Preneet Cheema Brar*1, Sara K Kim2, Nipapat Visavachaipan3, Maria F Contreras1 and Brenda Kohn1
1New York University School of Medicine, New York, NY, 2New York University School of Medicine, 3Bumrungrad International Hospital, Thailand

 

Background: Obese adolescents are at high risk for vitamin D deficiency (VDD) because Vitamin D is sequestrated in adipose tissue. Vitamin D deficiency is defined as 25 (OH) D levels < 20 ng/ml; 50 nmol/L. Observational studies in adolescents support an association between VDD, Type 2 diabetes and metabolic syndrome.

Objective: a) To determine the prevalence of VDD in an inner city multi ethnic cohort of obese adolescents and b) to study the efficacy of 50,000 IU of weekly PO vitamin D2 (Ergocholecalciferol) X 6 weeks in normalizing 25 (OH) D levels (based on published Endocrine Society guidelines, 2011)

Methods: In a retrospective design from July 2011- 2013, we reviewed metabolic profile, pre and post treatment 25(OH) D levels of obese adolescents with VDD (> 95% weight for age). Though different regimens for vitamin D supplementation were used only obese adolescents who received 50,000 IU once weekly for either 4- 6 weeks were studied.

Results: Of the 53 obese adolescents identified (56% were female, age: 11.7± 4.4 years; BMI: 32.3± 7.7; mean± SD) only 3 adolescents had 25 (OH) D levels which were sufficient (>30 ng/ml; 75 nmol/L). Average 25 (OH) D levels in this obese cohort was 21± 8 ng/dl. 40 subjects had a record of being treated and the pretreatment 25 (OH) D level was 15.9± 4.6 ng/dl. While 83% received treatment for 6 weeks, a subset were treated for 4 weeks. Of those adolescents, post treatment 25 (OH) D levels were available in only 34%. 8 (44%) normalized their 25 (OH) D levels and this level went above 30 ng/ml (34.8± 4.4 ng/dl) while 10 adolescents (56%) failed to optimize their level to above > 30 ng/ml.

Conclusions: These results illustrate the following points:

  1. Obese adolescents have invariably VDD and correction of their deficiency should be considered an effective addition to the management of their obesity to maximize non skeletal benefits of Vitamin D such as its role in glucose homeostasis.
  2.  Obese adolescents may require 2-3 fold higher doses (as suggested by the Endocrine society for adults) to optimize levels of 25(OH) D levels (>30 ng/dl) and this treatment course may need to be repeated 2-3 times/year to maintain optimal levels.
  3. We suggest that adipose tissue is dynamically altered in obese adolescents which affects local metabolism of Vitamin D, it’s reentry into the circulation and metabolic clearance rates, an area that deserves investigation.

 

Nothing to Disclose: PCB, SKK, NV, MFC, BK

13929 26.0000 SAT-0254 A Efficacy of Treatment of Obese Vitamin D Deficient Adolescents Based on Endocrine Society Guidelines 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Marija Pfeifer*1, Tinkara Duhovnik2, Marija Troskot2, Ajda Bicek2 and Bogdan Lorber2
1University Medical Center Ljubljana, Ljubljana, Slovenia, 2University Medical Center, Ljubljana, Slovenia

 

Background:Carbamazepine (C) and oxcarbazepine (O) are antiepileptic drugs that induce P450 24A1 (24-hydroxylase), the enzyme involved in vitamin D inactivation. Longtime treatment with antiepileptic drugs and its effect on vitamin D metabolism may cause vitamin D insufficiency.

Aim:To assess the relation between long-term treatment with C and O and vitamin D serum levels and to evaluate the difference in vitamin D levels, bone turnover markers and BMD in the group of epileptic patients on antiepileptic treatment and age matched healthy controls. In the intervention part of the study the effects of vitamin D supplementation on these parameters were assessed in patients only.

Methods:Prospective case-control study was performed in 32 patients (aged 28 to 59 years) treated with C or O for at least one year, mean duration of treatment 10.3 ± 7.5 (SD) years; twenty-two healthy hospital staff aged 29 to 60 years formed the control group at baseline. Serum concentrations of vitamin D, calcium and bone turnover markers [type 1 procollagen amino-terminal-propeptide (PINP), skeletal alkaline phosphatase (S-ALP), carboxy-terminal telopeptide (CTX)] were assessed in patients before and after one year of vitamin D replacement. BMD was measured using dual-energy X-ray absorptiometry. The control group hasn’t been treated with vitamin D.

Results:There was no difference in serum vitamin D concentrations between patients and controls at baseline. Both groups were vitamin D insufficient, hospital staff controls having vitamin D deficiency (levels below 50 nmol/L) in 59.1% as compared to only 46.9% of patients. No significant difference was observed in Z scores of BMD. With one year vitamin D supplementation in epileptic patients treated with antiepileptic drugs, increase in vitamin D concentrations, in BMD at the distal third of radius (p<0,0001) and of the bone formation marker S-ALP was observed as well as the borderline significant increase in BMD of the lumbar spine (p = 0,051).

Conclusions: There was no difference in serum vitamin D concentrations and BMD in patients treated with C or O as compared to healthy hospital staff controls. Vitamin D insufficiency was found in both groups while the proportion of vitamin D deficiency was greater in the control group. One-year vitamin D supplementation in epileptic patients resulted in improvement of BMD at radius and of borderline improvement at lumbar spine. Bone formation marker S-ALP increased. We recommend replacement of vitamin D, and measurement of BMD in patients on antiepileptic drugs. Hospital staff represents a risk group for vitamin D insufficiency and deserves further evaluation.

Nothing to disclose: PM, DT, TM, BA, LB.

 

Nothing to Disclose: MP, TD, MT, AB, BL

14783 27.0000 SAT-0255 A Effects of Vitamin D Replacement on BMD and Bone Turn-over Markers in Epileptic Patients Treated with Carbamazepine (C) or Oxcarbazepine (O) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Joely A. Straseski*1 and Sara P Wyness2
1Univ of Utah School of Medicine, Salt Lake City, UT, 2ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT

 

Objective:Analyze the performance of 6 automated total 25-hydroxyvitamin D assays using 25(OH)D2/D3 and 25(OH)D3 only samples.

Methods: Access 2 and DxI 800 (Beckman Coulter*), ARCHITECT i2000SR(Abbott), ADVIA Centaur XP (Siemens), Liaison XL (DiaSorin) and Modular E170 (Roche Diagnostics) assays were evaluated for imprecision, method comparison and concordance. Imprecision used control material tested in duplicate twice daily for 5 days. Method comparisons used residual serum samples with endogenous D2 and D3 (n=50) or D3 only (n=86). Comparisons with all 136 samples were intended to simulate real-world laboratory testing. Results were compared to in-house LC-MS/MS (traceable to NIST SRM 972) using Passing-Bablok regression and Bland-Altman bias plots. Acceptability criteria were CV <10% and bias <15.8%.

Results:Imprecision was acceptable for all assays except E170 and Centaur with imprecisions of 11%. Regression analysis of all samples compared to LC-MS/MS showed under-recovery of ARCHITECT, DxI, E170 and Liaison while Access and Centaur over-recovered. Compared to D2/D3 samples, E170 and Centaur showed the greatest improvement in slope without D2 while Liaison was unaffected. Also, E170 under-recovered with D2/D3 and over-recovered in the absence of D2. Access, Centaur and DxI assays exhibited the opposite effect. Constant bias improved without D2 present for all assays except ARCHITECT and E170. Testing all samples, Centaur had the lowest overall bias; E170 and Liaison did not meet acceptable limits. Testing D2/D3 samples, DxI and Access had the lowest bias; ARCHITECT, E170 and Liaison did not meet acceptable limits. Without D2, the Liaison still exceeded this limit; ARCHITECT had the lowest bias. Concordance with LC-MS/MS at 20 ng/mL ranged 77% (Centaur) to 89% (DxI). ARCHITECT, E170 and Liaison concordance improved without D2.

Overall, Access and DxI had slopes close to 1 and acceptable bias for all sample groups. Liaison had the lowest slopes and was not affected by D2. While ARCHITECT slope and intercept were not greatly affected by D2, bias and concordance improved without D2 present. E170 and Centaur assays were most affected by D2, based on improvements in slope, intercept or bias when D2 was absent.

Conclusions:It is important to consider the effects of D2 and D3 on individual assay performance. Assessing performance using total vitamin D may mask possible interferences in supplemented populations.

*Assays pending US FDA approval

 

Nothing to Disclose: JAS, SPW

14865 28.0000 SAT-0256 A Performance Characteristics of Six Automated 25-Hydroxyvitamin D Assays: Mind Your 3's and 2's 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Cecilia Fenili*, Ana Mari­a Sequera, Gabriela Ruibal, Mirta Gurfinkiel and Andrea Kozak
Argentine Society for Endocrinology and Metabolism, CABA, Argentina

 

At the present, the Vitamin D (VIT D) status is frequently measured in risk populations, in big cities and mainly in winter. Also it is accepted that the VIT D deficiency is a negative prognostic factor associated to different pathologies, and this has increased its measurement. There have been developed various automatic systems for 25-OH VIT D, that for being faster and less laborious are replacing the manual RIAs. Aim: To compare and establish by ROC plot analysis the consensus cutoff values for deficiency of VIT D (accepted for RIA) and the cutoff limits with greater sensitivity (S) and specificity (Sp) in the other automatic systems evaluated. Materials and Methods: 254 serum samples (collection in winter time) from healthy adults (18 - 45 years) not supplemented with VIT D, were included. Samples were aliquoted and stored at -20ºC during the study. Total 25 OH VIT D was tested in all samples by four methods: radioimmunoassay (RIA, DIASORIN); chemiluminiscence (CLIA1, ADVIA Centaur,Siemens Diagnostics), electrochemiluminiscence (ECLIA, Cobas e411, Roche Diagnostics) and chemiluminiscence (CLIA2, Architect, Abbott Laboratories). Cutoff levels with best S and Sp were calculated by ROC plot analysis. Samples with VIT D values ≤ 20.0 ng/ml by RIA(consensus cut-off) were interpreted as true positives. Results: VIT D values (ng/ml) (median and range) by RIA were 24.0 (7.0-94.0), with 39 % sample results below 20 ng/ml; by CLIA1 were 18.7 (7.2-49.8) with 57 % sample results < 20 ; by ECLIA were 23.7 (3.0-60.4) with 33 % sample results < 20 and by CLIA2 were 17.8 (4.1-57.3) with 58 % sample results < 20. Significant differences were found between RIA and CLIA1, CLIA1 vs ECLIA and CLIA2 vs (RIA, vs ECLIA, vs CLIA1) (p< 0.001, Friedman, Dunn test). No significant differences were found between RIA vs ECLIA (p= NS).ROC plot analysis showed that samples with VIT D ≤ 20.0 ng/ml by RIA would have by CLIA1 a cutoff of 19.62 ng/ml (S: 83.3 %, Sp: 56.5, AUC: 0.727), by ECLIA a cutoff of 19.60 ng/ml (S: 70.8 %, Sp: 81.7, AUC: 0.818) and by CLIA2 a cutoff of 13.1 ng/ml (S: 63.9 %, Sp: 88.9, AUC: 0.823). Conclusions: the cut-off obtained with greater sensitivity (S) and specificity (Sp) in the automatic systems evaluated are not all equivalents to the RIA. We consider necessary the unique cut-off used to be revised to define as insufficiency as sufficiency of VIT D, such as performance of different methods in the follow up of patients under supplementation treatment.

 

Nothing to Disclose: CF, AMS, GR, MG, AK

14902 29.0000 SAT-0257 A Is It Correct to Use the Same Vitamin D Insufficient or Sufficient Cut-off Value If We Measure with Different Immunoassays? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Tatiane Vilaca*1, Marília Brasilio Rodrigues Camargo2, Olguita Ferreira3 and Marise Lazaretti-Castro4
1Universidade Federal de Sao Paulo UNIFESP, Sao Paulo, Brazil, 2Universidade Federal de Sao Paulo UNIFESP, 3CETEC Centro Tecnológico de Minas Gerais, 4Universidade Federal de São Paulo UNIFESP, Sao Paulo SP, Brazil

 

Background

Strontium (Sr) is an alcaline Earth metal, like calcium (Ca). Both are absorbed by the same pathways. Previous studies had shown that Sr could be used as a surrogate of Ca absorption. Vitamin D has a main role in this function. The aim of this study was to investigate whether vitamin D supplementation in deficient women with low bone mass could enhance Ca absorption.

Patients and methods

Twenty-five vitamin D deficient women (25OHD<50 nmol/L, according to the Endocrino Society guidelines) were submitted to a four-hour strontium overload test. After an overnight fast, blood was drawn for baseline determinations (creatinine, total Ca, PTH, 1,25(OH)2D). All the patients received 1 gr of Sr ranelate dissolved in deionized water. Sr determinations were made at 0, 30, 60, 120 and 240 min. The women were treated until reaching sufficient vitamin D levels (25OHD>75 nmol/L) and the test was repeated. The fraction of Sr absorbed dose (FAD) was used to evaluate Ca absorption, calculated by the formula: FADt = [(Srt – Sr0) x 15% body weight]/ Sr administered dose . 

Results

Changing vitamin D status from deficient to sufficient resulted in a significant increase in 1,25(OH)2D (24.97 ± 4.64 x 34.62 ± 9.14 pg/mL p< 0.001) and a reduction in PTH (73.87 ± 37.50 x 58.24 ± 20.13 pg/mL p=0.006), but no change was detected in calcium absorption. The FAD did not differ in any of the moments evaluated (30, 60, 120 or 240 min) before and after treatment.

Discussion

The relation between vitamin D levels and Ca absorption is controversial. Heaney et all proposed 25OHD concentrations 80-90 nmol/L as the threshold for maximum Ca absorption. On the other hand, Need and colleagues described its impairment only with 25OHD< 10 nmol/L, suggesting that severe vitamin D deficiency is needed to compromise this function. Recently, evaluating postmenopausal women, Gallagher et all found a correlation between Ca absorption and 1,25 (OH)2D but not 25OHD. They hypothesized that at very low levels of 25OHD the lack of substrate causes a decrease in 1,25(OH)2D production and harms mineral absorption.  At not so low levels, secondary hyperparathyroidism is effective to enhance 1,25 (OH)2D enough to maintain adequate Ca absorption. This theory is in agreement with our findings, once there were not severely vitamin D deficient women in our sample.

Conclusion

In patients with mild vitamin D deficiency, cholecalciferol supplement does not enhance intestinal calcium absorption.

 

Nothing to Disclose: TV, MBRC, OF, ML

15298 30.0000 SAT-0258 A No Change in Calcium Absorption in Postmenopausal Women before and after Vitamin D Oral Administration Using Strontium As a Surrogate 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Riyad Sulimani*1, Ashry Gad2, Suliman Alshehri3, Abdulaziz Alothman2 and Assim A Alfadda4
1King Saud University, RIYADH, Saudi Arabia, 2King Saud University, 3Ministry of health , Saudi Arabia, 4College of Medicine, King Saud University, Riyadh, Saudi Arabia

 

Aim : To study the prevalence of vitamin D deficiency among Saudi female students and  its seasonal variation

 Methods : This is a cross sectional study investigating the prevalence of vitamin D deficiency among Saudi female students - in intermediate and secondary schools- in the Riyadh region , Saudi Arabia  . Demographic data of the girls including their exposure to sunlight and life style were obtained. Vitamin D deficiency was defined as level below 50 nmol/l while insufficiency was defined as levels between 50-75 nmol/l.

Results :  A total of 2167 students were recruited . Their mean age was 16.13± 1.77 years  Fasting morning samples for vitamin D estimation were taken during the summer months of May and June and during the winter months of December , January and February. A total number of students recruited during summer was 2167 while repeat samples for winter were obtained from 1048 students . The mean winter vitamin D level was 39.5 ± 28 nmol/l while it was 26.17 ± 18 nmol/l in summer (p=0.000). The majority of the girls were minimally exposed to sun with 35 % exposed for 1-10 minutes during winter months; but with practically no exposure during the hot summer months. Their consumption of dairy products was inadequate with mean calcium intake of 283±212.3 /day.

Discussion: It is observed that vitamin D deficiency occurs with high frequency among Saudi female students. The deficiency appears to be more profound during summer months – temperatures reaching up to 107 f -in contradiction to  reports from other countries with more temperate climates where vitamin D deficiency is observed more frequently during winter months. In summer, direct sun exposure is tradionally completely avoided  in Saudi Arabia which could explain the difference in vitamin D levels between winter and summer months. 

Conclusion : It is concluded that vitamin D deficiency is common among Saudi adolescent girls. Attention to vitamin D supplementation is more needed especially during summer months  to prevent severe vitamin D deficiency. Our observation also suggest that even some casual sun exposure for short periods may significantly raise vitamin D levels.

 

Nothing to Disclose: RS, AG, SA, AA, AAA

15025 31.0000 SAT-0259 A Vitamin D Deficiency Is More Prevalent in Summer Among Saudi Female Students 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Kerstin Landin-Wilhelmsen*1, Taye Demeke2, Amra Osmancevic3, Penelope Trimpou4, Göran Oleröd5, Anders Harald Lindahl5 and Lars Wilhelmsen6
1Section for Endocrinology, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, 2Lärjedalen Primary Health Care, Gothenburg, Sweden, 3Department of Dermatology, Gothenburg, Sweden, 4Sahlgrenska University Hospital, Gothenburg, Sweden, 5Department of Clinical Chemistry, Gothenburg, Sweden, 6Institution of Medicine, Gothenburg, Sweden

 

Background: Reference or recommended levels of serum vitamin D, 25(OH)D have been discussed. There are still uncertainties if serum 25(OH)D levels <10 ng/ml (<25 nmol/l) should be denoted deficiency and >10<20 ng/ml (>25<50 nmol/l) should be considered as insufficiency.

Aim: The aim was to study the prevalence of serum 25(OH)D according to the recommended concentrations, in relation to season, body composition, life style factors, bone measures and fractures in the population during 13 years follow-up.

Methods: A random population sample of men and women from the World Health Organization (WHO, MONItoring of trends and determinants for CArdiovascular disease), project, Gothenburg, Sweden, (latitude 57°North) was studied in 1995, n=608, 25-64 years and re-examined in 2008, n=412 aged 38-78, participation rate 68%. Serum 25(OH)D was measured with a RIA method (DiaSorin, Stillwater, MN, USA). Body composition and bone mass were measured, physical activity, coffee consumption and smoking data were asked for via standardized questionnaires. X-ray verified fractures were retrieved from the hospital registers until 2012.

Results:  In 2008, serum 25(OH)D was similar in men, mean 24.0+10.4 ng/ml (60.0+26.1 nmol/l) range 6-60 ng/ml (15-150 nmol/l) and women 24.8+9.1 ng/ml (62.0+22.7 nmol/l) range 7-65 ng/ml (17-162 nmol/l), and increased with increasing age.

Four (1%) had vitamin D deficiency; 25(OH)D levels <10 ng/ml (<25 nmol/l) and 259/412 (63%) had vitamin D insufficiency; levels >10<20 ng/ml (>25<50 nmol/l). The figures were 5% versus 49% in 1995.

There was no seasonal variation in 25(OH)D in 2008 as seen 13 years ago with high levels during the summer months. Serum 25(OH)D did not correlate with degree of physical activity, which was a plausible explanation for being outdoors, as it did 13 years ago. Serum 25(OH)D correlated inversely and independently with body fat and serum parathyroid hormone.

The fracture incidence increased with age. Women aged 45-64 years who had vitamin D insufficiency in 1995 suffered from more fractures (28%) during 17 years follow-up than women of the same age with sufficient vitamin D concentrations (16%), (p=0.02; OR 1.11-3.48). Calcium/vitamin D supplementation was rare in 1995 and was used by 9% in 2008 and their 25(OH)D levels were higher than those without these agents at similar age.

Conclusions: Serum 25(OH)D increased with increasing age. In contrast to the findings 13 years ago, no seasonal variation and no correlation between 25(OH)D and degree of physical activity were seen. Serum 25(OH)D correlated inversely with body fat and parathyroid hormone in men and women. The majority of this Swedish random population sample had Vitamin D levels considered as insufficient.

 

Nothing to Disclose: KL, TD, AO, PT, GO, AHL, LW

15959 32.0000 SAT-0260 A The Majority of Men and Women from a Random Population Sample in Sweden Are Vitamin D Insufficient, the WHO Monica Project, Gothenburg 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Selin Dincer1, Sebila Dokmetas*2 and Fatih Kilicli3
1Cumhuriyet University, 2Medipol University, Istanbul, Turkey, 3Cumhuriyet University, Sivas, Turkey

 

Background: There is controversy about the diagnostic features, dose, duration and criteria concerning vitamin D deficiency. In this study, we investigated the relation of vitamin D levels with symptoms, demographic, clinical and laboratory parameters and the changes induced by treatment in patients with vitamin D deficiency living in a Central Anatolia city of Turkey.

Methods: Five hundred and thirty-three patients having 25-OHD levels <30 ng / mL and age > 18 years living in a city with a continental climate were examined. Patients' age, symptoms, clothing style, health and satisfaction in their own health state, treatment duration were recorded. Patients on treatment were followed-up for 1-6 months.

Results: Mean serum 25(OH)D at the time of diagnosis was 7.59±4.41 ng/ml. 74%of the patients had serious deficiency, 24.2% had deficiency, 1.3% had insufficiency.  Mean serum 25(OH)D after treatment was 24.42±14.77 ng/ml. By treatment, 57.6% of the cases reached the target values, 25.4%had insufficiency, 14.7% had deficiency and 2.3% had near the border serious deficiency of vitamin D. 74.4% of the women had protective way of clothing and 25.6% weared daily clothes leaving the head exposed to sunlight. We have found that response to treatment decreased as the body mass index increased. Abundant bone and muscle pain were present at diagnosis in 61.4% of the patients, 79% were not satisfied with their health status. Ca, PTH and ALP levels were normal at the time of diagnosis. 25(OH) D levels at diagnosis was 7.85±4.06 at the age of 30-49, 8.44±5.95 at the age of 50-69 and 6.34±3.84 at the age of 15-29. There was significant increase by age.

Conclusion:  We found high percentage of vitamin D deficiency in people living in a city of Middle Anatolia especially in women at reproductive age. Treatment should be continued until a sufficient level of 25(OH)D is reached.

 

Nothing to Disclose: SD, SD, FK

15052 33.0000 SAT-0261 A Evaluation of Response to Vitamin D Treatment in Patients with Osmeomalacia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Helenius Jan Kloosterboer*1, Peter Schot2 and Marjanne Prins2
1KC2, Oss, Netherlands, 2OrgaNext Research

 

NDD is a novel fixed dose combination of nandrolone decanoate (25 mg) and vitamin D3 (28.000IU) /0.5 ml sesame oil in development for mitigation of disuse atrophy and loss of physical function in elderly women recovering after hip fracture surgery at risk of vitamin D deficiency.

To determine the safety, tolerability and multiple dose pharmacokinetics of subcutaneously injected NDD, 16 healthy women (65-78 years of age) received two 0.5 ml injections at day 1 and subsequently one 0.5 ml injection at day 8, 15 and 22. Blood samples were taken day at screening, day 1 (pre-dose), 2, 3, 4, 8, 11, 15, 16, 18, 22, 23, 24, 25, 35, 50 and 112. To correct for seasonal changes in vitamin D3 (D3) and 25-(OH) vitamin D3 (25-(OH) D3) levels, 14 women were included in a control group. In the control group blood samples were collected at screening, day 25 and 112. During the study safety and tolerability were monitored in both groups. In serum levels of nandrolone, D3 and 25-(OH) D3 were measured using validated LCMS/MS assays.

Nandrolone shows first order kinetics: After dose 5 AUC0-72 is 143.6 h*ng/ml, Cmax , T max , T ½  and Kel  are 2.89 ng/ml, 46.3h, 478.5h and 1.67/h*10-3, respectively. For D3 and 25-(OH) D3 Cmax , T max, T ½ and Kel could not be calculated because mean serum levels did not significantly change after the first and last injections. Baseline-corrected AUC0-72 after dosing at day 1 was -23.6 and -21.0 h*ng/ml and after dosing at day 22 160.8 and -25.1 h*ng/ml for D3 and 25-(OH) D3, respectively. At day 25 D3 and 25-(OH) D3 levels in the NDD group were not significantly different from those in the control group. Between day 25 and 112 serum levels of 25-(OH) D3 declined in the control group but not in the NDD group. The injections were well tolerated and no clinically relevant (serious) adverse events occurred. In the NDD group one subject discontinued the study because of Lyme disease.

In a post-hoc analysis the results of the 25-(OH) D3 measurements in the NDD group were analyzed depending on the screening level (> or < 30 ng/ml). Baseline corrected levels at day 25 and 112 in the group < 30 ng/ml were + 4.7 and +6.4 ng/ml, in the group > 30 ng/ml the baseline corrected levels were -3 and - 8 ng/ml.

In conclusion: multiple injections with NDD are safe and well tolerated, both ND and D3 are released from the oil depots and effects on the 25-(OH) D3 level are dependent on the screening level, suggesting that 25-(OH) D3 levels are regulated.

 

Nothing to Disclose: HJK, PS, MP

16640 34.0000 SAT-0262 A Safety, Tolerability and Multiple Dose Pharmacokinetics of a Fixed Dose Combination of Nandrolone Decanoate + Vitamin D3 in Healthy Elderly Females (65 years of age or older) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Ye An Kim*1, Kyoung Min Kim1, Sung Hee Choi2, Soo Lim3, Jae Hoon Moon4, Sang Wan Kim5, Eu Jeong Ku1, Kyong Yeun Jung1, Chan Soo Shin6 and Hak Chul Jang7
1Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 2Seoul Nat Univ Bundang Hosp, Seongnam-Si, Korea, Republic of (South), 3Seoul National University Bundang Hospital, Seongnam, Korea, Republic of (South), 4Seoul National University College of Medicine, Korea, Republic of (South), 5Seoul Metropolitan Government Boramae Medical Center, Seoul, Korea, Republic of (South), 6Seoul Nat Univ College of Med, Seoul, Korea, Republic of (South), 7Seoul National University Bundang, Seongnam-Si, Korea, Republic of (South)

 

Background

Dietary vitamin C might have a protective role in bone loss in postmenopausal women. Few studies evaluated the relative contribution of vitamin C on bone mineral density (BMD) in adjunction with vitamin D, which is an important regulator of bone metabolism.

Objective

We investigated the association between dietary vitamin C intake and bone mineral density (BMD) in postmenopausal women using the data from the Third Korean National Health and Nutrition Examination Survey (KNHANES IV, 2009).

Design

Dietary information was assessed with a 24-hour dietary recall questionnaire. BMD was measured at lumbar spine and hip using dual x-ray absorptiometry. Subjects with premenopausal state, renal insufficiency (Cr≥1.4mg/dl), histories of osteoporosis treatment, estrogen/progesterone users, and supplementary vitamin and mineral users were excluded.

Results

A total of 5690 women were enrolled and 2073 subjects aged 50 years and older were included. BMDs for all sites showed significant positive correlations with the dietary vitamin C tertiles with more strong relationships for hip than that of lumbar spine ( r=0.148 for lumbar spine, r=0.221 for femur neck, r=0.214 for total hip, p<0.001, respectively). Moreover, subjects with osteoporosis at lumbar spine or hip showed significant lower values of dietary vitamin C intake than subjects without osteoporosis of identical site (74.4 ± 66.2 to 94.1 ± 78.6 for lumbar spine, 65.5 ± 56.6 to 94.3 ± 79.2 for femur neck, 46.3 ± 38.2 to 89.2 ± 76.0 for total hip, p <0.001, respectively). These positive associations between dietary vitamin C and BMD were not consistently observed in premenopausal women. Interestingly, the associations with dietary vitamin C intake and BMD at each site were stronger in subjects with low serum vitamin D less than 50 nmol/L. Lower dietary vitamin C intakes (<100mg/d) showed higher prevalence of osteoporosis (OR = 1.505, 95% CI 1.086-1.948, p = 0.009) after adjusting dietary calcium and vitamin D. In age 50s and 70s or older groups, lower dietary vitamin C was associated with osteoporosis while there was no association between dietary vitamin C and osteoporosis in 60s.

Conclusions

Dietary vitamin C intake showed positive relationships with BMDs at all skeletal sites in postmenopausal women. These results could suggest that dietary vitamin C have protective effects on bone loss of postmenopausal women and could be encouraged.

 

Nothing to Disclose: YAK, KMK, SHC, SL, JHM, SWK, EJK, KYJ, CSS, HCJ

15444 35.0000 SAT-0263 A Favorable Effect of Dietary Vitamin Con Bone Mineral Density in Postmenopausal Women (KNHANES IV 09') 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Nasser M. Rizk*1, Esma Ahmedou Moud Moud2, Salwa Saeed2, Amina Saleh Fadel1, Samah ebrahim Ahmed2, Fadheela Dadbakhsh Arzemohmmed2 and Ayman El-Menyar3
1Qatar University, Doha, Qatar, 2Qatar University, Qatar, 3Hammad medical coroprtaion, HMC, Doha, Qatar

 

Background:  Several studies indicate an association between vitamin-D deficiency and coronary artery disease 1,2.

Objectives: The aim of this study was to evaluate the relation between different grades of vitamin-D deficiency and coronary artery disease, and to determine if there was a relation between vitamin-D deficiency and the severity of the coronary artery lesion among CAD patients.

Methods: A prospective-retrospective case–control association study included 110 healthy volunteers and 129 CAD patients. They were enrolled from the cardiology department-Heart Hospital, Hammed Medical Corporation (HMC)-Doha, Qatar, from November 2011 to November 2012. Based on the severity of coronary arteries stenosis, CAD patients were divided into: group 1 (severe stenosis with > 50%  luminal lesion) and group 2 (minimal stenosis with luminal lesion ≤ 50%). 25 hydroxy-vitamin D (Vit D) and vitamin-D binding protein (Vit D –BP) were performed by Eliza in Biomedical labs – Qatar University. Data are expressed as mean with 95% CI of the mean unless mentioned otherwise.

Results: The mean ± SD age in years of study subjects was (56.00±9.1) for CAD patients and (44.77±16.3) for healthy controls. Males were (76.7%) among CAD and (72.15%) among healthy controls. CAD had significantly lower mean values of  Vitamin D (16.30, (10.10-30.39) than the healthy controls subjects (21.21, (13.2- 27.5) ng/ml, p =0.011 but had significantly higher (Vit D –BP) (3720, 3660-3750) than for healthy subjects (3650, 3610-3736) pg/ml, p=0.003. CAD patients with severe stenosis had significantly lower mean values of Vit D (12.7, 9.33-26.9) than CAD with minimal or no stenosis (19.8, 11.7-32.8) , with p value =0.036, but no significant difference for Vit D-BP between both groups with p=0.419. For CAD patients with severe stenosis, the groups with deficient (<10 ng/ml) and insufficient levels (10-30 ng/ml) of vitamin D had the highest percentage (58.8%) of patients with the numbers of  blood vessels affected (2 or more) than patients with optimal Vit D (>30 ng/ml) level (52,32%), with p=0.737. CAD patients with optimal levels of vitamin-D had the highest percentages (60.70%) with ejection fraction (EF) (> 50%), while CAD with insufficient/deficiency vit-D group had the highest percentage (51.10%) of severe EF (< 50%). Spearman’s correlation revealed that Vitamin-D levels, has significant correlation with Vit D-BP (r=0.322, p=0.022); and troponin (r=-0.289, p=0.019); but insignificant with the numbers of blood vessels affected (r=-0.063, p=0.620); and the ejection fraction (r=-0.069, p=0.637).

Conclusion:The results of the present study suggest that Vit D could have an impact on the severity of the coronary artery lesion independent on the numbers of blood vessels affected. Further investigations are needed to explore the possible mechanisms of Vit D deficiency on CAD.

 

Nothing to Disclose: NMR, EAMM, SS, ASF, SEA, FDA, AE

16885 36.0000 SAT-0264 A Association Between Vitamin D and Coronary Artery Disease in Qatar 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Julianne Cook Botelho*, Ashley Ribera, Hans C Cooper and Hubert W Vesper
Centers for Disease Control and Prevention, Atlanta, GA

 

Laboratory measurements are used to make patient care and public health decisions. However, the accuracy and reliability of these tests prevent appropriate detection, treatment and prevention of diseases. The aim of the CDC Standardization Programs for testosterone (T), estradiol (E2), and vitamin D [25(OH)D] are to standardize clinical measurements such that accurate and comparable measurements are obtained regardless of the measurement procedure, location, and time. To support the clinical and research community the CDC has established Reference Services, Standardization-Certification Programs, and Quality Assurance Monitoring Services.

As part of the Reference Laboratory Services the CDC has established higher order reference measurement procedures for total testosterone, total estradiol, and 25-hydroxyvitamin D2 and D3 in serum using LC-MS/MS. These measurement procedures are traceable to primary reference materials and to JCTLM certified reference measurement procedures.  The CDC collaborates with the clinical, research, metrological and proficiency testing (PT) communities to assign target values to materials.  These materials are used for method comparisons, calibration, and accuracy controls. CDC Standardization-Certification Programs are operating for T and E2 with the Hormone Standardization (HoSt) Program and 25(OH)D with the Vitamin D Standardization-Certification Program (VDSCP). In both of these programs, 4 blinded challenges are sent over the period of a year.  Bias and imprecision assessments using established protocols and final assessment are made using criteria derived from biological variability. At present, 22 participants are enrolled in the HoSt-T Program and 28 in VDSCP. Participants include clinical, academic, and pharmaceutical laboratories as well as immunoassay manufacturers. Approximately 80% of participants have meet the established criteria and successful laboratories are published on the CDC website (http://www.cdc.gov/labstandards/hs.html). The CDC is also working with external quality assessment and PT providers on accuracy-based surveys to allow the performance of clinical laboratories to be monitored and the impact of standardization programs on patient care to be assessed. In addition the CDC provides quality assurance monitoring services to help assure accuracy over time for research studies and clinical trials by providing accuracy based blinded quality control materials.

CDC Standardization Programs collaborate closely with stakeholders such as the Partnership for Accuracy in Hormone Testing (PATH) and The Endocrine Society to assure clinical and public health needs are met.  One example of this collaboration is through the development of common reference ranges for T. Through these efforts and collaborations the CDC is working towards standardizing testosterone, estradiol and vitamin D measurements.

 

Nothing to Disclose: JCB, AR, HCC, HWV

17065 37.0000 SAT-0265 A CDC Standardization Programs – Testosterone, Estradiol, and Vitamin D 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Pratibha Shahajirao Pawal*
T. N. Medical College & B.Y.L. Nair hospital, Mumbai, Mumbai

 

Title: Study Of Various Vitamin D3 Supplementation Protocols That Are Used In Community Practice For Treatment Of Hypovitaminosis D

Authors: Pawal PS,Joshi AS,Lathia T,Mittal S,Sharma BR,Dalwadi PP,Bhagwat NM, Chadha MD, Varthakavi PK.

Acknowledgement: Dhoyle JP, Rahate S,Halankar S.

ABSTRACT

  • Introduction: Hypovitaminosis D is widely prevalent in India (70-90%). Different dosing protocols have been used for Vitamin D(VITD) supplementation; however there is no universally accepted regimen.
    • Objectives: Comparison of serial VITD concentrations attained with various VITD supplementation protocols in VITD deficient subjects.
    • Methods: 242 subjects were screened.105 consenting subjects( age 20-60 years) with Hypovitaminosis D(VITD <16ng/ml) participated in the study and were randomized to receive 4 different supplemental regimens i.e. single dose 6lacIU orally, single dose 6lacIU intramuscular, 60000IU once weekly for 8 weeks and 2000IU daily for 8 weeks.
    • Outcome measures: Primary outcome measure was the serial serum VITD concentration attained. VITD, Parathyroid Hormone(PTH), calcium, phosphorus, alkaline phosphatase were monitored at baseline, 1,3,6,8 & 12 weeks of therapy.

Results: 66.5% subjects were found to be vitamin D deficient (<20ng/ml). Baseline VITD concentrations for Oral, IM, Weekly and Daily groups were 10.6±3.7; 9.7±4.5; 8.9±4.4 and 10.2±4.3 ng /ml respectively.  VITD concentrations  increased significantly in all groups at 3 weeks(P <0.001).After 8 weeks, VITD concentrations for Oral, IM, Weekly and Daily groups were 34.6±9.4; 40.6±15.1 ; 40.2±13.9 and 24.7±7.7ng/ml respectively. VITD concentration decreased from 8 weeks to 12 weeks in all groups except in IM group which maintained steady increasing trend from 8wks to 12 wks.VITD level >100ng/ml was observed in 40% of subjects in oral group while none of other groups showed VITD >100ng/ml at all time points. All groups were compared with mean percentage increment in VITD concentration at different time points. Serum intact PTH was increased in only in 40% of subjects with VITD <16 ng/ml.

Conclusions: Only IM mega dose group showed sustained increment of VITD concentration at 12 weeks without VITD toxicity or hypercalcaemia. Only oral group had VITD levels >100 ng/ml(40%) without clinical manifestations of hypervitaminosisD .Oral loading dose is adequate for maintaining VITD sufficiency only for duration of 3 months & need for resupplementation at 3 monthly interval. Weekly group also showed decline in VITD sufficiency at 12 weeks indicates need for retesting and supplementation.2000IU daily is not adequate to achieve sufficiency in VITD deficient subjects.

 

 

Nothing to Disclose: PSP

15555 38.0000 SAT-0266 A Study of Various Treatment Protocols for Hypovitaminosis D 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0229-0266 4784 1:00:00 PM Vitamin D Metabolism & Action Poster

Elizabeth Parra Garnica*, Pritisheel Banga and Soe Naing
University of California, San Francisco, Fresno Medical Education Program, Fresno, CA

 

Background: Primary Hyperparathyroidism (PHPT) is rarely diagnosed during pregnancy.  Acute pancreatitis is a rare complication of PHPT and is associated with significant maternal and fetal morbidity during pregnancy. However, there is a paucity of information and recommendations in the literature on the appropriate management of this serious complication.

Clinical Case: A 28-year-old pregnant woman, who conceived twins with IVF treatment, was admitted to the hospital with a one day history of severe epigastric pain and vomiting at 17.5-weeks’ gestation. She did not have any significant past medical history and she was on prenatal vitamins only. Her blood tests revealed elevated lipase of 3356 (NR 12-53 U/L) and amylase of 2967 (NR 20-130 U/L). Abdominal ultrasound showed an enlarged pancreas and large volume ascites. There was hypercalcemia with albumin-corrected serum calcium of 13.5 mg/dL, ionized calcium of 7.11 (NR 4.48-5.28 mg/dL) and PTH of 177.9 (NR 14.0-72.0 pg/mL).  She was therefore diagnosed with acute pancreatitis due to PHPT and a multidisciplinary team consisting of surgeons, obstetricians, an endocrinologist, gastroenterologists and hospitalists were immediately involved in her care. She was given aggressive IV fluid hydration, IV furosemide, and subcutaneous calcitonin. Her calcium level came down to 11.5 mg/dL 24 hours later. There was also drastic improvement in clinical and biochemical parameters of acute pancreatitis within 3 days. On her 5th day of hospitalization, she underwent parathyroidectomy in which right superior parathyroid adenoma was removed.  Serum calcium and PTH levels were normalized post-operatively and she was discharged home on 7thday of hospitalization.  Her serum calcium and PTH remained within normal range when she was last reviewed at 28 weeks of gestation.

Conclusion:  Acute pancreatitis due to PHPT during pregnancy is very rare and is associated with significant maternal and fetal morbidity. Aggressive intravenous hydration, loop diuretics and subcutaneous calcitonin appeared to be effective and safe initial medical therapies. Parathyroidectomy should be considered as soon as the patient is stabilized. This case illustrated that early recognition and prompt management by a multidisciplinary team is vital for the successful outcome.

 

Nothing to Disclose: EP, PB, SN

14407 1.0000 SAT-0193 A Acute Pancreatitis Due to Primary Hyperparathyroidism during Pregnancy: Multidisciplinary Team Approach for the Successful Outcome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Kaniksha Desai*1 and Shon Edward Meek2
1Mayo Clinic Florida, Jacksonville, FL, 2Mayo Clinic-Jacksonville, Jacksonville, FL

 

Background:  Osteogenic osteomalacia is a rare tumor which results in hypophosphatemia.  This is often secondary to mesenchymal tumors. Very rarely it has been reported in patients with neurofibromatosis. Definitive treatment is localization of the tumor and surgical removal.  Here we present a case where a woman presented with progressive weakness, inability to walk, and multiple fractures and was found to have a nerve sheath tumor in her left calf and was diagnosed with neurofibromatosis.

Case: 51 year old woman presented to the clinic with 4-5 years of progressive weakness with a decreased ability to walk and was also noted to have bilateral feet fractures and a hip fracture.  She was previously worked up for muscle weakness but no secondary etiology was found.  During her examination she was noted to have multiple skin lesions including café-au-lait macules and axillary freckling which were biopsied and consistent with neurofibromatosis. She was also noted to have significant proximal muscle weakness, especially in her lower extremities. During her workup here she was noted to have low phosphorus level of 1.8 mg/dL and a low Vitamin D level of 12.7 ng/ml and a normal PTH level.  Further laboratory studies showed that she had an elevated fibroblast growth factor 232 H RU/mL (normal <180 RU/mL) and urinary phosphorus level of 466 which was consistent with hypophosphatemic osteomalacia.  She was treated with Neutra-Phos and cholecalciferol and was noted to have a slight improvement in her weakness and an increase in her phosphorus levels to 2.1 mg/dL.  She had an octreotide scan which did not show any focal lesion and then proceeded to have a PET scan which showed increased uptake in the calf muscle. She had an MRI completed which showed a 2.7 cm mass in the left gastrocnemius muscle.  She subsequently was taken to surgery and had the tumor removed which showed pathology consistent with a nerve sheath tumor. 

In conclusion, a detailed physical exam and measurements of basic labs including calcium and phosphorus measurements are important in evaluating patients with weakness and fractures.

 

Nothing to Disclose: KD, SEM

14822 2.0000 SAT-0194 A Oncogenic Osteomalacia Secondary to a Schwannoma in a Patient with Neurofibromatosis That Presented with Weakness and Multiple Fractures 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Rodolfo J Galindo*1, Ageliki S Valsamis2, Isabela J Romao2 and Yael Tobi Harris2
1Hofstra University - School of Medicine, Great Neck, NY, 2Hofstra North Shore LIJ School of Medicine, Great Neck, NY

 

Introduction: Etiologies of hypercalcemia associated with cancer include humoral hypercalcemia of malignancy (i.e. tumoral production of parathyroid-related peptide [PTHrP]), local osteolytic changes, calcitriol-mediated and rarely ectopic hyperparathyroidism.

Clinical case: A 58-year-old man presented with syncope and falls during orthostatic postural changes. He also reported malaise, weight loss, polyuria and diffuse abdominal pain. He had been diagnosed with anal squamous cell carcinoma one year prior, and had responded well to chemotherapy.  No systemic disease had been found on initial staging.  His medical history also included bipolar disorder (never treated with lithium). His medications included gabapentin and docusate. On presentation, he was bradycardic to 48 bpm and had orthostatic hypotension. Physical exam revealed temporal wasting, dry mucous membranes, leg edema and confusion. Laboratory evaluation showed hypercalcemia (Corrected Calcium [CCa] of 15.3 mg/dl, n=8.4-10.5), suppressed PTH (8.5 pg/mL, n=15-65) and hypophosphatemia. Computerized tomography (CT) of the head and chest were unremarkable. Bone scan did not reveal any lesions. CT of the abdomen and pelvis demonstrated multiple solid hepatic lesions. A liver biopsy revealed metastatic squamous cell carcinoma. Further evaluation for hypercalcemia revealed elevated PTHrP (6.7 pmol/L, n<2), decreased 25-hydroxy-vitamin D (25-OH-D of 27.2 ng/ml, n: 30-100) and increased 1, 25 dihydroxy-vitamin D (1, 25(OH2) D of 75 pg/ml, n=18-64). A diagnostic evaluation for causes of elevated calcitriol was unrevealing. The patient’s calcium level improved transiently with standard therapy with saline hydration, calcitonin, and zolendronic acid, and he was discharged home. A few weeks later, the patient was readmitted and again had elevated CCa, PTHrP and 1, 25-OH2-D (12.3 mg/dl, 11 pg/ml and 205 pg/ml respectively). He received chemotherapy - including dexamethasone - and his CCa levels improved. After rapid recurrence of hypercalcemia, prednisone 40 mg daily was started. However over a five month course, the hypercalcemia responded poorly to biphosphonates and/or prednisone, showing only significant improvement with chemotherapy.

Conclusions: This is a rare case of combined elevation of PTHrP and calcitriol and the first case of calcitriol production by a metastatic colorectal squamous cancer. Treatment of the underlying malignancy is a key element to control hypercalcemia of malignancy, particularly in patients with combined etiologies.

 

Nothing to Disclose: RJG, ASV, IJR, YTH

15387 3.0000 SAT-0195 A Hypercalcemia of Malignancy Secondary to Combined Elevation of Calcitriol and Parathyroid-Related Peptide in a Patient with Anal Squamous Cell Carcinoma and Liver Metastasis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Sophia Hu*, Amy Chow and Louis F Amorosa
Rutgers-RWJMS, New Brunswick, NJ

 

Introduction: Statin-induced rhabdomyolysis is a rare cause of myopathy found in <0.1% of patients who use statins. Rhabdomyloysis can cause acute oliguric renal failure (AORF) associated with hyperphosphatemia and hypocalcemia. In the recovery diuretic phase, delayed hypercalcemia may occur in 30% of patients caused by multiple mechanisms including secondary hyperparathyroidism (SHPT). We present a patient with unusually severe statin-induced rhabdomyolysis, which resulted in diffuse myocellular or interstitial calcium deposition and late onset of hypercalcemia with suppressed iPTH.   

Clinical case: A 60 year-old male with coronary artery disease was admitted to the hospital for profound weakness one week following the initiation of simvastatin 80mg daily. Initial labs showed BUN 47 mg/dL (6-23), creatinine 2.4 mg/dL (0.5-1.2), calcium 8.6 mg/dL (8.6-10.4), potassium 6.2 mEq/L (3.5-5), phosphorus 2.7 mg/dL (2.5-4.5), CPK 153 U/L (25-210), 25(OH)D 20 ng/mL (25-80) and iPTH 144 pg/mL (9-76). In one week, he developed progressively worsening proximal upper and lower extremity weakness, inability to raise his head and dysphagia. Simvastatin was discontinued at this point. Repeat labs showed Ca 5.5 mg/dL, K 6.5 mEq/L, PO4 7.6 mg/dL, BUN 47 mg/dL, Cr 2.1 mg/dL, CPK 426,270 U/L, AST 4480 IU/L (12-45), ALT 667 IU/L (3-40) and ionized calcium 3.0 mg/dL (4.6-5.3). Urine myoglobin was positive. He became oliguric and emergent hemodialysis was initiated. EMG showed diffuse myopathy. Left shoulder MRI showed increased T2 signal involving almost all muscles of the shoulder, consistent with myositis. Right leg muscle biopsy showed findings consistent with statin-associated myofiber lesions: severe myonecrosis, partial deficiency of myophosphorylase and myofiber type 2 atrophy. His muscle weakness improved but he remained oliguric. One month later, he developed hypercalcemia of 13.7 mg/dL. Other labs included Cr 2.5 mg/dL, ionized Ca 7.3 mg/dL, 1,25(OH)2D <8.0 pg/mL (18-64), iPTH 7 pg/mL, TSH 6.89 mIU/L (0.35-5.5) and free T4 1.38 ng/dL (0.9-1.8). Evaluation for humoral hypercalcemia of malignancy was negative. Whole body bone scan showed diffuse soft tissue and muscle uptake of radiotracer in the chest wall, shoulders, proximal upper and lower extremities, pelvis and hips. Hemodialysis was continued and normalization of his Ca to 8.2 mg/dL was achieved eight days later.

Conclusion: Secondary hypercalcemia following rhabdomyolysis-induced AORF may not always be a result of SHPT. In this patient, the bone scan and iPTH level indicate that the hypercalcemia was likely the result of dissolution of calcium phosphate complexes in injured muscles or their interstitium. These complexes likely contributed along with myoglobin to the patient’s AORF. Moreover, the patient’s profound weakness associated with myopathy likely resulted in a component of immobilization hypercalcemia.

 

Nothing to Disclose: SH, AC, LFA

15520 4.0000 SAT-0196 A Acute Renal Failure Caused By Simvastatin-Induced Rhabdomyolysis Associated with Secondary Hypercalcemia Not Related to Hyperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Katica Bajuk Studen*1, Antonela Sabati Rajic1 and Marija Pfeifer2
1University Medical Center, Ljubljana, Slovenia, 2University Medical Center Ljubljana, Ljubljana, Slovenia

 

A 61-year old man was referred to our center because of primary hyperparathyroidism (PHP). His baseline serum calcium level was 3.25 mmol/L and intact parathormone level was 146 pg/ml, calciuria was 0.16 mol/mol of creatinine (low normal), and Ca/creat clearance ratio was 0.006.  He was treated with cinacalcet (60 mg per day) which lowered his calcium level to upper limit  normal. He did not have osteoporosis or kidney stones, but suffered myocardial infarction a year earlier. With morphologic work up we found an adenoma of the right lower parathyroid gland. He was operated later on and histological examination confirmed parathyroid adenoma.  Cinacalcet treatment was discontinued. However, at the check-up three months later an elevated calcium level was found (2.80 mmol/l) with parathyroid hormone in the lower half of the normal values (32 ng/ml). We again assessed the 24-hour calciuria (0.021 mol/mol creatinine) and calculated the calcium/creatinine clearance ratio, which was extremely low (0.0007) confirming familial hypocalciuric hypercalcemia (FHH). We concluded that this FHH patient  also developed PHP. We additionally examined two of his relatives referred to us because of hypercalcemia. We confirmed PHP in one relative (parathyroid adenoma resected and confirmed histologically), after operation this patient also had persistent hypercalcemia and hypocalciuria. The other relative was diagnosed with FHH only.

In conclusion, FHH is a consequence of an inactivating mutation of calcium sensing receptor (CaSR). A decreased sensitivity of CaSR is a characteristic of PHP caused by adenoma as well. We report a case of a unique family with hypocalciuric hypercalcemia in which two members also developed PHP. When familial appearance of extreme hypocalciuria with hypercalcemia is found, genetic testing is not obligatory to establish the diagnosis of FHH.

 

Nothing to Disclose: KB, AS, MP

15842 5.0000 SAT-0197 A Clinical Case: A Man with Familial Hypocalciuric Hypercalcemia WHO Developed Primary Hyperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Maria Teresa Pereira1, Andre Filipe Couto de Carvalho2, Helena C Cardoso*2, Susana Garrido1, António Canha3, Vitor Valente3, Moreira Costa3 and Fatima Borges4
1Hosp Santo Antonio, Porto, Portugal, 2Hosp Santo Antonio, Porto, Portugal, Porto, Portugal, 3Hosp Santo Antonio, Porto, Portugal, Portugal, 4Hospital de Santo Antonio, Porto, Portugal

 

Introduction: Primary hyperparathyroidism (1º HPTH) is a common cause of hypercalcemia. A successful cervical exploration results in surgical removal of pathological parathyroid (PT) tissue in most cases. However, in about 1-12% of surgeries, persistent/ recurrent postoperative HPTH occurs.

Clinical case: A 56-year-old man with recurrent depressive syndrome presented with PTH-dependent hypercalcemia detected in routine biochemical study 1.5 years before. He was previously submitted to left hemithyroidectomy for HPTH and concomitant cytological diagnosis of follicular neoplasm with simultaneous cervical exploration and removal of lower left and right parathyroid glands. PT histology was "normal". The patient remained with persistent disease with elevated serum calcium of 2.66 mmol/L (N: 2.09-2.42), iPTH 232 pg/mL (N: 15-65), phosphorus 0.73 mmol/L (N: 0.87-1.45) even after correction of vitamin D deficit. A 99mTc-sestamibi scan was suggestive of a right PT adenoma image and he was re-explored with completion thyroidectomy. An intraoperative iPTH assay failed to demonstrate an adequate fall. After surgery, both serum iPTH and total calcium values were high - 274 pg/mL and 2.86 mmol/L, respectively. Cervical magnetic resonance image (MRI) and a new 99mTc-sestamibi location study suggested the existence of a suspicious remaining PT in the left cervical region. A third cervical re-exploration was performed at this point, with identification of an aberrant PT in the left tracheoesophageal groove, posterior to the common carotid artery. A parathyroidectomy was carried out with simultaneous implantation of PT fragment in the ipsilateral sternocleidomastoid fascia. Histopathology confirmed a PT gland with nodular hyperplasia. His postoperative course was uneventful, and at last follow-up PTH and calcium levels were normalized.

Conclusion: Patients with persistent hypercalcemia after an unsuccessful initial surgical approach must be carefully evaluated with more accurate imaging location studies before being considered a surgical re-exploration. In these cases, it should be always considered the presence of ectopic parathyroid tissue. The possibility of iatrogenic hypoparathyroidism poses therapeutic challenge with potential life-threatening results if untreated.

 

Nothing to Disclose: MTP, AFCDC, HCC, SG, AC, VV, MC, FB

16307 6.0000 SAT-0198 A Persistent Primary Hyperparathyroidism in a Patient with an Ectopic Parathyroid Gland – a Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Samaneh Dowlatshahi*1, SeyedAmirhossein Afsharimani2, Erica Gold Sinsheimer3 and Harvey Friedman4
1St Francis Hosp, Evanston, IL, 2st Francis hospital, 3Endo and Metab Consultants Ltd, Skokie, IL, 4St Francis hospital

 

Introduction:

Pseudohypoparathyroidism (PHP) is a rare disorder defiend by end-organ un-responsiveness to parathyroid hormone (PTH). Type Ib PHP is characterized by resistance to PTH mainly in the renal tissue and in a few others tissues such as the thyroid, but without features of Albright hereditary osteodystrophy (AHO). This type is characterized by blunted nephrogenous cyclic-AMP (cAMP) response to exogenous parathyroid hormone (PTH). In this report we present an adult onset presentation of PHP 1B confirmed with laboratory and genetic testing, who presented with multiple seizures.  

Clinical Case:

A 24 year African American male, presented with new onset seizure episodes since three days prior to admissions. Patient denied any muscle spasm, weakness, tongue biting, urinary incontinence. He was not able to remember the episodes and per witnesses it involved his whole body with shaking movements and eye rolling, and mouth drooling. Episodes were being provoked wit feeling unease at his throat and coughing. Patient had episodes of hand clenching when he plays piano since the ago of 20. On physical exam, trousseau and  chvostek signs were present.  CT head revealed Diffuse calcification of the BG (caudate and  lentiform nucleus) and cerebellum (dentate nucleus) in a symmetric and bilateral pattern. This finding was confirmed with MRI. Blood tests revealed calcium: 5.6 mg/dl (8.5-10.5), ionized calcium: 0.55 mmol/l (1.15-1.29), phosphorus 6.1 mg/dl (2.40-4.30), 25 OH Vit D 17.6 ng/ml (30-100), PTH intact: 157 pg/ml (15-65), 24 h urinary calcium: 24 mg/24h (100-300). We started him IV calcium gluconate two times daily adjusted according to ionized calcium to keep the levels above 1.1, calciteriol 0.25 mg/day, and ergocalciferole 50000 units weekly for up to 8 weeks, patient’s calcium total and ionized level improved to normal values. With high-normal serum phosphate and normal alkaline phosphatase, and a lack of symptoms associated with osteomalacia, vitamin D deficiency alone was unlikely to be the cause of hypocalcaemia. There was nopeculiar clinical features of Albright hereditary osteodistrophy. The diagnosis of PTH resistance (pseudohypoparathyroidism type Ib) was made clinically and patient was referred for a genetic test which confirmed the diagnosis.  

Conclusion:

Pseudohypoparathyroidism presents with end organ resistance to PTH, associated with hypocalcemia, hyperphosphatemia, and elevated PTH. Intracranial bilateral symmetric calcification can be seen in up to 50% of PHP cases. There is no correlation between the extent of calcification and serum calcium. It is extremely important to perform a complete biochemical analysis (that always includes calcium, phosphate, magnesium and parathyroid hormone serum measurements) in order to distinguish PHP from other disorders in in every patient presenting symptoms suggestive of hypocalcaemia.



 

Nothing to Disclose: SD, SA, EGS, HF

11314 7.0000 SAT-0199 A Pseudohypoparathyroidism Presented As Bilateral Symmetrical Intracranial Calcification 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Sara J. Healy*1 and Kyaw Kyaw Soe2
1The Ohio State Univ Wexner Med Ctr, Columbus, OH, 2The Ohio State Univ Med Ctr, Columbus, OH

 

Introduction: Parathyroid carcinoma is rare, accounting for less than 1% of cases of primary hyperparathyroidism. We present a case of parathyroid cancer which progressed over a three year period due to interruption of treatment.

Clinical case: A 50 year-old female presented to the ED with shortness of breath, and CT scan incidentally showed a left thyroid nodule. Ultrasound confirmed a 3 cm nodule. She complained of a lump in her throat and change in voice. She had no personal or family history of hypercalcemia or thyroid or parathyroid disease. FNA at an outside facility was read as follicular neoplasm, and FNA slides were read at OSU as Hurthle Cell Neoplasm. Thyroid function tests were normal. She underwent left thyroid lobectomy in August 2010 and surgical pathology showed an intrathyroid parathyroid carcinoma with extrathyroidal extension measuring 5.0 x 3.1 x 2.2 cm. There was extensive angiolymphatic invasion of the tumor, with positive margins and two negative lymph nodes.  Due to lack of insurance, she did not follow up until March 2012, when ultrasound showed 0.9 cm hypoechoic mass in left thyroid bed concerning for persistent carcinoma. FNA of the mass showed insufficient cellular material, but PTH washout from FNA was 6059 pg/mL. Her surgeon recommended central neck dissection to remove the remaining parathyroid tissue. However, was she lost to follow up for another 1.5 years. She presented to a free clinic in September 2013 complaining of dysphagia, bony pain, constipation, and 40 lb weight loss, and serum Ca was 16 mg/dl (8.6-10). She was sent to the ED and labs showed Ca 14.5, ionized Ca 8.19 mg/dl (4.6-5.3), PTH 1652.7 pg/ml (14-72), phos 2.0 mg/dl (2.7-4.5), 25 OH vitamin D 5.78 ng/ml (25-80). On exam she had multiple small palpable mobile nodules in the left neck. She had neck US, CT neck and chest, and PET scan which showed multiple soft tissue masses in the left thyroidectomy bed involving the esophagus concerning for recurrence of disease. There were also two left upper lobe pulmonary nodules concerning for metastasis and a few foci of FDG avidity in the sacrum. She was treated for hypercalcemia and returned for surgery in October 2013. She underwent total laryngopharyngectomy, total thyroidectomy, cervical and upper thoracic esophagectomy, tracheostomy, and bilateral neck dissection. Surgical pathology showed parathyroid carcinoma metastatic to multiple sites in the esophagus and paralaryngeal and paratracheal soft tissues. PTH dropped from 1600 to 25 pg/mL on the day of surgery and she developed hungry bone syndrome requiring IV calcium gluconate 1g/hr and elemental calcium 800 mg four times daily. She followed up regularly after surgery and serum calcium remains normal on ergocalciferol, calcitriol, and CaCO3.

Conclusion: Parathyroid carcinoma is a rare disease with a high rate of recurrence. The mainstay of treatment is surgery and medical management of hypercalcemia.

 

Nothing to Disclose: SJH, KKS

12128 8.0000 SAT-0200 A Recurrent Parathyroid Carcinoma: Clinical Course Three Years after Diagnosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Arshpreet Kaur*, Jeremy P Crim, Sri Prakash L Mokshagundam and Betty Cheng Villafuerte
University of Louisville, Louisville, KY

 

Background: Hyperparathyroidism-Jaw tumor (HPT-JT) syndrome is a rare autosomal dominant form of familial hyperparathyroidism caused by a mutation in the HRPT2 gene, which is important to recognize due to a 15-fold increased risk of parathyroid cancer.(1) We describe an unusual case of hyperparathyroidism with initial presentation as a brown tumor of the jaw which failed to regress after parathyroidectomy. Clinical Case: We report the case of a 21-year old healthy African American male who presented with a 6-week history of pain and numbness around the right lip. He was treated by 2 sequential molar teeth extractions resulting in right facial swelling and worsening pain. Computed tomography of the face and mandible revealed a 3 cm expansile mandibular lesion with thin sclerotic margins. Bone biopsy showed giant cell granuloma suggestive of brown tumor from hyperparathyroidism. Further evaluation revealed a serum calcium level of 16 mg/dl (normal 8.6 – 10.3), PTH of 1030 pg/ml (normal 10 - 65) and 25-OH vitamin D level of 11 ng/ml (normal 30 – 100). He reported chronic polyuria, polydipsia, constipation, and a 20 lb weight loss over 6 weeks due to inability to eat. There was no family history of hyperparathyroidism. Sestamibi scan suggested a left inferior parathyroid adenoma. He was treated with saline diuresis, calcitonin and cinacalcet without improvement in hypercalcemia. He underwent a left inferior parathyroidectomy and left thyroid lobectomy with intra-operative PTH monitoring. A large smooth encapsulated 8.1 gm cystic left inferior parathyroid mass was removed. Pathology revealed oncocytic parathyroid adenoma with cystic changes. Hyperparathyroidism-Jaw Tumor syndrome was considered in view of patient’s young age and the cystic and atypical parathyroid pathology. Parafibromin staining was negative suggesting HRPT2 mutation. Post-operatively, his facial pain and jaw lesion continued to worsen, and a repeat CT showed an enlarging right mandibular lesion, with groundglass matrix suggestive of fibrous dysplasia. Genetic testing for HRPT2 mutation is in progress. Conclusion: HPT-JT syndrome should be considered in young patients with atypical, cystic or malignant parathyroid histology. The syndrome is important to recognize because of the increased risk of parathyroid cancer and other tumors, including renal and uterine tumors.(1) Parafibromin staining of the resected tumor can serve as a less costly, rapid approach prior to genetic testing.(2,3)

 

Nothing to Disclose: AK, JPC, SPLM, BCV

13050 9.0000 SAT-0201 A Hyperparathyroidism - Jaw Tumor Syndrome: A Cause of Hyperparathyroidism in Young Adults 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Thomas Jensen*1 and Cecilia C. Low Wang2
1University of Colorado School of Medicine, Aurora, CO, 2Denver VAMC and Univ Colorado Sh, Denver, CO

 

Objectives:

  1.  To describe a rare case of hypercalcemia due to Primary Hyperparathyroidism (PHPT) and Humoral Hypercalcemia of Malignancy (HHM).

  2.  To advise aggressive screening of patients found to have persistently elevated and rising Parathyroid hormone-related peptide  (PTHrP).

    Case:  A 72 year old male presented with confusion, fever, weight loss of 40 lbs over a couple of months,  right hip pain and calcium level of 14.7 mg/dL and albumin 2.8 g/dL.  Parathyroid Hormone (PTH) was 147 pg/ml (10-56pg/ml) along with elevated PTHrP 6.8 pmol/L (<2.0pmol/L).  Phosphorus was low at 2.0, 25 Vitamin D 15.6 ng/mL, 1-25 Vitamin D was 129.4 pg/m (10-75 pg/ml).  SPEP, UPEP, and TSH were normal.  Sestamibi exam localized to right inferior lobe.  CT scan of chest, abdomen, and pelvis did not find pathological sources for PTHrP.    Patient was initially treated with cinacalcet and calcitonin and then had right inferior parathyroidectomy that was positive for adenoma.  Calcium fell to 8.3 mg/dL post op though calcium rose to 10.1 mg/dL at discharge and PTH was undetectable.  PTHrP was still elevated at 4 pmol/L and 1-25 Vitamin D fell to 27 pg/ml though mental status improved.  Patient was re-admitted 2 weeks later with delirium and calcium up to 11.9 mg/dL with albumin of 2 g/dL.  PTHrP was up to 8.5 pmol/L.  Repeat CT scan revealed rapidly expanding mass in soft tissue adjacent to prior right hip arthroplasty.  Initial concern was for infection given fever, but biopsy revealed high grade epitheliod angiosarcoma.  Due to patient’s poor functional reserve, he was treated conservatively with fluids, IV bisphosphonate, and calcitonin prior to discharge to hospice where the patient passed away. 

    Discussion:  HHM is caused by tumors that release a peptide with close homology in the N-terminal sequence to PTH that binds with the type 1 PTH receptor.  PTHrP can be elevated in certain tumors including squamous cell cancers of lung and head and neck, as well as breast, and renal, with rare causes from neuroendocrine tumors and certain sarcomas such as chondrosarcoma though any tumor in theory could release it (1).  Epitheliod Angiosarcoma is a rare neoplasm derived from cells lining blood vessels that tends to be aggressive with high mortality rates.  There are no case reports of PTHrP being elevated in association with Angiosarcoma at this time.   Anywhere from 4-15% of patients with hypercalcemia in cancer are found to have PHPT as the cause.  It is rare to find hypercalcemia caused by both elevated PTH and PTHrP.  The occurrence of both HHM and PHPT is unknown.  HHM has a poor prognosis with one study finding median survival time of 64 days even with treatment (2).  This case highlights the importance of considering more than one cause of hypercalcemia in patients whose calcium levels do not improve after definitive treatment for PHPT and in the setting of concern for malignancy, an elevated PTHrP should prompt aggressive cancer screening.

 

Nothing to Disclose: TJ, CCL

15460 10.0000 SAT-0202 A Double Trouble: A Case of Primary Hyperparathyroidism and Humoral Hypercalcemia of Malignancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Karla M Arce*1, Melissa Li-Ng2 and Laurence Kennedy3
1Cleveland Clinic, Cleveland, OH, 2Cleveland Clinic, Shaker Heights, OH, 3Cleveland Clinic Foundation, Cleveland, OH

 

Background

DiGeorge syndrome is due to an embryologic defect in the development of the 3rd, 4th and 5th branchial pouches resulting in hypoparathyroidism as one of the manifestations. The treatment of hypoparathyroidism can become cumbersome during pregnancy and lactation due to endogenous production of parathyroid hormone-related peptide (PTHrP) by the placenta and mammary glands.  Moreover, studies have shown that secretion of PTHrP increases throughout pregnancy, peaking in the third trimester and continues during lactation.

Clinical case:

A 28-year-old Caucasian woman with a history of DiGeorge syndrome was referred for hypercalcemia noted after pregnancy.  She was diagnosed with DiGeorge syndrome when she was 6 weeks old, after presenting with seizures. Hypoparathyrodism was confirmed at that time and she was started on calcium and calcitriol, which she remained at various doses over the years.  During pregnancy her medication dosages required frequent adjustments and prior to evaluation she was taking calcitriol 0.25mcg daily, hydrochlorothiazide (HCTZ) 12.5mg daily, magnesium 250mg three times a day (TID) and calcium carbonate 750mg TID.  The pregnancy was without complications.  She delivered a baby girl at term and began breast-feeding immediately.  At that time her serum calcium was 8.6 mg/dl (8.5-10.1mg/dl), phosphorus 3.4 mg/dl (2.5-2.9 mg/dl) and magnesium 1.6 mg/dl (1.7-2.4 mg/dl). Two weeks post-partum, serum calcium increased to 12.7 mg/dl and calcitriol 0.25 mcg was decreased to every other day. Two months post-partum she remained hypercalcemic and serum calcium was 13.1 mg/dl, subsequently calcium carbonate was stopped and calcitriol 0.25 mcg was decreased to every 3 days. The patient continued to breast-feed for 12 months and her calcitriol requirements gradually increased and reached pre-pregnancy levels within days of weaning at 13 months post-partum.

Conclusion

This case report illustrates the importance of monitoring serum calcium closely in patients with hypoparathyroidism during breastfeeding.  In multiple case reports as well as in our case, pregnant and lactating hypoparathyroid women have been found to have a rise in the serum calcium, with decreasing requirements of supplemental calcitriol.  Studies have established that the exogenous production of vitamin D requirements fall during breast-feeding through a PTHrP and prolactin mediated mechanism. Production of PTHrP from the mammary gland in response to elevated prolactin and lower estradiol levels leads to calcium and phosphate mobilization from bone. Our case highlights the importance of the role of PTHrP in calcium regulation in patients with hypoparathyroidism.

 

Nothing to Disclose: KMA, ML, LK

16388 11.0000 SAT-0203 A Post Partum Hypercalcemia in a Patient with Digeorge Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Supamit Ukarapong*1, Jaime Haidet2, Melanie Shoaf2 and Gary David Berkovitz1
1University of Miami, Miller School of Medicine, Miami, FL, 2Akron Children's Hospital, Akron, OH

 

Introduction : Long term glucocorticoid therapy is associated with increased risk for vertebral fractures in both adults and children.  Whereas recommendations have been established for the use of bisphosphonates in adults receiving treatment with glucocorticoids, the use of bisphosphonates in children remains controversial.  We present a case of a child with multiple vertebral fractures following high dose glucocorticoid therapy but who had rapid recovery of fractures after cessation of glucocorticoids and short term treatment with Zoledronic acid.

Clinical Case : A 12-year-old boy with autoimmune lymphoproliferative syndrome (ALPS) presented with severe back pain after 5 months of therapy with sirolimus and prednisone (8mg/m2 BSA/day).  The diagnosis of ALPS and initiation of immunosuppressive therapy occurred within two weeks of the appearance of lymphadenopathy and splenomegaly.  There was no history of trauma prior to the onset of back pain.  Physical examination indicated signs of Cushing syndrome and tenderness to palpation over spinous processes in the thoracolumbar region.  Lateral radiogram of thoracolumbar spine indicated wedge shape fractures of T11- L5 ranging between grade 1 to 2 according to Genant method.  Bone mineral density of vertebra was markedly subnormal (height-corrected Z score of -4 S.D. for age).  Although serum level of 25-hydroxyvitamin D (20 ng/ml) was below normal, serum levels of calcium, phosphorus, alkaline phosphatase and PTH were normal.  Urinary N-telopeptide was normal for age.  Glucocorticoids was tapered over 6 weeks and then stopped.  A single dose of intravenous Zoledronic acid (0.04 mg/kg) was administered.  No electrolyte abnormalities occurred.  Treatment with cholecalciferol 50,000 units per week for 8 weeks was started as soon as vitamin D insufficiency was identified and vitamin D level subsequently normalized.  Four months after treatment with zoledronic acid, the patient reported marked improvement of his back pain.  Radiographic evaluation indicated improvement in vertebral fractures.  Vertebral height ratio (anterior to posterior vertebral body height on lateral radiogram) was significantly increased when compared to the initial radiogram (mean±S.D.; 0.74±0.07 v.s. 0.84±0.1, p<0.05).  An average increase in the height ratio was 13.5 percent.  A follow-up DEXA scan will be performed 12 months after the therapy.

Conclusion:  Treatment with Zoledronic acid resulted in rapid and marked improvement in vertebral fractures in this child with ALPS who had received high dose glucocorticoid therapy.  The rate of of recovery was greater than that expected just with cessation of glucocorticoid and treatment with vitamin D.  This case indicates that Zoledronic acid may be useful in the treatment of children with vertebral fractures associated with high dose glucocorticoids.  Studies of a larger group of affected children should be considered.

 

Nothing to Disclose: SU, JH, MS, GDB

16550 12.0000 SAT-0204 A Rapid Recovery of Vertebral Fractures in a Child with Glucocorticoid-Induced Osteoporosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Anis Rehman*1, Nicole C Dombrowski2 and Muhammad Hammad Siddiqi3
1Akron General Medical Center, Cleveland Clinic Affiliate, Akron, OH, 2Akron General Medical Center/Northeast Ohio Medical University, Kent, OH, 3Dow Medical College/Civil Hospital Karachi, Karachi, Pakistan

 

Introduction

Parathyromatosis and parathyroid carcinoma are very rare causes of primary hyperparathyroidism (PHPT).  Parathyromatosis occurs with benign parathyroid tissue spillage during surgery, leading to multiple hyperfunctioning parathyroid nodules scattered through the mediastinum and neck. We present a unique case of recurrent PHPT in a patient with parathyroid carcinoma and parathyromatosis who is not a surgical candidate but has initially responded to cinacalcet.

Case Report

A 62-year-old female with a history of hypertension initially presented with severe hypercalcemia with PHPT in 1993.  She underwent neck exploration with left superior parathyroidectomy revealing parathyroid carcinoma and left inferior parathyroidectomy revealing a hyperfunctional parathyroid gland.  PHPT persisted, and in 2004, ultrasound revealed a right thyroid nodule concerning for malignancy.  She had near-total thyroidectomy revealing Hashimoto’s thyroiditis.  The left lobe had microscopic foci of abnormal parathyroid tissue consistent with parathyroid carcinoma.  In 2006, she underwent left central neck dissection for worsening hypercalcemia.  The pathology report revealed recurrent parathyroid carcinoma and fibro-fatty tissue of multiple parathyroid foci, likely consistent with parathyromatosis.  Since 2006, total calcium levels ranged from 9.8-10.8 (8.5-10.1 mg/dl), PTH 69-157 (14-72 pg/ml) with normal albumin and Cr. 

The patient presented to the endocrine office in 2013 with worsening fatigue and confusion over several months.  Laboratory testing revealed significantly elevated PTH 239.1 pg/ml, Ca 12.8mg/dl, and ionized Ca: 1.60 mg/dl (4.43-4.93 mg/dl).  Her clinical presentation suggested the diagnosis of progressive recurrent low grade parathyroid carcinoma with parathyroidomatosis; however, her Sestamibi parathyroid scan with SPECT was unremarkable.  She was not a surgical candidate, and medical management was recommended to treat the severe hypercalcemia.

Hydrochlorothiazide was discontinued from her hypertension regimen. She was started on cinacalcet 30 mg twice daily and advised to keep well-hydrated.  Calcium level in one week was significantly improved at 9.8mg/dl with PTH 230.4 pg/ml.  The patient later required phosphorus supplementation.  Her symptoms have remarkably improved with cinacalcet, and she is now normocalcemic despite a persistently elevated PTH.

Conclusion

This case illustrates that cinacalcet can quickly and effectively lower calcium levels in a non-operative patient with severe hypercalcemia due to recurrent PHPT.

 

Nothing to Disclose: AR, NCD, MHS

12387 13.0000 SAT-0205 A Recurrent Primary Hyperparathyroidism Secondary to Parathyroid Carcinoma and Parathyromatosis: Medical Management with Cinacalcet 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Katie L O'Sullivan*1, Meltem Zeytinoglu1 and Tamara J. Vokes2
1University of Chicago, Chicago, IL, 2University of Chicago Medicine, Chicago, IL

 

Background: The potential health benefits of Vitamin D supplementation have gained significant attention recently in both medical literature and the media leading to increased widespread intake of Vitamin D in the US1,2. However, there is little awareness of possible risks of high Vitamin D intake in patients with certain medical conditions such as primary hyperparathyroidism. 

Clinical Case: A 73 year-old female with a history of osteoporosis presented with fatigue, anorexia, 15-lb weight loss, light-headedness, polyuria and depression symptoms over 1 year duration. Seven months earlier, in an effort to treat the above symptoms, she sought help from an alternative health provider who performed a general health assessment and prescribed 50,000 units of Vitamin D2 weekly as well as 5,000 units of D3 daily. She did not follow-up again with this provider but remained compliant with this regimen. On presentation to our clinic, physical examination revealed a frail woman with a depressed affect. She had tachycardia (103bpm), decreased skin turgor and dry mucous membranes suggesting mild dehydration. 

Initial lab tests were consistent with primary hyperparathyroidism: elevated calcium (14.3 mg/dL, n<10.2 mg/dL), elevated ionized calcium (7.6 mg/dL, n<5.4 mg/dL), low phosphate (2.2 mg/dL, n>2.5 mg/dL), and elevated PTH (291 pg/mL, n<75 pg/mL).  Vitamin D 25-OH was also elevated (>100 ng/mL, n<52 ng/mL).  Nuclear imaging of the parathyroid gland showed a focus of increased activity posterior to the right inferior pole of the thyroid consistent with parathyroid adenoma.

She was hospitalized for severe hypercalcemia, aggressively rehydrated with intravenous normal saline, and started on cinacalcet. She underwent surgical exploration of the neck and an enlarged right upper parathyroid gland was removed. Intra-operative PTH level fell to normal levels 25 minutes after resection (19 pg/mL), suggesting the adenoma was the source of excess production of PTH. Pathology of the surgical specimen revealed a hypercellular parathyroid gland weighing 390mg. One month after surgery the patient reports improved mood, increased energy and a 10-lb weight gain. Laboratory results revealed normal calcium (9 mg/dL) and normal PTH (42 pg/mL).

Conclusion: This case illustrates the danger of unmonitored high-dose Vitamin D supplementation in patients with primary hyperparathyroidism.  Although it is recommended to replace vitamin D in hyperparathyroid patients with vitamin D deficiency this should be done using smaller doses and careful monitoring of calcium levels.3 With the widespread use of prescribed and over-the-counter Vitamin D supplements, healthcare providers should be aware of conditions that can cause hypercalcemia in patients on high-dose Vitamin D therapy including primary hyperparathyroidism, granulomatous disease, and use of certain medications such as thiazide diuretics.

 

Disclosure: TJV: Advisory Group Member, NPS. Nothing to Disclose: KLO, MZ

12903 14.0000 SAT-0206 A Severe Hypercalcemia Exacerbated By Excessive Vitamin D Supplementation in the Setting of Primary Hyperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Sean J Iwamoto*, Jessica M Clima and Karen Elizabeth Earle
California Pacific Medical Center, San Francisco, CA

 

Introduction:

About 90% of hypercalcemia cases are secondary to hyperparathyroidism or malignancy. However, after ruling those out, rarer causes require investigation. We present two cases of severe symptomatic hypercalcemia, both in men who received injections of poly(methyl methacrylate) (PMMA) for cosmetic purposes.

Clinical Cases:

Case 1: A 57-year-old man with past medical history of hypogonadism on testosterone, prior prostate lobe resection for symptomatic urinary obstruction, and family history of hyperparathyroidism, presented to the emergency department with symptomatic hypercalcemia. Physical examination was notable for enlarged pectoralis muscles. Initial labs revealed acute renal failure and hypercalcemia: elevated serum creatinine (4.0 [n=0.8-1.3] mg/dl), elevated serum calcium (13.8 [n=8.5-10.1] mg/dl), normal intact PTH (22 [n=14-72] pg/ml), decreased total 25-hydroxyvitamin D (23 [n=30-100] ng/ml), and normal total 1,25-dihydroxyvitamin D (53 [n=18-72] pg/ml).

Case 2: A 55-year-old man with past medical history of well-controlled HIV on HAART and hypogonadism presented to the emergency department with symptomatic hypercalcemia. Physical examination was normal but initial labs revealed acute renal failure and hypercalcemia: elevated serum creatinine (2.5 [n=0.60-1.10] mg/dl), elevated serum calcium (13.3 [n=8.5-10.1] mg/dl), decreased intact PTH (<2 [n=14-72] pg/ml), decreased total 25-hydroxyvitamin D (17 [n=30-100] ng/ml), and normal total 1,25-dihydroxyvitamin D (36 [n=18-72] pg/ml).

In both cases, treatment included IV fluids and pamidronate; however, calcium levels did not normalize. Work up for occult malignancy, lymphoma, hyperparathyroidism, sarcoidosis, hypervitaminoses A and E, thyrotoxicosis, familial hypocalciuric hypercalcemia, and adrenal insufficiency was negative. Both men had histories of receiving PMMA injections into their pectoralis muscles for cosmetic purposes. CT scans of both men revealed areas of multiple soft tissue densities in the chest wall compatible with subcutaneous injected material. They were empirically started on prednisone with temporary stability of calcium levels. Nonetheless, their treatment courses over more than one year have been hampered by relapses of severe hypercalcemia, and recurrent nephrolithiasis in Case 1, with cessation of prednisone.

Conclusion:

We present two cases of severe hypercalcemia in the setting of PMMA injections, which have a reported <0.01 to 2.5% risk of granuloma formation (1) but no documented resulting hypercalcemia. The mechanism of action is thought to be secondary to microspheres of collagen substrate that stimulate local reactions leading to development of granulation tissue. Although both patients refused biopsies for pathological diagnosis, each demonstrated response to steroids, suggesting an underlying granulomatous etiology.

 

Nothing to Disclose: SJI, JMC, KEE

14880 15.0000 SAT-0207 A Suspected Granuloma-Induced Severe Hypercalcemia in the Setting of Poly(methyl methacrylate) Injections: Two Case Reports 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Isabel R Hsu*1, Elaine S Kamil2, Kevin V Lemley1 and Pisit Pitukcheewanont1
1Children's Hospital Los Angeles, Los Angeles, CA, 2Cedars-Sinai Medical Center, Los Angeles, CA

 

Background: Antenatal Bartter Syndrome is a subset of Bartter Syndrome, which usually presents with polyhydramnios in utero. Hyperparathyroidism has been reported in patients with Bartter Syndrome, however, serum calcium levels are usually low to normal. We report three cases of antenatal Bartter-like syndrome with hyperparathyroidism, hypercalcemia, bilateral nephrocalcinosis, and nephrogenic DI.

Case presentations: All three patients were born premature with prenatal history of polyhydramnios and suspected to have antenatal Bartter Syndrome. They developed polyuria and polydipsia. In addition hypokalemia, hypernatremia, and hypercalcemia with bilateral medullary nephrocalcinosis were also noted. Water deprivation test was consistent with nephrogenic DI. Evaluation of hypercalcemia (Case 1: 11.4 mg/dL; Case 2: 11.8 mg/dL, Case 3: 11.7 mg/dL; normal range 8.3-10.7 mg/dL) demonstrated inappropriately elevated intact PTH level (Case 1: 62.8 pg/mL, Case 2: 126.3 pg/mL, Case 3: 135.5 pg/mL; normal 10-65 pg/mL). In addition, 25(OH) Vitamin D levels were within normal limits and 1,25(OH)2 Vitamin D levels were elevated inappropriately for hypercalcemia, suggesting primary hyperparathyroidism. All patients had normal skeletal survey, negative sestamibi scan, as well as negative testing for William’s Syndrome and CASR mutation. Cinacalcet was initiated with subsequent normalization of hypercalcemia and hyperparathyroidism with improvement but not resolution of polyuria.

Case 1: A 23 month old ex-27 week premature Hispanic male was referred for evaluation of hypercalcemia. Gene testing for Bartter Syndrome showed heterozygous variant in the KCNJ1 gene (g.27329A>G; p.T86A).

Case 2: A 15 month old ex-34 week premature Hispanic female was referred for development of hypercalcemia and hyperparathyroidism. Gene testing for Bartter Syndrome showed heterozygous mutation in the KCNJ1 gene (g.27722A>G; p.R217G).

Case 3: A 3 month old ex-32 week premature Hispanic female was referred for evaluation of hypernatremia and hypercalcemia. KCNJ1 gene was not detected.

Conclusion: We report a syndrome of three cases of antenatal Bartter-like syndrome with hyperparathyroidism, hypercalcemia, bilateral nephrocalcinosis, and nephrogenic DI. Normalization of hypercalcemia and hyperparathyroidism can be achieved with cinacalcet treatment, however, polyuria was still present. Further evaluation is needed to determine the definite etiology.

 

Nothing to Disclose: IRH, ESK, KVL, PP

16537 16.0000 SAT-0208 A Syndrome of Antenatal Bartter-like Syndrome, Hyperparathyroidism, Hypercalcemia, Bilateral Nephrocalcinosis and Nephrogenic DI in Three Patients Treated with Cinacalcet 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Maria Batool*1, Vaishnavi Amit Parnerkar2, M Luiza Caramori3 and John P Bantle4
1University of Minnesota Medical Center, Minneapolis, MN, 2University of Minnesota, MN, 3Univ. of Minnesota, Minneapolis, MN, 4University of Minnesota, Minneapolis, MN

 

INTRODUCTION

Autoimmune polyendocrine syndromes (APS) are a heterogeneous group of rare diseases characterized by autoimmune activity against more than one endocrine organ.

The two major autoimmune polyendocrine syndromes, APS-I and APS-II, both have Addison's disease as a prominent component.

CLINICAL CASE

A 44 year old male presented with muscle cramps and elevated creatine kinase (CK). He endorsed salt craving but denied lightheadedness, dizziness or fatigue. Past medical history was pertinent for autoimmune thyroid disease diagnosed 7 years earlier with positive thyroid peroxidase antibodies. He was taking 125 µg of levothyroxine daily. There was no family history of autoimmune disorders. Vital signs were normal with no orthostasis. On physical exam, generalized skin darkening and increased buccal mucosal pigmentation was noted.

A morning cortisol level was 1.4 µg/dl (4-22) . Sodium 128 mmol/L (133-144), potassium 5.6 mmol/L (3.4-5.3) and creatine kinase 4321 U/L (30-300). TSH was 9.74 mU/L (0.4-5.0) and Free T4 was 0.95 ng/dL (0.70-1.85). Morning ACTH and cortisol levels were 233 pg/ml (10-47) and 1.4 µg/dl (4-22), respectively. ACTH stimulation test was done (250 µg) with a 60 minute cortisol level of 1.3 µg/dl. Aldosterone  <1.6 (Upright : 4.0-31 ng/dL), renin activity 32.6 and 21-hydroxylase antibody level of 138.7 U/ml (0-1).

The patient was diagnosed with having rhabdomyolysis associated with primary addisonian hyponatremia and started on hydrocortisone and fludrocortisone. The symptoms disappeared after initiation of treatment. Six weeks post-treatment CK was 386 U/L and sodium was 134 mmol/ L.

CONCLUSION

APS-II is an autoimmune polyendocrine syndrome consisting of autoimmune adrenal insufficiency associated with autoimmune thyroid disease and/or diabetes mellitus type 1.

The prevalence of APS-II has been estimated at 1.4 to 2.0 cases per 100,000 population (1, 2). More than 20 years may elapse between the onset on one endocrinopathy and the diagnosis of the next (4).

Majority of patients who present with Addison's disease (50%) later develop autoimmune thyroid disease. In contrast, less than 1% of patients with autoimmune thyroid disease or type 1 diabetes mellitus develop adrenal insufficiency (3). Our patient is unusual in that his autoimmune thyroid disease pre-dated the diagnosis of Addison's disease by 7 years and was he was fortunate in that he remained on levothyroxine up until the diagnosis of adrenal insufficiency without having an adrenal crisis.

In patients with co-existing thyroid disease and adrenal insufficiency at diagnosis, it is recommended that thyroid hormone replacement be deferred until after steroid replacement is started to prevent life-threatening adrenal crisis. Management of APS-II is based on lifelong replacement hormone therapy for the affected glands and periodic monitoring for other endocrinopathies that have not yet manifested.


 

Nothing to Disclose: MB, VAP, MLC, JPB

15132 17.0000 SAT-0209 A Years in the Making- a Case of Autoimmune Polyendocrine Syndrome Type 2 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Maria Katrina Malabanan Mallonga* and Eduardo Thomas M. Aquino
St. Luke's Medical Center, Quezon City, Philippines

 

Background:

Primary hyperparathyroidism, which is rare in pregnancy, may be a cause of morbidity to the mother and fetus due to the effects of hypercalcemia, if no appropriate intervention is done. Surgery is the mainstay of treatment, with the approach depending if the diseased gland is localized preoperatively. We present a case of primary hyperparathyroidism diagnosed in the first trimester of pregnancy, with no pre-operative localization, and underwent parathyroidectomy with intraoperative PTH monitoring.

Case:

Patient is a 31 year old female, gravida 3, para 1 (1011), who was in her 9th week of pregnancy, consulted due to left flank pain. Work-up revealed urinary tract infection and bilateral nephrolithiasis on ultrasound. Further investigation showed elevated total calcium at 11.9 mg/dl (normal value 8.5-10.1 mg/dl) and an elevated intact PTH of 141.2 pg/ml (normal value 15-65 pg/ml). Since patient was pregnant, parathyroid scintigraphy was not done. She was referred to Surgery service for evaluation and was advised parathyroidectomy. On her 19thweek of pregnancy, she was scheduled to undergo parathyroidectomy. At this time, intact PTH was 250.9 pg/ml and ionized calcium was 1.50 mmol/L (normal value 1.00-1.30 mmol/L). She underwent right inferior parathyroidectomy with frozen section and intraoperative PTH assay, which revealed a parathyroid adenoma. Pre-excision intact PTH level was 759.8 pg/ml, which dropped to 27.9 pg/ml 30 minutes post-operatively. Calcium levels were monitored which dropped to 1.31 mmol/L  two days post-surgery. Patient’s post-operative stay in the hospital was uneventful until discharge.

Conclusion:

Primary hyperparathyroidism in pregnancy poses a risk to both mother and fetus due to the effects of hypercalcemia thus intervention by a skilled surgeon is the treatment of choice, usually done in the second trimester of pregnancy. We presented this case, which was diagnosed in the first trimester of pregnancy, with no pre-operative radiologic localization done, and a successful surgical outcome.

 

Nothing to Disclose: MKMM, ETMA

13652 18.0000 SAT-0210 A A Case of Primary Hyperparathyroidism in Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Wonjin Kim*, Jo Eun Kim, Yumie Rhee and Sung-Kil Lim
Yonsei University College of Medicine, Seoul, Korea, Republic of (South)

 

Bisphosphonate use is an important treatment of choice in osteoporosis patients worldwide. However, long-term side effects of this drug are also well-known: osteonecrosis of the jaw, atypical femoral fracture, etc. On account of the harmful effect, whether to maintain or stop the drug is still debated. The aim of this study is to find out the efficacy of drug holiday of alendronate assessed by quantitative computed tomography (qCT). Patients diagnosed with osteoporosis who were treated with alendronate and had a drug holiday period for more than 1 year were included. They performed qCT of spine and femur annually. Total 32 patients (mean age 74.5 ± 5.2 years, 30 females) were analyzed. Mean duration of alendronate treatment was 7.79 ± 1.8 years and they were well-complianced during therapeutic period. Baseline qCT bone mineral density (BMD) were 72.4 ± 17.7 mg/cc in the spine and 0.632 ± 0.1 g/cm2 in the femur. After 1 year of follow-up, spine BMD decreased slightly to 71.1 ± 18.3 mg/cc, but there were no statistical significance. Meanwhile, femur BMD significantly decreased to 0.632 ± 0.1 g/cm2 (p = 0.001). BMD of the spine and femur significantly decreased after 2 years of drug holiday compared to the baseline (spine, 67.6 ± 17.6 mg/cc, p = 0.031; femur, 0.635 ± 0.1 mg/cm2, p = 0.002). We also measured bone turnover marker of c-telopeptide of type I collagen (CTx) which showed significant increase year by year: baseline, 0.145 ± 0.1 ng/mL; at first year, 0.241 ± 0.1 ng/mL; at second year, 0.280 ± 0.1 ng/mL (p < 0.001). Comparing spine and femur BMD of the first year of drug holiday to the next year, they showed positive correlations (spine, r = 0.475, p = 0.040; femur, r = 0.649, p = 0.003). So, BMD measured at the first year of drug holiday might expect the increment or decrease of BMD in the following year. In conclusion, BMD changes of spine and femur decreased slightly after the drug holiday. As well, there was a small, but significant increase of bone turnover marker CTx. These changes are not large enough even though they had drug cessation period for more than 1 year.

 

Nothing to Disclose: WK, JEK, YR, SKL

14293 19.0000 SAT-0211 A The Changes of Ctx and Bone Mineral Density Assessed By Quantitative Computed Tomography during Alendronate Drug Holiday 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Jennifer Anna Burns Gibert*, Sue Alison Brown and Mary L. Vance
University of Virginia, Charlottesville, VA

 

Multifactorial Severe Hypercalcemia in a Patient with Concomitant Sarcoidosis and Primary Hyperparathyroidism (HPT)

Background:  The etiology of severe hypercalcemia can be multifactorial in a patient with simultaneous disease processes known to affect calcium metabolism.  

Clinical Case:  A 56-year-old man with a 12-year history of pulmonary sarcoidosis intermittently treated with prednisone, chronic kidney disease with baseline creatinine of 1.4-1.7 mg/dL (0.7-1.3), and nephrolithiasis presented with hypercalcemia of 14.8 mg/dL (8.5-10.5), albumin of 3.8 g/dL (3.2-5.2) during evaluation for implantable cardioverter defibrillator placement for non-ischemic cardiomyopathy prompting hospitalization.  Three years prior, he had hypercalcemia of 15.1 mg/dL attributed to sarcoidosis and treated with prednisone.  He now had renal manifestations of hypercalcemia with polyuria and acute on chronic kidney disease. The patient had no central nervous system, gastrointestinal tract, musculoskeletal symptoms or signs of hypercalcemia.

Diagnostic evaluation indicated multifactorial hypercalcemia mediated by primary HPT and sarcoidosis with calcium of 16 mg/dL, albumin of 3.8 g/dL, elevated 1,25-dihydroxy vitamin D of 81 pg/mL (18-64) suggestive of active sarcoidosis, elevated intact PTH of 168.7 pg/mL (9-77), 25-hydroxy vitamin D of 23 ng/mL (25-80), creatinine of 3.9 mg/dL, phosphorus of 4.3 mg/dL (2.3-4.7), and PTH related protein of 1.2 pmol/L (<2.0).  24H urine collection showed calcium of 645 mg/24H (100-250 mg/24H), creatinine 28.8 mg/dL (20-25 mg/kg/24 H, male), and urine volume of 500 mL.  Serum and urine protein electrophoresis were normal.  Neck ultrasound (US) identified bilateral upper parathyroid adenomas.  Nuclear medicine sestamibi scan was normal.  Renal US showed nephrolithiasis and diffuse increased renal cortical echogenicity.

Treatment included normal saline, calcitonin, furosemide, and prednisone 40 mg daily tapered to 10 mg daily over 11 days.  Pre-operative serum calcium levels were 11.5-16 mg/dL.  Subtotal parathyroidectomy was performed (left and right upper, left lower) with intraoperative PTH levels declining from pre-incision values of 105 and 115 pg/mL to a 15 minute post-excision value of 43 pg/mL.  Pathology identified enlarged hypercellular parathyroid tissue.  In the immediate post-operative period calcium decreased to 10.7 mg/dL.  Three weeks post-operatively calcium was 9.6 mg/dL.  Five months post-operatively calcium was 9.4 mg/dL with a 1,25-dihydroxy vitamin D of 15 pg/mL on prednisone 15 mg daily.

Conclusion:   Patients with concomitant sarcoidosis and primary HPT can present with higher serum calcium levels than patients with a single disease process.  Hypercalcemia caused by both primary HPT and sarcoid-associated elevation of 1,25-dihydroxy vitamin D can have an additive effect on calcium levels.

 

Nothing to Disclose: JABG, SAB, MLV

14502 20.0000 SAT-0212 A Multifactorial Severe Hypercalcemia in a Patient with Concomitant Sarcoidosis and Primary Hyperparathyroidism (HPT) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Adriana Bednarova*, Martin Kuzma, Peter Jackuliak and Juraj Payer
University Hospital Bratislava, Bratislava, Slovakia

 

Background: Primary hyperparathyroidism (PHP) leads to osteoporosis affecting especially cortical bone. On the other hand bone density (BMD) can rise in trabecular bone in patients with PHP but the quality of this bone is lower  comparing with healthy controls and leads to more frequent fractures.

Aim: to evaluate trabecular bone score (TBS) of lumbar spine (L1-L4) in patient with PHP and compare it with healthy controls.

Subjects and methods: From 36 patient with PHP we excluded patients who have already taken any medication for osteoporosis before the diagnosis of PHP. Finally 20 patients remained in the group (8 males and 12 females) with average age 67 years and in these patients we set up TBS from previously measured DXA scans of lumbar spine. We compared it with TBS of 14 controls with average age  69 years without PHP and without treated osteoporosis.

Results: Average TBS in patient with PHP was 1.24 (+-0.139) and in patients  without PHP 1.25 (+-0.115) so there was no significant difference between patients and control group. On the other hand both values of TBS were below normal range (TBS in healthy subjects is supposed to be 1.35 or higher). Average BMD in patients with PHP and controls did nof differ (1.037 g/cm2 vs 0.995 g/cm2). Although women with PHP had significantly lower BMD then men with PHP, there was no difference in TBS in these subgroups.

Conclusion: Although we did not confirm the difference in TBS between patients and controls (probably because of small sample) according to the literature we found that patients with PHP have low quality of trabecular bone (set up on low TBS) in spite of normal BMD of lumbar spine. We suppose that TBS could be better indicator for bone status in patients with PHP comparing to BMD of lumbar spine.

 

Nothing to Disclose: AB, MK, PJ, JP

15048 21.0000 SAT-0213 A Trabecular Bone Score in Patients with Primary Hyperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0193-0213 4787 1:00:00 PM Hyperparathyroidism and Metabolic Bone Disease Poster

Karen T. Le*1 and Angela M. Leung2
1Cedars-Sinai Medical Center, Los Angeles, CA, 2UCLA David Geffen School of Medicine, Los Angeles, CA

 

Background: Gnathodiaphyseal dysplasia (GDD) is an autosomal dominant syndrome that is characterized by cemento-osseous lesion of jawbones resulting in facial deformities, bone fragility, bowing and cortical thickening of tubular bones, and diaphyseal sclerosis of long bones.  Three mutations of the ANO5 gene have been described thus far in the limited literature of this disease.  This case reports a new, fourth mutation.

Clinical case: A 41 year-old Caucasian man was seen in consultation for a history of multiple fractures.  Since age 12, he has experienced several fractures of his long bones, including the bilateral femurs, tibia, fibula, and radius, all of which healed slowly and required multiple surgeries.  His father, sister, and son also report multiple long bone fractures, and his sister has a facial deformity.  Recently, the patient developed severe osteomyelitis of the right mandible that was complicated by Ludwig's angina, thus making the choice of a bisphosphonate a relative contraindication for treatment.  Genetic analysis of the ANO5 gene revealed a heterozygous mutation in exon 11 (c.1067 G>A) that resulted in the amino acid substitution p.Cys356Tyr.  This is a new, undocumented variant sequence of the ANO5 gene that is presumed to be the cause of GDD in this patient and his family members.

Discussion: In 1969, GDD was first described by Akasaka et al in a large Japanese family of 21 patients, all of whom had experienced frequent bone fractures in adolescence and purulent osteomyelitis of the jaws in their adult years. By genetic linkage analysis of the Japanese family, Tsutsumi et al. mapped the GDD locus to chromosome 11p14.3-15.1 (1).  Until now, only two missense mutations (p.Cys356Arg, p.Cys356Gly) have been reported, both involving the same cysteine residue at position 356.  Sequence analysis of these mutations showed heterozygous T-to-C and T-to-G single base substitutions in the codon for Cys356 in affected members of a Japanese and African-American family, respectively (2).  In 2012, Marconi et al. described a third mutation of the ANO5 gene in exon 15 that caused a p.Thr513Ile substitution in an Italian family with GDD (3).  At present, the function of ANO5 remains unknown, and it is difficult to understand the role of these mutated ANO5 proteins in the pathophysiology of GDD.  Thus far, ANO5 is suspected to be an integral membrane glycoprotein with key roles in osteogenesis and myogenesis.  The predisposition to developing osteomyelitis of the jaws in these patients makes treatment decisions utilizing bisphosphonates a difficult choice.  There are currently no recommendations for the optimal treatment of bone fragility among GDD patients.

Conclusion: We report the fourth mutation in the ANO5 gene (c.1067 G>A) causing gnathodiaphyseal dysplasia (GDD) as a rare cause of bone fragility.

 

Nothing to Disclose: KTL, AML

15199 1.0000 SAT-0214 A A New Mutation in Gnathodiaphyseal Dysplasia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0214-0228 4790 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Letícia Alarcão Maxta*1, Thaís Helena Monteiro de Oliveira1, Lívia Grimaldi Abud Fujita1, Gustavo Rocha Dissenha1, Ricardo A Guerra2 and Evandro S Portes2
1Hospital do Servidor Público Estadual, São Paulo, Brazil, 2Hospital do Servidor Publico Estadual de Sao Paulo

 

Background

Familial primary hypoparathyroidism is a rare condition that may be asymptomatic or manifest with diversified clinical signs and symptoms delaying diagnosis and family investigation.

Clinical case

A 47-year-old caucasian women, with no relevant medical history, began investigation for progressive hand tremors initiated one year earlier. Her physical exam showed signs of parkinsonism, with bradykinseia, hypomimia, postural hand tremors and horizontal nystagmus Head CT detected basal ganglia and thalamus calcification, compatible with Fahr´s disease. Initial laboratory exams showed: total calcium:  6,9 mg/dL (n: 8,8 – 10,6 mg/dL); ionized calcium 3,2 mg/dL (n: 4,7 – 5,3 mg/dL); phosphate: 5,7 mg/dL (n: 2,5 – 4,5 mg/dL); magnesium: 1,7 mg/dL (n: 1,9 – 2,5 mg/dL); albumin: 4,1 mg/dL (n: 3,5 – 5,0 g/dL); PTH: <3,0 pg/mL (n: 10 – 65 pg/mL); 24 hour calciuria: 33,4 mg/24h (n: 50 – 200 mg/24h).

She was diagnosed with primary hypothyroidism and received proper oral supplementation with calcium and vitamin D. There was no history of neck surgery or radiation which raised the suspicion for a genetic cause.

The patient´s children, despite asymptomatic, were also investigated. Two out of four children had clinical signs of hypocalcemia (positive Chvostek and Trousseau signs) and laboratory results compatible with primary hypoparathyroidism. Initial laboratory results are shown: 16-year-old daughter – total calcium: 6,7 mg/dL; ionized calcium: 0,76 mmol/dL; phosphate: 6,3 mg/dL; magnesium: 1,9 mg/dL ; albumin: 4,9 mg/dL; 25OH vitamin D: 22,5 ng/mL (n: >30 ng/mL); PTH: < 3,0 ng/mL. 14-year-old son – total calcium: 6,8 mg/dL; ionized calcium: 0,76 mmol/dL; phosphate: 10 mg /dL; magnesium: 1,7 mg/dL; albumin: 4,7 mg/dL;  vitamin D: 23 ng/mL; PTH: 13 pg/mL.

They also received adequate oral supplementation with calcium and vitamin D.

Genetic investigation is currently being performed

Conclusion

Primary hypoparathyroidism in patients with no history of neck surgery or radiation should be suspected to be of a genetic cause. Familial investigation may provide an early diagnosis and treatment can prevent symptomatic hypocalcemia.

 

Nothing to Disclose: LAM, THMDO, LGAF, GRD, RAG, ESP

14197 2.0000 SAT-0215 A Familial Primary Hypoparathyroidism: A Clinical Case in a Brazilian Family 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0214-0228 4790 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Dooman Kim*1, Seoung Yang2, Juri Park3 and Ho Young Son3
1Hallym Univ Coll of Med, Seoul, Korea, Republic of (South), 2Hallym University College of Medicine, Seoul, Korea, Republic of (South), 3College of Medicine, Hallym University, Seoul, Korea, Republic of (South)

 

 The combination of hypoparathyroidism, sensorineural deafness and renal dysplasia, named HDR syndrome, is a rare disease. Heterozygous abnormalities of GATA3 gene are associated with this syndrome. Here we report a novel heterozygous mutation, c.255_256ins4 (GTGC), in GATA3 gene. A 41-year old man was diagnosed as having idiopathic hypoparathyroidism and has been treated with 1α-hydroxyvitamin D3 and calcium carbonate. Three years later, he had a hearing impairment and revealed sensorineural deafness by audiogram. Renal ultrasonography did not show abnormality in the kidney. His son was also diagnosed with hypoparathyroidism and hearing deafness due to seizure episode at age 12 years. His son’s renal ultrasonography showed right kidney aplasia. DNA analysis was performed in his son. Sequenced analysis identified a novel mutation, c.255_256ins4 (GTGC), in the GATA3 gene. A boy showed classical triad of HDR syndrome. But his father had only two clinical feature of HDR syndrome (hypoparathyroidism and sensorineural deafness), besides he did not complain of a hearing impairment when diagnosed with hypoparathyroidism. Taking into consideration this clinical heterogeneity, screening of GATA3 gene mutations is worthwhile for diagnosis and genetic counseling, when patients have hypoparathyroidism and deafness.

 

Nothing to Disclose: DK, SY, JP, HYS

11392 3.0000 SAT-0216 A A Novel Mutation in GATA3 Gene in HDR Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0214-0228 4790 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Mustafa Tosur*1, Maria San Andres2, Fadeke T Adewole2, William Riley2 and Phillip D K Lee2
1Texas Children's Hospital / Baylor College of Medicine, Galveston, TX, 2University of Texas Medical Branch, Galveston, TX

 

Background:

The human calcium sensing receptor gene (CASR, chromosome 3q21.1) encodes a 1078 amino acid protein which regulates parathyroid hormone secretion and renal tubular calcium reabsorption. Heterozygous loss of function mutations and deletions of CASR are associated with hypocalciuric hypercalcemia.  We report two cases of hypocalciuric hypercalcemia associated with novel CASR mutations.

Case Presentations

Case 1: An 8 year old male was incidentally found to have hypercalcemia during evaluation for gastroenteritis. Family history and examination were noncontributory. Additional testing showed persistent hypercalcemia (Ca 11.3, 11.3, 11.9 mg/dL, RR:  8.6-10.6) with normal iPTH levels (20, 42, 47.5 pg/mL, RR 12-88), and random urine Ca <1 mg/dL, normal head/neck ultrasound and negative MEN1 mutation screen. CASR sequencing showed heterozygous c.513C>A (exon 4, p.S171R) and c.2968A>G (exon 7, p.R990G) mutations. Father and sister had normal Ca, mother had Ca 11.0 with normal PTH; with heterozygous CASR c.513C>A (exon 4, p.S171R) mutation.

Case 2: A 7 year- old female was found to have incidental hypercalcemia during evaluation for abdominal pain and precocious puberty (Tanner B2 P1). Family history was noncontributory. Tests showed Ca 12.7 mg/dL, iPTH 21.9 pg/mL (RR: 12-88), random urine Ca of 5.5, 4.9 and 3.3 mg/dL, normal head and neck ultrasound. CASRsequencing showed heterozygous c.652T>A (exon 4, p.Y218N) mutation.

Conclusion: The novel CASR mutations in these cases are similar to the following previously reported exon 4 mutations: p.S171R for Case 1; p.Y218C, p.Y218H and p.Y218S for Case 2. These exon 4 mutations are within the extracellular venus fly-trap domain of CaSR, which contains several putative Ca binding sites; the functional significance of the specific mutations is reviewed. Our approach to diagnosis and management of incidental hypercalcemia in children will also be presented.

 

Nothing to Disclose: MT, MS, FTA, WR, PDKL

11692 4.0000 SAT-0217 A Two Novel Calcium Sensing Receptor Gene Mutations Associated with Hypocalciuric Hypercalcemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0214-0228 4790 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Arti P Shah*1, Peggy Joyce Stenger2, Robert Hufnagel3 and Thomas Andrew Burrow3
1Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 2Cincinnati Children's Hosp Med, Hamilton, OH, 3Cincinnati Children's Hospital, Cincinnati, OH

 

Background/Objectives: Extracellular calcium-sensing receptor (CaSR) is essential for parathyroid regulation of calcium homeostasis. Activating mutations of CASR gene result in sporadic or autosomal dominant hypocalcemia (OMIM #146200). We report a novel mutation of the CASR gene with an autosomal dominant (AD) inheritance pattern resulting in hypocalcemia in a father and daughter.

Clinical Case: A 3-year-old African American female was found to have low calcium of 6.5 mg/dl (8.5-10.1 mg/dl) and high phosphorous level of 7 mg/dl (3.9-5.1 mg/dl) on routine labs. Her past medical history included an acute event at 4 months resulting in hypoxic ischemic encephalopathy (HIE), developmental delay, seizure disorder and G-tube dependence. She had been tolerating her G-tube feeds at presentation and did not have an increase in seizure activity. Upon chart review, it was noted that she had multiple low calcium levels dating back to 4 months of age without further evaluation or treatment. Her father also had a history of symptomatic hypocalcemia since his teenage years. Other evaluation of the patient included low parathyroid hormone level of 11 pg/ml (22-84 pg/ml), normal 25 hydroxy vitamin D level of 43.7 ng/ml (20-60 ng/ml) and negative FISH for 22q11 deletion. CASR gene sequencing was significant for a novel mutation in the proband and father.

Sequence analysis of the CASR gene revealed a novel point mutation in exon 6, c.2519C>A, resulting in a nonsynomnomous substitution, p.A840D, in the distal portion of the 7-transmembrane G-protein coupled receptor (GPCR) domain of the CaSR protein. In silico analysis indicates this base is highly conserved throughout most vertebrates, and the substitution of asparagine for arginine is pathogenic. Additional CASR mutations in this region are associated with gain-of-function of CaSR.    

Conclusion: We describe a novel mutation in the CASR at A840D resulting in AD hypocalcemia in this family, presumably through gain-of-function at the transmembrane portion of the GPCR.

 

Nothing to Disclose: APS, PJS, RH, TAB

12121 5.0000 SAT-0218 A Novel Mutation in Calcium Sensing Receptor Gene Resulting in Autosomal Dominant Hypocalcemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0214-0228 4790 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Nawaporn Numbenjapon*1, Adisorn Lumpaopong2, Prapaipim Thirakhupt2, Kwanjai Thanakitcharu2 and Boonchai Boonyawat2
1Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand, 2Phramongkutklao hospital, Bangkok, Thailand

 

Background: The calcium sensing receptor (CASR) is a key regulator of calcium homeostasis. Activating mutation of CASR gene results in autosomal dominant hypocalcemia (ADH) characterized by hypocalcemia, hypercalciuria and inappropriately low parathyroid hormone (PTH). However, the presence of ADH with type 5 Bartter syndrome is rarely reported.

Clinical case: An 11-year-old girl presented with hypocalcemic seizures since 15 days of age. According to the low levels of serum calcium and PTH, hypoparathyroidism was initially diagnosed. Standard treatment with oral calcium and active vitamin D failed to control seizure and resulted in the increase of hypercalciuria and nephrocalcinosis. According to the presence of hypomagnesemia and hypokalemic metabolic alkalosis in this patient, oral magnesium, moduretic (hydrochlorothiazide and amiloride), and spironolactone were added to the regimen. Although additional treatment with hydrochlorothiazide (HCTZ) improved hypercalciuria, it failed to alleviate hypocalcemic symptoms including seizure. Mutation analysis of CASR gene by direct DNA sequencing of all coding exons (exons 2-7) and exon-intron junction demonstrated a novel and de novo heterozygous activating mutation [c.2463C>G (p.F821L)] in the exon 7, suggesting ADH. Together with the presence of hypokalemic metabolic alkalosis and secondary hyperaldosteronism in this patient at 8 years of age, ADH combined with type 5 Bartter syndrome was diagnosed. Subcutaneous recombinant human PTH 1-34 (Teriparatide®) therapy twice daily resulted in the increase level of serum calcium, the alleviation of seizure and the improvement of hypercalciuria. HCTZ was able to wean off at 2 years after Teriparatide® therapy.  No adverse reaction was found over a three-year period of treatment.

Conclusion: A novel and de novo gain-of-function mutation of CASR gene causing hypercalciuric hypocalcemia was identified in this patient. Treatment with Teriparatide® is effectively controlled hypocalcemic seizures, improved hypercalciuria and nephrocalcinosis in a child with ADH and type 5 Bartter syndrome.

 

Nothing to Disclose: NN, AL, PT, KT, BB

13764 6.0000 SAT-0219 A A Novel Activating Mutation of Calcium Sensing Receptor Gene in a Girl with Autosomal Dominant Hypocalcemia and Type 5 Bartter Syndrome: Successful Treatment with Recombinant Human Parathyroid Hormone 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0214-0228 4790 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Rei Nishimura*1, Takeshi Usui2, Yoshiki Okayama1, Masanobu Fujimoto3, Naoki Miyahara1, Yuki Kawashima1, Keiichi Hanaki4 and Susumu Kanzaki1
1Tottori University Faculty of Medicine, Yonago, Japan, 2National Hospital Organization Kyoto Medical Center, Kyoto, Japan, 3Tottori University Faculty of Medicine, Yanago, Japan, 4Faculty of Medicine Tottori University, Yonago, Japan

 

Background: Pseudohypoparathyroidism (PHP) is a rare heterogeneous genetic disorder characterized by end-organ resistance to parathyroid hormone (PTH), due to partial deficiency of the α subunit of the stimulatory G protein (Gsα), encoded by the GNAS gene. PHP type 1a (PHP 1a) is associated with a clinical feature known as Albright hereditary osteodystrophy (AHO), and known for the mutation on GNAS gene on the maternal allele. However, recent reports reveal that some PHP 1a patients have the methylation defect without the mutation on GNAS, and complicate mechanism of the GNAS gene abnormality on PHP 1a.
We describe three cases of PHP 1a from three families, bearing heterozygous mutations in GNAS, which were not previously reported.

Clinical cases: Case1: 7-year-old girl had typical symptoms of AHO and mental retardation. Her mother also showed AHO. Biochemical examination showed normocalcemia and increased serum PTH levels, and hypothyroidism. She was treated with levothyroxine (l-T4) only. Sequencing analysis of GNAS identified a heterozygous mutation in exon 1 (L46P, CTG>CCG).
Case2: 24-year-old woman showed typical symptoms of AHO and mental retardation. Her mother also showed AHO. Biochemical examination showed hypocalcemia and increased serum PTH levels, and hypothyroidism. She was treated with 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] and l-T4, and Kaufmann’s treatment because of hypogonadism. Sequencing analysis of GNAS identified a heterozygous mutation in splice acceptor site of intron 1 (IVS1+1G>A).
Case3: 25-year-old woman showed typical symptoms of AHO and mental retardation. Her mother didn’t show AHO. Biochemical examination showed hypocalcemia and increased serum PTH levels, and hypothyroidism. She was treated with 1,25(OH)2D3 and l-T4. Sequencing analysis of GNAS identified a heterozygous mutation in exon 1 (G47S, GGT>AGT).

Conclusion: Surprisingly, all three cases carried novel heterozygous mutations on the similar site of GNAS gene (exon1 and intron1). However, all cases showed different degree of clinical features, that were consistent with the previous reports. The exon 1 and intron 1 of GNAS gene might be hot spot for PHP 1a in Japan.

 

Nothing to Disclose: RN, TU, YO, MF, NM, YK, KH, SK

15564 7.0000 SAT-0220 A Three Novel Heterozygous Mutations Were Found in Exon 1 and Intron 1 of GNAS Gene in Patients with Pseudohypoparathyroidism Type 1a 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0214-0228 4790 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Janusz S Pachucki1, Kaisa Kettunen2, Anna-Elina Lehesjoki2 and Krystian Jazdzewski*1
1Medical University of Warsaw, Warsaw, Poland, 2University of Helsinki

 

MULIBREY nanism is a rare autosomal recessive syndrome. The disease affects several organs although patients may survive till late adulthood. The disease is caused by mutations in the TRIM37 gene encoding a protein with peroxisomal and nuclear localization. The pathomechanism underlying the MULIBREY phenotype is unknown. The majority of cases has been described in Finland and those patients are frequently homozygous for one founder mutation. The novel mutations from other geographical regions are very rare. The major morbidity in MULIBREY nansims patients comes from heart failure due to constrictive pericarditis and liver cirrhosis. Primary hyperparathyroidism has been observed in some patients from Finland although its association with the MULIBREY phenotype has not been published.

A 25 yo woman presented to endocrine service due to spontaneous hypercalcemia when evaluated for pericardial and pancreatic calcification. At that time she had been diagnosed with dwarfism of unknown etiology (Silver-Russell syndrome). She was treated with levothyroxin for mild primary hypothyroidism of unknown etiology. She graduated from university and work full time as a fashion designer. Pericardial calcification was noted four years earlier during ovarian tumor surgery (fibroma). The multiple biochemical and hormonal evaluations were consistent with primary hyperparathyroidism (total and ionized calcium level 2,79 mmol/L and 1,39 mmol/L, iPTH level 110 pg/ml, 24-hour urinary calcium about 5 mmol/24-hours). The parathyroid scintigraphy and neck ultrasonography did not reveal enlarged parathyroid gland. The abdominal ultrasound and later abdominal CT was consistent with liver cirrhosis. Heart MRI, and ultrasound were consistent with constrictive pericarditis. To confirm the clinical suspicion of MULIBREY nanism the patient had eye exam, which revealed yellowish plagues on both sides. The genetic analysis showed that she was compound heterozygous for two novel mutations in the TRIM37 gene, one introducing a termination codon 1999C>T/p.(Arg667*), the other being a frameshift mutation 2125delA/p.(Met709Cysfs*60). Theinheritance of the mutations was confirmed by sequencing the parental TRIM37 genes. Since the patient had only intermittent signs of heart failure the pericardiectomy was defervesce. During the following two-year observation calcium level remained mildly elevated and parathyroid surgery was delayed due to lack of localized single parathyroid adenoma and suspicion of parathyroid hyperplasia.

This observation together with data from Finnish patients with MULIBREY nanism support the hypothesis that the TRIM37 gene mutations predispose to hyperparathyroidism probably due to parathyroid hyperplasia. Further observation and studies are needed to evaluate the effect of TRIM37 gene mutations on thyroid function.

 

Nothing to Disclose: JSP, KK, AEL, KJ

15823 8.0000 SAT-0221 A Primary Hyperparathyroidism in Patient with Mulibrey Nanism Caused By Two Novel Mutations 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0214-0228 4790 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Mary Scott Ramnitz*1, Jaydira Del Rivero2, Pravitt Gourh1, Diana Ovejero-Crespo1, Nisan Bhattacharyya1, Lori C. Guthrie3, Raphaela Goldbach-Mansky1, Felasfa Wodajo4, Patricia Seo-Mayer5, Bita Arabshahi6, Malaka Jackson7, Adele Boskey8, Kenneth E. White9, Alfredo A. Molinolo1, Rachel I Gafni1 and Michael T. Collins3
1National Institutes of Health, 2National Institute of Child Health and Human Development, National Institutes of Health, 3Section on Skeletal Disorders and Mineral Homeostasis, Bethesda, MD, 4Virginia Hospital Center, 5Pediatric Specialists of Virginia, 6Inova Fairfax Hospital, 7University of South Carolina School of Medicine, 8Weill Medical College of Cornell University, 9Indiana University School of Medicine

 

Introduction: Familial tumoral calcinosis (FTC)/hyperostosis-hyperphosphatemia syndrome (HHS) is a rare autosomal recessive disorder caused by mutations in fibroblast growth factor-23 (FGF23), N-acetylgalactosaminyltransferase 3 (GALNT3), or KLOTHO.   The result is a functional deficiency in FGF23 causing hyperphosphatemia, increased renal tubular reabsorption of phosphorus (TRP), and elevated or inappropriately normal 1,25-dihydroxyvitamin D3 (1,25-D3).  Affected individuals may develop ectopic calcifications and/or diaphyseal hyperostosis. 

Methods: Six patients with FTC/HHS were evaluated.  Radiographic, biochemical, histologic, and genetic analyses were performed and several therapeutic interventions were attempted.

Results: All patients had hyperphosphatemia and increased TRP; 5 patients had elevated or inappropriately normal 1,25-D3.  Compound heterozygous mutations in GALNT3 were identified in 5 of the 6 patients to date.  C-terminal FGF23 was elevated while intact FGF23 was low in all patients, consistent with increased proteolytic cleavage of FGF23. Two patients had overwhelming systemic inflammation and elevated C-reactive protein (CRP) (81.8-176 mg/L, nl<3.0). Clinical manifestations ranged from asymptomatic to multiple, large disabling calcifications with fluid levels visible on imaging.  In addition to a low phosphate diet, different combinations of phosphate-lowering therapy were attempted using sevelamer, aluminum hydroxide, acetazolamide, niacin and probenecid with variable response.   One patient experienced complete resolution of a calcific mass after 13 months of medical treatment with sevelamer, acetazolamide, and probenecid.  In the patients with systemic inflammation, treatment with an interleukin-1 (IL-1) antagonist, anakinra or canakinumab, significantly decreased the CRP with a notable decrease in peri-lesional edema in one patient and improvement of overall well-being in both patients.  Histologic analyses of resected tissue revealed not only ectopic calcification, but also ossification in a background of chronic inflammation with foreign body giant cells and foamy macrophages.  Fourier transform infrared spectroscopy performed on several, grossly different pathologic specimens revealed hydroxyapatite crystals of varying size and composition. 

Conclusion: This cohort expands the phenotypic and genotypic understanding of FTC/HHS and demonstrates the vast range of clinical manifestations despite similar biochemical profiles and genetic mutations.  Two patients had overwhelming systemic inflammation which has not been described previously in FTC/HHS; their response to IL-1 antagonists suggests that anti-inflammatory treatment may be a useful adjuvant. Importantly, this is the first description of true ectopic ossification reported in FTC/HHS, possibly driven by the adjacent inflammation.

 

Nothing to Disclose: MSR, JD, PG, DO, NB, LCG, RG, FW, PS, BA, MJ, AB, KEW, AAM, RIG, MTC

16275 9.0000 SAT-0222 A Familial Tumoral Calcinosis: Lessons from a Rare Disorder of Ectopic Mineralization 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0214-0228 4790 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Betul Ersoy*1, Seniha Kiremitci2 and Sachiko Kitanaka3
1Celal Bayar University School of Medicine, Isbantul, Turkey, 2celal bayar university, manisa, Turkey, 3Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

 

Hereditary vitamin D-resistant rickets (HVDRR) is a rare recessive genetic disorder caused by mutations in the VDR that result in end organ resistance to 1,25-(OH)2D3 action. Here, we describe a patient with HVDDR with severe alopecia and rickets. Patient was three years old male presenting with gait disorder. He had hypocalcemia (8 mg/dL), secondary hyperparathyroidism (1232 pg/mL), and elevated serum alkaline phosphatase (661 U/L) and 1,25-dihydroxyvitamin D3 (>250 pg/mL). DNA sequence analyses of the Vitamin D Receptor (VDR) gene of ligand binding domain (LBD) showed that the patient had homozygous mutation for Q152X at exon 5. This mutation was a C to T transition resulting in a premature stop at codon 152. Although his parents were non-consanguineous, both of his parents were found to be heterozygous for the mutation. The patient was initially treated with calcitriol (80 ng/kg/d) and high dose oral calcium (150 mg/kg/d) for one year. At the end of the first year, intermittent intravenous (iv) calcium therapy (5 days per month) was started, because of insufficient clinical and radiological improvement. After two years from intermittent iv calcium therapy, there was a clear clinical improvement based on clinical and X-ray findings as well as permenant improvement in biochemical findings. However, alopecia in our patient remained unchanged, despite treatment and improvement of rickets. We report the case of HVDRR with a mutation in the LBD and severe alopecia that was successfully treated with intermittent (5 days per month) intravenous calcium treatment.

 

Nothing to Disclose: BE, SK, SK

16729 10.0000 SAT-0223 A Succesfully Modified Intermittent Intravenous Calcium Treatment in a Patient with Hereditary Vitamin D Resistant Rickets (HVDRR) with Alopecia: Presence of Nonsense Mutation in Ligand Binding Domain of Vitamin D Receptor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0214-0228 4790 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Jessica Hwang*1, David H Sarne2, Peter Angelos3, Benjamin Christopher James1 and Jennifer Gnerlich4
1University of Chicago, Chicago, IL, 2The University of Chicago, Chicago, IL, 3Univ of Chicago, Chicago, IL, 4University of Chicago

 

Background: Severe secondary hyperparathyroidism leading to the formation of marked osteodystrophy (osteitis fibrosa cystica) is uncommon with current medical management. We report a case of uremic leontiasis ossea involving the mandible, maxilla, skull and fingers producing symptoms requiring surgical intervention.

Clinical Case: A 28 year old African-American female with ESRD (on hemodialysis since 2005) presented to the emergency room complaining of worsening facial deformity over 3 months that was now causing difficulty breathing. She was recently discharged from an outside hospital after being worked up for both SVC syndrome and acromegaly and was told she should follow-up with a dentist. Physical exam revealed profound firm, non-tender maxillary and mandibular hypertrophy with nasal flattening, wide-spaced teeth and palatal changes. She noted discomfort in her fingertips which were swollen but non-tender.

Her serum calcium was 10.1 mg/dL (RR 8.4-10.2) and serum phosphorous was 6.5 mg/dL (RR 2.5-4.4). PTH was 3627 pg/mL (RR 15-75). Alkaline phosphatase was extremely elevated at 598 U/L (RR 20-120). Hand x-rays demonstrated calcification of vessels, subperiosteal resorption and acro-osteolysis. CT of the face showed extensive demineralization of the mandible, maxilla and skull. Neck ultrasound and parathyroid scan demonstrated multi-gland parathyroid hyperplasia. On DXA scanning she had Z scores in the lumbar spine of -6.1, the femoral neck of -5.3 and the proximal forearm of -4.4 with a comment that it was difficult to distinguish bone from soft tissue.

Review of her history revealed that she had not been treated with phosphate binders or calcimimetic agents for years. She underwent a successful subtotal parathyroidectomy with the resection of 3.5 glands with the intact gland weights ranging from 2.1-3.1 grams.

Conclusion: In hemodialysis patients, phosphate excretion is decreased, causing hypocalcemia and ultimately a secondary increase in PTH. Failure to adequately manage phosphate and calcium will lead to severe hyperparathyroidism. In some cases this will lead to marked osteodystrophy. Parathyroid surgery may be required to adequately reduce the PTH levels and allow bone mineralization to correct these defects.

 

Nothing to Disclose: JH, DHS, PA, BCJ, JG

11411 11.0000 SAT-0224 A Uremic Leontiasis Ossea: Severe Osteodystrophy of the Mandible, Maxilla and Skull 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0214-0228 4790 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Vipin Verma*1, Julianna Barsony2 and Priya Kundra3
1MedStar Georgetown University Hospital/MedStar Washington Hospital Center, Washington, DC, 2Georgetown University Medical Center, Washington, DC, 3Washington Hospital Center, Washington, DC

 

Gain-of-function mutation in calcium sensing receptor (CaSR) resets the calcium (Ca) regulated PTH secretion to the left resulting in hypoparathyroidism (HP) but is also implicated in pathogenesis of of the rare Bartter’s syndrome type 5 (BS). We present a case of BS presenting with severe hypocalcemia (HC) and hypomagnesemia who was successfully treated with teriparatide (rPTH).

BS is a disorder of renal tubular absorption characterized by renal salt wasting, hypokalaemic metabolic alkalosis, elevated renin and aldosterone levels, and normal to low blood pressure.1 BS patients with activating CaSR mutations also have hypomagnesaemia and HP. 58- year old woman presented with dizziness, hand numbness, perioral tingling and syncope. Initial laboratory analysis showed ionized calcium (iCa) 0.71 (1.12-1.32 mmol/L) and serum creatinine (Cr) 0.7 (0.5-1 mg/dl). Past medical history included rheumatoid arthritis, hypertension, glaucoma and peptic ulcer disease. Home medications were prednisone, leflunomide, amlodipine, metoprolol, telmisartan, brinzonidine eye solution, esomeprazole, aspirin, and atorvastatin. Family history was notable for several episodes of mild HC in sister. Patient’s symptoms resolved with intravenous (IV) Ca infusion. Subsequent outpatient evaluation showed intact PTH 25-35 (12-65 pg/ml), low 25 OH vitamin D (D3) 27.4 (32-100 ng/ml) that was appropriately replaced with cholecalciferol, and low normal serum Ca (8.4-8.6 mg/dl). Patient, however, continued to has recurrent HC episodes (seizures, dizziness, perioral numbness and palpitations), eventually requiring 3 times a week IV Ca. During one of these HC events, laboratory evaluation was consistent with BS - iCa 0.67, PTH 21.6, Cr 0.6, D3 53.2 ng/ml, magnesium (Mg) 1.3 (1.6-2.3 mg/dl), potassium (K) 2.9 (3.5-5.1 mmol/l) and bicarbonate 31 (22-30 mmol/l). Hypocalcemia fluctuated in severity. Analysis of coding sequence of CaSR was performed, which showed heterozygous sequence variant with c.492+19G>A nucleotide change probably representing a gain-of-function mutation in our patient. Her calcium metabolism normalized by twice daily teriperatide injections and remained normal for the past 4 years.

Our case is unique, as initial presentation of BS was with intermittent symptomatic severe HC in her sixth decade. BS should be considered as a possible etiology in patients with intractable severe HC and recombinant PTH analogs may be effective treatment options although further studies are needed to evaluate its long term efficacy and safety.

 

Nothing to Disclose: VV, JB, PK

16259 12.0000 SAT-0225 A Late Onset Bartter's Syndrome Type 5, Successfully Treated with Recombinant PTH 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0214-0228 4790 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Quang Vutrong Ton*1 and Steven David Wittlin2
1University of Rochester School of Medicine & Dentistry, 2Univ of Rochester Sch of Med and, Rochester, NY

 

Background: Denosumab, a human monoclonal antibody directed against RANK ligand that is used to treat osteoporosis, has been shown to cause hypocalcemia in patients with chronic kidney disease after the first dose. Hypocalecmia occurring after subsequent injections, however, has not yet been reported.

Clinical Case: A 56-year old woman with a history of liver transplantation due to NASH that has resulted in chronic glucocorticoid use, chronic stage 4 kidney disease, and osteoporosis presented with oral parasthesias and increased confusion.

Seven years prior to her presentation, she was diagnosed with osteoporosis and initially treated with alendronate. Alendronate was discontinued due to liver failure and she was placed on teriparitide for two years. Three years prior to presentation, she received two injections of denosumab, six months apart, with no adverse effects. One week before admission, she received a third dose of denosumab (60 mg) subcutaneously. Her laboratory values before administration of denosumab consisted of a serum calcium of 8.6 mg/dL (normal 8.6-10.2 mg/dL), a serum urea nitrogen of 63 mg/dL (normal 6-20 mg/dL), and a baseline creatinine of 3.38 mg/dL (normal 0.51-0.95 mg/dL).

Her physical examination was remarkable for carpopedal spasm and confusion. Blood tests revealed hypocalcemia with a serum calcium of 4.8 mg/dL, and an ionized calcium of 2.4 mg/dL (normal 4.8-5.2 mg/dL). Her ECG: revealed a prolonged QTc interval of 509 milliseconds (compared with 462 milliseconds on a previous ECG). Other laboratory values included a serum urea nitrogen of 51 mg/dL, a creatinine of 3.09 mg/dL, an albumin of 4.1 g/dL (normal 3.5-5.2 g/dL), and a PTH of 268.3 pg/mL (normal 15-65 pg/mL). She was treated with aggressive intravenous normal saline and 9.4 mEq calcium gluconate. Her ionized calcium level rose to 4.6 mg/dL after 3 days of hospitalization. She was discharged on calcium carbonate 1000 mg four times daily and calcitriol 0.25 mcg twice daily.

Conclusion: It has been hypothesized that patients with chronic kidney disease would be at higher risk of hypocalcemia with denosumab due to increased dependence on PTH-mediated bone turnover. Physicians should be aware of this potentially fatal adverse effect in patients with renal insufficiency and that previous history of administration does not obviate this danger.

 

Nothing to Disclose: QVT, SDW

15496 13.0000 SAT-0226 A Severe Hypocalcemia Following a Third Denosumab Injection in a Patient with Moderate Renal Insufficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0214-0228 4790 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Aleida Rodriguez*1, Malgorzata Kochanek2, Tahira Yasmeen3 and Bela Nand2
1UIC/Advocate Christ Medical Center, Oak Lawn, IL, 2University of Illinois/Advocate Christ Medical Center, 3The University of Illinois/Advocate Christ Medical Center

 

Introduction

Proton pump inhibitors (PPIs) are one of the most prescribed medications. These are indicated for GERD and peptic ulcer disease and are generally safe. Evidence suggests that hypomagnesemia is a serious adverse effect PPI therapy [1]. Low magnesium (Mg) levels can cause cardiovascular and CNS effects, including QRS widening, arrhythmias, seizures and coma. We describe a patient presenting with a seizure resulting from severe hypomagnesemia and hypocalcemia while on chronic PPI treatment.

Case

A 51 y/o woman presented to the ED after a witnessed seizure with tongue-biting, muscle stiffness and urinary incontinence. PMH included DM type 2, hypertension and GERD for which she was on Omeprazole for five years with no history of diuretic use. She had neuromuscular excitability, negative Chvostek’s sign but a positive Trousseau’s sign with carpopedal spasm. Laboratory investigation revealed a serum sodium 140 mEq/L, potassium 3.2 mEq/L, chloride 101 mEq/L, bicarbonate 27 mEq/L, BUN 27 mg/dL, creatinine 1.7 mg/dL, calcium 5.6 mg/dL, Mg 0.4 mEq/L, glucose 318 mg/dL albumin 3.1 mg/dL. ECG showed QTc prolongation. Further laboratory results revealed an inappropriately low iPTH level 17 pg/mL (10-65pg/mL), low ionized calcium 0.87 mmol/L (1.1-1.4 mmol/L), phosphorous 3.3 mg/dL and a high 1,25dihydroxyvitamin D 86.2 pg/mL (25-65pg/mL), aldosterone 1.8 ng/dL (4.5-35.4ng/dL), renin 1.7 ug/L/hr (0.8-5.8 ug/L/hr), and spot urine Mg 14 mg/dL. The fractional excretion of Mg was >2 %, measured after Mg infusions. The hypomagnesemia corrected with IV supplementation and discontinuation of PPIs.

Homeostasis of Mg is regulated through a complex interaction between absorption in the gastrointestinal (GI) tract and excretion in the kidneys. Mg is absorbed in the GI tract via passive diffusion accounting for 90% of absorption and active transcellular transport across the apical lumen. Active transport is accomplished by transient receptor potential melastatin (TRMP) cation channels known as TRMP6 and TRMP7. It is speculated that PPIs induce hypomagnesemia by affecting these channels [3]. This is a class effect and may be greater in patients who have received long term PPI therapy while on diuretics and who have a concomitant genetic predisposition [3,6].

To our knowledge, there have been only four case reports of PPI-induced hypomagnesemia resulting in seizures. The hypomagnesemia usually corrects after 1-2 weeks of discontinuation of the PPIs. Our patient presented with seizures secondary to hypomagnesemia and hypocalcemia and corrected at an unexpectedly faster rate than the reported average [3].

Conclusion

Increased awareness is necessary among clinicians about hypomagnesemia as a potentially serious adverse effect of PPIs. Prompt treatment of hypomagnesemia induced hypocalcemia and hypokalemia is essential to prevent fatal complications of these electrolyte abnormalities.

 

Nothing to Disclose: AR, MK, TY, BN

15512 14.0000 SAT-0227 A Seizure Resulting from Proton-Pump Inhibitor Induced Hypomagnesemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0214-0228 4790 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Amit Bansal*1 and Ankur Gupta2
1Wright State University, Dayton, OH, 2Wright State Physicians, Dayton, OH

 

Introduction: Fat soluble vitamin malabsorption is common after biliopancreatic diversion with duodenal switch (BPD-DS) type of bariatric surgery. We describe a patient requiring extremely high dose of vitamin D with persistently serum low vitamin D levels; a simple trick lead to drastic reduction in the vitamin D requirement with improvement in levels.

Case Presentation:  A 53 year old man status post BPD-DS surgery in 2005 was referred by a bariatric surgeon for management of persistently low serum 25-hydroxy vitamin D levels despite taking very high dose of vitamin D. He had been taking 4 capsules of 50,000 IU cholecalciferol oral daily for nine months.  Laboratory evaluation showed low serum 25-hydroxy vitamin D (25-OH VD) level 15 ng/ml, elevated PTH level 90 pg/ml, and low normal corrected total serum calcium level 8.6 mg/dl. He was ruled out for celiac disease. 

He refused to take intramuscular form of vitamin D. We then added the liquid ergocalciferol 6000 IU oral daily to his current regimen.  Repeat labs six weeks later showed serum 25-OH VD level 31 ng/ml, PTH 72 pg/ml, and total serum calcium 8.9 mg/dl.  Vitamin D and PTH improved to normal value. We asked patient to discontinue cholecalciferol with assumption that he might not be absorbing the capsules and increased liquid ergocalciferol to 8,000 IU oral daily. Repeat labs after two months showed serum 25-OH VD level of 21 ng/ml.  We then added 50,000 IU ergocalciferol capsule oral weekly to his current regimen.  After one-month, his serum 25-OH VD level dropped to 16 ng/ml. We then recommended him to cut ergocalciferol 50,000 IU gel cap and to squeeze the liquid content out and take with apple sauce. The patient chose to chew the capsule instead. We increased frequency of 50,000 IU ergocalciferol capsule to three times oral weekly to his current regimen. Repeat labs three months later showed improvement of serum 25-OH VD level to 24 ng/ml. At that time, we discontinued liquid 8000 IU ergocalciferol and increased frequency of 50,000 IU ergocalciferol capsule to five times oral weekly.  His serum 25-OH VD 2 months later increased to 26 ng/ml. At that time, we recommended him to take ergocalciferol 50,000 IU oral daily.

Conclusion: Vitamin D in capsule form might not be as effective as liquid form in certain patents with bariatric surgery especially malabsorptive type of bariatic surgery; gastric bypass and BPD-DS.  This case highlights that a simple trick of taking liquid vitamin D out from the gel capsule is much more effective than swallowing the whole capsule. He is currently taking one fourth of the initial dose of vitamin D with improvement in his serum vitamin D level.

 

Nothing to Disclose: AB, AG

15526 15.0000 SAT-0228 A Bariatric Surgery Patient Requiring Extremely High Dose of Vitamin D 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM SAT 0214-0228 4790 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Paraskevi Xekouki*1, Mihail Zilbermint1, Fabio R Faucz2, Maya Beth Lodish1, Annabel Sophie Berthon1, Marie Helene Schernthaner-Reiter1, Aaron Hodes3, Maria De La Luz Sierra1, Jerome Yves Bertherat4 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2National Institutes of Health, Bethesda, MD, 3Drexel University College of Medicine, Philadelphia, PA, 4INSERM U 1016, Cochin Institute, Paris Descartes University, Paris, France

 

Background: Recently inactivating mutations in Armadillio Repeat Containing 5 (ARMC5), a putative tumor-suppressor gene, were reported in macronodular a hyperplasia with Cushing's syndrome (1) Aim of the study: The aim of this study was to determine the prevalence of   ARMC5 germ line mutations in a cohort of patients with primary aldosteronism  (PA) seen at the National Institutes of Health. Patients-methods: Twenty-four patients diagnosed with PA were screened for ARMC5 germ line mutations by bi-directional Sanger sequencing. Diagnosis of PA was performed according to the guidelines published by The Endocrine Society (2). If an aldosterone- and cortisol co-secreting adrenocortical tumor was suspected, additional testing was performed as previously described (3). Patients harboring mutations in genes that have been related to PA were excluded. Results: Among 24 patients tested, 17 patients were found to harbor a genetic variation in ARMC5 (39.6%), with two of them having two different variations. Twelve of these patients had an aldosterone producing adenoma (APA), six had bilateral hyperplasia, two patients had PA in the context of macronodular adrenal hyperplasia, 1 had unilateral hyperplasia, and 1 diagnosed with biochemical PA but no obvious adrenal abnormality was seen on imaging studies. In total, 10 different variations were detected (9 were exonic and 1 intronic) with 8 of them already being described. Five  exonic variations were predicted to be damaging and the intronic one was predicted to create a cryptic splice site according to in silico analysis. Allele frequencies for one of the benign variations reached statistical difference between patients and controls. However, both total general frequency as well as the total frequency of damaging variants were highly significant (p < 0.0001) especially when their frequencies were compared to controls of American ancestry.Conclusions: Our data indicate that ARMC5 gene, in addition to macronodular adrenal hyperplasia, may be implicated in PA as well. We are unable to perform functional studies, since the function of the gene is still under investigation.  We suggest that ARMC5 to be considered  among the panel of genes screened for PA

 

Nothing to Disclose: PX, MZ, FRF, MBL, ASB, MHS, AH, MDLLS, JYB, CAS

14089 5.0000 SAT-0841 A Mutations of ARMC5 Gene May be Implicated in Primary Hyperaldosteronism (PA) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Andre Valcour*1, Joshua Soldo2, Renee M Parker2, Brian Lauber2 and Fabrizio Bonelli2
1LabCorp, Burlington, NC, 2DiaSorin Inc., Stillwater, MN

 

Studies indicate 14-23% of treatment-resistant hypertension (RHTN) may be attributed to primary aldosteronism (PA), and patients with untreated PA are at an increased cardiovascular risk, as shown by higher rates of stroke, myocardial infarction, and arrhythmias (1). While PA can be successfully treated with unilateral laparoscopic adrenalectomy and/or a mineralocorticoid receptor antagonist, very few RHTN patients are tested for PA today.  In patients with PA, aldosterone is inappropriately secreted (high) and renin levels are suppressed (low).  Current clinical practice for case detection of PA is to use the ratio (ARR) of serum aldosterone (ALDO) to plasma renin activity (PRA), with an ARR > 30 [(pg/mL)/(ng/mL/hr)] being a positive screening test for suspected PA (PA+) (2).  However, there are many confounding factors that can affect the accuracy of the ARR, especially if the PRA value is very low. The objectives of this study were to 1) analytically characterize the recently FDA cleared DiaSorin LIAISON fully automated chemiluminescence immunoassay (CLIA) for direct renin concentration (DRC) including a correlation to the DiaSorin PRA RIA, 2) establish case detection cutoffs (CDC) for low plasma renin levels for DRC and PRA, 3) select a CDC for elevated ALDO using the reference ranges established in the recently FDA cleared DiaSorin LIAISON CLIA for ALDO, and 4) compare the sensitivity and specificity of the ALDO and renin CDC (PRA or DRC) to the ARR for PA case detection. In November 2013, 1043 samples submitted to LabCorp for routine PRA testing were also tested the same day by the CLIA DRC, and 958 of these EDTA plasma specimens had sufficient volume remaining for CLIA ALDO testing from the same sample tube.  The CLIA DRC analytical testing met manufacturer claims and demonstrated good correlation to the PRA (r=0.88; N=829).  Receiver Operating Characteristic (ROC) curve analysis resulted in a DRC CDC <9.80 pg/mL (90.1% sensitivity, 92.3% specificity) as compared to PRA < 1.0 ng/mL/hr (N=1043).  An ALDO CDC >236 pg/mL was selected based on the 97.5th percentile of the Supine Observed Range in EDTA plasma.  The ARR (ALDO/PRA) identified 179 out of 958 patients (18.7%) as PA+, while the combination of ARR and ALDO CDC identified 41 (4.3%) as PA+.  In comparison, the use of ALDO CDC and PRA CDC identified 41 (4.3%) as PA+, and 40 out of the same 41 patients as PA+ with DRC CDC.   Kappa analysis comparing DRC CDC to PRA CDC resulted in a very good agreement (k=0.975) with 97.6% positive agreement and 99.9% negative agreement.  Results suggest superior specificity (PA+) using ALDO CDC with the ARR, or using ALDO CDC with the renin CDC (PRA or DRC), as compared to only using the ARR. In conclusion, the two automated immunoassays nearly equally identified the same patients as did the PRA in combination with the ALDO CDC.

 

Disclosure: JS: Employee, DiaSorin Inc.. RMP: Employee, DiaSorin. BL: Employee, DiaSorin Inc.. FB: Employee, DiaSorin Inc.. Nothing to Disclose: AV

15152 6.0000 SAT-0842 A Analytical Performance of Immunoassays in a Suspect Primary Aldosteronism Population 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Geneviève Oligny-Longpré*1, Agostino De Venanzi2, Livia Mara Mermejo3, Isabelle Bourdeau4 and Andre Lacroix1
1Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada, 2Centre hospitalier de l'Universite de Montreal, Montreal, QC, Canada, 3Centre hospitalier de l'Universite de Montreal, Montral, QC, Canada, 4Centre hospitalier de l’Université de Montréal (CHUM), Université de Montréal, Montreal, QC, Canada

 

Background: The mechanisms involved in the renin-independent regulation of aldosterone secretion in primary aldosteronism (PA) are incompletely understood. Although mutations of various ion channels in approximately 50% of unilateral aldosteronomas (APA) increases aldosterone secretion, the mechanisms regulating aldosterone from the more frequent bilateral idiopathic hyperplasia (IHA) and in 50% of APA remain unknown outside of rare familial forms (FH-1  and FH-III). Preliminary studies identified aberrant expression of several GPCRs regulating excess aldosterone in PA secondary to APA or IHA.

Objective: To investigate the aberrant renin-independent regulation of aldosterone by various GPCR in patients with PA. 

Patients and Methods: An in vivo screening protocol was conducted under dexamethasone suppression in 42 patients with PA (24 APA, 14 IHA and 4 undefined) and 24 control subjects with adrenal incidentalomas with subclinical cortisol secretion, but normal renin-aldosterone axis regulation. Basal plasma aldosterone concentration (PAC), renin, cortisol and ACTH were measured in fasting, supine subjects prior to a 2h-upright posture test, standard mixed meal, 1-24 ACTH, GnRH, metoclopramide and vasopressin conducted over 3 days. Agonist-induced aldosterone secretion was considered positive if it was > to the mean difference + 2SD of agonist-induced PAC in the control group (C) except for the upright posture test where an upright-stimulated renin-independent PAC increase of ≥50% was considered positive in PA patients.

Results: 85% of PA patients had a renin-independent increase in PAC during upright posture. Vasopressin (10 IU im) promoted a significant increase in PAC in 53.8% of patients with PA but none in C. Metoclopramide (10 mg orally) increased PAC abnormally in 57.1% of patients with PA compared with 7.7% in C. GnRH 100 mcg iv increased aldosterone in 17.1% of PA patients but not in C. 12.1% of PA patients increased PAC following a mixed meal but none was observed in the C. Over-responsive PAC following ACTH administration was observed in 62.5% of PA patients compared to none in C. ACTH-independent cortisol secretion was also observed in 33.3% of PA patients following vasopressin, metoclopramine, GnRH, upright posture or a mixed meal but concomitant co-secretion of cortisol and aldosterone upon specific agonist stimulation was only seen in 11.9% of PA patients. Excluding ACTH responses, 92.9% of PA patients had at least one PAC positive aberrant response. 

Conclusion : This study confirms the frequent regulation of aldosterone by various aberrant receptor signaling in PA both from IHA and APA etiologies. It provides additional insights into the mechanisms responsible for the renin-independent but non autonomous aldosterone production.

 

Nothing to Disclose: GO, AD, LMM, IB, AL

14881 7.0000 SAT-0843 A Plasma Aldosterone Secretion Is Regulated in Vivo By Various Aberrant Hormone Receptors in Primary Aldosteronism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Nicole Nigro*1, Bettina Winzeler1, Isabelle Suter-Widmer1, Philipp Schuetz2, Birsen Arici1, Martina Bally2, Claudine Angela Blum1, Christian Nickel1, Roland Bingisser1, Andreas Bock3, Andreas Huber2, Beat Mueller2 and Mirjam Christ-Crain1
1University Hospital Basel, Basel, Switzerland, 2Kantonsspital Aarau, Aarau, Switzerland, 3Kantonsspital Aarau, Aarau

 

Background: Hyponatremia is common and its differential diagnosis and consecutive therapy management challenging. Mostly, the differential diagnosis of hyponatremia is based on the clinical assessment of the volume status, which is often cumbersome in daily routine. Mid-Regional pro atrial natriuretic peptide (MR-pro ANP) is associated with the extracellular fluid volume and may have a role in the assessment of volume status in patients with severe hyponatremia.

Design and Setting: Prospective multicentre observational study in two tertiary referral centers in Switzerland.

Methods: 227 consecutive patients admitted to the emergency department with severe hypoosmolar hyponatremia (Na<125mmol/L) were included. A standardized diagnostic evaluation of the underlying cause of hyponatremia was performed and patients were carefully clinically evaluated from an expert panel. MR-pro ANP levels were compared between different aetiologies of hyponatremia and for prediction of the volume status.

Results: MR-pro ANP levels were higher in patients with hypervolemic hyponatremia compared to patients with hypovolemic or euvolemic hyponatremia (p=0.0002). The area under the curve to predict an excess of the extracellular fluid volume compared to euvolemic patients was 0.73 (95% CI 0.62-0.84). Additionally, in multivariate analysis MR-pro ANP remained an independent predictor for excess of extracellular fluid volume compared to euvolemic patients after adjustment for congestive heart failure (p=0.012).

Conclusion: MR-pro ANP levels are associated with volume status in patients with severe hyponatremia and remains an independent predictor for volume status after adjustment for congestive heart failure.

 

Disclosure: PS: Speaker, Thermo Fisher Scientific BRAHMS GmbH. BM: Speaker, Thermo Fisher AG. MC: Speaker, Thermo Fisher AG. Nothing to Disclose: NN, BW, IS, BA, MB, CAB, CN, RB, AB, AH

15187 8.0000 SAT-0844 A Mid-Regional Pro-Atrial Natriuretic Peptide (MR-pro ANP) for the Assessment of the Volemic Status in Patients with Severe Hyponatremia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Tanja Dudenbostel*1, David A Calhoun2 and Peng Li3
1University of Alabama CV Disease, Madison, AL, 2Univ of Alabama, Birmingham, AL, 3UAB, Birmingham, AL

 

A number of studies have demonstrated a significant relation between aldosterone levels and indices of obesity, including body mass index and waist circumference levels. Anecdotally we have observed high urinary sodium (U-Na) levels in our referral hypertension clinic.To study the levels of U-Na and urinary aldosterone (U-Aldo) and the relationship with obesity indexed as quartiles of BMI in a single center cohort of 1132 European American(EA) and African American(AA) patients with resistant hypertension (RHTN). To further investigate U-Na and U-Aldo levels in a subgroup of 36 patients before and after a suppression test with 3-day oral sodium loading with sodium chloride tablets (3x1g daily).

U- Aldo and U-Na levels were positively correlated with BMI (p<0.0001). U-Na was found to be increasing across quartiles of BMI (1.Quartile of BMI (Q) U-Na 138.9, 2.Q U-Na 166.3, 3.Q U-Na  181.4, 4.Q U-Na 207.9 mEq/24h, p<0.0001). For every 1 unit increase of BMI, there was an average of 3.11 units increase of the U-Na level. Men had higher U-Na levels than women (205.8±3.5 versus 157.0±3.2, p<0.0001). There was a positive correlation between U-Aldo and U-Na levels (r2 =0.0311 p<0.001) and after adjusting for sex, age, race and BMI (p=0.0079); for every unit increase of U-Aldo, there was a 0.69 unit increase of U-Na levels.

To begin to understand the underpinnings that alter U-Aldo and U-Na levels in overweight and obese patients, we assessed  U-Aldo and U-Na levels before and after sodium loading in a subgroup of 36 patients. 22 patients showed an increase in U-Aldo (14.1±8.2 to 20.6±10.2 mcg/24 h, p<0.0001). in several patient the increase in U-Aldo was >50% compared to baseline. We refer to those patients as “non-suppressors”, and 13 patients showed a decrease (21.7±4.9 to 15.3±4.7 mcg/24h), we refer to those patients as suppressors. As expected U -Na was increased in both groups, in “non-suppressors” (181.7±79.1 and after 272.1±193.6 mEq/24h) and “suppressors” (U-Na before 175.2±68.2 and after 244.3±91.5 mEq/24h). U-Potassium levels after sodium loading were higher in the “non-suppressors” group (103.1± 78.5 versus 66.2± 25.1mEq/24h, p=0.017).

We found increasing U-Aldo and U-Na levels with increasing BMI in a large cohort of EA and AA patients with RHTN. In a subgroup of patients exposed to sodium loading, approximately 2/3 of patients showed an increase in U-Aldo levels, while 1/3 of patients showed suppressible U-Aldo levels. Although speculative, some patients seem to have an underlying aldosterone dysregulation with non-supressible aldosterone levels in the setting of high sodium intake. Especially in obese patients, mechanisms, either directly or indirectly, by adipocytes and/or adipocyte- released factors may be involved in the sodium-potassium-aldosterone dysregulation.

 

Nothing to Disclose: TD, DAC, PL

17076 9.0000 SAT-0845 A Increased Urinary Sodium Levels in a Large Cohort of Obese Patients and Paradox Aldosterone Regulation after Sodium Loading 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Jennifer Barber1, Tricia McKeever1, Sarah E McDowell2, Jenny A Clayton3, Robin E Ferner2, Richard Gordon4, Michael Stowasser5, Kevin O'shaughnessy6, Ian Hall7 and Mark Glover*7
1University of Nottingham, 2University of Birmingham, 3University of Nottingham NHS Trust, 4University of Queensland, Brisbane, Australia, 5University of Queensland School of Medicine, Greenslopes and Princess Alexandra Hospitals, Brisbane, Australia, 6University of Cambridge, 7University of Nottingham, Nottingham, United Kingdom

 

Thiazide diuretics are one of the most widely used and cost-effective class of anti-hypertensive agents worldwide. Thiazide-Induced Hyponatraemia (TIH) is one of their major adverse effects and the leading cause of drug-induced hyponatraemia severe enough to require hospital admission. Greater understanding of thiazide-induced hyponatraemia could improve clinical practice and improve understanding of the pathophysiology of this paradigm of disordered sodium and water handling in the kidney. We report a systematic review and meta-analysis of the clinical and laboratory characteristics of patients with thiazide-induced hyponatraemia.

Medline, Embase, Web of Science and PubMed were searched to identify relevant articles published before September 2013. Articles were included only if original human data were presented. A proportions meta-analysis was conducted to look at the weighted frequency of clinical phenotype, drug history and laboratory findings for the combined number of papers contributing to each separate analysis. Results are presented as mean (95% confidence interval). Confidence intervals were determined with a random effects model using the DerSimonian and Laird method to calculate weights.

We identified 101 articles detailing 4204 patients with thiazide-induced hyponatraemia. Meta-analysis showed that 72% (68–76) of patients were women, of average age 73 (57–88) years and body mass index 23.7 (20.7–26.6) kg/m2who presented 27 (12–39) days after starting thiazide treatment with a trough sodium concentration of 117 (114–120) mmol/L. Corresponding serum potassium and urinary sodium concentrations were 3.4 mmol/L (3.0–3.5) and 62 (45–80) mmol/L respectively; serum and urine osmolalities were 242 (238–246) and 400 (366–434) mOsm/kg. Thiazide-induced hyponatraemia was most often reported with hydrochlorothiazide, bendroflumethiazide and indapamide.

Patients with thiazide-induced hyponatraemia were characterised by advanced age, female gender, inappropriate saliuresis and mild hypokalaemia. Low BMI was not found to be a significant risk factor, despite previous suggestions. The time from thiazide initiation to diagnosis of hyponatraemia suggests that the recommended practice of performing a single investigation of serum biochemistry 7–14 days after thiazide initiation may be suboptimal. The poor quality and heterogeneous nature of many reports highlights the need for larger and more systematic studies of this important condition.

 

Nothing to Disclose: JB, TM, SEM, JAC, REF, RG, MS, KO, IH, MG

11807 10.0000 SAT-0846 A A Systematic Review and Meta-Analysis of Thiazide-Induced Hyponatraemia: Time to Reconsider Electrolyte Monitoring Regimens after Thiazide Initiation? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Takamasa Ichijo*, Rieko Kunishita, Mai Tasaki, Ken Kanazawa, Ayano Doi, Kaoru Yamashita, Hiromi Ouchi and Mariko Higa
Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan

 

Primary aldosteronism (PA) is the most common endocrinological hypertension and its prevalence is about 10% of all patients with hypertension. It is known that the cardiovascular risk with PA is much higher and echocardiography shows more severe left ventricular hypertrophy than the blood pressure adjusted essential hypertension. Thus, we evaluate the parameters of echocardiography in 91 adrenal venous sampling (AVS) performed patients with PA in our series to survey which were affected and correlated to severity of aldosterone excess secretion.

We screened patients with hypertension and 167 of those showed the aldosterone-renin ratio (ARR, aldosterone in ng/dl) ³20, which we considered positive. We, then, performed the confirmatory tests, such as rapid ACTH stimulating, captopril challenge, upright plus furosemide, and saline infusion tests, to those patients to diagnose PA. When any of those confirmatory tests were positive, and when surgical treatment is practicable, the diagnosis unilateral hyperaldosteronism (UHA) or bilateral hyperaldosteronism (BHA) was made by ACTH loading-AVS after CT scans. We, then, finally perform unilateral laparoscopic adrenalectomy upon AVS documented unilateral hyperaldosteronism. Otherwise, we administrated MRBs, spinorolactone or eplerenone. We then analyzed 91 cases with PA including both 17 patients with UHA, all pathologically confirmed as aldosterone producing adenomas and 74 patients with BHA as suspicious of IHA for the parameters of cardiac echography.

The mean age was 56.5±12.0 years old including 35 males and 56 females, and the mean ARR was 54.7±82.8. Ninety-one both AVS and cardiac echography performed cases were classified into 17 cases with UHA and 74 cases with BHA by AVS. Our AVS results showed the mean ARR (mARR), measured at the first visit and each time at conformational tests, was significantly higher in UHA than BHA, 80.3 ± 89.0 vs. 52.0 ± 56.5, respectively. The cardiac echography revealed significant positive correlation between mARR and the left ventricular diameter at end-diastole (LVDd) (p=0.009), left ventricular end- diastolic volume (EDV) (p=0.0059), and end-systolic volume (ESV) (p=0.0223), but left ventricular diameter at end-systole (LVDs) (p=0.0518).

 These our results indicate the aldosterone excess promotes myocardial fibrosis and left ventricular dilatation, and these are consistent with previous reports. It is also reported that patients with PA have several times higher risk for heart disease, such as myocardial infarction or atrial fibrillation, compared with blood pressure and duration adjusted patients with essential hypertension. In conclusion, our results showed the relationship between aldosterone excess and heart structure change. Therefore, the early diagnosis and treatment is fundamentally important for PA management.

 

Nothing to Disclose: TI, RK, MT, KK, AD, KY, HO, MH

12282 11.0000 SAT-0847 A The Analysis of Echocardiography in 91 Patients with Primary Aldosteronism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Tanja Dekkers1, Sabine C Käyser2, Hans J.M.M. Groenewoud1, Gert Jan van der Wilt2, Carel JC Bakx2, Mark C van der Wel2, Pim WJJ Assendelft2, Ad RMM Hermus3, Jacques W.M. Lenders4 and Jaap Deinum*3
1Radboud University Medical Center, Nijmegen, Netherlands, 2Radboud university medical center, 3Radboud university medical center, Nijmegen, Netherlands, 4Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical University Dresden, Germany

 

The prevalence of primary aldosteronism (PA) in hypertensive patients is still subject of debate. In this meta-analysis the data regarding the prevalence of PA in both primary care and referral centers was systematically reviewed and analyzed. A meta-regression model was used to assess which factors might contribute to the large heterogeneity between studies. Studies found in PubMed, EMBASE, Web of Science, the Cochrane Library, and reference lists. Articles must have been written in English, German, French, Spanish or Dutch and published between January 1990 and October 2013. Search terms included (hyper)aldosteronism, Conn(s) syndrome, prevalence, incidence, and epidemiology. All studies describing an adult patient population in whom the diagnosis of PA was verified by a confirmation test, were included. Of the 1483 identified studies, 39 met the selection criteria, providing data for 42510 patients. Two researchers independently assessed inclusion criteria, patient characteristics, health care setting, diagnostic methods and PA prevalence. Methodological quality and risk of bias in individual studies were assessed using a validated protocol.

Prevalence varied from 3.2-12.7% in primary care; prevalence varied from 1-29.8% in referral centres. Due to high heterogeneity, data could not be pooled to calculate a mean prevalence (weighted for the number of participants in each study). Meta-regression showed higher prevalence in studies that have been performed after 2000, in the USA, when the study purpose had been to assess the prevalence, when ARR had been used for screening, when the cut-off for the screening test had been relatively high, when the fludrocortisone suppression test had been used as a confirmation test, and when the cut-off for the confirmation test had been relatively high.

This meta-analysis systematically summarizes the prevalence of PA. A meta-regression analysis shows that methods for screening and confirmation largely determine the study result. Due to methodological limitations and considerable clinical heterogeneity among studies, a definite answer about the real prevalence of PA remains under debate.

 

Nothing to Disclose: TD, SCK, HJMMG, GJV, CJB, MCV, PWA, ARH, JWML, JD

15649 12.0000 SAT-0848 A The Prevalence of Primary Aldosteronism: A Meta-Analysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Martin Bidlingmaier*1, Harald Schmidt2 and Christoph Milczynski2
1Klinikum der Universität München, München, Germany, 2Limbach Laboratory, Heidelberg, Germany

 

Primary Aldosteronism (PA) is the most common form of secondary hypertension. Prevalence in patients with Resistant Hypertension (uncontrolled blood pressure despite ≥ 3 antihypertensive drugs) is estimated in prospective studies to be 14-23%. The Aldosterone to Renin Ratio (ARR) can be used in the screening and is recommended by clinical practice guidelines in patients at risk. Use of ARR depends on the availability of reliable and sensitive methods to measure Aldosterone and Renin. We investigated the performance of a new automated, commercially available Chemiluminescent Immunoassay (CLIAs) for measurement of Aldosterone in comparison to our standard Aldosterone assay (RIA) with clinical samples. Aldosterone (PAC) was measured using the new CLIA on the LIAISON Analyzer (DiaSorin, Saluggia, Italy) and the Siemens coat-a-count RIA. Direct Renin (DRC) was measured on the LIAISON Analyzer. EDTA plasma samples were taken from 200 normotensive patients (N), 50 essential hypertensive (EH) patients and 50 PA patients. The latter groups were defined by post-saline Aldosterone >50pg/mL (RIA). 50 matched serum/plasma samples were measured with the LIAISON Aldosterone CLIA to analyze matrix commutability. Median PAC by RIA were 58pg/mL (range 35-259pg/mL) in N; 60 pg/mL (range 35-181 pg/mL) in EH and 221pg/mL (45-761pg/mL) in PA. Median PAC by CLIA was 70pg/mL (range 30-228 pg/mL) in N; 81 pg/mL (range 30-193pg/mL) in EH and 234pg/mL (range 45–670pg/mL) in PA. DRC was 20µU/mL (range 3-274µU/mL) in N; 50µU/mL (range 5-625µU/mL) in EH and 7µU/mL (range 2-35µU/mL) in PA. ROC analysis of the data identified a range of ARR values between 9.5 to 12.0 (PAC pg/mL; DRC µU/L) that provide acceptable balance between sensitivity and specificity (100%/80% to 98%/86%). Passing Bablok comparison of aldosterone concentrations from CLIA versus RIA revealed good correlation and agreement (y=1.04x+4.28). Significant correlation was observed between serum and plasma samples using the CLIA (r2=0.92; y=0.987+8.2). Preliminary data from salt load suppression tests and the high correlation to aldosterone concentrations measured by RIA indicate that the cut-off value (50pg/mL) can be used also for aldosterone concentrations measured by CLIA. Our data indicate that the new automated aldosterone CLIA in conjunction with the established automated CLIA for renin concentration can be used as a reliable and sensitive method for definition of the ARR.

 

Disclosure: MB: Speaker, DiaSorin. Nothing to Disclose: HS, CM

15796 13.0000 SAT-0849 A Screening for Primary Aldosteronism: Aldosterone to Renin Ratio (ARR) Using Two Automated Chemiluminescent Immunoassays 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Riia Karoliina Sustarsic*1, Jenny Manolopoulou2, Philipp Grimminger3, Chris Martin Roffe2, Martin Reincke4 and Martin Bidlingmaier5
1Medizinische Klinik und Poliklinik IV, Munich, Germany, 2Immunodiagnostic Systems Ltd., Boldon, United Kingdom, 3Medizinische Klinik und Poliklinik IV, Ludwig-Maximilian University, Munich, Germany, 4Klinikum der Universität München, Ludwig-Maximilian University, Munich, Germany, 5Klinikum der Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany

 

Identifying patients with primary aldosteronism (PA) is essential for their optimal treatment. Screening by measuring aldosterone to renin ratio (ARR), confirmatory tests as the saline infusion test (Na-load) as well as differential diagnosis including adrenal venous sampling (AVS) for distinguishing between bilateral and unilateral disease rely strongly on reliable measurement of aldosterone, renin and cortisol. In this study, we demonstrate the potential of new automated assays on one analyzer (IDS-iSYS) during the diagnostic workup from screening to differential diagnosis and follow up after initiation of therapy. Initially samples had been measured by our current routine assays (Liaison Direct Renin and Cortisol, Siemens Coat-A-Count Aldosterone), and then by the new IDS-iSYS Aldosterone and Direct Renin assays. Cortisol in the AVS series was measured using the extremely rapid (7 minutes) IDS-iSYS Cortisol assay currently being developed. ARR was determined in 140 PA patients, 203 essential hypertensives (EH) and 261 normotensive subjects. ROC analysis revealed a cut-off at 1.1 ng/dL/µU/mL for discrimination between PA and EH when using the iSYS assays (sensitivity 98.6%, specificity 81.8%). In 9 out of the 140 PA patients we had access to screening samples, Na-load tests and AVS series (5 bilateral disease and 4 unilateral adenomas later treated by adrenalectomy) and also post-op samples. Na-load tests indicated PA in all 9 patients (iSYS aldosterone >5 ng/dL after Na-load). In samples from AVS series, iSYS measurements for cortisol and aldosterone showed concurrent results to the currently applied methods and led to the same diagnoses. Aldosterone was <10 ng/dL in all samples from patients who had adrenalectomy in line with successful treatment. Aldosterone was also normalized in the post-op Na-load tests (<5 ng/dL). Overall, the IDS-iSYS assays showed concurrence in diagnostic accuracy when compared to the routinely used assays. The availability of a very rapid cortisol assay provides advantages for the confirmation of correct placement of the catheter during AVS. The IDS-iSYS family of automated assays for aldosterone, renin and cortisol could become a valuable tool in the diagnosis and treatment of PA.

 

Disclosure: JM: Employee, Immunodiagnostic systems. CMR: Employee, Immunodiagnostic Systems Ltd.. MB: Consultant, Immunodiagnostic Systems Ltd., Investigator, Immunodiagnostic Systems Ltd.. Nothing to Disclose: RKS, PG, MR

16123 14.0000 SAT-0850 A Primary Aldosteronism: Biochemical Workup from Screening to AVS to Post-Op Control on a Single Automated Platform 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Fidel Allende*1, Sandra Solari1, Carmen Campino1, Cristian A Carvajal1, Agustin Benitez2, Carlos F Lagos1, Andrea Vecchiola1, Alejandra Tapia1, Carolina P Valdivia1, Cristobal A Fuentes1 and Carlos E Fardella1
1Pontificia Universidad Catolica de Chile, Santiago, Chile, 2Pontificia Universidad Católica de Chile, Santiago, Chile

 

Around 15% of patients with essential hypertension (HT) have impairment of the 11β-hydroxysteroid dehydrogenase type-2 (11β-HSD2) enzyme that inactivates cortisol (F) in cortisone (E) (1). The 11β-HSD2 activity may be estimated by the F/E ratio in morning serum or in 24 h urine samples. Even though urine seems to be an easier to collect sample, the need for 24 h collection makes it not always a reliable sample.  Immunoassay based methods for cortisol and cortisone shows lack of accuracy since they may be susceptible to interference from other steroid metabolites; besides the difficulty of finding specific antibodies to E. Liquid chromatography tandem mass spectrometry (LC/MSMS) is the reference method for steroid specificity and structure, being the gold standard methodology for steroids measurements (2). Aim: Develop and validate a reliable, high sensitivity and selectivity LC/MSMS method, for the simultaneous determination of F and E in serum to identify HT patient with 11β-HSD2 activity impairment. Methods: Steroid-free serum enriched with known concentrations of each analyte were used for method optimization and validation. Steriods were extracted from 300 µL of serum with solid phase extraction, using D4-Cortisol and D2-Cortisone as internal standards, being afterwards analyzed in LC/MSMS, with the new detector MS/MS 4500QTrap®, with a chromatographic column Intersil® ODS-3 and the ionization source in mode ESI+. For clinical validation of the methodology 64 normotensive subjects (NT) were analyzed. Results: The method quantification range was 0.1-20 ug/dL with an average correlation coefficient of 0.998 (n=5) for both analytes, an 85% average recovery, matrix effect between 85-115% for F and E. LOD and LLOQ were 0.02 and 0.1 ug/dL respectively. The coefficient of variation intra and inter assay were <3 and <7% respectively and the accuracy between 96-105%. Mean ± SD values for F and E in the serum of the 64 NT were 14.6 ± 7.3 and 2.69 ± 0.9 ug/dL, respectively. Conclusion: The developed LC/MSMS method is accurate and precise according to FDA and suggested acceptance criteria for method validation. It also showed a good sensitivity, recovery and matrix effect for the simultaneous measurement of F and E. This methodology allowed quantifying F and E with high specificity in clinical samples providing an innovative tool to be applied in a clinical endocrinology to identify 11β-HSD2 activity impairment.

 

Nothing to Disclose: FA, SS, CC, CAC, AB, CFL, AV, AT, CPV, CAF, CEF

16302 15.0000 SAT-0851 A Validation of an Analytical Method By LC-MS/MS to Identify Possible Causes of Essential Hypertension 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Gabriela Paula Finkielstain*1, Rosa Simsolo2, Miriam Romo2, Alberto Quilindro2, Hugo Cozzani2, María Grippo2, Beatriz Grunfeld2 and Ignacio Bergadá3
1Hospital de Niños R. Gutiérrez, Buenos Aires, Argentina, 2Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina, 3Hospital de Niños Dr. Ricardo Gutiérrez, Buenos Aires, Argentina

 

Long term glucocorticoid and mineralocorticoid treatment in patients with CAH might increase the risk of cardiovascular disease. However, whether these consequences occur early in adolescents and young adults remain controversial. We aimed to assess cardiovascular risk as well as the renal handling of an oral sodium load test in adolescents and young adults with salt wasting (SW) and simple virilizing (SV) CAH due to 21-hydroxilase deficiency. We performed a cohort study including all patients with CAH with regular follow-up at the Division of Endocrinology clinic, and healthy volunteers (controls), Tanner stage 5, age ≤ 28 years. Compliance to therapy was monitored by regular hormonal measurements. Eighteen CAH patients (15 SW, 3SV) (5 males) aged 14.6-28.0 yr and 11 controls (6 males) aged 17.1-26 yr were included in the study. No patient was lost to follow-up. CAH patients were significantly shorter than controls (-0.80 ± 0.28 SDS vs 0.60 ± 0.21 SDS; p=0.002). BMI (SDS) was significantly higher in CAH patients than in controls (1.04 ± 0.19 vs 0.43 ± 0.13, P=0.03). CAH patients received mean equivalent glucocorticoid and 9α-fludrocortisone doses of 14.5 ± 2.4 mg/m2 and 0.9 ± 0.02 mg/d respectively. Ambulatory blood pressure measurements (ABPM) were performed to evaluate blood pressure (BP) circadian rhythm and systolic and diastolic loads. Daytime (systolic 120.4 ± 3.3 vs 121.1 ± 1.9, diastolic 71.6 ± 1.5 vs 70.5 ± 1.8 mmHg) and nighttime (systolic 108.0 ± 1.3 vs 108.8 ± 1.1, diastolic 59.8 ± 1.7 vs 58.4 ± 1.5 mmHg) BP were not significantly different in patients and controls. Physiological nocturnal dip in BP was absent in 12/18 CAH patients and in 3/11 controls respectively (Chi2: 0.039) Standard bidimensional echocardiography was performed to assess left ventricular hypertrophy (LVH) and ventricular function. LVH was not found in CAH or controls. Doppler ultrasonography showed increase (0.8 mm) in intima media thickness (IMT) at different sites of the left and right carotid artery IMT in 2/18 CAH patients and in 1/11 controls. Total sodium renal excretion and plasma renin activity (PRA) were measured at baseline and at the end of a 3-day oral sodium load test (NaCl 10 gr/d). No significant difference in total sodium excretion was found between the CAH and the control group (B: 161.8 ± 20.7 vs 148.5 ± 22.6 mEq/d; Post: 269.0 ± 21.6 vs 254.6 ± 25.6 mEq/day). Baseline PRA was significantly higher in CAH patients (B: 9.9 ± 1.9 vs 3.6 ± 0.8 ng/ml/h, P=0.009; Post 6.4 ± 1.2 vs 0.70 ± 0.1 ng/ml/h, P=0.0004), and no significant suppression was observed after the load test in CAH patients (Post: 6.4 ± 1.2 ng/ml/h, ns vs baseline). Conclusions: Adolescents and young adults with CAH did not show overt signs of high BP and early cardiovascular disease. These patients showed increased PRA and failed to suppress it when exposed to an oral sodium load test, which be an additional risk factor for cardiovascular morbidity.

 

Nothing to Disclose: GPF, RS, MR, AQ, HC, MG, BG, IB

11813 16.0000 SAT-0852 A Blood Pressure Profiles, Cardiovascular Risk and Renal Handling of an Oral Sodium Load Test in Adolescents and Young Adults with Congenital Adrenal Hyperplasia (CAH) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Ayako Takano*1, Masaaki Yamamoto1, Hitoshi Sugihara1, Tomoko Nagamine1, Naomi Takeichi1, Akira Ishizaki1, Shiro Onozawa2, Satoru Murata2 and Shinichi Oikawa1
1Graduate School of Medicine, Nippon Medical School, Tokyo, Japan, 2Nippon Medical School, Tokyo, Japan

 

【Background】

The diagnostic steps for primary aldosteronism (PA) include case screening tests, confirmatory tests, and localization. The aldosterone renin ratio is commonly used to screen for PA. In the confirmatory steps, diagnostic guidelines in Japan recommend the use of any of three testing procedures: the captopril-challenge test (CCT), furosemide upright test (FUT), and saline infusion test (SIT). Furthermore, the ACTH stimulation test (AST) is also reported to be a useful test because of its high diagnostic accuracy for PA. However, it remains unclear which confirmatory tests are optimal to confirm a diagnosis of PA. In the current study, we aimed to investigate the diagnostic usefulness of each confirmatory test in PA and identify whether the test can predict unilateral aldosterone hypersecretion.

【Methods】

We enrolled 65 consecutive patients with primary aldosteronism who underwent all the four confirmatory tests (CCT, FUT, SIT, and AST) as well as adrenal venous sampling (AVS) at Nippon Medical School between January 2009 to July 2013. The diagnosis of PA and lateralization of aldosterone hypersecretion were determined by performing ACTH-stimulated AVS based on the guidelines of the Japan Endocrine Society.

【Result】

The percentages of patients with positive CCT, FUT, SIT, and AST were 73.8%, 81.5%, 53.8%, and 90.8%, respectively. The percentage of patients with positive SIT was significantly higher in the patients with unilateral aldosterone excess (unilateral group, 85%) than in those with bilateral aldosterone excess (bilateral group, 46%) (P<0.05). On the other hand, there were only 3 (4.6%) cases with single positive AST in PA. Interestingly, the number of positive confirmatory tests was significantly larger in the unilateral group than in the bilateral group (P<0.01).

【Conclusion】

Our data indicates that AST is the most useful test in the diagnosis of PA. In addition, SIT and the number of confirmatory tests that yield positive results might help to determine the laterality of aldosterone hypersecretion in PA.

 

Nothing to Disclose: AT, MY, HS, TN, NT, AI, SO, SM, SO

13002 17.0000 SAT-0853 A The Significance of Confirmatory Tests in Primary Aldosteronism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Kyeong Seon Park*1, Jung Hee Kim1, Eu Jeong Ku1, A Ram Hong1, Do Joon Park1, Sung Hee Choi2, Chan Soo Shin1, Sang Wan Kim3 and Seong Yeon Kim1
1Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 2Seoul Nat Univ Bundang Hosp, Seongnam-Si, Korea, Republic of (South), 3Seoul Metropolitan Government Boramae Medical Center, Seoul, Korea, Republic of (South)

 

Confirmatory testing of primary aldosteronism is necessary in the patients with a positive screening test. The saline infusion test (SIT) is the most frequently used confirmatory test for diagnosis of PA. However, SIT was limited in hospitalized patients, and was not allowed to be performed in patients with severe uncontrolled hypertension. The captopril challenge test (CCT) can be easily performed in outpatient clinics, but the high false positive rates limited the use of CCT. The aim of our study was to investigate the diagnostic value of the CCT in PA compared with SIT.

 Our study was conducted retrospectively by medical records review in Seoul National University hospital and SMG-SNU Boramae Medical Center from 2011 to 2013. Forty-six patients who had the positive case detection by baseline ARR were subjected to SIT and CCT. A positive SIT was defined as plasma aldosterone concentration (PAC) after SIT over 10 ng/dl. The positive result of CCT to confirm PA was defined if PAC at 60 or 90 minutes after 50 mg of oral captopril did not drop below 12ng/dL.

The sensitivity of the CCT and SIT were 94.3% and 88.6%. The specificity of the CCT and SIT were 54.5% and 81.8%. The accuracy was 84.8% for the CCT and 87.0% for the SIT. The positive likelihood ratios of SIT and CCT were 4.31 and 1.83. The area under the receiver-operating characteristic (ROC) curve was similar in SIT and CCT (0.888 vs. 0.891). The percentage of patients with positive CCT was concordant with that with positive SIT (McNemar test, P=0.125). All patients with PAC after administration of captopril over 25 ng/dl (n=20) were diagnosed with PA. Only one patient with PAC during the CCT below 12 ng/dl was diagnosed with PA.

 The captopril challenge test showed higher sensitivity and lower specificity in diagnosing PA compared with the SIT. Considering the convenience and high sensitivity of the CCT, the patients with PAC during the CCT below 12 ng/dl may not need further confirmatory testing.

 

Nothing to Disclose: KSP, JHK, EJK, ARH, DJP, SHC, CSS, SWK, SYK

14339 18.0000 SAT-0854 A Diagnostic Accuracy of the Captopril Challenge Test in Primary Aldosteronism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Charikleia Stefanaki*1, Dario Boschiero2, Eleni Koromboki3, Nikolaos Zakopoulos3 and George P. Chrousos4
1University of Athens Medical School, Athens, Greece, 2Biotekna, Venice, Italy, 3Athens University Medical School, Athens, Greece, 4University of Athens School of Medicine, Athens, Greece

 

The natural history of essential hypertension entails a sequence of neuro-endocrine alterations in the human body, which possibly result in body composition and compartment changes that can be detected using bio-impedance analyzers (BIA). Indeed, hypertension may be caused by chronically increased activity of the stress axis and/or renin-angiotensin system via pleiotropic mechanisms, including increased vasoconstriction and salt and water retention. This was a pilot, two-Center, case-control, cross-sectional study, whose main aim was to evaluate body composition and compartment changes in patients with newly diagnosed untreated essential hypertension using advanced bioimpedometry (BIA-ACC and TomEEx devices, Biotekna Co, Venice, Italy). Psychometric questionnaires (DASS21 and PSS-14 questionnaires) were also administered. Twenty untreated patients [20] with essential hypertension and twenty [20] normotensive age-, gender- and weight- matched controls agreed to participate after meeting the inclusion criteria of the study. The psychometric scores were in the normal range in our hypertensive patients [MdnDASS21DEPRESSION = 8.40, MdnDASS21ANXIETY = 6.36, MdnDASS21STRESS = 12, MdnPSS14= 33], while their fat mass (Hypertensive group: Mdn = 38, Control group: Mdn = 42.75, U = 117, p = 0.024, r = 0.35) and lean body mass (Hypertensive group: Mdn = 62.00, Control group: Mdn = 57.25, U = 117, p = 0.025, r = - 0.35) were, respectively, lesser and greater than those of the controls. Using, impedometry, hypertensive patients demonstrated major body composition and compartment changes compared to controls. They had intracellular dehydration [IntraCellular Water – ICW (%Weight) - (Hypertensive group: Mdn = 53, Control group: Mdn = 56.86, U = 90, p = 0.0020, r = 0.46)], with increased extracellular water volumes [ExtraCellular Water – ECW (%Weight) - (Hypertensive group: Mdn = 47, Control group: Mdn = 43.14, U = 90, p = 0.0023, r = -0.468)], largely deviating from the control group. They also had major differences in potassium and magnesium homeostasis, with a significant augmentation of extracellular potassium (ECK+) as percent of total body potassium (TBK) (Hypertensive group: Mdn = 2.35, Control group: Mdn = 1.96, U = 72, p = 0.0003, r = - 0.545) and a reduced K+/Mg2+ ratio (Hypertensive group: Mdn = 4.5, Control group: Mdn = 4.63, U = 72, p = 0.0042, r = 0.44). Regional spectroscopy (TomEEx) detected presence of increased water or “inflammation” in the entire abdominal area of the hypertensive group. We speculate that body water compartment shifts from the intracellular to the extracellular space, along with potassium loss and low magnesium may be related to the pathophysiology of hypertension. They may reflect a genetic/epigenetic predisposition to stress and/or renin-angiotensin system hyperactivity and/or action that usually presents with hypertension at mid-age.

 

Disclosure: DB: Chief Scientific Officer, BIOTEKNA. Nothing to Disclose: CS, EK, NZ, GPC

14486 19.0000 SAT-0855 A Major Water and Electrolyte Compartment Shifts in Patients with Newly Diagnosed Essential Hypertension: Complementary Use of Two Advanced Bio-Impedance Analysers 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Mitsuhide Naruse*1, Naomi Matsuo2, Mika Tsuiki3, Kanako Nakao3, Maiko Kakita3, Rieko Nakatani3, Kazutaka Nanba4, Yusuke Hirokawa1, Takeshi Usui3, Tetsuya Tagami3 and Akira Shimatsu3
1Kyoto Medical Center, Kyoto, Japan, 2National Hospital Organization Kyoto Medical Center, Japan, 3National Hospital Organization Kyoto Medical Center, Kyoto, Japan, 4University of Michigan, Ann Arbor, MI

 

Objective: Adrenal venous sampling (AVS) has been recommended as an essential step for subtype classification in patients with PA, especially if the adrenal surgery is considered as treatment (Clinical Practice Guideline, Endocrine Society). Besides the drawbacks of AVS requiring expertise staff in the specialized centers, unstandardized cutoff of diagnosis, potential complications, and reproducibility of the results remain to be solved. The objective of the present study was to investigate the reproducibility of the subtype classification by AVS in PA. Subjects and Methods: Results of AVS data after ACTH loading were obtained for analysis from 16 patients with PA. In these patients, adrenal vein blood samples were obtained more than once from the right adrenal vein to assure the successful sampling during intraprocedural cortisol measurement. Intraprocedural difference of plasma aldosterone concentration (PAC, pg/ml), aldosterone/cortisol (mcg/dl) (A/C) ratio, lateralized ratio (LR), and prevalence of dissociated subtype diagnosis were determined. Data of blood sampling were used only when the catheterization was judged successful from the Selectivity Index larger than 4.0 (44 samples). Results: Intraprocedural difference of PAC (PACmax-PACmin) in the right adrenal vein ranged from 20 to 120000 pg/ml with a median of 6300 (IQR: 1875 to 13088) pg/ml. Percent difference of PAC ([PACmax-PACmin/PACmin]x100) in the right adrenal vein ranged from 0.326 to 3252% with a median of 14.67(IQR: 7.823 to 54.83)%. Difference of A/C ratio and percent difference of A/C in the right adrenal vein ranged from 0.190 to 177.9 with a median of 4.443(IQR: 2.432 to 13.93) and from 1.423 to 2672% with a median of 22.22 (IQR: 12.88 to 60.52) %, respectively. Difference of LR and percent LR ranged from 0.018 to 39.54 with a median of 0.593 (IQR: 0.175 to 3.237) and from 1.423 to 1782.4% with a median of 22.22 (IQR: 12.88 to 60.52) %, respectively. Subtype classification showed a discrepancy of at least one of the multiple determinations in 1/16 patients if LR >2.6 used as a cutoff and 4/16 patients if LR>4.0 used as a cut-off. Conclusion: These results clearly demonstrated that PAC and A/C ratio in the adrenal vein varied in each blood sampling even under successful catheterization. In addition, subtype classification showed discrepant results in some of the PA patients. It is therefore suggested that reproducibility should be considered in the subtype diagnosis before surgical indication.

 

Nothing to Disclose: MN, NM, MT, KN, MK, RN, KN, YH, TU, TT, AS

14604 20.0000 SAT-0856 A Reproducibility of Subtype Classification By Adrenal Venous Sampling in Primary Aldosteronism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Hironobu Umakoshi*1, Tomikazu Fukuoka2, Mayu Minamoto2, Daisuke Utsunomiya2, Maki Yokomoto2, Kazuo Murakami2, Shiori Kondo2 and Mitsuhide Naruse1
1National Hospital Organization Kyoto Medical Center, Kyoto, Japan, 2Matsuyama Red Cross Hospital, Matsuyama, Japan

 

Background: Primary Aldosteronism (PA) is one of the most common causes of curable hypertension. Adrenal venous sampling (AVS) has been recommended as a gold standard testing for subtype classification. However, AVS is available only in limited specialized centers with expertise staffs and is sometimes associated with complications such as adrenal vein rupture and bleeding.In addition, approximately half of the patients are bilateral PA.AVS-sparing approach is therefore clinically important. Sonoyama et al. (JCEM, 2011) have shown that corsyntropin stimulation test with low dose dexamethasone suppression is useful in distinguishing unilateral PA. Objective: The aim of the present study was to provide further evidence for the diagnostic significance of the corsyntropin stimulation test in subtype classification of PA. Patients and Methods: Thirty seven patients with PA who underwent ACTH stimulation test and AVS after corsyntropin loading were included in this study. The subtype classification was determined by the lateralized ratio of 4.0 as a cutoff. The subjects were divided into unilateral PA (n=14) and bilateral PA (n=23).  Corsyntropin stimulation test was performed in the morning after overnight dexamethasone (1mg) suppression. Plasma aldosterone concentrations (PAC) were measured every 30 min over 120 min after i.v. administration of 250mcg of corsyntropin. Results: The peak levels of PAC after corsyntropin stimulation were significantly higher in unilateral PA (720±604.1 pg/ml, p>0.05) than in bilateral PA (276±90.5 pg/ml). Receiver operating characteristic curve analysis showed the AUC was highest at 60 min after corsyntropin stimulation, with the optimal cut off peak PAC levels above 323 pg/ml with sensitivity of 87.5% and specificity of 92.3% for the diagnosis of unilateral PA. Peak PAC levels above 549 pg/ml showed 100% specificity with sensitivity of 38.4%. Conclusions: The present results demonstrated that corsyntropin stimulation test is useful in distinguishing unilateral PA. Corsyntropin stimulation test could be one of the AVS-sparing approaches in PA.

 

Nothing to Disclose: HU, TF, MM, DU, MY, KM, SK, MN

15741 21.0000 SAT-0857 A Corsyntropin Stimulation Test with Low Dose Dexamethasone Suppression Is Useful for Subtype Classification in Primary Aldosteronism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Maiko Kakita*, Mika Tsuiki, Kanako Nakao, Youhei Ueda, Rieko Nakatani, Kazutaka Nanba, Takeshi Usui, Tetsuya Tagami, Akira Shimatsu and Mitsuhide Naruse
National Hospital Organization Kyoto Medical Center, Kyoto, Japan

 

Background: Left ventricular remodeling is one of the most important target organ damages in primary aldosteronism (PA). Aldosterone antagonism in addition to blood pressure control has been recommended to prevent organ damage in PA. Whether aldosterone antagonist is indispensable even if the blood pressure is sufficiently controlled remains to be elucidated. Cornell voltage criteria has been reported to excel the classical Sokolow-Lyon (SL) voltage criteria in detecting electrocardiographic (ECG) left ventricular hypertrophy (LVH) in essential hypertension (EH) (Peter M. et al, 2004) and to correlate well with the left ventricular mass index by ultrasonography in PA (Kuris S. et al, 2013). Aims of the study were 1) to compare the extent of LVH in PA with EH using the ECG-LVH criteria and 2) to elucidate factors affecting the LVH . Subjects and methods: Forty patients with aldosterone-producing adenoma (APA) and age- and sex-matched eighty patients with EH were studied. The diagnosis of APA was surgically confirmed. ECG-LVH determined by Cornell product and SL criteria and clinical manifestation were compared between PA and EH groups. Factors affecting the ECG-LVH were investigated by logistic analysis. Results: Duration of hypertension (8.1±6.9 vs. 5.3±6.7 yrs) was longer (p<0.05) and hypertension severity estimated by a total drug dose (1.3±0.9 vs. 0.5±0.5) was larger (p<0.01) in PA group than EH group. There was a significant positive correlation between the severity of hypertension and Cornell product but not SL criteria in both groups (PA: r2=0.215, p<0.05; EH : r2=0.055, p<0.05). No significant correlation was seen between the duration of hypertension and ECG-LVH. Cornell product was 2159.3±635.5mm•msec in PA and 2020.34±754.78mm•msec in EH. SL criteria was 3.16±1.02mV in PA and 2.99±0.79mV in EH group. Prevalence of ECG-LVH with Cornell product was 30% in PA group and 28.6% in EH group. There was however no significant difference in the extent of ECG-LVH and its prevalence between PA and EH groups. There was a significant positive correlation between PAC and Cornell product in both groups. Conclusions: The present study demonstrated that there was no significant difference in the ECG-LVH between PA and EH groups despite of the different duration of hypertension and severity. It is therefore suggested that development of LVH could be prevented even in PA patients, if hypertension is appropriately controlled by medication.

 

Nothing to Disclose: MK, MT, KN, YU, RN, KN, TU, TT, AS, MN

14451 22.0000 SAT-0858 A Electrocardiographic Left Ventricular Hypertrophy (ECG-LVH) in Primary Aldosteronism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Faryal Sardar Mirza1, Farheen Kassim Dojki*2 and Pamela Taxel3
1Univ of Connecticut Health Center, Farmington, CT, 2University of Connecticut, Farmington, CT, 3Univ of Connecticut Hlth Ctr, Farmington, CT

 

Background and Purpose: The incidence of hypertension (HTN), an important risk factor for cardiovascular disease increases in women after menopause, suggesting that endogenous estrogen may have a beneficial effect on blood pressure (BP) regulation. The purpose of this study was to evaluate the effect of lowering of estrogen to very low levels on BP in postmenopausal women with early stage breast cancer treated with aromatase inhibitors (AIs).

Methods: 33 postmenopausal women starting therapy for early stage breast cancer with AIs (anastrozole, letrozole and exemestane) were evaluated at baseline and at 12 weeks after initiation of treatment with AI therapy. Serum estradiol (E2), estrone (E1), sex hormone binding globulin, lipid panel, C-reactive protein and 24-hr urine sodium (Na) and creatinine (Cr) were measured, along with 24-hr ambulatory BP monitoring at these two time points.

Results: Mean age of the subjects was 60 +/- 7 years and mean BMI was 28 +/- 7 kg/m2. There was a significant increase in the 24-hr systolic blood pressure (SBP) (117 +/- 11 to 120 +/- 11 mm Hg, P = 0.012), diastolic blood pressure (DBP) ( 70 +/- 7 to 72 +/- 6 mm Hg,P = 0.009) and 24-hr mean arterial pressure (MAP) from 87 +/- 7 to 89 +/- 7 mm Hg (P = 0.009) from baseline to 12-weeks after initiation of AI treatment. Similar significant increases were seen in the day time and night time measures of SBP, DBP and MAP. As expected, there was a significant decline in the level of estradiol E2 (17 +/- 11 to 9 +/- 4 pg/ml, P = 0.001) and estrone (38 +/- 16 to 20 +/- 8 pg/ml, P < 0.001). Free estrogen index (FEI) was calculated to adjust for the variability in the sex hormone binding globulin (E1+E2 /SHBG) which also decreased significantly with AI therapy (4 +/- 3 to 2 +/- 2 pmol/nmol, P < 0.001). There were no significant changes in the lipids, inflammatory markers and the 24-hr urinary Na/Cr ratio.

Conclusion: These results suggest that lowering of estrogen levels with aromatase inhibitors in postmenopausal women with breast cancer is associated with an overall increase in BP as measured by the 24-hr ambulatory BP monitoring. These results warrant further testing in a larger clinical trial to verify and determine the long-term impact of these findings.

 

Nothing to Disclose: FSM, FKD, PT

15611 23.0000 SAT-0859 A Effect of Aromatase Inhibitors on 24 Hour Ambulatory Blood Pressure in Postmenopausal Women with Early Stage Breast Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Xiaomu Li*1, Zhiqiang Lu2 and Xin Gao2
1Zhongshan Hospital, Fudan University, China, 2Zhongshan Hospital, Fudan University, Shanghai, China

 

Endocrine hypertension is one of the major causes of secondary hypertension, and adrenal hypertension, including Primary aldosteronism (PA), Cushing’s syndrome (CS) and pheochromocytoma (PCC), is the main subtype of endocrine hypertension. There is a common characteristic of abnormal morphology in adrenal gland among these 3 diseases, which suggests the possibility for adreanal morphology evaluation with CT scan for the screening of adrenal-endocrine hypertension.  In order to explore the this means for screening and diagnosis of adrenal-endocrine hypertension, we used the adrenal thin-section CT scan (3mm sections/slices thick without intravenous contrast administration) as a screening test in 1024 out-clinic patients diagnosed and treated as essential hypertension from the Hypertension Clinic of Zhongshan Hospital, Fudan University, Shanghai, China, 2011-2013. Furthermore, in the patients with adrenal morphologic abnormalities findings, endocrinology screen and confirmatory tests, CT scan with intravenous contrast were performed to make the accurate diagnosis of adrenal-endocrine hypertension. Among the 1024 “essential hypertension” patients, including 424 male and 600 female patients, with the age of 60.9±9.3 year-old, the blood pressure levels of 138±10/87±6 mmHg, and the average hypertension duration of 13.8±5.3 year. After adrenal thin layer scanner CT scan, 100 patients (9.8%) with adrenal lesion were found. After endocrinology functional measurements, a total of 48 cases (4.7%) with functional lesions were diagnosed, including 40 cases (3.9%) for primary aldosteronism, 6 cases (0.6%) for Cushing's syndrome and 3 case (0.3%) for pheochromocytoma. In conclusion, the present results showed a high prevalence of adrenal-endocrine hypertension for 4.7% in this “essential hypertensive” population with well-controlled and long duration of hypertension, by the screening protocol with CT scan as the first-step screening test. Adrenal CT scan may be an effective method to screen and diagnose adrenal-endocrine hypertension. The screening for adrenal-endocrine hypertension will be beneficial for the treatment of patients, provide the appropriate therapies, and prevent the cardiovascular complications for these patients with adrenal-endocrine hypertension.

 

Nothing to Disclose: XL, ZL, XG

14873 24.0000 SAT-0860 A Adrenal CT Scan in the Screen and Diagnosis of Adrenal-Endocrine Hypertension: A Cross-Sectional Study in a Population Diagnosed and Treated As Essential Hypertension 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Sandrine Urwyler*1, Clara Sailer2, Philipp Schuetz3 and Mirjam Christ-Crain1
1University Hospital Basel, Basel, Switzerland, 2Faculty of Medicine, University of Basel, Switzerland, 3Kantonsspital Aarau, Aarau, Switzerland

 

Introduction: The stress hormone copeptin, which is co-secreted with arginine vasopressin, has been shown to reflect individual physical stress levels and to be outcome biomarker in several diseases. Information about the influence of psychological stress on copeptin levels is lacking, but is important for interpretation of copeptin levels in the clinical setting.

Methods: In this prospective observational study we measured copeptin levels in 25 healthy medical students before and after a written medical examination. The primary endpoint was the increase of copeptin levels from immediately prior the examination compared to after the examination. Secondary endpoints were comparison to other stress markers (serum and salivary cortisol).

Results: Of the 25 voluntary medical students (median age 23 years, median BMI 21.9 kg/m2) 15 (60%) were female. The median subjective stress level on the visual analogue scale (VAS) before the examination was 5 (IQR 4, 7) compared to after the examination VAS 3 (2, 3). Median copeptin levels before the examination were significantly higher as compared to copeptin levels after the examination (median (IQR) 3.1 pmol/l (2.4 , 4.3) vs 2.3 pmol/l (2.7, 2.8), p< 0.0001). Also serum cortisol (median (IQR) 561 nmol/l (386, 651) vs 297 nmol/l (235, 327), p< 0.0001) and salivary cortisol levels (median (IQR) 12.5 nmol/l (8.2, 17) vs 6.9 nmol/l (5.7, 8), p<0.0001) were elevated prior the examination compared to after the examination. No correlation between copeptin and cortisol levels could be found.

Conclusion: Psychological stress leads to an increase of copeptin levels although less pronounced than in somatic disease. Psychological stress must therefore be taken into consideration when using copeptin as a biomarker in the clinical setting.

 

Disclosure: PS: Speaker, Thermo Fisher Scientific BRAHMS GmbH. MC: Speaker, Thermo Fisher AG. Nothing to Disclose: SU, CS

14435 25.0000 SAT-0861 A Copeptin As a Stress Marker during a Written Examination the Coexam Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM SAT 0837-0861 4793 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-T/C Poster

Katherine Beckwith-Fickas*1, Sajad Salehi1, Wei Quan How2, DeAsia Gilmer3, Amanda Nwaopara1, Ikeoluwa Adeshina1, Sally Radovick4 and Fredric Edward Wondisford5
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins University School of Medicine, Malaysia, 3Howard University School of Medicine, Washington, DC, 4Johns Hopkins School of Medicine, Baltimore, MD, 5Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ

 

Type 2 diabetes (T2D) typically arises in obese individuals and is characterized by systemic insulin resistance, impaired pancreatic insulin secretion, and inappropriate gluconeogenesis.  The newly discovered hormone betatrophin, found in liver and adipose tissue, induces β cell proliferation and increases plasma insulin levels in leptin and leptin receptor-deficient mice. The role of betatrophin in less severe and more physiological insulin resistant states, such as diet-induced obesity (DIO) is not known.  In addition, it is not known if expression of betatrophin is modulated by anti-diabetes agents such as metformin. To study the effects of obesity and metformin on betatrophin expression, we generated DIO mice using male C57BL/6J mice fed a 60% high fat diet (HFD, Research Diets) for 15 weeks. Using 6 mice in each group, DIO mice were given metformin for 3 weeks at 12.5 mg/kg body weight, 25 mg/kg body weight, or 50 mg/kg body weight in the drinking water.  Age-matched mice fed a regular diet were also assessed.  Glucose intolerance was confirmed in DIO mice by glucose tolerance testing (p < 0.05). Quantitative RT-PCR results indicate that betatrophin is expressed in liver and adipose tissue in lean and DIO mice. Compared to lean mice, DIO mice exhibited significantly higher betatrophin expression in visceral fat, subcutaneous fat, and brown fat (p < 0.05).  There was no difference in expression in the liver between DIO and lean mice. DIO mice treated with metformin for 3 weeks did not show significant differences in betatrophin expression in liver compared with controls.  However, metformin treated DIO mice showed significantly lower betatrophin expression in visceral and brown fat that was dose responsive compared to control treated DIO mice (p < 0.05). These results indicate that levels of betatrophin in fat tissue from DIO mice correlate negatively with glucose tolerance.  Levels of betatrophin in fat tissue are subsequently decreased by metformin in a dose response manner.  This study suggests a novel role for metformin in the control of pancreatic β cell proliferation in an obese mouse model.

 

Nothing to Disclose: KB, SS, WQH, DG, AN, IA, SR, FEW

16116 2.0000 SAT-1053 A Betatrophin Expression in a Diet Induced Obesity (DIO) Mouse Model Treated with Metformin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Maria Silvia Bianchi*1, Alejandro Montaner2, Leandro Martinez1, Stefania Bianchi1, Norma Alejandra Chasseing1, Carlos Libertun3 and Victoria A Lux-Lantos3
1IBYME-CONICET, Buenos Aires, Argentina, 2Fundación Pablo Cassará (ICT Milstein-CONICET), Buenos Aires, Argentina, 3Instituto de Biología y Medicina Experimental, CONICET, Buenos Aires, Argentina

 

IMT504, the prototype of the PyNTTTTGT class of immunomodulatory oligonucleotides, accelerates tissue repair in models of bone injury and sciatic nerve crush. In addition, we have previously shown that IMT504 induces a marked recovery of single-dose streptozotocin (STZ)-induced toxic diabetes in male rats that correlates with early expression of progenitor cell markers (1), without altering immune parameters (2).IMT504 also improves the diabetic condition in an autoimmune diabetes model induced by multiple low doses of STZ in mice (MLDZ), evaluated 25 days after the end of IMT504 treatment. Here, we evaluated the early effects of IMT504 in MLDZ diabetic mice and its mechanism of action.

Male Balb/C mice were ip-injected with STZ (40mg/kg) for 5 consecutive days or diluent as control (C). STZ mice with blood glucose ≥ 250 mg/dl and controls were daily sc-injected with IMT504 (IMT: 20mg/kg/dose) (STZ-IMT, C-IMT, respectively) or saline (STZ, C) and killed after two consecutive decreases in glycemia in STZ-IMT mice (2-5 doses of IMT). Blood samples and pancreases were collected for hormonal/cytokine determinations and histological studies.

The prompt normalization observed in STZ-IMT blood glucose [glycaemia at sacrifice (mg/dl): C=137±14, C-IMT: 103±8, STZ: 352±41*, STZ-IMT: 145±9, * different from all: p<0.001] was accompanied by a decrease in apoptosis rate (apoptotic positive cells/total islets: C: 0.05±0.03*, C-IMT: 0.18±0.05, STZ: 0.70±0.23*, STZ-IMT: 0.37±0.13, *: p<0.01) without changes in the number of islets/pancreas area between the animal groups. Furthermore, a change in cytokine profile was accompanied by a clear reduction of leukocyte infiltration in and around islets and by an increase in indolamine 2,3-dioxigenase expression (IDO positive islets/total islets: C: 0.41±0.13, C-IMT: 0.49±0.19, STZ: 0.72±0.31, STZ-IMT: 0.93±0.07*, *: significantly different from C and C-IMT, p<0.03).

Taken together, these results suggest that IMT504 promotes rapid blood glucose normalization by modulating the immune system and preserving/recovering pancreatic islets.

 

Nothing to Disclose: MSB, AM, LM, SB, NAC, CL, VAL

14633 3.0000 SAT-1054 A Early Improvement in Type I Diabetes in Mice By Oligodeoxynucleotide IMT504 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Valerie N Babinsky*1, Fadil M Hannan1, M Andrew Nesbit1, Alison Hough2, Liz Bentley2, Tertius A Hough2, Elizabeth Joynson2, Michelle Stewart2, Sara Wells2, Duncan Richards3, Roger D Cox2 and Rajesh V Thakker1
1University of Oxford, Oxford, United Kingdom, 2MRC Harwell Mammalian Genetics Unit, United Kingdom, 3GlaxoSmithKline Clinical Unit, United Kingdom

 

The G-protein coupled calcium-sensing receptor (CaSR) is a pivotal regulator of extracellular calcium homeostasis. The CaSR is also expressed in pancreatic beta cells, where it has been shown to regulate insulin secretion in vitro. However, the role of this receptor in glucose homeostasis is unknown. We investigated a mouse model, known as Nuf, with an activating CaSR mutation (Leu723Gln) to determine whether abnormal CaSR function in vivo affects glucose tolerance, and to assess whether a CaSR-targeted drug may rectify any alterations of plasma glucose concentrations. All studies were conducted in accordance with institutional welfare guidelines. A glucose tolerance test was performed by administering a 2g/kg intraperitoneal glucose bolus to fasted mice (N=6-9 mice per group) and collecting blood samples at 0 and 30 mins. Plasma glucose and insulin concentrations were measured using an Analox glucose analyser and Milliplex mouse immunoassay, respectively. Glucose tolerance testing revealed adult homozygous male and female Nuf mice (Nuf/Nuf) to have significantly raised plasma glucose concentrations (male glucose = 31.2±2.9 vs 19.8±1.7 mmol/L, P<0.01; female glucose = 23.5±2.2 vs 14.5±0.8 mmol/L, P<0.01) and reduced plasma insulin concentrations (male insulin = 0.50±0.03 vs 0.85±0.08 ng/mL, P<0.01; female insulin = 0.54±0.05 vs 0.74±0.05 ng/mL, P<0.01) when compared to wild-type littermates at 30 mins. We next evaluated the effect of the selective CaSR antagonist ronacaleret on the impaired glucose tolerance of Nuf mice. A dose ranging study demonstrated that 90mg/kg of ronacaleret administered twice daily by oral gavage over 5 days was tolerated by Nuf mice and successfully increased plasma calcium concentrations. Age-matched male and female Nuf mice were randomised to receive either ronacaleret or drug vehicle (N=7-11 mice per group) using the 90mg/kg dosing regimen. Administration of ronacaleret over 5 days lowered plasma glucose concentrations in male and female Nuf/Nuf mice (male treatment group glucose = 21.4±3.0 vs 32.8±2.9 mmol/L, P<0.05; female treatment group glucose = 13.7±1.9 vs 18.1±1.8 mmol/L, P<0.05) compared to Nuf/Nuf mice receiving drug vehicle only. Thus, ronacaleret-treated Nuf mice displayed glucose concentrations that were not significantly different from wild-types. These findings demonstrate that the CaSR is a determinant of glucose homeostasis and novel target for the modulation of plasma glucose concentrations.

 

Disclosure: VNB: Researcher, GlaxoSmithKline. FMH: Researcher, GlaxoSmithKline. DR: Employee, GlaxoSmithKline. RVT: Researcher, GlaxoSmithKline. Nothing to Disclose: MAN, AH, LB, TAH, EJ, MS, SW, RDC

12465 4.0000 SAT-1055 A A Targeted Agent Rectifies the Impaired Glucose Tolerance Associated with a Calcium-Sensing Receptor Gain-of-Function Mouse Model 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

LuGuang Luo*, Souriya Vang and Johnny Luo
Roger Williams Medical Center, Providence, RI

 

Pancreatic islet dysfunction in Type I and some cases of Type II diabetes results in hyperglycemia due to decreased insulin production.  Although islet transplantation has been proposed as a long-term solution, immune rejection as well as apoptosis resulting from the tissue harvesting process has presented significant challenges.

Apoptosis can result from exogenous pathways through the trans-membrane FAS receptors, endogenous pathways through the release of cytochrome C by the mitochondria, and be mediated by miRNAs, which are small non-coding RNAs that are involved in the regulation of mRNAs.

The application of human bone marrow has been shown to increase islet function.

We hypothesize that a significant mechanism contributing to bone marrow’s effect on islet longevity is due to an anti-apoptosis effect on both external and internal pathways.

Human islets were co-cultured with human bone marrow in vitro.  Insulin secretion and response to high glucose was measured as an indicator of islet function.  Gene expression studies were performed to measure the levels of apoptosis factors in culture and miRNA expression was also performed to measure correlation with apoptosis factors.   

Human islets co-cultured with bone marrow showed to have sustained insulin function.  Anti-apoptosis factor BCL-2 gene expression was up regulated (5.55 fold increase co-culture vs. islet only, n=3 p<0.05, day 5), pro-apoptosis factor Fas was down regulated (5.8 fold decrease co-culture vs. islet n=3 p<0.05, day 5), and mir-146a showed to have increased transcription levels (12.64 fold increase, co-culture vs. islet only n=3 p<0.05, day 5).

A target site for mir-146a is in the 3’UTR of Fas mRNA, suggesting that mir-146a can down regulate Fas and thus Fas mediated apoptosis through the external pathway.  In addition, the increase in Bcl-2 suggests that bone marrow is also capable of reducing apoptosis through the internal pathway.  Results indicate that one mechanism of bone marrow’s effects on islets is through reducing apoptosis through regulation both pro and anti apoptosis factors and that the effects may occur on a post-transcriptional level.

 

Nothing to Disclose: LL, SV, JL

16842 5.0000 SAT-1056 A Effects of Human Bone Marrow on Human Islet Survival: Reducing Apoptosis on a Post-Transcriptional Level 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Senthil Senniappan*1, Nina Tatevian2, Sanda Alexandrescu2, Pratik Shah3, Ved Bhushan Arya3, Sarah Flanagan4, Sian Ellard4, Dyanne Rampling3, Michael Ashworth3, Robert Brown2 and Khalid Hussain5
1Alder Hey Childrens Hospital, Liverpool, United Kingdom, 2UT Health-Medical School at Houston, 3Great Ormond Street Hospital, London, 4University of Exeter Medical School, United Kingdom, 5Sidra Medical & Research Center, Qatar

 

Congenital hyperinsulinism (CHI) is the commonest cause of recurrent and persistent hypoglycaemia in infants. Histologically there are two distinct types: focal and diffuse. The medical therapy for diffuse CHI involves diazoxide, glucagon and octreotide. The patients who are unresponsive to medical therapy require a near total pancreatectomy. However, this often fails to provide the best outcome as some patients continue to have recurrent hypoglycaemia whilst others develop diabetes mellitus in the long term.

We aimed to understand the gene expression pattern in the pancreatic tissues of the patients with diffuse CHI so as to identify novel mechanism(s) and therapeutic options. Gene expression microarray using RNA extracted from six fresh frozen pancreatic tissue samples (obtained from children who underwent pancreatectomy) revealed significant overexpression of mammalian target of rapamycin (mTOR) and insulin-like growth factors in the diffuse CHI patients in comparison with normal controls. Immunostaining suggested an activation of mTOR pathway (which regulates cellular proliferation) in diffuse CHI and transdifferentiation of exocrine pancreatic elements into insulin producing cells, contributing to β-cell hyperplasia.

The use of mTOR inhibitor sirolimus was studied in 8 infants with medically unresponsive diffuse CHI (who would have required pancreatectomy otherwise). The genetic aetiology in these patients included homozygous ABCC8 mutation (x3), maternal ABCC8 mutation (x2), paternal ABCC8 mutation (x1), compound heterozygous ABCC8 mutation (x1) and no identified mutation (x1). 7 out of the 8 infants responded to sirolimus therapy (average dose 3mg/m2/day) and were able to come off intravenous fluids and glucagon infusions thereby preventing the need for a major surgery. Subsequent follow up (range 4 to 16 months) revealed that the patients were normoglycaemic on sirolimus (with or without concomitant octreotide therapy).  One infant with homozygous ABCC8 mutation did not respond to sirolimus therapy. Transient elevation of liver enzymes and triglycerides were noted in some patients but there were no major side effects.

Treatment with mTOR inhibitors offers an alternative therapeutic option for the patients with severe forms of diffuse CHI thereby preventing the need for near total pancreatectomy. Further studies are required to assess the long term safety and efficacy of mTOR inhibitors in the management of diffuse CHI.

 

Nothing to Disclose: SS, NT, SA, PS, VBA, SF, SE, DR, MA, RB, KH

PP01-1 14944 6.0000 SAT-1057 A The Activation of Mtor Pathway As Revealed By Gene Expression Profiling and the Role of Mtor Inhibitors in Congenital Hyperinsulinism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Sung Hoon Yu*1, Dong Hyun Kang1, Jung Hun Ohn1, Juri Park1, Jun Goo Kang1, Ohk Hyun Ryu1, Chul Sik Kim1, Seong Jin Lee1, Eun Gyung Hong1, Doo-Man Kim1, Sung-Hee Ihm1, Jae Myung Yu1, Moon Gi Choi1, Hyung Joon Yoo1 and Dong-Sun Kim2
1College of Medicine, Hallym University, Seoul, Korea, Republic of (South), 2College of Medicine, Hanyang University, Korea, Republic of (South)

 

Introduction

The proliferation of vascular smooth muscle cells (VSMCs) plays a crucial role in atherosclerosis. Gemigliptin is fifth DPP-4 inhibitor to treat patients with diabetes in the world. DPP-4 inhibitors have a wide variety of pharmacological activities, however there are not sufficient data in vascular smooth muscle cells (VSMCs) proliferation by intermittent hyperglycemia. In this study, we demonstrated that the effect of gemigliptin on the proliferation of VSMCs with glucose fluctuations .

Methods

Primary cultures of male Otsuka Long-Evans Tokushima fatty (OLETF) rat VSMCs were obtained from enzymatically dissociated rat thoracic aorta. VSMCs with gemigliptin (100 μM) were incubated for 72 h with alternating normal (4.8 mmol/L) and high glucose (24.5 mmol/L) media every 12 h. The proliferation of VSMCs, proliferative molecular pathway (including p44/42 MAPK, MEK, p38, JNK, Akt) and apoptotic pathway were analyzed with gemigliptin.

Results

We found enhanced proliferation of VSMCs incubated with intermittent high glucose medium compared to normal glucose media using the methylthiazoletetrazolium assay (relative ratio 1.95 ± 0.11 vs. 1.00 ± 0.08, p < 0.05). However, the proliferation of VSMCs with intermittent glucose was decreased with gemigliptin treatment (relative ratio 0.97 ± 0.11 vs. 1.95 ± 0.11, p < 0.05). In Western blot analysis, treatment with intermittent high glucose for 72 h increases phospho-p44/42 MAPK(ERK1/2), phospho MEK1/2, phopspho p38 MAPK, PI3 kinase expression compared to treatment with normal glucose. These effects were suppressed with gemigliptin. In the apoptotic pathway, Bcl-xl, Bcl-2, phospho-Bad, and caspase-3 were not affected by glucose fluctuations or gemigliptin for 72 h.

Conclusions

Glucose fluctuations increased the proliferation of OLETF rat VSMCs via the MAPK (ERK1/2, p38 MAPK) and PI3 kinase pathway. These effects were inhibited by antidiabetes agent gemigliptin.

 

Nothing to Disclose: SHY, DHK, JHO, JP, JGK, OHR, CSK, SJL, EGH, DMK, SHI, JMY, MGC, HJY, DSK

13507 8.0000 SAT-1059 A The Effect of Gemiglipitin on the Proliferation of Rat Aortic Vascular Smooth Muscle Cells with Glucose Fluctuations 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Sivaporn Sivasinprasasn*, Piangkwan Sa-nguanmoo, Wasana Pratchayasakul, Krekwit Shinlapawittayatorn, Siriporn C Chattipakorn and Nipon Chattipakorn
Chiang Mai University, Chiang Mai, Thailand

 

Women have a lower incidence of cardiovascular diseases than men at a similar age but the incidence is increased after the onset of menopause.(1)  Moreover, women also have increased prevalence of metabolic syndrome following menopause, suggesting the possible protective effect of estrogen on cardiometabolic function.(2)  Although obesity is known to increase cardiovascular risks, its impact in combination with estrogen deprivation on the heart is still inconclusive.  Thus, we investigated the effects of high-fat diet-induced obesity (i.e. obese-insulin resistance) combined with estrogen deprivation on cardiac autonomic balance, mitochondrial function and cardiometabolic parameters in ovariectomized rats.  In the present study, adult female ovariectomized (O) or sham (S) operated rats were randomly received either normal diet (ND, 19.77% fat) or high-fat diet (HF, 57.60% fat) (n= 6-10/group) for 12 weeks.  The heart rate variability (HRV), left ventricular (LV) function and metabolic parameters were determined at 4, 8 and 12 weeks.  Cardiac mitochondrial functions including mitochondrial reactive oxygen species (ROS) production, mitochondrial swelling, and mitochondrial membrane potential changes were determined.

Insulin resistance was developed at 8 weeks in ND-fed ovariectomized rats (NDO), HF-fed sham rats (HFS) and HF-fed ovariectomized rats (HFO) as indicated by increased plasma insulin levels with euglycemia, increased OGTT and HOMA index.  However, only HFO had elevated plasma cholesterol level at 8 weeks, whereas HFS had increased cholesterol at 12 weeks.  Moreover, only HFO rats had depressed HRV and impaired LV functions as indicated by the significant decrease in fractional shortening (%FS) as early as 8 weeks, whereas other groups exhibited these disorders at 12 weeks.  Cardiac mitochondrial dysfunction demonstrated by mitochondrial membrane depolarization, increased ROS production and augmented mitochondrial swelling, was also earlier initiated in HFO (at 8 weeks) than NDO and HFS (at 12 weeks). 

The findings in this study indicate that either endogenous estrogen depletion or obesity alone impaired metabolic parameters, LV performance and cardiac mitochondrial and autonomic functions.  However, high-fat diet-induced obesity in combination with estrogen deprivation further accelerated the development of cardiometabolic impairments in female rats.

 

Nothing to Disclose: SS, PS, WP, KS, SCC, NC

13641 9.0000 SAT-1060 A High-Fat Diet Consumption Accelerated the Development of Cardiac Mitochondrial Impairments and Metabolic Disorders in Estrogen-Deprived Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Yoswaris Semaming*, Jantira Sanit, Sirinart Kumfu, Nattayaporn Apaijai, Wanpitak Pongkan, Tharnwimol Inthachai, Siriporn C Chattipakorn and Nipon Chattipakorn
Chiang Mai University, Chiang Mai, Thailand

 

Cardiac complication is the most common serious complication of diabetes mellitus, and that oxidative damage has been shown to play important roles in the occurrence and development of cardiac dysfunction (1, 2). Protocatechuic acid (PCA) is a phenolic compound, a main metabolite of anthocyanin, found in many plants such as Hibicus sabdariffa Linn., and has been reported to exert antidiabetic and antioxidant activities (3). In the present study, we investigated the effects of PCA on metabolic status, cardiac contractile function and cardiac mitochondrial function in streptozotocin (STZ)-induced diabetic rats. Male Sprague-Dawley rats were induced to be a type 1-diabetes (T1DM) by a single intraperitoneal injection of 50 mg/kg STZ. At 10 days after STZ injection, T1DM rats were divided into 5 groups (n=8/group) to receive the following: oral administration of vehicle, or PCA at 50 or 100 mg/kg/day, or subcutaneous injection of insulin (4 U/kg/day), or a combination of PCA 100 mg/kg/day and subcutaneous injection with insulin (4 U/kg/day) for 12 weeks.  Normal control rats were received vehicle orally.  The echocardiography and heart rate variability (HRV) were measured every 4 weeks together with blood sampling from tail vein to measure FBG, insulin and malondialdehyde (MDA) levels.  At the end of treatment, cardiac mitochondrial function was carried out.  The results showed that T1DM rats were characterized by hyperglycemia, weight loss, decreased plasma insulin level, increased plasma MDA level, depressed HRV as indicated by increased low-frequency to high-frequency (LF/HF) ratio, and cardiac dysfunction as shown by decreased ejection fraction (EF) and decreased %fractional shortening (%FS).  Cardiac mitochondrial dysfunction was indicated by increased ROS production, mitochondrial depolarization and mitochondrial swelling.  Beginning at week 4 of insulin treatment, and at week 8 of PCA treatment at both doses, significantly improved metabolic parameters, including reduced FBG levels, decreased plasma MDA levels, and significantly improved cardiac function as shown by increased EF and %FS, and decreased LF/HF ratio were observed.  However, the improvement of cardiac mitochondrial dysfunction in T1DM rats was observed in week 12 in all treatment groups.  Our results demonstrated for the first time the efficacy of PCA in improving cardiac function and cardiac autonomic balance, and preventing cardiac mitochondrial dysfunction in STZ-induced diabetic rats.

 

Nothing to Disclose: YS, JS, SK, NA, WP, TI, SCC, NC

14292 10.0000 SAT-1061 A Protective Effects of Protocatechuic Acid on Cardiac Function, Heart Rate Variability, and Cardiac Mitochondrial Function in Streptozotocin-Induced Diabetic Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Ju Hee Lee*1, Ye Eun Kang1, Ji Min Kim1, Hyun Jin Kim1, Koon Soon Kim1, Jung Uee Lee2 and Bon Jeong Ku1
1Chungnam National University Hospital, Daejeon, Korea, Republic of (South), 2Daejeon St. Mary's Hospital, The Catholic University of Korea, Daejeon, Korea, Republic of (South)

 

Atherosclerosis remains a leading cause of death and morbidity in developed societies. Although advances in vascular interventions improve the mortality of cardiovascular disease, neointimal hyperplasia remains clinically significant obstacles limiting the success of vascular interventions. Identification of signaling pathways involved in migration and proliferation of vascular smooth muscle cells(SMCs) is an important approach in development of modalities to combat this syndrome. Mig-6 is an immediate early response gene that can be induced by various mitogens, stresses and hormones. The cytoplasmic protein MIG-6 interacts with and inhibits the kinase domains of epidermal growth factor receptor(EGFR). Mig-6 is also known to regulate cholesterol homeostasis recently. However, the role of Mig-6 in vascular biology is remains unknown. To investigate the role of Mig-6 in the development of atherosclerosis or neointimal hyperplasia, we generated conditionally ablated Mig-6 in the vascular smooth muscle using transgelin-Cre (TaglnCreMig-6f/f; Mig-6d/d). We provided endoluminal injury to the one side of femoral artery by balloon dilatation in Mig-6d/d and Mig-6f/f mice. At 4 weeks after injury, no difference in morphology was noted in uninjured arteries. However, Mig-6d/d vessel demonstrated a 5.3-fold increase in the neointima/medial ratio compared to Mig-6f/f vessel(p=0.04). Phosphor EGFR from cultured vascular SMCs was increased in Mig-6f/f mice compared to Mig-6d/d mice in western blot analysis. Transfection with siMig-6 in human vascular SMCs also significantly increased phosphorylation of EGFR. In the migration assay, Mig-6d/d vascular SMCs showed 2.5-fold increased migration compare to the cells from Mig-6f/f mice(P<0.001) In addition, the Mig-6 knockout vascular SMCs also showed a 1.5-fold increased proliferation compared to wild-type cells(p<0.001). The Mig-6 ablated human vascular SMCs by siRNA also showed increase of migration and proliferation compared to the wild type. To verify the role of Mig-6 in human atherosclerosis, we examined the human atherosclerotic artery by immunohistochemistry. The Mig-6 expression of the atherosclerotic artery is decreased in the smooth muscle fiber compared to the normal artery. We are hopeful that this information will provide new insight into developing more effective ways to treat and prevent atherosclerosis, especially in-stent restenosis after percutaneous vascular intervention.

 

Nothing to Disclose: JHL, YEK, JMK, HJK, KSK, JUL, BJK

15790 11.0000 SAT-1062 A Mig-6 Plays a Critical Role in the Development of Atherosclerosis Associated with Neointimal Hyperplasia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Tae-Hwa Chun*1, Richard Barnes II2 and Mayumi Inoue1
1Univ of Michigan, Ann Arbor, MI, 2University of Michigan

 

CD36 (also known as fatty acid translocase, FAT) and CD47 (also known as integrin associated protein, IAP) are the downstream targets of thrombospondin-1 (THBS1 or TSP-1). THBS1 plays the major role in high-fat diet induced obesity, insulin resistance, and muscle fibrosis (Inoue et al., Endocrinology 2013). To delineate the molecular pathways directed by THBS1 in obesity and diabetes, we assessed the role of Cd36 or Cd47 in diet-induced obesity and diabetes. [Method/Result] Eight-wk-old male C57BL/6J mice (WT) and age- and sex-matched Cd36-/- (Cd36KO) or Cd47-/- (Cd47KO) mice were fed low-fat chow diet (LFD), short high-fat diet (HFD) (3 weeks), or long HFD (6~8 weeks). On LFD, no significant difference in weight was observed between WT and Cd36KO mice (WT 24.8 ±0.4 g, KO 24.0 ±0.5 g). During 3-wk-HFD, however, WT mice gained 22% of the initial weight, whereas Cd36KO gained only 5%. Oxygen consumption - VO2 (ml/kg lean mass/hr), RER, or total activity during 3-wk-HFD was not different between WT and Cd36KO mice. Cd47KO mice displayed no significant difference in weight compared to age- and sex-matched WT mice on LFD (WT 24.4±0.7 g, Cd47KO 24.4 ±0.6 g). On HFD, Cd47KO mice gained 25% of weight in 3 weeks, which was comparable to that of WT mice. Consistent with the weight change observed, the fat pads isolated from Cd36KO mice weighed 50% less relative to WT; however, the fat pads from Cd47KO mice weighed the same as WT mice. WT mice developed fasting hyperglycemia and impaired glucose tolerance in 8 weeks of HFD. Cd36KO mice, however, displayed significantly lower fasting blood glucose and insulin levels coupled with markedly improved glucose tolerance (fasting glucose, WT 164 ±8 mg/dL vs. Cd36KO 123 ± 4 mg/dL; fasting insulin, WT 48±6 vs. Cd36KO 12±2 mU/L). On the other hand, after 6 weeks of HFD, Cd47KO mice displayed significantly higher fasting glucose level as well as elevated peak and 2 hour glucose levels during i.p. glucose tolerance test (fasting, WT 109±7 vs. Cd47KO 131±8 mg/dL; at 15 minutes, WT 169±8 vs. Cd47KO 224±10; at 2 hour, WT 96±9 vs. Cd47KO 137±5). [Conclusion] THBS1 exerts pleiotropic effects on multiple target organs. Our study suggests that the loss of Cd36 is beneficial for obesity and diabetes, whereas the loss of Cd47 leads to impaired glucose tolerance with minimal effects on weight. These results suggest the presence of complex interplay among the effectors of THBS1 in the regulation of obesity and diabetes.

 

Nothing to Disclose: THC, RB, MI

15370 13.0000 SAT-1064 A Opposing Roles Played By CD36 and CD47 in Obesity and Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Chesinta B Voma*1 and Andrea M P Romani2
1Cleveland State University, Brooklyn, OH, 2Case Western Reserve Univ, Cleveland, OH

 

Magnesium (Mg2+) deficiency has been correlated with the onset and progression of several pathological conditions including diabetes, and obesity. The current western diet is approximately 35% deficient in Mg2+. The effect of Mg2+ deficiency on hormonal physiological control has not been fully elucidated, and we continue to interpret the serum concentrations relative to urinary Mg2+ excretion. This is further complicated by the fact that the principal reservoir of Mg2+ (i.e., the bone) is not readily exchangeable with circulating Mg2+ in the extracellular space. Thus in states of a negative Mg2+ balance, initial losses come from the extracellular space since equilibrium with bone stores does not begin for several weeks.

Clinical and experimental evidence indicates several hormones including insulin regulate whole body Mg2+ homeostasis by controlling absorption, renal secretion and transport in-and out of cells. Within the cell, including the hepatocyte, Mg2+ is highly concentrated within organelles including the endoplasmic reticulum, in which 15-20 mM [Mg2+]Total has been measured. H6PD, the reticular counterpart of the cytosolic G6PD, is the main NADPH generating enzyme within the endoplasmic reticulum of the hepatocyte and is regarded as an ancillary enzyme in pre-receptor glucocorticoid activation. NADPH-dependent 11β-HSD1 generates cortisol from its inactive form cortisone, thus eliciting high intra-hepatic active glucocorticoid concentrations, which in turn affect hepatocyte metabolism and response to insulin. Low Mg2+ has been associated with insulin resistance and obesity. Yet, no clear cause-effect relationship has been identified. In this study we have tested the hypothesis that Mg2+depletion alters hepatic metabolism and hormonal response via an increased reticular production of cortisol, leading to the onset of obesity, insulin resistance, and diabetes.

                To this end, HepG2 cells were grown in the presence of 0.6 (deficient) or 1.0 mM (physiological) [Mg2+ ]o and analyzed for NADPH and  11β-HSD1-mediated cortisol production. In addition, H6PD, G6Pase, and 11β-HSD1 expression levels were analyzed by RT-PCR and Western Blot analysis. Insulin responsiveness was assessed as pAKT level by Western Blot analysis.  Our results indicate that NADPH production increased by ~60% in Mg2+ deficient cells, and resulted in increased cortisol production. In addition, Mg2+deficient cells showed 3 to 4 fold increase in H6PD and 11β-HSD1 mRNA and protein expression.

                Taken together, our results support the hypothesis that Mg2+ deficiency increases H6PD activity and expression, setting the conditions for increased production of cortisol and decreased insulin responsiveness within the hepatocyte.

 

Nothing to Disclose: CBV, AMPR

14052 14.0000 SAT-1065 A Increased NADPH and Cortisol Production in Mg2+ Deficient HepG2 Cells: Implications for Obesity and Diabetes Onset 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Huxing Cui*1, Donald A Morgan2, Kamal Rahmouni3 and Michael Lutter4
1University of Iowa Carver College of Medicine, Iowa City, 2University of Iowa Carver College of Medicine, 3University of Iowa Carver College of Medicine, Iowa City, IA, 4University of Iowa, Iowa City, IA

 

The incidences and prevalence of obesity and associated disorders, such as diabetes and hypertension, are increasing worldwide. While there is a general consensus that the central nervous system (CNS) mechanisms play a key role in these processes, the underlying neural substrates remain to be fully understood. Central melanocortin signaling, mainly via acting on melanocortin-4 receptor (MC4R), is thought to be a key downstream target of leptin’s action in the brain to maintain energy balance and glucose homeostasis and to activate the sympathetic nervous system. Loss of function of MC4R in both humans and rodents develop severe obesity and diabetes. MC4Rs are widely expressed in the CNS, including certain hypothalamic nuclei that are known to be involved in the regulation of energy balance, glucose metabolism and sympathetic outflow, such as paraventricular nucleus, dorsomedial nucleus and lateral hypothalamic area (LHA). Understanding the individual function of MC4R expression in different brain circuits may help to identify a way to effectively combat obesity, diabetes and hypertension. The LHA, which is directly innervated by leptin-responsive pro-opiomelanocortin neurons in the arcuate nucleus of hypothalamus and express MC4R, is a historically recognized ‘feeding center’ in the brain to regulate multiple physiological processes including food intake, reward-related behaviors and autonomic function. We have previously reported that LHA MC4R-expressing neurons are co-expressed with anoretic peptide neurotensin and functionally active form of leptin receptor, which suggests that this subpopulation of LHA neurons could be metabolically important [1]. Here, by using a Cre-dependently reactivatable MC4R-null (MC4R-TB) mouse line, we further show that restoration of MC4R signaling specifically in the LHA has no measurable effects on food intake and body weight on both high fat diet and regular chow, but significantly improves glucose intolerance seen in MC4R-TB mice without affecting circulating insulin, glucagon and leptin levels as well as insulin sensitivity in peripheral metabolic organs such as brown adipose tissue (BAT), soleus muscle and liver. Whole body 18F-FDG PET/CT scanning identify the BAT as a primary source where glucose uptake is facilitated by activating MC4R signaling specifically in the LHA. Direct multifiber recording of sympathetic nerve activity (SNA) further demonstrate that the SNA subserving the BAT is increased upon activation of LHA MC4Rs. These results suggest that sympathetic activity driven by LHA MC4R signaling is capable for effective disposal of blood stream glucose without altering energy balance.

[1] Cui H, Sohn JW, Gautron L, Funahashi H, Williams KW, Elmquist JK, Lutter M. Neuroanatomy of melanocortin-4 receptor pathway in the lateral hypothalamic area. J Comp Neurol. 2012; 520(18):4168-83.

 

Nothing to Disclose: HC, DAM, KR, ML

12224 15.0000 SAT-1066 A Body Weight Independent Regulation of Glucose Metabolism and Sympathetic Activity By Melanocortin 4 Receptor Signaling in the Lateral Hypothalamus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Isabel Andrea Garcia-Tornadu*1, Victoria Sundblad1, Nicolás Gilio1, Gabriel Adrián Rabinovich1 and Damasia Becu-Villalobos2
1IBYME-CONICET, Buenos Aires, Argentina, 2Instituto de Biologia y Medicina Experimental CONICET, Buenos Aires, Argentina

 

Type 2 diabetes is a disease of impaired glucose homeostasis and insulin action with an etiology that encompasses genetic, cellular and environmental factors. Recent observations suggest that a deficiency of beta cell protein glycosylation and glucose transport may underly a pathogenic pathway leading to diabetes. It has been proposed that galectins, a family of endogenous glycan-binding proteins, may stabilize glucose transporters of beta cells at the cell surface, extending their half-life. In this context, we studied the effect of disruption of galectin 1 on glucose homeostasis and insulin sensitivity using galectin 1 (Gal1-/-) knockout mice. Body weight and food intake were increased at 2 and 6 months of age in female Gal1 -/- mice. Fasted glucose levels were high in 6 month old females (p < 0.04), and glucose intolerance to an ip administration of 2g/kg was evidenced. On the other hand, insulin sensitivity was preserved, but already at 2 months of age fasted serum insulin levels were decreased and glucose (3g/kg) -stimulated insulin secretion was greatly diminished in the female mutant model. Blunted response correlated with an increase in pancreatic insulin content at 2 and 6 months of age (P<0.02). Surprisingly, male Gal1-/- mice presented normal body weight, food intake, and glucose tolerance. These results point to an altered insulin secretory response in the transgenic mouse, and highlight a sex-biased contribution of galectin 1 to critical biological events which regulate glucose homeostasis.

 

Nothing to Disclose: IAG, VS, NG, GAR, DB

13927 16.0000 SAT-1067 A Disruption of Galectin-1 Impairs Glucose Homeostasis and Increases Food Intake in Female Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Ana Beatriz Emiliano*1, Nermarie Velazquez2, Nicholas Socci3, Melis Atalar4, Randy Seeley5 and Jeffrey M Friedman6
1Rockefeller University, New York, NY, 2Duke University School of Medicine, Durham, NC, 3Memorial Sloan Kettering Cancer Center, New York, NY, 4Bilkent University, Ankar, Turkey, 5Univ of Cincinnati, Cincinnati, OH, 6HHMI/Rockefeller Univ, New York, NY

 

Data from human bariatric surgery studies show that blood glucose level generally falls within days of the operation. The mechanisms for this acute effect on glucose homeostasis are not known. Vertical sleeve gastrectomy (VSG), a type of bariatric surgery, has been proven an effective treatment for type 2 diabetes, leading to a rapid improvement in glycemic control. To investigate the mechanisms underlying the acute lowering of blood glucose associated with VSG, we performed a liver transcriptome analysis of DIO mice on post-operative day 3. Controls were 1) sham-operated DIO mice, 2) sham-operated DIO mice pair-fed to the VSG group, and 3) untreated DIO mice pair-fed to the VSG group.  Body weight, food intake and blood glucose were measured at baseline and daily. Insulin, leptin, ghrelin, GLP-1 and glucagon plasma levels were obtained at baseline and on post-operative day 3. Total liver RNA was extracted utilizing the trizol technique. RNA sequencing was performed using Illumina HiSeq 2000 on four biological replicates from each of the four experimental groups. FASTQ files were generated with rnaStar mapperGene. Gene expression level was determined with the HTSeq program. Only genes with a fold decrease greater then 1.5 and a false discovery rate (FDR) of less than 0.05 (p value) in the VSG gene list compared to the other experimental group lists were included in the analysis. VSG led to a striking lowering of blood glucose compared to the other treatment groups, on all post-operative days. The difference was statistically significant, with the average blood glucose of the VSG group being approximately 70, 80 and 90 mg/dL on post-operative days 1, 2, and 3, respectively, in comparison to blood glucose levels of 125 mg/dl or higher in the other treatment groups (p<0.05). Insulin tolerance test did not reveal different slopes between the various treatment groups. Weight loss did not differ significantly between the treatment categories. Food intake was significantly lower in the sleeve gastrectomy group compared to the sham group (p<0.05). GLP-1 level was higher in the sleeve gastrectomy group (p<0.05), while insulin level was higher in the sham group (p<0.05). The transcriptome analysis showed a significant decrease in the expression of glycogen synthase 2 (GYS2), pyruvate dehydrogenase, endothelial lipase, hepatic lipase, lipin 2 and sterol regulatory element binding transcription factor 1 (SREB1) genes. Taken together, our data suggest that the acute glycemic effects of VSG in mice are not accounted for by either food intake reduction or increased insulin action. Specifically, the lower insulin plasma level and the decreased expression of GYS2 and SREB1 genes in the VSG group are indicative of decreased insulin signaling. Further studies are necessary to elucidate the mechanisms underlying the rapid fall of blood glucose observed after VSG.

 

Nothing to Disclose: ABE, NV, NS, MA, RS, JMF

17001 17.0000 SAT-1068 A Sleeve Gastrectomy-Induced Molecular LIVER Adaptions: Dissecting ACUTE Glycemic Changes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Ling He*1, Jia Cao2, Shumei Meng3, Evan Chang2, Sally Radovick1 and Fredric Edward Wondisford4
1Johns Hopkins School of Medicine, Baltimore, MD, 2Johns Hopkins School of Medicine, 3John Hopkins Medicine, Baltimore, MD, 4Johns Hopkins University School, Baltimore, MD

 

Metformin, discovered nearly a century ago, is a first-line anti-diabetic agent and over 150 million people worldwide take this medication.  It is clear that the major effect of metformin is to suppress glucose production in the liver.  Yet, its mechanism of action in the liver remains controversial. We demonstrate that metformin at concentrations found in the portal vein of animals (60-80 µM) activates AMPK kinase through the phosphorylation of AMPKα subunit at T172. It has been suggested that the AMPK αβγ complex is formed immediately after protein synthesis because the α subunit alone is unstable. However, we expressed AMPKα1 alone both in primary hepatocytes and in the hepatoma Hepa1-6 cell line, and AMPKα1 is stable and does not constitutively associate with βγ subunits. Strikingly, low metformin concentrations (60-80 µM) promote the formation of AMPKαβγ complex, and the formation of this complex leads to an increase in net a subunit phosphorylation at T172 due to an increase in LKB1 phosphorylation and a decrease in PP2C dephosphorylation of the a subunit. In primary hepatocytes, depletion of AMPKα1 and α2  abolished the inhibition of glucose production by low metformin concentration (80 µM), indicating that the metformin effect is AMPK-dependent. In addition, the cAMP-PKA pathway negatively regulates AMPK activity through phosphorylation at S485/497 on the α subunit, which in turn prevents complex formation and reduces net phosphorylation at T172. Intriguingly, low dose salicylate treatment prevents the phosphorylation of AMPKα S485, which blocks cAMP-PKA negative regulation, and indirectly increases the formation of the AMPK αβγ complex. Thus, metformin and salicylate synergistically suppress hepatic glucose production, and decrease blood glucose levels in mice fed a high-fat diet. By promoting AMPK complex formation, metformin and salicylate synergistically activate AMPK, suggesting their utility in combination therapy of patients with diabetes or cancer.

 

Nothing to Disclose: LH, JC, SM, EC, SR, FEW

15412 18.0000 SAT-1069 A Metformin and Salicylate Inhibit Glucose Production in the Liver By Promoting Formation of the AMPK αβγ Complex 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Carole Fournier*1, Leonidas G. Karagounis2, Sandra Sacco2, Marie-Noëlle Horcajada2, Karim Bouzakri3, Elizabeth Offord2 and Patrick Ammann1
1Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland, 2Nestlé Research Center, Lausanne, Switzerland, 3Geneva University, Switzerland

 

Hepatokines such as FGF21 and myokines as myonectin were shown to be involved in the regulation of energetic metabolism. Furthermore moderate protein undernutrition (MPU) is frequently observed with aging and the prevalence of metabolic diseases increases in postmenopausal women. Therefore, we investigated the impact of MPU and estrogen deficiency on glucose and lipid metabolism and the hepatic and muscular responses.

Seven-month-old female rats were ovariectomized (OVX) and fed an isocaloric moderate 5% casein protein diet (MCD; N=10) or an adequate 14% casein diet (ACD; N=10) for 13 weeks. Fasting blood glucose, triglycerides (TG), insulin, glucagon, FGF21 were measured by enzymatic assays or ELISA. Gene expressions of PPARα, PGC-1a (two key transcription factors involved in lipid oxidation) and FGF21 were assessed in liver while myonectin was assessed in gastrocnemius (GAS) by qRT-PCR. Glucose transporter type 4 (GLUT4) protein amount was measured in GAS by western blotting. Hepatic steatosis was quantified by Oil Red O staining and image analysis.

After 13 weeks, regardless the estrogenous status, MCD increased fasting blood glucose (+44% vs. SHAM-ACD; +53% vs. OVX-ACD p<0.01) and TG (+48% vs. SHAM-ACD; +23% vs. OVX-ACD p<0.05) without affecting insulinemia. In OVX rats, these changes were associated to higher serum glucagon and FGF21 circulating and hepatic rna levels (+78%, +98% and +64% vs. OVX-ACD p<0.05 respectively). The OVX-ACD group showed an increase of hepatic mRNA levels of PPARα and PGC1-α (+45% and +48% vs. SHAM-ACD p<0.05) while MCD precluded the OVX-related rise of these genes (-40% and -43% vs. OVX-ACD p<0.05 respectively) in association with an increase of the hepatic fat content (+56% vs. OVX-ACD p=0.099). In SHAM rats, MCD didn’t influence these hepatic parameters however, MCD reduced myonectin mRNA levels (-27% vs. SHAM-ACD p=0.06) and GLUT4 protein amount (-51% vs. SHAM-ACD p<0.01) in GAS. In OVX rats, MCD increased myonectin gene expression (+24% vs. OVX-ACD p=0.07) and didn’t significantly affect GLUT4 protein levels.

In SHAM rats, MPU reduced markers of muscle glucose uptake but didn’t affect hepatic markers of lipid oxidation and liver fat content. In OVX rats, MPU increased hepatic fat content and FGF21 production as well as myonectin gene expression in GAS. The MPU-related alterations of glucose and lipid metabolism are associated with different hepatic and muscular responses according to the estrogenous status.

 

Disclosure: CF: Investigator, Nestlé. LGK: Employee, Nestlé. SS: Coinvestigator, Nestlé. MNH: Employee, Nestlé. EO: Employee, Nestlé. PA: Investigator, Servier. Nothing to Disclose: KB

15829 19.0000 SAT-1070 A Muscular and Hepatic Responses to an Isocaloric Reduced Protein Intake Diverge According to the Estrogenous Status 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Mathieu Ferron*1 and Gerard Karsenty2
1Institut de recherches cliniques de Montreal, Montreal, QC, Canada, 2Columbia Univ Medical Center, New York, NY

 

Osteocalcin (OCN) is a hormone produced by osteoblasts that enhances insulin secretion and insulin sensitivity. It exists in two forms, γ-carboxylated (GLA) and inactive or undercarboxylated (GLU or GLU13) and bioactive (1). We had recently shown that osteoclasts, the bone-resorbing cells, are responsible for the decarboxylation and activation of the GLA-OCN abundantly present in the extracellular matrix (ECM)(2). Thus, our results imply that the γ-carboxylation of OCN should have an inhibitory effect on the bioactivity of this hormone and therefore on whole body glucose homeostasis. Gamma-carboxylation of proteins occurs in the lumen of the endoplasmic reticulum and involves two enzymes: 1) γ-carboxylase (GGCX), which uses reduced vitamin K as a cofactor, and 2) vitamin K epoxide reductase (Vkorc1), which recycles vitamin K through reduction. In vertebrates a novel paralogue of Vkorc1, named Vkorc1l1, have been identified. However, the function of Vkorc1l1 in vivo remains unknown. Since γ-carboxylase, Vkorc1 and Vkorc1l1 are expressed in osteoblasts, we decided to determine their respective role in the regulation of OCN bioactivity and glucose homeostasis by generating mutant mice lacking each of these genes in osteoblasts only (Ggcxosb-/-, Vkorc1osb-/- and Vkorc1l1osb-/-). While Ggcx and Vkorc1-null mice died shortly after birth from hemorrhages, Ggcxosb-/- and Vkorc1osb-/- mice were born at the expected Mendelian ratio and were viable. Both Ggcxosb-/- and Vkorc1osb-/- mice displayed a 10-fold increase in circulating GLU13-OCN levels and a 50 to 80% decrease in their serum levels of GLA-OCN. The OCN content in the bone ECM was decreased by more then 90% in Ggcxosb-/- and Vkorc1osb-/- mice, demonstrating the importance of GLA residues for OCN binding to bone mineral. The change in circulating levels of uncarboxylated OCN were associated with a significant improvement of glucose handling and of insulin sensitivity in Ggcxosb-/- as measured by glucose tolerance test (GTT) and insulin tolerance test (ITT) respectively. In contrast and unexpectedly, Vkorc1l1osb-/- mice displayed the opposite metabolic phenotype i.e., glucose intolerance and insulin resistance. These defects were associated with decreased serum levels of active GLU13-OCN in Vkorc1l1osb-/- mice and an increase in the accumulation of the inactive GLA-OCN in the bone ECM. Moreover, while Vkorc1-/- and Ggcx-/- osteoblasts secreted higher levels of GLU13-OCN, Vkorc1l1-/- osteoblasts carboxylated OCN more efficiently in culture. Lastly, we could show that Vkorc1l1 protein interact physically with Vkorc1 and GGCX, possibly modulating their enzymatic activity. Taken together, these results demonstrate that γ-carboxylation plays an important role in osteocalcin endocrine function and suggest that γ-carboxylation of osteocalcin is regulated differently by Vkorc1 and Vkorc1l1.

 

Nothing to Disclose: MF, GK

16208 20.0000 SAT-1071 A Regulation of Osteocalcin Endocrine Functions By the Vitamin K Epoxide Reductases 1 and 1l1 (Vkorc1 and Vkorc1l1) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Steven W Yau*, Vincenzo C Russo, George A Werther and Matthew A Sabin
Murdoch Childrens Research Institute, Parkville, Vic, Australia

 

Introduction: Insulin-like growth factor binding protein-2 (IGFBP-2) is reduced in obesity and type 2 diabetes mellitus, and over-expression of IGFBP-2 protects against these conditions(1). Precise mechanisms are not clear, although recent evidence suggests possible IGF-independent actions - mainly via the Heparin Binding Domain (HBD) or Gly-Arg-Asp (RGD) domain of IGFBP-2 binding to cell-surface or integrin receptors(2).

Hypothesis/Aims: IGFBP-2 directly enhances insulin signalling and glucose uptake via IGF-independent pathways. Our aim was to investigate the effect of IGFBP-2 on phosphatidylinositol 3-kinase (PI3K)/AKT signalling and glucose uptake in human skeletal muscle and explore possible mechanisms.

Methods: All experiments utilised in-vitro cultures of fully-differentiated human skeletal myotubes, held in serum-free media and in the absence of exogenous IGF-1. Treatments were as follows: A) IGFBP-2 (0 or 100ng/ml for 24h) prior to insulin stimulation (0 or 100nM insulin for 30min); B) IGFBP-2 or insulin stimulation in the absence/presence of Wortmannin (PI3K inhibitor; 100nM); C) IGFBP-2 siRNA (or scrambled siRNA as control) for 24h prior to dosing with ‘add-back’ IGFBP-2 for 24h and then insulin stimulation; D) Wild-type (WT) IGFBP-2 or HBD-mutant IGFBP-2 (HBDmut: 100ng/ml) for 24h. Outcomes (n=4) included p-AKT(ser473), p-mTOR(ser2448), p-GSK3β(ser9), PTEN and Glut-4 protein levels in cell lysates by Western immunoblotting and glucose uptake using 2-deoxyglucose uptake assays.

Results: A) IGFBP-2 increased basal p-AKT 5-fold and doubled insulin-stimulated p-AKT levels (p<0.05). B) Wortmannin completely ablated insulin-induced (p<0.001), and IGFBP-2-induced (p<0.01) increases in p-AKT. C) IGFBP-2 gene silencing reduced insulin-stimulated p-AKT by 61% (p<0.01) and glucose uptake by 60% (p<0.001). Adding back IGFBP-2 completely restored and further enhanced insulin signalling (400%; p<0.001) and glucose uptake (300%; p<0.001). D) IGFBP-2 increased p-mTOR (2-fold, p<0.001) and membrane Glut-4 (2.2-fold, p<0.001), while decreasing p-GSK3β (48%, p<0.001) and PTEN levels (34%, p<0.01). Compared to WT, HBDmut IGFBP-2 only modestly increased p-AKT (73%, p<0.01), p-mTOR (64%, p<0.01), and membrane Glut-4 (60%, p<0.05), while decreasing p-GSK3β (51%, p<0.001) and PTEN levels (37%, p<0.01) to similar levels.

Conclusion: These findings indicate that IGFBP-2 directly enhances insulin action, insulin sensitivity and insulin-induced glucose uptake in human skeletal myotubes, and that a significant part of this effect may be mediated via cell-surface association. Further studies will elucidate specific domains of IGFBP-2 which affect glucose metabolism.

 

Nothing to Disclose: SWY, VCR, GAW, MAS

16518 21.0000 SAT-1072 A IGFBP-2 Enhances Insulin Signalling Pathways in Human Skeletal Muscle By Cell Surface Binding – an IGF-Independent Process? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Craig L Doig*1, Agnieszka Ewa Zielinska2, Rachel S Fletcher3, Andrew Philp3 and Gareth Geoffrey Lavery2
1University of Birmingham, United Kingdom, 2University of Birmingham, Birmingham, United Kingdom, 3University of Birmingham

 

In response to metabolic stressors (exercise, nutrition, ageing) skeletal muscle nicotinamide adenine dinucleotide (NAD+), acting through sirtuin signalling pathways can enhance mitochondrial oxidative capacity, mitochondrial biogenesis, and insulin sensitivity. NAD+ synthesis is governed by a combination of de novo and salvage pathways. However, the role that the recently identified nicotinamide riboside kinase 2 (NMRK2) pathway plays in controlling cellular NAD+ availability is unknown. NMRK2 phosphorylates the vitamin nicotinamide riboside (NR) to nicotinamide mononucleotide (NMN) and onto NAD+. To examine NMRK2 we studied its expression profile in mouse tissues and show high expression in skeletal muscle and to a lesser extent cardiac tissue, with it being absent in other tissues examined. We then profiled NAD+ biosynthesis genes in C2C12 and primary derived myoutubes, tibialis anterior (TA-glycolytic metabolism) and soleus (Sol-oxidative metabolism). In all cases enzymes of the de novo and niacin salvage pathways were not expressed, with nicotinamide phosphoribosyltransferase (NAMPT), which recycles nicotinamide to NAD+, and NMRK2 being the only enzymes expressed. More interestingly, NMRK2 mRNA and protein is induced during muscle differentiation, whereas NAMPT expression is constant. NMRK2 expression is 6-fold enriched in TA versus SOL and 6-fold enriched in TA compared to NAMPT expression. In the H6PDHKO, a model of myopathy due to aberrant sarcoplasmic reticulum(SR) NADP/NADPH balance, NMRK2 is massively up regulated (>50 fold in TA and >10 fold in Sol) with NAD+ levels increased by 20%. This may be an adaptive response to redress SR NADP/NADPH status. H6PDHKO muscle has increased expression of sirtuin regulated PGC1a, increased but deregulated mitochondria number, and increased expression of genes controlling mitochondrial folate and proline metabolism. Likewise, muscle cells maintained in low glucose have increased NAD+ levels associated with significantly increased Nmrk2 expression. SiRNA depletion of NMRK2 results in reduced NAD+ content and perturbed mitochondrial TCA cycle and respiratory chain enzyme levels. Based on these ongoing studies we hypothesise Nmrk2 is a fundamental regulator of skeletal muscle NAD+ biosynthesis, that when dysregulated can have an impact upon mitochondrial function, and is crucial to the ability of muscle to regulate metabolic homeostasis and adaptation.

 

Nothing to Disclose: CLD, AEZ, RSF, AP, GGL

16743 22.0000 SAT-1073 A Defining a Novel Pathway to NAD+ Synthesis in Skeletal Muscle 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Dheshnie Keswell*1, Hendriena Victor1, Naomi S Levitt1, Tommy Olsson2 and Julia H Goedecke3
1University of Cape Town, South Africa, 2Umeå University, Umea, Sweden, 3South African Medical Research Council, Cape Town, South Africa

 

We hypothesise that differences in skeletal muscle expression of genes involved in insulin signaling and glucose transport may explain our previous finding that black SA women are more insulin resistant than white SA women. Therefore, we examined ethnic differences in skeletal muscle gene expression and the association with insulin sensitivity in obese black and white SA women.  Body composition (dual energy x-ray absorptiometry), insulin sensitivity (euglycemic hyperinsulinemic clamp) and the expression of insulin receptor substrate 1 (IRS1), syntaxin 4 (STX4) and vesicle-associated membrane protein (VAMP) in skeletal muscle were measured in 16 obese black and 16 obese white premenopausal SA women matched for age  (36±5 vs. 37±4 years, P=0.670) and BMI (37.8±4.9 vs. 35.2±3.6 kg/m2, P=0.097). In contrast to our previous findings, there were no differences in insulin sensitivity (M/I: 6.7±3.8 vs. 6.8±3.2 mg/min/kg lean body mass/mU/l, P=0.872) between the two ethnic groups. Furthermore there were no differences in skeletal muscle gene expression (IRS1: 1.2±0.05 vs. 1.2±0.07, P=0.757; STX4: 1.1±0.04 vs. 1.1±0.07, P=0.669; VAMP: 1.1±0.04 vs. 1.1±0.07, P=0.710) between black and white women, respectively. However in black, but not white women, there was a positive association between insulin sensitivity (M/I) and the skeletal muscle expression of IRS1 (r=0.59, P=0.045) and the GLUT4 transport genes; STX4 (r=0.86, P=0.001) and VAMP (r=0.76, P=0.004). In conclusion, the association between insulin sensitivity and genes involved in skeletal muscle insulin signaling and glucose transport differ by ethnicity in SA women. These results suggest that the pathogenesis of insulin resistance and the risk for type 2 diabetes may differ in these two ethnic groups.

 

Nothing to Disclose: DK, HV, NSL, TO, JHG

16667 23.0000 SAT-1074 A Ethnic-Specific Associations Between Insulin Sensitivity and Skeletal Muscle Gene Expression in Black and White South African (SA) Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Naveen Sharma*1, Micah N Zuhl1 and Carol A Stevens2
1Central Michigan University, Mount Pleasant, MI, 2Central Michigan University

 

Irisin is a recently discovered myokine, derived as a proteolytic cleavage product from its precursor fibronectin type II domain containing 5 (FNDC5).  FNDC5 expression is driven by the transcriptional co-activator PPAR-γ co-activator-1 α (PGC1-α), which can be influenced by nutritional status and physical activity.  Taken together, it has been postulated that irisin might have therapeutic potential for the treatment of metabolic abnormalities.  As a result, initial studies have attempted to characterize irisin during different modes of exercise, and in the background of insulin resistance, in both human and animal models.  Given the relative novelty of the discovery of irisin, there is little known about certain baseline values that would be important for future experimental design in rodent models, including the effect of acute fasting and sex differences.  The goal of the current study was to characterize the effects of an overnight fast on both male and female adult rats on plasma irisin concentrations.  Plasma was obtained from 4 cohorts of Sprague-Dawley rats: Fasted Males, Fed Males, Fasted Females, and Fed Females.  Male rats were 17.2 ± 0.7 months old, and female rats were 18.5 ± 1.0 months old.  Food was removed from the cages of Fasted rats at 17:00h on the night before the experiment, resulting in an 18h fast.  Fed rats had ad libitum access to their food.  Under isoflurane anesthesia, aortic blood was collected in heparinized syringes.  Plasma irisin concentrations were determined by a commercially available ELISA kit, and plasma glucose concentrations were determined by the enzymatic hexokinase method.  Male rats were significantly heavier (P ≤ 0.05) than female rats (729.2 g versus 436.2 g).   As expected the overnight fast significantly reduced (P ≤ 0.05) plasma glucose concentration in Fasted Males (119.5 ± 4.4 mg/dl) compared to Fed Males (142.2 ± 6.1 mg/dl), and significantly reduced (P ≤ 0.05) plasma glucose concentration in Fasted Females (119.4 ± 6.8 mg/dl) compared to Fed Females (140.8 ± 3.4 mg/dl).  There was no statistical difference in plasma irisin concentration between Fed Males and Fasted Males (392.3 ± 65.9 ng/ml versus 355.9 ± 139.4 ng/ml) or between Fed Females and Fasted Females (121.8 ± 5.7 ng/ml versus 114.2 ± 5.6 ng/ml).  The ratio of irisin to body weight was significantly greater (P ≤ 0.05) in male versus female rats (0.54 ± 0.09 versus 0.29 ± 0.03).  These data indicate acute fasting does not influence the concentration of plasma irisin.  In an attempt to compare male and female rats directly, irisin to body weight ratio indicated that a sex difference exists, however this finding is likely confounded by differences in body composition. We speculate that more comprehensive anthropometric assessment including fat mass and fat-free mass would likely reveal more accurate sex-specific details.

 

Nothing to Disclose: NS, MNZ, CAS

16266 24.0000 SAT-1075 A Effects of Acute Fasting on Plasma Irisin Concentration in Adult Male and Female Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Luqman Aribidesi Olayaki*, Abdulgafar Abdulraheem and Sikiru Abayomi Biliaminu
University of Ilorin, Ilorin, Nigeria

 

Diabetes mellitus is a metabolic disease characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both. Although, oral hypoglycemic agents and insulin are the mainstay of treatment of diabetes, they have prominent side effects and fail to significantly alter the course of diabetic complications. Orange peel extract (OPE) has been shown to lower blood glucose level in streptozotocin-induced diabetic rats. However, no report has been seen on effect of OPE on blood glucose level in type 2 diabetes mellitus (T2DM) model rats and its mechanisms of action have not been established. This study aim at investigating the effect of common sweet orange peel (Citrus sinensis) ethanolic extract on plasma glucose in fructose-induced diabetic (T2DM) rats, comparing to the effect of metformin, an oral hypoglycemic drug, and to suggest the possible mechanisms of its action. Diabetes mellitus was induced in rats by feeding the rats with 20% fructose diet (dissolved in water) for 6 weeks. After the induction of diabetes, the animals were grouped into five groups of 6 rats each. Healthy control (HCN) received 2ml/kg body weight of normal saline. Diabetic control (DCU) received 2ml/kgbw of normal saline (DTE1) treated with OPE (150mg/kgbw), diabetic (DTE2) treated with OPE (300mg/kgbw) and diabetic (DTM) treated with metformin (100mg/kgbw). The rats were treated daily with oral administration of OPE for 14 days. The food and water intake of each group were measured everyday and the body weight of each rat were measured every 3rd day during the experimental period. After treatment period, fasting blood glucose, OGTT, serum insulin, liver glycogen content and gatrocnemius glucose uptake were evaluated. The OPE treatment lowered blood glucose, induced a significant improvement of OGTT (p<0.05), significantly increased serum insulin level, increased glucose uptake by gastrocnemius and significantly increased liver glycogen content compared to the diabetic control (p<0.05). The ethanolic extract of orange peel thus exhibited antidiabetic action and improved glucose tolerance in a dose dependent manner in fructose-induced diabetic rats. The results indicate that hypoglycemic effect of OPE was related to potentiation of pancreatic secretion of insulin from the beta cells coupled with extra-pancreatic mechanisms such as increasing glucose uptake by muscles and inhibition of glycogenolysis in the liver.

 

Nothing to Disclose: LAO, AA, SAB

14321 25.0000 SAT-1076 A Orange Peel Extract Increased Muscle Glucose Uptake and Hepatic Glycogen Content in Fructose-Induced Diabetic Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Xinli Zhang*1, Yan Zhao1, Walter G Thomas1, Johannes D Veldhuis2 and Chen Chen1
1The University of Queensland, Brisbane, Australia, 2Mayo Clinic & Graduate School of Medicine, Rochester, MN

 

Significant insulin and growth hormone (GH) reductions have been reported on streptozotocin (STZ)-induced diabetic animal models, linking to hyperglycemia and loss of body weight. Hexarelin is a synthetic growth hormone secretagogue, able to protect pancreatic β-cell function and stimulate GH secretion. Thus we aim to investigate the effect of hexarelin on insulin and growth hormone secretion in STZ-induced diabetic animal model.

To set up animal models, male Wistar rats at age of 6-week old were injected intra-peritoneally with a single dosage of 65mg/kg STZ to induce diabetes for 6 weeks. During 6 weeks disease development, blood glucose levels (once a week), water consumption (daily) and body weight gains (twice a week) were monitored. After 4 weeks of disease development, a group of control and diabetic animals were receiving daily hexarelin (100mg/kg) treatment for 2 weeks. Pancreatic β-cell morphology and pulsatile GH secretion in rats from all groups were assessed at the end. In addition, fasting levels of insulin, free fatty acids (FFAs) and IGF-1 were measured.

We observed a significant hyperglycemia and declined body weight gains throughout 6 weeks disease development in STZ-treated diabetic rats. Associated with decreased insulin secretion, confocal imaging showed impaired pancreatic islet structure with significantly reduced β-cells. Pulsatile GH secretion in STZ-rats was characterized by a significant decline in total (356±75.3 vs 1243±141ng/ml, p<0.001), pulsatile (192±24.6 vs 1053±136ng/ml, p<0.001), basal (19.2±9.67 vs 213±41.9ng/ml, p<0.001) and the mass of GH secreted per burst (118±23.0 vs 355±39.9ng/ml/h, p<0.001) compared to control. In addition, impaired GH secretion followed an increase in fasting level of FFAs but a decrease in fasting level of IGF-1 in diabetic rats. After hexarelin treatment, blood glucose level was gradually decreased in STZ-treated rats; body weight gain was increased in both control and STZ groups. Impaired pancreatic islet structure was partially recovered with increased insulin levels. Pulsatile GH secretion in STZ group was significantly increased in total (826±197 vs 356±75.3ng/ml, p<0.05), pulsatile (524±44.6 vs 192±24.6ng/ml, p<0.001), basal (159±36.6 vs 19.2±9.67ng/ml, p<0.01) but not the mass of GH secreted per burst (178±28.9 vs 118±23.0ng/ml/h, p=0.14) compared to that in STZ without hexarelin treatment. There were no much elevations of GH secretion in hexarelin-treated control group. In addition, hexarelin treated STZ rats showed dramatic decrease in fasting level of FFAs whereas suppression in fasting level of IGF-1.

These results suggest that STZ-induced diabetes is associated with impairment of insulin and pulsatile GH secretion followed by increased levels of fasting FFAs and IGF-1 in rats. Hexarelin treatment is able to normalize impaired insulin, pulsatile GH secretion and fasting level of FFAs, but not IGF-1.

 

Nothing to Disclose: XZ, YZ, WGT, JDV, CC

12445 26.0000 SAT-1077 A Effects of in Vivo Hexarelin Treatment on Insulin and Pulsatile Growth Hormone Secretion in Streptozotocin-Induced Diabetic Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Suryavathi Viswanadhapalli*, Qian Shi, Yves Gorin and Hanna E Abboud
University of Texas Health Science Center at San Antonio, San Antonio, TX

 

Tubulointerstitial fibrosis is a major pathological feature of diabetic nephropathy (DN) that eventually results in loss of renal function. Hyperglycemia increases reactive oxygen species (ROS) generation and contributes to matrix accumulation and tubulointerstitial fibrosis. In addition to mitochondria, the Nox family of NADPH oxidases is now recognized as major source of ROS.  However, the role of Nox enzymes and their downstream targets in tubular epithelial cell injury remains largely unknown.  In vitro studies were performed in primary human proximal tubular epithelial cells (HPRTECs).  mRNA and protein levels of  Nox isoforms were analyzed by reverse transcriptase PCR and Western blotting, respectively. We found that Nox4 is the most abundant Nox isoform expressed in HRPTECs. HRPTECs were exposed to normal glucose (NG, 5mM) or high glucose (HG, 25mM) concentrations in serum-free medium for short and prolonged periods of time. HG significantly increases Nox4 expression, as well as the accumulation of extracellular matrix proteins, fibronectin and alpha-smooth muscle actin at early (4 h) and late time points (24 h). However, exposure of the cells to HG did not altered Nox5 protein expression. Furthermore, treatment of the cells with HG caused sustained activation of mammalian target of rapamycin complex 1 (mTORC1) as evidenced by the increase in phosphorylation of p70S6K at Thr389, mTOR at Ser2448 and 4E-BP1 at Thr37/46.  Nox4 knockdown using specific siRNA or its inhibition with an adenovirus encoding a dominant negative truncated form of Nox4 (AdDN-Nox4) significantly attenuated the HG-induced activation of mTORC1 pathway and the increase in fibronectin and alpha-smooth muscle actin expression.  Expression of extracellular matrix proteins in cells exposed to high glucose was also decreased in cells pretreated with mTORC1 inhibitor rapamycin or the small molecule Nox4 inhibitor GKT137831. These data indicate that HG increases matrix protein expression through Nox4-dependent activation of mTORC1 pathway in HRPTECs. Nox4 and or mTOR inhibitors provide potential therapeutic strategy to treat tubular injury associated with diabetic nephropathy.

 

Nothing to Disclose: SV, QS, YG, HEA

14747 27.0000 SAT-1078 A Nox4-Dependent Activation of mTOR Signaling Pathway Mediates the Effect of High Glucose on Matrix Accumulation in Human Proximal Tubular Epithelial Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Mao Luo*1, Rong Li1, Xin Deng1, Meiping Ren1, Ni Chen1, Min Zeng1, Fei Liu1, Yan Yang2, Qin Wan1 and Jianbo Wu3
1Luzhou Medical College, Luzhou, China, 2University of Missouri, 3University of Missouri, Columbia, MO

 

MicroRNA-103 (miR-103) plays a critical role in regulating insulin sensitivity in type 2 diabetes (DM2). Recent data suggest that Secreted frizzled-related protein 4 (SFRP4) is a potential risk biomarker for pre-diabetes. Platelets are enriched for miR-126. The objective of this study was to test the hypothesis that platelet-derived miR-103b regulation of SFRP4 expression might be a novel biomarker for the early diagnosis of DM2.  In Q-RT-PCR assays, miR-103b expression was low; conversely, gene expression of SFRP4 was enriched in both pooled leukocyte depleted platelets (LDPs) and individual patients with pre-DM. Using the luciferase reporter gene assay, we found that a miR-103b mimic significantly decreased relative luciferase activity in the presence of the SFRP4 3'UTR. Conversely, a miR-103b inhibitor increased relative luciferase activity. When the miR-103b seed sequence of the SFRP4 3'UTR was mutated, the effects of the miR-103b mimic and miR-103b inhibitor were abrogated. This finding suggested that miR-103b directly bound to the SFRP4 mRNA 3'UTR seed sequence and regulated its expression.Furthermore, SFRP4 mRNA and protein levels were upregulated by a miR-103b mimic but downregulated by a miR-103b inhibitor. These results suggest that platelet-derived miR-103b could be a novel biomarker for the early diagnosis of DM2.

 

Nothing to Disclose: ML, RL, XD, MR, NC, MZ, FL, YY, QW, JW

11066 28.0000 SAT-1079 A Platelet-Derived Mir-103b As a Novel Biomarker for Early Diagnosis of Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Lindsey Marie Van Sambeek*1, Dianne K Newman2 and Roberta Kato3
1Saint Louis University, 2California Institute of Technology/Howard Hughes Medical Institute, CA, 3Children's Hospital Los Angeles

 

BACKGROUND: Cystic fibrosis-related diabetes (CFRD) affects up to half of cystic fibrosis (CF) patients and is associated with increased mortality and more frequent pulmonary exacerbations (PEx)1.  However, it is unclear to what degree good glycemic control mitigates these risks.  CFRD patients have a high treatment burden managing respiratory complications of CF and additional interventions for diabetes should be well justified.  Lower airway glucose has not been measured directly from sputum and analyzed within a clinical context.

HYPOTHESIS: We anticipated that CF patients with CFRD would have increased sputum glucose (SG), correlating with higher hemoglobin A1C (HbA1C), longer hospitalizations, more frequent PEx and worse lung function than CF patients without CFRD.

METHODS: Spontaneously expectorated sputum samples from pediatric CF patients enrolled in a cross-sectional, prospective study were collected and analyzed for glucose concentration (hexokinase assay, Sigma).  Data on age, sex, ethnicity, BMI, CFRD diagnosis, HbA1C and pulmonary function test results, and PEx hospital admission history were collected. 

RESULTS: The 21 patients were 12/9 (M/F), 10 were diagnosed with CFRD, mean age was 15.4 years (range, 9-20), mean BMI z-score was -0.962 (range, -2.38-0.89), and mean HbA1C% for the previous two years was significantly higher in patients with CFRD than without (6.0% vs 5.6%, [SD, 0.429 vs 0.148, p=0.0018]).  The median SG concentration was 0.423 mM (range, undetectable [<0.001 mM] to 3.143).  SG did not correlate with age, sex, CFRD diagnosis, or positive sputum culture for Pseudomonas aeruginosa or Staphylococcus aureus.  Surprisingly, there was no significant correlation between SG and HbA1C%, forced expiratory volume in one second (FEV1), frequency of PEx, or length of hospital admission for PEx. 

Mean SG was lower in samples from well patients (0.49 mM, SD = 0.727), than outpatient acutely ill patients (0.91 mM, SD = 1.172) or patients hospitalized with PEx (1.49 mM, SD = 1.213), although this trend did not reach statistical significance.  The four samples with undetectable glucose levels were all from outpatient samples.  SG was also strongly correlated with BMI z-scores at time of collection (R2 = 0.369, p = 0.0035).  In this population, average HbA1C% was not significantly correlated with age, the frequency or length of PEx, or average FEV1.

CONCLUSIONS: In CF patients, SG varied directly with BMI z-scores and showed a non-statistically significant trend towards increasing during acute PEx.  Interestingly, these samples from pediatric patients indicated a much lower SG than what has been reported in non-exacerbating CF adults (0.423 mM vs 3.2 mM)2.  It is frequently assumed that airway glucose contributes to pulmonary infections in CF patients, but the mechanism and the factors influencing SG concentration remain unclear.

 

Nothing to Disclose: LMV, DKN, RK

15402 30.0000 SAT-1081 A Characterizing the Role of Sputum Glucose in Cystic Fibrosis-Related Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1052-1081 4795 1:00:00 PM Glucose, Insulin, and Metabolism: Basic Mechanisms Poster

Joseph Frankl*1, Marie S Thearle2, Clifton Bogardus1 and Jonathan Krakoff3
1NIH NIDDK, Phoenix, AZ, 2Natl Institutes of Hlth, Phoenix, AZ, 3NIH, Phoenix, AZ

 

Recent work in Pima Indians demonstrated that carriers of HLA haplotype DRB1*02 have an increased acute insulin response and decreased risk for the development of type 2 diabetes mellitus (T2DM), implicating loss of self-tolerance in the pathogenesis of T2DM. We hypothesized that T cell receptor (TCR) repertoire characteristics would differ between 1) individuals with normal glucose regulation (NGR; fasting plasma glucose <5.6 mmol/l and 2 hour plasma glucose <7.8 mmol/l) and the protective haplotype versus those without the protective haplotype and T2DM and 2) between individuals with NGR who develop T2DM versus those who do not. Each TCR beta chain consists of a combination of one each of 54 Variable (V), 2 Diversity (D), and 13 Joining (J) genes and includes the highly variable complementarity determining region 3 (CDR3). In an initial study, differences in the properties of the TCR repertoire were investigated by performing high throughput sequencing of the CDR3 region of TCR with the immunoSEQ assay (Adaptive Biotechnologies) from genomic DNA in full heritage Pima Indian men with T2DM who lacked the HLA-DRB1*02 haplotype (n=7; age=34±8 y; pfat=31.2±4.7%) and compared them to a group with NGR plus the presence of HLA-DRB1*02 (n=11; age=31±8 y; pfat=30.2±8.7%).  V, J, and D gene frequencies and CDR3 length were compared between groups. CDR3 length was significantly shorter in those with T2DM (mean±SE, 36.92±0.02 v 37.34±0.02 nucleotides; p<.0001). Frequencies of the V-gene TRBV7-8 were higher in those with T2DM (2.06±0.31 v 1.19±0.14%, p=.034). High throughput CDR3 TCR sequencing was also performed in a cohort of full heritage Pima Indian men (n=27; age=28.9±7.1 y; pfat=28.8±7.1%) and women (n=20; age=29±7.0 y; pfat=37.1±6.8%) with NGR and lacking the HLA-DRB1*02 haplotype. Follow-up data was available for 41; thirteen developed T2DM (median FU time=6.0 y) and 28 remained free of T2DM at their last follow-up visit (median FU time=7.6 y). In a proportional hazards model, shorter CDR3 length was associated with an increased risk of T2DM (HRR=2.99 per 1 nucleotide decrease; p<.0001), as was a greater frequency of TRBV7-8 (HRR=3.13 per 1% increase in TRBV7-8; p<.0001). In the variable portion of the TCR, shorter CDR3 length and higher TRBV7-8 frequency are associated with and predict development of T2DM indicating T cell autoimmunity may play an important role in progression to T2DM in Pima Indians.

 

Nothing to Disclose: JF, MST, CB, JK

13079 1.0000 SAT-0995 A T Cell Receptor Repertoire Variation Is Associated with Type 2 Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0995-1004 4798 1:00:00 PM Diabetes Complications and Genetics Poster

Sarah Jean Glastras*1, Hui Chen2, Sonia Saad3 and Carol Pollock3
1Kolling Institute, Royal North Shore Hospital, Sydney, Australia, 2University of Technology Sydney, Sydney, Australia, 3Kolling Institute, University of Sydney

 

Developmental programming underpins the association between maternal obesity and the increased risk of chronic disease in the offspring, including diabetes, hypertension and chronic kidney disease. GLP-1 receptor agonists are medications used to reduce blood sugar levels and achieve modest weight loss. They may also have beneficial effects on the kidney. We hypothesized that GLP-1 agonists may reduce markers of oxidative stress in the kidneys of offspring of obese mothers. Female rats were fed either normal or high-fat diet (HFD) for 6 weeks prior to pregnancy, during pregnancy and weaning and their offspring were weaned to normal or HFD. They were randomized to exendin-4 (Exd4) or placebo at Day 21 and their kidneys harvested at Week 9. Offspring of obese mothers fed HFD had increased weight and reduced glucose tolerance but not if fed normal diet (HH [mother HFD, offspring HFD] 437g, HC [mother HFD, offspring chow] 384g, CC [mother chow, offspring chow] 377g: HH vs CC, p < 0.001; HH vs HC, p < 0.001). Exd4 significantly ameliorated these effects (HH-Exd4 354g, HH-Exd4 vs HH, p < 0.001). However, the kidneys in the offspring of obese mothers, regardless of postnatal diet, had increased markers of inflammation and oxidative stress. By RT-PCR, mRNA expression of inflammatory markers, monocyte chemoattractant protein-1 (MCP-1) and transforming growth factor (TGFß) was significantly increased in the kidneys of offspring of obese mothers regardless of postnatal diet (MCP-1 HH or HC vs CC, p < 0.05, p < 0.01; and TGFß HH or HC vs CC, p < 0.01). Increased MCP-1 mRNA expression in the kidneys of the HH group was ameliorated by Exd4 (HH vs HH-Exd4, p < 0.05). Inducible nitric oxide synthase (iNOS) mRNA, a measure of oxidative stress, was measured by RT-PCR which was increased by maternal obesity with or without HFD consumption in postnatal life and ameliorated by Exd-4 therapy (HH or HC vs CC, p < 0.05, p < 0.01; HC vs HC-Exd4, p < 0.05). Superoxide dismutase (SOD) are enzymes with important anti-oxidant and anti-inflammatory effects. Exd4 increased SOD activity significantly in the offspring of obese mothers fed normal diet (p < 0.05). We conclude that maternal obesity has lasting effects on inflammatory and oxidative stress pathways in the offspring’s kidneys. GLP-1 receptor agonists, such as Exd-4 may protect against deleterious effects of maternal obesity on offspring’s kidneys.

 

Nothing to Disclose: SJG, HC, SS, CP

15775 2.0000 SAT-0996 A GLP-1 Receptor Agonist Exendin-4 Ameliorates Oxidative Stress and Inflammation Induced By Maternal Obesity Expressed in Offspring's Kidneys 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0995-1004 4798 1:00:00 PM Diabetes Complications and Genetics Poster

Renu A Kowluru*1 and Anjan Kowluru2
1Wayne State Univ, Detroit, MI, 2Wayne State University, Detroit, MI

 

Clinical studies have documented a close relationship between hyperlipidemia and the severity of retinopathy in diabetic patients. In the pathogenesis of this blinding disease, increased oxidative stress plays a key role, and the retinal mitochondria are damaged and capillary cell apoptosis is accelerated. Our recent studies using streptozotocin-induced diabetic rats (type I model) have shown that ROS generated by NADPH oxidase 2 (Nox2), an enzyme with membranous (gp91phox and p22phox) and cytosolic (p47phox, p40phox, p67phox and Rac1) cores, damage retinal mitochondria. Furthermore, Nox2 activation is observed in retinal endothelial cells within 3 hours of high glucose insult, and precedes mitochondrial damage and capillary cell apoptosis (observed after 72 hours). The aim of this study is to investigate the role of lipotoxicity in Nox2-mediated ROS generation and mitochondrial damage in the development of diabetic retinopathy. Retinal endothelial cells were incubated for 3-96 hours with palmitate in the presence or absence of a ceramide biosynthesis inhibitor, Fumonisin B-1. Cells incubated in normal glucose (5mM) served as control. Levels of reactive oxygen species (ROS) were quantified fluorometrically, Nox2 activity by a luminescence assay, Rac1 activation by G-LISA, and mitochondria damage by measuring the expression of mtDNA-encoded protein, cytochrome b (Cyt b). The results were confirmed in the retina from type II diabetic animal model, Zucker diabetic fatty (ZDF) rats, at 6 weeks and 12 weeks of age. As with high glucose, within 3 hours of palmitate exposure, ROS levels were increased in retinal endothelial cells by over 50%, and within 24 hours, the levels were elevated over 2 fold and Nox2 and Rac1 were activated by over 70% compared to the cells incubated in normal glucose. At 96 hours of palmitate exposure, the expression of Cyt b was decreased by ~50% and cell apoptosis was elevated by over 2.5 fold. Addition of Fumonisin B-1 inhibited increase in ROS, Nox2 and Rac1 activation, and also ameliorated decrease in Cyt b expression and increase in apoptosis. Consistent with the increase in retinal ROS and Nox2 after 6 weeks of streptozotocin-induced diabetes in rats, ROS, Nox2, p47phoxand Rac1 were also elevated in the retina from 6 weeks old ZDF rats, an age when these rats are hyperlipidimic, but not hyperglycemic. Increase in retinal ROS and activation of Nox2 continued at 12 weeks of age (a duration when ZDF rats have both hyperlipidemia and hyperglycemia), but their mitochondria remained intact with no increase in capillary cell apoptosis. Thus, the hyperlipidemic conditions activate retinal Nox2 before mitochondria are damaged and capillary cell apoptosis is accelerated. Regulation of Nox2-activation could be a novel therapeutic target to inhibit the progression of retinopathy in diabetic patients with hyperlipidemia before their hyperglycemia becomes overt.

 

Nothing to Disclose: RAK, AK

11905 3.0000 SAT-0997 A Diabetic Retinopathy and NADPH Oxidase-2 Activation By Hyperlipidemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0995-1004 4798 1:00:00 PM Diabetes Complications and Genetics Poster

Jiancheng Xu*, Di Wang, Chun Yang and Wei Xu
the First Hospital of Jilin University, Changchun, China

 

Diabetic cardiomyopathy (DCM) is a major cause of death of patients with diabetes. It is known that apoptosis has been considered to play a critical role in DCM. Our recent studies have demonstrated the important role of endoplasmic reticulum stress (ER stress) in diabetes-induced cardiac cell death. The aim of this study was to investigate cardiac protection by tauroursodeoxycholic acid (TUDCA), a bile acid derivative that acts as a chemical chaperone to enhance protein folding and ameliorate ER stress, in the development of DCM. At 2 weeks, and 2 and 5 months after diabetes onset with Type 1 diabetic mouse model induced with multiple low-dose streptozotocin, cardiac remodeling and dysfunction were determined using echocardiography and hemodynamic evaluation and cardiac fibrosis was detected by Picric acid-Sirius red staining; ER stress signal pathway and apoptosis were detected by western blotting assay and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) assay. Mechanism of cardiac protection by TUDCA was used by cell culture with embryonic rat heart derived cells (H9c2). Apoptotic cells and CHOP, the activated form of caspase-3 and caspase-12 delineated that diabetes mainly induced cardiac cell death at the early stage of diabetes (2 weeks), but not in the late stages (2 and 5 months). However, there was no apoptotic cell death in the hearts of diabetic mice treated with TUDCA. In parallel with apoptotic effect, significant up-regulation of the ER chaperones, including phosphorylated eIF2α (p-eIF2α), GRP78, GRP94 and cleaved ATF6 proteins were significantly increased in the heart of diabetic mice at 2 weeks after diabetes onset. However, none of these increased ER chaperones in the hearts of diabetic mice were observed in the heart of diabetic mice treated with TUDCA. Pre-exposure of H9c2 cells to TUDCA significantly prevented high glucose or tunicamycin-induced ER stress and apoptosis, while same pretreatments did not have any effect on normal H9c2 cells. These results suggest that ER stress exists in the diabetic heart, which may cause the cardiac cell death. TUDCA can attenuate diabetes-induced cardiac cell death via suppression of cardiac ER stress and associated apoptotic effects. This study could provide important theoretical support for prevention and treatment of DCM. The study also might open up a new way for the drugs in research and development for diabetic cardiovascular complications.

 

Nothing to Disclose: JX, DW, CY, WX

12352 4.0000 SAT-0998 A Tauroursodeoxycholic Acid Attenuate Apoptosis Via Inhibition of Endoplasmic Reticulum Stress Against Diabetic Cardiomyopathy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0995-1004 4798 1:00:00 PM Diabetes Complications and Genetics Poster

Diane Donegan*1, Laurie K Bale2, Sara L Harstad1 and Cheryl A Conover1
1Mayo Clinic, Rochester, MN, 2Mayo Foundation, Rochester, MN

 

Diabetic nephropathy is the leading cause of end-stage renal disease world-wide.  Therefore, there is tremendous interest in identifying factors involved in the development of diabetic nephropathy in order to prevent/delay the associated morbidity and mortality.    Insulin like growth factor (IGF)-I is believed to contribute to the development of diabetic nephropathy characterized by increased basement membrane thickness and mesangial expansion.   Pregnancy-associated plasma protein-A (PAPP-A) is a cell-associated zinc metalloproteinase that cleaves inhibitory IGF binding proteins, thereby increasing local IGF-I availability for receptor activation.  Recently, PAPP-A knockout mice with streptozotocin-induced diabetes were found to be resistant to basement membrane thickening and mesangial expansion, suggesting a pathological role of the IGF system in glomeruli that is driven by PAPP-A. Therefore, we studied PAPP-A and the IGF system in human mesangial cells (HMC). HMC were incubated with and without proinflammatory cytokines and growth factors associated with diabetic nephropathy i.e. tumor necrosis factor (TNF)-α, transforming growth factor ( TGF)-β, interleukin (IL)-1β and IL-6. PAPP-A mRNA expression was increased 3.8-fold (P= 0.049) by IL-1β and 1.153 fold (P=0.031) by TGF-β compared to control as determined by real time PCR. PAPP-A protein and proteolytic activity in HMC conditioned medium was similarly increased with IL-1β treatment.  There was a trend towards an increase in PAPP-A expression with TNF-α but the difference was not significant at 24hours (P = 0.17).  IL-6 had no effect on PAPP-A mRNA expression. IGF-1 mRNA was not expressed by HMC nor was IGF-1 detected using ELISA; however IGF-1 receptor mRNA was expressed by HMC and phosphorylation of the receptor occurred in the presence of its ligand.  In summary, HMC in culture do not produce IGF-1, but are primed to respond to it when produced by other cells. Local bioavailability of IGF-1 is regulated by PAPP-A whose expression is influenced by inflammatory cytokines known to be pathogenic in diabetic nephropathy. Therefore, PAPP-A may represent a novel target in the prevention of diabetic nephropathy.

 

Nothing to Disclose: DD, LKB, SLH, CAC

14774 5.0000 SAT-0999 A Regulation of Papp-a in Human Mesangial Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0995-1004 4798 1:00:00 PM Diabetes Complications and Genetics Poster

Nawal Mohammed Alrasheed*1, Nouf Mohammed Alrasheed2, Hala A Attia3, Maha A Al-Amin2, Iman H Hasan2, Hanaa N Al-Ajmi4, Raeesa A Mohamad2 and Nasr A Sinjilawi5
1Princess Nora Bint Abdul Rahman University, Riyadh, Saudi Arabia, 2King Saud University, Riyadh, Saudi Arabia, 3King Saud university, Riyadh, Saudi Arabia, 4King Saud Universty, Riyadh, Saudi Arabia, 5King Khalid University Hospital, Riyadh, Saudi Arabia

 

Diabetic nephropathy (DN) is one of the major causes of morbidity and mortality in humans. It has been associated with endothelial dysfunction leading to renal damage. Adenosine monophosphate -activated protein kinase (AMPK) and its downstream kinase; LKB1 has been implicated in the maintenance of endothelial function via regulating endothelial nitric oxid synthase (eNOS) and reducing oxidative stress. The purpose of this study was to investigate whether the renoprotective effects of fenofibrate are mediated via modulation of LKB1¨MAMPK mRNA expression in rats with DN. Diabetes was induced in rats by a single intraperitoneal injection of streptozotocin (55 mg kg-1). Diabetic rats were given finofibrate(100 mg kg-1, p.o) for twelve weeks. Treatment with fenofiobrate significantly improved the renal function as revealed by the significant reductions in the kidney/body weight ratio [9.9 ± 0.37 vs. 13.24 ± 0.75 mg/g (P<0.01)], urinary albumin excretion [18.26 ± 0.574 vs. 26.7 ± 1.55 mg/dl (P<0.001)], serum creatinine [0.86 ± 0.0366 vs. 1.35 ± 0.1 mg/dl (P<0.001)] and blood urea nitrogen [23.98 ± 0.82 vs. 32.52 ± 1.44 mg/dl (P<0.001)], in addition to a significant increase in creatinine clearance [2.76 ± 0.11 vs. 1.71 ± 0.12 mg/dl (P<0.01)] compared with diabetic control group. STZ-induced oxidative damage was ameliorated by treatment with fenofibrate as indicated by significantly increased levels of glutathione and catalase together with a significant decrease of lipid peroxidation (P<0.001). Administration of fenofibrate caused significant increases in eNOS mRNA expression [6.25 ± 1.75 vs. 0.64 ± 0.09 (P<0.01)] and NO production (57.60 ± 2.86 vs. 42.20 ± 1.50 mmole/g tissue) compared to diabetic control reflecting the improvement of endothelial function.  Fenofibrate also significantly increased the expression of AMPK and LKB1 compared to control diabetic rats [6.045 ± 1.17 vs. 1.48 ± 0012 (P<0.05) and [8.21 ± 1.64 vs. 2.11 ± 1.69, respectively).  Our results give further insights into the mechanisms underlying the protective role of fenofibrate in DN via modulation of AMPK, LKB1 and eNOS mRNA expression.

 

Nothing to Disclose: NMA, NMA, HAA, MAA, IHH, HNA, RAM, NAS

11312 6.0000 SAT-1000 A Renoprotective Effects of Fenofibrate Via Modulation of LKB1-AMPK mRNA Expression in a Rat Model of Diabetic Nephropathy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0995-1004 4798 1:00:00 PM Diabetes Complications and Genetics Poster

Lindsey E Nicol*1, My Linh Nguyen1 and Daniel L. Marks2
1Oregon Health & Science University, Portland, OR, 2OHSU, Portland, OR

 

Introduction: The anti-inflammatory effects of the cholinergic pathway modulated by alpha-7 nicotinic acetylcholine receptor (CHRNA7) have been described in macrophages and other cell types but its role in the pancreatic islet is undefined.   Islet inflammation contributes to the decline in islet function and is part of the early pathophysiology of diabetes.  We hypothesize CHRNA7 agonists can reduce the islet inflammatory responses to metabolic insults and attenuate the onset of diabetes.   Methods: Expression of CHRNA7 in the islet was verified using quantitative PCR (qPCR) comparing isolated islets from wildtype (wt) and CHRANA7 KO mice, murine endocrine verses exocrine tissue, and islets isolated from primates.  A series of in vitro experiments were performed using isolated murine islets exposed to various insults mimicking endogenous metabolic toxicity while co-cultured in CHRNA7 agonists.  Islet inflammation and markers of the downstream pathway of CHRNA7 activation were assessed using qPCR.   An in vivo study comparing islet inflammation between wt and CHRNA7 KO mice was carried out.  Animals were placed on high fat diet for 14 weeks, glucose and insulin tolerance tests were performed and islets were isolated.  Islet inflammation was assessed by qPCR. Results: In vitro studies demonstrated CHRNA7 agonists suppressed expression of CXCL10 (P<0.05) and (trend) IL-6 (P <0.09) in islets exposed to lipopolysaccaride (LPS) or high concentrations of glucose (IL-6; P<0.06).  Expression of the downstream marker of the CHRNA7 signaling pathway (Suppressor of Cytokine Signaling 3 (SOCS3)) was increased (p<0.05) in isolated islets treated with CHRNA7 agonist.  Isolated islets from CHRNA7 KO mice had increased levels of CXCL10 (P<0.05) and a key pro-inflammatory transcription factor,  IκBα (P<0.01) but no differences in glucose homeostasis were observed between the two genotypes.  Conclusions: CHRNA7 is expressed in the islets of mice and primates allowing a translational link for the current data and future studies.  Agonists of CHRNA7 dampen the expression of IL-6 and CXCL10, key inflammatory markers associated with the risk of developing diabetes. The CHNRA7 KO model shows increased inflammation in the islet and potential tool for further studies looking at the use of in vivo CHRNA7 agonists in the prevention of islet inflammation.  Whether such agonists will also prevent the onset of diabetes needs further deliniation.  Future aims will include assessing the role of islet verses whole body CHRNA7 experssion.  A floxed CHRNA7 mouse is currently underdevelopement in our lab to be utilized for the creation of an islet conditional CHRNA7 KO mouse.

 

Nothing to Disclose: LEN, MLN, DLM

14882 7.0000 SAT-1001 A The Role of CHRNA7 in Controlling Islet Inflammation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0995-1004 4798 1:00:00 PM Diabetes Complications and Genetics Poster

Jayesh J Sheth*1, Avisek Majumder1, Frenny Sheth1, Ankna Shah1, Premal Thakor2, Navneet N Shah3, Rama Vaidya4 and Mamta Lele4
1FRIGE’s Institute of Human Genetics, Ahmedabad, India, 2Gujarat Diabetes Association, Ahmedabad, India, 3Sterling Hospital, Ahmedabad, India, 4Medical Research Centre- Kasturba Health Society, Mumbai, India

 

Background: Several studies have found about 12Ala variant of PPAR-γ2gene to be associated as a protective factor to insulin resistance in type 2 diabetic patients (T2D). Although the findings are inconsistent, it is likely to be due to the confounding factors like nutrition, obesity and ethnic diversity (1-3).

Aim: To study Pro12Ala polymorphism (rs1801282) of PPAR-γ2 gene, Body Mass Index (BMI) and vitamin D3 [125(OH) D3] in relation to haemoglobin glycation (HbA1c) in T2D patients from Western India.

Materials & Method: Study comprises of a total 902 subjects that include 381 T2D patients & 521 non-diabetic subjects. All study subjects were divided into four groups as follow: group-I: 352subjects (169 T2D & 183 controls) with D3 level of ≤ 25nmol/L and BMI>25kg/m2; group-II: 137subjects (53 T2D & 84 controls) with D3 level of > 25nmol/L and BMI≤25kg/m2, group-III: 216 subjects (77 T2D & 139 controls) with D3 level of ≤ 25nmol/L and BMI≤25kg/m2 and group-IV: 197 subjects (82 T2D and 115 controls) with D3 level of > 25nmol/L and BMI>25kg/m2. Anthropometric indices like age, BMI and waist-hip ratio were recorded. All subjects were investigated for biochemical parameters and genotype study for Pro12Ala variation of PPAR-γ2gene.

Result: The 12Ala allele frequency of PPAR-γ2 gene was 8.3% in T2D patients and 9.5% in non-diabetic subjects (p=0.37). The mean HbA1c level (%) of T2D patients with 12Ala allele (n=60) was 8.0±1.7 compared to 8.2±1.9 in patients with Pro12Pro genotype (321) (p=0.21). Inverse correlation between A1c and D3 levels was observed in both T2D and control subjects [β(A1c, D3) = -0.212, r = 0.11, p= 0.057 in T2D and β(A1c, D3) = -0.046, r = 0.21, p=0.712 in non-diabetic subjects]. The mean A1c level (%) was significantly lower in group-II T2D patients with 12Ala allele (10) as compared to group-I T2D patients having same allele (23) (7.6±1.8% vs. 8.7±2.0%, p=0.05). However, patients who were homozygous for 12Pro allele, the mean A1c remains nearly equal in both group-I (146) and group-II (43) (8.5±1.9 vs. 8.1±1.9, p=0.15). Moreover, no significant effect of polymorphism was observed between group-III and group-IV T2D patients. In control subjects there was also a significant change of A1c level in group I and group-II by the effect of polymorphism but no significant change was observed between group-III and group-IV.

Conclusion: Study demonstrates that D3 has a likely role in regulating insulin sensitization, resulting in poor glycemic control in subjects with low D3 levels. The obese T2D patients with 12Ala allele and low D3level have significantly poor glycemic control compared to non-obese T2D patients having same allele and normal D3 level. From this study, it can be observed that the genetic effect of 12Ala allele is likely to depend on the life style and nutritional factors like BMI and D3 suggesting the gene-nutritional-metabolic interaction.

 

Nothing to Disclose: JJS, AM, FS, AS, PT, NNS, RV, ML

11319 8.0000 SAT-1002 A Effect of PPAR-γ2 Gene Pro12Ala Polymorphism (rs1801282), Vitamin D3 and BMI in Type 2 Diabetic Subjects; Its Association with Hemoglobin A1c Level: A Study on 902 Subjects from Western India 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0995-1004 4798 1:00:00 PM Diabetes Complications and Genetics Poster

Lev M Berstein*1, Aglaya G Iyevleva1, Tatyana E Poroshina2, Dmitry A Vasilyev1 and Evgeny N Imyanitov1
1N.N.Petrov Research Institute of Oncology, St.Petersburg, Russia, 2N.N.Petrov Research Institute of Oncology, St. Petersburg, Russia

 

Metformin (MF) is broadly used for treatment of type 2 diabetes (DM2) and is discussed as an addition to combined anticancer treatment in patients with or without DM2. Variable response to MF is the challenge for finding the predictors of sensitivity to this medicine. The aim of this study was to evaluate the interactions between some known by present hormonal-metabolic and constitutive genetic markers of potential reaction to MF.  The allele specific real time PCR with DNA isolated from blood cells was used for studying of allelic polymorphisms of organic cation transporter 1 /OCT1_R61C and rs622342/, C11orf65 (located near ATM), serine/threonine kinase STK11/LKB1, leptin receptor /LepR_Gln223Arg/ and sex hormone binding globulin /SHBG_D356N/ genes in 156 postmenopausal women (60,7±0,7 yrs). The group included DM2 patients without (32) or with (64) cancer, cancer patients without DM2 (23), and healthy females (37); of the total 96 DM2 patients 85 were with new-onset diabetes. Hormonal-metabolic status was evaluated by anthropometry (BMI, W/H ratio), measurement of fasting glucose, glycated hemoglobin (HbA1c), lipids, insulin, estradiol (E2), and by calculation of insulin resistance (HOMA) index. The following genotypes were subsumed towards the group with potentially positive MF response: OCT1_R61C (CC), OCT1_rs622342 (AA+AC), C11orf65 (CC), STK11/LKB1_rs8111699 (GG), LepR_Gln223Arg (AA+GG), SHBG_D356N (GA). A statistically significant increase of HOMA was found in carriers of aforesaid genotypes of OCT1_R61C (DM2all + cancer, new-onset DM2 ± cancer) and OCT1_rs622342 (cancer without diabetes + healthy) while the decrease of HbA1c - in carriers of GA genotype of SHBG_D356N (new-onset DM2 ± cancer) when compared with carriers of respective ‘metformin response-negative’ genotypes. Tendency to the increase of HOMA and W/H ratio values was revealed in carriers of ‘metformin-positive’ genotypes of OCT_622342 (new-onset DM2 ± cancer) and to the increase of E2 level – in combined group of cancer patients without DM2 and healthy females carrying GG genotype of STK11/LKB1. For the carriers of ‘metformin-positive’ genotype of C11orf65, on the contrary, was characteristic statistically significant decrease of HOMA (DM2all + cancer) and HbA1c (new-onset DM2 ± cancer) and tendency to the decrease of HbA1c and blood E2 values (DM2all + cancer). No any association was found with studied hormonal-metabolic parameters in carriers of 'metformin-positive' genotypes of LepR_Gln223Arg. Conclusions: 1. Postmenopausal women - carries of distinct genotypes predictive for potential MF response do not have similar hormonal-metabolic characteristics. 2. The comparative role of hormonal-metabolic and genetic markers in prediction of real metabolic as well as antineoplastic response to metformin in diabetics and non-diabetics suffering and not suffering with cancer warrants additional study.

 

Nothing to Disclose: LMB, AGI, TEP, DAV, ENI

11427 9.0000 SAT-1003 A Hormonal-Metabolic Status of Postmenopausal Females Carrying Single-Nucleotide Polymorphisms Associated or Not Associated with Potential Response to Metformin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0995-1004 4798 1:00:00 PM Diabetes Complications and Genetics Poster

Rahim Vakili*1, mohhamad Reza Abbszadegan1, Nosrat Ghaemi2, seid Hosean dehghan Manshadi3 and Marta Ghahraman4
1mashhad university of medical sciences, mashhad, Iran, 2mashhad university of medical sciences, Iran, 3mashhad university of medical sceiences, 4mashhad university of medical sciences

 

Autoimmune pollyendocine type1 (APS-1) is a rare inherited autosomal recessive disorder.Typical symptom appears in within the first decade of life and followed by adrenocortical insufficiency, mucocutaneous candidiasis, Addison's disease, and hypoparathyroidism. The clinical phenotype of APECEP is depends on mutations in autoimmune regulator gene (AIRE) which mapped to chromosome 21q22.3. We analyzed AIRE gene in subject to identify AIRE gene variants and may new mutations to facilitate the genetic diagnosis of APS-1 in Iranian patients. We detect a novel insertion mutation, Lys50AsnfsX168 in exon 2 of one of our patients using bidirectional sequencing. We also identified known mutations Arg139Stop, Arg257Stop and Leu323SerfsX51 in compound newly discovered mutation. According our report analysis of AIRE gene establishes a useful diagnosis method in patient with incomplete or unusual clinical presentation

 

Nothing to Disclose: RV, MRA, NG, SHD, MG

11282 10.0000 SAT-1004 A Novel Mutation of the Aire Gene in Iranian Patients with Autoimmune Polyglandular Syndrome Type I 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0995-1004 4798 1:00:00 PM Diabetes Complications and Genetics Poster

Pendar Farahani*1 and Mitchell Levine2
1Queen's University, Kingston, ON, Canada, 2McMaster University

 

Background: Women with diabetes have a considerably higher risk of cardiovascular related morbidity and mortality than men with diabetes.

Objective: To investigate LDL-C goal attainment amongst men versus women with diabetes and dyslipidemia.

Method: A sub-cohort of patients with diabetes was identified amongst patients with dyslipidemia on lipid-lowering pharmacotherapy in a Canadian database from primary care settings. HgbA1c and components of fasting lipid profile for men and women with diabetes were compared using ANOVA. Chi-square was used for LDL-C goal attainment comparison between men and women.

Results: 101 men and 97 women with dyslipidemia and diabetes were identified in the database. Average age was 65 (9) [mean (SD)] and 63 (11) years-old for men and women, respectively. No significant differences for HgbA1c was detected between men [6.8% (1.3)] and women [6.8% (1.0)] as an indicator of blood glucose management (P-value: 0.30). However, only 64% of female patients achieved LDL-C goal in comparison to 81% of male patients (P-value: 0.003). Average LDL-C on lipid lowering pharmacotherapy was 2.07 (0.76) mmol/l amongst men and 2.39 mmol/l amongst women.     

Conclusion: This study demonstrated women with diabetes are more likely than men to have a LDL-C above treatment goals. However, this pattern of gender gap was not observed for HgbA1c goal attainment. The concept of gender gap is useful for identifying at-risk groups for prevention and treatment efforts.

 

Nothing to Disclose: PF, ML

11033 1.0000 SAT-0966 A Gender Gap for LDL-C Goal Achievement Amongst Patients with Diabetes and Dyslipidemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Iryna Oleksandrivna Kostitska*
Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine

 

Diabetic gastroparesis (DG) is a frequent condition present in nearly 50% of the diabetic population both type 1 and type 2 [1,2], caused by gastrointestinal autonomic neuropathy. The medical literature found a strong correlation between other chronic complications of DM: nephropathy, retinopathy, neuropathy and gastroparesis. DG is sometimes associated with gastrointestinal symptoms and poor metabolic control, nutritional deficiencies, dehydration, electrolytes disturbances in a patient with uncontrolled diabetes. Usually, the patient not only has the chronic complications and gastrointestinal (GI) autonomic neuropathy, but also other diabetic complications [3]. Lack of GI symptoms does not exclude severe gastric emptying abnormalities.

Case presentation patient 32 year old male with history of type 1 DM duration 15 years, presents to the endocrinology department with 3 days of worsening nausea, vomiting and abdominal discomfort to the point where he couldn’t tolerate any oral diet. Four months earlier, he was hospitalised elsewhere to investigate persisting symptoms of nausea and vomiting for which he was prescribed omeprazole. On the last measurement glycemia control was not optimal with glycohemoglobin (HbA1C) level of 10,4 %, fasting plasma glucose 9,7 mmol/L, sometime hypoglycemic episodes and absent diabetic ketoacidosis. The subject had a history peripheral neuropathy, retinopathy and nephropathy. An evaluation was always done including X-ray, endoscopy and 13C-octanoic breast test which showed gastroparesis. Treatment was started with correction of insulin therapy and added of Domperidone 10 mg t.i.d., Alpha-lipoic acid 600 mg daily and Benfotiamine 600 mg per day during of 3 weeks. After this personal management all clinical symptoms of DG absent and present positive effect of carbohydrate metabolism.    

DG is debilitating disorders that are difficult to treat with currently available therapies. Early identifying and treating both of these issues will go a long way to improve the overall well-being of these patients.

 

Nothing to Disclose: IOK

11106 2.0000 SAT-0967 A Diabetic Gastroparesis Is the Difficult Complication of Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Xia-Nan Zheng, Hong Li* and Sheng-Cheng Mao
Sir Run Run Shaw Hospital Affiliated with Zhejiang University School of Medicine, Hangzhou, China

 

Assessing the Impact of Chronic Complications on Inpatient Costs of Type 2 Diabetes: Experience from Hangzhou Background: Previous studies have found that diabetic complications are associated with an increase in average annual medical cost. However whether chronic complications have an impact on inpatient spending is unknown. We performed a retrospective study to find the determinants of inpatient costs of type 2 diabetes in a diabetes center in Hangzhou, China. Methods: All patients with type 2 diabetes admitted to our department from December of 2010 to February of 2012 were identified. Clinical and demographic information was extracted from the electronic database and extensive chart review was performed. Total inpatient spending included pharmacological costs, diagnostic tests, surgeries, medical materials and other costs. We analyzed the association between chronic complications and inpatient costs using generalized linear model to better fit a gamma distribution. Costs were expressed as Chinese Currency RMB, year 2012 values. Results: Among 596 patients with a mean age of 55 years and an average duration of diabetes of 90 months, 81.2% had at least one chronic complications by the time they were discharged. Stroke and coronary artery disease had a prevalence of 2.2% and 7% respectively, retinopathy 36.4%, nephropathy 24.7%, neuropathy 43.1% and diabetic foot 6.2%. The total cost of patients with chronic complications was 17 % higher than that of patients without complications (6761 vs. 5757 RMB; p=0.001). Costs for medications and diagnostics represented 34 % and 19% of total inpatient costs, respectively. Coronary artery disease was associated with a significant increase in total inpatient spending and diagnostic tests (8466 vs. 6428.99 RMB on total cost; p<0.05) but not on medications. Presence of neuropathy and diabetic foot apparently increased total inpatient costs as well as costs on medication and tests (7632.53 vs. 5768.94 RMB on total cost for neuropathy, P<0.01; 10672.22 vs. 6301.95 RMB on total cost for diabetic foot, p<0.01). Stroke, retinopathy and nephropathy were not related with inpatient costs. Conclusions: This study has confirmed that the prevention of diabetic complications will not only benefit patients, but reduce healthcare expenditure during hospitalization. Neuropathy, diabetic foot and Coronary artery disease increase inpatient costs while microvascular complications have little impact. It will be critically important for physicians and health policy planners to direct resources in future years towards developing cost-effective ways of dealing with diabetic foot and neuropathy.

 

Nothing to Disclose: XNZ, HL, SCM

11983 3.0000 SAT-0968 A Assessing the Impact of Chronic Complications on Inpatient Costs of Type 2 Diabetes: Experience from Hangzhou 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Jayanta Chakraborty*1, Semanti Chakraborty2 and Ankan Bandopadhyaya3
1Vivekananda Institute Of Medical Sciences, kolkata, India, 2All India Institute of Medical Sciences, kolkata, India, 3RGKAR medical college,Kolkata, Kolkata, India

 

Glutamic acid decarboxylase antibody 65 ( GAD)  acts against various tissues  in addition to beta cells, like nerve cells, thyroid cells etc.  The present study was undertaken as a pilot study to find out a relation between type2 diabetes, autoimmunity and coronary atherosclerosis.

A total of 26 patients were studied to assess an association between GAD and angiographic significant coronary artery disease ( CAD). The patients were considered to be GAD positive if GAD concentration was found to be greater than or equal to 1.0 U/ml.

Out of 26 subjects (mean age - 55.04 ± 7.64 years), 5 subjects (19.23%) were found to be GAD positive. Four GAD positive subjects (15.38%) were found to have CAD whereas 1 GAD positive subject(3.85%) was negative for any CAD. Remaining 21 subjects (80.77%) were GAD negative, out of which 18 subjects (69.23%) were not found to have any coronary artery disease and 3 , (11.54%) were found to have CAD. overall,7 subjects (26.92%) were found to have CAD whereas 19  (73.08%) were found negative for CAD. Significant association found between GAD antibody positivity and CAD (p value–0.010).No significant association was found between gender and occurrence of CAD (p value-0.340) as determined by Fischer’s exact test. Among 19 males (73.08%), 4(15.38%) were found to have CAD and 15(57.69%) were negative for CAD. Out of 7 females (26.92%), 3 (11.54%) were positive for CAD and 4(15.38%) were negative for CAD. . No significant difference found by using unpaired t-test between GAD positive and GAD negative subjects with respect to age (p value-0.453),BMI(p value-0.682).No significant difference found by using Wilcoxon-Mann-Whitney test between GAD positive and GAD negative subjects with respect to systolic blood pressure (p value-0.119), diastolic blood pressure (p value-0.568).

 In conclusion, from the present study, significant association was found between GAD antibody positivity and CAD in Type2 diabetics, (p value–0.010)  . No significant difference of gender, age, BMI, SBP, DBP was found between the GAD positive and GAD negative subjects.

                              Our study strongly endorse that coronary atherosclerosis is an autoimmune disorder.  Secondly, GAD antibody testing is a non-invasive, less expensive screening test for diagnosis and pharmacologic treatment of coronary artery disease in Type2 diabetics.

 

Nothing to Disclose: JC, SC, AB

12389 4.0000 SAT-0969 A Type2 Diabetes, Autoimmunity and Coronary Atherosclerosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Ivan Pchelin* and Alexander Shishkin
St. Petersburg State University, St. Petersburg, Russia

 

Correction of anemia is essential for patients with diabetic nephropathy. However, still there are a lot of contradictions related to benefits and risks of antianemic treatment. Erythropoietin therapy has a variety of non-hematopoietic effects that are not currently taken into consideration by treatment protocols. The aim of this study was to assess the influence of treatment with erythropoietin alpha on serum levels of interleukin-6 (IL-6) in patients with early diabetic nephropathy.

We included 36 patients with type 2 diabetes mellitus and early diabetic nephropathy (CKD stages 1-3) complicated with anemia. Patients with non-renal causes of anemia and/or iron overload were not included. Written informed consent was obtained from all study subjects. The main group (17 patients) received standard doses of erythropoietin alpha subcutaneously (starting from 30 IU/kg with further correction according to NKF-K/DOQI Guidelines, 2006) and iron medication orally (ferrous sulfate, 200 mg per day) for 16 weeks. The control group (19 patients) received only oral iron medication (ferrous sulfate, 200 mg per day) for the same period of time. Besides performing routine clinical tests we measured serum concentrations of IL-6 using enzyme immunoassay (ProConIL-6 test system) before and after 16 weeks of treatment. Mann-Whitney test was used to compare mean levels of IL-6 in study groups. Wilcoxon test was used to assess dynamics of this parameter during treatment in each group.

Before treatment we found no difference in mean serum levels of IL-6 in clinical groups: main group – 32.0±4.6 pg/ml, control group – 35.2±5.0 pg/ml (reference value – <5 pg/ml). After 16 weeks of treatment only patients who had received erythropoietin alpha had significantly lower concentrations of IL-6 as compared to initial values (W=3.40; p<0.001). Mean serum levels of IL-6 were as follows: main group – 4.8±1.5 pg/ml, control group – 33.2±4.4 pg/ml (U=36.0; p<0.001). Inappropriately slow increase in hemoglobin and hematocrit levels was associated with higher serum concentrations of IL-6 in the main group.

The results of the study suggest that comprehensive antianemic therapy with erythropoietin and iron medications leads to a reduction in serum concentrations of IL-6 in anemic patients with early stages of diabetic nephropathy. Further studies are needed to elucidate clinical implications of this effect.

 

Nothing to Disclose: IP, AS

12463 5.0000 SAT-0970 A Erythropoietin Therapy Reduces Serum Level of Interleukin-6 in Anemic Patients with Early Stages of Diabetic Nephropathy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Samir Patel*1, Palak Patel2 and Mihir Patel3
1Western Reserve Health Education/NEOMED, youngstown, OH, 2Qingdao Medical College, China, 3St. Mary's Hospital, waterbury, CT

 


BACKGROUND

Patients with Type II Diabetes Mellitus (T2DM) have higher risk of cardiovascular (CV) events and it remains the major cause of long-term morbidity and mortality. Previous studies have shown that oral hypoglycemic agents, lower the blood glucose, but fail to improve CV outcomes. Furthermore, studies have revealed a reduction in CV events with use of Dipeptidyl peptidase-IV (DPP-IV) inhibitors on a short term basis, however long-term effect on CV events of DPP-IV inhibitors were questionable.

 

AIM

A Meta-analysis was conducted, to determine the long-term effect of DPP-IV inhibitors as monotherapy on adverse CV events in middle-aged T2DM population compared to placebo and/or other oral hypoglycemic agents.

 

METHODS

A thorough search of electronic databases, including MEDLINE, Scopus, Cochrane and www.clinicaltrials.gov; was performed for selection of randomized controlled trials (RCTs) of DPP-IV inhibitors through Dec 2013 by using the key words, ‘alogliptin’, ‘DPP4i’, ‘gliptins’ ‘linagliptin’, ‘saxagliptin’, ‘sitagliptin’, and ‘vildagliptin’. RCTs were selected for meta-analysis if (1) RCTs comparing DPP-IV inhibitors monotherapy to placebo and/or other oral hypoglycemic agents as monotherapy, (2) duration of treatment ≥52 weeks to see long-term effect, (3) reported data on adverse CV events (death from CV causes, nonfatal MI or acute coronary syndrome, CHF, stroke, and arrhythmias) (4) mean age of 45-65 years and (5) were published in English.

 

RESULTS

Six RCTs met our inclusion criteria, comprising of 12,791 patients who were randomized to DPP-IV inhibitors and 12,610 patients to a comparator or placebo, with a median duration of therapy of 94 weeks, and mean JADAD score of 4.3. Pooled statistical analysis was performed by MedCalc 12.7v software. As compared with placebo or other comparator monotherapy, DPP-IV inhibitors monotherapy showed a trend towards reduction in adverse CV events but remain statistically non-significant. [Risk Ratio (RR) = 0.88, 95% CI (0.70, 1.09), p = 0.078]. In further subgroup analysis, Linagliptin reduced adverse CV events with statistical significance [RR = 0.45, 95% CI (0.23, 0.90), p<0.001] as compare to placebo.  EXAMINE trial of Alogliptin and SAVOR-TIMI 53 trial of Saxagliptin demonstrated statistically significant reduction in CV events [p<0.001, non-inferiority].  However, other trials for Saxagliptin, Sitagliptin and Vildagliptin showed lowering trend in adverse CV events without statistical significance.

 

CONCLUSION

DPP-IV inhibitors, which are very effective in reducing the blood glucose, failed to show overall reduction in long-term adverse CV events in middle-aged T2DM patients even when few individual studies shown reduction in long-term adverse CV events. However, lowering trend for adverse CV events needs to be confirmed by long-term follow up of ongoing trials.

 

Nothing to Disclose: SP, PP, MP

12557 6.0000 SAT-0971 A Long-Term Effect of Dipeptidyl Peptidase-IV Inhibitors on Cardiovascular Events in Type 2 Diabetes Mellitus Middle-Age Patients: A Meta-Analysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Kevin M Pantalone*1, Todd M Hobbs2, Brian J Wells1, Sheldon X Kong2, Michael W Kattan1, Jonathan R Bouchard3, Changhong Yu1, Brian Sakurada2, Alex Milinovich1, Wayne Weng4 and Robert S Zimmerman1
1Cleveland Clinic, Cleveland, OH, 2Novo Nordisk, Plainsboro, NJ, 3Novo Nordisk, Inc., Plainsboro, NJ, 4Novo Nordisk Inc., Plainsboro, NJ

 

Introduction: Patients with type 2 diabetes mellitus (T2D) are at risk of developing diabetes-related complications and comorbidities. The objective of this analysis was to evaluate the prevalence of these complications and comorbidities in patients with T2D in a large integrated health system. 

Methods: An enterprise-wide electronic health record system (EHR) at a large U.S. academic health center was used to conduct a cross-sectional analysis of 94,600 patients with T2D with a baseline glycosylated hemoglobin (A1C) value available on or before the index date of July 1, 2013. Patients with diabetes were identified using ICD-9 codes. Patients with type 1 diabetes were effectively excluded by requiring at least one prescription for an oral hypoglycemic agent. The population was divided into four groups based on the index A1C level: <7%, 7–7.9%, 8–8.9%, and ≥9%.

Results: The population had a mean age of 66.8 years, was 48.7% female, and 72.7% White. A total of 53,383 (56.4%), 20,278 (21.4%), 9137 (9.7%), and 11,802 (12.5%) patients were included in each of the A1C categories, respectively. The mean ages (years) for patients across the A1C categories were 68.1, 68.0, 65.5, and 59.6, respectively.  An analysis of comorbidities and complications within each A1C category revealed the following distributions: hypertension (84.3, 84.3, 82.1, 78.2%) cardiovascular disease (41.8, 43.1, 42.8, 33.6%), retinopathy (5.5, 7.4, 8.0, 8.2%), nephropathy (19.8, 18.4, 17.0, 12.6%), neuropathy (27.4, 24.8, 25.2, 22.8%), cerebrovascular disease (18.4, 18.0, 17.0, 13.5%) and peripheral vascular disease (11.3, 11.4, 11.0, 9.1%). The percentages of patients with two, three, and four or more comorbidities were 27.6, 17.5, and 14.6%, respectively.

Conclusion: A high prevalence of hypertension and cardiovascular disease were observed among this population with T2D. The prevalence rates of nephropathy, neuropathy and peripheral vascular disease varied across A1C categories.  Retinopathy was more prevalent among patients with higher A1C levels.  A majority of patients have more than one comorbidity. This analysis underscores the importance of managing both glycemic control and the associated comorbidities and complications of diabetes.

 

Disclosure: KMP: Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Eli Lilly & Company, Medical Advisory Board Member, Eli Lilly & Company, Medical Advisory Board Member, Sanofi, Medical Advisory Board Member, Novo Nordisk, Researcher, Novo Nordisk. TMH: Employee, Novo Nordisk. BJW: Researcher, Novo Nordisk. SXK: Employee, Novo Nordisk. MWK: Researcher, Novo Nordisk, Consultant, GlaxoSmithKline, Consultant, Merck & Co.. JRB: Employee, Novo Nordisk. BS: Employee, Novo Nordisk. WW: Employee, Novo Nordisk. RSZ: Speaker Bureau Member, Santarus, Speaker Bureau Member, Johnson &Johnson, Speaker Bureau Member, Merck & Co., Speaker Bureau Member, Jansen Pharmaceuticals, Speaker Bureau Member, Novo Nordisk, Researcher, Novo Nordisk. Nothing to Disclose: CY, AM

12643 7.0000 SAT-0972 A Complications and Comorbidities Among Patients with Type 2 Diabetes Mellitus in a Large Integrated Health System 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Eun Yeong Mo*1, Sungdae Moon2, Eun sook Kim3 and Je ho Han3
1Catholic Univ, Incheon, Korea, Republic of (South), 2Catholic Univ of Korea, Incheon, Korea, Republic of (South), 3Catholic Univ, Incheon

 

Background: It has been suggested that arterial stiffness and atherosclerosis are independent predictors of cardiovascular disease. The relationships of arterial stiffness with carotid plaque however, have rarely been investigated in type 2 diabetes. The present study reports the associations of carotid plaque score assessed by B-mode ultrasound with brachial-ankle pulse-wave velocity in type 2 diabetic patients without cardiovascular disease.Methods: In this study, participants consisted of 522 type 2 diabetic patient free of cardiovascular disease(age 55.84±10.9 years, diabetic duration 7.39±7.5). Brachial-ankle pulse-wave velocity (baPWV) was measured non-invasively using VP2000 (Colin Corporation) automated ABI/PWV analyzer to assess arterial stiffness. Carotid ultrasound examination included measurements at sites free of plaques of intima-media thickness (IMT) at the common carotid arteries (CCA) and assessment of atherosclerotic plaques in the extracranial carotid arteries. The plaque scoring quantified method was that: grade 0 for normal or no observable plaque, grade 1 for 1 small plaque with diameter stenosis <30%, grade 2 for 1 medium plaque with 30% to 49% diameter stenosis or multiple small plaques, grade 3 for 1 large plaque with 50% to 99% diameter stenosis or multiple plaques with at least 1 medium, and grade 4 for 100% occlusion.Results: Patients with higher plaque grade had worse clinical and laboratory profile than those with lower plaque grade, including age, prevalence of hypertension, clinical BP, diabetic duration, fasting glucose, GFR and baPWV(m/s). Multivariate analyses showed that plaque score was mainly associated with age, male sex, hypertension, mean IMT and baPWV(m/s).(P < 0.05). baPWV was positively associated with plaque score in sex-adjusted analysis (r= 0.39 , P < 0.001 ). And baPWV was independently associated with plaque grade in patients over 49years of age.Conclusion: This study showed arterial stiffness was associated with carotid plaque grade. Especially, measurement of carotid artery stenosis may improve the assessment of atherosclerosis in type 2 diabetic patients without cardiovascular disease except younger patients.

 

Nothing to Disclose: EYM, SM, ESK, JHH

14605 8.0000 SAT-0973 A Relationship Between Carotid Plaque and Arterial Stiffness in Type 2 Diabetes without Cardiovascular Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Ibrahim Sahin*1, Zuhal Karaca1, Cagatay Taskapan2, Fatma Ozyalin2 and Saim Yologlu2
1Inonu University School of Medicine, Malatya, Turkey, 2Inonu University, Malatya, Turkey

 

Previous studies showed that type 2 DM could affect bone metabolism through several mechanism and it may increases risk for osteoporosis(1). Some of glucose lowering therapies has been reported to effect on bone turnover(2). However the effect of insulin therapy on bone metabolism markers has not been well documented yet. This study aimed investigates passible effect of human insulin and analogue insulin on bone resorption and formation marker in patients with type 2 diabetes mellitus.

This study had prospective and parallel design. Study population were consisted of thirty-three insulin naïve type 2 diabetic patients on oral anti-diabetics with poor glycaemic control. Of these, 13 patients were initiated analogue insulin (detemir and aspart insulin) and 10 patients were initiated human insulin (regular and NPH insulin) as a basal and bolus insulin therapy. Fasting plasma glucose (FPG), postprandial plasma glucose (PPG), A1C, Ca, P, PTH, osteocalcin (OC) and type 1 collagen C telopeptide (CTX) levels were measured before initiation and after 3 months of insulin therapy period.

Baseline characteristics of patients, including age, body mass index, FPG, PPG A1C, Ca, P, PTH and biochemical markers were similar between the two groups. Osteocalcin levels, biomarker of bone formation, were significantly increased ( 4.38±2.46 vs  5.49±3.61 ng/ml, p= 0.028), and CTX levels, biomarker of bone resorption, were significantly decreased ( 315.7±240.2 vs 228.9±204.5 ng/ml, p=0.039) compared to the baseline in the analogue insulin-treated group. However, there was no significant chance in OC and CTX levels compared to the baseline in the human insulin-treated group (p>0.05).

Our results indicate that analogue insulin (detemir and aspart ), but not human insulin, may improve bone turnover in type 2 diabetic patients.

 

Nothing to Disclose: IS, ZK, CT, FO, SY

14997 9.0000 SAT-0974 A Alteration in Bone Metabolism Markers Fallowing 3-Months Insulin Therapy in Patients with Type 2 Diabetes Mellitus: Analogues Vs. Human Insulins 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Paula Freitas*1, Eva Lau1, Oliveira Joana2, Mariana Lobo3, Tiago Silva Costa4, Alberto Freitas4 and Davide Carvalho5
1Centro Hospitalar São João; Faculty of Medicine, Porto University, Portugal, 2Centro Hospitalar São João; Faculty of Medicine, Porto University, 3Center for Research in Health Technologies and Information Systems, 4Center for Research in Health Technologies and Information Systems, Faculty of Medicine of University of Porto, 5Centro Hospitalar São João, Faculty of Medicine, University of Porto, Portugal

 

Introduction: Diabetes mellitus (DM) is the third modifiable risk factor for pancreatic cancer (PCa), after smoking and obesity. However, most epidemiological studies focuses only on type 2 DM.

Aims: To evaluate the: 1) prevalence of hospitalizations for CaP in: a) DM vs general population, b) type 1 DM vs type 2 DM, 2) PCa mortality in DM vs general population, 3) prevalence of dyslipidaemia, obesity, hypertension and alcohol intake in patients with PCa (DM vs general population).

Methods: Retrospective analysis of patients admitted to a terciary hospital between 1988 and 2012.  Cohorts were defined based on the primary and/or secondary diagnosis of PCa and / or diabetes, coded according to the ICD-9-CM. The prevalence of hospitalizations is expressed in percentages and χ2 test was used for inferential analysis, with a significance level to α = 0.05.

Results: The prevalence of CaP was higher in diabetic patients [0.30% (316/104007)] vs general population [0.11% (1016/897645), p <0.001]. There were no differences in the prevalence of CaP between type 1 and 2 DM. The prevalence of CaP was higher in men in the general population and in diabetics, regardless the type. The CaP associated mortality was higher in the general population vs. diabetic patients [(20.47% vs 18.67%, p <0.001)]. The PCa mortality was greater in diabetic men; no differences were found in the general population, concerning gender. In patients with PCa, the prevalence of dyslipidemia (3.50% vs 1.10%, p <0.001) and hypertension (39.90% vs16, 70%, p <0.001) was higher in diabetic vs general population; the prevalence of obesity (2.80% vs 4.10%, p=0,003) was lower in diabetics; no differences were found in alcohol consume.

Conclusion: The prevalence of hospitalizations for CaP was higher in diabetics, but not differences were found, concerning the type of diabetes. The CaP mortality was higher in the general population, comparing to diabetics.

 

Nothing to Disclose: PF, EL, OJ, ML, TSC, AF, DC

15695 10.0000 SAT-0975 A Hospitalization and Mortality for Pancreatic Cancer and Diabetes: A Cohort from a Tertiary Hospital 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Jung Min Kim*1, Jee Hee Yoon2, Soo Jeong Kim2, Hee Kyung Kim3 and Ho-Cheol Kang2
1St. Carollo Hospital, Suncheon, Korea, Republic of (South), 2Chonnam National University Medical School, Gwangju, Korea, Republic of (South), 3Chonnam National University College of Medicine, Gwangju, Korea, Republic of (South)

 

Objective: Diabetes mellitus is well known risk factors of several cancers including pancreatic, breast and colorectal cancer. However, relationship between diabetes and lung cancer is still unclear. Recently, some studies reported diabetes is independently associated with mortality of lung cancer. The aim of this study is to determine the effect of diabetes on lung cancer survival.

Methods: We retrospectively reviewed medical records of 2,164 patients coexisted diabetes and lung cancer at the time of diagnosing lung cancer who attended Chonnam National University Hwasun Hospital between 2005 and 2012.

Results: The overall survival of lung cancer was not different (p =0.920) between diabetic group (262 cases) and non- diabetic group (1902 cases). There was no significant difference between diabetic and non-diabetic groups in sub-group analyses using first-line therapy and cancer types (SCLC and NSCLC). Good glycemic control (HbA1c < 7%) and metformin use were not associated with improved survival in diabetic patients with lung cancer (p=0.19).

Conclusions: Diabetes is not associated with poorer prognosis in patients with lung cancer. Goal of glycemic control in diabetic patients with lung cancer should be modest, considering the limited survival time and the risk of hypoglycemia.

 

Nothing to Disclose: JMK, JHY, SJK, HKK, HCK

15740 11.0000 SAT-0976 A Diabetes Does Not Negatively Influence on Overall Survival of Lung Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Ramesh Jayanthy* and Nagendar Jakka
osmania general hospital, hyderabad, India

 

Male Sexual dysfunction (SD) includes erectile, ejaculatory,orgasmic dysfunctions and hypoactive sexual desire disorder (HSDD).We did a cross sectional study to know the association of  glycemic status, dyslipidemia  and hormonal status with SD in  males with Type 2  DM

 60 consecutive male type 2 diabetic patients  aged  30 to 60 years, were included in the study after excluding other etiological factors of SD .These subjects were compared with 18  BMI matched diabetic males without SD. SD was diagnosed with history, clinical examination, International Index of Erectile Function  questionnaire  and Premature ejaculation diagnostic tool. Prevalence of  SD is 70% ( n=42), ED  65 % (n=39), Orgasmic dysfunction is 26.66 (n=16) HSDD is 15 % (n=9) and PE is 36.66 % ( n=22).HbA1c (9.131 ± 0.303 vs. 6.989 ± 0.095 % ; P=0.000) were higher in SD patients. Non HDL cholesterol (145.531 ± 36.832 vs. 112.611 ± 22.799 mg/dl  ; P=0.001 ) and TG levels( 215.500 ± 21.283 vs. 137.056 ± 7.019 mg/dl ; P= 0.021 ) were higher in SD group. Testosterone  (347.892 ±22.821 vs. 455.522 ± 39.640 ng/dl ; P=0.016) and LH (5.953± 0.491 vs. 9.083 ±0.809 IU/L ; P=0.001 )   was lower in SD patients. No significant difference was found in age   (P= 0.335)  and  duration of  DM (P=0.056) in  SD group  compared to Non SD group.

Conclusion : Poor glycemic control, dyslipidemia are important factors  associated with sexual dysfunction in diabetic males. Statistically significant low LH  and testosterone levels seen in these patients suggest that functional hypogonadism also contributes to SD in diabetic male.

 

Nothing to Disclose: RJ, NJ

16006 12.0000 SAT-0977 A A Study of Correlation of Metabolic and Hormonal Parameters with Sexual Dysfunction in Males with Type 2 Diabetes Mellitus in India 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Ugur Ünlütürk*1, Altug Sacit Kesikli2, Gürcan Günaydin3, Can Ates1, Esranur Ademoglu1, Ali Riza Uysal4 and Rifat Emral1
1Ankara University School of Medicine, Ankara, Turkey, 2Hacettepe University, Institute of Oncology, Ankara, Turkey, 3Hacettepe University Institute of Oncology, Ankara, Turkey, 4Ankara University School of Medicine

 

Background:The lack of enough randomized controlled studies in the treatment of type 2 diabetes is the most important obstacle in recommending a single-drug or a combination treatment to the other. The pleiotropic effects of the treatment choices other than the control of hyperglycemia in type 2 diabetes are also equally important.

Objectives:The aim of this study was to evaluate the effect of early short term basal insulin treatment on serum levels of high molecular weight adiponectin (HMWA), a metabolically active anti-inflammatory adipokine that increases insulin sensitivity.

Materials and methods: The effects of short-term early use of basal insulin on serum adiponectin levels in type 2 diabetic patients who has poor glycemic control despite life-style modifications and use of metformin was investigated in an open-labeled randomized prospective setting. Fifty-three of 64 randomly selected T2DM patients completed the study: 23 in the early basal insulin (insulin detemir) treatment arm and 30 in the gliclazide-MR arm.

Results:Glucose homeostasis, hemoglobin A1c levels and changes in body weight were not different between the two treatment arms. During the course of both treatments, body weights were found to increase significantly.  Compared to the sulfonylurea-only study arm, levels of adiponectin have been shown to increase significantly with early basal insulin therapy. Such increased levels continued even after the switch to sulfonylurea therapy.

Conclusions: These results suggest that through increasing adiponectin levels, early short term basal insulin treatment might be a promising approach in preventing late complications associated with T2DM.

 

Nothing to Disclose: UÜ, ASK, GG, CA, EA, ARU, RE

16344 13.0000 SAT-0978 A The Effect of Early-Short Term Basal Insulin Treatment on Adiponectin Levels in Patients with Type 2 Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Valerie Ann Uy Valdez*1 and Leilani Basa Mercado-Asis2
1University of Santo Tomas, Manila, Philippines, 2University of Santo Tomas, Manila City, Philippines

 

Nonalcoholic Fatty Liver Disease in Patients with Pre-impaired Glucose Tolerance: A Preliminary Report

Context        

Pre-impaired glucose tolerance (pre-IGT) or compensated hyperinsulinemia, is characteristic of the early stage of diabetes mellitus (DM), where beta cells compensate for insulin resistance by increasing insulin secretion to maintain normoglycemia.  Pre-IGT, defined as second hour glucose level of <140 mg/dL, and insulin level of >30 uIU/mL after a 75-gram oral glucose load; was observed in 42-68% of individuals high risk to develop DM. With continuing beta cell failure, increasing insulin levels can no longer compensate for the insulin resistance and insulin secretion eventually fail, leading to the progression to type 2 DM.

Nonalcoholic fatty liver disease (NAFLD) is a common feature of insulin resistance, with a prevalence of 54.5% and 33% in patients with diabetes mellitus and pre-diabetes respectively.  However, its prevalence or association with pre-IGT patients has not yet been elucidated. 

Objective

We determined if nonalcoholic fatty liver disease was present in patients with pre-impaired glucose tolerance, and its relationship with body mass index (BMI), lipid profile and insulin levels.

Study Design & Participants

This was a descriptive study on the determination of nonalcoholic fatty liver disease in pre-IGT patients, conducted at a university hospital.  A total of eight (8) subjects with pre-IGT participated in the study.

Intervention

Liver ultrasound was done on the subject using the Samsung S3000 machine. The Hamaguchi Scoring System, which is based on echo contrast, bright liver, deep attenuation and vessel blurring, was used to diagnose NAFLD, with a score of ≥ 2. The presence of fatty liver was then further classified into mild, moderate and severe.  Descriptive statistics and the Pearson product-moment correlation were used for data analysis.

Outcome Measures and Results

The baseline characteristics of the subjects were as follows: mean age of 35 ± 7 years, with an average BMI of 24.8 ± 3.33 kg/m2; 87.5% were female.  Average total cholesterol, triglyceride, HDL and LDL levels were 193.19 mg/dL, 87.76 mg/dL, 72.84 mg/dL and 102.53 mg/dL respectively; kidney and liver function tests were likewise within normal limits.  The mean second hour glucose and insulin level were 92.84 mg/dL and 61.69 uIU/mL, after a 75-G oral glucose load.  Mild nonalcoholic fatty liver disease was identified in 3 of the 8 subjects, which only had moderate positive correlation with BMI and insulin levels.

Conclusion

Nonalcoholic fatty liver disease was identified in 37.5% of patients with pre-impaired glucose tolerance, which correlated with higher BMI and insulin levels.

 

Nothing to Disclose: VAUV, LBM

16462 14.0000 SAT-0979 A Nonalcoholic Fatty Liver Disease in Patients with Pre-Impaired Glucose Tolerance: A Preliminary Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Sandeep Kumar Mathur*1, Prashant Mathur2, Poonam Punjabi2, Deepak Kumar Gupta3, Jyoti Thanvi4, Mukul Mathur5 and Krishan Mohan6
1SMS Medical College, Jaipur, India, 2SMS Medical College, Jaipur, Rajasthan, India, 3University of Rajasthan, Jaipur, India, 4Jaipur College of Engineering & Research, Jaipur, India, 5S.M.S.Medical College, Jaipur, India, 6Birla Institute of Scientific Research, jaipur, India

 

Background: Primary unresponsive to pioglitazone seen in about one fifth of diabetics and was found not to be related to common clinical and biochemical characteristics of the patient and Pro12Ala polymorph of PPAR–gamma gene. 

Subjects: A total of 104 newly diagnosed type 2 DM patients as per ADA criteria and no contradiction to the drug were treated with pioglitazone 30 mg per oral once daily for at least 12-24 weeks.

Genotyping: We designed 10 primer sets flanking variants SNP markers spanning PPAR-gamma and its co-activators gene. The PCR products produced by amplification of these genomic regions were subjected to HRM melting analysis for screening of polymorphs of PPAR-gamma and its co-activator gene.

Results: Total 88 patients completed at least 12 weeks of follow up. There was wide inter-individual variation in glycemic response (coefficient of variance was 66.44%, 95.75 %, and 75.22 % respectively for FPG, PPG and HbA1c). Eighteen (20.45%) patients were primary non-responders in whom less than 10% decrease in HbA1c level was observed. While 70 (79.55 %) patients were responders who showed more than 10 % decrease in HbA1c from baseline levels after the treatment.

On melting curve (HRM) analysis we found that exon 1 of PPAR-gamma gene amplified using primer set ENSG1 was highly polymorphic among all the patients, but there was wide overlapping in Tm of this fragment between responders and non responders. No polymorphism was noticed in other flanking variants SNP markers spanning PPAR-gamma and its co-activator gene amplified with other primer sets.

Conclusions: Primary unresponsiveness to pioglitazone is not related to common SNP polymorphs of PPAR-gamma and its co- activator Gene.

 

Nothing to Disclose: SKM, PM, PP, DKG, JT, MM, KM

16704 15.0000 SAT-0980 A Primary Unresponsiveness to Pioglitazone Is Not Related to PPAR-Gamma and Its Co- Activator Gene SNP Polymorphs 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Nalini Santanam*1, Abid Yaqub2, Carla Cook3 and Todd Gress3
1Marshall University School of Medicine, Huntington, WV, 2Marshall University SOM, Proctorville, OH, 3Marshall University School of Medicine

 

Type 2 Diabetes Mellitus (T2DM) is a chronic disease that manifests with low-grade inflammation. Pathways that modulate inflammation are thus potential targets for inflammatory diseases such as diabetes. CX3CL1 (fractalkine) is a unique chemokine that acts both as a chemoattractant (soluble form) and adhesion molecule (membrane anchored) and is the only one of its kind that belongs to the CX3C family of chemokines. It was recently identified to be an adipochemokine, since it was also synthesized by adipose tissue and was higher in diabetics compared to non-diabetics. We recently initiated the ADVANCE trial to investigate the feasibility of using cell-phone texting services to improve provider/patient communications and provide diabetes education to T2DM patients in rural West Virginia. This trial includes patients with diabetes either receiving standard of care or standard of care plus education/communication through cell phone texting. Clinical endpoints (HbA1c, BMI) and blood are obtained from these patients at baseline and at 3 months, 6 months and one year. The goal of this study was to investigate if there are longitudinal changes in CX3CL1 levels (ELISA) and identify circulating regulators of this chemokine (i.e. circulating microRNAs- whole genome microarray). Our results showed a significant lowering of CX3CL1 longitudinally in these patients, which correlated with HbA1c and BMI. Circulating miRNAs (miR-16, miR-195, miR-15b) that target CX3CL1 were upregulated in the serum with time which correlated with lowering of the CX3CL1 levels. Our results thus far suggest that CX3CL1 is an excellent modifiable target for the treatment of diabetes. We are currently exploring the role of the CX3CL1 pathway in diabetes.

 

Nothing to Disclose: NS, AY, CC, TG

16827 16.0000 SAT-0981 A Longitudinal Changes in CX3CL1 Targeting Micrornas in Patients with T2DM 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Walaa Ayoub*1, Ryan D Mills2, Sunil Thomas3, Rashim Gupta3, Jessica Eve Shill2, Sharon Wu Lahiri2 and Abraham Thomas4
1Henry Ford Medical Center, Detroit, MI, 2Henry Ford Health System, Detroit, MI, 3Henry Ford Hospital, Detroit, MI, 4Henry Ford Med Ctr, Detroit, MI

 

Background: Some patients with diabetes have severe insulin resistance requiring over 2 units/kg/day of insulin. These patients can be difficult to manage due to discomfort from and decreased rate of insulin absorption from such high volumes. In the USA, most insulin has a concentration of 100 units/ml. U-500 regular insulin (500 units/ml) has been used in patients with severe insulin resistance. Although there is increasing use of U-500 insulin, there are no large scale studies on the efficacy of U-500 insulin.

Methods: An IRB-approved retrospective study identified 97 subjects from the Endocrinology clinic started on U-500 insulin with follow up data 3 and 6 months later. The aim of this study was to examine the changes in hemoglobin A1c (A1c) and weight over time. A1c was measured at three time points: 0, 3, and 6 months; while weight was measured twice. Paired t-tests were used to compare the two weight values and the two systolic blood pressure (SBP) values. A1c values were non-normally distributed so a square-root transformation was performed. A repeated-measures mixed model (GEE method) was done to examine the effect of U-500 insulin over time on A1c. Because that test was significant, three paired t-tests compared initial, 3-month, and 6-month HbA1c in a pairwise fashion. In order to control the type I error rate which can be inflated by multiple pairwise tests, a Benjamini-Hochberg p-value adjustment was applied and adjusted p-values are reported. A Wilcoxon signed-rank test was used to compare diastolic blood pressure (DBP), Total Daily Dose of insulin in units (TDD), number of injections, total cholesterol, HDL, LDL, and triglycerides due to their non-normal distributions. All analyses were done using SAS 9.2 (SAS Inc, Cary, NC, USA). Statistical significance was set at p<0.05.

Results: The mean age of the 97 subjects was 59.3 ± 11.8 years with 47 females and 50 males. The racial background of the subjects was 61 White, 14 Black, 18 Asian, and 4 Hispanic. The mean (± SD) A1c was 9.6± 1.9 % at baseline and significantly decreased to 8.5 ± 1.5% (p <0.001) 6 months after initiation of U-500 insulin. The mean DBP (77.42±11.63 vs. 75.96 ±15.62, p= 0.0336) and number of total daily insulin injections (4.47±1.16 vs. 2.92 ± 0.88.56, p <0.001) decreased significantly at 6 months compared to baseline. There were no significant differences in weight, SBP, TDD, or lipids, 6 months after initiation of U 500 insulin. No episodes of severe hypoglycemia requiring assistance were reported in any of the subjects’ medical charts.

Conclusion: U- 500 insulin significantly lowered A1c by 1.1% at 6 month. This occurred without an increase in weight or documented severe hypoglycemia. A significant decrease in the number of insulin injections was noted at 6 months. Future studies will need to determine the optimal dosing and frequency of U-500 insulin injections as well determine if there is an improvement in adherence with U-500 insulin.

 

Nothing to Disclose: WA, RDM, ST, RG, JES, SWL, AT

11939 17.0000 SAT-0982 A Analysis of the Efficacy of U-500 Regular Insulin in Patients with Type 2 Diabetes and Insulin Resistance 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Grigorios Rombopoulos*1, Magdalini Hatzikou1, Dimitra Latsou2 and John Yfantopoulos2
1Novartis Hellas S.A., 2University of Athens

 

BACKGROUND: Hypoglycemia (Hypo) is a common, unpredictable and potentially dangerous adverse effect of type 2 diabetes (T2D) therapy. Oral antidiabetic (OAD) agents differ in their propensity to cause Hypo. Hypo has a negative impact on healthcare resources and quality of life (QoL), and can affect compliance and diabetes control.

OBJECTIVE: To estimate the impact of different OADs on Hypo prevalence, and on the QoL of patients with T2D in Greece.

METHODS: A cross-sectional epidemiological study was conducted in 6631 patients with T2D. Hypo events with different treatment regimens, T2D control rates and QoL were assessed. Hypo episodes were defined as laboratory-confirmed (<70 mg/dl) symptomatic events. QoL was measured using the patient-administered ADDQoL-19 questionnaire. Diabetes control was defined as Hb1Ac ≤7% (53 mmol/mol).

RESULTS: Mean age was 60 years and mean T2D duration 10 years. 59% of patients had HbA1c >7%; 20.4% of patients had a history of laboratory-confirmed Hypo. Most patients [5470 (82%)] were on combination therapies, while 966 (14.5%) were on oral monotherapy. 173 (2.5%) and 22 (0.3%) patients were receiving monotherapy with insulin or a GLP-1 analog, respectively. Differences in the overall QoL of patients in the three OAD monotherapy groups [biguanides, DPP4is and sulfonylureas (SUs)] were not statistically significant between groups, regardless of Hypo status. Patients treated with biguanide or DPP4i monotherapy had lower rates of Hypo vs. patients on SU monotherapy (4.3%, 10.8% and 34.9%, respectively; p≤0.001). QoL in Hypo patients treated with biguanides or DPP-4is was better compared to SUs (-2, -2.1 and -3.8, respectively; p<0.001). Similarly, more patients on biguanides and DPP4i monotherapies achieved HbA1c ≤7% than on SU (60.0%, 57.0% and 31.2%, respectively; p≤0.001). Patients receiving combinations of biguanides with DPP4is vs. biguanides with SUs had significantly less Hypo (5.6% vs. 24%, respectively; p≤0.001), better diabetes control (54.3% vs. 34.7%, respectively; p≤0.001) and better QoL (-2.9 vs. -3.2, respectively; p≤0.05).

CONCLUSIONS: Biguanides, DPP4is and their combinations are associated with lower rates of Hypo, and better QoL and diabetes control, compared with SUs alone or in combination with biguanides. In diabetes, treatment should attain good glycemic control without debilitating hypoglycemic episodes, which compromise patients’ QoL.

 

Disclosure: GR: Medical Advisor, Novartis Pharmaceuticals. MH: Employee, Novartis Pharmaceuticals. JY: Investigator, Novartis Pharmaceuticals. Nothing to Disclose: DL

12501 18.0000 SAT-0983 A Association of Hypoglycemia with Different Oral Antidiabetic Treatments and Its Impact on Quality of Life and Disease Control in Patients with Type 2 Diabetes Mellitus (the HYPO study) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Shervin Yousefian*1, Lina Leykina2 and Matthew C Leinung1
1Albany Medical College, Albany, NY, 2Albany Medical Center, Albany, NY

 

USE OF INSULIN PUMP THERAPY IN PATIENTS WITH TYPE 2 DIABETES AFTER FAILURE OF MULTIPLE DAILY INJECTIONS. 4 YEAR FOLLOW UP

INTRODUCTION:  Long-term efficacy of continuous subcutaneous insulin infusion (CSII) in management of type 2 diabetes has not been well studied. In 2010 we reported the short-term efficacy of CSII in type 2 diabetics who had failed multiple daily injections (MDIs). This study is a 4-year follow up on the same cohort to assess the long-term benefit of (CSII) in patients who transitioned from MDIs between 2008-2009. 

METHODS: This is a retrospective cohort study. All data was obtained from review of the electronic records of patients at Endocrinology clinic of Albany Medical College. Data analysis was done with SPSS 21.0. Out of 59 patients included in 2010 analysis, 4 were lost to follow up and 2 passed away due to malignancy.  

RESULTS: Out of 53 patients, 45 stayed on CSII through the last visit. Reasons for discontinuing CSII therapy (total 8 patients) were: successful bariatric surgery (n=2), resolution of pregnancy (n=2), financial hardship (n=2), and patient’s preference (n=2).The average duration of follow up was 49.7 +/- 14.1 (SD) months. Average A1C at the time of the last visit improved significantly when compared to the average A1C prior to transitioning to SCII, dropping by 0.79% (P=0.001). Average A1C at last visit (8.20%) was not significantly different from the average A1C at the endpoint of the initial analysis in 2010 (7.94%; P>0.05).Frequency of daily boluses correlated with improved A1C. Those who bloused more than 2.5 times a day, had improved A1C at last visit (7.8% vs. 8.9%; P=0.04). This was clinically and statistically significant. No significant increase in BMI was found in our cohort of patients between 2009 and 2013 (36.0 vs. 36.1; P=0.6).There was no significant correlation between use of bolus calculator vs. manual boluses and improvement in A1C (Chi2= 0.021, P=0.99). There was direct correlation between initial A1C and extent of its improvement.  Patients with A1Cs in highest tertile (>8.0%) had greater reduction in A1C (0.27%, P=0.01).

CONCLUSION: Our study shows that transition to insulin pump therapy in patients who fail MDIs can result in sustained long term improvement of glycemic control without weight gain. Overall improvement correlated with number of boluses per day irrespective of use of the calculator or manual bolus. Those patients who started with the highest A1c correlated with the greatest improvement of A1C.

 

Nothing to Disclose: SY, LL, MCL

12679 19.0000 SAT-0984 A Use of Insulin Pump Therapy in Patients with Type 2 Diabetes after Failure of Multiple Daily Injections. 4 Year Follow up 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Frank Lavernia*1, Donna Tomky2, Theresa McGhee3, Terry Dex4, Mehul Dalal4, Jeffrey Frimpter4, Wei Zhou5, John Stewart5 and Aleksandra Vlajnic4
1North Broward Diabetes Center, Coconut Creek, FL, 2ABQ Health Partners, Albuquerque, NM, 3AbsoluteCARE Medical Center, Atlanta, GA, 4Sanofi US, Inc., Bridgewater, NJ, 5Sanofi Canada, Laval, QC, Canada

 

Concern about hypoglycemia is a major driver of clinical inertia. We used Diabetes FORWARD (DF), a large practice-based research network focused on patients with type 2 diabetes mellitus (T2DM) and their providers across the US, to compare characteristics of patients grouped by the self-reported significance of severe (SH) and nocturnal (NH) hypoglycemia. Eligible patients were aged ≥ 18 y, with a diagnosis of T2DM.

Patients enrolled in DF between March 2012 and November 2013 rated the significance of SH (N=1,912) and NH (N=1,911). Characteristics of patients concerned with SH (n=114) or NH (n=155) were different than those who were not: patients were more likely to be female (SH: 63.2% vs 52.2%, P = 0.0227; NH: 71.6% vs 51.2%, P = 0.0001); African American (SH: 27.2% vs 13.1%, P = 0.0045; NH: 27.7% vs 12.7%, P = 0.0005); have lower BMI (< 25 kg/m2; SH: 13.5% vs 6.4%, P = 0.240; NH: 10.6% vs 6.5%, P = 0.0274); be less educated (some high school/graduate; SH: 47.4% vs 35.5%, P = 0.0087; NH: 44.5% vs 35.5%, P = 0.0010); have a longer duration of diabetes (SH: 15.4 yrs vs 10.7 yrs, P = 0.0001; NH: 15.5 yrs vs 10.5 yrs, P = 0.0001); have worse self-reported general health (rated poor; SH: 15.8% vs 5.7%, P = 0.0003; NH: 13.5% vs 5.7%, P = 0.0001); and be treated with basal insulin (SH: 32.5% vs 16.1%, P = 0.0001; NH: 35.5% vs 15.4%, P = 0.0001) and with fewer OADs (0 OADs; SH: 28.1% vs 8.1%, P = 0.0001; NH: 26.5% vs 7.7%, P = 0.0001). Patients concerned by SH had a higher Charlson Comorbidity score (1.45 vs 1.08, P = 0.0070). Patients concerned by NH were younger (57.6yrs vs 59.8yrs, P = 0.0236) and appeared to show less improvement in A1C (A1C: at registration 8.0%, at 9 months 7.8%).

Demographic differences in patients reporting hypoglycemia as significant may be important considerations in diabetes education and treatment decisions. Clinical characteristics suggest that these patients have more advanced illness. Lack of A1C improvement in those reporting NH as significant suggests a possible obstacle to glycemic control. Further investigation is needed into non-adherence or clinical inertia in patients concerned by hypoglycemia and with inadequate glycemic control.

 

Disclosure: FL: Advisory Group Member, Sanofi, Advisory Group Member, Jansen Pharmaceuticals, Advisory Group Member, Eisai, Advisory Group Member, Eli Lilly & Company. DT: Advisory Group Member, Sanofi, Advisory Group Member, Medtronic Minimed, Advisory Group Member, Perrigo Diabetes, Advisory Group Member, Abbott Laboratories, Speaker, Bristol-Myers Squibb, Speaker, Jansen Pharmaceuticals. TD: Employee, Sanofi, Employee, Sanofi, Stock ownership, Merck & Co., Stock ownership, Proctor & Gamble, Stock ownership, Pfizer, Inc.. MD: Employee, Sanofi, Employee, Sanofi. JF: Employee, Sanofi, Employee, Sanofi. WZ: Employee, Sanofi. JS: Employee, Sanofi, Employee, Sanofi. AV: Employee, Sanofi, Employee, Sanofi. Nothing to Disclose: TM

15854 20.0000 SAT-0985 A Significance of Hypoglycemia in Patients with Type 2 Diabetes Mellitus in Primary Care 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Takashi Kadowaki1, Masakazu Haneda2, Nobuya Inagaki3, Atsushi Taniguchi4, Kazuki Koiwai4, Henning Rattunde5, Uli C Broedl5 and Hans-Juergen Woerle*5
1Univ of Tokyo, Tokyo, Japan, 2Asahikawa Medical University, Asahikawa, Japan, 3Graduate School of Medicine, Kyoto University, Kyoto, Japan, 4Nippon Boehringer Ingelheim, Tokyo, Japan, 5Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany

 

Background: Empagliflozin (EMPA) is a potent and selective sodium glucose co-transporter 2 (SGLT2) inhibitor in development for the treatment of type 2 diabetes mellitus (T2DM). A Phase II trial (NCT01193218) investigated the safety and efficacy of 52 weeks’ EMPA monotherapy in Japanese patients with T2DM.

Methods: In a 12-week dose-finding period, patients (mean age 57.5 [SD 9.9] years; mean BMI 25.5 [SD 3.9] kg/m2) were randomized to double-blind EMPA 5 mg (n=110), 10 mg (n=109), 25 mg (n=109) or 50 mg (n=110) (all once daily) or placebo (n=109) for 12 weeks. In a 40-week double-blind extension period, patients treated with EMPA 10 mg or 25 mg continued and patients originally assigned placebo, EMPA 5 mg or 50 mg were re-allocated EMPA 10 mg or 25 mg. Efficacy is reported for patients who took EMPA 10 mg or 25 mg in both treatment periods (ie 52 weeks; n=109 each); safety for all patients who took ≥1 dose of EMPA 10 mg (n=267) or 25 mg (n=265) during the 52 weeks.

Results: At baseline, mean HbA1c was 7.92% in both groups, mean FPG was 156.8 mg/dL (EMPA 10 mg) and 155.0 mg/dL (EMPA 25 mg), mean body weight was 68.5 kg (EMPA 10 mg) and 68.7kg (EMPA 25 mg), mean SBP was 128.0 mmHg (EMPA 10 mg) and 125.5 (EMPA 25 mg) and mean DBP was 78.3 mmHg (EMPA 10 mg) and 77.8 mmHg (EMPA 25 mg). Adjusted mean (SE) changes from baseline in HbA1c were -0.67±0.09% on EMPA 10 mg and -0.86±0.09% on EMPA 25 mg, in FPG were -24.7±3.2 mg/dL on EMPA 10 mg and -31.3±3.4 mg/dL on EMPA 25 mg, in body weight were -3.1±0.4 kg on both EMPA 10 mg and EMPA 25 mg, in SBP were -2.9±1.7 mmHg on EMPA 10 mg and -2.5±1.8 mmHg on EMPA 25 mg, and in DBP were -2.9±1.0 mmHg on EMPA 10 mg and -2.0±1.1 mmHg on EMPA 25 mg. Treatment emergent adverse events (AEs) were reported in 70.8% of patients on EMPA 10 mg and 66.8% on EMPA 25 mg. Confirmed hypoglycemic AEs (≤70 mg/dL and/or requiring assistance) were rare (1 patient in each of the EMPA 10 mg and 25 mg groups) and no patients required assistance. AEs consistent with urinary tract infection were reported in 7 patients (2.6%) on EMPA 10 mg and 3 patients (1.1%) on EMPA 25 mg. AEs consistent with genital infection were reported in 8 patients (3.0%) on EMPA 10 mg and 2 patients (0.8%) on EMPA 25 mg. AEs consistent with volume depletion were reported in 3 patients (1.1%) on EMPA 10 mg and 3 patients (1.1%) on EMPA 25 mg.

Conclusion: EMPA monotherapy led to sustained reductions in HbA1c, FPG, body weight, SBP and DBP over 52 weeks in Japanese patients with T2DM, and was well tolerated.

 

Disclosure: TK: Investigator, Boehringer Ingelheim, Medical Advisory Board Member, Boehringer Ingelheim, Speaker Bureau Member, Boehringer Ingelheim, Medical Advisory Board Member, Tanabe-Mitsubishi, Investigator, Tanabe-Mitsubishi, Speaker Bureau Member, Tanabe-Mitsubishi, Medical Advisory Board Member, Chugai, Investigator, Chugai, Speaker Bureau Member, Chugai, Investigator, Astellas, Speaker Bureau Member, Astellas. MH: Medical Advisory Board Member, Boehringer Ingelheim, Investigator, Boehringer Ingelheim, Speaker Bureau Member, Boehringer Ingelheim, Medical Advisory Board Member, Taisho, Investigator, Tanabe-Mitsubishi, Speaker Bureau Member, Tanabe-Mitsubishi, Investigator, Astellas, Speaker Bureau Member, Astellas, Investigator, Chugai, Investigator, Taisho. NI: Investigator, Boehringer Ingelheim, Medical Advisory Board Member, Boehringer Ingelheim, Speaker Bureau Member, Boehringer Ingelheim, Medical Advisory Board Member, Tanabe-Mitsubishi, Investigator, Tanabe-Mitsubishi, Speaker Bureau Member, Tanabe-Mitsubishi, Medical Advisory Board Member, Chugai, Investigator, Chugai, Medical Advisory Board Member, Taisho, Investigator, Astellas, Speaker Bureau Member, Astellas. AT: Employee, Boehringer Ingelheim. KK: Employee, Boehringer Ingelheim. HR: Employee, Boehringer Ingelheim. UCB: Employee, Boehringer Ingelheim. HJW: Employee, Boehringer Ingelheim.

11174 21.0000 SAT-0986 A Safety and Efficacy of Empagliflozin Monotherapy in a 52-Week Study in Japanese Patients with Type 2 Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Maximilian von Eynatten*1, Stuart Ross2, Enrique Caballero3, Stefano Del Prato4, Baptist Gallwitz5, Diane Lewis-D'Agostino6, Zelie Bailes7, Sandra Thiemann8, Sanjay Patel9 and Hans-Juergen Woerle10
1Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, 2University of Calgary, Calgary, AB, Canada, 3Joslin Diabetes Center, Boston, MA, 4University of Pisa, Pisa, Italy, 5UniversitaetsklinikumTuebingen, Tuebingen, Germany, 6Boeheringer Ingelheim, Ridgefield, CT, 7Boehringer Ingelheim, Bracknell, United Kingdom, 8Boehringer Ingelheim, Ingelheim, Germany, 9Boehringer Ingelheim Ltd., Bracknell, United Kingdom, 10Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany

 

Glycemic control in early stages of T2D is vital in preventing long-term complications. Whereas glucose-lowering monotherapy may be appropriate in mild to moderate hyperglycemia, initial dual therapy may be considered for individuals with pronounced hyperglycemia. We compared 2 common treatment strategies (monotherapy or initial combination with metformin) for controlling marked hyperglycemia in previously untreated patients with newly diagnosed T2D using the DPP-4 inhibitor linagliptin. This previously untreated cohort was chosen to explore the efficacy of oral DPP-4 inhibition in T2D individuals with short disease duration.

This international double-blind clinical trial randomized 316 treatment-naïve individuals with recently diagnosed (≤12 months) and uncontrolled T2D (baseline HbA1c, 8.5%–12.0%) to receive linagliptin 5 mg QD (n=157) or initial combination therapy of linagliptin 5 mg QD + metformin BID (uptitrated in the first 6 weeks; maximal dose 2000 mg/d) (n=159) for 24 weeks. The primary endpoint was the difference in change from baseline HbA1c between groups in the per-protocol cohort of subjects completing the trial exclusively on study drug (linagliptin, n=113; linagliptin + metformin, n=132).

Subjects (54% women) were mainly white (58%) or Asian (38%) with a mean (±SD) age, HbA1c, and BMI of 48.8 (11.0) years, 9.8 (1.1) %, and 29.7 (5.6) kg/m2. Both linagliptin monotherapy and the initial combination of linagliptin +metformin significantly reduced mean HbA1c (±SE) levels by –2.0% (0.1) and –2.8% (0.1) after 24 weeks, respectively. The treatment difference of      –0.8% (95% CI, –1.1 to –0.5) demonstrated superiority for the initial dual therapy over monotherapy (P<0.0001). Moreover, 40% and 61% of individuals in the monotherapy and combination arms achieved HbA1c <7.0% at week 24. Overall, treatments were well tolerated, with very few drug-related or serious adverse events. Hypoglycemia occurred in ≤3.2% of patients in each arm. Body weight was maintained with linagliptin and decreased in the combination arm (–1.3 kg between-group difference; P=0.0033).

Linagliptin achieved clinically significant improvements in glucose control in individuals with newly diagnosed T2D and marked hyperglycemia whether given as monotherapy or in initial combination with metformin. Of note were the large HbA1c reductions, particularly with dual therapy.

Supported by Boehringer-Ingelheim.

 

Disclosure: MV: Employee, Boehringer Ingelheim . SR: Researcher, Novo Nordisk, Researcher, Eli Lilly & Company, Researcher, Merck & Co., Researcher, Sanofi, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Eli Lilly & Company, Speaker Bureau Member, Merck & Co., Speaker Bureau Member, Sanofi, Advisory Group Member, Boehringer Ingelheim, Researcher, Boehringer Ingelheim, Speaker Bureau Member, Boehringer Ingelheim, Advisory Group Member, Sanofi, Advisory Group Member, Merck & Co., Advisory Group Member, Eli Lilly & Company, Advisory Group Member, Novo Nordisk. EC: Advisory Group Member, Boehringer Ingelheim . SD: Advisory Group Member, Eli Lilly & Company, Advisory Group Member, Boehringer Ingelheim , Researcher, Sanofi, Researcher, Novo Nordisk, Researcher, Eli Lilly & Company, Researcher, Boehringer Ingelheim , Speaker Bureau Member, Sanofi, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Eli Lilly & Company, Speaker Bureau Member, Boehringer Ingelheim , Advisory Group Member, Novo Nordisk, Advisory Group Member, Sanofi. BG: Advisory Group Member, Boehringer Ingelheim, Advisory Group Member, Eli Lilly & Company, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Novo Nordisk, Advisory Group Member, Merck & Co., Advisory Group Member, Roche Pharmaceuticals, Advisory Group Member, Sanofi, Advisory Group Member, Takeda, Speaker Bureau Member, Astra Zeneca, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Boehringer Ingelheim , Speaker Bureau Member, Eli Lilly & Company, Speaker Bureau Member, Novartis Pharmaceuticals, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Merck & Co., Speaker Bureau Member, Roche Pharmaceuticals, Speaker Bureau Member, Sanofi, Speaker Bureau Member, Takeda, Advisory Group Member, Bristol-Myers Squibb, Advisory Group Member, Astra Zeneca. DL: Employee, Boehringer Ingelheim . ZB: Employee, Boehringer Ingelheim . ST: Employee, Boehringer Ingelheim . SP: Employee, Boehringer-Ingelheim. HJW: Employee, Boehringer Ingelheim.

12503 22.0000 SAT-0987 A Linagliptin Monotherapy Versus Initial Combination Therapy with Metformin in Patients with Newly Diagnosed Type 2 Diabetes (T2D): A Randomized Controlled Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Gary E Striker*1, Elena Yuberro-Serrano1, Leonid Poretsky2 and Helen Vlassara1
1The Mount Sinai Hospital, New York, NY, 2Mount Sinai Beth Israel, New York, NY

 

Background:Morbidity and mortality in diabetes correlate with kidney disease (DKD), and directly with increasing albuminuria (AER).  In experimental animals we found that reduction of advanced glycation endproducts (AGEs) reduced AER, DKD and inflammation and oxidative stress (Infl/OS). Since Sevelamer Carbonate (SC) treatment reduces AGEs, HbA1c and Infl/OS, the current study aimed to extend these findings to include albuminuria, gender, age, and race.

Methods: This two center, randomized, intention-to-treat, six-month, open label, single blinded study compared subjects with T2DM (HbA1c >6.5%) and stage 2-4 DKD (uAlb/uCr>300mg/gm) treated with SC or calcium carbonate for 6 months without changing either medications or dietary AGE intake (½ of the subjects in each arm received Metformin [Met]).  Since Met, gender, race/ethnicity, and age affect study outcomes, selected sub-analyses were performed.  Results:  SC reduced AGEs, 8-isoprostanes and VCAM1, increased anti-inflammatory gene expression (Nrf2, AGER1, SIRT1, ERα), and reduced pro-inflammatory genes (RAGE and TNFR1), particularly in women >65yo.  HbA1c was only decreased by SC (p=0.037) in subjects not treated with Met, in women and those >65yo.  SC reduced albuminuria, independently of baseline eGFR or rate of decline.  

Conclusions:  SC reduced AGEs, cellular pro-inflammatory responses and albuminuria, whereas anti-Infl/OS defenses were increased.  The beneficial effects of SC were more prominent in <65yo vs. >65yo, in women and in caucasians. HbA1c was reduced by SC in subjects not receiving Met.  Age, gender and race influenced outcomes.  A larger and longer trial is needed to determine if renal disease progression is altered.

 

Disclosure: GES: Principal Investigator, Sanofi. HV: Coinvestigator, Sanofi. Nothing to Disclose: EY, LP

12666 23.0000 SAT-0988 A Control of Oral Advanced Glycation Endproducts (AGEs) By Sevelamer Carbonate Improves Glucose Metabolism and Albuminuria in Stage 2-4 Diabetic Kidney Disease (DKD) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Dirk Jan Stenvers*1, Lydia J Schouten1, Jordy Jurgens1, Erik Endert1, Andries Kalsbeek2, Eric Fliers3 and Peter H Bisschop1
1Academic Medical Center, Amsterdam, Netherlands, 2Netherlands Institute for Brain Research, Amsterdam, Netherlands, 3Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands

 

Low glycemic index (low-GI) diets reduce HbA1C in patients with type 2 diabetes, but require intensive dietary support. Using a low-GI liquid meal replacement may be an alternative approach. In this study we investigated if breakfast replacement with a low-GI liquid meal would reduce postprandial glycaemia and/or improve long-term glycaemia.
In a randomised cross-over design, 20 patients with type 2 diabetes either isocalorically replaced breakfast with Glucerna SR (Abbott Nutrition) or consumed a free choice breakfast for 3 months. Postprandial glucose incremental area under the curve (AUC) was measured at home using continuous glucose measurement. After 3 months, meal glucose profiles and morning oral glucose tolerance were assessed on two consecutive days at the clinical research unit (CRU).
Isocaloric low-GI breakfast replacement reduced the AUC of post-breakfast glucose excursions at home compared to a free choice breakfast (141 (114-174) vs 259 (211-318) mmol·min/L, P=0.0002 [estimated marginal means (95% CI)]). Low-GI breakfast replacement also reduced glucose AUC at the clinical research unit compared to an isocaloric breakfast (low GI 97 (60-188), control 253 (162-386) mmol·min/L, P<0.001 [median (IQR)]. However, 3 months low-GI breakfast replacement did not affect fasting glucose, HbA1C or lipid levels, and even slightly reduced oral glucose tolerance as measured by an oral glucose tolerance test on the morning of the second day at the CRU.
In conclusion, low-GI liquid meal replacement is a potential approach to reduce postprandial glycaemia in patients with diabetes. However, clinical trials into the clinical benefits of replacing multiple meals in poorly controlled patients are required before this approach can be adopted in the dietary treatment of type 2 diabetes.

 

Nothing to Disclose: DJS, LJS, JJ, EE, AK, EF, PHB

12671 24.0000 SAT-0989 A Breakfast Replacement with a Low Glycemic Index Liquid Formula in Type 2 Diabetes: A Cross-over Clinical Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Ashley Ann Thorsell*1, Megan Elizabeth McGarvey1 and Jill Waalen2
1Scripps Clinic, La Jolla, CA, 2Scripps Translational Science Institute, La Jolla, CA

 

We aim to demonstrate benefit of a monitored and structured exercise program in overweight or obese patients with Diabetes Mellitus (DM).

Randomized and controlled trial of patients from Scripps Clinic, San Diego, CA.  Inclusion criteria: age 18-70 years; prior diagnosis of Pre-DM, Type 1 or Type 2 DM; BMI 25-45kg/m2. Exclusion criteria: severe DM complications; uncontrolled psychiatric illness; non-English speaker; unable to exercise 150 minutes a week; unable to complete a 1-mile walk test. At screening, patients were randomized to the experimental group (EG) or control group (CG), and completed a health survey and activity assessment. Physical fitness was assessed with a 1-mile walk test. Both groups received nutrition and DM education. The EG participated in a monitored moderate-intensity exercise class, taught by a qualified instructor, for 150 minutes a week for 12 weeks. The CG was counseled to perform 150 minutes of unguided, medium-intensity exercise per week. Vitals, glucose logs, and adverse events were reviewed monthly by a physician. Fasting blood glucose (FBG), A1C, LDL and health-related quality of life surveys were evaluated at screening and 12 weeks.

Baseline characteristics of the two groups (n= 17) were similar. Weight loss was significant in the EG (12.9 vs. 2.6 lbs, p=0.01), as was lower BMI (2.2 vs. 0.5 kg/m2, p=0.03). There was a favorable decreasing trend in A1C, FBG, and waist circumference in the EG. Health-related quality of life scores improved in both groups. Lipid profiles and systolic blood pressure (BP) reduction were not observed in either group.

The cardio-metabolic benefits of exercise include BP and LDL reduction, weight loss, enhanced glycemic control, and insulin sensitivity.  The promising results of the LOOK Ahead trial revealed that intensive lifestyle intervention improves physical fitness, glycemic control, and cardiovascular risk factors relative to diabetes support and education. Other studies have shown that exercise is enhanced when behavioral strategies parallel supervised exercise. Such approaches may be cost-effective in the management of DM and obesity, and should prompt further attention towards observed and structured exercise programs to enhance compliance.

Our study has shown that monitored and structured exercise positively affects weight, DM control, and health-related quality of life scores.  With our second group of patients, we hope to prove statistical significance in cardiovascular benefit, with both BP and LDL reduction.

 

Nothing to Disclose: AAT, MEM, JW

12899 25.0000 SAT-0990 A Impact of Prescribed and Monitored Medium-Intensity Exercise on Diabetes, Obesity, Cardiovascular Profiles and Quality of Life 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Michael A Weber*1, Traci A Mansfield2, James F List2 and Agata Ptaszynska2
1SUNY Downstate College of Medicine, New York, NY, 2Bristol-Myers Squibb, Princeton, NJ

 

Hypertension is common in patients with type 2 diabetes (T2D). Limiting renal glucose reabsorption with dapagliflozin (DAPA) induces glucosuria, caloric loss, and mild diuresis causing weight loss and blood pressure (BP) reduction. DAPA 10 mg significantly reduced HbA1c and seated systolic BP (SBP) vs placebo (PBO) in 2 randomized, double-blind, 12-wk studies of patients with T2D and inadequate glycemic (HbA1c, 7.0%–10.5%) and BP control (seated SBP/DBP, 140–164/85–104 mmHg) receiving other glucose-lowering drugs and an ACEI/ARB (Study 1, NCT01137474, N=613) or an ACEI/ARB plus a second antihypertensive drug (Study 2, NCT01195662, N=449). To assess consistency across different patient characteristics, a subgroup analysis was performed on adjusted mean change from baseline in HbA1c and seated SBP at 12 wks for age (<65, ≥65, or ≥75y), sex, race (white, black, Asian, or other), ethnicity (Hispanic, not Hispanic), baseline HbA1c (<8%, ≥8% to <9%, or ≥9%), and baseline seated SBP (<150 or ≥150 mmHg). In Study 1, DAPA 10 mg significantly reduced the co-primary efficacy end points of HbA1c (difference vs PBO, –0.46%, P<0.0001) and seated SBP (–3.1 mmHg, P=0.001). There was a significant (P<0.0001) treatment interaction between baseline HbA1c subgroups; DAPA produced greater mean reductions in HbA1c as baseline HbA1c increased from <8% (difference vs PBO, –0.33%) to ≥8% to <9% (–0.45%), and to ≥9% (–0.90%). There was no significant treatment interaction for seated SBP across baseline SBP subgroups (difference vs PBO <150 mmHg, –4.2 mmHg; ≥150 mmHg, –1.9 mmHg). In Study 2, DAPA 10 mg significantly reduced HbA1c (–0.61%, P<0.0001) and seated SBP (–4.3 mmHg, P=0.0002). There was a significant (P<0.01) treatment interaction between baseline HbA1c subgroups; DAPA produced greater mean reductions in HbA1c as baseline HbA1c increased from <8% (difference vs PBO, –0.43%) to ≥8% to <9% (–0.87%) and to ≥9% (–0.79%). There was no significant treatment interaction for seated SBP across baseline SBP subgroups (difference vs PBO <150 mmHg, –3.1 mmHg; ≥150 mmHg, –5.1 mmHg). In both studies, similar proportions of DAPA and PBO patients experienced adverse events and hypoglycemia (Study 1, 37% vs 35% and 3% vs 1%; Study 2, 44% vs 42% and 6% vs 3%). No BP-related safety issues were noted. Serum uric acid decreased with DAPA vs PBO (Study 1, –0.27 vs 0.05 mg/dL; Study 2, –0.43 vs –0.03 mg/dL). No effects on serum sodium, potassium, or calcium were seen with DAPA despite its diuretic effect. Across subgroups of age, sex, race, ethnicity, baseline HbA1c, and seated SBP, DAPA consistently reduced HbA1c and seated SBP with beneficial effects on uric acid and without adverse effects on serum electrolytes. DAPA causes consistent BP lowering with a good safety profile across all levels of BP in hypertensive patients with T2D and is particularly effective in glucose regulation in those patients whose previous control was inadequate.

 

Disclosure: MAW: Advisory Group Member, Takeda, Advisory Group Member, Arbor Pharmaceuticals, Consultant, Boehringer-Ingelheim, Consultant, Daiichi Sankyo, Consultant, Astra Zeneca, Consultant, Takeda, Consultant, Forest Research Laboratories, Consultant, Medtronic Minimed, Consultant, Boston Scientific. TAM: Employee, Bristol-Myers Squibb. JFL: Employee, Bristol-Myers Squibb. AP: Employee, Bristol-Myers Squibb.

14970 26.0000 SAT-0991 A Dapagliflozin Reduces HbA1c and Systolic Blood Pressure in Patients with Type 2 Diabetes: Subgroup Analysis Based on Patient Characteristics 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Elena Barengolts*1, Buvana Manickam2, Yuval Eisenberg2, Arfana Akbar3, Nathan Chertok3, Emily Lelchuk3, Hiba Mohiuddin3, Chizelle Onochie3, Subhash C Kukreja4, Hassan Zaidi3, Karthik Cherukupally3 and Irina Ciubotaru4
1University of Illinois at Chicago, Chicago, IL, 2University of Illinois at Chicago, College of Medicine, Chicago, IL, 3Jesse Brown VAMC, Chicago, IL, 4UIC Section of Endocrinology, Chicago, IL

 

INTRODUCTION: There is a growing number of randomized, controlled trials (RCT) that observed no effect of vitamin D on glycemic control. This double-blind RCT evaluated whether high doses of vitamin D2 for 1 year affect glucose homeostasis.

METHODS: A total of 205 African American male veterans 35-85 years old, with BMI 28-39 kg/m2, dysglycemia (A1C 5.7-6.9%) and vitamin D insufficiency (25OHD 5-29 ng/mL) were randomized to receive placebo (PL) or 50,000 IU vitamin D2 supplementation (DS) for 1 year. Doses were adjusted with the goal of maintaining circulating 25OHD =/>40 ng/ml. An oral glucose tolerance test (OGTT) was performed at baseline and 1 year later. Oral glucose insulin sensitivity (OGIS, http://webmet.pd.cnr.it/ogis) and proportion of subjects developing diabetes or returning to better glycemic status were evaluated. 

RESULTS: Average 25OHD levels rose from 14 to 47 ng/mL after DS with a mean dose of about 75,000 IU per week. The 25OHD levels were variable depending on adherence and season. Among DS subjects only 60% achieved 25OHD =/>40ng/ml and 19% had 25OHD<25 ng/ml. Conversely, up to 24% PL subjects had 25OHD=/>30 ng/ml. There were no differences between PL (N=84) and DS (N=90) groups in A1C (Mean [SD] 6.1 [0.2] vs 6.1 [0.3]% in PL vs DS, respectively) or proportion of subjects developing diabetes (12% vs 10% in PL vs DS, respectively). The number of subjects who converted to better glycemic status based on A1C levels (including conversion from T2DM to prediabetes and prediabetes to normal or remaining at A1C 5.7%) was 9.5% vs 20% (p=0.08) in PL vs DS, respectively. Comparison of 2 contrasting subgroups, DS with 25OHD 30-90 ng/ml (N=63) vs PL with 25OHD<25ng/ml (N=62) suggested improved OGIS (ml min-1 kg-1). The OGIS increased by 10.6 in DS vs decreased by 15 in PL (p=0.046). In these subgroups, similar to the entire group, a trend for increased conversion to favorable glycemic status was seen (12.2% vs 7.1%, in DS vs PL, respectively). The elevated serum calcium (10.2-10.4 mg/dl) was seen in 3 and 4 subjects in PL and DS groups, respectively.

DISCUSSION: This trial added to the controversy surrounding the role of vitamin D in glucose homeostasis. Although high doses of vitamin D supplementation had no effect on progression from prediabetes to diabetes or A1C levels, there was a trend in proportion of subjects whose A1C returned from diabetes to prediabetes and from prediabetes to normal or remained at the lowest prediabetes value of 5.7% (p=0.08). This improvement might be due to increased insulin sensitivity, which had become apparent only by comparing two groups with contrasting serum 25OHD levels, suggesting that vitamin D might benefit glycemia albeit less dramatically than weight loss.

CONCLUSION: In AAM with dygsycemia and vitamin D deficiency doses of vitamin D2 supplementation that increased serum 25OHD levels to upper-normal range for 1 year may improve insulin sensitivity and glycemic status.

 

Nothing to Disclose: EB, BM, YE, AA, NC, EL, HM, CO, SCK, HZ, KC, IC

15097 27.0000 SAT-0992 A In African American Men with Dygsycemia and Vitamin D Deficiency, Vitamin D Supplementation for 1 Year MAY Improve Insulin Sensitivity and Glycemic Status. DATA from a Randomized Controlled Trial of Vitamin D Intervention at Veteran Administration (DIVA, NCT01375660) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Su Jin Jeong* and JongHwa Kim
General Hospital, Bucheon, Korea, Republic of (South)

 

Stevia is a new nonnutritive sweetener representing a family of glycosides, in particular rebaudioside A.
Stevioside may decreased plasma glucose levels in some studies.
This trial evaluated the glycemic effects of 2 weeks of consumption of 16 mg rebaudioside A , 986 mg erythritol (n = 25) as a sweetener in peoples with prediabets and type 2 diabetes mellitus. Those patients was performed 75g OGTT before and after had Sweetr GI-0.
Primary outcome was the change from baseline to end of treatment in fructosamin level.
Secondary end points were change from baseline to end of treatment in fasting plasma glucose level and 75g OGTT
Change in fructosamin level from baseline to end periods for Sweete GI-0 did not differ significantly(244.0±19.6 vs 241.7±23.4, p=0.3657).
Changes from baseline to end study for Sweete GI-0 in fasting plasma glucose(102.6±10.7 mg/dl vs 101.3±9.2 mg/dl), 75g OGTT(154.9±54.3 mg/dl vs 141.9±42.2 mg/dl), insulin(7.6 ±4.3 IU/ml vs 7.2±5.1 IU/ml) and C-peptide(2.9±1.6 ng/ml vs 2.7±1.3 ng/ml) did not differ significantly(p> 0.05 for all).
Assessments of change in blood pressure, body weight, and fasting total cholesterol showed no differences by treatment.
Sweete GI-0 was well tolerated and records of adverse events did not differ during study periods.
We suggest that consumption of sweetener, Sweete GI-0 dose not alter glucose homeostasis in peoples with glucose intolerance.

 

Nothing to Disclose: SJJ, JK

15105 28.0000 SAT-0993 A Glycemic Effect of Sweetener, Sweete GI-0 in Peoples with Glucose Intolerance 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Ja Young Jeon*1, Kee-Ho Song2, So Young Ock1, Yoon-Sok Chung3 and Dae Jung Kim1
1Ajou Univ Sch of Med, Suwon, Korea, Republic of (South), 2Konkuk University School of Medicine, Seoul, Korea, Republic of (South), 3Ajou Unversity School of Medicine, Suwon, Korea, Republic of (South)

 

BACKGROUND:

From KNHANES III (2005), the proportions of well-controlled diabetes was reported 22.9% for HbA1c <6.5% and 43.5% for HbA1c <7%. We investigated the levels of glycemic control and the factors associated with glycemic control using data from the Fifth Korea National Health and Nutrition Examination Survey (KNHANES V) (2010-2012).

METHODS:

We analyzed data from KNHANES V (2010-2012). Of 16,431 subjects aged ≥30 years, we excluded 531 subjects with non-respondents on previous diagnosis of diabetes made by physicians, or current use of antidiabetic medications including insulin and oral hypoglycemic agents (OHA). Subjects with diabetes diagnosed by physician or those taking antidiabetic medications was classified as known diabetes. Among subjects with known diabetes, 157 individuals without level of HbA1c were excluded.

RESULTS:

The prevalence of known diabetes was 7.7% (n=1498, estimated to be 2.32 million people). Near normal glycemia with HbA1c goal of <6.5% and <7% were 27% or 45.6%, respectively. HbA1c increased as duration of diabetes was long. HbA1c in subjects with duration of diabetes ≤5 years was lower than in subjects with duration of >5 years. HbA1c in group taking only OHA was significantly lower than in group administrating only insulin or OHA and insulin combination. In logistic regression analysis, older age, longer duration of diabetes, insulin use, family history of diabetes, high education level, normal kidney function, and higher body mass index were associated with HbA1c goal of >6.5%.

CONCLUSION:

The level of adequate glycemic control was slightly improved before. Glycemic control of patients with long duration of diabetes is harder even though they receive insulin treatment.

 

Nothing to Disclose: JYJ, KHS, SYO, YSC, DJK

13667 29.0000 SAT-0994 A Glycemic Control of Patients with Type 2 Diabetes in Korea: The Fifth Korea National Health and Nutrition Examination Survey (KNHANES V) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0966-0994 4802 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Yoshitaka Hayashi*1, Yuko Takano2, Kenji Kasai3, Tsuneo Imai4 and Yoshiharu Murata5
1Nagoya University, Res Inst of Environmental Medicine, Nagoya, Japan, 2Nagoya University, Graduate School of Medicine, 3Aichi Medical University, 4Aichi Medical University, Nagakute, Aichi, Japan, 5Nagoya Univ, Aichi, Japan

 

Multiple bioactive peptides are produced through tissue-specific processing of proglucagon, which is encoded by glucagon gene (Gcg). Glucagon-GFP knock-in mice (Gcggfp/+) express green fluorescent protein (GFP) in islet α-cells and intestinal L-cells. Homozygous mice (Gcggfp/gfp) lack all the proglucagon-derived peptides, including glucagon and GLP-1, thereby, are designated as glucagon-gene knock-out (GCGKO) mice (1). Hyperplasia of islet α-cells have been documented in animal models deficient in glucagon action, i.e. glucagon receptor knock-out mice, and GCGKO mice develop hyperplasia of GFP-positive α-like cells in their islets. Whereas glucagon receptor knock-out mice display lower blood glucose levels, GCGKO mice are normoglycemic, suggesting that decline in blood glucose levels is not a prerequisite for proliferation of α or α-like cells (1,2).
 The present study was aimed to characterize pancreatic neuroendocrine tumors (panNETs), which develop in the GCGKO mice. Hyperplasia of α-like cells in the GCGKO mice is progressive and all the GCGKO mice, but none of the control heterozygous mice, developed macroscopic GFP-positive tumors with diameter of approximately 15 mm in the pancreas at 15 months of age. The tumor showed several features compatible with pancreatic neuroendocrine tumors (panNETs), such as organoid structures with trabecular and cribriform patterns and expression of chromogranin A and synaptophysin. Dissemination of GFP-positive cells in the liver and lung were identified in 100% and 95%, respectively, of the 15-month-old GCGKO mice, but not at all in the heterozygous Gcggfp/+ mice. Macroscopic metastatic tumor in the liver and lung were identified in 42% and 5.2%, respectively, of the 15-month-old GCGKO mice. In subrenal capsule transplantation assay, the mass of panNET grafts increased in the GCGKO mice but not in the control mice. Collectively, the GCGKO mouse is a novel, unique model animal model to study development, pathogenesis and metastasis of panNETs. Furthermore, subrenal capsule transplantation assay suggested that the humoral factors or condition specific to the GCGKO mice play important roles in proliferation of the panNET.

 

Nothing to Disclose: YH, YT, KK, TI, YM

PP10-2 12266 1.0000 SAT-0962 A Pancreatic Neuroendocrine Tumors in Mice Deficient in Glucagon Gene 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0947-0965 4805 1:00:00 PM Beta-Cell Biology and Insulin Secretion Poster

Kathryn L Gatford*, Hong Liu, Zuleeza Ahmad, Miles J De Blasio, Gary K Heinemann, Tina Bianco-Miotto and Julie A Owens
University of Adelaide, Adelaide, Australia

 

Restricted growth before birth (IUGR) increases the risk of diabetes in adulthood (1), implying that insulin secretion fails to adequately adapt and up-regulate in response to insulin resistance. Consistent with this, in adult IUGR men (2) and in sheep with IUGR induced by surgical placental restriction (3), insulin secretion is inadequate for the level of insulin resistance. Effects of IUGR on adaptive changes in insulin secretion in response to increased demand for insulin have not been directly tested, however. We have developed a direct test of the plasticity of insulin secretion, using chronic mild hyperglycemia to increase the demand for insulin in sheep (4). We hypothesised that PR would impair plasticity of insulin secretion when challenged by hyperglycemia in the adult sheep. We therefore measured glucose tolerance and insulin secretion and β-cell mass and function in adult sheep born from control (CON) pregnancies and growth-restricted (PR) pregnancies before and during 16 days of moderate hyperglycemia (HG) or euglycemia (EUG) (20 CON-EUG; 20 CON-HG; 15 PR-EUG; 15 PR-HG). Hyperglycemia impaired glucose tolerance (AUC glucose increased by 100%, P < 0.001) and increased insulin secretion (particularly second phase; two-fold, P < 0.001). Hyperglycemia also increased β-cell function (particularly second phase; 6.5-fold, P = 0.034) in males. Placental restriction did not alter glucose tolerance, β-cell mass or β-cell function but impaired insulin secretion (particularly second phase; P = 0.030) in male singletons. Placental restriction in the face of hyperglycemic challenge did not alter glucose tolerance or β-cell mass. However, hyperglycemia induced greater increases in first phase insulin secretion (+50%, P < 0.001) and β-cell function (particularly second phase, 4.5-fold, P = 0.016) in PR sheep than CON sheep. Contrary to our hypothesis, placental restriction enhanced the plasticity of insulin secretion in response to hyperglycemic challenge in young adult sheep. Together with the elevated glucose-stimulated insulin secretion we previously observed in vitro in islets from twin lambs, compared to those from singletons (5), this suggests that IUGR induces insulin hyper-secretion from β-cells, at least in young sheep. Whether this β-cell compensatory adaptation leads to exhaustion of β-cells with ageing and the onset of type 2 diabetes is yet to be investigated.

 

Nothing to Disclose: KLG, HL, ZA, MJD, GKH, TB, JAO

PP10-4 16658 2.0000 SAT-0947 A Restriction of Placental Growth Increases Plasticity of Insulin Secretion in Response to Hyperglycemic Challenge in Adult Sheep 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0947-0965 4805 1:00:00 PM Beta-Cell Biology and Insulin Secretion Poster

Leonid E Fridlyand*1 and Louis H Philipson2
1University of Chicago, Chicago, IL, 2Univ of Chicago Medicine, Chicago, IL

 

Innovative treatments of Type 2 diabetes mellitus target messenger pathways through activation of G-protein coupled receptors by hormones and neurotransmitters. The two main signals of activated messenger pathways in pancreatic beta-cells are cAMP and inositol 1,4,5-trisphosphate /diacylglycerol generated by phospholipase C (PLC). These pathways interact with each other and with other second messengers such as intracellular calcium to regulate insulin secretion. However, the complex nature of the receptors and second messenger interactions makes it extremely difficult to understand how they are regulated. We used a systems biology approach for analysis and developed an updated computational model that incorporate modern data on glucose metabolism, plasma membrane potential, G-protein-coupled-receptors, cytoplasmic and endoplasmic reticulum calcium dynamics, cAMP and PLC pathways that regulate second messenger interactions. The values of most of the model parameters were inferred from available experimental data. We were able to simulate the beta cell messenger dynamics under a wide range of experimental conditions on the basis of this computational model. Interestingly, our simulation has shown that the regulatory properties of adenylyl cyclase isoforms can explain a synergistic action of glucose and glucagon-like peptide 1 on insulin secretion that could exacerbate hypoglycemia. On the other hand, we found that in some cases acetylcholine (and by implication other activators of PLC) can inhibit activation of glucose-stimulated insulin secretion by glucagon-like peptide 1. These results support the utility of constructing a virtual beta cell to understand novel signaling interactions in insulin secretion.

 

Nothing to Disclose: LEF, LHP

PP10-1 15559 3.0000 SAT-0948 A Systems Biology Approach to Analyze the Receptor and Second Messenger Interactions in the Pancreatic Beta Cell 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 0947-0965 4805 1:00:00 PM Beta-Cell Biology and Insulin Secretion Poster

Seth Weaver*, Dragana Jokic, Deepa Mokshagundam, Leila Gobejishvili, Shirish S Barve and Sri Prakash L Mokshagundam
University of Louisville, Louisville, KY

 

The role of the gut microbiome in the pathophysiology of Type 2 Diabetes Mellitus (T2DM) and its complications has been gaining increasing recognition. Increased gut permeability and microbial translocation are postulated to play a significant role in mediating the effect of the gut microbiome on diabetes through their effects on inflammatory pathways. While there is considerable support for these in animal modles, human studies evaluating the role of gut permeability and microbial translocation have only been recently initiated. CD14 is an effective mediator for the activation of monocytes in response to bacterial endotoxins. The serum soluble CD14 (sCD14) levels increase during the systemic response to bacterial invasion and endotoxin. We have previously demonstrated that monocytes from subjects with T2DM show a robust response to endotoxin. Thus, sCD14 may be a useful marker of monocyte activation by endotoxin and reflect increased gut permeability and bacterial translocation in T2DM.

We evaluated 17 subjects with poorly controlled T2DM and 11 healthy controls. After clinical evaluation, fasting blood sample was drawn for measurement of A1c, cytokines, sCD14. Subjects with T2DM had a mean A1c of 8.2+/-1.3%. There were significantly elevated Il-6 (1.99 +/- 1.66 pg /ml vs 0.49 +/- 0.39 pg/ml p=0.0025) and MCP-1 levels (457 +/- 213 pg/ml vs 269 +/- 135 pg/ml p = 0.005) in subjects with T2DM indicating a pro-inflammatory state in T2DM. Serum TNF and IL-8 were higher in subjects with T2DM, but did not reach statistical significance. Importantly, sCD14 was significantly elevated in subjects with T2DM (2486 +/- 398 ng/ml vs 1895 +/- 952 ng/ml p=0.04) when compared with healthy controls. In subjects with T2DM, sCD14 levels  correlated with IL-6 (r=0.579, p<0.05) and IL-8 (r=0.53, p<0.05). These assciations were not seen in control subjects.

These results clearly indicate a potential role for increased intestinal permeability and endotoxin mediated monocyte activation in the pro-inflammatory state in T2DM. Further studies with a larger cohort of well- defined subjects to delineate the relationship between the gut microbial flora, micribial trnslocation, and the observed cytokine responses will help clarify mechanisms by which the gut microbiome affects T2DM and its complications. Such studies could set the stage for clinical trials evaluating the role of interventions, including probiotics, in mitigating the effects of T2DM and its complications.

 

Nothing to Disclose: SW, DJ, DM, LG, SSB, SPLM

14216 1.0000 SAT-1005 A Circulating Soluble CD14 and Its Relation to Serum Cytokines in Type 2 Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Jingsong Zhao*1, John Corbin1, Ken Der2, Liching Cao1, Ira D Goldfine1 and Paul Rubin1
1XOMA Corporation, Berkeley, CA, 2XOMA (US) LLC, Berkeley, CA

 

Endogenous hyperinsulinemic hypoglycemia disorders, such as insulinoma and congenital hyperinsulinism, are severe diseases of excess insulin secretion that are often resistant to current medical treatment.  XMetD is a fully human IgG2 allosteric monoclonal antibody that selectively binds with high affinity to the insulin receptor (INSR) and antagonizes insulin-dependent signaling.  As a novel INSR inhibitor, we tested efficacy of XMetD in an animal model of hyperinsulinemia-induced hypoglycemia.  Employing subcutaneously implanted osmotic mini-pumps secreting insulin, sustained and stable reductions of blood glucose levels were maintained in rats.  Single dose escalating injection of XMetD in insulin pump-implanted rats demonstrated that XMetD raised levels of both blood glucose and serum insulin in dose and time-dependent manners.  Serum levels of XMetD showed dose proportionality with terminal half-lives of approximately one week.  Using pharmacokinetic/pharmacodynamic (PK/PD) modeling to simulate the relationship between XMetD serum exposure and blood glucose levels, we have chosen XMetD doses of 3, 10, and 30 mg/kg in the subsequent repeat-dose, long-term study.  In an eight week study of rats implanted with insulin mini-pumps, we have shown that therapeutic administration of twice weekly XMetD, in a dose-related fashion, increased both blood glucose and serum insulin levels throughout the dosing period.  At 10 mg/kg, XMetD normalized fasting blood glucose levels in hypoglycemic rats.  Taken together, our results suggest XMetD restored blood glucose levels in animals by specific inhibition of INSR signaling and thereby could have therapeutic benefit in human diseases of endogenous hyperinsulinemic hypoglycemia.

 

Nothing to Disclose: JZ, JC, KD, LC, IDG, PR

12053 2.0000 SAT-1006 A Xmetd, an Inhibitory Allosteric Insulin Receptor Monoclonal Antibody, Is Efficacious for the Treatment of Hyperinsulinemic Hypoglycemia in Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Foiqa Chaudhry*1 and Kwame Safo Ntim2
1University of Florida, Gainesville, FL, 2Univ of Florida, Gainesville, FL

 

BACKGROUND:  Insulinomas are rare neuroendocrine tumors, and very rarely diagnosed in a patient with known type 2 diabetes mellitus.  Left unmanaged, they can contribute to significant morbidity and mortality.

CLINICAL CASE:

An 84 year old gentleman was diagnosed with type 2 diabetes ten years prior with a hemoglobin A1c of 8.9.  He maintained an A1c between 6.5 and 8.0 on metformin and glipizide until he began suffering recurrent falls and hypoglycemia.  Despite stopping his oral diabetic medications for the prior two years, he needed multiple glucose tablets daily to maintain euglycemia.  An episode of unconsciousness brought him to medical attention.  A 72 hour fast was conducted after he was ruled out for acute cardiac or neurologic causes of syncope.  When blood glucose noted to be 36 mg/dl, his proinsulin level was greater than 800 pmol/L (ref < 18.8), c-peptide 10.4 ng/mL (ref 0.80-3.10) and insulin 64 uIU/mL (ref < 23).  Sulfonylurea panel was negative and he had normal thyroid function, LFT’s and cortisol levels.  His renal function was at his baseline with creatinine of 1.3 mg/dL (ref 0.5-1.2).  Abdominal CT scan revealed lobulated heterogeneously enhancing mass with coarse calcifications in the body and tail of the pancreas. The mass measured 9.0 x 4.7 cm at the greatest dimension.  He underwent distal pancreatectomy with splenectomy and pathology confirmed 11.5 x 6.1 x 3.0 cm tumor invading the peripancreatic soft tissue and the spleen.  Resection margin was negative but nine out of twelve lymph nodes were positive for neuroendocrine tumor.  Post operatively, he required low dose Lantus to maintain euglycemia and no longer suffered from recurrent falls or syncopal episodes.  He will require ongoing oncology follow up.

CONCLUSION

High index of suspicion for insulinoma is required to ensure appropriate workup of hypoglycemia in a patient with known type 2 diabetes mellitus.  With appropriate intervention, there can be significant reduction in morbidity and mortality.

 

Nothing to Disclose: FC, KSN

13334 3.0000 SAT-1007 A Insulinoma in a Type 2 Diabetic 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Christian C.K. Kim*1, Thomas Rosano2, Erin E. Chambers3, Manjunath Pai4 and James Desemone1
1Albany Medical College, Albany, NY, 2Albany Medical Center, 3Waters Corporation, 4Albany College of Pharmacy

 

Objective:We present a unique case of overdose with insulin glargine and insulin aspart requiring a prolonged dextrose infusion to prevent hypoglycemia. We have measured the serum levels of insulin aspart and the insulin glargine metabolite to understand pharmacokinetics when supra-therapeutic doses are administered.

Background:Insulin glargine is a basal insulin analog that is used to treat diabetes mellitus. At therapeutic doses, the time-action profile of insulin glargine is relatively constant over 24 hours. Insulin aspart is a rapid-acting insulin analog with a therapeutic duration of action of 2-4 hours. The pharmacokinetics of these compounds when given in supra-therapeutic doses has not been well studied. Insulin glargine is hydrolyzed in the subcutaneous injection depot and absorbed into the blood as its metabolites, M1 and M2. M1 is the active form of the drug and the major metabolite. Aspart is absorbed without modification.

Method:We have used liquid chromatography-tandem mass spectrometry to detect and quantitate the M1 and insulin aspart levels in the serum in an individual who administered large supra-therapeutic doses of these medications. Blood samples were collected from the time of the presentation and at approximate 5 hour intervals until the risk of hypoglycemia abated.

Case Report:43 year old male with Type 1 diabetes mellitus for 20 years and schizoaffective disorder for 10 years who had two insulin analog overdoses separated by 11 weeks. The first overdose was with 1500 units of glargine and 600 units aspart and second overdose was with 900 units of glargine and 600 units of aspart. He injected multiple sites in his abdomen (300 units at each site). Both of these overdoses resulted in the need for prolonged dextrose infusion to prevent hypoglycemia.

Results:The first overdose required approximately 110 hours of dextrose infusion and the second overdose required 96 hours of dextrose infusion. Serum concentration of M1 varied during the recovery phase of both overdoses and was detected up to 90 hours after the first overdose and 54 hours after the second overdose. Higher serum concentrations of the M1 metabolite correlated with the need for higher rates of IV dextrose infusion. Insulin aspart was detected up to 29 hours in the first overdose and 22 hours in the second overdose.  During these time periods, higher rates of IV dextrose infusion were needed.

Conclusion: The hypoglycemic metabolic effect of insulin glargine was prolonged to more than 4 days when a large supra-therapeutic dose was injected. Higher rates of dextrose infusion were required to prevent hypoglycemia when serum concentrations of the active metabolite of insulin glargine, M1, were higher. These findings are in contrast to the smooth metabolic effect that is observed when insulin glargine is given in therapeutic doses.  The pharmacokinetic profile of the concomitant insulin aspart overdoses was also prolonged.

 

Nothing to Disclose: CCKK, TR, EEC, MP, JD

13491 4.0000 SAT-1008 A Insulin Glargine and Insulin Aspart Overdose with Pharmacokinetic Analysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Madiha M Alvi*, Matthew P. Gilbert, Annis M. Marney and Joel J Schnure
The University of Vermont College of Medicine, South Burlington, VT

 

Introduction:  Bactrim induced hypoglycemia is a well reported drug-drug interaction in patients with diabetes treated with sulfonylureas. However, reports are rare in the absence of diabetes medications. The sulfamethoxazole (SMX) component of Bactrim can induce hypoglycemia by stimulating pancreatic cells to secrete insulin. Renal failure exacerbates this by prolonging the half-life of drug metabolites.

Case:  A 52 year old female with past medical history significant for Type 2 diabetes mellitus, resolved following RYGB 2 years previously, was admitted to ICU after a motor vehicle accident with injuries including open wound infected with multi drug resistant bacteria for which she was started on Bactrim. A week later, she was found confused and agitated with serum glucose at 37 mg/dl. She was treated with intravenous D50 boluses, glucagon, continuous D10 IV drip, TPN, Hydrocortisone. She was mechanically ventilated, BP 106/85 mm of Hg, HR 109 bpm, afebrile, BMI 33. Lab data: BUN 14 mg/dl, creatinine 2.04 mg/dl, GFR 26 ml/min/1.73m2 (n>60), plasma glucose 40 ng/ml, elevated c-peptide (38.6 ng/ml, n<1.1-4.4), insulin (295.7 uIU/ml, n<0-29), proinsulin (230 pmol/L, n<3-20). Serum trimethoprim level was 17.0 mcg/mL (therapeutic >2.0) and SMX level was 217 mcg/mL (therapeutic >50).  AST and ALT were mildly elevated at 96 U/L (15-46) and 81 U/L (9-52) respectively.  Thyroid function and ACTH stimulation tests were normal. Bactrim was stopped at this point. The differential diagnosis included hypoglycemia due to critical illness (hepatic, renal failure, sepsis), Bactrim-induced hypoglycemia in absence of sulfonylureas, and nesidioblastosis. Insulinoma was considered unlikely due to absence of hypoglycemia prior to admission or since RYGB. We elected to follow renal function, SMX, insulin, and C-peptide levels on subsequent days to establish the diagnosis non-invasively. Three days after discontinuing Bactrim, labs showed decreased SMX level of 167 mcg/mL, C-peptide 6.3 ng/ml, Insulin 5.7 uIU/ml, pro-insulin 100 pmol/L and serum glucose improved to 100 mg/dl, despite worsening renal function (creatinine 3.08 mg/dl, GFR 16). Blood glucose remained in a normal range off supportive therapy, confirming the diagnosis of Bactrim induced hypoglycemia.

Conclusions:  Bactrim induced hypoglycemia can occur in patients without concurrent diabetes medication and with history of RYGB and may be exacerbated by underlying renal failure. The contribution of adult-onset islet cell hyperplasia (ie. nesidioblastosis or non-insulinoma pancreatogenous hypoglycemic syndrome), while popular in the literature, cannot be confirmed clinically or with labs. Following serum drug and insulin levels may obviate the need for invasive testing. Treatment strategies include discontinuing offending medications, using oral/IV glucose, and glucagon. Octreotide may be considered for refractory cases.

 

Nothing to Disclose: MMA, MPG, AMM, JJS

14563 5.0000 SAT-1009 A Bactrim Induced Severe Hypoglycemia in a Diet-Controlled Diabetic Patient with History of Gastric Bypass (RYGB) Surgery - Use of Serum Drug & Insulin Levels for Diagnosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Marie E. McDonnell1, Elizabeth Herman*1, Rishabh Sachdev2, Marina Donahue1, Mufaddal Mahesri3, Donna Kelleher-Yassen1, Jennifer Britton-Colonnese1 and Sara M Alexanian1
1Boston Medical Center, Boston, MA, 2Boston University School of Medicine, Boston, MA, 3Boston University, Boston, MA

 

Hypoglycemia (glucose < 70 mg/dl) in the hospital has been implicated in studies to increase adverse outcomes including increased mortality and average hospital length of stay (aLOS). However, some show worse outcomes with noniatrogenic (NH) vs. iatrogenic (IH) hypoglycemia and others show no difference. To address this, we conducted a chart review of 139 inpatients who had been identified on a daily report to have a hypoglycemic value on a routine lab chemistry in the prior 24 hours.  Patients who received insulin at home or in hospital within the last 24 hours (glargine) or last 8 hours (regular or lispro) prior to results or who received sulphonylurea were classified as iatrogenic hypoglycemia (IH), N=57. The remaining patients were classified as non-iatrogenic hypoglycemia (NH), N=82.

Compared to IH, NH was younger (52 vs. 63), had shorter aLOS both total and following event (6 vs. 10 days and 5 vs. 8 days, respectively) and had a low diabetes prevalence (14% vs. 93%), and HA1c (5.6% vs. 8%), all p<0.05. The NH group had better renal function (GFR 53 vs. 38 mg/dl), p=<0.01. There was no difference in mortality or ICU admission between the groups, although there were more deaths in the IH group. NH also had a higher glucose value (62 mg/dl vs. 55mg/dl), and was less likely to have recurrent hypoglycemia (OR 0.43), p<0.01.

Prior to the event, the NH group trended toward a longer duration of "NPO status,"  defined as having an active order for no nutrition, noted as 0 or hours duration, (6+/- 14 hrs vs. 2 +/- 7 hours) p=0.07. When we removed the 34 subjects with NPO status at the time of hypoglycemia from the analysis,  (23 NI,11 IH), total aLOS and aLOS following event were no longer different between the groups, p= 0.2276 and 0.2727 respectively.  Age, glucose, HA1c, GFR and recurrent hypoglycemia during hospital stay remained significant.

In conclusion, we found that NH was more common than IH detected on routine labs and NH patients were lower risk as measured by LOS, GFR, HA1c and recurrent events. The NH group contained more NPO patients and for a longer duration than IH, and when these patients were excluded, aLOS was no longer different. The results suggest that NH occurs commonly in a lower risk hospitalized cohort and prolonged fasting is likely a significant factor. Failure to identify this group in large datasets likely explains conflicting reports of the outcome differences between IH and NH.

 

Nothing to Disclose: MEM, EH, RS, MD, MM, DK, JB, SMA

16900 6.0000 SAT-1010 A Identifying Noniatrogenic Hypoglycemia Subtypes for Accurate Hospital Risk Assessment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

David R. Saxon*1, Aaron W Michels2 and Michael T. McDermott3
1University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, 2University of Colorado Denver, Aurora, CO, 3University of Colorado School of Medicine, Aurora, CO

 

Background: Insulin autoimmune syndrome (Hirata’s disease) is a rare disorder having been described in only 58 non-Asian patients as of 2009 (1). Experience in managing this condition and understanding of its clinical course during treatment is therefore extremely limited.

Clinical Case: A 71-year-old Caucasian man was referred for evaluation of severe hypoglycemia. He had been experiencing daily episodes of diaphoresis and disorientation associated with home glucometer readings less than 40 mg/dL with correction of hypoglycemia resulting in resolution of symptoms. Symptoms occurred in the late post-prandial period (i.e. 4-6 hours after meals). He had not previously been exposed to exogenous insulin therapy or sulfonylureas. About one month prior to onset of symptoms he had taken indomethacin and amoxicillin/clavulanic acid. 

Fasting laboratory tests were as follows: fasting plasma glucose 58 mg/dL (70-105 mg/dL), proinsulin 14,650 pmol/L (<=26.8 pmol/L), insulin 271 uIU/mL (2-23 uIU/mL), C-peptide 7.1 ng/mL (0.8-3.5 ng/mL), beta-hydroxybutyrate 6.6 mg/dL (0.0-3.0 mg/dL), and insulin antibodies >50.0 (ARUP Laboratories; 0.0-0.4 U/mL). Other laboratory results were normal including complete blood count with differential, electrolytes, renal function, liver enzymes, UPEP, SPEP, ANA, and hepatitis C antibody. HbA1c was 6.0%. CT chest, abdomen, and pelvis with contrast was unremarkable.

Given positive insulin antibody level, serum was further analyzed at the Immunology Lab at the Barbara Davis Center for Diabetes. The diagnosis of insulin autoimmune syndrome was confirmed given an insulin autoantibody (IAA) level of 6.61 (normal <0.01) in a radioimmunoassay and serologic typing revealed the presence of a HLA-DR4 allele, which has been associated with insulin autoimmune syndrome. Scatchard analysis revealed the insulin antibodies had an extremely high affinity and capacity for insulin with an ability to bind 18 units of insulin/liter blood. The insulin antibodies were polyclonal in nature with the majority being IgG1 and IgG4.

Patient was initiated on prednisone 60mg daily and response to therapy has been monitored with a continuous glucose monitor (Dexcom) and serial IAA titers.

Conclusion: This case illustrates how continuous glucose monitoring and serial IAA titers can be used to monitor the clinical course of a patient being treated for insulin autoimmune syndrome.

 

Nothing to Disclose: DRS, AWM, MTM

14298 7.0000 SAT-1011 A Management of Insulin Autoimmune Syndrome in a Non-Asian Male: Use of Immunosuppression, Continuous Glucose Monitoring, and Serial Antibody Titers 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Deirdre Cocks Eschler*, Georgia Kulina, Mirella Mourad, Khadeen C Cheesman, Emilia Bagiella, Adolfo Garcia-Ocana and Carol J Levy
Icahn School of Medicine at Mount Sinai, New York, NY

 

BACKGROUND:  Gestational diabetes mellitus (GDM) has potential short and long term consequences to the mother and the fetus with no clear cutoff of blood glucose (BG) associated with increased risk (HAPO study). Placental factors are known to play a role but the exact molecular mechanism is unknown.  In GDM mouse models, hepatocyte growth factor (HGF) and its receptor, c-Met, play a potential role; pregnant knockout mice for c-Met in the pancreas had a significant decrease in β cell mass, premature β cell apoptosis, higher BG, lower plasma insulin and IGT. In humans, circulating HGF increases from 10 weeks gestation steadily until delivery. HGF has been shown to correlate with gestational-age size and circulating c-Met  with preeclampsia in pregnant women but these parameters have not yet been studied in relation to GDM. In non-pregnant adults, levels correlate with insulin resistance in patients with the metabolic syndrome. 

DESIGN: Cross-sectional, IRB-approved, study in which blood samples are collected from consented pregnant women, >18 years of age with and without gestational diabetes, at the 24-28 week obstetrical (OB) visit during which the oral glucose tolerance test is performed and again after 36 weeks gestation. Plasma is analyzed with specific ELISAs for HGF and c-Met, additional plasma and blood components are frozen and stored, with consent, for potential future analysis of other metabolic factors. Following delivery, charts are reviewed for pregnancy outcomes (preeclampsia, baby size, c-section, neonatal hypoglycemia, early labor). In order to achieve adequate power, a sample size of 40 pregnant women with GDM and 40 matched pregnant women without GDM is needed.

CLINICAL ENDPOINTS: We aim to document an association between HGF and GDM and assess if HGF and/or c-Met levels correlate with severity of GDM and with pregnancy outcome.

PRELIMARY DATA: HGF and c-Met levels have been analyzed on 32 controls and 10 GDM subjects. While a statistical difference in HGF/c-Met levels has not yet been found between the groups, the sample size is too small to yet draw conclusions. If differences are not found at adequate sample size, the DNA will be analyzed for HGF/c-Met gene polymorphisms.

SIGNFICANCE:  Data in mice suggests that HGF/c-Met has an important role in β cell expansion and survival during pregnancy. If similar results are found in humans, future studies and analyses can determine potential diagnostic and therapeutic roles for HGF/c-Met in GDM

 

Nothing to Disclose: DCE, GK, MM, KCC, EB, AG, CJL

15079 8.0000 SAT-1012 A Hepatocyte Growth Factor and Gestational Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Bert M. Bieler*1 and Geetha K Bhat2
1Cooper University Hospital, Camden, NJ, 2Cooper University Hospital, Voorhees, NJ

 

Background:  Pseudohypoglycemia is a condition which is associated with a low glucose concentration in the absence of classical signs and symptoms of hypoglycemia. It occurs in situations in which there is impaired microcirculation resulting in low capillary glucose levels, but the serum blood glucose is normal. Pseudohypoglycemia does not meet Whipple’s Triad for true hypoglycemia. The most common causes include leukocytosis, polycythemia, delay in separation of plasma from formed blood elements, chronic anemia in a hemolytic crisis, trypanosomasis, hypovolemic shock, Raynaud phenomenon, and immunoglobulin M (IgM) macroglobulinemia. 

Clinical Case:  We report the case of a 64 year old Caucasian female, with a past medical history of primary hypothyroidism, depression, and Raynaud phenomenon, who was injured in a fall. She suffered from multiple traumatic injuries including a subdural hematoma, subarachnoid hemorrhage, bilateral pnuemothoraces, rib fractures, and vertebral fractures. She was admitted to the trauma service, started on anti-seizure medications and analgesics, and had a right chest tube placed. Upon routine point of care blood glucose (POCBG) testing, she was noted to be severely hypoglycemic, with BG in the 20-30mg/dl (normal >70mg/dl) range. Concurrent plasma glucoses were normal and the patient remained asymptomatic, which is in contrast to the findings in true hypoglycemia. She was started on a Dextrose 10% infusion and a work-up for causes of hypoglycemia ensued, including an AM cortisol and Cosyntropin test. POCT blood glucoses from her fingertips continued to be very low, with plasma glucoses remaining normal and without signs or symptoms of hypoglycemia. We were consulted and recommended POCBG testing to be done at an alternative site in the forearm. Unlike the fingerstick blood glucoses, readings in the forearm were in the normal range and consistent with the serum glucose. This, along with the patient’s history of Raynaud’s, clinched the diagnosis of pseudohypoglycemia. It was concluded that the impaired microcirculation due to Raynaud’s caused increased extraction of glucose from the capillaries resulting in the low glucose estimations. The patient was counseled about her diagnosis and was advised to avoid blood glucose testing from finger tips in the future.

Conclusions:  Pseudohypoglycemia should be considered in asymptomatic patients with low blood glucose levels before initiating an extensive work up. Alternative blood glucose monitoring sites should be considered in patients with impaired microcirculation.

 

Nothing to Disclose: BMB, GKB

16540 9.0000 SAT-1013 A Pseudohypoglycemia: When Low Is Not Really Low 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Sindhu Basavaiah Igala*1, Anthony Domingo2, Arnaldo Villafranca III2, Linette Rivera3 and Joaquin Gomez-Daspet2
1USF, Tampa, FL, 2University of South Florida, Tampa, FL, 3USF, TAMPA, FL

 

OCTREOTIDE S ROLE IN MANAGING INTENTIONAL SULFONYLUREA OVERDOSE: A CASE REPORT

Sindhu Igala M.D.,Anthony C. Domingo M.D., Arnaldo Villafranca M.D.,
Joaquin Gomez-Daspet M.D.., Linette Rivera M.D
James A. Haley Veterans’ Hospital
University of South Florida College of Medicine Division of Endocrinology and Me

Sulfonylurea agents are a common form of pharmacotherapy utilized in the treatment of type 2 diabetes. Excess sulfonylureas cause severe hypoglycemia, with onset delayed up to 12 hours, and prolonged effect up to several days post-exposure. Octreotide is a long-acting synthetic analog of somatostatin that can be utilized to counteract the insulin-releasing properties of sulfonylureas [3]. We report a case involving a patient who intentionally overdosed on his home meds which included a sulfonylurea, and the use of octreotide to address his persistent, difficult to control hypoglycemia.

61-year-old male with 10 year history of type 2 diabetes, laryngeal carcinoma post chemoradiation, and major depressive disorder, presented to the JAHVA ER after ingesting approximately 20 tablets of various home meds, including glipizide, in an intentional overdose. Blood glucose on arrival to ER was 24 mg/dL Patient transferred to unit for further management. Three days after presentation to ER, first dose of subcutaneous octreotide 50 mcg given due to persistent hypoglycemia. Dextrose 10% infusion at 50 mL/hr also started. His glucose rose from 60 mg/dL 1 hr before injection to 119 mg/dL 1 hour after injection. His sugars ranged from 180-230 mg/dL, but began to drop again 12 hours after octreotide injection. Therefore, another 50 mcg dose of octreotide was administered, and repeated every 6 hours for 24 hours. Once sugars trended into 200-300 mg/dL ranges, dextrose fluids were discontinued and euglycemia maintained through oral/feeding tube intake alone. Patient stabilized and transferred to in-hospital psychiatric ward for further management without residual effects.

Sulfonylureas are an important class of diabetic medications that can promote euglycemia through increasing endogenous secretion of insulin.Octreotide, when combined with dextrose, can minimize this effect. When given subcutaneously, octreotide is quickly and completely absorbed, reaching 100% bioavailability in as little as 30 minutes [4]. Adverse effects related to short-term use of octreotide are minimal and may include gastrointestinal upset and diarrhea [3,5]. Recommended dosing schedule appears to differ in the literature, ranging from 50 mcg administered subcutaneously every 6 hours [3,6] to every 8 hours

 

Nothing to Disclose: SBI, AD, AV III, LR, JG

13071 10.0000 SAT-1014 A Octreotide s Role in Managing Intentional Sulfonylurea Overdose 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Daniel E. Okorodudu*1 and Matthew J. Crowley2
1Duke University Medical Center, Durham, NC, 2Duke University Medical Center

 

Background: Reactive hypoglycemia in a patient without diabetes is rare and potentially life-threatening. A thorough work-up can be challenging but is necessary for appropriate therapy.

Clinical Case: A 61 year-old white male was referred for evaluation of an eight-year history of symptomatic hypoglycemia. The patient endorsed glucometer BGs as low as 20 mg/dL. Episodes primarily occurred in the postprandial state up to 3 times a day, though he occasional experienced fasting lows. Of note, the patient had previously been told he had prediabetes but he denied use of antiglycemic agents, family history of diabetes, or history of gastric bypass.

Evaluation in clinic demonstrated a BG of 61 mg/dL, an insulin level of >300 μM/mL, a proinsulin of 10 pmol/L, and a C-peptide of 6.3 ng/mL (all elevated). Sulfonylurea screen, cortisol, liver, renal labs, and CT abdomen were unrevealing. A 72-hour fast was completed without incidence of BG <68 mg/dL however insulin antibody level was noted to be 180 μM/mL (ref 0-5). A mixed-meal tolerance test showed an excessive postprandial BG drop from 229 mg/dL at one hour post-ingestion to 63 mg/dL at two hours. Hemoglobin A1c remained elevated at 6.1. The patient was instructed to adhere to a low carbohydrate diet which offered some improvement in the frequency of his reactive hypoglycemia episodes, but they persisted (2-3 times weekly). A trial of acarbose was initiated but poorly-tolerated. Of note, the patient’s hemoglobin A1c improved to 5.7 with the low carbohydrate diet; because the reactive hypoglycemia episodes persisted despite this improvement, prediabetes was felt to be less likely the sole cause and the patient’s elevated insulin antibodies were investigated further. Repeat levels remained excessively high. Ultimately, the patient’s reactive hypoglycemia was felt to be due to insulin autoimmune syndrome. A trial of prednisone was offered, but he preferred to continue management with diet alone. Currently, he experiences <2 reactive hypoglycemia episodes per month.     

Discussion: To date, fewer than 500 cases of insulin autoimmune syndrome (Hirata disease) have been documented, with the vast majority being of Japanese descent. Affected patients typically have other autoimmune diseases or exposure to a sulfhydryl-group-containing drug. Few cases remain idiopathic; we know of no previously reported case of a Caucasian male developing apparently idiopathic Hirata disease. Hypoglycemia with Hirata disease may occur in both the fasting and postprandial states, which may relate to the particular behavior of the autoantibodies binding to the insulin molecule or its receptor.

For reactive hypoglycemia associated with Hirata disease, low carbohydrate diet is a mainstay of therapy. Discontinuation of any offending agents is crucial, while corticosteroids, immunosuppressive agents, and even plasmapheresis are therapeutic options in refractory cases.

 

Nothing to Disclose: DEO, MJC

17011 11.0000 SAT-1015 A Prolonged and Unexplained Reactive Hypoglycemia in a Caucasian Male: An Unusual Case of Hirata Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Ryan D Mills*1 and Fred Whitehouse2
1Henry Ford Health System, Detroit, MI, 2Henry Ford Hospital, Detroit, MI

 

Introduction:  The antimicrobial agent tigecycline is indicated for community acquired pneumonia, complicated intra-abdominal infections, and soft tissue infections.  Hypoglycemia, a rare side effect (<2%), is noted in the drug’s package insert.  No published case reports are available that describe this phenomenon.  Herein we describe such a case.

Clinical Case:  A 62 year old male with 49 year history of type 1 diabetes mellitus fell and sustained a right calcaneal fracture requiring open reduction and internal fixation.  A polymicrobial osteomyelitis and cellulitis developed. This led to a non-healing foot wound which required debridement, skin grafting, and a prolonged antibiotic course (8 weeks).  His initial antibiotic regimen included IV vancomycin and ertapenem.  A skin rash was found 30 days after initiating these agents.  The regimen was changed to IV tigecycline.  The patient received a loading dose of 100 mg on tigecycline treatment day 1 and 50 mg doses twice daily until completion of therapy (20 days).  

Within 48 hours of receiving the loading dose the patient developed repeated episodes of hypoglycemia.  Episodes took place in the early morning and early evening.  Hypoglycemic glucose values ranged from 40 to 60 mg/dL by home glucometer and the patient complained of hypoglycemia symptoms.  The pre-antibiotic insulin regimen (stable in dose for >1 year) consisted of NPH insulin 20 units with breakfast and 10 units at bedtime, Regular insulin 10 units before breakfast and 5 units before dinner, and Aspart insulin 5 units with lunch (0.67 units/kg).  By the end of the tigecycline treatment course the insulin regimen was reduced to NPH insulin 20 units before breakfast and 4 units at bedtime, and Aspart insulin 5 units before dinner (0.37 units/kg).  The frequency of hypoglycemia declined, but sporadic episodes continued.  None of his other medications led to hypoglycemia.  He had been taking his non-insulin medications (simvastatin, fluoxetine, klonopin, aspirin) for long periods of time prior to his infection.  He denied increase in activity levels, anorexia, nausea, and emesis.  His post-antibiotic, total, daily insulin amounts reached 40 units (0.54 units/kg).  Hypoglycemia resolved with discontinuation of tigecycline.

Conclusion:  The occurrence of hypoglycemia due to tigecycline has been stated in the federal drug administration’s adverse event reporting system, a phase 3 trial comparing tigecycline versus ertapenem in diabetic foot infections, and the drug’s package insert (1,2).  The medical literature lacks published case reports describing the phenomenon.  The mechanism leading to hypoglycemia is unknown. Patients with diabetes receiving anti-hyperglycemic medications should be counseled on the possibility of this adverse event and be advised to diligently monitor glucose levels during tigecycline treatment so that steps may be taken to adjust the insulin doses if hypoglycemia occurs.

 

Nothing to Disclose: RDM, FW

15859 12.0000 SAT-1016 A Hypoglycemia Due to Tigecycline Therapy for a Non-Healing Foot Wound 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

David Ni*1, Shikha G Khosla2 and Eric S Nylen3
1Temple University School of Medicine, Philadelphia, PA, 2Veterans Affairs Medical Center, Washington, DC, 3VA Medical Center, Washington, D.C.

 

Background: Sertraline is a commonly prescribed antidepressant which has been associated with glycemic dysregulation. Despite rare reports and a poorly elucidated mechanism, it should be considered in the work up of hypoglycemia. 

Clinical Case: A 58 year old African American male with poorly controlled type 2 Diabetes but normal renal and hepatic function was admitted for severe hypoglycemia. One month prior to admission, his home insulin regimen was increased from 50 to 70 units of basal insulin to improve glycemic control. His morning sugars on the new regimen were approximately 120 mg/dL. Twelve days prior to admission, he was started on sertraline 25 mg which was titrated to 50 mg. A week after initiation however, he noted lower morning sugars at about 80 mg/dL and experienced two episodes of symptomatic hypoglycemia with fingerstick values as low as 40 mg/dL in the absence of any dietary or activity changes.

One day prior to admission, he skipped dinner but administered the bedtime glargine. The next morning, he became severely hypoglycemic with a fingerstick glucose of 35 mg/dL. His C-peptide at time was noted to be 0.21 ng/mL (reference range 0.8-3.1 ng/mL) with an insulin level of 41 microIU/mL (reference range < 17 microIU/mL). All diabetic medications were held at admission but the patient continued to have episodes of hypoglycemia with a glucose as low as 52 mg/dL on day 3 of admission.

Sertraline was continued during the first three days of admission with fasting serum glucoses recorded as 61 mg/dL on the second day and 78 mg/dL on third day. After discontinuation of the sertraline, morning serum glucoses improved to 142 mg/dL on the fourth day and 209 on the fifth day. The patient was discharged soon after on his usual insulin regimen of 70 units of basal insulin however, he was readmitted shortly thereafter for Hyperosmolar Hyperglycemic State (HHS).

Conclusion: SSRIs are preferred over TCA medications for management of depression in patients with diabetes due to a worsening of metabolic profile with the latter. This case demonstrates through temporal correlation that sertraline can precipitate hyperinsulinemic hypoglycemia and may cause hypoglycemia even in the absence of anti-diabetic agents.  Though rarely reported and not mechanistically defined, this SSRI should remain in consideration in the work up of hypoglycemia.

 

Disclosure: DN: Shareholder, Abbott Laboratories, Shareholder, Merck & Co., Shareholder, Novo Nordisk, Shareholder, Novartis Pharmaceuticals, Shareholder, GlaxoSmithKline, Shareholder, Johnson &Johnson. Nothing to Disclose: SGK, ESN

15325 13.0000 SAT-1017 A Sertraline Induced Hypoglycemia in a Type II Diabetic Patient 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Pooja Sahni*1, Nitin Trivedi2, Jarrod Faucher3 and Abdulkadir Omer1
1St.Vincent Hospital, Worcester, MA, 2St. Vincent Hospital, Worcester, MA, 3Grove Medical Associates, Auburn, MA

 

Background: Autoimmune hypoglycemia is characterized with low blood glucose associated with high serum insulin and anti-insulin antibody levels. It has been reported more commonly in Japanese population than in non-Japanese population.

Clinical Case:  A 65 year old Caucasian female is evaluated with episodic symptoms of tremor, sweats, headache, lack of concentration without loss of consciousness occurring 2-3 hr. after breakfast or lunch as often as once a week for six months. Finger stick blood glucose readings revealed blood glucose of 35 mg/dL, 38 mg/dL and 48 mg/dL obtained during the presence of symptoms. Her symptoms resolved with improvement of her blood glucose levels after oral intake of sugar containing drinks. She denied using oral antidiabetic medications, insulin, herbal substances, and any other medications that may potentially cause hypoglycemia. Furthermore, she denied performing strenuous exercise.  Her past medical history was significant for morbid obesity, hyperlipidemia, hypothyroidism, and GERD.  Hemoglobin A1C on a recent laboratory work up was 6.1%. Her home medications included levothyroxine, propranolol (for migraine prophylaxis) omeprazole and pravastatin. She denied family history of hypoglycemia. Physical examination was unremarkable other than obesity (BMI: 40 kg/m2). She was instructed to come to laboratory in the presence of symptoms. A blood sample obtained during such symptoms and when the fingerstick blood glucose was 48 mg/dL, revealed following profile: venous blood glucose: 60 mg/dL, serum insulin 202 IU/ml (n :< 21), proinsulin 31.3 pmol/L (n :< 28.9), C-peptide 8 ng/ml (n: 0.9-7), Beta-hydroxybutyrate 0.12 mmol/L (n: 0.02-0.27) anti-insulin antibody >50 U/ ml (n :< 0.4).  A screening for serum sulfonylurea and meglitinides was negative. The repeated episodes of hypoglycemia associated with significantly elevated anti-insulin antibodies led to a diagnosis of insulin antibody syndrome. The patient was started on nutritional management for obesity and prediabetes. Option of systemic steroid use is discussed.

Clinical lesson: Although autoimmune hypoglycemia is an uncommon cause of hypoglycemia, it should be kept in the differential diagnosis during the evaluation of hypoglycemia. It is not known if it is correlated with hypothyroidism or prediabetes.

 

Disclosure: NT: Speaker, Novo Nordisk. Nothing to Disclose: PS, JF, AO

13101 14.0000 SAT-1018 A RARE Case of Autoimmune Hypoglycemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Teeranun Jirajariyavej*1, Akshay Bhanwarlal Jain2 and Andrew George Gianoukakis3
1Harbor UCLA Medical Center, Torrance, CA, 2City of Hope, Azusa, CA, 3Harbor UCLA Med Ctr, Torrance, CA

 

Background:  Glycogen storage disease (GSD) type Ia is characterized by accumulation of glycogen and fat in the liver and kidneys. The lack of glucose-6-phosphatase-alpha (G6Pase), an enzyme that catalyzes the hydrolysis of glucose-6-phosphate to glucose and phosphate, results in disturbed gluconeogenesis and glycogenolysis in the liver. As a consequence, severe hypoglycemia results and lactic acid levels increase due to shunting of glucose-6-phosphate into alternative pathways. Other metabolic derangements include hypertriglyceridemia and hyperuricemia. We present a case of a patient with GSD type Ia admitted with difficult-to-control hypoglycemia.

Clinical Case: A 22 year-old Hispanic male with GSD type Ia diagnosed at the age of 2 months was admitted after an episode of unconsciousness due to hypoglycemia. He complained of severe right upper quadrant pain associated with the episodes of hypoglycemia. In the distant past, a hepatic adenoma had been resected. On admission, he was normothermic, BP 132/78, P 78, RR 18. Significant hepatomegaly was found on physical examination. Hypoglycemia was controlled with a continuous intavenous infusion of 10% dextrose. Attempts to wean off IV dextrose were unsuccessful. Hypoglycemic challenge demonstrated a venous blood glucose of 32 mg/dl occurring 4 hours postprandially and approximately 90 minutes after discontinuation of IV dextrose. Laboratory data obtained simultaneously showed beta hydroxy butyrate 0.2 mM (0.0-0.3 mM), Lactic acid 6.2 mmol/L (0.5-2.2 mmol/L), Insulin 0.8 uIU/mL (1.9-23.0 uIU/mL), proinsulin 0.73ng/mL (0.8- 3.10 ng/mL), and triglycerides of 576 mg/dl. Random cortisol was 5.7 mcg/dL, with an adequate response to cosyntropin stimulation; baseline, time 30 and 60 min cortisol levels were 7.8, 22.3 and 25.5 mcg/dL respectively. Renal function was normal with a creatinine of 0.65 mg/dL and GFR 163.3 mL/min/1.73 m2. Computer tomography of the abdomen with contrast showed an enlarged liver with a craniocaudal measurement of 29 cm (normal adult span= 17 cm) and diffusely low attenuation, most consistent with fatty infiltration.  Within the left lateral segment of the liver there was a 1.9 cm heterogeneously enhancing lesion suggestive of a hepatic adenoma. Oral, uncooked dietary starch was initiated at 1.75 g/kg every 4 hours and the frequency of hypoglycemic symptoms improved. The patient was discharged on uncooked cornstarch 2.5 g/kg every 4 hours after 4 days without recurrent hypoglycemia. Lactic acid levels decreased to 2.3 mmol/L upon follow up.

Conclusion: GSD type Ia is an uncommonly encountered etiology of hypoglycemia, hypertriglyceridemia hepatomegaly, and renal insufficiency. Dietary therapy with small frequent meals and snacks high in complex carbohydrates can help prolong periods of euglycemia and ameliorate metabolic abnormalities.

 

Nothing to Disclose: TJ, ABJ, AGG

15536 15.0000 SAT-1019 A Frequent hypoglycemia in Glycogen Storage Disease Type Ia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Jing H. Chao*1, Bronwyn H. Bryant2, Paul E. Swanson2 and Tracy Susan Tylee1
1University of Washington, Seattle, WA, 2University of Washington

 

Background: Non-islet cell tumor hypoglycemia (NICTH) is a rare paraneoplastic phenomenon mediated by tumor overproduction of IGF-II resulting in fasting hypoglycemia (1). Complete resection of tumor is curative. Pre-operative management of hypoglycemia has been well described. However, there is no literature to guide peri-operative management of blood glucose (BG) in a patient with NICTH.

Clinical Case: A 71-year-old woman without a history of diabetes mellitus presented with confusion and a BG of 37 mg/dl. Her symptoms resolved following treatment with juice in the ED. Over the next several weeks, she continued to have episodes of fasting hypoglycemia. Due to concern for an insulinoma, an abdominal CT was obtained. This showed three intra-abdominal tumors, with the largest measuring 18 cm. Biopsy of the masses was consistent with solitary fibrous tumors, which confirmed the diagnosis of NICTH. She continued to have episodes of hypoglycemia, requiring continuous IV infusion of D20 at 50 cc/hr to maintain BG between 55-110 mg/dl. She was ultimately admitted for surgical resection of the tumors. 

Intra-operatively, we continued D20 at 50 cc/hr. Her BG increased from 100 mg/dl at the start of surgery to 166 mg/dl immediately after resection of the tumors. Post-operatively, IVF was changed to D10 at 100 cc/hr. After 24 hours with BG ranging 109-133 mg/dl, we changed the IVF to D5 at 100 cc/hr. We actively titrated down the rate of the IVF every 24 hours, with BG remaining >100 mg/dl. By post-operative day (POD) 2 she was on D5 at 75 cc/hr.  Due to post-operative ileus, oral diet was held, so we continued D5 at 75 cc/hr until POD 5 when she resumed an oral diet.  Her BG remained normal off IV dextrose infusion.

Conclusions: The half-life of IGF-II ranges from 10-25 minutes (2). Based on this IGF-II should be cleared within 125 minutes of complete tumor resection, and tumor mediated hypoglycemia should resolve quickly, as was the case with our patient. Factors affecting IGF-II clearance and post-operative complications, such as renal dysfunction and persistent ileus, may lead to prolonged requirement for IV dextrose infusion. Therefore, peri-operative BG management should involve close monitoring of BG and active titration of the IV dextrose solution to maintain average BG >100 mg/dl. Using this approach, we were able to avoid post-operative hypo- or hyperglycemia. To our knowledge, this is the first case report describing peri-operative management of BG in a patient with NICTH.

 

Nothing to Disclose: JHC, BHB, PES, TST

15689 16.0000 SAT-1020 A Peri-Operative Management of Non-Islet Cell Tumor Hypoglycemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Shalini Paturi* and Janice L Gilden
Rosalind Franklin University of Medicine and Science/Chicago Medical School and Captain James A Lovell Federal Health Care Center, North Chicago, IL

 

Background:  Syncope, an abrupt and transient loss of consciousness and postural tone, is followed by a complete, rapid and spontaneous recovery. Etiologies include cardiac (arrhythmias, valvular abnormalities), Neurogenic Orthostatic Hypotension (NOH), Endocrine disorders (hypoglycemia (HYPO), thyroid, adrenal dysfunction, pheochromocytoma, and carcinoid), seizure disorders, psychogenic, and drugs.

Clinical case: A 27 year old previously healthy athletic man with no history of alcohol or drug use was referred for 4 months syncopal episodes, the first one resulted in a motor vehicle accident. Symptoms were postural dizziness, lightheadedness, chest pain, dyspnea, palpitations, tremulousness, loss of consciousness, and muscle weakness upon prolonged standing, lasting for 2-5 mins. There was abnormal sweating and hot flashes. Physical exam was normal (nl) except for symptomatic orthostasis. Cardiac evaluation; EKG Bezett QTc= 471 ms, nl echocardiogram/exercise stress test, Holter monitor: sinus tachycardia, Loop recorder: rare paroxysmal atrial fibrillation, not correlating with symptoms, Tilt table test: Heart rate increased from 81 to 121 beats/min with symptoms and BP decreased from 119/73 to 81/61 mmHg after nitroglycerin. Fludrocortisone and midodrine therapy were started. Neurological evaluation; nl EEG, EMG/NCV: mild ulnar and median neuropathy, nl endocrine tests including gonadal function. Vitamin B12 (nl), CPK 796 U/L (35 – 232), ALT 92 U/L (10 – 65); compatible with fatty liver

Bedside tilt test continued to show orthostasis, which did not always correlate with symptoms.  Blood sugars (BS) by Continuous Glucose Monitoring (CGMS): excursions from 53 to 160mg/dl (2.9-8.9 mMol/l) with a 2 hr postmeal decrease and symptoms, which is suggestive of reactive HYPO.  Oral glucose tolerance was nl [fasting BS 76 mg/dl (4.2 mMol/l), 2 hour BS 111 mg/dl (6.2 mMol/l), C-peptide 2.14 ng/mL (0.8 - 3.85), Insulin 16.82 mIU/L (0.0 - 24.9)]. A diet consisting of small meals and snacks (high protein, low carbohydrates), with Acarbose for meals minimized BS fluctuations and some symptoms upon repeat CGMS. Gastric Emptying test was normal.  He then developed a self-limiting, discoloration of finger tips and petechiae.  Skin biopsy was performed and showed cutaneous leukocytoclastic vasculitis. ANA, RF, and other autoantibodies were negative, nl serum Light chains and K/L ratio. CPK increased to 1,786 U/L, and muscle weakness worsened with cramping, and inability to stand for a prolonged period of time.  DNA testing for mitochondrial disorders was negative. After Coenzyme Q10 was started, muscle fatigue/cramping and syncopal symptoms improved.

Conclusion: This case describes the challenges in evaluating patients with multiple causes of dizziness and syncope, including NOH and HYPO, which may occur in the setting of other abnormalities, such as myopathy and nonspecific vasculitis.

 

Disclosure: JLG: Principal Investigator, Shire. Nothing to Disclose: SP

13866 17.0000 SAT-1021 A Hypoglycemia in a Patient with Syncope, Neurogenic Orthostatic Hypotension, and Muscle Weakness 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Chie Takahashi*1, Yasuhiro Naiki2 and Reiko Horikawa1
1National Center for Child Health and Development, Tokyo, Japan, 2Natl Ctr for Child Hlth & Dev, Tokyo, Japan

 

Background:

Hyperinsulinism is the most common cause of persistent hypoglycemia in infants and young children. Early diagnosis and appropriate management are essential to prevent neurological damage.

Objective:

To clarify clinical characteristics and pathophysiology, and to assess management in patients with PHHI.

 Methods:

We retrospectively reviewed 23 patients with PHHI, diagnosed and treated at our institute in past 20 years.

 Results:

Twenty-three patients consisted of 14 males and 9 females. Fourteen patients were diagnosed at neonatal period, 5 cases were at infancy and 4 cases were after 1 year old. Three patients had ammonia levels at 170〜200 μg/dl and diagnosed as having hyperinsulinemic hyperammonemic hypoglycemia (HIHA), which was confirmed by detection of GLUD1 gene mutations. Diazoxide was effective in 12 patients including 3 patients with HIHA. In five patients (except HIHA), medication could be stopped after four months to eleven years. Seven patients were unresponsive to diazoxide and received pancreatectomy; 5 received 95% to 99% sub/near-total pancreatectomy, whose pancreas showed diffuseβcell hypertrophy. Among those who had diffuse region, one had paternally transmitted KCNJ11 mutation. Four patients out of five developed diabetes mellitus after operation. One patient remained hypoglycemic and has been treated by long-acting octreotide. Two patients showed paternally transmitted heterozygous mutation in the ABCC8 gene and diagnosed as focal region by 18F-DOPA PET-CT. They underwent extended enucleation or partial pancreatectomy. They were completely cured after transient postprandial hyperglycemia treated byαglucosidase inhibitor alone. Two cases with HIHA without GLUD1 mutation were complicated with tuberous sclerosis, suggesting chromosomal micro-deletion.

Conclusion:

Diversity in clinical manifestation both in short and long term, and in etiology, was observed in patients with PHHI. Genetic analysis and images with 18F-DOPA PET-CT support choosing appropriate management.

 

Nothing to Disclose: CT, YN, RH

12745 18.0000 SAT-1022 A Clinical and Pathophysiological Features in Twenty-Three Patients with Persistent Hyperinsulinemic Hypoglycemia in Infancy (PHHI) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Yousuf Khan, Quratulain Nafees* and Raymond Y Liang
Hackensack University Medical Center Mountainside, Montclair, NJ

 

Background:

Von Gierke Disease (VGD) is a rare genetic disorder of glycogen metabolism predisposing to hypoglycemia, lactic acidosis and seizures. VGD commonly results from glucose-6-phosphatase (G6Pase) deficiency. Patients with this condition are dependent on continuous supply of glucose through frequent doses of oral cornstarch syrup to maintain their blood glucose levels. When oral feeding is not possible for some reason this plan needs to be altered to protect them from severe complications.

Case Details:

A 45 y/o Irish male with G6Pase deficiency diagnosed in infancy presented to the emergency room with nausea, vomiting, and watery diarrhea of 3 days duration. Physical exam revealed hepatomegaly and mild abdominal tenderness. Labs showed a lactate of 4.5 and mild elevation of liver transaminases. CT abdomen revealed right sided colitis and fatty liver. A diagnosis of infectious versus inflammatory colitis was made. Patient was admitted to the hospital and oral feeds were held. Patient was kept on 10% dextrose drip and blood glucose was monitored with hourly finger sticks. Fluid status was maintained with half normal saline and serum lactate and electrolytes were monitored. With improvement in symptoms and labs, patient was started on oral corn starch with simultaneous tapering of dextrose drip. After a few hours of observation patient was discharged to home with proper education and follow up instructions.

Discussion:

Important considerations in the management of patients with G6Pase deficiency are adequate glucose supply and choice of intravenous fluids. When patient has to remain NPO, the patient should be on continuous 10% dextrose drip. The regular 5% dextrose should be avoided because it does not supply enough glucose. Lactated ringer (LR) must be avoided because it increases the risk of lactic acidosis. Glucagon should be avoided because it has minimal effect on raising the blood glucose levels and more over it aggravates lactic acidosis through stimulation of glycogenolysis. Oral feeding with corn starch should be gradually started with simultaneous tapering of dextrose drip over 3-6 hours with careful blood glucose monitoring.

 

Nothing to Disclose: YK, QN, RYL

16145 19.0000 SAT-1023 A Von Gierke Disease: A Tough Time for Glycemic Control 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Pegah Yousefzadeh*, Stephen H Schneider and Louis F Amorosa
Rutgers-RWJMS, New Brunswick, NJ

 

Objective:To describe a case of levofloxacin-induced hypoglycemia and treatment options.

Clinical Case: An 85 year-old nursing home resident was admitted with altered mental status. He had a past medical history of prostate cancer metastatic to the bone and liver, and chronic kidney disease. He was treated with levofloxacin for pyelonephritis since two weeks prior to his admission. The patient was not diabetic. The nursing home staff noted lethargy and diaphoresis on multiple occasions prior to admission. Physical examination was notable for tachycardia and lethargy. There was no skin pigmentation. Initial laboratory values revealed: glucose 11 (70-100 mg/dL), sodium130 (136-145 mEq), creatinine 5.2 [baseline 1.2 mg/dL (0.5-1.2 mg/dL)], BUN 50 (6-23 mg/dL), INR 1.17 s, ALT 14 (3-40 IU/L), AST 61 (12-45 IU/L), alkaline phosphatase 633 (45-115 IU/L), platelet count 84 (140-440), WBC count 12.0 (3.5-10.5).

The hypoglycemia was presumed to be secondary to sepsis. He was started on 10% dextrose (D10) drip. Levofloxacin was continued. He received 4 mg of IV dexamethasone and 50 mcg of SC octreotide to treat suspected adrenal insufficiency or sulfonylurea toxicity. Despite a D10 drip running at 150 cc/hr, the patient remained profoundly hypoglycemic. Levofloxacin was discontinued. Hydrocortisone was started. A hypoglycemic agent screen revealed no evidence of sulfonylurea toxicity. At the time that serum glucose was 26, c-peptide was 38.9 (1.1-4.4 ng/mL) and insulin was 140 (26-24.9 mcIU/mL). The patient remained hypoglycemic for 48 hours after the last dose of levofloxacin despite all efforts to normalize his serum glucose. He was given a second dose of SC octreotide following which the glucose started to improve. The steroids and D10 drip were discontinued. He remained normoglycemic and responded appropriately to a cosyntropin stimulation test.

Fluoroquinolones can cause hypoglycemia. The mechanism of action is similar to sulfonylureas in which binding to the ATP-sensitive K+ channel on β-cells causes increased insulin release. Higher concentrations of fluoroquinolones are achieved in patients who are already at risk for hypoglycemia. These include use of sulfonylureas, acute kidney insufficiency, genetic polymorphisms in the cytochrome system that alter the clearance of oral hypoglycemic agents, and concurrent treatment with quinolones further inhibits the cytochrome P-450 system. Octreotide binds to the somatostatin receptor on pancreatic β-cells and blocks insulin secretion. Therefore, it may be used to reverse hypoglycemia associated with fluoroquinolones. In our case, octreotide should have been used with a higher dose and frequency to be effective.

Conclusion: It is crucial to identify patients that are at high risk for developing hypoglycemia before treatment with fluoroquinolones. Octreotide may be used in reversing hypoglycemia associated with fluoroquinolones.

 

Nothing to Disclose: PY, SHS, LFA

16472 20.0000 SAT-1024 A Hypoglycemia Associated with Levofloxacin in a Non-Diabetic Patient 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Eva Lau*1, Joana Isabel Oliveira2, Ana Isabel Oliveira2, Paula Freitas1 and Davide Carvalho3
1Centro Hospitalar São João; Faculty of Medicine, Porto University, Portugal, 2Centro Hospitalar São João, Faculty of Medicine, Porto University, Porto, Portugal, 3Centro Hospitalar São João, Faculty of Medicine, University of Porto, Portugal

 

Introduction: Insulinomas are the most frequent cause of hypoglycemia resulting from endogenous hyperinsulinism. Nearly 90-95% of insulinomas are benign, and long-term cure with total resolution of preoperative symptoms is expected after complete resection. Objectives: To characterize demographic, clinical, pathological and imaging data of insulinomas identified in the last 23 years. Methods: Retrospective analysis of insulinomas identified in Pathology registration, between January/1980 and October/2013. Results: We identified 10 patients, 7 (70 %) were female. The median age of onset symptoms was at 50 years old, with a median time to surgery of 1 month. Within 9, all presented neuroglycopenic syntoms and only 2 did not not report autonomic symptoms. The Whipple's triad was present in these 9 cases at diagnosis and none was associated with MEN-1. Abdominal CT was performed in 9, with tumor location in 6; MRI was performed and diagnostic in 2; abdominal ultrasound held and nondiagnostic in 4; endoscopic ultrasound performed and nondiagnostic in 1; angiography and scintigraphy successfully in 1. Preoperative treatment with diazoxide was performed in 3 cases. Two patients were submitted to tumor enucleation; the remaining to partial pancreatectomy. All of the tumors were solitary, 6 located in the head, 1 in the body and 3 in the tail, with a median diameter of 2 cm. 2 presented surgical invasion of margins, but no lymphatic or vascular invasion. There were surgical complications (fistule and infection) in 3 patients. No recurrence of symptoms or of the tumor. Discussion and Conclusion: Similar to the literature, there was a female predominance of insulinomas, clinically characterized by Whipple triad and median symptoms presentation at 50 years old. None of the patients recurred after the surgery.

 

Nothing to Disclose: EL, JIO, AIO, PF, DC

15778 21.0000 SAT-1025 A Retrospective Analysis of Insulinomas in a Terciary Hospital Between 1980 and 2013 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1005-1025 4808 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

James Deer*1, Juraj Koska1, Jessica S Ross2, Sherman Mitchell Harman1, L. Ashley Cowart2 and Peter D Reaven1
1Phoenix VA Health Care System, Phoenix, AZ, 2Medical University of South Carolina

 

Diets high in saturated fatty acids (SFA) are a potentially important risk factor for the development of insulin resistance (IR), possibly through formation of lipid intermediates such as diacylglycerols (DAG) or ceramides (Cer). To test the association of diet induced IR with plasma DAG and Cer in humans, an acute model of SFA-induced IR was developed. We compared plasma lipidomic measurements after an SFA-enriched diet versus a standard heart-healthy diet.

Thirteen participants (mean age 52 ± 9 [SD] years, BMI 30 ± 3 kg/m2, 11 males, 10 whites) with either normal glucose tolerance (n=6) or impaired glucose tolerance(n=7) consumed, in random order, an SFA-enriched diet (4,800 kcal, 64% SFA) and a standard American Heart Association (AHA) diet for 24 hours. IR was estimated from steady state plasma glucose (SSPG) during the last 30 minutes of a 3-hr octreotide insulin suppression test performed 4 hours after the morning meal. Plasma DAG and Cer were measured by mass spectrometry in pre-IST blood samples.

After the SFA diet, SSPG was increased (indicating decreased glucose disposal) compared with the AHA diet (median 242 vs. 170 mg/dl, p<0.0001). The SFA diet significantly decreased C18:1/18:1 DAG but increased 11 (out of 16) DAG species (C14:0/14:0, 16:0, 18:0, 18:1; C16:0/16:0, 18:0, 20:0; C18:0/16:1, 18:0, 18:1, 20:4) and 6 of 12 Cer species (C16:0, C18:0, C18:1, C22:0, C26:0, dihydro-C16:0). In partial (for diet) Spearman correlations, higher SSPG was associated with higher DAGs containing C14:0, C16:0, C18:0 or C18:1 in at least one of the positions (r=0.63-0.71, p<0.001 all). It was also associated with higher C16:0 (r=0.42, p=0.04) and C24:1 (r=0.52, p=0.008) Cer, and lower C26:0 Cer (r=-0.49, p=0.01). In multiple regression models, the effect of SFA diet on SSPG remained significant if adjusted individually for each of these lipid intermediates. In stepwise regression analysis, a final selection model (R2=0.77) included C18:0-containing DAGs (partial R2=0.42), C18:0 Cer (0.23), C22:1 Cer (0.10) and C22:0 Cer (0.04). The effect of SFA diet on SSPG disappeared (p=0.5) when analyzed in an aggregate model containing these four lipid moieties.

An oral SFA-enriched diet acutely increased IR and plasma dialcylglycerol and ceramide concentrations. Regression models indicate that development of dietary induced IR may be attributable, in part, to combined elevations of stearic acid containing diacylglycerols and ceramides.

 

Nothing to Disclose: JD, JK, JSR, SMH, LAC, PDR

15021 1.0000 SAT-1026 A Acute Oral Saturated Fatty Acid-Induced Insulin Resistance Is Associated with Increased Plasma Stearic Acid Lipid Intermediates 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Maria Clarissa Yasmin Ong Tio*1, Timothy R. Koves1, Catherine Mikus1, C. Lawrence Kien2 and Deborah M. Muoio1
1Duke Molecular Physiology Institute, Durham, NC, 2Department of Pediatrics and Medicine, University of Vermont, Colchester, VT

 

Skeletal muscle is a principal target of insulin action and plays a key role in regulating whole body energy metabolism. Whereas skeletal muscle glucose uptake and insulin signaling are diminished in the fasted state, feeding and subsequent pancreatic insulin secretion alter metabolic as well as growth signaling pathways. Although nutrient-induced regulation of gene expression has been widely characterized by targeted PCR analyses, a comprehensive unbiased skeletal muscle transcriptomic analysis in response to overnight fasting and controlled refeeding has not been reported.

We sought to define the signaling and metabolic pathways that are most transcriptionally responsive to fasting and refeeding in the human skeletal muscle.

Healthy males (n=9) and females (n=9) between 18 to 40 years old, with BMIs >18 and <30, without any evidence of dyslipidemia, type 2 diabetes mellitus, or insulin resistance were fed a controlled diet (proteins, 19.7% kcal; carbohydrate, 51.6% kcal; fat, 28.4% kcal; palmitic acid, 5.3% kcal; oleic acid, 15.9% kcal) for seven days. Following a 12-hour overnight fast, muscle biopsies were collected at 0700 hours on day eight (fasted state), and again 3 hours after eating a standardized breakfast (one-third daily kcal; re-fed state).

Microarray analysis (Affymetrix HG-U133 Plus 2.0) of fasted and re-fed skeletal muscles revealed 2,996 genes upregulated in fasting and 1,448 genes upregulated in refeeding (±1.3-fold, p<0.05). Interestingly, gene set analysis of transcripts upregulated in the fasted state showed immune response, cytokine signaling, and stress responses as the top gene expression signatures. On the other hand, the most robustly upregulated metabolic genes involved pathways of NAD biosynthesis and redox sensing, cholesterol and LDL metabolism, and carnitine transport. By comparison, genes upregulated after re-feeding were enriched in processes involving extracellular matrix and collagen remodeling, muscle development, Wnt-protein binding, and macromolecule biosynthesis. Metabolic genes upregulated in the fed state involved pathways of circadian regulation and insulin signaling. Analyses to integrate gene expression changes with metabolomic profiles are ongoing. These findings highlight the broad impact of nutritional and diurnal factors on muscle gene expression, and should be considered in future clinical studies that involve the human skeletal muscle in the fed and fasted states.

 

Nothing to Disclose: MCYOT, TRK, CM, CLK, DMM

16893 2.0000 SAT-1027 A A Transcriptomic Analysis of Responses to Overnight Fasting and Refeeding in the Human Skeletal Muscle 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Ruby Jane Sahid Guerrero1 and Leilani Basa Mercado-Asis*2
1Univ of Santo Tomas Hosp, Manila, Philippines, 2Univ of Santo Tomas, Quezon, Philippines

 

Brachial Artery Flow Mediated Dilatation is Normal in Patients with Pre-IGT (Impaired Tolerance test)

Pre-IGT is a metabolic state with normoglycemia because of compensated hyperinsulinemia. It is the earliest subclinical stage of diabetes mellitus observed in 42-68% of high risk. Without treatment, there is progressive deterioration of B-cell function leading to the development of overt diabetes. Peripheral macrovascular endothelial function can be non-invasively assessed using brachial artery flow-mediated dilatation (FMD). FMD has found to be abnormally decreased in patients with IGT and DM. Our study was undertaken to determine brachial artery flow-mediated dilatation in patients with pre-IGT. This is a descriptive study. Subjects were recruited based on risk factors for diabetes- first degree relative, obese, PCOS and with history of gestational diabetes. Subjects with normal blood chemistries had 75grams OGTT with 2nd hour measurements of glucose and insulin level. Five patients with pre-IGT underwent brachial artery flow mediated dilatation. Our study showed that brachial artery flow-mediated dilatation is still normal for patients with pre-IGT which indicates that this is a subclnical disease where endothelial dysfunction is stil not observed.

 

Nothing to Disclose: RJSG, LBM

16444 3.0000 SAT-1028 A Brachial Artery Flow Mediated Dilatation Is Normal in Patients with Pre-Igt (Impaired Tolerance test) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

William A Bauman*1, Kirsten N Swonger1, Dwindally Rosado Rivera1 and Michael F LaFountaine2
1James J. Peters VA Medical Center, Bronx, NY, 2Seton Hall University, South Orange, NJ

 

The homeostatic model assessment of β-cell function (HOMA-β) and insulin resistance (HOMA-IR) is calculated from the fasting plasma insulin (FPI) and glucose (FPG) concentrations.  The ability of the β-cell to respond appropriately to elevations in the blood glucose concentration is requisite to maintain carbohydrate homeostasis and to preserve end-organ insulin sensitivity. The use of iontophoresis to deliver insulin transdermally has been used as an accepted model to evaluate the vascular actions of insulin on blood perfusion in the cutaneous microcirculation.  Under normal circumstances, insulin-mediated vasodilatation is expected to occur through an endothelium-dependent mechanism (i.e., nitric oxide-mediated vasodilatation).  The relationship between the HOMA-β and HOMA-IR as they relate to the hemodynamic actions of insulin on the microvasculature has not yet been reported.  A prospective, open-label, non-randomized trial was performed in otherwise healthy, non-diabetic men (n=8) and women (n=2).  FPI and FPG were obtained in the morning prior to testing. HOMA-β and HOMA-IR were calculated using previously described methods (1). Iontophoresis with insulin (Humulin; Eli Lilly & Company, Indianapolis, IN) and placebo (i.e., preservative-free normal saline) was performed bilaterally over the distal portion of the tibialis anterior muscle. Laser Doppler flowmetry characterized peak blood perfusion unit (BPU) responses (% change from baseline) to the iontophoretic conditions (drug vs. placebo).  BPU response of the placebo was subtracted from that of insulin (NetIns).  Descriptive statistics were performed for demographic characteristics, NetIns, HOMA-β, and HOMA-IR within the cohort.  Simple regression analyses were performed to determine the linearity between NetIns and HOMA- β and between NetIns and HOMA-IR.  An a priori level of significance was set at p≤0.05.  The cohort was characterized as follows: age=41±12 years old, height=1.74±0.09 m, weight=81.2±14.1 kg, and BMI=26.5 kg/m2±2.9.  FPI and FPG were 15.9 ±10.1 µU/ml and 93.5±6.7 mg/dl, respectively; these values generated mean values for HOMA-β=189.9±93.7 and HOMA-IR=67.6±47.6.  The NetIns response to iontophoresis was 357.4±296.9%.  A significant negative association was observed between NetIns and HOMA-β (R2=0.47; p=0.02), but no significant relationship was observed between NetIns and HOMA-IR (R2=0.2; p=0.19).  These data suggest that a progressive decline in β-cell function is associated with a commensurate reduction in peripheral sensitivity to the vasodilatory actions of insulin on the microvasculature.  The changes observed may characterize the subclinical pathological process that is present in the microvasculature, possibly in part as a consequence of β-cell dysfunction, which appears to antedate the appearance of IR.

 

Nothing to Disclose: WAB, KNS, DR, MFL

16953 4.0000 SAT-1029 A HOMA β-Cell Function Negatively Correlates to the Vasodilatory Response of Insulin in the Cutaneous Microvasculature 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Leon S Farhy*1, Pattie Hellmann1, Murry Adams1, Aimee Y Zhang2 and Anthony L. McCall1
1University of Virginia Health System, Charlottesville, VA, 2University of Virginia, Charlottesville, VA

 

Background. Glucagon counterregulation (GCR) is a critical, early protection mechanism against hypoglycemia, which is impaired in type 1 diabetes (T1DM). Our in vivo animal studies, model-based analyses (1) and a clinical study (2), all suggest that alpha-cell inhibitors (ACI) may improve GCR by increasing the pulsatile glucagon response to hypoglycemia (3). We have recently shown (4) that peripheral infusion of GABA enhances GCR in STZ-treated rats and is protective against hypoglycemia. The current study further addresses this hypothesis by testing whether two other ACI, GLP-1 and leptin, can  enhance the glucagon response to insulin-induced hypoglycemia if given peripherally.

Methods. Wistar male rats (~300g) had diabetes induced with streptozotocin (80mg/kg) and then were treated with insulin pellets after diabetes was confirmed (BG>350 mg/dL for 2 consecutive days). Each rat was used as its own control and was tested on two separate occasions. On a test day, blood glucose (BG) was lowered to 100-150mg/dL after which a constant (50uL/min) i.v. infusion of saline (control day) or GLP-1 (6-37 or 72-107) (30 pmol/kg/min) or leptin (0.5 ug/min) (intervention day) started at t=-10min. At t=0min, a 12U/kg i.v insulin bolus was given. The ACI infusions were either switched off at hypoglycemia (BG<60 mg/dL) or continued for the entire duration of the experiment.. Blood sampling was done every 10min for BG and glucagon from  t= -20 to 80min. GCR was estimated via the product R={mean of 2 lowest BG values from t=10 to 40min} x {mean glucagon from t= 50 to 80min}. R measures the BG level-specific GCR response to hypoglycemia with higher values indicating a stronger response.  Data are presented as mean ± SEM.

Results. Continuous leptin infusion significantly enhanced GCR vs. saline infusion (R=6270±629 vs. 3170±220, p<0.04).  There was a trend for improved GCR if the leptin infusion was switched-off at hypoglycemia (R=5550±538 vs. 3370±122, p=0.1). We also detected a trend for a higher initial glucagon fold change over basal with a leptin switch-off vs. continuous leptin infusion (1.6±0.14 vs. 2.4±0.37; p=0.1). Compared to our previous results, peripheral continuous infusion of leptin appear superior to GABA in restoring GCR (R=6270±629 vs. 3160±300, p<0.001), but was not as protective against hypoglycemia. At the chosen infusion rates, peripheral infusion of GLP-1 with or without a switch-off was ineffective in enhancing GCR.

Conclusions. Our findings further support the hypothesis that peripheral infusion of ACI can enhance GCR in T1DM (3).  Leptin seems to have an excellent potential for GCR enhancement and appears superior to other ACI we have tested so far.  These results could lead to new dual-hormone clinical strategies for treatment of T1DM with enhanced hypoglycemia protection. 

 

Nothing to Disclose: LSF, PH, MA, AYZ, ALM

14729 5.0000 SAT-1030 A Enhancement of Glucagon Counterregulation (GCR) By Peripheral Leptin Infusion in Diabetic Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Marcio W Lauria*1, Mario J Saad2, Roberto Pimentel Dias3, Alexandre G Oliveira2, Liliane D Cardoso4, Ana Carolina M Silva4 and Maria Marta Sarquis Soares5
1FM/ Univ Fed de Minas Gerais, Belo Horizonte MG, Brazil, 2FCM/UNICAMP, Campinas SP, Brazil, 3IPSEMG Hospital, Belo Horizonte MG, Brazil, 4Felicio Rocho Hospital, Belo Horizonte MG, Brazil, 5Universidade Federal de Minas Gerais, Belo Horizonte MG, Brazil

 

Introduction: Type B insulin resistance syndrome (TBIRS) is a rare autoimmune disorder characterized by antibodies production against insulin receptor and a broad spectrum of glucose metabolism abnormalities ranging from hypoglycemia to diabetes. It is seen predominantly in African American women and Asians descendants. The autoantibodies can either mimic or inhibit the insulin cellular effects. TBIRS generally occurs associated with an underlying autoimmune systemic disease such as lupus and may also be a paraneoplastic event (1).

Case Report: A 27 years old, African Brazilian woman, with normal BMI, presented with extensive, very severe acanthosis nigricans, hirsutism and amenorrhea for two years.  Laboratory tests identified leucopenia, hyperinsulinemia (>200mUI/ml), elevated testosterone (649 ng/dl), elevated TSH, the presence of TPO antibodies and ANF of 1:640. Screening for occult cancer (thoracic, abdominal and pelvic CT scans, endoscopy, excisional biopsy of enlarged axilar linfonode) was negative. Four years before presentation, she had the diagnosis of transverse myelitis with a complete recovery three months after glucocorticoid therapy. After six months of follow-up, she lost weight and became diabetic: fasting plasma glucose=174 mg/dl, A1C=11.2% with elevated C peptide (7.3 ng/ml). GAD, IA2 and Anti-insulin antibodies were all negative. Metformin was initiated and approximately six months later she referred hypoglycemic episodes despite having never used insulin or any oral hypoglycemic drugs. Metformin was discontinued but she remained with fasting hypoglycemic events. Insulin receptor autoantibodies, measured by immunoprecipitation followed by immunoblotting with a established anti-IR antibody, were remarkably positive (1:1280). Prednisone (1 mg/kg/day) was initiated leading to glycemic normalization and clinical improvement of the acanthosis nigricans. After six weeks of treatment, laboratory tests showed: fasting glucose= 72mg/dl, A1C= 5.7%, total testosterone= 35ng/dl and insulin= 6.7mUI/ml. Prednisone dose was tapered and azathioprine was associated.

Discussion: The case reported shows how heterogeneous TBIRS can be and the difficulty of managing a disease that can switch from hyper to hypoglycemia due to different actions the antibodies can have. This patient did not fulfill the criteria for lupus although she presented with other signs of autoimmunity such as leucopenia, Hashimoto’s thyroiditis and a past history of transverse myelitis. Screenings for cancers were also negative. About one-third of patients with TBIRS may remit spontaneously, whereas a switch from hyperglycemia to hypoglycemia is an indicator of poor prognosis (1).  Fortunately, we observed prompt response to prednisone with clinical and laboratory improvements.

 

Nothing to Disclose: MWL, MJS, RPD, AGO, LDC, ACMS, MMSS

11925 6.0000 SAT-1031 A Type B Insulin Resistance Syndrome : Case Report with Prompt Response to Prednisone Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Lars C Moeller*1, Emmanouil-Dimitrios Manikas1, Iona Isaac2, Rana Malek3, Robert Kenneth Semple2 and Dagmar Führer1
1University Duisburg-Essen, Essen, Germany, 2University of Cambridge, Cambridge, United Kingdom, 3University of Maryland School of Medicine, Baltimore, MD

 

Background: Diabetes mellitus with insulin resistance is characterized by hyperinsulinemia and, most often, obesity. Very rarely, severe insulin resistance is caused by autoantibodies to the insulin receptor (type B insulin resistance). The mortality of type B insulin resistance is high (>50%) and management of this disease is not yet standardized.

Clinical case: A 45 yo woman presented with weight loss of 20 kg within 4 months and glucose levels > 500 mg/dl, which could not be controlled with 600 to 800 units/d of insulin administered via insulin pump. Strikingly, the patient suffered from unusually widespread acanthosis nigricans. Because of the severity of the insulin resistance combined with features of insulin deficiency, an autoimmune disorder with production of antibodies against the insulin receptor was suspected. Elevated anti-SS-A, anti-ds-DNA and anti-RNP levels demonstrated presence of an autoimmune disease. Ultimately, immunoprecipitation revealed high levels of insulin receptor autoantibodies. Immunosuppressive therapy with immunoglobulin i.v. (20 g/d for 6 days) had no effect on glucose levels or insulin dose. Similarly, plasmapheresis (5x within one week) could not improve the severe insulin resistance. As the patient’s condition was deteriorating with further weight loss, we started rituximab (750 mg/m2in two doses two weeks apart) together with cyclophosphamide (100 mg/d p.o.) and dexamethasone 40 mg/d for 4 days (1). Three months after initiation of rituximab therapy, the patients well being has greatly improved. Fasting glucose levels ranged from 80 to 110 mg/dl and glucose levels could be controlled with a very low insulin dose of insulin glargine 6 IU and 10 IU prandial insulin/d. HbA1c decreased from 11.8 to 8.6% (normal <6.05%). Further improvement and possibly remission is expected in the next months.

Conclusion: In this patient, a rare autoimmune disease with production of insulin receptor autoantibodies caused diabetes mellitus with features of insulin deficiency and severe insulin resistance. Immunoglobulin treatment and plasmapheresis failed to improve the condition. Finally, treatment with rituximab, cylophosphamide and steroids was successful in normalizing glucose levels and reducing insulin requirement from >600 units to 16 units/d.

 

Nothing to Disclose: LCM, EDM, II, RM, RKS, DF

13694 7.0000 SAT-1032 A Successful Treatment of a Patient with Extreme Insulin Resistance Due to High Levels of Insulin Receptor Autoantibodies (Type B Insulin Resistance) with Rituximab 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Ichiro Mori*1, Mikako Oida1, Yoshihiko Kitada1, Masahiro Yamauchi1, Takahide Ikeda2, Kazuo Kajita2, Hiroyuki Morita3 and Tatsuo Ishizuka1
1Gifu University Graduate School of Medicine, Gifu, Japan, 2Gifu University Graduate School of Medicine, gifu, Japan, 3Gifu University Graduate School of Medicine, Japan

 

Introduction: Type B insulin resistance syndrome (IRS) which was a disorder proposed by Flier et al in 1976, is a rare autoimmune disease characterized by the presence of autoantibodies against the insulin receptor. The majority of the patients present marked hyperglycemia and compensated hyperinsulinemia, but some patients may present with hypoglycemia caused by an insulin-like effect of the receptor autoantibodies. A common feature of type B IRS is the co-occurrence of autoimmune disorders, such as systemic lupus erythematosus (SLE) and rheumatoid arthritis. About 60% of the patients are spontaneously remitted. When autoimmune disorders are successfully treated with steroid and immunosuppressive agents, hypoglycemia or hyperglycemia with the fall of insulin receptor antibody titers may be observed. We have reported here a rare case of type B IRS presented with hypoglycemia in a patient with SLE.

Case report: 17 year old Japanese woman had both shoulders and cubital arthralgia and butterfly rash for one years ago. In addition, stomatitis, loss of hair, photo-allergy, and proteinuria were presented suggesting SLE with lupus nephritis (WHO classII) diagnosed by renal biopsy. She was initially treated with 30 mg/day prednisolone, but did not improve pyrexia and proteinuria. Cyclosporine (150mg/day) and Tacrolimus (3 mg/day) in addition to steroid pulse therapy two times were administered, but there are no apparent improvement of clinical symptom. Moreover, hypoglycemia (less than 60mg/dl) early in the morning and in the night were appeared. No hypoglycemia-caused drugs had been received. CT scan did not show the oncogenic lesion which secret insulin.Based on above data, we doubted type B IRS. Therefore, we examined an insulin acceptor antibody by immunoprecipitation method. When we changed an immunosuppressive drug in mycophenolate mofetil (MMF), the hypoglycemia and pyrexia was disappeared.

Conclusion: When hypoglycemia occurred in autoimmune disease such as SLE and rheumatoid arthritis, we have to suspect Type B IRS.

 

Nothing to Disclose: IM, MO, YK, MY, TI, KK, HM, TI

14172 8.0000 SAT-1033 A Type B Insulin Resistance Syndrome Presenting Hypoglycemia in a Patient with Systemic Lupus Erythematosus (SLE) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Miguel Pasquel*1, Alvaro Ontaneda2, Nicolas Jara3, Patricia Duran3, Luis Narvaez1 and Francisco J Pasquel4
1Instituto VIDA, Quito, Ecuador, 2Hospital Carlos Andrade Marin, Quito, Ecuador, 3Hospital Metropolitano, Quito, Ecuador, 4Emory University School of Medicine, Atlanta, GA

 

A 36 year old Hispanic female from Ecuador with hypothyroidism, dermatomyositis and eight month history of rheumatoid arthritis (RA) presented with symptomatic hyperglycemia (BG 500mg/dL) and weight loss (15 lbs) after a RA flare treated with higher doses of steroids. The patient was irregularly treated therafter with insulin glargine (0.25 units/kg) and presented eight months later with worsening clinical status leading to wasting (BMI 17.7 kg/m2) and severe dehydration requiring hospital admission. On physical exam severe acanthosis nigricans with skin lesions on the neck, armpits and groins was observed. No hirsutism was noted. On admission BG was 413mg/dl, HbA1c 15%, fructosamine 558 umol/L, TSH 2.3 (uUI/ml), ketonuria (+). Extreme insulin resistance was evidenced by high insulin requirements during continuous insulin infusion (65units/Kg/day, ~ 3200 units/day). Subsequent transition to subcutaneous insulin was achieved with ~1200-1500 units/day of insulin glargine and 7-9 divided doses of insulin aspart (~1000 units/day). In the next 6 months after discharge the patient had moderate improvement in her overall clinical status including weight gain (13 Lbs), however, a persistently high HbA1c (12%) was recorded. A diagnosis of Type B insulin resistance was confirmed with the presence of insulin receptor antibodies (enzyme immunoassay 369.7; N:neg). Insulin antibodies were also positive (45%; N:<10%).  Islet cell, anti-GAD, and TPO antibodies were negative. Immunotherapy with rituximab, cyclophosphamide, and dexamethasone was started as previously described (1). No significant improvement was observed after the initial cycle, however after a second cycle (six weeks later) insulin requirements fell abruptly one week post-treatment leading to permanent insulin discontinuation. Diabetes remission was achieved with medication discontinuation, and again confirmed 18 months post immunotherapy (fasting BG 67mg/dL, HbA1c 4.9%, C-peptide 2.1 ng/ml) along with resolution of acanthosis nigricans. The patient remains on low dose of corticosteroids (prednisone 5 mg/day) and continues to have normal glycemic metabolism.

Type B insulin resistance is a rare syndrome manifested by autoantibodies against the insulin receptor leading to severe insulin resistance. It was initially described in middle-aged females with history of autoimmune diseases but very few cases of Type B insulin resistance with concomitant mixed connective tissue disease have been reported. We present a case of severe acanthosis nigricans and extreme insulin resistance responsive to immunosuppressive therapy and continued remission after eighteen months of follow-up.

 

Nothing to Disclose: MP, AO, NJ, PD, LN, FJP

15705 9.0000 SAT-1034 A Severe Acanthosis Nigricans and Diabetes Resolution after Immunosuppresion in Latin-American Female with Multiple Autoimmune Disorders 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Mansa Krishnamurthy*1, Robert Kenneth Semple2 and Mia Pingul1
1East Carolina University, Greenville, NC, 2Cambridge Univ Inst of Metab Sci, Cambridge, United Kingdom

 

BACKGROUND: Mutations in the insulin receptor impair insulin action in vivo, and cause extreme insulin resistance. Here we report a novel heterozygous mutation at codon 1131 of the beta subunit of the receptor resulting in severe insulin resistance and hyperandrogenism without obesity, diabetes or dyslipidemia.

CLINICAL CASE: A lean (BMI 21 kg/m2) 12 year old Caucasian female presented with severe acanthosis nigricans and clitoromegaly noted at the onset of puberty (11 years of age). She was premenarchal with Tanner stage 5 breasts.  Family history was significant for a paternal grandmother with diabetes, and her father with complaints of “hypoglycemia.” There was no history of polycystic ovarian syndrome.

Initial investigation revealed elevated insulin levels (fasting: 100.5uIU/ml, normal <17 uIU/ml; and two hour post-prandial insulin: 1000 uIU/ml, normal <53 uIU/ml) with normal fasting glucose and hemoglobin A1c. Lipid panel, 17 hydroxyprogesterone, gonadotropins and liver function tests were normal. Total testosterone (61 ng/dl, normal <38 ng/dl) and androstenedione (254 ng/dl, normal <224 ng/dl) were elevated.

Severe insulin resistance and hyperandrogenism in a lean adolescent raised the suspicion of a monogenic form of insulin resistance, while the normal lipid panel and liver function tests implicated the insulin receptor specifically. Analysis of the coding sequence and splice junctions of the INSR gene revealed substitution of the highly conserved arginine at codon 1131 of the beta subunit for tryptophan. Her father was also heterozygous for this variant and is likely also to have severe insulin resistance. This amino acid substitution as a cause of insulin resistance has not yet been reported.

Metformin was started to increase insulin sensitivity. After 3 months of therapy, menarche ensued and acanthosis nigricans significantly improved. Glucose levels continue to be within normal range.

CONCLUSIONS: Our case highlights the importance of distinguishing insulin resistance commonly found in those with obesity from those with monogenic defects. This novel missense mutation likely confers severe insulin resistance with autosomal dominant inheritance. Although there is no evidence base to guide treatment of children with monogenic forms of insulin resistance due to their rarity, dietary and lifestyle modifications and insulin-sensitizing agents play a key role in management.

 

Nothing to Disclose: MK, RKS, MP

15942 10.0000 SAT-1035 A A Novel Mutation in the Insulin Receptor in a Lean Adolescent with Severe Acanthosis Nigricans and Hyperandrogenism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Bettina L Engh*1 and Michael G Carlson2
1The Frist Clinic, Nashville, TN, 2The Frist Clinic Medical Group, Nashville, TN

 

Background:  CSII can be an effective treatment option in DM2.  The V-Go disposable insulin infusion device (Valeritas, Inc.; Bridgewater, NJ) is FDA-approved for the treatment of DM2 with U-100 rapid-acting insulin analogs.  The V-Go device delivers preset basal rates (20, 30, or 40 units/d) and on-demand meal boluses in 2-unit increments up to 38 units/day, which limits its use in patients with large insulin requirements (>80 units/d) unless concentrated insulin preparations are used.  We describe the first case report of U-500 regular insulin use in the V-Go infusion device in an obese patient with uncontrolled DM2 and severe insulin resistance.

Clinical case:  A 67 year old morbidly obese male (wgt 153 kg, BMI 54 kg/m2) with DM2 for 15 yrs had persistently poor glycemic control (Hb A1c 8.4%-9.0%) despite increasing doses of premixed insulin with meals (200-250 units/d).  He consented to a 3-month trial of CSII with the V-Go infusion device and U-500 regular insulin (Eli Lilly & Co.; Indianapolis, IN) due to his large insulin requirement.  The V-Go “20” device (basal pump rate=20 units/d; actual basal insulin rate=100 units/d) was used with meal boluses of 30 units (3 clicks) per meal and correction boluses of 1 click (10 units) per 80 mg/dl over 200 mg/dl.  Home BG monitoring was performed before meals and at bedtime.  Daily mean BG improved from 187 to 136 mg/dl, and HbA1c improved to 6.8%.  Daily insulin requirement decreased from 250 to 190 units/d.  Weight remained stable.  No episodes of symptomatic hypoglycemia occurred during CSII with U-500 regular insulin.  No adverse reactions or device malfunctions were observed during V-Go/U-500 insulin therapy.  Patient satisfaction with therapy was high, and he chose to continue V-Go/U-500 insulin therapy.

Conclusion:  We describe the first case report of U-500 regular insulin use in the V-Go disposable insulin delivery device in a patient with DM2 and severe insulin resistance.  Glucose control improved and insulin requirement declined without significant weight gain, hypoglycemia, or delivery device malfunction.  CSII using U-500 regular insulin and the V-Go infusion device may be an appropriate treatment option in DM2 with severe insulin resistance.

 

Nothing to Disclose: BLE, MGC

15912 11.0000 SAT-1036 A Efficacy and Safety of Continuous Subcutaneous Insulin Infusion (CSII) with U-500 Regular Insulin and a V-Go Insulin Infusion Device in an Obese Patient with Type 2 Diabetes Mellitus (DM2) and Severe Insulin Resistance 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Vinita Singh*1, Subuhi Humera2, Sammer Jazbeh2, Tahira Yasmeen3 and Erin Dana Drever4
1Loyola University Medical Center, Maywood, IL, 2Advocate Christ Medical Center, Oak Lawn, IL, 3The University of Illinois/Advocate Christ Medical Center, 4University of Illinois at Chicago, Advocate Christ Medical Center, Oak Lawn, IL

 

INTRODUCTION: Severe insulin resistance secondary to anti-insulin antibodies is well documented. The prevalence of this phenomenon was higher with older animal insulin preparations, and with the advent of recombinant and semisynthetic human insulin preparations this is a rare occurrence. Anecdotal reports of effectiveness of U-500 insulin in severe insulin resistance are available. We present a case report of a patient with severe insulin resistance and positive anti-insulin antibody treated with U-500 insulin. 

CASE: 70 year old male with type 2 diabetes, hypertension, hypothyroidism, chronic kidney disease, congestive heart failure, and morbid obesity was evaluated in the outpatient endocrine clinic for uncontrolled diabetes. He had a 13 yr history of diabetes complicated by nephropathy and neuropathy.  His most recent HbA1C was 9.3% and he had been on insulin for 3 years prior to his evaluation in clinic.  His insulin requirement had been progressively increasing, and at the time of his evaluation he was on a total daily insulin dose of 604 u/day (140 U of glargine twice daily and 108 U of aspart with meals). In spite of this very high total daily insulin dose, his blood sugars remained elevated (300-400 mg/dL). He was evaluated for Cushing’s syndrome and the presence of insulin autoantibodies. Insulin autoantibody level was 33.9 (normal <0.4 U/ml). Salivary cortisol levels were normal. Insulin auto-antibody was thought to be contributing to his insulin resistance. Because of his elevated creatinine and history of heart failure, metformin and pioglitazone were not considered for treatment. He was started on U-500 insulin, initially 36 U TID premeals and subsequently increased to 50/54/36 U with breakfast/lunch/dinner respectively. His blood sugar levels have improved significantly and currently range from 100-200 mg/dL. The patient has reported improved energy and sense of wellbeing with no episodes of hypoglycemia in the past three months while using U-500 insulin.

DISSCUSSION: Anecdotal reports describe patients with anti-insulin antibody mediated insulin resistance receiving treatment with steroids, insulin analogues, plasmapheresis and immunosuppressants. There have been few case reports describing the use of U-500 insulin in patients with severe insulin resistance. Use of U-500 insulin allows high doses of insulin to be administered in smaller injection volumes. Studies have shown that use of U-500 insulin not only decreases the daily insulin dose requirement, but also improves glycemic control by decreasing the HBA1c by >1%. Possible mechanisms by which glycemia may improve include a longer duration of action, an altered release rate of U-500 insulin from subcutaneous sites or an altered affinity of the insulin receptor for U-500 insulin. Therefore, we demonstrate that U-500 insulin may be considered as an alternative treatment modality for antibody induced insulin resistance.

 

Nothing to Disclose: VS, SH, SJ, TY, EDD

16477 12.0000 SAT-1037 A U-500 Insulin: Possible Treatment Strategy for Patients with Anti-Insulin Antibody Mediated Insulin Resistance 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Katie Hanley*1 and Maeve C Durkan2
1Portiuncula Hospital/ Galway University Hospital Group, Galway, Ireland, 2Galway University Hospital Group, Galway, Ireland

 

Lipodystrophies are heterogenous disorders  due to defective fat metabolism .There are varying phenotypes , the classical hallmark being patterns of absent subcutaneous fat .They are congenital or acquired , with resultant partial or generalized subcutaneous fat loss and a strong association with metabolic complications , including DM2 patients who may have difficult glycemic control.

WW, aged 32 years was referred for management of DM2( diagnosed 3 years earlier) with poor control  and progressing rapidly to insulin. She was one of many siblings born to consanguineous parents . 2siblings with DM2 were treated elsewhere.

Her age atpresentation and family history suggest other forms of DM, such as MODY, LADA or other primary disorders that may masquerade as DM2 . The physical exam is a clue to eliciting this i.e.BMI,  fat distribution ,response to therapies etc. On exam she had strikingly thin limbs with no subcutaneous fat and significant muscle wasting. In contrast her abdomen was visibly distended with truncal fat.She had distinctive bird-like facies with micrognathia . Her skin was mottled red in appearance, thin and hardened and she looked older than her stated age. She had thin wispy hair. She had abnormal LFTs consistent with NAFLD and liver ultrasound confirmed fatty liver. 

We surmised that her unusual phenotype suggested an underlying lipidodystrophy, supported by her cosanguinous heritage  and consistent with a genetic , autosomal recessive lipodystrophy. The history, physical exam (thin limbs and truncal obesity)  were in keeping with a familial partial lipodystrophy,  mandibuloacral dysplasia / Adult 'progeroid' or Werners syndrome.. This is a rare autosomal recessive form with a progeroid(premature aging) aspect.

 Mandibuloacral dysplasia (MAD) comes in two subtypes: MAD type A and MAD type B, both characterized by loss of subcutaneous fat from arms and legs with a normal/ excessive truncal fat deposition . MADB has a more generalized loss of subcutaneous fat  and  is more apparent in females . Both subtypes of MAD are associated with,micrognathia, dental crowding, hypoplastic mandible and clavicle, delayed closure of cranial sutures andprogeroid features (pinched nose, premature loss of teeth, loss of hair, scleroderma-like skin atrophy, spine rigidity and waddling gait

There are few documented cases of madibuloacral dysplasia worldwide with the most common cause being due to a deformation in lamin A. 

WW refused consent to genetic testing; her brother did.  He has been confirmed as having a homozygous mutation, ( nonsense mutation) exon 33 for the gene WER in keeping with Werner syndrome. 

 The case report highlights the need to be vigilant in characterizing diabetes subsets, looking for distinct phenotypes, and the role of a good clinical exam which uncovered this rare underlying primary lipodystrophy. This will shape the course of her diabtes and metabolic management . 

 

Nothing to Disclose: KH, MCD

16094 13.0000 SAT-1038 A Diabetes & Lipodystrophy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Fady Hannah-Shmouni*1, Abhimanyu Garg2 and Ole-Petter Riksfjord Hamnvik3
1Yale-New Haven Hospital, New Haven, CT, 2University of Texas Southwestern Medical Center, Dallas, TX, 3Brigham and Women's Hospital, Boston, MA

 

Background: Familial partial lipodystrophy, Dunnigan variety (FPLD), is an autosomal dominant disorder due to heterozygous missense mutations in the lamin A/C (LMNA) gene that is characterized by loss of subcutaneous fat from the extremities and from the trunk but accumulation of excess fat in the face, neck, back and visceral abdomen. FPLD predisposes patients to metabolic complications of insulin resistance such as diabetes and dyslipidemia. However, many endocrinologists may not be familiar with the clinical features and diagnosis of FPLD. We report a case where the diagnosis was made late at the age of 50 years.

Clinical Case:  A 50-year-old women with multiple surgeries related to atherosclerotic disease (including coronary artery bypass graft, aorto-bifemoral bypass and aortic aneurysmal repair: known family history of premature coronary artery disease), menstrual abnormalities, severe dyslipidemia, and cirrhosis was referred for diabetes management with fasting blood glucose of 150-200 mg/dl and hemoglobin A1c of 8.5%, receiving only a Thiazolidinedione. She complained of ongoing fatigue and claudication. Her body mass index was 24 kg/m2 and she had spindly but muscular arms and legs, increased chin skinfold thickness and dorsocervical fat pad (similar clinical features in father and his sisters). An abdominal computerized tomography showed lack of subcutaneous fat. Thus, a diagnosis of partial lipodystrophy was suspected and after obtaining written informed consent from the patient, genotyping for LMNA revealed a heterozygous c.1445G>A (p.R482Q) mutation. She was started on a once daily glargine insulin regimen, requiring 100 units per day, and later pre-meal Aspart insulin in the dose of 14-20 units was added, with improvement in hemoglobin A1c to less than 6% with no hypoglycemia (Fasting blood glucose 110-140 mg/dl).

Conclusion: The diagnosis of FPLD should have been suspected in this patient much earlier in view of diabetes, dyslipidemia, hepatic steatosis resulting in cirrhosis, and menstrual abnormalities in a non-obese young woman with muscular habitus. Early diagnosis and management of metabolic complications could have prevented serious morbidities such as coronary heart disease and cirrhosis.

 

Nothing to Disclose: FH, AG, OPRH

11947 14.0000 SAT-1039 A Delayed Diagnosis of Familial Partial Lipodystrophy, Dunnigan Variety: Success with Insulin Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Fady Hannah-Shmouni*1, Sandra Michelle Sirrs2 and Andre Mattman2
1Yale-New Haven Hospital, New Haven, CT, 2Vancouver General Hospital, Vancouver, BC, Canada

 

Background: Diabetes mellitus (DM) is a frequent complication of the MELAS syndrome. Metformin is a first line therapy for DM but it is not known if this therapy may increase the risk of lactic acidosis in patients with MELAS. Therefore, we evaluated the impact of metformin therapy on lactate levels in adult patients with MELAS.  

Methods: We reviewed serial data over 4 years on lactate levels of 27 adults at a single center with genetically confirmed MELAS in the ambulatory setting. 

Results: 18/27 patients with sufficient data were included. Of the 18 patients, 7 had DM (2 on metformin 1gm BID, 2 previously on metformin but discontinued given nausea, 3 never on metformin), 3 with impaired glucose tolerance (IGT) and 8 without DM. Altogether, 41 fasting lactate levels (normal range: 0.5-2.2 mmol/L) were recorded and analyzed:

With DM and Metformin (n = 2): 3 samples, Median = 2.8 mmol/L, Range = 1.4 - 3.5 mmol/L

With DM Previously on Metformin (n = 2): 3 samples, Median = 3 mmol/L, Range = 3 - 3.6 mmol/L

With DM Without Metformin (n = 3): 10 samples, Median = 1.7 mmol/L, Range = 1 - 2.6 mmol/L

With IGT Without Metformin (n = 3): 6 samples, Median = 1.35 mmol/L, Range = 0.9 - 3.6 mmol/L

Without DM (n = 8): 19 samples, Median = 2.6 mmol/L, Range = 0.5 - 15.8 mmol/L

Conclusion: Lactate levels did not differ by metformin status in MELAS patients with DM. Results do not rule out, nor suggest, a relationship between metformin therapy and lactic acidosis in adult patients with MELAS. Given this uncertainty, we believe that a trial of metformin is feasable in MELAS patients with DM but would suggest monitoring of lactate levels before and after initiation of therapy to ensure no deterioration.

 

Nothing to Disclose: FH, SMS, AM

11949 15.0000 SAT-1040 A Metformin Therapy and Lactate Levels in Adult Patients with Melas and Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Naji Torbay*1 and Rita Nawar2
1The Weight Care Clinic, Beirut, Lebanon, 2The Weight Care Clinic, Dubai, United Arab Emirates

 

In recent years, a number of studies have investigated the association between cholesterol gallstone disease (GSD) and the metabolic syndrome (MetS). The main risk factors for GSD such as obesity, type 2 diabetes, dyslipidemia, and hyperinsulinemia are also well-known components of MetS (1). Thus suggesting that MetS is a risk factor for GSD (2) and that GSD might also be just another component of MetS (1). The current hypothesis is that the phenotype of GSD may result from the interaction between insulin resistance, genetic factors, and a number of environmental factors (1, 3).

The aim of this retrospective study was to investigate whether the relationship between GSD and MetS is present in the Lebanese population, particularly the predictors of insulin resistance (IR) among patients who reported a past history of cholecystectomy.

The medical charts of 1726 new non-diabetic patients who attended our weight-loss clinic in the years 2011-2013 were reviewed; 138 (8%) of whom reported having had a cholecystectomy.  IR was determined by the routinely calculated HOMA-IR index (value > 2.5 indicative of IR) (4). Age, height, weight, BMI, and plasma glucose and insulin levels at fasting and post oral glucose tolerance test (OGTT) were also collected. Multivariate logistic regression analysis was used to explore for predictors of IR.

Of the 138 subjects - mean age of 43.4±11.8 years - IR was present in 57% of the patients. Patients with IR had a mean BMI of 35.8±6.2 kg/m2, fasting glucose of 110.4±94.0 mg/dl, fasting insulin of 19.8±9.8 µIU/ml, 1-hour post OGTT glucose of 156±49.4 mg/dl, and 1-hour post OGTT insulin of 142.5±87.0 µIU/ml. There was a significant association between IR and having an elevated BMI (OR 1.196, 95% CI: 1.062-1.347, p<0.003), elevated fasting blood sugar (OR 1.109, 95% CI: 1.030-1.194, p<0.006), and elevated 1-hour post OGTT insulin (OR 1.022, 95% CI: 1.009-1.035, p<0.001) among patients with a cholecystectomy.

               This is further proof that there is a very intricate relationship between GSD and IR in the Lebanese that needs additional investigation. Given the significant association shown in this study, we conclude that all patients reporting a past history of cholecystectomy should be fully investigated for the concomitant presence of IR and managed accordingly.

 

Nothing to Disclose: NT, RN

15916 16.0000 SAT-1041 A Cholecystectomy Patients Are Likely to be Insulin Resistant 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Manav Batra*1, Sandeep S Dhindsa2, Sanaa Abuaysheh3, Nitesh D Kuhadiya1, Kelly Green3, Antoine Makdissi4, Jeanne Hejna5, Husam Ghanim6, Ajay Chaudhuri7, Sartaj Sandhu8 and Paresh Dandona9
1University at Buffalo, Buffalo, NY, 2SUNY at Buffalo, Amherst, NY, 3SUNY at Buffalo, 4State Univ of New York at Buffal, Buffalo, NY, 5Suny at Buffalo, 6State University of New York at Buffalo, Buffalo, NY, 7SUNY at Buffalo, Williamsville, NY, 8Diabetes and Endocrinology Center of Western New York, Williamsville, NY, 9State Univ of NY, Buffalo, NY

 

Hypogonadotropic hypogonadism (HH) is associated with increased insulin resistance compared to eugonadal type 2 diabetics (T2DM), based on HOMA-IR. We have now investigated whether insulin resistance is increased in the HH and the effects of testosterone supplementation on insulin sensitivity and on mediators of insulin signaling. Twenty six patients with HH and T2DM were compared with 24 eugonadal patients with T2DM at baseline. From the HH patients, 12 were treated with testosterone 200mg every 2 weeks injected intramuscularly for 6 months. Fasting blood samples and fat biopsies were obtained at baseline and at 6 months. Using hyperinsulinemic euglycemic clamps, we demonstrated that patients with HH have 28% lower glucose infusion rates (GIR) for a given rate of insulin infusion compared to eugonadal patients. Following testosterone treatment, there was an increase in GIR by 30%, consistent with a reversal of insulin resistance. Basal expression of mediators of Insulin signaling including IR, IRS-1 and GLUT-4 was lower by 32%, 35% and 27% (p<0.05), respectively, in HH adipose tissue (AT) compared to eugonadal. Following testosterone, the AT expression of IR, IRS-1 and GLUT-4 increased significantly by 63±15%, 54±17% and 59±14%, respectively, while there was a decrease in the expression of PTP-1B by 23±8% and TLR-4 by 21±11%, both of which interfere with insulin signaling. There was a significant fall in circulating mononuclear cells expression of SOCS-3 by 27±8% and IKKβ by 23±11%, both known to interfere with insulin signaling. Additionally, plasma concentrations of FFA, TNFα and CRP, all of which interfere with insulin signaling, fell by 35%, 18% and 26%, (p<0.05) respectively. Therefore, testosterone supplementation has an insulin sensitizing effect in HH patients at various levels involving an increase in the expression of mediators of insulin signaling and a reduction in factors that interfere with insulin signaling.

 

Nothing to Disclose: MB, SSD, SA, NDK, KG, AM, JH, HG, AC, SS, PD

12192 17.0000 SAT-1042 A Testosterone Restores Insulin Sensitivity and Improves Insulin Signal Transduction in Patients with Diabetes and Hypogonadotropic Hypogonadism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Youngman Oh*1, Qing Cai1 and Jo Lynne W Robins2
1Virginia Commonwealth University, Richmond, VA, 2Virginia Commonwealth Universty, Richmond, VA

 

Insulin resistance (IR) represents a common metabolic derangement that contributes to the development of many obesity-related comorbidities including type 2 diabetes mellitus (T2DM). Although it is generally established that low-grade adipose tissue inflammation contributes to the burden of IR, the pathophysiology underlying the development of IR is complex. In addition to alterations in other metabolic pathways, perturbations in the growth hormone/insulin-like growth factor-1 (IGF-1) axis have been implicated in the process. Levels of a specific IGF-1 binding protein, IGFBP-3, are associated with obesity, IR and diabetes. Our group has previously demonstrated that, through activation of a dedicated receptor (IGFBP-3R), IGFBP-3 inhibits cytokine-induced NF-kB activity and improves insulin signaling in human adipocytes. Furthermore, obese adolescents demonstrate reductions in total IGFBP-3 and increases in proteolytic fragments of IGFBP-3 when compared with their non-obese counterparts IGF-BP3. These findings suggest a regulatory role for the IGFBP-3/IGFBP-3R system in glucose homeostasis.

Despite evidence suggesting that IGFBP-proteolysis is associated with increasing adiposity, the specific mechanisms responsible for the protein’s degradation are, as of yet, unclear. Neutrophil serine proteases (NSPs) are released at sites of inflammation and activate pro-inflammatory cytokines. Although classically associated with innate immunity and pathogen destruction, NSPs are also involved in the pathogenesis of many chronic inflammatory conditions. Moreover, recent studies demonstrated significant suppression of α-1-antitrypsin activity (AAT, an endogenous NSP inhibitor) in T2DM.      

Interestingly, our preliminary studies demonstrated NSPs as specific IGFBP-3 proteases and increased serum NSPs and IGFBP-3 proteolysis in obese individuals as well as DIO mice compared to those in lean counterparts. In vitro and in vivo studies further demonstrate that NSP inhibitors such as Aralast (clinical formulation of AAT) and a novel small peptide inhibitor inhibit IGFBP-3 proteolysis and sensitize obesity-induced IR. Taken together these findings suggest that obesity-induced NSPs proteolyze serum IGFBP-3, thereby impairing anti-inflammatory, insulin-sensitizing IGFBP-3/IGFBP-3R cascade in insulin-target cells and resulting in IR and T2DM. Therefore, restoration of functional IGFBP-3/IGFBP-3R cascade by treatment with NSP inhibitors may prevent/reverse obesity-induced IR and T2DM as well as diabetes co-morbidities. Additional in vivo studies are warranted to validate Aralast as well as a novel small peptide inhibitor as preventive and/or therapeutic interventions for chronic inflammation (obesity)-induced IR and T2DM.

 

Nothing to Disclose: YO, QC, JLWR

14808 18.0000 SAT-1043 A The NSP-IGFBP-3/IGFBP-3R Axis Is a New Therapeutic Target for Obesity-Induced Insulin Resistance and T2DM 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Antonios Chatzigeorgiou1, Christian A. Koch*2, Kyoung-Jin Chung3 and Triantafyllos Chavakis1
1Technische Universität Dresden, Dresden, Germany, 2University of Mississippi Medical Center, Jackson, MS, 3Dept. of Clinical Pathobiochemistry, Technische Universität Dresden, Dresden, Germany

 

Obesity and its complications, such as insulin resistance and type 2 diabetes mellitus (T2DM) are metabolic diseases characterized by the presence of chronic low grade inflammation. Del-1 is an endothelial-derived anti-inflammatory factor that antagonizes the leukocyte-endothelial interactions and inflammatory cell recruitment chronic inflammatory responses (1-4). However, the levels of Del-1 in human plasma of obese or T2DM subjects and its potential contribution to the development of obesity-related T2DM have not been described thus far.    

We measured the levels of Del-1 in human plasma of 58 subjects by ELISA. The subjects were divided into 4 groups based on their BMI and the diagnosis of T2DM or glucose intolerance: “non-obese normal controls”, “obese normal controls”, “obese-pre T2DM” and “obese T2DM”. Other parameters such as fibrinogen, insulin, fructosamine, blood pressure and heart rate were also measured. Mann-Whitney U test and the Spearman's rho correlation method were used for statistical analysis.

The levels of Del-1 were significantly downregulated in obese-pre T2DM individuals as compared to the non-obese normal controls (p=0.031). Similarly, the levels of Del-1 were significantly higher in obese normal controls as compared to obese pre-T2DM and T2DM, when the latter were considered as one group. The levels of Del-1 among all individuals showed a tendency to a negative correlation with the age of the individuals (p=0.078). This correlation became significant among the obese subjects (p=0.009). In addition, in non-obese normal controls the levels of Del-1 were positively correlated with BMI (p=0.005).

Del-1 is potentially implicated in the development and pathophysiology of obesity-related T2DM. Studies of larger sample size are required to evaluate and establish the role of plasma Del-1 levels as potential marker in monitoring the progress of metabolic diseases such as T2DM and their complications.

 

Nothing to Disclose: AC, CAK, KJC, TC

15288 19.0000 SAT-1044 A Plasma Developmental Endothelial Locus-1 (Del-1) Levels in Obesity and T2DM 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Yuval Eisenberg*1, Arfana Akbar2 and Elena Barengolts1
1University of Illinois at Chicago, Chicago, IL, 2Jesse Brown VAMC, Chicago, IL

 

Background:

Interferon-γ-inducible protein (IP-10) is a potent chemoattractant for inflammatory cells including T-cells, B-cells and monocytes. IP-10 has been found elevated in T1DM, T2DM and patients at risk for these diseases, as well as correlating with severity of diabetic nephropathy.  Vascular Endothelial Growth Factor (VEGF) plays a key role in angiogenesis and has also been shown elevated in patients with diabetes and metabolic syndrome. Dynamic changes in serum IP-10 or VEGF levels in response to glucose tolerance testing has not been extensively evaluated in human subjects.

Aim:

To evaluate changes in serum protein biomarkers in response to oral glucose tolerance testing in a population of African American male (AAM) veterans with dysglycemia (A1C 5.7-6.9) and hypovitaminosis D

Methods:

African American VA patients enrolled in an ongoing randomized clinical trial of vitamin D intervention for the prevention of diabetes (DIVA- NCT01375660) completed 75g standard oral glucose tolerance testing (OGTT) at baseline of enrollment.  Multiplex immunoassay measurements were performed on serum samples from 0 and 60min.

Results:

Measurement of IP-10 (CXCL-10) showed marked reduction 60 min after OGTT.  Mean IP-10 levels were 676 pg/ml and 571 pg/ml at 0 and 60 min, respectively (p=0.01). Conversely, VEGF levels increased from 412 pg/ml to 447 pg/ml at 0 and 60 min (p=0.04). Additionally, GIP (glucose-dependent insulinotropic peptide) increased significantly after oral glucose load.  Mean GIP levels were 12.6 pg/ml and 58.4 pg/ml at 0 and 60 min (p<0.01).

Discussion:

Pro-inflammatory cytokines play an important role in the pathogenesis of diabetes.  Cytokine profiles for diabetic patients are being increasingly used to identify markers of inflammation as potential early diagnostic and therapeutic targets.  IP-10 appears to be specifically involved in beta cell apoptosis.  This study of prediabetic patients notes high overall levels of IP-10 (compared to literature reports) but a significant reduction 60 min after oral glucose administration.  A potential mechanism for IP-10 decline during OGTT may be mediated by reduced free fatty acid levels (FFA) (associated with a rise in insulin) through NFkB pathway. VEGF levels correlate with markers of metabolic syndrome, and related vascular remodeling plays a key role in atherosclerotic disease.  Serum changes in response to glucose described here are consistent with previously found acute rise. GIP levels significantly increased, as expected, and served to help validate multiplex immunoassay measures.

Conclusion:

In a population of AAM with dysglycemia and hypovitaminosis D, oral glucose load significantly reduced an inflammatory marker, IP-10, although overall levels were elevated.  VEGF levels, also elevated in this population, increased in response to OGTT.

 

Nothing to Disclose: YE, AA, EB

16554 20.0000 SAT-1045 A IP-10 Levels Decline, and VEGF Levels Rise in Response to Oral Glucose Tolerance Test in Patients with Dysglycemia and Hypovitaminosis D 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Yunna Jiang*1, Sotonte Ebenibo2, Jim Wan3 and Samuel Dagogo-Jack1
1University of Tennessee Health Science Center, Memphis, TN, 2University of Tennessee, Memphis, TN, 3The University of Tennessee Health Science Center, Memphis, TN

 

Background: Release of adipokines and proinflammatory cytokines, along with ectopic lipid accumulation, promotes the development of inflammation and insulin resistance in the islets and contributes to beta cell failure. Hypoadiponectinemia has been reported to precede the development of insulin resistance. Studies have shown hsCRP as an independent predictor of risk for diabetes. However, data on early dysglycemia and ethnic patterns are lacking. We studied the role of adiponectin and hsCRP during the earliest stage of glycemic dysregulation, and assessed whether disparities exist in the role of these two markers.

Method: 333 normoglycemic (confirmed with 75-gm OGTT) African American and Caucasian offspring of either one or both parents with type 2 diabetes were recruited. Adiponectin and hsCRP levels were drawn at the baseline. Fasting glucose was checked prospectively quarterly and OGTT was checked annually. The primary end point was progression to prediabetes (impaired fasting glucose and/or impaired glucose tolerance) or diabetes.

Statistical Analysis: Data was analyzed using t-test, logistic regression, and correlation procedures under SAS 9.3

Result: Among the 333 normoglycemic participants, 151(45.3%) were Caucasian and 182 (54.8%) were African American. During 5 years follow-up, 110 participants (33%) progressed to prediabetes (N=100) or diabetes (N=10), and 223 participants (67%) remained normoglycemic. There were significant differences in BMI (31.4+6.92 vs. 29.6+7.30 P=0.035) and HgbA1c (5.66+0.47% vs. 5.52+0.43% P=0.006) between progressor and nonprogressor groups. Adiponectin level in progressor group was significantly lower than nonprogressor group (8.37+4.02 vs. 9.92+5.77 mcg/mL P = 0.012). Among the two ethnic subgroups, the adiponectin level in nonprogressors was significantly higher than in progressors (8.91+5.47 vs. 7.21+3.34 mcg/mL P = 0.03) among black but not white subjects. Baseline hsCRP levels did not differ significantly by glycemic progression status. An inverse relationship was observed between adiponectin levels with progression to prediabetes (P = 0.034, OR= 0.945 [95% CI 0.896-0.996]) after adjustment for BMI, race, hsCRP and HgbA1c.

Conclusion: In our biracial cohort study of healthy offspring of diabetic parents, baseline hypoadiponectinemia independently predicted progression to prediabetes.

 

Nothing to Disclose: YJ, SE, JW, SD

15471 21.0000 SAT-1046 A Incident Prediabetes in Relation to Baseline Adiponectin and hsCRP Levels in a Biracial Cohort Study of Normoglycemic Offspring of Diabetic Parents 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Mary-Anne Doyle*1 and Curtis Cooper2
1University of Ottawa, Ottawa, ON, Canada, 2University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada

 

Background: An association between hepatitis C (HCV) and type 2 diabetes (T2DM) was first recognized in 1994.1 Although the exact mechanism is not understood, HCV is thought to impair glucose metabolism by directly interfering with insulin signalling pathways.  The presence of insulin resistance and T2DM in HCV has been associated with poor response to HCV antiviral therapy, acceleration of liver fibrosis and increased risk of hepatocellular carcinoma.  Eradication of HCV has been associated with improvements in insulin resistance but to date has not been shown to induce remission of diabetes. 

Clinical Case:A 49-year-old man with no history of diabetes was referred to Endocrinology with polyuria, polydipsia, a fasting blood sugar of 18 mmol/L, and a haemoglobin A1c (HbA1c) of 10%.  His past medical history included haemophilia, blood transfusion acquired HCV, non-alcoholic steatohepatitis, and early-stage cirrhosis.  In 2004, he received pegylated-interferon/ribavarin (peg-IFN/rib) treatment for HCV which did not achieve a sustained virological response (SVR).      

The patient was diagnosed with T2DM and was started on treatment (Metformin 500 mg twice daily and Gliclazide 80 mg twice daily).  Within a month, his HbA1c was 7.7% and fasting blood sugars were 5-7 mmol/L. 

Two years later, he was retreated with a 48-week course of peg-IFN/rib plus a HCV protease inhibitor (boceprevir).  His HbA1c at the start of treatment was 7.9%. Antiviral response to HCV-therapy correlated with a significant improvement in glucose control. He achieved an SVR and within a year of completing antiviral therapy he was no longer requiring any diabetes medications.  More than 2 years after the completion of HCV antiviral treatment completion, the patient has maintained an HbA1c of 5.8% without diabetes medication. 

Clinical Lessons: Despite the extensive literature describing an association, T2DM is under recognised as an extrahepatic manifestation of HCV.  This case provides further evidence of the role that HCV plays in causing diabetes and highlights the potential reversibility of glucose abnormalities with successful eradication of HCV.  Increased awareness of the association between these two chronic diseases may help to improve detection of undiagnosed HCV infection, identify patients with reversible causes of diabetes, guide therapeutic decisions for HCV treatment and improve outcomes in patients afflicted by both these diseases.

 

Nothing to Disclose: MAD, CC

13138 22.0000 SAT-1047 A Successful Hepatitis C Antiviral Therapy Induces Remission of Type 2 Diabetes: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Janna Prater*1 and Arthur Chernoff2
1Albert Einstein Medical Center, Elkins Park, PA, 2Albert Einstein Med Ctr, Philadelphia, PA

 

A 40 yo man presented to ER with incoherent slow speech and confusion after a 3 day history of diarrhea and headache. Diabetes (DM) presumably type 1 was diagnosed 10 years ago; initially he was treated with metformin (MF) 850 mg bid with insulin glargine 12 Units QAM added years later. His mother had DM dying at 59 after several CVAs. 2 brothers had insulin-treated DM. A 3rd brother did not have DM.

On exam vital signs were normal, BMI 21. He was confused and disoriented with expressive aphasia, diffuse weakness but normal sensation. Hyponatremia was due to hyperglycemia. Lactate 52.1 mg/dl (6.3-18.9) with an anion gap = 11, BUN 22 mg/dL, creatinine 0.7 mg/dL, HgBA1C 9.0%; LFTs, TSH, ammonia, alcohol, RPR, HIV, ANA, Zoster, HSV1, 2 and cultures of blood, urine and CSF were all normal or negative. CSF protein and glucose were 122 mg/dl and 296 mg/dl respectively. Head CT showed symmetric calcifications in the basal ganglia and subacute infarcts of the left temporal and parietal lobes. An MRI was suggestive of cerebritis/atypical herpes encephalitis. He was treated with acyclovir, ceftriaxone and doxycycline. MF was stopped due to lactic acidosis. He improved and went to rehab.

 One month later right facial and 4/5 limb weakness with numbness and hemi-neglect developed. Expressive aphasia recurred. Lactate 25.7 mg/dl, pyruvate 0.6 mg/dl. FBG 208 mg/dl, C-peptide 1.1ng/ml, insulin 3.0 mIU/ml yielded HOMA-IR: %B 17.3, %S 93, IR 1.1; GAD-65 <1u/ml. MRI spectroscopy identified an elevated lactate doublet peak consistent with metabolic encephalopathy. A muscle biopsy showed numerous red ragged fibers that were SDH+/COX-; EM showed abnormal mitochondria with para-crystalline inclusions consistent with Mitochondrial myopathy, Encephalopathy, Lactic Acidosis and Stroke like episodes (MELAS). He was treated with L-arginine, L-carnitine, COQ10 and glargine.

The Lesson: When is DM not type 1 or 2? When it is MELAS. MELAS is due to a maternally inherited mutation in mitochondrial DNA that affects cellular respiration. Usually signs such as weakness, headache and seizure occur in childhood but may occur later. In most, stroke occurs by age 40. High lactate levels occur. MELAS-associated DM is due to insufficient insulin secretion from mitochondrial dysfunction of β-cells, occurs in early adulthood and invariably requires insulin. This is an acknowledgement of the role that oxidative phosphorylation plays in glucose-stimulated insulin secretion and an insulin secretory defect may be a major factor in the pathophysiology of the DM in MELAS. The diagnosis of MELAS can be made non-invasively using MR Spectroscopy. No specific treatment for MELAS exists. Although treatment with L-arginine and COQ10 rests only on empirical observation and clinical trials are needed, MELAS as a cause of DM should be kept in mind since adding L-arginine and COQ10 may slow disease progression and be beneficial in treating stroke-like symptoms.

 

Nothing to Disclose: JP, AC

12183 23.0000 SAT-1048 A A Case of Diabetes in a Patient with Melas (Mitochondrial myopathy, Encephalopathy, Lactic Acidosis and Stroke-like episodes) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Yunna Jiang*1, Peter Law2, Muthiah Muthiah1 and Abbas E Kitabchi3
1University of Tennessee Health Science Center, Memphis, TN, 2University of Tennessee HealthScience Center, Memphis, 3Univ of TN Hlth Sci Ctr, Memphis, TN

 

Background: Hyperosmolar hyperglycemic state (HHS) is one of the two most serious acute complications of diabetes along with diabetic ketoacidosis (DKA). With aggressive and early intervention, the mortality of HHS could be lowered to 0. However, if the condition remains unrecognized, the prognosis is dismal.

Case Series: Mortality case one: 79 year-old man with diabetes, multiple comorbidities, and malnutrition who was admitted for incision and debridement of his stage IV sacral decubitus ulcer. Septic shock secondary to Klebsiella bacteremia developed on post operative day two. He was transferred to ICU. Tube feeding was started subsequently. Serum osmolality increased to 331 mosmol/kg with glucose level 1153 mg/dL after two days of feeding. Patient rapidly expired within 24 hours.

Mortality case two: 68 year-old man with multiple comorbidities, malnutrition and diabetes was admitted for acute stroke. Tube feeding was started due to risk of aspiration. HHS developed one day after the tube feeding with serum osmolality of 347 mosmol/kg and glucose level of 673 mg/dL. His condition deteriorated and expired after 14 days.

Mortality case three: 66 year-old man with past medical history of Guillain-Barre Syndrome was admitted for gastrostomy tube placement. Serum osmolality rose to 344 mosmol/kg with glucose level of 652 mg/dL one day after the tube feeding trial was initiated. Patient expired on day 4.

During their ICU stay, HHS was not diagnosed, and no treatment protocol was initiated.

Discussion: Surgery and acute stress stimulate release of counterregulatory hormones such as epinephrine, glucagon, cortisol, growth hormone and inflammatory cytokines such as interleukin-6 and tumor necrosis factor-alpha. Insulin resistance, decreased peripheral glucose utilization, impaired insulin secretion, increased lipolysis and protein catabolism resulted from these neurohormonal changes leading to hyperglycemia. With hyperosmotic tube feeding and diabetes history, the risk to develop HHS is high.

Conclusion: Iatrogenic HHS secondary to tube feeding during the perioperative period or acute stress needs to be identified and treated early. Endocrinology should be included in the multi-disciplinary care team to avoid high mortality.

 

Nothing to Disclose: YJ, PL, MM, AEK

13225 24.0000 SAT-1049 A Iatrogenic Hyperosmolar Hyperglycemic State Secondary to Tube Feeding, Remains Fatal If Unrecognized 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Beatrice Hong*
Duke University Medical Ctr, Durham, NC

 

Title:  Falsely Elevated Glycated Hemoglobin in the setting of Hemoglobinopathy I

Objective: To describe a case of a woman with Hemoglobinopathy I and its effect on Hemoglobin A1c.

Case Presentation: A 56 yo African American female with a history of type 2 diabetes mellitus, hypertension and hyperlipidemia presents with fever, malaise and cough.  Evaluation reveals sepsis and pyelonephritis prompting inpatient admission. The patient manages her diabetes with an insulin pump and reports good control, but had discontinued her pump several days prior to admission.  Admission laboratory tests reveal a blood glucose of 240mg/dL and hemoglobin A1c of 15.7%, corresponding to an average calculated blood glucose of 432mg/dL.  Hemoglobin is 13.3g/dL and hematocrit  0.40 L/L. RDW is at upper limit of normal at 14.5%.  During her hospitalization, her diabetes is easily controlled by her home insulin regimen, with blood glucoses ranging from 105 mg/dL to 170 mg/dL.  The patient later reveals that she has a known hemoglobinopathy. Subsequent investigation reveals an alpha chain variant hemoglobinopathy most consistent with hemogloin alpha chain variant I.  Fructosamine level was 254 (0-285 umol/L) indicating good blood glucose control consistent with glucoses measured during her admission.

Discussion:  Hemoglobin A1c is a useful and commonly used tool to assess long-term glycemic control in people with diabetes mellitus.  HgA1c results are affected by multiple factors, including anemia and hemoglobinopathies.  More common hemoglobin variants, including S,C, D and F, have well documented effects  on HgA1c.  In this case, our patient was found to have a rare alpha chain variant known as Hemoglobin I. Hemoglobin I significantly elevates HgA1c when measured with ion-exchange high-performance liquid chromatography. In contrast, fructosamine provides a more accurate result of the patient’s recent glycemic control.

Conclusion: Hemoglobin variants are known to potentially affect Hemoglobin A1c results. Hemoglobin I is a rare alpha chain variant that falsely elevates HgA1c.  Alternative methods to assess glucose control should be considered in all individuals with a Hemoglobin I variant.

 

Nothing to Disclose: BH

16458 25.0000 SAT-1050 A Falsely Elevated Glycated Hemoglobin in the Setting of Hemoglobinopathy I 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Nora Alghothani*1, Benjamin D Korman2 and Kathleen M Dungan3
1The Ohio State University, Columbus, OH, 2Northwestern University Feinberg School of Medicine, 3Ohio State University, Columbus, OH

 

Background:  The concurrent diagnosis of AOSD & DKA has not been previously reported for new onset DM2.  However, the inflammatory milieu that is characteristic of AOSD may result in impaired beta cell function & insulin resistance that is reversible upon treatment of the disease process.

Clinical Case:  A previously healthy 31 yo Caucasian man presented to ED with neck pain & a six day history of sore throat, cough, headache, & generalized malaise.  He also reported a 30-lb weight loss over the past month, polydipsia, & polyuria. Exam revealed obesity (BMI 36.2), acanthosis nigricans, pain on neck flexion, & temp of 101 o F.  LP was normal.  Glucose was >550 mg/dl, prompting inpatient admission. Lab analysis showed an acidosis, AG of 15, & elevated urine & serum ketones with A1c of 12.2% (n 4.3 - 6.1). Patient was stabilized with fluids & IV insulin before transition to SQ insulin.  His GAD Ab was neg, C-peptide was 1.3 ng/mL (n 0.9-3.6), & he had several family members with DM2 suggesting a diagnosis of DM2. By day 3, patient developed fever of 102.4o F & his WBC count had increased to 22.7 K/mL (n 4.5 - 11.0) with neutrophil predominance. All cultures & infectious serologies were neg.  CT scans revealed multiple enlarged sub-cm lymph nodes in the chest, splenomegaly, & fatty liver. Flow cytometry was consistent with a reactive process vs early T-cell lymphoproliferative disorder. During work-up, patient continued to spike overnight fevers to 103.9oF.  On day 9, he developed worsening myalgias, bilateral shoulder & elbow arthralgias, neck pain, & a new rash that responded to scheduled ibuprofen, but were unaffected by acetaminophen. Rash would appear only when febrile & consisted of transient non-pruritic salmon-colored macules on face, neck, & trunk. Dermatopathology showed mild superficial & deep perivascular dermatitis with a focal interface reaction.  ANA & RF were neg, but acute phase reactant, ESR, was significantly elevated (>140 mm/hr, n 0 – 14). Patient was diagnosed with AOSD & started on prednisone. He remained asymptomatic until prednisone taper ended at which time fever, rash, myalgias, & arthralgias recurred; he was therefore restarted & maintained on low dose prednisone for 1 year before successful discontinuation. As for diabetic control, A1c improved to 5.9% with normalization of ESR, & insulin was gradually stopped within few months. He has remained in remission & recently decided to hold metformin.

Conclusion:  This is the first case demonstrating coincident onset of both AOSD & DKA in DM2. There is a large body of research to support the importance of systemic inflammation, particularly IL-1 & TNF-alpha, in interfering with peripheral insulin sensitivity & beta cell function. AOSD is characterized by a marked inflammatory cytokine milieu, & thus could conceivably precipitate DKA in a patient who is predisposed to DM2.  Moreover, treatment of the inflammatory process was associated with prompt remission of DM.

 

Disclosure: KMD: Advisory Group Member, Eli Lilly & Company, Investigator, Novo Nordisk, Advisory Group Member, Sanofi. Nothing to Disclose: NA, BDK

14344 26.0000 SAT-1051 A Concurrent Diagnosis of Adult Onset Still's Disease (AOSD) & Diabetic Ketoacidosis (DKA) in a Man Predisposed to Type 2 Diabetes (DM2) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Saturday, June 21st 3:00:00 PM SAT 1026-1051 4810 1:00:00 PM Glucose Metabolism Poster

Unurjargal Sukhbaatar*1, Tselmeg Mijiddorj2, Aki Oride3 and Haruhiko Kanasaki4
1Shimane University School of Medicine, Izumo, Japan, 2Shimane University School of Med, Izumo Shi, Japan, 3Shimane University, Izumo, Japan, 4Shimane Univ Sch of Med, Izumo, Japan

 

Gonadotropin-inhibitory hormone (GnIH) was first identified in the quail as a novel neurohormone that acts directly on the anterior pituitary to inhibit gonadotropin release. GnIH inhibits not only gonadotropin release from the pituitary gland but also inhibits the release of gonadotropin-releasing hormone (GnRH) from the hypothalamus. In this study, we examined how GnIH receptors were regulated in pituitary gonadotroph cells and GnRH-producing neurons in the hypothalamus. In the mouse pituitary gonadotroph cell line LbT2, GnRH increased the expression of the GnIH receptor G-protein coupled receptor 74 (GPR74). GnRH also stimulated the expression of GPR74 and GPR147 in primary cultures of rat anterior pituitary cells. In addition, when GnRH was administrated to LbT2 cells in a pulsatile manner, low frequency GnRH pulse stimulation preferentially stimulated GPR74 and GPR147 expression compared to high frequency GnRH pulses. In the mouse hypothalamic GnRH-producing cell line GT1-7, hypothalamic kisspeptin did not significantly increase the expression of GnIH receptors. However, the intermittent administration of kisspeptin to GT1-7 cells significantly increased GPR74 and GPR147 mRNA expression. The overexpression of constitutively active MEK kinase (MEKK) as well as protein kinase A (PKA) in LbT2 cells increased the expression of GPR74 mRNA. Conversely, in GT1-7 cells, although the overexpression of either MEKK or PKA failed to stimulate GnIH receptor expression, the combined overexpression of both increased GPR74 and GPR147 mRNA levels. Our current observations suggested that two central controllers of reproductive function, GnRH and kisspeptin, stimulated the expression of GnIH receptors in pituitary gonadotroph cells and hypothalamic GnRH neurons.

 

Nothing to Disclose: US, TM, AO, HK

13603 5.0000 SAT-0349 A Expression of Gonadotropin-Inhibitory Hormone Receptors in Mouse Pituitary Gonadotroph LT2 Cells and Hypothalamic Gonadotropin-Releasing Hormone-Producing GT1-7 Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, June 21st 3:00:00 PM SAT 0345-0354 4815 1:00:00 PM GPCR Structure/Function Poster

Jana Fischer*, Anne Müller, Heiko Krude, Annette Grüters-Kieslich, Gunnar Kleinau and Heike Biebermann
Charité - Universitätsmedizin Berlin Campus Virchow, Berlin, Germany

 

Thyrotropin and its receptor, the thyrotropin receptor (TSHR), are essential for function of the thyroid gland. The TSHR belongs to the family of glycoprotein hormone receptors, a subfamily of G-protein coupled receptors (GPCRs). It is well known that inactivating mutations of the TSHR are the molecular causes for congenital hypothyroidism or hyperthyrotropinemia. Activating TSHR mutations cause non-autoimmune hyperthyroidism if they occur as germline mutations or toxic adenomas if those mutations are somatic. However, unsolved cases of hyperthyrotropinemia as well as a huge spectrum of phenotypical variability of TSHR mutation carriers led to the hypothesis that new and unrecognized interaction partners of the TSHR may exist that might explain these conditions. The capability of GPCRs to form higher order complexes (homo- as well as heterodimerization) with effects in ligand binding and signal transduction is now accepted since several years. The TSHR is also known to form homodimers which has an influence on TSH binding shown as negative cooperativity. For several other GPCRs homo-and heterodimerization with other GPCRs but also interactions with other cytosolic and membrane bound proteins indicate that GPCRs work in a protein network that influence the function of the GPCRs in its cellular context. Thereby interacting proteins can play an important role in fine-tuning the function of GPCRs.

To  screen for new TSHR interaction partners we designed a human thyroid cDNA library and performed interaction partner screening by applying a bimolecular fluorescence complementation. This assay was based on the complementation of two Yellow Fluorescent Protein (YFP)-fragments that were fused to human TSHR cDNA and a human thyroid cDNA library. In a case of an interaction the two fragments come into close proximity and form the native structure of YFP. Positive interaction pairs were selected by FACS (fluorescence-activated cell sorting) analysis.

In the first screen we identified one interaction partner, a heat-shock protein that is a chaperone highly expressed in the thyroid gland. Our study unravelling new interaction partners of the TSHR indicate that indeed the TSHR is able to interact with other proteins. The functioning of the TSHR in a protein network might explain the complexity of thyroid function under normal and pathophysiological conditions.

 

Nothing to Disclose: JF, AM, HK, AG, GK, HB

14696 6.0000 SAT-0350 A Identification of a New Interaction Partner for Human Thyrotropin Receptor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, June 21st 3:00:00 PM SAT 0345-0354 4815 1:00:00 PM GPCR Structure/Function Poster

Hui Huang*1 and Ya-Xiong Tao2
1Auburn University, Auburn, AL, 2Auburn University, Auburn University, AL

 

The melanocortin-3 receptor (MC3R) is a G protein-coupled receptor expressed primarily in the central nervous system but also in the gastrointestinal tract, kidney, and immune cells. It has various physiological functions, regulating feed efficiency, nutrient partitioning, fasting responses, natriuresis, and immune reactions. MC3R has been shown to couple to the stimulatory G protein Gs, and stimulate adenylyl cyclase to increase intracellular cAMP level. Previous studies reported conflicting data on whether activation of MC3R stimulates ERK1/2 phosphorylation or not. The highly conserved DRYxxI motif at the cytoplasmic end of transmembrane domain 3 (TM3) and the intracellular loop 2 (IL2) are known to be important for receptor function in many other GPCRs. To better understand the function of each residue in this domain of human MC3R, we performed alanine-scanning mutagenesis generating 18 mutants. We showed that all mutants had normal cell surface expression. Alanine mutation of eleven residues, D178, R179, Y180, I183, Y185, A186, R188, Y189, I192, M193, and T194 decreased the maximal binding and maximal cAMP production of MC3R stimulated by NDP- or lpha-melanocyte stimulating hormone (MSH). Mutation of two residues, T182 and L187 did not alter maximal binding but result in impaired signaling in Gs-cAMP-PKA pathway and mutation of five residues, Y185, A186, R188, M193, and T194 impaired signaling in ERK1/2 pathway. We also showed that alanine mutants of seven residues, D178, R179, Y180, T182, I183A, L187, and I192 that were defective in cAMP pathway responded normally in ERK1/2 pathway, demonstrating biased signaling. In summary, we provided comprehensive information on the structure-function relationship of the cytoplasmic end of TM3 and the IL2 of MC3R. We confirmed that MC3R activated MAPK pathway and identified residues that were critical for ligand binding, signaling in Gs-cAMP-PKA pathway, and signaling in MAPK pathway. We also reported biased signaling of MC3R. These data demonstrated that the cytoplasmic end of TM3 and the IL2 were critical for MC3R function.

 

Nothing to Disclose: HH, YXT

16978 7.0000 SAT-0351 A Functions of the Cytoplasmic End of Transmembrane Domain 3 and the Intracellular Loop 2 of Human Melanocortin-3 Receptor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, June 21st 3:00:00 PM SAT 0345-0354 4815 1:00:00 PM GPCR Structure/Function Poster

Paul Grzesik1, Annika Kreuchwig1, Gunnar Kleinau2, Ralf Schuelein1, Joerg Gromoll3 and Gerd Krause*1
1Leibniz-Institut fuer Molekulare Pharmakologie (FMP), Berlin, Germany, 2Charité - Universitätsmedizin Berlin Campus Virchow, Berlin, Germany, 3University Clinics, Muenster, Germany

 

Stimulation of the human lutropin receptor (hLHR) by the two hormones choriogonadotropin  (CG) or lutropin (LH) results in different physiological function with regard to differing signaling casades.

The molecular determinants of the receptor/hormone interaction, leading to different activation modes are still unclear. To elucidate the structural distinctions on the extracellular receptor activation we here focus on the hinge region, an extracellular segment crucial for signaling and hormone interaction. We used new extended crystal structural insights of the extracellular domain (leucine-rich repeat domain including also fragments of the hinge-region) of the follicotropin receptor (FSHR) in complex with FSH to generate the corresponding homologous molecular models of hLHR in complex with LH and CG. Combining in silico, experimental mutagenesis, membrane expression and cAMP activation studies, we used a specific natural occurred hLHR variant that lacks exon 10 (hLHR-delExon10), including 27 amino acids originally encoded within the LHR hinge region, which is in total comprised by 77 residues. In contrast to CG, only LH-induced signaling is decreased in hLHR-delExon10. We utilized these different effects to elucidate structural distinctions of the hinge region on the extracellular activation of hLHR.

In contrast to the FSHR structure, our secondary structure predictions and homology models of hLHR suggest that residues in the hinge region comprising exon10 and the following residues likely contain a high propensity for helical structures. This is supported by our findings that helical structure maintaining block-wise poly-alanine scan mutations within exon10 revealed not any function related amino acid specificity (similar EC50,cAMP activation) for both LH and CG. Unexpectedly, the structure disturbing double proline (303/305) mutant within exon10 of hLHR shows a clear negative effect on CG but not on LH signalling.

This observed opposite signaling behavior between LH and CG on hLHR-delExon10 and on the double proline hLHR mutant can be assigned to different particular sites of action and structural features within the hinge region of hLHR. Receptor activation mediated by sulfated tyrosine is strongly related to LH induction, since residue sTyr331 (downstream of exon10, but within the hinge region) is spatially strongly delocalized in the hLHR-delExon10 variant.  In contrast CG activation is less sulfation sensitive, but instead CG activates the receptor by interaction with structural elements within exon10. Hence their structural disturbance affects only CG signalling, while sTyr331 stays in its original spatial location and allows proper LH interaction. In conclusion our data show that specific structural elements in the middle of the hinge region of hLHR are transmitting the signal and are jointly responsible for different activation modes by LH and CG.

 

Nothing to Disclose: PG, AK, GK, RS, JG, GK

16982 8.0000 SAT-0352 A Structural Impact on the Hinge Region of Lutropin Receptor on Understanding Different Effects of LH and CG Signalling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, June 21st 3:00:00 PM SAT 0345-0354 4815 1:00:00 PM GPCR Structure/Function Poster

Moyuru Hayashi1, Yukiko Yamada1, Naoya Emoto2 and Motoyuki Shimonaka*1
1Tokyo University of Science, Tokyo, Japan, 2NMS Chiba-Hokusoh Hosp, Chiba-ken, Japan

 

Thyroid hormones are synthesized at tyrosine residues of thyroglobulin (Tg) molecule by iodination and coupling reactions, and released from Tg by restricted cleavages of peptide bonds. Although it is known that thyroid-stimulating hormone (TSH) is the key regulator of the hormone synthesis and several proteases are involved in this processing procedure, the detailed mechanisms of regulation of thyroid hormone synthesis are still unclear. Tg is currently recognized as no more than a scaffold protein for thyroid hormone synthesis, but several reports suggest that it might have cryptic functions. In this study, we examined whether Tg directly regulates the processing of Tg itself for the synthesis of thyroid hormones in thyroid epithelial cells.

 Cultured rat thyroid epithelial cells, FRTL-5, were treated with Tg purified from porcine thyroid glands and measured the proteolytic activities of cathepsin B/L and dipeptidyl peptidase II (DPP II) in the cultured cells by using synthetic substrates. Tg stimulated the activities of cathepsin B/L and DPP II in the FRTL-5 cells dose dependently. On the other hand, TSH stimulated the cathepsin B/L activity but inhibited DPP II activity. Insulin had no effect on both proteases. Tg also affected the mRNA levels of these proteases in thyroid cells measured by quantitative PCR. It has been demonstrated that thyroid epithelial cells secrete plasminogen-like protease and/or plasminogen activator. It was found that activities of these proteases released from FRTL-5 cells were stimulated by the treatment of Tg, while TSH had no effect on the activity of plasminogen-like protease and rather inhibited the activity of plasminogen activator. Then we examined the molecular sizes of these proteases by using zymography on Tg-containing gels and western blotting. The plasmin activities were detected by Tg-zymography as gel-lysed bands at 75 kDa and 50 kDa and plasminogen activator activity at 43 kDa, respectively. The apparent molecular masses of these proteases analyzed by western blotting, however, were larger than the expected ones, they seemed to exist as either multimeric forms or complexes bound to other proteins.

 These results suggest that Tg regulates thyroid hormone synthesis in the different way from TSH by altering the activities of hormone-processing enzymes in thyroid epithelial cells. To elucidate whether these effects of Tg on thyroid cells induce changes in the hormone production, we are now under investigation for quantifying the amount of thyroid hormones secreted from the Tg-treated cells using suspended culture and perfusion culture.

 

Nothing to Disclose: MH, YY, NE, MS

14111 9.0000 SAT-0353 A Thyroglobulin Stimulates the Activities of Cathepsin B/L and Dipeptidyl Peptidase II in Frtl-5 Rat Thyroid Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, June 21st 3:00:00 PM SAT 0345-0354 4815 1:00:00 PM GPCR Structure/Function Poster

Tatiana V Novoselova*1, Rachel Larder2, Debra Rimmington2, Chris Lelliott3, Elizabeth Wynn3, Stephen O'Rahilly4, Adrian J L Clark5, Darren Logan3, Anthony P Coll2 and Li F Chan6
1WHRI, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom, 2CIMR, Cambridge, United Kingdom, 3Wellcome Trust Sanger Institute, Cambridge, United Kingdom, 4University of Cambridge, Cambridge, United Kingdom, 5St George's University of London, London, United Kingdom, 6William Harvey Research Institute, John Vane Science Centre, Queen Mary, University of London, London, United Kingdom

 

Recently, rare loss-of-function mutations of melanocortin-2-receptor accessory protein 2 (MRAP2) have been associated with severe, early-onset obesity in humans. In addition, whole body deletion and targeted brain specific deletion of the Mrap2 gene resulted in severe obesity in mice. In vitro data have shown Mrap2 interaction with the melanocortin-4-receptor (MC4R) affecting receptor signalling as a consequence. However, the mechanism by which Mrap2 regulates body weight in vivo is less well understood with differences between Mrap2 and Mc4r knockout (KO) mice phenotypes. In this study we show that Mrap2 complete KO mice, derived from an independent line and on two separate genetic backgrounds, have severe early obesity without detectable changes to food intake or energy expenditure. Hence, replicating recently published data [1]. To further investigate the in vivo role of Mrap2 as a Mc4r accessory protein we used a plasma membrane enrichment technique to demonstrate a reduction of hypothalamic Mc4r protein surface expression in Mrap2 KO mice compared with wild-type littermates. Taken together, this work corroborates the role of Mrap2 in obesity and confirms that, at least in part, this is due to defective central melanocortin trafficking.

 

Nothing to Disclose: TVN, RL, DR, CL, EW, SO, AJLC, DL, APC, LFC

15795 10.0000 SAT-0354 A Melanocortin 2 Receptor Accessory Protein 2 (Mrap2) Regulates Hypothalamic Melanocortin-4-Receptor Trafficking in Vivo 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Saturday, June 21st 3:00:00 PM SAT 0345-0354 4815 1:00:00 PM GPCR Structure/Function Poster

Ying Liu*1, Philip Alton Berry1, Yue Zhang1, Jing Jiang1, Kurt R. Zinn2 and Stuart J Frank1
1University of Alabama at Birmingham, Birmingham, AL, 2Univ of Alabama at Birmingham, Birmingham, AL

 

The transmembrane growth hormone receptor (GHR) is believed to exist at least in part as a preformed homodimer on the cell surface. Structural and biochemical studies suggest that GH binds GHR in a 1:2 stoichiometry to effect acute GHR conformational changes that trigger activation of the receptor-associated tyrosine kinase, JAK2, and downstream signaling. Despite information about GHR-GHR association derived from elegant FRET/BRET studies, assessment of the dynamics of GH-induced GHR conformational changes has been lacking. To this end, we adapted the split luciferase complementation assay to study effects of GH on GHR-GHR interaction in real time. This protein association assay relies on reconstitution of luciferase activity when two proteins, each molecularly fused to either an N-terminal or C-terminal fragment of firefly luciferase, achieve close proximity, thereby reconstituting luciferase activity; further, luciferase activity in cells is long-lived and easily detected and quantified continuously by bioluminescence detection equipment with great sensitivity and low background.  We prepared cDNA plasmids to drive expression of chimeras of human GHR fused at its C-terminus to either Nluc (residues 1-398 of firefly luciferase) or Cluc (luciferase residues 394-550) via a 10 residue flexible linker. We verified that each plasmid encoded immunoblottable and GH signal-competent chimeras. As controls, we made similar fusions of human EPOR or human estrogen receptor (ER). Expression of GHR-Nluc with GHR-Cluc by transfection in JAK2-expressing, GHR-deficient gamma 2A human fibrosarcoma cells specifically yielded luciferase signal in the absence of GH that was not detected with either chimera alone or with cotransfection of a GHR chimera with either an EPOR or ER chimera, consistent with a GHR-GHR predimerization model. Further, coexpression of GHR-Cluc in cells that stably expressed GHR-Nluc yielded a reliable GH dose-dependent change in luciferase signal with a characteristic profile. GH caused an acute (0-5 min) increase (1.5-2-fold over baseline) in complementation followed by a rapid partial decline (5-15 min) and a subsequent more moderate decline (15-40 min) to baseline complementation levels. GHR antagonists, B2036 and G120R, as well as our antagonist monoclonal antibody, anti-GHR-ext mAb (but not a control antibody) blocked the GH-induced changes in complementation, verifying specificity. Studies are underway to dissect the relative contributions of receptor phosphorylation and downregulation to this kinetic profile that presumably reflects GH-induced conformational changes of GHR dimer partners that underlies initiation of GH signaling.

 

Nothing to Disclose: YL, PAB, YZ, JJ, KRZ, SJF

13394 5.0000 SAT-0677 A Investigation of Real Time GH-Induced Ghr Dimer Conformational Change Using the Split Luciferase Complementation Assay 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

Jessica K Devin*, Hui Nian, Chang Yu and Nancy J Brown
Vanderbilt University Medical Center, Nashville, TN

 

Adults with abdominal obesity are at high risk for cardiovascular disease and also exhibit diminished growth hormone (GH) secretion; the latter further contributes to the development of visceral adiposity, impaired fibrinolysis and inflammation.(1;2)  Growth hormone releasing hormone (GHRH), the primary stimulus for endogenous GH secretion, is a substrate of dipeptidyl peptidase-4 (DPP4).(3)  One strategy to increase endogenous GH levels and thereby optimize body composition and decrease cardiovascular risk is to enhance its stimulation by GHRH.  This study tested the hypothesis that acute DPP4 inhibition with the currently available anti-diabetic therapy, sitagliptin, would increase stimulated GH secretion and GH-dependent vasodilation by decreasing the degradation of GHRH. Fourteen healthy, lean (mean BMI 23.1 ± SD1.6 kg/m2) adults (7 females), age 18-37 years, participated in this double-blind, placebo-controlled crossover study.  On two study days separated by at least one week subjects received DPP4 inhibitor (sitagliptin 200 mg p.o.) or placebo, followed by stimulation of GH (arginine 30 grams i.v.) one hour later. Sitagliptin significantly decreased plasma DPP4 activity (from mean 25.8±SD 5.1U/L after placebo to 5.4±2.8; p=0.001). Overall, the peak GH response to arginine was greater in females than males (mean 23.2 ±SD 12.3 ng/mL vs. 14.1±11.2; p=0.04). Sitagliptin did not affect the GH response to arginine, however. Forearm blood flow (FBF) as assessed by strain gauge plethysmography increased during GH stimulation (p<0.001), starting 30 minutes after the completion of arginine infusion. Vasodilation during GH stimulation, as summarized by FBF area under the curve (AUC), significantly correlated with both GH AUC (rs=0.66, p=0.01) and peak GH response (rs=0.64, p=0.02) after sitagliptin but not placebo. GLP-1 levels were higher after sitagliptin (p=0.01 vs. placebo) in both males and females, but remained stable during GH stimulation. Moreover, GLP-1 response as summarized by AUC did not correlate with FBF AUC (rs=0.09, p=0.77). In females only, sitagliptin significantly potentiated vasodilation during GH stimulation (p=0.003 vs. placebo) without affecting blood pressure or pulse. Our results demonstrate a correlation between vasodilation and GH stimulation in the setting of DPP4 inhibition.  DPP4 inhibition also potentiated the vasodilatory response to GH stimulation in females. These data are the first to suggest an effect of DPP4 inhibition on the vascular effects of GH.

 

Nothing to Disclose: JKD, HN, CY, NJB

13838 6.0000 SAT-0678 A Sitagliptin Enhances Vasodilation during Stimulated Growth Hormone Secretion in Healthy Females 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

Yair Argon*1, Adda Grimberg1, Ron G Rosenfeld2 and Michal Marzec1
1Children's Hospital of Philadelphia, Philadelphia, PA, 2Oregon Health and Science University, Portland, OR

 

The Insulin-like growth factor (IGF) pathway is recognized as one of the most critical endocrine factor impacting growth. Recent work in our lab has characterized a novel mechanism controlling IGF production – an obligatory interaction with the chaperone Glucose Regulated Protein 94 (GRP94)(1,2) In the absence of active GRP94, newly synthesized IGF-I or IGF-II fail to mature, the pro-hormones are not processed to receptor-reactive forms and thus are not available for signaling. Furthermore, the bioavailable IGFs is proportional to the activity of GRP94; designed mutants of GRP94 with partial activity support a lower level of IGFs production in cultured cells (3) and during muscle growth and differentiation (4). Therefore, we postulated that functional polymorphisms of the human GRP94 gene exist, affect the level of IGFs production and thus affect the quality of human growth.

Consistent with this hypothesis is a variant found in a patient with primary IGF deficiency. This patient is heterozygous for a point mutation, P300L, in GRP94 that is located in the linker domain of the chaperone, a domain that is needed for the activity as a chaperone. When used in a cell complementation assay, where viability of cells is made dependent on GRP94 (3), this human variant is hypomorphic, supporting only ~65% of IGF production relative to wild type GRP94. Furthermore, when tested in vitro the nucleotide binding activity of a recombinant version of this mutant protein is impaired. These data strongly support a causative relationship between the mutant GRP94 and the extremely low level of circulating IGF-I in the patient. A search of genomic databases showed that the P300L variant is not unique, but rather is found in approximately 3% of genomes. Thus, this hypomorphic version of the chaperone GRP94 may represent a novel causative genetic factor in early human development that acts to limit growth factors and perhaps other hormones.

 

Nothing to Disclose: YA, AG, RGR, MM

16297 7.0000 SAT-0679 A Variation in GRP94 Activity Impacts Production of Igfs and Human Growth 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

Kim M.J.A. Claessen*1, Natasha M Appelman-Dijkstra2, Neveen A.T. Hamdy1, Alberto M. Pereira2 and N R Biermasz3
1Leiden University Medical Center, Netherlands, 2Leiden University Medical Center, Leiden, Netherlands, 3Leiden University Medical Center, Leiden

 

Background

Adult Growth Hormone Deficiency (GHD) is associated with decreased bone mass and increased fracture risk. Recombinant human GH (rhGH) replacement therapy leads to progressive increases in bone mineral density (BMD) for up to 7 years of treatment, but little is known on effects of rhGH therapy on bone mass or fracture risk thereafter.

Methods

230 GHD patients (mean age 47.1 years, 52.6% female) on rhGH replacement therapy for ≥5 years were included in the study. BMD measurements were evaluated at the lumbar spine (LS) and femoral neck (FN) at baseline and at 5, 10 and 15 years after start of therapy. Clinical fracture incidence was also assessed over the period of follow-up. All patients received hormonal replacement therapy for other pituitary deficiencies and calcium and/or vitamin D supplements as required, and a number additional bisphosphonate treatment.

Results

211 patients completed 5 years, 98 patients 10 years, and 43 patients 15 years of rhGH therapy. Ten patients (4.3%) received bisphosphonates at baseline and 12.2%, 19.4% and 18.6% received these agents after respectively 5, 10 and 15 years of rhGH replacement. Mean duration of treatment with bisphosphonates was 6.9±4.3 years. Mean LS BMD remained stable in women, but demonstrated a significant 4% increase in men after 15 years of rhGH therapy. There was no additional benefit of bisphosphonate therapy on BMD. Fifteen patients (7%) sustained a clinical vertebral fracture during follow-up. The incidence rate of clinical fractures during rhGH replacement was 20.1/1000py in our GHD cohort.

Conclusions

In adult GHD, long-term rhGH replacement therapy stabilises BMD. On the long-term, bisphosphonate therapy does not appear to confer additional beneficial effects on BMD or fracture risk in these patients.

 

Nothing to Disclose: KMJAC, NMA, NATH, AMP, NRB

15083 8.0000 SAT-0680 A Effects of up to 15 Years of Recombinant Human GH (rhGH) Replacement on Bone Metabolism in Adults with Growth Hormone Deficiency (GHD): The Leiden Cohort Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

Elenilde Gomes Santos*1, Roberto Salvatori2, Thiago Oliveira Ferrão3, Carla R .P. Oliveira4, João A. M. Santana1, Francisco Assis Pereira5, Anita H O. Souza6, Enaldo Vieira Melo3, Carlos Carvalho Epitácio-Pereira7, Ingrid Alves Silva Oliveira3, Julianne Alves Machado3, Francisco José Santana-Junior3 and Manuel H Aguiar-Oliveira8
1Federal University of Sergipe, Aracaju, Brazil, 2Johns Hopkins Univ Sch of Med, Baltimore, MD, 3Federal University of Sergipe, 4Univ Federal de Sergipe, Aracaju Sergipe, Brazil, 5Univ of Sergipe, ARACAJU - SE, Brazil, 6Federal Univ Sergipe Univ Hosp, Aracaju-SE, Brazil, 7FEDERAL UNIVERSITY OF SERGIPE, Aracaju, Brazil, 8Federal Univ Sergipe Univ Hosp, Aracaju SE, Brazil

 

Adult-onset GH deficiency (GHD) causes increased visceral adiposity, linked to reduced insulin sensitivity (IS) and high cardiovascular risk. Furthermore, GHD causes increased activity of the enzyme 11β-hydroxy-steroid dehydrogenase 1 (11β-HSD1), which converts cortisone (E) to cortisol (F), possibly contributing to the phenotype. However, congenital GHD may have different consequences. The aims of this work were to study the activity of the 11β-HSD1 by measuring F/E ratio and to correlate it with body composition parameters (assessed by DXA), and to assess visceral and subcutaneous fat distribution (by sonography) in a group of adults with isolated GHD (IGHD), due to the c.57+1G→A mutation in the GHRH receptor gene. We previously reported that these subjects have increased IS. We studied 23 IGHD adults (39.3±12 yrs, BMI=23.9±5.0 Kg/m2, % body fat 34.6±9.7, 52% female) and 21 age-matched controls (40.5±9.7 yrs, BMI=25.7±4.5 Kg/m2, % body fat 35.0±8.0%, 62% female).  Thickness of subcutaneous and visceral fat was measured by Koda’s method and corrected by height. Serum fasting morning (7-9 AM) cortisol and cortisone were measured by liquid chromatography/tanden mass spectrometry method. Waist/hip (W/H) ratio (0.98±0.06 vs. 0.89±0.07, p<0.0001), trunk fat (43.0±7.5% vs. 37.4±9.2%, p<0.01) and trunk/extremity fat (TR/EXT) ratio (1.05±0.15 vs. 0.89±0.18, p<0.001) were all higher in the IGHD subjects. Sonographic subcutaneous fat index was not different between two groups (1.39±0.73 vs. 1.29±0.60), but sonographic visceral fat index was higher in IGHD group (5.51±2.15 vs. 3.51±1.26, p < 0,001). Cortisol (16.4±6.5 vs. 11.80±4.6 µg/dl, p=0.014) and F/E ratio (6.78±2.57 vs. 5.21±1.67, p=0.027) were higher in IGHD. Correlations were found between W/H ratio and TR/EXT ratio (r=0.621, p<0.0001), thickness visceral fat (r=0.685, p<0.0001), and visceral fat index/subcutaneous index ratio (r=0.439, p=0.005), F (r=0.407, p=0.01) and F/E ratio (r= 0.351, p=0.029). The TR/EXT ratio correlated with visceral fat thickness (r=0.431, p=0.006) and visceral fat index/subcutaneous index ratio (r=0.379, p=0.017), and F (r=0.376, p=0.017). Mancova, using TR/EXT ratio, visceral fat index and F/E ratio as dependent variables and group as factor, and age, BMI SDS, W/H ratio, FFM (g), FM (g) as cofactors, revealed that age had a significant effect on visceral fat index (p= 0.009) and on F/E ratio (p=0.013). BMI SDS and W/H ratio have similar significant effect on TR/EXT ratio (p=0.007 and 0.009) and on F/E ratio (p=0.011, p=0.008). In conclusion, lifetime congenital untreated IGHD causes an increase in visceral adiposity with high F/E ratio. Despite this, insulin sensitivity is increased, suggesting that there is a threshold of GH secretion necessary for visceral adiposity to impair IS. Visceral obesity and increased 11β-HSD1 need a minimal GH secretion to translate into increased insulin resistance.

 

Nothing to Disclose: EGS, RS, TOF, CRPO, JAMS, FAP, AHOS, EVM, CCE, IASO, JAM, FJS, MHA

11273 9.0000 SAT-0681 A Increased Visceral Adiposity and Cortisol to Cortisone Ratio Do Not Result in Insulin Resistance in Adults with Lifetime Isolated GH Deficency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

Nicoleta C Olarescu*, Ansgar Heck, Kristin Godang and Jens Bollerslev
Oslo University Hospital, Oslo, Norway

 

Context:Recent data suggest that sex hormone-binding globulin (SHBG) is positively related to insulin sensitivity and has a strong invers correlation with liver lipids (1). Hyperinsulinemia, impaired glucose sensitivity, and overt diabetes mellitus are common features of active acromegaly and the improvement of insulin sensitivity after therapy in acromegaly depends, to some extent, on treatment modalities (2, 3).

We hypothesized that SHBG levels are related to disease activity and insulin resistance in acromegaly and SHBG changes after treatment will reflect the improvement of glucose metabolism in these patients.

Patients:Nighty eight adult patients with active acromegaly diagnosed from 1998 to 2013 at a tertiary referral center were evaluated before (42 women, 56 men, age 48.6 ± 12.9), and after (n = 58) different treatments (somatostatin analogues (SA) (n = 24) or/and transphenoidal surgery (TS) (n = 34)).

Outcome Measures:HOMA-IR was derived from fasting glucose and insulin using the HOMA2 computer model. Body composition (DXA), serum SHBG, adiponectin and leptin were measured. Univariate correlation analysis, partial correlations controlling for confounders and multiple linear regression models were used to assess the relations between SHBG circulating levels and disease activity, insulin resistance and body composition at baseline and after treatment.

Results:At baseline, SHBG was higher in women than in men (48 ± 30 vs. 29 ± 11 nmol/l, p <0.001). SHBG correlated negatively with age (r = -0.27, p = 0.009), BMI (r = -0.33, p = 0.001), IGF-I (r = -0.27, p = 0.009), ALAT (r = -0.42, p <0.001), insulin (r = -0.30, p = 0.005), HOMA-IR (r = -0.22, p = 0.042) and lean mass (limbs, trunk, total body (r < -0.40, p < 0.001 for all), but positively with adiponectin (r = 0.45, p < 0.001). After adjusting for age, gender, and hormonal treatment use (sex and/or thyroid hormones), all correlations were preserved excepting the correlations with lean mass and ALAT.

After treatment SHBG increased significantly (36 ± 26 vs. 44 ± 32 nmol/l, p <0.001) whereas insulin, glucose and HOMA-IR decreased. The change of SHBG (%) correlated negatively with the change of glucose (r = -0.47, p= 0.01), insulin (r = -0.36, p = 0.012), HOMA-IR (r = -0.39, p=0.006) and IGF-I (r = -0.49, p<0.001) and positively with the change of adiponectin (r = 0.37, p = 0.013). The increase of SHBG was best determined by the decrease of serum glucose and the increase of adiponectin (r2= 0.55, p < 0.001). IGF-I, glucose, insulin, HOMA-IR decreased and SHBG increased more in TS compared with SA group.

Conclusions: In a large cohort of patients with acromegaly, we present for the first time that SHBG levels correlate with disease activity and insulin resistance. Furthermore, we demonstrate that the increase of SHBG after treatment may represent a good biochemical marker for improvement of insulin sensitivity.

 

Nothing to Disclose: NCO, AH, KG, JB

16785 10.0000 SAT-0682 A The Relation of Sex Hormone-Binding Globulin with Insulin Resistance in Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

John D. Carmichael*1, Vivien Shelley Bonert1, Jan Frystyk2, James Mirocha3 and Shlomo Melmed1
1Cedars-Sinai Med Ctr, Los Angeles, CA, 2Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark, 3Cedars-Sinai Medical Center, Los Angeles, CA

 

Background: Acromegaly diagnosis is made by measuring serum IGF-I levels and the GH response to an oral glucose load (OGTT).  The OGTT has not been sufficiently validated to diagnose acromegaly in subjects with insulin resistance or type 2 diabetes mellitus (DM), and many clinicians are reluctant to perform OGTT in subjects with a high risk of hyperglycemia. Measurement of IGF-I is subject to false negative and positive results in subjects with diabetes mellitus as well as those with insulin resistance. A novel, alternative test for diagnosis in these subjects is required.

Methods: Prospective clinical trial comparing timed assessment of hormonal responses to injection of placebo, OGTT, and injection of rhIGF-I in three groups: acromegaly, type 2 DM, and healthy control subjects. Subjects were blinded to placebo and rhIGF-I injections. Primary endpoints included GH nadir, GH AUC, and delta GH from baseline.  Between group and between intervention comparisons were made for GH dynamic responses, factoring changes in IGF-I, IGF binding proteins, glucose, insulin and ghrelin. Groups and interventions were compared by non-parametric Kruskal-Wallis or Wilcoxon rank sum testing.

Inclusion Criteria: Male or female subjects 18 years or greater with active acromegaly (ACRO) and excess GH produced by a pituitary tumor, with elevated serum IGF-I and non-suppressed GH after OGTT. Subjects with type 2 DM (DM) had elevated fasting plasma glucose ≥126 mg/dl, or random glucose ≥200 mg/dl. Healthy controls (HC) were without significant medical history. Acromegaly subjects were non-diabetic and without treatment for acromegaly, with washout of medical therapy if needed prior to study entry. Subjects with DM withheld medical therapy for DM for 24h prior to study visits. All subjects were without hepatic or renal disease.

Results: Timed tests were performed with assessments at 0, 15, 30, 60, 90, 120, and 180 minutes in 28 subjects [ACRO: n=10 (5M/5F) DM: n=8 (4M/4F) HC: n=10 (5M/5F)]. Median AUC, GH nadir, and delta GH was significantly different between groups in response to IGF-I: [AUC: (ACRO: 1311.3; DM: 12.2; HC: 16.4; p<0.001) GH nadir: (ACRO: 6.11 ng/ml; DM: 0.009 ng/ml; HC: 0.013 ng/ml; p<0.001) delta GH: (ACRO: 1.37 ng/ml; DM: 0.039 ng/ml; HC: 0.010 ng/ml; p<0.001)] GH response to OGTT was similar to rhIGF-I injection: [AUC: (ACRO: 1454.7; DM: 19.9; HC: 34.5; p=0.003) GH nadir: (ACRO: 7.1 ng/ml; DM: 0.011 ng/ml; HC: 0.020 ng/ml; p=0.002) delta GH: (ACRO: 1.11 ng/ml; DM: 0.069 ng/ml; HC: 0.036 ng/ml; p=0.019 between group, all p values non-significant comparing OGTT to rhIGF-I within ACRO, DM, and HC groups). Hyperglycemia was routinely observed in all DM subjects after OGTT, but not after rhIGF-I. No subjects experienced hypoglycemia after rhIGF-I.

Conclusions: Injected rhIGF-I is an effective test to distinguish acromegaly from subjects with DM and healthy euglycemic controls requiring further validation.

 

Disclosure: JDC: Advisory Group Member, Genentech, Inc., Advisory Group Member, Pfizer, Inc., Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Ipsen. VSB: Advisory Group Member, Ipsen. SM: Ad Hoc Consultant, Novartis Pharmaceuticals, Ad Hoc Consultant, Genentech, Inc., Principal Investigator, Pfizer, Inc., Ad Hoc Consultant, Ipsen. Nothing to Disclose: JF, JM

14200 11.0000 SAT-0683 A Recombinant Human IGF-I Administration As an Alternative to Oral Glucose Tolerance Testing for Acromegaly Diagnosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

Sofiya Milman*1, Gil Atzmon1, Derek Huffman1, Junxiang Wan2, Jill P Crandall1, Pinchas Cohen2 and Nir Barzilai1
1Albert Einstein College of Medicine, Bronx, NY, 2University of Southern California, Los Angeles, CA

 

Attenuated growth hormone and insulin-like growth factor 1 (GH/IGF-1) signaling is associated with extended lifespan in several lower organisms. However, the effect of diminished GH/IGF-1 activity on survival in humans has not been confirmed. We tested the hypothesis that IGF-1 levels in nonagenarians (n=184), measured at study enrollment, predict the duration of their incremental survival. In the Kaplan-Meier analysis, females with IGF-1 levels below the median (≤96 ng/mL) had significantly longer survival compared to females with levels above the median, p<0.01. However, this survival advantage was not observed in males (p=0.83). On the other hand, in both males and females with a history of cancer, lower IGF-1 levels predicted longer survival (p<0.01). IGF-1 level remained a significant predictor of survival duration in linear regression models after multivariable adjustment in females (p=0.01) and individuals with a history of cancer (p<0.01). We showed for the first time that low IGF-1 levels predict life expectancy in exceptionally long-lived individuals.  

 

Nothing to Disclose: SM, GA, DH, JW, JPC, PC, NB

12318 12.0000 SAT-0684 A Low Insulin-like Growth Factor-1 Level Predicts Survival in Humans with Exceptional Longevity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

Nathalie Saad* and Gregory A Kline
University of Calgary, Calgary, AB, Canada

 

PREVALENCE OF GROWTH HORMONE DEFICIENCY IN PATIENTS WITH UNEXPLAINED CHRONIC FATIGUE AFTER UNDERGOING BONE MARROW TRANSPLANTION IN ADULTHOOD

Nathalie Saad, MD, FRCPC1 and Gregory Kline, MD, FRCPC1

(1) Department of Medicine, Division of Endocrinology and Metabolism, University of Calgary, AB, Canada

Background

Many patients who undergo bone marrow transplantation (BMT) in adulthood experience unexplained chronic fatigue afterwards. It is known that growth hormone deficiency (GHD) causes a clinical syndrome with decreased energy and vitality. The purpose of this study was to evaluate the prevalence of severe GHD within a sample of these patients using the insulin tolerance test (ITT) which is the gold standard to diagnose GHD. We also aimed to evaluate if a relationship exists between patients’ reported fatigue and peak serum growth hormone response. 

Methods

Patients aged 18-65 years old with a history of allogenic or autologous BMT in adulthood and in complete remission with chronic fatigue were assessed for this study. They received a full work-up for fatigue and those with unexplained chronic fatigue were eligible for this study.  At their testing day, patients filled out the Fatigue Severity Scale (FSS) questionnaire where a score of 4 or more indicates significant fatigue. Afterwards, the patients underwent an ITT and a peak serum growth hormone cut-point less than 3.0 ug/L was used for the diagnosis of severe adult GHD. The statistical method of simple linear regression was then used to analyze the data and the results were reported using the estimated coefficient of the linear regression.

Results

A total of 18 patients were tested in this study and the proportion with severe GHD within this sample was 50%. There was not a statistically significant linear relationship between fatigue score and peak serum growth hormone response. However, an outlier was present in the data which represented a patient with unexplained chronic fatigue upon enrolment which had resolved when evaluated at the testing day by the FSS score. Therefore, the data was also analyzed by excluding this outlier. These results showed that the proportion of severe GHD was 47%. Furthermore, there was a statistically significant moderately strong negative linear relationship between fatigue score and peak serum growth hormone response (b = -0.1699, p-value = 0.0083, r = -0.6173).

Conclusion

This study demonstrates that severe GHD was highly prevalent in this sample of patients with unexplained chronic fatigue who had undergone bone marrow transplantation in adulthood. Further studies are required to determine if severe GHD may be an underlying cause for chronic fatigue in this particular group of patients.

 

Nothing to Disclose: NS, GAK

13552 13.0000 SAT-0685 A Prevalence of Growth Hormone Deficiency in Patients with Unexplained Chronic Fatigue after Undergoing Bone Marrow Transplantion in Adulthood 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

Raffaella Radin*1, Leila Danesi1, Elena Cassinerio2, Laura Zanaboni2, Maria Domenica Cappellini2, Maurizio Poggi3, Chiara Ottaviani3, Vincenzo Toscano4, Marco Zavattaro5, Francesco Cavagnini6, Luca Persani7 and Massimo Scacchi8
1IRCCS, Istituto Auxologico Italiano, 2Cà Granda Foundation Ospedale Maggiore Policlinico, 3II Faculty of Medicine, Sapienza University of Rome, 4Sapienza, Università di Roma, Roma, Italy, 5Università del Piemonte Orientale “A. Avogadro”, 6Istituto Auxologico Italiano IRCCS, Neuroendocrinology Research Lab, Cusano Milanino, Italy, 7Univ of Milan/Dept Medical Sci, Milan, Italy, 8University of Milan, Milan, Italy

 

Introduction. The real prevalence of growth hormone deficiency (GHD) in thalassemic adults is still a matter of debate. We showed that in these patients the initial diagnosis of severe GHD by GHRH + arginine testing was not confirmed upon a second application of the same challenge in a relevant proportion of cases. These observations, together with others’ findings, suggest that a single test may not be sufficient for the correct diagnosis of GHD in adult thalassemia. Interestingly, a similar conclusion has been recently drawn for the diagnosis of GHD following traumatic brain injury. Therefore, we elected to assess the prevalence of severe GHD in adult thalassemia by two stimulation tests (GHRH + arginine and glucagon). Study design. Eighty adult thalassemic patients (38 men and 42, mean age 38.1 ± 7.4 years; BMI 20-25 kg/m2) underwent GHRH (1 μg/kg b.w. as an i.v. bolus) + arginine (0.5 g/kg b.w. as a 30 min i.v. infusion) testing. The patients classified as severely GH deficient (GH peaks lower than 9 μ/l) were subsequently tested with glucagon 1 mg i.m. (severe GHD defined by GH peaks lower than 3 μg/l). Results.  Fifteen out of 80 patients (18.75%) were classified as severely GH deficient by GHRH + arginine testing. Only 2 of these patients, however, displayed an insufficient GH response to acute glucagon administration. Thus, when using the combination of two tests, the prevalence of severe GHD in adult thalassemics dropped to 2.5%. Conclusion. When the diagnosis of GHD in adult thalassemic patients is established by two validated challenges, its prevalence appears to be definitely lower than previously reported with the use of a single test. In our opininon, in this clinical condition two tests are required for the diagnosis of GHD, in order to avoid inappropriate and expensive GH treatments.

 

Nothing to Disclose: RR, LD, EC, LZ, MDC, MP, CO, VT, MZ, FC, LP, MS

15711 14.0000 SAT-0686 A The Prevalence of Severe Growth Hormone Deficiency in Adult Thalassemic Patients, As Assessed By Two Different Stimulation Tests 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

Jakob Dal*1, Jens Otto Jørgensen1, Ansgar Heck2, Jens Bollerslev2, Marianne Andersen3, Lars Oestergaard Kristensen4, Ulla Feldt-Rasmussen5, Marianne C Klose6, Jan Frystyk7 and Peter Laurberg8
1Aarhus University Hospital, 2Oslo University Hospital, Oslo, Norway, 3Odense University Hospital, Denmark, 4Copenhagen Univ Hosp Herlev, Gentofte, Denmark, 5Rigshospitalet, 6National University Hospital, Rigshospitalet, Copenhagen, Denmark, 7Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark, 8Aalborg University Hospital, Aalborg, Denmark

 

Discordant values for GH and IGF-I are prevalent in acromegalic patients considered well controlled after somatostatin analog treatment if stringent cut-off values are applied: the time has come for a prospective study targeting normalization of either GH or IGF-I

Context: Discordant values of GH and IGF-I in patients with acromegaly are well recognized and clinically challenging. The significance and prevalence are uncertain and depend on assays and cut off levels. We have previously reported from a single center that patients well controlled on somatostatin analogs (SA), as judged by normalized IGF-I levels, exhibit significantly elevated nadir GH levels compared to surgically cured patients.

Objective: To characterize GH and IGF-I levels in acromegaly patients during SA treatment as compared to surgically cured patients using stringent criteria based on standardized assays and proper reference data.

Design and Setting: Serum samples obtained during an oral glucose load [1 h basal period + 2 h glucose load (75g)] were obtained from 58 patients considered well controlled on SA treatment from 6 different centers and 23 patients considered cured after surgery alone. All samples were analyzed in a single laboratory using novel monoclonal chemiluminescence immunoassay for GH and IGF-I (IDS-iSYS; Immunodiagnostic Systems), calibrated against International Standard 98/574 and 02/254, respectively. Cut-off levels for GH and IGF-I were based on reference data obtained under identical conditions from 55 healthy subjects.

Main Outcome: Mean±SE levels of GHnadir and IGF-I and prevalence of discordant values as function of treatment, age and gender.

Results: Mean±SE levels of GHnadir were significantly elevated among SA treated patients compared to surgically cured patients [0.69±0.08 vs. 0.36±0.06, P < 0.02], whereas there was no difference in IGF-I SDS levels [1.51±0.14 vs. 1.31±0,15, P=0.39]. The prevalence (%) of elevated values was 71 (SA) vs. 39 (surgery) [P< 0.01] and dominated by elevated GHnadir levels in the SA group. No significant difference was found in gender and age between subgroups.

Conclusions: 1) The prevalence of discordant values for GH and IGF-I in ‘well treated’ acromegalic patients is high when employing state of the art assays and stringent cut off levels, 2) Elevated GH levels in SA treated patients with normalized IGF-I levels is a frequent occurrence, 3) The clinical significance of these findings are best evaluated in a prospective study targeting treatment response to SA according to either GHnadir or IGF-I SDS.


 

Nothing to Disclose: JD, JOJ, AH, JB, MA, LOK, UF, MCK, JF, PL

13788 15.0000 SAT-0687 A Discordant Values for GH and IGF-I Are Prevalent in Acromegalic Patients Considered Well Controlled after Somatostatin Analog Treatment If Stringent Cut-off Values Are Applied: The Time Has Come for a Prospective Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

Maximilian Bielohuby*1, Sayyed Hamid Zarkesh-Esfahani2, Jenny Manolopoulou3, Mohaddesh Toghiany Khorasgani4, Zahra Sadat Aghili2, Ian Robert Wilkinson5, Richard J Ross6 and Martin Bidlingmaier7
1Medizinische Klinik und Poliklinik IV, Munich, Germany, 2Department of Biology, Faculty of Sciences, University of Isfahan, Isfahan, Iran, 3Immunodiagnostic Systems Ltd., Boldon, United Kingdom, 4Department of Immunology, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran, 5The University of Sheffield, Human Metabolism, Sheffield, United Kingdom, 6Univ of Sheffield, Sheffield, United Kingdom, 7Klinikum der Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany

 

Development of new growth hormone (GH) agonists and antagonists requires animal models for pre-clinical testing. Ideally, in such models effects of treatment can be monitored using the same pharmacodynamic (PD) markers later used in clinical practice. For GH, IGF-I is the most important PD marker. However, in intact rodents IGF-I shows no response to recombinant human GH (rhGH) administration, and there is little evidence for effects of GH antagonists except when administered at very high dose or expressed in transgenic mice. We therefore explored whether intact rabbits could be a better laboratory animal model to test GH agonists and antagonists by monitoring IGF-I.

Methods: As none of the commercially available IGF-I assays is validated for rabbit IGF-I, we tested precision, sensitivity, linearity, and recovery using the automated iSYS IGF-I assay (IDS, Boldon, UK) in rabbit serum. IGF-I was also measured in rabbits of different strains, age groups and sexes, and in rabbits (n=6-10/group) treated with rhGH (Norditropin, Novo Nordisk; 1mg/kg), GH antagonist (Somavert, Pfizer, 1mg/kg) or PBS (control).

Results: Precision (1.7-3.3%CV) and linearity (90.4-105.6%) of the assay were good in rabbit samples. Compared to recombinant human IGF-I, recovery was threefold lower for recombinant rabbit IGF-I. IGF-I was significantly affected by sex, age and genetic background. In contrast to rodents, rabbits displayed a significant rise in IGF-I 24h after a single rhGH injection (286±22 vs. 434±26ng/ml; p<0.01). GHA treatment lowered IGF-I from the fourth injection onwards (323±17 vs. 212±29ng/ml; p<0.01).

We conclude that the IDS-iSYS IGF-I assay can also be used to measure IGF-I in rabbits. Similar to rodents, rabbits display variations in IGF-I depending on sex, age and genetic background. Unlike in rodents, the IGF-I response to rhGH or GHA treatment in rabbits, which taxonomically belong to the order of lagomorpha, mimics the pharmacodynamics seen in humans, thus suggesting rabbits as a suitable noval laboratory animal model to test GH agonists and antagonists.

 

Disclosure: JM: Employee, Immunodiagnostic systems. RJR: Other activities, please specify:, Asterion Ltd, Director, Diurnal Ltd. Nothing to Disclose: MB, SHZ, MTK, ZSA, IRW, MB

14917 16.0000 SAT-0688 A Rabbits Are a Suitable Animal Model for the Pre-Clinical Development of Growth Hormone Agonists and Antagonists 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

Nadège C van Varsseveld*, Christa Christina van Bunderen, Evelien Sohl, HC Comijs, B Penninx, Paul Lips and Madeleine L. Drent
VU University Medical Center, Amsterdam, Netherlands

 

Background:Serum IGF-1 concentration decreases, while the prevalence of depression increases with advancing age. Although basic research indicates a link between low IGF-1 levels and depression in adults, this has not yet been explored in a large prospective study in humans. This study investigates whether lower IGF-1 levels are associated with prevalent depression and with an increased risk of developing depression during 10 years of follow-up in a large sample of older individuals.

Methods:The study included 1275 participants, aged ≥ 65 years, from the Longitudinal Aging Study Amsterdam (LASA), an ongoing, multidisciplinary cohort study in Dutch community-dwelling older persons. Serum IGF-1 concentration (nmol/l) was determined. Depression was assessed using the Center for Epidemiological Studies-Depression Scale (CES-D) and the Diagnostic Interview Schedule (DIS), resulting in three categories: major depression (MDD), minor depression (CES-D score ≥ 16 but DIS negative for MDD) and clinically relevant depressive symptoms (CES-D score ≥16, i.e. ‘major plus minor depression’). Potentially confounding factors (e.g. demographics, life style, somatic health) were adjusted for.

Results:At baseline, 161 participants (12.6%) had minor depression, while 32 (2.5%) had MDD. Unadjusted, compared with IGF-1 concentrations in the highest tertile, IGF-1 concentrations in the lowest tertile were associated with prevalent MDD (Odds ratio [OR] = 2.77, 95% confidence interval [CI] = 1.15 – 6.65). This association did not remain statistically significant after adjustment for relevant confounders (p = 0.08). In contrast, IGF-1 concentrations in the middle tertile were associated with decreased odds of clinically relevant symptoms in men (OR = 0.44, 95% CI = 0.21 – 0.92). During follow-up, 223 (24.8%) persons developed clinically relevant depressive symptoms, including 22 (2.4%) participants who developed MDD. Women with lower IGF-1 concentrations tended to have a lower risk of developing MDD (Hazard ratio [HR] = 0.22, 95% CI = 0.05 – 1.02). Significant associations between IGF-1 concentration and the risk of developing clinically relevant depressive symptoms were not observed.

Conclusions: In this study, low-normal IGF-1 concentration was associated with prevalent MDD in older persons, although this association was no longer statistically significant after adjustment. Prospectively, we did not find an increased risk of developing MDD or clinically relevant depressive symptoms in elderly with a low-normal IG-1 concentration.

 

Nothing to Disclose: NCV, CCV, ES, HC, BP, PL, MLD

13645 17.0000 SAT-0689 A The Association of Serum Insulin-like Growth Factor-1 with Depression in Community-Dwelling Older Individuals 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

Giulia Brigante*1, Chiara Diazzi1, Giulia Ferrannini1, Sara De Vincentis1, Giovanni Guaraldi2, Anna Ansaloni1, Manuela Simoni1 and Vincenzo Rochira1
1Chair and Unit of Endocrinology & Metabolism, Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy, 2Metabolic Clinic, Infectious and Tropical Disease Unit, Modena, Italy

 

INTRODUCTION: Growth Hormone Deficiency (GHD) is frequent in patients with Human Immunodeficiency Virus 1 (HIV-1), undergoing Highly Active Antiretroviral Therapy. GHD seems to depend on HIV-related lipodystrophy and to be less frequent in women. AIM OF THE STUDY: To investigate the association of gender, body composition and GH/Insulin-like Growth Factor-1 (IGF-1) axis, and to clarify whether GHD in HIV-infected patients is functional or a clinical entity. METHODS: We compared 47 HIV-infected patients prospectively enrolled, with 36 hypopituitary subjects retrospectively selected reviewing record charts. We evaluated basal serum GH, IGF-1, GH peak and area under the curve (AUC) after standard GH Releasing Hormone+Arginine test; BMI, waist and hip circumference and body composition by dual-energy X-ray absorptiometry (DEXA). Data were analyzed by nonparametric Mann-Whitney test. RESULTS: HIV-infected patients had higher GH peak, AUC, and IGF-1 (p<0.0001). BMI (p=0.003), total (p<0.0001) and trunk fat mass (p=0.0003) were higher in hypopituitary patients; waist to hip ratio (WHR) was higher in HIV-infected patients (p<0.0001). GH peak was lower in hypopituitary men than women (p=0.001). Men showed higher WHR (p=0.0082), total (p=0.0002) and trunk lean mass (p=0.0008), while women had higher total (p=0.0017) and trunk fat mass (p=0.0176). No gender differences were found in HIV-infected patients. GH peak, AUC, and IGF-1 were higher (p<0.0001) in HIV-infected than hypopituitary men. No difference was found in women. CONCLUSIONS: GHD seems to be worse in hypopituitary patients, suggesting that primary pituitary disease affects GH/IGF-1 axis more than HIV-1. Moreover, fat distribution more than fat mass per se seems to affect GH/IGF-1 axis in HIV-infected patients, since they have lower BMI but higher WHR. Furthermore, men seem to have a worse deficit than women, suggesting a possible role of gender in GH/IGF-1 status. These differences could help distinguishing functional from clinical GHD in HIV-infected subjects, and better targeting treatment strategies.

 

Nothing to Disclose: GB, CD, GF, SD, GG, AA, MS, VR

14734 18.0000 SAT-0690 A GH Deficiency in HIV-Infected Patients Compared to Hypopituitary Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

Naoki Edo*, Megumi Miyakawa, Hisanori Suzuki, Akira Takeshita, Yasuhiro Takeuchi and Shozo Yamada
Toranomon Hosp, Tokyo, Japan

 

<Background an Aim>Multinodular goiter is detected more frequently in acromegaly than in general population. On the other hand, the incidence of thyroid cancer is considered to be a relatively rare event in this condition (Endocr Rev 25(1): 102-152, 2004). In this study, we evaluated the findings of thyroid ultrasonography in our cases of acromegaly.

<Method> We analyzed, retrospectively, the findings of 100 cases of acromegaly that received pituitary operation and thyroid ultrasonography at our hospital between 2010 and 2013. Thyroid ultrasonography was performed regardless of the existence of symptom or not.

<Results> We excluded six cases with TSHoma, five cases with Hashimoto’s disease, one case with autonomously functioning thyroid nodule, one case with Basedow’s disease, one case with follicular adenoma, one case with adrenal Cushing’s disease and one case with postoperative painless thyroiditis. We also excluded six cases of re-operation, two cases with years of preoperative dopamine agonist therapy. Of remaining 76 cases, there were three cases (4.0%) with thyroid papillary carcinoma (Papi-Ca). Ultrasonography findings of the cases with Papi-Ca did not differ from those with no underlying disease. In terms of laboratory findings, thyroglobulin (Tg) of the three cases with Papi-Ca was significantly higher than the other 73 cases. However, there were no difference in growth hormone (GH), insulin-like growth factor, the ratio of nadir GH and pre GH in octreotide loading test and thyroid function. Besides, we divided the 73 cases without Papi-Ca into four groups according to thyroid size and existence of cyst or nodule (group1 (n=10): normal, group2 (n=15): cysts or nodules without enlargement, group3 (n=16): enlargement without nodules nor cysts and group4 (n=32): nodular goiter). Between the group without thyroid enlargement (group1+2) and the group with thyroid enlargement (group3+4), nadir GH level after 75g oral glucose tolerance (75gOGTT) test was significantly higher in the enlargement group (p <0.05).

<Discussion> Our result here showed that diffuse enlargement was found in 21.9% and that nodules and/or cysts in 64.4%. And thyroid Papi-Ca was found in 0.92% of all patients (n=326) of acromegaly operated at our hospital between 2010 and 2013. Furthermore, GH excess may contribute to the enlargement of thyroid. It is reported that thyroid Papi-Ca is found in 0.49% of normal subjects by ultrasonography in Japan (Journal of the Japan Thyroid Association 1(2): 109-113, 2010). Although our subjects were not consecutive, it was indicated that the prevalence of thyroid Papi-Ca is not rare in patients of acromegaly. Thus our result indicated that the screening of thyroid by ultrasonography is importance in patients of acromegaly.

 

Nothing to Disclose: NE, MM, HS, AT, YT, SY

16776 19.0000 SAT-0691 A Evaluation of Thyroid Ultrasonographic Findings in Cases of Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

Maria Izabel Chiamolera*1, Claudia M.A.F. Ferrer2, Jose de Sa1, Milena Gurgel Teles3, Rosa Paula Mello Biscolla4 and Jose Gilberto Vieira5
1Fleury Medicina e Saude, São Paulo, Brazil, 2Grupo Fleury, São Paulo, Brazil, 3Fleury Medicina e Saúde, São Paulo, Brazil, 4UNIFESP, São Paulo, Brazil, 5Fleury Medicina e Saude, Sao Paulo, Brazil

 

Measurement of circulating IGF-I is an important biochemical tool to evaluate growth hormone (GH) secretion and action. Circulating IGF-I varies greatly with age, pubertal status, gender and also presents ethnic-specific variation. Consequently, specific reference intervals should be determined for each population. IGF-I assays are difficult to standardize, mainly due to the presence of high concentration of binding proteins. With the availability of an IGF-I chemiluminescence immunoassay (LIAISON IGF-I, DiaSorin) calibrated against the WHO new International Reference Reagent (IRR) 02/254 we analyzed results from 1.229 sequential IGF-I measurements from subjects under 21 years-old and 17.260 from subjects over 21 years-old. Patients in use of any medication that could affect IGF-I concentration such as GH, GnRH analogues and somatostatin analogues, and/or with IGFBP3 levels out of the reference range were excluded. For individuals under 21 years-old we adjusted age based on bone-age exam (± 2 SD). From the initial population, 241 subjects were excluded from the group under 21-years-old and 1033 from the group over 21 years-old. The two groups were also divided based on age ranges and gender. Statistical analyses were performed using EP Evaluator® software. The results showed higher values in upper and lower limits of the reference range when comparing to the manufacture manual values. In the group under 21 years-old values were from 5 up to 52% higher, in both genders. For the older group the upper reference limits were up to 38% higher with less difference in the lower limits. These new reference limits should increase the accuracy of clinical diagnosis, growth monitoring and follow up on treatment of both GH deficiency and acromegaly, and reinforce the need of local normal range evaluation.

 

Nothing to Disclose: MIC, CMAFF, JDS, MGT, RPMB, JGV

16301 20.0000 SAT-0692 A Establishing Reference Interval for IGF-I in a Brazilian Population for Liaison® Assay 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

Paolo Beck-Peccoz1, Charlotte Höybye2, Robert D Murray3, Suat Simsek4, Alfonso Leal-Cerro5, Francesco Minuto6, Markus Zabransky*7 and Gunter Stalla8
1University of Milan, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy, 2Karolinska University Hospital, Stockholm, Sweden, 3Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom, 4VU University Medical Center, Amsterdam, Netherlands, 5Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío Seville, Sevilla, Spain, 6Univ of Genova, Genova, Italy, 7Sandoz Int'l GmbH, Holzkirchen, Germany, 8Max-Planck Institute for Psychiatry, Munich, Germany

 

Introduction: PATRO Adults is an ongoing, international, open, longitudinal, non-interventional study of the long-term safety and efficacy of Omnitrope® (Sandoz), a recombinant human growth hormone (rhGH). This study will provide additional data on the long-term safety of rhGH in adult patients with severe GH deficiency (GHD). Here we present safety data from an interim analysis.

Methods: Eligible patients are male or female adults who are receiving treatment with Omnitrope® and who have provided informed consent. Patients treated with another rhGH before starting Omnitrope® therapy are eligible for inclusion. The primary objective of the study is to assess the safety and efficacy of Omnitrope® in adults treated in routine clinical practice. Particular emphasis is placed on the risk of glucose intolerance or diabetes and normalisation of IGF-1 levels. 

Results: To date (November 2013), 600 patients have been enrolled in the study; 309 (52%) have received previous GH treatment. Mean (SD) age of enrolled patients is 50.4 (15.3) years, and mean (SD) body mass index is 29.5 (6.4) kg/m2. So far, 438 adverse events (AEs) have been reported in 157 (26%) patients, with 47 (10.7%, in 29 [5%] patients) regarded as serious. Thirty-nine AEs (8.9%) in 25 (4.2%) patients were suspected as drug-related. These included 10 nervous system disorders, 8 general disorders/administration site conditions, 7 musculoskeletal/connective tissue disorders and 3 investigations (increased IGF levels). One serious AE (dyspnoea) in 1 (0.2%) patient was suspected as drug-related. Of the 50 patients who have discontinued treatment, 10 (1.6%) did so due to an AE.

Conclusions: On the basis of this interim analysis, Omnitrope® treatment in adults with GHD is well tolerated in a real-life clinical practice setting, both in rhGH-naïve and previously treated patients. The ongoing PATRO Adults study will provide important data on the diabetogenic potential and overall safety of long-term GH treatment in this population

 

Disclosure: PB: Committee Member, Sandoz. CH: Committee Member, Sandoz. RDM: Committee Member, Sandoz. SS: Committee Member, Sandoz. FM: Research Funding, Sandoz. MZ: Employee, Sandoz. GS: Committee Member, Sandoz. Nothing to Disclose: AL

12473 21.0000 SAT-0693 A The Patro Adults Study of Omnitrope® for the Treatment of Adult Patients with Growth Hormone Deficiency: Latest Results 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0673-0693 4821 1:00:00 PM GHRH, GH & IGF Biology & Signaling Poster

Fabiola Costenaro*1, Gabriela dos Santos Costa1, Ticiana Costa Rodrigues2 and Mauro Antonio Czepielewski3
1PPG Endocrinologia, Porto Alegre, Brazil, 2Hospital de Clínicas de Porto Alegre, UFRGS, Porto Alegre, Brazil, 3Faculdade de Medicina UFRGS, Porto Alegre, Brazil

 

In ACTH-dependent Cushing’s syndrome (CS) 10-20% of patients have unknown or occult ACTH tumor (OAT) despite extensive investigation and long term follow-up. We describe 8 patients with this situation attended in a tertiary neuroendocrinology center. They presented severe CS, hypokalemia and high levels of plasma ACTH. They underwent to DDAVP test and  an inferior petrosal sinus sampling (IPSS), when the magnetic resonance image were negative. If the diagnostic procedures were suggestive of Cushing´s Disease (CD), a transsphenoidal surgery (TS) was done. When they were suggestive of ACTH ectopic syndrome (AES) cervical, chest and abdominal tomography (TC) were performed, tumor markers like cromogranin A and calcitonin where measured when available, and images as octreoscan, endoscopy, mammography and bone scintigraphy were performed in different cases aiming to find the source of AES. Eight white patients (five males) were diagnosed with CS at mean age of 36.6yr old (range33-63yr). Definitive diagnosis about 4.5yr later (range1-9yr) and 3 patients kept with OAT until the last evaluation. Unsuccessful TS was performed in five patients. Bilateral adrenalectomy (BA) was performed in all patients, in two severe cases it was an urgency condition. The follow up was 7,0 yrs (range:0,1-14 yr). The detailed description and the final observation of the patients are: 1°- 38 y, female,  bilateral breast carcinoma with neuroendocrine differentiation  treated with RT + chemotherapy (QT) + Octreotide and 14yr of follow-up. 2°- 39 y, male,  CD under control after adrenalectomy with 8 yr of follow up. 3°- 41y, male, with OAT tumor with SMRI and IPSS negative for CD who died in the immediate postoperative time of an urgency adrenalectomy. 4º- 37 y, male, bone metastasis of neuroendocrine tumor without unknown primary ACTH tumor submitted to QT and RT with follow up of 8 yrs who died from respiratory insufficiency 5 yr after etiologic diagnosis. 5°- 33 y, female, became pregnant during investigation and after that a thymic carcinoid was diagnosed. Tumor was resected twice and she undergone to RT. In follow up for 8yr. 6º- 63 y, female, OAT with negative investigation for CD and AES. Submitted to BA and is well in follow up for 6 years. 7°- 36 y, male, OAT with negative investigation for CD and AES. BA was performed and follow up for 9 yr.  8º - 30 y, male, presented colestasis secondary to hepatic invasion (from neuroendocrine tumor) by a pancreatic primary tumor tree yr after CS. Died in the same yr of etiologic diagnosis. Conclusions: In the patients described - 1. bilateral adrenalectomy was very important for to improve the morbidity/mortality of CS and for the long survival of the patients; 2.We observe high prevalence of carcinoid tumors (outside of the lungs); 3. Even using a rigorous approach, the final diagnosis of ACTH-Dependent Cushing´s syndrome is a challenge and only established after long term follow up.

 

Nothing to Disclose: FC, GDSC, TCR, MAC

16510 1.0000 SAT-0658 A Diagnostic Challenge in 8 Patients with Unknown or Occult ACTH-Dependent Cushing Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0658-0672 4825 1:00:00 PM Cushing's Disease and Syndrome: Diagnosis and Managment Poster

Laure Cazabat Sage*1, Martin Dupuy2, Anne Boulin2, Michèle Bernier3, Bertrand Baussart2, Luc Foubert2, Marie-Laure Raffin-Sanson4, Philippe Caron5, Jerome Yves Bertherat6 and Stephan Gaillard2
1Hôpital Ambroise Paré. Assistance publique hôpitaux de Paris, Boulogne Billancourt, France, 2Hôpital Foch, Suresnes, France, 3Foch hospital, Suresnes, 4Assistance publique hôpitaux de Paris, Hôpital Ambroise Paré, Service d'Endocrinologie, France, 5CHU Larrey, TOULOUSE, France, 6APHP - Hôpital Cochin Université Paris Descartes, Paris, France

 

Objective: Silent corticotroph adenomas (SCAs) present as non-functional pituitary tumours in routine preoperative evaluation. The objective of this study was to evaluate the diagnostic accuracy of MRI T2-weighted sequences for detecting the corticotroph subtype preoperatively.

Design: The preoperative T2-weighted MRI sequences were retrospectively evaluated in patients with SCA and two control groups: clinically manifest corticotroph macroadenomas (CSMs) and case-matched, non-functional gonadotroph macroadenomas (NFGMs). All were selected from a registry of 1,096 patients in whom transsphenoidal surgery was performed in the same tertiary reference centre. T2-weighted MRI sequences were independently classified by one senior endocrinologist and one senior radiologist who were blinded to the clinical and histological features. 

Patients: 17 patients with SCA, 14 with CSM and 60 with NFGM

Measurements: Pituitary MRI including T2-weighted sequences. Two aspects were retained: multiple microcysts (MMs) and the absence of microcysts. Hormonal data included plasma prolactin, IGF-1, testosterone or oestradiol, LH, FT4, TSH, morning plasma cortisol and an ACTH-stimulation test, when available.

Results: MMs were present in 76% (13/17) of SCAs, 21% (3/14) of CSMs and 5% (3/60) of NFGMs. The presence of MMs in clinically non-functioning macroadenomas had a sensitivity of 76% and a specificity of 95% for predicting SCA.

Conclusion: The presence of MMs in T2-weighted MRI is a good diagnostic tool to suggest the corticotroph subtype in an apparently non-functional pituitary tumour.

 

Nothing to Disclose: LC, MD, AB, MB, BB, LF, MLR, PC, JYB, SG

16174 2.0000 SAT-0659 A Silent, but Not Unseen: Multi-Microcystic Aspect on T2-Weighted MRI in Silent Corticotroph Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0658-0672 4825 1:00:00 PM Cushing's Disease and Syndrome: Diagnosis and Managment Poster

Carlos André Minanni1, Ana Luiza de Almeida Cardoso1, Edoarda Vasco de Albuquerque Albuquerque1, Ludmilla Malveira Lima Lopes1, Andrea Glezer2, Elisa Del Rosario Ugarte Verduguez3, José Gallucci-Neto4, Wagner Farid Gattaz5, Berenice B Mendonca6, Marcello D Bronstein7, Marcio Carlos Machado8 and Maria Candida Barisson Villares Fragoso*9
1University of São Paulo Medical School, Division of Endocrinology and Metabolism, Brazil, 2Division of Endocrinology and Metabolism, Hospital das Clínicas, University of Sao Paulo Medical School., Sao Paulo, Brazil,, Sao Paulo, Brazil, 3FACULDADE DE MEDICINA DA UNIVERSIDADE DE SAO PAULO, BRAZIL, 4INSTITUTO DE PSIQUIATRIA. FACULDADE DE MEDICINA DA UNIVERSIDADE DE SAO PAULO, BRAZIL, 52INSTITUTO DE PSIQUIATRIA. FACULDADE DE MEDICINA DA UNIVERSIDADE DE SAO PAULO, BRAZIL, 6Univ Sao Paulo Fac Med, Sao Paulo, Brazil, 7University of São Paulo Medical School, São Paulo, Brazil, 8Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 9University of Sao Paulo, Sao Paulo-SP, Brazil

 

Background Factitious Cushing’s syndrome (FCS) is extremely rare condition and its diagnosis is challenging mainly due to a cross reactivity with synthetic glucocorticoids in immunoassays.  Münchhausen’s syndrome (MS) is a chronic factitious disorder with intentional production of signals/symptoms to assume the sick role without external incentive. Case report a 26-year-old woman (nurse) was evaluated for amenorrhea-galactorrhea due to macroprolactinoma. Transsphenoidal surgery was performed. Immunohistochemistry showed a diffuse staining for PRL and ACTH. Four years later, she presented overt CS with an intermittent hypercortisolism. She denied exogenous glucocorticoids. Urinary total cortisol was elevated (UTC, 12.200 mcg/24 h - nv 50- 310 μg/24 h), and also midnight salivary cortisol (0.2- 2.3 μg/dL – nv < 0.12 μg/dL) with normal morning serum cortisol (Fs). ACTH was normal (14 pg/ml - nl 10 - 46 pg/ml). DHEA-S was low (208 ng/ml-nl 988 - 3400 ng/ml). DDAVP test was inconclusive for CS. Abdominal CT showed normal adrenal glands and pituitary MRI exhibited remnant tumor tissue. To further investigate HPLC/MS revealed a low UFC level at 6 mcg/24 h (nl 3 - 43 μg/24 h) and a suppressed morning Fs (1.6 mcg/dL – nl 7-25 μg/dL). Psychiatric evaluation did not identify any mental disorder. She developed high levels of triglycerides, amylase, and lipase. A new CT revealed atrophic adrenal glands and pancreatitis. High levels of serum prednisone and prednisolone (7.4μg/dL and 97μg/dL, respectively-nv <0.1μg/dL) were observed by HPLC. Unfortunately the patient had a fatal outcome. Discussion We reported a case of factitious CS with a fatal outcome. The diagnosis of FCS represents a challenge to the physician and includes as diferencial diagnosis cyclic CS. There are few cases in literature of FCS, one of them with also fatal outcome. The synthetic glucocorticoids in the blood and urine by HPLC were confirmed in all 18 cases. Besides, 9 patients with a psychiatric evaluation presented psychiatric disorder. Overt CS was present in 8 cases. Conclusion We described a patient with MS and fatal outcome. Factitious CS is an important diagnosis to consider in patients with apparent hypercortisolism. The main point is the discordant hormonal data among UTC, serum F, ACTH and DHEAS associated to atrophic adrenal glands. HPLC analysis of blood and urine steroids is the definitive test for the diagnosis of FCS and should be performed when there is clinical suspicious of glucocorticoid mishandling.

 

Nothing to Disclose: CAM, ALDAC, EVDAA, LMLL, AG, EDRUV, JG, WFG, BBM, MDB, MCM, MCBVF

13174 3.0000 SAT-0660 A Fatal Factitious Cushing's Syndrome (Münchhausen's syndrome) in a Patient with a Prolactinoma and Silent Corticotrophinoma: Case Report and Literature Review 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0658-0672 4825 1:00:00 PM Cushing's Disease and Syndrome: Diagnosis and Managment Poster

Jyothsna Palla*1 and Ambika Amblee2
1Rush University Medical Center and John H. Stroger Hospital of Cook County, Chicago, IL, 2J Stroger Hosp-Cook County, Chicago, IL

 

Background:

Inferior petrosal sinus sampling (IPSS) is the gold-standard test to differentiate between a pituitary and an ectopic source in patients with ACTH-dependent Cushing’s syndrome (CS) but it does not reliably lateralize the corticotropin-secreting adenomas (CA). Recently prolactin (PRL) measurement during IPSS has been shown to help lateralize the adenoma within the pituitary gland. We present a case where we used PRL measurement during IPSS to accurately lateralize a CA. 

Case:

A 27 year old woman presented to the emergency room with seizures and was found to have significant hypokalemia. Clinical features were typical of CS. Initial tests were consistent with ACTH-dependent CS: random cortisol of 48.3 µg/dl (n 4.46 - 22.70 ug/dl), 24hr urinary cortisol level was elevated at 161.9 µg/dl (n<50 µg/dl /24hr), post 1 mg dexamethasone suppression test (DST) cortisol was 34.62 mcg/dl, ACTH levels of 148 pg/ml (n 6-50 pg/ml) and post 8 mg DST  cortisol levels of  8.62 mcg/dl. MRI Sella showed a well circumscribed oval lesion 7.8 x 9.4 x 7 mm3 in size in the right pituitary gland. IPSS was planned.

Bilateral inferior petrosal sinuses (IPS) were catheterized successfully. Sampling was done from right IPS (rt.), left IPS(lt.) and peripheral vein (P)  at 1  and  5 minutes before and  at 3,5 ,10 and 15 minutes after CRH administration.  Samples were sent for both ACTH and PRL assay concomitantly.

The IPS/P ACTH ratio was > 2 (2000 lt. /97 P) in the basal state and > 3 (6910 lt. /151 P) post - CRH confirming a pituitary source. The IPS/P PRL ratios were ≥ 1.8 on both sides confirming accurate IPS catheter placement bilaterally. 

The maximum ACTH inter-sinus gradient (AISG) of ≥ 1.4 is used to lateralize source of ACTH within the pituitary gland. The AISG calculated for our patient lateralized to the left (lt.) side (5630 lt. /1440 rt. = 3.9). The PRL-adjusted ACTH level was calculated by dividing the IPS ACTH level by a concomitantly drawn ipsilateral IPS PRL level. The maximum PRL-adjusted AISG calculated showed lateralization to the rt. side (52.45 rt. /19.91lt. = 2.63). 

Based on the above results, the patient underwent transphenoidal resection of the right pituitary adenoma and pathology confirmed a CA .Laboratory testing done 8 weeks after surgery showed resolution of hypercortisolemia: 8 Am cortisol of 3.39 µg/dl, ACTH 49 pg/ml and 24hr urinary free cortisol level of 1.7µg/dl. Patient was started on hydrocortisone replacement due to symptoms of adrenal insufficiency. 

Conclusions: 

- PRL measurement along with the ACTH levels has been recommended to improve the accuracy of IPSS to distinguish pituitary-dependent Cushing’s disease from ectopic ACTH syndrome as its IPS to P ratio confirms accurate IPS catheter placement. 

- PRL-adjusted AISG also accurately lateralizes CA, as in our patient, directing the surgeon to perform the appropriate targeted surgery and prevent   complications from extensive pituitary surgery.

 

Nothing to Disclose: JP, AA

15417 4.0000 SAT-0661 A Accurately Lateralizing a Corticotropin-Secreting Adenoma By Adding Prolactin Measurement during Inferior Petrosal Sinus Sampling in a Patient with Cushing's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0658-0672 4825 1:00:00 PM Cushing's Disease and Syndrome: Diagnosis and Managment Poster

Susan Yuditskaya*1, Susmeeta T. Sharma2 and Lynnette K. Nieman1
1National Institutes of Health, Bethesda, MD, 2Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD

 

Background:Many cases of ACTH-producing ectopic pituitary adenomas have been reported. However, few have involved the clivus, and none have shown biochemical features suggestive of ectopic ACTH syndrome (EAS). Breast carcinoma has been reported to rarely cause EAS and can metastasize to the pituitary gland.

Case: A 47 year-old woman was treated for a 4 cm invasive ductal breast carcinoma characterized by angiolymphatic invasion, negative estrogen & progesterone receptor (ER, PR) status, and metastasis to 1 sentinel node.  She presented 3 years later with profound proximal muscle weakness and truncal weight gain (58 kg) that had progressed rapidly, even while undergoing chemotherapy. Medical evaluation revealed type 2 diabetes mellitus, hypertension, hypokalemia, hyperpigmentation, and multiple stigmata of Cushing’s syndrome (CS). Biochemical testing showed urine free cortisol (UFC) of 1000-4400 mcg/day [Normal (N) 3.5-45], plasma ACTH of 130-260 pg/mL (N <46), serum cortisol of 30-75 mcg/dL (N 5-25), and loss of diurnal variation.  CRH stimulation test and 8 mg dexamethasone suppression test both suggested EAS. Pituitary MRI revealed a suspicious area of inhomogeneity involving bony structures surrounding the posterior pituitary, extending from the dorsum sella, through the clivus, to the posterior sphenoid bone. The pituitary gland enhanced homogenously, and the stalk was midline. Inferior petrosal sinus sampling showed a clear central-to-peripheral gradient (peak post-CRH petrosal-to-peripheral ACTH ratio=14). During transsphenoidal surgery, soft amorphous tumor tissue was found inferior to the sella within the upper clivus and at the posterior sphenoid bone, with significant bony destruction. No tumor was seen within the pituitary gland. Whether the tumor was contiguous with the posterior pituitary could not be definitively determined. Pathology confirmed an ACTH-staining neuroendocrine neoplasm, negative for p53, ER, PR, and epithelial markers. Proliferative index was low (MIB1<3%). Post-operatively, cortisol (12-20 mcg/dl), ACTH (46-91 pg/ml) and UFC (90-200 mcg/day) decreased, but hypercortisolemia persisted. The patient remains on ketoconazole (800 mg/d) for medical control, while awaiting the effects of radiation therapy.

Conclusion: We report an unusual case of ACTH-dependent CS secondary to an invasive, retrosellar probable ectopic pituitary adenoma, with many biochemical features of ectopic ACTH syndrome. Though less likely, hormonally active breast cancer metastasis to the sella cannot be excluded given the absence of ER and PR in the original carcinoma.

 

Nothing to Disclose: SY, STS, LKN

15127 5.0000 SAT-0662 A Ectopic Corticotropinoma or ACTH-Secreting Breast Cancer Metastasis? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0658-0672 4825 1:00:00 PM Cushing's Disease and Syndrome: Diagnosis and Managment Poster

Hans Kumar Ghayee*1, Elizabeth E King1, Richard J. Auchus2, Ibrahim A Hashim1, Xian-Jin Xie1 and Alana Christie1
1University of Texas Southwestern Medical Center, Dallas, TX, 2University of Michigan, Ann Arbor, MI

 

Introduction: The diagnosis of Cushing’s syndrome presents challenges, even in experienced hands.  While establishing hypercortisolism may sometimes be straightforward, determining the source can be difficult, particularly when trying to distinguish pituitary from ectopic sources of ACTH.  A variety of tests have been introduced to aid in this dilemma to include the high dose dexamethasone suppression test, the CRH stimulation test, and bilateral inferior petrosal sinus sampling (IPSS).  Most agree that IPSS should be considered the gold standard, but it is difficult to perform and requires a high level of expertise.  As such, IPSS is not widely available.  Therefore we evaluated the adjunctive role of plasma ACTH in differentiating between pituitary and ectopic disease. 

Design: This was a retrospective analysis of a small cohort of patients evaluated and treated at UT Southwestern Medical Center between 2006 and 2013.

Methods: 10 patients charts were reviewed, and laboratory and pathologic results were included in our analysis.  6 patients were diagnosed as having pituitary Cushing’s, proven by ACTH positive pathological specimens.  4 patients were diagnosed with ectopic sources of ACTH, based on a combination of clinical features and/or IPSS results. 

Results: The 6 patients with pituitary Cushing’s had a mean ACTH value of 76 pg/mL (49-101).  In contrast, the ectopic ACTH patients’ mean ACTH was 246 pg/mL (139-405).

Conclusion: ACTH is a helpful adjunct when trying to distinguish between ectopic and pituitary sources of Cushing’s syndrome.

 

Nothing to Disclose: HKG, EEK, RJA, IAH, XJX, AC

16556 6.0000 SAT-0663 A Value of ACTH Distinguishing Pituitary Versus Ectopic Causes of Cushing's Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0658-0672 4825 1:00:00 PM Cushing's Disease and Syndrome: Diagnosis and Managment Poster

Rafael Loch Batista*1, Ana Elisa Evangelista Alcantara2, Clarissa Groberio Borba3, Nina de Castro Musolino4, Valter Angelo Sperling Cescato5, Vanielle Carvalho Machado3 and Malebranche Beraldo Carneiro da Cunha Neto6
1Hospital das Clinicas, FMUSP, Brazil, 2Hospital Das Clinicas, Pinheiros, SP, Brazil, 3Hospital das Clínicas, FMUSP, 4Hospital das Clínicas, FMUSP, São Paulo, Brazil, 5Instituto de Psiquiatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 6Neuroendocrine Unit, Division of Neurosurgery; University of São Paulo Medical School, Sao Paulo, SP, Brazil

 

Background: Pituitary carcinomas are very rare (0.1-0.2% of pituitary tumors). The diagnosis requires evidence of metastatic disease even in cases with local aggressive tumor.

Case Report: A 55 y female patient was diagnosed with Cushing Disease due to a macroadenoma and operated twice by transsphenoidal surgery (TS), elsewhere, in 2008 and 2009, without clinical improvement. She seek our Hospital with persistent symptoms of CD. Laboratory tests revealed hypokalemia (K=2.4mEq/L-NR:3.5-5), very high serum levels of ACTH (793pg/mL,NR<46) and cortisol (Fs) (52mcg/dL, NR:5-25), abnormal high levels of midnight salivary F (msF) (6.45mcg/dl, NR:< 0.13) and urinary 24h F (Fu) (>1100mcg/24h, NR:50-310). Magnetic resonance imaging (MRI) showed a invasive sellar mass to left cavernous sinus. She presented symptoms of pituitary apoplexy confirmed by another TS, performed at our Hospital in the end of 2009. Hystopathology (HE) diagnosed a pituitary adenoma positive to ACTH and Ki67 (<5%) and negative to P53 by immunohistochemistry (IMH). She presented a complete clinical and laboratorial hypercortisolism remission, actually she followed with clinical and laboratorial adrenal insufficiency requiring glucocorticoid replacement for two years, although ACTH remained slightly elevated (60pg/mL). In 2012, she returned with recurrence of clinical and laboratorial hypercortisolism rapidly progressive (ACTH:670pg/mL, Fu:822mcg/24h, msF:0.74mcg/dL). The sellar MRI depicted a tumor extension to the clivus. Ketoconazole was started and after a new partial tumor resection by TS she underwent radiotherapy. The HE and IMH showed a pituitary adenoma positive for ACTH and high reactivity to Ki67 (10-15 %) and P53. She returned 3 mo after showing a rapid clinical worsening: hyperpigmentation, severe myopaty, intense low back pain, dyspnea and generalized edema, hypertension and diabetes mellitus. Laboratory showed hypokalemia (2 mEq/L), very high ACTH (4087pg/ml), Fs (71mg/dL) and Fu (2348mcg/24h) levels. Imaging exams depicted sellar tumor growth, and suggest hepatic and lumbar spine metastasis. Liver biopsy showed neuroendocrine pattern with IMH positive for ACTH and Ki-67 (5-10 %). She was reassigned to oncology group but dying one month later due lung infection. Clinical lesson: Macroadenoma in Cushing's disease is uncommon. In this patient the rapid worsening when recurred associated with increased of Ki67 could be an indicative of tumor behavior transformation to carcinoma.

 

Nothing to Disclose: RLB, AEEA, CGB, NDCM, VASC, VCM, MBCDCN

16675 7.0000 SAT-0664 A Evolution of Cushing's Disease By Pituitary Carcinoma: A Diagnostic Challenge 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0658-0672 4825 1:00:00 PM Cushing's Disease and Syndrome: Diagnosis and Managment Poster

Min Wong*1, Harley Smyth2, Kalman Kovacs3, Eva Horvath4, Brenda Birkin5, Ian Sue-Chue-Lam6 and Donald W Killinger7
1Endocrinology, Toronto, ON, Canada, 2Trillium Health Centre, 3St Michael's Hosp U of Toronto, Toronto, ON, Canada, 4St. Michael's Hospital, U of Toronto, 5William Osler Hlth Ctr, Mississauga, ON, Canada, 6Queen's University, 7Western University, Etobicoke, ON, Canada

 

Silent Corticotroph Adenoma (Subtype-1) with Episodic Cushing’s Disease


Min M Wong, Harley S. Smyth, Kalman Kovacs, Eva Horvath, Brenda L.Birkin, Ian Sue-Chue-Lam, Donald W. Killinger


Department of Neurosurgery, Trillium Health Center, Mississauga, ON, Department of Laboratory Medicine, Division of Pathology, St. Michael’s Hospital, Toronto, ON, Division of Endocrinology, Etobicoke General Hospital, Etobicoke, ON

Background Silent corticotroph adenomas (SCA) present as non-functioning adenomas. They represent between 1 and 6% of surgically removed pituitary tumors. Episodic Cushing’s syndrome is recognized with increasing frequency and its true incidence is unknown.

Case study A 66-year-old female presented with a pituitary macroadenoma and no clinical features suggestive of a secretory adenoma. At surgery, the tumor could only be partially resected because of extension into the left cavernous sinus. Tumor tissue stained for ACTH and stained positively for Ki-67 in approximately 6%, topoisomerase-2-alpha in 4 %, P-27 in 90 %, Cox-2 in 10%, P-53 in 1% of tumor cells. Electron microscopy revealed a corticotroph adenoma (subtype-1) with Crooke’s hyaline changes in the majority of tumor cells.  Postoperatively the patient did well for 6 years with UFC levels under 200 nmol/24 hrs (50-195), serum cortisol levels between 200 -500 nmol/ l (300-660) but with elevated ACTH levels between 60 and 80 pmol/l (<10).

In April of 2012 she developed a severe headache, marked peripheral edema, nausea and vomiting and ptosis of her left eyelid. Her potassium was 2.2 mmol/l, UFC  >4000 nmol/24 hrs, serum cortisol 1061 nmol/l and ACTH 115 pmol/l. She was treated with ketoconazole up to 400 mg 3 times daily. Her condition stabilized and resolved by Oct 2012. She remained well on no medication for 9 months. In June 2013 she had a similar episode and was treated with ketoconazole and cabergoline up to 1 mg daily. The problem stabilized and resolved by October 2013. She has continued off medication with normal UFCs and serum cortisol levels and ACTH levels between 60 and 80 pmol/l. Whether the ketoconazole and the cabergoline were factors in either remission or whether these occurred spontaneously is uncertain. Her magnetic resonance scans have shown a modest but significant increase in the size of this adenoma.

Conclusion This case shows that a silent corticotroph adenoma can be a cause of episodic Cushing’s. The ACTH secreted by SCAs may be immunoreactive but biologically defective. It is commonly elevated when cortisol levels are normal. Therefore, measurement of ACTH in apparently non-functioning macroadenomas may detect SCAs prior to surgery. Episodic Cushing's can only be detected by long term follow up and the factors underlying these episodes are unknown.

 

Nothing to Disclose: MW, HS, KK, EH, BB, IS, DWK

12734 8.0000 SAT-0665 A Silent Corticotroph Adenoma ( Subtype-1) with Episodic Cushing's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0658-0672 4825 1:00:00 PM Cushing's Disease and Syndrome: Diagnosis and Managment Poster

Castro Bali*1, Soumya Chandra Reddy1, Murat Gokden2, Fred Faas2 and Monica Agarwal3
1University of Arkansas for Medical Sciences and Central Arkansas Veteran Health System, Little Rock, AR, 2University of Arkansas for Medical Sciences, Little Rock, AR, 3Univ of Arkansas for Med Sciences, Little Rock, AR

 

Introduction We report a case of Cyclic Cushing's syndrome (CS) related to ACTH producing Crooke's cell adenoma (CCA) complicated by pituitary apoplexy. Case 38 year old man with Pituitary macroadenoma and panhypopituitarism was hospitalized for profound generalized edema and hypokalemic alkalosis. The physical examination was remarkable for purplish striae in the flank region and anasarca. The ACTH was 277 (7-69 pg/ml) and morning cortisol was 41.4 (5-23 mcg/dl). MRI Sella showed pituitary macroadenoma without any mass effect. Two years earlier, he had presented to ER with severe headache, polyuria and blurred vision. MRI sella showed a hemorrhage in the 2.2 cm pituitary macroadenoma. Pituitary axes evaluation revealed ACTH 426 (5-46 pg/ml), evening Cortisol 37.8 (3-16 mcg/dl), Free T4 0.47 (0.61-1.12 ng/dl), TSH 0.49 (0.34-5.6mIU/L), Testosterone 82.6 (400-1080ng/dl), LH 2.5 (1-8mIU/mL), FSH 3.8 (1-19 mIU/mL), IGF-1 was 232 (109-284 ng/mL), Prolactin 23.8 (0-20 ng/mL), Serum osmolality 305 (278-298 mOsm/kg), Urine osmolality 341 (300-900 mOsm/kg) and Sodium 144 (136-145 mmol/L). The symptoms resolved without neurosurgical intervention. He was started on levothyroxine and testosterone. He was reevaluated 2 months later and the tests showed ACTH 72 (10-80 pg/ml), morning cortisol 14 (5-23 mcg/dl), evening cortisol 8 (3-16 mcg/dl) and 24 hr urinary cortisol 78 (< 45 mcg/24 hrs). On this admission ACTH was persistently elevated and the diurnal variation of cortisol was blunted. The 24 hr urinary cortisol was markedly elevated at 4270 mcg/24 hrs. The high dose dexamethasone suppression test showed insuppressible cortisol of 38.2 mcg/dl. Octreotide scan and PET scan did not reveal any evidence of ectopic source of ACTH. He had transsphenoidal resection of the macroadenoma. The pathology showed ACTH positive pituitary adenoma with significant subpopulation of adenoma cells showing Crooke's cell features. Six weeks after the surgery, the ACTH was 18 pg/ml. He was initiated on low dose dexamethasone post-surgery with plan to reassess the HPA axis in future. Conclusion Cyclic CS is a rare disorder characterized by intermittent hypercortisolism. Cushing's disease is the most common cause of Cyclic CS (1). Crooke's hyaline change is the cytoplasmic accumulation of keratins in ACTH-producing cells and is thought to occur as a result of cortisol negative feedback. These changes are usually seen in the normal pituitary corticotrophs surrounding ACTH producing adenoma but on rare occasions these changes also occur in the ACTH producing adenoma leading to Crooke's cell adenoma (2). Although most CCAs are macroadenomas but clinically silent and microadenomas have also been reported. CCAs are rare, innately aggressive, invasive macroadenomas which can secrete higher level of ACTH. CCAs needs close follow up due to unfavorable prognosis and high risk of recurrence (3).

 

Nothing to Disclose: CB, SCR, MG, FF, MA

15464 9.0000 SAT-0666 A Crooke's Cell Adenoma Causing Cyclic Cushing's Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0658-0672 4825 1:00:00 PM Cushing's Disease and Syndrome: Diagnosis and Managment Poster

Tiffany Burns*1, Deepthi Rao2, Mamata Ojha3 and Saleh Aldasouqi4
1Michigan State University, 2Michigan State University, Okemos, MI, 3Michigan State University, East Lansing, MI, 4Michigan State University, East lansing, MI

 

Background:

Cushing disease is most commonly caused by benign pituitary microadenomas that may cause subtle symptoms and are difficult to detect. We report a case of  rapidly progressive Cushing Disease due to Crooke Cell Adenoma.

Case:

An 18 year old female with no history of exogenous steroid use presented with new onset hypertension, edema and severe headache. She also reported unintentional weight gain of 60 pounds over approximately one year, menstrual irregularities and anxiety. She sought medial attention multiple times and was given anti hypertensive medications. She was admitted to the hospital due to uncontrolled hypertension. On exam the patient had classic cushingoid features; truncal obesity, purple striae, buffalo hump, and moon facies. All the screening tests were indicative of Cushings. Cortisol was elevated on dexamethasone suppression test and ACTH was also elevated. Subsequently, MRI showed 1.3 x 2.0 x 1.4 cm complex cystic pituitary mass. Patient underwent transsphenoidal resection of the tumor. Pathologic report was strongly positive for pancytokeratin indicating a Crooke Adenoma variant of the ACTH secreting adenoma. Now four months later the patient is doing well and has had significant clinical improvement.

Discussion:

This case represents an unusual cause of Cushing Disease attributed to the rare Crooke macroadenoma. The rapid progression made the clinical diagnosis easy but the clinicopathologic features of this tumor variant are not well defined in the literature.

 

Nothing to Disclose: TB, DR, MO, SA

17044 10.0000 SAT-0667 A Rapidly Progressive Cushing Disease Due to Crooke Adenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0658-0672 4825 1:00:00 PM Cushing's Disease and Syndrome: Diagnosis and Managment Poster

Azusa Yamato*1, Akira Takeshita1, Hisanori Suzuki1, Megumi Miyakawa1, Noriaki Fukuhara1, Kentaro Horiguchi2, Hiroshi Nishioka1, Shozo Yamada1 and Yasuhiro Takeuchi1
1Toranomon Hospital, Tokyo, Japan, 2Chiba University Medical School, Chiba, Japan

 

Background: We have experienced postoperative transient hypercortisolism despite of successful transsphenoidal surgery (TSS) in some patients with Cushing’s disease (CD) who receive preoperative cortisol suppression therapy with metyrapone (adrenal-blocking drug).

Objective: The aim of this study is to clarify the influence of preoperative adrenal-blocking therapy on assessing early postoperative endocrinological results in patients with CD.

Design, Setting and Patients: We reviewed the medical records of 67 patients who underwent TSS for CD between January 2011 and March 2013 at Toranomon Hospital, Tokyo. Among them, we selected 59 patients (50 females, 9 males; range 21-81 years old) whose tumors were totally removed, judged from operative findings and postoperative MRI. The 59 patients were classified into two groups; group M including 18 patients with preoperative metyrapone treatment and group N including the remaining 41 patients without preoperative metyrapone treatment. We defined an early postoperative (short-term) remission criterion as morning cortisol < 2 mg/dL one week after TSS and a long-term remission criterion as a need of hydrocortisone replacement therapy or normal cortisol levels with improvement of physical manifestation of CD 6 months after TSS.

Results: Seven of 18 patients in group M and 30 of 41 patients in group N met the short-term remission criterion. Short-term remission rate was significantly lower in group M (38.9%) than in group N (73.2%) (p=0.01). We could follow up 56 out of 59 patients at the time of 6 months after TSS (17 patients of group M and 39 patients of group N). Fifteen of 17 patients in group M and 35 of 39 patients in group N met the long-term remission criterion (88.2% vs 89.7%) (p=0.60). In the patients of group M, dose of metyrapone (250 to 2500mg / day, median 1000 mg / day) and duration of preoperative medication (one to 10 months, median two months) had no correlation with long-term remission rate. Meeting the criterion of short-term remission predicted long-term remission accurately in 78.0% of subjects in group N but only 44.4% in group M (p=0.001).

Conclusion: Long-term surgical remission rate of CD had no relevance to preoperative use of metyrapone in the cases of apparently successful TSS. When the patients with CD have been treated by metyrapone before surgery, more than half of cases did not meet the short-term remission criterion, although they became to remission at 6 months after surgery. Therefore, it is concluded that we must be very careful when we assess the surgical failure immediately after surgery or predict long-term surgical outcome by early postoperative endocrine data in patients with preoperative metyrapone treatment.

 

Nothing to Disclose: AY, AT, HS, MM, NF, KH, HN, SY, YT

13722 11.0000 SAT-0668 A The Influence of Preoperative Use of Metyrapone (adrenal-blocking drug) on Assessing Early Postoperative Results in Patients with Cushing's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0658-0672 4825 1:00:00 PM Cushing's Disease and Syndrome: Diagnosis and Managment Poster

Soamsiri Niwattisaiwong*1, John Suh2, Robert J Weil1 and Amir H Hamrahian1
1Cleveland Clinic Foundation, Cleveland, OH, 2Cleveland Clinic, Cleveland, OH

 

Background: Radiotherapy (RT) is commonly used to treat Cushing disease (CD) when pituitary surgery has failed. Clinically significant hypercortisolism during pituitary irradiation for CD is rare.

 Clinical case: A 29-year-old man presented with visual field defect from pituitary macroadenoma (34 x 32 x 20 mm) compressing the optic apparatus. The patient had no significant clinical manifestations of CD other than weight gain. Initial biochemical evaluation of pituitary function was unremarkable. The patient was not evaluated for CD due to paucity of symptoms, and the presence of mass effect requiring surgical intervention. The pituitary tumor was subtotally removed by transsphenoidal surgery and stained only with antibodies to ACTH. A second transsphenoidal surgery was attempted. However, the tumor was substantially fibrotic and harder to resect. Due to the proximity of a component of residual tumor to the optic nerve, RT to a dose of 50.4 Gy in 28 fractions was used. Urine free cortisol (UFC) and plasma ACTH prior to the RT were 44.7 µg/24 hr (< 60 µg) and 109 pg/mL (8-42 pg/mL), respectively. After 7 fractions of RT over 2 weeks, the patient developed ankle edema, hypertension, and hypokalemia (K 2.8 meq/L) with markedly elevated UFC 9203 µg/24 hr and high plasma ACTH 139 pg/mL. Four weeks after the initiation of RT, UFC decreased to 94.3 µg/24 hr and normalized (10.2 µg/24 hr) by the end of RT. A month later, the patient had a non-detectable 24-hr UFC and required hydrocortisone therapy. His adrenal function slowly recovered and hydrocortisone was discontinued in 3 months. The patient remains in remission with normal ACTH and UFC 7 years after the RT.

 Clinical lesson: RT may induce acute ACTH release from ACTH-producing macroadenomas and lead to transient, severe hypercortisolism. We are aware of only one previous case report that has described similar clinical presentation following RT in a patient with a large ACTH-producing macroadenoma (1). Acute tumor cell death may play a role in the ACTH release, although tumor cell death usually occurs late and more slowly after RT. Other possible mechanisms include ACTH release in response to radiation-induced local inflammation and ACTH leakage following radiation-induced cell membrane damage. Since the majority of patients with CD have microadenoma, the amount of ACTH release during RT might be very minimal or persist too transiently to result in significant hypercortisolism. With large tumors, this phenomenon may be more common than previously suspected. This unusual but clinically significant adverse effect may suggest close observation and biochemical monitoring in patients with large corticotroph adenomas during RT.

 

Nothing to Disclose: SN, JS, RJW, AHH

11320 12.0000 SAT-0669 A Significant Hypercortisolism during Fractionated Radiotherapy in a Patient with a Large Corticotroph Macroadenoma: A Rare Side Effect of Radiotherapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0658-0672 4825 1:00:00 PM Cushing's Disease and Syndrome: Diagnosis and Managment Poster

Jorien Werumeus Buning*1, Pauline Brummelman1, Janneke Koerts2, Robin PF Dullaart3, Gerrit van den Berg1, Melanie M. van der Klauw1, Oliver M. Tucha2, Bruce H.R. Wolffenbuttel1 and André P. van Beek1
1University Medical Center Groningen, Groningen, Netherlands, 2University of Groningen, Groningen, Netherlands, 3University of Groningen, University Medical Center Groningen, Groningen, Netherlands

 

Background

A wide variety in hydrocortisone substitution dose-regimens are considered physiological for patients with secondary adrenal insufficiency. However, it is likely that cognition is negatively influenced by higher cortisol exposure to the brain. So far, no studies have been performed to assess the effects of treatment regimens administered for a substantial period of time with a low physiological hydrocortisone dose in comparison to a high physiological hydrocortisone dose on cognition.

Methods

This randomized, double blind cross-over study included 47 patients (mean(SD) age, 51(14) years, range 19-73) with secondary adrenal insufficiency. Patients were randomized to either group 1 (n=22), who first received a low dose during 10 weeks followed by a high dose for another 10 weeks, or group 2 (n=25), who first received a high dose followed by a low dose. All patients received a thrice-daily weight adjusted dose, with a total daily dose of 0.2-0.3 mg/kg body weight in the low dose condition and a total daily dose of 0.4-0.6 mg/kg body weight in the high dose condition. Cognitive performance of patients was measured at baseline and after each treatment period. A battery of 11 standardized cognitive tests which resulted in 37 test scores covering 4 cognitive domains (memory, attention, executive functioning and social cognition) was used.

Results

Serum cortisol levels in the high dose condition were significantly higher compared to the serum cortisol levels in the low dose condition for both study periods. No differences in cognitive performance was found between the two dose regimens, except for short term memory (15 Words Test, p = 0.028,  Z-score high dose (SD) = -0.03 (1.03), Z-score low dose (SD) = 0.35 (1.01), d = 0.38) and variability of reaction time in the phasic alertness task (Test of Attentional Performance, p = 0.015, Z-score high dose (SD) = -0.42 (0.79), Z-score low dose (SD) = -0.14 (0.82), d= 0.35).

Conclusion

Overall, no major negative influence on memory, attention, executive functioning and social cognition was observed after 10 weeks of treatment with a higher physiological dose of hydrocortisone in patients with secondary adrenal insufficiency when compared to a lower dose. However, minor effects of high doses of hydrocortisone on aspects of attention and short-term memory are present.

 

Nothing to Disclose: JW, PB, JK, RPD, GV, MMV, OMT, BHRW, APV

15839 13.0000 SAT-0670 A The Effects of Glucocorticoid Treatment on Cognition in Patients with Secondary Adrenal Insufficiency – Results from a RCT 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0658-0672 4825 1:00:00 PM Cushing's Disease and Syndrome: Diagnosis and Managment Poster

Elizabeth E King1 and Simone M Howell*2
1UT Southwestern Medical Center, Dallas, TX, 2Corcept Therapeutics, Dallas, TX

 

INTRODUCTION: Mifepristone (MIFE), a glucocorticoid receptor (GR) antagonist indicated for Cushing's syndrome, does not bind to the mineralocorticoid receptor (MR). Compensatory increases in cortisol can overwhelm 11b-HSD2 activity which can exacerbate hypokalemia, edema, and hypertension (HTN) due to activation of the MR by excess cortisol.  This case highlights 4yrs of data following therapy with MIFE in a 53 y/o woman (PT) with Cushing's disease (CD).  Specific areas of interest include treatment of HTN, potassium (K+) response, tumor recurrence, mood, and quality of life (QoL).

CASE: CD was diagnosed in 1996 and initially treated with transphenoidal surgery which had to be repeated two years later. The disease persisted, and medical therapy utilizing cabergoline and ketoconazole was ineffective.  PT enrolled in SEISMIC, a 24 week open-label MIFE study, and was followed on trial for 2 yrs on the long-term extension study. PT continued on MIFE upon FDA approval.

PT's MIFE dose was escalated from 300mg to 900mg and later stabilized at 600mg based on clinical symptoms, glucose, blood pressure (BP), and K+ blood levels. After 24 weeks on MIFE, amlodipine 5mg QD was added to losartan/HCTZ 100-12.5mg QD for BP.  BP has remained normal with no additional increases in medication burden after 4 years. 

K+ decline began after 4 weeks of starting MIFE and K+ supplementation was initiated.  Two systemic illnesses associated with concomitant K+ of 2.5mEq/L led to temporary high dose K+ supplementation of 20mEq TID.  At year 3, spironolactone 50mg BID was added, and K+ supplements were weaned entirely. K+ has remained in the normal range since. 

MRI shows stability throughout the course of MIFE TX with no tumor growth.  BMI has gone from 28 to 25.6 and waist circumference from 100cm to 83cm. The pre MIFE baseline BECK DEPRESSION INVENTORY (BDI-II) score indicated mild depression and anxiety.   After 4 years of MIFE TX, BDI-II scores show no depression or anxiety and normal test scores as compared to healthy individuals. CushingQoL testing scores have improved 56% over baseline.

CONCLUSION: This case illustrates 4 yrs of TX efficacy with MIFE in CD. Concomitant TX with spironolactone can effectively control resultant hypertension and hypokalemia. Importantly, serial MRI demonstrates stable tumor in the pituitary. Improvement was seen in BMI, waist circumference, mood, anxiety, and all test parameters of QoL over the 4 yrs of TX with MIFE.

 

Disclosure: SMH: Employee, Corcept. Nothing to Disclose: EEK

14338 14.0000 SAT-0671 A Clinical Management in a Female with Persistent Cushing's Disease Treated with Mifepristone for Four Years 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0658-0672 4825 1:00:00 PM Cushing's Disease and Syndrome: Diagnosis and Managment Poster

Francesca Lugli*1, Donato Iacovazzo1, Serena Piacentini1, Antonio Bianchi2, Antonella Giampietro2, Francesco Doglietto3, Mario Balducci2, Libero Lauriola1, Giulio Maira2, Alfredo Pontecorvi2 and Laura De Marinis1
1Università Cattolica del Sacro Cuore, Rome, Italy, 2Catholic University, Rome, Italy, 3University of Brescia, Brescia, Italy

 

Background: there are several findings in the literature about the efficacy of temozolomide (TMZ) treatment in aggressive pituitary adenomas and carcinomas.

Clinical case: we describe the case of a female patient, now 79 yrs old, who came to our attention in 2004, affected by a non functioning pituitary macroadenoma, that was surgically partially removed. The histology report showed positive immunostaining for ACTH, GH and PRL, with a Ki-67 less than 1%. The following MRI showed  residual disease causing recurrent episodes of ophthalmoplegia, but, at that time, a second surgery was not considered as the patient had been diagnosed with a prothrombin gene mutation. In 2011 the patient was enrolled in a clinical trial and treated with pasireotide LAR, aiming to control further growth of the lesion. However, during the following months, a severe ACTH-dependent hypercortisolism manifested, together with a further growth of the pituitary tumour. Treatment with pasireotide was withdrawn and the patient underwent a new surgical partial resection (histology: positive immunostaining for ACTH and Ki-67 around 5%). After surgery, severe hypercortisolism persisted, despite medical treatment with ketoconazole first, and then mitotane. The pituitary tumour showed further regrowth in a few months.

Considering the severe Cushing’s disease and the aggressiveness of the tumour, the patient was submitted, in October 2012, to conventional radiotherapy (3000 cGy in 10 days) associated with TMZ (75 mg/m2/die), that has been subsequently continued at the dosage of 150 mg/m2 for five days every month. The methylation status of MGMT promoter had been evaluated with evidence of a 10% methylation rate. The patient is tolerating well the treatment with TMZ without major side effects. In the following months an important clinical and biochemical response was appreciated with the onset of secondary hypoadrenalism (January 2014: cortisol 26 ng/ml, NV: 60-220; ACTH 11 pg/ml, NV: 10-55) and a significant shrinkage of the pituitary adenoma.

Conclusion: TMZ is a valid option in the treatment of aggressive pituitary adenomas, inducing tumour shrinkage and control of hormone hypersecretion.

 

Nothing to Disclose: FL, DI, SP, AB, AG, FD, MB, LL, GM, AP, LD

16695 15.0000 SAT-0672 A Temozolomide: A Useful Treatment for an Aggressive ACTH Secreting Pituitary Adenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0658-0672 4825 1:00:00 PM Cushing's Disease and Syndrome: Diagnosis and Managment Poster

Kurt A Mossberg*1, Charles R Gilkison2, William J. Durham3, Melinda Sheffield-Moore4, Dennis J Zgaljardic5, Brent Masel5 and Randall J Urban1
1Univ of TX Med Branch, Galveston, TX, 2Univ of TX Medcl Branch, Galveston, TX, 3University of Texas Medical Branch at Galveston, Galveston, TX, 4University of Texas Medical Branch, Galveston, TX, 5Transitional Learning Center, Galveston, TX

 

Background and Purpose: Growth hormone (GH) deficiency is known to occur in approximately 20% of individuals who suffer from a moderate to severe traumatic brain injury (TBI). Our objective was to assess the effects of GH replacement on aerobic capacity in individuals who sustained a TBI as adults.

Subjects: Ten individuals who sustained a TBI at least 12 months prior to study enrollment were identified as GH deficient by glucagon stimulation testing (maximum GH response less than 8ng/mL).

Procedures: Subjects had peak cardiorespiratory capacity including pulmonary ventilation, oxygen consumption and carbon dioxide production determined by an automated metabolic cart during a graded treadmill exercise test. Heart rate was monitored by ECG. Initial walking speed was adjusted in the first 2 minutes of the test to accommodate for TBI induced gait impairments. Speed was then held constant while incline was increased 2% each minute until exhaustion. Tests were performed at baseline and after 12 months. After baseline testing, subjects injected active drug subcutaneously daily for 1 year.

Data Analysis: Paired samples t-tests were performed with Bonferroni correction for multiple comparisons.  All analyses were carried out at α < 0.05.

Results: Peak O2 consumption, peak oxygen pulse (estimate of cardiac stroke volume) and peak ventilation all significantly increased (p<0.05). Submaximal ventilatory equivalents (VEq) for carbon dioxide (VEq/VCO2) and oxygen VEq/VO2) showed the greatest differences between baseline and 12 months.

Discussion and Conclusion: The observed changes suggest that GH replacement has a positive impact on cardiorespiratory fitness in survivors of TBI.  The VEq is an estimate of efficiency of breathing and may play a role in the subjective complaints of fatigue observed in patients recovering from TBI.  All changes observed are consistent with subjective comments by most subjects that they were more active and better able to participate with family and work.

 

Nothing to Disclose: KAM, CRG, WJD, MS, DJZ, BM, RJU

14872 1.0000 SAT-0715 A Improved Aerobic Capacity after Growth Hormone Replacement in Growth Hormone Deficient Patients Recovering from Traumatic Brain Injury 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Ana Paula Meireles de Melo*1, Daniela Espindola Antunes2, Angelica Amorim Amato3, Sergio Alberto Cunha Vencio4, Silvia Leda Franca Moura de Paula5 and Cecília Pacheco Elias1
1University of Brasilia, 2Federal University of Goias, 3University of Brasilia, Brasilia, Brazil, 4Institute in Pharmaceutical Sciences, Goiania, Brazil, 5Federal University of Goias, Goiania, Brazil

 

Glucocorticoid hypersecretion has been suggested to be a possible link between insulin resistance and the features of the metabolic syndrome (1) in type 2 diabetes (T2D). In accordance, many T2D patients show abnormal cortisol suppression with dexamethasone when investigated for hypercortisolism (2). It is not clear whether there is hyperactivity of the hypothalamic pituitary-adrenal (HPA) axis in T2D and, if so, what are the factors underlying it. The aim of the present study is to investigate the HPA axis in patients with T2D and correlate parameters of HPA activity with glicemic control and markers of metabolic syndrome. We have performed an observational study on 22 T2D patients (4 males and 18 females);  serum matinal cortisol and post-dexamethasone (0,5, 1 and 2 mg) levels, ACTH and late salivary cortisol, glycemic control, HOMA-IR, body mass index (BMI), waist circumference (WC), blood pressure, triglycerides, total cholesterol, LDL and HDL cholesterol levels were mesured. Mean age was 56.9 (± 10.9) years. Mean cortisol and ACTH levels at 8am were 13.9(± 4.4) mcg/dl and 22.8(± 13.7) pg/mL, respectively. Salivary cortisol levels were increased in 50% of the patients, mean were 0,47 µg\dl (±,58). A considerable proportion of patients failed to suppress cortisol secretion (values > 1,8mcg\dl) after 0,5 mg (22,7%;p=0,549), 1 mg (18,0%;p=0,236) and 2 mg (13,6%;p=0,871) on dexamethasone tests. Among the eleven patients with increased salivary cortisol levels, 4 patients (18,18%) failed to suppress cortisol secretion after 0,5mg and 1 mg dexamethasone tests, and 3  patients (13,63%) also failed to suppress cortisol secretion after 2mg. No correlation was found between the measured variables (age, gender, BMI, WC, fasting glucose, A1C, total cholesterol, LDL, HDL and triglycerides) and hyperactivity of the HPA axis, as indicated by logistic regression analysis. Studies have suggested that obese patients with DM2 are at risk  for subclinical Cushing´s Syndrome (CS), with prevalence ranging from 2 to 3%, greater than in the general population. These studies also found a prevalence of false positives results after 1mg dexamethasone suppression test ranging from 5,4% to 15% (3). Our preliminary results  suggest that HPA axis activity is increased in patients with T2D, in accordance with previously reported data (1), however we did not conclude investigation for adrenal incidentaloma/subclinical CS. These findings add further weight to the hypothesis that abnormalities in cortisol action may be a factor that links insulin resistance, hypertension, glucose intolerance, and obesity (4).

 

Nothing to Disclose: APMDM, DEA, AAA, SACV, SLFMD, CPE

16646 2.0000 SAT-0716 A Alterations of the Hypothalamic-Pituitary-Adrenal Axis in Patients with Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Daojun Mo1, Maria Fleseriu2, Rong Qi3, Christopher J Child*4 and Dana Sue Hardin3
1Eli Lilly and Co, Indianapolis, IN, 2Oregon Health & Science University, Portland, OR, 3Eli Lilly and Company, Indianapolis, IN, 4ELI LILLY AND CO WINDLESHAM, Surrey, United Kingdom

 

Reduced Fracture Risk in Adult Patients on Growth Hormone Replacement for Growth Hormone Deficiency:  An Analysis of the Hypopituitary Control and Complications Study (HypoCCS)

Author(s): Daojun Mo1, Maria Fleseriu2, Rong Qi1, Christopher Jeremy Child3, Dana Sue Hardin1

Institutions:

1Eli Lilly and Company, Lilly Research Laboratories, Indianapolis, IN, United States; 2Northwest Pituitary Center, Departments of Medicine and Neurological Surgery, Oregon Health & Science University, Portland, OR,  United States,  3Eli Lilly and Company, Lilly Research Laboratories, Windlesham, United Kingdom;

Context: There are no controlled studies on effects of long-term growth hormone (GH) replacement on fracture risk in adult patients with GH deficiency (GHD).

Objective: We assessed the GH treatment effect on fracture risk in the international Hypopituitary Control and Complications Study (HypoCCS) surveillance database.

Design and Participants:  Fracture incidence rates were summarized for 9641 patients with GHD (8374 were GH treated and 1267 untreated) over a follow-up period of 4.6 ± 3.8 years (mean ± SD). The GH treatment effect on fracture risk was evaluated by Cox proportional hazard (PH) modeling.

Results:   GH treated patients had a lower fracture incidence rate than untreated patients [11.9 vs. 19.1 per 1,000 person years].   GH therapy was significantly protective against fracture (hazard ratio [HR] 0.688, P=0.003] using PH modeling that adjusted for risk factors including preexisting osteoporosis (PO) (HR 1.728, P<0.001), age > 60 years (HR 1.896, P<0.001), female (HR 1.240, P=0.020),  fracture history (HR 1.798, P<0.001),  depression (HR 1.776, P<0.001),  increased body weight (HR 1.008 for each 1-kg increase, P<0.001) and use of corticosteroids (HR 1.238, P=0.029). GH therapy was not protective against fracture in the HypoCCS cohort with PO (HR 0.987, P=0.971) using PH modeling.

Conclusions:  To the best of our knowledge, this study represents the first report on fracture risk from a long-term adult GH replacement study and suggests that GH therapy is protective against fracture for adult patients with GHD who had no previously reported osteoporosis. The results also indicate that established osteoporosis could be a predominant risk factor for fracture, and that GH is not protective against fracture in patients with PO. 

Key words: growth hormone deficiency, GH replacement, fracture, osteoporosis

 

Disclosure: DM: Investigator, Eli Lilly & Company, Investigator, Eli Lilly & Company, Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. MF: Principal Investigator, Novartis Pharmaceuticals, Ad Hoc Consultant, Novartis Pharmaceuticals, Ad Hoc Consultant, Ipsen, Principal Investigator, Ipsen, Ad Hoc Consultant, Genentech, Inc., Principal Investigator, Corcept, Consultant, Novartis Pharmaceuticals. RQ: Investigator, Eli Lilly & Company, Investigator, Eli Lilly & Company, Investigator, Eli Lilly & Company, Employee, Eli Lilly & Company. CJC: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. DSH: Investigator, Eli Lilly & Company, Investigator, Eli Lilly & Company, Employee, Eli Lilly & Company, Employee, Eli Lilly & Company.

13053 3.0000 SAT-0717 A Reduced Fracture Risk in Adult Patients on Growth Hormone Replacement for Growth Hormone Deficiency: An Analysis of the Hypopituitary Control and Complications Study (HypoCCS) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Kevin C.J. Yuen*1, Jan Frystyk2, Bethany J Klopfenstein3, William D. Rooney4, James R. Pollaro4, Dennis R. Koop4 and Jonathan Quentin Purnell3
1Oregon Health and Science University, Portland, OR, 2Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark, 3Oregon Health & Science University, Portland, OR, 4Oregon Health & Science University, Portland

 

Context: Previous studies have reported that GH replacement doses exceeding 0.3 mg/day promote lipolysis and impair insulin sensitivity in GHD adults. We (1) and others (2) have shown that low dose GH (LGH) therapy improved insulin sensitivity without altering total body adiposity in GHD adults; however the mechanism is unclear. Given the association of intra-abdominal fat accumulation and chronic hypercortisolemic states (e.g., Cushing’s syndrome) with insulin resistance, we hypothesized that changes in insulin sensitivity following LGH therapy in GHD adults may be mediated through alterations in cortisol production rates (CPR) and ectopic fat accumulation.

Aims: We examined the effects of LGH (0.1 mg/day) therapy on insulin sensitivity, CPR, and ectopic fat accumulation [intramyocellular (IMCL), extramyocellular (EMCL) and intrahepatic lipid (IHL) content], in a group of GHD adults.

Methods: In this double-blinded study, 17 GHD adults were randomized to receive 3 months of either daily LGH (3M/5F, age 40.3 ± 3.7 yr, BMI 35.7 ± 3.9 kg/m2) or Placebo (4M/5F, age 38.1 ± 4.3 yr, BMI 34.2 ± 3.6 kg/m2) injections. Fasting blood samples were collected at Baseline, Month 1 and Month 3, whereas 3-hr glucose clamps, 24-hr CPR (measured by isotope dilution and mass spectrometry), DEXA and magnetic resonance spectroscopy of the liver and soleus muscle were performed at Baseline and Month 3.

Results: At Month 1, LGH therapy did not alter fasting levels of glucose, insulin, C-peptide, total IGF-I, IGF-I bioactivity and IGF-I/IGFBP-3 molar ratio. At Month 3, LGH increased clamp glucose infusion rates (GIR) and IGF-I/IGFBP-3 molar ratio and decreased fasting insulin (all P < 0.05), but fasting levels of glucose, C-peptide, lipid profile, free fatty acid, adiponectin and IGF-I bioactivity, and total fat mass, total lean mass, 24-hr CPR, IMCL, EMCL and IHL were unchanged. In the Placebo-treated group, all measurements were unchanged at Months 1 and 3 compared to Baseline.

Conclusion: Increased GIR and IGF-I/IGFBP-3 molar ratio without changes in fasting glucose, body composition, lipolysis, 24-hr CPR, IMCL, EMCL and IHL suggest that LGH therapy enhances insulin sensitivity predominantly at the muscle without altering CPR and ectopic fat accumulation in GHD adults. This may be related to the increased IGF-I bioavailability (reflected by the increased IGF-I/IGFBP-3 molar ratio) by LGH therapy acting on the abundant muscle, in contrast to scarce hepatic, IGF-I receptors.

 

Nothing to Disclose: KCJY, JF, BJK, WDR, JRP, DRK, JQP

11082 4.0000 SAT-0718 A Short-Term Low Dose Growth Hormone (GH) Therapy Improves Insulin Sensitivity without Altering 24-Hour Cortisol Production Rates and Ectopic Fat Accumulation in GH-Deficient (GHD) Adults 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Kevin C.J. Yuen*1, Jan Frystyk2, Sharon A Rhoads1, Stacy E. Legg1 and Martin Bidlingmaier3
1Oregon Health and Science University, Portland, OR, 2Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark, 3Klinikum der Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany

 

Context: The GST has been proposed as a reliable alternative test to the ITT in diagnosing adult GH deficiency (1). However, we have found that a substantial number of patients with glucose intolerance and high BMIs failed the GST compared to those with normoglycemia and BMIs less than 30 kg/m2 (2). This raises the question of the reliability of the GST in assessing GH reserve in patients with underlying glucose intolerance and/or obesity. As acute GH blockade with high dose PV (1 mg/kg) increases endogenous GH secretion (3), we hypothesized that PV administered prior to the GST (PV-GST) will further increase endogenous GH and cortisol secretion, and consequently improve the diagnostic accuracy of this test in assessing adult GH and cortisol reserve.

Aims: We assessed the potential of PV-GST on the characteristics of peak GH and cortisol levels compared to the GST and ITT, the correlation between serum PV and peak GH levels, and the effects of PV on IGF-I levels in adults suspected of GH and/or cortisol deficiency.

Methods: In this proof-of-concept pilot study, 10 adults suspected of adult GH and/or cortisol deficiency underwent the PV-GST, GST and ITT in random order at least 3 weeks apart. For the PV-GST, subcutaneous PV (1 mg/kg) was administered 3 days before the GST.  

Results: Following PV administration, IGF-I decreased (P < 0.05) and GHBP increased (P < 0.01) compared to pre-PV administration, baseline GST and baseline ITT levels. However, peak GH, total cortisol and free cortisol levels following PV-GST, GST and ITT were unchanged. Serum PV levels measured during the PV-GST correlated positively with peak GH, baseline GH, and changes in baseline GH (Dbaseline GH) and peak GH levels (Dpeak GH) compared to those achieved with the GST (all P < 0.05). Five patients failed (GH-deficient, 50%) and the remaining 5 patients passed (GH-sufficient, 50%) all 3 tests. In the GH-deficient patients, serum PV levels correlated positively with peak GH levels, whereas in the GH-sufficient patients, serum PV levels correlated positively with Dbaseline GH and Dpeak GH (all P < 0.05). Three patients preferred the PV-GST, 4 to the ITT and 3 to the GST.

Conclusion: The PV-GST may be used to improve the diagnostic accuracy of the GST in the workup of adult GH, but not cortisol, deficiency. Further larger studies are needed to verify if PV priming to the GST could be widely recommended in the evaluation of adult GH reserve.

 

Nothing to Disclose: KCJY, JF, SAR, SEL, MB

13966 5.0000 SAT-0719 A The Utility of Pegvisomant-Primed Glucagon Stimulation Test (PV-GST) Compared to the Insulin Tolerance Test (ITT) and the Glucagon Stimulation Test (GST) in Assessing Adult Growth Hormone (GH) and Cortisol Reserve 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Aimee J Varewijck*1, Steven W.J. Lamberts2, Aart Jan van der Lely1, Sebastian J.C.M.M. Neggers1, Leo J. Hofland2 and Joseph A M J L Janssen1
1Erasmus MC, Rotterdam, Netherlands, 2Erasmus Medical Center, Rotterdam, Netherlands

 

Background: Currently available IGF-I assays produce different total IGF-I values within the same serum samples. Using serum total IGF-I levels for diagnosis and long-term monitoring of therapy in GH deficiency (GHD) may therefore lead to different clinical interpretations and treatment decisions when different IGF-I immunoassays are used.

Aim of the study: To compare total IGF-I values measured by Siemens Immulite 2000 total IGF-I assay to the new IDS-iSYS total IGF-I assay in serum samples from adults with GHD before- and during GH replacement treatment.

Methods: Total IGF-I values were measured in 104 GHD subjects: before starting GH treatment and after 12 months of GH treatment. Total IGF-I was measured by both Immulite 2000 (calibrated against standard WHO IRR 87/518) and IDS-iSYS (calibrated against standard IS 02/254). For both assays individual Z-scores were calculated using assay-specific age-specific normative range values.

Results: Immulite 2000: After 12 months of GH therapy, total IGF-I increased from baseline 9.1 ± 4.6 nmol/L (mean ± SD) to 16.6 ± 7.5 nmol/L (P<0.001); Z-score increased from baseline -2.23 (-3.87 to + 1.73) (mean, range) to -0.60 (range -3.89 to +3.93) (p<0.001). IDS-YSIS: After 12 months of GH therapy, total IGF-I increased from baseline 9.6 ± 4.2 nmol/L (mean ± SD) to 16.5 ± 6.8 nmol/L (P<0.001); Z-score increased from baseline -1.43 (-3.28 to + 1.76) (mean, range) to +0.21 (-3.00 to + 3.28) (12 months after start of GH therapy) (p<0.001).

Absolute values for total IGF-I differed significantly between both methods at baseline (p<0.001) but not after 12 months of GH therapy (p= 0.32); Z-scores for total IGF-I differed significantly between both methods at baseline (p<0.001) and after 12 months of GH therapy (p<0.001).

Conclusions: In adults with GHD, absolute en Z-scores for total IGF-I significantly differed when samples were measured with either the Immulite 2000 or the IDS-iSYS assay. Our study suggests that the introduction of the new IDS-iSYS assay may have considerable consequences for the clinical diagnosis and interpretation of IGF-I levels during GH therapy of GH deficiency.

 

Nothing to Disclose: AJV, SWJL, AJV, SJCMMN, LJH, JAMJLJ

13103 6.0000 SAT-0720 A The Introduction of the Ids-Isys Total IGF-I Assay May Have Considerable Consequences for the Clinical Interpretation of Total IGF-I Levels in the Diagnosis and Treatment of GH Deficiency in Adults 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Zuleyha Karaca*1, Fatih Tanriverdi1, Ayhan Lale2, Kursad Unluhizarci1 and Fahrettin Kelestimur1
1Erciyes University Medical School, Kayseri, Turkey, 2Erciyes University Medical School, Kayseri

 

Effects of Gender on Growth Hormone Response to Glucagon Stimulation Test

Introduction: Glucagon stimulation test (GST) can be used in the evaluation of growth hormone (GH) axis besides hypothalamo pituitary adrenal axis. Peak GH response to glucagon is known to be affected by age and body mass index. The aim of this study was to investigate the effects of gender on GH response to GST.

Materials and Methods: 47 healthy individuals (21 males and 26 females) were enrolled into the study. IGF-1 levels of the volunteers were found to be in the normal range according to their age- and sex-matched references. GST was performed in the morning after an overnight fast. 1 mg glucagon was applied intramuscularly and blood samples were obtained in the basal state and after 90, 120, 150, 180, 210 and 240 minutes following administration of glucagon.

Results: The mean age of the patients was 43.7±13.4 years. Median peak GH response to GST was 4 ng/ml (min: 0.36, max:29). Basal GH levels were higher in females, but peak GH response to GST did not differ between sexes. Peak GH response to GST was found to be negatively correlated with age, weight and body mass index (BMI) in females, but not in males. Peak GH response to glucagon was found to be significantly and progressively decreased by increasing decades in females until 5th decade, but not in males. Peak GH response to GH was found to be negatively correlated with estradiol and positively correlated with FSH in females, but there were no correlations between peak GH response and FSH or testosterone in males.

Conclusion: GH response to GST decreased prominently by age in women, but not in men. The response is also affected by sex steroids. So normal peak GH cut-off levels may need to be reevaluated according to menopausal status and age in women in larger study groups.

 

Nothing to Disclose: ZK, FT, AL, KU, FK

11526 7.0000 SAT-0721 A Effects of Gender on Growth Hormone Response to Glucagon Stimulation Test 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Ana Beatriz Winter Tavares*1, Ignácio Seixas2, Diego Silvestre2, Carlos Montes Paixão Junior2 and Flavia Lucia Conceicao3
1Universidade Federal do Rio de Janeiro, RIo de Janeiro, Brazil, 2Universidade Federal do Rio de Janeiro, Brazil, 3Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil

 

The diagnostic assessment of growth hormone GH secretion depends, in most cases, of provocative tests. The insulin tolerance test (ITT) is considered the gold standard test in assessing GH reserve, but it is not recommended in elderly patients because of the cardiovascular risk. The glucagon stimulation test (GST) is an alternative and reliable test in assessing GH secretion, and can be used in all ages, due to its few contraindications, besides its ability to assess both GH and ACTH secretion. We studied the GH and ACTH secretion through GST in elderly subjects from the geriatric ambulatory of our hospital, a population where this test is not extensively studied. Exclusion criteria were: known pituitary disease, severe acute disease, terminal renal chronic disease, and the presence of any other disease that could interfere with the evaluation of the somatotrophic axis. Forty-three subjects (5 males and 38 females, 77.1 ± 5.2 years), were submitted to GST. The GST was performed by intramuscular injection of 1 mg of glucagon and blood samples were collected at baseline and after 90, 120, 150 and 180 minutes. The GST was stopped in one subject who had severe hypotension followed by seizure after 90 minutes. Twenty-three of 42 subjects (54.7%) had GH peak at 150 minutes; and 19 of 42 subjects (45.2%) had cortisol peak at 180 minutes. GH peak ranged from 0.73-19.6 ng/dL; and cortisol peak ranged from 8.5 to 42.1 μg/dL. Ten subjects (23.8%) had GH peak below 3 ng/mL. Fifteen subjects (35.7%) had cortisol peak below 18 μg/dL, among which three subjects had basal cortisol higher than the peak. Seven of 42 subjects (16.6%) had GH below 3 ng/mL and also cortisol below 18 μg/dL. Nine of 43 subjects (20,9%) had side effects during the test, which included: nausea, dizzinnes, vomiting, sweating, indisposition, and 1 case of severe hypotension accompained by seizure (with transfer to the emergency service of our hospital) in a patient without previous history of seizures; all of them without hypoglicemia associated (capillary glycemia), and these last two side effects are not commonly described and represent a potential risk in elderly. We concluded that GST is able to stimulate the GH and ACTH axis in the majority of cases, but GH was below 3 ng/mL in 23.8%, and cortisol was below 18 μg/dL in 35.7% of the subjects. We cannot discard hypothalamic or pituitary disease in these cases because we did not perform a sella turcica MRI in all cases, however, the possibility of a false-positive result of the test is the most likely one. Moreover, GST may be carefully used in elderly because of the frequency of side effects, including hypotension and its hazard in occult vascular disease; and seizure, which was not described previously in the literature. These side-effects may be potential contraindications to GST in this population.

 

Nothing to Disclose: ABWT, IS, DS, CMPJ, FLC

16408 8.0000 SAT-0722 A The Glucagon Stimulation Test in Elderly: Assessment of GH and ACTH Release 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Yasufumi Seki*, Masami Ono, Nobuhiro Miki, Yoichi Oshima, Masaki Ryuzaki, Yuki Mizuguchi, Michita Niiyama, Yuki Murayama, Naohiro Yoshida, Daisuke Watanabe, Fumiko Mori, Takashi Ando, Satoshi Morimoto and Atsuhiro Ichihara
Tokyo Women's Medical University, Tokyo, Japan

 

Context: (Pro)renin receptor [(P)RR] is a single trans-membrane receptor that binds both renin and its precursor prorenin, thereby regulating a down-stream cascade of the renin-angiotensin-aldosterone system. This receptor also transduces renin or prorenin signal intracellularly through mitogen-activated protein kinases and has been postulated to cause organ damages associated with hypertension or diabetes. An extracellular domain of (P)RR is present in blood as a soluble form [s(P)RR], however, clinical significance of circulating s(P)RR remains unknown.

Objective: We prospectively observed alteration of s(P)RR in endocrine patients with growth hormone deficiency (GHD) and examined its correlation with clinical characteristics.

Subjects and Methods: Patients were 76 adults (26 males and 50 females) with hypothalamus and/or pituitary disease. Growth hormone deficiency was determined with GH-releasing peptide-2 stimulation test. Thirty-six subjects belonged to GHD and the remaining forty subjects were not deficient of GH (non-GHD). Serum s(P)RR concentration was determined by ELISA kit (IBL Co., Gunma, Japan). Of the 36 GHD subjects, 16 were treated with human GH and serum samples were obtained 6 to 12 months after the replacement. The number of deficient pituitary hormones and the proportion of diabetes insipidus (DI) were greater in the GHD than in the non-GHD group, but all hypopituitary patients had been receiving supplementation of hydrocortisone, levothyroxine, gonadal steroids and desmopressin appropriately.

Results: At baseline, mean (± SD) serum s(P)RR levels was higher in the GHD group than in the non-GHD group (23.5 ± 3.8 ng/mL vs 21.7 ± 3.5 ng/mL, P = .029). Body weight (BW), BMI, serum HDL-cholesterol and triglyceride levels, and the incidence of dyslipidemia were higher, but eGFR and serum IGF-1 levels were lower in the GHD than in the non-GHD group. There was no difference in age, sex, serum HbA1c or LDL-cholesterol levels, and the incidence of hypertension between the two groups. Overall, serum s(P)RR levels correlated positively with BW and BMI, and negatively with log peak GH to GHRP-2 and serum HDL-cholesterol level, whereas it did not correlate with age, the presence of DI, or serum IGF-1 level and its SD score. In the 16 patients who received GH supplement therapy, mean s(P)RR level significantly decreased from 30.3 ± 2.7 ng/mL to 26.8 ± 4.6 ng/mL (paired t-test, P = .015) after an average of 8.4-month GH therapy.

Conclusion: Growth hormone deficiency was associated with a slight but significant reversible elevation of circulating s(P)RR. The underlying mechanism would involve a GH-dependent but IGF-I non-mediated alteration in lipid metabolism.

 

Nothing to Disclose: YS, MO, NM, YO, MR, YM, MN, YM, NY, DW, FM, TA, SM, AI

13679 9.0000 SAT-0724 A A Circulating Soluble (Pro)Renin Receptor Level and Its Changes with Growth Hormone Replacement in Patients with Growth Hormone Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Rajshree M Patel*1, Cielo Alleyn2 and Alan L Burshell1
1Ochsner Clinic Foundation, New Orleans, LA, 2Ocshner Clinic Foundation, New Orleans, LA

 

Pituitary stalk interruption syndrome (PSIS) is a functional disruption of hypothalamus and pituitary with significant endocrine consequences. Most cases are diagnosed in childhood.1,2  PSIS is a frequent cause of GH deficiency and other pituitary hormone deficiencies . PSIS can present with partial or complete gonadotropin deficiency.3  GH axis is required for brain development and the GH deficiency is associated with anatomic brain abnormalities, motor deficit and cognitive impairment.

A 24 year old female, college student presented with primary amenorrhea, short stature and dyspareunia. reports normal libido. There was no history of brain irradiation, head trauma or brain surgery.  She had breast augmentation surgery. Family members were above 5’10” tall. She was 4’11” tall, weighed 99 lbs. and pubic hair distribution tanner stage 2. Lab tests showed TSH 1.35 mIU/L (0.40-4.50) FT4 1.10 ng/dL (0.71-1.51) cortisol 13.8 ug/dL (4.46-22.7) DHEA-S 185 mcg/dL(45-320) prolactin 22.9 ng/mL(5.2-26.5) LH 0.4 mIU/mL FSH 1.6 mIU/mL estradiol <10 pg/mL progesterone <0.5 ng/mL GH <0.3 ng/mL(0.00-8.00) IGF-1 was 48 ng/mL(116-358). Transvaginal ultrasound revealed small uterus, endometrial strip 1.5 mm and small ovaries. MRI of the brain showed small anterior pituitary, absence of the pituitary infundibulum with a small 0.4 cm high T1 signal nodule near the median eminence and lack of posterior pituitary bright spot suggesting ectopic posterior pituitary findings consistent with PSIS and absence of a large portion of the body of the corpus callosum. Bone density results show T-score of -4.0 at lumbar spine and -2.9 of total hip. Bone age was 15 years old; epiphyses were open. Treatment with low dose estradiol and growth hormone was initiated to optimize final height. Goals of treatment include optimization of bone mass, body composition and better quality of life.

PSIS is associated with GH deficiency and gonadotropin deficiency. The deficiency of GH-IGF-1 axis can cause agenesis of corpus callosum. This is the first reported case of PSIS with partial agenesis of the corpus callosum with combined GH deficiency and gonadotropin deficiency presenting in adulthood with primary amenorrhea. The possibility of PSIS with GH deficiency and structural brain defects should be considered in adults with a long history of GH deficiency and/or primary amenorrhea; patients may develop additional hormonal abnormalities years later.

 

Nothing to Disclose: RMP, CA, ALB

14008 10.0000 SAT-0725 A An Unusual Presentation of the Pituitary Stalk Interruption Syndrome in an Adult 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Antonio Bianchi*1, Linda Tartaglione1, Antonella Giampietro2, Domenico Milardi3, Flavia Angelini4, Marilda Mormando3, Francesca Lugli5, Serena Piacentini6, Giuseppe Grande7, Donato Iacovazzo8, Sabrina Chiloiro3, Alfredo Pontecorvi2 and Laura De Marinis6
1Catholic University, School of Medicine, Rome, Italy, 2Catholic University, Rome, Italy, 3Catholic University of the Sacred Heart, Rome, Italy, 4Catholic University, School of Medicine, Italy, 5Policlinico 'A. Gemelli', Rome, Italy, 6Università Cattolica del Sacro Cuore, Rome, Italy, 7Catholic University School of Medicine, Rome, Italy, 8Barts and The London School of Medicine, London, United Kingdom

 

The IGF-I response to recombinant human Growth Hormone (rhGH) showed some individual variability and the responsible factors for this behavior remain unknown. Some studies have emphasized the possible role of isoforms of the GH receptor (GHR), showing conflicting results.

Therefore, we investigated the possible influence of the isoforms of the GHR to the diagnosis of GHD and in determining adult hormone replacement therapy responsiveness.

We studied 69 patients with GHD (M: 37, F: 32 , mean age 40.9 , median age 41) treated with rhGH using an identical standardized protocol in a single centre, with a duration of follow-up (median) up to 60 months.

We have observed that there is no significant difference in terms of IGF-I levels and GH peak at diagnosis of GHD, while the presence of the d3-GHR in homozygosity is related to a significant increase in IGF-I levels at 6 and 12 months of therapy; main determinants of the increase of IGF-I at both 6 and 12 months appear to be the dose of rhGH , the patient's age at diagnosis and the genotype of the GH receptor. No differences between genotypes were found in the long term follow-up.

GHR isoforms seem to affect the IGF-I response to rhGH in short term follow-up, but further prospective studies will clarify whether this hypothesis may have a predominant role in the variability of patient response to hormone replacement therapy.

 

Nothing to Disclose: AB, LT, AG, DM, FA, MM, FL, SP, GG, DI, SC, AP, LD

16691 11.0000 SAT-0726 A Determinants of IGF-I Response to Rhgh in Adult Ghd: Role of GH Receptor (GHR) Isoforms 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Ignacio Bernabeu*1, Paula Andujar-Plata2, Eva Fernandez-Rodriguez2, Celsa Quinteiro3 and Felipe F Casanueva4
1Complejo Hospitalario Universitario de Santiago de Compostela, Universidad de Santiago de Compostela, Santiago de Compostela, Spain, 2Complejo Hospitalario Universitario de Santiago de Compostela, Spain, Santiago de Compostela, 3Fundación Publica Galega de Medicina Xenómica. Complejo Hospitalario Universitario de Santiago de Compostela, 4Universidad de Santiago de Compostela, Santiago de Compostela, Spain

 

The efficacy and safety of hrGH treatment in adults with GH deficiency (GHD) has important interindividual variability that could be explained by some genetics variations. The aims of this study were: 1- to evaluate the genotype of GH receptor (regarding exon 3 deletion) and the polymorphism in the promoter region of the IGF-I gene (CA repeats) in a series of adult patients with GHD; 2- to assess the effects of both genetic factors on initial IGF-I levels and 3- to evaluate if d3-GHR and/or IGF-I (CA) genotypes were associated with higher incidence of adverse effects and/or treatment discontinuation.

This retrospective study included 44 adult patients with GHD, diagnosed according to present criteria1. Demographic, clinical and biochemical characteristics were evaluated at baseline and six months, one year, and three years after the initiation of hrGH treatment. GHR and IGF-I genotypes were analyzed in 35 patients. IGF-I at baseline was lower than the normal range for sex and age in 64% of patients and within normal range in 36%.

37.1% of patients were d3-GHR carriers (31.4% heterozygous, 5.7% homozygous). The presence of d3-GHR was not related to IGF-I at baseline. Although adverse events were more frequent in the d3-GHR carriers (30.7% vs. 18.2% in fl/fl), this association was not statistically significant (p= 0.4). d3-GHR carrier status was not related to treatment discontinuation (p= 0.47).

88.2% of patients were carriers of the 19CA allele (47.1% heterozygous and 41.2% homozygous) and 11.8% were non-carriers. IGF-I at baseline was low in 3 of 4 patients non-carriers of the 19CA allele (75%), a proportion statistically higher than in homozygous carriers (8/14; 57.1%) and than in heterozygous carriers (2/16; 12.5%)  (p=0.028). However, the small number of non-carriers of the 19CA allele (n=4) prevent us to obtain a definitive conclusion. IGF-I genotype was neither associated with the development of adverse events (p= 0.55) nor treatment discontinuation (p= 0.55).

In conclusion, although adverse events were more frequent in the d3-GHR carriers, d3-GHR carrier status was not related to baseline IGF-I level, adverse events or treatment discontinuation. IGF-I levels at baseline were lower in non-carriers of the 19CA allele, but this result should be considered with caution given the small number of patients. IGF-I genotype was neither related to adverse events nor treatment discontinuation.

 

Disclosure: IB: Clinician, Ipsen, Clinician, Pfizer, Inc., Clinician, Novartis Pharmaceuticals, Clinician, Pfizer, Inc.. Nothing to Disclose: PA, EF, CQ, FFC

13899 12.0000 SAT-0727 A Influence of Exon 3 Deleted GH Receptor and of the IGF (CA) Repeat Polymorphism on the Efficacy and Safety of Somatropin Treatment in GH Deficient Adult Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Michelle M Mangual*1, Jose Hernan Martinez2, Monica Santiago2, Carlos Rafael Figueroa3, Rafael Trinidad3, Madeleine Gutierrez2, Alfredo Sanchez4, Maria de Lourdes Miranda3, Eva Gonzalez2, Coromoto Palermo2 and Oberto Torres2
1Sa, San Juan, PR, 2San Juan Hospital, San Juan, PR, 3San Juan City Hospital, San Juan, PR, 4San Juan City Hospital, PR

 

A middle aged woman with isolated ACTH deficiency associated with transient growth hormone deficiency.

Introduction:

Isolated ACTH deficiency (IAD) is a rare entity characterized by secondary adrenal insufficiency with low levels of serum cortisol, decreased production of ACTH, adequate secretion of other pituitary hormones and normal pituitary structure on radioimaging. Due to the rarity of its occurrence the prevalence of IAD as a cause of secondary adrenal insufficiency has not been determined. To our knowledge 200 cases are described in the literature since it was first recognized by Steinberg et al. in 1954. IAD can be caused by a traumatic brain injury or lymphocytic hypophysitis in adults and genetic defects such as proopiomelanocortin processing defect or transcription factor Tpit gene mutation in the neonatal period or childhood. Other etiologies remain to be elucidated. Impairment of growth hormone (GH) secretion has been noted in 20 to 30% of patients with IAD which is normalized after glucocorticoid replacement. TSH can be mildly elevated given that the physiological inhibitory effect of cortisol on TSH is absent.  

Case report:

This is the case of a 56 y/o female patient initially referred to the endocrine clinic complaining of tiredness, fatigue, weakness, oligomenorrhea, hotflashes and an elevated TSH level. She reported a history of a previous episode of syncope 10 years before evaluation and 3 episodes of near syncope 2 years later associated to tiredness, weakness and sweating. Physical exam was unremarkable and she was initially treated for hypothyroidism with levothyroxine 0.25 mg PO daily. In the subsequent visits the patient complained of worsening tiredness associated to dizziness, nausea and occasional vomiting. A serum cortisol level of 0.1 µg/dl with an ACTH level of 3.9 pg/dl suggested the diagnosis of secondary adrenal insufficiency that was confirmed by repeated testing. An ACTH stimulation test showed no rise in serum cortisol from baseline. Complete evaluation of anterior pituitary hormones was unremarkable. A pituitary MRI was normal. An insulin tolerance test demonstrated ACTH and GH deficiency. Treatment was initiated with low dose hydrocortisone and symptoms resolved. After 8 months of treatment a glucagon stimulation test revealed persistent ACTH deficiency but GH secretion normalized.

Conclusion:

IAD is a rare cause of secondary adrenal insufficiency that can present with nonspecific symptoms and could be potentially fatal in an acute stress period. Prompt recognition is essential to decrease morbidity and mortality. Symptoms of adrenal insufficiency and GH deficiency may overlap therefore it is important to recognize that transient GH deficiency may present with IAD to avoid unnecessary exposure to GH replacement therapy and its potential adverse effects and high cost.

 

Nothing to Disclose: MMM, JHM, MS, CRF, RT, MG, AS, MDLM, EG, CP, OT

15879 13.0000 SAT-0728 A A Middle Aged Woman with Isolated ACTH Deficiency Associated with Transient Growth Hormone Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Mustafa Kulaksizoglu*1, Suleyman Hilmi Ipekci2, Gulsum Gonulalan3, Mine Ozturk1, Ahmet Kaya1, Mustafa Sait Gonen4 and Mehtap Cakir1
1Necmettin Erbakan University, Konya, Turkey, 2Selcuk University Med Faculty, Konya, Turkey, 3Konya Numune Hospital, Konya, Turkey, 4Bilim University, Istanbul, Turkey

 

Anemia is a well known consequence of hypopituitarism and was first described nearly sixty years ago. Anemia may be secondary to deficiency of a number of pituitary hormones. The aim of this study was to evaluate anemia frequency and other hematological changes in patients with hypopituitarism who are not on GH treatment but receiving combined androgen and/or  thyroid and/or glucocorticoid hormone replacement therapies according to their detected deficiencies. Patients with isolated anterior pituitary hormone deficiencies, chronic renal disease, malignancies, patients taking drugs that have effects on hematological parameters were excluded from the study and 67 patients with full records were enrolled in the study. Anemia was defined as Hb<13 g/dL in men and Hb<12 g/dL in women according to the WHO definition (1). Parameters were evaluated at diagnosis before treatment and after hormone replacement therapies planned according to individual needs. Sixty patients had central hypothyroidism while in 59 patients secondary hypocortisolism was detected. Thus 59 patients were under combined LT4 and cortisol replacement therapies. Twenty male patients had low free testosterone levels whereas 16 were under androgen replacement therapy. Number of women with low estradiol levels was fifteen. 53 patients were GH deficient but none of them were on GH replacement therapy. Anemia frequency of female patients was 47.1% at diagnosis and decreased to 26.5% after replacement therapies. Anemia frequency of male patients was 69.7% at the diagnosis and decreased to 39.4 % after replacement therapies. In subgroup analysis, among 60 patients who had central hypothyroidism 37 (61%) of them had anemia and recovery from anemia was seen in 19 (31%) patients after levothyroxine. Among 59 patients who had central hypocortisolism 36 (61%) of them had anemia and prednisolone treatment corrected anemia in 18 (30%) patients. Sixteen patients had androgen deficiency of whom 11 (68%) had anemia and recovery from anemia was noted in 5 (31%) patients. 15 patients had low estradiol levels, 5 (33%) of them had anemia and 3 (20%) of them recovered after thyroid and glucocorticoid therapies. 53 patients had GH deficiency, 39 (73%) of them had anemia and 17 (43.6%) of them recovered after replacement therapies with levothyroxine, prednisolone and in some cases testosterone. In total 29 patients still had anemia after replacement therapies. Among them 22 (75.8%) of them were GH deficient. Only cortisol (p=0.046) and IGF-1 (p=0.07) levels correlated with decreased Hb levels in our study group before treatment. Glucocorticoid, thyroid and androgen hormone replacement is sufficient to correct anemia in most cases but not in all ones. Especially in patients with anemia resistant to therapies with glucocorticoid thyroid and androgen hormones, GH replacement may be necessary to correct the anemia of hypopituitarism.

 

Nothing to Disclose: MK, SHI, GG, MO, AK, MSG, MC

11975 14.0000 SAT-0729 A Do We Need to Replace GH to Correct Anemia in Hypopituitarism? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Orlando Vicente Jaramillo*
Hospital Nacional de Ninos, San Jose, Costa Rica

 

Background: congenital pan hypopituitarism is an unusual diagnosis at adulthood and mutation in PROP1 gene has never to our knowledge been diagnosed in Costa Rica.  Successful growth hormone treatment until predicted parental height is achieved is unusual given the late diagnosis and pubertal development with bone age maturation Clinical case: A 35 year old farmer with no pathologic medical history or surgery was admitted to the psychiatric hospital with an episode of confusion, hypotension, nausea and vomits. Low sodium was found in a general lab evaluation and referred to the endocrinology department for further evaluation. Completely asymptomatic at the time of first visit, ortostatism was found during examination.  Weight: 42 kg, Height: 141 cm, Tanner 1, no body hair.

Anterior pituitary stimulation tests where performed evidencing pan hypopituitarism. General labs demonstrated a  total cholesterol at 548 mg/dl, triglycerides at 2692

mg/dl, HDL-cholesterol at 20 mg/dl. Hydrocortisone and a few days later levothyroxine where initiated.

The patient was referred to the Hospital Nacional de Niños. With a bone age of 11 years growth hormone therapy was initiated with excellent growth and later on testosterone treatment was added to induce puberty. GH therapy was stopped when the patient attained a height of 168,5 cm.

The patient as well as 6 out of his 8 brothers and sisters where studied and found to have a homozygous Arg120Cys mutation in PROP1.

Conclusion: this is to our knowledge the first patient diagnosed with a mutation in PROP1 gene in Central America, treated with GH as an adult, attaining predicted parental height.

I would like to thank Ron Rosenfeld, Vivian Hwa and Esteban Soto for their cooperation with this case.

 

Nothing to Disclose: OVJ

16422 15.0000 SAT-0730 A First Adult Patient with a Mutation in PROP1 Treated with Growth Hormone in Costa Rica 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Kinjal K Shah*1 and Robert J Anderson2
1VA-Nebraska Western Iowa Healthcare System, Omaha, NE, 2VA - Nebraska Western Iowa Healthcare System / Creighton University Medical Center, Omaha, NE

 

PRIMARY OBJECTIVE: To review the evidence of improvement in outcomes following growth hormone replacement therapy (GHRT) in patients with growth hormone deficiency (GHD) as a result of traumatic brain injury (TBI).  

DESIGN and METHODS: We reviewed eight studies published to date in the English literature in MEDLINE regarding GHRT in TBI-associated GHD.

RESULTS: 140 patients with GHD due to TBI from various causes were treated with rhGH; 30% (n = 42) had moderate-severe TBI, while in 68% (n=95) of patients no details were available on the severity of injury. Mean duration from injury to treatment initiation was >1 year in most studies. GHD was diagnosed by a single stimulation test in most patients while in 27 patients more than 1 test was used. ITT was the most common test followed by Glucagon stimulation test (GST), GHRH-Arginine, GHRH-GHRP-6, Arginine, and GHRH. Peak GH cutoff for the diagnosis of GHD for GST and ITT was ≤3 ng/ml in 1 study, and in 3 studies it was <3ng/ml. For the GHRH –arginine test, the peak GH cutoff was based on age and BMI. Associated hormone deficiencies were treated in 98 patients. rhGH treatment was given for 3 months in 11, 6 months in 9, 1 year in 79 and >1 year in 41 patients.  Control groups varied and consisted of patients with TBI with or without GHD but not treated, patients treated with placebo or patients with GHD due to non-TBI causes and treated.   End points reviewed showed moderate improvements in the cognitive functions of memory capacities and processing speed in 4 studies, while improvement in attention and executive functions in 1 study was attributed to simultaneous individualized cognitive rehabilitative psychotherapy. Marked increase in personal and functional domains in health related Quality of Life (QoL) was seen in 4 studies, while no improvement was noted in 1 study. BMI and IGF-1 levels improved significantly in most studies; however, there was no significant correlation with the observed improvements of QoL and cognitive functions.

CONCLUSIONS: A majority of the studies available evaluated patients with moderate to severe TBI. Discrepancies existed in diagnostic tests for  GHD, in hormone assays, definition of GHD, duration of treatment, duration from injury to when treatment was initiated, associated pituitary hormone deficiencies and simultaneous other hormone replacements. Most of the studies showed improvement in QoL and cognitive functions, although there was no standard neuropsychiatric test used to measure improvements in these functions. The vast majority of currently reported TBI patients suffer a mild TBI, and GHD is increasingly diagnosed in them. Thus, there is a need for extensive prospective study of mild TBI patients with standard testing to delineate the potential for improvement in the outcomes of cognitive functions, Qol, and physical rehabilitation following GHRT.

 

Nothing to Disclose: KKS, RJA

14767 16.0000 SAT-0731 A Therapeutic Benefits of Growth Hormone Replacement Therapy in Growth Hormone Deficient Patients Following Traumatic Brain Injury: A Systematic Review 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Paula Paes B Silva*1, Saurabha Bhatnagar2, Seth Herman2, Ross Zafonte3, Anne Klibanski4, Karen K. Miller5 and Nicholas A Tritos6
1University of Sao Paulo Medical School, Sao Paulo, Brazil, 2Spaulding Rehabilitation Hospital/Massachusetts General Hospital/Harvard Medical School, Boston, MA, 3Spaulding Rehabilitation Hospital/Massachusetts General Hospital/Harvard Medical School, Boston, 4Massachusetts General Hospital and Harvard Medical School, Boston, MA, 5Massachusetts Gen Hosp, Boston, MA, 6Massachusetts General Hospital/Harvard Medical School, Boston, MA

 

Traumatic brain injury (TBI) is complicated by hypopituitarism in a subset of patients, but which patients are at particularly high risk for developing hypopituitarism is not clearly defined. To determine predictors of hypopituitarism in adults with TBI, we identified 163 adults (48 women) with TBI and median age 42 y (range, 18-76), who underwent neuroendocrine evaluation at our Center (2007-2013) at a median interval of 40.4 months (0.2-430.4) after TBI. Most common causes of TBI were motor vehicle accident (MVA, 36%), fall (18%), military blast exposure (16%), and sports-related (15%). Fifty one patients (31%) were diagnosed with ≥1 pituitary hormone deficiencies; such patients had higher body mass index (BMI, P=0.0003), but were comparable in age and gender to those without deficiencies. Fourteen patients (9%) developed central adrenal insufficiency and were more likely than those without hypoadrenalism to have suffered MVA (64% vs. 34%, P=0.04), experienced post-traumatic seizures (21% vs. 5%, P=0.04), demonstrated any intracranial hemorrhage (67% vs. 31%, P=0.05) or focal cortical (frontal) parenchymal contusions (56% vs. 18%, P=0.02) on MRI. Twelve patients (7.5%) had central hypothyroidism; such patients had a higher mean BMI (P=0.02) and were more likely than those without hypothyroidism to have suffered MVA (75% vs. 33%, P=0.008).  Nineteen patients (12%) had hypogonadism; these patients had a higher mean BMI than those without gonadotropin deficiency (P=0.04), and were more likely to be taking opioids (P=0.0005) or glucocorticoids (P=0.02). Thirty four patients (21%) were diagnosed with growth hormone (GH) deficiency, based on a peak GH <3 ng/ml on glucagon stimulation testing; such patients had a higher mean BMI (P=0.0005), higher fasting glucose (P=0.01) and were less likely to be employed (41% vs. 62%, P=0.04) than those without GH deficiency. Ten patients (6.2%) had central diabetes insipidus (DI); they were more likely to have suffered MVA (100% vs. 32%, P<0.001), be hospitalized for TBI (100% vs. 54%, P=0.0014), have suffered post-traumatic seizures (30% vs. 5%, P=0.01), and have demonstrated any degree of intracranial hemorrhage (83% vs. 25%, P=0.006), subarachnoid hemorrhage (50% vs. 9%, P=0.01), or focal cortical (frontal) contusions (100% vs. 17%, P<0.001) on MRI. Our findings suggest that evaluation for hypopituitarism may be particularly important in TBI patients whose injuries were a consequence of an MVA, complicated by post-traumatic seizures, or resulted in any intracranial hemorrhage or focal cortical (frontal) parenchymal contusions on MRI.  There is no type of injury, or lack of a particular sign or symptom that eliminates the need to test TBI patients for hypopituitarism.

 

Nothing to Disclose: PPBS, SB, SH, RZ, AK, KKM, NAT

14715 17.0000 SAT-0732 A Predictors of Pituitary Hormone Deficiencies in Adults with History of Traumatic Brain Injury 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Jeffrey S Taylor*1, Amy Denise Anderson2, Shane McNamee3 and Robert A Adler4
1Virginia Commonwealth University Medical Center, Richmond, VA, 2University of Virginia, Charlottesville, VA, 3McGuire Veterans Affairs Medical Center, Richmond, VA, 4McGuire Vet Affairs Med Ctr, Richmond, VA

 

PURPOSE

Blast traumatic brain injury (bTBI) is increasingly common in military personnel.  Many symptoms seen after bTBI are also seen with pituitary dysfunction, a known consequence of other TBI.  Depression, post-traumatic stress disorder (PTSD), and certain medications complicate diagnosing pituitary dysfunction in this population.  Here, we expand our prior study on the incidence of pituitary dysfunction in post-bTBI male veterans, while limiting the confounding factors of antiepileptic and opioid medication use.

METHODS

Male veterans (n=37) with a history of blast exposure were evaluated by blinded TBI staff for presence and severity of TBI.  Subjects taking antiepileptics (other than valproate) or opioids (other than low-dose tramadol) within 2 months were excluded.  On day 1, fasting morning serum cortisol, LH, FSH, total testosterone (TT), SHBG, FT4, PRL, and IGF-1 levels were obtained, followed by an ACTH-stimulated cortisol level.  On day 2, GH response to glucagon stimulation, 1-2mg IM based on weight, was assessed over 240 minutes.  Bioavailable testosterone (BT) was calculated.

RESULTS

Of 37 subjects with blast exposure, 23 had mild and 2 had moderate TBI.  27% were obese (BMI >35).  Nearly all had PTSD.  Time from blast exposure to sample collection was 2 to 113 months.  41% of mild and all moderate TBI subjects had low serum TT vs 33% of blast-exposed only subjects.  Far fewer subjects in all 3 groups had low BT levels.  90% of obese subjects had low serum TT vs 22% of non-obese subjects.  93% of all subjects with low TT had low or inappropriately normal gonadotropins.  45% of mild and all moderate TBI subjects had low peak GH response to glucagon vs 25% of blast-exposed only subjects.  80% of obese subjects had a low peak GH response to glucagon vs 26% of non-obese subjects.

CONCLUSIONS

Pituitary dysfunction after bTBI may contribute to post-TBI symptom burden.  Though underdiagnosed, treatment may improve recovery and quality of life.  These data suggest that hypogonadism and GH deficiency are seen frequently after bTBI.  However, these deficiencies also appear to be strongly associated with obesity.  PTSD and/or depression may also affect pituitary function.  Further investigation is needed to clarify the extent to which these confounders affect diagnosing true pituitary dysfunction in the bTBI population and to determine if hormone replacement is beneficial.

 

Nothing to Disclose: JST, ADA, SM, RAA

13093 18.0000 SAT-0733 A Anterior Pituitary Dysfunction in Male Military Veterans with Blast Traumatic Brain Injury 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Dennis J Zgaljardic*1, Kurt A Mossberg2, William J. Durham3, Charles R Gilkison4, Melinda Sheffield-Moore5, Randall J Urban2 and Brent Masel1
1Transitional Learning Center, Galveston, TX, 2Univ of TX Med Branch, Galveston, TX, 3University of Texas Medical Branch at Galveston, Galveston, TX, 4Univ of TX Medcl Branch, Galveston, TX, 5University of Texas Medical Branch, Galveston, TX

 

Background:  TBI results in cognitive impairments in memory, executive functioning, and information processing speed.  There have been few treatment interventions made available in the chronic phase with only marginal success.  Growth hormone deficiency (GHD) occurs in approximately 15-20% of individuals with a history of TBI and is typically associated with self-report of fatigue, decreased exercise tolerance, depression, osteoporosis, hypercholesterolemia, and atherosclerosis.  Replacement of growth hormone (GH) in persons who are GHD post-TBI have resulted in improvement in neuropsychological test performance (1) which can lead to improved participation in activities of daily living, post-acute rehabilitation, and return to school/work, as well as improved quality of life.  In the current study, we report on the preliminary neuropsychological test performances of an independent sample of patients with chronic TBI following 12 months of open label GH replacement therapy.  The aim of the current ongoing study is to expand upon our prior work in order to refine the scope of cognitive impairment associated with GHD post-TBI.    

Methods: A sample of individuals (N=9) with a history of chronic TBI (at least 2 years post-injury onset) completed 1-year of GH replacement therapy with neuropsychological testing (processing speed, verbal memory, and executive skills) performed at baseline and 12 months. 

Results: Paired sample T-tests were performed with Bonferroni correction for multiple comparisons.  Study participants demonstrated significant gains on an index of information processing speed (p = .008).  No other statistically significant cognitive gains were found.   

Conclusions: Despite the small sample size preliminary findings from our ongoing study suggest that chronic TBI patients demonstrate improvements on an index of information processing speed following 12 months of GH replacement therapy.  These improvements in information processing speed may help facilitate improvements in other cognitive domains (e.g., memory). 

 

Nothing to Disclose: DJZ, KAM, WJD, CRG, MS, RJU, BM

12376 19.0000 SAT-0734 A Growth Hormone Replacement Therapy Improves Neuropsychological Test Performance in a Sample of Patients with Chronic Traumatic Brain Injury 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Narayana Prasad Pothina*1, Stephen L Atkin2 and Thozhukat Sathyapalan3
1Hull & East Yorkshire Hospitals NHS Trust, Hull, United Kingdom, 2Hull York Medical School, E Yorkshire, United Kingdom, 3Hull York Medical School, Hull, United Kingdom

 

Introduction

Gulf war syndrome (GWS) is described as a cluster of medically unexplained chronic symptoms of fatigue, headache, musculoskeletal pain, skin disorders, sleep disturbances and neuro-cognitive disorders in veterans of the first Gulf War. Studies have shown subtle changes in the hypothalamic-pituitary-adrenal axis in the Gulf war veterans with GWS. We present a case series of patients with diagnosis of GWS who underwent dynamic pituitary testing.

Methods

We have retrospectively analysed the seven gulf war veterans who presented to us in the last 18 months with diagnosis of GWS and ongoing fatigue. All of them underwent baseline pituitary profile, 9 am testosterone, sex hormone binding globulin and thyroid function tests. This was followed by pituitary dynamic testing: insulin stress test (IST) or glucagon stimulation test (if IST contraindicated), thyrotropin releasing hormone stimulating test and gonadotropin releasing hormone stimulation test.

Results

All patients were male, with a mean age of 46.28 years. Two of the seven patients (28.6%) had normal hypothalamo-pituitary function. Rest of the 5 patients (71.4%) had various pituitary hormonal deficiencies of which all patients had hypothalmic-pituitary-adrenal axis dysfunction needing steroid replacement. Four patients had suboptimal growth hormone response and low adult growth hormone deficiency quality of life (AGHDA QoL) questionnaire response needing growth hormone replacement. One patient had hypothalmic-pituitary-gondal dysfunction needing testosterone replacement. All patients had normal MRI scan of pituitary.  All patients who needed replacement had variable improvement in their symptoms after 6 months of replacement.

Conclusion

Hypothalamic-pituitary dysfunction is associated with Gulf War Syndrome.  Pituitary hormone replacement therapy in this cohort of patients with hormonal dysfunction could improve some of their symptoms and quality of life.

 

Nothing to Disclose: NPP, SLA, TS

16186 20.0000 SAT-0735 A Pituitary Dysfunction in Gulf War Syndrome Patients - a Case Series 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Maria E Vrontakis-Lautatzis*1, Beata Biernacka2, Lin Zhang3 and Gilbert Kirouac3
1Univ of Manitoba, Winnipeg, MB, Canada, 2University of Winnipeg, 3University of Manitoba

 

Galanin is a 29-30 amino acid regulatory peptide, widely distributed in the nervous

system and gastrointestinal tract. Galanin and its receptors have been implicated in

numerous biological functions including anxiety-like behaviours and stress related

disorders. Psychological stress or anxiety affects the motility of the gastrointestinal

tract. In the current study we sought to examine the relationship between stress

induced behavior and galanin distribution in the  descending colon and compare

morphological changes with behavioral changes in an animal model of post-

traumatic stress disorder (PTSD). In this model a  conditional fear is generated

when animal is placed in an environment in which it has previously experienced

electric foot shock, the contexual cues of the shock box inducing immobility

behavior due to induced anxiety. This model has been further refined into high

responders (HR)  and low responders (LR)based on imobility elicit by a novel tone

 one day after exposure.Analysis of the histology of the descending colon, indicate

that in high (HR) , there is significant folding and thickening of the mucosa and

submucosa as compared to (LR), non-stressed animals or control animals (CTR).

  Quantitative data for Galanin distribution in the descending colon of HR, LR, and

CTL rats indicate that the relative optical density (OD) of Galanin was the highest

in low responders (LR) followed by high responders (HR) and control animals

(CTR). PCR results reveal that the expression levels of Galanin  and Gal Receptors

(1-3) in high (HR)  and low (LR) responders  were different in descending colons

and hypothalami. The results of this study suggest that galaninergic system elicits

 stress modulatory actions, and support the notion that they may serve as a drug

target in PTSD.

 

Nothing to Disclose: MEV, BB, LZ, GK

14743 21.0000 SAT-0736 A Differential Regulation of Galanin in the Central and Peripheral Nervous System in a Rat Model of Post-Traumatic Stress Disorder 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0715-0736 4826 1:00:00 PM Pituitary Hormone Deficiency: Diagnosis and Management Poster

Ayse Kubat Uzum*1, Gulsah Yenidunya Yalin1, Nurdan Gul2, Nese Colak3, Ferihan Aral4 and Refik Tanakol5
1Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey, 2Istanbul Faculty of Medicine, Istanbul, Turkey, 3Istanbul Univ Medical Fac, Istanbul, Turkey, 4Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey, 5Instanbul Faculty of Medicine, Istanbul, Turkey

 

Introduction: High GH and IGF I levels  increase tubular phosphate reabsorbtion with a direct effect or interference of humoral factors. We aimed to define the  relationship  between initial serum phosporus levels and clinical activity of the disease with the effect of phosphorus decrement in predicting remission in acromegaly  patients.

Material-Method: Fifty one patients (24 female, 27 male)followed up  with the diagnosis of acromegaly in Istanbul Medical Faculty Department of Endocrinology and Metabolic Diseases outpatient clinic, were included. The patients’ IGF -1, phosphorus levels,GH  responses to oral glucose supression test (OGST) preoperatively, were analysed from their files retrospectively. Then were divided into two groups for phosphorus level; P<4,5mg/dl (group 1;n:23,%45.1), >4,5 mg/dl (group 2; n:28, %54,9) and classified into two subgroups  as with remission and nonremission. Normal plasma IGF-1 (adjusted for age and gender) and normal GH supression in OGST (<1 mcg/dl) was defined remission.

Results: The mean age was 45.8±11.1 and 37.6±10.3 for group 1 and group 2,respectively. The mean follow up was 92,6( 6-384)months. Thirty eight  patients had macroadenoma (%74.5) and 13 patients (%25.5) had microadenoma. Preoperative complications were;  visual field defects (3,4), hypertension (16,20), diabetes mellitus (5,8), insulin resistance (16,17), carpal tunel syndrome (5,5), artropathy (2,4), left ventricle hypertrophy (9,12) for group 1 and group 2, respectively. In group 1; 9 patients had active disease, 7 had partial remission, 7 had complete remission and 15,7,6 for group 2, respectively.  Preoperative  phosphorus levels decreased from  4.0±0.3 mg/dl to 3.2±0.5 mg/dl in group 1 (p<0.001) and 4.8± 0.3 mg/dl to 3.6±0.4 mg/dl in group 2 (p<0.001) with treatment. In remission,plasma phosphorus and IGF-1 regressed by 27% and 69% respectively.There was positive correlation with serum P levels  at diagnosis and the lowest GH levels in OGST (r:0,047;p<0.05),age at diagnosis (r:0.836, p<0.001),third year IGF-1 levels  after treatment (r:0,342,p<0.05) and Ki 67 score in histochemichal evaluation (r:0,954; p<0.05).

Conclusion: High plasma phosphorus levels can be an indicator for disease activity in Acromegaly patients. Increases in the plasma phosphorus levels, must alert the physician for onset of disease activity, during the follow up of Acromegaly patients who are under remission after aproppriate treatments.

 

Nothing to Disclose: AKU, GYY, NG, NC, FA, RT

12735 1.0000 SAT-0589 A Can Serum Phosphorus Levels be Used As a Clinical Activity Indicator during the Follow up of Acromegaly Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Emanuel R Christ*1, Catherine Waeber Stephan2, Beatrice Waser3 and Jean Claude Reubi4
1University Hospital of Berne, Berne, Switzerland, 2Clinique générale, Fribourg, Switzerland, 3Division of Experimental Pathology, University of Berne,, Bern, Switzerland, 4Univ-Bern/ Inst of Pathology, Bern, Switzerland

 

Background:

Patients with active acromegaly associated with an AIP mutation tend to respond less to somatostatin analogs after surgery. The underlying pathophysiological background is ill defined. Possible mechanisms include a decreased expression of somatostatin-2 receptors (sst2) and/or an alteration of post-receptor mechanisms.

Case report:

A 19-year-old patient presents in September 2011 with clinical features acromegaly. In September 2011, the MRI showed a macroadenoma (37x25x20mm) with suprasellar expansion and infiltration into the right cavernous sinus. Due to the young age of the patients an investigation for an AIP-mutation was performed and finally confirmed.

In November 2011 a transsphenoidal approach was performed to remove the intrasellar part of the tumor followed by a transcranial operation in April 2012 in order to eliminate as much as possible of the suprasellar part and minimize the risk for local complications. After the second operation clinical and biochemical evaluation indicated that the acromegaly was not controlled yet, in keeping with MRI studies showing small remaining tissue in the suprasellar region and the right cavernous sinus.

Immunohistochemistry for somatostatin receptors of the surgical specimen was performed that did not identify sst2. However, a significant density of sst5was detected. A test dose of 100 ug of Sandostatin did not show a significant effet on GH levels whereas 200 ug of Pasireotide resulted in a significant drop of GH levels. Consequently, Pasireotide LAR 40 mg and then 60mg was administered every 4 weeks. Clinical signs, in particular peripheral edema, rapidly resolved and biochemical control significantly improved with normalization of IGF-1 concentrations in spring 2013 . Remarkably, radiological follow-up showed a d reduction of the tumor size within 12 months. With the exception of worsening of glucose intolerance (HbA1C 6.5%) that needed Metformin for metabolic control, the therapy was well tolerated.

Conclusion:

  • In acromegalic patients with persistent disease following surgery that do not respond to Octreotid or Lanreotide, reliable immunohistochemical examination of the sst-receptor status of the tumor specimen may be an option in order to optimize medical therapy.
  • Whether the presence of sst5 (and absence of sst2) is a common feature of acromegalic patients with AIP mutations, thereby explaining the poor response to Octreotide, remains to be established.
  • This case suggests that personalized medicine is not only mandatory in oncology, but is also an option in endocrinology.

 

Nothing to Disclose: ERC, CW, BW, JCR

12993 2.0000 SAT-0590 A Personalized Endocrinology in an Acromegalic Patient with AIP Mutation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

James Ahlquist*1, Quah Boon Leong2, Ute Pohl2 and Jonathan Pollock3
1Southend Hospital, Westcliff on Sea, United Kingdom, 2Queen's Hospital, Romford, United Kingdom, 3Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, United Kingdom

 

PANCH tumour (Pituitary Adenoma with Neuronal Choristoma), is a very rare form of pituitary pathology composed of a mixed pituitary adenoma and gangliocytoma.  We describe a patient with acromegaly who had evidence of growth hormone and prolactin synthesis in the neuronal component of a PANCH tumour.  A 55 year old woman was found to have facial features of acromegaly, confirmed biochemically: basal GH 13.56 ng/mL, GTT nadir 8.87 ng/mL, IGF1 raised at 97.2 nmol/L (ref 9-40).  Pituitary function was otherwise normal.  MRI revealed a 25 mm mass in the pituitary fossa, with cavernous sinus extension; there were no unusual radiological features.  She underwent endoscopic trans-sphenoidal surgery, during which the tumour was noted to have an unusual, slightly fibrous consistency.  Intra-operative histological examination suggested that the tumour may be a ganglioglioma.  Following surgery IGF1 had fallen to 273 ng/mL (ref 99-254) and pituitary function remained intact. 

Histological examination of the tumour revealed islands of pituitary adenoma embedded in a neuropil substrate made up of ganglion-like cells, some of which showed dysplastic features (cytomegaly, binucleation and dysmorphism).  Ganglion cells were embedded within both the adenoma and the neuroglial tissue.  Immunohistochemistry confirmed that the adenoma cells were positive for GH & prolactin, with scattered cells positive for TSH also.  In addition, a subpopulation of the ganglion cells also showed strong staining for prolactin, and weak staining for GH, TSH and ACTH.  Both pituitary adenoma and ganglion cells were strongly positive for synaptophysin; chromogranin only stained rare small cells.  Glial fibrillary acid protein staining was generally negative throughout.  The neural tissue features were typical of a neuronal choristoma. 

The combination of a pituitary adenoma with neuronal choristoma (PANCH) is a very rare form of pituitary pathology.  The finding of neuronal tissue expressing GH and prolactin in association with a somatotroph adenoma is intriguing.  The pathogenesis of this phenomenon is not clear.  It has previously been suggested that the GH adenoma arises from paracrine stimulation from the neural tissue; however the finding of prolactin and GH positive staining in the neural tissue component argues against this mechanism.  The combination of two distinct GH & prolactin-positive cell types, pituitary adenoma and gangliocytoma, occurring within a single tumour, suggests two possible mechanisms: that the neuronal cell population arises as a result of neuronal differentiation within a pituitary adenoma, or that both neuronal and anterior pituitary cells develop from a common embryonic cell origin.  Further work will be required to clarify the specific cellular origin of this rare form of pituitary pathology.

 

Nothing to Disclose: JA, QBL, UP, JP

14479 3.0000 SAT-0591 A Immunohistochemical Features of Pituitary Adenoma with Neuronal Choristoma (PANCH), a Rare Cause of Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

John D. Carmichael*1, Maureen P Neary2, Eunice Chang3, Michael S. Broder3 and William H Ludlam2
1Cedars-Sinai Med Ctr, Los Angeles, CA, 2Novartis Pharmaceuticals Corporation, East Hanover, NJ, 3Partnership for Health Analytic Research, LLC, Beverly Hills, CA

 

About half of acromegaly patients require treatment after surgery, usually with pharmacologic therapy. If treatment goals are not met by initial therapy, multiple modalities or medications may be required. Guidelines regarding treatment sequencing are vague, and little is known about which drug treatments are used most commonly and in what order.

This study combined data from 2 major US insurance claims datasets during 1/1/2002-12/31/2010. Patients who had at least 2 medical claims with acromegaly (ICD-9-CM code 253.0) in any diagnosis field and at least 1 pharmacologic treatment claim were included. Treatments were identified in pharmacy and medical claims using National Drug Codes (NDC) and Healthcare Common Procedure Coding System (HCPCS) codes. We reported patient demographics as well as first, second, and subsequent drug therapy, treatment duration, and patterns of treatment switching.

Among 740 patients newly treated with drug therapy during 2002-2010, octreotide LAR was the most common drug used (31.2% of patients). Median first-line treatment duration was 163 days; however, duration was censored in 44.1% of patients.  An analysis was performed on the sample of patients from 2008-2010, to allow for review of treatment sequences focused in more recent years.  Among the 371 patients who initiated first-line drug therapy during this time period, 63.8% received somatostatin analogues (octreotide LAR 29.6%; octreotide SA 18.6%; lanreotide 15.6%), 29.9% received dopamine agonists, and 6.2% received pegvisomant.

During 2008-2010, 503 patients received 2 different drug therapies. Somatostatin analogues were the most common single-agent second-line treatment (49.9%), followed by dopamine agonists (16.3%). Multi-drug combinations were used in 19.7% of patients; somatostatin analogues were included in 88.9% of combination therapies. Median second-line treatment duration was 190 days; however, duration was censored in 46.9% of patients.

Among 209 patients receiving 3 different drug therapies, somatostatin analogues again were the most common single-agent third-line treatment (51.2%), followed by dopamine agonists (17.7%). Combination therapy was used in 16.3% of patients; somatostatin analogues were included in 81.5% of combination therapies.

This study, using claims data from across all major regions of the US, demonstrates the wide variety of treatment patterns used in clinical practice. This variation may reflect differences in physician experience or patient clinical characteristics, or a lack of consensus on ideal treatment sequencing; these reasons cannot be fully studied using claims data. Further investigations will explore the impact of treatment decisions on cost and utilization.

 

Disclosure: JDC: Advisory Group Member, Genentech, Inc., Advisory Group Member, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Pfizer, Inc.. MPN: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. EC: Employee, Partnership for Health Analytic Research, LLC. MSB: Employee, Partnership for Health Analytic Research, LLC. WHL: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals.

16418 4.0000 SAT-0592 A Patterns of Pharmacologic Treatment in US Patients with Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Nicolas Marcelo Vitale, Maria Eugenia Cespedes* and Alberto Benjamin Chervin
Hospital Santa Lucia, Buenos Aires, Argentina

 

Introduction: Even if surgery is the treatment of choice, at present somastotatin analogs are more frequently used as primary indication.

Materials and Methods: we retrospectively evaluated at a single site 59 patients (p) with acromegaly treated with octreotide (OCT): 24 males and 35 females between 19 and 81 years old; 28 p (47.45%) received OCT as primary therapy (group A): 10 microadenomas (m) and 18 macroadenomas (M) with no visual impairment, and 31 (52.54%) post-surgery (group B), all M.

Treatment duration ranged between 6 and 108 months. Nineteen patients received 20 mg/28 days (in 12 p were subsequently increased to 30 mg) and 40 initially received 30 mg.

Pegvisomant (PEG-V) was added in 6 cases and in 1 case OCT was replaced with PEG-V. 39 patients received concomitant treatment with cabergoline (CAB) and 10 adjuvant radiotherapy (RT).

We defined: a) complete biochemical response as a decrease in GH levels below 2.5 ng/ml and normalization of IGF-1 according to gender and age, and partial response as a decrease in GH and/or IGF-1 levels below 50%, b) complete clinical response as resolution of signs and symptoms, c) tumor shrinkage as reductions greater than 25% from baseline.

Results: Thirty subjects (50.84%) achieved complete biochemical response: 17 out of 30 (56.66%) received 30 mg, 9 (30%) 20 mg and 4 (13.33%) achieved it after dose increase; 25 subjects (42.37%) exhibited partial response.

After addition of PEG-V, 2 patients had complete response and 4 had partial response. Seventeen out of 39 p treated with CAB and 5 of 10 p receiving RT, achieved complete response.

Adverse effects were biliary sludge and/or lithiasis in 34.48%.

Groups (A and B) were compared: 14 p of group A (50%) and 16 (51.61%) of group B, achieved complete biochemical response, while 13 p in group A (46.42%) and 12 in group B (38.7%) had partial response.

Complete clinical response was achieved in 21 p from Group A and 19 from Group B. Tumor shrinkage was observed in 16 p from Group A (61.53%) and in 5 from Group B (23.8%), excluding 2 p from A (with RT) and 10 from B (8 with RT and 2 with no postoperative tumor residues).

Conclusion: half of patients achieved normalization of GH and IGF-1 levels with OCT as monotherapy or combined with other drugs, with resolution of symptoms in near 70%. No differences were found in clinical and biochemical response between groups A and B. It should be noted that tumor shrinkage occurred in a larger number of patients in group A.

 

Nothing to Disclose: NMV, MEC, ABC

11176 5.0000 SAT-0593 A Comparative Results of the Use of Octreotide As Primary Therapy Versus Post-Operative Indication 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Yuki Kasamo*1, Shingo Fujio2, Mika Habu2, Syunji Yunoue3, Hirofumi Hirano4, Hiroshi Tokimura2, Kazunori Arita2, Hiroshi Arimura3 and Yoshihiko Nishio2
1Graduate School of Medical and Dental Sciences, Kagoshima University, Kaghosima, Japan, 2Graduate School of Medical and Dental Sciences Kagoshima University, Kagoshima, Japan, 3Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan, 4Graduate School of Medical and Dental Sciences Kagoshima University, kagoshima, Japan

 

【Purpose】The Acromegaly Consensus Group met in 2009 to revisit the guidelines on criteria for cure as defined in 2000. We investigated the differences of the therapeutic effects and clinical features in surgically-cured acromegalics according to these two criteria.

【Patients and methods】From 2005 through 2013, 73 acromegalics underwent endonasal-transsphenoidal surgery in our hospital. We were able to assess postoperative GH secretory function in 69 patients. On the basis of random GH, nadir GH after OGTT, and IGF-1 level, the patients’ GH secretory status was categorized into three groups;  controlled group (C, 35 patients: 15 male and 20 female): random GH <1 ng/L or nadir GH after OGTT<0.4 ng/L and a normal IGF-1 level, conventionally controlled group (CC, 19 patients: 6 male and 13 female): nadir GH after OGTT<1 ng/L and a normal IGF-1 level, and poorly controlled group (PC, 15 patients: 4 male and 11 female): nadir GH after OGTT>=1 ng/L. We analyzed these three groups and investigated clinical outcomes of each.

【Results】PC group was younger than C and CC groups (mean age: PC 39±16 years vs C 51±12 years, p=0.003; vs CC 52±18 years, p=0.046 ). There were no significant differences among the groups based on pre-surgical tumor size, GH level, and IGF-1 SD scores. Multiple regression analysis showed that pre-surgical knosp grades showed positive correlation with nadir GH during OGTT. HbA1c level 6 months after surgery was lower than pre-surgical HbA1c in C group (p= 0.003), HDL-CHO was postoperatively elevated in C and CC groups（p<0.01、p<0.01, respectively）. HOMA-R was postoperatively decreased in C, CC, PC groups（p<0.01、p<0.01、p<0.01, respectively）. There were no differences among these three groups based on postoperative total cholesterol, LDL, HDL, HbA1c and HOMA-R. Based on SF36, C group showed that post-surgical MCS score was higher than pre-surgical score (p＝0.013). Postoperative MCS did not differ between C and CC groups.

【Discussion】Remission rate after surgery in our hospital was 51% according to Acromegaly Consensus Group’s new criteria.  Patients with low knosp grade tended to achieve remission after surgery. According to new criteria, surgically-cured acromegalics improved lipid profile, sugar profile and QOL, but there were no differences regarding clinical outcomes according to the two criteria.

 

Nothing to Disclose: YK, SF, MH, SY, HH, HT, KA, HA, YN

13798 6.0000 SAT-0594 A Therapeutic Effects in Acromegalics According to the Latest Criteria 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Aimee J Varewijck*1, Aart Jan van der Lely1, Sebastian J.C.M.M. Neggers2, Steven W.J. Lamberts3, Leo J. Hofland1 and Joseph A M J L Janssen1
1Erasmus MC, Rotterdam, Netherlands, 2Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands, 3Erasmus Medical Center, Rotterdam, Netherlands

 

Background: Currently available IGF-I assays produce different total IGF-I values within the same serum samples. Using serum total IGF-I levels for diagnosis and long-term monitoring of therapy in acromegaly may therefore lead to different clinical interpretations and treatment decisions when different IGF-I immunoassays are used.

Aim of the study: To compare total IGF-I values measured by Siemens Immulite 2000 total IGF-I assay to the IDS-iSYS total IGF-I assay, in serum samples from patients with untreated acromegaly and during their treatment follow-up.

Methods: Total IGF-I values were measured in 14 acromegalic patients: before and 12 months after starting medical treatment. Total IGF-I was measured both by Immulite 2000 (calibrated against standard WHO IRR 87/518) and IDS-iSYS (calibrated against standard IS 02/254).  For both assays individual Z-scores were calculated using assay-specific age-specific normative range values.

Results: Immulite 2000: After 12 months of medical therapy, total IGF-I decreased from 79.7 ± 37.2 nmol/L (mean ± SD) (baseline) to 39.4 ± 16.8 nmol/L (P=0.002); Z-score decreased from 10.9 (range 2.7 to + 23.6) (baseline) to 3.6 (0.6-9.3) (p=0.002). IDS-iSYS: After 12 months of medical therapy, total IGF-I decreased from 75.4 ± 37.9 nmol/L (baseline) to 33.5 ± 14.3 nmol/L (after 12 months medical therapy (P=0.001); Z-score decreased from 9.8 (range 2.1 to + 24.7) (baseline) to 2.8 (0.99 to 7.4) (p=0.001).

Absolute values for IGF-I between both assay methods did not differ at baseline (p=0.18) but became significantly different after 12 months of medical therapy (p=0.009); Z-scores for IGF-I did not differ significantly between both methods at baseline (p=0.16), nor after 12 months of therapy (p=0.18).

Conclusions. Although, absolute values for total IGF-I were significantly different between both assay methods after 12 months of therapy, Z-scores for IGF-I did not significantly differ between both assay methods at baseline nor after 12 months of medical therapy. Our study suggests that the introduction of the new IDS-iSYS total IGF-I assay probably does not have important consequences for the diagnosis and clinical interpretation of IGF-I values during treatment of acromegaly.

 

 

Nothing to Disclose: AJV, AJV, SJCMMN, SWJL, LJH, JAMJLJ

13126 7.0000 SAT-0595 A The Introduction of the Ids-Isys Total IGF-I Assay Probably Does Not Have Clear Consequences for the Clinical Interpretation of Total IGF-I Levels in the Diagnosis and Treatment of Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Susana Mallea Gil*1, Ignacio Bernabeu2, Adriana Spiraquis1, Lourdes Loidi3 and Carolina Ballarino1
1Hospital Militar Central, Buenos Aires, Argentina, 2Complejo Hospitalario Universitario de Santiago de Compostela, Universidad de Santiago de Compostela, Santiago de Compostela, Spain, 3Fundación Pública Galega de Medicina Xenómica, Complejo Hospitalario Universitario de Santiago de Compostela, Universidad de Santiago de Compostela

 

Background: Pegvisomant (PEG) is one of the most effective therapies for acromegaly. It is usually well-tolerated; however, it might cause adverse events such as drug-induced liver injury. Bernabeu et al. found that the UGT1A1*28 genotype associated with Gilbert´s syndrome predicts an increased incidence of liver abnormalities during PEG therapy in Spanish acromegalic patients (1).

Clinical case: In 1996 a 39-year-old man was sent to the Endocrinology Service because he presented arterial hypertension. He had a 2-year history of headaches, sweating, feet and hands enlargement, weight gain, erectile dysfunction and hyperglycemia. Lab tests: IGFI: >5.4 U/ml (NR: 0.6-5.4), OGTT: non-suppressible GH. MRI confirmed a pituitary adenoma of 18 x15 mm. A transsphenoidal surgery was performed. The symptoms and hormonal test improved, GH and IGFI levels continued slightly elevated. Bromocriptine was indicated without normalization of IGFI. Two years later, he was medicated with cabergoline with poor tolerance and response. In 2005 he was started on octreotide 30 mg monthly. In 2007 the patient underwent coronary bypass surgery. In 2010 a cholecystectomy was performed. In 2012 octreotide was switched to lanreotide 120 mg monthly. Because of increased IGFI levels, in March 2013 PEG 15 mg was added every other day. The liver function tests were normal. Four months later, the patient began with abdominal pain, severe asthenia and decreased appetite. Liver test showed: alanine aminotransferase: 1858 UI/l (NR: 10-41), aspartate aminotransferase: 1196 UI/l (10-40), alkaline phosphatase: 272 UI/l (40-129), total bilirubin: 1.56 mg/dl (0.1-1), g-glutamyl transpeptidase: 739 UI/l (8-619). Tests for viral and autoimmune hepatitis were negative. Elevated Ferritin: 4836 ng/ml (30-400), iron: 180 ug/dl (59-158), transferrin saturation: 104% (15-50) suggested probable hemochromatosis. A liver biopsy was performed: severe cholestatic hepatitis and hemosiderosis. A heterozygous genotype UGT1A1*28 polymorphism was found.

Liver function tests returned to normal 2 months after PEG discontinuation.

Conclusion:  Drug-induced liver injury is the most serious adverse event resulting from PEG therapy in acromegalic patients. It is reversible even in severe hepatitis, as in the case of this patient. A heterozygous genotype UGT1A1*28 was found in this male Argentine patient confirming the increased incidence of liver dysfunction during PEG therapy in Spanish patients carriers of UGT1A1*28 allele.

 

Nothing to Disclose: SM, IB, AS, LL, CB

12510 8.0000 SAT-0596 A Pegvisomant-Induced Cholestatic Hepatitis in an Acromegalic Patient with UGT1A1*28 Mutation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Meltem Zeytinoglu*1, Jill Apel2, Savitri Fedson1, Gene H Kim1 and Robert M Sargis1
1University of Chicago, Chicago, IL, 2Rush University Medical Center, Chicago, IL

 

Background: 

Cardiovascular disease is an important complication of acromegaly, contributing to increased morbidity and mortality. Acromegalic cardiomyopathy is characterized by a set of histologic and structural changes, including myocardial hypertrophy with interstitial fibrosis, lymphomononuclear infiltration, myocyte necrosis, and biventricular hypertrophy. These changes ultimately compromise systolic and diastolic function, and are present in more than 90% of patients with prolonged GH excess (1). 

Clinical case:

A 56 year-old male presented with acute worsening of headaches that had been present for one month. His medical history was remarkable for hypertension, hyperlipidemia, chronic kidney disease from LECT-2 amyloidosis, and non-ischemic dilated cardiomyopathy for which he had two prior orthotopic heart transplants. A head CT scan revealed a soft tissue density extending from the left cavernous sinus into the sella turcica. Pituitary MRI demonstrated an enlarged left half of the pituitary and the appearance of a partial empty sella on the right. Hypothalamic-pituitary hormonal function was unremarkable other than an elevated IGF-1 level (464 ng/mL, N<225 ng/mL), with normal GH (1.5 ng/mL, N<4.2 ng/mL) and IGF-1 Binding Protein 3 (6.6 mcg/mL, N <6.9 mcg/mL) levels. A 75-gram oral glucose tolerance test was performed, and GH was found to be non-suppressible. With a diagnosis of acromegaly, the patient underwent transsphenoidal resection of the presumed GH-secreting adenoma. Surgical pathology revealed a 0.7 cm pituitary microadenoma with patchy staining for GH. The patient's cardiomyopathy was previously deemed idiopathic. Review of surgical pathology from his native heart revealed mild atheromatous changes, cardiomegaly with biventricular dilatation, diffuse myocyte hypertrophy with associated lymphocytic infiltration and interstitial fibrosis. Seven years following initial transplant, the patient developed worsening heart failure and underwent re-transplantation. Pathology of the resected transplanted heart was notable for coronary artery vasculopathy, negative amyloid staining, patchy fibrosis, and large aggregates of lymphocytes disrupting normal myocyte architecture. 

Conclusion:

Acromegalic cardiomyopathy is a rare cause of heart failure, but may be reversible with medical or surgical therapy. Longer duration and older age portend worse outcomes. In some patients, heart failure may be so severe as to require transplantation. Few cases have been reported on acromegalic patients receiving transplantation, and it is unclear if persistent growth hormone excess accelerates transplant failure. Here, we report a case of recurrent heart failure likely exacerbated by GH excess. While rare, measurement of IGF-1 levels in patients with idiopathic cardiomyopathy may identify a small subset of patients who may respond to GH-directed therapies.

 

Disclosure: RMS: Advisory Group Member, CVS Caremark. Nothing to Disclose: MZ, JA, SF, GHK

13330 9.0000 SAT-0597 A Recurrent Post-Heart Transplant Cardiomyopathy in a Patient with Undetected Growth Hormone Excess 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Jonathan Huang*, Luis Miguel Franco, Cynthia Peacock and Morali Divatia Sharma
Baylor College of Medicine, Houston, TX

 

Background: Patients with rare chromosomal abnormalities may have clinical features suggesting additional medical conditions that can be easily overlooked and assumed as part of the chromosomal abnormality phenotype.

Clinical case: A 53-year-old man was diagnosed at the age of 33 with a deletion in the distal long arm of chromosome 1 (1q43). The deletion was initially found on karyotype. It was later confirmed by chromosomal microarray analysis to involve a complex rearrangement in chromosome 1q: a small (530-620 Kb) duplication at 1q43 and a large (8.4-8.5 Mb) terminal deletion distal to the duplication. He is the oldest known surviving patient with this syndrome and has been followed by the adult genetics service for many years. Notable features of this syndrome observed in this patient include dysmorphic facial features (microcephaly and hypertelorism), intellectual disability, impaired motor function (wide-based gait), and seizure disorder (1). However, unlike other cases reported in the literature, the patient also had cutis verticis gyrata, bilateral exotropia, hypertrophy of frontal bones, marked prognathism, oily skin texture, and macroglossia. Many of these additional features were assumed to be part of the genetic abnormality phenotype for years. By age 53, the patient had also developed cardiomyopathy with congestive heart failure (ejection fraction 20-25%), hypertension, hyperlipidemia, and benign prostatic hyperplasia. These conditions were presumed to be age-related medical conditions.

As part of the patient’s seizure workup, a routine MRI brain without contrast incidentally revealed an enlarged pituitary gland. The patient was then referred to endocrinology and initial evaluation confirmed a diagnosis of acromegaly with elevated growth hormone (90.20 ng/ml, nl 0.06-5.00 ng/ml) and elevated IGF-1 (813 ng/ml, nl 87-267 ng/ml). He was started on monthly lanreotide injections as the patient was high risk for surgery due to his cardiomyopathy. His pituitary function was otherwise normal except for secondary hypogonadism for which he was given low-dose testosterone replacement. Over the course of the following two years, growth hormone levels improved (15.1 ng/ml) and IGF-1 levels returned to normal (247 ng/ml). Echocardiogram also exhibited improvement in cardiac function (ejection fraction 30-34%) with therapy. At this point, the family refused pituitary surgery so lanreotide was continued.

Conclusion: This is the first case to be reported of a patient with terminal chromosome 1q deletion syndrome and a pituitary macroadenoma manifesting as acromegaly. Clinical manifestations of known disorders, like acromegaly, can be subtle and easily overlooked in patients with concurrent genetic abnormalities that have unique phenotypic characteristics. Clinicians should avoid anchoring bias and maintain a high degree of suspicion for other coexisting conditions.

 

Nothing to Disclose: JH, LMF, CP, MDS

14819 10.0000 SAT-0598 A Acromegaly in a Patient with a Chromosome 1q43 Deletion 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Kentaro Suda*1, Ryusaku Matsumoto1, Hidenori Fukuoka2, Genzo Iguchi2, Yushi Hirota2, Hironori Bando1, Hitoshi Nishizawa1, Michiko Takahashi1, Kazuhiko Sakaguchi2 and Yutaka Takahashi1
1Kobe University Graduate School of Medicine, Kobe, Japan, 2Kobe University Hospital, Kobe, Japan

 

Although it is well known that serum IGF-I levels are negatively correlated with HbA1c in patients with type 1 diabetes, those are generally unchanged in patients with type 2 diabetes (T2DM) because of the influence of obesity. It has also been reported that patients with acromegaly who demonstrate poorly controlled diabetes sometimes exhibit normal or decreased serum IGF-I levels. The aim of this retrospective study was to evaluate the effect of type 2 diabetes on serum GH and IGF-I levels in relatively lean Japanese patients.

A total of 327 hospitalized patients (189 men and 138 women; age 60.5±14.2; body mass index (BMI) 26.9±5.9 kg/m2; HbA1c 9.1±2.1 %) with T2DM in Kobe University Hospital from 2011 to 2013 were enrolled. Patients with pituitary disease and pregnant women were excluded. Serum GH and IGF-I level were measured, and analyzed the factors correlated between serum GH or IGF-I levels and diabetes-related factors such as fasting plasma glucose (FPG), HbA1c levels, BMI, duration of diabetes, HOMA-IR, and fasting C peptide levels (CPR).

Although there were no correlations between the serum GH levels and FPG or HbA1c, serum IGF-I levels were significantly decreased in patients with FPG³a200mg/dl compared with those with FPG <200mg/dl (IGF-I SDS -0.68±1.74 vs. -0.02±1.42, p = 0.02). In addition, serum IGF-I levels were significantly decreased in in patients with HbA1c ³a12% compared with those with HbA1c<12% (IGF-I SDS -0.64±1.29 vs. -0.05±1.47, p = 0.04). Multiple linear regression analyses revealed that CPR levels were positively correlated with serum IGF-I levels (p = 0.04), while there were no correlations with BMI, duration, FPG, or HbA1c levels.

In conclusion, serum IGF-I levels significantly decreased in relatively lean Japanese patients with poorly controlled T2DM. Impaired insulin secretion may play a role as a mechanism. It is suggested that in the diagnosis of acromegaly with poorly controlled diabetes, these factors should be taken into account.

 

Nothing to Disclose: KS, RM, HF, GI, YH, HB, HN, MT, KS, YT

13580 11.0000 SAT-0599 A The Effect of Type 2 Diabetes on Serum GH and IGF-I Levels in Relatively Lean Japanese Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Birgit Harbeck*1, Sven Sufke1 and Hendrik Lehnert2
1University of Lübeck, Lübeck, Germany, 2University of Luebeck, Luebeck, Germany

 

Introduction:

Acromegaly is a rare but clinically important endocrine disease caused by growth hormone excess, usually from a pituitary adenoma. The prevalence of acromegaly is estimated to be 4-6 cases per million per year. GH-producing pituitary adenomas frequently cosecrete prolactin, less common other certain anterior pituitary hormones.

Clinical Case:

A 45 year-old male patient with a history of pancreoprivic diabetes mellitus was admitted to the hospital with severe hyperglycemia. Clinical examination showed signs of acromegaly. Medical history revealed chronic alcoholism; a lesion of the pituitary gland had been detected earlier. Laboratory evaluation showed elevated levels for glucose and HbA1c as well as high levels of IGF-1. The patient underwent extensive endocrinological work-up. Blood tests demonstrated elevated levels of GH, ACTH and cortisol. LH, FSH and testosterone were suppressed. 1 mg- and 8 mg-dexamethasone suppression tests were performed, showing suppression only with 8 mg. CRH stimulation pointed to central hypercortisolism. In conclusion, a GH-/ACTH-coproducing pituitary adenoma was suspected. Pseudo-Cushing´s syndrome was excluded. Biochemical evaluation was followed by MRI of the pituitary which showed evidence of a pituitary macroadenoma (20x15x12mm) infiltrating left sinus cavernosus. Ophthalmological examination demonstrated bilateral quadrantanopsias. Transsphenoidal surgery for the pituitary adenoma was successfully performed. Pathological findings confirmed the diagnosis of a hormonally active pituitary adenoma cosecreting STH and ACTH. After surgery acromegaly and clinical symptoms markedly improved and cortisol secretion normalized. The patient made an uneventful recovery.

Conclusions:

GH-/ACTH-cosecreting pituitary adenomas may present with severe hyperglycemia. Further investigations, including endocrine testing and imaging, are needed to detect the underlying tumor.

 

Nothing to Disclose: BH, SS, HL

12474 12.0000 SAT-0600 A Severe Hyperglycemia As Initial Manifestation in a Patient with Acromegaly and Coexisting Preclinical Cushingxs Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Melek Eda Ertorer*1, Hulya Karaoglu Serinsöz1, Sibel Bascil2, Okan Sefa Bakiner1, Emre Bozkirli1 and Neslihan Bascil Tutuncu3
1Baskent University Faculty of Medicine, Adana, Turkey, 2Baskent University Faculty of Dentistry, Adana, Turkey, 3Baskent University Faculty of Medicine, Ankara, Turkey

 

INTRODUCTION: Bone mineral densitometry (BMD) measurements are usually unpredictable due to interfering factors in acromegaly. Eugonadal acromegalic patients exhibit increased cortical bone BMD at distal radius, whereas trabecular bone at spine usually demonstrate insignificant change. Osteoporosis is usually due to accompanying hypogonadism and results in decrease in lumbar vertebral BMD. Growth hormone is also an important factor acting on gingival tissue and alveolar bone. In this study, we aimed to evaluate BMDs and presence of periodontitis of cases with acromegaly and inquire the impact of interfering factors.

MATERIAL AND METHODS: Forty-seven acromegalic patients and 60 age-matched controls with any accompanying condition known to affect calcium and bone metabolism were included. Age, gender, duration and activity of acromegaly, past and present therapy options, pituitary hormone profiles and replacement therapies, periodontal analysis were recorded.  

RESULTS: Eighteen males (38.3%) and 29 females (61.7%) with a mean age 46.6±11.5 years were included. Twenty-five (53.1%) had active, 22 (46.8%) had inactive acromegaly. The latter were older, had longer duration of disease; p=0.04, p=0.003, respectively. Serum calcium, phosphorus levels, 24-hour urinary calcium excretion levels and BMD measurements at lumber spine and femur neck exhibited insignificant difference regarding disease activity (p>0.05). Osteoporosis was detected in 6 cases (12.76%) in study group. One acromegalic man exhibited low density at femur, whereas five patients; two premenopausal and three postmenopausal women demonstrated osteoporosis at lumbar spine. More number of cases had periodontitis in control group (66.7% vs 44.7%), being dominantly advanced periodontitis (43.3% vs 12.8%) (p=0.022 and p=0.0001, respectively). Number of cases with chronic periodontitis and the severity were indifferent between active and inactive acromegaly groups; 48% vs 40.9% (p>0.05). Other study parameters were indifferent, as well. Repeated measures analysis of variance performed to investigate the relationship between GH change in time and periodontitis subgroups demonstrated statistically insignificant distribution (p>0.05).

DISCUSSION: Herein, we demonstrated that acromegaly exerted no clear negative impact on vertebral BMD in the absence of overt hypogonadism. Detection of less number of cases with periodontitis with less severity had been considered as a supportive data to that finding. Moreover, it is possible that chronic exposure to excess growth hormone may have a protective effect against periodontitis. However this proposal needs to be proven with larger number of patients.

 

Nothing to Disclose: MEE, HKS, SB, OSB, EB, NBT

12854 13.0000 SAT-0601 A Low Prevalence of Periodontitis and Preserved Vertebral Bone Density in Acromegaly: Excess GH May Not Impact Negatively on Trabecular Bone 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Mirela Costa de Miranda*1, Marilena Nakaguma2, Felipe HG Duarte1, Raquel S Jallad3 and Marcello D Bronstein4
1Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Sao Paulo, Brazil, 2Hospital das Clinicas, University of São Paulo Medical School, São Paulo, SaoPaulo, 3Hosp das Clinicas Univ of Sao Paulo Medical School, Sao Paulo SP, Brazil, 4University of São Paulo Medical School, São Paulo, Brazil

 

Dramatic size reduction with primary pharmacological therapy of a giant pituitary macroadenoma in an acromegalic patient.

Authors: Mirela C de Miranda MD, Marilena Nakaguma MD, Felipe H. G. Duarte, MD, PhD, Raquel S Jallad MD, PhD, Marcello D Bronstein MD, PhD

Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clinicas, University of São Paulo Medical School, São Paulo

Background: Primary pharmacological therapy may be the only viable treatment option for many patients with acromegaly, especially those presenting with large invasive tumors. Long-acting somatostatin analogs are currently the first-line treatment of choice in this setting, where they can provide biochemical control and reduce tumor size in a significant proportion of patients. However, the dose and duration of follow up has not been standardized. There are, moreover, indications that biochemical and tumor shrinkage effects may be dissociated in acromegaly (1).  Case report: A 51 years old woman presented with clinical and biochemical evidence of acromegaly. Serum GH was high at 30.4ng/mL, IGF-1 was 4.5 times the upper level of normality and serum PRL 3600ng/mL. The patient presented visual impairment and pituitary MRI depicted a large and invasive mass (7.0 x 6.3 x 5.8 cm), extending superiorly into the optic chiasm and the III ventricle, without invading the cavernous sinuses. She was put on cabergoline, 1.5mg per week, and MRI three months after showed a tumor reduction of almost 30% of its volume. However, as hormonal control was not achieved, octreotide-LAR, 20mg each 28 days, was associated. Octreotide-LAR and cabergoline doses were progressively increased up to 40mg each 28 days and 7mg/week, respectively. After three years of follow up, the patient presented with 85% reduction of its initial volume, current size 4.0 x 3.5 x 3.0 cm, but without complete hormonal control (GH: 0.9ng/mL; IGF1 2xULN; PRL: 9.4 ng/mL). Conclusion: This case illustrates a progressive and dramatic tumor size reduction through primary pharmacological treatment of acromegaly in a long-term follow up with high doses of cabergoline and octreotide-LAR. It points out the effectiveness of pharmacological therapy for acromegaly in cases non-expected to be surgical cured and making a potential harmful debulking unnecessary.

References: Casarini AP, Pinto EM, Jallad RS, Giorgi RR, Giannella-Neto D, Bronstein MD. Dissociation between tumor shrinkage and hormonal response during somatostatin analog treatment in an acromegalic patient: preferential expression of somatostatin receptor subtype 3.J Endocrinol Invest. 2006;29(9):826-30.

 

Nothing to Disclose: MCDM, MN, FHD, RSJ, MDB

15092 14.0000 SAT-0602 A Dramatic Size Reduction with Primary Pharmacological Therapy of a Giant Pituitary Macroadenoma in an Acromegalic Patient 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Bernardo Dias Pereira*1 and Ana Maria Fortuna2
1Hospital Garcia de Orta, E.P.E., Almada - Setúbal, Portugal, 2Centro Hospitalar do Porto, E.P.E., Porto, Portugal

 

Background: Acromegaloid Facial Appearance (AFA; OMIM: 102150) syndrome is a very rare inherited cause of pseudoacromegaly characterized by progressive coarsening of facial features, overgrowth of oral mucosa and large, doughy hands. Nowadays 6 case reports have been described (1-3). Here we describe a further family with AFA syndrome.

Clinical cases: Probands were a 31 yo female and his 37 yo brother which were reffered to our department due to suspected acromegaly. Both siblings had a previous history of oral surgery 13 and 20 years ago due to hypertrophic intraoral tissue. Additionally, the male proband had mild learning difficulties, uncontrolled hypertension, left ventricular hypertrophy and a paroxystic atrial fluter. He was medicated with lisinopril 5 mg, amiodarone 200 mg and clobazam 10 mg. Family history was remarkable for their mother, which was remembered by both siblings as having “rough facial features”. At physical examination both patients were hypertensive (male: 135/100 mmHg; female: 140/92 mmHg), obese (male BMI: 38.9 Kg/m2; female BMI: 30.2 Kg/m2), and had a raised cephalic perimeter (CP; male CP: 60 cm, >+2SD; female CP: 57 cm, +2SD). Their facial appearance was globally coarse with thickened lips and superior eyelids, enlarged nose and marked gingival hypertrophy. Additionally, enlarged doughy hands without digital clubbing were noticed, as was hyperextensibility of metacarpophalangeal joints. Biochemical surveys of both siblings revealed no evidence of abnormal glucose metabolism, hypothyroidism or GH axis hypersecretion. High-resolution chromossomal analysis found no abnormalities. At follow-up both patients underwent repeated oral surgeries due to their evolving extensive gingival hypertrophy. Taking into account the aforementioned familiar phenotype, AFA syndrome was considered the final diagnosis of this syndrome of somatic overgrowth.

Conclusion:  Here we presented a further kindred with AFA syndrome affected in 2 consecutive generations. We also highlight the importance of a carefull family history and physical examination to collect the striking features of each disorder associated with an acromegaloid phenotype and achieve a correct diagnosis. Additionally, apropriate biochemical surveys can exclude an endocrine-related etiology and avoid further unnecessary and expensive investigations.

 

Nothing to Disclose: BDP, AMF

14148 15.0000 SAT-0603 A Is This a Fipa Case? Acromegaloid Facial Appearance Syndrome Should Not be Forgotten in the Differential Diagnosis of Pseudoacromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Kristin Beaver*, Robert L Dodd and Laurence Katznelson
Stanford Univ, Stanford, CA

 

Acromegaly is a condition of growth hormone hypersecretion caused by a somatotroph pituitary adenoma. While transsphenoidal surgery (TSS) is first-line treatment for most patients, it may be contraindicated due to associated morbidities such as severe obstructive sleep apnea syndrome (OSA) that potentially complicate peri- and post-operative management. Somatostatin analogs (SSAs) are the mainstay of medical treatment in acromegaly and have demonstrated benefit with respect to biochemical control and tumor shrinkage. However, there is little information on their potential to improve pharyngeal swelling and OSA, and hence reduce the risk of surgical complications. We present a patient with acromegaly who received a SSA to reduce pharyngeal thickness and macroglossia in an attempt to improve OSA prior to surgery. A 55-year-old male patient presented with typical acromegalic features, including macroglossia, increased spacing of lower teeth, and prognathism. His serum insulin-like growth factor-1 (IGF-1) level was elevated (612 ng/mL [normal, 46–284 ng/mL]), and MRI revealed a 1.4-cm right-sided sellar lesion with no chiasmal compression or cavernous sinus involvement. He had severe OSA treated with a nasal continuous positive airway pressure (CPAP) device. Given the severity of his OSA and pharyngeal thickness, his pulmonologist strongly recommended placement of a tracheostomy for surgical airway management. He was placed on octreotide LAR (20 mg/28 days; dose increased to 30 mg/28 days after 3 months) to normalize IGF-1. After 6 months of SSA treatment, his OSA had improved significantly and TSS was performed safely without the need for tracheostomy. His post-operative IGF-1 was normal, and he was restarted on his nasal CPAP 4 months following surgery. In patients with acromegaly, airway swelling and associated OSA may exacerbate surgical risk by complicating peri- and post-operative airway management. In selected patients, short-duration SSA treatment may alleviate acromegaly co-morbidities, such as OSA, thereby improving surgical candidacy.

 

Disclosure: LK: Consultant, Genentech, Inc., Consultant, Novartis Pharmaceuticals, Investigator, Novartis Pharmaceuticals. Nothing to Disclose: KB, RLD

14259 16.0000 SAT-0604 A Pre-Operative Somatostatin Analog Therapy Reduces Perioperative Risk from Obstructive Sleep Apnea in Acromegaly: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Alfredo Sanchez Cruz*1, Jose Hernan Martinez1, Maria de Lourdes Miranda2, Coromoto Palermo1, Eva Gonzalez1, Oberto Torres1, Monica Santiago1, Carlos Rafael Figueroa2, Rafael Trinidad2, Michelle M Mangual3 and Madeleine Gutierrez1
1San Juan Hospital, San Juan, PR, 2San Juan City Hospital, San Juan, PR, 3Sa, San Juan, PR

 

Background: Acromegaly most commonly results from an excess production of growth hormone (GH) and secondary increase in IGF-1. More than 95% of the time from the pituitary gland, but the source of excess GH secretion may not necessarily be pituitary in origin.  Ectopic Acromegaly may arise due to neuroendocrine tumors by production of GHRH (GH releasing hormone) and in less than 0.5% of the cases from ectopic pituitary remnants in the sphenoid sinus.

 Clinical Case:  We present a case of a 37 years old man with typical symptoms of acromegaly. Initial laboratory evaluation consistent with the diagnosis of acromegaly, hGH= 2.699 ng/ml (0.014-1.406 ng/ml) and IGF-1= 956.00 ng/ml (109-284ng/ml), prolactin and TSH levels were normal. A Brain MRI with special attention to pituitary gland revealed normal size and configuration with no definitive lesions identified. However a large heterogeneous mass involving the sphenoid sinus extending into the posterior ethmoidal air cells was seen. Patient underwent transphenoidal surgery. Immunostaining analysis of the sphenoidal mass revealed; GH (+), prolactin (+), TSH (+), ACTH (-), FSH (-), and LH (+). Post-surgical evaluation showed persistent levels of GH and IGF-1 (hGH=1.413 ng/ml and IGF-1= 802 ng/ml), and no glucose suppression after an oral glucose tolerance test.  After surgery MRI showed normal size pituitary gland but residual heterogeneous material involving the sphenoidal sinus. Due to the persistence of biochemical and radiological abnormalities patient required Gamma-knife treatment and medical therapy with Cabergoline and Sandostatin.

 Conclusion: In patients with clinically and biochemical evidence of acromegaly but with normal findings in the pituitary gland, ectopic origin due to embryological pituitary remnants should be consider. Ectopic acromegaly is a very rare clinical presentation. Lack of consideration of this etiology could be responsible for failed TES in endocrinologically active tumors.

 

Nothing to Disclose: AS, JHM, MDLM, CP, EG, OT, MS, CRF, RT, MMM, MG

14928 17.0000 SAT-0605 A Acromegaly with a Normal Pituitary Gland 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Charlotte Hoybye*
Karolinska Hospital, Stockholm, Sweden

 

Introduction: A few reports on the short acting somatostatin analogue (SSA) octreotide rapid relieve of severe headache in patients with Acromegaly have been published but this is the first report of octreotide being effective in a patient resistant to long-acting SSA.

Clinical case: A 31 year old woman was admitted in April 2012 with typical signs and symptoms of Acromegaly, including headache. GH was 42 µg/L, IGF-I 1350 µg/L (73-244). MRI showed a supra- and parasellar pituitary macroadenoma. In May 2012 the patient underwent transsphenoidal adenomectomy. Post-operative clinical and laboratory status were unchanged despite a tumour reduction of approximately 50% on MRI. Treatment with a long-acting SSA was initiated, however, without effect on disease activity. In October 2012 the patient was re-operated. Post-operative GH and IGF-I levels were largely unchanged. Treatment with another brand of long-acting SSA was attempted and it also resulted unsuccessful. In July 2013 the tumour remnant was irradiated with the Gamma Knife. The headache became worse and in October 2013 the patient received octreotide sc injections with immediate relief of the headache. Treatment with pegvisomant  and cabergoline was added. In December 2013 IGF-I was 231µg/L but the patient still needs octreotide to control headache. No pituitary insufficiencies have developed and continuous treatment with anti-inflammatory agents, paracetamol and tramadol has been without any relief of headache.

Conclusion: Treatment resistant severe headache in Acromegaly is desperate for the patient and very frustrating for the physician. This clinical case highlights the immediate effect of octreotide in such a patient, a treatment today easily forgotten with long-acting SSA being the treatment of choice in Acromegaly.

 

Nothing to Disclose: CH

14415 18.0000 SAT-0606 A Severe Headache Relieved By Short-Acting Somatostatin Analogue in a Patient with Acromegaly Resistant to Long-Acting Somatostatin Analogues 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Gita Avotina*1 and Ingvars Rasa2
1Riga East Clinical University Hospital, The University of Latvia, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia, 2Riga East Clinical University Hospital, Riga Stradins University, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia

 

Introduction: Risk of developing tumors in acromegaly pts is higher than in the general population. Thyroid cancer is estimated to be the most common between pts with acromegaly, estimated prevalence in the literature is approximately 6%. The calculated risk of thyroid carcinoma in acromegalic pts appears to be 60 higher that is expected to be in the general population. This is fifth reported case in Latvia. Clinical case: A 62yrs old woman with acromegaly and thyroid carcinoma was admitted in 2013 in The Department of Endocrinology in Riga East Clinical University Hospital to decide further therapy. Acromegaly was diagnosed in 2009 and treated with octreotide LAR 30 mg every 28 days, later 20 mg every 21 days due to a severe hormonal activity. In 2009, STH was 19.7ng/mL (normal range 0.06–5.0 ng/mL) and IGF-1 – 860mkg/L (normal range 81–225 mkg/mL), in 2010 – STH was 2.69 ng/mL, in 2011 – STH – 2.22ng/mL, IGF-1 – 235 mkg/L, in 2012 – STH – 2.0ng/mL, IGF-1 – 279mkg/L, in 2013 – STH 2.6ng/mL, IGF-1 – 245 mkg/L. As a result of treatment, pituitary adenoma’s size in magnetic resonance imaging decreased from 1.3cm in 2009 to 1.0cm in 2010. In 2011, pt was diagnosed during thyroid ultrasound exam with multiple thyroid nodules1.6cm and 1.3cm in the left lobe and 1.9cm in the right lobe, which appeared cold in scintigraphy. Core biopsy was performed and it demonstrated papillary thyroid carcinoma. Skeletal technetium (99mTc) sestamibi scan was performed in 2013, which revealed metastasis in 5th right rib and possible metastasis in 5th left vertebrae. Tumor classification: T2mN0M0. Total thyroidectomy was performed and pt was admitted in hospital for radionuclide therapy with J-131 to reduce postoperative residual tissue. Technetium (99mTc) sestamibi scan after radionuclide therapy revealed no dissemination of tumor. Pt follow-up continues at Outpatient Clinic. Conclusion: Although this is only fifth reported case in Latvia, patients with acromegaly is predisposed for development of goiter and tumors. In acromegaly guidelines it is not emphasized that acromegaly patients should be screened for goiter and thyroid cancer. Thyroidectomy and following radionuclide therapy is successful treatment for stage II thyroid carcinoma in patients with acromegaly.

 

Nothing to Disclose: GA, IR

11980 19.0000 SAT-0607 A Case Study about Patient (pt) with Acromegaly and Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Miguel Augusto OMeara*1, Maria I Toro2 and Carlos Alberto Covaleda3
1Cardioinfantil Foundation Cardiology Institute, Bogota, Colombia, 2SAN IGNACIO HOSPITAL, Bogota, Colombia, 3MATERNOINFANTIL HOSPITAL

 

Background

GH-producing adenomas could stimulate overgrowth of other tumors. We described the first case in literature of a GH  adenoma and chondrogenic neoplasm in  the sella turcica  and its possible relationship.

 Clinical Case

A 54 year-old woman was referred to endocrinology due to an incidental finding of pituitary lession and who is diagnosed clinically with acromegaly and supported by paraclinical with elevated basal Gh (basal Gh: 5,95ng/ml n<0.4ng/ml) and not suppressed with the glucose suppression test (30 minutes: 6,37ng/ml, 60 minutes: 14,7ng/ml and 120  minutes:  15,4ng/ml, n<0,3ng/ml)  Somatomedin  C: ( 622ng/ml, n 94 - 252 ng/m)

During clinical follow-up she presented local symptoms with defects of the field of vision, emergency transsphenoidal surgery was required presenting an adequate evolution but with a pathology report described as chordoma, with immunohistochemistry markers: positivity in the tumor cells with EMA, S100, CK A1-A3, and Vimentin and focally for confirming ACE of this lesion

The patient continued postoperative controls at local hospital during the following 10 months, with biochemical controls of somatomedin: normal, but GH levels not within therapeutic goals with octreotide (Greater than 1,0Ung/ml) and with an imaging control that described a neoplasia that occupied the base of the skull specially the sphenoid, the ethmoid cells and the basilar part of the occipital, with  a  infrasellar,  parasellar  and retrosellar  component. 

Ten months later, the patient needed to be taken back to surgery due to tumor growth;  so a  resection was performed again , this time  in the pathology the report confirmed the presence of a GH adenoma

Conclusion

To our knowledge we presented the first reported case of collision sellar tumor that involves a GH producing adenoma and a chondrogenic neoplasm. But There are other types of  joint lessions  described not infrecuenty  perhaps the over expression of IGF1 and PTTG ( present in up to 90% of the GH adenomas) that also   express  fibrolastic growth factor (FGFb), exerts an antiproliferative effect on the chondrocytes  facilitating the growth of such tumors situation  to which Physicians should be aware

 

Nothing to Disclose: MAO, MIT, CAC

13468 20.0000 SAT-0608 A Acromegaly and Chordoma the Coexistence of Two Primary Lesions: Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Charles R Buchanan*1, Dunia Ismail2, Jennifer Kalitsi1, Nadia Gordon1, Peter Bullock1, Ritika R Kapoor1 and Simon J B Aylwin1
1King's College Hospital, London, United Kingdom, 2Royal Alexandra Childrens' Hospital, Brighton, United Kingdom

 

Introduction:

 Pituitary giagantism is a rare condition arising from excessive secretion of growth hormone (GH) during childhood, usually associated with a pituitary micro- or macroadenoma. Succesful treatment goals include limiting final height attainment as well as normalisation of GH to prevent future development of acromegaly and co-morbidities, definitive tumour control, and replacement of any pituitary hormone deficiencies. We present a case requiring the full spectrum of standard therapeutic options to aim for these targets.

 Case Report:

 History: A 15 yr old boy presented with 3 yr history of intractable occipital headache and complaint of rapid, excessive growth during puberty. He was psychologically distressed by his height of 203cm, and how this impacted on social relationships and daily lifestyle. He had mild clinical features suggestive of GH excess. Pubertal development age appropriate. Bone age not advanced. No visual deficit.

 Investigations: Serum IGF-I 103 nmol/L(RR 13-66), Testo 3.7 nmol/L (low for pubertal status), fT4 15pmol/L. Cortisol response to Synacthen was impaired (447 nmol/L at 30 min). Serum GH failed to suppress with oral glucose (basal 28 mcg/L, nadir 11 mcg/L. MRI pituitary was consistent with a pituitary macroadenoma (17mm x 13mm), impinging on posterior aspect of the optic chiasm, with lateral invasion of left cavernous sinus. GH was partially suppressed by Octreotide (100mcg) from 50 to 25 mcg/L by 6 hrs, and possibly better suppression by Pasireotide (600 mcg) from 28 to 8 mcg/L by 6 hrs.

 Treatment & Progress: Testosterone treatment (Nebido 1000 mg IM) was started to accelerate epiphyseal fusion, with hydrocortisone replacement at standard dose. Depot Octreotide was started. Over 2 months the headaches failed to improve and a slight unilateral upper quadrant visual field deficit was apparent. Trans-sphenoidal debulking of tumour was performed, leaving residual left parasellar and posterior tumour mass. Histology showed pituitary adenoma, strongly immuno-positive for GH, with Ki67 3%.

 Outcome: Headaches improved. Visual fields normalised. Post-op. oral glucose suppression showed basal GH level 3 mcg/l. Serum IGF-I levels remained markedly elevated, and treatment with Pegvisamont to block peripheral effects of GH was started, the dose rising to 60 mg/day, which achieved normalisation of IGF-I after 2 months. Epiphyses on hand radiograph for “Bone age” were then effectively fused and height has stabilised at 205 cm.

 Radiotherapy to control residual tumour was offered, but the patient declined at that stage, wishing to focus on a return to his academic studies with a view to radiotherapy after current academic year, unless changed clinical circumstances led to reconsider that plan. However, interval MRI scan after 4 months showed significant increase in residual adenoma and the patient will shortly proceed to radiotherapy.

 

Nothing to Disclose: CRB, DI, JK, NG, PB, RRK, SJBA

15291 21.0000 SAT-0609 A Pituitary Gigantism: A Challenging Paediatric Case 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Kitty Kit Ting Cheung*, Anthony WI Lo and Francis CC Chow
Prince of Wales Hospital, N.T., Hong Kong

 

“Open-and-Close” Pituitary Surgery in an Acromegalic Man, a Lesson to Learn from a Case of Ectopic GHRH Acromegaly

Kitty KT Cheung1, Anthony WI Lo2, Francis CC Chow1

Medicine and Therapeutics1, Anatomical and Cellular Pathology2

The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong

Background 

Ectopic-acromegaly is rare. Only 99 cases have been reported in the literature so far. Diagnosing ectopic-acromegaly is challenging given the clinical and biochemical manifestations can almost be indistinguishable from those of patients with growth hormone secreting pituitary adenomas. Failure to distinguish between pituitary and ectopic-acromegaly would lead to unnecessary major neurosurgery. A review of this rare disease through a case illustration serves to reiterate the importance of clinical vigilance required to prevent an unnecessary invasive surgery.    

 

Case Presentation 

The patient was a 41 years old Caucasian man with features of acromegaly. Investigation of showed both enlarged pituitary and a mass lesion in the lung. Excision of the lung mass showed a carcinoid tumor. No tumor was detected in the pituitary during neurosurgery. However, the patient did improve clinically and biochemically. Retrospective investigation on the excised lung mass shows small proportion of tumor cells containing growth hormone releasing hormone (GHRH). This patient was, in fact, suffering from acromegaly, likely due to ectopic GHRH production from the lung neuroendocrine tumor.

 

Conclusion 

An open-and-close transsphenoidal surgery might have been avoided in this patient with ectopic GHRH acromegaly, if the following were considered:  (1) the correct diagnosis being thought of, after the successful resection of the lung carcinoid tumor, (2) a longer wait for the IGF1 to normalize after the lobectomy, (3) prompt demonstration of the presence of GHRH of the resected lung mass, or (4) a measurement of the plasma GHRH level post-operatively.

 

Nothing to Disclose: KKTC, AWL, FCC

11175 22.0000 SAT-0610 A “Open-and-Close” Pituitary Surgery in an Acromegalic Man, a Lesson to Learn from a Case of Ectopic GHRH Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Carlos Rafael Figueroa*1, Jose Hernan Martinez2, Monica Santiago2, Michelle M Mangual3, Madeleine Gutierrez2, Rafael Trinidad3, Alfredo Sanchez4, Paola Mansilla2, Coromoto Palermo2 and Maria de Lourdes Miranda5
1San Juan City Hospital, Caguas, PR, 2San Juan City Hospital, San Juan, PR, 3San Juan City Hospital, 4San Juan City Hospital, PR, 5San Juan City Hosp, Bayamon, PR

 

Thirty-two years old female G2P1A0 seen at our endocrinology clinic nine years ago complaining of persistent menstrual irregularities associated to elevated prolactin values. MRI done revealed a pituitary microadenoma. However, she refused treatment for microprolactinoma. Four years afterwards, patient return complaining of recurrent episodes of headache. Repeated MRI showed a Pituitary Macroadenoma, so start on cabergoline treatment.

Once more, patient was lost to follow up and on 2012 she visited our clinic at 24th weeks of gestation with history of progressive hands and feet enlargement. On physical examination marked prognathism, hands and feet enlargement, acanthosis nigricans and hirsutism were found, so acromegaly was suspected. Elevations of prolactin and IGF-1 levels were found during whole pregnancy.

After six months post-partum, laboratories were repeated and basal and 2hr insulin showed marked elevation, increased HOMA index, and normal IGF-1 and GH values. Thus, the diagnosis of Insulin Mediated Pseudoacromegaly was confirmed.

 

Nothing to Disclose: CRF, JHM, MS, MMM, MG, RT, AS, PM, CP, MDLM

12809 23.0000 SAT-0611 A Young Female with Acromegaloid Pituitary Macroadenoma and an Uncomplicated Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0589-0611 4827 1:00:00 PM Acromegaly: Diagnosis, Management and Outcomes Poster

Nicolas Kissell*, James O. Mudd, Lindsay E. Chong and Kevin C.J. Yuen
Oregon Health and Science University, Portland, OR

 

Introduction: Cardiac abnormalities induced by hypopituitarism are uncommon, and have been attributed to TSH, cortisol and/or GH deficiencies. We report a case of panhypopituitarsim in a woman with undiagnosed Sheehan syndrome for 20 yrs who presented with non-ischemic cardiomyopathy that partially recovered with glucocorticoid and thyroid hormone therapy.

Case: A 40-yr old woman with no previous cardiac history, presented to the ED with cardiogenic shock. Chest X-ray revealed vascular congestion, ECG revealed sinus tachycardia with no ischemic changes, cardiac catheterization revealed non-obstructed coronary arteries, and echocardiography revealed marked tricuspid regurgitation, normal size left ventricle and global hypokinesia with an ejection fraction of 10%. She was treated with vasopressors and an intra-aortic balloon pump. She underwent extensive workup (including an endomyocardial biopsy) but none were revealing to ascertain the cause of her cardiomyopathy. When she became more conscious, she volunteered a history of severe postpartum hemorrhage 20 yrs ago after the birth of her second child that required a partial hysterectomy to control the bleeding. In addition, she subsequently failed to lactate and has been amenorrheic since. This prompted further endocrine workup that revealed the presence of central hypothyroidism, hypoadrenalism, hypogonadism and GH deficiency. Bone densitometry confirmed the presence of osteopenia, while MRI of her pituitary demonstrated an empty sella. She was treated with levothyroxine and high dose hydrocortisone during her hospital stay, and her dose of hydrocortisone was tapered to a maintenance dose of 20 mg/day upon hospital discharge. At 3 and 10 months of follow-up, her 2 echocardiography studies revealed some improvement in her ejection fraction of 35%.

Discussion: This case report highlights the importance of thorough history taking in the diagnosis of cardiomyopathy. In young women presenting with congestive heart failure, it is important to consider panhypopituitarsim as a potential etiology. To our knowledge, no other cases have been reported this far out from the primary insult of postpartum hemorrhage. Additionally, unlike previous case reports demonstrating reversibility of cardiomyopathy following hormone replacement therapy (1, 2), our patient still demonstrated echocardiographic evidence of persistent cardiomyopathy, possibly due to the effects of prolonged duration of untreated panhypopituitarism.

 

Nothing to Disclose: NK, JOM, LEC, KCJY

14001 1.0000 SAT-0694 A Persistent Non-Ischemic Cardiomyopathy Induced By Panhypopituitarism Secondary to Sheehan Syndrome Following a Distant History of Severe Postpartum Hemorrhage 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Shwetha Mallikarjuna*, Carmel Maria Fratianni and Michael G Jakoby IV
Southern Illinois University School of Medicine, Springfield, IL

 

Background:  Pituitary apoplexy is a rare, potentially life-threatening condition usually caused by hemorrhage into a pituitary adenoma.  Anticoagulation with warfarin or unfractionated heparin has been documented to cause pituitary hemorrhage, but little is published regarding treatment with low molecular weight heparin (LMWH) and pituitary bleeding risk.  We present a case of pituitary hemorrhage in a woman with a previously undiagnosed pituitary macroadenoma after enoxaparin was started as part of treatment for atrial fibrillation. 

Clinical case:  A 60-year-old woman presented to the Emergency Department for evaluation of new onset and persistent palpitations.  She was found to be in atrial fibrillation and discharged home on enoxaparin (70 mg twice daily) and warfarin (5 mg daily).  She returned 2 d later after four doses of enoxaparin and two doses of warfarin with abrupt onset of severe headache, nausea, and vomiting.  Prothrombin time was 14.0 sec (11.9-14.3), and INR was 1.1 (0.9-1.1). MRI of the sella turcica revealed an 18 x 12 x 10 mm macroadenoma and intrapituitary hemorrhage.  Evaluation of pituitary function was notable for FSH 15 mIU/mL (16.7-113.6), 8 AM cortisol 4.8 mg/dL, 8 AM ACTH 28 pg/mL (0-46), TSH 0.46 mIU/L (0.34-5.60), free T4 0.8 ng/dL (0.5-1.3), and prolactin 0.7 ng/mL (2.7-19.6).  The patient improved quickly with conservative therapy including analgesics, antiemetics, and high dose dexamethasone.  Enoxaparin and warfarin were stopped, and the patient was discharged home after 48 hr on a regimen that included prednisone 5 mg daily for suspected early secondary adrenal insufficiency.  However, she returned 3 d later due to recurrent headache and new visual field changes.  Repeat MRI showed accumulation of more blood in the sella turcica, and transphenoidal resection of the pituitary tumor and evacuation of blood was performed.  The patient did well after surgery, experiencing complete resolution of headache and vision changes.  She was discharged home on prednisone and thyroxine for management of secondary adrenal insufficiency and hypothyroidism, respectively. 

Conclusion:  Unfractionated heparin has been documented to trigger pituitary hemorrhage in patients later discovered to have pituitary adenomas when used to manage unstable angina and myocardial infarction.  Though regarded as safer and more convenient than unfractionated heparin, this case illustrates that LMWH such as enoxaparin is also a risk for pituitary bleeding.  The patient’s INR indicates lack of anticoagulation from warfarin at time of presentation.    To the authors’ best knowledge, this is just the second case in which LMWH alone was the clear precipitant of pituitary hemorrhage in a patient with unsuspected pituitary adenoma.  Pituitary apoplexy should be considered and evaluated promptly in patients anticoagulated with LMWH who present with headache and other provocative symptoms.

 

Disclosure: MGJ IV: Advisory Group Member, Sanofi, Speaker Bureau Member, Sanofi. Nothing to Disclose: SM, CMF

16300 2.0000 SAT-0695 A Pituitary Apoplexy Following Anticoagulation with Enoxaparin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Toluwalope Adenike Adedugbe*1, Oluwarotimi Bolaji Olopade2, Sandra Omozehio Iwuala3, Olufemi Adetola Fasanmade1, Abayomi Ajayi4 and Augustine E Ohwovoriole5
1Lagos University Teaching Hospital, Lagos, Nigeria, 2Lagos Univ Teaching Hosp, surulere, lagos, Nigeria, 3Lagos Univ Teaching Hosp, Lagos, Nigeria, 4Nordica Fertility Centre, Lagos, Nigeria, 5University of Lagos, Yaba Lagos, Nigeria

 

BACKGROUND: Sheehan’s syndrome (SS) is a necrosis of the pituitary gland which results from severe intra- or post-partum haemorrhage.  Clinically, SS presents with varying degrees of pituitary failure including secondary infertility. Spontaneous conception in SS is difficult or rare as the case may be. Women with SS seeking conception may have to resolve to assisted reproductive technology (ART). Use of ovum donation in solving this problem appears to have received little attention.

We report a case of SS resulting in panhypopituitarism in whom successful pregnancy was achieved through egg donation. A 35-year-old woman with chief complaints of inability to conceive was referred to our endocrine services, as P2+1. Her last pregnancy 3 years earlier was associated with difficult delivery. She had emergency caesarean section and was transfused with several units of blood. Following delivery, she failed to lactate which was followed by development of easy fatiguability, loss of axillary and pubic hair, persistent amenorrhea and inability to conceive.  She admitted to a history of cold intolerance and constipation. Physical examination showed a woman looking much younger than age. Her face was rather full. Axillary and pubic hair was sparse. Pulse was regular with rate of 88 beats per minute and blood pressure of 160/120mmHg. Her external genitalia were normal. Lab work up showed HB of 11.5 (12.5-14.5)g/dl. Fasting plasma glucose, electrolytes, urea and osmolality were within normal limits. Results of basal hormal test were as follows: Thyroid hormones were low: T3-2.3(3.1-6.8)pmol/L; T4-2.6(12-22)pmol/L; TSH-0.68(0.35-5.5)mU/L. Oestradiol and other gonadotrophins were low: Oestradiol-<75(100-350)pmol/L; FSH-2.6(10-25)IU/L; LH-0.5(30-100)IU/L; Testosterone-<0.01(0.3-2.7)nmol/L. Morning cortisol was also low-2.49(4.3-22.4)nmol/L. MRI showed empty sella turcica. Hystero-salpingogram was normal. Based on the results of lab findings and clinical features, final diagnosis of SS associated with panhypopituitarism (leading to secondary hypothyroidism, hypogonadism, adrenocortical failure, secondary infertility) was made. We could not find cause for hypertension. The patient was managed by a team of endocrinologists and gynaecologist. Hormone replacement with cortisol and thyroxine restored her to Eu-metabolism. Blood pressure was controlled with alpha methyl dopa. Attempt at ovulation induction failed. Egg donation from an anonymous donor was resorted to and pregnancy was successfully carried till term and she was delivered via caesarean section of a baby boy with birth weight of 5kg.

CONCLUSION: With current practice, women with SS can have babies using appropriate technology now available in many parts of the world including Africa. The use of egg donation may appear to have some advantage over ovulation induction especially in developing world like Nigeria, Africa.

 

Nothing to Disclose: TAA, OBO, SOI, OAF, AA, AEO

16730 3.0000 SAT-0696 A Successful Pregnancy Using Ovum Donation in Sheehan's Syndrome: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Maria Mercedes Pineyro*, Patricia Furtenbach, Ramiro Lima, Saul Wajskopf and Raul Pisabarro
Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay

 

Background: Herniation of the suprasellar visual system (SVS) into a secondary empty sella (ES) has been reported, usually following treatment of a pituitary tumor. Brain and optical chiasm herniation have been rarely reported following dopamine agonist (DA) treatment for large prolactinomas. We report a case of brain and optical chiasmal herniation, presumably secondary to an ES due to apoplexy of a prolactinoma.

Clinical Case: A 32-year-old female presented to a neurologist complaining of holocranial oppressive headaches, of severe intensity, with a frequency of 2 or 3 per week, which resolved following treatment with NSAID. Her past medical history was significant for acute vision loss of both eyes accompanied by right 3rdnerve palsy when she was 16 years old. She does not recall endocrine or imaging evaluation at that time. She refers spontaneous partial recovery of left eye vision within 3 months, with permanent blindness of right eye. She did not return to follow up visits since then, until her neurologist consultation. Menarche was at 30 years, followed by oligomenorrrhea. Neurology examination revealed blindness of the right eye with complete right third nerve palsy. Brain MRI revealed herniation of frontal lobe and optic chiasm into the pituitary sella, as well as a pituitary hypointense lesion measuring 5x5 mm after gadolinium injection. At this point she was referred to our department. Laboratory test was significant for a prolactin (PRL) level of 206 ng/ml (4.79-23.3 ng/ml) and secondary hypothyroidism. Her corticotrophin axis was normal. Repeated PRL was 258 ng/ml (4.79-23.3 ng/ml). Formal visual field test showed left bitemporal hemianopia (right eye blindness).  She was started on bromocriptine 2.5 mg/day and levothyroxine 50 mcg/day. Prolactin levels and menstrual cycles normalized. A repeat brain MRI performed 5 months later showed disappearance of pituitary mass, with no changes in brain and chiasmal herniation. At this point she is concerned about fertility and potential pregnancy risks.

Discussion: SVS herniation has been rarely reported following pituitary apoplexy. We found only three reported cases of brain associated with optic chiasm herniation in large prolactinomas following DA treatment. Of these, one patient was asymptomatic at diagnosis, one presented with seizures and the other presented with visual field deterioration. Reported management of this entity has been DA dose reduction or chiasmapexy. In one case, untethering of optic apparatus through a transglabelar approach was performed. To our knowledge, this is the first reported case of brain associated with chiasmal herniation secondary to pituitary apoplexy of a prolactinoma. Pregnancy effects on brain herniation are unknown.

In conclusion, this case highlights frontal lobe herniation in combination with optic chiasmal herniation can be a complication of pituitary tumor apoplexy.

 

Nothing to Disclose: MMP, PF, RL, SW, RP

13800 4.0000 SAT-0697 A Brain and Optic Chiasmal Herniation into Sella after Pituitary Tumor Apopolexy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Adam Hassan Maghrabi*1 and Ligia Maria Belalcazar2
1UTMB, Dickinson, TX, 2Univ of Texas Med Branch, Glaveston, TX

 

Background: Pituitary tumor apoplexy during pregnancy is a medical emergency associated with significant morbidity and mortality to both mother and fetus. Surgical management is usually the treatment of choice when there is neurological compromise (1,2).

Clinical Case: A 29-year-old Hispanic female was admitted to the hospital with sudden onset of severe headache, vomiting, blurry vision and photophobia during the 27th week of pregnancy. She had a 3 year history of prolactinoma, successfully treated with cabergoline.  An MRI, 1 year prior to presentation, had shown her tumor to be 7mm in size. When pregnancy was documented at 4 weeks gestation, patient’s cabergoline was switched to bromocriptine, with poor tolerance. 9 weeks later, she was placed back on cabergoline 0.5 mg twice a week, and was maintained on that dose until day of admission.  Physical exam, including neurological, was grossly normal. MRI revealed an intrasellar mass, 1.1 x1.5 x1.7cm, with a blood fluid level, and mass effect upon the optic chiasm causing mild superior displacement.  Visual fields were normal.  Endocrine workup revealed a TSH of 1.07 uIU/mL and a Free T4 of 0.66 ng/dL; her morning cortisol was 1.6 µg/dL, and 8.4 µg/dL at 1 hour post-stimulation with 1 µg of cosyntropin. Prolactin level was 24.2 µg/L and did not change after dilution. Patient was diagnosed with pituitary apoplexy.  She was started on high-dose hydrocortisone and levothyroxine replacement. Cabergoline dose was increased to 1 mg twice a week. Headaches and visual symptoms improved. Neurosurgical intervention was deferred and steroid doses decreased.  The plan is to proceed with vaginal delivery at 36 weeks gestation if she remains stable, and subsequent evaluation for trans-sphenoidal surgery.

Conclusion: This case illustrates that conservative management, with adequate hormonal replacement and careful surveillance of neurological compromise, in pregnant patients with pituitary macroadenomas undergoing apoplexy, is possible and may delay or avoid emergency neurosurgical intervention and support fetal development to proceed closer to term.

 

Nothing to Disclose: AHM, LMB

11919 5.0000 SAT-0698 A Challenges in the Management of Pituitary Apoplexy during Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Gerard Daoming Lim* and Cherng Jye Seow
Tan Tock Seng Hospital, Singapore, Singapore

 

Background:

Pregnancy is a known precipitating factor for pituitary apoplexy but such cases are uncommon. We report a very rare case of a pregnant patient with acromegaly who presented with pituitary apoplexy. She was managed surgically with a positive outcome for both mother and fetus.

Report:

A 29 years old lady who was 2 months pregnant presented with sudden onset of headache, vomiting and blurring of vision. Her past medical history included type 2 diabetes mellitus and hypertension. On examination, she had features of acromegaly including coarse facial features and large hands and feet. Blood pressure was stable. Cranial nerve examination revealed poor visual acuity in the left eye and right hemianopia. Biochemical results: Growth hormone (GH) 97.9 ug/L (<8.00ug/L), Insulin like growth factor 1 (IGF1) 1394 ug/L (103-351 ug/L), prolactin 411 mIU/L (73-478 mIU/L), free thyroxine level 17 pmol/L (8-21 pmol/L), thyroid stimulating hormone 0.92 mIU/L (mIU/L) and random cortisol 647 nmol/L (240-618 nmol/L). HbA1c was 12.3%. Magnetic resonance imaging (MRI) of the brain revealed a large hemorrhagic pituitary mass 2.8 x 2.8 x 3.2 cm with a suprasellar component compressing on the optic nerves and optic chiasm. She was started on intravenous hydrocortisone, intensive insulin regime and monitored in the intensive care unit. In view of her visual deficits, the decision was made to proceed with trans-sphenoidal resection of the pituitary tumour. There was residual tumour left in the cavernous sinus post operatively. Histology showed a pituitary adenoma positive for GH. The post operative course was complicated by transient diabetes insipidus. Her vision improved post surgery and ultrasound by the obstetrician showed a viable fetus.

Discussion

Management of acromegaly in a pregnant lady is challenging and superimposed pituitary apoplexy is rare, with only a handful of case reports so far. Blood pressure and glycemic control needs to be controlled strictly. A review of the literature included management options such as initiation of dopamine agonists, somatostatin analogs and surgery. Medical therapy should be instituted to stabilise such patients initially, and the decision for conservative or surgical management should involve a multidisciplinary team comprising the neurosurgeon, endocrinologist, opthalmologist and obstetrician. Indications for surgery would include visual field defects and a drop in neurological status.  Follow up of the patient biochemically will be challenging as the patient is pregnant. It would also be challenging for the patient to conceive after such an incident, and it would require close cooperation with the obstetrician and fertility expert if the patient wishes to conceive again.

 

Nothing to Disclose: GDL, CJS

12150 6.0000 SAT-0699 A Pituitary Apoplexy in an Acromegalic Pregnant Patient: An Under-Recognized Diagnosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Sophie Grand'Maison*1, Florence Weber1, Marie-Josée Bédard2, Michele Mahone1 and Ariane Godbout3
1Centre hospitalier de l'Université de Montréal (CHUM), Montréal, QC, Canada, 2Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada, 3Centre de recherche du Centre hospitalier de l’Université de Montréal (CR-CHUM), Montreal, QC, Canada

 

A Challenging Case of Severe and Sudden Headache During Pregnancy

Introduction: Severe and sudden onset headache is a condition sometimes challenging during pregnancy. Rapid recognition of some conditions with possible endocrine disturbance are important to ensure maternal and fetal well being.

Clinical Case: A 33 year-old woman was admitted to the CHUM obstetrical ward at 39 weeks gestation with sudden onset of severe headache. Obstetrical history of this G6P3A2 woman revealed that she had had previous pregnancies complicated by gestational hypertension and preeclampsia. The present pregnancy had been uneventful until she reported severe and sudden bilateral headache accompanied by nausea and dizziness 24 hours prior to admission. No head trauma was reported, blood pressure and preeclampsia work-up were within normal values so the patient was discharged after 10 hours of observation.

She returned the next day with residual headache. Work-up was also normal. However, she fainted when leaving the hospital and was immediately readmitted for acute medical stabilization and further evaluation. A complete neurological exam at that point showed meningeal irritation and retinal exudate. Cranial nerve evaluation and lumbar puncture results were normal. A cerebral CT scan showed a prominent and slightly hyperdense pituitary gland of 12 mm in contact with the optic chiasma. Pituitary apoplexy was suspected and an MRI performed 7 days after headache onset confirmed sellar central hemorrhagic infarction and pituitary hyperplasia compatible with sub-acute pituitary apoplexy. Visual fields were normal. Labor was induced at 40 weeks under hydrocortisone coverage. She delivered a healthy 3.6 Kg baby boy and began breastfeeding without problem. Initial hormonal work-up (TSH 1.64 mUI/L (0.35-3.00), prolactin 391.0 ug/L (non pregnant range: 3.0-29.0), cortisol 475.0 nmol/L (non pregnant range: 119.0-618.0)) and biochemical results including sodium, potassium and glycemia were normal. At 2 months postpartum, endocrine work-up was still normal and a control MRI showed an important regression of pituitary size with a central remnant cyst of 6mm.

Conclusion: Pituitary apoplexy is a rare cause of severe and sudden headache during pregnancy. It can result from an acute hemorrhagic infarction of a preexisting pituitary adenoma or event more exceptionally, as this case suggests, in a physiologically enlarged gland. It is imperative to search for endocrine disturbance and start appropriate hormonal replacement since apoplexy can impair pituitary function. A multidisciplinary team approach (involving internists, endocrinologists, obstetricians and, when appropriate, neurosurgeons) can greatly reduce the morbidity and mortality that can result from this pituitary disorder.

 

Nothing to Disclose: SG, FW, MJB, MM, AG

13509 7.0000 SAT-0700 A A Challenging Case of Severe and Sudden Headache during Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Thanh Duc Hoang*1, Vinh Quang Mai2, Patrick W Clyde2 and K.M Mohamed Shakir2
1Naval Medical Center San Diego, San Diego, CA, 2Walter Reed National Military Medical Center, Bethesda, MD

 

Background: Crouzon’s syndrome is an autosomal dominant genetic disorder characterized by facial bone deformities, headaches, seizures, and mental retardation.   Herein we report a patient with Crouzon’s syndrome associated hypopituitarism and empty sellar syndrome.

Clinical case: A 63 year-old person presented to his primary care doctor at the age of 16 for evaluation of facial deformity. Specifically, the patient noted a high and wide forehead with  the anterior posterior diameter of the head smaller than the transverse diameter.  In 2000, he presented with weakness, pre- syncope, erectile dysfunction, and mild hyponatremia. A detailed endocrine evaluation revealed secondary adrenal insufficiency, secondary hypogonadism, and secondary hypothyroidism, thus, confirming a diagnosis of hypopituitarism. A growth hormone stimulation test utilizing a combination of arginine and growth hormone releasing factor confirmed growth hormone deficiency. Additionally, a genetic test performed revealed mutation in the fibroblast growth factor receptor 2 (FGFR2 gene), mutation of Cys-342→Arg. Skull X-ray confirmed craniostenosis and a head CT confirmed scaphocephaly, absence of the coronal suture, and a partially empty sella. Patient is currently treated with levothyroxine, testosterone, and hydrocortisone.

Discussion: Crouzon’s syndrome is an autosomal dominant genetic disorder characterized by facial bone deformities, headaches, seizures, and mental retardation. Other facial deformities in Crouzon’s syndrome may include prominent nose, frontal bossing, and ocular proptosis. In children with Crouzon’s syndrome, one third of the patients had signs of reduced growth hormone secretion and significantly lower pituitary height. This disorder is associated with a variety of amino  acid point mutations in the extracellular domain of FGFR2. FGFR2 gene mutation may also be associated with various other types of craniostenosis syndromes such as Apert syndrome, Pfieffer syndrome, Jackson-Weiss syndrome, Bears-Stevenson syndrome, and FGFR- related isolated coronal synotosis. The mutation in this gene may be inherited from an affected parent or may be de novo.

Conclusions:  Adult  patients with Crouzon’s syndrome may present with hypopituitarism and empty sellar syndrome.

 

Nothing to Disclose: TDH, VQM, PWC, KMMS

11438 8.0000 SAT-0701 A Crouzon's Syndrome Associated Hypopituitarism and Empty Sellar Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Nidhi Choudhary*, Tabinda Dugal and Joanna Rees
Royal Cornwall Hospital Trust, Truro, United Kingdom

 

Introduction/ Background

Pituitary apoplexy is a rare but life threatening disorder. The variability of clinical presentations poses great challenges for the initial diagnosis. The clinical presentation may include severe headache, impaired consciousness, fever, visual disturbances, variable ocular paresis and hypocortisolism. It usually results from sudden haemorrhage or infarction-induced swelling in a pituitary adenoma. Signs of meningeal irritation are very rare. With presentation of headache, fever, pleocytosis and meningism it can masquerade as infective meningitis. 

Clinical Case

We present the case of this 69 year old gentleman who while on holiday in Portugal developed sudden onset of severe headache and fever. He was well prior to the onset of headache and had no significant past medical history apart from hypertension. He was alert and orientated but had left sided hemianopia and no other cranial nerve deficits. There was history of air travel 1 day prior to the onset of symptoms.

Initial investigations were carried out in Portugal. CT scan showed a 2.8 cm pituitary mass with evidence of haemorrhage. This was confirmed on MRI scan. Lumbar puncture showed 150 neutrophils with low CSF sugars. Subsequently CSF cultures showed no bacterial growth. Pituitary profile showed prolactin of 16 miu/L (n 86-324 miu/L), T4 17.4 pmol/L (n 11-24pmol/L), testosterone of 0.3 nmol/L (n 6.7- 25.8 nmol/L), LH 2.1 iu/L (n 1.7-8.6iu/L) and FSH 2.9 iu/L (n 1.5-12.4 iu/L). Visual field testing confirmed marked left sided hemianopia. He was treated for bacterial meningitis after the results of CT, MRI scan and lumbar puncture. He was commenced on hydrocortisone 10/5/5 mg and testogel 50 mg/5g once a day. He was repatriated to the UK and reviewed by neurosurgeons who suggested a conservative approach for managing pituitary apoplexy .His visual field improved significantly over the next few weeks.  He was getting very aggressive on testosterone replacement which was stopped and he subsequently had normal testosterone levels. Glucagon test showed adequate cortisol response to glucagon stimulation. (Peak cortisol 613 nmol/L at 90 minutes)

Conclusions and clinical lesson

This case highlights the importance of timely recognition of pituitary apoplexy which can present as infective meningitis .In the presence of improving neuro-opthalmic symptoms and signs, a conservative approach with frequent monitoring of signs and symptoms for cranial nerve deficits and visual field testing can be taken. Rechecking pituitary function after an interval of time is mandatory as pituitary function can return to normal in some cases.

 

Nothing to Disclose: NC, TD, JR

15385 9.0000 SAT-0702 A Pituitary Apoplexy Presenting As Acute Meningoenchephalities 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Chadi Richeh*1, Boby G Theckedath2, Sharleen Sidhu3 and Janice L Gilden4
1Rosalind Franklin Univ of Med &, Chicago, IL, 2Capt. James A Lovell FHCC, North Chicago, IL, 3Chicago Medical School, IL, 4RFUMS/Chicago Med Schl, North Chicago, IL

 

Pituitary Apoplexy with Resolution of Tumor and Hormonal Function

Background:   Infarction or hemorrhage of a pre-existing pituitary adenoma is the most common cause of pituitary apoplexy.  Apoplexy has been reported to occur in about 70% of non-functioning pituitary macroadenonas and  commonly occurs in macroprolactinomas.  Furthermore, the use of dopamine agonist therapy  can contribute to a higher incidence of apoplexy.  Complete resolution of endocrine function following apoplexy is rare in nonfunctioning adenomas . 

Clinical Case: A 53 yr old woman was referred for management of an incidentally discovered pituitary adenoma.  History is significant for a meningioma resection 15 years prior to detection of a pituitary microadenoma.  According to the patient,  periodic followup MRIs were negative. However, the MRI demonstrated a pituitary microadenoma 0.6x0.4x0.7 cm size, with no lab data available.Repeat MRI 2 yrs later showed  an increase in size to  1x1.1x0.5cms . Hormonal evaluation: ACTH  17 pg/ml(normal 0-47), Am cortisol 11.95mcg/dl (normal 4.3-22.4),  LH 2 mIU/ml  (normal 1-9),  FSH 4 mIU/ml (normal 1-18), Estradiol 112.61pg/ml(normal 0-256), Prolactin (PRL)  98ng/ml(normal 2-18), TSH 1.25 u IU/ml (normal 0.34-4.82),  Free T4 0.63 ng/dl(normal 0.59-1.61),IGF-1  103 ng/ml(normal  50-317).Pt was asymptomatic.  The repeat MRI  was stable following 1 month of dopamine  agonist therapy with Cabergoline (CAB) 0.25 mg twice weekly.  Three months later,  PRL decreased to 2 ng/ml.  A repeat MRI done 4 months later now revealed a 7mm bleed  into the adenoma which was stable in size. Stress doses of steroid were administered and then  gradually tapered in a month.  Pituitary hormonal evaluation was normal  including   Prolactin of  1  ng/ml.

MRI done 15 months following the bleed (22 months of CAB) demonstrated a normal pituitary gland without evidence of an adenoma or bleed.  PRL remained normal.  There was no biochemical or clinical evidence of pituitary dysfunction, and hormonal changes were compatible with menopause, including PRL= 1 ng/ml, , Estradiol < 11.8 pg/ml, LH 40 mIU/ml, FSH= 67 mIU/ml.  CAB therapy was then tapered and eventually stopped.  One year later, MRI continued to be normal.  Hormonal evaluation remained  normal for a postmenopausal woman  with  PRL= 9 ng/ml, Estradiol < 11.8 pg/ml, LH= 40 mIU/ml, FSH=62 mIU/ml.

Conclusion.   This case demonstrates spontaneous resolution of a pituitary tumor with normal hormonal function occur  following a bleed with dopamine agonist therapy.

1. LIU #1Liu, ZH, Tu, PH, Pai, PC, Chen, NY, Lee, ST, & Chuang, CC (2012). Predisposing factors of pituitary hemorrhage. European Journal of Neurology, 19(5), 733-8. doi:

 

Disclosure: JLG: Principal Investigator, Shire. Nothing to Disclose: CR, BGT, SS

14185 10.0000 SAT-0703 A Pituitary Apoplexy with Resolution of Tumor and Hormonal Function 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Fatima Al Kaabi*1, Khalid Saaran2 and Muhammad Houri3
1AL Ain Hospital, Al Ain, United Arab Emirates, 2Al Ain Hospital, 3Al Ain Hospital, Al Ain, United Arab Emirates

 

Introduction:

Pituitary apoplexy (PA), an uncommon potentially life-threatening condition, it should be considered in patients with acute neurological symptoms and signs, especially if they have ophthalmologic symptoms and signs. This is true even in patients who are not known to have pituitary disease.

Case presentation:

26 years old male presented with thunder headache, blurred vision and confusion along with nausea vomiting and low grade fever. Initially meningitis was suspected. Patient was started on antibiotics and LP was planned. CT scan showed Sellar mass lesion.

 MRI showed 3.2 x 3.5 x 2.6 cm sellar mass with suprasellar extension and invasion of the right cavernous sinus with possible hemorrhage. Optic nerves were splayed, displaced and thinned out with deformed optic chiasm.

Review of system was significant for erectile dysfunction for one year. Examination was remarkable for poor vision, right lateral VF defect and limited right lateral gaze. Initial  labs showed normal electrolytes,elevated CRP and leukocytosis, low freeT4 and normal TSH.

Apoplexy was suspected. Hormonal panel was drawn then stress dose steroids and thyroxin were started. Urgent neurosurgery and ophthalmology evaluation were requested.  Hormonal panel later revealed Prolactin 79 mcg/L  (2.60-13.10)  (dilution ruled out  the Hook effect ) . Random cortisol 363 nmol/L 

Testosterone 0.77 nmol/l ( 6.10- 27.10 ) TSH: 2.34 mili IU/L ,T4:6.8 pmol/L  ( 7.5-21.1) ACTH. IGF-1, FSH and LH were normal. Finding consistent with macroadenoma with mild elevation in prolactin related to stalk compression.

 Ophthalmology evaluation revealed poor vision in both eyes with VF deficit and signs of compression.  Trans-sphenoidal decompression was done  four weeks after presentation.

Pathology confirmed the diagnosis of apoplexy of a non-functional pituitary macroadenoma.  After surgery, visual deficit and ophthalmoplegia improved but did not resolve. Prolactin dropped to 7.5 mcg/L He is currently receiving thyroxin and hydrocortisone. Two months after surgery he still has VF deficit and diplopia.

Discussion:

Our patient had typical symptoms of PA including thunder headache, ophthalmoplegia,VF deficit, confusion. Still, the main concern was meningitis till the CT was done.

Most cases of   apoplexy occur in those who have a pre-existing adenoma (pituitary tumor apoplexy). And it could be the presenting feature (as in our case)

For this reason clinicians should be aware of this diagnosis. Urgentimaging and appropriate referral should be done.

Treatment consists of stress dose steroids, supportive care in a critical care area with surgical intervention for patients who are deteriorating or those presenting with ophthalmoplegia and/or  VF deficit. There is some controversy regarding the timing of surgery. However, early surgical intervention has been shown to improve outcome for patients with visual symptoms.

 

Nothing to Disclose: FA, KS, MH

16857 11.0000 SAT-0704 A Apoplexy As the First Manifestation of Pituitary Macroadenoma in a Young Patient 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Nilsa Jimenez*1, Farheen Kassim Dojki2 and Prashant Grover3
1University of Connecticut, Farmington, CT, 2University of Connecticut, Meriden, CT, 3Saint Francis Hospital and Medical Center, Hartford, CT

 

Pituitary apoplexy is uncommon but life-threatening condition if overlooked. Severe hyponatremia and rhabdomyolysis are rare clinical presentations of pituitary apoplexy. A 45-year-old orthodontist with past medical history of hypertension presented to the emergency department with one day history of altered mental status and ten day history of positional headaches, fatigue, problems with manual dexterity and lower extremity muscle pain. Physical examination was uremarkable except for a temp of 100.0 F, blood pressure of 173/57 and a waxing waning mental status. Initial investigation revealed serum sodium of 108mmol/L (135-145mmol/L), which was likely the cause for altered mental status, elevated creatinine kinase (CK) at 4,094 U/L (30-170 U/L)with urine osmolality greater than serum osmolality (756 mosml vs 247 mosmol/kg). During hospitalization his CKs peaked to 16,000 associated with renal failure. He was initially treated with hypertonic saline which slightly raised his serum sodium and improved his mental status. A CT scan of the brain done to rule out other causes for altered mentation showed a small hypodensity in the right basal ganglia region. MRI of the brain showed pituitary adenoma with increased signal intensity consistent with hemorrhage confirming the diagnosis of pituitary apoplexy. Endocrinological evaluation revealed a low TSH, ACTH, Cortisol, GH, FHS, LH consistent with hypopituitarism and secondary adrenal insufficiency due to apoplexy. He was started on Hydrocortisone 100mg every 6 hours until his sodium remained above 120mmol/L as well as thryoid replacement with dramatic return to baseline. He was seen by neurosurgery as an outpatient and underwent a transnasal endoscopic resection of the pituitary adenoma. Pathology revealed a macroadenoma with fresh hemorrhage. It is not unusual to see hyponatremia in hypopituitarism: this could be a form of secondary syndrome of inappropriate antidiuretic hormone (SIADH) or it could be secondary to subnormal secretion of aldosterone. However, it is a rare presentation to see rhabdomyolysis in patients with panhypopituitarism and to date there is very limited data on this topic. There have been isolated case reports linking hypothyroidism with spontaneous rhabdomyolysis due to hypothyroid myopathy. Another explanation could be water intoxication due to cortisol deficiency in hypopituitarism. Cortisol has a significant effect on body water regulation by regulating the extracellular fluid preventing the water moving into cells. Once this process is inhibited, water intoxication causes cellular edema and lysis of the muscle cells. Hence serum chemistry, cortisol and CK levels should be checked to prevent organ damage as acute kidney injury. Remembering that patient with hypopituitarism and adrenal insufficiency can present with rhabdomyolysis and hyponatremia is important and timely management is crucial.

 

Nothing to Disclose: NJ, FKD, PG

16500 12.0000 SAT-0705 A Pituitary Apoplexy: A Rare Clinical Presentation of Rhabdomyolysis and Altered Mental Status 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Sarah Catford*1, Louise Bentley2, Saurabh Prakash2 and Rosemary Wong3
1Western Health, Melbourne, Australia, 2Western Health, Melbourne, 3Cabrini Med Ctr, Malvern VIC, Australia

 

Background

Hypothalamic-pituitary dysfunction occurs in 2-8% of neurosarcoidosis, and accounts for <1% of intrasellar lesions (1,2). Sarcoidosis was found in 11 of 92 stalk biopsies at the Mayo Clinic (3). Suggestive MRI features of the stalk and brain may be additional early clues to the diagnosis (3), as demonstrated in our case of neurosarcoidosis presenting with panhypopituitarism.

Clinical case

A previously well, 29 year-old Egyptian man presented with a two-month history of headache and lethargy. CT brain in the Emergency Department revealed pituitary stalk thickening, and CXR showed bilateral hilar prominence. His pituitary profile was consistent with panhypopituitarism: total testosterone <0.3 nmol/L (n 8.3-30.2), LH and FSH <1 IU/L, cortisol 27 nmol/L (n 119-618), ACTH 2.1 pmol/L (n<20), fT4 8.9 pmol/L (n 10-19), TSH 2.88 mIU/L (n 0.5-4), GH 5 mIU/L (n 0-7), IGF-1 9 nmol/L (n 12-30). Serum prolactin was mildly elevated 969 mIU/L (n 45-375), consistent with stalk effect. Full blood examination revealed a normocytic anaemia and leucopenia. Serum calcium, LDH and b2microglobulin were normal. Investigations for hepatitis, HIV, tuberculosis, and germ cell tumours were unremarkable. An MRI pituitary and brain with gadolinium demonstrated nodular uniform thickening (6 mm) and abnormal enhancement of the pituitary stalk, and nodular enlargement of the pituitary. Unexpectedly, there were other foci of enhancement in the corpus callosum, optic chiasm, optic nerves, and floor of the third ventricle. Radiologically, these lesions were highly suggestive of neurosarcoidosis. Further imaging showed mediastinal, hilar, mesenteric and portal caval lymphadenopathy. Serum ACE level was elevated, 254.5 U/L (n 29-112), and he had hypercalciuria 9.7 mmol/24 hr (n 2-7.5). Mediastinal lymph node biopsy confirmed the diagnosis of sarcoidosis with evidence of non-necrotising granulomas.

The patient commenced hormone replacement therapies, ddAVP and treatment for neurosarcoidosis with high dose prednisolone initially at 1mg/kg daily. Initiation of corticosteroid therapy unmasked diabetes insipidus. Bone marrow biopsy was not undertaken as his anaemia and leucopenia normalized with pituitary therapies. Monitoring response to therapy will include serum ACE levels and serial imaging of affected sites.

Conclusion

1.Neurosarcoidosis is an important consideration in newly diagnosed hypothalamic-pituitary dysfunction.  

2.Haematologic cytopaenias can be a feature of panhypopituitarism. 

3.Suggestive radiological features may assist with timely diagnosis of neurosarcoidosis, which is important as treatment with immunosuppressant therapy may avoid definitive hormonal deficiencies (4).

 

Nothing to Disclose: SC, LB, SP, RW

16608 13.0000 SAT-0706 A Neurosarcoidosis Presenting As Panhypopituitarism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Erwyn Chua Ong*1, Ronak Patel2 and Leonid Poretsky1
1Mount Sinai Beth Israel, New York, NY, 2Mt Sinai Beth Israel, New York, NY

 

Introduction: Pituitary sarcoidosis is a rare disorder.  We report a case of pituitary sarcoidosis which dramatically improved  after 3 days on steroid therapy, obviating the need for neurosurgical intervention.

Case: A previously healthy 42-year-old male presented to the eye clinic with 1-month history of blurry vision and was found to have bitemporal hemianopsia.  He reported a 2-month history of fatigue, night sweats, unintentional weight loss, bilateral jaw swelling, and peri-oral numbness. Examination revealed bilateral enlargement of the parotid glands, submandibular lymphadenopathy, and decreased vision in the bitemporal visual fields.  Brain MRI: 1.6 x 1.8 cm sellar mass with suprasellar extension, causing mass effect on the optic chiasm, compatible with pituitary macroadenoma.  Labs: prolactin (with dilution) 21.3 (2.1-17.7 ng/mL), LH 5.07 (<10 mIU/mL), FSH 7.6 (1-18 mIU/mL), ACTH 12 (6-50 pg/mL), TSH 0.41 (0.55-4.78 mIU/mL), GH 0.9 (<10 ng/mL), IGF-1 194 (52-328 ng/mL), AM cortisol 10.7 (4-22 ug/dL), fT4 0.68 (0.86-1.76 ng/dL), total testosterone 176 (262-1593 ng/dL), alpha-subunit 0.3 (n < 0.6 ng/mL), HIV test negative, ACE level 118 (9-67 U/L).  ACTH stimulation test: cortisol 10.7 ug/dL (baseline), 21.9 (30’), 27.1 (60’). CT chest showed bilateral hilar lymphadenopathy.  Tuberculosis was ruled out.  Parotid gland biopsy showed non-caseating granulomas, most compatible with sarcoidosis.  The patient was started on prednisone, 40mg BID; levothyroxine, 50 mcg daily.  He was tentatively scheduled for urgent transsphenoidal decompression.  After 3 days on steroid therapy, he reported significant improvement in vision and reduced parotid gland swelling.  After 4 days on steroid therapy, repeat brain MRI revealed reduced size of the suprasellar soft tissue compared to the prior MRI.  Surgical intervention was not pursued.  The patient  continued to improve and remained asymptomatic on clinic follow-up at 4 weeks after initial presentation.

Discussion: Sarcoidosis is a multi-system disorder characterized by the presence of non-caseating granulomas in affected tissues.  Hypothalamus and pituitary gland are the most frequently involved neuroendocrine sites, resulting in hypopituitarism.  Hypothalamo-pituitary sarcoidosis is present in < 1% of all intrasellar lesions. Management is primarily with steroid therapy. Neurosurgical intervention should be considered if the granulomatous tissue causes mass effect or obstruction.  In our patient, although mass effect was present, symptoms and radiologic findings dramatically improved  after extremely short time on steroid therapy, obviating the need for neurosurgical intervention.  We conclude that, in some cases, with careful observation, surgical resection of the pituitary mass in patients with pituitary sarcoidosis can be safely postponed since beneficial effects of steroid therapy may be seen within a few days.

 

Nothing to Disclose: ECO, RP, LP

16469 14.0000 SAT-0707 A An Atypical Presentation of Pituitary Sarcoidosis: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Natividad González-Rivera*1, Tomás Martín-Hernández2, Raul M. Luque3, Eva Venegas4, Alberto Torres-Cuadro5, Alejandro Ibañez-Costa6, Justo P Castano3 and Alfonso Soto7
1Unidad de Gestión de Endocrinología y Nutrición. Hospital Universitario Virgen Macarena, Sevilla, Spain, 2Virgen Macarena University Hospital. Sevilla, Sevilla, Spain, 3Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofia, CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn) and ceiA3, Córdoba, Spain, 4Instituto de Biomedicina de Sevilla (IBiS), Consejo Superior de Investigaciones Científicas, Endocrinology Unit of Virgen del Rocío University Hospital, University of Seville, Sevilla, Spain, 5Virgen Macarena University Hospital. Sevilla, 6University of Córdoba; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofia, and CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn), Córdoba, Spain, 7Metabolism and Nutrition Unit, Hospital Virgen del Rocio, Sevilla, Spain

 

Introduction: Primary pituitary sarcoma in the absence of prior irradiation is an exceptional cause of pituitary tumour. There are just a few cases described in the literature, and current treatment options (surgery, radiotherapy or even chemotherapy) are generally unsuccessful. We describe a new case in which the information of the expression profile of key molecular and pharmacological targets in the tumoral piece obtained after surgical resection could provide a new valuable tool to better define the choice for subsequent therapeutic treatment.

Clinical case: A 40 year-old man consulting for headache and decreased vision. The MRI showed a mass on the parieto-occipital left lobe of 37x28 mm suggesting the existence of a meningioma as well as, a large heterogeneous pituitary tumour of 43x40 mm invading both cavernous sinuses and important suprasellar extension, compressing optic chiasm, and filling supraoptic and infundibular third ventricle recess impinging the hypothalamus. Hormonal study showed hypopituitarism and 
after hormonal replacement treatment, the patient underwent an expanded endoscopic transesphenoidal surgery. The pathologist reported a collision tumor composed of spindle cells mesenchymal neoplasm of low grade and non-secreting pituitary adenoma. Immunochemistry of the tumor was positive for vimentin and actin smooth muscle, negative for all pituitary hormones, and showed a Ki-67>10 %. A piece of the tumor was processed for a molecular expression profile study, which showed that the tumor expressed high levels of type 2 dopamine receptor but very low expression of all the somatostatin receptor subtypes. Three months after the surgery, MRI showed a residual tumour on the right side of the pituitary site of 18x21x13 mm and a 30x30x32 mm parietal lobe mass. A SPECT-CT was performed with 111 In-Octreotide showing intense uptake in the parietal region located in the meningioma but complete absence of uptake in hypothalamic-pituitary area. Subsequently, fractionated stereotactic radiotherapy was administered, and then, based in the molecular profile study, it was recommended treatment with high-dose of cabergoline.

Conclusion: We describe a rare primary pituitary sarcoma and propose that the information provided by the SPECT-CT with 111 In-octreotide can be complemented by a molecular expression profile of the tumor as a tool to better select the subsequent medical treatment of these rare tumors using receptor-specific targeted therapies.

 

Nothing to Disclose: NG, TM, RML, EV, AT, AI, JPC, AS

12385 15.0000 SAT-0708 A Expression Profile of Key Molecular/Pharmacological Targets in Pituitary Sarcomas As a New Valuable Tool to Better Select the Subsequent Medical Therapeutic Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Dorothy A Fink*1, Bryan McColgan2, Julio A Valentin3, John C Ausiello4, Jeffrey N. Bruce5, Gabrielle Page-Wilson6 and Rhonda Kay Trousdale7
1College of Physicians and Surgeons, Columbia University, New York, NY, 2Columbia Unviersity College of Physicians and Surgeons, 3Columbia Unviersity College of Physicians and Surgeons, 4Columbia Univ Coll of P & S, New York, NY, 5Columbia University, College of P & S, New York, NY, 6Columbia University College of Physicians & Surgeons, New York, NY, 7Harlem Hospital, New York, NY

 

Background:  Li Fraumeni Syndrome is an autosomal dominant disorder that manifests at an early age with malignancies, most commonly sarcomas, breast cancers, adrenocortical carcinomas, and brain tumors.  The brain tumors associated with Li-Fraumeni typically include high grade gliomas and choroid plexus carcinomas; pituitary tumors have not been described in this syndrome.

Clinical Case:  A 32 year-old African American woman with Li-Fraumeni syndrome and history of cystosarcoma phyllodes of the breast treated with lumpectomy in 2004, and ductal carcinoma in situ treated with bilateral mastectomy in 2012, presented with headaches, peripheral vision loss, and 2 years of amenorrhea.  Her physical examination was notable for mild hypertension, morbid obesity, and bitemporal hemianopsia.  Expressible galactorrhea was not detected and her reflexes were 1+ throughout without delayed relaxation.  Laboratories confirmed hypogonadotropic hypogonadism and central hypothyroidism.  Her prolactin was mildly elevated at 45 ng/mL (nl: 1.9-25).  A brain MRI revealed a 2.8 x 1.3 x 1.2 cm3sellar/suprasellar mass with irregular borders, involving the pituitary gland and craniopharyngeal duct and compressing the optic chiasm.  She underwent stereotactic transnasal transsphenoidal gross total resection of the tumor.  Pathology demonstrated a mesenchymal neoplasm with a spindle cell population in a patternless arrangement. Immunohistochemical studies were positive for BCL-2, TTF-1, S100 as well as for estrogen and progesterone receptors, and negative for cytokeratins, melanoma markers, and CD34.  Pathology was consistent with a sarcoma.  Post-operative PET/CT scan did not demonstrate abnormal FDG activity.  Due to the history of Li Fraumeni and cystosarcoma phyllodes, this tumor was thought to be either a primary pituitary sarcoma or a metastasis from the patient’s malignant cystosarcoma phyllodes of the breast.

Conclusion:  To our knowledge, this is the first case report of a sarcoma in the pituitary in Li Fraumeni Syndrome.  While Li Fraumeni is a rare syndrome, the potential for pituitary involvement and subsequent hypopituitarism should be considered in the care of affected patients.

 

Nothing to Disclose: DAF, BM, JAV, JCA, JNB, GP, RKT

16058 16.0000 SAT-0709 A Sarcoma in the Pituitary in a Patient with Li-Fraumeni Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Hasmik Arzumanyan*1 and Audrey Elisabeth Arzamendi2
1Kaiser Permanente Oakland Medical Center, Oakland, CA, 2UC Davis Medical Center, Sacramento, CA

 

Background

Pituitary hyperfunction occurs rarely in primary empty sella syndrome (ESS), and elevated GH is perhaps the rarest manifestation of all. It is uncommon for a somatotroph tumor to evade visualization on MRI, much less, for an empty sella alone to be present. Failure to identify a responsible pituitary lesion poses a challenge to definitive acromegaly treatment, which generally demands source localization and surgical resection; though rare case reports have described auto-remission of acromegaly after spontaneous infarct or hemorrhage of the causative adenoma.

Clinical case

A 55-year-old male presented with classic signs and symptoms of acromegaly. Biochemical acromegaly was confirmed with serum IGF-1 level of 560 ng/mL (81-225 ng/mL), GH 16.7 ng/ml (0.05-3.00 ng/mL), and failure of GH to suppress with 75g OGTT (GH nadir - 7 ng/ml). Pituitary MRI revealed an empty sella, and pan-CT and Octreoscan were negative for ectopic lesions. GHRH level was 7 pg/ml (5-18 pg/ml). The patient was started on octreotide, but self-discontinued it due to side effects, and declined further workup or treatment.

The patient was hospitalized three years later with persistent signs and symptoms of acromegaly. Remarkably, IGF-1 was now normal at 92 ng/mL, which was confirmed with repeat testing one week later. IGFBP-3 was 6430 ng/mL (2592-4770 ng/mL). Pituitary MRI again showed an unchanged empty sella without evidence of hemorrhage or infarction.  Spontaneous remission of acromegaly was suspected, however, repeat OGTT failed to suppress GH. Petrosal sinus sampling (PSS) showed a 6-fold central-to-peripheral GH gradient consistent with central GH production.

The patient underwent transsphenoidal exploration of the sella turcica, and an intrasellar mass with overlying dural invasion was identified and resected. Cytology was consistent with a pituitary adenoma, and immunohistochemistry positive for GH and prolactin. Post-operatively, the patient did well. GH normalized, and other pituitary hormones remained stable.

Conclusion

It is rare that an acromegaly-causative pituitary tumor is not visualized within the sella turcica, and even rarer that this occurs with ESS. In such patients with normalizing IGF-1 levels, acromegaly auto-remission and secondary ESS resulting from pituitary apoplexy must be considered; however biochemical acromegaly may persist, and should be more definitively ruled out with confirmatory testing. In patients with ESS and active acromegaly, low GHRH and consistent PSS can confirm central GH production, and transsphenoidal exploration may enable successful identification and resection of the adenoma.

 

Nothing to Disclose: HA, AEA

15341 17.0000 SAT-0710 A Acromegaly Pseudo-Remission in a Patient with Empty Sella Syndrome (ESS): Conforming Persistent Disease, and Localizing the Lesion 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Kranthi Andhavarapu1, Donald Velarde2, Mohamad Horani3 and Mohamad Hosam Horani*4
1Banner Baywood Hospital, 2Mercy- Gilbert Hospital, 3Arizona College Prep, 4Alsham Endocrinology, Chandler, AZ

 

Case presentation :A 33-year-old Caucasian male presented with severe headache, associated with nausea, vomiting, subjective fever, photophobia , diplopia and ptosis of left eyelid concerning for meningitis. Subarachnoid hemorrhage was excluded by CT and CSF analysis. CSF showed an aseptic meningitis pattern. Physical examination revealed dysconjugate gaze, left occulomotor palsy and double vision.  Urgent MRI revealed 1.7 * 2.6 * 2.3 cm enhancing mass-like lesion within the sellar and suprasellar region with differentials including complex hemorrhagic pituitary macroadenoma  vs craniopharyngioma. MR angio favored a primary pituitary lesion with narrowed left ICA cavernous segment due to invasion from mass. Labarotorey tests  revealed serum cortisol 1.4 ug/dl, ACTH < 5Pg/ ml, Total testosterone 13 ng  dl, LH < 0.1, TSH 0.07, Free T4 0.6, Prolactin 6.2, and IGF-1 of 134 ng/ ml Patient was started on IV decadron and IV Levothyroxine  then  underwent emergent transphnoidal surgery with rapid  total resolution of his visual symptoms.

Discussion : Pituitary apoplexy is defined as a sudden loss of blood supply to the pituitary gland, leading to tissue necrosis and hemorrhage. In its classical form it is characterized by acute headache, ophthalmoplegia, visual loss and pituitary insufficiency. Meningeal irritation signs, clinically indistinguishable from infectious meningitis, are considered rare presenting signs.

Isolated third cranial nerve palsy and/or ptosis is another uncommon presentation of puitutary  apoplexy  Oculomotor palsy in the absence of  invading tumor to cavernous sinus ,  may be caused first by unilateral erosion of the posterior clinoid process, resulting in latero-posterior protrusion of the adenoma. Hemorrhage may result in sudden kinking of the oculomotor nerve at the entrance of the oculomotor trigone. (1)

Conclusion: Pituitary apoplexy as underlying mechanism of meningitis should be suspected in patients with underlying endocrine abnormalities or lesions to the fossa. Early diagnosis and treatment including neurosurgical decompression of sella and adequate hormonal substitution are crucially important in patients with oculomotor nerve palsy in pituitary apoplexy.

 

Nothing to Disclose: KA, DV, MH, MHH

13251 19.0000 SAT-0712 A Aseptic Menigitis and Third Nerve's Palsy As First Presentaion of Apoplectic Pituitary Adenoma in Young Male 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Patamaporn Lekprasert*1, Lakshmi Kannan2, Nissa Blocher3 and Catherine Anastasopoulou4
1Albert Einstein Medical Center, Elkins park, PA, 2Einstein Medical Center, Philadelphia, PA, 3Albert Einstein Medical Center, Philadelphia, PA, 4Einstein Endo Assc, Elkins Park, PA

 

Pituitary metastasis (PM) is a rare complication of malignancy. The incidence of PM among all intracranial metastases is 0.87%. PM accounts for less than 1% of clinically apparent pituitary lesions. There are limited data regarding the clinical aspects of this disease. We therefore report an unusual case of PM from mixed small-cell, and non-small-cell lung cancer.

Case description:

Our case is a 47 year-old African American man who was diagnosed with stage IV mixed small-cell and non-small-cell lung cancer with bone metastasis for one year. He finished four cycles of Carboplatin and Etoposide chemotherapy nine months ago, and was getting prophylactic whole brain irradiation and Denosumab for bone metastasis.  He presented to our hospital with shortness of breath, and frequent fall. His physical examination was positive for mild dehydration, and right-sided pleural effusion. He had stable vital signs and intact neurologic examination. The brain MRI revealed new findings of heterogeneously enhanced sellar mass, measuring 12.3x11.8x16 mm, with thickening of the pituitary stalk and the right thalamic mass. The diagnosis of brain metastasis was made. During the admission, he was diagnosed with secondary adrenal insufficiency, hypothyroidism, hypogonadism, and growth hormone deficiency. He was started on Hydrocortisone 20 mg in the morning and 10 mg in the afternoon, Levethyroxine 50 mcg/day, and Testosterone 100 mg IM biweekly. His symptoms improved after thoracentesis and hormone replacement, and he was transferred to our rehabilitation facility for physical therapy. Two weeks later, he developed headache, bilateral ptosis, and third cranial nerve palsy. Repeated MRI of the brain showed progressively enlarged sellar mass with bilateral cavernous sinus extension, and increase in size of the right thalamic mass. Given his ptosis and ophthalmoplegia, palliative transphenoidal hypophysectomy, which aimed to preserve his vision, was done. Soft tumor with increased vascularidty was encountered during the surgery. His pathology confirmed metastatic mixed small-cell and non-small-cell carcinoma, consistent with his primary lung cancer. At four weeks after surgery, he was clinically stable on previous hormone replacement regimen. His vision was preserved, however bilateral ptosis persisted. Interestingly, he did not have diabetes insipidus despite neoplastic involvement of the pituitary stalk. Palliative sellar irradiation was planned for the near future.

Conclusion:

Pituitary metastasis is rare, and overall has poor prognosis. The main treatment is palliative hypophysectomy and/or sellar irradiation. It should be suspected in the setting of a sellar mass in a patient with known malignant disease, new–onset ophthalmoplegia, and panhypopituitarism especially secondary hypothyroidism and diabetes insipidus.

 

Nothing to Disclose: PL, LK, NB, CA

14204 20.0000 SAT-0713 A A Rare Case of Pituitary Metastasis from Mixed Small-Cell and Non-Small-Cell Lung Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Monica Loto*1, Santiago Gonzalez Abbati2, Karina Danilowicz2, Lucrecia Mutti3, Alejandro Szcope2 and Rafael Torino2
1Hospital Britanico, Buenos Aires, Argentina, 2British Hospital, Buenos Aires, Argentina, 3British Hospital, Buenos Aires

 

Introduction

Schwannomas are encapsulated benign tumors made entirely of neoplastic Schwann cells. Intracranial schwannomas represent almost 8% of all primary intracranial neoplasms. However, intrasellar localization is extremely infrequent, and the origin is still being debated. We report a case of a schwannoma mimicking a pituitary non-functioning adenoma.

Case report

A 64-yr-old man was referred to the Endocrinology and Neurosurgery Departments for the evaluation of a probable pituitary tumor discovered incidentally on a brain magnetic resonance imaging (MRI). He had no relevant medical history, and had no clinical signs of pituitary dysfunction or visual disturbances.

The MRI revealed a 15 mm sellar mass, isointense on both T1 and T2-weighted images, compressing optic chiasm and displacing pituitary stalk. The lesion was homogeneously enhanced with gadolinium.

Initial biochemical evaluation and visual field exam were normal. A presumptive diagnosis of macroadenoma was considered, and a trans-sphenoidal surgery was decided due to chiasmatic compression. At the time of the procedure, a solid tumor without necrosis, located above the pituitary gland, was identified. A total removal of the hypervascularizated fibrous mass was performed, and intraoperatively a non-adenomatous tumor was firmly considered. Intraoperative CSF leak was detected and the dura was sealed tightly.

After surgery, several complications appeared: an ischemic stroke with a severe right-sided hemiparesis with ad-integrum restitution, insipidus diabetes with mild hypernatremia riquiring desmopressin, cerebrospinal fluid leakage requiring lumbar drainage and surgical repair, and finally aseptic meningitis.

Final pathological diagnosis was Schwannoma Antoni A type with parallel-organised spindle-shaped cells with hyperchromatic nuclei. Immunohystochemical staining confirmed the diagnosis being positive for S-100 protein. Currently, one month after surgery, the patient is in a very good condition, but with panhypopituitarism, under replacement with hydrocortisone, levothyroxine and desmopressin.

Conclusions

Intrasellar schwannomas, though very infrequent, should be considered among the differential diagnosis of sellar pituitary adenomas and other suprasellar masses. The harder consistency and greater vascularity of these tumors make trans-sphenoidal surgery more difficult, and predispose patients to postoperative complications.

 

Nothing to Disclose: ML, SG, KD, LM, AS, RT

15277 21.0000 SAT-0714 A Intrasellar Schwannoma, a Very Infrequent Tumor: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0694-0714 4829 1:00:00 PM Pituitary Apoplexy; Empty Sella and Sellar Masses Poster

Jelena Maletkovic*1, Marilene B. Wang2, Marvin Bergsneider2 and Anthony P Heaney3
1UCLA David Geffen School of Medicine, Los Angeles, CA, 2David Geffen School of Medicine at UCLA, Los Angeles, CA, 3UCLA-David Geffen Schl of Med, Los Angeles, CA

 

BACKGROUND: Pituitary tumors are common and typically extremely slow-growing benign adenomas. Following surgical pituitary resection imaging schedules to assess for recurrence and for growth of tumor residual vary and there is no clear consensus on the optimal imaging interval and duration of post-op imaging. At our center MRI of the pituitary is performed 3 and 12 months after surgery and then annually for 3-5 years. Advances in neurosurgical techniques have enabled more complete resection of even extensive macroadenomas. We sought to re-evaluate our current imaging schedule and document tumor recurrence and regrowth rates.

METHODS: Retrospective analysis of a database identified 215 skull-base surgeries between 2008- 2010 performed by a single surgical team (MB & MW).  Patients with sellar masses other than pituitary tumors were excluded leaving a total of 163 patients. 74 patients had a minimum of 3 year follow up following tumor resection. 8 patients who received radiation for extensive residual tumor were excluded from analysis. MRI scans in the remaining 66 patients were analyzed for the presence of residual tumors on the first postoperative 3 month image. Patients that exhibited growth of existing tumor residue or developed new recurrence were identified over the follow up period.

RESULTS: 45 of 66 (68%) patients had no visible tumor on MRI study 3 months post-op. 38 of these patients (58%) exhibited no recurrence or residual tumor during the 3 year follow up. One patient had tumor recurrence at the 2 year time point. Six of the 45 patients (13%) had questionable tumor recurrence after one or two years but this could not be distinguished from post-operative changes and did not change across the  3 year study.

Of the remaining 21 of all 66 patients (31%), 9 (14%) were reported as probable residual tumor at 3 months. The “probable” residual tumor has remained stable in 7 patients and decreased in 1 patient over the follow up period. In 1 patient with probable residual tumor, tumor growth was seen after two years. 12 patients (18%) had definite residual tumor on the 3 month post-op MRI. Only one of these patients exhibited tumor growth after 3 years whereas tumor residual remained stable in 10 patients and decreased in 1 patient.

In summary, of 45 patients who had no tumor visible at 3 months post-op 1 patient (2%) has demonstrated definite recurrent tumor. Of 9 patients that were initially reported as possible residual tumor, one patient (11%) demonstrated tumor growth over the 3 year interval. Finally of 12 patients that had definite tumor visible at 3 months post-op, tumor growth occurred in only 1 patient (8%).

CONCLUSION:  Recurrence or growth of tumor residual is very uncommon (3 of 66, 4.5%) in the vast majority of pituitary tumors. Given the improved surgical resection  now attainable in most pituitary tumors our data serve to generate discussion about the optimal imaging schedule in patients with pituitary tumors.

 

Nothing to Disclose: JM, MBW, MB, APH

16549 1.0000 SAT-0636 A Towards Defining the Optimal Imaging Schedule Following Pituitary Tumor Resection 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Hidetoshi Ikeda*1, Koh Yamamoto2, Shunsuke Sato3 and Genichiro Ohashi2
1Research Institute for Pituitary, Koriyama, Japan, 2Reserach Institute for Pituitary disease, Koriyama, Japan, 3Institute for Pituitary disease

 

Introduction

Owing to the recent diagnostic development using MET-PET, early diagnosis and treatment of ACTH-producing adenomas has become possible. As a result, early endocrine abnormalities and an early pathological picture of ACTH-producing adenomas have become clear.

Materials

We examined 58 patients who, upon MET-PET analysis, showed ACTH secretion abnormalities, and underwent TS surgery between 2009 and 2013. ACTH production was histologically proven in all cases. Sixteen patients were men and 42 were women. Patients were aged 11–77 years, and the average age was 48 years.

Methods

Before surgery, basal values of pituitary hormones were assessed and midnight cortisol levels were measured. In addition, an overnight dexamethasone suppression test (DST, with a dose of either 0.5 or 8 mg of dexamethasone), a CRH stimulation test, and a DDAVP test were performed. Patients who showed an abnormality in ACTH secretion in at least one of those above parameters underwent composite MET-PET fusion 3T-MRI, which disclosed a high uptake of MET suggestive of adenoma localization. Resected specimens were immediately fixed in formalin. H&E, Ag staining and immunohistochemical staining with ACTH, GH, PRL, TSHβ, FSHβ, LHβ and Ki-67 antibodies were done.

Results

Twenty-one cases were Cushing’s adenoma and 37 cases were early ACTH-producing adenomas. Of the 37 cases, 29 (78%) patients had high levels of either ACTH or cortisol, 17 (46%) patients showed high levels of midnight F, and 28 (76%) patients were poorly suppressed after the 0.5 mg dexamethasone dose in the DST, 29 (78%) patients showed a positive  response to the CRH stimulation test, and 10 out of 30 (33%) patients with ACTH-producing adenoma showed a positive response to the DDAVP test. Pathological analysis revealed that 10 cases of Cushing’s disease (48%) had corticotroph adenomas, and an additional 11 cases (52%) had plurihormonal adenomas. Conversely, all of the early cases of ACTH-producing adenomas were plurihormonal adenomas.

Conclusion

From a pathological point of view, early lesions of ACTH-producing adenomas mature to Cushing’s adenoma, and in accordance with the maturation of ACTH-producing adenomas, they seem to gain autonomous secretion of ACTH.

 

Nothing to Disclose: HI, KY, SS, GO

11933 6.0000 SAT-0641 A Clinicopathological Comparative Study Between Early Lesions of ACTH-Producing Adenomas and Cushing's Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Ibrahim A Hashim*, Elizabeth E King, Alaa A. Daghlas and Hans Kumar Ghayee
University of Texas Southwestern Medical Center, Dallas, TX

 

The use of Inferior Petrosal Sinus Sampling (IPSS) procedure to differentiate between ACTH dependent Cushing from an ectopic ACTH syndrome (EAS), although requires expertise, is widely available.  The addition of prolactin measurement to that of ACTH has been suggested to increase accuracy and thus reduce false negative rate. We evaluated the impact of adding prolactin to ACTH in IPSS procedures performed in a large academic center.

Samples from patients who were being investigated by IPSS for ACTH source were stored at -70°C until analysis. Prolactin was measured by ELISA (DuoSet, R&D systems, MN, USA).  ACTH had been measured and results reported. Measurement of prolactin was performed retrospectively on saved sample aliquots. Prolactin normalized ACTH was calculated as [(ACTH IPSS / ACTH Peripheral) / (Prolactin IPSS / Prolactin Peripheral)]

Patients (n=9) had undergone IPSS over a 28 month period. 7 patients were reported as having pituitary dependent ACTH production (central/peripheral ACTH ratio >2.09 and >3.0 post CRH administration). One patient had ectopic ACTH production, whereas one patient was difficult to cannulate and thus difficult to assess. In the patient who was difficult to cannulate, the ACTH data suggested a questionable pituitary source for ACTH.  This patient was reclassified as ectopic ACTH syndrome following prolactin normalization of ACTH.

Calculation of normalized ACTH values correlated well with clinical findings. The addition of prolactin to the analysis of IPSS samples provided a reassurance for ACTH ratio calculations, as well as an aid in those with difficult catheterization studies.

 

Nothing to Disclose: IAH, EEK, AAD, HKG

12530 7.0000 SAT-0642 A The Value of Prolcatin Measurement in the Evaluation of ACTH Dependent Cushing's or Ectopic ACTH Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Liudmila Ya Rozhinskaya*1, Ekaterina A Pigarova2, Zhanna E Belaya1, Larisa K Dzeranova1, Natalia N Molitvoslovova1, Galina A Melnichenko1, Ivan I Dedov1, Oksana Dmitrieva3, Mikhail Chernikov4 and Oggo Concortium5
1Endocrinology Research Centre, Moscow, Russia, 2Endocrinology Research Centre, Moscow, Russian Federation, 3Aston Consulting, Mosсow, Russia, 4Aston Consulting, Mosocw, Russia, 5Federal Districts Head Endocrinologists of Russian Federation, Russia

 

Introduction: The Russian Registry of patients with tumors of the hypothalamic-pituitary region (OGGO) is a national registry founded in 2004 by Russian Society of Endocrinology and Endocrinology Research Centre as a patient registry for acromegaly, in 2006 it was expanded to collect information on all lesions of the hypothalamic-pituitary region. In 2010 the first fully electronic version and in 2013 a new upgraded electronic online version were implemented. At this point the Registry is actively supported by 22 out of 83 regions of Russia, representing about 1/3 of population.

Materials and Methods: There are overall 5340 patients registered in the OGGO from 2004 to 2013.

Results: The largest part of registered patients constitutes patients with acromegaly (53%), followed by patients with prolactinomas (26%), inactive pituitary tumors (9%), Cushing's disease (6%), mixed secretion pituitary tumors (4%) and other tumors (2%). Prevalence of Cushing's disease in Russian Federation that can be calculated from number of patients registered in the database is >3 patients per 1 000 000 population. Among 431 patients with Cushing's disease 85% are women. Peak incidence is between the ages of 20-30 years. Two percent of patients have got first (highest) degree of disability, 22% - second degree and 12% - third degree, 27% don't have any established degree of disability, and 33% - no data. Seventy percent of patients with Cushing's disease are in remission. Hypopituitarism is present in 34% of patients (hypocortisolism - 70%, hypogonadism - 41%, hypothyroidism - 30%, diabetes insipidus - 20%, GH-deficiency - 10%), visual disturbances due to chiasmatic involvment in 5.3% and neurologic complications in 43% (e.g. headaches – 91%, vertigo – 15%, ptosis – 6%). Surgery was performed in 60% of patients, 31% received radiation therapy and 15.5% - underwent total adrenalectomy. Drug therapy is received by 27% of patients, mainly consisting of ketokonazole > 90%, bromocriptine - 44%, cabergoline - 8%, long acting somatostatin analogs <4%.

Conclusions: Our database indicates that Cushing's disease is a rare and highly disabling disease. The definitive remission rate of 70% is quite promissing as medical treatment choices are still limited.

 

Disclosure: LYR: Coinvestigator, Novartis Pharmaceuticals, Clinician, Novartis Pharmaceuticals, Coinvestigator, Ipsen, Coinvestigator, Pfizer, Inc.. LKD: Clinical Researcher, Pfizer, Inc.. NNM: Clinical Researcher, Ipsen. Nothing to Disclose: EAP, ZEB, GAM, IID, OD, MC, OC

13378 8.0000 SAT-0643 A Russian Registry of Patients with Tumors of the Hypothalamic-Pituitary Region (OGGO): October 2013 Update for Cushing's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Ula Abed Alwahab, Georgiana Alina Dobri*, Charles Faiman, Laurence Kennedy and Amir Hekmat Hamrahian
Cleveland Clinic Foundation, Cleveland, OH

 

Introduction:
A serum cortisol level < 1.4 µg/dl after a 2 day low dose dexamethasone suppression test (LDDST) can be used to rule out Cushing disease. The diagnostic value of adding a corticotropin releasing hormone (CRH) stimulation test to the dexamethasone suppression test has been debated in the literature.
Methods:
We reviewed the Cleveland Clinic pituitary database in order to identify patients who had a suppressed cortisol value (< 1.4 µg/dl) after a 2 day LDDST but had a cortisol value > 1.4 µg/dl at 15 min after CRH Stimulation(Dex-CRH test). Patients were instructed to take 8 doses of 0.5 mg of Dexamethasone every 6 hours orally starting at noon so the last dose of dexamethasone would be at 6 AM. Ovine CRH injection (1 µg/kg, maximum 100 µg) was given IV 2 hours afterwards.
Results:
A total of 154 patients underwent the Dex-CRH test between 2002 and 2013. Among them, we identified 4 patients (2.6%) [95% CI: 0.09%-5.11%] who were able to suppress cortisol adequately to <1.4 µg/dl after the 2 day LDDST but had an elevated cortisol of >1.4 µg/dl after CRH stimulation. The suppressed cortisol levels after LDDST were <0.1, <0.1, 1.1 and 1.2 µg/dl and the stimulated Cortisol levels after CRH injection were: 1.8, 2.1, 2.3 and 6.1 µg/dl.
The median (range) age was 36 years old(24-37). All were women.Three of these patients had pathology-proven new or recurrent Cushing disease; the fourth was lost to follow up. The dexamethasone levels prior to the administration of CRH were available in these 3 patients and they were: 493,496 and 496 ng/dl.
Discussion:
The addition of a CRH test after the 2 day LDDST confirmed the presence of Cushing disease in 3 out of 4 patients with an appropriately suppressed cortisol level after the 2 day LDDST. The standard LDDST is slightly different from the Dex-CRH test regarding the timing of dexamethasone administration. There are no data in the literature as to how this protocol variance would affect the results, however it is unlikely that the timing difference would matter since the biological plasma half-life of dexamethasone is reported as 36-54 hours.
Conclusion:
The addition of the CRH test to the 2 day LDDST appears to provide additional case detection in a small percentage (up to 5%) of patients evaluated for new or recurrent Cushing disease.

 

Nothing to Disclose: UA, GAD, CF, LK, AHH

13969 9.0000 SAT-0644 A Dexamethasone Suppression-Crh Stimulation Test Provides Additional Case Detection in Patients Evaluated for Cushing Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Tanya Burton*1, Elisabeth LeNestour2, Maureen P Neary3 and William H Ludlam3
1Optum, Waltham, MA, 2inVentiv Health Clinical, France, 3Novartis Pharmaceuticals Corporation, East Hanover, NJ

 

OBJECTIVE: To describe treatment patterns for Cushing disease (CD).

METHODS: A retrospective cohort study design was used to analyze administrative claims data of commercial health plan enrollees with evidence of Cushing disease (CD) between 2007-2011. Children and adult CD cases were identified using a Cushing syndrome (CS) diagnosis code (ICD-9: 255.0) and at least one code for a CD-related diagnosis or procedure (e.g., pituitary neoplasm or hypophysectomy). CD cases were observed for 6 months before and at least 6 months after their first CD-related claim. Medication use during this time was described descriptively.

RESULTS: 885 enrollees met the CD selection criteria. Mean (SD) age was 42 (14) years, 75% were female. Median follow-up time was 2.4 years with a minimum of 6 months and a maximum of 5.5 years. During the study period, 208 (24%) had evidence of a hypophysectomy, 611 (69%) a CD-related medication, and 241 (27%) had neither. Only 23 (3%) had evidence of a bilateral adrenalectomy. Of the 208 with a hypophysectomy, 179 (86%) had evidence of pituitary supplementation.  Among the 611 with a CD-related medication (with and without surgery), 336 (55%) had at least one claim levothyroxine, followed by 262 (43%) with hydrocortisone and 250 (41%) with at least one sex hormone (testosterone, estrogen, and/or progestin). Antifungals were filled by 210 (34%) with a CD-related medication, and 57 (27%) of all antifungal fills were for oral ketoconazole. Less common medications included 73 (12%) with 9-alpha fludocortisone, 62 (10%) with cabergoline, and 19 (3%) with bromocriptine. Only three CD cases (<1%) had a fill for mitotane.  Nearly all CD cases, 848 or 96%, had at least one concomitant medication filled during the study period, of which 684 (81%) had two or more different types. Common concomitant fills included 766 (90%) with at least one antibiotic sometime during the study period, followed by 480 (57%) with an antihypertensive, 432 (51%) with an antidepressant or mood stabilizer, 274 (32%) with a hyperglycemic, and 263 (31%) with an osteoporosis medication including calcium and vitamin D.

CONCLUSION: The majority of identified CD cases were treated with hypophysectomy and/or pituitary supplementation. Bilateral adrenalectomy was rare and pituitary irradiation was not found in our database. Levothyroxine was the most common drug filled. Of the antifungals filled, more than a quarter was for oral ketoconazole.

 

Disclosure: TB: Researcher, Novartis Pharmaceuticals. MPN: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. WHL: Employee, Novartis Pharmaceuticals. Nothing to Disclose: EL

14087 10.0000 SAT-0645 A Treatment Patterns Associated with Cushing Disease in a Large US Managed Care Health Plan 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Tanya Burton*1, Elisabeth LeNestour2, Maureen P Neary3 and William H Ludlam3
1Optum, Waltham, MA, 2inVentiv Health Clinical, France, 3Novartis Pharmaceuticals Corporation, East Hanover, NJ

 

OBJECTIVE: To quantify the additional clinical burden of Cushing disease (CD) cases compared to CD-free controls.

METHODS: A retrospective matched-cohort study design was used to analyze administrative claims data of commercial health plan enrollees with evidence of Cushing disease (CD) from 2007-2011. Each CD case was matched to three randomly selected disease-free controls by age, sex, region, and index year. CD cases were identified using a Cushing syndrome diagnosis code (ICD-9: 255.0) and at least one code for a CD-related diagnosis or procedure (e.g., pituitary neoplasm or hypophysectomy). CD cases were observed for 6 months before and at least 6 months after their first CD-related claim. Controls were observed during a similar period of time starting in the same index year. Rates of new comorbid conditions following the first CD-related claim were compared using incidence rate ratios (IRR) and 95% confidence intervals (CI) from the Poisson distribution.

RESULTS: Among the 885 selected CD cases and 2,655 matched controls, the mean (SD) age was 42 (14) years and 75% were female. Follow-up time ranged from 6 months to 5.5 years with a median of 2.4 years for cases and 1.5 years for controls. Compared to controls, CD cases had 5 times the rate of osteoporosis (IRR: 5.0, 95% CI: 3.7-6.9) and diabetes (IRR: 5.2, 95% CI: 4.0-6.8), 4 times the rate of obesity (IRR: 3.8, 95% CI: 3.0-4.8) and cardiovascular disease (IRR: 3.7; 95% CI: 3.0-4.5), 3 times the rate of hypertension (IRR: 2.9, 95% CI: 2.4-3.5), mood disorders (IRR: 3.0, 95% CI: 2.2-4.0), depression (IRR: 2.6, 95% CI: 2.0-3.3) and liver disease (IRR: 2.7, 95% CI: 2.1-3.3), and twice the rate of dyslipidemia (IRR: 2.0, 95% CI: 1.7-2.4), menstrual abnormalities (IRR: 1.8, 95% CI: 1.5-2.1), and acne (IRR: 1.9, 95% CI:1.4-2.7). Among children (<18 years), no one had evidence of short stature but CD cases had 9 times the rate of abnormal weight gain (IRR: 9.2, 95% CI: 3.0-50.9) compared to CD-free controls.

CONCLUSION: An algorithm identified CD cases in a large managed care health plan, and the sex and age distribution of the selected population matched the known epidemiology of CD. Study findings indicate that CD cases have a clinical burden higher than CD-free controls, with many comorbidity rates two to five times higher.

 

Disclosure: TB: Researcher, Novartis Pharmaceuticals. MPN: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. WHL: Employee, Novartis Pharmaceuticals. Nothing to Disclose: EL

14561 11.0000 SAT-0646 A Incremental Clinical Burden of Cushing Disease in a Large US Managed Care Health Plan 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Tanya Burton*1, Elisabeth LeNestour2, Maureen P Neary3 and William H Ludlam3
1Optum, Waltham, MA, 2inVentiv Health Clinical, France, 3Novartis Pharmaceuticals Corporation, East Hanover, NJ

 

OBJECTIVE: To compare health care resource utilization and costs of Cushing disease (CD) cases compared to CD-free controls.

METHODS: A retrospective matched-cohort study design was used to analyze administrative claims data of commercial health plan enrollees with evidence of Cushing disease (CD) from 2007-2011. Each CD case was matched to three randomly selected disease-free controls by age, sex, region, and index year. CD cases were identified using a Cushing syndrome diagnosis code (ICD-9: 255.0) and at least one code for a CD-related diagnosis or procedure (e.g., pituitary neoplasm or hypophysectomy). CD cases were observed for 6 months before and at least 6 months after their first CD-related claim. Controls were observed during a similar period of time starting in the same index year. Per patient per month (PPPM) counts and costs of all-cause health care resource utilization were compared descriptively. Costs were CPI-adjusted to 2011 dollars and included health plan- and patient-paid amounts.

RESULTS: Among the 885 selected CD cases and 2,655 matched controls, the mean (SD) age was 42 (14) years and 75% were female. Follow-up time ranged from 6 months to 5.5 years with a median of 2.4 years for CD cases and 1.5 years for CD-free controls. Compared to controls, CD cases had a higher proportion of inpatient (IP) admissions (50% vs. 11%, p<0.001), emergency department (ED) visits (61% vs. 20%, p<0.001), and outpatient (OP) hospital visits (95% vs. 63%, p<0.001). Average monthly counts of resource utilization for cases were 2-4 times higher than controls: outpatient hospital and physician office visits (2.5 vs. 0.9, p<0.001), ED visits (0.1 vs. 0.04, p<0.001), and inpatient admission (0.03 vs. 0.01, p<0.001). Average PPPM total all-cause costs were also higher for cases than controls ($3,224 vs. $486, p<0.001). Total costs were driven primarily by medical costs for cases ($2,790) and controls ($382). Average PPPM pharmacy costs were 4 times higher for cases than controls ($434 vs. $104, p<0.001).

CONCLUSION: In this study, high health care resource utilization and costs were identified for CD cases compared to CD-free controls.  In addition to the cost of CD treatment, the cost difference included the costs of diagnosing and treating multiple comorbidities such as diabetes and cardiovascular disease, which are more commonly observed in an older population.

 

Disclosure: TB: Researcher, Novartis Pharmaceuticals. MPN: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. WHL: Employee, Novartis Pharmaceuticals. Nothing to Disclose: EL

14584 12.0000 SAT-0647 A Economic Burden of Cushing Disease in a Large US Managed Care Health Plan 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Alejandro Ayala*1 and Alex Manzano2
1University of Miami Miller School of Medicine, Miami, FL, 2Univ of Miami Miller Schl of Med, Coral Gables, FL

 

Cushing’s disease is a rare and devastating neuroendocrine disorder characterized by chronic hypercortisolism due to a hyperactive ACTH-secreting pituitary adenoma. Patients with Cushing’s disease often develop debilitating sequelae (eg, cardiovascular disease, glucose intolerance, cognitive impairment) (1), underscoring the urgent need for early diagnosis and treatment. Transsphenoidal surgery (TSS) is generally first-line treatment for Cushing’s disease. Remission rates following TSS are highly variable and disease recurrence, even several years after early remission, is not uncommon (2). Recognizing Cushing’s disease recurrence can be challenging, and although there is general acceptance among endocrinologists that surgically-treated patients need lifelong follow-up, there are currently no standardized guidelines for long-term monitoring following TSS. To begin addressing this need we have created a systematic monitoring algorithm to facilitate early detection of recurrent Cushing’s disease following TSS. We integrated information from PubMed-indexed articles that reported relapse rates in surgically-treated Cushing’s disease patients and our own clinical experiences to generate this novel algorithm. Reported rates of Cushing’s disease recurrence following surgery range from 3 to 47% (mean time to recurrence 16–49 months). We propose that patients with post-operative serum cortisol levels, measured 2–3 days after surgery, of <2 µg/dL (ie, patients in immediate remission) be monitored semiannually for 3 years and annually thereafter. Patients with postoperative cortisol levels of 2–5 µg/dL may experience subclinical Cushing’s disease or persistent, overt disease and should be evaluated every 2–3 months until biochemical control is achieved or additional treatment is initiated. Patients with postoperative cortisol levels of >5 µg/dL often have persistent disease, and second-line treatment, such as immediate repeat pituitary surgery, radiotherapy, and/or medical therapy may be considered. This follow-up algorithm is proposed with the aim to, (a) serve as a tool to enable early diagnosis and treatment of recurrent Cushing’s disease, thereby minimizing the detrimental effects of hypercortisolism, and (b) begin addressing the need for standardized guidelines for vigilant monitoring of Cushing’s disease patients treated by TSS, as is demonstrated by the reported rates of recurrence.

 

Disclosure: AA: Speaker, Pfizer, Inc.. Nothing to Disclose: AM

15269 13.0000 SAT-0648 A Early Detection of Recurrent Cushing's Disease: Proposal of a Novel Post-Surgical Monitoring Algorithm 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Michael S. Broder*1, Maureen P Neary2, Eunice Chang1, Gordon H Sun3 and William H Ludlam2
1Partnership for Health Analytic Research, LLC, Beverly Hills, CA, 2Novartis Pharmaceuticals Corporation, East Hanover, NJ, 3Partnership for Health Analytic Research, Beverly Hills, CA

 

Cushing's disease (CD) is a rare endocrine disorder resulting from excess adrenocorticotropic hormone production from a pituitary tumor. Because of the wide variety of nonspecific symptoms associated with CD, many years typically elapse between symptom onset and diagnosis. Our objective was to analyze a large US commercial healthcare claims database in order to estimate the CD risk associated with 10 important signs and symptoms, with the goal of potentially improving early identification of this rare disease.

We conducted a retrospective case-control study using a commercial insurance claims database from 2008 to 2012. We identified patients with CD using the ICD-9-CM diagnosis code for Cushing’s syndrome (255.0) plus at least 1 diagnosis or procedure code indicating the presence of pituitary disease. We matched CD patients to randomly selected control patients without CD by age, gender, and geographic region in a 1:2 ratio. Based on expert clinician opinion, we used ICD-9-CM diagnosis codes to estimate the risk of CD-associated signs and symptoms: hirsutism, localized adiposity, facial plethora, polycystic ovary syndrome, deep venous thrombosis, hypokalemia, abnormal weight gain, muscle weakness, osteoporosis, and female balding.

In a cohort of 5,625 patients, the 3 most prevalent conditions in the CD subgroup were abnormal weight gain (11.5%), osteoporosis (8.5%), and polycystic ovary syndrome (8.1%), compared with 1.2%, 1.4%, and 0.7% in the non-CD group. The prevalence of the 10 key conditions in the non-CD subgroup ranged from 0.03% to 1.4%. The highest relative risk (RR) associated with any of the 10 conditions was 27.8 for hirsutism, and the lowest was 5.1 for female balding.

Analysis of a US healthcare claims database demonstrated that the RR of having any one of the 10 relevant conditions was at least 5 times greater in CD patients compared to non-CD patients. If clinicians consider the diagnosis of CD when the highest-risk conditions are seen, identification of this rare disease might improve. Further analysis of the risk associated with combinations of these conditions is currently underway, and the results might be useful in developing clinical decision aids to identify patients at highest risk of CD.

 

Disclosure: MSB: Employee, Partnership for Health Analytic Research, LLC. MPN: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. EC: Employee, Partnership for Health Analytic Research, LLC. GHS: Employee, Partnership for Health Analytic Research, LLC. WHL: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals.

16440 14.0000 SAT-0649 A Identification of Potential Markers for Cushing's Disease As an Aid to Diagnosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Ferdinand Roelfsema*1, Alberto M. Pereira1, Nienke R. Biermasz2 and Johannes D Veldhuis3
1Leiden University Medical Center, Leiden, Netherlands, 2Leiden University Medical Center, Netherlands, 3Mayo Clinic, Rochester, MN

 

Previous investigations by our group have shown that hormone secretion by hyperfunctioning pituitary tumors is characterized by increased basal (nonpulsatile) secretion, enhanced pulse frequency, amplified pulse mass and increased disorderliness (1-3). Tools for analyzing patterns of hormone secretion have advanced and improved. A recently described tool is spikiness, which quantitates short-lived sudden increases in hormone levels (4, 5). In addition, the algorithm for ApEn was refined and more precise, and re-named JackApEn.  We aimed to explore whether these new tools contribute to new insights in the pathological secretion of hormones. Consequently, we reanalyzed available data files of 24-hour hormone profiles (10-min interval) of 24 patients with active acromegaly, 17 with untreated prolactinoma and 20 patients with active Cushing’s disease, and compared with matched controls. Spikiness was increased in active acromegaly,  Cushing’s disease and  prolactinoma compared with healthy controls : Acromegaly 0.501 ±  0.029 vs 0.394 ± 0.013, P= 0.002; Cushing’s disease ACTH 0.577 ± 0.027 vs 0.512 ± 0.017, P = 0.04, cortisol 0.758 ± 0.045 vs 0.417 ± 0.014, P<0.0001; prolactinoma 0.776 ± 0.052 vs 0.379 ± 0.016, P<0.0001). Likewise, Jack ApEn was increased in the three groups of patients. In acromegaly, Jack ApEn was 1.349 ± 0.066 vs 0.456 ± 0.032, P<0.0001; in prolactinoma patients 1.808 ± 0.084 vs 0.990 ± 0.038, P<0.001. JackApEn for ACTH in Cushing’s disease was 1.563 ± 0.042 vs 0.992 ±0.047, P<0.0001 and for cortisol 1.687 ± 0.061 vs 1.062 ± 0.027. The present data confirm previous reports on disorganized hormone secretion by hyperfunctioning pituitary adenomas. The new finding is increased spikiness in these patient groups, reflecting sudden short-lived serum (plasma) hormone increases. The mechanisms behind increased disorderliness and spikiness are not established yet, but may include diminished feedback signaling and loss of anatomical cell-cell interaction of the endocrine network in the adenoma (6).

 

Nothing to Disclose: FR, AMP, NRB, JDV

11502 15.0000 SAT-0650 A Hormone Secretion By Pituitary Adenomas Is Characterized By Increased Disorderliness and Spikiness 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Sjoerd D. Joustra*1, Roland D. Thijs2, Rosa van den Berg3, Marieke van Dijk3, Alberto M. Pereira1, Gert J. Lammers2, Eus J.W. van Someren4, Hans A. Romijn3 and Nienke R. Biermasz3
1Leiden University Medical Center, Leiden, Netherlands, 2Leiden University Medical Center, 3Leiden University Medical Center, Netherlands, 4VU University and Medical Center, Amsterdam

 

Context: Patients treated for nonfunctioning pituitary macroadenoma (NFMA) frequently have fatigue and alterations in sleep characteristics and sleep-wake rhythmicity. Since NFMA often compress the optic chiasm, these complaints might be related to dysfunction of the adjacent suprachiasmatic nucleus (SCN).

Objective: To explore whether indirect indices of SCN functioning are altered in the long-term after surgery for NFMA.

Methods: We studied 17 NFMA patients in long-term remission after transsphenoidal surgery, receiving adequate and stable hormone replacement for hypopituitarism, and 17 controls matched for age, gender, and BMI. Indirect indices of SCN function were assessed from ambulatory 24-hour recordings of skin and core body temperature, blood pressure, and salivary melatonin levels. Altered melatonin secretion was defined as absent evening rise, considerable irregularity, or daytime values >3 pg/ml. We additionally studied 8 patients treated for craniopharyngioma.

Results: Distal-proximal skin temperature gradient did not differ between NFMA and controls, but proximal skin temperature was decreased during daytime (P=0.006). Core body temperature and non-dipping of blood pressure did not differ, whereas melatonin secretion was often altered in NFMA (OR 5.3, 95%CI 0.9–30.6). One or more abnormal parameters (≥2.0 SD score of controls) were observed during nighttime in twelve and during daytime in seven NFMA patients. Similar patterns were observed in craniopharyngioma patients.

Conclusion: The majority of patients previously treated for NMFA showed signs of altered diurnal rhythms in skin temperature and/or melatonin secretion. These observations suggest that suprasellar tumors may persistently affect diurnal regulation of physiological rhythms, possibly through effects on the SCN.

 

Nothing to Disclose: SDJ, RDT, RV, MV, AMP, GJL, EJWV, HAR, NRB

11646 16.0000 SAT-0651 A Alterations in Diurnal Rhythmicity in Patients Treated for Nonfunctioning Pituitary Macroadenoma; A Controlled Study and Literature Review 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Julie M Silverstein*1, Bithika M Thompson2, Jie Zheng2, Stacy Hurst2, Albert H Kim2, Ralph G Dacey2, Keith M Rich2, Gregory J Zipfel2, Michael R Chicoine2 and Clay F Semenkovich2
1Washington University School of Medicine, St Louis, MO, 2Washington University School of Medicine, St. Louis, MO

 

There is no consensus regarding optimal peri-operative steroid management of patients with pituitary adenomas or cysts undergoing pituitary surgery.  Patients undergoing pituitary surgery generally receive “stress” doses of glucocorticoids around the time of surgery to prevent adrenal insufficiency, but compelling data to support the routine use of peri-operative steroids are unavailable. Given the pleiotropic adverse effects of steroids, appropriately avoiding glucocorticoid use could decrease peri-operative complications. We conducted a pilot prospective study to test the hypothesis that withholding glucocorticoids in patients with an intact hypothalamic-pituitary-adrenal (HPA) axis undergoing transsphenoidal surgery is safe.  Patients (including those with non-functioning adenomas, acromegaly, TSH-secreting adenomas, or prolactinomas) with an intact HPA axis scheduled to undergo transsphenoidal resection of a pituitary adenoma or cyst were randomized either to receive IV hydrocortisone at the time of anesthesia induction and then dexamethasone 0.5mg IV q 6 x 4 doses (STER group, n= 11) or to undergo surgery without peri-operative steroids (NOSTER group, n= 8).  For all subjects, an 8 am cortisol level was determined either on post-operative day one (NOSTER group) or on post-operative days two or three, at least 24 hours after the last dose of dexamethasone (STER group).  Patients whose 8 am cortisol was < 15 mcg/dl were treated with prednisone 5mg daily.  All patients underwent a cosyntropin stimulation test four to six weeks after surgery and prednisone was discontinued if testing was consistent with an intact HPA axis.  Data regarding length of hospital stay, incidence of diabetes insipidus (DI), hyperglycemia, incidence of adrenal insufficiency (AI), development of delayed hyponatremia, and complications were collected.  There was no difference in post-operative glucose levels in non-diabetic patients (121 +/-  5 mg/dl vs. 128 +/- 17 mg/dl, p= 0.15), in the development of transient  DI (54.6% vs. 42.9%, p= 1.0), in the development of delayed hyponatremia (9.1% vs. 28.6%, p= 0.53), in the number of patients discharged on glucocorticoids (27.3% vs. 14.3%, p= 1.0) or in the number of patients who developed permanent AI (9.1% vs. 0%, p=1.0) in the STER and NOSTER  groups respectively.  One patient in the NOSTER group died of post-operative meningitis and there were no deaths or serious complications in the STER group. There was a trend towards an increase in length of hospital stay in the STER group compared to the NOSTER group (4.36 days vs. 3.71 days, p= 0.418).  While this study is limited by small sample sizes that increase the possibility of a type II error, these results provide data suitable for designing a larger study to confirm that withholding glucocorticoids in patients with an intact HPA axis undergoing transsphenoidal resection of pituitary adenomas or cysts may be beneficial.

 

Disclosure: JMS: Clinician, Pfizer, Inc.. CFS: Researcher, Merck & Co., Clinician, Merck & Co.. Nothing to Disclose: BMT, JZ, SH, AHK, RGD, KMR, GJZ, MRC

15037 17.0000 SAT-0652 A Peri-Operative Glucocorticoids Can be Withheld Safely in Patients with an Intact Hypothalamic-Pituitary-Adrenal Axis Undergoing Transsphenoidal Surgery of a Pituitary Adenoma or Cyst 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Ekaterina Manuylova*1, Laura Maria Calvi2, G Edward Vates1, Catherine Hastings1 and Ismat Shafiq1
1University of Rochester, Rochester, NY, 2University of Rochester School of Medicine, Rochester, NY

 

Introduction: Several studies have demonstrated the utility of perioperative cortisol level for predicting hypothalamic-pituitary-adrenal (HPA) function and limiting the need for postoperative GC replacement. However, glucocorticoids (GC) are routinely used before and after transsphenoidal surgery (TSS) for pituitary adenoma in many medical centers in the USA and worldwide. We instituted a steroid sparing protocol in 2012 utilizing a serum cortisol level on post-operative day 1 (POD-1) approximately 18-24 hour after receiving dexamethasone peri-operatively and then again on post-operative Day-6 (POD-6).

Objectives:

1-     To evaluate the safety of using a cut off cortisol level of 14 ug/dl on POD-1 after dexamethasone use during surgery.

2-     To evaluate the benefit of obtaining second cortisol level on Day 6.

Patients and methods: The charts of 86 adult patients having TSS at the University of Rochester Medical center from 2/2012 to 8/2013 were retrospectively reviewed. The analysis excluded patients with Cushing disease, suspected pituitary apoplexy, prior history of radiotherapy and preoperative GC use. All patients received dexamethasone 4 mg during induction of anesthesia for the TSS. Early morning cortisol levels were measured POD-1. Patients with a cortisol level ≥14ug/dl were discharged without CG replacement. Morning cortisol level was checked routinely on POD-6 and/or if patients experienced any signs or symptoms of adrenal insufficiency (AI). If POD-6 cortisol level was <14ug/dl and/or accompanied with symptoms of AI, GC replacement was initiated. Standard descriptive statistical methods were used including mean, standard deviation, and percent difference. 

Results: Forty eight patients without known HPA axis dysfunction preoperatively were included in the study. 68.8 % (33 patients) had POD-1 cortisol level ≥14ug/dl. 31.2 % (15 patients) had POD-1 cortisol level <14ug/dl and were discharged on GC. 38 of the 48 patients had POD-6 cortisol level available. 55 % (21 patients) had cortisol ≥14ug/dl. 44 % (17 patients) had cortisol <14ug/dl. 12 of the 17 patients on follow were weaned off GC in 2-4 weeks and only 5 patients remained on GC treatment. During postoperative period up to 16 months there were no hospital admissions for adrenal crisis. 

Conclusion: We used a cortisol level of ≥14ug/dl to guide the need for early CG replacement in the setting of intraoperative dexamethasone use. Though dexamethasone has a half-life of greater than 24 hours, using the POD-1 cortisol level still leads to avoidance of CG use in approximately 2/3 of the patients postoperatively. POD-6 cortisol level further guided the use and discontinuation of CG in the patients after TSS. We speculate that avoidance of unnecessary postoperative GC replacement accelerates recovery and diminishes postoperative complications, including medication errors.

 

Nothing to Disclose: EM, LMC, GEV, CH, IS

15157 18.0000 SAT-0653 A Morning Serum Cortisol Level after Transsphenoidal Surgery for Pituitary Adenoma Predicts Hypothalamic-Pituitary-Adrenal Function Despite Intraoperative Dexamethasone Use 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Rafael Loch Batista*1, Nina de Castro Musolino2, Clarissa Groberio Borba3, Valter Angelo Sperling Cescato4, Gilberto Ochman Silva5 and Malebranche Cunha Neto3
1Hospital das Clinicas, FMUSP, Brazil, 2Hospital das Clínicas, FMUSP, São Paulo, Brazil, 3Hospital das Clínicas, FMUSP, 4HC FMUSP, Sao Paulo, Brazil, 5USP

 

Introduction: Clinically Nonfunctioning Pituitary Adenomas (NFPA) are approximately 30% of all pituitary tumors. The treatment of choice is surgical resection. Although surgery can relieve symptoms related tumor compression, complete surgical resection is not frequent and radiotherapy is required in many cases. The role of dopamine agonists have not yet been well established in NFPA and better designed studies are lacking to prove its effectiveness Last year, we present preliminary data from this study, with 67 patients.. Here we present the final results of this project, including more than 100 patients.

Objective: To evaluate the useful of cabergoline in patients with NFPA who had evident residual tumor after transsphenoidal (TS) surgery in reducing and /or maintain a stable tumor rest.

Methods: We compared two groups of NFPA patients who presented residual tumor in a MRI performed six months after surgery: 52 patients treated by cabergoline - 3.5mg/week (A) and 49 patients followed without cabergoline (B). No patients were treated by irradiation before or during the follow-up. All patients were evaluated every 6 months with MRI for 12 months. Change of tumor volume bigger than 15% were considering significant. Statistical analysis was performed using the statistical program SOFA.

Results: The MRI in group A showed stabilization of residual tumor in 71,15% (37/52) and tumor reduction in 21,15% (11/52) of patients, while tumor progression was observed in 7,69% (7,69%). In group B, stabilization was observed at 81.63% (40/49), reduction in 4,08% (2/49) and growth in 14.28% (7/49) of patients. Statistical difference between groups A and B was obtained regarding tumor reduction - 21,15% (A) vs. 4,08% (B), p < 0.01 - and tumor progression - 7,69% (A) vs. 14.28% (B) p = 0.037 - with no difference in the stabilization of residual tumor (p = 0.44).

Conclusions: Cabergoline, after TS surgery, was useful in reducing or stabling residual tumor in significant number of NFPA patients in a 12 months follow up. The use of cabergoline was associated with greater tumor shrinkage and no medication use (conservative treatment) was associated with higher rates of growth of the tumor rest.

 

Nothing to Disclose: RLB, NDCM, CGB, VASC, GOS, MC

16189 19.0000 SAT-0654 A Cabergoline Effectivenes in Patients with Clinically Nonfunctioning Pituitary Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Thomas Graillon*1, Frederic Castinetti2, Thierry Brue3, Isabelle Morange4, Tarek Adetchessi5, Philippe Metellus5, Stephane Fuentes5, Régis Gras5 and Henry Dufour6
1CHU Timone, Marseilles, France, 2La Conception Hospital, Marseille, France, 3Centre de Recherche en Neurobiologie et Neurophysiologie de Marseille, France, 4CHU Timone, Marseille - CDX 05, France, 5Hopital La Timone, Marseilles, France, 6Aix Marseille University, Marseille, France

 

Introduction: Giant pituitary adenomas (PA) remain rare and challenging tumors. Transsphenoidal (TS) and/or transcranial (TC) approaches can be performed.

Objective: May recent advances in endonasal endoscopy for PA surgery change surgical results?

Material and Methods: Among a prospective clinical data base of 1700 PA, 17 cases of PA responding to the definition of giant PA (diameter > 40 mm) were operated via TC approach. 9 patients required TC approach first. Indication for a complementary TS approach was retained in 6 of these cases. 8 patients underwent TS approach first. Indication for a complementary TC approach was retained in all of these 8 cases. TS approach was performed via endoscopy in 7 cases and via microscopy in 7 cases. Pre and postoperative characteristics of the patients and PA were collected. Each approach,  their complications, advantages, and disadvantages were studied to define optimal indications. Maximal diameter average in our cohort was 51.5mm. Visual disturbance was obvious in 88% of cases and was the most frequent revealing symptom. Most part of these giant PA was benign and non-secreting.

Results: In most of these giant PA collected cases, TC or TS approaches alone were not sufficient to provide a satisfying tumor removal. Combination of TS and TC approach was required in 82 % in order to improve tumor removal. Resection was total in 24% of cases and subtotal in 70% of cases. The use of endoscopic endonasal technique increased the amount of removal but did not increase the cure rate of giant adenoma. Cavernous sinus invasion decreased total tumor removal rate from 50% to 9%. Visual outcome: TC approach provided more frequent and with a higher quality visual improvement, than TS approach. But, paradoxically, visual impairment rate was higher after TC approach than TS approach (17.5% versus 7%), related to ischemic and/or traumatic chiasm lesion. Postoperative panhypopituitarism occurred in 35% of cases without difference between TC and TS approaches. Inversely, postoperative diabetes insipidus occurred in 47% of TC approaches versus only 8% of TS approaches. Postoperative ischemia was observed in 23.5% of TC approach with clinical symptoms varying from none to severe hemiparesia. Half cases equally presented chiasm ischemic lesion. Postoperative intratumoral bleeding was more frequent after TS approach related to residue apoplexy, involving risk of visual impairment, subarachnoid bleeding, hydrocephalus and vasospasm.

Conclusion: Despite a high morbidity, TC approach remains mandatory in current management of giant PA combined or not with endoscopic TS approach in order to provide maximal tumor removal. Surgical approach decision is mostly related to the PA morphology, and the shape of suprasellar extension. Endoscopic endonasal approach vs microscopic approach does not lower the amount of complication and does not increase the cure rate in giant PA.

 

Disclosure: TG: Clinical Researcher, Novartis Pharmaceuticals. TB: Clinical Researcher, Pfizer, Inc., Clinical Researcher, Novo Nordisk, Clinical Researcher, Novartis Pharmaceuticals, Clinical Researcher, Ipsen, Clinical Researcher, Serono, Clinical Researcher, Sandoz. Nothing to Disclose: FC, IM, TA, PM, SF, RG, HD

16958 20.0000 SAT-0655 A Giant Pituitary Adenomas Surgery: What Is the Best Route? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Qing Fang*1, Ivo J P Arnhold2, Anna Flavia F Benedetti3, Berenice Bilharinho Mendonça4, Thierry Brue5, Luciani R S Carvalho4, Frederic Castinetti6, Fernanda de Azevedo Correa7, Jun Z. Li1, Qianyi Ma1, Rachel Reynaud8 and Sally A Camper1
1University of Michigan, Ann Arbor, MI, 2University of Sao Paulo, São Paulo, Brazil, 3University of Sao Paulo, 4University of São Paulo, Hospital das Clinicas, São Paulo, Brazil, 5Centre de Recherche en Neurobiologie et Neurophysiologie de Marseille, France, 6La Conception Hospital, Marseille, France, 7Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo FMUSP, São Paulo, Brazil, 8Aix Marseille Université and APHM, Marseille Cedex 05, France

 

Pituitary disorders leading to growth insufficiency are genetically heterogeneous, as there are more than a dozen different causal genes. There are examples of recessive, dominant, and X-linked inheritance, and some of the dominant disorders have incomplete penetrance.  For most of the known genes, the clinical features of affected individuals are variable.  This makes molecular genetic diagnoses difficult.  In addition, many cases of pituitary hormone deficiency have no known cause.  Next generation sequencing promises to revolutionize diagnosis of genetic disorders.  Here we report on our experience with sequencing exomes of 18 individuals with hypopituitarism: eight patient samples from sporadic cases in consanguineous pedigrees, and three familial cases with 2-3 affected individuals.  The clinical characteristics of most patients included multiple pituitary hormone deficiencies (MPHD), and there were two sporadic cases with IGHD.  Most of the probands had been screened for mutations in known genes using Sanger sequencing, and none were identified.  Mutations in the transcription factor HESX1 are a rare, known cause of MPHD and IGHD, and we found examples of both in this set.  A proband with a familial case of pituitary aplasia is a compound heterozygote for novel, predicted loss of function changes in HESX1 (p.R159W and p.R160H), and an individual homozygous for the previously reported p.I26T was found, although the clinical features are different (1).  This patient had eutopic posterior lobe and pituitary hypoplasia but did not develop cortisol deficiency.  A sporadic consanguineous case of IGHD was discovered to be homozygous for a p.L144H mutation in GHRHR in a 13130 kb region of run of homozygosity.  This patient also has a CYP21A2 variant leading to congenital adrenal hyperplasia.  No lesions in known candidate genes were found in any of the other samples.  Thus, we have the opportunity to discover novel causes of pituitary hormone insufficiency in the remaining 15 people.  We are using our knowledge of the developing pituitary transcriptome in the mouse to prioritize candidate genes (2).  In summary, this exome sequencing pilot revealed a small fraction of probands with mutations in known genes (17%), and promises to lead to the discovery of novel genes and pathways necessary for normal pituitary function.

 

Disclosure: TB: Clinical Researcher, Pfizer, Inc., Clinical Researcher, Novo Nordisk, Clinical Researcher, Novartis Pharmaceuticals, Clinical Researcher, Ipsen, Clinical Researcher, Serono, Clinical Researcher, Sandoz. Nothing to Disclose: QF, IJPA, AFFB, BBM, LRSC, FC, FDAC, JZL, QM, RR, SAC

16546 21.0000 SAT-0656 A Gene Identification in Patients with Hypopituitarism: Next Generation Exome Sequencing Experience 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

IIonka Kreitschmann-Andermahr*1, Sonja Siegel2, Daniel Starz3, Johannes Kohlmann3, Sven-Martin Schlaffer3, Tsambika Psaras4 and Michael Buchfelder3
1University of Duisburg-Essen, Essen, Germany, 2University Hospital Essen, Essen, Germany, 3University Hospital Erlangen, Erlangen, Germany, 4Klinikum Köln Merheim

 

Even years after successful treatment of Cushing’s disease (CD), patients’ psychosocial well-being and health-related quality of life (HRQoL) can remain severely impaired. As the reasons for these long-term impairments are yet unclear, we conducted a postal survey to elucidate the role of possible influencing factors. A set of self-assessment inventories including questionnaires on depression (Hospital Anxiety and Depression Scale, HADS), HRQoL (Short Form SF-36, Tuebingen Cushing’s Disease CD-25), coping style (Freiburg Questionnaire on Coping with Illness, FKV-LIS) as well as a self-developed questionnaire on past and present symptoms, course of diagnosis, disease and treatment was sent to all patients with CD who had been operated upon an ACTH-producing pituitary adenoma in a single large tertiary neurosurgical referral center between 2005 - 2012. The answers from 101 patients (21 male, 80 female) were received und could be analyzed using SPSS.

At time of the survey (on average 6.2y after diagnosis) 28.7% of the patients suffered from severely impaired psychological HRQoL (SF-36 > 2 SD below mean), 11.9% from depression (HADS) and 22.8% from anxiety (HADS). Gender, age, rural vs. urban health care environment, length of the diagnostic process and number of doctors visited before diagnosis had no influence on psychosocial parameters. Patients with self-reported subnormal cortisol levels (20.8%) at the time of the survey suffered more from impaired physical HRQol (p=0.014) and depression (p=0.17) than patients with normal or elevated cortisol levels. Interestingly, maladaptive coping styles (FKV-LIS, „depressive coping“ and „minimizing importance“) correlated significantly with all scales measuring severity of depression, anxiety and impaired HRQoL (all p<0.05).

Our survey indicates that most of the investigated demographic and health care parameters seem to be unrelated to psychosocial well-being of patients after pituitary surgery for CD. However, self-rated HRQoL and psychosocial impairment are clearly influenced by the patient’s way of coping with the illness. Therefore, it should be considered to include psychological training sessions of positive coping styles into the medical follow-up strategy for patients with CD.

 

Nothing to Disclose: IK, SS, DS, JK, SMS, TP, MB

14758 22.0000 SAT-0657 A What Are the Causes of Long-Lasting Psychosocial Impairment in Patients with Cushing's Disease? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0636-0657 4830 1:00:00 PM Cushing's and Non Functional Tumors Poster

Netee Papneja*1, Gudrun Martina Caspar-Bell2, Syed Ali Imran3, Paul Edward Cooper4 and Stan Van Uum5
1University of Western Ontario, London, ON, Canada, 2Univ of Saskatchewan, Saskatoon, SK, Canada, 3Dalhousie University, Halifax, NS, Canada, 4The University of Western Ontari, London, ON, Canada, 5Department of Medicine, Western University, London, ON, Canada

 

Introduction: The prevalence of pituitary adenomas in autopsy series is 10.5%, and about 40% of these are non-functioning pituitary adenomas (NFPAs). Symptomatic NFPAs require trans-sphenoidal surgical resection.  However, the best management of asymptomatic NFPAs remains unclear. Asymptomatic patients are often managed with serial monitoring only, with growth occurring in about 35% of patients. Therefore, taking the ‘’wait and see’’ approach for patients with asymptomatic macroadenomas is debatable.

Medical treatment with dopamine agonists (DAs) has been available for several years. A review by Colao et al in 2008 summarized 24 reports on treatment of 199 patients with NFPA with various DAs. Tumor size increased in only 8.5% of patients. There are several published studies on tumor response to bromocriptine, but only few regarding cabergoline (CBG), even though CBG is a more potent dopamine agonist. 

Methods: We performed a systematic review of the literature to identify and summarize all observational studies on the use of CBG in NFPAs.  We reviewed the literature for all English language publications from 1950-2012 in Pubmed, EMBASE, MEDLINE, and Cochrane database. We identified six observational studies assessing the use of CBG in NFPAs and two studies that reported the use of CBG combined with Quinagolide or octreotide.

Results: CBG was used in a dose varying from 1 to 3 mg/week in 60 patients with NFPA with or without previous surgery. Follow-up varied from 6 to 78 months. Some degree of tumor shrinkage was detected in 26 out of the 60 patients (43.3%). Stabilization of adenoma size was found in 45% of patients, and increase in adenoma size was found in 11.6%. One single study evaluated ten patients with NFPA treated with cabergoline (0.5mg once a day) and Octreotide (200 mcg 3 times a day) for six months, with significant adenoma shrinkage observed in 60%.  In five patients treated with quinagolide for six months followed by CBG for 6 months, no effect on adenoma size was observed.

Conclusion: Although the studies included in this review reflect a very heterogeneous population of a fairly small number of NFPA patients with varying CBG dosages and varying periods of follow-up, the results are encouraging in view of the high rate of tumor control. We suggest that there is a need for a prospective randomized placebo-controlled trial to assess the clinical useful ness of CBG treatment in patients with NFPAs.

 

Nothing to Disclose: NP, GMC, SAI, PEC, SV

12933 1.0000 SAT-0612 A A Review of Treatment with Cabergoline for Non-Functioning Pituitary Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Paulo Vinicius Gonçalves Holanda Amorim*1, Ericka Barbosa Trarbach1, Cristina B Formiga2, Mariana F Guzzo2, Valter Angelo Sperling Cescato3, Andrea Glezer4 and Marcello D Bronstein2
1Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 2Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3Instituto de Psiquiatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 4Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil

 

Nonfunctioning pituitary adenomas (NFPA) are amongst the most frequent pituitary tumors. Somatostatin receptors (SSTR) and dopamine D2 receptors (DRD2) serve as potential therapeutic target and have been extensively investigated in pituitary adenomas. However, results of SSTRs and DRD2 expression in subgroups of pituitary tumors remain controversial. The aim of this study was to evaluate gene expression of SSTR2, SSTR3, SSTR5 and both isoforms of DRD2 (long: DRD2L and short: DRD2S) in a cohort of NFPA patients. We performed relative quantitative PCR using 2-ΔΔCt method in mRNA extracted from tumors samples of 21 patients diagnosed with NFPA. For the detection of expression levels of SSTRs  and DRD2, TaqMan® probe and SYBR® green systems were respectively used. GAPDH and GUSB were used as housekeeping genes for normalization in DRD2 and SSTRs assays, respectively. A commercial pool of normal pituitary RNA was used as calibrator. mRNA overexpression was defined by value 1.5-fold (or greater). Values are shown as mean ± SEM, and statistics for SSTRs are performed by Kruskal-Walis and Dunn’s tests using JMP Software v10. In agreement with previous studies(1,2), we found that SSTR3 was overexpressed in 81% of NFPA tumors (RQ = 318.2 ± 140.3), whereas SSTR2 (RQ = 2.0 ± 0.7) and SSTR5 (RQ = 2.8 ± 1.9) were highly expressed in only 10%. Therefore, SSTR3 was the most predominantly expressed somatostatin receptor in NFPA, when compared to SSTR2 (p<0,01) and SSTR5 (p<0,0001). We also detected an elevated expression level DRD2 mRNA in 61.9% of NFPA (RQ = 3.2 ± 0.8) with no difference in expression of DRD2L and DRD2S isoforms . In conclusion, our results, supporting previous data in literature(1,2),  shows that not only SSTR3 but also DRD2 mRNA were highly expressed in NFPA, pointing to a potential therapeutic role of dopaminergic agonists and somatostatin analogs as pasireotide.

 

Nothing to Disclose: PVGHA, EBT, CBF, MFG, VASC, AG, MDB

16256 2.0000 SAT-0613 A Evaluation of SSTR2, SSTR3 and SSTR5 and DRD2-Long and Short Isoforms Gene Expression in Nonfunctioning Pituitary Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Cornelie D. Andela*1, Nienke D. Niemeijer1, Margreet Scharloo1, Jitske Tiemensma2, Shaaji Kanagasabapathy1, Alberto M. Pereira3, Noëlle GA Kamminga1, Adrian A Kaptein3 and Nienke R. Biermasz1
1Leiden University Medical Center, Netherlands, 2University of California Merced, 3Leiden University Medical Center, Leiden, Netherlands

 

Purpose: Patients treated for pituitary adenomas generally report a reduced quality of life (QoL). At present, the patient’s perspective of QoL has not been fully addressed and this, and further insight in potential determinants of QoL in pituitary diseases is required to design strategies to improve QoL. We aimed to define patients’ perceived QoL and to identify potential factors they perceive to contribute to QoL.

Methods: We conducted four independent focus groups of 6 patients each, per specific pituitary disease (Cushing’s disease, Non-functioning pituitary macroadenoma, acromegaly, prolactinoma). In two sessions these focus groups discussed aspects of QoL. Verbatim transcripts were analyzed using a grounded theory approach.

Results: The issues raised by the patient groups were compatible with statements and items of available QoL questionnaires. In addition, other QoL aspects emerged, such as visual limitations (physical problems); issues with a desire to have children/family planning, fear of collapsing, fear of recurrence, panic, persisting thoughts, problems with an altered personality, anger, jealousy, sadness, frustration (psychological problems); and difficulties communicating about the disease, lack of sympathy and understanding by others, and a reduced social network (social problems). Next, this study uncovered factors which might contribute to a decreased QoL (e.g. less effective coping strategies, negative illness perceptions, negative beliefs about medicines, unmet needs regarding care).

Conclusions:  This focus group study demonstrated that important disease-specific aspects of QoL are neglected in current pituitary disease-specific questionnaires and elucidated potential factors that contribute to a decreased QoL. Information provided in this study can (and will) be used for developing additional items for disease-specific QoL questionnaires and for the development of a self-management intervention aiming to improve QoL in patients treated for pituitary diseases.

 

Nothing to Disclose: CDA, NDN, MS, JT, SK, AMP, NGK, AAK, NRB

13043 3.0000 SAT-0614 A Towards a Better Quality of Life (QoL) for Patients with Pituitary Diseases: Results from a Focus Group Study Exploring Qol 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Rafael Loch Batista*1, Nina de Castro Musolino2, Clarissa Groberio Borba3, Valter Angelo Sperling Cescato4, Gilberto Ochman Silva5 and Malebranche Cunha Neto3
1Hospital das Clinicas, FMUSP, Brazil, 2Hospital das Clínicas, FMUSP, São Paulo, Brazil, 3Hospital das Clínicas, FMUSP, 4HC FMUSP, Sao Paulo, Brazil, 5USP

 

INTRODUCTION : clinically nonfunctioning pituitary adenomas are common pituitary neoplasms , accounting for about 30 % of pituitary tumors . However , despite these tumors often do not secrete hormones , we can find the expression of pituitary hormones in immunohistochemical evaluation of these tumors .

METHODS : We evaluated 446 patients with nonfunctioning pituitary adenomas in our service . Of these, 415 were submitted to surgery. All patients underwent surgery and pathological examination were diagnosed with pituitary adenoma and all underwent immunohistochemical evaluation of pituitary hormones ( LH , FSH , TSH , GH , ACTH and prolactin ) . All patients had no hormonal hypersecretion

RESULTS : We identified 267 Null Cell tumors ( 66.08 % ) . 47 ( 11.64 %) expressed gonadotropins , and among these 30 ( 63.82 %) expressed only FSH , 13 ( 27.65 %) expressed only LH and 4 ( 8.51 %) expressed LH and FSH. 32 only expressed ACTH ( 7.92 % ), 31 only expressed TSH ( 7.67% ), both without evidence of hormonal hypersecretion . Of these patients , 217 were women (48.65 % ) and 229 were men (51.35 % ) . Among the different immunohistochemical profiles of patients with nonfunctioning adenomas , we identified some differences between the sexes . Tumors that expressed exclusively ACTH and TSH had a higher prevalence in men ( 65.6 % and 80.65 % , respectively) . Tumors that express LH and FSH were also more prevalent in males ( 59.18 %). Tumors that expressed prolactin were more frequent in women ( 66.7 % ) . Null Cell Adenomas were found in similar prevalence between men and women ( 45.7 % in men and 54.3 % in women ) . Plurihormonal were also identified with equal prevalence between the sexes ( 48.3 % in men and 51.7 % in women ) .

CONCLUSION : The most prevalent immunohistochemical profile in this large series of patients was null cell . This finding differs from some other series of patients with clinically nonfunctioning pituitary adenomas , which can reflect the local reality. The prevalence of clinically nonfunctioning pituitary adenomas was equal between the sexes . Differences between the sexes is seen in specific immunohistochemical expression profiles:, ACTH being isolated (silent ) and TSH was markedly more prevalent in men .

 

Nothing to Disclose: RLB, NDCM, CGB, VASC, GOS, MC

16394 4.0000 SAT-0615 A Immunohistochemical Profile of Clinically Nonfunctioning Pituitary Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Rafael Loch Batista*1, Malebranche Cunha Neto2, Clarissa Groberio Borba2, Valter Angelo Sperling Cescato3, Gilberto Ochman Silva4 and Nina de Castro Musolino5
1Hospital das Clinicas, FMUSP, Brazil, 2Hospital das Clínicas, FMUSP, 3HC FMUSP, Sao Paulo, Brazil, 4USP, 5Hospital das Clínicas, FMUSP, São Paulo, Brazil

 

INTRODUCTION: Silent corticotrophic pituitary adenomas (SCA) stain adrenocorticotropic hormone but not presenting with Cushing disease. SCA are more agressive than others nonfunctional pituitary adenomas.

OBJECTIVE: Compare SCA with Null Cell pituitary adenomas (NCA), in terms of cavernous sinus invasion and progression/recorrence.

METHODS: We compared 31 SCA and 93  NCA, diagnosed a tour institution from 2003 to 2011. All was maked surgery and immunohistochemical exam.

RESULTS: Sex and age was comparable. Tumor size was comparable (2,73 vs 2,38 cm). Cavernous sinus invasion was observed in 42% of SCA and 27% of HNA (p 0,018). SCA were gross totally resected 46% at surgery time vs 62% for NCA (0,04). Progression recorrence rates at 2 years were 19% for SCA and 11% for NCA (0,023).

CONCLUSION: SCA and NCA exhibited comparable size, but SCA is more invasive and exhibited more recorrence/progression than NCA.

 

Nothing to Disclose: RLB, MC, CGB, VASC, GOS, NDCM

16718 5.0000 SAT-0616 A Comparative Study of Silent Corticotrophic Adenomas and Null CELL Pituitary Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Marcello D Bronstein*1, Cristina BF Bueno2, Milena Caccelli3, Mariana F Guzzo4, Thais P Sickler5, Felipe HG Duarte6, Andrea Glezer7 and Raquel S Jallad8
1University of São Paulo Medical School, São Paulo, Brazil, 2Division of Endocrinology and Metabolism, Hospital das Clínicas, University of Sao Paulo Medical School., Sao Paulo, Brazil,, São Paulo SP, Brazil, 3Unidade de Neuroendocrinologia da Disciplina de Endocrinologia e Metabologia, HC-FMUSP, Sao Caetano do Sul -SP, Brazil, 4HC FMUSP, Sao Paulo, Brazil, 5Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of Sao Paulo Medical School., Sao Paulo, Brazil, 6Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Sao Paulo, Brazil, 7Division of Endocrinology and Metabolism, Hospital das Clínicas, University of Sao Paulo Medical School., Sao Paulo, Brazil,, Sao Paulo, Brazil, 8Hosp das Clinicas Univ of Sao Pa, Sao Paulo SP, Brazil

 

Hypopituitarism is a common feature in patients harboring pituitary tumors, especially macroadenomas (MAC). Pathophysiology may involve different mechanisms and the outcome of initial hypopituitarism is often unclear, because patients are frequently left on replacement therapy without assessing their potential recovery, often leading to maintenance of an unnecessary treatment. Therefore this evaluation should be done. Both surgical and medical treatment can lead to hormonal normalization in secreting pituitary adenomas, as well as mass reduction, with consequent potential decompression of portal vessels. The presence of normal of elevated serum PRL seems to be an indirect evidence of presence of sufficient amounts of normal pituitary tissue (1,2), data not confirmed by other studies (3 ,4). Some authors (3,5,6) pointed to a less compromised pituitary function in patients harboring GH-secreting tumors compared to non-functioning pituitary adenoma (NFA) patients. Recovery of normal pituitary function was reported to occur shortly or within 6 months after surgery(7), but further improvement may occur at 12 months (8.) Warfield et al(9) first demonstrated  recovery of pituitary function in men harboring macroprolactinomas medically treated, which was confirmed by other studies (10,11). Nevertheless, a recent prospective study by Karavitaki et al(12) showed more modest results. We conducted a retrospective study on recovery of pituitary function after surgical and medical therapy for pituitary macroadenomas, excluding radiotherapy, severe head trauma, apoplexy and empty sella. Pituitary function was performed at least 3-6 months after surgery and 6 months after starting drug treatment. There were 35 patients harboring NFA: 17 females; mean age at diagnosis 54±7 yrs, submitted to neurosurgical treatment. Deficiency in GH, gonadal, corticotrophic and  thyrotrophic axis was  present in 54.5%, 57%, 7% and 40% of patients  and was reversed in 22%; 16%; 42% and 14% of cases, respectively. The presence of normal/high serum PRL levels was predictive of recovery. Considering acromegaly, 94 patients were submitted to surgery: 62 females; mean age at diagnosis 42±12 yrs. Deficiency in gonadal, corticotrophic and  thyrotrophic axis was present in 46%, 7% and 11% and was only reversed in gonadal axis (26%). No recovery of pituitary function was found in 50 acromegalic patients medically treated with somatostatin analogs or dopamine agonists (DA). Regarding macroprolactinomas, 68 patients on DA (50 females; mean age at diagnosis 30±11 yrs): deficiency in GH, gonadal, corticotrophic and thyrotrophic axis was present in 8.8%, 91%, 3% and 4.4% of patients and was reversed in 67%; 89%; 50% and 67% of cases, respectively. In conclusion, our data support the potential pituitary function recovery after MAC treatment stressing the need of laboratory reevaluation before starting hormonal replacement.

 

Nothing to Disclose: MDB, CBB, MC, MFG, TPS, FHD, AG, RSJ

11993 6.0000 SAT-0617 A Recovery of Hypopituitarism after Surgical or Medical Therapy for Pituitary Adenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Sabrina Chiloiro*1, Antonio Bianchi2, Antonella Giampietro3, Donato Iacovazzo2, Barbara Trapasso2, Serena Piacentini3, Linda Tartaglione2, Francesca Lugli2, Alfredo Pontecorvi2 and Laura De Marinis2
1Catholic University of the Sacred Heart, Rome, Italy, 2Catholic University, School of Medicine, Rome, Italy, 3Università Cattolica del Sacro Cuore, Rome, Italy

 

Introduction: In 2004, the WHO defined atypical pituitary adenomas (APAs) those with Ki-67>3%, excessive p53 expression and increased mitotic activity. The usefulness of this classification is still controversial.

Aim: To compare the clinical and prognostic features  in a series of typical and atypical pituitary adenomas. 

Materials and methods: We retrospectively reviewed 343 consecutive PAs. APAs represented 18,7% of the cases. TPAs represented 81,3% of the cases. All patients were operated on in the department on Neurosurgery at our Institution and followed up in the last 9 years at the Hypothalamic-Pituitary Disease Unit of the same institution. APAs and TPAs didn’t differ for age at diagnosis, gender, tumor size and extension. ACTH-secreting PAs were more frequent in APAs than TPAS (15,6% vs 6,8% p=0,02). Radical surgery occurred in 51,5% of APAs and in 71,2% in TPAs (p=0,003). Partial surgery was more likely in APAs than TPAs (OR: 0,43; IC95%: 0,247-0,749). From the 231 patients that underwent radical surgery, recurrence occurred in 42 cases: 7/33 APAs (21,2%) and 35/198 TPAs (17,7%) p>0,05. Disease-free survival time (DFST) didn’t differ between APAs and TPAs (HR:1,508; IC95%: 0,65-3.497). According to our experience, a Ki-67 value above 1,5% correlated better with partial recetion and with a worse DFST.  For this reason, we compared recurrence risk and DFST in PAs with KI-67>1,5% and PAs with Ki-67<1,5%. Among the 232 patients that underwent radical surgery, recurrence occurred in 25% (19/75 cases) of PAs with Ki-67>1,5% and in 14,7% (23/156 cases) of PAs with Ki-67<1,5% (HR:2,166; IC95%: 1,154-4,064). PAs with Ki-67>1,5% showed a worse DFST as compared to PAs with Ki-67<1,5% (HR:2,166; IC95%: 1,154-4,064).   

 Conclusion: In our experience, APAs and TPAs didn’t differ for recurrence and DFST, while PAs  with Ki-67>1,5% showed an higher recurrence risk and a worse DFST. We propose that a Ki-67>1,5% may be useful as prognostic marker.

 

 

 

Nothing to Disclose: SC, AB, AG, DI, BT, SP, LT, FL, AP, LD

16977 7.0000 SAT-0618 A Correlation Between Atypical Pituitary Adenomas and Ki-67 Li: Clinical and Prognostic Aspects 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Alison K Cullinane*1, Rie Maurer2, Erin A Crocker3, Edward Raymond Laws Jr.4 and Whitney W Woodmansee3
1University of South Florida Morsani College of Medicine, Tampa, FL, 2Brigham and Women's Hospital, Boston, MA, 3Brigham and Women's Hospital/ Harvard Medical School, Boston, MA, 4Harvard Medical School, Boston, MA

 

Pituitary lesions often produce functional disruptions of the endocrine system and can lead to an increased risk of obesity and metabolic syndrome. The aim of this study was to determine the prevalence of diabetes mellitus (DM) in patients with pituitary lesions as compared to the general population.

A retrospective study of 343 subjects who underwent surgical resection of a primary pituitary lesion at Brigham and Women’s Hospital (BWH) between 2008-2011 was conducted to determine prevalence of DM. Subjects were considered to have DM if they met one or more of the following criteria: prior DM diagnosis, use of glucose-lowering agents and/or insulin, HbA1c ≥ 6.5%, or ≥ 2 random plasma glucose values ≥ 200 mg/dl.  National Health and Nutrition Examination Survey (NHANES) data (2007-2010) served as the reference population. DM prevalence was compared using logistic regression estimates obtained from NHANES data. Uni and multivariable logistic regression was performed to identify predictors of DM in pituitary subjects.

Of the 343 subjects assessed, 74 were excluded due to missing HbA1c values to give a final study population of 269 (F=142 M=127). The majority of subjects had pituitary adenomas (n=213,79.1%) and most had lesions >10mm in size (n=209, 77.7%). The average age was 46.4 ± 15.6 yrs. The average BMI was 29.4 ± 7.0, with 71.4% with a BMI ≥ 25, and 39.4% with a BMI ≥ 30. At the time of surgical resection, 50 (18.6%) patients were on thyroid hormone, 73 (27.1%) on glucocorticoids, 2 (0.7%) on GH, 33 (12.3%) on gonadal hormones and 12 (4.5%) on DDAVP. The BWH subjects had a crude DM prevalence of 17.8 % (95% CI, 13.5-23.0%) compared to the NHANES DM prevalence of 9.6 % (95% CI, 8.8-10.4%). The prevalence of DM among BWH subjects was significantly greater than observed in NHANES after accounting for age, sex, and BMI (p=.0011), even after exclusion of subjects with acromegaly and Cushing’s disease (p=.0047).  Significant predictors of DM on univariable analysis included age (OR 1.04, 1.02-1.06), BMI (OR 1.14, 1.09-1.19), family history of DM (OR=2.78, 1.47-5.27) and use of glucocorticoids (OR=2.26, 1.18-4.34), while tumor size and type were not. Only age, BMI and family history of DM remained significant predictors of DM in the multivariable logistic regression.

These data suggest that pituitary patients are at increased risk of DM compared with the general population. Clinicians should be aware that managing DM may be an additional challenge in treating pituitary patients.

 

Disclosure: WWW: Medical Advisory Board Member, Eli Lilly & Company, Medical Advisory Board Member, Genentech, Inc., Medical Advisory Board Member, Corcept, Principal Investigator, Ipsen, Principal Investigator, Pfizer, Inc.. Nothing to Disclose: AKC, RM, EAC, ERL Jr.

12828 8.0000 SAT-0619 A Increased Risk of Diabetes Mellitus in Pituitary Patients Compared to the General Population As Represented By NHANES 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Shingo Fujio*1, Yuki Kasamo2, Mika Habu1, Syunji Yunoue3, Hirofumi Hirano4, Hiroshi Tokimura1, Hiroshi Arimura3, Yoshihiko Nishio1 and Kazunori Arita1
1Graduate School of Medical and Dental Sciences Kagoshima University, Kagoshima, Japan, 2Graduate School of Medical and Dental Sciences, Kagoshima University, Kaghosima, Japan, 3Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan, 4Graduate School of Medical and Dental Sciences Kagoshima University, kagoshima, Japan

 

Introduction

The frequency of GHD in nonfunctioning pituitary-adenoma is reported to be 50-80%. Although Insulin Tolerance Test (ITT) and GHRP2 loading test are recommended for determining GHD, the diagnostic time is not clearly defined. We investigated the change of GH secretion ability in patients with nonfunctioning pituitary adenoma, and examined suitable diagnostic time.

Subjects and methods

1) ITT was examined before, one week after and three months after the operation in 29 patients (13 men, 16 women) with nonfunctioning pituitary adenoma in our hospital.  At the same time, we measured IGF-1 value and GH basic value.

2) IGF-1 was followed up for a long period in 24 patients (5 men, 19 women) with nonfunctioning pituitary adenoma after the operation except in those with sGHD.

Results

1) The peak GH during ITT decreased from preoperative level of 7.95±9.00 ng/ml to 6.26±7.54 ng/ml at postoperative one week, and improved to 10.7±13.7 ng/ml at postoperative three months. Therefore, the frequency of GHD also decreased from preoperative 41.3% to 31.0% at postoperative three months.

On the other hand, IGF-1 SDS improved from preoperative value of -0.93±1.76 to -0.08±1.89 at postoperative one week, however, fell significantly to -1.41±1.55 at postoperative three months. GH basic value measured fasting and 30-minute after the rest, decreased gradually from the preoperative value of 0.66±0.84 ng/ml and reached 0.33±0.44 ng/ml at postoperative three months.

In 24 patients with long-term follow up, IGF-1, IGF-1 SDS further fell after the third month of operation (-0.76±1.44) to -1.28±1.47 at the time of last observation (42.2 ±13.6 months).

Conclusion

In many cases, GHD is determined at three months after the operation; however, GH may most often react to stimulated secretion during this period and thus may be overlooked. During postoperative course, secretion stimulation test should be examined again if IGF-1 remarkably decreases.

 

Nothing to Disclose: SF, YK, MH, SY, HH, HT, HA, YN, KA

14329 9.0000 SAT-0620 A Change of GH Secretion in Patients with Nonfunctioning Pituitary Adenom 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Bercem Aycicek Dogan*1, Ayse Arduc2, Mazhar Muslum Tuna3, Narin Nasiroglu Imga1, Serhat Isik4, Dilek Berker1 and Serdar Guler5
1Ankara Numune Education and Research Hospital, Ankara, Turkey, 2National Institute of Diabetes and Digestive and Kidney Diseases, Diabetes, Endocrine and Obesity Branch, National Institutes of Health, Bethesda, Maryland 20892, 3Ankara Numune Education and Research Hospital, Ankara, Turkey, 4Ankara Numune Training and Research Hospital, Ankara, Turkey, 5Hitit University, Faculty of Medicine, Corum, Turkey

 

Introduction:

Hyperprolactinemia is associated with endothelial dysfunction and atherogenic risk factors. The aim of this study was to investigate atherogenic risk factors in prolactinoma after withdrawal period of long-term cabergolin therapy.

Material-Method:

Thirty-eight nonobese women with microprolactinoma who were meeting Pituitary Society criteria for withdrawal of long-term cabergolin therapy (CAB) in 115 patient with prolactinoma participated to our study. The patients were evaluated at the time of admitted to the study and after withdrawal of CAB at 3rd month visit and 12th month visit. Thirty patients were completed the 3rd month visit, until now. Group 1 (21 patients; 37±7 years old) consisted of patients with recurrence of hyperprolactinemia after withdrawal of CAB, Group 2 (9 patients; 35±7 years old) consisted of patients with prolactinoma who were not with recurrence and Group 3 (30 patients, 39±6.9 years old) consisted of healthy controls. Anthropometric, metabolic and inflammatory  parameters were evaluated. Endothelial function was measured with the flow-mediated dilation (FMD) of a brachial artery and carotid intima media thickness (CIMT) was evaluated by experienced endocrinologist using high-resolution ultrasonography.

 

Results:

At the time of cessation of CAB; patients with prolactinoma and the control group were similar in terms of anthropometric, metabolic and inflammatory markers. And, there were not difference between the 3 groups in respect to these parameters. The mean CIMT value was higher in patients with prolactinoma than the control group (0.76 ± 0.15 mm vs. 0.68 ± 0.11 mm, p = 0.021). Also, FMD values were significantly lower in the patients with prolactinoma [median 2.6% (-37.1%) -34.3%] compared to control group [median 11.9% (-5.7%) -36.7%] (p = 0.002).

At the third month evaluation; there were not difference between patients with prolactinoma and control groups in respects to the anthropometric, metabolic and inflammatory markers. Also, no difference was observed between Group 1 and Group 2. And, only mean CIMT values were significantly higher in Group 1 than Group 2 among these parameters (0.78 ± 0.08 vs 0.63 ± 0.11, p = 0.002).

Conclusions:

Preliminary results of our study indicated that endothelial dysfunction is still remainder problem in patients with prolactinoma at the time of cessation of CAB and this is increasing with recurrency of hyperprolactinemia. So, we think that additional studies are need to determine the mechanisms which are underlying prolactinoma-associated atherosclerosis.

 

Nothing to Disclose: BAD, AA, MMT, NNI, SI, DB, SG

16844 10.0000 SAT-0622 A Evaluation of Atherosclerosis after Cessation of Cabergoline Therapy in Patients with Prolactinoma: Preliminary Results of a Prospective Cohort Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Yuki Kasamo*1, Shingo Fujio2, Mika Habu2, Syunji Yunoue3, Hirofumi Hirano4, Hiroshi Tokimura2 and Kazunori Arita2
1Graduate School of Medical and Dental Sciences, Kagoshima University, Kaghosima, Japan, 2Graduate School of Medical and Dental Sciences Kagoshima University, Kagoshima, Japan, 3Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan, 4Graduate School of Medical and Dental Sciences Kagoshima University, kagoshima, Japan

 

【Purpose】Adults with severe Growth Hormone Deficiency (sGHD) exhibit multiple cardiovascular risk factors such as abdominal obesity, hypercholesterolemia,  hypertriglyceridemia, and abnormal body component. Decreased quality of life (QOL) is also a common feature of adults with sGHD. Growth Hormone Replacement Therapy (GHRT) is expected to reduce the risk of cardiovascular events and to improve QOL in patients with sGHD. We examined therapeutic effects of growth hormone replacement therapy in adults with sGHD in our hospital.

【Patients and methods】From 2006 to 2013, 34 adults with sGHD received GHRT. Of these, 30 patients (17 male, age 50±14 years) received GHRT for more than a year. We analyzed the changes of IGF-1, visceral/subcutaneous fat ratio (V/S ratio), body composition, lipid profile (Total cholesterol, LDL, HDL), and QOL (Adult Hypopituitarism Questionnaire, AHQ) before and after GHRT in these 30 patients.

【Results】IGF-1 SD score was significantly elevated after GHRT (p<0.001). Lean body mass increased significantly (47.8±8.6 kg to 49.1±8.2 kg, p=0.04). V/S ratio, percentage of body fat, and lipid profile were slightly improved but not statistically significant.

Based on AHQ, psycho-social and condition-related domains improved significantly (p=0.016 and p=0.022, respectively). As for subsections of psycho-social domain, depression (p=0.007), limitation of social activities (p=0.039), vigor (p=0.013), and sleep (p=0.009) subdomains’ scores increased significantly.

【Discussion】GHRT improved IGF-1 SD score, lean body mass of body component, and some domains of AHQ significantly. GHRT continued for more than a year in adults with sGHD was supposed to improve patients’ QOL and some cardiovascular risk factors.

 

Nothing to Disclose: YK, SF, MH, SY, HH, HT, KA

14373 11.0000 SAT-0623 A The Effect of Growth Hormone Replacement Therapy in Adults with Severe Growth Hormone Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Ozgur Mete*1, Karen Gomez Hernandez2, Shereen Z Ezzat3 and Sylvia L. Asa1
1University Health Network, Toronto, ON, Canada, 2University Health Network, Toronto, Canada, 3University Health Network, University of Toronto, Toronto, ON, Canada

 

Background: Initially thought to represent a third variant of silent corticotroph adenoma, silent subtype III adenomas represent a distinct histologic variant of pituitary adenoma. We investigated the clinicopathological features of these uncommon pituitary tumors to define their characteristics.

Methods: A retrospective review of institutional pathology records from 2002 to 2013 revealed 20 silent subtype III adenomas from a total of 992 adenomas (2%). Patient age, gender, clinical, biochemical and radiological features, as well as immunohistochemical and ultrastructural characteristics of these tumors were reviewed.

Results: Clinical and Biochemical Features: This cohort included 12 females and 8 males. The mean age at diagnosis was 46.7 (range, 15-75) years. Five patients who were referred only for pathology consultation had incomplete endocrine data. Of the remaining 15, 1 had mild acromegaly with elevated IGF-1 levels, 1 had clinical and biochemical evidence of PRL excess leading to amenorrhea-galactorrhea syndrome, 2 presented with clinical and biochemical evidence of hyperthyroidism characterized by increased sTSH and free T4, 5 had mildly elevated PRL levels (range: 18.2-91.1 ug/l) consistent with stalk compression, and 6 had no evidence of hormone excess. Radiological Features: All tumors were macroadenomas with a mean tumor size of 2.75 cm (range, 1.2 cm to 6.1 cm). Incomplete radiologic data was available for 7 patients; among the other 13, infrasellar and/or parasellar growth was identified in 5 and 7 had mild suprasellar extension. Only 3 of 6 tumors showing predominant suprasellar extension were not associated with any infrasellar or parasellar growth. Ten of 13 patients with follow-up data had residual/recurrent disease postoperatively. Immunohistochemical and Ultrastructural Features: All tumors were positive for Pit-1 and were negative for Tpit and SF-1. While 3 cases expressed only Pit-1, others revealed variable and patchy positivity for GH, PRL, TSH, alpha-subunit, and ER. One tumor was negative for CAM5.2, 12 had perinuclear CAM5.2 positivity and 7 were diffusely positive; scattered fibrous bodies were identified in 3 tumors. The mean MIB-1 labeling index was 4% (range, 1-8%). 11 tumors subjected to ultrastructural examination showed large polygonal or elongated tumor cells with nuclear pleomorphism and spheridia.

Conclusions: The distinction of uncommon silent subtype III adenomas from typical pituitary adenomas is of clinical significance, given its characteristically aggressive behavior. These are Pit-1 lineage plurihormonal adenomas which can be associated with hyperprolactinemia, acromegaly or even hyperthyroidism. These findings argue against the use of the nomenclature “silent” for these adenomas. Instead, we propose the use of “poorly differentiated Pit-1 lineage adenoma” for these uncommon tumors.

 

Nothing to Disclose: OM, KG, SZE, SLA

15476 12.0000 SAT-0624 A Clinicopathological Features of Pituitary Silent Subtype III Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Michael William O'Reilly*1, Gabriella Bugg2, Harriet Pearce2, Rosalind Mitchell3, Andrew Alan Toogood4, Neil John Gittoes5 and John Ayuk6
1University of Birmingham, Birmingham, United Kingdom, 2Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom, 3Queen Elizabeth Hospitals Birmingham, Birmingham, United Kingdom, 4University Hospitals Birmingham, Solihull, United Kingdom, 5Queen Elizabeth Hospital, Birmingham, United Kingdom, 6University Hospital Birmingham, Birmingham, United Kingdom

 

Surgical debulking is the treatment of choice for non-functioning pituitary adenomas (NFPAs) presenting with compressive symptoms. Prophylactic radiotherapy (RT) may reduce risk of tumour recurrence but is associated with significant morbidity and a high risk of hypopituitarism. Use of RT has declined at our institution in the last decade, with increased emphasis on more aggressive surgical debulking. Here we aimed to compare outcomes of treatment for NFPAs at our institution since 2005 with older management strategies. 

We reviewed records of consecutive patients undergoing transsphenoidal surgery for NFPA at Queen Elizabeth Hospital Birmingham between 1999 and 2012. Cases were subdivided into those presenting pre- and post-2005. Treatment strategy was categorised as surgery alone or surgery + RT. Pituitary function testing was performed preoperatively, 6 weeks postoperatively and annually thereafter. Cox's hazard analysis was used to identify predictors of recurrence.

180 patients were included (60% male) in the study. Mean age at diagnosis was 56.8±14.5 years. 53 patients were treated pre-2005 and 127 from 2005-2012 (mean follow-up 10.5±1.7 and 5.3±1.8 years, respectively). The rate of prophylactic RT use was higher in the 1999-2004 group (35.8% v 2.4%, p<0.0001), as was the rate of long-term panhypopituitarism (52.8% v 31.4%, p=0.006). Complete tumour clearance (empty sella or no residual tumour) significantly reduced the risk of recurrence (HR 0.37, 95% CI 0.14-0.95, p=0.03). A higher proportion of patients with invasive tumour on preoperative imaging were left without residual tumour in the 2005-12 group (26.1% v 5.2%, p=0.003). Five-year recurrence-free survival rates were similar in both time groups (83.1% v 78.4%, p=0.28).

Lower rates of adjuvant pituitary RT since 2004 have led to a significant reduction in long-term hypopituitarism in our cohort. More aggressive surgical debulking with evolving surgical expertise results in reduced postoperative tumour burden and may contribute to lower rates of tumour regrowth in recent years. Long-term follow-up is required to validate these findings.

 

 

Disclosure: JA: Medical Advisory Board Member, Novartis Pharmaceuticals, Medical Advisory Board Member, Ipsen. Nothing to Disclose: MWO, GB, HP, RM, AAT, NJG

12604 13.0000 SAT-0625 A Evolving Clinical Management of Non-Functioning Pituitary Adenomas: Improved Surgical Clearance Reduces Requirement for Prophylactic Radiotherapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Bernardo Dias Pereira*1, Tiago Nunes Silva2, Henrique Vara Luiz3, Luisa Raimundo4 and Jorge Ralha Portugal2
1Hospital Garcia de Orta, E.P.E., Almada - Setúbal, Portugal, 2Garcia de Orta Hospital, Almada, Portugal, 3Hospital Garcia Orta. E.P.E., Lisbon, Portugal, 4Hospital Garcia Orta, E.P.E., Lisbon, Portugal

 

Transsphenoidal surgery is recommended for non-functioning pituitary adenomas causing compressive symptoms. The reported rate of relapse following  transsphenoidal surgery is about 35 to 45%(1,2). Our main objective was to identify predictors of recurrence in the follow-up period of our cohort of surgically treated and radiotherapy-naïve patients with non-functioning pituitary macrodenomas. We performed a single institution, retrospective follow-up analysis of all radiotherapy-naïve patients who underwent surgery for non-functioning pituitary adenomas between 1992 and 2012. A total of 52 patients (male sex, n/%: 28/53.8%) where suitable for analysis. Mean age of diagnosis was 57.4±11.9 years. Hypopituitarism was confirmed in 42 patients (80.7%; GH, n/%: 4/100%; FSH/LH, n/%: 30/81.1%; ACTH, n/%: 13/54.2%; TSH, n/%: 16/42.1%). Forty four patients (84.6%) had a visual field defect, mainly bitemporal hemianopsia (n/%: 21/40.4%). Mean tumor size was 30.2±8.2 mm, mainly with suprasselar extension (n/%: 48/92.3%). Transsphenoidal approach was the preferred route in 51 patients (98.1%). Median follow-up time was 78.5 months (min.-max.: 3-216). Recurrence rate was documented in 22 patients (42.3%) at a median follow-up time of 36 months (min.-max.: 12-132), and 14% relapsed after more than 100 months of follow-up. Extrasselar tumour remnant (suprasselar and/or cavernous sinus invasion) was the only significant predictor of recurrence (n/%: 13/65%, χ2=0.023), whereas absent remnant (n/%: 1/14.3%, χ2=0.117) or intrasselar remnant (n/%: 7/36.8%, χ2=0.563) were not associated with tumor relapse. Younger age at diagnosis (relapse: 56.5±10.9 years; no relapse: 58.1±12.8 years, U=0.455), sex (males relapses, n/%: 13/46.4%; females relapses, n/%: 10/41.7%, χ2=0.785) or ACTH immunostaining (ACTH positive and relapse n/%: 2/40%; ACTH positive and no relapse n/%: 3/60%, χ2=1.000) were also not significantly associated with recurrence. Our data highlight the need for close postoperative surveillance and timely retreatment of patients with non-functioning pituitary adenomas, specially those with an extrasselar tumour remnant. These patients also need long term follow-up, has 14% of our relapses ocurred after more than 100 months of follow-up.

 

Nothing to Disclose: BDP, TNS, HVL, LR, JRP

14130 14.0000 SAT-0626 A Predictors of Recurrence in Non-Functioning Pituitary Adenomas after Surgery: A Single Institution Follow-up Experience 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Iulia Potorac*1, Françoise Cattin2, Julie Kreutz1, Patrick Petrossians1, Albert Beckers1 and Jean-François Bonneville1
1CHU de Liège-University of Liège, Liège, Belgium, 2CHU Jean Minjoz, Besancon, France

 

Introduction: Cavernous sinus invasion and optic chiasm compression are two of the most relevant factors in the management and prognosis of pituitary adenomas. However, few publications have dealt with the different types of extensions of pituitary macroadenomas depending on their functional type. T2-weighted signal begins to impose itself as a new criterion that separates pituitary adenomas, at least in the case of GH-secreting ones, into subgroups with different behavior. The aim of our study was to compare extension patterns in 3 of the most frequent types of pituitary macroadenomas and to relate them to adenoma T2-weighted signal on diagnostic MRIs.

Materials and methods: The diagnostic MRI examinations of 148 patients with pituitary macroadenomas (PA) (≥10mm) recently diagnosed in 2 tertiary medical centers were reviewed. These pituitary adenomas were GH-secreting (GHPA) in 79 cases, prolactin-secreting (PRLPA) in 32 and non-functioning (NFPA) in 37 cases. The following details were recorded: gender, age at diagnosis, maximum diameter of adenoma, presence of cavernous sinus invasion and of optic chiasm compression, predominant vertical direction of adenoma extension, as well as T2-weighted signal of adenoma.

Results: For GHPA and NFPA, distribution between genders was relatively equal. Age at diagnosis was lowest in PRLPA patients (43yrs), followed by GHPA (47yrs) and highest for NFPA patients (62yrs). Median maximum diameter of adenoma was highest for NFPA (25mm), compared to PRLPA (21.5mm) and GHPA (17mm). Cavernous sinus invasion was more frequent in NFPA: 59% compared to 41% for PRLPA and only 30% of GHPA (p=0.01). Optic chiasm compression was significantly more frequent in NFPA (65%) compared to PRLPA (31%) and GHPA (25%) (p<0.0001). Predominant inferior extension was rarer for NFPA (24%) compared to GH (61%) and PRLPA (59%) (p=0.0007). Hyperintensity on T2-weighted sequences was more frequent in NFPA (89% of adenomas) and PRLPA (44%), compared to GHPA (24%). For GHPA, T2-hypointensity was more often encountered (62%), whereas only 1 NFPA, respectively 2 PRLPA T2-hypointense adenomas were found. 

Conclusions: Functionally different types of pituitary macroadenomas present with different patterns of extension. T2-weighted signal at diagnosis seems to be related to the functional character of the adenoma with hyperintensity and to a lesser extent, isointensity being more frequent in NFPA and PRLPA. Macroadenomas with these types of T2-weighted signal seem to be larger, with more important extensions (towards the cavernous sinus and the optic chiasm), thereby defining a more aggressive type of pituitary adenoma. T2-weighted signal intensity could therefore represent an indicator as to the underlying morphological characteristics of the adenoma and genetic mechanism of tumorigenesis and could constitute a prognostic factor for the evolution of pituitary adenomas.

 

Nothing to Disclose: IP, FC, JK, PP, AB, JFB

16032 15.0000 SAT-0627 A Extension Patterns in Pituitary Macroadenomas and Relation to T2-Weighted Signal on Diagnostic MRI Examinations 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Steven Ramondt*1 and Jitske Tiemensma2
1University of California, Merced, Merced, CA, 2University of California Merced

 

Background: Pituitary adenomas are rare and benign tumors that may result in considerable, chronic comorbidity. The Illness Perception Questionnaire - Revised (IPQ-R) has been used to assess illness perceptions of patients after long-term remission of a pituitary adenoma.  However, no study has validated the use of the IPQ-R to measure illness perceptions in patients suffering from an endocrine disorder.

Objective: We therefore aimed to evaluate whether the factor structure of the IPQ-R corresponds to the original version of the scale and explore the validity of the IPQ-R as an instrument to measure illness representations in patients with pituitary adenomas.

Method: Illness representations of 193 pituitary patients were assessed using the IPQ-R. These patients were in long-term remission of Cushing’s disease (n= 52), acromegaly (n= 79), or NFMA (n= 62). The factor structure was examined using a confirmatory factor analysis.

Results: All items loaded significantly on their relevant factor and factor loadings for the seven factors were all acceptable (λ > .40). Goodness of fit indices indicated moderate fit (RMSEA = 0.076 (90% CI: 0.069-0.082); CFI = 0.879). All illness representation dimensions demonstrated good internal reliability, with Cronbach’s alpha values ranging between 0.705 and 0.907.

Conclusion: This study is unique in its use of multiple disorders to test the factor structure of the IPQ-R. All items loaded well on all seven tested dimensions of the IPQ-R. Goodness of fit indices indicated moderate fit. These findings support the IPQ-R as a robust and valid tool to assess illness representations of pituitary patients.

 

Nothing to Disclose: SR, JT

13484 16.0000 SAT-0628 A Evaluation of the IPQ-R's Core Seven Factor Structure in Pituitary Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Franziska Reining*1, Jörg Flitsch2 and Jens Aberle2
1Universitätsklinikum Hamburg Eppendorf, Hamburg, Germany, 2University medical center Hamburg Eppendorf, Hamburg, Germany

 

Objective: We retrospectively evaluated patients who were treated for pituitary microadenomas between 2008 and 2012 at a single center. The objective was to determine remission rates and complication rates.

Methods: We conducted a retrospective data base research, focusing on diagnosis, early remission and surgery-related complications.

Results: A total of 976 patients underwent transsphenoidal surgery for pituitary lesions of various kinds within 4 years. About one third, 333 patients were diagnosed with hormone-producing adenoma prior to the operation. Of those, 26 patients were diagnosed with microprolactinoma, with a primary remission rate of 92%, 39 patients were diagnosed with GH-producing microadenomas with a remission rate of 89% (in cases of primary operation) and 50% in cases of a secondary operation. Cushing’s disease was existent in 109 patients with remission rates of 92% in cases of primary therapy, 64% in cases of secondary and a remission rate of 60% in cases of tertiary surgical therapy. One patient underwent a fourth operation and did not go into remission after surgery. 5 patients were diagnosed with micro-TSHoma and had a remission rate of 100%. Epistaxis was the most common complication (n=9), followed by transient diabetes insipidus (n=7), SIADH (n=6) and partial anterior insufficiency (n=5), other complications such as complete pituitary insufficiency (n=1), sinusitis (n=1) and pulmonary embolism (n=1) were very uncommon. There was no mortality in surgery for microadenomas in this series.

Conclusions: High remission rates after surgery for microadenomas are achievable and present a realistic goal of transsphenoidal surgery, complications are mostly pituitary related and do usually not pose a major threat to the patients health.

 

Nothing to Disclose: FR, JF, JA

14630 17.0000 SAT-0629 A A Current Series of Surgically Treated Hormone-Active Microadenomas Treated at a Single Center 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Silas Culver1, Yuval Grober1, David A Ornan1, James Patrie2, Edward Hudson Oldfield3, John Anthony Jane Jr.4 and Michael O Thorner*5
1University of Virginia, 2University of Virginia, School of Medicine, Charlottesville, VA, 3Univ of Virginia, Charlottesville, VA, 4Univ of VA, Charlottesville, VA, 5University of Virginia Health System, Charlottesville, VA

 

Introduction: Rathke’s cleft cysts (RCC) are benign embryonic remnants and are found in 13-33% of the general population.  When symptomatic, they compress adjacent structures, causing headache, visual disturbance, or pituitary hormone deficits.  Most RCCs are asymptomatic.  Surgical resection has generally been indicated to treat symptomatic RCCs, but carries the risk of complications including headache, visual disturbance, or development of pituitary hormone deficits. This retrospective study seeks to characterize the outcomes for conservative management of patients with presumed RCC.

Methods: We utilized a word search program to search all radiology reports of brain MRIs performed at UVA from 2006 through 2013 for the words “Rathke Cleft Cyst”. The individual patient identified by this search and in whom the interpreting radiologist identified a RCC and for whom there were at least 2 separate MRI scans over time were reviewed.  We included patients who ultimately had surgical resection but included only MRI scans up to the time of surgery.  Each of these patients’ MRIs was reviewed by a neuroradiologist (DAO) to provide dimensions of each cyst on each MRI. The volume of each cyst as a function of time from the time of the first image was analyzed. Each RCC was categorized as having increased, decreased, or as having no change in size.  Previously developed criteria were used to determine whether a change in size of a pituitary lesion was significant.(1)  

Results: 76 patients met inclusion criteria, age 4 years to 76 years old.   Length of follow up was 1-126 months;  median length of follow up 24.5 months.  43 of these patients (57%) had no detectable change in the size of their cysts while 22 (29%) increased and 11 (14%) decreased.   Only 10 patients (13%) had an increase in cyst size that was significant.  22 of the patients were followed for <1 year and 5 (23%) increased in size.  In 24 patients followed 1-3 years 8 (33%) increased in size;  30 patients followed >3 years 9 (30%) increased in size.   18 (24%) of the patients in our study ultimately had surgical resection and  only 10 increased in size while 6 stayed the same and 2 decreased in size prior to surgery.

Discussion: Brain MRI prevalence has resulted in an increase in the discovery of incidental RCCs. Operative management carries risk for the patient. A better understanding of the natural history of these cysts is crucial to deciding how to proceed.  We demonstrate that the majority of radiologically diagnosed RCCs remain unchanged or even decrease in size over time. A majority of the cysts followed for greater than 3 years either stayed the same or decreased in size.  Only a small subset of these for which the increase in size was actually significant and required surgical intervention.  In the absence of other indications for surgery conservative management with clinical observation and repeat imaging (probably initially annually) is optimal.

 

Nothing to Disclose: SC, YG, DAO, JP, EHO, JAJ Jr., MOT

16410 18.0000 SAT-0630 A A Case for Conservative Management: Natural History of Radiographically Diagnosed Rathke Cleft Cysts 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Amit Tirosh*1, Carlos Benbassat2, Avner Lifshitz1 and Ilan Shimon1
1Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel, 2Rabin Medical Center and Sackler School of Medicine, Tel-Aviv University, Petah-Tiqva, Israel

 

Objective - Men with prolactin secreting tumors usually harbor macroadenomas. The degree of pituitary dysfunction may vary among different adenoma size subgroups, as is recovery after treatment. Our study objective was to characterize hypopituitarism and recovery after treatment in men with macroprolcatinomas.

Design - A retrospective study, including a consecutive group of men with pituitary macroadenomas (>10 mm) and hyperporlactinemia (>10xULN).

Methods - Patients were divided into three categories according to adenoma size at presentation: 10-19 mm (group A), 20-39 mm (group B), and >40 mm (group C). We compared total testosterone, gonadotropins, cortisol, thyroid hormones and hemoglobin levels at presentation and after treatment.

Results - Eighty three patients were included; 26, 31 and 26 patients in groups A, B and C, respectively. Pretreatment hypogonadism prevalence was 72.7%, 93.5% and 90.9%, (p=0.022; A vs B & C), central hypocortisolism - 0%, 6.9% and 33.3% (p=0.005), and central hypothyroidism – 6.3%, 17.9% and 26.1% (NS) in groups A, B and C, respectively. Only 26.2% of all patients presented with hypocortisolism and/or hypothyroidism (42.9% in group C). Anemia (Hb <13.5 gr%) was detected in  31.6%, 57.1% and 80.0% in groups A, B and C, respectively (p=0.04). FT4 levels at presentation had strong positive correlation with post treatment FT4 levels (r=0.45, p=0.035). Larger adenoma diameter correlated strongly with lower FT4 levels following treatment (r=-0.42, p=0.043).

Conclusion - Macroprolactinomas in men caused partial hypopituitarism, affecting testosterone and cortisol more in patients with larger adenomas. However, most of the men did not have pituitary hormones affected, beside testosterone.

 

Nothing to Disclose: AT, CB, AL, IS

12706 19.0000 SAT-0631 A Hypopituitarism Patterns and Prevalence Among Men with Macroprolactinomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Gustavo Varela*1, Nicolas Picon2, Karina Danilowicz3, Marcos Manavela4 and Oscar Domingo Bruno3
1Hospital de Clínicas “José de San Martín”. Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina, 2Hospital de Clinicas Jose de San Martin, Buenos Aires, Argentina, 3Hospital de Clinicas, Buenos Aires, Argentina, 4Consultorios de Endocrinología Dr Manavela, Caba, Argentina

 

Non-functioning pituitary adenomas (NFPA) represent 30% of all pituitary tumors. We analyzed basal characteristics and long-term evolution of a group of Argentinian patients with NFPA evaluated in our hospital.

Among 1256 patients in our pituitary registry with neuroendocrine diseases, 925 patients with pituitary adenomas were identified. 236 were due to NFPA (25.2%). We retrospectively analyzed the medical records of 134 patients with NFPA evaluated during 1992 and 2013, 51.8% women. Mean age at diagnosis was 54 years, range 17 to 79. The patients were divided according to the therapeutic strategy in group 1: expectant or medically treated due to no tumor contact to optic chiasm (n=37) and group 2: surgery. Follow-up was between 6 months to 21 years.

The reasons for evaluation were menstrual irregularities in 42.2% of premenopausal women and visual abnormalities in 76% and 56.2% of postmenopausal women and men, respectively. On clinical examination hypertension was found in 28.3%, dyslipidemia 21.6% and diabetes 7.4%. The basal and follow-up laboratory evaluation showed: in Group 1, central hypogonadism (CH) in 82 and 85.7%, GH deficiency (GHD) 32 and 50%, central hypothyroidism (H) 20.5 and 33.3%, secondary adrenal insufficiency (AI) 22.2 and 33.3%; in group 2, CH 73.2 and 79.2%, GHD 36 and 63%, H 23 and 57.7%, AI 29.8 and 56.6%, and permanent post-surgical diabetes insipidus 9.2%. Basally, visual abnormalities were detected in 75.2% of all the patients and on follow-up worsened in 9% of group 1 and improved in 65.5%, stabilized in 22.9% and worsened in 11.4% of group 2.

The radiological evaluation showed macroadenomas in 73.1%.

One surgery was performed in 77.5%, with additional radiotherapy in 23.4%, because of surgical remnant in 74% and recurrence in 26%.Immunohistochemistry was null-cells 52.2%, positive for gonadotropins 17.5%, plurihormonal 15%, corticotropin 7.5%.

On follow-up in group 1 no change was detected radiologically in 71.4%, a decrease in tumor volume in 14.2% and increase in 14.2%. In group 2 after surgery no tumor was detected in 31.1%, stable remnant in 45%, regrowth in 9% and recurrence in 1.2%.

We conclude that in NFPA with a conservative approach 85.6% of the lesions decreased or remained stable, while on those treated surgically or with radiotherapy, the lesion remained stable or decreased in 76%, with visual field stable or better in 88.4%. After surgery, pituitary function deteriorated. The main objective with surgery in NFPA should be reduction of tumor mass.

 

Nothing to Disclose: GV, NP, KD, MM, ODB

12987 20.0000 SAT-0632 A Non-Functioning Pituitary Adenomas: A Retrospective Study of 134 Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Guadalupe Vargas*1, Baldomero Gonzalez1, Etual Espinosa2, Victoria Mendoza3 and Moises Mercado4
1Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, Mexico, Mexico, 2Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, 3HECMN IMSS, Mexico City, Mexico, 4Hospital de Especialidades Centro Médico Nacional Siglo XXI, IMSS, UNAM, Mexico City, Mexico

 

Background:  Although the use of postoperative radiation therapy (RT) in the management of nonfunctioning pituitary adenomas (NFPA) can effectively prevent tumor recurrences and regrowth of remnants, it can potentially result in hypopituitarism, and less frequently in optic atrophy or cerebrovascular disorders.  RT in this scenario has also been associated with a reduced quality of life, although this has not been formally evaluated.

Objective:  To evaluate the quality of life of patients with NFPA, comparing those subjects who received RT to those who did not.

Patients and methods:  Cross-sectional study of 177 subjects who had undergone transsphenoidal surgery for NFPA.  The SF-36 questionnaire was used to assess quality of life.  This questionnaire has been previously validated in the Mexican population.  The results of the questionnaire were analyzed taking into account demographic, clinical and hormonal variables after dividing the study population into those who received RT and those who did not.

Results: Of the 177 patients, 50 had received RT (mean age 55.7 ± 12.8 years, 30 males) and 127 had not (mean age 54.6 ± 13.1 years, 59 males).  The prevalence of diabetes, hypertension and dyslipidemia was similar among the radiated and the non-radiated patients.  Results of the SF-36 questionnaire, which evaluated vigor, pain, physical and social performance, as well as general and mental health, did not differ between the two groups.

Conclusions:  RT used adjunctively in the management of patients with NFPA does not compromise quality of life, as judged by the SF-36 questionnaire.

 

Nothing to Disclose: GV, BG, EE, VM, MM

16570 21.0000 SAT-0633 A Comparison of Quality of Life in Patients with Non-Functioning Pituitary Adenomas Who Had Received Radiotherapy and Those Who Had Not 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Almudena Vicente*1, Cristina Lamas2, Miguel Aguirre3, Julia Silva4, Mubarak Alramadán5 and Iván Quiroga6
1Hospital Virgen de la Salud, Toledo, Spain, 2Complejo Hospitalario de Albacete, Spain, 3Hospital General Universitario, Ciudad Real, 4Hospital General La Mancha Centro, Alcázar de San Juan, Spain, 5Hospital Virgen de la Luz, Cuenca, 6Hospital Nuestra Señora del Prado, Talavera

 

BACKGROUND: Incidentally discovered pituitary tumors  represent an increasingly important proportion of patients referred to the endocrinologist or neurosurgeon, due to growing  availability and use of imaging techniques.The majority of them are pituitary adenomas. OBJETIVE: To describe the clinical features and outcomes of incidentally discovered pituitary adenomas (IDPAs) in a study population from Castilla-La Mancha (Spain). DESIGN: Retrospective observational study. METHODS:  The study included 348 patients with a presumptive diagnosis of pituitary adenoma between 2000 and 2012. Review of medical records of patients with IDPA was carried out. RESULTS: Frecuency of IDPAs was 20.9%. Seventy three patients (31 male/42 female; aged 56 ± 20 years) were studied. Mean follow-up time was 45.6 ± 33.5 months. Patients with IDPAs were  significantly older than patients with clinically evident pituitary disease (56±20 vs 41.3±17 years )(p<0.01). Reasons that led to diagnosis were headache, dizziness, syncope, head injury, mental disability and cancer staging. IDPAs were detected by CT scan, MR imaging and 18F-FDG-PET imaging in 26, 45 and 2 patients respectively. Mean size was 19.7 mm (range 3-80). Fifty-one (69.9%) out of 73 patients had macroadenomas whereas 21(30·1%) had microadenomas. At presentation, visual field defects and deficiency of ≥ 1 pituitary axes were detected respectively in  42,8% and 43,3% of the patients with available data. No patient had evidence of diabetes insipidus at initial assessment.  Forty-seven IDPAs (64.4%) were non-functioning pituitary adenomas (NFPA), 23 (31.5%) prolactinomas, 1 (1.4%) GH-secreting adenoma and two (2.7%) ACTH- secreting adenomas. In terms of treatment, 25 (34.2%) patients were underwent surgery. The surgical indication resulted from tumor size and/or visual alterations or hormonal hypersecretion. Surgery was not performed in 48 patients (65.8%): Twenty-four patients were  treated with dopaminergic agonists (20 prolactinomas and 4 NFPA ) and 24 were conservatively followed due to advanced age and/or comorbidities or refuse of surgery. At the end of follow-up, deficiency of ≥ 1 pituitary axes was significantly more frequent in surgically treated patients (60% vs 25%)(p< 0.05). 75%(15/24) of IDPAs conservatively managed remained stable, 8%(2/24) decreased in size and 4%(1/24) increased in size during follow up. CONCLUSIONS: Our data show that most  IDPAs are macroadenomas and clinically non-functioning, although functioning adenomas are not uncommon. Hormonal and visual assessment should be done at initial presentation, since visual field defects and hormonal dysfunction are not negligible. Conservative management for non-operated IDPAs could be reasonable and safe, since the majority remained stable in size during follow up. Surgical approach may be beneficial in terms of improving mass effects, but pituitary function may worsen.

 

Nothing to Disclose: AV, CL, MA, JS, MA, IQ

13267 22.0000 SAT-0634 A Clinical Features and Outcomes of Incidentally Discovered Pituitary Adenomas in Castilla La Mancha (Spain) ; A Retrospective Multicenter Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Churn-Ern Yip*1, Netee Papneja2, Syed Mohammad1, Khaled M AlDahmani1, Mary MacNeil3, Deborah A Zwicker3, Chris Theriault1, Kara Thompson1, Stan Van Uum2, David B Clarke1 and Syed Ali Imran1
1Dalhousie University, Halifax, NS, Canada, 2University of Western Ontario, London, ON, Canada, 3Cape Breton Regional Hospital, Sydney, NS, Canada

 

Pituitary incidentalomas (PI) are frequently encountered during brain imaging studies.   The natural history of PI is still debated, and to date, no large North American study has assessed the epidemiological trends of PI.  The aim of our study was to determine the epidemiological trends of PI in two Canadian tertiary care centers.  A retrospective analysis of clinic data collected on all PI patients from Dalhousie University, Halifax, Nova Scotia, Canada (2006-2012) and the University of Western Ontario (2006-2013) was performed.  A total of 293 patients with PI were identified during the study period.  These included 157 (54%) females and 136 (46%) males.  The mean age was 53.5 years (range 16-91 years).  Most common indications for the initial diagnostic imaging were headache (20%), dizziness or vertigo (11%) and stroke or transient ischemic attack (9%).  The initial imaging modalities included CT scan (47%) and MRI scan (53%). Of the PI, there were 155 non functioning adenoma (52.9%), 31 Rathke’s cleft cyst (10.6%), 24 prolactinoma (8.2%), 18 pituitary cyst (6.1%), 14 enlarged normal pituitary glands (4.8%), 12 craniopharyngioma (4.1%), 11 acromegaly (3.8%), 11 empty sella syndrome (3.8%), 5 ACTH producing adenomas (1.7%), 4 meningioma (1.4%), 2 arachnoid cyst (0.7%), 2 other clival chordoma (0.7%), and 1 TSH producing adenoma (0.3%). In terms of tumor size, there were 145 (74%) macroadenomas and 42 (21%)  microadenomas while 9 (5%) were undefined.  Forty one (14%) of all PI were clinically functioning.   Seventy five (25%) patients on presentation had at least a single hormonal deficiency: secondary hypogonadism in 80%, secondary hypothyroidism in 35%, low IGF1 levels in 33%, secondary adrenal insufficiency in 21% and diabetes insipidus in 1%.  Eighty three (28%) patients eventually underwent pituitary surgery.   Of the 175 patients from the Dalhousie University clinic, 51 (29%) underwent surgery and the most common indications for surgery were: visual field abnormalities (29%), tumor growth (14%), and proximity to the optic chiasm (6%). Our data suggest that patients with PI require thorough hormonal work up at diagnosis and require regular follow up.

 

Nothing to Disclose: CEY, NP, SM, KMA, MM, DAZ, CT, KT, SV, DBC, SAI

13774 23.0000 SAT-0635 A Natural History of Pituitary Incidentalomas: A Canadian Perspective 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM SAT 0612-0635 4834 1:00:00 PM Clinical Aspects of Non-Functioning Pituitary Tumors Poster

Rebecca J Watters*1, Ryan J Hartmaier1, Adrian V. Lee1, Kostantinos Verdelis1, Brendan Lee2, Yuqing Chen2, Bert W O'Malley2, Jianming Xu2, Shiming Jiang2, Adam Brufsky3, Deborah Galson1 and Steffi Oesterreich1
1University of Pittsburgh, Pittsburgh, PA, 2Baylor College of Medicine, Houston, TX, 3University of Pittsburgh Medical Center, Pittsburgh, PA

 

Estrogen signaling plays a critical role in the etiology of breast cancer, but also is necessary for bone health and maintenance. In each of these tissues, estrogen signaling via the estrogen receptor is regulated by the nuclear co-factor SRC-1 (encoded by NCOA1), and there is published evidence that SRC-1 plays a role in both estrogen response in bone, and in breast cancer metastases.  Given such dual roles of SRC-1 in the host (e.g. bone), and in tumor cell-intrinsic phenotypes, we hypothesize that SRC-1, and its naturally occurring genetic variants, are critical for bone metastases, which represents the most frequent metastatic site for ER-positive disease.  Towards this goal, we have characterized a non-synonymous SNP in SRC-1 (rs1804645; 2% MAF; P1272S) in activation domain 2 (AD2), which attenuates ER’s transcriptional activity of breast cancer cells in vitro.  Bone mineral density (BMD) of tamoxifen treated patients carrying the SNP is significantly decreased, confirming loss of tamoxifen’s agonist activity observed by us in in vitro.  We recently finished generating a knock-in mouse model for this SNP, with the goal to characterize the effect of this variant on estrogen signaling, differentiation, and activation of individual bone cell types.  The SRC-1P1278S/P1278S mice are fertile, and do not show any obvious gross abnormalities.  There is no significant difference in BMD between wild-type and SRC-1 knock-in mice at baseline.  However, we observed that the presence of the variant results in increased activation and subsequent migration of osteoclasts.  In support of this data, the SRC-1 variant mice also demonstrated increased expression of MMP9, calcitonin receptor, and cathepsin K in osteoclasts.  We are currently characterizing the phenotypes of osteoblasts, changes in BMD after ovariectomy and estrogen stimulation, and importantly susceptibility to bone metastases.  In summary, we have successfully generated a unique SRC-1 SNP mouse model that can be utilized to asses SRC-1’s dual roles in both host and tumor cells.

 

Nothing to Disclose: RJW, RJH, AVL, KV, BL, YC, BWO, JX, SJ, AB, DG, SO

13015 1.0000 SAT-0405 A A Naturally Occurring SRC-1 Variant Correlates with Clinical Bone Loss, and Increased Osteoclast Activity in a Novel Mouse Model 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Bruno Ferraz-de-Souza*1, Maria L Katayama2, Maria AK Folgueira2, Pedro Henrique S Correa1, Ana Claudia Latronico3 and Regina M Martin4
1Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), Sao Paulo, Brazil, 2University of Sao Paulo Sch of Medicine (FMUSP), Brazil, 3University of Sao Paulo School of Medicine (FMUSP), Sao Paulo, Brazil, 4Hospital das Clinicas, University of Sao Paulo School of Medicine, Sao Paulo, Brazil

 

Background: The vitamin D receptor (VDR) is a nuclear receptor that regulates gene expression through direct DNA binding when activated by calcitriol (1,25-dihydroxyvitamin D3). Hereditary vitamin D resistant rickets (HVDRR) is an autosomal recessive disorder characterized by early-onset severe hypocalcemia and resistance to calcitriol due to VDR mutations. Despite the permanent molecular defect, HVDRR patients may have spontaneous healing of rickets and normalization of calcemia; we follow a patient with a severely disrupted VDR (homozygous p.Arg30* mutation) and spontaneous remission of HVDRR before puberty. The molecular mechanism of such remission is unknown.

Objective: To identify a subset of calcitriol/VDR target genes in human fibroblasts by comparing the genomic response to calcitriol in the presence or absence of a functional VDR, allowing the exploration of compensatory nuclear receptor networks that might contribute to the molecular mechanisms of HVDRR spontaneous remission.

Results: Transcriptional response to calcitriol (10 nM, 24-h treatment) was analyzed in human control and p.Arg30* fibroblasts using Human Gene 2.0 ST microarrays. In control fibroblasts, expression levels of 1,178 transcripts were altered by calcitriol in comparison to vehicle; 725 transcripts were downregulated by calcitriol while 453 transcripts were upregulated (Benjamini-Hochberg p<0.05). Amongst these, previously known VDR targets were recognized, including CYP24A1, and several new calcitriol/VDR targets were identified. Differential gene expression analysis in mutant p.Arg30* fibroblasts identified only 2 transcripts responding to calcitriol, showing the extreme insensitivity of this dysfunctional VDR model. One of those (EGR1) could represent non VDR-mediated calcitriol signaling in these cells. Notably, basal (vehicle) transcriptional output was considerably different between control and mutant fibroblasts, potentially reflecting unliganded actions of the VDR.

Discussion: Analysis of transcriptomic response to calcitriol in human fibroblasts is revealing a large set of calcitriol/VDR targets and largely lack of signaling in the absence of a functional VDR. The definition of calcitriol/VDR targets in this system will allow investigation of compensatory nuclear receptor-based mechanisms involved in the molecular basis of HVDRR spontaneous recovery and shed light on the extra-skeletal actions of vitamin D.

 

Nothing to Disclose: BF, MLK, MAF, PHSC, ACL, RMM

12189 2.0000 SAT-0406 A Transcriptomic Response to Calcitriol in Human Fibroblasts with or without a Functional Vitamin D Receptor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Andrzej Slominski*1, Tae-Kang Kim1, Yukimasa Takeda2, Zorica Janjetovic1, Anna Brozyna3, Cezary Skobowiat1, Jin Wang4, Arnold Postlethwaite4, Wei Li4, Robert C Tuckey5 and Anton M Jetten2
1Univ of Tennessee HSC, Memphis, TN, 2NIH/NIEHS, Research Triangle Pk, NC, 3Nicolaus Copernicus University, 4Univ of Tennessee HSC, 5The Univ of Western Australia, Crawley, Australia

 

Retinoic acid orphan receptor (ROR)α and RORγ are expressed in human skin cells which produce the noncalcemic vitamin D metabolites, 20-hydroxyvitamin D (20(OH)D3) and 20,23-dihydroxyvitamin D3 (20,23(OH)2D3)(1). CHO cells stably expressing a TET-on RORα or RORγ expression vector and a RORE-LUC reporter, and a mammalian two-hybrid model examining the interaction between the ligand binding domain (LBD) of RORα or RORγ with an LBD-interacting LXXLL-peptide, were used to study ROR-antagonist activities (2-4). These assays revealed that  20(OH)D3 and 20,23(OH)2D3 as well as 20(OH)D2 function as antagonists of RORα and RORγ. This was supported by the finding that 20(OH)D3 inhibits the activation of the promoter of the Bmal1 gene, a target of RORα and data showing that 20(OH)D3 and 20,23(OH)2D3 inhibited IL-17 promoter  activity in Jurkat cells overexpressing RORa or RORγ. Molecular modeling using crystal structures of the LBDs of RORα and RORγ revealed docking scores for 20(OH)D3, 20,23(OH)2D3 and 1,25(OH)2D3 are similar to those of the natural ligands (cholesterol derivatives), predicting good binding to the receptor. Importantly, 20(OH)D3, 20,23(OH)2D3 or 1,25(OH)2D3 caused inhibition of ROR-responsive element activity in keratinocytes and melanoma cells and inhibited IL-17 production by immune cells. Our study identifies a novel signaling pathway, in which 20(OH)D3 and 20,23(OH)2D3 act as antagonists of RORα and RORγ mediated transactivation, that  opens new possibilities for local (skin) or systemic regulation.

 

Nothing to Disclose: AS, TKK, YT, ZJ, AB, CS, JW, AP, WL, RCT, AMJ

11897 3.0000 SAT-0407 A RORa and RORg Are Expressed in Human Skin and Serve As Receptors for Endogenously Produced Noncalcemic 20-Hydroxy- and 20,23-Dihydroxy-Vitamin D 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Teresa Te-Ying Liu*1, Melanie J Grubisha1, Stacy L Wendell2, William A Ricke3, Richard J. Auchus4 and Donald Benedict DeFranco1
1University of Pittsburgh School of Medicine, Pittsburgh, PA, 2University of Pittsburgh School of Medicine, 3University of Wisconsin, Madison, WI, 4University of Michigan, Ann Arbor, MI

 

Benign prostatic hyperplasia (BPH) is a common disorder affecting elderly men; as the size of the prostate increases due to tissue remodeling, lower urinary tract symptoms (LUTS) such as urinary frequency, urgency and retention begin to emerge.  While the pathogenesis of BPH remains unclear, multiple factors including hormonal imbalance, disruption of apoptosis and chronic inflammation are thought to contribute to disease progression.  The prostate, mainly an androgen dependent organ, converts testosterone to the higher affinity androgen receptor (AR) ligand dihydrotestosterone (DHT) through 5α-reductases (5AR).  However, 5AR inhibitors are not particularly effective therapies for BPH perhaps due to adaptations of the prostate to the changing steroid hormone milieu.  For example, androgenic precursors that accumulate upon 5AR inhibition may be diverted to steroidogenic enzymes generating ligands (e.g. 3β-adiol) of the beta isoform of estrogen receptor (ERβ).  The activity of ERβ, a receptor that limits proliferation and survival of prostate epithelial cells may therefore be essential for limiting BPH progression in the context of 5AR inhibition.  We found that while the 5AR inhibitor dutasteride induces apoptosis in the human prostate epithelial cell line BPH-1, it also enhances expression of a pro-inflammatory enzyme, cyclooxygenase-2 (COX-2) in an AR dependent manner.  We therefore hypothesize that the effectiveness of 5AR inhibition in reducing BPH progression may be limited by coincident induction of COX-2.  Indeed, genetic and pharmacological ablation of COX-2 in BPH-1 cells altered steroid metabolism revealing another level of COX-2 effects on steroid receptor action that could impact BPH progression.  RNA-seq experiments performed on BPH-1 and COX-2 ablated BPH-1 cells reveal genetic alterations in the AR and TGFβ pathways.  Additionally, ablation of COX-2 resulted in the decreased expression of PTGSE2, the gene encoding the enzyme prostaglandin E2 synthase.  Examination of intracellular prostaglandin E2 (PGE2) by mass spectrometry revealed a marked decrease in PGE2 accumulation upon COX-2 ablation.  Our results suggest that clinical trials underway to examine the efficacy of COX-2 inhibitors in conjunction with 5AR inhibitors may need to consider the novel actions of COX-2 to regulate steroid hormone metabolism that would differentially impact the competing effects of AR and ERβ.

 

Nothing to Disclose: TTYL, MJG, SLW, WAR, RJA, DBD

15309 4.0000 SAT-0408 A 5α-Reductase Inhibitors and COX-2 Alter Intraprostatic Steroid Homeostasis in Benign Prostatic Hyperplasia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Päivi Sutinen*, Marjo Malinen, Sami Heikkinen and Jorma Juhani Palvimo
University of Eastern Finland, Kuopio, Finland

 

Androgen receptor (AR) plays an important regulatory role during prostate cancer development. The AR’s transcriptional activity is regulated by androgenic ligands, but also by post-translational modifications, including SUMOylation. SUMOylation is a reversible and bulky modification in which small ubiquitin-related modifier protein (SUMO-1, -2, or -3) is attached to target protein´s specific lysine residues. To study in a systematic genome-wide fashion the role of AR SUMOylation in prostate cancer chromatin environment, we constructed PC-3 cell lines that stably express wild-type (wt) or SUMOylation-deficient AR (AR-K386R,K520R) and analyzed their androgen-regulated transcripts and binding to chromatin. Our genome-wide gene expression analyses reveal that the SUMOylation modulates the AR function in a target gene selective manner. The SUMOylation does not only repress the AR activity on target genes, but it also activates, because the mutant exhibited attenuated transcriptional activity on several genes. Additionally, a group of genes were insensitive to the AR SUMOylation. Interestingly, the genes differently regulated by androgen due to the AR SUMOylation sites are significantly enriched in cell proliferation, cellular movement, cell death and apoptosis. In line with these data, the SUMOylation mutant AR cells proliferate faster and are more sensitive to apoptosis than the wtAR-expressing cells. Moreover, chromatin immunoprecipitation coupled to deep sequencing (ChIP-seq) analyses indicate that the SUMOylation can regulate the AR´s chromatin occupancy on many target loci in a fashion that parallels their differential expression between the wtAR and the SUMOylation-deficient AR cells. De novo motif analyses revealed that FOXA1, CEBP and AP-1 motifs, but not AR-binding motifs, are differentially enriched at the wtAR- and the SUMOylation-deficient AR-preferred genomic binding positions. Taken together, our data indicate that SUMOylation does not simply repress the AR activity, but it regulates AR’s interaction with the chromatin and the receptor’s target gene selection, playing a role in regulating the AR activity on genes involved on cell proliferation.

 

Nothing to Disclose: PS, MM, SH, JJP

14335 5.0000 SAT-0409 A Sumoylation Modulates the Transcriptional Activity of Androgen Receptor in a Target Gene and Pathway Selective Manner 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

William J Kovacs*1, Ann L Benko2 and Nancy J Olsen2
1Penn State Univ College of Med, Hershey, PA, 2Penn State College of Medicine, Hershey, PA

 

Numerous clinical and experimental observations have suggested that androgenic hormones can modulate the expression of autoimmune diseases. We sought to determine whether inherited differences in androgen sensitivity conferred by variation in the exon 1 CAG repeat region of the Androgen Receptor (AR) gene were associated with differences in the clinical or humoral immune manifestations of lupus in a cohort of female subjects.  We found no difference between a healthy control group (n=25) and the lupus subjects (n=39) in the average length of all AR exon 1 CAG repeat alleles (19.69 ± 0.47 vs 19.03 ± 0.28 repeats) or in  weighted mean AR CAG repeat lengths corrected for nonrandom X-inactivation by methylation analysis of CpG islands in close proximity to AR exon 1 (19.86 ± 0.47 vs 19.24 ± 0.33).  These data suggested that inherited differences in androgen sensitivity do not confer any predisposition to the development of lupus. We did find remarkable relationships between weighted mean AR CAG repeat lengths and measures of autoimmune disease expression among the lupus patient themselves.  A clinical phenotyping score, the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), was found to be inversely correlated with the weighted mean AR CAG repeat length (r2 = 0.2665; p = 0.0117).   We also found significant inverse correlation between weighted mean AR CAG repeat length and the level of expression of antinuclear antibodies, the characteristic immunologic aberration in lupus (r2 = 0.4730; p = 0.0003). In addition, we used autoantigen microarrays to investigate whether AR CAG repeat length might be related to differences in the breadth of the autoimmune response. Cluster analysis of the specific patterns of IgG autoantibody reactivity against 83 distinct antigens for each of 23 female lupus patients revealed evidence of more exuberant autoreactivity in individuals with shorter AR CAG repeat length.  We also analyzed the microarray data by examining each individual’s autoantibody reactivities in comparison to the average signals observed from the serum of healthy controls.  For each of the 83 autoantigens we established an arbitrary cut-off for a “positive” test based on the mean plus 3 SD of fluorescence intensity observed in the serum from 8 healthy controls.  For the lupus subjects, values above each of these antigen- specific cutoff levels were scored as positive tests. We noted a significantly greater proportion of autoreactive IgG antibodies in individuals with shorter (≤19) AR CAG repeat length (25.7 % of tests vs  14.2% of tests in female lupus patients with AR CAG repeat length >19 ; p < 0.0001).  Our findings of more severe clinical manifestations and more exuberant humoral autoimmunity in women with shorter AR exon 1 CAG repeat length support a role for genetically determined sensitivity to androgenic hormones as a modulator of humoral autoimmune processes.

 

Nothing to Disclose: WJK, ALB, NJO

11875 6.0000 SAT-0410 A Androgen Receptor Gene Exon 1 CAG Repeat Length Inversely Correlates with Manifestations of Humoral Autoimmunity in Women with Lupus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Hong Zhao*1, Robert T Chatterton Jr.2, Jeremy Zhang3, Enze Jiang3, Matthew T Dyson3, David C Brooks4, Francesco J. DeMayo5 and Serdar Ekrem Bulun1
1Northwestern Univ, Chicago, IL, 2Northwestern Univ Med Sch, Chicago, IL, 3Northwestern University, 4Northwestern University, Chicago, IL, 5Baylor College of Medicine, Houston, TX

 

In the US, more than 1 in 4 men develop symptomatic inguinal hernias, and more than 600,000 inguinal hernia repair surgeries are performed annually. While, the underlying molecular mechanisms of inguinal hernias are currently unknown, exogenous estrogen induces scrotal hernia development in male mice, which we propose to serve as the counterpart of inguinal hernia in humans. To develop a more physiologically relevant source for estrogen, we have generated a humanized aromatase (Aromhum) mouse model. Aromatase is a key enzyme for estrogen biosynthesis.  We demonstrated that locally increased estrogen levels in the lower abdominal muscle tissue in Aromhum  mice, but not circulating estrogen levels, lead to the development of scrotal hernias with nearly complete penetrance.  The aromatase inhibitor letrozole completely reversed this phenotype. In both wild type (WT) and Aromhum mice, the expression of estrogen receptor α (ERα) mRNA and protein in skeletal muscle varied in different muscle groups, and was highest in the lower abdomen, modest in the upper abdomen, and lowest in thigh. Skeletal muscle tissue from the lower abdomen had significantly greater proportion of fibroblasts than the upper abdomen in all mice, and similarly all mice had a greater proportion of ERα positive fibroblasts in the lower abdomen than in upper abdomen.  However, human aromatase expression resulted in a striking increase the total number of fibroblasts in the lower abdominal tissue relative to wild type.  The percentage of Ki67-positive fibroblasts indicated proliferation was approximately 3-fold higher in the lower abdomen of Aromhum  mice than that of WT mice and the upper abdominal muscle tissue of Aromhum mice. E2 stimulated incorporation of BrdU in primary cultured fibroblasts from WT mice with a maximum at 0.1 nM in lower abdominal muscle tissue and at 1.0 nM in upper abdominal muscle tissue, indicating higher estrogen sensitivity in fibroblasts of the lower abdomen. Fulvestrant (ICI) inhibited these responses.  In the hypothalamus, kisspeptin is a functional mediator of ERα. Interestingly, a microarray analysis of mRNA revealed a high concentration of kisspeptin only in the lower abdominal muscle tissue of Aromhum mice, which was confirmed by real-time RT-PCR analysis.  Kisspeptin staining was observed in fibroblasts, but not in muscle cells of both lower and upper abdomen. C2C12 myoblast differentiation was increased with E2 treatment as demonstrated by increased mRNA levels of Myh2, Myog, Myomaker and CCKN1.  In conclusion, aromatase expression in the lower abdominal skeletal muscle tissue can cause scrotal hernias by increasing local estrogen production, which triggers the abnormal expansion of ERα positive fibroblasts and the improper differentiation of surrounding muscle possibly due to elevated kisspeptin expression.

 

Nothing to Disclose: HZ, RTC Jr., JZ, EJ, MTD, DCB, FJD, SEB

15299 7.0000 SAT-0411 A Promotion of Scrotal Hernias By Elevated Aromatase: Involvement of Kisspeptin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Yassine Rechoum*1, Daniela Rovito2, Domenico Iacopetta2, Ines Barone2, Sebastiano Ando3, Andrew Ciupek4, Nancy L Weigel4 and Suzanne A Fuqua4
1Baylor College of Med, Houston, TX, 2University of Calabria, Rende, Italy, 3Faculty of Pharmacy, Castrolibero, Italy, 4Baylor College of Medicine, Houston, TX

 

Background: We have previously shown a role for AR overexpression in tamoxifen resistance in ERα-positive breast cancer.  We now have explored whether AR overexpression might similarly be involved in resistance to the aromatase inhibitor (AI) anastrazole (Anas).

Methods: MCF-7 cells were transfected to express the aromatase gene (MCF-7 Arom), or aromatase and AR (MCF-7 AR Arom cells).  ZR-75-B cells were engineered with shRNA vectors to knockdown Rho GDIa levels which led to endogenous up-regulation of AR.  MTT and soft agar assays were used to evaluate proliferation, and luciferase reporter assays to evaluate transcriptional activities.  Microarray analyses were used to evaluate gene expression associated with Anas resistance.  Chromatin immunoprecipitation (ChIP) assays, confocal microscopy, and proximity ligation assays were used for co-localization of AR and ERα.

Results: The AI Anas inhibited androstendione (AD)-stimulated growth of MCF-7 Arom cells, but not MCF-7 AR Arom cells.  Enhanced activation of pIGF-1R and pAKT were associated with Anas resistance in AR Arom cells, and specific inhibition of these two signaling pathways restored AI sensitivity.  Sensitivity was also restored with the AR antagonists bicalutamide and enzalutamide.  Treatment with AR antagonists in combination with the steroidal ER antagonist faslodex effectively blocked resistance, suggesting that both the AR and ERα growth pathways must be completely blocked to restore sensitivity to hormonal therapies in AR-overexpressing ERα-positive breast cancers.  Aromatase inhibitors were unable to inhibit ERα transcriptional activity in AR-overexpressing cells.  Microarray analysis revealed that both AR and ERα-regulated genes were up-regulated in resistant cells; up-regulated genes included GREB1 and CTSD which are regulated by AR and ERα, and two AR-regulated genes ETNK2 and FKBP5.  Pathway analysis of the microarray data demonstrated that activated Raf, EGFR, and MEK pathways were significantly associated with resistance.  We found that agonist-occupied AR recruited ERα to androgen-responsive promoters in AR-overexpressing cells, and that AR could be recruited via its potential interactions with ERα to estrogen-responsive promoters.  Resistance associated with AR overexpression was confirmed in two other models with endogenous up-regulation of AR (knockdown of Rho GDIa and long-term culture in tamoxifen).  These results suggest that the relative levels of AR and ERα is breast tumors may be a key determinant of hormone therapy resistance.

Conclusions: We conclude that it is essential to completely block both AR and ERα signaling in patients whose tumors express elevated levels of AR.  Furthermore, AR-overexpressing, ERα-positive patients might benefit from combined hormonal and biologic targeted therapy to avoid acquired hormone resistance.

 

Nothing to Disclose: YR, DR, DI, IB, SA, AC, NLW, SAF

15213 8.0000 SAT-0412 A AR Is an ER-α Collaborating Factor in Hormone-Resistant Breast Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Takao Susa*, Reina Ikaga, Takashi Kajitani, Masayoshi Iizuka, Mimi Tamamori-Adachi and Tomoki Okazaki
Teikyo Univ Schl of Med, Tokyo, Japan

 

We previously demonstrated parathyroid hormone-related protein (PTHrP) gene repression by various steroid hormones and encountered surprising regulatory processes where dihydrotestosterone (DHT) exerted its inhibitory effect through the estrogen receptor (ER) α, but not the endogenous androgen receptor (AR), which is otherwise functional in breast cancer MCF-7 cells. To elucidate the molecular mechanism of such intricate ligand-dependent regulation, we investigated whether an entangled ligand-nuclear receptor (NR) interaction is present in hormone-sensitive prostate cancer LNCaP cells.

First, we confirmed whether LNCaP cells expressed a functional AR at negligible levels of ERα/β, glucocorticoid receptor, and progesterone receptor. Second, both suppression of PTHrP and activation of the PSA gene were observed after treatment with estradiol (E2), DHT and R5020, but not with vitamin D3 and dexamethasone. Experiments with siRNA targeted to each NR revealed that the AR, but not the other NRs, monopolized the role as the mediator of shared hormone-dependent regulation. Further, this finding was invariably associated with the nuclear translocation of the AR.

The AR in LNCaP cells has a point mutation (Thr-Ala877) in its ligand binding domain (LBD) that results in the partial loss of the AR’s ligand specificity and cross-reaction with several ligands, including E2 and progesterone. To verify whether the skewed crosstalk of AR (Thr-Ala877) to E2 and R5020 was initiated by its LBD mutation, we employed wild-type AR (wt) and AR (Thr-Ala877) expression-based experiments to determine whether this AR mutation leads to the distorted ligand-NR interaction. Reporter assay using the luciferase vector linked to the canonical ARE and each AR expression vectors revealed that E2 in addition to DHT, but not R5020, stimulated the promoter activity via AR (wt) in the LNCaP cells. In addition, we demonstrated by intracellular localization analysis of enhanced green fluorescent protein-AR that the mutation of (Thr-Ala877) in the AR of LNCaP cells was not responsible for the distorted ligand-AR interaction. Furthermore, the reporter assay revealed that MCF-7 cells and prostate cancer Rv22 cells exhibited the similar distorted E2-AR (wt) signaling but not in AR-positive MDA-MB-453 cells.

We speculate that unknown entangled interaction exists between the AR (wt) and E2 not only in LNCaP cells but also in other sex hormone-sensitive cancer cells. Understanding the unusual ligand-NR relationship in hormone-sensitive cancer cells may offer insights into the development of a novel cancer-specific treatment modality.

 

Nothing to Disclose: TS, RI, TK, MI, MT, TO

16565 9.0000 SAT-0413 A Aberrant, but Physiological, Interactions Between the Non-Mutated Androgen Receptor and E2 in Several Sex Hormone-Responsive Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Jennifer K Richer*1, Nicholas D'Amato2, Nicole Spoelstra2, Marc B Cox3 and Anthony Elias4
1University of Colorado Anschutz Medical Campus, Aurora, CO, 2University of Colorado Anschutz Medical Campus, 3Univ of Texas at El Paso, El Paso, TX, 4Univ of Colorado Anschutz Medical Campus, Aurora, CO

 

Background:  The androgen receptor (AR) is widely expressed in breast cancer, but its role, particularly in estrogen receptor positive (ER+) tumors is not fully understood. In a cohort of 192 women with ER+ breast cancers, we found that a high ratio (≥2.0) of AR to ER percent cells positive by IHC indicated an over four fold increased risk for failure while on tamoxifen (HR=4.43). In preclinical cell line models of ER+/AR+ breast cancer, DHT is proliferative in vitro and in vivo, and anti-androgens such as bicalutamide (bic) and enzalutamide (enza) inhibit DHT-mediated proliferation. Surprisingly enza, a new generation AR inhibitor that decreases ligand-mediated nuclear translocation, decreased E2-mediated proliferation of ER+ breast cancer cells, while bic does not. Hypothesis: We hypothesized that nuclear localization of AR is necessary for maximal E2-mediated ER activity and proliferation, and targeting AR with Enz or other agents that impede AR nuclear entry will inhibit growth of ER+/AR+ human breast cancer cell lines and decrease tumor burden in preclinical models. We also postulated that if tamoxifen and enza inhibit E2-mediated proliferation by different means, the combination would result in additive or synergistic tumor shrinkage in vivo. Results:  Both Enz and MJC13, which inhibits AR release from heat shock proteins, thereby impeding its nuclear translocation, blocked E2-induced proliferation of ER+AR+ breast cancer cell lines, while Bic did not. Both DHT and to a lesser extent, E2 treatment, induced nuclear translocation of AR, and Enz inhibited AR nuclear localization in both instances, while Bic did not. In vivo, ENZ inhibited growth of MCF7 xenografts as effectively as tamoxifen, and the combination of the two agents gave an additive effect. Conclusions: Our results suggest that AR plays a previously-unrecognized role in E2-mediated ER activity in ER+/AR+ breast cancer. Enz or other agents that inhibit AR nuclear localization, may serve as effective therapeutics in ER+/AR+ breast cancers. Furthermore, Enz may be useful when combined with traditional anti-estrogens.

Funded by DOD BCRP Clinical Translational Award BC120183 to JKR

 

Nothing to Disclose: JKR, ND, NS, MBC, AE

16564 10.0000 SAT-0414 A Androgen Receptors in Estrogen Receptor Positive Breast Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Akash Gupta*1, Jie Zhu1, Robert T Chatterton Jr.1, Vamsi Parini2, Yuanming Xu1, Teresa K Woodruff1, Seema A Khan2, Serdar Ekrem Bulun3 and Hong Zhao3
1Northwestern University, Chicago, IL, 2Northwestern University, 3Northwestern Univ, Chicago, IL

 

Early testing of candidate drugs or existing pharmaceuticals in breast tissue especially associated with pregnancy and breast feeding is difficult due to the lack of a suitable working model to mimic estrogen and progesterone function in vivo.  Estrogen receptor α (ERα) and progesterone receptor (PR), which are expressed in human mammary epithelial cells (HMECs) in vivo are gradually lost in two-dimensional (2D) cell culture and eventually many cell properties disappear. Therefore, better in vitro models are required which can mimic and maintain normal architecture and hormone receptor expression similar to that of the normal human breast.  To evaluate mammary gland function in vitro we developed a mouse mammary gland organ culture (MMOC) system and mouse and human breast glandular subunit (organoid) culture systems. We have successfully cultured whole mouse mammary gland up to 14 days, in which ERα and PR were increased with treatment of 1 nM estradiol (E2) or 1 nM  E2 plus 50 nM progesterone (P4) as compared to control.  Moreover, cell proliferation, shown by Ki-67 staining, is also significantly increased after treatment with E2 or E2 plus P4.  The normal architecture of the mouse mammary glands was preserved in ex-vivo culture conditions in chambers containing 95% O2 and 5% CO2. Next, organoids from mouse mammary glands and human reduction mammoplasty samples were successfully isolated and cultured in a 3D matrigel system for up to 1 month as shown by immunohistochemical analysis of organoids exposed to estrogen and progesterone.  Both ERα and PR expression were found to be in the normal range in both human and mouse mammary organiods during the entire culture period.  For example, ERα positive cells were 6.35% and 4.2% of the total human epithelia after treatment with 1 nM E2 and 1 nM E2 +50 nM P4, respectively, compared to the control of 3.67%.  PR expression was not significantly increased. Ki67 immunostaining in both human and mouse organoids was increased in presence of 1nM E2 alone and in combination with 50 nM P4 as compared to vehicle control. In summary, we have successfully cultured mouse whole mammary glands and organoids and human mammary tissue biopsy material in a 3D culture system.  Such glands or organoids are normally responsive to sex steroid hormones. These in vitro models will be useful tools to test the effects of candidate drugs or existing pharmaceuticals in the breast including conditions mimicking the breast of pregnancy and lactation.

 

Nothing to Disclose: AG, JZ, RTC Jr., VP, YX, TKW, SAK, SEB, HZ

17008 11.0000 SAT-0415 A Development of Mouse Mammary Organ Culture and Human Breast Organoid 3D Culture Systems 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Joshua D Stender*1, Irida Kastrati2, Maayan Yakir1, Jonna Frasor2 and Christopher Kevin Glass3
1Univ of CA - San Diego, La Jolla, CA, 2University of Illinois at Chicago, Chicago, IL, 3University of California-San Diego, La Jolla, CA

 

In breast cancer, infiltration of macrophages establishes an inflammatory tumor microenvironment, which can foster an extremely aggressive and therapy resistant tumor.   Although inflammatory cytokines are known to modulate the transcriptional potential of estrogens and contribute to an endocrine-resistant state in cell-based model systems, the underlying molecular mechanisms remain poorly defined. We have used the human breast cancer cell-line MCF-7, an estrogen receptor a (ERα) positive and inflammatory cytokine sensitive cell line, to define the global impact inflammatory cytokines on the ERα cistrome and ERα-dependent transcriptional activity using next-generation sequencing methods.  IL-1β and TNFα treatments establish an ERα cistrome that substantially overlaps with the E2-dependent ERα cistrome and results in ERα-dependent, ligand-independent activation of gene expression.  Cytokine stimulation of MCF-7 cells results in phosphorylation of ERα at S305 which drives the ligand-independent activation of ERα.  Pharmacological inhibition of IKKα/β blocks cytokine-dependent S305 phosphorylation, inhibits the cytokine-dependent ERα cistome, and abolishes cytokine-dependent gene activation.  Additionally, S305 phosphorylation by cytokine treatments blocks the ability of tamoxifen to inhibit the expression of a subset of E2-dependent target genes and mutation of S305 to alanine restores tamoxifen sensitivity in the presence of IL-1β or TNFα. Collectively, these results provide molecular details dictating how inflammatory cytokines activate the transcriptional potential of ERa and drive an endocrine-resistant state in human breast cancer cells.  In addition, they highlight the potential for anti-inflammatory therapies to be utilized in the treatment of patients with tamoxifen-resistant breast cancer.

 

Nothing to Disclose: JDS, IK, MY, JF, CKG

14937 13.0000 SAT-0417 A Inflammatory Cytokines Alter the Sensitivity of Breast Cancer Cells to Endocrine Treatments 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Osamu Hiraike*1, Ayako Sakurabashi1, Akira Shirane1, Houju Fu1, Mana Hirano2, Tomohiko Fukuda1, Michihiro Tanikawa2, Yuichiro Miyamoto3, Kaori Koga1, Katsutoshi Oda1, Kei Kawana1, Yutaka Osuga1 and Tomoyuki Fujii1
1The University of Tokyo, Tokyo, Japan, 2University of Tokyo, Tokyo, Japan, 3The University of Tokyo

 

Liver X receptors (LXRs) are involved in the detection and regulation of whole-body cholesterol level, and in the regulation of inflammatory responses. It has also been revealed that the activation of LXRs inhibits the proliferation of multiple types of human cancer cells. The gene encoding the deleted in breast cancer 1 (DBC1/KIAA1967/CCAR2) is originally identified as a tumor suppressor and a previous study demonstrated that DBC1 might function to regulate SIRT1 deacetylase through its specific inhibition, and depletion of the endogenous DBC1 negatively regulates p53-dependent apoptosis. However, DBC1 also associates with oestrogen receptor (ER) α and ERβ, and DBC1 promotes ERα-positive breast cancer cell survival and inhibit ligand-dependent transcriptional activation function of ERβ. These functions of DBC1 are postulated to be tumorigenic functions.

Herein we report that DBC1 could serve as a negative regulator of LXRs. Immunoprecipitation and immunofluorescence studies show that LXRs and DBC1 interact in a ligand-independent manner similar to ERs. In vitro pull down assays revealed a direct interaction between DBC1 amino-terminus and AF-2 domain of LXRs. The function of DBC1 involves inhibition of SIRT1 interaction with LXR and of SIRT1-mediated deacetylation of LXR. As a result, DBC1 shows inhibition of the ligand-dependent transcriptional activation function of LXR and RNA interference-mediated depletion of endogenous DBC1 stimulates the expression of LXR targets including ATP-binding cassette transporter A1 (ABCA1) and G1 (ABCG1). These results implicate the novel mechanism that DBC1 might regulate the anti-proliferative effect of LXRs

 

Nothing to Disclose: OH, AS, AS, HF, MH, TF, MT, YM, KK, KO, KK, YO, TF

13133 14.0000 SAT-0418 A Putative Tumor Suppressor DBC1/CCAR2 Negatively Regulates the Nuclear Receptor LXR 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Ashwini L Chand*1, Zhe Zhao2 and Colin D Clyne3
1Monash University, Melbourne, Australia, 2Prince Henry's Institute, Australia, 3MIMR-PHI Institute of Medical Research, Melbourne, Australia

 

Introduction
Women with ER-negative breast tumors have a poor prognosis and fewer treatment options compared to those with hormone dependent, ER-positive tumors. Liver receptor Homolog 1 (LRH-1) also belongs to the nuclear receptor (NR) family and functions similarly to ERalpha in the regulation of gene transcription. The oncogenic actions of LRH-1 are implicated with elevated expression often observed in breast, hepatic, gastric, colon and pancreatic cancers. Previous studies from our laboratory showed that LRH-1 is highly expressed in ER-positive and ER-negative breast carcinomas and the surrounding stroma. The effect of LRH-1 in ER-positive breast tumor cells is well studied; however very little is documented of its expression and function in ER-negative breast tumors. In the present studies, we investigated the role of LRH-1 in hnRNPA1-induced cell proliferation.
Methods
LRH-1 and hnRNPA1 were knocked down in human breast cancer cell lines using specifically targeted siRNAs. The effects of reduced LRH-1 and hnRNPA1 on cell proliferation, cellular lactate production, and expression of markers of cell cycle were examined. Chromatin immunoprecipitation (ChIP) was used to analyse the interaction of LRH-1 and c-Myc on the hnRNPA1 promoter.
Results
We identified heterogeneous nuclear ribonucleoproteins, hnRNPA1 and its isoform, A2/B1 as regulated by LRH-1 in ER-negative and ER-positive breast cancer cells. Knockdown of LRH-1 resulted in marked decreases in hnRNPA1 and hnRNPA2/B1 at mRNA and protein levels, and reduced cell proliferation. ChIP analysis demonstrated LRH-1 and c-Myc binding to the proximal hnRNPA1 promoter region known to be critical for transcriptional activation. LRH-1-mediated reduction in hnRNPA1 and hnRNPA2/B1 levels resulted in reduced PKM2 and increased PKM1 mRNA expression, reflective of reduced cellular lactate production. High LRH-1 and hnRNPA1 expression was significantly associated with poor patient prognosis in luminal B tumor subtype.
Conclusions
This is the first study to identify an LRH-1-dependent regulation of proliferation in ER-negative tumor cells. We demonstrate that LRH-1, along with c-Myc, can regulate the expression of hnRNPA1 impacting its cellular actions in the regulation of metabolic pathways associated with aerobic glycolysis. These findings suggests a unique LRH-1 mediated link to tumor cell metabolism via the regulation of cellular splicing machinery. In addition association of increased LRH-1 and hnRNPA1 in breast tumors is implicated.

 

Nothing to Disclose: ALC, ZZ, CDC

16595 15.0000 SAT-0419 A Liver Receptor Homolog 1 (LRH-1) Regulates Heterogeneous Nuclear Ribonucleoprotein A1 Expression to Induce Proliferation in Breast Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Yuet-Kin Leung*1, Joanne Nugent2, Ming-Tsung Lee3, Leigh Campbell Murphy4 and Shuk-Mei Ho1
1University of Cincinnati College of Medicine, Cincinnati, OH, 2University of Manitoba Manitoba, 3Univ. of Cincinnati, Cincinnati, OH, 4Univ of Manitoba, Winnipeg, MB, Canada

 

Bcl2L12 was identified Bcl2L12 as a novel protein partner for estrogen receptor beta5 (ERβ5) in our previous study. Ectopic expression of ERβ5 can counteract the anti-apoptotic function of Bcl2L12 and promote chemotherapeutic agent-induced apoptosis in breast cancer (BCa) cell lines. To elucidate the clinical significance of this finding, we examined the protein level of ERβ1, ERβ5 and Bcl2L12 in a cohort (429 subjects) of breast tumor by tissue microarray (TMA) and immunohistochemistry (IHC).  IHC results were correlated with outcome and established clinical parameters to delineate the roles of ERβ1, ERβ5, and Bcl2L12 in BCa. Positivity of cytoplasmic level of ERβ1 showed significant correlation with node positivity and increase in tumor size in patients with confirmed BCa-related death and/or recurrence.  In contrast, nuclear ERβ5 positivity was significantly associated with node negativity in the patients with the same clinical outcome. The status of ERα did not affect the findings from both ERβ markers. In Kaplan-Meier analyses, positivity of cytoplasmic ERβ1 seems to associate with BCa-related death but not recurrence. On the other hand, positive signal of nuclear ERβ5 significantly predicts longer survival on patients with confirmed BCa-related death and –recurrence. Nuclear positivity of Bcl2L12 was significantly associated with shorter survival in patients with BCa-related death. In conclusion, our study suggested that ERβ5 and Bcl2L12 can be used as good prognostic markers in BCa.

 

Nothing to Disclose: YKL, JN, MTL, LCM, SMH

17040 16.0000 SAT-0420 A Estrogen Receptor beta5 Inhibits Bcl2L12 Function and Confers Better Breast Cancer Survival 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Shino Murakami*1, Anusha Nagari1 and W Lee Kraus2
1University of Texas Southwestern Medical Center, Dallas, TX, 2UT Southwestern Medical Center, Dallas, TX

 

Estrogen receptor alpha (ERa) is a ligand-regulated, DNA-binding transcription factor that nucleates the de novo formation of enhancers across the genome in response to estrogen signaling.  ERa enhancers have all of the features that are associated with active enhancers (e.g., H3K4me1, H3K27ac, enrichment of p300/CBP and Mediator, and the eRNA production), although the roles these features play in ERa enhancer function are not well understood.  p300 and CBP are bromodomain-containing protein acetyltransferases that are recruited to liganded ERa at enhancers through the steroid receptor coactivators (SRCs; a.k.a. p160 coregulators), which interact directly with ERa.  Mediator, a multisubunit coregulator complex that is thought to bridge enhancers and the core transcription machinery, also interacts directly with ERa through the Med1 subunit.  Interestingly, the SRC proteins and Med1 interact in a mutually exclusive manner with the same ligand-induced hydrophobic cleft on ERa.  We are using a combination of biochemical, molecular, genomic, genetic, and chemical approaches to dissect the distinct functions of SRC-p300/CBP and Mediator at ERa enhancers.  Mutant ERa that are resistant to p300/CBP-mediated acetylation or that selectively bind Mediator versus SRCs are providing insights into the specific mechanistic roles of SRC-p300/CBP and Mediator in ERa activity at enhancers.  Genomic and molecular approaches are providing insights into ERa enhancer complex assembly, chromatin regulation, enhancer-promoter looping, and transcription activation. Collectively, these studies will allow a greater understanding of the different functions of p300/CBP and Mediator at ERa enhancers, as well as their downstream effects.

 

Nothing to Disclose: SM, AN, WLK

16115 17.0000 SAT-0421 A Dissecting the Distinct Roles of p300/CBP and Mediator in Estrogen Receptor Enhancer Function 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Marianne Greene*1, Muriel Lainé2, Bradley Green3, Emily Corcoran4, Anhui Wu3, Robert N Hanson4, Eugene R Desombre5 and Geoffrey L Greene1
1Univ of Chicago, Chicago, IL, 2Univeristy of Chicago, Chicago, IL, 3University of Chicago, Chicago, IL, 4Northeastern University, Boston, MA, 5Ben May Inst for Cancer Res, Chicago, IL

 

Radiotherapy based on the use of Auger electron-emitting radiolabeled steroids and their analogs is capable of specifically targeting receptor-expressing cancer cells both in primary tumors and in metastases. Therapy resistant estrogen receptor (ER) positive breast cancers and androgen receptor (AR) positive prostate cancers are potential targets for such compounds. Previous studies have demonstrated the cellular toxicity of iodine 123- and iodine 125-labeled 11β-methoxy-17a vinyl-estradiol (I123-VME2 and I125-VME2) in cultured MCF7 breast cancer cells. However, the effectiveness of this approach in mouse models has not been demonstrated. Human studies have also demonstrated the potential use of these compounds for imaging purposes by showing that I123-VME2 can identify ER positive tumors in breast cancer patients. In the current study, we treated ovariectomized, SCID mice bearing ER positive MCF-7 K1 tumor explants with 2-5 mCi of high specific activity I123-VME2 and observed that tumor weight and size were significantly reduced, compared to control mice, 6-12 weeks after treatment. These results indicate that receptor-targeted internal radiotherapy approach is a promising treatment modality for therapy resistant ER positive breast cancers in postmenopausal women. Similar studies to target AR in castration-resistant prostate cancers are ongoing.

 

Nothing to Disclose: MG, ML, BG, EC, AW, RNH, ERD, GLG

16413 18.0000 SAT-0422 A Targeting Estrogen Receptor Alpha with Radiolabeled Estradiol for Breast Cancer Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Tsu-Chung Chang*
National Defense Medical Center, Taipei, Taiwan

 

RARRES3, a class II tumor suppressor gene, was identified as a major retinoids-induced gene in cancer cells of different origins. Recent studies indicated that RARRES plays an important role in cell proliferation, differentiation, and apoptosis. In spite of these cellular activities, the molecular mechanism of this gene expression has not been clearly elucidated. Previously, we identified a DR5-containing promoter fragment as the primary regulatory region which confers transactivation of all-trans retinoic acid (atRA) to this gene. In addition to the DR5 element, there are an inverted repeat nuclear receptor core elements separated by 6 bp (IR6) and a p53 response element (p53RE) within this promoter fragment. Further studies demonstrated that RARRES3 gene is a downstream target of p53 protein, and its expression is also significantly suppressed by estradiol. Estrogen receptor α (ERα) and tumor suppressor protein p53 signals were shown to exert opposing effects on cellular proliferation in ER target tissues. Here, we investigated the interplay of  estradiol and p53 on the regulation of RARRES3 gene expression in human breast cancer MCF-7 cells. In transient transfection assays, we showed that the IR6 element is essential for the estradiol-mediated inhibition as promoter constructs with mutated IR6 element markedly enhanced transactivation activity. The binding of liganded ER to the IR6 element was validated by electrophoretic mobility shift assay (EMSA). In addition, we found that p53 plays an essential role in the estradiol-mediated down-regulation of RARRES3 expression in MCF7 cells. In the presence of estradiol, the RARRES3 gene expression was significantly inhibited; however, the inhibition was abolished in the p53 knockdown MCF7 cells. Further studies using chromatin immunoprecipitation (ChIP) assay indicated that the liganded ER was recruited to the IR6-containing promoter regions. Binding of the liganded ER suppressed RARRES3 transcription activation in MCF-7 cells by increased and decreased recruitment of nuclear receptor corepressor (NcoR) and retinoic acid receptor (RAR) to the RARRES3 gene promoter, respectively, in a p53-dependent manner. In summary, our results demonstrated that p53 plays an essential role in the estradiol-mediated down regulation of RARRES3 gene expression. This study also suggests a p53-centered regulatory network that coordinates the estradiol and atRA signals in modulating RARRES3 gene expression.

 

Nothing to Disclose: TCC

15535 19.0000 SAT-0423 A Estradiol Inhibited RARRES3 Gene Expression in a p53-Dependent Mechanism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Dan Tian*, Natalia M Solodin, Prashant Rajbhandari, Kelsi Bjorklund, Elaine T Alarid and Pamela K Kreeger
University of Wisconsin-Madison, Madison, WI

 

The regulation of estrogen receptor α (ERα) expression is important in breast cancer prognosis and treatment, as the level of ERα in cells modulates its sensitivity to 17β-estradiol (E2) and can be used to predict tumor responsiveness to anti-cancer treatments. ERα RNA and protein levels, however, are dynamic after E2 treatment. To analyze these dynamics, we developed a novel mass-action kinetics model of ERα regulation at the RNA (nascent RNA and mRNA) and protein (total and phosphorylated ERα) levels. A simple ERα model without feedback was unable to explain the experimental data. We then asked if modification with different feedback mechanisms within the model could improve model fit. As a first approximation, feedback was assumed to be proportional to the concentration of phosphorylated ERα. Systematic evaluation of these mechanisms demonstrated that two mechanisms of feedback were necessary to capture system dynamics, with mechanisms regulating degradation of phosphorylated ERα and nascent RNA synthesis rate best fitting the experimental data. Model analysis suggested that phosphorylated ERα degradation rate must be higher than non-phosphorylated ERα protein degradation rate. Modeling results also indicated that feedback inhibition of nascent RNA synthesis rate was necessary to capture the rapid decrease in ERα RNA levels following E2 treatment. Experimental analysis by ChIP confirmed that ERα phosphorylated at residue serine 118 binds directly to the ESR1 promoter, suggesting that direct feedback of phosphorylated ERα on RNA synthesis is possible. Combined, our computational analysis and experimental data identify phosphorylated ERα as a critical regulatory element that modulates ERα RNA and protein dynamics.

 

Nothing to Disclose: DT, NMS, PR, KB, ETA, PKK

12382 20.0000 SAT-0424 A A Mathematical Model Examining the Regulation of ERα Levels in Breast Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Lydia Edjekouane*1, Samira Benhadjeba2, Euridice Carmona3 and Andre Tremblay4
1Research Center, Sainte-Justine Hospital, Montreal, QC, Canada, 2Research Center, Sainte-Justine Hospital, Montreal, Canada, 3CHUM Research Center, 4Ste Justine Hosp-Univ of Montr, Montreal, QC, Canada

 

Members of the hyaluronidase family are required for the hydrolysis of the glycosaminoglycan hyaluronan, a critical component of the extracellular matrix involved in diverse cellular functions, such as cell proliferation, migration, and differentiation, Of the six known hyaluronidase members, Hyal-1, Hyal-2 and Hyal-3 are encoded in a tightly linked cluster located on chromosome 3p21.3 in humans, where chromosomal and genome abnormalities are frequent events in many epithelial tumours. In particular, Hyal-1 expression is found elevated in prostate, bladder, liver and breast cancer, correlating with tumor growth and metastasis. However, the mechanism by which Hyal-1 expression is regulated in cancer cells remains to be determined. Using a subset of morphologically heterogenous classified ovarian tumors, our group has demonstrated a significant increase in Hyal-1 expression in clear cell and in mucinous epithelial ovarian cancer (EOC) subtypes, but not in serous and endometrioid samples or normal ovaries. Similarly, Hyal-1 enzymatic activity was found elevated only in EOC cell lines derived from clear cell and mucinous subtypes. Interestingly, Hyal-1 expression inversely correlated with that of estrogen receptor ERa, a nuclear hormone receptor that regulates estrogenic gene expression. Ectopic expression of ERa in ovarian cancer TOV21G cells led to a decrease in Hyal-1 expression, a result also observed in breast cancer MCF-7 cells treated with estrogen, suggesting that Hyal-1 gene is negatively regulated by ERa in both cancer cells. Such inhibitory effect of estrogen was selective to Hyal-1 since other genes in the Hyal cluster were not repressed. Using chromatin immunoprecipitation and luciferase reporter assays, we have identified consensus estrogen response elements (ERE) within the proximal promoter region of Hyal-1 that mediate responsiveness to estrogen. We have also determined that more distal elements from Hyal-1 transcriptional start site are involved in recruiting ERa. Given its emerging role in tumorigenesis, the identification of Hyal-1 as an ERa target gene may provide mechanistic insights to our understanding of reproductive cancers.

 

Nothing to Disclose: LE, SB, EC, AT

16867 21.0000 SAT-0425 A Regulation of the Hyal-1/2/3 Gene Cluster By Estrogen in Ovarian and Breast Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Georgette Moyle-Heyrman*, Maria V Barbolina and Joanna Elizabeth Burdette
University of Illinois at Chicago, Chicago, IL

 

Ovarian cancer (OVCA) is the most lethal gynecological malignancy. Emerging evidence indicates ovarian cancer (OVCA) originates from the fallopian tube epithelium (or oviductal tubal epithelial cells- TEC). One risk factor for OVCA is the use of estrogen only hormone replacement therapy. Estrogen receptor (ER) and progesterone receptor (PR) are prognostic biomarkers in OVCA with the presence of receptors correlating with improved disease-specific survival. Despite estrogen’s influence in OVCA, selective estrogen receptor modulators (SERM) typically demonstrate only a 20% response rate. This low response could be due to a variety of factors including the loss of estrogen receptor signaling or the cell of origin. The response of TEC to SERMs is not known, which if this cell type does give rise to OVCA, would be useful when determining therapy options.

This study characterizes the response of ER ligands in TEC. First, the receptor status was determined by Western blot in two normal murine tubal epithelial cell lines (MTEC) from C57BL/6 and CD1 backgrounds as well as a human fallopian tube secretory cell line (FTSEC) immortalized with HTERT and SV40. Both MTECs, but not FTSEC, express ERα, PRA and PRB. Loss of the receptors in the FTSEC could be due to growth in culture as continuous passaging of MTEC CD1 cells revealed loss of ERα, PRA and PRB. The response to estrogen (E2) was investigated revealing E2dependent ERα degradation and PR upregulation in both MTEC cell lines, but not in FTSEC.

MTECs were further probed for response to the SERMs 4-hydroxytamoxifen (4OHT), raloxifene (RAL) and desmethylarzoxifen (DMA). Western blotting showed PR downregulation by treatment with SERMs, while ERα was degraded by DMA, but not 4OHT or RAL. Analysis of mRNA revealed upregulation of PR by E2, which could be blocked by co-treatment with all SERMs tested indicating that SERMs function as antagonists in MTECs. To investigate the functional response of E2 signaling in MTECs, proliferation and migration assays were performed. No change in proliferation was observed in response to E2 or SERMs, while migration was increased by E2, but not by any of the SERMs.  

Finally, high grade serous cancer cell lines Kuramochi, OVCAR4 and SKOV3 were investigated for estrogen receptor status and E2 responsiveness. All of the serous cancer cell lines investigated expressed ERα, but none had detectable PRA or PRB in the presence or absence of E2.

This study demonstrates that TEC cells express ERα and that SERMs function as antagonists in these cells. If the TEC is the origin of OVCA, it is of great importance to understand the implications of SERM therapy, especially in women with BRCA mutation taking prophylactic tamoxifen to reduce their risk of breast cancer.

 

Nothing to Disclose: GM, MVB, JEB

15096 22.0000 SAT-0426 A Response of a Putative Ovarian Cancer Progenitor Cell Type, Oviduct Tubal Epithelial Cells, to Selective Estrogen Receptor Modulators 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Dorien Baetens*1, Tülay Güran2, Lode De Cauwer3, Leendert H Looijenga4, Karolien De Bosscher5, Martine Cools6 and Elfride De Baere1
1Ghent University, Ghent, Belgium, 2University of Birmingham, 3VIB, 4Erasmus Medical Center, Rotterdam, Netherlands, 5Ghent Univ - VIB, Zwijnaarde, Belgium, 6Univ Hosp Ghent, Ghent, Belgium

 

Disorders of sex development (DSDs) are congenital conditions characterized by atypic development of chromosomal, gonadal or anatomical sex. The prevalence of these conditions is 1 in 4500, although milder genital abnormalities are seen in 1 in 300 births. Today, the molecular cause is known in only 50% of cases.
Here, we used homozygosity mapping in a Turkish patient with syndromic 46,XY DSD and a consanguineous background to identify the causal gene defect.
We identified a potential functional candidate gene for DSD in the largest homozygous region (chr 14) namely ESR2, encoding the Estrogen Receptor beta. Sanger sequencing revealed a homozygous in-frame deletion in ESR2 in this patient, c.541_543del (p.Asn181del). Segregation analysis showed that both parents and a healthy sibling are heterozygous carriers for the mutation; another healthy sibling is homozygous for the wild type allele. The deleted amino acid is located in the functionally important DNA-binding domain and is highly conserved. This deletion was absent in an ethnically matched control population. ESR2 mutation screening in a 46,XY DSD cohort revealed an additional heterozygous mutation c.251G>T (p.Gly84Val). Different prediction programs suggest an alteration of protein function (SIFT, Polyhen, Mutation Taster). In addition the affected amino acid is conserved until fruitfly.
Immunohistochemistry in an 8-weeks old human male embryo showed ER-beta expression in the hindgut and the eyes, which might recapitulate the systemic manifestations of the index case.
Dose-response assays with DPN, ERE-luc and TK-3xEREluc constructs, and ER-beta wild type and mutant constructs in HEK293T cells showed a differential transcriptional activation of the ER-beta mutants. Additional localization and EMSA studies are ongoing.
In conclusion, our study sustains a role of ESR2 as novel disease gene for syndromic 46,XY DSD. It is expected that further functional studies of ER-beta mutants found will provide insights into their molecular consequences and into the role of ESR2 in the pathogenesis of 46,XY DSD.

 

Nothing to Disclose: DB, TG, LD, LHL, KD, MC, ED

14529 23.0000 SAT-0427 A Identification and Functional Characterization of ESR2, a New Disease Gene for 46,XY Disorders of Sex Development (DSD) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Clifford James Cookman* and Scott M Belcher
University of Cincinnati, Cincinnati, OH

 

Medulloblastoma (MD) is the most common pediatric central nervous system malignancy. Estrogen receptor β (ERβ; ESR2) is expressed in human MD tumors and human MD‑derived cell lines. We previously demonstrated that 17β‑estradiol (E2) increases proliferation of MD-derived cells through activation of ERβ, and that the ER antagonist Faslodex (ICI 182,780) inhibits MD growth and increases apoptosis in vivo. Reported here are results of pharmacological studies investigating the pro-survival mechanism of estrogen action in the human MD cell line D283 Med. The D283 Med cells overexpress c-Myc and are therefore dependent on exogenous L-glutamine for survival. To examine the mechanism of the pro-survival effects of E2, metabolic stress resulting from glutamine-withdrawal was used to induce a moderate level of apoptosis similar to what is observed in vivo. Supplementation of D283 Med cultures lacking L‑glutamine with 10 nM E2 increased cell viability by 16% (p=0.0184) and decreased caspase 3 activity by 35% (p=0.0002). The ERβ selective agonist, DPN (10 nM), fully protected D283 Med cells from metabolic stress (p=0.0001). Neither the ERα selective agonist, PPT (10 nM), nor the GPR30 agonist G-1 (10 nM) mimicked the protective actions of E2 or DPN. The pro-survival effect of E2 was blocked by ICI 182,780 (10 nM), and the ERβ selective antagonist PHTPP (5 µM), but not the ERα selective antagonist MPP (1 µM). Those results indicated that ERβ was responsible for the pro-survival effects of E2, and are consistent with in vivo findings demonstrating that ERβ increased MD tumor growth. In MD tumors isolated from the Ptch+/- P53-/- mouse model of MD, immunohistochemical analyses revealed that treatment with Faslodex inhibited tumor growth, decreased expression of IGF-1R, and decreased phosphorylation of ERK1/2. Based on those findings, additional pharmacological experiments were conducted to determine whether the ERβ-dependent protective effects of E2 involved growth factor signaling. In D283 Med cells, inhibition of the IGF-1R with NVP-AEW541 (10 µM) or MEK1/2 with U0126 (10 µM) blocked E2-induced decreases in caspase 3 activity. Those findings suggest that the ERβ-dependent protective effects of E2 were mediated by increases in IGF-1/ERK signaling. In contrast to other estrogen responsive tumors where ERβ is implicated as a pro-apoptotic factor, ERβ activation in MD stimulates pro-survival signaling that result in increased MD tumor growth.

 

Nothing to Disclose: CJC, SMB

16054 24.0000 SAT-0428 A Estrogen Protects Medulloblastoma from Caspase 3-Dependent Apoptosis through Erβ (ESR2) Mediated Increases in Insulin-like Growth Factor Receptor 1 (IGF-1R) Signaling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Clifford James Cookman* and Scott M Belcher
University of Cincinnati, Cincinnati, OH

 

Medulloblastoma (MD) is the most common pediatric solid tumor. These malignancies of the brain arise from estrogen-responsive granule cell neuron precursors. We previously demonstrated that human tumors and MD derived cell lines express estrogen receptor β (ERβ), and that physiological levels of 17β-estradiol increased MD growth and migration. Previous in vivo studies in a xenograft model of MD demonstrated that MD is an estrogen-responsive tumor and that the ER inhibitor ICI 182,780 (Faslodex) blocked estrogen stimulated tumor growth. The mechanism and therapeutic efficacy of Faslodex was analyzed in the Ptch+/- P53-/- mouse model of MD. Beginning on post-natal day 21, Ptch+/- P53-/- mice were treated by weekly intramuscular injection of Faslodex or with castor oil vehicle. Treated mice were observed daily for MD symptoms which included ataxia or abnormal gait. Faslodex treatment resulted in a significant increase in symptom-free days compared to the control group (median day of symptom onset: 52 vs. 35 days, p<0.0001). Immunohistochemical analysis revealed that the number of cleaved caspase 3 immunopositive cells observed in treated tumors was increased 4‑fold compared to control tumors (p=0.0028). Mitotic figure counts and immunohistochemical staining for phosphorylated histone H3 revealed that proliferation was not affected by treatment. Those data demonstrated that inhibition of ER signaling decreases MD tumor growth by increasing apoptosis relative to tumor cell proliferation. To investigate the possible role of ERβ in MD growth, the PtchC/C Atoh1-cre mouse model of MD, with 100% incidence of MD due to the loss of patched protein expression in granule cell precursors, was crossed with the ERβ-null (Esr2-/-) knockout mouse to generate an ERβ-null MD mouse model. To assess the effects of ERβ-ablation on MD growth, tumor mass of ERβ-null and WT ERβ+/+PtchC/C Atoh1-cre mice were compared at PND45. Tumor mass was decreased by 23% in the ERβ-null mice (425.3 ± 23.3 vs.549.1 ± 20.9 mg, p <0.0008). With this new ERβ-null MD model, we have confirmed that MD are estrogen responsive and that loss of ERβ function decreases the rate of MD growth, suggesting that selective ERβ inhibition may be useful in treating MD.

 

Nothing to Disclose: CJC, SMB

15985 25.0000 SAT-0429 A Estrogen Receptor Beta (ESR2) Regulates Growth of Medulloblastoma By Modulating Apoptosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Hai Phi Nguyen*1, Christina Tzagarakis-Foster2 and Amy Elizabeth Scandurra3
1University of San Francisco, 2Univeristy of San Francisco, San Francisco, CA, 3University of San Francisco, San Francisco, CA

 

DAX-1 (dosage-sensitive sex reversal, adrenal hypoplasia congenita, critical region on X-chromosome, gene 1) is an orphan receptor classified within the nuclear hormone receptor family. DAX-1 functions as a global negative regulator of steroid hormone production by repressing the expression of multiple genes involved in the steroidogenic pathway. Our results show DAX-1 is tightly associated with ligand activated Estrogen receptor (ER) and carries out its repressive phenotype by recruiting many cofactors including histone deacetylase-1 (HDAC1), histone deacetylase-3 (HDAC3), and Sin3A-associated protein, 130kDa (SAP130). In addition, we found induction of DAX-1 in hormone dependent breast cancer cells significantly decreases cell proliferation through the transcriptional repression of key cell cycle genes, such as cyclin D1, the major regulator of entry into the G1 stage of the cell cycle. Furthermore, through the use of DAX-1 LXXLL domain mutants, we have mapped the interaction domain within DAX-1 that is essential for association of HDAC1, HDAC3 and SAP130.   These results further elucidate the role of DAX-1 as a transcriptional repressor in mammalian cells.

 

Nothing to Disclose: HPN, CT, AES

17101 26.0000 SAT-0430 A Dax-1 Inhibits Proliferation and Tumor Formation of Estrogen Receptor Positive Breast Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Amy Elizabeth Scandurra*1, Hai Nguyen2 and Christina Tzagarakis-Foster3
1University of San Francisco, San Francisco, CA, 2University of San Francisco, 3Univeristy of San Francisco, San Francisco, CA

 

DAX-1 (Dosage Sensitive Sex Reversal Adrenal Hypoplasia Congenita on the X Chromosome, gene 1) is a member of the Nuclear Hormone Receptor superfamily.  DAX-1 is classified as an orphan “sub-type” of nuclear receptor since, to date, no known ligand has been identified that is able to bind to the DAX-1 protein.  Studies have shown that DAX-1 plays a key role early on in mammalian sex determination as well as in the expression of steroid hormones.  Notably, mutation of the human DAX-1 gene results in a disorder that leads to the failure of the adrenal gland to properly develop called adrenal hypoplasia congenita (AHC).  This disorder is fatal if left untreated.  Furthermore, duplication or over-expression of the DAX-1 gene in humans results in individuals that are male by genotype (i.e. have X and Y chromosomes), but are phenotypically female. This is a phenotype known as dosage sensitive sex-reversal (DSS).  More recently, DAX-1 has been shown to play a role in regulating growth of cancer cells, however the precise molecular mechanism of DAX-1 control is not well characterized.  For example, in some types of cancer DAX-1 expression is upregulated, while in others it’s expression is highly downregulated or completely absent. In an effort to better understand DAX-1 function both in normal and disease states we are examining one type of posttranslational modification, SUMOylation. SUMOylation involves the addition of the small polypeptide conjugate SUMO (Small Ubiquitin-like Modifier) to proteins. SUMO is similar to Ubiquitin in that it is a small polypeptide, which can be covalently linked to a target protein by an isopeptide bond and that bond formation requires an enzyme pathway. However, they differ greatly in their functions; ubiquitin tags proteins for degradation whereas SUMO can have a variety of effects including changes in localization, protein-protein interaction, interaction with DNA, and in some cases stabilization of the target protein.  SUMOylation of nuclear hormone receptors can have profound effects on their function. To study the effects of SUMOylation on DAX-1, the overall SUMOylation status of DAX-1 in mammalian cell lines was determined. It was found that DAX-1 is SUMOylated in several cell lines, both normal and carcinoma cells. Mutations were made in predicted SUMOylation sites within the DAX-1 gene that were identified using the SUMOsp 2.0 program program.  Mutants were transfected into mammalian cell lines and assayed for changes in gene expression and activity.  Here, we present the results of these experiments and propose a model for the function of SUMOylation of DAX-1 in mammalian cells.

 

Nothing to Disclose: AES, HN, CT

16931 27.0000 SAT-0431 A Effects of Sumoylation on Dax-1 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Bhoomika Mathur*1, Anthony Chau1, Linda Wheeler2, Christopher Mathews2, David D Moore3 and Sayeepriyadarshini Anakk4
1University of Illinois at Urbana- Champaign, IL, 2Oregon State University, 3Baylor Coll of Med, Houston, TX, 4University of Illinois, Urbana, IL

 

Ribonucleotide reductase (Rrm), the rate-limiting enzyme for de novo dNTP synthesis, catalyzes the reduction of 2’-hydroxyl group of ribonucleoside diphosphate. It consists of two subunits, Rrm1, which remains relatively constant while the Rrm2 subunit is specifically up regulated in S phase of the cell cycle by known cell cycle surveillance kinases Atm, Atr and Chk1.

We have discovered an unexpected regulation of Rrm2 by nuclear receptor Constitutive Androstane Receptor (Car), which is a crucial regulator of xenobiotic metabolism. Car activation by its agonist 1,4-Bis (2-(3,5-dichloropyridyloxy)) benzene (TCPOBOP) induces robust expression of Rrm2 at the transcript as well as the protein levels. This data unveils a new role for Car in regulating dNTP synthesis. To determine how Car mediates Rrm2 induction, we examined the Rrm2 promoter and validated the putative Car binding site using promoter luciferase assays and Chromatin Immuno-precipitation, which clearly indicated that Car directly binds and activates Rrm2transcription.

Consistent with Rrm2 induction, Car activation led to increased proliferation and increased dTTP and dATP levels, which was completely lost in Car null mice. Further, increase in NDP kinase, which phosphorylates dNDPs to dNTPS along with dCMP deaminase, which converts dCMPs to dUMPs strongly corroborate this selective increase in dTTP and the observed decrease in dCTP levels upon Car activation. Taken together, our findings suggest that by modulating dNTP pool size via Rrm2, Car may directly mediate cellular proliferation, DNA repair and tumorigenesis.

 

Nothing to Disclose: BM, AC, LW, CM, DDM, SA

15397 28.0000 SAT-0432 A Constitutive Androstane Receptor, a Xeno-Sensor, Regulates dNTP Levels and Cellular Proliferation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Linh M. Vuong*1, Karthikeyani Chellappa2, Joseph Dhahbi1, Bin Fang2, Eugene Bolotin2, Nate P. Hoverter3, Marian L. Waterman3 and Frances M. Sladek2
1University of California, Riverside, CA, CA, 2University of California, Riverside, CA, 3University of California, Irvine, CA

 

The opposing processes of cellular proliferation and differentiation are well studied in normal development and cancer but the molecular mechanisms that control the switch between them remain elusive. To tease out one potential mechanism, we examined the interplay between hepatocyte nuclear factor (HNF) 4α, a member of the nuclear receptor superfamily, and transcription factor 7-like 2 (TCF7L2 or TCF4), one of several T-Cell Factor/Lymphoid Enhancer Factor (TCF/LEF) family members in the Wnt/β-catenin pathway. Both Wnt/β-catenin and HNF4α have been shown to play a role in hepatocellular carcinoma (HCC), with HNF4α typically downregulated and Wnt/β-catenin activity upregulated in HCC progression; overexpression of HNF4α can block this progression1,2,3. Others have observed a physical interaction between HNF4α and TCF44 and LEF15 off the DNA as well as co-localization of HNF4α and TCF4 in the HCC (HepG2) genome6. We recognized that the core consensus binding sites for HNF4α and TCF/LEF are identical and identified more than ninety binding motif sequences shared by HNF4α and TCF1 (TCF7) using a high throughput in vitro DNA binding assay. To examine in greater depth the interplay between HNF4α and TCF, we employed a human colon cancer (HCT116) line that has lost expression of HNF4α, has a deregulated Wnt/β-catenin activity, and expresses only one of the TCF/LEF family member, TCF4. We generated a Tet-On inducible line that ectopically expresses human HNF4α2 under control of doxycycline (DOX). Characterization of the line shows that HNF4α2 decreases cell count and reduces tumor growth in xenografts in nude mouse. We performed RNAseq on cells that were treated with or without DOX for 24 hours and found that HNF4α2 upregulates many of the genes involved in metabolism and apoptosis and downregulates genes involved in cell cycle and DNA replication; these results are consistent with the role of HNF4α inhibiting proliferation. To determine whether there is competition between the two factors on the chromatin level, we performed ChIPseq for TCF4 in the presence and absence of HNF4α, as well a ChIPseq for HNF4α. We observed in vivo competition between TCF4 and HNF4α2 on a small number of genes that function in cellular proliferation and differentiation. We speculate that these genes could explain the anti-proliferative effects of HNF4α2 and could help explain the dichotomy between cellular proliferation and differentiation.

 

Nothing to Disclose: LMV, KC, JD, BF, EB, NPH, MLW, FMS

16573 29.0000 SAT-0434 A HNF4α2 Competes with TCF4 for Transcription Regulation of Genes That Inhibit Cellular Proliferation in Human Colon Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM SAT 0405-0434 4836 1:00:00 PM Proliferative Effects of Nuclear Receptors and Coregulators Poster

Edra London*1, Maria V Nesterova2, Vincent Huang3 and Constantine A Stratakis4
1NICHD, Bethesda, MD, 2NICHD, NIH, Bethesda, MD, 3National Institute of Child Health and Human Development intramural summer student program (NSSP), 4National Institutes of Health (NIH), Bethesda, MD

 

PKA and cAMP signaling pathways are central to cellular metabolism regulation in all organ systems that are involved in obesity. PKA has four regulatory (RIα, RIIα, RIβ, RIIβ) and four catalytic (Cα, Cβ, Cγ, Prkx) subunit isoforms that have tissue-specific expression. Knockout (KO) of RIIβ in mice led to a lean DIO resistant phenotype in mice[1], as did KO of catalytic subunit Cβ despite distinct phenotypic differences between genotypes including PKA activity in brain.[2] RIIβ is highly expressed in white and brown adipose tissue (WAT and BAT) and brain, with low levels elsewhere. The lean phenotype was recently attributed to altered hypothalamic GABAergic signaling.[3] Cβ expression is also tissue-limited while RIIα and Cα are more ubiquitously expressed. We found that disruption of RIIα, a subunit previously not studied for its involvement in energy homeostasis, confers resistance to DIO, glucose intolerance, and fatty liver in mice. RIIαKO mice had decreased weight gain and fat mass after 14wk ad libitum access to high-fat diet (HFD) compared to WT littermates. There was decreased intake of HFD, but not of control chow in mutants. We hypothesized that altered PKA signaling in WAT was integral to decreased adiposity and that decreased HFD intake was due to changes in PKA-regulated signaling in brain. We measured PKA activity in WAT and found dramatically increased basal activity (>10-fold) and increased total PKA activity in response to HFD. PKA expression changes supported activity changes in WAT of KO mice. Basal mitochondrial respiration was elevated in primary preadipocytes and differentiated preadipocytes from RIIαKO mice. A two-fold increase in adipose triglyceride lipase mRNA (p<0.05) in RIIαKO WAT supports the possibility of increased lipolysis. In brain, we confirmed high RIIα protein levels in WT hypothalamus; PKA activity assays are pending. We conclude that RIIα represents a promising new therapeutic target for obesity interventions as WAT physiology in RIIαKOs favors decreased fat accumulation, and further study of the RIIαKO mouse can increase our understanding of PKA regulated intake and energy balance.

 


[1] Cummings DE, Brandon EP, Planas JV, Motamed K, Idzerda RL, McKnight GS 1996 Genetically lean mice result from targeted disruption of the RII beta subunit of protein kinase A. Nature 382:622-626

[2] Enns LC, Morton JF, Mangalindan RS, McKnight GS, Schwartz MW, Kaeberlein MR, Kennedy BK, Rabinovitch PS, Ladiges WC 2009 Attenuation of age-related metabolic dysfunction in mice with a targeted disruption of the Cbeta subunit of protein kinase A. J Gerontol A Biol Sci Med Sci 64:1221-1231

[3] Zheng R, Yang L, Sikorski MA, Enns LC, Czyzyk TA, Ladiges WC, McKnight GS 2013 Deficiency of the RIIbeta subunit of PKA affects locomotor activity and energy homeostasis in distinct neuronal populations. Proceedings of the National Academy of Sciences of the United States of America 110:E1631-1640

 

Nothing to Disclose: EL, MVN, VH, CAS

15463 5.0000 SAT-0879 A Protein Kinase a (PKA) Subunit R2alpha Knockout Mice Are Leaner Than WT Mice, but Also Eat Less When Given High-Fat Diet: Is Central or Peripheral PKA Regulation the Cause of Diet-Induced Obesity (DIO) Resistance? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Kristen Eckstrand, Ronald Cowan, Heidi Silver, Kevin Dean Niswender and Malcolm Avison*
Vanderbilt University Medical Center, Nashville, TN

 

Central insulin resistance (IR) may contribute to alterations in striatal dopamine (DA) tone.  Given the importance of DA signaling in behavioral self-regulation, and the importance of behavioral self-regulation and impulse control in weight maintenance, we hypothesized that: 1) an association exists between the degree of insulin resistance (measured by HOMA-IR), and impulse control (measured using a stop-signal task - SST); 2) this association is mediated by the impact of IR on the activation of brain circuits controlling “going” and/or “stopping” during the SST (measured by functional MRI - fMRI).

To test these hypotheses, we measured brain activation and associated SST performance on a trial-by-trial basis in a cohort of right-handed obese (BMI=37.1 ± 0.7, range 30-39; n=48) volunteers (age 47.1 ± 1, range 30-39 yrs) with T2DM (HOMA-IR=7.8±0.8) who were otherwise healthy, and had no history of insulin therapy.

Multivariate regression using HOMA-IR and BMI as independent predictors confirmed an association of increased HOMA-IR with poorer overall SST performance (shorter critical Stop Signal Delay – cSSD; r2 = 0.14, p=0.046).  This decline was not explained by decreased speed of “stopping” (increased Stop Signal Response Time – SSRT), but by increased speed of “going”, i.e. a significant negative association of median Go Response Time (mGRT) with HOMA-IR (r2 = 0.12, p=0.061). BMI was not a significant predictor of overall SST performance.

Contrasting the BOLD fMRI response in stop success (SS) with stop error (SE) trials (i.e. the contrast CON(SS>SE)) revealed a significantly greater bilateral activation of dorsal striatum in SS compared with SE trials.  Furthermore increasing CON(SS>SE) was a significant predictor of longer mGRT (R2 = 0.42, p = <0.001),  and thus better overall SST performance (longer cSSD: R2 = 0.33, p = 0.001). These results are consistent with a large literature implicating activation of these areas in successful motor inhibition.

Interestingly, HOMA-IR was a significant predictor of reduced striatal activation (CON(SS>SE) vs HOMA-IR: R2 = 0.19, p = 0.05), suggesting that IR may degrade inhibitory performance by blunting effective activation of striatal inhibitory pathways.  Mediation analysis confirmed that the impact of HOMA-IR on striatal activation contributes significantly (p = 0.05) to the increased impulsivity, reflected in the decreased mGRT observed with increasing IR.

These findings suggest a neural mechanism by which obesity-associated IR may increase impulsivity and degrade behavioral self-regulation, promoting a vicious cycle of further increased feeding, obesity, and severity of IR. They further suggest that strategies for normalizing activation of striatal inhibitory pathways may contribute to effective weight management, and have a consequent salutary impact on T2DM.

 

Disclosure: RC: Investigator, Novo Nordisk. HS: Investigator, Novo Nordisk. KDN: Investigator, Novo Nordisk. MA: Investigator, Novo Nordisk. Nothing to Disclose: KE

16135 6.0000 SAT-0880 A Neural Basis for an Association of Heightened Impulsivity with Insulin Resistance in Obesity Associated T2DM 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Susan J. Melhorn1, Vidhi Tyagi1, Christian Ludwig Roth2 and Ellen A. Schur*1
1University of Washington, Seattle, WA, 2Seattle Children's Rsrch Inst, Seattle, WA

 

Background: Glucagon-like peptide 1 (GLP-1) has incretin effects that are well-documented, but whether GLP-1 has an independent role in human satiety perception is debated. We hypothesized that blockade of GLP-1 receptors by the GLP-1 antagonist Exendin-[9-39] (Ex-9) would suppress subjective satiety, increase hunger, and increase ad libitumfood intake.

Methods: After an overnight fast, 8 normal weight participants (BMI 19-24.7 kg/m2, age 19-29 yr) were enrolled in a double-blind, placebo-controlled, randomized crossover study of Ex-9 to determine if the satiating effects of a meal are dependent on GLP-1 signaling in humans. Following a fasting blood draw, iv infusion of Ex-9 (600-750 pM/kg/min) or saline began and continued for the extent of our study (~2.5h). Thirty minutes after the infusion began, subjects consumed a standardized breakfast (20-40% of their estimated daily caloric needs-percent given was matched between subjects) followed 90 minutes later by an ad libitumbuffet meal. Visual analog scale ratings of hunger and fullness (0-100 mm) as well as blood draws for plasma glucose, insulin, D-xylose, and GLP-1 concentrations were performed serially. Statistical testing was by paired t-tests (2-tailed) and repeated measures two-way analysis of variance.

Results: After eating the standardized breakfast meal, subjects rated themselves as less hungry during Ex-9 infusion compared to placebo (Ex-9 8±3 mm, Placebo 20±7 mm; P=0.02) and as experiencing a greater decrease in hunger due to consumption of the breakfast (Ex-9 -62±5 mm, Placebo -41±9 mm; P=0.01), findings that were contrary to the hypothesis. Total caloric intake at the buffet meal did not differ with Ex-9 treatment (Ex-9 910±187 kcal, Placebo 998±220 kcal; P=0.54) nor did energy intake calculated as a percentage of total daily needs (Ex-9 29±6%, Placebo 32±7%; P=0.53). However, Ex-9 increased glucose (F1,7=9.57, P=0.02), insulin (F1,7=8.65, P=0.02), and GLP-1 (F1,6=19.8, P=0.004) during the overall infusion period, due largely to higher post-meal excursions. Excursions of D-xylose, reflecting gastric transit time, were not significantly different between treatments.

Conclusions: Blockade of GLP-1 receptors was not sufficient to acutely suppress subjective satiety following a standardized meal or to increase voluntary food intake in healthy, normal-weight subjects. GLP-1 may act synergistically with other adipose and gut-derived signals to promote post-meal satiety. The rise in endogenous GLP-1 levels during Ex-9 infusion could reflect higher glucose levels and/or a negative feedback loop in which activation of GLP-1 receptors on enteroendocrine cells are necessary to inhibit further GLP-1 secretion.

 

Nothing to Disclose: SJM, VT, CLR, EAS

14060 7.0000 SAT-0881 A Evidence Against a Role for GLP-1 in Postprandial Satiety in Humans 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Mônica Cristina Nogueira*1, Clarissa Silva Martins1, Alfredo Sérgio Berbel Jr.1, Margaret De Castro1, Sonir Roberto Antonini2 and Ayrton C. Moreira1
1Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil, 2Ribeirão Preto Medical School - University of São Paulo, Ribeirão Preto, Brazil

 

Introduction: Craniopharyngioma (CF) is a nonglial intracranial tumor derived from a malformation of embryonal tissue. Lesions of hypothalamus or adjacent brain structures by the tumor and/or its treatment are possible factors of obesity, which is present in ≈50% of patients. These lesions can cause changes in hormone secretion such as insulin, ghrelin, and PYY(1). GHRL gene and its receptor (GHS-R) are expressed in stomach, pituitary, hypothalamus, and in adrenal, gastrointestinal and neuroendocrine tumors. There are no studies on GHRL and GHS-R expression in CF(2). Objectives: In this study, we investigate biochemical markers including basal plasma glucose, lipids, insulin, ghrelin, PYY, and HOMA-IR calculation in patients with CF as well as the expression of GHRL and GHS-R genes in the CF tumors. Methods and results: 37 CF patients (17F, 20M) were divided into two groups: CF1 group included 10 children and adolescents (4F, 6M) aged 12±4.2yr and CF2 group included 27 adults (13F, 14M) aged 36±14yr. Two control groups were formed: C1 group included 9 children and adolescents (4F, 5M) aged 14±2.8yr and C2 group included 23 adults (14F, 9M) aged 42±13yr. Basal glucose was adequate in 90% whereas dyslipidemia was found in around 60% of CF patients. There were no differences of insulin, HOMA-IR, and PYY among CF1, CF2, and respective controls. Ghrelin (pg/ml) was higher in CF1 compared to C1 groups (1507±480 vs 940±274; p=0.006), without difference between CF2 and C2 groups (1251±550 vs 1342±542; p=0.4). Furthermore, the expression of GHRL and GHS-R genes was determined by qPCR and evaluated by 2-ΔΔCT in CF tissue samples (n=12) and normal pituitaries (n=7). GHRL was expressed in 11 samples of tumors and in all samples of pituitaries. In addition, GHRL expression was higher in CF tumors than in normal pituitaries (5.79±5.97 vs 1.16±0.47; p=0.018). GHS-R was expressed in 4 samples of tumors and in all samples of normal pituitaries. GHS-R expression was lower in CF tumors than in normal pituitaries (0.03±0.05 vs 1.05±0.27; p=0.0006). Conclusion: Basal circulating ghrelin levels were higher in children with CF and could contribute to obesity observed in these patients. In addition, we demonstrate, for the first time, the presence of GHRL in CF tumors, suggesting local hormone synthesis, which might have autocrine/paracrine modulatory effects. The pathophysiological relevance of GHRL expression in obesity related to CF tumors remains to be elucidated.

 

Nothing to Disclose: MCN, CSM, ASB Jr., MD, SRA, ACM

14682 8.0000 SAT-0882 A Biochemical and Molecular Evaluation of Orexigenic and Anorexigenic Hormones of Patients with Craniopharyngioma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

João AB Pedroso*1, Isadora C Furigo1, Thais T Zampieri1, Angela MR Lobo1 and Jose Donato Jr.2
1University of Sao Paulo, Sao Paulo, Brazil, 2University of Sao Paulo, Sao Paulo - SP, Brazil

 

Calorie-restricted diets can be an efficient nutritional intervention to promote weight loss in obese subjects. However, the long-term success in maintaining the weight lost is usually poor because individuals tend to eat more after dieting. So, putative interventions that could attenuate the hyperphagia after a period of caloric restriction could have a substantial impact on obesity treatment success rate. Leptin is a key hormone for the long-term regulation of body weight. Leptin resistance is a hallmark of obesity and some proteins such as the suppressor of cytokine signaling 3 (SOCS3) plays an important role in inhibiting leptin signaling. Because fasting-induced hyperphagia takes a relatively long time to cease (several days in mice), we hypothesized that SOCS3 may play a role in inducing the hyperphagia and weight regain generally observed after a period of caloric restriction. Thus, we generated cell-specific SOCS3 knockout (SOCS3 KO) mice using the Cre-loxP system by deleting Socs3 gene only in leptin receptor-expressing cells. SOCS3 KO mice and control (CON) littermates were fasted for 48h and then refed ad libitum for 7 days. SOCS3 KO mice showed an attenuated food intake and weight regain during the refeeding days. We euthanized SOCS3 KO and CON mice in ad libitum state and after 48h fasting, 1, 3, 5 and 7 days of refeeding. Both groups exhibited a decreased circulating leptin levels during fasting. However, while leptin levels in CON group increased above basal levels during the refeeding period suggesting a leptin resistance state, leptin levels in SOCS3 KO group remained at the basal levels. We performed gene expression analyses in the hypothalamus and only the CON group exhibited an increased SOCS3 mRNA expression after 48h fasting. In addition, 48h fasting caused a peak in the expression of the orexigenic neuropeptides AgRP and NPY. This peak was attenuated in SOCS3 KO mice. Furthermore, the expressions of protein tyrosine-phosphatases, which are associated with leptin resistance, were greater in CON group compared to SOCS3 KO group after 1 day (PTPRe, PTPN2) and 5 days (PTP1B, PTPN11, PTPRe, PTPN2) of refeeding. In conclusion, these results indicate that the inhibitory role of SOCS3 in leptin signaling amplifies fasting-induced hyperphagia and weight regain. Therefore, our findings demonstrate that the suppression of SOCS3 is a potential therapeutical approach to prevent weight regain after calorie-restricted diets.

 

Nothing to Disclose: JAP, ICF, TTZ, AML, JD Jr.

14947 9.0000 SAT-0883 A SOCS3 Expression in Lepr-Expressing Cells Amplifies Fasting-Induced Hyperphagia and Weight Regain 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Alexander D Miras1, Samantha Scholtz1, Navpreet Chhina1, Giuliana Durighel1, Jimmy D Bell1, Carel W Le Roux2 and Anthony P Goldstone*1
1MRC Clinical Sciences Centre, Imperial College London, London, United Kingdom, 2University College Dublin, Dublin, Ireland

 

Background: Patients after gastric bypass surgery for obesity have lower brain-hedonic responses to food than BMI-matched patients after gastric banding surgery and/or unoperated controls [1]. We hypothesised that this is at least partially related to elevated plasma levels of anorexigenic gut hormones such as PYY and GLP-1 after gastric bypass, and hence food hedonic-reward responses would be attenuated after suppression of these hormones.

Methods: Randomised cross-over design study of 9 weight stable adults (mean ± SEM age 47.1 ± 1.7 years, 8 female) after gastric bypass surgery (pre-operative body mass index (BMI) 51.2 ± 4.8 kg/m2, current BMI 37.1 ± 2.6, time since surgery 15.6 ± 2.4 months). Subjects participated in an established functional MRI paradigm evaluating food pictures [1], in the post-prandial state, after either Saline injection or combined subcutaneous administration of Octreotide (to suppress plasma PYY and GLP-1) and short acting insulin (to avoid hyperglycaemia). Picture appeal ratings were available in all 9 subjects but fMRI data was only available for 7 subjects due to contraindications to MRI scanning.

Results: Compared to Saline administration, Octreotide/Insulin administration increased food appeal ratings (2.79 ± 0.28 vs. 3.14 ± 0.19 (out of 5), P<0.05). Octreotide/Insulin also increased average % BOLD activation across a priori regions of interest involved in reward processing (nucleus accumbens, caudate, anterior insula and amygdala: -0.013 ± 0.033 vs. 0.049 ± 0.023, P<0.05) and in the nucleus accumbens alone (-0.076 ± 0.053 vs. 0.025 ± 0.037, P<0.05). There were no significant effects on BOLD activation during a control auditory-motor-visual task.

Conclusion: Acute suppression of the exaggerated post-prandial rise in plasma PYY and GLP-1 after gastric bypass surgery using Octreotide increases anticipatory food reward. This suggests that increased anorexigenic gut hormones may mediate lower brain hedonic-reward responses to food after gastric bypass surgery.

 

Disclosure: CWL: Medical Advisory Board Member, Novo Nordisk. APG: Principal Investigator, Pfizer, Inc., Planning Group Member, Pfizer, Inc., Speaker, Jansen Pharmaceuticals. Nothing to Disclose: ADM, SS, NC, GD, JDB

16696 10.0000 SAT-0884 A Role for Increased Plasma PYY and GLP-1 in Reducing Anticipatory Food Reward after Gastric Bypass Surgery 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Haneesha Mohan*1, Hiroshi Iwakura2 and Suraj Unniappan1
1University of Saskatchewan, Saskatoon, SK, Canada, 2Kyoto University, Kyoto, Japan

 

Nesfatin-1 is an endogenous, circulating, meal-responsive anorexigenic peptide. Prohormone convertases are proposed to cleave the first 82 amino acids of nucleobindin-2 [NUCB2] to produce nesfatin-1. Nesfatin-1 is present in the brain, and peripheral tissues including the stomach, pancreas and liver. Nesfatin-1 administration decreases food intake and body weight, and increases glucose stimulated insulin secretion. While circulating nesfatin-1 is known to increase post-prandially, the dietary components that modulate NUCB2/nesfatin-1 remain unknown. We hypothesized that macronutrients [carbohydrate, fat and protein] differentially regulate nesfatin-1 expression and release. The tissue specific NUCB2 mRNA [real-time PCR] expression and nesfatin-1 in circulation [ELISA] in vivo using male C57BL/6 mice after acute [oral gavage and sample collection within 120 minutes] or chronic [17 weeks on solid diet] feeding of high fat [60%], carbohydrate [70%] or protein [60%] diets was conducted. In addition, NUCB2 mRNA and nesfatin-1 release in response to glucose, fatty acids [Linolenic acid, octanoic acid, oleic acid], and amino acids [L-Tryptophan] was studied in vitro in mouse ghrelinoma [MGN3] cells. Mice [n=6-7] chronically fed on a control diet and a high fat diet had significantly higher body weight than mice fed a high protein or carbohydrate diet. NUCB2 mRNA expression was significantly lower in the liver of mice fed a high protein diet compared to other mice. Serum NUCB2/nesfatin-1 was elevated in mice chronically fed with a high protein [66.15±16.53 ng/mL] and carbohydrate diet [19.91±8.24 ng/mL] compared to control [2.95±0.25 ng/mL] and high fat [2.25±0.17 ng/mL] diet. Glucose stimulated NUCB2 mRNA expression in MGN3 cells [n = 9 wells] at 25, 50 and 100 mM. Oleic acid inhibited NUCB2 mRNA expression in MGN3 cells at 1 µM [~0.62 fold], 10 µM [~0.59 fold] and 100 µM [~0.58 fold] compared to untreated controls at 4 hours post-incubation. Cells incubated with L-Tryptophan for 4 hours had significantly higher NUCB2 mRNA expression at 10 mM [~1.65 fold] compared to controls. L-Tryptophan also increased NUCB2/nesfatin-1 secretion at both 1 mM [1.14±0.09 ng/mL] and 10 mM [1.08±0.06 ng/mL] compared to controls [0.67±0.08 ng/mL]. Our results, for the first time, indicate that macronutrients differentially regulate NUCB2 mRNA expression and NUCB2/nesfatin-1 release in vitro and in vivo. In conclusion, while proteins and carbohydrates stimulates, fat inhibits nesfatin-1.

 

Nothing to Disclose: HM, HI, SU

16895 11.0000 SAT-0885 A Macronutrients Differentially Regulate Nucleobindin-2/Nesfatin-1 In Vivo in Male Mice and In Vitro in Cultured Stomach Ghrelinoma (MGN3) Cells from Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Danila Del Rio*1, Paula Stucchi1, Francisco Hernández-Nuño1, Victoria Cano1, Beatriz Merino1, Miriam Martin1, Julie Ann Chowen2, Marisol Fernandez-Alfonso3, Lidia Morales1, Nuria Del Olmo1 and Mariano Ruiz-Gayo1
1Universidad CEU-San Pablo, Madrid, Spain, 2Hospital Infantil Universitario Niño Jesús. Universidad Autónoma de Madrid. CIBERobn, Instituto de Salud Carlos III, Madrid, Spain, 3Universidad Complutense, Madrid, Spain

 

Our hypothesis is that eating high-fat food (HFD) is a cue to alter gene expression in brain areas regulating food reward, leading to changes in feeding behavior and to further increase body weight (BW). Because adolescents appear to be more sensitive than adults to the influence of HFD, studies were performed in five-week old male mice. We observed that: i) acute exposition to HFD selectively increased c-Fos immunolabeling in the prefrontal cortex (PFC), ii) short-term place-conditioning triggered strong and long-lasting place preference in a HFD-induced conditioned-place preference (CPP) paradigm, iii) mice preferred to eat HFD when they had the possibility to choose between standard chow and HFD, and iv) mice on HFD displayed nocturnal hyperphagia and had increased BW and white adipose pads. Gene expression quantification in the CPF revealed a correlation between the intensity of HFD-conditioning in the CPP assay and the expression of Per2, dopamine D-1 receptor (D1dr) and tyrosine hydroxylase (Th) genes. Furthermore, 48h HFD triggered: i) changes in gene expression that were compatible with an increase in dopaminergic activity (cannabinoid receptor type 1, Cnr1, D1dr, D2dr and Th) in the CPF, as well as ii) a widespread de-synchronization of the circadian expression profile of clock genes (Clock and Per2) and genes relevant for de novo synthesis of fatty acids [glucose-6-phosphate dehydrogenase, (G6PD) malic enzyme (ME1) and fatty acid synthase, (FASN)]. Furthermore our study suggests that motivational cues might have an impact on biological clocks and metabolic pathways sensitive to FA metabolism, leading to the hypothesis that motivation, chronobiology and FA metabolism share common neural substrates during the initial steps of HFD-induced obesity.

 

Nothing to Disclose: DD, PS, FH, VC, BM, MM, JAC, MF, LM, ND, MR

13013 12.0000 SAT-0886 A Motivational Cues in Response to a High Fat Diet Account for Changes in Feeding Behavior, Body Weight Increase and Gene Expression De-Synchronization in Adolescent Mice. Role of the Prefrontal Cortex 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Claudio Ferrante, Chiara Di Nisio, Annalisa Chiavaroli, Rugia Shohreh, Lucia Recinella, Sheila Leone, Giustino Orlando, Adriana Ricciuti, Fabio Manippa, Michele Vacca and Luigi Brunetti*
G. d'Annunzio University, Chieti, Italy

 

Context: Apelin, the endogenous ligand for the APJ receptor, is derived from a 77 amino acid prepropeptide which is processed to several smaller peptide fragments, including apelin-36 and apelin-13, the latter considered the most biologically active. The wide-ranging distribution of apelinergic fibers and receptors throughout the CNS, suggests a role of apelin-13 on energy balance regulation, albeit the studies reporting the acute effects of this peptide on food intake are inconsistent.

Objectives: We investigated the role of acute intrahypothalamic apelin-13 injection on food intake and hypothalamic levels of peptide mRNAs and monoamines involved in feeding regulation, in rats fed a standard laboratory chow diet.

Design: 72 h after stereotaxic cannula placement, 40 male adult Wistar rats were acutely injected into the hypothalamic arcuate nucleus, at 09:00 a.m., with either vehicle (saline) or apelin-13 (1-5 μg). Food consumption in the following 24 h was recorded. Animals were then sacrificed, and total RNA was extracted from hypothalami and reverse transcribed to evaluate gene expression (relative quantification) of orexigenic [agouti-related peptide (AgRP), neuropeptide Y (NPY) and orexin A] and anorexigenic [cocaine and amphetamine-regulated transcript (CART), corticotrophin releasing hormone (CRH) and proopiomelanocortin (POMC)] peptides. Furthermore, we evaluated dopamine (DA), norepinephrine (NE) and serotonin (5-HT) steady state concentrations (ng/mg tissue) in rat hypothalamus homogenate. Food intake, neuropeptide and monoamine activity data were analyzed by analysis of variance (ANOVA) followed by Newman-Keuls post-hoc test.

Results: Compared to vehicle, apelin-13 significantly increased food intake (ANOVA, P<0.0001), throughout 24 h post-injection. Furthermore, apelin-13 stimulated orexin A (ANOVA, P<0.01) and inhibited CART (ANOVA, P<0.01) gene expression. Finally, we found a reduction of 5-HT steady state levels (ANOVA, P<0.01), possibly linked to decreased hypothalamic 5-HT synthesis.

Conclusions: Apelin-13 intrahypothalamic administration has orexigenic effects which could be partially mediated by increased orexin A and reduced CART and 5-HT levels, in the hypothalamus.

 

Nothing to Disclose: CF, CD, AC, RS, LR, SL, GO, AR, FM, MV, LB

11877 13.0000 SAT-0887 A Role of Apelin-13 in Hypothalamic Control of Feeding in Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Samantha Mary Mirczuk*1, Benjamin Joseph Robinson2, Camille C Robson2, Andrew James Lessey3, Victoria J Lipscomb4, Stijn J Niessen5, Imelda Mary McGonnell1 and Robert C Fowkes1
1The Royal Veterinary College, London, United Kingdom, 2Royal Veterinary College, London, United Kingdom, 3The Royal Veterinary Coll, London, United Kingdom, 4Royal Veterinary College, Hertfordshire, United Kingdom, 5The Royal Veterinary College, North Mymms, United Kingdom

 

The mammalian natriuretic peptide family consists of three members, Atrial-, B-type, and C-type natriuretic peptides (ANP, BNP and CNP, respectively), and exert their effects on blood pressure, sodium homeostasis, growth and reproduction, via their selective guanylyl cyclase receptors, GC-A or GC-B. Previous attempts to map spatial expression profiling have generated conflicting results, due predominantly to the range of techniques employed, and the relative paucity of tools to examine the natriuretic peptide system at the molecular level. Here, we describe a comprehensive spatial expression screen of the natriuretic peptide system in mouse tissues,  as well as feline biopsy samples collected at surgery, using our novel multiplex qRT-PCR system. Total RNA was extracted from adipose, adrenal, brain, heart, kidney, liver, ovary, and testis of 12wk old C57/B6 mice, liver from cats undergoing corrective surgery for portosystemic shunts, or primary pituitary cells from cats undergoing surgery for acromegalic tumors. Subsequently, multiplex qRT-PCR analyses for Nppa, Nppb, Nppc, Npr1, Npr2, Npr3, Corin, Furin, Actb, Gapdh and Rpl19 were performed. Spatial expression profiles for Nppa (ANP) and Nppb (BNP) were tightly conserved, with high levels of each transcript detected in cardiac ventricles. Nppc (CNP) expression was more broadly distributed, with the highest expression levels seen in forebrain. Expression of Npr1 and Npr2 was consistently high in all tissues examined, although the abundance of Npr1 expression in forebrain was only half that seen in other tissues. In contrast, Npr3 (clearance receptor), Corin and Furin (processing enzymes) were ubiquitously expressed. On further examination, sexually dimorphic differences were seen for Nppc (adrenal, adipose), Npr3 (kidney), Furin (cardiac ventricles), and Corin (liver), suggesting gender-specific roles for these components of the natriuretic peptide system in these tissues. In the feline tissues, Npr1 and Npr2 were detected in both liver and pituitary samples, but Nppa and Nppc were only detected in the pituitary tumour sample. These data represent the most comprehensive tissue-specific expression profiling of the natriuretic peptide system in endocrine tissues, suggest potential gender-specific roles for CNP signalling in adrenal and adipose tissue, and confirm that the CNP/GC-B is the predominate natriuretic peptide system in the brain.

 

Nothing to Disclose: SMM, BJR, CCR, AJL, VJL, SJN, IMM, RCF

16238 14.0000 SAT-0888 A Expression Profiling of the Natriuretic Peptide System in Endocrine Tissues of Mice and Cats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Christian Ludwig Roth*1, Clinton Elfers2, Kelly Henry3, Rachael Burke3 and Robert Patrick Doyle3
1Seattle Children's Rsrch Inst, Seattle, WA, 2Seattle Children's Research Institute, Seattle, WA, 3Syracuse University, New York

 

Novel anti-obesity drugs with increased efficacy and safety are currently being sought. Drawbacks of peptide based obesity therapies are that the peptides need to be injected, because of hydrolysis/proteolysis in the gastrointestinal tract, passage across the enterocyte and often a need to pass the blood brain barrier. In our approach, we make use of the vitamin B12 (B12) dietary uptake pathway to overcome these major hurdles. The goal of this project is the development of an orally active anti-obesity therapeutic. This therapeutic is based on the combination of an endogenous gut peptide with appetite suppressing effects [peptide-YY 3-36 (PYY3-36)] and B12 producing a B12-PYY3-36 conjugate.

Methods: In the current experiments we tested the conjugate against native PYY3-36 on food intake and weight gain in male rats (n=4/group, mean body weight 332.0 and 330.1 g respectively). Both drugs were subcutaneously delivered in 5 pulses per day of each 5-10 nmoles/kg/h by implanted micro-infusion pumps (iPrecio). Food intake was continuously monitored using dietary cages (Omnitech) for 5 days on saline followed by 5 days on B12-PYY3-36 conjugate or native PYY3-36.

Results: Mean food intake was reduced by 17% (19±2 g vs. 23±2 g/d, p=0.031) during B12-PYY3-36 conjugate treatment vs. saline and by 11% (20±2 g vs. 22±2 g/d, p=0.094) during PYY3-36 vs. saline. The rate of average daily weight gain dropped from 4.3±1.1 g/d to 2.6±0.9 g/d (-40%, p=0.041) by B12-PYY3-36 conjugate treatment and from 4.5±1.4 g/d to 3.1±0.7 g/d (-31%, p=0.107) by PYY3-36 treatment.

Conclusion: The pilot study demonstrates that the reductions of daily food intake and weight gain were at least as strong for the novel B12-PYY3-36 compound as compared to PYY3-36. With these promising results, we will next test the anorectic effects of the B12-PYY3-36 upon oral delivery.

 

Nothing to Disclose: CLR, CE, KH, RB, RPD

16365 15.0000 SAT-0889 A Testing the Vitamin B12 Dietary Pathway for Delivery of Peptide-YY 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Anika M Toorie*, Nicole E. Cyr, Ross Beckman, Ronald Stuart and Eduardo A. Nillni
The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI

 

Sirtuin1 (Sirt1) is a NAD+- dependent deacetylase that functions as a critical nutrient and energy sensor in peripheral and central tissues. In recent years, Sirt1 has been extensively studied to elucidate its role in whole body energy homeostasis. Our laboratory previously demonstrated that Sirt1 functions in an orexigenic capacity within the arcuate nucleus (ARC) of lean rats via a melanocortin-dependent mechanism. We show that similarly to Sirt1 levels in ARC, Sirt1 levels are increased in the paraventricular nucleus (PVN) of Diet-Induced Obese (DIO) rodents, compared to their lean counterparts. An in-vitro promoter assay revealed that increasing the activity of Sirt1 increased prohormone convertase 2 (PC2) promoter activity, while inhibition of Sirt1 activity decreased PC2 promoter activity. PC2 is an enzyme that catalyzes the conversion of prohormones to their biologically active derivatives; PC2 facilitates the conversion of proCorticotropin Releasing Hormone (proCRH) into the bioactive CRH1-41 peptide. CRH affects food intake by acting as a neurotransmitter and via its regulation of the HPA axis. Sustained activation of the HPA axis results in chronically elevated levels of baseline circulating glucocorticoids (GC), resulting in altered metabolism and increased orexigenic action in a diet-dependent manner. In the current study, we investigated Sirt1’s effect on the hypothalamus-pituitary-adrenal (HPA) axis. We show that DIO rodents display elevated peripheral GC compared to their lean counterparts. In addition, pharmacological activation of Sirt1 in lean and DIO rats’ increases circulating glucocorticoids. We also provide evidence that inhibition of Sirt1 activity reduced PC2 protein levels specifically within the PVN of DIO rats. These results demonstrate that PVN Sirt1 regulates a key enzyme that processes pro-CRH (PC2), likely augmenting the HPA axis. Lastly, Sirt1 activation in the PVN of DIO rats increases the expression of pituitary proopiomelanocortin (POMC), and the processing enzymes responsible for its conversion into adrenocorticotropin (ACTH), which is the endogenous secretagogue of GC. Current studies are aimed at investigating the acute effects of Sirt1 manipulation on bioactive CRH, ACTH and GC’s and its role in energy balance.

 

Nothing to Disclose: AMT, NEC, RB, RS, EAN

14639 16.0000 SAT-0890 A Sirt1 Activation in the Paraventricular Nucleus of the Hypothalamus (PVN) of Obese Rats Regulates Prohormone Convertase 2 (PC2) and through Corticotropin Releasing Hormone (CRH) the Expression of Pituitary Pro-Opiomelanocortin (POMC) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Bharath K Mani*1, Angela Kay Walker1, Eduardo J. Lopez Soto2, Jesica Raingo2, Charlotte Lee1, Mario Carlos Perello3, Zane Bruce Andrews4 and Jeffrey Marc Zigman1
1UT Southwestern Medical Center, Dallas, TX, 2Multidisciplinary Institute of Cell Biology, Buenos Aires, Argentina, 3Multidisciplinary Institute of Cell Biology (IMBICE-CONICET/CICPBA), La Plata, Buenos Aires, Argentina, 4Monash University, Clayton, Australia

 

Growth hormone secretagogue receptor (GHSR) 1a is the only known receptor for ghrelin, mediating ghrelin-related effects on eating, body weight and blood glucose control, among others. The expression pattern of GHSR within the brain has been assessed previously using several neuroanatomical techniques. However, inherent limitations to these techniques and the lack of reliable anti-GHSR antibodies and reporter rodent models that identify GHSR-containing neurons have prevented a more comprehensive functional characterization of ghrelin-responsive neurons. Here, we have systematically characterized the brain expression of an enhanced green fluorescence protein (eGFP) transgene controlled by the Ghsr promoter in a recently-reported GHSR reporter mouse. Expression of eGFP in coronal brain sections was compared with GHSR mRNA expression detected in the same sections by in situ hybridization histochemistry. eGFP-immunoreactivity was detected in several areas including the prefrontal cortex, insular cortex, olfactory bulb, amygdala and hippocampus, which showed no or low GHSR mRNA expression. In contrast, eGFP expression was low in several midbrain regions and in several hypothalamic nuclei ─ particularly the arcuate nucleus, where robust GHSR mRNA expression has been well-characterized. eGFP expression in several brainstem nuclei showed high to moderate degrees of co-localization with GHSR mRNA labeling. Further quantitative PCR and electrophysiological analyses of eGFP-labeled hippocampal cells confirmed faithful expression of eGFP within GHSR-containing, ghrelin-responsive neurons. In summary, the GHSR-eGFP reporter mouse model may be a useful tool to study GHSR function ─ particularly within the brainstem and hippocampus, however it underrepresents GHSR expression in nuclei within the hypothalamus and midbrain.

 

Nothing to Disclose: BKM, AKW, EJL, JR, CL, MCP, ZBA, JMZ

13052 17.0000 SAT-0891 A Neuroanatomical Characterization of a Growth Hormone Secretagogue Receptor-Green Fluorescent Protein Reporter Mouse 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Siriporn C Chattipakorn*, Hiranya Pintana, Jirapas Sripetchwandee, Nattayaporn Apaijai, Luerat Supakul and Nipon Chattipakorn
Chiang Mai University, Chiang Mai, Thailand

 

Our previous study demonstrated that 12-week high-fat diet (HFD) consumption induced obesity, peripheral insulin resistance, brain mitochondrial dysfunction and impaired cognitive function.(1-2)  Garlic extract has been shown to exert several beneficial properties including anti-oxidative effect in various organs.  However, the effects of garlic extract on the brain of obese-insulin resistant rats induced by 12-week HFD have not yet been investigated.  In the present study, we tested the hypothesis that garlic extract improved cognitive function and brain mitochondrial function, impaired by long-term HFD in obese-insulin resistant rats.  Male Wistar rats were randomly divided into 2 groups (n=24/ group) and fed either normal diet (ND) or HFD for 12 weeks.  At week 12, rats in each dietary group were divided into 3 subgroups to receive either vehicle, garlic extract at 250 mg/kg/day or garlic extract at 500 mg/kg/day for 28 consecutive days.  At the end of treatment, cognitive function was determined by the Morris Water Maze test.  Then, blood samples were collected to determine the metabolic parameters.  Finally, animals were sacrificed and brains were removed for determining brain mitochondrial function.  We found that HFD led to increased body weight, visceral fat, plasma insulin levels, plasma total cholesterol levels and plasma MDA levels with euglycemia, indicating the development of peripheral insulin resistance.  Furthermore, HFD-fed rats demonstrated brain oxidative stress, cognitive impairment and brain mitochondrial dysfunction as indicated by increased brain mitochondrial ROS production, brain mitochondrial depolarization and brain mitochondrial swelling.  The treatment with both doses of garlic extract (250 and 500 mg/kg/day) in HFD-fed rats attenuated those deleterious effects by significantly decreased body weight, visceral fat, plasma insulin levels, plasma cholesterol levels, as well as plasma and brain MDA levels.  Garlic extract also restored the cognitive function and brain mitochondrial function, impaired by long-term HFD consumption.  All of these findings suggest that garlic extract decreases oxidative stress, and improves peripheral insulin sensitivity and brain mitochondrial function, leading to the improvement of the cognitive function in obese-insulin resistant rats.

 

Nothing to Disclose: SCC, HP, JS, NA, LS, NC

11735 18.0000 SAT-0892 A Garlic Extract Restores Brain Mitochondrial Function and Attenuates Cognitive Impairment in Obese-Insulin Resistant Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Lucia Recinella1, Chiara Di Nisio1, Rugia Shohreh1, Annalisa Chiavaroli1, Claudio Ferrante1, Sheila Leone1, Fabio Manippa1, Adriana Ricciuti1, Giustino Orlando1, Roberto Salvatori2, Michele Vacca1 and Luigi Brunetti*1
1G. d'Annunzio University, Chieti, Italy, 2Johns Hopkins University School of Medicine, Baltimore, MD

 

Context: Besides growth hormone (GH) secretion, ghrelin stimulates feeding and body weight gain upon both central and peripheral administration. The interactions between GH and ghrelin axis are still not fully expored. GH receptor deficiency is associated with increased food intake and a blunted ghrelin-induced feeding response in mice [1].

Objectives: The aim of the present study was to evaluate whether a functionally intact GH axis is required for ghrelin acute effects on feeding, using a mouse model of autosomal recessive isolated GH deficiency (GHD) due to targeted ablation of the GH-releasing hormone (GHRH) gene [GHRH knockout (GHRHKO)]. We also studied the effects of ghrelin on hypothalamic dopamine (DA), norepinephrine (NE), serotonin (5-hydroxytryptamine, 5-HT) and their metabolite steady state concentrations in these animals.

Design: 16 male mice homozygous for GHRHKO allele (-/-) and 16 male  heterozygous (+/-) animals, aged 3 months, with unrestricted access to chow and water, were divided into two groups (n=8 for each group) and injected into the arcuate nucleus of the hypothalamus, at 09.00 a.m., with either ghrelin (3 nmol) or vehicle (saline). Food consumption in the following 24 h was recorded. Animals were then sacrificed, and DA, NE, 5-HT, levodopa (L-DOPA), 3,4-dihydroxyphenylacetic acid (DOPAC), homovanillic acid (HVA) and 5-hydroxyindolacetic acid (5-HIIA) steady state concentrations in hypothalamic homogenate were evaluated by high performance liquid chromatography (HPLC). Data were analyzed by one-way analysis of variance (ANOVA), followed by Newman-Keul’s multiple comparison test.

Results: Compared to vehicle, ghrelin treatment significantly increased food intake both in -/- and +/- mice. However,  the increase in feeding in response to ghrelin was higher in -/- than +/- mice (ANOVA, P<0.0001) and it was associated with increased NE levels (ANOVA, P<0.05). In both genotypes ghrelin decreased DA levels (ANOVA, P<0.001), possibly by increasing its turnover, as revealed by increased HVA/DOPAC (ANOVA, P<0.0001) and DA/NE (ANOVA, P<0.001) ratios. In addition, 5-HT levels were lower in ghrelin treated groups compared to vehicle (ANOVA, P<0.01), whithout any effect on 5-HT catabolism.

Conclusions: GHD due to lack of GHRH is associated to increased orexigenic effects of ghrelin, which could be related to increased activity of NE.

 

Nothing to Disclose: LR, CD, RS, AC, CF, SL, FM, AR, GO, RS, MV, LB

11864 19.0000 SAT-0893 A Effects of Growth Hormone-Releasing Hormone (GHRH) Gene Targeted Ablation in Ghrelin-Induced Feeding Response in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Xian Liu*1, Zheng Zhu2 and Haifei Shi2
1Miami Univ, Oxford, OH, 2Miami University, Oxford, OH

 

Brain-derived neurotrophic factor (BDNF) is one of the anorexigenic neurohormones regulating energy homeostasis. Sex differences exist in the regulation of energy homeostasis in response to calorie scarcity or excess. BDNF differentially regulates energy homeostasis in male and female rats. The mechanism for such sex difference however is not clear. Expression of Bdnf mRNA in the ventromedial nucleus of the hypothalamus (VMH) is closely associated with energy status and reproductive status. Modification of Bdnf expression by negative or positive energy status has not been compared between male and female rats. We hypothesized that Bdnf expression in the VMH was differentially regulated by altered energy balance in male and female rats. Using dietary intervention, including fasting-induced negative energy status and high-fat diet (HFD) ad libitum feeding-induced positive energy status, along with HFD pair-feeding (HFD-PF) and low-fat diet (LFD) feeding, effects of diets and changes in energy status on VMH Bdnf expression of male and female rats were measured using quantitative RT-PCR.

Fasting male and diestrous female rats, but not estrous female rats, had lower VMH Bdnf expression than their fed counterparts following 24-hour fasting, suggesting that they reduced Bdnf expression to drive hyperphagia and body weight gain. Male HFD obese and HFD-PF non-obese rats had similarly reduced expression of VMH Bdnf compared with LFD lean males, indicating that dampened Bdnf expression was associated with feeding a diet high in fat instead of increased adiposity. Decreased BDNF signaling during HFD feeding would increase a drive to eat and may contribute to diet-induced obesity in males. In contrast, VMH Bdnf expression was stably maintained in cycling female rats when energy homeostasis was disturbed. These findings suggest sex-distinct regulations of central Bdnf expression by energy imbalance and feeding a diet high in fat.

 

Nothing to Disclose: XL, ZZ, HS

12026 20.0000 SAT-0894 A Expression of Brain-Derived Neurotrophic Factor in the Ventromedial Hypothalamus Is Differentially Regulated By Energy Status Between Males and Females 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Matheus Porceban*1, Ernane Torres Uchoa2, Priscila Marlys Sá Rivas1, Jose Antunes-Rodrigues3 and Lucila Elias2
1University of São Paulo, 2Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil, 3Univ of Sao Paulo Sch of Med, Ribeirao Preto SP, Brazil

 

It is known that ADX leads to reduced body weight and hypophagia, however, there are no data on interaction of glucocorticoids and ghrelin, hormone synthesized in the stomach, with orexigenic action. Thus, we evaluated in this study the response to ghrelin stimulus in adrenalectomized rats with or without corticosterone replacement. Adult male Wistar rats (Ethical Committee on Animal Experiments of Ribeirão Preto Medical School, Nº 104/2012, 7 to 10 animals per group) were subdivided into ADX (0.5% ethanol in 0.9% NaCl), ADX+B (25 mg/L of corticosterone in 0.5% ethanol and 0.9% NaCl) or Sham (0.5% ethanol  in water) groups and treated for 7 days. The animals were acclimatized in metabolic cages and on 7th day, the food was removed at 4h30pm and 1 hour later the rats were treated with ip injection of vehicle (0.9% NaCl) or ghrelin (39µg/Kg). The food intake was measured 1 hour after the injection. Another group of animals, 7 days after surgery, was decapitated at 5:30pm for blood sample collection for measurement of serum concentration of acylated ghrelin, by ELISA. The stimulus with ghrelin increased (p<0.05) food intake in the three groups (saline vs ghrelin: Sham: 0.97 ± 0.1 g/100g vs 1.6 ± 0.1 g/100g of body weight; ADX: 0.5 ± 0.1 vs 1.0 ± 0 of body weight; ADX+B: 1.0 ± 0.1 g/100g vs 1.5 ± 0.2 g/100g of body weight). Though the ADX group showed the orexigenic effect of ghrelin, it was lower than in Sham and ADX+B groups, since the anorexigenic effect of ADX was maintained after ghrelin treatment. There was no difference in the serum concentration of ghrelin among the three groups (Sham: 107.6 ± 1.9; ADX: 107.9 ± 1.0; ADX+B: 106 ± 0.9 pg/ml).  In conclusion, glucocorticoid deficiency induced by ADX does not affect the production of acylated ghrelin. Although ghrelin is able to induce food intake after ADX, this effect is attenuated by the absence of endogenous glucocorticoids. These data indicate that hypophagia in primary adrenal insufficiency is associated with lower appetitive ingestive behavior, at least in part, due to lower ghrelin action on  food intake, which seems to be modulated by glucocorticoids.

 

Nothing to Disclose: MP, ETU, PMSR, JA, LE

13042 21.0000 SAT-0895 A Adrenalectomy (ADX) Reduces the Orexigenic Response to Ghrelin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Tiago Morais*1, Sofia Pereira1, Angela Moreira2, Madalena Costa3, Duarte Monteiro2 and Mariana Pereira Monteiro4
1Instituto Ciências Biomédicas Abel Salazar - UP, Porto, Portugal, 2Instituto de Ciências Biomédicas Abel Salazar - UP, 3Instituto Ciências Biomédicas Abel Salazar - UM, Porto, Portugal, 4Instituto Ciências Biomédicas Abel Salazar - UP, Matosinhos, Portugal

 

The vagus nerve is the major neuroanatomical link between the gastrointestinal tract and the brain. The role of the vagus nerve in food intake regulation has been the focus of recent research, since the mechanisms leading to decreased food intake and body weight after vagotomy are still ill understood. In addition, vagotomy has demonstrated to limit the extent of weight loss observed after gastric bypass. The aim of this study was to evaluate the role of gastro-intestinal hormones and energy expenditure in food intake behaviour and body composition of vagotomised rats.

Adult male Wistar rats were randomized into three groups, which were submitted to sub diaphragmatic truncal vagotomy with piloroplasty (VAG), sham surgery (SHAM) fed ad libitum or sham surgery pair fedto the vagotomy group (SHAM-PF). After recovery from the surgery, the successfulness of the procedure was assessed with the feeding response to the acute administration of CCK-8 and animals in the vagotomised group that failed the CCK-8 test were excluded from further analysis. Body weight and food intake were daily monitored, basal metabolic rate was measured by indirect calorimetry and spontaneous locomotor activity was recorded. Rats were sacrificed 30 days after surgery when the stomach, white (WAT) and brown adipose tissue (BAT) were removed and weighed.  Blood was collected to measure plasma levels of glucose, insulin, ghrelin, GLP-1 and leptin by ELISA. Tissue samples from subcutaneous and visceral WAT were placed for 24 hours in culture medium and their secretome was collected to measure leptin levels in the medium.

Food intake, body weight and the percentage of WAT and BAT were significantly lower, in vagotomised rats compared to controls, with no difference in basal energy expenditure or locomotor activity. Vagotomised animals also presented significantly lower fasting blood glucose and insulin, with similar total ghrelin and GLP-1 levels compared to controls. Pair feeding of sham operated rats resulted in a phenotype similar to the observed in the vagotomised rat, with the exception of the stomach size that was significantly higher. Plasma leptin levels were significantly lower in the VAG and SHAM-PF when compared to controls, but there were no significant differences in leptin secretome levels between the groups.

Truncal vagotomy decreases body weight and body fat content, which can be attributed to decreased food intake, as pair feeding is able to reproduce most of the phenotypical modifications observed after the procedure. These results suggest that gastroparesis might have a major role in short term regulation of food intake, since stomach size is the sole characteristic that distinguishes VAG from Sham-PF.

 

Nothing to Disclose: TM, SP, AM, MC, DM, MPM

16756 22.0000 SAT-0896 A Vagotomy Decreases Food Intake and Body Weight without Changing Gastrointestinal Hormones Levels or Energy Expenditure 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0875-0896 4841 1:00:00 PM Central Regulation of Metabolism Poster

Daniela Handke*1, Peter Kühnen1, Johannes Hebebrand2, Anke Hinney2, Annette Grüters-Kieslich1 and Heiko Krude1
1Charité - Universitätsmedizin Berlin Campus Virchow, Berlin, Germany, 2Univ of Duisburg, Essen, Germany

 

Background: Pro-opiomelanocortin (POMC) is a key regulator of body weight within the hypothalamus. Recently we identified an epigenetic variant in the POMC locus that was significantly associated with obesity in children and adolescents1. This DNA hypermethylation variant is located at the border of the 3´-intron2-CpG island and seems to be triggered by an adjacent Alu element1. To estimate the origin of this variant which i) might be inherited from the parents or ii) occur as a random event during re-methylation of the genome after implantation or iii) could in principle be the result of external influences e.g. maternal metabolic state, we tested the heritability of this variant in trio families with one obese child (n=50 families), obese monozygotic twin pairs (MZ twins; n=20) and dizygotic twin pairs (DZ twins; n=20).

Methods: The DNA methylation was analysed in DNA extracted from peripheral blood cells with a sodium-bisulfite based protocol and pyrosequencing.

Results: We found that the POMC DNA hypermethylation variant was not inherited in the trio families since 20% of the children were found to harbour the variant while the parents did not. In the MZ/DZ twin pairs the POMC methylation variant was not concordant. We identified in 31% of the cohort, pairs in whom only one twin were hypermethylated. In addition we could recapitulate the significant association of the hypermethylation variant with the obese phenotype in the adult parents.

Conclusion: The analysis of the hypermethylation variant of the POMC locus in trio families and twins revealed that the variant is not inherited by the genetic background and is most likely not the result of external or maternal imprinting mechanism. This was most evident by the finding that several obese children with the variant have parents without the variant and most convincingly several monozygotic twin pairs were discordant for the variant. Based on our previous findings and the present data we conclude, that the POMC hypermethylation variant, which is highly associated with childhood obesity occurs most likely due to individual stochastic events in early embryonic development.

 

Nothing to Disclose: DH, PK, JH, AH, AG, HK

14493 5.0000 SAT-0928 A The Origin of the Obesity Associated Pomc DNA Hypermethylation Variant 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0924-0941 4842 1:00:00 PM Human Obesity: Targets and Therapies Poster

David C Lau*1, Arne Astrup2, Ken Fujioka3, Frank Lyons Greenway III4, Alfredo Halpern5, Michel Krempf6, Carel W Le Roux7, Rafael Violante Ortiz8, John Wilding9, Christine Bjørn Jensen10 and F Xavier Pi-Sunyer11
1University of Calgary, Calgary, AB, Canada, 2University of Copenhagen, Frederiksberg C, Denmark, 3Scripps Clinic, La Jolla, CA, 4Pennington Biomed Res Ctr, Baton Rouge, LA, 5Universidade Sao Paulo, Sao Paulo, Brazil, 6Université de Nantes, Nantes, France, 7University College Dublin, Dublin, Ireland, 8Instituto Mexicano del Seguro Social, Cuidad Madero, Tamaulipas, Mexico, 9University of Liverpool, Liverpool, United Kingdom, 10Novo Nordisk A/S, Søborg, Denmark, 11St Luke's Roosevelt Hosp, New York, NY

 

The primary objective of this trial was to investigate the efficacy of the glucagon‐like peptide‐1 receptor agonist (GLP‐1RA) liraglutide 3.0 mg, as adjunct to diet and exercise, for weight management. Key safety and tolerability data are presented.

Participants (BMI ≥27 kg/m2 with ≥1 comorbidity or ≥30 kg/m2) were advised on a 500 kcal/day deficit diet and exercise program and randomized 2:1 to once-daily subcutaneous liraglutide 3.0 mg (n=2487) or placebo (n=1244). Clinicaltrials.gov ID: NCT01272219.

Baseline characteristics: age 45.1 years, 78.5% female, body weight 106.2 kg, BMI 38.3 kg/m2. Liraglutide induced greater mean weight loss (primary endpoint; 8.0%) than placebo (2.6%) after 56 weeks (estimated treatment difference [ETD] -5.4%; p<0.0001, LOCF). Consistent with the known effects of GLP-1RAs, the most common adverse events (AEs) with liraglutide were mild/moderate nausea and diarrhea, mostly transient and with onset in weeks 1−4. AEs leading to withdrawal occurred in 9.9% of liraglutide-treated participants, mostly in weeks 1–12 and due to gastrointestinal AEs, vs. 3.8% with placebo. A similar proportion of individuals reported serious AEs in both groups (liraglutide: 6.3% and 8.7 events/100 patient years of exposure [PYE]; placebo: 5.0% and 7.0 events/100 PYE). None occurred in ≥1% of individuals. 3 deaths occurred: 1 with liraglutide and 2 with placebo (1 cardiovascular-related death in each group). Liraglutide treatment was not associated with increased risk of depression or suicidality.

The frequencies of gallbladder-related AEs and pancreatitis were higher with liraglutide (3.1 and 0.3 events/100 PYE, respectively) than placebo (1.4 and 0.1 events/100 PYE). An increase in mean serum lipase activity was seen with liraglutide, but few individuals (0.6% vs. 0.2% with placebo) had levels ≥3 times the UNR. Most elevations were transient and not predictive of pancreatitis. While liraglutide reduced mean systolic and diastolic BP vs. placebo at week 56 (ETD -2.8 and -0.9 mmHg, p<0.001), it increased mean pulse (ETD 2.5 beats/min, p<0.0001) and a persistent increase of >20 beats/min at ≥2 consecutive visits occurred in 5.1% vs. 1.4% of participants, respectively. Cardiovascular events were similar with liraglutide (8.7% and 11.9 events/100 PYE) vs. placebo (9.9% and 14.2 events/100 PYE). There were no cases of medullary thyroid carcinoma or C-cell hyperplasia and liraglutide did not increase concentrations of calcitonin. Finally, injection site reaction rates were 22.4 and 14.9 events/100 PYE with liraglutide and placebo, respectively, with similar allergic reaction rates between treatments (2.6 and 3.2 events/100 PYE).

In conclusion, the safety profile of liraglutide 3.0 mg was consistent overall with the known effects of a GLP-1RA. The clinical significance of the imbalance in gallbladder and pancreatitis events is currently unknown.

 

Disclosure: DCL: Researcher, Astra Zeneca, Researcher, Boehringer Ingelheim, Researcher, Bristol-Myers Squibb, Researcher, Eli Lilly & Company, Researcher, Novo Nordisk, Medical Advisory Board Member, Amgen, Medical Advisory Board Member, Astra Zeneca, Medical Advisory Board Member, Boehringer Ingelheim, Medical Advisory Board Member, Bristol-Myers Squibb, Medical Advisory Board Member, Jansen Pharmaceuticals, Medical Advisory Board Member, Eli Lilly & Company, Medical Advisory Board Member, Novo Nordisk, Medical Advisory Board Member, Roche Pharmaceuticals, Medical Advisory Board Member, Valeant Pharmaceuticals, Speaker Bureau Member, Amgen, Speaker Bureau Member, Astra Zeneca, Speaker Bureau Member, Boehringer Ingelheim, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Eli Lilly & Company, Speaker Bureau Member, Merck & Co., Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Valeant Pharmaceuticals. AA: Advisory Group Member, BioCare, Advisory Group Member, Pathway Genomics Corp, Advisory Group Member, Vivus USA, Board Member, Dentacom Aps, Shareholder, Dentacom Aps, Consultant, Arena Pharmaceuticals Inc, Consultant, Basic Research , Consultant, Boehringer Ingelheim Pharma GmbH & Co KG, Consultant, Gelesis, Consultant, Gerson Lehrman Group, Consultant, Novo Nordisk, Consultant, S-Biotek, Consultant, Twinlab. KF: Consultant, Eisai, Speaker Bureau Member, Eisai, Consultant, NPS, Speaker Bureau Member, NPS, Consultant, Vivus USA, Speaker Bureau Member, Vivus USA, Consultant, Isis, Consultant, NaZura, Consultant, Novo Nordisk, Consultant, Zafgen, Consultant, Orexigen, Speaker Bureau Member, Abbott Laboratories, Speaker Bureau Member, Takeda, Researcher, Eisai, Researcher, Novo Nordisk, Researcher, NPS, Researcher, Orexigen, Researcher, Enteromedics, Researcher, Shire, Speaker Bureau Member, WeightWatchers. FLG III: Patent holder, Patent holdings, Consultant, Align2Action, Consultant, BARONova, Consultant, Basic Research, Consultant, Citius Pharmaceutical, Editorial Board member, Diabetic Living, Consultant, Eisai, Consultant, General Nutrition Corp, Consultant, Medacorp, Consultant, Guidepoint Global, Consultant, Japan Tobacco Pharmaceutical Division, Medical Advisory Board Member, Jenny Craig, Consultant, Lithera Inc, Patents licencee and stockholder, NeuroQuest, Scientific Board Member, Novo Nordisk, Stockholder, NuMe Health, Scientific Board Member, Orexigen, Stockholder, Origin Biomed, Advisory Group Member, Pam Labs, Stockholder, PlenSat, Consultant, Thetis Pharmaceuticals, Consultant, Unigene Labs, Advisory Group Member, Zafgen, Researcher, Novo Nordisk, Researcher, Hanmi Pharmaceuticals. AH: Advisory Group Member, Novo Nordisk, Speaker Bureau Member, Novo Nordisk. MK: Medical Advisory Board Member, Astra Zeneca, Medical Advisory Board Member, Bristol-Myers Squibb, Medical Advisory Board Member, Novo Nordisk. CWL: Medical Advisory Board Member, Novo Nordisk. RV: Medical Advisory Board Member, Merck Sharp & Dohme, Medical Advisory Board Member, Boehringer Ingelheim, Medical Advisory Board Member, Novo Nordisk, Medical Advisory Board Member, Bristol-Myers Squibb, Medical Advisory Board Member, Astra Zeneca, Medical Advisory Board Member, Eli Lilly & Company, Researcher, Eli Lilly & Company, Researcher, Novo Nordisk, Speaker Bureau Member, Merck Sharp & Dohme, Speaker Bureau Member, Boehringer Ingelheim, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Astra Zeneca. JW: Advisory Group Member, Astellas, Advisory Group Member, Astra Zeneca, Speaker Bureau Member, Astra Zeneca, Speaker Bureau Member, Boehringer Ingelheim, Advisory Group Member, Bristol-Myers Squibb, Speaker Bureau Member, Bristol-Myers Squibb, Researcher, Bristol-Myers Squibb, Advisory Group Member, Jansen Pharmaceuticals, Speaker Bureau Member, Jansen Pharmaceuticals, Speaker Bureau Member, Eli Lilly & Company, Advisory Group Member, Novo Nordisk, Speaker Bureau Member, Novo Nordisk, Researcher, Novo Nordisk, Speaker Bureau Member, Merck & Co.. CBJ: Employee, Novo Nordisk, Employee, Novo Nordisk. FXP: Medical Advisory Board Member, Novo Nordisk, Medical Advisory Board Member, Weight Watchers, Medical Advisory Board Member, Johnson &Johnson, Medical Advisory Board Member, Vivus USA, Medical Advisory Board Member, Zafgen, Medical Advisory Board Member, Eisai.

12496 6.0000 SAT-0929 A Safety and Tolerability of Liraglutide 3.0 Mg in Overweight and Obese Adults: The Scale Obesity and Prediabetes Randomized, Double-Blind, Placebo-Controlled 56-Week Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0924-0941 4842 1:00:00 PM Human Obesity: Targets and Therapies Poster

Ralph DeFronzo*1, Richard Mauritz Bergenstal2, Bruce W. Bode3, Robert Kushner4, Andrew J Lewin5, Trine Vang Skjøth6, Christine Bjørn Jensen6 and Melanie Davies7
1University of Texas Health Science Center, San Antonio, TX, 2HealthPartners Institute, Minneapolis, MN, 3Atlanta Diabetes Assoc, Atlanta, GA, 4Northwestern University FSM, Chicago, IL, 5National Research Institute, Los Angeles, CA, 6Novo Nordisk A/S, Søborg, Denmark, 7University of Leicester, Leicester, United Kingdom

 

Obesity increases risk of multiple comorbidities including T2DM and cardiovascular (CV) disease. A 5-10% weight loss can decrease risk but is difficult to achieve and maintain by lifestyle changes alone (1). Liraglutide at doses up to 1.8 mg is approved for treatment of T2DM. Four phase 3 studies for weight management (SCALE) were recently completed. This study evaluated the effects of liraglutide (3.0 and 1.8 mg) as adjunct to diet and exercise on weight loss (primary endpoint) and cardiometabolic risk factors (waist circumference, glycemia, blood pressure [BP], pulse, fasting lipids, and CV biomarkers) in overweight/obese adults with T2DM.

846 individuals (male 50%, mean age 54.9 y, BMI 37.1 kg/m2 [27.0−67.6], HbA1c 7.9%, diabetes duration 7.3 y [0.2−36.5], 11.5% on diet and exercise, 57.3% on metformin, and 31.2% on combination OADs) were randomized (2:1:1) to liraglutide 3.0 mg, 1.8 mg, or placebo for 56 weeks; all arms included a 500 kcal/day deficit diet and exercise. Clinicaltrials.gov ID: NCT01272232.

At week 56, mean (least square) weight loss was 5.9%, 4.6% and 2.0% for 3.0 mg, 1.8 mg, and placebo, respectively; 3.0 mg and 1.8 mg were superior to placebo (p<0.0001); 3.0 mg was superior to 1.8 mg (p=0.0024). Weight loss was accompanied by reductions in waist circumference of 6.0, 4.9, and 2.8 cm respectively; 3.0 mg and 1.8 mg were superior to placebo (p≤0.0004); 3.0 mg was superior to 1.8 mg (p=0.0224). HbA1c decreased by 1.32%, 1.13% and 0.38% from baseline with 3.0 mg, 1.8 mg, and placebo respectively (p<0.0001 vs. placebo; p=0.0125 for 3.0 mg vs. 1.8 mg). At baseline, systolic (S) /diastolic (D) BP and lipids were well controlled. SBP reductions were 3.0, 3.1, and 0.4 mmHg from baseline (~130 mmHg) for the 3 arms respectively; greater with 3.0 mg and 1.8 mg (p<0.05 vs. placebo), with no significant differences between treatments in DBP at week 56. Similar pulse changes of 2.0 and 2.2 beats/min occurred with liraglutide 3.0 and 1.8 mg vs. -1.5 beats/min for placebo (p<0.0001 vs. placebo). Liraglutide 3.0 mg reduced total cholesterol, VLDL and triglycerides (‑4%, ‑13%, ‑14%, p<0.05) and increased HDL (+3%, p<0.05) vs. placebo whereas 1.8 mg had no effects. Liraglutide had no significant effects on LDL and FFA. Reductions in high-sensitivity C‑reactive protein occurred with liraglutide 3.0 and 1.8 mg (-27% and -25% vs. placebo, p≤ 0.0002). Decreases in plasminogen activator inhibitor-1 (-24%, p=0.0004) and urinary albumin/creatinine ratio (-20%, p=0.0086) occurred only with liraglutide 3.0 mg vs. placebo; No treatment effects on adiponectin occurred. Fibrinogen increased by 5% vs. placebo with 3.0 mg only (p=0.046).

In conclusion, liraglutide 3.0 mg as an adjunct to diet and exercise caused significant weight loss that was associated with additional benefits for multiple cardiometabolic risk factors compared to liraglutide 1.8 mg and placebo in overweight/obese adults with T2DM.

 

Disclosure: RD: Consultant, Bristol-Myers Squibb, Consultant, Takeda, Consultant, Amylin Pharmaceuticals, Consultant, Novo Nordisk, Consultant, Boehringer Ingelheim, Consultant, Jansen Pharmaceuticals, Consultant, Lexicon Pharmaceuticals, Inc., Researcher, Amylin Pharmaceuticals, Researcher, Takeda, Researcher, Bristol-Myers Squibb, Researcher, Boehringer Ingelheim, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Novo Nordisk. RMB: Medical Advisory Board Member, Abbott Diabetes Care, Researcher, Abbott Diabetes Care, Medical Advisory Board Member, Bayer, Inc., Researcher, Bayer, Inc., Researcher, Becton Dickinson, Medical Advisory Board Member, Boehringer Ingelheim, Researcher, Boehringer Ingelheim, Medical Advisory Board Member, Bristol-Myers Squibb, Medical Advisory Board Member, Calibra, Researcher, Calibra, Medical Advisory Board Member, Eli Lilly & Company, Researcher, Eli Lilly & Company, Medical Advisory Board Member, Halozyme Inc, Researcher, Halozyme Inc, Medical Advisory Board Member, Helmsley Trust, Medical Advisory Board Member, Helmsley Trust, Medical Advisory Board Member, Hygieia, Researcher, Hygieia, Medical Advisory Board Member, Johnson &Johnson, Researcher, Johnson &Johnson, Medical Advisory Board Member, Medtronic Minimed, Researcher, Medtronic Minimed, Researcher, Merck & Co., Medical Advisory Board Member, Novo Nordisk, Researcher, Novo Nordisk, Researcher, ResMed, Researcher, Roche Diagnostics, Medical Advisory Board Member, Roche Diagnostics, Medical Advisory Board Member, Sanofi, Researcher, Sanofi, Medical Advisory Board Member, Takeda, Researcher, Takeda, Medical Advisory Board Member, Valeritas. BWB: Consultant, Novo Nordisk, Researcher, Novo Nordisk, Speaker Bureau Member, Novo Nordisk, Medical Advisory Board Member, Novo Nordisk, Consultant, Eli Lilly & Company, Researcher, Eli Lilly & Company, Speaker Bureau Member, Eli Lilly & Company, Medical Advisory Board Member, Eli Lilly & Company, Consultant, Sanofi, Researcher, Sanofi, Speaker Bureau Member, Sanofi, Medical Advisory Board Member, Sanofi, Researcher, Merck & Co., Speaker Bureau Member, Merck & Co., Speaker Bureau Member, Amylin Pharmaceuticals, Researcher, Johnson &Johnson. RK: Medical Advisory Board Member, Novo Nordisk, Medical Advisory Board Member, Vivus USA, Medical Advisory Board Member, Takeda, Medical Advisory Board Member, Zafgen, Medical Advisory Board Member, Retrofit, Researcher, WeightWatchers, Researcher, Aspire Bariatrics. AJL: Researcher, Pronova Biopharma Norge A/S, Researcher, Phasebio Pharmaceuticals Inc, Researcher, Pfizer, Inc., Researcher, Novo Nordisk, Researcher, Novartis Pharmaceuticals, Researcher, Merck Sharp & Dohme, Researcher, Jansen Pharmaceuticals, Researcher, Isis Pharmaceuticals, Researcher, Gilead Sciences Inc, Researcher, Hoffmann-La Roche, Researcher, Esperion Therapeutics Inc, Researcher, Eli Lilly & Company, Researcher, Elcelyx Therapeutics Inc, Researcher, Catabasis, Researcher, Bristol-Myers Squibb, Researcher, Boehringer Ingelheim, Researcher, Bayer, Inc., Researcher, Barvarian Nordic, Researcher, Amylin Pharmaceuticals, Researcher, Amgen, Researcher, Akros Pharma Inc, Researcher, Sanofi, Researcher, Theracos, Researcher, TransTech Pharma. TVS: Employee, Novo Nordisk, Employee, Novo Nordisk. CBJ: Employee, Novo Nordisk, Employee, Novo Nordisk. MD: Medical Advisory Board Member, Novo Nordisk, Consultant, Novo Nordisk, Researcher, Novo Nordisk, Speaker Bureau Member, Novo Nordisk, Medical Advisory Board Member, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Researcher, Novartis Pharmaceuticals, Speaker Bureau Member, Novartis Pharmaceuticals, Medical Advisory Board Member, Sanofi, Consultant, Sanofi, Stockholder, Sanofi, Speaker Bureau Member, Sanofi, Medical Advisory Board Member, Eli Lilly & Company, Consultant, Eli Lilly & Company, Researcher, Eli Lilly & Company, Speaker Bureau Member, Eli Lilly & Company, Medical Advisory Board Member, Merck Sharp & Dohme, Consultant, Merck Sharp & Dohme, Researcher, Merck Sharp & Dohme, Speaker Bureau Member, Merck Sharp & Dohme, Researcher, Servier, Speaker Bureau Member, Servier, Researcher, GlaxoSmithKline.

12366 7.0000 SAT-0930 A Effects of Liraglutide 3.0 Mg and 1.8 Mg on Body Weight and Cardiometabolic Risk Factors in Overweight and Obese Adults with Type 2 Diabetes Mellitus (T2DM): The Scale Diabetes Randomized, Double-Blind, Placebo-Controlled, 56-Week Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0924-0941 4842 1:00:00 PM Human Obesity: Targets and Therapies Poster

John Wilding1, Arne Astrup2, Ken Fujioka3, Frank Lyons Greenway III4, Alfredo Halpern5, Michel Krempf6, David C Lau7, Carel Le Roux*8, Rafael Violante Ortiz9, Rune Viig Overgaard10, Christine Bjørn Jensen10 and F Xavier Pi-Sunyer11
1University of Liverpool, Liverpool, United Kingdom, 2University of Copenhagen, Frederiksberg C, Denmark, 3Scripps Clinic, La Jolla, CA, 4Pennington Biomed Res Ctr, Baton Rouge, LA, 5Universidade Sao Paulo, Sao Paulo, Brazil, 6Université de Nantes, Nantes, France, 7University of Calgary, Calgary, AB, Canada, 8University College Dublin, Dublin, Ireland, 9Instituto Mexicano del Seguro Social, Cuidad Madero, Tamaulipas, Mexico, 10Novo Nordisk A/S, Søborg, Denmark, 11St Luke's Roosevelt Hosp, New York, NY

 

Obesity is commonly associated with impaired insulin sensitivity and pancreatic beta-cell dysfunction, both of which are implicated in the pathogenesis of type 2 diabetes mellitus (T2DM).  

This trial investigated the effects of liraglutide 3.0 mg, as adjunct to diet and exercise, on weight loss (primary endpoint) and insulin secretion and action in overweight/obese individuals with and without prediabetes at screening.

Adults (BMI ≥27 kg/m2 with ≥1 comorbidity or ≥30 kg/m2) were advised on a 500 kcal/day deficit diet and exercise program and randomized 2:1 to once-daily subcutaneous liraglutide 3.0 mg or placebo. Randomization was stratified by prediabetes status (ADA 2010 criteria) and BMI at screening. Areas under the curve (AUCs) for glucose, insulin and C-peptide during a 75-g 120 min OGTT at week 0 and 56 were estimated (least square [LS] means, full analysis set [FAS] with LOCF), as were indices of insulin secretion (IS, C-peptide deconvolution method), insulin sensitivity (SI, Matsuda index) and beta-cell function (disposition index [DI], IS*SI) (completers, exploratory analyses). Clinicaltrials.gov ID: NCT01272219.

Of 3731 randomized individuals (age 45.1 years, gender 78.5% female, body weight 106.2 kg, BMI 38.3 kg/m2, glycemic status 61.2% with prediabetes), 71.9% with liraglutide 3.0 mg and 64.4% with placebo completed 56 weeks.

At week 56, more weight loss was observed with liraglutide 3.0 mg (˗8.0%) (n=2432) than with placebo (˗2.6%) (n=1220) (estimated treatment difference [ETD] 5.4%, p<0.0001, LSmeans, FAS with LOCF, ANCOVA).

Fasting and post-load glycemia was improved with liraglutide 3.0 mg, as both FPG and glucose AUC were lower with liraglutide 3.0 mg than with placebo (ETD ‑6.9 mg/dL and -36.4 h*mg/dL, respectively; p<0.0001, ANCOVA). Post-load insulin and C-peptide were also improved as AUCs were higher with liraglutide 3.0 mg than with placebo (estimated treatment ratios 1.10 and 1.07, respectively; p<0.0001, ANCOVA on log scale). Improvements applied to individuals both with and without prediabetes, but glucose-lowering was most prominent in individuals with prediabetes (p<0.0001).

Improved post-load glucose with liraglutide 3.0 mg, as compared to placebo, was accompanied by increased IS (11% vs. 1%), increased SI (21% vs. 10%) and improved beta-cell function (35% vs. 11%) (all p<0.0001, ANOVA). Similar effects were seen in individuals both with and without prediabetes.

In conclusion, liraglutide 3.0 mg, as adjunct to diet and exercise, led to weight loss and improvements in insulin secretion and action, all of which likely explain the observed improvements in fasting and post-load glycemia in overweight and obese individuals with and without prediabetes.

 

Disclosure: JW: Advisory Group Member, Astellas, Advisory Group Member, Astra Zeneca, Speaker Bureau Member, Astra Zeneca, Speaker Bureau Member, Boehringer Ingelheim, Advisory Group Member, Bristol-Myers Squibb, Speaker Bureau Member, Bristol-Myers Squibb, Researcher, Bristol-Myers Squibb, Advisory Group Member, Jansen Pharmaceuticals, Speaker Bureau Member, Jansen Pharmaceuticals, Speaker Bureau Member, Eli Lilly & Company, Advisory Group Member, Novo Nordisk, Speaker Bureau Member, Novo Nordisk, Researcher, Novo Nordisk, Speaker Bureau Member, Merck & Co.. AA: Advisory Group Member, BioCare, Advisory Group Member, Pathway Genomics Corp, Advisory Group Member, Vivus USA, Board Member, Dentacom Aps, Shareholder, Dentacom Aps, Consultant, Arena Pharmaceuticals Inc, Consultant, Basic Research , Consultant, Boehringer Ingelheim Pharma GmbH & Co KG, Consultant, Gelesis, Consultant, Gerson Lehrman Group, Consultant, Novo Nordisk, Consultant, S-Biotek, Consultant, Twinlab. KF: Consultant, Eisai, Speaker Bureau Member, Eisai, Consultant, NPS, Speaker Bureau Member, NPS, Consultant, Vivus USA, Speaker Bureau Member, Vivus USA, Consultant, Isis, Consultant, NaZura, Consultant, Novo Nordisk, Consultant, Zafgen, Consultant, Orexigen, Speaker Bureau Member, Abbott Laboratories, Speaker Bureau Member, Takeda, Researcher, Eisai, Researcher, Novo Nordisk, Researcher, NPS, Researcher, Orexigen, Researcher, Enteromedics, Researcher, Shire, Speaker Bureau Member, WeightWatchers. FLG III: Patent holder, Patent holdings, Consultant, Align2Action, Consultant, BARONova, Consultant, Basic Research, Consultant, Citius Pharmaceutical, Editorial Board member, Diabetic Living, Consultant, Eisai, Consultant, General Nutrition Corp, Consultant, Medacorp, Consultant, Guidepoint Global, Consultant, Japan Tobacco Pharmaceutical Division, Medical Advisory Board Member, Jenny Craig, Consultant, Lithera Inc, Patents licencee and stockholder, NeuroQuest, Scientific Board Member, Novo Nordisk, Stockholder, NuMe Health, Scientific Board Member, Orexigen, Stockholder, Origin Biomed, Advisory Group Member, Pam Labs, Stockholder, PlenSat, Consultant, Thetis Pharmaceuticals, Consultant, Unigene Labs, Advisory Group Member, Zafgen, Researcher, Novo Nordisk, Researcher, Hanmi Pharmaceuticals. AH: Advisory Group Member, Novo Nordisk, Speaker Bureau Member, Novo Nordisk. MK: Medical Advisory Board Member, Astra Zeneca, Medical Advisory Board Member, Bristol-Myers Squibb, Medical Advisory Board Member, Novo Nordisk. DCL: Researcher, Astra Zeneca, Researcher, Boehringer Ingelheim, Researcher, Bristol-Myers Squibb, Researcher, Eli Lilly & Company, Researcher, Novo Nordisk, Medical Advisory Board Member, Amgen, Medical Advisory Board Member, Astra Zeneca, Medical Advisory Board Member, Boehringer Ingelheim, Medical Advisory Board Member, Bristol-Myers Squibb, Medical Advisory Board Member, Jansen Pharmaceuticals, Medical Advisory Board Member, Eli Lilly & Company, Medical Advisory Board Member, Novo Nordisk, Medical Advisory Board Member, Roche Pharmaceuticals, Medical Advisory Board Member, Valeant Pharmaceuticals, Speaker Bureau Member, Amgen, Speaker Bureau Member, Astra Zeneca, Speaker Bureau Member, Boehringer Ingelheim, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Eli Lilly & Company, Speaker Bureau Member, Merck & Co., Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Valeant Pharmaceuticals. CL: Medical Advisory Board Member, Novo Nordisk. RV: Medical Advisory Board Member, Merck Sharp & Dohme, Medical Advisory Board Member, Boehringer Ingelheim, Medical Advisory Board Member, Novo Nordisk, Medical Advisory Board Member, Bristol-Myers Squibb, Medical Advisory Board Member, Astra Zeneca, Medical Advisory Board Member, Eli Lilly & Company, Researcher, Eli Lilly & Company, Researcher, Novo Nordisk, Speaker Bureau Member, Merck Sharp & Dohme, Speaker Bureau Member, Boehringer Ingelheim, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Astra Zeneca. RVO: Employee, Novo Nordisk. CBJ: Employee, Novo Nordisk, Employee, Novo Nordisk. FXP: Medical Advisory Board Member, Novo Nordisk, Medical Advisory Board Member, Weight Watchers, Medical Advisory Board Member, Johnson &Johnson, Medical Advisory Board Member, Vivus USA, Medical Advisory Board Member, Zafgen, Medical Advisory Board Member, Eisai.

12468 8.0000 SAT-0931 A Liraglutide 3.0 Mg Improves Insulin Secretion and Action in Overweight and Obese Adults without Diabetes: Results from Scale Obesity and Prediabetes, a Randomized, Double-Blind and Placebo-Controlled 56-Week Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0924-0941 4842 1:00:00 PM Human Obesity: Targets and Therapies Poster

Manassawee Korwutthikulrangsri*, Preamrudee Poomthavorn, Pat Mahachoklertwattana, Suwannee Chanprasertyothin, Patcharin Khlairit and Sarunyu Pongratanakul
Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

 

Fibroblast growth factor 21 (FGF21) has been demonstrated to be involved in glucose metabolism (GluMet). However, the role of FGF21 in humans is yet unclear. Elevated serum FGF21 level was associated with obesity and impaired glucose tolerance. Studies in children are still limited. This study aimed to investigate serum FGF21 in obese children with and without abnormal GluMet and to evaluate dynamic changes of serum FGF21 during an oral glucose tolerance test (OGTT). Two hundred and nine obese children, aged 11.7±2.5 years were enrolled. All children underwent the OGTT with serum glucose and insulin levels measurement. Fasting serum FGF21 levels were measured. Insulin sensitivity and β-cell function indices were calculated from the serum glucose and insulin levels. Fifty out of 209 participants had their serum FGF21 levels serially measured during the OGTT. Out of 209 children, there were 31 (15%), 124 (59%) and 54 (26%) children with normal glucose tolerance (NGT), hyperinsulinemia with normal glucose (HI) and abnormal glucose tolerance (AGT: impaired fasting glucose, impaired glucose tolerance and diabetes), respectively. There was a trend towards increasing in serum FGF21 in children with NGT to HI and AGT [median (IQR): 74 (40-151), 98 (52-183) and 132 (91-224) pg/mL, respectively, P = 0.006]. Greater serum FGF21 level was associated with lower insulin sensitivity (Matsuda index, r = -0.248, P = 0.000; HOMA-IR, r = 0.166, P = 0.017). In addition, serum FGF21 was positively associated with β-cell function index (HOMA-β, r = 0.177, P = 0.010) and areas under the curve of glucose and insulin levels (r = 0.201, P = 0.004 and r = 0.245, P = 0.000, respectively). Dynamic changes of serum FGF21 during the OGTT in the opposite direction of glucose and insulin levels were demonstrated. Median (IQR) serum FGF21 levels were decreased from 114 (56-206) at baseline to 81 (43-165) at 60 min, and then increased to 149 (91-330) pg/mL at 120 min (P = 0.001). The fold change of serum FGF21 over the baseline at 120 min in children with AGT was less than that of children with NGT and HI [1.36 (1.03-1.43) vs 1.71 (1.18-2.12), P = 0.033]. In conclusion, greater basal serum FGF21 was demonstrated in obese children with AGT as compared to those without AGT. On the contrary, the change of serum FGF21 in response to the oral glucose load was less pronounced in children with AGT. Therefore, FGF21 may be one of the regulators of GluMet in obese children.

 

Nothing to Disclose: MK, PP, PM, SC, PK, SP

12925 9.0000 SAT-0932 A Serum Fibroblast Growth Factor 21 in Obese Children and Its Dynamic Changes during an Oral Glucose Challenge 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0924-0941 4842 1:00:00 PM Human Obesity: Targets and Therapies Poster

Dagmar Lallemand-Jander*1, Leonie Maron1, Mila Maeder1 and Esther Kirchhoff2
1Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland, 2Swiss Association of Obesity in Childhood and Adolescence, Aarau, Switzerland

 

Long term efficacy of family-based behavioral therapy for obese children in group programs has been demonstrated by randomized controlled studies, confirming reduction of obesity in 70% of children until 1 year after the end of therapy. Since physical incapacity, psychological co-morbidity or parental occupation hinder obese children in participating in therapy groups, the aim was to examine whether treatment is also effective in improving the health of obese children in a multiprofessional individual setting (MIS).

In a single center prospective longitudinal cohort study, 52 children were treated within nationally certified group programs (MGP: 88 h/12 months of therapy for children and parents, each 1/3 of time by dietician, psychologist and gym instructor) and 96 children in an individual setting (MIS: about 22 h/12 months for children and their parents on a similar multiprofessional basis). At therapy start (T0) and one year thereafter (T2), BMI and psychological and nutritional parameters were assessed by validated, standardized questionnaires (strengths and difficulties, SDQ; adiposity-related eating cognitions and disorders, AD-EVA) and by food frequency lists (FFL).

At T0, physical and psychological parameter in MIS children (11.4±2.9 years; 54% girls; 66% morbidly obese with BMI >99.5thpercentile of WHO references, BMI-standard deviation score (SDS) 2.8±1.1) were not significantly different from MGP patients. Both after MGP and MIS therapy, obesity was significantly reduced (ΔBMI-SDS= -0.19 and -0.33, respectively, p<0.000). Mental health difficulties (in 20.8%), namely emotional problems (in 12.4%), were 2-fold more prevalent in both groups than in a normative sample and scored significantly higher in morbidly obese children compared to less obese ones (p=0.018). At T2, an improvement in total SDQ score was more prominent, the higher the initial score was. In obese children, knowledge on healthy eating was similar to the normative sample. Diet composition was neither associated with BMI nor with therapy outcome. While preclinical eating disorders such as vomiting were rare and even decreased until T2 (p=0.03), scores of emotional eating, craving for food and preoccupation with body shape were more pathological than in the normative sample, but all improved during therapy, mainly craving (p=0.048).

This is the first study to show equal effects of multiprofessional group and individual settings on weight loss and improvement of pathogenic eating habits in obese children, without producing side effects such as eating disorders. The more obese children are, the more attention mental health problems need.

 

Nothing to Disclose: DL, LM, MM, EK

15448 10.0000 SAT-0933 A Beneficial Effects of Family-Based Multiprofessional Therapy on Obesity and Eating Behavior in Children Are Independent on Group or Individual Settings 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0924-0941 4842 1:00:00 PM Human Obesity: Targets and Therapies Poster

Annemarie Rietman*1, Takara L. Stanley2, Clary B. Clish3, Vamsi K Mootha4, Marco Mensink1, Steven K. Grinspoon5 and Hideo Makimura6
1Wageningen University, Wageningen, Netherlands, 2Massachusetts General Hospital and Harvard Medical School, Boston, MA, 3Broad Institute of MIT and Harvard, Cambridge, MA, 4MIT/Broad Inst, Harvard Med Sc, Cambridge, MA, 5Massachusetts General Hospital/Harvard Medical School, Boston, MA, 6Massachusetts General Hospital/ Harvard Medical School, Boston, MA

 

Introduction: Branched chain amino acids (BCAA) are elevated in obesity and are associated with metabolic risk factors [1]. β-aminoisobutyric acid (B-AIBA) is a recently identified small molecule myokine that is inversely associated with cardiometabolic risk [2]. The association of these metabolites with detailed body composition parameters and each other are not known. We hypothesized that BCAA and B-AIBA would be preferentially associated with abdominal visceral adipose tissue (VAT) and inversely to each other.

Methods: Forty-eight normal weight and obese men and women were studied. Subjects underwent abdominal CT scan for VAT and subcutaneous adipose tissue (SAT), DXA scan for total body fat, and a 2-hour oral glucose tolerance test (OGTT). Metabolic profiling was performed using liquid chromatography tandem mass spectrometry for 65 polar metabolites. We performed a targeted statistical analysis to determine the relationship of BCAA and B-AIBA with body composition and metabolic parameters.

Results: Fifteen normal weight (53.3% male; age 44.2±2.5y; BMI 22.6±0.3kg/m2; waist circumference 80.1±2.1cm; mean±SEM) and 33 obese (39.4% male; age 37.8±1.7y; BMI 35.3±0.8kg/m2; waist circumference 110.8±2.0cm; mean ± SEM) subjects were studied. Obese subjects had higher plasma BCAA levels compared to normal weight subjects (p=0.005; t-test). B-AIBA levels tended to be lower in obese subjects (p=0.08; t-test). BCAA were significantly associated with VAT (R=0.49; p=0.0006) and trended to an association with SAT (R=0.29; p=0.06) but was not associated with total body fat percentage (R=0.1; p=0.53). BCAA were related to parameters of insulin sensitivity (IS) including fasting insulin (R=0.48; p=0.0006), HOMA (R=0.48; p=0.00007), HbA1c (R=0.36; p=0.014), insulin AUC (R=0.47; p=0.001) and glucose AUC (R=0.53; p=0.0001). B-AIBA was not associated with BCAA (R=-0.04; p=0.8) but was inversely associated with parameters of IS (fasting insulin: R=-0.38, p=0.008; HOMA: R=-0.38, p=0.009; HbA1c: R=-0.33, p=0.03; insulin AUC: R=-0.32, p=0.03 and glucose AUC: R=-0.3, p=0.04). B-AIBA was also inversely associated with SAT (R=-0.37; p=0.01) and total body fat percentage (R=-0.42; p=0.004) but only trended to an association with VAT (R=-0.27; p=0.07).

Conclusion: BCAA and B-AIBA are both associated with parameters of IS but are not associated with each other. Furthermore, BCAA are more strongly associated with VAT while B-AIBA is more strongly associated with SAT and total body fat.

 

Nothing to Disclose: AR, TLS, CBC, VKM, MM, SKG, HM

14517 11.0000 SAT-0934 A Novel Association Between Branched Chain Amino Acids, ß-Aminoisobutyric Acid and Abdominal Visceral Adiposity: A Metabolomics Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0924-0941 4842 1:00:00 PM Human Obesity: Targets and Therapies Poster

Belinda S Lennerz*1, Christian Denzer1, Friederieke Denzer2, Susanne Lang-Russ2 and Martin Wabitsch3
1Ulm University, Ulm, Germany, 2Ulm University, 3University of Ulm, Ulm, Germany

 

Background: Published retrospective case reports (1) and anecdotal experience suggest a positive effect of Dexamphetamine on impetus and weight in patients with hypothalamic obesity. Based on these observations, patients presenting to our obesity clinic with hypothalamic obesity are offered off-label treatment with dexamphetamine.

Methods: Between 2010 and 2013, patients starting dexamphetamine treatment were enrolled in a prospective observation study. BMI-SDS was determined and impetus was rated on a scale from 1-5 at baseline and every three months. A retrospective chart review was conducted to establish BMI-SDS development prior to treatment initiation. Dexamphetamine administration was initiated at a single dose of 5mg per day, and titrated to effect up to a dose of 20mg / day in 2-3 single doses. Side effects were recorded in a standardized fashion.

Results: 6 Patients, 2 male, 4 female, age 17.5 years on average (range: 14.5-23.8) were included in the study. The primary diagnosis was craniopharyngeoma in 5 patients, and neonatal meningitis in one patient. Time from initial CNS insult to initiation of dexamphetamine treatment was 6.6 years on average (2.7-17.4). All patients demonstrated a steady increase in BMI-SDS from the time of initial diagnosis up until the initiation of treatment. Baseline BMI-SDS was +3.1 (1.9-4.1). After an average treatment duration of 1.6 years (0.2-3.0), all patients experienced a sustained increase in impeto, and a stabilization or reduction in BMI SDS by 0.3 (0-0.8). No significant side effects were reported.

Conclusion: Dexamphetamine lead to improved impeto and stabilization or reduction of BMI SDS in a cohort of 6 patients with hypothalamic obesity. Considering the projected increase in BMI-SDS according the natural course of the disease, these findings are promising and warrant further study. 

This research was funded by the Federal Ministry for Education and Research (BMBF,  01GI1120A) and is integrated in the Competence Network Obesity (CNO).

 

Nothing to Disclose: BSL, CD, FD, SL, MW

17013 12.0000 SAT-0935 A Dexamphetamine Treatment for Hypothalamic Obesity – a Prospective Case Series 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0924-0941 4842 1:00:00 PM Human Obesity: Targets and Therapies Poster

Gabriela López-Moreno*1, Vicente Campos Beltran1, Elva L Perez-Luque2 and Herlinda Aguilar-Zavala1
1Universidad de Guanajuato, Celaya, Mexico, 2Univ de Guanajuato, Leon Guanajuato, Mexico

 

Introduccion. Wnt via signaling regulates adipogenesis and adipocyte function. Secreted frizzled-related proteins (SFRPs) are a family of secreted proteins (SFRP1-5) that bind and inhibit Wnts. In other studies, the SFRP5 has been recently implicated in adipocyte dysfunction in obesity. In obesity-related metabolic disorders serum SFRP5 levels are significantly lower in individuals with hyperglycemia and in overweight and obese subjects. Circulating SFRP5 levels correlated with markers of adiposity like as body mass index, waist-to-hip ratio, percent body fat.

Objective. To compare the circulating SFRP5 levels in normal weight subjects and obese subjects and its relationship with anthropometric and metabolic measures.

Material and methods. We selected 74 normal weight subjects and 80 obese subjects without chronic, infectious or degenerative disease. We made Anthropometric measures and a blood samples were taken of each individual for determinate fasting glucose, lipid profile, serum insulin, adiponectin, and SFRP5 which were measured by RIA and ELISA methods respectively. The IR was calculates by HOMA model. For comparison we used t student test and Spearman Rank correlation.

Results. In obese subjects, the circulating SFRP5 levels are significantly lower (54 vs 38.6 pg/ml p<0.01), but fasting glucose (94 vs 86 mg/dl, p<0.001), fasting insulin (13.2 vs 6.0 μUI/ml, p<0.00001), HOMA IR (3.1 vs 1.2, p<0.00001) and creatinine (0.89 vs 0.80 mg/dl, p<0.003) were significantly high than normal weight subjects. Circulating SFRP5 levels are negatively correlated with fasting glucose levels (R =-0.24, p<0.002), HOMA IR (R=-0.45, p<0.001) BMI (R=-0.31, p<0.001), WHR (R=-0.30, p<0.001) and percent body fat (R=-0.23, p<0.003). The circulating adiponectin levels positively correlates with SFRP5 levels (R= 0.64, p<0.001).

Conclusion. Circulating SFRP5 levels were decreased in obese subjects. The strong correlation of SFRP5 protein with adiponectin levels suggestion un role anti-inflammatory

 

Nothing to Disclose: GL, VCB, ELP, HA

17077 13.0000 SAT-0936 A Comparison of the Circulating SFRP5 Levels Between Normal Weight and Obese Subjects and Its Relationship with Anthropometric and Metabolic Measures 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0924-0941 4842 1:00:00 PM Human Obesity: Targets and Therapies Poster

Carel W Le Roux*1, Arne Astrup2, Ken Fujioka3, Frank Lyons Greenway III4, Alfredo Halpern5, Michel Krempf6, David C Lau7, Rafael Violante Ortiz8, John Wilding9, Christine Bjørn Jensen10 and F Xavier Pi-Sunyer11
1University College Dublin, Dublin, Ireland, 2University of Copenhagen, Frederiksberg C, Denmark, 3Scripps Clinic, La Jolla, CA, 4Pennington Biomed Res Ctr, Baton Rouge, LA, 5Universidade Sao Paulo, Sao Paulo, Brazil, 6Université de Nantes, Nantes, France, 7University of Calgary, Calgary, AB, Canada, 8Instituto Mexicano del Seguro Social, Cuidad Madero, Tamaulipas, Mexico, 9University of Liverpool, Liverpool, United Kingdom, 10Novo Nordisk A/S, Søborg, Denmark, 11St Luke's Roosevelt Hosp, New York, NY

 

Obesity is a chronic disease associated with multiple progressive comorbidities including hypertension, dyslipidemia, type 2 diabetes and atherosclerosis. A 5-10% weight loss has been shown to improve weight-related comorbidities. This phase 3 trial investigated the effects of liraglutide 3.0 mg, as adjunct to diet and exercise, on weight loss (primary endpoint) and cardiometabolic risk factors (waist circumference, blood pressure, triglycerides, HDL cholesterol and other biomarkers).

Individuals (BMI ≥27 kg/m2 with ≥1 comorbidity or ≥30 kg/m2) were advised on a 500 kcal/day deficit diet and exercise program and randomized 2:1 to once daily sc liraglutide 3.0 mg (n=2487) or placebo (n=1244). Randomization was stratified by prediabetes status (ADA 2010) and BMI. Data are shown for the full analysis set (exposed individuals with ≥1 post-baseline assessment) with LOCF. The trial has an ongoing 2-year extension for participants with prediabetes. Clinicaltrials.gov ID: NCT01272219.

Baseline characteristics were: age 45.1 years, 78.5% female, body weight 106.2 kg, BMI 38.3 kg/m2, 61.2% with prediabetes). At week 56, individuals treated with liraglutide 3.0 mg (n=2437) achieved more weight loss (8.0%, least square mean) than those treated with placebo (n=1225; 2.6%) (estimated treatment difference [ETD] -5.4% [95%CI ‑5.8; -5.0]; p<0.0001). Weight loss was accompanied by reductions in mean waist circumference (ETD ‑4.2 [-4.7; -3.7] cm), systolic BP (ETD -2.8 [‑3.6; -2.1] mmHg) and diastolic BP (ETD ‑0.9 [-1.4; -0.4] mmHg) for liraglutide vs placebo (all p<0.001). Mean pulse was increased at week 56 with liraglutide 3.0 mg vs placebo (ETD 2.5 [1.9; 3.0] beats/min, p<0.0001). Improvements in all fasting lipids were seen with liraglutide 3.0 mg vs placebo: triglycerides (ETD -9% [-12; -7]), total cholesterol (-2% [‑3; ‑1]), VLDL cholesterol (-9% [‑11; -7]) (all p<0.0001); LDL cholesterol (-2% [-4; -1]) and HDL cholesterol (+2% [1; 3]) (both p<0.01); and free fatty acids (-4% [-7; -1]) (p<0.05). Improvements in concentrations of high-sensitivity C-reactive protein (ETD -30% [‑34; ‑26]), plasminogen activator inhibitor-1 (-21% [-26; -17]) and adiponectin (+8% [5; 12]) (all p<0.0001) were also observed with liraglutide 3.0 mg vs placebo. No treatment effects on fibrinogen or urinary albumin:creatinine ratio were seen. Liraglutide led to a greater reduction in net use of anti-hypertensive (odds ratio [OR] 1.7, p<0.0001) and lipid-lowering (OR 1.5, p=0.02) medications, while maintaining greater beneficial effects on BP and lipids at week 56 compared to placebo.

In conclusion, weight loss with liraglutide 3.0 mg, as adjunct to diet and exercise, produced improvements in a wide range of cardiometabolic risk factors, including inflammatory markers, in overweight or obese individuals, which if sustained in the long term may be associated with reduced cardiovascular events.

 

Disclosure: CWL: Medical Advisory Board Member, Novo Nordisk. AA: Advisory Group Member, BioCare, Advisory Group Member, Pathway Genomics Corp, Advisory Group Member, Vivus USA, Board Member, Dentacom Aps, Shareholder, Dentacom Aps, Consultant, Arena Pharmaceuticals Inc, Consultant, Basic Research , Consultant, Boehringer Ingelheim Pharma GmbH & Co KG, Consultant, Gelesis, Consultant, Gerson Lehrman Group, Consultant, Novo Nordisk, Consultant, S-Biotek, Consultant, Twinlab. KF: Consultant, Eisai, Speaker Bureau Member, Eisai, Consultant, NPS, Speaker Bureau Member, NPS, Consultant, Vivus USA, Speaker Bureau Member, Vivus USA, Consultant, Isis, Consultant, NaZura, Consultant, Novo Nordisk, Consultant, Zafgen, Consultant, Orexigen, Speaker Bureau Member, Abbott Laboratories, Speaker Bureau Member, Takeda, Researcher, Eisai, Researcher, Novo Nordisk, Researcher, NPS, Researcher, Orexigen, Researcher, Enteromedics, Researcher, Shire, Speaker Bureau Member, WeightWatchers. FLG III: Patent holder, Patent holdings, Consultant, Align2Action, Consultant, BARONova, Consultant, Basic Research, Consultant, Citius Pharmaceutical, Editorial Board member, Diabetic Living, Consultant, Eisai, Consultant, General Nutrition Corp, Consultant, Medacorp, Consultant, Guidepoint Global, Consultant, Japan Tobacco Pharmaceutical Division, Medical Advisory Board Member, Jenny Craig, Consultant, Lithera Inc, Patents licencee and stockholder, NeuroQuest, Scientific Board Member, Novo Nordisk, Stockholder, NuMe Health, Scientific Board Member, Orexigen, Stockholder, Origin Biomed, Advisory Group Member, Pam Labs, Stockholder, PlenSat, Consultant, Thetis Pharmaceuticals, Consultant, Unigene Labs, Advisory Group Member, Zafgen, Researcher, Novo Nordisk, Researcher, Hanmi Pharmaceuticals. AH: Advisory Group Member, Novo Nordisk, Speaker Bureau Member, Novo Nordisk. MK: Medical Advisory Board Member, Astra Zeneca, Medical Advisory Board Member, Bristol-Myers Squibb, Medical Advisory Board Member, Novo Nordisk. DCL: Researcher, Astra Zeneca, Researcher, Boehringer Ingelheim, Researcher, Bristol-Myers Squibb, Researcher, Eli Lilly & Company, Researcher, Novo Nordisk, Medical Advisory Board Member, Amgen, Medical Advisory Board Member, Astra Zeneca, Medical Advisory Board Member, Boehringer Ingelheim, Medical Advisory Board Member, Bristol-Myers Squibb, Medical Advisory Board Member, Jansen Pharmaceuticals, Medical Advisory Board Member, Eli Lilly & Company, Medical Advisory Board Member, Novo Nordisk, Medical Advisory Board Member, Roche Pharmaceuticals, Medical Advisory Board Member, Valeant Pharmaceuticals, Speaker Bureau Member, Amgen, Speaker Bureau Member, Astra Zeneca, Speaker Bureau Member, Boehringer Ingelheim, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Eli Lilly & Company, Speaker Bureau Member, Merck & Co., Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Valeant Pharmaceuticals. RV: Medical Advisory Board Member, Merck Sharp & Dohme, Medical Advisory Board Member, Boehringer Ingelheim, Medical Advisory Board Member, Novo Nordisk, Medical Advisory Board Member, Bristol-Myers Squibb, Medical Advisory Board Member, Astra Zeneca, Medical Advisory Board Member, Eli Lilly & Company, Researcher, Eli Lilly & Company, Researcher, Novo Nordisk, Speaker Bureau Member, Merck Sharp & Dohme, Speaker Bureau Member, Boehringer Ingelheim, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Astra Zeneca. JW: Advisory Group Member, Astellas, Advisory Group Member, Astra Zeneca, Speaker Bureau Member, Astra Zeneca, Speaker Bureau Member, Boehringer Ingelheim, Advisory Group Member, Bristol-Myers Squibb, Speaker Bureau Member, Bristol-Myers Squibb, Researcher, Bristol-Myers Squibb, Advisory Group Member, Jansen Pharmaceuticals, Speaker Bureau Member, Jansen Pharmaceuticals, Speaker Bureau Member, Eli Lilly & Company, Advisory Group Member, Novo Nordisk, Speaker Bureau Member, Novo Nordisk, Researcher, Novo Nordisk, Speaker Bureau Member, Merck & Co.. CBJ: Employee, Novo Nordisk, Employee, Novo Nordisk. FXP: Medical Advisory Board Member, Novo Nordisk, Medical Advisory Board Member, Weight Watchers, Medical Advisory Board Member, Johnson &Johnson, Medical Advisory Board Member, Vivus USA, Medical Advisory Board Member, Zafgen, Medical Advisory Board Member, Eisai.

12500 14.0000 SAT-0937 A Liraglutide 3.0 Mg Improves Body Weight and Cardiometabolic Risk Factors in Overweight or Obese Adults without Diabetes: The Scale Obesity and Prediabetes Randomized, Double-Blind, Placebo-Controlled 56-Week Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0924-0941 4842 1:00:00 PM Human Obesity: Targets and Therapies Poster

Mopelola Adetola Adeyemo*1, Jennifer R. McDuffie2, Sheila M Brady3, Tania Andrea Condarco2, Rubi Maricela Garcia1, Van S Hubbard4 and Jack A Yanovski1
1NIH, Bethesda, MD, 2NICHD/NIH, Bethesda, MD, 3Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 4National Institute of Diabetes and Digestive and Kidney Diseases/NIH, Bethesda, MD

 

Background: Previous studies have reported that obese patients prefer high-fat foods more than normal-weight patients.1,2 Several studies have shown that orlistat reduces weight and thus obesity-associated comorbid conditions amongst obese adolescents and adults.3,4 Since orlistat produces gastrointestinal symptoms after consumption of high-fat meals, it could theoretically cause development of a conditioned taste aversion in response to the taste of fat, which might assist in decreasing dietary fat intake.5 However, no studies have investigated if orlistat may influence perception of the sensory properties of fat and thus fat liking.

Methods: We conducted a randomized double-blind placebo-controlled trial in 200 obese (BMI: 41.5 ± 0.7) adolescents aged 6-12 years randomized to 120 mg orlistat three times daily (n=100) or placebo (n=100) for 6 months. Participants were presented with 5 chocolate milks and 5 puddings that varied in fat content (0, 2, 3.5, 8, and 16%) twice in random order at baseline and after 6mo orlistat or placebo. Participants rated their perception of sweetness and creaminess of these foods on a 100-mm visual analog scale.  Fat mass was measured by DEXA. We used ANCOVA to assess the relationship between change in taste preference ratings and orlistat. Covariates included change in fat weight, socioeconomic status, sex, age, and race.

Results: The orlistat group had a significant decrease in fat mass (-3.2 kg ± 0.1, p=0.008) compared to the placebo group after 6mo treatment (-1.7 kg ± 0.1 p=0.1) and 83% of the orlistat-treated group reported having oily stools. Baseline and 6mo taste ratings were available for 145 participants (71 orlistat-treated, 74 placebo-treated). After correction for multiple comparisons, there were no significant differences in change of perceived sweetness or creaminess ratings by drug treatment. Independent of drug treatment group, greater reduction in fat mass from baseline was associated with a greater reduction in ratings of milk chocolate creaminess at 0% fat (p=0.03). Cumulatively and at 2, 3.5, and 16% fat content, age was inversely associated with change in ratings of chocolate sweetness (all p<0.04). Similarly, age was inversely associated with change in ratings of pudding sweetness overall (p=0.02). The same association was found between age and pudding creaminess overall (p=0.004) and at 2, 3.5, and 8% fat content (all p<0.01). Lower socioeconomic status was associated with a greater reduction in preference ratings of chocolate creaminess at 2% fat content (p=0.005) and both chocolate (p=0.03) and pudding sweetness at 0% fat content (p=0.02). 

Conclusion

We found no evidence that 6mo treatment with orlistat decreases perception of properties of fat and thus liking for fat. However this study found 6-month changes in fat ratings were influenced by age, weight loss, and socioeconomic factors.  

 

 

Nothing to Disclose: MAA, JRM, SMB, TAC, RMG, VSH, JAY

13107 15.0000 SAT-0938 A Effect of Orlistat on Ratings of Fat-Containing Foods Among Obese Adolescents 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0924-0941 4842 1:00:00 PM Human Obesity: Targets and Therapies Poster

Aksam A Yassin*1, Ahmad Haider2, Gheorghe Doros3, Abdulmaged M Traish4 and Farid Saad5
1Institute of Urology and Andrology, Norderstedt, Germany, 2Private Urology Practice, Bremerhaven, Germany, 3Boston University School of Public Health, Boston, MA, 4Boston Univ Sch of Med, Boston, MA, 5Bayer Pharma AG, Berlin, Germany

 

Introduction: Improvements of anthropometric parameters on long-term testosterone replacement therapy (TRT) from our registry studies have been reported in 2013 (Saad, Obes 2013; 21(10): 1975-1981; Yassin and Doros, Clin Obes 2013; 3(3-4): 73-83). Here, we report updated information on a longer treatment duration and subgroup analyses according to age groups. 

Methods: 561 hypogonadal men from both registry studies were divided into age groups ≤65 (Group A, n=450; minimum: 32, maximum: 65 years) and >65 years (Group B, n=111; mimimum: 66, maximum: 84 years). Following an initial 6-week interval, all men were treated with three-monthly TU injections for up to 6 years.

Results: Mean weight (kg) decreased from 102.52±15.56 to 90.15±9.69 in Group A and from 102.83±15.64 to 95.35±9.03 in Group B. Model-adjusted mean change from baseline was -14.78±0.35 and -15.14±0.71 kg, resp. Changes in weight were statistically significant each year compared to the previous year in both groups. 

The mean percent change from baseline was -13.56±7.56% in Group A and -13.28±7.14% in Group B. This change was statistically significant each year compared to the previous year (p<0.0001) in both groups. 

Waist circumference (cm) decreased from 106.54±9.03 to 98.26±7.1 in Group A and from 108.95±10.75 to 100.72±9.45 in Group B. The mean change from baseline was 9.34±0.2 cm in Group A and 10.45±0.47 cm in Group B. Changes in waist circumference were statistically significant each year compared to the previous year in both groups. 

Body mass index (BMI; kg/m2) decreased from 32.58±5.08 to 29.02±3.01 in Group A and from 32.84±4.86 to 30.35±2.61 in Group B. The mean change from baseline was -4.72±0.11 and -4.81±0.22 kg/m2, respectively (p<0.0001 for all). Changes in BMI were statistically significant each year compared to the previous year in both groups.

Conclusions: TRT in hypogonadal men resulted in meaningful and sustained weight loss and reductions of waist circumference and BMI independent of age.

 

Disclosure: AAY: Speaker, Ferring Pharmaceuticals, Speaker, Bayer Schering Pharma. AH: Speaker, Bayer Schering Pharma, Speaker, Takeda. GD: Coinvestigator, Bayer Schering Pharma. FS: Employee, Bayer Schering Pharma. Nothing to Disclose: AMT

13209 16.0000 SAT-0939 A Meaningful and Sustained Improvements of Weight and Waist Circumference in Hypogonadal Men on Long-Term Treatment with Testosterone Undecanoate (TU) Injections Are Independent of Age: Observational Data from Two Registry Studies 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0924-0941 4842 1:00:00 PM Human Obesity: Targets and Therapies Poster

Ahmad Haider*1, Aksam A Yassin2, Gheorghe Doros3, Abdulmaged M Traish4 and Farid Saad5
1Private Urology Practice, Bremerhaven, Germany, 2Institute of Urology and Andrology, Norderstedt, Germany, 3Boston University School of Public Health, Boston, MA, 4Boston University School of Medicine, Boston, MA, 5Bayer Pharma AG, Berlin, Germany

 

Introduction: Inverse associations between testosterone and obesity are well established. Obesity has a greater impact on the decline of testosterone with advancing age than age itself. 

Methods: From two prospective, cumulative registry studies of 561 hypogonadal men, 362 men with obesity grade I (BMI 30-34.9), grade II (BMI 35-39.9) and grade III (BMI ≥ 40 kg/m2) were selected. All men received TU injections for up to 6 years. Measures were taken at each three-monthly visit. 

Results:

Grade I (n=185, mean age: 58.4±8.0 years): Weight (kg) decreased from 101.88±6.2 to 89.34±6.7. Changes were statistically significant for all six years vs. previous year. Change from baseline was -12.55±0.44 kg, percent change from baseline -12.28±0.44%. Waist circumference (WC; cm) decreased from 107.07±7.57 to 97.09±6.95. Changes were statistically significant for five years vs. previous year and approached significance at the end of six vs. five years. Mean change from baseline was -9.24±0.3 cm. BMI (kg/m2) decreased from 32.51±1.39 to 28.63±1.92, mean change from baseline -3.99±0.14 kg/m2.  

Grade II (n=131, mean age: 60.6±5.6 years): Weight (kg) decreased from 117.02±6.99 to 96.78±7.47. Changes were statistically significant for all six years vs. previous year. Change from baseline was -20.67±0.51 kg, percent change from baseline -17.66±0.43%. WC (cm) decreased from 114.23±7.51 to 102.52±6.5. Changes were statistically significant for all six years vs. previous year. Mean change from baseline was -12.29±0.33 cm. BMI (kg/m2) decreased from 37.39±1.46 to 31.05±2.02, mean change from baseline -6.58±0.16 kg/m2.  

Grade III (n=46, mean age: 60.3±5.4 years): Weight (kg) decreased from 129.02±5.67 to 103.33±4.17. Changes were statistically significant for all six years vs. previous year. Change from baseline -27.15±0.74 kg, percent change from baseline -20.83±0.54%. WC (cm) decreased from 118.41±5.69 to 106.48±4.91. Changes were statistically significant for all six years vs. previous year. Mean change from baseline was -12.44±0.36 cm. BMI (kg/m2) decreased from 41.93±1.5 to 33.62±1.58, mean change from baseline -8.79±0.23 kg/m2.  

Conclusions: All changes were more pronounced with increasing obesity grade. All changes were in a clinically meaningful magnitude and sustainable for the full observation period. TRT seems to be an effective approach to achieve sustained weight loss in obese hypogonadal men, thereby potentially reducing cardiometabolic risk.

 

Disclosure: AH: Speaker, Bayer Schering Pharma, Speaker, Takeda. AAY: Speaker, Bayer Schering Pharma, Speaker, Ferring Pharmaceuticals. GD: Coinvestigator, Bayer Schering Pharma. FS: Employee, Bayer Schering Pharma. Nothing to Disclose: AMT

13211 17.0000 SAT-0940 A Reductions of Weight and Waist Size in 362 Hypogonadal Men with Obesity Grades I to III Under Long-Term Treatment with Testosterone Undecanoate (TU): Observational Data from Two Registry Studies 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0924-0941 4842 1:00:00 PM Human Obesity: Targets and Therapies Poster

Farid Saad*1, Ahmad Haider2, Aksam A Yassin3, Gheorghe Doros4 and Abdulmaged M Traish5
1Bayer Pharma AG, Berlin, Germany, 2Private Urology Practice, Bremerhaven, Germany, 3Institute of Urology and Andrology, Norderstedt, Germany, 4Boston University School of Public Health, Boston, MA, 5Boston University School of Medicine, Boston, MA

 

Introduction: There is a robust inverse association between testosterone and obesity. Testosterone replacement therapy (TRT) in excessively obese hypogonadal men has not yet been studied. 

Methods: From two cumulative, prospective, registry studies of 561 hypogonadal men (total testosterone ≤ 12.1 nmol/L plus symptoms of testosterone deficiency), 46 men with obesity grade III (BMI ≥ 40 kg/m2) were selected. Their mean age was 60.28±5.39 years. They received parenteral TU 1000 mg/12 weeks for up to 6 years.  

Results: Mean weight (kg) decreased from 129.02±5.67 (minimum: 119, maximum: 141) to 103.33±4.17 (minimum: 96, maximum: 112). This decrease was statistically significant vs baseline (p<0.0001) and each year compared to previous year (p<0.0001). Mean change from baseline was
-27.15±0.74 kg. The magnitude of weight loss was dependent on treatment duration: the longer the treatment, the greater the weight loss. Minimum weight loss was 5 kg in a subject who had received 15 months of treatment, maximum weight loss of 41 kg was observed in a man who had been treated for 69 months. No subject gained weight. 

Percent change from baseline was -2.73±0.45% after one year, -7.26±0.44% after two, -10.86±0.45% after three, -14.1±0.47% after four, -17.43±0.48% after five, and -20.83±0.54% (minimum: -15.73%, maximum: -28.06%) after six years. 

Waist circumference (cm) decreased from 118.41±5.69 (minimum: 105, maximum: 132) to 106.48±4.91 (minimum: 95, maximum: 116). This decrease was statistically significant vs baseline (p<0.0001) and each year compared to previous year (p<0.0001) with the exception of year 6 which had a p-value of 0.0132 vs year 5. The mean change from baseline was 12.44±0.36 cm. The greatest reductions of 19 cm each were observed in two men who had been treated for 69 and 72 months, resp. 

Body mass index (BMI; kg/m2) decreased from 41.93±1.5 (minimum: 40.08, maximum: 46.51) to 33.62±1.58 (minimum: 30.52, maximum: 36.08). The mean change from baseline was 8.79±0.23 kg/m2.

There were no drop-outs. 

Conclusions: All anthropometric changes were progressive and remained statistically significant each year compared to previous year for the full observation period. TRT seems to be an effective approach to achieve sustained weight loss in excessively obese hypogonadal men.

Patients with a BMI ≥ 40 are candidates for metabolic surgery. In hypogonadal men with excessive obesity, TRT may provide a non-invasive alternative.

 

Disclosure: FS: Employee, Bayer Schering Pharma. AH: Speaker, Bayer Schering Pharma, Speaker, Takeda. AAY: Speaker, Bayer Schering Pharma, Speaker, Ferring Pharmaceuticals. GD: Coinvestigator, Bayer Schering Pharma. Nothing to Disclose: AMT

13216 18.0000 SAT-0941 A Excessively Obese Hypogonadal Experience Substantial and Sustained Weight Loss upon Long-Term Treatment with Testosterone Undecanoate (TU) Injections: Observational Data from Two Registry Studies 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0924-0941 4842 1:00:00 PM Human Obesity: Targets and Therapies Poster

Reeti Chawla*1, Loren Lynette Armstrong2, Janani Rangarajan2, Denise Scholtens2, M. Geoffrey Hayes3 and William L. Lowe Jr.2
1Ann and Robert H. Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL, 2Feinberg School of Medicine, Northwestern University, Chicago, IL, 3Northwestern University, Feinberg School of Medicine, Chicago, IL

 

Sex differences in adiposity and fat distribution are present throughout childhood with female newborns exhibiting greater subcutaneous truncal fat compared to males. Sex-specific associations of obesity variants have been identified in adults and may also be present at other times during development.  To address this, we used genome-wide association data from newborns in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study which examined associations of glucose tolerance during pregnancy with risk of adverse pregnancy outcomes.  We previously demonstrated that loci associated with adult obesity influence newborn adiposity, but genome-wide analyses among HAPO newborns failed to identify sex-specific loci that demonstrated a genome-wide significant association with birthweight (BW) or newborn sum of skinfolds (SS).  Therefore, we determined whether established adult obesity variants or known BW loci exhibit sex-specific associations among HAPO newborns.  Single nucleotide polymorphisms (SNPs) in 47 genomic regions previously showing genome-wide association with adult obesity or BW were identified. After adjustment for ancestry, gender, gestational age at delivery, parity, maternal age, body mass index, height, blood pressure, smoking status and alcohol intake, genotyped and imputed SNPs were tested for association with BW and SS among an approximately equally distributed cohort of male and female HAPO newborns [1095 Afro-Caribbean (AC), 1363 Northern European (EU), 616 Mexican American (MA), and 1207 Thai (TH)].  After trimming for linkage disequilibrium (r2>0.5, D’=1), separately in each ancestry group, we identified 37 independent SNPs in 19 genomic regions and 33 independent SNPs in 13 genomic regions associated with BW among females and males respectively (p<0.001). 45 independent SNPs in 17 genomic regions and 21 independent SNPs in 13 genomic regions were associated with SS among females and males respectively (p<0.001). Meta-analyses identified 26 independent SNPs significantly associated with BW or SS among females and 15 independent SNPs associated with BW or SS among males (p<0.001). All of these regions were identified in our original analyses and demonstrated association in both sexes, with the exception of SNPs in RBJ/POMC/ADCY3.  SNPs in this genomic region were more highly associated with BW among AC, EU, and MA females, with similar association between sexes in TH newborns. SNPs in this region were also more highly associated with newborn SS among AC and MA females, with similar association between sexes among EU and TH newborns.  Our data suggest that variants in adult obesity loci or known birthweight loci exhibit evidence for association with newborn adiposity among HAPO newborns, but that these associations are not sex-specific.  One possible exception is the genomic region RBJ/POMC/ADCY3 which may influence newborn adiposity primarily in females.

 

Nothing to Disclose: RC, LLA, JR, DS, MGH, WLL Jr.

12520 1.0000 SAT-0897 A Genes Previously Demonstrating Association with Adult Obesity and Birthweight Have Few Sex-Specific Associations with Newborn Adiposity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Daniel Li Tu Chen*1, Dorit Samocha-Bonet1, Carsten Liess2, Anne Poljak3, Aimin Xu4, J Zhang4, Christian Thoma5, Mike Trenell5, Brad Milner6, Arthur Jenkins7, Don Chisholm1 and Jerry R Greenfield8
1Garvan Institute of Medical Research, Sydney, Australia, 2Philips Healthcare, Hamberg, Germany, 3University of New South Wales, Sydney, Australia, 4University of Hong Kong, Hong Kong, Hong Kong, 5Newcastle University, Newcastle, United Kingdom, 6St Vincent's Hospital, Sydney, Australia, 7University of Wollongong, Wollongong, Australia, 8Garvan Institute of Medical Research, Darlinghurst, Australia

 

Background: While insulin resistance and obesity coexist, 30% of obese individuals remain insulin-sensitive.  The importance of liver vs visceral fat in determining the site(s) of insulin resistance remains controversial. We undertook a study to examine the relationship between liver and visceral fat and liver and muscle insulin resistance.

Methods: Sixty-four obese subjects aged 50±11 years were studied. Two-step (15 and 80 mU/m2/min) hyperinsulinemic-euglycemic clamps were performed with deuterated glucose.  Subjects in the top tertile of glucose infusion rate (GIR) during the high-dose clamp (indicating muscle insulin sensitivity) were deemed Musclesen; the bottom two tertiles were deemed Muscleres. Subjects in top tertile of percent endogenous glucose production (EGP) suppression were deemed Liversen; those in the bottom two tertiles were deemed Liverres. Body composition and visceral/liver fat were measured by DXA and MRI, respectively.

Results: BMI was similar in the MusclesenLiversen, MusclesenLiverres, MuscleresLiversen and MuscleresLiverres groups (35±1; 36.5±1.8; 35.6±1.6; 36.9±0.8 kg/m2, respectively; P=0.61). MuscleresLiverres had higher systolic blood pressure than MusclesenLiverres (130±3 vs. 112±2 mmHg; P=0.007) and higher HbA1c than MusclesenLiversen (5.6± 0.1 vs 5.1± 0.1%; P<0.001). Subjects with dual site insulin resistance (MuscleresLiverres) had greater amounts of visceral fat (306±15 cm2 P=0.001) than subjects with single site insulin resistance (MuscleresLiversen 233±13cm2; MusclesenLiverres, 209±7cm2) and dual site insulin-sensitivity (MusclesenLiversen 222±17cm2). MuscleresLiverres had higher liver fat than MusclesenLiverres, (18.6±2.2 vs. 6.1±2.5%; P=0.02) and MusclesenLiversen (5.2±1.2% MusclesenLiversen, P=0.001). In the total cohort, liver fat was significantly associated with EGP suppression (r= -0.4, P=0.002) and GIR at the high dose insulin clamp (r= -0.69, P<0.001).

Conclusions: Not all obese humans are insulin-resistant. Insulin resistance in both muscle and liver is associated with the worst metabolic profiles and is characterized by elevated visceral and liver fat. Future clinical models that involve metabolic phenotyping could allow clinicians to identify ‘dual insulin-resistant’ obese individuals, in order to instigate more intensive, and pathogenesis-targeted, interventions to reduce obesity-related complications.

 

 

Disclosure: DLTC: Speaker, Astra Zeneca. Nothing to Disclose: DS, CL, AP, AX, JZ, CT, MT, BM, AJ, DC, JRG

13464 2.0000 SAT-0898 A Dual Insulin Resistance in Muscle and Liver, but Not a Single Site, Is Associated with Visceral and Liver Lipid Accumulation in Obesity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Rachel K Crowley*1, Beverly Hughes2, Joanna Gray3, Theresa McCarthy3, Susan Hughes4, Cedric H Shackleton4, Nicola Crabtree4, Peter Nightingale3, Paul M Stewart4 and Jeremy W Tomlinson4
1Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, United Kingdom, 2Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, UK, 3Queen Elizabeth Hospital, Birmingham, United Kingdom, 4University of Birmingham, Birmingham, United Kingdom

 

Dysregulation of enzymes that control local tissue steroid metabolism has been implicated in the pathogenesis of obesity and insulin resistance, however longitudinal changes in glucocorticoid metabolism have not been investigated. In order to evaluate the role of glucocorticoid metabolism in development of insulin resistance and obesity, and to identify biomarkers for future development of metabolic disease, we conducted a prospective longitudinal observational study over 5 years of 57 obese and overweight individuals with no prior diagnosis of diabetes mellitus.

The participants underwent yearly oral glucose tolerance tests and 24 hour urine collection for measurement of glucocorticoid metabolites. Abnormal glucose tolerance was defined using the criteria for diagnosis of diabetes mellitus, impaired fasting glucose and impaired glucose tolerance established by the American Diabetes Association. The Homeostasis Model Assessment (HOMA2IR) was used to measure insulin sensitivity. Activity of 5α-reductase was defined by the ratio of 5α-tetrahydrocortisol (5αTHF) to tetrahydrocortisol (THF), and of 11β-hydroxysteroid dehydrogenase type 1 by the ratio of 5αTHF+THF to tetrahydrocortisone (THE).

Higher 5α-reductase activity, but not 11β-hydroxysteroid dehydrogenase type 1 activity, was predictive of increased fasting insulin at final visit (11.4 compared to 7.4 mU/L in subjects with lower 5α-reductase activity, p<0.05), area under the curve insulin response to oral glucose tolerance test (176.7 compared to 89.1mU/L.h, p<0.01) and HOMA2-IR (1.3 compared to 0.8, p<0.01). Higher total glucocorticoid production was associated with abnormal glucose tolerance and increased body mass index. A change from normal glucose tolerance to abnormal glucose tolerance over the course of the study could not be predicted by any steroid parameter.

Increased 5a-reductase activity and glucocorticoid secretion rate over time are linked to the development of metabolic disease, and may represent targets for therapeutic intervention, which merits further study.

 

Nothing to Disclose: RKC, BH, JG, TM, SH, CHS, NC, PN, PMS, JWT

16784 3.0000 SAT-0899 A Longitudinal Changes in Glucocorticoid Metabolism Are Associated with Later Development of Adverse Metabolic Phenotype 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Thomas Reinehr*1, Alexandra Kulle2, Barbara Wolters3, Caroline Knop4, Nina Lass4, Maik Welzel2 and Paul-Martin Holterhus5
1University of Witten-Herdecke, Datteln, Germany, 2: Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University Hospital of Schleswig – Holstein, Campus Kiel / Christian – Albrechts University of Kiel, Kiel, Germany, 3University of Witten/Herdecke, Datteln, 4Vestische Youth Hospital, 5Univ Hosp Schleswig-Holstein, Kiel, Germany

 

Background: Clinical features of Metabolic Syndrome (MetS) and Cushing´s Syndrome (CS) are similar suggesting a pathogenetic role of hypothalamus-pituitary-adrenal axis (HPA) in MetS. However, prior research has identified controversial results and studies in children are scarce.

Objective: The aim of the study was to determine whether MetS diagnosis and specific clusters of MetS components (waist circumference, dyslipidemia, hypertension, impaired glucose metabolism) are associated with serum cortisol (SC) or free cortisol levels in 24h urine (UFC).

Methods: We examined cortisol levels (SC and UFC) and features of the MetS (waist circumference, blood pressure, fasting lipids, glucose, insulin) in 264 obese children (mean age 11.0±2.8 years, 48% male, mean BMI 28.2±5.4 kg/m²) without CS. CS was excluded by low dose dexamethasone test.

Results: Slightly increased UFC concentrations were measured in 30.7% of the children (>27 µg/ day < 11 years >55 µg/ day > 11 years). UFC concentrations were <50 µg/day in 95% of the children <9 years and <81 µg/day in 95% of the older children. The UFC concentrations divided by BMI were <2.8 in 95% of the patients independent of age.

The 33 obese children with MetS demonstrated significantly (p=0.003) higher UFC levels (42 [26-69] µg, data as median and interquartile range) as compared to the 231 obese children without MetS (28 [19-44] µg), while the SC levels did not differ significantly (12 (8-19) versus 11 (8-16) µg/dl; p=0.321). The number of features of the MetS were significantly correlated to UFC (r=0.22, p=0.001), but not to SC levels (r=0.09). Except fasting glucose (SC:r=0.25, UFC:r=0.01), all parameters of the MetS were stronger related to UFC as compared to SC concentrations (waist: UFC:r=0.29, SC:r=0.19; systolic blood pressure: UFC:r=0.23, SC:r=0.22, diastolic blood pressure: UFC:r=0.015, SC:r=0.12; HDL-cholesterol: UFC:r=-0.15, SC:r=0.02; triglycerides: UFC:r=0.16; SC=r=-0.06; HOMA: UFC:r=0.17, SC:r=0.06). In multiple backwards linear regression analyses adjusted to age, gender and pubertal stage, UFC concentrations (µg/day) but not SC levels were significantly related to insulin resistance HOMA (b-coefficient 1.5, 95% confidence interval 0.2-2.6, p=0.016), but not to any parameter of the MetS (r²=0.06).

Conclusions: Since nearly one third of obese children demonstrated slightly increased 24h urinary cortisol concentrations norm values adapted to obese children may help to avoid unnecessary dexamethasone suppression tests. Our findings support the hypothesis that changes in the HPA axis are related to the MetS in obesity. However, in contrast to UFC concentrations SC levels seem not to be a suitable marker for this relationship.

 

Nothing to Disclose: TR, AK, BW, CK, NL, MW, PMH

11091 4.0000 SAT-0900 A Relationships Between 24h Urine Free Cortisol and Metabolic Syndrome in Obese Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Sara Vandewalle*1, Tom Fiers2, Youri Taes1, Patrick Debode3, Maria Van Helvoirt3, Inge Roggen4, Jean-Marc Kaufman2 and Jean De Schepper4
1Ghent University Hospital, Ghent, Belgium, 2Ghent University Hospital, Gent, Belgium, 3Zeepreventorium, De Haan, Belgium, 4Brussels University Hospital, Brussels, Belgium

 

Background: Adrenarche is a gradual process of increasing adrenal androgen (AA) (principally DHEAS) secretion from early childhood through adolescence, independently from cortisol output. In girls pronounced adrenarche has been related to insulin resistance. Data on circulating AA and cortisol in obese boys are scarce and conflicting, especially during puberty. We hypothesize that DHEAS might increase further during pubertal development in obese boys,  given the puberty associated changes in insulin and IGF-1 secretion, both known to modulate DHEAS secretion in vitro.

Objective: To study the differences in circulating DHEAS, androstenedione(A4) and cortisol between obese and normal weighed boys at different pubertal stages.

Methods: 90 obese (BMI SDS >2)  boys, aged 10-19y were investigated at start of a residential obesity treatment program as well as 90 age-matched healthy controls were studied. Pubertal status was assessed by Tanner staging. Morning A4 and cortisol were determined by liquid chromatography-tandem mass spectrometry, and DHEAS, IGF-1 and SHBG by commercial immunoassays.  

Results: Before puberty obese boys had significantly (p<0.05) higher median (P25-P75) (percentage difference obese-controls) A4 (26.1 (15.7-46.2) vs 17.5 (10.8-20.2)ng/dl (33%)), DHEAS (138 (114-152) vs 89.6 (41.1-106) µg/dl (35%)) and cortisol (11.7 (9.3-15.1) vs 8.2 (6.8-10.3) µg/dl (30%)) concentrations, compared to controls. During puberty differences in DHEAS varied from G2: 174 (114-244) vs 133 (81.1-180) µg/dl (23%)(p=ns), G3: 225 (144-288) vs 142 (87.1-181)µg/dl (+36%) (p<0.05), G4: 204 (162-315) vs 221 (157-322) µg/dl (-8%) (p=ns) and G5: 370 (268-469) vs 348 (223-438)(+6%) µg/dl (p=ns). A4 ranged from G2: 46.7 (38.7-57.0) vs 23.1 (18.9-34.3) ng/dl (50%)(p<0.001), G3: 64.6 (49.6-102) vs 31.1 (25.5-47.5) ng/dl (52%) (p<0.001), G4: 79.4 (58.7-93.5) vs 47.1 (35.8-73) ng/dl (41%) (p<0.001), G5: 81.7 (63.0-117) vs 80.9 (66.3-85.3)ng/dl (1%) (p= ns) and cortisol from G2: 15.6 (14.2-18.3) vs 7.9 (6.4-10.9) µg/dl (49%)(p<0.001), G3: 18.5 (12.0-21.4) vs 9.7 (5.8-14.7) µg/dl (48%)(p<0.01), G4: 16.4 (12.9-18.8) vs 8.1 (5.9-11.3) µg/dl (51%) (p<0.001), G5: 16.8 (12.9-19.2) vs 11.9 (8.6-16.5) µg/dl (30%) (p<0.05). DHEAS was not related to IGF-1 and SHBG, neither in the obese, nor in the control group.

Conclusion:  DHEAS is increased in obese boys before puberty and early puberty, while the more persisting A4 elevation might be explained by an increasing testicular contribution during puberty.  On the other hand,  a  very stable cortisol elevation was observed  up to adult stage of pubertal development. Our data suggest that in boys peripheral IGF-1 and hyperinsulinemia are not involved in AA synthesis during puberty.

 

Nothing to Disclose: SV, TF, YT, PD, MV, IR, JMK, JD

13030 5.0000 SAT-0901 A Adrenarche in Male Childhood Obesity : Exaggerated or Just Accelerated ? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Marianne Andersen*1, Louise Christensen2, Thue Kvorning3, Rasmus Larsen4, David Hougaard5, Kim Brixen2, Kurt Højlund2 and Dorte Glintborg6
1Odense University Hospital, Denmark, 2OUH, 3Institute of Sport Science and Clinical Biomechanics, University of Southern Denmark, Odense, 4Department of Informatics and Mathematical Modelling, Technical University of Denmark, kgs. Lyngby, 5Department of Clinical Biochemistry and Immunology, Statens Serum Institut, Copenhagen S, 6Odense University Hospital, Odense, Denmark

 

Background:

Central obesity is associated with low testosterone levels and increased risk of type 2 diabetes. Testosterone therapy (TT) decreased fat mass during 6 months therapy in ageing men (1) without changing insulin sensitivity (2).

Strength training for 12 weeks increased maximum voluntary contraction (MVC) whereas muscle strength was unchanged during TT or placebo (3).  

Aim:

To study changes in insulin sensitivity, fat metabolism and fat mass during strength training compared to TT and placebo.

Methods: Double-blinded, randomized, controlled trial of six months TT (gel) in 68 men aged 60-78 years with bioavailable testosterone < 7.3 nmol/l and waist > 94 cm randomized to strength training (ST) (n=23), TT (50-100 mg/day, n=22) or, placebo (n=23) for 24 weeks (3). The ST group was further randomized to TT or placebo after 12 weeks (3).

Outcomes after 12 weeks: Euglycemic hyperinsulinemaic clamp, indirect calorimetry, lean body mass (LBM). Total, central, extremity, visceral, and subcutaneous fat mass were established by DXA- and MRI-scans.

Results:

No significant differences in outcome measures were found between groups before intervention.

0-12 weeks strength training: Δ fat mass was significantly, inversely associated with Δ glucose infusion rate (GINF) -0.54, Δ stimulated glucose oxidation -0.67, and Δ FFA during euglycemic hyperinsulinemic clamps -0.60 (p < 0.05). The highest associations were obtained between Δ GINF and Δ inner thigh fat -0.82 and Δ outer thigh fat -0.76; (p<0.05). No significant associations were found during TT or placebo. Glucose metabolism regional fat deposits and LBM were unchanged during 12 weeks strength training.

Conclusions:

Changes in total and regional fat mass - especially of the thigh - were inversely associated with improved insulin sensitivity during 12 weeks strength training.

    1   Frederiksen L, Hojlund K, Hougaard DM, Mosbech TH, Larsen R, Flyvbjerg A, Frystyk J, Brixen K & Andersen M. Testosterone therapy decreases subcutaneous fat and adiponectin in aging men. Eur J Endocrinol, 2012..

    2   Frederiksen L, Hojlund K, Hougaard DM, Brixen K & Andersen M. Testosterone therapy increased muscle mass and lipid oxidation in aging men. Age (Dordr ), 2012.

    3   Kvorning T, Christensen LL, Madsen K, Nielsen JL, Gejl KD, Brixen K & Andersen M. Mechanical muscle function and lean body mass during supervised strength training and testosterone therapy in aging men with low-normal testosterone levels. J Am Geriatr Soc, 2013.

 

Nothing to Disclose: MA, LC, TK, RL, DH, KB, KH, DG

14358 6.0000 SAT-0902 A Changes in Total and Regional Fat Mass during Strength Training Were Inversely Associated with Improved Insulin Sensitivity Assessed By Euglycemic Hyperinsulinemic Clamp 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Nasser Mohmmed Al-Daghri*1, Majed S Alokail2, Theodoros I Roumeliotis3, Omar Al-Attas4, Khalid Alkharfy5, Sherif H Abd-Alrhaman4, Shaun Sabico4, Antigoni Manousopoulou6, Akul Singhania3, Christopher Woelk3, Paul Townsend7, George P. Chrousos8 and Spiro D Garbis3
1King Saud University, Riyadh, Saudi Arabia, 2King Saud Univ Coll of Sci, Riyadh, Saudi Arabia, 3Southampton University, 4King Saud University, Riyadh, 5King Saud University, 6University of Southampton, United Kingdom, 7University of Manchester, Manchester, United Kingdom, 8University of Athens School of Medicine, Athens, Greece

 

Obesity is a basic component of the metabolic syndrome that has been associated with insulin resistance, hypertension and an increased risk of diabetes mellitus type-2 and cardiovascular disease, as well as several cancers. This proof-of-principle study compared the proteomic profiles of age-matched non-diabetic overweight and obese females (n=28) and males (n=31). This study measured the expression of a total of 2470 serum proteins of which the majority were found for the first time in human serum. Of these ~10%, corresponding to about 250 proteins, exhibited differential expression between men and women (p<0.05). The log2-fold change ranged from ± 0.3 to over 5.0 and included both novel and known proteins. The proteins of known function belonged to the following pathways: beta-estradiol function, development, lipid and prostanoid metabolism, vitamin D function, Central Nervous System function, immunity/inflammation and tumorigenesis. In general, this proteomics evidence shows measurable gender-specific differences in the serum proteome, explaining the results of many physiologic and pharmacologic studies showing marked sexual dimorphism. We suggest that the pleiotropic nature of obesity and its metabolic syndrome component also manifest sexual dimorphism in the proteome that should be taken into account in clinical study design, diagnosis and treatment.

 

Nothing to Disclose: NMA, MSA, TIR, OA, KA, SHA, SS, AM, AS, CW, PT, GPC, SDG

11234 7.0000 SAT-0903 A Sexual Dimorphism of the Human Milieu Intérieur Proteome in Overweight and Obese Men and Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Lisa M Neff*1, Dinah M Zeiss1, Mindy Hoffmann1, Katherine Lowry2, Monica Edwards1, Sarah Rodriguez1, Kelley Wachsberg1, Robert Kushner3 and Lewis Landsberg1
1Northwestern University Feinberg School of Medicine, 2Southern Illinois University School of Medicine, 3Northwestern University Feinberg School of Medicine, Chicago, IL

 

Background: In the United States, obesity prevalence increases significantly with age for women but not men.1   Weight gain during perimenopause may account for some of the observed sex difference.  It is controversial whether the weight gain that occurs is a result of changes in metabolism related to aging itself or to the hormonal changes of menopause.  Body temperature is an understudied variable linked to metabolism.  It is estimated that a 1°C change in body temperature produces a 10-13% change in energy expenditure.  Recent data suggests that oral temperature declines abruptly around age 50-59 in women with no further decline later, whereas men experience a gradual decline from mid-life onward.2  There are no known studies of core body temperature in pre- and post-menopausal women.  We hypothesized that core temperature would be lower in postmenopausal women, due to lower progesterone levels.   

Methods: Data were obtained from two related studies of core temperature conducted by the same investigators using the same methods.  Study 1 included lean and obese adults, ages 25-40.  Study 2 included overweight and obese men and postmenopausal women, ages 18-65.  Sample size from the combined studies was 23 men and 25 women (12 premenopausal , 13 postmenopausal).  Subjects were studied during an admission to the Clinical Research Unit.  Premenopausal women were studied during the follicular phase of the menstrual cycle.  Core body temperature was measured every minute for 24 hours (CorTemp System,HQ Inc.).  Subjects’ activities were standardized and included periods of rest, food consumption, exercise, and sleep. Resting energy expenditure (REE) was measured by indirect calorimetry.  Body composition was measured by DEXA.

Results: Mean 24 hour core body temperature was 0.25 ± 0.06 °C lower in postmenopausal women than  premenopausal  women (p=0.001).  Mean core temperature during sleep was 0.28 ± 0.08 °C  lower in postmenopausal than premenopausal women (p=0.002), and similar differences were found during mealtime and after exercise (all p< 0.05).  Mean 24 hour core temperature was 0.34 ± 0.05 °C lower in men than in premenopausal women (p<0.001), with similar differences found during sleep, mealtime, and exercise (all p < 0.01).  Mean core temperature was not different between postmenopausal women and men.  There was a significant correlation between age and 24 hour core  temperature for women (r=0.615, p=0.001) but not for men in our cohort under age 65.  There was no correlation between core temperature and adjusted REE (kcal/kg).

Conclusions:  In this analysis, postmenopausal women, like men, have lower core body temperatures than premenopausal women.  If confirmed in future studies, this reduction in core temperature may be driven by a reduction in progesterone levels during the menopausal transition.  Although exploratory in nature, these findings may have implications for energy metabolism in perimenopausal women.

 

Disclosure: RK: Researcher, Aspire Bariatrics, Researcher, WeightWatchers, Medical Advisory Board Member, Retrofit, Medical Advisory Board Member, Zafgen, Medical Advisory Board Member, Takeda, Medical Advisory Board Member, Vivus USA, Medical Advisory Board Member, Novo Nordisk. Nothing to Disclose: LMN, DMZ, MH, KL, ME, SR, KW, LL

16515 8.0000 SAT-0904 A 24-Hour Core Body Temperature Is Lower in Postmenopausal Women Than Premenopausal Women: Potential Implications for Energy Metabolism and Mid-Life Weight Gain 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Beverly M Kocarnik*1, Steven E Kahn2, Wilfred Y Fujimoto3, Tomoshige Hayashi4, Marguerite J McNeely5, Donna Leonetti6 and Edward J Boyko7
1University of Washington, WA, 2VA Puget Sound Health Care System and University of Washington, Seattle, WA, 3Univ of Washington, Kailua-Kona, HI, 4Osaka University, 5Univ of Washington, Seattle, WA, 6University of Washington, 7Va Puget Sound Health Care Sys, Seattle, WA

 

The relationship between estradiol levels and adiposity in men has been actively investigated, with some studies reporting a positive association between estradiol levels and fat mass and others finding no association. A recent study found that men taking an aromatase inhibitor had increased body fat after 16 weeks, leading to the conclusion that estrogen deficiency was associated with increased adiposity (1). We used longitudinal and cross-sectional data from the Japanese-American Community Diabetes Study to further examine this association. Subjects had baseline measurements of total testosterone and estradiol levels, fasting plasma glucose and single-slice intra-abdominal (IAF) and subcutaneous fat areas at the level of the umbilicus by computed tomography (CT). CT fat areas were re-measured 7.5 years later. We performed univariate and multiple linear regression analyses to determine whether there was an association between Δ IAF area over 7.5 years and baseline estradiol levels. Estradiol levels were grouped into tertiles, given the distribution of the data and concerns about assay sensitivity at its lower limits.  The population included 113 Japanese-American men with the following mean characteristics: age 61.1 years, BMI 25.5 kg/m2, total testosterone level 4.8 µg/mL, and estradiol level 26.9 pg/mL. In univariate analyses, we found no statistically significant association between estradiol tertiles and the following variables of interest: baseline weight (p = 0.98), Δ weight (p = 0.49), baseline IAF (p = 0.55), Δ IAF (p = 0.65), baseline testosterone (p = 0.09), and fasting plasma glucose (p = 0.32). The multiple linear regression model to predict Δ IAF over 7.5 years included the following independent variables: baseline estradiol (tertile 2 vs 1, β = -2.91, 95% CI -17.7 to 11.8; tertile 3 vs 1, β = -0.44, 95% CI -15.4 to 14.6, overall p = 0.92), age (β = 0.44, 95% CI -0.67 to 1.54, p = 0.44), baseline IAF area (β = -0.1, 95% CI -0.23 to 0.02, p = 0.11), Δ weight (β = 5.34, 95% CI 3.63 to 7.06, p < 0.0001), and testosterone (β = -6.43, 95% CI -11.27 to -1.60, p = 0.01). In this model, only Δ weight and total testosterone level at baseline were significantly associated with Δ IAF. A first order interaction term between estradiol and testosterone was entered into this model but was not significant (p = 0.57). Given concerns about the sensitivity of estradiol levels at the lower range of the assay, we also examined the association between estradiol measured on a continuous scale and Δ IAF in the highest two estradiol tertiles only. There was no association in this model either (β = 0.29, 95% CI -0.67 to 1.25, p = 0.55). In summary, our results confirm our earlier finding of a significant negative association between total testosterone level and Δ IAF area (2). However, they do not support an independent association between estradiol level and Δ IAF area over 7.5 years of follow-up in Japanese-American men.

 

Nothing to Disclose: BMK, SEK, WYF, TH, MJM, DL, EJB

12883 9.0000 SAT-0905 A Estradiol Levels in Men Are Not Correlated Cross-Sectionally with Intra-Abdominal Fat Area and Do Not Predict Change in This Fat Depot Longitudinally 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Megan Crawford*1, Chandra Chataut2, Elizabeth F Avery1, Imke Janssen1, Lynda H Powell1, Howard M Kravitz1 and Rasa Kazlauskaite1
1Rush University Medical Center, Chicago, IL, 2John Stroger Hospital, Chicago, IL

 

Background:  The waist-to-height ratio appears to be the best indicator of adiposity related to cardiometabolic risk among people of Asian backgrounds.  However, little is known regarding which of the adiposity indicators relates best to cardiometabolic risk factors among midlife women of diverse racial/ethnic backgrounds.

Methods:  This cross-sectional analysis utilized baseline data from the Study of Women’s Health Across the Nation (SWAN), collected by 7 academic medical centers.  SWAN recruited Caucasian, African American, Hispanic American, Chinese American and Japanese American women age 42-52 years, who had at least 1 menstrual period within 3 months of enrollment and were not taking reproductive hormone therapy. A standardized protocol was used to measure adiposity indicators [body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR), waist-to-hip ratio (WHipR)] and metabolic risk factors [blood pressure, fasting serum lipid and glucose  levels].  General linear models were applied to investigate the relationships between each of the adiposity indicators and each of the indices of the metabolic syndrome across the five racial/ethnic groups. Receiver Operator Characteristics (ROC) curve analysis was done using Area Under the Curve (AUC) measurements to further evaluate these relationships. 

Results:  The analysis included 2911 women, mean age 46 yrs (± 2.7 SD),  49% Caucasian, 27% African American, 8% Hispanic American, 8% Chinese American, and 9% Japanese American.  The ROC analysis revealed that for predicting HDL <50 mg/dL and impaired fasting glucose (≥100 mg/dL), the WHtR (AUC=0.72 for both) was similar to WC and significantly better than BMI and WHipR (p<0.01).  For predicting hypertriglyceridemia (≥150 mg/dL), the WHtR (AUC=0.73) was similar to WHipR and significantly better than BMI (p<0.01) and WC (p=0.04). For predicting systolic hypertension (BP >140 mm Hg), the WHtR (AUC=0.70 for both) was similar to WC and BMI, and significantly better than WHipR (p<0.01).

Conclusions: In general, central distribution of adiposity, whether represented by waist circumference, waist-to-height ratio, or waist-to-hip ratio, were associated with each of the cardiometabolic risk factors studied.  The waist-to-height ratio performs best as the single indicator of adiposity related to cardiometabolic risk factors across midlife women of diverse racial ethnic backgrounds.

 

Nothing to Disclose: MC, CC, EFA, IJ, LHP, HMK, RK

12920 10.0000 SAT-0906 A Waist-to-Height Ratio Performs As Well As Waist Circumference As the Principal Adiposity Indicator of Cardiometabolic Risk Across Five Ethnic Groups of Midlife Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Shaloo Gupta1, Lance Richard2 and Anna Forsythe*3
1Kantar Health, Princeton, NJ, 2Eisai Europe Ltd, Hatfield, United Kingdom, 3Eisai Inc., Woodcliff Lake, NJ

 

Background: Obesity remains an economic burden on society and is associated with varies comorbid conditions. This study examined the health-related quality of life (HRQoL) and the prevalence of weight-related comorbidities across different BMI categories in the 5EU.

Methods: Results were from the 2013 5EU National Health and Wellness Survey (N=62,000), a nationally representative, online survey of respondents aged ≥ 18 years. This analysis focused on overweight (BMI>=25 & <30 kg/m2), obese class I (BMI>=30 & <35 kg/m2), obese class II (BMI>=35 & <40 kg/m2), and obese class III (BMI>=40 kg/m2) respondents. Respondents provided information on HRQoL (SF-36v2: mental (MCS), and physical component summary (PCS), and the diagnosis of weight-related comorbidities (type 2 diabetes, hypertension, dyslipidemia, and arthritis) and comorbidities experienced in the past 12 months (sleep difficulties, pain, depression and anxiety). Generalized linear models compared BMI categories controlling for age, gender and the Charlson Comorbidity Index.

Results: Among 31,014 respondents (France=6,790, Germany=8,111, UK=8,043, Italy=4,529, Spain=3,541), 64.9% were overweight, 23.4% were obese class I, 7.6% were obese class II, and 4.0% were obese class III. The proportion of type 2 diabetes (overweight: 6.8%; obese class I: 12.9%; obese class II: 18.3%; obese class III: 21.2%), hypertension (overweight: 22.8%; obese class I: 32.6%; obese class II: 40.8%; obese class III: 45.1%), dyslipidemia (overweight: 19.5%; obese class I: 23.3%; obese class II: 24.0%; obese class III: 23.3%), and arthritis (overweight: 11.2%; obese class I: 15.8%; obese class II: 19.0%; obese class III: 20.1%) increased as BMI increased (all p<0.001 vs. overweight). Comorbidities experienced in the past 12 months also increased across the BMI categories (all p<0.001 vs. overweight). After adjustments, all three obese class respondents exhibited significantly lower MCS (overweight: 47.2; obese class I: 46.4; obese class II: 44.9; obese class III: 44.2) and PCS (overweight: 50.7; obese class I: 48.7; obese class II: 46.2; obese class III: 43.2) scores than overweight respondents (all p<0.001 vs. overweight).

Conclusions: Data suggests increasing BMI is associated with worse HRQoL, and more comorbidities. Even with the awareness of obesity increasing in Europe, it still remains a significant burden on a patient’s HRQoL. There remains an unmet need for improved endorsements for weight loss options.

 

Disclosure: SG: Consultant, Eisai. LR: Employee, Eisai. AF: Employee, Eisai.

14646 11.0000 SAT-0907 A Health-Related Quality of Life and Weight-Related Comorbidities Across Different Body Mass Index Categories in Europe 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Yoshimi Tatsukawa*1, Michiko Yamada1, Keiko Ueda1, Ikuno Takahashi1, Waka Ohishi1 and Shuhei Nakanishi2
1Radiation Effects Research Foundation, Hiroshima, Japan, 2Hiroshima University, Japan

 

Background: It is well known that Asian populations have higher risk of developing diabetes mellitus (DM) compared with Caucasians, even though the number of obese Asians is limited. Epidemiology studies have revealed a positive association between metabolic risk factors and trunk fat mass, and a negative association between metabolic risk factors and lower extremity fat mass; however, only a limited number of studies have examined the effects of body fat distribution on the incidence of DM among non-obese people.

Objective: To determine whether or not the effects of obesity and metabolic risks related to the incidence of DM differ according to body fat distribution among elderly Japanese.

Methods: The subject population includes 1,536 people (466 males and 1,070 females, with an average age of 65.3) who underwent Adult Health Study (AHS) health examinations in Hiroshima during the period from 1994 through 1996.  The AHS population consists of A-bomb survivors and their controls. The subject population was classified into an obese group (BMI≥25kg/m2)and a non-obese group (BMI<25kg/m2). In accordance with AHA/NHLBI criteria for diagnosis of metabolic syndrome, we defined those having at least two of the criteria other than abdominal obesity as “metabolically unhealthy”; non-obese subjects were then classified into two groups, “metabolically healthy non-obese: MHNO” and “metabolically unhealthy non-obese: MUNO”. We compared DM risks in MUNO and the obese group with those in MHNO and reviewed the effects of body fat distribution, as measured with whole-body DEXA, on DM risks. DM was defined as glucose ≥126mg/dl fasting or ≥200mg/dl nonfasting, or physician-diagnosed DM, or the use of medication for DM. We followed the population up to 2011 in order to observe the incidence of new DM cases.  

Results: During the follow-up period, 213 subjects developed DM. After adjustments were made for age, smoking, alcohol consumption, and radiation dose, the relative risks (95%CI) of DM for MUNO and the obese group, compared with MHNO, were 2.13(1.26-3.60) and 2.79 (1.56-4.98), respectively, for males; and 2.00(1.25-3.20) and 2.35(1.55-3.56),  respectively, for females. A significant increase in DM risk was also observed for MUNO and the obese group. Trunk fat mass percentage (trunk fat mass in relation to total body fat mass) is one of the significant risk factors for incident DM, while significant negative association was observed between lower extremity fat mass percentage (lower extremity fat mass in relation to total body fat mass) and incident DM. After adjustments were made for the percentages of trunk fat mass and lower extremity fat mass, in addition to such risk factors as age, decrease in relative risk for DM was observed, specifically in MUNO.

Conclusions: The possibility exists that body fat distribution may play a part in incidence of DM among non-obese people with metabolic risks.

 

Nothing to Disclose: YT, MY, KU, IT, WO, SN

12719 12.0000 SAT-0908 A Association Between the Distribution of Body Fat and the Incidence of Diabetes Mellitus Among Elderly Japanese 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

James N Anasti Jr.*1, Angel Gonzales-Rios2, Leonardo Claros3, Maher El Chaar4 and Elizabeth Mary Vessio5
1St Luke's University Hosp, Bethlehem, PA, 2St Luke's University Hospital, Bethlehem, 3St luke's University Hospital, Allentown, PA, 4St Luke's University Hospital, Allentown, PA, 5St Luke's University Hospital, Bethlehem, PA

 

Introduction: Bariatric surgery has increased significantly over the last decade.  Aside from assessment of menstrual function, very little has been published about these patients’ reproductive history. Since females comprise the majority of those undergoing these procedures, important aspect of their OB/GYN history and fertility issues may provide insight for present and future care of these women.

Methods: Reproductive health surveys were given to 100 consecutive women who were scheduled for bariatric surgery at our institution. Patients were asked to return these surveys by mail. They were then reviewed and collated as was information from their preoperative visit. Age-matched patients with BMI<35 (n=100) were randomly selected from our OB/GYN clinic to serve as controls.

Results: Of the 100 surveys issued 77 were returned (77%). The mean BMI was 43.3 and age 38.8 yrs; 96% were premenopausal and 48% were less than 36 yrs old. These were compared to age matched controls with BMI <35.  Irregular menses were noted in 31% (controls= 12%, p=0.003) with PCOS reported in 19% (controls= 8%, p=0.04). A prior pregnancy was achieved by 87% of patients. Overall, 15% of their pregnancies were complicated by miscarriages (controls= 11%, p=NS) , 27% gestational diabetes (controls=10%, p=<0.001) and 19% preeclampsia (controls= 4%, p=0.012).   Future fertility was a major concern in 26%, overall, and 47% in those under 36.  This did not differ significantly from controls. Of the 53% using contraception equal numbers employed OCP (26%), Tubal Ligation (22%), Condoms (20%) and IUDs (20%). This did not differ significantly from controls. The leading co-morbidities were sleep apnea (40%; controls= 6%, p<0.001) and depression (31%; controls=12%, p=0.003) while only 10% had preexisting diabetes mellitus (controls 4%, p=NS)

Conclusion:   The unique female concerns such as menstrual control, future fertility, contraception needs, pregnancy history and depression are currently not being addressed.  A preoperative visit with an OB/GYN may help to educate and inform women on these reproductive health issues.

 

Nothing to Disclose: JNA Jr., AG, LC, ME, EMV

14634 13.0000 SAT-0909 A The Importance of the Reproductive History in Women Undergoing Bariatric Surgery 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Paula Freitas1, Joana Isabel Oliveira*2, Eva Lau1, Mariana Lobo3, Tiago Silva Costa4, Alberto Freitas4 and Davide Carvalho5
1Centro Hospitalar São João; Faculty of Medicine, Porto University, Portugal, 2Centro Hospitalar São João, Faculty of Medicine, Porto University, Porto, Portugal, 3Center for Research in Health Technologies and Information Systems, 4Center for Research in Health Technologies and Information Systems, Faculty of Medicine of University of Porto, 5Centro Hospitalar São João, Faculty of Medicine, University of Porto, Portugal

 

Introduction: Obesity has been associated with an increased risk of developing heart failure (HF). This association appears to be largely mediated by some other obesity related conditions, such as hypertension and coronary heart disease, but also directly by the adverse effects of obesity on left ventricular structure, systolic and diastolic function.

Objectives: 1) To assess the prevalence of hospitalizations for HF in obese patients vs. general population, 2) To assess the HF mortality in obese patients vs. general population.

Methods: Retrospective analysis of patients admitted to our hospital between 1988 and 2012. Cohorts were defined according to primary and/or secondary diagnosis of HF and/or obesity, coded according to the ICD-9-CM. The prevalence of hospitalizations is expressed in percentages and chi-squared test was used for inferential analysis, with a significance level to α=0.05.

Results: We found a higher prevalence of HF hospitalizations in patients with obesity [16% (5897), p<0.001] vs. general population [4.7% (45399), p<0.001]. The prevalence was higher in females in both groups. When evaluated each year, we noticed that the number of hospitalizations for HF became higher in obese patients vs. general population since 2004. Regarding HF mortality, it was higher in the general population [3.18% (1445), p<0.001] vs. obese patients [1.53 %, (90), p<0.001]. In both groups, the HF mortality was higher in females.

 Conclusion: The prevalence of HF hospitalizations was higher in obese patients than the general population. In contrast, the HF mortality was lower in patients with obesity, which seems to be in agreement with the idea that obesity may be associated with longer survival in patients with HF ("obesity paradox").

 

Nothing to Disclose: PF, JIO, EL, ML, TSC, AF, DC

16396 14.0000 SAT-0910 A The Obesity Paradox: Heart Failure Mortality Is Lower in Obese Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Yaxin Lai*1, Chenyan Li2, Jinyuan Mao1, Aihua Liu1, Weiping Teng1 and Zhongyan Shan1
11st Affiliated Hospital of China Medical University, 21st Affiliated Hospital of China Medical University, Shenyan, China

 

The relationship between the distribution of abdominal fat and thyroid function 

Lai Yaxin,  Li Chenyan, Mao  jinyuan, Yu Xiaohui, Liu Aihua, Teng Weiping, Shan Zhongyan.

Department of Endocrinology, The First Affiliated hospital of China Medical Unicersity, China

Liaoning Key lab of Endocrine Diseases, China

Obesity especially central obesity is an independent risk factor of cardiovascular diseases. In subjects with subclinical hypothyroidism and even in euthyroid subjects, there is positive correlation between thyrotropin and body mass index. However, there are only a few studies concerning thyroid function and body fat distribution. The aim of our study is to discuss the correlation between thyroid function and abdominal subcutaneous fat and visceral fat. For this purpose, 763 residents aged between 40 and 65 years-old were randomly selected from a community, they received a detailed questionnaire, their height, weight, waist circumference, hip circumference and blood pressure were measured. Fasting blood was collected to test TSH, FT4, FT3 and TPOAb. MRI scan was conducted to measure the subcutaneous fat (SF) and visceral fat (VF) area. Pearson correlation analysis showed that SF and LnTSH were positively correlated (r=0.183, P=0.000), but no correlation was found between VF and LnTSH. SF and FT4 were negatively correlated (r=-0.164, P=0.000), VF and FT4 was positively correlated with (r=0.118, P=0.004).  SF and FT3 were negatively correlated (r=-0.098, P=0.015), VF and FT3 was positively correlated with (r=0.261, P=0.000). Variables relevant to subcutaneous fat or visceral fat area in single correlation model were put into the regression model, and the results showed that systolic blood pressure, TSH and FT3 were risk factors of subcutaneous fat area, while BMI, waist circumference, uric acid and OGTT 2h blood glucose were risk factors of visceral fat area. Our cross-sectional epidemiological study showed TSH elevation and FT3 decrease were risk factors of subcutaneous fat area, which indicated TSH and FT3 may play a certain role in the distribution of body fat.

 

Nothing to Disclose: YL, CL, JM, AL, WT, ZS

14404 15.0000 SAT-0911 A The Relationship Between the Distribution of Abdominal Fat and Thyroid Function 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Naji J Aljohani*1, Nasir Alhamdan2, Ahmed Bahnassy2 and Ashwag Alfagih2
1King Saud bin Abdul-Aziz university, Riyadh, Saudi Arabia, 2King Fahad Medical City, Riyadh, Saudi Arabia

 

Obesity is considered a major risk factor for diabetes mellitus (DM) and hypertension, and identifying people at highest risk through ethnically appropriate waist circumference (WC) cut-off points was the main target of this study. Data were randomly collected nationwide and analyzed from a cross-sectional study of 4350 Saudi adults aged 15- 64 years using a stratified, multi-stage, cluster random sampling technique. DM subjects were either known cases or subjects with fasting blood glucose ≥7.0mmol/L. Hypertension was determined by having systolic blood pressure ≥ 140. Waist circumference (WC) in cm was measured midway between the lower costal margin and iliac crest during the end-expiratory phase. Mean age for the study subjects was: 36.55+12.99 years (37.5+ 13.9 years for males; 35.6+11.96 for females). The mean waist circumference for all subjects was 92.75+13.65 cm (95.2+14.01cm for males versus 89.9+12.6cm for females; p <0.001). The prevalence of DM was 23.8% for all subjects. It was 25.3% among males significantly higher than that among females 22.4 % (p=0.025). The prevalence of hypertension among all subjects was 25.5%; it was 27.1% among males significantly higher than that among females 23.9% (p=0.013). ROC curve was done and revealed that WC cutoff points for DM risk are 97 cm and 91 cm for men and women respectively and for hypertension are 97 cm and 90 cm again for men and women respectively. Findings of the present study recommend that the Arab population utilize a much lower WC in identifying patients at risk for DMT2 and hypertension. Prospective studies are needed to confirm these observations.

 

Nothing to Disclose: NJA, NA, AB, AA

12391 16.0000 SAT-0912 A Waist Cut-off Values to Predict Diabetes Mellitus Type 2 and Hypertension Risk in Arab Adults 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Saleh Ahmad Alasiri*
King Saud University, Riyadh, Saudi Arabia

 

Objective:To assess the association between body mass index (BMI) and pregnancy outcome in Saudi women undergoing IVF with or without intracytoplasmic sperm injection (ICSI). 

Design:   Retrospective cohort analysis.

Setting: University-affiliated IVF Unit

Patient(s): Patients receiving IVF with or without ICSI treatment.

Intervention(s): subjects divided into 4 groups according to their BMI to analyze their demographic and clinical characteristics, IVF treatment cycle and IVF lab and outcome parameters:  normal with BMI ≤ 24.9 kg/m2 (n = 93) overweight with BMI 25.0 - 29.9 kg/m2 (n = 99), obese with BMI 30.0 - 34.9 kg/m2 (n = 93) and severely obese with BMI ≥ 35.0 kg/m2 (n = 73).                            

Main outcome Measure(s):

The primary outcome was biochemical pregnancy which was defined as the detection of a positive β- hCG concentration 2 weeks after embryo transfer. Ovarian stimulation parameters and IVF/ICSI cycle outcomes were compared. Other factors associated with BMI were demographic, clinical, and IVF lab data. 

Association between BMI and biochemical pregnancy was done by multivariate analyses to control for confounding. 

Result(s):

In our study, BMI was not found to be significantly associated with biochemical pregnancy, where the Odds Ratio (OR) for the association was found to be 1.05, with a 95% confidence interval of 0.80-1.37 (p-value = 0.72). On the other hand, male factor was associated with reduced chances of pregnancy (OR=0.45, 95% CI=0.21-0.97). In addition, FSH total, daily FSH dose and duration of FSH stimulation in days were also associated with increased chances of pregnancy, p-value = 0.03, 0.02, and 0.01 respectively. Other factors were not found to be statistically significant.

Conclusion(s):

Female BMI does not appear to have an adverse effect on biochemical pregnancy rates in women treated with IVF/ICSI treatment. However, counseling women on the increased obstetric and neonatal complications associated with increased maternal BMI is mandatory.

 

Nothing to Disclose: SAA

13432 17.0000 SAT-0913 A Effects of Female BMI in Saudi Women on the Outcome of IVF / Icsi Treatment Cycles 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Meral Mert*1, Refik Tanakol2, Hande Karpuzoglu3, Semra Dogru Abbasoglu3, Ozlem Soyluk Selcukbiricik4, Harika Boztepe5, Sema Yarman4 and Faruk Alagol5
1Bakirköy Training and Research Hospital, Istanbul, Turkey, 2Istanbul Faculty of Medicine, Istanbul, Turkey, 3Istanbul University Istanbul Medical Faculty, Istanbul, Turkey, 4Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey, 5Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey

 

Introduction: An activation of the hipotalamo-pituitary (HPA) axis has been hypothesized in obesity on the basis of some experimental studies. Being a non-invasive method, midnight salivary cortisol (MSC) level has been used as a valuable indicator of free plasma cortisol level. Salivary cortisol levels may be affected by individual factors such as nutrition, sleep, medication, activity and gender. The aim of this study was to evaluate the worth of the midnight salivary cortisol level in obese patients.

Design and Methods: The study group included healthy subjects whose 1 mg overnight dexamethasone suppression test (1 mg-DST) were <1.8 µg/dl. All the subjects underwent a detailed physical examination and their measurements of height, weight, body mass index (BMI), waist and hip circumference and also the status of their education and exercise were recorded. Midnight salivary cortisol (MSC) level, salivary cortisol level after 1 mg-DST of all subjects were measured. Saliva samples were collected at 00:00 to plastic tubes with the help of plastic pipettes, without brushing their teeth, but after rinsing their mouth. Salivary cortisol level was measured with luminescense immunoassay kit. Differences and correlations were analysed by using  Kendall’s Taub and Mann Whitney-U tests as statistical analysis.

Results:   The study group consisted of 102 female and 16 male subjects and 35 out of them were smoker whereas 83of them were nonsmoker. Eightyfive subjects in the study group were found to be obese (BMI>30 kg/m2) and 33 subjects  were non obese.  MSC level were 0,323± 0,62 µg/dl and salivary cortisol level after 1 mg-DST were 0,109± 0.186 µg/dl in female subjects. MSC level were 0,241± 0,460 µg/dl   and salivary cortisol level after 1 mg-DST were 0,153± 0.372µg/dl in male subjects. The mean midnight salivary cortisol level of the  obese and non-obese subjects were 0,292 ± 0,621 µg/dl and 0,350 ± 0,648 µg/dl respectively.  Salivary cortisol level after 1 mg-DST were 0,096±0.143 µg/dl and 0,178±0.2.64µg/dl in obese and non-obese patients respectively. There was no significant correlation between MSC and BMI, age, sex, smoking, exercise, waist and hip circumference, educational status, overnight dexamethasone suppression test, salivary cortisol level after 1 mg-DST and urinary cortisol level.

Conclusion: Although plasma cortisol level and its valuable predictor MSC level may be independent predictor s of metabolic parameters in obese and non-obese patients, we could not fýnd any significant correlation between them and BMI in our study.

 

Nothing to Disclose: MM, RT, HK, SDA, OSS, HB, SY, FA

14473 18.0000 SAT-0914 A Does Body Mass Index Affect Midnight Salivary Cortisol Level in Obese Patients ? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Juma Musabah Alkaabi*1, Syed Shah2 and Fatima Almaskari3
1FMHS, UAE University, Alain ABD, United Arab Emirates, 2College of Medicine and Health Sciences- UAE University, ALAIN, 3College of Medicine and Health Sciences- UAE University, ALAIN, United Arab Emirates

 

Background: There is reported worldwide increase in the prevalence of childhood obesity.  

Objectives: The aim of this study was to identify the prevalence of overweight and obesity among youth aged 15 to 18 years and its correlation with 25-hydroxyvitamin D levels in a school-based sample of schoolchildren Al Ain, United Arab Emirates.

Methods: It was a cross-sectional study. A random sample of 1018 adolescents aged 12 to 18 years was selected from 140 Schools. A self-administered questionnaire was used to obtain socio-demographic characteristics, physical activity and dietary habits. Blood samples were collected after overnight fast for more than 8 hours. Blood pressure (BP), height weight, waist and hip circumference measurements were made by trained nurses. Body mass index (BMI) less than 85th, greater than 85th but less than 95th, and ≥95th percentiles for age and gender were used to define normal, overweight and obese according to the 2000 CDC growth charts. Fasting blood glucose and plasma lipids were also measured.  Serum 25 (OH) D concentrations were measured in subset of youth aged 15 to 18 years.

Results: The age of study participants (n=315) ranged from 15 to 18 years. Of these 169 (52%) were females. Out of all the participants, a high proportion (34%) were overweight and obese. Overall 65% of study participants had vitamin D insufficiency (15-30 ng/mL) and 13% had vitamin D deficiency (‹15 ng/mL). A high proportion (21%) of female youth had vitamin D deficiency compared to their male counterparts (5%). After adjustment for age, female gender, obesity was negatively correlated with vitamin D levels (p‹0.05). Physical activity scores were positively and significantly (p‹0.05) correlated with vitamin D levels.

Conclusion: The present findings emphasize the alarming trends of obesity in children and high prevalence of vitamin D deficiency. There is significant disparity by gender and vitamin D deficiency prevention programs should particular focus female children.

 

Nothing to Disclose: JMA, SS, FA

15595 19.0000 SAT-0915 A Alarming Trends in Obesity Among Youth; Impact on Vitamin D Levels? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Chantacha Sitticharoon*
Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

 

Adiponectin, visfatin, and omentin are adipokines previously shown to be involved in insulin sensitizing action. This study aimed to determine the interactions among these subcutaneous and visceral adipose tissue gene expressions, their serum levels, and other clinical parameters including the homeostasis model assessment-estimated insulin resistance (HOMA-IR), and the quantitative insulin sensitivity check index (QUICKI). Adiponectin expression in both subcutaneous and visceral adipose tissues and serum adiponectin showed the highest among these adipokines. Subcutaneous adiponectin had positive correlations with serum adiponectin (R=0.533, p<0.05) and QUICKI (R=0.41, p=0.06). Serum adiponectin levels displayed negative correlations with body weight, BMI (R~-0.41, p<0.05), and HOMA-IR (R=-0.348, p=0.06) and positive correlations with QUICKI (R=0.39, p<0.05) and serum omentin-1 (R=0.36, p=0.05). Subcutaneous omentin negatively correlated with waist and hip circumferences (R~(-0.45)-(-0.48)), but positively correlated with QUICKI (R=0.41), p<0.05 all. Serum omentin-1 levels showed a positive correlation with QUICKI (R=0.45) but negative correlations with body weight, BMI, waist circumference, hip circumference (R~(-0.43)-(-0.52)), p<0.05 all and HOMA-IR (R=-0.337, p=0.069). Expression and serum levels of visfatin did not have significant correlation with any clinical parameters. There were positive correlations between subcutaneous expressions of adiponectin, visfatin, and omentin (R~0.540-0.975) and between visceral expressions of these genes (R~0.687-0.724), p<0.01 all. In conclusion, adiponectin and omentin, not visfatin, especially synthesized from subcutaneous adipose tissue, displayed correlations with decreased obesity and increased insulin sensitivity. The expressions of these adipokines were linked to each other in each type of adipose tissue but there was no cross-link between expressions in subcutaneous and visceral adipose tissues.

 

Nothing to Disclose: CS

16527 20.0000 SAT-0916 A Comparisons and Interactions Among Subcutaneous and Visceral Adipose Tissue Expressions and Serum Levels of Adiponectin, Visfatin, and Omentin and Their Correlations with Clinical Parameters and Peripheral Metabolic Factors in Obese and Non-Obese Female Subjects 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Kemal Agbaht* and Serap Kutlu
Balikesir State Hospital, Balikesir, Turkey

 

Background:  The relationship between Hashimoto’s thyroiditis and insulin resistance remains to be established.

Aim:To evaluate the role of Hashimoto’s thyroiditis, in insulin resistance and to determine the potential adipocytokines and other peptides that may mediate this relationship, in an obese population

Subjects/Methods: Eighty consecutive euthyroid obese women aged 20-65 years old admitted to Obesity Polyclinic were required to be included in the study. Exclusion criteria were any rheumatological disease, diabetes mellitus, adrenal or pituitary diseases, any medication (but antihypertensive or levothyroxine), acute infection, abnormal thyroid, liver or kidney functions. Their anthropometric measurements (by a body composition analyzer using bioelectrical impedance analysis method), fasting serum glucose, insulin, glucagon, ghrelin, visfatin, leptin, anti-TPO, lipid profiles, and other routine laboratory were studied. Anti-TPO positive subjects were compared with those who do share similar anthropometric characteristics and TSH levels, but not have thyroid autoimmunity.

Results:Anti-TPO (+) subjects (n=25) had lower fasting serum glucose, insulin, ghrelin and HOMA-IR levels, compared to their anti-TPO (-) peers (n=55). Accordingly, they had less metabolic disturbances (1.88±1.03 versus 2.50±1.03 met IDF-defined metabolic syndrome criteria, p=.009). They had comparable circulating leptin, visfatin, and glucagon levels. In the whole study group, anti-tpo titers well correlated with HOMA-IR (r=-.333, p=.011), ghrelin (r=-.289, p=.023), and insulin (r=-.280, p=.033) levels. A regression analysis suggested that, HOMA-IR was independently associated with BMI and lower anti-TPO titers.

Conclusion: Presence of thyroid autoimmunity, may be associated with a lower fasting insulin and glucose levels reflecting a greater insulin sensitivity, less metabolic disturbances in a given otherwise anthropometrically comparable obese euthyroid female population; by mechanism(s) probably involving decreased ghrelin secretion.

 

Nothing to Disclose: KA, SK

12212 21.0000 SAT-0917 A Presence of Hashimoto's Thyroiditis in Euthyroid Obese Women Might be Associated with a Greater Insulin Sensitivity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Mayumi Yamamoto*1, Akihiro Nishio2 and Aki Kanoh1
1Gifu Univ, Gifu, Japan, 2Gifu University, Gifu, Japan

 

[Background] On the basis of various lines of evidence from epidemiological data, the guidelines for criteria to select the high risk group for lifestyle related disease like metabolic syndrome have been established. However, those for high risk group in young adults have not been established. To create appropriate improved criteria for high risk group of lifestyle related disease in young adults, we assessed annual health check-up data of Gifu University students, Japan.

[Subjects and Methods] Annual health check-up data of 2,168 Gifu University students, including 1,361 male and 807 female students, (age range, 18–29 years) were analyzed. All the students were of the Japanese or Asian race. Abdominal circumference, body mass index (BMI), blood analysis data; GOT, GPT, g-GTP, LDL/HDL cholesterol, triglyceride (TG), uric acid (UA), fasting plasma glucose, fasting serum insulin level, and dental health check-up results were analyzed by chi-square test using the statistical package for JMP software (SAS Institute Japan co.).

[Results] There were significant correlations between BMI and abdominal circumference, blood pressure, GPT, g-GTP, LDL cholesterol, TG, fasting serum insulin level, and number of teeth requiring treatment, in both male and female students. There was no significant relationship between BMI and fasting blood glucose level; none of the students had a fasting glucose level of >110 mg/dl. Although 181 (13.3%) male students and 47 (5.8%) female students had a BMI of >25 and anomalous values of data described above, only 31 (2.3%) male students were diagnosed as having metabolic syndrome on the basis of the Japanese metabolic syndrome criteria.

[Discussion] It is valuable to initiate early intervention for improving the lifestyle of young adults to prevent the onset of lifestyle related disease. Therefore, appropriate criteria of high risk group of lifestyle related disease in health care screening should be established for young adults based on the evidence. The results of the present study suggested that the existing metabolic syndrome criteria are not sufficient for screening of high risk group of lifestyle related disease in Japanese young adults. We found that including data of BMI, GPT, and fasting insulin levels might be useful for the screening of young adults who require intervention of lifestyle modification.

 

Nothing to Disclose: MY, AN, AK

15798 22.0000 SAT-0918 A Obesity in Japanese University Students: Metabolic Syndrome Criteria Are Insufficient for Screening of Young Adults Requiring Intervention 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Paulyn Chinwe Nwaukwa*1, Boladale Alalade2, Anthony Chinedu Anyanwu3, Sandra Omozehio Iwuala4 and Augustine E Ohwovoriole5
1LAGOS UNIVERSITY TEACHING HOSPITAL, Lagos, Nigeria, 2Federal Medical Centre . Abeokuta, Nigeria, 3Division of EDM, Dept of Medicine, Lagos University Teaching Hospital, Lagos, Nigeria, 4Lagos Univ Teaching Hosp, Lagos, Nigeria, 5University of Lagos, Yaba Lagos, Nigeria

 

BODY FAT ESTIMATION IN HIV POSITIVE NIGERIAN PATIENTS ON HAARTS USING BIA.

1Dept of Medicine, Lagos University Teaching Hospital. Idi-Araba. Lagos

2Federal Medical Centre, Abeokuta. Ogun State.

Background .Human immunodeficiency virus (HIV) infection is a major health challenge in the world. Most organs including body fat are targets for the virus at various stages of the infection. The viral infection and/or its treatment are associated with metabolic dysfunctions including abnormalities with body fat composition and distribution. The pattern of body fat change in the disease has not been characterized in Nigerian subjects infected with the virus as has been done among other populations.

Research Hypothesis. There is no change in percentage body fat in  HIV positive Nigerian patients on HAARTS.   

Methodology

This was a case control study carried out at Lagos University Teaching Hospital in Nigeria. There was a total of 52 subjects with equal number of healthy controls and HIV subjects comprising 26 males and 26 females. Information obtained included age, sex, eight, waist circumference and height. HIV infected patients on antiretroviral treatment for more than six months and 103 healthy controls were matched for sex and for age. Bioelectric impedance analyzer was used to determine the fat composition in subjects and controls. This was expressed in percentages. Statistical analysis of the data obtained was done using SPSS19.

Results.

The mean age of the study participants was 33.38+ 4.6years for the HIV subjects and 33.38+ 4.6 years for the controls. The mean BMI was 23.89+4.5 kg/m2 for HIV subjects and 25.71+5.3kg/m2  for the controls. The mean BIA was 29.21+10.0% in the healthy controls which was significantly higher than the mean BIA of 26.21+9.6% in the HIV subjects, (t=6.47, p<0.001). The body fat assessment using BIA, male and female HIV subjects had a significantly lower BIA compared to controls. The mean BIA for male control subjects was 22.88+6.7% and 20.74+8.5% for the male HIV subjects (p<0.001). The mean BIA for female controls was 35.55+ 8.8% and 31.69+ 7.8% for the female HIV subjects (p<0.007).

 Conclusion

In this study, male and female with HIV treated on HAARTs when matched for age and sex were found to have less body fat compared to healthy controls using BIA assessment. Bioelectric impedance analyzer (BIA) remains a good means of assessment of the percentage body fat in this group of patients.

 

Nothing to Disclose: PCN, BA, ACA, SOI, AEO

15920 23.0000 SAT-0919 A Body Fat Estimation in HIV Positive Nigerians Using Bia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Panagiota Pervanidou*1, Giorgos Chouliaras1, Despoina Bastaki1, Katerina Papanicolaou1, Christina Kanaka-Gantenbein2 and George P. Chrousos2
1University of Athens Medical School, Athens, Greece, 2University of Athens School of Medicine, Athens, Greece

 

Background: Pediatric obesity commonly co-exists with anxiety, depression and social withdrawn (internalizing problems), while, epidemiological studies have shown an increased co-existence of obesity with delinquent and aggressive behaviors (externalizing problems). The Hypothalamic-Pituitary-Adrenal Axis is involved in the pathophysiology of anxiety and affective disorders and disturbed cortisol concentrations, elevated or decreased, have been reported in chronically stressed individuals with anxiety and/or depression (melancholic vs. atypical depression pattern, respectively). Fewer studies have also shown cortisol abnormalities in children with behavioral problems. 

Objectives and Hypothesis: We investigated the prevalence of internalizing and externalizing symptoms, reported by both parents and children, in a clinical population of obese children compared to normal-weight ones. In addition, we examined the role of cortisol as a potential mediator between stress-related symptoms, behavioral problems  and obesity.

Population and Methods: One hundred and ten (50% females) obese children (mean BMI z-score: 3.17 ± 1.32) were compared to 31 (58.6% females) normal weight controls (mean BMI z-score: -0.13 ± 0.60).  The Child Behavior Checklist [CBCL] (Achenbach, 1991) was used to measure children’s internalizing (anxiety, depression, social withdrawal) symptoms and externalizing (delinquent /aggressive) behaviors. Appropriate questionnaires were completed by parents and children. Salivary samples were collected serially  5 times a day. Salivary cortisol was measured by electrochemiluminescence immunoassay.

Results: T-scores of symptoms of anxiety, depression and social withdrawal, reported by children, were significantly higher (p=0.03) in the obese children than in the lean controls (49.3±12.3 vs. 43.2±9.1, respectively). The same was observed  in the mothers’ reports (p<0.001) (60.6±11.3 vs. 50.6±10.4, respectively). Delinquent and aggressive behaviors, reported by mothers, were significantly higher (p=0.003) in obese children than in controls (57.2 ±10.5 vs. 48.2±13.3, respectively), which was not confirmed by the children themselves. The salivary cortisol area under the curve (AUC) was significantly smaller in the obese children than the controls (p=0.03), however, the significance was lost when age and sex were inserted in the analysis. No significant associations were noted between cortisol concentrations and total internalizing/externalizing symptoms in children.

Conclusions: There is a high prevalence of parent and child- reported internalizing symptoms and parent-reported behavioral problems in a clinical sample of obese children. In this cross-sectional setting, salivary cortisol was not shown to mediate such associations.

 

Nothing to Disclose: PP, GC, DB, KP, CK, GPC

16165 24.0000 SAT-0920 A Increased Symptoms of Anxiety, Depression, Social Withdrawal and Delinquent /Aggressive Behaviors in a Clinical Population of Obese Children and Adolescents: Is Salivary Cortisol the Link? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Alalade Boladale*1, Oluwarotimi Bolaji Olopade2, Sandra Omozehio Iwuala3 and Augustine E Ohwovoriole4
1Federal Medical Centre Abeokuta Ogun State, ABEOKUTA, Nigeria, 2Lagos Univ Teaching Hosp, Surulere, Nigeria, 3Lagos Univ Teaching Hosp, Lagos, Nigeria, 4University of Lagos, Yaba Lagos, Nigeria

 

Background .Quantification of the body fat percentage, its scientific and clinical implications is critical to timely intervention as it has been proven to be a better measure of patient’s risk of cardiovascular diseases than the body mass index. Several techniques have been developed to assess body fat including imaging, dual energy X ray absorptiometry, bioelectrical impedance analysis (BIA) and underwater weighing. The use of anthropometric indices to derive percentage body fat provides an inexpensive surrogate. There has been no study comparing this surrogate with direct measurements of percentage body fat(%BF) in Nigeria.

Research Hypothesis. There is a strong relationship between percentage body fat (%BF) obtained using BIA and anthropometric indices

Objective.To determine the relationship between %BF determined with BIA and anthropometric indices.  

Methodology

The study was a cross sectional study carried out at Lagos University Teaching Hospital on 129(73 females and 56males) apparently healthy subjects. BIA measurements were performed to determine the percentage body fat using the standard protocol. Anthropometric measurements including height, weight, circumferences of waist, hip and neck were taken and BMI was derived from the raw data. Duremberg formula was used to derive the percentage body fat from BMI and Rope & Choke equation to predict %BF from other indices.

Statistical analysis was done using SPSS19. The estimates of %BF by BIA and the anthropometric indices were compared using student t test. Values are expressed as means and standard deviations. p<0.05 was regarded as significant

 

Results

0ne hundred and twenty nine subjects comprising 73females and 56males were studied. Mean age was 27.91 + 6.9years. The mean BMI was 23.11+4.97kg/m2 for females and 24.22+3.94kg/m2 for males .The mean %BF composition obtained by BIA was 31.79+9.53%, 20.67+8.04%,Duremberg formula, 28.35+6.79%,19.84 +5.74% and Rope and choke equation 29.94 +9.73%,29.93 +8.03% for females and males respectively. There is a strong correlation between the %BF obtained using BIA and the anthropometric indices r= 0.819 and 0.773 for females and r=0.917 and 0.832 for males.

Conclusion.

There is correlation between body fat estimation using BIA and the anthropometric indices. These surrogate measures can be used reliably in our environment to estimate body fat.

 

Nothing to Disclose: AB, OBO, SOI, AEO

16826 25.0000 SAT-0921 A Comparison of Surrogate Measures of Percentage Body Fat with Standard Techniques in Nigerians 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Li Li*1, Richard Shelton1 and Barbara Ann Gower2
1University of Alabama at Birmingham, Birmingham, AL, 2Univ of AL at Birmingham, Birmingham, AL

 

Obesity, affecting 17% of children and adolescents and 36% of adults, is a global health problem. Although the cause of the obesity epidemic is multi-factorial, accumulating evidence indicates that early life exposure to a wide range of maltreatment increases the risk for metabolic syndrome, including obesity. Childhood maltreatment (CM), approximate 3 million cases reported annually in the U.S. alone, has been demonstrated to have lasting effects on endocrine, immune and central nervous systems, leading to various physical illnesses, including obesity. However, whether CM predisposes individuals to obesity, and the underlying mechanisms for such associations, are not known. In the present study, we aimed to determine whether CM is associated with obesity in adults, and to identify potential underlying mechanisms. CM was assessed by the Childhood Trauma Questionnaire that measured physical neglect, emotional neglect, physical abuse, emotional abuse, and sexual abuse. Body composition was measured by dual-energy X-ray absorptiometry. All participants were requested to provide saliva samples at wake-up, and 15, 30 and 60 mins post wake-up for the measurement of cortisol awakening response and the calculation of area under curve, representing the HPA axis activity. Linear regression was used to evaluate the associations between CM and the HPA axis activity. Compared with age-, sex- and race-matched controls (without CM exposure), CM subjects had higher body mass index and greater waist circumference. Moreover, CM subjects also tended to have greater total body fat and android fat mass, but less lean mass. Compared with controls, CM subjects had a blunted cortisol response, which was associated with increased body mass index, greater waist circumference, and greater total fat and android fat mass. Our results suggest that body composition and body fat distribution may be influenced by CM exposure. Furthermore, perturbation of the HPA axis may be mechanistically associated with total and central body fat. Future preventive interventions in obesity may target people with CM to reduce the risk for obesity and metabolic syndrome.

 

Nothing to Disclose: LL, RS, BAG

12709 26.0000 SAT-0922 A Impacts of Childhood Maltreatment on Obesity and Its Mechanisms 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Xueyao Yin1, Fenping Zheng2, Jiaqiang Zhou2, Ying Du2, Qianqian Pan2, Saifei Zhang2, Dan Yu2 and Hong Li*3
1The Affiliated Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, China, 2The Affiliated Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3Sir Run Run Shaw Hospital Affiliated with Zhejiang University School of Medicine, Hangzhou, China

 

Central obesity is considered to be a central component of metabolic syndrome. Waist circumference (WC) has been widely used as a simple indicator of central obesity. This study aimed at evaluating the sensitivity and cut-off points of WC for predicting the metabolic risk factors in middle-aged Chinese. The study involved 923 subjects aged 40–65 years. The metabolic risk factors were defined according to the Chinese Joint Committee for Developing Chinese Guidelines on Prevention and Treatment of Dyslipidemia in Adults. WC cutoff values 85–90cm and ≥90cm were defined as central pre-obesity and obesity in males (80–85cm and≥85cm in females). First, WC corresponding to body mass index (BMI) 24kg/m2 and VFA 80cm2 was 88.55cm and 88.51cm in males, and 81.46cm and 82.51cm in females respectively. Second, receiver operating characteristic curves showed that the optimal cutoff of WC was 88.75cm in males, larger than that in females (81.75cm). Third, participants with higher WC were more likely to have accumulating metabolic risk factors. The prevalence of metabolic risk factors increased linearly and significantly in relation to WC levels. In conclusion, the WC cutoff values of central pre-/central obesity are optimal to predict multiple metabolic risk factors.

 

Nothing to Disclose: XY, FZ, JZ, YD, QP, SZ, DY, HL

13578 27.0000 SAT-0923 A Central Obesity and Metabolic Risk Factors in Middle-Aged Chinese 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM SAT 0897-0923 4844 1:00:00 PM Clinical Studies in Obesity Poster

Lina Merjaneh*1, John S Parks1, Andrew B Muir2 and Doris Olukemi Fadoju1
1Emory University, Atlanta, GA, 2Emory University School of Medicine, Atlanta, GA

 

BACKGROUND:  Trichorhinophalangeal syndrome type I (TRPSI) is a rare congenital syndrome, characterized by distinct craniofacial and skeletal malformations that include thin scalp hair, pear-shaped nose, cone-shaped epiphyses, hip dysplasia and short stature. It is inherited in an autosomal dominant manner and caused by haploinsufficiency in the TRPS1 gene, a transcription repressor expressed in cartilage and hair. Inconsistent responses to growth hormone (GH) treatment have been reported in affected patients.  

CLINICAL CASE:  A 7 year-old male with a history of bilateral hip dysplasia since age 3 years presented with a height SDS score of -2.4. The diagnosis of TRPSI was suspected only after combining features of 2 other siblings and the mother, all of whom were short in stature. They also had thin sparse scalp hair, long flat philtrum, thin upper vermilion border, bulbous nose tip, high arched narrow palate and overcrowded teeth. Laboratory evaluation of the 7 y.o. and his 5 y.o. brother showed normal thyroid function, IGF1, IGFBP3, and metabolic panel. The 7 y.o. had normally shaped phalangeal epiphyses with a delayed bone age (- 4.3 SD). The 5 y.o. had conical phalangeal epiphyses with a delayed bone age (- 3.5 SD).  Heterozygous TRPS1 gene nonsense mutation was found (c.3368 G>A; p.Trp1123Stop) in both brothers which is a variant that has not been reported previously.  After 2 years of GH treatment (0.24-0.32 mg/kg/week), the older sib experienced a 1 SDS gain in height. His untreated younger brother had no growth acceleration in the same interval. GH-responsive short stature was therefore identified, despite a pre-treatment peak GH response of 15.3 ng/mL to insulin and normal circulating concentrations of IGF1 (180 ng/mL, normal: 37-217) and IGFBP3 (3.9 mg/L, normal: 1.4-6.1). Whereas bone age advanced normally in the year prior to GH treatment, it advanced 4.5 years during the 2 year treatment.

We postulate that TRPS1 haploinsufficiency causes inadequate response to GH or GH-dependent growth factors in the epiphyseal plate in association with previously described dysregulation of chondrocyte differentiation and proliferation. Treatment with exogenous GH may compensate for this inadequate response by providing higher levels of GH and IGF1 locally.

CONCLUSION: This report emphasizes the importance of examining all family members when suspecting a genetic syndrome.  Despite a normal GH-IGF1 axis, growth rate may be GH-responsive in TRPSI. Bone age advanced rapidly during treatment, so the effect on final height is unknown.  The significant skeletal abnormalities in this family with a previously unreported nonsense mutation argue against the hypothesis that downstream mutations of TRPS1 cause mild phenotypes. More studies are needed before recommending TRPSI as an indication for GH treatment.

 

Nothing to Disclose: LM, JSP, ABM, DOF

11635 1.0000 SAT-0121 A Novel Trichorhinophalangeal Syndrome Type I (TRPS1) Gene Mutation in a Family with Short Stature Responsive to Growth Hormone Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Mustafa Tosur*1, Cara A Geary2, Ravi S Radhakrishnan2, William F Tarry2, Jianli Dong2, Reuben Matalon2 and Phillip D K Lee2
1Texas Children's Hospital / Baylor College of Medicine, Galveston, TX, 2University of Texas Medical Branch, Galveston, TX

 

Persistent müllerian duct syndrome associated with 46,XY, del(10q25.3q26.13)

Background: Persistent müllerian duct syndrome (PMD ) with antimüllerian hormone (AMH) deficiency is usually associated with mutations or deletions of AMH(chromosome 19p13.3) although many cases have no identified gene association. We report a male infant with PMD and AMH deficiency associated with interstitial deletion of 10qter.

Clinical Case: A full term 3230g infant was born to a healthy 27 year old. Fetal ultrasounds had shown possible genital ambiguity; amniocentesis was refused.  Genital exam showed a 0.5 cm phallus with basal meatus, normal scrotum with no palpable gonads, no vaginal orifice, and a rectal fistula with an imperforate anus. Other findings included micrognathia, hypertelorism, broad flat nasal bridge, high arched palate, nail hypoplasia, and sacral dimple.

Voiding cystourethrogram with ultrasound, cystoscopy and laparoscopy showed normal bladder, urethral orifice, distal vagina, cervix and bilateral abdominal testis. At 24 hours testosterone was 210 ng/dl (RR 132-813) with low AMH (14.77 ng/ml, RR 15.5-48.1). At one month, testosterone was 84.6 ng/dl and AMH was 14.77 ng/ml (RR 39.1-91.1). Chromosome analysis showed 46,XY, del10(10q25.3q26.13) involving an 8.2MB interstitial deletion.  A NOTCH2 variant (1p11.2) was also identified via whole exome sequencing. AMH sequencing revealed no abnormalities.

Following multidisciplinary team and parent discussion, male gender was assigned. Testosterone cypionate 25 mg IM was given monthly for 4 doses resulting in penile length 1.5 cm. Hypospadias repair was performed at 5 months with further surgical procedures planned. The patient has continued to grow normally.

Conclusion: This case suggests an association of 10qter elements with male differentiation including AMH expression and is similar to a case of 46, XY, del(10q26.1) in which AMH was not characterized (1). Regional candidate genes include FGFR2 (10q26.13). For our case, possible involvement of NOTCH2 is also considered.

 

Nothing to Disclose: MT, CAG, RSR, WFT, JD, RM, PDKL

11691 2.0000 SAT-0122 A Persistent Müllerian Duct Syndrome Associated with 46,XY, Del(10q25.3q26.13) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Emir Tas*1 and Luigi R Garibaldi2
1Children's Hospital Pittsburgh of UPMC, Pittsburgh, PA, 2Children's Hospital of UPMC, Pittsburgh, PA

 

Introduction: Diazoxide is the accepted first line medical treatment for persistent hyperinsulinemic hypoglycemia of infancy. It is generally safe, effective and well tolerated, although occasional severe adverse reactions are described. We report a patient with cardiopulmonary failure and fluid retention, massive hepatomegaly, and direct hyperbilirubinemia which were improved following discontinuation of diazoxide treatment.

Case Report: The patient was born at 35 weeks via emergent C-section due to fetal distress with marked acidosis at birth (pH:6.89 and base deficit:15). Serum glucose at 3 hrs of life was 20 mg/dl. He required high glucose infusion rates of up to 21 mg/kg/min to maintain euglycemia. Hyperinsulinemia was proven via a critical blood sample(glucose 47 mg/dl, insulin 22 uU/ml). Cortisol, growth hormone, and lactate levels were appropriate for the degree of hypoglycemia, whereas the beta hydroxy butyrate level was undetectable. He had elevated liver enzymes, and direct hyperbilirubinemia. Diazoxide was started at day 10 and the dose increased to 10 mg/kg/day which resulted in adequate blood glucose control. Over the succeeding days he was gradually weaned off the IV fluids. Liver enzymes normalized, but hyperbilirubinemia worsened (direct 5 mg/dl; total 7.3 mg/dl) despite clinical improvement. After optimization of enteral feeding and improved PO intake he was discharged home at 4 weeks with ursodiol and diazoxide.

On the 59th day of life he presented with cardiorespiratory failure, hypothermia, hyponatremia, hepatomegaly, hyperbilirubinemia (direct 5.1 mg/dl; total 8.3 mg/dl), hyperglycemia (199 mg/dl) and hypoalbuminemia (2.3 mg/dl). ECHO showed elevated right sided pressures with RV hypertrophy. Beckwith-Wiedemann Syndrome (BWS) was considered due to macroglossia; the alpha feta protein (AFP) level was high at 9,752 ng/ml (ref:<400) raising concerns for hepatoblastoma. Abdominal US showed an enlarged liver; MRI confirmed hepatomegaly without focal liver pathology. Diazoxide treatment was discontinued because of hyperglycemia and concerns for adverse reactions. There was marked improvement in clinical status in a week; fluid balance became negative, he was successfully extubated, and AFP levels returned to normal. He did not have hypoglycemia after cessation of diazoxide and was able to fast 8 hours.  Hepatomegaly resolved and the patient was discharged at 80 day of life without any medication.

Conclusion: We postulate that the risk of diazoxide toxicity increases in patients with hypoalbuminemia and direct hyperbilirubinemia because this drug is normally bound by plasma proteins which are usually diminished with impaired liver function. Caution should be exercised using diazoxide in patients with ongoing liver injuries.

 

Nothing to Disclose: ET, LRG

11748 3.0000 SAT-0123 A Existing Liver Injury Increases the Risk of Diazoxide Toxicity: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Emir Tas*1, Jessica Sebastian2, Svetlana A Yatsenko3, Suneeta Madan-Khetarpal2, Francis X Schneck2 and Selma Feldman Witchel2
1Childrens Hospital Pittsburgh of UPMC, Pittsburgh, PA, 2Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, 3University of Pittsburgh, Pittsburgh, PA

 

Introduction: The prevalence of hypospadias is estimated to be 4 in 1000 newborn males; cryptorchidism is often an associated finding (1). Here we report a male infant with penoscrotal hypospadias and his mother who had a bicornuate uterus.

Case Report: The proband was the product of a 33+ week gestation to a G3P2 mother via vaginal delivery. Pregnancy was complicated by incompetent cervix and bicornuate uterus. Physical exam showed penoscrotal hypospadias, moderately severe chordee, and right undescended testis. No obvious digit anomalies were noted. Renal US showed pelvicaliectasis of the left kidney with partially extrarenal pelvis. Skeletal survey demonstrated thoracolumbar scoliosis with otherwise normal findings. Other findings were mild developmental delay, and macrocephaly. SNP microarray study revealed 589 kb deletion at 7p15.2. This region encompasses the homeobox (HOX) A cluster genes which includes HOXA13. FISH analysis with the RP11-145I24 clone (7p15.2) confirmed the microarray findings. The same deletion was also demonstrated in the patient's mother. The patient’s older brother had been born at 29 weeks gestation due to preterm labor; he has a normal phenotype and does not carry the 7p15.2 deletion.

Conclusion: The proband and his mother had features of the hand-foot-genital syndrome (HFGS) which is characterized by urogenital and limb anomalies. In addition to abnormalities of the ureters and urethra, affected males may have hypospadias and cryptorchidism. Affected females may present with incomplete Mullerian fusion, bicornuate uterus, an increased risk of premature labor, pregnancy loss or stillbirth. HFGS is an autosomal dominant disorder, caused by mutations in the HOXA13 gene on chromosome 7p15. Deletions involving the HOXA cluster are rarely reported in the literature with only a few individuals described (2).Patients with the chromosome 7p14-p15 deletions have features of the HFGS as well as additional manifestations due to haploinsufficiency of other genes in the deleted regions. Our patient and his mother carry the smallest microdeletion in the HOXA cluster, manifest mild skeletal finding of thumb and great toe hypoplasia, and both have urogenital defects, consistent with HFGS. The family history of urogenital anomalies prompted the genetic testing leading to the identification of HFGS in this family despite the minimal skeletal phenotype.

 

Nothing to Disclose: ET, JS, SAY, SM, FXS, SFW

12226 4.0000 SAT-0124 A Familial Hand-Foot-Genital Syndrome Associated with Deletion of HOXA13 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Atsuko Kawano, Yuichi Mushimoto and Kenichi Miyako*
Fukuoka Children's Hospital, Fukuoka, Japan

 

Background: Down syndrome is often associated with congenital hypothyroidism or autoimmune thyroid disease.  We describe a patient who had Down syndrome with congenital hypothyroidism in whom multiple anti-thyroid antibodies appeared and report the prevalence of positive anti-thyroid antibodies in patients with congenital hypothyroidism at our hospital.

Clinical case: The patient was a 3-year-old boy. Levothyroxine sodium was initiated because of persistent jaundice and an elevated level of TSH (13.95 μIU/ml) at the age of 28 days.  At 2 years of age, thyroid function tests showed TSH <0.03 μIU/ml (n: 0.35-4.94), fT4 2.53 ng/dl (n: 0.70-1.85), and fT3 5.85 pg/ml (n: 1.71-3.71), leading to discontinuation of treatment.  The anti-thyroid antibodies were also positive: anti-thyroglobulin antibody, 299 IU/ml (n: <28); anti-thyroid peroxidase antibody, 144 IU/ml (n: <16); thyroid-stimulating antibody, 505% (n: ≤180); and TSH receptor antibody, 69.4% (n: ≤15).  After 2 months, levothyroxine sodium was resumed because the TSH was 150.18 μIU/ml, and the fT4 was <0.40 ng/dl.

Prevalence of positive anti-thyroid antibodies: We studied 147 patients who had elevated TSH levels on newborn screening or on thyroid function tests performed because of symptoms suggesting hypothyroidism.  Patients younger than 6 months were not included because of possible effects of transplacental maternal antibodies.  Anti-thyroid antibodies were positive in 17 patients (11.6%).  Of 17 patients with positive antibody (antibodies), 7 had Down syndrome.  Five patients had only anti-thyroglobulin antibody, 9 had only anti-thyroid peroxidase antibody, and 1 had only TSH receptor antibody.  All of these antibodies were positive in only our patient, and both anti-thyroglobulin antibody and anti-thyroid peroxidase antibody were positive in 1 patient.  Both patients with multiple antibodies had Down syndrome.  Our patient and the one with anti-thyroglobulin antibody had transient hyperthyroidism during the course of apparently painless thyroiditis.

Conclusion: Anti-thyroid antibodies should be checked even in patients with congenital hypothyroidism, especially Down syndrome, because these antibodies can affect the clinical course of treatment for congenital hypothyroidism.

 

Nothing to Disclose: AK, YM, KM

12476 5.0000 SAT-0125 A A Case of Down Syndrome with Positive Anti-Thyroid Antibodies during Treatment for Congenital Hypothyroidism: Pitfalls in the Management of Congenital Hypothyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Yuichi Miyakawa*1, Yohei Matsubara2, Atsumi Tsuji2, Kei Takasawa1 and Kenichi Kashimada1
1Tokyo Medical and Dental University, Tokyo, Japan, 2Tokyo Medical and Dental University (TMDU), Tokyo, Japan

 

Background: Pseudohypoparathyroidism type 1a (PHP1a) is a hereditary disorder characterized by hypocalcemia due to resistance to PTH accompanied with obesity, developmental delay and skeletal features called Albright hereditary osteodystrophy. Discovering PHP1a patients before developing hypocalcemia is important because hypocalcemia could cause serious clinical problems, such as generalized tetany and seizure. For early diagnosis, elucidating clinical details of PHP1a during early childhood is essential. Obesity and developmental delay have been reported to appear prior to hypocalcemia, however, the details of those clinical symptoms have not been documented. Here we report six PHP1a patients from three families who showed language delay and obesity without delayed gross motor development.

Cases: All six patients showed maternally inherited mutations of GNAS (Case 1A: Q35X, Case 2A, 2B, 2C: A189MfsX14, Case 3A, 3B: P114WfsX7) and remarkable increased level of intact PTH. Vitamin D therapy was started immediately after the diagnosis. Except Case 3A and 3B, hypocalcemia was not observed at diagnosis.

Case 1A (4 yrs female) and three siblings, Case 2A (14 yrs female), 2B (7 yrs male) and 2C (4 yrs female), did not speak any words until two and a half years old, however, their verbal development was improved by five years of age. The IQ scores of Case 1A and Case 2B were 100 (at 4 yrs old) and 99 (at 5 yrs old) respectively. Currently Case 2A and 2B are attending regular class of junior high school and primary school, respectively. Siblings of Case 3A (5 yrs male) and Case 3B (4 yrs female) showed language delay and their IQ scores were 72 and 86, respectively. We are now observing their development with supportive care.

Conclusion: Language delay with obesity might be a clinical feature of PHP1a during early childhood, and the delay of some PHP1a patients is temporal, disappearing in late childhood. For early diagnosis of PHP1a, careful clinical approach, including detailed assessment for language development, might be important.

 

Nothing to Disclose: YM, YM, AT, KT, KK

13308 6.0000 SAT-0126 A Three Families of Pseudohypoparathyroidism Type 1a (PHP1a) with Delayed Language Development during Early Childhood 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Filippina Filia Dimitriadi*1, Robert Gonsalves2, Francesco De Luca3 and Anita Azam1
1St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, 2Arizona College of Osteopathic Medicine, Glendale, AZ, 3St. Christopher's Hospital for Children, Philadelphia, PA

 

Background: Graves' Disease is a common pediatric thyroid disorder, which can be associated with other autoimmune endocrine disorders such as Type 1 Diabetes Mellitus.  We report a case of newly diagnosed Type 1 Diabetes Mellitus that occurred 12 hours after the initiation of treatment for hyperthyroidism due to Graves' disease.

Clinical Case: ND, a 6 2/12 female presented with a 2-month history of diarrhea, weight loss , palpitations, difficulty concentrating, protrusion of the eyes, polyphagia, polyuria, polydipsia, and nocturia.

Upon initial examination, her physical examination was remarkable for bilateral exophthalmos with lid lag, a smooth diffuse goiter without palpable nodules , fine upper extremity tremor, and tachycardia (HR 160-180 bpm). Her weight was at the 50-75th percentile and height at the 90-95thpercentile for age.

During her hospitalization, biochemical studies confirmed hyperthyroidism with a low TSH of 0.04 mIU/mL (0.5-4.3) , a raised Total T4 of 36.4 ug/dL (4.2-12) , FT4 >8 ng/dL (0.9-1.4) and  T3 >7.81 ng/mL (0.9-2.4). An EKG confirmed sinus tachycardia and an echocardiogram was normal. Initial blood glucose on admission was 56 mg/dL. Methimazole (0.5mg/kg/day) and atenolol (1mg/kg/day) were initiated. 

On the second day of hospitalization, her blood glucose was significantly elevated to 695 mg/dl. Further investigation showed a raised HgbA1c of 9.5% and a normal VBG. UA revealed moderate ketonuria. She was started on a basal-bolus insulin regimen. TSI elevation to 807% confirmed Graves' Disease. Anti-GAD 65 and Anti-insulin antibodies were later found to be elevated to 193.6 (nl <5) and 28 (nl <5) respectively.

ND responded well to the treatment for both hyperthyroidism and diabetes. Evaluation for possible Autoimmune Polyglandular Syndrome (APS II/III) revealed negative 21-hydroxylase abs, and a normal peak cortisol of 28.7 mcg/dL in response to 250mcg of Cosyntropin ,excluding primary adrenal insufficiency.

Conclusion: To our knowledge, this is the first reported case of a child with new-onset Graves' Disease, shortly followed by the onset of Type 1 Diabetes Mellitus.

 

Nothing to Disclose: FFD, RG, FD, AA

14092 7.0000 SAT-0127 A New-Onset Type 1 Diabetes Mellitus Diagnosed Shortly after the Initiation of Treatment for Newly Diagnosed Grave's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Zohreh Shoar*1, Barbara A Kelly1 and Carol E Anderson2
1Albert Einstein Medical Center, Philadelphia, PA, 2St Christopher's Hosp. for Children, Section of Medical Genetics, Philadelphia, PA

 

Background:

Cytogenetic studies provide the possibility to diagnose genomic alterations early in life and guide the management and treatment plans. Here we present a female infant with dysmorphic features, hypotonia, and congenital heart disease whose cytogenetic study revealed two copy number variations: one deletion of the Prader-Willi/Angelman Syndrome (PW/AS) critical region, and the other with a variable clinical presentation including Maturity Onset Diabetes of Youth type 5 (MODY5).

Clinical Case:

A 2250 gram female late term infant was born by vacuum assisted vaginal delivery to a 28 years old African American mother following an uneventful pregnancy, adequate perinatal care, and normal perinatal laboratory and ultrasound results. The amniotic fluid was moderately meconium stained but delivery was uneventful. The infant was small for gestational age (weight <10%, height at 25%, head circumference <10%). Physical exam revealed dysmorphic features: occipital bossing, low-set posteriorly rotated ears with prominent antihelix, high palate, micrognathia, small rocker-bottom feet, Mongolian spots on mid-forehead and buttocks, and generalized decreased muscle tone and poor suck. Initial laboratory results including CMV viral culture, glucose levels, and newborn screening were normal. A renal ultrasound showed small otherwise unremarkable kidneys and head ultrasound was normal. Chromosomal Microarray Analysis (CMA) showed two copy number alterations: an interstitial deletion on 15q11.2q13 that encompasses the critical region deleted in PW/AS and a second deletion on 17q12 contains multiple reference genes and overlaps the genomic region of patients with 17q12 syndrome. The 17q12 syndrome is associated with variable clinical presentations including MODY5, renal cystic disease, pancreatic atrophy, liver and genital tract abnormalities, and autistic or attention deficit hyperactivity disorders. The patient continued with feeding difficulties and further evaluation, on day 10 of life, showed moderate pharyngeal dysphasia. A nasogastric tube (NG) feeding was initiated to prevent further failure to thrive. In addition, the patient had several episodes of bradycardia. An echocardiogram showed trivial patent ductus arteriosus and patent foramen ovale with left to right shunt. At the 6 months visit, she was still on NG feeds with some oral intake, but no improvement in weight or tone despite receiving speech and physical therapy. The patient is being monitored for endocrine abnormalities associated with both of these de novo deletions.

Conclusion:

This case illustrates that CMA can reveal modifying genetic factors (single gene, microdeletions, microduplications, and etc.) that could impact the severity of the effects of the genetic syndrome and metabolic/endocrine disorder on the patient.

 

Nothing to Disclose: ZS, BAK, CEA

14177 8.0000 SAT-0128 A Coexistence of Prader-Willi Syndrome and Microdeletion Containing Mody 5 Gene in a Female Infant 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Manjula Chatterjee*1 and Pankaj Jain2
1The Brooklyn Hosp Ctr, Brooklyn, NY, 2The Brooklyn Hospital Ctr, Brooklyn, NY

 

Background: AIS results from mutations that cause impairment of androgen receptor (AR) function. The typical presentation is a phenotypic female presenting with primary amenorrhea. Incidence is estimated to be 1 in 64,000. It is an X-linked recessive condition. Situs inversus is characterized by reversal of major organs from their normal position. Transmission is mainly autosomal recessive but X-linked cases have been reported.

Objective:  To present an unusual case of situs inversus and androgen insensitivity syndrome (AIS) in the same individual.

Method: Clinical, biochemical, chromosomal, and radiographic features were assessed. Hormonal testing and karyotype were done at Quest diagnostics. Bone density was done using GE Lunar system.

Clinical case: Index female patient, of Middle Eastern descent, was found to have situs inversus at the time of immigration to the United States of America during health screening at age sixteen. The primary care physician performed various radiological investigations to confirm the diagnosis. Chest X-ray showed heart on right side and abdominal x-ray revealed antrum bubble on left side of the abdomen. Abdominal sonogram revealed spleen on right side and liver on left. Incidentally, pelvic sonogram failed to show any internal female organs. No gonads were seen on either sonogram. Patient was then referred to endocrinology for further evaluation. Other than primary amenorrhea, there were no complaints. Physical examination was significant for tall stature (74th percentile), and slim built (weight 27th percentile, BMI 12th percentile) female phenotype. Heart sounds were normal except apical impulse was on right side. Pubertal signs revealed axillary and pubic hair at Tanner stage I, and breast at III. Hormone tests showed high levels of testosterone (964 ng/dl), free testosterone (105.1 pg/ml), low serum estradiol (28 pg/ml), and an unsuppressed antimullerian hormone (>440 ng/ml). Adrenal hormones and gonadotropins were not high. Karyotype was 46 XY confirming the diagnosis of AIS. MRI of lower abdomen and pelvis showed a gonad in right inguinal canal, with the other gonad less well defined. Genetic studies to detect AR mutation is underway. Unfortunately, mother is not alive to confirm the mode of transmission. Bone density scan (Z-score not reported) is reported to show no changes when read as a female. Patient had extremely low serum 25-OH Vitamin D level for which therapy was initiated, supplemented with oral calcium. 

Conclusion:  We present a case with coincident findings of two conditions in the same patient, and to our knowledge this has not been previously described in literature.

 

Nothing to Disclose: MC, PJ

14241 9.0000 SAT-0129 A Unique Case of Androgen Insensitivity Syndrome (AIS) and Situs Inversus in the Same Individual 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Chelsey Grimbly1, Oana Caluseriu2, Peter Metcalfe2, Mary M Jetha1 and Elizabeth T Rosolowsky*1
1University of Alberta, Edmonton, AB, Canada, 2University of Alberta

 

Background: Disorders of sexual development are a complex group of congenital entities with variable clinical presentation as a result of discordance among chromosomal, gonadal, and phenotypic sex. 17ßHSD deficiency type 3 is a rare cause of 46,XY sex reversal due to blocked conversion of androstenedione (A) to testosterone (T). Affected newborns often appear phenotypically female, may have ambiguous genitalia, and/or bilateral inguinal masses. Commonly reared as girls, they have an increased chance of virilizing at puberty. Diagnosis relies on hCG-stimulated A and T. Lack of standardized cut-offs blur distinctions among 17ßHSD deficiency, complete androgen insensitivity syndrome, and 5-alpha reductase deficiency. Genetic testing is usually reserved for confirmatory purposes.

Clinical Case: A 1-month old female infant was found to have bilateral inguinal masses during a routine physical examination. Pelvic ultrasound confirmed inguinal gonads and absent uterus. Karyotype showed normal male complement, 46,XY. Baseline hormone levels were:  T 1.2 nmol/L (normal 0.62-2.0 nmol/L), A 4.5 nmol/L (<3.0 nmol/L), and T:A 0.3 (>0.8). Following a short hCG stimulation test (1500 IU daily for 2 days), T was 2.1 nmol/L, A 5.4 nmol/L, and T:A 0.4.

Our multidisciplinary clinical team pursued genetic testing for 17ßHSD deficiency on the basis of low T:A ratios and persistent low T after stimulation. This involved petitioning for provincial government funding on an expedited basis. Meanwhile, the patient underwent prolonged hCG stimulation testing (1500 IU twice weekly for 3 weeks) in an attempt to obtain clear diagnostic results, testing which was cumbersome for the infant and parents and hospital and laboratory personnel. The parents were committed to raising the baby as a girl and experienced considerable anxiety over the absence of a diagnosis and the presence of testes.

Genetic results became available before completion of hCG stimulation and revealed a previously reported homozygous mutation in the HSD17B3 gene (c.389 A>G) predicted to determine complete loss of enzyme activity. The cost of genetic testing was comparable to prolonged hCG stimulation testing.

Conclusion: Genetic diagnosis of 17ßHSD type 3 deficiency excluded other causes of 46,XY sex reversal, reduced parental anxiety, provided the basis for anticipatory guidance and customized genetic counseling, and could have minimized prolonged hormone testing. We advocate for a more prominent role for timely genetic testing in diagnosing rare endocrine diseases, including 46,XY sex reversal in infants.

 

Nothing to Disclose: CG, OC, PM, MMJ, ETR

14287 10.0000 SAT-0130 A Genetic Testing Is Essential for the Rapid Diagnosis of 17ß-Hydroxysteroid Dehydrogenase (17ßHSD) Deficiency Type 3 in a Complete 46,XY Sex Reversed Infant 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Hae Woon Jung*1, Hwa Young Kim2, Kyung Min Lee2, Andrew Dauber3, Vivian Hwa4, Ron G Rosenfeld4, Young Ah Lee2, Choong Ho Shin1 and Sei Won Yang2
1Seoul National University Children's Hospital, Seoul, Korea, Republic of (South), 2Seoul Natl Univ College of Med, Seoul, Korea, Republic of (South), 3Boston Childrens' Hospital, Boston, MA, 4Oregon Health and Science University, Portland, OR

 

Background:Microcephalic primordial dwarfism (MPD) is characterized by intrauterine growth restriction (IUGR), impaired post natal growth and microcephaly. Majewski Osteodysplastic Primordial Dwarfism Type II (MOPD II) syndrome is distinctive in this class by a relatively proportionate head circumference (HC) at birth with later progression to disproportionate microcephaly, skeletal dysplasia, unusual facial features and abnormal dentition among other reported anomalies.

Clinical case:Two Korean male siblings were followed from birth to the current ages of 18 and 9 years for short stature. The brothers were born to nonconsanguineous parents. The birth weight and length of the older brother was 1070g (-9.3 SDS) and 33cm (-5.9 SDS) respectively. The birth weight, length and HC of the younger brother was 1080g (-9.2 SDS), 36cm (-4.9 SDS), and 26.5cm (-7.1 SDS) respectively. At initial presentation, facial features were not clearly dysmorphic and skeletal dysplasia was not evident. Growth hormone (GH) stimulation tests revealed normal GH secretion with normal levels of insulin like growth factor-I (IGF-I), and IGF-binding protein 3 (IGFBP-3). A trial of GH therapy was started in the older sibling at 3 years of age, but discontinued with little effect. IGF-I insensitivity was suspected, but analysis of the IGF-I and IGF-I receptor genes were normal. Growth velocity (GV) of the older sibling was consistently 3.5-4.4cm/yr until 12 years of age when GV decreased and a final height of 104.9cm was reached. Dysmorphic facial features with prominent nose and micrognathia as well as bony dysplasia with metaphyseal widening in the distal radius and ulna became more evident in both siblings at an older age. A defect outside the GH-IGF-I axis was suspected. Sequence analyses revealed compound heterozygous mutations in the pericentrin (PCNT) gene in the probands, with the unaffected father carrying a c.1207+1G>A mutation (splicing defect) in exon 7 and the unaffected mother carrying a c.3031dupA in exon 15. Both mutations are predicted to result in frameshifts and early protein termination.

Conclusion: Novel compound heterozygous mutations of the PCNT gene are reported through the case of two Korean siblings. It is the first report of confirmed PCNT mutations leading to diagnosis of MOPD II in Korea and underlines the importance of integrating careful clinical and genetic assessments in identification of rare causative mechanisms of growth failure.

 

Nothing to Disclose: HWJ, HYK, KML, AD, VH, RGR, YAL, CHS, SWY

14408 11.0000 SAT-0131 A Novel Mutations of the Pericentrin Gene in Korean Brothers Leading to Diagnosis of Majewski Osteodysplastic Primordial Dwarfism Type II Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Maria Fernanda Contreras*1, Bina Shah2 and Resmy Palliyil Gopi3
1New York University, 2New York University School of Medicine, New York, NY, 3NYU School of Medicine, New York, NY

 

Background: Turner Syndrome (TS) affects approximately 1 in 2,500 live female births. In general TS result in short stature and skeletal features. (1) The stature abnormality in TS is implicated due to haploinsufficiency of SHOX gene. The adult height in patients with TS may primarily be defined by the dosage effect of SHOX gene. Rarely, stature can be normal in TS girls if there is sufficient SHOX gene. Common reasons for normal stature in TS are: 1) Mosaicism, represented by 45X/46XX or 45X/47XXXcell lineages, deletion of the long arm of the X (Xq-), 2) Duplication or sufficient copies of SHOX gene even in the setting of X chromosomal abnormalities 3) In addition, gonadal estrogen deficiency can lead to normal stature.(2)

Case Report: We report a 12 year old girl diagnosed prenatally from amniocentesis done for advanced maternal age. She presented with normal stature, height 159cm (50-75%, 0.12 SDS), normal growth velocity and regular menstrual cycles. Psychological evaluation showed IQ 75 with learning difficulties and mild language delay. Physical exam revealed Tanner IV breast and Tanner V pubic hair development, Negative for high arch palate, low posterior hair line, scoliosis, cubitus valgus, short fourth metacarpals, cardiac and renal problems.

Results:Chromosome analysis showed 45X (3)/47XXX(81). Renal Ultrasound and echocardiaogram were normal. Pelvic Sonogram revealed hormonally stimulated uterus and ovaries. Serum LH: 4.37mIU/L, FSH: 7.4mIU/L, estradiol: 22pg/ml and thyroid function tests were all normal. Bone age at chronologic age of 11.5 yr was 13 years and predicted adult height 167 cm.

Conclusion: Normal stature in TS is rarely possible, especially in the cases of mosaicism where sufficiency or excess copies of SHOX genes are present. A thorough history, physical exam and postnatal karyotyping is necessary in cases of 45X/47XXX syndrome. Establishing a phenotype genotype correlation in these patients is difficult and the wide spectrum of presentation poses a diagnostic challenge.

 

Nothing to Disclose: MFC, BS, RP

11326 12.0000 SAT-0132 A Normal Stature in a Case of Turner Syndrome: When It Is Possible? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Marisa M Fisher*1, Susanne M Cabrera2 and Erik Allen Imel3
1Indiana University School of Medicine, Indianapolis, IN, 2Medical College of Wisconsin, Milwaukee, WI, 3IN Univ School of Med, Indianapolis, IN

 

Introduction:

            Neonatal severe hyperparathyroidism (NSHPT) causes severe symptomatic hypercalcemia, usually due to homozygous inactivating mutations within the calcium sensing receptor (CaSR) gene.  However, a dominant heterozygous inactivating mutation, R185Q, is described.  Surgical parathyroidectomy is the first-line treatment, but a lack of surgical expertise in infants increases complication rates. Cinacalcet, a calcimimetic, targets the CaSR to lower parathyroid hormone (PTH) and calcium, but little has been published on its use in infants with NSHPT.  Here, we report the successful management with cinacalcet of two young patients with de novo heterozygous R185Q mutations.

Clinical Cases:

            Our first patient, a Caucasian male, had been noted at birth to have a bell shaped chest and respiratory distress. He was later noted to have hypotonia, nephrocalcinosis, and feeding dysfunction.  By 12 months, he had significant gross motor and speech delays.  Laboratory testing revealed hypercalcemia due to primary hyperparathyroidism (HPT) (Ca 13.2 mg/dL, PTH 76 pg/mL).  IV fluids, calcium restriction and pamidronate only transiently improved hypercalcemia.  At 13 months, cinacalcet was started.  Calcium improved quickly, and dietary calcium restriction and phosphorus supplementation were safely discontinued.  Motor delay and feeding dysfunction also improved.. For 24 months, calcium has remained stable in the 10.4 – 12.0 mg/dL range, with cinacalcet titrated from 15 mg to 30 mg twice daily. 

            Our second patient, a black female, presented at 4 weeks with rib fractures and diffuse osteopenia.  Lab tests demonstrated primary HPT (Ca 12.7 mg/dL, PTH 152 pg/mL).  She was initially treated with calcium restriction alone, but developed severe PTH and alk phos elevation. Cinacalcet was started at 4 months of age.  Her PTH levels normalized and calcium levels decreased.  During 10 months of treatment, cinacalcet has been titrated from 1 - 2.3 mg/kg/day to maintain eucalcemia.  Her failure to thrive improved and she is achieving developmental milestones.

Clinical Lessons and Conclusions:

            These two cases outline the successful management with cinacelcet monotherapy of two young patients with NSHPT due to heterozygous R185Q mutations.  Cinacalcet was easily administered, well tolerated, and resulted in calcium improvements, accompanied by improvements in neurodevelopment and growth.  These cases strengthen the literature regarding cinacalcet therapy in NSHPT and provide information regarding dosing and response in infants.  Cinacalcet may be a viable first-line therapy in the treatment of NSHPT.

 

Nothing to Disclose: MMF, SMC, EAI

11454 13.0000 SAT-0133 A Treatment of Neonatal Severe Hyperparathyroidism with Cinacalcet: Successful Therapeutic Course of Medical Management in Two Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Sung Yoon Cho1, Dong-Kyu Jin1 and Heon-Seok Han*2
1Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, Republic of (South), 2Chungbuk Natl Univ Hosp, Chongju, Korea, Republic of (South)

 

Background: Osteogenesis imperfecta (OI) comprises a heterogeneous group of disorders characterized by susceptibility to bone fractures that range in severity from perinatal death to a subtle increase in fracture frequency. Of the types of OI, OI type I is the most common, and this is usually mild and non-deforming. It is characterized by an autosomal dominant inheritance pattern, blue sclera, and absence of dentinogenesis imperfecta.

 Clinical case: Our patient appeared healthy at birth and did not experience any fractures until 12 months of age. He experienced left femur shaft fracture at 12 months of age, left tibia fracture at 29 months of age, and right forearm both bone fracture at 35 months of age. Blue sclera, frequent fractures without adequate trauma, nearly normal stature, the absence of dentinogenesis imperfecta, no bony deformity, and no limitation of mobility were characteristics suggestive of OI type I that were observed in the patient.  The patient’s mother had blue sclera and a history of frequent fracture episodes until the age of 15 years. A novel COL1A1 missense mutation (c.2T>G) was found in the patient and his mother, and this is the first such case reported in the literature. At 3 yr of age, cyclic treatment of pamidronate was started. After 1 year of treatment, the bone mineral density increased in lumbar spine and femur neck, and radiography showed laminatic sclerosis at distal metaphysis of both tibia, fibula and femur, so called zebra stripe sign from cyclic bisphosphonate treatment.

 Conclusion: This is a clinical and radiological findings of one Korean patient with OI type I with a novel mutation in the start codon of COL1A1 (c.2T>G) disrupting the start codon of the gene (ATG to AGG (Met1Arg)). Identification of this mutation expands the knowledge and significance of the start codon of the COL1A1 gene in the pathogenesis of OI type I.

 

Nothing to Disclose: SYC, DKJ, HSH

11575 14.0000 SAT-0134 A Osteogenesis Imperfecta Type I Caused By a Novel Mutation in the Start Codon of the COL1A1 Gene in a Korean Family and the Course of Pamidronate Treatment for 1 Year 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Melissa Bauters*1, Michael Guo2, Andrew Dauber2 and Emily C Walvoord1
1Indiana University School of Medicine, Indianapolis, IN, 2Boston Children's Hospital, Boston, MA

 

Background: Kenny-Caffey Syndrome (KCS) is a rare syndrome characterized by severe short stature, cortical thickening of long bones and hypoparathyroidism.  Patients with KCS classically present with hypocalcemic seizures and have a characteristic appearance of small eyes, frontal bossing, triangular facies and poor dentition.  The genetic basis of the sporadic form of this syndrome (KCS type 2) was found in 2013 to be due to mutations in the FAM111A gene (1).  Only nine genetically proven European and Japanese patients have been reported in the literature (1, 2).  We present a phenotypically unique patient from the United States.

Clinical case: A 2 ½ year-old girl presented for evaluation of extreme short stature with a height nearly 6 SD below the mean for age.  Past medical history revealed normal birth weight and length and normal attainment of developmental milestones.  She was hospitalized at six months of age for failure to thrive and was only found to have a mild transaminitis, which resolved spontaneously.  She was noted to have dysmorphic features, including a prominent forehead, a flat nasal bridge and an upturned nose.  Her IGF-1, IGF-BP3 and GH stimulation testing were normal.  She was started on GH therapy at the age of 3 years 7 months for idiopathic short stature and showed a rapid initial response.  She continued to show a moderate growth response throughout childhood.  Her height z-score increased from -5.99 to -3.96 by the age 12 years 1 month.  Chromosomal microarray revealed a 493 kb duplication on chromosome 4 that was also present in her mother.  Recently performed whole exome sequencing detected a de novo heterozygous point mutation (c.1706G>A) in the FAM111A gene causing a missense change (p.Arg569His).  This mutation is the most common recurrent mutation known to cause KCS.

This patient has a number of classic features of KCS: (1) Characteristic facial features; (2) Soft dental enamel, abnormal eruption pattern and small tooth size; (3) Severe myopia; (4) Mild medullary stenosis, cortical thickening of long bones and bilateral coxa valga; (5) Normal intelligence.  However, she is phenotypically unique as she had normal calcium, phosphorus and PTH levels on multiple occasions throughout her life.  She is also the first patient with KCS to be treated with GH.

Conclusion: This is the first U.S. patient with genetically confirmed KCS.  Her lack of hypoparathyroidism and response to GH therapy are novel.  This case expands the phenotype of KCS and demonstrates the need to consider the diagnosis in patients with severe short stature even in the absence of hypoparathyroidism.

 

Disclosure: ECW: Principal Investigator, Eli Lilly & Company. Nothing to Disclose: MB, MG, AD

12865 15.0000 SAT-0135 A Kenny-Caffey Syndrome: An Expanded Phenotype and Response to Growth Hormone Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Kanthi Bangalore Krishna*1, Emir Tas2 and Jadranka Popovic3
1Children's Hospital of Pittsburgh, Pittsburgh, PA, 2Children's Hospital Pittsburgh of UPMC, Pittsburgh, PA, 3Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA

 

Background: NS has mostly been associated with hematological malignancies. Recently, an increased association between NS and primary brain tumors has been recognized(1).Over 50% of NS patients have mutations in the PTPN11 gene. SHP-2, the coding protein of PTPN11, participates in a signal transduction pathway (RAS) which is involved in oncogenesis (2). Majority of NS patients have short stature (SS) and GH therapy is an approved treatment. Current clinical guidelines do not recommend obtaining a brain MRI prior to initiating GH treatment. Here, we present a patient with NS, who developed a primary brain tumor after treatment with GH for > 1 year.

Clinical Case: 11 year old white, adopted, prepubertal male with clinical features of NS that was also genetically confirmed (p.Asp61Gly, Exon3, PTPN11), was evaluated by Endocrinology for SS at age 8 3/12years (height -3.5 SDS, BMI at 50thpercentile). He also had a history of pulmonary stenosis, Crohn’s disease, bilateral cryptorchidism, unexplained leukopenia and anemia (unremarkable bone marrow exam per hematologist). Bone age was concordant with chronological age and an IGF-1 level was low (86ng/ml, ref 88-474). He was started on a standard GH dose (0.3mg/kg/week). After 15 months, he presented to the Emergency Department with lethargy and altered mental status following an upper respiratory infection. An MRI of the brain showed a large right temporal lobe tumor and a small right cerebellar tumor. He underwent subtotal resection of the tumors which showed histologic and immunohistochemical features of DNET, WHO grade 1(GFAP, EGFR, and p53 negative, Ki67 proliferation index <2%). A year after tumor resection, his growth velocity was noted to be suboptimal at 3.6cm/year. Following a multidisciplinary team discussion, GH therapy was restarted with a plan for close follow up and regular brain MRI. Repeat MRIs in the past 1 year showed no change in residual tumor size. He continues to take GH and IGF-1 levels remain between 1 and 2 SDS for age.

Discussion: This patient with NS did not have any clinical evidence of CNS involvement and/or neoplastic process in the brain at the initiation of GH therapy. Interestingly, after 15 months of GH treatment he was diagnosed with a DNET in the brain. It is difficult to say whether this tumor was present before GH was started and worsened with GH treatment or whether the tumor progression was independent of GH treatment. RAS pathway (potentially oncogenic) is upregulated both in NS and certain primary brain tumors. Given this association of NS and primary brain tumors, we recommend obtaining a brain MRI at baseline prior to initiation of GH treatment in patients with NS.

 

Nothing to Disclose: KB, ET, JP

14139 16.0000 SAT-0136 A Dysembryoplastic Neuroepithelial Tumor (DNET) in a Prepubertal Boy with Noonan Syndrome(NS) Receiving Growth Hormone (GH) Therapy. Should Brain MRI be Routinely Performed in Children with NS Prior to Initiating GH Therapy? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Nursen Gurtunca*1, Michael A. Levine2, Suneeta Madan-Khetarpal3, Jessica Hartman4 and Luigi R Garibaldi5
1Childrens Hosp of Pittsburgh of UPMC, Pittsburgh, PA, 2Children's Hosp of Philadelphia, Philadelphia, PA, 3Childrens Hospital of Pittsburgh of UPMC, Pittsburgh, PA, 4Children's Hospital Of Pittsburgh of UPMC, Pittsburgh, PA, 5Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA

 

The most common cause of hypophosphatemic rickets is inactivation of the PHEX gene, which is responsible for X-linked hypophosphatemic rickets (XLH). PHEX, a Zn metalloendopeptidase, interacts with Dentin Matrix Protein-1 (DMP1), and DMP1 mutations cause type 1 autosomal recessive hypophosphatemic rickets (ARHR1). DMP1 is an extracellular protein that is produced by osteoblasts and osteocytes, and interacts with PHEX as a substrate/ligand. XLH and ARHR1 have similar clinical phenotypes due to shared pathophysiology of increased fibroblast growth factor 23 (FGF23) expression, which accounts for renal phosphate wasting with hypophosphatemia, reduced generation of calcitriol, and defective skeletal mineralization. Few patients have been reported with DMP1 mutations. We now report a patient with two novel DMP1 mutations, including an intragenic deletion, and highlight the role of copy number variant analysis in this evaluation. Our patient is a 31 month old Caucasian female noted to have bowed legs since 15 months.  She was referred to endocrinology for evaluation of short stature, hypophosphatemia and elevated alkaline phosphatase (AP) level. Her height was at the 7 % tile and weight at 44 % tile. She had mild frontal bossing, widening of the wrists and marked bowing of the legs. No dental abnormalities were present. The tubular reabsorption of phosphate was low normal   (84 %) in the setting of normocalcemia (Ca 10.1 mg/dl), hypophosphatemia (Phos 2.9 mg/dl (Ref. Range 4.5 - 5.5)), and normal levels of PTH (13 pg/ml).  AP was elevated (477 IU/L (Ref. Range <290)). Vitamin D levels were normal on daily multivitamin (25OHD 63 ng/ml and, 1, 25(OH) 2 D 71 pg/ml).  C-terminal FGF23 level was normal (197 RU/mL expected value < 230). Lower extremity X-ray showed rickets. Treatment with calcitriol and neutral phosphate led to improvement in her growth velocity, bone deformities and AP. Genetic testing revealed normal sequences for PHEX and FGF23, but sequence analysis of DMP1 revealed a single nonsense mutation, c.403G>T (p.Gly135X) in exon 6 that is predicted to generate a truncated DMP1 protein with no putative biological function. To identify a potential second mutation, we performed copy number analysis, which revealed a heterozygous intragenic DMP1 deletion of approximately 8.15 kb encompassing exons 1-3. Genotyping of the family revealed that the unaffected mother and father were heterozygous for the nonsense and deletion mutations, respectively, confirming that the mutations were on different alleles. A younger unaffected brother was wild type. These findings are consistent with a diagnosis of ARHR1 and highlight a limitation of PCR-based sequencing analysis in the evaluation of mutations. Although intragenic deletions are an uncommon cause of gene inactivation, these mutations must be considered when standard tests do not reveal mutation(s) in candidate genes.

 

Nothing to Disclose: NG, MAL, SM, JH, LRG

14574 17.0000 SAT-0137 A Autosomal Recessive Hypophosphatemic Rickets 1 Due to Novel Nonsense and Deletion Compound Mutations in DMP1 Encoding Dentin Matrix Protein-1 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Marlyn Fernandez*1, David Bleich2 and Maya P Raghuwanshi3
1UMDNJ-NJMS, Newark, NJ, 2UMDNJ-NJ Med School, Newark, NJ, 3UMDNJ-NJ Med Sch, Newark, NJ

 

Pseudohypoparathyroidism (PHP) arises from impaired PTH signaling due to failure of   cAMP dependent Gs protein activation leading to PTH resistance. We present an unusual case of a patient with PHP having offspring with osteogenesis imperfect (OI) and possibly co existing PHP.

A 32 year old gravid female was evaluated for hypocalcemia. She had a medical history of hypothyroidism and seizures. Currently treated with calcitriol, levothyroxine and prenatal vitamins.

Her obstetric history included the delivery of a full term male who later on was found to have expressive speech delay, tibial bowing, plagiocephaly and blue/grey sclera.  The child tested positive for COL 1A1/1A2 mutation consistent with OI type IV. Moreover, he was born with elevated PTH, low Vitamin D and hypocalcemia requiring calcium infusion.  An accurate diagnosis was never established; nevertheless, the child remains on calcium and vitamin D supplements.Her second child passed away one month after birth. He also had skeletal malformations but the cause of death was never determined. She is now 36 weeks pregnant with her third child, also found to have fractures on screening ultrasound.

The patient has no family history of calcium or skeletal abnormalities; but her husband and multiple members of his family were born with skeletal malformations and history of fractures.

On physical exam she was short, obese and had a round face, short limbs with no deformities in her hands or feet.  Chevostek’s and Trousseau were negative. Labs showed PTH: 191pg/ml, corrected Ca: 7.1mg/dl, ionized Ca: 4.3mg/dl, PO4: 4.7mg/dl, Mg: 2.0mg/dl, 24 hr urine Ca: 27mg/24hrs, 24 hour urine PO4: 1.0gm/24hrs, urine cAMP: 0.9umol/L, alkaline phosphatase 166u/l, Cr: 0.6mg/dl, 25OH Vitamin D: 32.1ng/ml, TSH: 5.090, calcitriol: 20pg/ml. Bilateral hand x-Ray was normal and DEXA scan including non dominant distal radius revealed osteopenia.

PHP is a group of disorders that arise from impaired PTH signaling due to failure of cAMP dependent Gs protein activation leading to PTH resistance.

Albright hereditary osteodystrophy (AHO) refers to the phenotypic features such as brachydactyly, rounded face, short stature, central obesity, subcutaneous ossifications and variable degrees of mental retardation.  These subjects also have other hormone resistance syndromes such as hypothyroidism. Our patient did not only have elevated TSH but met some of the clinical features AHO. Genomic imprinting is a phenomenon seen in this disease. The most clinically evident abnormality is renal PTH resistance, which in most cases presents as hypocalcemia, hyperphosphatemia, and elevated PTH.  Some PHP patients remain normocalcemic or have intermittent hypocalcemia throughout life.

It is interesting to speculate that our patient’s firstborn with OI also has PHP simultaneously. However, the hypocalcemia could have also been secondary to a decline in circulating maternal PTH levels.

 

Nothing to Disclose: MF, DB, MPR

13143 18.0000 SAT-0138 A Pseudohypoparathyroidism Type Ib in a Mother and Osteogenesis Imperfecta in Her Offspring, an Unusual Case 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Marjorie C Golekoh*1, Shayne F Andrew2, Vivian Hwa2, Ron G Rosenfeld2 and Philippe Backeljauw3
1Children's Hospital of Michigan, Detroit, MI, 2Oregon Health and Science University, Portland, OR, 3Cincinnati Children's Hospital Medical Center, Cincinnati, OH

 

Background: Normal intrauterine and postnatal growth require an intact insulin-like growth factor 1 (IGF-1) and IGF-1 receptor (IGF1R) axis. Mutations and deletions within the IGF1R gene, located on chromosome 15q26.3, can affect IGF1R synthesis, signal reception and post-receptor signaling, resulting in intrauterine and postnatal growth failure and microcephaly.  We report a novel heterozygous deletion of the IGF1R gene in a child with short stature, who also has neurofibromatosis type 1 (NF-1).

Clinical Case: An 8-yr-old male with NF-1 presented with severe growth failure. He was born small for gestational age (SGA) at 36 weeks: birth weight was 1,930g (-2.25 SDS), length 43.2cm (-2.3 SDS) and head circumference 32.5cm (-1.5 SDS). He continued with postnatal growth failure (height -3.4 SDS) and microcephaly (-2 SDS) at 8 yrs of age.  Parental heights were -0.5 (mother) and 0.2 SDS (father).  He had mild motor and language developmental delays. His mother and maternal half-sister also have NF1.  Brain MRI was suspicious for a low-grade neoplasm at the left cerebellar peduncle.  On exam he had multiple café-au-lait spots, a thin upper lip and 5th finger clinodactyly. IGF-1 (161 ng/mL) and IGF-binding protein-3 (4,030 ng/mL) were at the mean for age.  He had normal free thyroxine, growth hormone binding protein, acid-labile subunit and stimulated growth hormone concentrations. Routine chromosome analysis was normal (46, XY). Single nucleotide polymorphism microarray identified a maternally inherited deletion of 0.282 mb on 15q26.3, which included exons 4-21 of the IGF1R gene. No other pathogenic copy number variants were detected.  His father did not carry the same deletion.  Flow cytometric analysis by fluorescence-activated cell sorting (FACS) of live cells derived from the patient (peripheral blood mononuclear cells and primary dermal fibroblasts) indicated that the fluorescence emitted by IGF1R-phycoerythrin-labeled cells was markedly reduced in the patient (~50% and 60%, respectively) compared to normal cells (100%), although internalization of cell surface IGF1R upon IGF-I binding was normal. IGF-I induced signaling (phospho-AKT), however, was significantly reduced.

Conclusion: Evaluation of growth failure in this child with NF-1 revealed a novel heterozygous deletion of exons 4-21 of the IGF1R gene.  Functional analysis showed significant decreases in both IGF1R expression and IGF-1-induced signaling supporting IGF1R gene haploinsufficiency as a cause of short stature and microcephaly in the proband.

 

Nothing to Disclose: MCG, SFA, VH, RGR, PB

13847 19.0000 SAT-0139 A A Novel Heterozygous Insulin-like Growth Factor 1 Receptor (IGF1R) Gene Deletion in a Child with Short Stature and Neurofibromatosis 1 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Rajan Senguttuvan*, Mona Saleh, Mark Wheeler, Chetanbabu Patel, Cindy Chin and Priti Patel
University of Arizona, Tucson, AZ

 

Background

Hyperinsulinism is a rare cause of persistent hypoglycemia in the neonatal period. Diazoxide is a specific K+ ATP channel agonist and is often a first-line treatment for neonatal hyperinsulinism 1, 2. There are very few case reports documenting diazoxide induced pulmonary hypertension 1, 2.

Clinical Case

We present a full term male infant born via Cesarean section with multiple congenital anomalies including macrocephaly, macrosomia, facial dysmorphism and cryptorchidism. His birth weight was 4360g (>97%), head circumference 44 cm (>97%), and length 52 cm (76-90%). In the NICU he developed hypoglycemia that was managed with dextrose infusions. ACTH stimulation test demonstrated adrenal sufficiency. Laboratory evaluation suggested normal pituitary function. Following discharge on DOL 28 he had hypoglycemia at home requiring readmission. Lab tests and glucagon challenge test were suggestive of hyperinsulinism as the cause of hypoglycemia. Diazoxide was started on DOL 41 at a dose of 9.8 mg/kg/day and was increased to 14.6 mg/kg/day. With stabilization of his glucose values, he was discharged on DOL 46. Genetic studies for overgrowth syndromes, Simpson Golabi Behmel and Beckwith Wiedemann syndromes were negative. He presented to the ER on DOL 47 with respiratory distress requiring intubation. Subsequently, the patient was diagnosed with severe pulmonary hypertension requiring sildenafil and inhaled nitric oxide. Given that diazoxide can be associated with pulmonary hypertension in rare cases, it was discontinued on DOL 60. His pulmonary hypertension improved significantly and he was extubated to BIPAP on DOL 71. While on TPN and feeds he continued to have intermittent hypoglycemia managed with dextrose infusions.

Discussion:

Diazoxide acts by opening ATP sensitive potassium (KATP) channels in pancreatic beta cells, thereby inhibiting insulin release 1, 2. KATP channels have two basic subunits, sulfonylurea receptors (SUR1, SUR2A or SUR2B) and potassium channels (Kir 6.1 or Kir 6.2) 2. SUR1 is found in pancreatic ß cells, SUR2A in cardiac muscle, and SUR2B in smooth muscle, including pulmonary artery smooth muscle cells 2. Diazoxide activates all known KATP channels and this may lead to adverse clinical outcomes such as pulmonary hypertension and cardiopulmonary failure which are widely under recognized 2. In summary, this case is an example of pulmonary hypertension likely induced by diazoxide. As in previous case reports, the pulmonary hypertension was reversible with the withdrawal of diazoxide 1, 2. Given that diazoxide is considered first line treatment for hyperinsulinism, it is essential that pediatric endocrinologists are aware of the potential life threatening complications that may arise with its use.

 

Nothing to Disclose: RS, MS, MW, CP, CC, PP

15150 20.0000 SAT-0140 A Diazoxide Induced Pulmonary Hypertension in an Infant 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Margarida Vieira*1, Joana Simoes-Pereira1, Ana Teixeira1 and Maria Conceição Pereira2
1Portuguese Institute of Oncology, Lisbon, Portugal, 2Portuguese Institute of Cancer, Lisbon, Portugal

 

Background: Swyer Syndrome (or pure gonadal dysgenesis) is a chromosomal aberration characterized by a karyotype 46, XY in a phenotypic female subject. Deletions in the SRY gene are responsible for 20% of the cases. These individuals are completely devoid of any gonadal steroid production and have a high risk for malignant transformation of germ cells (until 75%).

Case report: A 14-years-old girl with neither personal nor familiar diseases came to our centre with lumbar pain, polyuria and pollakiuria. On examination, the patient got a Tanner B1P3 and it was palpable a large, fixed and stone-like pelvic mass, without any other signs. CT scan revealed a solid median pelvic mass with calcifications, dilatation of the left ureter and retroperitoneal adenopathies. The biopsy of the mass was suggestive of a malignant germinal tumour. Chemical analysis showed: α – fetoprotein = 3041.9 ng/ml (N < 10 ng/ml), CA 125 = 53.6 U/ml (N < 35 U/ml), CEA < 0.5 ng/ml (N < 3 ng/ml) and β HCG = 64.6 U/l (N < 5 U/l). The patient underwent neoadjuvant chemotherapy (cisplastin, etoposide and bleomicin) and bilateral gonadectomy. Blood sample and tumour karyotype were 46, XY and molecular study identified a microdeletion in SRY gene in Yp11.23 which is responsible for gene codifying sequence. At 15-years-old the patient started hormonal therapy with estradiol (progesterone formulation was added after completing the breast development). The patient has gained an adult sexual maturation and final stature near mid-parental height. Currently the patient is 23-years-old and maintain follow up in endocrinology and oncological outpatient clinic.

Conclusion: The present case emphasizes the importance of a multidisciplinary approach in Swyer Syndrome. The evidence of a malignant neoplasm requires prompt treatment and the induction of a normal puberty development is highly relevant. The management of this period needs special knowledge in gonadal steroids pharmacotherapy.

 

Nothing to Disclose: MV, JS, AT, MCP

15273 21.0000 SAT-0141 A Microdeletion in the Sry Gene in a Phenotypic Female 46, XY Patient with Swyer Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0121-0141 4850 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Lucia Speroni*, Maël Montévil, Tessie Paulose, Florent Cerruti, Carlos Sonnenschein and Ana M Soto
Tufts University, Boston, MA

 

Hormones are main regulators of mammary gland morphogenesis. During fetal life and before puberty, mammary gland development is estrogen (E2) independent. After puberty, hormones regulate ductal elongation and branching of the epithelium. Thereafter, the mammary gland undergoes changes during each estrus cycle and during pregnancy, lactation and involution. Several hormones act together with E2 throughout all of these stages. We developed a hormone-responsive 3D culture model in which mammotrophic hormones, E2, progestagen and prolactin, induce T47D breast epithelial cells to form structures similar to those observed in vivo (1), namely, elongating ducts, branching ducts and alveoli, respectively. Here we present SAMA, which facilitates the morphometric analysis of epithelial structures in a 3D model; its advantages over the manual analysis are 1) it is less biased as it requires minimum intervention by the user, 2) some unique parameters can be assessed, 3) the analysis is less time-consuming, and 4) the robustness of the 3D model can be assessed automatically in terms of experimental consistency between replicates and repeats. Briefly, carmine-stained whole mounts of 3D gels were imaged using a Zeiss LSM 510 system using the HeNe 633 nm laser. 15 tiles/gel were acquired with a 20x objective. Using the imaging software FIJI, tiles were stitched together into a composite image which was processed to obtain homogenously pixelated structures. Process automation was obtained by incorporating the required plugins into a macro. Epithelial structures were counted and measured using the “3D object counter” followed by the “3D ROI manager” plugins. Lumen formation was analyzed by using differences in pixel intensity in the structures. Darker areas (lumen) were then filled and subtracted from the original image giving rise to an image containing only lumen. The lumen were then counted and measured by 3D object counter and the 3D ROI manager. Branching and budding of structures were analyzed using “Skeletonize” plugin. Other parameters used to evaluate the morphology of the structures included Elongation, Sphericity and Ratio Volume Ellipsoid. Results indicate that prolactin + E2 generate 1) more elongated structures among the structures that have lumen (p=0.026) , and 2) more complex structures in terms of geometrical branches (budding) (p=0.048) than E2 alone. With promegestone + E2, 1) structures are more elongated (p=0.0057), and 2) the surface of structures is more complex than in E2 alone (p=0.041).

 

Nothing to Disclose: LS, MM, TP, FC, CS, AMS

14956 1.0000 SAT-0067 A Development of Software for Automated Morphology Analysis (SAMA) to Analyze Morphogenic Effects of Mammotrophic Hormones in Vitro 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Dallas A Vanorny*, Nisan M Hubbard and Kelly E Mayo
Northwestern University, Evanston, IL

 

The placenta is a structure unique to mammals that is essential for the growth of the fetus by regulating the exchange of nutrients and gases between the fetal and maternal circulation. Genetic manipulation in mice has revealed a number of genes, including members of the nuclear receptor superfamily, that are critical for placental function at specific developmental stages and within distinct cell populations, and these studies are beginning to establish the molecular pathways involved in the formation and regulation of various placental substructures. To explore of the roles of additional nuclear receptors during placental development, we used high-throughput RT-qPCR to profile the expression of all 49 members of the nuclear receptor superfamily in the placentas of CD1 mice from embryonic day 8.5 (E8.5) to E18.5. We found that more than 40 nuclear receptors were expressed within the placenta, and the most abundant transcripts detected were retinoid X receptor alpha (Rxra), chicken ovalbumin upstream promoter transcription factor I and II (COUP-TFI and II), peroxisome proliferator-activated receptor alpha (Ppara), and progesterone receptor (Pgr). In addition, we found a number of nuclear receptors that were dynamically expressed during placental development including proliferator-activated receptor delta (Ppard), liver X receptor-alpha (Lxra), Rxra, vitamin D receptor (Vdr), and neuron-derived orphan receptor 1  (Nor1). Our analysis also shows that nuclear receptors previously implicated from global knockout studies to have a role in placental function, including members of the PPAR, COUP-TF, and RAR/ROR/RXR families, are dynamically expressed during placental development. Future studies are aimed at better understanding the specific functions of these and other nuclear receptors that are dynamically regulated during placental development.

 

Nothing to Disclose: DAV, NMH, KEM

16280 2.0000 SAT-0068 A High-Throughput Expression Profiling in the Mouse Placenta Reveals Dynamic Expression of Nuclear Receptors during Placental Development 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Dallas A Vanorny, Nisan M Hubbard, Abha J Chalpe* and Kelly E Mayo
Northwestern University, Evanston, IL

 

The placenta is vital for the development and growth of a mammalian embryo during pregnancy by performing critical functions including nutrient and gas exchange, hormone production, and immune protection. Placental dysfunction can result in a number of fetal defects including growth retardation, disease, and even death. The formation and maintenance of the placenta requires extensive intercellular signaling between trophoblast, mesenchymal and vascular cell types for normal function. The Notch signaling pathway is a juxtacrine cell communication system comprised of four Notch receptors, five ligands, and many modifiers and target/effector genes. Several studies have examined Notch pathway gene expression within the placenta, but the specific roles of Notch receptors and ligands in the establishment or function of distinct placental cell types remains to be explored. In this study, we examined the expression of Notch pathway genes during the development of the mouse placenta from embryonic day 8.5 (E8.5) to E18.5 using high throughput qPCR. Transcripts for all four Notch receptors were expressed, with Notch2 being the most abundant. The ligands Jag1, Jag2, Dll1, and Dll4 were also expressed, though we did not observe appreciable expression of Dll3. In addition, several receptor and ligand transcripts were dynamically regulated, with increased expression at the later stages of placenta development, which corresponds to a modest increase in the expression of the Notch target/effector gene Hes1 between E14.5 and E18.5. These data suggest that key components of the Notch pathway are expressed and that Notch signaling may be active and regulated during placental development. To test this more directly, we utilized the Transgenic Notch Reporter (TNR) mouse, which harbors a transgene with multiple Notch-responsive transcription factor binding sites controlling the expression of an eGFP reporter. In the placenta of TNR embryos, eGFP mRNA expression increased between E8.5 and E12.5 before declining for the remainder of the time course; thus, the Notch pathway appears to be most active at a time when the mature placenta is being formed. Further characterization of the Notch pathway using the eGFP reporter for cellular localization and gene knockout approaches should elucidate roles for Notch signaling in normal development and placental dysfunction.

 

Nothing to Disclose: DAV, NMH, AJC, KEM

16286 3.0000 SAT-0069 A Expression and Activity of the Notch Signaling Pathway during Mouse Placental Development 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Changhwan Ahn*1 and Eui-Bae Jeung2
1Chungbuk National University, Cheongju, Korea, Republic of (South), 2Biochemistry and molecular biology of veterinary medicine college, Chungbuk National Univ, Cheongju, Korea, Republic of (South)

 

Introduction: Tight junctions (TJs) are composed of a branching network of sealing strands. TJs regulate paracellular conductance and ionic selectivity. TJ components include the peripheral protein ZO-1, junctional adhesion molecules (JAMs) and the integral proteins such as occludin and claudin. Claudins are a family of proteins that are the most important components in the tight junctions. The established paracellular transport barriers that control transportation of molecules within intercellular space. The present study focused on the expression of claudin, suggesting as major working molecules in the paracellular transport system. Methods: To study the regulation and roles of claudin family, we examined expression of mouse placental claudin family. Pregnant C57/BL6 mice were used in this study and tight junction proteins including Claudin-1 to Claudin-24 expressions. The pregnant mice were divided into 3 groups depending on pregnant day (on days 12.5, 16.5, and 20.5 of gestation). Results: In the transcription levels, Claudin-1, claudin-2, claudin-4 and Claudin-5 expression levels were relatively high expression when compared to other claudin family in all the periods of pregnant. The claudin-4 expression, which reduces permeability of ions, was increased over a period of time. However, caludin-5 expression that is the responsive protein for a decrease in paracellular conductance, were decreased. In previous study using the siRNA, Claudin-1 and 4 has been known as a responsive gene for a decrease in paracellular conductance. On the other hand, claudin 2 and 5 has been known as increase paracellular conductance. In addition, immunohistochemistry was performed to identify their localization for inferring permeability in placenta. Conclusion: Due to claudins function as effectors of ion transport at the end of regulatory pathways, they must be transducing proteins that modulate the function of claudins and thus link the physiologic inputs to the final effectors. This study will provide the claudin expressions and their localization in the mouse placenta, which may contribute to assuming the roles of these tight junction genes regarding the maternal-fetal ion transportation in the placenta.

 

Nothing to Disclose: CA, EBJ

12320 4.0000 SAT-0070 A The Expressions of Claudin Molecule in the Placenta of Mouse 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Eun-Kyeong Shin*1 and Eui-Bae Jeung2
1Chungbuk National University, Cheongju Chungbuk, Korea, Republic of (South), 2Biochemistry and molecular biology of veterinary medicine college, Chungbuk National Univ, Cheongju, Korea, Republic of (South)

 

Introduction: Pre-eclampsia (PE) is a medical condition characterized by high blood pressure and significant amounts of protein in the urine of a pregnant woman. The PE syndrome is thought in many cases to be caused by a shallowly implanted placenta that becomes hypoxic. Hypoxia can result from a failure at any stage in the delivery of oxygen to cells. In peripheral tissues, oxygen again diffuses down a pressure gradient into cells and their mitochondria, where it is used to produce energy in conjunction with the breakdown of glucose, fats and some amino acids. Methods: As an expression of beta-oxidation related gene, ACADVL was detected by gene-fishing technology using the placenta of human. We conducted in vitro experiments to confirm preliminary study. We induced hypoxic stress in BeWo cell cultured under 1% O2, 5% CO2, and balanced with N2. The expression of beta-oxidation related genes (ACADVL, EHHADH, HADH, ACAA) were observed under hypoxic condition in BeWo cells by using real-time PCR. Results: The expression of genes known as biomarkers for hypoxia, HIF-1α, was increased in BeWo cells induced preeclampsia. The elevated level of HIF-1α is indicative that our experimental conditions closely mimicked ones that are associated with preeclampsia. The beta-oxidation related genes, ACADVL, EHHADH, HADH expressions were significantly increased by hypoxic stress in BeWo compare with normoxic control. Conclusion: Further study is being done on the release of HIF-1α and its affect on the metabolism of beta-oxidation in BeWo cells. Taken together, these results indicate that changes of beta-oxidation related genes observed under hypoxic BeWo cells are similar to ones associated with preeclampsia, and the expression of beta-oxidation related genes were up-regulated by hypoxic stress. It may be involved in pathogenesis of preeclampsia during gestation.

 

Nothing to Disclose: EKS, EBJ

12324 5.0000 SAT-0071 A The Regulation of Beta-Oxidation Related Genes Under Hypoxic Condition in Bewo Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Hyun Yang* and Eui-Bae Jeung
Biochemistry and molecular biology of veterinary medicine college, Chungbuk National Univ, Cheongju, Korea, Republic of (South)

 

Introduction: Preeclampsia is a pregnancy-specific disease characterized by concurrent development of hypertension, proteinuria, and oxidative stress in the placenta. Preeclampsia-like genetic models were also developed by modification of preeclampsia-related genes, such as catechol-O-methyltranferase (COMT). Methods: In this study, we induced COMT inhibition in mice during pregnancy to reproduce physiological conditions associated with preeclampsia. The expression of gene known as hypoxia biomarker, HIF-1α, was highly induced in the placenta of this model. The over-expression of HIF-1α demonstrates that our experimental conditions closely were similar with preeclampsia. We measured the expression of several calcium transporters (TRPV5, TRPV6, PMCA1 and CaBP-9k) in the placenta, duodenum and kidney after COMT inhibition on gestation day 17.5 (GD 17.5). In addition, we evaluated the calcium transporters in the kidney, duodenum of non-pregnant female mice. Results: Placental TRPV5, TRPV6 and PMCA1 expressions were down-regulated by COMT inhibitor (ro41-0960). In addition, the reduced PMCA1 expression in the placenta was reversed by calcium supplementation. Duodenal expressions of TRPV5, TRPV6, and PMCA1 were decreased in the COMT-inhibited mice, and slightly recovered after calcium supplementation. Renal expression of TRPV5, TRPV6, and PMCA1 was also decreased by COMT inhibition, while it was reversed by calcium supplementation to the level of control. Duodenal- and renal calcium transporting genes, TRPV5, TPRV6, PMCA1 and CaBP-9k, were down-regulated by COMT treatment in female mice. Conclusion: Taken together, these results indicate that physiological changes observed in COMT inhibition were showed similar symptom to preeclampsia, which may be related with disturbance of calcium metabolism during pregnancy.

 

Nothing to Disclose: HY, EBJ

12327 6.0000 SAT-0072 A The Expression of Calcium-Relating Genes in COMT-Inhibited Mouse Model 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Debra F Skafar*1, Shivali Ramesh Patel2, Brian Kilburn3 and D Randall Armant4
1Wayne State Univ Sch of Med, Detroit, MI, 2Wayne State University, Detroit, MI, 3Mott Ctr for Human Growth/Dev, Wayne State Univ Schl of Med, Detroit, MI, Detroit, MI, 4Wayne State Univ Schl of Med, Detroit, MI

 

Studies in the baboon and in women undergoing in vitro fertilization suggest that inappropriately elevated estradiol can impair placental development in the first trimester. Normally, serum estradiol levels remain below 10 nM in the first trimester of pregnancy, rising sharply thereafter. This hypothesis was examined using the first trimester cytotrophoblast cell line HTR-8/SVneo treated with estradiol concentrations between 1 and 100 nM. The estrogen receptor (ER)-beta subtype-specific ligand, diarylpropionitrile (2,3-bis(4-Hydroxyphenyl)-propionitrile) (DPN) and ER-alpha subtype specific ligand, 4,4′,4″-(4-Propyl-[1H]-pyrazole-1,3,5-triyl) trisphenol (PPT) were used at concentrations between 1 and 1000 nM.  Cells were cultured in phenol red–free medium containing charcoal-stripped FBS.  Results were analyzed using ANOVA, followed by the appropriate post tests (Dunnett’s or Bonferroni).  We find that estradiol significantly increased apoptosis at concentrations of 10 nM and greater (p< 0.05 and less), as measured by TUNEL, and decreased cell proliferation at concentrations of 1 nM and greater (p<0.001), as measured by nuclear Ki67 expression. These effects were blocked by the antiestrogen ICI 182,780.  Although Western immunoblotting indicated that the HTR-8/SVneo cell line expressed both ER-alpha and ER-beta, treatments with PPT and DPN demonstrated that the effects of estradiol are mediated through ER-alpha, exclusively.   In addition, caspase 3 and caspase 8 were elevated by an ER-alpha-mediated mechanism at concentrations of 25 nM and greater (p< 0.05), while Ki67 exhibited an ER-alpha-mediated decrease (p<0.001).  Finally, the anti-apoptotic protein BCL2-alpha decreased in response to estradiol concentrations of 10 nM or greater (p<0.001). These results provide a mechanism through which abnormally high estradiol can impair placental development in primates, potentially leading to IUGR and/or preeclampsia in humans.

 

Nothing to Disclose: DFS, SRP, BK, DRA

13011 7.0000 SAT-0073 A Elevated Estradiol Compromises Trophoblast Survival in First Trimester Human Trophoblast Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Ming Zhang*1 and Carole R Mendelson2
1University of Texas Southwestern Medical Center, Dallas, TX, 2UT Southwestern Med Ctr, Dallas, TX

 

Preeclampsia (PE) is a pregnancy-related disease, which is characterized by the onset of hypertension and proteinuria in the second half of pregnancy. PE affects 6%–8% of pregnancies and remains a leading cause of maternal and neonatal morbidity and mortality. Impaired placentation is thought to play a role in the pathogenesis of preeclampsia. MicroRNAs (miRNAs) are endogenous, short, non-coding RNA molecules of 19–24 nucleotides, involved in the regulation of many cellular processes such as cell differentiation, proliferation, apoptosis, angiogenesis and metabolism. In human placenta, miRNAs are synthesized and expressed primarily in trophoblasts, where they regulate cellular function and adaptation to stress. By miRNA microarray analysis of total RNA from freshly isolated human cytotrophoblasts, before and after differentiation to syncytiotrophoblast in culture, we identified several differentially expressed miRNAs upon trophoblast differentiation. Members of miR-515 family, which belong to the placenta-specific chromosome 19 miRNA cluster (C19MC), were significantly downregulated upon syncytiotrophoblast differentiation. Using TaqMan-based RT-qPCR, decreased expression of several miR-515 family members, including miR-519e* and miR-518f, during syncytiotrophoblast differentiation was confirmed. Notably, we also observed a significantly higher expression level of miR-519e* in placentas from women with preeclampsia than in gestationally-matched normotensive women. By comparative analysis of several target prediction programs (i.e. Targetscan, DIANA, miRDB, miRnada), we identified a number of predicted target genes of these miRNAs, including hCYP19A1, Sp1 and Notch2. hCYP19A1 encodes aromatase P450, the key enzyme in biosynthesis of estrogens, which contribute to maintenance of human placental differentiation and function. hCYP19A1 expression was markedly upregulated during human trophoblast differentiation as miR-519* and miR-518f declined. Previously, we found that transcription factor Sp1 induced hCYP19A1 expression by binding to a GC box in its promoter region. We presently observed that upon syncytiotrophoblast differentiation, downregulation of miR-519e* and miR-518f and induction of hCYP19A1 were associated with a significant increase in Sp1 mRNA levels. Further investigations will be performed to confirm these miR-515 family targets and to define the regulation and role of the miR-515 family in the pathogenesis of preeclampsia.

 

Nothing to Disclose: MZ, CRM

14858 8.0000 SAT-0074 A Role of the microRNA-515 Family in Human Trophoblast Differentiation and Preeclampsia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Stuart Handwerger*1 and Cherie A Kessler2
1Cincinnati Children's Hospital Medical Center, 2Cincinnati Children's Hosp, Cincinnati, OH

 

During human placental development, mononuclear cytotrophoblast cells (CTB) differentiate to a multinucleated syncytiotrophoblast cell (STB) phenotype. The differentiated STB form the outermost cells of the villous trophoblast layer and are in direct contact with maternal blood. A better understanding of the regulation of trophoblast differentiation is essential since STB are critical for the maintenance of pregnancy and fetal growth and development, and abnormalities in villous trophoblast differentiation are present in many pathologic conditions of pregnancy, including preeclampsia and IUGR. To learn more about the transcriptional regulation of CTB differentiation, we developed an in vitro cell culture model in which enzymatically dispersed CTB isolated from normal term placentas (>90% purified) differentiate spontaneously over 4 days to form a STB phenotype that expresses abundant amounts of hCG, hPL, hGHv and other proteins normally expressed in vivo by STB cells. The TFs TFAP2A, FoxF1 or ETS1, which are abundant in CTB undergoing differentiation, were knocked down in freshly isolated CTB by shRNA and siRNA technologies. After 4 days of culture, mRNAs for the STB marker genes were measured by qPCR using gene-specific primers, and the STB marker proteins were measured by Western blot analyses using highly specific antibodies. We observed in multiple experiments that knockdown of each of the 3 TFs (85-95% inhibition) blocked the inductions of hPL, hCG and other STB marker genes by 50-80% (p<0.005-0.01 in each instance), suggesting a role for each TF in the differentiation process. Knockdown of TFAP2a also blocked the inductions of FOXF1 and ETS1 expressions by 40-60%; and knockdown of FOXF1 and ETS blocked the expressions of the other two TFs. Transient transfection studies in human trophoblast cells (primary cells and JEG3 choriocarcinoma cells) demonstrated that the proximal promoters of each of the 3 TFs are induced by overexpression of the other 2 TFs. Taken together, these findings strongly suggest that TFAP2A, FOXF1 and ETS1 are critical components of the transcriptional network that regulates human trophoblast differentiation and that the 3 TFs act in concert, forming a novel regulatory pathway in which the induction of the TFs are closely linked.

 

Nothing to Disclose: SH, CAK

14994 9.0000 SAT-0075 A Novel Transcriptional Regulation of Human Villous Trophoblast Differentiation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Anna Caroline Hein*1, Manu Vatish2, Tomoshige Kino1, Dimitris Grammatopoulos3 and Alan H DeCherney4
1NICHD/NIH, Bethesda, MD, 2University of Oxford, Oxford, United Kingdom, 3Univ of Warwick Biomed Res Inst, Coventry, United Kingdom, 4Natl Inst of Hlth, Potomac, MD

 

The placental enzyme 11beta-hydroxysteroid dehydrogenase type 2 (11β-HSD2) acts as a glucocorticoid (cortisol in humans) barrier by converting active cortisol into inactive cortisone. Thus, the 11β-HSD2 protects the fetus from exposure to the 10-fold higher concentration of cortisol in maternal blood. It is known that 11β-HSD2 expression is reduced in the placental syncytiotrophoblast layer in placenta-related disorders such as pre-eclampsia and intrauterine growth restriction (IUGR). This results in excessive cortisol reaching the fetus and can lead to in utero fetal programming, which predisposes individuals to metabolic diseases and behavioural disorders in later life.

The role of 11β-HSD2 in trophoblast biology is not well understood. In this study, we investigated the influence of 11β-HSD2 on trophoblast endocrine function and trophoblast proliferation, differentiation (cell fusion into the multinucleated syncytiotrophoblast layer) and apoptosis.

We used the human choriocarcinoma cell line BeWo, which is a well-established model system for placental differentiation after stimulation of the cAMP pathway, and an siRNA approach to knockdown 11β-HSD2 expression.  To assess proliferation and apoptosis, cell viability and activation of caspase-3/7 were measured. We also determined effects on transcription of the fusogenic machinery, in particular mRNA expression of Syncytin-1 and -2. Endocrine differentiation was assessed by measuring cell capacity to secrete human chorionic gonadotropin (hCG), progesterone and estradiol.

Treatment of Bewo cells with forskolin, a cAMP-stimulator, resulted in up-regulation of Syncytin-1, Syncytin-2 and 11β-HSD2 by 2, 4.2 and 12.6 fold, respectively, on mRNA level as well as increased production of hCG and progesterone by 9.7 and 2.8 fold, respectively.  Knockdown of 11β-HSD2 reduced proliferation of BeWo cells, but did not alter activation of caspase-3/7, a molecular event associated with the differentiation pathway. Knockdown of 11β-HSD2 did not affect forskolin-induced Syncytin-1 and -2 mRNA upregulation, although decreased forskolin-induced hCG and progesterone secretion by 53 and 47%, respectively. In contrast, estradiol secretion was not affected by siRNA treatment suggesting preserved viability of the cells. Taken together, these results suggest that induction of 11β-HSD2 in trophoblast cells is necessary for their normal development and function. Furthermore, reduced 11β-HSD2 expression may affect key trophoblast functions and might contribute to placental dysfunction.

 

Nothing to Disclose: ACH, MV, TK, DG, AHD

14127 10.0000 SAT-0076 A Novel Role of the Enzyme 11beta-Hydroxysteroid Dehydrogenase Type 2 (11β-HSD2) on Trophoblast Biology 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Guadalupe Estrada-Gutierrez*1, Violeta Castro-Leyva1, Aurora Espejel-Nuñez1, Veronica Zaga-Clavellina1, Enrique Reyes-Muñoz1, Iyari Morales-Mendez1 and Silvia Giono-Cerezo2
1Instituto Nacional de Perinatologia, Mexico City, Mexico, 2Escuela Nacional de Ciencias Biologicas, IPN, Mexico City, Mexico

 

Decidualization, the differentiation of endometrial stromal cells (ESCs) into decidual stromal cells (DSCs) by estradiol and progesterone, is important for successful implantation and maintenance of pregnancy. DSCs are the main resident cell type at the maternal-fetal interface and could play a key role in the immune response to intrauterine infections during pregnancy. Steroid hormones exert a powerful effect on several immune system functions, yet it is not clear their role in the regulation of the inflammatory network in human decidua.  The aim of this work was to compare the pro- and anti-inflammatory response elicited by ESCs and DSCs in the presence of group B streptococci (GBS), to assess the role of steroid hormones in the regulation of this response. To achieve this goal, primary cultures of ESCs (n=10) were characterized using vimentin as a marker for fibroblasts. Decidualization was induced with 36nM estradiol + 300nM progesterone to generate DSCs,  and was confirmed quantifying prolactin and IGFBP-1 secretion. Cultures of ESCs and DSCs were infected overnight with group B streptococci (GBS), and levels of expression and protein of IL-8 and IL-10 were measured in the bacteria-free cell lysates and supernatants, respectively, using commercial qRT-PCR and ELISAs. Expression and secretion of IL-8, a pro-inflammatory cytokine, was significantly increased in ESCs infected with GBS, compared to non-infected ESCs (p<0.05). Although levels of IL-8 were higher in infected versus non-infected DSCs (p<0.005), secretion of this cytokine by these hormone-primed cells was significantly reduced compared to ESCs (p<0.005). The anti-inflammatory cytokine IL-10 was barely detected in cells lysates and supernatants from ESCs even under infection conditions, but expression and secretion were significantly increased in control DSCs (p<0.05) and more importantly in infected DSCs (p<0.005). In light of our results, we propose that DSCs play a key role in the immune response to intrauterine infections during pregnancy, orchestrating the regulation of pro- and anti-inflammatory cytokines. An uncontrolled pro-inflammatory response in gestational tissues could result in preterm birth, whereas anti-inflammatory immune responses initiated prematurely could result in survival of the pathogen. This delicate homeostatic balance induced by estradiol and progesterone may contribute to the maintenance of pregnancy.

 

 

Nothing to Disclose: GE, VC, AE, VZ, ER, IM, SG

15612 11.0000 SAT-0077 A Steroid Hormones Induce Homeostatic Balance of Pro- and Anti-Inflammatory Immune Responses in Human Decidua 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Aska Toda*1, Kenjiro Sawada1, Yasuto Kinose1, Ikuko Sawada1, Kae Hashimoto1, Tomoyuki Fujikawa2, Akiko Itai2 and Tadashi Kimura1
1Osaka Univ Med Schl, Suita-shi, Japan, 2IMMD. Inc., Tokyo, Japan

 

[Background] Preterm delivery (PTD) remains a serious challenge in perinatology, as no effective therapy is available other than tocolytic agents; however, tocolysis with these agents is rarely successful beyond 24–48 hours and has not been shown to improve neonatal outcomes. Intrauterine infection and/or inflammation, represented by chorioamnionitis (CAM), is the most firmly established trigger of early PTD. Proinflammatory cytokines in response to bacteria or bacterial products (e.g., lipopolysaccharide (LPS)) are considered to play pivotal roles in the pathology of PTD. Among these cytokines, IL-6 is assumed to be a key player, as proven by many papers including ours. In this study, we determined to identify what kind of cell produce IL-6 in placentae complicated with CAM and analyze the potential of targeting IKKβ signaling to suppress IL-6 production, using a novel IKKβ inhibitor, IMD-0560 (IMMD. Inc. Tokyo, Japan).

[Methods and Results] First, we examined the expressional pattern of IL-6 in placentae complicated with severe CAM and found that IL-6 is mainly expressed in amniotic mesenchymal stromal cells rather than epithelial cells. Primary amniotic mesenchymal stromal cells (AMSCs) were collected and the strong expression of IL-6 as well as IL-6 receptor was confirmed by RT-PCR. In AMSCs, treatment of inflammatory cytokines such as TNFα and IL-1β drastically induced IL-6 production followed by the phosphorylation of IKK. The pretreatment of IMD-0560 almost completely inhibited IL-6 production from AMSCs. Using an experimental LPS-induced preterm delivery mouse model, the therapeutic potential of IMD-0560 was examined. IMD-0560 was delivered 1h before LPS treatment vaginally. Mice in the IMD-0560 group had a significantly lower rate of preterm delivery than that of the controls without any apparent adverse events on the mice and their pups.

[Conclusion] IL-6 was strongly expressed mainly in amniotic mesenchymal stromal cells in placentae complicated with CAM. An IKKβ inhibitor, IMD-0560, significantly decreased the rate of preterm delivery in LPS-induced inflammatory model mice, at least partly, by inhibiting IL-6 production from AMSCs. Targeting IKKβ signaling could be a promising option for the prevention of preterm delivery and needs to be further explored for future clinical application.

 

Nothing to Disclose: AT, KS, YK, IS, KH, TF, AI, TK

13794 12.0000 SAT-0078 A Targeting Ikkß Signaling Prevents Preterm Delivery through the Inhibition of Interleukin-6 (IL-6) Production from Amniotic Mesenchymal Stromal Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Katherin Scholz Romero1, Helen L. Barrett2, Marta H Kubala1, Harold David McIntyre*3, Leonie K Callaway2 and Marloes Dekker Nitert2
1The University of Queensland, 2The University of Queensland, Herston, Australia, 3Mater Health Services, S Brisbane QLD, Australia

 

Background: Preeclampsia (PE) is a syndrome of hypertension and proteinuria in pregnancy that is associated with adverse outcomes for mother and infant and with alterations of placental function. The incidence of PE is higher in insulin resistant states such as obesity and gestational diabetes mellitus. Recently, it has been shown that patients with PE have high circulating levels of the metabolic regulator fibroblast growth factor 21 (FGF21). FGF21 is synthesized in many metabolic organs but also in the placenta. The aim of this study was to compare the expression of FGF21 and its receptors in placental tissue from pregnancies complicated by PE and control pregnancies. Circulating FGF21 in maternal and cord blood was also studied.

Methods: Placentae were obtained with informed consent from 20 women with and 18 without late-onset preeclampsia. The participants were matched for maternal BMI, age and gestational age at delivery. mRNA expression was determined by qPCR with TBP as endogenous control and the expression was normalized for cellular composition of the sample. Protein expression was quantified by Western Blot and FGF21 levels were measured by ELISA in maternal and cord serum of ten mother-baby dyads. Nonparametric testing was performed and the results are expressed as median and interquartile range.

Results:  FGF21 mRNA expression was significantly increased by 18-fold in placental tissue from PE pregnancy (2.94 (0.14- 15.38 AU) compared with normal pregnancy (0.15 (0.04-2.1) AU, P=0.0092). Placental FGF21 protein was not significantly different between women with (0.0036(0.0029-0.031) or without (0.0058(0.0022-0.024) AU) PE. Placental mRNA expression of the FGF receptors (1-4) was not different between the groups; however, the co-receptor β-Klotho was significantly higher expressed in PE placentae  (8.76(3.76-101.9) AU) compared to control (1.58(0.61-5.95) AU, P=0.0013). Maternal FGF21 serum levels were not significantly increased in PE (0.44(0.3-1.0) compared to control (0.38(0.21-0.66) pg/mL). FGF21 was not detected in cord blood in either group.

 Conclusions: FGF21 mRNA but not protein expression is increased in the placenta of women with PE. The lack of changes in protein expression, the similar serum concentrations of FGF21 in women with or without PE and the lack of detectable FGF21 in cord blood suggest that placental FGF21 does not contribute to the pathology of PE.

 

Disclosure: HDM: Speaker, Novo Nordisk, Speaker, Astra Zeneca, Advisory Group Member, Danone. MD: Speaker, Nestle. Nothing to Disclose: KS, HLB, MHK, LKC

11208 13.0000 SAT-0079 A Placental Fibroblast Growth Factor 21 (FGF21) mRNA but Not Protein Expression Is Increased in Preeclampsia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Juan Fuentes*1, Jacob Bourgeois2, Xiaoyuan Kong1, Marcia Gordon1 and Michael Edward Fant1
1USF Morsani College of Medicine, Tampa, FL, 2USF School of Public Health, Tampa, FL

 

Background: Plac1, an X-linked gene, is expressed primarily by the trophoblast and is essential for normal placental development. By examining a mutant mouse model, our laboratory observed that Plac1 is also expressed in the fetal brain and directly influences its growth in a developmentally regulated and paternally imprinted manner.

Objective: The objective of this study is to examine neuronal Plac1 expression and determine its effect on brain development. 

Methods: Plac1 was deleted in murine ES cells and bred against a C57BL/6 background. Embryos were obtained at various gestational ages, genotyped using a PCR-based strategy and observed postnatally. Embryonic Plac1 expression and brain structure was assessed by qRT-PCR, immunohistochemistry (IHC) and T2-weighted MRI. Behavioral phenotyping was performed using the TSE Phenomaster home cage system.

Results: Our results indicate that Plac1 is expressed throughout the fetal brain and its absence results in significant structural abnormalities. In situ hybridization, IHC and qRT-PCR localized Plac1 expression to all regions of the fetal brain (midbrain, hindbrain/cerebellum and cortex). IHC and MRI of an adult male knockout (KO) revealed decreased brain volume (10%), increased heterogeneity in the medulla, and a dysmorphic cerebellum compared to the WT male. IHC analysis confirmed the cerebellar abnormalities (including reduced folia), a thin cortical mantle, and hippocampal abnormalities. NF-M immunostaining (specific for axons) revealed a striking disruption of axonal tracts involving, in part, the corpus callosum, fornix, cerebellum, and cortex in both the KO males and Xm-X females. Similarly, anti-NeuN immunostaining revealed a significant reduction in mature neurons in both genotypes. Interestingly, differential gene microarray analysis of KO vs WT placentae revealed a striking number of down-regulated genes and pathways known to be important for axon guidance and neurogenesis. Finally, behavioral analyses revealed that adult Xm-X females exhibit significant reductions in their speed of movement, increased rearing behavior, and increased sleep-time compared to age-matched WT controls indicating that the observed structural abnormalities have functional consequences.

Conclusions: Plac1 is expressed throughout the developing brain where it plays a significant and non-redundant role. These findings identify Plac1 as a novel X-linked determinant of brain development.  Its absence is associated with major disruptions in the cellular architecture of brain regions and axonal tracts that result in abnormal functional outcomes.

 

 

 

Nothing to Disclose: JF, JB, XK, MG, MEF

15468 14.0000 SAT-0080 A Plac1 (Placenta-specific 1) Silencing Is Associated with Abnormal Brain Development and Function 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Daniel C Mandel*1, Marissa Kraynak2, Amber Edwards2, Kenneth Lewis3, Dinesh Shah4, Ian Michael Bird5 and David H Abbott6
1University of Wisconsin, Madison, WI, 2University of Wisconsin-Madison, Madison, WI, 3OpAns, LLC, Durham, NC, 4Univ of Wisconsin, Madison, WI, 5Univ of Wisconsin-Madison, Madison, WI, 6Univ of Wisconsin & Wisconsin National Primate Research Center, Madison, WI

 

Introduction: Parturition is triggered following an integrated process of hormonal signaling between mother, placenta, and fetus. Preterm parturition is a significant cause of human morbidity and mortality. 17OHPc is the only FDA-approved, primary preventative strategy against recurrent preterm parturition, yet its mechanism of action is unclear. Since 17OHPc is structurally similar to endogenous 17OHP, we hypothesized that either 17OHPc is metabolized to 17OHP in vivo with direct conversion to cortisol, or via other mechanisms, including adrenal enzyme inhibition, alters hypothalamic-pituitary adrenal (HPA) axis feedback to reduce cortisol-CRH drive of the placental parturition clock.

Methods: Rhesus monkeys demonstrate human-comparable fetal adrenal development, as well as steroidogenic function in the adult adrenal and placenta. Pregnant rhesus monkeys, in mid (day 66-80) or late (day 99-116) gestation (term:165 days), received 17OHPc or inert vehicle at a human dose/frequency equivalent across a 14-day period (n=3-5/group). Daily blood collection (0600h-0900h), a dexamethasone (Dex) suppression/ACTH stimulation test on study day 13, and a follow-up assessment around study day 27, permitted LC-MS/MS determination of circulating steroid hormone and 17OHPc levels in selected plasma samples. Area under the curve (AUC) was determined for individual steroids through follow-up and Dex/ACTH AUC was calculated separately. Product/substrate ratios were calculated to represent relative enzyme activity for 21-hydroxylase, 17-hydroxylase, 17,20-lyase and 3-betaHSD at each timepoint. Following conversion to SI units, AUC was calculated for each enzyme ratio and log10 transformed for comparison.

Results: 17OHPc became detectable in drug injected dams 15 min after first administration (p=0.02) and remained detectable at day of followup. In late-gestation alone, 17OHPc increased relative 17,20-lyase activity (increased DHEA/Cortisol ratio, p=0.05), and diminished relative 21-hydroxylase activity (p=0.05) during Dex/ACTH testing. In addition, late-gestation administration of 17OHPc led to a reduced AUC for 17OHP (p=0.04).

Conclusion: Late-gestation 17OHPc treatment may subtly alter adrenal steroidogenesis, diminishing release of cortisol relative to DHEA, and reducing 17OHP, so favoring the delta-5 pathway through 17,20-lyase. This is consistent with one of the proposed hypotheses involving 17OHPc relative diminution of 21-hydroxylase. Relative reduction of endogenous cortisol drive may prevent premature cortisol-mediated activation of placental CRH and its induction of contraction activated proteins.

 

Disclosure: DHA: Ad Hoc Consultant, Viamet Pharmaceuticals Inc.. Nothing to Disclose: DCM, MK, AE, KL, DS, IMB

14711 15.0000 SAT-0081 A 17-Hydroxyprogesterone Caproate (17OHPc) Induces Relative Reduction of ACTH-Stimulated Cortisol Release in Late Gestation Rhesus Monkeys 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Mary A M Cleaton*1, Owen R Vaughan1, Amanda N Sferruzzi-Perri1, Abigail L Fowden1, Anne C Ferguson-Smith2 and Marika Charalambous3
1Centre for Trophoblast Research, University of Cambridge, United Kingdom, 2University of Cambridge, United Kingdom, 3Queen Mary University of London, London, United Kingdom

 

The paternally-expressed imprinted gene Dlk1 (Delta-like homologue 1) encodes a Notch family protein that is present in both membrane-bound and soluble forms and is known to function during embryonic development to control growth and survival (1,2). Additionally, Dlk1 is implicated in postnatal control of metabolic parameters, including the appropriate and timely development of brown adipose tissue (3) and the propensity to develop obesity on a high fat diet (1). In the adult, Dlk1 expression is low, as is the concentration of soluble DLK1 in blood plasma (4). The exception to this is pregnancy, when levels dramatically increase to a peak of approximately 8-fold that of non-pregnant adults (4). As the peak level of serum DLK1 during pregnancy correlates with the number of fetuses carried, we hypothesised that the source of maternal serum DLK1 in pregnancy was the conceptus or, alternatively, that the conceptus was signaling to the mother to elevate her endogenous DLK1 production.

To test these hypotheses, we utilised genetic mouse models and the imprinting status of Dlk1 to create crosses in which the mother, fetus, placenta or combinations thereof lacked the ability to express Dlk1. Analysis of maternal serum DLK1 levels in these crosses during pregnancy demonstrated that the pregnancy-induced elevation does not occur in the absence of Dlk1 expression in the conceptus. Thus, the conceptus is the source of the additional DLK1.

We investigated the significance of maternal serum DLK1 by studying compromised pregnancy. Dietary manipulation or corticosterone treatment during pregnancy, which caused fetal and placental growth restriction, also resulted in significant alterations in maternal serum DLK1 levels. This suggested that maternal serum DLK1 may act in pregnancy as a read-out of fetal wellbeing. Furthermore, DLK1 may act as a conceptus-derived signal to promote maternal metabolic adaptations to pregnancy, as experimental induction of comparable increases in serum DLK1 in non-pregnant mice perturbed lipid storage mechanisms and promoted a switch in whole-body metabolism towards fatty acid utilisation (5). This suggests that DLK1 may be a useful biomarker of fetal and maternal wellbeing.

 

Nothing to Disclose: MAMC, ORV, ANS, ALF, ACF, MC

12488 16.0000 SAT-0082 A Maternal Plasma DLK1 in Pregnancy Is Conceptus-Derived and May Act As a Read-out of Fetal and Maternal Wellbeing 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Ana Cheong*1, Alan Martinez2, April Batcheller2, Yuet-Kin Leung3, Michael Thomas1 and Shuk-Mei Ho4
1University of Cincinnati, Cincinnati, OH, 2University of Cincinnati, 3University of Cincinnati College of Medicine, Cincinnati, OH, 4Univ of Cincinnati, Cincinnati, OH

 

Embryo implantation failure is a major contributor to female infertility. However, why the embryo fails to attach to the receptive endometrium remains largely unknown. Emerging evidence suggests environmental toxciants such as xenoestrogen disrupt multiple events during embryo implantation. Bisphenol-A (BPA), a ubiquitous environmental toxicant, is a xenoestrogen suspected to adversely affect female reproduction. Rodent studies demonstrated high dose BPA (20uM or higher) attenuated blastulation of the in vitro preimplantation mouse embryos. Adult rats force-fed with BPA experienced implantation loss. Yet, it is unknown whether high fat content in western diet can modulate the adverse effect of BPA on female reproduction. To study the effect of high fat diet and BPA on embryo implantation, the female Sprague Dawley rats were fed with control diet (AIN 93G diet), or exposed to high fat diet (HFD; 40 kcal %), low dose BPA (250ug/kg BW) alone, HFD and low dose BPA, HFD and higher dose BPA (2500 ug/kg BW), and estradiol (EE2, 0.01 ppm) to mimic the environmental BPA exposure. Pregnant day 2 rats exposed to HFD diet had heavier ovaries with more developing follicles when compared to the BPA exposed and control groups. Pregnant day 8 rats with HFD exposure had more implantation sites along the two uterine horns and were supported by dense vasculature when compared to the BPA and EE2 exposed groups. On the contrary, BPA exposure attenuated ovulation and caused asymmetrical distribution of placenta along the two uterine horns of the same exposed rat and reduced vascularization of the placenta. This indicated that HFD is supportive towards embryo implantation by stimulating follicle development, symmetrically increased embryo implantation in uteri, and induced angiogenesis during gastrulation. More importantly, high fat diet counteracted the adverse effect of BPA on embryo implantation, postulating that high fat content in the western diet is protective towards the environmentally toxic effect of BPA on female reproduction. This study was supported in part by grants funded by National Institute of Environmental Health Sciences (R01ES015584, U01ES019480, U01ES020988, and P30ES006096).

 

Nothing to Disclose: AC, AM, AB, YKL, MT, SMH

16940 17.0000 SAT-0083 A High Fat Content in the Western Diet Ameliorated the Adverse Effect of Bisphenol-a during Embryo Implantation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Maria Fernanda Garces*1, Natalia E. Poveda1, Elizabeth Sanchez1, Ángel Y. Sánchez1, Susana B. Bravo2, María J. Vázquez3, Carlos Dieguez4, Rubén Nogueiras5 and Jorge Eduardo Caminos1
1Universidad Nacional de Colombia, Bogota, Colombia, 2Instituto de Investigaciones Sanitarias–IDIS, Santiago de Compostela, Spain, 3Universidad de Santiago de Compostela, Santiago de Compostela, Spain, 4Univ of Santiago Fac of Med, Santiago Compostela, Spain, 5University of Santiago de Compostela/CIBERobn, Santiago de Compostela, Spain

 

Nesfatin-1 is an anorexigenic neuropeptide derived by post-translational cleavage from the N-terminus region DNA binding/EF-hand/acidic amino acid rich region (NEFA)/nucleobindin2 (NucB2) protein through proteolytic prohormone convertases (1). This neuropeptide was originally localized in different appetite controlling areas such as the hypothalamic paraventricular nucleus, arcuate nucleus, supraoptic nucleus, lateral hypothalamic area, and nucleus tractus solitarius (1,2). The objective of this study was to determine the expression and the changes that occur to mRNA and protein of NucB2 and Nesfatin-1 serum levels during gestation.

 

This study utilized molecular and immunological approaches to investigate the expression and regulation of NucB2/Nesfatin-1 protein throughout gestation in rat fed under ad libitum and food restricted conditions (30% nutrient restriction). NucB2 was immunolocalized in the amnion and decidua of the rat placenta. Nesfatin-1 serum levels were measured by radioimmunoassay on gestational days 12, 16, 19 and 21, showing a significant (p< 0.01) decrease in serum levels after day 12 until the end of gestation in rats fed ad libitum. These results were correlated with the analysis of NucB2 mRNA, with a significant (p< 0.01) reduction observed in both the mRNA and protein of NucB2 during the gestational days 12, 16 and 21. It was also observed that food restriction decreases nesfatin-1 serum levels and NucB2 placental expression at day 16 of gestation when compared to pregnant rats fed ad libitum.

 

This study illustrates for the first time through molecular and immunological approaches the NucB2 expression and regulation on rat placenta and that this peptide is regulated throughout pregnancy. Consistent with previous reports, our results provide additional evidence supporting the role of NucB2 protein as an anorexigenic peptide that may contribute to the regulation of feeding behavior and energy homeostasis. NucB2/Nesfatin-1 might play an important metabolic role during pregnancy and fetal development and its energy balance mediating role should be studied in various physiological and pathological conditions throughout gestation.

 

Nothing to Disclose: MFG, NEP, ES, ÁYS, SBB, MJV, CD, RN, JEC

15392 18.0000 SAT-0084 A Regulation of NucB2/Nesfatin-1 throughout Rat Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Maria Fernanda Garces*1, Carlos E. Ruíz-Linares1, Alexsandra Ortiz-Rivera1, Mario O. Parra1, Juan P. Alzate1, Elizabeth Sanchez1, Carlos Dieguez2, Rubén Nogueiras2 and Jorge Eduardo Caminos1
1Universidad Nacional de Colombia, Bogota, Colombia, 2University of Santiago de Compostela/CIBERobn, Santiago de Compostela, Spain

 

Omentin-1 is an adipocytokine with anti-inflammatory activity that is abundantly expressed in visceral fat and its serum levels correlate negatively with different metabolic risk factors (1-3). Different studies of omentin-1 mechanisms of action have demonstrated a similarity with adiponectin; therefore omentin-1 has been considered as a "good" adipokine (3,4). The objective of this study is to determine during human and rat gestation, under varying physiological conditions, the serum profiles of omentin-1 and correlate these with the known adiponectin serum profile.

After written informed consent was provided, forty patients that had normal maternal and perinatal outcomes and delivering at term (39.22 +/- 0.84 weeks gestation), were studied during early, middle, and late pregnancy (11.6th-13th, 24th-26.3th, and 34th-37.3th weeks, respectively) in the period 2012-2013. Additionally, twenty healthy eumenorrheic women were included in this study, and their serum levels of adipocytokines were measured both during the follicular (days 3- 4) and luteal phase (days 21-23) of the menstrual cycle. Furthermore, serum levels was analyzed in five groups of pregnant rats fed ad libitum (n=12 rats/group), five groups of pregnant rats subjected to food restriction (65% nutrient restriction, n=12 rats/group), and a group of age-matched virgin rats (n=12 rats), fed ad libitum, was used as a control group. All groups were sacrificed at the end of days 8, 12, 16, 19, and 21 of gestation.

In humans, serum levels in the three gestational periods analyzed are significantly lower when compared with the eumenorrheic group. Also, serum omentin-1 levels were not significant with advancing gestation. These results show that omentin-1 has an inverse relationship with the HOMA index, body mass index (BMI), insulin levels, total cholesterol, HDL cholesterol, LDL cholesterol and triglycerides. On the other hands, rat omentin-1 levels had a tendency to decrease with advancing gestation, with levels being the lowest on day 21. Moreover, omentin-1 serum levels are lower on day 21 of gestation when compared to virgin control rats. In conclusion, throughout pregnancy serum omentin-1 levels decrease both in the human and rat animal model. The analysis of the serum profile during gestation in the two species is similar, which would permit the consideration of a rat animal model for future studies related to the regulation of omentin-1 during pregnancy in humans. Further study will be necessary to evaluate whether omentin can be adopted as a clinical biomarker during gestation.

 

Nothing to Disclose: MFG, CER, AO, MOP, JPA, ES, CD, RN, JEC

15484 19.0000 SAT-0085 A Serum Omentin-1 Levels Decreases during Pregnancy in Humans and Rat 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Rebekah L Viner*1, Yvonne Bodenburg2, George Saade3, Randall J Urban4 and Larry Denner4
1UTMB, Galveston, TX, 2Univ of Texas Med Branch, Galveston, TX, 3University of Texas Medical Branch, Galveston, TX, 4Univ of TX Med Branch, Galveston, TX

 

The duration of pregnancy is carefully timed. Disruptions in this timing often have profound effects on the health of the offspring. Proper control of the synthesis of steroid hormones is essential to the normal reproductive process. We have found that inositol requiring enzyme 1 alpha (IRE) is necessary for normal pregnancy. Granulosa cell-specific knockout of this kinase in mice extends the time to delivery. We discovered this kinase through a loss-of-function screen using RNA interference and forskolin stimulated progesterone secretion to identify kinases that potently inhibit progesterone production in the human KGN granulosa cell line. Further, knockdown of IRE potently inhibited CYP11A1 mRNA in response to forskolin treatment in both the KGN cells and primary human luteinized granulosa cells (HGLC) obtained from patients undergoing in vitro fertilization.  Immunocytochemistry and subcellular fractionation localized IRE to the nuclear membrane. IRE is prototypically known as one of the three ER stress signal transducers. However, in steroidogenesis ER stress is not induced even though the cells have this pathway that responds to tunicamycin and thapsigarin via phosphorylation of IRE and eIF2, BiP up-regulation, XBP1 splicing, and ATF6 cleavage.  These results led us to conclude that IRE regulation of CYP11A1 expression and progesterone in response to forskolin is independent of its role in ER stress. IRE is also important for steroidogenesis in adrenal Y1 and placental JEG3 cells, suggesting this may be a general mechanism. With global concerns increasing over declining fertility in humans, IRE represents a novel mechanism regulating steroidogenesis and pregnancy.

 

Nothing to Disclose: RLV, YB, GS, RJU, LD

16969 20.0000 SAT-0086 A IRE Regulates Steroidogenesis and Delays Pregnancy in Granulosa Cell-Specific Knockout Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Chandrashekara N Kyathanahalli*1, Jeyasuria Pancharatnam2 and Jennifer Catherine Condon3
1University of Pittsburgh, 2University of Pittsburgh, Pittsburgh, PA, 3Univ of Pittsburgh, Pittsburgh, PA

 

Introduction: In most pregnant mammals, the onset of labor is associated with an increase in circulating levels of estradiol (E2) accompanied by a precipitous decline in progesterone (P4) and/or its receptor function (PR). However the hormonally regulated local uterine mediators that govern the transition between uterine quiescence and contractility remain largely undefined. We propose that the uterine endoplasmic reticulum stress response (ERSR) which surges from early to mid gestation and declines dramatically towards term is a novel P4/E2 regulated mediator of gestational length. Furthermore we have defined that the gap junction protein connexin 43 (Cx-43), a component of the uterine contractile architecture, which regulates uterine myocyte contractility, is the local myometrial target of the uterine ERSR.

Results:  A. In vivo analysis has defined the relevance of the ERSR to gestational length by administering Tunicamycin (TM 0.04 -1 mg/kg b.w) (an ERSR inducer) to pregnant mice. While low levels of ER stress (TM 0.04 mg.kg b.w) did not effect gestational timing, higher ER stress levels (TM 0.2 – 1 mg/kg b.w.) led to increased uterine Cx-43 levels and a preterm birth phenotype which occurred 12-24 h post TM administration. In contrast co-administration of phenylbutrate (an ERSR reducer) reversed the ER stress induced preterm birth phenotype by restoring Cx-43 levels, allowing for live births at term.
B. In vivo administration of 1mg exogenous P4 daily, delays the onset of labor which we have found to be associated with a prolonged gestational profile of uterine ERSR and decreased Cx-43 levels. In contrast administration of the PR antagonist RU486 (150ng) which results in the onset of pre-term birth was found to be associated with a rapid decline in the uterine ERSR  and an accelerated increase in Cx-43 levels, prior to the onset of labor. In vitro analysis of the human uterine myocyte (hTERT-HM) cell line pretreated with P4 (10 nM) or E2 (10 nM) ( 24 or 48h) and exposed to TM ( 5ug/mL) for 24 or 48h demonstrated that while P4 had the capacity to increase uterine myocyte ERSR, E2 actively downregulated the ERSR.

Conclusion: These data suggest that the local uterine action of P4/PR action across gestation may aid in the maintainence of the appropriate levels of ERSR to preserve uterine quiescence across gestation via increased Cx-43 levels, whereas elevated E2 levels are a likely candidate that allows for the uterine resolution of ERSR at term.

 

Nothing to Disclose: CNK, JP, JCC

17031 21.0000 SAT-0087 A The Uterine Endoplasmic Reticulum Stress Response Regulates Gestational Length By Targeting Myometrial Connexin 43 Levels in a P4/PR and E2 Dependent Manner 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Mary Rebecca Moreci*1, Karen Florio1, Stanley N Caritis2, Jennifer Catherine Condon3 and Jeyasuria Pancharatnam1
1University of Pittsburgh, Pittsburgh, PA, 2University of Pittsburgh, 3Univ of Pittsburgh, Pittsburgh, PA

 

Preterm birth poses serious health issues and health care costs. Progesterone and estrogen (E2) play a role in the timing of parturition. Increased E2 action at term mediated by estrogen receptor alpha (ERα) is thought to signal the timing of labor. Circulating E2 levels increase towards term however they are significant throughout gestation. To explain the conundrum of suppression of the uterotonic action of E2 while this action is actively maintained in other tissues (e.g mammary glands) during pregnancy, we postulate that alternate uterine specific ERα isoforms play a tissue specific role across gestation. We demonstrate that differential splicing and alternative promoter usage likely permits temporal regulation of E2 action during pregnancy in a tissue specific manner. Utilizing pregnant mouse uteri (E11-E19) and human myometrial tissue we performed western and RTPCR analysis to establish the gestational profile of ERα isoforms and the splice factors hnRNPA1 and SRSF1. RTPCR analysis demonstrated that different ERα isoforms are produced via alternative promoter usage. QPCR was utilized to examine mRNA levels of splice factors and ERα isoforms in the mouse uterus. We have identified abundantly expressed gestationally regulated C-terminally truncated forms of ERα, in the human (51 kDa, ERΔ7) and mouse (C-TERP) pregnant uterus that lacks a ligand binding domain and AF-2 domain, in addition to the 46 kDa (ERα46) isoform and the full-length 66 kDa isoform (ERα66). siRNA knockdown of ERα46 in hTERT cells reveals it is a transcriptionally active form of ERα while ERΔ7 acts in a dominant negative fashion. In the mouse, we see a decline in the truncated ERα isoforms, with the ERα66 isoform becoming the dominant nuclear isoform 2 days prior to the onset of labor. Pregnant mice treated with time-release progesterone (P4) pellets, delay the switch to uterine ERα66 dominance at term. Splice factors SRSF1 and hnRNPA1, are gestationally regulated in the mouse and are shifted by P4 administration indicating a potential regulatory roles for these splice factors in ERα isoform variant expression. Conservation in ER isoform gestational profiles between the pregnant mouse uterus and human myometrium validates the pregnant mouse as a useful model to study ERα isoforms and their function in pregnancy. We find truncated forms of the uterine ERα early in gestation and hypothesize that, while functionally active, are able to inhibit full length ERα function across gestation. We further postulate that P4 gestationally controls ERα isoform ratios by regulating splice factors that govern the gestational profile of these alternate ERα isoforms allowing for spatial and gestational regulation of E2 action in the pregnant uterus.

 

Nothing to Disclose: MRM, KF, SNC, JCC, JP

17046 22.0000 SAT-0088 A Progesterone Governs the Ratio of Alternate Splice Variants of Uterine Erα in Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0067-0088 4856 1:00:00 PM Female Reproductive Endocrinology: Pregnancy Poster

Ji-Sun Lee*1 and Eui-Bae Jeung2
1Chungbuk National University, Cheongju Chungbuk, Korea, Republic of (South), 2Biochemistry and molecular biology of veterinary medicine college, Chungbuk National Univ, Cheongju, Korea, Republic of (South)

 

Introduction: 2-Methoxyestradiol(2-ME) is an endogenous metabolite of 17β-estradiol(E2) that interacts with estrogen receptors and microtubules, and it has a low affinity for estrogen receptors (ERs). It has been identified as a potential novel antitumor agent combining anti-proliferative activity on a wide range of tumor cell types with anti-angiogenic actions. Combined treatment with agents that possess anti-proliferative and anti-angiogenic activity results in anti-tumor synergy and reduced likelihood of anti-tumor drug resistance. Also, 2-ME attracted considerable interest as a potential anti-cancer therapeutic. In recent study, 2-ME has a role as a potent inhibitor of estrogen-induced tumor angiogenesis and tumorigenesis in F344 rat pituitaries. Methods: To performe in vitro experiment to evaluate estrogenic effect of 2-ME using GH3 cells, we measured mRNA expression of CaBP-9k and progesterone receptor (PR), the indicators of estrogenic effects using real-time PCR. Results: CaBP-9k mRNA expression was increased in 2-ME (10-7M) treatment group in parallel with response to E2 (10-9M). As a blocker for ER activity, ICI 182 780 reversed the both E2-mediated and 2-ME-mediated increase of CaBP-9k and PR mRNA. We also investigated how 2-ME is associated with ERs and PR. 2-ME did not significantly induce ER transcripts but PR transcripts. Conclusion: We demonstrated that 2-ME has an estrogenic effect on in vitro condition. Based on the in vitro study, we need to perform next experiment using in vivo model in which immature female mice could be used to explore the estrogenic effect of 2-ME on physiologic condition.

 

Nothing to Disclose: JSL, EBJ

12323 1.0000 SAT-0001 A Observation on Estrogenic Effect of 2-Methoxyestradiol (2-ME) in Rat Pituitary GH3 Cell 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0001-0016 4857 1:00:00 PM Female Reproductive Endocrinology Poster

Marissa Kraynak*1, Matthew T Flowers2, Robert A Shapiro1, Amita Kapoor1, Amber K Edwards2, Jon E Levine3 and David H Abbott4
1University of Wisconsin-Madison, Madison, WI, 2University of Wisconsin-Madison, WI, 3University of Wisconsin-Madison, 4Univ of WI-Natl Primate Rsch C, Madison, WI

 

Non-ovarian estradiol, synthesized within neurons of the hypothalamus, regulates episodic release of GnRH in primates [1]. In order to test whether such non-ovarian estradiol contributes to negative feedback regulation of gonadotropin, nine adult (>2 years) female marmosets (Callithrix jacchus), with regular ovarian cycles and housed with a testis-intact male pairmate, were ovariectomized (OVX) during the early-to-mid follicular phase and subjected to aromatase inhibition or control vehicle treatment. Daily oral letrozole (LET, 1 mg/kg; n=6) or vehicle (Ensure ®; 1 ml/kg; n=3) treatment commenced the morning after OVX on study day 1. Plasma chorionic gonadotropin (CG; marmoset pituitary gonadotrope equivalent of LH) and steroid hormone levels were determined by validated RIA and LC-MS/MS assays, respectively. Ten days following OVX, circulating CG levels in the vehicle control group (C) reached maximal post-OVX values. Plasma CG levels in LET females were comparable to those in C females during this initial post-OVX period. Between 11-30 days following OVX, however, plasma CG levels in LET females exhibited an additional increase above controls (area-under-the-curve CG levels: LET, 172±23; C, 93±32 ng/mL*20 days; mean±SEM; p<0.044). Intravenous injection of 1 μg GnRH following 30 days of treatment with either LET or vehicle induced comparable elevations of pituitary CG release in both female groups. Plasma estradiol levels in long-term (≥ 2 months) LET OVX females (4±3 pg/mL) were lower (p<0.031) than in comparable OVX controls (10±2 pg/mL). These results suggest that non-ovarian estradiol in adult female marmoset monkeys contributes additional negative feedback regulation of pituitary CG release beyond that provided by ovarian hormones. The absence of differential pituitary CG responses to exogenous GnRH in LET and C females implicates a hypothalamic component in non-ovarian estradiol regulation of gonadotropin secretion. Neuroestradiol may thus exert subtle regulatory control over ovarian function, an influence that may extend to Old World primates, including humans.

 

Disclosure: DHA: Ad Hoc Consultant, Viamet Pharmaceuticals Inc.. Nothing to Disclose: MK, MTF, RAS, AK, AKE, JEL

13919 2.0000 SAT-0002 A Aromatase Inhibition Elevates Post-Ovariectomy Gonadotropin Levels in Female Marmoset Monkeys Revealing a Non-Ovarian Source of Negative Feedback 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0001-0016 4857 1:00:00 PM Female Reproductive Endocrinology Poster

Weiling Yin*1, Sean Maguire1, Brian Pham1, Alexandra N Garcia1, Nguyen-Vy Dang1, Jingya Liang1, Andrew Wolfe2, Hans A Hofmann3 and Andrea C Gore1
1University of Texas at Austin, Austin, TX, 2Johns Hopkins University School of Medicine, Baltimore, MD, 3Univ of Texas at Austin, Austin, TX

 

Estrogen replacement therapy is often used to relieve menopause related symptoms, but little is known about its effects on neuroendocrine systems. Using a rat model of menopause, we addressed a clinically relevant question of the importance of the timing and duration of estradiol treatment on neuroendocrine gene expression networks. Young (Y, 4 mo) and middle-aged (MA, 11 mo) Sprague-Dawley female rats were ovariectomized (OVX) and implanted s.c. with a Silastic capsule containing vehicle (VEH) or estradiol (E2). The duration of E2 treatment was compared in MA rats given E2 (c.f. VEH) for 3 or 6 months. The timing of E2 treatment was tested in MA rats given E2 treatment immediately at OVX for 3mo, then switched to 3 mo of VEH, vs. a group of rats given VEH for 3 mo, then switched to E2 for 3 months. At the end of the study, rats were euthanized, and the arcuate nucleus (ARC) and the medial preoptic area (mPOA) of the hypothalamus were collected for real-time PCR using a 48-gene Taqman low density array card containing genes related to energy balance, reproduction and circadian rhythms. Covariance networks were created between genes for each treatment group and then compared across groups and regions using matrix correlations. Weighted gene co-expression network analysis (WGCNA) was used to find modules of highly correlated genes and representative module eigengenes. Our results showed that 1) Covariance networks in the mPOA, but not ARC, showed group associations by hormone treatment. 2) Overall, more associated gene modules were identified in the ARC than in the mPOA. Circadian rhythm-associated genes (Bmal1, Clock, Cry2, Per1, Per2, Dbp, Mtnr1b) were differentially correlated with hormone receptors (Esr1, Esr2, Gper, Pgr) regulate energy balance (Pomc, Igf1, Lepr, Trh), and reproduction (Kiss1, Tac2, Pdyn) in ARC and mPOA. 3) E2 differentially affected progesterone, thyroid hormones, corticosterone and pituitary hormones depending on age, timing and duration of treatment.  Our results suggest that estradiol affects suites of genes in a region-specific manner. Furthermore, our identified putative target genes and hormones demonstrate differentially regulation by age, timing and duration of E2 treatment.

 

Nothing to Disclose: WY, SM, BP, ANG, NVD, JL, AW, HAH, ACG

16303 3.0000 SAT-0003 A Timing and Duration of Estradiol Treatment Affect Hypothalamic Gene Expression Networks 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0001-0016 4857 1:00:00 PM Female Reproductive Endocrinology Poster

Thomas Fisher*1, Jun Shu2 and Genevieve S. Neal-Perry3
1Montefiore Medical Center, Bronx, NY, 2Albert Einstein College of Medicine, Bronx, NY, 3University of Washington, Seattle, WA

 

Vitamin D (VD) deficiency has reached near epidemic levels in reproductive aged women. We previously demonstrated that in utero VD deficiency programs estrous cycle dysfunction and oligoovulation. We recently reported that GnRH neurons express VDR and conditional deletion of VDR in GnRH neurons (GnRHVDR-/-) programs delayed puberty and oligoovulation. Kisspeptin signaling is important for puberty, regular estrous cyclicity and GnRH neuronal function. We hypothesize that VDR signaling in GnRH neurons disrupts hypothalamic responsiveness to excitatory input from kisspeptin. To test this hypothesis we assessed gonadotropin release in GnRHVDR-/- mice created with cre-LoxP technology and infused with intracerebroventricular (ICV) kisspeptin (10 pmol).

Methods: Prepubertal GnRHVDR-/- and control (VDRflox/flox) female mice (5 wks) were ovariohysterectomized (OVX), allowed to recover for 5 days, and then primed with a regimen of estradiol (E2) and progesterone (P) that induces a robust LH surge. On the day of OVX, 3rd ventricle ICV cannulas were placed for kisspeptin infusion. Three hours after the P injection, females were ICV infused with saline (vehicle) at zero minutes and kisspeptin at thirty minutes.  Blood samples were collected at 0 minutes (baseline), immediately before and 30 minutes post ICV infusion of saline and kisspeptin.

Results: Compared to control mice (n=2), GnRHVDR-/- mice (n=2) had equivalent levels of baseline LH and FSH and kisspeptin-induced FSH release. In contrast, ICV kisspeptin infusion induced a 50-fold increase in LH release from control mice compared to a 3.5-fold increase in LH release from GnRHVDR-/- mice.

Conclusion: These preliminary data strongly suggest that reduced VDR signaling in GnRH neurons may adversely affect puberty and disrupt estrous cyclicity by reducing hypothalamic responsiveness to kisspeptin. 

 

Nothing to Disclose: TF, JS, GSN

16852 4.0000 SAT-0004 A Conditional Deletion of VDR in GnRH Neurons of Female Mice Attenuates Responsiveness to Icv Kisspeptin Infusion 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0001-0016 4857 1:00:00 PM Female Reproductive Endocrinology Poster

Ana Paula Abreu*1, Victor M. Navarro2, Martha A. Bosch3, Joy N. Liang4, Delanie B. Macedo5, Serap Simavli1, Sekoni D. Noel6, Iain Robert Thompson1, Rona S. Carroll6, Oline K. Ronnekleiv7, Ana Claudia Latronico8 and Ursula B Kaiser6
1Brigham and Women's Hospital and Harvard Medical School, Division of Endocrinology/Diabetes, Boston, MA, 2Harvard Medical School and Brigham and Women's Hospital, Boston, MA, 3Div of Neurosci, Oregon Reg Primate Rsrch Ctr, Beaverton, OR, 4Brigham and Women's Hospital/Harvard Medical School, Boston, MA, 5Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 6Brigham and Women's Hospital/Harvard Med School, Boston, MA, 7Oregon Reg Primate Rsrch Ctr, Beaverton, OR, 8Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Loss-of-function mutations in makorin ring finger 3 (MKRN3) have been recognized as a cause of familial central precocious puberty. Analysis of Mkrn3 expression in the arcuate nucleus of mice showed high expression levels in juvenile mice, with a marked reduction prior to puberty onset, suggesting that MKRN3 inhibits puberty initiation. The function of MKRN3 is not known but based on its amino acid sequence, it is predicted to act as an ubiquitin ligase. Our aim is to investigate how loss of function of MKRN3 results in early activation of GnRH secretion. We hypothesize that MKRN3 interacts with GnRH or its stimulators (e.g., kisspeptin, neurokinin B or their cognate receptors), targeting them to degradation. As a first step to analyze if MKRN3 acts as an ubiquitin ligase, we performed affinity purification of HEK293T cells co-transfected with MKRN3 and His-tagged ubiquitin (Ub-His), and were able to detect MKRN3 in immunoprecipitated Ub-His protein complexes. Furthermore, Western blot analysis showed a pattern typical of ubiquitination. Taken together, these data suggest that MKRN3 acts as an ubitiquitin ligase and ubiquitinates itself. Secondly, we performed in situ hybridization (ISH) assays to analyze Mkrn3 expression and map the distribution of Mkrn3 in the hypothalamus of male and female mice at different developmental stages. ISH detected high and diffuse Mkrn3 expression in the hypothalamus of postnatal day P1 male and female mice, with more localized expression in the arcuate and ventromedial nuclei at P10. Hypothalamic Mkrn3 expression was very low by P15 and in adult male and female mice, confirming our previous study by RT-qPCR. Finally, to detect Mkrn3 expression in two neuronal populations critical for reproduction -GnRH and Kiss1 neurons- we performed single cell RT-PCR in cells derived from Kiss1-GFP and Gnrh-GFP intact juvenile or ovariectomized adult female mice. Mkrn3 was expressed in ~35% and 20% of arcuate Kiss1 neurons at age P13 and in adult mice, respectively. Mkrn3 was expressed in ~30% of GnRH neurons at P13 but was not detected in GnRH neurons from adults. In conclusion, MKRN3 interacts with ubiquitin and likely acts through ubiquitination of important regulators of GnRH secretion. The temporal and spatial pattern of Mkrn3 expression in the hypothalamus of mice and co-localization in Kiss1 and GnRH neurons in mice suggests that MKRN3 acts as a brake for GnRH secretion and corroborates our genetic findings in humans.

 

Nothing to Disclose: APA, VMN, MAB, JNL, DBM, SS, SDN, IRT, RSC, OKR, ACL, UBK

16952 5.0000 SAT-0005 A Deciphering the Functional Mechanisms By Which MKRN3 Regulates Puberty Initiation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0001-0016 4857 1:00:00 PM Female Reproductive Endocrinology Poster

Shah Saddad Hussain* and Kambadur Muralidhar
University of Delhi, New Delhi, India

 

Glycoengineered recombinant Glycoprotein hormones:as the therapeutics for the Superovulation in Indian Water Buffalo (Bubalus bubalis)

Embryo transfer techniques in water buffalo were derived from those in cattle. The success rate is reported to be much lower in buffaloes, due to their inherent lower fertility and also possibly poor superovulatoryresponse(1) For a successful embryo transfer programme, availability of gonadotropins, particularly buffalo FSH (buFSH) is the main hurdle. It has been observed that Oligosaccharide structures on the glycoprotein hormone FSH, have been shown to play an important role in the biosynthesis,  metabolic fate, plasma half life and regulation of potency of the hormone consequently the in vivo bioactivity of the hormone (2,3) Expression of recombinant glycoprotein hormones with Glycan Moiety similar to that in human hormones is a difficult task due to the structural complexity and mandatory core glycosylation during biosynthesis

Our objective was to utilize engineered Pichia pastoris expression system to achive partial success in this direction. We modified the pichia strain GS115 (OCH1Knockout)

The cDNAs encoding the mature secreted forms of buFSHα and buFSHβ (without their cognate signal peptides) were PCR-amplified using the buffalo pituitary cDNA  as the template and  primers  designed to introduce Xho I and NotI sites at the 5′ and 3′ends of cDNA, respectively. The forward primer also had additional sequences that allowed the recreation of the Kex2 cleavage. The amplified DNAs were cloned into pGAPZαA vector and recombinant buFSH was expressed by co-transformation of the Pichia cells (Mn3GnT2) with both the expression constructs.   The clone of P. pastoris hyperexpressing the heterodimericbuFSH was generated by co- transforming the yeast cells with pGAPZαA buFSHα and pGAPZαA buFSHβ using electroporation. The transformants selected on Zeocin (100 μg/ml) were tested for their ability to secrete heterodimeric buFSH into the culture medium .In vitro biological activity was determined by the receptor binding assay. The different gel filtration protein peaks were tested for their ability to inhibit radio-labeled FSH binding  to rFSHR expressing  HEK 293 cells in an  RRA. It was observed that the protein peak representing  the recombinantbuFSH was able to inhibit the binding of 125I hFSH to the rFSHR in a dose dependent mode.

      The displacement curve obtained with Pichia medium showed parallelism with that of the authentic FSH suggesting that buFSH secreted by Pichia cells was similar to the humanFSH.

 

Nothing to Disclose: SSH, KM

14992 6.0000 SAT-0006 A Glycoengineered Recombinant Bubaline Follicle Stimulating Hormone (buFSH) As a Therapeutic for the Induction of Superovulation in Indian Bubalus Bubalis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0001-0016 4857 1:00:00 PM Female Reproductive Endocrinology Poster

Jordan Pereira* and Brian D Cohen
Union College, Schenectady, NY

 

The human FSH receptor is a g protein-coupled receptor (GPCR) expressed on the surface of granulosa cells in the ovary and Sertoli cells in the testes.  Like many other GPCR, FSHR has a sequence of amino acids consistent with a caveolin interaction motif. This motif (ΦXΦXXXXΦXXΦ) is found between amino acids 479-489 in the primary receptor sequence in the putative 4th transmembrane domain.  Caveolin is a protein found in cell membrane microdomains such as lipid rafts. These densely packed regions of the membrane are enriched for sphingolipids and cholesterol and are thought to be involved in signal transduction.  Caveolin can be found in caveolae, a flask-like structure which is a specific type of lipid raft, or in non-caveolae lipid rafts.  Although the receptor has this motif, it was unknown if hFSHR biochemically interacted with caveolin.  To test this hypothesis, hFSHR was isolated by immunoprecipitiation from HEK-293 cells stably transfected with hFSHR cDNA.  Analysis by western blot of co-immunoprecipitated proteins revealed the presence of caveolin-1. In addition, disruption of lipid rafts by cholesterol withdrawing agents demonstrated that lipid raft residency is necessary for normal signal transduction by hFSHR.  Together these results suggest that caveolin-1 plays an important role in cell signaling by sequestering hFSHR into lipid rafts for normal receptor function.

 

Nothing to Disclose: JP, BDC

16327 7.0000 SAT-0007 A Interaction of Human Follicle Stimulating Hormone Receptor with Caveolin-1 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0001-0016 4857 1:00:00 PM Female Reproductive Endocrinology Poster

Tomohiro Yonezawa*1, Sora Kodama2, Ryutaro Ichinose2, Motoko Ohata2, Shiro Kurusu2 and Mitsumori Kawaminami2
1University of Tokyo, Tokyo, Japan, 2Kitasato University, Aomori, Japan

 

Communicating the time of ovulation is important to enhance the probability of fertilization in mammals. Estrous females release several specific chemical compounds into their body fluids which enhance the sexual behavior of males to females. These phenomena have been reported to be activated by estrogen. In this study, we hypothesized that gonadotropin-releasing hormone (GnRH) also has direct effects to regulate the sexual behavior and chemical release during the estrous phase. First, the effects of GnRH on courtship behavior in mice were determined. Hypogonadal (hpg) mice, which are deficient in GnRH production by the natural mutation of GnRH-associated peptide, were utilized. Silastic tubes with estrogen were implanted into ovariectomized hpg adult female mice. One week later, GnRH agonist (des-Gly(Pro9)-GnRH ethylamide, 0.5 nmol/5 μl) or vehicle was intracerebroventricularly (icv) injected to these females. They were mated with the wild type vigorous male mice 30 min after icv injection and their behaviors were video-recorded. The duration and frequency of sniffing behavior and mounting behavior of the male to the female were activated by GnRH agonist during one hour after icv injection. When these females were mated with the vomeronasal organ-removed wild type males, the behavior was not altered between GnRH and vehicle icv injection. Second, to identify the specific GnRH-stimulated urinary chemicals of females, the urine were collected 30 min after GnRH agonist or vehicle icv injection to the estrogen-implanted ovariectomized hpg mice. The urine samples were extracted with dichloromethane (1:1 ratio, v/v) and analyzed by gas chromatography linked mass-spectrometry (GC-MS). Three novel specific compounds were identified from the urine of GnRH agonist-injected mice compared to vehicle-injected mice. Two of them were synthesized. These chemicals diluted with the deodorizing water (1:10,000) were applied on the perineal area of ovariectomized mice with cotton swabs and these mice were mated with wild type vigorous male mice. The chemical application increased the frequency of sniffing behavior of the male compared to the vehicle application. These results suggest that GnRH in the female mice has direct effects to enhance the sexual behavior of males and release several chemoattractants into the urine which induce the courtship behavior of males.

 

Nothing to Disclose: TY, SK, RI, MO, SK, MK

14345 8.0000 SAT-0008 A Effects of Gonadotropin Releasing Hormone on Sexual Behavior and Chemoattractants Release into the Urine of Female Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0001-0016 4857 1:00:00 PM Female Reproductive Endocrinology Poster

Alexandra N Garcia*1, Kelsey Bezner2, Christina K Depena2, Weiling Yin1 and Andrea C Gore1
1University of Texas at Austin, Austin, TX, 2University of Texas at Austin

 

Menopause is the physiological cessation of ovarian function during which menstrual cyclicity ceases and ovarian hormones such as estrogens and progesterone decline. Menopause is associated with neurobehavioral changes, including increased anxiety and depression, which can greatly interfere with a person’s quality of life. It has been postulated that a strong social network can ‘buffer’ these specific menopausal symptoms. Both human and animal studies show that having a strong social support network, such as close friends (human) or being caged with family members (animals) leads to a lower amount of depressive and anxiety symptoms. Furthermore, considering the strong role that estradiol (E2) plays in mediating social behaviors and affecting underlying neural circuits involved in social interactions, this area merits new research. Therefore, we sought to determine the effects of estradiol on the social behavior, and effects on underlying neural circuits. For this study we had two groups of young female rats that were ovariectomized at 3 months and implanted subcutaneously with a capsule containing either E2 or cholesterol (vehicle). Three months later, the animals were tested on three behavioral tests of social interaction and social memory: an olfactory preference test, a sociability test, and an ultrasonic vocalizations (USV) test. Tests were conducted using social pairs of female rats housed as cage mates. The data showed that there were no differences between the estradiol and vehicle groups in the olfactory preference test. There was a significant (p< .05) difference between treatments in the amount of USV calls emitted during the USV test. Specifically, vehicle animals called significantly more to their cage mates than the E2 treated rats. In the sociability test, vehicle treated animals had significantly more freezing periods than the E2 treated animals. In addition, compared to vehicle rats, the E2 treated animals spent more time in proximity to other rats in a social novel paradigm. Ongoing work will assess associated gene expression changes in the brains of these animals. In addition, we are currently testing middle-aged rats on similar behavioral tests in order to determine effects of chronological age on social behaviors.

 

Nothing to Disclose: ANG, KB, CKD, WY, ACG

16051 9.0000 SAT-0009 A The Effects of Estradiol on Social Behaviors in Ovariectomized Female Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0001-0016 4857 1:00:00 PM Female Reproductive Endocrinology Poster

Licy L. Yanes Cardozo*, Damian G. Romero and Jane F. Reckelhoff
Univ. of Mississippi Med. Ctr., Jackson, MS

 

Menopause is associated with a higher prevalence of hypertension, obesity, and insulin resistance in women. The mechanisms underlying menopause-associated cardio-metabolic comorbidities remain to be elucidated. Lack of estrogens had been proposed to be one of the main mechanisms. In vivo and in vitro studies suggest that estrogens decrease blood pressure (BP) acting as a vasodilator.  However, randomized clinical trials have shown no effect of estradiol replacement on BP in postmenopausal women, suggesting that the time that estradiol replacement begins is a critical factor in the response to estradiol. Aging female Dahl Salt Sensitive (DS) rats develop spontaneous hypertension by 12 mos of age and are no longer estrous cycling.

In the present study, we aimed to determine the impact of estradiol replacement on hypertension in the aging female DS rats, and hypothesized that chronic estradiol replacement would normalize BP in aging female DS.

Female DS rats, aged 12 mos, were implanted subcutaneously with 17β-estradiol pellets of two increasing concentrations (1x and 5x) consecutively. Animals were maintained in standard rodent diet (0.3% NaCl) with free access to water. BP was measured by radiotelemetry throughout the study period. At the end of the experimental period, plasma estradiol, insulin, leptin and aldosterone were determined by radioimmunoassay and visceral fat weighted.

The low estradiol dose (1x) increased plasma estradiol levels by about 3-fold compared to placebo (13.54±2.29 vs. 4.28±1.2 pg/ml; p<0.01). This dose of estradiol caused a transient 10 mm Hg reduction in BP that lasted only 4 days (164±2 vs. 154±5 mmHg; p<0.05) and then BP returned to baseline values (164±3 vs. 165±3 mm Hg). Subsequently, the higher dose (5x) of 17β-estradiol increased plasma estradiol by almost 40-fold compared to placebo (84.28±9.67 vs. 2.30±0.45 pg/ml, p<0.001), but caused only a transitory decrease in BP without reaching statistical significance. In contrast, high dose estradiol-treated rats had lower levels of plasma aldosterone (19.50± 1.66 vs. 44.62±8.36 ng/dl; p<0.05), leptin (4.32 ±0.62 vs. 8.20±1.45 ng/ml, p<0.05) and visceral fat (23±4 vs. 11±3 mg/gr body weight) at the end of the treatment.

In summary, estradiol treatment caused a tachyphylactic effect on BP in aging female DS rats despite the sustained reduction in plasma aldosterone, leptin and visceral obesity. Our study suggests that the tachyphylactic effect of estradiol on BP with aging may contribute to the lack of cardio-protective effects of estradiol supplementation seen in postmenopausal women.

 

Nothing to Disclose: LLY, DGR, JFR

15285 10.0000 SAT-0010 A Effect of Estradiol Replacement in Hypertension in the Aging Female Dahl Salt Sensitive Rat 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0001-0016 4857 1:00:00 PM Female Reproductive Endocrinology Poster

Wasana Pratchayasakul*, Piangkwan Sa-nguanmoo, Hiranya Pintana, Jirapas Sripetchwandee, Rungroj Tawinvisan, Nipon Chattipakorn and Siriporn C Chattipakorn
Chiang Mai University, Chiang Mai, Thailand

 

Previous studies showed that either estrogen deprivation or obesity can cause insulin resistance and cognitive dysfunction (1,2).  In addition, our previous study demonstrated that 12-week high-fat diet (HFD) consumption induced peripheral insulin resistance, brain insulin resistance and brain oxidative stress, leading to impaired cognitive function (2,3).  However, whether estrogen deprivation combined with HFD-induced obesity accelerates the occurrence of brain oxidative stress, hippocampal synaptic dysfunction and cognitive impairment has never been investigated.  We tested the hypothesis that estrogen deprivation combined with HFD-induced obesity aggravates brain oxidative stress and hippocampal synaptic dysfunction, leading to impaired cognitive function earlier than either estrogen deprivation or HFD consumption alone.  Seventy-two female rats were divided into sham-operated (Sham; S) and ovariectomized (OVX; O) groups.  A week after the surgery, rats in each group was divided into 2 subgroups and fed with either normal (ND) or HFD for 4, 8 and 12 weeks.  At the end of each time point, blood samples were collected to determine the metabolic parameters.  The cognitive function was tested by the Morris Water Maze prior to brain removal for determining brain oxidative stress.  The hippocampal synaptic function was determined using the long-term potentiation (LTP) and dendritic spine density.  We found that 1) peripheral insulin resistance was initially observed at week 8 in ovariectomized ND (NDO) rats, sham-operated HFD (HFS) rats, and ovariectomized HFD (HFO) rats; 2) the occurrence of brain oxidative stress and hippocampal synaptic dysfunction were also observed at week 8 in NDO, HFS and HFO rats; 3) the impaired cognitive function developed earlier (at week 8) in HFO rats, and was found later at week 12 in NDO and HFS rats; and 4) the severity of peripheral insulin resistance, brain oxidative stress, hippocampal synaptic dysfunction and cognitive decline in HFO rats were significantly greater than those in NDO and HFS rats.  All of these findings suggest that obesity accelerates and aggravates the severity of hippocampal synaptic dysfunction and cognitive declines in estrogen-deprived rats via increased brain oxidative stress and decreased dendritic spines.

 

Nothing to Disclose: WP, PS, HP, JS, RT, NC, SCC

11974 11.0000 SAT-0011 A Obesity Aggravates the Severity of Hippocampal Synaptic Dysfunction and Cognitive Declines in Estrogen-Deprived Rats Via Increased Brain Oxidative Stress and Decreased Dendritic Spines 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0001-0016 4857 1:00:00 PM Female Reproductive Endocrinology Poster

Jessica Bauer*1, Yan Sun2, Jun Shu2, Streamson C Chua3 and Genevieve S. Neal-Perry4
1Beth Israel Medical Center, New York, NY, 2Albert Einstein College of Medicine, Bronx, NY, 3Albert Einstein Coll of Med, New York, NY, 4University of Washington, Seattle, WA

 

Female reproductive aging in rodents is characterized by reduced responsiveness to estradiol (E2) positive feedback conditions, delayed and attenuated LH surges, and reduced activation of GnRH neurons, as determined by c-fos co-expression. Of note female reproductive senescence in rats is also associated with increased central adiposity. Increased adiposity disrupts hypothalamic-pituitary axis (HP) responsiveness to E2 positive feedback in young reproductive aged females and weight loss rescues HPA function thereby raising the possibility that increased adiposity in middle-aged females contributes to age-related HP-axis dysfunction. We hypothesize that increased metabolic adiposity in middle-aged females contributes to age-related LH surge and GnRH neuron dysfunction during E2-positive feedback conditions. To test this hypothesis we surgically removed metabolically active abdomino-pelvic fat (VF females; visceral fat, perinephric, and gonadal fat pads; N=6) and performed sham surgery on control (N=6) middle-aged retired females. Females were allowed to recover for 2 wks before they were ovariectomized (OVX), primed with a regime of E2 and progesterone that reliably induces a LH surge. Groups of rats were received jugular vein catheters for serial blood sampling (N=5-6) or perfused and brains collected (N=6) for dual label IHC for GnRH and c-fos. To determine the effect of age-related metabolic fat on anterior (A-hypo) and posterior (P-hypo) hypothalamic gene expression, qRT-PCR was used a separate group of control and VF females (n=3-4). Glucose tolerance tests were also performed in all females. Repeated measures ANOVA and student’s t-test were used for statistical analysis. Results: GTT were not significantly different between groups. VF females had a 2.6 and 2.5-fold increase in peak (P=0.03) and total LH release (P=0.04) compared to control rats. VF females had a 1.5-fold increase in the percent of GnRH/cFos neurons compared to control middle-age females (P=0.03). VF females had increased IGF1 (P=0.01) and tended to increase VGluT2 and POMC mRNA in the P-hypo. Compared to controls, there was no effect of VF on A-hypo IGF1 mRNA, IGF1R or Kiss1 mRNA in A-hypo or P-hypo. Conclusion: This study suggests that increased adiposity in reproductively senescing female rats may contribute to characteristic age-related changes in the ability of E2 to induce a robust LH surge and activate GnRH neurons through effects on IGF1 and glutamateric and POMC neuropathways.

 

Nothing to Disclose: JB, YS, JS, SCC, GSN

16519 12.0000 SAT-0012 A Age-Related Adiposity Adversely Affects Activation of GnRH Neurons and Contributes to Age-Related LH Surge Dysfunction 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0001-0016 4857 1:00:00 PM Female Reproductive Endocrinology Poster

Piangkwan Sa-nguanmoo*, Wasana Pratchayasakul, Hiranya Pintana, Jirapas Sripetchwandee, Sivaporn Sivasinprasasn, Sirinart Kumfu, Nattayaporn Apaijai, Jantira Sanit, Nipon Chattipakorn and Siriporn C Chattipakorn
Chiang Mai University, Chiang Mai, Thailand

 

We previously demonstrated that long-term high-fat diet (HFD) consumption in both male and female rats led to brain insulin resistance and brain mitochondrial dysfunction, indicated by the impaired brain insulin receptor function (insulin-induced long term depression; LTD) and impaired brain insulin signaling (1-3).  Moreover, we found that estrogen treatment improved those impairments only in obese-female rats (2). However, the temporal relationship between HFD-induced obesity and estrogen deprivation on brain insulin resistance and brain mitochondrial dysfunction has never been investigated.  We hypothesized that estrogen deprivation combined with HFD consumption accelerates the occurrence of brain insulin resistance and brain mitochondrial dysfunction compared to the estrogen deprivation alone or HFD-induced obesity alone. Seventy-two female rats were divided into sham-operated (Sham; S) and ovariectomized (OVX; O) groups.  A week after the surgery, rats in each group were divided into 2 subgroups and fed with either normal diet (ND) or HFD for 4, 8 and 12 weeks, and blood samples were collected to determine the metabolic parameters at each time point.  Brains were rapidly removed for determining brain insulin-induced LTD, brain insulin signaling and brain mitochondrial function.  We found that ovariectomized ND rats (NDO), sham-operated HFD rats (HFS) and ovariectomized HFD rats (HFO) began to develop peripheral insulin resistance, as indicated by hyperinsulinemia with euglycemia and increased OGTT at week 8. However, only HFO rats developed the brain insulin resistance and brain mitochondrial dysfunction at week 8. Rats in the NDO and HFS groups demonstrated brain insulin resistance and brain mitochondrial dysfunction in week 12. At the end, the levels of plasma glucose and brain mitochondrial swelling in the HFO rats were significantly greater than those in the NDO and HFS rats.  These findings suggest that despite the similar temporal development of peripheral insulin resistance, the combination of estrogen deprivation and obesity accelerates the occurrence of brain insulin resistance and brain mitochondrial dysfunction than either obesity or estrogen deprivation alone.

 

Nothing to Disclose: PS, WP, HP, JS, SS, SK, NA, JS, NC, SCC

11765 13.0000 SAT-0013 A Obesity with Estrogen Deprivation Accelerates Brain Insulin Resistance and Aggravates Brain Mitochondrial Dysfunction 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0001-0016 4857 1:00:00 PM Female Reproductive Endocrinology Poster

Chunxia Lu*1, Ye Lu2 and Vasantha Padmanabhan3
1Univ of Michigan, Ann Arbor, MI, 2University of Michigan, 3University of Michigan, Ann Arbor, MI

 

Polycystic Ovary Syndrome (PCOS), a hyperandrogenic disorder, is a major cause of infertility in women of reproductive age with 70% of them manifesting insulin resistance.  Our studies in sheep found that gestational testosterone (T) excess induced maternal hyperinsulinemia and culminated in a PCOS phenotype in the offspring including manifestation of insulin resistance [1].  Furthermore, prenatal T excess altered mRNA expression of mediators of insulin signaling pathway in a tissue-specific manner [2]. The relative contribution of androgen and insulin in programming these disruptions remains to be determined.  We tested the hypothesis that prenatal T excess by its androgenic action or perturbed maternal insulin homeostasis alters activity levels of key members of insulin pathway in a tissue- and development-specific manner. We examined changes in the phospho protein levels of components of the insulin signaling pathway [AKT(protein kinase B), GSK3b (glycogen synthase kinase-3 beta, a glycogen synthesis mediator) and mTOR (mammalian target of rapamycin)] in insulin target tissues  (skeletal muscle and liver) isolated from control (C), prenatal T- treated, prenatal T+ androgen antagonist (flutamide)-treated (TF), and prenatal T+ insulin sensitizer (rosiglitazone)-treated (TR) day 90 female fetuses (D90) (n= 6-16 / group) and two year old females (Y2, n= 8-13/group) by western blot analysis.  Student’s T test was used to compare treatment effects. Results revealed that p-GSK3b(Ser9) tended to be up regulated (p=0.07) in liver, but reduced in muscle (p=0.009) of D90 T-treated fetuses. The increase in liver p-GSK3b, suggestive of increased insulin sensitivity as an adaptive process at this age, was accompanied by a tendency for p-mTOR upregulation (p=0.07). Both interventions prevented the increase in liver p-GSK3b suggestive of involvement of both androgen and insulin signaling pathways. In contrast, prenatal T-induced decrease in muscle p-GSK3b was reversed only by rosiglitazone, indicative of mediation of this inhibition via insulin signaling pathway. At two years of age, p-GSK3b levels were similar between C and prenatal T-treated groups in both muscle and liver. However, prenatal T and TR females had reduced p-AKT-Ser(473) (p=0.02) in liver, but not in muscle. The reduced p-AKT-Ser was reversed in the TF group supportive of prenatal androgen programming of insulin resistance in liver during later life. In summary, our study indicates prenatal T excess leads to differential responses at different target tissues at different time points in life.  During fetal life, the increase in muscle GSK3b activity stemming from reduced p-GSK3b likely reduces glycogen synthesis leading to impaired insulin sensitivity. In contrast, in the adult impaired insulin sensitivity appears to be programmed via AKT activity.  These findings may be of translational relevance to human PCOS.

 

Nothing to Disclose: CL, YL, VP

15939 14.0000 SAT-0014 A Developmental Programming: Trajectory of Impact of Gestational Testosterone Excess on Insulin Target Tissues 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0001-0016 4857 1:00:00 PM Female Reproductive Endocrinology Poster

Rodrigo Rodrigues Marcondes1, Katia Candido Carvalho2, Natalia Garcia2, Daniele Coelho Duarte2, Jose Maria Soares Jr3, Leonardo Tomiatti Costa4, Vinicius Cestari Amaral2, Gisele Giannocco5, Edmund Chada Baracat3 and Gustavo Arantes R Maciel*1
1Faculdade de Medicina Universidade de Sao Paulo, Sao Paulo, Brazil, 2Faculdade de Medicina Universidade de Sao Paulo, 3Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 4Faculdade de Medicina Unversidade de São Paulo, 5Faculdade de Medicina do ABC, Santo Andre, SP, Brazil

 

Introduction: Sex steroids exposure can induce abnormalities in reproductive system that result in chronic anovulation. In rodents, such changes resemble polycystic ovary syndrome (PCOS) in humans. One hypothesis is that environmental insults could induce epigenetic changes that would result in reproductive abnormalities. However, it is not known whether histone acetylation or deacetylation is associated to the neuroendocrine disorder found in the syndrome. Objective: The aim of this study was to analyze the transcriptional expression of genes related to histone acetylation or deacetylation in the hypothalamus of PCOS rat models induced by testosterone or estradiol. Methods: Fifteen rats aged between 0-3 days of age were used in this study. These animals were sorted in three groups according with sc administration of the following compounds: testosterone propionate (1.25 mg) (T-PCOS; n=5), estradiol benzoate (0.5 mg) (E-PCOS; n=5) and vehicle (0.1 mL) (Controls; n=5). With 90 days of life, the animals were euthanized and the hypothalamuses were removed to evaluate the gene expression of Histone Deacetylase A (Hdac4 – related to deacetylation), KAT8 Regulatory NSL Complex Subunit 1 (Kansl1/Mll1 – related to acetylation), E1A Binding Protein P300 (Ep300 – related to acetylation) by quantitative Real Time PCR. Data analysis was performed using SABiosciences PCR array data analysis software available online and fold regulation higher than 2.0 was considered significant. Results: The PCOS rat models induced by estradiol (E-PCOS) exhibited increased fold expression of Hdac4 (2.4), Mll1 (2.6) and Ep300 (2.3) compared to control animals (P<0.05). T-PCOS rats did not show significant increase in the expression of genes analyzed in this study. Conclusion: Our data showed that PCOS rat models induced by estradiol, but not testosterone, exhibited transcriptional upregulation of factors related to histone acetylation or deacetylation in hypothalamus.

 

Nothing to Disclose: RRM, KCC, NG, DCD, JMS, LTC, VCA, GG, ECB, GARM

16086 15.0000 SAT-0015 A Transcriptional Expression of Genes Related to Histone Modification in the Hypothalamus of Female Rats Submitted to Neonatal Exposure to Sex Steroids 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0001-0016 4857 1:00:00 PM Female Reproductive Endocrinology Poster

Hyeran Jang*1, Tyler Guarneri2, Carlo Serra3, Mi-Jeong Lee4, Susan K Fried5, Shalender Bhasin6 and Ravi Jasuja7
1Brigham and Women's Hospital, Boston, MA, 2Brigham and Women's Hospital, 3Brigham and Women’s Hospital, 4Boston University School of Medicine, 5Boston University School of Medicine, MA, 6Brigham and Women's Hospital - Harvard Medical School, Boston, MA, 7Brigham & Women's Hospital, Boston, MA

 

Background: Early postnatal events are being increasingly recognized as contributors to the risk of metabolic and reproductive disorders in adulthood, such as PCOS (polycystic ovarian syndrome). In this study, we evaluated the programming effects of a single developmentally-entrained pulse of testosterone given to female mice in early postnatal period on the metabolic and reproductive phenotype in adult life. 

Methods: CD-1 female mice pups were injected with either 5µg of testosterone enanthate (TE) or vehicle within 24 hours after birth. After insertions of tattoos for group segregation, the mouse pups were mixed and given back to lactating mothers to eliminate maternal effects. Then mice were followed to adult age.

Results: An injection of 5µg of TE increased blood testosterone (T) levels in female mice within 6 hr after birth mimicking the natural testosterone surge observed in neonatal male mice during this period. Blood T levels then fell rapidly and remained low for the duration of the study. Neonatal T exposure (NT) increased LH levels more than 2-fold (0.35±0.07 vs. 0.87±0.21, ng/ml) in adult age, but did not impact blood E2 or FSH. 66% of NT mice were not cycling regularly and most acycling mice did not have corpus luteum in the ovary, confirming the phenotype of anovulation in the female mice exposed to transient T in early life. Longitudinal assessment of body composition by NMR revealed that NT group had greater body weight, lean body mass (LBM) and fat mass (FM) than their litter-mate controls. NT mice displayed increased white adipose tissue accumulation in all depots, increased adipose cell size accompanied by insulin resistance. The brown adipose tissue (BAT) clearly displayed white fat infiltration with down-regulation of several markers including Ucp-1, Cidea, BMP-7 as well as BAT differentiation-related transcription regulators, PGC1-α and PRDM16.

Conclusion: A single pulse of T administered to female mice during a specific developmental window in early postnatal life was associated with features of reproductive and metabolic dysfunction in adult, as can be observed in women with PCOS, including increased adiposity and insulin resistance. The mechanisms of these reprogramming effects of developmentally-entrained testosterone exposure need further investigation.

 

Disclosure: SB: Principal Investigator, Abbott Laboratories, Principal Investigator, Eli Lilly & Company. Nothing to Disclose: HJ, TG, CS, MJL, SKF, RJ

16252 16.0000 SAT-0016 A A Single Developmentally-Entrained Pulse of Testosterone in Female Neonatal Mice Disrupts Reproductive and Metabolic Functions in Adult Life 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0001-0016 4857 1:00:00 PM Female Reproductive Endocrinology Poster

Anju Elizabeth Joham1, Sanjeeva Ranasinha2, Sophia Zoungas3 and Helena J. Teede*2
1Monash University, Clayton VIC, Australia, 2Monash University, Melbourne, Australia, 3Monash University, Clayton VIC, Australia

 

Context: Polycystic ovary syndrome (PCOS) affects 9-21% of women. PCOS has been associated with an increased risk of type 2 diabetes (T2DM), however the independence of this risk and the impact of body mass index (BMI) is unclear.

Objective: To assess the prevalence of T2DM and the impact of obesity in young reproductive-aged women with and without PCOS, in a community-based cohort.

Design: Longitudinal analysis of data from the Australian Longitudinal Study on Women’s Health (ALSWH).

Setting: General community

Participants: Women were randomly selected from the national health insurance database. Standardised data collection occurred at 6 survey time points (years 1996, 2000, 2003, 2006, 2009 and 2012). Longitudinal data from 6384 women who responded to surveys 4, 5 and 6 were examined for this study.

Main outcome measures: Self-reported PCOS and T2DM

Results: In survey 6 in women aged 34 to 37 years, PCOS prevalence was 8.8% (95% CI 8.0 – 9.6) and the prevalence of T2DM was 3.8% in women with PCOS and 0.8% in women without PCOS respectively (p<0.001). On univariate regression analysis, both PCOS and BMI were associated with increased odds of T2DM. A mutivariable random effects logistic regression model to examine the longitudinal association between T2DM and PCOS adjusting for BMI, age, hypertension, smoking and demographic factors revealed that both PCOS and longitudinal BMI were independently associated with increased odds of T2DM (OR 3.5, 95% 1.6-7.9, p=0.002 and OR 1.08 per BMI unit, 95% CI 1.03-1.12, p<0.001 respectively). A significant interaction was observed between PCOS and BMI for this outcome. Further sensitivity analysis by PCOS status, showed that BMI did not independently impact on the risk of T2DM in women with PCOS (OR 1.0, 95% CI 0.9-1.1, p=0.93), but that BMI mediated the risk of T2DM in women without PCOS (OR 1.10 per BMI unit, 95% CI 1.05-1.15, p<0.001).

Conclusions: In the largest longitudinal, community-based cohort of reproductive-aged women, increased risk of T2DM in PCOS was shown to be independent of BMI. Regular screening and implementation of preventive measures are warranted in women with PCOS.

 

Nothing to Disclose: AEJ, SR, SZ, HJT

PP04-1 15284 2.0000 SAT-0018 A Longitudinal Risk of Type 2 Diabetes in Reproductive-Aged Women with Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0017-0035 4858 1:00:00 PM Female Reproductive Endocrinology I Poster

Johannes D Veldhuis*1, Roy B Dyer2, Sergey A Trushin2, Olga P Bondar2, Ravinder J. Singh2 and George G Klee2
1Mayo Clinic & Graduate School of Medicine, Rochester, MN, 2Mayo Clinic, Rochester, MN

 

Sex-hormone binding globulin (SHBG) is a biomarker of age, body composition, insulin resistance and sex steroids in men.  However, regulation of SHBG concentrations across the adult female lifespan is poorly defined.  We postulate that SHBG regulation is evaluable when quantified by criterion methods, such as mass spectrometry (MS), performed at the Mayo Center for Clinical and Translational Science Activities (CCATS).  Participants were healthy nonpregnant women (N=120) ages 21 to 79 yr.  Outcomes comprised SHBG, testosterone (T), estradiol (E2) and estrone (E1) each determined by MS.  Analysis consisted of uni- and multivariate regression of SHBG concentrations on age, body mass index (BMI), total and visceral abdominal fat (TAF, AVF), albumin, glucose, insulin, sex steroids and selected cytokines.  Statistical estimation by univariate regression showed that MS-estimated SHBG correlated negatively with BMI, TAF, AVF, insulin, free T and bioavailable T (bio T) (each P≤10-4).  The same key outcomes were reproduced in 3 other (1 other MS and 2 immunologic) SHBG assays.  By stepwise multivariate regression analysis, free and total T (both positive) and bio T (negative) were correlated with SHBG in all 4 assays (each P<10-15, R2≥0.481).  In addition, TAF and BMI were negatively associated with SHBG (P≤0.0066) in 2 SHBG assays each, and estrone and IL-8 with SHBG weakly (P≤0.035) in one SHBG assay each.  When sex steroids were excluded, SHBG was jointly associated with AVF and albumin in women (P<10-5, R2≥0.237).  In conclusion, according to the MS data, selected T moieties and body composition surrogates jointly specify SHBG in women, together explaining about 50% of the interindividual variation in SHBG levels over the female lifetime.

 

Nothing to Disclose: JDV, RBD, SAT, OPB, RJS, GGK

12019 5.0000 SAT-0021 A Immunologic and Mass-Spectrometric Estimates of SHBG Concentrations in Healthy Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0017-0035 4858 1:00:00 PM Female Reproductive Endocrinology I Poster

Emma Billington* and Bernard Corenblum
University of Calgary, Calgary, AB, Canada

 

Background: Women with hypothalamic amenorrhea (HA) can have ovulation induced with either pulsatile GnRH (pGnRH) or gonadotropin injections. Predicting ovulatory response in women with HA is difficult, as measurements of the oocyte pool, day 3 serum FSH level or antral follicle count, cannot be interpreted. Anti-mullerian hormone (AMH), produced by pre-antral and antral follicles, is shown to indicate follicular pool size, fertility status and menopause timing. Both very low and very high AMH levels are predictive of poor response to ovulation induction with gonadotropin therapy. Because AMH production is independent of hypothalamic regulation and AMH levels do not vary cyclically, we hypothesized that AMH levels may be useful for predicting response to pGnRH in women with HA.

Methods: This is a prospective study in all women with HA who presented for ovulation induction between July 1, 2012 and November 30, 2013.  All women had a serum AMH level drawn prior to the initiation of therapy and completed at least one cycle of pGnRH were included. A positive ovulatory response was a serum estradiol level >800 pmol/L and the presence of a dominant follicle >1.8cm on ultrasound. Pregnancy was defined as ultrasound evidence of a viable pregnancy.

Results: Nine were studied; eight had functional HA and one had a resistant prolactinoma. Mean +/-SD age was 34.1 +/- 3.9 years. 2 had undetectable AMH levels, 1 had low but detectable AMH level, 5 had normal AMH levels, and 1 had an elevated AMH level.

Evidence of normal follicular development following pGnRH was observed in 7/9 (78%) women, including the woman with a prolactinoma. Pregnancy was achieved in 5/9 (56%) women. All three women with low or undetectable AMH levels had normal responses to pGnRH, and one achieved pregnancy. Three of the 5 women with normal AMH levels responded to pGnRH, and all 3 of these women achieved pregnancy. The one woman with an elevated AMH level responded to pGnRH and achieved pregnancy. Although there was a trend towards higher baseline AMH levels in the group who became pregnant compared to those who did not (5.17 +/- 5.93 ng/mL versus 1.01 +/- 1.03 ng/mL, p = 0.22), levels did not vary significantly between the two groups.

Interpretation: In women with HA, undetectable, low, or elevated baseline AMH levels do not preclude a normal response to pGnRH, and normal baseline AMH levels do not guarantee a normal response. This small study suggests that AMH, as a measurement of follicular pool size, is not helpful for predicting which women with HA will respond to therapy with pGnRH, and demonstrates that pregnancy can still be achieved despite undetectable levels of AMH.

 

Nothing to Disclose: EB, BC

12427 6.0000 SAT-0022 A Low or Undetectable Anti-Mullerian Hormone (AMH) Levels Do Not Preclude Response to Pulsatile GnRH in Women with Hypothalamic Amenorrhea 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0017-0035 4858 1:00:00 PM Female Reproductive Endocrinology I Poster

Nicolas R Crisosto*1, Amanda Ladron de Guevara1, Carolina Fux2, Paula Szafryk2, Barbara Echiburu1, Gabriel Iraci2, Francisco Antonio Perez-Bravo1 and Teresa Sir-Petermann1
1University of Chile, Santiago, Chile, 2Universitary Hospital, National Córdoba University, Cordoba, Argentina

 

Context: Polycystic ovary syndrome (PCOS) is a hyperandrogenic disorder associated with chronic oligo-ovulation and polycystic ovarian morphology. It is the most common cause of hyperandrogenism with a prevalence reaching up to 15% when using the Rotterdam criteria described in 2003. Hyperandrogenism and chronic anovulation are the main elements of this definition, and the ultrasound pattern of polycystic ovaries is the third element incorporated in the 2003 consensus (1). According to this definition, diagnosis of PCOS may be established with 2 of the 3 criteria described, generating four different phenotypes.  A considerable ethnic variation has been observed in the clinical manifestations of PCOS. The phenotypic distribution in Latin American populations with different ethnic characteristics is only partially known, and for this reason, the present study compares the metabolic profile of 2 groups of PCOS women from 2 neighboring countries with different ethnic composition Objective: To evaluate the metabolic profile in Chilean and Argentinian women with PCOS according to the Rotterdam criteria. Design: Observational cross-sectional study. Setting: Academic centers.  Patients: Women with PCOS, aged 18-39 years: Chilean (PCOSCh n=220) and Argentinian (PCOSAr n= 206) were evaluated. Intervention: Physical exam, fasting blood samples for androgens, gonadotropins, metabolic parameters, and a transvaginal ultrasound.  Main outcome measures: A comparative analysis of the metabolic profile was conducted in both populations divided into four phenotypes.  Results: The distribution of the different phenotypes was different in both populations (X2= 14.5, p<0.002).  PCOSCh women showed higher body mass index and a higher percentage of metabolic syndrome in all phenotypes compared to PCOSAr, and these in turn exhibited significantly higher diastolic blood pressure in phenotypes A, B and C and a higher percentage of hypertension in phenotypes A and D, than PCOSCh. Conclusion: The data show differences in the metabolic profile of both populations. PCOSCh women presented greater metabolic alterations such as dysglycemia, dyslipidemia and a higher prevalence of metabolic syndrome, independent of the phenotype; while PCOSAr patients showed more elevated blood pressure. Ethnic diversity associated with environmental factors are fundamental elements in the analysis of the PCOS phenotypes.

 

Nothing to Disclose: NRC, AL, CF, PS, BE, GI, FAP, TS

12607 7.0000 SAT-0023 A Metabolic Profile of the Different Phenotypes of Polycystic Ovary Syndrome in Two Populations of Latin America 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0017-0035 4858 1:00:00 PM Female Reproductive Endocrinology I Poster

Toshiya Matsuzaki*, Takeshi Iwasa and Minoru Irahara
Department of Obstetrics and Gynecology, The University of Tokushima Graduate School, Institute of Health Biosciences, Tokushima, Japan

 

Hyperandrogenemia has become an important factor in the diagnosis of polycystic ovary syndrome (PCOS), in Japan as well as Western countries, since the Japanese PCOS diagnostic criteria were revised in 2007; the presence of hyperandrogenemia or elevated LH with normal serum follicle-stimulating hormone (FSH) for a diagnosis of PCOS, as well as menstrual dysfunction and polycystic ovary morphology(1,2).  On the other hand, clinical and biochemical hyperandrogenism was less prevalent in Japanese patients than in the Western population, and elevated LH levels were more common in Japanese patients with PCOS(3). The revised electrochemiluminescence immunoassay (ECLIA) reagent for total testosterone (T) (ECLusys TESTO II; New T assay)(Roche Diagnostics K.K., Tokyo, Japan), which has lower cross-reactivity with DHEA-S than the previous reagent (ECLusys TESTO I; Old T assay), has recently been developed. We studied the improvement between New and Old T assays in regards to the diagnostic performance of serum T for patients with PCOS. Serum T levels were measured in both normal women (Control, n=92) and PCOS patients (n=86). The rate of elevated T using each kit was significantly higher in the PCOS group than in the Control group, and significantly higher using New T assay (38/86, 44.2%) compared with Old T assay (26/86, 30.2%). A significant correlation was found between T level and body mass index, but not LH level. Furthermore, higher detection rates of hormonal abnormalities were seen in PCOS patients using combined measurement of both T and LH (63/80) compared with single measurement of either T (37/80) or LH (36/80). Therefore, the serum T assay is essential for the diagnosis of PCOS, and New T assay combined with the LH assay may improve the diagnostic process for PCOS in Japan.

 

Nothing to Disclose: TM, TI, MI

12794 8.0000 SAT-0024 A Improvement in Diagnostic Performance of the Revised Total Testosterone Measuring System in Japanese Women with Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0017-0035 4858 1:00:00 PM Female Reproductive Endocrinology I Poster

Gislaine Krolow Casanova1 and Poli Mara Spritzer*2
1Hospital de Clinicas de Porto Alegre and Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, 2Hospital de Clínicas de Porto Alegre and Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

 

Age, years since menopause and new biomarkers of cardiovascular risk (CV) risk, such as ultra-sensitive C reactive protein (CRP) and atrial natriuretic peptide (ANP), may provide important information regarding the possible interaction between hormone therapy (HT) and CV risk. The plasma levels of ANP are increased in a variety of conditions, such as heart failure, acute myocardial infarction and hypertension. Nevertheless, not much is known about the effects of estrogen on ANP and about the impact of HT on the atrial natriuretic system. The aim of this randomized crossover study was to evaluate the effects of oral low-dose and non-oral HT on CRP, ANP and CV risk factors in recent postmenopausal women. Forty-four patients received oral low-dose HT (estradiol 1mg+drospirenone 2 mg/day) for 3 months. Forty-two patients received non-oral conventional HT (1.5 mg/day percutaneous 17βestradiol gel or equivalent for nasal route) for 3 months followed by 200 mg/day micronized progesterone by vaginal route 14 d/cycle. After 3 months, patients were crossed-over without washout. The main outcome measures were lipids, glucose, BMI, waist circumference, fibrinogen, von Willebrand factor, CRP-stratified cardiovascular risk and ANP levels. The mean age was 51±3 years and mean time since menopause was 22±10 months. No carryover effect was found for any studied variables.  CRP-related CV risk decreased in a higher number of non-oral HT patients, who moved to intermediate and low CV risk classes (P=0.02). No effect of HT was observed on ANP levels (baseline 67.4(18.4-104.5), oral low-dose 43.5(14.4-95.9) and non-oral 39.8(15.5-67.5) pg/mL). No deleterious effects were observed on markers of endothelial function after oral low-dose and non-oral HT: von Willebrand factor  baseline 118±37%, oral low-dose 119±38%, non-oral HT 108±3%, p< 0.01; fibrinogen  356±58 mg/dL; oral low-dose 343±77 mg/dL; non-oral HT 326±71 mg/dL. In conclusion, low-dose oral and non-oral HT for 6 months had neutral or beneficial effects in recent post-menopausal women with no clinical evidence of CV disease.

 

Nothing to Disclose: GKC, PMS

12994 9.0000 SAT-0025 A Impact of Low-Dose Oral or Non-Oral Hormone Therapy on C-Reactive Protein and Atrial Natriuretic Peptide in Menopause: A Randomized Crossover Clinical Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0017-0035 4858 1:00:00 PM Female Reproductive Endocrinology I Poster

Teresa Sir-Petermann*1, Natalie Vantman1, Francisca Concha1, Barbara Echiburu1, Cecilia Pereira1, Amanda Ladron de Guevara1, Nicolas R Crisosto1, Francisco Antonio Perez-Bravo1 and Jose L Santos2
1University of Chile, Santiago, Chile, 2Pontificia Universidad Católica de Chile, Santiago, Chile

 

We have previously shown that sons of PCOS women (PCOSs) exhibit higher body weight since early infancy. In addition, insulin resistance became evident as the subjects got older. These metabolic derangements were not observed in the daughters of PCOS women. It is accepted that family influences (epigenetic and genetic factors) play a role in determining eating behavior and childhood obesity. Moreover, in the case of the PCOS condition, it is posible that the mother may protect the daughters and not the boys against over eating. Our objective was to evaluate different metabolic parameters in PCOSs during prepuberty and early puberty and to asses the eating behavior using the Child Eating Behavior Questionnaire (CEBQ ).  Design: Twelve  PCOSs and 25 controls were included. Controls were selected from public schools near our academic Unit . We performed a complete physical examination and pubertal development assessment according to Tanner stage, on each boy. Anthropometric measurements included: weight, height,waist, hip, BMI and BMI SD score. A 2-hour oral glucose tolerance test was performed with measurement of glucose and insulin, and serum lipids in the basal sample.  Results: Age, weight, height,  BMISDS were not different between both groups. Waist to hip ratio was significant higher in the PCOSs group. Glucose concentration were higher in PCOSs compared to controls. Regarding CEBQ, PCOSs showed a significant higher score in the subscale "food responsiveness" meaning  a high preference for more tasty food  compared to controls. In a simple linear regression analysis BMI was positively correlated with the subscale "food responsiveness" (r=0.52, p=0.05) in PCOSs. In the controls BMI were positively correlated with the subscale "enjoyment of food" (r= 0.47, p= 0.02) and the subscale "food responsiveness" (r= 0.51, p= 0.01). This study indicate that sons of PCOS women exhibit metabolic derangements during the prepubertal and early pubertal period associated with a higher preference for more tasty food compared to controls. In both groups,  BMI correlated  with a positive inclination for eating, reflecting an increase in the prevalence of obesity in chilean boys as a consequence of social changes leading to a rise in consumption of high-calorie foods and sedentary habits.

 

Nothing to Disclose: TS, NV, FC, BE, CP, AL, NRC, FAP, JLS

13295 10.0000 SAT-0026 A Metabolic Profile and Eating Behavior Score in Prepubertal and Early Pubertal Sons of Women with Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0017-0035 4858 1:00:00 PM Female Reproductive Endocrinology I Poster

Juliano S Silveira1, Ruth Clapauch*2 and Eliete Bouskela3
1Universidade do Estado do Rio de Janeiro, 2Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil, 3Universidade do Estado do Rio de Janeiro (UERJ)

 

Hot flashes are common in postmenopausal women and have been recently reported to be markers of cardiovascular (CV) risk, but the exact mechanisms and menopause stage at which this risk is significant are unclear. Endothelial dysfunction is the earliest sign of CV disease, so we investigated the association between this dysfunction and hot flashes in 2 groups of women: early (< 10 years, n=42) and late (≥10 years, n=37) post menopause (PM), both comprising symptomatic (>3 on a scale of 0 to 10 of hot flashes presence and intensity) or not (≤3) patients. Early PM women were 52.6 ± 0.6 years, 25 were symptomatic and 17 not; late PM women were 60.2 ± 0.9 years, 14 with and 23 without hot flashes. Similar prevalence of diabetes and thyroid disease was found between subjects with or without hot flashes, whereas hypertension was more prevalent in symptomatic (85.7%) vs. asymptomatic (30.4%) late postmenopausal women (p=0,0019). Endothelial function was assessed by noninvasive venous occlusion plethysmography at baseline and post-hyperemia. Data analysis was performed by Mann Whitman test. In both groups, women with hot flashes had lower post-hyperemia response: early symptomatic PM women 6.2 (4.6 -7.7) vs asymptomatic 8.5 (7.3 - 11.1) ml/min/100ml, p = 0.0038 and late symptomatic PM women 5.3 (4.5 - 7.5) vs asymptomatic 8.5 (7.6 - 9.9) ml/min/100ml, p = 0.0042. In the early PM group, women with hot flashes had longer prior use of oral contraceptives (5 [1.5 - 10] vs 2 [0 - 5.5] years, p = 0.0131), less hours of sleep/night (6 [5 - 6] vs 7 [6 - 8], p = 0.0029), higher systolic (133 [126.5 - 139.5] vs 129 [116 - 131] mmHg, p = 0.0257) and diastolic (80 [74 - 84] vs 74 [64,5 - 81-5] mmHg, p = 0.0231) blood pressures compared to women without hot flashes. In late PM group, women with hot flashes also had longer prior use of oral contraceptives (10 [2.8 - 17.8] vs 5 [0 - 9] years, p = 0.0407) and higher systolic blood pressure (138 [130 - 146] vs 127 [119 - 140] mmHg, p = 0.0258) compared to asymptomatic ones. In conclusion, in both recent and late post menopause, women with hot flashes showed endothelial dysfunction characterized by decreased endothelium-dependent vasodilation. Hot flashes were associated in both groups with longer duration of prior oral contraceptive use and higher systolic blood pressure. In recent PM women, symptoms were also associated to fewer hours of sleep and higher diastolic pressure.

 

Nothing to Disclose: JSS, RC, EB

13433 11.0000 SAT-0027 A Hot Flashes Are Associated with Decreased Endothelium-Dependent Vasodilation in Early and Late Postmenopausal Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0017-0035 4858 1:00:00 PM Female Reproductive Endocrinology I Poster

Mario Vega*1, David H Barad2, Vitaly A Kushnir2, Emanuela Lazzaroni-Tealdi2, Yan-Guang Wu2, Ho-Joon Lee2 and Norbert Gleicher3
1St. Luke's-Roosevelt Hospital Center, NY, 2The Center for Human Reproduction, New York, NY, 3Center for Human Reproduction, New York, NY

 

Autoimmune processes have been documented as a possible etiology of various causes of reproductive failure, including up to 30% of cases of primary ovarian insufficiency [1]. We previously noted an association between presence of autoantibodies, in general, and premature ovarian senescence [2], recently reviewed [3]. Whether specific autoantibody groupings reflect this association better than others is, however unknown. We, therefore, retrospectively investigated a cohort of 452 consecutive infertility patients between November 2012 and October 2013 with mean age of 39.4 ± 5.7 years and, in reflection of their FOR, with anti-Müllerian hormone (AMH) of 1.4 ± 2.2 ng/mL. Among those, AMH levels were available in 390/452 (86.3%) patients; 409/452 (90.5%) had been tested with a limited antiphospholipid antibody (APA) panel, including anticardiolipin antibodies, anti-β2-glycoprotein I antibodies and antiphosphatidylserine antibodies, all in IgA, IgG and IgM isotypes as well as lupus anticoagulant. In addition these patients had been tested for antinuclear antibody, a thyroid antibody panel, including anti-thyroid peroxidase, anti-thyroglobulin and anti-thyrotropin receptor antibodies, antiadrenal (anti-21 hydroxylase) antibodies, antiovarian antibodies and total immunoglobulin levels in IgG, IgM, IgA and IgE.  Using an analysis of covariance (ANCOVA), neither ANA, antithyroid antibodies, antiadrenal/antiovarian antibodies or total immunoglobulin levels were, individually, and adjusted for age, associated with decreased age-specific AMH levels and, therefore a diagnosis of low FOR. Out of 348 women, however, 61 (14.9%) tested positive for at least one APA, representing a 63.9% higher prevalence than reported in healthy women of childbearing age [4]. Moreover, presence of at least one APA, even after adjusting for age, was associated with decreased AMH levels (t= -2.78, p <0.0057). As expected older age was, in general, associated with decreased AMH levels (t= -10.60, p<0.001). These data suggest that APAs, amongst here-evaluated immune parameters, most closely associate with low FOR. If confirmed, their presence, therefore, may be viewed as a potential indicator of risk for low FOR and premature ovarian senescence.

 

Nothing to Disclose: MV, DHB, VAK, EL, YGW, HJL, NG

14026 12.0000 SAT-0028 A Low Functional Ovarian Reserve (FOR) Is in Infertile Women Associated with Presence of Antiphospholipid Antibodies 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0017-0035 4858 1:00:00 PM Female Reproductive Endocrinology I Poster

Xiaohui Yu*1, Zhongyan Shan2, Chenyan Li1, Jinyuan Mao1, Weiwei Wang1, Xiaochen Xie1, Weiwei Zhou3, Chenyang LI3, Bin Xu4, Lihua Bi5, Lihua Bi5, Tao Meng6, Jianling Du Du7, Shaowei Zhang8, Zhengnan Gao9, Xiaomei Zhang10, Liu Yang11, Chenling Fan1 and Weiping Teng12
1The Endocrine Institute and The Liaoning Provincial Key Laboratory of Endocrine Diseases, Department of Endocrinology and Metabolism, The First Hospital of China Medical University, Shenyang, China, 2Institute of Endocrinology,The First Hospital of China Medical University, Shenyang, China, 3Shenyang Women’s and Children’s Hospital, Shenyang, China, 4Department of Obstetrics and Gynecology, No.202 Hospital of People's Liberation Army, Shenyang, China, 5Dalian Obstetrics and Gynecology Hospital, Dalian, China, 6Department of Obstetrics and Gynecology, The first Hospital of China Medical University, Shenyang, China, 7Department of Endocrinology, The First Affiliated Hospital of Dalian Medical University, Dalian, China, 8Department of Endocrinology, No.202 Hospital of People's Liberation Army, Shenyang, China, 9Department of Endocrinology, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian, China, 10Department of Endocrinology, The first Hospital of Dandong, Dandong, China, 11Shenyang Women and Children Health Care Center, Shenyang, China, 12The Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China

 

Iron deficiency (ID) is common in women of child-bearing age, especially in pregnant women. ID has adverse effects on thyroid metabolism. Impaired maternal thyroid function during pregnancy may cause neurodevelopmental delays in the offspring. We performed this study to explore the effect of iron nutrition on thyroid function in early pregnancy and before pregnancy. In order to eliminate the effect of iodine intake and thyroid autoimmunity, we selected the individuals with adequate iodine intake (For pregnant women: the median urinary iodine concentration (UIC) was 150 to 500 μg/L; and for non-pregnant women: the median UIC was 100 to 300 μg/L ) and negative TPOAb. A total of 4,403 women including 3,348 pregnant women and 1,055 non-pregnant women of reproductive age were included. Serum TSH, FT4, TPOAb and ferritin were measured in all participants. The reference intervals for TSH, FT4 and TPOAb were same as those in the paper of LI Chenyan(1). And it was ≥12μg/L for ferritin. ID was defined as serum ferritin level < 12μg/L. We found serum FT4 levels were lower in ID group than those in normal iron group (in pregnant women: 15.50±1.81 μg/L vs. 16.39±3.05μg/L, p = 0.004；in non-pregnant women: 15.00±3.04 μg/L vs. 15.76±1.90 μg/L, p = 0.001). And meanwhile the prevalence of isolated hypothyroxinemia in ID group was higher than that in normal iron group [in pregnant women: 6.9% vs. 1.3%, χ2 = 20.928, p = 0.001, OR = 5.549 (2.432-12.658); in non-pregnant women: 7.6% vs. 2.5%, χ2 = 6.978, p = 0.020, OR = 3.260 (1.292-8.228)]. However in ID group, serum TSH levels and the prevalence of hypothyroidism or hyperthyroidism were similar to those in normal iron groups. Moreover, the serum ferritin level was significantly lower in women with isolated hypothyroxinemia than that in normal controls in early pregnancy (61.85±52.90 vs. 76.20±52.95, p = 0.049). And the prevalence of ID was higher in women with isolated hypothyroxinemia than that in normal controls whether in early pregnancy or in non-pregnancy (in pregnancy: 14.0% vs. 2.9%, χ2=20.518, P < 0.001); in non-pregnancy: 20.0% vs. 7.7%, χ2=5.891, P=0.029). Linear regression showed that serum FT4 levels were correlated with ferritin (both p < 0.01 in pregnancy and before pregnancy). And Logistic regression results indicated that ID was the independent risk factor for isolated hypothyroixinemia (in pregnancy: OR = 3.550, P = 0.010; in non-pregnancy: OR = 3.916, P = 0.005). We speculate that the poor iron nutrition can cause lower FT4 levels, and ID was an independent risk factor for isolated hypothyroixinemia in women of child-bearing age.

 

Nothing to Disclose: XY, ZS, CL, JM, WW, XX, WZ, CL, BX, LB, LB, TM, JDD, SZ, ZG, XZ, LY, CF, WT

14211 13.0000 SAT-0029 A Iron Deficiency: A Risk Factor for Isolated Hypothyroxinemia during Early Pregnancy and before Pregnancy in Areas with Adequate Iodine in China 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0017-0035 4858 1:00:00 PM Female Reproductive Endocrinology I Poster

Christian Trolle1, Kristian Havmand Mortensen2, Mette Bjerre3, Niels Holmark Andersen1 and Claus H. Gravholt*1
1Aarhus University Hospital, Aarhus, Denmark, 2Cambridge University Hospitals, Cambridge, United Kingdom, 3Aarhus University, Aarhus, Denmark

 

Background: Osteoprotegerin (OPG) is as a potential biomarker of cardiovascular disease. Cardiovascular disease is a cardinal trait of Turner syndrome (TS), causing half of the 3-fold excess mortality. This cross-sectional and prospective study aimed at elucidating OPG levels in TS and the relation of OPG to validated cardiovascular risk markers as well as aortic diameter.

Methods and Results: Adult females with TS (n=99) were examined thrice (mean follow-up 4.7±0.5 years), and 68 age-matched healthy female controls were examined once. The plasma concentration of OPG was measured with an enzyme-linked immunosorbent assay (R&D Systems, MN, USA). Aortic diameter was assessed by cardiovascular magnetic resonance. Echocardiography, 24-hour blood pressures, and blood samples were also performed.

OPG levels (median with range) were lower in TS (777 (326-10569) ng/L) compared to controls (979 (398-1987) ng/L; p<0.05) and did not change during follow-up. Levels of OPG were higher among females with TS who were receiving antihypertensive therapy (938 (490-2638) vs. 752 (326-10569) ng/L; p=0.06) and/or older than 50 years of age (996 (542-4996) vs. 756 (326-10569) ng/L; p<0.05).  In TS, contrary to controls, OPG correlated with BSA-indexed aortic diameter (r=0.31-0.45; p<0.05), age (r=0.29; p<0.05), BSA (r=-0.20; p<0.05), weight (r=-0.23; p<0.05) and plasma estradiol levels (r=-0.34; p<0.05). OPG levels were elevated in TS with an aortic diameter in the upper when compared with the lower tertile (p<0.05).

Conclusion: Levels of OPG are reduced in TS and correlate with aortic diameter, age, BSA, weight and estradiol in TS (but not controls), and a range of cardiovascular risk factors are associated with OPG levels. Our novel results indicate that OPG may be of value for cardiovascular risk stratification in TS.

 

Nothing to Disclose: CT, KHM, MB, NHA, CHG

15884 14.0000 SAT-0030 A Osteoprotegerin in Turner Syndrome - a Prospective Study. Relation to Aortic Diameter and Cardiovascular Risk Factors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0017-0035 4858 1:00:00 PM Female Reproductive Endocrinology I Poster

Carolin Lechtermann1, Cordula Kiewert2, Ralf Herrmann1, Alexandra Gellhaus3, Berthold P Hauffa4, Markus Schmidt5 and Corinna Grasemann*4
1UK-Essen, Kinderklinik II, 2University Hospital Essen, Essen, 3University Hospital, Essen, Germany, 4Universität Duisburg - Essen, Kinderklinik II, Essen, Germany, 5Sana Klinikum Duisburg

 

Introduction:

Preeclampsia, a hypertensive disorder in pregnancy with increased morbidity and mortality for mother and child, develops in 2 – 8 % of pregnancies worldwide. Winter season and vitamin D deficiency have been associated with onset of preeclampsia. 

Patients and Methods:

To investigate the seasonal influence on vitamin D metabolism, maternal serum samples were obtained from 63 pregnant women at term, of which 43 had normal pregnancies and 20 had preeclampsia. Samples were obtained strictly during winter and summer months. Serum 25-OH vitamin D, 1,25-(OH)2 vitamin D, creatinine and calcium were measured.  In a subgroup of patients, the placental gene expression of CYP24A1 (1.25-(OH)2 vitamin 24-hydroxylase), CYP27B11 (1α-hydroxylase) and the vitamin D receptor (VDR) were quantified by rtPCR.

Results:

25-OH vitamin D was significantly lower in preeclampsia compared to healthy controls (18.21 ± 27.1 vs 33.4 ± 20.3 ng/ml). In healthy controls 25-OH vitamin D was higher in the summer than in the winter (49.2 ± 29.2 vs 19.5 ± 16 ng/ml). Surprisingly, there were no seasonal changes in 25-OH vitamin D levels in preeclampsia (18.8 ± 17.2 vs 17.6 ± 23.5 ng/ml). 1.25-(OH)2 vitamin D was elevated with no seasonal changes in healthy controls (748.5 ± 462 vs. 612.3 ± 455.7 pmol/ml).  In preeclampsia significantly lower values were detected in the winter compared to summer months (291 ± 217 vs 815 ± 478 pmol/ml).

Two-factorial analysis of variance produced a statistically significant model (p < 0.0001) whith an effect of season (p < 0.01) and preeclampsia (p = 0.01) on maternal 25-OH vitamin D levels, as well as a significant interaction effect of the two variables (p = 0.02). 

Placental gene expression of CYP24A1 and VDR did not differ between groups or season. Placental gene expression of CYP 24A1 negatively correlated with maternal 25-OH vitamin D in patients with preeclampsia (r -0.76, p = 0.01, Spearman correlation) but not in controls. CYP27B1 mRNA was not detectable in placental samples.

Conclusion:

Patients with preeclampsia had significantly lower 25-OH vitamin D serum levels at term than healthy controls, especially during the summer months. The lowest 1,25-(OH)2 vitamin D in preeclampsia was found in winter, indicating that compensatory mechanisms fail during times of severe vitamin D deficiency. Whether this finding explains the higher incidence of preeclampsia during winter season needs to be investigated further.

Our data indicate that placental gene expression of VDR and CYP27B1 is not relevant for maternal vitamin D status or the development of preeclampsia.  Solely the regulation of placental CYP 24A1 expression might be altered in preeclampsia and is linked to maternal 25-OH vitamin D status. Further studies are needed to better understand the role of vitamin D metabolism in the underlying pathophysiology of this disorder.

 

Nothing to Disclose: CL, CK, RH, AG, BPH, MS, CG

15898 15.0000 SAT-0031 A Maternal Vitamin D Status in Preeclampsia: Seasonal Changes Are Not Influenced By Placental Gene Expression of Vitamin D Metabolizing Enzymes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0017-0035 4858 1:00:00 PM Female Reproductive Endocrinology I Poster

Costanzo Giulio Moretti*1, Martina Colicchia2, Alessandro Dal Lago3 and Salvatore Ulisse4
1UOC of Endocrinology, Diabetology and Metabolic Diseases, Rome, Italy, 2University of Rome TorVergata, 3Sant'Eugenio Hospital, 4Univ of Rome, Roma, Italy

 

BACKGROUND: A failure in thyroid hormone availability during early pregnancy is associated with recurrent miscarriage (RM) and several adverse outcomes. In order to hypothesize the involvement of a transient impairment of the pituitary–thyroid axis in early pregnancy as responsible of miscarriage, we have evaluated data collected by the follow-up of euthyroid women affected by unexplained recurrent miscarriage (RM) treated with levothyroxine (LT4) comparing the outcome with a control group of untreated women.

METHODS: This is a retrospective study evaluating a cohort of 458 euthyroid women  affected by RM followed over 5 years. Starting from at least 3 months before expected programmed pregnancy, 227 out of 458 women were treated with low doses of levothyroxine (LT4), while 231 did not receive any thyroid hormone supply. In both groups we assessed the number of full-term pregnancies, abortions and failure to conceive.

RESULTS:  We have observed a significant improvement of full-term pregnancy in the group of treated women (59%) compared to the control group of untreated women (13%). In the  group of women treated with LT4 there was a lower percentage of miscarriage and failure to conceive respect to the control group, respectively 12 vs 30% and 29 vs 57%.

CONCLUSIONS: In euthyroid women affected with RM who underwent low-dose levothyroxine treatment, a statistically higher pregnancy and parturition rate was observed comparing to the control group (p<0.0001). A better response to treatment was obtained starting LT4 treatment at least three months before planning pregnancy. A frequent evaluation of serum TSH and FT4 was crucial to prevent transient thyroid impairment in pregnant women and in order to tailor the therapy to every single patient. We conclude that  transient impairment of thyroid hormone availability may be responsible of RM even in euthyroid women and treatment with low doses of LT4 can improve the pregnancy outcome.

 

Nothing to Disclose: CGM, MC, AD, SU

16997 16.0000 SAT-0032 A Low Dose Levothyroxine Treatment Improves Outcome in Euthyroid Women Affected By Unexplained Recurrent Miscarriage 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0017-0035 4858 1:00:00 PM Female Reproductive Endocrinology I Poster

Aleksandra Kruszynska*1, Jadwiga Slowinska-Srzednicka1, Aleksandra Wycisk2, Katarzyna Podkowska2 and Wojciech Zgliczynski1
1The Medical Centre of Postgraduate Education, Warsaw, Poland, 2Students' Endocrinology Club, Medical Centre of Postgraduate Education

 

Context: Both polycystic ovary syndrome (PCOS) and chronic autoimmune thyroiditis (AIT, Hashimoto disease) are common endocrinopathies and the AIT is the most prevalent cause of hypothyroidism in areas with sufficient iodine intake. Patients with PCOS are probably more susceptible to the development of autoimmune diseases. The data about the prevalence of AIT and its association with insulin resistance in PCOS is limited and it has not been assessed in the Polish population.

The aims of the study were: to assess the prevalence of AIT and hypothyroidism in PCOS patients and the level of  insulin resistance in AIT group vs patients without AIT.

Subjects and Methods: We analyzed data of 192 young (aged 18-40) PCOS women, who were the patients of our Endocrinology Department (years 2009-2012), in whom PCOS was recognized with AES Criteria and TSH, thyroid antibodies, thyroid USG and OGTT were performed.

Results:

1. In the PCOS group: AIT was present in 63 women (32.8%), markedly increased thyroid antibodies (anty-TPOab or anty-TGab or both) were present in 42 patients (21.9%) and the ultrasound changes typical of AIT were found in 83 women (43.2%)

2. TSH level in the whole group was 1.8 mU/l (mean value), while in AIT group vs non-AIT group was 2.48 vs 1.48 mU/l; p<0,05.

3. TSH higher than 2.5 mU/l or within normal range, but in patients taking l-thyroxin, was present in 39 women (20.3%) of the whole group and in 27 (42.9%) women with AIT.

4. PCOS women with AIT were more insulin resistant than non-AIT group: fasting insulin was 9.4 vs 5.5 uIU/ml, p<0,05; HOMA was 2.1 vs 1.2, p<0,05 and AUCinsulinwas 7448 vs 4786, p<0,05, respectively.

Conclusions:

1) AIT is a very common disease in patients with PCOS; subclinical or evident hypothyroidism is present in about 20% of PCOS women and in about 40% PCOS women with AIT.

2) PCOS patients with AIT are more insulin resistant than the patients without AIT.

3)  All PCOS patients should be screened for Hashimoto disease and hypothyroidism.

 

Nothing to Disclose: AK, JS, AW, KP, WZ

14755 17.0000 SAT-0033 A The Autoimmune Thyroiditis and Insulin Resistance in PCOS Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0017-0035 4858 1:00:00 PM Female Reproductive Endocrinology I Poster

Grace Huang*1, Elizabeth Tang2, Adam Aakil2, Stephan Anderson2, Hernan Jara2, Maithili Davda3, Helene Stroh3, Thomas G Travison3, Shalender Bhasin1 and Shehzad Basaria4
1Brigham and Women's Hospital - Harvard Medical School, Boston, MA, 2Boston Medical Center, Boston, MA, 3Brigham and Women's Hospital, Boston, MA, 4Brigham and Women's Hospital-Harvard Medical School, Boston, MA

 

Objective: To determine dose-dependent effects of testosterone administration on cardiovascular risk markers in women with low testosterone levels.

Methods: 71 hysterectomized women with or without oophorectomy with total testosterone<31ng/dl and/or free testosterone<3.5 pg/ml received a standardized transdermal estradiol regimen during the 12-week run-in period, and were then randomized to receive weekly intramuscular injections of placebo, or 3, 6.25, 12.5 or 25 mg testosterone enanthate for 24 weeks. Total and free testosterone levels were measured by LC-MS/MS and equilibrium dialysis, respectively.  Insulin sensitivity and inflammatory markers were measured at baseline and 24-weeks. In a subset of women, magnetic resonance imaging of the abdomen was performed to quantify abdominal fat volume.

Results:  59 women who completed the 24-week intervention were included in the final analysis. The five groups were similar at baseline. Mean on-treatment nadir total testosterone concentrations were 14, 79, 105, 130 and 232 ng/dl in the placebo, 3, 6.25, 12.5 and 25-mg groups, respectively.  No significant changes in fasting glucose, fasting insulin, HOMAIR, high sensitivity C-reactive protein or adiponectin were observed at any testosterone dose when compared to placebo.  Similarly, no dose or concentration-dependent changes were observed in abdominal fat on magnetic resonance imaging.

Conclusion:  Testosterone administration over a wide range of doses for 24-weeks in women with low testosterone levels was not associated with worsening of cardiovascular risk markers.

 

Disclosure: SB: Principal Investigator, Abbott Laboratories, Principal Investigator, Eli Lilly & Company. SB: Investigator, Abbott Pharmaceuticals , Clinician, Eli Lilly & Company. Nothing to Disclose: GH, ET, AA, SA, HJ, MD, HS, TGT

14804 18.0000 SAT-0034 A Testosterone Dose-Response Relationships with Cardiovascular Risk Factors in Androgen-Deficient Women: A Randomized, Placebo-Controlled Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0017-0035 4858 1:00:00 PM Female Reproductive Endocrinology I Poster

Mizuho Yoshida*1, Kana Fujiwara1, Makiko Koyama1, Tomomi Nakamura1, Hideya Sakakibara2 and Fumiki Hirahara1
1Yokohama City University School of Medicine, Yokohama, Japan, 2Yokohama City Univ Schl of Med, Yokohama, Kanagawa, Japan

 

[Purpose]  The treatment goal of amenorrhea due to weight loss is to increase body weight and recover menstruation. However, in cases that require time for recovery of menstruation, hormone replacement therapy (HRT) may be used to prevent osteoporosis and uterine atrophy. On the other hand, starting menstruation in severely underweight patients carries the risk of causing anemia and wasting. Consequently, it is necessary to select an appropriate therapy for each individual patient. In order to understand the current situation of HRT use for amenorrhea due to weight loss, we examined cases from our department.

[Methods]  The medical records of 73 patients aged from 10 to their 30’s,  diagnosed with amenorrhea due to weight loss at the women’s health clinic in our department between January 2003 and July 2013, were retrospectively studied. The degree of weight loss was divided by BMI into a severe group (BMI less than 15), a moderate group (BMI of 15 or 16), and a mild group (BMI 17 or more) and the treatment received, menstruation recovery rate and bone density were examined.

[Results]  The average age at the time of the initial visit was 21 years old. The patient distribution with respect to BMI was: 20 patients in the mild group (27%), 28 patients in the moderate group (38%) and 25 patients in the severe group (34%). The rate of HRT use was 80% in the severe group, 89% in the moderate group and 95% in the mild group. There were no cases in which treatment was discontinued because of adverse events due to HRT, such as progression of anemia. The menstruation recovery rate was only about 30% in the moderate and severe groups, on the other hand, it was higher, at 55%, in the mild group. In addition, a comparison of lumbar spine bone mineral density (L2–4) before and after treatment showed no improvement in any group and, in fact, the moderate and severe groups showed a decline after treatment compared to before treatment (before treatment 0.823 g/cm2, after treatment 0.777 g/cm2).

[Conclusions]  This study suggests that HRT is a safe treatment for patients with severe weight loss, however, it does not contribute to menstruation recovery. In addition, bone density is not improved by HRT alone. Therefore, further study of treatment methods should be considered.

 

Nothing to Disclose: MY, KF, MK, TN, HS, FH

15530 19.0000 SAT-0035 A Study on Efficasy of HRT for Amenorrhea Due to Weiht Loss 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0017-0035 4858 1:00:00 PM Female Reproductive Endocrinology I Poster

Antonio Mancini*1, Chantal Di Segni1, Sebastiano Raimondo1, Giovanni Gadotti2, Valentina Fuoco2, Francesco Guidi3, Christian Bergamini4, Francesco Volta5, Romana Fato4, Daniela Romualdi1, Rosanna Apa2, Alfredo Pontecorvi6 and Antonio Lanzone1
1Catholic University of the Sacred Heart, Rome, Italy, 2Catholic University of The Sacred Heart, Rome, Italy, 3Catholic University of The sacred Heart, Rome, Italy, 4University of Bologna, Bologna, Italy, 5University of Bologna, Rome, Italy, 6Catholic University School of Medicine, Rome, Italy

 

It is well known that insulin resistance (IR) is associated with polycystic ovary syndrome (PCOS). Oxidative stress (OS) is, in turn, related to IR, with a vicious cycle. Mechanisms underlying reciprocal influences between IR and OS are still poorly understood. Most studies concern obese PCOS women; the physiopathology of normal weight PCOS is still more complex.

 In order to investigate influence of hormonal parameters on indexes of OS in normal weight PCOS, we have evaluated the concentrations of Coenzyme Q10 (CoQ10), a component of mitochondrial respiratory chain, also endowed with antioxidant properties, and malondialdehyde (MDA), a product of lipid peroxidation, in plasma of PCOS patients (n=7, age 20-25 ys, mean BMI 24.8±2.6) and normal menstruating women (n=7, age 20-25 ys, mean BMI 22.0±2.5). Women with normal HOMA index were included  (1.01± 0.64 and 1.03±0.2, respectively). CoQ10 levels were determined by HPLC according to Takada et al. and MDA levels were determined spectrophotometrically at 535nm by TBARS assay. Despite we did not find significant differences between values of CoQ10  and MDA in the two groups, when performing a linear regression study, we found a significant correlation between Testosterone levels and  MDA (r= 0.31, p<0.05) but not with CoQ10  (r= 0.22).

These preliminary data suggest that OS is not simply related to IR in normal weight PCOS. However index of OS correlate with testosterone levels. Further studies will allow to gain insight into the reciprocal influences of hyperandrogenism and OS  in such a condition.

 

Nothing to Disclose: AM, CD, SR, GG, VF, FG, CB, FV, RF, DR, RA, AP, AL

15753 1.0000 SAT-0036 A Oxidative Stress in Normal Weight Women with Polycystic Ovary Syndrome: Relationships with Testosterone Levels 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Sheila Bunecker Lecke*1, Debora Martinho Morsch2 and Poli Mara Spritzer3
1Hospital de Clínicas de Porto Alegre and Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil, 2Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil, 3Hospital de Clínicas de Porto Alegre and Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

 

Obesity is a major risk factor for insulin resistance, type 2 diabetes and cardiovascular disease. Pigment epithelium-derived factor (PEDF) is a pleiotropic protein and has been shown to be an adipokine that induces insulin resistance and plays a role in glucose metabolism. The aim of the present study was to assess PEDF serum levels in obese women with no evidence of clinical disease and to determine whether PEDF is associated with hormonal and metabolic variables.  Forty-four women of reproductive age and with regular menses (32.0 ± 5.5 years) were included in the study. They were BMI-stratified into non-obese (<30 kg/m2) and obese (>=30 kg/m2, grade 1 and 2 obesity) subgroups. None of participants had received any drugs known to interfere with hormonal levels for at least 3 months before the study. The study was approved by the Institutional Review Board and written informed consents were obtained from all the participants. Total serum PEDF was determined by enzyme-linked immunosorbent assay (Chemicon International, USA & Canada). Non-obese (n=28) and obese (n=16) women had similar age (p=0.786). PEDF serum levels were higher in obese than in non-obese women [21.3 ± 8.7 versus 15.0 ± 5.2 ug/ml, p=0.005].  While total (p=0.200), HDL (p=0.103) and LDL-cholesterol (p=0.060) did not differ between obese and non-obese participants, obese women presented higher free androgen index [5.8 (4.1 – 8.4) versus 4.1 (3.3 – 5.4), p=0.013), triglycerides [72 (61 – 140) versus 51 (37 – 71) mg/dl, p=0.004], fasting insulin [11.8 (9.6 – 15.9) versus 4.6 (2.5 – 8.3) mIU/ml, p<0.001], and leptin levels [28.9 (27.4 – 42.3) versus 12.7 (6.1 – 21.6) ng/ml, p<0.001]. Circulating PEDF levels were significantly associated with BMI, fasting insulin and leptin levels. Our results indicate that PEDF is elevated in obese women with no clinical disease and associated with insulin and leptin levels. These data suggest that PEDF may be a candidate mediator of obesity-induced metabolic changes.

 

Nothing to Disclose: SBL, DMM, PMS

13705 2.0000 SAT-0037 A Pigment Epithelium-Derived Factor Is Associated with Obesity, Insulin and Leptin Levels in South Brazilian Women of Reproductive Age 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Devina Luhur Willard*, Melanie M Mott, Nicole R Kitos and Andrea D Coviello
Boston University School of Medicine, Boston, MA

 

Background: Polycystic Ovary Syndrome (PCOS) is the most common endocrine disorder in premenopausal women. The diagnosis of PCOS is based on the presence of 2 of 3 conditions: clinical or biochemical hyperandrogenism, oligomenorrhea, and polycystic ovaries. The Endocrine Society’s PCOS Clinical Practice Guideline (1) requires the exclusion of disorders with similar presentations in the diagnosis of PCOS including thyroid disease, hyperprolactinemia/pituitary disease, late-onset congenital adrenal hyperplasia (LOCAH), as well as hyper/hypo-gonadotropic ovarian failure and androgen-secreting tumors. Objective: To determine testing rates for disorders to exclude in the diagnosis of PCOS. Methods: Women ages 18-50 years with newly-diagnosed PCOS (n=716) were identified in the electronic medical record (EMR) at Boston Medical Center from 2006-2011. Race-ethnicity (RE) was self-reported (Black, Hispanic, White, or Other). Presence of oligomenorrhea, irregular menses, amenorrhea, infertility, hirsutism, and acne were determined from the problem list. The presence of recommended blood tests including testosterone, DHEAS, LH, FSH, TSH, prolactin, 17-hydroxyprogesterone (17OHP) as well as pelvic ultrasound were determined from the EMR. Group comparisons were by ANOVA and Chi2/Fisher's exact, alpha=0.05 (SASv9.1). Results: Mean age at PCOS diagnosis was 27±7 years. RE composition was: Black 32%, Hispanic 15%, White 28%, and Other REs 24%. Reproductive disorders were more prevalent than hyperandrogenic disorders. Most PCOS phenotypes were more common in Black women than all other REs (p<0.05). Testosterone (40%) and DHEAS (30%) levels were obtained more frequently than pelvic ultrasound (17%). TSH was the most commonly obtained test (63%). Less than half the cases were screened for other disorders: 30-37% had gonadotropins (ovarian failure), 35% had a prolactin (hyperprolactinemia/pituitary disease) and 11% had a 17OHP (LOCAH). Screening rates were higher in Black, Hispanic, and Caucasian patients than Other REs (p<0.05). Summary: Less than half of women with newly-diagnosed PCOS were screened for related disorders. Thyroid disease was the most commonly excluded disorder. Conclusion: Appropriate clinical testing in women being evaluated for PCOS was low. Greater awareness of the medical conditions to exclude when diagnosing PCOS may facilitate appropriate diagnosis and treatment of these disorders in affected women.

 

Nothing to Disclose: DLW, MMM, NRK, ADC

11355 3.0000 SAT-0038 A Practice Patterns in the Diagnosis of PCOS: Low Testing Rates for Other Disorders with Similar Clinical Presentations 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Sarantis Livadas*1, Christos Pappas1, Athanasios Karachalios1, Evangelos Marinakis1, Nikoleta Tolia1, Maria Drakou1, Phillipos Kaldrymides1, Dimitrios Panidis2 and Evanthia Diamanti-Kandarakis1
1Athens University Medical School, Athens, Greece, 2Aristotle Univ Thessaloniki, Thessaloniki, Greece

 

Hyperandrogenemia modifies phenotypic characteristics of women with polycystic ovary syndrome (PCOS). The aim of the present study was to evaluate a) the prevalence of hyperandrogenemia in PCOS women (Rotterdam criteria), and b) the impact of either the degree or the type of hyperandrogenemia on phenotype. For this purpose anthropometric, clinical, hormonal, metabolic and ultrasound characteristics of 1218 women with PCOS were analyzed in this cross-sectional study. We have found that the prevalence of hyperandrogenemia was 58.8%. Women with hyperandrogenemia had higher luteinizing hormone (LH), follicle stimulating hormone (FSH), free androgen index, lower sex hormone binding globulin (SHBG) and fasting glucose levels compared to women with normal androgens (p<0.001 for all comparisons, p=0.001 for fasting glucose). Regarding the presence of isolated hyperandrogenemia, the group with only elevated testosterone (T) levels was termed GT and an analogous categorization was made for dehydroepiandrosterone sulfate (DHEAS) [GD] and androstenedione (Δ4) [GΔ4], respectively. GT, GD and GΔ4 comprised the 17.2%, 7,6% and 4,1% of total cohort, respectively. These groups differed significantly between them in LH, LH/FSH ratio, and SHBG (p<0.001). inconclusion, hyperandrogenemia is found in almost 60% of women with PCOS (Rotterdam criteria) and it affects hormonal characteristics of these women such as LH and SHBG values. Regarding the impact of isolated hyperandrogenemia on PCOS characteristics it appears that Δ4 and testosterone elevations are associated with increased LH levels.

 

Nothing to Disclose: SL, CP, AK, EM, NT, MD, PK, DP, ED

14137 4.0000 SAT-0039 A Prevalence and Impact of Hyperandrogenemia in 1218 Women with Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Yan-Guang Wu*1, Ho-Joon Lee1, David H Barad1, Vitaly A Kushnir1, Emanuela Lazzaroni-Tealdi1 and Norbert Gleicher2
1The Center for Human Reproduction, New York, NY, 2Center for Human Reproduction, New York, NY

 

Granulosa cells (GCs) play a crucial role in regulation of folliculogenesis and oogenesis. They form the follicular microenvironment, which facilitates oocyte development, supplies energy, disposes of waste and participates in molecular signaling (1). Defects of GC function result in abnormalities in both oocyte nuclear and cytoplasmic maturation. Although poor oocyte quality is routinely observed in older infertile women (2), the impact of reproductive aging on the function of GCs has so far not been fully elucidated. We here examine the effect of maternal aging on cell proliferation and gene expression in in vitro cultured human GCs by investigating 12 in vitro fertilization (IVF) patients, 4 oocyte donors (ages 21-30 years) and 4 younger (22-37 years) and older (42-47 years) infertility patients, respectively. We specifically examined GC proliferation by counting cell number with a hematocytometer, apoptosis by DAPI staining and gene expression by real-time PCR, following in vitro culture in presence or absence of 10IU/ml follicle stimulating hormone (FSH). Our results demonstrate significantly lower proliferation and higher apoptosis with advancing female age during in vitro culture of GCs. FSH supplementation in culture stimulated GC growth and prevented luteinization, evaluated by FSH receptor and aromatase mRNA expression; but this effect dissipated with advancing female age. These data demonstrate age-related functional declines in human GCs, characterized by changes in GC luteinization, proliferation, apoptosis and ability to respond to FSH during in vitro culture. Poor oocyte quality in older infertile women may, therefore, be related to the loss of normal ovarian GC function.

 

Nothing to Disclose: YGW, HJL, DHB, VAK, EL, NG

13858 5.0000 SAT-0040 A Proliferation and Luteinization Are Affected By Advancing Female Age in Cultured Human Granulosa Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Vitaly A Kushnir*1, Aritro Sen2, Stephen R Hammes2, David H Barad1, Emanuela Lazzaroni-Tealdi1, Yan-Guang Wu1, Ho-Joon Lee1 and Norbert Gleicher3
1The Center for Human Reproduction, New York, NY, 2University of Rochester, Rochester, NY, 3Center for Human Reproduction, New York, NY

 

Others and we have previously reported on the clinical efficacy of androgens, and especially DHEA supplementation, in infertile women with low functional ovarian reserve (FOR) in improving oocyte numbers, egg and embryo quality and pregnancy as well as delivery rates (1,2). We hypothesize that these positive effects of DHEA are mediated through the androgen receptor (AR). In fact, studies in global and granulosa cell (GC)-specific androgen receptor (AR) knockout female mice (3) have established that AR actions are absolutely essential for normal follicular development. AR signaling in GCs regulates female fertility by controlling pre-antral follicle growth and development to antral follicle stage, while preventing follicular atresia. Moreover in a recent study (4) we have shown that androgens (dihydrotestosterone, DHT and testosterone, T) regulate the expression of miR-125b, a microRNA that contribute to androgen-induced follicular survival as well as increase follicle stimulating hormone (FSH) receptor protein levels in GCs, resulting in enhanced FSH-mediated follicular growth. Despite these studies, direct effects of DHEA have so far not been demonstrated in the mouse model. Our results show that DHEA mimics DHT effects on mouse follicular development. Using an in vitro follicle culture system, we find in 3 experiments, involving 5 follicles each, isolated from 8-9 week old animals, DHEA (100nM), in comparison to media, significantly increases follicle growth (P<0.05); this effect is completely abolished by addition of the AR antagonist flutamide (100nM) to DHEA supplementation. Moreover in mouse whole ovary organ culture, antral follicle count increased significantly with FSH (10mg/mL) + DHEA (100nM) supplementation compared with FSH alone (P<0.05). This increase was partially diminished by addition of flutamide (100nM).  We have also previously reported (5) that DHEA supplementation in patients with low FOR increases anti-Müllerian hormone (AMH) levels. Thus, we further investigated AMH mRNA levels in wild type (WT) and GC-specific AR knockout mice. AMH mRNA in GCs was significantly higher in WT than GC-specific AR knockout mice (P<0.05). Interestingly, in GC culture, DHT supplementation resulted in significant increase in AMH mRNA expression in comparison to placebo (media; P<0.05). These experiments in a mouse model support clinical observations of improved AMH levels, follicle numbers and growth after DHEA supplementation in women with low FOR. Moreover, in support of our recent findings (4), here we demonstrate that this DHEA effect, to a substantial degree, is AR-mediated and that FSH and DHEA work synergistically at small growing follicle stages.

 

Disclosure: DHB: , Fertility Nutraceuticals, LLC. NG: , Fertility Nutraceuticals, LLC. Nothing to Disclose: VAK, AS, SRH, EL, YGW, HJL

13950 6.0000 SAT-0041 A Proof of Concept in a Mouse Model for Beneficial Effects of Dehydroepiandrosterone (DHEA) on Small Growing Follicles 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Marcello Maggio*1, Fulvio Lauretani2, Francesca De Vita3, Alberto Parise4, Chiara Bussolati3, Elisa Gatti3, Simonetta Morganti5, Graziano Ceresini1, Elisabetta Dall'aglio3 and Gian Paolo Ceda1
1University of Parma, Parma, Italy, 2University-Hospital of Parma, 3University of Parma, Italy, 4University of Parma, 5University-Hospital of Parma, Parma

 

Estrogens represent the main risk factor of several  types of cancer, especially breast and endometrial cancer (1,2). In vitro studies suggest that carotenoids could play a role in the prevention of estrogen-dependent carcinoma due to their inhibitory action on both the activity and expression of peripheral and hepatic aromatase (3-4). However, the hypothesis of an inverse relationship between the circulating levels of carotenoids and estrogens  has never been addressed in a study population  of older subjects. We cross-sectional investigated the relationship between carotenoids and  estradiol (E2) levels in 586 postmenopausal women ≥65 years from the InCHIANTI study with complete data on serum concentrations of carotenoids and E2. α-caroten, β-caroten, β-criptoxantin, lutein, zeaxanthin and lycopene levels were detect by High-Performance Liquid Chromatography(HPLC). Total E2 was assessed by ultrasensitive RIA. General linear models adjusted for age (model 1) and for multiple confounders including BMI, smoke, caloric intake, IL-6, selenium, CRP, IGF-1, fasting insulin, liver function, COPD and testosterone (model 2) were used to investigate the relationship between carotenoids and E2 levels. The mean age of the study population was 76.2±7.7 mean±SD. After adjustment for age (model 1), total carotenoids levels were significantly and negatively associated with E2 levels (β±SE -0.09±0.05, p=0.05). In the multivariate analysis (model 2), after adjustment for multiple confounders,  the inverse relationship between carotenoids and E2 was substantially unaffected (β±SE -0.13±0.06, p=0.03). In older women, carotenoids levels are independently and inversely associated with E2 suggesting a potential involvement of carotenoids in the modulation of estrogen-dependent cancers.

 

Nothing to Disclose: MM, FL, FD, AP, CB, EG, SM, GC, ED, GPC

13014 8.0000 SAT-0043 A Relationship Between Carotenoids and Estradiol Levels in Older Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Neelaveni Kudugunti*1, Rakesh Kumar Sahay2 and Ramesh Jayanthy3
1Osmania Medical college/Osmania General Hospital, Hyderabad, India, 2Osmania General Hospital, Hyderabad, India, 3Sai's Institute of Endocrinology, Andhra Pradesh, India

 

Background- Increasing number of women  are being diagnosed with mild thyroid dysfunction during pregnancy and  treated with levothyroxine, due to its association with adverse obstetric outcomes and impaired neuropsychological development in the offspring. However there are limited data to indicate the risk of developing hypothyroidism after pregnancy and also whether treatment should be continued outside of pregnancy .

Objective- Our study aimed to determine whether subclinical hypothyroidism resolves after pregnancy and  also to know the risk of hypothyroidism after pregnancy.

Methods- This  retrospective study analysed the medical records of 522 pregnant women with subclinical hypothyroidism , who had been followed up for 2 yrs after pregnancy.

 Results-Out of 522  pregnant women with subclinical hypothyroidism(TSH- 4-10 µIU/ml),for 467/522(89.46%) women levothyroxine was discontinued post pregnancy, of these 384 (73.56%) women  had normal thyroid function (TSH <5µIU/ml) post pregnancy on 2 yrs followup, whereas 61(11.68%) and,22(4.2%) women developed hypothyroidism (TSH>10) within 1st year and 2nd year followup respectively, who either had higher TSH(>7.5)or goiter and/or anti TPO antibody positivity. Only   55/522(10.54%) of women , who were requiring higher doses of levothyroxine(>75µg/day) with goiter and /or anti TPO anbody positivity were continued on levothyroxine after pregnancy(at lower doses ,quarter to half the dose of pregnancy),  who maintained  euthyroid status  during followup.

Conclusions- The majority  cases of subclinical hypothyroidism in pregnancy are transient. Post pregnancy risk of hypothyroidism is higher in women with goiter,positive anti TPO antibodies,higher TSH at baseline and higher requirement of levothyroxine during pregnancy.

 

Nothing to Disclose: NK, RKS, RJ

15638 9.0000 SAT-0044 A Risk of Hypothyroidism after Pregnancy in Women with Subclinical Hypothyroidism during Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Hang Wun Raymond Li*1, Karen SL Lam1, Sidney CF Tam2, Vivian C.Y. Lee1, Tracy W.Y. Yeung1, Pik To Cheung3, William Shu-Biu Yeung1, Pak Chung Ho1 and Ernest Hung Yu Ng1
1The University of Hong Kong, Hong Kong, 2Queen Mary Hospital, Hong Kong, 3The Univesity of Hong Kong, Hong Kong

 

Background:

Polycystic ovary syndrome (PCOS), being a common reproductive endocrine disorder resulting in oligo-amenorrhoea and anovulatory subfertility, is also associated with the metabolic syndrome (MetS) which is an important long term health problem. Hyperandrogenism is a cardinal feature of PCOS.  This study analysed the predictive value of the androgen indices on the occurrence of MetS in women with PCOS.

Methods:

We prospectively recruited 462 Hong Kong Chinese women diagnosed with PCOS by the Rotterdam criteria during April 2011 to March 2013. All subjects attended the clinic within the first 5 days of spontaneous or induced menstruation. Fasting serum was assayed for total testosterone, sex hormone-binding globulin (SHBG), anti-Mullerian hormone (AMH), glucose, insulin and lipid profile. Cross-sectional analyses of the clinical and biochemical parameters at recruitment were performed. MetS was defined according to the Joint Interim Statement (Alberti et al, 2009). Prediction of the occurrence of MetS by SHBG and free androgen index (FAI = 100 X total testosterone / SHBG) was determined using the receiver-operator characteristic (ROC) curve as well as the univariate and multivariate logistic regression analyses after controlling for body mass index (BMI) and HOMA-IR.

Results:

Out of the 462 recruited PCOS subjects, 72 (15.6%) had MetS at recruitment.  Compared to those without MetS, subjects having MetS had significantly higher BMI, waist circumference, SHBG, FAI and HOMA-IR. There was no significant difference in age, total testosterone, antral follicle count (AFC) and AMH among the two groups. Area under the ROC curve of SHBG for prediction of MetS (0.863, 95% CI 0.828–0.893 was higher than that of FAI (0.804, 95% CI 0.765–0840, p=0.005). A cut-off SHBG level at 26 nmol/L gave a sensitivity of 89% and specificity of 75% in predicting MetS. Univariate binary logistic regression revealed that SHBG, FAI, BMI and HOMA-IR, but not total testosterone, mean AFC nor AMH, were significant predictors of MetS.  Putting SHBG, BMI and HOMA-IR into a multivariate logistic regression model showed that SHBG (p=0.001), BMI (p<0.001) and HOMA-IR (p=0.004) all remained as significant independent predictors of MetS.

Conclusions:

Serum level of SHBG was a good independent predictor of MetS in women with PCOS after controlling for adiposity and insulin resistance measures.

 

Nothing to Disclose: HWRL, KSL, SCT, VCYL, TWYY, PTC, WSBY, PCH, EHYN

13739 10.0000 SAT-0045 A Serum Level of Sex Hormone-Binding Globulin Is a Good Independent Predictor of Metabolic Syndrome in Women with Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Iris Yaish*1, Foad Azem1, Rona Limor1, Sivan Shamai1, Naftali Stern1, Orit Gutfeld1, Karen Michele Tordjman2 and Etty Osher1
1Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, 2Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

 

Background and aim of study: Differentiated thyroid carcinoma and thyrotoxicosis are commonly diagnosed in women in their reproductive years.  In fact,  37% of women diagnosed with thyroid cancer are younger than 45 years of age. Gonadal germ cells are very vulnerable to radiotherapy. Following RAI treatment, retrospective studies have reported an 18-48 months earlier age at menopause. However, despite these reports,  the full impact of RAI treatment on gonadal reserve  has never been systematically studied. The aim of this study is to prospectively evaluate the effect of RAI therapy on ovarian reserve as assessed by the level of anti-Mullerian hormone (AMH), a common tool in the evaluation of women who present for fertility treatment.
Study Design: This  prospective study aims at enrolling 30 patients, between the ages of 18-45 years, who are scheduled to undergo RAI treatment. Baseline evaluation includes a complete reproductive history and  physical examination. Subjects with previous history of pelvic surgery or irradiation are excluded. Serum AMH, estradiol and gonadotropins are assessed at baseline,  and subsequently every 3 months for a year  following RAI treatment. While each subject serves as her own control, AMH levels  will also be compared to the expected decline over time.
Preliminary Results: Ten patients, aged 20-40 have been enrolled in the study so far. All had experienced menarche  between the ages of 11 and 12 years, and reported regular menstrual periods before treatment. Five women had borne children.  Seven women received RAI for papillary thyroid cancer (all StageI) at doses between 30-150 mCi.  Three patient received  treatment for  Graves' disease (10-18 mCi). The levels of AMH in the patients before the RAI treatment were 1.3 – 6.9 ng/ml. At 3 months, they decreased by more than 50% in  2 patients who received 150 mCi RAI (from 5.9±1.3 to 2.0±0.06). Additional data will be available shortly.
Conclusions: If confirmed, these preliminary data would suggest an early  deleterious effect of RAI on ovarian reserve. This could potentially  affect treatment decision particularly in young women with thyroid cancer.

 

Nothing to Disclose: IY, FA, RL, SS, NS, OG, KMT, EO

13806 11.0000 SAT-0046 A The Effect of Radioactive Iodine 131I Treatment on Ovarian Reserve : Preliminary Data from a Prospective Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Yan-Guang Wu*1, Ho-Joon Lee1, David H Barad1, Vitaly A Kushnir1, Emanuela Lazzaroni-Tealdi1 and Norbert Gleicher2
1The Center for Human Reproduction, New York, NY, 2Center for Human Reproduction, New York, NY

 

Negative effects of female reproductive aging on assisted reproductive technologies are wildly acknowledged (1).  They include age-related declines in implantation and pregnancy rates as well as increases in spontaneous miscarriage. Declines in oocytes quality and quantity are generally believed to be the main underlying mechanism. Granulosa cells (GCs) form the follicular microenvironment, which facilitate oocyte development, supplies energy, disposes of waste and participates in molecular signaling (2).Although it is reported that certain defects of gene expression result in loss of normal function, which in turn lead to follicle/oocyte dysfunction, the impact of reproductive aging on the gene expression of GCs has so far not been fully elucidated. The objective of this study was, therefore, to examine effects of maternal aging on GC gene expression in women undergoing in vitro fertilization (IVF) treatments. We for that purpose collected GCs after oocyte retrievals from 27 patients, 7 oocyte donors (ages 22-30 years, 10 younger (ages 22-37 years) and 10 older infertile patients (ages 42-47 years). Expressions of genes related to gonadotropin and sex hormone action, steroidogenesis, apoptosis and luteinizationwere investigated by real-time PCR. Results indicated that FSH receptor, aromatase and 17β-HSD expressions are down regulated with advancing female age, while LH receptor, P450scc and progesterone receptor areup regulated. Expression of estrogen receptor, androgen receptor, StAR and apoptosis-related genes (Bcl-2, Bax, Survivn) did not differ significantly between age groups. These results suggest that with advancing female age increasingly earlypremature luteinization occurs in GCs. We also observed a higher (>1) serum progesterone estradiol ratio (P4/E2) in the older patient group(1.96±0.47) than in younger (0.5±0.15) and donor group (0.26±0.08; P<0.01), further supporting the premise of premature luteinization.In conclusion, our data demonstrate age-related decline in human GCs, characterized by changes in gene expression, consistent with premature luteinization in older women. These observations suggest hypothetical new treatment approaches for older infertile women.

 

Nothing to Disclose: YGW, HJL, DHB, VAK, EL, NG

13816 12.0000 SAT-0047 A The Impact of Advancing Female Age on Gene Expression of Human Granulosa Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Takehiro Hiraoka*, Osamu Hiraike, Yasushi Hirota, Miyuki Harada, Tetsuya Hirata, Kaori Koga, Yutaka Osuga and Tomoyuki Fujii
The University of Tokyo, Tokyo, Japan

 

Subclinical hypothyroidism (SH) is a laboratory diagnosis defined as a serum thyroid stimulating hormone (TSH) above the defined upper limit of the reference range, with a serum free thyroxine (T4) within the reference range1. Recent studies have demonstrated its contribution to the increased risk of cardiac dysfunction, ischemic heart disease, and elevated low-density lipoprotein. The adverse effects on obstetrical outcomes including spontaneous pregnancy loss, preterm birth, have also been reported, thus the latest guidelines from The Endocrine Society recommend levothyroxine replacement in all pregnant women with SH to maintain TSH values below 2.5 mIU/L2. Similarly, the impact of thyroid dysfunction on infertility has been the subject of several recent articles and it remains to be a matter of controversy3.

To investigate the association between SH and infertility, we retrospectively reviewed the medical records of 180 infertile women who first visited the infertility clinic of our hospital from January 2009 to April 2012, and the study was approved by the institutional review board. These participants underwent blood thyroid test and were followed-up more than a year, and those who possess past or current history of overt hypo- or hyperthyroidism, recurrent pregnancy loss were excluded from this study. Patients were divided into two groups based on the levels of TSH and thyroid hormone, namely Euthyroid and SH group. The etiology of infertility and the prognosis of infertility treatment were analyzed and compared to each group by the statistical analysis of Chi-squared test, Fisher’s exact test, and multivariate analysis, as appropriate. In addition, to offer insight into the upper normal limit of serum TSH concentration of infertile women, we set revised upper limit of TSH to 2.5/3.0/3.5/4.0 mIU/L, and respectively divided patients into two groups based on whether TSH values were below or at/above each redefined upper limit, and compared each group in the way described above.

The frequency of SH was 4.3% in our patients, and there was no difference in live birth rate between Euthyroid and SH group. The redefined upper normal limit of TSH level did not change the result. The significant increase of unexplained infertility was observed in the group with TSH levels exceeding either 2.5 or 3.5 mIU/L (p<0.01 respectively, Chi-square test).

Although we could not find a significant influence of SH on live birth rate in our patients, the elevation of TSH values at/above 2.5 or 3.5 mIU/L could be associated with unexplained infertility. We conclude that further research in larger groups of patients is warranted to clarify the true normal value of TSH in subfertile population.

 

Nothing to Disclose: TH, OH, YH, MH, TH, KK, YO, TF

13598 13.0000 SAT-0048 A The Impact of Subclinical Hypothyroidism on Female Subfertility 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Sylvia Yamashita Hayashida*1, Jose Maria Soares Jr1, Priscila Dias Miraldi2, Jose Antonio Marcondes2, Cristiano Roberto Barcellos3, Alvaro Anzai4, Gustavo Arantes R Maciel5 and Edmund Chada Baracat1
1Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 2Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3Faculdade de Medicina da Universidade de São Paulo, Sao Paolo, Brazil, 4Faculdade de Medicina da Universidade de São Paulo, Presidente Prudente - SP, Brazil, 5Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil

 

Hirsutism is a hallmark of polycystic ovary syndrome (PCOS), but not all subjects present this feature. The reasons for that are not well known to date.  Objective: To evaluate the influence of insulin on the severity of hirsutism in patients with PCOS. Methods: Data of two hundred twenty six (226) patients with PCOS according to the Rotterdam criteria (2003) were retrospectively collected and analyzed.  Aged range was 13-41 years (mean ±25.7 yrs). Oligomenorrhea was present in 57.6 % of patients and 28.8 % presented amenorrhea. The mean body mass index ( BMI ) was 30.4 ± 7.4  kg/m2;  25.7 % normal , 27.9 % overweight , 36.7 % obese and 9.7 % morbidly obese . All subjects were submitted to  oral glucose tolerance test with glucose and insulin assessment (OGTT + INS).  The degree of hirsutism was rated according to the scale of modified Ferriman and Gallwey score (mFG) and correlated with BMI, fasting insulin, fasting glucose, insulin and glucose at 120 minutes post-stimulation. The patients were also classified into two groups according to the mFG score . ANOVA, T Test and Pearson's linear regression were used for statistical analysis.  Results: In the overall assessment, abnormal fasting insulin (> 20 mIU / mL) was observed in 62 ( 27.1 % ) patients. Abnormal and post-stimulus insulin ( I120 ) was present in 85 subjects   (37.1 % ).  Patients with mild hirsutism (mFG< 12) displayed a mean I120 of 131 mIU /mL and a median of 80.1 mIU / mL,  whereas patients with more severe hirsutism (mFG≥ 12) evidenced I120 mean of 173.1 mIU / mL with a median value of 129.7 mIU / mL ( p = 0.03). The mean systolic blood pressure (SBP ) (p<0,001) , serum free testosterone (p=00,2) and different methods of assessing insulin sensitivity as basal insulin (p=0,015), insulin overload post (p=0,036), Glucose / insulin ratio (p=0,004), HOMA (p=0,040), QUICK (p=0,007) and area under the curve of insulin (p=0,012) were significantly higher in patients with higher score of hirsutism (≥ 12 degree). Conclusion: Insulin resistance and insulin seem to be related to the degree of hirsutism in patients with polycystic ovary syndrome.

 

Nothing to Disclose: SYH, JMS, PDM, JAM, CRB, AA, GARM, ECB

15364 14.0000 SAT-0049 A The Influence of Insulin on the Degree of Hirsutism of Patients with Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Kerstin Landin-Wilhelmsen*1, Anna-Maria Denes2, Yvonne Wettergren3, Inger Bryman4 and Charles Hanson5
1Section for Endocrinology, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, 2Department of Chemical and Biological Engineering, Gothenburg, Sweden, 3Department of Surgery, Gothenburg, Sweden, 4Department of Reproduction Medicine, Gothenburg, Sweden, 5Department of Obstetrics and Gynecology, Sweden

 

Background: In the chromosomally normal population, loss of one of the sex chromosomes leading to X chromosome monosomy (45,X) is a part of the process of ageing. The frequency of monosomic cells thus increases with age. Women with Turner syndrome (TS) already have monosomic 45,X cells at birth. The classic karyotype 45,X is found in up to 50% of these women, whereas the others are mosaics and have a second cell line, most commonly a disomic 46,XX cell line. The aim of this study was to test the hypothesis that TS women with mosaicism have an increased proportion of disomic cells with increasing age.

Methods: Fluorescence in situ hybridization (FISH) was performed on buccal smear cells obtained at 0 (baseline) and 10 years from 42 women with TS aged 26-66 years (mean±SD: 42±11) from the Gothenburg Turner Center. DNA probes specific for chromosomes X (DXZ1) and Y (DYZ3) were used to characterise the sex chromosomes. At least 100 cells were analysed for each patient.

Results: At 10 years, the percentage of disomic cells had increased in 29 of 42 participants (69%), and there was a positive correlation between % change and age (r = 0.38, p = 0.023). The correlation between % change and age in 46,XX or 46,XY cells was stronger in women >36 years of age, compared to women ≤ 36 years of age. The average increase of disomic cells was 5.7±13.0%.

Conclusions: The proportion of disomic cells increases with time in women with TS in contrast to the situation in the general population. This indicates that monosomic 45,X cells have a decreased cell cycle rate and/or are more prone to undergo apoptosis.    

The level of mosaicism in women with TS correlates with both the number and seriousness of stigmata (1). It would therefore be of interest to investigate whether an increase, decrease, or lack of change in proportion of disomic cells has an impact on the phenotype and health of the individual. The increase in the number of disomic cells might affect the length of life of women with TS.

 

Nothing to Disclose: KL, AMD, YW, IB, CH

14433 15.0000 SAT-0050 A The Proportion of Disomic Cells Increases with Time in Women with Turner Syndrome – a 10-Year Follow-up Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Gesthimani Mintziori*, Efstratios M Kolibianakis, Grigorios F. Grimbizis, Basil C. Tarlatzis and Dimitrios G Goulis
Aristotle University of Thessaloniki, Greece

 

Introduction. The evidence of the impact of ovarian stimulation (OS) for in-vitro fertilization (IVF) on thyroid function or autoimmunity is inconclusive, based mainly on assessments just before and after OS (1). Τhe aim of this study was to closely monitor the changes on thyroid function and autoimmunity throughout OS for IVF.

Description of methods/design. In a prospective, interventional study (ThyrART), a flexible GnRH-antagonist protocol was applied to 42 women undergoing IVF [(classic or intra-cytoplasmic sperm injection (ICSI)], with initiation according to follicular size and estradiol (E2) concentrations. All women were assessed five times during OS [day 3 of menstrual cycle, day 5 of menstrual cycle, day of hCG administration, oocyte pick-up (OPU) day and day of pregnancy test (15 days after OPU)]. Assessment included thyroid function tests (TSH, fT3, fT4) and autoimmunity (anti-TPO, anti-Tg).

Results. Women had a median (inter-quartile range) age of 36 (6) years, body mass index (BMI) 22.6 (4.8) kg/m2 and baseline mean (± standard error of the mean) TSH 1.82 ± 1.55 μΙU/mL, fT3 3.37 ± 0.05 pmol/L and fT4 1.30 ± 0.03 ng/dL. A significant increase was recorded in TSH concentrations between OPU day and the day of the pregnancy test (p = 0.017), whereas anti-TPO concentrations were decreased (p = 0.043). No changes were recorded in fT3 and fT4 concentrations throughout OS.

Conclusions. This study demonstrated that OS can influence thyroid function and this influence is reflected in TSH concentrations, 15 days after OPU. As the threshold for TSH concentrations for the first trimester of pregnancy is particularly low (< 2.5 μΙU/mL), special care, such as universal baseline screening and levo-thyroxine supplementation in selected cases, have to be considered in women undergoing OS for IVF.

 

Disclosure: BCT: Clinical Researcher, Merck Serono, Speaker Bureau Member, Merck Sharp & Dohme Unrestricted research grants, Travel grants and Honorarium IBSA & Ferring Travel grants, Honororia Merck Sharp & Dohme , Clinical Researcher, IBSA & Ferring . Nothing to Disclose: GM, EMK, GFG, DGG

13973 16.0000 SAT-0051 A Thyrart: A Prospective Study on Thyroid Function and Autoimmunity during Ovarian Stimulation for ΙVF 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Thaís Rasia Silva*1, Fernanda do Amarante1 and Poli Mara Spritzer2
1Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, 2Hospital de Clínicas de Porto Alegre and Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

 

Body composition as well as lifestyle factors have been suggested as determinant factors for bone mineral density (BMD) in both pre- and postmenopausal women. The aim of this study was to investigate the association of dietary pattern and habitual physical activity with BMD and the influence of lean mass (LM) and time since menopause on the risk of bone mass decline in postmenopausal women with no clinical evidence of disease. In this cross-sectional study, 100 participants were enrolled and anthropometry, hormonal and metabolic profile, body composition by bioelectrical impedance analysis, BMD by dual energy x-ray absorptiometry, rest metabolic rate by indirect calorimetry, dietary pattern by semi quantitative food frequency questionnaire and habitual physical activity by pedometer were performed. Mean age was 55.2±4.9 years and mean time since menopause was 6.8±1.0 years. When stratified according to time since menopause (≤5 or >5 years) the groups were similar regarding years at school, skin color, BMI, body composition, resting metabolic rate, mean steps per day, and metabolic variables. The group with >5 years since menopause had higher prevalence of osteoporosis. Protein, carbohydrate, fat and micronutrient ingestion were similar between the groups. However, the median daily serving portions of dairy foods, fruits and vegetables were below the recommendations in both groups. A positive correlation was observed between lumbar spine, femoral neck, and total femoral BMD with BMI (r=0.311, 0.466 and 0.512 respectively, P<0.005) and LM (r=0.312, 0.304 and 0.291, P<0.005), independently of age and time since menopause. Compared with women who underwent menopause ≤5 years, women who underwent menopause >5 years ago had a 3-fold increased risk for low bone mass (95% CI 1.27-7.34, P=0.016). When adjusted for time since menopause, the risk for low bone mass increased with low BMI (<25 kg/m2) (OR=5.36, 95%CI 1.62-17.8) and low LM (<23.1 kg) (OR=2.95, 95%CI 1.15-7.55).  Previous hormone therapy, mean steps per day and low protein intake did not influence the risk for low bone mass. In conclusion, in this cross-sectional study with postmenopausal women with no clinical evidence of disease, time since menopause and lean mass but not lifestyle factors, were predictors of BMD. Further studies are needed in order to determine whether the adequate intake of specific food groups could attenuate the aging impact on BMD.

 

Nothing to Disclose: TRS, FDA, PMS

12990 17.0000 SAT-0052 A Time Since Menopause and Lean Mass but Not Lifestyle Factors Are Associated with Low Bone Mass in Postmenopausal Women: A Cross-Sectional Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Najiba Lahlou*1, Pietro Santulli2, Jean Guibourdenche3, Cherif Beldjord4, Marie-Laure Kottler5, Charles Chapron6 and Anne Gompel7
1Paris-Descartes University , APHP, Cochin, PARIS, 2Paris Descartes University , APHP, Cochin Port Royal, 3Paris Descartes University , APHP, Cochin, 4Paris Descartes University , APHP, Cochin, 5University Hospital, Caen, France, 6Paris Descartes University , APHP, Cochin Port Royal, France, 7Paris Descartes University , APHP, Cochin Port Royal, Paris, France

 

Unexpected inhibin B, insulin-like peptide 3, and testosterone production by mother ovaries in a pregnancy with sustained high hCG levels. A clue to hyperreactio luteinalis ? 

 

Context : Inhibin B (INHB) is undetectable in pregnant woman serum except in women bearing a mutated FSH receptor gene enhancing FSH receptor sensitivity to hCG (1). Insulin-like peptide3 (INSL3) which may play a role in preventing follicular atresia, is produced in small amount by theca cells in cycling women, but is undetectable in amniotic fluid from female fetuses.

Subject : during the follow-up of a 19 year old pregnant woman from 24 to 36 weeks of gestation, US imaging evidenced large multicystic ovaries, a finding consistent with the so-called hyperreactio luteinalis syndrome. That, combined to mother clitoris enlargement, led us to complete the hormone investigation, especially as the fetus was a female.

Methods : the reagents for hormone assays were : hCG, FSH, LH from Siemens (Saint Denis, France). INSL3 from Phoenix (Burlingame CA), antimullerian hormone (AMH), INHA,  and INHB from AnshLabs (Houston, TX). Steroids were measured by UPLCMSMS on Quattro Premier (Waters, Milford, MA).

Results: both INSL3 and INHB levels were markedly elevated, about 10 times as high as in normal pregnancy.Their level peaked at 35 weeks. hCG levels were also markedly increased : more than twice above the upper limit of normal, with levels at 29, 35 weeks  higher than at 24 and 36.  Huge values of testosterone (T), androstenedione (4A), estradiol (E2) and 17OH-progesterone (17OHP) were also found. AMH level was normal : 32 pmol/L.

Weeks of gestation 24                29                35                36       Reference values*

hCG IU/L              86920          112180        102290        82410       5000–40000

INSL3 pg/ml          324              308              1200            564              < 40

INHB pg/ml           542              628              948              840              < 40

T   nmol/L             70                171              160              175               < 5

4A nmol/L             225              410              510              450              < 11

E2  nmol/l              35               109              154              155               4-27

17OHP nmol/L       222              621              516              486              5–20

*personal data

Cortisol, progesterone, estriol, DHEA sulfate, alphafetoprotein, and INHA levels were within physiological ranges.

Conclusions: these data give evidence that sustained high hCG levels in the 2nd and 3rd trimester of pregnancy induced a prolonged stimulation of maternal ovaries, leading to the development of numerous cysts, and to hyperproduction of both ovarian steroids and ovarian peptides INHB and INSL3. If the lack of hCG-sensitive mutation in the FSH receptor gene is confirmed in this woman (work in progress), these data suggest that hyperstimulated theca cells can exceptionally produce INHB as do Leydig cells in subjects with genetically activated LH receptor (2).

References :1- Vasseur et al. N Engl J Med  2003, 349 :753.

                     2- Soriano-Guillen et al. J Clin Endocrinol Metab 2006, 91 :3041.

 

Nothing to Disclose: NL, PS, JG, CB, MLK, CC, AG

13081 18.0000 SAT-0053 A Unexpected Inhibin B, Insulin-like Peptide 3, and Testosterone Production By Mother Ovaries in a Pregnancy with Sustained High Hcg Levels. a Clue to Hyperreactio Luteinalis ? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Eftychia Koukkou*1, Nikolaos Oikonomou2, Marina A Michalaki3, Irene Mamali4, Georgios Adonakis2, Neoklis Georgopoulos5 and Kostas B Markou6
1E Venizelou Hosp, Athens, Greece, 2Department of Obstetrics and Gynecology, University of Patras, Greece, 3Endocrine Division, Patra, Greece, 4Department of Endocrinology, University of Patras, Greece, 5University of Patras, Medical School, Patras, Greece, 6Univ of Patras, Patras, Rio Axaias, Greece

 

Urinary Iodine Excretion remains stable during pregnancy in Greece, an iodine sufficient area

Background: Limited studies in the literature report increased renal iodine loss, among other factors, as responsible for increased iodine demand during pregnancy.

 Aim: To study Urinary Iodine Excretion (UIE) throughout pregnancy trimesters.

Patients and Methods: We prospectively studied 26 pregnant women throughout all trimesters of pregnancy, in Patras, an urban area of Greece. Serum FT4, TSH, Tg, abTPO and UIE were determined. At the same time, the UIE of their euthyroid healthy messmates, who followed the same diet, was also measured.

 Results: The median UIE of the pregnant women, studied prospectively during the three trimesters, remained constant [UIE median (min-max) (mcg/L): 1st trimester:  102.4 (60-272); 2nd trimester: 137,5 (42-313); 3rd trimester: 113,9 (64-296), ANOVA for repeated measurements, p: ns].  No difference was found between the UIE of the pregnant women and their messmates in all three trimesters [UIE: median (min-max) mcg/L: 1st trimester Messmates 136(51.8-391.5) vs Pregnant women 102.4 (60-272), ns; 2nd trimester Messmates 161(99,1-442,6) vs  Pregnant women 137,5 (42-313), ns ; 3rd trimester Messmates 113,5 (75,6-302,9) vs Pregnant women 113,9 (64- 296), ns independent samples t-test). Serum FT4 decreased gradually in pregnant women during the three trimesters [FT4 (mean±SD) (ng/dl): 1st trimester:  1.14±0.15; 2nd trimester: 0.95±0.16; 3rd trimester: 0.92±0.16, ANOVA for repeated measurements, p<0.05] whereas serum TSH remains unaltered [TSH (mean±SD): 1st trimester:  1.62±0.94; 2nd trimester: 1.92±1.09; 3rd trimester:1.59±0.62, ANOVA for repeated measurements, ns].

Conclusions: Our results suggest that in a situation of a stable iodine intake, as indicated by the stable UIE of the messmates, the UIE of the pregnant women does not increase as pregnancy progresses. It seems that increased iodine requirements in pregnancy are possibly due to extra – renal causes. This finding needs to be confirmed by further studies in other populations with different daily iodine intakes.

 

Nothing to Disclose: EK, NO, MAM, IM, GA, NG, KBM

16672 19.0000 SAT-0054 A Urinary Iodine Excretion Remains Stable during Pregnancy in Greece, an Iodine Sufficient Area 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Chenyan Li*1, Shiqiao Peng2, Xiaomei Zhang3, Jinyuan Mao4, Xiaochen Xie5, Zhongyan Shan6 and Weiping Teng7
11st Affiliated Hospital of China Medical University, Shenyan, China, 21st Hospital of China Medical University, 3Department of Endocrinology, The first Hospital of Dandong, Dandong, China, 41st Affiliated Hospital of China Medical University, 5The Endocrine Institute and The Liaoning Provincial Key Laboratory of Endocrine Diseases, Department of Endocrinology and Metabolism, The First Hospital of China Medical University, Shenyang, China, 6Institute of Endocrinology,The First Hospital of China Medical University, Shenyang, China, 7The Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China

 

ABSTRACT

CONTEXT:  WHO/UNICEF/ICCIDD-recommended epidemiological criteria were based on median UIC for assessing iodine intake in pregnant women. However, doctors prefer a one-size fits all criterion for defining iodine deficient proposed by WHO/UNICEF/ICCIDD in China.

OBJECTIVE: We aimed to observe changes in iodine nutrition of pregnant women at different periods of pregnancy, to establish a rational indicator evaluation of iodine nutrition in pregnancy and to provide evidence for reasonable iodine supplementation during pregnancy at iodine sufficient area.

DESIGN: 600 women who planned to be pregnant and 220 pregnant women were enrolled in this study. Pregnant women were evaluated in follow-up visits at 8,12,16,20,28,36 weeks of gestation and 3,6 months postpartum. Timed spot urine samples and serum were collected at every woman at follow-up visits, and 24-hr urine samples were collected at weeks 8 of gestation. Iodine and creatinine in the urine and thyroglobulin (Tg) in the serum were measured in all subjects. Inorganic iodine in circulation were measured using inductively coupled plasma-mass spectrometry (ICP-MS) at 8,20,36 weeks of gestation and 6 months postpartum.

RESULTS: The overall median urinary iodine concentration (UIC) during pregnancy was highest at 8 weeks of gestation and decreased from 183.6 to 104.2 μg/l during pregnancy, and it remained significantly higher than that 3 months after delivery (p<0.001). Changes of serum inorganic iodine (SI) were similar to that of urine iodine–creatinine ratio (UI/Cr) in pregnant and postpartum women. In pregnancy, the median inorganic iodine in serum was lowest at the eighth weeks of gestation (60.53μg/g), which rose significantly until 20 weeks (106.53μg/g) and then began to decline(36w: 84.67μg/g, 6 months postpartum: 73.45μg/g). 24-hour urine iodine excretion was regarded as gold- standard. The area under the receiver operating characteristic (ROC) curve for the UI/Cr was 0.92 (95% CI 0.85 to 0.98) for diagnosis of iodine deficiency, and the area under the ROC curve for the SI was 0.78 (95% CI 0.68 to 0.88). The area under the ROC curve for the SI was 0.82 (95% CI 0.71-0.93) for diagnosis of iodine excessive, and the area under the ROC curve for the UI/Cr was 0.75 (95% CI 0.62-0.87).The areas under these curves were significantly different (p<0.001). The area under the ROC curve for the UI were 0.61 (p= 0.11) and 0.65 (p= 0.08), for the Tg were 0.54 (p= 0.53) and 0.53(p= 0.74).

CONCLUSIONS: Iodine intake assessed by UIC in Chinese pregnant women was unreasonable, which could increase the prevalence of iodine deficiency in late pregnancy. UI/Cr could reflect the 24 hour iodine excretion and iodine nutrition in circulation during pregnancy and postpartum.

 

Nothing to Disclose: CL, SP, XZ, JM, XX, ZS, WT

15967 20.0000 SAT-0055 A Iodine Status of Pregnant and Postpartum in an Iodine-Sufficient Area: A Longitudinal Study in China 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Laura Owen*1 and Brian G. Keevil2
1University Hospital of South Manchester, Manchester, United Kingdom, 2Univ Hospital of South Manchester, Manchester, United Kingdom

 

Estradiol measurement is most commonly performed by immunoassays which have several limitations. Firstly, the sensitivity of these assays is not sufficiently sensitive for certain patient groups such as males, post-menopausal females and children. Secondly there is a greater potential for interference from structurally related compounds or heterophilic antibodies. Additionally, total oestrogen status may be a useful measure however immunoassays are currently only routinely available for estradiol.

 We have developed a liquid chromatography tandem mass spectrometry (LC-MS/MS) assay for the measurement of estradiol and estrone. The assay does not require derivitisation and has a novel sample preparation that results in a rapid run time making it suitable for routine clinical use.

It is the only specific LC-MS/MS assay for estradiol measurement available in the UK in an accredited NHS laboratory and has been offered as a service to all UK laboratories for the last 6 months. During this period there have been 30 patients whose clinicians and local clinical scientists have sought specific LC-MS/MS estradiol and estrone measurement using this assay. A review of these patients has shown that of these, 24 patients were breast cancer patients. These patients were all being considered for or taking aromatase inhibitor therapy. It is difficult to establish the presence of residual ovarian function or detect early restoration of ovarian in these patients using conventional immunoassays due to their limited sensitivity.

Of the 24 samples received, only 12 had estradiol below 10 pmol/L however all samples would have been below the detection limit for most immunoassays. This means that using this assay, these patients were able to be managed appropriately to reduce the risk of restoration of ovarian function and potential pregnancy.

The remaining 6 samples were all sent for specific LC-MS/MS analysis due to suspected immunoassay interference. Of these, only 3 samples also gave raised estradiol concentrations using LC-MS/MS.

We have shown several clinical areas where the availability of this sensitive and specific LC-MS/MS assay for estradiol and estrone has had a direct impact on the quality of patient care and has proven to fill gap previously not covered by immunoassay. This assay is available in an accredited NHS laboratory to make it accessible for all clinicians and their patients in the UK.

 

Nothing to Disclose: LO, BGK

14434 21.0000 SAT-0056 A LC-MS/MS Measurement of Estradiol in Routine Patient Care 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Tomoya Segawa*1, Makio Shozu2, Hiroshi Ishikawa2, Kenji Oomi3, Yoshiaki Watanabe3, Osamu Miyauchi3 and Shokichi Teramoto1
1Shinbashi YUME Clinic, Tokyo, Japan, 2Chiba University, Chiba, Japan, 3Shinbashi YUME clinic, Tokyo, Japan

 

[Objective]

Measurement of serum estradiol (E2) levels in conjunction with ultrasonographic measurement of follicular diameter is now widely used for monitoring preovulatory follicular growth at IVF. Several commercially available kits are used for the measurement of serum E2 levels, and recently, a new assay kit, namely iE2 TM(TOSOH, Japan) has been released in Japan. This new kit employs a monoclonal antibody that is more specific for E2 than ever used, and uses certified reference materials IRMM CRM577 for calibration. The kit is expected to improve the accuracy of measurement of E2 levels by discriminating estrone (E1) that coexists as circulating estrogens more at significant level, especially during an early follicular phase. In this study, we analyzed a clinical usefulness of this kit in terms of assessment for early follicular growth. 

[Materials and Methods]

Institutional Review Board approval was not required for the present study due to its retrospective nature. Clinical data were retrospectively collected from medical records of patients who undergo IVF cycles in our clinic (n= 7,233). Range (mean ± S.D.) of patient age is 29 to 48 (40.4±4.0) years old. Causes of infertility included tubal factor, endometriosis, oligo- or azo-spermia, and unknown etiology. Serum E2 levels were measured by the new kit, old kit (E2 kit, TOSOH) or both. Follicular diameter was assessed by transvaginal ultrasonography. The data were collected from the day 3 to 19 of the menstrual cycle. The exclusion criteria to eliminate possible pregnancy and on-going endogenous LH surge are followed: hCG >0.3IU/L, Progesterone >0.8ng/ml, or LH >20IU/L.

 [Results]

Usefulness of E2 measurement was assessed at day 3 of the cycle, when E1, a potential cross-reactant exists more compared to a late follicular phase. Prediction of growing follicles (>11mm) with the E2 measurement was assessed by ROC analysis. The AUC value for E2 measured by the new kit was 0.722 (Cut off 40mg/dl, Sensitivity 70.2%, Specificity 66.3%) for prediction of the growing follicles. The AUC value for E2 measurement by the old kit was 0.644 (Cut off 91mg/dl, Sensitivity 35.1%, Specificity 89.5%), which was significantly lower than that determined by the new kit (p< 0.05). Next we calculated serum E2 level every 1mm increase of follicular diameter between 11mm to 20mm. The E2 levels determined by the new kit were ~30% lower than those determined by the old kit (p<0.01) in smaller follicles (11-17mm), while the difference between two measurements was not significant for larger follicles (18-20mm). This supports the notion that the old kit measured substance(s) other than E2, probably of E1, and which caused difficulty in assessment of the follicular growth.

 [Conclusions]

The new kit, iE2, appeared to measure E2 more specifically than the old one does. This would be useful for hormonal assessment of follicular growth, especially during early to mid follicular phase.

 

Nothing to Disclose: TS, MS, HI, KO, YW, OM, ST

16525 22.0000 SAT-0057 A Measurement of Estradiol Using a New Assay Kit, iE2, Is Useful for Monitoring Follicular Growth 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Nashwah Taha*1 and Catherine Yu2
1University of Toronto, 2St. Michael's Hosp, Toronto, ON, Canada

 

Background

Virilization during pregnancy is rare; the differential diagnosis includes androgen-secreting tumors, luteoma of pregnancy, hyperreactio luteinalis, fetal aromatase deficiency, and iatrogenic causes. The management for each differs greatly; therefore a careful history, physical examination, and investigations are necessary to narrow down the differential diagnosis.

Case

A 34-year-old woman presented with symptoms of virilization, including acne, hirsutism, deepened voice, and marked clitoromegaly that began at 20 weeks gestation. She had a naturally conceived twin pregnancy with no complications, and delivered two healthy females at 37 weeks by caesarean section. The twins had normal anatomy and no signs of virilization. Immediately postpartum, she developed severe edema which responded to diuretics. Five months postpartum, she was assessed and found to have persistent clitoromegaly (6mmx3mm), acne, a deep voice, and hirsutism. Laboratory investigations at this time revealed an elevated bioavailable testosterone level and otherwise normal biochemical and hormonal profile. No ovarian imaging was obtained at the time of presentation. A careful history ruled out an iatrogenic cause of virilization, and biochemical analysis did not suggest an androgen-secreting tumor. Fetal aromatase deficiency and luteoma of pregnancy were unlikely given the lack of virilization of the female twin infants. Based on these findings, the diagnosis of hyperreactio luteinalis was made and no therapy was initiated. Seven months post-partum, the patient’s hirsutism, acne and clitoromegaly spontaneously resolved, and her menses normalized, confirming the diagnosis.

Conclusion

Recognition of hyperreactio luteinalis is important since misdiagnosis as an ovarian androgen-secreting neoplasm may result in unnecessary surgery. A conservative management is usually appropriate as spontaneous resolution and regression of ovarian size and hormonal function may be expected after delivery.

 

Nothing to Disclose: NT, CY

16823 23.0000 SAT-0058 A Hyperreactio Luteinalis – a Rare but Important Cause of Clitoromegaly and Virilization during Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Haruhiko Kanasaki*1, Tomomi Mitsuo2 and Aki Oride3
1Shimane Univ Sch of Med, Izumo, Japan, 2Shimane University School of Medicine, Izumo, Japan, 3Shimane University, Izumo, Japan

 

Uterine arteriovenous malformation (AVM) can cause sudden massive hemorrhage. We report a case of uterine AVM following curettage in a patient treated conservatively with an intermediate-dose pill. An 18-year-old gravida 2 para 0 underwent curettage at 12 weeks of gestation and was examined for massive genital hemorrhage that occurred in postoperative month 4. Abundant blood flow in a mass within the uterine lumen was observed on color Doppler ultrasonography, and the patient was diagnosed with AVM. Six days after starting oral norgestrel/ethinyl estradiol, the hemorrhage ceased, and computed tomography on day 37 of administration showed disappearance of the abnormal vasculature. After 12 months, the patient’s course remains favorable without relapse. Transarterial embolization for AVM can cause ovarian failure and subsequent placental malpositioning. Administration of oral norgestrel/ethinyl estradiol may be an alternative conservative treatment option for patients who wish to maintain fertility.

 

Nothing to Disclose: HK, TM, AO

13659 24.0000 SAT-0059 A Disappearance of a Uterine Arteriovenous Malformation Following Long-Term Administration of Oral Norgestrel/Ethinyl Estradiol 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Anitha Somasundaram*1, Kevin Donohue2 and Serge Jabbour3
1Mercy Catholic Medical Center, Aldan, PA, 2Albert Einstein Medical Center, Plymouth Meeting, PA, 3Thomas Jefferson University, Philadelphia, PA

 

Background: Hyperandrogenism in females can be of ovarian or adrenal origin. We present a rare case of bilateral leydig cell hyperplasia as the cause of postmenopausal hyperandrogenism.

Clinical Case: A 64-year-old Caucasian female was referred to us for evaluation of high testosterone. Since her menopause at age 50, she noted worsening of her hirsuitism, deepening of her voice and diffuse hair loss. Her review of systems was significant for increased libido and muscular mass. Past medical history was significant for well controlled type 1 diabetes and multinodular goiter (subcentimeter nodules). Past surgical history was significant for hysterectomy (without oophorectomy) for fibroids. She had two children, aged 34 and 35, both healthy.  Her medications included insulin (glargine and aspart).

On exam, her vitals were normal (BP 120/60 mm Hg) and BMI was 24.9 Kg/m2. She had diffuse hair loss and a deep voice. She was not Cushingoid or acromegalic. She had facial hirsuitism, mostly on her chin and upper lip. 

Labs showed normal comprehensive metabolic panel, cortisol and ACTH, LH of 32 mIU/ml (7.7 – 58.5 mIU/ml), FSH of 49 mIU/ml (25.8 - 135 mIU/ml), DHEAS of 68 mcg/ dL (45-430 mcg/ dL), estradiol of 56 pg/mL (<5 - 54.7 pg/mL), testosterone of 506 ng/dL (2 - 45 ng/dL) with free testosterone of 40 pg/mL (0.1 - 6.4 ng/dL), androstedione of 2.37 ng/mL (0.13 – 0.82 ng/mL). Ultrasound (pelvis and transvaginal) showed normal ovaries. MRI of abdomen and pelvis showed normal ovaries with few tiny cysts of no significance, normal adrenals without any masses. MRI of pituitary was normal. Bilateral oophorectomy was performed and histopathology revealed bilateral leydig cell hyperplasia. On follow-up few months later, patient’s hirsutism, hair loss had resolved and testosterone levels normalized.

Conclusion: High testosterone in this patient can be only due to ovarian or adrenal mass, latter excluded by normal adrenal MRI. Functioning ovarian tumors consists of sex-cord stromal tumors (arrhenoblastoma, estrogen secreting granulosa theca cell tumors) and steroid cell tumors (hilus cell, leydig cell and lipoid cell tumors). In postmenopausal women with symptomatic hyperandrogenism, virilization (or both) who have no obvious ovarian or adrenal mass, bilateral laparoscopic oophorectomy is likely the procedure of choice. Ovarian sampling is only indicated in premenopausal women, although it requires a very skilled radiologist and can lead to misleading results.

 

Nothing to Disclose: AS, KD, SJ

14262 25.0000 SAT-0060 A An Unusual Case of Postmenopausal Hyperandrogenism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Yoshimasa Kawarai*1, Hiroshi Ishikawa1, Tomoya Segawa2, Hidekazu Nagano3, Tomoaki Tanaka3 and Makio Shozu1
1Chiba University, Chiba, Japan, 2Shinbashi YUME Clinic, Tokyo, Japan, 3Chiba University Graduate School of Medicine, Chiba, Japan

 

Nonclassical congenital adrenal hyperplasia (NCCAH) is caused by a partial deficiency of the steroidogenic enzyme 21-hydroxylase, and produces mild-to-moderate hyperandrogenemia resulting in hirsutism, polycystic ovaries, oligomenorrhea, and subfertility. The severity of disease depends on the residual activity of the enzyme and a mild case can be misdiagnosed as polycystic ovary syndrome (PCOS). Here we report a case of a patient in whom NCCAH was diagnosed on the basis of continuously high serum progesterone level during infertility treatment.

A 38-year-old woman with infertility was referred to our department for the investigation of continuous high serum progesterone level, which was unaffected by her menstrual cycles. She had noticeable hirsutism and oligomenorrhea since she was 20 years old, and had visited doctors in two tertiary medical facilities; however, no diagnosis had been made. On physical examination, mild clitoromegaly and mild hypoplasia of the vaginal fornix were noticed. Ultrasonography revealed bilateral polycystic ovaries and a small uterus. Magnetic resonance imaging showed a normal appearance of the adrenal glands. Repeated measurement of serum progesterone level revealed that the level was ≥1.3 ng/ml even at the third day of menstruation. Serum 17-hydroxyprogesterone (OHD) level was as high as 37.2 ng/ml and elevated to 156 ng/ml after adrenocorticotropic hormone (ACTH) loading. Serum androgens were also elevated: testosterone, 2.42 ng/ml, androstenedione, 7.3 ng/ml, and free testosterone, 3.8 pg/ml. According to the basal 17-OHP and ACTH stimulated 17-OHP levels, NCCAH was diagnosed. Genetic analysis revealed combined heterozygous missense mutations of CYP21A2 (P30L, V281L, and I172N), which probably decreased 21-hydroxylase activity. Dexamethasone administration effectively reduced the levels of 17-OHD as well as androgens, thereby resulting in the disappearance of multiple cysts in the ovaries and restoration of regular ovulation.

NCCAH may present as subfertility or infertility with multicystic ovaries, irregular menstruation, and mild hyperandrogenism, thus resembling PCOS; however, unlike PCOS, glucocorticoid replacement is crucial for its management and is also effective for infertility treatment.

 

Nothing to Disclose: YK, HI, TS, HN, TT, MS

12148 26.0000 SAT-0061 A A Case of Nonclassical Congenital Adrenal Hyperplasia in Which Aberrant Serum Progesterone Provides a Diagnostic Clue 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Michael Spivak* and Naila M Goldenberg
Mercy Health Partners, Mason, OH

 

Abstract

Objective:  Hepatic adenomas are benign liver lesions, which often are found incidentally upon work up of elevation of serum transaminases. These lesions are usually solitary in nature, are found in females of reproductive age, and their incidence has been strongly associated with use of oral and injectable forms of birth control. The documented cases and studies demonstrating this relationship showed that these lesions often spontaneously regress if offending factor has been removed. The relationship between these tumors and progesterone containing intra-uterine devices (IUD) has not been yet demonstrated and clearly established in scholarly literature.  

Case:  We are presenting a rare case of a 27 year old female with elevation of serum transaminases and multiple nodular liver lesions consistent with hepatic adenomas, who has been utilizing Mirena IUD for a year prior to initial work up. Progression of lesions and of serum transaminases was observed for 6 months after Mirena IUD has been removed, which subsequently demonstrated stability in number and size of lesions.  

Results:  For the first time, we are demonstrating a connection between use of progesterone containing IUD and development of hepatic adenoma.

Conclusion:  Our case demonstrates a role of therapy with progesterone containing IUD in development of hepatic adenoma. Clinician must be aware of possibility of this potential complication and appropriately educate patients prior to initiating the therapy.

 

Nothing to Disclose: MS, NMG

11362 27.0000 SAT-0062 A Development of Liver Adenomatosis Following Utilization of Progesterone Containing Intrauterine Device 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Bekir Ucan*1, Mustafa Sahin2, Mustafa Ozbek3, Müyesser Sayki Arslan4, Omer Ant5, Levent Sirvan5, Utku Mahir Yildirim4, Erman Cakal1 and Tuncay Delibasi4
1Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey, 2Ankara University School of Medicine, Ankara, Turkey, 3Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey., Turkey, 4Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey., 5Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey

 

We report a leydig cell tumor in a 51-year-old woman who presented with severe clinical hyperandrogenism and atherosclerosis.

On clinical evaluation, she presented with severe hirsutism. Patient had previously been diagnosed with polycystic ovary syndrome and was receiving treatment for seven years. She developed widespread atherosclerotic vascular disease. Although ultrasound (US) and magnetic resonance imaging (MRI) showed normal ovaries, elevated testosterone and estrogen levels with normal DHEA-S levels revealed ovarian pathology. Selective ovarian vein sampling was done to lateralize the tumor. Patient could not be operated immediately because of cerebrovascular event and serious carotid artery stenosis.  Abdominal hysterectomy and left salpingo-oophorectomy were performed after stabilization of patients. Histopathological examination revealed  leydig cell tumor within the  left ovary. Hyperandrogenaemia normalized post-operatively. 

Early diagnosis is important to prevent morbidity in leydig cell tumors. Ovarian vein sampling should be considered in diagnosis of these patients even though US of ovaries shows normal findings.

 

Nothing to Disclose: BU, MS, MO, MSA, OA, LS, UMY, EC, TD

16320 28.0000 SAT-0063 A Possible Role of Late Diagnosis of Leydig Cell Tumor on Atherosclerosis in Postmenopausal Woman 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Suzi Kochar*1, Janice L Gilden2 and Paula Butler3
1Mount Sinai Medical Center, Chicago, IL, 2RFUMS/Chicago Med Schl, North Chicago, IL, 3Mt Sinai Hosp Med Ctr, Chicago, IL

 

Background: Loss of function mutations of the gene that encodes the androgen receptor result in androgen insensitivity syndrome (AIS) in 46,XY individuals with functional testes and normal testosterone formation.

Clinical Case: A 35 yr old obese (BMI: 31.5 kg/m²) Filipino female, previously in good health, was admitted with left flank pain and found to have large perinephric hematoma on abdominal CT.  Incidental blood glucose was 529 mg/dl (29.4mMol/l).  Over the past 6 mos, she had polyuria/polydipsia and 20 lbs weight loss.  Breast development was at age 16, but no menarche.   A pelvic ultrasound at age 17 was reported to show small ovaries.  Pelvic examination and pap smear at age 20 revealed a small uterus.  Patient is sexually active with normal libido. Patient is unaware of any other family members with reproductive problems. Physical exam showed a 6’11” tall, 309 lbs phenotypic female with acanthosis nigricans, no pubic or axillary hair, and no clitoromegaly. Laboratory tests: Prolactin (6.4 ng/ml, n 0-25 ng/ml), FSH (16.1 mIU/ml, n 3.9-8.8 mIU/ml), LH (7.7 mIU/ml, n 2.1-10.9 mIU/ml), Estradiol (46 pg/ml, n 19-144 pg/ml), Total Testosterone (105 ng/dl, n 2-45 ng/dl), Free Testosterone (13.5 pg/ml, n 0.1-6.4 pg/ml) and DHEAS (85 ng/dl, n 102-1185 ng/dl). Pelvis ultrasound: small uterus (2.5 x 0.7 cm) but bilateral ovaries and adnexal structures were not visualized. MRI: no discrete gynecologic structures; a round fluid signal focus was seen within left inguinal canal with second contralateral fluid signal focus seen anterior to right iliac muscle near the orifice of right inguinal canal. The possibility of non-descendent testicles could not be excluded. Karyotyping was done and revealed 46 XY in all metaphases. FISH Assay probing SRY of Y-chromosome was positive in all cells ruling out SRY deletion.  The patient underwent bilateral orchiectomy with testicular biopsy showing immature seminiferous tubules and Leydig/Sertoli cells in the fibrous tissue.  Postoperatively, she was started with Estradiol 2mg once daily.  The therapy was changed to estradiol transdermal patch due to complaints of migraine, breast tenderness and increased acne. The perinephric hematomas, as well as the newly diagnosed diabetes were appropriately treated.  She was also discovered to have Von-Willebrand disease. 

Conclusion: This case highlights the need to perform a careful history for all patients with primary amenorrhea.  Complete androgen insensitivity syndrome is an X-linked recessive disorder in which a 46,XY person can have the phenotype of a normal woman (including normal external genitalia and a small uterus), but testes may be palpable in the inguinal canal or labia.  These patients are at increased risk of developing germ cell carcinoma. Therefore, close attention should be given when evaluating patients with primary amenorrhea.

 

Nothing to Disclose: SK, JLG, PB

14079 29.0000 SAT-0064 A A Case of Undiagnosed Complete Androgen Insensitivity Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Pei Shan Yeo*1 and Cherng Jye Seow2
1Tan Tock Seng Hospital, Singapore, Singapore, Singapore, 2Tan Tock Seng Hospital, Singapore, Singapore

 

Introduction

Secondary amenorrhea is characterized as absence of menses for 3 cycles or 6 months in women who previously had menses. The cause of secondary amenorrhea mostly stems from disorders of the hypothalamic-pituitary-ovarian axis or general health status, such as stress or accelerated unexpected weight loss.

We describe an interesting diagnostic journey of a young lady who presents with secondary amenorrhea, initially attributed to hyperprolactinemia. However, despite treatment and resolution of hyperprolactinemia, amenorrhea persisted. After a detailed evaluation, the diagnosis of polycystic ovarian syndrome (PCOS) was eventually made.

Case Presentation

An 18 years old Chinese lady presented with secondary amenorrhea of one year duration. History was unremarkable for anorexia, excessive exercise or intentional weight loss. There were no complaints of headache, visual disturbances or galactorrhea. She did not experience any symptoms suggestive of any thyroid disorders. On examination, she did not appear Cushingoid. Her BMI was 25.6. Urine pregnancy test and thyroid function test were normal. Prolactin was elevated at 1.5 times of upper limit of normal. There was no obvious etiology for the hyperprolactinemia and an imaging of the pituitary gland was normal. An initial diagnosis of idiopathic hyperprolactinemia was made and bromocriptine was started and continued for the next year. Despite normalization of the prolactin level, amenorrhea persisted. She was referred for a second opinion and her history and physical examination was suspicious for possible PCOS with features of hyperandrogenism. Ferriman Gallwey score was 10. Total testosterone was elevated at 3 nmol/L (RI: 0-2) and free androgen index 14.3%. A revised diagnosis of PCOS was made. Lifestyle modifications were instituted, oral contraceptives started and bromocriptine discontinued.

Discussion

PCOS is a common endocrinopathy. It is characterized by menstrual irregularity due to ovulatory dysfunction, androgen excess and the possible presence of polycystic ovaries. This leads to a variable clinical presentation ranging from secondary amenorrhea to hyperandrogenic features. In a portion of these hyperandrogenic women, some have mildly elevated prolactin levels like in our patient. The significance of hyperprolactinemia is uncertain at present, but may then pose as a red herring in the workup and diagnosis of secondary amenorrhea. This case has proven to be an excellent example to cautiously consider all causes of secondary amenorrhea, with close follow-up of the patient for clinical resolution of amenorrhea and the route to seek alternative diagnosis when her menses failed to return with normalization of the prolactin levels. Apart from that, managing this young patient has also allowed us to put into practice the various principles of managing PCOS and endocrine complications associated.

 

Nothing to Disclose: PSY, CJS

12181 30.0000 SAT-0065 A Polycystic Ovarian Syndrome As a Cause of Secondary Amenorrhea in a Young Woman: Do Not be Befuddled By the Associated Hyperprolactinemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Natalya Volkova*1, Maria Antonenko2, Ilia Davidenko3, Igor Reshetnikov4, Irina Dzherieva5 and Tatiana Dimitriadi6
1Rostov state medical university, Rostov on Don, 2Rostov State Medical University, Rostov-on-don, Russia, 3Rostov State Medical University, Rostov-on-Don, Russia, 4Rostov State Medical University, Rostov-on-Don, Russia, 5Rostov State Medical University, Rostov on Don, Russia, 6Regional Diagnostic Centre, Rostov on Don, Russia

 

Background: Hyperandrogenism (HA) is colorful syndrome which includes non specific reproductive, metabolic, and dermatologic symptoms. Nowadays there is no any definitive test or sign that could establish the diagnosis of HA. 

Clinical case: Young woman 22 y.o. admitted at the endocrinology department with the suggested diagnosis of hyperandrogenism. Her complaints were inability to lose weight, hair loss, unwanted face and body hair, severe acne, and menstrual irregularities during last 2 years. She was overweight since adolescence but considerable weight gain in last 2 years (more than 20kg). Menarche started at age 13, regular menses with molimina since age 15. She was sexual active since age 18 and did not take any contraceptive pills. She married 4 years ago, but didn’t live with husband for last 2 years. Her past medical history was not notable for any chronical diseases. Previous results of laboratory investigations included PRL 100 iu/l (30-450), LH 2,3 u/l (2-12), FSH 3,2 u/l 2-12), TSH 1,25 u/l (0,4-4), total testosterone 3,0 (0,5-3,0). Physical examination revealed obesity (BMI 33,9kg/m2), pink abdominal striae, hirsute score 2 (Ferriman-Gallwey) and no androgenic alopecia. Thus, such complaints as hair loss and unwanted body hair were not proved. Her face was covered with severe pustule acne. In order to exclude Cushing Syndrome as a cause of patient’s complaints there was performed 1 mg dexamethasone suppression test (plasma cortisol was less than 50nmol/l). Repeated total testosterone result was in reference range. Nevertheless complaints and objective appearance, patient was very happy and funny, which was not ordinary in such circumstances. As a part of examination she was screened for depression with CES-D scale, which is short self-report scale designed to measure depressive symptomatology in the general population. Her score was 37, which was consistent with severe depression. She was consulted by psychiatrist. There were diagnosed endogenous reccurent latent depression, prolonged phase, and prescribed antidepressants. Independently of psychiatrist, she was also consulted by dermatologist. There was diagnosed acne rosacea as a consequence of psychogenic scratching. Accordingly, such complaints as weight gain, acne, menstrual irregularities were consequences of depression, but not HA.  After 3 months on treatment with antidepressants, she lost 10kg, her menses became regular, and there were no any acne, which was proved the correctness of established final diagnosis.    

Conclusion: in a case of HA, every complaint should be objectified by careful physical examination and correlated with psychogenic status. Since there are objective difficulties concerning laboratory assays for testosterone measurement and its reference intervals as well as diagnostic criteria for PCOS as a predominant cause of HA , the clinical judgement is crucial.

 

Nothing to Disclose: NV, MA, ID, IR, ID, TD

16787 31.0000 SAT-0066 A Clinical Symptoms of Hyperandrogenism As a Sign of Depression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0036-0066 4860 1:00:00 PM Female Reproductive Endocrinology III Poster

Ahmed M Soliman*1, Mahesh J Fuldeore1, Hongbo Yang2, Ella Xiaoyan Du2, Eric Q. Wu2 and Craig A Winkel3
1AbbVie, North Chicago, IL, 2Analysis Group, Inc., Boston, MA, 3Department of Obstetrics and Gynecology

 

Background: Endometriosis imposes a high economic burden to patients and society, but may remain undiagnosed for many years. Limited data exist on the healthcare utilization patterns and medical and pharmacy costs among endometriosis patients prior to being diagnosed.

Objectives: This study compared healthcare costs before and after endometriosis diagnosis with average healthcare costs in women without endometriosis.

Material/Methods: Using the Truven Health MarketScan® Databases, patients aged 18-45 years with an endometriosis diagnosis (International Classification of Diseases code 617.xx) were matched 1:1 to women without endometriosis (controls) by age, region, and insurance type. The first recorded endometriosis diagnosis date was assigned as the index date for each patient and for the matching control; 1 year of continuous eligibility was required pre- and post-index.  Individuals’ ages and comorbidities during the pre-index year were summarized.  Yearly healthcare costs (in 2010 US dollars) during the 5 years pre- and post-index were compared between patients and controls using Wilcoxon signed-rank tests.

Results: Among 37,570 matched pairs selected, mean age at index date was 36.4 years. Common comorbidities among patients included upper respiratory infections (34%), ovarian cysts (23%), and uterine fibroids (16%). Inpatient, outpatient, and emergency room visits were more prevalent among endometriosis patients than controls in the pre-index year (8.6%, 98.0%, and 26.4% vs. 8.2%, 86.7% and 15.2% respectively, all p<0.05) and in the post-index year (39.7%, 98.2%, and 25.7% vs. 7.7%, 87.0%, and 15.0% respectively, all p<0.05). In the pre-index year, mean medical and pharmacy costs were $5,167 and $874 for patients versus $2,828 and $579 for controls, respectively.  In the first year after index date, the corresponding costs were $12,005 and $1,194 for patients versus $3,115 and $632 for controls, respectively.  In each of the following 4 years, cost differences between patients and controls were $2,394, $1,943, $2,242, and $1,493 for medical costs and $412, $385, $464, and $491 for pharmacy costs.  All yearly costs were significantly higher for Endometriosis patients during the 5 years pre- and post-index (p<0.05).

Conclusions: Patients with endometriosis incurred significantly higher healthcare costs than those without endometriosis, both before and after disease diagnosis.

 

Disclosure: AMS: Employee, Abbott Laboratories, Employee, Abbott Laboratories. MJF: Employee, Abbott Laboratories, Employee, Abbott Laboratories. HY: Consultant, Abbott Laboratories. EXD: Consultant, Abbott Laboratories. EQW: Consultant, Abbott Laboratories. CAW: Consultant, Abbott Laboratories.

14036 1.0000 SAT-0089 A Significant Economic Burden Among Endometriosis Patients before and after Diagnosis: A Retrospective Claims Database Analysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

Ahmed M Soliman*1, Katherine L Gooch1 and Craig A Winkel2
1AbbVie, North Chicago, IL, 2Department of Obstetrics and Gynecology

 

Objective

Endometriosis is a chronic disease that affects women in their child-bearing age with varying symptoms involving pelvic pain during menstruation, between menses and pain during sex. The goal of this study was to assess the quality of life in women reporting endometriosis diagnosis and its association with symptoms presentation.

 

Study Design

A cross-sectional online survey of women within the United States was conducted between August and September 2012.  Data collected from the surveyed women included demographics, symptoms presentation and quality of life data (SF-12). The SF-12 health survey instrument was used to measure quality of life among respondents. Women reporting Endometriosis diagnosis who experienced one or more of the following endometriosis-related symptoms (pelvic pain during menstruation, between menses and pain during sex) in the 4 weeks prior to survey administration were classified as endometriosis patients with current symptoms

Descriptive statistics were used to report means. Group comparisons were undertaken using ANOVA.

Results

Among all respondents aged 18-49 years, 2,054 women reported having being diagnosed with endometriosis either empirically or surgically. At the time of survey administration, the average age for endometriosis-diagnosed women was 36.5 years.  SF-12 scores showed that women diagnosed with endometriosis had lower quality of life estimates compared to population norm based average across all the 8 domains of SF-12. The average physical component score (PCS) and metal component scores (MCS) in endometriosis diagnosed women was 48.71 and 42.21 respectively. Women with endometriosis who had ever had endometriosis-related symptoms also had a lower quality of life compared to women diagnosed incidentally with endometriosis who never had symptoms (PCS:  48.53 vs. 50.53, MCS: 41.87 vs. 45.79, p-value for both <0.01). Among endometriosis-diagnosed women who had ever experienced endometriosis-related symptoms, women with current symptoms had lower quality of life as compared to endometriosis-diagnosed women who were not currently experiencing symptoms (PCS: 48.05 vs. 50.59, MCS: 40.87 vs. 46.08, p-value for both <0.01). Women reporting current symptoms who recorded one or more endometriosis-related symptoms as severe had significantly lower quality of life compared to women who did not record any symptom as severe (PCS: 44.30 vs. 50.1, MCS: 37.35 vs. 42.8, p <0.001).

Conclusion

Endometriosis is a chronic gynecological disorder that is associated with significant quality of life burden. Results from this cross sectional study of US women with endometriosis showed that physical and mental health related quality of life is significantly impacted by the proximity and severity of endometriosis related symptoms. 

 

Disclosure: AMS: Employee, Abbott Laboratories, Employee, Abbott Laboratories. KLG: Employee, Abbott Laboratories, Employee, Abbott Laboratories. CAW: Consultant, Abbott Laboratories.

14152 2.0000 SAT-0090 A Quality of Life (QOL) in Endometriosis Patients and Its Correlation with Symptomatic Burden: A Cross Sectional Survey Among US Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

Miyuki Harada*1, Nagisa Oi1, Tetsuya Hirata1, Kaori Koga2, Tomoyuki Fujii2 and Yutaka Osuga2
1University of Tokyo, Tokyo, Japan, 2The University of Tokyo, Tokyo, Japan

 

<Objectives> The excision of ovarian endometrioma (EMoma) has been reported to impair the ovarian function.  But existing studies only examined the quantitative effects, that is, the ovary underwent excision of EMoma yields less number of ooytes compared to healthy ovary. The objectives of the present study is to elucidate whether laparoscopic excision of EMoma impairs the quality of oocytes from affected ovaries.

<Methods> Cases were collected from patients who underwent IVF from May 2010 to April 2013 in our university hospital.  Inclusion criteria were as follows: a) history of laparoscopic excision of unilateral EMoma over 3cm in diameter, b) no other history of intervention for ovaries than laparoscopic surgery mentioned in section a), c) absence of EMoma in both ovaries when controlled ovarian stimulation for IVF was conducted. In 25 cycles of 21 patients fulfilled the inclusion criteria, oocytes recovered from ovaries with a history of excision of EMoma (P-Ov) were compared to those from contralateral healthy ovaries (H-Ov).  

<Results> Mean age of patients was 37.0 (+/- 0.7, SEM) and mean number of oocytes recovered was 7.3 (+/- 1.0).  Mean diameter of EMoma excised was 5.0 (+/- 0.3) cm.  Mean number of oocytes recovered from P-Ov was 2.2 (+/- 0.4), which was significantly smaller than that from H-Ov (5.1 +/- 0.7) (p = 0.009, Mann Whitney U test).  No oocytes were recovered from P-Ov in 5 cycles, which was more frequent than 1 cycle in H-Ov.  There is no difference between oocytes from P- and H-Ov as for both normal fertilization (2PN) rate per cycle (63.6% vs. 69.5%, p=0.49, Fisher’s exact test) and the rate of top-quality embryos per 2PN embryos (40.0% vs. 49.0%, p=0.43).  10 embryos from P-Ov (10 single embryo transfer (SET)) and 26 embryos from H-Ov (24 SET and 1 sequential transfer on day 3 and 5) have been transferred so far.  There is no difference between embryos from P- and H-Ov as for both hCG positive rate (40.0% vs. 48.0%, p=0.72) and clinical pregnancy rate (40.0% vs. 28.0%, p=0.69).  

<Conclusions> The present study shows that although the number of oocytes recovered from ovaries with a history of laparoscopic excision of EMoma were less than healthy ovaries, the quality of oocytes was same in affected and healthy ovaries.

 

Nothing to Disclose: MH, NO, TH, KK, TF, YO

12076 3.0000 SAT-0091 A Laparoscopic Excision of Ovarian Endometrioma May Exert Quantitative but Not Qualitative Effects on Affected Ovaries in IVF Settings 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

Ahmed M Soliman*1, Katherine L Gooch1 and Craig A Winkel2
1AbbVie, North Chicago, IL, 2Department of Obstetrics and Gynecology

 

Objective

Symptomatic UF patients present with several gynecological bleeding and pain symptoms, however the estimated prevalence varies by data source. The purpose of this research was to estimate the prevalence of UF among US pre-menopausal women and evaluate the symptoms profile of women reporting UF diagnosis.

Study Design

A cross-sectional online self-reported survey of pre-menopausal US women between 18 and 54 years old was conducted between August and September 2012 using Harris Poll Online (HPOL) respondent panel as a sampling frame.

 Materials and Methods

Data collected from women who completed the survey included demographics, age at diagnosis, history of symptoms experienced and recent symptom experience and severity. Descriptive statistics were used to report means and proportions. National estimates were derived using sampling weights computed for each individual based on age group.

Results

 

Among completed surveys (n=59,411), 6.38% (95% CI: 6.06-6.7%) of women aged 18 – 49 years reported being previously diagnosed by a physician with UF.  This prevalence extrapolated to US national statistics estimates 4,287,640 women with UF. UF was significantly more prevalent in women aged 45 to 49 (14.36%). Women diagnosed with UF were significantly older than general population (41.3 vs. 33.5 years, p <0.001). The average age at diagnosis was 34.6 years. Diagnosed women reported multiple gynecologic UF-related symptoms including heavy menstrual bleeding (41.3%, among which 41.2% had severe symptoms), bleeding/spotting between periods (21.6% among which 10.3% had severe symptoms), passage of clots (31.48% among which 22.83% had severe symptoms), pelvic pressure (17.51% among which 13.36% had severe symptoms) and constipation/bloating/diarrhea (52.95%, among which 15.37% had severe symptoms). Moreover, heavy menstrual bleeding, bleeding/spotting between periods, passage of clots, pelvic pressure and constipation/bloating/diarrhea were rated as extremely bothersome by 59.4%, 29.9%, 33.7%, 23.9, and 25.9% of patients, respectively. 

Conclusion

UF poses a significant clinical burden on pre-menopausal women in the US. Symptomatic UF patients experience a multitude of bleeding and non-bleeding symptoms. A significant proportion of the women rated their uterine fibroids associated symptoms as severe.

 

Disclosure: AMS: Employee, Abbott Laboratories, Employee, Abbott Laboratories. KLG: Employee, Abbott Laboratories, Employee, Abbott Laboratories. CAW: Consultant, Abbott Laboratories.

14308 4.0000 SAT-0092 A Uterine Fibroids (UF) in US Women: A Cross Sectional Evaluation of Prevalence, Symptoms Burden and Severity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

Hiroyuki Ishiguro*1, Hiromi Hyodo2, Yuichiro Tomita3 and Shunichi Kato2
1Tokai Univ Sch of Med, Kanagawa, Japan, 2Tokai University School of Medicine, Kanagawa, Japan, 3Tokai Univ Hachioji Hosp, Hachioji-shi, Tokyo, Japan

 

[Introduction]  Gonadal dysfunction and impaired fertility have been identified as potential late effects of therapy in childhood cancer survivors treated with stem cell transplantation (STC).  Previous irradiation of the uterus carries an increased risk of an adverse pregnancy outcome.  However, changes in uterus size after SCT in childhood cancer survivors are not fully elucidated.  [Aims]  Our objective was to evaluate the relationship between irradiation and changes in uterus size in childhood cancer survivors.  [Methods]  We reviewed the clinical records of 31 female patients who received allogeneic SCT at Tokai University Hospital.  The median age of the 31 patients at SCT was 8.1 years, the median age at the last evaluation was 23.0 years, and the median follow-up duration after SCT was 13.0 years.  The study population was categorized into 3 groups according to presence of menarche before or after SCT, and amenorrhea after SCT: group B, menarche before SCT (n=7); group A, menarche after SCT (n=18), and group N, amenorrhea after SCT (n=6).  Uterine length by transabdominal ultrasound and LH, FSH, and E2 were longitudinally assessed after SCT.  [Results]  Among the 31 female patients, pregnancy or delivery was confirmed in six patients during the follow-up period.  Uterine length was reduced in group B (median 61.0 mm, -1.2 SD), group A (53.0 mm, -1.6 SD), and group N (51.0 mm, -1.6 SD) compared with their height, although no significant difference among groups was observed.  No significant improvement in uterine length was observed in female patient treated with estrogen/progesterone replacement therapy.  [Conclusion]  Uterine irradiation at a young age reduces adult uterine length and the radiotherapy-induced damage is probably irreversible.

 

Nothing to Disclose: HI, HH, YT, SK

11414 5.0000 SAT-0093 A Changes in Uterus Size after Stem Cell Transplantation in Childhood Cancer Survivors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

Sule Temizkan*1, Osman Temizkan2, Kadriye Aydin3, Suna Kucur2 and Osman Asicioglu2
1Kartal Training and Research Hospital, Istanbul, Turkey, 2Div of Obstetrics and Gynecology, Sisli Etfal Training and Research Hospital, Istanbul, Turkey, 3Div of Endocrinology, Kartal Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey

 

Objective: PRL may have stimulatory  effects on vascular resistance, on the experimental models and  clinical conditions.  We aimed to analyze uterine, endometrial and intraovarian blood flow by doppler ultrasonography in hyperprolactinemic patients before and after treatment with cabergoline.

Design: Case control study

Setting: Department of Obstetrics and Gynecology, Sisli Etfal Training Hospital, Istanbul,Turkey.

Patients: Twenty four women with symptomatic hyperprolactinemia  in reproduction age were included to the study. The control  group consisted of 10 healthy women.

Intervention: All hyperprolactinemic patients were studied prior to and following the suppression of circulating prolactin levels by cabergoline.

Main Outcome Measure(s): The patient and control group were examined  by standard B-mod  and color transvaginal ultrasonography. Pulsality index (PI), resistance index (RI) and systolic/diastolic ratio (S/D) were recorded.

Results: The mean prolactin value was 115.8 ± 104.5 ng/ml before treatment and 4.4 ± 2.3 ng/ml after the treatment (p<0.01). The mean prolactin level of control group was 11.5 ± 3.7. There was no correlation between PRL and PI in uterine (r = -0.023, p = 0. 89), spiral (r = 0.113, p = 0.525) and intraovarian arteries (r = 0.321, p = 0.065).  PI  was statistically significant lower after treatment with cabergoline in uterine, spiral and intraovarian arteries  (p=0.021,  p<0.01, p<0.01 respectively) but there was no statistically difference in PI and RI in these arteries between before treatment and control group.

Conclusion: Hyperprolactinemia does not increase endometrial, uterin and intraovarian artery resistance. Cabergoline treatment decreases the uterine, endometrial and intraovarian vascular resistance. This effect of cabergoline on endometrial, uterin and intraovarian arteries seems to be distinct from lowering the blood PRL levels to normal ranges.

 

Nothing to Disclose: ST, OT, KA, SK, OA

13689 6.0000 SAT-0094 A Color Doppler Analysis of Uterine, Endometrial and Intraovarian Blood Flow before and after Treatment with Cabergoline in Hyperprolactinemic Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

Waclaw Jez1, Tomasz Jerzy Irzyniec*2 and Agnieszka Frelich1
1The Specialized Hospital No 2, Bytom, Poland, 2Medical University of Silesia, Katowice, Poland

 

Introduction: Mosaicism 45,X/46,XY is a very rare abnormality in women with Turner syndrome (TS), and occurs in 60 000 live-born females. The aim of study is the analysis the hypophysis – gonadal axis (HGA) and some clinical and psychosocial parameters  of eight TS-women (age 22,4 ± 4 y.) with karyotype 45,X/46,XY (TSY) and compare them to 101 TS women (age 25,4 ± 7 y.) with karyotype 45,X (TSX).

Methods: The HGA was examined by estimation of gonadotropins (FSH, LH) and 17 β-estradiol (E2) levels. The information about personal and psychosocial parameters were assessed at the direct interviews, which was conducted by the same group of investigators in Poland in the years 1995-2011.

Results: Although women both groups did not significantly differ in E2levels -71,2 ± 40 vs. 142,4 ± 301 pmol/l, we observed significantly higher levels of FSH 56,8 ± 35 vs. 36,2 ± 23 IU/l p=0.02 and not significant LH 34,2 ± 26 vs. 23,4 ± 17  IU/l p=0,09. The dimensions (AP) of the uteri in TSY women was smaller than in TSX  (14,4 ± 6  vs. 19,8 ± 7 mm p=0,048). The occurance of the genital tract surgery was more frequent in TSY than in TSX group (87,5 vs 4% p<0,001). TSY women differed with TSX in some factors of medical, personal and intrapsychical resources. They felt isolated more often (63 vs 28% p=0,04), had a stronger sense of their illness (50 vs 19% p=0,044)  and tended to contact other people less frequently (43 vs. 84% p=0,017). 

Conclusions: 1.  There is only a slight difference between women with Turner Syndrome and karyotype  45,X/46,XY and those with 45,X  it refers to the psychosocial sphere of their life. 2. Significantly higher concentrations of gonadotropins in the TS women with mosaicism 45,X/46,XY suggests that their demand on hormonal replacement therapy is higher. 3. Medical aspects may remain in connection with the psychosocial functioning of women with 45,X/46,XY Turner Syndrom.

 

Nothing to Disclose: WJ, TJI, AF

14800 7.0000 SAT-0095 A Selected Clinical and Psychosocial Aspects of Women with 45,X/45,XY Turner Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

Monica M Laronda*1, Adam E Jakus2, Kelly A Whelan1, Ramille N Shah1 and Teresa K Woodruff1
1Feinberg School of Medicine, Northwestern University, Chicago, IL, 2Northwestern University, Evanston, IL

 

Certain cancer therapies can lead to impairment of fertility and endocrine function. Hormones produced by the ovary are important for reproduction, and maintain women’s overall health by protecting against brain, cardiovascular, and bone diseases. The field of oncofertility has sought to provide options for preserving and restoring fertility in patients at risk for iatrogenic ovarian failure, including freezing eggs and ovarian tissue for later use. Autotransplantation of cryopreserved ovarian cortical tissue has resulted in 17 reported live births, with short-term restoration of endocrine function, but also carries the risk of reintroducing cancer cells. After IRB approved consent, our lab obtained 20% of patient tissue for research, while 80% of the tissue was cryopreserved for patient use. Ovarian cortical tissues from 4 participants with acute lymphoblastic leukemia were selected for this study. These tissues stained positive for SALL4, confirming that they contained metastatic cancer cells within their ovaries and making them ineligible for current transplant techniques. We are investigating materials that will support long-term growth of ovarian cells, to reduce the risk of transferring diseased cells through ovarian tissue transplantation. We developed a technique by which all cells can be removed from ovary tissue pieces, leaving a decellularized scaffold of extracellular matrix on which patient ovarian cells can be seeded for transplantation. Because human ovarian tissue is rare, we used bovine ovaries as a proxy to develop the decellularization/recellularization procedures. We discovered, through high resolution SEM, the cortex is comprised of tightly organized collagen fibers, while the medulla contains additional flexible components such as laminin and elastin. Primary mouse granulosa and theca cells seeded onto the bovine medulla scaffold responded to FSH in vitro by producing estradiol. We tested the ability of seeded bovine ovarian scaffolds to function in vivo and produce hormones, by grafting these composites under the renal capsule of ovariectomized pre-pubertal mice. Mice with grafts produced estradiol at levels equivalent to controls. These data support further development of an artificial organ to provide an environment that sustains quiescent and growing ovarian follicles, restores endocrine function, and reduces the risk of re-introducing cancer cells to young women who survived treatment and wish endocrine or fertility restoration.

 

Nothing to Disclose: MML, AEJ, KAW, RNS, TKW

15055 8.0000 SAT-0096 A Engineered Endocrine Organ Transplant Utilizing a Decellularized Ovary Scaffold 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

Mana Hirano*1, Osamu Hiraike1, Akira Shirane1, Ayako Sakurabashi1, Houju Fu1, Tomohiko Fukuda1, Wataru Isono1, Noriko Yano1, Michihiro Tanikawa1, Hajime Oishi2, Tetsu Yano2, Kaori Koga1, Katsutoshi Oda1, Kei Kawana1, Yutaka Osuga1 and Tomoyuki Fujii1
1The University of Tokyo, Tokyo, Japan, 2National Center for Global Health and Medicine, Tokyo, Japan

 

Context: Transcription factor Forkhead box L2 (FOXL2) plays an essential role on ovarian follicular development because mutations in FOXL2 is related with an autosomal dominant genetic disorder, blepharophimosis-ptosis-epicanthus inversus syndrome (BPES), and the patients with BPES displays familial premature ovarian insufficiency (POI)1. It has been shown that FOXL2 could interact with estrogen receptor (ER) α and β at the protein level2 and FOXL2 selectively suppresses ERα-mediated transcription of AP1-regulated genes3. However, it remains to be solved the molecular mechanism of the interaction between FOXL2 and ERβ.

Objective: The present study aimed to investigate the physiological function of FOXL2 on ovarian follicular development, and we studied the effect of FOXL2 on canonical estrogen response elements.

Design: We examined the expression of FOXL2 at various stages of follicular development using human ovary specimens. Human ovarian tissues from 15 reproductive aged patients with regular menstrual cycles who were taking no hormonal drugs and underwent hysterectomy for carcinoma of the uterine cervix or endometrium were subjected to immunohistochmestry. Human luteinized granulosa cells (LGCs) were obtained from infertile patients undergoing transvaginal oocyte retrieval for in vitro fertilization.This study was approved by the institutional review board and written informed consent was obtained in each patients. To confirm the physical interaction between FOXL2 and ERβ, we used immunoprecipitation and in vitro pull down assays. Transcriptional function of FOXL2 was assayed using dual luciferase assay system. To reveal the role of FOXL2 in folliculogenesis and luteinization, mRNA levels of related genes were analyzed by quantitative RT-PCR.

Result: Firstly, we found that expression level of FOXL2 tended to be higher at primary and secondary follicles compared to that at corpora lutea. Immunoprecipitation assays using KGN and COV434 cells and in vitro pull down assays using bacterially expressed GST ERβ AF-1 and GST ERβ AF-2 fusion proteins revealed a direct interaction between FOXL2 and AF-1/2 domain of ERβ regardless of the presence of E2 (17β-Estradiol). The luciferase activity of canonical estrogen response elements by ERβ showed that expression of FOXL2 led to a significant decrease in ligand-dependent transcriptional activation function of ERβ. We evaluated the effect of FOXL2 on the endogenous gene expression, and the siRNA-mediated knockdown of endogenous FOXL2 resulted in an increase of aromatase mRNA, a known E2 target gene4 in LGCs

Conclusion: These data indicated a significant role of FOXL2 in the repression function of ERβ. Considering the fact that the lack of ERβ reduces the number of corpora lutea5, we might speculate that FOXL2 and ERβ interact in human ovary and play pivotal roles on normal follicular development by affecting aromatase expression.

 

Nothing to Disclose: MH, OH, AS, AS, HF, TF, WI, NY, MT, HO, TY, KK, KO, KK, YO, TF

11292 9.0000 SAT-0097 A A Familial Premature Ovarian Insufficiency Gene Product FOXL2 Represses Transcriptional Activation Function of Estrogen Receptor β 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

Manuel Maliqueo*1, Inger Sundström Poromaa2, Eszter Vanky3, Helena Åkerud2, Solhild Stridsklev3, Fernand Labrie4, Thomas Jansson5 and Elisabet Stener-Victorin6
1Institute of Neuroscience and Physiology, Göteborg, Sweden, 2Uppsala University, Uppsala, Sweden, 3Norwegian University of Science and Technology, Trondheim, Norway, 4Endoceutics, Quebec, QC, Canada, 5University of Texas Health Science Center, San Antonio, 6University og Gothenburg, Goteborg, Sweden

 

Women with polycystic ovary syndrome (PCOS) have elevated androgen levels and administration of testosterone propionate (TP) to pregnant rats reduces placental and fetal weight. The mechanistic target of rapamycin (mTOR) and signal transducer and activator of transcription 3 (STAT-3) signaling pathways are involved in regulating placental nutrient transport, metabolism, protein synthesis and growth. In a translational approach, we tested the hypothesis that high maternal androgens dysregulate placental mTOR and STAT-3 signaling.

Experiment 1: Placenta and blood samples were collected at delivery from 38 women with PCOS and 40 controls. E1, E2, DHEA, T, DHT, Δ4-dion, Δ5-diol, ADT-G, Etio-G and 3alpha-DIOL-G were measured by GC-MS/MS and LC-MS/MS. The phosphorylation and total protein expression of mTOR effectors (eukaryotic initiation factor 4E binding protein 1 (4E-BP1) and S6 ribosomal protein (S6RP)) and STAT-3 were measured by western blot in placenta from 25 women with PCOS and 25 controls matched by age and BMI.

Experiment 2: Pregnant rats were injected (sc) daily with 0.5 mg/ Kg BW of TP (TP; n=6) or sesame oil (control; n=9) from GD15 until GD19. To explore the role of androgen and estrogen receptors in the placental response to TP two group of rats were injected with TP plus flutamide (7 mg/Kg BW; n=9) or TP plus tamoxifen (10 μg/Kg BW; n=9). Placentas and blood samples were collected on GD21 to determine protein expression and sex steroid concentrations.

Results: All androgens and glucuronidated metabolites, except DHEA and 3alpha-DIOL-G, were higher and E2 was lower in women with PCOS compared with control. An increased STAT-3 phosphorylation was observed in placentas from PCOS women (P=0.047). mTOR effectors were similar between groups. In pregnant rats, total T was higher in TP compared to controls (P=0.023). No differences were observed in circulating estrogens. On the other hand, TP reduced phosphorylation of S6RP (P=0.045) and increased total STAT-3 (P=0.02). Flutamide or tamoxifen did not modify the effect of TP.

Conclusion: Steroidogenesis is dysregulated in pregnant women with PCOS with increased circulating androgens and reduced estradiol levels. Moreover, the placental STAT-3 pathway is activated in conditions associated with elevated androgens levels and may play an important role in the pregnancy outcome in women with PCOS. The effect of androgens on the STAT-3 pathway appear not to be mediated by androgen or estrogen nuclear receptors.

 

Nothing to Disclose: MM, IS, EV, HÅ, SS, FL, TJ, ES

16954 10.0000 SAT-0098 A Altered STAT-3 Signaling in the Placenta from Women with Polycystic Ovary Syndrome – Role of Androgens and Estrogens? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

Martha I. González-Dóminguez*1, Maria-Luisa Lazo-de-la-Vega-Monroy1, Silvio Zaina1, Mirna Sabanero2, Leonel Daza Benitez3, Juan M Malacara4 and Gloria Barbosa Sabanero1
1University of Guanajuato, Campus Leon, Leon, Guanajuato, Mexico, 2University of Guanajuato, Campus Guanajuato, Guanajuato, Guanajuato, Mexico, 3UMAE No. 48 IMSS, Leon, Guanajuato, Mexico, 4Univ de Guanajuato, Leon Gto, Mexico

 

INTRODUCTION: Intrauterine growth is a biological process regulated by maternal, placental and fetal endocrine signals. The placenta plays an important role controlling the growth and development of the fetus through the transfer of nutrients and the endocrine system. Birth weight is an indicator of the health of the newborn. It is known that birth weight different to normal weight confers an increased risk for metabolic diseases like diabetes, obesity and hypertension. Leptin, the product of ob gene, has been proposed as an important key player in fetal growth. The concentrations of this hormone in cord blood (CB) are positively correlated with birth weight and placental weight. Leptin acts mainly through the long isoform of ob-Rb receptor. However it is not known whether expression of ob-Rb receptor in the placenta is associated with birth weight.

OBJECTIVE: To evaluate the expression of ob-Rb and its correlation with birth weight in placentas of newborns small (SGA), appropriate (AGA) and large (LGA) for gestational age.

METHODS: We examined healthy women in late pregnancy and their newborns at term SGA, AGA and LGA (n = 20 per group). Leptin levels in CB were determined by ELISA and placental ob-Rb level was evaluated by Western blot, using anti-ob-Rb as primary antibody (1:1000) and anti-rabbit IgG-HRP as secondary antibody (1:10000). Densitometric analysis was normalized measuring tubulin expression.

RESULTS: A positive correlation between birth weight and placental weight (p˂0.0001) was found among the three groups (SGA, AGA and LGA). Leptin levels were increased in serum of LGA (p ˂ 0.001) and decreased in SGA newborns (p = 0.019) compared to AGA newborns. Placental ob-Rb expression showed significant differences, finding a decreased expression in SGA (30%, p=0.009) and LGA (30%, p=0.009) compared to AGA and a positive correlation between birth weight and the expression of the ob-Rb receptor (r=0.525, p=0.0004) was found between SGA and AGA.

CONCLUSIONS: The ob-Rb receptor is involved in leptin signaling and its low expression in LGA and SGA placentas suggests that altered leptin signaling could be one of the placental mechanisms negatively impacting on health in adult life.

 

Nothing to Disclose: MIG, MLL, SZ, MS, LD, JMM, GB

15283 11.0000 SAT-0099 A Leptin Receptor in Placentas of SGA, LGA and AGA Newborns 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

Ramon Bossardi Ramos*1 and Poli Mara Spritzer2
1Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil, 2Univ Fed do Rio Grande do Sul, Porto Alegre RS, Brazil

 

Obesity is one of the largest global health problems and is associated with increased morbidity and mortality. Individual susceptibility to obesity is influenced by genetic and environmental factors and the Fat Mass and Obesity associated gene (FTO) is one of the candidate genes for obesity. A single-nucleotide polymorphism (SNP) in intron 1 of FTO gene, rs9939609 T/A has been linked to increased risk of obesity, metabolic syndrome, and high cardiovascular risk in men and women. The aim of this cross-sectional study was to investigate the association of an FTO variant with obesity traits in women from Southern Brazil. Two hundred forty-six participants, 98 of them at reproductive age and 148 postmenopausal women were evaluated and genotyped by real-time PCR for the SNP rs9939609 of the FTO gene. The genotypic distribution was TT: 39.1%, TA: 45.7%, AA: 15.2%. Participants had a mean age of 41.3 (SD 14.4) years, and mean BMI of 26.9 (SD 4.6) kg/m2. The sample presented normal blood pressure and lipid profile. The age of participants did not differ significantly between AA and TT/TA genotypes (39.8 ±14.9 vs. 41.0 ± 14.0 years; p=0.65). A significant association was found for the AA genotype with BMI both in crude (28.4 ± 5.4 vs. 26.6 ± 4.6, p=0.04) as well as in age-adjusted analyses (p=0.04). Furthermore, women carrying the AA genotype had significantly higher waist circumference than women carrying the TT/TA genotypes in crude (86.6 ± 11.6 vs. 82.5 ± 10.4, p=0.04) as well as in age-adjusted analyses (p=0.01). In a binary logistic regression analysis, women carrying the AA genotype presented an OR 2.70 (1.17 – 6.20) for waist circumference greater than 88 cm, (p=0.01) or OR 2.42 (1.01 - 5.7) when adjusted for age. No interaction was observed between the FTO polymorphism and obesity traits across the life course. In conclusion, we found an association between the FTO SNP rs9939609 and higher obesity risk in women from Southern Brazil. Our data suggest this association may not change throughout adult life.

 

Nothing to Disclose: RBR, PMS

12981 12.0000 SAT-0100 A Genotype/Phenotype Association Between the Fto Gene Variant rs9939609 T/a and Obesity Traits in Women from Southern Brazil: A Cross-Sectional Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

V Daniel Castracane*1, Urvi Shah1, Adriana Flores-Villacrez1 and Christopher G Maguire2
1TX Tech Univ Hlth Sci Ctr, Odessa, TX, 2TX Tech University Health Sciences Center of the Permian Basin, Odessa, TX

 

Introduction: Irisin, a recently identified myokine, demonstrates a role in the production of brown adipose tissue and an effect on metabolism, and may make a contribution to weight regulation.  The production of irisin in muscle is activated by exercise, but some recent reports suggest that irisin production may also occur in adipose tissue.  In the present study, we have examined irisin levels in a longitudinal study in lean and obese pregnant women and, in a second study, have conducted a cross sectional study in normal weight, overweight, obese and in morbidly obese (MO) late pregnant women.   Methods: Lean (n= 8) and obese (n= 8) pregnant women in a longitudinal protocol provided blood samples from first trimester until term and irisin was assayed  by ELISA at 8, 24, and 36 weeks.    In a separate study we compared  late gestation samples in normal (n=8), overweight (n=9), obese (n=28) and MO (n=12) pregnant women for any changes in irisin levels.  Irisin was assayed with an ELISA (Phoenix Pharmaceuticals/Aviscere Bioscience).   Results: Serum irisin levels did not change from first through third trimester in either lean or obese pregnant women and there were no relationships between irisin values and BMI.  Comparison of lean, overweight, obese and MO pregnant women in the late third trimester are not different, despite increases in BMI with each successive group.  Conclusions:  Serum irisin levels  are unchanged during the course of pregnancy in lean or obese pregnant women and values are unrelated to BMI.   These same results were confirmed in a cross sectional study, which also included MO subjects.  There was no indication of a role for irisin during pregnancy and no association with adiposity.  Whether exercise would stimulate irisin during pregnancy and have a beneficial effect on gestational weight gain has not been studied.

 

Nothing to Disclose: VDC, US, AF, CGM

14841 13.0000 SAT-0101 A Longitudinal and Cross Sectional Comparison of Serum Irisin Levels in Lean and Obese Pregnant Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

V Daniel Castracane*1, Adriana Flores-Villacrez1, William Meachum1 and Christopher G Maguire2
1TX Tech Univ Hlth Sci Ctr, Odessa, TX, 2TX Tech University Health Sciences Center of the Permian Basin, Odessa, TX

 

Introduction:  Steroid hormones can vary greatly in nonpregnant women and dramatic differences have been reported between lean and obese women.   Few studies have compared steroid hormones in lean and obese pregnant women.  Methods:  Pregnant women were enrolled at 8 weeks of gestation and provided blood samples from 8 weeks and every two through gestation.  No subjects provided less than 12 blood samples on this schedule.  Serum levels for estradiol (E2), estriol (E3), progesterone (P), testosterone (T), and cortisol (F) were determined by chemiluminescent immunoassay (Immulite; Siemens).  For most analytes, assays were done on all samples; for estriol, every fourth week samples were used. Comparisons were made between lean (n=9) and obese (n=9) subjects.  Results:  Mean serum levels of estradiol were similar starting at 8 weeks of gestation and both lean and obese increase dramatically through gestation. E2 levels are not significantly different, although a small increase in late gestation is seen in the obese subjects..  Levels of estriol are low in early pregnancy and start to rise by 20 weeks of gestation.  Obese subjects generally (but not always) have slightly higher levels than lean subjects.  Mean serum levels of P are virtually identical until late gestation, when mean levels  at 36 weeks in lean subjects (145 ng/ml) are greater than levels in obese women (106 ng/ml).   Mean serum levels of T are identical in both groups. Levels are unchanged until the third trimester when both groups increase to max levels (120-130 ng/ml).  Mean F levels are not significantly different and increase throughout gestation.  Conclusions:  Steroid levels in lean and obese pregnant women are not significantly different over the course of pregnancy.  Any expected differences, such as those seen in nonpregnant women, were not observed.

 

Nothing to Disclose: VDC, AF, WM, CGM

14903 14.0000 SAT-0102 A Longitudinal Comparison of Serum Steroid Hormone Levels in Lean and Obese Pregnant Women (Estradiol, estriol, progesterone, testosterone, cortisol) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

V Daniel Castracane*1, Savitha Singh1, Urvi Shah1, Adriana Flores-Villacrez1 and Robert Porter Kauffman2
1TX Tech Univ Hlth Sci Ctr, Odessa, TX, 2Texas Tech Univ Hlth Sci Ctr, Amarillo, TX

 

Background:  In earlier studies, we have compared maternal serum leptin levels in singleton and twin pregnancies to determine the source of leptin in the maternal circulation.  These studies indicated no difference between singleton and twin levels of leptin and that in both cases, the correlation with BMI was virtually identical, suggesting that maternal adipose tissue was the major, if not exclusive, source of leptin in the maternal circulation.

We wished to extend these studies to latter gestation to determine if the same relationship exists in late gestation  as seen at 15-20 wks GA.   We also are aware that in gestational diabetic pregnancies, leptin levels are elevated in both serum and placenta, but no physiological evidence to confirm the maternal source of leptin in these late gestation singleton or twin,  or gestational diabetic pregnancies.

Materials and Methods:  Normal pregnant women (controls) (n= 32), twins (n= 11) and gestational diabetic (n= 17) were enrolled at 34-37 wks GA and a single blood sample was obtained from each subject, centrifuged and serum was stored at -70C until assayed.  Leptin levels were determined by ELISA assays (Millipore).  Sample size is small and subject enrollment continues for this study.  Data was examined by analysis of covariance with Bonferroni correction for pairwise comparisons.

Results: Leptin levels demonstrated a linear correlation with BMI in all groups (p<0.001), but no difference was found between the three groups (p=0.10).  Pairwise comparison also yielded no significant difference among the three groups.

Conclusions:  These preliminary results at 34-37 wks GA indicate that the major source of maternal circulating leptin comes from maternal adipose tissue, as indicated by the correlation with BMI for all three pregnancies.  These results are in agreement with our earlier study at 15-20 wks GA.  Patient recruitment continues to provide a better statistical base for these studies.

 

Nothing to Disclose: VDC, SS, US, AF, RPK

15067 15.0000 SAT-0103 A Comparison of Serum Leptin Levels in Singleton, Twin and Gestational Diabetic Pregnancies: Determination of the Source of Maternal Serum Leptin in Late Gestation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

Melissa Emma Heard*1, Stepan B Melnyk1, John Mark P Pabona2, Frank A Simmen2 and Rosalia CM Simmen2
1University of Arkansas Medical Sciences, Little Rock, AR, 2University of Arkansas for Medical Sciences, Little Rock, AR

 

Endometriosis is a chronic, steroid hormone-dependent gynecological disease that is associated with pelvic pain and infertility in reproductive-age women. Its etiology is poorly understood, despite well-accepted risk factors. Paradoxically, while obesity is associated with many chronic diseases, obese women have lower risk for endometriosis, which has been attributed partly to their highly irregular menstrual cycles. We previously established a mouse model of endometriosis in which immune-competent C57BL/6J mice, when IP-injected with endometrial fragments from syngeneic mice null for the progesterone receptor co-regulator Krüppel-like Factor 9 (KLF9), developed ectopic lesions, recapitulating many of the disease features found in women. Because recipients with lesions are not immune-compromised and show serum estradiol (E) and progesterone (P) levels comparable to those of vehicle-injected controls, this model provides a system to evaluate effects of obesogenic high fat diet on endometriosis.  Post-weaning (3 week-old) female mice were provided normal (17% total kcal from fat; CD; n=7) or high fat (45% total kcal from fat; HFD; n=9) diets until study completion. Mice at age 8 weeks were IP-administered minced Klf9 KO endometrial fragments and evaluated for ectopic lesions 4 weeks later. Mice of both diet groups had comparable serum E and P levels and all developed lesions. However, HFD mice were heavier, developed more lesions (CD=1.4±0.3 vs. HFD=2.3±0.2;  P=0.01), showed lesions with lower Pgr, Pgr-B and Esr1 expression and a higher percentage of Ki67+ cells, and had elevated peritoneal fluid TNFα, than CD mice. Gene expression array and Ingenuity Pathway Analyses showed up-regulated angiogenic, inflammatory and oxidative stress and conversely, down-regulated pro-apoptotic and immune response genes in HFD than CD lesions; these were confirmed by QPCR for inflammation (Cxcl4, Il17a, Csf2, Il17b) and glutathione biosynthesis (Gsr, Gss and Gclc)-related transcripts. Sera and peritoneal fluids differed in antioxidant-oxidant balance for HFD and CD mice, with higher 3’-Nitrotyrosine levels and lower GSH/GSSG, Cysteine/Cystine and Met/Homocysteine ratios for the HFD group. Our results demonstrate that HFD creates a unique environment of systemic and localized inflammation and oxidative stress that may contribute to the pathology of endometriosis and suggest that excessive weight gain in women with normal reproductive cycles may pose a risk for this disease.

 

Nothing to Disclose: MEH, SBM, JMPP, FAS, RCS

12491 16.0000 SAT-0104 A High Fat Diet Promotes Endometriosis in a Mouse Model of Endometriosis Via Oxidative Stress and Inflammatory Signaling Pathways 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

Djana Harp*1, Adel Driss1, Samantha Jefferson2, Javaughn Baker3, Minerva Garcia-Barrio1, Neil Sidell4, Robert N Taylor5 and Winston E Thompson6
1Morehouse School of Medicine, Atlanta, GA, 2Georgia State University, Atlanta, GA, 3Emory University, Atlanta, GA, 4Emory University School of Medicine, Atlanta, GA, 5Wake Forest Schl of Med, Winston-Salem, NC, 6Morehouse Schl of Med, Atlanta, GA

 

Endometriosis is a disease involving the deposition of endometrial tissue outside of the uterine cavity into the peritoneal cavity of the abdomen or pelvis.   The pathogenesis of endometriosis is complex but the disease microenvironment involves the proliferation of new blood vessels around the lesions as a fundamental contributor to its invasion and development of inflammatory responses.

The role of exosomal microRNA (miRNA) in endometriosis is unclear.  Exosomes are extracellular vesicles stemming from the endosomal compartment of cells by fusion of multivesicular bodies with the plasma membrane.  Exosomes are 30 – 150 nm in diameter and contain unique mRNAs, miRNAs, other non-coding RNAS, and proteins.  miRNAs are a recently discovered class of non-coding RNAs that play key roles in the regulation of gene expression at the post-transcriptional level. Mature miRNAs are short, single-stranded RNA molecules approximately 22 nucleotides in length and are involved in a wide range of biological processes such as cell cycle control, apoptosis and angiogenesis.

 To determine if there is a differential profile of miRNA in exosomes in endometriosis, we used conditioned medium from stromal cells cultured from endometriosis lesions as well as from phase-matched eutopic endometrial cells from female patients with endometriosis and from healthy controls, from which exosomes were isolated by chemical precipitation. The expression of 2 pro-angiogenic miRNAs (hsa-miR-21 and hsa-miR-126) in the total RNA isolated from the exosomes was quantified by real-time PCR and normalized to the control RNA U6B.

Significantly different expression levels were found for miR-126 in endometriosis lesion cells (p=0.001, 400-900 fold higher), compared to those from eutopic endometrium of healthy controls or subjects with endometriosis. Similar profiles were found for miR-21. The miR-126 level was 2 fold less in eutopic endometrium of subjects with endometriosis than healthy controls (p = 0.038). miR-21 was 3-fold higher in the eutopic endometrial cells of subjects with endometriosis than healthy controls (p =0.034). Aberrant expression levels of miR-21 and miR-126 in the exosomes from eutopic endometrium and endometriosis lesions may uncover a novel mechanism underlying the role of angiogenesis establishment essential to endometriosis lesion proliferation.

 

Nothing to Disclose: DH, AD, SJ, JB, MG, NS, RNT, WET

16406 17.0000 SAT-0105 A Potential Role in Endometriosis of Pro-Angiogenic Mirnas Secreted in Exosomes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

Yuechao Zhao*1, Yiru Chen1, Ping Gong1, Milan K Bagchi1, Robert N Taylor2, John A Katzenellenbogen1 and Benita S Katzenellenbogen1
1University of Illinois at Urbana-Champaign, Urbana, IL, 2Wake Forest Schl of Med, Winston-Salem, NC

 

Endometriosis is a prevalent gynecological disorder in which endometrial tissue creates inflammatory lesions at extra-uterine sites, leading to pelvic pain and impaired fertility. Although dysregulated estrogen signaling has been implicated, there is incomplete understanding of this disease etiology and hence current therapeutic approaches are still of limited effectiveness. Using a murine model which recapitulates estrogen-dependent ectopic lesion establishment and lesion-host environment crosstalk, we investigated roles of the estrogen receptor coregulator, repressor of estrogen receptor activity (REA), in endometriosis. When surgically transplanted into wild type intact or estrogen-supplemented host animals, ectopic uterine implants derived from donor uterine tissues with a reduced level of REA displayed an enhanced growth rate and more extensive cell proliferation and vascularization, which are pathological features of the human disease. Also, wild type lesions established in transgenic host animals with half the normal gene dosage of REA showed markedly increased neuron innervation as well as inflammatory responses, including elevated cytokine production, NFκB activation, COX2 expression and immune cell infiltration, which are aspects leading to endometriotic lesion progression and associated with pain in patients. Thus, multiple aspects of disease progression observed upon loss of the repressive actions of REA in either donor tissue or host animals were evident by greatly increased ectopic lesion growth and inflammatory responses. Importantly, loss of REA in primary cultured human endometriotic stromal cells also led to elevated proliferative activity and increased expression of several cell cycle regulators.  These findings delineate beneficial roles of this estrogen receptor corepressor in restraining multiple pathological aspects of endometriosis. The observations support the key role of estrogen receptor-dependent activities in the progression of endometriosis and propose REA as a critical endogenous regulator of this disease.

 

Nothing to Disclose: YZ, YC, PG, MKB, RNT, JAK, BSK

12900 18.0000 SAT-0106 A Multiple Beneficial Roles of Repressor of Estrogen Receptor Activity (REA) in Suppressing Endometriosis Progression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0089-0106 4861 1:00:00 PM Female Reproductive Tract Poster

Nuria Camats*1, Laura Audí2, Mónica Fernández-Cancio2, Pilar Andaluz2, Primus E Mullis1, Antonio Carrascosa2 and Christa E Flueck3
1University Children's Hospital Bern, Bern, Switzerland, 2Hospital Universitari Vall d'Hebrón, Barcelona, Spain, 3Pediatric Endocrinology and Diabetology, Bern, Switzerland

 

Background:

Steroidogenic factor-1 (SF-1/NR5A1) regulates adrenal and sex development and function. NR5A1 mutations manifest in patients with a very broad phenotype, generally in 46,XY individuals with disorders of sex development (DSD) and in 46,XX women with ovarian insufficiency. But so far, no genotype-phenotype correlation has been found.

Hypothesis:

We hypothesized that the broad phenotype of SF-1 mutations may be due to a second hit in a gene with similar function. Liver receptor homolog-1 (LRH-1/NR5A2) might be a good candidate as both transcription factors LRH-1 and SF-1 belong to the same NR5A family, have a high similarity, bind to the same promoter binding elements, share common target steroidogenic genes and have a partially overlapping tissue expression profile. Thus we studied the role of LRH-1 in SF-1 deficiency in vitro and in vivo.

Experimental Design, Methodology and Patients:

In vitro, we assessed the interplay between DAX-1, SF-1 and LRH-1 (isoforms 1 and 2) in non-steroidogenic HEK293 cells. Previous studies showed that heterozygote SF-1 mutation V20L may cause quite severe 46,XY DSD but is also found in a healthy carrier father. Thus, V20L was chosen to perform comparative in vitro studies. Effect of wild-type SF-1 and/or V20L SF-1 in combination with LRH-1 isoforms 1 or 2 on SF-1 regulated promoter luciferase reporter constructs (CYP17A1 and HSD3B2) was investigated in transfection experiments. We also compared the expression of these factors (including LRH-1 isoforms) in human steroidogenic tissues. In human, we searched for NR5A2 gene mutations in a cohort of 21 subjects harboring heterozygote NR5A1mutations.

Results:

In vitro assays showed that LRH-1 isoform 1 transactivated the CYP17A1, and both isoforms 1 and 2 transactivated the HSD3B2 promoter. When SF-1 activity was lost, both isoforms of LRH-1 transactivated the HSD3B2 promoter similarly to wild-type SF-1. DAX-1 inhibited SF-1 and LRH-1-mediated transactivation. Gene profiles revealed that LRH-1 was expressed in human adult and fetal adrenal tissues and testes. However, we found no mutations in NR5A2 in 21 subjects with heterozygote NR5A1mutations.

Conclusions:

In vitro, LRH-1 is able to regulate transcription of steroidogenic genes similarly to SF-1. LRH-1 can (partially) replace SF-1 in case of deficiency in HEK293 cells. However, there were no mutations in NR5A2/LRH-1 in heterozygote NR5A1/SF-1 patients with a severe phenotype of SF-1 deficiency. Thus the variability in phenotypes with SF-1 genotypes remains elusive.

 

Nothing to Disclose: NC, LA, MF, PA, PEM, AC, CEF

13012 1.0000 SAT-0107 A LRH-1 Is Able to Rescue SF-1 Deficiency in Steroidogenesis in Vitro but May Not Explain the Broad Phenotype of SF-1 Deficiency in Men 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0107-0114 4867 1:00:00 PM Sex Determination & Reproductive Axis Development; Transgender Medicine Poster

Hee Young Kang*1 and Eui-Bae Jeung2
1Chungbuk National University, CheongjuCheongju Chungbuk, Korea, Republic of (South), 2Biochemistry and molecular biology of veterinary medicine college, Chungbuk National Univ, Cheongju, Korea, Republic of (South)

 

Introduction: Steroidogenic factor 1 (SF-1) is essential for the development and function of steroidogenic tissues. Stable incorporation of SF-1 into embryonic stem cells has been reported to prime the cells for steroidogenesis. Methods: In this study, we established SF1 transgenic mouse embryonic stem cell (SF1-mES cells) and analyzed expression of steroidogenesis-related genes and gonadal lineage-markers. We measured the secreted progesterone in the cell medium because progesterone is the first metabolite of sex steroid hormone. As well as, we differentiated mES cells into functional granulosa-like cells or sertoli-like cells using various culture condition including growth factors or hormones. To test the phenotype for granulosa-like cell, we confirmed transcripts of specific forkhead transcription factor FOXL2 and the follicle stimulating hormone receptor (FSHR). In the other hand, we monitored some specific genes related with differentiation into testicular tissue. Results: We observed the progress to primitive streak–mesendoderm by gene expression analyses. In addition, we observed that differentiated SF1-mES cells expressing the steroidogenic enzymes, such as 3β-hydroxysteroid dehydrogenase, cytochrome P450-containing enzyme (CYP)-11A1, and CYP19A1. Using the advanced approach, we explored culture conditions that optimize SF-1-mediated differentiation of ES cells into defined steroidogenic and gonadal lineages. We induced functional granulosa-like cells or sertoli-like cells. Conclusions: We established the effective protocol to generate functional ovarian or testicular cells. The derivation of these cells explores new avenues for the further study and potential application of these cells in steroidogenesis.

 

Nothing to Disclose: HYK, EBJ

12322 2.0000 SAT-0108 A Differentiation of Mouse Embryonic Stem Cells into Ovarian or Testicular Cell 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0107-0114 4867 1:00:00 PM Sex Determination & Reproductive Axis Development; Transgender Medicine Poster

Martine de Vries*1, Lieke JJJ Vrouenraets2, Anne B Wichmann3, Maartje HN Schermer4, Miranda Fredriks2 and Henriette Aleida Delemarre5
1Leiden University Medical Centre, Leiden, Netherlands, 2Leiden University Medical Centre, Oegstgeest, Netherlands, 3VU University, Amsterdam, Netherlands, 4Erasmus Medical Center, Rotterdam, Netherlands, 5LUMC, Leiden, Netherlands

 

Background

In 2009, The Endocrine Society published clinical practice guidelines for the treatment of children and adolescents with gender dysphoria (GD). The guidelines recommend the use of GnRH agonists to suppress puberty in adolescence, and the use of cross-sex hormones starting around age 16 for eligible patients. In actual practice, there is no consensus on the use of these early medical interventions. In some countries they are part of treatment protocol. Elsewhere in the world it is not standard of care due to various ethical concerns, including fear for harms of the treatment and doubts about children’s competence to make these far-reaching decisions. The aim of our study was to gain more insight in the contexts of treatment disagreements surrounding early medical interventions and the underlying considerations of proponents and opponents.

Methods

(1) systematic review of the literature on treatment discussions in children with gender dysphoria

(2) qualitative study (semi-structured interviews) to identify considerations of key-informants (pediatric endocrinologist, psychologist, psychiatrist, ethicist) of 10 treatment teams worldwide

Results

The literature and the interviews show 6 fundamental topics that give rise to different, and even opposing, views on treatment of adolescents: 1) the (non-)availability of an explanatory model for GD (genetic, hormonal, neurodevelopmental and social factors);  2) the nature of GD (normal variation, social construct or (mental) illness); 3) the role of physiologic puberty to form a consistent gender identity;  4) the role of comorbidity; 5) ideas about possible physical or psychological harms of early medical interventions as well as of refraining from interventions; 6) ideas about decision making authority and child competence.

Interestingly, the Endocrine Society guidelines are debated both for being too liberal and for being too limiting. Many teams using the guidelines are exploring the possibility of expanding the current age limits.

Conclusion

Judgment on GD treatment is affected by fundamental ideas on the nature of gender and GD. As long as discussion remains on the abovementioned topics, and as long as there are only limited long-term treatment data, there will be no agreement on treatment options. There is an urgent need for systematic interdisciplinary and (worldwide) multicenter research and debate, not only on long-term outcomes, but also specifically on the nature of gender (dysphoria). The guidelines will only have a sound foundation once consensus is reached on these fundamental issues.

 

Nothing to Disclose: MD, LJV, ABW, MHS, MF, HAD

13685 3.0000 SAT-0109 A Early Medical Treatment of Children with Gender Dysphoria: An Empirical Ethical Study on Arguments of Proponents and Opponents Concerning Early Interventions 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0107-0114 4867 1:00:00 PM Sex Determination & Reproductive Axis Development; Transgender Medicine Poster

Aline Zamboni Machado*1, Mirian Y Nishi2, Elaine Maria Frade Costa3, Berenice B Mendonca4 and Sorahia Domenice5
1Disciplina de Endocrinologia e Metabologia, Laboratório de Hormônios e Genética Molecular/ LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 2University of São Paulo, Hospital das Clinicas, Sao Paulo, Brazil, 3Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil, 4Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo FMUSP, São Paulo, Brazil, 5Hospital das Clínicas, Disciplina de Endocrinologia e Metabologia, Laboratório de Hormônios e Genética Molecular/LIM42, FMUSP, SP, Brazil, Sao Paulo, Brazil

 

Introduction: The genes Ptgds, Map3k1, Fgf9 and its receptor Fgfr2 participate in the process of male gonadal development amplifying the Sox9 expression, which is a key factor to the testicular determination. Aim: To screen the presence of MAP3K1 allelic variants in patients with 46,XY gonadal dysgenesis (46,XY GD) in whom FGF9 and FGFR2 genes were previously studied. Patients and methods: Thirty tree 46,XY DSD patients with GD were studied. The hot spots exons 2, 3, 10, 11, 13 and 14 of gene MAP3K1 were studied by PCR amplification and directly sequenced in ABI PRISM 3130 DNA Sequencer. Results: A novel MAP3K1 allelic variant, c.1916T>C (p.Leu639Prol) was identified in heterozygous state in two sisters with isolated partial GD. In these sisters a novel FGFR2 variant, c.1361 C>T (p. Ser453Leu) had already been found in the previous study. Their mother is a carrier of the both, FGFR2 and MAP3K1 variants. These two allelic variants were not found in 100 normal controls screened and the both variants were probably damage on predictions sites as Polyphen, SIFT and Mutation Taster. Discussion and Conclusion: Several single-gene defects have been associated with the pathogenesis of 46,XY GD, although an intrafamilial phenotype variability may be observed among the affected members. These patients may present different degrees of genital virilization. Two or more different genes defects might synergize to modify the phenotype spectrum of the 46,XY DSD patients with GD. In our family, although both FGFR2 and MAP3K1 variants were identified in the two sisters, their phenotype was not identical. The oldest sister presented Müllerian derivatives (uterus and Fallopian tubes), Wolffian derivatives (bilateral epididymis and vans deferens) and ambiguous genitalia characterized by microphallus (3.0 cm of length) and the presence of two perineal openings. While in the youngest sister, Fallopian tubes were identified but the uterus was not present, Wolffian derivatives were present (bilateral epididymis and vans deferens) and the undervirilized genitalia was characterized by microphallus (2.5 cm of length) and one perineal opening. It´s the first time that heterozygous variants in the both genes FGFR2 and MAP3K1 are found in a familial non-syndromic 46,XY GD. To elucidate, if the combined action of these altered proteins contribute to the disruption of the normal testis development, functional studies are being conducted.

 

Nothing to Disclose: AZM, MYN, EMFC, BBM, SD

13827 4.0000 SAT-0110 A Inherited Digenic Missense Variants in FGFR2 and MAP3K1 Genes in Two Siblings with 46,XY Partial Gonadal Dysgenesis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0107-0114 4867 1:00:00 PM Sex Determination & Reproductive Axis Development; Transgender Medicine Poster

Yael Sofer*1, Nir Sharon2, Mariana Yaron3, Michal Yacobi Bach1, Iris Yaish1, Naftali Stern3 and Yona Greenman3
1Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, 2Hebrew University, Jerusalem, Israel, 3Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

 

Background: Treatment of male to female transsexual individuals consists of a combination of estrogen and anti-androgenic compounds including cyproterone acetate (CA), spironolactone, and GnRH analogues (GA). Modest hyperprolactinemia is almost universal in series using a combination of ethynil-estradiol and CA. These high prolactin levels have been attributed to estrogen being administered in supra-physiological doses.

Aims: To characterize the frequency and causes of hyperprolactinemia during hormonal treatment of transsexual women.

Methods: Retrospective study of patients treated in the transgender clinic of a tertiary referral center.

Results: One hundred and twenty four transsexual women (mean age 28.3 ± 10 y) treated in our clinic were followed for a mean period of 18 ± 22 months. Most subjects were single (83.4%), 8.2% were married, 7.4% divorced and 14% had children. Nearly one fifth (19.4%) had an academic degree, 34.7% had completed high school (missing data for 46%) and 66% were currently employed. Almost half of the cohort (44.3%) has received hormonal treatment, mostly without proper medical supervision, prior to referral to our institution. Smokers (42%) and patients with co-morbidities were preferentially treated with transdermal estrogen preparations.  Estrogen treatment was titrated to achieve estradiol levels in the normal pre-menopausal range. Initial antiandrogenic treatment consisted of GA (10.2%), CA (70%) or spironolactone (17.6%).

By 18 months of treatment there was a mean weight loss of 3.6 kg (p=0.0016). Although weigh loss was not significant at six months, systolic (-4.9 mmHg; p= 0.0005), mean arterial pressure (-2.26 mmHg; p= 0.02), total cholesterol (-15 mg%) and LDLc (-18 mg%; p= 0.0009)  decreased at that time point.

A significantly greater increase in prolactin levels (mIU/l) over baseline was already evident 3 months after initiation of CA treatment (400±333) in comparison to spironolactone (9.8±89) treated patients (p=0.0002), reaching levels of 715±423 and 195±101 mIU/l respectively after 12 months(p=0.017). Prolactin did not increase in GA treated patients but their number throughout follow up was too small for analysis.  There were no significant differences in estradiol serum concentrations among groups.

Conclusions: CA treatment was associated with a pronounced increase in prolactin levels, in comparison to other anti-androgenic therapies, independent of estradiol levels. Our results shed a new light on the pathophysiology of hyperprolactinemia during cross-sex hormonal treatment of transsexual women, with possible clinical implications.

 

Nothing to Disclose: YS, NS, MY, MY, IY, NS, YG

13790 5.0000 SAT-0111 A High Prolactin Levels in Transsexual Women Are Related to the Anti-Androgen Treatment Modality 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0107-0114 4867 1:00:00 PM Sex Determination & Reproductive Axis Development; Transgender Medicine Poster

Tatiana S Pelaes*1, Nathalie Oliveira Santana2, Rosana Barbosa Silva2, Elaine Maria Frade Costa2, Maria Helena Palma Sircili3, Flávia Siqueira Cunha4, Berenice B Mendonca5 and Sorahia Domenice3
1Hospital das Clínicas, Disciplina de Endocrinologia e Metabologia, Laboratório de Hormônios e Genética Molecular/LIM42, FMUSP, SP, Brazil, Sao Paulo, Brazil, 2University of Sao Paulo, Sao Paulo, Brazil, 3Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 4Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 5Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular, LIM 42, Hospital das Clínicas, Faculdade de Medicina, São Paulo University, São Paulo, Brazil, São Paulo, Brazil

 

Ovotesticular disorders of sex development (OTDSD) patients present a wide spectrum of phenotypes, and this diagnosis is confirmed only by the presence of testicular and ovarian tissue. While laboratory methods for the detection of testicular tissue in DSD patients are well standardized, through hCG stimulating test, there are few tools to investigate the presence of ovarian tissue in DSD patients. Combined LH and FSH stimulation test have been used to induce ovarian estrogenic secretion. We assessed the role of the GnRH analogue (GnRHa) as a stimulating test of hormonal secretion of testis (T) and ovaries (E2) in patients with suspected 46,XX OTDSD.

Patients: We evaluated four 46,XX DSD patients, all reared as males. At first evaluation, they had 0.9, 10, 15 and 15 years of age,  respectively. All of them presented ambiguous external genitalia, and palpable gonads were present in the two older patients. The older patients presented spontaneous pubertal development and one of them had gynecomastia. Ultrasonography identified  uterus in 3 patients,  7 pelvic and one inguinal gonads.  All patients had 46,XX karyotype and absent SRY. GnRHa stimulation test was performed by IM administration of 3.75 mg of leuprorelin, and LH, FSH, T and E2 levels were measured before and 24 hours after drug administration. All patients underwent gonadal surgery and histological analysis was performed.

Results: All patients showed increased levels of LH and FSH after GnRHa stimulation. The two prepubertal patients had increased E2 levels (<13 to 42 and 19 to 53 pg/mL) without increment of their prepubertal T levels. The histological analysis of excised bilateral gonads identified just normal ovarian tissue in both patients. The two postpubertal patients had an increase of both T (273 to 357 and 629 to 743 ng/dL) and E2 (13.6 to 49 and 37 to 63 pg/mL) levels. In these patients, histological analysis identified bilateral ovotestis and ovotestis plus testis, respectively.

Discussion: The stimulating test using multiple doses of combined gonadotropin hormones has been proposed as the most effective tool to identify ovarian tissue in OTDSD patients. Our findings suggest that GnRHa stimulation test might be a useful test in suspected OTDSD patients. Further studies are required to evaluate the accuracy of this method.

 

Nothing to Disclose: TSP, NOS, RBS, EMFC, MHPS, FSC, BBM, SD

15066 6.0000 SAT-0112 A GnRH Analogue's Use in the Diagnostic Approach of Patients with Suspected 46,XX Ovotesticular Disorders of Sex Development 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0107-0114 4867 1:00:00 PM Sex Determination & Reproductive Axis Development; Transgender Medicine Poster

Kei Takasawa*1, Emanuele Pelosi2, Masatoshi Takagi3, Tomohiro Morio1, Hiroshi Asahara3, David Schlessinger2, Shuki Mizutani3, Peter Koopman4 and Kenichi Kashimada1
1Tokyo Medical and Dental University, Tokyo, Japan, 2National Institutes of Health Biomedical Research Center National Institute on Aging, Intramural Research Program, 3Tokyo Medical and Dental University, 4The University of Queensland

 

Background: Steroidogenic factor 1 (SF1; Ad4BP/NR5A1) plays key roles in gonadal development. Initially, the Sf1 gene is expressed in mouse fetal gonads of both sexes from 9.5 dpc, but later is up-regulated in testes and down-regulated in ovaries after sex determination (1). While Sf1 expression is activated and maintained by Wilms Tumor 1 (WT1) and LIM homeobox 9 (LHX9) (2), the mechanism of sex-specific regulation remains unclear, especially suppressive mechanisms in ovary. We focused on the transcription factor Forkhead box L2 (FOXL2) which has been considered to be important for ovarian folliculogenesis and granulosa cell development (3), and hypothesized that Sf1 is repressed by FOXL2 during ovarian development.

Material and Methods: We used the murine testicular somatic cell line TM3 in in vitro systems including qRT-PCR, reporter assays and chromatin immunoprecipitation (ChIP) assays. Mouse embryos were collected from the ICR outbred strain or Foxl2-null mice for in vivo assays.

Results: In vivo RT-PCR analysis of 11.5 to 14.5 dpc ICR mouse gonads of female showed the reciprocal relationship between the dynamics of Sf1 and Foxl2 expression on and after 12.5 dpc. In an in vitro system, up-regulation of Sf1 by the WT1 splice variant WT1-KTS was antagonized by FOXL2 as determined by qRT-PCR. A 674-bp Sf1 promoter fragment which was previously reported to be sufficient to direct Sf1 expression in fetal gonads in vivo (2) was used for reporter assays, and we localized the Sf1 proximal promoter region involved in this antagonism to a 674-bp interval. A conserved FOXL2 binding site between -229 to -222 bp (GCCAAGGT) was identified within the proximal promoter by in vitro ChIP assay. Introducing mutations into this site abolished negative regulation by FOXL2 in reporter assays. Therefore we confirmed the mechanism by which FOXL2 suppresses Sf1 is to antagonize WT1-KTS action by directly binding to the Sf1 promoter in vitro. Finally, in Foxl2-null mice, Sf1 expression of fetal ovaries was increased two-fold relative to wild-type XX fetal gonads at 13.5 dpc. The antagonism by FOXL2 prevents WT1-KTS from maintaining Sf1 transcription, resulting in down-regulation of Sf1 expression in the developing ovary.

Conclusion: Our results support the hypothesis that FOXL2 negatively regulates Sf1 expression by antagonizing WT1-KTS during early ovarian development in mice and provide new mechanistic insight into the differentiation of ovaries.

 

Nothing to Disclose: KT, EP, MT, TM, HA, DS, SM, PK, KK

12085 7.0000 SAT-0113 A FOXL2 Transcriptionally Represses Sf1 Expression By Antagonizing WT1 during Ovarian Development in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0107-0114 4867 1:00:00 PM Sex Determination & Reproductive Axis Development; Transgender Medicine Poster

Agnethe Berglund*1, Kirstine Stochholm1, Mette hansen Viuff1 and Claus H. Gravholt2
1Aarhus University Hospital, Aarhus, Denmark, 2Aarhus University Hospital, Aarhus University, Institute of Clinical Medicine, Aarhus C, Denmark

 

The Epidemiology of Males with 46,XX Disorder of Sex Development ;

 A Nationwide Cohort Study

Agnethe Berglund1, Kirstine Stochholm1, Mette Hansen Viuff 1, Claus Højbjerg Gravholt 1,2

1Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus C, Denmark; 2Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark

Aim: Males with 46,XX Disorder of Sex Development (DSD) are rare, and the epidemiology of these patients have never been studied in a systematic manner. This study aims to estimate prevalence, incidence, diagnostic delay, mortality, morbidity and medication in all Danish males ever diagnosed with 46,XX DSD.

Patients and methods: From the Danish Cytogenetic Central Registry identification number, age at diagnosis and date of diagnosis for all males in Denmark diagnosed with 46,XX DSD were retrieved. By Statistics Denmark all index-persons were matched on age with 100 male controls from the background population. Information regarding death, hospitalizations and prescribed medication was retrieved for both index-persons and controls.

Results: 69 Danish males with 46,XX DSD and 6900 controls were identified. The overall prevalence was estimated from 1908-2012. During 1963-1992 the prevalence was 5 per 100,000, which is interpreted as reflecting the “real” prevalence. From 1993 and onwards prevalence was decreasing reflecting that a number of individuals are probably awaiting diagnosis. Total mortality was significantly increased compared to the background population (HR=4.05, CI=2.41-6.83), and median lifespan was a reduced with 37.8 years. Total morbidity was also increased, although not reaching significance (HR=1.22, CI=0.92-1.61). There was no difference in total medication comparing index-persons and the background population (HR= 0.87, CI=0.65-1.18).

Conclusion: The prevalence of males with 46,XX DSD is 5 per 100,000. Mortality is significantly increased, while morbidity is increased with borderline significance and medication was comparable with the background population.

 

Nothing to Disclose: AB, KS, MHV, CHG

14470 8.0000 SAT-0114 A The Epidemiology of Males with 46,XX Disorder of Sex Development ; A Nationwide Cohort Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Saturday, June 21st 3:00:00 PM SAT 0107-0114 4867 1:00:00 PM Sex Determination & Reproductive Axis Development; Transgender Medicine Poster

Mitzi Rettinger*1, Beth Marek1, Josh Cooper1, Greg Kirkovits1, Yunming Ying1, Uma Sreenivasan1, Russell P Grant2, Matthew Crawford2 and Brett Holmquist3
1Cerilliant, Round Rock, TX, 2LabCorp, Burlington, NC, 3Endocrine Sciences, Calabassas Hills, CA

 

Disorders of thyroid metabolism affect large numbers of patients worldwide.  Reference ranges for thyroid hormones vary among patient sub-groups and disease states and are an important part of clinical diagnosis of thyroid dysfunction.  Triiodothyronine (T3) and thyroxine (T4) are the most commonly tested hormones.  Reverse triiodothyronine (rT3) is an inactive isomer of T3.  The molar ratio of T3 to rT3 is used as a diagnostic marker. Currently most assays for thyroid hormones are based on radioimmunoassay (RIA) which can be expensive, have limited shelf life, lack specificity and typically only analyze for T4 and T3.1 Thus there is a significant clinical diagnostic need for a robust and accurate method for rT3. In recent years there has been significant push to develop LCMSMS methods for quantitation of thyroid hormones.  These methods have the potential for higher accuracy even on the low end and better specificity, with the ability to quantitate the different thyroid hormones separately.  Calibrators for LCMSMS methods are critical to accuracy of results and must be carefully evaluated.

The importance of proper selection and certification of reference materials and their impact on clinical decisions is illustrated with rT3. Often, purity is assigned by non-specific techniques such as TLC and no information regarding impurity profile is provided.  For use in a quantitative application it is critical to have high purity, well-characterized reference materials. LabCorp evaluated the Cerilliant rT3 solution reference standard using their methods at two sites.  Initial results indicated the Cerilliant standard was 30 to 50 % high relative to a calibrators prepared in-house from powder rT3 obtained from Sigma-Aldrich.  Comparison, at Cerilliant and LabCorp, of the powder to the Cerilliant certified spiking solution and the LabCorp in-house calibrators showed ~30% bias relative to the LabCorp calibrators, similar to the Cerilliant certified solution standard. The study showed that the observed bias of the certified solution standard was due to in-house calibrators prepared from research grade rT3 which had limited vendor certification, lot-to-lot variability and in-homogeneity due to lower purity.  

The calibrator for the LabCorp method was changed to the Cerilliant certified solution standard.  A multi-day, multiple batch study with over 1500 samples at two sites was conducted to generate a transform equation for existing reference intervals using the EP Evaluator.  Transformed reference intervals for adults (> 16 years) changed from 13.5 – 34.2 ng/dL to 9.2 – 24.1 ng/dL and for children (1-15 years) from 12.2 – 32.4 ng/dL to 8.3 – 22.9 ng/dL. Transformed reference intervals were verified using specimens from 80 healthy adults and 80 healthy children.

 

Disclosure: MR: Management Position, Cerilliant. BM: Employee, Cerilliant. JC: Employee, Cerilliant. GK: Management Position, Cerilliant. YY: Employee, Cerilliant. US: Chief Scientific Officer, Cerilliant. RPG: Management Position, LabCorp. MC: Employee, LabCorp. BH: Employee, LabCorp.

11524 1.0000 SAT-0546 A Accurate Reference Standards for Accurate Quantitation of Thyroid Hormones: Impact on Clinical Reference Ranges 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Tim IM Korevaar*1, Marco Medici1, Akhgar Ghassabian2, Edward Visser3, Henning Tiemeier1, Theo J Visser4 and Robin P. Peeters5
1Erasmus Medical Center, Rotterdam, 2Erasmus University Medical Center, 3Erasmus Medical Ctr, Rotterdam, Netherlands, 4Erasmus Univ Med Ctr, Rotterdam, Netherlands, 5Erasmus Univ Rotterdam, Rotterdam, Netherlands

 

Context: Elevated TSH, hypothyroxinemia and TPO-antibody (TPOAb) positivity during early pregnancy are associated with various adverse outcomes such as decreased neurocognitive development of the child. Surprisingly, thyroid dysfunction during pregnancy is not associated with classical symptoms and most women are even asymptomatic. Current guidelines advocate aggressive case finding in high risk cases, but all known risk factors (RFs) lack sensitivity which makes clinical identification of high-risk women very difficult. We therefore investigated whether easily obtainable characteristics are associated with the risk of maternal thyroid dysfunction in pregnancy.
Material and methods: Serum TSH, FT4 and TPOAb levels were determined during early pregnancy in 6278 pregnant women from the Generation R study. Multivariate analyses with backward selection was used to identify RFs for abnormal thyroid function and included maternal age, parity, BMI, smoking, alcohol use, education, child gender and medical/obstetrical history. Analyses of neurocognitive outcomes were additionally adjusted for maternal education, gender, alcohol use, gestational age at birth, birth weight and age at assessment.
Results: RFs for an elevated TSH were BMI >25, non-smoking, ethnicity and parity <2 (odds ratios (OR) range 1.41-2.71). None of the women with ≤1 RF had an elevated TSH (0/105) compared to 6.1% of women that had all RFs (72/1174, p<0.0001)
RFs for hypothyroxinemia were age >31, family history of diabetes, (former) smoking, parity >2, non-Dutch ethnicity, and BMI >25 (OR range 1.54-3.35). Amongst women without RFs, hypothyroxinemia was seen in 1% (6/610), whereas the prevalence increased to 14.4% when ≥4 RFs were present (24/167; OR 24.9, p<0.0001).
RFs for TPOAb positivity were family history of thyroid disease, ethnicity and parity <2 (OR range 1.77-3.99). TPOAb positivity was seen amongst 1.2% (2/174) of women without RF compared to 9.8% amongst women with ≥2 RFs (77/782; OR 8.2, p<0.0001). The number of RFs which were identified for hypothyroxinemia were linearly associated with child IQ scores (β -1.51 ±0.26; p<0.0001) and autistic symptoms (0.005 ±0.002; p=0.006) at 5 years of age, these effects decreased considerably after correction for hypothyroxinemia.
Conclusions: This is the first multivariate identification of RFs for maternal thyroid dysfunction during pregnancy. According to these RFs, women with an increased risk of thyroid dysfunction can be identified in a very simple and sensitive manner. Furthermore, these risk factors were associated with decreased child IQ and increased risk of autistic symptoms.

 

Nothing to Disclose: TIK, MM, AG, EV, HT, TJV, RPP

12658 2.0000 SAT-0547 A Which Basic Patient Characteristics Are Predictors of Thyroid Dysfunction during Pregnancy? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Ethem Turgay Cerit, Mujde Akturk*, Yusuf Tavil, Alev E. Altinova, Cagri Yayla, Mustafa Altay, Cigdem Ozkan, Canan Demirtas and Nuri Cakir
Gazi University Faculty of Medicine, Ankara, Turkey

 

Background and aim: Although the patients with hypothyroidism gain weight, whether fat mass is responsible for increasing weight is controversial. Epicardial adipose tissue thickness (EATT) has been shown to be correlated with visceral adipose tissue.  Serum omentin-1 levels are secreted from visceral fat and EATT. EATT and omentin 1 levels have been suggested to be related with atherosclerosis. In this research, our aim was to investigate body composition changes, EATT and serum omentin-1 levels in patients with hypothyroidism.

Methods:The study included 28 patients with newly diagnosed overt hypothyroidism who were evaluated at baseline and 6 months after thyroid hormone replacement therapy (THRT) and the age, sex and body mass index matched 28 healthy euthyroid control subjects. Body composition was measured by dual energy x-ray absorptiometry and EATT was measured by transthoracic echocardiography.

Results:Body weight, body mass index and lean body mass were increased in patients with hypothyroidism compared with post treatment (p=0.012, p=0.014 and p=0.034, respectively). Total fat mass and android fat mass, which is an indicator of visceral adipose tissue, did not show a significant change before and after THRT (p=0.96 and p=0.75). In patients with hypothyroidism,  glomerular filtration rate (GFR) was increased after treatment compared to before treatment (p<0.001). EATT was higher in patients with hypothyroidism than the control group (p<0.001) and significantly decreased  6 months after THRT (p=0.012). In linear regression analysis, free T4 levels were found to be an independent factor to predict EATT (p<0.001). Serum omentin-1 levels were significantly lower than the control group (p=0.037). However, serum omentin-1 levels were significantly increased (p=0.001) and reached to a similar level with the control group 6 months after THRT (p=0.47).

 Conclusion: The increase in lean body mass -not adipose tissue mass-  was found to be responsible for weight gain in hypothyroidism. Increased GFR leading to free water clearance may explain the decrease in lean body mass, after achievement of euthyroidism. The increased amount of EATT and decreased  omentin-1 levels can contribute to the pathogenesis of atherosclerosis in addition to other factors in hypothyroidism.

 

Nothing to Disclose: ETC, MA, YT, AEA, CY, MA, CO, CD, NC

14037 3.0000 SAT-0548 A Evaluation of Body Composition Changes, Epicardial Adipose Tissue and Serum Omentin-1 Levels in Hypothyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Buthaina Almahmeed*1 and Catherine Mary Kelly2
1University of Toronto, Toronto, ON, Canada, 2Women's Coll Hosp, Toronto, ON, Canada

 

Abstract: Parathyroidectomy-Induced Thyroiditis

Background: Parathyroidectomy-induced thyroiditis is a transient complication that is thought to be due to surgical manipulation of the thyroid gland during more extensive parathyroid surgeries. It appears histologically as a multifocal granulomatous folliculitis. It is under-appreciated mainly because the majority of patients are asymptomatic, and our case represents one of six similar cases published in the literature.

Case: A 70 year old lady with no prior history of thyroid disease underwent parathyroidectomy for primary hyperparathyroidism in July 2013. Three parathyroid glands were removed. The surgical procedure was uncomplicated and she was discharged the next day with normal calcium and PTH levels. She presented three days later to a community hospital emergency department with a headache and peri-orbital numbness. Her calcium level was normal at 2.28 mmol/L but TSH was found to be suppressed at <0.02 mIU/L, with a free T4 of 59 pmol/L. She was assessed in the endocrinology clinic two weeks later and her free T4 was declining, suggesting a diagnosis of parathyroidectomy- induced thyroiditis. She was managed conservatively and treated with propranolol for symptom control. Free T4 normalized four weeks later reaching a level of 12 pmol/L, with a TSH of 0.32 mIU/L. Her most recent free T4 and TSH levels were performed on August 28, 2013 and were 13 pmol/L and 3.67 mIU/L, respectively.

Conclusion: Parathyroidectomy may lead to a transient, taumatic thyrotoxicosis. Biochemical thyrotoxicosis can be associated with clinical symptoms of varying severity. It is a self-limiting condition but symptomatic treatment may be needed until the thyrotoxic phase resolves. Because clinically significant thyrotoxicosis can occur, patients undergoing parathyroidectomy should be informed of this potential complication.

 

Nothing to Disclose: BA, CMK

16764 4.0000 SAT-0549 A Parathyroidectomy-Induced Thyroiditis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Kamal A S Al-Shoumer*1 and Vasanthy S Nair2
1Kuwait University/Faculty of Medicine, Division of Endocrinology, Safat, Kuwait, 2Faculty of Medicine, Kuwait University, Safat, Kuwait

 

INTRODUCTION:  Adiponectin and resistin are some of the recently discovered adipocytokines that participate in the regulation of intermediate metabolism. The aim of this study was to evaluate circulating levels of adiponectin and resistin in patients with thyroid hyperfunction and compare their levels with controls

SUBJECTS & METHODS:Twenty nine untreated hyperthyroid patients and 34 normal controls were studied. Patients and controls were matched for age, sex and body mass index. The subjects were assessed after an overnight fast and their blood was collected for measurement of adiponectin, resistin, glucose, insulin, intact proinsulin and thyroid function.

RESULTS:  Adiponectin level was significantly lower in untreated hyperthyroid patients than normal subjects (patients versus controls, mean±SEM, 2.04±0.27 vs. 2.73±0.39, p=0.049) whereas resistin level was similar in patients and controls. Fasting glucose (p=0.01), insulin (p=0.007), and intact proinsulin (p=0.02) were significantly higher in the patients than controls. Within the patients, adiponectin demonstrated a trend of negative correlation with free T3 (r = -0.35, p=0.08) and free T4 (r = -3.2, p=0.09).  However, the adiponectin to resistin ratio demonstrated stronger inverse relation with free T3 (r= -0.38, p=0.05) and with free T4 (r= -0.42, p=0.03). On the other hand, neither adiponectin, resistin nor adiponectin to resistin ratio were associated with TSH, age, BMI, fasting glucose, insulin or intact proinsulin.

CONCLUSION: Untreated hyperthyroidism is associated with reduction in adiponectin but normal resistin levels. Adiponectin and adiponectin to resistin ratio demonstrated inverse relation with thyroid status. It is possible that inadequate secretion of adiponectin plays a role in the adverse metabolic changes associated with hyperthyroidism.

 

Nothing to Disclose: KASA, VSN

13458 5.0000 SAT-0550 A Reduced Adiponectin and Adiponectin to Resistin Ratio in Untreated Hyperthyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Henry Mauricio Arenas*1 and Christian Ivan Garcia2
1Universidad Tecnológica de Pereira. Clinica Comfamiliar, Pereira, Colombia, 2Universidad Tecnológica de Pereira, Pereira, Colombia

 

Thyroid Dysfunction after Exposure to Iodinated Contrast Media in an Area with Iodine Excess

Sudden exposure to high quantities of iodine could lead to thyroid dysfunction. To date, there is few information that permit us to confirm this findings. In Pereira a city with iodine excess, we wanted to explore, what happened in euthyroid patients when they are expose to a high iodine concentration. To evaluate this, we design a study with 100 patients that assisted to our clinic scheduled for angiography, excretory urography (EU), or computerized tomography(CT)

Methods. We apply a questionnaire to patients who assisted to a procedure with iodinated contrast media with inclusion and exclusion criteria that allowed us to exclude patients with thyroid dysfunction or thryroid disease.  We measured TSH, free thyroxin(FT4), thyroglobulin(TG), thyroperoxidase antibodies(TPO), and creatinin at time 0, or maximum after 120 minutes after the injection of iodinated contrast media , and we repeated the same measures at three months after exposure to iodine media contrast.

Results. A total of 100 patients were evaluated.  41 % greater than 60 years old. 87% of the patients had normal creatinine clearance.  66 % of patients were subjected to CT,  27% subjected to angiography and the remaining 7% were studied with EU.  2% of patients had TSH values less than 0.5 and 17 % of patients values greater than 4.5 mui/L. 99% of the patients had normalFT4 values.  11% of the patients showed high values of anti TPO. 6 patients had TG values higher than 79 ng/ml.

In the follow up,  89 patients attended to  the second samples , 34 % of these were men and 66 % women , 36 % with greater than or equal to 60 years , we observed a total of 19(21.3 %) with hypothyroidism , 18 subclinical and 1 overt. 11 patients had subclinical hypothyroidism de novo in the period after the administration of contrast media (9 women and 2 men) . 10 of 11 patients showed normal creatinine clearance values. 7 (63.7 %) of 11 patients with de novo hypothyroidism were 60 years or older. We didn´t observe cases of subclinical or overt hyperthyroidism. Of the 11 patients with subclinical hypothyroidism in the period after administration of iodinated contrast media, 8 (73%) were subjected to CT , 2 ( 18%) to angiography and 1 (9 % ) to EU.

Conclusion: In an area of iodine excess prior to performing procedures with iodinated contrast media, we observed 17% of subclinical hypothyroidism, especially in people over 60 years (p <0.05) elevated anti -TPO (11%), elevated TG (6%) and subclinical hyperthyroidism (2%). At follow-up, subclinical hypothyroidism de novo is frequently observed (21.3%), but not hyperthyroidism, especially in women and people over 60 years old. No relationship with lower creatinine clearances was observed. It is frequently observed that, people who present high values of anti-TPO and TG prior to contrast media, can increase these values after the administration of contrast medium.

 

Nothing to Disclose: HMA, CIG

15478 6.0000 SAT-0551 A Thyroid Dysfunction after Exposure to Iodinated Contrast Media in an Area with Iodine Excess 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Ines Bucci*, Sandra Melanzi, Luca Damiani, Camilla Tinari, Cesidio Giuliani and Giorgio Napolitano
University of Chieti-Pescara, Chieti, Italy

 

Down subjects are at increased risk for both neonatal and adult thyroid dysfunction. Up to 30% of patients with trisomy 21 suffer from hypothyroidism; most of them have chronic autoimmune thyroiditis (CAT), however, increased level of TSH without autoimmunity is not an unusual finding.  Focus of our study has been the evaluation of thyroid function and autoimmunity in Down subjects during a 25 years follow up. 190 subjects (67F, 123M, age 0.5-40 years) have been studied. At first observation thyroid status of the whole cohort was classified as follows: 118 euthyroidism; 6 congenital hypothyroidism; 14 CAT; 2 Graves’ disease; 6 subclinical hyperthyroidism and negative TSHr-TPO autoantibodies (TPOAb-); 44 non-autoimmune subclinical hypothyroidism (TPOAb-). Of the 190 subjects admitted, 107 have been followed up for >5 years (mean follow up 16.1 ± 6.3 years): 72 were younger than 8 yrs old and 3 out of them were TPOAb+ (4.1%); the remaining 35 were > 8 yrs old and 4 out of them were TPOAb+ (11.4%). At first examination 71 were euthyroid, 9 suffered from CAT, 5 from subclinical hyperthyroidism and were TSHrAb- and TPOAb-, 22 from increased TSH levels and were TPOAb-. At the end of the follow up, 46 Subjects (42.9%) were euthyroid, 10 (9.3%) were treated with L-T4, 39 (36.4%) had CAT, 1 (0.9%) suffered from Graves’ disease, 11 (10.3%) had non-autoimmune subclinical hypothyroidism (TPOAb-). Of particular interest is the evaluation of the 27 subjects with non-autoimmune subclinical disease (5 hyper-, 22 hypothyroid) at first visit. 12 (44.4%) were euthyroid at the end of the follow up, 9 (33.3%) developed CAT, 2 (7.4%) started LT-4 treatment because of TSH levels > 10 mUI/L and in 4 (14.8%) non-autoimmune subclinical hypothyroidism was confirmed. Finally, 33 (30.8%) subjects developed thyroid autoimmune disease during the follow up; mean age at first observation of TPOAb+ was 22.7 ± 8.0 years. Our data confirm the increased incidence of thyroid disorders in Down syndrome; they also show that a relevant percentage of subjects with increased TSH level and TPOAb- normalize their TSH with time. More than 30% of these subjects, however, developed thyroid autoimmunity  during the follow up. We finally observed that the mean age at first TPOAb+detection was 22 years, which is significantly lower than in general population, thus confirming the observation that Down syndrome has to be considered as a premature aging syndrome.

 

Nothing to Disclose: IB, SM, LD, CT, CG, GN

16678 7.0000 SAT-0552 A Thyroid Dysfunction in Down Subjects: A 25 Years Follow up 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Magnus R. Dias da Silva*1, Maria Clara C. Melo2, Marina M.L. Kizys2, Ângela C. Vidi2, Ana Luiza R. Rolim2, Susan C. Lindsey2, Haron S. Dorta2, Ilda S. Kunii1 and Rui M. B. Maciel2
1Universidade Federal de São Paulo - UNIFESP, São Paulo, Brazil, 2Universidade Federal de São Paulo, São Paulo, Brazil

 

Thyrotoxicosis is the most common cause of flaccid muscle paralysis in young male adults called thyrotoxic periodic paralysis (TPP) and is characterized by transient hypokalaemia and hypophosphataemia (1), recently linked to mutations in the potassium channel Kir2.6 in 33% of patients (2). Two new genome-wide association studies based on Thai and Chinese patients with (TPP) identified a novel regulatory genetic variant rs623011 located in chromosome 17q24.3, which raised the hypothesis of Kir2.1 transcription reduction under high thyroid hormone (T3) (3,4). We aimed at examining the variant rs623011 frequency in 40 TPP Brazilians, and verify possible T3-regulated candidate genes in 17q23.4 locus by analysing potassium channel expression during and after muscle attack. We used PCR-sequencing for genotype, and RT-qPCR of a TPP patient during toxic and euthyroid state for real-time ion-channel quantitative expression analysis. We compared genotype findings against Thai/Chinese cohort, sex-matched thyrotoxic without paralysis (TWP) subjects and 1000 Genomes Project controls. The frequency of the variant rs623011 (T>C) was significantly higher in TPP patients than in TWP patients (61.1% vs. 34.4%, OR=3.42, p = 0.039), similar to what was found in Thai/Chinese TPP patients, and was significantly more common than the minor allele frequency (MAF) observed in the general population from the 1000 Genomes database (61.1% vs. 29.0%, OR=4.87, p < 0.005). In addition, we first demonstrated in TPP and TWP that Kir2.1 expression was down regulated during thyrotoxicosis. Most interestingly, in the TPP patient carrying the risk allele this is likely related to the increased anti-sense Kir2.1 counterpart expression observed. On the other hand, the TWP patient carries the protective allele (TT). The regulatory genetic variant rs623011, formerly pointed in Asian TPP patients only, is also associated with allelic susceptibility to TPP in Brazilians. Since no other deleterious gene mutations were found in this locus, and based on what we have observed about the decrease of Kir2.1 expression in the thyrotoxic state, we hypothesize that a T3-driven regulatory mechanism may dynamically alter Kir2.1 expression in the skeletal muscle, therefore, contributing to the reduced inward-rectifying current that occurs during the attack of thyrotoxic hypokalaemic muscle paralysis.

 

Nothing to Disclose: MRD, MCCM, MMLK, ÂCV, ALRR, SCL, HSD, ISK, RMBM

16992 8.0000 SAT-0553 A Evaluation of the Regulatory Genetic Variant rs623011 (17q24.3) As a Contributing Cause in Thyrotoxic Paralysis By Expression Analysis of Potassium Channels during and after Thyrotoxicosis in a Case-Control Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Yong Hee Hong*1, Dong Hwan Lee2 and Sun Hee Lee3
1Soonchunhyang University Hospital, Bucheon, Korea, Republic of (South), 2College of Medicine, Soonchunhyang University, Seoul, Korea, Republic of (South), 3Graduate School of Medicine, Gacheon University of Medicine and Science, Gil Medical Center, Incheon, Korea, Republic of (South)

 

Introduction : Thyroxine-binding globulin (TBG) deficiency is known as a nonharmful condition transmitted as an X-linked trait. But TBG deficiency may lead to hypothyroidism requiring hormone supplementation very rarely. The suggested mechanisms are impaired transport, extrathyroidal storage of thyroid hormone and abnormal hypothalamus-pituitary axis response caused by fluctuation of free T4 level. 

Patients and Methods : Data of 33 patients with TBG deficiency were studied from 1997 until 2011 in Pediatric Endocrinology Department of Soonchunhyang University Hospital. All patients were evaluated for thyroid function and TBG levels. In cases of TBG deficiency with hypothyroidism, after L-thyroxine supplementation during 3 years, discontinuing L-thyroxine treatment for 4 weeks, laboratory evaluation were performed again. Complete TBG deficiency was defined as <0.03 mg/L, partial TBG deficiency was defined as below 50% of normal range for age.

Results : All 33 patients had partial TBG deficiency. 19 patients had abnormal thyroid function requiring L-thyroxine supplementation. Initial mean TSH level was 9.4±6.1 uIU/mL in hypothyroid patients with partial TBG deficiency, 3.4±1.5 uIU/mL in euthyroid patients with partial TBG deficiency. Initial mean Free T4 level was 1.6±1.1 uIU/mL in hypothyroid patients with partial TBG deficiency, 2.7±1.0 uIU/mL in euthyroid patients with partial TBG deficiency. There were statistically differences in initial TSH and Free T4 levels between 2 patients group(P value = 0.004, 0.005). TBG level was decreased by 24.4±13.4 % compared with normal range for age in hypothyroid patients with partial TBG deficiency and 39.1±13.7 % in euthyroid patients with partial TBG deficiency. There were statistically differences between 2 patients group(P value = 0.039). 3 patients with hypothyroidism and partial TBG deficiency were transient, but 16 patients were permanent hypothyroidism after their 3 year old age.

Conclusion : Although very rare, TBG deficiency can cause hypothyroidism requiring L-thyroxine supplementation, even in partial TBG deficiency. We should carefully follow up thyroid function in TBG deficiency patients.

 

Nothing to Disclose: YHH, DHL, SHL

14465 9.0000 SAT-0554 A A Study of Thyroxine-Binding Globulin(TBG) Deficiency with Congenital Hypothyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Jiri Horacek*, Jaroslav Maly, Ioannis Svilias, Jaroslav Vizda and Pavel Zak
Charles University in Prague, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic

 

With increasing free T4 levels, a gradually rising risk of venous thromboembolism has been described in case-control studies (1,2). However, the reports on the influence of thyroid hormones on coagulation and fibrinolysis, while suggesting a hypercoagulable state in thyrotoxicosis, have only been rare and often of low methodological quality (3). In hyperthyroidism, an increase in fibrinogen (FBG), von Willebrand factor (VWF), factor VIII (FVIII) and plasminogen activator inhibitor (PAI) as well as a decrease in tissue type-plasminogen activator (t-PA), have repeatedly been described, while for other factors the results were inconclusive.

We analyzed multiple markers of hemostasis in a cohort of patients shifting from severe hypothyroidism to mild hyperthyroidism during their differentiated thyroid cancer treatment. As cancer itself influences the coagulation system we excluded those with possible residual disease (i.e. a measurable thyroglobulin level during follow up). In 90 patients following total thyroidectomy for cancer, multiple tests were performed on two occasions: (a) before radioiodine remnant ablation, i.e. in hypothyroidism (TSH, median 109.6 mIU/L; interquartile range (IQR) 78.6-141.9, reference range (RR) 0.15-5.0 ), and (b) 6 to 8 weeks later on levothyroxine treatment, with low-normal to suppressed TSH (median 0.14 mIU/L; IQR 0.04-0.50). Wilcoxon test for paired data was used for comparisons.

During levothyroxine treatment, a significant increase in FBG from median 3.4 to 3.8 g/L (p<0,001; RR 2.0-4.0), in VWF from median 85 to 127 % (p<0,001; RR 50-160), in FVIII from median 111 to 148 % (p<0,001; RR 60-150), and in PAI from median 6.5 to 13.9 ug/L (p<0,001; RR 1.0-25.0) was observed. As a novel finding, the activation times of primary hemostasis (i.e. platelet adhesion and aggregation), evaluated by the PFA-100 System after stimulation with collagen and epinephrine or ADP, were significantly shortened; for epinephrine from median 148 to 117 s (p<0,001; RR 75-145) and for ADP from median 95 to 80 s (p<0,001; RR 62-104). We did not confirm a significant decrease in t-PA (2.1 to 2.0 ug/L; p = 0.380, RR 1.0-10.0) or an increase in D-dimer (0.32 to 0.30 mg/L; p = 0.463, RR 0.0-0.5).

Still, these results together suggest that an increase in thyroid hormones shifts the hemostatic balance towards a hypercoagulable and hypofibrinolytic state. This may contribute to the increased cardiovascular mortality observed in (even mild) thyrotoxicosis (4).

 

Nothing to Disclose: JH, JM, IS, JV, PZ

13215 10.0000 SAT-0555 A An Increase in Thyroid Hormone Levels Is Associated with a Pro-Coagulation Shift in Hemostatic Balance 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Yuerong Yan*, Jing Zeng, Zhe Yan and Hui Huang
Department of Endocrinology and Metabolism in West China Hospital of Sichuan University, Chengdu, China

 

Relationship between depression and thyroid hormone levels in patients with Graves Disease

      Yan Yue-rong  Zeng jing  Yan Zhe  Huang Hui

   Department of Endocrinology and Metabolism, West China Hospital, Sichuan University Chengdu, 610041, China

   Corresponding author: Huang Hui, Email:sansan1880@126.com

Objective Psychological disturbances are often occured in patients with hyperthyroidism, especially depression. We assessed the relationship between depression and thyroid hormone levels in Graves Disease patients. Methods 188 out-patients(18-68 years old) with Graves Disease were enrolled in the study, who visit the Department of Endocrinology and Metabolism in West China Hospital of Sichuan University from November 2012 to November 2013. Patients with mental disorders caused by other diseases were excluded. All patients were advised to join a face-to-face interview, complete the Zung Self-Rating Depression Scale (Zung score) and be detected plasma levels of TSH, FT4, FT3 and TRAb. Results All patients were divided into 3 groups according to the FT4 level: high FT4 level group(FT4>22.0pmol/L), normal FT4 level group(12.0≤FT4≤22.0pmol/L) and low FT4 level group(FT4<12.0pmol/L). There were 56, 113 and 19 patients respectively in those three groups.‚A total of 14 patients were diagnosed with depression. The percentages of patients with depression in those three groups were 10.71%(6/56), 6.19% (7/113) and 5.26%(1/19) respectively. ƒThe significant difference of Zung scores was found (P<0.05) in those 3 groups, but there were no difference in the percentages of depression (p>0.05). „In Pearson correlation analysis, Zung scores were significantly positively correlated with serum FT3 (r = 0.372, P <0.000) and FT4 levels (r = 0.288, P <0.000). Zung scores and serum TSH levels were negatively correlated but no statistically significance (r= -0.028, P = 0.614).  Conclusion Both the incidence of depression and the degree of depression might be increased with the elevation of FT4 levels in the Graves Disease patients.

 

Nothing to Disclose: YY, JZ, ZY, HH

13380 11.0000 SAT-0556 A Relationship Between Depression and Thyroid Hormone Levels in Patients with Graves Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Jung Hae So*, Young Min Choi, Jin Hwa Kim, Sang Yong Kim and Hak Yeon Bae
Chosun University Hospital, Gwangju, Korea, Republic of (South)

 

Background and Aims: Although controversy still remains, it has been suggested that subclinical hypothyroidism (SCH) has a strong impact on the risk of cardiovascular disease (CVD). Recent reports indicate that serum TSH gradually increase with age and a low activity of thyroid hormone might be beneficial in the older adults. The objective was to evaluate the assoiciation between serum TSH and CVD risk by Framingham risk score (FRS) in apparently healthy older adults.

Methods: We retrospectively studied 350 asymptomatic older adults without a history of any disease who were 60-79 years of age and who underwent voluntary health check-ups at the Health Promotion Center of our hospital from June 2009 to June 2011.

Results: A multiple linear regression analysis demonstrated that TSH had a significant negative correlation with CVD 10-year risk by FRS when adjusted for confounding variables in all subjects (β ± SE, -0.117 ± 0.039, R2, 0.185). After adjusting for risk factors associated with increasing CVD risk, SCH (OR 0.28 [CI 0.12-0.67] and upper tertile of TSH (OR 0.55 [0.30-0.98]) were significantly negative associated with CVD 10-year risk ≥ 20%.

Conclusion: Serum TSH was negatively associated with CVD risk by FRS in older adults. We propose that elevated TSH may be protective effect on CVD risk in older adults.

 

Nothing to Disclose: JHS, YMC, JHK, SYK, HYB

13498 12.0000 SAT-0557 A Serum Thyrotropin and Framingham Risk Score in Apparently Healthy Older Adults 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Seo Young Sohn*, Na Kyung Kim, Ji Young Joung, Sun Mi Park, Yoon Young Cho, Jae Hoon Chung and Sun Wook Kim
Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, Republic of (South)

 

Background: There are limited data about whether patients who receive initial treatment for differentiated thyroid cancer (DTC) gain or lose weight during long-term follow-up under TSH suppression. The purpose of this study was to evaluate whether DTC patients under TSH suppression by levothyroxine (T4) replacement experience long-term weight gain after initial treatment.

Methods: A retrospective analysis was performed on 700 patients with DTC who underwent total thyroidectomy followed by either radioiodine therapy (RAIT) and T4 replacement or T4 replacement alone. The control group included 350 age-matched patients with benign thyroid nodules. Anthropometric data were measured at baseline, 1-2 years, and 3-4 years after thyroidectomy. Comparisons were made between baseline and follow-ups. This study also examined the impact of the preparation method for radioiodine therapy (RAIT), comparing thyroid hormone withdrawal (THW) and recombinant human TSH (rhTSH).

Results: Significant gains in weight and BMI were observed 3-4 years after initial treatment for DTC in women but not in men. These gains among female DTC patients were significant compared to age-matched control. Women in the THW group gained significant amount of weight and BMI compared to baseline, while there was no increase in the rhTSH group. There were no changes in weight and BMI in men according to RAIT preparation methods.

Conclusion: Female DTC patients showed significant gains in weight and BMI during long-term follow-up after initial treatment although they were under TSH suppression. These changes were seen only in patients who underwent THW for RAIT but not in the rhTSH group. These weight and BMI gains were not observed in male DTC patients using either THW or rhTSH.

 

Nothing to Disclose: SYS, NKK, JYJ, SMP, YYC, JHC, SWK

15821 13.0000 SAT-0558 A Weight Changes in Patients with Differentiated Thyroid Carcinoma during Postoperative Long-Term Follow-up Under TSH Suppression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Hae Sang Lee*1 and Jin Soon Hwang2
1Ajou University School of Medicine, Suwon, Korea, Republic of (South), 2Ajou Univ School of Med, Suwon City, Korea, Republic of (South)

 

Objectives Graves’ disease is the most common cause of hyperthyroidism in children. Antithyroid drugs (ATD) are the first line treatment in children and inorganic iodide has been used in combination with ATD for more effective normalization of thyroid hormones in some cases of severe thyrotoxicosis. This study aimed to investigate clinical characteristics of childhood thyrotoxicosis and effectiveness of inorganic iodide in the early phase of treatment.

Patients Sixty-seven pediatric patients (53 girls / 14 boys, 11.1±3.4 years), with newly diagnosed thyrotoxicosis due to Graves’ disease were recruited. Forty-nine patients were treated with ATD alone while eighteen patients were treated with combination of ATD and potassium iodide (KI).

Measurements Initial levels of serum free T4, T3, TSH, and thyroid antibodies were recorded for all included patients. Thyroid function tests (TFT) were repeated two weeks after the initiation of ATDs while TFTs and measurement of thyroid antibodies were done eight weeks later.

Results All patients (n=67) received ATDs (either PTU or MMI) and 49 patients (73%) were treated with ATD alone while 18 patients (27%) were treated with combination of ATD and KI. The levels of thyroid antibodies at initial presentation and eight weeks later demonstrated no significant differences between groups. No significant differences were found between serum levels of free T4, T3 and TSH at initial diagnosis, but mean free T4 values were significantly lower (p < 0.05) in the group receiving combined therapy of ATD + KI, after two weeks of treatment. Similarly, serum T3 levels rapidly decreased after two weeks of treatment and mean levels were significantly lower (p < 0.05) in the group receiving combined therapy compared with those of the patients receiving ATD alone. Serum TSH levels after two weeks of treatment showed no significant differences between two groups.

Conclusions The use of KI in combination with ATD is effective for more rapid normalization of thyroid hormones in the early phase treatment of childhood thyrotoxicosis, but larger studies with adequate power are needed in future.

 

Nothing to Disclose: HSL, JSH

13168 14.0000 SAT-0559 A Effects of Short-Term Potassium Iodide Treatment for Thyrotoxicosis Due to Graves' Disease in Children and Adolescents 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Jae Hoon Moon*1, Jiyeong Seo1, Ji Won Han1, Kyoung Min Kim1, Sung Hee Choi1, Soo Lim1, Young Joo Park1, Do Joon Park1, Ki Woong Kim1 and Hak Chul Jang2
1Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 2Seoul National University Bundang Hospital and Seoul National University College of Medicine, Seoul, Korea, Republic of (South)

 

Several studies have evidenced the association between subclinical hyperthyroidism and the risk of cognitive impairment in the elderly. However, the effect of long-term TSH suppressive therapy on cognitive function of elderly patients with differentiated thyroid carcinoma (DTC) is still unclear.
A total of 50 DTC patients aged 65 years or older (mean age = 70.9 ± 5.0 years; male-to-female ratio = 8:42) who have received a TSH suppressive therapy for at least 5 years were included in this study. The comprehensive cognitive function domains in these patients were compared to those in 1:2 age-, sex-, education period-, and depressive mood-matched control subjects.
In the patient group, the mean duration of TSH suppressive therapy was 8.6 ± 3.7 years. Serum free T4 levels in the patient group were higher than those in the control group (1.64 ± 0.26 vs. 1.15 ± 0.17 ng/dl, p < 0.001). Serum TSH levels were suppressed in patient group when compared with control group (0.15 [0.51] vs. 1.90 [1.67], p < 0.001). Age, sex, education period, Geriatric Depression Scale (GDS-K), and Cumulative Illness Rating Scale (CIRS) were not different between patient and control groups. All assessed cognitive domains were comparable in both groups. In the patient group, those with higher serum free T4 levels performed better on Mini-Mental state, Word List Memory, Constructional Praxis Recall, and Trail Making A. These associations between serum free T4 and cognition were maintained in Mini-mental state, Word List Memory, and Trail Making A even after adjusting for age, education period, GDS-K, and CIRS. However in the control group, serum free T4 and TSH levels were not associated with any of the assessed cognitive domains.
In conclusion, Our results demonstrated the safety of long-term TSH suppressive therapy on the cognitive function in elderly patients with DTC. Furthermore, the positive correlation between serum free T4 level and the cognitive function suggest the potential beneficial effect of exogenous levothyroxine on the cognitive function of patients who lack endogenous thyroid hormone.

 

Nothing to Disclose: JHM, JS, JWH, KMK, SHC, SL, YJP, DJP, KWK, HCJ

11323 15.0000 SAT-0560 A The Effect of Long-Term TSH Suppressive Therapy on the Cognitive Function of Elderly Patients with Differentiated Thyroid Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Soo Heon Kwak1, Ye An Kim*2, Kyu Eun Lee2, Hoonsung Choi3, Tae Hyuk Kim2, Sung Hee Choi4, Soo Lim5, Ki Woong Kim2, Do Joon Park2, Kyong Soo Park6, Hak Chul Jang7 and Young Joo Park2
1Seoul National University Hospital, 2Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 3Seoul National Univ Coll of Med, Seoul, Korea, Republic of (South), 4Seoul Nat Univ Bundang Hosp, Seongnam-Si, Korea, Republic of (South), 5Seoul National University Bundang Hospital, Seongnam, Korea, Republic of (South), 6Seoul Natl Univ Hosp, Seoul, Korea, Republic of (South), 7Seoul National University Bundang, Seongnam-Si, Korea, Republic of (South)

 

Genetic factors are thought to be an important determinant of thyroid function and autoimmunity. However, there are limited data on theses genetic variants in Asians. In this study, we performed a two-staged genome-wide association study on plasma thyroid stimulating hormone (TSH) and free thyroxin (fT4) concentration, and anti-thyroid peroxidase (anti-TPO) antibody positivity in up to 4,238 Korean subjects. In the stage 1 genome scan, 3,396 participants from Ansung cohort were investigated using 1.42 million genotyped or imputed markers. In the stage 2 follow-up, 10 makers were de novo genotyped in 842 participants form the Korean Longitudinal Study on Health and Aging study. An intronic variant in VAV3, rs12126655, which was reported in Europeans, was significantly associated with plasma TSH concentration in the joint stage 1 and 2 analysis (P=2.2 10-8). We found that a novel variant, rs2071403, located at 75 base-pair proximal to the translational start site of TPO was significantly associated with plasma anti-TPO antibody positivity in the joint stage 1 and 2 analysis (P=1.3 10-10). This variant had a nominal sex specific effect and its association was more significant in females. Subjects who had rs2071403A allele, which was associated with absence of anti-TPO antibody, had decreased TPO mRNA expression in their thyroid tissue. Another intronic variant of HLA-DPB2, rs733208, had a suggestive association with anti-TPO antibody positivity (P=4.2 10-7). In conclusion, we have identified genetic variants strongly associated with TSH level and anti-TPO antibody positivity in Koreans.

 

Nothing to Disclose: SHK, YAK, KEL, HC, THK, SHC, SL, KWK, DJP, KSP, HCJ, YJP

15540 16.0000 SAT-0561 A A Genome-Wide Association Study on Thyroid Function and Anti-Thyroid Peroxidase Antibody in Koreans 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Aida Xochitl Medina-Urrutia*, Rosalinda Posadas-Sanchez, Juan Gabriel Juarez-Rojas, Enrique Mendoza-Perez, Esteban Jorge-Galarza, Maria Carmen Gonzalez-Salazar, Guillermo Cardoso-Saldaña, Wendy Angelica Ocampo-Arcos, Angel Rene Lopez-Uribe and Carlos Posadas-Romero
National Institute of Cardiology, Mexico, Mexico

 

Overt hypothyroidism is associated to cardiovascular disease (CVD). The contribution of mild thyroid failure as a CVD risk factor is controversial. In this cross-sectional study, we explored the association of thyroid function to the presence of coronary artery calcium (CAC), as a subclinical CVD marker. In 1429 Mexican subjects without clinical evidence of CVD (age 53±9 years; 50% women), CAC was analyzed by computed tomography, and serum thyroid stimulating hormone (TSH) and free thyroxine (FT4) by quimioliminicence. We found that 164 women (23%) and 101 men (14%), had subclinical hypothyroidism (SCH: TSH> 4.5 mUI/ml and FT4 0.8-1.8 ng/dl). In comparison to euthyroid subjects, the prevalence of positive CAC was higher in SCH men (38.3% vs. 53%, p<0.01), but similar among women (12.0% vs 13.5%, p=0.6). Mean concentrations and the prevalence of traditional risk factors was similar in women and men with and without SCH; while Framingham 10-year risk score prevalence was higher for SCH men, compared to euthyrod men (31.0 vs. 21.2%, p=0.03). Multivariable analysis showed that SCH was an independent predictor for positive CAC, even after Framingham score adjustment (odds ratio: 1.7, 95% confidence interval: 1.09-2.65, p=0.02).

Compared to euthyroid subjects, SCH men were significantly more likely to present positive CAC. These findings, suggest that mild thyroid failure is independently related to CVD.

 

Nothing to Disclose: AXM, RP, JGJ, EM, EJ, MCG, GC, WAO, ARL, CP

16457 18.0000 SAT-0563 A Subclinical Hypothyroidism Is Related to Coronary Artery Calcium in Apparently Healthy Men but Not in Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Sebastiano Raimondo*1, Chantal Di Segni1, Francesco Leo2, Jacopo Pareo2, Alfredo Pontecorvi3, Carolina Ierardi2, Patrick Orlando4, Sonia Silvestri4, Luca Tiano5, Andrea Silvestrini1, Elisabetta Meucci1 and Antonio Mancini1
1Catholic University of the Sacred Heart, Rome, Italy, 2Catholic University of The Sacred Heart, Rome, Italy, 3Catholic University School of Medicine, Rome, Italy, 4Polytechnic University of Marche, Ancona, Italy, 5Polytechnic University of the Marche, Ancona, Italy

 

It is well known that heart failure is associated with oxidative stress (OS). Reactive oxygen species in fact influence sarcolemmal and mitochondrial ione channels, which are responsible for cardiomyocyte excitability and are important in myocardial remodeling after a myocardial infarction. On the other hand, a low-T3 syndrome, as in other chronic diseases, can be present and represents a bad prognostic sign. In order to evaluate the relationship between thyroid hormones and indexes of OS, we have studied a group of 12 patients (10 males e 2 females, age 49-73) affected by heart failure (NYHA II-III; EF<40%), evaluating Coenzyme Q10 (CoQ10) (component of mitochondrial respiratory chain also endowed with antioxidant properties) in total and oxidized form and total antioxidant capacity (TAC). CoQ10 was evaluated by HPLC TAC by a spectrophotometric method, using H2O2–metmyoglobin system, which, interacting with the chromogen ABTS, induces the appearance of its radical forms with a latency phase (LAG) proportional to antioxidant content of the sample. We divided the patients according to the fT3 levels: group A with low T3 levels (n=5, mean ± SEM: 1.9±0.16 pg/ml) and group B with normal fT3 levels (n=7, mean±SEM: 3.2±0.016 pg/ml). Patients of group A showed a significantly greater proportion of oxidized CoQ10 (11.3±0.2 % vs 4.9±3 %) and an increased LAG (160±8.17 sec vs 86.7±8.17 sec), suggesting an increased OS in this subgroup. These preliminary data indicate an increased OS in patients with heart failure, especially in those who present low T3 levels and suggest that this hormonal alteration can have a role in the physiopathology of this condition. The reciprocal influences of OS and low T3 remain to be established.

 

Nothing to Disclose: SR, CD, FL, JP, AP, CI, PO, SS, LT, AS, EM, AM

14422 19.0000 SAT-0564 A Evidence of Oxidative Stress in Heart Failure with Low-T3 Syndrome: Preliminary DATA 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Meredith McFarland*1, Qalb Khan1, René J Alvarez Jr.2 and Ajay D Rao2
1Temple University School of Medicine, 2Temple University School of Medicine, Philadelphia, PA

 

Background

Studies examining the association between thyroid function and all-cause mortality have yielded conflicting results, mostly because of heterogeneity of baseline cardiovascular risk.  A direct link between TSH and cardiac function has been lacking.  A functional thyrotropin receptor has been found to be expressed in ventricular myocytes and has been implicated in TSH-induced brain natriuretic peptide (BNP) secretion, suggesting direct functional effect of TSH on the heart(1).  In a recent NHANES study, hypothyroidism was associated with greater mortality as compared to euthyroidism in those participants with congestive heart failure (CHF)(2).  Hypothyroidism was also associated with greater mortality in Blacks with CHF(2). We hypothesized that thyroid function status would be a predictor of morbidity in patients admitted with acute heart failure exacerbations as measured by BNP, ejection fraction (EF), and hospitalizations in a predominantly non-white population.

Methods

We conducted a retrospective study at Temple University Hospital (TUH, Philadelphia, USA).  We identified admissions for heart failure to the TUH Heart Failure Service during the calendar year 2012 with TSH values drawn during the inpatient admission.  Data extracted included race, age, gender, thyroid function, any prior history of hypothyroidism, EF, amiodarone use, creatinine level, brain natriuretic peptide level, and history of drug or alcohol abuse. We also measured the total number of hospitalizations these patients had for an acute heart failure exacerbation from January 2012 to December 2013.

Results

344 admissions for heart failure were examined during the calendar year 2012.  The population was predominantly male (62% male) with mean age of 59±14 years and mostly Black (66% Black, 9% Hispanic, 15% White).  Median ejection fraction was 25% (interquartile range (IQR) 15-45%) and median BNP was 1134 pg/mL (IQR 361-1930 pg/mL).  Median TSH was 1.88 mIU/L (IQR 0.983-3.44 mIU/L) and TSH was above the upper limit of normal of the hospital assay (>5.10 mIU/L) in 15% of the admissions.  Both TSH (r=0.15, p=0.01) and EF (r=-0.34, p<0.01) significantly correlated with BNP.  In those admissions where TSH > 5.10, BNP was significantly higher (1923±185 pg/mL vs 1245±76 pg/mL, p=0.0008).  TSH did not correlate with hospitalizations during the calendar years 2012-2013.  Having a TSH > 5.10 was a significant predictor of BNP (p=0.04), even after accounting for age, gender, ethnicity, # of hospitalizations, and EF.

Conclusions

This retrospective study demonstrates an association between thyroid status and cardiac function in mostly non-white individuals admitted for CHF.  Potential cross-talk between TSH and natriuretic peptides may be a further line of inquiry within these racial/ethnic groups.  Definitive studies examining the role of thyroid supplementation and their effect on BNP in this population is needed.

 

Nothing to Disclose: MM, QK, RJA Jr., ADR

14403 20.0000 SAT-0565 A The Effect of Thyroid Status on the Acute Heart Failure Exacerbation: A Retrospective Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Marek Ruchala*1, Ariadna Zybek2 and Ewelina Szczepanek-Parulska2
1Poznan University of Medical Sciences, Poznan, Poland, 2Univ of Medical Sciences, Poznan, Poland

 

Irisin is a recently newly discovered peptide secreted by muscle and fat tissue that has significant influence on the body metabolism and thermogenesis. Irisin promotes a “browning” of subcutaneous white adipose tissue causing increased energy expenditure and heat production. Irisin may be potentially associated with the health-promoting role of physical exercises. Other, well-known factors that influence the metabolic state of the organism are thyroid hormones.

The aim of the study is to assess irisin and creatine kinase (CK) levels in patients affected by hypo- and hyperthyroidism.

A studied group of 20 patients newly diagnosed with thyroid function impairment was admitted to our department or outpatient clinic between July 2013 and January 2014. Routine clinical examination, laboratory tests (irisin, thyroid-stimulating hormone - TSH, free thyroxin – FT4 and triiodothyronine – FT3, and CK concentrations), thyroid ultrasound examination were performed in all cases. The difference between irisin level in hypo- and hyperthyroid patients was analyzed statistically, as well as the associations between irisin, TSH, free thyroid hormones and CK level.

The negative irisin and TSH level was correlated negatively (r = -0.4924, p=0.023), the irisin and FT4 level were correlated positively (r = 0.4833, p=0.036). CK level was negatively correlated with irisin, (r = -0,7272, p=0,014) FT4 (r = -0.9636, p=<0.0001) and FT3 concentrations (r = -0.8838, p= 0.0.0007). The mean serum irisin level was lower in hypothyroid than hyperthyroid patients, but the difference was at the border of statistical significance (p=0.0726).

The thyrometabolic state seems to influence the irisin serum concentration. Gathered data suggest that irisin level in patients with hypothyroidism is lower that with hyperthyroidism. Presented high CK level in hypothyroid patients indicated the possible role of muscle destruction in irisin level decrease.

 

Nothing to Disclose: MR, AZ, ES

16752 21.0000 SAT-0566 A Changes in Irisin Levels in Patients with Thyroid Function Impairment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Irmak Sayin, Aycan Fahri Erkan, Berkay Ekici, Utku Kutuk, Ahmet Corakci* and Hasan Fehmi Tore
Ufuk University Medical Faculity, Turkey

 

Objective:  Subclinical hypothyroidism, has multiple effects on  the cardiovascular system.  Epicardial fat is a metabolically active organ and is clinically related  with cardiovascular disorders and atherosclerosis. Echocardiographic assessment of epicardial fat thickness (EFT) is a simple tool for cardiovascular risk stratification in clinical practice. In our study we aimed to assess the effects of Levothyroxine (LT4) treatment on EFT thickness in patients with subclinical hypothyroidism (SCH).

Methods: The study included 22 patients with SCH and 16 healthy controls. Serum thyroid-stimulating hormone (TSH),  free triiodothyronine (fT3), free thyroxine (fT4) levels and EFT were determined in all subjects. Correlation analysis and linear regression analysis were performed for EFT thickness.

Results: Mean EFT was 4,1 and 6,05  mm in control and  SCH subjects respectively. EFT of SCH patients was high compared with control subjects at baseline (p<0.001). EFT did not changed significantly after 3 months of follow-up period in control subjects; 4,1  to 4,3 mm respectively (p:0,142). But in SCH subjects; after LT4 treatment EFT reduced from 6,05 to 5,14 mm and this was statistically significant (p<0.001). Correlation analysis showed that EFT  was significantly positively correlated with  age, body mass index, thyroid-stimulating hormone and negatively correlated with fT4.

Conclusions: Epicardial fat thickness may be a useful indicator of cardiovascular risks in patients with SCH and LT4 therapy may be an effective option in reducing these risks.

 

Nothing to Disclose: IS, AFE, BE, UK, AC, HFT

15652 22.0000 SAT-0567 A Assesment of Epicardial FAT Thickness in Subclinical Hypothyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Helga Agusta Sigurjonsdottir*, Margret Jona Einarsdottir and Elias Olafsson
Landspitali University Hospital, Reykjavik, Iceland

 

Introduction: It has been suggested that antiepileptic drugs (AEDs) may cause altered thyroid function in adults. The clinical impact of this is unclear. The aim of this study was to retrospectively evaluate thyroid function in patients taking AEDs and correlate the results with the type of AEDs used and the gender of the patient.

Methods: Adult epileptic patients (over 18 years of age) who attended the neurology outpatient clinic at Landspitali University Hospital (LUH), the only University Hospital in Iceland, from 1st of January 1998 to 31st of December 2011 were included in the study. Patients with previous history of thyroid disease or that had used AEDs for less than 3 months were excluded. Information on medication use, medical history, serum levels of free thyroxine (fT4) and thyroid-stimulating hormone (TSH) was collected from medical records. The patients were invited for a blood test if either TSH or fT4 had not already been obtained. The data was analyzed using logistic regression and Mann-Whitney test.

Results: We identified 165 individuals, including 92 women. The mean age at inclusion was 45.6 (±15.5) years. The mean serum TSH level was 2.2 (±1.3) mIU/L, range <0.01–7.98 (reference value 0.30–4.20 mIU/L). The mean serum level of fT4 in our group was 14.2 (±2.9) pmol/L, range 8.1-24.4 (reference value 12-22 pmol/L) compared with 16.9 (±6,1) pmol/L in a sample of 13248 measurements at LUH, comprising all measurements in a single hospital (LUH), done during one year and this difference was significant (p<0,001). The difference in fT4 level between men in our group and the LUH group as well as women in our group compared to the LUH group was significant (p<0.001 and p<0.001 respectively). Thirty-five patients (21%) had fT4 levels below the reference range and normal TSH levels, defined as central hypothyroidism (CH) and CH was defined as an outcome measure. Logistic regession was used to evaluate potential risk factors for this outcome. Regression modeling showed statistically significant associations with the use of either carbamazepine (CBZ) or oxcarbazepine (OCBZ), especially for women; odds ratio 15.0 (95% CI 4.6 to 49.5).

Conclusion: CH is observed more often in individuals taking CBZ or OCBZ, especially women. CH was not associated with other AEDs in our study. The fT4 level was lower among those using AEDs, compared with all individuals who had their fT4 level measured in a single University Hospital clinical laboratory during one year.

 

Nothing to Disclose: HAS, MJE, EO

16801 23.0000 SAT-0568 A Antiepileptic Drugs and Central Hypothyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Huai-Dong Song*
Ruijin Hosp, Shanghai, China

 

Thyroid-stimulating hormone (TSH) is a sensitive indicator of thyroid function. High and low TSH levels reflect hypothyroidism and hyperthyroidism, respectively. Even within the normal range, small differences in TSH levels, on the order of 0.5 to 1.0 mU/l, are associated with significant differences in blood pressure, BMI, dyslipidemia, risk of atrial fibrillation, and atherosclerosis. Most of the variance in TSH levels is thought to be genetically influenced. We conducted a genome-wide association study of TSH levels in 1,346 Chinese Han individuals. In the replication study, we genotyped four candidate SNPs with the top association signals in an independent isolated Chinese She cohort (n = 3,235). We identified a novel serum TSH susceptibility locus within XKR4 at 8q12.1 (rs2622590, Pcombined = 2.21 × 10-10), and we confirmed two previously reported TSH susceptibility loci near FOXE1 at 9q22.33 and near CAPZB at 1p36.13, respectively. The rs2622590_T allele at XKR4 and the rs925489_C allele near FOXE1 were correlated with low TSH levels and were found to be risk alleles for patients with papillary thyroid carcinoma (PTC) (OR = 1.41, P = 0.014 for rs2622590_T, and OR = 1.61, P = 0.030 for rs925489_C). The rs2622590 and rs925489 genotypes were also correlated with the expression levels of FOXE1 and XKR4, respectively, in PTC tissues (P = 2.41 × 10-4 and P = 0.02). Our findings suggest that the SNPs in XKR4 and near FOXE1 are involved in the regulation of TSH levels and contribute to the risk of PTC.

 

Nothing to Disclose: HDS

14223 24.0000 SAT-0569 A Genome-Wide Association Study Identifies a Novel Susceptibility Gene for Serum TSH Levels in Chinese Populations 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0546-0569 4869 1:00:00 PM Thyroid Disease and Thyroid Hormone Action Poster

Mohammed Ahmed*
King Faisal Specialists Hospital & Research Centre, Riyadh, Saudi Arabia

 

Postpartum thyroiditis (PPT) is an autoimmune destructive thyroiditis, presenting within one year after delivery. It has a prevalence of 7% . Predisposing risk factors include previous PPT, T1 diabetes, and positive anti TPO antibodies in 60-85% patients,  but 0-5%  patients develop PPT without the presence of TPO antibodies. Usual presentations consist of transient hyperthyroidism (THYPER) alone, transient hypothyroidism (THYPO) alone, or THYPER followed by THYPO and subsequent  recovery. Hyperthyroidism usually begins in 1-4 mos. post delivery and can last for 2-8 wks. followed by hypothyroidism lasting for 2 wks to 6 mos. and eventual recovery.  Reversible hyopothyroidism increases risk for future  permanent hypothyroidism in 20-40% within several years. Hypothyroidism resolving within several wks. without treatment is the hall mark of PPT. 

AIM:

We present a case of PPT presenting 6 mos. postpartum. She had no known risk factors, including no previous PPT during previous 3 pregnancies, not a diabetic, negative thyroid antibodies. She went through all 3 phases consisting of THYPER lasting for several  wks, followed by THYPO lasting for 14 wks with eventual normalization.  

Case History:

A 35-year old physician’s wife  presented for a second opinion for treatment of hyperthyroidism. She elected not to use methimazole (MTZ) that was prescribed at another facility. She had 3 previous uneventful pregnancies. She was was 6mos. Postpartum and stopped breast feeding 4 mos. earlier. O/E:  she had tachycardia (PR 132 best/min). hyperreflexia, warm moist skin and a 60 G nontender diffuse goiter but no eye signs. AntiTg /anti TPO antibody titers were 26/<5  U/ml respectively, and thyrotropin-receptor antibody (TRAb) was negative. The possibility of postpartum thyroiditis  was entertained. She was advised to refrain use of MTZ and propranolol  was started. Follow up clinical course and  thyroid function tests are shown below:

At Presentation: FT4>100 (RR: 12-22 pmol/l), T3 7.1 (RR: 1.3-3.1 nml/l, TSH <0.005 (RR: 0.27-4.2 mUl/l , I-123 Thyroid uptake 0.1 %. Two wks later: FT4 39, T3 2.5, TSH <0.005, 4 Wks. later FT4  11.5, FT3 1.3, TSH: 0.018, Nine wks later FT4 7.1, TSH 17.3, Thirteen Wks later FT4 10.4, TSH 5.7, Twenty-one wks later FT4 11.7, T3 1.3, TSH 3.7. Only Propranolol was used during hyperthyroidism. Pt. has remained normal to-date at 25 wks.  FU.

 Conclusion:  We present a case of PPT who went through triple phase of severe transient hyperthyroidism, followed by transient hypothyroidism  and recovery. She did not have  the presence of usual predisposing factors of previous episode of PPT, positive ant-TPO antibodies,T1 diabetes. PPT  can be differentiated form Grave’s disease by negative I-123 thyroidal uptake & negative TRAb.

 

Nothing to Disclose: MA

11163 1.0000 SAT-0463 A Triple Phase Post Partum Thyroiditis Associated without Known Risk Factors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Mariam Gangat*1, Sadana Balachandar2 and Ian Marshall3
1Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, 2Rutgers - RWJMS, New Brunswick, NJ, 3Rutgers-RWJMS, New Brunswick, NJ

 

Objective: To report two patients diagnosed with both Graves’ disease (GD) and Hashimoto’s thyroiditis (HT) who presented with recurrences of hyperthyroidism due to both GD and HT.

Methods: Retrospective chart reviews were performed on these two patients to document their clinical and biochemical presentations, therapy, and course.

Results: These two patients initially presented with hyperthyroidism due to Graves’ disease. Therapy with antithyroid medication was followed by temporary resolution until recurrence of hyperthyroidism occurred due to Hashimoto’s thyroiditis in the form of Hashitoxicosis.  Hypothyroidism then spontaneously developed in one patient, while the other patient remained biochemically hyperthyroid. Eventually, significant hyperthyroidism developed in both patients due to Graves’ disease, requiring radioablation therapy.

Conclusion: The relationship between GD and HT remains controversial. On one hand, they are suggested to be 2 separate disease processes due to unique genetic differences demonstrated by genome studies.  They have also been regarded to represent 2 ends of the same spectrum based on reports of occurrence of both HT and GD in monozygotic twins and in the same family. Our report not only describes the occurrence of both these autoimmune processes in the same two patients, but is the first to report the recurrence of hyperthyroidism due to GD and due to HT in the same individuals.

 

Nothing to Disclose: MG, SB, IM

11650 2.0000 SAT-0464 A Unique Presentation of Both Hashimoto's Thyroiditis and Graves' Disease in the Same Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Mehtap navdar Basaran*1, Mazhar Muslum Tuna2, Ersen Karakilic1, Bercem Aycicek Dogan3, Narin Imga Nasiroglu4, Dilek Berker5 and Serdar Guler6
1Ankara Numune Education and Training Hospital, Ankara, Turkey, 2Ankara Numune Education and Research Hospital, Ankara, Turkey, 3Ankara Numune Training and Research Hospital, Ankara, Turkey, 4ankara numune education and training hospital, 5Ankara Numune Education and Research Hospital, Ankara, Turkey, 6Hitit University, Faculty of Medicine, Corum, Turkey

 

Introduction

Medullary thyroid carcinoma (MTC) is an uncommon malignant tumor of calcitonin-producing C cells. Familial syndromes of MTC includes; Multiple endocrine neoplasia (MEN) 2A, MEN 2B, and familial medullary thyroid carcinoma.  RET tumoral development is well known for neural crest originated cells like MTC, some  reports also indicates a tendency for papillary thyroid carcinoma(PTC) development. Some polymorphisms can be correlated  with PTC at V804M mutation .We are reporting findings of 26 family members with V804M mutation on RET proto-oncogene which is presenting with MTC or PTC.

Material and Methods

Twentysix (26) members of a Turkish family (origin from Ankara) were evaluated. They were followed at the Endocrinology and Metabolism department of Ankara Numune Research and Education Hospital between 2011 and 2013. Testing for the RET proto-oncogene mutation was performed at reference centers for Turkey. Laboratory tests were performed for calcitonin and carcinoembryonic antigen for all sixteen V804M mutation positive members. Screening for pheochromocytoma and hyperparathyroidism was performed both at diagnosis and annually during the follow-up in RET positive gene carriers. All operations were performed at our hospital by exprienced surgeons.

Results

Sixteen of 26 family members have positive RET V804M proto-oncogene mutation (figure-1). Leu 769 polymorphism was positive for the ten of sixteen V804M mutation positive members.

Eleven family members who has V804M mutations has gone to total thyroidectomy (table-1). Five members with MTC was first generation, the other two was at second generation. MTC sizes was between 2-8 mm in all cases. Central lymph node metastasis was seen in only one member.

Two members of second generation who was brothers had PTC without MTC. PTC sizes was 2 mm in one and 3 mm in the other and there was no central lymph node metastasis. Leu 769 polymorphism was positive for this two members.

Mean calsitonin level of RET positive members was 13,27 pg/mL (1 – 49,8 pg/mL). Only two members had elevated calsitonin levels.

No family members in our study have pheochromocytoma or hyperparathyroidism.

Conclusion

Our finding showed that V804M mutation which has a well known relationship with MTC, can also be associated with PTC, even without MTC existence. Futhermore we suggest that coincidence of Leu 769 polymorphism with V804M mutation can be a role on PTC development.

 

Nothing to Disclose: MNB, MMT, EK, BAD, NIN, DB, SG

11164 3.0000 SAT-0465 A RET V804M Proto-Oncogene Mutation Presenting with Medullary and Papillary Thyroid Carcinomas in a Turkish Family 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Michael Marchese*1, Subhashini Yaturu2, Joseph Sacco3 and Mandeep Sidhu3
1Albany Stratton VA Medical Center, Albany, NY, 2Stratton VAMC, Rensselaer, NY, 3Stratton VAMC

 

Background:Hyperthyroidism leads to a hyperdynamic circulatory state. Only 6% of hyperthyroid patients have an initial presentation of high output congestive heart failure and few case reports with low-output congestive heart failure secondary to dilated cardiomyopathy as well as few with reversible chylous ascites. We report an unusual presentation of Graves’ disease with tense ascites and high-output heart failure.

Clinical Case: A 64 year old male presented with unintentional weight loss and diarrhea of 6 weeks and bilateral lower extremity edema of 2 weeks duration. Within 2 weeks fluid accumulated at a rapid speed, beginning at his ankles, proceeding up his legs and abdomen, up to a stage 4 anasarca. Past history was significant for CAD with MI s/p PCI to LCX 14yrs ago, quiescent and stable until 6 weeks prior to presentation. Exam revealed tachycardia, tachypnea, normal size thyroid without exophthalmoses and tense ascites.  Bilateral minimal pleural effusions noted on CXR. Labs include: TSH: 0.00uIU/mL (0.35-5.50), FT4: 3.39ng/dL (0.7-1.5), T3: 224.8ng/dL (60-150), TSI: 356% (0-139); BNP: 630pg/mL (<100); total bilirubin: 1.7mg/dL (0.1-1.0), Alk. Phos: 178units/L (50-136); normal AST, ALT & LDH. Thyroid scan and uptake could not be done as he had contrast for a CT abdomen. Patient responded very well initially to appropriate treatment with diuresis, large-volume paracentesis, beta-blockers and PTU. US thyroid noted a heterogeneously enlarged gland with increased blood flow.  ECHO cardiogram revealed bi-atrial enlargement with normal right and left ventricular systolic function and normal LV dimensions and LVEF >55%. US and CT abdomen revealed massive ascites, normal liver parenchyma with no evidence of discrete solid or cystic lesions or dilated intrahepatic bile ducts. Left and right heart cath reported hemodynamics consistent with high output heart failure. He had two readmissions for worsening, rapidly accumulating tense ascites and spontaneous bacterial peritonitis requiring multiple large volume paracentesis with switch to tapazole. He was treated with radioiodine therapy with 29.6mCi while on PTU. Then complete resolution of the ascites occurred with improvement of TFTs and PTU dose was reduced. Current plan is repeat radioiodine therapy.

Lesson: Though extremely rare, thyrotoxicosis can present with massive ascites without underlying liver disease.

 

Nothing to Disclose: MM, SY, JS, MS

12696 4.0000 SAT-0466 A Thyrotoxicosis Presenting with Rapidly Progressive Severe Systemic Edema and Tense Ascites in the Setting of Dynamic Systolic Function 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Reena Mary Thomas*, Xiaoyin S Jiang, Tracy Lynn Setji and Diana B McNeill
Duke University Medical Center, Durham, NC

 

Background: Henoch-Schönlein purpura (HSP) has previously not been shown to be associated with either Graves’ disease naïve to PTU or Methimazole nor to papillary thyroid carcinoma. We present a patient with HSP who subsequently developed both Graves’ disease and metastatic papillary thyroid carcinoma.

Presentation: A 32-year-old man with a remote history of ALL, developed an itchy petechial rash on the dorsum of his ankles and lower legs during a two-hour episode of palpitations, shortness of breath, light-headedness and feeling unwell. He reported no history of recent infections, new medications or insect bites. One week later, he was diagnosed to have Graves’ disease, started on Methimazole 10 mg PO daily and empirical amoxicillin therapy for the rash. Two days later, he was hospitalized with severe abdominal pain, nausea and vomiting. The rash worsened and he was treated with a 5-day course of IV/PO Doxycycline. CT abdomen and pelvis with contrast was normal. Two weeks later, he reported fatigue and weight loss of 20 lbs. He had mild tachycardia, bilateral lid lag, small diffuse goiter and erythematous petechial non-blanching, non-tender, non-itchy macules on the lower extremities, bilateral flanks and volar aspect of his forearms.  There were no oral ulcers or joint inflammation. Family history was positive for hypothyroidism. WBC was 20.4 (3.2 - 9.8 X109); ESR 27 (0-15mm@1hr); CRP 16.8 mg/L (<10 mg/L), TSH 0.06 uIU/mL (0.34-5.66 uIU/ml), FT4 2.6 pg/ml (0.52-1.21 ng/dl), FT3 6.18 pg/ml; TRab 12.96 IU/L (0-1.75 IU/L), TSI 3.1 (<1.3). Biopsy of the rash revealed perivascular deposits of IgA, fibrin and C3 deposits in the dermis confirmatory of leukocytoclastic vasculitis. Platelet count, peripheral smear, coagulation studies, renal, hepatic panel and urine analysis were normal.  ANA, c-ANCA, p-ANCA and serology for hepatitis viruses, EBV, CMV, RPR and HIV were negative. He was treated with Methimazole and tapering course of Prednisone for 1 ½ months, following which the rash resolved. One month later, ultrasound guided FNA of a right thyroid nodule (2.2 cm) was positive for papillary thyroid carcinoma.  Neck lymph node mapping was positive for metastatic disease in the lymph nodes in the central neck and right lateral neck compartments. He had a total thyroidectomy with bilateral central lymph node and modified right lateral neck dissection surgery. BRAF mutation analysis was negative. He is due for radioiodine ablation therapy.

Conclusion: HSP is usually associated with infections, drugs and insect bites. This is the first reported case of HSP associated with both Graves’ disease and metastatic papillary thyroid carcinoma. The trigger for HSP in this case could have been the autoimmunity of Graves’ disease. On the other hand, HSP could be a paraneoplastic presentation of metastatic papillary thyroid carcinoma.

 

Nothing to Disclose: RMT, XSJ, TLS, DBM

11197 5.0000 SAT-0467 A Henoch-Schönlein Purpura (HSP) – a Possible Harbinger of Graves' Disease and Metastatic Papillary Thyroid Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Ritu Madan*1, Rachna Manju Goyal2, Jacqueline Jonklaas3 and Kenneth Burman4
1National Institutes of Health, Bethesda, MD, 2Georgetown University Hospital, Arlington, VA, 3Georgetown Univ Med Ctr, Washington, DC, 4MedStar Washington Hospital Center, Kensington, MD

 

Background: There are sporadic case reports of methimazole causing hepatocellular failure since it causes cholestasis more frequently. We, hereby, present a case of methimazole induced fulminant liver failure.

Case: A 67yo female presented with fatigue, anorexia, nausea, palpitations and a 10 lb weight loss in 3 weeks with an accompanying history of thrombotic thrombocytopenic purpura (TTP), Type 2 DM, hyperlipidemia and hypertension. She was tachycardic and overweight on exam. She had a symmetrically enlarged thyroid gland without a bruit and no eye signs. Initial labs showed anemia, thromobocytopenia, elevated bilirubin (2g/dl) and normal liver enzymes. Further testing showed TSH <0.005mcIU/ml, free T4 7.7ng/dl, TT3 651ng/dl, TRab 21 IU/L (reference 0-1.75IU/L) and TSI 409% (reference range 0-39%). She was started on plasmapheresis for treatment of her TTP and methimazole 30 mg BID was initiated for Graves’ disease. She remained on plasmapharesis for about a week without an improvement in her platelet count (10,000-20,000), free T4 levels (7ng/dl) or total T3 levels (600ng/dl). At this time, hydrocortisone 100mg TID was initiated and methimazole was increased to 30 mg TID. Also, since the TTP was not responding to plasmapheresis, an intravenous dose of Rituximab was administered. With this dose escalation, the free T4 and total T3 decreased to 2.1ng/dl and 136ng/dl respectively after 4 days. About a week after medication changes, she was found unresponsive in her room with normal vital signs. Immediate labs showed normal blood glucose, electrolytes and kidney function. But AST and ALT were found to be elevated at that time, 999U/L and 629U/L respectively with peaking to 4991U/L and 2320U/L after 12 hours. ALP levels remained normal. Methimazole was discontinued immediately. AST and ALT trended down to 1909U/L and 1076U/L in a day and eventually were normal after 15 days. Her mental status improved in 1-2 days. Viral hepatitis, autoimmune hepatitis, Wilson’s disease, tylenol toxicity and shock liver were excluded by appropriate workup. She remained on plasmapheresis for 10 days for TTP and her free T4 levels remained stable at 2ng/dl without any medications. On discontinuation of plasmapharesis, free T4 levels trended up to  >3ng/dl and lithium was started and RAI ablation was planned once the patient was more stable.

Discussion: Methimazole induced hepatotoxicity occurs more commonly with advanced age and higher doses. The cause of this adverse effect is unknown at this time. 

 

Nothing to Disclose: RM, RMG, JJ, KB

14692 6.0000 SAT-0468 A Methimazole Induced Fulminant Hepatic Failure 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Samaneh Dowlatshahi*1, SeyedAmirhossein Afsharimani2, Erica Gold Sinsheimer3 and Harvey Friedman4
1St Francis Hosp, Evanston, IL, 2st Francis hospital, 3Endo and Metab Consultants Ltd, Skokie, IL, 4St Francis hospital

 

Introduction: Heterophile antibodies that interfere with the TSH assay have been described in the past. Human antimouse antibody (HAMA), which is the most commonly encountered heterophile antibody, may be present in the serum of up to 10% of patients. The incidence increases in people who have received or have been treated with radiolabeled mouse monoclonal antibodies. It has been suggested that these heterophile antibodies are natural antibodies in normal people, although they could represent autoantibodies. We present a patient with falsely elevated TSH levels secondary to presence of HAMA.

Clinical Case: A 45 year old male presents with an incidentally found abnormal thyroid panel which showed elevated TSH levels along with normal free T3 and free T4. Patient complaints of prolonged constipation. He was started on increasing doses of levothyroxine. At 6 weeks follow up TSH did not show any significant changes. TSH was repeated at another laboratory with the addition of mouse serum to the patient's sample, and it was normalized.

Conclusion: A common and the first test to diagnose thyroid dysfunction is TSH measurement. HAMA is one of the multiple factors that can interfere with this test result and can result in costly diagnostic evaluation and unnecessary treatment. It is crucial to evaluate for the interfering factors prior to initiating unnecessary and potentially harmful clinical interventions. In this case we report the presence of HAMA as the interfering substance in the TSH assay.

 

Nothing to Disclose: SD, SA, EGS, HF

11313 7.0000 SAT-0469 A An Interesting Case of Falsely Elevated TSH Level Due to Human Anti-Mouse Antibodies (HAMA) Interference with Thyrotropin Assay 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Daniel Macedo*1, Valeriano Leite2, Margarida Vieira2 and Helena Vilar3
1Portuguese Institute of Oncology, Lisbon, Lisbon, Portugal, 2Portuguese Institute of Oncology, Lisbon, Portugal, 3Portuguese Cancer Centre of Lisbon, Lisbon, Portugal

 

Acute suppurative thyroiditis secondary to Escherichia Coli urinary tract infection

 Authors: Daniel Macedo1, Margarida Vieira1, Helena Vilar1, Valeriano Leite1

1 - Endocrinology department, Portuguese Institute of Oncology, Lisbon, Portugal

Introduction: Acute suppurative thyroiditis is a rare disorder, usually related to congenital malformations such as piriform fistula. The hematogeneous spread  during bacterial infection to a pre-existing abnormal thyroid gland also constitutes a possible mechanism of disease.

Clinical case: A 58-year old man with personal history of multinodular goiter,  morbid obesity and congestive heart failure was medicated with ciprofloxacin for an urinary tract infection. The patient showed no improvement after 14 days of antibiotherapy. Concomitantly he developed a left-sided neck painful swelling resulting in dysphagia and dyspnea. He was then admitted in the hospital to start on meropenem. The urine cultures were positive for Escherichia Coli and a clinical hyperthyroidism was detected on the hormonal assays (TSH: <0.02 µUI/mL (0-3-4.2); T4L 6.82 ng/dL (0.9-1.7)).  Ultrasound (US) and CT of the neck revealed a 6cm heterogeneous left-sided cervical mass with a big calcification and an apparent abscess. Since the compressive symptoms worsened, he was referred to our institution for further investigation. The antibiotherapy was mantained and he started corticoids and methimazole. An inconclusive fine-needle aspiration cytology (FNAC) justified a surgical biopsy, which revealed extensive inflammatory infiltration and abscessed areas in thyroid tissue. US-FNAC of the abscess was performed and the cultures of the drained material grew Escherichia Coli. Otolaryngology evaluation ruled out piriform fistula. The patient had remarkable improvement. He was discharged asymptomatic, with normal thyroid function, after 21 days of meropenem.

Conclusion: The authors report a very uncommon case of an acute suppurative thyroiditis within the context of Escherichia Coli bacteriemia. The acute and expressive presentation simulated an aggressive thyroid neoplasia that could have led to inappropriate management, such as surgery.

 

Nothing to Disclose: DM, VL, MV, HV

15401 8.0000 SAT-0470 A Acute Suppurative Thyroiditis Secondary to Escherichia coli Urinary Tract Infection 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Alicia Lynn Warnock* and Henry B Burch
Walter Reed National Military Medical Center, Bethesda, MD

 

BACKGROUND

The 2007 National Health Interview Study (CDC/NCHS) found 4 of every 10 adults use complementary and alternative medicine (CAM) with natural products most commonly selected (1).  PTC is generally considered a slow-growing, treatable cancer; however, we present a patient with PTC who choose alternative medicine and subsequently succumbed to her disease.

 CASE

A 63 yo female was referred 7/2013 for an enlarging neck mass. Three years prior the patient’s primary physician palpated thyroid asymmetry, but the patient refused imaging stating that she had a history of known goiter for over 15 years. Ultrasound examination 18 months later to evaluate an enlarging right lobe noted two distinct nodules, 2.3 cm and 3.6 cm maximal diameter, respectively, with microcalcifications, cystic areas, and increased vascularity. CT showed indistinct margins between the thyroid mass and right SCM muscle and numerous pulmonary nodules consistent with metastatic disease.  FNA confirmed PTC.  Despite numerous counseling sessions with multidisciplinary team members, the patient refused all conventional treatment, opting instead for naturopathic care consisting of a regimen ranging from 30-60 natural products in the form of pills and/or drops for over a year.

               She returned to our facility urgently in 7/2013 with the mass enlarging significantly and causing conversational dyspnea, orthopnea, and impairment of head rotation. She complained of diffuse body pains causing limited mobility, and intense left 3rd finger pain.  Repeat FNA of the thyroid mass failed to reveal anaplastic change. PET-CT was notable for widespread metastatic disease involving the lungs, mediastinum, hilum, osseous structures, all with profound hypermetabolic activity.

               Her disease was deemed inoperable due to envelopment of great vessels, inability to access the trachea, and the degree of vascularity.  She was treated with EBRT of 35 Gy in 14 fractions to the thyroid mass and 30 Gy in 10 fractions to the left distal middle finger. She also received zolendronic acid for her bony metastases.  Unfortunately, the patient had little benefit from any treatment.  She was placed in a Hospice program and passed away 9/2013, 1 month after completing her radiation therapy.

 CONCLUSION

CAM use has gained widespread popularity, and was utilized by up to 38.3% of adults and 11.8% of children over the last decade (1). Even when faced with a diagnosis of metastatic cancer, some competent patients choose an alternative treatment plan, against all medical advice.  Knowledge about patient beliefs concerning CAM can assist the physician in frank discussion of therapeutic options with their patients.  While it is not known whether the patient’s tumor transformed or was an aggressive variant at baseline, but it is possible that early conventional therapy would have prevented the dismal outcome in this patient.

 

Nothing to Disclose: ALW, HBB

11338 9.0000 SAT-0471 A A Fatal Choice of Alternative Medicine for Differentiated Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Maria Monina Clauna Lumanta*1 and Elizabeth P Pacheco2
1The Medical City, Pasig City, Philippines, 2The Medical City, Quezon, Philippines

 

Thyrotoxic Heart Disease (THD) is a threatening complication of thyrotoxicosis increasing risk of morbidity and mortality.1 Over the past few decades, there has been an increase in the number of reports about newly recognized (atypical or unusual) manifestations of Graves’ disease (GD). Anasarca, spider angioma and right-sided heart failure are atypical manifestation of GD and THD 5, but however, these were evident in this case. The reversibility of these cardiac findings are not yet entirely determined and understood. Epidemiology data on THD and Thyrotoxic cardiomyopathy are currently lacking.1

A 58-year-old Filipina with uncontrolled Graves’ Disease for 7 years presenting with  anasarca, spider angioma and pancytopenia. As an outpatient, TSH was low (0.27-4.2), free T4 and free T3 were both high. Thyroid scintigraphy showed diffuse thyromegaly with signs of hyperfunction. Carbimazole was started. Abdominal ultrasound showed hepatosplenomegaly with mildly dilated IVC. Upon admission, she was complaining of dizziness, bilateral lower extremity pain & swelling, She was dyspneic and hypotensive. There was anasarca, pallor, lid retraction, diffusely enlarged thyroid lobe. There was neck vein distention, bibasal rales, spider angiomas over the chest, systolic murmur, shifting dullness, grade 2 bipedal edema, cyanotic nail beds, fine hand tremors and left calf tenderness. 2-d Echocardiography showed dilated both atriums, ventricles with multi-segmental areas of hypokinesia, linear echogenicity in RA w/ hyperechoic density at its tip, need to rule out thrombus; EF decreased to 40%, moderated diastolic dysfunction, dilated IVC and main pulmonary artery, severe MR, TR and PR and moderate pulmonary hypertension. She was started on norepinephrine drip, digoxin and carbimazole. D-dimer was slightly elevated. Trans-esophageal echocardiography showed negative for mass and thrombus. Dipyridamole Thallium Scan showed no inducible myocardial ischemia. Carbimazole was shifted later to Propylthiouracil because of impending thyroid storm. There was worsening of leucopenia while on PTU and RAI therapy of 10 mCi was given. After 1 month, the patient improved and had no dyspnea, decrease in ascites and bipedal edema.

The unusual manifestations of GD are diverse and affect various body systems. Anasarca is a rare manifestation of hyperthyroidism unless thyrotoxicosis is so severe and chronic that it caused THD, CHF and chronic passive congestion of the liver. Epidemiologic data on THD and thyrotoxic cardiomyopathy are currenly lacking. This is due to the lack of diagnostic criteria and to the late introduction of the term thyrotoxic cardiomyopathy in clinical and research practice.1  A comprehensive history and physical examination in the background of a good knowledge on the pathophysiology of Graves’ disease is necessary to avoid misdiagnosis and unimportant laboratory and ancillary tests.


 

Nothing to Disclose: MMCL, EPP

16917 10.0000 SAT-0472 A Graves' Thyrotoxic Heart Disease: An Atypical Presentation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Eui Dal Jung Sr.*, Ho Sang Shon Sr. and Eon Ju Jeon
Catholic University of Daegu School of Medicine, Korea, Republic of (South)

 

Percutaneous ultrasound-guided Radiofrequency ablation (RFA) is a minimally invasive treatment that has been widely used as an alternative to surgery in the care of patients with malignant tumors of the liver, renal cell carcinoma, and other tumors. Recently, RFA is an alternative treatment modality for benign thyroid nodules instead of surgery, mainly for the cosmetic reasons, and limited cases of local recurrences or focal distant metastases of differentiated thyroid cancer(DTC) in the high-risk reoperative condition or for the palliative purpose. However, RFA for the initial treatment of the DTC is rare. We report a case of RFA for the papillary thyroid cancer in high-risk surgical patient. A 49-years-old woman with congestive heart failure due to severe mitral valve regurgitation, chronic kidney disease, and type 2 diabetes mellitus was incidentally diagnosed with papillary microcarcinoma without metastasis on fine-needle aspiration cytology. She underwent RFA for papillary microcarcinoma. On 5-year follow-up, there is no recurrence of the findings.

 

Nothing to Disclose: EDJ Sr., HSS Sr., EJJ

11420 11.0000 SAT-0473 A Radiofrequency Ablation for the Papillary Thyroid Cancer in High Surgical Risk Patient 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Hillary Barnes Loper*1, Ravi Kant2, Kashif M. Munir1 and Rana Malek1
1University of Maryland School of Medicine, Baltimore, MD, 2AnMed Health and Medical University of South Carolina

 

Background: Papillary thyroid cancer (PTC) accounts for approximately 80% of all thyroid cancers.   Although PTC generally follows an indolent course, distant metastases are associated with decreased survival.  Brain metastasis from a thyroid primary is extremely uncommon, only 0.15 – 1.3% of all metastatic thyroid carcinoma.(1)

 Clinical Case: A 60-year old man presented with a three month history of slurred speech, ataxia, and acute onset headache.  Imaging revealed a large intracranial hemorrhage in the right parietal region and a 4 x 3.5 x 2.5 cm mass within the hemorrhage.  A craniotomy with excision of the mass was performed with near resolution of symptoms.  Surgical pathology confirmed metastatic adenocarcinoma consistent with a thyroid primary (immunoreactive for CK7, TTF1, PAX-8, thyroglobulin).  The patient had no personal or family history of thyroid carcinoma.  Subsequent thyroid ultrasound showed an unremarkable thyroid gland and an enlarged, lobular left-sided level two lymph node without a fatty hilum.  Fine needle aspiration of the lymph node confirmed metastatic papillary thyroid carcinoma.  Laboratory evaluation showed TSH 0.75 mIU/L (0.47-4.68 mIU/L), free T4 0.88 ng/dL (0.6-2.5 ng/dL) and thyroglobulin 88.6 ng/mL (2.0-35 ng/mL).  The patient completed brain radiotherapy and is currently on levothyroxine suppression while awaiting total thyroidectomy.

Conclusion:  To our knowledge, this patient represents the first reported case of papillary thyroid cancer with metastatic spread to the brain without evidence of disease within the thyroid itself based on imaging.   Immunohistochemical analysis of the brain tumor was crucial to diagnostic accuracy, especially given a normal appearing thyroid gland.  Immunohistochemical markers used to identify thyroid lesions belong to the following categories: cell adhesion (galectin-3, E-cadherin, fibronectin [FN]), receptor signaling (RET), gene transcription control (thyroid transcription factor 1 [TTF-1]), secretion (thyroglobulin [TG], calcitonin, carcinoembryonic antigen [CEA]), cell cycle regulation (p27, cyclin D1), and cellular structure (cytokeratin). (2) In general, the presence of brain metastases portends a poor prognosis in papillary thyroid cancer. Performance status (PS) and realization of surgery or stereotactic radiosurgery (SRS), however, have been shown to impact survival of these patients.  A recent retrospective study demonstrated an overall survival of 27 months with PS <2 versus 3 months with PS ≥2 (p=0.0009), and overall survival of 11.9 months after surgery or SRS versus 3.6 months in their absence (p=0.04).(3) The finding of thyroid cancer in brain metastases, often aided by immunohistochemical analysis, requires aggressive treatment.  Neurosurgery and/or radiotherapy have been shown to improve overall survival.

 

Nothing to Disclose: HBL, RK, KMM, RM

14871 12.0000 SAT-0474 A Newly Diagnosed Papillary Thyroid Cancer with Brain Metastasis and Normal Sonographic Imaging of the Thyroid Gland 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Yin Chian Kon*1, Yingshan Lee2 and Rinkoo Dalan2
1Tan Tock Seng Hosp, Singapore, Singapore, 2Tan Tock Seng Hospital, Singapore, Singapore

 

Background: In patients with "rapid iodine-turnover, rapid responder" variant of Graves' thyrotoxicosis, serum fT4 and fT3 levels may decline precipitously upon starting anti-thyroid drug, yet escalate acutely upon ATD discontinuation. Such patients demonstrate a rapid turnover of the small intra-thyroidal iodine pool by a higher uptake of I 123 at 4 hours compared to 24 hours1. We describe 3 further cases.

Case 1: A 55-year-old Chinese female presented with weight loss due to Graves’ thyrotoxicosis: fT4 49 pM (8-21), USS thyroid isthmus 0.2 cm; right lobe 4.4 x 1.5 x 1.1 cm; left lobe 3.7 x 1.9 x 1.1 cm. After one month on oral carbimazole (CMZ) 5 mg t.i.d, serum fT4 decreased to 5 pM, fT3 3.8 pM (3.5-6). She was blocked and replaced with CMZ 15-20 mg om, LT4 75-86 mcg od. Over the next 14 months, serum fT4:11-16 pM, fT3: 3.8-6.1 pM, TSH 0.01-0.17 mIU/L (0.34-5.6). Serial serum TRAb/TSI were > 30 IU/L (<1)/>4444% (50-180) at diagnosis; >30 IU/L / 2857% at 4.5 months; 24.5 IU/L / >3076% at 13.5 months.

Case 2: A 56-year-old Chinese female presented with Graves’ thyrocardiac failure and atrial fibrillation: fT4 69 pM, USS thyroid isthmus 0.27 cm; right lobe 4.9 x 1.8 x 1.8 cm; left lobe 4.6 x 1.7 x 1.8 cm. She was anti-coagulated and started on CMZ 15 mg om. Two months later, serum fT4 decreased to 6 pM. CMZ was reduced to 5 mg om. Four weeks later, she remained biochemically hypothyroid (fT4 4 pM, fT3 3.7 pM). CMZ dose was further reduced to 2.5 mg od. Over the next 17 months, serum fT4: 7-11 pM, fT3: 3.3-5.1 pM, TSH 0.47-0.98 mIU/L. Serum TRAb/TSI decreased steadily from 5.4 IU/L / 1487% at 3 months from diagnosis to 3.0 IU/L / 287% at 20 months. Notably, fT3 remained normal, fT4 increased to normal as TRAb/TSI levels decreased towards normal.

Case 3: An 81-year-old Chinese female presented with Graves’ opthalmopathy and thyrotoxicosis: fT4 28 pM, USS thyroid isthmus 0.3 cm; right lobe 3.6 x 1.6 x 1.8 cm; left lobe 4.0 x 1.8 x 2.0 cm. After 2 months on CMZ 5 mg om, serum fT4 decreased to 8 pM.  After another 2 months on reduced CMZ dose 5 mg eod, serum fT4 rebounded to 18 pM, fT3 10.2 pM, TSH < 0.01 mIU/L, TRAb > 30 IU/L, TSI > 4444%. Over the following 28 months, CMZ was gradually titrated down from 7.5 mg (3/7) 5 mg (4/7) to 2.5 mg od. Serum fT3 measured within the normal range, while fT4 decreased from 9 pM to 5 pM and then back to 9 pM, as TRAb/TSI levels decreased (>30/>4444%-26.7-19.5-9.0-4.2-3.8/2500%-3.5), and serum TSH levels normalized.

Conclusion: These patients have small thyroid glands and yet highly elevated TRAb/TSI levels at diagnosis. Serum fT4 levels may plunge acutely on starting moderate doses of ATD. Serum fT4 may remain low or low normal, and TSH suppressed, when fT3 is normal. Both recover as the high TRAb/TSI levels decrease towards normal, concomitant with fine tapering down of CMZ dose.

References:

1. Dalan R, et al. High iodine turnover Graves' disease: the intriguing 'rapid responder' variant of thyrotoxicosis. Ann Clin Biochem 2008;45: 612-615

 

Nothing to Disclose: YCK, YL, RD

11500 13.0000 SAT-0475 A Rapid Responder Variant of Graves' Thyrotoxicosis: Clinical Characteristics and Diagnostic Clues 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Chee Kian Chew* and Rinkoo Dalan
Tan Tock Seng Hospital, Singapore, Singapore

 

Introduction

This is a case of a patient with hyperthyroidism from 2 common etiologies but a rare association. He had recurrent hyperthyroidism with Graves’ disease after an episode of subacute thyroiditis because of development of Graves’ disease.

Case Report

This  40 years old gentleman, with no known medical illness, was admitted for fever associated with painful anterior neck swelling and weight loss of 7kgs for 3 weeks. He denied any symptoms of upper respiratory tract infection or other symptoms of hyperthyroidism. On physical examination, he was febrile with temperature of 38.2 °C and tachycardic with heart rate of 102 beats per minute. His blood pressure was 145/90 mmHg. He had a tender and diffusely enlarged goiter. Signs of thyroid eye disease and other specific signs of hyperthyroidism were notably absent. Examinations of his throat, lung, abdomen, cardiovascular system and neurological system were unremarkable. There is no family history of Graves’ disease. Biochemical investigations were consistent with thyrotoxicosis secondary to subacute thyroiditis: Free T4 54 pmol/L (8-21), TSH <0.02 mIU/L (0.34-5.60), TRAb 1.4 Iu/L (<0.4) and ESR 110 mm/hr (1-10). The technetium scan showed mildly enlarged gland with decreased uptake of Tc-99m tracer suggestive of thyroiditis. His symptoms improved with Ibuprofen and Propranolol.

At 6 weeks follow up, his thyroid function normalized with Free T4 of 10 pmol/L (8-21), TSH of 0.88 mIU/L (0.34-5.60). However, on subsequent follow up at 5 months, he complained of weight loss and palpitation suggestive of recurrence. Examination revealed a small painless diffuse goiter and he was tachycardic  with heart rate of 109 beats per minute. Thyroid function test confirmed biochemical thyrotoxicosis: free T4 47.8 pmol/L (8-21) and TSH <0.02 mIU/L (0.34-5.60). Interestingly, although the TSH receptor antibody (TRAb) was normal, thyroid stimulating immunoglobulin (TSI) was elevated to 683% (50-179), confirming the diagnosis of Graves’ disease. He was then started on carbimazole.

Discussion

Subacute thyroiditis and Graves’ disease are 2 common etiologies of hyperthyroidism but the association of these 2 diseases is rare with incidence of 0.15% of the patients with Graves’ disease and 0.76% of the patients with subacute thyroditis (1). The postulated mechanism of the association is that the stress of subacute thyroiditis  itself can induce Graves’ disease. The release of thyroid antigens and corresponding activation of the immune system due to viral invasion of the thyroid gland in subacute thyroiditis may cause the subsequent Graves’ disease (1,2).

Conclusion

Graves’ disease should be suspected if there is persistent or recurrent hyperthyroidism after an episode of subacute thyroiditis although it is rare.

 

Nothing to Disclose: CKC, RD

11529 15.0000 SAT-0477 A Graves' Disease after Resolution of Subacute Thyroiditis : A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Min Ling*1, Jeff Flack1, Chuong Bui1, Seymour Atlas1, Jing Jing Li2, Tao Yang2, Sandra Harvey1 and Tang Wong1
1Bankstown-Lidcombe Hospital, Bankstown NSW, Australia, 2Liverpool Hospital, Liverpool NSW, Australia

 

Context:  Patients with differentiated thyroid carcinoma (DTC) usually respond well to surgery and radioactive iodine treatment with an excellent overall survival rate.  However, thyroid cancers with foci of poorly-differentiated histology often develop progressive and radioactive iodine resistant disease thus creating a clinical challenge for management.

Case:  A 60-year-old woman with progressive iodine-refractory thyroid cancer with skeletal and pulmonary metastases developed right sided ataxia.  Multifocal mixed papillary and poorly-differentiated thyroid carcinoma was diagnosed six years prior at total thyroidectomy for multinodular goitre.  Whole body scintigraphy following course six of I131 therapy (cumulative dose 29.7GBq) identified a new iodine-avid posterior fossa lesion.  Magnetic resonance imaging (MRI) of the brain confirmed a right posterior fossa extra-axial mass (20x23x25mm) consistent with a meningioma.  She underwent excision of the lesion and histopathology confirmed WHO-Grade-1 meningioma containing a metastatic poorly differentiated thyroid carcinoma.  Immunohistochemistry stained positive for thyroglobulin, thyroid transcription factor-1 and cytokeratin MNF116 in the metastatic thyroid carcinoma.  Despite initial resolution of cerebellar signs following metastectomy and subsequent cranial external beam radiotherapy, the patient died twelve months later from disease progression outside the central nervous system.  She was intolerant of tyrosine kinase inhibitor (Sorafenib).

Discussion:  Although the mechanism behind tumor to tumor metastasis is unknown, thyroid cancer and meningioma share some common biological, metabolic, molecular features and hormonal factors, including the presence of psammoma bodies and somatostatin receptors on both tumors, thyroid hormone receptors on meningioma cells, and possible linked gene mutations (1, 2).  Other studies have demonstrated meningiomas themselves exhibit iodine avidity on scintigraphy, in the absence of thyroid cancer, the proposed mechanism being edema and high vascularity (3, 4).

Conclusion:  This is the first reported case of poorly-differentiated thyroid cancer metastasising within an intracranial meningioma from initial multifocal mixed thyroid cancer.  Although meningiomas may physiologically concentrate I131, our case highlights the importance of excluding metastatic disease in similar patients with apparently benign lesions.  The clinical management remains a challenge in these patients with progressive radioiodine refractory disease with distant metastasis.

 

Nothing to Disclose: ML, JF, CB, SA, JJL, TY, SH, TW

14784 16.0000 SAT-0478 A Tumor within Another Tumor: An Unusual Case of Metastatic Poorly Differentiated Thyroid Carcinoma within an Intracranial Meningioma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Enver Simsek*1, Cigdem Binay2, Huseyin Ilhan3, Enver Ihtiyar3, Ilknur A.Sivrikoz1, Emine Dundar3 and Nevbahar Akcar3
1Eskisehir Osmangazi University School of Medicine, Eskisehir, Turkey, 2Osmangazi University School of Medicine, Eskisehir, Turkey, 3Eskisehir Osmangazi University School of Medicine, Eskişehir, Turkey

 

Background: Although thyroid nodules are less common in children and adolescents, the malignancy rate for nodules is higher among children and adolescents than adults. A nodule that is discovered in a patient presenting with hyperthyroidism is usually a benign nodule or benign toxic adenoma and, thus, nodules are biopsied only infrequently.

Objective: To report a case of papillary thyroid carcinoma presenting with a hyperfunctioning (hot) thyroid nodule.

Case report: A 14-year-old female presented with symptoms of thyrotoxicosis and multi-nodular goitre. Laboratory findings were consistent with the diagnosis of thyrotoxicosis. Thyroid ultrasonography showed an enlarged thyroid gland with cystic and solitary nodules, diffuse heterogeneous echo, and microcalcifications. Doppler scans revealed increased vascularity within the left thyroid lobe and a solitary nodule. Thyroid scintigraphy revealed an autonomous nodule. Cytological examination of fine-needle aspirations from the solid nodule and left thyroid lobe revealed papillary thyroid carcinoma. The patient underwent total thyroidectomy. Histopathology of the thyroid gland and lymph nodes were also consistent with papillary thyroid carcinoma with nodal metastases.

Conclusion: Contrary to the guidelines published by major endocrine societies, the detection of an autonomously functioning thyroid nodule in children and adolescents does not exclude the possibility of thyroid carcinoma. Suspicious hot nodules should be evaluated cytologically.

 

Nothing to Disclose: ES, CB, HI, EI, IA, ED, NA

11557 17.0000 SAT-0479 A Metastatic Papillary Thyroid Carcinoma in an Autonomous Hyperfunctioning Thyroid Nodule in an Adolescent 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Rochelle Celestino Lingad-Sayas*1 and Gia Dimayuga Wassmer2
1Makati Medical Center, Makati, Philippines, 2Makati Med Cntr, Makati City, Philippines

 

Background: In some studies linking Hashimoto’s Thyroiditis with the occurrence of Papillary thyroid carcinoma, some even MicroPapillary Carcinoma, conflicting findings in their co-occurrence were cited- some related to lower tumor stage and better prognosis in Papillary Carcinoma while others with multifocal and bilateral disease in MicroPapillary Carcinoma. This is a case of an incidental Micropapillary Carcinoma in the background of Hashimoto’s Thyroiditis found to have Central Lymph Node and Paratracheal Metastasis.

Clinical case: A 34-year old woman, a diagnosed case of recurrent parotid gland carcinoma, was found incidentally on metastatic work-up to have Multinodular Nontoxic Goiter with nodules the largest of which is 0.82 cm. On physical examination, the right lobe is palpable, firm, irregularly shaped, and nodular while the left lobe is hardly palpable.  Patient was admitted for Excision of recurrent Adenoid Cystic Carcinoma of right parotid gland and possible near total or total thyroidectomy with frozen section.  Intra-operatively, the left lobe and isthmus was sent for frozen section with the finding of Hashimoto’s Thyroiditis, with this the surgeon proceeded to Total thyroidectomy with Central Node dissection.  On follow-up, final histopathologic diagnosis is Metastatic Papillary Microcarcinoma, tumor size of 0.2 cm at left thyroid lobe.   Metastasis noted in two Level 6 lymph nodes in the right and one paratracheal lymph node.  Also, Hashimoto’s Thyroiditis, right and left thyroid lobes was confirmed by the final report.  Calcium and levothyroxine was started and titrated accordingly.  Two months after surgery, patient was referred for RAI with which she received 150mci. A whole body scan post-RAI was done revealing functioning thyroid residual in the anterior cervical region with no evidence of distant functioning metastasis.  Six months after RAI, levothyroxine replacement was withdrawn, and tests were done revealing high TSH 153.111 (0.27-3.75 uiu/ml), low Thyroglobulin 0.111 (2-70 ng/ml), and high Anti-Thyroglobulin 712.24 (up to 100 iu/ml).  A repeat whole body scan was done showing no functioning thyroid tissue and no evidence of distant metastasis.  Patient is currently on suppressive doses of levothyroxine and calcium supplements.      

Conclusion: This case illustrates not only the potential for co-occurrence of Hashimoto’s Thyroiditis and Micropapillary Carcinoma of the Thyroid, but also the possibility of metastatic disease.

 

Nothing to Disclose: RCL, GDW

15569 18.0000 SAT-0480 A Incidental Metastatic Micropapillary Carcinoma in the Background of Hashimoto's Thyroiditis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Thanh Duc Hoang*1, Diane U Elegino-Steffens2, Patrick Malafronte2, Vinh Quang Mai2, Patrick W Clyde2 and K.M Mohamed Shakir2
1Naval Medical Center San Diego, San Diego, CA, 2Walter Reed National Military Medical Center, Bethesda, MD

 

Background:  It is generally considered that thyroid Fine Needle Aspiration Biopsy (FNAB) has low sensitivity to diagnose medullary thyroid cancer (MTC).  Herein we report a patient with a family history of MTC in whom a diagnosis and extent of the disease was made by FNAB of bilateral thyroid lobes and by determination of calcitonin, procalcitonin and carcinoembrogenic antigen (CEA) levels in FNAB samples.

Clinical case:  A 41-year-old female presented with a family history of MTC in her mother. Physical examination revealed a 20-gm thyroid gland without any palpable nodules or abnormal cervical lymphadenopathy. Thyroid US showed two hypoechoic nodules 0.6 cm and 0.4 cm in the superior right lobe; and FNAB revealed benign follicular cells. However, upon repeat FNAB of the parenchyma in both lobes scattered atypical cells and a clump of amorphous material in the background colloid suspicious for amyloid were observed. A baseline serum calcitonin was 58 pg/mL (ref 0.0-5.0), which peaked to 889 pg/mL under calcium stimulation. Her 55-year-old mother was found to have a left 5.4 cm hypoechoic nodule with coarse calcification confirmed by thyroid US; and FNAB showed clusters of follicular cells with absent colloid suggesting follicular neoplasm. A baseline serum calcitonin level was 1797 pg/mL (ref 0.0-5.0).  Histopathological examination following surgery confirmed a left superior 2 cm MTC.  

In our patient’s FNAB aspirates, calcitonin levels in the right and left lobe were measured 3360 pg/mL and 3380 pg/mL; procalcitonin levels were 192 ng/mL and 186 ng/mL; and CEA levels were 158 ng/mL and 144 ng/mL, respectively.  A presumptive diagnosis of MTC was made and the patient underwent total thyroidectomy with central lymph node dissection. Histopathological examination confirmed a 7 mm MTC in right lobe, 8 mm MTC in left lobe, areas of C- cell hyperplasia, and amorphous material consistent with amyloid.  RET proto-oncogene studies revealed MEN2 and FMTC mutations, exons 10, 11, 13-16, consistent with a heterozygous mutation.

Conclusion:  Data are sparse on the use of calcitonin, CEA and procalcitonin levels in FNAB aspirates of patients suspected for MTC. Our case report illustrates that they may prove useful especially in combination with FNAB of the thyroid parenchyma, in addition to routine nodular sampling.  However, further studies are needed.

 

Nothing to Disclose: TDH, DUE, PM, VQM, PWC, KMMS

11561 19.0000 SAT-0481 A Usefulness of Fine Needle Aspiration Biopsy Calcitonin Levels to Diagnose Medullary Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Weiying Lim*, Dawn Shao Ting Lim, Chiaw Ling Chng and Adoree Yi Ying Lim
Singapore General Hospital, Singapore, Singapore

 

BACKGROUND:

Most pituitary metastases are derived from breast, lung and gastrointestinal tract adenocarcinomas. Pituitary metastases from thyroid carcinoma are very rare. Pituitary metastases are found in about 1% of all pituitary resections and about 2% are from thyroid carcinoma. A PUBMED search revealed 22 reported cases of pituitary metastases from thyroid carcinoma- 11 follicular, 8 papillary, 2 medullary and 1 insular. The commonly reported presenting symptoms to suggest pituitary metastases in these cases include cranial nerve involvement (in particular optic nerve, oculomotor nerve, trochlear nerve) and hypopituitarism. Hypopituitarism was more often associated with papillary and medullary rather than follicular thyroid carcinoma. Treatment strategies include neurosurgery, radioiodine, external radiotherapy and radiosurgery. Prognosis was poor for most cases and cure was only described in 1 case of papillary thyroid carcinoma.

CLINICAL CASE:

A 50 year old woman presented with neck swelling, hoarseness, dyspnoea and dysphagia. Positron emission tomography (PET) scans revealed locally aggressive thyroid carcinoma with metastases to lymph nodes and bone. She had a total thyroidectomy and laryngectomy with bilateral neck dissection. Histology revealed poorly differentiated thyroid carcinoma. She developed giddiness and magnetic resonance imaging(MRI) showing pituitary metastases. She was started on radiotherapy but continued to develop ptosis and diplopia. She did not have diabetes insipidus and had normal anterior pituitary function. She was given a course of radioactive iodine of 200mci with no improvement and passed away few months later.

A 65 year old woman presented with loss of appetite and weight, increased goitre size and dyspnoea. CT scan done to assess degree of airway obstruction incidentally revealed a pituitary mass. MRI showed a large pituitary mass with mass effect. Formal ophthalmology review showed right central scotoma with left inferior hemifield defect. She also had diabetes insipidus and panhypopituitarism. She had a total thyroidectomy and histology revealed thyroid follicular carcinoma. She underwent a transsphenoidal resection of pituitary mass which confirmed pituitary metastases from thyroid follicular carcinoma. 2 doses of radioactive iodine (250mCi) was given but unfortunately developed intraventricular haemorrhage during the last admission with eventual demise.

CONCLUSION:

Pituitary metastases from thyroid carcinoma are rare, but including our 2 cases have been reported from all types of thyroid carcinoma. As illustrated in our 2 cases, cranial nerve involvement tends to be the first presentation. Despite aggressive therapy, prognosis tends to be poor. Early diagnosis and collaborative management with neurosurgeons, radiation oncologists, nuclear medicine physicians and endocrinologists is important.

 

Nothing to Disclose: WL, DSTL, CLC, AYYL

17106 20.0000 SAT-0482 A Thyroid Carcinoma with Pituitary Metastasis: 2 Case Reports and Review of Literature 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Josh Matthew Lakoff*, Syed Ali Imran and Churn-Ern Yip
Dalhousie University, Halifax, NS, Canada

 

Objective: Thyroid cancer incidence is on the rise. While most cases are identified through evaluation of thyroid nodules, other histologic findings are important clues and should raise suspicion for occult malignancy

Case Presentation: A 43 year-old male of African descent was evaluated for intractable hiccups associated with vomiting and 40lbs of weight loss. Investigations revealed bilateral hilar and mediastinal adenopathy with partial collapse of the left lower lobe and slight reduction in diffusion capacity. Biopsy by bronchoscopy and mediastinoscopy identified non-caseating granulomas as well as psamomma bodies. A short course of prednisone for presumed sarcoidosis completely resolved the lung abnormalities and pulmonary function testing with no improvement of the primary complaint. Ultrasound of the thyroid gland revealed a 3.3mm hypoechoic nodule in the right lobe and a 2mm focus on the left. Fine needle biopsy was benign for the left nodule but the right side was malignant and consistent with papillary thyroid carcinoma. Total thyroidectomy was performed and surgical pathology showed multifocal micropapillary carcinoma of classic variant with three tumours (largest 5mm) with evidence of capsular and probable lymphovascular invasion. One of two level VI lymph nodes were involved. The patient now awaits iodine ablation. The weight loss has stabilized but the hiccups persist.

Discussion: Psamomma bodies (PB) are round, dark, glassy appearing structures that form by concentric lammelated calcification. PB are most commonly associated with papillary thyroid carcinoma (PTC) where they have been seen in up to 50% of cases. It has been suggested that this is an adaptive process that leads to apoptosis, preventing the growth and spread of neoplastic cells. PB are seen in one quarter of thyroid fine needle aspiration biopsies and can be detected on thyroid ultrasound. When identified, their presence is positively correlated with gross lymph node metastases and higher TNM staging and a tendency towards extrathyroidal extension.

Sarcoid reaction refers to lymphadenopathy demonstrating non-caseating granulomas in the absence of systemic findings of sarcoidosis. There have been several case reports documenting sarcoid reaction in the setting of PTC, typically in regional lymph nodes. This may be a local tissue response and defence mechanism against carcinoma.

 Conclusion: This case highlights the diagnostic and prognostic value of psamomma bodies in the setting of papillary thyroid carcinoma. We provide some guidance for properly investigating this finding when noted outside the context and location of suspected malignancy. Clinicians should also be aware of the rare association of sarcoid reaction with thyroid malignancy.

 

Nothing to Disclose: JML, SAI, CEY

11649 21.0000 SAT-0483 A Psamomma Bodies and Sarcoid Reaction in Occult Papillary Carcinoma: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Xiaolan Lian*
Peking Union Medical College hospital, CAMS and PUMC, Beijing, China

 

Hypothyroidism is very common, about one in 300 American person. Most patients with hypothyroidism will require lifelong thyroid hormone replacement. Levothyroxine ( L-T4) is as therapy for the treatment of hypothyroidism. Hypersensitivity reactions to L-T4 are rare. However, it must be faced problems how to deal with hypersensitivity reactions to L-T4 because of the lack of alternative medicine. This report presents three cases with L-T4 hypersensitivity reaction and review the solution of hypersensitivity reactions of L-T4. Case 1, a 33-year-old woman presented because of subclinical hypothyroidism and Hashimoto’s thyroiditis. She was prescribed 25μg L-T4 (Letrox, BERLIN_CHEMIE, Germany). Approximately 24 hours after the first dose she had generalized urticarial, facial angioedema. These symptoms were aggressive when she continued to take the medication. She did not take the drug after three days. The pattern gradually disappeared after 7 days. After one month, she was prescribed another L-T4( Euthyrox, Meck-Serono,Germany),6.25μg qd for two weeks without any symptoms. Then the dose of L-T4 was gradually increased to 50μg qd during three months. She denied the recurrence of symptoms. Case 2, a 38-year-old woman refereed to our clinic with subclinical hypothyroidism. She was prescribed Letrox 37.5μg qd. She had abdominal pain and diarrhea about one hour after the first dose. The same symptoms had appeared when she took the drug for three consecutive days. These symptoms disappeared when she withdrawn the medication. After one month, she was prescribed another L-T4( Euthyrox, Meck-Serono,Germany), 6.25μg qd for two weeks without any symptoms. Then the dose of L-T4 was gradually increased to 50μg qd. Case3, a 32-year-old woman presented because of hypothyroidism. She prescribed Euthyrox,25μg,qd. She had fever on that day of taking the medication. The same symptoms had appeared when she took the drug again. The fever disappeared when she did not take the medication. Then she was prescribed desiccated thyroid,20mg qd. She denied the recurrence of symptoms. Besides these, hypersensitivity reactions of L-T4 have liver damage, epilepsy, asthma in published articles. Management of hypersensitivity reaction of L-T4 may replace L-T4 from different manufacturers or desiccated thyroid at first. If it fails, desensitization to L-T4 will be processed.

 

Nothing to Disclose: XL

13555 22.0000 SAT-0484 A Management of Hypersensitivity Reactions of Levothyroxine 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Henrique Vara Luiz*, Bernardo Dias Pereira, Tiago Nunes Silva, Andreia Veloza, Ana Catarina Matos, Isabel Manita, Maria Carlos Cordeiro, Luísa Raimundo and Jorge Ralha Portugal
Garcia de Orta Hospital, Almada, Portugal

 

Introduction: Thyroid hormone resistance (THR) is a rare entity, characterized by reduced tissue response to thyroid hormone action. In most cases, it is caused by mutations in the thyroid hormone receptor beta (THRB) gene and usually presents with goiter associated with high levels of FT3 and FT4 and non-suppressed TSH. The main differential diagnosis is inappropriate TSH secretion from a pituitary adenoma. The association of THR and differentiated thyroid carcinoma (DTC) is extremely rare (9 cases described in the literature), and the oncologic management of these patients is challenging, given the difficulty in reaching TSH suppression.

Clinical case: A 27-year old Portuguese man presented with a thyroid nodule identified by cervical ultrasound. He was being treated for 4 years with levothyroxine (L-T4) 75mg/day and his mother and maternal aunt underwent total thyroidectomy for papillary carcinoma at a young age. He had no symptoms of thyroid dysfunction. Laboratory testing (treated with L-T4) revealed an elevated TSH level of 4.8mU/L [0.4-4.5], a high FT4 level of 2.6ng/dL [0.9-1.7] and FT3 level of 209ng/dL [70-204], and negative thyroid autoantibodies. Reviewing previous exams of the patient we found that his thyroid function demonstrated the same pattern prior to L-T4 prescription. Cervical ultrasound identified a mixed nodule located on the left lobe, with microcalcifications, measuring 15mm of maximal dimension. Ultrasound-guided fine needle aspiration cytology was consistent with papillary carcinoma. The patient was submitted to total thyroidectomy with no surgical complications, and histological examination confirmed the diagnosis of papillary thyroid carcinoma, classic type, with 1x0,5cm (T1N0M0). For this reason radioiodine therapy was not performed. After surgery very elevated levels of TSH persisted, despite good compliance to increasing dosages of L-T4. Nine months after the surgical intervention, treated with L-T4 200mg/day, our patient had a TSH measurement of 144mU/L and a FT4 level of 3.03ng/dL, with a tiroglobulin value of 1.6ng/mL and negative thyroid autoantibodies. He was still clinically euthyroid. Basal pituitary function, alpha subunit and pituitary MRI were normal. Genetic analysis identified a mutation in the THRB gene (R243W), which was not found in his parents.

Conclusion: We present a case of DTC associated with THR. Resistance to thyroid hormone was only suspected after surgery but the patient already had a thyroid function consistent with this diagnosis prior to total thyroidectomy. Despite increasing doses of L-T4, TSH levels remained elevated. Additional therapeutic options to attempt TSH suppression are L-T3 and triiodothyroacetic acid (TRIAC).

 

Nothing to Disclose: HVL, BDP, TNS, AV, ACM, IM, MCC, LR, JRP

11746 23.0000 SAT-0485 A Management of Differentiated Thyroid Carcinoma in a Patient with Thyroid Hormone Resistance: Difficulties and Challenges 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Francesco Latrofa*1, Maria Antonietta Altea1, Michele Marino2, Francesca Menconi1, Marenza Leo1, Eleonora Sisti1, Maria Antonietta Profilo1, Paola Lepri1, Marco Nardi1, Paolo Vitti2, Claudio Marcocci1 and Roberto Rocchi1
1University of Pisa, Italy, 2University Hospital, Pisa, Italy

 

Context. Total thyroid ablation (TTA) (near-total thyroidectomy followed by radioiodine [131I] ablation after L-T4 withdrawal) was shown to be more effective compared to near-total thyroidectomy alone on the short-term evolution of patients with mild to moderate Graves’ ophthalmopathy (GO) treated with i.v. glucocorticoids. A similar beneficial effect could be postulated in patients with moderate to severe GO. TTA is the usual treatment of differentiated thyroid carcinoma.

Patient findings. We report on two patients with moderate to severe GO and papillary thyroid cancer who developed dysthyroid optic neuropathy (DON) concomitantly to hypothyroidism due to L-T4 withdrawal for 131I ablation.

Patient #1, a 55 years old woman with a goiter and a multifocal papillary thyroid cancer, had an active [Clinical Activity Score (CAS)=5/7], moderate to severe GO at the time of thyroidectomy. At CT scan the diameter of the right and the left medial-rectus muscles was 8 and 10 mm, that of the right and the left lateral-rectus muscles 8 and 10 mm, respectively. After L-T4 withdrawal, left eye visual acuity decreased from 10/10 to 1/10 and the omolateral visual field was impaired. After radioiodine treatment, euthyroidism was rapidly restored with T4 and T3 and GO was treated with i.v. glucocorticoid. Nevertheless, visual acuity was not restored and orbital decompression was then performed.

Patient #2, a 50 years old man with a large goiter and an occult bilateral papillary thyroid cancer had an active (CAS=3/7), moderate to severe GO at the time of thyroidectomy. The diameter of the right and the left rectus-inferior eye muscles was 10 and 12 mm, respectively. After L-T4 withdrawal the patient developed a right DON: visual acuity decreased from 10/10 to 4/10 and the omolateral visual field was impaired. Following 131I radioiodine treatment, euthyroidism was rapidly restored with T4 and T3. Treatment with i.v. glucocorticoids yielded a prompt normalization of the visual acuity.

Conclusions. In moderate to severe GO, DON can be precipitated by acute hypothyroidism/hyperthyreotropinemia, suggesting that hypothyroidism should be avoided in patients with such grade of GO.

 

Nothing to Disclose: FL, MAA, MM, FM, ML, ES, MAP, PL, MN, PV, CM, RR

14463 24.0000 SAT-0486 A Hypothyroidism Due to L-T4 Withdrawal Can Precipitate Optic Neuropathy in Patients with Moderate to Severe Graves' Ophthalmopathy: Report on Two Cases 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Suhalia Bakerywala*1, Monica D Schwarcz2, Michael D. Goldberg2, Guy Valiquette2 and Irene A Weiss3
1New York Medical College, Valhalla, NY, 2Westchester Medical Center, 3Westchester Medical center

 

BACKGROUND: Tyrosine kinase inhibitors (TKIs) are frequently used therapy for various malignancies.Thyroid related side effects appear to be rare. We present a patient with thyrotoxicosis induced by TKI.

CASE: A 53 year old woman with Chronic myeloid leukemia presented to the emergency department with new onset atrial fibrillation.She gave a one week history of acute onset enlargement and tenderness of her thyroid gland and dysphagia along with palpitations, anxiety and tremors.The patient denied any recent illness, fevers, chills,colds etc. She had been started on Nilotinib,a TKI two weeks prior to presentation.Physical examination showed an irregularly irregular tachycardia of 120-150bpm.On exam, the thyroid gland was enlarged at about 60 grams,firm and tender and without bruits.No lymphadenopathy was noted. A fine tremor was noted in outstretched arms.Laboratory investigations revealed a hematocrit of 21.2%,a white blood count of 4.6K/mm2 and a platelet count of 26K/mm2.Chemistry prolife was normal.An elevated ESR at 80 mm/hr, a suppressed TSH of 0.003mIU/L, an elevated total T3 of 229.6 ng/dL, a free T4 of 4.6 ng/dL and thyroid stimulating immunoglobulin of 65% (negative).The patient was treated with propranolol and  cardiazem for heart rate control, with hydrocortisone 100 mg IV q8h and she was admitted to the Medical Intensive Care Unit.Atrial fibrillation resolved with beta and calcium channel blockers.The thyroid swelling decreased rapidly and the patient reported that her pain was significantly reduced over the next 2-4 days.A slow taper of steroids was initiated. A thyroid uptake and scan showed a 24 hour uptake of 1.7%.Over a four day period on high dose steroids,the total T3 levels decreased from 229.6 to 67.2 ng/dL and the free T4 from  4.6 to 2.6 ng/dL;the TSH level remained suppressed.

DISCUSSION: There have been several clinical reports of Sumanitib induced thyrotoxicosis (1) and we found one report of Nilotinib induced hypothyroidism(2).Partial inhibition of tyrosine kinase of pituitary or hypothalamic thyroid hormone transporter(TH) feedback may alter the metabolism of TH and contribute to TKI mediated impairments of thyroid function. Investigators suggest that a destructive thyroiditis occurs through follicular cell apoptosis (3).It also remains unclear whether the thyroid dysfunction seen with TKIs is mediated by an autoimmune mechanism such as IL2 and alpha-interferon (3).

CONCLUSION: Prospective trials are needed to define the incidence of thyroid dysfunction during therapy with many newly approved TKIs for various malignancies. Periodic surveillance of thyroid function during tyrosine kinase inhibitor therapy is recommended.

 

Nothing to Disclose: SB, MDS, MDG, GV, IAW

11848 25.0000 SAT-0487 A Tyrosine Kinase Inhibitor Induced Thyrotoxicosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Lisa Kenigsberg*1, Yelena Kogelman2, Genna Waldman Klein2, Hnin Khine2 and Leslie S Lam2
1Children's Hospital at Montefiore, Bronx, NY, 2Montefiore Medical Center, Bronx, NY

 

Introduction: Thyrotoxic Periodic Paralysis (TPP) is a rare complication of thyrotoxicosis involving a massive intracellular shift of potassium, resulting in hypokalemia and muscle paralysis. It has been well-described in individuals of Asian descent, with an incidence of 1.8-1.9% among Asian thyrotoxic patients. However, TPP remains much less common in the US, with an incidence of 0.1-0.2% among thyrotoxic patients.1 It is rarely reported in Hispanic individuals.

Clinical Case: A 20 year-old Hispanic male presented with significant muscle weakness. One day prior to presentation, he ate 6 candy bars and later developed severe muscle weakness in his extremities. The next morning, he was found by his mother to be unable to get out of bed and was taken to the Pediatric ED. The patient had a similar episode 3 months prior which self-resolved; therefore, he did not seek medical attention.

History was significant for anxiety disorder and a 40lb weight loss. His exam was significant for hypertension, tachycardia, and 2/5 strength in his proximal muscles. He was noted to have a large goiter, a fine tremor, and tongue fasciculations. Blood work revealed hypokalemia. Thyroid function tests were sent which revealed hyperthyroidism.

He was diagnosed in the Pediatric ED with TPP and hyperthyroidism, later confirmed through antibody testing to be due to Graves’ disease. He was admitted to the PICU and started on IV fluids with potassium, Methimazole, and Propranolol. His potassium was monitored closely and after 12 hours had normalized with a resultant improvement in his strength. The patient was discharged home on Methimazole and Propranolol and paralysis has not recurred. He is scheduled for radioiodine ablation next month.

Conclusion: This case emphasizes the age and ethnic diversity seen in patients with TPP. When a patient presents to a pediatric ED with hypokalemia, gastrointestinal or urinary loss is frequently the primary cause. If acute muscle weakness is present, familial hypokalemic periodic paralysis is added to the differential. In our predominately Hispanic population, TPP is not often entertained.  In fact, this is the first pediatric patient diagnosed with this condition at our institution in over 10 years.

TPP is a difficult condition to recognize. The reported average delay to diagnosis is almost 14 months.2 Yet, with a careful history and exam, the astute clinician can make the correct diagnosis at initial presentation.  

 

Nothing to Disclose: LK, YK, GWK, HK, LSL

13958 26.0000 SAT-0488 A Thyrotoxic Periodic Paralysis in the Pediatric ED: An Unusual Case in a Hispanic Male 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Taiga Inoue*1, Gul Bahtiyar2, Brooks Mirrer3, Ronny Cohen3 and Alan Scott Sacerdote4
1Woodhull Medical & Mental Health Center, Brooklyn, NY, 2NYU School of Medicine, New York, NY, New York, NY, 3NYU School of Medicine, Brooklyn, NY, 4Woodhull Med & Mental Hlth Ctr, Brooklyn, NY

 

Background: Secondary pulmonary hypertension is a known complication of hyperthyroidism, and it can lead to dilatation of the right atrium and ventricle and ultimately to right-sided heart failure. It has also been shown that in an individual with patent foramen ovale (PFO), right-to-left intracardiac shunt can be observed in the presence of elevated right atrial pressure.

Case Report: Here we report a case in which we observed resolution of right-to-left shunt through PFO with treatment of hyperthyroidism in a 41-year-old Scandinavian female who was newly diagnosed with Grave's disease, presenting with dyspnea at rest, palpitations, diaphoresis, tremor, and photophobia. She was noted to have chemosis, stare, and thyroid bruit. Serum TSH by chemiluminescence was 0.013 (0.4-5.5) mIU/L, total T4 by chemiluminescence was >30.0 (4.5-12.0) mcg/dl, T3RU by spectrophotometry was 53.89 (22.50-37.0) %, total T3 by immunoassay was >800 (60.0-181.0) ng/dl. TSIG by bioassay was 500 (<140) % Baseline. Baseline transthoracic echocardiogram (TTE) at the initial presentation revealed severe tricuspid regurgitation, pulmonary arterial pressure of 60mmHg, and atrial septal defect (ASD) of secundum/PFO type with right-to-left shunt. The patient was started on methimazole 10 mg daily for treatment of Grave's disease. Approximately 8 weeks after the initial TTE, repeat study was performed, which demonstrated only mild pulmonary arterial hypertension and no evidence of the previously demonstrated ASD.

Conclusions:

  • We postulate that the severe pulmonary hypertension leads to an elevated right atrial pressure, and recurrence of a pre-existing PFO served as a conduit for the right-to-left intracardiac shunt.
  •  With the aforementioned treatment of Graves's disease, this right-sided hypertension improved, leading to resolution of the PFO.  This is the first reported case of resolution of PFO  with improvement of hyperthyroidism.

 

Nothing to Disclose: TI, GB, BM, RC, ASS

11922 27.0000 SAT-0489 A Resolution of Intracardiac Shunt with Methimazole in a Patient with Hyperthyroid Graves' Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Yelena Kogelman*1, Lisa Kenigsberg2 and Leslie S Lam1
1Montefiore Medical Center, Bronx, NY, 2Children's Hospital at Montefiore, Bronx, NY

 

Introduction: Thyroid cancer is a rare diagnosis in children with an annual incidence of 0.54 per 100,000 children1. It is even rarer in association with Graves’ disease in children. When it does occur, the disease is often more invasive than in adults.

Clinical Case: An 8 year old, previously healthy girl presented to her primary care doctor with auditory hallucinations. Prior to being started on anti-psychotic medications, thyroid function tests were sent which showed hyperthyroidism. Physical exam revealed a smooth and symmetric goiter but no discrete nodules and no lymphadenopathy. Further workup showed strongly positive anti-thyroglobulin and anti-thyroperoxidase antibody titers as well as elevated thyroid stimulating immunoglobulins at 407% (<141%). A thyroid ultrasound revealed a markedly enlarged heterogeneous gland with a focal mass in the left lower lobe measuring 2.8 cm with central calcifications. FNA of the nodule confirmed a diagnosis of papillary thyroid cancer, follicular variant.

She underwent a total thyroidectomy with central and lateral neck dissection and was found to have locally invasive disease with bilateral cervical node metastases and extra- thyroidal extension into the skeletal muscles of the neck. A diagnostic radioactive iodine scan revealed diffuse metastasis to the lungs. She was treated with 64 mCi I-131 for thyroid remnant ablation and placed on high dose Synthroid for hypothyroidism and TSH suppression. One year after RAI therapy, she has no detectable disease on surveillance whole body scan. She continues to have persistent anti-thyroglobulin antibodies.

Conclusion: Current guidelines do not recommend routine thyroid ultrasounds for pediatric cases of autoimmune hyperthyroidism. However, thyroid nodules and cancer can be found in children with Graves’ disease. When thyroid cancer is diagnosed in children it tends to be more aggressive than in adults. This case illustrates that it may be prudent to consider routine thyroid ultrasound in the evaluation of autoimmune hyperthyroidism in the pediatric population.

 

Nothing to Disclose: YK, LK, LSL

14033 28.0000 SAT-0490 A An Unusual Pediatric Case of Invasive Papillary Thyroid at Presentation of Graves' Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Cecile N Chougnet*1, Isabelle Borget1, Network Tuthyref2 and Martin Schlumberger1
1Gustave Roussy, Villejuif, France, 2TUTHYREF, France

 

Introduction: A randomized phase 3 trial on metastatic or locally advanced medullary thyroid cancer (MTC) showed that vandetanib treatment is effective, leading to Regulatory Approvals in US and EU, but its use is associated with significant toxicities. The objective of the present study was to describe the toxicity profile and response rate of vandetanib treatment in real life conditions in France.

Methods: 68 patients were treated with vandetanib in the frame of a temporary use authorization (called ATU) in France from August 2010 to February 2012, drug was available on physician's request for locally advanced or metastatic MTC, with patient’s agreement for data collection for safety. In this independant study, patients' characteristics, treatment parameters, toxicity profile and efficacy were retrospectively collected for all patients. 8 patients were excluded from the analysis because either vandetanib was not started (n=2) or had been given in a trial before ATU (n=3), or was given for a non MTC cancer (n=2).

Results: Data from the 60 MTC patients who were treated with vandetanib were analyzed. Mean age was 58 years [11-83], 39 patients were males, and 6 patients had a hereditary MTC. 56 (93%) had metastatic disease in the mediastinum (82%), bones (65%), liver (53%) and lung (53%), and 4 had locally advanced disease. Previous treatments were: surgery (49 patients), chemotherapy (7 patients) and other tyrosin-kinase inhibitors (3 patients). Median follow-up was 20 months from initiation of vandetanib treatment. Median duration of vandetanib treatment was 10 months (range: 0.3 to 36 months), and 15 patients are still treated with vandetanib (range 18 to 36 months); 23 patients discontinued treatment for disease progression. Best tumor response was a complete response in one patient, a partial response in 12 (20%), stable disease in 33 (53%) and progression in 12 (20%); 2 patients died before any tumor evaluation. All patients had at least one adverse event (AE) during treatment: main AE were folliculitis, diarrhea and asthenia. Grade 3 and 4 toxicities were documented in 21 and 6 patients, respectively. Dose reduction were reported in 19 patients and 16 patients discontinued treatment for toxicity. One patient with severe diarrhea, related to disease progression 7 months after vandetanib was started, died from heart failure after severe hypokaliemia.

Conclusion: Vandetanib is an option for these MTC patients for its efficacy but AE should be monitored carefully and should be minimized by educating patients and care providers.

 

Disclosure: CNC: I received research support via the TUTHYREF network, AstraZeneca set up the ATU and managed drug supply. MS: Board Member, Astra Zeneca, Clinical Researcher, Astra Zeneca. Nothing to Disclose: IB, NT

12002 29.0000 SAT-0491 A Efficacy and Toxicity of Vandetanib for Advanced Medullary Thyroid Cancer Treatment in Real Life Conditions 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Su Kyoung Kwon*1, Bu Kyung Kim2, Young Sik Choi3 and Yo-Han Park4
1Kosin University College of Medicine, Busan, Korea, Republic of (South), 2Kosin Univ Sch of Med, Busan, Korea, Republic of (South), 3Kosin University College of Medicine, 4Kosin University College of Medicine, Busan

 

Background: Thyroid storm is a rare and potentially life threatening medical emergency. We experienced a case of thyroid storm associated with sepsis caused by pneumonia, which had a catastrophic course, including recurrent cardiac arrest and subsequent multiple organ failure (MOF).

Clinical case: 22 years old patient with 10 years history of Graves’ disease was transferred to our hospital because of heart attack following dyspnea and fever for 1 month. She had a heart attack at her home just after the arrival of emergent medical technician and was recovered after cardiac resuscitation. Just after arriving at ER, she had a second heart attack and her heart was recovered again after 20 minutes of cardiac resuscitation. She was diagnosed with thyroid storm associated with Graves’ disease complicated by pneumonia and sepsis. Burch and Wartofsky score was 110. In spite of full conventional medical treatment of thyroid storm after emergent cardiac resuscitation and general supportive management, she had shown progressive MOF and hemodynamic unstability. Because of hepatic failure and refractory hypotension below 70/40mmHg, we reduced the amount of beta blocker and antithyroid drug and could not start therapeutic plasmapheresis for removal of thyroid hormones. We had started continuous veno-venous renal replacement treatment (CRRT) with intra-venous albumin and plasma supplementation for the treatment of acute kidney injury associated with hypotension and sepsis. After initiation of CRRT, the body temperature and pulse rate of the patient began to be stabilized immediately, whithin 1 hour and 3 hours later, the blood pressure was reached to 120/60mmHg. The blood levels of thyroid hormone and liver enzyme that was examined the following day showed marked improvement. We stopped antithyroid drug 3 days after initiation of CRRT because of aggravating hyperbilirubinemia. The patient had shown progressive improvement of thyroid function even after cessation of antithyroid drug and was successfully recovered from thyroid storm.

Conclusion: This is the first case of thyroid storm that was successfully treated by only CRRT not combined with plasmapheresis in case that was unfit for using antithyroid drug.

 

Nothing to Disclose: SKK, BKK, YSC, YHP

16761 30.0000 SAT-0492 A Successful Treatment of Thyroid Storm Associated with Multiorgan Failure after Cardiac Resuscitation By Continuous Renal Replacement Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Mark Henry Joven*1 and Robert J Anderson2
1Creighton University, Omaha, NE, 2VA - Nebraska Western Iowa Healthcare System / Creighton University Medical Center, Omaha, NE

 

Background: Thyroid nodules associated with a subnormal TSH usually are evaluated with a radionuclide scan and thyroid uptake to identify a potential autonomous nodule prior to consideration of FNAB because of the low malignancy risk. We present a patient in whom a “hot” nodule turned out to be an aggressive follicular carcinoma with pulmonary metastases and subclinical hyperthyroidism.

Clinical Case: An 85-year-old female with atrial fibrillation and early Alzheimer's dementia was referred to our clinic for an enlarging right thyroid nodule. The nodule, initially the size of her fingertip, grew to golf ball size over 4 months. She had associated hoarseness, but no other compressive symptoms. She complained of alternating diarrhea and constipation. Examination revealed a non-tender 5.5 x 3 cm thyroid mass on the right with slight leftward tracheal deviation. Laboratory results: TSH-0.34 uIU/ml (ref: 0.5-5.0); FT4-1.1 ng/dl (ref: 0.6-1.6); TSI-125% (ref: 0-129). Ultrasound showed an enlarged right thyroid lobe with a large heterogeneous mass (4.2 x 3.4 x 4.1 cm) with an inferior curvilinear coarse calcification. Thyroid scan showed an inferior right lobe dominant “hot” nodule with relative suppression of the uninvolved gland. The 4-hour and 24-hour uptakes were 12% (ref: 5-15) and 19% (ref: 15-35), respectively. Given her age and her atrial fibrillation, pre-treatment with methimazole was deemed a safer initial option. An abdominal CT done for gastrointestinal symptoms was normal, but it revealed masses at the lung bases. A chest CT confirmed pulmonary lesions. FNA biopsy of the right thyroid nodule showed atypical cells highly suspicious for follicular neoplasm. Pre-treatment serum thyroglobulin was 3546.5 ng/ml (ref:1.3-31.8). She underwent a total thyroidectomy. Pathology confirmed a 5 cm unifocal follicular carcinoma with lymphovascular invasion. Treatment with 154 mCi of 131I was given as well as L-T4 suppressive therapy. Post-131I whole body scan displayed pulmonary metastases. An additional 211 mCi of 131I for persistent residual tumor was given 18 months after the first dose.

Conclusion: Hyperthyroidism resulting from a functioning thyroid cancer is exceedingly rare. It is typically caused by follicular cancer and may be due to activating mutations in the gsp or TSHR genes. Less than 1% of autonomously functioning thyroid nodules contain a neoplasm. Our patient had a functioning follicular cancer with subclinical hyperthyroidism. It is unclear whether the pulmonary metastases contributed to thyroid hormone excess. Flexibility in the approach to functioning thyroid nodules is essential. The presence of thyroid malignancy in a “hot” nodule should be suspected in an elderly patient with a rapidly growing nodule.

 

Nothing to Disclose: MHJ, RJA

12051 31.0000 SAT-0493 A Follicular Thyroid Cancer Presenting As a Hot Thyroid Nodule and Subclinical Hyperthyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Ina Krull*, Natalie Rogowski-Lehmann, Sarah Sigrist, Marco Siano, Michael Brändle and Stefan Bilz
Cantonal Hospital St. Gallen, Switzerland

 

Introduction

Ipilimumab (IPI), a cytotoxic-T-lymphocyte-associated antigen-4 (CTLA-4) antibody, has been the first agent to demonstrate an overall survival benefit for metastatic melanoma through increased T-cell activation. Various immune-mediated adverse events, among them gastrointestinal and dermatologic being most frequent, have been reported. Hypophysitis, leading to pan- or partial hypopituitarism, thyroid and primary adrenal dysfunction may occur and lead to significant morbidity if not recognised and properly managed. 

Case report

A 66-year-old man who had been treated with two cycles of IPI was referred because of new-onset overt hyperthyroidism (free thyroxine 54 pmol/l). Thyroid function had been normal prior to therapy. The diagnosis of Graves’ disease was established based on increased TSH receptor antibodies and diffuse hyperperfusion of the thyroid gland on colour-flow ultrasonography. Carbimazole 10 mg t.i.d. was started and rapidly tapered to 5 mg q.d. because of rapid clinical and biochemical resolution. However, overt hypothyroidism developed despite stopping antithyroid drug therapy and thyroxine treatment became necessary 8 weeks after the initial presentation and a total of 4 cycles of IPI. The TSH receptor antibody titer further increased at this time and increased thyroid peroxidase antibodies were detected. TSH receptor antibodies and hypothyroidism persisted 6 months after the last IPI treatment and the patient remained euthyroid on thyroxine therapy.

Conclusion

Hypothyroidism may occur in up to 3 % of patients treated with IPI. Graves’ disease is less frequently observed and only 3 cases have been reported in the literature. The rapid onset of hypothyroidism despite tapering and finally stopping antithyroid drug therapy and the increase of the TSH receptor antibody titer suggests a switch from stimulating to blocking antibodies. Whether the immune mediated thyroid dysfunction following IPI is reversible remains to be established.

 

 

Nothing to Disclose: IK, NR, SS, MS, MB, SB

14864 32.0000 SAT-0494 A Thyroid Dysfunction in a Patient Treated with Ipilimumab: Autoimmune Thyroid Disease Associated with Anti-CTLA-4 Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

James C. Clifford*1, Babette Carlson Glister2, Vinh Quang Mai1, Patrick W Clyde3 and K.M Mohamed Shakir1
1Walter Reed National Military Medical Center, Bethesda, MD, 2Walter Reed National Military Med, Silver Spring, MD, 3Walter Reed Bethesda National Mi, Silver Spring, MD

 

Background

A unique feature of Medullary Thyroid Carcinoma (MTC) is the tumor’s ability to synthesize and secrete multiple tumor markers, including calcitonin (CT) and carcinoembryonic antigen (CEA). We present a rare case of a patient with negative preoperative levels of serum CT and CEA in the setting of MTC.

Case

Patient is a 45yo male smoker with a history of a seminoma referred for evaluation of thyroid nodules.  The patient denied weight loss, diarrhea, flushing, hypercalcemia, neck irradiation, or a family history of thyroid cancer.  The exam was notable for a 20g nodular thyroid without lymphadenopathy (LAD).  US was notable for a 2.6x1.9x1.6cm isoechoic RUP nodule and a 1.9x1.0x1.6cm hypoechoic RLP nodule.  Both nodules were homogenous, well defined, had internal vascularity, and lacked calcifications.  MRI was notable for two thyroid lesions without LAD.  FNAB of the superior nodule demonstrated cellular features consistent with adenomatous hyperplasia.  FNAB of the inferior nodule demonstrated atypical cells that were plasmacytoid, discohesive, pleomorphic, and contained nucleoli.  A preoperative CT was 8 (nl <10 pg/mL) and CEA was 3.3 (nl <5.0 ng/mL for smokers).  The patient underwent a total thyroidectomy and CLND with removal of 3 negative lymph nodes.  The inferior lobe contained a 1.6x1.6x1.3cm encapsulated MTC with free margins and without lymphovascular space invasion.  The superior lobe contained a 2.7x1.8x1.4cm encapsulated follicular variant PTC with free margins and without lymphovascular space invasion.  The inferior tumor had positive reactivity for CT.  The superior tumor had positive reactivity for thyroglobulin and negative reactivity for CT.  The patient underwent a modified right neck dissection with removal of 25 negative lymph nodes and was treated with 195mCi of 131I.

Conclusion

It is extremely rare for MTC to present without a concurrent elevation in serum CT, especially when the MTC is more than 1cm.  This case illustrates a 1.6cm MTC that was not associated with an elevated pre-operative CT or CEA.  The lack of CT elevation could be explained by an assay hook effect, the tumor’s inability to secrete its synthesized CT, or by tumor production of a variant CT that is not recognized by the assay antibody.  This case was also notable for the simultaneous occurrence of a PTC.  It is important for clinicians to recognize that an aggressive form of thyroid cancer, such as MTC, may present without elevations in CT or CEA levels.

 

Nothing to Disclose: JCC, BCG, VQM, PWC, KMMS

12114 33.0000 SAT-0495 A Simultaneous Occurrence of Calcitonin Negative Medullary Thyroid Carcinoma and Papillary Thyroid Carcinoma in a Patient with a Testicular Seminoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Yin Chian Kon*1, Yingshan Lee2, Timothy Quek2 and Rinkoo Dalan1
1Tan Tock Seng Hosp, Singapore, Singapore, 2Tan Tock Seng Hospital, Singapore, Singapore

 

Background: In patients with "rapid iodine-turnover, rapid responder" variant of Graves' thyrotoxicosis, serum fT4 and fT3 levels may decline precipitously upon starting anti-thyroid drug, yet escalate acutely upon ATD discontinuation1. We describe a patient with such labile TFTs who failed 131I ablation twice despite minimal goiter and discontinuing CMZ. We speculate that this is due to rapid 131I turnover causing suboptimal intra-thyroidal retention.

Case report: A 78-year-old female was referred in June 2007 for labile thyroid function tests. She had a subtotal thyroidectomy for toxic MNG 10 years ago. In May 2004, she had thyrotoxic relapse and was started on oral carbimazole (CMZ) 25 mg od. Subsequently, she became and remained hypothyroid despite reducing CMZ dose to 5 mg od. She relapsed in May 2007 fT4 19.7 pM, TSH undetectable, after CMZ was discontinued for 4 months . USS thyroid then showed right thyroid lobe measuring 4.0 x 2.1 x 3.1 cm, left lobe 5.6 x 2.9 x 2.6 cm, and isthmus 0.6 cm.  The left lobe showed multiple nodules, with a dominant 1.2 x 1.3 x 0.9 cm nodule. Tc-99m pertchnetate scan showed diffuse heterogeneous uptake with no dominant hot or cold nodules. Subsequently, on restarting CMZ 2.5 mg od, she became hypothyroid (fT4 5 pM, RR 8-20, TSH 8.9 mIU/L, RR 0.34-4.5) within 3 months. On CMZ 5 mg once weekly, she regained euthyroidism (fT4 8 pM, TSH 0.91 mIU/L). In Nov 2007, she received 5 mCi 131I, after discontinuing CMZ for 6 days. She then fluctuated between spontaneous hyperthyroidism fT4 9, fT3 6.4 pM (4.3-8.3) TSH 0.01 mIU/L, TRAb > 40 IU/L (1.0), and hypothyroidism, fT4 4-6 pM, TSH 11.8-21 mIU/L, while on CMZ 2.5-5 mg od. In Feb 2012, as she became thyrotoxic fT4 22 pM, fT3 6.6 pM (3.5-6), TSH 0.02 mIU/L  off CMZ, she received #2 dose of 131I at 25 mCi. Subsequent TFT trend remained labile, from mild spontaneous hyperthyroidism, fT4 15 pM, fT3 6.4 pM, TSH <0.01 mIU/L, TRAb 3.0 IU/L (<0.4), TSI 614% (<180); to hypothyroidism, fT4 3 pM, fT3 2.9 pM, TSH 28 mIU/L, TRAb 2.8 IU/L, TSI 566% on minimal CMZ dose 2.5 mg om. In Jan 2014, CMZ was reduced to 2.5 mg 3 times a week. The patient declined further 131I.

Conclusion: This case suggests that a patient with the intriguing "rapid iodine-turnover, rapid responder" variant of Graves' thyrotoxicosis1 may present with repeated 131 iodine failure and labile TFTs post-radioiodine. A high TSI level may cause rapid 131I turnover and thus suboptimal intra-thyroidal retention, while decreased substrates for thyroid hormone synthesis, coupled possibly with limited functional mass from limited goitrous hyperplasia and post 131I exposure, may predispose to rapid development of hypothyroidism upon exposure to low daily doses of CMZ. 

Reference:

1. Dalan R, et al. High iodine turnover Graves' disease: the intriguing 'rapid responder' variant of thyrotoxicosis. Ann Clin Biochem 2008;45: 612-615

 

Nothing to Disclose: YCK, YL, TQ, RD

16163 34.0000 SAT-0496 A Graves' Disease with Labile Thyroid Function after Failed Radio-Iodine Therapy: A Manifestation of Rapid Iodine Turnover, Rapid Responder Graves' Variant? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Ayse Arduc1, Sahzene Yavuz2, Joyce D Linderman3, Sheila Smith3, Elena Eliseeva4, Susanne E Neumann4 and Francesco S. Celi*5
1National Institute of Diabetes and Digestive and Kidney Diseases, Diabetes, Endocrine and Obesity Branch, National Institutes of Health, Bethesda, Maryland 20892, 2University of Florida, FL, 3Diabetes Endocrinology Obesity Branch, NIDDK, NIH, Bethesda, MD, 4NIDDK-NIH, 5Virginia Commonwealth University, Richmond, VA

 

Background: The delivery of radioactive iodine for the treatment of thyroid cancer is based on the stimulation of the TSH receptor (TSHR) by endogenous TSH, or by injection of recombinant TSH. Occasionally patients with history of Graves’ disease fail to mount a robust rise in TSH after thyroid hormone withdrawal. Anti TSHR antibodies (TRAbs) may inhibit directly the thyrotroph and play a role in the prolonged suppression of the TSH (1).

Case presentation: A 53 y.o. male with 15-month history of Graves’ disease controlled with methimazole 5 mg/day was diagnosed with a 2 cm thyroid nodule. A fine needle aspiration showed papillary thyroid cancer and the patient underwent total thyroidectomy (T3N0Mx). At the time of surgery the patient had the following thyroid function tests: (TSH 0.03, n.r. 0.4-4.0 mcIU/ml, T3 116, n.r. 90-215 ng/dl, and fT4 1.4, n.r. 0.8-1.9 ng/dl). The patient was initially treated with levothyroxine, 150 mcg qd, which was substituted for a month with liothyronine 15mcg t.i.d. in preparation for radiodiodine ablation. On the last day of liothyrone therapy his thyroid function tests were as follows: TSH 0.06 mcIU/ml, T3 171 ng/dl, and undetectable free T4. Eleven days after withdrawal the TSH rose only to 7.91 mcIU/ml with undetectable T3 and free T4. The patient underwent radioablation after rhTSH admisnitration. A bioassay performed on HEK-EM 293 cells stably TSHR demonstrated that the patient’s serum was able to stimulate  the TSHR cAMP production during suppressive therapy with minimal changes following therapy withdrawal. IgG-depletion of the serum resulted in suppression of the TSHR cAMP, with minimal increase at the end of the withdrawal, indicating that the TSHR cAMP production was driven by the patient’s TRAbs.

Conclusion: In our patient, the inadequate TSH elevation after thyroid hormone withdrawal in spite of undetectable thyroid hormone was likely caused by direct inhibition of the thyrotroph by TRAbs. Since the patient’s therapy was carefully titrated to maintain a euthyroid state, it is unlikely that the blunted rise in TSH was secondary to thyrotroph suppression by prolonged thyrotoxicosis. The presence of TRAbs should be considered an important variable in the management of thyroid cancer patients with history of Graves’. Furthermore, TRAb-induced stimulation of TSHR-mediated cAMP production can contribute to the worse prognosis of patients with thyroid cancer and underlying Graves’ disease. Finally, in hypothyroid patients with positive TRAbs, the TSH assay may not be a sufficiently sensitive test to determine the adequacy of the therapy. This report also illustrates the clinical relevance of TRAbs-mediated, TSH-independent TSHR stimulation or inhibition.

1          Brokken LJ et al MF 2003 Thyrotropin receptor autoantibodies are associated with continued thyrotropin suppression in treated euthyroid Graves' disease patients. J Clin Endocrinol Metab 88:4135–4138

 

Nothing to Disclose: AA, SY, JDL, SS, EE, SEN, FSC

12188 35.0000 SAT-0497 A Impaired Thyrotroph Dynamics during Thyroid Hormone Withdrawal in a Patient with Differentiated Thyroid Cancer and Underlying Graves' Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Sakiko Kobayashi*1, Jaeduk Yoshimura Noh1, Taeko Shimizu1, Isao Kurihara2, Kiminori Sugino1, Hiroshi Itoh2 and Koichi Ito1
1Ito Hospital, Tokyo, Japan, 2School of Medicine, Keio University, Tokyo, Japan

 

Background: Familial dysalbuminemic hyperthyroxinemia (FDH) is an autosomal dominant disorder, and the most common disease in inherited euthyroid hyperthyroxinemia in Caucasians. It is extremely rare in Asian population and only two families with FDH have been reported in Japan.
Clinical Case: A 30-yr-old Japanese woman, who was incidentally found to have thyroid dysfunction in a mental clinic in which she was treated for postpartum depression, was admitted to our hospital in 2004. She had extremely elevated serum FT4 (>7.77 ng/dl, 0.8≤n≤1.6 ng/dl), relatively elevated FT3 (7.8 pg/ml, 2.2≤n≤4.3 pg/ml) and normal TSH  (1.20μIU/ml, 0.20≤n≤4.50μU/ml). Clinical thyroid examination revealed no other abnormalities than a small goiter. Her TgAb was positive (1.7 IU/l, n≤0.3 IU/l), but other anti-thyroid antibodies including TPOAb, TRAb and TS-Ab were negative. Thyroglobulin was normal (20ng/ml, n≤35 ng/ml). The result of the 24-hour radioactive iodine uptake test was normal (23% / 24hrs). When the levels of FT3, FT4 and TSH were measured by 3 different laboratory kits, the results were similar, and FT4 was still high in the equilibrium dialysis method (2.61ng/dl, 0.77≤n≤1.93 ng/dl). When immunoglobulin was excluded from patient’s serum by protein A, the result was almost the same, and the possible effect of anti-triiodothyronine antibody, anti-thyroxine antibody was denied. By affinity chromatography, FT4, T4 and albumin was extracted to the same fraction and the levels of FT4 and T4 were extremely high. Combined with the fact that the serum albumin concentration was normal, it suggested the binding of thyroxine and albumin was strong. By combination of reversed phase liquid chromatography and mass spectrometry technique, amino acid sequence of human serum albumin was determined, and the patient was found to be a heterozygote for R218P (the normal arginine was replaced with proline) mutation in the human serum albumin.
Clinical Lesson: This is the report of the third FDH family in Japan. R218H (arginine is replaced with histidine) mutation of human albumin is predominantly found in Caucasian patients. R218P mutation was found in this patient, and it is the same mutation as 2 previously reported families in Japan, characterized by extremely elevated serum FT4 levels and relatively elevated serum FT3 level. Though it is rare in Asian people, FDH should be reminded as one of the differential diagnosis of SITSH.

 

Nothing to Disclose: SK, JYN, TS, IK, KS, HI, KI

13571 36.0000 SAT-0498 A A Case of Familial Dysalbuminemic Hyperthyroxinemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Ana Margarida Balsa*1, Joana Guimarães2, Ana Raquel Ferreira2 and Rosa Dantas2
1Centro Hospitalar do Baixo Vouga, Portugal, 2Centro Hospitalar do Baixo Vouga

 

Background: Takotsubo cardiomyopathy (TC) is characterized by acute, transient left ventricular apical ballooning precipitated by emotional or physiologically stressful stimuli and has been previously associated with Grave’s disease based on few clinical reports. More recently the association with exogenous thyrotoxicosis and radioiodine-induced thyroiditis has also been described. Iatrogenic hyperthyroidism on patients under levothyroxine replacement therapy for hypothyroidism had never been reported as a cause of TC. The authors describe two female patients with TC associated with levothyroxine over-replacement.

Clinical cases: A 74-year-old and a 48-year-old female patients, medicated with levothyroxine (respectively, 2,27 mcg/Kg  and 1,85 mcg/Kg) for autoimmune thyroiditis were both admitted on our emergency room with precordial pain. The first had an ECG with ST-segment elevation in the anterior precordial leads, and the latter had sinus tachycardia with deep T-wave inversion and QT interval prolongation. Further investigation revealed a mild elevation of cardiac biomarker levels, severe apical hypokinesis but no significant coronary lesions on catheterisation. The suppressed TSH levels were only demonstrated on the cardiac ICU: 0,21 and 0,07 mIU/L, respectively. Levothyroxine dose was reduced.  Both patients showed improvement of the apical hypokinesis on the discharge echocardiogram and normalization of cardiac biomarker levels.

Conclusion: this case report emphasizes the importance of correct dose adjustment on patients under levothyroxine replacement therapy and stresses that TSH should be determined in all patients presenting with acute coronary syndrome and typical finding of TC.

 

Nothing to Disclose: AMB, JG, ARF, RD

12215 37.0000 SAT-0499 A Takotsubo Cardiomyopathy Associated with Levothyroxine over-Replacement 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Saima Khan*, Carlos Felipe Nunez, Harmeet Singh Narula, Allison McLarty, Thomas Bilfinger and Harold E Carlson
Stony Brook Univ, Stony Brook, NY

 

Background: Thymic hyperplasia is a rarely recognized pathological entity associated with autoimmune thyroid disease, especially Graves disease.  Thymic hyperplasia often regresses after treatment of hyperthyroidism.  On the other hand, hyperthyroidism persists after thymectomy.

Clinical Cases: In this case series, we report 5 patients (ages 26-69 years) with autoimmune thyroid disease and incidentally-discovered anterior mediastinal masses. At the time the mediastinal masses were found, 3 patients had a prior history of autoimmune thyroid disease (2 with hyperthyroid Graves disease and 1 with Hashimoto’s thyroiditis and treated hypothyroidism) while 2 patients were diagnosed with hyperthyroid Graves disease and a mediastinal mass at the same time. An 18-fluorodeoxyglucose (FDG) PET/CT scan was performed in 4 cases (3 with Graves, 1 with Hashimoto’s) and showed avid uptake in the mediastinal mass in all 4 cases.  In 2 of the 5 cases, the mass regressed after treatment of hyperthyroidism with methimazole. Three patients underwent thymectomy because the mediastinal mass was irregular in shape or heterogeneous on CT scan (findings suggesting malignancy); in all 3 cases, the final pathologic diagnosis was benign thymic hyperplasia. 

Enlargement of lymphatic tissue, including the thymus, has been recognized as an occasional feature of Graves’ disease.  Unlike the case of myasthenia gravis where thymectomy may result in cure, hyperthyroidism persists after thymectomy in cases of Graves’ disease.  Hashimoto’s disease has occasionally been associated with malignant thymoma, but very rarely with thymic hyperplasia.  The mechanism of thymic enlargement in thyroid disease is unclear, but the observation that medical treatment of Graves’ disease with anti-thyroid drugs results in resolution of the thymic enlargement suggests that either the antibodies directed against the thyroid or the hyperthyroid state itself may play a role. 

Conclusions: Our findings further support the notion that most cases of anterior mediastinal masses associated with autoimmune thyroid disease are due to benign thymic hyperplasia.  Neither CT scan findings nor FDG uptake on PET scans accurately distinguish malignant thymic masses from benign hyperplasia.  Since the thymic enlargement associated with autoimmune thyroid disease frequently regresses with medical treatment, the mediastinal mass may not require resection or immediate biopsy and may instead be managed by close radiologic follow-up, expecting a decrease in size of the mass after treatment of the thyroid disorder. Recognition of the association between thymic hyperplasia and thyroid autoimmunity, and its benign course, can spare patients from surgery.

 

Nothing to Disclose: SK, CFN, HSN, AM, TB, HEC

14108 38.0000 SAT-0500 A Thymic Hyperplasia in Autoimmune Thyroid Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Anna VanderHeiden*1 and Ildiko Lingvay2
1University of Texas Southwestern Medical Center at Dallas, Dallas, TX, 2University of Texas Southwestern Medical Center, Dallas, TX

 

Mucocele Masquerading as a Thyroid Cancer Recurrence

Anna VanderHeiden, Ildiko Lingvay

Internal Medicine, Division of Endocrinology, UTSW Dallas, Texas, USA

Background:

False-positive diagnostic radioactive iodine whole body scan in the setting of differentiated thyroid carcinoma surveillance can lead to unnecessary treatment. A high level of suspicion and knowledge of physiologic and pathologic iodine uptake is necessary to avoid such occurrences.

Clinical Case:

67-year old gentleman presented for thyroid cancer surveillance. He was diagnosed 7 years prior, when he underwent total thyroidectomy for a 6.5 cm follicular carcinoma with vascular and capsular invasion. His treatment also included 151 mCi of radioactive iodine 2 months after the surgery. The postablation scan did not show uptake outside the expected areas.  Periodic surveillance, which included neck sonograms and suppressed thyroglobulin levels, was negative for the first 5 years. Thereafter, a small but gradual elevation in suppressed thyroglobulin level was noted, from 0.5 to 0.8 ng/mL (normal <= 2), while the neck sonogram remained negative. To further explore the source of this small elevation in thyroglobulin, a diagnostic radioiodine whole body scan was performed, which showed one large, 2.1 X 1.8 X 1.9 cm radioiodine-avid lesion, localized in the base of the neck posteriorly, anterior to the junction of C7/T1 vertebral bodies, consistent with metastasis of thyroid cancer. This lesion was located between the trachea and the esophagus, and was suspicious for tracheal invasion and involvement of the esophagus. The concomitant stimulated thyroglobulin level (TSH 44 mIU/L ) was 10 ng/mL.

A neck MRI confirmed the presence of a hyperintense mass, possibly within the esophagus, midline and to the left at the C7-T1 level. A biopsy was not performed.

The patient underwent neck excision of the central neck mass, which required a partial esophagectomy and pharyngectomy with closure. The pathology showed a benign mucin-filled cyst with no atypia or carcinoma identified, and the TTF-1 immunostain was negative.

Conclusion:

Radioiodine can be a useful tracer for detection of thyroid cancer recurrence. Its usefulness stems from the high specificity for thyroid-origin tissue. However, radioiodine uptake also occurs in secretory tissues like nasopharynx, salivary and parotid glands, and the GI tract.  Our patient presented with radioactive iodine uptake in a benign mucin-filled cyst, which presumably had enhanced expression of sodium-iodine symporter or other mechanisms like passive diffusion of radioidine-containing saliva into the cyst. This is the first reported case of an esophageal mucocele masquerading as a thyroid cancer recurrence. Similar presentations have been described for frontal sinus mucoceles, bronchogenic cysts, benign ovarian mucinous cystadenoma, and laryngocele, all of which exhibited I-131 uptake.

 

Nothing to Disclose: AV, IL

12230 39.0000 SAT-0501 A Mucocele Masquerading As a Thyroid Cancer Recurrence 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Ketherine Ketherine* and Cherrie Gail R. Lumapas-Gonzales
St.Luke's Medical Center - Quezon City, Manila, Philippines

 

We report two rare cases which initially presented as primary hyperparathyroidism. They underwent parathyroidectomy and total thyroidectomy. Histopathology results revealed unremarkable parathyroid gland and incidental findings of papillary thyroid microcarcinoma with lymph nodes metastasis.

Case 1. 61- year-old female presented with hypercalcemia (10.5 mg/dL N:8.5-10.1 mg/dL) and increased intact parathyroid hormone (PTH) (78.4 pg/mL N:12-65 pg/mL). Bone densitometry showed osteopenia. She had a history of benign colloid nodular goiter, post right thyroid lobectomy 30 years ago. She also noted to have left thyroid nodule. FNAB result showed colloid goiter. She underwent parathyroidectomy and completion thyroidectomy with modified radical neck dissection. Histopathology revealed papillary microcarcinoma multifocal (0.7cm,0.4cm) left thyroid lobe; One right lymph node and  two of three central lymph nodes positive for metastasis; One parathyroid gland identified was unremarkable. The intact PTH level fell to normal range after surgery (<3 pg/mL). Three months later, she received Radio Active Iodine (RAI).

Case 2. 59-year-old female presented with recurrent nephrolithiasis. She had high normal serum calcium (9.6 mg/dL N:8.5-10.1 mg/dL) and elevated serum intact PTH (92.8 pg/mL N:12-65 pg/mL). Parathyroid 99mTc (sestaMIBI) scintigraphy revealed intense sestamibi uptake in the lower left thyroid lobe, suggestive of a parathyroid adenoma. Thyroid ultrasound showed left lobe thyroid nodule (solid, measuring 0.4 x 0.2 x 0.4cm). She underwent parathyroidectomy of left inferior parathyroid gland and total thyroidectomy. Histopathology examination revealed papillary microcarcinoma of the right thyroid lobe (0.3cm); One lymph node at left inferior paratracheal positive for metastatis; Two specimens are labelled as left inferior parathyroid gland, but it turned out to be nodular hyperplasia of the thyroid and nodular hyperplasia with lymphocytic thyroiditis. Soon after the surgery, she was given TSH-suppression with levothyroxine. Five months later, she received RAI.

Co-existence of primary hyperparathyroidism and non-medullary thyroid carcinoma has been reported in some case reports and surgical series. However, to the best of our knowledge, this is the first report of two cases with initial presentation as primary hyperparathyroidism, which their histopathology results turned out to be unremarkable parathyroid gland and papillary thyroid microcarcinoma with lymph nodes metastasis. There were some reports showing that papillary thyroid carcinoma can be falsely interpreted as hyperfunctioning parathyroid glands on sestaMIBI. This case underlines the need for a clinical high index of suspicion for papillary thyroid cancer presented as primary hyperparathyroidism.

 

Nothing to Disclose: KK, CGRL

13706 40.0000 SAT-0502 A Metastatic Papillary Thyroid Microcarcinoma, a Great Mimicker of Primary Hyperparathyroidism: A Report of Two Cases 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Wen Yang Benjamin Ho*1 and Cherng Jye Seow2
1Tan Tock Seng Hospital, 2Tan Tock Seng Hospital, Singapore, Singapore

 

Graves' disease associated with Immune Thrombocytopenic Purpura : an uncommon association with grave therapeutic implications

Wen Yang Benjamin Ho 1, Cherng Jye Seow 2, Tan Tock Seng Hospital Department of Endocrinology

Introduction

The association between idiopathic thrombocytopenia purpura (ITP) and autoimmune thyroid diseases has long been recognised. We report a patient with ITP and newly diagnosed Graves’ disease. Platelet count eventually normalised with a combination of corticosteroids and treatment of thyrotoxicosis.

Case Report

A 39 years old Chinese lady presented with proximal myopathy of 2 weeks duration, associated with thyrotoxic symptoms such as polyphagia, loss of weight, oligomenorrhea and a diffusely enlarged goiter on examination. Thyroid function test: free T4 level 49 pmol/L  (RI: 8-21), TSH 0.03 mIU/L (RI:0.34-5.60), TSH receptor antibody 4.5 IU/L (RI:<0.4). Incidentally, she was noted to have asymptomatic but profound thrombocytopenia (Platelet count 5 x 109/L (RI 170-420). Blood film was normal except thrombocytopenia . Infective screen ( Hepatitis B, C , HIV , Dengue) and autoimmune markers ( ANA, anti-ds DNA , Lupus anticoagulant) were negative. Vitamin B12 and folate levels were normal. She was started on carbimazole 30mg daily and high dose prednisolone at 60mg daily. Initially, her platelet counts remained persistently low. However, as her thyrotoxic symptoms and free T4 levels started to recover, a marked concurrent improvement of her platelet counts was noted in parallel with her falling T4 levels. Her platelet counts eventually normalised to a level of  203 x 109/L   3 weeks later. She is currently on tapering doses of prednisolone with a view to discontinue treatment soon

Discussion

The association between ITP and autoimmune thyroid disease has been well documented. It has been postulated that thrombocytopenia is associated with excess of circulating thyroid hormone or to an autoimmune mechanism involving platelet-bound antibodies. This case highlights the importance of recognizing the association of autoimmune thyroid disease with ITP as this has subsequent therapeutic implications on the management of ITP.  As demonstrated, recognizing and treating coexisting autoimmune thyroid disease in the setting of ITP can  influence the natural history of ITP and its response to conventional treatment with corticosteroids. This is consistent with studies showing that treatment of autoimmune thyroid disease can improve ITP which is initially refractory to immunosuppressants.  Therefore, for all patients with unexplained thrombocytopenia or thrombocytopenia refractory to treatment, we recommend evaluating for clinical signs/symptoms of thyroid disease.

Presenting author: Ho Wen Yang Benjamin

Email: benjaminhwy@gmail.com

1 and 2. Department of Endocrinology, Tan Tock Seng Hospital, Singapore

 

Nothing to Disclose: WYBH, CJS

12272 41.0000 SAT-0503 A Graves' Disease Associated with Immune Thrombocytopenic Purpura : An Uncommon Association with Grave Therapeutic Implications 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Mohammad Kawji*1 and Julie Samantray2
1Wayne State University, Detroit, MI, 2Division of Endocrinology, Diabetes, and Metabolism. Wayne State University, Detroit, Michigan, United States

 

Introduction:

The incidence of thyroid cancer associated with thyrotoxicosis caused by Graves’ Disease (GD) is 3.8%, however the risk is much higher in GD patients with a thyroid nodule 15% (1).Most carcinoma associated with hyperthyroidism is found incidentally and majority of the cases are micro carcinoma (2).  There is conflicting data about the progression and aggressiveness of thyroid cancer in patients with graves disease when compared to euthyroid patients (1).

Case:

A 25 year old healthy female presented with complaints of unintentional weight loss of 12 Lbs over 2 months, frequent palpitation, anxiety, tremors, and heat intolerance.

Her physical examination was remarkable for sinus tachycardia and diffusely enlarged goiter without any palpable nodules or cervical lymph nodes. Her TSH was 0.011 (N > 0.5 micro IU/ml) and FT4 was 3.2 (N<1.8 ng/dl), I 131 imaging showed an enlarged thyroid gland with homogeneous uptake of 78.8% at 24 hours. She was treated with Methimazole (MMI) and propranolol for 9 months. She remained in remission for 16 months before needing to restart MMI for recurrence of hyperthyroidism symptoms. Ultrasound of thyroid showed increased vascularity without any nodule.

Second I 131 study showed homogenous uptake of 83%. She was given 10.8 mCi of I131. Continued to be hyperthyroid at 5 months post treatment and hence received a second dose of 19.6 mCi. 6 month follow up showed persistent hyperthyroidism. A second thyroid ultrasound showed two small solid ill-defined sub centimeter lesions (0.6 cm, 0.8 cm) in the right lobe. Near total thyroidectomy was performed as a definitive treatment. Postoperative histological exam revealed papillary thyroid carcinoma, 2.2 cm follicular variant, involving the inferior pole right lobe arising in diffuse hyperplasia GD background. She had remnant ablation with 52.4 mCi of I131. Post therapy scan showed residual uptake in thyroid bed only. She was started on thyroxine suppressive therapy and her symptoms improved.

Conclusion:

Patients with GD may need to be screened for presence of concurrent thyroid nodule(s). These nodules should be evaluated carefully prior to radioactive ablation treatment to rule out malignancy.  Whether ultrasound guided biopsy should be considered for small thyroid nodules in GD patients treated previously with RAI or not is matter of debate. Graves’ disease and subsequent RAI treatment can cause cytomorphological changes that might lead to atypia and erroneous diagnosis of thyroid cancer (3).

FNA should be considered for sub cm nodules with suspicious US appearance considering the risk of aggressive thyroid ca in these patients. Total thyroidectomy as definitive treatment may be considered as first line approach for patients with graves hyperthyroidism and concurrent suspicious thyroid nodules.

 

Nothing to Disclose: MK, JS

13248 42.0000 SAT-0504 A Incidental Thyroid Cancer in a Young Patient with Graves Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Pavani Srimatkandada*1, Harrison W Farber2 and Andrea D Coviello1
1Boston University School of Medicine, Boston, MA, 2Boston Medical Center

 

Background:  There have been reports of an association between pulmonary arterial hypertension (PAH) and thyroid disease, primarily hypothyroidism, which may be due to a shared immunogenetic component. Clinical Case:   We describe a case of rapid enlargement of the thyroid gland with compressive symptoms and hyperthyroidism in a patient with PAH treated with epoprostenol for 6 months.  The 33 year old man presented to a local ER with a chief complaint of difficulty breathing and rapid, severe neck enlargement; he had no personal or family history of thyroid disease.  Physical exam was notable for HR 120; plethoric face, no exophthalmos, proptosis, or lid lag; neck exam revealed a severely enlarged lobular thyroid without discrete nodules and bilateral cervical lymphadenopathy.  Due to severe compressive symptoms a neck CT with contrast was obtained which showed a diffusely enlarged thyroid gland with cervical lymphadenopathy. Laboratory evaluation revealed: TSH <0.02 mIU/L (ref 0.4-4.0), FT4 4.48 ng/dL (ref 0.70-1.80), T3 8.63 pg/mL (ref 2.3-5.0), TSI activity 334%, and antiTPO Abs <1.0 (ref <5.0).  He was started on methimazole (MMI) and a beta blocker (BB).  TFTs normalized on MMI but the BB was stopped due to deterioration in cardiopulmonary function.  He underwent thyroidectomy due to continued compressive symptoms including dysphagia with the inability to swallow solid food and orthopnea requiring him to sleep in a recliner.  Post thyroidectomy he resumed eating solid food and slept lying down. His cardiopulmonary function improved, oxygen requirements decreased, and he lost weight.  Surgical pathology confirmed hyperplastic thyroid follicles with fibrosis and chronic inflammation, consistent with Graves’ disease.  Discussion:  Hypothyroidism or elevated TSH has been reported in patients with PAH and one review estimates that hypothyroidism affects 22% of PAH patients but hyperthyroidism is uncommon, 6% (1).  The prostacyclin epoprostenol may have caused rapid thyroid enlargement and hyperthyroidism by activating cyclic adenosine monophosphate in the thyroid membrane (2,3).  Conclusions:  Clinicians should be aware of the disproportionately high rates of autoimmune thyroid disease in patients with PAH, particularly hyperthyroidism given the adverse effects of excess thyroid hormone on cardiopulmonary function including increased oxygen demand.  Furthermore, they should be aware of the potential for rapid development of compressive goiter and severe hyperthyroidism in those treated with prostacyclins.

 

Nothing to Disclose: PS, HWF, ADC

12294 43.0000 SAT-0505 A Rapid Development of Compressive Goiter and Severe Hyperthyroidism in a Patient with Pulmonary Arterial Hypertension after Treatment with Epoprostenol 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Melia Karakose1, Mustafa Caliskan2, Müyesser Sayki Arslan3, Erman Cakal2 and Tuncay Delibasi*3
1Diskapi Yildirim Beyazit Teaching and Research Hospital, Ankara, Turkey, 2Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey., Ankara, Turkey, 3Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey

 

Introduction:RTH is a rare an autosomal dominant hereditary disorder characterized by a reduced responsiveness of the pituitary and peripheral target tissues to thyroid hormone. The common characteristic clinical features are goitre but absence of the usual symptoms and metabolic consequences of thyroid hormone excess. We describe two patients with RTH in whom differentiated thyroid cancer was diagnosed.

Clinical Case:Patient 1. A 56-year-old Turkish women was admitted to our clinic because of MNG and her laboratory results were detected as follows; TSH: 2.81 mUI/L (range, 0.55-4.78), fT4:2.45ng/dl(range,0.74-1.52), fT3:6.2pg/ml(range,2.3-4.2), anti-TG ab and anti-TPO ab  were negative. She had no signs or symptoms of typical thyrotoxicosis. MRI scan did not detect the presence of a pituitary tumor. TSH showed exaggerated response to TRH and was supressed following T3 administration. The a-subunit of TSH was normal (0.76 IU/L, range, 0-1.6). We considered this situation thyroid hormone resistance.Thyroid ultrasonography showed MNG. FNAB was performed and cytological examination showed ‘atypia of undetermined significance’. Total thyroidectomy was performed. Pathologic examination revealed PTC, tumor size was 0.2 cm (right lobe).

Patient 2. A 33-year-old Turkish man was admitted to our clinic because of  her mother’s RTH and MNG  disease (patient 1). Serum thyroid function tests showed elevated fT4, fT3 and TSH (fT4:1.95 ng/dl, fT3:7.2 pg/ml, TSH:5.52 mUI/L). Anti-TG and anti-TPO ab were negative. He had no signs or symptoms of typical thyrotoxicosis. TSH secreting pituitary adenoma was ruled out because the patient had a normal level of the α-subunit of TSH (0.36 IU/L, range, 0-1.6), a negative MRI of the pituitary gland, an exaggerated response of TSH to a thyrotropin-releasing hormone stimulation test and TSH was supressed following T3 administration. Thyroid nodules were detected on physical examination. Ultrasonographic evaluation of the thyroid gland were detected MNG. The dominant nodule was 27x42x51mm in size in the the left lobe and  had foci of macrocalcification  with mixed echogenicity. Two FNAB was performed and cytological examination resulted as non diagnostic. The patient underwent total thyroidectomy and PTC was detected in two focus with diameters of 0.4cm in the left lobe and 0.4cm in isthmus.

Conclusion:RTH is very rare and might be overlooked. There are two  situation that  need to be explained; one  of them is  whether patients with RTH are at an increased risk for thyroid cancer and  the other one is  whether thyroid cancer is  more aggressive in patients with RTH because of the difficulty in suppressing serum TSH concentration. There is no consensus on how to overcome the persistently high TSH in patients with RTH and DTC. Further studies are needed to explain the relationship between RTH and DTC which might be helpful for the treatment of these patients.

 

Nothing to Disclose: MK, MC, MSA, EC, TD

13922 44.0000 SAT-0506 A Papillary Thyroid Carcinoma in Two Patients with Resistance to Thyroid Hormone 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Chrystal Wa*1, Thomas Semrad2 and Alison Marie Semrad3
1University of California, Davis, Sacramento, CA, 2University of California, Davis Comprehensive Cancer Center, Sacramento, CA, 3UC Davis Medical Center, Sacramento, CA

 

Background: ATC is an aggressive thyroid tumor that represents 1-2% of all thyroid cancers. We describe a case of ATC treated with combination Cisplatin/Paclitaxel and concurrent radiation therapy with 4 years disease free survival.  

Clinical case: A 65 year old male with a history of a longstanding multinodular goiter presented with a painful enlarging left sided neck mass of two weeks duration and nightly fevers. Ultrasound revealed interval enlargement of his left thyroid lobe with a heterogeneous 4.8x3.3x4.4cm mass with calcifications. Four years prior, bilateral FNA biopsies of thyroid nodules were benign and interval ultrasounds were stable. The patient underwent urgent total thyroidectomy with level VI neck dissection. Pathology revealed ATC (5 cm) of the giant cell type with extrathyroidal extension, vascular invasion, and negative lymph nodes. Histologic stains were positive for AE1/AE3 and Ki-67 was >80% positive. A post-operative PET/CT scan revealed gross residual disease within the neck that was not felt to be resectable, but no distant metastases. Therefore, an aggressive multimodal treatment regimen was pursued as follows: Cisplatin 60mg/m2 was administered on days 1 and 22, paclitaxel 50mg/m2 was administered weekly for 5 weeks as well as concurrent radiation therapy to 70 Gy using a 9-field intensity-modulated radiotherapy (IMRT) technique.  The patient’s course was complicated by grade 3 dysphagia, grade 2 fatigue and weight loss. Post-treatment PET/CT scans showed a good response with a single focus of low FDG activity in the left neck. Subsequent FNA biopsy of this lesion was negative for malignancy. Surveillance PET/CT scans and neck ultrasounds have been negative for disease recurrence. 

Conclusion: Anaplastic thyroid cancer is classified as stage IV disease at the time of diagnosis. It carries a poor prognosis, with a mean survival of 2-6 months. Treatment is not yet standardized, but should include cytoreductive surgical resection, chemotherapy, and radiation.  A variety of doxorubicin-containing regimens are described; though, there is increasing evidence that taxanes may have activity as radiosensitizers in the treatment of advanced disease. The combination of doxetaxel and cisplatin was described in a case series of eight patients with response rates of up to 50%. Emerging biologic therapies targeting the BRAF mutation, P13K/mTOR inhibitors, and other multi-kinase inhibitors are under investigation.

 

Nothing to Disclose: CW, TS, AMS

12418 45.0000 SAT-0507 A Combined Chemotherapy and Radiation for Treatment of Anaplastic Thyroid Cancer (ATC): A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Uroosa Kamran*
Macneal Hospital, Berwyn, IL

 

“Thyrotoxicosis warrants anticoagulation”

Introduction:

Hyperthyroidism is  a  hypercoagulable state  associated with increased thrombotic risk. The use of anticoagulation to prevent thromboembolic complications of thyrotoxicosis  is controversial. This case describes a patient who experienced ischemic stroke  in  the state of thyrotoxicosis when her heart was in normal sinus rythm.

Case  :

The patient was a 44-year-old woman who presented to the hospital with right sided weakness and sensory loss in her upper and lower extremities without aphasia . Her symptoms began when she woke up in the morning. She denied other associated symptoms like headache, visual  disturbance, nausea, vomiting, chest pain, palpitations. Her past medical history was significant for GERD which was treated with Esmoprozole. Family history revealed father had diabetes. Patient was married, unemployed living with her family. Patient denied using drugs or alcohal. No history of smoking. On her physical exam BP was 140/85, heart rate was 88 b/m. Neuro exam was significant for hemiparesis and hemisensory loss on right side. Power was 1/5 in both  right upper and lower extremities. Results of a computed tomography scan and MRI with and without contrast of her head were normal .EKG was in normal sinus rhythm with heart rate of 88 beats/min. A carotid ultrasound scan showed slight atheromatous changes but no critical lesions. Her serum cholesterol levels were within normal limit. An echocardiogram was done which showed no evidence of intracardiac thrombosis. Patient was started on Aspirin 81 mg once daily.  Further investigations revealed the state of Thyrotoxicosis with TSH levels of 0.001 mciu/ml(0.550-4.780 mciu/ml)and T4 levels were 4.6 ng/dl( 0.7-1.7ng/dl). Patient was diagnosed with Grave’s Disease with elevated TSH receptor antibodies. She was started on Propranolol and Methimazole by Endocrinology service.  Her symptoms slowly improved with physical therapy. She was discharged home to continue therapy as outpatient.

Conclusion:

Thyroid hormone has numerous effects on coagulation. Studies indicate that hyperthyroidism is associated with increased thrombotic risk. Coagulation abnormalities such as shortened activated partial thromboplastin time, increased fibrinogen levels, and increased factor VIII and factor X activity, and clinical sequelae such as stroke are seen frequently in patients in sinus rhythm with thyrotoxicosis.  Studies suggest that hyperthyroidism is associated with a prothrombotic state and ischemic stroke , which warrants anticoagulation in all patients with thyrotoxicosis independent of atrial arrhythmias at least until a euthyroid state has been restored .

 

Nothing to Disclose: UK

17055 46.0000 SAT-0508 A Thyrotoxicosis Warrants Anticoagulation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Chul Yun Park*1, Eon Ju Jeon2, Ga Young Kim3, Ji Hyun Lee2, Ho Sang Shon Sr.2 and Eui Dal Jung Sr.2
1Catholic University of Daegu, School of Medicine, Dague, Korea, Republic of (South), 2Catholic University of Daegu School of Medicine, Korea, Republic of (South), 3Catholic university of Daegu, school of medicine, Korea, Republic of (South)

 

The occurrence of Graves’ disease following subacute thyroiditis (SAT) is rare. The pathophysiology of it is not well known. We report a case of Graves’ disease following SAT presented with creeping. A 45-year-old woman presented with neck pain, and thyrotoxic symptoms. Neck pain migrated from left lobe to right lobe of the thyroid. Thyroid scan revealed decreased uptake in the both lobes except the superior portion of the right thyroid gland. Initially, the patient was diagnosed with SAT and treated with steroid therapy. Four months later, thyroid function test showed suppressed thyroid-stimulating hormone (TSH), elevated free thyroxine (T4) and TSH receptor antibody. Thyroid scan revealed increased uptake compatible with Graves’ disease. The autoimmune alteration after SAT may lead to the development of Graves’ disease in the susceptible patients. These patients should be monitored for the development of Graves’ disease.

 

Nothing to Disclose: CYP, EJJ, GYK, JHL, HSS Sr., EDJ Sr.

12704 47.0000 SAT-0509 A A Case of Graves' Disease Following Subacute Thyroiditis Presented with Creeping 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Ana O Hoff*1, Debora Seguro Danilovic1, Gilberto Castro2, Carla Papadia1, Suemi Marui3 and Rosalinda Camargo1
1Instituto do Cancer do Estado de Sao Paulo (ICESP), Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 2Instituto do Cancer do Estado de Sao Paulo, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 3Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil

 

Post-thyroidectomy hyperthyroidism in thyroid cancer is rare. It has been reported in patients with well-differentiated thyroid cancer (WDTC), particularly, follicular thyroid carcinoma (FTC) and is either due to thyroid hormone (TH) production from functional metastases or due to hyper-conversion of T4 to T3 due to overexpression of type 2 deiodinase (D2) by the tumor tissue. The treatment of metastatic WDTC has evolved significantly over the past decade with the development of tyrosine kinase inhibitors (TKI). Sorafenib has been recently approved by the FDA for the treatment of progressive iodine-refractory WDTC. Other TKIs are under development; lenvatinib, a multi-tyrosine kinase inhibitor is under investigation on a Phase 3 Trial (SELECT study).

We report 2 patients with metastatic FTC treated with total thyroidectomy and radioactive iodine that presented, during long-term follow-up, with thyrotoxicosis despite stable doses of levothyroxine (LT4). Evaluation included measurements of total T3, free T4 (FT4) and TSH on LT4 treatment (Patient A: T3 337ng/dL, FT4 0.51ng/dL, TSH < 0.03mIU/mL; Patient B: T3 316ng/dL, FT4 0.47ng/dL, TSH < 0.03 mIU/mL) and off LT4 treatment (Patient A: T3 < 39ng/dL, FT4 < 0.3ng/dL, TSH 0.74 mIU/mL; Patient B: T3 < 39ng/dL, FT4 < 0.3ng/dL, TSH 85mIU/mL). The high T3/T4 ratio while on LT4 and undetectable levels while off LT4 indicated that the thyrotoxicosis was due to increased conversion of T4 to T3. To control T3 thyrotoxicosis LT4 dose was reduced by 50% to maintain T3 within normal range. Both patients had progressive, iodine-refractory metastatic FTC and were included in a phase 3 randomized, placebo controlled trial with lenvatinib.  Upon initiation of the study there was rapid reduction of T3 levels in both patients (Patient A: T3 < 39 ng/dL, 4 weeks on study). Patient B developed acute symptomatic hypothyroidism within 1 week of treatment; T3, FT4 and TSH prior to TKI were 158 ng/dL, 0.12 ng/dL, TSH 0.05 mIU/mL, respectively and 9 days later were <38 ng/dL, 0.35 ng/dL, 16 mIU/mL, respectively. Both patients required a significant increase of LT4 from 50 mcg to 175 mcg/day. They remain on study with stable disease.

Conclusion: We report 2 patients with metastatic FTC with T3 thyrotoxicosis completely abolished by lenvatinib. The rapidity of T3 reduction suggests a direct effect of lenvatinib on T4 to T3 conversion. Whilst there were no observations of hypothyroidism in the Phase 2 Trial of Lenvatinib and the final results of the Phase 3 Select Trial are still pending; these findings indicate that there may be the need to monitor thyroid function in patients treated with lenvatinib. In addition, it indicates a potential mechanism for the hypothyroidism observed in patients treated with TKIs.

(Reference values: T3(80-200 ng/dL); FT4(0.9-1.7 ng/dL); TSH(0.27-4.2mIU/mL)

 

Disclosure: AOH: Principal Investigator, Eisai. DSD: Investigator, Eisai. GC: Investigator, Eisai. Nothing to Disclose: CP, SM, RC

16322 48.0000 SAT-0510 A Reversal of T3 Thyrotoxicosis By Lenvatinib in Metastatic Follicular Thyroid Carcinoma: Report of 2 Cases 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Andrea Kozak*1, Cecilia Fenili2, Lucrecia Almazan3, Miriam Elisa Colombani4, Sandra Tortarolo5, Gimena Delgado5, Laura Pugliese3, Milagros Aguiar6, Sergio Damilano7, Patricia Fainstein Day1, Hugo E Scaglia4 and Antonio Cardinalli3
1Hospital Italiano de Buenos Aires, Buenos Aires, Argentina, 2Argentine Society for Endocrinology and Metabolism, CABA, Argentina, 3Prevención & Asistencia Labs., Junín, Argentina, 4IABE, La Plata, Argentina, 5Hospital Italiano de Buenos Aires, CABA, Argentina, 6Sanatorio Junín, Junín, Argentina, 7Laboratorio Bioanalítica, CABA, Argentina

 

Background: If a discrepancy in clinical and biochemical results of thyroid axis is observed, it should be excluded the presence of interferences (heterophile antibodies (HA), HAMA) or the presence of different molecular forms of the hormones. It has been described a form of TSH with high molecular weight (MW), the macro-TSH (TSH-IgG), which may be recognized differently by immunoassays (IE), depending on the monoclonal antibodies used in the design, leading to differences between results.

Clinical case: : A short stature 6 years old boy without apparent thyroid disease was studied. Unexpectedly TSH(µUI/mL) measurement in serum samples with ECLIA Cobas e411 (Roche) show markedly elevated results (TSH=455 µUI/mL ; TSH=427 µUI/mL; Reference value= <5.0 µUI/mL, with peripheral thyroid hormones and antibodies (TSH, T4, FT4, T3, thyroid antibodies (AA)) within the reference values over several measurements. Discrepances are shown between this TSH results and TSH IQMA, Architect (Abbott) (A) =21 (µUI/mL) in the same sample; Reference value= <4.5 µUI/mL. Linearity assay for TSH (results of increasing serial dilutions samples) was performed and excludes interference with HA, as pararelism is shown. %Macro-TSH and determination of  FreeTSH (TSH unbound IgG) was performed with Polyethylene glycol precipitation (PEG25%; E1) and Protein A-Sepharose Precipitation (PAS; E2), that behaved similarly and suggested the presence of a high MW form of TSH. Free TSH= 14.5 and 16.0 µUI/mL, % Macro-TSH= 92,7 and 96,2, respectively). Precipitation with PAS determined the nature of the immune IgG complex: IgG-TSH or Macro-TSH. Confirmation of Macro-TSH was performed by Sephacryl G100 chromatography elution shown in the high MW peak (>150KD).

Conclusions: If clinical and biochemical differences in the results are observed, it should be suspected the presence of an interference or different molecular forms of the hormones. In the patient studied, we detected the presence of Macro-TSH, comprising an immune complex of TSH-IgG that appears to be biologically inactive.

 

Nothing to Disclose: AK, CF, LA, MEC, ST, GD, LP, MA, SD, PF, HES, AC

12733 49.0000 SAT-0511 A Macrothyrotropin (MACRO-TSH): A Cause of Discrepancy in the Outcome of the Thyroid Axis? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Yusef Hazimeh*1, Syed Mehdy2, Raina Patel2, Wei Wang2 and Subhashini Yaturu3
1Albany Med College, Albany, NY, 2Stratton VAMC, Albany, NY, 3Albany Medical College

 

Background:

Papillary variant of oncocytic thyroid cancer commonly metastasizes through lymphatic vessels to regional lymph nodes.  Usually they are slow growing tumors. We present a case with interesting features: 1. Metastatic lesion in the jugular vein 2. Clinical behavior is more like anaplastic though histologically well differentiated. 3. Mets to subcarinal area without regional lymph node metastases in the neck 4. Papillary variant of oncocytic carcinoma with negative BRAF.

Case:

A 59 year old man referred from ER for evaluation of rapidly increasing mass in the neck of 2 months duration. US thyroid showed a 5 cm heterogeneous mass with irregular borders and intra nodular vascularity. FNA reported as a neoplasm with both oncocytic and papillary features, favoring a papillary carcinoma. CT neck and chest revealed a 5.0 cm right thyroid mass with mild tracheal deviation and multiple lung nodules, highly suspicious for metastases (largest 2 cm) but no neck lymphadenopathy. He had total thyroidectomy with pathology demonstrating solid, papillary variant of oncocytic carcinoma with areas of extensive tumor necrosis and no evidence of undifferentiated/anaplastic carcinoma. The neoplasm had multifocal invasion of skeletal muscles and blood vessels, and a mitotic rate of > 3/10 high power field.  His post-op Tg level was 302 ng/mL (1.4 - 29.2) with negative Tg antibodies. His bone scan was negative for metastases. Pretreatment I-131 scan showed focal uptake in thyroid bed and no uptake in lung nodules. He was treated with 200 mci of I-131. Post RAI treatment scan did not show any focal activity in the lungs. Repeat CT chest and neck 4 months after 1stCT chest (6 weeks after I-131 Rx), showed increase in size of all lung lesions with the largest 3.4 cm, new bilateral pulmonary lesions, new subcarinal lymph node of 3.7 cm showing central necrosis and metastases in right jugular vein.  US thyroid was negative for any enlarged lymph nodes. Histopathology of wedge resection of the lung and subcarinal mass was consistent with well differentiated papillary variant of oncocytic carcinoma with no anaplastic changes. PET-CT done one week post lung resection revealed hyper metabolic lymph node in right neck compartment III and multiple lung foci.  The patient is stage IVc (T3NxM1).  BRAF was negative. He was started on tyrosine kinase inhibitor, sorafenib, in addition to suppressive dose of levothyroxine.

Learning point: 1. CT chest helped to identify lung mets. 2. Aggressive clinical behavior despite well differentiated histopathology needs aggressive therapy. This case represents an unusually fast progressing papillary variant of oncocytic cell carcinoma.  3. The treatment will be challenging as only limited reports show benefit with this kind of therapy.

 

 

Nothing to Disclose: YH, SM, RP, WW, SY

12904 50.0000 SAT-0512 A Well Differentiated Oncocytic Carcinoma of Thyroid By Histology with a Clinical Behavior like an Anaplastic Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

tae Hyun Kim1, moo Woong Kim*2 and Soonho Kim3
1Kwangju Christian Hospital, Gwangju, Korea, Republic of (South), 2Kwangju Christian hospital, 3Kwangju Christian Hospital

 

A 50-year-old man with no symptoms was admitted because of a thyroid nodule. Ultrasound scan revealed the presence of a nodule with a hyperechogenic rim on the left lobe of the thyroid, and the nodule appeared to be connected to the esophagus (figure A). The patient was asked to drink carbonated water to induce the entry of air into the nodule connected to the esophagus, and changes to the form of the nodule were observed. Compared to the first ultrasound, the ultrasound re-examination showed a ring-down artifact from the air bubbles (figure B). Esophagography was performed, and a Killian–Jamieson diverticulum that resembled a protruding sack from the left of the cervical esophagus (figure C) was observed. Typically, when a thyroid nodule is detected, fine-needle aspiration cytology (FNAC) is used to determine whether the nodule is tumorous. If a nodule from the lower part of the left thyroid lobe appears to be connected to the esophagus, then one must consider the possibility of esophageal diverticulum. In cases where esophageal diverticulum is suspected, we believe that administering carbonated water is a useful method to observe the changes in the shape of the nodule and to circumvent invasive examinations.

 

Nothing to Disclose: THK, MWK, SK

12736 51.0000 SAT-0513 A Easy Way to Distinguish Killian–Jamieson Diverticulum and Thyroid Nodule 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Munira Siddiqua Abbasi*1, Sandra Indacochea Sobel2 and Hussain Mahmud3
1UPMC, Pittsburgh, PA, 2Univ of Pittsburgh Med Ctr, Pittsburgh, PA, 3University of Pittsburgh, Munhall, PA

 

Background:

Struma Ovarii is a rare form of ovarian teratoma that contains thyroid tissue as an exclusive or predominant element. Malignant transformation is an uncommon occurrence in struma ovarii, with most cases revealing classical papillary thyroid carcinoma (PTC). There are few reported cases of follicular variant PTC (FVPTC) in struma ovarii, with similar morphological and molecular profile as FVPTC in thyroid but the appropriate management after resection of this type of ovarian tumor is not clear.

 In the thyroid gland, encapsulated FVPTC behaves more like follicular thyroid adenoma / follicular thyroid cancer with no lymph node metastasis or recurrences and is considered a low-grade tumor that can be treated by lobectomy alone without requiring total thyroidectomy or radioactive iodine (RAI) treatment.[i]We report two cases of encapsulated FVPTC present in mature ovarian teratomas.

 Clinical Cases:

The first patient was a 59-year-old postmenopausal woman who underwent total abdominal hysterectomy and bilateral salpingo-oopherectomy (TAHBSO) for a symptomatic 5.6 cm heterogeneous left ovarian mass presenting with reactive ascites. Pathology confirmed struma ovarii with evidence of encapsulated FVPTC, without capsular/vascular invasion or distant metastasis. Thyroid ultrasound revealed a 1 cm thyroid nodule that was biopsied and noted to be benign.

 The second patient was a 36-year-old woman with history of left oophorectomy due to teratoma 10 years prior to presentation. She represented with pelvic pain and imaging showed a 14 cm right ovarian mass. She underwent TAH and right oophorectomy. Pathology revealed a mature teratoma with a 1.2 cm encapsulated FVPTC without capsular/vascular invasion or distant metastasis. Thyroid ultrasound revealed a normal thyroid gland.

 As both patients were euthyroid and there was no evidence of malignancy in the thyroid gland, the decision was made to treat conservatively without thyroidectomy or RAI.

 Conclusion:

To the best of our knowledge, there are no reported cases of encapsulated FVPTC arising in struma ovarii and hence no guidelines are available for the management of these patients. Data suggest minimal risk of recurrence after thyroid lobectomy alone in patients with non-invasive encapsulated FVPTC of thyroid gland. Therefore, we opted to treat our patients with encapsulated FVPTC in struma ovarii conservatively, without thyroidectomy or RAI.

Further molecular testing will be valuable in understanding the pathogenesis of this type of tumor variant arising in struma ovarii.

 

Nothing to Disclose: MSA, SIS, HM

12796 52.0000 SAT-0514 A Encapsulated Follicular Variant of Papillary Thyroid Carcinoma Arising in Struma Ovarii 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Taniya Nayantara de Silva* and Gabriel Ikponmosa Uwaifo
Louisiana State University Health Sciences Center, New Orleans, LA

 

A 60 year old woman with history of osteopenia and hypertension presents with a prominent left thyroid lobe.  She notes occasional dysphagia but denies voice hoarseness or shortness of breath when lying flat.  She has had no radiation exposure to her head or neck.  She is unaware of any family history of thyroid cancer.  Ultrasound reveals a heterogenous, diffusely enlarged thyroid gland with innumerable nodules.  Fine needle aspiration biopsy of bilateral dominant nodules is performed.  Cytology of both nodules is suspicious for a follicular neoplasm.  Patient undergoes a total thyroidectomy.  Intraoperatively, her entire gland is noted to appear quite nodular.  Pathology is consistent with a 1.6 X 1.6 X 1.6 cm right sided minimally invasive follicular carcinoma.  Associated pathology findings are multiple bilateral follicular adenomas (0.1-1.4 cm) and hyperplastic nodules.

Given the unusual multicentricity of her pathology she is clinically evaluated for Cowden Syndrome (CS).  Review of her past diagnostic studies reveals mammograms significant for fibroglandular densities .  Further chart review reveals diagnoses of fibroids, hypertrophic actinic keratosis, and sebaceous hyperplasia made by her gynecologist and dermatologist respectively. Patient is found to meet clinical criteria for CS as she has one major criteria (follicular thyroid cancer) and three minor criteria (fibrocystic disease of the breast, uterine fibroids, and lipomas).  PTEN mutation testing is found to be negative.  A geneticist confirms a diagnosis of CS despite the negative PTEN mutation analysis.  In light of this diagnosis the patient contacts many family members she had previously not been in contact with to discuss their medical histories.  She discovers several of her cousins had thyroid and skin cancers.   The patient is recommended to undergo surveillance mammograms, MRI and skin exams every 6 months.  Her 1st-degree relatives are recommended to be screened for CS.

While Cowden Syndrome is rare, it is underdiagnosed. The absence of dermatalogic findings should not preclude an evaluation for CS.  A negative PTEN mutation analysis should not preclude a diagnosis of CS in patients who meet diagnostic criteria.  Clinically CS is significant as patients with CS are at greater risk of developing breast, thyroid and other malignancies.  As it is an autosomal dominant condition first degree relatives of an individual with CS should be screened for the disorder.  All those found to be affected with CS should undergo aggressive cancer screenings.

 

Nothing to Disclose: TND, GIU

13134 53.0000 SAT-0515 A Lessons from the Zebra: A Clinical Diagnosis of Cowden Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Ismary O De Castro1 and Spencer Peterson*2
1Memorial Health University Physicians, Savannah, GA, 2Memorial University Medical Center, Savannah, GA

 

Background:  Hyperthyroidism has many clinical manifestations frequently involving the cardiovascular system; however, it rarely presents as bradycardia requiring additional therapies other than thionamide treatment.

Clinical case:  A 47 year old hispanic male with vitiligo and untreated hyperthyroidism presented for recurrent dizziness and syncope. He reported symptoms of weight loss, palpitations, shortness of breath, and diarrhea occurring over a previous two year period. Despite initial aggressive medical management with methimazole and propranolol in the outpatient setting, the patient was admitted to the hospital a few days later for profound symptomatic bradycardia with TSH (<0.01, n=0.35-5.50), Free T4 (5.61, n=0.58-1.64) and normal serum potassium, calcium and magnesium levels. Thyrotoxic periodic paralysis was not suspected.  Even after discontinuation of his propranolol and treatment with atropine, glucagon, intravenous fluids, and increased dosing of methimazole, his bradycardia persisted over a 48 hour period.  With no other evidence for electrolyte abnormalities, heart failure, ischemia, or arrhythmias which can be seen in hyperthyroidism, a dual-chamber permanent pacemaker was placed in combination with methimazole treatment subsequently alleviating his symptoms and bradycardia.

Conclusion:  Hyperthyroidism, left untreated, can have devastating effects on the cardiovascular system, and this case highlights a rare finding of bradyarrhythmia in which standard medical therapy with methimazole was insufficient to treat this degree of hyperthyroidism, and further invasive measures with permanent pacemaker insertion was needed to control the patient’s symptoms.  Thyroid hormone mediates the expression of structural and regulatory genes in the cardiac myocyte usually resulting in increased heart rate.  The manifestation of bradycardia in severe Graves' disease however, is poorly understood.

 

Nothing to Disclose: IOD, SP

13754 54.0000 SAT-0516 A "Graves' Disease Presenting with Bradyarrhythmia Requiring Permanent Pacemaker Placement” 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Mary Anne Pandy Calimon*1 and Stefanie Wong Lim-Uy2
1St. Luke's Medical Center Quezon City, Philippines, 2St. Luke's Medical Center Quezon City, Quezon City, Philippines

 

Background: Thyroid cancer, even when well-differentiated, usually appear as cold or hypofunctioning at scintigraphy because their iodine uptake is retained at much lower level in tumoral tissue than in the adjacent normal tissue.  However, rare reports exist that malignant nodules may also present as solitary hot nodules. 

Methods: We report the clinical and laboratory findings in a patient with a thyroid nodule, with emphasis on the pathologic findings after complete surgical removal of the thyroid gland.

Clinical Case: A 37 year-old female presented with a palpable nodule on the left thyroid lobe associated with occasional palpitations. Results of thyroid function tests revealed subclinical hyperthyroidism. Thyroid ultrasound showed a 2.6 x 2.1 cm cystic nodule and 1.0 x 0.8 cm hypoechoic nodule on the left lobe. 99mTc  thyroid scintigraphic imaging was consistent with an autonomous hyperfunctioning nodule. Fine needle aspiration biopsy showed findings consistent with papillary carcinoma and patient subsequently underwent total thyroidectomy. Pathologic examination disclosed a papillary microcarcinoma, lymphocytic thyroiditis and colloid nodule.

Conclusion: Although the detection of a hyperfunctioning nodule in a thyroid gland is usually considered benign, it still does not exclude the possibility of a malignancy. In our case, papillary microcarcinoma, lymphocytic thyroiditis and thyroid autonomy may exist simultaneously. Thus, careful evaluation is warranted so that malignancy is not overlooked.


 

Nothing to Disclose: MAPC, SWL

14506 55.0000 SAT-0517 A Papillary Thyroid Carcinoma in an Autonomous Hyperfunctioning Thyroid Nodule 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Cristina Alvarez-Escola*1, Beatriz Pelegrina2, Beatriz Lecumberri Santamarí1, Paola Parra1 and Luis Felipe Pallardo1
1La Paz University Hospital, Madrid, Spain, 2La Paz University Hospital, Madrid

 

Rising levels of anti-thyroglobulin antibodies (TgAb) may indicate recurrent/ progressive disease in patients treated for a differentiated thyroid carcinoma (DTC). In this situation, the potential effects of immune modulating drugs (IMD) on TgAb and/or disease progression should also be considered. We present the long-term outcome and TgAb and TPO antibodies (TPOAb) monitoring of 4 female patients with DTC, considered to be free of disease after total thyroidectomy and 131I ablation, 2 of whom were treated with IMD during their follow-up.

A 84 year-old woman with Hürthle cell thyroid carcinoma showed undetectable TgAb and TPOAb for 11 years. During a 6-weeks treatment with Imiquimod® for a basocellular epithelioma, TPOAb and TgAb increased up to 135.20 UI/ml and 44 UI/ml, respectively, with no evidence of metastatic disease.Three months after Imiquimod withdrawal, TgAb and TPOAb became undetectable again.

A 69 year-old woman treated for a sclerosis variant (sv) papillary thyroid carcinoma (PTC) in 2002, showed a sharp decline in TgAb levels with detectable TPOAb and undetectable Tg (basal and stimulated). In 2012 TPOAb levels slightly increased, and a stimulated Tg 4.75 ng/ml was detected. A metastatic nodule on the thyroid bed was identified and tracheal infiltration was observed during surgery.

A 46 year-old woman treated for a PTC in 1991, had undetectable TgAb and TPOAb. After being started on human immunoglobulin (HI) for an autoimmune thrombocytopenic purpura diagnosed in 2008, TgAb and TPOAb levels rose up to 337UI/ml and 132 UI/ml, respectively, and became undetectable 3 months after HI withdrawal. No evidence of PTC recurrence was found.

In a 64 year-old woman treated for a svPTC in 2001, TgAb decreased to 18 U.I/m, and TPOAb became undetectable, but 6 years later TgAb started an increasing trend, reaching 384 UI/ml in 2009. FNA revealed PTC metastasis in a cervical lymph node (CLN). Surgical lymphadenectomy found 3 PTC metastatic CLN.

Conclusions: 1) An increase on TgAb, and probably on TPOAb, should rise the suspicion of DTC progression/recurrence 2)Additional diagnostic procedures are required to rule out the presence of potential metastasic disease, and guide further treatments 3) The effects of any IMD used should be considered when interpreting sudden changes in TgAb and TPOAb levels 4) There is no clear evidence regarding the duration of IMD effects. In our series, TgAb and TPOAb levels became undetectable 2 to 3 months after IMD withdrawal.

 

Nothing to Disclose: CA, BP, BL, PP, LFP

14579 56.0000 SAT-0518 A Changes in Serum Anti-Thyroglobulin and Anti-Peroxidase Antibody Levels As Markers of Disease Recurrence/Progression in Patients with Differentiated Thyroid Carcinoma. the Effect of Immune Modulating Drugs 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Caroline J Davidge-Pitts*1, Ian D Hay1, Michael J Levy1 and Thomas J Sebo2
1Mayo Clinic, Rochester, MN, 2Mayo Clinic College of Medicine, Rochester, MN

 

BACKGROUND: Pancreatic metastases from differentiated thyroid cancer (DTC) are rare, with only 16 cases reported in the world literature. If left untreated, these metastases can lead to significant morbidity including obstructive jaundice. Unfortunately, many patients are poor surgical candidates and non-surgical options remain limited. Ultrasound -guided ethanol ablation (UEA) has been used to treat inoperable insulinomas. However, UEA has not been reported in the treatment of DTC metastatic to the pancreas.

CLINICAL CASE:  A 59 year old woman, with a history of a thyroidectomy for a 4 cm papillary thyroid carcinoma (PTC) five years previously, presented to our institution with her third nodal recurrence requiring modified neck dissection.  At time of thyroidectomy, the primary tumor had not invaded locally and no neck nodal metastases (NNM) were found or removed.  Ablation with radioiodine (I-131) was performed after the first postop NNM discovery; thereafter, three whole body scans were negative for I-131 uptake. At 7 postoperative  years, a CT scan demonstrated bilateral lung nodules. These nodules concentrated I-131 and therefore 150 mCi of therapeutic I-131 was administered. At 14 postoperative years, serum thyroglobulin (Tg) had risen from 24 to 104 ng/ml and FDG PET/CT scan of the abdomen revealed a 3.9 cm mass in the pancreatic head with obstruction of the main pancreatic duct, suspicious for metastatic disease.  She underwent endoscopic ultrasound and fine needle aspirate which confirmed metastatic PTC. Five months later, her serum Tg had risen to 204 ng/ml, with an increase in size of the pancreatic lesion to 4.8 cm. The patient declined surgical intervention of her pancreatic lesion despite concerns of impending obstructive jaundice. We elected to proceed with UEA of the pancreatic lesion with a total of 3.42 ml of 95% ethanol over four sessions. No complications occurred. The lesion has remained stable and she has not required further ethanol injections. She has not developed jaundice to date (four years later), although she has progression of her disease to the brain, skin, bones and muscle.

CONCLUSION: UEA is a novel therapeutic approach for the treatment of DTC metastatic to the pancreas in patients who are poor surgical candidates, thereby reducing morbidity and improving quality of life.

 

Nothing to Disclose: CJD, IDH, MJL, TJS

14589 57.0000 SAT-0519 A Pancreatic Metastases from Differentiated Thyroid Carcinoma: A Novel Therapeutic Approach Using Ultrasound-Guided Ethanol Ablation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Cesar Abuchaibe*1, Omar Naeem Akhtar2 and Dario Martinez3
1The Jewish Hospital of Cincinnati - Mercy Health, Cincinnati, OH, 2Mercy Health, Mason, OH, 3The Jewish Hospital of Cincinnati Mercy Health, cincinnati, OH

 

Background

To present a case of Thyroid Storm following RAI therapy and bring the question if it was due to RAI vs withdrawal from antithyroid medication.

Thyroid storm is an acute life threatening hyper metabolic state in patients with thyrotoxicosis. RAI therapy and withdrawal of antithyroid medication are two well described causes of this condition.  This case illustrates how difficult it can be to determine whether a thyroid storm could be secondary to RAI therapy or withdrawal of Methimazol.  Studies have shown that after RAI therapy, patients pretreated with anti-thyroid medication (Methimazol) have lower level of thyroid hormones than non-pretreated patients.

Although this patient was pre medicated with Methimazol and discontinued it 10 days before the RAI therapy; it is unclear if the tapering time of the Methimazol influenced in the patient going into withdrawal.  It is also important to remember that RAI therapy increases circulating stimulating TSH receptor Ab from the degenerating follicles; these can precipitate a Thyroid storm.  The vast majority of these Ab are released during the first couple of weeks after I131 administration hence a thyroid storm is more likely to occur during this time as on this patient. 

Presentation

36 y/o Hispanic male with a history of ALL post Bone marrow transplant and Grave’s disease treated with Methimazol and recent RAI who was seen in consult for a Thyroid storm.  The patient was originally seen in clinic for loss of appetite, insomnia, diarrhea and reduced concentration.  At that moment his laboratory data was as follow: 

TSH <0.01 µIU/mL  total T4 17 ug/dl  FT4 2.54 ng/L  total T3  2.87 ng/ml  TSI Ab positive  TSHR Ab positive  RAI uptake and scan: uniform uptake. Confirming Grave’s disease.

He was started on Metoprolol and Methimazol but the symptoms persisted therefore RAI therapy was offered.   The patient discontinued Methimazol two weeks before the RAI therapy.   For the RAI therapy he received 15.6 mCi of I131.  

Ten days after RAI therapy the patient started experiencing palpitations, chills, fever and malaise. His physical exam showed a febrile patient (102.7), tachycardic Afib/RVR (120).  No proptosis and thyroid moderately enlarged and tender.  TSH <0.02 µIU/mL and FT4 6 ng/L.  Burch and Wartofsky score of 50 based on his symptoms, highly suggestive of a thyroid storm.  The patient was started on PTU, Hydrocortisone, SSKI drops and Propranolol.  Symptoms resolution was obtained in 2 days and he was discharge with Methimazol and Propranolol.  At two month follow up: TSH 13.3 µIU/mL FT4 0.34 ng/L; he was started on levothyroxine for post ablative hypothyroidism.  

Conclusion

Even though RAI therapy is a well known precipitating cause of Thyroid storms, caution should be taken when evaluating the duration of anti-thyroid medication withdrawal before RAI therapy for hyperthyroid patients.

 

Nothing to Disclose: CA, ONA, DM

14677 58.0000 SAT-0520 A A Case of Thyroid Storm Following Radioactive Iodine (RAI): Was It a Consequence of RAI or Withdrawal from Methimazol 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Maria Batool1, Vaishnavi Amit Parnerkar*2 and M Luiza Caramori3
1University of Minnesota Medical Center, Minneapolis, MN, 2University of Minnesota, MN, 3Univ. of Minnesota, Minneapolis, MN

 

INTRODUCTION

Thyroid dysfunction, specifically hypothyroidism, is a known adverse effect of tyrosine kinase inhibitors (TKI) blocking the VEGFR pathway.  Axitinib, a relatively new TKI, was approved by the FDA in January 2012 for the treatment of advanced renal cell carcinoma.

Herein we report an uncommon case of Axitinib induced hyperthyroidism.

CLINICAL CASE

A 59 year old male with metastatic renal cell carcinoma was seen in consultation for abnormal thyroid function tests.  He had no personal or family history of thyroid disease or any history of head and/or neck radiation. There was no recent history of upper respiratory illness, pain in the neck area or dysphagia. Weight had been fluctuating and he felt cold. He appeared clinically euthyroid on physical exam.

The patient had been started on Axitinib 3 weeks prior and the drug was stopped on the day prior to the consult due to fatigue and dyspnea.

Laboratory studies revealed TSH 0.02 mU/L (0.4-5.0), Total T3 201 ng/dL (60-181) and Free T4 5.32 ng/dL (0.70-1.85). TSH was 2.35 mU/L a month prior to the initiation of Axitinib. TSI and thyroglobulin antibodies were negative. CRP and IL-6 levels were elevated indicating an ongoing inflammatory process.

A thyroid uptake and scan was planned but deferred in light of high 24-hour urinary iodine levels, consistent with recent exposure to IV contrast containing iodine. A diagnosis of drug induced hyperthyroidism was made and methimazole 20 mg daily was started, with normalization of thyroid function tests in 4 weeks. The patient was admitted to the hospital weeks later due to respiratory failure and passed away. The cause of death was stated as sepsis.

CONCLUSION

TKIs are molecules targeting the tyrosine kinase receptor approved for the treatment of several hematologic malignancies and solid tumors.

The mechanism of thyroid dysfunction associated with TKIs remains largely unknown, but direct toxic effects, capillary regression in the thyroid gland, decreased biological activity of circulating TSH and impaired hypothalamic-pituitary-thyroid axis have all been proposed (2). Our case is consistent with the few reports in literature illustrating the very early thyroid dysfunction associated with Axitinib (1) but it also puts forward hyperthyroidism as the presenting abnormality which hitherto has not been frequently reported.

There are no guidelines recommending the frequency of thyroid function testing in patients receiving these agents. Current recommendations are for thyroid function to be checked before therapy and then monitored “periodically” (1). There are data suggesting that patients who developed hypothyroidism while treated with TKIs may have a significantly better prognosis (4). The unique effects of Axitinib and other TKIs on the thyroid gland would be of even greater significance given the emerging prospect of using these agents in the treatment of radioiodine-resistant thyroid cancer (3).


 

Nothing to Disclose: MB, VAP, MLC

15206 59.0000 SAT-0521 A Axitinib Induced Thyroid Dysfunction- a Blessing in Disguise 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Susan Yuditskaya*1, Verena Gounden1, Steven J. Soldin2 and Francesco S. Celi3
1National Institutes of Health, Bethesda, MD, 2Georgetown University, Bethesda, MD, 3National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD

 

Background:  Most athyreotic patients achieve normal triiodothyronine (T3) levels when treated with levothyroxine (LT4), but heterogeneity in their T3 levels has also been noted. A minority of patients with target TSH and thyroxine (T4) levels within the normal range exhibit low serum T3 levels, and occasionally complain of hypothyroid symptoms. An impaired conversion of exogenously administered T4 into T3 has been hypothesized to play a causal role in this phenomenon.

Case:  A 45 year old woman with history of stage I papillary thyroid carcinoma on stable suppressive LT4 treatment with 175 mcg LT4 daily (2.6 mcg/Kg) had her LT4 dose reduced after the 5-year follow-up visit showed no evidence of residual/recurrent disease. At that time, her thyroid function tests were as follows: TSH 0.11 mcIU/mL [normal (N) 0.4–4.0], free T4 1.3 ng/dL (N 0.8–1.5),  and T3 71 ng/dL (N 80-200). Once the LT4 dose was reduced to 150 mcg, the patient developed hypothyroid symptoms including overwhelming fatigue, hair shedding, memory loss, poor concentration, bloating, and bradycardia (50 bpm). Concurrently, T3 levels became persistently undetectable (<40 ng/dL), and TSH rose to 7.98 mcIU/mL. Free T4 was within the normal range (1.1 ng/dL). Low T3 levels were confirmed by mass spectroscopy (MS) at 42.9 ng/dL [N 79.8–187]. Thyroid binding globulin and liver function were normal, and an ACTH stimulation test ruled out adrenal insufficiency. Low-normal reverse T3 [13 ng/dL (N 10-24)] indicated absence of consumptive hypothyroidism. Increase of LT4 dose to 200 mcg daily did not resolve the symptoms, nor the biochemical findings (TSH 8.54 mcIU/mL, free T4 1.2 ng/dL, T3 62 ng/dL). Pharmacokinetic (PK) analysis after a single LT4 600 mcg dose showed low T3 levels over 480 min (61.3–70.6 ng/dL by immunoassay; 32–48 ng/dL by MS), suggestive of impaired T4-T3 conversion. A delay in peak total T4 levels [300 min; N 156+60 (1)] also demonstrated a mild degree of malabsorption, without obvious causes. The therapy was adjusted to include liothyronine (LT3), with a regimen of LT4 150 mcg daily and LT3 5 mcg twice daily, with resolution of the symptomatology. The latest thyroid function tests are as follows - TSH  0.18 mcIU/mL, free T4 0.9 ng/dL, and T3 78 ng/dL - and the treatment is currently being optimized towards a therapeutic goal of normalized TSH and T3 levels. 

Conclusion: This is an unusual case of symptomatic hypothyroidism likely secondary to impaired T4 to T3 conversion, with a component of LT4 malabsorption. Etiology of each remains elusive despite detailed workup.

 

Nothing to Disclose: SY, VG, SJS, FSC

15234 60.0000 SAT-0522 A Low Serum Triiodothyronine Levels Associated with Symptomatic Hypothyroidism in an Athyreotic Patient on Adequate Levothyroxine Replacement 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Kinjal K Shah*1, Valentina D. Tarasova2, Michael Davidian2 and Robert J Anderson3
1VA-Nebraska Western Iowa Healthcare System, Omaha, NE, 2Creighton University School of Medicine, Omaha, NE, 3VA - Nebraska Western Iowa Healthcare System / Creighton University Medical Center, Omaha, NE

 

Background: Painful thyroiditis is mentioned as a complication of 131I therapy in Graves’ disease, but the course is not thoroughly documented.

 Clinical case: A 44-year old female, chronic smoker was diagnosed with Graves’ disease 4 years earlier. She started methimazole (MMI) and remained on a stable dose of 5mg six days a week for 18 months. She then opted for radioactive iodine ablation (RAI). Her only symptom was occasional fatigue. Physical examination was significant for a diffusely enlarged, non-tender, 30 gram thyroid gland. Minimal lid lag was present bilaterally. Other treatment included oral propranolol 20 mg/day.  On MMI her TSH was 0.38 uIU/ml (ref: 0.4-5.1) and free T4 was 0.91 ng/dl (ref: 0.7-1.6). In preparation for the radioiodine therapy, she started a low iodine diet for 2 weeks, and stopped MMI 7days prior to the procedure. RAI uptake was 31% (ref: 5-15%) at 4 hours and 46.5% (ref: 15-35%) at 24 hours. Oral administration of 19 mCi of 131I was given. After 1 week, she developed severe pain in the anterior neck, more on the right side, with radiation to the angle of the jaw. She had fatigue, tremor and odynophagia. On examination, her temperature was 96.3°F, heart rate 88/minute, and blood pressure was 118/92 mmHg. Her anterior neck was asymmetric, swollen, warm and exquisitely tender. The thyroid was enlarged on the right side, firm, and non-fluctuant. The TSH was 0.65 uIU/ml and free T4 was 1.40 ng/dl. NSAIDS and hydrocodone-acetaminophen were ineffective for pain control. Prednisone 40 mg/day provided relief. This was continued for 1 month with a tapering dose. Thyroid ultrasound performed after the pain resolved revealed heterogeneous lobes with variable solid areas, decreased blood flow and no discrete nodules. Symptoms completely resolved after one month at which time the thyroid remained diffusely enlarged and non-tender. Three months following RAI ablation, she developed hypothyroid symptoms with a TSH of 19.66 uIU/ml and a free T4 of 0.48 ng/dl. She has remained asymptomatic on levothyroxine.

 Conclusion: Acute painful radiation thyroiditis after radioiodine treatment for hyperthyroidism of Graves’ disease is uncommon. The usual episode involves mild tenderness that quickly responds to NSAIDs. It is more frequent after larger doses of 131I treatment for post-surgical remnant ablation in patients with thyroid cancer, in which case it is frequently painless and associated with transient thyrotoxicosis. Our patient’s presentation was unique with extremely painful thyroiditis without laboratory signs of transient thyrotoxicosis. Her course and response to glucocorticoids are a reminder that acute painful radiation thyroiditis after radioiodine for hyperthyroidism of Graves’ disease is an uncommon and readily treatable complication of 131I treatment.

 

Nothing to Disclose: KKS, VDT, MD, RJA

15276 61.0000 SAT-0523 A Painful Acute Radiation Thyroiditis Induced By 131I Treatment of Graves' Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Alan Chang*, Barbara Simon and Renee E Amori
Drexel University College of Medicine, Philadelphia, PA

 

Simultaneous Medullary, Classical Papillary, and Follicular Variant of Papillary Thyroid Carcinoma in a Single Thyroid

Background: Thyroid carcinomas are the most common cancers seen in endocrinology.  The subtype of thyroid cancer depends on the embryonic origin of the cells and there have been reports of medullary thyroid carcinoma (MTC) in the same thyroid gland as differentiated thyroid carcinomas (DTC).  There have been approximately 65 cases of concurrent thyroid cancers in one thyroid.1  Concurrent papillary-medullary thyroid cancers are discovered usually post-mortem and the occurrence may be as high as 35%.2  However, post-operative concurrent thyroid cancers are less frequent, up to 7%.2

Clinical case: A 48 year old male presented for evaluation of a symptomatic multinodular goiter.  A thyroid ultrasound showed a 1.7x1.1x1.5 cm thyroid nodule on the right lobe and multiple sub-centimeter nodules on the left lobe.  Cytology from an ultrasound guided fine needle aspiration of the right thyroid nodule was interpreted as a follicular neoplasm.  There was no history of radiation exposure or family history of thyroid disease.  Thyroid function tests were normal.  As he had multiple nodules, he underwent a total thyroidectomy.  Histopathological analysis of the tissue demonstrated five different foci of thyroid carcinoma: four in the left lobe and one in the right lobe.  Three different sub-types of cancers were found: classical papillary, follicular variant of papillary, and medullary thyroid carcinoma.  The papillary foci measured 0.6x0.4x0.3 cm, 0.4x0.4x0.4 cm, and 0.1x0.1x0.1 cm all in the left lobe; the follicular variant measured 0.4x0.2x0.1 cm in the left lobe; and the medullary carcinoma was 1.2x1.1x1.0 cm in the right.  He underwent an iodine ablation, and post-treatment whole body scan with no evidence of metastasis.  The calcitonin levels were trended and were always undetectable, below 2 pg/ml, while carcinoembryonic antigen (CEA) levels were always normal below 2.5 ng/ml.  It was decided that genetic testing would be addressed after treatment. 

Conclusion: Simultaneous MTC and DTC are described, but are uncommon.  This case demonstrates multifocal DTC with classic papillary and follicular variant of thyroid carcinoma in addition to the dominant MTC.  It is unclear whether there is genetic link between DTC and MTC but current literature shows it is non-related.1  Clinicians should remember to treat simultaneous DTC and MTC as individual tumors and according to their respective guidelines.

 

Nothing to Disclose: AC, BS, REA

15380 62.0000 SAT-0524 A Simultaneous Medullary, Classical Papillary and Follicular Variant of Papillary Thyroid Carcinoma in a Single Thyroid 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Rosalinda Yossie Asato Camargo*1, Olivia Bonfim2, Elaine Oliveira Dias2, Suemi Marui3, Raquel Moyses4 and Nicolau Lima5
1Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 2Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3Faculdade de Medicina USP, Sao Paulo SP, Brazil, 4Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil, 5Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Background: Hashimoto’s Thyroidists (HT) is the most common cause of diffuse goiter and hypothyroidism. It is an autoimmnune disorder characterized by increased serum thyroid autoantibodies. The histhologic features include diffuse lymphocytic infiltration, atrophic follicles, well-developed germinal centers, and fibrosis.  HT is usually asymptomatic and surgery is rarely necessary except in cases where the disease is associated with nodular lesions suggesting malignancy. Thyroidectomy for relief of compressive symptoms has been controversial because of variable outcomes and morbidity. We present a 48-year-old woman with a huge thyromegaly which presented  compressive symptoms and had an unsightly appearance in the anterior neck.

Summary:  The patient was referred to our Thyroid Unit because of a painless progressive enlargement of the neck during the past 10 years. Physical examination revealed a huge diffuse goiter that had a very hard consistency. Ultrasound examination of the thyroid gland revelead a bulky, markedly hypoechoic goiter with heterogeneous aspect, and increased diffuse blood flow on color Doppler. A multislice computed tomography  (CT) scan showed an estimated thyroid volume of 304.7 mL.  The TSH level was 10.6 uIU/mL (0,27-4,20 uIU/mL),  the serum free T4 was 0.62 ng/dL  (0.93 - 1.7 ng/dL), and total T3 was 130 ng/dL (80-200 ng/dL). The circulating antithyroid antibodies showed TPOAbs  > 999 IU/mL (< 9 IU/mL), and TgAbs  1656 IU/mL (< 4 IU/mL). The serum thyroglobulin was 0.5 ng/mL (< 35 ng/mL). Fine-needle-aspiration cytology of both lobes was suggestive of chronic lymphocitic thyroiditis. The patient was submitted to a total thyroidectomy and did not develop any complications. The thyroid gland weight was 323 g and the cytological diagnosis of Hashimoto’s thyroiditis was confirmed by histology. 

Conclusion:  We present a rare case of Hashimoto's thyroiditis who developed a bulky goiter. In this case, thyroidectomy was very effective and safe in improving compressive and cosmectic symptoms, with no postoperative complications.

 

Nothing to Disclose: RYAC, OB, EOD, SM, RM, NL

15435 63.0000 SAT-0525 A A Rare Case of Hashimoto's Thyroiditis Presenting a Huge Diffuse Goiter and Compressive Symptoms 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Radhika Deshmukh*1, Bantwal Suresh Baliga2 and Lori Fuller1
1East Alabama Endrocrinology, Opelika, AL, 2East Alabama Endo, PC, Columbus, GA

 


Background: We report a 23 year-old woman, with refractory hypothyroidism undergoing therapy with levothyroxine(LT4) treatment after total thyroidectomy. Her first visit, revealed very low free thyroxine (FT4) levels accompanied by very high TSH levels. Both parameters did not change significantly with oral dose of 200 mcg of LT4 and 10 mcg of liothyronine(LT3). Investigations did not reveal malabsorption. She responded well to IV doses of levothyroxine. TSH only became normal during parental therapy with LT4.


Case report: We report a 23 year old woman who presented in the clinic with severe hypothyroidism. She was referred here by a thyroid surgeon for evaluation of refractory hypothyroidism. She underwent total thyroidectomy for MNG in 2009. Since then she had persistently high TSH levels despite being on oral LT4 200 mcg QD. During the first visit she complained of tiredness, muscle pains & dry skin. She claimed compliance with medications.
On examination the patient was clinically hypothyroid with delayed deep tendon reflexes. The rest was unremarkable, with the exception of dry skin and myalgia. Thyroidectomy scar seen. Last TSH was 248 uIU/mL (range 0.450-4.500) ,FT4 0.62ng/dL (range 0.82-1.77). There was no family history of thyroid disorders. Liothyronine 10 mcg QD was added.A follow up was scheduled with TFTS.
During the follow up she was on levothyroxine 200 mcg QD and liothyronine 10 mcg QD. TSH was 328 uIU/mL(range 0.450-4.500) & FT4 0.92ng/dL (range 0.82-1.77).Suspecting noncompliance, her mother was asked to supervise her medications. The subsequent visits showed TSH between 200 to 300 uIU/mL (range 0.450-4.500) ranges. Suspecting malabsortion, it was decided to start IV Levothyroxine on 50 mcg QD, five days a week and oral Levothyroxine 200 mcg QD on weekends. During her follow up four weeks later she felt better. TSH came down to 25.. The IV dose was gradually raised over 14 week period. 14 weeks later, the TSH dropped to 0.05 uIU/mL (range 0.450-4.500) & FT4 increased to 1.2ng/dL (0.82- 1.77). The patient also underwent upper GI  endoscopy &  no evidence of malabsorption was found. Currently the patient is on IV LT4 300 mcg QD for 3 days/ week & oral LT4 200 mcg QD for 4 days a week. TFTS are in the normal range.

Conclusion: There are very few cases that are reported in the literature which in spite of adequate doses of levothyroxine, continue to have elevated TSH. This might be due to poor compliance, the most frequent cause [1–3] or due to malabsorption. In the above case, the patient was compliant with oral therapy, certified by supervised administration of LT4. Hence poor compliance was excluded. The GI work up for the patient was normal and not consistent with malabsorptive disease. Hence, the patient had selective malabsorption of oral levothyroxine (LT4) which responded very well to IV LT4 initially. This was followed by IV and oral doses of LT4.


 

Nothing to Disclose: RD, BSB, LF

16045 64.0000 SAT-0526 A Refractory Hypothyroidism in a Young Patient 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Bu Kyung Kim*1, Jee-Yeong Jeong2, Chul Ho Oak3, Young Sik Choi3, Su Kyoung Kwon4 and Yo-Han Park5
1Kosin Univ Sch of Med, Busan, Korea, Republic of (South), 2Kosin University College of Medicine, Korea, Republic of (South), 3Kosin University College of Medicine, 4Kosin University College of Medicine, Busan, Korea, Republic of (South), 5Kosin University College of Medicine, Busan

 

The Philippines has already been successfully overcome iodine deficiency. However, endemic goiter still has been recognized and 50,000 newborns have mental problems due to iodine deficiency in Philippines. In this study, we evaluated iodine nutrition status by urinary iodine concentrations and thyroid volumes and investigated an awareness status of iodine deficiency by questionnaires in high school students of Tuguegarao, Philippines.

 A total 260 students measured urinary iodine and among them 146 students finished measuring thyroid volume by ultrasonography and answering questionnaire. UI was measured with an iodine selective electrode method by Orion 4-Star Plus pH/ISE Portable Meters (Thermo Fisher Scientific, Beverly, MA, USA).To assess the accuracy of the UI assay, the Kosin University Laboratory participated in the EQUIP Program (Ensuring the Quality of Iodine Procedures) of the Centers for Disease Control and Prevention (CDC) in Atlanta, GA, USA. Thyroid volumes were measured using a portable ultrasound instrument equipped with a 10MHz linear transducer (LOGIQ BOOK XP, GE healthcare, Seoul, Korea). The questionnaires were consisted of five main questions and two sub-questions.

 A mean urinary iodine level was 378.5 µg/L. According to the ICCIDD criteria, only 3.8% of students were iodine deficiency status. 56.8% of the students answered they have heard about the problems associated with iodine deficiency. Although 62.3% of students answered they can list some problems resulting from iodine deficiency, almost students (70.5%) listed only goiter. They didn’t listed miscarriage, stillbirth and retard development of children. Almost students received information about iodine deficiency disorders from school (47.9%), television, and radio (41.1%). 33.6% of students didn’t use iodized salt and the most of them answered they didn’t use iodized salt because they don’t know why it need. There was no significant difference in urinary iodine level, height, and weight between iodized salt using group and non-using group. However the thyroid volume was bigger in non-using group than using group (4.35 ± 2.47 vs 3.71 ± 1.03, p=0.032)

 These results clearly indicate that iodine deficiency has been overcome in the Philippines. Therefore, we suggest that to eliminate iodine deficiency a specific strategy which focus on fragility group of iodine deficiency would be need.  Maybe they are women of pregnant and childbearing age especially in area of low socioeconomic status. And this strategy would be more potent, if it used as a school education program or the TV and radio commercials.

 

Nothing to Disclose: BKK, JYJ, CHO, YSC, SKK, YHP

13757 65.0000 SAT-0527 A Current Iodine Nutrition Status and Progress Towards Elimination of Iodine Deficiency and Goiter in Tuguegarao, Philippines 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0463-0527 4871 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Alessandro Antonelli*1, Silvia Martina Ferrari1, Alda Corrado1, Marco Nardi2, Stefano Sellari Franceschini1 and Poupak Fallahi1
1University of Pisa, Pisa, Italy, 2University of Pisa, Italy

 

Interferons (IFNs) and tumor necrosis factor-α (TNF-α) cooperate in activating several inflammation-related genes, which sustain chronic inflammation in autoimmune thyroid diseases (AITD). Much is known about the positive signaling of IFNs to activate gene expression in AITD, while the mechanisms by which IFNs negatively regulate genes remain less studied. While IFNs inhibit (C-X-C motif) ligand 8 (CXCL8) chemokine secretion in several human cell types, their effects on thyroid and orbital cells in Graves’ disease were not evaluated. Our aim was to study the interplay between TNF-α and type I or type II IFNs on CXCL8 secretion by these cells. CXCL8 was measured in supernatants of primary cultures of thyroid cells, and orbital fibroblasts and preadipocytes basally and after a 24 h incubation with TNF-α. CXCL8 was detected in all cell types supernatants in basal conditions being significantly increased by TNF-α. Twenty-four hours incubation with IFN-γ or IFN-β or IFN-α dose dependently and significantly inhibited both basal and TNF-α-induced CXCL8 secretion. The degree of the inhibitory effect was IFN-γ>IFN-β>IFN-α. In conclusion, this study demonstrates that type I and type II IFNs downregulate both basal and TNF-α-induced CXCL8 secretion by human thyroid and orbital cells in Graves’ disease, IFN-γ being the most powerful inhibitor.

 

Nothing to Disclose: AA, SMF, AC, MN, SS, PF

12637 3.0000 SAT-0530 A Type I and Type II Interferons Inhibit Both Basal and Tumor Necrosis Factor-α-Induced CXCL8 Secretion in Primary Cultures of Thyrocytes in Graves' Disease and in Primary Fibroblasts or Preadipocytes from Graves' Ophthalmopathy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0528-0545 4877 1:00:00 PM Thyroid Autoimmunity Poster

Naoki Hattori*1, Takashi Ishihara2 and Akira Shimatsu3
1Ritsumeikan University, Kusatsu-City, Shiga, Japan, 2Kobe City General Hospital, Ashiya-Shi, Japan, 3National Hospital Organization Kyoto Medical Center, Kyoto, Japan

 

Objective. The condition of high serum TSH but normal thyroid hormone levels includes latent hypothyroidism due to chronic thyroiditis, excessive iodine intake and drug-induced thyroid dysfunction, immediately after thyroid hormone replacement therapy and adrenal insufficiency.  TSH is a glycoprotein consisting of α and β subunits and the molecular weight is approximately 28kDa.  There are several case reports describing macro-TSH with molecular weight greater than 100kDa.  In this study, we investigated the prevalence and pathophysiology of macro-TSH in patients with latent hypothyroidism.

Methods. Macro-TSH was screened by polyethylene glycol (PEG) method in 680 patients with latent hypothyroidism (384 women and 296 men, 64.5 ± 19.2 years) and 38 patients with overt hypothyroidism (24 women and 14 women, 65.6 ± 16.1 years) as a control.  Serum samples with PEG precipitation ratio [(total TSH – free TSH)/total TSH x 100] greater than 75% (mean + 1.5SD in controls) were subjected to gel filtration chromatography to confirm macro-TSH.

Results. Among 680 serum samples, 117 showed PEG precipitation ratio greater than 75%.  TSH was eluted at the position of molecular mass greater than 100kDa in 11 patients with latent hypothyroidism (1.62%) on gel chromatography, being diagnosed as macro-TSH.  Total serum TSH levels in patients with macro-TSH ranged from 9.0 to 716 µU/mL (median 12.2 µU/mL).  Free TSH levels ranged from 0.68 to 14.55 µU/mL (median 3.09 µU/mL) and were within normal range in 9 of 11 patients.  In one serum sample with macro-TSH, addition of mouse serum to the assay system significantly decreased TSH levels, indicating that human anti-mouse antibody (HAMA) may be responsible for the development of macro-TSH in this patient.  

Conclusion. The prevalence of macro-TSH was 1.62% in patients with latent hypothyroidism, lower than that of macroprolactinemia (10-20% in patients with hyperprolactinemia), in which anti-PRL autoantibodies form macro-PRL.  Free TSH levels were normal in most patients with macro-TSH, suggesting that bioactive TSH levels might be normal.  Because HAMA was not detected in 10 of 11 patients with macro-TSH, it is possible that other mechanisms such as autoantibodies to human TSH might be involved in the pathogenesis of macro-TSH in these patients.  Macro-TSH should be considered in the differential diagnosis of patients with high serum TSH but normal thyroid hormone levels.

 

Nothing to Disclose: NH, TI, AS

PP12-2 12951 4.0000 SAT-0532 A Macro-TSH in Patients with Latent Hypothyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0528-0545 4877 1:00:00 PM Thyroid Autoimmunity Poster

Gulhan Akbaba*1, Dilek Berker2, Serhat Isik3, Narin Nasiroglu Imga2, Kerim Kucukler4, Yasemin Tutuncu5 and Serdar Guler4
1Mugla Sitki Kocman University, Faculty of Medicine, Mugla, Turkey, 2Ankara Numune Education and Research Hospital, Ankara, Turkey, 3Ankara Numune Training and Research Hospital, Ankara, Turkey, 4Hitit University, Faculty of Medicine, Corum, Turkey, 5Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey

 

Aim: Chronic Autoimmune thyroiditis (CAT) has a high prevalence in general population. Paratracheal lymph nodes (PLNs) are seen common in patients with autoimmune thyroiditis. We aimed to investigate the PLNs changes and the relationship between the course and severity of the disease in CAT patients 5 years after the diagnosis.

Methods: A total of 169 consecutive patients with newly diagnosed thyroiditis and 32 healthy subjects were included to study. All patients underwent sonographic examinations of the thyroid and paratracheal regions. Eighty four patients, which can be reached 5 years after the diagnosis, underwent sonographic examinations in order to control of thyroid and paratracheal regions. Thyroid function tests, thyroid autoantibodies (ATA) (anti-thyroperoxidase antibody (TPO-Ab) and anti-thyroglobulin antibody (Tg-Ab)) were performed in all patients. Diagnosis of CAT was based upon the presence of parenchymal hypoechogenicity (compared to adjacent muscle structures) in conjunction with elevated levels of TPO-Ab and/or Tg-Ab. Controls had no signs of nodular thyroid disease including normal thyroid function tests, negative ATA and normal sonographic findings of thyroid gland.

Results: Paratracheal lymph node positivity ratio and PLNs volume was significantly higher in CAT group than the controls.  (patients with PLNs 75.1 % vs 25 %  p<0.001; volume of PLNs  0.23±0.45cm3 vs 0.09±0.08 cm3, p=0.012). In CAT group, long diameter and short diameter of PLNs are statistically significantly higher than the control group (p = 0.010 vs p = 0.046)  but the long diameter to the short diameter ratio between the groups were found same (p = 0.455). There was statistically significant positive correlation between TPO-Ab and the number of PLNs (p = 0.008) whereas no statistically significant correlation was found between the number of PLNs and TSH (p = 0.245).   Five  year after diagnosis there was no statistically significant difference in number of PLNs (p = 0.673) but statistically significant decrease was found in thyroid volume and PLNs volume (p <0.001) in  CAT group.

Conclusion: Paratracheal lymph nodes are often present in patients with CAT and is a valuable sonographic finding to distinguish thyroiditis from healthy subjects.  Five years after the diagnosis, the PLNs size was found smaller but still remains in CAT patients. Paratracheal lymph nodes may be associated with   thyroid autoimmunity.

 

Nothing to Disclose: GA, DB, SI, NNI, KK, YT, SG

16869 5.0000 SAT-0533 A Changes in the Charactersitics of Paratracheal Lymph Nodes in Patients with Chronic Autoimmune Thyroiditis for Five Years Follow-up 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0528-0545 4877 1:00:00 PM Thyroid Autoimmunity Poster

Anne L Caston-Balderrama*1, Michael John McPhaul2, Michael Phillip Caulfield3 and Richard E Reitz4
1Quest Diagnostics Inc, San Juan Capistrano, CA, 2Medical Director, Endocrinology, San Juan Capistrano, CA, 3Quest Diagnostics Nichols Institute, San Juan Capistrano, CA, 4Quest Diagnostic Inc, San Juan Capistrano, CA

 

The measurement of serum thyroglobulin (Tg) is an important post-operative tumor marker test for patients with differentiated thyroid cancer. In clinical practice, laboratories routinely screen for the presence of antibodies that recognize thyroglobulin (TgAb) prior to Tg testing, as the presence of TgAb will interfere with the measurement of Tg using immunometric assays, causing elevations in  radioimmunoassay and suppression in two-site immunoassays.  However, not all TgAb assays are equivalent and potentially may not measure all TgAb present which could lead to unrecognized inappropriate Tg results.

The present study was performed to determine the level of concordance of 3 commercial TgAb assays (Beckman Coulter, Siemens Immulite 2000 and Roche Diagnostics Cobas Elecsys Modular E170) in recognizing the presence of TgAb.  All 3 TgAb assays were standardized and traceable to the WHO 1st RP 65/93, however, each assay reports different TgAb values and has different cut-points for TgAb positivity.  A total of 295 patient samples were tested in each assay and determined as positive or negative for TgAb based on their respective cut-points (95thpercentile):  <4 IU/mL (Beckman Coulter),  <40 IU/mL (Siemens Immulite),  and <115 IU/mL (Roche Diagnostics).  Concordance of TgAb positivity between methods was compared using the Beckman assay as the referent method.  Compared to Beckman, Siemens had 3 false positives (1%) and 16 false negatives (5%); Roche had 4 false positives (1.4%) and 12 false negatives (4.1%).

From these analyses, it is clear that the assignment of samples to the category of ‘Tg antibody positive’ or 'negative’ is dependent on the TgAb assay used as well as the cut-point titer used.  In this study we used the 95th percentile cut-point provided by the manufacturer.  The concordance between methods can be improved by assigning different cut-points for each assay.  However, even with different cut-points the assays are not 100% concordant.  Based on the nature of antibodies there will always be an inherent variability in any TgAb assay and it is unlikely that any one assay will have a 100% detection rate and therefore a “false” Tg measurement by immunoassay is always a possibility.  The recent development of mass spectrometry (MS) assays that degrade endogenous antibodies and Tg and that measure a specific peptide within Tg will remove this issue and permit accurate measurement of Tg in all samples.  However, it is currently not feasible to perform all Tg measurements by MS and so we will have to continue to rely on current TgAb measures to screen samples prior to Tg measurement.  This study highlights the potential limitations of this approach.

 

Disclosure: ALC: Employee, Quest Diagnostics. MJM: Employee, Quest Diagnostics. MPC: Employee, Quest Diagnostics. RER: Employee, Quest Diagnostics.

16414 6.0000 SAT-0534 A Assignment of Anti-Thyroglobulin (Tg) Antibody Status Varies with Results Obtained from Different Automated Anti-Tg Immunoassay Platforms 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0528-0545 4877 1:00:00 PM Thyroid Autoimmunity Poster

Won Kyoung Cho*1, Yeon Jin Jeon2, In Ah Jung3, Shin Hee Kim2, Jung-Pil Jang3, Eun-Jeong Choi3, Min Ho Jung2, Tai-Gyu Kim3 and Byung-Kyu Suh2
1College of Medicine, The Catholic University of Korea, Korea, Republic of (South), 2College of Medicine, The Catholic University of Korea, Seoul, Korea, Republic of (South), 3College of Medicine, The Catholic University of Korea

 

Background: The Toll-like receptors are germline-encoded receptors that play an essential role in initiating the immune response against pathogens. We aimed to assess the association of TLRs polymorphism with autoimmune thyroid disease (AITD) in Korean children.

Methods: We try to investigate the polymorphism of TLR1, rs4833095, rs5743611; TLR3, rs3775291, rs3775296; TLR4, rs11536889, rs10759932, rs1927911; TLR5, rs5744168; TLR6, rs5743810, rs2381289; TLR9, rs352140, rs187084, rs352162; TLR10, rs4129009, rs11096956, rs10004195 in 85 Korean AITD (GD=50, HD=35; M=16 , F=69 , mean age=12.9 3.1 years ) and 183 controls.

Results: The frequencies of the TLR3 (rs3775296) AA genotype in HD (OR=4.526 (1.46-13.998), p=0.013, cP=0.039) was higher than normal group. The frequencies of the TLR4 (rs1927911) T allele in GD (OR=0.484 (0.257-0.912), p=0.023, cP=0.046) was lower than normal group. The frequencies of the TLR10 (rs4129009) GG genotype in AITD (OR=0.233 (0.080-0.682), p=0.004 , cP=0.012) and Non-TAO(OR=0.157 (0.037-0.68), p=0.009 , cP=0.027) were lower and A allele in Non-TAO(OR=6.36 (1.48-27.36), p=0.009, cP=0.018) was higher than normal group. The frequencies of the TLR10 (rs10004195) AA genotype in AITD (OR=0.365 (0.175-0.762), p=0.005 , cP=0.015), GD (OR=0.445 (0.187-1.055), p=0.006, cP=0.018) and non-TAO(OR=0.293 (0.120-0.723), p=0.005, cP=0.015) and A allele in AITD(OR=0.490 (0.271-0.883), p=0.016 , cP=0.032) and non-TAO (OR=0.414 (0.219-0.787), p=0.006, cP=0.012) were lower and TT genotype in AITD(OR=2.04 (1.131-3.677), p=0.016 , cP=0.048) and non-TAO(OR=2.41 (1.27-4.57), p=0.006, cP=0.018) and T allele in AITD (OR=2.742 (1.313-5.728), p=0.005, cP=0.01) and non-TAO (OR=3.412 (1.383-8.422), p=0.005, cP=0.012) were higher than normal group.

Conclusions: Our results suggest that the polymorphism of TLR 3,4 and 10 might contribute to the pathogenesis of AITD.

 

Nothing to Disclose: WKC, YJJ, IAJ, SHK, JPJ, EJC, MHJ, TGK, BKS

14208 7.0000 SAT-0535 A Association of Toll-like Receptor-3,-4 and-10 Polymorphisms with Autoimmune Thyroid Disease in Korean Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0528-0545 4877 1:00:00 PM Thyroid Autoimmunity Poster

Tanja Diana*1, Jasmin Franken1, Michael Kanitz2 and George Jean Kahaly3
1Gutenberg University Medical Center, Mainz, Germany, 2Johannes Gutenberg University Medical Center, Germany, 3Johannes Gutenberg University Medical Center, Mainz, Germany

 

Context and Objective: Cell-based bioassays are sensitive diagnostic tools but can exhibit variable reproducibility. In order to promote standardization of results among laboratories that perform thyroid-stimulating antibody (TSAb) bioassays, we calibrated TSAb levels against an international standard using a FDA-cleared TSAb bioassay.

 Methods: TSAb activity was measured using Chinese Hamster Ovary cells expressing a chimeric TSH-receptor and a c-AMP response-element (CRE)-dependent luciferase. The second international standard (IS, NIBSC code 08/204,113 mIU per Ampoule, monoclonal TSAb, M22) was used for calibration. High TSAb positive sera were alternatively applied for standard curves. Three users performed all experiments in one laboratory. TSAb were measured in triplicate and results were reported as percentage of specimen-to-reference ratio (SRR) and converted into mIU/L.

 Results: A total of 95 dilution experiments were performed using 12 high TSAb-positive sera of patients with Graves’ disease. The international standard (IS) dose-response curve was obtained using concentrations from 0.3125 to 200 mIU/L. Each concentration was prepared in 1:11 diluted normal serum. The linear range of the IS dilution curve was between 5 and 100 mIU/L. When diluting high TSAb-positive patient sera, the IS concentrations 10, 20, 40 and 80 mIU/L were used as a four-point calibration curve on the same plate. Mean ± SD values were 485±41, 403±32, 266±30, and 163±20, respectively. Subsequently, two-fold dilutions were prepared from 1:88 to 1:45056.  Mean ± SD values were 532±50, 514±44, 452±50, 336±50, 219±37, 141±28, 99±17, and 76±12, respectively. The average IU measurement for the assay cut-off (SRR 140%) corresponded to 10.4 ± 0.81 mIU/L. All standard curves had R2 values > 0.95. Low coefficient of variation (CV %) values for the IS four-point calibration curve (5, 4, 6, and 6, respectively) were noted. Low CV % values (≤ 7) were observed for the high TSAb positive dilution curve (1:88 to 1:45056). High TSAb positive serum showed a larger linear range than the IS allowing standard curves that can cover a larger SRR% range.

 Summary and Conclusions: Dilution experiments using the IS and high-positive TSAb sera showed a high correlation coefficient and excellent reproducibility. For the first time, standardization of a bioassay correlating TSAb SRR% to IU/L was achieved. These results will allow improved comparison of studies involving TSAb levels. In addition, reporting TSAb in IU/L will be clinically useful for serial TSAb measurements during patient management.

 

Disclosure: GJK: Consultant, Quidel. Nothing to Disclose: TD, JF, MK

14636 8.0000 SAT-0536 A Standardisation of a Thyroid-Stimulating Antibody Bioassay 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0528-0545 4877 1:00:00 PM Thyroid Autoimmunity Poster

Tanja Diana*1, Malte Cronau2, Michael Kanitz3 and George Jean Kahaly2
1Gutenberg University Medical Center, Mainz, Germany, 2Johannes Gutenberg University Medical Center, Mainz, Germany, 3Johannes Gutenberg University Medical Center, Germany

 

Context and Objective: Thyroid-associated orbitopathy (TAO) occurs rarely in patients with autoimmune Hashimotos’ thyroiditis (HT). Since TSH-receptor (TSHR) stimulating autoantibodies (TSAb) play a putative role in the pathogenesis of TAO, we looked for the presence of TSAb in HT patients with or without TAO.

 Methods: Serum TSAb levels were measured with a novel, commercially available, FDA-cleared bioassay that utilizes Chinese Hamster Ovary cells, expressing a chimeric TSHR and a cAMP response element (CRE)-dependent luciferase. Sera samples, positive, reference and normal controls were diluted 1:11 in reaction buffer, added to the cell monolayers and each plate was incubated for three hours at 37°C, 5% CO2. Results of TSAb activity were reported as percentage of specimen-to-reference ratio (SRR %). A TSAb value ≥ 140% is considered to be positive.

Results: A total of 1340 sera samples were collected from 576 HT patients with TAO (n=29/576, 5%, 23 female, mean age ± SD 44.03 ± 16.53 years) or without TAO (n=547, 95%, 452 female, 36.06 ± 18.27 yrs.) as well as from 302 euthyroid healthy donors (controls). Compared to controls (SRR% 53 ± 16) and patients with HT only (64 ± 70), serum TSAb levels were markedly higher in TAO+HT patients (252 ± 209, p<0.001). TSAb were present in 42/77 (55%) versus 71/961 (7%, p<0.001) serum samples of HT+TAO and HT patients, respectively. Serum TSAb titers significantly correlated with both clinical activity and clinical severity of TAO. In smokers, serum TSAb levels were markedly higher in HT+TAO patients (174 ± 183) vs. HT only (75 ± 89, p=0.0023). Even in hypothyroid (serum TSH 30.50 ± 53.20 mU/L) HT+TAO patients, serum TSAb levels were markedly higher (377 ± 143 p=0.0092) compared to patients with HT, only (97 ± 106). In female patients with HT+TAO, TSAb levels were higher (166 ± 163) compared to patients with HT, only (66 ± 71). Age had no impact on serum TSAb levels. In patients with combined HT+TAO, serum TSAb titers correlated highly (R=0.75, p<0.001) with serum thyroid binding inhibitory immunoglobulins (TBII, automated binding ECLIA assay).

Conclusions: Serum TSAb are highly prevalent in patients with both HT+TAO and, as with Graves’ disease, TSAb may be involved in the pathophysiology of the associated orbital involvement.

 

Disclosure: GJK: Consultant, Quidel. Nothing to Disclose: TD, MC, MK

14712 9.0000 SAT-0537 A Thyroid-Stimulating Autoantibodies Are Prevalent in Patients with Hashimoto's Thyroiditis and Associated Orbitopathy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0528-0545 4877 1:00:00 PM Thyroid Autoimmunity Poster

Francesco Latrofa*1, Debora Ricci2, Lucia Montanelli1, Paolo Piaggi3, Barbara Mazzi1, Francesca Bianchi1, Federica Brozzi1, Pierina Santini1, Emilio Fiore1, Michele Marino2, Massimo Tonacchera4 and Paolo Vitti2
1University of Pisa, Italy, 2University Hospital, Pisa, Italy, 3Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ, 4University of Pisa, Pisa (PI), Italy

 

Context. Thyroglobulin autoantibodies (TgAb) are considered non-pathogenic, because they can be detected in the sera of subjects with no evidence of thyroid disease and do not bind the complement. Their subclass distribution is debated. Radioidine (131I) treatment for Graves’ disease (GD) is one of the events inducing a rise in TgAb levels.

Design. Sera with positive TgAb (AIA-Pack, Tosoh Bioscience, Japan) were collected from 25 GD patients (18 females and 7 males), age 41.5 (30.8-56.8) yr, at the time of 131I treatment and three and six months thereafter. To prevent the exacerbation of Graves’ Ophthalmopathy, all patients received oral prednisone. Total TgAb, TgAb light chains and TgAb subclasses were measured by ELISA at each time point. Data were analysed by the non-parametric Friedman test and, when the results were significant, values at baseline were compared with those after three and six months in the post-hoc analysis.

Results. Total TgAb IgG assessed by ELISA rose significantly (p=0.024): 1:100 (1:100-1:330) before 131I treatment, 1:330 (1:100-1:660) at three months (p=0.10) and 1:330 (1:330-1:1000) at six months (p=0.048). TgAb κ chains did not change (p=0.052), TgAb λ chains increased significantly (p=0.001), being 0 (0-1:100) before 131I treatment, 0 (0-1:330) at three months (p=0.03) and 1:100 (0-1:330) at six months (p=0.002). A significant rise in IgG1 and IgG3 levels was observed after 131I (p=0.008 and 0.006, respectively), while IgG2 and IgG4 levels did not change. The increase in IgG1 levels was persistent: 0 (0-1:100) before 131I treatment, 1:100 (0-1:100) at three months (p=0.028) and 1:100 (0-1:100) at six months (p=0.024). At variance, the increase in TgAb IgG3 was transient: 0 (0-1:100) before 131I treatment, 1:100 (0-1:330) at three months (p=0.028) and 0 (0-1:100) at six months (p=0.72).

Conclusions. 131I treatment for GD increases the levels of the complement-activating IgG1 and IgG3 subclasses. In autoimmune thyroid disease the rise in TgAb levels is associated with a switch in their subclass distribution.

 

Nothing to Disclose: FL, DR, LM, PP, BM, FB, FB, PS, EF, MM, MT, PV

12882 10.0000 SAT-0538 A Thyroglobulin Autoantibodies Switch to IgG1 and IgG3 Subclasses after 131I Treatment for Graves' Hyperthyroidism: Autoantibodies Subclasses Are Related to the Activity of Autoimmune Thyroid Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0528-0545 4877 1:00:00 PM Thyroid Autoimmunity Poster

Susana Mallea Gil*, Marta Aparicio, Florencia Rodriguez, Karina Bertini, Viviana Ercoli, Silvia Gimenez, Cristian Ojeda, Adriana Andrüsh, Noel Aldabe, Mariel Iriarte, Silvina Sankowicz, Carolina Ballarino and Alicia Filomia
Hospital Militar Central, Buenos Aires, Argentina

 

Patients with autoimmune thyroid diseases (AITDs) are likely to develop celiac disease (CD) among other autoimmune disorders. The prevalence of CD in general population is about 0.33-1% and the frequency of AITDs-CD association is about 1.2-4.8%. CD can be asymptomatic in adults. Autoimmune polyendocrine syndrome (APS) is the association of autoimmune endocrine diseases with other non-endocrine autoimmune disorders (1). Our objectives were to determine the frequency of CD in adult patients with AITDs and to asses the presence of 21-hydroxylase antibodies in patients with this association during the period January 2011- December 2013 in one single medical center in Buenos Aires.We studied a consecutive cohort of 595 patients with AITDs. The following antibodies were screened: Tiroperoxidase by MEIA, TSH receptor by Radioreceptor assay, IgA Endomisium by IFI, IgA and IgG transglutaminase by ELISA, 21-hydroxylase by RIA. In 595 patients with AITDs: 86% had Hashimoto's thyroiditis (HT) and 14% had Graves’ disease, 83% were female, mean age: 52.37± 16.78 years. Twenty-two patients (3.6%) had AITDs-CD; seven of them were previously affected with CD and 15 patients were newly diagnosed. In all of them CD was confirmed by endoscopy and duodenal biopsies. Tiredness, alopecia, osteoporosis, infertility and anemia were found as predominant symptoms in these 15 patients. All patients with AITDs-CD association had HT. We were able to perform 21-hydroxylase antibody in 8/22 patients with AITDs-CD, it were positive in 4/8; all of them had normal ACTH and cortisol. Forty-six out of 595 (7.7%) patients had some other autoimmune disorders: 5/46 had adrenal insufficiency, 3/46 type 1 diabetes, 2/46 premature ovarian failure and the other patients had non-endocrine diseases excluding CD. Conclusions: in this study the prevalence of AITDs-CD association was 3.6%, in accordance with the literature. In the patients with this association (8/22) we found that 21-hydroxilase was positive in 50%, none had adrenal insufficiency. In patients with AITDs, we suggest assessing the presence of CD in subjects who present unspecified symptoms as the ones found in our patients in order to prevent complications resulting from non-diagnosed CD. The presence of adrenal antibodies enables an early diagnose of adrenal insufficiency, which prevents medical emergencies. APS is poorly diagnosed because it is not usually sought.

 

Nothing to Disclose: SM, MA, FR, KB, VE, SG, CO, AA, NA, MI, SS, CB, AF

12845 11.0000 SAT-0539 A Association Between Autoimmune Thyroid Diseases, Celiac Disease and Adrenal Antibodies 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0528-0545 4877 1:00:00 PM Thyroid Autoimmunity Poster

Celestino Neves*1, César Esteves2, Oksana Sokhatska2, Carmo Palmares2, José Luís Medina3, Luís Delgado2 and Davide Carvalho2
1São João Hospital, Faculty of Medicine, University of Porto, Porto, Portugal, 2Centro Hospitalar São João, Faculty of Medicine, University of Porto, Portugal, 3Faculty of Medicine, University of Porto, Porto, Portugal

 

Background: There is evidence that subclinical hypothyroidism is associated with an increased cardiovascular risk.

Objectives: To evaluate the interrelationships between autoimmune thyroiditis, subclinical hypothyroidism and cardiovascular risk factors.

Methods: We recorded thyroid function tests, BMI, insulin resistance markers comprising the Homeostasis Model Assessment for insulin resistance (HOMA-IR), the Quantitative Insulin Sensitivity Check Index (QUICKI), HISI (Hepatic Insulin Sensitivity Index), WBISI (Whole-Body Insulin Sensitivity Index), IGI (Insulinogenic Index) and the levels of total cholesterol (TC), HDL, LDL-cholesterol, triglycerides (TG), apolipoprotein B (ApoB), ApoA1, lipoprotein(a) (Lp[a]), homocysteine, CRP (C-reactive protein), folic acid and vitamin B12, in 255 subjects with autoimmune thyroiditis (94% female): 186 euthyroid patients and 69 patients with subclinical hypothyroidism. Mann-Whitney test, logistic regression and Spearman correlations were used for statistical analysis. Results were adjusted for age and BMI. A two-tailed p<0.05 was considered statistically significant.

Results: Patients with higher TC (OR=1.008, P=0.03), CRP (OR=1.684, p=0.04) and thyroglobulin antibodies (OR=1.002, P=0.02) had higher risk of developing subclinical hypothyroidism. In the total group of patients, we observed positive correlations between TSH and CRP (r=0.132; p=0.043), TSH and HOMA-IR (r=0.158; p=0.029), between FT3 and HDL cholesterol (r=0.163; p=0.009), and between FT4 and IGI (r=0.224, p=0.002). Also, in the total group TSH levels were negatively correlated with HISI (r=-0.158, p=0.029) and WBISI (r=-0.164, p=0.024). In the group with subclinical hypothyroidism there were negative correlations between FT3 and homocysteine (r=-0.357, p=0.011), and between FT4 and anti-TPO antibodies(r=-0.281, p=0.020).

Conclusions: The interrelationships between thyroid function, CRP, lipid profile and insulin resistance reflect an increased cardiovascular risk in subclinical hypothyroidism due to autoimmune thyroiditis.

 

Nothing to Disclose: CN, CE, OS, CP, JLM, LD, DC

15260 12.0000 SAT-0540 A Autoimmune Thyroiditis, Subclinical Hypothyroidism and Cardiovascular Risk Factors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0528-0545 4877 1:00:00 PM Thyroid Autoimmunity Poster

Mariusz Nowak*1, Beata Kos-Kudla2, Bogdan Marek3, Dariusz Kajdaniuk1, Lucyna Siemiñska1 and Wanda Foltyn4
1Medical University of Silesia, Zabrze, Poland, 2Medical University, Zabrze, Poland, 3Medical University of Silesia, Zabrze, Poland, 4Med Univ of Silesia, Zabrze, Poland

 

Thyroid orbitopathy (TO) is the most frequent extrathyroid manifestation of Graves' disease. The aim of this study was to evaluate the serum concentration of interleukin-8 (IL-8), Plated Derived Growth Factor-AA (PDGF-AA) and Vascular Endothelial Growth Factor (VEGF) in the blood of patients with active OT before and after immunosuppressive therapy.

Patients and Methods: The study was performed in group of 39 patients with clinically active TO (Group A) in euthyroid (n=18, Group A I) and hyperthyroid (n=21, Group A II) stage of Graves’ disease in moderate or severe stage of TO. Concentration of studied proangiogenic factors in serum samples were measured by an enzyme linked immunosorbent assay (ELISA) before (group A) and after (group A1)  intensive pulse methylprednisolone treatment and one month after the end of additional oral metyloprednisolone treatment  (Group A2). The project was carried out with the permission of The Bioethic Board of the Medical University of Silesia.

Results: We have found significant increase of the serum concentrations of studied proangiogenic factors in TO group when compared with control group before immunosuppressive therapy (IL-8: 28.89±13.03 v 17.57±3.4 pg/ml, p= 0.001; PDGF-AA: 3173.6±1480.3 v 1768.9±520.0,  p=0.0006; VEGF: 542.4±328.1 v 94.6±55.3 pg/ml, p=0,0002) and significant decrease of PDGF-AA (3173.6±1480.3 v 2325.9±1456.8 pg/ml, p=0.03) and Il-8 (28.89±13.03 v 19.29±4.08 pg/ml, p=0.0002) and not significant decrease of VEGF (542.4±328.1 v 375.9±275.8 pg/ml) serum concentrations  after intravenous methylprednisolone therapy.  One month after the end of additional oral metyloprednisolone treatment  (A2) concentration of  Il-8  and PDGF-AA still decreased and were was not significant difference with value in control group (Il-8: 16.90±4.82 v 17.57±3.4 pg/ml; PDGF-AA: 1853.1±795.4 v 1769.9±520.0 pg/ml). Serum concentration of VEGF was still significantly higher compared with control (654.3±504.4 v 94.6±55.3 pg/ml, p=0.0001).  We have not observed difference in serum concentration of studied proangiogenic factors between patients in euthyroid (A I) or hyperthyroid (A II) stage of Graves' disease with active TO (Il-8: 43.49±24.95 v 31.72±15.35 pg/ml, p=0.411 ; PDGF-AA: 3107.5±1266.6  v 3088.8±1509.7 pg/ml, p=0.968; VEGF: 534,9±323.8 pg/ml v 542.9±281.4 pg/ml, p=0.746). After intensive immunosuppressive therapy we have obtained significant reduction of activity and severity of TO measured by clinical activity score (CAS) and NO SPECS classification index.

Conclusions: Results of the present study confirm the fact that angiogenesis could play a role in pathogenesis of thyroid orbitopathy. Increased concentration of proangiogenic factors in patients with Graves’ disease with an active stage of TO and its decreasing after immunosuppressive therapy can reflect the degree of inflammatory activity. 

 

Nothing to Disclose: MN, BK, BM, DK, LS, WF

11480 13.0000 SAT-0541 A Serum Concentration of Il-8, PDGF-AA and VEGF in Patients with Active Thyroid Orbitopathy before and after Immunosuppressive Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0528-0545 4877 1:00:00 PM Thyroid Autoimmunity Poster

Janete P Moura1, Walter Bloise*2 and Lidia Y Mimura3
1FMUSP, Sao Paulo, Brazil, 2Hosp das Clinicas Schl of Med, Sao Paulo, Brazil, 3Hosp das Clinicas FMUSP, Sao Paulo, Brazil

 

Introduction- We have demonstrated that PPAR-ϒ antagonist and cyclooxygenase -2 Inhibitor (sodium diclofenac) was effective to treat mild or moderate Graves´ Ophthalmopathy (GO) and also in one patient with the severe form (1,2).   Background- The aim of this report is to show the preliminary results of this treatment on 4 patients with severe GO and visual impairment. Methods and Patients findings- Four patients (3 males) with aging and CAS (clinical activity score) measured in the first approach, ranging between 44 to 61 years old and 5 to 7 respectively. Visual acuity measured by the Snellen chart of the most affected eye of all patients ranging between 0,3 to 0,8. Sodium diclofenac was administered by intramuscular injection 75mg every 12 hours in the first 7 days followed by 50 mg orally every 12 hours. Renal function was checked monthly. Results- The visual acuity improved in all patients after 7 days and returned to normal except in one patient whose visual acuity changed from 0,4 to 0,7 and is still receiving the drug.  No adverse effects were observed. The hyperthyroidism showed by one single patient was not affected by the treatment. Conclusions- If the benefits of this targeted treatment could   be validated by a controlled and expanded study it will be a safe and less expensive option for the treatment of this controversial disease.

References

1)     Walter Bloise; Lidia Yuri Mimura; Janete Moura; Wilian Nicolau. Treatment of mild to moderate Graves' ophthalmopathy with sodium diclofenac: a pilot study. Brazilan Archives Endocrinol Metabol, 2011; 55(9): 692-5

2)     Janete Moura, Lidia Y Mimura, Walter Bloise: Treatment of Severe Graves Ophthalmopathy with a PPAR-{gamma} Antagonist and Cylooxygenase-2 Inhibitor Endocr Rev 2012 33: SUN-431

 

Nothing to Disclose: JPM, WB, LYM

16629 14.0000 SAT-0542 A Treatment of Severe Gravesx Ophthalmopathy with a PPAR-ϒ Antagonist and Cyclooxigenase-2 Inhibitor: Preliminary Results 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0528-0545 4877 1:00:00 PM Thyroid Autoimmunity Poster

Anna Louise Mitchell*1, Lemonia Mathiopoulou2, Margaret Morris2, Bijay Vaidya3, A Jane Dickinson2, Anthony Quinn3, Colin M Dayan4, Julie McLaren5, Janis L Hickey6, John H Lazarus4, Geoffrey E Rose7, Peter Foley6, Caroline J MacEwen8 and Petros Perros9
1Newcastle University, Newcastle upon Tyne, United Kingdom, 2Newcastle upon Tyne NHS Hospitals Trust, Newcastle upon Tyne, United Kingdom, 3Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom, 4Cardiff University School of Medicine, Cardiff, United Kingdom, 5Thyroid Eye Disease Charitable Trust, Bristol, United Kingdom, 6British Thyroid Foundation, Harrogate, United Kingdom, 7Moorfields Eye Hospital, London, United Kingdom, 8Ninewells Hospital, Dundee, United Kingdom, 9Newcastle upon Tyne NHS Hospitals Trust, Newcastle Upon Tyne, United Kingdom

 

Background: In the early phase of Graves’ orbitopathy (GO), when there is increased disease activity, treatment can dramatically improve the final cosmetic and visual functional outcome. Diagnostic delay can result in significant morbidity and increases patient dissatisfaction. It can be a challenge for endocrinologists to recognise GO and decide who should be referred to an ophthalmologist.

Aim: To develop and test a clinical assessment tool for use in all patients diagnosed with Graves’ disease (GD). The purpose of the tool is to guide clinicians towards a possible diagnosis of GO in those patients with GD who have orbital signs or symptoms, and thereby prompt earlier ophthalmic referral.

Methods: A 20 point assessment tool was devised, comprising polar (“yes/no”) questions in 2 sections aimed at eliciting GO symptoms and signs. The tool was tested on 104 GD patients in two centres over 17 months: 77 attending endocrine clinic and 27 positive controls with GO attending multidisciplinary thyroid eye clinics. Those referred from endocrine clinics according to protocol were assessed and followed up in the multidisciplinary thyroid eye clinic to determine the appropriateness of referral and whether treatment was initiated.

Results: 88 of the 104 patients (85%) were female: the mean age at assessment was 48.5 years (range 18-76 years). All 27 controls scored above the threshold for referral but none met the criteria for urgent referral. Excluding the controls, 77 people with GD were evaluated using the tool. 27 (35%) scored above the threshold for referral: 2/27 (7%) scored for signs, 6/27 (22%) scored for symptoms and 19/27 (70%) scored for both signs and symptoms. GO was confirmed in 24 (89%) and 14 (58%) were offered 1 or more specific treatments: 2 radiotherapy, 2 orbital decompression, 1 IV steroids and 1 Botulinum toxin treatment. In addition, 7 were prescribed selenium and 5 artificial tears.

Discussion: The timely, accurate diagnosis of GO is important as early intervention in the active phase of disease can improve prognosis. This clinical assessment tool uses polar answers to 20 questions to assist the clinician in making a diagnosis of possible GO and to suggest the need for referral to specialist ophthalmic care. The tool, which is sensitive to the diagnosis of GO, does not require specialist skills in ophthalmic assessment but can quickly and easily be used for assessment of all GD patients in any setting. Overall, over half of those referred following use of this tool were offered specific treatment, suggesting its use might actively alter management of patients who might not otherwise have been referred to specialist ophthalmic care.

 

Nothing to Disclose: ALM, LM, MM, BV, AJD, AQ, CMD, JM, JLH, JHL, GER, PF, CJM, PP

13049 15.0000 SAT-0543 A Diago (Diagnosis of Graves' orbitopathy): An Office Tool for Practising Endocrinologists 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0528-0545 4877 1:00:00 PM Thyroid Autoimmunity Poster

Thiago Machado Nogueira*1, Allan Pieroni Gonçalves2, Ana Carolina Arato Gonçalves2, Luzia Diegues Silva2 and Mario Luiz Ribeiro Monteiro3
1Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 2Hospital da Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Upper eyelid retraction (UER) is the most common feature of Graves Orbitopathy (GO). In clinical practice, the measurement of margin reflex distance (MRD) is usually the method utilized for UER evaluation both pre- and post-operatively. However, this method measures the upper eyelid position only at its central portion (12 o’clock position) and therefore may disregard important abnormalities of its contour (e.g. eyelid flare).

Our objective was to compare the surgical outcome analysis of UER provided by the MRD and a digital image processing contour assessment (DIPCA) method, based on 13 radial midpupil lid distances (MPLDs) at each 15° of the palpebral fissure according to a previously described method.1MRD was obtained from the digitally measured MPLD at the 90° position.

In a prospective randomized interventional study, 21 eyes (12 patients) with UER from inactive Graves Orbitopathy had their eyelid fissure analyzed both by the MRD and a DIPCA method. Exclusion criteria included previous eyelid surgery and strabismus. Patients underwent UER surgical correction by the same surgeon and eyelid fissures parameters measured preoperatively and at 1-month follow-up. Eyes were divided in two groups: group 1 composed by eyes with remaining UER (MRD >5mm) and group 2 without UER (MRD ≤ 5mm) after surgery. Eyes from both groups had their MPLDs plotted in polar plot graphs and had their upper eyelid contour compared to a normal variation range comprehending the interval between the 5th and the 95thpercentiles of the MPLDs of 29 control eyes from 16 randomly chosen Hospital employees without palpebral abnormalities or previous eyelid surgery. Patients in both groups were further subdivided according to their postoperative DIPCA. MRD and DIPCA were compared.

Eight eyes were included in group 1 and 13 in group 2. All eyes in group 1 (with remaining postoperative UER) had poor results on DIPCA while 5 of the 13 eyes in group 2 (considered normal by MRD) still presented an abnormal lid contour. Eyes with postoperative normal MRD and DIPCA had preoperative MRDs (mean ± SD) of 5.85 ± 0.65mm. Eyes with normal postoperative MRD and abnormal DIPCA had preoperative MRD of 6.73 ± 0.81mm while those with abnormal MRD and DIPCA had 7.28 ± 0.73mm. The comparison of postoperative results obtained by MRD and DIPCA (Fisher test, p = 0.006) suggest a significant disagreement between the methods.

We conclude that MRD taken alone is an insufficient method for assessment of UER surgical correction at 1-month postoperative stage. Good results in DIPCA and MRD ≥ 5mm were associated with lower preoperative MRD. More aggressive surgical correction of patients with more UER led to postoperative MRD ≤ 5mm, but was also frequently associated with an abnormal DIPCA.

 

Nothing to Disclose: TMN, APG, ACAG, LDS, MLRM

16357 16.0000 SAT-0544 A A Comparative Study of Pre- and Postoperative Quantification of Upper Eyelid Retraction in Graves Orbitopathy Using Margin Reflex Distance and Digital Eyelid Image Processing Methods 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0528-0545 4877 1:00:00 PM Thyroid Autoimmunity Poster

Jing Li*1, Xiaojing Jin1, Qian Jin1, Zhongyan Shan2 and Weiping Teng3
1the First Affiliated Hospital of China Medical University, Shenyang, China, 2Institute of Endocrinology, China, 3The Endocrine Institute, Shenyang, China

 

Coumestrol is a common phytoestrogen isolated from a variety of clovers, alfalfa and other leguminous plants which are food sources for both humans and farm animals. Especially coumestrol has receptor-dependent anti-estrogenic activity. As estrogens have multiple actions on immune functions, the effects from xenoestrogens may be superimposed upon the endogenous pituitary-gonadal axis and affect the incidence or development of autoimmune diseases. The purpose of this study was to investigate the influence of coumestrol on experimental autoimmune thyroiditis (EAT). Six-week-old CBA/J mice were randomly assigned into three groups, which were fed with phytoestrogen-free food and drinking water containing only 1% tween80 (T group), 0.8mg/L coumestrol in 1% tween80 (L group) and 8 mg/L coumestrol in 1% tween80 (H group), respectively. Those mice were immunized twice with murine thyroglobulin (Tg) and Freund’s adjuvant at a two-week interval. Sera, thyroid, spleen, ovarian and uterus were collected immediately after the mice were sacrificed 4 weeks after the second immunization of Tg. Serum anti-Tg antibodies were detected by ELISA. Splenic helper T (Th) and regulatory T(Treg)cell responses were investigated using immunofluorescent staining and flow cytometry as well as quantitative RT-PCR. In addition to scoring the extent of intrathyroid mononuclear cell infiltration and assessing ovarian and uterine weights, serum estradiol level was examined by ELISA. We found that the extent of mononuclear cell infiltration in the thyroid showed a reduced but not statistically significant trend in both coumestrol-treated groups (H and L groups; P=0.447, 0.372; n=13-14 per group). Coumestrol administration also markedly decreased serum TgAb level. Serum anti-Tg IgG2a, IgG3 and IgG1 titers were significantly reduced in L group (n=13) as compared with that of the control group (P=0.042, 0.027 and 0.015; n=10). Flow cytometric analysis showed that the percentage of Th1 as well as the ratio of Th1/Th2 in the splenocytes were significantly down-regulated in L group when compared with that of the control group (P=0.038, 0.032; n=5 per group). The mRNA expression of IFN-γ, a typical Th1 cytokine, was markedly decreased in L group as compared to that of the control group (P=0.008; n=5 per group). There were no significant differences in the percentages of splenic Th2, Th17, Treg subset or their typical cytokine/transcription factor mRNA expressions (n=5-8 per group). Although serum estradiol level and the ovary weight were not significantly changed in L group or H group, the wet uterine weight was markedly lower in L group than that of the control group (P=0.017; n=10 per group). Our findings suggest that coumestrol intake can reduce the production of thyroid autoantibodies in autoimmune thyroiditis through suppression of Th1 response, which may ameliorate the disease.

 

Nothing to Disclose: JL, XJ, QJ, ZS, WT

13238 17.0000 SAT-0545 A Coumestrol Has an Inhibitory Effect on Autoantibody Production through Modulation of Th1 Response in Experimental Autoimmune Thyroiditis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM SAT 0528-0545 4877 1:00:00 PM Thyroid Autoimmunity Poster

Shuhong Hu1 and Qin Hu*2
1Tongji Hospital,Tongji Medical School of Huazhong University of Science and Technology, Wuhan, China, 2Department of Endocrinology, Tongji Hospital, Tongji Medical School of Huazhong University of Science and Technology

 





Objective To summarize the clinical manifestations, diagnosis and treatment of the primary hyperparathyroidism (PHPT).

Methods  The clinical data of eighty-nine patients with PHPT admitted between 1991 to 2013 were retrospectively analyzed.

Results The mean age of the 89 patients was 44.7±15.8 years (range, 13-86 years), the male to female ratio is 1:2.1. The median duration of PHPT was five months(range, one month-13years). 79% of the 89 patients were symptomatic. The median serum parathyroid hormone (PTH) level of the 89 patients was 697.3 pg/ml (26.4 - 5000.0 pg/ml), the mean serum calcium level was 3.03±0.56 mmol/L. The 24h urine calcium level was 10.02±4.73mmol/24h (n=36). The sensitivity of localization of the parathyroid lesions of technetium-99m methoxy-isobutyl-isonitrile (99mTc-MIBI) was 96%, higher than ultrasound (71%), CT (69%) and MRI (75%) (P < 0.05, respectively), there was no significant difference among the latter three groups (P > 0.05). 62% of the 89 patients had been misdiagnosed. 52% had been misdiagnosed as kidney stones or bone diseases (include fracture, metabolic bone disease and bone tumor). The remaining had been misdiagnosed as peptic ulcer, rheumatoid arthritis or pancreatitis. 79 cases had been treated surgically. The median serum PTH level was 748.2 pg/ml (46.1-5000.0 pg/ml) before surgery, 79.9 pg/ml (11.35 - 838.0 pg/ml) 15 minutes after surgical removal of the lesions ( P < 0.05 vs preoperative) and 22.9 pg/ml (2.3-1203.0 pg/ml) on the first postoperative day( P < 0.05 vs preoperative). Serum calcium was 3.03±0.56 mmol/L before surgery , 2.25±0.37 mmol/L (P < 0.05 vs preoperative) on the first postoperative day and 2.08±0.36 mmol/L on the second postoperative day (P < 0.05 vs preoperative). After the operation, 42 cases(53%)had perioral and limb numbness, 2 cases (3%)had a voice hoarse and bucking while drinking, 1 case had tetany. All these symptoms improved after calcium supplementation. 67 patients (85%) had been diagnosed as parathyroid adenoma pathologically , 7 patients ( 9% ) as hyperplasia, 3 patients (4%) as cysts and 2 patients ( 3% ) as carcinoma. Among 67 cases of adenomas, 62 cases were a single parathyroid adenoma, 1 case was multiple parathyroid adenomas and 4 cases were ectopic parathyroid adenomas. The ectopic lesions were located below the thyroid , in the rib cage, left mediastinum and above the sternum respectively.

Conclusion  Delayed diagnosis rate of PHPT is still very high. The clinician should be familiar with the various clinical manifestations of PHPT and enhance understanding of pathogenesis of the disease. The simultaneous determination of serum calcium and PTH level is the keypoint of early diagnosis of PHPT. 99mTc-MIBI should be the first choice of preoperative imaging examination for localization of the lesions, followed by ultrasound, CT and MRI. Surgery is the  effective and safe treatment.

 

Nothing to Disclose: SH, QH

12101 1.0000 SAT-0299 A Analysis of Diagnosis and Treatment of Eighty-Nine Patients with Primary Hyperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Se Hee Park*1, Sena Hwang1, Cheol Ryong Ku1, Ji In Lee2, Kyu Yeon Hur3, Myung-Shik Lee3, Chul-Ho Lee1, Kyo Yeon Koo1, Jin-Sung Lee1 and Yumie Rhee1
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Ajou University School of Medicine, Suwon, Korea, Republic of (South), 3Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, Republic of (South)

 

Von Hippel–Lindau (VHL) disease is an inherited tumor syndrome caused by germline mutations in the VHL tumor suppressor gene. It is characterized by hemangioblastoma (HAB) in the central nervous system (CNS) and retina, renal cell carcinoma (RCC), pancreatic tumor and cysts, and pheochromocytoma. In this study, we detected 26 germline mutations in the VHL gene of Korean patients, of which one was a novel mutation, c.417_418insT. Together with this study, we also integrated our data with the published literature to have total 55 VHLgermline mutations in Korea and determined a unique hotspot at codon 70. Eight unrelated patients (8/55, 14.5%) had same amino acid substitutions at codon 70 (Glu70Lys) and showed VHL type 1 phenotypes. Although this mutation may be predicted to have a mild effect on VHL function, four patients (50%) subsequently developed multiple CNS HABs or retinal HAB. However, this hotspot has not been reported in China or Japan. This study provides information on the spectrum of VHL mutations in Korean VHL disease and contributes to a better understanding of VHL disease in terms of improvements in the clinical management of VHL families in East Asian countries.

 

Nothing to Disclose: SHP, SH, CRK, JIL, KYH, MSL, CHL, KYK, JSL, YR

12281 2.0000 SAT-0300 A Germline Mutations of Glu70Lys Is Highly Frequent in Korean Patients with Von Hippel-Lindau (VHL) Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Shani Avniel-Polak, Gil Leibowitz, Benjamin Glaser, David J. Gross and Simona Grozinsky-Glasberg*
Hadassah-Hebrew University Medical Center, Jerusalem, Israel

 

Background: Most patients with neuroendocrine tumors (NETs) require systemic treatment, often with limited therapeutic effect. Everolimus (RAD001) and Torin1 are mTOR inhibitors (mTORi) known to suppress cell proliferation in NETs, whereas the dual mTOR/PI(3)K inhibitor NVP-BEZ235 is more efficient compared to RAD001 in NET cells suppression. However, cancer cells may use mTORi induced autophagy to escape the anti-proliferative effect and to prolong survival. Chloroquine (CQ) and its derivative hydroxychloroquine (HCQ) have been shown to inhibit autophagy.

Aim: To explore the effect of autophagy inhibitors alone or in combination with mTORi on NET cell proliferation, apoptosis and the autophagic process.

Methods: NET cell line BON-1 was treated with NVP-BEZ235, Torin1, RAD001, HCQ and CQ alone or in combinations. Cell viability was examined by XTT method. Flow cytometry and Western blot analysis were used to assess drug effect on cell cycle, apoptosis, PI3K/Akt/ mTOR and autophagy pathways.

Results: NVP-BEZ235 & Torin1 significantly decreased NET cell viability compared to RAD001, whereas HCQ and CQ mildly suppressed cell viability. RAD001 in combination with HCQ or CQ did not increase the inhibitory effect of either drug given alone. However, the administration of Torin1 but more so of NVP-BEZ235 significantly reduced cell viability, arrested cells in G0/G1, and induced a higher degree of apoptosis, both alone but mainly in combination with either HCQ or CQ, compared to each drug alone. The combination of NVP-BEZ235 and autophagy inhibitors significantly increased the accumulation of LC3-II, a marker for autophagy inhibition, indicating a possible relationship of the inhibition to increased apoptosis.

Conclusion: The combination of the dual PI(3)K/mTOR inhibitor NVP-BEZ235 with autophagy inhibitors seems promising for the inhibition of cell proliferation in this NET cell model.

 

Nothing to Disclose: SA, GL, BG, DJG, SG

12743 3.0000 SAT-0301 A The Combination of the Dual PI(3)K/mTOR Inhibitor NVP-BEZ235 with Autophagy Inhibitors Is Synergistic in Suppressing Neuroendocrine Tumor Cell Viability 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Samira Mercedes Sadowski*1, Corina M Millo2, Candice Cottle-Delisle1, Roxanne Merkel1, Lily Yang3, Stephen J Marx4, Naris Nilubol1, Peter Herscovitch2 and Electron Kebebew1
1National Cancer Institute, NIH, Bethesda, MD, 2NIH -Clinical Center, Bethesda, MD, 3National Institutes of Health, Bethesda, MD, 4National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD

 

Background

Neuroendocrine tumors (NET) are rare malignancies. Surgical resection remains the only curative treatment option and the extent of disease is the main prognostic factor in patients with malignant NET. The aim of this study was to prospectively determine the accuracy of 68Gallium-DOTATATE PET/CT as compared to 11In- Octreotide SPECT/CT to detect unknown primary and metastatic NETs.

Methods 

In an ongoing prospective study, 68Gallium-DOTATATE PET/CT and 111In- Octreotide SPECT/CT were compared in 20 consecutive patients with suspected NET and correlated to functional status, tumor grade, surgical pathology results and axial imaging.

Results

68Gallium-DOTATATE PET/CT detected 56 lesions versus 15 lesions detected on 111In- Octreotide SPECT/CT and 32 lesions detected on contrast CT scan. 68Gallium-DOTATATE PET/CT had an average SUVmax of 72.6 [range 6.2 to 191]. In 5 patients, 68Gallium-DOTATATE PET/CT was positive with a negative 111In- Octreotide SPECT/CT and in 5 patients it found additional lymph-node metastases. In 6 patients no lesions were detected, consistent with all imaging modalities and biochemical testing results.  In 6 of the 20 patients (30%), surgical intervention was undertaken as a result of the findings on 68Gallium-DOTATATE PET/CT showing additional lesions and metastatic disease not seen by the other imaging modalities.

Conclusions

68Gallium-DOTATATE PET/CT detected more NETs than 111In- Octreotide SPECT/CT and contrast CT scan, and metastases of NETs. It should be implemented in the management of patients with NETs as it can significantly optimize patient care decisions.

 

Nothing to Disclose: SMS, CMM, CC, RM, LY, SJM, NN, PH, EK

13140 4.0000 SAT-0302 A Prospective Evaluation of 68Gallium-Dotatate PET/CT in Detecting Unknown Primary and Metastatic Neuroendocrine Tumors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Hyung Jin Choi*1, Mi-Hyun Park2, Bo-Young Kim2, Hae-Mi Woo2, Jiwon Jeong3, Yong Joo Hong3, Hyun Jeong Jeon3, Taekeun Oh3, Sung-Soo Koong3 and Soo Kyung Koo2
1Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 2Center for Biomedical Sciences, National Institute of Health, Cheongwon-gun, Korea, Republic of (South), 3Chungbuk National University College of Medicine, Cheongju, Korea, Republic of (South)

 

MEN1 is an autosomal dominant disorder characterized by multiple endocrine tumors of the parathyroids, pancreatic islets, and anterior pituitary. Previous studies have suggested that MEN1 gene in chromosome 11 acts as a tumor suppressor gene. Germline and somatic mutations in MEN1 gene contribute to the tumorigenesis of MEN1 tumors, in keeping with the “two-hit” model of hereditary cancer. However, it is now known whether there is tumor heterogeneity with different tumor-specific tumorigenesis mechanisms among multiple tumors of different tissue origin from a single MEN1 patient. To study the tumorigenesis mechanism of each tumor, we performed whole-exome sequencing, SNP arrays and Sanger sequencing of three parathyroid tumors, one pancreas insulinoma, and a blood sample from a MEN1 patient. Whole-exome sequencing and Sanger sequencing discovered a novel 2 base-pair deletion germline mutation in MEN1 gene in all samples (c.1382_1383delAG). Whole-exome sequencing and SNP array revealed copy-neutral loss of heterozygosity (LOH) of chromosome 11 in left upper parathyroid tumor and left lower parathyroid tumor, suggesting that these chromosomal alterations contributed to tumorigenesis of these two parathyroid tumors (chromosome 11 LOH score average 0.55 in left upper, 0.08 in left lower). However, no chromosomal alteration in chromosome 11 and no somatic mutation were observed in right parathyroid tumor and pancreas insulinoma. Whole-exome sequencing suggested several candidate somatic mutations in right parathyroid tumor and pancreas insulinoma (EIF2AK4, ZNF219, ADRA2B, ANKRD31, MCC, DNHD1, SLC37A4). These results reveal that there is tumor heterogeneity among tumors of a single MEN1 patient and different tumor-specific tumorigenesis mechanisms could contribute to the pathogenesis of MEN1 tumors.

 

Nothing to Disclose: HJC, MHP, BYK, HMW, JJ, YJH, HJJ, TO, SSK, SKK

13561 5.0000 SAT-0303 A Whole-Exome Sequencing Reveals Tumor Heterogeneity with Different Tumor-Specific Tumorigenesis Mechanisms Among Three Parathyroid Tumors and a Pancreas Tumor from a MEN1 Patient 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Daria Gazizova*1, Dmitry Beltcevich2, Anatoly N Tiulpakov3, Dmitry Mikhaylenko4 and Tatiana Soldatova2
1Endocrine Research Center, Moscow, Russia, 2Endocrine research center, Moscow, Russia, 3Endocrinology Research Center, Moscow, Russia, 4State Federal Institute of Urology of the Health Ministry of Russia, Moscow, Russia

 

Objective: MEN 2 is a genetic disease due to germline RETgene mutations and represents 25% of all MTC cases. It consists of MEN 2A, familial MTC (FMTC), and MEN 2B. These syndromes are characterized by a strong genotype-phenotype correlation. To obtain an insight into the molecular heterogeneity of MEN 2 in Russia, 27 MEN 2A families and 8 MEN 2B families were analyzed. Four novel mutations were discovered.

Results and conclusions: In MEN 2A cases the most frequent RET amino acid substitution was C634R (11/27, 41%), followed by C634Y (3/27, 11%) C634S (2/35, 7%), L790F (2/35, 7%) and other mutations in single families. One unclassified by ATA classification for aggressiveness mutation (K603Q) and four novel mutations were found: Y826S, del632-636 ins6, compound heterozygous mutations Y791F+I852M, C634R+ I852M.  Cases with Y826S, Y791F+I852M, C634R+ I852 mutations can be characterized as moderately aggressive (ATA class B), del632-636ins6 in 3 family members as high risk aggressive mutation (ATA class C). All MEN 2B cases carried a Met to Thr mutation in exon 16 (n=8).

The comparison of the prevalence of RET germline mutations in the present study with those found in studies published by other European Study Groups showed no evident difference (p=0,13) (1). Knowledge of the new RET mutations phenotype can guide decisions regarding prophylactic thyroidectomy, surveillance and management of PHEO and PHPT.

 

Nothing to Disclose: DG, DB, ANT, DM, TS

13576 6.0000 SAT-0304 A Mutation Analysis of the RET Proto-Oncogene in 35 Russian Families with Men 2A, Men 2B and Fmtc: Four Novel Mutations for Men 2A 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Shruti S Desai*1, Sita D Modali2, Vaishali I Parekh3 and Sunita K Agarwal1
1National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD, 2National Institute of Diabetes and Digestive and Kidney Diseases,NIH, Bethesda, MD, 3National Institutes of Health, NIDDK, Bethesda, MD

 

Mouse models of human disease are a valuable resource for testing experimental therapeutic interventions. Mice heterozygous in the germline for the multiple endocrine neoplasia type 1 (MEN1) gene recapitulate the human MEN1 syndrome, and therefore serve as a robust model of MEN1. MEN1 patients carry a germline heterozygous inactivating mutation in MEN1 that predisposes to the development of tumors in specific endocrine tissues: pancreas, parathyroids and pituitary. We have previously shown that the pro-apoptotic β-cell differentiation factor HLXB9 is a downstream target of menin, the product of MEN1. HLXB9 is a homeobox transcription factor that controls β-cell differentiation during the early and late stages of endocrine pancreas development. We showed that HLXB9 was phosphorylated by the serine/threonine kinase GSK-3β at Ser-78 and Ser-80. In a mouse insulinoma cell line (MIN6) menin knockdown reduced HLXB9-induced apoptosis and increased nuclear phospho-HLXB9 (pHLXB9), suggesting that pHLXB9 was potentially tumorigenic. Furthermore, in MIN6 cells and in 2 other rodent insulinoma cell lines GSK-3β inhibition by LiCl significantly reduced cell proliferation and induced apoptosis. Therefore, we examined whether LiCl treatment in the mouse model of MEN1 could reduce tumorigenesis. After 9 months, these mice develop a pre-tumor stage of islet hyperplasia. Islet tumors (insulinomas) that develop after 12 months show loss of both copies of Men1. At age 12 months, we treated 5 Men1+/- mice each with either LiCl or PBS as control by IP injection for one month. Treatment at this early pre-tumor stage would help to study the effect of LiCl during tumor development. Post-treatment (after one month), the pancreas from all 10 mice was processed for formalin fixed paraffin embedded tissue sectioning. Colorimetric TUNEL staining was performed to detect apoptosis. Nuclear pHLXB9 was detected by immunohistochemistry. Preliminary analysis showed TUNEL positive cells in 9 islets scored from 5 mice that were treated with LiCl, and none in the 5 mice treated with PBS. This suggested that LiCl treatment caused apoptosis that could lead to tumor regression. Reduced nuclear pHLXB9 staining was observed in a few islets.  These results indicate that inhibition of a tumorigenic pathway that is activated upon menin reduction or menin loss can induce apoptosis. Further studies in this mouse model could help to elucidate whether LiCl treatment affects the other tumors of MEN1.

 

Nothing to Disclose: SSD, SDM, VIP, SKA

13717 7.0000 SAT-0305 A Inhibitory Effect of LiCl Treatment on Pancreatic Islet β-Cell Tumorigenesis in the Mouse Model of Multiple Endocrine Neoplasia Type 1 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Laurie Amy Wing*, John V Conaglen, Goswin Y Meyer-Rochow and Marianne Susan Elston
Waikato Hospital, Hamilton, New Zealand

 

Introduction: Pheochromocytoma in pregnancy is rare, reported to occur in approximately 1: 15 000 pregnancies. Paragangliomas represent only 19% of all chromaffin cell tumours in pregnancy (1). In a recent review fetal mortality appeared lower with  mothers who had a paraganglioma when compared to pheochromocytoma (7.1 vs 17%) (1). Fetal mortality was considerably higher in women with bilateral pheochromocytomas (27%) (1).

Case series: We present the management and outcome of eight pregnancies in four SDHB-positive mothers who had concomitant paragangliomas. Notable features in our series include favourable fetal and maternal outcomes, and the absence of symptoms in the mothers despite documented catecholamine excess in most cases, and normal vaginal deliveries in three pregnancies. In the remaining cases elective caesarean section was undertaken without complication. Asymptomatic secretory paragangliomas or pheochromocytomas in pregnancy have not been well described previously.

Conclusion: Despite historically high fetal and maternal mortality rates in pregnant patients with chromaffin cell tumours, a subset of asymptomatic women with SDHB-associated paragangliomas may be able to be considered for vaginal delivery. With adequate alpha-blockade and multidisciplinary care the outcome of patients with SDHB-related paragangliomas in pregnancy may be better than for pheochromocytoma.

 

Nothing to Disclose: LAW, JVC, GYM, MSE

14351 8.0000 SAT-0306 A Pregnancy Complicated By Paraganglioma in SDHB Mutation Carriers - a Case Series 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Naykky Maruquel Singh Ospina*, Geoffrey B Thompson, Robert A Lee, Carl C Reading and William F. Young Jr.
Mayo Clinic, Rochester, MN

 

Background: The most common feature of multiple endocrine neoplasia type 1 (MEN1) is primary hyperparathyroidism (PHP), which occurs in approximately 95% of the patients. The management of recurrent PHP in this population is a challenge given the high rates of recurrence. Up to 40-60% of the patients develop recurrent hypercalcemia within 10 to 12 years after their initial parathyroid surgery.  Current treatment options include reoperation, percutaneous ethanol ablation (PEA), and medical treatment—each associated with different levels of risks and benefits.  

Objective: Evaluate the safety and efficacy of PEA for the treatment of recurrent PHP in patients with MEN1. 

Methodology: We performed an electronic search to identify patients with a billing code for MEN1 who were seen at Mayo Clinic between 1977 and 2013. MEN1 was diagnosed based on current diagnostic criteria. Patients with recurrent PHP who underwent PEA were identified and their clinical information was collected. Unpaired t test analysis was used to compare mean values.

Results: A total of 37 patients underwent 80 treatments of PEA that included 123 sessions of ethanol administration. Twenty-one patients were women (56.8%) and the mean age at diagnosis of PHP was 33.8 years. The mean pre-procedure calcium level was 10.7 mg/dL +/- 0.57 (SD) and the mean post-procedure calcium level was 9.6 mg/dL +/- 0.76 SD (p<0.01). The post-procedure calcium level was available for 74 of the treatments.  In 14 (18.9%) treatments the post-procedure calcium was more than 10.1 mg/dL. Post-procedure hypocalcemia occurred in 6 treatments (8.1%); 4 (5.4%) of these cases had serum calcium concentrations ≤ 8.5 mg/dL and 1 of them required treatment with calcium carbonate (CC) for 6 months. The other two cases (2.7%) of hypocalcemia were defined by the presence of symptoms and required treatment with CC and calcitriol for 17 months and CC for 4 years respectively.

Normocalcemia was achieved in 54 of the treatment episodes (73%) and the mean duration of normocalcemia was 24.8 months. During follow up normocalcemia was achieved for up to 1 year in 18 of the treatments (37.5%), for 1-2 years in 12 treatments (25%) and in 18 treatments it lasted more than 2 years (37.5%).

PEA was safe with transient hoarseness occurring in 4 (5%) of the treatments. 

Conclusion: The treatment of recurrent PHP in patients with MEN1 represents a challenge that is associated with increase morbidity. PEA is an effective treatment option for achieving normocalcemia in the majority of the cases (73%). PEA is associated with low rates of hypocalcemia requiring treatment (4.0%) and no permanent complications.

 

Nothing to Disclose: NMS, GBT, RAL, CCR, WFY Jr.

14769 9.0000 SAT-0307 A Percutaneous Parathyroid Ethanol Ablation in Patients with Recurrent Primary Hyperparathyroidism and Multiple Endocrine Neoplasia Type 1 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Eleni Daniel*1, Matthew James Bull2, Robert Andrew Jones3 and John Newell-Price1
1University of Sheffield and Department of Endocrinology, Sheffield Teaching Hospitals, Sheffield, United Kingdom, 2Sheffield Teaching Hospitals, Sheffield, United Kingdom, 3University of Sheffield, Sheffield, United Kingdom

 

Background:

Patients with mutations of the succinate dehydrogenase genes SDHB, SDHC, and SDHD (SDHx) are predisposed to developing pheochromocytoma (PHE) and paraganglioma (PGL). PGLs may cause symptoms due to catecholamine hypersecretion or local growth, but are often asymptomatic, and can develop at any age and may become malignant, locally aggressive or recurrent. Although annual biochemistry and imaging is recommended, there are no longitudinal reports of patients followed over many years.

Method:

A retrospective review of case records and investigations of patients with SDHx mutations monitored in a dedicated clinic at a regional referral centre, Sheffield, UK since 2005. All patients underwent annual clinical review by one experienced clinician (JN-P), annual biochemical investigations (urine catecholamines, urine metanephrines, or plasma metanephrines) and a rapid sequence MRI (total scan time 25 mins) of the sympathetic/parasympathetic chain biannually.

Results:

A total of fifty-four consecutive patients were analyzed: SDHB (36 patients), SDHC (7), SDHD (11); of these 13 patients were index cases and 41 patients were asymptomatic relatives at the time of initial screening. Mean duration of follow-up was 53.8 months. During the 8 years of the study 95 MRI scans were performed: 67 scans were negative for an SDHx-related tumor and 28 were positive.  Index cases: all 13 index cases presented with a PGL/PHE (median age 33y, range 15-69y); 2/13 developed further PGL during follow-up.  Asymptomatic relatives: 41 asymptomatic relatives had biochemical screening every 15.2 months and an MRI every 28.4 months: Six had PGL (median age 31y, range 18-60y) - 5/41 were diagnosed with PGL at the first screening visit; only 1/41 had a small PGL detected at subsequent screening visits, which is currently under surveillance.

Conclusions:

This is the first report of longitudinal screening data for patients with SDHx mutations using rapid sequence MRI. The majority of PGL detected in asymptomatic relatives were at the first screening visit and we suggest, therefore, that all relatives testing positive for an SDHx mutation are offered baseline screening as soon as possible. Our data indicate that biannual imaging with rapid sequence MRI and annual biochemical follow-up is a reasonable approach for asymptomatic SDHx carriers.

 

Nothing to Disclose: ED, MJB, RAJ, JN

15318 10.0000 SAT-0308 A Rapid-Sequence MRI for Long-Term Monitoring of Succinate Dehydrogenase (SDHx) Mutation Carriers 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Malgorzata Trofimiuk-Müldner*1, Ewelina Lewkowicz2, Dorota Pach1, Agnieszka Kieltyka1, Agnieszka Stefanska2, Anna Sowa-Staszczak2, Aleksandra Gilis-Januszewska1 and Alicja Hubalewska-D1
1Jagiellonian University Medical College, Krakow, Poland, 2University Hospital in Krakow, Krakow, Poland

 

Cancer registers are important tools in improving the knowledge of epidemiology of rare malignancies, such as GEPNETs. Identification of factors influencing survival of GEPNET patients may improve their management by better selection of subjects requiring more close follow-up and more aggressive therapeutic approach.

Aim: to assess epidemiology of GEPNET tumors in Krakow and Krakow district area.

Material and methods:The data from GEPNETs register run in the Endocrinology Department, University Hospital in Krakow, were assessed. 88 patients (49 females, 39 males) aged 59+/-17 years diagnosed with GEPNETs between January 2007 and December 2011, living in Krakow and Krakow district area,were included in further analysis. 75% of them were followed in the Endocrinology Department, University Hospital in Krakow. Factors influencing 2-year survival were assessed.

Results: The mean follow-up period was 2.7+/-1.6 years. Two-year survival was 77%. The most frequent primary localization of GEPNETs was small intestine (20%), followed by appendix (18%), pancreas (16%), stomach (16%), rectum (15%). Well differentiated GEPNETs prevailed (NET G1 constituted 64% of the group, NET G2 - 28%, and NEC 8%). Most of the tumors (63%) were diagnosed  at stage I according to AJCC/UICC. Distant metastases were found at diagnosis in 31% of patients (to regional lymph nodes in 25%, and distant in 18% of patients). Metastases were most frequently observed in colonic NETs (67%).The standardized incidence rates of GEPNETs in Krakow and Krakow district area ranged from 1.5  to 2.7 cases/100 000 persons/year, an average of 2.1/100 000 persons/year. No statistically important trend in GEPNETs incidence between 2007 and 2011 was noted. In univariate analysis the following factors were associated with poor prognosis: grade NET G2 (p<0.001), stage (AJCC/UICC) III (p=0.002) or IV (p<0.001) at diagnosis, both nodal and distant metastases at diagnosis (p<0.001), colonic GEPNETs (p=0.039), and management outside specialized GEPNET center (p=0.007). In multivariate standardized models the independent risk factors of poorer prognosis were: higher stage at diagnosis (8-10-fold increased risk of death for stage III and IV vs. stage I), metastases at diagnosis (10-fold increased risk of death), the residence outside the limits of Krakow city (3-5-fold increased risk of death), and the management outside the Department of Endocrinology, University Hospital in Krakow (7-fold increase in risk of death).

Conclusions: GEPNET incidence in Krakow and Krakow district area is similar to the incidence observed in most  European countries. The GEPNET patient survival is influenced not only by the disease extent at diagnosis (staging) and by proliferation indices (grading), but also by area of residency (probably  due to mismatch in health care providers availability) and the experience of the center taking care of GEPNET patients.

 

Nothing to Disclose: MT, EL, DP, AK, AS, AS, AG, AH

15522 11.0000 SAT-0309 A Epidemiology of Gastro-Entero-Pancreatic Neuroendocrine Tumors (GEPNETs) in Krakow and Krakow District Area 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Alicja Hubalewska-D*1, Anna Sowa-Staszczak2, Dorota Pach1, Monika Tomaszuk2, Malgorzata Trofimiuk-Müldner1, Agnieszka Stefanska2, Monika Buziak-Bereza1, Agata Jabrocka-Hybel1, Aleksandra Gilis-Januszewska1, Maciej Malecki1, Tomasz Marcin Bednarczuk3, Grzegorz Kaminski4 and Aldona Kowalska5
1Jagiellonian University Medical College, Krakow, Poland, 2University Hospital in Krakow, Krakow, Poland, 3Medical University of Warsaw, Warsaw, 4Military Institute of Medicine, Warsaw, Poland, 5Holycross Cancer Center, Kielce, Poland

 

Introduction: Apart from huge progress in imaging diagnostics the localization of hardly detectable  insulinomas is a challenge for endocrinologists. Results of 3 years’ experience assessing the diagnostic efficiency of labelled glucagon-like peptide-1 scintigraphy in the detection of insulinomas not diagnosed by other available methods is presented.

Material and Method: 37 patients (24 women and 13 men, mean age 46.5±17.8 years, min.16.0 years, max.77.0 years) were enrolled in this study. There were 32 patients with clinical and biochemical symptoms and signs of insulinoma, one patient with malignant insulinoma, one patient with suspected local recurrence of malignant insulinoma (MEN1) and three with nesidioblastosis. In all patients prior examinations (CT/MRI/SRS/EUS) were negative or equivocal. [Lys40(Ahx-HYNIC-99mTc/EDDA)NH2]-exendin-4 SPECT/CT scans were performed  in each patients.

Results: In 27 cases with suspicion of insulinoma a focal uptake in the pancreas was found – classified as insulinoma. In four negative cases reactive hypoglycaemia was diagnosed. In one case exogenous stimulation of insulin level by patient was revealed. In one case with malignant insulinoma pathological accumulation of the tracer was found only in the region of local recurrence. The GLP-1 study was negative in the other malignant insulinoma patient. In two patients with suspected nesidioblastosis diffuse accumulation of tracer was observed. In one case with suspicion of nesidioblastosis, a focal accumulation of the tracer was observed - histopathology revealed coexistence of insulinoma and nesidioblastosis.

Conclusion: 99mTc-GLP-1 receptor scintigraphy is a promising diagnostic tool for patients with clinical symptoms of insulinoma. It enables the localization of even very small tumours with excellent sensitivity, and proper imaging is the most important step for successful surgery and complete patient recovery.

 

Nothing to Disclose: AH, AS, DP, MT, MT, AS, MB, AJ, AG, MM, TMB, GK, AK

15539 12.0000 SAT-0310 A Searching for an Unknown Insulinoma Focus – Is Labelled Glucagon-like Peptide-1 Scintigraphy an Answer? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Naomi Takeichi*, Hitoshi Sugihara, Akira Asai, Shunsuke Kobayashi, Tomoko Nagamine, Ayako Takano, Toshiko Wakakuri, Mototsugu Nagao, Masaaki Yamamoto, Hideki Tamura and Shinichi Oikawa
Graduate School of Medicine, Nippon Medical School, Tokyo, Japan

 

Background: Growth hormone (GH) secretagogues (GHSs), which are developed from the met-enkephalin structure, stimulate GH secretion by acting on a specific receptor (GHS-R) for which ghrelin has been shown to be a natural ligand. We have reported the possibility that the GH-releasing peptide (GHRP)-2 test may be an alternative to the insulin tolerance test for assessing hypothalamus-pituitary-adrenal (HPA) axis function (1). The GHS-R is mainly localized in the hypothalamus and pituitary gland, and also localized in the pancreatic islet. moderately abundant in the pancreatic islet. Ghrelin has been reported to suppress or to have no effect on insulin secretion. In the present study, we examined the effect of GHRP-2, one of GHSs, on insulin secretion in patients with insulinoma and the expression of GHS-R in the tumor cells.

Methods: GHRP-2 tests were performed in 8 patients with insulinoma. A 100-µg dose of GHRP-2 was administered intravenously to each of the subjects. Blood samples were obtained before and 15, 30, 45, and 60 min after the GHRP-2 injection, and serum insulin and plasma glucose concentrations were measured. The GHRP-2 test was repeated at least 2 weeks after the insulinoma was resected. Immunohistochemistry was performed using anti-GHS-R rabbit serum (2) via the avidin-biotin-peroxidase complex method in 4 resected tumors.

Results: In 7 of 8 patients, insulin secretion increased to 229 ± 112% (Mean±SD) of the basal value and plasma glucose level decreased to 90.8 ± 11.8% of the basal value in the GHRP-2 test before the operation. In the remaining 1 case, insulin secretion was reduced from 11.5 to 7.3 µIU/ml in response to the GHRP. In all the cases, the hypoglycemic episodes disappeared after removal of the insulin-producing tumor. In 7 patients who showed increased insulin response to the GHRP before the operation, insulin secretion decreased to 62.7 ± 18.9% of the basal value in the GHRP-2 test after the operation. Immunostaining of GHS-R was scattered in the 4 resected tumors, including the 1 case in which insulin response to GHRP was decreased before the operation.

Conclusion: The results of this study suggest that the GHRP-2 test might be useful for the diagnosis and the evaluation of curative effect in insulinoma. In addition, GHRP might have partially direct effects on insulin secretion. To confirm our findings, further studies are necessary with higher number of cases.

 

Nothing to Disclose: NT, HS, AA, SK, TN, AT, TW, MN, MY, HT, SO

15687 13.0000 SAT-0311 A Usefulness of the Growth Hormone-Releasing Peptide-2 Test in Insulinoma Diagnosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Andrea M Isidori*1, Mara Boschetti2, Emilia Sbardella3, Giovanni Vitale4, Maria Chiara Zatelli5, Annamaria Colao6 and Rosario Pivonello7
1Sapienza University of Rome, Rome, Italy, 2Univ of Genoa, Genova, Italy, 3Sapienza Univ., Rome, Italy, 4Univ. of Milan, Milan, Italy, 5Univ. of Ferrara, Ferrara, Italy, 6University, Naples, Italy, 7Federico II Univ, Naples, Italy

 

The syndrome of ectopic ACTH secretion (EAS) remains a diagnostic challenge because the source is often occult. Aim of this analysis was to investigate the role of molecular vs. conventional imaging in the localization of the secreting tumor by reviewing all reports providing data on patients with EAS who underwent a nuclear medicine investigation. The wide time-frame (1998-2013) allowed appraisal of temporal trends in the use of Octreoscan, MIBG, FDG-PET, Fluoro-Dopa-PET, Gallium-Somatostatin-receptor-PET. Accuracy of the modalities was analyzed according to the clinical stratification of EAS into 'overt', when tumor was readily identifiable, 'covert', when revealed by molecular imaging or follow-up, and 'occult' when never detectable. A total of 209 cases were retrieved (F:47.1%; 43.5±16.5 yrs). Tumors were located in the lung (42%), pancreas (6.1%), thymus (5.2%), adrenal glands (5.2%), thyroid (2.3%), ileum (1.4%), olfactory bulb (1.4%), other rare sites (15.4%) or remained occult (21%); available histologies were: bronchial-NETs (58.2%), GI-NETs (12.1%), pheochromocytoma (4.9%), medullary thyroid carcinoma (2.5%), neuroblastoma (2.5%), paraganglioma (1.8%) and other rare histologies (18%). Overall, 52% of patients had an 'overt' EAS (108/209), 13% 'occult', 7% 'partial-occult' (unknown primary with ACTH+ metastases), while 28%  (58/209) met the criteria of 'covert' EAS. CT located the source of ectopic ACTH in 61% (111/182), MRI in 48% (49/102), Octreoscan in 46% (77/167), FDG-PET in 46% (38/82), Fluoro-Dopa-PET in 52% (11/21), MIBG in 27% (4/15), Gallium-Somatostatin-PET in 92% (12/13). The use of Octreoscan remained stable up to 2010, while MIBG drastically diminished; FDG-PET and gallium-tracers’ use gradually increased in recent years. In the subgroup of 'covert' EAS the main tumor sites were: lung (48%), mediastinum-thymus (17%), pancreas (5%), ileum (3%), and were smaller than overt tumors (18.6±10.6 vs. 28.5±28.9 mm p<0.05). In the localization of 'covert' EAS, Octreoscan was the most used technique, revealing the hidden source of ACTH in 61.7% of cases (sensitivity 63%), FDG-PET had a sensitivity 54.2%, while MIBG was rarely helpful. Fluoro-Dopa-PET was successful in 4 coverts (of whom 2 were also positive to other modalities), while Gallium-Somatostatin-PET was the only scan that revealed an occult source in covert cases that were negative to all other tracers (3/3). The identification of the source of ACTH production is often difficult with conventional radiology. Nuclear medicine improves the identification of otherwise unknown tumor sites, as demonstrated by the greater number of covert EAS reviewed in this case series. Octreoscan confirms a good availability/reliability ratio, but still fails in a relevant number of tumors; in these cases the Gallium-Somatostatin-receptor-PET scans appear to be the most promising modalities.

 

Disclosure: AC: Scientific Board Member, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals. RP: Principal Investigator, Novartis Pharmaceuticals, Coinvestigator, Novartis Pharmaceuticals, Coinvestigator, Viropharma, Coinvestigator, IBSA, Consultant, Novartis Pharmaceuticals, Consultant, Ipsen, Consultant, Pfizer, Inc., Consultant, Viropharma, Consultant, Ferring Pharmaceuticals, Consultant, Italfarmaco, Speaker, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals. Nothing to Disclose: AMI, MB, ES, GV, MCZ

15742 14.0000 SAT-0312 A Molecular Imaging of Ectopic ACTH Secreting Tumors: A Systematic Review 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Donato Iacovazzo*1, Francesca Lugli1, Antonio Bianchi2, Ettore Capoluongo3, Emanuela Lucci-Cordisco2, Roberto Persiani2, Giovanni Battista Doglietto2, Alfredo Pontecorvi2, Guido Rindi1 and Laura De Marinis2
1Università Cattolica del Sacro Cuore, Rome, Italy, 2Catholic University, Rome, Italy, 3Catholic University School of Medicine, Rome

 

GEP NETs, especially gastrinomas, occur in 40-70% of MEN1 patients and represent the main cause of death in these patients.

We aim to investigate the efficacy of lanreotide autogel (ATG) in the treatment of MEN1-related gastrinomas.

We report a monocentric series of 7 MEN1 patients (3 M, 4 F) treated with lanreotide ATG (120 mg/4 weeks) for a mean period of 62.1 months. Plasma gastrin levels have been measured at diagnosis, 3 months after starting lanreotide and then every 6 months. Five of the 7 patients underwent surgery, at least 3 months after starting lanreotide treatment, while 2 patients refused surgical treatment.

Mean plasma gastrin levels at diagnosis were 5562 pg/ml (1300-17178 pg/ml; n.v. 30-115) and fell, after 3 months of treatment, to 117.1 pg/ml (53-241 pg/ml; mean reduction 78.9%). Five patients underwent surgery and 3 of these had persistent hypergastrinemia. In these patients the treatment with lanreotide was resumed with normalization of gastrin plasma levels and disease stabilization. Two patients refused surgery: during follow up gastrin levels remained controlled with no evidence of disease progression.

Lanreotide ATG proved efficacy in the biochemical control of hypergastrinemia with normalization of plasma gastrin levels in 70% of patients and a mean reduction of 78.9% after the first 3 months of treatment. Moreover, lanreotide demonstrated efficacy in the long-term control of disease and allowed tumor stabilization in all patients.

 

Nothing to Disclose: DI, FL, AB, EC, EL, RP, GBD, AP, GR, LD

16141 15.0000 SAT-0313 A Efficacy of Lanreotide Autogel in MEN1-Related Gastrinomas: A Case Series 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Andrea Estrada*1, Aradhana Venkatesan2, Christopher L Wolfgang3, Lori C. Guthrie4, Elliot K Fishman5, Ihab Kamel5, Syed Z Ali5, Michael Goggins3, Ralph H Hruban3, Anirban Maitra6, Rachel I Gafni7, Anne Marie Lennon3 and Michael T. Collins8
1National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 2National Institutes of Health, Bethesda, MD, 3Johns Hopkins University School of Medicine, Baltimore, MD, 4Section on Skeletal Disorders and Mineral Homeostasis, Bethesda, MD, 5Johns Hopkins University School of Medicine, 6MD Anderson, 7NIH, Bethesda, MD, 8National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD

 

Background:  The McCune Albright syndrome (MAS) exists along a clinical spectrum that includes polyostotic fibrous dysplasia, café-au-lait macules, and hyperfunctioning endocrinopathies including GH excess, precocious puberty, hyperthyroidism, FGF23-mediated hypophosphatemia and hypercortisolism.  It is due to somatic activating mutations in GNAS. Gastrointestinal manifestations, which include gastroesophageal reflux, polyps, pancreatitis, pancreatic cysts, and hepatic telangectasias, have been reported in MAS, but their prevalence is not known.  The same GNAS mutations that are responsible for MAS have been found in 66% of intraductal papillary mucinous neoplasms (IPMNs), cystic neoplasms of the pancreas known to be precursors of pancreatic cancer.  In the general population, IPMNs occur most commonly in the 7thdecade of life.

Objective: Determine the prevalence and characteristics of pancreatic neoplasms in MAS.

Patients and Methods:  Thirteen patients (aged 7 to 67 y, median 20) in the National Institutes of Health cohort of subjects with MAS underwent abdominal MRI and magnetic resonance cholangiopancreatography (MRCP) screening for pancreatic neoplasms.  Identified IPMNs were further categorized according to the 2012 international consensus guidelines into those with either high risk or worrisome features; including main duct dilatation ≥5 mm, cysts ≥ 3 cm, mural nodule, thickened wall or solid component, jaundice secondary to the cyst or history of acute pancreatitis.

Results: Four of the thirteen patients (31%) had IPMNs, all of which exhibited worrisome or high-risk stigmata.  Two had main pancreatic duct IPMN, one had branch duct IPMN and the fourth was a mixed- IPMN. The median age was 43 (range 17 to 67).  EUS with biopsy and ERCP were performed on one patient.  Findings included a main duct IPMN with multiple cysts in the head, body, and tail in communication with a markedly dilated main duct (maximum diameter 1.2 cm). 

Conclusions:  Gastrointestinal neoplasms, particularly IPMNs, appear to occur more frequently and at a younger age in patients with MAS compared to the general population. This suggests that pancreatic neoplasms may be another clinical feature of MAS.  Given the malignant potential of IPMNs in the general population, screening for pancreatic neoplasms in patients with MAS may be warranted.  Further determination of the natural history and spectrum of IPMNs in MAS is needed. Additionally, the MAS pancreas may be a potential model for studying the pathogenesis of pancreatic cancer.

 

Nothing to Disclose: AE, AV, CLW, LCG, EKF, IK, SZA, MG, RHH, AM, RIG, AML, MTC

16442 16.0000 SAT-0314 A Pancreatic Pathology in Mccune Albright Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Jaydira Del Rivero*1, Ritu Madan2 and Stephen J Marx3
1National Institute of Child Health and Human Development, National Institutes of Health, 2National Institutes of Health, Bethesda, MD, 3National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD

 

Introduction:  Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant hereditary disorder that usually first presents with primary hyperparathyroidism resulting from multiple parathyroid tumors. Neuroendocrine tumors of the pancreas, duodenum, anterior pituitary gland, stomach, and lung are also an integral part of MEN1 syndrome. Non-endocrine mesenchymal tumors, such as lipomas, angiofibromas, and collagenomas, have also been shown to be associated with MEN1. It has been previously reported that the MEN1gene contributes to the development of multiple esophageal and uterine leiomyomata however, its specific role in tumorigenesis is still not well understood.

Methods: A chart analysis of patients who presented to The National Institutes of Health with MEN1 syndrome was conducted.

Results: Three patients with uterine leiomyomas were identified. The mean age of MEN1 diagnosis was 36 years; primary hyperparathyroidism and uterine leiomyomas presented at an average age of 35 and 39 years, respectively. All uterine leiomyomas were diagnosed after the diagnosis of MEN1 was established.  All three patients underwent total hysterectomies for the uterine fibroids. One patient developed metastatic leiomyomatosis eight years after with the diagnosis of benign uterine leiomyoma. This discovery was made after an esophageal mass resection, pathology confirming metastatic leiomyomatosis.

Discussion: Molecular genetic studies of MEN1 associated tumors like parathyroid, enteropancreatic, pituitary tumors, and mesenchymal tumors, such as lipomas and angiofibromas, demonstrated loss of heterozygosity (LOH) in MEN1 gene. In a previous report by McKeeby et al., 10 out of 15 leiomyomata in 5 MEN1 patients had LOH at MEN1 gene locus.  This led us to hypothesize that leiomyomas have a higher prevalence in MEN 1 patients and can occur at multiple locations. This retrospective chart review did not confirm our hypothesis of higher prevalence but definitely showed that symptomatic uterine fibroids in MEN 1 patients occur at a younger age and require hysterectomy more often. We may not have been able to detect the exact prevalence because of the retrospective nature of the study. Further studies are required to enhance our knowledge on the association of leiomyomas with MEN 1 syndrome and thus help in the management of this complex disorder.

 

Nothing to Disclose: JD, RM, SJM

16452 17.0000 SAT-0315 A Uterine Leiomyomas Associated with Multiple Endocrine Neoplasia Type 1 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Marije J. Veenstra*1, Peter van Koetsveld1, Fadime Dogan1, William E. Farrell2, Steven W.J. Lamberts1, Richard A. Feelders1, Wouter W. de Herder1 and Leo J. Hofland1
1Erasmus Medical Center, Rotterdam, Netherlands, 2Keele University, Stoke on Trent, Staffordshire, United Kingdom

 

Introduction

Somatostatin (SS) can regulate hormone secretion and cell proliferation in neuroendocrine tumors (NETs) and SS analogues play a significant role in their treatment. In the current study we evaluated whether endogenous SS could have a role in NETs. SS mRNA expression and CpG methylation within the promoter region in NETs and NET cell lines was determined. In addition, the influence of the demethylating epidrug 5-aza-2’-deoxycytidine (5-aza-dC) was evaluated.

Materials and methods

SS mRNA expression was determined by RT-qPCR in tumor tissue derived from 18 gastroenteropancreatic (GEP)-NETs. Methylation of 15 CpGs in the SS gene promoter associated CpG island was determined by pyrosequencing. In NET cell lines BON-1, QGP-1 and DMS-79, SS mRNA expression and CpG methylation was determined. In BON-1 and DMS-79 the effect of treatment with 5-aza-dC on SS mRNA and DNA methylation levels was evaluated.

Results

BON-1 expressed SS mRNA (ratio SS/hprt 1.4 ±0.1) at a considerably lower level compared to QGP-1 and DMS-79 (ratios 8.2 ±0.8 and 8.8 ±0.4, respectively). Pyrosequencing data showed higher methylation in the SS gene promoter associated CpG island in BON-1 cells (median 25%, range 19-67%) than in QGP-1 (median 4%, range 2-10%) and DMS-79 (median 1%, range 1-3%).  IC20 and IC50inhibitory concentrations of 5-aza-dC induced a significant 2.2 and 4.0 fold increase, respectively, in SS mRNA expression in BON-1 cells, whereas the drug had no effect on SS mRNA expression in DMS-79. Correspondingly, in BON-1 cells, CpG methylation decreased at several positions with 5-aza-dC treatment. In the GEP-NET tumors we found highly variable SS mRNA expression, which was accompanied by highly variable CpG methylation levels. However, in this small series of tumors we did not find a statistically significant correlation between SS mRNA expression- and promoter region CpG methylation levels.

Discussion

In the NET cell line models SS mRNA expression was inversely related to CpG methylation of the SS promoter region. The epidrug 5-aza-dC reversed the (partial) silencing of SS expression in BON-1 cells, however in DMS-79, which has high expression and low methylation, the epidrug was without effect. These findings suggest that CpG methylation impacts on SS transcription. We found highly variable SS mRNA expression among GEP-NETs, which might be attributed to epigenetic regulation. Moreover, analysis of SS promoter region CpG methylation revealed high variability as well, however no statistical significant correlation between gene expression and CpG methylation was found in this small series of GEP-NETs. Studies in larger series of tumors are required to unravel whether methylation or other epigenetic modifications of the SS gene promoter region are responsible for variable endogenous SS expression, and have an impact on clinicopathological features and outcomes.

 

Disclosure: RAF: Investigator, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals. WWD: Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Ipsen, Speaker, Pfizer, Inc.. Nothing to Disclose: MJV, PV, FD, WEF, SWJL, LJH

16664 18.0000 SAT-0316 A Epigenetic Regulation of Endogenous Somatostatin Expression in Neuroendocrine Tumors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Vikki Louise Poole*, Martin Read, Rachel Watkins, Bhavika Modasia, Waraporn Imruetaicharoenchoke, Kristien Boelaert, Jayne A Franklyn, Vicki Smith and Christopher John McCabe
University of Birmingham

 

Whilst radioiodine ablation is an effective therapy for many patients with thyroid cancer, a subset of patients are incapable of accumulating sufficient iodine-131 for effective treatment, due to low sodium iodide symporter (NIS) activity. Previous work has identified that the overexpression of pituitary tumor transforming gene (PTTG) binding factor (PBF) in thyroid cells leads to the redistribution of NIS from the plasma membrane into intracellular vesicles, thereby reducing radioiodine uptake. With radioiodine being proposed as a potential treatment for breast carcinomas, where PBF has been reported to be overexpressed, it is important to discern the relationship between PBF and NIS in breast cancer cell-lines. Immunofluorescent microscopy revealed co-localisation between NIS and PBF in co-transfected MCF-7 and T47D cells, with increased intracellular staining for NIS compared to cells transfected with NIS alone. We have recently identified PBF as a tyrosine phosphorylated protein, with Src phosphorylation at residue Y174 critical to NIS regulation in thyroid cells. Importantly, phosphorylated PBF co-localised at the plasma membrane with NIS in T47D breast cells. Functional studies in MCF-7 and MDA-MB-231 cells demonstrated that PBF significantly repressed radioiodine uptake in cells expressing exogenous NIS (25% and 30% reduction respectively, both n=3 and p<0.05). Treatment with PP1, a Src-inhibitor shown to inhibit the phosphorylation of PBF, restored the ability of MCF-7 and MDA-MB-231 cells to uptake iodine-125 (1.24- and 1.69- fold increase respectively, n=3, p<0.05). Combined all-trans retinoic acid (ATRA) and dexamethasone treatment has previously been shown to enhance NIS expression and radioiodide uptake in MCF-7 cells. Our present data confirm these findings (5 fold increase compared to vehicle, n=3, p<0.05). Importantly, in the face of NIS-induction via ATRA and dexamethasone, PBF retained its ability to repress iodide uptake (31% reduction, n=3, p<0.05). This repression was overcome by targeting PBF phosphorylation via PP1 treatment, which restored radioiodine uptake to vector only transfected levels (1.22-fold increase, p=ns, n=3). Taken together, these data suggest that PBF alters the subcellular location of NIS and represses its activity in breast cancer cells. Further, tyrosine phosphorylation of PBF modulates the ability of breast carcinoma cell-lines to take up radioiodine, with important implications for adapting NIS as a potential therapy in breast cancer.

 

Disclosure: KB: Principal Investigator, HRA Pharma. Nothing to Disclose: VLP, MR, RW, BM, WI, JAF, VS, CJM

16874 19.0000 SAT-0317 A Modulation of Radioiodine Uptake By Pbf in Breast Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0299-0317 4883 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Benford Mafuvadze, Yayun Liang and Salman M Hyder*
University of Missouri, Columbia, MO

 

Cholesterol is the synthetic precursor of steroid hormones such as estrogens and progestins, which control the growth of many types of human breast cancer. Enzymes responsible for converting cholesterol into steroid hormones are present within breast tumor cells, resulting in local estrogen production.  This could lead to tumors becoming resistant to anti-estrogen therapy. In this study we determined whether oxidosqualene cyclase (OSC), an enzyme in the cholesterol biosynthetic pathway, might be targeted to suppress progression of breast cancer cells. Using in silico analysis we previously identified the OSC inhibitor RO 48-8071 (RO), as a potential ligand which could be used to control the progression of estrogen receptor-alpha positive (ERα +ve) breast cancer cells. However, real-time PCR analysis of mRNA from human breast cancer biopsies obtained at various stages of disease did not identify significant differences in OSC expression between tumor tissues or between tumor and normal mammary cells. Nevertheless, since RO reduced tumor cell viability, we examined other potential targets by which it might exert its anti-proliferative effects. Since the growth of hormone-responsive tumors is ERα-dependent, we determined whether RO affected ERα. Using non-human mammalian cells engineered to express human ERα protein and an ERα–responsive luciferase promoter (Indigo Biosciences) we found that RO inhibited 17β-estradiol (E2)-induced ERα responsive luciferase activity.  Inhibition was dose-dependent, with an IC50 of approximately 10 μM under conditions that were non-toxic to the cells. In order to determine whether RO influenced the biological activity of ERα, we selected treatment conditions (5 μM RO, 16-18h) that did not affect cell viability or influence ERα protein levels. We then treated BT-474 breast cancer cells with 10 nM E2 ± 5 μM RO for 16-18 h and used Western blotting to measure levels of PR, an estrogen responsive gene. RO reduced PR levels in BT-474 cells, confirming that it blocks ERα activity in tumor cells.  Real-time PCR and Western blotting revealed no effect of RO on levels of either ERα mRNA or protein.  Our findings demonstrate that an important means by which RO suppresses hormone-dependent growth of breast cancer cells is through its ability to arrest the biological activity of ERα. We suggest therefore that our studies support further investigation of RO as a potential therapeutic agent for use against hormone-dependent breast cancers.

 

Nothing to Disclose: BM, YL, SMH

11310 1.0000 SAT-0279 A Oxidosqualene Cyclase Inhibitor Suppresses Transcriptional Activity of Estrogen Receptor-α in Human Breast Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Kiyoshi Takagi*1, Yasuhiro Miki2, Yoshiaki Onodera1, Yasuhiro Nakamura1, Takanori Ishida3, Hironobu Sasano1 and Takashi Suzuki1
1Tohoku University Graduate School of Medicine, Sendai, Japan, 2International Research Institute of Disaster Science, Tohoku University, Sendai, Japan, 3Tohoku Univ Sch of Med, Sendai, Japan

 

ARHGAP15 is a member of RhoGAP protein and inactivates Rac1 by converting GTP-bound form to GDP-bound form. We have previously pointed out ARHGAP15 as a possible androgen responsive gene in human breast carcinomas by microarray analysis. Although several studies have suggested pivotal roles of Rac1, ARHGAP15 has not been well examined in breast carcinomas. Therefore, in this study, we first immunolocalized ARHGAP15 in 82 breast carcinoma tissues. ARHGAP15 immunoreactivity was detected in the cytoplasm of carcinoma cells, and significantly associated with that of Rac1 (P = 0.0015). ARHGAP15 immunoractivity was significantly associated with improved prognosis for disease-free (P = 0.0036) and breast cancer-specific survival (P = 0.049). In subsequent in vitro experiments, real time PCR analysis demonstrated induction of ARHGAP15 mRNA by dihydrotestosterone, biologically active androgen. Moreover, ARHGAP15 was found to inhibit migration activity of carcinoma cells by wound healing assays. These results suggested that Rac1 signaling is associated with migration and invasion of breast carcinoma cells, and ARHGAP15 may suppress the progression of breast carcinomas by inactivating Rac1 signaling.

 

Nothing to Disclose: KT, YM, YO, YN, TI, HS, TS

15739 2.0000 SAT-0280 A Tumor Suppressive Roles of ARHGAP15 in Human Breast Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Michael P Shea*1, Kathleen A O'Leary1 and Linda A Schuler2
1University of Wisconsin-Madison, 2University of Wisconsin-Madison, Madison, WI

 

Elevated circulating prolactin (PRL) levels are associated with increased incidence of estrogen-receptor alpha positive (ERα+) breast cancer, risk of metastasis, and treatment resistance. The mechanisms underlying the onset of therapy-resistant ERα+ tumors are not well understood, but emerging evidence is now implicating tumor-initiating cells (TICs) in tumor growth, treatment resistance, and differentiation. TICs represent a discrete subpopulation of cancer cells which have the ability to drive the growth of an entire heterogeneous tumor. To examine TICs in ERα+ mammary carcinomas, we utilized a transgenic mouse model (NRL-PRL) that mimics the local expression of PRL within the mammary epithelia as observed in women. Nulliparous NRL-PRL females developed invasive mammary carcinomas with high incidence. PRL-induced tumors exhibited wide histological diversity and the majority were ERα+ (>75% of tumors). Although NRL-PRL tumor development is accelerated by supplemental estrogen, end stage tumors are estrogen insensitive resembling anti-estrogen resistant clinical cancers. Fluorescence-activated cell sorting was utilized to characterize tumor cell subpopulations in a panel of carcinomas with differing histotypes. ERα+ tumors induced by PRL were found to be comprised of both luminal (EPCAMhiCD49f+) and basal (EPCAMmedCD49f+) subpopulations. This result is distinct from the luminal but ERα-negative (MMTV-Her2/neu), and claudin-low (p53-/-) murine models of breast cancer. The luminal/basal cell ratios for NRL-PRL, MMTV-Her2/neu, and p53-/- derived tumors were 2.4±0.3, 46.0±1.8, and 0.004±0.005, (mean±S.D., N=3-4), respectively. Limiting-dilution transplantations of sorted cells with luminal and basal surface marker expression profiles from NRL-PRL adenocarcinomas each regenerated tumors which resembled the parent tumor with regards to both histotype and ERα expression, indicating that cells with TIC activity are present within each subpopulation.  Characterization of TICs in ERα+ carcinomas will reveal properties that may contribute to disease progression and treatment failure, including modulation of TIC activity by hormones such as PRL and ovarian steroids, providing targets for specific therapy.

 

Nothing to Disclose: MPS, KAO, LAS

14885 3.0000 SAT-0281 A Tumor-Initiating Cells in Prolactin-Induced ER+ Mammary Carcinomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Tessie Paulose*, Maël Montévil, Lucia Speroni, Carlos Sonnenschein and Ana M Soto
Tufts University, Boston, MA

 

Ovarian and pituitary hormones regulate normal breast development as well as risk factors for breast carcinogenesis. Mammographic density is a breast cancer risk factor that correlates with high stromal fibrous content. An appropriate three-dimensional (3D) model of the breast in which hormones affect epithelial and stromal components might correct this deficiency. We developed a 3D culture model using T47D breast epithelial cells that proliferate in rat-tail collagen-1 (Col-1), i.e., the main fibrous component of normal stroma. This novel 3D model is sensitive to hormones such as estrogen (E2), promegestone (P) and prolactin (Prl). In it, E2 induces ductal elongation, P induces lateral branching and Prl induces budding, resembling hormonal effects seen in mammary glands in situ (1). To explore the link between biomechanical properties of the stroma and hormonal regulation of cell-matrix interactions, we further developed this model in which T47D and stromal cells (fibroblasts) are embedded in 0.5 and 1 mg/ml Col-1 (high). Our overall objectives were 1) to explore the hypothesis that high stromal density favors malignant growth of epithelial cells; and 2) determine whether hormones affect the biomechanical properties of Col-1 and influence epithelial phenotype. Thus, we altered the properties of extracellular matrix (ECM) to explore the interaction between altered morphogenesis and hormone-driven organization by epithelium and fibroblasts. Carmine-stained gels were imaged by confocal microscopy and 3D morphometric analysis was done using FIJI software. We observed that elon1 (a parameter generated by FIJI that denotes the ratio between the long-axis and mid-axis of a 3D structure) is significantly higher in 0.5 mg/ml Col-1 compared to 1 mg/ml Col-1 suggesting that lower density of Col-1 promotes ductal formation (Mean elon1 of all structures in 0.5 mg/ml Col-1 ± SD = 1.86 ± 0.27; 1 mg/ml Col-1 = 1.42 ± 0.04; p&lt;0.05). Remarkably, in 1 mg/ml Col-1 gels with fibroblasts, significantly higher number of ductal structures with lumen was observed compared to gels without fibroblasts (Mean elon1 of 1 mg/ml Col-1+fibroblasts = 1.78 ± 0.2; 1 mg/ml Col-1 only = 1.41 ± 0.06; p&lt;0.05). In addition, preliminary results suggest that addition of fibroblasts in 1 mg/ml Col-1 with E2 and P resulted in an increased number of elongated structures compared to gels without fibroblasts. These results, together with previous studies (1,2) suggest a reciprocal interplay between epithelial and stromal cells, and the ECM (matrix rigidity and Col-1 fiber alignment) as well as epithelial and stromal cells. Finally, that hormones acting on the epithelium modify Col-1 fiber organization in periductal stroma, suggesting a link between hormones and mammographic density.

 

Nothing to Disclose: TP, MM, LS, CS, AMS

14998 4.0000 SAT-0282 A A Novel 3D Model to Study the Link Between Hormonal Exposure and Mammographic Density in Breast Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Reena Mary Thomas*, Adva Eisenberg, Michael Harrison and Larry Gene Moss
Duke University Medical Center, Durham, NC

 

Background: Ectopic ACTH secreting neuroendocrine differentiated metastatic prostate carcinoma tumors are rare. We present a case of ectopic ACTH secreting castrate-resistant metastatic tumor of the prostate and highlight the challenges in management.

Presentation: A 51- year old male with hypertension presented with pain in his chest wall and pelvis. CT chest, abdomen and pelvis showed diffuse mottled sclerosis of his axial and appendicular skeleton. Serum PSA was 295 ng/ml (0-4.0 ng/ml). Prostate biopsy showed Gleason 4+5 prostate adenocarcinoma. He was treated with leuprolide depot, bicalutamide and pamidronate. Two months later, he developed a tender, soft tissue right chest wall mass, axillary lymphadenopathy, and liver lesions. PSA was 4.58 ng/ml and undetectable testosterone.  Chest wall mass biopsy showed carcinoma with neuroendocrine features - small cell carcinoma by morphology. Following 2nd dose of leuprolide depot, he had radiotherapy to the chest wall mass. Two months later, he presented with profound weakness, facial and chest flushing, weight loss, severe hypokalemia and hyperglycemia. Twenty-four hour urine cortisol was 11,786 mcg/24h (15-102 mcg/24h), serum cortisol 63.4 mcg/dl (5-25 mcg/dl), ACTH 206 pg/ml (15-66 pg/ml), PSA 43.45 ng/ml and testosterone 74 ng/dl (175-181 ng/dl). Androstenedione and DHEA-S were not elevated.  He was treated with cisplatin-etoposide, ketoconazole, spironolactone, potassium supplements, and insulin.  He was hospitalized two weeks later with staphylococcal sepsis, treated with IV antibiotics. Subsequently, he reported fatigue, muffled hearing, anorexia, alopecia, muscle weakness and generalized edema.  Circulating tumor cell count was 242, serum chromogranin A 805 ng/ml (n<93 ng/ml), serum ACTH 131 pg/ml and serum cortisol 41.2 mcg/dl. Post 2nd chemotherapy cycle abiraterone acetate was initiated, after stopping ketoconazole. Retrosternal mass biopsy was positive for neuroendocrine markers CD56, pancytokeratin, TTF-1, synaptophysin, chromogranin and CK 20 (focal), negative for PSA – a small cell variant of prostate carcinoma.  Post 3rd chemotherapy cycle, chromogranin A decreased to 393 ng/ml, 24-hr urine cortisol 36.1 mcg/24h, serum cortisol 10.9 mcg/dl, ACTH 113 pg/ml, PSA 23.57 ng/ml and testosterone 17 ng/dl.  He was switched back to ketoconazole due to side effects of abiraterone acetate and initiated on prednisone 7.5 mg po daily. His chemotherapy is ongoing.

Conclusion: This case highlights a rare, early neuroendocrine differentiation of metastatic prostate adenocarcinoma following androgen deprivation therapy into an ectopic ACTH secreting aggressive variant of castrate-resistant metastatic prostate carcinoma. The challenges include chemotherapeutic treatment of the tumor, its excess mineralocorticoid and corticosteroid effects and side effects of treatment, all associated with a high morbidity.

 

Disclosure: MH: Consultant, Dendreon, Speaker, Dendreon, Consultant, Exelixis, Inc., Principal Investigator, Exelixis, Inc.. Nothing to Disclose: RMT, AE, LGM

11332 5.0000 SAT-0283 A Ectopic Secretion of ACTH from a Neuroendocrine Differentiated Metastatic Prostatic Carcinoma – a Rare Phenomenon Presenting Unique Challenges in Management 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Inge Seim*, Patrick Thomas, Penny L. Jeffery, Carina M. Walpole, Adrian C. Herington, Colleen C. Nelson, Lidija Jovanovic, Eliza J. Whiteside and Lisa K. Chopin
QUT, Brisbane, Australia

 

There is rapidly emerging evidence that long non-coding RNAs (lncRNAs) play an important role in cancer. lncRNAs display exciting potential as novel therapeutic and diagnostic or prognostic targets and regulate key processes in cancer progression. We have recently discovered the lncRNA, GHSROS (growth hormone secretagogue receptor opposite strand), which is encoded on the antisense strand of the ghrelin receptor gene. Our initial studies demonstrated that GHSROS increases cell migration in lung and breast cancer cell lines. Here, we expand our studies to investigate the role of GHSROS in prostate cancer, the most common invasive cancer in males and the second most common cause of cancer-related death in men. Using quantitative RT-PCR (qRT-PCR) we demonstrated that GHSROS is expressed and upregulated in clinical prostate cancer specimens. Using the xCELLigence real-time cell analysis system, the effects of stable GHSROS over-expression on cell proliferation and cell migration were measured in the PC3 and DU145 prostate cancer cell lines. GHSROS over-expression significantly increased cell proliferation 1.76 ± 0.18 fold in the PC3 cell line and 1.74 fold ± 0.73 in the DU145 prostate cancer cell line (P<0.01). GHSROS overexpression also increased cell migration (through an 8µm porous membrane) 1.54 ± 0.35 fold in the PC3 cell line and 1.94 ± 0.43 fold in the DU145 cell line (P<0.05) compared to vector controls. Unpublished microarray (Affymetrix Human Gene 1.0 ST) and qRT-PCR validation data in our laboratory revealed that a number of genes related to the immune response are regulated by GHSROS in the MDA-MB231 breast cancer cell line, where GHSROS also increases cell migration. We replicated these findings in GHSROS-over-expressing PC3 prostate cancer cells, demonstrating that immune response genes, including human leukocyte antigen class II genes (HLA-class II), are regulated by GHSROS. We, therefore, hypothesise that GHSROS plays a role in regulating the immune response to cancer cells and may enhance evasion from the immune system. In conclusion, our study indicates that GHSROS has clinical significance in prostate cancer progression, as it is expressed in clinical cases of prostate cancer and stimulates cell proliferation and migration in vitro. GHSROS regulates the expression of genes associated with the innate and adaptive immune system and could enable metastatic cancer cells to evade anti-tumoural and immune responses. GHSROS may present a target for the development of antisense therapies for cancer treatment.

 

Nothing to Disclose: IS, PT, PLJ, CMW, ACH, CCN, LJ, EJW, LKC

12469 6.0000 SAT-0284 A The Long Non-Coding RNA, Ghsros, Promotes Cell Proliferation and Migration, and Repression of Immune Response Genes in Prostate Cancer Cell Lines in Vitro 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Jean Pierre Raynaud*1, Yann Neuzillet2, Frank Giton3, Jean Fiet4, Thierry Lebret2 and Henry Botto2
1university Pierre & Marie Curie, Paris, France, 2Hopital Foch, Suresnes, France, 3APHP CIB CHU Sud Henri Mondor, Creteil, France, 4INSERM IMRB CHU Henri Mondor, Creteil, France

 

INTRODUCTION AND OBJECTIVES: In prostate cancer (PCa) patients, obesity has been associated with worse outcome, especially more frequent biochemical recurrence after radical prostatectomy and low testosterone (<3ng/mL) with tumor aggressiveness, assessed by the predominant Gleason pattern (prdGP). This study aims to compare histological feature with patient’s gonadal status to identify an accurate predictor of high-risk disease before undergoing radical prostatectomy.

METHODS: From a prospective study of 431 PCa patients requiring radical prostatectomy, 296 preoperative sera have been stored at -70°C to assay, in a specialized laboratory in GC-MS, Testosterone (T), bioavailable T (bioT), Dihydrotestosterone (DHT), Δ4-Androstenedione (Δ4), Δ5-Androstenediol (Δ5), Dehydroepiandrosterone (DHEA) and DHEA-sulphate (S-DHEA), Androsterone (ADT), Estradiol (E2), Estrone (E1) and E1-sulphate (S-E1). Gleason score and predominant Gleason pattern (prdGP) were determined in prostate tissue specimens, and crosschecked by two uro-pathologists.

RESULTS: The testosterone GC-MS values were stratified according to T (<3; 3-4; 4-5; 5-6; 6-7 ;>7 ng/mL) leading to 6 groups (N= 27; 39; 63; 72; 35; 60) with an increase in mean T (2.4; 3.4; 4.6; 5.4; 6.4; 8.0 ng/mL), respectively. Parallel increase was observed for bioT (0.97; 1.30; 1.44; 1.50; 1.87; 1.89 ng/mL), DHT (0.19; 0.29; 0.40; 0.53; 0.59; 0.74 ng/mL), and, to a lesser extent, for ADT (0.17; 0.21; 0.18; 0.20; 0.21; 0.24 ng/mL) and for Δ5 (0.51; 0.75; 0.93; 1.06; I.15; 1.38 ng/mL). E2 increased slightly (23; 27; 28; 28; 30; 34 pg/mL). The E2/T ratio went down from 9.8 to 4.2 at the highest T concentrations. The other steroids assessed were stable.

The body mass index (BMI) decreased  (29.9; 27.2; 26.2; 26.0; 25.0; 25.2) from low to high T. When the patients were stratified according to normal BMI <25, n=121, overweight BMI 25-30, n=131 and obese BMI >30, n=44, the mean BMI was 22.7, 27.1, and 32.8, respectively. The prostate weights were similar (49; 46; 52 g).

In the tissue specimens, a slight increase in GS (6.8; 6.9; 7.0) was observed. The incidences of prdGP 4 were 25% in the normal group and 32% in the overweight group: they were statistically different (p=0002, P=0.003) with the incidence of 50% in the obese group. The corresponding hormone levels in each groups were, for T: 5.9; 5.2; 4.6 ng/mL statistically lower in the obese group (p= 0.004 and p=0.04) as well as for DHT: 0.55; 0.47; 0.40 ng/mL (p= 0.0004 and P=0.003). E1 (43 pg/mL) in the obese group was significantly higher (p=0;03) than the 39 and 37 recorded in the normal and overweight groups.

CONCLUSIONS: In diagnosed PCa patients, the pre-operative ratio T/E2 should be used to evaluate the hormonal milieu because it is strongly related to body composition and obesity. Supplementation with testosterone in obese prostate cancer might be useful to reduce the aggressiveness of their cancer.

 

Nothing to Disclose: JPR, YN, FG, JF, TL, HB

14879 7.0000 SAT-0285 A Prostate Cancer Aggressiveness Is Strongly Dependent of Overweight and Obesity and Related to Androgen Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Samantha Rose Lewis*1, James L Mohler2 and Joan Susan Jorgensen3
1University of Wisconsin-Madison, Madison, WI, 2Roswell Park Cancer Institute, Buffalo, NY, 3Univ of Wisconsin, Madison, WI

 

De novo steroid production is usually confined to the gonads and adrenal cortex and is regulated by pituitary gonadotropin hormones. However, intratumoral steroid synthesis was discovered in castration-resistant prostate cancer (CRPC) and is gonadotropin-independent. Despite the aggressive growth fueled by local steroid production, the mechanisms by which intratumoral synthesis is initiated and maintained in CRPC remain unknown. Recently, we reported that Steroidogenic Factor 1 (NR5A1, ADBP4, SF1), a key regulator of steroidogenesis in normal endocrine tissues and normally absent in prostate tissue, was present in prostate cancer cell lines, which included DU145, LNCaP, PC-3, BCaPT10 and BCaPM-T10. Further, we showed that SF1 expression promoted steroidogenesis and tumor growth in prostate cancer cells in vitro, and loss of SF1 expression abolished growth of prostate cancer xenografts in castrated mice. Currently, there is no reliable diagnostic marker to differentiate aggressive from indolent prostate cancer.  Instead, we rely on exam and serum levels of prostate-specific antigen (PSA) to diagnose prostate cancer and these features, Gleason grade, and radiographic tests to stage prostate cancer. However, prostate cancer is a heterogeneous disease, and the prognosis of individual patients remains difficult to predict.  There is a need to identify new biomarkers that improve our ability to distinguish indolent from aggressive prostate cancer to guide clinical decision-making. Based on our previous work, we hypothesized that SF1 is over-expressed in aggressive prostate cancer. To extend our findings from prostate cancer cell lines, we assayed for the presence of SF1 in biopsy samples of prostate disease. SF1 expression was detected in islands of prostate epithelial cells in CRPC, but was not detected in localized prostate cancer or benign prostate hyperplasia samples.  Investigation of expression data from publicly available databases uncovered examples of elevated SF1 expression within CRPC samples. Sections of a prostate tissue microarray (TMA) constructed from radical prostatectomy cores of androgen-stimulated benign prostate hyperplasia and androgen-stimulated prostate cancer and transurethral resection of the prostate cores of CRPC was immunostained. SF1 expression was detected only in a subset of samples of CRPC. Together, these findings suggest that SF1 as a potentially important therapeutic target for, biomarker of, and driving force behind the growth of, CRPC.

 

Disclosure: JLM: Member of advisory committees or review panels, NCCN, Member of advisory committees or review panels, Genomic Health Scientific Advisory Board . Nothing to Disclose: SRL, JSJ

16173 8.0000 SAT-0286 A Steroidogenic Factor 1 is Over-expressed in Castration-Resistant Prostate Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Kokichi Sugano*1, Eri Haneda1, Yoshiaki Matsumura1, Takeshi Inoue1 and Kiyotaka Kawashima2
1Tochigi Cancer Center Research Institute, Utsunomiya, Japan, 2Tochigi Cancer Center Hospital, Utsunomiya, Japan

 

BACKGROUND: Hyperhomocysteinemia is associated with cardiovascular disease and 677T homozygotes of the methylene-tetrahydrofolate- reductase (MTHFR) gene, while the role of hyperhomocysteinemia and MTHFRC677T polymorphism in prostate cancer was unelucidated. Plasma homosysteine levels were higher in males than in females, implying the testosterone regulation of renal cystathionine b-synthase for sex-dependent differences (1,2). OBJECTIVE: A total of 141 patients who underwent transrectal ultrasonography (TRUS) guided needle biopsy were investigated for the C677T polymorphism of the MTHFR gene and plasma homocysteine levels. Of the 141 subjects, 82 subjects were diagnosed as prostatic cancer and 59 subjects as benign disease. In those diagnosed with prostate cancer and underwent total prostatectomy or endocrine therapy, plasma homocysteine levels were serially monitored in 1, 3 and 6 months after initiation of treatment. RESULTS: Plasma homocysteine levels were significantly higher in subjects with prostate cancer than those without malignancy (11.89 ± 0.65 nmol/ml vs. 10.23 ± 0.49 nmol/ml, p=0.0452) and inversely correlated with serum folic acid levels. In comparison with MTHFR genotypes, plasma homocysteine level was the highest in those with 677 T/T than those with C/C or C/T genotypes (p=0.0432) in the prostate cancer, while these differences were not observed in those without malignancy. Receiver operating characteristic (ROC) analysis indicated AUCs for each genotype were 0.7092 for T/T, 0.6268 for C/T and 0.5020 for C/C, respectively, resulting the sensitivity and specificity of the plasma homocysteine 42.86% and 92.86% in 677T/T homozygotes. Serially monitored plasma homocysteine levels did not show a significant decrease in those undergoing total prostatectomy or endocrine therapy.  CONCLUSION: Plasma homocysteine levels were increased in prostate cancer patients with 677T homozygote of the MTHFR gene and not regulated by plasma testosterone levels.

(1) Vitvitsky et al. Am J Physiol Renal Physiol. 2007 Aug; 293(2): F594-600. (2) Prudova et al. Antioxid Redox Signal. 2007 Nov; 9(11): 1875-81.

 

Nothing to Disclose: KS, EH, YM, TI, KK

16350 9.0000 SAT-0287 A Plasma Homocysteine and MTHFR C677T Polymorphism in Prostate Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Yasuhiro Miki*1, Kiyoshi Takagi2, Zhulanqiqige Doe3, Sota Tanaka3, Takashi Suzuki2, Hironobu Sasano2 and Kiyoshi Ito1
1International Research Institute of Disaster Science, Tohoku University, Sendai, Japan, 2Tohoku University Graduate School of Medicine, Sendai, Japan, 3Tohoku University, International Research Institute of Disaster Science, Sendai, Japan

 

Cortisol is a hormone that regulates blood pressure and the immune system in response to physical or emotional stress. Several investigators have suggested that glucocorticoids such as cortisol may also play a role in reproductive physiology. Cortisol and other steroid hormones are synthesized in peripheral target tissues or in endocrine-related cancer tissues from inactive precursors. This mechanism is called intracrine signaling. 11β-Hydroxysteroid dehydrogenase type 2 (11β-HSD2) catalyzes the conversion of cortisol to the inactive metabolite cortisone. In endometrial cancer, 11β-HSD2 activity levels are inversely related to malignancy. However, there are currently no reports regarding how intratumoral cortisol and/or cortisone levels relate to the severity of endometrial cancers. In this study, we examined the levels of cortisol and cortisone in 35 endometrial carcinoma tissue samples (G1, 12; G2, 10; G3 9; serous, 4) and 4 nonpathological endometrial tissue samples with corresponding serum samples. In addition, intratumoral androstenedione and estradiol levels were measured. Steroid levels were measured by liquid chromatography/electrospray tandem mass spectrometry analysis. Informed consent was obtained from all the patients. The research protocol for this study was approved by the Ethics Committee at Tohoku University School of Medicine. The median tissue cortisol level (ng/g) was as follows: nonneoplastic endometrial tissue, 0.15; G1, 0.45; G2, 0.74; G3, 2.03; serous, 1.45. The median tissue cortisone level (ng/g) was as follows: nonneoplastic endometrial tissue, 9.8; G1, 8.1; G2, 7.4; G3, 4.5; serous, 6.1. Intratumoral cortisol level was significantly higher in the G3 and serous patient groups than in the normal, G1, or G2 groups. Relatively low level of cortisone was detected in normal, G1, and G2 samples compared to G3 and serous samples (not significant). The levels of these hormones in circulation did not relate to the malignancy of the endometrial carcinomas. Cortisol levels were significantly correlated with serum cortisone levels but not intratumoral cortisone levels in the endometrial cancers. These findings suggest that intratumoral cortisol may be important for endometrial cancer. The levels of cortisol and cortisone may be regulated in endometrial cancer tissues via an intracrine pathway.

 

Nothing to Disclose: YM, KT, ZD, ST, TS, HS, KI

11695 10.0000 SAT-0288 A Intratumoral Concentration of Stress Hormone, Cortisol in Endometrial Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Jaesung Peter Choi*1, Reena Desai2, David J Handelsman3 and Ulla K Simanainen4
1The University of Sydney, Australia, 2ANZAC Research Institute, Sydney NSW, Australia, 3University of Sydney, Sydney NSW, Australia, 4ANZAC Research Institute, Concord NSW, Australia

 

Inactivating mutations in the phosphatase and tensin homolog (PTEN) gene cause Cowden syndrome, which increases the risk of hormone dependent reproductive cancers. We demonstrated that androgen actions via androgen receptor (AR) protect against experimental breast cancer in mice. Therefore, we hypothesized that a functional AR may reduce PTEN inactivation induced uterine pathology.

To test our hypothesis, uterine pathology was compared between wild-type (WT), complete AR knockout (ARKO), heterozygous PTEN knockout (PTENKO) and combined heterozygous PTEN and complete AR knockout (PTENARKO) female mice (Cre/LoxP system; global deletion). Serum and ovarian steroids were analyzed using liquid chromatography tandem mass spectrometry.

Against our hypothesis PTEN inactivation induced uterine pathology was significantly reduced by AR inactivation as 23% (12/52) of PTENKO mice developed severe macroscopic uterine pathology compared with 4% (1/24) in PTENARKO at a median age of 45 weeks (p=0.03) whereas uterine pathology was absent in WT (n=32) or ARKO (n=11) females. Macroscopic uterine pathologies manifest as increased uterine weight was evident in PTENKO [1690±334mg (mean±SE); n=52] females compared with WT (156±23mg; n=32), ARKO (119±17mg; n=11) and PTENARKO (516±163mg; n=24) (p≤0.007). This could be due to increased ERα expression in PTENKO uterus (confirmed by immunohistochemistry) with expression of the estrogen dependent gene, G6PDH, increased in PTENKO (9.1±3.1;n=9) compared to WT (1.3±0.5;n=7), ARKO (4.6±1.4;n=7) and PTENARKO (4.8±2.1;n=8).

Serum testosterone (T), dihydrotestosterone (DHT) and ovarian estradiol were similar, but serum progesterone (P4) was significantly increased in PTENKO (17±2.2ng/ml; n=28) compared to WT (4.4±0.7ng/ml; n=18), ARKO (3.5±0.9ng/ml; n=8) and PTENARKO (5.4±1.2ng/ml; n=16) consistent with more corpora lutea (CL) in PTENKO ovaries (10.5±1.7; n=4) compared to WT (6.3±0.9; n=4), ARKO (5±0.6; n=4) and PTENARKO (4.8±0.9; n=4) (p≤0.05) although P4 is thought to protect against uterine cancer.

Our results demonstrated AR mediated androgen actions protect against PTEN inactivation induced uterine pathology possibly by altering ERα expression in the uterus.

 

Nothing to Disclose: JPC, RD, DJH, UKS

12547 11.0000 SAT-0289 A Androgen Receptor Inactivation Reduces PTEN Inactivation Induced Endometrial Cancer By Decreasing Estrogen Sensitivity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Surya Narayan Mulukutla*1 and Sonali Thosani2
1Baylor College of Medicine, Houston, TX, 2UT-MD Anderson Cancer Center, Houston, TX

 

Background: Gastrointestinal stromal tumors (GIST) are neuroendocrine tumors with a broad clinical presentation. Rarely, they are associated with a paraneoplastic phenomenon of tumour related hypoglycemia. We describe the fascinating case of a patient with GIST whose evidence of disease progression was characterized by episodes of recurrent, persistent hypoglycemia.

Case Presentation:  A 58 year old Caucasian woman was diagnosed with metastatic GIST tumor involving small bowel and liver, seven years prior to her current presentation.  Two years prior to the diagnosis of GIST, patient was diagnosed with Type 2 Diabetes. ell controlled on oral agents. Patient was tried on various chemotherapeutic regimens and had stabilization of disease with Nexavar for the last three years.  During treatment, she experienced a weight loss of 50 pounds and did not require any medications to control diabetes; however, due to worsening renal function, Nexavar was stopped. Six weeks after stopping Nexavar, she had severe persistent hypoglycemia (glucose <40 mg/dL), occurring both fasting and postprandially. Inpatient hospitalization with 72 hour fast revealed severe hypoglycemia occurring within 3 hours of fasting.   At a serum glucose level of 32 mg/dL, patient was noted to have C-peptide level 0.2 ng/ML (0.9-7.1), Insulin level  <2.0 mIU/mL (2-29), negative sulfonylurea screen, GH 0.21 (0.0-3.61), IGF-1 30 ng/ML (45-173), IGFII 578 ng/mL (288-736). In response to 1 mg intravenous glucagon, her glucose increased to 72 mg/dL, and 93 mg/dL at 30 and 60 minutes, respectively. Due to her response to glucagon in the presence of undetectable insulin and C-peptide level, we confirmed that her hypoglycemia was due to an IGF-II mediated process.  CT scans of her abdomen and pelvis confirmed progression of disease involving the liver. After review of the current literature, we chose to treat her hypoglycemia with oral Methylprednisolone  0.5 mg/kg and patient was restarted on Nexavar to treat underlying tumor. She had complete resolution of hypoglycemia while on Methylprednisolone, but her kidney and liver dysfunction progressed on Nexavar. Patient died with liver failure a few weeks later.

Conclusion:

GIST induced hypoglycemia is a rare occurrence with a very poor prognosis.  Treatment of underlying tumor is cornerstone of therapy though steroids are usually required while awaiting response to chemotherapy.  The pathognomonic feature of an elevated IGF-II: IGF-1 ratio (>10) has been previously described and was present in our patient.  Through autocrine and paracrine mechanisms, IGF-II stimulates tumor growth and hypoglycemia can be an interesting initial symptom suggestive of disease progression.

 

Nothing to Disclose: SNM, ST

12644 12.0000 SAT-0290 A Hypoglycemia As the Initial Presentation of Gastrointestinal Stromal Tumor Progression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Lorna Gilligan*, Anne-Marie Hewitt, Angela E Taylor, Dion Morton and Paul A Foster
University of Birmingham, Birmingham, United Kingdom

 

Globally, colorectal cancer (CRC) is the fourth leading cause of cancer death and rates continue to rise. Epidemiological evidence suggests estrogens have both protective and proliferative effects in CRC (1). However, little is known about estrogen activation enzymes, such as steroid sulfatase (STS) and 17β-hydroxysteroid dehydrogenases (17βHSD), in CRC, and how these enzymes are regulated in the colon. Thus, this project investigated how estrogens affect CRC growth kinetics and whether inflammatory cytokines - known to be involved in colonic tumorigenesis - alter estrogen activation pathways. Estrogenic enzyme expression and activity in CRC cell lines and human tissue were characterized using qRT-PCR, proliferation assays and radiolabelled activity assays. Estrogen metabolism in CRC cells was further analysed via a novel UPLC-MS/MS technique to quantify both estrogens and their sulfates simultaneously.

Results showed that 17βHSD2 mRNA expression is reduced in human CRC (n= 43, p=0.001). Despite no alteration in STS mRNA expression, STS activity was increased in CRC (n=59, p=0.013). Average STS activity rose from 2.68nmol/mg/h to 3.15nmol/mg/h. To generate a cell line model representative of estrogen metabolism in human CRC, the CRC cell line HCT116 was transfected to overexpress either STS or 17βHSD2. STS overexpression increased, whereas 17βHSD2 overexpression decreased, cell proliferation (p<0.01). The inflammatory mediators TNFα and/or IL-6 altered estrogen metabolism in CRC cell lines by reducing 17βHSD2 mRNA and significantly increasing STS activity (Colo205 p<0.01, Caco-2 p<0.001). Intriguingly, despite STS activity increasing, STS mRNA expression was unaltered by TNFα and IL-6 treatment.

Human CRC tissue favors estrogen activation via STS activity and loss of 17βHSD2. CRC cell lines overexpressing STS have elevated proliferation, whereas growth rates in cells overexpressing 17βHSD2 are attenuated. The inflammatory mediators TNFα and IL-6 reduced 17βHSD2 expression and increased STS activity: this altered estrogen metabolism mirrored that seen in human CRC tissue. This suggests inflammation may regulate estrogen metabolism in CRC. In conclusion, an increase in estrogen activation promotes CRC proliferation and this effect may be regulated by TNFα and IL-6. Thus, targeting estrogen activation pathways may be of clinical benefit to patients with CRC.

 

Nothing to Disclose: LG, AMH, AET, DM, PAF

14657 13.0000 SAT-0291 A Inflammation Regulates Estrogen Activation in Colorectal Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Leticia F. Leal*1, Eva Szarek1, Sonir Roberto Antonini2 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2Ribeirão Preto Medical School - University of São Paulo, Ribeirão Preto, Brazil

 

PDE8B and PRKAR1A mutations have been associated with bilateral adrenocortical hyperplasia (BAH) in humans; complete absence of Prkar1a in the adrenal cortex of mice leads to BAH and tumor formation. However, haploinsufficiency of Prkar1a in mice do not result in adrenal abnormalities. To examine a potential additive effect of Prkar1a and Pde8b deficiency we crossed two mouse strains: Pde8b-/-(KO)(C57BL/6N-Pde8btm1a(KOMP)MBP) and Prkar1a+/-mice to generate double heterozygous mice Prkar1a+/-;Pde8b+/- (herein referred to as RP mice). Adrenals from female wild-type (WT), Pde8b+/-(+P), KO and RP mice were collected at 6, 9 and 12 months (mo; n=3-5/genotype). Histology revealed progressive subcapsular hyperplasia in RP mice starting at the age of 6 months. Dexamethasone suppression test (DST) was performed to determine whether mice displayed hypercorticoteronaemia.. RP and KO mice had higher basal corticosterone levels than WT (201 x 140 and 315 x 140 ng/mL, respectively); however, following DST suppressed corticosterone levels and cortical atrophy both in KO and WT mice. Apoptotic cells, assessed by positive staining for cleaved Caspase3 were detected within the cortex of all mice following DST; RP mice showed 73% fewer, and +P mice showed 140% more, Caspase3+ cells than WT. To determine the mechanism leading to early hyperplasia, as shown by histology, cellular proliferation was assessed by Ki67 immunostaining; Ki67+ cells decreased in RP adrenals. We further assessed the relationship between Pde8b/Prkar1a ablation and adrenal steroidogenesis. RP mice presented increased mRNA levels of SF1 at 6mo and 9mo as well as of Star, Cyp11a and Mc2r at 6mo that were correlated with hypercorticosteronaemia. Wnt pathway activation, a known mediator of BAH formation is humans, was evaluated by Wnt and β-catenin expression; Wnt4 was decreased in RP adrenals and β-catenin expression was expanded to zona fasciculata, and localized to cytoplasm and nucleus in 9mo RP and KO mice. In conclusion, we show that combined Pde8b and Prkar1a haploinsuffiency results in BAH as well as increased steroidogenesis and Wnt pathway activation in mice, providing a model of how these genes may work together in predisposition to BAH in humans.

 

Nothing to Disclose: LFL, ES, SRA, CAS

16489 14.0000 SAT-0292 A Combined Pde8b and Prkar1a Haploinsufficiency: Effects on Steroidogenesis and Signaling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Yerong Yu*1 and Dongmei Chen2
1West China Hospital, Sichuan University, Chengdu, China, 2West China Hospital, Sichuan University, Chendu, China

 

Background:

Cushing’s syndrome (CS) comprises the clinical manifestations of exposure to elevated glucocorticoid hormones, either from exogenous sources or endogenous overproduction by the adrenal glands. CS caused by Corticotropin-releasing hormone (CRH) production and adrenocorticotropin(ACTH) production, is rare.  Hear we describe the clinical presentation, course, laboratory values and pathologic findings of a patient with acute-onset Cushing syndrome 6 months after removal of thymic and lung neuroendocrine carcinomas.

Clinical Case

A 27-Year-old Chinese male presented with fever, cough and back pain for 2 weeks. The chest CT imaging revealed a 8.5´3.8cm tumor at mediastinum and a 3.5 x 2.0cm tumor at right lung. The operation was performed and the tumors were removed. Histopathology demonstrated a neuroendocrine carcinoma with positivity for ACTH reactivity but the patient revealed no clinical features indicating CS. The patient received adjuvant chemotherapy and was in remission for 6 months. Then he reported acute onset of redness and swelling of his face, edema of the ankles, muscle weakness, wide purple striae (axillary, lower abdomen, groin area), and 10kg weight gain within two months. Laboratory evaluation demonstrated an extremely elevated urinary cortisol secretion (1104.6ug/24hr and 821.9 ug/24hr), morning serum cortisol did not suppressed after 1mg and 8mg Dexamethasone. Serum ACTH was elevated (79.53ng/L) inspite of hypercortisolism, confirming ACTH-dependent CS. Pituitary MRI showed an equivocal enlargement of the pituitary and the chest CT scanning revealed an irregular 5.7cm x2.0cm mass in the anterior mediastinum. He underwent repeat resection and the histopathology demonstrated a recurrent neuroendocrine carcinoma with the same features as the previous lesion but this time both ACTH and CRH were positive in numerous cells. Normalization of serum ACTH after surgery was compatible with ectopic ACTH/CRH production. Three month after his second surgery, the Cushingnoid features were gradually disappeared, he experienced a 5kg weight loss. Clinical presentation, cortisol metabolism, and pituitary imaging were normal at a visit one year after the second operation.

Clinical lessons:

The present case met the ectopic ACTH/CRH syndrome diagnosis and the clinical lessons as follows: 1) The patient had dual carcinoid tumors which located at two irrelevantly organs but with the identical phenotype.  2) Even though histopathology demonstrated the neuroendocrine carcinoma with positivity for ACTH reactivity at the first surgery but the patient revealed no evidence indicating CS. the patient presented with CS 6 months after first surgery as the tumor tissue relapsed, which may related with the tumor microenvironment changed by the surgery.

 

Nothing to Disclose: YY, DC

13513 15.0000 SAT-0293 A Acute-Onset Cushing's Syndrome 6 Months after Removal of Thymic and Lung Neuroendocrine Carcinoma: From Ectopic ACTH/Crh 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Saori Itoshima*1, Akiko Yuno1, Tomomi Kato1, Hidetoshi Kamada1, Akemi Ikota1, Takeshi Usui2, Akira Shimatsu2 and Shigeki Koizumi1
1Kin-i-kyo Chuo Hospital, Sapporo, Japan, 2National Hospital Organization Kyoto Medical Center, Kyoto, Japan

 

Background: Parathyroid Carcinoma is a rare cause of refractory hypercalcemia, which is the most common cause of death in these patients. Denosumab, a humanized monoclonal antibody inhibiting receptor activator of nuclear factor κB ligand (RANKL), has been introduced for the treatment of osteoporosis and bone metastasis of solid tumors, but is rarely used for parathyroid hormone(PTH)-induced hypercalcemia.

Clinical Case: A 39-year-old Japanese woman was referred to our hospital at the age of 37, because of frequent episodes of hypercalcemia. Her medical history was remarkable for primary hyperparathyroidism with the resection of left parathyroid adenoma 4 years earlier at another institution. Subsequent histological analysis revealed the presence of parathyroid carcinoma. She underwent re-operation and received irradiation, but serum calcium levels rose gradually. Computed tomography scan of her lung showed multiple small metastases 19 months before admission. Her hypercalcemia initially responded to the standard therapy such as the calcimimetic cinacalcet and bisphosphonate, but ultimately became unmanageable. On admission, laboratory tests were consistent with primary hyperparathyroidism, elevated levels of serum calcium 13.3 mg/dL (reference range, 8.5-10.2 mg/dL), PTH 1920 pg/mL (reference range, 10-65 pg/mL), and TRACP-5b >1500 mU/dL (reference range, 125-420 mU/dL). Hybrid single photon emission computed tomography/computed tomography (SPECT/CT), using 99mTc-sestamibi (MIBI) was performed and showed a mass of 2cm in the hypopharynx. Genetic analyses of the HRPT2 (CDC73) and MEN1 were performed. The interval of iv zoledronate administration was shortened, and the dose of cinacalcet was increased to 150 mg daily. However, Ca levels were further elevated to 15.1 mg/dL, showing refractoriness to the treatments with cinacalcet, iv fluids, iv calcitonin, and iv bisphosphonate. Given the reported hypocalcemic side effects of denosumab, 120mg was administered on 21st day of hospitalization. Her intractable hypercalcemia dramatically improved, and Ca levels fell from 15.1 to 10.1 mg/dL in 10 days and remained between 8.5 and 12.6 mg/dL for 1-2 months. Thereafter, she continued to receive cinacalcet 75mg daily, and received denosumab at the doses of 120mg per 4 to 15 weeks as needed when Ca levels rose above the reference range on measurements. TRACP-5b levels fell to 147 mU/dL, indicating potent suppression of bone turnover, while PTH levels remained elevated at 2560 pg/ml. She was able to continue her work without hospitalizations for the last 6 months.

Conclusions: Present case demonstrates that denosumab is very effective for the management of refractory hypercalcemia in metastatic parathyroid carcinoma.

 

Nothing to Disclose: SI, AY, TK, HK, AI, TU, AS, SK

14372 16.0000 SAT-0294 A Denosumab for the Treatment of Refractory Hypercalcemia in Metastatic Parathyroid Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Andrea Havens Ramirez*1, Ruth A Niven2, Bradford J Wood1, Richard Chang3, Stephen J Marx4 and Michael T. Collins5
1National Institutes of Health, Bethesda, MD, 2University of Tel Aviv, Israel, 3Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD, 4National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, 5National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD

 

Background:  Parathyroid carcinoma is a rare and difficult to treat disease.  New treatment modalities, including radiofrequency ablation and the RANKL inhibitor denosumab have been reported individually, but not together. (1, 2)

Clinical case:  A 58-year-old man was referred to our center with metastatic parathyroid carcinoma that was unable to be localized.  On arrival his calcium was 4.5 mmol/L (normal 2.05- 2.50 mmol/L) and PTH 2600 pg/mL (normal 15-65 pg/mL) with creatinine 4.7 mg/dL (normal 0.77-1.19 mg/dL). 

Prior treatment included resection of the right inferior parathyroid gland 3 years earlier with pathology consistent with an adenoma, but without resolution of hypercalcemia.  One year later a second neck exploration identified metastatic parathyroid carcinoma in a lymph node.  A third neck exploration 6 months later with right thyroid lobectomy and excision of paratracheal lymph nodes had no significant effect on PTH (>1,000 pg/ml) or calcium.  The only finding on imaging studies was liver lesions thought to be hemangiomas.  Calcium was intermittently controlled with bisphosphonates until renal function declined.  He did not tolerate cinacalcet.

On arrival to our institution, he was treated with saline hydration followed by 60 mg of denosumab.  There was no response and one week later he received 120 mg of denosumab after which there was a marked decrease in calcium, magnesium, and phosphorus, eventually requiring intravenous, then oral supplementation of each.  In parallel, creatinine returned to the patient’s baseline level of 1.5 mg/dL, but PTH rose to 3000 pg/mL.  In the face of normalization of renal function, the patient developed a hyperchloremic metabolic acidosis with hyperkalemia, possibly due to denosumab-induced inhibition of bone turnover and resultant loss of the buffering capacity of the skeleton.

Imaging studies found no definite parathyroid disease, but the diagnosis of hepatic hemangiomas was questioned.  Hepatic venous sampling showed a two-fold elevation in PTH levels relative to peripheral values, consistent with hepatic metastases.  Multimodality image fusion-guided radiofrequency and then microwave ablation was performed in two sessions with subsequent fall in parathyroid hormone levels from >3,000 to 200 pg/mL.  

Thirty days following the last denosumab dose the patient still required oral calcium supplementation and renal function remained at baseline.  One week following radiofrequency ablation parathyroid hormone levels remained stable.

Conclusion:  This case demonstrates the utility of combined denosumab with microwave and radiofrequency ablation to control metastatic parathyroid carcinoma.  It also supports a role for osteoclast-mediated bone turnover in calcium, phosphate, and magnesium homeostasis, as well as the role of skeleton in maintaining acid base status.

 

Nothing to Disclose: AH, RAN, BJW, RC, SJM, MTC

14708 17.0000 SAT-0295 A Successful Palliation of Metastatic Parathyroid Carcinoma with Denosumab and Microwave and Radiofrequency Ablation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Maria Batool*1, Ameer Khowaja2 and Sidney A Jones3
1University of Minnesota Medical Center, Minneapolis, MN, 2Hennepin County Medical Center, Minneapolis, MN, 3Ridgeview Medical Center, Chaska, MN

 

Introduction

Pancreatic islet cell tumors presenting with signs and symptoms of hypoglycemia typically produce excess insulin or both insulin and proinsulin. These tumors are generally associated with spontaneous hypoglycemia, though in rare cases, can present with reactive hypoglycemia. We present a case of a female with no family history of MEN syndrome and symptoms of severe reactive hypoglycemia in the postpartum period due to a proinsulinoma.

Case Presentation

A 31 year old postpartum woman was referred for evaluation of recurrent hypoglycemia.  She had an uneventful full term pregnancy. In the postpartum period she experienced symptoms of dizziness, confusion, and perioral and hand tingling. Her symptoms were most noticeable after meals. One week prior to her endocrinology visit she had an episode of altered mental status, pallor and diaphoresis two hours after breakfast. Point of care blood glucose measured by emergency responders was 20 mg/dL. She was given oral glucose tablets with resolution of symptoms and was then sent to the emergency room for management.

Initial lab work in the emergency room was notable for serum glucose of 66 mg/dl but was otherwise unrevealing. A referral was made to endocrinology for further evaluation. Work up included normal serum electrolytes, cortisol, liver, kidney, and thyroid function tests. Mixed meal tolerance study showed:  baseline- glucose 57 mg/dL, insulin 9.2 µIU/mL;  1 hour-glucose 49 mg/dL, insulin 39.3 µIU/mL; 2 hours – glucose 56 mg/dL, insulin 13.2 µIU/mL;  3 hours- glucose 80 mg/dL, insulin 7.2 µIU/mL.  Repeat  fasting lab work revealed  glucose 72 mg/dL, insulin 8.7 µIU/mL (2.6-24.9 µIU/mL), C-peptide 1.8 ng/mL (1.1-4.4 ng/mL), proinsulin 100 pmol/L (3-20 pmol/L),  and undetectable insulin antibodies.  The woman was started on acarbose to try to ameliorate her symptoms but she continued to have postprandial symptoms, most obvious to her after her breakfast meal.  Labs drawn after a 17 hour fast yielded no hypoglycemia with proinsulin level of 66 pmol/mL with normal insulin and C-peptide levels. Acarbose was discontinued with her work up continuing. One hour postprandial proinsulin level was 240 pmol/L, insulin of 36.2 µIU/mL and corresponding glucose of 30 mg/dL.

Abdominal CT with contrast showed a 1 cm nodule in the ventral aspect of the pancreatic tail consistent with a neuroendocrine tumor. She underwent laparoscopic distal pancreatectomy with pathology revealing islet cell tumor measuring 1.1 x 1.0 x 0.8 cm with no increased mitosis. Her symptoms resolved post operatively with no symptoms of hypoglycemia.

Conclusion

Insulinoma or proinsulinoma are generally associated with spontaneous hypoglycemia.  We present a case of a proinsulinoma presenting with signs and symptoms of reactive hypoglycemia in the postpartum period. This case illustrates the fact that symptoms of reactive hypoglycemia can, in rare cases, be caused by islet cell tumors.

 

Nothing to Disclose: MB, AK, SAJ

15049 18.0000 SAT-0296 A Proinsulinoma Presenting with Reactive Hypoglycemia in a 31 Year Old Postpartum Female 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Shay Bracha1, Jacob Anthony Fischer2, Cheri Peyton Goodall3, Austin Viall1 and Patrick Everett Chappell*1
1Oregon State University College of Veterinary Medicine, Corvallis, OR, 2Oregon State University, Corvallis, OR, 3Oregon State University, College of Veterinary Medicine, Corvallis, OR

 

Osteosarcoma is the most common skeletal tumor in dogs, sharing many characteristics with the disease in humans. An increasing body of evidence suggests an important role for five hydroxytryptamine (serotonin/5HT) in bone physiology. Osteoblasts, osteocytes, and osteoclasts express functional 5HT receptors (5HTR) that have been shown to play a critical role in bone modulation, dependent on gut-derived serotonin. We recently demonstrated that the receptor isoform 5HTR2A is present in canine osteosarcoma cell lines, and that its signaling is altered in comparison to normal osteoblasts. Additionally, like many malignant tumors, osteosarcomas have been shown to synthesize and secrete neuroendocrine peptides, many of which elicit effects on tumor proliferation. We have found that the canine osteosarcoma cell lines COS and HMPOS express the gene for gonadotropin-releasing hormone (GnRH), and further, that they secrete GnRH into the culture media. Within the hypothalamus, GnRH release can be stimulated by the neuropeptide kisspeptin/metastin (Kiss1), a factor initially characterized in several cancers, and this effect can be modulated by circulating ovarian estradiol (E2). We sought to determine if the functional relationship among these reproductive axis hormones was recapitulated in osteosarcoma cells, potentially contributing to tumor regulation. Following confirmation of the presence of gnrhr, gpr54 and esr1/esr2 expression in excised canine osteosarcomas and established tumor cell lines, we found that 10nM kisspeptin treatment rapidly (~45min) stimulated GnRH secretion from COS and HMPOS cells, an effect that was potentiated by 1nM E2 pre-treatment. Further, our studies revealed that exposure of osteosarcoma cell lines to GnRH, kisspeptin, and E2 all potently increased expression levels of 5HTR2A after 4 hours. Pre-treatment of COS cells with these reproductive axis hormones led to differential responsiveness to 5HTR2A antagonism, as determined by evaluation of cell viability. Taken together, these studies suggest that at least in the dog, osteosarcoma is responsive to locally-produced endocrine neuropeptides and ovarian steroids, which may then act in an autocrine or paracrine fashion to affect tumor cell viability via modulation of serotonin receptor levels. Therefore, targeting these pathways may represent novel therapeutic targets to treat osteosarcomas in veterinary and human medicine.

 

Nothing to Disclose: SB, JAF, CPG, AV, PEC

16395 19.0000 SAT-0297 A Modulation of Serotonin Receptor Expression in Canine Osteosarcoma By Hormones of the Reproductive Axis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Naoko Hashimoto*, Eri Komai, Masanori Fujimoto, Takashi Kohno, Akina Shiga, Akitoshi Nakayama, Tomoko Takiguchi, Seiichirou Higuchi, Ikki Sakuma, Hidekazu Nagano, Sawako Suzuki, Koutaro Yokote and Tomoaki Tanaka
Chiba University Graduate School of Medicine, Chiba, Japan

 

BACKGROUND: Synovial sarcoma is a soft tissue type of malignant tumor that arises from transformed cells of mesenchymal origin, constituting 8-10% of all sarcomas. It is known to occur typically from synovium near the joints of extremities and occasionally in other regions of the body such as lung and vaginal wall. Importantly, SYT–SSXfusion gene resulting from the chromosomal translocation t(X;18)(p11;q11) has been shown to be detected in almost all synovial sarcomas. Here, we report a 26-year-old female of synovial sarcoma in fallopian tube, associated with ectopic renin secretion from tumor presenting with abdominal pain, hypokalemia and secondary hypertension.

Case Reports: A 23-year-old woman was transferred to our hospital because of acute abdominal pain. She was diagnosed as hemorrhagic shock due to a right adnexal mass and then emergency operation was performed. The pelvic mass arising from the right fallopian tube, a size of approximately 14 cm, was resected. The histopathological findings showed biphasic pattern consisted of epithelial like cells and spindle cells. In addition, genetic analysis of tumor detected a fusion gene transcript of synovial sarcoma translocation (SYT) gene from chromosome 18 and synovial sarcoma X chromosome breakpoint 1 (SSX1) gene, confirming a diagnosis of synovial sarcoma. Despite the surgical resection, the abdominal tumor had recurrence and gradually enlarged after the initial operation. Although it partially responded to chemotherapy, the tumor acquired resistance to the treatment with anti-cancer drugs. Intriguingly, she presented severe hypertension with hypokalemia in accordance with tumor recurrence, and endocrinological examination clarified that high levels of plasma renin activity with the elevation of serum aldosterone concentration, resulted in secondary hypertension. Indeed, immunohistochemical as well as gene expression analysis by RT-qPCR using tumor tissue samples revealed that renin was highly expressed in tumor and renin-producing tumor cells increased with reasonable progression of hypertension in clinical course. Consistently, her blood pressure and serum potassium level was rapidly normalized in response to the administration of 4mg of candesartan.

Conclusion: Thus, we first describe a rare case of renin-producing synovial sarcoma with  SYT–SSX mutation arising from the fallopian tube.

 

Nothing to Disclose: NH, EK, MF, TK, AS, AN, TT, SH, IS, HN, SS, KY, TT

16781 20.0000 SAT-0298 A A Rare Case of Renin Producing Synovial Sarcoma in Fallopian tube, Complicated with Secondary Hypertension 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0279-0298 4887 1:00:00 PM Hormone Dependent Tumors Poster

Leandro Venturutti*1, Rosalia Ines Cordo Russo2, Patricio Yankilevich3, Robert H Oakley4, Tim H-M Huang5, Roxana Schillaci6, John A Cidlowski7 and Patricia Virginia Elizalde2
1Instituto de Biologia y Medicina Experimental - CONICET, Buenos Aires, Argentina, 2Instituto de Biología y Medicina Experimental (IBYME-CONICET), Buenos Aires, Argentina, 3IBIOBA (CONICET) - MPSP, Buenos Aires, Argentina, 4National Institute of Environmental Health Sciences, Research Triangle Park, NC, 5University of Texas Health Science Center, San Antonio, TX, 6Instituto de Biología y Medicina Experimental, CONICET, Buenos Aires, Argentina, 7NIEHS/NIH, Research Triangle Pk, NC

 

Breast cancer (BC) displaying gene amplification and/or overexpression of ErbB-2 (ErbB-2-positive subtype), a member of the ErbBs family of receptor tyrosine kinases, is associated with increased metastatic potential and poor prognosis. The most commonly used therapeutic option for ErbB-2-positive BC is the antibody trastuzumab (TZ). However, many patients show de novo or acquired TZ resistance. On the other hand, increasing evidence has revealed the involvement of microRNAs (miRNAs) in BC cancer growth and metastasis. We previously identified a novel role for miR-16 as a tumor suppressor in progestin-induced BC progression (1). We also reported that miR-16 is up-regulated upon TZ treatment in TZ-sensitive, but not in TZ-resistant BC cell lines (2). In addition, we showed that miR-16 overexpression could serve as an alternative therapy for TZ-resistant BC, and that miR-16-induced cyclin E (CCNE) down-regulation could account for some of its antiproliferative effects (2). Here, our first aim was to elucidate the mechanism by which TZ up-regulates miR-16 expression in TZ-sensitive BC cells. Recruitment of c-Myc to its response elements (E-boxes) in the DLEU2 (miR-16 host gene) proximal promoter has been found by us and others to be a mechanism underlying miR-16 repression. Our chromatin immunoprecipitation studies showed that TZ blocked c-Myc loading at the miR-16 promoter, thereby increasing miR-16 expression. In addition, TZ repressed c-Myc expression. Implicated in these effects was inhibition by TZ of the Phosphatidylinositol 3-phosphate (PI-3K)/AKT and p42/p44 mitogen-activated kinases (MAPK) pathways, which control c-Myc transcriptional activity and stability by modulating its phosphorylation status. Interestingly, TZ was unable to block c-Myc recruitment to the DLEU2 promoter or to induce c-Myc downregulation in cells with intrinsic or acquired resistance. Our second aim was to identify novel miR-16 targets which, along with CCNE, could account for miR-16 effects on BC growth. We performed a whole-genome gene expression microarray using ErbB-2 overexpressing BC cells transfected with a miR-16 precursor. Among the top down-regulated genes, we found cyclin J (CCNJ) and FUSE Binding Protein 1 (FUBP1), both of which were predicted as miR-16 targets by bioinformatics analysis. TZ induced CCNJ and FUBP1 down-regulation in TZ-sensitive BC cells, but not in unresponsive cells. In addition, silencing CCNJ or FUBP1 by using siRNAs abrogated proliferation of TZ-sensitive and -resistant BC cells. Our study demonstrates that TZ enhancement of miR-16 expression is mediated by c-Myc, and identifies two novel miR-16 targets underlying its antiproliferative effects.

 

Nothing to Disclose: LV, RIC, PY, RHO, THMH, RS, JAC, PVE

11236 1.0000 SAT-0318 A Tumor Suppressor Mir-16 Mediates Trastuzumab Therapeutic Effects in Breast Cancer Via Its Novel Targets, Cyclin J (CCNJ) and Fuse Binding Protein 1 (FUBP1) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0318-0329 4889 1:00:00 PM Therapies for Cancer Poster

Darshan Shah*1, David S. Yatsonsky II1 and Raj Kumar2
1The Commonwealth Medical College, Scranton, PA, 2The Commonwealth Med Coll, Scranton, PA

 

Acute Lymphoblastic Leukemia (ALL) is one of the most common pediatric cancers. Of the children that are diagnosed, approximately 80% are cured with a 5 year survival between 70-83%. However, data for adults is far less promising with cure rates below 40% and 5 year survivals under 33%.  Because of their lymphocytic actions, glucocorticoids (GCs) such as dexamethasone and prednisolone are included in many therapeutic regimens for the treatment of various forms of leukemias and lymphomas. Although a significant number of acute lymphoblastic leukemia patients respond well to GCs, some reveal primary GC resistance, and those sensitive to GCs almost exclusively develop secondary resistance after prolonged GC therapy. GCs work by inducing apoptosis in the leukemic cells via the intrinsic apoptotic pathway. Though the exact mechanism of resistance to GCs in leukemia is not known, large clinical surveys suggest a correlation between functional glucocorticoid receptor (GR) expression levels and primary GC sensitivity and prognosis. There are reports suggesting anti-proliferative effects of estrogen receptor-β (ERβ) in epithelial breast cancers. Since ERβ is also present in blood leukocytes and the thymus,  in this study, we determined whether an ERβ agonist, diarylproprionitrile (DPN) could kill leukemic cells First, using western blot analysis we confirmed the expression of  ERβ in both CEM-C1-15 (GC resistant) and CEM-C7-14 (GC sensitive) leukemic cells. Further, when cells were treated with different concentrations of DPN (1μM, 10μM, and 100μM) with and without 1μM Dexamethasone, there was a significant cell death observed only in CEM-C1-15 resistant cells after 72h treatment with 100μM DPN and 1μM Dex combined. As expected, CEM-C7-14 sensitive cells showed significant cell death with 1μM Dex alone whereas CEM-C7-15 cells were non-responsive to similar Dex treatment. Interestingly, both cells failed to respond to DPN treatment alone. Together, these data suggest that ERβ and GR may be synergizing to restore Dex sensitivity in GC- resistant leukemic cells. Future studies are needed to determine the underlying mechanisms.

 

Nothing to Disclose: DS, DSY II, RK

14142 2.0000 SAT-0319 A Treatment of Estrogen Receptor β Agonist Restores Dexamethasone Sensitivity in Steroid Resistant Leukemic Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0318-0329 4889 1:00:00 PM Therapies for Cancer Poster

Claudia Pivonello*1, Mariarosaria Negri1, Maria Cristina De Martino1, Maria Napolitano2, Cristina de Angelis1, Francesco Izzo2, Annamaria Colao1, Leo J. Hofland3 and Rosario Pivonello4
1Università Federico II, Naples, Italy, 2National Cancer Institute, G. Pascale Foundation, Naples, Italy, 3Erasmus Medical Center, Rotterdam, Netherlands, 4Federico II University, Naples, Italy

 

The mTOR and IGF/insulin signaling pathways are frequently dysregulated in HCC. Cytotoxic activity of mTOR inhibitors (mTORi) has been demonstrated in experimental models of HCC. However, early clinical studies showed that mTORi alone have modest antitumor activity in patients with advanced HCC. IGF/insulin-dependent Akt activation, via IGF1R and IR activation, has been suggested as potential mechanism of the mTORi resistance in HCC. The aim of this study was to evaluate the expression of mTOR and IGF/insulin pathway components and the effects of mTORi alone and in combination with the dual IGF1R/IR inhibitor, OSI-906, on cell proliferation, secretion, migration and invasion in two human HCC cell lines, the HepG2 and HuH7. The expression of mTOR and IGF/insulin pathways components were evaluated by qRT-PCR. The effect of RAP and OSI-906 and their combination (RAP 10-10M and OSI-906 10-6M) was evaluated after 3 days on a) cell proliferation, measured by DNA assay; b) cell secretion, by evaluation of AFP concentrations, measured by CLIA assay; c) cell cycle, evaluated by FACS; d) cell migration, evaluated by Scratch assay, e) cell invasion, evaluated by Matrigel assay and signaling pathways, evaluated by western blot. Both cell lines express mTOR components, IGF1R and IR and high levels of IGF2. In both cell lines, cell proliferation was inhibited by RAP in a dose depending manner with a maximal effect at 10-10M (~40%, p<0.0001) and by OSI-906 only at 10-6M (~15%, p<0,01), while the combination was more potent (p<0.001) than single agents showing additive effect. AFP secretion was significantly suppressed after single agents treatment but the combined treatment did not show any additive effect; cell cycle was blocked in G0/G1 phase by OSI-906 (p<0.01), but not by RAP whereas the combination showed an additive effect (p<0.001). In HuH7 cell line, cell migration was inhibited by OSI-906 (~35%, p<0.001) but not by RAP, but the combination (~47%, p<0.0001) showed an additive effect, whereas cell invasion was blocked by RAP (~60%, p<0.0001) and OSI-906 (~47%, p<0.0001) and by combination (~67%, p<0.0001). HepG2 cells did not show invasion capability and both RAP and OSI-906 did not have any effect on migration. Preliminary data on cell signaling demonstrated inhibition of ERK1/2, Akt and p70S6k activation after combined RAP and OSI-906 administration in HepG2. In conclusion, the results of the current study data provide the evidence that combination of RAP and OSI-906 shows synergistic inhibition of cell proliferation and cell cycle block preventing Akt activation with combined therapy in experimental models of HCC.

 

Disclosure: AC: Study Investigator, Ferring Pharmaceuticals, Study Investigator, Merck & Co., Principal Investigator, Novartis Pharmaceuticals, Study Investigator, Novo Nordisk, Consultant, Novartis Pharmaceuticals, Principal Investigator, Ipsen, Consultant, Ipsen, Principal Investigator, Pfizer, Inc., Consultant, Pfizer, Inc., Principal Investigator, Lilly USA, LLC, Consultant, Italfarmaco, Study Investigator, Ferring Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Study Investigator, Merck & Co., Speaker, Ipsen, Study Investigator, Novo Nordisk, Speaker, Pfizer, Inc., Consultant, Novartis Pharmaceuticals, Consultant, Ipsen, Consultant, Pfizer, Inc., Consultant, Italfarmaco, Speaker, Novartis Pharmaceuticals, Speaker, Ipsen, Speaker, Pfizer, Inc.. RP: Principal Investigator, Novartis Pharmaceuticals, Coinvestigator, Novartis Pharmaceuticals, Coinvestigator, Viropharma, Coinvestigator, IBSA, Consultant, Novartis Pharmaceuticals, Consultant, Ipsen, Consultant, Pfizer, Inc., Consultant, Viropharma, Consultant, Ferring Pharmaceuticals, Consultant, Italfarmaco, Speaker, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals. Nothing to Disclose: CP, MN, MCD, MN, CD, FI, LJH

15191 3.0000 SAT-0320 A Targeting the Insulin-like Growth Factor 1 (IGF1R) and Insulin (IR) Receptor with a Dual IGF1R/IR Inhibitor, OSI-906, to Potentiate mTOR Inhibitor Effects in Exeperimental Models of Hepatocellular Carcinoma (HCC) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0318-0329 4889 1:00:00 PM Therapies for Cancer Poster

Yan-He Lue*1, Ronald S. Swerdloff2, Victor Ganela3, Emily Ren3, Kevin Bruhn3 and Christina Wang4
1Harbor-UCLA Med Ctr/LA Biomed, Torrance, CA, 2Dept of Med/Endo, Harbor-UCLA Med Ctr/LA Biomed, Torrance, CA, 3LABioMed at Harbor-UCLA, Torrance, CA, 4Harbor - UCLA Med Ctr, Torrance, CA

 

Humanin (HN), a 24-amino acid mitochondrial derived peptide is an endogenous anti-apoptotic peptide in many tissues. We have demonstrated that HN attenuates male germ cell apoptosis induced by testicular hormonal deprivation, testicular hyperthermia, and cyclophosphamide (CYP) treatment in rodents. We question whether synthetic HN or its analogs, while protecting germ cells from apoptosis, may affect cancer cell death in response to chemotherapy. To answer this question, we used a potent humanin analog HNG with or without CYP in a mouse melanoma lung metastasis model. Five mice were used as control. Twenty mice were inoculated intravenously with B16 murine melanoma cells (200,000 cells/mouse). Among these 20 tumor-bearing mice, 5 mice received no further treatment, and the remaining 15 mice were divided into 3 groups of 5 and were treated 1 week after melanoma cell injection: 1) HNG daily i.p injection (5mg/kg BW) for 2 weeks; 2) a single CYP i.p. injection (200mg/kg BW); 3) combined CYP with HNG treatment for 2 weeks. All mice were sacrificed 3 weeks after tumor inoculation, and 2 weeks after HNG and/or CYP treatment. The number of tumors in the lungs was counted under stereomicroscopy. Germ cell apoptosis was detected by TUNEL assay and quantified as the number of apoptotic seminiferous tubules per 100 tubules (Apoptosis Index, AI). Non-treated tumor-bearing mice had increased germ cells apoptosis (AI: 18.63±1.94) as compared with control (AI: 8.83±1.85, p=0.001). CYP treatment significantly increased germ cell apoptosis (AI: 24.88±2.04, P<0.001) in comparison with control and HNG treated (AI: 15.08±1.75) mice. HNG treatment for 2weeks attenuated CYP induced germ cell apoptosis (AI: 12.32±0.70, p<0.001). While HNG treatment might mitigate the number of tumors in the lung, CYP treatment not only decreased number of tumors (106.8±17.56, p=0.006) but also tumor size as compared with non-treated tumor-bearing (148.2±27.55) mice. Importantly, combined HNG and CYP treatment significantly decreased number of tumors (47.6±10.53, p<0.001) compared to CYP treatment alone. We conclude that 1) HNG protects germ cell from apoptosis induced by CYP treatment; 2) HNG has additive anti-cancer effect on CYP suppression of lung metastatic melanoma formation in mice. The long term effects of HNG on male fertility preservation and on the suppression of cancer formation remain to be determined.

 

Nothing to Disclose: YHL, RSS, VG, ER, KB, CW

15626 4.0000 SAT-0321 A The Potent Humanin Analog (HNG) Protects Germ Cells from Apoptosis and Additively Suppresses Metastatic Lung Melanoma Formation after Cyclophosphamide Treatment in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0318-0329 4889 1:00:00 PM Therapies for Cancer Poster

Numan AL_Rayyan*, Chris Shidal, Kavitha Yaddanapudi and Davis Keith
University of Louisville

 

The Soy-derived Peptide Lunasin Inhibits the Growth of Melanoma Cells in Vitro and in Vivo

Melanoma is the fifth most common cancer in the United States and it is the most serious form of skin cancer that causes 75% of skin cancer deaths.  BRAF inhibitors have been a mainstay for treating melanoma; however the efficacy of these inhibitors is becoming limited due to the development of drug resistance. Thus, adjuvant and alternative therapies need to be developed for melanoma treatment. Lunasin, a peptide extracted from soybean, is a 43-44 amino-acid peptide which contains a predicted helix domain homologous to a conserved region found in chromatin-binding proteins and a C-terminal end that include a RGD cell adhesion motif followed by a poly-aspartic acid tail. Recently, lunasin has been shown to inhibit the growth of several cancers including breast, leukemia and colon cancers. In this study, we evaluated lunasin as a potential treatment for melanoma. To study the effect of lunasin on melanoma cell proliferation, MTS cell-proliferation assays under adherent culture conditions were performed after 72 h of treatment with lunasin alone or in combination with the BRAF inhibitor vemurafenib. The results showed that treatment A375 and SKMEL-28 cell lines with lunasin caused decreased cell viability, and that this activity was additive to the effect vemurafenib. Colony forming assay in soft agar for the A375 cells showed that both lunasin and vemurafenib significantly reduced colony forming capacity. Interestingly, lunasin also inhibited spheroid formation of A375 cells in low adherent conditions by 90%. In vivo xenograft studies where A375 melanoma cells were subcutaneously injected into athymic nude mice showed that both daily intraperitoneal (IP) injection and every other day intravenous (IV) injection of lunasin at 30 mg/kg inhibited tumor growth and decreased tumor weight by 35% and 46% for the IV and IP treatments respectively. In addition, toxicity panels comparing the control and treatment groups demonstrated that lunasin does not have negative effects on liver or kidney function. These results demonstrate that lunasin has a significant effect on melanoma cell proliferation both in-vitro and in-vivo. The results suggested that lunasin has the potential to act as a therapeutic molecule against melanoma that can be used in combination with vemurafenib.

·         First and second author contributed equally.

 

Nothing to Disclose: NA, CS, KY, DK

16136 5.0000 SAT-0322 A The Soy-Derived Peptide Lunasin Inhibits the Growth of Melanoma Cells in Vitro and in Vivo 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0318-0329 4889 1:00:00 PM Therapies for Cancer Poster

Yhun Y Sheen*1, So Y Park2, Min J Kim2, Sang A Park2, Jung S Kim3, Jeong S Nam4 and Dong Hyun Kim5
1Ewha Women's Univ, Seoul, Korea, Republic of (South), 2Ewha womans university, 3Ewha Womans University, seoul, Korea, Republic of (South), 4Gacheon University, 5College of Medicine Inje University, Busan, Korea, Republic of (South)

 

There have been reports that cancer stem-like cells may be responsible for tumor recurrence after chemotherapy. In order to investigate, if EW-7197 would improve the efficacy of chemotherapy, we investigated the effects of EW-7197 and combinatorial treatment with paclitaxel on the characteristic markers of cancer stem cells in MDA-MB-231 orthotropic xenograft NOD/SCID mice. EW-7197 alone inhibited the NANOG and OCT4 compared to control. Paclitaxel treatment alone increased NANOG and OCT4, whereas EW-7197 combinatorial treatment with paclitaxel significantly inhibited the elevated level of NANOG and OCT4. Either paclitaxel or EW-7197 alone decreased ALDH and paclitaxel combination with EW-7197 significantly inhibited the ALDH. Paclitaxel treatment increased the mRNA levels of NANOG, OCT4 and SOX2.  EW-7197 combination treatment with paclitaxel significantly inhibited the elevated levels of NANOG, OCT4 and SOX2 mRNAs. EW-7197 alone also inhibited the mRNA levels of NANOG, OCT4, and SOX2. We compared the effect of either EW-7197 alone or combination treatment on the characteristic markers of cancer stem cells such as NANOG, OCT4, SOX2, MYC, and KLF4 mRNAs in attached and sphere cultured MDA-MD-231 cells. Paclitaxel dramatically increased NANOG mRNA, and concomitant treatment with EW-7197 decreased the elevated NANOG mRNA by paclitaxel in only sphere but not in attached MDA-MB-231 cells. Likewise, paclitaxel increased SOX2, MYC and OCT4 mRNAs, and concomitant treatment with EW-7197 decreased them in sphere but not in attached MDA-MB-231 cells. Paclitaxel did not change KLF4 mRNA which was inhibited by EW-7197 alone or in combination with paclitaxel only in sphere cultured MDA-MB-231 cells. These findings suggest that paclitaxel increased cancer stem-like cells, and EW-7197 inhibits cancer stem-like cells. We experiment on BALB/c-nu/nu MB231 cells xenograft mice for survival analysis and EW-7197 and paclitaxel combination therapy lengthen the life span of mice compared to the paclitaxel mono therapy. In summary, EW-7197 could be effective therapeutic choice for breast cancer metastasis. Also EW-7197 and paclitaxel combination therapy could be more effective than paclitaxel alone therapy for anti-metastatic effect and survival.

 

Nothing to Disclose: YYS, SYP, MJK, SAP, JSK, JSN, DHK

16575 6.0000 SAT-0323 A TGF-β Inhibitor, EW-7197 Inhibits Cancer Stem Cells Markers in Paclitaxel Treated MDA-MB-231 Orthotropic Xenograft NOD/SCID Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0318-0329 4889 1:00:00 PM Therapies for Cancer Poster

Terra G Arnason*1, Valerie MacDonald1, Matthew Gaunt1, Gerald Davies1, Liubov Lobanova1 and Troy Harkness2
1University of Saskatchewan, Saskatoon, SK, Canada, 2University of Saskachewan, Saskatoon, SK, Canada

 

Cancer metabolism uniquely adapts to supply the energy necessary to sustain accelerated cell growth. We have investigated the usefulness of insulin-sensitizing agents in modifying cancer metabolism specifically in multiple drug resistant (MDR) models, both in vitro and in vivo. We have limited our in vitro studies to breast cancer cells that were successfully selected for MDR, and that can be compared to their parental cancer cells. Importantly, we have also established an in vivo animal model of MDR using companion canines who spontaneously present with lymphoma and exhibit high rates of treatment resistance. Using these models, we have evidence that Metformin, a non toxic and well tolerated oral agent widely used world-wide as a first line agent in the treatment of type 2 diabetes (DM2) is effective at killing both MDR cancers and their parental cell lines in vitro, and in  reversing markers of MDR in vivo.

The problem of treatment resistant cancer is large and immediate, and is limited by the ability to detect, follow and treat these cancers. Early detection and screening programs have greatly improved the disease free duration in breast cancer, yet upwards of 50% return years later with aggressive MDR disease. Lymphoma is also a cancer with a high rate of inherent and acquired drug resistance. Limited treatment options are available once MDR is present, and may indicate a switch to palliation. We have used canonical and novel biomarkers of MDR to monitor cell (in vitro) and tissue (in vivo) entry to and exit from MDR states.  Companion canines presenting with lymphoma that failed to respond to first line agents (CHOP protocol) or subsequently relapsed were considered MDR and were recruited to our study for randomization with oral metformin.

Cell line studies reveal that Metformin inhibits  histone deacetylase activity (HDACi), as well as promoting cellular apoptosis. While known to be cytotoxic to cancer cells in vitro, we find Metformin is also effective against MDR cells either as monotherapy or combination therapy, although to a lesser extent than the parental cancer cell lines. The MDR protein markers also readily reverse with Metformin exposure. Importantly, we also report that the same MDR markers are present in treatment resistant canines and metformin exposure also shifted them toward normal levels. Subsequent combination chemotherapy effectively reduced tumor size, abolished MDR markers, and provided 6 months of disease remission.

We speculate that Metformin as adjunct therapy is effective on drug resistant cancers of multiple cell types in vitro and in vivo and that MDR biomarkers are useful tools to monitor the entry to and exit from drug resistant states.

 

Nothing to Disclose: TGA, VM, MG, GD, LL, TH

15181 7.0000 SAT-0324 A Validation of Metformin Use in Treating Multiple Drug Resistant Breast Cancer and Lymphoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0318-0329 4889 1:00:00 PM Therapies for Cancer Poster

Dorota Dworakowska*1, Dorota Dudka2, Gregory Weitsman3, Peter James King4, Salvador J Diaz-Cano5, Márta Korbonits6, Ashley B. Grossman7, Simon J B Aylwin5, Klaus-Martin Schulte1, Krzysztof Sworczak2 and Tony Ng3
1Kings College Hospital, London, United Kingdom, 2Medical University of Gdansk, Gdansk, Poland, 3Kings College London, London, United Kingdom, 4Barts & The London Medical Sch, London, United Kingdom, 5King's College Hospital, London, United Kingdom, 6William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom, 7University of Oxford, Oxford, United Kingdom

 

Introduction:

Adrenocortical carcinoma (ACC) is a rare disease with a poor prognosis and limited therapeutic options.

Aim:

The aim of this study was to assess the anti-proliferative effect of combinatorial targeting of the PI3K/Akt/mTOR pathway with different drugs and simultaneous targeting of the MEK/Raf/ERK pathway in H295R adrenocortical cancer cells.

Material and Methods:

The cytotoxicity of LY294002 (pan-PI3K inhibitor), everolimus (mTOR inhibitor), BEZ235 (dual PI3K/mTOR inhibitor) and U0126 (MEK1/2 inhibitor) was assessed by Alamar blue assay in the H295R cell line. After finding the maximal cytotoxic concentrations for all inhibitors, we used suboptimal concentrations for experiments where multiple agents were used simultaneously. Everolimus and BEZ235 were kindly provided by Novartis, Switzerland; LY294002 and U0126 were commercially available. 

Results:

While everolimus, BEZ235 and LY294002 caused 20±6%, 15.6±6% and 11±1% cytotoxicity when used as single agents, co-treatment of cells with everolimus and BEZ235 showed a synergistic cytotoxic effect of 54±9% (p=0.007) (the strongest effect for combination of two inhibitors in our system, N=3 independent experiments). Addition of LY294002 to everolimus and BEZ235 increased the effect further to 65±7%.

We also explored the potential benefit of combined inhibition of PI3K/mTOR and MEK1/2. Addition of U0126 to BEZ235 had a synergistic effect (42±3% vs 14±5% and 15±5.6% alone, respectively, N=3 independent experiments). We observed only an additive effect if the MEK1/2 inhibitor was added to everolimus alone or in combination with BEZ235.

Conclusions:

The combination of agents inhibiting PI3K/Akt/mTOR and MEK/Raf/ERK pathways results in a synergistic cytotoxic effect. Our results suggest also that multiple mode of inhibition of the same pathway may result in a greater cytotoxic effect in adrenocortical cancer cells which cannot be achieved by simple dose escalation. We suggest that new combinations targeting those pathways require further investigation to improve the treatment of ACC patients.

 

Nothing to Disclose: DD, DD, GW, PJK, SJD, MK, ABG, SJBA, KMS, KS, TN

15719 8.0000 SAT-0325 A Simultaneous Targeting PI3K/Akt/mTOR and MEK/RAF/ERK Pathways Results in a Synergistic Anti-Proliferative Effect in an Adrenocortical Carcinoma Model 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0318-0329 4889 1:00:00 PM Therapies for Cancer Poster

Ramadevi Subramani*1, Rebecca Lopez2, Arunkumar Arumugam3, Sushmita B Nandy3, Thiyagarajan Boopalan4 and Rajkumar Lakshmanaswamy5
1Texas Tech University Health Sciences Center, El Paso, TX, 2Texas Tech University Health Sciences, El Paso, TX, 3Texas Tech University Health Sci, El Paso, TX, 4Texas Tech Univ, El Paso, TX, 5Texas Tech Univ Health Sci Ctr, El Paso, TX

 

Pancreatic cancer is one of the most lethal cancers.  Increasing incidence and mortality indicates that there is still much lacking in detection and management of the disease. This is partly due to a lack of specific symptoms during early stages of the disease. Several growth factor receptors have been associated with pancreatic cancer.  Here, we have investigated if an RNA interference approach targeted to IGF-IR could be effective and efficient against pancreatic cancer growth and metastasis. For that, we evaluated the effects of short interfering RNA (siRNAs) mediated inhibition of IGF-1R on tumor growth and metastasis using HPAC and PANC-1 pancreatic cancer cell lines. We found that silencing IGF-1R inhibits pancreatic cancer growth and metastasis by blocking key signaling pathways such AKT/PI3K, MAPK, JAK/STAT and EMT. Silencing IGF-1R resulted in an anti-proliferative effect in PANC-1 and HPAC pancreatic cancer cell lines.  Matrigel invasion, transwell migration and wound healing assays also revealed a role for IGF-1R in metastatic properties of pancreatic cancer.  These results were further confirmed using Western blotting analysis of key intermediates involved in proliferation, epithelial mesenchymal transition, migration, and invasion. In addition, soft agar assays showed that silencing IGF-1R also blocks the colony forming capabilities of pancreatic cancer cells in vitro. Western blots as well as flow cytometric analysis revealed the induction of apoptosis in IGF-1R silenced cells. Interestingly, silencing IGF-1R also suppresses the expression of insulin receptor β.  All these effects together significantly control pancreatic cancer cell growth and metastasis.  To conclude, our results demonstrate the significance of IGF-1R in pancreatic cancer.

 

Nothing to Disclose: RS, RL, AA, SBN, TB, RL

17038 9.0000 SAT-0326 A Targeting Insulin-like Growth Factor 1 Receptor Inhibits Pancreatic Cancer Growth and Metastasis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0318-0329 4889 1:00:00 PM Therapies for Cancer Poster

Hee Young Kang*1, Dong-Oh Lee2 and Eui-Bae Jeung3
1Chungbuk National University, CheongjuCheongju Chungbuk, Korea, Republic of (South), 2Chungbuk National Univ, Cheongju, Korea, Republic of (South), 3Biochemistry and molecular biology of veterinary medicine college, Chungbuk National Univ, Cheongju, Korea, Republic of (South)

 

Introduction: Interferon α (IFN-α) is made and released from host cells in response to the presence of pathogens. As another glycoprotein hormone, erythropoietin (EPO) controls red blood cell production in the bone marrow. As cytokines, they have been used to treat some hematological malignancies, such as the renal anemia. Transgenic expression system using bovine species is very useful for pharmaceutical production as producing recombinant proteins in milk. Methods: We established constructs capable of producing recombinant human IFN-α and EPO proteins in milk. In these recombinant constructs, we applied mammary gland-specific αS1-casein promoter region (-175 to +796 nt) with the highest activity in our previous promoter study. To minimize developmental toxicity by constitutive exogenous expression, we introduced doxycycline (dox)-inducible system to IFN-α/EPO expressing constructs. In these systems, tet-controlled transactivator (TA) is affected by mammary gland-specific αS1-casein promoter and binding of TA to the tetracycline response element (TRE) results in transcription of downstream genes, IFN-α/EPO under the presence of dox. To confirm dox-enhanced IFN-α/EPO construct, we introduced the unitary tet-on IFN-α/EPO vector into bovine mammary gland cell line (MAC-T cell), and then treated the cells with 0.1-1 mg/mL dox. Results: We observed a robust increase in IFN-α/EPO expression. Like this, we established the unitary tet-on IFN-α/EPO vector that combined a tet-on activator cassette controlled by αS1-casein promoter with a responder cassette-containing gene encoding IFN-α/EPO controlled by the TRE promoter. Furthermore, we generated bovine transgenic fibroblasts containing mammary gland-specific and dox-inducible IFN-α/EPO construct. Conclusions: These transgenic fibroblasts may provide a source for somatic cell nuclear transfer to generate transgenic cattle producing recombinant human IFN-α or EPO protein during lactation.

 

Nothing to Disclose: HYK, DOL, EBJ

12321 10.0000 SAT-0327 A Generation of Transgenic Fibroblasts for Producing Dox Inducible Human Interferon-α or Erythropoietin in Bovine Milk 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0318-0329 4889 1:00:00 PM Therapies for Cancer Poster

Theresa Gorski1, Stefanie Petzold-Quinque2, Sandy Richter2, Melanie Penke1, Susanne Schuster1, Antje Garten1 and Wieland Kiess*3
1University of Leipzig, Faculty of Medicine, Leipzig, Germany, 2Center for Pediatric Research, University of Leipzig, Leipzig, Germany, 3University of Leipzig, Dept. of Women´s & Child Health, Leipzig, Germany

 

NAMPT (Nicotinamide phosphoribosyltransferase) catalyzes the rate-limiting step in the NAD-biosynthesis from nicotinamide and regulates the activity of NAD-dependent enzymes. Cancer cells are highly dependent on NAD for energy and DNA repair processes and are expected to be more susceptible to the inhibition of NAD synthesis than non-transformed cells. Can inhibition of NAMPT by FK866 sensitise leukemia cells for chemotherapeutic agents?

Viability was measured using WST-1 assay. Cell death was analysed in Jurkat and Molt-4 cells by PI staining. Western Blotting was performed. NAD levels were measured using a colorimetric NAD/NADH Assay or HPLC. NAMPT activity was measured in leukemia cell lines and PBMCs using radioactively labelled 14C-nicotinamide.

NAMPT expression and enzymatic activity was significantly higher in leukemia cell lines compared to normal PBMCs. Incubation with FK866 [10nM] for 24h reduced NAMPT activity by 91.1±3.6% in Jurkat cells and by 97.8±1.2% in Molt-4 cells. NAD levels were reduced by FK866 by 83.9±1.0% (Jurkat) or 79.2±2.8% (Molt-4). The combination of etoposide and FK866 caused increased cell death compared to each substance alone. In contrast, combining FK866 and methotrexate or doxorubicin showed no increased effect. Apoptosis induction as measured by caspase-3 activation was not further increased by the addition of FK866 to etoposide. Etoposide decreased the expression of the NAD-dependent deacetylase SIRTUIN1 (SIRT1). The acetylation of the SIRT1 target p53 was enhanced after combining etoposide with FK866. Concomitantly, the transcriptional activity of p53 was increased as shown by an increased expression of p21.

The combination of etoposide and FK866 caused increased cell death which was not caspase-3-mediated, but induced acetylation and transcriptional activity of p53. Combining FK866 and etoposide could therefore be a novel therapeutic strategy to enhance the efficancy of etoposide against leukemia cells.

 

Nothing to Disclose: TG, SP, SR, MP, SS, AG, WK

13745 11.0000 SAT-0328 A Chemosensitization of Leukemia Cells through Inhibition of NAMPT 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0318-0329 4889 1:00:00 PM Therapies for Cancer Poster

Jie Zhu*1, Rama K Mishra2, Gary E Schiltz2, Karl A Scheidt2, Kelly A Whelan3 and Yogeshwar Makanji4
1Northwestern University, Chicago, IL, 2Northwestern University, 3Feinberg School of Medicine, Northwestern University, Chicago, IL, 4Prince Henry's Inst, Chicago, IL

 

Background: Cancer-related weight loss relates to 30% of all cancer deaths. Recent studies in rodent cancer-related cachexia models have shown that targeting the myostatin/activin signaling pathway can reverse wasting and improve the life quality. Targeting activin and its related signaling pathway may hold promise as a therapeutic approach to cancer-related cachexia. We performed an in silico screen based on the activin crystal structure and tested the resulting hit compounds for functional antagonism of activin signaling in cell-based, ex vivo, and in vivo assays.

Method: We used a three-tier in silico screening process applying different druggable filters to the ZINC database containing ~18 million compounds which generated a,  ~10 million compounds set. This compound set was then subjected to a virtual high throughput screening (vHTS) followed by standard precision (SP) as well asextra precision (XP) docking tools and the in-silico hits were generated. Candidate compounds underwent solubility testing at 200 μM. The LβT2 gonadotrope cell line stably transfected with -338FSHβ-luc was used to test for toxicity and the functional antagonism of activin-stimulated FSHβ transcription. The human liver HepG2 cell line was used for secondary functional screening of antagonism of activin-stimulated apoptosis. Lead compounds were further evaluated in ex vivo ovary culture(s) to assess the effects on activin-stimulated granulosa cell proliferation. The most effective lead compound was injected into ovariectomized mice and the effect on activin-stimulated FSH serum levels was compared with that of follistatin and inhibin.

Result: The interacting junction between the two activin βA subunits (residues 48-56) of the activin A dimer forms a pocket for interacting with activin type I receptor (ALK4) and was used as the docking site for in silico screening of activin antagonists. The 39 identified candidate compounds underwent solubility and toxicity testing, which resulted in 11 low toxicity candidate compounds for further testing. NUCC-474 and NUCC-555 showed strong antagonistic activity in both cell-based assays. NUCC-555 inhibited activin A-mediated cell proliferation in ex vivo ovary cultures more potently than NUCC-474. As an in vivo proof of principle, we treated mice with 15mg/kg, 30 mg/kg or 60 mg/kg NUCC-555 which resulted in a decrease in FSH level with dose dependent manner.

Conclusion: We utilized a virtual screening strategy coupled with robust functional assays to identify a set of small molecule activin antagonists. The lead compound, NUCC-555, has low toxicity and significant antagonistic activity against activin in several in vitro, ex vivo, and in vivo assays. These data provide an important proof-of-concept for our screening strategy and form the basis for further lead optimization through medicinal chemistry for the clinical appilication.

 

Nothing to Disclose: JZ, RKM, GES, KAS, KAW, YM

13990 12.0000 SAT-0329 A As in silico-Aided Screening of Activin Antagonists As Potential Therapeutics for Cancer-Related Cachexia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM SAT 0318-0329 4889 1:00:00 PM Therapies for Cancer Poster

Surya P Singh*1 and Shikha Chouhan2
1Banaras Hindu University, Varanasi UP, India, 2Banaras Hindu University

 

Purpose: Bisphenol A is a common plasticizer that causes reproductive damage in males; however the mechanism of how this damage is inflicted remains elusive. The aim of this study was to elucidate the mechanism behind Bisphenol A’s damaging action by evaluating its effect on the expression of inducible nitric oxide synthase and steriodogenic acute regulatory protein in mice testis.

Method: Male Swiss albino mice were treated with Bisphenol A at a concentration of 50, 100 and 200 µg/kg body weight/day intraperitoneally for a period of two months.

Results: Tissue nitrite levels, malondialdehyde values and testicular injury scores were elevated. Sperm count, serum testosterone levels and catalase activity were reduced in the Bisphenol A treated groups. An intense increase in inducible nitric oxide synthase expression was observed in Leydig and Sertoli cells of the Bisphenol A treated mouse, whereas the expression of the steriodogenic acute regulatory protein was down regulated in the same cells.

Conclusion: The present study suggests that Bisphenol A induces oxidative stress by altering the expression of inducible nitric oxide synthase in the testis of male mouse. Consequently, this effect leads to the down regulation of steriodogenic acute regulatory protein expression, thereby causing structural and functional damage in the male testis.

 

Nothing to Disclose: SPS, SC

11247 1.0000 SAT-0355 A Increase in the Expression of Inducible Nitric Oxide Synthase on Exposure to Bisphenol a: A Possible Cause for Decline in Steroidogenesis in Male Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM SAT 0355-0371 4967 1:00:00 PM Endocrine Disrupting Chemicals Action in Physiology and Cancer Poster

Tatiana Y. Kostrominova*
Indiana University School of Medicine Northwest, Gary, IN

 

Obesity is reaching epidemic proportions in developed countries and is on the rise in developing countries. A number of studies documented a link between BPA exposure and obesogenic effects on adipose tissue and liver. Skeletal muscle is one of the most important organs for glucose homeostasis in humans and abnormal lipid and glucose metabolism in skeletal muscle could result in the development of obesity and type 2 diabetes. It was previously reported that BPA is accumulated in skeletal muscle following the exposure, but it is not known how BPA affects skeletal muscle structure and function, and which receptors are mediating the effects. To evaluate skeletal muscle-specific affects we treated cultured skeletal muscle cells in vitro with BPA. Our experiments showed that exposure to 1-100μM of BPA down-regulated the expression of genes involved in a skeletal muscle differentiation program in differentiated myotubes in vitro. At BPA concentration of 1μM myogenin expression was down-regulated ~20% and AChR expression was down-regulated ~50% in differentiated C2C12 myotubes. The expression of myogenic genes in non-differentiated myoblasts was affected only at 100μM of BPA. We analyzed mRNA expression of two skeletal muscle-specific degradation pathway proteins MURF1and MAFbx after exposure to 1-100μM of BPA. MAFbx expression was not changed while expression of MURF1 was decreased ~50% at 100μM of BPA, suggesting that at these concentrations BPA exposure does not cause severe cell damage and does not activate muscle-specific degradation pathways. We also tested whether BPA can activate obesity-enhancing gene expression in cultured skeletal muscle cells. Exposure of C2C12 myotubes to 1-100 μM of BPA increased mRNA expression of FAB4 (2-4 fold), down-regulated CPT-1 expression (2-fold at 100 μM) and had no effect on expression of ApoD and LPL. Overall our data suggest that BPA exposure can affect the differentiation program and lipid metabolism in skeletal muscle cells.

 

Nothing to Disclose: TYK

11831 2.0000 SAT-0356 A Effects of BPA on Cultured Skeletal Muscle Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM SAT 0355-0371 4967 1:00:00 PM Endocrine Disrupting Chemicals Action in Physiology and Cancer Poster

Tyler M Bauman*1, Julia A Taylor2, Kristen S Uchtmann1, Frederick S vom Saal2 and William A Ricke1
1University of Wisconsin, Madison, WI, 2University of Missouri, Columbia, MO

 

Introduction and objective

Bisphenol-A (BPA) is an estrogen-like compound found ubiquitously in many industrial products. The actions of BPA as a selective estrogen receptor modulator (SERM) have led to studies on the effects of BPA on the development of estrogen-responsive organ systems. The purpose of this study was to investigate the effects of BPA on the development of the embryonic mouse prostate. 

Methods

CD-1 female mice were time mated and fed BPA in tocopherol-stripped corn oil at 4 doses: 0 (controls), 5, 50, or 500 μg/kg/day from gestation day (GD) 9-18. Mice were sacrificed at GD 18. The urogenital sinus (UGS) was collected, fixed in 10% neutral-buffered formalin, and embedded in paraffin. Paraffin blocks were serially sectioned and stained for basal marker p63. Images were acquired, and the UGS was reconstructed in three dimensions using 3D reconstruction software. The volume of the anterior prostate (AP) was compared between treated and control mice.

Results

A total of 4 reconstructed UGS per treatment group were included in the analysis. A significant increase in the AP volume was observed in the 500 μg treatment group compared to control UGS (1.66 ± 0.11E6 vs. 1.30 ± 0.22E6 μm2; p = 0.027). Anterior prostate volume was also increased in the 50 μg treatment group but failed to reach statistical significance (1.64 ± 0.25E6; p = 0.08). No difference was observed between control UGS and 5 μg of BPA treatment (1.48 ± 0.26E6; p = 0.33).

Conclusions

Feeding pregnant mice BPA at a 500 µg/kg/day dose leads to unconjugated serum BPA levels of 0.24 ng/ml and results in larger anterior prostate volumes compared to control mice. These findings reveal that serum levels of BPA within the range reported in human fetuses can alter prostate development in mice.

 

Nothing to Disclose: TMB, JAT, KSU, FSV, WAR

11929 3.0000 SAT-0357 A Treatment with Bisphenol-a Is Associated with Larger Anterior Prostate Volume in Gestational Day 18 Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM SAT 0355-0371 4967 1:00:00 PM Endocrine Disrupting Chemicals Action in Physiology and Cancer Poster

Almudena Veiga-Lopez*1, Jacob Scott Moeller2, Anthony Pease3, Wen Ye2, Rohit Sreedharan4 and Vasantha Padmanabhan4
1Univ of Michigan Med Schl, Ann Arbor, MI, 2University of Michigan, 3Michigan State University, East Lansing, MI, 4University of Michigan, Ann Arbor, MI

 

Exposure to endocrine disruptors with steroidogenic potential, such as bisphenol A (BPA) is of concern. Developmental exposure to BPA increased body weight and induced adipocyte hypertrophy in rodents. We hypothesized that prenatal BPA treatment will alter adipocyte size and adipose tissue mass and distribution with postnatal overfeeding exacerbating this effect. Pregnant sheep were treated from days 30 to 90 of gestation with BPA (0.5 mg/kg BW/day, s.c., in corn oil; internal dose achieved was ~2.6 ng/ml in day 90 fetuses) or corn oil (control [C]). A subset of C and BPA-treated females were overfed starting at 8 wks of age. At 21 mo, body weight of overfed animals were ~33% above (p<0.01) that of maintenance-fed females (C: 77.3±2.1 vs. BPA: 78.0±3.5; n.s. and C-OF: 103.5±3.9 vs. BPA-OF: 103.4±2.9; n.s.). Adipose tissue distribution was assessed using computed tomography (n=5-8/group) followed by image analysis (Analyze 6.0, AnalyzeDirect). Area and mean cell diameter of dissociated adipocytes were calculated using computerized image analysis (Image-Pro Plus). Differences among groups were analyzed using a permutation test based on Kolmogorov-Smirnov statistics and ANOVA. Overfeeding increased total (C: 10.3±1.1, BPA: 12.3±1.2, C-OF: 21.4±0.7, BPA-OF: 20.7±1.0 dm3; p<0.0001), subcutaneous (C: 3.7±0.5, BPA: 4.2±0.4, C-OF: 10.1±0.5, BPA-OF: 8.6±0.6 dm3; p<0.0001), and visceral (C: 6.6±0.6, BPA: 8.1±0.9, C-OF: 11.4±0.3, BPA-OF: 12.1±0.5 dm3; p<0.0001) fat in both C-OF and BPA-OF groups compared to their maintenance-fed counterparts, with no BPA-specific effect. BPA treatment increased mean adipocyte area (C: 8,684.4±66.3 vs. BPA: 11,906.6±83.8 μm, p<0.01) and diameter (C: 102.6±0.4 vs. BPA: 120.3±0.5 μm, p<0.005). Overfeeding also increased mean adipocyte area (C: 8,684.4±66.3 vs. C-OF: 11,384.1±75.9 and BPA: 11,906.6±83.8 vs. BPA-OF: 13,460.4±90.5 μm, p<0.005) and diameter (C: 102.6±0.4 vs. C-OF: 117.1±0.4 and BPA: 120.3±0.5 vs. 127.8±0.5 μm, p<0.005), consistent with obesity-driven adipocyte hypertrophy. Overfeeding did not exaggerate effects of prenatal BPA treatment on adipocyte size or fat distribution. These findings suggest that prenatal BPA treatment, at a dose relevant to human exposure, has detrimental effects in reprogramming adipocyte morphology, but not fat mass and distribution and raises concerns relative to the risk of obesity and metabolic syndrome from prenatal BPA exposure.

 

Nothing to Disclose: AV, JSM, AP, WY, RS, VP

12640 4.0000 SAT-0358 A Developmental Programming: Impact of Prenatal Bisphenol a and Postnatal Obesity on Adipocyte Morphology and Fat Distribution in Sheep 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM SAT 0355-0371 4967 1:00:00 PM Endocrine Disrupting Chemicals Action in Physiology and Cancer Poster

Thozhukat Sathyapalan*1, Eric S Kilpatrick2, Mo Aye3, Alan S Rigby1, Natalie J Thatcher4 and Stephen L Atkin5
1Hull York Medical School, Hull, United Kingdom, 2Hull and East Yorkshire NHS Trust, Hull, United Kingdom, 3Hull and East Yorkshire Hospital NHS Trust, Howden, United Kingdom, 4European Food Safety Authority, Parma, Italy, London, Italy, 5Weill Cornell Medical College Qatar, Doha, Qatar

 

Background

In patients with subclinical hypothyroidism, soy protein and isoflavone combination has been shown to increase the risk of developing overt hypothyroidism; however, it is unclear if soy affects thyroid function in those without existing thyroid compromise.

Materials and Methods

Two double blind randomised trials were undertaken in which thyroid function was performed routinely at the beginning and end as a secondary end point. In both trials soy protein 30g with and without 66mg of soy isoflavones were used (preparation 1); soy protein alone that was isoflavone free (less than 300 parts per billion following serial ethanol washing) (preparation 2) was used for a period of 12 weeks. Study 1: 197 women within two years of the onset of the menopause to determine the safety of soy on markers of bone turnover as the primary end point.  Study 2: 210 men with T2DM with a total testosterone level ≤12nmol/L with normal gonadotrophins with the primary end point of testosterone change. Here the secondary thyroid endpoints are presented. 

Results

All patients had normal thyroid function at baseline in both the studies.  In post menopausal women there was a significant increase in TSH (1.58 ± 0.93 vs. 2.57 ± 1.19 mU/L; p value <0.01) and reduction of free thyroxine (1.08 ± 0.17 vs. 0.92 ± 0.17 ng/dL; p value 0.02) after preparation 1 after 3 months compared to baseline.  In men with type 2 diabetes there was a significant increase in TSH (1.82 ± 0.10 vs. 3.28 ± 0.11 mU/L; p value <0.01) and reduction in fT4 (0.98 ± 0.02 vs. 0.86 ± 0.02 ng/dL; p value <0.01) with preparation 1 but not after preparation 2 after 3 months compared to baseline. None of the patients developed subclinical or overt hypothyroidism during this period.  There were no changes in fT3 after either preparation 1 or preparation 2.  There was no significant change in TSH or thyroxine after supplementation of preparation 2 in both the studies.

Conclusions

There was a significant increase in TSH and reduction in free T4 only after soy protein with isoflavones suggesting a direct effect on the thyroid that is unlikely to be clinically significant unless thyroid compromise is already present. We have previously shown that isoflavone alone has no effect on thyroid function suggesting that the isoflavones in the soy protein matrix is active component.

 

Nothing to Disclose: TS, ESK, MA, ASR, NJT, SLA

13280 5.0000 SAT-0359 A Soy Protein with Isoflavones Impairs Thyroid Function 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM SAT 0355-0371 4967 1:00:00 PM Endocrine Disrupting Chemicals Action in Physiology and Cancer Poster

Thozhukat Sathyapalan*1, Eric S Kilpatrick2, Mo Aye3, Alan S Rigby1, William D. Fraser4, Natalie J Thatcher5 and Stephen L Atkin6
1Hull York Medical School, Hull, United Kingdom, 2Hull and East Yorkshire NHS Trust, Hull, United Kingdom, 3Hull and East Yorkshire Hospital, Howden, United Kingdom, 4University of East Anglia, Norwich, United Kingdom, 5European Food Safety Authority, Parma, Italy, London, Italy, 6Weill Cornell Medical College Qatar, Doha, Qatar

 

Background

It is controversial whether soy can affect bone mineral density during the menopause, though some studies have suggested a small positive effect, but the safety of soy in women in the early menopause when bone loss is greatest is unknown.

Aims and Objectives

To determine if soy protein with and without phytoestrogens has an effect on bone turnover markers in postmenopausal women 2 years within the onset of the menopause when bone loss is at its greatest.

Materials and Methods

This was a parallel, double-blind, placebo-controlled trial in women within two years of the onset of the menopause with either 15g soy protein with 66mg phytoestrogen (preparation 1) or 30g soy protein alone that was isoflavone free of less than 300 parts per billion following serial alcohol washing (preparation 2) for 6 months.

Results

Two hundred women were randomised to either soy protein alone or soy protein and phytoestrogen preparation.  There was a significant decrease in serum collagen type 1 cross-linked Beta C-telopeptide (βCTX) (bone resorption marker) after   preparation 1 at 3 months (0.41 ± 0.17 vs. 0.22 ± 0.15 µg/L; p value <0.01) and at 6 months (0.41 ± 0.17 vs. 0.15 ± 0.09 µg/L; p value <0.01) compared to baseline.  There was no significant change in  propeptide of type I collagen (P1NP) (bone formation marker) after preparation(1) at 3 months (50.84 ± 25.43 vs. 50.51 ± 21.54 µg/L; p value 0.49) but a significant decrease  at 6 months ((50.84 ± 25.43 vs. 35.01 ± 17.62 µg/L; p value <0.01) compared to baseline.  There were no significant changes in bone turnover markers with preparation 2.  The changes in bone turn over markers with preparation 1 were significantly more than the corresponding changes with preparation 2. 

Conclusion

There was a significant decrease in bone turn over markers of resorption and formation after supplementation with 15g soy protein and phytoestrogens for 6 months. An initial effect on osteoclast followed by decreased osteoblast function may have beneficial effects on bone health.  There was no significant change in bone turn over makers with 30g soy protein alone for 6 months.

 

Nothing to Disclose: TS, ESK, MA, ASR, WDF, NJT, SLA

13286 6.0000 SAT-0360 A The Effect of Soy Phytoestrogens on Bone Turn over Markers in Women during Early Menopausal Period 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM SAT 0355-0371 4967 1:00:00 PM Endocrine Disrupting Chemicals Action in Physiology and Cancer Poster

Maria Izabel Chiamolera*1, Marina M.L. Kisys2, Nina I Sena-Souza1, Renata M. Romano3, Tania Maria Ortiga-Carvalho4, Rui M. B. Maciel5, Gisele Giannocco6, Magnus R. Dias da Silva7 and Marco A. Romano8
1UNIFESP, Sao Paulo, Brazil, 2Universidade Federal de Sao Paulo - UNIFESP, Sao Paulo, Brazil, 3UNIFESP, São Paulo, Brazil, 4Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, 5Universidade Federal de Sao Paul, Sao Paulo, SP, Brazil, 6Faculdade de Medicina do ABC, Santo Andre, SP, Brazil, 7UNIV FEDERAL DE SAO PAULO, Sao Paulo, Brazil, 8Universidade Estadual do Centro-Oeste, Guarapuava, Brazil

 

Thyroid hormone (TH) is essential for life and its production is regulated by hypothalamus-pituitary-thyroid (HPT) axis. Recently, endocrine disrupting chemicals, including the most widely used herbicide glyphosate, have been implicated with adverse effects in the endocrine system, but only few studies have been done to analyze its effect on the HPT-axis. The aim of the present study is to investigate effects of glyphosate in TH production and HPT-axis interference. In order to evaluate the effect of gestational exposure on possible disrupting effects in HPT-axis of male-offspring, Glyphosate Roundup Transorb ® was administered to mothers from gestational day (GD) 18 to post natal day (PND) 5, and arranged in control, 5 and 50 mg/kg group. At PND90, blood was collected for hormonal dosages (TSH, T3 and T4), and pituitary, liver and heart tissues were obtained for analysis of ß-Tsh, deiodinase type-1 (Dio1), type-2 (Dio2) and type-3 (Dio3), thyroid hormone transporters Mct8 and Oatp1c1, heart myoglobin (Mb), Glut4 and Serca2 mRNA by quantitative RT-PCR. After being exposed to glyphosate, animals showed a trend of T3 decrease without apparent alterations in T4 or TSH concentration, possibly due to a reduction of mRNA levels of Dio1 observed in the liver. In the pituitary, transcripts of Dio2, Mct8 and Oatp1c1 presented an important increase in expression, and with no changes in ß-Tsh and Dio3 mRNA content. Heart Mb and Glut4 mRNA levels showed a significant decrease in mRNA content, while no change was observed in heart Serca2 mRNA concentration. Our in vivo study suggest that glyphosate-based-herbicide disrupted peripheral conversion from T4 to T3, possibly through altering the transcription of Dio1 in the liver, but this alteration may have been compensated at some degree in the pituitary due an increase of Dio2 expression. In fact, expression of Dio1, Dio2, Mct8, heart Mb and Glut4 genes recapitulate a behavior similar to what is observed in hypothyroid state. Upcoming studies are needed to further analyze if these HPT-axis alterations are due to a local lack of thyroid hormone secondary to the direct action of glyphosate itself or by some other secondary cell signaling events.

 

Nothing to Disclose: MIC, MMLK, NIS, RMR, TMO, RMBM, GG, MRD, MAR

16755 7.0000 SAT-0361 A Glyphosate Mimics Tecidual Hypothyroidism in Perinatally Treated RATS 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM SAT 0355-0371 4967 1:00:00 PM Endocrine Disrupting Chemicals Action in Physiology and Cancer Poster

Michael P Reilly*, Connor D Weeks, Viktoria Y Topper, Lindsay M Thompson and Andrea C Gore
University of Texas at Austin, Austin, TX

 

Endocrine disrupting chemical (EDC) exposures during critical periods of development influence neuronal development and the manifestation of sexually dimorphic behaviors that emerge in adulthood. Among these behaviors, social information processing is sexually dimorphic and regulated by sex steroids. Oxytocin and vasopressin serve as primary neurotransmitters mediating these behaviors; these neuroendocrine circuits are hormone sensitive and potential targets of prenatal EDC exposures. Here, we tested effects of prenatal exposures to a class of EDCs, polychlorinated biphenyls (PCBs) on social behaviors. On gestational day 16 and 18, pregnant Sprague-Dawley rats were injected intraperitoneally with Aroclor 1221 (0.5 mg/kg or 1 mg/kg), an estrogenic PCB mixture. Positive and negative controls were estradiol benzoate (EB) and vehicle (DMSO/sesame oil mix). In adulthood, male and female offspring were used as experimental rats for behavioral testing. Using a three-chamber social apparatus, adult rats exposed to PCBs during gestation were allowed to engage in two social behavioral paradigms. In the first, Sociability, the animal is presented with a choice between spending time in a chamber containing a same-sex stimulus animal (social) or an empty chamber (non social). In the second, Social Novelty, the experimental animal is allowed to choose between a familiar rat (from the Sociability phase) or a novel same-sex stimulus rat. Results showed that during Sociability, A1221 treated groups (0.5 mg/kg in males; 1.0 mg/kg in females) spent a significantly (p<0.05) higher ratio of their exploratory time in direct contact with the stimulus animal when compared to DMSO and EB groups. In both sexes, during Social Novelty, both doses of A1221 abolished the natural preference toward spending more time investigating the novel animal. Additionally, the significant (p<0.05) preference toward increased direct nose-to-nose contact was lost in females treated with EB, and A1221 (0.5 mg/kg and 1.0 mg/kg). These data suggest a sex- and dose-specific effect of PCBs on some aspects of sociality present in the experimental animals. In ongoing work, I will perform immunohistochemistry of oxytocin, vasopressin, and receptors in selected brain regions to determine underlying hormonal and/or neuroanatomical differences in the pathways involved in the social behaviors.

 

Nothing to Disclose: MPR, CDW, VYT, LMT, ACG

14125 8.0000 SAT-0362 A The Neuroendocrine Disruption of Adult Social Behavior Via Gestational Exposure to Endocrine-Disrupting Chemicals 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM SAT 0355-0371 4967 1:00:00 PM Endocrine Disrupting Chemicals Action in Physiology and Cancer Poster

Chinaza Egbuta*, Jessica Lo and Debashis Ghosh
SUNY Upstate Medical University, Syracuse, NY

 

Biosynthesis of estrogens from androgenic precursors is catalyzed by cytochrome P450 aromatase (CYP19A1) coupled with P450 reductase.  Inhibition of aromatase by the triazole compounds letrozole and anastrozole is a commonly used therapy for estrogen-dependent postmenopausal breast cancer.  Azoles in general have been widely used as agricultural fungicides and anti-mycotic drugs that target 14alpha-demethylase (CYP51A1) critical for fungi cell membrane assembly.  Previously, some of these azoles were shown to inhibit aromatase, thereby raising the possibility of their endocrine disruptive effects.  However, mechanistic analysis of their inhibition in purified enzyme has never been undertaken.  We have evaluated the inhibitory effects of three common fungicides bifonazole (BFZ), imazalil (IMZ), and flusilazole (FLZ), in human aromatase purified from placenta (pArom), and compared their inhibition kinetics to letrozole (LTZ).  BFZ exhibits potent inhibitory effects with an IC50 of 270nM and a Ki of 68nM.  Those of IMZ and FLZ are 1100nM and 3200nM, and 278nM and 547nM respectively.  Statistical analysis of the inhibition kinetics data using the extra-sum-of-squares F test and Akaike criterion suggest that the modes of inhibition by the azole fungicides are mixed, whereas LTZ inhibition could be either mixed or non-competitive.  We interpret these results in the context of the X-ray structure of pArom-androstenedione (ASD) complex (Nature 457: 219, 2009).  Binding cavity computations suggest that the aromatase molecule has three possible ligand sites in relation to its heme moiety.  The substrate-binding cavity at the heme proximal site closely compliments the structure of natural substrates ASD and testosterone, and steroidal aromatase inhibitors (J Med Chem 55: 8464, 2012).  As the structures of LTZ and the azole fungicides are entirely dissimilar to the ASD backbone, they could bind either to a structurally rearranged active site, or to a different binding cavity, or both.  A comparison with nine other P450 structures establishes that aromatase has a more pronounced binding cavity at its heme-proximal region, the site for reductase coupling.  Alternatively, the active site access channel could serve as a secondary site providing a rationale for inhibition.  Thus, the enzyme kinetics and structural analysis demonstrate that azole fungicides are potent inhibitors of human aromatase, possibly via multiple enzyme binding sites.

 

Nothing to Disclose: CE, JL, DG

14951 9.0000 SAT-0363 A Mechanism of Inhibition of Estrogen Biosynthesis By Azole Fungicides 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM SAT 0355-0371 4967 1:00:00 PM Endocrine Disrupting Chemicals Action in Physiology and Cancer Poster

Yanina Benzo*1, Sonia A. Ronchetti1, Melisa C Crocco1, Diana M Kelmansky2, Beatriz Haydee Duvilanski1 and Jimena P. Cabilla1
1INBIOMED (UBA-CONICET), Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina, 2Instituto de Cálculo. Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Argentina

 

Cadmium (Cd) is a heavy metal widely used in industry and is an extensive environmental contaminant. General population is exposed to Cd primarily through cigarette smoking, dietary sources, and drinking water. Despite the metal has no known physiological function, there is increasing evidence suggesting that Cd exerts potent metallohormone actions, mainly by mimicking estrogen (E2) actions. Although it has been reported its E2-like activities in cell lines, its in vivo effects remain largely unknown. The objective of the present work was to study the in vivo metalloestrogen Cd effects in hormone-responsive tissues. Adult female Wistar rats were ovariectomized and immediately exposed to 1 ppm Cd in drinking water during 1 month. Control rats were given tap water without Cd. Samples of vaginal smears were collected daily. Body weight and water consumption were monitored periodically and did not differ among control and treated groups. Protein expression was determined by western blot.

Cd administration augmented the relative frequency of proestrus and estrus (number of proestrus + estrus/total number of samples x100), control: 0%; Cd: 60%). Besides, Cd exposure significantly increased uterine wet weight (relative to body weight, control: 0.116 ± 0.008 mg; Cd: 0.3 ± 0.06 mg*, p<0.05, n=6). In anterior pituitary gland, Cd was able to increase E2 receptor α 46 kDa-splicing variant (TERP2; relative units as % of control; control: 100 ± 8; Cd: 138 ± 11*, p<0.05, n=3) and prolactin protein levels (relative units as % of control; control: 100 ± 22; Cd: 165 ±12*, p<0.05, n=3). Similarly to E2, 1 ppm Cd caused a two-fold increase of  soluble guanylyl cyclase α1 subunit protein expression, which is up-regulated by E2 and correlates with its proliferative effects (relative units as % of control; control: 100 ± 27.57; 1 ppm Cd: 199.15 ± 30.24*, p<0.05, n=4).

Conclusion: in this work we demonstrated that a low dose of Cd through water consumption displayed xenoestrogenic actions in vivo in hormone-dependent tissues. This metalloestrogen promoted uterus growth and apparition of stages of estrous cycle in castrated animals and increased the expression of several E2-responsive genes in anterior pituitary gland, thus underlying the importance of Cd as a potential neoplastic agent mainly in E2-dependent tissues.

 

Nothing to Disclose: YB, SAR, MCC, DMK, BHD, JPC

15962 10.0000 SAT-0364 A Cadmium Exposure through Water Consumption Exerts Xenoestrogenic Effects in Uterus and Pituitary Gland from Ovariectomized Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM SAT 0355-0371 4967 1:00:00 PM Endocrine Disrupting Chemicals Action in Physiology and Cancer Poster

Melisa C Crocco1, Sonia A. Ronchetti1, Jimena P. Cabilla1, Yanina Benzo*1, Diana M Kelmansky2 and Beatriz Haydee Duvilanski1
1INBIOMED (UBA-CONICET), Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina, 2Instituto de Cálculo. Facultad de Ciencias Exactas y Naturales, Universidad de Buenos Aires, Argentina

 

Inorganic Arsenic (iAs) is one of the most toxic metalloids. Contaminated water consumption-mediated As exposure is one of the greatest environmental health threats worldwide. It has been suggested that iAs could display xenoestrogen activities. A recent report has shown that iAs mimics the proliferative effect of 17β-estradiol (E2) in a hormone-dependent tumor cell line (MCF-7), however, estrogen-like actions were not studied in vivo yet. The aim of this study was to prove whether iAs is able to reproduce E2 physiological response on hormone-dependent tissues as uterus and pituitary gland.

Adult female Wistar rats were ovariectomized and exposed to iAs at different doses in drinking water (0.1 or 1 ppm) for 30 days. Control groups received free access to tap water without As (negative control) or were implanted s.c. with 500 µg E2 capsule (positive control). Animals were weighed once a week. Estrous cycle and water consumption were determined daily. The glandular area and epithelial height were determined by image analysis of optic microscopy in separate sections of the uterus (Control, n = 5; iAs 0.1 ppm, n = 6; 1 ppm iAs, n = 6; E2, n = 5). The estimated means were obtained by ANOVA, and a posteriori comparisons were performed using the Tukey method. Protein expression was assessed by western blot.

Both iAs doses (0.1 and 1 ppm) were able to increase the frequency of proestrus and estrus. The percentage of glandular area regarding uterine endometrium area was significantly greater in animals treated with 0.1 ppm As and E2 (Control: 1.09%; 0.1 ppm iAs: 5.17% *; 1 ppm iAs: 1.87 %; E2: 10.53% *; *p<0.0001). Similarly, the height of the uterine epithelium increased in animals treated with 0.1 ppm iAs and E2 (Control: 9.03µm; 0.1 ppm iAs: 16.94µm*; 1ppm iAs: 9.37µm; E2: 33.43µm*; *p<0,0001). Besides, 0.1 ppm iAs treatment, like E2, significantly augmented protein expression of E2-responsive genes in the pituitary gland [(% of Control, C) prolactin, iAs: 153 ± 6.5*, E2: 220 ± 30.2*; cyclin D3, iAs: 128.8 ± 4.1*, E2: 159.3 ± 5.3*; estrogen receptor α, iAs: 154.1 ± 6.1*, E2: 96.7 ± 6.6. *p<0.05 vs. C].

Inorganic arsenic at low doses induces proliferative activities in the uterus and the anterior pituitary gland. In turn, it causes morphological changes in the uterus and in the expression of E2 inducible genes. These results indicate that this metalloid affects reproductive physiology and may promote the development of hormone-dependent diseases.

 

Nothing to Disclose: MCC, SAR, JPC, YB, DMK, BHD

15973 11.0000 SAT-0365 A Arsenic Mimics the in Vivo Estrogen Proliferative Effects in the Uterus and Anterior Pituitary Gland from Ovariectomized Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM SAT 0355-0371 4967 1:00:00 PM Endocrine Disrupting Chemicals Action in Physiology and Cancer Poster

Meghan Quigley*, Amy Elizabeth Siebert, Julieta Saluzzo, Bryan Allender and Sumi Dinda
Oakland University, Rochester, MI

 

The estrogen, 17beta-estradiol (E2), is known to enhance cellular division in target cells by binding to the estrogen receptor (ER-alpha).  It has recently been reported that the phytoestrogen epigallocatechin-3-gallate (EGCG), a flavanol found in green tea and cocoa, suppresses cancer cell proliferation and may have antitumor properties. Thus, it is important to elucidate if the antitumor effects of EGCG involve ER-alpha. In this study, the effects of EGCG alone and in combination with hormones and anti-hormones were examined on cellular viability as well as expression and cytolocalization of ER-alpha protein in the hormone-dependent T-47D breast cancer cell line. Western blot analysis revealed alterations in the expression of ER-alpha after 24 hours of treatment with varying concentrations of EGCG (5 – 60 µM). The phytoestrogen induced a concentration-dependent decrease in ER-alpha protein levels, with a 56% reduction occurring with 60 µM EGCG when compared to untreated controls.  In order to determine the cellular influence of EGCG, image cytometric analysis with propidium iodide staining was utilized to quantify alterations in T-47D cell number and viability.  After six days of treatment, a 15 - 70% reduction in T-47D cell viability was observed upon treatment with 10 – 60 µM EGCG respectively.  To gain further insight into possible similarities between this phytoestrogen and other known effectors of ER-alpha, the optimal concentration of EGCG (60 μM) was used in combination with hormones and anti-hormones.  Down-regulation of ER-alpha protein levels was observed after 24 hour co-treatment of T-47D cells with 60 µM EGCG and 10 nM E2.  Similar effects also occurred when EGCG was in used in combination with the pure ER-alpha antagonist ICI (1 µM).  The proliferative effect of E2 in T-47D cells was reversed when treated in combination with EGCG.  In contrast, the combination of EGCG with ICI showed no further reduction in cell number as only 5% of the cells were viable after 6 days of treatment.  Additionally, confocal microscopy was utilized to examine the cytolocalization of ER upon exposure to EGCG alone and in combination with hormones and anti-hormones. Studies are currently underway to clearly delineate the interactions among the flavonoids and steroid receptors (estrogen and progesterone receptors) in breast cancer cells.

 

Nothing to Disclose: MQ, AES, JS, BA, SD

16409 12.0000 SAT-0366 A The Effects of Epigallocatechin-3-Gallate (EGCG) on Estrogen Receptor Alpha in T-47D Breast Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM SAT 0355-0371 4967 1:00:00 PM Endocrine Disrupting Chemicals Action in Physiology and Cancer Poster

Thozhukat Sathyapalan*1, Eric S Kilpatrick2, Alan S Rigby1, Natalie J Thatcher3 and Stephen L Atkin4
1Hull York Medical School, Hull, United Kingdom, 2Hull and East Yorkshire NHS Trust, Hull, United Kingdom, 3European Food Safety Authority, Parma, Italy, London, Italy, 4Weill Cornell Medical College Qatar, Doha, Qatar

 

Background

The effect of soy on testosterone levels in men with compensated hypogonadism is unknown, though increased habitual intake of soy phytoestrogens has been associated with a reduced risk of both type 2 diabetes (T2DM) and cardiovascular disease. 

Materials and Methods

A randomised double-blind, parallel study was undertaken with 210 T2DM men aged between 55 – 70 years with a total testosterone level ≤12nmol/L but with normal gonadotrophins. They were randomised either to preparation 1 (30g soy protein with 66mg of phytoestrogens) or preparation 2 (30g soy protein alone without any phytoestrogens; less than 300 parts per billion by serial ethanol washing) for 12 weeks.  Endothelial function was measured using the endopat 2000. The primary outcome was the change in total testosterone levels, whilst the secondary outcome was the change in cardiovascular risk markers.   

Results

The baseline parameters were comparable between the two groups.  There was a significant increase in serum total testosterone with both preparation 1 (9.83 ± 0.21 vs. 11.34 ± 0.36nmol/L  p value <0.01) and preparation 2 (9.22 ± 0.23 vs. 10.33 ± 0.3nmol/L; p value <0.01) .   There was a significant reduction in HbA1c (52.71 ± 1.19 vs. 50.16 ± 1.26 mmol/mol; p value =0.01), fasting glucose (7.93 ± 0.21 vs. 6.45 ± 0.15 mmol/L; p value <0.01), fasting insulin (19.78 ± 1.72 vs. 8.98 ± 0.63 µIU/mL; p value <0.01) and HOMA-IR (7.23 ± 0.73 vs. 2.59 ± 0.2; p value <0.01) after preparation 1 that was significantly greater than that for the preparation2. There were no changes in weight after either preparation. 

Triglycerides (1.67 ± 0.09 vs. 0.87 ± 0.04 mmol/L; p value-<0.01) and hsCRP (3.13 ± 0.46 vs. 0.69 ± 0.11; p value -<0.01) reduced significantly with preparation 1.  Diastolic blood pressure reduced significantly after both preparation 1 (80.86 ± 0.99 vs. 78.22 mmHg; p value 0.03) and preparation 2 (80.01 vs. 78.06 mmHg; p value 0.05) preparation.  There were no changes in systolic blood pressure for either group. There was a significant increase in reactive hyperemia index (RHI) (1.30 ± 0.06 vs. 2.35 ±0.08) with preparation 1 where as there was a significant reduction with preparation 2(1.92 ± 0.08 vs. 1.25 ± 0.25).

Conclusions

Soy protein with and without 66 mg phytoestrogen per day significantly improved testosterone levels in men with type 2 diabetes and low testosterone levels after 12 weeks.  There was a significant improvement in cardiovascular risk markers including glycemic control, triglycerides and hsCRP with soy protein and phytoestrogen combination compared to supplementation with soy protein alone.  

 

Nothing to Disclose: TS, ESK, ASR, NJT, SLA

13284 13.0000 SAT-0367 A The Effect of Soy Phytoestrogens on Cardiovascular Risk Markers in Men with Type 2 Diabetes and Subclinical Hypogonadism - a Randomised Double Blind Parallel Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM SAT 0355-0371 4967 1:00:00 PM Endocrine Disrupting Chemicals Action in Physiology and Cancer Poster

Beomhee Choia*1, Seung-Hwa Lee2, Sung Woo Han2, Seok Hoon Lee2 and Kyu-Nam Kim2
1CHA Anti-aging Institute,CHA University, Seoul, Korea, Republic of (South), 2Ajou University School of Medicine, suwon, Korea, Republic of (South)

 

Chronic low-grade inflammation is a cause of insulin resistance. Serum mercury is related with inflammation. This study investigated the association between serum mercury and insulin resistance. Subjects from the 2008-2010 Korean National Health and Nutrition Examination Survey (KNHANES) were selected (n=29,235) and the relevant data of 5,388 subjects (2,643 males and 2,745 females) were analyzed cross-sectionally. Homeostasis model assessment for insulin resistance (HOMA-IR) was compared according to serum mercury quartiles and the odds ratio of having the highest quartile of HOMA-IR according to serum mercury quartiles was calculated. Serum mercury levels in men and women were 5.90 μg/L and 4.12 μg/L, respectively, and fasting blood sugar (FBS), insulin, and HOMA-IR were significantly correlated with serum mercury. The correlation was stronger in men than in women. In men, FBS and HOMA-IR showed step-wise increases as the quartiles of serum mercury increased. HOMA-IR was significantly different in the third and fourth quartiles of serum mercury compared with the first quartile. In women, FBS and HOMA-IR were significantly different in the third and fourth quartiles of serum mercury compared with the first quartile. In addition, the odds ratio of having the highest quartile of HOMA-IR was significant in the top quartile of serum mercury (OR=1.720, 95% CI; 1.172-2.526) compared with the lowest quartile in men. In this large population-based study, serum mercury was correlated with HOMA-IR and may be a risk factor for insulin resistance in the Korean population.

 

Nothing to Disclose: BC, SHL, SWH, SHL, KNK

15423 14.0000 SAT-0369 A Serum Mercury May be a Risk Factor for Insulin Resistance in Healthy Koreans:Analysis of the Fourth and Fifth Korean National Health and Nutrition Examination Surveys 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM SAT 0355-0371 4967 1:00:00 PM Endocrine Disrupting Chemicals Action in Physiology and Cancer Poster

Elaine M F Costa*1, Fabiana M.N. Mendez2, Mirian Y Nishi3, Luciana Pinto Brito4, Chayrra Chehade Gomes5, Berenice B Mendonca6, Paulo Hilario Saldiva7 and Maria Ines Borella5
1University of São Paulo, Hospital das Clinicas, São Paulo, Brazil, 2University of São Paulo, Medical School. Laboratorio de Hormonios e Genetica Molecular/LIM42, Sao Paulo, Brazil, 3University of São Paulo, Hospital das Clinicas, Sao Paulo, Brazil, 4Laboratório de Hormônios e Genética Molecular- LIM/42, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 5University of São Paulo,, Sao Paulo, Brazil, 6Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular, LIM 42, Hospital das Clínicas, Faculdade de Medicina, São Paulo University, São Paulo, Brazil, São Paulo, Brazil, 7University of Sao Paulo, Sao Paulo, Brazil

 

Background: Air quality in urban areas tends to have undesirable concentrations of contaminants from biomass combustion. Recent data indicated that particle matter from diesel exhaust represents 23% of air particles in some areas. In addition, several studies have shown that female and male reproductive health can be negatively affected by air pollution. In vivo and in vitro studies demonstrated that diesel exhaust particles (DEP) modulate the estrogen activity, acting through estrogen receptors (ERs). Objective: We aimed to evaluate acute exposure to a mixture of the metals present in DEP on ovary of zebrafish. Methods: We evaluated the morphology and follicle reserve by histological analyses and count atretic oocytes, respectively. We also evaluated the expression pattern of ERs in ovaries of zebrafish by real time PCR. Adult females were exposed to ambient concentrations of combined metals (Ni = 0.181 mg / L, Fe = 0.07455 mg / L Pb = 0.05 mg / L; Cd = 0.029 mg / L; = 0.161 mg Cr / L, Cu = 0.017 mg / L) for 3 days. Statistical analysis was performed using the SPSS 13.0 computer package. The comparison of the number of atretic oocytes between the exposed and control groups was assessed using a paired-samples t test. The comparison of the triple ER gene expression between the groups was performed by the Mann-Whitney test. The level of significance was set as 5%. Results: The mean of atretic oocyte count was similar in both the exposed and control groups (1.5 ± 0.4 and 1.34 ± 0.3, respectively) (p> 0.05). The mean expression of the three estrogen receptor genes (esr1, esr2a, esr2b) were: 0.68, 1.32, 0.54, respectively. No significant difference in expression of these genes in relation to controls was observed. Discussion: Previous reports demonstrated a negative effect of metals on zebrafish ovaries, however they used Cd or Pb separately at higher doses than those used in present study, as well as longer exposure. In contrast, we tested, for the first time, the effects of the combination of trace elements in ambient concentration. Based on our data we can assume that: ambient concentration of metals was insufficient to alter the chosen parameters; time exposure was very short or adult animals was resistant to effects of trace elements. Conclusion: Acute exposure to environmental concentrations of trace elements in DEP did not diminish the number of atretic oocytes and also did not alter the ovary morphology or ER expression of ovaries of adult zebrafish.

 

Nothing to Disclose: EMFC, FMNM, MYN, LPB, CCG, BBM, PHS, MIB

16631 15.0000 SAT-0370 A Effects of Acute Exposure to Environmental Concentrations of Trace Elements in Diesel Exhaust Particles on Ovary of Zebrafish 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM SAT 0355-0371 4967 1:00:00 PM Endocrine Disrupting Chemicals Action in Physiology and Cancer Poster

Tselmeg Mijiddorj*1, Unurjargal Sukhbaatar2, Aki Oride3 and Haruhiko Kanasaki4
1Shimane University School of Med, Izumo Shi, Japan, 2Shimane University School of Medicine, Izumo, Japan, 3Shimane University, Izumo, Japan, 4Shimane Univ Sch of Med, Izumo, Japan

 

The present study demonstrates the action of pituitary adenylate cyclase-activating polypeptide (PACAP) on gonadotropin-releasing hormone (GnRH)-producing neuronal cells, GT1-7. Because we found the expression levels of PACAP type 1 receptor (PAC1R) to be low in these cells, we transfected them with PAC1R expression vector and observed the outcome. PACAP increased the activity of the serum response element (Sre) promoter, a target of extracellular signal-regulated kinase (ERK), as well as the cAMP response element (Cre) promoter in GT1-7 cells overexpressing PAC1R. We also observed ERK phosphorylation and cAMP accumulation upon PACAP stimulation. PACAP stimulated the promoter activity of GnRH receptor (GnRHR) with increasing levels of GnRHR proteins. Notably, the increase in GnRHR promoter activity from kisspeptin was potentiated in the presence of PACAP. A similar increasing effect of PACAP on the action of kisspeptin was observed for Cre promoter activity. On the other hand, the Sre promoter activated by kisspeptin was inhibited by co-treatment with kisspeptin and PACAP. Likewise, kisspeptin-increased GnRHR promoter activity and Cre promoter activity were both potentiated in the presence of cAMP, whereas the Sre promoter activated by kisspeptin was inhibited in the presence of cAMP. Our observations show that PACAP increases GnRHR expression and stimulates kisspeptin’s effect on GnRHR expression in association with the cAMP/PKA signaling pathway in GT1-7 cells overexpressing PAC1R. In addition, PACAP was shown to have an inhibitory effect on ERK-mediated kisspeptin action.

 

Nothing to Disclose: TM, US, AO, HK

13593 16.0000 SAT-0371 A Pituitary Adenylate Cyclase-Activating Polypeptide (PACAP) Increases Expression of the Gonadotropin-Releasing Hormone (GnRH) Receptor in GnRH-Producing GT1-7 Cells Overexpressing PACAP Type I Receptor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM SAT 0355-0371 4967 1:00:00 PM Endocrine Disrupting Chemicals Action in Physiology and Cancer Poster

Pinar Gumus Balikcioglu*1, Dorothee Kim Dang Newbern2, James Bain3, Michael Muehlbauer3, Robert Stevens2, Metin Balikcioglu4, Olga Ilkayeva3, Sarah Armstrong2, Krystal Irizarry2 and Michael Freemark3
1Duke University Medical Center, NC, 2Duke University Medical Center, 3Duke University Medical Center, Durham, NC, 4SAS Institute, Cary

 

BACKGROUND:

Obesity is the major determinant of insulin resistance, impaired glucose tolerance, and type 2 diabetes mellitus (T2D). However, only one-half of obese adolescents are insulin resistant and a much smaller percentage develop overt T2D.  The factors predicting insulin resistance in obese children are unclear.

OBJECTIVES:

To use metabolomic profiling and Principal Component Analysis (PCA) to identify biomarkers predicting insulin resistance and weight gain in obese adolescents.

DESIGN/METHODS:

We studied 82 overweight or obese pubertal adolescents (BMI ≥ 90%) aged 12 to 18 years, prior to and 6 mo after enrollment in a lifestyle program; 50% were female, 53% African-American, 21% Caucasian, and 10% Hispanic.  Body fat % (BF%) was estimated by electrical bioimpedance.  Fasting blood samples were analyzed for 45 acylcarnitine (AC) species, 15 amino acids, insulin, glucose, leptin, adiponectin, lipids, lactate, uric acid, fatty acids, ketones, and C-reactive protein.  PCA was used to correlate blood levels with 2 surrogate measures of insulin resistance: HOMA-IR and adiponectin. 

RESULTS:

Mean BMI% was 98.3 (SD 1.43), BMIz 2.30 (0.36), and body fat (BF)% 43.9 (7.25); BF% was higher in females than males.  Levels of the branched chain amino acids (BCAA) Leu/Ile and Val and uric acid were 12-18% higher (p<0.001) in males than females; conversely leptin was 49% higher in females (p<0.002).  HOMA-IR and Adiponectin were comparable.  In the cohort as a whole, HOMA-IR correlated positively with BMIz (R2=0.18) and triglycerides (R2=0.22) and a metabolic signature consisting of BCAA levels and metabolites (Leu/Ile, Val, Glu, C3, C5, C5:1 AC), uric acid, glucogenic AA (Pro, Ala), and long-chain acyl carnitines (R2=0.537, p<0.0001).  Conversely, HOMA-IR correlated negatively with metabolites of complete fatty acid oxidation (ketones, C2 AC, R2=0.537, p< 0.0001).   However, these correlations were driven largely by findings in males; in females, only BMIz correlated with HOMA-IR.  Likewise, Adiponectin, an insulin sensitizer, correlated inversely with BCAA, uric acid, and medium chain AC in males but not in females.  Leptin correlated with age and measures of body fat (BMIz) but not insulin sensitivity.  Interestingly, the major factors predicting a reduction in BMIz during lifestyle intervention were baseline levels of ketones and other metabolites of complete fatty acid oxidation (N=35, R2=0.194, p=0.040)

CONCLUSIONS:

There are striking sex dependent differences in biomarkers associated with insulin resistance and weight gain in obese adolescents. HOMA-IR and adiponectin in males are predicted by levels of BCAA, glucogenic AA, uric acid, ketones, and metabolites of complete fatty acid oxidation.   In contrast, HOMA-IR in females is asscociated primarily with BMIz.  Baseline levels of ketones and metabolites of complete fatty acid oxidation may predict weight loss during lifestyle intervention.

 

Nothing to Disclose: PG, DKDN, JB, MM, RS, MB, OI, SA, KI, MF

PP11-2 12267 1.0000 SAT-0142 A Gender Differences in Biomarkers Predicting Insulin Resistance and Weight Gain in Obese Adolescents: Metabolomic Profiling and Principal Component Analysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0142-0151 5063 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

David Carmody*, Megan Scott, Ashley Nicole Pastore, Rochelle N Naylor, Jessica Hwang, Michael E Msall, Scott J Hunter, Louis H Philipson and Siri Atma W Greeley
University of Chicago, Chicago, IL

 

Neonatal diabetes mellitus is a monogenic disorder caused by mutations in over 20 genes and occurs in approximately 1:100,000 births. Heterozygous activating mutations in the ATP-sensitive potassium (KATP) channel genes KCNJ11 and ABCC8 are most common and usually allow for treatment with oral sulfonylureas (SU) instead of insulin. Many of these patients also exhibit a spectrum of neurodevelopmental problems, from mild learning disorders to more severe mutations causing cognitive dysfunction or rarely seizures. Although these impairments have been thought to be due to mutated KATP channels that are widely expressed in the brain, the possibility that early diabetes and consequent glycemic excursions could lead to such dysfunction has not been addressed in a systematic fashion. Our objective was to compare neurodevelopmental outcomes in subjects with KATP mutations in comparison to subjects with mutations in genes not known to play a role in neurodevelopment, as well as healthy sibling controls.

 We performed targeted neuropsychological testing in subjects selected through the Monogenic Diabetes Registry (http://monogenicdiabetes.uchicago.edu/). Subjects were evaluated using a battery of neurodevelopmental and behavioral assessments including the Behavior Assessment System for Children (BASC), Behavior Rating Inventory of Executive Function (BRIEF), Vineland Adaptive Behavior Scales, Wechsler Adaptive Scale of Intelligence (WASI-II), Delis-Kaplan Executive Function System (D–KEFS) trail making task, Wechsler Intelligence Scale for Children (WISC-IV), Wechsler Adult Intelligence Scale (WAIS-IV) digit span task, Wechsler Individual Achievement Test (WIAT-III)  and Visual-Motor Integration (VMI).

 18 subjects with KATP mutations, 8 with other mutations (INS, GATA6, PDX1, GCK), and 25 sibling controls were assessed. Individuals with KATP mutations had significant differences in specific problem solving areas (Metacognition, WASI-II and WISC-4 Digit span) and behavioral symptoms (withdrawal, externalization and atypicality). Subgroup analysis of those with KCNJ11 mutations suggest that specific mutations confer varying degrees of impairment when assessed by VMI, while visual scanning was globally impaired in those with KCNJ11 mutations.

 Our data supports previous case reports noting a variety of neurodevelopmental problems in those with KATP mutations. This strongly suggests that the impairments seen in KATP subjects is likely due to direct effects of widely expressed mutated KATP channels in the brain. Careful characterization of the mutation specific neurodevelopmental problems will allow us to determine the potential cognitive beneficial effects of SU treatment. Our data can be used to counsel families and guide structured neurodevelopmental assessments and treatments based on the initial genetic diagnosis in patients with neonatal diabetes.

 

Disclosure: RNN: Advisory board meeting participant., Quest Diagnostics. Nothing to Disclose: DC, MS, ANP, JH, MEM, SJH, LHP, SAWG

PP11-1 17034 2.0000 SAT-0143 A Comprehensive Neuropsychological Testing in a Large Group of Subjects with Neonatal Diabetes: KATP Channel Mutations Are Consistently Associated with Specific Impairments, While Other Gene Causes Are Not 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0142-0151 5063 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Sonja Stutte1, Bettina Gohlke1, Annika Peiler1, Mark Born2, Peter Bartmann1 and Joachim Woelfle*1
1Children's Hospital, University of Bonn, Bonn, Germany, 2Children's Hospital, Bonn, Germany

 

Introduction: Early nutrition in infants with low birth weight aims at normalization of growth and the prevention of morbidity, but also has an impact on long-term health. Data on the interaction of early nutrition with metabolism and body composition later in life in extremely low birth weight (ELBW) infants are lacking.

Objective: To evaluate body composition, metabolism, growth and their interaction with early nutrition in former ELBW infants.

Patients/Methods: We assessed qualitative and quantitative nutritional intake during initial hospitalization and subsequent infantile growth parameters in 61 former ELBW infants with a birth weight < 1000g. In two follow-up exams, we measured physical and biochemical development at 5.7 and at 9.5 years. At 2nd follow up, in addition to re-assessing the metabolic profile body composition was analyzed by DEXA.

Results: Protein intake between birth and discharge was associated with weight gain in the first six months of life (r=0.51; p<0.01). Weight-catch-up preceded height-catch-up. Protein intake in early infancy correlated highly significant with abdominal fat mass, but not with lean-body-mass at 9.5 ys. In contrast to nutrient intake, birth weight associated with lean-body-mass (r= 0.433; p<0.001). Early protein and carbohydrate intake were associated with HDL-cholesterol, early catch-up growth correlated with fasting insulin at follow-up. Stepwise linear regression confirmed that protein intake predicted fat mass (p<0.05), whereas only gender and birth weight SDS contributed significantly to lean body mass variation (p<0.05).

Conclusion: Our results suggest an important impact of early nutrient intake on body composition and metabolism in later childhood in ELBW children.

 

Nothing to Disclose: SS, BG, AP, MB, PB, JW

16680 3.0000 SAT-0144 A Early Postnatal Nutrition and Its Impact on Body Composition, Growth and Metabolic Parameters in Children Born with Extremely Low Birth Weight 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0142-0151 5063 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Diego Gaytan-Saracho*, Patricia Medina-Bravo, Carolina Domínguez-Hernández, Miguel Klünder-Klünder, Miguel Flores-Armas and Feng Huang-Yang
Hospital Infantil de México Federico Gómez, Mexico Distrito Federal, Mexico

 

It´s know that babies who were small for gestacional age (SGA) have higher risk to present cardiovascular disease and type 2 diabetes (T2D) in the future.  This hypothesis suggests that babies that suffered malnutrition arrange some adaptations in order to modify the body functions and structures permanently. These adaptations could bring high metabolic and cardiovascular risk. Also it had been associated with metabolic syndrome and glucose metabolism dysfunction.  Nevertheless, few studies have evaluated if this association is related by the increase of abdominal body fat deposit and therefore a dysfunction in adipocytokines production.  Our objective was to evaluate if obese children who were small for gestational  age,  have higher metabolic risk represented in more abdominal body fat, adipocytokines alteration, dyslipidemia, insulin resistance (IR) compared with obese children who were born appropriate for gestational age  and children with normal body weight and who were appropriate for gestational age (AGA).

Methods. Cross sectional study was conducted on 92 children, both sexes, from 6 to 12 years old. They were divided in 3 groups. Group 1: SGA and obese. Group 2: Obese and AGA.  Group 3: adequate body mass index (BMI) and AGA. Glucose, insulin, lipids, liver function test and total adiponectin and high molecular weight (HMW) adiponectin were measured along with abdominal body fat by magnetic resonance imaging (MRI).

Results. We found that obese children and SGA had more fasting glucose (p= 0.054) and insulin levels (p< 0.001). A higher homeostatic model assessment- insulin resistance HOMA-IR (p<0.001), higher glucose (p<0.001), and insulin at 120 minutes (p<0.001), more subcutaneous fat index (p=0.007), total abdominal fat (p=0.022) and lower concentrations of HMW adiponectin (p=0.024) compared with others groups. We found that SGA and obese children (group 1) had lower concentrations of HMW adiponectin: -2.38 [IC95% -4.27; -0.42, p=0.018] and higher amounts of subcutaneous fat 28.05 [IC95% 0.40; 55.7, p= 0.047] compared with the other groups.   

We concluded that obese children who were SGA babies is factor that brings them to a higher amount of abdominal body fat, the HOMA-IR values and lower concentrations of high molecular weight adiponectin. With this information, we could prevent fetal growth alterations and provide the adequate nutrient content to the fetus and in some way, prevent metabolic alterations in the growing child.

 

Nothing to Disclose: DG, PM, CD, MK, MF, FH

15462 4.0000 SAT-0145 A Increased Abdominal Fat and Low High Molecular Weight Adiponectin Levels in Obese Children Born Small for Gestational Age 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0142-0151 5063 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Catherine S. Choong*1, Helen C Atkinson2, Rishi S Kotecha3, Nicholas Gottardo3, Denise Anderson4, Hazel Gough3, Kerrie Graham3, Fiona Kerr3, Mandy Taylor5 and Catherine H Cole3
1Princess Margaret Hospital for Children, Subiaco WA, Australia, 2The University of Western Austrailia, Perth, Australia, 3Princess Margaret Hospital for Children, Perth, Australia, 4The University of Western Australia, Perth, Australia, 5Sir Charles Gairdner Hospital, Perth, Australia

 

Background: Survivors of childhood acute lymphoblastic leukemia (ALL) have twice the risk of developing obesity in later life- an effect previously attributed to high doses of cranial irradiation.  Despite replacement of cranial radiation with intrathecal chemotherapy for the vast majority of ALL patients, obesity remains a significant problem during treatment and in later life.

Objective:To determine the change in body mass index (BMI) of children undergoing treatment for ALL at Princess Margaret Hospital (PMH).

Methods: Height and weight at the beginning of each treatment phase were obtained for all children diagnosed with pre-B and T-cell ALL at PMH between 2003-2007 (n=80). BMI was calculated and converted to z-scores adjusting for age and sex using the CDC 2000 growth charts. BMI centile categories were defined as underweight (<5th), normal (5-85th), overweight (85th-95th) and obese (>95th). Differences among BMI z-scores were analysed by repeated measures ANOVA using proc mixed in SAS 9.3.

Results: The mean duration of treatment was 3.2 years for boys (n=51) and 2.2 years for girls (n=29). At diagnosis 80% had a normal BMI with 8% overweight and 8% obese. Mean BMI z-scores increased from induction (0.18) to consolidation (0.58) then decreased by interim maintenance (0.05), thereafter BMI z-scores increased during maintenance (P<0.05). After 2 years of maintenance therapy BMI z-scores were greater in girls than boys (mean1.15 vs0.41; P<0.02). By the end of treatment only 42% of children were in the normal range for BMI. The increase in children in the obese category at the end of treatment compared to the beginning of treatment was significant for girls (7.4 vs 40.7 %; P<0.05 McNemar test) but not boys (8.5% vs 12.8%).

Conclusion: During treatment for ALL, a significant increase in BMI z-score was observed during maintenance therapy, with less than half of patients in the normal BMI category at the end of treatment. This increase in BMI was greater for girls than for boys with over 40% of girls in the obese category by the end of treatment.  This sex difference is notable, given that the duration of treatment in girls is shorter than for boys. Further studies are needed to determine the reasons for these observations and whether specific early intervention during therapy may reduce the risk of obesity in ALL survivors.

 

Nothing to Disclose: CSC, HCA, RSK, NG, DA, HG, KG, FK, MT, CHC

12055 5.0000 SAT-0146 A Changes in Body Mass Index during Treatment for Childhood Acute Lymphoblastic Leukemia at Princess Margaret Hospital from 2003-2007 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0142-0151 5063 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Nadine George Haddad*1, Zeina Melhem Nabhan2, Alan D. Rogol3 and Erica A Eugster4
1Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, 2Riley Hosp for Children, Indianapolis, IN, 3Univ of Virginia, Charlottesville, VA, 4Indiana University School of Medicine

 

Background:

Hypothalamic obesity is a common complication of treatment for childhood craniopharyngioma, and has been reported following both surgery and conventional radiation (CR). Proton beam radiation therapy (PBRT) is a newer treatment modality that has the advantage of delivering targeted doses of radiation to the tumor while relatively sparing normal tissue due a remarkable fall off in energy delivered to adjacent tissue. It is unknown whether PBRT alters the risk of hypothalamic obesity in children undergoing treatment for craniopharyngioma.

Objective:

To investigate change in body mass index (BMI) following treatment for craniopharyngioma in children receiving PBRT compared with other treatment regimens.

Methods:

Following IRB approval, we conducted a retrospective chart review of children who had received treatment for craniopharyngioma at Riley Hospital for Children between 1994 and 2012.

Results:

Twenty children (12 boys) aged 7.69 ± 4.30 years (range: 2.25 - 15.75) who had undergone treatment for craniopharyngioma were identified. Treatment consisted of subtotal tumor resection followed by PBRT (n=9), cyst decompression followed by PBRT (n=2), subtotal tumor resection followed by CR (n=4) and surgical resection alone (n=5).  In the 11 children treated with PBRT, the BMI z-score after an average duration of follow up of 4.2 years (range 0.5 - 8.25) was not significantly different from that seen at baseline (1.43 ± 1.45 vs.  1.30 ± 1.34, p=0.54). In the 9 children who received other treatment regimens, the average BMI z-score was 0.44 ± 1.5 at diagnosis and 1.90 ± 1.32 (p = 0.072) after an average duration of follow up of 9.22 years (range: 3.4 - 16.25). The rate of change in BMI-z-score during follow-up was significantly higher in children who received PBRT compared with those who did not (1.52 ± 0.78 vs 0.249 ± 0.68, p = 0.004).

Conclusion:

No differences in BMI z-score following treatment with PBRT in children with craniopharyngioma were detected. In contrast, the rate of change in BMI was significantly higher in children treated with other regimens. These data suggest that there is no added risk of hypothalamic obesity specific to PBRT. Prospective studies are required to delineate the individual contributions of surgery, PBRT and CR to the development of hypothalamic obesity in children with craniopharyngioma.

 

Disclosure: ADR: Consultant, Trimel, Consultant, SOV Therapeutics, Consultant, Abbott Laboratories, Consultant, Versartis. EAE: Principal Investigator, Endo Pharmaceuticals, Investigator, Abbott Laboratories. Nothing to Disclose: NGH, ZMN

15404 6.0000 SAT-0147 A Body Mass Index Remains Stable in Children with Craniopharyngioma Following Treatment with Proton Beam Radiation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0142-0151 5063 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Juliana oliveira Soares*1, Daniel Alves Bulzico2, Maria Alice Bordallo3, Isabel Rey Madeira4, Marcos Antonio Borges4, Beatriz camara Fernandes5 and Alexandra Monteiro Grisolia4
1Brazilian National Institute of Cancer (INCA Brazil, RJ)., 2Brazilian National Institute of, Rio de Janiero, Brazil, 3Brazilian National Institute of Cancer (INCA Brazil, RJ), 4Universidade do Estado do Rio de janeiro, UERJ, 5Hospital Municipal Jesus, HMJ

 

Metabolic syndrome (MS) represents the cluster of obesity, hypertension, dyslipidemia and impaired glucose metabolism, with insulin resistance as a central mechanism. Children treated for craniopharyngioma, who knowingly progress with high incidence of hypothalamic obesity (up to 50%), would present early the metabolic syndrome components  during childhood and adolescence and consequently may have a higher risk for cardiovascular disease in latter life.

 This is a cross-sectional evaluation study being conducted at The Pediatric Endocrinology Section of The Brazilian National Institute of Cancer (INCA Brazil, RJ). All cases with childhood diagnosed craniopharyngioma during 1988 to 2011 were included.

 For this preliminary report, 23 cases were evaluated with 13 females (56%) and 10 males (44%). The average age of diagnosis was 7.7 (±3.11). All cases were treated with tumor resection as a primary therapy. Of all the surgical interventions 13 were submitted at INCA and 10 of then in other institutions. Nine (39%) had complete resection and 14 (60%) remained with residual lesions after surgery.

 Amongst the studied population 16 (69%) of cases had overweight, in which 10 (43%) had obesity. The prevalence of high blood pressure was 13%, dyslipidemia 78% and the insulin resistance assessed by HOMA-IR 34%. Increased waist circumference was observed in 69% of cases. MS, defined as the International Diabetes Federation criteria, was diagnosed at 4 (17%) cases.

 Inflammatory parameters (leptin, interleukin-6, adiponectin and C-reactive protein) were evaluated between normal, overweight and obesity cases. Only leptin was significant higher among case with overweight and obesity [9,49(3,25 – 26,7); 22,54(20,16 – 27,08); 31,73(21,84 – 34,84), respectively P=0,02]. No significant statistical difference was found in glucose, HOMA-IR, HDL, triglycerides levels between groups of the studied population.

 This preliminary study shows that early life diagnosed craniopharyngioma patients seem to be a group of high prevalence of obesity and exposed to precocious cardiovascular risks factors.

 

Nothing to Disclose: JOS, DAB, MAB, IRM, MAB, BCF, AMG

15356 7.0000 SAT-0148 A The High Prevalence of Metabolic Syndrome and Cardiovascular Risks in Patients with Craniopharyngioma Diagnosis during Childhood and Adolescence 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0142-0151 5063 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Steven W Yau*, Kung-Ting Kao, Erin J Alexander, Vincenzo C Russo, George A Werther and Matthew A Sabin
Murdoch Childrens Research Institute, Parkville, Vic, Australia

 

Introduction: Insulin-like growth factor (IGF) binding protein 2 (IGFBP-2) may represent a critical link between body composition and insulin sensitivity(1). In adults, reduced levels are associated with obesity and insulin resistance(2). A previous study in a small cohort of obese children demonstrated that circulating IGFBP-2 was positively associated with insulin sensitivity but no association was seen with fat mass(3). The aim of this study was to investigate the relationship between anthropometric parameters, body composition, insulin sensitivity and energy intake with IGFBP-2 levels in a large cohort of overweight/obese Australian children.

Methods: Overweight and obese children were recruited from the Weight Management Service at the Royal Children’s Hospital (RCH), Melbourne, Australia. Comprehensive environmental, clinical and anthropometric data were collected along with a serum sample as part of the ‘Childhood Overweight BioRepository of Australia (COBRA)’ project(4). Insulin sensitivity was calculated by homeostasis model assessment (HOMA) and serum IGFBP-2 levels were measured by ELISA. Ethics was approved by the RCH Human Research Ethics Committee.

Results: 192 overweight/obese children were recruited (90 male/ 102 females, mean age 11 ± 0.26 (SE) years, BMI 32.1 ± 0.67 kg/m2, BMI z-score 2.45 ± 0.03). As expected insulin sensitivity correlated negatively with body weight (p<0.0001), BMI (p<0.0001), BMI z-score (p=0.0227), waist circumference (p<0.0001), % fat mass (p=0.0016), % truncal fat mass (p=0.0021), systolic and diastolic blood pressure (p<0.0001). Circulating IGFBP-2 negatively correlated with age (n=192; r=-0.1568, p=0.0299), height (n=190; r=-0.1657, p=0.0223), body weight (n=190; r=-0.1699, p=0.0191), BMI (n=190; r=-0.1762, p=0.0498), systolic blood pressure (n=175; r=-0.1774, p=0.0189), diastolic blood pressure (n=175; r=-0.1701, p=0.0244), % fat mass (n=142; r=-0.1712, p=0.0417), triglyceride (n=158; r=-0.2374, p=0.0027) and insulin (n=100; r=-0.2483, p=0.0127) and positively with insulin sensitivity (HOMA) (n=159; r=0.1766, p=0.026). Interestingly, there were no significant associations between dietary energy intake and IGFBP-2 levels.

Conclusion: These data demonstrate that circulating IGFBP-2 levels in obese youth inversely correlate with obesity and its metabolic markers, while positively correlating with insulin sensitivity. Similar findings in adults suggest that IGFBP-2 insufficiency may play an important role in the evolution of obesity and insulin resistance in early life.

 

Nothing to Disclose: SWY, KTK, EJA, VCR, GAW, MAS

16431 8.0000 SAT-0149 A IGFBP-2 Levels Are Associated with Increased Fat Mass and Reduced Insulin Sensitivity in Obese Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0142-0151 5063 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Shruti A. Fadia*1, Shufang Wu2, Bruce Bernstein2, Bryon Lauer2 and Francesco De Luca1
1St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, 2St. Christopher's Hospital for Children, Philadelphia, PA

 

Background: Vitamin D deficiency is highly prevalent in obese individuals. In addition, epidemiological studies have suggested that vitamin D deficiency may increase the risk for cardiovascular disease. Yet, it is still unclear whether low vitamin D levels are causally linked or simply associated with an impaired cardiometabolic status. We have previously shown that oxidative stress, a known risk factor for cardiovascular diseases, is associated with obesity and features of insulin resistance in children. The aim of this study was to determine whether the correction/improvement of vitamin D deficiency in an obese pediatric population is associated with improved oxidative stress status.

Methods: Urine samples for markers of oxidative stress were prospectively obtained from obese children (2-18 years) undergoing evaluation for vitamin D deficiency. Exclusion criteria included prior diagnosis of diabetes mellitus, hypertension, and use of medications known to affect insulin sensitivity or glucose metabolism. Subjects found with vitamin D deficiency (25-hydroxyvitamin D level < 20 ng/mL) or insufficiency (25-hydroxyvitamin D level 20-30 ng/mL) were treated with vitamin D according to standard of care guidelines.  A repeat urine sample was obtained at the follow-up visit (3-6 months). Retrospective chart review was performed to obtain anthropometric data and results of laboratory studies such as hemoglobin A1C, fasting glucose, insulin, and lipid levels at the initial and follow-up visits. Urinary 8-isoprostane and hydrogen peroxide, two established markers of oxidative stress, were measured using ELISA.

Results: 64 patients (39% male; mean age 12.1 ± 3.6 years; BMI Z-score, 2.32 ± 0.53) were recruited. 25 patients (38%) were African-American, 4 Caucasian (6%), 29 Hispanic (45%), and 7 other (11%). Mean initial 25-hydroxyvitamin (25OHD) level was 19.7 ± 6.8 ng/mL (range 4-35 ng/mL), while the mean urinary 8-isoprostane level was 6195 ± 4736 pg/mL and hydrogen peroxide level was 279 ± 78 ng/mL.

Thus far, 20 patients have been seen for follow up. Initial mean 25OHD level was 20.1 ± 5.6 ng/mL for this subset of patients. 25OHD levels were significantly higher (27.5 ± 8.9 ng/mL, Ρ 0.008), while the urinary 8-isoprostane levels and hydrogen peroxide levels were significantly lower than those obtained at the initial visit (4814 ± 3719 pg/mL, Ρ 0.011 and 251 ± 62 ng/mL, P 0.036 respectively). There was no significant change in BMI Z-score, fasting glucose, insulin, hemoglobin A1C, or lipid levels between initial and follow up visits.

Discussion: Although these results are preliminary and should be interpreted with caution, they suggest a favorable association between vitamin D treatment and markers of oxidative stress in obese children. Further analysis using a larger cohort is warranted.

 

Nothing to Disclose: SAF, SW, BB, BL, FD

16985 9.0000 SAT-0150 A Association Between Vitamin D Status and Markers of Oxidative Stress in Obese Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0142-0151 5063 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Asma Javed*, Zi Ye, Thais Coutinho, Iftikhar J Kullo and Seema Kumar
Mayo Clinic, Rochester, MN

 

Background: Obesity is a risk factor for vitamin D insufficiency and studies in adults have shown presence of endothelial dysfunction in asymptomatic vitamin D deficient subjects with improvement following vitamin D supplementation.  

Objective:To determine whether vitamin D3 supplementation improves endothelial function in obese adolescents with vitamin D insufficiency.

Methods:We enrolled 19 obese adolescents (mean age 15.8 ± 1.7; range 13-18 years, 36.8% female) with vitamin D insufficiency (25 (OD) D levels < 30 ng/ml) in an open label, single center prospective trial. Vitamin D supplementation was provided at 100,000 IU orally once a month for 3 months. Weight, height, blood pressure (BP), waist and hip circumference measurements were made at baseline and at the end of the study. We assessed endothelial function in the fasting state by measuring flow mediated dilatation (FMD) of the brachial artery as per published guidelines of the American Society of Echocardiography.

Biochemical parameters obtained at baseline and 3 months of once a month Vitamin D supplementation included 25 (OH) D concentrations, lipid profile, fasting glucose and insulin. Calcium intake and physical activity were assessed at baseline and end of study using a short calcium questionnaire (SCQ) and international physical activity questionnaire (IPAQ) respectively. Matched pair and simple correlation analyses were used to determine change in parameters and correlation between change in 25 (OH) D concentrations and other variables.

Results: Mean BMI of the subjects was 36.1 ± 6.04 kg/m2. Mean 25(OH) D concentrations increased from 22.4 ± 4.9 to 34.8 ± 6.7 (ng/ml) (P < 0.01). Mean (+- SD) FMD (%) was 9.5 ± 3.53 at baseline and did not change significantly at the end of the study (10.3 ± 3.83, P=0.83). There was no change in mean reactive hyperemia (%) at baseline of 449.8 ± 243.53 to 513.9 ± 325.6 (P=0.81) at the end of the study. Mean triglyceride concentration (mg/dl) increased from 105.1 ± 50.2 to 140.2 ± 71.6 (P=0.02) despite no change in BMI or other anthropometric measurements. Mean HDL, LDL, fasting glucose and insulin concentrations did not change (all P values > 0.05). SCQ and IPAQ scores did not change. Change in 25 (OH) D levels was not correlated with change in FMD or RH as well as lipids, glucose or insulin. Although the concentration of triglycerides increased over the 3 month period, this was not correlated with change in 25(OH) D levels (P=0.58).

Conclusions: Supplementation with once monthly Vitamin D in obese adolescents with Vitamin D insufficiency increased 25(OH)D levels but did not impact endothelial function.

 

 

Nothing to Disclose: AJ, ZY, TC, IJK, SK

16061 10.0000 SAT-0151 A Effect of Vitamin D Supplementation on Endothelial Function in Obese Adolescents with Vitamin D Insufficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0142-0151 5063 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

C S Bal*, Aayushi Garg, Saurav Chopra and Sanjana Ballal
All India Institute of Medical Sciences, New Delhi, India

 

Differentiated thyroid cancer (DTC) is rare in paediatric and adolescent population. Nodal and pulmonary metastases at the time of initial presentation are seen in large proportion of paediatric DTC patients. Unlike in adults, DTC in children and adolescents is observed to have a favourable overall prognosis in spite of aggressive initial presentation. This study was aimed at identifying the prognostic factors predicting remission in paediatric and adolescent (DTC) patients presenting with pulmonary metastases at diagnosis. Among the 481 DTC patients treated at our tertiary care center with age ≤ 21 years, 53 (11%) patients were diagnosed with pulmonary metastases at initial presentation. None of the patients had history of exposure to radiation in infancy or childhood. Pulmonary metastasis was diagnosed by chest x-ray in 10 patients (macronodular). Of the x-ray negative patients, CT scans detected pulmonary metastases in 29 patients (micronodular) and in the remaining 14 patients, lung lesions were detected either in pre- or post therapy 131I whole-body scans (diffuse). The demographic characteristics and treatment profile of patients were retrospectively extracted from clinic database. Statistical analyses were performed using chi square/Fisher’s exact test. Stepwise multivariate logistic regression was used to identify the independent predictors of remission. Thirty-eight patients (71.7% became disease free with mean number of administration 3.5 (range: 1-10) and mean 131I activity required to achieve complete remission was 410 mCi (range: 88-1264 mCi). During the median follow-up of 72 months (range, 12-324 months) none of the children showed evidence of recurrence, however, 14 patients had biochemically and/or structurally persistent disease and 1 patient died due to disease progression. Univariate analysis revealed adverse prognostic factors like age >15 years at the time of diagnosis, macronodular pulmonary metastases and surgical methods lesser than total/near-total thyroidectomy. The same factors of decreased likelihood of remission retained significance in multivariate logistic regression as well. To conclude, the present study suggests that more aggressive treatment with RAI is required in patients with age>15 years and/or with macronodular lung metastases in order to achieve remission. Moreover, this study reconfirms that total/near-total thyroidectomy is associated with better response to RAI therapy.

 

Nothing to Disclose: CSB, AG, SC, SB

PP11-3 13077 1.0000 SAT-0152 A Prognostic Factors in 53 Paediatric and Adolescent Differentiated Thyroid Cancer Patients Presenting with Pulmonary Metastases 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0152-0161 5064 1:00:00 PM Thyroid Pediatric Endocrinology Poster

Trang N. Le*, Francesco S. Celi and Edmond P. Wickham III
Virginia Commonwealth University, Richmond, VA

 

Background: Thyroid stimulating hormone (TSH) secretion is extremely sensitive to circulating levels of thyroid hormone and is used clinically as an index of thyroid homeostasis. Increased TSH levels, even within the euthyroid range, have been associated with cardiometabolic risk factors such as obesity, lipid status, and blood pressure in adults; however, this relationship has been less completely characterized children and adolescents.

Hypothesis: Higher levels of TSH, even within the normal reference range, will be associated with traditional cardiometabolic risk factors including obesity, blood pressure, lipid and glucose metabolism in children and adolescents without evidence of thyroid disease.

Methods: Data were extracted from the cross-sectional National Health and Nutrition Examination Survey database, 2007-2010, for subjects aged 12-19 years to assess for relations between TSH levels, body mass index (BMI), and cardiometabolic risk factors. Inclusion criteria were TSH within the normal range (0.35-5.6 uIU/mL) and negative thyroid peroxidase antibodies (≤9.0 IU/mL); exclusion criteria included a history of thyroid disease or diabetes or pharmacologic treatment for hypertension or dyslipidemia. Univariate and multivariate analyses were performed of associations between TSH and age, sex, race, BMI Z-score, systolic and diastolic blood pressure, fasting lipid parameters (total cholesterol [TC], HDL-cholesterol, LDL-cholesterol, triglycerides [TG], and apolipoprotein B [ApoB]) and glucose metabolism (fasting glucose, fasting insulin, 2-hour glucose and homeostasis model assessment of insulin resistance [HOMA-IR]), with a pre-determined significance level of <0.01 to account for multiple comparisons.

Results: A sample of 1,167 euthyroid adolescents were eligible for analysis (mean age 15.0±1.91 yrs, 53.0% male), with a mean TSH of 1.60±0.83 uIU/mL. In univariate analyses, significant positive linear correlations were observed between TSH and BMI Z-score (r=0.08, p=0.008), systolic blood pressure (SBP) (r=0.11, p<0.001), TC (r=0.12, p<0.001), TG (r=0.12, p=0.007), ApoB (r=0.14, p<0.002), fasting glucose (r=0.16, p<0.001), fasting insulin (r=0.13, p=0.002), 2-hour glucose (r=0.18, p<0.001),), and HOMA-IR (r=0.15, p<0.001). Subsequent multivariate analyses indicated that relations between TSH and SBP, TC, ApoB, fasting glucose, fasting insulin, and HOMA-IR remained significant after controlling for the impact of age, sex, race, and BMI Z-score.

Conclusion: In U.S. adolescents without evidence of thyroid disease, TSH levels (even within the normal reference range) are positively correlated with multiple cardiometabolic risk factors. Moreover, these relations are independent of the previously-established impact of age, sex, race, and obesity on many of these parameters.

 

Nothing to Disclose: TNL, FSC, EPW III

PP11-4 14121 2.0000 SAT-0153 A Thyroid Stimulating Hormone Levels Are Associated with Cardiometabolic Risk Factors in Euthyroid Adolescents 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0152-0161 5064 1:00:00 PM Thyroid Pediatric Endocrinology Poster

Suzy Bianco*1, Diana Martinez2, Renata Machado Soares3, Elizabeth Mora Garzon3, Lattoya J Lartey3, Tatiana L Fonseca3, Layla M Camargos3, Elizabeth A McAninch3 and Antonio C Bianco3
1University of Miami, Miami, FL, 2University of Miami, Miami, 3University of Miami

 

The type 3 deiodinase (D3) mediates the major pathway for thyroid hormone inactivation such that mice with homozygous inactivation of the D3 gene (Dio3) exhibits robust thyroid and metabolic phenotypes that include infertility. To learn more about the effects of Dio3 inactivation on puberty and fertility, the complexity of the Dio3-/- homozygous phenotype was overcome by studying Dio3+/- heterozygous mice, which are systemically euthyroid. Puberty onset was estimated by anogenital distance, gonadal weight, serum luteinizing hormone (LH) and sex steroid levels, and age at vaginal opening (VO). Reproductive competence was estimated by the appearance of a vaginal plug and pregnancy rate in mating females. Anogenital distance and gonadal weight were not altered in Dio3+/- animals, whereas VO was consistently 1-day earlier in Dio3+/- females (*p<0.03), indicating precocious puberty. Additional signs of precocious puberty in the Dio3+/- females were elevated serum LH and estradiol levels at puberty. Conversely, Dio3+/- males exhibited delayed puberty, as evidenced by a 4-day delay in the pubertal surge of serum LH and testosterone levels when compared with littermate controls. Dio3+/- females also exhibited reduced fertility, as indicated by pregnancy success that followed the vaginal plug (40±11% vs. 100±0%; ***p<0.0001). Conclusions: Heterozygosis for Dio3 inactivation altered puberty onset in a sexually dimorphic fashion, with precocity in females and delay in males. Heterozygosis for Dio3 inactivation also resulted in low female fertility. These results indicate a role for Dio3 on sex-specific pubertal maturation and fertility.

 

Nothing to Disclose: SB, DM, RMS, EMG, LJL, TLF, LMC, EAM, ACB

16284 3.0000 SAT-0154 A Heterozygosis for Inactive Type-3 Deiodinase Gene in Mice Results in Delayed Puberty in Males and Precocious Puberty with Low Fertility in Females 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0152-0161 5064 1:00:00 PM Thyroid Pediatric Endocrinology Poster

Dorte Hansen*1, Rikke Havgaard Mikkelsen2 and Maria Smedegaard Andersen2
1Odense University Hospital, Odense, Denmark, 2University of Southern Denmark, Odense, Denmark

 

Juvenile thyrotoxicosis (JT) is a rare disease in childhood. Previous studies have presented incidence rates ranging between 0.9-6.5/100.000 person years. In Denmark a nationwide study was performed in 1982-1988, showing an incidensrate of JT of 0.79/100.000 person years in children younger than 15 years. A few studies have demonstrated an increasing incidence of JT in accordance with the increasing incidence of other autoimmune diseases like type 1 diabetes and coeliac disease. The objective of the present study was to determine if the incidence rate of JT in Denmark has increased over the last decades.

Methods In this nationwide, retrospective study all children less than 15 years old and diagnosed with thyrotoxicosis between 1998-2012 were identified through the Danish National Patient Registry. The medical records of all patients were reviewed to verify the diagnosis. Incidence rates according to age, gender and time of diagnosis were calculated. The results were compared to previous published national data from 1982-1988.

Results A total of 237 patients diagnosed with JT between 1998-2012 were identified. The mean age at diagnosis was 12.1 years, and the female:male ratio was 4.3:1.The mean IR during the study period was 1.58/100.000 person years and increased from 1.31/100.000 person years in 1998-2002 to 1.83/100.000 person years in 2008-2012. The IR had increased significantly since 1982-1988 (p<0.001). The IR was significantly higher in females compared to males (p<0.001) and increased significantly with age (p<0.001).

Conclusion The incidence rate of thyrotoxicosis in children below 15 years has increased significantly in Denmark since 1982-1988, and has continued to increase in the last 15 years. Still thyrotoxicosis is a rare disease in Danish children, with an overall IR of 1.58/100.000 person years. The highest incidence rates were found in females and adolescents.

 

Nothing to Disclose: DH, RHM, MSA

12906 4.0000 SAT-0155 A Increasing Incidence of Juvenile Thyrotoxicosis in Denmark 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0152-0161 5064 1:00:00 PM Thyroid Pediatric Endocrinology Poster

Mimi S. Kim*1, Houchun H Hu1, Mitchell E. Geffner1, Patricia C Aggabao2, Anh Dao-Tran3 and Vicente Gilsanz1
1Children's Hospital Los Angeles, The Saban Research Institute, Los Angeles, CA, 2Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, 3Children's Hospital Los Angeles, Los Angeles, CA

 

Background: Brown adipose tissue (BAT) generates heat during non-shivering thermogenesis, via programmed mitochondrial uncoupling, in response to cold temperatures. Thyroid hormone receptors, type 2 deiodinase, and TSH receptors are present on brown adipocytes, indicating that thyroid hormone is a regulator of BAT. It is unknown whether the absence of thyroid hormone in humans with severe primary hypothyroidism would down-regulate the development of BAT and its thermogenic function. As BAT is more prevalent in children than adults, we studied a pediatric patient with severe hypothyroidism due to Hashimoto thyroiditis, pre- and post-replacement with thyroid hormone.

Methods: An 11.6-year-old female with severe hypothyroidism was recruited from the pediatric endocrinology clinic. Prior to levo-thyroxine (LT4) replacement, she had serum analytes (free T4, TSH, thyroglobulin, thyroid antibodies) drawn, and a magnetic resonance imaging (MRI; 3T system; Achieva, Philips Healthcare) scan to provide thyroid and BAT measures. Chemical-shift water-fat MR technique was used to obtain quantitative measurements of fat and water content (fat fraction) in the supraclavicular adipose depot. Infrared thermal imaging (FLK-Ti32, Fluke) was performed to assess skin temperature differences between the supraclavicular area and other areas of the upper thorax and neck. In addition to the baseline visit, she had a follow-up visit when TSH normalized, with serum thyroid function tests, MRI, and thermal imaging repeated. Data are presented as mean ± SD.

Results: The patient was severely hypothyroid at diagnosis (TSH 989 µIU/mL, free T4 0.10 ng/dL, thyroglobulin 3.0 ng/mL, elevated anti-thyroid antibodies) with no detectable thyroid tissue on MRI. Low MRI measures of fat fraction (56.1% ± 3.7) indicated that BAT was abundantly present in the supraclavicular fossa. Thermal imaging showed a 3°C higher temperature in the supraclavicular area when compared to the suprasternal notch. The patient was euthyroid in 2 months (TSH 4.3 µIU/mL, free T4 1.49 ng/dL, T3 102 ng/dL) at which time there was a small decrease in BAT in the supraclavicular fossa as indicated by an increase in fat fraction (60.7% ± 3.8). The overall size of the supraclavicular fat depot decreased in volume from 84.79 mL to 41.21 mL. Thermal imaging revealed a higher and more homogeneous skin temperature throughout the upper thorax.

Conclusion: These findings document the presence of BAT and thermogenesis in the absence of thyroid hormone in a severely hypothyroid adolescent. This suggests a role for TSH, and/or TRH, as a potential regulator of BAT.

 

Nothing to Disclose: MSK, HHH, MEG, PCA, AD, VG

14430 5.0000 SAT-0156 A Presence of Brown Adipose Tissue in the Absence of Thyroid Hormone in a Severely Hypothyroid Adolescent 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0152-0161 5064 1:00:00 PM Thyroid Pediatric Endocrinology Poster

Patria Alba Aponte*1, Naim Mitre2 and Matthew Maximilian Feldt3
1Children's Mercy Hospital and Clinics, Kansas City, MO, 2Children's Mercy Hospitals and C, Kansas City, MO, 3Children's Mercy Hospital, Kansas City, MO

 

More Than One Way to Skin a Thyroid.   Managing Pediatric PrimaryHypothyroidism with Weekly Intramuscular Levothyroxine: A case series report

 Introduction:

Oral levothyroxine (L-T4) supplementation is usually an effective therapy in pediatric hypothyroidism. Adult literature describes circumstances in which parenteral L-T4 is required after failure to oral therapy due to malabsorption, pseudomalasorption, GI disease, or poor compliance. In the pediatric population there is a paucity of information. We present three cases of successfully treated primary hypothyroidism with intramuscular (IM) levothyroxine.

 

Case 1: 16 year old female with post ablative hypothyroidism secondary to Graves’s disease was placed on oral L-T4 replacement therapy but was unable to remain euthyroid, TSH: 409 uIU/mL (0.35-5.5uIU/mL). Evaluation for malabsorption was negative. Poor compliance was ruled out by observed administration. L-T4 IM 100 mcg was initiated and titrated up to 500 mcg IM weekly with normalization of TSH achieved in 6 months.

Case2: 12 year old female with autoimmune hypothyroidism (AH) remained euthyroid on oral L-T4 for 2 years. However, TSH became elevated (186 uIU/mL) despite increasing doses of L-T4 as high as 200 mcg/day with observed administration. Malabsorption evaluation was negative. L-T4 IM 100 mcg weekly was started and was increased by 100 mcg every 6 weeks to 500 mcg weekly until the TSH normalized.

Case 3: 6 year old female with developmental delay and AH failed to remain euthyroid on enteral L-T4, administered via G-tube. Malabsorption evaluation was negative. L-T4 IM 25 mcg was started and titrated to 300 mcg weekly, achieving normalization of TSH.

 Conclusion:

To our knowledge, this is the first pediatric case series of successful intramuscular L-T4 therapy in refractory primary hypothyroidism. Prior adult studies have shown safe and effective use of weekly intramuscular L-T4. Weekly administration is plausible, since L-T4 has an elimination half life of about 7-10 days. The relative bioavailability between oral and IV dosage is close to 50%. The IM equivalence seems similar. Poor compliance is the most common cause for non response to oral L-T4 therapy. Other causes should be investigated before making a diagnosis of non compliance; although, in the cases presented, a specific cause was not found. Our case series demonstrates that once weekly intramuscular L-T4 dosing may be a safe, successful and well tolerated treatment regimen for pediatric patients. Additional studies including larger number of patients are warranted to clarify the efficacy and safely of this method.

 

Nothing to Disclose: PA, NM, MMF

11620 6.0000 SAT-0157 A More Than One Way to Skin a Thyroid. Managing Pediatric Primary Hypothyroidism with Weekly Intramuscular Levothyroxine: A Case Series Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0152-0161 5064 1:00:00 PM Thyroid Pediatric Endocrinology Poster

Mamatha Kambalapalli*1, Gary Lee Francis2 and Anshu Gupta3
1VCU, Richmond, VA, 2Medical College of Virginia, Richmond, VA, 3VCU, Glen Allen, VA

 

Introduction:  Autoimmune thyroiditis (AIT) is common in children. Recent studies have reported a high prevalence of thyroid nodules in up to one-third of children with AIT (1). Thyroid nodules although uncommon in children are more likely to be malignant compared to adults (26% vs. 5%) (2). There is however, scant data about US characteristics and prevalence of thyroid nodules in children with AIT in United States.

Objective:  To evaluate the US characteristics of thyroid gland in children with AIT and assess prevalence of thyroid nodules in children with AIT.

Methods: Retrospective review of US characteristics of 154 children between 6-18yrs age with goiter from July 2008 to Dec 2010 was done. US characteristics were compared with patient’s age, gender, levels of Thyroid stimulating hormone (TSH) and thyroid peroxidase antibody titer (TPO). Thyroid gland heterogeneity and nodule prevalence in those with AIT and those with negative antibodies was compared.

Results:  Prevalence of Thyroid gland heterogeneity was more in those with positive antibodies (83%, 57/69) compared to those with no antibodies (53%, 25/47; p-value: 0.0007). Prevalence of nodules was not different in children with goiter in the presence or absence of antibodies (17%). There was no correlation of degree of heterogeneity or presence of thyroid nodule with TSH level or TPO antibody titer.

Conclusion: In this study prevalence of nodules in AIT was much lower (17%) compared to previously reported 32%. Prevalence of nodules in AIT was not higher than in children with goiter and negative antibodies.

 

Nothing to Disclose: MK, GLF, AG

11275 7.0000 SAT-0158 A Ultrasound Characteristics of Autoimmune Thyroiditis in Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0152-0161 5064 1:00:00 PM Thyroid Pediatric Endocrinology Poster

Eileen A. Báez*1, Marie L. Haymon2 and Stuart Alan Chalew3
1LSUHSC, New Orleans, LA, 2Children's Hospital of New Orleans, New Orleans, LA, 3LSU Health Sciences Center and Children's Hospital of New Orleans, New Orleans, LA

 

In adults, thyroid tissue permeated throughout by small cysts on ultrasound has been termed “polycystic thyroid disease (Thyroid 20:205-208, 2010).”  The condition is rare and associated with the development of hypothyroidism, but not linked with the presence of thyroid auto-antibodies.   

The occurrence and significance of this condition in children is unclear. Over the last several years, we diagnosed 6 patients (4 males and 2 females, mean age 12.4 years, range 7y10m – 14y2m at diagnosis) with similar polycystic thyroid changes on ultrasound (US) as has been previously noted in adults.    In 3 of 6 patients, the unusual polycystic thyroid anatomy was incidentally noted during head and neck imaging unrelated to thyroid concerns. One of these patients had Gorlin Goltz syndrome, a condition not previously associated with thyroid pathology.   Two other patients presented with goiter, and one patient was referred for a possible nodule (not subsequently present on imaging).   On ultrasonography, all 6 patients had increased thyroid gland size, with multiple small cysts (≤5 mm) throughout the gland, but without  evidence of vascular changes or echogenicity.   All 6 patients had normal free T4, TSH, and negative thyroid auto-antibodies.  Two patients were placed on thyroid replacement therapy (one with Gorlin Goltz).  Follow up blood work and imaging for these 2 patients were unchanged after 20 months and 4 years respectively.  Two untreated patients have been followed for 3 months, and 3 years respectively.  These remain biochemically euthyroid, antibody negative and without ultrasound change.    Two patients have been lost to follow up.

Pediatric polycystic thyroid is an uncommon condition, frequently asymptomatic and  often discovered incidentally during head and neck imaging for a non thyroid indication.  All patients in our series demonstrated increased thyroid size on US.  Our small patient series followed for up to 4 years did not show anatomic or biochemical progression over this short period.  Though, 2 patients were on thyroid replacement therapy which may have inhibited progression of pathology.  In adults, similar abnormal thyroid anatomy has been associated with eventual hypothyroidism.  Thus it may be prudent to arrange long term follow up of pediatric patients identified with polycystic thyroid as they may gradually demonstrate loss in thyroid function over time.

 

Nothing to Disclose: EAB, MLH, SAC

14116 8.0000 SAT-0159 A Pediatric Polycystic Thyroid: Rare Innocent Finding or Harbinger of Disease? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0152-0161 5064 1:00:00 PM Thyroid Pediatric Endocrinology Poster

Tal Grunwald*1, Elizabeth A Suarez1 and Francesco De Luca2
1St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, 2St. Christopher's Hospital for Children, Philadelphia, PA

 

Background

Graves' disease typically presents with a goiter, while the usual physical finding associated with thyroid cancer is a solitary thyroid nodule. We present a case of an adolescent female with clinical and biochemical hyperthyroidism and a lateral neck mass, without a goiter or a thyroid nodule, and found to have metastatic papillary thyroid cancer.

Clinical Case

A.R. is a 15-year old female who was seen in the Endocrinology clinic at St. Christopher’s Hospital for Children because of hyperthyroidism. Laboratory tests requested by her pediatrician 2 weeks prior to her visit revealed elevated FT4 (1.63 ng/dL; nl 0.93-1.6), suppressed TSH (0.02 mIU/L; nl 0.45-4.5) and normal total T3 (148 ng/dL; nl 71-180). She was found to have positive thyrogloblulin antibody (11 IU/mL; nl, <1), positive thyroid peroxidase antibody (367 IU/mL; nl, 0-26) and positive TSI (231%; nl 0-139%), consistent with Graves disease. Her review of systems was positive for a 12 lb weight loss over 1 year, and palpitation and lightheadedness that started a week prior to her endocrine visit. On examination, she was found to be normotensive, with blood pressure of 112/68, and with normal heart rate of 80. She had no thyromegaly nor palpable thyroid nodules but found to have a discrete left neck mass, which measured 4 cm x 5 cm. No other masses/lymphadenopathies were appreciated on neck palpation. Repeat thyroid function tests at the time of her visit revealed a persistently low TSH (0.082 mIU/L), but her free T4 (1.2 ng/dl) and total T3 (108 ng/dl) levels had normalized.

A neck ultrasound showed a normal sized thyroid without thyroid nodules. Inferior and lateral to the left thyroid lobe and lateral to the blood vessels, a 3.7 x 5.1 x 2.8 cm solid mass with mixed echogenicity was identified. No discrete cervical lymphadenopathy was noted. Excision biopsy of the mass was performed and revealed metastatic papillary thyroid carcinoma. Repeat thyroid function tests prior to her thyroidectomy showed persistently elevated TSI of  254% but normal TSH (2.020 uIU/ml), Free T4 (1.26 ng/dl) and T3 (129 ng/dl).

Conclusion

This is an atypical presentation of metastatic papillary thyroid cancer in the absence of thyroid nodule and goiter in an adolescent female with newly-diagnosed Graves' disease. The cause of her transient biochemical hyperthyroidism, despite her persistently high TSI titer is unclear. It also underscores the importance of including metastatic thyroid cancer in the differential diagnosis of a neck mass even in the absence of thyroid nodule or goiter.

 

Nothing to Disclose: TG, EAS, FD

16825 9.0000 SAT-0160 A Unusual Presentation of Both Graves Disease and Metastatic Papillary Thyroid Cancer in an Adolescent Female 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0152-0161 5064 1:00:00 PM Thyroid Pediatric Endocrinology Poster

Toni Eimicke*1, Jeanne Parker1, Eleanor Mulcahy2, Alan Howard Morris1 and Jerrold S. Olshan1
1The Barbara Bush Children's Hospital @ Maine Medical Center, Portland, ME, 2Maine CDC CSHN

 

While investigating the prevalence of transient congenital hypothyroidism (CH), one group of investigator (1) reported 44.7% of infants with CH in their population were lost to follow-up (LTFU) by 3 years of age. This led us to discover there is a dearth of literature focusing on follow-up rates of CH patients and strategies to optimize these rates. Given the critical role of thyroid hormone in normal cognitive development and growth in infancy and childhood, it is imperative that children with CH are closely monitored in the first 3 years of life. The authors of the aforementioned study concluded that further research is necessary to develop evidence-based guidelines, including follow-up program operations and reassessment methods, for providers caring for children with CH.  

Patients identified by the Maine Center for Disease Control (CDC) Newborn Bloodspot Screening Program (NBSP) as having CH are a unique population in that they are all initially evaluated by pediatric endocrinologists and nearly all continue to be followed by this specialty through 3 years of age. A review of Maine’s newborn program screening data confirmed that 94.4% of children with CH who turned 3 years of age during the 2012 and 2013 calendar years (N=18) have received appropriate follow-up by pediatric endocrinologists. Based on this encouraging data, we suspect our CH patient population will have a much lower degree of loss to follow-up than is described by other investigators. To quantify our rates of follow-up, we will perform a retrospective analysis of at least 139 patients (to allow for 5% precision) identified through Maine CDC NBSP as having CH. If this retrospective data analysis concludes that we have low LTFU rates, we believe this will provide evidence to support guidelines that include endocrinology involvement in all CH patients for at least the first 3 years of life.

 

Nothing to Disclose: TE, JP, EM, AHM, JSO

16293 10.0000 SAT-0161 A Optimizing Congenital Hypothyroidism Follow-up in the First 3 Years of Life 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM SAT 0152-0161 5064 1:00:00 PM Thyroid Pediatric Endocrinology Poster

Gang Xi*, Christine Wai and David R Clemmons*
University of North Carolina at Chapel Hill, Chapel Hill, NC

 

AMP-activated protein kinase (AMPK), an important regulator of cellular energy metabolism, has been shown to regulate skeletal muscle differentiation but studies that have investigated its role in osteoblast differentiation have given contradictory results. In the current study, we carefully determined the temporal sequence of AMPK activation during differentiation in MC-3T3 E1 osteoblasts. The results showed that differentiation medium, containing 10% FBS , 50ug/ml ascorbic acid and 4 mM β-glycerol phosphate, stimulated AMPK activation at the early stages of differentiation (e.g. days 3-9) but this change  was significantly attenuated  at the later stages of differentiation (e.g. days 12-21). Therefore, AMPK activation during differentiation appeared to be biphasic. Since our previous study showed that the timing of differentiation was significantly accelerated in osteoblasts overexpressing IGFBP-2 and delayed in IGFBP-2 knockdown cells, to further assess whether early AMPK activation is important for osteoblast differentiation, we examined AMPK activation in these cell types.  AMPK activation was enhanced in IGFBP-2 overexpressing cells (e.g., 35 ± 6% and 87 ± 9% increases on days 3 and 6, p<0.05) and impaired in IGFBP-2 knockdown cells (e.g., 41 ± 4% and 53 ± 5% reductions on days 3 and day 6, p<0.05). Consistently, either IGF-I or a peptide containing the  heparin bind domain of IGFBP-2, both reagents have been shown to stimulate osteoblast differentiation, enhanced AMPK activation at the early stage of differentiation (e.g., 64 ± 12% or 76 ± 18% increase on day 6, respectively, compared to control cultures, p<0.05). Therefore, these results suggested that activation of AMPK at the early stages is stimulating osteoblast differentiation.

To definitely define the role of AMPK in the osteoblast differentiation, we manipulated AMPK activation using chemical compounds and mutagenesis at different stages of differentiation.  Addition of the AMPK inhibitor, compound C, caused a highly significant reduction in differentiation as indicated by Alizarin Red staining and expression of osteocalcin. However, this suppression only occurred when the inhibitor was added at an early stage, such as on day 0 or day 3 and the addition at later time points had no effect. In contrast overexpression of constitutively activated AMPK (AMPK T172D) dramatically inhibited cell differentiation (e.g., 88 ± 10% suppression of osteocalcin expression compared to control cells, p<0.01). The addition of the AMPK inhibitor, compound C, after day 9 partially restored differentiation, thereby demonstrating that suppression of AMPK activation at the later stages was required for optimal osteoblast differentiation. In summary, these findings clearly indicate that an ordered sequence of   AMPK activation followed by its inhibition is necessary component of the series of events leading to osteoblast differentiation.

 

Disclosure: DRC: Chief Scientific Officer, Vascular Pharmaceuticals. Nothing to Disclose: GX, CW

18014 1.0000 LBSA-0267 A Sequential Activation Followed By Inactivation of AMP-Activated Protein Kinase Is Required for Osteoblast Differentiation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM LBSA 0267-0273 5236 1:00:00 PM Bone, Calciotropic Hormones, & Vitamin D Poster

Naziya Tahseen*1, Hongying Dai2, Gary Krueger1 and Tarak Srivastava1
1Children's Mercy Hospitals and Clinics, Kansas City, MO, 2Children's Mercy Hospital, Kansas City, MO

 

Background: Bisphosphonates (BPs) are anti-resorptive agents that decrease bone turnover markers and increase bone mineral density (BMD) by inhibiting the osteoclasts. BPs are used in children for treatment of primary osteoporosis, secondary osteoporosis and osteogenesis imperfecta. Our earlier observations in 17 children suggested that the Bisphosphonates effect on Bone mineral density is sustained for up to 2 years [Pediatr Nephrol 2009; 24:613-7]. 

Hypothesis: The effect of Bisphosphonates is reversible over time and change in serum osteocalcin will precede the change in lumbar spine BMD.

Objectives: To evaluate the changes in bone turnover markers [serum osteocalcin, serum bone specific alkaline phosphatase (BS-ALP) and urine N-telopeptide (N-TX)] and Lumbar spine BMD z-score on dual energy x-ray absorptiometry (DXA scan) in children following BPs therapy, and to identify the impact of gender, activity and pubertal status. 

Design: Retrospective study of children and adolescents who were treated with bisphosphonates from January 1997 and January 2011 in our Bone disorders clinic. A total of 391 subjects were identified using ICD codes 733.0 (Osteoporosis), 733.90 (NOS disorders of bone and cartilage), 756.51 (Osteogenesis imperfecta) and 275.42 (Hypercalcemia). 167 of these subjects were treated with BPs, among whom 111 children had >3 DXA scan and were included in the analysis. Data including age, gender, height, weight, activity, bone turnover markers, spine L2-L4 BMD z-score and serum parathyroid hormone (PTH) were collected. Data was analyzed in three time periods: (a) Baseline to 5-year follow up which would be period for the overall impact of therapy (Period 0-5 years), (b) 1-3 years following initiation of BPs therapy which would be period of maximum drug impact (Period 1-3 years) and (c) >5 year follow up (Period >5 years). The mean age for the group was 11.6 + 4.4 years, 63 (56.8%) were girls, 40 (36.0%) pre-pubertal and 32 (28.8%) non-ambulatory. Mixed regression analysis was used to analyze the data.

Results: There was significant improvement in biochemical and bone density changes following treatment with bisphosphonates. From baseline to 5 years follow up, osteocalcin, a bone formation marker, was the first to recover (p=0.0070), prior to increase in lumbar spine z-score (p<0.0001). Urine N-TX, a bone resorption marker, remained suppressed (p<0.0001) even after 5 years of BPs therapy. Ambulatory status had a beneficial effect on response to Bisphosphonates therapy while pubertal status and gender had no effect. 

Conclusion: A rise in serum osteocalcin preceded the reversible change in lumbar spine BMD Z-score from baseline to 5 years follow up. After 5 years of initial treatment lumbar spine BMD z-score decreased, suggesting that the effects of Bisphosphonates therapy are not irreversible.

 

Nothing to Disclose: NT, HD, GK, TS

17893 2.0000 LBSA-0268 A Skeletal Response to Bisphosphonates Is Not Irreversible and Is Preceded By a Rise in Serum Osteocalcin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM LBSA 0267-0273 5236 1:00:00 PM Bone, Calciotropic Hormones, & Vitamin D Poster

Aliya Aziz Khan*1, Sacha Dubois2, Osama Ahmed Khan3, Mohammed Zohair Rahman3 and Christine Derzko4
1McMaster University, Oakville, ON, Canada, 2Lakehead University, 3McMaster University, 4St. Michael's Hospital, Toronto, ON, Canada

 

Purpose

Bone loss in association with the menopausal transition begins approximately 2 years before the last menstrual period.  This study evaluated the efficacy of ALN in comparison to placebo in preventing bone loss in perimenopausal women with low BMD.

Methods

Inclusion Criteria: Women,  aged 40-55, experiencing at least five menstrual cycles per year, confirmed FSH level of > 20 iu/L and lower than 40 iu/L on two separate occasions; reduced bone density T < - 1.0 of the lumbar spine, total hip or femoral neck.

Exclusion Criteria: No patient was enrolled if any of the following criteria were met: patients with hyperthyroidism, hyperparathyroidism, liver disease, acromegaly, Cushing’s syndrome, rheumatoid arthritis, myeloma, Paget’s disease, renal osteodystrophy, osteomalacia, or polycystic ovarian disease; patients treated with any of the following medications less than six months prior to enrolment: androgens, calcitonin, systemic corticosteroids, fluoride, PTH, SERMS, estrogen, oral contraceptives, bisphosphonates, vitamin D > 2000 IU daily, or vitamin D metabolites; patients not clinically euthyroid or who have had a dosage change of > 25 ug of levothyroxine within the previous year; patients with impaired renal function (serum creatinine > 177 umol/L); patients consuming excess alcohol defined as more than four of the following per day: 30 mL of distilled spirits, 340 mL of beer or 120 mL of wine, and subjects with a history of allergy or intolerance to bisphosphonates. Patients with esophageal abnormalities that delay esophageal emptying such as stricture or achalasia were excluded. Patients with hypocalcemia (corrected calcium < 2.2 mmol/L), patients unable to stand or sit upright for 30 minutes and patients who had a positive beta HCG test on screening were also excluded.

Patients meeting study criteria were randomized to either therapy or control groups

Therapy consisted of 70mg of Alendronate and 2800 IU cholecalciferol once per week for one year;  Control subjects received a placebo tablet. All patients also received 500 mg of supplemental calcium carbonate daily.

Biochemistry tests at baseline and 12 months included: bone specific ALP, creatinine, random urine creatinine, and N-telopeptide (NTX) in serum and urine. BMD was measured by  Dual-energy X-ray absorptiometry  at LS,FN, and TH sites.

 Differences at 12 months in BMD  and biochemical markers were compared. Given random assignment, analysis of covariance was performed with the BMD at 12 months as our dependent, the baseline BMD as the covariate, and group (ALN versus placebo) as a fixed factor.

Conclusion

This study has demonstrated that in perimenopausal women treatment with alendronate over 12 months is  effective in lowering bone turnover and improving BMD at the LS.

Early intervention with a bisphosphonate for 12 months in the menopausal transition may be effective in maintaining BMD and microarchitectural integrity.

 

Disclosure: AAK: Principal Investigator, Amgen, Principal Investigator, NPS, Principal Investigator, Merck & Co.. Nothing to Disclose: SD, OAK, MZR, CD

18044 3.0000 LBSA-0269 A A Randomized, Double-Blind, Placebo-Controlled Study to Evaluate the Effects of Alendronate (ALN) on Bone Mineral Density (BMD) and Bone Turnover in Perimenopausal Women with Low BMD 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM LBSA 0267-0273 5236 1:00:00 PM Bone, Calciotropic Hormones, & Vitamin D Poster

Hande Peynirci*, Canan Ersoy, Vildan Gürsoy, Ayten Girgin, Mehmet Ali Asik, Ahmet Gültepe, Güven Özkaya and Alparslan Ersoy
Uludag University Medical School, Bursa, Turkey

 

INTRODUCTION: Pathologic changes in bone tissue due to chronic kidney diease (CKD) is related with alterations in calcium, phosphorus, vitamin-D and parathyroid hormone (PTH). Osteoporosis (OP)  in these patients is only a part of a wider spectrum of metabolic bone problems, namely uremic osteodystrophy. Dual energy X-ray absorptiometry (DEXA) have been widely used for the assesment of bone mineral deficiency status in renal insufficient patients. In this study, we planned to compare the laboratory, imaging and treatment methods associated with bone metabolism in patients with or without renal failure younger than 45 years with elevated PTH levels.

METHOD: Patients with  PTH abnormality were divided into two groups depending on whether they had renal insufficiency or not. Patients' age, gender, co-morbidities and the type and duration of dialysis were recorded.  Urea, creatinine, albumin, sodium, potassium, chloride, calcium, phosphorus, PTH and 25-OH-vitamin D with 24-hour urinary excretion of calcium and phosphorus values and DEXA results were recorded for all patients.

RESULTS: The records of about 300 patients were analyzed and 187 patients fulfilled the inclusion criteria. Among all patients with PTH abnormality 29 had renal insufficiency while 158 had normal renal function. Sixteen of CKD patients (55.2%) were women, 13 were men and the mean age was 40.5 (range 20-48) years. Patients without CKD, 143 (90.5%) were women, 15 were men and the mean age  was 36 (22-47) years. Except one patient who was diagnosed as compansated CKD, 4 patients were managed with peritoneal dialysis, 19 with hemodialysis and 5 with both. In the follow up of these patients, 16 patients underwent renal transplantation. Duration of  dialysis ranged from 3 years to 24 years, mean duration was 11.78 years. Urea, creatinine, chloride, phosphorus, PTH and 25-OH-D levels were statistically significantly elevated in patients with CKD compared to those without. Except  Z score at wards , all of the T and Z scores at lomber, femur neck, trocanteric and intertoracanteric areas were found statistically significantly lower in CKD patients. Thirteen of the 29 patients (44.8%) with CKD and 44 of 158 patients without CKD (27.8%) had undergone surgery.

CONCLUSION: Senility and postmenopousal status are important unchangeable risk factors for OP.  CKD is also an extra facilitiating factor. In this study we evaluated and compared the bone mineral status of patients with or without CKD in young population. The important conclusions of our study can be stated as; patients with CKD had lower BMD scores (both T and Z in all sites) as expected and their vit D’s were higher due to replacement therapies. Low vit D level seemed to be an additional risk factor for OP in patients without CKD although our country has advantage for sunshine exposure. DEXA also seemed to be a reliable method for OP detection in both groups.

 

Nothing to Disclose: HP, CE, VG, AG, MAA, AG, GÖ, AE

17897 4.0000 LBSA-0270 A Comparison of Laboratory and Imaging Methods Associated with Bone Metabolism in Patients with and without Renal Failure Under the Age of 45 Years with Elevated Parathormon Levels 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM LBSA 0267-0273 5236 1:00:00 PM Bone, Calciotropic Hormones, & Vitamin D Poster

Aliya Aziz Khan*1, Angela M. Cheung2, Osama Ahmed Khan3, Mohammed Zohair Rahman3, Ken Pritzker4 and Brian Lentle5
1McMaster University, Oakville, ON, Canada, 2University Health Network, Toronto, ON, Canada, 3McMaster University, 4University of Toronto, 5University of British Columbia

 

Purpose
This study describes characteristics and histomorphometric and radiographic features of atypical femoral fractures (AFF) as seen in 19 cases referred for evaluation.

Methods

All patients referred for evaluation of AFF were reviewed.
Patients meeting the ASBMR criteria for AFF were further evaluated and tetracycline labeled bone biopsies were completed. Radiographs were reviewed by a musculoskeletal radiologist.

Results

All fracture lines were transverse or short oblique and 15 of 19 patients demonstrated thickened cortices on x-ray. We report 19 cases of AFF in patients on long term bisphosphonate (BP) therapy. 14 of 19 fractures occurred without a fall or direct trauma to the femur with 5 cases occurring after a fall from standing height. All patients were female; average age was 65 years (range 23-80 years). 4 of the 19 cases were of Chinese descent, 4 were East Indian, with 11 being Caucasian. Average BP durations of use was 9.8 years (range 6-15 years). 9 of 19 patients were on alendronate alone, 2 patients were on risedronate alone, 6 patients on a combination and 1 patient on a combination of pamidronate and alendronate. 1 patient was on a combination of alendronate and denosumab. Prodromal thigh or groin pain was seen in 12 of the 19 patients for 1 to 15 months prior to fracture. Proton pump inhibitor use was present in 6 patients. 2 patients were on prednisone for rheumatoid arthritis and 2 patients on prednisone for asthma. 1 patient had a diagnosis of osteogenesis imperfecta type IV with a history of multiple fragility fractures and had experienced a femoral fracture after 12 years of IV pamidronate with features consistent with an AFF. All patients had 25OH Vit D levels > 50nmol/L. 18 of the patients with radiographic features of AFF had been on a bisphosphonate for > than 6 years. 1 patient had been on alendronate for 5 months.  8 of 19 patients had bilateral femoral fractures.

Bone Biopsy Results
A large number of patients with radiographic features of an AFF had evidence of mineralization abnormalities on tetracycline labeled bone biopsy. Decreased osteoid surface and mean mineralized trabecular width was seen in 6 of 11 biopsies. Diffuse label was noted in 5 of 11 biopsies. Mineralization abnormalities were noted in a significant number of patients with radiographic features of AFF. All of the women had normal or mildly reduced serum vitamin D levels.

Conclusion
Histomorphometric features seen on bone biopsy in women sustaining an AFF in association with long term bisphosphonate use included evidence of mineralization abnormalities and decreased bone formation. 1 patient had features of decreased bone formation and mineralization abnormalities with only 5 months of bisphosphonate exposure. Improved understanding of the pathophysiology leading to these fractures may be gained with further histomorphometric data in larger numbers of patients.

 

Disclosure: AAK: Principal Investigator, Amgen, Principal Investigator, NPS, Principal Investigator, Merck & Co.. AMC: Advisory Group Member, Eli Lilly, Merck, Consultant, Warner Chilcott, Principal Investigator, Eli Lilly, Merck, Speaker, Amgen. Nothing to Disclose: OAK, MZR, KP, BL

18033 5.0000 LBSA-0271 A Atypical Femoral Fractures: Radiographic and Histomorphometric Features in 19 Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM LBSA 0267-0273 5236 1:00:00 PM Bone, Calciotropic Hormones, & Vitamin D Poster

Jeffrey David Roizen* and Michael A. Levine
The Children's Hospital of Philadelphia, Philadelphia, PA, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States, 19104, Philadelphia, PA

 

Optimal bone and mineral metabolism require normal vitamin D metabolism. The first step in activation of vitamin D to calcitriol is 25-hydroxylation of parent calciferols to generate 25(OH)D3, a process mediated principally by the hepatic p450 enzyme CYP2R1. Elderly individuals have lower circulating 25(OH)D concentrations than the young, and are less responsive to vitamin D supplementation than younger control subjects. We hypothesized that decreased responsiveness of the elderly to supplementation with calciferols is due to reduced expression of the CYP2R1 enzyme. We therefore determined the relative abundance of hepatic Cyp2R1 mRNA as well as transcripts encoding enzymes that degrade 25(OH)D in liver (Cyp3A11) and kidney (Cyp24A1), as well as serum concentrations of 25(OH)D3 and substrate cholecalciferol in male mice at four different ages (13 weeks (young adult), 26 weeks (early middle-age), 39 weeks (late-middle age) and 49 weeks (elderly). Transcript abundance was measured by digital qRT-PCR and normalized to Hgprt mRNA; cholecalciferol was measured by HPLC and 25(OH)D3 was measured by LC/MS/MS. Mice received a standard chow diet (NIH #31M) containing 4180 IU/kg cholecalciferol, and were estimated to ingest 20 IU (400-600 IU/kg body weight) of cholecalciferol daily. We observed a statistically significant decline of the relative abundance of Cyp2R1 mRNA in the liver with aging (one way ANOVA p = 0.0077), with Tukeys post-test analysis revealing significant differences between 13 weeks and 39 weeks (normalized ratio 1.00 ± 0.04 at 13 weeks vs 0.68 ± 0.04 at 39 weeks; mean ± SEM,  p<0.01) and between 13 weeks and 49 weeks (normalized ratio 1.00 ± 0.04 at 13 weeks vs 0.60 ± 0.10 at 49 weeks, p<0.001). Liver Hgprt mRNA abundance did not change with aging. Concurrent with the decrease in Cyp2R1 mRNA there was a statistically significant decline in the ratio of 25(OH)D3 to cholecalciferol (one way ANOVA p = 0.0003), with Tukeys post-test analysis showing significant differences between 13 weeks and 49 weeks (normalized ratio 1.00 ± 0.011 at 13 weeks vs 0.72 ± 0.04 at 49 weeks, p<0.001) and between 26 weeks and 49 weeks (normalized ratio 0.99 ± 0.06 at 13 weeks vs 0.72 ± 0.04 at 49 weeks, p<0.001). There were no significant differences in the relative abundance of Cyp24A1 in the kidney or in Cyp3A11 in the liver with aging. Using linear regression we determined a curve with 25(OH)D3/cholecalciferol vs normalized Cyp2R1 abundance with a R2 value of 0.44. In conclusion, Cyp2R1 mRNA abundance declines with aging and this change correlates with reduced conversion of calciferols to 25(OH)D3 in the mouse. Thus  these results indicate that physiologic alterations in expression of Cyp2R1 affect vitamin D homeostasis, and suggest that decreased expression of CYP2R1 contributes to the pathophysiology of low circulating levels of 25(OH)D and decreased responsiveness to vitamin D supplementation in the elderly.

 

Nothing to Disclose: JDR, MAL

17956 6.0000 LBSA-0272 A CYP2R1 Expression Decreases with Aging and Is Associated with Reduced Generation of 25(OH)D in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM LBSA 0267-0273 5236 1:00:00 PM Bone, Calciotropic Hormones, & Vitamin D Poster

Kurt A Josef*1, Thomas R Bailey2 and D Craig Wright3
1Independent Researcher, Radnor, PA, 2TRBailey Consulting, 3LPJP, LLC

 

Vitamin D deficiency is at epidemic levels with 1B persons worldwide.   According to the New England Journal of Medicine, 50% of postmenopausal women remain vitamin D deficient in spite of oral supplementation.[1] The American Academy of Dermatology (AAD) does not recommend getting vitamin D from sun exposure (natural) because ultraviolet (UV) radiation can lead to skin cancer.  Transdermal vitamin D delivery mimics physiologic vitamin D production.  A pharmacokinetic study of a novel topical technology (trademarked TransEpi® Technology) was conducted.  The purpose was to demonstrate TransEpi®’s ability to produce a significant increase in vitamin D serum levels and to assess safety.

The 5-week pilot study enrolled healthy subjects (n=6) with screening and baseline blood serum vitamin D levels 25(OH)D less than 30ng/mL.  

The primary endpoint was defined as a numerically significant increase in serum vitamin D levels following 28 days of study product application.  The safety endpoint was the absence of vitamin D excess, i.e., 25(OH)D levels in excess of 1O0ng/mL.  Tolerability endpoint was defined as the absence of skin irritation or cutaneous side effects.

Intent to treat (lowest vitamin D serum level compared to day 35 serum level) demonstrated a mean increase of 26%.  With the lower of screening or baseline vitamin D serum levels as the basis, the study resulted in a mean level increase of 24%. Week 5 vitamin D serum level compared to week 3 demonstrated a mean increase in vitamin D serum levels of 20%.  One subject was excluded for non-compliance. Subjects had increases in Vitamin D levels up to 42%.

The overall patient experience with TransEpi® enabled vitamin D cream was good: 3 mild irritations, possibly study product related, all resolved at the next visit without treatment.  There were no adverse events.

This pharmacokinetic study suggests that TransEpi® Technology provided clinically meaningful increases in Vitamin D blood serum levels with good tolerability.


 

Disclosure: KAJ: Independent Contractor (including contracted research), Avidas Pharmaceuticals. TRB: Consultant, Avidas Pharmaceuticals. DCW: Clinician, Avidas Pharmaceuticals.

17988 7.0000 LBSA-0273 A Transepi® Technology Pharmacokinetic Study of Transdermal Vitamin D 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Saturday, June 21st 3:00:00 PM LBSA 0267-0273 5236 1:00:00 PM Bone, Calciotropic Hormones, & Vitamin D Poster

Salma Khan*1, David Turay2, Jennifer Simpson2, Saied Mirshahidi3, Tino Sanchez2, Carlos A Casiano3 and Nathan R Wall4
1Loma Linda University, Loma Linda, CA, 2Loma linda university, 3loma linda university, 4Loma Linda University

 

African-American men have the highest rate of prostate cancer (PCa) incidence in the U.S.  In addition, their prostate cancer mortality rate is more than twice as high as the rate for white Americans.  The causes of higher rates of prostate cancer among African-American males are largely unknown.  Many studies are underway to unravel the impact of a wide variety of potential risk factors, including dietary and other lifestyle differences, occupational exposures, hormonal and genetic differences.  Several lines of evidence suggest that one of the main events associated with the conversion to an aggressive phenotype is increased resistance to apoptosis (3) mainly due to upregulation of antiapoptotic genes, including Bcl-2, Bcl-XL, Mcl-1, and Survivin.  Recently, we reported that Survivin is released in PCa sera and found to be in the exosomes.  Therefore, we hypothesize that other inhibitors of apoptosis (IAP) proteins could be potential target proteins released differentially in prostate cancers in African American (AA-PCa) and Caucasian (CC-PCa) populations.  In this study, we have collected serum samples from prostate cancer patients of AA-PCa and CC-PCa, exosomes were isolated by ExoQuick kit and quantified by acetylcholinesterase activity assays.  Western blotting and densitometric analysis were done to detect differences in expression levels of IAPs in AA and CC exosomes.  Exosomes release was higher in AA patient sera compared to CC.  In addition, we found a relative overexpression of XIAP in AA-PCa compared to CC-PCa in exosomes, however, there was no differences in cIAP-1 and cIAP-2 release.  Based on our data, other than Survivin, XIAP is another potential target protein in AA-PCa patients.  Thus, exosomal expressions profiles of XIAP in addition to Survivin would be potential biomarkers in assessing aggressive phenotype of AA-PCa.  Blocking of XIAP release will not only interrupt the cancer proliferation and interfere with anti-apoptotic pathways, but also prevent cancer aggressiveness.

 

Nothing to Disclose: SK, DT, JS, SM, TS, CAC, NRW

17789 1.0000 LBSA-0330 A Differential Expression of Inhibitors of Apoptosis (IAP) Proteins in African American and Caucasian Patients with Prostate Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Saturday, June 21st 3:00:00 PM LBSA 0330 5238 1:00:00 PM Tumor Biology Poster

Chandrew Rajakumar*, Haiyan Guan, David Langlois and Kaiping Yang
Western University, London, ON, Canada

 

Background: Bisphenol A (BPA) is one of the most commonly exposed endocrine disrupting chemicals to humans. In animal model systems, exposure to BPA has been linked to developmental abnormalities, infertility, cancer, metabolic and behavioral disorders. During human pregnancy, considerable amount of BPA is detected in both maternal and umbilical cord blood as well as amniotic fluid. Furthermore, BPA accumulates in the human placenta, suggesting that placental development and function are particularly vulnerable to BPA. Indeed, animal studies show that BPA exposure during critical periods of gestation results in abnormal placentation and altered genome-wide DNA methylation in the placenta. However, little is known about the potential adverse effect of BPA on the human placenta. Objective: The present study was undertaken to examine the effects of BPA on human placental gene expression using human trophoblast cells as an in vitro model system. Methods: Cytotrophoblast cells were isolated from placentas of uncomplicated pregnancies at term, and cultured for two days to allow for differentiation to syncytiotrophoblast cells. Cells were then exposed to environmentally relevant concentrations of BPA (0.1 – 2 µg/ml) for 24 hours, after which mRNA levels of genes encoding several prominent placental hormones (CRH, hCG, and leptin), glucose transporter-1 (Glut-1; the primary regulator of glucose transplacental transport to the fetus), aromatase (the only enzyme known for the biosynthesis of estrogens from androgens), and 11β-HSD2 (the enzyme responsible for the conversion of maternal cortisol to its inactive metabolite cortisone thereby protecting the fetus from exposure to high levels of maternal cortisol) were determined by qRT-PCR. In addition, changes in 11β-HSD2 protein and activity following exposure to BPA were also assessed by western blotting and radiometric conversion assays, respectively. Results: BPA exposure dramatically increased levels of aromatase mRNA (290%), CRH mRNA (220%), hCG mRNA (350%), and Glut-1 mRNA (190%), while levels of leptin mRNA were significantly reduced (35%). In addition, levels of 11β-HSD2 mRNA, protein and activity were profoundly elevated in a time- and concentration-dependent manner (maximal increase of ~500%). Conclusion: The present study demonstrates that BPA severely disrupts human placental gene expression in vitro. Given that the foregoing placental hormones/factors play critical and dynamic roles in regulating pregnancy adaption and parturition as well as fetal organ growth and maturation, our present findings not only underscore the potential adverse effects of BPA exposure on human placental function but also have significant clinical implications for a role of BPA in the pathogenesis of pregnancy complications, such as preterm birth and abnormal fetal development.

 

Nothing to Disclose: CR, HG, DL, KY

17834 2.0000 LBSA-0373 A Bisphenol A Disrupts Gene Expression in Human Placental Trophoblast Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Saturday, June 21st 3:00:00 PM LBSA 0372-0373 5239 1:00:00 PM Endocrine Disrupting Chemicals Poster

Kathryn M. Appleton*1, Mi Hye Lee2, Christine Alele2, Deirdre K Luttrell2, Yuri K. Peterson1 and Louis M. Luttrell3
1College of Pharmacy, Medical University of South Carolina, Charleston, SC, 2College of Medicine, Medical University of South Carolina, Charleston, SC, 3Medical University of South Carolina, Charleston, SC

 

Following agonist activation of heterotrimeric G protein signaling, G protein-coupled receptors (GPCRs) undergo desensitization and sequestration that render the cell less responsive to subsequent stimuli.  Direct interaction between arrestins and agonist-occupied GPCRs uncouples the receptor and G protein, and targets the GPCR-arrestin complex for endocytosis.  Arrestins also serve as signaling scaffolds independent of G protein signaling by recruiting catalytically active proteins to the desensitized ligand-occupied receptor.  “Biased” agonists that dissociate G protein-dependent and arrestin-dependent signaling have been described for several GPCRS, yet ligands with the capacity to dissociate arrestin-dependent signaling from arrestin-dependent receptor desensitization have yet to be reported. Here, we describe two arrestin pathway-selective ligands for the human type 1 parathyroid hormone receptor (hPTH1R): bPTH(3-34) and D-Trp12,Tyr34-bPTH(7-34), that promote arrestin-dependent signaling without generating stable GPCR-arrestin complexes or causing desensitization. In HEK293 cells the conventional hPTH1R agonists hPTH(1-34) and hPTH(1-31) elicit robust cAMP and intracellular Ca2+ responses, assemble stable receptor-arrestin complexes that can be quantified via fluorescence microscopy or intermolecular bioluminescence resonance energy transfer (BRET) between rLuc-arrestin3 and hPTH1R-YFP, promote sustained arrestin-dependent PTH1R desensitization and internalization, and trigger both G protein- and arrestin-dependent activation of ERK1/2.  In contrast to the “neutral” antagonist peptide hPTH(7-34), which fails to elicit a measureable response in any assay, the arrestin pathway-selective agonists bPTH(3-34) and D-Trp12,Tyr34-bPTH(7-34) stimulate ERK1/2 activation in the absence G protein-dependent cAMP or Ca2+ responses.  Interestingly, neither ligand promotes formation of stable receptor-arrestin complexes or receptor internalization as measured by hPTH1R-YFP/rLuc-arrestin3 BRET or fluorescence microscopy.  Whereas, pre-stimulation with hPTH(1-34) and hPTH(1-31) attenuates the cAMP response to a subsequent hPTH(1-34) challenge,  bPTH(3-34) and D-Trp12,Tyr34-bPTH(7-34) do not desensitize the PTH1R to subsequent full agonist challenge.  Using arrestin3 intramolecular fluorescent arsenical hairpin (FlAsH) BRET reporters that monitor changes in arrestin conformation, we find that the non-desensitizing arrestin pathway-selective ligands generate “conformational signatures” that are distinct from the conserved signature produced by conventional agonists. These results demonstrate that arrestin-dependent signaling can be pharmacologically dissociated from arrestin-dependent PTH1R desensitization, and expand the range of ligand efficacy that can be obtained using “biased” GPCR ligands.

 

Nothing to Disclose: KMA, MHL, CA, DKL, YKP, LML

17777 1.0000 LBSA-0374 A Dissociation of Arrestin-Dependent Signaling from Arrestin-Dependent Receptor Desensitization Using Functionally-Selective Parathyroid Hormone Receptor Ligands 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Membrane Receptors and Intracellular Signaling Saturday, June 21st 3:00:00 PM LBSA 0374-0375 5240 1:00:00 PM G Protein-Coupled Receptor Signaling Poster

Patricia M Hinkle*, Sundeep Malik, Zachary J Maben and Terrance M Dolan
Univ. of Rochester Med. Ctr., Rochester, NY

 

ACTH acts by binding to the melanocortin-2 (MC2) receptor, which requires the accessory protein MRAP (MC2-receptor accessory protein) for activity. MRAP facilitates trafficking of the MC2 receptor to the plasma membrane and is critical for ACTH binding and signal transduction. In humans, glucocorticoid deficiency results from inactivating mutations of either MRAP or the MC2 receptor. MRAP is a small protein with a single transmembrane domain that forms a highly unusual structure, an antiparallel homodimer. One MRAP molecule spans the membrane with the N-terminus facing the cell exterior and the other with the N-terminus facing the cytoplasm. Mutations in two highly conserved regions of the MRAP N-terminus inactivate it, but the dual topology of MRAP makes it impossible to ascertain whether the critical regions of the molecule are required on the extracellular or cytoplasmic side of the plasma membrane. To bypass this dilemma, we created constructs in which tandem copies of either wildtype or mutant MRAPs were fused to the extracellular amino-terminal end of the MC2 receptor, thereby fixing the orientation of the two MRAP molecules. MRAP-MRAP-MC2-receptors were localized on the plasma membrane, displayed no constitutive activity, and responded to low concentrations of ACTH with increases in cAMP comparable to those generated by MC2 receptor expressed together with MRAP. Mutations in either the Tyr-rich or Lys-rich regions of the MRAP N-terminus strongly inhibited signaling by the tandem MRAP-receptor protein when they were on the first copy of MRAP (on the extracellular side). The same mutations had no effect on cAMP responses to ACTH when they were present in the second copy of MRAP (on the cytoplasmic side). In contrast, a tandem construct containing one wildtype and one mutant MRAP, but no receptor, displayed dual orientation and supported signaling by co-expressed MC2 receptor. A protein containing tandem wildtype MRAPs fused to a signaling-incompetent (E80K)MC2 receptor did not respond to ACTH but surprisingly it permitted co-expressed wildtype MC2 receptor to signal, suggesting that an MRAP dimer can interact with two MC2 receptors in a receptor oligomer to generate ACTH responses. These results show for the first time that two essential regions of the N-terminus of MRAP are required extracellularly to promote ACTH binding and signal transduction but not intracellularly where the MC2 receptor interacts with its cognate G protein.

 

Nothing to Disclose: PMH, SM, ZJM, TMD

18023 2.0000 LBSA-0375 A ACTH Responses Require Actions of the Mrap Accessory Protein on the Extracellular Surface of the Melanocortin-2 Receptor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Membrane Receptors and Intracellular Signaling Saturday, June 21st 3:00:00 PM LBSA 0374-0375 5240 1:00:00 PM G Protein-Coupled Receptor Signaling Poster

Hyun Yang1, Jae-Hwan Lee2 and Eui-Bae Jeung*1
1Biochemistry and molecular biology of veterinary medicine college, Chungbuk National Univ, Cheongju, Korea, Republic of (South), 2Chungdaero-1, Cheongju, Korea, Republic of (South)

 

Introduction: Gene knockout is the most powerful tool to determine gene function or permanently modify the phenotypic characteristics of animal. Existing methods for gene disruption are limited by their efficiency, time to completion, and/or the potential for confounding off-target effects. Here, we demonstrate a rapid single-step approach to knockout targeted gene in mice using zinc-finger nucleases (ZFNs). This process often results in the generation of mutant (knockout) alleles. Methods: With the concept of this approach, we designed ZFNs to target the sodium/calcium/potassium exchanger3 (NCKX3) gene in C57bl/6j. We generated NCKX3-/- mice and assessed the phenotypic characterization and the molecular regulation of active calcium transporting genes when the mice were fed different calcium diets during growth. Results: General phenotypes showed no distinct abnormalities. Thus, the potassium/sodium/calcium exchanger of NCKX3–null mice proceeded normally in this study. Therefore, the compensatory molecular regulation of this mechanism was elucidated. Renal TRPV5 mRNA of NCKX3-/- mice increased in both male and female mice. The expression of TRPV6 mRNA were down-regulated in the duodenum of male mice only, not in female. Renal- and duodenal expression of PTHR, VDR and GR were also examined, however, the levels of PTHR and VDR mRNA were not changed. GR mRNA expression was increased in the kidney of NCKX3-/- mice, not changed in male mice. Conclusion: Depletion of the NCKX3 gene in a KO mouse model had little phenotypic effect, suggesting that its depletion may be compensated for by calcium transporter genes in the kidney and duodenum of mice.

 

Nothing to Disclose: HY, JHL, EBJ

17774 1.0000 LBSA-0376 A Phenotype of NCKX3 Gene Disruption By ZFN Is Compensated for By the Induction of Other Calcium Transporter Genes in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Saturday, June 21st 3:00:00 PM LBSA 0376 5241 1:00:00 PM Gene Regulation & Developmental Expression Poster

Michael Koren*1, Jaime Blais2, Frank S Czerwiec3, John Ouyang4, Biff F. Palmer5, Kimberly Sikes6, Lily Shi3 and Ann M Dandurand7
1Jacksonville Center For Clinical Research, Jacksonville, FL, 2Otsuka Pharmceutical Development & Commercialization, Inc., Princeton, NJ, 3Otsuka Pharmaceutical Development & Commercialization, Inc, Rockville, MD, 4Otsuka Pharmaceutical Development and Commercialization, Inc., Rockville, MD, 5University of Texas Southwestern Medical Center, Dallas, TX, 6Otsuka Pharmaceutical Development& Commercialization, Inc, Rockville, MD, 7Otsuka Pharmaceutical Development & Commercialization, Princeton, NJ

 

Introduction: Hyponatremia, a common electrolyte abnormality in hospitalized patients, is associated with increased cost and morbidity. Previous studies have not prospectively addressed the effect of tolvaptan on hospitalized patients’ length of stay (LOS).

Objectives: This prospective, randomized trial evaluated the effect of tolvaptan (T) in safely reducing overall, medically-necessary LOS and time to improvement in neurocognitive symptoms in patients with hyponatremia.

Methods: Hospitalized patients with mild to moderately symptomatic dilutional hyponatremia (serum sodium <130 mEq/L) were randomized in a 1:1 ratio to receive T (15-60mg) with ad-libitum fluid management or placebo with fluid restriction (FR) (< 1.5L/day). Patients were stratified by Clinical Global Impression-Severity (CGI-S) Score (3-4 and 5-6, out of a maximum of 7). Primary endpoint was time to clinical readiness for hospital discharge, collected up to 45 days post treatment initiation. Key secondary endpoint was change from baseline in blinded rater assessed CGI-S at 48 h post first dose or at discharge or rescue therapy.  Generalized Wilcoxon test was applied to the 1° endpoint and analysis of covariance (ANCOVA) model was applied to the key 2° endpoint.

Results: From 10/2010 – 03/2013 only 124 patients were randomized in a planned 400 patient trial. This slow accrual rate contributed to early termination of the trial. Median LOS for T and FR did not significantly differ (3.5 vs. 4.0 days respectively; p=0.9495). Baseline mean CGI-S scores for T and FR were 3.88 and 3.65 respectively. Neurocognitive scores showed a nominally greater improvement of   -0.30 (95% CI=-0.70, 0.11; p= 0.1460) for patients treated with T versus FR (change from baseline = -1.01 for T vs -0.71 for FR). Mean baseline serum sodium levels in each cohort were equivalent (126 mEq/L). Serum sodium normalized (Na >135 mEq/L) in 16/60 (26.8%) and in 7/54 (13.0%) patients upon decision to discharge for T and FR respectively. Of note, 32.5% of patients had serum sodium ≤130 mEq/L at discharge and 11.4 % were discharged with serum sodium ≤125 mEq/L suggesting that serum sodium may influence, but not prevent discharge.  In addition, the decision to discharge was seldom made by the physician managing hyponatremia. Common treatment emergent AEs for T were consistent with previously reported results.

Conclusions: T resulted in nominal improvement in neurocognitive scores compared to FR but no significant difference in LOS in hospitalized patients with symptomatic dilutional hyponatremia. Common practice of discharging patients before completely correcting hyponatremia likely offset any expected LOS reductions attributable to the effect of T on improving hyponatremia. Future studies evaluating the clinical impact of treating hyponatremia should consider the practice of discharging hyponatremic patients before normalizing electrolyte status.

 

Disclosure: MK: Principal Investigator, Otsuka. JB: Employee, Otsuka. FSC: Employee, Otsuka. JO: Employee, Otsuka. BFP: Independent Contractor (including contracted research), Otsuka. KS: Employee, Otsuka. LS: Employee, Otsuka. AMD: Employee, Otsuka.

18017 1.0000 LBSA-0737 A Effect of Tolvaptan on Symptoms and Length of Stay in Hospitalized Patients with Dilutional Hyponatremia: Analysis of Salacia, a Prospective, Randomized Clinical Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM LBSA 0737-0741 5244 1:00:00 PM Neuroendocrinology & Pituitary Poster

Ulla Feldt-Rasmussen*1, Djordje Marina2, Marianne C Klose3, Anette Nordenbro4 and Annette Liebach5
1Rigshospitalet , University of Copenhagen,, Copenhagen, Denmark, 2Rigshospitalet , University of Copenhagen,, 3Rigshospitalet , University of Copenhagen,, Koebenhavn Oe, Denmark, 4Glostrup University Hospital, 5Glostrup University Hospitak

 

Context: Pituitary hormone alterations in the early recovery phase after brain injury may have implications for patient’s long-term functional recovery. It is not yet clear whether such hormonal alterations reflect damage to the hypothalamo-pituitary region, or represent stress response and adaptation to acute illness following brain injuries.     

Objective: To assess the pattern and prevalence of pituitary hormone alterations three months after severe brain injury with relation to functional outcome at one-year follow-up.

Design: Prospective study.

Setting: Tertiary university referral center.

Participants: Patients admitted to neurorehabilitation after severe traumatic (N=111) and non-traumatic (N=52) brain injury.

Main outcome measures: Functioning and ability, as measured by Functional Independence Measure and Glasgow Outcome Scale-Extended at one-year follow-up and their relationship to endocrine alterations measured 3.3 months (median) after the initial injury.

Results: At 3 months, increased stress hormones (i.e. 30 min. stimulated cortisol, prolactin and/or IGF-I) and/or suppressed gonadal- or thyroid hormones were recorded in 68% and 32% of the patients, respectively. At one year, lower functioning level (Functional Independence Measure) and lower capability for normal life activities (Glasgow Outcome Scale-Extended) was related to both increased stress hormones (p≤0.01) and reduced gonadal and/or thyroid hormones (p≤0.01) measured in the early phase.

Conclusion: The present study suggests that brain injury-related endocrine alterations mimicking secondary hypogonadism and hypothyroidism most probably reflect prolonged stress response in the early period after severe brain injury, rather than pituitary insufficiency per se. Elevated stress hormones and reduced gonadal hormones probably reflect more severe disease states, and may predict one-year functional outcome in very severe traumatic brain injury.

 

Disclosure: UF: Principal Investigator, Novo Nordisk, Principal Investigator, Novartis Pharmaceuticals, Speaker, Pfizer, Inc., Speaker, Novo Nordisk, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Advisory Group Member, Pfizer, Inc.. Nothing to Disclose: DM, MCK, AN, AL

18057 2.0000 LBSA-0738 A Early Endocrine Alterations Reflect Prolonged Stress and May Predict One-Year Functional Outcome in Patients with Severe Brain Injury 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM LBSA 0737-0741 5244 1:00:00 PM Neuroendocrinology & Pituitary Poster

Yuqing Shu1, Qiyong Lou1, Jiangyan He1 and Zhan Yin*2
1Institute of Hydrobiology, Chinese Academy of Sciences, 2Institute of Hydrobiology, Chinese Academy of Sciences, Wuhan, China

 

Prolactin (Prl) is an anterior pituitary hormone with broad ranges of functions. Its capabilities of lactogenesis, maternal behavior, growth and development, osmoregulation and epithelial ion transport have been reported in many vertebrates.

In our present studies, zebrafish prl1 locus (ENSDARG00000037946) has been targeted via transcription activator-like effector nucleases (TALEN). Originally, a 210 amino acid peptide is encoded by the prl1 gene. Two mutant lines were generated by targeting the position between 3rd and 4th amino acids from N-terminus using TALEN procedure. The mutation sites were confirmed by DNA sequencing of the prl1 locus. The depletions of the Prl1 protein have also been confirmed by western blot analyses using specific antibody against carp Prl. All prl1-/- zebrafish progenies died during the 4-16 days post-fertilization stage in regular egg medium. However, the prl1-/- zebrafish embryos can be raised to adulthood with the salinity at 5000 mg/L for the fish culture water, which is equivalent to briny water with its salinity 90 times higher than the one of normal culture media. Our results have also demonstrated that no obvious defects, including growth and reproduction, have been observed in the prl1-/- zebrafish once they were kept in briny water. This clearly indicates the function of Prl in fresh water fish is mainly involved in the osmoregulation. The regulatory mechanisms of zebrafish Prl1, including ion transportation, have been under investigation in the laboratory currently. Our study here certainly provides valuable evidence for the understanding of the mechanisms of the Prl in phylogenetic and physiological perspectives.

 

Nothing to Disclose: YS, QL, JH, ZY

17974 3.0000 LBSA-0739 A Knockout Zebrafish Model for the Understanding of Prolactin Action 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM LBSA 0737-0741 5244 1:00:00 PM Neuroendocrinology & Pituitary Poster

Eleanor Thong*
The Alfred Hospital, Prahran, Australia

 

Background:Metastasis to the pituitary gland (MP) are rare and constitute less than 1% of all pituitary tumor resections(1). Hyperprolactinemia can be an associated finding, but this is usually mild.

Clinical case: A 76-year old woman presented with progressive visual disturbance over 5 months. 14 months ago, she was diagnosed with locally invasive renal cell carcinoma (RCC), and underwent radical left nephrectomy and adjuvant tyrosine kinase inhibitor (TKI) therapy.  Restaging CT scans revealed progressive disease with new pulmonary and liver metastases 8 months later.

Clinical examination revealed a dense bitemporal hemianopia, confirmed by perimetry. Initial CT imaging of the brain revealed a hyperdense solid mass lesion arising from the infundibular stalk and extending into the suprasellar cistern, measuring 28 x 15 x 13 mm.

Biochemical investigations revealed marked hyperprolactinemia of 6338 mIU/L, with a repeat level of 5404 mIU/L. FSH (0.4 IU/L) and LH (0.1 IU/L) were suppressed, and TFTs suggested secondary hypothyroidism (serum TSH 1.06 mU/L, free T4 8.3 pmol/L, free T3 1.6 pmol/L). Serum cortisol at 9am was 37 nmol/L, with a corresponding serum ACTH level of 2.4 pmol/L.

She was regarded to have a pituitary macroprolactinoma with optic chiasm compression and hypopituitarism. Dexamethasone 1mg daily, Thyroxine 50mcg daily, and Quinagolide 75mcg daily was commenced.

Biochemical response was demonstrated with normalisation of serum PRL, achieved after two months of Quinagolide therapy. The patient had transient improvement in her vision, but shortly developed a left abducens nerve palsy. MRI imaging revealed an increase in size of the pituitary mass to 28 x 18 x 19 mm with probable cavernous involvement. The patient underwent a left pterional craniotomy and debulking of her pituitary mass, complicated by intra-operative bridging vein haemorrhage.

Histology of the mass revealed clear cell renal carcinoma. Quinagolide was ceased. The patient's vision and left abducens nerve palsy did not improve. Consensus from her oncologist and family was not to pursue futher chemoradiation or TKI therapy, given her guarded prognosis.

Conclusion:The clinical presentation of MP may be indistinguishable from other pituitary lesions, and pre-operative diagnosis can be challenging. Posterior pituitary involvement suggested by diabetes insipidus (DI), and rapidly evolving symptoms such as opthalmoplegia and cranial neuropathy warrant consideration of malignancy. Pituitary lesions from RCC are rare, highly vascular and appear to behave differently from other MP. DI is a less common finding, while visual field abnormalities and hypopituitarism are more common rather than posterior pituitary involvement, which is favoured in most carcinomas due to direct systemic arterial supply. Mild hyperprolactinaemia may also be frequently detected but the serum PRL level rarely exceeds 4000 mIU/L.

 

Nothing to Disclose: ET

17900 4.0000 LBSA-0740 A Pituitary Metastases from Renal Cell Carcinoma Masquerading As a Pituitary Macroprolactinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM LBSA 0737-0741 5244 1:00:00 PM Neuroendocrinology & Pituitary Poster

Angela Rogers*1 and John A. H. Wass2
1University of Oxford, Oxford, United Kingdom, 2Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, United Kingdom

 

Background: Growth hormone-suppressive treatment is withdrawn in the majority of women with acromegaly following confirmation of pregnancy. Studies have shown it is safe to do so with respect to tumour growth and maternal and fetal outcomes.(1, 2) There are, however, case reports of patients with acromegaly treated with somatostatin analogues during pregnancy, when clinically indicated, whose infants are born of normal weight and length with no malformations. Consensus guidelines encourage reporting of outcomes in medically treated pregnant women with acromegaly.      

Clinical case: A 30 year old female presented with acromegaly.  She experienced headache and described a 1.5 year history of amenorrhoea. IGF-1 was elevated at 223.6 nmol/L (reference range 15-39.9 nmol/L). The preoperative MRI scan showed a pituitary macroadenoma elevating and compressing the optic chiasm with extensive invasion of the right cavernous sinus. The patient underwent endoscopic trans-sphenoidal pituitary surgery and 6 weeks post operatively, her IGF-1 level was 147.4 nmol/L. Lanreotide was initiated. MRI scan at three months showed residual tumour within the right cavernous sinus.

Her menses returned 4 months following surgery and the patient reported she was pregnant 2 months later. Her IGF-1 was 72.5 nmol/L and the somatostatin analogue was withdrawn. By 28 weeks gestation, she began to experience headaches, which became severe. MRI scan showed no change in the size of the residual tumour. Octreotide 100mcg by subcutaneous injection was commenced which helped considerably with the headaches. As is characteristic in these circumstances the octreotide alleviated the headaches for an hour or two.  By 32 weeks gestation, the patient was administering this every 2 hours. At this stage therefore bromocriptine 10mg daily was added in to reduce the lactotroph hyperplasia in the pituitary and thereby hopefully to improve the headaches albeit that the primary tumour was not prolactin secreting.  This had the desired effect and the headaches improved significantly. There was no gestational diabetes mellitus or gravid hypertension. A baby of normal weight and length with no malformations was born at 36 weeks by spontaneous vaginal delivery. Postpartum octreotide and bromocriptine were stopped and lanreotide recommenced. IGF-1 post-partum was 92.5 nmol/L and the patient has subsequently received external beam radiotherapy.

Conclusion: This case demonstrates the successful treatment of headaches in acromegaly during pregnancy using octreotide and bromocriptine. Octreotide can be used safely in pregnancy and is well known to alleviate headaches in acromegaly in non-pregnant patients. Although cessation of growth-hormone suppressive therapy is usually advised, physicians should be aware of the clinical indications when recommencement of therapy is beneficial.

 

Nothing to Disclose: AR, JAHW

17958 5.0000 LBSA-0741 A Use of Octreotide and Bromocriptine in the Successful Treatment of Headache in a Patient with Acromegaly during Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Saturday, June 21st 3:00:00 PM LBSA 0737-0741 5244 1:00:00 PM Neuroendocrinology & Pituitary Poster

Jeremy Jones*1, Ben Yi Tew2, Maya otto-Duessel2, Sumanta K Pal2, Tommy Tong2 and Markus Kalkum2
1Beckman Research Institute, CIty of Hope, Duarte, CA, 2City of Hope

 

The anti-coagulant warfarin prevents the gamma-carboxylation (gla) of target proteins by interfering with the vitamin K cycle through its inhibition of the vitamin K epoxide reductase (VKOR). Most known gla proteins are found in the blood clotting cascade, but we demonstrate using immunoprecipitation and mass spectrometry that the androgen receptor (AR) can also be gamma-carboxylated. This modification occurs at amino acid 2E and can be prevented by warfarin treatment. This residue has been found to be mutated in partial androgen insensitivity syndrome patients. Warfarin, likely through its ability to control carboxylation, alters AR conformation and inhibits AR transcriptional activity, as does siRNA-mediated knockdown of VKOR, the target of warfarin. We further demonstrate that warfarin treatment reduces AR target gene expression in benign mouse prostate tissue in vivo. Interestingly, retrospective studies have shown that prolonged use of warfarin reduces the incidence of prostate cancer, an effect that is not observed for other cancers. In a small series of patients at our institution, we found that one allele of a functional SNP in VKOR is found at a significantly higher rate in prostate cancer patients than would be expected in the general population. We also found that VKOR is highly expressed in normal human prostate epithelia but is lost in cancerous tissue, a pattern of expression that appears to be unique to prostate cancer. We hypothesize that the lower prostate cancer incidence observed in men taking warfarin is due to the ability of warfarin to reduce AR activity, similar to the effect of 5-alpha reductase inhibitors. Importantly, we show for the first time that a nuclear receptor and transcription factor can be regulated by gamma-carboxylation.

 

Nothing to Disclose: JJ, BYT, MO, SKP, TT, MK

17854 1.0000 LBSA-0435 A Warfarin-Dependent GAMMA-Carboxylation Regulates Androgen Receptor Activity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM LBSA 0435-0437 5246 1:00:00 PM Nuclear/Steroid Hormone Receptor Signaling Poster

Pamela M England*1, Felipe De Jesus Cortez1 and Robert Fletterick2
1UCSF, SAN FRANCISCO, CA, 2Univ of CA - San Francisco, San Francisco, CA

 

The mainstay of current prostate cancer therapies are drugs that directly inhibit androgen
receptor (AR) function by competitively inhibiting the binding of hormones (TES, DHT)
to the receptor (e.g. Casodex, Flutamide, MDV3100, ARN-509). However, tumor cells
become resistant to such antiandrogens within a few years of treatment and the
progression of prostate cancer subsequently resumes. We hypothesize that the limited
efficacy of antiandrogens is due in part to the fact that they bind AR with affinities
weaker than or, at best, comparable to native hormones. This allows endogenous ligands
to competitively activate the receptor, and selective pressure to drive escape mechanisms.
Here we report the development of a new antiandrogen—only differing by one atom from
Casodex —that binds over 10-fold more tightly to AR than the parent compound. We
expect the PK, PD, and cost of producing this drug to be indistinguishable from that for
Casodex. The improved affinity of the new antiandrogen is attributed to a strategic
substitution of a single atom in the A-ring of Casodex, designed to alter the electronics of
the molecule. We speculate that even higher affinity ligands can be produced by
capitalizing on this strategy.

 

Nothing to Disclose: PME, FDJC, RF

17940 2.0000 LBSA-0436 A Strategy for Inhibiting Androgen Receptor Activation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM LBSA 0435-0437 5246 1:00:00 PM Nuclear/Steroid Hormone Receptor Signaling Poster

Pamela M England*1, Felipe De Jesus Cortez1, Holly A Ingraham2 and Robert Fletterick3
1UCSF, SAN FRANCISCO, CA, 2UCSF, San Francisco, CA, 3Univ of CA - San Francisco, San Francisco, CA

 

Nuclear receptors (NRs) are essential for proper development and normal
physiology. Although 13% of all FDA-approved drugs specifically bind to NRs, only 8
of 48 NRs have been extensively targeted. Indeed, finding bona fide synthetic
ligands remains an obstacle for assessing and harnessing the therapeutic potential
of NRs in human health. We hypothesize that the lack of synthetic ligands for NRs
stems in part from the inability of large, non-optimized ligands typically used in
high-throughput screens to adequately sample the hormone binding pockets (HBPs)
of NRs. Here we present a novel strategy for developing synthetic NR ligands termed
Fixed-point Build-out Chemistry. This fragment-based drug discovery process
rapidly (~3 days) identified new ligand scaffolds targeting LRH-1, an NR implicated
in metabolic disorders and cancers. Specifically, high-affinity (~5 µM) fragments
were identified via formation of reversible links between fragments in a fragment
library and Cys346 in the LRH-1 HBP. Fragment binding orientations, determined
using computational and biophysical methods, showed that fragments thoroughly
sampled subsites comprising the LRH-1 HBP and are suitable for synthetic
elaboration to produce high affinity ligands. Our findings establish a rapid approach
for developing specific tool compounds and preclinical leads for LRH-1 and other
hard-to-drug NRs.

 

Nothing to Disclose: PME, FDJC, HAI, RF

17946 3.0000 LBSA-0437 A Ligand Scaffolds for Nuclear Receptor Lrh-1 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Saturday, June 21st 3:00:00 PM LBSA 0435-0437 5246 1:00:00 PM Nuclear/Steroid Hormone Receptor Signaling Poster

Halley Wasserman*, Nancy Crimmins, Stavra Xanthakos and Lin Fei
Cincinnati Children's Hospital Medical Center, Cincinnati, OH

 

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of liver disease in childhood affecting approximately 38% of obese children. 7-23% of obese pediatric patients have elevated TSH levels (≥4mcIU/mL) with normal free T4 (subclinical hypothyroidism). The clinical significance of obesity-related TSH elevation is unknown; however it has been associated with increased risk of metabolic syndrome, cardiovascular disease, and mortality in adults. Overt hypothyroidism is associated with decreased fatty acid oxidation, decreased hepatic output of triglycerides, and increased lipid peroxidation, factors that could contribute to the development of NAFLD. Studies in adults and one in children have found associations between subclinical hypothyroidism and elevated ALT and/or evidence of fatty liver on ultrasound raising the possibility that TSH is an independent predictor of nonalcoholic steatohepatitis(1-4).  However, to date no study has looked at the relationship between subclinical thyroid disease and liver pathology, the gold standard in diagnosis, in NAFLD patients. 

To determine whether TSH was associated with histopathologic findings of NASH in childhood, we first analyzed data on 854 patients, ages 5 to 19 years, [40.8% male, 45% African American, 6% Hispanic, BMI z-score 2.44 (range 1.41- 3.95)] seen in the obesity clinic at our institution. We found TSH was correlated with ALT (r =0.19, p<0.001). Furthermore, a dichotomized TSH (< or > 3 mclU/mL) was significantly associated with an increase in ALT (p=0.02). A subset of these patients (n=74, 60% male, 13% African American, 21% Hispanic)had undergone liver biopsy at our institution between January 2008 and May 2013 for clinical evaluation of NAFLD. These patients were not on medications known to affect liver or thyroid function, had not been previously diagnosed with a thyroid disorder, and had a TSH value obtained within one year of liver biopsy. Steatosis, lobular and ballooning grades, fibrosis stage, and overall NAFLD activity score were each compared (logistic regression) with the following:  ALT, AST, GGT, LDL, HDL, total cholesterol, triglycerides, glucose, insulin, and TSH. ALT was significantly associated with NASH activity score (p=0.002). Triglycerides had the most significant effect on steatosis grade (p<0.001) whereas insulin had the most significant effect on ballooning (p=0.003), all analyzed in a logistic regression model with proportional odds. TSH in the upper quartile (>3mIU/L) did not significantly affect any histopathologic findings of NASH even after accounting for BMI, race and ethnicity. Thus, while elevated TSH was associated with elevation in ALT, it did not correlate with presence or severity of NASH in pediatric patients.  This data challenges the theory that subclinical hypothyroidism plays a direct role in the development of NASH.

 

Nothing to Disclose: HW, NC, SX, LF

18032 1.0000 LBSA-0162 A TSH Elevation in Obese Adolescents Not Associated with Severity of Nash on Liver Biopsy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Saturday, June 21st 3:00:00 PM LBSA 0162 5247 1:00:00 PM Pediatric Endocrinology Poster

Brian P Bostick*1, Javad Habibi1, Lixin Ma2, Nathan Rehmer1, Shawn B Bender1, Alex Meuth1, Ravi Nistala1, Susan C McKarns3, Guanghong Jia1, Mona Garro1 and James R. Sowers4
1University of Missouri, Columbia, MO, 2University of Missouri - School of Medicine, 3University of Missouri - Columbia, Columbia, MO, 4Harry S Truman VA Hospital and University of Missouri, Columbia, MO

 

Obesity is a global epidemic with more than 1.5 billion overweight or obese people worldwide. Rising obesity rates parallel increased consumption of a high-fat/high-fructose Western diet (WD). Over-nutrition induced obesity is complicated by multiple co-morbidities, notably insulin resistance (IR) and cardiovascular disease (CVD). Early CVD in over-nutrition/obesity manifests as diastolic dysfunction. Few treatments exist for diastolic dysfunction but studies implicating the mineralocorticoid receptor (MR) in inflammation, fibrosis and oxidant stress have spurred clinical trials, such as TOPCAT, for the MR antagonist spironolactone in diastolic dysfunction (1). Based on these studies, we hypothesized that low-dose spironolactone would prevent cardiac diastolic dysfunction, independent of blood pressure, by reducing fibrosis, oxidant stress and inflammation. To test this hypothesis, we conducted a trial of low-dose spironolactone in a model of WD induced obesity and diastolic dysfunction.

Four week-old C57BL6/J female mice were fed a WD and 1.0mg/kg/day of chronic low dose spironolactone (LDSp, n=7) via subcutaneous pellet with WD fed (WD, n=7) and control diet fed (CD, n=7) groups. This LDSp has been shown to exert no effect on blood pressure. After 16 weeks, we assessed diastolic function by cardiac MRI. Body weight and fat composition were obtained along with glucose tolerance testing for IR. Immunohistochemistry was performed for cardiac oxidant stress, fibrosis and collagen content. Flow cytometry of heart tissue was conducted to examine inflammatory mechanisms.

Cardiac MRI revealed diastolic dysfunction with WD feeding that was prevented by LDSp (LV diastolic relaxation time 33.4 ± 1.2ms for WD, 20.6  ± 1.5ms for CD and 24.3 ± 0.9ms for WD+LDSp, p value <0.01). Body weight and fat mass were increased by WD feeding but not improved by LDSp. WD feeding caused IR that was not improved by LDSp. 3-nitrotyrosine staining showed significant oxidant stress with WD feeding that was ameliorated by LDSp. Cardiac fibrosis was markedly increased with WD feeding but prevented by LDSp. This fibrosis was driven by increases in the collagen 1:3 ratio and fibronectin that were prevented by LDSp. Flow cytometry showed evidence for reduced CD11b/CD301 double positive cells in the WD fed heart indicative of deficiency in anti-inflammatory M2 macrophage polarization. LDSp treatment showed a trend toward increasing CD11b/CD301 positive cell populations.

These findings suggest that WD induces diastolic dysfunction by increasing oxidant stress and fibrosis which may be mediated by a deficiency in anti-inflammatory M2 macrophage polarization. MR antagonism with spironolactone may prevent the decrease in M2 macrophage polarization with improved oxidant stress and fibrosis. This work supports a novel BP independent mechanism for spironolactone in treatment of WD induced diastolic heart failure.

 

Nothing to Disclose: BPB, JH, LM, NR, SBB, AM, RN, SCM, GJ, MG, JRS

17932 1.0000 LBSA-0862 A Low Dose Spironolactone Treatment Prevents Cardiac Diastolic Dysfunction, Oxidant Stress and Fibrosis in a Model of Insulin Resistance and Obesity in Concert with a Modulation of Inflammation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM LBSA 0862-0865 5248 1:00:00 PM Cardiovascular Endocrinology Poster

William E. Rainey*1, Koshiro Nishimoto2, Celso E. Gomez-Sanchez3 and Aalok Rajen Sanjanwala2
1The University of Michigan, Ann Arbor, MI, 2University of Michigan, Ann Arbor, MI, 3University of Mississippi Medical Center, Jackson, MS

 

Background: Primary aldosteronism (PA) is the most common of adrenal diseases; affecting approximately 1 in 50 adults. Despite the common nature of PA, little is known regarding the origins of aldosterone-producing adenomas (APA) or idiopathic hyperaldosteronism (IHA). Recent studies have demonstrated that many human adrenals have distinct clusters of aldosterone synthase expressing cells that extend beyond the normal zona glomerulosa (ZG) into the adjacent fasciculata. These, so-called, aldosterone-producing cell clusters (APCC) have been observed in both normal adrenal and adrenal tissue adjacent to APA from PA patients with a suppressed renin-angiotensin axis.  The latter observation suggests that APCC express CYP11B2 in a renin-independent manner. Hypothesis: APCC are found in the majority of adult adrenals and accumulate with age. Design and Methods: 42 normal adrenal glands were collected from renal transplantation donors (40.3 ± 14.7, 16 - 65 y/o [mean ± S.D., range]; 27 male and 15 female). Immunohistochemistry for CYP11B2 was used to detect adrenal gland APCC. APCC frequency and size were independently scored from 0 (low) to 5 (high) by five researchers.  Scoring was based on APCC length (along capsule) and thickness (from capsule) and expressed as the mean ± SD. Laser capture microscopy was used to isolate ZG, zona fasciculata (ZF) and APCC mRNA. Microarray analysis was used to compare their transcriptome profile (n=4 for each). Results: Analysis of CYP11B2 immunostaining indicated that 32 of 42 adrenals had an APCC score greater than 1. Comparison between the youngest (16-28 y/o; n=11) and oldest (51-65 y/o; n=10) quartile of subjects demonstrated that older subjects had a 3.4-fold higher APCC score compared to younger subjects.  Using all adrenal samples, there was a clear correlation of APCC with age (r=0.671, p<0.001).  APCC did not differ in males vs. females. Microarray analysis of APCC, ZG, and ZF defined gene differences and similarities between each group. Principal component analysis demonstrated separate clustering for the APCC, ZG and ZF sample groups, and that APCC  had more similarity to ZG than ZF.  APCC had 53 and 430 transcript differences (p<0.001) between ZG and ZF, respectively. Compared to ZG, the APCC had a 5-fold increase in CYP11B2 transcript expression, indicating a higher capacity to produce aldosterone.  Summary and Conclusion: APCC are common in non-diseased adrenals and increase with age. The role of APCC in both the development of IHA and as a precursor to APA warrants further examination.

 

Nothing to Disclose: WER, KN, CEG, ARS

18029 2.0000 LBSA-0863 A Aldosterone-Producing Cell Clusters: Harbingers of Primary Aldosteronism? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM LBSA 0862-0865 5248 1:00:00 PM Cardiovascular Endocrinology Poster

Whitney A Danse*1, Melanie N Kuehl2, Alicia C Chechele1 and Brant R Burkhardt2
1University of South Florida, 2University of South Florida, Tampa, FL

 

Pancreatic-Derived Factor (PANDER, FAM3B) is an important regulator of glucose and lipid metabolism and increased expression has been found to induce lipid accumulation in the liver via the induction of hepatic insulin resistance and lipogenesis. This suggests a role of PANDER as an important factor in the pathogenesis of nonalcoholic fatty liver disease (NAFLD). PANDER has been primarily characterized with regards to its expression from the pancreas; however recent research suggests that PANDER is also produced within the liver itself. To investigate the regulation and expression of hepatic derived PANDER, we examined hepatic PANDER levels in mice and characterized the minimal element of the PANDER promoter in a liver-derived cell line. Initial western analysis was performed on 15 different murine-derived tissues and revealed robust expression within the murine liver and to a lesser extent in the brain and ovary. Furthermore, hepatic PANDER levels were measured in the fasted and fed state of our PANDER transgenic and control mice and revealed increased levels in the post-prandial state. Our prior studies identified the glucose-responsiveness of the PANDER promoter within the liver but our objective here was to map the minimal glucose-responsive element. Therefore, promoter deletion analysis was performed utilizing PANDER promoter-luciferase constructs in the BNL-CL2 hepatic cell line. The minimal element was identified between -293 to -3 of the hepatic transcriptional start site. The region between -193 to -93 of the TSS was demonstrated as being necessary for basal promoter activity. This region contains three E-box elements which may serve as a binding site for carbohydrate responsive element binding protein (ChREBP). ChREBP is a critical hepatic transcriptional factor responsible for activating genes in response to elevated levels of glucose. Co-transfection reporter studies revealed that PANDER promoter activity is upregulated in response to increased levels of ChREBP under both starved and elevated glucose conditions. This suggests that ChREBP may play a role in mediating the glucose-responsiveness of the PANDER promoter within the liver, and indicates another mechanism for regulation of hepatic insulin signaling via PANDER.

 

Nothing to Disclose: WAD, MNK, ACC, BRB

17907 3.0000 LBSA-0864 A Postprandial and Chrebp Mediated Hepatic Pander Expression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM LBSA 0862-0865 5248 1:00:00 PM Cardiovascular Endocrinology Poster

Won Ju Hwang*1, Jina Kim2, Jong Uk Won3 and Oisang Hong4
1Kyung Hee University, Seoul, Korea, Republic of (South), 2Kyung Hee University, 3Yonsei University, 4University of California San Francisco

 

Background:

Cardiovascular disease is the leading cause of death among Korean workers, constituting 32% of actual CVD risk prevalence among blue collar workers. The prevalence of metabolic syndrome has recently increased in Korea.

Aims:

The purpose of this study was to evaluate the effects of a health promotion program to reduce metabolic syndrome risk factors, using a socioeclological model, provided to blue-collar workers in South Korea.

Design:

A pre- and post-test experimental study design was used. The program, which included two hours of lecture-based health education and one hour of small group discussion, was provided each week for six weeks. Telephone counselling was also provided. The topic of education included cardiovascular disease and metabolic syndrome, smoking and alcohol consumption, diet, exercise, and medication adherence instructions.

Methods:

One hundred and four blue-collar workers who had at least two metabolic syndrome risk factors participated in the study.

Anthropometric (weight, waist circumference, and waist-hip-ratio), biological (blood pressure, blood glucose, total cholesterol, triglyceride, high-density and low-density lipoprotein cholesterol) and health behavior and psychosocial variables (depression and health-related quality of life) were measured for program evaluation.

Results:

Most of the metabolic syndrome risk factors were reduced, including weight and waist circumference, blood pressure, total cholesterol, blood glucose and total cholesterol, high-density lipoprotein cholesterol, while depression and health-related quality of life were improved (p < 0.05). Changes related to blood pressure, and lipid level were not significant.

Conclusions:

The program was effective in decreasing weight and waist circumference and improving depression and health-related quality of life, whereas it was ineffective in modifying biological risk.

Blue-collar workers are a vulnerable group and have relatively higher rates of health problems and unhealthy lifestyles. Provision of socioeclological programs targeting these workers may reduce metabolic risk factors and improve health behavior and quality of life.

 

Nothing to Disclose: WJH, JK, JUW, OH

17835 4.0000 LBSA-0865 A Effects of a Cardiovascular Health Promotion Programme Offered to Blue-Collar Workers in Korea 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Saturday, June 21st 3:00:00 PM LBSA 0862-0865 5248 1:00:00 PM Cardiovascular Endocrinology Poster

Shahnawaz Imam*1, Rodis Paparodis2, Deepak Sharma1 and Juan Carlos Jaume3
1University of Wisconsin, Madison, WI, Madison, WI, 2University of Wisconsin School of Medicine and Public Health, Madison, WI, 3University of Wisconsin - Madison, Madison, WI

 

Tumor immunity controls cancer.  Failure of tumor immunity allows for cancer development. Studying the immune microenvironment of cancer may unravel the reason for that failure (1). Lymphocytes as well as other immune cells like Natural Killer (NK) cells and macrophages in the immune microenvironment of thyroid cancer for example, are providing clues to explain why the immune system favors tumor progression as opposed to regression (1). 

We have recently shown that the risk of developing thyroid cancer is higher in patients with a silent form of Hashimoto thyroiditis (euthyroid Hashimoto’s) (2).  However, the risk of thyroid cancer in patients with Graves disease although controversial may be lower (Paparodis et al, accepted abstracts).  We show here that the presence of functionally active NK cells and M1 macrophages in the thyroid immune microenvironment of Graves, may be protective of thyroid cancer.  We have compared intra-thyroidal NK cell populations in Hashimoto thyroiditis (HT) (n=8), Graves diseases (n=8) and Multiple Nodular Goiter (MNG) (n=3) patients and found that NK cells were significantly higher in Graves (56.08±10.91) and MNG (34.77±5.74) as compared to HT (11.55±3.74).  Functionally active NK cells produce large amounts of IFNg and promote the conversion of M2 macrophages to M1 subtype.  Our data shows that functionally active NK cells were also significantly higher in Graves (38.14±11.52) than in MNG (11.60±6.51) and HT (5.77±4.25).  We also studied NK cell cytotoxic production and determined that NK cells produced significantly higher amount of cytotoxic cytokines in Graves than in HT: Granulysin (16.53±7.38) vs. (0.51±0.07), Granzyme B (21.25±8.88) vs. (0.57±0.05) and Perforin (20.00±13.23) vs. (0.84±0.11) respectively.  Macrophages identified as CD14+ and CD68+ cells were also significantly higher in Graves (8.23±2.99) and MNG (11.64±5.20) as compared to HT (1.88±0.78).  By sorting macrophages into M1 and M2 we found that M1 macrophages were significantly higher in Graves as compare to HT (7.41±3.08) vs. (0.22±0.15) for CCR2, and (14.48±8.19) vs. (0.65±0.32) for CXCR1 respectively.  Also, M1 production of IL12 (9.62±5.76) vs. (0.68±0.50) and TNFa (21.25±9.18) vs. (2.99±0.90) was significantly higher in Graves than in HT. To the contrary, M2 macrophages were significantly more in HT than in Graves as detected by ARGINASE1 (16.95±9.60) vs. (1.42±0.90) and DECTIN1 (11.11±8.93) vs. (0.18±0.16) respectively.  Also, M2 production of IL10 (11.55±3.73) vs (0.99±0.96) and was significantly higher in HT than in Graves.

 We concluded that in the setting of thyroid autoimmunity, the presence of functionally active NK cells and higher M1/M2 macrophage ratio in Graves disease may provide Graves’ patients with a more effective form of tumor immunity as compared to patients with Hashimoto’s.

 

Nothing to Disclose: SI, RP, DS, JCJ

18043 1.0000 LBSA-0570 A Presence of NK Cells and M1/M2 Macrophage Ratio Provides Clues for Protection Against Thyroid Cancer in Graves Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM LBSA 0570-0572 5249 1:00:00 PM Thyroid Poster

Amudha Doraiswamy1, Suehazlyn Zainudin2, Norasyikin Abdul Wahab3, Hamat Hamdi Che Hassan4, Zanariah Hussein5 and Nor Azmi Kamaruddin*3
1Hospital Putrajaya, Putrajaya, Malaysia, 2Universiti Kebangsaan Malaysia Medical Centre, Malaysia, 3National University of Malaysia, Kuala Lumpur, Malaysia, 4National University of Malaysia, 5Hospital Putrajaya, W P Putrajaya, Malaysia

 

Introduction– Administration of levothyroxine (LT4) replacement in hypothyroid patients as cumulative single weekly dose may be helpful in ensuring patient compliance. However, the effects of cumulative high dose of LT4 on cardiac function of these patients needs to be evaluated.

Objective- To evaluate the effects of cumulative single weekly LT4 replacement on thyroid profile and cardiac function of hypothyroid patients.

Subjects and methods- This was a prospective, case-control study involving hypothyroid patients who had been biochemically euthyroid on a stable fixed daily dose of LT4 replacement over the past 3 months.  Patients were randomised to receive either weekly single dosing (GW) or continued on daily dosing (GD) and followed up for 3 months. The single weekly dose was calculated based on the required daily dose multiplied by seven. At month 0 and month 3, thyroid and lipid parameters, electrocardiogram (ECG), and transthoracic echocardiograms (TTE) were performed for both groups.  Systolic time interval (STI) was determined by measuring the aortic ejection time (AET) during TTEs. Thyroid profile and ECG of subjects in GW were also reviewed at month 1 and 2. A 24-hour electrocardiogram (Holter) was recorded within 72 hours of the weekly LT4 dose at month 0 and month 3 respectively for GW.

Results- Twenty-five patients were recruited in each group. All baseline parameters were comparable between the two groups.  The mean age was 40.10 ± 8.12 years in GW compared to 46.20 ± 7.12 years in GD, p=0.45. The mean LT4 dose in GW was 88.28 ± 30.5mcg/kg/day and in GD was 94.10 ± 34.82mcg/kg/day.

At the end of 3 months, there were no significant difference in thyroid profile between the GW and GD groups. The median TSH was 2.94(1.89-3.76)mIU/L in GW and 3.38(1.09-6.76)mIU/L in GD, p=0.51. At month 3, 56.5% of patients in GW and 54.2% of patients in GD became biochemically hypothyroid (TSH >2.5mIU/L) whereas 8.7% of patients in GW and 8.3% of patients in GD became hyperthyroid (TSH <0.5mIU/L). There was also no significant difference in lipid profile at study end. There were no significant change in AET measurements at the end of 3 months in the GW compared to GD, ie. 0.298 ± 0.028 versus 0.309 ± 0.024; p= 0.53 respectively. Holter recordings did not show any silent arrhythmias or significant difference in mean, minimum, or maximum heart rate. There was no increase in the number of bradycardia or supraventricular extrasystolic episodes at the end of 3 months.

Conclusion- Short term once weekly dose of LT4, as an alternative to daily dosing regimen was shown to be efficacious and safe on cardiac function for treatment of hypothyroidism.

 

Nothing to Disclose: AD, SZ, NAW, HHC, ZH, NAK

17951 2.0000 LBSA-0571 A Efficacy and Cardiac Safety of Short Term Weekly Levothyroxine Administration in Hypothyroid Patients on Replacement Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM LBSA 0570-0572 5249 1:00:00 PM Thyroid Poster

Gustavo Varela*1, Nicolas Picon2, Monica Susana Sala2, Patricia Arce3, Andrea Paes de Lima4, Licina Tessone4, T Castiglione5, Boris Elsner5 and Graciela Arebalo de Cross2
1Hospital de Clínicas “José de San Martín”. Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina, 2Hospital de Clinicas Jose de San Martin, Buenos Aires, Argentina, 3Instituto de Investigaciones Metabólicas Dr. Zanchetta, 4Hospital de Clinicas Jose de San Martin, 5Pathology Center Dr Boris Elsner

 

Introduction: Thyroid nodules (TN) reported as atypia of undetermined significance or follicular lesion of indetermined significance (AUS/FLUS) know as Bethesda Category III (CIII-B) representing up to 7% of total fine needle aspiration (FNA) of TN. The malignancy risk has been reported in 5-15%. 

Objectives: The aim of our study was to correlate clinical and ultrasonographic findings in patients CIII-B who progressed to malignancy.

Methods:  Among 1985 patients with TN who underwent to FNA in 3 institutions of Argentina between 2011 and 2013, 68 patients (3.42%) had cytological diagnosis of AUS/FLUS.  We retrospectively analyzed the medical records and evaluated the clinical and sonographic features and the results of recategorization (cytology) or definitive (pathology). Patients were divided in 2 groups according to initial behavior: Group 1 repeat FNA and Group 2 surgery in patients with clinical and / or ultrasound features suggestive of malignancy.

Results:  68 patients with AUS / FLUS were included, 54 females (79.41%) and 14 males (20.58%). The  median age was 48 years (range 22 - 77 years). Initially, FNA  was repeat in 60.29% (41/68), surgery in 23.52% (16/68), monitoring in 7.35% (5/68) and 8.82% (6/68) discontinued the evaluation. Group 1: the reclassification was: unsatisfactory in 12.19% (5/41), benign in 43.90% (18/41), AUS/FLUS in 24.39% (10/41), suspicious for follicular neoplasm (SFN) in 9.75% (4/41), suspicious of malignancy (SM) in 7.31% (3/41) and malignant (M) in 2.43% (1/41). In the subgroup of patients with AUS/FLUS, SFN, SM and M 61,11% (11/18)  underwent surgery with these results: follicular adenoma (FA) = 4, multinodular goiter (MNG) = 1, colloid nodule (CN) = 1, differentiated thyroid cancer (DTC) = 5 [papillary thyroid carcinoma (PTC) = 4 and follicular thyroid carcinoma (FTC) =1]. Group 2: the pathology of  patients who underwent  initial surgery reported: PTC  50% (8/16) , FA  31.25% (5/16) , MNG 12.5% (2/16) and Hashimoto 's Thyroiditis (HT) in the 6 25% (1/16). The final results of cytology or pathology were obtained in 67.64% (46/68): benign lesions in 71.73% (33/46) (Bethesda Category II = 19, FA = 9, MNG = 3, HT = 1, CN = 1) and DTC in 28.26% (13/46) (PTC = 12 and FTC = 1) of patients.

Conclusions:
In the reassessed TN CIII-B, DTC was diagnosed in 28.26%; 61.53% (8/13) through initial surgery and 38.46 % (5/13) through  repeat FNA. Therefore, surgery could be suggested as initial behavior in TN CIII-B with clinical and/or ultrasound features suggestive of malignancy.

 

Nothing to Disclose: GV, NP, MSS, PA, AP, LT, TC, BE, GA

18039 3.0000 LBSA-0572 A Thyroid Nodules Bethesda Category III (CIII-B): Clinical, Ultrasound and Evolution Correlation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Saturday, June 21st 3:00:00 PM LBSA 0570-0572 5249 1:00:00 PM Thyroid Poster

Thomas William Tilston*1, Richard C Brown1, Anna L Hopkins1, Bradley Arms-Williams1, Yuxiang Sun2 and Timothy Wells3
1Cardiff University, Cardiff, United Kingdom, 2Baylor College of Medicine, Houston, TX, 3Cardiff University, Cardiff Wales, United Kingdom

 

Recent pre-clinical studies1,2 and epidemiological evidence3,4 suggest that the temporal pattern of food consumption influences metabolic outcome.   However, our understanding of the physiological impact of feeding patterns has been hampered by technical limitations in regulating food delivery to laboratory animals.  In this study we have used a CLAMS-based system to overcome this problem, investigating the metabolic effect of 3 weeks of grazing (consumption of 0.5g (mice) or 1/24th of the total daily food intake of ad libitum(AL)-fed controls (rats) every 30 mins during the dark phase (18.00h-06.00h)) and meal feeding (MF: three 1-hour periods of AL food access at 18.00h, 23.30h and 05.00h).

In comparison to AL controls, grazing increased cumulative food intake (cF/I) in adult wild type (WT) mice (7-8 month-old C57BL6 males) by 17% (P<0.01), whereas MF reduced cF/I by 14% (P<0.05).   Grazing induced a transient increase in weight gain (0.25 ± 0.62g (grazing) vs -1.06 ± 0.19g (AL) at day 7; P<0.05), whereas MF mice showed a sustained reduction in body weight gain (-2.73 ± 1.12g (MF) vs -1.01 ± 0.29g (AL) at day 14; P<0.05).

While mean cF/I in grazing ghrelin-null males was 118% of that in AL ghrelin-null mice, cF/I was more variable than in WT littermates.   Remarkably, the effect of MF on cF/I was completely abolished in ghrelin-null mice, as was the effect of both grazing and MF on body weight gain.

Given that these effects of patterned feeding are ghrelin-dependent, we used automated blood sampling to determine ghrelin profiles in young (6 week-old) grazing and MF rats.   In comparison to AL controls, grazing and MF rats both showed a 15% reduction in cumulative food intake, but only MF animals exhibited less weight gain than AL controls.   AL-fed rats showed the well-established mid-light phase peak in circulating (total) ghrelin, followed by a progressive decline, reaching a nadir at the end of the dark phase.   Grazing and MF rats showed a marked anticipatory rise in ghrelin in the second half of the light phase (P<0.01), followed by a rapid decline after the commencement of feeding, reaching levels seen in AL rats after 2 hours.   However, MF rats showed a large preprandial rise in circulating ghrelin before the end-dark phase meal (P<0.05), while grazing rats showed a sustained doubling in mean circulating ghrelin in the last third of the dark period.

Thus, our data indicate that while grazing-induced hyperphagia may not be ghrelin-dependent, the weight gain associated with this pattern of feeding is.   In contrast, the integrity of the ghrelin system is essential for both the hypophagia and weight loss effects of meal feeding.   Furthermore, since the pattern of ghrelin exposure has reciprocal effects on growth hormone secretion and fat accumulation5,6, changes in feeding behavior that modify daily ghrelin profiles may have a substantial impact on the balance between growth and adiposity.

 

Nothing to Disclose: TWT, RCB, ALH, BA, YS, TW

17926 1.0000 LBSA-0942 A The Weight Gain and Weight Loss Effects of Grazing and Meal Feeding Are Mediated By Ghrelin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM LBSA 0942-0943 5252 1:00:00 PM Obesity Poster

Christian L Roth*1, Hedieh Eslamy2, Catherine Pihoker3, Clinton Elfers4, Jeffrey Ojemann2 and Williams Dobyns5
1Seattle Children's Research Institute, University of Washington, 2Seattle Children's Hospital, 3Childrens Hosp & Med Ctr/A5902, Seattle, WA, 4Seattle Children's Research Institute, Seattle, WA, 5Seattle Children's Research Institute

 

Excessive weight gain and its resultant cardiometabolic abnormalities occur frequently in patients with hypothalamic tumors and lesions, a disorder designated as hypothalamic obesity (HO). However, few studies correlate the location and size of damaged brain areas with subsequent development of HO.

Methods: We performed retrospective analysis of brain imaging studies and clinical outcome in 43 children and adolescents with lesions in the sellar region including 39 with craniopharyngiomas and 4 with Rathke’s cleft cysts. All subjects had surgery by craniotomy or transsphenoidal approach (mean age 8.7 years), and 20 subjects underwent irradiation. All were on hormonal replacement as required. Brain images were retrospectively assessed using electronically stored MRI data about 1.7 years following surgery (mean age 10.4 years). BMI z-scores were assessed at time of surgery, 1 and 2 years post-surgery and at the most recent appointment (~5 years after surgery, mean age 14.0 years). We developed a novel MRI scoring system to assess brain lesions using anatomical landmarks but not requiring any measurements. Lesion scores were assessed in 4 images: A) midsagittal, B) coronal through the anterior commissure, C) coronal between anterior commissure and mammillary bodies, and D) coronal through the mammillary bodies. This allowed us to assess damage in brain areas critical in energy homeostasis, such as the arcuate nucleus close to the floor of the third ventricle, pituitary and pituitary stalk (section A), anterior hypothalamus including paraventricular nucleus (section B), ventromedial nucleus (section C), and dorsomedial nucleus and posterior hypothalamic area (section D). In addition, ventriculomegaly and residual tumor were assessed in all sections.

Results: The majority of patients (27/43) had abnormalities affecting the anterior hypothalamus. But patients with HO (20/43) had lesions extending to the posterior hypothalamus significantly more frequently (16/20) than those without HO (6/23), an area that includes the dorsomedial nuclei (p<0.001). The strongest association was found between the BMI z-score at the last appointment and a posterior hypothalamic lesion (section D, p=0.003). We found additional associations between the most recent BMI z‑score and deficient mammillary bodies, lateral ventriculomegaly, anterior hypothalamic and medial hypothalamic damage (sections B and C, all 3 values with p<0.01).

In summary, the extent of hypothalamic damage leading to HO can be assessed retrospectively in MRI images using anatomical landmarks in the pituitary-hypothalamic area. The scoring system could be applied effectively even with mildly suboptimal (fair to good) images. Prospective assessment of the risk for developing HO should allow earlier intervention strategies to reduce morbidity from obesity.

 

Nothing to Disclose: CLR, HE, CP, CE, JO, WD

18015 2.0000 LBSA-0943 A Semi-Quantitative Analysis of Hypothalamic Damage on MRI Predicts Risk for Hypothalamic Obesity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Saturday, June 21st 3:00:00 PM LBSA 0942-0943 5252 1:00:00 PM Obesity Poster

Anouk van Berkel*1, Jyotsna U Rao2, Benno Kusters3, Tuna Demir3, Erik Visser2, Arjen Mensenkamp4, Jeroen A.W.M. van der Laak2, Egbert Oosterwijk3, Jacques W.M. Lenders5, Fred C.G.J. Sweep3, Ron A. Wevers3, Ad RMM Hermus1, Hans J.F. Langenhuijzen4, Henricus P.M. Kunst6, Karel Pacak7, Martin Gotthardt3 and Henri J.L.M. Timmers8
1Radboud University Medical Center, Nijmegen, 2Radboud University Medical Center, 3Radboud University Nijmegen Medical Center, Nijmegen, Netherlands, 4Radboud University Nijmegen Medical Center, 5Raboud University Medical Center, Nijmegen, Netherlands, 6Radboud University Nijmegen Medical Centre, Nijmegen, 7National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, 8Radboud University Medical Center, Nijmegen, Netherlands

 

Background: Pheochromocytomas and paragangliomas (PPGLs) can be localized by 18F-FDG PET. The uptake is particulary high in tumors with an underlying succinate dehydrogenase (SDH) mutation. The latter are characterized by compromised oxidative phosphorylation and a pseudo-hypoxic response which mediates an increase in aerobic glycolysis, also known as the Warburg effect. The aim of this study was to explore the hypothesis that increased uptake of 18F-FDG in SDHx-related PPGLs compared to other PPGLs is reflective of increased glycolytic activity and is correlated with expression of different proteins involved in glucose uptake and metabolism through the glycolytic pathway.

Methods: Twenty-seven PPGLs collected from patients with hereditary mutations in SDHB (n=2), SDHD (n=3), RET (n=5), NF1 (n=1), MAX (n=1) and apparently sporadic patients (n=15) were investigated. Pre-operative 18F-FDG PET/CT studies were analyzed; mean and maximum standardized uptake values (SUVs) in manually drawn regions of interest were calculated. Expression of proteins involved in glucose uptake (GLUT-1 and 3), phosphorylation (HK-1, 2 and 3), glycolysis (MCT-4) and angiogenesis (VEGF, CD34) were examined in paraffin-embedded tumor tissues using immunohistochemical staining with peroxidase-catalyzed polymerization of diaminobenzidine as read-out. Expression was correlated with corresponding SUVs.

Results: Both maximum and mean SUVs for SDHx-related tumors were significantly higher than for apparently sporadic and other hereditary tumors (P<0.01). The expression of HK-2 and HK-3 were significantly higher in SDHx-related PPGLs compared to apparently sporadic PPGLs (P=0.022, P=0.025). The expression of HK-2 and VEGF were significantly higher in SDHx-related PPGLs compared to other hereditary PPGLs (P=0.039, P=0.008). No statistical differences in the expression was observed for GLUT-1, GLUT-3 and MCT-4. Percentage anti-CD 34 staining and mean vessel perimeter were significantly higher in SDHx-related PPGLs compared to apparently sporadic tumors (P=0.050, P=0.010). Mean SUVs significantly correlated with the expression of HK-2 (P=0.027), HK-3 (P=0.013), VEGF (P=0.049) and MCT-4 (P=0.020).

Conclusion: Activation of aerobic glycolysis in SDHx-related compared to other PPGLs is associated with increased 18F-FDG accumulation, probably due to accelerated glucose phosphorylation by hexokinases rather than increased expression of glucose transporters.

 

Nothing to Disclose: AV, JUR, BK, TD, EV, AM, JAWMV, EO, JWML, FCGJS, RAW, ARH, HJFL, HPMK, KP, MG, HJLMT

PP14-1 11371 1.0000 SUN-0798 A Correlation Between in Vivo 18F-Fluorodeoxyglucose PET and Immunohistochemical Markers of Glucose Uptake and Metabolism in Pheochromocytoma and Paraganglioma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 11:30:00 AM PP14 4891 11:15:00 AM Adrenal Tumors & Pheochromocytomas; Hypothalamic-Pituitary-Adrenal Axis Poster Preview

Jami L Josefson*1, Dinah M Zeiss2, Stacy Smrz3, Mary J Kwasny2 and Boyd E. Metzger4
1Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, 2Northwestern University Feinberg School of Medicine, 3Ann & Robert H. Lurie Children's Hospital of Chicago, 4Feinberg School of Medicine, Northwestern University, Chicago, IL

 

Excessive gestational weight gain (GWG) among American women has steadily increased over the past 20 years, in parallel with the increasing prevalence of maternal obesity. Concurrently, the frequency of both large-for-gestational age neonates and newborns with excessive adiposity has also increased. Evidence suggests that these newborns have increased risk of childhood obesity. Maternal glucose levels in pregnancy, across the range less than diagnostic of diabetes, are associated with increased birth weight and fetal adiposity. Whether excessive GWG in women with normal glucose tolerance is associated with increased neonatal adiposity requires further study. The objective of this study was to determine whether weight gain above Institute of Medicine (IOM) recommended amounts in an ethnically diverse obstetric population is associated with increased neonatal adiposity. Women with fasting, 1, and 2 hour 75-g OGTT values less than International Association of the Diabetes and Pregnancy Study Groups (IADPG) threshold for diagnosis of gestational diabetes mellitus were recruited. All women enrolled were carrying singleton pregnancies and delivered full term. GWG was calculated from weights measured at first and last prenatal visits. Neonatal adiposity was measured by air displacement plethysmography at 24-72 hours of life. Analysis of 168 participants (pre-pregnancy BMI categories: 3% underweight, 63% normal weight, 15% overweight, and 19% obese) demonstrated no difference in body fat of neonates born to mothers who met (33%) or exceeded (40%) GWG guidelines. The 27% of women who gained less than GWG guidelines had neonates with significantly lower mean body fat of 9.4% (sd 3.7%) compared to neonates of mothers who met (neonatal mean body fat 11.2%, sd 3.3%) or exceeded guidelines (neonatal mean body fat 11.4%, sd 3.7%)(ANOVA p=0.01). Mean glucose levels (sd) on 75-g OGTT were, fasting: 76.5 (5.6), 1 hr: 115.2 (26.7), 2 hr: 100.3 (19.7) mg/dl, all lower than thresholds of 92, 180, and 153 mg/dl, respectively, recommended by the IADPG. In this cohort of women with normal 75-g oral glucose tolerance tests, excessive GWG was not associated increased neonatal adiposity. These study findings indicate that excessive GWG was not an important modifier of increased neonatal adiposity among women with normal glucose tolerance.

 

Nothing to Disclose: JLJ, DMZ, SS, MJK, BEM

PP20-1 13075 1.0000 SUN-1027 A Excessive Gestational Weight Gain in Women with Normal Glucose Tolerance Was Not an Important Modifier of Neonatal Adiposity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 11:30:00 AM PP20 4894 11:15:00 AM New Approaches to Screening, Diagnosis, and Prevention of Diabetes Poster Preview

Radhika Jindal*, Nitin Gupta, Tuhin Dubey, Mohammad Asim Siddiqui and Subhash Kumar Wangnoo
Indraprastha Apollo Hospital, Delhi, India

 

Aims and objectives:

We studied the association of pregestational BMI, risk of GDM and post partum dysglycemia in pregnant women, diagnosed as GDM, visiting our centre.

Material and methods:

The study included 62 women, more than 18 years old, who were diagnosed as GDM (as per ADA criteria) attending the endocrine clinic. Pregnant females with type 1 diabetes, preexisting type 2 diabetes and those with acute metabolic decompensation were excluded from the study. The patients were followed with 75 grams oral glucose tolerance test (OGTT) at 6 weeks post-partum with additional 1hour plasma glucose (PG) estimation. BMI was categorized as per WHO criteria as obese (>30 Kg/m2), overweight (25- 29.9 Kg/m2), normal (18.5- 24.9 Kg/m2) and underweight (<18.5 Kg/m2).

Results:

Out of 62 women with GDM, 8 were obese, 25 were overweight, 29 had normal BMI and none of them was underweight. BMI of study population on linear regression analysis was found to have a negative correlation with gestational age at diagnosis (r= -0.28, p = 0.027). BMI correlated positively with fasting plasma glucose (FPG) (r= 0.354, p= 0.005); 1 hour PG (r= 0.069, p=0.594); 2 hours PG (r=0.038, p=0.772) in the OGTT done for the diagnosis of GDM. In the OGTT done post partum, pregestational BMI correlated positively with FPG (r= 0.211, p=0.1), 1 hour PG (r= 0.301, p=0.018), 2 hours PG (r= 0.3, p=0.018).  Obese women developed GDM at an earlier gestational age (21.37 ± 9.07 weeks) as compared to overweight (25.56 ± 7.08 weeks) and women with normal BMI (28 ± 5.85 weeks). 

Conclusion:

A higher pregestational BMI significantly correlates with an earlier diagnosis of GDM, higher FPG in pregnancy and a higher 1hour PG and 2 hours PG in the postpartum OGTT. We suggest that an isolated FPG may miss postpartum dysglycemia; hence, a postpartum OGTT should be done, especially in women with a higher pregestational BMI. We also suggest that overweight and obese women be counseled for weight loss before planning conception.

 

Nothing to Disclose: RJ, NG, TD, MAS, SKW

PP20-2 15774 2.0000 SUN-1030 A Association of Pregestational Body Mass Index with Risk of Gestational Diabetes and Post-Partum Dysglycemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 11:30:00 AM PP20 4894 11:15:00 AM New Approaches to Screening, Diagnosis, and Prevention of Diabetes Poster Preview

Makarios Eleftheriades*1, Ioannis Papastefanou2, Irene Lambrinoudaki3, Athanassios Akalestos4, Dimitra Kappou3, Vania Polymerou5, Demetrios Lavranos5, Panagiota Pervanidou3, Demetrios Hassiakos6 and George P. Chrousos7
1Embryocare, Fetal Medicine Unit, Athens, Greece, Athens, Greece, 2Fetal Medicine Unit, 3rd Department of Obstetrics and Gynaecology, University of Athens Medical School, Attikon University Hospital, Athens, Greece, Athens, Greece, 3University of Athens Medical School, Athens, Greece, 4Roche Diagnostics (Hellas) S.A., Athens, Greece, 5Bioiatriki SA, Athens, Greece, 6Athens University Medical School, Athens, Greece, 7University of Athens School of Medicine, Athens, Greece

 

Objective: The aim of this study was to examine serum concentrations of placental growth factor (PLGF) and Interleukin–6 (IL–6) at 11 to 14 gestational weeks in pregnancies that subsequently developed gestational diabetes mellitus (GDM). Methods: A prospective case control study including 40 cases of GDM without previous history of GDM and 94 normal controls (C). First trimester PLGF, IL-6, biophysical and biochemical markers and maternal–pregnancy characteristics (MP) were analyzed.

Results: log10 transformed PLGF (log10 PLGF) was not related to maternal factors (MF). However, log 10 PLGF was increased (unpaired Student t – test, p = 0.0085) in the GDM group (mean=1.764047) compared to the C group (mean=1.684283) and  was associated with fasting glucose levels (p=0.04) at the oral glucose tolerance test (OGTT). log10 PLGF had a strong relation with birth weight adjusted for gestational age (p=0.002, R2 = 0.0989) in the C but not in the GDM group (p=0.692). IL – 6 was only related to maternal weight (W) amongst the MP characteristics (R2 =0.0679, p=0.01). IL -6 was significantly increased (p=0.001) in the GDM group (median=2) compared to the C group (median=1.5) and this association persisted after adjustment for W. IL-6 was inversely related to birthweight adjusted for gestational age at delivery (r=-0.3382, p<0.001) and glucose levels at OGTT. W and maternal age (A) were the only significant predictors of GDM amongst the MF [Detection rate (DR) =59.4% for 25% False Positive Rate (FPR), Area Under the Curve (AUC)=0.7291, Model R2 = 0.1096, p<0.001]. log10 PLGF alone was a significant predictor of GDM (DR =48.6% for 25% FPR, AUC= 0.6300, Model R2 = 0.0374, p<0.001). Combination of W, A and log10 PLGF resulted in an improved prediction (DR =71.4% for 25% FPR, AUC=0.7778, Model R2 = 0.1698, p<0.001). IL–6 alone was a significant predictor of GDM (DR =51.3% for 25% FPR, AUC= 0.6731, Model R2 = 0.0616, p<0.001). Combination of W, A and IL–6 yield an improved prediction (DR =67.5% for 25% FPR, AUC=0.7586, Model R2 = 0.1521, p<0.001).

Conclusion: Women with GDM have increased levels of PLGF and IL–6 at 11 to 14 weeks. PLGF is positively related to birthweight, whereas IL – 6 has a negative association with birthweight. A linear association amongst the examined biochemical indices and glucose levels at OGTT was present. The combined use of PLGF and IL -6 improves the performance of screening for GDM provided by maternal factors alone.

 

Nothing to Disclose: ME, IP, IL, AA, DK, VP, DL, PP, DH, GPC

PP20-3 15042 3.0000 SUN-1028 A Increased Maternal Serum Placental Growth Factor (PlGF) and Interleukin (IL)-6 at 11 to 14 Weeks of Gestation in Low Risk Pregnancies Are Predictive of Gestational Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 11:30:00 AM PP20 4894 11:15:00 AM New Approaches to Screening, Diagnosis, and Prevention of Diabetes Poster Preview

Fatma Ela Keskin*1, Mucahit Ozyazar2, Esra Suheda Hatipoglu3, Ayse Selcen Bay4, Ayse Deniz Elmalı4, Basak Yilmaz4, Abdullah Tuten4, Ayhan Bingol4, Ugur Uygunoglu4 and Gokhan Erkol4
1Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey, 2Istanbul Univetsity, Cerrahpasa Medicine Faculty, Istanbul, Turkey, 3Liv Hospital, Istanbul, Turkey, 4Istanbul University, Istanbul, Turkey

 

Objective:

To evaluate the association between cognitive functions, depression and metabolic status in cases with gestational diabetes mellitus.

Method:

In this crossectional study 44 patients with gestational diabetes mellitus (GDP) and 56 subjects with a normal pregnancy (NP), matched for age, origin and education were included. Status of depression was evaluated with Beck’s depression scale (BDS). Cognitive functions were evaluated with Montreal cognitive assessment (MOCA) and brief repetible battery of neurophysiological tests (BRB-N). Additionally fasting blood glucose (FBG), postprandial blood glucose (PBG), HbA1c, insulin, total cholesterol (T-chol), HDL, LDL, triglyceride (TG) levels of both groups were obtained. Two groups were compared based on their BDI, MOCA and BRB-N scores and metabolic parameters.

Results:

The mean age of GDP and NP was 31.4 ± 3.7 and 29.8 ±4.6 years, respectively (p=0.06). The mean FBG and PBG were significantly higher in GDP (FBG in GDP: 99.1±23.5 mg/dl and in NP: 75.1±11.4 mg/dl, p˂0.001). PBG in GDP was 165.4±39.3 mg/dl and in NP was 114.8±24.7 mg/dl (p˂0.001). BMI in GDP and NP was 27.6 ± 5.8 and 25.4± 5.6 kg/m2(p=0.03). Domain score for symbol digit modalities (SDM) in GDP and NP was 33.4±11.2 and 38.5±10.1, respectively (p=0.02). Additionally GDP had lower domain scores for spatial recall (SR) and long term SR (SR in GDP: 14±4 and in NP: 16.3±5.2, p=0.02, long term SR in GDP: 4.5±1.9 and in NP: 5.4±2.3, p=0.04). Also score for MOCA was significantly lower in GDP (20.8±5.3) compared to the score in NP (23.7±3.9) (p=0.03). SDM score was negatively correlated with BDI (r=-0.2, p=0.03) and PBG (r=-0.2, p= 0.02). There was also a negative correlation between the domain score for SR and PBG (r=-0.2, p=0.04). Also the score for long term SR decreased as BMI (r=-0.2, p=0.04) and FBG (r=-0.2, p=0.03) increased. Score for BDI were similar between the 2 groups (p=0.3).

 

Conclusion:

In this study cases with gestational diabetes mellitus performed worse in symbol digit modalities and spatial recall of BRB-N in addition to MOCA compared to controls. The decline in cognitive functions were related with their BMI and blood glucose levels, showing association of cognitive functions with metabolic status. Our findings may be a clue for early onset of impairment in cognitive functions in case of disrupted glucose homeostasis, particularly in cases with new onset diabetes during pregnancy.

 

Nothing to Disclose: FEK, MO, ESH, ASB, ADE, BY, AT, AB, UU, GE

PP20-4 15102 4.0000 SUN-1029 A Cognitive Dysfunction and Gestational Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 11:30:00 AM PP20 4894 11:15:00 AM New Approaches to Screening, Diagnosis, and Prevention of Diabetes Poster Preview

Farah Meah*1, Linda A DiMeglio2, Carla Joy Greenbaum3, Janice Blum4, Jay Sosenko5, Alberto Pugliese6, Craig Beam7, Ping Xu7 and Carmella Evans-Molina4
1Indiana Univ Health, Indianapolis, IN, 2Indiana Univ Sch of Med, Indianapolis, IN, 3Benaroya Res Institute, Seattle, WA, 4Indiana University School of Medicine, Indianapolis, IN, 5Univ of Miami, North Miami, FL, 6Univ of Miami Sch of Medicine, Miami, FL, 7University of South Florida, Tampa, FL

 

The incidence of Type 1 diabetes (T1D) is increasing at a rate of 3-5% per year. Genetic factors do not fully account for this increase, suggesting an influence of environmental factors.  The Accelerator/Overload hypothesis postulates that chronically increased β cell secretory demand, occurring as a result of overnutrition, obesity, and insulin resistance, leads to activation of intrinsic β cell stress pathways that may either trigger autoimmunity through formation of neoantigens or act independently to accelerate autoimmune-mediated β cell death. To gain insight into the natural history of T1D, non-diabetic first-degree (age 1-45 years) and second or third-degree (age 1-20 years) relatives of individuals with T1D are screened for the presence of glutamate decarboxylase (GAD65), insulin (mIAA), and islet antigen-2 (IA-2) autoantibodies, followed by measurement of islet cell antibodies (ICA) and zinc transporter 8 (ZnT8) autoantibodies if any one initial test is positive.  Individuals positive for > 1 autoantibody are followed longitudinally in the TrialNet Pathway to Prevention (PTP) Cohort.  Among PTP participants, the contribution of obesity and insulin resistance to the progression of islet-associated autoimmunity or T1D has not been described.  BMI or BMI percentiles were calculated for adult and pediatric PTP participants. Insulin resistance was estimated using the homeostasis model assessment (HOMA1-IR).  A Cox proportional hazards model was used to determine the relationship between insulin resistance and BMI and single to multiple autoantibody conversion as well as progression to T1D. In single autoantibody-positive PTP participants (n=4661, 41.3% male, 58.7% female, mean age 21.7, mean BMI 22.9 + 6.7, mean BMI percentile 59.0 + 29.9, mean HOMA1-IR 2.0 + 1.6), there was no statistically significant relationship between BMI (p=0.347), BMI percentile (p=0.795), or HOMA1-IR (p=0.263) and progression to multiple autoantibody status.  Similarly, among PTP participants positive for > 2 autoantibodies (n=3525, 46.3% male, 53.7% female, mean age 17.9, mean BMI 21.5 + 6.4, mean BMI percentile 60.5 + 29.0, mean HOMA1-IR 1.9 + 2.1), there was no association between BMI (p=0.855), BMI percentile (p=0.095), or HOMA1-IR (p=0.899) and progression to T1D. Taken together, this analysis does not support a role for the Accelerator/Overload Hypothesis among a cohort of individuals with established autoantibody positivity.  However, further research is needed to determine the role of metabolic parameters in initial triggering of β cell autoimmunity and to identify additional environmental factors responsible for the increasing incidence of T1D.

 

Nothing to Disclose: FM, LAD, CJG, JB, JS, AP, CB, PX, CE

PP26-1 13523 1.0000 SUN-0966 A Body Mass Index and Insulin Resistance Do Not Impact Progression from Single to Multiple Autoantibody Positivity or Progression to Type 1 Diabetes Among Trialnet Pathway to Prevention Participants 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 11:30:00 AM PP26 4895 11:15:00 AM Diabetes Clinical Care; Genetics & Epidemiology Poster Preview

Rashmi Nedadur*1, Cheril Clarson2, Selam Mequanint3, Tracy Robinson4 and Tamara Spaic5
1University of Western Ontario, 2Children's Hosp Western Ontari, London, ON, Canada, 3LHSC, 4LHSC, Children's Hospital, 5St Joseph's Health Care, London, ON, Canada

 

Transition from pediatric to adult diabetes care is a high risk period during which there is an increased rate of disengagement from care and increased diabetes-related complications. A population based cohort study was conducted from 2002-2012 using uniquely linked pediatric and adult clinical diabetes electronic medical records (Web DR). The goal was to determine the impact on glycemic control and diabetes-related complications in the two years prior and subsequent to transition from pediatric to adults diabetes care in youth with Type 1 Diabetes (T1D). Transition occurred at 18 years of age. Clinical parameters analyzed were physician validated and documented with each visit.
Data were available on 148 subjects (47.3 % male) aged 16-20 who had clinical information recorded in Web DR. The majority of subjects 89 (60.1%) were using insulin pump therapy, 58 (39.2 %) were on multiple daily insulin injections, and 1 (0.7 %) on premixed insulin. Five (3.4 %) subjects were also on metformin. The mean A1C values were 8.7 ± 1.7 % during the 2 years prior to transition and 8.9 ± 1.8 % in the 2 years following transition (p=0.33). There were no significant differences between the mean weight (p=0.14) or systolic blood pressure (p=0.74), however the mean diastolic blood pressure increased from 67.3 ± 6.3 to 72.6 ± 7.9 mmHg (p<0.001) in the 2 years following transition. Screening for microalbuminuria and dyslipidemia following transition was completed in 47 (31.8%) and 36 (24.3%) participants. Mean LDL values did not differ pre and post transition (p=1.00). Prior to transition there was only 4 (2.7 %) participant with nephropathy and 1 (0.7%) with dyslipidemia. Rates of diabetes related complications following transition were: nephropathy 8 (5.4 %), retinopathy 4 (2.7 %), neuropathy 4 (2.7 %) , and hypertension 3 (2.0 %), and dyslipidemia 7 (4.7 %).

Our study demonstrated a trend toward deteriorating glycemic control and increasing diabetes-related complications during transition from pediatric to adult diabetes care in T1D patients followed in a tertiary diabetes center. The low uptake of complication screening is of concern, particularly in an academic center were routine complication screening is part of standard care. Reasons for these low screening rates require further exploration.

 

Nothing to Disclose: RN, CC, SM, TR, TS

PP26-2 15420 2.0000 SUN-0967 A Diabetes Care in Young Adults with Type 1 Diabetes after Transition to Adult Care 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 11:30:00 AM PP26 4895 11:15:00 AM Diabetes Clinical Care; Genetics & Epidemiology Poster Preview

Vaman Khadilkar*1, Anuradha Khadilkar2, Lavanya Parthasarathy3, Shashi Chiplonkar1 and Supriya Phanse-Gupte3
1Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India, 2Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India, 3Hirabai Cowasji Jehangir Medical Research Institute,Jehangir Hospital, Pune, India

 

Growth parameters are important indicators of a diabetic child’s overall health, and are influenced by factors like metabolic control and disease duration. Despite modern treatment regimens, reduced longitudinal growth is not uncommon (1). However, longitudinal growth studies in Indian diabetic children are scarce. Thus aim of the study was to compare height velocity of 4-15 year old Indian diabetics with healthy children and identify factors affecting height velocity. We hypothesized that diabetics would have reduced longitudinal growth which would be further compromised in those with long standing disease.

160 diabetic children (70 boys) were enrolled from a tertiary care centre at Pune (Western India). Standing height (portable stadiometer) and weight (electronic scale) was measured for all. The mean height (HAZ), weight (WAZ) and body mass index (BAZ) for age Z scores were estimated from contemporary Indian references (2). Yearly height velocity values were calculated for each subject by dividing difference between annual height measurements by age increment. Z scores of height velocity were calculated using measurements recorded on 400 healthy Indian children (unpublished data). Disease duration, insulin regimens, HbA1C was recorded. Tanner staging was performed by a trained pediatrician. Linear regression (SPSS version 12) was used to identify factors affecting height velocity.

Mean age of diabetics was 9.4±4.4 years. Data on height velocities is presented on 70 children. There were no significant differences between boys and girls for anthropometric parameters. Mean HAZ of boys and girls was -1.1±1.1 and -1.2±1.2 respectively. Around 29% of children had HAZ below -2 and 43% children had low height velocity scores (height velocity< 25th centile, Z score<-0.7 of healthy Indian children). HAZ of those who were diagnosed at <3 yrs of age was least (-1.6±1) amongst all diabetics. Similarly, disease duration was the most important factor affecting height velocity after adjusting for tanner staging (P<0.05, β=-0.449). There was no relationship seen between HbA1C and height velocity. Children on both insulin regimens-intensive and conventional had comparable height velocity Z scores.

Diabetic children were shorter and had lower height velocity in comparison with healthy children. Diabetics with long standing disease were found at higher risk of having reduced longitudinal growth. Children diagnosed at younger age need more attention to optimize growth.

 

Nothing to Disclose: VK, AK, LP, SC, SP

PP26-3 15583 3.0000 SUN-0968 A Reduced Longitudinal Growth in Indian Children and Adolescents with Type 1 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 11:30:00 AM PP26 4895 11:15:00 AM Diabetes Clinical Care; Genetics & Epidemiology Poster Preview

Naiemh Abdalrahaman*1, Christie McComb2, John Edward Foster2, Robert S Lindsay3, John McClure2, Martin McMillan4, Russell Drummond5, Derek Gordon5, Gerard McKay5, M G Shaikh6, Colin Perry7 and S F Ahmed8
1University of Glasgow, 2BHF Glasgow Cardiovascular Research Centre, University of Glasgow, UK., 3BHF Glasgow Cardiovascular Research Centre, University of Glasgow, United Kingdom, 4University of Glasgow, Glasgow, United Kingdom, 5Stobhill Diabetes Centre, Stobhill Hospital, Glasgow, UK, 6Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, UK., 7Western Infirmary,Glasgow, UK, Glasgow, United Kingdom, 8Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, UK

 

Objective: Case:control study of trabecular bone microarchitecture and vertebral marrow adiposity in young women with T1DM. Research Design &Methods: 30 cases with a median age at diagnosis of 9.7yrs (0.46,14.8) and 28 healthy women(controls) were studied at a median age of 22yrs(16.9,37.5).Measurementsincluded MRI-based assessment of proximal tibial bone volume/total volume (appBV/TV), trabecular separation(appTb.Sp), vertebral bone marrow adiposity (BMA) and abdominal adipose tissue and biochemical markers of GH/IGF-1 axis (IGF-1, IGFBP3, ALS) and bone turnover. Results: Median appBV/TV in casesand controls was 0.3(0.22, 0.37) and 0.33(0.26, 0.4), respectively (p=0.008) and median appTb.Sp in T1DM was 2.59 (2.24, 3.38) and 2.32 (2.03, 2.97), respectively (p=0.004). The median appBV/TV was 0.28 (0.22, 0.33) in those cases with retinopathy (n,15) compared to 0.33 (0.25, 0.37) in those without retinopathy (p=0.02). Although visceral adipose tissue in cases was higher than in controls at 5,733mm3(2030, 11,144) and 3,460mm3(1,808, 6,832), respectively (p=0.003), there was no difference in vertebral BMA. Serum CTX, a marker of bone resorption, was 0.15mg/l (0.03, 0.39) and 0.2 mg/l (0.05, 0.49) in cases and controls, respectively (p=0.04). Serum IGF-1 and ALS were also lower in cases and the latter showed an inverse association to appTbSp (r,-0.3, p=0.04) and vertebral BMA(r,-0.3, p=0.03).   Conclusion: Detailed MRI studies in young women with childhood-onset T1DM have shown clear abnormalities of bone health microarchitecture. Underlying pathophysiological mechanisms may include a microvasculopathy and GH resistance.

 

Nothing to Disclose: NA, CM, JEF, RSL, JM, MM, RD, DG, GM, MGS, CP, SFA

PP26-4 16705 4.0000 SUN-0969 A Abnormalities in Bone Microarchitecture and Bone Marrow Adiposityin Young Women with Type 1 Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 11:30:00 AM PP26 4895 11:15:00 AM Diabetes Clinical Care; Genetics & Epidemiology Poster Preview

Colin Hyslop1, Sue Tsai1, Pere Santamaria1 and Carol Huang*2
1University of Calgary, 2University of Calgary, Calgary, AB, Canada

 

Type I diabetes (T1DM) is caused by autoimmune destruction of β-cells. Immune therapy can blunt the attack on β-cells, but the residual β-cell mass at diagnosis is often insufficient for restoration of normal blood glucose despite halting immune destruction, which likely hampers the ability of immune agents to cure T1DM in humans. We hypothesize that using a growth factor to increase β-cell mass while applying an immune modulator to attenuate autoimmune attacks on β-cells will be more efficacious in restoring β-cell mass and reversing hyperglycemia than an immune agent alone. We chose prolactin because it is a physiologic growth factor that enhances β-cell mass by increasing β-cell proliferation and it increases insulin synthesis in vivo. We will treat diabetic NOD mice with a 5-day course of anti-CD3 ± a 21-day course of prolactin (Prl) and determine the rate of long term diabetes cure. We treated 20 diabetic mice in the CD3 group and 20 mice in the CD3+Prl group and followed them for 40 weeks after treatment. We found that a higher proportion of mice in the CD3+Prl group had sustained normal blood glucose in comparison to the CD3 group (Kaplan-Meier diabetes free survival, p=0.04). Interestingly, of the entire treatment group, 6/20 mice in the CD3 group never experienced diabetes reversal while all 20 mice in the CD3+Prl group experienced a period of normoglycemia.  In comparison to the CD3-only group, the CD3+Prl group had higher pancreatic insulin content (0.018 ± 0.005ng/ml/mg pancreas vs 0.005 ± 0.0003ng/ml/mg, N=3-4, p<0.05), and in response to glucose, they secreted a higher amount of insulin (AUC: 5.33±2.30ng/ml vs. 2.04±0.88ng/ml, n=9-11, p=0.05). They have higher β-cell mass (0.56 ± 0.13mg vs 0.12 ± 0.04mg, N=7, p<0.05), which was accompanied by a higher β-cell proliferation rate (5.2± 0.7% vs N=4, 1.4 ± 0.4% N=3-4, p<0.05). In terms of the immune system, we did not detect a difference in the number of CD4+ or CD8+ T cells, the number of Foxp3+/CD4+ regulatory T cells, or proliferation of CD4+ or CD8+ T cells between the two treatment groups. However, the CD3+Prl group had a higher proportion of islets that are free of insulitis at 40 weeks (13.6 ± 2.9% vs. 4.8 ± 0.7%, N=3, p<0.05).  In conclusion, prolactin is an effective therapeutic adjunct in improving anti-CD3-mediated diabetes cure in NOD mice, and this positive effect is associated with an increase in β-cell mass and insulin content in the pancreas of the prolactin-treated mice.

 

Nothing to Disclose: CH, ST, PS, CH

PP23-1 16468 1.0000 SUN-0970 A Prolactin As an Adjunct in Treatment of T1DM 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 11:30:00 AM PP23 4899 11:15:00 AM The Beta Cell and Diabetes Complications: Basic and Clinical Aspects Poster Preview

Ram Prakash Narayanan*1, Adrian H Heald2, William ER Ollier3 and J Martin Gibson2
1University of Liverpool, Warrington, United Kingdom, 2The University of Manchester, Salford, United Kingdom, 3Centre for Integrated Genomic Medical Research, Manchester, United Kingdom

 

Altered circulating concentrations of IGF-I, IGFBP-1 and IGFBP-2 have been associated with renal function in diabetes. We have studied associations of genes coding for IGF-I, IGF-II and six IGF binding proteins with estimated glomerular filtration rate in 991 Caucasian type 2 diabetes subjects from Salford, UK.

Using a Sequenom massARRAY platform, 16 IGF1, 15 IGF2, 9 IGFBP1, 4 IGFBP2, 10 IGFBP3, 5 IGFBP4, 8 IGFBP5 and one IGFBP6 SNPs were successfully genotyped. Longitudinal eGFR data for the years 2002 to 2009 was obtained from integrated primary care and hospital electronic medical records using the MDRD equation. Mixed effects regression models adjusted for age, gender, study duration and prescription of ACE inhibitors and angiotensin 2 receptor blockers were used to study SNPs as predictors of longitudinal eGFR.

IGF2 rs12417332, IGFBP1 rs9658238, IGFBP3 rs2132572 and IGFBP4 rs538399 were associated with preservation of eGFR, while IGFBP1 rs1908751, IGFPB2 rs7603372, IGFBP3 rs2132571 and IGFBP5 rs2241193 were associated with a deterioration in renal function. All the significantly associated proteins were included in a stepwise regression model along with age, gender and the earlier medications as covariates.  This identified four independent SNP associations– IGFBP3 rs2132572 (β 0.44, 95% CI 0.23 to 0.65, p<0.001), IGFBP2 rs7603372 (β -0.65, 95% CI -0.84 to -0.46, p<0.001), IGFBP4 rs538399 (β 0.32, 95% CI 0.12 to 0.52, p=0.001) and IGF2 rs12417332 (β 0.32, 95% CI 0.06 to 0.58, p 0.013) remained.

This study suggests that SNPs within IGF2, IGFBP2, IGFBP3 and IGFBP4 may influence longitudinal changes in renal function in a Caucasian type 2 diabetes population.

 

Nothing to Disclose: RPN, AHH, WEO, JMG

PP23-2 12276 2.0000 SUN-0981 A IGF Binding Protein Genes May Influence Renal Function in Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 11:30:00 AM PP23 4899 11:15:00 AM The Beta Cell and Diabetes Complications: Basic and Clinical Aspects Poster Preview

Sarah Z Hatab*1, Pamela D Winterberg2 and Andrew B Muir1
1Emory University School of Medicine, Atlanta, GA, 2Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, GA

 

BACKGROUND

Recurrent episodes of acute kidney injury (AKI) are strongly associated with incident chronic kidney disease (CKD) and progression of CKD. Impaired renal function with increased serum creatinine is typical of untreated DKA and is thought, in most cases, to be fully reversible once renal perfusion is restored by volume repletion. The incidence of AKI, as well as risk factors associated with the severity of AKI during DKA are not well described in children with type I diabetes (T1D).

METHODS

We conducted a retrospective cohort study of all children under 19 years old with known T1D presenting at our two tertiary pediatric intensive care units with DKA between August 2012 and August 2013. DKA was defined using ISPAD criteria.  AKI was defined according to pRIFLE criteria which classify AKI based upon the magnitude of change in estimated glomerular filtration rate (eGFR): R (risk, eGFR decreased by 25%), I (injury, eGFR decreased by 50%), and F (failure, eGFR decreased by 75%). GFR was estimated using the modified Schwartz equation and change in eGFR was calculated from baseline values (or 100mL/min/1.73m2 for those without baseline values).

RESULTS

The median age of the 112 subjects was 13 years (interquartile range 11, 15). Mild, moderate and severe DKA was present in 29, 35 and 36 percent of patients, respectively. AKI occurred in 95% of cases at presentation: 2 (2%), 43 (38%) and 61 (55%) patients were classified into pRIFLE categories F, I and R, respectively. The median time to resolution of DKA was 9 hours (interquartile range 6, 14). Of the 67 subjects who had serum creatinine concentrations measured 20 hours after initiation of DKA treatment, AKI had not yet resolved in 14  (20%) children. Multiple linear regression analysis revealed DKA severity and the number of previous DKA episodes as variables that were independently associated with the severity of AKI at DKA presentation (p<0.001). Duration of diabetes, age, peak serum sodium, and HbA1C at DKA presentation were not independently associated with the magnitude of change in eGFR.

CONCLUSION

AKI occurs frequently in children presenting in DKA and some patients have delayed recovery of kidney function after resolution of acidosis/volume expansion. The severity of AKI in DKA is strongly associated with the number of previous DKA episodes. Current understanding of mechanisms of renal injury suggests that recurrent subclinical AKI may exacerbate diabetic nephropathy. Further studies will determine whether subclinical kidney damage with each DKA episode persists and contributes to the increased susceptibility to future injury.

 

Nothing to Disclose: SZH, PDW, ABM

PP23-3 16522 3.0000 SUN-0982 A Effect of Recurrent Diabetic Ketoacidosis Episodes on the Severity of Acute Kidney Injury in Pediatric DKA 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 11:30:00 AM PP23 4899 11:15:00 AM The Beta Cell and Diabetes Complications: Basic and Clinical Aspects Poster Preview

Marzieh Salehi*1, Amalia Gastaldelli2 and David A D'Alessio3
1University of Cincinnati College of Medicine, Cincinnati, OH, 2CNR, Inst of Clinical Physiology, Pisa, Italy, 3Univ of Cincinnati, Cincinnati, OH

 

Gastric bypass (GB) surgery changes postprandial glucose dynamics, with more rapid increases and decreases of glycemia, higher peaks and lower nadirs. This is associated with hyperinsulinemia which has been attributed to increased stimulation by glucose and GLP-1. It is not known the extent to which the unique meal-induced insulin secretion profile in individuals with GB is the result of the greater glycemic excursion or changes to the beta-cell sensitivity to glucose. The aim of this study was to characterize β-cell sensitivity to glucose during up-and-down glucose infusions in GB and control subjects.

Twelve non-diabetic subjects after GB (GB) and 7 non-surgical controls with normal glucose tolerance (CON) were enrolled. The two groups were matched for age (43 ± 3 vs. 42 ± 3 yr), BMI (32 ± 2 vs. 31 ± 1 kg/m2), lean and fat mass (31 ± 1 & 35 ± 4 vs. 35 ± 4 & 34 ± 3 kg), and A1C level (5.2 ± 0.1 vs. 5.0 ± 0.2 %). Subjects received graded glucose infusions at increasing and then decreasing rates (0, 4, 8, 16, 8, 4, 0 mg/kg/min) for 40 minutes each.

Fasting glucose levels were similar in both groups while GB subjects were more insulin sensitive (HOMA-IR: 0.7 ± 0.2 vs. 2.3 ± 0.8; p<0.05). Administration of increasing doses of glucose caused lower rates of insulin secretion in the GB subjects compared to the controls (AUCISR(40,160min): 20.4 ± 3.7 vs. 39.2 ± 2.7 nmol, p<0.01), leading to a larger glycemic levels in these individuals most evident after the highest rate of the glucose infusion (AUCGlucose(40,240min): 19.4 ± 1.5 vs. 12.2 ± 1.3 g.dl-1.min, p<0.01). The β-cell sensitivity to glucose was less in the GB subjects compared to the controls during both the rise (34 ± 6 vs. 85 ± 8 pmol.min-1.mM-1, p<0.001) and fall of blood glucose (36 ± 6 vs. 88 ± 16 pmol.min-1.mM-1, p<0.001).

These findings indicate that GB subjects have lower β-cell sensitivity to glucose than controls, raising the possibility that this is an adaptation to the change in glucose dynamics after surgery.

 

Disclosure: DAD: Ad Hoc Consultant, Jansen Pharmaceuticals, Advisory Group Member, Lilly USA, LLC, Advisory Group Member, Novo Nordisk, Investigator, Merck & Co., Ad Hoc Consultant, Roche Pharmaceuticals, Investigator, Johnson &Johnson. Nothing to Disclose: MS, AG

PP23-4 15333 4.0000 SUN-0971 A Beta-Cell Response to Graded up & Down Glucose Infusion after Gastric Bypass Surgery 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 11:30:00 AM PP23 4899 11:15:00 AM The Beta Cell and Diabetes Complications: Basic and Clinical Aspects Poster Preview

Neville Ngai Chung Tam*1, Xiang Zhang2, Xiao Hong3, Dan Song1, Linda Levin4, Jarek Meller5 and Shuk-Mei Ho1
1University of Cincinnati College of Medicine, Cincinnati, OH, 2Univ of Cincinnati, Cincinnati, 3Medpace Inc, 4Univ of Cincinnati, 5University of Cincinnati

 

Increased susceptibility of estrogen-induced bladder outlet obstruction in a novel mouse model

1Xiang Zhang, 1Neville Tam, , 2Hong Xiao, Dan Song, Linda Levin, Jarek Meller and Shuk-Mei Ho (1 Equal contributions)

Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, Ohio 45267. 2 Medpace, Inc., 5375 Medpace Way, Cincinnati, OH 45227

Prostatic and lower urinary tract disorders are common urological diseases in men. The initial goal of the study was to investigate the role of metallothionein-1 (MT1) in prostate carcinogenesis using prostate-specific overexpression of MT1 in transgenic mice. Incidental findings of estrogen-induced bladder outlet obstruction (BOO) and genomic deletion in the transgenic mice prompted us to study the factors that contribute to the susceptibility and severity of BOO. We generated 12.1ΔMT1 mice which carry a 3.5 kb MT1 transgene insertion with a concomitant 12.1-kb noncoding deletion ~52 kb upstream of the nearest gene, Grin2a. Adult male 12.1ΔMT1 and wild type (WT) mice were treated with testosterone (T), 17β-estradiol (E2), bisphenol A (BPA), T + E2 or T + BPA. Histological and immunohistochemical analysis of the prostate, bladder and urethra were performed. No prostate precancer or cancer was observed in WT or 12.1ΔMT1 mice with or without hormonal treatment. Following E2 or T+E2 treatment, 12.1ΔMT1 mice developed high incidence of severe BOO with increased urine retention, thinner detrusor wall, and narrowing of bladder neck and urethral lumen, and basal cell hyperplasia in bladder body and urethra, compared with WT mice. The bladder neck and urethra of 12.1ΔMT1 mice exhibited an increased expression of NMDAR2A, encoded by Grin2a. Bioinformatic analysis mapped two evolutionary conserved noncoding sequences in the deleted region, implicating potential regulatory DNA elements. 12.1ΔMT1 mice were more susceptible to estrogen induction of severe BOO. We established a novel mouse model to study the hormonal and genetic influences in BOO development.

Sources of Research Support: NIH grants R01CA062269, R01CA015776, R01CA112532, R01ES015584, R01ES022071, U01ES019480, U01ES020988, and P30ES006096 and I01BX000675 awaded to SMH; CA156042 awarded to N.T.

 

Nothing to Disclose: NNCT, XZ, XH, DS, LL, JM, SMH

PP18-1 17009 1.0000 SUN-0369 A Increased Susceptibility of Estrogen-Induced Bladder Outlet Obstruction in a Novel Mouse Model 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 11:30:00 AM PP18 4900 11:15:00 AM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster Preview

Margaret R Bell*, Bethany G Hart, Karla Rodriguez, Michael P Reilly and Andrea C Gore
University of Texas at Austin, Austin, TX

 

The brain is particularly vulnerable to endocrine disrupting chemicals (EDCs) during the critical period of gestation, when gonadal hormones have long-term organizing effects that promote hormone-sensitive and sexually dimorphic behaviors later in life. Puberty and adolescence are also times of continued neural sensitivity to organizing effects of hormones. Therefore, we sought to determine how exposures to a class of EDCs, polychlorinated biphenyls (PCBs) at human-relevant dosages, during these two critical periods of development could interact to affect adult animals. We exposed male and female Sprague-Dawley rats to PCBs (Aroclor 1221, 1mg/kg/day, ip injection) and/or vehicle during gestation (embryonic days 16, 18, 20), adolescence (postnatal days 24, 26, 28), or both, to create four groups in a 2X2 design. Rats were tested for sociosexual and anxiety-related behaviors in adulthood (P80-90) one week prior to collection of fresh brain tissue. The effects of PCBs depended greatly on exposure period, as prenatal and juvenile PCB exposure resulted in reduced and increased adult body weight, respectively. Effects of PCB exposure on behavior also depended on the period of exposure and sex of the rat. For example, the preference for a hormone-treated over a no-hormone stimulus animal was increased by prenatal PCB exposure in males, but not in females. Alternatively, the production of frequency-modulated ultrasonic vocalizations, indicative of hedonic responses to an opposite-sex conspecific, was affected by juvenile PCB exposure, but only in animals that were naïve to prenatal PCBs, and only in females.  Similarly, time spent in the closed arm of an elevated plus maze, indicative of elevated anxiety, was reduced by juvenile exposure, but only in animals that were previously exposed to prenatal PCBs, and only in females. To gain insight into underlying mechanisms, we have begun quantifying mRNA of oxytocin, vasopressin, and their receptors, selected for their roles in sociosexual and anxiety behaviors and because they are sexually dimorphic and hormone sensitive. Preliminary qPCR of oxytocin receptor and vasopressin gene expression in the medial amygdala showed sex differences but no treatment effects. Further work will explore gene expression throughout the hypothalamus. Taken together, these results demonstrate the necessity to investigate effects of potential EDCs on throughout development in both sexes when considering potential health implications of the compounds.

 

Nothing to Disclose: MRB, BGH, KR, MPR, ACG

PP18-2 14823 2.0000 SUN-0370 A Interactions Between Gestational and Adolescent Exposure to Endocrine Disrupting Chemicals on Adult Social Behavior and Neural Gene Expression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 11:30:00 AM PP18 4900 11:15:00 AM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster Preview

Rebekah C Kennedy*1, Laura Healy2, Fu-Min Menn1, Kellie Fecteau1, Ling Zhao1, Jiyoung Bae1, Pan Hu1, Nancy A Gee3, Bill L Lasley3 and Jiangang Chen1
1University of Tennessee, Knoxville, TN, 2HistoTox Labs, Inc., Boulder, CO, 3University of California, Davis, CA

 

Triclocarban (TCC), an antimicrobial compound, affects pup survival during lactation in Sprague-Dawley (SD) rats.  Pup survival was only compromised when pups were raised by TCC exposed dams regardless of their in utero exposure status. Histopathology of mammary tissue from TCC exposed dams at the date of complete litter death revealed mammary gland involution with lobule separation with increased mature interstitial fat; thinning epithelial height, alveolar ectasia and increased epithelial vacuolation with fat. This study was designed to determine if mammary gland involution is a primary outcome of TCC exposure or secondary to its effect on suckling. Pregnant SD dams (n=6 control dams; n=3 0.5% w/w dams) were randomized into control or 0.5% w/w TCC treated groups from gestational day 5 (GD5) to postnatal day 6 (PND 6). Litter size was culled at PND 0. Four pup substitutions with age-matched pups born/raised by control dams, were conducted: on PND 1, half of the treated litter/per dam was replaced; on PND 3 the pups added on PND 1 were replaced; on PND 6, half of litter born to treated dams were replaced, and finally on PND 9, the pups added on PND 3 were replaced. Pups were examined daily for the size of milk bands. Dams were sacrificed on PND 14 and mammary tissue was collected for histopathology evaluation. Compared to the pups born/raised by control dams, milk band scores in pups born/raised by exposed dams were similar up to PND 3 but were significantly smaller on PND 6. Histology of mammary tissue revealed no indication of involution in either control or exposed dams. Higher levels of TCC were detected in pooled sera from pups raised by TCC exposed dams compared to controls. TCC concentrations in maternal milk correlated with TCC concentrations in the diet and were approximately four times the amount detected in the maternal circulation. Our results demonstrate that mammary involution is likely an indirect effect of TCC exposure during lactation as mammary tissue was not involuted in exposed dams when suckling activity was maintained by continuous addition of healthy pups. The high concentration of TCC in the milk compared to serum provides evidence for additional concern and highlights the necessity for future research on the safety of TCC exposures during lactation.  This study was supported by National Institute of Environmental Health Sciences (1R21ES017475-01A1).

 

Nothing to Disclose: RCK, LH, FMM, KF, LZ, JB, PH, NAG, BLL, JC

PP18-4 12546 4.0000 SUN-0365 A Mammary Gland Involution during Lactation Is a Secondary Effect of TCC Induced Neonatal Loss 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 11:30:00 AM PP18 4900 11:15:00 AM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster Preview

Nicholas A Tritos*1, Gudmundur Johannsson2, Márta Korbonits3, Karen K. Miller1, Ulla Feldt-Rasmussen4, Kevin C.J. Yuen5, Donna King6, Anders F. Mattsson7, Peter J. Jonsson8, Maria Koltowska-Haggstrom9, Anne Klibanski1 and Beverly MK Biller1
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Sahlgrenska Univ Hosp, Gothenburg, Sweden, 3William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom, 4Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark, 5Oregon Health and Science University, Portland, OR, 6Pfizer Inc, New York City, NY, 7Pfizer Health AB, Sollentuna, Sweden, 8Endocrine Care, Pfizer Health AB, Sollentuna, Sweden, 9Pfizer Endocrine Care, Sollentuna, Sweden

 

The safety of GH replacement in adults with GHD following cure of acromegaly has not been thoroughly investigated. To characterize the long-term safety of GH replacement in this population, KIMS was queried to identify subjects with stringently defined GHD following cure of acromegaly (acroGHD) and patients with GHD and history of clinically non-functioning pituitary adenoma (NFPA), as controls.

Data were evaluated to examine mortality (all-cause or secondary to cardiovascular or cerebrovascular disease), incidence of all cancers, benign or malignant brain tumors, cardiovascular or cerebrovascular disease, diabetes mellitus (DM), and serious adverse events. Both acroGHD and NFPA groups were compared to several cohorts from the general population (including WHO Global Burden of Disease) and to each other. Analyses were controlled for attained age, gender, BMI, and country/region. Analyses for some outcomes were additionally controlled for hypertension, dyslipidemia, DM, cardiovascular disease, malignancy or radiotherapy at baseline.

We identified 164 subjects (101 women) in the acroGHD and 2469 subjects (941 women) in the NFPA group, representing up to 1156 and 15701 patient-years, respectively. Cardiovascular mortality was increased in acroGHD vs. NFPA (SMR ratio=3.03, P=0.02), even after excluding patients with cardiovascular or cerebrovascular disease at KIMS entry. There was no difference in cerebrovascular mortality. All-cause mortality was similar in acroGHD [ratio between observed/expected (O/E) cases =1.32 (0.70-2.25; 95% CI)] and lower in NFPA [O/E=0.58 (0.48-0.70)] in comparison to the general population.

There were more cases of malignant brain tumors in both acroGHD [O/E=15.8 (1.77-57.05)] and NFPA [O/E=3.68 (1.47-7.58)] compared to the external reference population. The ratio between O/E cases of DM was increased in both acroGHD [O/E=3.84 (2.31-5.99)] and NFPA [O/E=3.86 (3.43-4.33)]. The incidence of DM increased with increasing BMI (P<0.0001). There was no difference in incidence of all cancers, benign or malignant brain tumors, cardiovascular or cerebrovascular disease, or DM between acroGHD and NFPA.

With the exception of increased cardiovascular mortality, these safety analyses suggested a comparable long-term safety in acroGHD and NFPA patients on GH replacement. Further investigation is needed to examine whether the increased cardiovascular mortality may be attributed to the history of chronic exposure to GH excess in the acroGHD group.

 

Disclosure: NAT: Researcher, Pfizer, Inc., Researcher, Ipsen, Consultant, Pfizer, Inc., Consultant, Corcept. GJ: Researcher, Novo Nordisk, Researcher, Pfizer, Inc., Speaker, Pfizer, Inc., Speaker, Novo Nordisk, Speaker, Merck Serono, Speaker, Otsuka, Advisory Group Member, Pfizer, Inc., Consultant, Viropharma, Consultant, Astra Zeneca. MK: Researcher, Pfizer, Inc., Researcher, Novartis Pharmaceuticals, Researcher, Syntaxin, Consultant, Pfizer, Inc., Consultant, Chiasma, Consultant, Sanofi, Consultant, Syntaxin. KKM: Principal Investigator, Pfizer, Inc., Principal Investigator, Ipsen. UF: Principal Investigator, Novartis Pharmaceuticals, Principal Investigator, Novo Nordisk, Speaker, Pfizer, Inc., Speaker, Novo Nordisk, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Advisory Group Member, Pfizer, Inc.. KCJY: Principal Investigator, Pfizer, Inc., Investigator, Novo Nordisk, Investigator, Eli Lilly & Company, Investigator, Versartris, Advisory Group Member, Pfizer, Inc., Advisory Group Member, Novo Nordisk, Advisory Group Member, Corcept. DK: Employee, Pfizer, Inc.. AFM: Employee, Pfizer, Inc.. PJJ: Employee, Pfizer, Inc.. MK: Employee, Pfizer, Inc.. AK: Investigator, Ipsen, Investigator, Novartis Pharmaceuticals, Investigator, Rhythm Pharmaceuticals. BMB: Consultant, Pfizer, Inc., Consultant, Novartis Pharmaceuticals, Consultant, Novo Nordisk, Principal Investigator, Novo Nordisk, Principal Investigator, Novartis Pharmaceuticals.

PP17-1 11586 1.0000 SUN-0589 A Long-Term Safety of Growth Hormone (GH) Replacement in Adults with GH Deficiency (GHD) Following Cure of Acromegaly – a Kims (Pfizer International Metabolic Database) Analysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 11:30:00 AM PP17 4909 11:15:00 AM Pituitary Tumors Poster Preview

Annamaria Colao*1, Marcello D Bronstein2, Thierry Brue3, Mihail Gr Coculescu4, Maria Fleseriu5, Mirtha Guitelman6, Vyacheslav Pronin7, Gerald Raverot8, Ilan Shimon9, Kayo Kodama Lievre10, Juergen Fleck10, Mounir Aout10, Alberto M Pedroncelli10 and Mônica Gadelha11
1Università Federico II, Naples, Italy, 2University of São Paulo Medical School, São Paulo, Brazil, 3Centre de Recherche en Neurobiologie et Neurophysiologie de Marseille, France, 4Academy of Medical Sciences of Romania University of Medicine and Pharmacy ‘Carol Davila’, National Institute of Endocrinology ‘CI Parhon’, Bucharest, Romania, 5Oregon Health & Science University, Portland, OR, 6Hospital Carlos G Durand, Buenos Aires, Argentina, 7IM Sechenov First Moscow State Medical University, Moscow, Russia, 8Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France, 9Rabin Medical Center and Sackler School of Medicine, Tel-Aviv University, Petah-Tiqva, Israel, 10Novartis Pharma AG, Basel, Switzerland, 11Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil

 

Background: Despite receiving maximum-approved doses of sst2-preferential somatostatin analogs, a proportion of patients with acromegaly do not achieve biochemical control (growth hormone [GH] <2.5μg/L and normalized insulin-like growth factor 1 [IGF-1]). This 24-week, randomized study (PAOLA) assessed the multireceptor-targeted somatostatin analog pasireotide LAR versus octreotide LAR and lanreotide Autogel in patients with inadequately controlled acromegaly.

Methods: Eligible patients: ≥18 years with mean GH levels ≥2.5μg/L and IGF-1 levels >1.3xULN (inadequate control) who had received octreotide LAR 30mg or lanreotide Autogel 120mg monotherapy for ≥6 months. Patients were randomized to: double-blind pasireotide LAR 40mg or 60mg; or continued treatment with open-label octreotide LAR/lanreotide Autogel (active control group). Primary endpoint: proportion of biochemically controlled patients (wk 24). Key secondary endpoint: proportion of patients with normalized IGF-1 (wk 24). Other secondary endpoints: proportion of patients with GH<2.5μg/L (wk 24); tumor volume reduction >25% (wk 24). Safety/tolerability was also assessed.

Results: In total, 198 patients were randomized to pasireotide LAR 40mg (n=65), 60mg (n=65), and active control (n=68). Significantly more patients achieved biochemical control (15.4% and 20.0% vs 0%; P=0.0006 and P<0.0001, respectively) and IGF-1 normalization (24.6% and 26.2% vs 0%; P<0.001 for both) with pasireotide LAR 40mg or 60mg compared with active control at 24 wks. Furthermore, more patients had GH levels <2.5µg/L (35.4% and 43.1% vs 13.2%) and tumor volume reduction >25% (18.5% and 10.8% vs 1.5%) with pasireotide LAR 40mg or 60mg compared with active control at 24 wks. The safety profile of pasireotide LAR 40mg and 60mg was similar to that for the active control group, except for the frequency and degree of hyperglycemia. The most common adverse events (AEs) were hyperglycemia (33.3%, 30.6%, 13.6%), diabetes mellitus (20.6%, 25.8%, 7.6%) and diarrhea (15.9%, 19.4%, 4.5%) in the three treatment groups, respectively; hyperglycemia-related AEs were observed in 76.2%, 61.3% and 40.9%.

Conclusions: Pasireotide LAR provides superior efficacy over continued treatment with octreotide LAR/lanreotide Autogel in patients with inadequately controlled acromegaly. Pasireotide LAR could become the new standard pituitary-directed treatment in patients with acromegaly inadequately controlled by sst2-preferential somatostatin analogs.

 

Disclosure: AC: Scientific Board Member, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals. MDB: Committee Member, Novartis Pharmaceuticals, Committee Member, Ipsen, Committee Member, Pfizer, Inc., Committee Member, Chiasma, Speaker, Novartis Pharmaceuticals, Speaker, Ipsen, Principal Investigator, Novartis Pharmaceuticals. TB: Investigator, Sandoz, Investigator, Novartis Pharmaceuticals, Speaker, Sandoz, Speaker, Novartis Pharmaceuticals, Advisory Group Member, Viropharma, Advisory Group Member, Novartis Pharmaceuticals, Speaker, Viropharma, Consultant, Novartis Pharmaceuticals, Speaker, Merck Serono, Investigator, Ipsen, Speaker, Ipsen, Advisory Group Member, Ipsen, Consultant, Ipsen, Investigator, Pfizer, Inc., Investigator, Novo Nordisk, Speaker, Novo Nordisk, Consultant, Pfizer, Inc., Advisory Group Member, Pfizer, Inc., Speaker, Pfizer, Inc., Investigator, Pfizer, Inc., Investigator, Sandoz, Speaker, Sandoz, Advisory Group Member, Viropharma, Speaker, Viropharma. MF: Principal Investigator, Novartis Pharmaceuticals, Ad Hoc Consultant, Novartis Pharmaceuticals, Ad Hoc Consultant, Ipsen, Principal Investigator, Ipsen, Ad Hoc Consultant, Genentech, Inc., Principal Investigator, Corcept, Consultant, Novartis Pharmaceuticals. GR: Speaker, Novartis Pharmaceuticals, Speaker, Ipsen. IS: Advisory Group Member, Novartis Pharmaceuticals, Coinvestigator, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Consultant, Pfizer, Inc., Coinvestigator, Pfizer, Inc., Speaker, Pfizer, Inc., Advisory Group Member, Novo Nordisk, Advisory Group Member, Neopharm. KK: Employee, Novartis Pharmaceuticals. JF: Employee, Novartis Pharmaceuticals. MA: Employee, Novartis Pharmaceuticals. AMP: Employee, Novartis Pharmaceuticals. MG: Advisory Group Member, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Speaker, Ipsen, Speaker, Pfizer, Inc., Principal Investigator, Novartis Pharmaceuticals, Coinvestigator, Novartis Pharmaceuticals, Coinvestigator, Pfizer, Inc.. Nothing to Disclose: MGC, MG, VP

PP17-2 14588 2.0000 SUN-0591 A Phase III, Multicenter, Randomized Study (PAOLA) Demonstrating That Pasireotide LAR Has Superior Efficacy over Octreotide LAR and Lanreotide ATG in Patients with Inadequately Controlled Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 11:30:00 AM PP17 4909 11:15:00 AM Pituitary Tumors Poster Preview

Ansgar Heck*, Kyrre E Emblem, Jens Bollerslev and Geir Ringstad
Oslo University Hospital, Oslo, Norway

 

Introduction:

Acromegaly is normally caused by a growth hormone (GH) producing pituitary tumor easily depicted on conventional T2 weighted magnetic resonance imaging (MRI). T2 weighted signal intensity, categorized into hypo-, iso- and hyperintense, has recently been shown to correlate with histological subtypes and response to Octreotide [1, 2]. The purpose of our study was to assess the value of MRI for prediction of somatostatin response in patients with acromegaly by use of a novel T2-weighted signal intensity distribution analysis.

Methods:

Fifty-eight consecutive, treatment naïve patients with acromegaly underwent conventional MRI including T2 weighted imaging. Clinical evaluation included GH day curve, IGF-1, an Octreotide test and MRI of the pituitary. Thirty-four patients were treated primarily with Octreotide for a median duration of 6 months.

On the T2-weighted MRIs, the tumor and representative in-slice areas of normal-appearing temporal grey matter were outlined by an experienced neuroradiologist. To correct for image- and scanner variations, normalized histogram curves were derived and fitted to a Gaussian shaped function. The amplitude and position values of this function were recorded and the relative tumor/reference tissue ratios of amplitude (AMP) and position (POS) derived. POS was used as a measure for the relative T2 signal intensity and AMP as a surrogate maker for the T2 signal homogeneity in the adenoma.

Results:

At baseline, POS correlated with GH, IGF-1, GH reduction after an Octreotide test and adenoma volume (GH: rs=-0.43; p=0.001; IGF-1: rs=0.37; p=0.004; GH reduction after Octreotide test: rs=-0.54; p<0.001; adenoma volume: rs=0.33; p=0.013).

After primary Octreotide treatment, POS correlated with GH reduction (rs=-0.66; p<0.001) (and IGF-1 reduction rs=-0.29; p=0.096). AMP correlated with GH at baseline (rs=0.30; p=0.024) and with the relative adenoma volume reduction (rs=-0.45; p=0.007).

Conclusion:

1. We present a new method for quantitative analysis of T2 signal characteristics in GH producing adenomas based on standard scans.

2. Low T2 intensity (POS) correlated with higher biochemical activity and lower adenoma volume at baseline and predicted biochemical treatment response.

3.  By this new method, the distribution pattern of the T2 signal correlated significantly to clinical characteristics and treatment outcome. In particular, heterogeneity of the T2 signal (low AMP) correlated with a better effect on adenoma volume reduction after primary treatment with Octreotide.

 

Nothing to Disclose: AH, KEE, JB, GR

PP17-3 12130 3.0000 SUN-0590 A Advanced T2-Weighted MRI Analysis Predicts Response to Somatostatin Analogues in Patients with Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 11:30:00 AM PP17 4909 11:15:00 AM Pituitary Tumors Poster Preview

Kadriye Aydin*1, Cisel Aydin1, Selcuk Dagdelen2, Gaye Guler Tezel1 and Tomris Erbas2
1Hacettepe University Medical School, Ankara, Turkey, 2Hacettepe University Medical School

 

Background: Acromegaly is associated with increased thyroid cancer risk, but  biological behaviour of the thyroid cancer in acromegaly  is not well defined. Genetic alterations such as point mutations of BRAF and RAS genes, and RET/PTC, PAX8/PPARγ gene rearrangements are frequently observed in differentiated throid cancers (DTC) and have prognostic implications. In this study we aimed to analyze BRAF, RAS, RET/PTC, PAX8/PPARγ mutations and gene rearrangements in thyroid cancer patients with acromegaly.

Design and Methods: We included fourteen patients with acromegaly who were operated in our center and diagnosed to have DTC in the study. Sections of pathologic specimens with thyroid cancer were prepared for testing and BRAF V600 and NRAS codon 61 point mutations, RET/PTC1, RET/PTC3, PAX8/PPARγ gene rearrangements were analyzed.

Results:  Eight male and six female patients with acromegaly were included. Mean age at diagnosis of acromegaly was 42.3±10.6 years while mean age at diagnosis of thyroid cancer was 46.9±8.8 years. Two of  the patients (14.3%) were detected to have positive BRAF V600 point mutation and three patients (21.4%) were detected to have NRAS codon 61 point mutation. Aggressive histologic features were extrathyroidal presence of tumour in one of the patients with positive BRAF mutations and infiltrative character of the tumour in the other. One of the patients with NRAS point mutation had vascular invasion whereas the other patient had thyroid capsul invasion by the tumor. Third patient with the positive NRAS point mutation had elevated thyroglobulin levels which was decreased after radioiodine therapy. RET/PTC 1, RET/PTC3, PAX8/PPARγ gene rearrangement fusion product was not detected in any patient. None of the patients including the patients with positive point mutations had recurrence, and local and/or distant metastasis.

Conclusion:  BRAF point mutation is found in 40-45% of thyroid papillary carcinoma (PTC), but the rate varies between 10% to 80% according to the histologic subtype. Prevalance of  NRAS mutation is about 10-20% in PTC. We detected BRAF V600 mutation in 14.3% of patients and NRAS codon 61  mutation in 21.4% of the patients with acromegaly. Acromegalic patients with DTC seem to have similar genetic alterations with general population having DTC.  Patients having positive point mutations for BRAF V600 and NRAS codon 61 had agressive histologic features consistent with the detected mutation.

 

Nothing to Disclose: KA, CA, SD, GGT, TE

PP17-4 14662 4.0000 SUN-0592 A Genetic Alterations in Differentiated Thyroid Cancer Patients with Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 11:30:00 AM PP17 4909 11:15:00 AM Pituitary Tumors Poster Preview

Sylvie Mader*1, David Cotnoir-White1, Mohammed El Ezzy1, Etienne Gagnon2 and Michel Bouvier3
1Universite de Montreal, Montreal, QC, Canada, 2Institute for Research in Immunology and Cancer (IRIC), Montreal, QC, Canada, 3Univ of Montreal, Montreal, QC, Canada

 

Most of the steroid hormone receptors (SHRs) are transcriptionally active as dimers but can also form heterodimers between receptors with similar or different ligand specificity, such as the estrogen receptor (ER) α/β or the GR/MR heterodimers, resulting in an increased diversity of target gene regulatory networks. However, the tools to study the formation and state of heterodimers in living cells are still limited. Here we describe novel protein complementation (PCA) and Bioluminescence Resonance Energy Transfer (BRET) assays to detect not only SHR homo/heterodimer formation but also simultaneously cofactor recruitment to specific ligand-activated dimers in living cells. In addition, these methods can be adapted to assess the impact of ligands on post-translational modifications of nuclear receptor dimers such as ubiquitination or SUMOylation. Using these approaches, we have characterized receptor-receptor interactions between members of the SHR family in live transfected HEK293 cells as well as the potency and selectivity of receptor ligands for coactivator recruitment by homo- and heterodimers. The novel approaches used in this study help shed light on the allosteric effects that shape NR activity and should allow to better model the specificity and diversity in target gene regulation by nuclear receptor dimers.

 

Nothing to Disclose: SM, DC, ME, EG, MB

PP21-1 16847 1.0000 SUN-0405 A Specificity of Ligand-Dependent Coactivator Recruitment in Steroid Receptor Homo- and Heterodimers 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 11:30:00 AM PP21 4910 11:15:00 AM Novels Ways to Regulate Nuclear Receptor Function Poster Preview

Lindsey S Treviño*, Michael J Bolt, Michael Alan Mancini, Dean P. Edwards and Nancy L Weigel
Baylor College of Medicine, Houston, TX

 

Studies have implicated progestin/progesterone receptor signaling in the etiology of breast cancer. PR function is altered by cell signaling, but the mechanisms of kinase-specific regulation are not well-defined. To examine the role of cell signaling in the regulation of PR transcriptional activity, we have utilized a mammalian-based estrogen response element (ERE) promoter array cell model and automated imaging and analysis platform developed in the Mancini lab. This experimental approach has been developed to enable direct visualization and quantification of different steps in steroid receptor-mediated transcriptional activation including binding to specific ERE DNA, chromatin modification, coregulatory protein recruitment and transcriptional activity (measured by FISH) at the single intact cell level in a high-throughput manner. To take advantage of this system and study effects of kinases on PR functions, we generated stable ERE array cell lines expressing inducible chimeric PR that contains a swap of the estrogen-receptor-α (ER) DNA-binding domain (DBD) for the DBD of PR. The stable cell lines expressing chimeric PR were characterized and respond properly to progestin agonist and antagonists. We have focused on two kinases: cyclin-dependent kinase 2 (Cdk2) which is required for optimal PR function, and DNA-dependent kinase (DNA-PK) which has recently been shown to be important for ER function. Following NU6102 (a Cdk1/2 inhibitor) or NU7441 (a DNA-PK inhibitor) treatment, chimeric PR chromatin decondensation (array size) and transcriptional activity are significantly decreased. Further, using an imaging approach akin to chromatin IP, we observe a quantitative reduction in the recruitment of steroid receptor coactivator 1 (SRC-1) with NU6102 that is not seen with NU7441. Chimeric PR binding to the ERE array DNA is unaffected by both inhibitors. In parallel, we determined the effect of kinase inhibition on hormone-mediated induction of primary and mature transcripts of endogenous genes in T47D breast cancer cells. Treatment with NU6102 inhibits expression of all of the PR targets examined; in particular, the effects are greater for the genes that exhibit a rapid increase in primary transcript expression in response to hormone. In contrast, this preferential pattern of inhibition was not seen with NU7441 treatment. Taken together these results indicate that Cdk2, but not DNA-PK, plays a role in direct acute activation of PR transcription.

 

Nothing to Disclose: LST, MJB, MAM, DPE, NLW

PP21-2 16192 2.0000 SUN-0417 A Differential Regulation of Progesterone Receptor-Mediated Transcription By Cyclin-Dependent Kinase 2 and DNA-Dependent Kinase 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 11:30:00 AM PP21 4910 11:15:00 AM Novels Ways to Regulate Nuclear Receptor Function Poster Preview

Nina V. Titova*1, Jonathan Robert Deans1, John Prins2, Yinsheng Wang3, Kenneth Huffman4 and Frances M. Sladek1
1University of California, Riverside, CA, 2University of California Riverside, CA, 3University of California Riverside, Riverside, CA, 4University of Texas Southwestern Medical Center, Dallas, TX

 

Prdx1 is an abundant antioxidative enzyme that is nitrated on tyrosine and has been shown to reduce nitration of plant and bacterial proteins. Protein nitration is significantly increased in mammals during metabolic stress, diabetes, aging, and cancer, and mice lacking Prdx1 exhibit accelerated aging and develop cancer in multiple tissues. Prdx1 has been shown to act as a co-activator for the androgen receptor but little else is known about transcriptional effects of this enzyme, which is abundant in the nucleus as well as the cytoplasm. Two other nuclear receptors (NRs), glucocorticoid receptor (GR) and HNF4a, regulate metabolism in the liver under various stress conditions. We used co-immunoprecipitation, mass spectrometry and protein binding microarray (PBM) technology to determine whether Prdx1 could act as a co-activator for GR and HNF4a. We found that GR and HNF4a were immunoprecipitated (IP’d) by anti-nitrotyrosine antibodies and that the signal correlated with degree of cellular stress. Co-IPs also showed that Prdx1 interacts with GR and HNF4a in mouse liver in the absence of DNA. PBMs using mouse liver nuclear extracts showed Prdx1 co-localizes to specific NR response elements, which were also bound by GR and HNF4a. Prdx1 seemed to enhance the ability of HNF4a to bind certain DNA sequences during stress.

In cancer cells, where metabolic stress is high, the levels of Prdx1 protein are often increased dramatically. We used human lung cancer cell lines from a primary and metastatic tumor with differential sensitivity to GR ligands from the same patient to assess the role of human Prdx1 on GR DNA binding. We found comparable high levels of nuclear GR and Prdx1 proteins after dexamethasone treatment in both cell lines even though the metastatic line was more sensitive to GR ligands than the primary line. We observed specific interactions between GR and Prdx1 in the GR-ligand sensitive line. This work shows for the first time that Prdx1 interacts with NRs HNF4a and GR and that it may affect their ability to bind DNA, and hence regulate transcription. On going experiments will determine whether Prdx1 alters NR nitration and whether that nitration affects DNA binding.

 

Nothing to Disclose: NVT, JRD, JP, YW, KH, FMS

PP21-4 14467 4.0000 SUN-0431 A The Antioxidant Enzyme Prdx1 Alters Nuclear Receptor DNA Binding during Conditions of Cellular Stress 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 11:30:00 AM PP21 4910 11:15:00 AM Novels Ways to Regulate Nuclear Receptor Function Poster Preview

Lisa M Neff*1, Dinah M Zeiss1, Mindy Hoffmann1, Katherine Lowry2, Monica Edwards1 and Lewis Landsberg1
1Northwestern University Feinberg School of Medicine, 2Southern Illinois University School of Medicine

 

Background: In controlled under- and overfeeding studies, significant inter-individual variation has been observed with respect to the magnitude of the resulting changes in body weight. The responsible mechanisms are unknown, but processes involved in adaptation to energy imbalance clearly play a role.  Around two-thirds of a typical human’s basal metabolic rate is spent in the cost of maintaining homeothermy.  Body temperature is known to be reduced in frank starvation, caloric restriction in non-obese individuals, and in states of leptin deficiency, but there are no known studies of the effect of weight loss on body temperature in obesity.  We hypothesized that body temperature would decrease during weight loss in obesity, as part of the adaptive response to weight loss that is mediated by leptin. 

Methods: We studied 20 overweight and obese adults (BMI 28 - 40 kg/m2)  during overnight admissions in the Clinical Research Unit at three timepoints: 1) before weight loss, 2) immediately after a 10% weight loss during continued negative energy balance, and 3) following two weeks of weight stability at a 10% reduced body weight.  Weight loss was achieved using a very low calorie diet (800 kcal/day).  At each timepoint, testing included measurement of core body temperature (CorTemp system, HQ Inc.), resting energy expenditure (REE; by indirect calorimetry), body composition (DEXA), and fasting levels of glucose, insulin, TSH, total T3, free T4, and leptin.  During the testing periods, subjects’ activities were standardized and included periods of rest, food consumption, exercise, and sleep.

Results: With active weight loss, there was a small 0.08 ± 0.15 °C decrease in mean 24 hour core body temperature (p=0.039) and a 0.16 ± 0.29 °C decrease in mean core temperature during sleep (p =0.040).  Total T3 decreased by 14.40 ± 20.38 mcg/dL (p=0.005) from visit 1 to visit 2. There was a significant correlation between change in leptin and change in total T3 with weight loss (r=0.523, p=0.018). There was also a correlation between the change in plasma leptin and the change in mean 24 hour core temperature with active weight loss (r=0.564, p=0.023).  Subjects with more rapid weight loss tended to have greater decreases in fasting leptin (r=0.539, p=0.014) and in core temperature during sleep (r=0.547, p=0.023).  With weight stabilization at a 10% reduced body weight, core temperature returned to baseline so that there was not a significant difference between mean core temperatures at visit 1 and visit 3. 

Conclusions:  Active weight loss was associated with a small decrease in core body temperature, through mechanisms that may be related to changes in leptin, such as decreases in sympathetic nervous system activity or alterations in thyroid hormone metabolism.  A reduction in body temperature remains a potential contributing factor responsible for some of the decrease in energy expenditure that is observed with weight loss in obesity.

 

Nothing to Disclose: LMN, DMZ, MH, KL, ME, LL

PP16-1 15491 1.0000 SUN-0908 A Core Body Temperature Decreases during Weight Loss in Obesity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 11:30:00 AM PP16 4914 11:15:00 AM Energy Expenditure Poster Preview

Joel Schmitz*1, Jan Mauer2, Hayley T Nicholls2, Motoharu Awazawa2, Nadine Evers3, Hella S Brönneke3, Michael Faust1 and Jens C Brüning1
1Center for Endocrinology, Diabetes and Preventive Medicine (CEDP), Cologne, Germany, 2Institute for Genetics, Cologne, Germany, 3Max Planck Institute for Neurological Research, Cologne, Germany

 

In the fight against obesity and its associated diseases, weight regain after primary successful weight loss is an ongoing challenge for patients as well as their physicians. Little is known about underlying mechanism for this phenomenon and treatment options are very limited. We established a novel feeding paradigm in mice using only dietary changes. Mice were fed a high fat diet (HFD) for 18 weeks to establish obesity. Weight reduction was then achieved by restricting dietary intake by 40 % for 6 weeks until mice were of equal body weight than a control group permanently on low fat fed (LFD). After weight reduction mice were either allowed unrestricted calorie intake of low fat diet (WR ad lib) or pair-fed the same amount of food the LFD control group consumed (WR pair). Interestingly only WR ad lib mice regained body weight weighing 13% more than the control LFD group within 8 weeks. WR pair mice did not regain body weight, indicating that hyperphagia rather than a decreased energy expenditure is mainly responsible for the observed weight regain. Consistent with this notion, we found a persistent increase in energy intake of up to 16% more calories in WR ad lib mice, while calorimetry showed only temporary changes of energy expenditure during weight loss.

Interestingly weight reduced animals showed a superior glucose clearance than LFD animals, despite still displaying systemic insulin resistance. The systemic insulin sensitivity recovered only when weight loss was maintained by prolonged pair-feeding. Explaining the discrepancy between high glucose clearance at a state of insulin resistance we found that glucose stimulated insulin secretion continued to be elevated 4-fold beyond weigh reduction and maintenance. Accordingly pancreatic beta-cell morphology showed a 3 fold increased pancreatic beta cell size in weight reduced animals compared to LFD mice.

Tissue specific insulin sensitivity was restored in the liver, but continued to be compromised in white adipose tissue even when weight loss was maintained. In addition, hepatic expression of inflammatory cytokines returned to normal, but remained significantly elevated in white adipose tissue, where macrophage infiltration continued to be present at levels seen in obesity.

To summarize, despite maintained weight loss, adipose tissue inflammation and insulin resistance persist long-term, while liver inflammation and insulin resistance appear readily reversible.

 

Nothing to Disclose: JS, JM, HTN, MA, NE, HSB, MF, JCB

PP16-2 11048 2.0000 SUN-0906 A Weight Reduction in Diet Induced Obesity: As Good As New? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 11:30:00 AM PP16 4914 11:15:00 AM Energy Expenditure Poster Preview

Poonamjot Deol*1, Jane R Evans1, Joseph Dhahbi2, Karthikeyani Chellappa1, Nadege Briancon3, Mary C Weiss3, Christian Lytle1, Tao Jiang1, James Borneman1 and Frances M. Sladek4
1University of California, Riverside, Riverside, CA, 2University of California, Riverside, CA, Riverside, CA, 3Pasteur Institute, Paris, France, 4University of California, Riverside, CA

 

Obesity was recently declared a disease by the American Medical Association. Excessive weight gain is a driver of metabolic syndrome, which includes diabetes, insulin resistance (IR), hypertension and fatty liver disease. One factor that is not well studied but correlates with the obesity epidemic in the U.S. is a 1000% increase in the consumption of soybean oil, which contains 50-60% linoleic acid (LA), a C18:2 PUFA. LA is an essential fatty acid and a precursor to arachidonic acid, which is linked to inflammation, a key player in obesity, diabetes, cancer, etc.  As a result of the increase in soybean oil consumption, the daily energy intake from LA in the U.S. has risen from 2% to >7% from 1909-1999. We recently identified LA as an endogenous ligand for HNF4α, a highly conserved nuclear receptor that is linked to diabetes and is a master regulator of liver-specific gene expression. To investigate the role of HNF4α in the obesity epidemic, we designed a series of specialized isocaloric diets that are moderately high in saturated fats (40%kcal total fat) with or without supplementation of soybean oil to achieve 2% kcal LA (HFD) or 10% kcal LA (LA-HFD). C57/BL6 (WT) mice on LA-HFD had increased weight gain, adiposity, diabetes and IR compared to HFD. They also had fatty livers with ballooning injury and fibrosis. RNAseq of the livers revealed a massive up-regulation of the lipid binding protein Cidea in the livers of LA-HFD treated mice. Coordinate dysregulation of other genes involved in metabolism, lipid binding, transport and storage and of Cyp genes in the LA, arachidonic and steroid pathways was also observed. We also treated HNF4α exon-swap mice with these specialized diets. These mice are genetically engineered to express just the P2-form of HNF4α so that in tissues, such as liver, where the P1 promoter is active, HNF4α7/8 is expressed instead of HNF4α1/2. Unlike the WT mice on LA-HFD, the exon swap mice did not develop obesity, diabetes, IR or fatty liver. qRT-PCR results show that Cidea expression in the livers of LA-HFD treated exon-swap mice was not increased as it was in WT mice. These results indicate that the exon-swap mice are resistant to the metabolic effects of soybean oil and that HNF4α may play a major role in the pathogenesis of obesity. Analysis of liver metabolomics, serum inflammatory markers (using Luminex) and the intestinal microbiome from diet-treated WT as well as exon-swap mice will be presented, and a systems biology approach will be used to identify factors involved in soybean oil-induced obesity.

 

Nothing to Disclose: PD, JRE, JD, KC, NB, MCW, CL, TJ, JB, FMS

PP16-3 15660 3.0000 SUN-0909 A Soybean Oil Induces Metabolic Syndrome Via HNF4α 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 11:30:00 AM PP16 4914 11:15:00 AM Energy Expenditure Poster Preview

Richard B Meagher*1, Elizabeth Cohen McKinney1, Suresh Ambati1, Diane L Hartzell2 and Clifton A Baile1
1University of Georgia, Athens, GA, 2Univ of Georgia, Athens, GA

 

Obesity is characterized by increased adipocyte development in muscle and in bone marrow as well as an expansion of visceral and subcutaneous adipose depots. Adipose tissues become the dominant endocrine organ. Initial evidence suggests that harmful changes in obese adipocyte gene expression and adipokine secretion are under epigenetic control. Considering that epigenetics is the study of cell-type-specific differences in a developmental context, it is important to examine isolated adipocytes from mammalian tissues. However, adipocytes represent only a subset of cell types in muscle, bone, and adipose tissue depots, and they are too large, sticky, and fragile to efficiently isolate in large numbers and sort into subtypes.

By contrast, we find adipocyte nuclei are relatively easy to isolate from fresh, frozen, or formalin fixed tissue. We have implemented an INTACT (Isolation of Nuclei TAgged in Specific Cell Types) technology, to enable the rapid isolation of adipocyte nuclei from various tissues. We expressed transgenic nuclear envelope transmembrane proteins (NETs) fused to a fluorescent protein reporter (e.g., mRFP1) and an immunoepitope tag (3xFlag) under control of the adipocyte-specific adiponectin promoter (ADNp). We have tested the ADNp controlled expression of several different NETs in 3T3-L1 preadipocytes, during their induced differentiation into adipocytes. Engineered NETs, including Nesprin3-RFP-Flag, SUN1-RFP-Flag, and RANGAP-GFP were all successfully targeted to the nuclear membrane of cultured adipocytes, although the SUN1-RFP-Flag construct was detected the earliest during adipocyte differentiation and may offer the most advantages. Further, anti-RFP or anti-Flag bound to paramagnetic beads efficiently captured SUN1-RFP-Flag tagged nuclei from the differentiated adult adipocytes.

We constructed transgenic mice expressing the ADNp::SUN1-RFP-Flag construct. These lines of mice are being expanded and characterized to confirm adipocyte tissue-specific gene expression. We plan to apply INTACT technology to capture adipocyte nuclei from visceral and subcutaneous adipose tissue, muscle, and bone and examine their epigenetic differences.

Once fully characterized, the INTACT adipocyte-tagged mouse also could be exercised, fed a high fat diet, calorie restricted, and/or given drug treatment to study the impact of each on adipocyte development. Using INTACT technology to examine adipocyte-specific epigenetic reprogramming following these treatments will provide much more robust and statistically supported data than any previous approach.

 

Nothing to Disclose: RBM, ECM, SA, DLH, CAB

PP16-4 14552 4.0000 SUN-0907 A An Intact Mouse Model with Affinity Tagged Adipocyte Nuclei for Epigenetic Studies of Obesity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 11:30:00 AM PP16 4914 11:15:00 AM Energy Expenditure Poster Preview

Eun Kyung KO*, Lawrence C Layman, Samuel D Quaynor and Lynn P Chorich
Georgia Regents University, Augusta, GA

 

Gonadotropin-releasing hormone (GnRH) neurons regulate the hypothalamic-pituitary-gonadal (HPG) axis, which is important for pubertal development and fertility. Disorders of puberty in humans, particularly normosmic hypogonadotropic hypogonadism (nHH) and Kallmann syndrome (KS), have increased our understanding of neuroendocrine function in reproductive biology. The molecular etiology of nHH/KS patients has been elucidated in ~40% of patients, and includes genes involved in GnRH neuronal migration, GnRH expression, secretion, and/or function. However, the function of many of these genes is unknown. One such gene is nasal LHRH factor (NELF), which is also known as NMDA receptor synaptonuclear signaling and neuronal migration factor (NSMF). NELF was originally identified in migratory GnRH neurons, and knockdown has been shown to impair GnRH neuron migration in vitro. The major splice variant of NELF—variant 2— is predominantly nuclear, with a functional nuclear localization signal and putative zinc finger domains. We hypothesize that NELF is a transcription factor, but downstream targets are unknown. Therefore, Nelf knockdown was performed in immortalized migratory GnRH neuronal (NLT) cells using Nelf shRNA lentiviral particles. Transduction efficiency was ~80%, and both RT-qPCR and immunoblot analyses confirmed NELF knockdown of ~70% compared to scrambled control lentiviral particles. Gene expression and miRNA microarrays reveal genes differentially expressed by NELF knockdown. Findings from NELF knockdown in GnRH neuronal cells provide candidate genes involved in NELF signaling, and potentially function, which will be critical to better understand human pubertal development and fertility. LCL funded by NICHD 33004.

 

Nothing to Disclose: EKK, LCL, SDQ, LPC

PP24-1 15254 1.0000 SUN-0155 A Knockdown of Nasal Embryonic LHRH Factor (NELF) in Immortalized GnRH Neurons 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 11:30:00 AM PP24 4915 11:15:00 AM Puberty and its Disorders: Pediatric Endocrinology I Poster Preview

Bonnie Marie McCann-Crosby*, Sheila K Gunn, M. John Hicks and Lefkothea P Karaviti
Baylor College of Medicine, Texas Children's Hospital, Houston, TX

 

Background: Gonadal dysgenesis (GD) is associated with increased risk of gonadal malignancy. Determining a patient's risk and appropriate timing of gonadectomy is challenging, but studies have indicated that immunohistochemical markers may help establish the diagnosis of malignant germ cell tumors.

Objective: Our objective was to identify the prevalence of specific immunohistochemical marker expression in patients with GD, and to determine if the patterns of expression can help identify malignancy versus a pre-malignancy state. 

Methods: The data for this retrospective, observational study were collected over a 10-year period and included karyotype, gonadal location, external masculinization score, age at time of gonadectomy or biopsy, microscopic description and diagnosis of gonadal tissue, and immunohistochemical staining, including octamer binding transcription factor (OCT) 3/4, placental-like alkaline phosphatase (PLAP), β-catenin, alpha-fetoprotein (AFP), and stem cell factor receptor CD117 (c-KIT).  Patients with complete or partial GD who had undergone gonadectomy or gonadal tissue biopsy were included.  Exclusion criteria were lack of detailed external phenotype description or insufficient gonadal tissue for review.

Results: The study included 23 patients, 3 of whom had evidence of germ cell malignancy (13%, gonadoblastoma, dysgerminoma): 2 had Swyer syndrome and 1 had 46,XY partial GD.  1 patient with XY GD had evidence of gonadoblastoma-like tissue.  All 4 patients had strong expressions of 4 tumor markers (OCT 3/4, PLAP, β-catenin, CD117), as did 3 other patients (13%) who did not have germ cell malignancy: 2 had XY GD and 1 had 46,XX GD.  β-catenin was expressed in 95% of patients in a cytoplasmic pattern, CD117 in 65%, OCT 3/4 in 52%, PLAP in 35%, and AFP in 1 patient (4%).


Conclusions: The expression of all 4 immunohistochemical markers (OCT 3/4, PLAP, β-catenin, CD117) may be instrumental in the decision-making process for gonadectomy, even in the absence of overt germ cell malignancy.  These specific tumor markers, used as a means of establishing potential pre-malignancy, may prove to be effective in defining the timing of gonadectomy, and avoiding development of germ cell malignancy.  Using this battery of markers as a means of establishing pre-malignancy may facilitate the decision-making process for gonadectomy.

 

Nothing to Disclose: BMM, SKG, MJH, LPK

PP24-2 14153 2.0000 SUN-0156 A Immunohistochemical Markers As Potential Predictors of Malignancy in Gonadal Dysgenesis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 11:30:00 AM PP24 4915 11:15:00 AM Puberty and its Disorders: Pediatric Endocrinology I Poster Preview

Harry J Hirsch*1, Talia Eldar-Geva2, Yehuda Pollak1, Fortu Bennaroch3 and Varda Gross-Tsur2
1Shaare Zedek Medical Center, Jerusalem, Israel, 2Shaare Zedek Medical Center and the Hebrew University, Jerusalem, Israel, 3Hadassah Mount Scopus Hospital, Jerusalem, Israel

 

Background: We previously showed in cross-sectional studies of PWS men (1) and women (2) that the etiology of hypogonadism is heterogeneous, with primary testicular failure common in PWS men and variable combinations of ovarian dysfunction and gonadotropin deficiency in women. Longitudinal studies confirmed these findings in children and adolescents, but few longitudinal data were reported for adults older than age 20 years (3,4). Objectives: Aims of this prospective study were to determine the age at which the type of hypogonadism (hypothalamic or primary gonadal defect) becomes established and if hormonal patterns are consistent throughout adulthood in individual patients. Methods: We assayed 149 blood samples (2-5 per pt) in 49 males (ages 2m-36y) and 190 samples (2-6 per pt) in 57 women (ages 1m-37y) with PWS (61 deletions, 43 UPD, 2 IC defect). Duration of follow-up was 4.0±1.6 (1-6)y. None received androgens or sex hormone replacement during the study period. Samples were assayed for LH, FSH, DHEAS, inhibin B, AMH, testosterone (in men) and estradiol (in women) using assay techniques and reference values as previously described (1,2). Results: In males, LH levels began to rise at age 12-13y and were  normal to high in men ages 20-35y. FSH began to rise at 8 years.  After age 20y, FSH was markedly high in 6 men (34.4±11.5mIU/ml), but was normal in 4 (3.5±1.6 mIU/ml).  Nine boys ages 10-15y had normal testosterone levels for age (2.2±2.7 nmol/l),  however  all 14 men above age 20y had low levels (5.7±3.4 nmol/l).  AMH levels showed the expected normal decrease with age, even though testosterone was low in all adult males. Inhibin B was normal (241±105 pg/ml) in infant males (<1 year), fell to low levels by 2y and remained low to undetectable  in most adolescents and adults (65±58 pg/ml). In females, LH was variable during childhood, low in 7 women >20y (0.21±0.18 mIU/ml) and normal in 6 (3.77±1.67 mIU/ml). In women ages 20 – 37y, FSH was low only in 3 (0.71±0.60 mIU/ml) and normal in 10 (6.42±3.78 mIU/ml).  Only 7 adult women had estradiol levels (157±133 pmol/l)  consistently above the lower limit of detection. AMH was below the normal median in most PWS females, although high levels  (3.67±2.66 ng/ml) were measured in 7 girls below age 12y. Inhibin B (19.6±16.8 pg/ml) was low or undetectable in all PWS females. An early and exaggerated rise in DHEAS was seen in some children as early as age 5y, but levels were in the normal ranges for all men and most women.  Conclusions: The type of hypogonadism (hypothalamic vs primary gonadal dysfunction) becomes apparent in late adolescence and early adulthood in PWS men and women. Hormonal profiles  are consistent and stable in PWS men and women >20y.  Primary gonadal dysfunction is a major component of hypogonadism in PWS. Recognition of age-related changes in reproductive hormones is important for tailoring individualized recommendations for hormone replacement and counseling.

 

Nothing to Disclose: HJH, TE, YP, FB, VG

PP24-3 12670 3.0000 SUN-0153 A Longitudinal Study of Reproductive Hormones in Prader-Willi Syndrome (PWS) from Early Infancy through the Fourth Decade 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 11:30:00 AM PP24 4915 11:15:00 AM Puberty and its Disorders: Pediatric Endocrinology I Poster Preview

Ah Reum Kwon*1, Ho-Seong Kim2, Duk-Hee Kim3, Yejin Kim4, Jung Min Ahn5 and Hyun-wook Chae5
1Severance Hospital, Seoul, Korea, Republic of (South), 2Severance Children's Hospita, Seoul, Korea, Republic of (South), 3Yonsei Univ Coll of Med, Seoul, Korea, Republic of (South), 4SEVERANCE CHILDREN'S HOSPITAL, SEOUL, Korea, Republic of (South), 5Yonsei University College of Medicine, Seoul, Korea, Republic of (South)

 

Purpose: KiSS-1 and its product, kisspeptin is necessary for puberty onset and proper adult gonadal function due to its stimulatory effect on the secretion of gonadotropin-releasing hormone (GnRH). Although the pathophysiological importance of KiSS-1 and kisspeptin is well known, the developmental patterns of expression of KiSS-1 genes and serum level of kisspeptin have not been explored to date. We report herein the expression profile of KiSS-1 genes and serum level of kisspeptin in the rat at different developmental stages.  

Methods: Spraque-Dawley (SD) strain female rats were used. To analysis expression of KiSS-1 mRNA, samples were obtained from hypothalamus, pituitary, ovaries, adrenal glands and pancreas in female rats at 4 day, 8 day, 14 day, 23 day, 27 day, 34 day, 38 day and 40 day. At the same time, blood samples were collected for analysis serum level of kisspeptin and luteinizing hormone (LH). The expression of KiSS-1 mRNAs was assessed by RT-PCR and the serum levels of kisspeptin and LH were analyzed by ELISA.

Results: The expressions of KiSS-1 gene in hypothalamus and ovary were increased according to developmental stages and were peaked at prepubertal stage (at day 27, respectively, 0.88 ± 0.22, 0.54 ± 0.25). However, there were no significant changes or correlations between developmental stages and KiSS-1 gene expression in pituitary, adrenal glands and pancreas. Serum kisspeptin level was increased according to developmental stages as KiSS-1 gene mRNA expression. However, peak level of kisspeptin (35.43 ± 3.60 pg/mL) was in pubertal stage at day 34. Serum LH level was also increased and peaked (23.29 ± 15.24 ng/mL) at pubertal stage (at day 38) as serum kisspeptin level. However, an increasing pattern was little delayed than that of kisspeptin level.

Conclusion: The expressions of KiSS-1 mRNA were increased in hypothalamus and ovary according to developmental stages in rat. Serum levels of kisspeptin were also increased during developmental stages, followed by serum LH levels. Furthermore, the peak expression of KiSS-1 mRNA and the peak serum levels of kisspeptin and LH were observed during prepubertal and pubertal stages in regular sequence. Therefore, serum kisspeptin levels can be an indication of KiSS-1 gene expression in hypothalamus and pubertal onset.

 

Nothing to Disclose: ARK, HSK, DHK, YK, JMA, HWC

PP24-4 12749 4.0000 SUN-0152 A Messenger Ribonucleic Acid Expression of KiSS-1 and Serum Level of Kisspeptin in Rat at Different Developmental Stages 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 11:30:00 AM PP24 4915 11:15:00 AM Puberty and its Disorders: Pediatric Endocrinology I Poster Preview

Maria Celeste Diaz Flaque*1, Florencia Cayrol1, Rosario Aschero1, Helena Sterle1, Eduardo Valli1, Federica Belardi1, Alejandra Paulazo1, Alicia Klecha1, Maria Laura Barreiro Arcos1, Patricia Virginia Elizalde2 and Graciela Alicia Cremaschi1
1Instituto de Investigaciones Biomedicas, UCA-CONICET, Buenos Aires, Argentina, 2Instituto de Biología y Medicina Experimental (IBYME-CONICET), Buenos Aires, Argentina

 

The cytochrome P450 (CYP) enzymes belong to a family of proteins that metabolize drugs used in chemotherapy, and is crucial to know the pattern of expression of these enzymes in each patient when starting chemotherapy to predict its effectiveness.

Thyroid hormones (TH)–3,5,30-triiodo-L-thyronine (T3) and L-thyroxine (T4)– are important regulators of the metabolism and physiology of most normal tissues. We recently showed that THs stimulate the proliferation and metabolism of T cells. We also found that THs modulate these functions by activating both canonical nuclear (TR) and membrane receptors (mTR, represented by integrin avβ3). In the present work, we studied the ability of THs to induce the expression of the CYP enzymes in human T-cell lymphomas (TCL). To differentiate between nuclear vs. membrane-initiated effects, TCL cells were treated with physiological concentrations of free (TH-free) or cell impermeable agarose-bound T3/T4 (TH-ag). CYP expression was assessed in the TCL human cell line Jurkat by measuring CYP3A4 mRNA levels.

 Treatment for 18 hours with TH- free and TH-ag induced a 4-fold increase in CYP 3A4 mRNA (n = 5, p <0.05), whereas this was inhibited by 98 ± 9 % by pre-treating Jurkat cells with the RGD peptide (inhibitor of THs at the integrin receptor).On the other hand, we evaluated THs-mediated induction of CYP expression in an in vivo model. EL-4 murine T-cell lymphomas were inoculated subcutaneosly in mice treated with T4 (hyperthyroid group H), PTU (hypothyroid group h) or water (control group C). We found that CYP3A4 mRNA was increased in tumors and livers from the H group (2-fold and 6-fold, respectively, n = 4), while decreased in the h group (1 time was in both cases, n = 4) with respect to C.

 These results present a new mechanism by which THs modulate CYP3A4 mRNA expression, through activation of genomic and non-genomic mechanisms via both the canonical TR and the mTR in TLC. These findings indicate the importance of evaluating thyroid status in patients during application of TCL therapeutic regimens and highlight the potential use of anti-TH therapy.

 

Nothing to Disclose: MCD, FC, RA, HS, EV, FB, AP, AK, MLB, PVE, GAC

PP25-1 11808 1.0000 SUN-0464 A Thyroid Hormones Induce Expression of Enzymes Involved in Chemotherapy Drug Metabolism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 11:30:00 AM PP25 4921 11:15:00 AM Thyroid Hormone Action Poster Preview

Michelle T Fleming*, Qing Fang and Sally A Camper
University of Michigan, Ann Arbor, MI

 

Maternal and fetal sources of thyroid hormone (TH) are important for the development of many organ systems. TH deficiencies cause variable intellectual disability and hearing impairment in mouse and man. The genetic basis for this variability is not clear. To explore the source of this variability we studied two TH deficient mouse strains, Prop1df/df and Pou1f1dw/dw, that both lack TSH. Despite their similar, profound lack of TSH, Prop1 mutants have only a mild elevation in hearing threshold, while the Pou1f1 mutants are profoundly deaf. Many aspects of eurosensory development are affected in Pou1f1 mutants, but few aspects are affected in the Prop1 mutants (1, 2). Here we report different degrees of impairment in middle ear development in the two mutants, which suggests that the deaf mutants have both conductive and neurosensory hearing deficits. The middle ear ossicles form by mesenchyme condensation during embryonic development. Residual mesenchyme normally clears by P14 creating an air filled space around the ossicles, but both mutants retain mesenchyme at P21. By 4 months this process is essentially complete in Prop1 mutants, but Pou1f1 mutants remain affected. In addition, the development of the auditory bulla, the seat of the tympanic membrane, is poorly formed in Pou1f1 mutants and only mildly affected in Prop1 mutants. Thus, the profound deafness of Pou1f1 mutants involves poor development of both the neurosensory apparatus in the cochlea and conductive structures of the middle ear. The different hearing abilities of Prop1 and Pou1f1 mice are due to genetic variations in the backgrounds of the strains (3). Mouse chromosome 2 contains a major modifier locus that affects the sensitivity to hypothyroidism induced hearing impairment (4). This suggests that one chromosomal region can rescue multiple developing structures in TH deficient animals. The relevant gene(s) in this region are unknown, but it contains modifiers of thyroid development that could be causal (5, 6). We hypothesized that Prop1 mutants are protected against hearing impairment by better thyroid development and residual TH production in the absence of TSH. To test this, we measured free T4 in serum of adult mice of all four genotypes. Normal mice from the Prop1 and Pou1f1 strains have significantly different T4 levels, 11.7 and 7.5 ug/dL, respectively. Free T4 levels in both mutants are near the detection limit, but the results suggest a higher residual level in the Prop1 mutants. Histological analysis revealed that both mutants have thyroid hypoplasia, but Pou1f1 mutants are more profoundly affected. This supports the hypothesis that, in the absence of TSH, strain differences in thyroid development and function underlie the difference in hearing abilities. Identification of genetic modifiers that cause variation in thyroid development in mice could help explain the variability seen in congenital hypothyroidism in humans.

 

Nothing to Disclose: MTF, QF, SAC

PP25-2 16966 2.0000 SUN-0465 A Genetic Resistance to Congenital Hypothyroidism Rescues Neurosensory and Conductive Hearing Impairment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 11:30:00 AM PP25 4921 11:15:00 AM Thyroid Hormone Action Poster Preview

Gabor Wittmann*1, Petra Mohacsik2, Balazs Gereben2 and Ronald M Lechan1
1Tufts Medical Center, Boston, MA, 2Institute of Experimental Med, Budapest, Hungary

 

Thyroid hormone (TH) enters the brain across the blood-brain-barrier via TH transporters expressed in brain endothelial cells.  In the mouse brain, two TH transporters, monocarboxylate transporter 8 (MCT8) and organic anion-transporting polypeptide 1c1 (OATP1c1) have been described in endothelial cells, and both were proven critical to maintain normal brain TH levels. Little is known about the expression of these transporters under pathophysiological conditions.  We previously reported that systemic administration of bacterial endotoxin (LPS) to rats markedly downregulates OATP1c1 mRNA selectively in brain endothelial cells but not in astrocytes (Wittmann et al., Abs. of the 93rd meeting of The Endocrine Society, 2011).  Here, we studied the effect of i.p. administered LPS (2.5μg/g body weight) on both OATP1c1 and MCT8 mRNAs in the mouse brain in a time-course experiment using in situ hybridization.  Both OATP1c1 and MCT8 mRNA were markedly reduced by 4h and virtually undetected in blood vessels at 9h.  The vascular hybridization signal for both transporters increased to approximately control levels by 24h, and was markedly elevated at 48h following LPS.  OATP1c1 mRNA in astrocytes, and MCT8 mRNA expression in neurons did not significantly differ from control levels at any time after LPS injection.  We conclude that the parallel downregulation of OATP1c1 and MCT8 suggests a hypothyroid status for the brain during systemic inflammation, and may be the mechanism underlying significantly increased type 2 deiodinase (D2) expression observed in astrocytes at 4h and 9h after LPS.  In addition, the marked upregulation of OATP1c1 and MCT8 mRNAs after endotoxemia suggests the possibility of a transient hyperthyroid status for the brain during the recovery phase from inflammation.

 

Nothing to Disclose: GW, PM, BG, RML

PP25-4 12504 4.0000 SUN-0463 A Parallel Regulation of Thyroid Hormone Transporter MCT8 and OATP1c1 mRNAs in Brain Blood Vessels during and after Endotoxemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 11:30:00 AM PP25 4921 11:15:00 AM Thyroid Hormone Action Poster Preview

Syreeta L Tilghman*1, Shawn Dion Llopis1, Patrick Carriere1, Lynez Preyan1, Anna Naiki1, Gina Nguyen1, Mary Nguyen1, Jamal Pratt1, KiTani Parker-Lemieux1, Christopher C Williams1 and Guangdi Wang2
1Xavier University of Louisiana, College of Pharmacy, New Orleans, LA, 2Xavier University of Louisiana, New Orleans, LA

 

Postmenopausal women with early-stage estrogen-dependent breast cancer are generally treated with antiestrogens (i.e., tamoxifen) or aromatase inhibitors (AI) (i.e., anastrozole and letrozole).  Acquired resistance remains a major clinical obstacle, thus creating a critical need to identify mechanism(s) of resistance and ultimately develop alternative therapies.  As such, many naturally occurring agents, particularly soy containing compounds, such as glyceollins, have gained interest as potential therapeutic breast cancer agents.  Several appear to directly affect tumorigenesis of estrogen-dependent and independent breast cancers.  In order to examine AI resistance, a letrozole-resistant breast cancer cell line (LTLT-Ca) was previously developed.  These cells undergo adaptive changes such as activation of the MAPK signaling pathway, increased expression of HER2 and IGFR, decreased expression of aromatase and ERα leading to estrogen-independence.  Previously, our lab characterized these cells and identified a proteomic signature associated with hormone independence, epithelial to mesenchymal transition (EMT), enhanced cell migration and invasion.  The objective of this study was to examine the effect of glyceollin I as a potential therapeutic strategy to overcome letrozole resistance.  Morphological studies were performed and results demonstrated that glyceollin I reversed the EMT-like phenotype of LTLT-Ca cells while restoring e-cadherin expression, suggesting an onset of mesenchymal to epithelial transition.  In addition, proliferation assays were performed and glyceollin I repressed proliferation by 57.3% and viablility by 69.6%. Glyceollin I treated LTLT-Ca cells exhibited an 82% and 67% decrease in migration and invasion respectively compared to control. Moreover, targeted gene expression arrays confirmed that glyceollin I caused a 3-fold decrease in Snail, Caveolin and Wnt11 with a concomitant 25-fold increase in TGFß2 expression.  Immunofluorescence studies supported gene arrays by demonstrating that glyceollin I induced TGFß2 protein levels.  Additionally, increased TGFß2 levels positively correlated with increased relapse free survival in ER negative and HER2 positive patients.  Taken together, our results revealed that glyceollins restore LTLT-Ca cells to a less aggressive epithelial phenotype, inhibit cell motility and proliferation which may be mediated inpart through increased TGFß2.  These studies potentially represent a novel approach to treating metastatic, endocrine resistant breast cancer.

 

Nothing to Disclose: SLT, SDL, PC, LP, AN, GN, MN, JP, KP, CCW, GW

PP19-1 15136 1.0000 SUN-0326 A A Novel Phyto-Antiestrogen Inhibits Motility of Letrozole Resistant Breast Cancer Cells through Increased TGFβ2 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 11:30:00 AM PP19 4926 11:15:00 AM Metastasis & Tumor Progression; Neoplasia of Endocrine Tissues Poster Preview

Rachel Watkins*, Neil Sharma, Vicki Smith, Rachel S Fletcher, Martin Read, Bhavika Modasia, Waraporn Imruetaicharoenchoke, Vikki Louise Poole, Jayne A Franklyn, Kristien Boelaert and Christopher John McCabe
University of Birmingham

 

Metastasis is a multistep process responsible for the vast majority of endocrine cancer deaths. We have previously identified the proto-oncogene PBF to be upregulated in differentiated thyroid cancer, and recently PBF expression has been correlated with distant thyroid cancer metastasis at diagnosis. Further, PBF potently induces breast cancer cell invasion in vitro, and our recent in vivo data demonstrate that colorectal tumours with higher PBF protein expression demonstrate increased vascular invasion. We now show that PBF significantly promotes cell invasion in thyroid carcinoma SW1736 cells compared to vector only (VO) (P<0.01). Cell invasion is related to and encompasses cell migration. In keeping with PBF’s role in cell invasion, overexpression of PBF in HCT116 cells induced ~60% greater migration compared to VO-transfected controls (P<0.001), implying a role for PBF in promoting cell movement. These data were supported by wound healing assays in TPC cells, which revealed that GFP-tagged PBF cells migrate significantly further than GFP-VO cells (VO = 11.6 μM/hour, PBF = 15.3 μM/hour, P<0.001). To begin to unravel the mechanism by which PBF promotes cell migration and invasion we used an IP-MS approach to discover PBF binding partners, and identified the cortical actin binding protein, cortactin. Interaction was confirmed through co-IP, immunfluorescence and Proximity Ligation Assays. The latter additionally indicated that this interaction occurs within or close to the plasma membrane. Interestingly, immunoflourescence demonstrated that PBF and cortatin co-localise at the leading edge of migrating MDA-MB-231 cells. PBF is phosphorylated by SRC at tyrosine 174 (Y174) and when phosphorylated it is preferentially located at the plasma membrane. PLA assays using the SRC inhibitor PP1 demonstrated that loss of PBF phosphorylation at Y174 and cortactin phosphorylation at Y421, Y470 and Y486 abrogates the interaction between PBF and cortactin. These data imply that cortactin preferentially binds to phosphorylated PBF. We therefore examined the ability of the phosphorylation status of PBF to modulate its induction of cell invasion. Substitution of tyrosine 174 resulted in a total loss of invasive capacity, confirming the critical importance of this residue. Taken together these data suggest that PBF induces cell invasion and migration across a range of cell lines, and that this occurs via its interaction with cortactin.

 

Disclosure: KB: Principal Investigator, HRA Pharma. Nothing to Disclose: RW, NS, VS, RSF, MR, BM, WI, VLP, JAF, CJM

PP19-2 16879 2.0000 SUN-0334 A A Novel Modulator of Cell Invasion and Metastasis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 11:30:00 AM PP19 4926 11:15:00 AM Metastasis & Tumor Progression; Neoplasia of Endocrine Tissues Poster Preview

Thomas Cuny*1, Peter van Koetsveld1, Fadime Dogan1, Georges Weryha2, Wouter W. de Herder1, Alain Enjalbert3, Anne Barlier3 and Leo J. Hofland1
1Erasmus Medical Center, Rotterdam, Netherlands, 2University Hospital of Nancy, Vandoeuvre-Les-Nancy, France, 3Aix-Marseille University, Marseille, France

 

Human gastroenteropancreatic neuroendocrine tumors (GEPNETs) represent a heterogeneous group of tumors whose treatment remains still problematic. While half of patients present with metastasis at diagnosis, little is known about potential factors from the tumoral microenvironment that could influence growth and spreading of tumor cells. We hypothesize that stromal fibroblasts may influence growth and migration potency of human GEPNETs cells. Two pancreatic human neuroendocrine cell lines, BON and QGP-1 and one human fibroblastic cell line, HFL1, were used. We assessed the interaction between BON/QGP-1 and HFL1 using two different approaches: 1) by co-incubation of either BON or QGP-1 in serum-free medium (BSA 0.2%) condition with HFL1, using Transwell permeable supports to obtain a coculture system without a "physical" contact between cell lines; 2) by using 72h HFL1-conditioned serum-free medium containing 0.2% BSA (HFL1cm). BON and QGP1  were incubated either with  BSA 0.2% alone (control) or with HFL1cm and 0.2% BSA in a 1:1 ratio. For both protocols, DNA measurement by Hoechst staining has been performed after 7 days, with media refreshed at day 3. In parallel, we assessed the influence of HFL1cm on the migration potency of BON over an 8 hour period using an in vitro scratch assay. Cells were attached in poly-L-lysine coated wells in DMEM+10%FCS. After 4 days, a scratch was made and medium was changed with either medium+0.2% BSA or HFL1cm with medium+0.2% BSA (ratio 1:1). Pictures were taken every 2 hours from T0 to T8 to assess the distance between two parallel banks made (Software ImageJ®). Results: In Transwell experiments, proliferation of either BON or QGP-1 significantly increased in the presence of HFL1 cells compared to control (155.7 ± 8.22 % vs 100 ± 2.5 % and 147 ± 4.1 % vs 100 ± 1.9 % respectively, p <0.0001). Similar results were obtained for BON and QGP-1 incubated with HFL1cm (153.7 ± 14.68% vs 100 ± 4.63%, p < 0.008, and 150.7 ± 10.45 vs 102.4 ± 3.2%, p < 0.0001, respectively). For migration assay, incubation of BON with HFL1cm resulted in a significant increase of migration potency (expressed in %) compared to control (T2 : + 122 ± 13.25%, p < 0.0001, T4 : + 70.56 ± 12.81 %, p < 0.0001, T8 : + 23.22 ± 12.6 %, p < 0.05). Conclusion : Human fibroblasts, as an actor of the tumor microenvironment, is able to produce factors that stimulate proliferation and migration of BON and QGP-1 and could, therefore, represent a novel therapeutic target for GEPNETs. Analysis of the relevant factors involved in this process, as well as studies on the role of fibroblasts in the response to drug treatment are ongoing.

 

Nothing to Disclose: TC, PV, FD, GW, WWD, AE, AB, LJH

PP19-3 13723 3.0000 SUN-0330 A The Impact of Fibroblasts on Proliferation and Migration of Human Pancreatic Neuroendocrine Cells: A Novel Pivotal Role in Tumor Microenvironment? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 11:30:00 AM PP19 4926 11:15:00 AM Metastasis & Tumor Progression; Neoplasia of Endocrine Tissues Poster Preview

Phoebe Sarkar*1, Jennifer H Gunter1, Amy A Lubik2, Nataly Stylianou1, Brett Hollier1 and Colleen C. Nelson1
1Queensland University of Technology - Translational Research Institute, Brisbane, Australia, 2University of British Columbia, Vancouver, BC, Canada

 

Advanced prostate cancer (PCa) is treated with androgen deprivation therapy (ADT), as prostate tumours are dependent on androgens for survival. Unfortunately, ADT offers a temporary remission and prostate tumours begin to capitalise on additional intratumoural or adrenal sources of androgens. This has led to continued development of antagonists to the androgen receptor (AR) and inhibitors of androgen synthesis to combat PCa which result in extended time to progression and cancer specific survival in advanced PCa patients.

A major side effect of ADT is the induction of features of the metabolic syndrome, including persistent hyperinsulinaemia, which is specifically associated with poor outcomes, including rapid progression and increased cancer mortality. Using patient databases (Oncomine™, Compendia Bioscience, Ann Arbor, MI) we observed that insulin receptor and IRS-2 are upregulated from primary versus metastatic primary tumours across eight clinical datasets. We hypothesized that following androgen withdrawal, high insulin levels promote an adaptive response that drives castrate resistance PCa progression.

To address this we undertook transcriptional profiling of AR-responsive LNCaP cell line following insulin treatment with or without androgens. We identified a number of pathways uniquely up-regulated by insulin including genes associated with increased potential for migration and invasion. We observed that in the absence of androgens, insulin promoted up to 3.4 fold increased migration through transwell and wound healing assays in LNCaP, DU145 and 22RV1 cells; and increased Matrigel invasion of LNCaP (2.5 fold, p=0.0106), DU145 (1.9 fold, p=0.007) and 22RV1 (2.4 fold, p=0.004) cells. AR inhibitor, bicalutamide, increased cell migration of LNCaP and 22RV1 by 72% and 45%, respectively. Insulin and bicalutamide do not appear to be additive suggesting a common pathway. Importantly, insulin- induced migration was blocked by inhibitors of insulin receptor, BMS-745807-04 (48%) and CP-751871 (42%), and by the MAPK inhibitor U0126 (46%). In agreement with our microarray data, QRT-PCR revealed insulin-induced molecular changes within the cells reminiscent of an epithelial-to-mesenchymal transition (EMT); androgen deprivation alone increased expression of vimentin and the SNAIL and ZEB1 transcription factors, which was further increased with insulin. Changes to protein expression and transcription factor localisation were consistent with mRNA. Recent studies report ‘obesity factors’ promoting EMT in prostate cancer cells. Our data indicates insulin can promote this plasticity. These novel results show insulin promotes PCa cell migration and invasion, possibly by inducing EMT-like changes within PCa cells and make a strong case for investigating the clinical efficacy of using insulin-sensitizing drugs such as metformin as an adjuvant therapy for PCa treatment.

 

Nothing to Disclose: PS, JHG, AAL, NS, BH, CCN

PP19-4 16872 4.0000 SUN-0339 A Insulin Increases Migration and Invasion in Androgen Deprived Prostate Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 11:30:00 AM PP19 4926 11:15:00 AM Metastasis & Tumor Progression; Neoplasia of Endocrine Tissues Poster Preview

Benjumin Hsu*1, Robert G Cumming1, Vasi Naganathan2, Fiona M Blyth2 and David J Handelsman3
1University of Sydney, Sydney, Australia, 2Concord Hospital & University of Sydney, Sydney, Australia, 3University of Sydney, Sydney NSW, Australia

 

Objectives

To examine relationships between reproductive hormones in older men and (a) total hip bone mineral density (BMD) loss over 2-years follow-up and (b) incident hip fractures over an average of 6-year follow-up.

Methods

1705 men aged 70 years and older from the Concord Health and Ageing in Men Project (CHAMP) were assessed at baseline (2005-2007) and 2-years follow-up (2007-2009). At baseline, testosterone (T), dihydrotestosterone, estradiol (E2), and estrone (E1) were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS), and SHBG, LH, and FSH by immunoassay. The calculated free testosterone (cFT) was computed using an empirical formula derived from the measured TT and SHBG. BMD of the total hip was measured by Dual X-Ray Absorptiometry (DXA) at both baseline and 2-years follow-up. Hip fracture data were collected at 4-monthly phone calls and verified radiologically.

Results

In univariate analyses, accelerated total hip bone loss was more likely among men in the highest quartiles of FSH, LH, and SHBG (vs lowest quartile) and in the lowest cFT quartile (vs highest quartile). In the multivariable analyses, the observed relationships for FSH, SHBG, and cFT with hip bone loss remained. Men were forty-percent less likely in the lowest quartile of FSH (OR:0.59 95%CI:0.36-0.95) to have accelerated hip bone loss when compared to men in the highest FSH quartile. There were significant linear trend (p<0.02) across FSH with lower circulating levels less likely to have hip bone loss. Men in the lowest SHBG quartile were fifty-six-percent (OR:0.44 95%CI:0.26-0.75) less likely to have accelerated hip bone loss when compared to men in the highest quartile. Significant linear trend (p<0.04) was observed across the cFT quartiles as men with lower levels of cFT were more likely to have an accelerated hip bone loss. Preliminary analyses on the relationship between reproductive hormones and incident hip fractures over 6-years of follow-up (n=42 hip fractures) revealed a very strong relationship with FSH, with an age-adjusted odds ratio of 0.12 (95%CI:0.02-0.97) for men in the lowest quartile compared to men in the highest FSH quartile.

Conclusions

Higher levels of FSH and SHBG and lower levels of cFT were strongly associated with accelerated total hip bone loss in older men. FSH further remained associated with incident hip fractures. This is the first study to report a longitudinally association between FSH levels and change in hip bone loss and hip fractures in men. Further studies are warranted on the role of FSH as a novel health biomarker among older men.

 

Disclosure: RGC: Speaker, Eli Lilly & Company. Nothing to Disclose: BH, VN, FMB, DJH

PP22-1 11376 1.0000 SUN-0246 A Longitudinal Relationship Between Reproductive Hormones and Total Hip Bone Loss and Hip Fractures Among Community-Dwelling Older Men: The Concord Health and Ageing in Men Project 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 11:30:00 AM PP22 4930 11:15:00 AM Osteoporosis: Risk Factors and Complications of Therapy Poster Preview

Laila Shaheen Tabatabai*1, Susan L. Stewart2, Joan R. Bloom3 and Deborah Sellmeyer4
1Johns Hopkins Hospital, Baltimore, MD, 2University of California, Davis, 3University of California, Berkeley, 4Johns Hopkins Bayview Medical, Baltimore, MD

 

Successful breast cancer therapy in premenopausal women can lead to bone loss and premature ovarian failure (POF).  In early POF, serum estradiol levels may be preserved while gonadotropin levels, including FSH, begin to rise.  Similar to natural menopause, POF ultimately results in amenorrhea, hypoestrogenemia, and sustained increases in FSH levels.  Women with POF are at increased risk for bone loss compared to women who remain premenopausal during breast cancer treatment.  Biomarkers to predict bone loss in premenopausal women after breast cancer treatment have not been examined.  We analyzed hormonal, dietary, and biomarker data from the Exercise for Bone Health: Young Breast Cancer Survivors study, a randomized, controlled trial of 206 women age < 55 years at diagnosis who had received adjuvant chemotherapy and were at least one year post diagnosis to determine if baseline parameters could predict ongoing bone loss; complete data was available for 175 women.  Women were randomized to a 12-month exercise program administered through the YMCA or a monthly health newsletter.  Bone mineral density (BMD) was measured by DXA, biologic samples obtained, and the Block98 food frequency questionnaire administered at baseline and after one year.  Overall results showed that bone density was maintained in the exercise group only among the subset of women who maintained lean mass (results reported previously).  In linear regression models in the whole cohort, baseline FSH levels predicted bone loss over the ensuing 12 months at the lumbar spine and femoral neck even after adjustment for age, ethnicity, treatment group (exercise vs. control), baseline bone density, and hsCRP (p<0.001).  Other baseline variables including calcitropic hormones, bone turnover markers, and dietary intakes were not significantly related to bone loss.  In multiply adjusted models, the 12-month rate of bone loss was 0.007% in the lowest tertile of FSH (FSH=9+7 IU/L, mean+SD), 0.96% in the middle tertile (FSH=41+11 IU/L), and 2.2% in the highest tertile (FSH=86+19 IU/L), p for trend < 0.001.  In summary, among premenopausal women with breast cancer treated with chemotherapy, baseline FSH levels are strongly associated with ongoing bone loss.  Furthermore, it appears that increasing FSH values are associated with higher rates of bone loss, even within the postmenopausal range.  This may have significant implications for preserving bone health in premenopausal women with breast cancer.  Upon completion of breast cancer treatment, baseline measurement of FSH level may predict which women will benefit from prophylactic osteoporosis treatment to prevent bone loss.  Further studies are needed to establish the optimal timing of FSH measurement in relation to breast cancer treatment and to investigate potential strategies to prevent bone loss.

 

Nothing to Disclose: LST, SLS, JRB, DS

PP22-2 14910 2.0000 SUN-0250 A FSH Levels Predict Ongoing Bone Loss in Premenopausal Women Treated for Breast Cancer More Than a Year after Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 11:30:00 AM PP22 4930 11:15:00 AM Osteoporosis: Risk Factors and Complications of Therapy Poster Preview

Ie-Wen Sim*1, Kerrie M Sanders2, John Seymour3 and Peter Robert Ebeling4
1NorthWest Academic Centre, University of Melbourne, Melbourne, Australia, 2Australian Catholic University, Melbourne, Australia, 3Peter MacCallum Cancer Centre, Melbourne, Australia, 4Monash University, Clayton, Victoria, Australia

 

Osteonecrosis of the jaw is a rare, but potentially severely debilitating, condition associated with antiresorptive therapy. The risk of developing antiresorptive drug-associated osteonecrosis of the jaw (ARONJ) is greatest in the setting of malignancy, due to higher cumulative doses of more potent antiresorptive drugs. Oral hygiene also has a significant role in the development of ARONJ, as most lesions occur after dental extraction and our previous data support a strong association between periodontitis, associated bacteria and ARONJ1. Given the significant morbidity attributable to ONJ and the lack of therapeutic options, prevention is crucial. Published Australian guidelines for ARONJ prevention in malignancy emphasise the importance of oral health assessment and education prior to commencing antiresorptive therapy2. In this retrospective study of the effectiveness of active dental surveillance in reducing ARONJ incidence, we reviewed data from all patients who received antiresorptive drugs at a dedicated cancer centre in Melbourne, Australia. Between 2003 and 2013, 1236 patients received antiresorptive therapy; the majority being indicated for multiple myeloma (28.2%), metastatic breast cancer (22.3%), and metastatic prostate cancer (16.4%). 28 cases of ARONJ were identified amongst this cohort (overall incidence 2.3%). Following implementation of Australian ARONJ prevention guidelines in 2008, there was a significant decline in ARONJ incidence in patients commencing antiresorptive therapy, ie a 3.8% incidence prior to 2008 compared with a 0.9% incidence from 2008 onwards (χ2 = 11.157, p = 0.001). Further, using a logistic regression model that included cumulative antiresorptive exposure, commencement of therapy from 2008 onwards was associated with a 70.9% (p = 0.01) decreased likelihood of developing ARONJ. This fall in the ARONJ incidence coincided with a greater emphasis on oral health assessment and surveillance in patients with cancer, and reaffirms the importance of oral hygiene in ARONJ prevention.

 

Disclosure: PRE: Researcher, Amgen, Researcher, Novartis Pharmaceuticals, Researcher, Merck & Co.. Nothing to Disclose: IWS, KMS, JS

PP22-3 12926 3.0000 SUN-0248 A Declining Incidence of Antiresorptive Drug-Associated Osteonecrosis of the Jaw (ARONJ) in Patients with Cancer: The Importance of Oral Hygiene 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 11:30:00 AM PP22 4930 11:15:00 AM Osteoporosis: Risk Factors and Complications of Therapy Poster Preview

Narayana Prasad Pothina*1, Anna Werpachowska1, Thozhukat Sathyapalan2 and Mo Aye3
1Hull & East Yorkshire Hospitals NHS Trust, Hull, United Kingdom, 2Hull York Medical School, Hull, United Kingdom, 3Hull and East Yorkshire Hospital NHS Trust, Hull, United Kingdom

 

Background

Teriparatide (rhPTH 1-34) is a potent anabolic agent. It has been shown that whole molecule PTH 1-84 followed by alendronate gives further gains in bone density (PaTH study). However, little is known about fracture outcomes with sequential therapy using rhPTH 1-34 followed by bisphosphonates. We submit observational data from “real-life” clinic patients from a UK metabolic bone center.

Materials and Methods

We reviewed very high risk osteoporosis patients (defined as age >55, pre-treated with bisphosphonates for at least 1 year, new fracture in addition to at least 1 prior fracture despite treatment, lumbar spine T-score ≤-4 or ≤-3.5 with any of rheumatoid disease/parental hip fracture/alcohol intake > 4 units/day) treated with rhPTH 1-34 for secondary prevention in line with UK national guidance. Both post-menopausal and secondary osteoporosis patients were included. All patients had rhPTH 1-34 for 18 months followed by parenteral/oral bisphosphonates. Adherence was checked using 3 monthly P1NP and 6-12 monthly DXA. Fractures were identified using DXA lateral morphometry and from radiology records.  

Results

A total of 87 patients were identified; 85 (97.7%) were female. Median age was 81 years. Over a median observation period of 79.59 mo. (range 24 – 113 mo.) from start of rhPTH 1-34, 33 fractures occurred in 23 (26.43%) patients: multiple vertebral fractures 6 patients (26%); single vertebra 2 (9%); hip 4 (17%); pelvis 1 (4%); multiple non-axial 2 (9%); single-site non-axial 7 (31%); multiple axial and non-axial 1 (4%). No fractures occurred during 18 mo. of rhPTH 1-34 therapy. Absolute risk of any major osteoporotic fracture during sequential therapy was 1 per 15.98 patient-years; that of hip fracture was 1 per 131.88 patient-years. Median time ± SD to fracture was 24 ± 24.35 mo. for all axial fractures; 42 ± 24.03 mo. for all non-axial fractures and 64 ± 19.79 mo. for hip fractures. Future fracture risk was not predicted by age, percentage change in bone density or increment in bone formation markers (P1NP) during rhPTH 1-34. Steroid use was associated with vertebral fractures.

Conclusion

In our “real-life” cohort, significant fracture risk remains in patients with very high-risk osteoporosis treated with sequential therapy despite good adherence. Whilst effective bone protection is crucial in very high-risk osteoporosis, better cost-effectiveness may be achieved by a lower treatment threshold for initiation of teriparatide.

 

Nothing to Disclose: NPP, AW, TS, MA

PP22-4 16214 4.0000 SUN-0251 A Residual Fracture Risk Following Sequential Teriparatide-Bisphosphonate Therapy in Patients with Very High Risk Osteoporosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 11:30:00 AM PP22 4930 11:15:00 AM Osteoporosis: Risk Factors and Complications of Therapy Poster Preview

Raju Panta* and Khagendra Dahal
Lakes Region General Hospital, Laconia, NH

 

Background

Low-density lipoprotein cholesterol (LDL-C) is the primary target of lipid lowering therapy in people at risk for cardiovascular disease. Mipomersen is an inhibitor of apolipoprotein B-100 (apoB) synthesis resulting in reduction of apoB and in turn reduction of LDL-C. In January 2013 the FDA approved mipomersen (injected subcutaneously) as an adjunct to diet and lipid-lowering medications for patients with homozygous familial hypercholesterolemia. We performed a meta-analysis of all published, randomized controlled trials (RCT) comparing mipomersen with placebo in adult patients with dyslipidemia.

Methods

PUBMED, Cochrane Central Register of Controlled Trials and EMBASE were searched from year 2000 to January 2014 for all RCTs using terms, “mipomersen”, “apoB synthesis inhibitor” and “randomized controlled trials”. The random-effects model for the analysis of the effect size was performed. Heterogeneity among the study effects was measured with I2statistics. A p-value of <0.05 was considered statistically significant.

Results

A total of 9 RCTs were identified, which included 603 randomized patients. Mipomersen, when compared to placebo resulted in a significant reduction of LDL-C (% change of mean: -32.18, 95% CI: -37.96 to -26.40 p-value <0.001, I2: 32.27), apoB (% change of mean: -32.57,  95% CI: -37.81 to -27.33 p-value <0.001, I2: 32.72), total cholesterol (% change of mean: -31.78, 95% CI: -39.02 to -24.53 p-value <0.001, I2: 63.83), triglyceride (% change of mean -34.16, 95% CI: -45.46 to -22.86 p-value <0.001, I2: 0.00) and non-HDL-cholesterol (% change of mean: -24.36, 95% CI: -30.03 to -18.69 p-value <0.001, I2: 59.00). However, mipomersen, when compared to placebo did not result in significant change in HDL-C (% change of mean 0.80, 95% CI: -4.77 to 3.17 p-value =0.693 I2: 11.73).  In safety analysis, mipomersen compared to placebo resulted in significantly more injection-site reactions (Odds ratio: 9.71, 95% CI: 2.88 to 32.77, p-value <0.001, I2: 78.21), also flu-like symptoms (Odds ratio: 2.24, 95% CI: 1.18 to 4.25, p-value 0.013, I2: 35.01), elevated liver function test (LFTs) ≥3x normal (Odds ratio: 5.17, 95% CI: 1.73 to 15.41, p-value 0.003, I2: 8.67) and hepatic steatosis (Odds ratio: 4.71, 95% CI 1.570 to 14.14, p-value 0.006, I2:  0.00).

Conclusion

The current meta-analysis of all the randomized controlled trials to date shows that mipomersen resulted in a significant reduction in LDL-C, apoB, total cholesterol, triglyceride and non-HDL cholesterol but no significant change in HDL-C. Mipomersen significantly increased adverse effects of injection-site reactions, flu-like symptoms, elevations in LFTs and hepatic steatosis when compared to placebo.

 

Nothing to Disclose: RP, KD

PP15-1 13300 1.0000 SUN-0839 A Efficacy and Safety of Mipomersen in Treatment of Dyslipidemia: A Meta-Analysis of Randomized Controlled Trials 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 11:30:00 AM PP15 4931 11:15:00 AM Lipids, Lipoproteins, Dyslipidemia & Fatty Liver Disease Poster Preview

Aalok Rajen Sanjanwala*1, Elizabeth Rowland-Fisher2, Anna Schwendeman3 and William E. Rainey1
1University of Michigan, Ann Arbor, MI, 2University of MIchigan, 3University of Michigan

 

Context: Apolipoprotein A-I (ApoA-I) is the major lipoprotein associated with high density lipoproteins (HDL). HDL has been shown to have cardio-protective effects through reverse cholesterol transport. These particles also provide cholesterol to adrenal cells where it is used as a precursor for steroidogenesis. Recently, synthetic HDL (sHDL) particles have been shown to reduce atherosclerotic plaque burden through facilitation of cholesterol efflux from macrophage cells. The effects of the sHDL particles on steroidogenic cells have not been explored.

 Objective: In this study we defined the effects of sHDL on steroidogenesis in human adrenal cells.  

 Methods:  Synthetic HDL, ETC-642, a complex between an ApoA-I mimetic peptide, sphingomyelin and dipalmitoylphosphatidylcholine, was prepared and characterized for purity and size distribution. The effect on steroidogenesis was examined in HAC15 adrenocortical cells. Cells were treated with ETC-642 with or without forskolin, 22 hydroxycholesterol (22OHC), or pregnenolone (P). Experiments included time and concentration response curves followed by assay of all three major adrenal steroids (aldosterone, cortisol and DHEA). RNA isolation and quantitative-RTPCR (qPCR) were used to study expression of 3-hydroxy-3-methyl-glutaryl-CoA reductase (HMGCR) and cholesterol side-chain cleavage (CYP11A1).   

 Results: ETC-642 (30µM) potently inhibited production of each steroid including cortisol (79 ± 3.5%, p < 0.001). Inhibition occurred in a concentration- and time-dependent manner over 1 - 36 h, and a concentration range of 1 - 100 µM. Forskolin(10 µM) stimulation of adrenal cell steroid production was also inhibited. However, steroid production in response to 22OHC (10 µM) and P (10 µM) was unaffected by ETC-642 treatment, suggesting a lack of cell toxicity. ETC-642 increased transcription levels for the rate-limiting cholesterol biosynthetic enzyme, HMGCR, over 2-fold after a 6h incubation. In contrast, the rate-limiting enzyme for steroid biosynthesis, CYP11A1, was not significantly affected.

 Conclusion: Adrenal steroidogenesis relies exclusively on cholesterol as a substrate and ETC-642 is known to facilitate cholesterol efflux. The current study suggests that ETC-642 inhibits steroid production in adrenal cells by sequestration of cholesterol; leading to a compensatory rise in adrenal cell cholesterol biosynthesis, but an overall drop in steroid production. As therapeutic use of sHDL is becoming more common, secondary effects on steroidogenic tissues should be monitored.

 

Nothing to Disclose: ARS, ER, AS, WER

PP15-4 12502 4.0000 SUN-0838 A Synthetic HDL Inhibits Adrenal Steroid Production 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 11:30:00 AM PP15 4931 11:15:00 AM Lipids, Lipoproteins, Dyslipidemia & Fatty Liver Disease Poster Preview

Yalcin Basaran*1, Abdullah Taslipinar2, Sinasi Erol Bolu3, Mehmet Ali Saracli1, Turker Turker1, Coskun Meric2, Cem Haymana2, Kamil Baskoy4, Mustafa Dinc2, Ferhat Deniz5, Mahmut Yazici2, Aydogan Aydogdu2, Alper Sonmez1 and Omer Azal2
1Gulhane Military Medical Academy School of Medicine, Ankara, Turkey, 2Gulhane School of Medicine, Ankara, Turkey, 3Memorial Atasehir Hospital, Istanbul, Turkey, 4GATA Haydarpasha Training Hospital, Istanbul, Turkey, 5GATA HAYDARPASHA Training Hospital, Istanbul, Turkey

 

The worldwide prevalence of obesity and type 2 diabetes is a growing epidemic problem. The accumulating evidence indicates that, in addition to genetic susceptibility and environmental factors, changes in the gut microbial composition may be responsible for that increase. The human microbiota consist of as many as 10 to 100 trillion microorganisms. This represents at least 10 fold more cells than those in the human body. It is predicted that each individual harbors at least 160 such species from a total of 1000 to 1150 prevalent bacterial species.

We designed a prospective study to identify the relation between the gut microbiota composition and these metabolic conditions. 27 morbidly obese individuals, 26 patients with newly diagnosed diabetes and 28 healthy control subjects were included in the present study. Fecal samples of the participants were analyzed by quantitative real-time PCR for the presence of Bacteroidetes, Firmicutes, Bifidobacteria (Actinobacteria) and Clostridium Leptum (Firmicutes).

Bacteroidetes concentrations were similar between the three groups and there were no significant differences in the fecal Bifidobacteria, Firmicutes and Clostridium Leptum levels among the obesity and diabetic groups. However, Bifidobacteria, Firmicutes and Clostridium Leptum counts were significantly lower in patients with obesity and diabetes, compared to healthy control individuals. Logistic regression analysis showed that metabolic parameters, such as BMI and HbA1c, waist circumference and HbA1c, and finally weight and FBG were independent risk factors for reduced proportions of Firmicutes, Bifidobacteria and Clostridium Leptum, respectively.

These findings support that both obesity and diabetes may be associated with compositional changes in the intestinal microbial composition. All these results suggest that the gut microbiota can be used as an important marker, helping to determine the risk and etiopathogenesis of aforementioned metabolic disorders.

 

Nothing to Disclose: YB, AT, SEB, MAS, TT, CM, CH, KB, MD, FD, MY, AA, AS, OA

LB-PP02-1 18045 1.0000 LBSU-1076 A Comparison of Gut Microbiota in Obese, Diabetic and Healthy Control Individuals 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 11:30:00 AM LB-PP02 5224 11:15:00 AM Obesity and Diabetes: From Basic Mechanisms to Treatment Poster Preview

Lucy Brooks1, Patrice Cani2, Amandine Everard2, Stephen R Bloom3, Gary Frost1 and Gavin Bewick4
1Imperial College London, London, United Kingdom, 2Louvain Drug Research Instiute, 3Imperial College London, United Kingdom, 4King's College London

 

Obesity is associated with low-grade inflammation, a state thought to drive co-morbid conditions such as insulin resistance, and one that has previously been linked to the microbiota. Clinical and experimental data indicates that microbiota can improve intestinal barrier function, preventing the detrimental leakage of proinflammatory bacterial lipopolysaccharide (LPS) into the circulation. Furthermore, prebiotics have also been shown to be important in preventing symptoms of inflammatory bowel diseases. We hypothesized that microbiota influence gut permeability via the production of SCFAs and subsequent activation of free fatty acid receptor 2 (FFAR2). To investigate the role of FFAR2 we used mice with targeted deletion of the receptor. We fed ffar2-/- and wild-type littermates a HFD supplemented with fermentable carbohydrate inulin or an isocaloric non-fermentable control diet for 14 weeks and measured gene expression of tight-junction proteins as well as chemokine MCP-1. We also carried out targeted enquiry of bacterial species important for the fermentation of inulin and known to be increased by fermentable carbohydrate supplementation. Total bacterial numbers were increased by supplementation consistent with previous studies. Additionally, the abundance of Bifidobacterium spp., which play a key role in fermenting inulin, was also increased. However, the abundance of Lactobacillus spp. was unaltered. Expression of occludin, ZO1 and claudin was increased by inulin supplementation. This increase was not dependent on expression of FFAR2. Whilst FFAR2 was not responsible for the increase in tight junction proteins claudin expression was increased in ffar2-/- animals on the control diet when compared to wildtype animals.  Although FFAR2 did not appear to play a role in gut permeability, expression of mcp1 was decreased by inulin supplementation in a FFAR2-dependant manner. This indicates that FFAR2 is involved in mediating the beneficial effects of inulin on gut inflammation and adds to an existing literature implicating FFAR2 in inflammatory bowel disease. However, FFAR2 appears not to play a role in mediating intestinal barrier function in obesity.

 

Nothing to Disclose: LB, PC, AE, SRB, GF, GB

LB-PP02-2 17989 2.0000 LBSU-1077 A Free Fatty Acid Receptor 2 (FFAR2) Is Important in Mediating the Effects of Fermentable Carbohydrate on Gut Inflammation but Not Intestinal Barrier Function in Obesity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 11:30:00 AM LB-PP02 5224 11:15:00 AM Obesity and Diabetes: From Basic Mechanisms to Treatment Poster Preview

Ajay Chaudhuri*1, Husam Ghanim2, Sandeep S Dhindsa3, Kelly Green4, Sanaa Abuaysheh4, Antoine Makdissi5, Nitesh D Kuhadiya6, Manav Batra6 and Paresh Dandona7
1SUNY at Buffalo, Williamsville, NY, 2SUNY at Buffalo, Buffalo, NY, 3SUNY at Buffalo, Amherst, NY, 4SUNY at Buffalo, 5State Univ of New York at Buffal, Buffalo, NY, 6University at Buffalo, Buffalo, NY, 7State Univ of NY, Buffalo, NY

 

Following our initial demonstration that treatment with exenatide results in reduction of systolic blood pressure (1), and the confirmatory data from subsequent studies on GLP-1 receptor agonists, we have now hypothesized that exenatide induces an increase in vasodilatory factors. A series of 12 patients with type 2 diabetes on treatment with OHA and insulin were started on exenatide 5 µg b.i.d; the dose was increased to 10µg b.i.d a week later for a period of 12 weeks. Another 12 patients were treated with placebo. Blood samples were obtained prior to and at 2, 4 and 6 hours after the first injection and then at 12 weeks. Systolic blood pressure decreased from 134±6 to 127±5 mmHg (NS) and diastolic blood pressure was reduced from 82±2 to 77±3 mmHg (NS). Plasma concentrations of cGMP increased by 47±19% at 2hr of a single dose and by 72±21% and at 12 weeks of treatment with exenatide (p<0.05). There was a significant increases in concentrations of cAMP by 28±9% and ANP by 26±11% while those of b-NP did not alter at 12 weeks of exenatide. In addition, plasma concentrations of angiotensinogen was reduced by 19±5% at 2hr of a single dose and by 28±7% at 12 weeks of treatment with exenatide (p<0.05). Plasma concentrations of renin and angiotensin II also fell significantly by 18±7% and 25±8% (p<0.05), respectively following a single dose while it did not change at 12 weeks. In contrast, there was no change in plasma endothelin-1 concentrations. These data demonstrate that exenatide treatment induces an increase in a series of vasodilators, cGMP, cAMP and ANP while suppressing the renin-angiotensin system as reflected in the plasma concentrations of renin, angiotensinogen and angiotensin II. These actions would contribute to the anti-hypertensive actions of exenatide in patients with type 2 diabetes on treatment with OHAs and insulin.

 

Nothing to Disclose: AC, HG, SSD, KG, SA, AM, NDK, MB, PD

LB-PP02-3 17818 3.0000 LBSU-1074 A Exenatide Induces an Increase in Vasodilatory Mediators 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 11:30:00 AM LB-PP02 5224 11:15:00 AM Obesity and Diabetes: From Basic Mechanisms to Treatment Poster Preview

Mukul R Jain*1, Amit Arvind Joharapurkar1, Rajesh Bahekar1, Harilal Patel1, Samadhan Kshirsagar1, Pradip Jadav1, Vishal Patel1, Kartikkumar Patel1, Vikram K Ramanathan1, Pankaj R Patel2 and Ranjit Desai1
1Zydus Research Centre, Ahmedabad, India, 2Cadila Healthcare Limited, Ahmedabad, India

 

DPP-4 inhibitors inhibit degradation of glucagon like peptide-1 (GLP-1) and GIP, the endogenous incretin hormones responsible for stimulating glucose-dependent insulin secretion. ZYDPLA1 is a novel and potent DPP-4 inhibitor under clinical development for the treatment of type 2 diabetes and has shown potential for once a week administration in humans. The in vitro effect of ZYDPLA1 was assessed using recombinant DPP-4 enzyme.  ZYDPLA1 competitively inhibited DPP-4 activity in vitro with an IC50 of 2.99 nM, and Ki of 9.3 nM. The calculated  Koff rate for ZYDPLA1 was 5.12 × 10–5S-1. ZYDPLA1 was more than 8000 fold selective for DPP-4 relative to DPP-8, and DPP-9, and was more than 10000 fold selective relative to fibroblast activation protein in vitro. The potency of ZYDPLA1 for DPP-4 inhibition was similar across the species. In C57BL/6J mice ZYDPLA1 administration showed a potent antihyperglycemic effect in oral glucose tolerance test. This effect was mediated through elevated circulating levels of GLP-1 and insulin. Potent antihyperglycemic  effect was also observed in Zucker fatty rats following meal tolerance test. Significant DPP-4 inhibition was observed for more than 48 hours in mice and rats and up to 168 hours in dogs and non-human primates. In conclusion, ZYDPLA1 is a potent, selective inhibitor of DPPP-4 that has the potential to become once a week therapy for treatment of type 2 diabetes.

 

Disclosure: MRJ: Employee, Zydus Research Centre, Cadila Healthcare Limited, Ahmedabad, India. AAJ: Employee, Zydus Research Centre, Cadila Healthcare Limited, Ahmedabad, India. RB: Employee, Zydus Research Centre, Cadila Healthcare Limited, Ahmedabad, India. HP: Employee, Zydus Research Centre, Cadila Healthcare Limited, Ahmedabad, India. SK: Employee, Zydus Research Centre, Cadila Healthcare Limited, Ahmedabad, India. PJ: Employee, Zydus Research Centre, Cadila Healthcare Limited, Ahmedabad, India. VP: Employee, Zydus Research Centre, Cadila Healthcare Limited, Ahmedabad, India. KP: Employee, Zydus Research Centre, Cadila Healthcare Limited, Ahmedabad, India. VKR: Employee, Zydus Research Centre, Cadila Healthcare Limited, Ahmedabad, India. PRP: Chairman, Cadila Healthcare Limited, Ahmedabad, India. RD: Employee, Zydus Research Centre, Cadila Healthcare Limited, Ahmedabad, India.

LB-PP02-4 17991 4.0000 LBSU-1075 A ZYDPLA1, a Novel Long-Acting DPP-4 Inhibitor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 11:30:00 AM LB-PP02 5224 11:15:00 AM Obesity and Diabetes: From Basic Mechanisms to Treatment Poster Preview

Mihail Zilbermint*1, Fabio R Faucz2, Maya Beth Lodish1, Eva Szarek1, Giampaolo Trivellin1, Ninet Sinaii2, Rossella Libe3, Guillaume Assie4, Stéphanie Espiard3, Ludivine Drougat4, Bruno Ragazzon4, Jerome Yves Bertherat5 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2National Institutes of Health, Bethesda, MD, 3INSERM Unité 1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Institut Cochin, Paris, France, 4INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, France, 5INSERM U 1016, Cochin Institute, Paris Descartes University, Paris, France

 

Context: Inactivating germline mutations of the probable tumor suppressor gene Armadillo Repeat Containing 5 (ARMC5) have recently been found. This is likely to be a genetic cause of ACTH-independent macronodular adrenal hyperplasia (AIMAH).

Objective:  We studied a large cohort of patients with AIMAH seen at the NIH Clinical Center for the presence of ARMC5 mutations. The clinical phenotype of patients with and without ARMC5 mutations was compared.

Methods: Blood DNA from 34 AIMAH patients was genotyped using Sanger sequencing. Diurnal serum cortisol measurements, plasma ACTH levels, 6 day Liddle’s test, adrenal computed tomography, and weight of adrenal glands at adrenalectomy were assessed.

Results: Germline ARMC5 mutations were found in 15 out of 34 patients (44.1%). In silico analysis of the mutations indicated that 7 (20.6%) predicted major implications for gene function. Midnight cortisol levels were higher in patients with ARMC5 damaging mutations compared to those without and/or with non-pathogenic mutations (14.5±5.6 vs. 6.7±4.3, p<0.001). All patients carrying ARMC5 mutation that were predicted to be pathogenic had clinical Cushing’s syndrome (7/7, 100%) compared to 14/27 (52%) of those without or with mutations predicted as benign (p=0.029). Repeated measures analysis showed overall higher urinary 17-hydroxycorticosteroids and serum cortisol values in the patients with ARMC5 damaging mutations during the 6 day Liddle’s test (p=0.0002).

Conclusions: Patients with ARMC5 mutations had a clinically severe Cushing’s syndrome associated with AIMAH. Knowledge of ARMC5 status may help clinicians with diagnosis of Cushing’s syndrome. Genetic counseling may be advised for the affected patients and their families.

 

Nothing to Disclose: MZ, FRF, MBL, ES, GT, NS, RL, GA, SE, LD, BR, JYB, CAS

OR14-1 11141 1.0000 A Macronodular Adrenal Hyperplasia Due to Mutations in an Armadillo Repeat Containing 5 (ARMC5) Gene: A Clinical and Genetic Investigation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 1:00:00 PM OR14 4716 11:30:00 AM Adrenal Tumors: Novel Causes and Mechanisms Oral

Zakariae Bram*1, Julien Wils2, Bruno Ragazzon3, Marthe Risk-Rabin4, Rossella Libe5, Jacques Young6, Marie-Christine Vantyghem7, Antoine Martinez8, Constantine A Stratakis9, Jerome Yves Bertherat10, Herve Lefebvre11 and Estelle Louiset12
1INSERM U982, Institute for Biomedical Research and Innovation, University of Rouen, Mont Saint Aignan, France, Mont Saint Aignan, France, 2INSERM U982, Institute for Biomedical Research and Innovation, Mont Saint Aignan, France, 3INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, France, 4INSERM U1016, University Paris V, Cochin Institute, Paris, France, Paris, France, 5INSERM Unité 1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Institut Cochin, Paris, France, 6University Paris Sud, Department of Endocrinology, Bicetre Hospital, INSERM U693, Le Kremlin-Bicêtre, Fance, Le Kremlin Bicêtre, France, 7Department of Endocrinology, Lille Regional University Hospital, INSERM U859, Lille2 University, Lille, France, Lille Cedex, France, 8CNRS UMR6247, INSERM U931, Gred, Clermont Université, Aubière, France, Aubiere, France, 9National Institutes of Health (NIH), Bethesda, MD, 10INSERM U 1016, Cochin Institute, Paris Descartes University, Paris, France, 11Institute for Biomedical Research and Innovation, University Hospital of Rouen, Rouen, France, 12Normandie University, UNIROUEN, INSERM U982, Laboratoire Différenciation et Communication Neuronale et Neuroendocrine, ROUEN, France

 

The frequency of Primary Pigmented Nodular Adrenal Disease (PPNAD)-associated hypercortisolism was found to be higher in women than men between the times of puberty and menopause. The aim of this study was to investigate the role of β-estradiol (E2) in the pathogenesis of cortisol hypersecretion from 33 PPNAD patients by using molecular, immunohistochemical and pharmacological approaches. Aromatase, the key enzyme for estrogen biosynthesis was found to be expressed in PPNAD female patients at mRNA and protein levels, suggesting possible production of estrogens in PPNAD tissues. Interestingly, aromatase mRNA expression was positively correlated with age in female patients harbouring PRKAR1A mutations. In primary cultured cells from 4/5 PPNAD patients, β-estradiol (E2) stimulated cortisol secretion, the stimulatory effect of E2 being inhibited by the PKA inhibitor H-89, indicating an involvement of the PKA pathway in E2 action on PPNAD tissues. The estrogen receptors ERα, and GPR30 were found overexpressed at mRNA and protein levels in PPNAD tissues. By using GPR30 and ERα synthetic ligands, like G1 and tamoxifen, as well as siRNA targeting GPR30 and ERα mRNA, we could demonstrate an involvement of the two receptors in the stimulatory effect of E2 on cortisol secretion. In the PPNAD cell line (CAR47.01), expression of GPR30 and ERα mRNA was positively modulated by the PKA pathway. In most patients, PPNAD results from inactivating mutations of the PRKAR1A gene which cause enhancement of PKA activity. In the adrenocortical cell line H295R, inhibition of PRKAR1A gene expression markedly stimulated expression of ERα and GPR30 mRNAs. Estrogen receptor-related receptor alpha (ERRα), which is known to mediate up-regulation of the aromatase gene (CYP19), was found to be up-regulated by the PKA pathway in the CAR47.01 cell line. ERRα was overexpressed in PPNAD tissues at mRNA and protein levels in comparison with normal adrenals. ERRα immunoreactivity was detected at high levels in the adrenal micronodules. Moreover, PPNAD ERRα positive cells were also positive for aromatase. Taken together, our results show that, in PPNAD tissues associated with Cushing’s syndrome, E2 abnormally stimulates cortisol secretion through activation of overexpressed ERα and GPR30 receptors. This finding may explain why the diagnosis of PPNAD is more frequent after puberty in female patients with Carney complex.

 

Nothing to Disclose: ZB, JW, BR, MR, RL, JY, MCV, AM, CAS, JYB, HL, EL

OR14-2 14886 2.0000 A β-Estradiol (E2) Stimulates Cortisol Secretion in Primary Pigmented Nodular Adrenal Disease: An Explanation for the Increased Frequency of Cushing's Syndrome in Female Patients with Carney Complex 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 1:00:00 PM OR14 4716 11:30:00 AM Adrenal Tumors: Novel Causes and Mechanisms Oral

Felix Beuschlein*1, Martin Fassnacht2, Guillaume Assie3, Davide Calebiro4, Constantine A Stratakis5, Andrea Osswald6, Cristina Lucia Ronchi7, Thomas Wieland8, Silviu Sbiera9, Fabio R Faucz10, Kathrin Schaak9, Anett Schmittfull11, Thomas Schwarzmayr12, Olivia Barreau13, Delphine Vezzosi14, Marthe Rizk-Rabbin15, Ulrike Zabel16, Eva Szarek5, Paraskevi Salpea5, Antonella Forlino17, Annalisa Vetro17, Orsetta Zuffardi17, Caroline Kisker18, Susanne Diener8, Thomas Meitinger8, Martin Lohse19, Martin Reincke1, Jerome Yves Bertherat20, Tim M. Strom12 and Bruno Allolio4
1Klinikum der Universität München, Ludwig-Maximilian University, Munich, Germany, 2Univ of Wuerzburg, Wuerzburg, Germany, 3INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, France, 4University of Wuerzburg, Wuerzburg, Germany, 5National Institutes of Health (NIH), Bethesda, MD, 6Medizinische Klinik und Poliklinik IV, 7University Hospital Wuerzburg, Wuerzburg, Germany, 8Institute of Human Genetics, Helmholtz Zentrum München, 9Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München, 10National Institutes of Health, Bethesda, MD, 11Institute of Human Genetics, Helmholtz Zentrum München, Neuherberg, Germany, 12Helmholtz Zentrum München and Technische Universität München, Munich, Germany, 13Inserm U1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, 14Hosp Rangueil, Toulouse Cedex, France, 15INSERM U1016, CNRS UMR 8104, 16Institute of Pharmacology and Toxicology, University of Würzburg, Germany, 17University of Pavia, Pavia, Italy, 18Rudolf Virchow Center for Experimental Biomedicine, University of Würzburg, 19University of Würzburg, Wurzburg, Germany, 20INSERM U 1016, Cochin Institute, Paris Descartes University, Paris, France

 

Background

Corticotropin-independent Cushing’s syndrome is caused by tumors or hyperplasia of the adrenal cortex.

Methods

Exome sequencing was performed in ten cortisol-producing adenomas and recurrent mutations in candidate genes were evaluated in additional 171 patients with adrenocortical tumors. Genome-wide copy number analysis was performed in 35 patients with cortisol-secreting bilateral hyperplasias. The effects of these genetic defects were studied both clinically and in vitro.

Results

Exome sequencing revealed somatic mutations in the PRKACA gene, which encodes the main catalytic subunit of cyclic AMP-dependent protein kinase (PKA), in 8 of 10 adenomas (c.617A>C in seven and c.595_596insCAC in one). Overall, PRKACA somatic mutations were identified in a total of 22 of 59 adenomas (37%) from patients with overt Cushing’s syndrome while these mutations were not detectable in patients with subclinical hypercortisolism (n=40) or in other adrenal tumors (n=82). Among 35 patients with cortisol- producing hyperplasias, 5 (two of whom were first-degree relatives) carried a germline copy number gain of the chromosome 19 region including the PRKACA gene. In vitro studies demonstrated impaired inhibition of both PKA catalytic subunit mutants by the PKA regulatory subunit, while cells from patients with germline chromosomal gains showed increased protein levels of the PKA catalytic subunit; in both instances, basal PKA activity was increased.

Conclusions

This report links genetic alterations of the catalytic subunit of PKA to human disease: germline duplications of this gene cause bilateral adrenal hyperplasias, whereas somatic PRKACA mutations lead to unilateral cortisol-producing adrenal adenomas.

 

Disclosure: MR: Speaker, Novartis Pharmaceuticals, Clinical Researcher, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals, Speaker, Pfizer, Inc., Speaker, Ipsen. BA: Consultant, Boehringer-Ingelheim, Coinvestigator, HRA-Pharma, Committee Member, Ipsen. Nothing to Disclose: FB, MF, GA, DC, CAS, AO, CLR, TW, SS, FRF, KS, AS, TS, OB, DV, MR, UZ, ES, PS, AF, AV, OZ, CK, SD, TM, ML, JYB, TMS

OR14-3 14491 3.0000 A Constitutive Activation of Prkaca in Adrenal Cushing's Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 1:00:00 PM OR14 4716 11:30:00 AM Adrenal Tumors: Novel Causes and Mechanisms Oral

Lalarukh Haris Shaikh*1, Ada ED Teo1, Grahame McKenzie2, Junhua Zhou1, Sudeshna G Neogi3, Ian McFarlane3, Nichola Figg4, Elena AB Azizan1, Anthony P Davenport1 and Morris J Brown1
1University of Cambridge, Cambridge, United Kingdom, 2Medical Research Council Cancer Unit, Cambridge, United Kingdom, 3Genomics CoreLab, Cambridge National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), Cambridge, United Kingdom, 4Division of Cardiovascular Medicine, Cambridge, United Kingdom

 

Small zona glomerulosa (ZG)-like aldosterone-producing adenomas (APAs), with common somatic mutations in CACNA1D or ATP1A1, may be a consequence of high turnover of adrenocortical cells, and long-presumed process of centripetal migration in the human adrenal (1). In order to understand the underlying mechanisms, we aimed [i] to compare by microarray the transcriptome of ZG vs zona fasciculata (ZF); [ii] to compare cell turnover in these zones; [iii] to examine effects on aldosterone production of up-regulated genes in the Wnt/β-catenin signalling pathway. RNA was extracted from the ZG and ZF of 21 human adrenals by Laser capture microdissection and analysed in an Affymetrix microarray comparison of the two zones. Genes which were many-fold up-regulated in ZG were validated by qPCR and immunohistochemistry (IHC). Functional analysis was carried out using Wnt pathway proteins to investigate canonical and non-canonical regulation of aldosterone production in primary adrenal and immortalised adrenocortical cell lines. The putative stem cell marker, and a key target for Wnt signalling, LGR5, was the most up-regulated gene in ZG (x25.0, P=10-23) vs. paired ZF. Its cognate ligand, RSPO3, (x5.27, P=10-11) and other WNT genes; WNT4 (x2.25, P=10-8), SFRP4 (x8.67, P=10-10), LEF1 (x5.86, P=10-15), FZD6 (x2.69, P=10-11) were also highly expressed in ZG. Microarray results were confirmed using qPCR. IHC confirmed selective localisation of LGR5 in ZG. TUNEL staining showed a high rate of apoptosis in the ZG. As expected from previous experiments (2), inhibition of the canonical WNT pathway downstream of b-catenin activation reduced aldosterone production (P=10-5). But surprisingly, in both primary human adrenal and H295R adrenocortical cells, RSPO3 caused dose-related inhibition of aldosterone secretion; and silencing of LGR5 increased aldosterone production (P<0.05). In conclusion, LGR5 is the most ZG-selective gene in human adrenal. Since activation by RSPO3 did not activate the canonical Wnt pathway, and inhibited aldosterone production, we infer that LGR5 – as previously reported (3) – is driving a non-canonical pathway. On the analogy of its role in intestinal crypts, we believe that LGR5 may drive not only loss of aldosterone production, but of ZG cells, through apoptosis and the centripetal migration of adrenocortical cells. We postulate that, in response to typically high salt intake, the role of up-regulated ZG genes in humans is to regulate aldosterone production, through interactions between the canonical and non-canonical WNT pathways.

 

Nothing to Disclose: LH, AET, GM, JZ, SGN, IM, NF, EAA, APD, MJB

OR14-4 14861 4.0000 A The Stem Cell Gene LGR5 Is the Most Specific Marker of Human Adrenal Zona Glomerulosa, and May be the Driver of Adrenal Zonation through Non-Canonical Wnt Activation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 1:00:00 PM OR14 4716 11:30:00 AM Adrenal Tumors: Novel Causes and Mechanisms Oral

Marc B Bailie1, Martin D Phillips2, Raili Kerppola2, James R Herman1, Paul G Pearson3, Gary D Hammer4, Randall W Whitcomb2, Julia Owens2 and Stephen W Hunt III*2
1INDS, Ann Arbor, MI, 2Atterocor, Inc., Ann Arbor, MI, 3Pearson Pharma Partners, Westlake Village, CA, 4University of Michigan, Ann Arbor, MI

 

ATR-101 is a novel small molecule therapeutic in clinical development for the treatment of adrenocortical carcinoma (ACC).  ACC is a rare and highly aggressive endocrine cancer of the adrenal cortex with an incidence of about 2 per million population.   ACC is usually diagnosed at a late stage resulting in very poor patient prognosis.  Many patients with ACC have treatment-resistant Cushing’s syndrome.  The only approved therapy for ACC, mitotane, has limited effectiveness and is poorly tolerated.  There is a significant need for new therapies to treat ACC.  ATR-101 is a selective inhibitor of ACAT1 (acyl coenzyme A:cholesterol acyltransferase).  ACAT1 catalyzes cholesterol ester formation from cholesterol and long-chain fatty acyl-CoA and, in the adrenal cortex, is particularly important in creating a reservoir of substrate for steroid biosynthesis.  As ACCs derive from the adrenal cortex and often retain many tissue-specific characteristics, we studied the effects of ATR-101 in normal canine adrenals as a model to understand the molecular mechanism of the compound.  Normal beagles were treated for either 7 or 14 days via once daily oral administration of ATR-101 and systemic and tissue-specific exposure, target tissue pharmacology, adrenal function, and histologic changes in the adrenals were evaluated.  ATR-101 plasma exposure was dose related and ATR‑101 levels were highest in adrenals compared to other tissues.  Cholesterol ester levels were decreased in the adrenals demonstrating that ATR-101 functions as an ACAT1 inhibitor in the target tissue.  ATR-101 treatment led to rapid, dose-dependent decreases in ACTH-stimulated cortisol levels and all other steroids and steroid intermediates assessed, consistent with ATR-101-mediated inhibition of ACAT1 and disruption of substrate availability for steroid biosynthesis.  At the termination of the treatment period, ATR-101 induced histological changes in the adrenals including significant apoptosis in the zona reticularis and zona fasciculata.  The results of this study provide insight into unique attributes of ATR-101 and support its development as a novel therapeutic for the treatment of ACC.  ATR-101 is in a human phase 1 clinical trial for ACC (ClinicalTrials.gov Identifier: NCT01898715.)

 

Disclosure: MBB: Consultant, Atterocor, Inc.. MDP: Employee, Atterocor, Inc, Employee, Atterocor, Inc. RK: Founder, Atterocor, Inc.. JRH: Consultant, Atterocor, Inc.. PGP: Consultant, Atterocor, Inc.. GDH: Founder, Atterocor, Inc.. RWW: Consultant, Atterocor, Inc.. JO: Founder, Atterocor, Inc., Founder, Atterocor. SWH III: Chief Scientific Officer, Atterocor, Inc., Chief Scientific Officer, Atterocor.

OR14-5 16732 5.0000 A ATR-101, a Selective ACAT1 Inhibitor in Development for Adrenocortical Carcinoma, Disrupts Steroidogenesis and Causes Apoptosis in Normal Canine Adrenals 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 1:00:00 PM OR14 4716 11:30:00 AM Adrenal Tumors: Novel Causes and Mechanisms Oral

Aude Salomon1, Michelle Keramidas2, Cecile Maisin1 and Michael Thomas*1
1Inserm U1036, iRTSV/BCI, Grenoble, France, 2Inserm U823, Albert Bonniot Institute, La Tronche, France

 

Adrenal carcinoma (ACC) is a rare endocrine neoplasm, notorious for its aggressive behavior, metastatic potential and poor outcome. Progress into the elucidation of the genes and pathways involved in the pathogenesis of ACC has helped to identify new putative targets for the development of selective treatment. Mutations of the ß-catenin gene have been found in a third of ACC. Here we studied the effects of its inhibition on the in vitro and in vivo growth of the human ACC cell line H295R, which harbors the Ser45mutation of ß-catenin. This mutation leads to a stabilized protein which is constitutively active. The cells were infected with lentiviral particles expressing short hairpin RNA (shRNA)-mediated silencing ß-catenin.

Two of the three shRNAs used, induced specific and substantial down-regulation of ß-catenin protein levels. In vitro cell proliferation assays showed that the expression of these shRNAs decreased cell growth compared to control cells expressing a non-targeting shRNA vector. Moreover, treament with ß-catenin shRNAs caused an increase in the percentage of cells in S and G2/M phases, as shown by flow cytometry. This cytostatic effect is due in part to a decrease of phosphorylated MAPK and to an up-regulation expression of the cyclin-dependent kinase inhibitors p57KIP2, p21WAF1/CIP1 and p27KIP1. In addition, we observed that the knock down of the ß-catenin gene decreased phosphorylated Akt level and increased apoptosis from 1.7% to 7.0%. Finally, low level of ß-catenin expression was sufficient to induce the reversal of the epithelial-to-mesenchymal transition, as was evidenced by increased epithelial marker E-cadherin and concomitantly decreased mesenchymal markers N-cadherin and vimentin. We then assessed the in vivo effects of targeting ß-catenin in H295R cells by transplanting them beneath the kidney capsule of Icr-Scid mice. The animals were sacrificed 46 days following transplantation. Tumor growth suppression was achieved by the two shRNAs showing in vitro efficacy. Xenografts were then processed for histological and immunohistological analyses. Proliferation, as measured by Ki-67, a marker expressed in proliferating cells was not significantly reduced in silenced tumors compared to the control ones. In contrast, p57, p27 and p21 proteins were found expressed at high levels in silenced tumors which might modulate cell cycle progression. Moreover, the depletion of ß-catenin induced an increase in apoptotic cells as revealed by cleaved caspase-3 activation.

Taken together, these findings indicate that the blockade of ß-catenin inhibits tumor growth in vitro and in vivo of ß-catenin-activated tumor cells and finally, shRNA technology may have potential therapeutic use in ACC.

 

Nothing to Disclose: AS, MK, CM, MT

OR14-6 11712 6.0000 A Gene Silencing of ß-Catenin in Adrenocortical Cancer Cells Causes Growth Inhibition and the Reversal of Epithelial-to-Mesenchymal Transition 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 1:00:00 PM OR14 4716 11:30:00 AM Adrenal Tumors: Novel Causes and Mechanisms Oral

E Michael Lewiecki*1, Socrates Papapoulos2, Kurt Lippuner3, Christian Roux4, Celia JF Lin5, David L Kendler6, Maria L Brandi7, Edward Czerwinski8, Edward Franek9, Peter Lakatos10, Salvatore Minisola11, Jean-Yves Reginster12, Soren Jensen13, Nadia Daizadeh5, Andrea Wang5, Mary Gavin5, Rachel B Wagman5 and Henry G Bone14
1New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, 2Leiden University Medical Center, Leiden, Netherlands, 3Bern University Hospital, Bern, Switzerland, 4Paris Descartes University, Paris, France, 5Amgen Inc., Thousand Oaks, CA, 6University of British Columbia, Vancouver, BC, Canada, 7University of Florence, Florence, Italy, 8Krakow Medical Center, Krakow, Poland, 9Central Clinical Hospital MSWiA, Warsaw, Poland, 10Department of Medicine, Semmelweis University, Budapest, Hungary, 11Department of Internal Medicine and Medical Disciplines "Sapienza" Rome University, Rome, Italy, Rome, Italy, 12University of Liège, Liège, Belgium, 13CCBR, Ballerup, Denmark, 14Michigan Bone and Mineral Clinic, Detroit, MI

 

Purpose: The FREEDOM trial open-label extension (1,2) is designed to evaluate the long-term efficacy and safety of denosumab (DMAb) for up to 10 years. Here we present data from the 5th year of the extension, representing up to 8 years of continued DMAb treatment.

Methods: All women in the extension received 60 mg of DMAb every 6 months and daily calcium and vitamin D. In this analysis, women in the long-term group received 3 years of DMAb in FREEDOM and 5 years of DMAb in the extension, totaling 8 years of DMAb treatment; women in the cross-over group received 3 years of placebo in FREEDOM and 5 years of DMAb in the extension, totaling 5 years of DMAb treatment.

Results: Of the women who entered the extension, 66% completed the 5th year. Bone turnover marker data showed that the reductions in serum C-terminal telopeptide of type 1 collagen and procollagen type 1 N-terminal propeptide were sustained through 8 years in the long-term group and were similarly reduced in the cross-over group. With 8 years of DMAb treatment in the long-term group, mean bone mineral density (BMD) continued to increase from the FREEDOM baseline for cumulative gains of 18.4% at the lumbar spine (LS) and 8.3% at the total hip (TH) (all p < 0.0001). With 5 years of DMAb treatment in the cross-over group, there were mean BMD increases from the extension baseline of 13.1% at the LS and 6.2% at the TH (all p < 0.0001). The incidence of new vertebral and nonvertebral fracture remained low throughout the extension, and hip fracture incidence was 0.2% and 0.1% for the long-term and cross-over groups, respectively, during year 8. The adverse event (AE) and serious AE profiles were consistent with data reported previously in the extension study.

Conclusions: Treatment with DMAb for up to 8 years was associated with persistent reduction of bone turnover, continued increases in BMD, and low fracture incidence. The benefit/risk profile for DMAb remains favorable.

 

Disclosure: EML: Advisory Group Member, Amgen, Advisory Group Member, Agnovos, Advisory Group Member, Merck, Principal Investigator, Merck, Advisory Group Member, Lilly, Principal Investigator, Lilly, Advisory Group Member, Radius Health, Principal Investigator, Amgen. SP: Speaker, Roche, Medical Advisory Board Member, GlaxoSmithKline, Consultant, Axsome, Speaker, Novartis, Medical Advisory Board Member, Merck & Co., Medical Advisory Board Member, Amgen. KL: Medical Advisory Board Member, Amgen, Medical Advisory Board Member, Eli Lilly & Company, Medical Advisory Board Member, MSD, Medical Advisory Board Member, Takeda, Medical Advisory Board Member, UCB, Investigator, Amgen, Investigator, MSD. CR: Board Member, MSD, Board Member, Lilly, Board Member, Amgen, Principal Investigator, MSD, Principal Investigator, Lilly, Principal Investigator, Bongrain, Speaker, UCB. CJL: Employee, Amgen, Employee, Amgen. DLK: Advisory Group Member, Amgen, Investigator, Amgen, Speaker Bureau Member, Amgen, Advisory Group Member, Eli Lilly & Company, Investigator, Eli Lilly & Company, Speaker Bureau Member, Eli Lilly & Company, Advisory Group Member, Pfizer, Investigator, Pfizer, Speaker Bureau Member, GlaxoSmithKline, Investigator, Astellis, Investigator, Novartis, Advisory Group Member, Merck & Co.. MLB: Principal Investigator, Amgen, Principal Investigator, Eli Lilly & Company, Principal Investigator, MSD, Principal Investigator, Novartis, Principal Investigator, Roche, Principal Investigator, Servier, Consultant, Amgen, Consultant, Eli Lilly & Company, Consultant, MSD, Consultant, Novartis, Consultant, Roche, Consultant, Servier. EC: Investigator, Amgen, Investigator, Servier, Investigator, Merck Serono, Speaker, Servier. EF: Speaker Bureau Member, Servier, Speaker Bureau Member, Novartis, Speaker Bureau Member, MSD, Speaker Bureau Member, Amgen, Advisory Group Member, Novartis, Investigator, Amgen, Speaker Bureau Member, Teva. PL: Advisory Group Member, Amgen, Speaker, Servier, Speaker, Roche. SM: Speaker, Abiogen, Speaker, Amgen, Speaker, Bruno Farmaceutici, Speaker, Eli Lilly & Company, Speaker, Merck Sharp & Dohme, Advisory Group Member, Merck Sharp & Dohme, Advisory Group Member, Amgen. JYR: Investigator, Organon Laboratories, Investigator, Danone, Investigator, Theramex, Investigator, Pfizer, Inc., Investigator, Servier, Investigator, GlaxoSmithKline, Investigator, Novartis Pharmaceuticals, Investigator, Lilly USA, LLC, Investigator, Amgen, Investigator, Roche Pharmaceuticals, Investigator, Teva, Investigator, Rottapharm, Investigator, Merck Sharp Dohme, Investigator, Bristol-Myers Squibb, Speaker, Danone, Speaker, Zodiac, Speaker, Ebewee Pharma, Speaker, Novo Nordisk, Speaker, Nycomed, Speaker, Theramex, Speaker, Analis, Speaker, Teva, Speaker, Teijin, Speaker, Merckle, Speaker, GlaxoSmithKline, Speaker, Roche Diagnostics, Speaker, Servier, Speaker, Novartis Pharmaceuticals, Speaker, IBSA-Genevrier, Speaker, Rottapharm, Speaker, Lilly USA, LLC, Speaker, Merck Sharp Dohme, Consultant, Asahi Kasei, Consultant, UCB, Consultant, Theramex, Consultant, IBSA-Genevrier, Consultant, NPS, Consultant, Nycoed-Takeda, Consultant, Merckle, Consultant, Roche Pharmaceuticals, Consultant, GlaxoSmithKline, Consultant, Amgen, Consultant, Wyeth, Consultant, Lilly USA, LLC, Consultant, Negma, Consultant, Novartis Pharmaceuticals, Consultant, Servier, Investigator, Therabel, Investigator, Boehringer, Investigator, Chiltern, Investigator, Galapagos, Speaker, Will Pharma. ND: Employee, Amgen, Employee, Amgen. AW: Employee, Amgen, Employee, Amgen. MG: Employee, Amgen, Employee, Amgen. RBW: Employee, Amgen, Employee, Amgen. HGB: Principal Investigator, Amgen, Consultant, Amgen, Principal Investigator, Merck, Consultant, Merck, Principal Investigator, Novartis, Consultant, Novartis. Nothing to Disclose: SJ

OR22-1 11518 1.0000 A Effect of Denosumab Treatment in Postmenopausal Women with Osteoporosis: Eight-Year Results from the Freedom Extension, Phase 3 Clinical Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 1:00:00 PM OR22 4723 11:30:00 AM Osteoporosis-Clinical Trials Oral

Bente L Langdahl*1, Christence S Teglbjaerg2, Pei-Ran Ho3, Roland Chapurlat4, Edward Czerwinski5, David L Kendler6, Jean-Yves Reginster7, Alan Kivitz8, E Lewiecki9, Paul D Miller10, Michael A Bolognese11, Michael R McClung12, Henry G. Bone III13, Östen Ljunggren14, Bo Abrahamsen15, Ugis Gruntmanis16, Yu-Ching Yang3, Rachel B Wagman3, Suresh Siddhanti3 and Eric Orwoll17
1Aarhus University Hospital, Aarhus, Denmark, 2Center for Clinical and Basic Research, Ballerup, Denmark, 3Amgen Inc., Thousand Oaks, CA, 4INSERM UMR 1033, Université de Lyon, Hôpital Edouard Herriot, Lyon, France, 5Krakow Medical Center, Krakow, Poland, 6University of British Columbia, Vancouver, BC, Canada, 7University of Liège, Liège, Belgium, 8Altoona Center for Clinical Research, Duncansville, PA, 9New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, 10Colorado Center for Bone Research, Lakewood, CO, 11Bethesda Health Research Center, Bethesda, MD, 12Oregon Osteoporosis Center, Portland, OR, 13Michigan Bone and Mineral Clinic, PC, Detroit, MI, 14Uppsala University, Uppsala, Sweden, 15University of Southern Denmark and Glostrup Hospital, Odense and Copenhagen, Denmark, 16North Texas VA Health Care System and UT Southwestern, Dallas, TX, 17Oregon Health & Science University, Portland, OR

 

Background: With aging of the overall population and increasing longevity of men, fractures (the primary consequence of osteoporosis) and the ensuing health care burdens are expected to greatly increase in coming years.1,2 Denosumab (DMAb) has been approved in several countries for the treatment of men with osteoporosis at high/increased risk for fracture. The phase 3 trial in men with low bone mineral density (BMD; T-score ≤ –2.0 and ≥ –3.5 at the lumbar spine or femoral neck, or T-score ≤ –1.0 and ≥ –3.5 with a prior major osteoporotic fracture) (ADAMO) showed that 12 months of DMAb treatment (60 mg every 6 months) significantly increased BMD compared with placebo.3 The study was preplanned as a 24-month trial, in which the second year was designed as an open-label phase to provide additional safety and efficacy information. We now report findings from the second year.  

Methods: The overall trial comprised two treatment periods: a previously reported 12-month, double-blind, placebo-controlled phase investigating the effects of DMAb vs placebo3 and a subsequent 12-month open-label treatment phase in which all men received DMAb. The primary objective of the open-label phase was safety, and exploratory efficacy endpoints included BMD and serum C-telopeptide (sCTX).

Results: Of the 242 subjects randomized, 228 subjects (mean age 65 years) entered the open-label treatment phase, and 219 (90.5%) completed the 24-month trial. After 24 months of DMAb treatment, percentage change in BMD from study baseline in subjects randomized to DMAb who continued DMAb (long-term) was 8.0%, 3.4%, 3.4%, and 0.7% at the lumbar spine, total hip, femoral neck, and distal radius, respectively (all p < 0.01). Subjects treated with placebo who crossed over to DMAb treatment (crossover) showed BMD gains (all p≤ 0.02 from baseline) similar to those observed in the long-term DMAb group during their first year of treatment. Significant reductions in sCTX were maintained (long-term) or achieved rapidly (crossover) following DMAb administration. DMAb was well tolerated throughout the 24-month study period. The incidence of adverse events was similar between groups and no new safety signals were identified.

Conclusions: In men with low BMD treated with DMAb for 2 years, bone resorption remained reduced, BMD increased further, and therapy was well tolerated. These effects were similar to those previously seen with DMAb treatment in postmenopausal women with osteoporosis, and in men (prostate cancer) and women (breast cancer) with hormone deprivation therapy.

 

Disclosure: BLL: Medical Advisory Board Member, Merck, Sharp & Dohme, Speaker, Amgen, Speaker, Eli Lilly & Company, Speaker, Merck, Sharp & Dohme, Investigator, Amgen, Principal Investigator, Eli Lilly & Company, Investigator, Merck, Sharp & Dohme, Principal Investigator, Axellus, Medical Advisory Board Member, Eli Lilly & Company, Medical Advisory Board Member, Amgen. PRH: Employee, Amgen, Employee, Amgen. RC: Clinical Researcher, Servier, Speaker, Chugai, Clinical Researcher, Chugai, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Amgen, Advisory Group Member, UCB, Clinical Researcher, Merck & Co., Speaker, Pfizer, Inc.. EC: Speaker, Amgen, Speaker, Servier, Investigator, Merck Serono, Investigator, Servier, Investigator, Amgen. DLK: Researcher, Eli Lilly & Company, Speaker Bureau Member, Eli Lilly & Company, Consultant, Eli Lilly & Company, Speaker Bureau Member, GlaxoSmithKline, Researcher, Amgen, Speaker Bureau Member, Amgen, Consultant, Amgen, Researcher, Novartis Pharmaceuticals, Speaker Bureau Member, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Researcher, Pfizer, Inc., Speaker Bureau Member, Pfizer, Inc., Consultant, Pfizer, Inc., Researcher, Astellas. JYR: Speaker, Novo Nordisk, Speaker, Ebewee Pharma, Speaker, Zodiac, Speaker, Danone, Speaker, Will Pharma, Investigator, Bristol-Myers Squibb, Investigator, Merck Sharp Dohme, Investigator, Rottapharm, Investigator, Teva, Investigator, Roche Pharmaceuticals, Investigator, Amgen, Investigator, Lilly USA, LLC, Investigator, Novartis Pharmaceuticals, Investigator, GlaxoSmithKline, Investigator, Servier, Investigator, Pfizer, Inc., Investigator, Theramex, Investigator, Danone, Investigator, Organon Laboratories, Investigator, Therabel, Investigator, Boehringer, Investigator, Chiltern, Investigator, Galapagos, Speaker, Zodiac, Speaker, Will Pharma, Speaker, Nycomed, Speaker, Theramex, Speaker, Analis, Speaker, Teva, Speaker, Teijin, Speaker, Merckle, Speaker, GlaxoSmithKline, Speaker, Roche Diagnostics, Speaker, Servier, Speaker, Novartis Pharmaceuticals, Consultant, IBSA-Genevrier, Consultant, Theramex, Consultant, UCB, Consultant, Asahi Kasei, Speaker, Merck Sharp Dohme, Speaker, Lilly USA, LLC, Speaker, Rottapharm, Speaker, IBSA-Genevrier, Consultant, NPS, Consultant, Nycoed-Takeda, Consultant, Merckle, Consultant, Roche Pharmaceuticals, Consultant, GlaxoSmithKline, Consultant, Amgen, Consultant, Wyeth, Consultant, Lilly USA, LLC, Consultant, Negma, Consultant, Novartis Pharmaceuticals, Consultant, Servier. AK: Principal Investigator, Amgen. EL: Advisory Group Member, AgNovos, Principal Investigator, Lilly USA, LLC, Advisory Group Member, Lilly USA, LLC, Principal Investigator, Merck & Co., Advisory Group Member, Merck & Co., Principal Investigator, Amgen, Advisory Group Member, Amgen, Advisory Group Member, Radius Health. PDM: Scientific Board Member, Amgen, Scientific Board Member, Merck & Co., Scientific Board Member, Lilly USA, LLC, Scientific Board Member, Radius Res, Investigator, Novo Nordisk, Investigator, Takeda. MAB: Principal Investigator, Amgen, Principal Investigator, Regeneron, Principal Investigator, Lilly USA, LLC, Speaker Bureau Member, Amgen, Speaker Bureau Member, Vivus USA. MRM: Principal Investigator, Amgen, Consultant, Amgen, Speaker, Amgen, Consultant, Lilly USA, LLC, Consultant, Merck & Co., Speaker, Merck & Co., Speaker, GlaxoSmithKline, Speaker, Warner Chilcott, Principal Investigator, Merck & Co.. HGB III: Principal Investigator, Amgen, Consultant, Amgen, Principal Investigator, Merck & Co., Consultant, Merck & Co., Principal Investigator, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals. ÖL: Speaker, Eli Lilly & Company, Speaker, Amgen. BA: Principal Investigator, Amgen, Advisory Group Member, Amgen, Principal Investigator, Novartis Pharmaceuticals, Speaker, Takeda, Speaker, Eli Lilly & Company, Speaker, Merck & Co., Advisory Group Member, Merck & Co.. UG: Study Investigator, Novartis Pharmaceuticals, Study Investigator, GlaxoSmithKline, Study Investigator, Amgen. YCY: Employee, Amgen, Employee, Amgen. RBW: Employee, Amgen, Employee, Amgen. SS: Employee, Amgen, Employee, Amgen. EO: Advisory Group Member, Wright Med Tech, Principal Investigator, Merck & Co., Advisory Group Member, Merck & Co., Principal Investigator, Eli Lilly & Company, Advisory Group Member, Eli Lilly & Company, Principal Investigator, Amgen, Advisory Group Member, Amgen. Nothing to Disclose: CST

OR22-2 12813 2.0000 A Denosumab for the Treatment of Men with Low Bone Mineral Density: 24-Month Results from the Adamo Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 1:00:00 PM OR22 4723 11:30:00 AM Osteoporosis-Clinical Trials Oral

John Yates*1, Paul D Miller2, Michael A Bolognese3, Grattan Woodson4, Ivo Valter5, Marcie Clarkin6, Gary Hattersley7, Morten Karsdal8 and Claus Christiansen9
1Radius Health Inc., Cambridge, MA, 2Colorado Ctr for Bone Rsrch, Lakewood, CO, 3Bethesda Health Research Center, Bethesda, MD, 4Atlanta Research Center, Atlanta, GA, 5CCBR, Tallinn, Estonia, 6Radius Health, Inc., Cambridge, MA, 7Radius Health, Inc, Waltham, MA, 8CCBR Clinical Research, Copenhagen, Denmark, 9Nordic Bioscience, Copenhagen, Denmark

 

Background Treatments that result in greater increases in bone mass than existing options, while preserving normal bone quality, are needed to reduce fracture risk more effectively than presently possible and avoid concerns regarding over-suppression of bone turnover.  Abaloparatide is a synthetic analog of PTHrP1-34 that has shown strong efficacy to stimulate bone formation, and increase bone mass and bone strength in animal models of osteoporosis.  We conducted two phase 2 placebo-controlled studies both of which included abaloparatide 80 µg sc daily (ABL) in postmenopausal women with osteoporosis.  Study 1 also included teriparatide (Forteo®) 20 µg sc daily (TER).  Together, these studies included 95, 94 and 45 women treated with placebo, ABL and TER, respectively. 

Results Relative to placebo, ABL increased spine BMD at 24 weeks by 5.1% and 5.8% and increased total hip BMD by 2.2% and 2.7% in Studies 1 and 2, respectively (all p<0.005).  The numerically greater increases in BMD in Study 2 occurred despite a higher average baseline spine BMD T-score (– 2.93 Study 1; – 2.33 Study 2).  At week 24, TER increased spine BMD by 3.9% (p <0.001), but had no significant effect on total hip BMD relative to placebo (0.1%).  The increases in bone turnover markers, especially those of resorption, were substantially higher with TER compared to ABL.   In a subset extension of Study 1 mean increases in BMD at 48 weeks relative to placebo were 12.2% and 7.9% for ABL and TER at the spine and 2.7, and 1.3 at the total hip, respectively.  Both ABL and TER were generally well tolerated. 

Comments ABL induces consistent, rapid, substantial increases in BMD over up to 48 weeks, which is the longest duration tested to date.  The BMD effects are greater than those seen with TER or, historically, with any other currently-approved treatment for osteoporosis.  The greater BMD efficacy is most likely due to greater selectivity of ABL to increase bone formation with a less marked increase in bone resorption relative to TER.  ABL is currently in a >2400-patient, phase 3, 18-month, placebo- and TER-controlled, fracture study which will complete later this year. ABL is a promising new therapy for treatment of osteoporosis. 

 

Disclosure: JY: Employee, Radius Health, Inc.. PDM: Investigator, Radius. MAB: Investigator, Radius. GW: Investigator, Radius. IV: Investigator, Radius. MC: Independent Contractor (including contracted research), Radius. GH: Employee, Radius. MK: Independent Contractor (including contracted research), Radius. CC: Independent Contractor (including contracted research), Radius.

OR22-3 15936 3.0000 A The PTHrP1-34 Analog, Abaloparatide (BA058), Induces Consistent, Marked and Rapid Increases in Hip and Spine BMD with Compared to Placebo and Teriparatide 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 1:00:00 PM OR22 4723 11:30:00 AM Osteoporosis-Clinical Trials Oral

John Yates*1, Paul D Miller2, Michael Anthony Bolognese3, Grattan Woodson4, Ivo Valter5, Marcie Clarkin6, Gary Hattersley7, Kris Hansen8, Morten Karsdal9 and Claus Christiansen10
1Radius Health Inc., Cambridge, MA, 2Colorado Center for Bone Research, Lakewood, CO, 3Bethesda Health Research Center, Bethesda, MD, 4Atlanta Research Center, Atlanta, GA, 5CCBR, Tallinn, Estonia, 6Radius Health, Inc., Cambridge, MA, 7Radius Health, Inc, Waltham, MA, 83M, St. Paul, MN, 9CCBR Clinical Research, Copenhagen, Denmark, 10Nordic Bioscience, Copenhagen, Denmark

 

Background  Abaloparatide (BA058) is a synthetic analog of PTHrP1-34 which greatly increases bone mass and bone strength with preservation of normal bone quality in animal models of osteoporosis.  Daily subcutaneous abaloparatide (ABLSC) at doses of up to 80 µg daily in postmenopausal women with osteoporosis for up to 48 weeks were associated with increases in spine and femoral neck BMD of up to 12.9% and 4.1%, respectively, and good safety and tolerability. The increases in BMD at the 80 µg dose exceeded those seen with teriparatide (Forteo®) 20 µg sc daily (TER) in a head-to-head study. ABLSC is in a large phase 3 fracture study due to complete this year.  Many, but not all, patients with osteoporosis can self-administer injections of TER or ABLSC, but a dosage form that increases BMD and avoids the need for injections would clearly be a valuable alternative for some patients. 

Methods  Using 3M’s sMTS (solid Microstructured Transdermal System), which consists of an array of 316 microprojections that penetrate the skin to about 250 µm, through the stratum corneum into the upper dermis, we developed a short-wear-time abaloparatide transdermal (ABLTD) patch coated with doses of 50, 100 and 150 µg, and a placebo patch.  A total of 199 postmenopausal osteoporotic patients applied a patch containing either one of these 3 doses or placebo daily to their peri-umbilical skin for 5 minutes once daily for up to 24 weeks. 

Results  Patch application was pain free and well accepted by patients.  At the end of treatment BMD increased dose dependently, with 50, 100 and 150 µg increasing spine BMD by 1.9%, 2.3% and 3.0% respectively (p<0.001 for trend) and total hip BMD by 1.0%, 1.3% and 1.5% (p<0.001), respectively.  The increases seen with ABLSC 80 µg daily were somewhat greater than those with ABLTD.  However, the increases in hip BMD at 24 weeks with all three doses of ABLTD greatly exceeded those seen with TER in a separate phase 2 study at the same time point  (0.1%).  Changes in biochemical markers of bone turnover were considerably less than those observed with ABLSC.  Low titer antibodies to ABL were detected in some patients, but these were not associated with any attenuation of efficacy or any relevant safety findings. ABLTDwas generally safe and well tolerated. 

Conclusions  This study provides strong proof of concept that a transdermal patch delivering abaloparatide produces meaningful increases in spine and hip BMD.  ABLTDwas well accepted and generally well tolerated.  With further optimization, this approach holds substantial promise for a future alternative to existing and investigational injectable treatments for osteoporosis.

 

Disclosure: JY: Employee, Radius Health, Inc.. PDM: Investigator, Radius. MAB: Investigator, Radius. GW: Investigator, Radius. IV: Investigator, Radius. MC: Independent Contractor (including contracted research), Radius. GH: Employee, Radius. KH: Employee, 3M. MK: Independent Contractor (including contracted research), Radius. CC: Independent Contractor (including contracted research), Radius.

OR22-4 16035 4.0000 A A Transdermal Patch Delivering the PTHrP1-34 Analog, Abaloparatide (BA058), Dose-Dependently Increases Spine and Hip BMD Compared to Placebo 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 1:00:00 PM OR22 4723 11:30:00 AM Osteoporosis-Clinical Trials Oral

Naim M Maalouf*1, Ildiko Lingvay2, Beverley Huet3, Madhuri Poduri3, Qing Yuan3, Lidia Szczepaniak4, Xilong Li3 and Edward Szczepaniak4
1UT Southwestern Medical Center, Dallas, TX, 2University of Texas Southwestern Medical Center, Dallas, TX, 3UT Southwestern Medical Center, 4Cedars-Sinai Medical Center, Los Angeles, CA

 

The thiazolidinedione pioglitazone (PIO) lowers bone mineral density (BMD) and increases the risk of fractures, although the underlying mechanism(s) have not been fully elucidated. PIO redistributes ectopic fat, and has been hypothesized to increase bone marrow (BM) fat, thereby reducing BMD and bone strength. This placebo-controlled double-blind randomized clinical study examined the impact of PIO on BM fat content. 42 subjects with metabolic syndrome (27 women/15 men, 83% Caucasians, mean age: 53 years, mean BMI: 33 Kg/m2) were randomized to PIO 45 mg daily or matching placebo (PBO) for 12 months. At baseline, 6 and 12 months, the following were measured: BMD at lumbar spine (LS), femoral neck (FN) and total hip (TH) by DXA scan; BM and liver fat by 1H magnetic resonance spectroscopy (MRS); beta-cell function and insulin sensitivity by insulin-modified frequently sampled intravenous glucose tolerance test. Changes between groups were compared by mixed model repeated measures. Compared with PBO, PIO significantly improved insulin sensitivity (SI:+1.9 vs. -0.3 min−1 per μU/ml × 104,  p= 0.0004), and lowered serum free fatty acids (-171 vs. +42 μM/L , p=0.01) and liver fat content (-5.4% vs -0.8%, p=0.002) at 12 months. Compared with PBO, PIO also significantly increased BM fat (+4.1 vs. -3.1%, p=0.005) and lowered TH BMD (-1.4% vs. +0.8%, p=0.024) at 12 months. In the PIO group, the change in BM fat was inversely and significantly correlated with the change in TH BMD (Spearman R= -0.56, p=0.015). In conclusion, PIO use for 12 months was associated with a significant increase in BM fat content, a change that was proportional with the decrease in TH BMD. These findings are compatible with the proposed model of fat redistribution from liver and other ectopic tissues to the BM compartment, a plausible mechanism for the increase in fracture risk with PIO use.

 

Disclosure: NMM: Principal Investigator, Takeda. IL: Investigator, Novo Nordisk, Investigator, Novo Nordisk, Advisory Group Member, Novo Nordisk. Nothing to Disclose: BH, MP, QY, LS, XL, ES

OR22-5 16548 5.0000 A Pioglitazone Increases Femoral Neck Bone Marrow Fat Content and Proportionately Reduces Total Hip Bone Mineral Density 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 1:00:00 PM OR22 4723 11:30:00 AM Osteoporosis-Clinical Trials Oral

Sri Harsha Tella*1, J Chris Gallagher2 and Lynette Smith3
1Creighton University, Omaha, NE, 2Creighton University Medical Center, Omaha, NE, 3University of Nebraska

 

BACKGROUND: Vitamin D is often recommended for use with calcium supplements to increase bone mineral density (BMD) and prevent osteoporosis, however there are few systematic studies on effect of different doses of vitamin D supplementation on BMD.

METHODS: We conducted two randomized, placebo-controlled trials in women with vitamin D insufficiency (serum 25-hydroxyvitamin D ≤20 ng/dl [50 nmol/liter]). Subjects in one trial were aged 25–45 years (198 Caucasian and African American) and in the other were aged 57-90 years (273 Caucasian and African American women). Older women were randomly assigned to placebo, vitamin D3 400, 800, 1600, 2400, 3200, 4000, or 4800 IU daily; calcium supplements were given to maintain total calcium intake of 1200-1400 mg/day. Younger women were randomized to placebo, 400, 800, 1600 and 2400IU/d and calcium intake was increased to 1000mg/day. Statistical difference between the groups was tested by ANOVA.

RESULTS: In the older women the mean percent change in all subjects for total body BMD at 12 months was 0.62% (±2.72) and there was no difference between Caucasian and African Americans (p=0.74). The percent change in femoral neck BMD was 0.59% (±3.58) and no difference was seen between the races (p=0.64). The percent change in spine BMD was 0.43% (±2.80) and there was no difference between the races. No significant difference was noted in BMD at any site between various vitamin D doses and placebo.

In the younger women the percent change in all subjects for total body BMD at 12 months was 0.57% (±2.09) and there was no difference between Caucasian and African Americans (p=0.70). The percent change in femoral neck BMD was 0.79% (±3.02) and no difference between the races was seen (p=0.62). The percent change in spine BMD was 1.22% (±2.41) and there was no difference between races (p=0.60). There was no significant effect of vitamin D on BMD at any site between various doses of vitamin D and placebo.

CONCLUSION: The increase in total body, spine and hip BMD in young and elderly women given vitamin D doses between 400 and 4800 IU daily and calcium supplementation is small and is not different from placebo. It remains to be seen whether there is any effect on fractures in these populations.

 

Nothing to Disclose: SHT, JCG, LS

OR22-6 12390 6.0000 A Effect of Vitamin D Supplementation on BMD in Young and Elderly Caucasian and African American Women: Two Randomized, Placebo Controlled Trials 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 1:00:00 PM OR22 4723 11:30:00 AM Osteoporosis-Clinical Trials Oral

Kanako Kobayashi*1, Tomohiro Tanaka2 and Yo-ichi Nabeshima1
1Foundation for Biomedical Research and Innovation, Kobe, Japan, 2Kyoto Univ Grad Schl of Medcn, Kyoto, Japan

 

β-Klotho is a transmembrane protein expressed in liver, pancreas and adipose tissues. Mice lacking β-klotho (KO) exhibit increased bile acid synthesis and lower body weight compared with their wild-type littermates. We have previously shown that β-Klotho is essential for the feedback suppression of hepatic bile acid synthesis in mice (1, 2). Since bile acids modulate both plasma lipid levels and body weight, we hypothesized that β-Klotho expressed in the liver has a potential role in regulating plasma lipid levels and body weight through its modulatory role in bile acid synthesis. By crossing KO mice with hepatocyte-specific β-klotho transgenic mice (Tg), we generated mice that express β-klotho solely in hepatocytes (KO/Tg). In KO/Tg mice, increased bile acid pool size (1.4-fold; P<0.05) and fecal bile acid excretion (2.8-fold; P<0.01) in KO mice were recovered to the level of control heterozygous littermates. We found that in KO/Tg mice, decreased plasma triglyceride level in KO mice (-44%; P<0.05) was also recovered. In contrast, the resistance to high-fat diet induced weight gain in KO mice (-10%; P<0.05) was not recovered in KO/Tg mice (-12%; P<0.05). These results demonstrate that hepatic β-Klotho expression is both necessary and sufficient for the regulation of plasma triglyceride level and further suggest a role of β-Klotho in extrahepatic tissues in body weight regulation. This is the first study showing that the plasma triglyceride level and body weight are both regulated by β-Klotho, but in a tissue-specific manner.

 

Nothing to Disclose: KK, TT, YIN

OR15-1 12949 1.0000 A Distinct Roles of Intra- and Extrahepatic β-Klotho in Regulating Plasma Triglyceride Level and Body Weight in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 1:00:00 PM OR15 4724 11:30:00 AM Endogenous and Exogenous Factors Regulating Lipid Metabolism Oral

Yun Shi*1, Margaret S Kim1, Zhen-Ju Shu1, Adam Salmon2 and Amrita Kamat2
1University of Texas Health Science Center at San Antonio, San Antonio, TX, 2South Texas Veterans Health Care System, San Antonio, TX

 

Non-alcoholic fatty liver disease (NAFLD), by itself and as a risk factor for insulin resistance and cardiovascular diseases, is a major public health concern. Hepatic steatosis, a salient feature of NAFLD, increases with age and obesity.  Advancing age, stress, and obesity increase circulating catecholamine levels which act via beta adrenergic receptors (β-ARs) to regulate lipid and glucose metabolism. Previously, we demonstrated that heightened β-AR signaling in rodent liver during aging is associated with increased hepatic steatosis and insulin resistance (1, 2). We also showed that pharmacological activation of β-AR, primarily β2-AR subtype, is sufficient to induce hepatic lipid accumulation (1). To further understand the role of β2-AR signaling in the development of hepatic steatosis, we are currently investigating whether increased β2-AR signaling is associated with augmented expression of cell death-inducing DNA fragmentation factor 45-like effector (Cide) family proteins, including Cidea and Fsp27 (Cidec), which are emerging as important regulators of various lipid metabolic pathways in liver and adipose tissues (3). To accomplish our goal, we performed comparative studies in young (6 mo old, n=6) vs. old (24 mo, n=8) wild-type and β2-AR knockout mice, and in animal models of fatty liver disease, obtained either through genetic manipulation (ob/ob and db/db mice, n=4-5 in each group) or dietary intervention (high fat diet, HFD, n=4) vs. respective controls. Significant increases in hepatic Fsp27 mRNA levels were observed in ob/ob, db/db, and HFD-fed mice compared to controls (100.9±10.8 fold increase, p<0.001; 6.6±1.4 fold increase, p=0.01; 2.7±0.6 fold increase, p=0.03), respectively. On the other hand, hepatic Cidea expression only increased in ob/ob and db/db mice but not in HFD mice. Interestingly, we and other investigators have found that in ob/ob and db/db mice, the expression of hepatic β2-AR or β-AR associated adenylyl cyclase activity is also increased; suggesting enhanced β-AR activation may contribute to excessive fat storage in these models of hepatic steatosis. However, no overt change in β2-AR mRNA content was found in HFD liver. Lastly, we observed that aging leads to a pronounced increase in hepatic Cidea mRNA levels (14.9±4.1 fold increase, p=0.01) and Fsp27 protein abundance. Furthermore, the age-related increase in Cidea mRNA is diminished in β2-AR knockout mice (p=0.035) which also display reduced hepatic fat accumulation. Taken together, our studies suggest that β2-AR signaling is positively associated with Cide protein expression in the development of hepatic steatosis during aging and in leptin-deficient (ob/ob) or leptin receptor-deficient (db/db) mice.

 

Nothing to Disclose: YS, MSK, ZJS, AS, AK

OR15-2 14182 2.0000 A Positive Association Between Beta2-Adrenergic Receptor (β2-AR) Signaling and Cide Family Proteins in Hepatic Steatosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 1:00:00 PM OR15 4724 11:30:00 AM Endogenous and Exogenous Factors Regulating Lipid Metabolism Oral

Jie Liu*1, Resat Cinar1, Keming Xiong1, James M. Ntambi2 and George Kunos1
1National Institutes of Health, Rockville, MD, 2University of Wisconsin-Madison, Madison, WI

 

High-fat diet (HFD)–induced obesity and insulin resistance are associated with increased activity of the endocannabinoid/CB1 receptor (CB1R) system, the body’s own marijuana-like substances, which promotes the hepatic expression of lipogenic genes, including stearoyl-CoA desaturase-1 (SCD1), the enzyme responsible for generating monounsaturated fatty acids (MUFAs). Mice deficient in CB1R or SCD1 remain lean and insulin-sensitive on an HFD, suggesting a functional link between the two systems. The HFD-induced increase in the hepatic levels of the endocannabinoid anandamide (AEA) has been attributed to reduced activity of the AEA-degrading enzyme fatty acid amide hydrolase (FAAH). We hypothesize that HFD induced MUFAs may serve as an endogenous FAAH inhibitor and therefore account for the elevated hepatic AEA level. Here we show that HFD-induced increased hepatic AEA levels and decreased FAAH activity are absent in SCD1−/− mice, and the monounsaturated fatty acid (MUFA) products of SCD1, palmitoleic and oleic acid, inhibit FAAH activity in vitro at low micromolar concentrations. HFD markedly increases hepatic SCD1 activity in WT mice as well as in CB1R−/− mice with transgenic re-expression of CB1R in hepatocytes, but not in global CB1R−/− mice. Treatment of HFD-fed mice with the SCD1 inhibitor A939572 prevents the diet-induced reduction of hepatic FAAH activity, normalizes hepatic AEA levels, and improves insulin sensitivity. SCD1−/− mice on an HFD remain insulin-sensitive, but develop glucose intolerance and insulin resistance in response to chronic treatment with the FAAH inhibitor URB597. An HFD rich in MUFA or feeding mice pure oleic acid fail to inhibit hepatic FAAH activity. We conclude that MUFAs generated via SCD1 activity, but not diet derived MUFAs, function as endogenous FAAH inhibitors mediating the HFD-induced increase in hepatic AEA, which then activates hepatic CB1R to induce insulin resistance. These findings reveal a positive feedback loop between the hepatic endocannabinoid/CB1 receptor system and SCD1 that contributes to increased lipogenesis and insulin resistance in DIO.

 

Nothing to Disclose: JL, RC, KX, JMN, GK

OR15-3 11652 3.0000 A Identification of Endogenous Inhibitors of Fatty Acid Amide Hydrolase in the Liver 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 1:00:00 PM OR15 4724 11:30:00 AM Endogenous and Exogenous Factors Regulating Lipid Metabolism Oral

Theodore C Friedman1, Rasheed Ivey2, Desean L. Lee*2, Indrani Sinha-Hikim2 and Amiya P Sinha-Hikim2
1Charles R. Drew Univeristy of Medicine and Science, Los Angeles, CA, 2Charles R. Drew University, Los Angeles, CA

 

Background and Objective:Smoking is a major risk factor for diabetes and cardiovascular disease and may contribute to non-alcoholic fatty liver disease (NAFLD). The health risk associated with smoking is exaggerated by obesity and is the leading causes of morbidity and mortality worldwide. We recently demonstrated that combined treatment with nicotine and a high-fat diet (HFD) triggers greater oxidative stress, activates hepatocellular apoptosis, and exacerbates HFD-induced hepatic steatosis (1). Furthermore, nicotine plus a HFD lead to substantial intramyocellular lipid (IMCL) accumulation in close association with intramyofibrillar (IMF) mitochondria along with IMF mitochondrial swelling and vacuolization (2). Both of these effects were blocked by the lipolysis inhibitor, acipimox, indicating the lipolysis mediates the hepatic and muscle steatosis. Here, we used PNU-282987, a specific alpha 7 nicotinic receptor agonist plus HFD to determine which nicotine receptor mediates the weight loss, lipolysis and hepatic/muscle steatosis.

Experimental Design: Adult C57BL6 male mice were fed a normal chow diet or HFD with 60% of calories derived from fat and received twice daily IP injections of 0.75 mg/kg BW of nicotine, PNU-282987 (0.26 mg/k BW) or saline for 10 weeks.

Results: As expected, nicotine blocked the HFD-induced weight gain and lead to hepatic and muscle steatosis. PNU-282987 led to a more dramatic weight loss than nicotine with a resultant decrease in abdominal girth and visible oil-like residue in the abdominal cavity. Light and electron microscopy revealed higher lipid accumulation with lower content of endoplasmic reticulum and glycogen in hepatocytes from mice on HFD plus nicotine, compared to mice on HFD alone. However, PNU-282987 treatment, as compared to nicotine treatment, attenuated HFD-induced hepatic steatosis.

Conclusions: Our data indicate the opposing roles of alpha 7 nicotinic receptor in regulation of body weight, lipolysis and nicotine plus HFD-induced hepatic steatosis.. The protecting effects of PNU-282987 on hepatic steatosis may be mediated by improved insulin sensitivity. Targeting the alpha 7 nicotinic receptor may prevent the detrimental effects of nicotine plus a HFD.

 

Nothing to Disclose: TCF, RI, DLL, IS, APS

OR15-4 16443 4.0000 A Nicotine Plus a High-Fat Diet Leads to Abdominal Lipolysis with Resulting Hepatic and Muscle Steatosis and Is Mediated By the Alpha 7 Nicotinic Receptor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 1:00:00 PM OR15 4724 11:30:00 AM Endogenous and Exogenous Factors Regulating Lipid Metabolism Oral

Chao Xu*1, Jiajun Zhao2, Ling Gao2, Guang Ning3, Tao Yang4, Li Chen5, Xulei Tang6 and Qingbo Guan2
1Shandong Provincial Hospital affiliated to Shandong University, Department of Endocrinology and Metabolism, China ;, Jinan, Shandong, 2Shandong Provincial Hospital affiliated to Shandong University, Jinan, China, 3Rui Jin Hosp, Shanghai, 4The First Affiliated Hospital of Nanjing Medical University, Nanjing, China, 5Qilu Hospital, Shandong University, Jinan, Shandong, 6The First Hospital of Lanzhou University, Lanzhou, China

 

Background

Dyslipidemia is an important global health problem, especially in the elderly population. Subclinical hypothyroidism (SCH) is defined by elevated serum thyroid-stimulating hormone (TSH) and normal serum-free T4. Population-based studies have demonstrated that serum lipids are elevated in patients with SCH. Notably, dyslipidemia and SCH increase progressively with age. However, few studies have assessed whether SCH plays a role in the increase of age-related dyslipidemia. In this study, we aimed to explore the association between SCH and lipid profiles in different age groups.

Methods

This study is a large-scale, population-based case-control study. Population were derived from the REACTION study conducted across China from 2011 to 2012. In the present study, cases (n=8,827) of dyslipidemia were firstly identified and then a frequency-matched random sample of controls (n=8,219) was drawn using strata according to residence, age, and gender. Individuals aged over 40 years were included. The relationships between TSH, the key indicator of SCH，and serum lipid parameters in each age group were evaluated after adjustment for thyroid hormones and common factors. The response association between TSH and each lipid parameter was analyzed in different age groups using the partial least squares method. We investigate the independent effects of SCH and age on lipid parameters using General Linear Model.

Results

The prevalence rates of SCH and dyslipidemia increased linearly and significantly with age. After adjustment for thyroid hormones and common confounding factors, TSH was positively associated with cholesterol parameters (TC and LDL-C) through the sixth decade of life after, and each 1 mIU/L increase in TSH was estimated to elevate the TC level by 0. 0147 mmol/L and 0.0551 mmol/L, respectively, in individuals aged 40 - 49 years and 60 - 69 years. Similarly, the LDL-C level caused by each 1 mIU/L increase in the TSH level tended to elevate higher in the 60- to 69-year age group than in the 40- to 49-year age group.

In elderly subjects aged 60 - 69 years, SCH increased the respective prevalence rates of high TC and high LDL-C 1.50- to 2.27-fold and 1.26- to 1.88-fold more than in younger subjects. Additionally, in elderly subjects aged 60 - 69 years, mild (TSH ≤ 10 µIU/L) and significant (TSH > 10 µIU/L) SCH increased the concentration of TC approximately 1.03-fold and 1.36-fold more than that in younger subjects; increased the concentration of LDL-C approximately 1.19-fold and 1.65-fold more than in younger subjects.

Conclusions

TSH exhibited a stronger effect on the TC and LDL-C level in moderately old subjects (aged <70–75 years) than in younger subjects. SCH was capable of augmenting and worsening the effects of aging on serum lipid profiles. Our findings may have important implications for guidelines and public health discussions aimed at preventing atherosclerotic diseases.

 

Nothing to Disclose: CX, JZ, LG, GN, TY, LC, XT, QG

OR15-5 11409 5.0000 A Subclinical Hypothyroidism Augments the Impact of Aging on Serum Lipid Profiles, a Population-Based Case-Control Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 1:00:00 PM OR15 4724 11:30:00 AM Endogenous and Exogenous Factors Regulating Lipid Metabolism Oral

Donna F Vine*1, Flora Wang1, Mary M Jetha2, Spencer Proctor1 and Geoff Ball1
1University of Alberta, Edmonton, Canada, 2University of Alberta, Edmonton, AB, Canada

 

Introduction: Polycystic ovary syndrome (PCOS) is a metabolic-endocrine disorder associated with obesity, insulin resistance and hyperandrogenemia, predisposing individuals to increased risk of cardiovascular disease (CVD) and Type 2 Diabetes. Dyslipidemia is a predominate feature of PCOS, however there remains limited data on the atherogenic dyslipidemic profile of fasting and non-fasting apoB-lipoproteins in adolescents with PCOS.

Aim: The aim of this study was to determine 1) the fasting and non-fasting metabolism of lipids and apoB-lipoproteins, and 2) the relationship of these atherogenic biomarkers with hyperandrogenemia in obese adolescent girls with PCOS compared to healthy-weight and obese controls.

Methods and Results:Obese girls aged 14-18 years with or without PCOS were recruited (BMI ≥95th percentile) and plasma lipid and lipoproteins [including apolipoproteins (apo) B100, a marker of hepatic lipoproteins (VLDL/LDL) and apoB48 a marker of intestinal chylomicrons] were measured during the fasted and non-fasting state following a high fat meal. PCOS patients had elevated fasting plasma TG, total and LDL-cholesterol, and lower HDL-cholesterol compared to obese and healthy-weight controls. Fasting plasma apoB48 and apoB100 concentrations were elevated 50% in obese patients with and without PCOS, compared to healthy-weight controls. The PCOS group had 25% higher fasting apoB100 and an exacerbated non-fasting TG and apoB48-response to the high fat meal. The free androgen index was highly correlated with fasting and non-fasting TG response in all groups. There was no difference in biochemical or anthropometrics between obese adolescents with and without PCOS.

Conclusion: Our data demonstrates obese adolescents with and without PCOS have elevated fasting and non-fasting atherogenic apoB-lipoproteins, and this is exacerbated in PCOS. These studies provide a rationale for early assessment of fasting and non-fasting apoB-lipoprotein metabolism, and the need to further understand the mechanisms of dyslipidemia and the development of efficious interventions to prevent CVD risk in young women with PCOS.

 

Nothing to Disclose: DFV, FW, MMJ, SP, GB

OR15-6 17004 6.0000 A Elevated Non-Fasting and Fasting ApoB-Lipoprotein Metabolism in Obese Adolescents with PCOS and Exacerbated Cardiovascular Disease Risk 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 1:00:00 PM OR15 4724 11:30:00 AM Endogenous and Exogenous Factors Regulating Lipid Metabolism Oral

Natthinee Charatcharoenwitthaya*1, Charintip Somprasit1, Athita Chanthasenanont2, La-or Chailurkit3, Suwannee Chanprasertyothin3 and Boonsong Ongphiphadhanakul4
1Thammasat University, Pathumthani, Thailand, 2Faculty of Medicine, Thammasat University, Pathumthani, Thailand, 3Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, 4Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

 

Background It is unclear whether low maternal 25-hydroxyvitamin D (25OHD) level is associated with gestational diabetes mellitus (GDM). Our objective is to examine the differences in 25OHD level (during the first trimester of pregnancy and during 24-28 weeks’ gestation), and vitamin D binding protein genotypes between pregnant women with GDM and pregnant women without GDM. The relationships between 25OHD level and glucose homeostasis were also examined.   

Methods A nested case-control study was conducted among pregnant women who participated in GDM screening project. Clinical data and blood samples were obtained during the first trimester of pregnancy and during 24-28 weeks’ gestation on the same day of blood glucose testing. Eighty women with GDM according to IADPSG criteria were matched with 80 women without GDM who had the same age range (< 25 years or ≥ 25 years) and the same pre-pregnancy body mass index (PPBMI) range (< 25 kg/m2 or ≥ 25 kg/m2). The 25OHD, fasting insulin, and parathyroid hormone were measured. Individual genotyping of rs2282679 in the GC gene was performed using real-time PCR.

Results The mean age was 32.8±4.4 years and the mean PPBMI was 24.2±5.5 kg/m2. Thirty women in each group had PPBMI ± 25 kg/m2.  The 25OHD levels were not different between women with GDM and women without GDM both during the first trimester of pregnancy (27.2±6.9 ng/ml vs. 28.7±6.7 ng/ml; p=0.16) and during 24-28 weeks’ gestation (35.3±9.3 vs. 36.5±7.6; p=0.39). Vitamin D deficiency (25OHD levels < 20 ng/ml) was found in 11 women (13.7%) with GDM and 10 women (12.5%) without GDM (OR 1.11; 95%CI: 0.44-2.80). Vitamin D inadequacy (25OHD < 30 ng/ml) was found in 55 women (68.7%) with GDM and 48 women (60%) without GDM (OR 1.47; 95%CI: 0.76-2.81). Women with GT alleles had lower first trimester 25OHD levels than women with TT alleles (26.3±6.5 ng/ml vs. 28.8±7.0 ng/ml; p=0.03). In multivariate analysis adjusting for age, and log PPBMI, neither log first trimester 25OHD level (p=0.18) nor GT alleles (p=0.16) was a significant predictor of GDM. The 25OHD level during 24-28 weeks’ gestation was not a predictor of GDM (p=0.50) after adjusting for age, log PPBMI, and GT alleles. There were no associations between 25OHD level and glucose homeostasis including fasting glucose, fasting insulin, HOMA IR, and HOMA B.

Conclusions Neither 25OHD levels nor genetic variation in GC gene (rs2282679 SNP) is a significant predictor of GDM.

 

Nothing to Disclose: NC, CS, AC, LOC, SC, BO

OR20-1 14735 1.0000 A Maternal Vitamin D Levels, Polymorphism of Vitamin D Binding Protein Gene and Risk for Gestational Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR20 4727 11:30:00 AM New Approaches to Screening, Diagnosis, and Prevention of Diabetes Oral

Jacklyn Karban*1, Loren Lynette Armstrong1, Janani Rangarajan1, Denise Scholtens1, Lynn P. Lowe1, Boyd E. Metzger1, William L. Lowe Jr.1 and M. Geoffrey Hayes2
1Feinberg School of Medicine, Northwestern University, Chicago, IL, 2Northwestern University, Feinberg School of Medicine, Chicago, IL

 

Maternal hyperglycemia during pregnancy is associated with greater risk of adverse newborn outcomes as well as increased childhood obesity and metabolic disorders later in life for both mother and child.  Maternal hyperglycemia is influenced by both genetic and environmental factors, and heritability is defined as the proportion of observed phenotypic variance that can be explained by additive genetic factors.  Studies in non-diabetic, non-gravid twins and families of European ancestry have yielded heritability estimates for fasting plasma glucose (FPG) between 20-75%.  To date, the heritability of maternal glucose levels during pregnancy has not been reported.  Given the marked insulin resistant state of pregnancy and changes in glucose metabolism, we estimated the heritability of FPG in pregnant women across a diverse set of ancestries representing different environments.  To accomplish this, we used common (minor allele frequency >1%) single nucleotide polymorphism (SNP) data from mothers who participated in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) genome-wide association study (GWAS), which examined associations between these common genetic variants and measures of maternal glucose metabolism during pregnancy.  Our sample included 1,367 European ancestry (EU), 1,075 Afro-Caribbean (AC), 817 Mexican American (MA), and 1,178 Thai (TH) mothers who underwent a 75-g oral glucose tolerance test (OGTT) at approximately 28 weeks gestation. Heritability was estimated separately in each of the four populations using genome-wide complex trait analysis (GCTA), limited to individuals with genotype call rate >99% and not sharing more than 5% of their genome with any other individual in the study, as well as limited to genotyped SNPs with genotype call rate >98%, and no departure from Hardy-Weinberg equilibrium (p>0.05).  We adjusted for ancestry (the first 20 principal components), maternal and gestational age at OGTT, parity and neonatal gender in a final set of 1,276 EU, 904 AC, 735 MA and 1,164 TH mothers, with the number of SNPs ranging from 448,632 (EU) to 722,964 (AC).  The heritability for FPG was estimated to be 71% in the EU population (SE = 0.30, p=0.009), 54% in the TH population (SE = 0.32, p=0.05), 44% in the MA (SE = 0.43 p=0.2), and 30% in the AC (SE = 0.43, p=0.2).  The FPG heritability estimates in the AC and MA overlap those of the larger EU and TH populations but do not reach significance likely due to their reduced sample size.  The addition of maternal mean arterial pressure, BMI, and height, covariates which themselves have known genetic components, into the model attenuated the heritability estimates.  These heritability estimates are consistent with those in non-gravid populations, and suggest a significant genetic contribution to FPG levels during pregnancy across diverse ancestries and different environments.

 

Nothing to Disclose: JK, LLA, JR, DS, LPL, BEM, WLL Jr., MGH

OR20-2 15134 2.0000 A Genome-Wide Heritability Estimates of Fasting Plasma Glucose Levels during Pregnancy in a Diverse Set of Populations 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR20 4727 11:30:00 AM New Approaches to Screening, Diagnosis, and Prevention of Diabetes Oral

Jennifer Huynh*1, Hang Lee1, Clary B. Clish2, David M. Nathan1, Ravi Thadhani1, Robert E. Gerszten1 and Rhonda Bentley-Lewis1
1Massachusetts General Hospital, Boston, MA, 2Broad Institute of MIT and Harvard, Cambridge, MA

 

Background: Metabolomics, the systematic study of small molecule products of biochemical pathways, has shown promise in identifying biomarkers predictive of metabolic diseases. A prior metabolomic study in a prediabetic population identified specific amino acid clusters as predictive of type 2 diabetes (T2DM). As gestational diabetes mellitus (GDM) shares pathophysiological similarities with T2DM, we hypothesized that the metabolomic profile predictive of T2DM could potentially identify women in their 1sttrimester of pregnancy who would subsequently develop GDM.

Objective: To identify metabolomic markers in the 1sttrimester of pregnancy that may serve to predict the development of GDM.

Methods: We conducted a nested case-control study of white women ages 18-40 years old who presented for prenatal care to the Massachusetts General Hospital (MGH) between September 1998 and January 2007 and participated in the MGH Obstetrical Maternal Study (MOMS). Participants were enrolled during their 1st trimester of a singleton pregnancy and were followed prospectively throughout pregnancy. Demographic and clinical data, as well as fasting serum samples, were collected at the first prenatal visit. Participants were identified as having GDM or normal glucose tolerance (NGT) in the 3rdtrimester: GDM was diagnosed by a 3-hr 100-g oral glucose tolerance test per Carpenter-Coustan criteria and NGT was defined by a 1-hr 50-g oral glucose challenge value < 140 mg/dl. Women with GDM were matched by age, BMI, gravidity, and parity to women with NGT. Liquid chromatography-mass spectrometry was used to measure the levels of 86 metabolites. Metabolites significantly different in univariate analyses between GDM and NGT groups were then used to construct a multiple regression analysis model to predict GDM. Comparisons of the predictability and goodness of fit across the nested models were carried out by receiver-operating characteristic curve analyses.

Results: Women with GDM (n = 96) and NGT (n = 96) were included in the analyses with mean ± SD age 32.8 ± 4.4 years, BMI 28.3 ± 5.6 kg/m2, gravidity 2 ± 1, and parity 1 ± 1. From among the 86 metabolites, 6 metabolites (anthranilic acid, alanine, glutamate, creatinine, allantoin, and serine) were identified as significantly different between the two groups in univariate analyses (p < 0.05). Due to collinearity among tested metabolites, alanine, creatinine, and anthranilic acid were chosen to construct a multiple logistic regression analysis model to predict GDM. The predictive accuracy of GDM was greater for alanine (area under the curve, AUC, 0.68) than for creatinine (AUC 0.58) or anthranilic acid (AUC 0.55).

Conclusions: Metabolic markers previously identified to be predictive of T2DM may not have the same predictive power to identify women who will develop GDM. However, further study in a larger, more racially/ethnically diverse population of women is needed.

 

Nothing to Disclose: JH, HL, CBC, DMN, RT, REG, RB

OR20-3 11915 3.0000 A Metabolomic Profiling in the Prediction of Gestational Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR20 4727 11:30:00 AM New Approaches to Screening, Diagnosis, and Prevention of Diabetes Oral

Mark McLean*1, Sue Lynn Lau1, Lorraine Pereira2, Susan Hendon2, Jennifer Bradford2 and Tien-Ming Hng2
1University of Western Sydney, Sydney, Australia, 2Blacktown Hospital, Sydney, Australia

 

Approximately half of women with a diagnosis of Gestational Diabetes Mellitus (GDM) fail to achieve conventional blood glucose level (BGL) targets using diet and lifestyle modifications alone.  Insulin therapy is usually employed in such cases, although recent studies demonstrate that oral hypoglycemic agents may be efficacious, safe, cheaper and more acceptable to patients. 

We performed a retrospective audit of outcomes in 1539 pregnancies complicated by GDM at Blacktown Hospital, Sydney, from 2008 to 2013.  All patients were recommended an appropriate diet and lifestyle plan and monitored BGLs, with a target of fasting <5.5mmol/L (99mg/dl) and 2-hour post-prandial <7.0mmol/L (126 mg/dl).  Women with BGLs above target were commenced on Metformin monotherapy (n=351) or insulin (n=334) according to the endocrinologist’s choice and/or patient’s preference.  91 Metformin treated women (26%) later needed insulin added or substituted because of inadequate response or dose-limiting side-effects. 

Although treatment was not randomly allocated, there were no significant baseline differences between the  Metformin and Insulin groups for age, pre-pregnancy weight, BMI, ethnicity or parity.  BGL control, measured as pre-delivery HbA1c levels, were lower in women initially commenced on metformin (mean 5.61% ± sem 0.02) compared with insulin (5.94% ± 0.03, p<0.001), and both were higher than the diet treated group (5.37% ± 0.01, p<0.001).  Maternal weight gain in the interval between GDM diagnosis and delivery was significantly higher in women using insulin alone (mean 3.7kg ± sem 0.23) compared with those on diet treatment only (2.5 ± 0.12, p<0.005) or metformin (2.9 ± 0.25, p=0.03).  Addition of metformin to insulin ameliorated this excess weight gain (2.6 ± 0.3, p<0.01).  Post-partum weight retention measured at 8-12 weeks post-delivery was not different between groups.

There was no significant difference in birth weight between metformin exposed infants (3240g ± 356) and those in the diet only group (3291g ± 598) or insulin treated group (3348g ± 331).  There was no significant effect of metformin exposure on the incidence of major perinatal outcomes, including stillbirth, fetal anomaly, mode of delivery or APGAR score at 5 minutes.   

In our clinical experience of pragmatic usage of metformin or insulin in treatment of GDM insufficiently controlled by diet, metformin treatment is convenient and well tolerated, is associated with at least equivalent glycemic control and perinatal safety to insulin treatment, but causes less maternal weight gain.

 

Nothing to Disclose: MM, SLL, LP, SH, JB, TMH

OR20-4 14962 4.0000 A Metformin Treatment of Gestational Diabetes Results in Similar Glycemic Control and Infant Outcomes but Less Maternal Weight Gain Than Insulin Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR20 4727 11:30:00 AM New Approaches to Screening, Diagnosis, and Prevention of Diabetes Oral

Brian Jay Feldman*1, Rajiv B. Kumar2, Bo Zhang3 and Honjgie Dai3
1Stanford University, Stanford, CA, 2Stanford University Medical Center, Stanford, CA, 3Stanford University

 

As recently as 10-15 years ago, the onset of of type-1 diabetes (T1D) was easily distinguished from type-2 diabetes (T2D), with children being most at risk for T1D and T2D occurring in overweight adults. However, the dramatic rise in obesity, coupled with the notable increase in T1D (in both children and adults), has resulted in a paradigm change, creating a large overlap in these previously discrete patient populations. This change has prompted the recognition that a rapid high-sensitivity diagnostic test for T1D would significantly advance the field by facilitating the expeditious triaging of patients that require acute intervention (T1D) from those that need less urgent treatment (T2D). Furthermore, in recent years, the development of novel T1D therapies has increased this need even greater as prompt intervention appears to impact the efficacy of these emerging treatments and the days-to-weeks required to obtain results using current platforms renders them inadequate. In spite of the widely recognized need, and intense effort to address this problem, developing next-generation technology that rapidly, accurately and cost-effectively detect the diagnostic autoantibodies in T1D patients has been surprisingly challenging. Therefore the aim of our study was to develop a robustly sensitive and specific test for T1D that could be performed rapidly and cost effectively to translate to point-of-care uses as well as to resource poor regions of the world. We developed a plasmonic gold chip for near-infrared fluorescence enhanced detection of islet cell autoantibodies. We tested our novel chip in 26 patients with new-onset T1D and 13 patients with new-onset T2D and 5 non-diabetic controls and compared the results with standard RIA. We found that the plasmonic gold chip and RIA both had a sensitivity of 100.0% and specificity of 85% in the patients tested. However, the chip results could be obtained from a finger prick blood sample with results in less than 2 hours and at a fraction of the cost of the RIA test.  In sum, we used advances in plasmonic gold chips and nanotechnology to develop a novel platform that meets the demanding needs of modern diabetes care and research and can also be applied in a variety of regions of the world. This new platform can be performed using ultralow sample volumes enabling point-of-care applications.

 

Nothing to Disclose: BJF, RBK, BZ, HD

OR20-5 11028 5.0000 A A Novel Plasmonic Chip for Biomarker Discovery and Point-of-Care Diagnosis of Type-1 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR20 4727 11:30:00 AM New Approaches to Screening, Diagnosis, and Prevention of Diabetes Oral

Natalie Dawn Ritchie*1 and Rocio Ines Pereira2
1Denver Health and Hospital Authority, Denver, CO, 2University of Colorado School of Medicine, Aurora, CO

 

Diabetes diagnosis rates have been increasing steadily in recent decades, leading to a prediction that prevalence will nearly double by 2030.  An important form of prevention involves diagnosing and treating prediabetes, an intermediary condition likely to worsen without remedial efforts.  Current estimates are that over one third of U.S. adults have prediabetes, and research on health disparities further shows minority groups suffer yet higher rates.  The National Diabetes Prevention Program (DPP) is ideally suited to improve the health of at-risk populations through weight loss.  Numerous effectiveness studies on the National DPP have been published, with programs in healthcare sites yielding improved weight loss outcomes over those in community settings.  However, models to date in healthcare sites have tended to serve higher socioeconomic groups, have unrealistic inclusion criteria, and include costly advanced professional staffing.  To address the need for large-scale translational efforts in healthcare settings targeting low-income and minority populations, we implemented the National DPP at Denver Health and Hospital Authority, a safety net medical system for the metro area’s underserved.  We aimed to demonstrate a real-world replication of the National DPP with lay healthcare professionals and achieve 5% weight loss among predominately minority and low-income individuals.  We created a registry indicating 6,093 adult patients were at high-risk for diabetes based on medical record data (e.g., A1C of 5.7 to 6.4) and recruited via mailings, phone outreach, and soliciting provider referrals.  To date, 693 patients enrolled in the program at varying intervals.  Patients referred by providers were far more likely to enroll in the program than those recruited via generic outreach efforts (38% vs. 10%).  Results from our first cohort of 79 participants completing the program indicated 4.79% weight loss, with average loss of 9.96 pounds t(78)=6.79, p <.01. Our translation of the National DPP successfully reached and achieved significant weight loss among a diverse and predominately underserved population with significant health risks and many barriers to participation in health promotion programs.  We present our translational model of the National DPP, show first-year results in recruitment, retention, and weight loss outcomes, and provide recommendations for future dissemination efforts.

 

Nothing to Disclose: NDR, RIP

OR20-6 16990 6.0000 A A Large-Scale Translational Model of the National Diabetes Prevention Program in a Safety Net Hospital 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR20 4727 11:30:00 AM New Approaches to Screening, Diagnosis, and Prevention of Diabetes Oral

Steven Jon Russell*1, Firas H. El-Khatib2, Kendra L Magyar1, Manasi Sinha1, Laura G Goergen1, Courtney Balliro1, Katherine McKeon2, David M. Nathan1 and Edward R Damiano2
1Massachusetts General Hospital, Boston, MA, 2Boston University, Boston, MA

 

BACKGROUND

The safety and effectiveness of automated glycemic control has not been tested in multiday studies in an unrestricted outpatient setting.

METHODS

In a random-order cross-over study, twenty adult subjects with type 1 diabetes each spent five outpatient days, with nights in a hotel, under automated glycemic control with a bihormonal bionic pancreas, and five days under usual care at home and at work with a patient-controlled insulin pump. There were no restrictions on diet or exercise. The bionic pancreas used data from its continuous glucose monitor (CGM) and a mathematical algorithm running on a smartphone to autonomously adapt and control the subcutaneous delivery of insulin and glucagon.  Plasma glucose (PG) levels were measured by fingerstick and with overnight venous sampling. In addition, CGM levels, which were masked to subjects under usual care, were compared between the two study arms.

RESULTS

The co-primary outcomes, mean five-day PG level and percent of time <70 mg/dl on the bionic pancreas, were 136 mg/dl and 4.0%, respectively.  After the first day of autonomous adaptation, the bionic pancreas achieved a lower mean CGM glucose level on Days 2–5 (151±21 versus 133±13 mg/dl, p<0.001).  On Days 2–5, the bionic pancreas achieved a lower mean CGM glucose level than usual care (133±13 versus 159±30 mg/dl, p<0.001), less time <70 mg/dl (4.1 versus 7.3%, p=0.01), and less time <60 mg/dl (1.5 versus 3.7%, p=0.02).

CONCLUSIONS

A wearable bihormonal bionic pancreas, initialized only with subject weight, achieved near-normoglycemia with minimal hypoglycemia in a multiday outpatient study.

 

Disclosure: SJR: Speaker, Tandem Diabetes. ERD: Coinvestigator, Tandem Diabetes Care. Nothing to Disclose: FHE, KLM, MS, LGG, CB, KM, DMN

OR26-1 11542 1.0000 A Multiday Outpatient Glycemic Control in Adults with Type 1 Diabetes Using a Bihormonal Bionic Pancreas: The Beacon Hill Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR26 4728 11:30:00 AM Type 1 and Cystic Fibrosis Related Diabetes: Technology and Peptides Oral

Mark Daniel DeBoer*, Daniel R Chernavvsky, Marc D. Breton and Boris P. Kovatchev
Univ of Virginia, Charlottesville, VA

 

Background: Adolescents with type 1 diabetes (T1D) frequently miss insulin boluses for food and have high HbA1c levels.  Closed-loop control (also known as the artificial pancreas, AP), utilizes continuous blood glucose monitor (CGM) inputs to modulate insulin delivery in response to high and low blood glucose (BG) levels, offering a potential solution to insulin omission for food.  However, safety and efficacy of the AP in this setting are unclear.

Objective: Perform a pilot study evaluating the safety and efficacy of the AP in adolescents following insulin omission for food.

Methods: We recruited adolescents age 13-18 years to participate in a randomized, cross-over trial.  On two separate days (with a wash-out day in-between) adolescents received either usual care (UC) through their home insulin pump or were connected to the AP.  The AP employs algorithms as part of UVa’s DiAs system that run on an Android smart phone and receives glucose information from a DexCom G4 continuous glucose monitor and informs insulin delivery via a Tandem T-Slim pump.  At 0900 study participants received an unannounced snack of 30g carbohydrate.  At 1300 they received a lunch of 80g, for which they only received insulin for 60g.  On the UC day (but not the AP day) they received their full high BG correction factor at lunch.  Study ended at approximately 1615. 

Results:  16 adolescents completed the trial.  Participants started AP study days with a lower mean BG than during usual care days (mean, interquartile range, 151 [108-197] vs. 180 [123-240] mg/dL, p<0.05).  Mean BG (193 +50 vs. 224 +60 mg/dL) and time in range 70-180 mg/dL (45% +35 vs. 21% +31) were lower in the hours following the snack on the AP day compared to UC (both p<0.05).  These difference remained significant after accounting the lower BG on the AP day as a covariate, p<0.05.  Following lunch there was no difference between AP and UC in mean BG (205 +64 vs. 247 +64, p=0.06) or time between 70-180 mg/dL (45 +42% vs. 19+18%, p=0.08). During the trial there was no significant difference in the rate of hypoglycemia <70 mg/dL, with 2 episodes during AP and 3 during UC.  All of these occurred in the time following the snack.  No other adverse events were noted during the trial.

Conclusions:  This study demonstrated safety of the AP following missed insulin for food.  Following the unannounced snack, participants had improved glycemic control without increases in hypoglycemia.  This demonstrates that the AP may partly compensate for missed bolus for food in adolescents with T1D.  Further testing is needed in longer-term settings.

 

Disclosure: MDB: Partial patent holder, Patent related to technology used in study.. BPK: Consultant, Dexcom, Partial patent holder, Patent holder of technology involved in study. Nothing to Disclose: MDD, DRC

OR26-2 11605 2.0000 A Use of an Artificial Pancreas Among Adolescents to Minimize Extreme Hyperglycemia in the Setting of Insulin Omission for Food 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR26 4728 11:30:00 AM Type 1 and Cystic Fibrosis Related Diabetes: Technology and Peptides Oral

Husam Ghanim*1, Nitesh D Kuhadiya2, Sanaa Abuaysheh3, Kelly Green3, Sandeep S Dhindsa4, Ajay Chaudhuri5, Antoine Makdissi6 and Paresh Dandona7
1State University of New York at Buffalo, Buffalo, NY, 2University at Buffalo, Buffalo, NY, 3SUNY at Buffalo, 4SUNY at Buffalo, Amherst, NY, 5SUNY at Buffalo, Williamsville, NY, 6State Univ of New York at Buffal, Buffalo, NY, 7Diabetes Ctr of W NY, Buffalo, NY

 

We have previously demonstrated an anti-inflammatory effect of exenatide, a GLP-1 receptor agonist, in type 2 diabetics. We have now investigated whether liraglutide, another GLP-1 receptor agonist, exerts an anti-inflammatory effect in patients with type 1 diabetes. Twelve patients were injected with liraglutide (1.2 or 1.8 mg daily) for 12 weeks while 12 others with similar age, BMI, gender distribution and HbA1c were injected with placebo. Fasting blood samples were obtained at baseline and 12 weeks. Liraglutide induced a significant reduction in plasma concentration of CRP by 18±7% (from 3.16±0.73 mg/ml to 2.75±0.84mg/ml, P<0.05), endotoxin by 16±5% (from 0.48±0.13 EU/ml to 0.41±0.15EUg/ml, P<0.05) and leptin by 25±11% (from 21.5±6.7 mg/ml to 16.7±5.6mg/ml, P<0.05). The mRNA expression of IL-1β, JNK-1, and SOCS-3 in peripheral blood mononuclear cells (MNC) fell significantly (p<0.05) by 22±5, 19±6 and 23±9, respectively. There was no change in these parameters in the placebo group. We conclude that liraglutide exerts a potent anti-inflammatory effect. This has important implications for a potential athero-protective effect since liraglutide reduced adiposity and systolic blood pressure in these patients. While this is the first demonstration of an anti-inflammatory effect of liraglutide in type 1 diabetes, it is also potentially relevant to patients with type 2 diabetes where, too, inflammation plays an important role in the pathogenesis of diabetic complications.

 

Nothing to Disclose: HG, NDK, SA, KG, SSD, AC, AM, PD

OR26-3 12184 3.0000 A Liraglutide Exerts an Anti-Inflammatory Effect 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR26 4728 11:30:00 AM Type 1 and Cystic Fibrosis Related Diabetes: Technology and Peptides Oral

Nitesh D Kuhadiya*1, Sandeep S Dhindsa2, Aditya Mehta3, Antoine Makdissi4, Sartaj Sandhu5, Husam Ghanim6, Manav Batra1, Ajay Chaudhuri7, Jeanne Hejna8, Kelly Green9, Natalie Bellini8 and Paresh Dandona10
1University at Buffalo, Buffalo, NY, 2SUNY at Buffalo, Amherst, NY, 3Diabetes and Endocrinology Center of Western New York, Buffalo, NY, 4State Univ of New York at Buffalo, NY, 5Diabetes and Endocrinology Center of Western New York, Williamsville, NY, 6SUNY at Buffalo, Buffalo, NY, 7UB Sch of Med, Williamsville, NY, 8Suny at Buffalo, 9SUNY at Buffalo, 10Diabetes Ctr of W NY, Buffalo, NY

 

We have previously demonstrated that the addition of liraglutide to insulin therapy in patients with type 1 diabetes(T1D) results in an the improvement in glycemic control, weight loss and a reduction in systolic blood pressure(SBP). We have now conducted the first prospectively randomized study investigating effects of liraglutide in T1D. We present an interim analysis of 47 patients that have completed the study (Placebo=14; Liraglutide = 33).  All patients had T1D for at least one year, on insulin therapy and had no detectable c-peptide in plasma (mean BMI: 29±1,mean A1c: 7.55±0.10%, mean age: 46±2 years, mean age of T1D diagnosis: 20±2). They were randomized to receive placebo, 0.6 , 1.2  and 1.8mg of liraglutide daily for 12 weeks. The number of patients receiving 0.6, 1.2 and 1.8mg doses was 10, 13 and 10 respectively (For purposes of this interim analysis, we have combined data on all 23 patients who received 1.2 and 1.8 mg). In combined group (1.2 and 1.8mg), HbA1c fell by 0.5% from 7.62±0.12% to 7.12±0.11%(p<0.0001, p=0.03vs placebo). Daily average blood glucose fell from 174±4 to 164±6mg/dl (p=0.08, p=0.05 vs placebo). Percent time spent between 70 to 160 mg/dl increased from 42±2 to 49±3%(p=0.05) and that between 160-400 mg/dl decreased from 52±2 to 45±3%(p=0.03) with no additional hypoglycemia. The dose of insulin did not alter. There was a reduction in body weight (194±8.5lbs to 184±8.9lbs,p<0.0001 in combined 1.2 and 1.8 mg groups and 165±8 to 158±8, p=0.0006 in 0.6 mg group) and daily carbohydrate intake (163±14g vs 123±15g;p<0.0002 in higher dose groups) over 12 weeks. SBP in 1.8 mg group fell by 9 mm (118±2.8 to 109±3,p=0.03). CRP fell by 18±7%. There was no change in any of these indices in patients treated with the placebo and 0.6 mg liraglutide. This is the first randomised double-blinded placebo controlled clinical trial to show that the addition of 1.2 mg and 1.8 mg of liraglutide to insulin significantly reduced HbA1c, mean blood glucose, blood pressure, body weight, carbohydrate intake and CRP in type 1 diabetes.  Our findings have significant implications for the future treatment of type 1 diabetes.

 

Nothing to Disclose: NDK, SSD, AM, AM, SS, HG, MB, AC, JH, KG, NB, PD

OR26-4 12186 4.0000 A Liraglutide As Additional Treatment to Insulin in Patients with Type 1 Diabetes Mellitus: A Randomized Clinical Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR26 4728 11:30:00 AM Type 1 and Cystic Fibrosis Related Diabetes: Technology and Peptides Oral

Jenise Colleen Wong*1, Matthew Spindler2 and Aaron Barak Neinstein1
1University of California San Francisco, San Francisco, CA, 2Leiden University Medical Center

 

People with type 1 diabetes (T1D) use a number of devices that collect and store large amounts of data, including blood glucose levels, carbohydrate intake, and insulin doses, in order to help manage their diabetes.  Patients typically use information from their devices when making real-time management decisions, and they or their health care providers can also retrospectively review and use this data to help adjust insulin regimens.  It is unknown how frequently people with T1D retrospectively review data on their own between clinic visits.  We conducted a cross-sectional survey of 98 adults with T1D (mean age 31.0 ± 14.7 years, 48% male, 66% non-Hispanic white, 68% on insulin pumps, 31% using continuous glucose monitoring, or CGM) to assess the frequency of using blood glucose monitor (BGM), insulin pump, and CGM data at home.  We defined “Downloaders” as those who downloaded data ≥4 times in one year, and “Reviewers” as those Downloaders who looked at their data ≥50% of the times that they downloaded (as opposed to simply downloading and giving the data to a provider without self-review).  Logistic regression was used to identify associated factors.  Only 21%, 26%, and 43% of BGM, insulin pump, and CGM users, respectively, ever downloaded data from their devices at home.  Even fewer met Downloader status (12% of BGM users, 15% of insulin pump users, and 37% of CGM users), and only 4% of BGM users, 3% of insulin pump users and 23% of CGM users were Downloaders who also met Reviewer status.  After adjusting for sex, ethnicity, insurance status, and highest level of education, older age was associated with increased odds of being a BGM Downloader (OR=1.08; 95%CI 1.02, 1.14; p=0.005); for every 10-year increase in age, there was a 2.1 times increased odds (95%CI 1.3, 3.6) of being a BGM Downloader.  No demographic factors were associated with insulin pump or CGM Downloader status or any Reviewer status.  In conclusion, nearly 60-80% of adults with T1D never download data from their devices and <25% retrospectively review their data at home on a regular basis.  As a group, subjects using CGM downloaded and reviewed their CGM data more frequently than did subjects using BGM or pumps.  Because self-review of device data can be helpful to patients in managing TID, more effort should be made to increase awareness and education about these device features and to improve usability for patients.

 

Nothing to Disclose: JCW, MS, ABN

OR26-5 15514 5.0000 A Few Adults with Type 1 Diabetes (T1D) Download and Retrospectively Review Their Diabetes Device Data 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR26 4728 11:30:00 AM Type 1 and Cystic Fibrosis Related Diabetes: Technology and Peptides Oral

Lalitha Gudipaty*1, Nora K Rosenfeld1, Chris Kubrak2, Amy J. Peleckis3, Saloni Malik1, Marina Cuchel4, Diva D. De Leon5, Denis Hadjiliadis3, Ronald C. Rubenstein6, Andrea Kelly6 and Michael R. Rickels3
1Hospital of the University of Pennsylvania, 2Children's Hospital of Philadelphia, 3Hospital of the University of Pennsylvania, Philadelphia, PA, 4Hospital of the Univerisity of Pennsylvania, 5Perelman School of Medicine at the University of Pensylvania, Philadelphia, PA, 6Children's Hospital of Philadelphia, Philadelphia, PA

 

With improved survival among individuals with cystic fibrosis (CF), cystic fibrosis related diabetes (CFRD) has emerged as a significant comorbidity that is associated with worse pulmonary function, worse nutritional status and increased mortality.  To better understand the pathophysiology underlying the development of CFRD, we are characterizing insulin secretion and secretory capacity across the spectrum of glucose tolerance abnormalities in subjects with CF. Here we present data from this ongoing cross sectional pilot study in pancreatic insufficient CF (PI-CF) subjects age >16 years with normal glucose tolerance according to Cystic Fibrosis Foundation criteria for a 75 g oral glucose tolerance test (1hr glucose <200 mg/dl and 2hr glucose <140 mg/dl) compared to normal control subjects.   All subjects underwent glucose potentiated arginine (GPA) testing during which acute insulin, C-peptide and proinsulin responses to arginine (5 g iv) were determined under fasting (AIRarg, ACParg, APRarg), 230 mg/dl (AIRpot, ACPpot, APRpot), and 340 mg/dl (AIRmax, ACPmax, APRmax) hyperglycemic clamp conditions. Proinsulin:insulin secretory ratios (PISR) in response to each injection of arginine were calculated as the molar APR divided by the molar AIR x 100.  To assess differences after adjusting for covariates, linear regression with robust variance estimates was used to account for the small sample size. 

Results:  PI-CF subjects (n=13) compared to normal control subjects (n=14) were more often female (53% vs. 36%; P < 0.05), younger (22.2 ± 1.8 vs. 27.3 ± 1.5 years, P < 0.05), and had lower BMI (22.2 ± 0.8 vs. 24.8 ± 0.7 kg/m2; P < 0.05) and fasting glucose (83 ± 2 vs. 90 ± 2 mg/dL, P ≤ 0.05).  After adjusting for these variables AIRarg (27.7 ± 3.0  vs. 23.7 ± 3.3) was not different, AIRpot (76.5 ± 12 vs. 119 ± 11 μU/ml; P ≤ 0.01) was significantly lower while AIRmax (108 ± 16 vs. 139 ± 17 μU/ml; P=0.2) was not significantly lower in PI-NGT compared with controls.  ACRarg (1.04 ± 0.1 vs. 1.5 ± 0.2 ng/mL; P < 0.05), ACRpot (2.8 ± 0.6 vs. 5.4 ± 0.6 ng/mL; P < 0.01) and ACRmax(3.5 ± 0.4 vs 5.3 ± 0.5 ng/mL; P < 0.01) were all lower in PI-NGT compared with controls.  PISRs were higher in PI-NGT compared to controls under 230 mg/dl (4.3 ± 0.4 vs. 3.0 ± 0.3 %; P <0.05) and 340 mg/dl (4.2 ± 0.5 vs. 2.0 ± 0.3 %; P ≤ 0.005) hyperglycemic clamp conditions.  Measures of β-cell sensitivity to glucose and insulin sensitivity were comparable between PI-NGT and controls.  

Conclusions:  These results indicate that patients with PI-CF manifest significantly reduced β-cell secretory capacity (as evidenced by lower AIRpot, ACRpot and ACRmax) and impaired proinsulin processing (increased PISR under hyperglycemic conditions) despite “normal” glucose tolerance.  The more pronounced impairment in C-peptide than insulin responses may reflect compensation by reduced hepatic insulin extraction.  These data support inherent β-cell capacity and processing defects in PI-CF.

 

Nothing to Disclose: LG, NKR, CK, AJP, SM, MC, DDD, DH, RCR, AK, MRR

OR26-6 14935 6.0000 A Characterization of Insulin Secretion in Postpubertal Adolescents and Adults with Cystic Fibrosis--Preliminary Results 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR26 4728 11:30:00 AM Type 1 and Cystic Fibrosis Related Diabetes: Technology and Peptides Oral

Rachel Elizabeth Jennings*, Andrew A Berry, Karen Piper Hanley and Neil Anthony Hanley
University of Manchester, Manchester, United Kingdom

 

The role of the incretin hormone glucagon-like peptide-1 (GLP-1) during normal human development is unclear. However, in other settings GLP-1 has been proposed to increase beta cell mass, via effects on proliferation, apoptosis and neogenesis (1). We have addressed this in human fetuses by quantifying GLP-1 secretion and determining how GLP-1 signalling impacts on the early human fetal pancreas in explant cultures. 

The gastrointestinal tract and pancreas was dissected from fetuses between 8 and 18 weeks post-conception (wpc), and cultured overnight in serum-free media. Levels of active GLP-1 were quantified using ELISA and radioimmunoassay, using antibodies directed against the N-terminal region and amidated C-terminus respectively. 

GLP-1 is first secreted by the stomach, duodenum, terminal ileum and rectum at 8 wpc. Levels of GLP-1 increased considerably during fetal development, most notably within the terminal ileum (~60x) and rectum (~200x). Active GLP-1 was secreted by the fetal pancreas, with a significant increase in secretion at >12 wpc. By immunohistochemistry, GLP-1 co-localised with prohormone convertase 1/3, detected at low levels in fetal pancreatic alpha cells as well as in enteroendocrine cells. Interestingly, the GLP-1 receptor (GLP-1R) was detected on SOX9-positive progenitor cells but was absent on NGN3-positive cells and fetal beta cells. GLP-1R was not detected on beta cells until after birth. Culturing fetal pancreatic explants for seven days with long-acting GLP-1 analogue decreased proliferation of progenitor cells by ~20% and increased the number of insulin- and ISL1-positive cells by 40-50%. The addition of a GLP-1R antagonist significantly reduced this response, suggesting an additional effect of endogenous GLP-1. No effect was observed on beta cell apoptosis.

Taken together, these studies identify active GLP-1 production from multiple sites within the developing human fetus with the potential to impact on human pancreas development and beta cell differentiation. Current studies are focused on what regulates GLP-1 production and defining precisely how GLP-1 signalling affects human pancreatic progenitor cells.

 

Nothing to Disclose: REJ, AAB, KP, NAH

OR23-1 13385 1.0000 A Glucagon-like Peptide-1 Secretion within the Developing Human Fetus and Its Role in Beta-Cell Development 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR23 4733 11:30:00 AM The Beta Cell and Diabetes Complications: Basic and Clinical Aspects Oral

Husam Ghanim*1, Ajay Chaudhuri2, Antoine Makdissi3, Sanaa Abuaysheh4, Kaushik Chatterjee5, Nitesh D Kuhadiya6, Manav Batra6 and Paresh Dandona7
1State University of New York at Buffalo, Buffalo, NY, 2UB Sch of Med, Williamsville, NY, 3State Univ of New York at Buffal, Buffalo, NY, 4SUNY at Buffalo, 5Suny at Buffalo, 6University at Buffalo, Buffalo, NY, 7State Univ of NY, Buffalo, NY

 

Since incretin based therapies stimulate and conserve β-cell function, we investigated action of these agents on plasma concentrations of betatrophin, a peptide secreted by hepatocytes and which stimulates β-cell function and proliferation. Two groups of 12 patients each with type 2 diabetes were treated with 100 mg sitagliptin daily or placebo for 12 weeks. Fasting blood samples were obtained at 0, 2, 8 and 12 weeks. Following sitagliptin treatment, there was a significant fall in plasma FFA concentrations (by 19±11%) and HbA1c (by 0.7%) and an increase in plasma concentrations of active GLP-1 (by 63±20%). Indices of inflammation fell significantly. There was a significant increase in betatrophin concentrations at 8 and 12 weeks (by 37±13%, from 1.12±0.31ng/ml to 1.38±0.36ng/ml; p<0.05). Another series of 12 patients was treated with exenatide injections (10 µg twice daily) for 12 weeks. Fasting blood samples were obtained at baseline, 3, 6 and 12 weeks. Plasma glucose and FFA concentrations and HbA1c levels fell significantly (by 25±11%, 21±5% and 1.2%, respectively) as did the indices of inflammation. Fasting Insulin levels increased (by 31±12%). Plasma concentrations of betatrophin did not alter. Thus, sitagliptin, a DPP-IV inhibitor, which is thought to exert its effects through an increase in GLP-1, clearly stimulates betatrophin independently of this peptide since exenatide, a GLP-1 receptor agonist, has no effect on betatrophin, a potentially important mediator of β-cell proliferation and function. We conclude that sitagliptin and possibly other DPP-IV inhibitors induce betatrophin and may thus positively modulate β-cell function and proliferation through another novel mechanism.

 

Nothing to Disclose: HG, AC, AM, SA, KC, NDK, MB, PD

OR23-2 12191 2.0000 A Contrasting Effects of Sitagliptin and Exenatide on Plasma Concentrations of Betatrophin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR23 4733 11:30:00 AM The Beta Cell and Diabetes Complications: Basic and Clinical Aspects Oral

Paresh Dandona*1, Husam Ghanim2, Kelly Green3, Ajay Chaudhuri4, Manav Batra5, Nitesh D Kuhadiya5 and Antoine Makdissi6
1State Univ of NY, Buffalo, NY, 2State University of New York at Buffalo, Buffalo, NY, 3SUNY at Buffalo, 4SUNY at Buffalo, Williamsville, NY, 5University at Buffalo, Buffalo, NY, 6State Univ of New York at Buffal, Buffalo, NY

 

Betatrophin is a peptide secreted by the liver which induces the proliferation of β-cells of the pancreatic islet and whose expression and secretion are increased in experimental insulin resistant states. Therefore, we have now investigated the concentrations of betatrophin in patients with T2DM and obesity. Fasting plasma betatrophin concentrations were measured in 19 normal weight healthy subjects, 18 patients with T1DM, 32 patients with T2DM, and 12 patients with T2DM and morbid obesity using an EIA kit. In normal subjects, mean betatrophin concentration was 0.61±0.18ng/ml; it was significantly elevated in patients with T2DM (1.23±0.24ng/ml; p<0.01) and T1DM (0.93±0.19ng/ml; p<0.05). The highest concentrations were observed in patients with morbid obesity and T2DM (1.57±0.42ng/ml; p<0.01). Thus, the absence of insulin, as in T1DM, and the reduction of insulin action, as in T2DM, results in an increase of betatrophin. To elucidate this further, we investigated the effect of a low dose infusion of insulin on plasma concentrations of betatrophin. Ten patients with type 2 diabetes were infused with insulin (3.5U/h) for 24h and glucose (5%, 100 ml/h) to maintain euglycemia. Plasma concentrations of betatrophin fell significantly within 2h by 16±11% and by 29±10% below the baseline (p<0.05) at 14h and continued to be suppressed until 24h. It is, thus, possible that insulin may exert a direct inhibitory effect on betatrophin secretion and concentrations through a negative feedback mechanism. Since also FFAs fell following insulin, it is possible that FFAs which induce insulin resistance, may also modulate the secretion and concentrations of betatrophin in plasma. These data support the concept that insulin and betatrophin have a negative feedback mechanism with betatrophin stimulating the population and function of the β-cell while insulin, a product of the latter, inhibits betatrophin secretion.

 

Nothing to Disclose: PD, HG, KG, AC, MB, NDK, AM

OR23-3 12182 3.0000 A Increased Betatrophin Concentrations in Type 2 and Type 1 Diabetes While Insulin Suppresses Betatrophin: Evidence of a Negative Feedback Mechanism? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR23 4733 11:30:00 AM The Beta Cell and Diabetes Complications: Basic and Clinical Aspects Oral

Karen SL Lam1, Elaine Y.L. Hui1, Michele Yuen*2, Chun-Yip Yeung1, Yu-Cho Woo3, Carol HY Fong3 and Aimin Xu1
1University of Hong Kong, Hong Kong, China, 2Queen Mary Hospital, Hong Kong, China, 3University of Hong Kong, Hong Kong, Hong Kong

 

Objective: Fibroblast Growth Factor 21 (FGF21) is a metabolic hormone produced by the liver, but also expressed in the other tissues including the adipose tissues, pancreas and kidney. Beneficial effects on body weight, carbohydrate and lipids metabolism have been observed in animals treated with recombinant FGF21. However, paradoxical increases in circulating FGF21 levels are found in obesity and diabetes. Elevated levels are also found in patients with impaired renal function. Its correlation with urinary albumin excretion in patients with diabetic nephropathy, even in the stage of microalbuminuria, suggests it to be an early indicator of subclinical diabetic nephropathy. Here we investigate whether serum FGF21 level can be usefully employed in the prediction of disease progression in patients with diabetic nephropathy.

Research Design and Methods: Baseline plasma FGF21 levels were measured with an ELISA in type 2 diabetic subjects, recruited from the Hong Kong West Diabetes Registry. The role of FGF21 in predicting chronic kidney disease (CKD) over a median follow-up of 4 years was analyzed using Cox regression analysis. CKD progression was defined as a deterioration in CKD staging and a 25% or greater drop in estimated glomerular filtration rate (eGFR) from baseline, as defined by International Society of Nephrology statements.

Results: At baseline, serum FGF21 levels increased progressively with CKD staging (P for trend <0.001; n=1136). Amongst 1071 subjects with baseline CKD stage ≤ 3, serum FGF21 levels were significantly higher in those with CKD progression (n=171) during follow-up than those with no progression (n=900) (P<0.001). On multivariable Cox regression analysis, serum FG21 was independently associated with CKD progression (hazard ratio [HR]: 1.24; 95% CI: 1.05-1.47; P=0.012), after adjustment for age, duration of diabetes, hypertension, C-reactive protein and eGFR. Serum FGF21 remained an independent predictor of CKD progression in a subgroup of subjects with normoalbuminuria and CKD stage 1 or 2 at baseline (HR 1.4; 95% CI 1.04-1.88; p=0.028; n=559)

Conclusions: Elevated FGF21 levels may represent a compensatory change to the metabolic derangement and renal injury in diabetic patients with renal disease and appear to be a useful biomarker for predicting disease progression in type 2 diabetic patients at early stages of diabetic nephropathy.

Supported by: the Hong Kong Research Grant Council (CRF HKU 02/12R)

 

Nothing to Disclose: KSL, EYLH, MY, CYY, YCW, CHF, AX

OR23-4 11973 4.0000 A Circulating Fibroblast Growth Factor 21 Level Predicts the Progression of Diabetic Nephropathy in Patients with Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR23 4733 11:30:00 AM The Beta Cell and Diabetes Complications: Basic and Clinical Aspects Oral

Nicolas R Bolo*1, Brandon Hager1, Gail Musen2, Alan M Jacobson3, Matcheri Keshavan1 and Donald C Simonson4
1Beth Israel Deaconess Medical Center, Boston, MA, 2Joslin Diabetes Center, Boston, MA, 3Winthrop-University Hospital, Mineola, NY, 4Brigham and Women's Hospital, Boston, MA

 

Type 1 diabetes mellitus (T1DM) is associated with a high prevalence of depression vs. age- and sex-matched controls.  We examined whether hyperglycemia might be an etiologic factor for depression either 1) by disrupting resting state functional connectivity (FC) in the insula and posterior cingulate cortex (PCC), which are important in integrating interoceptive and exteroceptive stimuli, or 2) by increasing levels of brain glutamate, a neurotransmitter that is elevated in depression, in the anterior cingulate cortex (ACC, a region involved in emotional control).  Eight non-depressed T1DM (3M / 5F; age = 26±1 yrs; HbA1c = 7.1±0.2%) and 11 healthy controls (CON; 6M / 5F; age = 29±3 yrs; HbA1c = 5.5±0.1%) were studied during a 60-min euglycemic (EU) basal period (T1DM: 111±8 mg/dl; CON: 93±2 mg/dl) followed by a 60-min +90 mg/dl hyperglycemic (HY) clamp (T1DM: 202±7 mg/dl; CON: 182±3 mg/dl).  T1DM received basal insulin replacement at 0.25 mU/kg/min throughout.  During steady-state EU and HY, FC was measured by resting-state functional magnetic resonance imaging using independent component analysis, and glutamate was measured in the ACC and a control region (occipital cortex) by proton magnetic resonance spectroscopy.  Subjects also completed the Symptom Checklist-90R depression subscale (SCL-90R-dep) to evaluate depressive symptoms.  FC of the right posterior insula and PCC with the salience network (comprising bilateral anterior cingulate, insula and amygdala) was significantly lower in T1DM than controls during HY (p < 0.05). In T1DM, HbA1c was negatively correlated with insula FC (r2 = 0.43, p = 0.08).  Glutamate levels in the ACC increased more in T1DM vs. CON during the HY clamp (4.8±1.3 vs -0.7±2.2 mmol/l brain weight; p = 0.07), but did not change in the occipital lobe during HY in either group.  SCL-90R-dep scores were higher in T1DM vs. CON (5.5±1.7 vs. 1.5±0.5, p < 0.05), but substantially below the range for clinical depression.  Conclusions: Compared with healthy controls, T1DM subjects have 1) lower FC of the insula and PCC to the salience network during acute hyperglycemia, 2) an association of reduced FC with higher HbA1c, 3) a greater increase in ACC glutamate during acute hyperglycemia, and 4) higher depressive symptoms. These data suggest that acute and chronic exposure to hyperglycemia disrupt functional connectivity and increase levels of glutamate in brain areas relevant to mood and emotion, both of which may increase susceptibility to development of depression.

 

Nothing to Disclose: NRB, BH, GM, AMJ, MK, DCS

OR23-5 16153 5.0000 A Hyperglycemia Disrupts Regional Brain Functional Connectivity and Increases Glutamate Neurotransmitter Levels in Type 1 Diabetes: A Link to the Development of Depression? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR23 4733 11:30:00 AM The Beta Cell and Diabetes Complications: Basic and Clinical Aspects Oral

Francisco J Pasquel*1, Dawn Smiley1, Farnoosh Farrokhi2, Saumeth Cardona1, Limin Peng3 and Guillermo E Umpierrez1
1Emory University School of Medicine, Atlanta, GA, 2Emory University, 3Emory Univeristy Rollins School of Public Health

 

This prospective randomized trial compared the prevalence and severity of hyperglycemia, the need for continuous insulin infusion (CII), and the number of perioperative complications in patients with (DM) and without diabetes (non-DM) undergoing CABG surgery. A total of 302 consecutive patients (age: 64±10 yr, M: 72%, BMI: 31±7 kg/m2) with DM (n=152, 50%) and non-DM (n=150, 50%) were enrolled. Compared to non-DM, patients with DM were heavier (BMI: 33±8 vs. 29±6, p<0.001), had higher admission BG (171±72 vs. 111±28 mg/dl, p<0.001) and HbA1c (8.0±2 vs. 5.6±0.5%, p<0.001). There were no differences in the number of surgical grafts, duration of surgery, APACHE score, or in the need for vasopressors after surgery (all p=NS). Patients with DM had higher preoperative (155±51 vs. 108±23 mg/dl, p<0.001), intraoperative (157±31 vs.138±20 mg/dl, p<0.001) and ICU (149±18 vs. 135±16 mg/dl, p <0.001) mean BG compared to non-DM patients. During the perioperative period, 93% of DM and 83% of non-DM developed hyperglycemia (BG>140 mg/dL); of them, a total of 94% of DM and 88% of non-DM received CII (p=0.06). The mean insulin dose during CII in the ICU was significantly higher in DM (161±229 units) compared to non-DM patients (61±84 units), both p<0.001. After discontinuation of CII, 98% of patients with DM and 49% of non-DM required transition to SC basal insulin, with a mean hospital BG after transition higher in DM compared to non-DM subjects (160±28 vs.125±13 mg/dl, p<0.001). There were no differences in the overall rate of composite of hospital complications including wound infection (deep and superficial) (4% vs 1%, p=0.17), pneumonia (4% vs 3%, p>0.9), bacteremia (1% vs 0%, p>0.9), respiratory failure (14% vs 17%, p=0.49) or major cardiovascular events (39% vs 36%, p=0.53) between DM and non-DM groups (49% vs. 45%, respectively, p=0.48). DM subjects, however, had higher hospital mortality (5% vs.0%, p=0.02) and more episodes of acute renal failure (20% vs. 12%, p=0.048) than non-DM subjects. In both groups, patients with mean perioperative BG≥140 mg/dl had similar number of complications compared to those with BG<140 mg/dl (DM: 49% vs. 48%, p=0.87; non-DM: 52% vs. 40%, p=0.16)

 In summary, most patients with and without diabetes developed perioperative hyperglycemia-requiring CII after CABG surgery. Despite a higher admission, intraoperative, and ICU blood glucose concentration in patients with diabetes, we observed no differences in a composite of hospital complications compared to non-diabetic subjects.

 

Disclosure: DS: Principal Investigator, Sanofi, Advisory Group Member, Sanofi. GEU: Principal Investigator, Boehringer Ingelheim , Principal Investigator, Sanofi, Principal Investigator, Merck & Co., Advisory Group Member, Sanofi. Nothing to Disclose: FJP, FF, SC, LP

OR23-6 16865 6.0000 A The Impact of Perioperative Hyperglycemia in Patients with and without Diabetes Undergoing Coronary Artery Bypass Surgery 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 1:00:00 PM OR23 4733 11:30:00 AM The Beta Cell and Diabetes Complications: Basic and Clinical Aspects Oral

Cassandra Dawn Kinch*1, Kingsley Ibhazeheibo2, Carol Schuurmans2, Hamid R Habibi3 and Deborah Marie Kurrasch4
1Univ of Calgary, Calgary, AB, 2University of Calgary, 3Univ of Calgary, Calgary, AB, Canada, 4University of Calgary, Calgary, AB, Canada

 

Children born to mothers with high urinary Bisphenol A (BPA) levels in the second trimester of gestation are hyperactive during childhood. However, the physiological insults incurred by prenatal exposure to endocrine disruptors such as BPA, remain poorly understood. Since neurogenesis (birth of neurons) is the main neurodevelopmental step occurring during the second trimester, we investigated whether prenatal BPA exposure could cause neurogenic perturbations within the hypothalamus, a small but powerful region of the brain responsible for controlling various neuroendocrine physiologies. Given that neural progenitors are responsive to estrogen, we reasoned that estrogenic BPA might influence the maintenance of the hypothalamic progenitor pool and affect timing of neuronal birth, perturbing establishment of key circuitry, and ultimately transducing into hyperactive behavior. By using the developmentally similar zebrafish as a model, we surpassed confounding effects observed in mammals such as degree of placental transfer and maternal metabolic dynamics. To evaluate the hypothalamic neurogenic profile, BPA-exposed fish were labeled with molecular markers for neuronal differentiation at key timepoints throughout the neurodevelopmental window. To assay BPA-induced behavioral changes we utilized movement tracking software to monitor locomotor patterns of exposed zebrafish. Significantly, exposure of embryonic zebrafish to a very low dose of BPA (0.0068uM) resulted in a 170% increase in hypothalamic neurogenesis with a concomitant hyperactive phenotype. Exposure to Bisphenol S (BPS), the main BPA analogue used in the production of BPA-free products, had similar neurogenic and locomotor effects. Surprisingly, these Bisphenol-induced effects were not mediated by the predicted estrogen receptor signaling pathways, but through a novel mechanism contingent on aromatase activity, the key enzyme for estrogen biosynthesis. Thus, by altering local estrogen synthesis, BPA/BPS may play a previously unappreciated role in inducing precocious cell cycle exit in hypothalamic progenitors. This study is the first to mechanistically link prenatal BPA/BPS exposure with changes in brain development (neurogenesis) and altered behavior. In addition, our results suggest that use of BPS, termed as the ‘safe alternative’ of BPA-free products, is equally harmful to developing brains and calls for continued societal push to eliminate all Bisphenol analogues from consumer goods production.  NSERC, CIHR (DMK); NSERC (HRH)

 

Nothing to Disclose: CDK, KI, CS, HRH, DMK

OR18-1 11171 1.0000 A Bisphenol a Exposure Induces Precocious Neurogenesis and Hyperactivity By Increasing Local Estrogen Synthesis within the Brain 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 1:00:00 PM OR18 4734 11:30:00 AM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Oral

Pheruza Tarapore*1, Bin Ouyang2, Yuet-Kin Leung2, Vinothini Janakiram1, Dan Song1, Rahul Rao2, Max Hennessy2 and Shuk-Mei Ho1
1University of Cincinnati College of Medicine, Cincinnati, OH, 2University of Cincinnati, Cincinnati, OH

 

Increase in the incidence of male reproductive problems within the last few decades are too rapid to be explained by genetic factors alone, and suggest environment/lifestyle may play a significant role in their development. Approximately 8% to 28% of couples are unable to conceive after one year of unprotected intercourse. Since exposure to Bisphenol A (BPA) is ubiquitous and consumption of high-fat diets is deeply ingrained in our culture, prenatal exposure to both BPA and high levels of dietary fatty acids is a legitimate public health concern. Our objective was to study the relative contributions of high fat butter (HFB) diet and BPA on rat spermatogenesis.

We performed a pilot experiment, where Taconic Sprague-Dawley (SD) rats were exposed in utero to normal diet (AIN-93G-no-soy diet-16% kcal fat), HFB (HFB - 39% kcal fat), HFB plus 2.5, 25 (HFB/BPA25), 250 (HFB/BPA250), 2500 µg/kg bw per day BPA, and HFB plus 0.5µg/kg bw per day ethinyl estradiol diets. We found that adult males exposed in utero to HFB ± BPA had qualitatively normal spermatogenesis within the testis. However, when treated with testosterone (T) and 17β-estradiol (E2) for 20 weeks (which mimic the changed T:E2 ratios observed in aging males), the male rats exposed in utero to HFB ± BPA, and not the unexposed rats, exhibited impaired spermatogenesis. Using hematoxylin and eosin staining, we found that on T+E2 treatment, 100% of HFB/BPA250 and 66% of HFB/BPA25, but not the unexposed rats; showed presence of >35% seminiferous tubules (STs) with arrested spermatogenesis. STs were also examined for BRDT, Prm-1, H3S10phos, androgen receptor and aromatase Cyp19 by IHC. Expression of BRDT in early spermatogonia and spermatocytes, as well as abnormal association of protamine-1 (prm-1) with meiotic / mitotic spermatocytes was observed. Our results suggest that while HFB diet leads to a block in spermatid elongation, the HFB/BPA diet also result in a significant number of tubules blocked for spermatocyte differentiation into round spermatids. The HFB diet/T+E2 alone also induced an increase in impaired spermatogenesis, however, the combined HFB/BPA250 showed a significance in relation to HFB alone. We have thus shown that gestation is a critical window for dietary fatty acids-BPA interaction, that reprogram spermatogenesis, resulting in subtle changes in germ cell differentiation in adulthood. Moreover, these changes may go unnoticed, until critical secondary exposures occur, to unmask their effects. This study is of particular relevance since obese men show increased estrone and E2 levels, and stress, xeno-oestrogens, inflammatory cytokines and poor dietary choices up-regulate aromatase to increase intracellular E2.

 

Nothing to Disclose: PT, BO, YKL, VJ, DS, RR, MH, SMH

OR18-2 17017 2.0000 A Gestational Exposure to High Fat Diet and Bisphenol a Reprograms Spermatogenesis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 1:00:00 PM OR18 4734 11:30:00 AM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Oral

Xiaoqian Gao, Jianyong Ma, Yamei Chen and Hong-Sheng Wang*
University of Cincinnati, Cincinnati, OH

 

Bisphenol A (BPA) is an environmental endocrine disrupting chemical that has been widely used in the production of plastic consumer goods. Because of BPA’s potential adverse impact on human health, another member of the bisphenol family, bisphenol S (BPS), is increasingly becoming an alternative to BPA in production of plastic bottles (often labeled “BPA-free”) and thermal paper. Wide human exposure to BPS has been reported in various populations including in those in the US. However, the potential health impact of BPS exposure is poorly defined. The goal of the present study is to define the rapid actions and underlying mechanisms of BPS in the heart. The rapid effects of BPS on ex vivo whole heart and isolated ventricular myocytes from adult rats were examined. We found that environmentally relevant concentration of BPS (1 nM) acutely induced ventricular arrhythmias in female adult rat hearts in the presence of catecholamine stimulation. In isolated ventricular myocytes of female adult rats, BPS (1 nM) acutely increased arrhythmogenic triggered activities. The action of BPS on female ventricular myocyte had an “inverted-U” shaped dose-response curve. The cellular mechanisms underlying the cardiac actions of BPS were investigated. Acute BPS treatment significantly increased sarcoplasmic reticulum (SR) calcium leak, and beat-to beat calcium release and reuptake. The phosphorylations of ryanodine receptors and phospholamban, key calcium handling proteins in the heart, were markedly increased upon BPS exposure. The responses of female cardiac cells to BPS were abolished by blockade of estrogen receptor beta but not estrogen receptor alpha. In conclusion, BPS promoted cardiac arrhythmias in the female rat hearts under stress condition, and the action was mediated by altering myocytes calcium handling processes and activation of estrogen receptor beta. This is the first study of the impact of BPS on mammalian organ and primary cells; our results suggest that exposure to BPS, a substitute for the well-studied BPA, may have acute cardiac toxicity similar to that of BPA.

 

Nothing to Disclose: XG, JM, YC, HSW

OR18-3 13116 3.0000 A Evaluation of the Rapid Effects of Bisphenol S (BPS) on the Heart: Impact on Arrhythmogenesis and Cardiac Calcium Handling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 1:00:00 PM OR18 4734 11:30:00 AM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Oral

Brandiese E.J. Beverly*1, Christy Lambright1, Johnathan Furr1, Hunter Sampson1, Gregory Travlos2, Paul M Foster2, Barry McIntyre2, VIckie Wilson1 and L. Earl Gray Jr.3
1US Environmental Protection Agency, 2NIH/NIEHS, 3US Environmental Protecton Agency

 

Sex differentiation of the male reproductive tract in mammals is driven, in part, by fetal androgen production.  In utero exposure to some phthalate esters (PEs) alters fetal Leydig cell differentiation, reducing the expression of several genes associated with steroid synthesis/transport, and consequently, lowering fetal androgen levels.  Simvastatin (SMV) is a cholesterol-lowering drug that directly inhibits 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, a coenzyme that facilitates the conversion of HMG-CoA to mevalonate in the cholesterol biosynthetic pathway.  SMV may also disrupt steroid biosynthesis, but through a different mechanism of action (MOA) than the PEs.  As cholesterol is a precursor of steroid hormone biosynthesis, we hypothesized that in utero exposure to SMV during the critical period of sex differentiation would lower fetal testicular testosterone (T) production without affecting genes involved in cholesterol and androgen synthesis and transport.  Secondly, we hypothesized that a mixture of SMV and a PE would reduce testosterone levels in an additive manner.  Pregnant Sprague Dawley rats were dosed orally with 0, 15.6, 31.25, or 62.5 mg/kg/day SMV from gestational days (GD) 14-18, and fetuses were evaluated on GD18.  On GD18, fetal T production and serum triglycerides, LDL, HDL, total cholesterol levels were reduced with increasing doses of simvastatin.  In addition, PEs downregulate about a dozen genes in the fetal testes that were unaffected by SMV treatment.  Individual administration of SMV (62.5 mg/kg/day) and DPeP (50 mg/kg/day) reduced fetal T production by 44% of control and 37% of control, respectively, p < 0.0001 versus control).  When SMV and DPeP were administered as a mixture, fetal T production was reduced in an additive manner (19% of control; p < 0.0001 versus control, SMV, and DPeP), thus demonstrating that a mixture of chemicals can induce additive effects on fetal T production even though they display different modes of action.

Abstract does not reflect the views of the EPA.  Support provided by USEPA/NTP IA#RW-75-92285501

 

Nothing to Disclose: BEJB, CL, JF, HS, GT, PMF, BM, VW, LEG Jr.

OR18-4 14053 4.0000 A Simvastatin and Dipentyl Phthalate Display Different Modes of Action but Exhibit Dose Additive Effects on Fetal Testicular Testosterone Production in Sprague Dawley Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 1:00:00 PM OR18 4734 11:30:00 AM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Oral

Samar Y Hafida*1, Jannifer Tyrrell2, Paul M Stemmer3, Steven Jones4 and Todd Leff1
1Wayne State University School of Medicine, Detroit, MI, 2Wayne State University School of Medicine, 3Wayne State University, Detroit, MI, 4Wayne State University

 

As of 2011, more than 20 million people in the United States have been diagnosed with Diabetes. Although over-nutrition and reduced physical activity are clear contributors, a large body of literature suggests that exposure to environmental toxicants may increase the susceptibility to diabetes, especially in concurrence with metabolic stresses such as obesity. Exposure to low levels of Pb is common in some urban settings including the city of Detroit.  Although the adverse effects of Pb on the neurologic and hematologic systems have been extensively studied, the effect of Pb on metabolism and glucose homeostasis is less well understood.  To determine if Pb exposure can increase susceptibility to diabetes in a setting of obesity, we examined the metabolic effects of Pb exposure in ZDF rats and high fat fed transgenic C57BL6 mice.  In ZDF female rats, Pb exposure via drinking water generated an average blood lead level (BLL) of 49 µg/dl.  After 7 weeks of exposure, a statistically significant hyperglycemia (compared to controls) was observered in Pb-treated animals that persisted until termination at 24 weeks (P<0.01 by repeated measures ANOVA).  Glucose intolerance, determined by OGTT was more severe in Pb-exposed animals compared to controls from week 12 on, and worsened as the experiment progressed (P<0.001 at week 16). Upon termination, mRNA levels of gluconeogenic genes were found to be elevated in livers of exposed rats compared to the controls.  The transgenic mouse model used, was a C57BL6 male mouse expressing the human islet-specific amyloid polypeptide (hIAPP), predisposing the animals to deposition of amyloid plaques in the islet, mimicking the histologic changes seen in Type 2 Diabetic humans. In this experiment, animals were exposed to lower doses of Pb in drinking water and BLL stabilized at 22 µg/dl.  Compared to control mice, exposed mice developed more severe hyperglycemia (P<0.0001 at week 20) and glucose intolerance (P<0.01 at week 26).  Both persisted from the 7th week until the termination of the experiment after 45 weeks of exposure.  Histological and biochemical analysis of tissues demonstrated that the livers of exposed animals were fatty, with reduced glycogen content. Histology of pancreatic tissue revealed a significant Pb-induced increase in amyloid deposition as well as a larger islet size, reflecting beta cell hyperplasia in the Pb treated mice.There were no effects of Pb exposure on body weight, food consumption or plasma insulin levels in either the rat or mouse experiment. Our findings clearly show that low levels of Pb exposure disrupt glucose homeostasis and promote the development of diabetes in the background of obesity. This becomes exceedingly important in urban industrialized regions such as Detroit, where the prevalence of Obesity, Diabetes and exposure to Pb is significant.

 

Nothing to Disclose: SYH, JT, PMS, SJ, TL

OR18-5 14568 5.0000 A Environmental Lead (Pb) Exposure Promotes Diabetes in Obese Rodents 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 1:00:00 PM OR18 4734 11:30:00 AM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Oral

Esther Calderon-Gierszal*1, Andre Kajdacsy-Balla2, Guannan Li2, Ke Huang2, Richard B van Breemen2 and Gail S. Prins3
1University of Illinois at Chicago, Chicago, IL, 2University of Illinois at Chicago, 3University of Illinois-Chicago, Chicago, IL

 

Evidence from rodent1 and adult human stem cell2 models suggests that early-life BPA exposure can reprogram the prostate and render it more susceptible to carcinogenesis with aging. To determine whether human embryonic prostate cells are similarly sensitive to BPA, the present studies derived two novel models of human prostate development using  hESC (H9).  First, we generated a pioneer in vitro model of directed differentiation of hESC into prostatic organoids using sequential exposure of hESC to stage-specific growth factors and steroids.  Differentiation to prostatic structures was confirmed by immunofluorescence (IF) and RT-PCR for multiple prostate markers including PSA. Next, the hESC cells were exposed to vehicle, 1 or 10 nM BPA throughout culture. Budding and nonbudding structures were quantitated 4 days following transfer to Matrigel. While 1 nM BPA increased total and budding organoid numbers (P<0.01), 10 nM BPA reduced (P<0.05) structure numbers vs vehicle.  Continued 3-D culture in BPA did not alter their differentiation to mature organoids at day 30 as assessed by IF and RT-PCR. However, BPA exposures at both doses resulted in focal clusters of resident stem cells within the organoids, a phenotype not observed in controls.  RT-PCR for OCT4, NANOG and CD49f confirmed increased expression of stem cell genes in 10 nM BPA vs control (P<0.05). These results indicate that BPA directly targets hESC and disrupts human prostate morphogenesis. To determine whether hESC-derived prostatic tissues are susceptible to developmental BPA reprogramming and carcinogenesis in vivo, hESC colonies were mixed with embryonic rat prostatic mesenchyme and grafted to the renal capsule of nude mice.  Mature prostatic-like tissues with human epithelium formed by 30 days; confirmed by multiple markers including PSA.  Developmental BPA exposure was modeled by daily oral dosing of host mice (250μg/kg BW) for 14 days after grafting, producing free serum BPA levels of 0.49 ng/mL 20 min post-dosing. Estradiol (E)-driven carcinogenesis was initiated by E+T pellets at one month, to model rising E levels with aging.  At 5 months, prostatic structures were evaluated for pathologic evidence of cancerous lesions.  E+T treatment alone did not induce prostate cancer vs T alone (7% vs 0%, respectively) and this was not significantly enhanced by developmental BPA exposure (14%). Importantly, developmental BPA alone increased the incidence of total lesions (squamous metaplasia, hyperplasia and intraepithelial neoplasia) from 4% in controls to 25% (P<0.037) in the BPA exposed grafts. These results indicate that exposure to environmentally relevant levels of BPA during development is sufficient to drive prostate pathology in the mature human prostate epithelium. Taken together, the present studies suggest that the developing human fetal prostate gland may be reprogrammed by BPA making it more susceptible to diseases with aging.

 

Nothing to Disclose: EC, AK, GL, KH, RBV, GSP

OR18-6 14070 6.0000 A Directed Differentiation of Human Embryonic Stem Cells (hESC) to Prostate: Novel Models That Verify Bisphenol A Effects on Human Prostate Development 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 1:00:00 PM OR18 4734 11:30:00 AM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Oral

Serban Radian*1, Plamena Gabrovska2, Brendan Holland3, Helen Wallace4, Anthony W Ryan5, Karen McGurren6, Karen Stals7, Anna-Marie Bussell7, Mark G Thomas8, Aidan Holland3, Elena Daniela Aflorei1, Sayka Barry1, Craig E Stiles1, Ida Pernicova1, Giampaolo Trivellin1, Judit Dénes9, Maria Herincs1, Laura C. Hernandez Ramirez9, Jade Samuels10, Ronan McCloskey11, Michal Azjensztejn12, Noina Abid12, Ajith V Kumar13, Brew A Atkinson4, Sian Ellard14, Ross McManus5, Chris J Thompson6, Gerard J Linden15, Lisa Bradley16, Amar Agha17, Steven J Hunter4, Patrick J. Morrison16 and Márta Korbonits1
1William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom, 2Barts and The London School of Medicine, London, United Kingdom, 3FIPA Patients Charity Group, 4Royal Victoria Hospital, Belfast, United Kingdom, 5Trinity College Dublin, Dublin, Ireland, 6Beaumont Hospital & RCSI Medical School, Dublin, Ireland, 7Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom, 8University College London, London, United Kingdom, 9Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom, 10St Bartholomew's Hospital, Barts Health NHS Trust, United Kingdom, 11Ronin Films, Belfast, United Kingdom, 12Royal Belfast Hospital for Sick Children, Belfast Health and Social Care Trust, Belfast, United Kingdom, 13Great Ormond Street Hospital, London, United Kingdom, 14University of Exeter Medical School, Exeter, United Kingdom, 15School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom, 16Belfast City Hospital, Belfast, United Kingdom, 17Beaumont Hospital, Dublin, Ireland

 

Background: Germline AIP mutations predispose to GH/PRL-secreting pituitary adenomas (PA) in a familial or apparently sporadic setting. A founder effect was established for the R304* mutation in several FIPA lineages and in a historical 18thcentury giant, all traceable to a small geographical hotspot region in Northern Ireland (1).

Aim:To identify the prevalence of the R304* mutation in the acromegaly population of the 2 major endocrine centres closest to the geographical hotspot area and to evaluate the prevalence of the R304* mutation in population samples from the identified small geographical area and from two Irish control cohorts.

Subjects:84 acromegaly patients in Belfast and 28 patients in Dublin were screened for AIP mutations.  952 voluntary subjects from the geographical hotspot area and 2 control cohorts: Belfast (1000) & Dublin (2095 anonymous) were screened for R304*. Lineages with R304*mutation from our international FIPA cohort were also included in the study. Microsatellite-based haplotype analysis of 14 markers in the 11q12.2-13.3 region was performed in all lineages.

Results:We identified 6 sporadic and 3 familial lineages in the Belfast and 1 FIPA lineage in the Dublin acromegaly cohort.

Population screening identified 2 R304* unaffected related carriers (1 lineage) without PA family history and 3 carriers (1 affected by acromegaly) from known R304* FIPA lineages. Two control subjects carried R304*, one unaffected (Belfast) and one anonymous Dublin sample of unknown clinical status.

Out of the total of 25 R304* lineages in our FIPA cohort, 12 were identified outside Northern Ireland/Ireland; 6 of these 12 had known Irish ancestry.

18 of the 19 Irish lineages shared significant portions (2.7-8.2Mbp) of a common mutated haplotype, with the exception of the anonymous Dublin sample, which is likely representing an independent recurrent mutation event. These 18 lineages sharing a common ancestor included 96 R304* subjects: 38 PA patients and 58 unaffected carriers. None of the 6 non-Irish lineages shared the common Irish R304* haplotype.

Conclusions: We observed an appreciable R304* prevalence (~1/500, excluding relatives of known patients) in the geographical hotspot area, higher than in Belfast (1/1000) and Dublin (~1/2000) control cohorts. This is in contrast with the complete absence of R304* in numerous control subjects from published studies and in genetic variant databases (0/4295 European Americans, http://evs.gs.washington.edu/EVS/). 18 Irish R304* lineages share a common ancestor. Our results suggest that clinically-based screening of acromegaly patients (familial or sporadic) followed by thorough cascade screening of their families will result only in very few R304* mutation carriers remaining unidentified.

 

Disclosure: MK: Researcher, Pfizer, Inc., Researcher, Novartis Pharmaceuticals, Researcher, Syntaxin, Consultant, Pfizer, Inc., Consultant, Chiasma, Consultant, Sanofi, Consultant, Syntaxin. Nothing to Disclose: SR, PG, BH, HW, AWR, KM, KS, AMB, MGT, AH, EDA, SB, CES, IP, GT, JD, MH, LCH, JS, RM, MA, NA, AVK, BAA, SE, RM, CJT, GJL, LB, AA, SJH, PJM

OR17-1 13305 1.0000 A Population Screening for the Irish Founder AIP Mutation R304* Reveals a Prevalence of 1/500 in the Local Population, While High Mutation Frequency Is Present Among Irish Familial and Sporadic Somatotropinoma Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 1:00:00 PM OR17 4743 11:30:00 AM From Genetics to Clinical Trials in Pituitary Disease Oral

Peter Gergics*, Michelle L. Brinkmeier and Sally A Camper
University of Michigan, Ann Arbor, MI

 

Pituitary hyperplasia frequently precedes the development of pituitary adenomas (1).  Genetically engineered mice make it possible to study the progression of pituitary hyperplasia to adenomas.  Little is known about the etiology of thyrotrope adenomas or transcription factors that uniquely specify this cell type.  To address these issues we studied the chorionic gonadotropin alpha subunit (CGA) knockout mouse, a.k.a. glycoprotein alpha subunit, aGSU, which has profound thyrotrope hypertrophy and hyperplasia and very few pituitary somatotropes and lactotropes (2).  This unique cell distribution suggests an adaptive response to differentiation of the POU1F1 lineage.  We carried out gene expression profiling in adult male and female mutants and wild types using an Illumina platform to identify differentially expressed genes that might be involved in thyrotrope hypertrophy and hyperplasia.  Cluster analysis identified multiple categories of molecular functions that could be involved.  Among these were transcription factors (TF), mRNA processing, unfolded protein response, and vesicle trafficking.  We focused first on differentially expressed transcription factors, and validated 46 by qRT-PCR: 27 increased and 19 decreased in mutants relative to wild type.  Five of the most highly changed genes were selected from each category for further analysis: Nupr1, Dkk3, Cdkn1c, Etv5, and Zfp533 were up-regulated and Klf9, Stat5a, Pou1f1, Hr, and Hsbp1l1 were down-regulated.  To identify genes likely to be relevant for thyrotrope fate and function, we screened these ten candidate TF genes for cell specific expression using a panel of immortalized mouse pituitary cell lines that represent different cell types: Pou1f1-lineage precursors (GHFT-1), pre-gonadotropes (alphaT3-1), thyrotropes (TalphaT-1), and corticotrope (ATT-20) (3-5).  Most genes were expressed in more than one cell line, and three were specific to GHFT-1 and TalphaT-1: Pou1f1, Klf9 and Etv5.  Klf9 is known to be a thyroid hormone induced gene (6). This strategy will be applied to the remaining differentially expressed transcription factors.  Genes with thyrotrope specificity will be tested in TalphaT-1 cells for functional alteration of Tshb expression.  In summary, we have identified and validated a set of transcription factors that exhibit highly altered expression in a mouse model of thyrotrope adenoma.  In addition, we have a collection of differentially expressed genes with distinct molecular functions that can be explored more deeply using this animal model.

 

Nothing to Disclose: PG, MLB, SAC

OR17-2 16381 2.0000 A Thyrotrope Adenoma Mouse Model Exhibits Altered Expression of Multiple Transcription Factor Genes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 1:00:00 PM OR17 4743 11:30:00 AM From Genetics to Clinical Trials in Pituitary Disease Oral

Weipeng Xiong*1, Mei Xu1, Katja Kiseljak-Vassiliades2, Sean Colgan1, Kelley S Brodsky1, Holger Eltzschig1, Bette K Kleinschmidt-Demasters1, Kevin Lillehei1 and Margaret E Wierman2
1University of Colorado School of Medicine, Aurora, CO, 2Veterans Affairs Medical Center, Denver, CO

 

Mammalian STE20-like kinase 4 (MST4) is a novel serine-threonine kinase with cell-specific actions including control of growth, apoptosis, as well as cell polarization. Using expression microarrays combined with whole-genome screens for copy number alterations (CNA), we recently identified that the MST4 transcript was amplified within ChrX q26.2 in one tumor and consistently upregulated at the transcript and mRNA level in human gonadotrope pituitary tumors. MST4 protein was detected by both immunoblot and immunohistochemistry in pituitary tumors and absent in normal pituitaries. Stable LβT2 mouse gonadotrope cell transfectants provided a model to explore the functional effects of MST4. In an attempt to mimic the tumor microenvironment, we developed a hypoxia model to understand the role of MST4. Under hypoxic stress (1% O2), MST4 decreased the rate of apoptosis as assessed by caspase 3 cleavage (-2.0-fold, p=0.02) and Hoechst staining of nuclear condensation (-2.89-fold, p=0.003). Increased rates of proliferation under hypoxic conditions were observed at day 3 (1.95-fold, p=0.01) in MST4 LβT2 cells compared to vector controls. Importantly, MST4 expression resulted in increased colony formation in a soft agar assay (1.5-fold, p=0.02) during long term hypoxic stress (5% O2) for 14 days. Analysis of stable transfectants expressing MST4 mutants (K53E-kinase dead, T178A-loss of autophosphorylation, and C-terminus deletion) revealed the protection from hypoxia-induced death required the MST4 N-terminal kinase domain, but not the regulatory C-terminus. Exposure to hypoxia (1% O2) for 17 h triggered an increase in hypoxia-induced factor-1 (HIF-1) protein as measured by immunoblot (6.2-fold, p=0.002) and HIF-1 activity demonstrated by induction in a hypoxia response element (HRE)-luciferase reporter assay (2.0-fold, p=0.001). Inhibition of HIF-1 activity using 17-dimethylaminoethylamino-17-demethoxygeldanamycin (17-DMAG, 3 µM for 17 h) or by lentiviral HIF-1 silencing (by 70 %) resulted in a loss of protection afforded by MST4. Studies with multiple kinase inhibitors revealed that MST4-dependent protection from hypoxia-induced cell death were dependent on the activation of both p38 MAPK and PI3K-Akt pathways. Together these data support the importance of the MST4 kinase in pituitary tumors to respond to a hypoxic environment to promote tumorigenesis and suggest it may be a potential therapeutic target.

 

Nothing to Disclose: WX, MX, KK, SC, KSB, HE, BKK, KL, MEW

OR17-3 15261 3.0000 A Mechanisms of Mammalian STE20-like Kinase 4 (MST4) to Promote Pituitary Tumor Cell Survival and Proliferation Under Hypoxic Conditions 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 1:00:00 PM OR17 4743 11:30:00 AM From Genetics to Clinical Trials in Pituitary Disease Oral

Rosario Pivonello*1, Maria Fleseriu2, Jacques Young3, Xavier Bertagna4, Amir H Hamrahian5, Mark E Molitch6, Chikara Shimizu7, Tomoaki Tanaka8, Akira Shimatsu9, Tracy White10, Annie Hilliard10, Chuan Tian10, Nicholas Sauter10 and Beverly MK Biller11
1Federico II University, Naples, Italy, 2Oregon Health & Science University, Portland, OR, 3Hôpital Bicêtre, Université Paris-Sud, Assistance Publique Hôpitaux de Paris, Paris, France, 4Centre de Référence des Maladies Rares de la Surrénale, Hôpital Cochin, Faculté de Médecine Paris Descartes, Université Paris 5, Paris, France, 5Cleveland Clinic Foundation, Cleveland, OH, 6Northwestern University, Chicago, IL, 7Hokkaido University Hospital, Sapporo, Japan, 8Chiba University Graduate School of Medicine, Chiba-city, Japan, 9National Hospital Organization Kyoto Medical Center, Kyoto, Japan, 10Novartis Pharmaceuticals Corporation, East Hanover, NJ, 11Massachusetts General Hospital, Boston, MA

 

Background: In a previous proof-of-concept study (LINC 1), the potent 11β-hydroxylase inhibitor LCI699 normalized urinary free cortisol (UFC) levels in 11/12 patients with Cushing’s disease after 10 weeks of treatment. This interim analysis of the first eight patients enrolled into a longer-term study (LINC 2) further evaluates LCI699 in patients with Cushing’s disease; the full analysis on all 19 enrolled patients is expected to be available for the ENDO meeting.

Methods: There were two study groups. The ‘follow-up cohort’ (FC; n=4) comprised patients previously enrolled in LINC 1; they were off treatment with LCI699 for at least 8 months, then offered re-enrollment if their baseline UFC level was >1xULN. Twice-daily LCI699 was initiated at the penultimate dose in LINC 1 that was efficacious and tolerable; doses were escalated as needed. The ‘expansion cohort’ (EC; n=15) comprised newly enrolled patients with baseline UFC levels >1.5xULN. LCI699 was initiated at 2mg bid (or 5mg bid if baseline UFC was >3xULN), then escalated every 2 weeks to 5, 10, 20 and 30mg bid until UFC was ≤ULN; dose was then maintained, increased (up to 30mg bid) or reduced for safety reasons up to week 22. The main efficacy endpoint was the proportion of responders (defined as UFC≤ULN or ≥50% decrease from baseline) at weeks 10 and 22.

Results: Of the 19 patients enrolled, eight are included in this interim analysis (FC, n=2; EC, n=6; male:female 3:5; aged 28–51 years). 7/8 patients (87.5%; FC 2/2; EC 5/6) were responders at week 10, while 6/8 patients (75.0%; FC 1/2; EC 5/6) were responders at week 22. All responders at both time points had UFC≤ULN. No responders required a dose increase during weeks 10–22; in fact, some patients had a dose reduction during this time period. The most common investigator-reported adverse events (AEs) were asthenia (n=5) and nasopharyngitis (n=4). One patient in the EC group discontinued after week 2 because of AEs (diarrhea, muscle weakness, malaise and papule). Hypokalemia (potassium <3.5 mEq/L) developed in four patients. At week 22, three patients had ACTH levels that were more than twice baseline levels. One patient experienced a hypocortisolism-related AE. There were no serious AEs.

Conclusions: This interim analysis demonstrates that 22 weeks of treatment with LCI699 reduces UFC to ≤ULN in 75% of patients, with good tolerability. A Phase III study of LCI699 in patients with Cushing’s disease (LINC 3) is planned to start in 2014.

 

Disclosure: RP: Principal Investigator, Novartis Pharmaceuticals, Coinvestigator, Novartis Pharmaceuticals, Coinvestigator, Viropharma, Coinvestigator, IBSA, Consultant, Novartis Pharmaceuticals, Consultant, Ipsen, Consultant, Pfizer, Inc., Consultant, Viropharma, Consultant, Ferring Pharmaceuticals, Consultant, Italfarmaco, Speaker, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals. MF: Principal Investigator, Corcept, Ad Hoc Consultant, Genentech, Inc., Principal Investigator, Ipsen, Ad Hoc Consultant, Ipsen, Ad Hoc Consultant, Novartis Pharmaceuticals, Principal Investigator, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals. JY: Investigator, Novartis Pharmaceuticals. XB: Investigator, Novartis Pharmaceuticals. AHH: Speaker, Novartis Pharmaceuticals. MEM: Investigator, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Investigator, Corcept, Consultant, Corcept, Investigator, Lilly USA, LLC, Consultant, Lilly USA, LLC, Investigator, Novo Nordisk, Advisory Group Member, Novo Nordisk, Advisory Group Member, Jansen Pharmaceuticals, Advisory Group Member, Bristol Myers Squibb/AstraZeneca, Scientific Board Member, Genentech, Inc., Consultant, Merck & Co.. AS: Advisory Group Member, Novartis Pharmaceuticals. TW: Employee, Novartis Pharmaceuticals. AH: Employee, Novartis Pharmaceuticals. CT: Employee, Novartis Pharmaceuticals. NS: Employee, Novartis Pharmaceuticals. BMB: Principal Investigator, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Consultant, HRA Pharma. Nothing to Disclose: CS, TT

OR17-4 14832 4.0000 A LCI699, a Potent 11β-Hydroxylase Inhibitor, Normalizes Urinary Free Cortisol Levels in Patients with Cushing's Disease: 22-Week, Multicenter, Open-Label Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 1:00:00 PM OR17 4743 11:30:00 AM From Genetics to Clinical Trials in Pituitary Disease Oral

S Melmed*1, V Popovic-Brkic2, Martin Bidlingmaier3, M Mercado4, AJ van der Lely5, N R Biermasz6, M Bolanowski7, M Coculescu8, J Schopohl9, K Racz10, B Glaser11, M I Goth12, Y Greenman13, P J Trainer14, E Mezosi15, I Shimon16, A Giustina17, D L Kleinberg18, S L Teichman19, R Mamluk20, A Haviv20 and C J Strasburger21
1Cedars-Sinai Med Center, Los Angeles, CA, 2Clinical Center of Serbia, Belgrade, Serbia, 3Klinikum der Univ Muenchen, Munich, Germany, 4Centro Médico ABC, Mexico City, Mexico, 5Erasmus Medical Center, Rotterdam, The Netherlands, 6Leiden University Medical Center, Leiden, 7Wroclaw University, Wroclaw, Poland, 8National Institute of Endo, Bucharest, Romania, 9University of Munich, Munich, Germany, 10Semmelweis University, Budapest, Hungary, 11Hadassah Medical Center, Jerusalem, Israel, 12Military Hospital, Budapest, Hungary, 13Sourasky Medical Center, Tel Aviv, Israel, 14Department of Endocrinology, Christie Hospital, Manchester, UK, 15University of Pecs,Pecs,Hungary, 16Rabin Medical Center, Petah-Tikva, Israel, 17University of Brescia, Brescia, Italy, 18NYU Langone Medical Center, New York, NY, 19San Francisco,CA, 20Chiasma, Jerusalem, Israel, 21Charite, Berlin, Germany

 

Background:Oral octreotide acetate (OOA), a novel formulation of octreotide, is biologically active, inhibiting pituitary growth hormone (GH) secretion in healthy volunteers. Accordingly, OOA was tested for acromegaly efficacy and safety in a phase III, global, multicenter, open-label, dose-titration, baseline-controlled study.

Methods:After screening, 155 subjects shown to be controlled (defined as IGF-I levels <1.3 ULN, and 2hr integrated GH <2.5 ng/mL, measured centrally), while on 3 months of injectable somatostatin receptor ligand (SRL), were enrolled. Following OOA pre-treatment baseline establishment and after 4 weeks from last SRL injection, subjects were switched to OOA. All entered a dose escalation phase, initially receiving OOA 40 mg/day, titrated as required to 60 mg/day, and up to 80 mg/day (divided into two separate daily doses), to normalize IGF-I levels. This was followed by a fixed dose phase for up to a total duration of 7 months of OOA treatment (core treatment period). Controlled patients were then offered an additional 6-month extension phase.

Results:Of 151 evaluable subjects that initiated OOA treatment and had at least one evaluation following first dose, 98 (65%) achieved the primary endpoint of hormonal control at their last assessment during the core treatment period, with IGF-I levels <1.3 ULN and mean 2 hr GH concentrations of <2.5 ng/mL. Following individual dose titration based on IGF-I levels, 61, 33, and 57 patients reached doses of 40, 60, and 80 mg, respectively. Of the 91 subjects who were controlled (IGF-I <1.3 ULN) at the end of dose escalation, 83 (91%) maintained this response at the end of the core treatment period. A total of 102 subjects completed the core treatment period, of whom 88 (86%) elected to continue treatment in the 6 month extension phase. Twenty-four subjects (15%) were considered treatment failures due to IGF-I level >1.3 ULN and terminated prior to the end of the core period. Seventeen subjects (11%) terminated for possible drug-related adverse events (AEs), consistent with known octreotide or disease-related AEs. Ten of the early terminations were due to GI symptoms (mostly mild to moderate nausea, diarrhea, or abdominal pain). Two deaths were reported: one of myocardial infarction in a patient with pancreatic carcinoma and obstructive jaundice, and another of suspected biliary obstruction and sepsis.

Conclusions: Oral octreotide acetate exhibits efficacy in controlling IGF-I and GH levels in acromegaly patients treated for at least 7 months, following a switch from injectable SRLs with a safety profile consistent with approved SRLs. OOA is a viable option for administration as oral acromegaly monotherapy.

 

Disclosure: SM: Principal Investigator, Pfizer, Inc., Ad Hoc Consultant, Genentech, Inc., Ad Hoc Consultant, Novartis Pharmaceuticals, Ad Hoc Consultant, Ipsen. VP: Coinvestigator, Roche Pharmaceuticals. MM: Speaker, Sanofi/Ipsen, Consultant, Sanofi/Ipsen, Speaker, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals. JS: Study Investigator, Chiasma, Study Investigator, Novartis Pharmaceuticals. PJT: Advisory Group Member, Roche Pharmaceuticals, Investigator, Chiasma, Advisory Group Member, unrelated to this study/product - unpaid ad hoc advisory board member. IS: Ad Hoc Consultant, Novartis Pharmaceuticals, Ad Hoc Consultant, Pfizer, Inc., Ad Hoc Consultant, Novo Nordisk, Ad Hoc Consultant, Neopharm. DLK: Advisory Group Member, Genentech, Inc.. SLT: Employee, chiasma. RM: Employee, Chiasma. AH: Employee, Chiasma Pharma. CJS: Advisory Group Member, Chiasma. Nothing to Disclose: MB, AV, NRB, MB, MC, KR, BG, MIG, YG, EM, AG

OR17-5 12380 5.0000 A Efficacy and Safety of Oral Octreotide in Acromegaly: Results of a Multicenter Phase III Trial in 155 Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 1:00:00 PM OR17 4743 11:30:00 AM From Genetics to Clinical Trials in Pituitary Disease Oral

John Roberts*1, Margareta Linden2, Camilla Cervin2 and Fredrik Tiberg3
1Novartis Pharmaceuticals Corporation, East Hanover, NJ, 2Camurus AB, Lund, Sweden, 3Camurus AB and Physical Chemistry, Lund University, Lund, Sweden

 

Background: Although octreotide is currently the most commonly used somatostatin analog, the long-acting (LAR) formulation must be reconstituted before intramuscular injection. In this open-label, Phase I, repeat-dose study, the pharmacokinetics and pharmacodynamics of a ready-to-use depot formulation of octreotide for subcutaneous (sc) administration – octreotide Fluid Crystal (FC) – was compared with octreotide LAR.

Methods: One week after receiving a single dose of octreotide sc 200μg, healthy adult male and female volunteers were randomized to three injections of octreotide FC 30mg/month (n=14) or octreotide LAR 30mg/month (n=14). Blood samples for octreotide and insulin-like growth factor 1 (IGF-1) analyses were collected pre- and post-injection and at pre-specified time points during the study. Adverse events were recorded.

Results: With octreotide FC, a steady, rapid increase to peak concentration (Cmax) was observed, followed by a slow, exponential decrease in concentration to day 28. After the third injection of octreotide FC (steady state): mean Cmax was 29.3ng/mL (SD 7.1), mean AUC28d was 3465h•ng/mL (SD 608) and median tmax was 24 hours (range 2–24). Octreotide LAR exhibited a burst concentration peak and rapid decline to undetectable values; this rebounded by day 7, stabilized from day 10 and finally decreased around day 21. After the third injection of octreotide LAR (steady state): mean Cmax was 1.8ng/mL (SD 0.6), mean AUC28d was 733h•ng/mL (SD 222) and median tmax was 1 hour (range 0.5–360). Relative bioavailability (using AUC28d) of octreotide FC versus LAR was 487% (90% CI: 411–578). More rapid and greater IGF-1 suppression was observed with octreotide FC compared with octreotide LAR during weeks 1−2, although variation in IGF-1 levels was generally lower with the LAR formulation. Similar IGF-1 levels were noted during weeks 3−4; AUC for IGF-1 suppression was similar in the two treatment groups. Injection-site reactions and systemic tolerability was comparable across both treatment groups.

Conclusions: In healthy volunteers, octreotide FC provides greater octreotide bioavailability with a more rapid onset and similar duration of effect compared with octreotide LAR. The FC formulation offers enhanced convenience as it may be supplied in a prefilled syringe with a thin needle. A Phase III study of octreotide FC in patients with acromegaly is planned.

 

Disclosure: JR: Employee, Novartis Pharmaceuticals. ML: Employee, Camurus. CC: Employee, Camurus. FT: Employee, Camurus, Employee, Camurus.

OR17-6 15732 6.0000 A Randomized Study Demonstrating That Octreotide Fluid Crystal Provides Sustained Octreotide Bioavailability and Similar IGF-1 Suppression to Octreotide LAR (Sandostatin LAR) in Healthy Volunteers 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 1:00:00 PM OR17 4743 11:30:00 AM From Genetics to Clinical Trials in Pituitary Disease Oral

Shagufta H Khan*1 and Raj Kumar2
1The Commonwealth Medical College, Scranton, PA, 2The Commonwealth Med Coll, Scranton, PA

 

Steroid hormone receptors (SHRs) are well-validated drug targets and are prognostic indicators in several endocrine-related cancers.  Due to available LBD/AF2 crystal structures, rational structure-based design of small molecule receptor modulators (SRMs) by necessity has been limited to how compounds modulate co-regulatory protein interactions with AF2.  Clinically this phenomenon has extensively been exploited; however, most of these SRMs bind in the ligand-binding pocket and exhibit partial agonist or mixed agonist activities that may not be desirable.  Though, it has been suggested that the tissue-specific residual activity of SHRs in the presence of SRMs may mainly be mediated via AF1, yet due mainly to the intrinsically disordered (ID) conformation of N-terminal domain (NTD), therapeutic targeting of the AF1/NTD has been limited. We have found that the ID AF1 of the glucocorticoid receptor (GR) is capable of undergoing a disorder-to-order transition upon interaction with the TATA-binding protein (TBP) such that AF1-mediated specific GR coactivators binding and subsequent transcriptional activity is significantly enhanced. Further, using surface plasmon resonance (SPR) method, we determined the binding of TBP with different fragments of GR containing AF1 sequences.  Our results showed that placing AF1 immediately upstream from the DNA binding domain (DBD) leads to stronger AF1-TBP interaction whereas AF1C  (amino acids 187-244) shows a weaker binding when compared with the AF1 sequences. Biophysical analyses showed a differential pattern of AF1 folding with significantly higher helical content and subsequent enhanced binding of AF1 with steroid receptor coactivators (SRCs) upon TBP interaction which is dependent upon the AF1 flanking sequences.  These data suggest that TBP can mediate structural reorganization of the AF1/NTD to facilitate the binding of co-activators required for maximal transcriptional activation.  Targeting ID proteins by small molecules to block protein-protein interactions is a rapidly evolving field, and our findings suggest that compounds that could block AF1-TBP interaction sites may provide potential avenues to modify AF1 activity needed for additional selectivity to target cell-tissue specific gene regulations of SHRs, which could complement or replace existing SRMs actions in current endocrine-based cancer therapies.

 

Nothing to Disclose: SHK, RK

OR21-1 15062 1.0000 A A Novel Mechanism for Structure-Based Therapeutic Targeting of Steroid Hormone Receptors' N-Terminal Domain 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 1:00:00 PM OR21 4745 11:30:00 AM Novels Ways to Regulate Nuclear Receptor Function Oral

Neeti Agarwal*1, Dinakar Iyer1, Toni Oplt1, Akhil Shenoy1, Ulrich Schubert2, Jeffrey B. Kopp3 and Ashok Balasubramanyam1
1Baylor College of Medicine, Houston, TX, 2Univ. of Erlangen-Nurnberg, Erlangen, Germany, 3NIDDK/NIH, Bethesda, MD

 

Hepatic steatosis is highly prevalent among monoinfected HIV patients.  The underlying mechanisms are unknown, but it is associated with a complex metabolic disorder of adipose defects and lipodystrophy.  We have shown that the HIV-1 accessory protein Vpr can induce the adipose defects by reciprocal transcriptional co-regulation of the glucocorticoid receptor and PPARγ.

We investigated the hypothesis that Vpr can also induce hepatic steatosis by dysregulating PPARα and LXRα-mediated gene expression in liver, using two mouse models -transgenic mice expressing Vpr (Vpr-Tg) under control of the PEPCK promoter, and WT mice infused with synthetic Vpr (sVpr) for two weeks.  mRNA levels of PPARa target genes encoding fatty acid oxidative enzymes and transport proteins ƒnwere significantly downregulated in Vpr-Tg compared to WT liver (Cpt1: -23%; Aox: -23%; Lcad: -27%; Ehhadh: -50%, Hsd10: -45%, Acaa2: -34%, MTP; -34%); this was associated with 48% decrease in the ratio of pT172-AMPK to total AMPK, 30% decrease in beta-oxidation, and blunted in vivo VLDL export (at 1hr: -70%; at 2hr: -30%) in Vpr-Tg liver. Conversely, mRNA levels of LXRa target genes responsible for de novo lipogenesis were significantly upregulated in Vpr-Tg compared to WT liver (Chrebp: +99%, Srebp1c: +77%, Lpk: +217%, Dgat: +27%, Fasn: +162%, and Scd1: +300%). Total protein levels of SREBP1c and ChREBP, intranuclear protein levels of SREBP1c (but not of ChREBP) and levels of their lipogenic target gene products were increased in Vpr-Tg liver. Similar results were observed in sVpr-treated compared to vehicle-treated mice. Circulating levels of plasma adiponectin were decreased in Vpr-Tg mice (total adiponectin -30%; HMW adiponectin -34%). Oil red O staining was significantly increased in Vpr-Tg compared to WT liver (+250%).  Thin layer chromatography demonstrated increased hepatic triglyceride content in Vpr-Tg mice compared to WT (+58%). Immunoprecipitation and luciferase assays indicated that Vpr binds to LXRα (master regulator of Chrebp and Srebp1c expression) and enhances LXRa-regulated promoter activity.

HIV-1 Vpr disrupts fatty acid oxidation, de novo lipogenesis and triglyceride metabolism in liver in a manner consistent with interference with PPARa and LXRa mediated gene expression, and produces a phenotype of hepatic steatosis.  These data indicate a novel and significant role for Vpr in the pathogenesis of HIV-associated fatty liver disease.

 

Nothing to Disclose: NA, DI, TO, AS, US, JBK, AB

OR21-2 16298 2.0000 A Mechanism of HIV-Associated Hepatic Steatosis: Role of HIV-1 Accessory Protein Vpr, Pparalpha and Lxralpha 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 1:00:00 PM OR21 4745 11:30:00 AM Novels Ways to Regulate Nuclear Receptor Function Oral

Massoud Motamed*1, Kimal Rajapakshe1, Sean Michael Hartig1, Cristian Coarfa1, Robb Moses2, David M Lonard2 and Bert W O'Malley1
1Baylor College of Medicine, Houston, TX, 2Baylor College of Medicine

 

Steroid receptor coactivator 1 (SRC-1) promotes diverse gene expression programs necessary for the dynamic regulation of gluconeogenesis, cancer metastasis, and inflammation in response to external stimuli.  Adaptation to changing levels of glucose is a challenge common to both normal and malignant cells.  Here, we explored the potential for SRC-1 to function as a regulator of energy metabolism in cancer cells in response to changes in glucose availability.  We found that SRC-1 is stabilized against degradation by the 26S proteasome in the absence of glucose.  Prior studies of the SRC family had demonstrated that nuclear localization was essential for proteasomal degradation.  Consistent with this report, glucose deprivation shifts SRC-1 localization from primarily nuclear to cytoplasmic.  We utilized a series of metabolic inhibitors to identify which aspects of the glucose-deprived metabolic state are coordinated by SRC-1, leading to the identification of NAD+/NADH as essential metabolites underlying the SRC-1 response to glucose deprivation.  Transcriptome analysis revealed that SRC-1 is essential for nutrient dependent regulation of complex I of the mitochondrial electron transport chain, the enzymatic complex responsible for the conversion of NADH to NAD+.  Consistent with SRC1’s role in promoting cellular adaptation to reduced glucose availability, knockdown of SRC-1 in cells resistant to glucose deprivation induced cytotoxicity and abrogated their ability to grow in the absence of glucose.  We suggest that SRC-1 responds to glucose deprivation by sensing attendant changes in the cellular pool of NAD+/NADH to promote cell survival via transcriptional control of complex I, the NADH consuming enzyme of the electron transport chain.  Taken together these data are indicative of a feedback loop, as the NAD+/NADH ratio directly impacts SRC-1 protein levels, which thereby modulates the enzyme that utilizes NADH.

 

Nothing to Disclose: MM, KR, SMH, CC, RM, DML, BWO

OR21-3 12863 3.0000 A Steroid Receptor Coactivator 1 Is an Integrator of Glucose and NAD+/NADH Homeostasis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 1:00:00 PM OR21 4745 11:30:00 AM Novels Ways to Regulate Nuclear Receptor Function Oral

Cecilia Jazmín Proietti*1, Franco Izzo1, Mara De Martino2, Florencia Mercogliano3, Natalia M Galigniana3, Rosalia Ines Cordo Russo1, Leandro Venturutti3, Roxana Schillaci1 and Patricia Virginia Elizalde1
1Instituto de Biología y Medicina Experimental (IBYME-CONICET), Buenos Aires, Argentina, 2Instituto de Biología y Medicina Experimental (IBYME) CONICET, Buenos Aires, Argentina, 3Instituto de Biología y Medicina Experimental, CONICET, Buenos Aires, Argentina

 

Progesterone receptor (PR), signal transducer and activator of transcription 3 (Stat3) and the ErbB family of receptor tyrosine kinases (RTKs), are major players in the breast cancer scenario. We have previously demonstrated that heregulin (HRG), a ligand of RTKs, transactivates PR both in C4HD cells, from a murine progestin-dependent mammary tumor, and in the human breast cancer cell line T47D (1). We have also shown that HRG activates Stat3 by a mechanism that requires PR signaling and that this event drives breast cancer growth (2). In this work, we studied whether HRG induces PR and Stat3 interaction in the progesterone response elements (PREs) in the promoters of two endogenous genes involved in cell cycle regulation and modulated by progesterone: bcl-X and p21CIP1. By performing chromatin immunoprecipitation assays, we found that HRG induces the assembly of Stat3 and PR as a transcriptional complex in the transcription of bcl-X and p21CIP1. Notably, this complex drives in vitro and in vivo HRG-induced breast cancer growth. In addition, we found that both the cytoplasmic and nuclear functions of Stat3 are required for HRG stimulation of p21CIP1 and Bcl-XL expression and for HRG-induced proliferation of breast cancer cells, as demonstrated both by in vitro [3H]-thymidine incorporation assays and by preclinical studies in mice. We also explored the clinical significance of PR and Stat3 nuclear coexpression in breast tumors through a retrospective study in a cohort of 125 PR+ primary invasive breast carcinomas. Immunofluorescence and confocal microscopy analyses revealed that PR and Stat3 nuclear coexpression correlated with better overall survival (OS), both in the total cohort (p=0.007) and in the subgroup of patients treated with the selective estrogen receptor modulator tamoxifen (TAM) (n=115) (p=0.043). Our findings demonstrate that HRG induces the assembly of a transcriptional complex between PR and Stat3 which binds the PREs in bcl-X and p21CIP1 promoters and drives breast cancer cell growth. In addition, nuclear coexpression of PR and Stat3 was demonstrated to correlate with better OS suggesting the presence of the complex PR/Stat3 as a potential predictor of benefit from TAM therapy in breast cancer patients.

 

Nothing to Disclose: CJP, FI, MD, FM, NMG, RIC, LV, RS, PVE

OR21-4 11988 4.0000 A Heregulin Induces Breast Cancer Growth By Upregulating p21CCIP1and Bcl-XL Expression Via Assembly of a PR/Stat3 Transcriptional Complex 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 1:00:00 PM OR21 4745 11:30:00 AM Novels Ways to Regulate Nuclear Receptor Function Oral

Hector L. Franco*1, Anusha Nagari2 and W Lee Kraus1
1UT Southwestern Medical Center, Dallas, TX, 2University of Texas Southwestern Medical Center, Dallas, TX

 

The interplay between mitogenic and proinflammatory signaling pathways plays key roles in determining the phenotypes and clinical outcomes of breast cancers.  We have used global nuclear run-on coupled with deep sequencing (GRO-seq) to characterize the immediate transcriptional responses of MCF-7 breast cancer cells treated with estradiol, TNFα, or both.  In addition, we have integrated these data with chromatin immunoprecipitation coupled with deep sequencing (ChIP-seq) for estrogen receptor alpha (ERα) and the p65 subunit of the NF-κB transcription factor.  Our results indicate extensive transcriptional interplay between these two signaling pathways at the transcriptional level, which is observed for a number of genes encoding classical mitogenic and proinflammatory proteins, as well as for genes encoding long non-coding RNAs, a poorly characterized class of RNAs which have been shown to play important roles in cancer outcomes. The synergistic and antagonistic interplay between estrogen and TNFα signaling at the gene level is also evident in the patterns of ERα and NF-κB binding, which relocalize to new binding sites that are not occupied by either treatment alone.  Interestingly, the chromatin accessibility of classical ERα binding sites is predetermined prior to estrogen treatment, whereas ERα binding sites gained upon co-treatment with TNFα require NF-κB and additional factors to promote chromatin accessibility de novo.  Our data suggest that NF-κB directly impacts ERα accessibility at a subset of enhancer locations that ultimately cause changes in gene expression patterns and subsequent cellular responses.  Taken together, our results provide a mechanistic framework for understanding the molecular basis for integration of mitogenic and proinflammatory signaling in breast cancers.

 

Nothing to Disclose: HLF, AN, WLK

OR21-5 16179 5.0000 A Functional Characterization of Latent Estrogen Receptor Alpha Enhancers Unveiled By Tnfα Signaling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 1:00:00 PM OR21 4745 11:30:00 AM Novels Ways to Regulate Nuclear Receptor Function Oral

Rajas Chodankar*1, Dai-Ying Wu2, Daniel S Gerke2 and Michael R Stallcup2
1Univ of Southern California, Los Angeles, CA, 2University of Southern California, Los Angeles, CA

 

Coregulator proteins assist steroid receptors (SR) to achieve their biological effects in cells by imparting their specificities of action and modulating the transcription of several target genes in a context-dependent and gene-specific manner. It is becoming apparent that most known coregulators are not functionally equivalent, however, the factors that impact coregulator specificity are largely unknown. In this study we show that Hic-5 (TGFB1I1), a versatile coregulator with diverse mechanisms of action on different glucocorticoid regulated gene subsets, can also impart specificity by differentially regulating two different SR in the same parental cells. We analyzed global Hic-5 function by depleting its protein levels via a siRNA mediated approach combined with Illumina whole genome expression analysis in U2OS osteosarcoma cells stably expressing either the glucocorticoid receptor (GR) or estrogen receptor alpha (ERα). A comparison of the classical coactivator or corepressor function of Hic-5 with respect to GR or ERα target genes revealed that effects of Hic-5 depletion on dexamethasone (Dex) regulated genes were four times greater than its effect on estradiol (E2) regulated genes. Using endogenous co-immunoprecipitation assays of Hic-5 with GR or ERα expressing U2OS cells we found that the Hic-5 interaction with GR was much stronger compared to ERα. Similar results were obtained from transiently transfecting Cos-7 cells with tagged GR, ERα and Hic-5 plasmids which indicated that Hic-5 coregulator function partly involved its interaction with the respective SR. In addition to modulating transcription of hormone responsive genes, Hic-5 also blocked hormone regulated transcription of an additional set of genes in the U2OS-GR cells by limiting the genomic site selection of GR on the DNA response elements. We found similarly that Hic-5 could also block E2 regulation of a set of genes in the U2OS-ERα cells. Surprisingly, similar numbers of E2 “blocked” genes and Dex “blocked” genes were seen in the two cell lines (~ 200). The fact that Hic-5 interaction with ERα is weaker than its interaction with GR suggested that the mechanisms by which Hic-5 blocks E2 and Dex regulation of genes may be distinct. In summary, Hic-5 is highly selective in modulating hormone regulated expression of GR target genes compared with ERα target genes. Furthermore, its mechanism of action of blocking transcription of genes is distinct from its classical coregulator function.

 

Nothing to Disclose: RC, DYW, DSG, MRS

OR21-6 14183 6.0000 A Hic-5 (TGFB1I1): A Versatile Steroid Receptor Binding Protein That Blocks Hormonal Regulation of Genes and Shows Selectivity in Its Coregulator Function for Different Steroid Receptors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 1:00:00 PM OR21 4745 11:30:00 AM Novels Ways to Regulate Nuclear Receptor Function Oral

Juliette Anne Brown*1, Thomas Mayer1, Raluca Bugescu1, Hillary Lauren Woodworth1, Gina Marie Leinninger1 and Patrick M Fuller2
1Michigan State University, East Lansing, MI, 2Beth Israel Deaconess Medical Center Harvard Medical School, Boston, MA

 

The lateral hypothalamic area (LHA) coordinates diverse physiologic stimuli with appropriate adaptive behaviors (including feeding, drinking and locomotor behavior) to maintain energy balance.  Several neuronal populations in the LHA express orexigenic neuropeptides and play important roles in promoting arousal and food seeking.  We hypothesized that a separate population of LHA neurons expressing the anorectic neuropeptide neurotensin (Nts) exert distinct control of adaptive behaviors to regulate energy balance.  To study LHA Nts neurons we used mice that express Cre recombinase in Nts neurons (NtsCre mice) to permit the detection and manipulation of these neurons.  In contrast to adjacent orexigenic neurons, LHA Nts neurons were activated by stimuli that suppress feeding and promote locomotor activity, including the hormone leptin and dehydration (which limits feeding in lieu of promoting water seeking).  These cue-activated LHA Nts neurons project into the midbrain, where Nts has been shown to activate midbrain dopamine (DA) neurons, increase locomotor activity and decrease feeding.  To investigate the functional role of LHA Nts neurons we injected adult NtsCre mice in the LHA with either a control AAV (sham injection) or an AAV that causes Cre-mediated expression of the Diphtheria Toxin subunit A (AAV-DTA), thus permitting the selective ablation of LHA Nts neurons.  Compared to control mice the AAV-DTA injected mice exhibited decreased metabolic rate and locomotor activity that caused them to accumulate body fat.  Collectively, these data reveal that LHA Nts neurons are anatomically poised to coordinate physiologic stimuli and midbrain DA action.  Loss of action via LHA Nts neurons decreases motivated physical activity and energy expenditure to promote weight gain, suggesting that disrupted action via the LHA Nts neuronal circuit may contribute to the pathogenesis of obesity.

 

Nothing to Disclose: JAB, TM, RB, HLW, GML, PMF

OR16-1 13984 1.0000 A Loss of Action Via Lateral Hypothalamic Neurotensin Neurons Decreases Energy Expenditure and Promotes Obesity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 1:00:00 PM OR16 4751 11:30:00 AM Energy Expenditure in Obesity Oral

Jessica M. Adams*1, Miho Yamashita2, Samantha R. Spierling2, Marcelo Rubinstein3 and Malcolm James Low2
1University of Michigan, Ann Arbor, MI, 2University of Michigan Medical School, Ann Arbor, MI, 3INGEBI, CONICET, Buenos Aires, Argentina

 

Mice lacking Pomc expression specifically in the hypothalamic arcuate nucleus (ArcPOMC-KO) are more obese than either melanocortin-4 receptor (Mc4r)- or Mc3r-KO mice, but similar to compound Mc3/4r-KO mice. From this, we infer complementary roles for the two receptor subtypes in the actions of POMC-derived melanocortin peptides to regulate energy balance. Studies from other laboratories using Mcr-KO models have generated conflicting results concerning the role of the melanocortin system in locomotor activity and its contribution to altered body weight. Therefore, we studied the interaction of two interventions, free access to low-profile radiotelemetric running wheels and normalization of body weight (BW) gain by chronic food restriction, on voluntary locomotor activity and metabolic profiles of ArcPOMC-KO mice. Mutant and wild-type (WT) controls of both sexes (n = 5-6) were single-housed with or without home cage running wheels starting at age 4 wk. Another group of ArcPOMC-KO mice was weight-matched to WT mice starting at weaning and provided running wheels. Activity, food intake and BW were monitored for 8 wk and then after a 16 hr fast, blood was obtained for measurement of glucose and insulin, followed by an IPGTT (2 g glucose/kg BW). One week later, plasma was collected after a 6 hr fast for cholesterol analysis. At age 6 wk, ad libitum fed ArcPOMC-KO mice had similar total running distances as WT mice, but their activity levels soon diverged and by age 11 wk they were running significantly less than WT mice (Male: 8,200 ± 5,800 vs 30,000 ± 5,200; Female: 3,900 ± 6,900 vs 37,300 ± 7,300 revolutions/24hr; P < 0.001), although their circadian activity pattern remained intact. Consequently, unlike previous reports using Mc4r-KO mice, ArcPOMC-KO mice of both sexes showed a minimal reduction in food intake and BW and no improvement in their abnormal fasting glucose, glucose tolerance, insulin, HOMA-IR or total cholesterol compared to the mutant mice without running wheels. In contrast, all of these metabolic parameters were normalized in the weight-matched ArcPOMC-KO mice with running wheel access, even though their nocturnal running was significantly less than that of WT mice (Male: 16,800 ± 7,100 vs 30,000 ± 5,200; Female: 10,700 ± 9,500 vs 37,200 ± 7,200 revolutions/night; P < 0.01) and not different from the obese mutants (Male 8,100 ± 5,700; Female 3,800 ± 6,800 revolutions/night) . However, a new peak of wheel running occurred in the 4 hr preceding lights off, when the food-restricted mice received their daily allotment of chow, suggesting the development of food-anticipatory locomotor activity. In conclusion, ArcPOMC-KO mice exhibit persistent hypolocomotor behavior when their BW has been matched to WT levels, indicating that this phenotype is a primary feature of POMC-deficiency and likely contributes to the development of obesity rather than being a consequence of it.

 

Nothing to Disclose: JMA, MY, SRS, MR, MJL

OR16-2 16289 2.0000 A Normalization of Body Weight Gain By Food Restriction Does Not Correct the Decreased Voluntary Wheel Running Activity of Neuronal Pomc-Deficient Mice but Improves Their Metabolic Profile 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 1:00:00 PM OR16 4751 11:30:00 AM Energy Expenditure in Obesity Oral

Marie S Thearle*1, Mathias Schlögl2, Susan M Bonfiglio2 and Jonathan Krakoff2
1National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ, 2Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ

 

Individual variation in the energy expenditure (EE) response to fasting or to overfeeding (OF), particularly with diets unbalanced in macronutrient content, may confer differing susceptibilities to obesity. We hypothesized that the EE increase with 24h of OF with 4 different diets varying in macronutrient content would have a large intra-individual component that would be related to the EE response to 24h of fasting, and that we would be able to identify phenotypes associated with body adiposity. EE over 24h was measured in 53 subjects (19 NA/14 W/9 H/11 B; 42 male; age 37±10 y; %body fat (DXA) 28.3±10.0%; mean±SD) with normal glucose regulation in a whole room indirect calorimeter during energy balance (EB), fasting, and OF conditions. OF was done 4 separate times in random order with a 3 day washout period in between OF diets; subjects consumed twice their caloric requirements with varying macronutrient content as follows:  50% carbohydrates (C), 30% fat (F), 20% protein (P) (BOF); 26% C, 44% F, 30% P (HPF); 75% C, 5% F, 20% P (CNP); 20% C, 60% F, 20% P (FNP). The %EE increase over EB was largest with the HPF and CNP diets (HPF 14.3±6.8, CNP 14.0±5.7, BOF 10.7±5.4, FNP 9.3±4.8%; p<0.0001 for the comparisons between CNP and HPF v FNP and BOF; 2-way ANOVA with Tukey’s test for post hoc comparisons). The contribution of the individual response to OF explained 49% of the variance in the %EE increase; the diets given explained 13% of the variance. The %EE increase averaged over all 4 OF diets (11.3±4.3%) was negatively correlated with %body fat (β=-0.17%; p=0.03 after adjusting for age, sex, race and diet). Smaller decreases in 24h EE with fasting (mean±SD: -8.1±5.0%) were correlated with greater increases in EE with OF (r=0.46, p=0.0005). If subjects were categorized into high v low EE changes with OF or fasting based on a median divide, 18 subjects had both high increases with OF plus low decreases with fasting (‘spendthrift’), and another 18 subjects had small increases with OF plus large decreases with fasting (‘thrifty’). The ‘spendthrift’ group had a lower average %body fat than the ‘thrifty’ group (23.2±9.2%v 32.4±9.3; p=0.005). Results were similar if women were excluded.  EE responses to OF and fasting are correlated, and phenotypes defined by responses to extreme dietary changes are related to adiposity. More or less efficient phenotypes may provide insight into individual differences in propensity for weight gain.

 

Nothing to Disclose: MST, MS, SMB, JK

OR16-3 13157 3.0000 A Energy Expenditure Response to 24 Hours of Overfeeding and Fasting Are Related to Adiposity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 1:00:00 PM OR16 4751 11:30:00 AM Energy Expenditure in Obesity Oral

Marc L Reitman*1, Beth Lute2, William Jou2, Dalya Lateef2, Margalit Goldgof2, Cuiying Xiao2, Ramon A. Pinol2, Alexxai Kravitz2, Yuning George Huang2, Clemence Girardet3, Andrew Butler4 and Oksana Gavrilova5
1NIDDK/NIH, Bethesda, MD, 2NIDDK, NIH, 3The Scripps Research Institute, Jupiter, FL, 4Saint Louis University School of Medicine, St Louis, MO, 5NIDDK, NIH, Bethesda, MD

 

The melanocortin system regulates metabolic homeostasis and inflammation.  Melanocortin agonists have contradictorily been reported to both increase and decrease metabolic rate and body temperature.  We find that these are two distinct physiologic responses occurring at similar doses. Intraperitoneal administration of the nonselective melanocortin agonist MTII causes a melanocortin-4 receptor (Mc4r) mediated hypermetabolism/hyperthermia.  This is preceded by a profound, transient hypometabolism/hypothermia that is preserved in mice lacking any one of Mc1r, Mc3r, Mc4r, or Mc5r.  The hypothermia is actively achieved via seeking a cool environment, unrestrained heat loss, and inhibition of brown adipose tissue thermogenesis.  These results suggest that the hypometabolic/hypothermic effect of MTII is not due to a failure of thermoregulation.  The hypometabolic/ hypothermic response (but not the accompanying hypotension) was prevented by dopamine antagonists and MTII selectively activated dopaminergic neurons in the arcuate nucleus; these neurons may contribute to the hypometabolism/hypothermia.  We propose that the hypometabolic/ hypothermic response is organized, regulated, and potentially physiologically beneficial.

 

Nothing to Disclose: MLR, BL, WJ, DL, MG, CX, RAP, AK, YGH, CG, AB, OG

OR16-4 14609 4.0000 A Biphasic Effect of Melanocortin Agonist Mtii on Metabolic Rate and Body Temperature 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 1:00:00 PM OR16 4751 11:30:00 AM Energy Expenditure in Obesity Oral

Ranganath Muniyappa1, Kong Chen1, Robert J Brychta1, Brent Samuel Abel1, Katherine Mullins1, Pamela Staker1, Lex H T Van der Ploeg2, Hillori Connors2, Keith Gottesdiener2, Marc L Reitman1 and Monica C. Skarulis*1
1NIH, Bethesda, MD, 2Rhythm Metabolic, Inc, Boston, MA

 

The melanocortin system integrates neural, metabolic, and hormonal signals to regulate energy homeostasis and body weight.  Previous studies of the cyclic peptide MC4R agonist, RM-493, demonstrated decreased body weight in nonhuman primates (Kievit et al., Diabetes, 62:490, 2013).  Phase II clinical studies in general obesity are ongoing.  This is the first human study to test the hypothesis that a MC4R agonist increases energy expenditure.  

Twelve weight-stable, healthy adults (6 M, 6 F; BMI 35.7 ± 2.9 [mean, SD]) were randomized to receive RM-493 (1 mg/24h) or placebo by continuous subcutaneous infusion over 72h, followed immediately by crossover to the other treatment.   All received a weight-maintenance diet (50% carb, 30% fat) and performed 30 minutes of standardized exercise daily as inpatients.  None of the subjects carried MC4R pathological variants.  RM-493 plasma levels reached steady state by 24h of treatment; no period effect was observed in the results.  REE was measured on the third treatment day in a room calorimeter at thermoneutrality in the post-absorptive state as the mean of two 30-minute periods.  RM-493 increased REE vs. placebo by 6.85% (95% CI: 0.68, 13.02%), on average by 111 kcal/24h (95% CI: 15, 207 kcal, p=0.03).  REE measured by hood method also tended to increase with RM-493 treatment (4.72 ± 8.14%, p=0.06).  24h EE tended to be higher while the thermic effect of a test meal and exercise EE did not differ significantly.  The 24h respiratory quotient (RQ) was lower during RM-493 treatment (0.833 ± 0.021 vs. 0.848 ± 0.022, p=0.02).  RM-493 treatment was associated with slightly higher fasting plasma free fatty acid (0.445 ± 0.089 vs. 0.327 ± 0.071 mEq/L, p=0.01),  glucose (94.9 ± 5.8 vs. 91.1 ± 3.6 mg/dl, p=0.002), insulin (26 ± 16 vs. 19 ± 12 mcU/mL, p=0.007), TSH (1.86 ± 1.00 vs. 1.51 ± 0.72 mU/L, p=0.009), T3 (112 ± 16 vs. 105 ± 13 ng/dl, p=0.02) and free T4 (1.02 ± 0.09 vs. 0.98 ± 0.12 ng/dl, p=0.03).  These changes were small, and their clinical relevance needs to be established in larger trials.  No adverse effects on heart rate or blood pressure were observed.  Few side effects occurred; all were mild and resolved completely. 

In obese subjects, RM-493 increased REE by 6.85% and lowered RQ compared to placebo.  The mechanism underlying the increase in REE cannot be determined in this small 12 patient study.  The observed subtle increase in thyroid function is interesting.  Acute administration of RM-493 increases REE and shifts substrate oxidation to fat.

 

Disclosure: LHTV: Management Position, Rhythm Metabolic Inc. HC: Employee, Rhythm Metabolic Inc. KG: Chief Executive Officer, Rhythm Metabolic . Nothing to Disclose: RM, KC, RJB, BSA, KM, PS, MLR, MCS

OR16-5 16059 5.0000 A A Randomized, Double-Blind, Placebo-Controlled, Crossover Study to Evaluate the Effect of a Melanocortin Receptor 4 (MC4R) Agonist, RM-493, on Resting Energy Expenditure (REE) in Obese Subjects 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 1:00:00 PM OR16 4751 11:30:00 AM Energy Expenditure in Obesity Oral

Amy K Sutton*1, Hongjuan Pei2, Korri H Burnett2, Martin Grosvenor Myers Jr.3, Christopher John Rhodes4 and David P Olson5
1University of Michigan, Ann Arbor, 2University of Michigan, 3Univ of Michigan, Ann Arbor, MI, 4Kovler Diabetes Center, University of Chicago, Chicago, IL, 5University of Michigan, Ann Arbor, MI

 

The paraventricular nucleus of the hypothalamus (PVH) contains a heterogeneous cluster of Sim1-expressing cell types that form the major autonomic output nucleus from the hypothalamus.  PVH neurons play critical roles in the control of food intake and energy homeostasis; however, the various roles of specific PVH neuronal subtypes in energy balance have yet to be defined.  Nitric oxide synthase-1 (Nos1) is expressed in a subset of Sim1-expressing PVH (Sim1PVH) neurons but their function in energy balance is unknown.  To determine the role of Nos1PVH neurons in feeding and energy expenditure, we employed Cre-dependent viral vectors to both map efferent projections and test their functional output.  We show that Nos1PVH neurons project to hindbrain and spinal cord regions important for food intake and energy expenditure control, respectively.  Moreover, pharmacogenetic activation of Nos1PVH neurons suppresses feeding to a similar extent as Sim1PVH neurons and increases energy expenditure and locomotor activity.  Furthermore, we found that oxytocin-expressing PVH neurons (OXTPVH) are a subset of Nos1PVH neurons.  OXTPVH cells project to pre-ganglionic, sympathetic neurons in the thoracic spinal cord and increase energy expenditure upon activation.  Somewhat surprisingly, their activation fails to alter feeding.  Thus, Nos1PVH neurons promote negative energy balance through changes in feeding, energy expenditure and activity.  This suggests a crucial role for non-OXT Nos1PVH neurons in the central regulation of energy balance.

 

Nothing to Disclose: AKS, HP, KHB, MGM Jr., CJR, DPO

OR16-6 15094 6.0000 A Nos1 Neurons in the Paraventricular Nucleus of the Hypothalamus Control Food Intake and Energy Expenditure 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 1:00:00 PM OR16 4751 11:30:00 AM Energy Expenditure in Obesity Oral

Ola Nilsson1, Michael Guo2, Nancy S Dunbar3, Jadranka Popovic4, Daniel P Flynn5, Christina Jacobsen6, Julian Lui7, Joel N Hirschhorn8, Jeffrey Baron*9 and Andrew Dauber10
1NICHD, NIH, Bethesda, MD, 2Harvard Medical School, Boston, MA, 3Connecticut Children's Medical Center, Hartford, CT, 4Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, 5Children's Hosp of Pittsburgh, Pittsburgh, PA, 6Chldrn's Hosp Boston, Boston, MA, 7NICHD, Bethesda, MD, 8Boston Children's Hospital, Boston, MA, 9NIH, Bethesda, MD, 10Boston Childrens' Hospital, Boston, MA

 

Short stature is frequently associated with delayed skeletal maturation. Short stature with advanced skeletal maturation occurs far less often. We used whole-exome sequencing to study three families with autosomal dominant short stature and advanced skeletal maturation. Affected family members presented with childhood short stature (height SDS -1.9 to -3.5), advanced bone age, early growth cessation, and adult short stature (height SDS -2.6 to -4.0). No endocrine explanation for short stature or advanced bone age was detected in any affected individual. All affected individuals had brachydactyly. Affected individuals in family 3 also had osteochondritis dissecans and early onset osteoarthritis. Less consistent features included macrocephaly, midface hypoplasia, and exaggerated lumbar lordosis. Whole exome sequencing identified novel heterozygous variants in the aggrecan gene (ACAN), which encodes a proteoglycan that serves as a major structural component of the extracellular matrix in growth plate and other cartilaginous tissues.  The sequence variants were present in all affected but in none of the unaffected family members. In family 1, a novel frameshift mutation in exon 3 (c.272delA) was identified, which is predicted to cause early truncation of the aggrecan protein. In family 2, a base-pair substitution was found in a highly conserved location within a splice donor site (c.2026+1G>A), which is also likely to alter the amino acid sequence of a large portion of the protein. In family 3, a missense variant (c.7064T>C) in exon 14 affects a highly conserved residue (L2355P) and is strongly predicted to perturb protein function. Our study indicates that heterozygous mutations in ACAN cause a mild skeletal dysplasia that presents as short stature with advanced bone age and early growth cessation. In the few previously reported families with ACAN mutations, short stature and articular disease has been noted, but the accelerating effect on skeletal maturation has not previously been described. Our findings thus expand the spectrum of ACAN defects and provide a new molecular genetic etiology for the unusual child who presents with short stature and accelerated skeletal maturation.

 

Nothing to Disclose: ON, MG, NSD, JP, DPF, CJ, JL, JNH, JB, AD

OR24-1 12606 1.0000 A Whole-Exome Sequencing Identifies ACAN Mutations in Autosomal Dominant Short Stature with Accelerated Skeletal Maturation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 1:00:00 PM OR24 4753 11:30:00 AM The Genetics of Growth: Pediatric Endocrinology Oral

Sarah L Kerns1, Jaime Guevara-Aguirre2, Shayne F Andrew3, Juan Geng4, Carolina Guevara5, Marco Guevara-Aguirre5, Michael Guo6, Yiping Shen4, Andres Zurita2, Ron G Rosenfeld3, Harry Ostrer7, Vivian Hwa8 and Andrew Dauber*9
1Icahn School of Medicine at Mount Sinai, New York, NY, 2Universidad San Francisco, Quito, Ecuador, 3Oregon Health and Science University, Portland, OR, 4Boston Children's Hospital, Boston, MA, 5Institute of Endocrinology, Metabolism, and Reproduction, Quito, Ecuador, 6Harvard Medical School, Boston, MA, 7Albert Einstein College of Medicine of Yeshiva University, New York, NY, 8Oregon Hlth Sci Univ, Portland, OR, 9Boston Childrens' Hospital, Boston, MA

 

The CDKN1C gene encodes a cyclin dependent kinase inhibitor that negatively regulates cellular proliferation. CDKN1C is a paternally imprinted gene, meaning that only the maternal allele is expressed and translated into functional protein. Mutations in CDKN1C are associated with several growth disorder syndromes. Loss-of-function mutations in CDKN1Cresult in Beckwith-Wiedemann Syndrome, which is characterized by prenatal overgrowth and embryonal tumors. Gain-of-function variants cause IMAGe Syndrome, which presents with intrauterine and postnatal growth retardation, adrenal hypoplasia, genitourinary anomalies in males, and metaphyseal dysplasia. Recently, loss-of-function of CDKN1C has been implicated as a possible mechanism in some cases of neonatal hyperinsulinism due to beta cell hyperplasia.

We studied a large six-generation family with 18 individuals affected by intrauterine growth retardation, severe short stature, and onset of diabetes in early adulthood. The pedigree followed a paternally imprinted pattern of inheritance. We performed genomewide linkage analysis of 14 individuals, using an Affymetrix 6.0 SNP array and identified a single genomewide significant 2.6 Mb linkage region on chromosome 11p15 (LOD 3.4).  Exome sequencing of 5 individuals resulted in identification of a single novel nonsynonymous variant in the region: a missense variant (p.R281I) in CDKN1C. Segregation analysis via Sanger sequencing showed that all subjects with the clinical phenotype carried this variant. MLPA analysis did not reveal any copy number variants or abnormalities in methylation in the region. This missense variant lies within the PCNA binding domain of CDKN1C, two amino acids downstream of the cluster of mutations found to cause IMAGe syndrome. Upon further phenotyping, our subjects did not demonstrate any evidence of adrenal insufficiency, with normal serum ACTH concentrations, but male subjects were uniformly found to have small testicular volumes. Subjects did not have metaphyseal dysplasia. Average height SDS of affected individuals was -5.01 versus -1.96 for controls. Typical age of onset of diabetes was in the mid-30s and was responsive to lifestyle modification and metformin. This family represents an important extension of the phenotypic spectrum of defects in CDKN1C and highlights the possibility of defects in CDKN1C resulting in a novel form of monogenic diabetes.

 

Nothing to Disclose: SLK, JG, SFA, JG, CG, MG, MG, YS, AZ, RGR, HO, VH, AD

OR24-2 12657 2.0000 A Novel Variant in CDKN1C Associated with Intrauterine Growth Restriction, Short Stature, and Early-Adulthood Onset Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 1:00:00 PM OR24 4753 11:30:00 AM The Genetics of Growth: Pediatric Endocrinology Oral

Jurgen Klammt1, David Neumann2, Shayne F Andrew*3, Doris Vokurkova2, Heike Stobbe1, Kyle Buckham3, Ron G Rosenfeld3, Roland Pfäffle4 and Vivian Hwa3
1University of Leipzig, Leipzig, Germany, 2University Hospital Hradec Kralove, Czech Republic, 3Oregon Health and Science University, Portland, OR, 4University of Leipzig, Dept. of Women´s & Child Health, Leipzig, Germany

 

Background: GH insensitivity (GHI) is caused by disturbances of GH receptor function or inability to transduce the hormone signal within the cell. Affected children are severely growth retarded and may also present with immune complications when the signaling protein STAT5B is defective. Only autosomal-recessive STAT5B mutations have been described to date.

Clinical case: Two male monozygotic twins were born after 36 weeks of an uneventful gestation. At the age of 14.5 years they presented with an identical height of 131.5 cm (-5.3 SDS). Bone age of the index patient was retarded by 4.9 years. Endocrine evaluation revealed normal stimulated GH serum concentrations (16.2 ng/ml) but IGF-1 levels were borderline detectable (56 µg/l) indicative of GH resistance. At that time rhIGF-1 therapy was commenced (0.12 mg/kg twice daily) but only a modest catch-up growth could be observed. At 17.1 years his height was 149.0 cm (-4.33 SDS) and weight 42.0 kg (-3.49 SDS). Biochemical evaluation re-confirmed the GH resistant state with reduced IGF-1 and ALS levels (102.7 µg/l, -5.13 SDS; 418 pmol/l, reference range 986-1678, respectively). IGFBP-3 was in the low-normal range (2.33 mg/l, -1.69 SDS). Interestingly, prolactin concentrations (290.6 mU/l, reference range 86-324) were normal as was GHBP concentrations. In addition to severe short stature, the proband also presented with eczema and mild respiratory infections during early life  but was otherwise healthy. Immunological phenotyping was unremarkable, although elevated IgE concentration (340.0 kU/l, normal < 114) was noted. Evaluation of the twin brother yielded similar results.

Molecular analysis of genomic DNA revealed a novel heterozygous variant in the STAT5B gene (c.530A>C, exon 5; p.Gln177Pro) that was not found in the parents, suggesting a de novo germline mutation, nor was the variant listed in > 6000 individuals investigated in the Exome Sequencing Project (https://esp.gs.washington.edu/drupal/) or the NCBI SNP data base. No additional variant(s) with potential pathological effects was identified in the GH1, GHR, IGFALS, IGF1, or IGF1R genes. Functional evaluation of the FLAG-STAT5B p.Gln177Pro variant (HEK293 reconstitution studies) indicated that although protein expression and GH-induced phosphorylation was comparable to wild-type FLAG-STAT5B, the Gln177Pro substitution compromised the transcriptional functions of the phosphorylated FLAG-STAT5B p.Gln177Pro as the variant could not translocate to the nucleus, and, furthermore, the variant could limit nuclear localization of the wild-type STAT5B.

Conclusion:  We describe, for the first time, a de novo heterozygous p.Gln177Pro STAT5B mutation with potential dominant-negative properties, implicated in clinical manifestations that are comparable to previously reported STAT5B deficient patients but with less severe co-morbidities.

 

Nothing to Disclose: JK, DN, SFA, DV, HS, KB, RGR, RP, VH

OR24-3 14941 3.0000 A Severe Short Stature and GH Insensitivity Due to a De Novo Heterozygous STAT5B Missense Mutation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 1:00:00 PM OR24 4753 11:30:00 AM The Genetics of Growth: Pediatric Endocrinology Oral

Julian Lui*1, Crystal Cheung2, Zhongyu Zhu3, Dimiter Dimitrov3 and Jeffrey Baron4
1NICHD, Bethesda, MD, 2National Institute of Health, Bethesda, MD, 3National Cancer Institute, Frederick, MD, 4NIH, Bethesda, MD

 

Growth plate function can be severely impaired in many acquired systemic disorders and in genetic disorders, including skeletal dysplasias, in which the bones are typically short and malformed, causing disability. Current medical therapies have limited efficacy for severe disease, with doses limited by effects on tissues other than growth plate cartilage. Recent studies have identified many paracrine factors that act in the growth plate to positively regulate chondrogenesis, and therefore might be used therapeutically if they could be targeted to growth plate cartilage. Similarly, targeting growth-promoting endocrine factors, such as growth hormone and insulin-like growth factor-I, specifically to the growth plate could potentially enhance therapeutic efficacy while diminishing adverse effects on non-target tissues. Therefore, we sought to identify polypeptides that would bind to cartilage tissue with high affinity and specificity and could be used to target therapeutic molecules specifically to the growth plate.

Based on previous expression microarray in the growth plate and soft tissues, matrilin-3 was selected as the cartilage-specific molecule for antibody development. Matrilin-3 is a cartilage matrix protein that is expressed at >500-fold higher levels in the tibial growth plate as compared to 7 other organs (liver, kidney, lung, heart, muscle, spleen, intestine) by quantitative real-time PCR (P<0.001, ANOVA). Using yeast display technology, we selected three single-chain variable human antibody fragments that bound with high affinity to both human and mouse recombinant matrilin-3. These antibody fragments bind not only to purified matrilin-3 protein, but also to mouse cartilage homogenates with high specificity (ELISA signal >20-fold higher than other tissue homogenates). The antibody fragments also bound with high specificity to cartilage structures in mouse embryo sections, as assessed by immunohistochemistry. When injected intravenously in mice, these antibody fragments preferentially homed to cartilage but not to other organs, as shown by ELISA signal specifically in homogenates of epiphyseal cartilage from the injected mice. We envision that coupling of these cartilage-binding antibody fragments to endocrine and paracrine signaling molecules that promote chondrogenesis could allow therapy targeted specifically to growth plate, thereby opening up broad new pharmacological approaches to treat skeletal dysplasias and other severe forms of linear growth failure.

 

Disclosure: JL: Coinvestigator, Provisional Patent Filed. JB: Coinvestigator, Provisional Patent Filed. Nothing to Disclose: CC, ZZ, DD

OR24-4 14027 4.0000 A Human Monoclonal Antibody Fragments for Targeting Therapeutics to Growth Plate Cartilage 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 1:00:00 PM OR24 4753 11:30:00 AM The Genetics of Growth: Pediatric Endocrinology Oral

Alexsandra C Malaquias*1, Michelle B Moraes1, Antonio M Lerario1, Ericka Barbosa Trarbach1, Miguel Mitne-Neto2, Alexandre C Pereira3, Debora R Bertola4, Milena Gurgel Teles5 and Alexander Augusto Lima Jorge1
1Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 2Fleury Medicina e Saude, São Paulo, Brazil, 3Instituto do Coraçao (InCor) da FMUSP, Sao Paulo, Brazil, 4Instituto da Crianca da Faculdade de Medicina da USP, Sao Paulo, Brazil, 5Fleury Medicina e Saúde, São Paulo, Brazil

 

Introduction: Noonan syndrome (NS) is an autosomal dominant disorder mainly characterized by dysmorphic facial features, congenital heart disease, postnatal short stature and chest deformities. Genes belonging to the RAS/MAPK pathway are known to be causative of NS. Moreover, a group of Noonan-related disorders (NRD), sharing some clinical features with NS, were also found to be caused by genes of the same pathway. The molecular investigation of NS/NRD is carried out by Sanger sequencing of several genes associated with these disorders. The order of the genes to be studied is determined by the frequency of mutations in each gene and by the genotype-phenotype correlation, which often results in expensive, laborious and time-consuming investigations.

 

Objectives: Development of a next generation sequencing (NGS) based genetic test for NS and NRD patients.

 

Subjects and Methods: We evaluated a targeted exon-capture strategy followed by massive parallel sequencing on the Ion Torrent platform. We selected 31 patients with previously identified pathogenic mutation in NS/NRD genes (9 PTPN11, 6 SOS1, 7 BRAF, 2 RAF1, 3 SHOC2, 3 KRAS and 1 HRAS). We designed a custom 123 kb oligonucleotide microarray targeting all exons of 12 genes with known involvement in NS or NRD and 20 additional NS candidate genes. Ten individual samples were multiplexed prior to sequencing in an Ion 316 chip. All samples were analyzed anonymously and previously identified mutations were not provided to the investigators performing the bioinformatics mutation analysis until the final report was finalized.

 

Results: Analysis of the sequence data revealed uniform coverage by 197,456 reads per patient (mean coverage 130x) and generated high-coverage (99% capture at ≥10x coverage in coding sequences). We identified a total of 497 single nucleotide variants, 179 of them were exonic and 71 were considered non-synonymous. One sample has failed the sample enrichment and had low coverage of target regions, for this reason it was excluded from further analysis. Twenty-seven pathogenic missense heterozygous mutations were identified in 28 patients. A second round analysis including indels, identified an inframe deletion previously associated with NS. Overall, the targeted NGS correctly identified a pathogenic mutation in 29 of 30 analyzed patients (sensitivity of 97%). Each patient had only one pathogenic variant. In the only patient without mutations identified by NGS, a BRAF mutation previously identified by Sanger sequencing was not confirmed by NGS. However, further analysis revealed that the first reported of this mutation was a false positive result. We did not identify potential pathogenic allelic variant in the novel candidate genes included in this study.

 

Conclusion: Array based target enrichment followed by NGS showed the same accuracy of Sanger sequencing. Therefore, NGS is ready for implementation in a diagnostic setting.

 

Nothing to Disclose: ACM, MBM, AML, EBT, MM, ACP, DRB, MGT, AALJ

OR24-5 13045 5.0000 A Targeted High-Throughput Sequencing of RAS/MAPK Pathway Genes for Diagnosis of Noonan Syndrome (NS) and Noonan-Related Disorders (NRD) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 1:00:00 PM OR24 4753 11:30:00 AM The Genetics of Growth: Pediatric Endocrinology Oral

Shweta Ramdas*1, Amita Adhikari1, Amanda McGinnis1, Sarah L Ward1, Goncalo Abecasis1, Robert C. Brumbaugh1, Jun Z. Li1 and Jessica Schwartz2
1University of Michigan, Ann Arbor, MI, 2Univ of Michigan Med Sch, Ann Arbor, MI

 

For insight into genetic contributions to variations in human stature, we have been analyzing DNA of the Mountain (Mt) Ok people of Telefomin, PNG, a group which is among the shortest on record worldwide. Adult height falls below the fifth percentile for males and females, compared to US and WHO standards, as documented under traditional lifestyle (early 1980’s) and persisting after sociocultural changes 25 yr later.  Serum GH and IGF1 were not deficient and serum albumin and prealbumin were consistent with adequate protein nutrition.  We genotyped 14 females and 13 males over 247K variant loci using the HumanExome Beadchip, a platform mainly for studying rare protein-coding variants (about 20K loci with minor allele frequency MAF>0.05), and compared the Mt Ok with similar data for 1,013 subjects from 52 countries in the Human Genome Diversity Panel (HGDP).  Mt Ok samples yielded high-quality data, and principal component analysis verified that they clustered closely with known Papuan samples (17) in HGDP and were distinct from other Melanesian samples. Identification of genomic segments shared identically by descent (IBD) between pairs of samples revealed over 10 times as many segments among the Mt Ok than among Papuans, with longer mean lengths for the former, consistent with the relative isolation of these Mt Ok people in Telefomin. We tested genetic association with the height phenotype, measured as the z-score in the worldwide distribution, with sex as covariate.  The z-scores ranged -4.9 to –1.2 for males and from -3.0 to -0.7 for females who were analyzed.  A variant in the COLGALT2 gene, encoding collagen beta(1-O)galactosyltranferase 2, showed significant association with height in an additive model (p = 9.45E-7). Gene-set enrichment of 182 nominally significant (p < 0.01) variants did not reveal significant pathway enrichment, although 23 of these genes were previously implicated in height or growth regulation. Analysis using the recessive model identified an associated variant (p = 1.1E-8) in LOXL1, encoding the Lysyl oxidase-like1 protein, which is involved in formation of cross-links in collagen. Logistic regression of PNG samples vs Papuan samples in HGDP, adjusted with sex, did not identify variants reaching genomewide significance.  However, pathway analysis of 518 genes in 995 nominally significant variants identified multiple enriched pathways (FDR < 0.05), including fibronectin type III, plasma membrane and nucleotide/nucleoside binding.  These preliminary findings are suggestive that Mt Ok people carry genetic variations associated with collagen formation, which may be associated with short stature in this population.  Work in progress is extending these observations to additional Mt Ok subjects, and may direct functional studies of genes associated with collagen and relevant cell pathways to evaluate their potential roles in human stature.

 

Nothing to Disclose: SR, AA, AM, SLW, GA, RCB, JZL, JS

OR24-6 16456 6.0000 A Genetic Analysis of the Mountain Ok People, a Short Stature Population in Papua New Guinea (PNG), Using Exome Chip Genotyping Data 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 1:00:00 PM OR24 4753 11:30:00 AM The Genetics of Growth: Pediatric Endocrinology Oral

Andrea Maria Mueller1, Kathrin A Schmohl2, Alexandra Wechselberger2, Kerstin Knoop1, Nathalie Schwenk1, Peter J Nelson2 and Christine Spitzweg*3
1University Hospital of Munich, Germany, 2University Hospital of Munich, Munich, Germany, 3University Hospital of Munich, LMU Munich, Munich, Germany

 

Mesenchymal stem cells (MSCs) are actively recruited into the tumour stroma, where they differentiate into carcinoma-associated fibroblast (CAF)-like cells, thereby forming the tumour’s fibrovascular network. There is growing evidence that thyroid hormones T3 and T4 play a critical role in the formation of the stroma by stimulation of angiogenesis, proliferation and inflammation – effects that are mediated through non-genomic mechanisms via the integrin αvβ3. Tetrac, a deaminated T4 derivative, is an inhibitor of thyroid hormone action at the integrin site. To improve the understanding of the effects of thyroid hormones on tumour stroma formation, we examined the effects of T3, T4 and tetrac on MSC biology in vitro.

Primary human bone marrow derived CD34- MSCs were grown in hepatocellular carcinoma cell-conditioned medium (cHCC medium) supplemented with 1 nM T3 or T4 with or without 100 nM tetrac for 14 days. Changes in expression levels of genes associated with CAF-like differentiation were analysed by quantitative real time PCR. In a second experiment, MSCs were treated with 1 nM or 100 nM T3 for 24 hours and their ability to migrate towards cHCC medium was monitored by time-lapse microscopy.

Treatment of MSCs with 1 nM T3 or T4 resulted in increased mRNA levels for various genes associated with CAF-like differentiation: (1) surface marker fibroblast activating protein; (2) indicator of tissue remodelling/invasion tenascin C; (3) markers of neovascularisation α-smooth muscle actin, desmin and vascular endothelial growth factor; (4) tumour promoting growth factors interleukin-6, transforming growth factor β1, stromal cell-derived factor 1, basic fibroblast growth factor, epidermal growth factor and hepatocyte growth factor. All the T3- and T4-triggered increases in expression levels were found to be tetrac-dependent and therefore integrin αvβ3-mediated. Furthermore, pre-treatment of MSCs with 1 nM or 100 nM T3 resulted in a 24% or 51% increase, respectively, in MSC migration towards cHCC medium parallel to the gradient between normal medium and cHCC medium, compared to untreated cells.

Our data suggest that T3 and T4 regulate the expression of MSC genes associated with CAF-like differentiation and enhance tumour signal-directed chemotaxis. These studies will increase our understanding of the mechanisms that regulate MSC differentiation and migration as a critical part of tumour stroma formation and for utilisation of MSCs as gene delivery vehicles.

 

Nothing to Disclose: AMM, KAS, AW, KK, NS, PJN, CS

OR25-1 16994 1.0000 A Effects of Thyroid Hormones T3 and T4 on Mesenchymal Stem Cell Differentiation and Migration 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 1:00:00 PM OR25 4762 11:30:00 AM Thyroid Hormone Action Oral

Yasuhiro Kyono*1, Laurent M. Sachs2, Preeti Ramadoss3, Anthony Neil Hollenberg4 and Robert J Denver5
1University of Michigan, Ann Arbor, MI, 2Muséum National d'Histoire Natur, Paris Cedex 05, France, 3Beth Israel Deaconess Med Cntr, Boston, MA, 4Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 5Univ of MI, Ann Arbor, MI

 

Postembryonic brain development is critically dependent on thyroid hormone (T3), the actions of which are mediated by T3 receptors (TRs). The TRs modify chromatin structure by recruiting histone-modifying enzymes. In addition to histone modifications, dynamic regulation of DNA methylation by de novo DNA methyltransferases (Dnmts) is important for gene regulation and has been implicated in neuronal and glial cell differentiation. From our preliminary data we hypothesized that T3 modulates DNA methylation in the developing brain by regulating Dnmt genes. Gene expression analysis in Xenopus tadpole brain using real-time reverse transcriptase quantitative PCR (RTqPCR) and in situ hybridization histochemistry showed that dnmt3a mRNA increased during metamorphosis, was widely distributed throughout the tadpole brain except in neurogenic zones, and could be induced in premetamorphic tadpoles by treatment with T3. Using chromatin immunoprecipitation (ChIP) sequencing for TR; targeted ChIP for TR, histone 3 (H3) and acetylated H3; electrophoretic mobility shift and transfection-reporter assays we identified two T3 response elements (T3REs) in the frog dnmt3a locus, one at 7.1kb upstream and another within the second intron at 4.5kb downstream of the predicted translation start site. These findings prompted us to investigate whether Dnmt3a was also a direct TR target gene in mouse brain. Dnmt3a mRNA analyzed by RTqPCR increased in the hippocampal region and cerebellum during the first three postnatal weeks, which corresponds to a time when plasma [T3] rises. Injection of T3 in postnatal day 6 mice induced Dnmt3a mRNA in the hippocampal region. Treatment of the mouse neuroblastoma cell line Neuro2a[TRb1] induced Dnmt3a mRNA with rapid kinetics, and this was resistant to protein synthesis inhibition. Using similar assays in mouse as in frog we identified two T3REs in mouse Dnmt3a, one at 30.1 kb and another at 49 kb downstream of the transcription start site. The 30.1 kb T3RE is within the second intron of mouse Dnmt3a and may be homologous to the intronic frog Dnmt3a T3RE. Our findings support that T3 can influence DNA methylation in the developing brain through direct regulation of Dnmt3a gene transcription, and that this is an ancient pathway in tetrapods that arose prior to the divergence of the amphibian and amniote lineages.

 

Nothing to Disclose: YK, LMS, PR, ANH, RJD

OR25-2 15012 2.0000 A Thyroid Hormone Receptors Directly Regulate Transcription of the De Novo DNA Methyltransferase Dnmt3a Gene in the Developing Brain 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 1:00:00 PM OR25 4762 11:30:00 AM Thyroid Hormone Action Oral

Anita Kinne*1, Katrin Manuela Hinz1, Melanie Wittner1, Josef Koehrle2 and Gerd Krause1
1Leibniz-Institut fuer Molekulare Pharmakologie (FMP), Berlin, Germany, 2Charite University Medicine Berlin, Berlin, Germany

 

Thyroid hormones (TH) are transported across cell membranes by monocarboxylate transporters MCT8 and MCT10 but also by other transmembrane transporter proteins such as the L-type amino acid transporters (Lat). However, the role of Lat2 in TH transport including the transport mechanisms was unclear.

Therefore, TH substrate specificity of Lat2 was determined. Lat2 is a sodium independent amino acid exchanger and requires association with CD98 for its cell surface expression. By using oocytes from Xenopus laevis for TH transport studies by Lat2 we observed a preferential uptake of 3,3`-T2 and its strong competition by TH metabolites such as 3-T1 and other T2 isomers. In comparison to 3,3’-T2 only limited T3 uptake was detectable. Uptake of rT3 and T4 was not observed for Lat2. 

Insight into structure-function relationships was obtained by homology modelling and site directed mutagenesis, which revealed structural determinants of Lat2 involved in TH transport. The Lat2 model is based on crystal structures of two proteins sharing sequence homology with Lat2, the arginine/agmantine antiporter (AdiC) and the amino acid polyamine and organocation transporter. We utilized the bound arginine at AdiC to predict the substrate binding site at Lat2. This enabled model-guided mutagenesis of Lat2 residues and thus we identified by in vitro studies positions in transmembrane helices 1, 3 and 5 sensitive for TH transport. These are either responsible for a common transport mechanism or for selective substrate recognition at Lat2.

Taken together we report for Lat2, (i) that it is involved in the transport of 3,3`-T2, (ii) that it likely has a similar substrate binding site as AdiC and we  (iii) localized residues involved in transport mechanisms of Lat2. Thus, we conclude Lat2 might contribute to termination of TH action by mediating influx and/or efflux of 3,3’-T2, which is generated either by T3 inactivation or by rapid Dio1-mediated rT3 degradation.

 

Nothing to Disclose: AK, KMH, MW, JK, GK

OR25-3 13697 3.0000 A Identification of Lat2 As a T2 Transporter and First Insights into Structure-Function Relationships 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 1:00:00 PM OR25 4762 11:30:00 AM Thyroid Hormone Action Oral

Kazuya Takahashi*1, Fumihiko Furuya1, Hiroki Shimura2 and Tetsuro Kobayashi1
1University of Yamanashi, Chuo, Yamanashi, Japan, 2Fukushima Medical University, Fukushima-shi, Japan

 

The pancreatic β-cell mass plays an essential role in determining the amount of insulin. In pancreatic β cells, chronic endoplasmic reticulum (ER)-stress lead to β cell death and contributing to the pathogenesis of diabetes. We reported the role of ligand-bound thyroid hormone receptor (TR) α in β-cell replication and in expansion of the β-cell mass during postnatal development. It is indicates that TR α is critical for postnatal pancreatic β-cell maintenance. To investigate the association between TRα and the survival of pancreatic β-cells under ER-stress, we fed TRα-deficient (TRα 0/0) mice and wild type (WT) mice with high-fat diet (HFD) for 30 weeks, analysed the glucose tolerance and the pathological findings of pancreas. HFD-fed TRα 0/0 had higher blood glucose levels and lower plasma insulin levels compared with HFD-fed WT mice. On glucose tolerance test, 30 min after glucose intraperitoneal injection of glucose solution, the blood glucose level was maximal in mice. HFD-fed TRα0/0 mice had significantly higher glucose levels compared with HFD-fed WT mice. The insulinogenic index between 0-30 min (the 30-minute insulin response divided by the 30-minute glucose level) was significantly decreased in HFD-fed TRα0/0 mice compared with that in HFD-fed WT mice (0.09 ± 0.02 vs. 0.69 ± 0.42, p<0.05). These data suggested that HFD-treatment reduces insulin secretion in the pancreas of TRα0/0 mice and raises glucose levels. The numbers of β-cells were significantly enhanced in HFD-fed WT mice, but not in HFD-fed TRα 0/0 mice. The ratio of TUNEL-positive cells was significantly increased in HFD-fed TR α0/0 mice. The expression of activating transcription factor 4 (ATF4), which contributes to adaptation to oxidative stress,was observed  in the pancreatic β-cells of HFD-fed WT mice, but not in that of HFD-fed TRα 0/0 mice. The expression levels of 8-hydroxydeoxyguanosine were enhanced in the β-cells of HFD-fed TRα 0/0 mice. These results indicate that endogenous TRα plays an important role for the expression of ATF4 and facilitates reduced apoptosis pancreatic β-cells under ER-stress.

 

Nothing to Disclose: KT, FF, HS, TK

OR25-4 14398 4.0000 A Impair Oxidative Endoplasmic Reticulumstress Response Caused By Deficiency of Thyroid Hormone Receptor α 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 1:00:00 PM OR25 4762 11:30:00 AM Thyroid Hormone Action Oral

Jeong Won Park*, Li Zhao, Dong wook Kim and Sheue-Yann Cheng
NIH - Nat'l Cancer Inst, Bethesda, MD

 

Significant progress has recently been made in the understanding of the mechanisms by which thyroid hormone receptors (TRs) mediate the biological activities of T3 in growth, differentiation, and development. However, an important question of how TRβ1 functions as a tumor suppressor in cancer cells is yet to be fully investigated. In the present study we explored how TRβ acted as a tumor suppressor in breast cancer MDA cells. Proliferation and invasiveness of cells were markedly inhibited by the stably expressed TRβ1 in MDA cells (MDA-TRβ cells) as compared with control cells (MDA-Neo cells). By screening cells with a panel of kinase inhibitors, we found that TRβ1 was phosphorylated by Src kinase at Y406. Phosphorylation of Y406 was coupled with T3-induced degradation of TRβ1. To further characterize functional consequences of phosphorylation at Y406, we mutated Y406 to Phe (TRβ1Y406F). TRβ1Y406F exhibited similar T3 affinity as the wild-type TRβ1. But the protein level of TRβ1Y406F remained stable when cells were treated with T3, further confirming that phosphorylation at Y406 signaled T3-induced degradation of TRβ1. Moreover, the proliferation rate and the extent of invasiveness were higher in MDA cells stably expressing TRβ1Y406F (MDA-TRβY406F cells) than in MDA-TRβ cells, suggesting TRβ1Y406F had gained oncogenic activity. Co-immunoprecipitation assays indicated that more TRβ1Y406F than wild-type TRβ1 was physically associated with Src, leading to activation of Src signaling as evidenced by increased phosphorylated Src (Y416).  Moreover, STAT, the downstream effector of Src signaling, was activated by increased phosphorylation at Y705, leading to elevated c-MYC and Cyclin D3 protein levels to increase cell proliferation. In addition, activation of STAT led to higher protein levels of MMP9 and cleaved MMP2 in MDA-TRβY406F cells than in MDA-TRβ cells, resulting in increased invasiveness in MDA-TRβY406F cells. Elevated integrins α5, β1, and αv were recruited by Src-TRβ1Y406F complex to remodel the cytoskeletal complex involving α-actinin, p-paxillin, and talin to increase migration of MDA-TRβY406F cells. That TRβ1Y406F had gained oncogenic activities was further confirmed in xenograft models in that injection of MDA-TRβY406F cells induced large tumors while tumor development was suppressed in MDA-TRβ cells. These findings indicate that phosphorylation of the T3-bound TRβ1 by Src at Y406 triggered TRβ1 degradation. The degradation of the TRβ1 perturbed the Src-TRβ1-integrin complex such that the Src-STAT signaling was markedly attenuated to suppress cell proliferation and invasiveness, thus confirming TRβ1 as a tumor suppressor. The stable association of TRβ1Y406F with Src led to constitutive activation of Src signaling to drive oncogenesis. The present study elucidated a novel mechanism by which TRβ1 functions as a tumor suppressor via Src-dependent phosphorylation.

 

Nothing to Disclose: JWP, LZ, DWK, SYC

OR25-5 12806 5.0000 A Src-Dependent Phosphorylation at Tyr406 Confers the Tumor Suppressor Function of Thyroid Hormone Receptor β 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 1:00:00 PM OR25 4762 11:30:00 AM Thyroid Hormone Action Oral

Ksenia N Tonyushkina*1, Stefanie Krug1, Tibor Mascari2 and Rolf O Karlstrom2
1Baystate Children's Hospital, Springfield, MA, 2University of Massachusetts, Amherst, MA

 

Abnormal Thyroid Hormone (TH) levels during embryogenesis have been shown to affect the thyroid stimulating hormone (TSH) set point postnatally, suggesting a link between embryonic TH levels and the maturation of negative feedback regulation in the hypothalamic-pituitary-thyroid (HPT) axis (1, 2). Clinically, in a subgroup of infants born with congenital hypothyroidism, TSH secretion is resistant to suppression by TH (3).  The mechanism underlying this “TH-resistance” remains unknown.  Using the zebrafish as an evolutionarily conserved model for HPT axis development, we recently showed that hyperthyroid conditions experienced during embryonic development lead to thyrotrope apoptosis and a depletion in the early thyrotrope pool (4). Here, we examine the effects of hypothyroid conditions on thyrotrope development in early larval zebrafish.

In this study we exposed larval zebrafish to the goiterogen 6-propyl-2-thiouracil (PTU), which blocks production and conversion of thyroxine (T4) to triiodothyronine (T3) by type I iodothyronine deiodinase.  PTU was previously shown to effectively reduce TH levels in teleosts and affect thyrotrope counts in the juvenile zebrafish pituitary (5).  Using a transgenic line in which the green fluorescent protein (GFP) is expressed under the control of the tshß promoter [TG(tshß:EGFP)],we quantified thyrotropes following exposure to 0.65mM PTU starting at 4 hours post fertilization (hpf). Thyrotropes were quantified at 2, 3, 4, 5, 7, 14 and 21 days post fertilization (dpf) using confocal microscopy.

Thyrotope numbers were increased in the presence of PTU starting at 5 dpf, 1-2 days after formation of thyroid follicles (6). PTU treatment led to a 44% increase in thyrotropes at 5 dpf (p<0.01).  At 7 dpf and 21 dpf, PTU treatment led to 45% (p< 0.001) and 66% (p<0.01) increases in thyrotrope numbers, respectively.  These increases in the thyrotrope population would be expected to lead to augmented TSH secretion, thus these findings suggest that functional feedback regulation in the HPT axis is established at larval stages around the time thyroid hormone production begins in the thyroid follicles.  We are now examining the mechanisms underlying thyrotrope expansion, and determining if increased thyrotrope numbers persist and contribute to TH-resistance later in life.  These studies promise to shed light on the mechanism for relative thyrotrope resistance to TH levels in postnatal mammals.

 

Nothing to Disclose: KNT, SK, TM, ROK

OR25-6 12948 6.0000 A Effects of Hypothyroidism on Thyrotrope Development in Zebrafish 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 1:00:00 PM OR25 4762 11:30:00 AM Thyroid Hormone Action Oral

Zara Zelenko*1, Laya Rajan1, Ashley Polin2, Derek LeRoith1 and Emily Jane Gallagher1
1Icahn School of Medicine at Mount Sinai, New York, NY, 2Icahn School of Medicine at Mount Sinai

 

Type 2 Diabetes (T2D) and obesity are both associated with an increased risk of cancer development. Elevated total cholesterol, low-density lipoprotein cholesterol, and triglycerides are frequently found in patients with T2D and obesity. Epidemiological studies report that dyslipidemia is associated with a greater risk of breast cancer progression and mortality. We previously found increased mammary tumor growth and pulmonary metastasis in hypercholesterolemic apolipoprotein E null (ApoE-/-) mice, compared to wild-type mice, when both were fed a cholesterol-rich diet. In this study we aimed to determine if hypercholesterolemia could drive the growth and metastasis of orthotopic human triple negative breast cancers. We crossed Rag-1 null (Rag-/-) mice with ApoE-/- mice; Rag-/- have no mature B or T lymphocytes and therefore represent an immunodeficient mouse model for inoculating human cell lines. 6-8 week old female Rag-/- and Rag-/-ApoE-/- mice were placed on a cholesterol-rich diet for 4 weeks. After 4 weeks serum cholesterol levels of Rag-/-ApoE-/- mice were nearly 5-fold higher than Rag-/- controls, 957.9±27mg/dl and 206.9±3mg/dl respectively, p<0.05 . 7x106 MDA-MB-231 and 2x106 MDA-MB-468 cells were injected orthotopically into 12 week old Rag-/- and Rag-/-ApoE-/- mice. Rag-/-ApoE-/- mice developed significantly larger tumors than control mice; MDA-MB-231 (435.41±87mm3 vs 183.79±20mm3, p<0.01) and MDA-MB-468 (291.50±36mm3 vs 65.42±8mm3, p<0.01). In addition, Rag-/-ApoE-/- mice developed more numerous pulmonary metastases than control mice. Western blot analysis of primary tumors show a significant increase in phospho-p38MAPK in MDA-MB-231 tumors from Rag-/-ApoE-/- mice compared to controls. In addition, MDA-MB-468 tumors from Rag-/-ApoE-/- show a significant decrease in E-cadherin expression. In vitro studies of MDA-MB-468 cells stimulated with cholesterol show an increase in phospho-p38MAPK and a decrease in E-cadherin expression. Overall, the data support the role of hypercholesterolemia in promoting primary tumor growth, increased pulmonary metastases, and epithelial-to-mesenchymal transition (EMT) in the primary tumor. These findings enhance our understanding of the effect of hypercholesterolemia on breast cancer progression.  Our ongoing studies aim to further decipher the mechanisms through which hypercholesterolemia enhances breast cancer progression.

 

Nothing to Disclose: ZZ, LR, AP, DL, EJG

OR19-1 15383 1.0000 A Hypercholesterolemia Enhances the Growth and Metastasis Human Triple Negative Breast Tumors in Immunodeficient Apolipoprotein E Null Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 1:00:00 PM OR19 4767 11:30:00 AM Metastasis & Tumor Progression; Neoplasia of Endocrine Tissues Oral

Tae Gyu Oh*1, Peter Bailey1, Eloise Dray2, Joel Goode1, Natalie Eriksson1, John W Funder3, Peter J Fuller4, Evan R Simpson3, Wayne D Tilley5, Peter J Leedman6, Christine L Clarke7, Sean Grimmond1, Dennis H Dowhan1 and George E. O. Muscat1
1Institute for Molecular Bioscience, University of Queensland, St Lucia QLD, Australia, 2Translational Research Institute, Woolloongabba QLD, Australia, 3Prince Henry's Institute of Medical Research, Clayton VIC, Australia, 4MIMR-PHI Institute and Monash University, Clayton VIC, Australia, 5University of Adelaide, Adelaide, Australia, 6Western Australian Institute for Medical Research, University of Western Australia, Perth WA, Australia, 7estmead Millennium Institute, Sydney Medical School, Westmead, University of Sydney, Sydney NSW, Australia

 

The epigenetic modification machinery includes Histone methyltransferases (HMTs) which methylate lysine or arginine residues and modify histones, cofactors and DNA binding proteins. There is an exponentially increasing body of literature indicating aberrant HMT expression and activity drives human disease. Importantly, there has been progress in developing compounds to modulate HMTs, allowing them to be therapeutically exploited. Specifically, arginine methylation by Protein arginine methyl transferases 1-8 (PRMTs) impact on a range of processes including, carcinogenesis and metastasis through changes involving transcription and RNA splicing. PRMTs function as coregulators for the nuclear hormone receptor (NR) dependent transactivation. NRs are hormone dependent DNA binding proteins that translate endocrine, metabolic and patho-physiological signals into gene regulation. The role of PRMT2-dependent signaling in breast cancer is emerging. We demonstrate protein arginine methyltransferase-2 (PRMT2) mRNA expression was significantly reduced in breast cancer relative to normal breast. Gene expression profiling, and pathway analysis following PRMT2-siRNA transfection into MCF-7 cell demonstrated that PRMT2-dependent gene expression is implicated in cell-cycle checkpoint control, kinetochore stability, DNA repair and carcinogenesis. PRMT2 depletion reduced cell migration and lower PRMT2 expression improves the probability of distant metastasis-free survival (DMFS). The expression of PRMT2 and retinoid-related orphan receptor gamma (RORγ) is inversely correlated in ER+ve breast cancer and increased RORγ expression enhances DMFS. Moreover, we observed the genes decreased after PRMT2-diminution are significantly associated with the probability of DMFS. Finally, weighted gene co-expression network analysis demonstrated a significant correlation between PRMT2-dependent genes, and cell-cycle checkpoint, kinetochore and DNA repair “circuits”. We observed that PRMT2 expression effected RAD51-dependent homologous recombination repair of DNA double stranded breaks. PRMT2-depleted cells exhibit high levels of gene conversion in a plasmid-based assay, which is the hallmark of DNA damage accumulation and a highly unstable genome.  Further, bioinformatics analysis revealed the PRMT2-dependent “circuits” are associated with pan-cancer metagene signatures associated with epithelial-mesenchymal transition and chromosomal instability. This study identifies the role and significant association between a histone methyltransferase (PRMT2)-dependent signature, RORγ, and DNA repair “circuits” in breast cancer survival outcomes.

 

Nothing to Disclose: TGO, PB, ED, JG, NE, JWF, PJF, ERS, WDT, PJL, CLC, SG, DHD, GEOM

OR19-2 16473 2.0000 A Breast Cancer and Metastasis Free Survival Are Effected By PRMT2 and Rorγ; Expression: Understanding the Role of DNA Repair 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 1:00:00 PM OR19 4767 11:30:00 AM Metastasis & Tumor Progression; Neoplasia of Endocrine Tissues Oral

Craig E Barcus*1, Elizabeth Holt2, Patricia Keely3, Kevin Eliceiri3 and Linda A Schuler4
1University of Wisconsin-Madison, Madison, WI, 2UW-Madison, 3University of Wisconsin-Madison, 4Univ of WI, Madison, WI

 

Estrogen receptor alpha (ERα) positive tumors constitute the majority of breast cancers.  While anti-estrogen therapies are effective for the majority of these tumors, resistant ERα+ tumors result in the majority of breast cancer deaths.  The mechanism(s) underlying the treatment failures is poorly understood; however, the hormone prolactin (PRL) is implicated in the progression of these tumors.  We previously reported that the stiffness of collagen extracellular matrices (ECM) strongly influences the outcome of PRL signals.  Stiff matrices, such as those surrounding advanced carcinomas, promote pro-tumorigenic PRL outcomes, specifically increasing signals through the FAK-SFK-ERK1/2 signaling cascade and invasion, whereas compliant matrices, mimicking physiological ECM, do not. PRL treatment also alters the alignment of stiff collagen matrices, which orient collagen fibers perpendicularly to the cells, enhancing invasion through the ECM (1).  In order to investigate the effect of matrix stiffness on 17β-estradiol (E2) signals and crosstalk with PRL, we cultured the luminal breast cancer cell lines, T47D and MCF-7, in compliant (1.2 mg/ml) and stiff (2.8 mg/ml) 3-D collagen matrices.  Matrix stiffness only moderately influenced E2-induced transcripts, and did not alter E2-induced cell growth, or phosphorylation of ERK1/2 in both cell lines.  However, addition of PRL significantly increased E2-induced cell growth of T47D cells in stiff matrices compared with compliant matrices.  Interestingly, PRL decreased E2-induced growth of MCF-7 cells in compliant but not stiff matrices, and increased invasion in stiff matrices.  These differences in the influence of matrix stiffness on outcomes of both E2 signals alone and PRL-E2 crosstalk between cell lines underscore the importance of cell context in hormonal responses.  Inhibition of JAK2 abrogated PRL-induced cell growth regardless of matrix stiffness, yet inhibition of SRC-family kinases (SFKs) only altered PRL effects in stiff collagen matrices, implicating SFKs as key mediators in the pro-tumorigenic stiff matrix environment in both cell lines.  Together, our results indicate that stiff extracellular matrices strongly enhance pro-tumorigenic crosstalk between E2 and PRL in luminal breast cancer cells, suggesting that PRL may be a key component of estrogen mediated tumor progression.

 

Nothing to Disclose: CEB, EH, PK, KE, LAS

OR19-3 14958 3.0000 A Stiff Collagen Matrices Enhance Pro-Tumorigenic Effects of PRL on Estrogen Actions in Luminal Breast Cancer Cells in Vitro 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 1:00:00 PM OR19 4767 11:30:00 AM Metastasis & Tumor Progression; Neoplasia of Endocrine Tissues Oral

Alice C Levine*1, Sudeh Izadmehr2, Grace Liao3, Amanda Leiter4, Shen Yao3, Shoshana Yakar5 and Alexander Kirschenbaum6
1Mt Sinai Med Ctr, New York, NY, 2Mount Sinai School of Medicine, New York, NY, 3Mount Sinai School of Medicine, 4Icahn School of Medicine at Mount Sinai, 5New York University College of Dentistry, New York, NY, 6Mount Sinai School of Medicine, New York

 

Background: Bone metastases are the major cause of morbidity and mortality in prostate cancer (PCa). While there are treatments for the osteolytic phase of PCa bone metastases, there are no therapies that inhibit the later osteoblastic phase.  Prostatic acid phosphatase (PAP) is a protein secreted by PCa cells and is highly expressed in PCa osteoblastic bone metastases. We previously demonstrated that PAP secreted by PCa cells induces the proliferation and differentiation of osteoblasts (OB) and modulates both autocrine (PCa cell) and paracrine (osteoblast) expression of RANK ligand (RANKL) and osteoprotegerin (OPG) to favor osteoblastogenesis over osteoclastogenesis. 

Hypothesis: Forced overexpression of PAP in the PAP-negative human prostate cancer cell line PC3-M will convert bone reaction in vivo from osteolytic to osteoblastic.

Methods: The PC3-M subline of the PC3 line, derived from human PCa bone metastases, does not express secretory PAP and induces an osteolytic bone reaction in vivo when directly inoculated into the tibiae of immunocompromised mice.  PC3-M cells were stably transfected to overexpress PAP.  Overexpression of PAP was confirmed by RT-PCR, Western blot and ELISA.   Male nu/nu mice (6-8 week old) were inoculated intratibially with either WT-PC3M-luc or PAP-PC3M-luc (10 mice per group). Noninvasive in vivo whole-body bioluminescent imaging (WBI) to determine luciferase activity in bone of tumor-bearing mice was performed every 14 days using the IVISÒ Imaging System (Xenogen). X-rays of inoculated tibiae as well as contra lateral (non-tumor bearing) tibiae were performed just prior to sacrifice of the animals, 8 weeks after intratibial inoculation.  Micro-CT of formalin fixed bones was performed utilizing the Skyscan micro-CT system.

Results: IVIS, X-ray, Micro-CT and histomorphometry demonstrated that 10/10 mice bearing WT-PC3M-luc had tumors and 7/10 mice bearing PAP-PC3M-luc had tumors in the tibiae.  In the WT-PC3M-luc group, all bone lesions were osteolytic as assessed by both X-ray and Micro-CT.  In contrast, of the 7 tumor bearing mice in the PAP-PC3M-luc group, 2 were mixed osteoblastic/osteolytic and 5 were osteoblastic.

Conclusions: Forced overexpression of PAP in the human PCa cell line PC3-M converts the bone phenotype from osteolytic to osteoblastic after intratibial inoculation in a mouse model.  These studies provide critical proof-of-principle data implicating secretory PAP produced by PCa cells in bone as a causal factor in the late, incurable, osteoblastic phase of PCa bone metastases and provide a rationale for the development of PAP inhibitors to treat osteoblastic PCa bone metastases.

 

Nothing to Disclose: ACL, SI, GL, AL, SY, SY, AK

OR19-4 13144 4.0000 A Prostatic Acid Phosphatase Secreted By Prostate Cancer Cells in Bone Metastases Induces an Osteoblastic Phenotype 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 1:00:00 PM OR19 4767 11:30:00 AM Metastasis & Tumor Progression; Neoplasia of Endocrine Tissues Oral

Delmar Muniz Lourenco Jr.*1, Rodrigo A Toledo2, Tomoko Sekiya3, Marmo Lucon3, C C Castro3, L A Bortolotto3, Sergio P A Toledo4 and Patricia L Dahia2
1University of Sao Paulo, Sao Paulo SP, Brazil, 2UTHSCSA, San Antonio, TX, 3University of Sao Paulo, Brazil, 4Univ of Sao Paulo Schl of Med, Sao Paulo SP, Brazil

 

CONTEXT: Germline TMEM127mutations are associated with familial pheochromocytoma (PHEO) and rarely with paragangliomas (PGL).

OBJECTIVE: To investigate the clinical expression and tumor penetrance in a large PHEO family due to a germline TMEM127mutation.

DESIGN, SETTING, AND PARTICIPANTS: At-risk family members were genetically screened and mutation-positive individuals were monitored for clinical features of the disease.

MAIN OUTCOME MEASURES: TMEM127genetic testing was provided to at-risk relatives and clinical surveillance and/or PHEO diagnosis was performed in mutation carriers.

 RESULTS: A total of 93 at-risk family members from a six-generation family were genetically tested and 47 of them were positive for the c.410-2A>C (IVS3-2A>C; p.L138fs) TMEM127 mutation. Relevant clinical data were collected from 34 genetically affected cases with follow up time of 9.7 +/- 7.1 y (2-20). Eleven mutation carriers (11/34; 32.3%) presented PHEO with mean age at clinical diagnosis 41.6 +/-10.5 y (22-55). Symptoms compatible with PHEO started at 31.5 +/- 12.2 y (17-55). The mean follow up time was 13.8 +/- 7.2 y (2-20).  Bilateral PHEOs were detected in 3 cases (28%).131I-MIBG scan was positive in 5 of  9 (56%) tumors. Adrenalectomy was performed in all 11 cases and tumor size at surgery varied from 6-40mm. Histological diagnosis of PHEO was confirmed and two of the bilateral cases presented multicentric tumors within the same adrenal gland.  No metastases or PGLs were detected. Penetrance of PHEO progressively increased with age, from 0% (0-20y) to 32.4% (51-65 y). No other tumors or recurrent clinical features were observed in mutation carriers.

 CONCLUSIONS: We describe clinical and genetic data of the largest reported TMEM127-positive family. Our data reinforce the predominance of benign and adrenal PHEO in TMEM127 mutation carriers. The occurrence of bilateral and multicentric tumor indicates the need of periodic surveillance after adrenalectomy. TMEM127 genetic testing should be actively offered for all at-risk relatives. The penetrance of PHEO increases after age 30, but remains lower than other PHEO susceptibility genes (33% at 65 y). Periodic adrenal imaging studies (MRI/CT) starting at age 20 y were particularly helpful for detecting PHEO in TMEM127 mutation-positive carriers, although they may performed at any age in symptomatic carriers. No other recurrent clinical features were noted in mutation carriers.

 

Nothing to Disclose: DML Jr., RAT, TS, ML, CCC, LAB, SPAT, PLD

OR19-5 16363 5.0000 A Clinical Features and Penetrance of Pheochromocytoma in a Large Family with a Germline TMEM127 Mutation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 1:00:00 PM OR19 4767 11:30:00 AM Metastasis & Tumor Progression; Neoplasia of Endocrine Tissues Oral

Yilun Deng*, Yuejuan Qin, Subramanya Srikantan, Anqi Luo and Patricia L Dahia
UTHSCSA, San Antonio, TX

 

We previously identified TMEM127 as a tumor suppressor gene involved in susceptibility to the neural crest tumor pheochromocytomas, and more recently also in renal cell carcinomas. Using cell lines depleted for TMEM127 by siRNA and mouse embryonic fibroblast (MEFs) derived from a Tmem127 knockout (KO) model that we recently generated, we reported that loss of TMEM127 leads to disrupted formation of hybrid early-to-late endosomal vesicles by Rab5 GTPase accompanied by activation of mTOR, implicating TMEM127 in early endosomal function. However, the mechanism through which mTOR is activated by TMEM127 loss remains unclear. To address this gap and further investigate the role of Tmem127 in other endosomal compartments, we now expanded the study into the late endosome/lysosome compartment, which is now recognized as an important platform for activation of many signaling pathways, including mTOR. We found that late endosomal and lysosomal vesicles, identified by Rab7-and LAMP2-positive puncta, respectively, are larger and more numerous in KO than wild-type (WT) MEFs (p<0.05). Moreover, transcription of several lysosomal genes, including genes encoding for multiple vacuolar ATPase (vATPase) subunits, which are components of the lysosome-tethered complex that regulates mTOR, and Mcoln1, a non-selective cation channel that is involved in lysosomal fusion with other membranes, is also upregulated in Tmem127 KO MEFs. Similarly, protein levels of the lysosomal marker LAMP2 are more abundant in the null cells. These data support increased lysosomal function in null Tmem127. Next, we investigated whether the enhanced lysosomal mass of Tmem127 KO cells could affect mTOR signaling. By confocal microscopy we found that the degree of mTOR colocalization with lysosomal vesicles is increased in null MEFs after amino acid exposure (p<0.05), consistent with a higher proportion of lysosomal-bound, active mTOR in Tmem127 null cells. Next, we found that TMEM127 coimmunoprecipitates with LAMTOR1/p18, a component of the Ragulator, a multiprotein complex that binds to vATPase and tethers mTOR to the lysosomal surface upon amino acid-induced activation. Further, Tmem127 KO cells show increased LAMTOR1 and vATPase protein expression, suggesting that Tmem127 may control their function and/or stability. In support of this idea, Tmem127 null cells are resistant to the decrease in mTOR signals mediated by inhibition of vATPAses. Taken together, these results suggest a model whereby TMEM127 exerts an inhibitory effect on mTOR signaling through its association with the Ragulator/vATPase lysosomal complex.  This work builds on a growing appreciation of the role played by the endolysosome system in cancer signaling and highlights possible opportunities for therapeutic development via modulation of endosomal pathways.  

Nothing to disclose: all authors. This work was supported by CPRIT and DOD-CDMRP awards.

 

Nothing to Disclose: YD, YQ, SS, AL, PLD

OR19-6 13162 6.0000 A A Lysosomal Role for the Pheochromocytoma Tumor Suppressor TMEM127 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 1:00:00 PM OR19 4767 11:30:00 AM Metastasis & Tumor Progression; Neoplasia of Endocrine Tissues Oral

Jaime Guevara Aguirre*1, Arlan L Rosenbloom2, Priya Balasubramaniam3, Enrique Teran1, Marco Guevara Aguirre4, Jannette Saavedra4, Patricio Procel4 and Valter D Longo3
1Universidad San Francisco de Quito, Quito, Ecuador, 2University of FL College of Medicine, Gainesville, FL, 3University of Southern California, 4Instituto de Endocrinologia IEMYR

 

We have reported absence of diabetes and protection from cancer in a unique cohort with growth hormone receptor deficiency (GHRD) from southern Ecuador (1). This report presents further information about the effects of lifelong absence of GH action, providing insight into the relationship of body composition, hormonal status, and disease risk. We propose that the absence of GH action is associated with marked insulin sensitivity that prevents the development of diabetes and reduces the risk for cancer, despite increased percentage body fat. We studied carbohydrate, lipid, and adipocytokine concentrations in an adult population of 27 GHRD and 35 comparably overweight control subjects, metabolic responses to a standard breakfast in 7 GHRD and 11 control subjects, and oral glucose tolerance tests (OGTT) in 7 GHRD and 7 controls. Despite matching for age & BMI, GHRD subjects had consistently greater mean % body fat (~50%) and lower lean/fat per DXA. Fasting insulin, 2 hour blood glucose, VLDL, and triglyceride levels were all significantly lower in the 27 subjects with GHRD, indicative of insulin sensitivity; both cholesterol (C) and HDL were elevated with comparable C/HDL, and LDL was elevated (P <0.001), consistent with dependence of the LDL receptor on GH action. The indicator of insulin sensitivity, HOMA2%S, was more than twofold greater in GHRD (261 ± 133 vs 108 ± 87, P<0.0001) and the measure of insulin resistance, HOMA2-IR, 1/3 that of controls in GHRD (0.59 ± 0.51 vs 1.74 ± 1.84, P<0.01). High molecular weight adiponectin (HMWA) was greater in GHRD (7.59 ± 4.07 mg/L vs 4.29 ± 2.89, P<0.001) and leptin lower (7.3 ± 4.7 ng/mL vs 10.4 ± 5.2, P<0.05). Although GHRD subjects were ~65% of the weight of controls but consumed the same quantity of standard breakfast (~1000 cal, 114 g CHO, 47 g fat, 40 g protein), their mean glucose concentrations during the 300 minute study were significantly lower (P<0.01) with mean insulin levels 1/3 those of controls (11.4 ± 4.2 vs 33.1 ± 15.5, P<0.01). Glucose and insulin results of the 2 hour OGTT were similar. The area under the curve for triglyceride responses to the mixed meal during the 1st 150 minutes did not differ but was significantly less from to 180 to 300 minutes in the GHRD. We have demonstrated marked insulin sensitivity despite high percent body fat in GHRD, as well as absence of leptin resistance and elevated levels of HMWA inconsistent with typical obesity associations. Because GHRD eliminates direct metabolic effects of GH, the most straightforward explanation for the dissociation of obesity and insulin resistance in this group is the lack of the counterregulatory/diabetogenic effect of GH. Because it is likely that the obesity associated hyperinsulinism is acting as a mitogen (directly and via the type 1 IGF receptor and hybrids) to explain increased cancer risk with obesity, the reduced cancer mortality with GHRD is likely also a benefit of their insulin sensitivity.

 

Nothing to Disclose: JG, ALR, PB, ET, MG, JS, PP, VDL

LB-OR02-1 17794 1.0000 A Enhanced Insulin Sensitivity in Subjects with Absent Growth Hormone Receptor Signaling Despite Increased Body Fat Content 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 1:00:00 PM LB-OR02 5223 11:30:00 AM Obesity and Diabetes: From Basic Mechanisms to Treatment Oral

Carol H Wysham*1, Julio Rosenstock2, Jaret Malloy3, Marion Vetter4, Yaohua He4, Peter Ohman5 and Nayyar Iqbal4
1Rockwood Center for Diabetes and Endocrinology, Spokane, WA, 2Dallas Diabetes and Endocrine Center, TX, 3Bristol-Myers Squibb, San Diego, CA, 4Bristol-Myers Squibb, Princeton, NJ, 5AstraZeneca, Gaithersburg, MD

 

Once-weekly (QW) exenatide consistently improves glycemic control and promotes weight loss in patients with type 2 diabetes mellitus (T2DM) but the current formulation requires reconstitution. A QW suspension containing exenatide dispersed in microspheres suspended in a triglyceride carrier, was developed to eliminate the need for reconstitution and allow delivery via a single-use autoinjector pen. This simplified approach may enhance adherence. An open-label, 28-week study compared exenatide suspension QW (ExSQW) to exenatide twice daily (ExBID) in patients with inadequately controlled T2DM. Patients treated with diet/exercise or a combination of oral medications (metformin, sulfonylurea or pioglitazone) were randomized (in a 3:2 ratio) to ExSQW 2 mg (n=229) or ExBID 10 mcg (n=148). The primary endpoint was change in A1C from baseline to Week 28 with ExSQW vs ExBID. Baseline characteristics were similar in both groups: mean±SD A1C of 8.48±1.03%, fasting plasma glucose (FPG) of 182±45 mg/dL, and body weight of 96.9±21.0 kg. At Week 28, the reduction from baseline in A1C (least-squares [LS] mean±SE) in the ExSQW group was greater than in the ExBID group (–1.39±0.09 vs –1.02±0.11%; P=0.007). Achievement of A1C <7% was comparable in the ExSQW vs ExBID groups (49% vs 43%; P=0.225). Similar FPG reductions were observed in both groups as early as Week 2. By Week 28, FPG reductions were –32.7±3.9 and –22.5±4.9 mg/dL for ExSQW and ExBID, respectively (P=0.166). Body weight decreased similarly in the ExSQW (–1.49±0.28 kg) and ExBID (–1.89±0.36 kg) groups. Gastrointestinal (GI) adverse events (AEs) were less frequent in the ExSQW group than in the ExBID group (nausea: 9.6% vs 21.2%; diarrhea: 5.2% vs 11.6%; vomiting: 3.5% vs 6.2%, respectively), while injection-site nodules occurred more often in the ExSQW group (12.7% vs 0.7%). No major hypoglycemia was reported; minor hypoglycemia was infrequent, generally mild, and occurred primarily in patients with concomitant sulfonylurea use. The ExSQW and ExBID groups, respectively, had low rates of serious AEs (2.6% and 4.8%) and withdrawals due to AEs (2.2% and 4.8%). The completion rate was slightly greater with ExSQW (86.0% vs 79.7%). ExSQW with autoinjector delivery simplified treatment with robust glycemic control, weight loss and less GI AEs, but more injection-site nodules, than ExBID.

 

Disclosure: CHW: Consultant, Sanofi, Speaker, Sanofi, Speaker, Merck & Co., Speaker, Novo Nordisk, Speaker, Lilly USA, LLC, Consultant, Jansen Pharmaceuticals, Speaker, Jansen Pharmaceuticals, Speaker, Boehringer Ingelheim Pharmaceuticals, Consultant, Boehringer Ingelheim Pharmaceuticals, Consultant, Bristol-Myers Squibb, Speaker, Bristol-Myers Squibb, Speaker, Astra Zeneca, Consultant, Astra Zeneca. JR: Advisory Group Member, Sanofi, Advisory Group Member, Novo Nordisk, Advisory Group Member, Eli Lilly & Company, Advisory Group Member, GlaxoSmithKline, Advisory Group Member, Takeda, Advisory Group Member, Merck & Co., Advisory Group Member, Daiichi Sankyo, Advisory Group Member, Jansen Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Boehringer Ingelheim, Advisory Group Member, MannKind, Advisory Group Member, Halozyme, Advisory Group Member, intarcia, Advisory Group Member, Lexicon Pharmaceuticals, Inc., Investigator, Merck & Co., Investigator, Pfizer, Inc., Investigator, Sanofi, Investigator, Novo Nordisk, Investigator, Roche Pharmaceuticals, Investigator, Bristol-Myers Squibb, Investigator, Eli Lilly & Company, Investigator, GlaxoSmithKline, Investigator, Takeda, Investigator, Novartis Pharmaceuticals, Investigator, Astra Zeneca, Investigator, Amylin Pharmaceuticals, Investigator, Jansen Pharmaceuticals, Investigator, Daiichi Sankyo, Investigator, MannKind, Investigator, Boehringer Ingelheim, Investigator, Intarcia, Investigator, Lexicon Pharmaceuticals, Inc.. JM: Employee, Bristol-Myers Squibb. MV: Employee, Bristol-Myers Squibb. YH: Employee, Bristol-Myers Squibb. PO: Employee, Astra Zeneca. NI: Employee, Astra Zeneca.

LB-OR02-2 17898 2.0000 A DURATION-NEO-1: Greater A1C Reductions with Exenatide Suspension Once Weekly By Autoinjector Pen Vs Exenatide Twice Daily in Inadequately Controlled Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 1:00:00 PM LB-OR02 5223 11:30:00 AM Obesity and Diabetes: From Basic Mechanisms to Treatment Oral

Stephanie E Simonds* and Michael A Cowley
Monash University, Clayton, VIC, Australia

 

Diabetes rates are continuing to increase globally, and there remains an unmet need for new therapies. We also have an incomplete understanding of how blood glucose levels are regulated. In particular it has recently emerged that the brain can have a significant effect on blood glucose. Both peripheral and central mechanisms control the production of blood glucose from the liver and the uptake of glucose by muscles and other organs. The central melancortin system has been implicated in the regulation of blood glucose, but the exact mechanism by which these neurons regulate glucose levels is not yet known. In research presented here we use engineered pharmacological selective chimeric ion channels, activating and inhibiting populations of key hypothalamic arcuate neurons, including POMC, AgRP and NPY neurons in mice and examine the impact of these electrical changes on blood glucose. We have established that these neurons are differentially important in the control of blood glucose in the feed and fasted state. Activating POMC neurons causes an improved response to a glucose challenge during a glucose tolerance test (p<0.05, n=5-8). Activation of AgRP neurons causes a reduced glucose tolerant response following a glucose challenge (p<0.05, n=5-8). In fasted mice, simply activating the AgRP neurons or inhibiting the POMC neurons can increase basal blood glucose (p<0.05, n=6). The ability of these hypothalamic neurons to control blood glucose is altered in obesity, with differences existing between lean and obese mice. This research provides new finding into how the melanocortin system regulates blood glucose, and may provide new targets for therapies to control blood glucose.

 

Nothing to Disclose: SES, MAC

LB-OR02-3 17970 3.0000 A How Central Melanocortin Neurons Control Peripheral Blood Glucose 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 1:00:00 PM LB-OR02 5223 11:30:00 AM Obesity and Diabetes: From Basic Mechanisms to Treatment Oral

Saket Gupta1, Ashwini Maratha2, Anandan Natarajan1, Thusitha Gajanayake2, Jakub Siednienko3, Shu Hoashi*4 and Sinead Miggin2
1Midland Regional Hospital, Mullingar, Ireland, 2National University of Ireland, Maynooth, Ireland, 3National University of Maynooth, Maynooth, Ireland, 4Midland Regional Hospital, Mullingar, Co Westmeath, Ireland

 

Inflammation has been associated with Type 2 diabetes (T2D). Herein, we sought to study the association between inflammation, glucose control and complications; elevated CRP was an exclusion criterion. We determined cytokines, adipokines & Toll-like receptors (TLR) mRNA expression levels in monocytes (M) and neutrophils (N) using QPCR in a cohort of 146 subjects: non-diabetic controls [NGT; n=34, BMI 26 (24-30) kg/m2, HbA1c 5.6 (5.4-5.7)%] and compared them with T2D with four different profiles:  good glycaemic control without complications [GC; n=27, BMI 32 (29-38) kg/m2, HbA1c 6.4 (6.0-6.9)%], good glycaemic control with complications [GCC; n=32, BMI 31 (28-35) kg/m2, HbA1c 6.9 (6.4-7.4)%], poor glycemic control without complications [PG; n=21, BMI 35 (31-37) kg/m2, HbA1c 10.2 (9.2-11)%] and poor glycaemic control with complications [PGC; n=32, BMI 34 (29-37) kg/m2, HbA1c 9.6 (8.9-10.8)%]. Data are expressed as median (Inter quartile range).

Data shown as [M vs. NGT] & [N vs. NGT] indicates overexpressed IL-6 [M: 11.1 (10.4-12.6) vs. 0.9 (0.9-1.0)]*, [N: 52.1 (44.4-56.0) vs. 0.9 (0.7-1.3)]*, TNFα [M: 1.2 (1.2-1.2) vs.1.0 (0.9-1.2)], [N; 6.4 (5.4-8.0) vs. 1.0 (0.8-1.1)]*, Rantes [M: 1.8 (1.3-2.8) vs. 1.2 (0.7-1.6)], [N: 25.8 (25.5-26.1) vs. 0.9 (0.8-1.1)]* & IFN-b mRNA [M: 10.0 (9.5-11.2) vs. 0.9 (0.8-1.2)]*, [N: 35.4 (35.0-36.1) vs. 1.0 (0.9-1.0)]* in monocytes & neutrophils in GC group compared to NGT. Serum IFN-β & Rantes levels were found raised in PG, and comparable in GC group, using multiplex cytokine profiling (P < 0.05).

Retinol binding protein 4 [M: 6.2 (4.3-7.0) vs. 1.0 (0.9-1.0)]*, [N: 39.6 (36.5-41.8) vs. 1.0 (0.8-1.1)]*, Lipocalin 2 [M; 2.5 (2.3-2.6) vs. 1.0 (0.9-1.1)], [N: 25.2 (18.8-32.9) vs. 1.0 (0.9-1.1)]* and adiponectin mRNA [M: 1.6 (1.4-1.7) vs. 1.1 (0.7-1.5)], [N: 30.7 (29.5-31.6) vs. 1.0 (0.9-1.0)]* were significantly overexpressed in GC neutrophils and monocytes. Similarly, all TLRs 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 were significantly overexpressed in monocytes & neutrophils in GC group compared to NGT. All data remained significant with BMI, age and gender adjustment. We found that PG, GCC and PGC patients have a trend towards suppressed cytokines, adipokines & TLRs mRNA expression, indicating downregulation of the receptors. The decline in expression was related to poor glycaemic control and complications rather than duration of disease.

Collectively, overexpressed cytokine, adipokine & TLR mRNA levels in monocytes and neutrophils from GC patients indicate an inflammatory milieu in early T2D. In contrast, the significantly suppressed levels of inflammatory markers in PG, GCC & PGC indicate a compromised innate immune state i.e. “burn out” disease and highlight the role of early T2DM management to achieve good glycaemic control and avoiding complications. Our novel data indicates that 10 TLRs, adipokines & neutrophils play a role in inflammation linked with T2D.  *p<0.05

 

Nothing to Disclose: SG, AM, AN, TG, JS, SH, SM

LB-OR02-4 17983 4.0000 A Burnt out Diabetes: Cytokines, Adipokines and TLRs Modulation in Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 1:00:00 PM LB-OR02 5223 11:30:00 AM Obesity and Diabetes: From Basic Mechanisms to Treatment Oral

Philip C. Johnston*1, Matthew Walsh2, Tyler Stevens2, Massimo Trucco3, Rita Bottino3, James Bena4 and Betul Hatipoglu5
1Royal Victoria Hospital, Belfast, Ireland, 2Cleveland Clinic, 3University of Pittsburgh, 4Cleveland Clinic Foundation, Cleveland, OH, 5Cleveland Clinic, Cleveland, OH

 

Background: In a select group of patients with chronic pancreatitis (CP), total pancreatectomy (TP) and autologous islet cell transplantation (IAT) is undertaken. IAT can reduce or prevent diabetes by preserving beta cell function. We examined which factors were associated with insulin independence in CP patients undergoing TP-IAT.

Methods: Data from 36 patients was obtained from a TP-IAT database (Aug 2008 to Feb 2014), in addition to clinic visits, questionnaires and follow up telephone calls. The incremental area under the curve [AUC] was calculated for pre and post-surgical 5 hour mixed meal measures of glucose, insulin, pro-insulin and c-peptide. Associations were evaluated between categorical and continuous factors with insulin independence at last visit using Wilcoxon rank sum tests and Fisher exact tests, while associations with islet yield (IEQ) and other factors were evaluated using Wilcoxon rank sum tests and Spearman correlations.

Results: Thirty six patients (F:18 M:18, non-hereditary:29,hereditary:7) with a mean age of 38 years (range 16-72 years) underwent TP-IAT. One third (12/36) were insulin independent, with a mean follow up of 29 months, (range 3-66 months). Those who were insulin independent at most recent follow up were more likely to be female (p=0.012), have normal disease extent on pre-operative pancreatic CT, p=0.011 and have significantly higher islet yield (6845.0 IEG/kg;n=12, [range 4879.5 - 8485.5] v 3333.0 IEG/kg;n=24 [range 2607.0 - 4820.0];p<0.001).

Pre-operative mixed meal c-peptide AUCC0-5hr (597.0 ng/mL/hr v 480.0 ng/mL/hr,p=0.83) and glucose AUCG0-5hr (2797.5 mg/dL/hr v 3757.7 mg/dL/hr,p=0.21) did not significantly differ between those with insulin independence and insulin dependence respectively. A positive association was observed between total islet yield and body weight at surgery (p=0.021), a significant negative association was observed between islet yield and pre-operative HbA1c (p=0.01) as well as age (p=0.038).

Conclusions: In this series, one third of patients remained insulin independent at follow up. Patients who received at least 6845 IEQ/kg were more likely to be insulin independent at follow up. Patients with advanced CP changes on pre-operative imaging should be counseled on the high likelihood of insulin dependence after surgery.

 

 

Nothing to Disclose: PCJ, MW, TS, MT, RB, JB, BH

LB-OR02-5 18021 5.0000 A Factors Associated with Insulin Independence after Total Pancreatectomy and Autologous Islet Cell Transplantation in Patients with Chronic Pancreatitis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 1:00:00 PM LB-OR02 5223 11:30:00 AM Obesity and Diabetes: From Basic Mechanisms to Treatment Oral

Ilkka Tikkanen1, Kirsi Narko2, Cordula Zeller3, Alexandra Green4, Afshin Salsali*5, Uli C Broedl5 and Hans-Juergen Woerle5
1Helsinki University Central Hospital, Helsinki, Finland, 2Boehringer Ingelheim Finland Ky, Helsinki, Finland, 3Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany, 4inVentiv Health Clinical, Maidenhead, United Kingdom, 5Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany

 

Objective: To investigate the efficacy and safety of empagliflozin in patients with type 2 diabetes and hypertension (mean seated systolic blood pressure [SBP] 130–159 mmHg and diastolic BP [DBP] 80–99 mmHg).

Methods: In this study (NCT01370005), patients were randomized to empagliflozin 10 mg, empagliflozin 25 mg, or placebo once daily for 12 weeks. All patients who received at least one dose of study drug were included in the treated set for safety analyses (n=276, 276, and 272 for empagliflozin 10 mg, empagliflozin 25 mg, and placebo, respectively). Randomized patients who received at least one dose of study drug and had a baseline HbA1c value and a baseline mean 24-hour SBP value were included in efficacy analyses (n=276, 276, and 271 for the respective groups). Co-primary endpoints were changes from baseline in HbA1c and mean 24-hour SBP (ambulatory BP monitoring [ABPM]) at week 12. A key secondary endpoint was change from baseline in mean 24-hour DBP (ABPM) at week 12.

Results: Across the randomized groups, the mean age (SD) was 60.2 (9.0) years, and BMI was 32.6 (5.1) kg/m2. Mean (95% CI) differences vs placebo in changes from baseline in HbA1c were ‑0.62% (‑0.72%, ‑0.52%) and -0.65% (-0.75%, -0.55%) with empagliflozin 10 mg and 25 mg, respectively (both p<0.001), in mean 24-hour SBP were ‑3.44 mmHg (-4.78, -2.09) and -4.16 mmHg (-5.50, -2.83) with empagliflozin 10 mg and 25 mg, respectively (both p<0.001), and in mean 24-hour DBP were ‑1.36 mmHg (‑2.15, -0.56) and -1.72 mmHg (-2.51, -0.93) with empagliflozin 10 mg and 25 mg, respectively (both p<0.01). Adverse events were reported by 48.9%, 51.4%, and 52.6% of patients on empagliflozin 10 mg, 25 mg, and placebo, respectively. Events consistent with volume depletion were reported in 1 patient each on empagliflozin 10 mg and placebo.

Discussion: In patients with type 2 diabetes, hypertension is a common comorbidity and enhances the risk of cardiovascular complications, thus a treatment approach that includes control of BP and glycemia may reduce the risk of cardiovascular complications and mortality.

Conclusion: Empagliflozin significantly reduced BP and was well tolerated in patients with type 2 diabetes and hypertension.

 

Disclosure: IT: Consultant, Boehringer Ingelheim, Speaker, Boehringer Ingelheim, Speaker, Boehringer Ingelheim . KN: Employee, Boehringer Ingelheim. CZ: Employee, Boehringer Ingelheim. AG: Employee of an organization contracted by Boehringer Ingelheim, Boehringer Ingelheim. AS: Employee, Boehringer Ingelheim. UCB: Employee, Boehringer Ingelheim. HJW: Employee, Boehringer Ingelheim.

LB-OR02-6 17886 6.0000 A Empagliflozin Reduces Blood Pressure in Patients with Type 2 Diabetes and Hypertension: A Phase III, Randomized, Double-Blind, Placebo-Controlled Trial (EMPA-REG BPTM) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 1:00:00 PM LB-OR02 5223 11:30:00 AM Obesity and Diabetes: From Basic Mechanisms to Treatment Oral

Sisi Liu*1, Annabel Sophie Berthon2, Eva Szarek2, Saloustros Emmanouil1, Paraskevi Salpea1 and Constantine A Stratakis2
1Section on Endocrinology and Genetics, NICHD, NIH, Bethesda, MD, 2National Institutes of Health (NIH), Bethesda, MD

 

Primary pigmented nodular adrenocortical disease (PPNAD) leading to Cushing syndrome (CS) is the most frequent endocrine manifestation of Carney complex (CNC); most patients with CNC have inactivating mutations in PRKAR1A, a gene encoding type 1 a-regulatory subunit (R1a) of the cAMP–dependent protein kinase (PKA). We generated mice lacking Prkar1a specifically in the adrenal cortex (AdKO), which developed PPNAD-like lesions. Deregulated differentiation, increased proliferation and resistance to apoptosis of adrenal cortical cells were found in these mice, which also demonstrated increased plasma corticosterone levels resistant to dexamethasone suppression. Our lab has demonstrated that celecoxib, a COX-II inhibitor, can effectively treat bone lesions in mice with Prkar1a defects. Our objective in this study was to investigate the role of celecoxib in the treatment of CS in AdKO mice; one group of female AdKO mice were fed with NIH-31 diet containing 1,500 mg/kg celecoxib for 6 months from 3 months to 9 months of age. The control group of age-matched female AdKO mice received normal NIH-31 diet. We found decreased serum corticosterone and PGE2 levels in celecoxib-treated mice. Treated mice also demonstrated 60% decrease in proliferation activity by Ki67 staining, and increase in apoptosis by TUNEL assay and cleaved caspase-3 staining. Decreased transcriptional levels of inflammasone pathway genes caspase-1 (38% of control), interleukin-1b (37% of control), PGE2 (30% of control), wnt pathway gene b-catenin (60% of control), steroidogenic gene sf1 (62% of control) and cell proliferation gene cyclin D1 (48% of control) were found in the adrenals of treated mice by RT-PCR. We conclude that a 6-month treatment with celecoxib reduced steroidogenesis in AdKO adrenals, and partially rescued the phenotype caused by abnormal PKA activity.

 

Nothing to Disclose: SL, ASB, ES, SE, PS, CAS

PP14-2 16004 1.0000 SUN-0795 A Can COX-II Inhibitor be Used for Treatment of Cushing Syndrome Due to cAMP-Dependent Protein Kinase Defects? a Mouse Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Angela Huebner*1, Ramona Juehlen1, Sebastian Gaertner1, Angela E Taylor2, Mirko Peitzsch1, Jan Idkowiak2, Vladimir Vukicevic1, Monika Ehrhart-Bornstein1, Graeme Eisenhofer1, Wiebke Arlt2 and Katrin Koehler1
1Technische Universität Dresden, Dresden, Germany, 2University of Birmingham, Birmingham, United Kingdom

 

ALADIN encoded by the AAAS gene is a nuclear pore complex protein and its dysfunction is associated with triple A syndrome. This syndrome is characterized by severe adrenal insufficiency, achalasia, alacrima in combination with progressive neurological impairment. However, the pathogenetic mechanisms leading to adrenal failure are not well understood. Previously we and others have shown that ALADIN is involved in oxidative stress response.

In order to investigate adrenocortical cell function we used the human adrenocortical carcinoma cell line NCI-H295R for stable shRNA AAAS knock-down and investigated viability and ROS detoxification as well as expression of key enzymes of the steroidogenic pathway. Steroids were quantified by LC-MS/MS. The impact of ALADIN down-regulation on the adrenocortical-medullary crosstalk was studied using primary bovine adrenocortical and medullary cells separately and in co-culture with and without oxidative stress.

Down-regulation of ALADIN significantly affected the glucocorticoid and androgenic pathways of NCI-H295R cells concerning enzyme expression, i.e. CYP17A1 and CYP21A2, and steroid output such as 17-hydroxyprogesterone, 11-deoxycortisol and androstenedion levels. ALADIN knock-down led to decreased cell viability and GSH/GSSG ratios under oxidative stress. Moreover, the nuclear import of APTX, LIG1 and FTH1 was impaired in these cells. In primary bovine adrenal cells ALADIN knockdown resulted in an increased doubling time. In contrast to the in vivo situation we observed a significant increase of Cyp17A1 and Cyp21A2 in cortical cells and an increase of TH und PNMT in medullary cells. Co-cultures of primary bovine adrenocortical and medullary cells differentially down-regulated with shRNA revealed an increase in PNMT and TH expression due to the Aaas knockdown in both cell types but not in combination of Aaas knock-down cells with WT medullary cells and vice versa. No additional effect was observed in the expression of Cyp11B1, Cyp11A1, Cyp17A1 and Cyp21A2 in cortical cells in co-culture with differently transfected medullary cells.

We conclude that ALADIN depletion results in an increased susceptibility against oxidative stress leading to alteration of adrenocortical function, in particular steroidogenesis. In addition ALADIN plays a role in adreno-medullary crosstalk and may be involved in both adrenocortical and medullary dysfunction in triple A syndrome patients.

 

Nothing to Disclose: AH, RJ, SG, AET, MP, JI, VV, ME, GE, WA, KK

PP14-3 16268 2.0000 SUN-0796 A Aladin Down-Regulation with and without Oxidative Stress Impairs Adrenocortical Function and Steroidogenesis and Affects Adrenocortical-Medullary Crosstalk 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

David C Kem*1, Hongliang LI2, Xichun Yu1, Alexandria Benbrook2, D. Campbell Liles2, Carolina Velarde Miranda3 and Celso E. Gomez-Sanchez4
1Univ of Oklahoma and VAMC, Oklahoma City, OK, 2OUHSC, Oklahoma City, OK, 3G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS, 4University of Mississippi Medical Center, Jackson, MS

 

Objective:We investigated whether activating autoantibodies (AAb) to the angiotensin AT1 receptor (AT1R) from patients with primary aldosteronism (PA) and AT1R-immunized rabbits induce vasoconstriction, stimulate aldosterone production and are blocked by a proprietary proteolysis resistant retro-inverso D-amino acid (RID) peptide.

Methods:We studied 13 subjects with biochemically confirmed PA and 20 normotensive control subjects. Six rabbits were immunized with a multiple antigenic peptide containing the AT1R-AAb epitope sequence (AFHYESQ). AT1R-AAb activity in serum/IgG from the PA subjects and AT1R-immunized rabbits was examined using AT1R-transfected CHO cells, and their contractile effects were assayed using perfused rat cremaster arterioles. Aldosterone stimulation was measured in vitro using human adrenal carcinoma HAC15 cells. The AT1R blocker losartan and AT1R-AAb epitope mimetic RID peptide (dQ-dS-dE-dY-dH-dF-dA) were examined for effects on blocking AT1R-AAb.

Results: Sera from PA subjects significantly increased AT1R activity in AT1R-transfected CHO cells (188±37, n=13 vs. control 97±18, n=20 in pM Ang II equivalent activity; p<0.001). This was blocked by the AT1R RID peptide and also by 10 mM losartan (p<0.05). PA sera constricted cremaster arterioles in vitro (19±5% vs. control 5±3% contraction from baseline; p<0.001)) and was blocked equally by 10 mM losartan and by the AT1R RID peptide. Similar data were obtained in AT1R-immunzed rabbit sera. IgG from 7 PA subjects increased aldosterone production by 1.8 fold over baseline (p<0.001) and markedly increased Ang II-induced aldosterone production by 3.5 fold (p<0.001) and was blocked by AT1R blocker. Injection of the AT1R RID peptide (1 mg/kg IV) into the AT1R-immunzed rabbits resulted in a drop of elevated systolic BP by 31% and diastolic BP by 21% to nearly normal within 90 minutes (p<0.05, n=6).

Conclusions: AT1R-AAb from PA and AT1R-immunized rabbits activate AT1R in transfected cells, increase arterial contractility in vitro and stimulate basal and Ang II-induced aldosterone secretion from adrenal cells. AT1R blockers and a newly designed proprietary proteolysis resistant decoy peptide were equally effective in blocking AAb effects in vitro and in vivo. These AAb and the RID peptide have important etiological and therapeutic implications.

 

Disclosure: DCK: Principal Investigator, VA and Univ sponsored patent-pending for the D-RI peptide . Nothing to Disclose: HL, XY, AB, DCL, CVM, CEG

PP14-4 13882 3.0000 SUN-0797 A Blockade of AT1R-Activating Autoantibodies Using a New Retro-Inverso Decoy Peptide 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Takayuki Hara*, Fumio Otsuka, Naoko Tsukamoto-Yamauchi, Kenichi Inagaki, Eri Nakamura, Takeshi Hosoya, Tomohiro Terasaka, Kanako Ogura-Ochi, Kishio Toma and Hirofumi Makino
Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan

 

Aldosterone plays a key role in the regulation of electrolytes and water balance via mineralocorticoid receptor (MR).  The excess of MR action leads to progress of cardiovascular and renal damages.  The regulation of aldosterone synthesis and secretion is important to control MR activity in vivo.  Aldosterone secretion from the adrenal glomerulosa is directly induced by angiotensin II (Ang II), potassium (K) and adrenocorticotropin (ACTH).  Under the presence of these major stimulators, adrenocortical steroidogenesis is indirectly regulated by local autocrine and/or paracrine factors resided in the adrenal tissues.  We previously reported the existence of the bone morphogenetic protein (BMP) and activin system in adrenocortical cells.  We showed that BMP-6 is involved in the stimulation of Ang II-induced aldosterone production by upregulating MAPK pathway while activin is related to ACTH-induced cAMP-PKA cascade in adrenocortical cells.  In the present study, we studied effects of melatonin functionally involved in the formation of circadian rhythm.  Melatonin has been reported to suppress ACTH secretion in the anterior pituitary and cortisol production in the adrenal by individual mechanisms.  However, the effect of melatonin on aldosterone production remained unknown.  Here we investigated melatonin action in the regulation of adrenocortical steroid production using H295R cells, by focusing on the activin system expressed in the adrenal.  In H295R cells and normal human adrenal tissue, the expression of melatonin receptor MT1 mRNA was detected.  Melatonin did not affect basal synthesis of aldosterone or cortisol.  However, melatonin slightly augmented ACTH-induced aldosterone synthesis but did not affect Ang II-induced aldosterone level.  Activin increased ACTH- but not Ang II-induced aldosterone production.  Of note, melatonin effectively enhanced aldosterone production induced by co-treatment with ACTH and activin, although melatonin had no effect on aldosterone production induced by Ang II and activin.  These changes in steroidogenesis became apparent when evaluated by the ratios of aldosterone to cortisol.  In accordance with the data of steroids, ACTH- but not Ang II-induced cAMP synthesis was also amplified in the presence of both melatonin and activin.  Furthermore, the ratios of ACTH-induced mRNA levels of CYP11B2/CYP17 were increased in the conditions treated with both melatonin and activin.  Thus, it was revealed that melatonin upregulates aldosterone production induced by ACTH and activin via cAMP-PKA pathway, which was different from the inhibitory effect of melatonin on cortisol synthesis.  These data suggest a new functional link and signaling crosstalk between melatonin and activin receptors in adrenocortical cells.

 

Nothing to Disclose: TH, FO, NT, KI, EN, TH, TT, KO, KT, HM

13553 5.0000 SUN-0799 A Regulatory Effects of Melatonin and Activin on Aldosterone Production By Human Adrenocortical Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Jennyfer Fernanda Rodrigues Domingues*1, Leonardo Domingues Araújo1, Fernanda Coeli-Lacchini1, Silvia Ruiz Roa2, Ernane Torres Uchoa1, Jose Antunes-Rodrigues1, Ayrton C. Moreira1, Margaret De Castro1 and Paula C. L. Elias1
1Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil, 2Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil

 

Introduction: Biological clock system has a primary role in the organism entrainment to environmental cues such as food availability. At molecular level, both central and peripheral tissues are involved to maintain the circadian rhythm of clock system. However, few studies have evaluated daily clock gene expression with different food entrainments. Objectives: To evaluate the expression of clock genes in adrenal tissue in animals submitted to different dietary patterns. Material and Methods: Male Wistar rats were submitted to different dietary patterns: Control group (CG): food and water ad libitum, Food Restriction group (FR; food from ZT [Zeitgeber time] 12-14) and Food Shift (FS; food from ZT3-5) for 21 days with light/dark cycle (lights on 0600h–ZT0) and were decapitated at ZT3 and ZT11. Blood was collected for corticosterone (B), assayed by RIA. Adrenal tissue was stored until RNA extraction. Expressions of Clock, Bmal1, Per1-3 and Cry1-2 genes were determined by qPCR and expressed as 2-DDCT. Results: CG rats showed greater weight than FR and FS groups (385.4±55.4g vs 245.5±32.0g vs 227.9±40.9g; P<0.0001). CG and FR groups showed lower B levels (µg/dL) at ZT3 vs ZT11 (1.0±0.6 vs 14.1±8.1, P<0.001) and (3.6±2.6 vs 20.7±7.6, P<.0001), respectively. In contrast, FS group showed an inverted pattern of B secretion compared to CG animals with higher levels at ZT3 vs ZT11 (22.7±6.2 vs 10.6±5.7, P=0.0007). There was no difference in the expression of Clock gene inter- and intra-groups. Bmal1 showed higher expression in CG at ZT3 compared to ZT11 (2.1±2.8 vs 0.7±0.8; P<0.05). On the other hand, Per2 showed lower expression in CG at ZT3 compared to ZT11 (1.1±1.0 vs 3.7±1.1; P<0.05). CG group presented no difference in gene expression between ZT3 and ZT11 considering Per1, Per3, Cry1 and Cry2. No daily difference was observed in gene expression of FR rats. In FS group, Bmal1 showed an inverse pattern from CG (4.8±9.0 vs 9.8±5.4; P<0.05), accompanied by higher expression of Per1, Per2 and Per3 at ZT3 (0.9±0.8 vs 0.3±0.3, P<0.04; 2.1±1.9 vs 0.5±0.4, P=0.07; and 0.8±0.7 vs 0.1±0.1; P<0.03). Finally, Cry1 and Cry2 presented no difference in expression between ZT3 and ZT11 in FS animals. Conclusion: Our data showed that shift in feeding time modulates adrenal gene expressions of Bmal1 and Per1-3 parallel to plasma B secretion. Additionally, less food availability at ZT3 blunted Bmal1 and Per1-3 oscillatory pattern, despite maintenance of regular light/dark cycle activity.

 

Nothing to Disclose: JFRD, LDA, FC, SRR, ETU, JA, ACM, MD, PCLE

15026 6.0000 SUN-0800 A Clock Genes Expression in Adrenal of Rats Submitted to Food Restriction 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Hiraku Kameda*1, Hideaki Miyoshi2, Chikara Shimizu3, So Nagai4, Akinobu Nakamura2, Takuma Kondo2, Dai Chida5, Yoichiro Iwakura6 and Tatsuya Atsumi2
1Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan, 2Hokkaido University Graduate School of Medicine, 3Hokkaido Univ Hosp, Sapporo, Japan, 4Sapporo Medical Center NTT EC, Sapporo, Japan, 5Saitama Medical University, 6Tokyo University of Science, Tokyo

 

【Introduction】

Recently, a pituitary gene expression analysis in adrenalectomized mice, a model of acute adrenal insufficiency, was reported (Nishida Y, et al. Obesity 2009;17:114-120.). To investigate gene expression of pituitary gland under chronic adrenal deficiency, we examined the pituitary of melanocortin 2 receptor (MC2R) deficient mice, a model of chronic adrenal insufficiency, and found increased gene expression of NMB.

【Materials and Methods】

Analysis of MC2R−/− mice pituitary gland: The gene expression was analyzed by DNA microarray method using total RNA from the pituitary gland of male MC2R−/− and wild type (WT) mice. MC2R−/− and WT anterior pituitary gland was immunostained with specific antibodies for ACTH and NMB. The plasma NMB level of each mouse was measured by an enzyme-linked immunosorbent assay.

Corticosterone pellet implantation: Corticosterone releasing pellets were administrated subcutaneously to MC2R−/− and WT mice. Three weeks after pellet administration, total RNA of the pituitary gland was extracted, and gene expression was analyzed by the real-time PCR.

Pituitary cell isolation: The pituitary cells from the C57BL/6J mice were isolated and cultured in DMEM:F-12 medium. Corticotropin releasing hormone (CRH) or dexamethasone (DEX) was added to the media at various concentrations. After 48 hour incubation, total RNA was extracted from isolated cells and gene expression was analyzed by the real-time PCR.

【Results】

The DNA microarray analysis showed approximately 13-fold higher NMB expression in the pituitary gland of the MC2R−/− mice than in the wild-type mice, but not in hypothalamus, heart, lung, liver, kidney, pancreas, spleen, colon, muscle, and testis. We detected an increasing NMB expression in the MC2R−/− pituitary corticotrophs by immunohistochemistry. Plasma NMB concentration was significantly higher in MC2R−/− mice than WT mice. Subcutaneous implantation of the corticosterone pellet decreased the NMB mRNA expression in pituitary gland as same as pituitary proopiomelanocortin. In isolated anterior pituitary cells, the NMB mRNA expression was increased by administration of CRH and was suppressed by DEX.

【Conclusion】

In this study, we first demonstrate the NMB expression in corticotrophs and its regulation by CRH and glucocorticoids. Further study to confirm the function of circulating NMB from pituitary corticotrophs is necessary.

 

Nothing to Disclose: HK, HM, CS, SN, AN, TK, DC, YI, TA

12241 7.0000 SUN-0801 A Expression and Regulation of Neuromedin B in Pituitary Corticotrophs of Male Melanocortin 2 Receptor-Deficient Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Hiroko Fujii*1, Mimi Tamamori-Adachi2, Takao Susa2, Masayoshi Iizuka2, Yuji Tanaka1 and Tomoki Okazaki2
1National Defense Medical College, Tokorozawa, Japan, 2Teikyo Univ Schl of Med, Tokyo, Japan

 

Glucose-dependent insulinotropic polypeptide (GIP) promotes not only glucose-dependent insulin, but also glucocorticoid secretion. Ectopic expression of the GIP receptor (GIPR) in the human adrenal gland causes significant hypercortisolemia after meal ingestion and leads to Cushing’s syndrome, implying that human GIPR activation is capable of robustly activating adrenal glucocorticoid secretion. However, the mechanisms through which GIP stimulates glucocorticoid secretion remain poorly understood. In this study, we transiently transfected the human GIPR expression vector to the cultured human adrenocortical carcinoma cells (H295R) and treated them with GIP to examine the direct link between GIPR activation and steroidogenesis. By qRT-PCR assay, we examined gene expression of steroidogenic transcription factors such as SF1 and StAR, and steroidogenic enzymes including 17a- and 21-hydroxylases (CYP17A1 and CYP21A2), and carried out immunofluorescence to prove that forced GIPR overexpression directly promotes production of steroidogenic enzymes, CYP17A1 and CYP21A2, at the single cell level. Immunofluorescence showed that the transfection efficacy of the GIPR gene to H295R was approximately 5%, and GIP stimulation promoted CYP21A2 and CYP17A1 expression in GIPR-introduced H295R cells (H295R-GIPR). Interestingly, those steroidogenic enzymes were also expressed in the cells adjacent to the GIPR-positive cells. The fold increase in the mRNA levels of SF1, NGF-1B, StAR, CYP11A1, HSD3β2, CYP21A2, and CYP17A1 were 1.2, 1.4, 2.1, 1.2, 1.2, 1.2, and 1.4 compared with those in H295R- GIPR without GIP treatment, respectively. Furthermore, the levels of ACTH receptor and ACTH precursor proopiomelanocortin mRNA were upregulated by 2-, and 1.5-fold, respectively. Those stimulatory effects of GIP on the gene expression were significant (p<0.05). These changes were also reflected in the culture medium in which 1.5-fold increase in the cortisol concentration was confirmed. An ACTH-receptor antagonist significantly inhibited StAR, CYP17A1 and CYP21A2 mRNA expression levels, and cortisol production. No CYP21A2 immunostaining was detected in cells with the ACTH receptor antagonists. These results demonstrated that GIPR activation promoted production and releasing of ACTH, and that steroidogenesis was activated by the endogenous ACTH/ACTH receptor, at least in part, in H295R cells.

 

Nothing to Disclose: HF, MT, TS, MI, YT, TO

16735 8.0000 SUN-0802 A Marked Cortisol Production By Intracrine ACTH in Gip-Treated Cultured Adrenal Cells in Which Gip Receptor Was Exogenously Introduced 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Leh Teng Loh*1, Nor Azmi Kamaruddin2 and Norasyikin Abdul Wahab2
1National University of Malaysia Medical Centre, Kuala Lumpur, Malaysia, 2National University of Malaysia, Kuala Lumpur, Malaysia

 

Background:

Normal pregnancy stimulates the maternal hypothalamic- pituitary- adrenal axis. There is a progressive rise in cortisol levels as the pregnancy advances. Previous studies have demonstrated a 2 to 3 folds increase in 24 hour urine free cortisol during the second and third trimester of pregnancy and this has been used as the diagnostic threshold for diagnosis of Cushing’s Syndrome in pregnancy. However the data on late night saliva cortisol is lacking. Late night saliva cortisol is a measurement of free cortisol. It is easier to collect than 24 hour urine cortisol and it has high sensitivity and specificity in the diagnosis of Cushing’s Syndrome.

Objectives:

The primary objective was to determine the difference of late night salivary cortisol between the normal pregnant women and nonpregnant control.

The secondary aims were to determine the difference of late night salivary cortisol in each trimester of pregnancy and to compare late night salivary cortisol with 24 hour urine total cortisol in pregnancy.

Method:

We conducted a cross sectional study on late night saliva cortisol and 24 hour urine cortisol in 28 pregnant women during first, second and third trimester. These were compared with the nonpregnant control.

Results:

The median age of the women was 28 to 31.5 years old. The median period of gestation was 10.5 weeks for first trimester, 18.5 weeks for second trimester and 33 weeks for third trimester. Comparing to the control group, the median late night saliva cortisol was 1.29, 1.92 and 3.69 fold elevated during the first, second and third trimester respectively. Whereas the median 24 hour urine cortisol were 1.23, 1.7 and 2.47 folds elevated during the first, second and third trimester respectively.  The differences of late night saliva cortisol and 24 hour urine cortisol to the control were statistically significant. There were positive correlation between both late night saliva cortisol and 24 hour urine cortisol with the period of gestation. The correlation coefficient was 0.596 for late night saliva cortisol and 0.549 for 24 hour urine cortisol.

Conclusion:

There was a graded increase in 24 hour urine and late night saliva cortisol over three trimester of pregnancy with significant correlation between the biomarker and the period of gestation. Our study demonstrated elevation in late night saliva cortisol up to 3.69 fold during third trimester of pregnancy.

 

Nothing to Disclose: LTL, NAK, NAW

12357 9.0000 SUN-0803 A Late Night Saliva Cortisol and 24 Hour Urinary Cortisol in Normal Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Waldemar Kanczkowski*1, Antonios Chatzigeorgiou1, Uta Lehnert1, Sylvia Großklaus1, Stefan Richard Bornstein2 and Triantafyllos Chavakis1
1Technische Universität Dresden, Dresden, Germany, 2University Hospital Carl Gustav Carus, Department of Medicine III, Technische Universität Dresden, Dresden (Germany), Dresden, Germany

 

Adrenal gland dysfunction and hypothalamus-pituitary-adrenal (HPA) axis dissociation are common problems in patients with sepsis. Previously, we demonstrated that endothelial dysfunction may actively participate in inflammation-related adrenal insufficiency. We focused on developmental endothelial locus-1 (Del-1), an endothelial-derived anti-inflammatory factor; because we found that its expression is strongly downregulated upon systemic inflammation in the adrenal gland. Interestingly, we found that during Systemic Inflammatory Response Syndrome (SIRS), Del-1 deficiency resulted in elevated inflammation, leukocyte accumulation and higher apoptosis in the adrenal glands, which was associated with decreased corticosterone and adrenocorticotropic hormone levels 24h post LPS-administration. These data indicated that Del-1 acts as a gatekeeper of adrenal gland inflammation and thereby of adrenal function in the course of SIRS.

However, little is known about Del-1 regulation in the adrenal gland during homeostatic conditions and sepsis.

The IL-17 cytokine family has evolved as one of the most crucial regulators of local and systemic inflammation during sepsis in the recent years. In fact we found that both IL-17A and its receptor IL-17RA are induced in the adrenal gland in the course of SIRS. Interestingly, we also found that IL17A stimulation resulted in decreased endothelial Del-1 expression. Along the same line, IL-17RA-deficient mice displayed increased corticosterone but not ACTH secretion during LPS-mediated SIRS. The above results suggest that the IL-17/IL-17R axis is a negative regulator in adrenal dysfunction by downregulating Del-1 and promoting adrenal inflammation.

 

Nothing to Disclose: WK, AC, UL, SG, SRB, TC

12816 10.0000 SUN-0804 A The Role of IL17 and Endothelial Homeostasis Dysregulation in LPS-Mediated Adrenal Gland Inflammation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Mitsuhiro Kometani*, Masashi Demura, Takashi Yoneda, Shigehiro Karashima, Masashi Oe and Yoshiyu Takeda
Kanazawa University, Kanazawa, Japan

 

Objective: DNA methylation is a fundamental epigenetic silencing mechanism. We have reported that CpG methylation status in the CYP11B2 or CYP11B1 promoter region influenced each gene expression in the normal adrenal gland. In order to clarify the epigenetic control of cortisol or aldosterone synthesis in subclinical Cushing’s syndrome (SCS) associated with overproduction of aldosterone, we analyzed DNA methylation status of these genes in 6 patients with cortisol-producing adenoma associated with overproduction of aldosterone. 

Methods: SCS was diagnosed according to the guideline of Japanese Endocrine Society. Overproduction of aldosterone was estimated using adrenal venous sampling. Adrenocortical adenomas were histologically evaluated and immunohistochemical analyses for the steroidogenic enzymes, including 3beta-HSD, CYP17, CYP11B1 and B2 were done. Isolated DNA was treated with bisulfite and amplified using primers specific for the human CYP11B1 or B2 promoter regions.

Results: Six cortisol-producing adenomas were hypomethylated in CYP11B1 promoter lesion (CpG1 8%, CpG2 10%, CpG3 10%, CpG4 10%). Pathological findings showed that one patient had an aldosterone co-production adenoma, and another had aldosterone producing adenoma in the adrenal tissue. Aldosterone co-production adenoma was more hypomethylated in CYP11B2 promoter lesion compared with cortisol production adenomas without overproduction of aldosterone.

Conclusion: DNA methylation status of CYP11B2 and B1 may influence the cortisol or aldosterone synthesis in hormone-producing adenomas as well as in the normal adrenal gland.

 

Nothing to Disclose: MK, MD, TY, SK, MO, YT

14500 11.0000 SUN-0805 A ‡@ Epigenetic Controls of CYP11B2 and CYP11B1 Gene in Subclinical Cushing Syndrome Associated with Overproduction of Aldosterone 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Isadora Pontes Cavalcante*1, Guilherme Asmar Alencar2, Beatriz M P Mariani3, André Faria Murad4, Madson Q. Almeida5, Carlos Alberto Buchpiguel6, Antonio M Lerario7, Maria Claudia N Zerbini3, Berenice B Mendonca8 and Maria Candida B V Fragoso9
1Institute of Biomedical Sciences, University of Sao Paulo, São Paulo, Brazil, 2Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 4Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, 5Hospital das Clínicas & Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 6Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, 7ICESP/University of Sao Paulo, São Paulo, Brazil, 8Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular, LIM 42, Hospital das Clínicas, Faculdade de Medicina, São Paulo University, São Paulo, Brazil, São Paulo, Brazil, 9University of Sao Paulo, Sao Paulo-SP, Brazil

 

Introduction: Primary Macronodular Adrenocortical Hyperplasia (PMAH) is a rare cause of Cushing's syndrome due to functioning macronodules. Recently, we have observed a very high and visible 18F-FDG uptake in PET/CT in PMAH. 18F-FDG is transported into cells by glucose transporters (GLUTs) and its accumulation forms the basis of using 18F-FDG as a marker of glucose for quantitative interpretation of PET scans through the standard uptake value (SUV). The transport of glucose across the cell membrane by GLUTs and intracellular phosphorylation by hexokinases (HKs) are critical to accumulation within the cell. HK2 is known for being overexpressed in many types of cancer, increasing their ability to metabolize glucose, a phenotype used clinically to detect malignant cells by PET. This finding is unexplainable in a benign adrenal disorder. Objective: To investigate whether increased uptake of the 18 FDG-PET/CT is associated with GLUT1 and HK2 gene and protein expression in PMAH. Methods: Expression of GLUT1 and HK2 was evaluated by RT-PCR and immunohistochemistry in 38 cases: PMAH (n=12), adrenocortical adenoma (ACA, n=16), adrenocortical carcinoma (ACC, n=10) and one normal adrenal gland. Results: The mean adrenal SUV in patients with PMAH was 5.1±1.7 (range: 3.3-8.9). We found a strong correlation between the nodule size and the SUV in patients with PMAH (R=0.920; p=0.002). We did not find any correlation between SUV and GLUT1 and HK2 expression in PMAH. Both GLUT1 and HK2 expressions were significantly higher in ACC than in ACA or PMAH (p<0.05). Furthermore, we observed the same expression pattern of GLUT1 and HK2 in normal adrenal tissue, ACA and PMAH adrenal tissue in both real time PCR and immunohistochemestry (p>0.05). Discussion: Our study is in accordance with a previous study, which observed a high glucose uptake in patients with PMAH.  We found a strong correlation between nodule size and SUV, which surprisingly is in agreement with studies in malignancies. We hypothesize this is because the number of hyperplastic cells in the nodules augments in parallel with an increase in the gland size. Conclusion: Patients with PMAH appear not to demonstrate an overexpression of GLUT1 and HK2. We observed a heterogeneous GLUT1 and HK2 expression, which leads us to believe that further investigation will be required to explain this high glucose uptake in PMAH.

 

Nothing to Disclose: IPC, GAA, BMPM, AFM, MQA, CAB, AML, MCNZ, BBM, MCBVF

14893 12.0000 SUN-0806 A Gene and Protein Expression Analysis of GLUT1 and HK2 in Primary Macronodular Adrenocortical Hyperplasia with High 18F-FDG Uptake in PET/CT 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Shigehiro Karashima*, Takashi Yoneda, Masashi Demura, Mitsuhiro Kometani, Masashi Ohe and Yoshiyu Takeda
Kanazawa University, Kanazawa, Japan

 

Objective: We have experienced patients with pheochromocytoma associated with overproduction of cortisol or aldosterone. In order to clarify the potency of steroid hormone production of pheochromocytoma, we measured the gene expression of  CYP17, CYP11B1 and B2 in pheochromocytomas. Next, the methylation status of CYP11B1 and B2 gene were studied in each tissue.

Methods: Seven pheochromocytomas in which one was associated with aldosterone overproduction and two have overproduction of cortisol were used. Aldosterone-overproducing was determined by the adrenal venous sampling. Excess production of cortisol was diagnosed by dexamethasone-suppression test and adrenal scintigraphy. The expression levels of mRNA of CYP17, CYPB1 and B2 were measured using real time PCR. Isolated DNA was treated with bisulfite and amplified using primers specific for the human CYP11B1 or B2 promoter regions.    

Results: The gene expression of CYP17, CYP11B1 and B2 was detected in all pheochromocytoma tissues. Pheochromocytoma associated with aldosterone-overproduction showed higher levels of CYP11B2 mRNA. However, methylation status of CYP11B2 promoter region was not low. Cortisol-overproduction pheochromocytoma showed elevated CYP11B1 mRNA levels and lower methylation status of CYP11B1 gene.

Conclusion: Pheochromocytoma could produce adrenocortical hormones. Epigenetic control of CYP11B1 gene may contribute to the overproduction of cortisol of pheochromocytoma. The mechanism of synthesis of steroid hormones of pheochromocytoma should be clarified.

 

Nothing to Disclose: SK, TY, MD, MK, MO, YT

15639 13.0000 SUN-0807 A Steroidogenic Enzyme Gene Expression in the Pheochromocytoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Esteban Martin Repetto*1, Ana Laura Bonelli2, Rocio Sanchez2, Maria Elisa Mercau3, Pablo Arias4 and Cora Beatriz Cymeryng3
1Universidad de Buenos Aires; CEFYBO-CONICET, Buenos Aires, Argentina, 2School of Medicine, University of Buenos Aires; CEFYBO-CONICET, 3Universidad de Buenos Aires, Facultad de Medicina; CEFYBO-CONICET, Buenos Aires, Argentina, 4Univ Nac de Rosario Med Sch, Rosario, Argentina

 

Background and aims:

We previously demonstrated that streptozotocin-induced (STZ) diabetes entails an increase in oxidative stress in rat adrenocortical tissue, as well as an altered corticosterone secretion. We also showed that systemic antioxidant treatment normalized these changes.  Present experiments were designed in order to test the hypothesis that STZ-induced oxidative stress might  modify corticosterone release by affecting pituitary ACTH secretion.  With this purpose,  we analyzed plasma ACTH levels and glucocorticoid secretion patterns in STZ treated rats with or without lipoic acid (LA) or α-tocopherol (αT) treatment  The effecto of antioxidant treatment on these parameters was also assessed in non-diabetic animals.

Materials and methods:

Male Wistar rats (220-240g BW) were randomly assigned to the following groups: CON (control), STZ (two injections of 40 mg/kg STZ separated by 48 h), LA (90 mg/kg ip every 48 h), αT (200 mg/kg po), STZ-LA or STZ-αT (where LA or αT treatment were initiated immediately after the confirmation of STZ-induced hyperglycemia). After 4 weeks, all animals were sacrificed and plasma ACTH and serum corticosterone levels (basal and ACTH-stimulated) were measured. In adrenal cortex homogenates lipid peroxidation (as TBARS), as well as the expression levels of CYP11A1 and MC2R (RT-qPCR) were  evaluated.

Results:

Antioxidants had no effect on fasting plasma glucose levels in STZ animals. Neither αT nor LA prevented the decrease in ACTH circulating levels detected in STZ-treated rats (CON: 40.9±6.8 p<0.05 vs. STZ, LA: 24.0±3.3, αT: 28.3±3.7, STZ: 22.6±2.7, STZ-TA 29.4±3.2, STZ-αT 20.3±3.4 pg/ml). At adrenal level, both antioxidants significantly prevented the increase in TBARS levels observed in STZ-treated rats and blocked the down-regulation of MC2R expression observed in the STZ group. CYP11A1 mRNA levels were not affected by any of these treatments. Both antioxidants normalized basal and ACTH-stimulated corticosterone output in STZ-treated rats while no effect on corticosterone secretion was observed in CON animals.

Conclusion:

Compared to control animals, STZ-diabetic rats showed lower baseline circulating levels of ACTH associated with a diminished expression of MC2R in the adrenal cortex. However an increase in basal serum corticosterone levels and a lower response to exogenous ACTH were determined in these animals. As antioxidant therapy prevented all effects observed on glucocorticoid release by the adrenal gland without modifying plasma ACTH levels we suggest that local regulatory signals associated with oxidative stress, whose identity remain to be elucidated, may contribute to the dysregulation of adrenal steroidogenesis in this animal model of diabetes.

 

Nothing to Disclose: EMR, ALB, RS, MEM, PA, CBC

16114 14.0000 SUN-0808 A HPA Dysfunction in Streptozotocin-Diabetic Rats: Effect of Lipoic Acid and α-Tocopherol Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Catherine Napier*1, Anna Louise Mitchell1, Earn Hui Gan1, Ian Wilson2 and Simon HS Pearce1
1Newcastle University, Newcastle upon Tyne, United Kingdom, 2Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom

 

Autoimmune endocrinopathies demonstrate a profound gender bias, with both autoimmune Addison’s disease (AAD) and Graves’ disease (GD) exhibiting a clear female preponderance. The reasons for this increased female susceptibility are not fully understood, but it is likely that a number of the 1000 genes contained on the X chromosome are of relevance. A SNP in the Xq21 immune receptor GPR174, encoding Ser162Pro, has recently been associated with Graves’ disease in Chinese and Polish populations, suggesting a role in female proclivity to autoimmunity. We investigated this SNP, rs3827440 , in a UK cohort of patients with AAD. Samples from 271 AAD cases and 140 healthy controls were genotyped for rs3827440 using TaqMan® SNP Genotyping Assays (C_25954273_10) on the Applied Biosystems 7900HT Fast Real-Time PCR System. Sex of all samples was confirmed using a PCR-based allele discrimination assay for a size polymorphism in the amelogenin gene (AMELX/Y).

The minor (T) allele was found in 60% of male AAD cases compared to 48% of male controls, and 43% of female cases vs 36% of female controls (p=0.017; Odds Ratio 1.73 [95% confidence intervals 1.1- 2.64]). Using a logistic regression analysis, under the assumption that a heterozygous (female) allele has half the effect of a homo(hemi)-zygous allele, showed marginal significance for association (p=0.056; OR 1.28 [95% CI 0.99-1.66]).

This study is the first to suggest that GPR174 could have a more generalised role in autoimmunity pathogenesis, beyond Graves’ disease. The lower female preponderance of Addison’s disease (F:M, 2.5:1) compared to Graves’ disease (6:1) could explain the weaker magnitude of association. GPR174 is a putative purinergic receptor which appears widely expressed in lymphoid tissues: further work to elucidate its functional role is now warranted as GPRs are promising 'drugable' targets.

 

Nothing to Disclose: CN, ALM, EHG, IW, SHP

16709 15.0000 SUN-0809 A Female Proclivity to Autoimmune Addison's Disease: Role of the X-Linked Gene GPR174 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Yasuhiro Nakamura*1, Saulo JA Felizola1, Kazue Ise1, Yoshikiyo Ono2, Fumitoshi Satoh2 and Hironobu Sasano1
1Tohoku University Graduate School of Medicine, Sendai, Japan, 2Tohoku University Hospital, Sendai, Japan

 

Background: Activating transcription factor 3 (ATF3) is a member of the ATF/CREB family of transcription factors and its expression is increased by various pathophysiological conditions. ATF3 was recently reported to be detected in a human adrenocortical cell line (H295R) and proposed as a rapid responder gene to angiotensin-II stimulation. However, its status and functions in human adrenal glands have remained unclear.

Materials and Methods: Immunohistochemical analysis of ATF3 was performed in normal adrenal gland (NA) (n=5), aldosterone-producing adenoma (APA) (n=5) and idiopathic hyperaldosteronism (IHA) (n=5). H295R adrenocortical cells were treated either with vector or the following substances: PP2 (SRC inhibitor), Go6983 (PKC inhibitor), NSC33994 (JAK2 inhibitor) and KN-93 (CaMKII inhibitor) with or without angiotensin-II (AII) treatment, and the mRNA levels of ATF3 were evaluated after 6h. 68 cases of APA(n=68) were also submitted to quantitative RT-PCR (qPCR) of ATF3, aldosterone synthase (CYP11B2), CYP17 and HSD3B2, and the results were compared to the clinicopathological findings of the respective patients.

Key findings: ATF3 was predominantly detected in APA and the zona glomerulosa (ZG) of NA and IHA. In APA, ATF3 mRNA levels were significantly correlated with those of CYP11B2 (P<0.0001 R=0.56) and HSD3B2 (P<0.0001 R=0.54), as well as with plasmatic aldosterone concentration (PAC) of the patients examined (P=0.0041 R=0.35).  In particular, ATF3 mRNA expression in the APAs was more abundant in female than in male patients (P=0.013). A significant decrement of ATF3 mRNA levels were detected in H295R cells when treated with CaMKII and SRC inhibitors under AII stimulation compared to AII alone.

Significance: ATF3 is a novel biomarker of aldosterone-producing cells in NA, IHA and APA and may play a pivotal role in both physiological and pathological aldosterone production and secretion.

 

Nothing to Disclose: YN, SJF, KI, YO, FS, HS

11764 16.0000 SUN-0810 A Activating Transcription Factor 3 (ATF3) in Aldosterone-Producing Cells of Normal and Pathological Adrenal Tissues 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

David C Kem*1, Hongliang LI2, Xichun Yu1, Alexandria Benbrook2, Maria Verena Cicala3 and Franco Mantero3
1Univ of Oklahoma and VAMC, Oklahoma City, OK, 2OUHSC, Oklahoma City, OK, 3University of Padova, Padova, Italy

 

Introduction:Autoantibodies to the angiotensin AT1 receptor (AT1R) in primary aldosteronism (PA) assayed by ELISA have been reported in those with an aldosterone-producing adenoma (APA) and not in idiopathic adrenal hyperplasia (IAH). We reported a large percentage of PA subjects harbor activating autoantibodies (AAb) to AT1R using different bioactivity assays.

Objective:To determine whether AT1R-AAb are present in IAH as well as APA subjects.

Methods:  We examined 25 subjects with PA including 13 APA and 12 IAH, all documented by adrenal venous sampling. Sera from each subject was incubated with AT1R-transfected CHO cells both before and after incubation with the AT1R blocker losartan. Ten of each group were supplied in blinded fashion from Padova (MC and FM) to our laboratory. AAb-induced AT1R activation was expressed as Ang II equivalent activity (pM) and compared to 10 normal control subjects from Padova also blinded to our laboratory.

Results: The normal subjects’ values had a single outlier that was considerably higher than the rest and this value suppressed dramatically with losartan while the remaining 9 had a minimal change in AT1R activity. This outlier was therefore removed and the upper limit of normal set at 500 pM. Eight of the 12 subjects with IAH had values greater than control and 7 of 13 with APA also were greater than control. As groups, the mean for IAH was 708±118 pM before and 278±54 pM after losartan. The APA group mean was 566±93 pM before and 269±46 pM after losartan compared to 312±44 pM for the controls before and 249±37 pM after losartan. AT1R-AAb activity in both IAH and APA was significantly elevated over controls (P<0.01). After losartan, neither group was significantly different from control or control + losartan (P>0.50).

Conclusions: We have independently confirmed AT1R-AAb from PA subjects were capable of contracting isolated cremaster arterioles in vitro and their IgG directly stimulated HAC15 adrenal cell aldosterone production and facilitated Ang II-induced aldosterone production. We conclude AT1R-AAb are frequently present in both IAH and APA subgroups of PA, are suppressible by ARBs and when present are capable of contributing to the pathophysiology of their hypertension.

 

Nothing to Disclose: DCK, HL, XY, AB, MVC, FM

13876 17.0000 SUN-0811 A AT1R Activating Autoantibodies Occur in Both Aldosterone Producing Adenoma and Idiopathic Adrenal Hyperplasia Subgroups in Primary Aldosteronism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Adina F. Turcu*1, Juilee Rege1, Robert Chomic1, Andreas G. Moraitis1, Ganesh S. Palapattu2, Hiromi Koso Nishimoto1, William E. Rainey1 and Richard J. Auchus1
1University of Michigan, Ann Arbor, MI, 2University of Michigan

 

Background: 21-hydroxylase deficiency (21OHD) accounts for the majority of congenital adrenal hyperplasia cases. When the non-classic form is included, 21OHD is one of the most common genetic diseases. A hallmark characteristic of 21OHD is adrenal androgen excess, which arises from the accumulation of steroid metabolites above the enzymatic blockage and the diversion of these precursors to androgens via accessible pathways. Men with classic 21OHD are prone to developing testicular adrenal rest tumors (TART). Previous studies have shown that TART cells produce steroids characteristic of the 21OHD adrenal; however, only a limited number of steroids have been studied.

Objective: To characterize the steroid profile in isolated 21OHD TART cells and their response to ACTH using liquid chromatography-tandem mass spectrometry (LC-MS/MS).

Methods: A TART was surgically removed from a 46 year-old patient with classic, salt-wasting 21OHD. Cells were isolated and grown to confluence, then treated with 10 nM ACTH for 24 or 48h. Twelve unconjugated steroids were quantified in the collected media by LC-MS/MS, both at baseline and after ACTH stimulation.

Results: 17α-hydroxyprogesterone (17OHP) and 16α-hydroxyprogesterone (16OHP) were the most abundant steroids secreted by the TART cells, accounting for 55% and 29% of all the steroids measured at baseline, with similar proportions after ACTH stimulation. Four C19 steroids: androstenedione (A, 7%), 11-hydroxyandrostenedione (11OHA, 5%), testosterone (T, 2.2%) and 11-hydroxytestosterone (11OHT, 0.4%) accounted for the majority of the remaining steroids. All steroids increased after ACTH stimulation: 17OHP 7-fold, 16OHP 6-fold, while A, 11OHA, T and 11OHT, 3-fold each at 48h.

Conclusions: We identified 16OHP as an abundant product of TART cells in amounts about half that of the characteristic marker steroid 17OHP. TART cells are also efficient in androgen production, suggesting co-expression of the key adrenal androgenic enzymes and cofactors (HSD3B2, CYP17A1 and cytochrome b5), which are not normally co-expressed in any one zone of the normal adrenal gland. We propose that 11OHA and possibly 11OHT might serve as serum markers of high adrenal androgen production, as their syntheses require the adrenal-specific 11β-hydroxylase enzyme.

 

Nothing to Disclose: AFT, JR, RC, AGM, GSP, HKN, WER, RJA

14585 18.0000 SUN-0812 A Analysis of Testicular Adrenal Rest Tumor (TART) Steroid Profile By Liquid Chromatography-Tandem Mass Spectrometry 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Tobias Akerstrom*1, Per Hellman2 and Peyman Bjorklund3
1Uppsala University, 2Univ Hosp, Uppsala, Sweden, 3Uppsala University, Sweden

 

Background

The understanding of the underlying genetic abnormalities in Aldosterone producing adenomas (APAs) is evolving. Today almost a 1000 APAs have been sequenced for KCNJ5 mutations with a mean mutation frequency of 40%. Recently, mutations in three new ion channels; ATP1A1, ATP2B3 and CACNA1D were observed. These mutations lead to increased intracellular Ca2+ levels in the glomerulosa cells and subsequent autonomous stimuli for aldosterone production, causing hyperaldosteronism.

Hypothesis

Aim of this study was to confirm the presence of ATP1A1, ATP2B3 and CACNA1D mutations in a large cohort of APAs previously screened for mutations in KCNJ5.

Methods

DNA and cDNA from 165 APAs were PCR-amplified and subjected to Sanger sequencing. Normal adjacent tissue or blood was used to determine the somatic nature of the mutations. All detected mutations were verified in an independent PCR reaction.

Results

Mutations were detected in ATP1A1; 6.1% (10/165), ATP2B3; 3.6% (6/165) and CACNA1D; 3.0% (5/165). KCNJ5 was previously shown to be mutated in 52.7% (87/165). We detected a total of nine novel deletions in ATP1A1 and ATP2B3, and one novel missense mutation in CACNA1D. In all available specimens the mutations were absent from constitutional DNA, and were confirmed in cDNA, validating their somatic nature. The mutations observed affected regions previously described as vital for the protein function. Tumors with mutations in KCNJ5 were larger than the other mutated APAs (p<0.05). While KCNJ5 mutated tumors most often occurred in females, tumors with ATP1A1 mutations were more common in males (p=0.01). ATPase mutated APAs had higher CYP11B2 expression than those with KCNJ5 mutation (p=0.001).

Conclusion

Mutations in ATP1A1, ATP2B3 and CACNA1D are mutually exclusive and occur in almost 15% of APAs. There is a significant difference in phenotype between these and KCNJ5 mutated tumors. All observed mutations affected a certain group of amino acids, suggesting that most mutations occur in “hot spot” regions and that these are essential for normal protein function.

 

Nothing to Disclose: TA, PH, PB

14791 19.0000 SUN-0813 A Mutation Status of ATP1A1, ATP2B3 and CACNA1D in a Large Multicenter Cohort of Aldosterone Producing Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Clara V Perani*, Inga D Neumann, Stefan O Reber and David A Slattery
University of Regensburg, Regensburg, Germany

 

Obesity is known to associate with several Hypothalamus-Pituitary-Adrenal (HPA) axis-related abnormalities [1].  This is also true during the peripartum period, where maternal obesity is often comorbid with pathologies characterized by HPA axis dysregulation.  However, little research has focused on the specific mechanisms through which obesity may impact the HPA axis changes that occur peripartum. 

We have previously shown that adrenal cholesterol delivery pathways [2] are altered at mid-lactation in the rat.  Specifically, adrenal lipid droplets are depleted, protein expression of low-density lipoprotein receptor (LDLR) and scavenger receptor B1 (SRB1), responsible for lipids uptake, is up-regulated and 3-hydroxy-3-methylglutaryl coenzyme A reductase (HMGCR) is down-regulated.  These changes are hypothesised to participate in the regulation of the maternal HPA axis that shows elevated basal glucocorticoid (CORT) levels and attenuated stress-induced activation [3,4].  Therefore, the aim of the present study was to determine whether consumption of a high fat diet for two weeks prior to mating and throughout the peripartum period (HF; 45% fat) affects adrenal plasticity and basal- and ACTH-induced CORT release at mid-lactation (L) i.e. 8 days after parturition.  Controls were fed with standard chow (normal fed, NF;10 % fat) and virgins (V) were included to assess if the changes were specific to the peripartum period. 

HF diet affected several parameters in L mothers.  Specifically, HF diet intake restored adrenal lipid droplets to V level; a cholesterol source that was reported to be preferentially recruited after ACTH stimulation (NF V 100±22.6 vs. L 16.9±8.7; HF V 86.3±16 vs. L 64.8±18.9; % relative to V NF).  The LDLR increase in L mothers was partially prevented (NF V 100±6.9 L 219.6±48.3; HF V 58.1±28 L 119.4±55.9 % relative to V NF) while SRB1 increase was not affected (NF V 100±6.6 L 157.2±9.3; HF V 104.8±15.5 L 150.6±21.6 % relative to V NF) by the HF diet.  L-associated reduction in HMGCR expression was prevented (NF V 100±12.2 L 65.4±8.3; HF V 93.1±24.4 L 79.2±16.1 % relative to V NF).

To assess in vivo HPA axis-related measures, repeated blood sampling was performed prior to and after ACTH injection (500pg/ml; stress levels [5]).  HF diet intake blocked the basal hyper-CORT observed in NF dams (NF V 188.1±187.2 L 524.3±301.2; HF V 191.7±280.7 L 351.3±320.5; CORT ng/ml) while plasma CORT levels 5 minutes after ACTH injection were exaggerated in L HF compared to V and NF dams (NF V 1023.8±337.5 L 1037.8±222.4; HF V 932.2±165.8 L 1710.2±431.7; CORT ng/ml).  Similar to the adrenal measures, HF diet intake only affected these parameters in the L group.

Taken together, our findings strengthen the importance of studying obesity and HPA axis functionality during the peripartum period.  Moreover, our findings suggest that adrenal glands changes may participate to obesity-associated HPA axis pathophysiology.

 

Nothing to Disclose: CVP, IDN, SOR, DAS

15810 20.0000 SUN-0814 A Impact of High-Fat Diet Intake on Lactation-Associated Adrenal Plasticity and (re)Activity: Novel Insights into Obesity-Associated Hypothalamus-Pituitary-Adrenal Axis Dysfunction 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Anouk van Berkel*1, Jacques W.M. Lenders2, Ad RMM Hermus1, Ianthe Piscaer3, Martin Gotthardt4 and Henri J.L.M. Timmers5
1Radboud University Medical Center, Nijmegen, 2Raboud University Medical Center, Nijmegen, Netherlands, 3Radboud University Medical Center, 4Radboud University Nijmegen Medical Center, Nijmegen, Netherlands, 5Radboud University Medical Center, Nijmegen, Netherlands

 

Background: 123I-MIBG scintigraphy is considered as gold standard for the functional imaging of pheochromocytoma and paraganglioma (PPGL). It targets cell membrane and vesicular catecholamine transporters of chromaffin cells. It is used to identify tumors as PPGL and to find multifocal and metastatic lesions. The various PPGL genotypes are increasingly recognized as important determinants of functional imaging results. 18F-FDG-PET can distinguish between PPGLs with different underlying genotypes1. It is unknown, whether this is also the case for 123I-MIBG and whether its uptake can be used for the functional characterization of PPGL. The aim of this study was to determine genotype-specific differences in uptake of 123I-MIBG among different hereditary and sporadic PPGLs by semi-quantitative analysis. Besides genotype, possible correlations between 123I-MIBG uptake and tumor size and concentration plasma metanephrines were investigated.

Methods: 49 PPGLs were investigated in 45 patients with hereditary mutations in SDHA (n=1), SDHB (n=2), SDHD (n=3), VHL (n=2), RET (n=11), NF1 (n=1), MAX (n=1) and 24 patients with sporadic tumors. 123I-MIBG scans were performed after thyroid blockade with KI. Images were obtained 24 hours post injection using an ECAM Dual or a Symbia-T16 camera (both Siemens Healthcare, USA). SPECT was analyzed with Inveon Research Workplace software (Preclinical Solutions, Siemens, USA). PPGLs and normal left adrenals were delineated using a fixed threshold region growing segmentation algorithm. The mean number of counts in the volume of interest (VOI) was divided by the number of counts in a 125-ml cubic or spheric VOI positioned in the patient’s upper central liver lobe. Tumor-to-liver (T/L) and normal-adrenal-to-liver (NA/L) ratios were calculated and correlated with tumor size and concentration of plasma metanephrines. Results were validated against analysis of planar and SPECT scans with Hermes 4.6A software (Hermes Medical Solutions, Sweden).

Results: T/L ratios of PPGL lesions were higher than NA/L ratios (mean ± SD 9.6 ± 9.4, range 0.4-46.1 vs. 1.7 ± 0.9, range 0.2-3.9, P<0.001). T/L ratios did not differ between adrenal and extra-adrenal PPGLs. Cut-off values to distinguish between physiological and pathological uptake were established at 0.6 (100% sensitivity, 7.7% specificity) and 3.9 (100% specificity, 71.0% sensitivity).  No statistic significant differences in 123I-MIBG uptake were found among PPGLs of various genotypes. 123I-MIBG uptake was significantly and positively correlated with maximum tumor diameter (R=0.586, P<0.001) and concentration of plasma metanephrines (R=0.397, P=0.008).

Conclusion: Liver normalized semi-quantitative 123I-MIBG uptake facilitates the distinction between pathological and physiological adrenal uptake. 123I-MIBG uptake does not distinguish between different hereditary forms of PPGL.

 

Nothing to Disclose: AV, JWML, ARH, IP, MG, HJLMT

11373 21.0000 SUN-0815 A Genotype-Specific Differences in Uptake of 123I-Metaiodobenzylguanidine Across Hereditary and Sporadic Pheochromocytomas and Paragangliomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Yoshikiyo Ono*1, Yasuhiro Nakamura2, Ryo Morimoto1, Yoshitsugu Iwakura1, Masahiro Nezu1, Kei Omata1, Ken Matsuda1, Masataka Kudo1, Takashi Maekawa2, Saulo JA Felizola2, Kazumasa Seiji1, Kei Takase1, Yoichi Arai1, Celso E. Gomez-Sanchez3, Hironobu Sasano2, Sadayoshi Ito1 and Fumitoshi Satoh1
1Tohoku University Hospital, Sendai, Japan, 2Tohoku University Graduate School of Medicine, Sendai, Japan, 3Univ of Mississippi Med Ctr, Madison, MS

 

Aldosterone-producing adenoma is a major subtype of primary aldosteronism. The number of cases of these adenomas, which are below the detection limit of computed tomography but diagnosed by adrenal venous sampling, has recently been increasing. However, the pathophysiology of these adenomas, especially those manifesting clinically overt hyperaldosteronism despite their small size, remains unknown. Therefore, we examined the correlation between tumor size and the status of intratumoral steroidogenic enzymes involved in aldosterone biosynthesis using immunohistochemistry. Forty patients with surgically proven aldosterone-producing adenomas were retrospectively studied. Multi-detector computed tomography, adrenal venous sampling, and laparoscopic adrenalectomy were performed in all of the patients studied. The tumor area at the maximum diameter of the sections was precisely measured by ImageJ software. The status of steroidogenic enzymes was immunohistochemically analyzed, and the findings were evaluated according to the H-score system, based on both the number of immunopositive cells and relative immunointensity. Adrenal masses were not detected by computed tomography in 20 patients. Blood pressure, plasma aldosterone concentration, urinary aldosterone excretion, and the number of antihypertensive agents also decreased significantly following the surgery in these patients, as well as in the patients with adenomas detectable by computed tomography. Maximum tumor area obtained in the specimens was significantly correlated with preoperative plasma aldosterone concentration, urinary aldosterone excretion, the H-score of CYP11B1, and was inversely correlated with the H-score of CYP11B2. These results demonstrated that small adenomas could produce sufficient aldosterone to cause clinically overt primary aldosteronism because of the significantly higher CYP11B2 expression per tumor area.

 

Nothing to Disclose: YO, YN, RM, YI, MN, KO, KM, MK, TM, SJF, KS, KT, YA, CEG, HS, SI, FS

13712 22.0000 SUN-0816 A Histopathology and Steroidogenesis of Microadenomas Associated with Primary Aldosteronism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Fabio R Faucz1, Annabel Sophie Berthon*2, Mihail Zilbermint2, Guillaume Assie3, Maya Beth Lodish2, Eva Szarek2, Giampaolo Trivellin2, Ninet Sinaii1, Rossella Libe4, Stéphanie Espiard5, Ludivine Drougat3, Bruno Ragazzon3, Benjamin Feldman1, Jerome Yves Bertherat6 and Constantine A Stratakis2
1National Institutes of Health, Bethesda, MD, 2National Institutes of Health (NIH), Bethesda, MD, 3INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, France, 4Institut Cochin, France, France, 5INSERM Unité 1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Institut Cochin, Paris, France, 6INSERM U 1016, Cochin Institute, Paris Descartes University, Paris, France

 

Recently, Armadillo Repeat Containing 5 (ARMC5) gene has been identified as a potential tumor suppressor gene in ACTH-independent macronodular adrenal hyperplasia (AIMAH). These results were confirmed in our cohort of patients with AIMAH in which germline ARMC5 mutations were found in 15 out 34 patients (44.12%). According to the expected tumor suppressors role of ARMC5, in silico analysis of the mutations demonstrates that 7 (20.6%) are predicted to affect ARMC5 expression. Moreover, all patients carrying these ARMC5 mutations have Cushing’s syndrome. Altogether these results demonstrate that ARMC5 plays an essential role in the Cushing’s syndrome associated with AIMAH. As the function of ARMC5 is completely unknown, we develop zebrafish model using antisense morpholino-oligonucleotide (MO) to knock down the zebrafish armc5 ortholog. After injection of 15 pg of armc5 MO, the zebrafish harbor phenotype at mid-through late stages of embryogenesis which is characterized by hyperactive spontaneous movement at 36 hours post fertilization (hpf), irregularities in the notochord and a “curly down” body curvature at 48 hpf. To further investigate which signaling pathway is altered, we perform RNA-seq on armc5 MO-injected embryos. These experiments reveal an upregulation of the genes involved in the musculature and liver. These results, which remain to be confirmed by injection of armc5 cDNA suggest the importance of armc5 during zebrafish development and permits us to have the first indication of armc5 pathway. From these results, we would like to analyze armc5 related pathway in mice model to better understand the role of armc5 in adrenocortical pathology.

 

Nothing to Disclose: FRF, ASB, MZ, GA, MBL, ES, GT, NS, RL, SE, LD, BR, BF, JYB, CAS

15911 23.0000 SUN-0817 A Functional Investigation of a New Aimah Suppressor Gene, ARMC5 Using Animal Models 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Rajani Maharjan*1, Joakim Crona2, Peter Stalberg2, Per Hellman1 and Peyman Bjorklund1
1Uppsala University, Sweden, 2Uppsala University, Uppsala, Sweden

 

Background

Pheochromocytoma and paraganglioma are rare, often benign, neuroendocrine tumors. PCC and PGL are derived from chromaffin cells of adrenal medulla and extraadrenal ganglia, respectively, and usually present symptoms caused by excess catecholamine secretion. Currently 13 susceptible genes (EPAS1, FH, MAX, NF1, PHD2, RET, SDHA, SDHB, SDHC, SDHD, SDHAF2, TMEM127, VHL) are identified. Recently we have identified somatic mutations in H-RAS in a subset of these tumours.

Aim of this study was to determine molecular signature of tumours harboring H-RAS mutation and describe clinical biochemical characteristics of patients presenting these tumours.


Methods

Tumour DNA was subjected to high resolution SNP array and subsequent copy number variation analysis. cDNA was analyzed by q-PCR to determine expression levels of KISS1R, MMP24, PNMT, RET VEGFA and WSF1, known to be differentially expressed in these tumours depending on the mutations in the susceptibility genes.

 

Results

Expression levels of KISS1R, PNMT, VEGFA and WFS1 in HRAS mutant showed significant (p < 0.05) differential expression and resembles expression pattern in tumours with RET/NF1mutations, whereas expression of MMP24 and RET showed similar pattern but not at significant level. The most frequent chromosomal changes observed were loss of 1p (5/5), loss of 3q, 6q (4/5) and 22q (3/5). Copy number analysis showed one gain and one loss at HRAS locus (11p15.5) in two of the samples. Patient’s biochemical characteristics revealed a marked excess of both epinephrine and norepinephrine.

 

Conclusion

Pheochromocytoma and paraganglioma harboring somatic H-RAS mutations mimic molecular pattern of tumours with RET/NF1/TMEM127 mutations. Patients with tumours harboring H-RAS mutation present a pattern of catecholamine excess similar to those with RET/NF1 mutations, which might be useful in decision making towards genotyping of the tumour.

 

Nothing to Disclose: RM, JC, PS, PH, PB

15715 24.0000 SUN-0818 A Patient Characteristics and Molecular Pattern of Pheochromocytoma and Paraganglioma Harboring Somatic H-RAS Mutations 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0795-0818 4772 1:00:00 PM Adrenal Tumors: Cushing's, Conn's, Pheochromocytoma Poster

Jessica Abramowitz*1, Yael Tobi Harris2 and Alyson K Myers3
1Hofstra North-Shore LIJ, Great Neck, NY, 2North Shore University Hospital/LIJHS, Great Neck, NY, 3North Shore Hospital, Manhasset, NY

 

Introduction:  Incidental adrenal masses are a common finding on routine abdominal imaging, 10-15% are bilateral, but are rarely lymphoma in origin.

Case Presentation:  A 49 year old Colombian-American male with no significant past medical history presented to the emergency department complaining of left sided flank pain worsening over the course of 3 weeks, as well as 15 pound weight loss, nausea and decreased appetite. He had no significant past medical history and no family history of endocrine tumors. Physical exam was unremarkable, with normal vital signs and no Cushingoid features or hyperpigmentation. Laboratory evaluation included normal electrolytes and urinalysis. CT scan of the abdomen and pelvis without contrast showed a left sided solid 11.8 x 7 cm isodense mass, and a right sided 5.8 x 3.6 cm mass with a 12.7 x 10.8 cm cystic component with peripheral calcifications and mass effect on the kidney, as well as left para-aortic lymphadenopathy. Given the large size of the adrenal masses, adrenal function was assessed and revealed normal plasma metanephrines, an elevated ACTH 297 pg/mL (0-49 pg/mL), with an 8 AM cortisol of 9 ug/dL. Cosyntropin stimulation test was performed with resulting cortisol of 12 ug/dL at 30 and 60 minutes. CT guided biopsy of one para-aortic lymph node revealed B cell lymphoma of large cell morphology, but the bone marrow biopsy was normal and staining for Epstein bar virus was negative. A metastatic evaluation with PET-CT showed hypermetabolic activity of the bilateral adrenal masses as well as the para-aortic lymph nodes, consistent with the diagnosis of primary adrenal lymphoma. The patient was treated with hydrocortisone replacement therapy and started on R-CHOP (Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin, Prednisone) chemotherapy. 3 months after the start of therapy, PET-CT revealed a decrease in size of the bilateral adrenal masses and the lymphadenopathy.

Conclusions:  Primary adrenal lymphoma is a rare diagnosis, but it represents an important clinical entity to consider in the assessment of bilateral adrenal masses.  Proper diagnosis is critical as 61% of patients present with adrenal insufficiency- a finding that is independent of tumor size. It also must be distinguished from adrenocortical carcinoma since it is not treated surgically.

 

Nothing to Disclose: JA, YTH, AKM

11609 1.0000 SUN-0747 A A Case of Primary Adrenal Lymphoma Presenting As Bilateral Adrenal Masses 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Abdulaziz M Alwosaibi*1, Wadei Elhakimi2, Jamal Alsaeed3, Mohammed Alqambar4, Mohammed Elsammak5, Abduljaleel Mammunji5 and Al-Motassem Yousef5
1king Fahad Specialist Hospital-Dammam, 2King Fahad Specialist Hospital, Dammam, Saudi Arabia, 3King Fahad Specialist Hospital, Saudi Arabia, 4King Fahd Specialist Hospital-Dammam, Qateef, Saudi Arabia, 5KFSH-Dammam

 

Background: Virilizing tumors of the adrenal gland are very rare, accounting for 5–6% of all adrenal tumors 1,2. Among them adrenal carcinomas are more common than benign adenomas.

Clinical case: A 42 year-old lady presented with a 10-year history of progressive virilizing symptoms. Baseline tests were consistent with hyperandogenism of adrenal source: A total testosterone of 6.62 nmol/liter (n 0.3-3.78),free androgen index 27.8% (n:0.5-7.3%),DHEA-S 14.22 mMol/L ( n 1.5-7.7).An Abdomen CT scan showed bilateral adrenal tumors, Right Side measured 6X3 cm heterogenous with Hounsfield units (HU) of 27 and 60% washout within 10 minutes. Left adrenal mass measured 3.5x3.5 cm with HU 30 and 60% washout within 10 minutes. The patient underwent a laparoscopic right adrenalectomy based on the size and imaging phenotype. The pathology revealed a 4 cm well circumscribed adrenal adenoma with no pathological evidence of malignancy. Postoperatively there was significant improvement of hyperandrogenism and patient conceived three months later, however post delivery she had  recurrence of hyperandrogenism clinically and biochemically and Follow up CT scan imaging showed the left adrenal mass increased in size to (4.3x3.5cm)from (3.5x3.5 cm). Patient underwent laparascopic Left adrenalectomy and pathology revealed a 6 cm adrenal adenoma with no evidence of malignant potentials. Post operatively she has been maintained on steroid replacement and remains disease-free after two years of follow up.

Conclusion: We report a rare case of benign bilateral virilizing large adrenal tumors in premenopausal woman.

 [1] (Slooten, H.V., Schaberg, A., Smeenk, D. & Moolenaar, A. Morphologic characteristics of benign and malignant adrenocortical tumors. Cancer 1985, 55: 766-773.)

2 [Adrenocortical carcinomas and adrenal pheochromocytomas: mass and enhancement loss evaluation at delayed contrast-enhanced CT.Szolar DH, Korobkin M, Reittner P, Berghold A, Bauernhofer T, Trummer H, Schoellnast H, Preidler KW, Samonigg H Radiology. 2005;234(2):479].

 

Nothing to Disclose: AMA, WE, JA, MA, ME, AM, AMY

12762 2.0000 SUN-0748 A A Rare Case of Bilateral Benign Androgen-Producing Large Adrenocorical Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Umal Azmat*1 and Lawrence Steven Kirschner2
1Ohio State University, Columbus, OH, 2Ohio State Univ, Columbus, OH

 

Background:

Adrenocortical carcinoma (ACC) is a rare but highly aggressive malignancy. Many patients have no symptoms until the tumor starts causing mass effect.  About 50% of these tumors are hormonally active and reported presentations include Cushing’s syndrome, virilization in females, feminization in males and hypertension in the setting of high aldosterone levels. However presentation with resistant hypertension in the setting of normal aldosterone, electrolytes, catecholamine and metanephrines, with only mildly elevated cortisol is very unusual.

Clinical case:

A 68 year old male with a known history of resistant hypertension (poorly controlled on 4 antihypertensive medications) with episodic spells of worsening hypertension accompanied with headaches and palpitations for about a year, presented with confusion, dizziness and markedly elevated blood pressure. At that time he was found to have an NSTEMI and underwent a left heart catheterization and received stents.  He underwent a CT scan of his abdomen during the same hospitalization and was found to have a 5.9 x 9.3 cm adrenal mass and a 3.5 x 7.1 cm destructive lesion involving the left sacrum. Endocrinology was consulted for a presumptive diagnosis of  pheochromocytoma given his history and presentation.  Laboratory investigations included plasma epinephrine, norepinephrine, dopamine, metanephrines, normetanephrines, renin, aldosterone and 24hr urinary metanephrines and catecholamine all of which were within the normal limits. Plasma cortisol level was mildly elevated at 26.27ug/dL (normal 3.09 - 22.40 ug/dL) and 24 hr urine cortisol was 141mcg/24 h (normal 3.5 - 45 mcg/24 h). He was also screened for malignancies appropriate for his age; PSA, CEA, Fecal occult blood and CT chest did not show any abnormalities. After pheochromocytoma labs returned normal, the patient underwent a biopsy of the sacral lesion and the pathology demonstrated metastatic adrenocortical carcinoma. A PET scan showed a small pulmonary nodule as well as an additional bone lesion in the right iliac bone. He was started on mitotane at discharge. He followed up with surgery but was deemed a non-surgical candidate at that time due to Stage 4 ACC, poor functional status and comorbidities. He continues to take mitotane and may be a candidate for systemic chemotherapy. He continues to require four antihypertensive medications with moderate blood pressure control.

Conclusion:

We report in this case a patient referred to cardiology for an NSTEMI with resistant hypertension and a history felt to merit a presumptive diagnosis of a pheochromocytoma. On endocrine evaluation, the correct diagnosis was found to be Stage IV ACC with bone and pulmonary metastasis. Therefore, ACC should be considered in the differential diagnosis of patients with resistant hypertension and an adrenal mass, especially when there is evidence for metastasis at the time of presentation.

 

Nothing to Disclose: UA, LSK

12025 3.0000 SUN-0749 A Adrenocortical Carcinoma with Initial Presentation Mimicking a Pheochromocytoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Vijay Babu Balakrishnan*1, Pankaj Sharda1 and Elias S Siraj2
1Temple University Hospital, Philadelphia, PA, 2Eastern Virginia Medical School, Norfolk, VA

 

Background: Cushing’s syndrome (CS) secondary to bilateral adrenal adenomas can present a challenge in choosing the best treatment option. In severe forms, bilateral adrenalectomy is an acceptable approach where as in milder cases a less aggressive approach may be warranted. Medical management of CS historically involved glucocorticoid synthesis inhibitors which have significant side effects. Mifepristone is a glucocorticoid receptor antagonist which has been recently approved for management of CS. With this background, we explored the use of mifepristone in a patient with mild CS.

Case Presentation: A 45 year-old woman was referred to us for resistant hypertension and hypokalemia. Evaluation confirmed primary hyperaldosteronism. Imaging showed bilateral adrenal masses with characteristics suggestive of benign adenomas (2.1 cm on the left and 1.7 cm on right). Adrenal vein sampling failed to show significant lateralization. It was decided to manage her with spironolactone 25 mg daily. Her hypokalemia resolved, but she still needed lisinopril, and/or hydrochlorothiazide for blood pressure control. During follow-up, she was noticed to have significant weight gain, fatigue, mild central obesity and mild lower extremity edema. Also mild type 2 diabetes was noted with HbA1c ranging from 6.3 to 7.5% and was later managed with lifestyle modifications. Laboratory tests showed: 24 hour urine free cortisol levels of 67 and 82 mcg/24 hr on 2 occasions (Normal 4-50 mcg/24hr), midnight salivary cortisol of 0.19 and 0.11 mcg/dl on 2 occasions (Normal < 0.09 mcg/dl) and AM cortisol level after 1 mg overnight dexamethasone of 13 mcg/dl (NL < 1.8 mcg/dl). ACTH levels were < 5 pg/ ml on several occasions. Despite absence of classical signs and symptoms, a diagnosis of mild CS was made and it was decided to manage her conservatively. 

Following its approval for the management of CS, we started her on mifepristone 300 mg daily, which was later increased to 600 mg daily. Within 2-3 months we were able to stop lisinopril and keep her only on spironolactone. She lost about 13 pounds and her edema improved.  Her HbA1c improved initially from 6.4% to 6.2%, but later started to go up slightly. Her ACTH levels increased from <5 to 36 pg/ml. She did not develop any signs or symptoms of adrenal insufficiency.

Conclusion: In a patient with adrenal CS, mifepristone treatment seems to be safe and effective in improving some of the manifestations of CS as well as normalizing the suppressed ACTH level.

 

Disclosure: ESS: Advisory Group Member, Corcept. Nothing to Disclose: VBB, PS

11121 4.0000 SUN-0750 A Effect of Mifepristone on Cushing's Syndrome Secondary to Bilateral Adrenal Adenomas: A Case Presentation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Myl Reyes Cabangon*1 and Carolyn Navarcan Montano2
1Makati Medical Center, Makati, Philippines, 2Makati Medical Hospital, Makati, Philippines

 

Background: Primary Adrenocortical Carninoma (ACC) is a very rare and aggressive malignancy with an annual incidence of 1 per 1 million people.  They often have metastatic disease at initial presentation with the most common at the liver, lungs, lymph nodes and bone.  While cutaneous metastasis of ACC is uncommon with currently two reported cases, in a 6 y/o boy and a 52 y/o woman.

Clinical case: An 84-year old women initially presented with right upper quadrant pain and CT scan of the abdomen showed: Cholelithiasis, pancreatic head mass and right adrenal gland mass 5.2x3x4.1cm, left adrenal gland was nodular without discrete mass. Workup showed: normal 1mg Dexamethasone suppression test (cortisol 48.6nmol/L, N<50nmol/L), elevated serum cortisol (812.7nmol/L, N138-690nmol/L), normal aldosterone (upright 11.8ng/dl, N4-31ng.dl), renin (upright 5.03ng/ml, N1.9-6ng/ml), and PAA/PRA 2.3, normal DHEA-S 49.3μg/dl.  Impression was:Bilateral nodular adrenal adenoma, rule out Cushing’s Syndrome. 

                  One month after, patient started to have palpable isolated masses on right, subcostal area and left upper arm measuring 1-2cm diameter, firm, movable, non erythematous subcutaneous nodules.  Accompanied with intermittent fever, decreased appetite and weight loss (6kg in 1month).  Excisional biopsy of subcutaneous nodules was done and patient was discharged stable.

                  Five days after discharge, she developed obstructive symptoms and started to be jaundiced. Repeat CT scan of abdomen showed: Interval increase in pancreatic head mass, significant increase in size of right adrenal mass, 6.3x4.7x7.2cm (5.2x3x4.1cm last month) now extends partly in adjacent right hepatic lobe and 2.1x1.4cm right lower perihepatic mass.  Histopathology report of the subcutaneous nodules showed: malignancy metastatic to subcutaneous tissue, Primary Adrenocortical CA is highly considered.  Immunohistochemistry staining showed positive for Cytokeratin and Vimentin, negative for Synaptophysin and CA 19-9, results showed Metastasis from Primary Adrenocortical Carcinoma. 

Conclusion: The prognosis of ACC is poor with an overall-year survival rate of 15-47%. When metastatic disease is present at initial presentation, death usually occurs within one year and surgical resection is the treatment of choice. Skin is a rare site of metastatic disease in patients with Primary ACC. Therefore, it is of paramount importance to recognize that the tumor is a metastatic presentation of an underlying carcinoma.

 

Nothing to Disclose: MRC, CNM

15733 5.0000 SUN-0751 A Subcutaneous Metastasis As Initial Presentation of Primary Adrenocortical Carcinoma (ACC) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Chia Hui Chang*, Ya Hui Hu and Shi Wen Kuo
Taipei Tzuchi Hospital, The Buddhist Tzuchi Medical Foundation, Taiwan, New Taipei City, Taiwan

 

Background:

    Adrenal NP-59 SPECT/CT scan is the best non-invasive imaging for adrenal functional study when adrenal vein sampling (AVS) is not available in primary aldosteronism. Nuclear medicine will play an important role in diagnosis and management of patients with primary aldosteronism in the future. Here, we reported an unusual case which revealed false-positive result in adrenal scintigraphy.

Clinical case:

     A 39-year-old female has stage II hypertension and hypokalemia for one year. Initially, ARR was over 184 (Aldosteron 23.93 ng/ml, n<35 ng/ml; PRA less than 0.13 ng/ml, n<3.95 ng/ml). ARB suppression test revealed positive result (Aldosteron 20.88 ng/ml, n< 35 ng/ml). Adrenal CT showed left adrenal tumor (1.3cm x 2.1cm) with irregular shape and calcification. However, adrenal scan disclosed bilateral greatly increased NP-59 uptake. Due to potential malignant risk of left adrenal tumor, she accepted left adrenalectomy. Pathology reported left cortical adenoma. At follow-up, the patient was free from hypertension or hypokalemia until now.

     Adrenal NP-59 SPECT/CT showing bilateral uptake imply bilateral adenoma or hyperplasia. Surprisingly, our patient could stop all anti-hypertensive drugs after unilateral operation. It seems that our scintigraphy showed a false-positive result of right adrenal gland.

Conclusion:

     We review the article for the sensitivity of adrenal image modality. The sensitivity was 85.4% for adrenal scintigraphy, 85% for CT scan and 74.1% for MRI. The overall sensitivity of combined scintigraphy and CT scan was 100% (1). Rouh-Fang Yen et al. reported about 10% false-positive rate in their adrenal NP-59 SPECT/CT scan (2). At present, due to AVS not available widely and doubt of the complications, the use of non-invasive NP-59 SPECT/CT imaging is increasing. It’s value has to be proved in large patients’ series with reference to AVS (3). In conclusion, we must pay an attention to the false positive and false negative result of adrenal NP-59 SPECT/CT scan.

 

Nothing to Disclose: CHC, YHH, SWK

14337 6.0000 SUN-0752 A An Unusual Case of Unilateral Functional Adrenal Tumor but Bilateral Uptake in Adrenal NP-59 SPECT/CT Scan 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Ricardo Rafael Correa*1, Charalampos Lysikatos-Lyssikatos2, Elena Belyavskaya3 and Constantine A Stratakis4
1National Institute of Health, Rockville, MD, 2National Institute of Health, Bethesda, MD, 3Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 4National Institutes of Health (NIH), Bethesda, MD

 

Non-pheochromocytoma neural crest-derived adrenal tumors are rare; neuroblastomas, ganglioneuroblastomas and ganglioneuromas all occur in the adrenal gland.

We report a 35 year-old male with no previous past medical or family history that presented with severe right groin pain for approximately 5 weeks. During the workup, a CT abdomen revealed a slightly lobulated, 5.8 cm right adrenal mass with little enhancement, homogeneous and no calcifications. Serum and urine catecholamines and metanephrines, aldosterone, cortisol and 17-OH steroids levels were all normal.  Further work up with FDG-PET scan showed minimal to low uptake in the right adrenal mass. An uncomplicated right open adrenalectomy through a midline incision was performed.Histological examination revealed a tumor composed of Schawn cells and neurites with occasional ganglion cells present compatible with benign ganglioneuroma. 

Ganglioneuromas are composed of ganglion cells, neurites and Schawn cells and differ from pheochromocytomas They may be primary or evolve for differentiating neuroblastomas.  The majority of them are sporadic but a few are familial. The molecular pathogenesis of the sporadic ones remains unknown. Ganglioneuromas are typically benign, inactive and therefore asymptomatic. The incidence has not been established but we know that less than 21% of the total cases of GNs occur in the adrenal glands.   Despite their generally benign nature, GNs may come to attention by compressing neighboring structures. The size of these tumors correlates with their malignant potential. Masses larger than 5 and 6cm have 33% and 92%, respectively, potential of malignancy). We conclude that ganglioneuromas should be considered in the differential diagnosis of adrenal gland tumors, albeit they are only rarely present.

 

Nothing to Disclose: RRC, CL, EB, CAS

16335 7.0000 SUN-0753 A Atypical Presentation of a Ganglioneuroma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Karla Cristina Borromeo Detoya*1, Daniela Ciltea2, Anis Rehman1 and Nairmeen A Haller3
1Akron General Medical Center, Cleveland Clinic Affiliate, Akron, OH, 2Akron Gen Prtnrs Physician Grp, Akron, OH, 3Akron General Med Ctr, Akron, OH

 

Introduction: Adrenocortical carcinoma (ACC) is a rare heterogeneous tumor with an annual incidence of 0.7-2 cases per million and poor prognosis. In Cushing’s Syndrome, 10% of cases are caused by ACC, which manifests under conditions of steroid excess in 60% of the cases. We report a case of adrenal adenoma without manifestation of Cushing-like features, progressing to metastatic ACC.

Clinical Case: A 76 year old Caucasian female, with a history of right adrenal cortical adenoma without Cushing’s features having underwent laparoscopic adrenalectomy one year prior, presented with complaints of progressive weakness, lower back pain and hyperglycemia. Physical examination was significant for bilateral lower extremity edema. Laboratory investigation revealed normal values of norepinephrine (609 pg/mL, n 112-658 pg/mL), free metanephrine (<25 pg/mL, n <=57 pg/mL), free normetanephrine (54 pg/mL, n <=148 pg/mL) and serum creatinine (0.86 mg/dL, n 0.51-0.95 mg/dL). Cortisol (63.7  ug/dL, n 2.5-10 ug/dL), renin activity (12.07 ng/mL/h, n 0.25-5.82 ng/mL/h), glucose (309 mg/dL, n 70-99 mg/dL) and HbA1c (8.6%, n 4.2-6.3%) were elevated. A diagnosis of new-onset Diabetes Mellitus Type II was made. An MRI of the abdomen and pelvis with contrast showed multiple retroperitoneal masses in the areas of the infra-hepatic vena cava (IVC) and the right kidney, with the largest measuring 7.5 x 6.0 x 5.5cm. Renal biopsy showed tumor necrosis and fewer than 25% of the tumor cells showing clear neoplasm favoring metastatic ACC. The patient was subsequently scheduled for palliative chemotherapy, radiation and surgical intervention including right nephrectomy and IVC stenting; however, the patient demised before the contemplated interventions.

Conclusion: This report describes a rare case of benign adenoma transforming into metastatic ACC. ACC presents with Cushing’s syndrome in 60% of the cases, along with metastasis. This patient did not initially have the typical Cushing-like features of a cortisol-producing tumor, and presented only with fatigue and uncontrolled hyperglycemia one year after adrenalectomy for adenoma.  In this case, the new onset of diabetes is secondary to elevated levels of cortisol from metastatic ACC. Furthermore, tumor extension into the renal artery and/or IVC caused compression symptoms. Other rare manifestations of ACC include virilization, feminization and Conn’s syndrome. It is recommended that clinicians should have a high index of suspicion for ACC in previously diagnosed cases of adrenal cortical adenoma to include routine screening and follow-up.

 

Nothing to Disclose: KCBD, DC, AR, NAH

16076 8.0000 SUN-0754 A Adrenal Cortical Adenoma Transforming into Adrenocortical Carcinoma in a Patient without Cushing's Features 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Ricardo Miguel Costa de Freitas*1, Maria Candida Barisson Villares Fragoso2, Antonio M Lerario3, João Evangelista Bezerra Neto4, Cristiane Maria Almeida4, Berenice B Mendonca5 and Afshin Gangi6
1Instituto do Cancer do Estado de Sao Paulo, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil, 2Hosp Das Clinicas- FMUSP, Sao Paulo SP, Brazil, 3ICESP/University of Sao Paulo, São Paulo, Brazil, 4Univ São Paulo Cancer Institute - ICESP, São Paulo, Brazil, 5Univ Sao Paulo Fac Med, Sao Paulo, Brazil, 6Université Louis Pasteur, Strasbourg, France

 

Background: Bone metastases from adrenocortical carcinoma (ACC) are seldom observed, accounting for less than 10% of cases. These patients have a poor prognosis with expected survival less than 24 months after diagnosis. Treatment options for such cases are palliative and include systemic and local therapies, such as radiation therapy. More recently, thermal ablative techniques have been successfully employed to treat symptomatic bone metastasis in a myriad of tumors. Here, we report the use of cryoablation to treat multiple foci of sclerotic bone metastasis in a patient with metastatic ACC.

Clinical case: A 39-year old woman, with Li-Fraumeni like syndrome presented with a nonfunctional ACC with 11 cm, high-grade, Weiss score 9, and ENSAT stage III. She received adjuvant therapy with mitotane and tumor bed radiation therapy, since surgical margins were focally positive. Four months after the initial diagnosis, the patient developed moderate to severe hip pain (Visual Analog Score – VAS = 7) and a 6 cm sclerotic bone metastatic lesion was diagnosed at the lesser trochanter of the right femur. In addition, bone scintigraphy has shown asymptomatic vertebral sclerotic metastases at the thoracic (D6) and lumbosacral levels (L2, L4, S2). The femoral lesion was treated by computed-tomography and fluoroscopy guided percutaneous cryoablation followed by a preventive dynamic hip screw internal fixation at the femoral level. This technique offers advantages to conventional surgical approaches to hip metastases, since these are of a higher complexity level, usually including gliding screws, intramedullary fixation or total hip replacement prothesis, and are associated with longer recovery times. Shortly after the procedure, dramatic symptom improvement was observed. Subsequently, the patient presented lumbar and sciatica-like pain, presumably related to progression of spinal lesions. Percutaneous cryoablation was also performed at L4 and S2 spinal levels, with excellent symptoms control for three months. Recurrence of pain was observed at the sacral level, being successfully controlled by another session of cryoablation, followed by conformational radiotherapy. Eight months after the initial cryoablative treatment, other foci of asymptomatic bone disease and visceral metastasis were diagnosed and systemic chemotherapy was initiated.

Conclusion: We successfully demonstrated the use of cryoablation for the treatment of symptomatic ACC bone metastases. Radiation therapy of bone is a therapeutic option, but may be of limited effectiveness, especially in larger lesions. In addition, radiation induced malignancy is a concern, especially in high-risk patients. Inasmuch, cryoablation and radiation therapy might be used concomitantly, with good results such as in this case.

 

Nothing to Disclose: RMCDF, MCBVF, AML, JEBN, CMA, BBM, AG

13319 9.0000 SUN-0755 A Image-Guided Percutaneous Cryoablation of Sclerotic Bone Metastases from Adrenocortical Carcinoma: A New Approach to a Multimodality Palliative Care 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Yusef Hazimeh*1, Mary Koeppe Luidens2, Carrie Carsello3, Carlie Sigel4 and Matthew C Leinung5
1Albany Med College, Albany, NY, 2Albany Medical Center, Albany, NY, 3Albany Medical College, 4Memorial Sloan-Kettering Cancer Center, 5Albany Medical College, Albany, NY

 

Background:

Incidentalomas are commonly encountered adrenal lesions. Fine needle aspiration is not indicated in work up of adrenal cell carcinoma (ACC). We present a patient who twice underwent fine needle aspiration (FNA) biopsy of an adrenal incidentaloma. Although the two FNAs missed the diagnosis, the patient turned out to have ACC with lung metastasis.  

Clinical case:

        A 61-year-old Caucasian male presented to the hospital with sudden shortness of breath. CAT scan of his lungs was diagnostic for pulmonary emboli.  Incidentally noted were a small lung nodule of 0.5 cm, and a left adrenal mass of 9.0 cm. FNA of the adrenal gland was done and was non-diagnostic.  A repeat FNA, done three weeks later did not indicate malignancy. He was referred to endocrinology four months after presentation where evaluation did not disclose any signs of an adrenal disorder. Hormonal work up revealed normal levels of urine catecholamines and cortisol as well as serum aldosterone to renin ratio, electrolytes and DHEA-S levels.  Repeat CAT scan of the abdomen revealed a bilobed heterogeneous mass in the left adrenal gland measuring 9.0 x 5.5 cm with central low density likely indicating necrosis. The mass was suspicious for ACC. CAT scan of his lungs revealed enlargement of the lung nodule to 0.8 cm. He underwent biopsy of the pulmonary nodule. Pathology of lung nodule was compared to original slides from adrenal glands by a pathologist experienced in adrenal tumors. Histologic review of the adrenal gland core biopsy showed cells resembling the adrenal cortex. The nuclei were uniformly low grade and were mildly enlarged, lacked prominent nucleoli, and exhibited fine chromatin. Mitotic activity was absent.  The majority of cells were lipid-rich and the predominant architectural pattern of growth was nested. No features associated with aggressive behavior were identified. The FNA of the left lung nodule (done five months after adrenal biopsy) demonstrated similarly bland lipid-rich cells with a capillary rich network. An extensive immunohistochemical panel was performed on the lung biopsy sample. The staining did not correlate with an ACC; however the material was extremely limited. The morphologic pattern was very similar to the adrenal biopsy and thus the determination was made that it was consistent with metastatic ACC.

Conclusion: 

Patients with suspected ACC should undergo surgical resection of tumor. Available guidelines support adrenalectomy for adrenal masses of more than 4 cm. FNA is not reliable in distinguishing malignant from benign adrenal tumor.

 

Nothing to Disclose: YH, MKL, CC, CS, MCL

15952 10.0000 SUN-0756 A Adrenal Cell Carcinoma: A Missed Diagnosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Jana Kollerova*1, Jan Malina2, Katarina Machalekova2 and Juraj Payer1
1University Hospital Bratislava, Bratislava, Slovakia, 2St Elisabeth Oncology Institute Bratislava, Bratislava, Slovakia

 

Several reports found the association between the renin-angiotensin-aldosterone regulation and symptoms of depression or anxiety. Case history: 40 year old female with 20 year-old history of schizophrenia was admitted to the Dep. of Psychiatry with worsening psychosis. Her psychiatric history was marked by 6 hospitalizations during the previous 4 years for worsening of her paranoid and delusional symptoms. Her condition only partially responded to medication and regular electroconvulsive therapy was also needed. Serum sodium and potassium concentrations recorded in the past were in the normal range, two years ago hypertension and tachycardia was noted and patient was put on a betablocker therapy. During the index hospitalization the patient had normal blood pressure on admission but severe hypokaliemia was observed for which no obvious explanation was found. The usual workup of the condition resulted in an MRI study that revealed a 6x5x5 cm left adrenal tumor. Subsequently hyperaldosteronism was confirmed with basal aldosterone 202 pg/ml. Left adrenalectomy was subsequently performed and revealed an aldosterone producing stage T2N0M0 adrenal carcinoma. No adjuvant chemotherapy was given. Postoperative period was uneventful, 18 months after the operation the patient is still in biochemical remission with no MRI signs of cancer recurrence. However, during the postoperative period the patient experienced complete absence of psychiatric symptoms which allowed substantial reduction of her antipsychotic medication and allowed the cessation of electroconvulsive therapy.

Our case demonstrates the direct and almost causal relationship between the removal of aldosterone producing carcinoma and the symptoms of schizophrenia. This observation could therefore lead us to an assumption that excessive aldosterone production in this patient contributed to the long term treatment refractory course of schizophrenia. Other tumor producing active peptides could also be involved. There are some reports of more frequent depressive disorders among patients with primary hyperaldosteronism and particularly in women. The mechanism of the observation is unknown. However, our report is the first to describe the association of hyperaldosteronism with the treatment refractory schizophrenia.

 

Nothing to Disclose: JK, JM, KM, JP

15093 11.0000 SUN-0757 A Aldosterone Producing Adrenal Carcinoma in a Patient with Treatment Refractory Schizophrenia – Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Leen Wehbeh1, Douglas Turner2, Kashif M. Munir3 and Rana Malek*3
1University of Damascus School of Medicine, 2University of Maryland School of Medicine, 3University of Maryland Medical Center, Baltimore, MD

 

Title: Cystic adrenal lymphangioma presenting as an enlarging adrenal mass

BACKGROUND: Adrenal lymphangiomas (AL) are rare, benign vascular lesions. ALs commonly present with abdominal pain or are incidentally discovered during imaging studies for an unrelated cause. They usually appear as a cystic mass on CT scans

CLINICAL CASE: A 69-year old female presented for evaluation of a left adrenal nodule discovered incidentally on a CT scan done for right-sided flank pain. The patient had no signs or symptoms consistent with pheochromocytoma, Cushing’s syndrome or hyperaldosteronism. Laboratory tests were normal: 24-hr urinary free cortisol 22.4 mcg/24hr (4.0 - 50.0 mcg/24hr), ACTH 24 pg/mL (6 - 50 pg/mL), 24-hr urinary catecholamines 42 mcg/24hr (26 121 mcg/24hr), 24-hr urinary metanephrines 265 mcg/24hr (224 - 832 mcg/24hr), DHEAS 62 mcg/dL (< or = 145 mcg/dL), aldosterone 2 ng/dL (< or = 28 ng/dL) and renin 0.62 ng/mL/hr (0.25 - 5.82 ng/mL/hr). A repeat CT scan showed the nodule to be hypodense, lobulated in appearance and have increased in size from 3.7 x 2.9 x 2.6 cm to 4.5 x 3.1 x 3 cm during the 6-month interval. Left adrenalectomy was performed based on growth over time and nodule size of > 4cm. Surgical pathology showed the nodule to be cystic lymphangioma with multiple calcifications. Immunohistochemistry for CD 31 and D2-40 showed positive staining of the cyst wall lining, supporting the diagnosis of AL.  Radiology review of original CT postoperatively was still inconclusive and deemed suspicious, despite knowledge of diagnosis.

CONCLUSION:

ALs are rare lesions of the adrenal gland often found incidentally with less than 50 cases reported in the literature. The largest case series included 9 patients over 24 years.   In that series 78% had imaging that characterized the lesion as having cystic components.  Our case presents an enlarging mass with radiographic features of an adrenal adenoma that was only determined to be cystic AL on surgical pathology.  While rare, cystic AL should be considered part of the differential diagnosis in an enlarging adrenal mass especially if biomarkers do not support a diagnosis of primary adrenal cancer. 

 

Nothing to Disclose: LW, DT, KMM, RM

16498 12.0000 SUN-0758 A Cystic Adrenal Lymphangioma Presenting As an Enlarging Adrenal Mass 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Alex Manzano*1, Gustavo L Fernandez-Castro2, Vania Nose3 and Alejandro Ayala1
1University of Miami Miller School of Medicine, Miami, FL, 2University of Miami Miller School of Medicine, 3Massachusetts General Hospital

 

Introduction:

Leiomyosarcomas are mesenchymal tumors, that very rarely present as a primary adrenal malignancy. Until now, there have been thirteen cases reported of primary adrenal leiomyosarcoma (PAL) in the medical literature in English.

Clinical case: A 63 years old Hispanic female referred to our clinic four months after having right adrenalectomy. Eight months prior to this encounter, she started to notice bilateral lower extremity edema with skin changes and diffuse non-specific abdominal pain. She denied weight loss, fever or vomiting. She has history of type II Diabetes Mellitus with retinopathy and peripheral neuropathy, coronary artery disease and post ablative hypothyroidism. Her HIV test was negative. CT scan of the abdomen revealed a large adrenal mass that appeared to be encroaching in the inferior vena cava measured 6.8 x 4.4 cm with hypodense areas, irregular borders and necrotic center. Pre operative workup to rule out functional adrenal mass was negative. She underwent a CT-guided adrenal biopsy showing spindle cell neoplasia with positive SMA in all tumor cells. Exploratory laparotomy was performed; right mass arising from the adrenal gland was cut in half and resected with difficulty.

Microscopic examination revealed spindle cell neoplasia. Mitotic index was focally 7 mitosis per 10 high power fields; atypical mitosis and necrosis were present.

The initial right adrenal biopsy showed immunohistochemistry is positive for actin and desmin and negative for S-100. Ki-67 is present in 40% of proliferating cells.

Immunohistochemistry from the surgical specimen revealed positive desmin, SMA and focal myogenin (MYF-4). S-100 protein and inhibin were negative. Ki-67 proliferative index focally greater than 50%. The diagnosis of intermediate grade leiomyosarcoma was confirmed.

Two months after surgery, surveillance PET scan revealed another right adrenal mass measuring 5.6 x 5 cm with standardized uptake value (SUV) of 2.1. Once again, fucntional workup for adrenal mass was negatice. Repeat surgical intervention and radiotherapy were reconsidered but ultimately the patient was treated with gemcitabine and taxotere. A follow up abdominal and pelvic CT scan revealed a progressive rapid enlargement of the 9.5 x 8.5 x 9.5 cm with prominent retroperitoneal lymph nodes.

 Conclusion:

Primary leiomyosarcomas of the adrenal gland are excessively rare. A total of thirteen reported cases have been listed in the most recent literature review. To our knowledge this will be the second case of PAL with documented recurrence, and the fourteenth reported in the current medical literature. Surgical removal of the tumor is the first step in treatment. Adjuvant therapies are still not well standardized based on the low incidence of cases. Areas of future research should focus on immunohistochemical diagnostic markers that could predict behavior of disease.

 

Nothing to Disclose: AM, GLF, VN, AA

13054 13.0000 SUN-0759 A Recurrent Primary Adrenal Leiomyosarcoma: A Case of a Rare Adrenal Tumor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Isao Minami*1, Takanobu Yoshimoto1, Kazutaka Tsujimoto1, Kyoichiro Tsuchiya1, Masatomo Mihara1, Hajime Izumiyama1, Koshi Hashimoto2, Keiko Honma3, Tomonobu Hasegawa4 and Yoshihiro Ogawa1
1Tokyo Medical and Dental University, Tokyo, Japan, 2Tokyo Medical and Dental University Graduate School, Tokyo, Japan, 3Keio University Hospital, Tokyo, Japan, 4School of Medicine, Keio University, Tokyo, Japan

 

A 69-year-old woman with severe hypertension and hypokalemia was referred to our hospital in May 2012. She was found to have Cushingoid features with weight gain and leg edema over a year. An endocrinological examination revealed dexamethasone (1 mg) non-suppressible high serum cortisol level (29.2 mcg/dl) and low plasma ACTH levels (2.0 pg/ml). A series of image analysis revealed a left adrenal tumor (79*42 mm) with liver and bone metastasis. She was diagnosed as adrenocortical carcinoma (ACC) at Stage IV with Cushing syndrome. She started to be treated with mitotane initially at 1.5 g/day and gradually increasing to 4.5 g/day, in combination with metyrapone plus dexamethasone. Although CT examination revealed decrease in left adrenal tumor in size, she presented a symptom of adrenal insufficiency with increased plasma ACTH levels (26.6 pg/ml) three months after mitotane treatment regardless of discontinuation of metyrapone and increase of dexamethasone. Her plasma concentration of mitotane reached above the therapeutic range (25.8 mg/L). Her plasma ACTH levels kept high (100 pg/ml<) even by treatment with high doses of dexamethasone (2.5-4.0 mg/day), while her blood pressure was elevated over 200/100 mmHg in spite of administration of 5 kinds of antihypertensive drugs including dihydropyridine calcium channel blocker (CCB) and eplerenone. Since it appeared that mitotane-induced CYP3A4-dependent drug resistance is involved in prolonged adrenal insufficiency and resistant hypertension, we started the administration of diltiazem, a benzodiazepine CCB with inhibitory action to CYP3A4. After the initiation of diltiazem, her blood pressure and plasma ACTH levels were markedly decreased, accompanied by decreased urinary excretion of 6β-OHF/F (138.7 to 53.0 mg/g cre), an index of CYP3A4 activity. This is an instructive case of mitotane-induced CYP3A4-dependent drug resistance in ACC and suggests that diltiazem may be therapeutically useful for this condition.

 

Nothing to Disclose: IM, TY, KT, KT, MM, HI, KH, KH, TH, YO

12269 14.0000 SUN-0760 A Mitotane-Induced CYP3A4-Dependent Drug Resistance in Adrenocortical Cell Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Marilena Nakaguma*1, Carlos André Minanni2, Mirela Costa de Miranda3, Antonio M Lerario4, Berenice B Mendonca5, Ana Claudia Latronico6, Madson Q. Almeida7 and Maria Candida B V Fragoso8
1Hospital das Clinicas, University of São Paulo Medical School, São Paulo, SaoPaulo, 2University of São Paulo Medical School, Division of Endocrinology and Metabolism, Brazil, 3Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Sao Paulo, Brazil, 4ICESP/University of Sao Paulo, São Paulo, Brazil, 5Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular LIM/42, Disciplina de Endocrinologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, 6Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 7Hospital das Clínicas & Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 8University of Sao Paulo, Sao Paulo-SP, Brazil

 

Development of Virilizing Adrenocortical Carcinoma During Pregnancy: case report

Marilena Nakaguma MD, Carlos André Minanni MD, Mirela C Miranda MD, Antonio M Lerario MD PhD, Berenice B Mendonca MD PhD, Ana Claudia Latronico MD PhD, Madson Q Almeida MD PhD, Maria Candida B V Fragoso MD PhD

Adrenal Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.

 Background: Adrenocortical carcinoma (ACC) is a rare disease (1 to 2 cases per million) associated with a poor outcome. Pregnancy in ACC female patients has been rarely reported. Because of the rarity, the clinical features of ACC diagnosed during pregnancy and its biological behavior remains to be determined. Clinical Case: A 29-yr-female patient was admitted to the hospital with low back pain. She underwent an abdominal CT which revealed nephrolithiasis. The kidney stones were surgically removed in July 2011. In February 2012, she got pregnant and developed hirsutism (upper abdomen and lower jaw). At the 37th week of pregnancy, a 2875-g female infant was delivered by cesarean section with no clinical evidence of adrenal insufficiency, normal genitalia and normal blood pressure levels. Nineteen days after delivery, the patient presented a right iliac fossa pain. An abdomen US revealed appendicitis and also displayed a heterogeneous mass in the left adrenal gland of 6.5 cm. When retrospectively evaluated, the first image already revealed the presence of an adrenal heterogeneous nodule with 2 cm. The patient underwent apendicectomy and subsequently readmitted for mass investigation. Hormonal evaluation revealed subclinical hypercortisolism and biochemical hyperandrogenism. Tumor staging was ENSAT 3. Patient underwent laparoscopic adrenalectomy witch was converted to open surgery and histopathological analysis showed a Weiss 5 ACC: high mitotic rate (> 11 per 50 high-power fields), atypical mitotic cells, a diffuse growth pattern (more than one third of the tumor), necrosis, sinusoidal invasion, and capsular invasion.  The TP53 mutation screening resulted negative. Patient was referred to our clinic for follow up. Adjuvant therapy with mitotane was started and the patient underwent adjuvant radiotherapy of tumor bed. After 9 months of follow up, she development abdominal secondary implants. She was referred to chemotherapy (EDP+mitotane). Conclusion: We reported a case for the first time showing the increase of size of an ACC during the pregnancy. Although she underwent a more aggressive treatment (complete resection plus adjuvant mitotane and radiotherapy), it did not change the aggressive behavior course of this ACC. This observation is supported by previous published data showing the poor ACC outcome associated with pregnancy.

 

Nothing to Disclose: MN, CAM, MCDM, AML, BBM, ACL, MQA, MCBVF

16805 15.0000 SUN-0761 A Development of Virilizing Adrenocortical Carcinoma during Pregnancy: Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Ha Nguyen*1 and Catherine Anastasopoulou2
1Albert Einstein Medical Center, Philadelphia, PA, 2Einstein Endocrine Associates, Elkins Park, PA

 

Introduction: Adrenal myelolipoma is an uncommon, benign and hormonally inactive tumor of the adrenal glands. They usually present as incidentalomas on imaging studies. To the best of our knowledge, all of the functioning adrenal myelolipomas that have been documented in the English literature were large tumors. We present the first case of hyperandrogenism due to a small 8mm adrenal myelolipoma.

Case: 67 year old Caucasian female presented with a 1 year history of scalp hair loss. At the same time, she also reported increased facial and lower abdomen hair growth. She denied abdominal pain or weight loss. Her menstruation had been irregular since menarche. Physical exam showed thin hair, but no obvious male pattern baldness. An evaluation was conducted which showed elevated levels of total Testosterone 104 ng/dL (reference range: 3-41 ng/dL), free Testosterone 19.2 pg/mL (0.1-6.4 pg/mL) and Androstenedione 188 ng/dL (<75ng/dL) with a normal DHEA-S level of 55 mcg/dL (< 145mcg/dL). TSH, 24 hour urine catecholamines, plasma metanephrine, 24 hour urine cortisol, and serum prolactin levels were normal.

Her abdominal computed tomography showed an 8 mm myelolipoma in the right (R) adrenal gland which measured -20 Hounsfield units. Her ovaries were mildly enlarged as reported on a transvaginal pelvic ultrasound (the R-ovary: 2.8 x 1.7 x 2.1 cm and the left (L): 1.6 x 2.7 x 1.6 cm). There were no ovarian cysts. To identify the primary cause of her elevated androgen levels, bilateral adrenal and ovarian vein sampling for testosterone levels was performed with the following results: R-ovary: 22ng/dL, L-ovary: 126 ng/dL, R-Adrenal 1266 ng/dL and L-adrenal 61 ng/dL. A diagnosis of right adrenal myelolipoma associated with hyperandrogenemia was made. The patient underwent a right adrenalectomy.

Conclusion: This case demonstrates the variability in clinical presentation, tumor size and hormonal activity of adrenal myelolipoma. A complete endocrine investigation should be considered to identify the right diagnosis and treatment for symptomatic patients with  this tumor type.

 

Nothing to Disclose: HN, CA

15515 16.0000 SUN-0762 A Tiny but Worth Attention: Adrenal Myelolipoma Associated with Hyperandrogenism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Yousuf Khan, Nafees Quratulain*, Mark Zaky, Gayon Hyatt and Raymond Y Liang
Hackensack University Medical Center Mountainside, Montclair, NJ

 

Background:

Primary adrenal lymphomas (PAL) are extremely rare and accounts only for less than 1% of all Non Hodgkin lymphomas (NHL). Most of the PALs are bilateral, occurs in older male, result in adrenal insufficiency and carries grave prognosis. We present a case of PAL in a female patient who was evaluated for fatigue.

Case details:

65 y/o female presented with fatigue, generalized weakness, anorexia and weight loss since 3 months. Family history was significant for Hürthle cell carcinoma of thyroid in one sibling and hypothyroidism in another. Physical exam was unremarkable with no palpable lymphadenopathy, hepatomegaly or splenomegaly. Initial work up showed severe anemia and mild hyponatremia. Further work up including colonoscopy, mammogram and ultrasound of the breasts were normal. CT scan of the chest, abdomen & pelvis revealed 7x7 cm right adrenal mass and 7x5 cm left adrenal mass with retroperitoneal, retrocrural and posterior mediastinal adenopathy. Additional labs showed low Cortisol, elevated ACTH, decreased DHEA and elevated LDH. Adrenal mass biopsy showed monoclonal population of large B cells with immunophenotype of CD20 (bright+), CD19 (-), Kappa (+), CD10 (+), CD5 (dim+) consistent with high grade B-cell lymphoma. Patient underwent bilateral adrenalectomy, radiation therapy and receiving chemotherapy.

Discussion:

PALs are extremely rare form of extra nodal NHLs with majority being large B cell type. In a study of 1,670 patients with NHL there were only 6 cases of adrenal lymphomas. Among these 6 cases only 3 were PALs and the rest were secondary adrenal lymphomas (SAL) that developed as part of metastasis. On literature review there are only about 106 cases of PALs reported so far. The median age at diagnosis was 65 years, 70% were bilateral tumors and male to female ratio was 2 to 1. In a case study the overall survival period for PAL was less than one year with 19 out of 20 patients studied dead by the end of first year after diagnosis. The poor prognostic factors described were large size of the tumor, presence of adrenal insufficiency, elderly age, and high LDH levels. As the prognosis of PALs is grave despite multimodality aggressive tumor therapy, it is important to discuss the nature of the disease, wishes of the patient and end of the life issues early in the course so that patients can have a meaningful time in their remaining life.

 

Nothing to Disclose: YK, NQ, MZ, GH, RYL

16903 17.0000 SUN-0763 A Primary Lymphoma of the Adrenal Glands 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Nithin Georgey Thomas1, Taiga Inoue2, Cesar del Rosario3, Gul Bahtiyar4 and Alan Scott Sacerdote*5
1Woodhull Medical and Mental Health Center, Brooklyn, 2Woodhull Medical & Mental Health Center, Brooklyn, NY, 3Woodhull Medical Center, Brooklyn, NY, 4SUNY Downstate Medical Center, Brooklyn, NY, 5Woodhull Med & Mental Hlth Ctr, Brooklyn, NY

 

Background: Cushing’s syndrome (CS) maybe caused by excess ACTH production (80-85%), usually by a pituitary tumor (Cushing’s disease), ectopic ACTH syndrome, or rarely, by ectopic CRH syndrome. CS can also be ACTH independent when it results from excess secretion of cortisol by unilateral or bilateral adrenocortical tumors, either benign or malignant or bilateral autonomous nodular adrenal hyperplasia. Ectopic production of cortisol by metastatic hepatocellular carcinoma (HCC) has not been previously reported and ectopic DHEA secretion by these tumours is very rare.

 

Clinical case:   We report a 53 year old woman who was admitted to the hospital with generalized dyspnea, and headache.  Past medical history included chronic Hepatitis B and Diabetes Mellitus. She was noted to have facial mooning, buffalo hump, hirsutism, facial plethora, proximal weakness, and abdominal striae. Her BMI was 51.4 kg/m2. Her BP was 130/92 mm Hg. Her serum cortisol by immunoassay[IA] was 42.3 (4.6-20.6) mcg/dl (collected while patient was taking dexamethasone 4 mg every 8 hours for cerebral edema due to metastases), and pre-dexamethasone urine free cortisol [UFC] by liquid chromatography mass spectrometry [LC/MS/MS] was 106.1(4.0-50.0) mcg/24 hrs with urine creatinine 0.9 g/day. Serum DHEA by LC/MS/MS was 4886 (102-1185) ng/ml, and serum DHEA-S by LC/MS/MS was 4477 (15-170) ng/ml. Her plasma ACTH by IA was 10 pg/ml(5-27). CT scan showed liver, adrenal, and brain masses and pulmonary nodules. CT guided liver and adrenal biopsies were done and she was diagnosed with HCC with metastases to the adrenals, lung and brain. ACTH immunoperoxidase staining of the biopsy specimen was negative. High serum cortisol while on high dose dexamethasone, and  high baseline UFC levels with high serum DHEA and DHEA-S and  low-normal levels of ACTH with absent tumour ACTH staining point towards an ACTH -independent ectopic CS; cortisol and DHEA being most probably secreted by  the HCC .

 

Conclusions:

1.      Metastatic Hepatocellular carcinoma can be associated with paraneoplastic Cushing’s syndrome, which is very rare and, to the best of our knowledge this is the first reported case with the tumor hypersecreting cortisol.

2.      This case is also one of the very few reported instances of DHEA secretion by an HCC.

3.      It is very unusual to see florid features of CS in patients with aggressive malignancies, where usually patient wasting, hypokalemia, and severe hyperglycemia are the presenting features.

 

 

Nothing to Disclose: NGT, TI, CDR, GB, ASS

12435 18.0000 SUN-0764 A ACTH Independent, Cortisol and DHEA Secreting Metastatic Hepatocellular Carcinoma Causing Cushing's Syndrome: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Oren Steen* and Ally P.H. Prebtani
McMaster University, Hamilton, ON, Canada

 

Background: Composite pheochromocytoma (CP) is a rare tumor of the adrenal medulla, consisting of neuroendocrine and neural components. Despite similar neural crest origins, pheochromocytomas and neurogenic tumors are distinct entities. Symptoms may arise from hypersecretion of hormones by either component; however, not all patients present with classic symptoms. Moreover, various medical conditions and substances can confound screening tests and complicate the diagnosis.

Clinical Case: The patient, a 46-year-old male, was seen in the endocrine clinic regarding a two year history of paroxysmal headaches, palpitations and diaphoresis. His medical history was significant for hypothyroidism and substance misuse (nicotine, marijuana and cocaine). Family history was negative for pheochromocytoma, hyperparathyroidism or thyroid malignancies. He was found to be hypertensive in clinic, and two café-au-lait spots and bilateral axillary freckles were noted on dermatological examination. Pheochromocytoma was suspected and investigations revealed 24-hour urinary catecholamines, metanephrines and VMA levels that were substantially elevated. He was asked to repeat the urine collection while abstaining from cocaine, given the potential confounding with cocaine-induced elevations of catecholamines and their metabolites; however, the patient did not comply with this. His plasma free metanephrines and chromogranin A were later found to be elevated. Abdominal computed tomography revealed a 5.8 x 5 cm mass in the left adrenal gland, with an attenuation of 40 Hounsfield units. He underwent an uncomplicated laparoscopic left adrenalectomy, after which his blood pressure normalized. Histological features of the tumor revealed findings consistent with a typical pheochromocytoma with neuroblastomatous infiltrates comprising <5% of the tumor. The mitosis karyorrhexis index was low and there was no ganglioneuromatous infiltrate evident. Medical oncology was consulted in view of the histopathological findings, and no adjuvant therapy was recommended. Unfortunately he did not fully comply with repeat imaging or biochemical evaluation. One year postoperatively, the patient remains completely asymptomatic and normotensive.

Conclusion: Cocaine-induced catecholamine effects can clinically mimic pheochromocytoma, thereby complicating the diagnosis. In addition, the biologic behaviour of CP with neuroblastoma is uncertain and warrants oncologic assessment and surveillance.

 

Nothing to Disclose: OS, APHP

11759 19.0000 SUN-0765 A A Perplexing Case Involving Cocaine, Pheochromocytoma and Neuroblastoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Fareeda Tabassum*1, Belayet Hossain2 and Zahra Khatami3
1Barking, Havering and Redbridge University Hospitals NHS Trust, 2Barking, Havering & Redbridge University Hospitals NHS Trust, Ilford, United Kingdom, 3Barking, Havering & Redbridge University Hospitals NHS Trust, London, United Kingdom

 

Background: Parathyroid hormone related peptide ( PTHrP ) is a common cause of humoral hypercalcemia of  malignancy. It is usually associated with carcinoma of the lung, prostate, & breast and  uncommonly with malignant  pheochromocytoma. We present a case of breast carcinoma metastatic into a benign paraganglioma causing PTHrP related hypercalcemia

Case Presentation: A 72 years old lady presented with tiredness, poor appetite, generalized body aches and constipation. Corrected calcium was 3.9mmol/l  ( 2.2 - 2.6 )at that time. She had a past history of hypertension and carcinoma of the left breast treated 5 years ago. She was followed up by oncology for 5 years and there was no evidence of carcinoma recurrence. Staging  CT scan at diagnosis of breast cancer showed a left adrenal mass 3.8x3.3cm  which remained unchanged on follow up images. 24 hour urine catecholamines and adrenal biopsy at that time were normal.

Other Investigations: FBC, U&E, CXR were normal, PO4 0.79mmol/l, ESR 108mm/hr, PTH 0.3pmol/l. Protein electrophoresis,  ACE and Vitamin D were normal. CT Scan showed left mastectomy and a left adrenal mass which remained unchanged. Bone scan did not show metastases., PTHrP was elevated 31.9pmol/L ( <1.8 ). Urinary metadrenaline 5895 nmol/24hour ( 0 – 2000 ),  normetadrenaline 3997 nmol/24hour ( 0 – 4400 ), 3-methoxytyramine 1086 nmol/24hr ( 0 – 2500 ). PET scan showed left adrenal mass. MIBG scan showed increased activity in left adrenal gland. Patient had left adrenalectomy for pheochromocytoma but became hypercalcemic again few days after surgery. Histology showed paraganglioma with micrometastases from previously treated breast cancer. Micrometastases were also found on bone marrow biopsy

Discussion: Adrenal incidentaloma on staging CT scan diagnosed as adenoma was a paraganglioma. The delay in diagnosis of paraganglioma caused complications and the presence of paraganglioma misled the team as the likely cause of hypercalcemia which  further delayed the diagnosis of  micrometastatses.

Conclusion: We present a case of hypercalcemia due to breast carcinoma metastatic into a paraganglioma. To our knowledge this pathology has not been described before. Although hyparcalcemia has been described with paragangliomas and pheochromocytomas, in patients with past medical history of cancer that is commonly associated with humoral hypercalcemia and paraganglioma, PTHrP production by the primary malignancy seems to be one of the differential diagnosis.

 

Nothing to Disclose: FT, BH, ZK

15754 20.0000 SUN-0766 A Resistant Hypercalcemia & Micrometastases in a Paraganglioma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Katsutoshi Takahashi*, Yuichi Takashi, Noriko Makita, Manabu Taguchi, Naoko Egami, Seiji Fukumoto and Masaomi Nangaku
University of Tokyo Hospital, Tokyo, Japan

 

Background: In primary CNS lymphoma, spontaneous regression of tumor has been one of the known clinical scenarios. However, this is not known for primary adrenal lymphoma (PAL).

Clinical case: A 82-year-old man presented with general malaise, recent weight loss and a faint. He showed typical symptoms of primary adrenal insufficiency. Initial tests were consistent with primary adrenal insufficiency due to PAL: an elevated ACTH concentration (122 pg/ml, n<63 pg/ml), high serum LDH (296 IU/l, n<237 IU/l), elevated serum soluble Interleukin-2 receptor (sIL-2R, 17000 IU/ml, n<582 IU/ml), bilateral huge round adrenal masses with apparent homogeneous nature on abdominal CT-scan (both adrenals 8.5 cm in diameter). He received 15-30 mg hydrocortisone for adrenal insufficiency under stress. Unexpectedly, in a few weeks, a repeat abdominal CT scan revealed bilateral adrenal mass shrunk to 4-5 cm in diameter without specific curative therapy. And the concentration of sIL-2R had markedly decreased to 2804 IU/ml. At this time, highly suspected diagnosis of PAL was not established by CT-guided core biopsy of left adrenal gland because it revealed only a small number of non-specific T lymphocytes and degenerating fat tissues. A third CT scan after 1 month detected enlarged adrenal masses (8.8-9.4 cm) with increased level of sIL-2R of 24936 IU/ml. Second adrenal biopsy successfully established the diagnosis of diffuse large B-cell lymphoma (DLBCL) and he had a CR to Rituximab-CHOP therapy after his 6th cycles of treatment.

Conclusion: We reported an instructive case of PAL (DLBCL), which initially puzzled us because of rapid tumor regression with non-specific pathological findings. It should be noted that “waxing and waning” of bilateral adrenal masses correlated with serum sIL-2R levels. We have to pay careful attention to a possibility of PAL, even if adrenal masses shrink.

 

Nothing to Disclose: KT, YT, NM, MT, NE, SF, MN

15329 21.0000 SUN-0767 A Rapid Regression of Bilateral Adrenal Masses: A Challenging Case of Primary Adrenal Lymphoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Yoshimichi Takeda*1, Masashi Ohe1, Mitsuhiro Kometani1, Takashi Yoneda1, Shigehiro Karashima1, Atsushi Hashimoto1 and Yoshiyu Takeda2
1Kanazawa University, Kanazawa, Japan, 2Kanazawa Univ Sch of Med, Ishikawa, Japan

 

A 70-year-old Japanese female visited our hospital because of unilateral adrenal tumor. She was suffered from papillary thyroid cancer and total thyroidectomy was done 6 years ago. She was prehypertensive with plasma renin activity (PRA), 0.3ng/mL/h and plasma aldosterone concentration (PAC), 149pg/mL. No hypokalemia was seen. Primary aldosteronism was confirmed by a captopril challenge test. Computed tomography and magnetic resonance imaging showed right adrenal hematoma. Adrenal venous sampling showed overproduction of aldosterone from bilateral adrenal gland. The laparoscopic right adrenalectomy was done because the tumor size gradually increased. Pathological findings showed the papillary thyroid cancer. No adrenal hyperplasia was seen. After operation, the blood pressure was normalized, however, PAC/PRA ratio was over 200. The CYP11B2 mRNA levels were detected by the real time PCR. These results may suggest that adrenal metastatic tissues from papillary thyroid cancer produce aldosterone. Further studies including immunohistochemistry with CYP11B2 antibody are necessary.

 

Nothing to Disclose: YT, MO, MK, TY, SK, AH, YT

16023 22.0000 SUN-0768 A A Case of Primary Aldosteronism Caused By Adrenal Metastases from Papillary Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Tomoko Takiguchi*1, Naoko Hashimoto1, Ikki Sakuma1, Akina Shiga1, Seiichirou Higuchi1, Akitoshi Nakayama1, Hidekazu Nagano1, Sawako Suzuki1, Hisashi Koide1, Tomohiko Yoshida1, Ichiro Tatsuno2, Koutaro Yokote1 and Tomoaki Tanaka1
1Chiba University Graduate School of Medicine, Chiba, Japan, 2Toho University Sakura Medical Center, Sakura-City, Japan

 

Introductions:

Adrenocortical carcinoma (ACC) is a rare disease with an overall unfavorable prognosis. Several lines of evidence have suggested that Weiss criteria is one of the useful index for the differential diagnosis between an adrenocortical adenoma (ACA) and ACC as well as prognosis prediction. In addition, a recent microarray study identified a set of genes whose combined expression patterns would be predictive of poor outcome in a cohort of ACC. However, we have still limited and incomplete knowledge on the factors predicting ACC patient outcome since ACC has a heterogenous behavior with a wide variety of biological aggressiveness. Here, we report 4 cases of ACC with addressing clinicopathological features as well as gene expression profile for prognostic markers and disorganized steroidgenesis determined using tumor tissue samples.

Case reports:

We analyzed four ACC cases (one man and three women) with the mean age of 37.8-year-old who underwent adrenalectomy at our institution. Endocrine studies revealed that two cases had overt Cushing’s syndrome and one with androgen-secreting tumor, while the rest one case presented non-functioning tumor. Steroid mapping showed increased metabolites of corticosteroid precursors with elevation of DHEA-S and androstensione. Intriguingly, all cases had disorganized steroidogenesis with differential hormone profiles. The pathological diagnosis of ACC was made based on Weiss’s criteria (score > 3). Two cases had metastasis: bone and liver. The mean size of the resected tumors was 80.6 mm and Ki67 labeling index was 14-23%. We examined the gene expression profile for steroidogenic enzyme, IGF-2, MIB-1, Tpoisomerase 2A and so on, using tumor tissues. The expression pattern of CYPB1/B2 and CYP17/HSD3B2 was consistent with Cushing syndrome’s profile, while the expression of DHEA-ST was heterogeneously elevated, suggesting disorganized expression of several steroidogenic enzymes. The expression of IGF-2 and Tpo2A mRNA was markedly increased in all four cases, and significantly greater than in ACA. IGF-2expression was likely correlated to the recurrence and metastasis among ACC.

Conclusion:

Taken together, these data suggest that the disorganized expression of steroidogenic enzymes is unique characteristics of ACC, possibly linking to heterogenous behavior in hormone profile and the overexpression of IGF-2 would be useful indicator for the prognostic marker, while further investigation is required.

 

Nothing to Disclose: TT, NH, IS, AS, SH, AN, HN, SS, HK, TY, IT, KY, TT

16723 23.0000 SUN-0769 A Clinicopathological Features and Gene Expression Profile for Prognostic Markers and Disorganized Steroidogenesis in 4 Patients with Adrenocortical Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Johnson Thomas*1, Lester Freedman2, Salini Chellappan Kumar3 and Kenneth H Hupart3
1Nassau University Medical Center, East Meadow, NY, 2Nassau University Medical Center, 3Nassau Univ Med Ctr, East Meadow, NY

 

Introduction Neuroblastoma(NB) is a malignancy of  childhood and it is the most common malignancy during infancy. It is very rare in adults and most patients reported in the literature were less than 30 years of age. Our patient is an elderly female presenting with adrenal insufficiency, bilateral adrenal masses and elevated concentrations of catecholamine metabolites attributed to this neuroendocrine tumor. Availability of the details of this case may assist in the future diagnosis of patients presenting with adrenal tumors. Case report A 79 year old female was admitted with hypotension, weakness & fever. Septic shock was diagnosed & intravenous fluids were begun. Because of bilateral adrenal masses (R-7.6 cm, L-7.5 cm) identified on admission CT and continued hypotension, adrenal insufficiency was suspected. Stress dose steroids were administered and the patient’s blood pressure rapidly improved. Cortisol drawn during hypotension was 10.4 ug/dl. The patient had no clinical evidence of malignancy; PPD and sputum AFB were negative. Right adrenal FNA showed inflammation and necrosis. She was discharged home on replacement glucocorticoids but was readmitted with weakness. A repeat CT showed progressive adrenal growth six weeks later. PET scan showed hypermetabolic adrenals (SUV 17.4, 20.7) and metastases to multiple bones and periaortic lymph nodes. Left adrenal biopsy showed a small cell neoplasm. Immunohistochemistry was positive for neuron specific enolase, synaptophysin, neurofilament and glial fibrillary acidic protein. This suggested NB. One week later she succumbed to her disease. Discussion Adult NB is a rare disease with about 70 cases reported in literature. Geriatric NB is even rarer. In children, NB cells are derived from neural crest cells. They have adaptive plasticity and may dedifferentiate making it difficult to diagnose NB by histology alone. Often immunohistochemistry and catecholamine metabolites are needed to make the diagnosis. Elevated catecholamines are present in about half of adult NB patients. Usually an adrenal tumor with elevated catecholamines would raise the suspicion of pheochromocytoma. Here we present a patient with rapidly growing bilateral neuroendocrine adrenal tumors presenting with adrenal insufficiency. The presence of tumor markers on immunostaining with elevated homovanillic acid and VMA permitted the diagnosis of NB. Our patient also had an elevated KI-67 index pointing towards an aggressive tumor which was mirrored clinically. This patient displayed bilateral adrenal tumors with elevated catecholamine metabolites.  Although this raises a suspicion of pheochromocytoma, her tumor proved to be NB. Currently there is no consensus regarding the management of adult NB. Early diagnosis with aggressive work up and appropriate treatment may increase life expectancy. Surgery followed by chemotherapy or radiation is the current approach.

 

Nothing to Disclose: JT, LF, SCK, KHH

16181 24.0000 SUN-0770 A Bilateral Adrenal Neuroblastoma in a Geriatric Patient with Elevated Catecholamine Metabolites 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Mabel Yau*1, Christian Enrique Pina1, Ahmed Khattab1, Maria I New1, Lauren B. Bruckner2 and Jeffrey R. Andolina2
1Icahn School of Medicine at Mount Sinai, New York, NY, 2University of Rochester School of Medicine and Dentistry, Rochester, NY

 

Background: This is the first reported case of an ovarian serous adenocarcinoma in an adrenalectomized patient with CAH. Malignant ovarian tumors in children are rare and compromise ~1% of all childhood cancers.

Clinical case: A 14-year-old female with classical congenital adrenal hyperplasia owing to 21-hydroxylase deficiency underwent bilateral adrenalectomy at 6 years old due to poor hormonal control. At 12 years of age, hydrocortisone dose was 20 mg/day (10mg/m2), 17-hydroxyprogesterone was 748 ng/dL, total testosterone was 612 ng/dL, and androstenedione was 150 ng/dL with ACTH of 1334 pg/mL. Owing to persistently elevated androgens, her glucocorticoid regime was changed to high doses of dexamethasone reaching up to 6 mg/day to achieve adrenal suppression. 

Because the patient was adrenalectomized, extra-adrenal androgen production was suspected and a pelvic ultrasound was obtained.  Ultrasound revealed a large cystic structure within the right adnexa as well as thickening of its wall, though the uterus and left ovary were normal. MRI was used to further evaluate the mass and demonstrated a cystic lesion arising from her right ovary suspicious for ovarian neoplasm. The patient underwent right salpingo-oophorectomy, and histopathological examination revealed ovarian serous adenocarcinoma, low-grade, and well-differentiated.  Tumor marker CA-125 was elevated and additional ovarian cancer staging workup confirmed stage IIIC due to one lymph node positive for carcinoma.  Within the next month, the patient then developed a large left ovarian cyst, which led to a complete total abdominal hysterectomy and removal of the left ovary and fallopian tube.  Pathology again confirmed the diagnosis of ovarian serous adenocarcinoma with microscopic focus of carcinoma in the left ovary.  The patient had no further evidence of disease after this surgery and CA-125 levels fell. Chemotherapy was started and the patient responded well, with normalization of CA-125 levels, and no evidence of carcinoma on follow up imaging.  The patient remains in complete remission now 10 months from diagnosis.

Conclusion: To our knowledge, this is the first reported case of an ovarian serous adenocarcinoma in a patient with CAH.  In our patient, this evaluation led to the discovery of an ovarian serous adenocarcinoma.  The relationship between CAH and ovarian carcinomas has yet to be established.

 

Nothing to Disclose: MY, CEP, AK, MIN, LBB, JRA

14724 25.0000 SUN-0771 A Ovarian Carcinoma in a 14-Year-Old Female Patient with Congenital Adrenal Hyperplasia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Secil Ozisik, Mehmet Calan, Ulku Aybuke Tunc, Tevfik Demir, Abdurrahman Comlekci, Mustafa Secil and Serkan Yener*
Dokuz Eylul University Medical School, Izmir, Turkey

 

BACKGROUND: ACC (adrenocortical carcinoma) is a rare and highly aggressive malignancy with an annual incidence of 0.7–2.0 cases per million population. ACC can occur at any age, with a peak incidence between 40 and 50 years, and women are more often affected (55–60%).  These tumors are mostly functional and cause Cushing's syndrome and/or virilization, or nonfunctional, and present as an abdominal mass or an incidental finding. Here we report a case of giant, androgen and cortisol secreting adrenocortical carcinoma with multiple hepatic and pulmonary metastasis.

CASE: A 52 year old post-menopausal female presented with excessive body hair and abdominal distention. She had virilization, plethora and muscular atrophy with extremity predominance. Abdominal examination revealed a giant abdominal mass. Her excessive body hair and giant abdominal mass promted further evaluation. Laboratory examination revealed elevated urinary cortisol [650 μg/24 hour (4,3-176 µg/24 hour)] and morning plasma cortisol [31,7 μg/dL (3,7-19,4 µg/dL)] while ACTH was suppressed [<5 pg/mL (0-46 pg/mL)]. Total testosteron [25,9 nmol/L (0,52-2,43 nmol/L)] and DHEAS [>1000 μg/dL (20-310 µg/dL)] were also elevated. Thus a hormonally active adrenal cortical tumor was suspected. On magnetic resonance imaging (MRI) of the abdomen a 25*23,5*23 cm left adrenal mass and multiple hepatic metastasis were detected. Also multiple pulmonary metastasis were demostrated by thorasic computed tomography (CT). Pathological examination of the percutaneous liver biopsy was reported as adrenocortical carcinoma metastasis. The patient died due to respiratory failure two weeks after the diagnosis before the initation of systemic chemotherapy.

CONCLUSION: Adrenocortical carcinoma (ACC) is a rare endocrine malignancy with high mortality. A majority of cases of ACC are metastatic at the time of diagnosis. The larger the tumor, more is the chance of it being malignant. Our case describes a rare giant adrenocortical carcinoma presenting with multiple hepatic and pulmonary metastasis. The patient died in two weeks after the diagnosis.

 

Nothing to Disclose: SO, MC, UAT, TD, AC, MS, SY

14452 26.0000 SUN-0772 A A Giant Adrenocortical Carcinoma Presenting with Multiple Hepatic and Pulmonary Metastasis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0747-0772 4774 1:00:00 PM Adrenal Case Reports 2 - Adrenal Tumors Poster

Gillian M Goddard*1, Nikolina Babic2, Alice C Levine3, Kalmon D. Post1 and Eliza B. Geer4
1Icahn School of Medicine at Mount Sinai, New York, NY, 2Mount Sinai School of Medicine, 3Mt Sinai Med Ctr, New York, NY, 4Mount Sinai School of Medicine, New York, NY

 

Background: ACTH levels are often utilized to localize the source of Cushing’s Syndrome (CS), with suppressed ACTH levels suggesting adrenal etiology and detectable or elevated levels suggesting pituitary or ectopic ACTH production. The protocol for determining the etiology of CS when the ACTH value is between 10–20 pg/ml has not been established.

Hypothesis: Single determinations of ACTH in the 10-20 pg/ml range do not distinguish between adrenal and pituitary CS.

Case 1: 36 yo F presented with a 9 month history of irregular menses, acne, hypertension, easy bruising, increasing facial fullness and hair growth.  Physical Exam showed obesity, moon facies, and hirsutism.  Labs revealed an elevated urinary free cortisol (UFC) of 220 mcg/24 hrs (<45 mcg/24 hrs), serum cortisol 21 mcg/dl, ACTH 11 pg/ml, DHEA-S 84 mcg/dl (35-430 mcg/dl) and HbA1c of 5.9%.   After 1 mg dexamethasone, her serum cortisol was 18.8mcg/dl (<1.8 mcg/dl) and ACTH <5 pg/ml.  Adrenal MRI revealed a 3.7 x 2.6 cm right adrenal mass consistent with an adrenal adenoma. She underwent right adrenalectomy.  Post-operative cortisol was 0.8 mcg/dl.

Case 2: 52 yo F presented with new T2DM, weight gain, fatigue, easy bruising, hirsutism, and a recent pelvic and shoulder fracture.  Physical exam showed a round, ruddy face and facial hirsutism. Her UFC was elevated at 220 mcg/24 hrs, serum cortisol was 33.5 mcg/dl and ACTH 15 pg/ml.  Low dose dexamethasone suppression test showed a cortisol of 22.6 mcg/dl and an ACTH of 12 pg/ml.  Imagining revealed an 8mm pituitary adenoma. Transsphenoidal adenomectomy was performed.  POD 5 cortisol was 1.8 mcg/dl and pathology was consistent with corticotroph adenoma.

Discussion: These cases demonstrate that ACTH alone is not sufficient to determine the etiology of CS, especially in the range of 10-20 pg/ml.  New ACTH assays have improved precision at low concentrations, calling into question historical cutoffs.  A Low DHEA-S, particularly in a younger patient, suggests adrenal CS, whereas normal or elevated DHEA-S suggests a pituitary (or ectopic) etiology.  High dose dexamethasone suppression testing (8mg) resulting in a suppressed cortisol is suggestive of pituitary disease.  CRH stimulation testing may also be helpful.  Recent reports suggest that some forms of adrenal CS, notably macronodular hyperplasia, may be driven by adrenal production of ACTH, further emphasizing the pitfalls in utilizing ACTH levels to localize the source of CS.

 

Nothing to Disclose: GMG, NB, ACL, KDP, EBG

13952 1.0000 SUN-0773 A Pitfalls of Using ACTH Alone in the Localization of Cushing's Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Pooja Raghavan*1, Talia Diker-Cohen2, Dhyan P Rajan3, Susmeeta T. Sharma4 and Lynnette K. Nieman2
1National Institutes of Health, North Bethesda, MD, 2National Institutes of Health, Bethesda, MD, 3Nassau University Medical Center, East Meadow, NY, 4Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD

 

Introduction:Exogenous glucocorticoid administration has been associated with many gastrointestinal complications, including colonic abscesses, perforation and peritonitis. Very few cases of colonic perforation have been reported in endogenous Cushing’s syndrome (CS); all in patients over 50 years of age in whom diverticulitis is more common. We report two CS patients, <50 years of age, with colonic perforation as the initial presentation.

Case 1:31-year old male with hypertension (HTN) and diabetes mellitus type 2 (DM2) presented with abdominal pain and hematochezia. CT abdomen revealed a sigmoid diverticular perforation fistulizing to the retroperitoneum with intraperitoneal free air. The patient underwent emergent sigmoid resection with end colostomy but due to poor wound healing, required seven re-operations over four weeks before final abdominal closure was achieved with full thickness skin grafting.  Laboratory tests confirmed ACTH-dependent CS: elevated 24-hour urinary free cortisol (UFC) (470 mcg/day, normal (N) 3.5-45), abnormal late night salivary cortisol (LNSC, 1270 ng/dl, N<100), elevated plasma ACTH (79 pg/ml, N<46), and an abnormal 1mg overnight dexamethasone suppression test (DST). An 8 mg DST suggested an ectopic source. However, CRH stimulation test, MRI pituitary (3mm hypointense lesion), and inferior petrosal sinus sampling (peak post-CRH petrosal-to-peripheral ACTH ratio = 23) were consistent with a pituitary source. Transsphenoidal resection (TSR) of the microadenoma led to remission of hypercortisolemia. Pathology confirmed ACTH-staining pituitary adenoma.

Case 2:43-year old male with HTN, DM2, and obstructive sleep apnea presented with severe abdominal pain, was found to have a diverticular perforation, and underwent emergent intestinal resection with end colostomy. Laboratory tests revealed ACTH-dependent CS: UFC=79-146 mcg/day, LNSC=0.22 mcg/dl (N<0.09), plasma ACTH=95 pg/ml, and an abnormal 1mg DST. CRH stimulation test, 8mg overnight DST and a pituitary MRI (7mm hypointense lesion) indicated a pituitary source. TSR of the microadenoma led to remission of CS. Pathology confirmed ACTH-staining pituitary adenoma. Colostomy reversal was successfully completed 6 months post-remission.

Conclusion: By masking signs of acute inflammation and causing an impaired immune response, prolonged endogenous hypercortisolemia can result in colonic perforation.  Early diagnosis and treatment may help prevent disabling complications in CS.

 

Nothing to Disclose: PR, TD, DPR, STS, LKN

16190 2.0000 SUN-0774 A Colonic Perforation As the Initial Presentation in Cushing's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Pooja Raghavan*1, Andrea Kassai2, Susmeeta T. Sharma3, Maya Peltsverger4 and Lynnette K. Nieman2
1National Institutes of Health, North Bethesda, MD, 2National Institutes of Health, Bethesda, MD, 3Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 4New Hanover Regional Medical Center, Wilmington, NC

 

Introduction: Cushing’s syndrome (CS) is associated with a variety of psychiatric disturbances; depression is the commonest, mania and psychosis are rare. We report 3 patients with ACTH-dependent CS who presented with acute psychosis. None of them had a prior history of psychiatric dysfunction. All had resolution of symptoms once eucortisolemia was achieved.

Clinical cases:

Case-1: 35 y.o. female presented with a 2-week history of mania and agitation. Over the next 5 years, she developed hypertension (HTN), prediabetes, amenorrhea, 75lb weight gain, and severe proximal muscle weakness and was admitted 5 times with visual and auditory hallucinations controlled partially on antipsychotics. Endocrine evaluation revealed ACTH-dependent CS (UFC=1,009 mcg/d, normal: 3.5-45). CRH stimulation test and a 9mm lesion on MRI Pituitary suggested a pituitary source. Transsphenoidal resection (TSR) of the ACTH-staining adenoma led to remission of CS and regression of psychosis.

Case-2: 40 y.o. female presented with frequent panic attacks unresponsive to sertraline treatment. She was later diagnosed with depression and bipolar disorder and required 18day hospitalization for paranoid delusions and agitation. Development of HTN, type 2 diabetes mellitus, amenorrhea, 60lb weight gain, hirsutism, and proximal muscle weakness led to the diagnosis of ACTH-dependent CS (UFC=137 mcg/d). MRI pituitary along with CRH stimulation and dexamethasone suppression tests indicated a pituitary source. TSR of an ACTH-staining adenoma led to remission of CS with resolution of psychosis and improvement in depression.

Case-3: 39 y.o. male presented with mania, agitation, combative behavior, 35lb weight gain and HTN (200/100 mmHg) requiring hospitalization for 10 days. Endocrine evaluation revealed cyclic ACTH-dependent CS (UFC=2,365 mcg/d). Diagnostic tests including inferior petrosal sinus sampling, performed in the setting of hypercortisolemia, suggested an ectopic source. Structural and functional imaging studies failed to identify the source of ACTH. Eucortisolemia was achieved on ketoconazole therapy (800mg/d) with resolution of psychosis.

Conclusion: Acute psychosis can occasionally be the initial manifestation in CS, regardless of the degree of hypercortisolemia. Recognition of this association can lead to early diagnosis of CS. Control of hypercortisolemia, via surgical or medical therapy, along with antipsychotic medications can help ameliorate psychiatric symptoms.

 

Nothing to Disclose: PR, AK, STS, MP, LKN

16229 3.0000 SUN-0775 A Acute Psychosis As the Initial Manifestation of ACTH-Dependent Cushing's Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Oren Steen*, Karan Bami, Winnie Chan, Nishma Singhal and Ally P.H. Prebtani
McMaster University, Hamilton, ON, Canada

 

Introduction: Severe hypercortisolism may cause immunosuppression leading to opportunistic infections.

Clinical Case: A 74 year-old female presented to hospital with progressive fatigue, weight loss and generalized weakness. She was newly diagnosed with hypertension, diabetes mellitus and severe hypokalemia. Examination revealed cachexia and profound muscle weakness; she lacked classic Cushingoid features. Investigations revealed a 24 hour urinary free cortisol of 11328 nmol (n<300 nmol) and plasma ACTH of 112 pmol/L (n<10.3 pmol/L). Cortisol levels did not suppress after 8 mg overnight dexamethasone suppression (2279 nmol/L pre-dex; 2549 nmol/L post-dex). She was diagnosed with ectopic ACTH syndrome (EAS).

CT of the chest, abdomen and pelvis was unremarkable aside from bulky adrenal glands, while octreotide scan showed increased uptake in the left adrenal. No lesion was seen on MRI sella with gadolinium. She was started on insulin for diabetes, and spironolactone and potassium replacement for hypertension and hypokalemia. She was discharged home with endocrine follow-up.

Within days, the patient was readmitted with confusion and functional decline. She deteriorated despite management with ketoconazole and octreotide for hypercortisolemia, and was intubated for decreased level of consciousness. She developed an upper GI bleed. Upper endoscopy revealed CMV duodenitis and she was treated with gancyclovir. HIV serology was negative. Trimethoprim-sulfamethoxazole (TMP-SMX) was initiated for PJP prophylaxis.

Adrenal vein sampling (performed in light of the previous octreotide scan result) did not demonstrate an ACTH gradient. Given her clinical deterioration without an identifiable source of ACTH, she underwent urgent bilateral adrenalectomy. Postoperatively, her hypokalemia resolved, and she was weaned off antihypertensives and insulin. Meanwhile, her respiratory status worsened, and bronchoalveolar lavage detected PJP (despite TMP-SMX prophylaxis) and subsequently also grew Mycobacterium tuberculosis. She was treated for both of these. She also developed hemorrhagic cystitis, possibly secondary to BK virus.

The patient was eventually extubated and required extensive rehabilitation prior to being discharged home with endocrine follow-up and continual surveillance for an ACTH source.

Conclusion: Prompt identification and treatment of hypercortisolemia are vital for the successful management of EAS complications. When a source cannot be found, bilateral adrenalectomy may be necessary to control symptoms and reduce the risk of immunosupression in severely ill patients. This case uniquely demonstrates a case of EAS resulting in infections with CMV, PJP, TB and possibly BK virus. It highlights the profound degree of immunosuppression these patients can experience and the need to maintain a high index of suspicion for multiple opportunistic co-pathogens.

 

Nothing to Disclose: OS, KB, WC, NS, APHP

12056 4.0000 SUN-0776 A Ectopic ACTH Syndrome (EAS) – an Unusual Suspect for Profound Immunosuppression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Sven Sufke*1, Birgit Harbeck1 and Hendrik Lehnert2
1University of Lübeck, Lübeck, Germany, 2University of Luebeck, Luebeck, Germany

 

Introduction:

Hyponatremia (Na <135 mmol/l) occurs in about 5-15% of hospitalized patients and syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a common cause counting for up to 50% of all diagnosed cases of hyponatremia. This disorder is characterized by excessive release of antidiuretic hormone. The ensuing water retention leads to the development of hyponatremia. Common causes of SIADH include CNS disturbances, malignancies, drugs (e.g. hydrochlorothiazide), surgery, pulmonary disease, hormone deficiency (cortisol, levothyroxine), hormone administration, HIV infection, hereditary causes and idiopathic origin.

Clinical Case:

A 79 year-old female patient was admitted to the hospital with dizziness and having trouble walking. Clinical examination was inconspicuous. Medical history revealed ischaemic cardiomyopathy, cardiac pacemaker, recurrent pneumonia and resection of the right adrenal gland. Laboratory evaluation showed reduced levels for sodium and serum osmolality as well as elevated levels for CRP, white blood cells, LDH, cortisol and TSH. SIADH due to pneumonia was suspected. Starting therapy with tolvaptan, sodium levels slowly normalized and clinical condition improved. Pneumonia was treated successfully by antibotics. Hypothyroidism was adequately substituted. The patient was discharged home and readmitted a few weeks later again with dizziness and nausea. As SIADH is often a paraneoplastic syndrome, the patient underwent extensive work-up for suspected malignant disease. Radiological evaluation showed no tumor signs. Blood tests demonstrated elevated levels of prolactin, ACTH and cortisol. 1 mg- and 8 mg-dexamethasone suppression tests were performed, showing suppression only with 8 mg. CRH-testing increased stimulated values for cortisol and ACTH. Based on these findings an ACTH producing pituitary adenoma was suspected. Since the patient was equipped with a pacemaker we could only perform PET-CT and somatostatin receptor scintigraphy. Diffuse enhancement in the pituitary was observed. Despite increasing tolvaptan dose and initiating adrenostatic drugs  (metopirone, pasireotide) which lead to normal cortisol levels the patient died of recurrent pneumonia. The autopsy findings revealed a normal pituitary and left adrenal gland.

Conclusions:

SIADH may present with severe biochemical hypercortisolism, most likely due to a stimulation of ACTH and cortisol secretion.

 

Nothing to Disclose: SS, BH, HL

12472 5.0000 SUN-0777 A Severe Hypercortisolism in Siadh 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Sadishkumar Kamalanathan*1, Jaya Prakash Sahoo2, Ashok Kumar Das2, Anurag Lila3, Tushar Ramkrishna Bandgar3 and Nalini Samir Shah3
1JIPMER, Puducherry, India, 2JIPMER, 3KEM Hospital, Mumbai, India

 

Background: Anabolic androgenic steroids have been documented to associated with growth and recurrence of hepatic adenomas. However, association between endogenously produced androgens and growth of  hepatic adenoma has  not been documented in literature. We produce evidence for concept that   endogenously  produced  testosterone is a trophic factor for growth of hepatic adenomas using support of  a clinical case of ACTH dependent Cushing’s syndrome.

Case report: A 25 year old lady presented  to us with characteristic Cushingoid habitus, amenorrhoea , metabolic abnormalities and   past  history of hypokalemic paralysis .There  was no history of intake of oral contraceptive use or of anabolic steroids in past.  Biochemical evaluation revealed a ACTH dependent Cushing’s syndrome.[ basal cortisol- 963 nmol/L(normal range NR 138-618) , basal ACTH- 35.2 pmol/L(NR 2-11) ,midnight cortisol-869 nmol/L (NR< 50), 24 hour urine free cortisol -67,040 nmol/d(NR < 2759)  , Low dose dexamethasone suppression test cortisol- 1129 nmol/L (NR< 50).Her baseline total testosterone was 3.75 nmol/L(NR 0.5-2.4).

MRI pituitary revealed a 4 x 4 mm microadenoma in left lobe of pituitary. An inferior petrosal sinus sampling (IPSS) and whole body positron emission tomography FDG-PET were done to rule an ectopic focus. FDG PET-CT and 99mTc-HYNIC-TOC   scintigraphy were non-contributory towards localisation. IPSS was suggestive of central lesion (central: peripheral ACTH   gradient of 20:1) lateralized to left pituitary(gradient of 3:1). Her ultrasound abdomen revealed an asymptomatic hepatic mass of size 2x2.5 cm  in segment 7 of liver .  CT guided FNAC of mass was suggestive of hepatic adenoma. Post central localization of etiological lesion, a transsphenoidal   pituitary surgery  was done ,following which, her Cushingoid features regressed along with her metabolic abnormalities . Her testosterone levels became undetectable (<0.3 nmol/L) postoperatively. Currently, she is in remission, being on replacement dose of corticosteroids. Nevertheless, she remained amenorrhoeic ever since .Her hepatic adenoma partially but significantly regressed (> 50%) in size 1 year postoperatively and is expected to regress further with time. The contribution of endogenously produced cortisol and estradiol towards the hepatic adenoma growth could not be assessed appropriately in this paradigm case.

Conclusion: We document significant regression of hepatic adenoma following induction of cure in Cushing’s disease and hence propose endogenously produced testosterone under ACTH control as a probable trophic factor for growth of hepatic adenomas. This hypothesis needs  confirmation by future basic research studies.

 

Nothing to Disclose: SK, JPS, AKD, AL, TRB, NSS

14834 6.0000 SUN-0778 A Proof of Concept for Endogenous Testosterone As a Trophic Factor for Hepatic Adenoma in a Case of ACTH Dependent Cushing's Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Caterina Policola*, Chiara Maria Assunta Cefalo, Simona Moffa, Barbara Altieri, Vinsin Alice Sun, Alfredo Pontecorvi and Silvia Della Casa
Endocrinologia e Malattie del Metabolismo, Università Cattolica del Sacro Cuore, Rome, Italy

 

Background: Anorexia Nervosa (AN) is a psychiatric disorder, affecting about 1 in 250 females,  usually starting in adolescence. It is characterized by self-induced weight loss, body image distortion and obsessive fear of gaining weight. Patients affected by AN have a Pseudo-Cushing’ s Syndrome (PCS); food deprivation hypoglicemia is a possible mechanism for an increased activation of the HPA axis. PCS is characterized by a high ACTH and cortisol levels, elevated urinary free cortisol excretion, not dexamethasone (Dex) suppressed  cortisol, and elevated nocturnal cortisol secretion. The lack of Cushing’s symptoms is due to resistence to cortisol. Clinical Case: We report a case of a 28 year-old woman who referred to us for peripheral oedemas, a 5-year history of restrictive AN, on psychiatric treatment and amenorreha. On examination she had peripheral and lower limb oedema, ecchymosis on her legs. Weight  was 47 Kg and BMI 17.8 Kg/m2 (on weight recovery). Liver and renal functions were normal, she had not heart failure, and albumina and proteins serum levels were normal. Severe osteoporosis was recorded. Hormonal values were: IGF-1 <25 ng/ml (v.n.: 80-330), TSH 0.79 mcUI/ml (0.35-2.8), fT3 1.5 pg/ml (2.3-4.2), fT4 10 pg/ml (8.5-15.5), LH <0.5 mcUI/ml (2.5-11), FSH <0.5 mcUI/ml (2.5-15), 17-betaEstradiol <15 pg/ml, Cortisol 357 ng/dl (60-220), Midnight cortisol 281 ng/dl, 1 mg Dex suppression test Cortisol  298 ng/ml, 24h Cortisoluria 1065 mcg/24 h (<70). Her Hormonal state was compatible with AN patient’s biochemical features and PCS, but she had basal ACTH: <5 pg/ml (10-55). An Abdomen Ultrasound showed an iso-hyperecogenic, solid nodule on the right adrenal gland. 8 mg Dex suppression test: cortisol was 260 ng/dl and ACTH <5 pg/ml. The Abdominal CT confirmed the presence of 3.2 x 2.2 cm  right adrenal gland mass, ipodense (likely an adrenal  adenoma. She underwent right retroperitoneoscopic adrenalectomy under pre and peri-operative protection with stress-dose Hydrocortison replacement. Histological examination confirmed the adrenal adenoma. The psychiatric disease improved after the operation. She was started on Hydrocortison and she had been on therapy for 1 year, because persistent suppression of the Pituitary-Adrenal axis. After normalization of basal ACTH and cortisol and Short Synacthen Test, Hydrocortison therapy was discontinued. The long-term follow-up revealed complete recovery of eating disorder with resumption of periods. Actually her pituitaty-adrenal axis is normal, she is not on therapy. Conclusion: The differential diagnosis between Cushing Syndrome and PCS in AN patients can be extremely difficult and it represent a challenge for the clinicians.

 

Nothing to Disclose: CP, CMAC, SM, BA, VAS, AP, SD

16018 7.0000 SUN-0779 A Hypercortisolism in a Patient Affected By Anorexia Nervosa 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Vadim Krylov*1, Ekaterina Dobreva2, Nikolay Kuznetsov2, Nona Vadimovna Latkina2 and Eugenia Marova2
1University Clinical Hospital – 1, I.M. Sechenov First Moscow State Medical University, Moscow, Russia, 2Endocrinology Research Centre, Moscow, Russia

 

Introduction: We report the clinical presentation of pheochromocytoma with Cushing's Syndrome due to ectopic production of ACTH, and assess the histopathological diagnosis, treatment modality and prognostic factors compared with the literature.
Case report: Cushing's Syndrome due to ectopic ACTH production is uncommon and due to pheochromocytoma is extremely rare. We discuss the case of a 50-year-old female who initially presented with vague, non-specific symptoms, such as general and muscle weakness, weight loss, body temperature rise, high blood pressure, increase in fasting blood glucose, in which an ACTH-secreting tumor found to be the cause of her clinical presentation. At admission: Height 168 cm, Weight 57 kg. asthenic constitution, diffusely hyperpigmented skin, "darkened elbow" symptom, and subcutaneous adipose tissue was insufficiently developed. Laboratory showed AM cortisol of 1488 mmol/l, PM cortisol of 1672 mmol/l, 24-hour urinary free cortisol of 3700 nmol/day, AM ACTH level of 178.7 mg /ml, PM ACTH level of 179,8 mg /ml and non-suppression of cortisol with overnight dexamethasone suppression test (1 mg and 8 mg). 24-hour urinary level of normetanephrine and metanephrine: Normetanephrine - 830 mg/day, Metanephrine - 1481 mg/day. Brain MRI showed no pathological changes. CT scan showed tumor of the left adrenal gland (2.7 x3,0x4,6 cm, density 38H). She underwent two weeks therapy by doxazozine before surgery. So, clinical and laboratory signs of Cushing syndrome and pheocromocytoma disappeared after left adrenalectomy.
Conclusion: Despite numerous guidelines in Pheochromocytoma and Cushing syndrome, there are still diagnosis and treatment mistakes due to rarity and complexity of clinical presentation in ACTH-ectopic syndrome caused by pheocromocytoma. So, we need to improve the guidelines for diagnosis and treatment of ACTH-ectopic tumors.

 

Nothing to Disclose: VK, ED, NK, NVL, EM

11342 8.0000 SUN-0780 A Cushing's Syndrome Due to Ectopic ACTH Production of Pheochromocytoma. Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Yuki Kobayashi*1, Masahiro Takei2, Keiko Takeshige3, Yousuke Ohkubo2, Mieko Kumagai2, Teiji Takeda4, Mitsuhisa Komatsu2 and Satoru Suzuki5
1Shinshu University School of Medicine, Matsumoto-shi, Japan, 2Shinshu University, Schoolo of Medicine, Matsumoto-shi, Japan, 3Shinshu University School of Medicine, Matsumoto-shi, 4Shinshu University, Matsumoto-Shi, Japan, 5Fukushima Medical University, Fukushima-shi, Japan

 

Clinical background: The prevalence of double pituitary adenomas, confirmed by autopsy and from surgical materials, is approximately 1% (1). In most cases, there is only one tumor that contains two different lesions contiguously in each tumor. Independent double pituitary adenomas with distinct hormonal features are very rare.

Case: A 67-year-old woman was admitted to our hospital because of acromegalic appearance. Laboratory data revealed a serum GH level of 4.6 ng/ml and serum insulin-like growth factor-1 level of 811 ng/ml. Oral glucose tolerance test showed no suppression of GH values. Endocrine examination showed a lack of circadian rhythmicity of ACTH and cortisol. Serum cortisol level was not suppressed by 0.5 mg of dexamethasone. Whereas the result of high dose dexamethasone suppression test was marginal. The response of ACTH and cortisol after corticotropin-releasing hormone stimulation was normal. Gadolinium enhanced magnetic resonance imaging revealed two isolated adenomas in the pituitary. These findings strongly suggested a diagnosis of acromegaly with subclinical Cushing’s disease. Transsphenoidal surgery was performed. Hematoxylin and eosin staining showed that the left and right adenomas were composed of basophilic and acidophilic cells, respectively. Immunohistochemical staining showed the left adenoma to be positive for ACTH and negative for GH. In contrast, the right adenoma was GH-positive and ACTH-negative.

Clinical lessons: Double pituitary adenomas are rare. In most cases, there is one tumor that contains two different lesions contiguously in each tumor, and independent double pituitary adenomas with distinct hormonal features are extremely rare. This is a rare case report of a combination of GH-producing adenoma (ACTH negative) and isolated ACTH-producing adenoma (GH-negative). We have also reviewed previous reported double pituitary adenomas and discussed functionality of the left adrenal tumor.

 

Nothing to Disclose: YK, MT, KT, YO, MK, TT, MK, SS

14304 9.0000 SUN-0781 A A Somatotropin-Producing Pituitary Adenoma Concomitant with an Isolated Adrenocorticotropin-Producing Pituitary Adenoma with a Left Adrenal Tumor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Satoshi Monno*1, Takamitsu Tachikawa2, Takashi Maekawa3 and Hironobu Sasano3
1Chiba-Nishi General Hosp, Matsudo, Japan, 2Chiba-Nishi General Hospital, Matsudo, Japan, 3Tohoku University Graduate School of Medicine, Sendai, Japan

 

Background: Cushing’s syndrome due to bilateral cortisol-secreting adenomas with unilateral DHEAS over-secretion has not been reported.

Clinical case: 39yo female manifested typical clinical symptoms of Cushing’s syndrome (CS) including amenorrhea for 2 years and hirsutism.  Results of initial endocrine evaluation were consistent with ACTH independent-CS including elevated 24Hr urinary cortisol secretion (469 μg/d, n <50 μg/d), abnormal LDDST (cortisol after 1mg dex 30.2 μg/dL, n <5 μg/dL ), elevated mid-night serum cortisol (18.9 μg/dL , n<5.2 μg/dL), ACTH-concentration below the level of detection (<1 pg/ml).  Serum DHEAS concentration was also elevated (6901 ng/ml, n 230-2660 ng/ml).  An abdominal CT-scan demonstrated bilateral adrenal enlargement (diameter of adrenal glands, right 3.1cm,left 2.4cm).  131I-methylnorcholesterol incorporation into both glands with left higher uptake than right adrenal, suggesting bilateral oversecretion of cortisol. 

Laparoscopic adrenalectomy of both side were performed separately; left adrenalectomy first, then right adrenalectomy in 3 months later.   Following the left adrenalectomy, results of endocrine evaluations were consistent with ACTH-independent CS.  Serum DHEAS concentration, however, was below normal range (143 ng/ml, n 230-2660 ng/ml).  Unexpectedly, her menstruation resumed 2.5 months after left adrenalectomy (before right adrenalectomy).  Pathological examination of the resected adrenal glands showed bilateral adrenocortical adenomas, one in left 3cm in diameter, and two in right 0.7cm and 1.3cm in greatest dimension, with adjacent atrophied zona fasciculate and reticularis.  These three adenomas were all mainly composed of compact cell, with pronounced expression of SCC, 3βHSD, 17-OH-lase and CYP11B1 suggesting overproduction of cortisol.  In the left adenoma, DHEAST positive dysmorphic cells with abundant eosinophilic cytoplasm were pronounced but the two adenomas of right adrenal were associated with mainly compact cells with weak DHEAST immunoreactivity in one adenoma and compact cells intermingled with clear cells in another adenoma.  CYP11B2 was positive only in right adenomas, but negative in left adenoma, suggesting the presence of aldosterone production in right adenomas. Ki67 labeling index was higher in the left adenoma (2.5%) than the right adenomas (1.5%).  These results indicated more pronounced cell proliferation and DHEAS production in the left adenoma compared to the right adenomas, consistent with clinical endocrine findings.

Conclusion: This is the first case demonstrating bilateral cortisol-secreting adenomas with unilateral over-secretion of DHEAS , and with resumption of menstruation by removing DHEAS producing site. Immunohistochemical evaluation of steroidogenic enzymes could provide clinically relevant inert information as to the neoplastic steroidogenesis.

 

Nothing to Disclose: SM, TT, TM, HS

14305 10.0000 SUN-0782 A Cushing's Syndrome Due to Bilateral Cortisol-Secreting Adenomas with Unilateral DHEAS over-Secretion. a Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Atsushi Yasuda*1, Toshiro Seki1, Kazuko Ito2, Masami Seki3, Atsushi Takagi2 and Masafumi Fukagawa1
1Tokai Univ Sch Med, Kanagawa, Japan, 2Tokai University School of Medicine, Kanagawa, Japan, 3Seirei Numazu Hospital, Shizuoka, Japan

 

Cushing’s syndrome due to bilateral cortisol-secreting adenomas rarely occurs. A 63-year-old man with Cushing’s syndrome due to bilateral adrenocortical adenomas is reported. The patient suffered from diabetes mellitus and hypertension for a decade. He presented with a typical Cushingoid appearance. The serum cortisol level was elevated with loss of the diurnal rhythm and the plasma adrenocorticotropic hormone (ACTH) level was undetectable. Plasma cortisol levels were not suppressed after either low or high dose overnight dexamethasone suppression tests. Computed tomographic scan showed masses in each adrenal gland. Adrenal scintigraphy revealed tracer accumulation in both adrenal glands. We based our preoperative diagnosis of bilateral adrenocortical tumors causing Cushing’s syndrome on the results of endocrinological investigations and imaging findings. Laparoscopic total adrenalectomy has become a standard technique for small adrenal tumors; however, bilateral adrenalectomy results in postoperative adrenal insufficiency, necessitating lifelong steroid replacement. To preserve adrenal function, the left adrenal gland was totally resected, while the right one was partially resected by laparoscopic approach. Hydrocortisone supplementation was initiated at a dose of 30 mg/day. However, symptoms of adrenal insufficiency developed, and adrenal steroid secretion did not respond to exogenous adrenocorticotropic hormone postoperatively. At the 1-year follow-up he was maintained on low-dose hydrocortisone, and with no recurrence of hypercorticolism. The present study comprised a relatively small number of patients and the surgical procedures, whether total/partial adrenalectomy or bilateral total adrenalectomy, applied were not uniform. Total adrenalectomy can cure Cushing’s syndrome, but results in permanent hormone replacement therapy. Bilateral cortisol-secreting tumors are a rare cause of Cushing’s syndrome, and a few cases of bilateral adrenal-preserving surgery were reported. However, our patient developed adrenal insufficiency, after discontinuing his oral cortisone supplement. This report shows that partial adrenalectomy does not necessarily preserve normal adrenocortical function.

 

Nothing to Disclose: AY, TS, KI, MS, AT, MF

13661 11.0000 SUN-0783 A A Rare Case of Cushing's Syndrome Due to Bilateral Cortisol-Secreting Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Jin Kyeong Shin*, Yeong Bok Lee, Hee Sun Kwon, Jang Won Son, Seong Su Lee, Sung Rae Kim and Soon Jib Yoo
The Catholic University of Korea, Bucheon St. Mary’s Hospital, Bucheon, Korea, Republic of (South)

 

Background: Pheochromocytoma is accompanied with cardiac manifestations due to catecholamine secretion. Most of the cardiac manifestations such as hypertension, cardiomyopathy, and tachycardia result from a rapid and massive release of catecholamines. More rarely, patients with pheochromocytoma present with bradycardia or hypotension. We report pheochromocytoma with sick sinus syndrome.

Clinical Case: A 33-year-old, previous healthy Asian male visited our hospital to evaluation of adrenal incidentaloma. Preoperative diagnosis of pheochromocytoma was based on positive biochemical test and I-131 MIBG scan. 24 hours ambulatory BP and ECG monitoring was performed before operation. The patients diagnosed with hypertension. He had sinus pause (5.2 sec) with mild dizziness in 24 hours ECG monitoring. There were no abnormal findings in echocardiography and electrophysiology study.  We started doxazocin and temporary pacemaker was inserted before laparoscopic adrenalectomy. After removal of the tumor, the results of biochemical test were normal ranges and the sinus pause resolved in 24 hours ECG monitoring.

Conclusion: Bradycardia without any atrial electrical activity is a feature of the sick sinus syndrome. Bradycardia was due to transient autonomic dysregulation caused by intermittent excess secretion of catecholamines in pheochromocytoma. In conclusion, it should be preceded that exist of life threatening complications existed before pheochromcytoma operation.

 

Nothing to Disclose: JKS, YBL, HSK, JWS, SSL, SRK, SJY

14282 12.0000 SUN-0784 A Sick Sinus Syndrome As First Manifestation of Pheochromocytoma : A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Saleha Babli*
Prince Sultan Military Medical City, Riyadh, Saudi Arabia

 

Introduction:

Cushing’s Syndrome (CS) is associated with an increased cardiovascular morbidity and mortality. Chronic endogenous and exogenous hypercortisolism frequently induce a hypercoagulable and thrombotic condition. Little is known about haemostatic features of patients with CS.

 Venous thromboembolic complication have frequently been reported in Cushing’s Syndrome especially after surgery, its involved several site mainly lower limps vein, pulmonary embolism, jugular vein thrombosis and cerebral sinus thrombosis.

This is a case of CS with right renal vein thrombosis found incidentally in CT scan.

Clinical case:

44 years old gentleman who presented in September 2013 with proximal myopathy and new onset diabetes and hypertension which were difficult to be controlled. His physical examination was consistent with CS which was proved biochemically to be ACTH dependant.

Cushing’s disease was ruled out by negative IPSS.

Extensive work up were failed to identify the ectopic source so the patient was managed medically with Octreotide, cabergoline and Ketokonazole  this lead to normalization of his 24 hours urine cortisol ( 24 hours urine cortisol at presentation was 4374 nmole/d  ( normal  25- 146  nmole/day) drop to 136 nmole/day ) . And over the time required dexamethasone replacement.

Repeated radiological imaging 6 months later in effort to identify the source of ectopic cortisol production was again failed. However his CT abdomen showed right renal Vein thrombosis (RVT) , patient was a symptomatic from this aspect.

Extensive work up for RVT including coagulopathy, homocystien level, connective tissue disease and nephrotic syndrome screen were all within normal limit ( protein S (free) 1.3 u/ml (N 0.5-1.3 u/ml), protein S (total) 1.25 u/ml (N 1.0-1.3 u/ml), protein S functional 0.94 u/ml (N 0.7-1.4 u/ml). protein C functional 1.4 u/ml (0.7-1.4 u/ml). anti thrombin III 1.2 u/ml (N 0.8-1.2 u/ml) . activated protein C resistance 1.0  ( N 0.7-1.1). plasminogen 1.3 IU/ml (0.75-1.4 IU/ml) . anticardiolipin  and antiphospholipid were negative. ANA , anti double strand DNA both were negative. 24 hours urine protein   was 0.15 g/day (normal 0-0.15 g/day), 24 hours albumin was 18 mg/d (N less than 30). Homocystien level 12.5 micro mole/l (n 0-15 micro mole/l ).

The only abnormality in his coagulation profile was low aPTT which was 23 (normal 27-40) whic was confirmed in more than one occasion. The aPT and INR were normal.

This decrease in aPTT most likely related to CS, as increase in thrombitic risk in these patient might be in part due to increase platelets, fibrinogen, tissue plasminogen activator and decrease in aPTT levels, which represent a potential hyper coagulable and hypofibrinolytic state .

Conclusion:

Cushing’s syndrome is associated with increase thrombotic risk . This is the first case demonstrating the occurrence of renal vein thrombosis in patient with cushing’s syndrome.

 

Nothing to Disclose: SB

14990 13.0000 SUN-0785 A Cushing's Syndrome Patient with Renal Vein Thrombosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Saba Wasim Aziz*1, Deepika Nallala2 and Carmel Maria Fratianni1
1Southern Illinois University School of Medicine, Springfield, IL, 2Springfield Diabetes and Endocrine Center, Springfield, IL

 

Background: ACTH-independent macronodular adrenal hyperplasia (AIMAH) is an uncommon cause of glucocorticoid excess, responsible for <1% of cases of Cushing’s Syndrome (CS). AIMAH with cortisol excess associated with McCune-Albright syndrome (MAS) is a rarely reported constellation, although they are allied phenotypes mapping to 20q13.32 with somatic mutations of GNAS1. We present a case of subclinical CS due to AIMAH arising in association with possible MAS.

Clinical Case: A 66 y/o male with h/o early onset puberty, Graves’ disease with postablative hypothyroidism & colonic adenomas was evaluated for incidentally noted bilateral adrenal nodules: 4.6cm on Right and 3.4cm on Left with radiographic features consistent with benign adenomas. Interval radiographic stability had been noted over 3 years time. There was no family h/o adrenal nodules or endocrine hyperfunction. The patient had no clinical features of Cushing’s aside from osteopenia documented by DEXA scan. He gave a clear h/o early puberty, and was “shaving a real beard” by 11 years. No café au lait spots or other lentingines were evident on physical examination which was otherwise unremarkable. Biochemical Evaluation: ACTH levels are repeatedly subnormal: ACTH 5.3, 7.5 pg/mL (10 – 60) with normal range am cortisol 13.0 mcg/dL (8-27.0). AM cortisol levels following 1 mg Overnight Dexamethasone Suppression Testing (ONDST) are reproducibly elevated:  cortisol 4.3, 3.2 and 3.4 mcg/dL (normal<1.8), with simultaneous Dexamethasone level documenting absorption:  Level  230 ng/dL (Expected 8am post 1 mg ONDST: 140 -195). Abnormal cortisol dynamics are documented with salivary cortisol done 12 hours apart, 12Noon & Midnight: Salivary Cortisol 134 ng/dL and 165 ng/dL (normal 7-9am 100-750, Midnight <100). Assessments of 24 hour Urine Free Cortisol have been in the normal or high normal range however: 45 , 43 and 17 mcg/24h [Normal 3.5 to 45]. While 24 hour urine cortisol is not frankly elevated, the inappropriate cortisols following ONDST and abnormal midnight salivary cortisol suggests subclinical CS. In retrospect he gives a history of sexual precocity and atraumatic fracture of left lower leg in childhood with persistent knee, back and hip pains. Radiologies are pending. Endocrine hyperfunction with past hyperthyroidism is also notable and could suggest MAS.

Conclusion: Patient with subclinical CS due to AIMAH should be monitored periodically for development of overt CS. Identification of aberrant receptors could direct a tailored pharmacological approach to control abnormal steroidogenesis; alternatively, unilateral or bilateral adrenalectomy could be considered. CS associated with MAS is a rare variant of AIMAH and should be suspected in patients with sexual precocity, skeletal manifestations and other endocrine hyperfunction.

 

Nothing to Disclose: SWA, DN, CMF

15321 14.0000 SUN-0786 A Subclinical Cushing's Syndrome Due to ACTH-Independent Macronodular Adrenal Hyperplasia Associated with Possible Mccune-Albright Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Rany Bassam Al-Agha*1 and Aashna Gill2
1Univ of alberta, Edmonton, AB, Canada, 2University of Alberta, Edmonton, AB

 

Cushing’s Syndrome Related Dilated Cardiomyopathy: Favorable Outcome With Treatment.

Rany Al-agha and Aashna Gill. 

Division of Endocrinology, University of Alberta.

Background- Increased cardiovascular risk related to Cushing’s syndrome is an established entity. Atherosclerotic coronary artery disease and hypertension are the two long term sequele of Cushing’s Syndrome that have been emphasized in previous studies, which tend to persist even after treatment of Cushing’s. Unlike coronary artery disease and hypertension, dilated cardiomyopathy secondary to Cushing’s Syndrome appears to be a rare condition which is reversible with treatment of Cushing’s. 

Case-We report a case of a 29 year old male with a history of new onset diabetes and dilated cardiomyopathy, who presented with acute heart failure and stroke. The ejection fraction was 19%. Endocrinology consultation was sought for management of Diabetes. Hemoglobin A1c was 14.5% (4.3-6.1%). The physical exam revealed findings suspicious for Cushing’s. On evaluation he was found to have an elevated 24 hr urinary cortisol of 702 nmol/24 hrs (normal <230nmol/hr), suppressed ACTH of <5 ng/L (normal 10 to 46 ng/l), and a 4 cm adrenal adenoma on CT abdomen. Pathology confirmed adrenocortical adenoma. Surgical resection was done. At one month follow up, there was complete reversal of dilated cardiomyopathy with near normalization of ejection fraction to 55%. At 5 months follow up hemoglobin A1c was normal at 5.4% (4.3-6.1%).

Conclusion-Based on our case and review of literature for other cases of dilated cardiomyopathy associated with Cushing’s, we conclude that dilated cardiomyopathy has a favorable outcome after treatment of Cushing’s. It appears that some patients are diagnosed with dilated cardiomyopathy before the diagnosis of Cushing’s is made. This may be due to high prevalence of obesity and metabolic syndrome in the population, masking the diagnosis of Cushing’s early on. We conclude that patients with no other known cause of dilated cardiomyopathy should be carefully evaluated for Cushing’s Syndrome, as the diagnosis and treatment of Cushing’s alters the management plan and results in complete reversal of this condition.

 

Nothing to Disclose: RBA, AG

15511 15.0000 SUN-0787 A Cushing's Syndrome Related Dilated Cardiomyopathy: Favorable Outcome with Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Dinesh Edem*1, Esther Irina Krug2, Ivana Milojevic3 and Amitoj Gill3
1Sinai Hospital of Baltimore, Baltimore, MD, 2Johns Hopkins University/ Sinai Hosp of Baltimore, Baltimore, MD, 3Johns Hopkins University/Sinai Hospital of Baltimore, Baltimore, MD

 

Introduction: Cushings Syndrome (CS) is a rare disorder caused by prolonged exposure to endogenous or exogenous glucocorticoids. Incidence of CS ranges from 0.7 to 2.4 per million(1). Symptoms of CS including obesity, diabetes, hypertension, bone loss and depression are common in the population, making the diagnosis of CS extremely difficult. We present a case study of 2 patients with CS due to adrenal adenoma and analysis of correlation between severity of symptoms, tumor size and degree of hypercortisolism.

Case 1: A 56 year old woman with T2DM, hypertension and hirsutism returns for follow-up with complaints of gradual weight gain, increasing abdominal girth and leg cramps. She has family history of T2DM, osteoporosis and diabetes. Physical exam is notable for abdominal obesity,plethora, round facies, and supraclavicular fat pads. Serial 11 PM salivary cortisol ranged between 4 - 7.1 ng/mL(n <4.3), an overnight DST revealed a cortisol of 7.8 mcg/dL(n < 5), random ACTH level was < 0.5 pg/mL(6-50) with corresponding cortisol of 18.2 mcg/dL. CT scan of the abdomen revealed a 5.5 X 4.7 cm right adrenal adenoma which was subsequently resected. Patient had an uneventful postoperative course with no evidence of adrenal insufficiency. In follow-up her weight decreased by 10 lbs and diabetes improved. Repeat testing a year later showed ACTH of 28, and DST showed cortisol of 0.5.

Case 2 : A 74 year old woman with postmenopausal osteoporosis, hypothyroidism, T2DM on metformin returns to clinic with a 3 month onset of increasing abdominal girth, weight gain, worsening fatigue, proximal  muscle weakness of her extremities and poor blood pressure control. DXA revealed significant bone loss despite ongoing treatment with Denosumab. Exam revealed normal BMI, increased abdominal girdth and muscle weakness, but no moon facies, plethora or striae. Serial 11 PM salivary cortisol ranged from 7.2 to 13.6 ng/mL(n <4.3), UFC of 162 mcg/24h (0-50), ACTH level < 5 pg/mL with corresponding cortisol level of 19mcg/dL . CT of the abdomen revealed a 4.5 X 2.1 cm left adrenal mass. Patient subsequently underwent a resection of a benign left adrenal cortical adenoma. Postoperatively on day 2, patient developed symptoms of adrenal insufficiency.  Hydrocortisone therapy resulted in resolution of symptoms. Her AI  gradually improved after several months of glucocorticoid replacement.

Discussion: These cases illustrate that in patients with CS due to cortisol secreting adrenal adenoma, clinical symptoms and tumor size may not correlate with severity of hypercortisolism and risk of post-operative adrenal suppression. Our patients had adrenal adenomas of almost the same size, but had varied clinical and biochemical picture. Risk of postoperative adrenal insufficiency appears to correlate with the preoperative severity of hypercortisolism.

 

Nothing to Disclose: DE, EIK, IM, AG

16547 16.0000 SUN-0788 A Size of Cortisol-Secreting Adrenal Adenoma, Clinical Symptoms and Severity of Hypercortisolism: Case Study of Two Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Ester Matilde Pardes*1, Lucas Lisandro Gutnisky2, Fabiana Fierro3, Fernando Latorre3, Antonio Colobraro3, Patricia San Martín2 and Amelia Rogozinski3
1Hospital Ramos Mejía, Buenos Aires, Argentina, 2J M Ramos Mejía Hospital, Buenos Aires, Argentina, 3J. M. Ramos Mejía Hospital, Buenos Aires, Argentina

 

BACKGROUND: ACTH-dependent Cushing´s Syndrome (CS) can present difficulties in identifying the ACTH source. Cushing´s disease (CD) once diagnosed can also present difficulties in identifying pituitary microadenoma lateralization due to discordant studies. We present a patient with CD and dissociated results between MRI image and inferior petrosal sinus sampling (IPSS) lateralization.

CLINICAL CASE: A 27-year-old man with classical stigmata of CS (moon facies, supraclavicular fat pads, acne, abdominal red-purple striae),  ankle edema, and hypertension treated with enalapril consulted us.  BMI- 28,3 kg/m2, BP- 130/100 mmHg.  ACTH-dependent CS was confirmed:  plasma ACTH-183 pg/ml (n< 48 pg/ml), 24hr-urinary free cortisol (UFC)-2145 ug/24 hs (n<90 ug/24 hs), cortisolemia post-1mg dexamethasone (DXM)-38,9 ug/dl. Basal cortisolemia-30,1 ug/dl and post 8mg- DXM-37ug/dl.

MRI showed a left pituitary microadenoma (5,7 mm); 3T-MRI suggested a left pituitary microadenoma but it also showed a discrete right hypodense area.

IPSS was requested to distinguish CD from an ectopic ACTH-syndrome. Co-secretion products were also determined :catecholamines, VMA, cromogranin, calcitonin- with normal results. Neck and chest CT scans were normal. Abdominal CT scan showed hyperplasic adrenal glands.

IPSS (basal ACTH at -10' and 0' and  post- DDAVP  at  2,'  5 'and 10') confirmed pituitary ACTH secretion with right lateralization:

 ACTH (pg/ml)                                             -10´             0'              2´          5´         10´

Peripheral Sample                                      130            127,2       147,8       175,4     228,8     

Right IPSS                                                 686,3        >1000       6279        4348      2934

Left IPSS                                                    195            239,9      792,9       543,3     582,1

Endoscopic pituitary surgery was indicated and a left microadenoma was resected. Before surgery he received ketoconazol,decreasing UFC to 250 ug/24h.

Plasma ACTH was measured  before surgery: 137 pg/ml and 24 hr-after surgery < 5 pg/ml. Hydrocortisone (HC)  treatment was indicated. At 14 days post surgery (withdrawing HC for 24 hs)- 8:00 a.m- plasma cortisol was <1 ug/dl and ACTH- 13 pg/ml.

Histological examination confirmed pituitary adenoma with ACTH+ immunostaining.

Six months after surgery,the patient  is under HC, showing a remarkable clinical improvement and normal BP - without requiring antihypertensive drugs.

LH, FSH, PRL, To, TSH, T4, IGF1 and routine laboratory studies are normal.

CONCLUSIONS:

1-    In our patient, the 8mg-DXM test showed no inhibition and CD diagnosis was confirmed by IPSS.

2-    The dissociation between MRI image (left) and IPSS response (right) posed the question as to which side should be approached. A predominance of the right sinus drainage over the left and/or the existence of contralateral drainage could account for this dissociation-among other factors.

3-    The clinical and laboratory remission after resection of the left microadenoma would suggest a better correlation with MRI than with IPSS for the lateralization of pituitary microadenoma. The long-term outcome will allow us to evaluate this assumption.

 

Nothing to Disclose: EMP, LLG, FF, FL, AC, PS, AR

15073 17.0000 SUN-0789 A Dissociation Between IPSS Lateralization of Pituitary Microadenoma and MRI Image in a Patient with Cushing's Disease: Post-Surgical Outcome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Carmen Campino*1, Pamela Trejo1, Cristian A Carvajal1, Andrea Vecchiola1, Carolina Valdivia1, Cristobal A Fuentes1, Jose F Delgado1, Carlos F Lagos1, Carmen A Carrasco1, Alejandro Martínez-Aguayo1, Marlene Aglony2, Hernan Garcia Bruce2, Carolina A Loureiro2 and Carlos E Fardella1
1Pontificia Universidad Catolica de Chile, Santiago, Chile, 2Pontificia Universidad Católica de Chile, Santiago, Chile

 

Familial hyperaldosteronism Type I (FH-I) is caused by the presence of a chimeric CYP11B1/CYP11B2 gene that produces high amounts of aldosterone in response to ACTH and hypertension. We have recently reported the inhibitory actions of progesterone on aldosterone synthesis via the chimeric or native aldosterone synthase enzymes using an in vitro assay (1). Objective: To investigate the changes of blood pressure, progesterone, aldosterone and plasma renin activity (PRA) in a woman with FH-I during the third trimester of pregnancy and postpartum. Patient and Methods: A hypertensive woman belonging to a family with FH-I who was 16 years old at the time of diagnosis with a blood pressure of 120/95 mmHg, a Na+-K+ level of 142-4.1 mEq/L, an aldosterone level of 11.3 ng/dl, plasma renin activity (PRA) of <0.2 ng/ml/h and an aldosterone/PRA ratio (ARR) of >56.5 (2). She was normotensive and normokalemic under treatment with dexamethasone (0.25 mg/day). At 21 years of age, she became pregnant and discontinued treatment. Blood pressure and aldosterone, PRA, Na+, K+ and progesterone levels were measured at pregnancy (28 and 36 weeks) and postpartum (45 days). Normal values of hormones (3-5) are in brackets [X±SE]. The blood sample drawn at 36 weeks of gestation was obtained 2 hours prior to cesarean delivery. Results: Patient’s values at pregnancy (28 and 36 weeks) and postpartum (45 days) were as follows: blood pressure (mmHg): 103/69, 110/70 and 136/94, respectively; Na+-K+ level (mEq/L): 138-4.3, 137-4.0 and 143-4.2, respectively; aldosterone level (ng/dl): 63.9 [44±5], 44.1[58±6] and 39.4 [6.5±1], respectively; PRA level (ng/ml*h): 4.6 [5.5±1], 1.57[5.4±0.9] and <0.2 [1.4±0.1], respectively; ARR: 13.9 [8.8±5.8]; 28.1[ 16.6±7.9] and >197 [4.9±0.7], respectively; and progesterone level (ng/ml): 103.7 [105±1], 306.7 [140±20] and 0.31 [0.38±0.06], respectively. The increases in blood pressure and ARR were concomitant with a decrease in progesterone levels. Conclusions: 1. Our results show that the clinical and biochemical characteristics of FH-I normalized during gestation and worsened postpartum. These observations were associated with changes in progesterone concentration, thereby supporting our previous study demonstrating that progesterone inhibits the activity of both native and chimeric aldosterone synthase enzymes in vitro. 2. Our results identify a novel role for progesterone that could protect women against developing hypertension during pregnancy.

 

Nothing to Disclose: CC, PT, CAC, AV, CV, CAF, JFD, CFL, CAC, AM, MA, HG, CAL, CEF

12200 18.0000 SUN-0790 A Pregnancy Normalized Familial Hyperaldosteronism Type I: A Novel Role for Progesterone? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Christian Perez*1, Mark Ott2 and Joel R L Ehrenkranz2
1University of Utah School of Medicine, Salt Lake City, UT, 2Intermountain Healthcare, Murray, UT

 

Background: There are 25 reported cases of ectopic ACTH secretion associated with pheochromocytoma. Two of these cases occurred in the postpartum period and resulted in either fetal or maternal death (1,2).

Clinical Case:  A 27 year-old woman had a four-year history of paroxysmal hypertension.  Workup of her postpartum labile hypertension showed elevated plasma normetanepherine (19.3 nmol/L; nl <.89 ) and 24 hr urinary metanepherines and normetanepherines (2911 µ/dl and 40826 µgm/dl respectively; nl <350 and <650).  MRI showed a large adrenal mass.  Over an eight week period following delivery, the patient developed hypokalemia, edema, altered mental status, hyperglycemia, and right upper lobe pneumonia due to Moraxella Catarrhalis.  120 mEq KCl supplementation per day was needed to maintain her serum K >3.2 mmol/L.  24 hour urinary cortisol was 275 µgm/dl (nl <45).  ACTH rose from 316 pg/ml to 605 pg/ml (nl <58 pg/ml) over a 3-day period.  Imaging of the pituitary, chest, and pelvis was normal.  CT of the abdomen showed a hypodense intrahepatic lesion interpreted as metastatic pheochromocytoma.

The patient’s pneumonia responded to ceftriaxone; blood pressure was controlled with alpha and beta blockade; hypercortisolism was treated with mifepristrone and spironolactone.  The patient underwent a right adrenalectomy and liver biopsy of the lesion identified on CT.  Intraoperative pathology of the adrenal tumor was consistent with a pheochromocytoma; biopsy of the liver CT lesion showed no malignant cells.  There was no evidence of retroperitoneal or abdominal metastases.  Examination of stained tissue confirmed the intraoperative diagnoses.  Immunohistochemical staining for ACTH identified ~10% ACTH stain positive cells distributed throughout the adrenal tumor.  Genetic markers of RET mutations were not present.

The patient’s hypertension, hypokalemia, and altered mental status remitted in the immediate postoperative period.  8 am ACTH and cortisol levels on postoperative day 1, while the patient was receiving dexamethasone 2 mg iv q6h, were <5 pg/ml (nl>6) and 2.8 µgm/dl (nl> 6) respectively.  The patient was discharged home on the second postoperative day feeling “the best I’ve felt in four years”.  

Conclusion:   This is the first case report of a pheochromocytoma present prior to and throughout pregnancy with the new onset of Cushing's syndrome following delivery in which both the fetus and mother survived.   Although the patient had symptoms consistent with a pheochromocytoma for four years, hypercortisolism appeared following delivery and had a very aggressive course resulting in opportunistic infection, encephalopathy, and life-threatening hypokalemia.  Immunohistochemistry suggested a non-clonal original of ACTH secreting cells in the adrenal tumor.  The basis for the new onset of ectopic ACTH secretion from a pheochromocytoma in the postpartum period remains to be determined.

 

Nothing to Disclose: CP, MO, JRLE

13317 19.0000 SUN-0791 A Postpartum Pheochromocytoma and Ectopic ACTH Secretion: The First Report of a Case in Which Both Mother and Child Survived 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Irfan Nuhoglu*, Mustafa Kocak, Hulya Coskun, H Onder Ersoz, Cihangir Erem and Nadim Civan
KTU Medical Faculty, Trabzon

 

PHEOCHROMOCYTOMA IN PREGNANCY: A CASE REPORT

INTRODUCTION:  Pheochromocytoma in pregnancy is a rare condition; with an estimated prevalance of 1/50000 pregnancy. If not properly diagnosed and treated it presents high potential of mortality and morbidity for both mother and fetus.

CASE: A 31 years old women was admitted to our endocrinology due to uncontrolled hypertension despite initiation of alpha methyl dopa therapy at 12th-week of the pregnancy. Her anamnesis revealed headache, palpitation and hypertensive attacks also before pregnancy, and laboratory examination of 24-h urine analysis resulted normetanephrine: 2565μg/day (88-444) and norepinephrine: 1009μg/day (15-80). Upper abdominal MRI scan revealed a 43*42*33mm solid mass in left surrenale and pheochromosytoma was considered. Blood pressure regulation was achieved by preoperative treatment with phenoxybenzamine, doxazosin and propranolol and the patient was underwent surrenalectomy by left lateral approach at 20th-week of pregnancy. Postoperatively the drug therapy was stopped and follow up and holter monitoring revealed regulated blood pressure values. 

CONCLUSION: The only way of diagnosing pheochromocytoma in pregnancy is its suspection. It is often confused with preeclampsia, especially in the second trimester. In early diagnosed  pheochromocytoma cases operation can be performed in the 2nd trimester following proper preparation to surgery. In cases being diagnosed in the last trimester of pregnancy, following regulation of blood pressure by alpha adrenergic blockers until fetal maturation, delivery can be achieved by cesarean section and the surrenal mass removed during the same operation.

 

Nothing to Disclose: IN, MK, HC, HOE, CE, NC

13455 20.0000 SUN-0792 A Pheochromocytoma in Pregnancy: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Deirdre Cocks Eschler*, Aarti Ravikumar, Gillian M Goddard, Lawrence Krakoff and Alice C Levine
Icahn School of Medicine at Mount Sinai, New York, NY

 

BACKGROUND: Uncontrolled hypertension in pregnancy can result in maternal and fetal morbidity and mortality.  Less than 40 cases have been reported to be a result of primary aldosteronism (PA).  We present the first report, to our knowledge, of PA in pregnancy responsive to spironolactone and illustrate the possible need for early surgical intervention.

CASE: A 25 year old nulliparous woman was admitted to the obstetrics unit at 23 weeks gestation for management of uncontrolled hypertension. She had a history of HTN diagnosed at age 17 and of hypokalemia while on a thiazide diuretic   A work-up for secondary HTN was initiated 5 weeks prior for recorded BPs in the 140-170s systolic despite labetalol 800 mg PO TID and nifedipine 60 mg PO TID.   24-hour urine free cortisol, metanephrine, and protein values and serum electrolytes and TSH were all normal. Upright aldosterone and renin values were 36 ng/dL and 1 ng/mL/hr respectively with an aldosterone to renin (ARR) ratio of 36 and repeated values on admission were 53 ng/dL and 1.2 ng/mL/hr respectively with an ARR ratio of 44. An MRI of the adrenals revealed an 8mm, lipid-rich left adrenal nodule, but as she entered her third trimester surgical exploration was no longer advisable. Despite maximal dose titration of Labetolol and Nifedipine BP remained 160/110.  An ultrasound revealed a female fetus.  Spironolactone 25mg PO BID was initiated.  A week later, her BP was 157/96 and spironolactone was increased to 50mg BID with a BP response to126/78 at 28 weeks gestation.  Unfortunately, due to possible medication adherence issues, the patient was admitted 1 week later with a BP of 205/147 and had an emergency C-section for possible HELLP syndrome. The baby is on a respirator in the NICU.

DISCUSSION: In the non-pregnant population, PA is mostly commonly due to bilateral adrenal hyperplasia and an ARR > 20 and a plasma aldosterone > 10 ng/dL with a suppressed renin signify a positive screen and warrant confirmatory testing.  PA in pregnancy, however, is most often caused by an adrenal adenoma and the diagnosis poses specific challenges due to the normal physiologic increases in both renin and aldosterone (with lack of gestational-specific reference ranges) as well as limitations in the use of confirmatory testing in pregnant women.  Suggestive features include severe hypertension, hypokalemia, and a suppressed renin.  Provided BP responds, most cases are managed medically with methyldopa, labetalol and/or calcium channel blockers (and eplerenone in a case report), with confirmatory testing and surgery deferred until postpartum.  This case is instrumental in showing that PA in pregnancy can be treated with the addition of spironolactone once the fetus is confirmed to be female and highlights the need for early, aggressive treatment and possibly even surgery.

 

Nothing to Disclose: DCE, AR, GMG, LK, ACL

15177 21.0000 SUN-0793 A Workup and Medical Management of Primary Aldosteronism during Pregnancy: A Case Report and Review of the Literature 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Foiqa Chaudhry* and Colleen Rose Digman
University of Florida, Gainesville, FL

 

BACKGROUND:  Paragangliomas are rare neuroendocrine tumors arising from extra-adrenal autonomic paraganglia.  Diagnosis and management during pregnancy presents unique challenges due to the paucity of data regarding management especially in the third trimester of gestation.

CLINICAL CASE:

A 28 year old woman, G3P1011, underwent an MRI for evaluation of persistent back pain at 36 6/7 weeks gestation.  This revealed a right adrenal mass that was confirmed on abdominal MRI to be a 3.8 x 3.5 x 4 cm solid, round, smoothly marginated mass with heterogeneity and no significant signal drop out.  She had remained normotensive during the pregnancy but experienced increased palpitations, anxiety, and night sweats for 1 year prior to the current pregnancy.  No family history of endocrine disorders was elicited.  Patient’s laboratory workup revealed elevated 24 hr urine normetanephrine (NME), greater than 2 times upper limit of normal. [serum free NME 5.3 nmol/L (ref < 0.90), serum free metanephrine < 0.20 nmol/L (ref < 0.50), 24 hr urine metanephrine 52 mcg/24 hr (ref 30-180), 24 hr urine NME 744 mcg/24 hr (ref 103-390), 24 hr total metanephrine 796 mcg/24 hr (ref 145-510) and 24 hr VMA 2.8 mg/24 hr (ref < 8.0)].  Dexamethasone suppression test, aldosterone and renin levels were within normal range.  Given symptoms, imaging characteristics and laboratory data, it was concluded that the patient had a pheochromocytoma and was admitted to the high risk obstetrics service.  She was started on phenoxybenzamine and underwent an uncomplicated C-section at 37 6/7 weeks gestation.  On POD 5 from C-section, she underwent laparoscopic right adrenalectomy.  Pathology specimen revealed mass adjacent to normal appearing adrenal gland and cytology positive for CD56 (+) neuroendocrine cells.  Thus, the diagnosis was most consistent with paraganglioma.  Follow up imaging, laboratory testing and workup for associated genetic/hereditary conditions is pending.  The patient and baby continue to do well with resolution of palpitations and anxiety. 

CONCLUSION:

Guidelines regarding management of pheochromocytoma/paraganglioma in the third trimester of pregnancy are lacking given rarity of condition.  This patient had been normotensive and tolerated mild orthostasis on alpha blockade with no adverse effects to the fetus/neonate.  She also underwent successful right laparoscopic adrenalectomy in the immediate postpartum period which resolved concerns of ongoing phenoxybenzamine use while breast feeding.   Though she was presumed to have a pheochromocytoma based on imaging and abnormal biochemistry, final pathology and immunohistochemistry confirmed a diagnosis of a paraganglioma.  Further workup for synchronous lesions as well as assessment for associated genetic conditions is required.

 

Nothing to Disclose: FC, CRD

13331 22.0000 SUN-0794 A Management of Paraganglioma in the Third Trimester of Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM SUN 0773-0794 4777 1:00:00 PM Adrenal Case Reports 3 - Cushing's, Conn's, Pheo Poster

Becky Thai Muldoon*1 and Manoj Mathew2
1Walter Reed National Military Medical Center, Bethesda, MD, 2Walter Reed National Military Medical Center

 

Introduction:  Hypophosphatemia (serum phosphate concentration <2.5 mg/dl) is commonly seen in hospitalized patients for a variety of reasons including sepsis, trauma and alcohol-related disorders but is less commonly seen in outpatients.  There are a limited number of drugs that can cause hypophosphatemia including diuretics, acyclovir and bisphosphonates.  However, bisphosphonate-induced hypophosphatemia is almost always short-lived and thought to be related to transient hypocalcemia with compensatory elevation of PTH causing phosphaturia.  Herein, we report a patient with previously undescribed prolonged hypophosphatemia following zoledronic acid infusion.

Clinical Case:  A 68 year-old retired scientist with a history of steroid-induced osteoporosis (with a lumbar spinal compression fracture and 2 inch height loss), hypertension, diabetes mellitus type 2, and elevated free kappa light chains presented to the Endocrinology Clinic for evaluation of hypophosphatemia and fatigue that appeared following an infusion of zoledronic acid 5 mg on 12 August 2011 and which has persisted for over 1 year. He does not drink alcohol or take phosphate-binding antacids.  His medications are simvastatin, esomeprazole, modafinail, levothyroxine, cyanocobalamin, telmisartan, ferrous sulfate, metformin, and aspirin. 

On day of zoledronic acid infusion in August 2011, patient’s baseline labs were calcium of 9.5 (normal 8.6-10.2mg/dL), phosphate 3.1 (normal 2.5-4.5mg/dL), creatinine 1.2 (0.7-1.2mg/dL), alkaline phosphatase 42 (40-129U/L), PTH 29 (13-75pg/mL), and 25-hydroxy vitamin D 70 (30-100ng/mL).  Two months after bisphosphonate his calcium, creatinine, alkaline phosphatase, and PTH were normal but phosphate was 2.1.  His phosphate remained persistently low (2.0-2.4) throughout 2012.  A 24-hour urine phosphate was normal at 922 mg (normal 400-1300 mg) but the fractional excretion of phosphate was elevated at 30% (normal 5-20%) suggesting a phosphate wasting disorder. However, he has no evidence of overt hyperparathyroidism, Fanconi syndrome, or other condition that would cause this.  His hypophosphatemia normalized to 2.6 in June 2013 and increased to 3.4 in July 2013.

Conclusion: This is the first description of a prolonged adverse effect of a zoledronic acid infusion.  The mechanism for this effect is unknown but may be due to either zoledronic acid’s direct effect on tubular reabsorption of phosphate or its causing a mild secondary hyperparathyroidism (PTH at baseline was 29 and was subsequently 40-50) due to a hypocalcemia which is masked by his kappa light chain disease.

 

Nothing to Disclose: BTM, MM

12777 2.0000 SUN-0247 A A Rare Case of Prolonged Hypophosphatemia Associated with Bisphosphonate Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Ekaterina Manuylova*1, Nancy Clark2 and Ismat Shafiq1
1University of Rochester, Rochester, NY, 2Univ of Rochester, Rochester, NY

 

Bisphosphonates are commonly used for the treatment of osteoporosis. It is a first line treatment for patients with low bone mineral density. Zolendronic Acid is particular convenient for patient with gastrointestinal symptoms due to its intravenous (IV) administration. Although up to one third of the patient experience flu-like symptoms within first several days, other complications are rare. Here we report a case of orbital pseudotumor after infusion of Zolendronic Acid.

A 66 year old man with past medical history of hypertension, hyperlipidemia, and gastroesophageal reflex (GERD) presented in December 2012 to his primary care doctor for the evaluation of back pain. Lumbar spine X-ray showed wedge defect at T12 vertebra compatible with compression fracture. Subsequent Dual-energy X-ray absorptiometry revealed bone mineral density in osteopenic range at both hips and normal density at L1-L4 region. Secondary causes of bone loss including primary hyperparathyroidism, hypercalciuria, hypogonadism, hyperthyroidism and vitamin D deficiency were excluded. Due to his long-standing history of GERD Zolendronic Acid 5 mg IV was used. Shortly after infusion patient developed chills, night sweats, joint pain and fatigue that lasted for four days. On day four he also started having pain in his right eye with movement and on next day he developed orbital erythema, swelling and decreased acuity. The symptoms did not respond to local corticosteroid and anti-bacterial agents. Orbital MRI showed right-sided orbital pseudotumor and perioptic neuritis. Symptoms resolved with high dose of glucocorticoid, however three months later patient developed another episode of blurry vision and was diagnosed with cystoid macular edema and wrinkling retinopathy, most likely related to prior pseudotumor.  He underwent intravitreal steroid injection with partial response 6 months after use of Zolendronic Acid, later followed by retinal surgery.  At the time of writing this abstract patient is still recovering from the retinal surgery and the prediction is that his vision will not restore to his baseline 10 months ago.

This case illustrates an unusual complication of Zolendronic Acid IV used for osteoporosis. There are several case reports in the literature about bisphosphonate-associated orbital inflammation. In reviewed cases IV Zolendronic Acid was used. Most common presenting symptoms are pain, redness and blurry vision. Physicians should be aware of this potential complication and be very careful in choosing this form of treatment especially for patients at risk for orbital inflammatory disease.

 

Nothing to Disclose: EM, NC, IS

14560 4.0000 SUN-0249 A Orbital Pseudotumor in a Patient Treated with Zolendronic Acid 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Supna K Sandhu*1, Mandana Moosavi2, Amninder S Gill1, Brian Lentle1, Kevin Lian1, Jacques Trollip1, Larry Dian1 and David L Kendler2
1University of British Columbia, 2University of British Columbia, Vancouver, BC, Canada

 

Bisphosphonates (BP) are commonly used in the management of osteoporosis; atypical femoral fractures (AFF) are potential complications associated with their use. In 2013, the American Society for Bone and Mineral Research (ASBMR) developed new criteria for diagnosing AFF. There have been no reports comparing the new criteria to the old criteria. The true incidence of AFFs is controversial, as are predisposing risk factors. Our study applied new and old criteria to a series of patients with subtrochanteric femoral fractures evaluated by chart and radiology review.

We conducted a retrospective chart and imaging review of 204 patients with a discharge diagnosis of subtrochanteric fracture at Vancouver General Hospital (VGH), Canada, from January 2005 to March 2013. Images were read by an experienced musculoskeletal radiologist and double-read.  Investigators were blinded to patients with AFFs.

A total of 3084 patients with hip fracture were admitted to VGH with 204 labeled as subtrochanteric. Eleven patients were excluded due to inadequate information. 24 (12.2%) fulfilled both the new and old ASBMR criteria for AFF; there were no differences between new and old criteria. All AFFs had bilateral disease and periosteal reactions on imaging. Three (3/24) had multifocal lesions, as defined by multiple areas of periosteal reaction on a single lateral femoral cortex. Subtrochanteric fractures not meeting criteria were most commonly intertrochanteric (71/93) indicating major deficiencies in hospital coding accuracy. Only one hospital radiologists’ report correctly diagnosed an AFF. AFFs occurred only in females with a median age of 74.5+/-10.6 years, following low-energy trauma. Most (75%) were oriental in ethnicity. 14 (58.3%) were reported to be on BPs, 4 were on glucocorticoids, 7 were on proton-pump inhibitors (PPIs), and 2 had rheumatoid arthritis. Odds ratio for BPs and AFFs (7.7, CI 3.1,19.2) and for PPIs and AFFs (4.6, CI 1.6,12.9) were statistically significant but odds ratios for other risk factors were not. Upon discharge, 9 (64.3%) patients had their BPs discontinued, 5 (35.7%) continued on BPs, and 1 was initiated on BP therapy. 75% (18/24) of patients were discharged from hospital on calcium and vitamin D.

AFFs are rare and form only a subset of subtrochanteric fractures. However, the characteristic criteria defined by the ASBMR task force are not easily confused with other subtrochanteric fractures. Our radiologists had no difficulty in identifying the radiologic criteria and AFF’s met all 5 of the new major ASBMR criteria. There was no difference between the new and old ASBMR criteria in our series of AFF patients. A significant association was found for AFF and BP use, as well as PPI use; AFFs were identified in an almost equal number of BP naïve patients. The identification of multiple areas of periosteal reaction on the lateral femoral cortex of 3 of our 24 AFF patients has rarely been reported.

 

Disclosure: DLK: Collaborator, Amgen, Consultant, Pfizer, Inc., Collaborator, Johnson &Johnson, Collaborator, Eli Lilly & Company, Collaborator, Novartis Pharmaceuticals, Collaborator, GlaxoSmithKline, Collaborator, Roche Pharmaceuticals. Nothing to Disclose: SKS, MM, ASG, BL, KL, JT, LD

11722 7.0000 SUN-0252 A Comparison of the New and Old Asbmr Criteria for Atypical Femoral Fractures and the Discovery of New Multifocal Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

David Marc Gorson*
Southwestern Vermont Medical Center, Bennington, VT

 

Vertebral fractures may be clinically silent and yet have important clinical implications, as they are associated with future vertebral and non-vertebral fractures. Early in 2013, guidelines for the performance of vertebral imaging including Vertebral Fracture Analysis (VFA) were published by the National Osteoporosis Foundation (NOF). These guidelines are:
  • Women age 65 and older and men age 70 and older, recommend vertebral imaging to diagnose vertebral fractures if T-score is -1.5 or below.
  • Women age 70 and men age 80 and older, recommend vertebral imaging to diagnose vertebral fractures, regardless of T-score.
  • Postmenopausal women and men age 50 and older with a low trauma fracture.
  • Postmenopausal women and men age 50-69, recommend vertebral imaging to diagnose vertebral fractures if there is historical height loss of 1 & 1/2 inches or more, prospective height loss of 1 & 1/2 inches or more or recent or ongoing long-term glucocorticoid treatment.

As a result of these guidelines, and in order to quantify how many abnormal VFA studies would be found in a community bone density center utilizing them, a series of 100 consecutive VFAs were analyzed using a GE Lunar Prodigy system. Guidelines as above were used to perform the VFA, with the exception that if the patient was already receiving therapy for osteoporosis, a VFA was not performed.

Results:

Vertebral abnormalities were determined using the semiquantitative analysis of Genant (1). There were 94 women and 6 men. The average age of the population was 72.3, with a range of 52-89. Sixteen of the 100 were abnormal, and the majority of those (9/16 or 56 percent) had Grade 1 abnormalities. Six (38%) had grade 2 and one of 16 (6%) had a grade 3 abnormality.  Of the 84 normals, 26 had evidence of DJD in the thoracic or lumbar spine, which may have obscured vertebral abnormalities.

Discussion:

The prevalence of vertebral fractures determined by VFA in prior reports has ranged from 7.9% (2) to as high as 42% (3). In this study, which used NOF guidelines to evaluate for vertebral fracture with VFA, 16% were found to have evidence of a vertebral fracture. As none of these patients were on therapy for osteoporosis, these findings would be expected to change clinical management.

Conclusion:

Guidelines by the NOF for vertebral imaging led to the detection of a significant number of patients with vertebral abnormalities consistent with osteoporosis. These results would be expected to modify clinician treatment, and to increase the use of osteoporosis therapy. This in turn would be expected to lead to a reduced incidence of future fractures. NOF guidelines for vertebral imaging including VFA are clinically useful and should be followed.

 

Nothing to Disclose: DMG

11749 8.0000 SUN-0253 A National Osteoporosis Foundation Guidelines for Vertebral Imaging Are Clinically Meaningful 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Evelyn MM Wong*1 and David L Kendler2
1University of British Columbia, Vancouver, BC, Canada, 2Univ of British Columbia, Vancouver, BC, Canada

 

Diabetes mellitus and osteoporosis are both common conditions with increasing prevalence in older adults. Patients with type II diabetes (T2 DM) have been reported to have increased fracture risk. Bone mineral density (BMD) may be paradoxically higher in patients with T2 DM as compared to nondiabetics with similar fracture risk. T2 DM is not currently a FRAX risk factor.  As a result, it has been proposed that FRAX underestimates fracture risk in T2 DM and there is a need for further assessment modalities in T2 DM patients. Trabecular bone score (TBS) can be determined from the dual-energy X-ray absorptiometry (DXA) anteroposterior (AP) spine image and may be indicative of bone microarchitecture.  It has been proposed that an adjustment to the FRAX score (increasing the score by 25%) be made for T2 DM patients based on TBS results. (1)

We studied cross-sectionally, consecutive T2 DM female patients referred to an osteoporosis clinic in Vancouver Canada and compared them to age and sex matched nondiabetic controls. All patients were prospectively evaluated on initial consultation with FRAX clinical risk factors, lumbar spine BMD, and TBS.  We determined bivariate and multivariate odds ratios to describe the relationship between fracture risk and BMD, TBS, FRAX scores, and osteoporosis medication use, stratified by diabetes status. In both diabetics and nondiabetics, FRAX was found to be the only significant predictor of prevalent fracture.

Using pharmacotherapy FRAX thresholds of 20% for osteoporotic fracture and 3% for hip fracture, we found that 12 (18.2%) T2 DM patients would be candidates for therapy.  After applying the T2 DM TBS correction to FRAX scores, 15 (22.7%) T2 DM patients would be candidates for therapy.

We conclude that TBS may be useful in clinical decision-making for patients with T2 DM.  A TBS FRAX correction may help to more appropriately determine T2 DM patients who may be candidates for osteoporosis pharmacotherapy.

 

Nothing to Disclose: EMW, DLK

12263 9.0000 SUN-0254 A Trabecular Bone Score (TBS) Contributes to Fracture Risk Assessment in Patients with Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Katherine Neubecker Bachmann*1, Pouneh K. Fazeli2, Elizabeth A. Lawson1, Brian M. Russell3, Ariana D. Riccio3, Erinne Neubecker Meenaghan1, Anu V. Gerweck3, Miriam A. Bredella1, Anne Klibanski1 and Karen K. Miller1
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Neuroendocrine Unit, Massachusetts General Hospital/Harvard Medical School, Boston, MA, 3Massachusetts General Hospital, Boston, MA

 

Anorexia nervosa (AN) and obesity are complicated by elevated fracture risk, but specific data about hip fracture risk are lacking. Traditional BMD measurements have limited fracture prediction ability at both weight extremes. Hip Structural Analysis (HSA) uses DXA data to estimate geometry and strength of the proximal femur. The offload-to-strength ratio, termed the factor-of-risk (Φ), is a biomechanically-based method to estimate hip fracture risk due to a fall where higher Φ values are associated with higher fracture risk. 

We performed HSA in 368 women (ages 19-45): 246 with AN, 69 lean controls (C), and 53 overweight/obese (OW) women of comparable age. We also calculated the peak factor-of-risk (Φpeak) using the peak fall load and attenuated factor-of risk (Φattenuated) using a fall load attenuated by trochanteric soft tissue. Body composition was determined by DXA.

Subperiosteal width, cortical thickness, cross-sectional area (CSA), cross-sectional moment of inertia (CSMI), section modulus (Z), and buckling ratio (BR) were impaired at all sites (narrow neck, NN; intertrochanteric region, IT; femoral shaft, FS) in AN compared to C (p≤0.02). Cortical thickness, CSA, CSMI, Z, and BR were better in OW than C at most sites (p≤0.03). Φpeak was higher in OW (1.42 +/- 0.18) than AN (1.37 +/- 0.23; p<0.05) and C (1.33 +/- 0.20; p<0.007), and did not differ between AN and C. Φattenuated was highest in AN (1.09 +/- 0.19) followed by C (0.89 +/- 0.14) and lowest in OW (0.67 +/- 0.16; p<0.0001). Lean body mass (LBM; R 0.15-0.69) was positively associated with most HSA parameters across and within groups (p<0.05). BMI (R 0.19-0.60) was associated with most HSA parameters across groups and within AN (p<0.01), but not consistently within C and OW groups. Within AN, durations of amenorrhea (R -0.25 -  -0.48, p<0.001) and illness (R -0.16 - -0.31; p<0.02) were associated with impaired cortical thickness, CSA, CSMI, Z, and BR at all sites, and with higher Φpeak and Φattenuated (R 0.4; p<0.0001). IGF-1 correlated positively with most HSA parameters at most sites across groups (R 0.20-0.38; p<0.03), and negatively with Φpeak (R -0.31 all groups; R -0.42 AN; p<0.04). Femoral neck (FN) BMD correlated with CSA, CSMI, Z, and BR across and within groups (R 0.27-0.91, p<0.04) but not consistently with subperiosteal width or endocortical width within groups. After controlling for FN BMD, LBM remained a significant predictor of most HSA parameters and Φattenuated across groups and in AN. When duration of amenorrhea was added to the model for AN, LBM and duration of amenorrhea were independent predictors of most HSA parameters.

Women with AN have impaired hip geometry and strength by HSA and elevated attenuated factor-of-risk, suggesting a higher risk of hip fracture. In contrast, hip geometry and strength are increased, and attenuated factor-of-risk decreased, in OW women compared to C, suggesting reduced risk of hip fracture.

 

Nothing to Disclose: KNB, PKF, EAL, BMR, ADR, ENM, AVG, MAB, AK, KKM

11431 10.0000 SUN-0255 A Comparison of Hip Geometry, Strength, and Estimated Fracture Risk in Women with Anorexia Nervosa and Overweight/Obese Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Mark Daniel DeBoer*1, Lindsay M. Griffin2, Hannah E. Agard3, Lee A Denson4, Meena Thayu5 and Mary B Leonard6
1Univ of Virginia, Charlottesville, VA, 2Children's Hospital of Philadelphia, Philadelphia, PA, 3Univ. of Virginia, Charlottesville, VA, 4Cincinatti Children's Hospital, Cincinatti, 5Janssen Pharmaceuticals, Whitehouse Station, NJ, 6Children's Hosp, Philadelphia, PA

 

Introduction

Childhood onset Crohn’s disease (CD) results in systemic inflammation that is associated with low IGF-1 levels and shortfalls in bone mineral density (BMD) and bone structure.  The objective of this study was to examine changes in IGF-1and cytokine levels following initiation of infliximab therapy in children and adolescents with CD, and to examine correlations with changes in peripheral quantitative CT (pQCT) measures of BMD and bone structure.

Methods

A total of 66 participants with CD, ages 5-20 (mean 13.4) years, completed the 12 month study.  Serum measurements of IGF-1, IL-6 and ESR were performed at baseline (0 weeks), 10 weeks, and 1 year after initiation of infliximab and tibia pQCT scans were obtained at baseline and 1 year.  Bone outcomes were expressed as sex, race and age specific Z-scores compared with >650 reference participants.  Multiple linear regression was performed to assess associations between IGF-1 and bone pQCT. 

Results

Systemic inflammation as assessed by IL-6 (14.4 [0.6-71.0] to 4.8 [0.1-398] pg/mL, p<0.001) and ESR (26 [0-100] to 8.5 [0-65] mm/hr, p<0.001) decreased during the 10 week induction period but were not different at 1 year.  Similarly, serum IGF-1 levels (164+80 to 213+98 ng/mL, p<0.001) and IGF-1 z-scores (-0.82+1.13 to -0.20+1.11 p<0.001) increased from baseline to 10 weeks, though 1-year IGF-1 z-scores were not significantly different from baseline (-0.70+0.91, p=0.18).  pQCT z-scores of bone density and structure were low prior to infliximab treatment and increased over the following year: trabecular BMD -1.44+1.11 to -0.96+1.09, cortical area -0.94+1.35 to -0.65+1.24, and muscle area -0.79+1.08 to -0.33+1.04 (all p<0.0001).  Using linear regression and adjusting for baseline values, change in IGF-1 z-score 0-10 weeks was associated with increases trabecular density (p<0.01), cortical thickness (p<0.05), and muscle area (p<0.01).

Conclusions

Following treatment with infliximab in children with CD, IGF-1 levels increase in the first 10 weeks and the degree of increase is associated with increased trabecular BMD, cortical thickness and muscle area over the first year after treatment.  More research is needed to further define the role of IGF-1 in bone growth and its relationship to systemic inflammation following treatment of IBD.

 

Nothing to Disclose: MDD, LMG, HEA, LAD, MT, MBL

12288 11.0000 SUN-0256 A Degree of Change in IGF-1 Is Related to Changes in Bone Density & Structure during on-Going Treatment with Infliximab in Pediatric Crohn's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Marilda Mormando*1, Antonella Giampietro2, Luigi Aurelio Nasto2, Antonio Bianchi3, Linda Tartaglione3, Sabrina Chiloiro1, Enrico Pola2, Alfredo Pontecorvi2, Gherardo Mazziotti4, Andrea Giustina4 and Laura De Marinis5
1Catholic University of the Sacred Heart, Rome, Italy, 2Catholic University, Rome, Italy, 3Catholic University, School of Medicine, Rome, Italy, 4University of Brescia, Brescia, Italy, 5Università Cattolica del Sacro Cuore, Rome, Italy

 

Introduction: Growth hormone (GH) and insulin-like growth factor 1 (IGF1) exert an important anabolic role on bone tissue through both endocrine and paracrine action. Both condrocites and osteoblasts express GH receptor (GHR) and two isoforms of this receptor are known: the full-lenght isoforms (fl) and an isoform codified by a gene with a deletion of exon 3 (d3). According to literature data, in children affectd by GH deficiency and Turner Syndrome , d3 isoform may confer a better sensitivity to GH action in term of growth velocity and final height. However, it is still unknown the effect of GHR on bone metabolism and skeletal fragility in patients affected by adult GH deficiency.

Patients and methods: we studied 93 patients affected by adult GH deficiency on replacement therapy with recombinant human GH (50 males and 43 females). Bone mineral density (by dual energy x ray absorptiometry) of femoral neck and lumbar spine was measured for each patient and a X-ray examination of the thoracic and lumbar spine was performed for assessment of vertebral fractures.  Biochemical measurement (calcium, 25-hydroxyvitamin-D, serum parathyroid hormone and bone metabolism markers) were also performed . GHR genotype (full lenght isoform: flfl; full lenght- d3 deletion: fld3; or d3 deletion- d3 deletion: d3d3) was assessed in each patient.

Results: 33% of all patients were osteopenic and 8% osteoporotic on lumbar spine. Thirty one patients (34%) showed almost one vertebral fracture and most of them were males (not significant difference). Flfl carriers were forty-nine; fld3 carriers were thirty-one and d3d3 carriers were thirteen. Patients carriers of both fl alleles showed significantly increased prevalence of vertebral fractures as compared to patients harbouring of almost one allele d3 (p 0.001). The age of patients was significantly related to vertebral fractures ( p 0.02); but no differences in bone metabolism markers, calcium, 25-hydroxivitman D and serum parathyroid hormone levels were founded in fractured compared to not fractured patients. Not fractured patients had higher IGF1 levels than  fractured patients ( p 0.07)

Conclusions: in adult patients affected by GH deficiency on replacement therapy with rhGH, the presence of GHR genotype with the deletion of exon 3  conferring an higher sensitivity to growth hormone therapy (probably for an increased intracellular signalling transduction), may represent a protective factor against the risk of vertebral fractures.

 

Disclosure: AG: Consultant, Ipsen, Consultant, Novartis Pharmaceuticals, Consultant, Pfizer, Inc.. Nothing to Disclose: MM, AG, LAN, AB, LT, SC, EP, AP, GM, LD

16607 12.0000 SUN-0257 A Role of GH Receptor Isoforms on Skeletal Fragility in Patients Affected By Adult GH Deficiency in Replacement Therapy with Rhgh 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Ichiro Tatsuno*1, Ayako Nagumo2, Yuta Sato2, Sawako Suzuki3, Hisashi Koide4, Tomohiko Yoshida3, Tomoaki Tanaka3, Takashi Terano5 and Takao Sugiyama6
1Toho University Sakura Medical C, Kashiwa-City, Japan, 2Toho University Sakura Medical Center, 3Chiba University Graduate School of Medicine, Chiba, Japan, 4Chiba Univ Grad Sch of Med, Chiba, Japan, 5Chiba Aoba Municipal Hosp, Chiba, Japan, 6National Hospital Organization Shimoshizu National Hospital

 

Background: Autoimmune rheumatic diseases sometimes require the long-term high-dose glucocorticoid (GC), but the treatment causes a high incidence of osteoporosis. We have demonstrated that the high-dose GC treatment have a high risk of clinical vertebral fractures, and that the age, female, initial dose, dose-increase, systemic vasculitis, and glucocorticoid-induced diabetes mellitus are its independent risk factors in the Chiba-Shimoshizu Rheumatic Cohort (CSRC) (1-7). Although the osteoporotic fracture has been known to be is an independent risk for the mortality in the postmenopausal osteoporosis, it is unclear whether the GC-induced osteoporotic fracture is an independent risk of the mortality in autoimmune rheumatic diseases.

Objectives: We investigated the clinical vertebral fracture as the risk of the mortality for 10 years in the female patients who were treated with high-dose glucocorticoids in the CSRC

Methods: CSRC has been conducted to analyze the both mortality and morbidity of the autoimmune rheumatic diseases since 1986 in Chiba prefecture, Japan. In the present study, the female patients aged 18 years or older: newly treated with high-dose glucocorticoids (an initial dose of 20 mg and higher prednisolone equivalent per day) for at least more than 6 months were studied. We compared the 42 dead female patients those died within 10 years, and 223 alive female patients those were followed for 10 years. Patients were excluded if they were previously treated with bisphosphonates, hormone replacement therapy, or selective estrogen receptor modulator to prevent bone loss.

Results: The causes of death were infectious and parasitic diseases (38.1%) , malignant neoplasm (14.3%), cardiovascular diseases (11.9%), digestive diseases (11.9%), intentional injuries (Suicides)(4.8%), neuropsychiatric disorders (2.4%), respiratory diseases (2.4%) and undetermined (14.3%). The dead group had significantly higher mean age (61.2 + 13.2 vs 39.1 + 13.5, p<0.001), lower daily dose (38.3 + 12.5 vs 45.6 + 15.8 g/day, p<0.001), lower BMI (20.0 + 2.9 vs 21.2 + 3.1, p<0.05), higher rate of smoking rate (31.0 vs 15.7%, p<0.05) and higher rate of fracture (64.3 vs 17.9%, p<0.001) in comparison to the alive group. According to the Kaplan-Meier analysis, the group with clinical fracture had significantly lower survival rate in comparison to the group without clinical fracture (P<0.001). Cox regression model demonstrated that the independent risks for mortality were age (>50 years) with HR 4.79 (1.98 – 11.60, P<0.001), smoking with HR 2.30 (1.17 – 4.53, p=0.016), and clinical fractures with HR 3.07 (1.52 – 6.23, p=0.002).

Conclusions: The prevalence of clinical vertebral fractures was higher in the dead group than the alive group in . The independent risks for mortality were age, smoking, and clinical fracture during the high-dose GC treatment in autoimmune rheumatic diseases.

 

Nothing to Disclose: IT, AN, YS, SS, HK, TY, TT, TT, TS

12946 13.0000 SUN-0258 A Clinical Vertebral Fracture Is Independently Associated with the Mortality in Female Patients Treated with High-Dose Glucocorticoid in Autoimmune Rheumatic Diseases 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Erik Allen Imel*1, George Eckert2, Ankita Modi3, Arun Krishna4, Zhuokai Li2, Joel Martin5, Marc Rosenman6, Anne Emoke de Papp7, Katie Allen5, C Conrad Johnston8 and Siu Hui5
1Indiana University School of Medicine, Indianapolis, IN, 2Indiana University Schools of Medicine and Public Health, 3Merck & Co. Inc., 4Merck & Co, Inc, NJ, 5Regenstrief Institute, Inc., 6Indiana University School of Medicine, 7Merck Rsrch Labs/Merck & Co In, North Wales, PA, 8IN Univ Sch of Med, Indianapolis, IN

 

Bisphosphonates (BIS) significantly reduce the risk of osteoporotic fractures in postmenopausal women with osteoporosis (OP). However, it is unclear what proportion of women remains at risk for fracture despite adherence to therapy outside of clinical trials. Using data from the Indiana Network for Patient Care (INPC), we estimated the proportion of women age 50+ who remained at high fracture risk despite being adherent to bisphosphonates for ≥2 years.

High fracture risk was defined by one of 3 outcomes occurring between 7 and 36 months from the start of the adherent period: (1) an incident osteoporotic fracture; (2) a BMD by DXA remaining low with T-score <-2.5 or (3) BMD declining ≥3% from pre-treatment. Data were extracted from the INPC, a health information exchange which includes electronic medical records from multiple Indiana healthcare systems as well as data from healthcare payers. The cohort consisted entirely of adherent patients, defined as having medication dispensing records showed >0.8 as the proportion of days covered with any oral bisphosphonate for a continuous period of ≥2 years during 2000-2012. Exclusions were other bone diseases. Fractures were identified by ICD-9 codes, excluding sites not associated with osteoporosis and multiple concurrent fractures suggesting trauma.

Of the 7444 women in the adherent cohort (defined above), 30% had some previous exposure to oral bisphosphonates prior to the adherent period. Race/ethnicity distribution (available on 6217) was 92% white, 8% black, <1% Hispanic. Mean age at the start of the adherent period was 68±10 (SD) years, and mean Charlson score was 1.3±1.8 (median=1). Of 1789 women in this cohort with BMD measurements prior to the adherent period, 25% had T-scores <-2.5.

Outcomes assessed during months 7-36 after the start of the adherent period indicated 501 (7%) women sustained ≥1 osteoporotic fractures. Of 600 women having  ≥1 DXA during months 7-36, 115 (19%) had a T-score <-2.5 at one or more sites. Among the subset of 303 women having both a pre- and post-treatment DXA, 77 (25%) had a BMD decrease ≥3% at any site, while 127 (42%) had at least one of the 3 outcomes.  Results were similar when post-treatment DXA outcomes were restricted to months 13-36.

Across a spectrum of Indiana clinical practices, a proportion of bisphosphonate adherent women remain at high risk for fracture even if responsive to therapy. Alternative treatments for osteoporosis could be considered for such patients.

 

Disclosure: EAI: Coinvestigator, Kyowa Hakko Kirin, Investigator, Merck & Co.. AM: Employee, Merck & Co.. AK: Employee, Merck & Co.. MR: Coinvestigator, Merck & Co.. AED: Employee, Merck & Co., Employee, Merck & Co.. Nothing to Disclose: GE, ZL, JM, KA, CCJ, SH

13044 14.0000 SUN-0259 A A Proportion of Osteoporotic Women Remains at Risk for Fractures Despite Adherence to Oral Bisphosphonates 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Pnina Rotman Pikielny*1, Alina Amitai2, Mira Maram Edry3, Shimona Yosselson Superstine4 and Alona Eliasaf3
1Meir Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Kfar-Saba, Israel, 2Meir Medical Center, Kfar-Saba, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Kfar Saba, Israel, 3Meir Medical Center, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Kfar Saba, Israel, 4School of Pharmacy, The Hebrew University of Jerusalem, Israel

 

Background: Osteoporosis treatments can reduce the risk of fractures by 30-50%, but adherence after one year is only about 50%. Low adherence to treatment increases the risk of fractures. Understanding possible reasons for low compliance can provide a basis for a strategic plan to improve compliance.

Objectives: Determine compliance and persistence with osteoporosis therapy and attitudes regarding resuming treatment among patients of a metabolic bone clinic that were on active therapy or drug holiday.

Methods: Compliance was assessed by medication possession ratio (MPR), representing the number of doses dispensed in relation to those prescribed. Persistence was defined as continuation of treatment without a >30-day gap in refills. Data were collected by personal interviews.  

Results: Of 100 patients interviewed (70.2±7.7 years-old), 55% were receiving treatment, 60% of them were taking oral medication, mostly a bisphosphonate. MPR≥80% was found in 82% of patients and <50% in 13%. MPR was 100% for zoledronate, denosumab and raloxifene, and 92%, 89% and 71% for teriparatide, oral bisphosphonates and strontium ranelate, respectively. Of 27 patients who took oral bisphosphonates, 63% Persisted with treatment. Of patients on oral bisphosphonates, 87% took them as directed. Of 40 patients on a scheduled medication break, 20% expressed concern about resuming treatment, while 65% expressed confidence in their physician’s treatment choice.

Conclusions: Compliance among our patients was higher than reported in the literature. MPR for bisphosphonate treatment was high; lower for strontium ranelate. We also found a high rate of taking oral bisphosphonates as directed. Compliance with percutaneous treatments (zoledronate and denosumab) was 100%. High persistence and compliance may be specific to patients from a dedicated bone clinic. This study provides new information about the attitudes of osteoporosis patients on a scheduled drug holiday. Most were not concerned about resuming treatment and did not have a preferred medication. These results indicate that a trusting relationship between doctor and patient seems to be an important factor in medication compliance.

 

Nothing to Disclose: PR, AA, MM, SY, AE

13728 15.0000 SUN-0260 A Compliance, Persistence and Preferences Towards Osteoporosis Treatment Among Post-Menopausal Israeli Women during Active Therapy or Drug Holiday 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Haleigh James*1, Pamela Holte2 and Ann E Kearns1
1Mayo Clinic, Rochester, MN, 2Mayo Clinic, Rochester

 

Vitamin D facilitates calcium absorption and promotes bone formation and mineralization, making it integral to skeletal health. It is especially important in hip fracture patients since it optimizes response to bisphosphonates, decreases fall risk, and is associated with decreased mortality in this population. Multiple studies document that despite these benefits of vitamin D, a care gap exists in assessing and prescribing vitamin D to patients with a fragility fracture of the hip.

To evaluate the current practices in Rochester, MN regarding vitamin D deficiency screening and treatment in hip fracture patients during hospitalization, we performed a retrospective chart review of 57 such patients admitted to an orthopedic service in 2010. Next, we reviewed the charts of 105 hip fracture patients who had serum 25-hydroxyvitamin D [25(OH)D] measured to determine prevalence of vitamin D deficiency, and whether or not demographic/clinical characteristics predicted deficiency. We then implemented a quality improvement initiative, which consisted of inserting a 25(OH)D checkbox in the electronic orderset for hip fracture patients, adding educational information to the orientation material for residents on the hip fracture service, and providing guidelines for appropriate supplementation doses based on 25(OH)D levels to the orthopedic teams. Finally, we performed another retrospective chart review of 57 hip fracture patients in 2013 after the quality improvement initiative was instituted to determine new rates of vitamin D deficiency screening and treatment.

Of the 57 patients admitted in 2010, 3.5% of them had 25(OH)D checked and 49.1% were discharged on a vitamin D supplement. Among 102 hip fracture patients who had 25(OH)D measured at the time of hospitalization, 33.3% had levels <20 ng/mL and 72.5% had levels <30 ng/mL. Gender, age, race, BMI, and multivitamin, calcium, and vitamin D supplement use did not reliably predict vitamin D deficiency. After implementation of our quality improvement initiative, 98% of hip fracture patients had 25(OH)D measured during hospitalization and 93% were dismissed on vitamin D supplementation with 73% receiving our recommended dose or higher. Based on our data, vitamin D deficiency continues to be very prevalent in hip fracture patients. Hospital-based strategies which prompt orthopedic teams to check 25(OH)D and initiate supplemenation increase rates of vitamin D deficiency screening and treatment in this population.

 

Nothing to Disclose: HJ, PH, AEK

14054 16.0000 SUN-0261 A Vitamin D Deficiency in Hip Fracture Patients: Prevalence and a Quality Improvement Initiative to Improve Screening and Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Harsha Karanchi*1, Alison Kleppinger1 and Anne Kenny2
1University of Connecticut Health Center, 2University of Connecticut Health Center, Farmington, CT

 

Hyponatremia may be an independent risk factor for osteoporosis and fractures but studies are few and results are inconsistent. In a rat model, hyponatremia decreases bone mineral density (BMD) through increased bone resorption and decreased bone formation but there are no human studies of hyponatremia and bone turnover.  Only one study showed gait impairment with hyponatremia. We tested these associations in frail older adults using secondary cross-sectional baseline data analyses from two randomized controlled trials. Hyponatremia was defined as serum sodium ≤ 137 mEq/L.

Results: The analyses included 191 subjects, 84 women (mean age 77±6 y) and 107 men (mean age 77 ±8y). Hyponatremia (n=29, 135±2 mEq/L) was compared with normal sodium (n=162, 140±2 mEq/L). Hyponatremia was associated with a 3 fold (odds ratio 3.01; p=0.01) increased risk of osteoporosis compared to those with normal sodium (37.9 vs. 16.9%; p=0.009). There was no significant difference between the two groups with respect to history of any fracture, total hip, femoral neck bone mineral density although there was higher L2-L4 BMD with hyponatremia (1.27 vs. 1.15 g/cm²; P=0.02). Bone resorption marker, urinary N-terminal telopeptide/creatinine, was significantly lower with hyponatremia (23.8 vs. 33.6 nmol/mmol; p=0.04). There were no differences with respect to bone formation markers, bone specific alkaline phosphatase and osteocalcin. With respect to physical performance looking at Physical Activity Scale in Elderly (PASE) score, Short Physical Performance Battery( SPPB) score, gait speed and Get up and Go test, no significant differences were found between the two groups.

Conclusions: Hyponatremia is associated with increased odds of osteoporosis in frail older adults. In this small sample, effect of hyponatremia on increased L2-L4 BMD is difficult to explain although possible role of higher lumbar compression fractures cannot be ruled out. The significance of low bone resorption marker with no difference in bone formation markers between groups is not clear and needs further investigation. In a population pre-selected for frailty, no significant differences were found in physical performance measures in subjects with hyponatremia compared to normal sodium.

 

Nothing to Disclose: HK, AK, AK

14124 17.0000 SUN-0262 A Hyponatremia Is Associated with Increased Odds of Osteoporosis in Frail Older Men and Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Suja S Shenoy*1, Sujay Madduri1, Rabia Cherqaoui1 and Gail Louise Nunlee-Bland2
1Howard University Hospital, Washington, DC, 2Howard Univ Hosp, Washington, DC

 

Objective:To compare the 10-year probability of hip fracture (HF) and major osteoporotic fracture (MOF) using WHO FRAX algorithm with and without femoral neck bone mineral density (FN-BMD) in African American (AA) patients with type 2 diabetes (T2D).

Methods: All patients who underwent routine osteoporosis screening by Dual Energy X-ray Absorptiometry (DXA) scan were identified from our radiology database. We included self-reported AA men and women aged 50 to 85 years with existing diagnosis of T2D. We excluded patients diagnosed or treated with FDA approved agents for osteoporosis, history of cancer, body weight > 275 lbs (125 kg), women with bilateral oophorectomy before the age of 35 years, history of secondary causes of osteoporosis and those with incomplete data. A standard FRAX questionnaire was used to obtain clinical risk factors (CRF) which included previous non-traumatic fractures, history of parental hip fractures, corticosteroid use, smoking, alcohol and rheumatoid arthritis. Anthropometric measurements were done at the time of DXA scan. FN-BMD was measured using the same Hologic densitometer at our institute for all the patients. WHO FRAX algorithm validated for US Blacks was applied to generate the 10-year probability of MOF and HF. Patients were sorted into two groups based on concordant or discordant treatment recommendations depending on FRAX scores with a threshold of 20% for MOF and 3% for HF. Simple t-test was use used for numerical variables and Fischer’s exact test for binary variables.

Results:A total of 170 patients matched our criteria, of which 162 (95%) had concordant 10-year fracture risk prediction by WHO FRAX algorithm with or without FN-BMD.  Out of the 8 patients who had discordant results only 1 (0.6%) patient met National Osteoporosis Foundation treatment criteria.  Age was the only CRF that was different between the two groups (64 ± 7.2 vs. 76 ± 9.1 years, p = < 0.001).

Discussion: In clinical practice, BMD is the gold standard in determining fracture risk. To improve fracture-risk prediction, the FRAX tool was introduced to identify patients at high risk for osteoporotic fracture.  The FRAX tool without FN- BMD was investigated in previous studies, which showed comparable results to FRAX with FN BMD. FRAX tool without FN-BMD could play an important role in fracture prediction when DXA scanning is unavailable.

Conclusions: FRAX scores without BMD provide similar estimates as FRAX scores with BMD in AA patients with T2D. Younger age is more indicative of a concordant prediction. Calculating the 10-year probability of MOF and HF without FN-BMD provides an opportunity of identifying AA with T2D at risk of such events.

 

Nothing to Disclose: SSS, SM, RC, GLN

16946 18.0000 SUN-0263 A 10-Year FRAX Calculations with and without Femoral Neck BONE Mineral Density in African American Patients with Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Laura Elizabeth Hinz*1, Elizabeth A Freiheit2 and Gregory A Kline1
1University of Calgary, Calgary, AB, Canada, 2University of Calgary, Canada

 

Background

Historically, treatment decisions for osteoporosis were based on bone mineral density (BMD). However, many fractures occur in patients with T-scores outside of the osteoporotic range, emphasizing the importance of multi-factorial risk assessments. The World Health Organization Fracture Risk Assessment Tool (FRAX) predicts ten year risk of osteoporotic fracture based on country-specific data. The tool incorporates age, gender, BMI, ethnicity and seven other dichotomous variables, with or without BMD.

Hypothesis/Questions

We hypothesized that physicians’ estimates of risk of osteoporotic fracture would differ significantly from that calculated by FRAX.  As a result, the group of patients selected for treatment would differ depending whether physicians used FRAX or their own judgement.

Experimental Design/Methodology

Our study was modelled after a hypertension study that gauged physicians’ abilities to estimate clinical risk and the factors that influenced their decision making (1). A survey consisting of five clinical scenarios was administered to 76 physicians, including Endocrinologists, Family Physicians, Internists, and Internal Medicine residents. They were asked to estimate each patient’s risk of osteoporotic fracture, whether they would offer preventative treatment and to outline the reasons for their decision. Their estimates were compared to the quantitative risk predicted by FRAX and national guidelines regarding treatment thresholds.

Major Results

In each scenario, there was a large and statistically significant over-estimation of fracture risk by physicians compared to that predicted by FRAX. The estimates for hip fracture risk were 2-4 fold higher than the FRAX estimates, while those for osteoportotic fracture risk differed by a factor of 0.9 to 1.5. More than 50% of participants were completely or somewhat unsure of their estimate in each case.  However, 67% of participants matched the guidelines decision to treat in 4 or 5/5 scenarios and the proportion matching did not vary greatly by physician type. The risk at which participants would offer treatment varied with physician group, with Endocrinologists, Family Physicians and Residents requiring at least 10% ten-year risk, while IM physician thresholds ranged more broadly from 2-50%.

Interpretation/Conclusions

Physicians greatly over-estimated the risk of hip fracture based on clinical information and participants uniformly lacked confidence in their risk estimates. Therefore, FRAX is necessary to accurately quantify risk, but because physicians varied in the level of risk required before they would offer treatment, uniform approaches to risk estimation may still not result in uniform clinical treatment decisions.

 

Nothing to Disclose: LEH, EAF, GAK

14189 19.0000 SUN-0264 A How Good Is Our Best Guess?: Clinical Application of the WHO FRAX Tool in Osteoporotic Fracture Risk Determination and Treatment Decisions 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Arthur Swislocki*1, Joanne LaFleur2, Chandra Laura Steenhoek3, Julie Horne4, Joy Meier5, Jonathan Nebeker2, Scott Mambourg6 and Jannet Carmichael7
1VA N CA Hlth Care System, Martinez, CA, 2University of Utah, Salt Lake City, UT, 3Department of Veterans Affairs Northern California Health Care System, Mather, CA, 4James H. Quillen Department of Veterans Affairs Medical Center, Mountain Home, TN, 5VA Northern California Health Care System, Martinez, CA, 6Ioannis Lougaris Department of Veterans Affairs Health Care System, Reno, NV, 7Department of Veterans Affairs Sierra Pacific Network (VISN 21), Reno, NV

 

Purpose

Identification of patients at high fracture risk is vital to improving osteoporotic care and outcomes.  Bone mineral density (BMD) testing has historically been considered the gold standard for screening and diagnosing osteoporosis.  However, while patients with T-scores below -2.5 have a well-documented increased risk of fracture, at least 80% of fractures in males occur in conjunction with T-scores above that range.  This, combined with the U.S. Preventive Services Task Force (USPSTF) guidance against routine BMD screening, means that this approach misses most men at risk for first fracture.  Thus, absolute risk assessment (ARA) is the preferred approach to guiding osteoporosis treatment decisions; however, male fracture absolute risk estimation is problematic due to poor discrimination of available tools.  External validation has found that the World Health Organization’s (WHO) Fracture Risk Assessment Tool (FRAXTM) performs well in predicting fracture in women, but appears to perform poorly in men.   Although such tools are appealing for informatics-based population medication management, it is not known whether they are compatible with risk factor information derived from electronic health records (EHRs). We compared two fracture ARA tools for such use: FRAX versus the Veterans Affairs (VA)-ARA.

 

Methods

In a case-control study of male veterans cared for in the VA’s Sierra Pacific network in 2002-2013, cases were those Veterans with a fracture during the study period. A non-fracture control matched on age and encounter date was randomly selected for each case. We calculated absolute hip and any major fracture risks using VA-ARA and FRAX; calculations did not incorporate DEXA scans. We estimated the odds of fracture associated with a high-risk classification for each tool. Among cases, we compared the sensitivity of the two tools for correctly classifying patients as high risk.

Results

Among a total of 8,742 patients, the mean (SD) age was 67.0 (11.1). The VA-ARA correctly classified 40.1% of fracture patients as high risk (32.9% and 34.5% for the hip and any major fracture rules, respectively). The FRAX classified 17.6% correctly (17.6% for hip and 0.2% for any major fracture). Patients classified as “high risk” using VA-ARA were 34% more likely to have a fracture (95% CI 23-47%, p<0.0001) and patients classified as “high risk” using FRAX were only 16% more likely to have a fracture (95% CI 4-31%, p=0.0081) compared to non-high risk.

 

Conclusions

Results show that absolute fracture risk estimation with the VA-ARA is more predictive of a first fracture than FRAX when risk factors are collected passively as a routine part of healthcare operations. Decision-support tools based on VA-ARA may improve early identification and care of males at risk for fracture.

 

Nothing to Disclose: AS, JL, CLS, JH, JM, JN, SM, JC

16274 20.0000 SUN-0265 A Comparing Fracture Absolute Risk Assessment Tools: An Osteoporosis Clinical Informatics Tool to Improve Identification and Care of Males at High Risk of First Fracture 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Gherardo Mazziotti*1, Filippo Maffezzoni, MD1, Mauro Doga1, Lorenz C Hofbauer2, Robert Adler3 and Andrea Giustina1
1University of Brescia, Brescia, Italy, 2Technical Univ Med Ctr, Dresden, Germany, 3McGuire Veterans Affairs Medical Center, Richmond, VA

 

Glucocorticoids induce skeletal fragility primarily by an inhibition of bone formation with impairment of bone quality and also induce abnormalities of glucose metabolism with the occurrence of diabetes mellitus in about 25-30% of patients exposed to glucocorticoid excess. Over the last few years, there has been experimental evidence for the existence of cross-talking between bone remodeling and glucose metabolism with uncarboxylated osteocalcin postulated to play a central role in the control of fuel metabolism via improvement of insulin secretion and sensitivity. Whether this experimental model can be translated to humans is still debated, and it is also unclear whether the modulation of bone turnover by anti-osteoporotic drugs may lead to changes in glucose metabolism. In this prospective observational study, we investigated whether treatment of glucocorticoid-induced osteoporosis (GIO) with bipshosphonates or teriparatide may influence glucose homeostasis in patients exposed to chronic glucocorticoid excess. We prospectively studied 111 patients (70 F, 41 M, median age 70, range: 55-89) attending an outpatient bone clinic, chronically treated with glucocorticoids for more than 6 months. Forty-six patients were treated with bisphosphonates, 33 patients with teriparatide (all taking also calcium and vitamin D3 at recommended doses) and 32 patients performed treatment calcium and vitamin D alone. The patients were evaluated for bone turnover and glucose metabolism during a 12-month follow-up. The primary end-point of the study was the change of glycated hemoglobin (HbA1c) after 12 months of treatment with bisphosphonates or teriparatide. In patients treated with teriparatide, but not in those treated with bisphosphonates or calcium and vitamin D alone, a statistically significant (p=0.02) decrease in serum HbA1c was observed during the 12-month follow-up. The change in HbA1c during 12-month treatment with teriparatide was not significantly correlated with the changes in ß-CTX and osteocalcin. The change in serum HbA1c during teriparatide treatment was significantly (p=0.01) greater in patients with diabetes as compared to those without diabetes, although in most cases the decrease of serum HbA1c was of relatively limited  but in about half of patients (6 out 13 cases) the decrease was ≥ 0.5%. Notably, in some patients the improvement of glucose homeostasis was concomitant with implementation of anti-diabetic treatments and/or decrease of glucocorticoid dosages. In conclusion, our study showed that currently used bone active drugs may produce limited effects on glucose metabolism in patients exposed to glucocorticoid excess. Interestingly, the bone anabolic drug teriparatide was shown to induce some improvement in glucose homeostasis in patients with diabetes and GIO.

 

Disclosure: LCH: Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Merck & Co., Advisory Group Member, Amgen. Nothing to Disclose: GM, FM, MD, RA, AG

14356 21.0000 SUN-0266 A Outcome of Glucose Homeostasis in Patients with Glucocorticoid-Induced Osteoporosis Undergoing Treatment with Bone Active-Drugs 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Elaine Yun Ning Cheung*1 and Ching-Lung Cheung2
1United Christian Hospital, Hong Kong, Hong Kong, 2The Univ of Hong Kong, Hong Kong

 

Preliminary data seemed to support the inverse relationship between non-alcoholic fatty liver disease (NAFLD) and osteoporosis. More advanced fatty liver disease might be associated with lower bone mineralization. However, this relationship had not been studied in US adult population. We examined this association based on epidemiological data taken from the third NHANES database (1988-1994). This sample comprised 14,797 subjects between 20-74 years old. They all received ultrasound examination. 3 broad-accredited radiologists specialized in hepatic imaging reviewed the ultrasound video images. Subjects were excluded if they did not have valid femoral neck (FN) bone mineral density (BMD) measurement (n=2545), taking excessive alcohol (>21 and >14 drinks/week respectively for men and women, n=569), transferrin saturation ≥50% (n=465), being hepatitis B or C carrier (n=428). Another 656 subjects were excluded since they had missing data in the multivariate model. BMD was measured using Hologic QDR-100 X-ray bone densitometer. Subjects with NAFLD were further categorized into having different degrees of steatosis (mild, moderate or severe). Among the 10,655 subjects involved in the final analysis, 3853 of them had NAFLD. 34.6% and 37.9% of subjects with and without NAFLD had osteopenia, respectively. On the other hand, 3% and 3.4% of subjects with and without NAFLD had osteoporosis, respectively. After adjusting for age, sex, race and ethnicity (simple model), having NAFLD made an individual less likely to have osteopenia (OR=0.645; 95% CI: 0.56-0.743, P<0.001) or osteoporosis (OR=0.657; 95% CI: 0.477-0.904, P=0.011). This association became insignificant after further adjustment for body mass index, education, physical activity, smoking and drinking status in the full model. The OR became 0.931 for osteopenia (95% CI: 0.791-1.096, P=0.384) while OR for osteoporosis was 1.194 (95% CI: 0.815-1.749, P=0.357). Analysis stratified by sex showed similar results. The results were also similar when the group without NAFLD was compared to that with severe steatosis. For the subjects with NAFLD, fibrosis score was positively associated with FN BMD in the simple model (p<0.001) but this association became insignificant after further adjustment in the full model. We concluded that FN BMD was not associated with either ultrasound-diagnosed NAFLD or fibrosis score based on this US adult database.

 

Nothing to Disclose: EYNC, CLC

14405 22.0000 SUN-0267 A Non-Alcoholic Fatty Liver Disease and Femoral Neck Bone Mineral Density 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Yvonne Ying-Ting Chow*1, David Scott2, Peter Robert Ebeling3, Dawn Dore4 and Graeme Jones4
1Western Health, Melbourne, Australia, 2The University of Melbourne, Melbourne, Australia, 3Monash University, Clayton, Victoria, Australia, 4University of Tasmania, Hobart, Australia

 

Introduction

Sarcopenia and osteoporosis have been studied independently as a risk factor for fractures but there is few data addressing the emerging concept of “sarco-osteoporosis”. The majority of fractures occur in patients above the World Health Organisation (WHO) threshold for osteoporosis and so assessment of risk factors other than bone mineral density (BMD) is important. Sarco-osteoporosis may be a clinical predictor of fracture risk.

Methods

Data from the Tasmanian Older Adult Cohort Study (TASOAC) were used to evaluate the association between sarco-osteoporosis and fracture incidence. 628 participants aged 60 years and above (mean ± SD 68.3 ± 5.5yr; female 48%) were categorised into four groups: controls, osteoporotic/osteopenic only (OP), sarcopenic only (SP) and sarco-osteoporotic/osteopenic (SOP). BMD and appendicular lean mass (ALM) was determined by Dual-Energy X-ray Absorptiometry (Hologic, USA). Hand grip strength (HGS) was measured with a dynamometer (North Coast™). OP was defined according to WHO diagnostic criteria. We assessed muscle mass (residuals of linear regression of ALM on height and total body fat [ALM-R]) and strength (HGS) definitions of sarcopenia independently. Participants in the lowest 20% of sex-specific distributions for ALM-R or HGS were classified as sarcopenic. 487 (78%) participants self-reported fracture data for 4.5 ± 0.4yr. Adjusted binary logistic regression analyses compared likelihood for incident fractures for OP, SP and SOP compared to controls.

Results

Using ALM-R and HGS to define sarcopenia, respective prevalence was controls (40% and 37%), OP (37% and 35%), SP (11% and 13%) and SOP (13% and 15%). Participants with SOP were generally older, more likely to be female and had a lower body mass index (BMI) and serum vitamin D levels (all P < 0.05). 50 (10%) participants reported one or more fractures during follow-up. Increased odds ratios (OR) for incident fractures were observed for SP (OR; 95% CI 4.2; 1.6 – 11.3) and SOP (4.9; 1.8 – 13.3) using the HGS definition, but not the ALM-R definition, after adjustment for age, gender, BMI, diabetes and daily activity.

Conclusion

In community-dwelling older adults, both sarcopenia and sarco-osteoporosis defined by muscle strength, but not muscle mass, are associated with an almost five-fold increase in fracture incidence over 4.5 years.

 

Disclosure: PRE: Researcher, Amgen, Researcher, Novartis Pharmaceuticals, Researcher, Merck & Co.. Nothing to Disclose: YYTC, DS, DD, GJ

15408 23.0000 SUN-0268 A “Sarco-Osteoporosis” Is a Predictor of Fracture Risk in Community-Dwelling Older Adults over 4.5 Years 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Dragana Jokic*1, Seth Weaver1, Sri Prakash L Mokshagundam2 and Sathya S Krishnasamy3
1University of Louisville, Louisville, KY, 2Robley Rex VA Medical Center, Louisville, KY, 3Univ of Louisville, Louisville, KY

 

Obesity and its complications are a major health care burden in the US for which bariatric surgery is an established and effective treatment. Osteoporosis occurs more often following bariatric surgery, however, and there is a higher fracture risk. Poor bone quality has been attributed to bone marrow fat, adipokines, altered diet and activity. While bone health in women after bariatric surgery has been studied extensively, there is less information about men.  We conducted a retrospective analysis of 139 men and women who underwent ROUX-NY gastric bypass surgery at the Robley Rex VA Medical Center between 2000 and 2010.  Results for 12 men and 12 women who had at least two bone density scans (Hologic densitometer) following the surgery (2-6 years apart) were reviewed.  We hypothesized that the amount of weight lost after bariatric surgery would predict bone loss, and that men would lose less bone than women because bariatric surgery is followed by an increase in testosterone levels in men.  We also reviewed serum levels of 25- OH vitamin D and PTH although patients were supplemented with vitamin D2 or D3 and calcium intermittently.  The mean age of the men was 58±8 years,  and their  preoperative BMI  was 47.6  ±5  kg/m2 while women were age 53 ± 8  years with a BMI of 45±6  kg/m2.Percent excess body weight loss at 5year post surgery was slightly greater (p <  0.34 ) in men(66.5±6.8 vs 57.2±6.5) than women though not significant. Overall, the decline in bone mineral density (BMD) in the hip was greater (p<0.001) than in lumbar spine, and was slightly, but not significantly greater in men than women (4.19±0.87 vs 3.01±0.79 %/yr).  Likewise, there was a slightly greater decrease in the LS spine BMD in men (1.19±0.73 vs 0.52 ± 0.7 %/yr).Four women (1LS/3hip) and 1 man (hip) developed osteoporosis. Weight loss at 1 year after surgery was a significant predictor of bone loss for women (R2=0.432) but not men. PTH levels (59.2±17.4 vs 49.2 ±16.4 pg/ml) as well as 25-OH vitamin D concentrations (23.5 ± 15.1 vs 19. 1 ± 7.1 ng/ml) were slightly higher in men than women.In conclusion, as in previous studies using DEXA, we found a greater decline in the hip BMD than in the spine, which contrary to our hypothesis, tended to be greater in men than women who also lost more weight.  We also noted that the rate of bone loss was predicted by excess body weight loss in women suggesting a link between fat metabolism and bone. A larger sample will be more informative.

 

Nothing to Disclose: DJ, SW, SPLM, SSK

16483 24.0000 SUN-0269 A Gender Differences in Bone Loss Among Veterans Who Underwent Bariatric Surgery 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Maria da Glória Tavares*1, Tassiane Alvarenga1, Ricardo Paranhos Moreira2, Daniel Fiordelisio de Carvalho3, Larissa Garcia Gomes2, Guiomar Madureira3, Berenice B Mendonca4 and Tania A Bachega3
1Laboratório de Hormônios e Genética Molecular-LIM42, Disciplina de Endocrinologia, Hospital das Clínicas, FMUSP, Sao Paulo, Brazil, 2School of Medicine, Sao Paulo University, Sao Paulo, Brazil, 3Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 4Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular LIM/42, Disciplina de Endocrinologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

 

Introduction: Patients with 21-hydrolylase deficiency (CAH) are undergone to long-term glucocorticoid (GC) exposure and increased prevalence of low bone mineral density (BMD) has been reported. There are controversies regarding the correlation among cumulative GC doses, time of therapy and BMD. Despite the use of weight-adapted GC doses, some patients appear more sensitive to GC action than others. In the normal population, genetic factors influence the BMD, and the BclI variant of the GC receptor gene (NR3C1) is associated with low BMD. Objectives: to determinate the prevalence of low BMD in a CAH series followed in a single center and to investigate if GC polymorphisms influence the BMD. Patients and Methods: Data of 44 adult patients (26 SW/18 SV, 33 Fem) with a mean age of 28.7±6 yrs were retrospectively evaluated. Patients received cortisone acetate during growth period and afterwards, dexamethasone 0.27±0.11 mg/day in tablets or elixir. Salt wasters also received fludrocortisone 50±25 mg/day. The mean of duration of GC therapy was 26.3±7 yrs. Lumbar spine and left femur BMD were evaluated by DXA and low BMD was considered as Z score ≤-2. The NR3C1 alleles (BclI, A3669G, N363S, ER22/23EK) were genotyped through sequencing. Association analyses of Z-scores with clinical characteristics and NR3C1 alleles were carried out using nonparametric tests. Results: Nine (20%) patients had Z-score ≤-2: 7 were females and 4 salt wasters. There was no significant difference between patient groups with low and normal BMD regarding age by the time of DXA, gender role, clinical form, duration of therapy (p>0.05 for all comparisons). Patients with low BMD presented significantly lower body mass index (BMI) than those with normal BMD, median 23 kg/m2 (25th:21/75th:23.5) and 28 kg/m2 (25th:25/75th:32), respectively, p<0.004. Among NR3C1 variants, only the BclI and A3669G alleles were in Hardy-Weinberg equilibrium, and were found in 48% and 18% of patients, respectively. Frequencies of Z-score ≤-2 did not differ between A3669G and wild-type (wt) carriers nor between BclI and wt carriers (p>0.05). Moreover, the BclI allele, which increases the NR3C1 transactivation, was observed in 66% and 43% of patients with low and normal BMD, respectively. Conclusions: in this CAH series receiving a homogeneous long-term GC regime, a high prevalence of low BMD was observed earlier in life, which was not modulated by NR3C1 variants. Only the BMI appeared to influence patients from bone loss.

 

Nothing to Disclose: MDGT, TA, RPM, DFDC, LGG, GM, BBM, TAB

16644 25.0000 SUN-0270 A Analysis of Predictive Factors for Low Bone Mineral Density in Young Adults with 21-Hydroxylase Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Francisco J A de Paula*1, Iana Mizumukai de Araujo2, Carlos Ernesto Garrido Salmon3 and Marcello Henrique Nogueira-Barbosa4
1Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil, 2Medical School of Ribeirão Preto, USP, Ribeirao Preto, Brazil, 3Ribeirão Preto Medical School, USP, Ribeirao Preto, Brazil, 4Ribeirão Preto Medical School, USP, Ribeirao Preto, Brazil

 

Introduction

The adipose tissue has diverse functional faces depending on its location and amount of stored fat. While obesity has detrimental effects on intermediary metabolism, it has positive influence on bone mass maintenance. Bone marrow fat (BMF) has a negative association with bone mineral (BMD) in several conditions (e.g., anorexia nervosa, aging, glucocorticoid therapy). However, the relationship of BMF and bone mineral density (BMD) in DM2 has scarcely been studied. In the present study, we have investigated BMD, bone remodeling and BMF in a group of patients having at least 5 years of DM2 diagnosis. The results were compared to data from a control group matched by age, gender, height weight and BMI.

Material and Methods

The study comprised two groups: DM2 (n=23, 10M/13F,  53±9years; 88,7± 16,4 Kg; 1,61±0,07m and 34,2± 7,4Kg/m2) and C (n=28 , 9M/19F,  51±9 years; 81,6± 15,0 Kg; 1,64±0,10m and 30,1± 3,2Kg/m2). The subjects of both groups were submitted to blood collection for glucose, HbA1c, triglycerides, cholesterol, HDL-cholesterol, 25-OHD, osteocalcina ‘and carboxyterminal telopeptide of type 1 collagen. BMD was assessed in lumbar spine, proximal femur and 1/3 radius.  Total body, android and gynoid fat as well as lean mass were estimated by DXA. 1-H magnetic resonance spectroscopy (1,5 T) was used to evaluate BMF.

Results

Diabetic patients showed higher HbA1c (DM2=9,7±2,8; C=5,3±0,9 %; p<0,05) and serum levels of glucose  (DM2=173±88; C=86±19 mg/dL; p<0,05)  than C group.  BMD was similar in all sites in the two group (e.g., L1-L4: DM2=1.069±0,138; C=0,974±0,148 g/cm², femoral neck= DM2=0,889±0,164; C=0,808±0,141 g/cm², total hip= DM2=1,042±0,173; C=0,973±0,108 g/cm²). Additionally, there was no significant difference in android (DM2= 3322±923; C=2771±937 g) and gynoid fat (DM2=5095±1820; C= 5189±1787 g) as well in BMF (DM2: 59,8±12,5; C=49,8±12,4%) between groups . BMD was not associated with body weight in both groups (DM2: r=0,30 and p=0,15; C: r=0,18 and p=0,36). Also, there was no association between BMD with android fat (DM2: r=0,24; p=0,25; C: r=0,08; p=0,65), HbA1C (DM2: r=0,12; p=0,56; C: r=0,39; p=0,07) and triglycerides (DM2: r=0,12; p=0,61; C: r=0,01; p=0,93), neither in DM2 nor in C group. Additionally, there was no relationship between BMF in L3 with body weight (DM2; r=-0,14; p=0,63; C=0,10; p=0,69) and BMD (DM2: r=-0,47; p=0,14; C=-0,31; p=0,21).

 Conclusions

Lipid accumulation, in peripheral and especially in central fat deposits, leads to a low-grade chronic inflammation state and lipid overflow to other tissues. Fat storage in muscle and liver is associated with insulin resistance and local functional disturbance. Type 1 diabetes mellitus is a classical cause of bone loss and recent studies showed increased BMF in DM1. The present study supports previous data showing that DM2 patients have normal bone mass. Additionally, they do not have increased bone marrow fat.

 

Nothing to Disclose: FJAD, IMD, CEGS, MHN

16722 26.0000 SUN-0271 A Vertebral Marrow Fat Is Not Associated with Bone Mass in Type 2 Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Adriana Lelis Carvalho*1, Marcello Henrique Nogueira-Barbosa2, Carlos Ernesto Garrido Salmon3 and Francisco J A de Paula4
1Medical School of Ribeirão Preto, USP, Ribeirão Preto, Brazil, 2Ribeirão Preto Medical School, USP, Ribeirao Preto, Brazil, 3Ribeirão Preto Medical School, USP, Ribeirao Preto, Brazil, 4Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil

 

Introduction

The adipose tissue has diverse functional faces depending on its localization and amount of stored fat. Currently, evidences have revealed an important interactive role between bone and adipose tissue in the regulation of energy and mineral metabolism. Consequently, a great interest emerged in the investigation about the metabolic network involving bone and adipose tissue on diabetes mellitus and osteoporosis. One of the less well known complications of T1-diabetes mellitus (DM1) is bone loss which occurs in humans and animal models. Bone marrow fat (BMF) has a negative association with BMD in several conditions (e.g., anorexia nervosa, aging, glucocorticoid therapy). However, the relationship of BMF and bone mineral density (BMD) in DM1 has scarcely been studied. In the present study we have investigated the BMD, bone remodeling and BMF in group of patients having at least 5 years of DM1 diagnosis. The results were compared to data from a control group matched by age, gender, height and weight.

Material and Methods

The study comprised two groups: DM1 (n=8M/3F, 29±6 years; 72±12 Kg; 1,70±0,07m and 24,8±3,7Kg/m2) and C (n=8M/3F,  29±3 years; 69±12Kg; 1,72±0,04m and 23,4±3,6Kg/m2). The subjects of both groups were submitted to blood collection for glucose, HbA1C, triglycerides, cholesterol, HDL-cholesterol, 25-OHD, osteocalcin, carboxyterminal telopeptide of type 1 collagen. BMD was assessed in lumbar spine, proximal femur and total body.  1-H magnetic resonance spectroscopy (1,5 T) was used to evaluate BMF.

Results

Diabetic patients showed higher HbA1C and serum levels of glucose than C group.  BMD was similar in all sites in the two group (L1-L4: DM1=0,991±0,117 vs C=0,999±0,157 g/cm2; femoral neck: DM1=0,938±0,144 vs C= 0,955±0,193 g/cm2;  total hip: DM1=1,092±0,149 vs C=1,044±0,197 g/cm2;  total body: DM1= 1,230±0,118 vs C= 1,173±0,149 g/cm2). Also, there was no significant difference in android (DM1=1,2±0,5 vs C= 1,3±0,5 Kg) and gynoid fat (DM1=2,9±0,9 vs C=3,1±0,8 Kg) as well in BMF (DM1=20±5% vs C=27±8% fat/water+fat) between groups. Furthermore, there was no association between lumbar spine BMD with android fat (DM1: r=-0,08;p 0,80 vs C: r=0,34;p 0,31), HbA1C (DM1: r=-0,29;p 0,38 vs C:r=-0,11;p 0,76) and triglycerides (DM1: r=0,47;p 0,14 vs C: -0,25;p 0,47), neither in DM1 nor in C group. Additionally, there was no relationship between BMF in L3 with lumbar spine BMD (DM1: r=0,38;p 0,351 vs C: r=0,03;p 0,91), android fat (DM1: r=-0,05;p 0,89 vs C: r=0,61;p 0,06) and body weight (DM1: r=-0,03;p 0,92 vs C: r=0,52;p 0,12).

Conclusion

Our preliminary results suggested the well-nourished DM1 patients have normal bone mineral density. In accordance, we did not observe increased bone marrow fat in this group of patients. Further study is necessary to verify if bone marrow fat increase is related to catabolic status in these patients.  

 

Nothing to Disclose: ALC, MHN, CEGS, FJAD

16850 27.0000 SUN-0272 A Bone Mineral Density and Bone Marrow Fat in Well-Nourished Type 1 Diabetes Mellitus Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Thanh P Ho*1, Jacob Hattenbach2, Joyce D Linderman2, Sheila Smith2, Louis Simchowitz2 and Francesco S. Celi3
1David Geffen School of Medicine at UCLA, Los Angeles, CA, 2NIH, Bethesda, MD, 3Virginia Commonwealth University, Richmond, VA

 

Introduction: Although epidemiologic data indicate that body mass is associated with reduced risk for fractures, obesity is a state of chronic inflammation and inflammatory mediators have deleterious effects on bone formation. However, it is unclear how inflammation contributes to bone density in healthy individuals with varying levels of adiposity.

Methods: Study volunteers with body mass index (BMI) in the range of 19.0-45.0 kg/m2were recruited to undergo laboratory tests, anthropometric and body composition assessment. Diabetes mellitus, cardiovascular disease, or chronic use of medications was considered exclusion criteria for participation in the study. Fat mass and bone mineral density (BMD) were assessed with dual-energy X-ray absorptiometry (DXA). Subjects were men and premenopausal women between 25 to 45 years old. Linear regression was performed after assessing statistically significant Pearson correlations between bone density and measures of adiposity, adipokines, cytokines, and markers of inflammation.

Results: Ninety-four participants age 36.3±6.0, of which 49 were female (52.1%), were studied. Mean weight was 90.0±21.5 kg, and fat mass was 33.4±15.2 kg. Mean BMI was 30.5±6.9 kg/m2; 69.1% were overweight or obese (BMI greater or equal to 25 kg/m2). Trunk, pelvis, spine, and total BMD were significantly associated with multiple measures of adiposity (all P <0.05). Adiponectin levels correlated positively with total Z score (r=0.221, P<0.04). Conversely, C reactive protein (CRP) was inversely associated with total Z score (r = -0.208, P<0.05). With sex-adjusted total Z score, adiponectin and CRP maintained a significant association (positive and negative, respectively) independent of BMI or fat mass (all P<0.04).

Discussion: Our data indicate that in a population of otherwise healthy, non-elderly adults, the state of inflammation plays a role in the maintenance of bone density independent of the state of adiposity.

 

Nothing to Disclose: TPH, JH, JDL, SS, LS, FSC

14206 28.0000 SUN-0273 A Effects of Inflammation and Adiposity on Bone Density in Non-Elderly Adults 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Rajaa Nahra*1, Lisa Ceglia2, Jessica K. Paulus3 and Christine A Wanke4
1Tufts Clinical and Translational Science Institute (CTSI), Boston, MA, 2Tufts Medical Center, Boston, MA, 3Tufts University Sackler School of Graduate Biomedical Sciences, Boston, MA, 4Tufts University School of Medicine, Boston, MA

 

 

Background: Among HIV-infected adults, the prevalence of osteoporosis is higher than in HIV-uninfected individuals. Adults living with HIV also have an increased risk of developing an adipose redistribution syndrome (HARS) and muscle loss. Data examining the relationships between bone, fat, and muscle mass in patients infected with HIV are scarce.

 

Objective: We examined the association between total body bone mineral density (BMD) and measures of central and appendicular fat and lean body mass in men and women infected with HIV.

Methods: HIV-positive women (n=153; mean age 43) and men (n=466; mean age 46) were evaluated for total body BMD by dual energy x-ray absorptiometry (DXA), anthropometric indices of central (waist circumference) and appendicular fat (triceps skin-fold), and DXA-derived measures (trunk-to-extremity fat ratio, trunk fat, appendicular fat, and appendicular lean body mass). Multivariable linear regression assessed the relationship between total body BMD and each of the body composition measures. Analyses were stratified by sex.

Results:Approximately 50% of the women and 25% of the men were Black. Trunk-to-extremity ratio was inversely associated with total body BMD in men (β=-0.02, p=0.01), but not women, after multivariable adjustment. Individual measures of central and appendicular fat by anthropometry and DXA were inversely associated with baseline total body BMD in men (p for all <0.05 except appendicular fat by DXA, p=0.1), but not women (β=0.02, p=0.2), after multivariable adjustment. Appendicular lean mass by DXA was positively associated with total body BMD in men (β=0.004, p<0.001), and there was a similar trend in the women but did not reach statistical significance at the 0.05 level.

Conclusions: Higher overall fat mass and lower lean mass are associated with lower total body BMD in men infected with HIV, but not women. Future studies with larger numbers of women infected with HIV are needed to confirm these findings.

 

Nothing to Disclose: RN, LC, JKP, CAW

14295 29.0000 SUN-0274 A Associations Between Body Adiposity and Bone Health in People Living with HIV 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0246-0274 4786 1:00:00 PM Osteoporosis-Risk Factors and Assessment Poster

Edwin Chng*
Tan Tock Seng Hospital, Singapore, Singapore

 

Introduction: Persistent eucalcemic elevation of parathyroid hormone (PTH) after curative parathyroidectomy for primary hyperparathyroidism is not uncommon.

Clinical case: A 50-year old lady presented with recurrent abdominal pain and urinary tract infection secondary to renal calculi. Initial tests were consistent with primary hyperparathyroidism: raised serum calcium level (3.08 mmol/L (RR: 2.15-2.58) with a corresponding raised PTH (19.1 pmol/L (RR: 0.8-6.9)), and borderline low serum phosphate level (0.8 mmol/L (RR: 0.8-1.6)). Renal panel was normal. Pre-operative localization detected a sestamibi-avid lesion in the right lower thyroid lobe. She underwent right parathyroidectomy and histopathology of the resected tumour was consistent with a parathyroid adenoma. No intraoperative PTH measurement was made. 

Post parathyroidectomy, her calcium levels normalized (2.21-2.50 mmol/L) but her PTH levels did not. Her vitamin D level was checked and noted to be low at 15 ug/L (RR: >30). Despite adequate vitamin D replacement, the patient had persistent eucalcemic elevation of PTH (7.9-9.0 pmo/L) up to 4 months. However, subsequent PTH levels normalised and she remained normocalcemic.

Discussion: In two recent studies of 161 patients (Lang BH et al) and 310 patients (Carsello CB et al), 50% and 21% of patients had at least 1 elevated PTH within the first 2 years of follow up respectively. In the study by Lang et al, advanced age, low 25(OH)D concentrations, high 10 min intraoperative PTH and high postoperative PTH were all independently associated with elevated PTH at 6 months. In the study by Carsello et al, greater BMI, high preoperative PTH concentrations and low 25(OH)D concentrations were associated with elevated PTH at 6 months. Recurrence was similar in those with or without elevated PTH at 6 months in both studies. 

In another extensive literature review, it was seen that 9-62% of patients could have eucalcemic elevation of parathyroid hormone postoperatively. This elevation did not corroborate with surgical failure. Predictive factors for this included preoperative lower 25(OH)D concentrations, high PTH concentrations and high bone turnover markers. Potential mechanisms include concomitant vitamin D deficiency, hungry bone syndrome and PTH resistance.

The presence of elevated PTH with low 25(OH)D concentrations suggest a possible benefit of postoperative calcium and vitamin D supplementation but there are no randomised controlled trials done to prove this. In my patient, vitamin D replacement helped to normalise PTH levels in the long term.

Conclusion: Eucalcemic parathyroid elevation after parathyroidectomy does not necessarily imply surgical failure or chances of recurrence. In fact this phenomenon has been reported in the literature in up to 50% of patients. Vitamin D replacement may help to normalise the PTH levels in the long term.

 

Nothing to Disclose: EC

11198 1.0000 SUN-0211 A Eucalcemic Parathyroid Hormone Elevation after Parathyroidectomy for Primary Hyperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Leila Pedroso De Paula*1, Rosa Franzen Moll2, Maria Tereza Sanseverino3 and Mauro Antonio Czepielewski4
1Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil, 2Hospital São Lucas PUC, Porto Alegre, Brazil, 3Hospital de Clínicas de Porto Alegre, Porto alegre, Brazil, 4Faculdade de Medicina UFRGS, Porto Alegre, Brazil

 

Background: The classification of various forms of hypophosphatemic rickets has been simplified by discovery of the central role that fibroblast growth factor 23 (FGF23) plays in the pathogenesis of the disease. In the algorithm for the investigation of a child presenting with the clinical features of rickets the use of serum FGF23 as a diagnostic tool remains limited to those with increased renal tubular phosphate loss. However, its measurement would be particularly appropriate as a diagnostic aid in patients with hypophosphatemic rickets of uncertain origin, even those without hyperphosphaturia.

 Clinica case: A 5- month old boy came to emergency room with failure to thrive and respiratory distress. His thorax X-ray showed seven broken costal arch and he had to go to mechanical ventilation because of an instable thorax and a viral pulmonary infection. He had widening of epiphyseal plates and pain to limb mobilization. Initial tests were consistent with hypophosphatemic rickets without hiperphosphaturia: very low phosphate concentration (0.3 mg/dl, n 4.5 to 6.7), normal calcium levels (9.5 mg/dl, n 9.0 to 11.0), markedly high serum alkaline phosphatase activity (1455 u/l, n < 462), abnormally normal PTH levels (20) and 1,25 dihydroxyvitamin D levels (46.8, n 16-65), normal creatinine (0,1) and unexpected very low 24hr urinary phosphate secretion was found(2 mg/l). Additional X-ray revealed fractures in both legs, arms and a very poor mineralized skeleton.

In his past history he had been an adequate gestational age child of a non consanguineous couple. He was diagnosed as having cow’s milk allergy when he was 1 month old and had received an amino acid based infant formula, a proton pump inhibitor omeprazole and antacids, that the parents used over the counter trying to stop his cry of pain. His mother was also vitamin D deficient (7, n > 30) and he was breast fed during a month.

Considering the failure to thrive, the other reasons of reduced dietary phosphate absorption and the hypophosphaturia it was believed initially that he had an FGF23-independent form of hypophosphatemic rickets. However, because of his impressive severe condition he had the FGF23 sent to measurement at Mayo Clinic and it was increased (405 ru/ml, n < 230).

The patient was treated by administration of Joulie's solution, calcium and calcitriol as well as iron and D vitamin. Since the serum phosphate increased, the phosphaturia did it also.

After dramatic days of “hungry bone syndrome”, when he had to receive calcium gluconate IV to avoid severe hypocalcaemia, he improved clinical, radiological and metabolic condition as well.

Conclusion: FGF23 measurement was diagnostic in a patient with hypophosphatemic rickets of a mix origin including nutritional, absorptive and FGF23 dependent. This is the first case demonstrating the possible role of FGF23 as a diagnostic tool even in hypophosphaturic hypophosphatemic rickets.

 

Nothing to Disclose: LPD, RFM, MTS, MAC

14222 2.0000 SUN-0212 A Severe Hypophosphaturic Hypophosphatemic Rickets with High FGF23 Levels 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Abdullah Abdulruhman Aljasser*
Prince Sultan Military Medical City, Riyadh, Saudi Arabia

 

Hereditary 1α25 dihydroxy Vitamin D resistant rickets (HVDRR) is a rare form of an autosomal recessive disorder.  Children with HVDRR present with a severe form of rickets in the second half of the first year of life and a variable degree of alopecia.

Biochemistry profile in HVDRR shows low calcium and phosphate with elevated alkaline phosphatase parathyroid hormone and 1α25 dihydroxy Vitamin D. High dose calcium therapy has shown clinical improvement and resolution of clinical and radiological rickets.  This means that optimal calcium level can tend to shown normal mineralization independent of Vitamin D receptor activity.

Case Study

We report a 4 years old girl of second degree consanguineous parents with severe rickets and alopecia.

Diagnosis of VDRR is based on clinical and biochemical bone profile including low calcium, phosphate with elevated alkaline phosphatase, parathyroid hormone and 1α25 dihydroxy Vitamin D.  The diagnosis was further confirmed by detecting abnormal homozygous mutation c.217c>T (P.Arg 73 term) in the VDR gene.

She was treated with intensive intravenous calcium infusion at a dose of 1.5 gm/m2 for one year.  Her serum calcium normalized within 3 days, and her parathyroid hormone became normal within two months.  She was able to walk for the first time in her life after three months of daily IV calcium treatment.  Her radiological findings were normalized after 9 months of daily IV calcium where her bone density improved and her fractures were healed completely.

Conclusion

Intensive intravenous calcium infusion for a duration more than 9 months at a dose 1.5 gm/ m2/ day is successful in healing the bones and restoring the milestones and growth in patients with severe rickets due to hereditary 1α25 dihydroxy Vitamin D resistant rickets (HVDRR).

 

 

Nothing to Disclose: AAA

11200 3.0000 SUN-0213 A Restoration of Normal Mile Stones and Growth with Intensive Intravenous Calcium Infusion Inpatient with Hereditary 1á25 Dihydroxy Vitamin D Resistant Rickets (HVDRR) Due to Homozygous Mutation C.217c>T (P.Arg 73 term) in the VDR Gene 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Nina Le* and Stephen G Rosen
Pennsylvania Hospital, Philadelphia, PA

 

Severe Electrolyte Abnormalities after Zoledronic Acid Treatment for Osteoporosis.   Nina P. Le and Stephen G. Rosen.  Pennsylvania Hospital and the University of Pennsylvania Health System.  Philadelphia, PA 19107.

Background:  Zoledronic acid (ZA) is used for the treatment of osteoporosis and Paget’s disease. The most common and severe known side effects include atypical bone fractures, osteonecrosis of the jaw and hypocalcemia. We explore a case of severe hyponatremia, hypokalemia, hypocalcemia, and hypophosphatemia following ZA treatment.

Clinical case: A 57-year-old woman with a history of osteoporosis, panhypopituitarism after transsphenoidal hypophysectomy for a pituitary adenoma, hypertension, and a cerebrovascular accident in the past received intravenous ZA for glucocorticoid-induced osteoporosis.  Previous treatment with an oral bisphosphonate was discontinued secondary to gastrointestinal intolerance.  Five days after receiving intravenous ZA 5 mg, she presented to the emergency department with dizziness, generalized weakness, nausea, vomiting, and subjective fevers. Laboratory  testing revealed serum levels of sodium (104 mM; normal range 136-145 mM), potassium (2.6 mM; normal range 3.5-5.1 mM), creatinine (0.47 mg/dL; normal range 0.60-1.10 mg/dL), calcium (8.0 mg/dL; normal range 8.6-10.3 mg/dL), ionized calcium (0.56 mM; normal range 1.03-1.17 mM), magnesium (1.9 mg/dL; normal range 1.7-2.5 mg/dL), phosphorus (1.5 mg/dL; normal range 2.4-4.7 mg/dL) and osmolality (216 mOsm/kg; normal range 275-295 mOsm/kg), respectively.  Her serum creatine kinase concentration was 1196 U/L (normal range 26-140 U/L).  Four months earlier, her laboratory values were all within normal limits. Urine studies revealed osmolality (299 mOsm/kg; normal range 50-1400 mOsm/kg), potassium (17.3 mM) and sodium (11 mM).  She was admitted into the ICU where she was treated with intravenous 3% saline. Her potassium and calcium were aggressively repleted. Additionally, she was started on high dose glucocorticoid replacement. Her serum sodium concentration gradually normalized.  At discharge, all of her serum electrolytes had normalized and have remained normal at outpatient visits.

Conclusion: ZA treatment may cause severe electrolyte abnormalities.  Potential mechanisms include muscle cell damage, excessive hypotonic fluid hydration, or tubulointerstitial nephritis with Fanconi syndrome.

Reference: Torimoto K, Okada Y, Arao T, Mori H, Tanaka Y.  A case of zoledronate-induced tubulointerstitial nephritis with Fanconi syndrome.  Endocr J.  2012; 59:1051-6.

 

Nothing to Disclose: NL, SGR

14276 4.0000 SUN-0214 A Severe Electrolyte Abnormalities after Zoledronic Acid Treatment for Osteoporosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Niyati Narsana*1, Ritu Madan2 and Barbara Mensah Onumah3
1Medstar Washington Hospital Center, Washington, DC, 2National Institutes of Health, Bethesda, MD, 3Washington Hospital Center, Washington, DC

 

Background: Denosumab is a fully human anti-RANKL monoclonal antibody currently approved for use in osteoporosis and as an adjunctive treatment in metastatic bone disease. Hypocalcemia is a common adverse effect of this drug with high grade hypocalcemia as common as 2%. This side effect can be explained by complete inhibition of osteoclast activity in bone. We encountered a patient with denosumab induced severe hypocalcemia who required intravenous calcium for more than a month, thereby raising several questions about appropriate management of such patients.

Case:  A 64-year old female with a recent diagnosis of multiple myeloma presented to her oncologist with complaints of perioral numbness and tingling in hands and feet. On examination, vitals were normal and Trosseau sign was positive. Her past medical history was significant for multiple myeloma that was diagnosed 3 months ago when she had presented with bilateral femoral fractures and was found to be anemic, in renal failure and had several lytic bone lesions. She was treated with intravenous fluids and bisphosphonates at that time with a total calcium level of 8.1 mg/dl three weeks prior to the current presentation. Also she was started on chemotherapy with bortezomib, dexamethasone and lenalidomide at that time. She also received denosumab 120 mg subcutaneously four days prior to this presentation. On labs, her total calcium was found to be 5.2mg/dl, ionized calcium 0.78 mmol/l (reference range 1.12-1.32 mmol/l) with normal kidney function and magnesium levels. Her 25,OH vitamin D level was 11 ng/ml.  In view of severe and acute hypocalcemia, she was hospitalized and started on intravenous calcium as well as oral calcium, calcitriol and Vitamin D2. She received intravenous calcium gluconate at the rate of 6-8g/hour (equivalent to 750-850 mg elemental calcium/hour), oral elemental calcium 3000 mg daily, calcitriol 1 mcg daily and Vitamin D2 150,000 units weekly. Despite aggressive oral treatment, she remained on calcium drip for 5 weeks since any attempts to wean her calcium drip would bring her ionized calcium levels down to the range of 0.8-0.9mmol/l, and she would become symptomatic.   Eventually, she was able to leave the hospital with an ionized calcium of 0.97 mmol/l and corrected calcium of 7.8 mg/dl and asymptomatic.

Conclusions: Denosumab is being increasingly used in management of solid tumors with bone metastases to prevent pathological fractures and neurologic sequelae. In our patient, prior bisphosphonate use and low 25-OH Vitamin D level rendered her more prone to develop hypocalcemia.  One should be aware of the potential of hypocalcemia with this drug and make sure that  patients are not Vitamin D deficient before the administration of denosumab, even if their underlying condition is characterized by hypercalcemia such as Multiple Myeloma.

 

Nothing to Disclose: NN, RM, BMO

11415 5.0000 SUN-0215 A Denosumab Induced Hypocalcemia in Multiple Myeloma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Jessie Teng*1, Sally K. Abell1, Rodney J Hicks2, Michael S Hofman2, Nirupa Sachithanandan3, Penelope McKelvie4 and Richard James MacIsaac3
1St Vincent's Hospital, Fitzroy, Australia, 2Peter MacCallum Cancer Centre, Melbourne, Australia, 3St Vincent's Hospital Melbourne, Australia, 4St Vincent's Hospital, Melbourne, Australia

 

Background

Management of humoral hypercalcaemia of malignancy (HHM) in the setting of renal impairment can be challenging.

 

Clinical Case

A 38 year-old man with a past history of primary hyperparathyroidism, presented with severe hypercalcaemia (corrected calcium 4.50 mmol/L). HHM was confirmed by undetectable serum PTH and elevated PTHrP level of 6.9 pmol/L (N <1.3 pmol/L). Serum 25(OH)-vitamin D level was low. He responded to hydration and intravenous bisphosphonate.  

Abdominal CT revealed a large pancreatic mass and multiple hepatic metastases. Tissue biopsy showed a well-differentiated neuroendocrine tumour (NET), however functional imaging with F-18 fluorodeoxyglucose (FDG) PET/CT and Ga-68 DOTA-TATE (GaTate) PET/CT scans revealed several discordant FDG-avid but non-GaTate avid (FDG+/GaTate-) liver lesions, which are more consistent with poorly differentiated neuroendocrine carcinoma. Given his diagnosis of pancreatic NET and history of primary hyperparathyroidism, MEN-1 mutation was confirmed on genetic testing.

His disease was deemed to be unresectable and he underwent six cycles of carboplatin/etoposide chemotherapy. At this stage, his clinical course was complicated by recurrent hypercalcaemia requiring intravenous pamidronate. Both PTHrP and calcitonin levels remained persistently elevated. Six weeks after his last bisphosphonate infusion, he presented with another hypercalcaemic crisis (serum calcium 4.91mmol/L) and renal failure (eGFR 13mL/min/1.73 m2). Intravenous bisphosphonates were avoided due to significant renal dysfunction; 120mg denosumab was administered. 10 days later, he developed symptomatic hypocalcaemia (serum calcium 1.52mmol/L), requiring three months of intermittent intravenous calcium infusion in addition to high dose oral electrolyte replacement.

Due to his limited therapeutic options for hormonal oversecretion, peptide receptor radionuclide radiotherapy (PRRT) was administered (1st cycle: 5 GBq Yttrium-90-DOTATATE; 2nd cycle: 7.9 GBq of Lutetium-177-DOTATATE). This was complicated by bone marrow toxicity requiring transfusion support. Interestingly, his calcium levels dropped transiently after each cycle of PRRT but currently, two months after his last PRRT treatment, he is maintaining normal serum calcium levels on oral calcium supplementation alone.

 

Clinical Lessons:

1)      Functioning NETs may show marked heterogeneity: functional imaging with both FDG and GaTate PET/CT scans is important in addition to tissue biopsy.

2)      Denosumab can cause severe symptomatic hypocalcaemia, especially in renal impairment and vitamin D deficiency: serum calcium levels should be monitored post-dose.

3)      PRRT is effective in targeting hormone-secreting, GaTate-avid lesions; de-differentiated, FDG-avid tumours have poorer prognosis but respond better to chemotherapy.

 

Nothing to Disclose: JT, SKA, RJH, MSH, NS, PM, RJM

11565 6.0000 SUN-0217 A A Challenging Case of Humoral Hypercalcaemia of Malignancy Due to PTHrP and Calcitonin Co-Secreting Neuroendocrine Tumour 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Baker Machhadieh*1, Manmeet Singh2, Jin Ming3 and Subhash C Kukreja4
1University of Illinois, Chicago, IL, 2University of illinois, 3University of Illinois, 4UIC Section of Endocrinology, Chicago, IL

 

Background: Parathyromatosis is a rare cause of recurrent or persistent hyperparathyroidism after parathyroidectomy. It is described as multiple nodules of benign hyperfunctioning parathyroid tissue scattered throughout the neck, mediastinum, or the arm if autotransplantation has been performed at this site. It’s postulated to arise from three possible etiologies: A low-grade malignancy, overgrowth of embryologic foci of parathyroid tissue and most commonly as postsurgical parathyromatosis due to inadvertent spillage of parathyroid cells during surgical extirpation (Kidney International (2012) 82, 1140)

Case: A 48-year-old AAM on peritoneal dialysis due to ESRD was referred for evaluation of serum PTH level in the 30,000 pg/ml range (normal; 12 to 88 pg/ml). He has past history of three parathyroid-related surgeries. The first surgery was performed in June 2010 for secondary hyperparathyroidism. He underwent parathyroid exploration with excision of 3 parathyroid glands, and autotransplantation of parathyroid tissue to left arm. His PTH level was 3222 pg/ml prior to surgery and decreased to244 pg/ml intra-operatively. Serum calcium decreased from 9.6 mg/dl to 5.6 mg/dl postoperatively. During follow up, serum PTH increased to 6651 pg/ml with normal serum calcium and in December 2011 he underwent wide en bloc excision of left forearm parathyroid tissue. Surgical pathology report confirmed clear margins of the en bloc excision. Postoperatively, his PTH level decreased to 91 pg/ml and he had normal serum calcium.  Six months after the forearm surgery, his serum PTH levels increased to 6900 pg/ml and in July 2012, he underwent resection of right parathyroid gland with a decrease in serum PTH to 755 pg/ml postoperatively.

Patient was referred to Endocrinology in August 2013 for markedly elevated serum PTH levels. Serial dilution of the sample and assay performed in a different laboratory confirmed marked serum PTH elevations. We also tested for interference due to heterophile antibodies and these results were negative. We performed simultaneous measurement of serum PTH from each arm. Serum PTH values in samples drawn from right and left arm showed values of 1278 pg/ml and 26997 pg/ml respectively along with normal serum calcium values. We therefore suspected that there was residual parathyroid tissue present in the left arm despite en bloc dissection of the parathyroid implant. Tc 99m sestimibi scan of the left forearm confirmed the presence of parathyroid tissue in the left antecubital region.  

We therefore conclude that parathyromatosis (infiltration of parathyroid tissue into the muscle) is the likely explanation of residual parathyroid tissue despite en bloc dissection of the forearm implant. In addition, the case illustrates the importance of drawing blood from the non-implanted arm or from both arms simultaneously when variable levels of serum PTH levels are present.

 

Nothing to Disclose: BM, MS, JM, SCK

15135 7.0000 SUN-0218 A Parathyromatosis in a Patient with Forearm Parathyroid Implant. Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Takaaki Murakami*, Takuo Nambu, Yuki Matsuda, Koji Matsuo, Shin Yonemitsu, Shogo Oki and Seiji Muro
Osaka Red Cross Hospital, Japan

 

Background: Pseudohypoparathyroidism (PHP) type II is a very rare disorder. The clinical mechanisms of abnormal PTH signaling in PHP type II remain unclear. Furthermore, it is questionable whether PHP type II should be listed as a disease entity because the results of the Ellsworth–Howard test in some patients with insufficicient PTH secretion, vitamin D deficiency or renal tubular damage have been reported to resemble the PHP type II pattern. 

Clinical case: A woman showed stiffness, numbness and muscle cramps. Laboratory tests revealed mild hypocalcemia (corrected serum calcium level, 8.3 mg/dL; normal range, 8.5–10 mg/dL), normophosphatemia (3.7 mg/dL; normal range, 2.5–4.5 mg/dL), normomagnesemia (2.0 mg/dL; normal range, 1.8–2.6 mg/dL), and the normal serum intact PTH level (41 pg/mL; normal range, 10–65 pg/mL). Her symptoms were gradually exacerbated, and the serum corrected calcium level decreased to 7.7 mg/dL. The 25-hydroxyvitamin D level was 29 ng/mL(normal range, 7–41 ng/mL). The urinary β2 microglobulin and N-Acetyl-β-D-Glucosamidase levels were also normal. She had a history of subtotal thyroidectomy without levothyroxine supplementation. Her surgical history suggested the possibility of secondary hypoparathyroidism; however, the serum intact PTH level and results of the Ellsworth–Howard test led to the diagnosis of PHP type II.

Conclusion: Conducting diagnostic studies, such as the Ellsworth–Howard test and measurements of the serum intact PTH level, is critical for making a definitive diagnosis in patients with hypocalcemia. Although very few cases of PHP type II without insufficient PTH secretion, vitamin D deficiency or renal tubular damage have been reported, this case demonstrates the importance of considering PHP type II in the differential diagnosis of patients presenting with hypocalcemia.

 

Nothing to Disclose: TM, TN, YM, KM, SY, SO, SM

11582 8.0000 SUN-0219 A Should Pseudohypoparathyroidism Type II be Listed As a Disease Entity? a Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Jessica Bihuniak*1, Jane Kerstetter2, Jennifer Brindisi3, Rebecca Sullivan1, Kelsey Mangano4, Sarah Larocque2, Belinda Kotler2, Christine Simpson1, Anna Maria Cusano1, Alison Kleppinger3, Jesse Reynolds1, James Dziura1, Anne Kenny3 and Karl Insogna1
1Yale University, New Haven, CT, 2University of Connecticut, Storrs, CT, 3University of Connecticut Health Center, Farmington, CT, 4Harvard Medical School, Boston, MA

 

Increasing dietary protein is known to increase urinary calcium (UCa), however, the source of this Ca remains unclear. It has been assumed that the skeleton was the principal source of the additional Ca, but studies done over the past two decades using dual stable Ca isotopes found that in the short term, dietary protein significantly improves intestinal Ca absorption and does not increase bone resorption. To clarify the impact of a moderately-high protein diet on BMD, we undertook a randomized, double-blind, placebo-controlled trial in 157 older adults. Subjects received either a 40 g whey protein isolate or an isocaloric maltodextrin control supplement daily for 18 months (mo). BMD (g/cm2) and body composition (kg) were assessed by DXA at baseline (0) and 18 mo in all subjects. GFR (mL/min/1.73 m2) was estimated from creatinine, age, sex, and race in all subjects. 24-hr urine urea (UU, g) and serum IGF-1 (ng/mL) were also measured at 0 and 18 mo in participants who continued to take either supplement for 18 months. Baseline dietary protein intake, determined by a 4-day food record, was 1.06-1.07 g/kg/d. Data are presented as Least Square Mean ± SE or Least Square Mean (95%CI). Over the 18 mo of study neither supplement group lost bone at any site. There were no significant differences between treatment groups for changes in lumbar spine [0.002 (-0.011, 0.014); P=0.8], total hip [0.001 (-0.007, 0.009); P= 0.9] or femoral neck [0.006 (-0.004, 0.016); P=0.2] BMD. There was a tendency toward slightly higher lean body mass in the protein supplemented group compared to the maltodextrin group at 18 months (42.6 ± 0.8 vs. 41.5±0.8; P=0.07). Estimated GFR did not change in either group from baseline to the 18-mo endpoint (maltodextrin: 77.2±2.31→75.4±1.92; protein: 73.5 ± 1.91→74.8 ± 2.35; normal value: >60). For participants who continued to take either supplement for the entire study period, UU was significantly higher in the protein group (23.3±1.00; normal range: 12-20) compared to the maltodextrin group (UU: 16.8±0.75; P<0.0001) at 18 mo, an indication that the intervention was received. Also as anticipated, IGF-1 levels were significantly lower in the maltodextrin group (79.4±3.41; normal range: 46-195) compared to the protein group (87.1±3.40; P= 0.0054) at the end of the study, consistent with the known effect of dietary protein on circulating levels of this growth factor. While protein supplementation did not improve bone mineral density, our data is consistent with the conclusion that protein supplementation above the Recommended Dietary Allowance (0.8 g/kg/d) may preserve lean body mass without adversely affecting bone density or kidney function in healthy older adults. Protein supplementation may have deterred the normal changes in body composition that occur with aging.

 

Nothing to Disclose: JB, JK, JB, RS, KM, SL, BK, CS, AMC, AK, JR, JD, AK, KI

16511 9.0000 SUN-0220 A The Effect of Long-Term Whey Protein Supplementation on Bone Mineral Density and Body Composition in Older Adults: A Randomized, Double-Blind, Controlled Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Sana Ghaznavi*1, Nathalie Saad1 and Lois E Donovan2
1University of Calgary, Calgary, AB, Canada, 2University of Calgary, Richmond Road Diagnostic and Treatment Centre, Calgary, AB, Canada

 

Familial Hypocalciuric Hypercalcemia and Primary Hyperparathyroidism: The Diagnostic Pitfalls Encountered When Determining the Etiology of Hypercalcemia During Pregnancy

Background: Primary hyperparathyroidism (PHPT) in pregnancy is associated with pre-eclampsia, intrauterine growth retardation, and neonatal tetany or death, which may be prevented by parathyroidectomy during pregnancy.  PHPT must be distinguished from Familial Hypocalciuric Hypercalcemia (FHH), which is a rare form of hypercalcemia that may lead to profound neonatal hypocalcemia (or rarely hypercalcemia), which cannot be prevented by parathyroidectomy.

Clinical Case: A 25-year-old female with hypercalcemia (serum calcium 2.55-2.79 mmol/L, reference range 2.12-2.54 mmol/L; PTH 33 ng/L, reference range 13-54 ng/L), presented prior to pregnancy.  Her calcium to creatinine clearance ratio (CCCR) was 0.79% pre-pregnancy and rose to 1.99% in her second trimester.  Both the probands’s mother and healthy male baby were found to be hypercalcemic.  Genetic analysis subsequently revealed a novel heterozygous CaSR mutation. 

Conclusion: As the first biochemical report of FHH in pregnancy, this case underscores the failure of current renal calcium excretion indices such as CCCR to distinguish FHH from PHPT during pregnancy. Genetic testing is the gold standard for diagnosis, but its use in pregnant patients is limited due to the existing time delay in obtaining results.  Instead clinicians need to consider hypercalcemia severity, associated symptoms or signs, presence of hypercalcemia in first-degree relatives, and available laboratory investigations completed prior to pregnancy to help distinguish between these two entities.  Making the correct diagnosis is crucial to mitigating the specific life-threatening risks to mother and offspring, which are unique to each disease.

 

Nothing to Disclose: SG, NS, LED

12298 10.0000 SUN-0221 A Familial Hypocalciuric Hypercalcemia and Primary Hyperparathyroidism: The Diagnostic Pitfalls Encountered When Determining the Etiology of Hypercalcemia during Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Keisho Hirota*, Akihiro Yasoda, Yugo Kanai, Yui Yamashita, Yoriko Ueda, Toshihito Fujii, Naotetsu Kanamoto, Masakatsu Sone, Masako Miura, Masashi Mukoyama and Nobuya Inagaki
Kyoto University Graduate School of Medicine, Kyoto, Japan

 

Introduction: Voriconazole is a triazole agent that chosen for the treatment of invasive aspergillosis. Voriconazole contains 3 fluoride atoms and recently reported to cause fluorosis that develops diffuse painful periostitis. Voriconazole-induced periostitis reveals diffuse extremity pain and elevation of alkaline phosphatase (ALP).

Clinical Case: The case is a 52-year-old woman with a history of overlapsyndrome and interstitial pneumonia. She underwent immunosuppressive therapy including cyclosporine and betamethasone. She admitted to our hospital for exacerbation of interstitial pneumonia and treated with endoxian pulse therapy. In the course of treatment, a cavity was seen in upper right lung field in CT. Pulmonary aspergillosis was suspected because of her clinical history and imaging findings, and oral voriconazole was initiated. Approximately 4 weeks after the initiation, rapid elevation of ALP was appeared. 2 months after the initiation of the therapy, the patient presented diffuse pain involving bilateral shoulders, humeri, scapulas, and hypochondriac and femoral regions. Bone scintigram was performed and revealed multiple areas of increased radiotracer uptake in bilateral scapulas, ribs, and cortex of femurs. CT scan revealed periosteal reactions in the same sites and exostosis in right scapula and left iliac bone. T2-weighted MRI revealed high intensity areas in the cortex of these regions, which were compatible with the findings of periostitis. Bone biopsy was performed from exostosis of left iliac bone and the pathological finding revealed an increase of bone tissue with osteosclerosis. This was compatible with the finding of periostitis, but not specific for it.

We suspected the patient was suffering from voriconazole-induced periostitis, because the symptoms began after the initiation of voriconazole and the pattern of bilateral multiple periosteal involvements was compatible. In fact, the plasma fluoride level was increased to 24.9 μmol/L (normal level, 1-4; toxic level, > 15). Voriconazole was discontinued and 3 weeks after stopping voriconazole, the bone pain ceased and ALP was decreased. The plasma fluoride level was 19 μmol/L at that time.

Voriconazole-induced periostitis occurs rarely in patients with collagen diseases, and this is the second report in the world, to our best knowledge. Furthermore, our case represented the earliest onset among those had ever been reported. Drug-drug interactions and inflammatory process on periosteum may affect the pathogenesis in our case.

Conclusion: Voriconazole-induced periostitis can develop in patients with connective tissue diseases. The skeletal symptoms are reversible, so physicians should diagnose voriconazole-induced periostitis when these patients complain diffuse body pain while taking voriconazole.

 

Nothing to Disclose: KH, AY, YK, YY, YU, TF, NK, MS, MM, MM, NI

14331 11.0000 SUN-0222 A Voriconazole-Induced Periostitis in a Patient with Overlapsyndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Lane Frey*, Mohit Agarwal, Raveena Reddy, Christian A. Koch, Albert W. Dreisbach and Jose S. Subauste
University of Mississippi Medical Center, Jackson, MS

 

Background: Episodes of acute, severe hypercalcemia may occur occasionally in primary hyperparathyroidism (PHPT). Parathyroid crisis is often serious and life-threatening.

Clinical Case: A 29 year old African American male with no PMHx presented to the ER one evening with complaints of fever, nausea/vomiting and muscle aches for the past ~3 days. He was oriented to person only, and his brother reported progressive worsening of his mental status in the past 48 hours.

The patient was hypotensive and tachycardic on presentation. An EKG revealed an osborne wave along with a shortened QT interval. Initial labs reported a S-Ca 29.5 mg/dL (n8.6-10.2), ionized Ca > 3.05 mmol/L (n1.22-1.38), Na 140 mmol/L (n136-145), K 3.3 mmol/L (n3.4-4.5), C02 16 mmol/L (n22-29), BUN 84 mg/dL (n6-20), Cr 7.31 mg/dL (n0.67-1.17), Alb 3.6 g/dL (n3.5-5.5), POC lactic acid 7.5 mmol/L (n0.7-2.1), AST 311 U/L (n0-40) and ALT 91 U/L (n0-41). No prior hx of kidney disease or hypercalcemia.

4 L of NS was bolused in the ER then 200 cc/hr of NS was continued. Subsequent labs revealed CPK > 20000 U/L (n38-174), Phos 8.7 mg/dL (n2.7-4.5), 25-OH Vit D 20.7 ng/mL (n20-100) and PTH > 5000 pg/mL (n8.5-72.5). PTH was diluted, final result of 7,475 pg/mL. Calcitonin was given. S-Ca had decreased to 18.1 mg/dL, and dialysis was started. The patient quickly decompensated requiring intubation and pressors. While switching to CRRT, he coded and was later pronounced dead. Labs drawn ~30 minutes prior to coding showed S-Ca 10.2 mg/dL, Phos 7.2 mg/dL, BUN 69 mg/dL, Cr 5.93 mg/dL, C02 12 mmol/L and K 6.5 mmol/L.

Final autopsy results showed a large, 14 gram parathyroid adenoma of the right inferior gland. No lymphovascular or capsular invasion. Surrounding muscle and renal vascular thrombosis along with occlusive thrombi in small vessels of both lungs were noted. Requested immunostaining of the parathyroid adenoma stained strongly positive for PRAD 1.

Conclusion: There have been very few reports of serum calcium and PTH that could compare with this case. Per literature review, the highest reported S-Ca was 31.2 mg/dL (1), PTH N/A. The highest reported PTH was 19,000 pg/mL (2), S-Ca 16.6 mg/dL. The concern initially was if this patient had been genetically predisposed to “crisis”.   

Genetic amplification in one proto-oncogene cyclin D1/PRAD 1 has been identified in ~20% of parathyroid adenomas. Also, there are rare inherited gene mutations in MEN 1, RET, CDC 73 (formerly known as HRPT2), or CDKN1 B that cause patients to be prone to hyperparathyroidism and/or parathyroid cancer (3). A proven link between the PRAD 1 and CDC 73 mutation is the tumor suppressor protein parafibromin (4), but its absence has only been linked with parathyroid malignancy. Genetic testing and identification of these specific mutations or amplifications offer the chance to diagnose parathyroid cancer and/or early hyperparathyroidism preventing future complications and, ultimately, death.

 

Nothing to Disclose: LF, MA, RR, CAK, AWD, JSS

12636 12.0000 SUN-0223 A Deadly Parathyroid Crisis in a Young Male 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Jose Gonzalo Sanchez, MD1, Ronak Patel*2 and Agustin Busta3
1Mt Sinai Beth Israel, 2Mt Sinai Beth Israel, New York, NY, 3Mount Sinai Beth Israel, New York, NY

 

Background: Management of primary hyperparathyroidism for multi glandular disease requires appropriate pre-operative imaging for accurate localization and effective surgery.

 Clinical Case:

An 81-year old woman was initially found to be hypercalcemic on routine blood work and continued to have persistent moderate to severe hypercalcemia before being seen by endocrinologist. She had a history of DM2 and denied any fatigue, constipation, fractures or nephrolithiasis. Initial calcium was 12 mg/dL(8.4-10.3 mg/dL) with an iPTH of 293 pg/mL (11-67 pg/mL). No other liver, renal or vitamin D abnormalities were found. DEXA scan revealed osteoporosis and alendronate was started. Sestamibi scintigraphy showed a possible parathyroid adenoma at the inferior right lobe of the thyroid gland, with no evidence of mediastinal ectopic uptake. Subsequent neck ultrasonography revealed a large complex cystic mass, retro-glandular to the left thyroid lobe. Per NIH guidelines1, she underwent a minimally invasive parathyroidectomy, with a total left upper & right lower gland excision, subtotal left lower gland excision and partial right upper gland excision. Intraoperative iPTH was 917 pg/mL and only lowered to levels ~450 pg/mL. The pathology for the right upper gland revealed fibroadipose tissue with scant parathyroid tissue while rest of the glands showed parathyroid hyperplasia. Bi-monthly lab work showed persistent disease but medical management was opted, as she remained asymptomatic. Approximately a year after surgery the patient had 2 episodes of hypercalcemic crisis, the worst with calcium of 18 mg/dL and iPTH >2000 pg/mL requiring hospitalization. After stabilization, a SPECT-CT revealed an enlarged ectopic retro-mediastinal right upper parathyroid gland. She was later scheduled for parathyroidectomy with mediastinal exploration. During surgery, intraoperative iPTH was 960 pg/mL and dropped to 222 pg/mL after removal of the ectopic tissue. Post-operative calcium and iPTH dropped to 8.8 mg/dL and 146 pg/mL, respectively. Pathology for ectopic gland revealed hypercellular parathyroid tissue with cystic changes. PTH levels continue to steadily decline and at a 6-month follow up visit, the patient denied any symptoms with an iPTH level at 42 pg/mL, and a calcium level of 10.4 mg/dL.

 Conclusion:

Single 99mTc sestamibi scans hold certain pitfalls, particularly on patients with ectopic glands. At times finding source of hyperparathyroidism especially with an ectopic gland could be difficult only with conventional diagnostic studies. The use of three-dimensional imaging such as SPECT-CT can aid in localization and improve sensitivity in the setting of multi-glandular disease. Concomitant readings of multiple imaging modalities2 can better improve accuracy during pre-operative planning and reduce the need for a cumbersome second neck exploration.

 

Nothing to Disclose: JGS, RP, AB

14637 13.0000 SUN-0224 A The Importance of Localization: Persistent Hyperparathyroidism from Unsuspected Ectopic Parathyroid Gland 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Marconi Abreu*1, Bridget Patricia Sinnott2 and Eunice Yung Chuang3
1UT Southwestern, Dallas, TX, 2UTSW, Dallas, TX, 3Mount Auburn Hospital, Cambridge, MA

 

Background: DiGeorge syndrome (DGS) classically presents in the neonatal period with symptomatic hypocalcemia related to congenital hypoparathyroidism or is discovered during work-up for cardiac malformations. We present 2 cases of delayed presentation and diagnosis of DGS. 

Case 1: 44 year old Hispanic male presented with bilateral leg edema and found to have bilateral DVT.  He was noted to have mildly asymptomatic hypocalcemia with corrected calcium 7.8 (8.4 - 10.2 mg/dL) and hypothyroidism with TSH 97.81 (0.40 - 4.50 mcIU/mL) requiring levothyroxine replacement. His medical history was remarkable for developmental delay but negative for recurrent infections or cardiac problems, tetany, seizures or chronic illness. His family history was negative for DGS. On a subsequent admission, he was found to have symptomatic hypocalcemia with corrected calcium 5.8, an inappropriately low PTH 11.2 (15.0 - 65.0 pg/mL) and vitamin D25 of 18, requiring treatment with calcitriol and calcium citrate. His exam was remarkable for a positive Chvostek's sign, learning disability, normal cardiac exam, mild hearing loss and absence of cleft lip/palate.  His echocardiogram was unremarkable. A FISH study revealed a 22q11.2 deletion confirming the diagnosis of DGS.

Case 2: 61 year old Caucasian female presented for follow up of hypothyroidism and hypoparathyroidism which were diagnosed at age 43.  Her neonatal history was remarkable for tetralogy of fallot, ankyloglossia (tongue-tie) and cleft palate defect.  She reported normal physical and mental development, but frequent respiratory infection during childhood. She went to college and works in a bank.  Her family history was negative for DGS. Comorbidities developing later in life include HTN, Type-2 DM and CKD 4, without proteinuria. Ultrasound showed normal sized kidneys.  Her exam was remarkable for oral candidiasis, a 3/6 diastolic murmur at apex, hepatosplenomegaly and 2+leg edema.  Her TSH was 2.6 on 200 mcg of LT4 therapy.  Her calcium was 9.1, PTH 12.6 and Vitamin D (25 OH) - 46 on calcitriol 0.25 mg every other day and 500 mg of calcium carbonate daily. A FISH study revealed a 22q11.2 deletion consistent with diagnosis of DGS.

Discussion: DGS is a rare disorder affecting 1 in 4000 births. It is commonly manifested by congenital hypoparathyroidism, developmental delay, cardiac and aortic arch anomalies, thymic aplasia, palatal anomalies and immune deficiency. It is usually diagnosed in the neonatal and early childhood period and rarely in adulthood. It is caused by hemizygous microdeletions in region 22q11.2, which typically occur de novo but can be inherited in up to 20% cases. With the potential benefit for genetic counseling, these cases highlight the wide phenotypic variability of DGS presentations and reinforces the importance of considering its diagnosis beyond the childhood period.

 

Nothing to Disclose: MA, BPS, EYC

12697 14.0000 SUN-0225 A Delayed Presentation and Diagnosis of Digeorge Syndrome in Two Adults 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Karoly Viragh*1, Judit Toke2, Agnes Sallai3, Zsuzsa Jakab2, Karoly Racz2 and Miklos Toth2
1Olive View-UCLA Medical Center, 2Semmelweis University, Budapest, Hungary, 3Semelweis University, Budapest, Hungary

 

BACKGROUND:

Pseudohypoparathyroidism (PHP) is a syndrome caused by end-organ resistance to PTH, which is classified as type I (a, b, or c) and type II. The phenotypic manifestation most commonly encountered with PHP (especially types Ia/Ic) is the syndrome known as Albright’s hereditary osteodystrophy (AHO), which includes constitutional, neuromuscular, and skeletal features. One of the most specific physical signs for AHO, and thus PHP, is brachydactyly, which has an unknown mechanism of development. The gradual, age-dependent appearance of short fingers and metacarpal(s), as presented here, is only very rarely documented.    

CLINICAL CASE:

Our female patient had normal birth, but showed slightly slowed motor development and increasing obesity from age 9 months. Macrocephaly, facial dysmorphism, and mild mental retardation were noted at age 12 months. Despite of multiple hospital visits and extensive workup for multiple disorders, she was not diagnosed with PHP until age 15 years, when she presented with perioral and upper/lower extremity numbness and tingling, and was found to have features of AHO. She had long QT on EKG. Her labs showed serum Ca 1.6 mmol/L (normal 2.2-2.6), serum Phosphate 2.16 mmol/L (normal: 0.8-1.45), serum PTH 398 pg/mL (normal 10-55), and 25-hydroxyvitamin D3 16.7 ng/mL (normal 30-73). Her PTH remained elevated despite normalized serum vitamin D. The patient had hypergonadotropic primary amenorrhea as well as insulin-resistance. Her primary hypothyroidism needed T4 substitution. Hand radiograph showed brachydactyly.  Brain CT showed extensive calcifications in the basal ganglia, as well as the subcortical and deep white matter. She had no family history of AHO or PHP. She is treated with calcitriol, calcium, levothyroxine and metformin.

            We present a unique series of 14 chronologic photographs from our patient with typical AHO/PHP phenotype to document the gradual development of brachydactyly from age 6 weeks to 18 years. The image series indicates that our patient’s short fingers became evident only after the age of 5 years. Clinical, biochemical and radiologic correlation (hand radiograph, CT brain) are also provided.

 CONCLUSION:

            Brachydactyly is one of the most specific signs of AHO and PHP, and should be recognizable by all endocrinologists, though it may not be present in early childhood. No similar photo collection is available in the clinical literature to our knowledge.

 

Nothing to Disclose: KV, JT, AS, ZJ, KR, MT

15101 15.0000 SUN-0226 A Gradual Development of Brachydactyly in Pseudohypoparathyroidism: A Unique Pictorial History with Clinical, Radiological and Biochemical Correlation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Georgiana Alina Dobri*, Ula Abed Alwahab, Divya Yogi-Morren, Adi Erach Mehta, Mary Vouyiouklis and Vinni Makin
Cleveland Clinic Foundation, Cleveland, OH

 

Introduction

We report a case of a patient with type 1 diabetes mellitus (DM) and glycogen storage disease (GSD) who presented with hyperglycemia and pancreatitis and was found to have severe hypercalcemia.

 Case summary

A 28 yo woman with type 1 DM with gastroparesis, type 1 GSD, s/p two failed pancreatic transplants and GERD (gastroesophageal reflux disease), presented with one week of worsening abdominal pain, vomiting and diarrhea. She had been taking TUMS-Extra for GERD, but she denied ingesting more than six pills daily. On examination, she was completely alert and oriented, with a BMI of 16 kg/m², blood pressure of 152/97 mmHg and abdominal tenderness on palpation. Her total calcium was 17.3 mg/dl (nl 8.5-10.5), albumin 3.7 mg/dl (nl 3.5-5) and ionized calcium 2.09 mmol/l (nl 1.08-1.30). The phosphorus was normal, PTH 5 pg/ml (nl 15-65), PTHrp and 1,25-OH vitamin D were undetectable, 25-OH vitamin D 4.5 ng/ml (nl 31-80) and 24 hour urine calcium was 51.7 mg/24h (nl 100-300). Her kidney function and EKG were normal. The blood glucose was 495 mg/dl (nl 65-100), anion gap 16 mmol/l (nl 0-15), pH 7.31 (nl 7.35-7.45), CO2 25 mmol/l (nl 23-32), lipase 600 U/l (nl 12-70), triglycerides 576 mg/dl (nl 30-149) and lactate 8.9 mmol/l (nl 0.5-2.2).  She was diagnosed with acute pancreatitis and presumed diabetic ketoacidosis (DKA). She was made NPO, started on an insulin drip, narcotics for pain and normal saline for volume repletion. She received 2 doses of 200 units of subcutaneous calcitonin and 90 mg of intravenous pamidronate with normalization of the calcium level within 24 hours. By the 3rd day, she developed hypocalcemia (7.2 mg/dl) and was started on calcium and vitamin D. Calcium rose within normal range and was maintained at six months of follow-up.

 Discussion

Severe hypercalcemia is a life-threatening condition which requires aggressive therapy and establishing the etiology is cornerstone in the chronic management and prevention of future hypercalcemic crisis. There are a few case reports of hypercalcemia associated with DKA or metabolic decompensation of type 1 GSD; all of them in children. The entertained explanations are the degree of lactic acidosis in GSD, insulin and IGF1 deficiencies and hyperglycemia in DKA. In this patient, the ingestion of TUMS (probably under-reported) might have aggravated the hypercalcemia, supported by the concomitant metabolic alkalosis. Hypercalemia resolved quickly along with the metabolic derangements and the ensuing hypocalcemia was probably related to the administration of pamidronate in a patient with low vitamin D reserve.

 Conclusion

Hypercalcemia associated with acute metabolic decompensation (DKA, GSD) requires prompt identification and treatment. It is imperative to remember that this state might be reversible with correction of the underlying metabolic derangement, before choosing therapies with long term effects which could cause hypocalcemia.

 

Nothing to Disclose: GAD, UA, DY, AEM, MV, VM

12725 16.0000 SUN-0227 A Severe Hypercalcemia in a Patient with Glycogen Storage Disease and Diabetic Ketoacidosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Eric Hernández-Triana*1, Andrea DEL PILAR Barrera-Hernández2, Julie Natalie Bohorquez-Romero2, Edna Margarita Prieto-Bogoya3, Mariana Villavecez-Franco2, Miguel Augusto Omeara-Novoa4, Andrés Bermudez-Bohorquez4, Luis Fernando Dorado-Palacios4 and Dimas Felipe Herrera-Rendón4
1Endocare Research Institute, Bogota, Colombia, 2UNIVERSIDAD DEL ROSARIO, Bogotá, Colombia, 3Litomedica s.a, Bogotá, Colombia, 4Endocare Research instutite, Bogotá, Colombia

 

The addition of the measurement of radio 33 to the usual determination in spine and hip increases the sensitivity of the DXA in the diagnosis of osteoporosis in postmenopausal women

 

Eric  Hernandez-Triana[1] [2] [3], Andrea P. Barrera-Hernández2,  Julie N. Bohorquez-Romero2, Edna M. Prieto-Bogoya3, Mariana  Villavecez-Franco 2,  Miguel A. Omeara-Novoa 1, Andres Bermudez-Bohorquez 1, Luis F. Dorado-Palacios1, Dimas, F. Herrera-Rendón1.

 

Introduction The measurement of bone density in lumbar spine and hip is considered the gold standard for the diagnosis of osteoporosis in postmenopausal women. Dual energy X-ray absorptiometry (DXA) is the gold standard modality for non-invasive diagnosis of osteoporosis to date, the utility of measuring radio 33 simultaneously with the AP lumbar spine and hip, is ignored.

Methods We performed a diagnostic test study with a nested concordance study to determine the diagnostic value of radius-33 in osteoporosis. We included women over 50 years with menopause in the period between 2008 and 2011.

 

Results A total of 3241 female patients who had a column DXA AP, dual femur and forearm ultradistal radius and 33 % were included. On the diagnostic gold standard for column and / or hip, radius -33 had a sensitivity of 95.5 % and specificity of 91 % (p = 0.000) for osteoporosis and a sensitivity of 76.5 % and specificity of 54.9 % p = 0.000 for the diagnosis of osteopenia. The radius 33 diagnosed an additional 35% of cases that were not diagnosed with gold standard tests.

 

Discussion DXA commonly used sites predicts only 40 % of the risk of fracture (41). If we include measuring radius 33 DXA sensitivity increase in 35.66 %, thereby detecting more patients at risk for fracture. Carrying an impact on the timeliness of care and perhaps reducing morbidity and mortality from fractures.

Keywords: osteoporosis, fracture risk, radio 33, DXA.


[1] Endocare Research Institute, Bogotá, Colombia.

[2] Universidad del Rosario facultad de Medicina Bogotá Colombia

[3] Unidad de metabolismo óseo Litomedica S.A, Bogotá Colombia.

 

Nothing to Disclose: EH, ADPB, JNB, EMP, MV, MAO, AB, LFD, DFH

15430 17.0000 SUN-0228 A The Addition of the Measurement of Radio 33 to the Usual Determination in Spine and Hip Increases the Sensitivity of the DXA in the Diagnosis of Osteoporosis in Postmenopausal Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Marlyn Fernandez*1, John Junghoon Shin2, RoseMarie Pasmantier3 and Mark Bernard Zimering4
1Rutgers-New Jersey Medical School, Newark, NJ, 2Veterans Affairs Med Ctr, East Orange, NJ, 3Veteran Affairs New jersey Helath Care System, 4Veterans Affairs New Jersey Heal, Lyons, NJ

 

Secondary hyperparathyroidism (HPT) evolving into normocalcemic primary hyperparathyroidism (NCPHPT) affecting a single gland is unusual.  We describe a case of secondary HPT developing into NCPHPT. Imaging studies including sestamibi and contrast CT revealed a lesion in the right axilla.

A 67 year old woman presented for evaluation of osteoporosis. She reported a history of hypertension, DVT, nephrolithiasis, a traumatic right humeral fracture, vertebral compression fractures and multiple rib fractures.  She is treated with alendronate, HCTZ and warfarin. For the past few years she has had stable bone density scores, including lumbar spine T score: -1.1, femoral neck T score: -2.4 and distal forearm T score:  -1.4.  

Initial workup showed secondary HPT:  PTH: 85pg/ml, corrected Ca 7.4mg/dl, 25OH vitamin D: 24.8ng/ml.  Subsequently, her labs revealed NCPHPT; PTH: 187pg/ml, corrected Ca: 9.3mg/dl, PO4: 3.2mg/dl, 25OHvitamin D: 25.4ng/ml, Cr: 0.9mg/dl, GFR: 62ml/min and alkaline phosphatase: 58u/l. An initial sestamibi scan showed a possible ectopic parathyroid gland in the right axilla and no abnormal uptake in the neck or mediastinum.

With vitamin D repletion, 25OHvitamin D increased to 40.6ng/ml, PTH declined to 136pg/ml, corrected Ca was 8.6mg/dl, ionized Ca: 4.9mg/dl, PO4: 3.0mg/dl, Cr: 0.5mg/dl, and 1,25 2OH vitamin D: 100.2pg/ml.  A contrast CT scan of the right axilla showed a 7mm oval shaped lesion. PET-CT scan exposed several lymph nodes without abnormal uptake in the axilla. A repeat sestamibi scan discovered new uptake in the neck corresponding to a left parathyroid adenoma but persistent uptake in the right axilla likely consistent with a lymph node.

NCPHPT is defined as persistent normal serum Ca levels in the presence of high PTH levels. It’s a relatively new entity and challenging situation as therapeutic recommendations are not established. Patients having NCPHPT can present with fractures and kidney stones yet unlike classic primary HPT there is no preponderance of cortical bone loss.

Sestamibi is an accepted localization modality for parathyroid adenomas; however it is nonspecific and not diagnostic.  Sweat glands, metastatic cancer or lymph nodes can also be positive with this imaging technique secondary to high ATP production.  Repeat sestimibi imaging in our patient revealed new uptake in the left neck consistent with a parathyroid adenoma.

There has been no report of surgically proven parathyroid adenomas occurring in the axilla in patients with HPT. Even though normal parathyroid tissue occurring in the axilla and a parathyroid adenoma in the neck was reported in one patient having primary HPT; this has not yet been surgically or biopsy proven in our patient. These results indicate how misleading sestamibi imaging may be and the importance of repeating it and considering other diagnostic possibilities associated with abnormal uptake in unusual locations in patients with HPT.

 

Nothing to Disclose: MF, JJS, RP, MBZ

13128 18.0000 SUN-0229 A Persistent Right Axillary Sestamibi Uptake in a Patient with Normocalcemic Primary Hyperparathyroidism Evolving from Secondary Hyperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Jenny Qian Dai-Ju*1, Vijaya Surampudi2, Teeranun Jirajariyavej3 and Andrew George Gianoukakis4
1Harbor-UCLA Medical Center, Torrance, CA, 2Harbor-UCLA Medical Center, Los Angeles, CA, 3Harbor UCLA Medical Center, Torrance, CA, 4Harbor UCLA Med Ctr, Torrance, CA

 

Background: Tumor-induced hypophosphatemia is a rare paraneoplastic syndrome caused by unregulated secretion of the phosphate and vitamin D regulating hormone Fibroblast Growth Factor-23 (FGF23). Tumors are usually of mesenchymal origin, slow growing and benign with metastases rarely reported. Hypophosphatemia is due to renal phosphate wasting and associated with low 1,25-dihydroxy vitamin D, and elevated or inappropriately normal plasma FGF23 (mean=1119.2 ± 941.6 RU/mL in nine patients with confirmed oncogenic osteomalacia) (1).

Clinical case: A 62-year-old male with no past medical history presented with a 1.5 month history of rectal pain, rectal bleeding and a 10 pound weight loss. Colonoscopy failed to detect a rectal mass. CT scan detected innumerable heterogeneously enhancing hepatic lesions filling both hepatic lobes (largest lesions measuring 6-7 cm) and numerous diffusely scattered pulmonary nodules throughout all lung fields (the largest measuring 1.6cm). Liver biopsy revealed a metastatic poorly differentiated carcinoma of unknown primary. Molecular diagnosis by BioTheranostics suggested a 90% probability of neuroendocrine tumor, subtype small/large cell lung carcinoma. However, TTF-1, synaptophysin and chromogranin stains were negative. The patient developed persistent and severe hypophosphatemia (0.9mg/dL, n 2.5 to 4.5 mg/dL) despite a normal serum phosphorus level (3.2 mg/dL) 6 weeks prior to admission. Ionized calcium 5.08mg/dL (n 4.5-5.3mg/dL), intact PTH 18 pg/mL (n 10-65 pg/mL) and PTH-Related protein 26 pg/mL (n 14-27 pg/mL) were within the normal range. 25-hydroxy Vitamin D 17.3 ng/mL (n 30-100 ng/mL) and 1,25-dihydroxy vitamin D <8 pg/mL (n18-72 pg/mL) were low. Serum creatinine 0.92 mg/dL (n 0.9-1.3 ml/dL) and GFR 88.6 mL/min/1.73 m2 were normal. Fractional excretion of phosphate was measured on two separate days, 61% and 59% with serum phosphorus levels of 1.9 and 1.4 mg/dL respectively, confirming renal phosphate wasting (n < 5% with hypophosphatemia). Plasma FGF23 measured by ELISA was very high, 6,881 RU/mL (n 44-215 RU/mL) and verified by repeat testing. Serum phosphorus was maintained with aggressive phosphorus supplementation (250 mg oral Neutra-Phos five times daily plus IV potassium-Phos 15mmol 1-2 doses prn daily). The patient subsequently developed acute renal failure and phosphate supplementation was tapered as serum phosphate levels normalized. The patient passed away only one month after admission. Family member declined autopsy.

Conclusion: This case represents an uncharacteristically, clinically aggressive FGF-23 producing tumor associated with severe hypophosphatemia. The FGF-23 level of 6,881 RU/mL represents one of the highest levels ever reported.

 

Nothing to Disclose: JQD, VS, TJ, AGG

15541 19.0000 SUN-0230 A Severe Hypophosphatemia Due to a FGF-23 Producing, Metastatic, Aggressive Tumor of Unknown Primary 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Jayender R Chintaparthi*1, Prem K Chandran2, Joseph A Buckwalter3, Andrew Bellizzi3, Parren S McNeely3 and Joseph Stephen Dillon1
1University of Iowa Hospitals and Clinics, Iowa City, IA, 2Associates In Kidney Care Plc, Des Moines, 3University of Iowa Hospitals and Clinics

 

Introduction:  Tumor-Induced Osteomalacia (TIO) is a rare, acquired paraneoplastic disease associated with renal phosphate wasting and osteomalacia. The causative lesions are usually small, benign, mesenchymal tumors, which express somatostatin (sst) receptors and produce phosphatonins (predominantly FGF23) leading to hypophosphatemia and osteomalacia.  Surgery is usually curative but identifying these small tumors can be difficult.  Different imaging modalities have been used including MRI, CT, FDG-PET, and 111In-Octreotide scintigraphy, with varying success rates. 68Ga-DOTATOC-based PET-CT is a novel, powerful approach to detect sst receptor positive tumors. We report a case of TIO in which the primary tumor was detected by this technique leading to successful surgical treatment

Clinical Case:  A previously well 42 year-old female developed multiple stress fractures involving axial and appendicular skeleton over 1 year.  Biochemical testing revealed hypophosphatemia, and normal calcium, PTH, 25-OH vitamin D and calcitriol levels. Urine testing confirmed renal phosphate wasting. DEXA scan revealed Z scores of -1.3 in the left hip and -3.2 in the lumbar spine.  FDG-PET/CT showed increased uptake in multiple areas including ribs and spine. Normal serum PTH and urinalysis ruled out hyperparathyroidism and Fanconi‘s syndrome.  Although the FGF-23 level was in the normal range and a primary tumor was not initially identified, TIO was considered the most likely diagnosis.

A 68Ga-DOTATOC-based PET-CT was performed due to its improved sensitivity over OctreoScan. This revealed focal uptake in the distal right femur consistent with sst receptor positive disease. MRI of this region confirmed a 1cm osteolytic soft tissue nodule in the cortex of the distal right femur. The lesion was removed surgically and pathology revealed a benign myopericytomatous lesion consistent with phosphaturic mesenchymal tumor. Her phosphate levels normalized within a week of surgery off all supplements. Her fractures, bone pain and muscle strength improved subsequently.

Conclusion:  68Ga-DOTATOC-based PET-CT is a highly sensitive imaging technique in detecting somatostatin receptor positive tumors causing Tumor-Induced Osteomalacia.

 

Nothing to Disclose: JRC, PKC, JAB, AB, PSM, JSD

13296 20.0000 SUN-0231 A Tumor-Induced Osteomalacia Diagnosed with 68-Ga Dotatoc PET Scan and Successfully Treated Surgically 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Heather Leigh Hofflich*1 and Annie Tan2
1Univ of California, San Diego, San Diego, CA, 2University of California, San Diego, La Jolla, CA

 

Background: Osteoporosis is a common disease affecting millions of men and women and commonly results from inadequate peak bone mass, postmenopausal estrogen deficiency, and age-related changes in bone and mineral metabolism. The current literature estimates that 30-50% of women have a secondary cause of osteoporosis and identifying the cause can be vital to helping the patient receive proper treatment. (1)

Clinical Case: A 57 year-old healthy female presents with back pain after lifting a heavy door. An MRI of the lumbar spine showed a compression fracture at L1. Patient was treated with conservative measures: physical therapy and a spine brace. Patient was then referred to the UCSD osteoporosis clinic for treatment and evaluation. DXA scan revealed lumbar spine T-score of -1.7, right femoral neck T-score of -1.9, and left femoral neck T-score of -2.1. A complete osteoporosis history was reviewed and the patient was found to have no risk factors. Laboratory testing was performed to look for secondary causes of osteoporosis that included CBC, CMP, magnesium, phosphorus, 25-OH vitamin D, TSH, SPEP and tTG-IGA antibodies.

Laboratory testing was notable for an elevated MCV 111.0 mm3 (normal: 79.0 – 99.0 mm3), mildly elevated AST and ALT, elevated PTT and INR, and elevated total bilirubin 3.2 mg/dL (normal <1.2 mg/dL). SPEP revealed a decrease in alpha-2 globulin fraction, which is associated with acute hepatic disease or a hemolytic process, and a polyclonal increase in gamma globulin fraction.  Abdominal US was ordered and showed a diffusely echogenic liver measuring 15.3 cm, consistent with cirrhosis. Moderate ascites and portal HTN were noted as well.  Patient was referred to hepatology and she later revealed consumption of alcohol of approximately 3-4 drinks per day since the age of 18.  A liver biopsy was performed and the patient was diagnosed with alcoholic hepatitis and cirrhosis with MELD 25. 

This previously healthy post-menopausal patient presented with a compression fracture and osteoporosis and was ultimately found to have severe liver cirrhosis as a result of investigation for other causes of her osteoporosis. The patient is currently having her underlying liver disease managed as the initial step in treating further progression of bone loss and osteoporosis.

 The prevalence of osteoporosis varies between 11-58% in patients with cirrhosis and cirrhosis portends a 2-fold increase in fracture risk. Excessive alcohol is an independent risk factor for osteoporosis and is associated with a 2.8-fold increased risk of hip fractures and higher risk of vertebral fractures (2) The etiology is multifactorial and likely is the result of disruption of hormonal regulators of bone formation and resorption. (3)

Conclusion: The search for secondary causes of osteoporosis is important for detection of underlying diseases, and is essential for improving bone health in these patients.

 

Nothing to Disclose: HLH, AT

13315 21.0000 SUN-0232 A The Importance of Searching for Secondary Causes of Osteoporosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Keiko Yamamoto*1, Makoto Fujiwara1, Yasuhisa Ohata1, Koji Miura1, Taichi Kitaoka1, Takuo Kubota1, Noriyuki Namba2, Keiichi Ozono3, Sachiko Kitanaka4 and Mayuko Tamura4
1Osaka University Graduate School of Medicine, Suita, Japan, 2Osaka University Graduate School of Medicine, Suita Osaka, Japan, 3Osaka Univ Grad Schl of Med, Suita Osaka, Japan, 4Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

 

Background: Hereditary vitamin D resistant rickets (HVDRR) is an autosomal recessive disease associated with impairment of bone and cartilage mineralization due to defective vitamin D receptor function. According to previous reports, infantile or childhood patients with HVDRR require parenteral administration of calcium to maintain serum calcium levels and bone mineralization. Clinical presentation: Elevation of serum alkaline phosphatase was found by chance in a two year old girl. The further examination revealed hypocalcemia and secondary hyperparathyroidism without vitamin D deficiency: serum calcium 7.7 mg/dl, phosphorus 3.0 mg/dl, alkaline phosphatase 8891 U/l, intact PTH 576 pg/ml, 1,25(OH)2D 137 pg/ml (20-60 pg/ml), FGF23 <10 pg/ml, urine calcium/creatinine <0.1 mg/mg. Radiographic surveys showed characteristic signs of rickets. These findings with alopecia suggested the diagnosis of HVDRR. A homozygous p.R73X mutation was detected by vitamin D receptor (VDR) gene analysis. This mutation has been previously reported and does not produce functional VDR. Initial treatment with oral active vitamin D (alfacalcidol) and calcium did not improve her serum calcium and intact PTH levels. She was referred to our hospital at the age of 2 years and 7 months. Constant serum calcium levels above 8.7 mg/dl and suppression of intact PTH levels were achieved by increasing the dose of oral calcium (calcium lactate) to 300 mg/kg/day (3 g/day) of elemental calcium. However, the dose of oral calcium had to be reduced to 240 mg/kg/day (2.4 g/day) due to elevated urine calcium/creatinine ratios (0.3-1 mg/mg). Subsequently, we treated her with oral calcium alone since the age of 3 years and 2 months. Four months after supplementation with calcium alone, her intact PTH levels further decreased to normal levels while her serum calcium levels remained normal (intact PTH 35.5 pg/ml, Ca 9.3 mg/dl). Other laboratory data were serum phosphate 5.5 mg/dl, alkaline phosphatase 1365 U/l, 1,25(OH)2D 20 pg/ml, FGF23 12 pg/ml, and urine calcium/creatinine 0.5 mg/mg. Although a follow up radiographic survey at the age of 2 years and 8 months showed no improvement, her genu varum showed some improvement at the age of 3 years and 6 months. Her alopecia remained unchanged.

Conclusion: We report a HVDRR patient whose serum calcium and intact PTH were normalized by treatment with oral calcium supplementation alone.

 

Nothing to Disclose: KY, MF, YO, KM, TK, TK, NN, KO, SK, MT

13341 22.0000 SUN-0233 A A Patient with Hereditary Vitamin D Resistant Rickets Treated with Oral Administration of Calcium 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Alexandre Hohl*1, Carina Gabriela Correa2, Bruno da Silveira Colombo2, Marcelo Fernando Ronsoni1, Julia Michels Ferreira3, Ana Paula Gomes Cunha Moritz4, Simone van de Sande-Lee4 and Marisa Helena Cesar Coral2
1Federal University of Santa Catarina, Florianopolis-SC, Brazil, 2Federal University of Santa Catarina, Brazil, 3Federal University of Santa Catarina, 4Federal University of Santa Catarina, Florianopolis, Brazil

 

Introduction: The consumption of anabolic steroids, supplements and similar products grows larger every day. Its use is mostly related to athletes and people who seek to improve their physical performance, or aesthetics. Among the many substances, the veterinary supplement ADE (similar to Synthol) has been increasingly used due to its oily vehicle that induces local edema, which simulates the increase of muscle mass.

Case report: Male, 24 y.o., previously healthy, presented fatigue, epigastric pain, nausea and vomit, which developed during 2 months, becoming worse progressively. Admitted the use of different substances for the purpose of building muscle mass: testosterone derivatives, growth hormone, nandrolone and the veterinary vitamin compound ADE which contains 20,000,000 IU of vitamin A, 5,000,000 IU of vitamin D3 and 6,800 IU of vitamin E in each 100 mL dose. The patient admitted having used 150 mL of ADE in the past 4 months. While hospitalized, physical examination on the patient revealed no changes and BMI was 25.1 kg/m2. Laboratory: creatinine 3.1 mg/dL (reference range [RR] 0.8 - 1.3), urea 54 mg/dL (RR 15 - 39), albumin 3.5 mg/dL (RR 3.4 – 5.0), ALT 160 mg/dL (RR 30 – 65), AST 11 mg/dL (RR 15 – 37), alkaline phosphatase 87 U/L (RR 50 – 136), total testosterone 23 ng/dL (RR 72 – 853), 25-hydroxyvitamin D (25OHD) 150 ng/mL (toxicity > 100), 1,25 - dihydroxyvitamin D 80 pg/mL  (RR 18 – 78), vitamin A 0.7 mg/dL (0.3 – 0.7), PTH < 3 pg/mL (RR 12 – 65), total calcium 13.6 mg/dL (RR 8.5 – 10.1), and urinary calcium/24 hours 635 mg/24h (RR 42 – 353). Viral serology were negative. Urinary tract ultrasonography: signs of parenchymal nephropathy. Diagnosis: hypercalcemia and acute kidney injury due to vitamin D intoxication caused by veterinary compound. Treated with intravenous hydration followed by corticotherapy (40 mg/day prednisone) and furosemide. On the fifth day of hospitalization, the patient was administrated with one 90mg dose of disodium pamidronate. The patient was completely cured from hypercalcemia and had his renal function normalized, being discharged from the hospital after 14 days. Outpatient evaluation 30 days later showed normalized laboratory tests, except 25OHD that was persistently increased 9 months after treatment (107 ng/mL), since vitamin D is deposited in fat tissue and may take a longer time to normalization.

Discussion: Excessive amounts of vitamin D raise the intestinal calcium absorption, leading to hypercalcemia and related complications. Intoxication reports have been documented about adults with more than 30,000 UI daily intake. This case’s patient had used approximately 62,500 UI/day. Bearing this in mind, this case is an important warning to overall population, raising awareness to the risks related with the use of veterinary substances for aesthetics purposes. However, reports regarding the outcomes of this practice are still lacking on scientific literature.

 

Nothing to Disclose: AH, CGC, BDSC, MFR, JMF, APGCM, SV, MHCC

13477 23.0000 SUN-0234 A Vitamin D Intoxication Induced By Veterinarian Vitamin Compound Usage: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Christoph Zechner*1 and Ugis Gruntmanis2
1UT Southwestern, Dallas, TX, 2North Texas VA Health Care System and UT Southwestern, Dallas, TX

 

Background: Mastocytosis is a rare disorder resulting from clonal proliferation of mast cells. Many organ systems including skin and bone can be affected, and bone involvement is a cause of decreased bone mineral density and fractures.

Clinical Case: A 65 year-old man presented for evaluation of osteopenia in his lumbar spine (T-Score -0.9) and femur (T-Score left proximal femur -1.8 and left femoral neck -1.4) associated with independent non-traumatic fractures of his left clavicle and bilateral humerus. Skin assessment revealed numerous erythematous 2 - 5 mm large macules and papules over the patient’s back. Affected skin areas demonstrated urticaria upon stroking (positive Darier’s sign), suggesting the diagnosis of cutaneous mastocytosis. Skin biopsy revealed cutaneous mastocytosis manifesting as urticaria pigmentosa. Systemic mastocytosis with bone involvement was considered as a possible etiology for his decreased bone density and fractures. Serum tryptase was elevated to 33.6 (normal: 1.9-13.5) μg/L. Bone marrow biopsy demonstrated multiple, dense mast cell infiltrates consisting of  ≥ 15 mast cells, spindle-shape or atypical morphology of >25% of mast cells, and CD25 expression of most bone marrow mast cells in addition to normal mast cell markers. Serum and bone marrow findings confirmed the diagnosis of systemic mastocytosis. Further tests revealed  normal serum calcium 9.5 mg/dl (nl 8.4 – 10.3), 25-hydroxyvitamin D 43.9 ng/ml (nl 10 - 55), parathyroid hormone 38.6 pg/ml (nl 15-65), and testosterone 6.09 ng/ml (nl 2.8 – 8). Skeletal survey was negative for multiple myeloma, and no M component was seen in serum and urine electrophoresis.

Clinical Lessons: Mastocytosis should be part of the differential diagnosis in a patient with macular/papular skin lesions, unexplained decrease of bone mineral density and fractures. Skin examination for Darier’s sign, easily done in an endocrinology office, is also a very helpful tool for suspecting this diagnosis. First line treatment for decreased bone density and fractures in systemic mastocytosis is similar to other etiologies including bisphosphonate use. Second line treatments specifically for mastocytosis include alpha-interferon and 2-Chlorodeoxyadenosine. The diagnosis of mastocytosis implies further diagnostic and therapeutic considerations, including drugs for symptom control, cytoreductive therapy for more aggressive forms of mastocytosis, and prescription of an epinephrine pen for increased anaphylaxis risk.

 

Nothing to Disclose: CZ, UG

13540 24.0000 SUN-0235 A Darier's Sign Suggests Mastocytosis As Cause of Decreased Bone Mineral Density and Fractures 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0211-0235 4789 1:00:00 PM Metabolic Bone Disease Poster

Regina P Silva*1, Thais T Zampieri1, Angela MR Lobo1, João AB Pedroso1, Renata Frazao1 and Jose Donato Jr.2
1University of Sao Paulo, Sao Paulo, Brazil, 2University of Sao Paulo, Sao Paulo - SP, Brazil

 

Gonadal steroids are important physiological regulators of energy homeostasis. It has been long known that reductions in sexual hormone levels lead to an increased body weight and fat mass. Leptin resistance is a hallmark of obesity. However, it is still controversial the interaction between gonadal steroids and leptin to regulate the energy balance. Thus, the goal of the present study is to determine whether low levels of gonadal steroids lead primarily to a leptin resistance state which will predispose females to early-onset obesity. Female mice (C57BL-6, 8 weeks old) were submitted to bilateral ovariectomy (OVX; n=24) or similar surgical procedure except that ovaries were not removed (Sham, n=24). After surgery, weight gain was monitored weekly. After 18 weeks, food intake was assessed daily for 1 week followed by in vivo tests to evaluate the glucose and insulin tolerance and leptin sensitivity. Leptin sensitivity was assess 4, 12 and 24 h after an ip injection of mouse recombinant leptin, food intake and body weight were measured. Blood samples, the hypothalamus, uterus and adipose tissue (subcutaneous, perigonadal and retroperitoneal) were collected. Leptin levels and hypothalamic gene expression analyses were performed. Ovariectomy efficiency were verified by uterus weight reduction in OVX group compared to Sham (P<0,05). As expected OVX induced significant weight gain and increased adiposity compared to sham group (P<0,05). Ovariectomized mice showed significant reduction in daily food intake and exhibited an increased glucose intolerance and insulin resistance. Although circulating levels of leptin were increased in OVX group, we observed that the acute anorexic effects of leptin are preserved in OVX mice. In addition, we observed an up-regulation of the leptin receptor expression in the hypothalamus. No variations in genes involved in leptin intolerance were observed 7 or 30 days after OVX, despite their weight gain. Increased Socs3, PTP1B, PTPN2 and PTPN11 mRNA were detected only after 24 weeks from OVX (P<0,05). The data suggest that increased adiposity after removal of the gonads is not caused by a state of leptin resistance. Future studies should investigate the molecular mechanisms related to weight gain in conditions of low levels of gonadal steroids.

 

Nothing to Disclose: RPS, TTZ, AML, JAP, RF, JD Jr.

15807 1.0000 SUN-0837 A Increased Adiposity after Ovariectomy Is Not Caused By Leptin Resistance 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Pendar Farahani*1 and Mitchell Levine2
1Queen's University, Kingston, ON, Canada, 2McMaster University

 

Background: Non-adherence to statins is a significant issue for the prevention and treatment of cardiovascular disease.

Objective: To investigate the reasons for stopping lipid-lowering therapeutics use in new drug users with dyslipidemia in a sample cohort of Canadian patients in primary care according to previous exposure to statins.

Method: In a sub-study of the survey of patient characteristics associated with lipid-lowering pharmacotherapy use in Canada, patients who recently began the lipid-lowering drug within the preceding 6 months of recruitment (new users or previous users who had stopped therapy for at least 12 months and were starting again) were assessed. At 8 months they were re-evaluated to determine whether they were still using their medication, if they had stopped, and the reasons for stopping. Patients were subdivided according to previous exposure to statins. 

Results: 180 patients were identified. At 8 months 18 (10%) patients had discontinued their medication. Adverse effects occurred in 17 patients, lack of effectiveness occurred in 5 patients and 2 patients identified that treating hyperlipidemia was no longer a priority. Muscle pain was the most common adverse effect.  Average LDL-C reduction was [- 1.66 (1.0) mmol/l] in new users without previous exposure to statins and [- 1.87 (1.2) mmol/l] in new users with previous exposure to statins (P-value = 0.30)

Conclusion: No differences were observed between subgroups with and without previous exposure to statins in patients’ characteristics, lipid profile improvement and adherence outcomes.

 

Nothing to Disclose: PF, ML

11039 4.0000 SUN-0840 A Previous Exposure to Statin and Adherence to Lipid-Lowering Therapeutics 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Katherine Samaras*1, John D Crawford2, Elizabeth Blanchard3, Nicole Kochan4, Julian N Trollor5, Henry Brodaty4 and Perminder Sachdev2
1Garvan Institute of Medical Research, Sydney NSW, Australia, 2University of New South Wales, Randwick, Australia, 3Garvan Institute of Medical Research, Darlinghurst, NSW, Australia, 4University of New South Wales, Kensington, Australia, 5University of New South Wales, Randwick

 

The cardiovascular (CV) risk factors of diabetes, hyperlipidemia and hypertension are associated with cognitive decline and are dementia risk factors. Metabolic syndrome (MS) describes clustering of these risks factors; it is unclear whether MS adversely affects cognition. Further, there is controversy whether statin use may impair cognition. We examined if Metabolic Syndrome (MS) and statin use were associated with greater cognitive decline in the elderly over 4 years.

Methods: Participants were drawn from the Sydney Memory and Aging Study, a longitudinal population-derived cohort recruited from the electoral roll (70-90 years at baseline), assessed at baseline, 2 and 4 years, as described.1 Global cognition was measured by neuropsychological testing in five domains (memory, processing speed, language, visuospatial and executive function), to form a composite normalized Z-score, as described.2 MS was defined using IDF criteria.1 Medical history and use of statin therapy and type were documented. Data on 677 participants were analyzed by repeated measure ANCOVA, with covariates (age, sex, years education, smoking, English/non-English speaking background and apolipoprotein E e4 genotype [APOEe4]).

Results:

Mean ± SD age at baseline was 78.3 ± 4.6 years, 47% males, BMI 27.1 ± 4.9 kg/m2, fasting glucose 5.6 ± 1.1 mmol/L. Baseline prevalences of MS, statin-use and diabetes were 54%, 52% and 11%, respectively.

Baseline global cognition was similar between participants with and without MS (-0.65 ± 1.3 v -0.52 ± 1.3, p=0.13). Metabolic syndrome was not associated with any greater decline in global cognition (p=0.97), nor with any domain decline score for memory, language, processing speed, visuospatial or executive function. Results were similar when subjects with diabetes were excluded.

Baseline global cognition was similar between statin-users or not (-0.58 ± 1.3 v -0.59 ± 1.3, p=0.92). Statin-use was not associated with any greater decline in global cognition over 4 years (p=0.25), however significantly greater decline in memory was observed (-0.27±0.04 v. -0.07±0.05, p=0.001). Statin-use was not associated with any greater 4-year decline in language (p=0.51), processing speed (p=0.85), visuospatial (p=0.75) or executive (p=0.96) functions. To examine whether CV risks may interact with statin-use to heighten the decline in memory, interactions were sought in models of statin use and CV or dementia risk factors (including covariates). None was found with diabetes, heart disease, stroke, smoking or APOEe4 carriage.

Conclusion: In this large cohort of community-dwelling well-elderly, statin-use was associated with greater decline in memory at 4 years, but no other cognitive domain. Metabolic syndrome was not associated with accelerated cognitive decline. The impact of metabolic risk and its treatment on cognition in the elderly requires greater interrogation.

 

Nothing to Disclose: KS, JDC, EB, NK, JNT, HB, PS

PP15-2 14285 5.0000 SUN-0841 A Statin Use but Not Metabolic Syndrome Is Associated with Cognitive Decline in the Elderly: The Sydney Memory and Ageing Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Zahid Ahmad* and Abhimanyu Garg
University of Texas Southwestern Medical Center, Dallas, TX

 

BACKGROUND: Familial hypercholesterolemia (FH) is an autosomal co-dominant disorder characterized by severe elevations in LDL-C, tendon xanthomas and premature coronary heart disease (CHD). Thus far, mutations in LDL receptor (LDLR), apolipoprotein B-100 (APOB), and proprotein convertase subtilisin-like kexin type 9 have been found to cause FH. Systematic genetic screening - in Europe, Australia, and Japan, as well as among the South African white Afrikaners, Christian Lebanese, French-Canadians, Ashkenazi Jews and Old-Order Amish - has revealed a high prevalence of disease-causing LDLR or APOB variants.

UNDERLYING QUESTION: Prior studies were limited to ethnically/racially homogenous populations, and little data exists on patients of African origin and other minorities. Therefore, we recruited a multi-ethnic FH cohort from Dallas metropolitan area lipid specialty clinics.

METHODS: All patients were identified using Simon-Broome criteria: LDL-C > 95th %ile for age and gender (after excluding any secondary causes of hypercholesterolemia) as well as the presence of either tendon xanthomas or a 1st degree family relative with premature CHD or LDL-C > 95th %ile.  A total of 105 males and 147 females, age 10 to 79 years (101 African-Americans, 78 non-Hispanic whites, 46 Hispanic whites, and 27 others) met entry criteria and consented to participate. We screened for mutations in the two most common FH-causing genes: LDLR and APOB. All exons and consensus splice sites of LDLR and exon 26 of APOB were genotyped using Sanger sequencing. Deletions and duplications of LDLR exons were detected with multiplex ligation-dependent probe amplification.

MAJOR RESULTS: Heterozygous variants in LDLR were identified in 84 patients and in APOB (p.R3527Q) in 6 patients. The remaining 162 patients (64%) had “unexplained FH.”  A lower proportion of Hispanic whites (52%) than either non-Hispanic whites (70%) or African-Americans (68%) were unexplained. Patients with LDLR mutations, as compared to the unexplained group, had higher baseline LDL-C (290 ± 67 vs. 239 ± 43 mg/dL, p < 0.0001) and lower baseline HDL-C (48 ± 15 vs. 54 ± 14 mg/dL, p < 0.001).

INTERPRETATION OF RESULTS AND CONCLUSION: Our results reveal a strikingly high prevalence of unexplained FH patients compared to previous studies. This finding may be due to diverse genetic background, polygenic inheritance, inability to detect cryptic mutations, or the presence of new undiscovered FH genes. Hypercholesterolemia in unexplained FH patients may also be contributed predominantly by environmental factors, such as diet and obesity. Future studies are needed to identify the causes of severe hypercholesterolemia in unexplained FH subjects.

 

Disclosure: ZA: Speaker, Sanofi, Speaker, Genzyme Corporation. AG: Advisory Group Member, Bristol-Myers Squibb, Speaker, Merck & Co., Advisory Group Member, Pfizer, Inc..

PP15-3 15274 6.0000 SUN-0842 A Familial Hypercholesterolemia: Systematic Genetic Screening in a Multi-Ethnic U.S. Cohort Reveals a Lack of Disease-Causing Mutations in a Large Proportion of Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Weerapan Khovidhunkit1, Wanee Plengpanich2, Suwanna Muanpetch1, Supannika Charoen1, Arunrat Kiateprungvej1, Sarat Sunthornyothin1 and Thiti Snabboon*1
1Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, 2King Chulalongkorn Memorial Hospital, Bangkok, Thailand

 

Severe hypertriglyceridemia usually results from a combination of genetic and environmental factors. We resequenced 3 candidate genes, LPL, APOC2 and APOA5, which encode lipoprotein lipase, apolipoprotein C-II, and apolipoprotein A-V, respectively, in Thai subjects with severe hypertriglyceridemia and compared with normolipidemic controls. Sequence variants were identified by sequencing exons and exon-intron junctions in 101 subjects with triglyceride levels ≥10 mmol/L (886 mg/dL) and compared with those of 111 normolipidemic subjects. We found 2 novel heterozygous missense mutations in LPL (p.Arg270Gly and p.Arg432Thr) and 1 novel frameshift mutation in LPL (p.Asp308Glyfs*5). Moreover, three previously-identified heterozygous missense mutations in LPL (p.Ala98Thr, p.Leu279Val, and p.Leu279Arg) were identified. Collectively, these rare mutations were found only in the hypertriglyceridemic group but not in the control group (13% vs. 0%, P<0.0001). One common variant of APOA5 (p.Gly185Cys, rs2075291) was found at a higher frequency in the hypertriglyceridemic group compared with the control group (25% vs. 6%, respectively, P<0.0005). Altogether, rare variants of LPL or APOA5 and/or the common APOA5 p.Gly185Cys variant were found in 37% of the HALP group vs. 6% in the controls (P=3.1 x 10-8). No rare variant of APOC2 was identified. In conclusion, both common and rare DNA variants in LPL and APOA5, but not APOC2, were more commonly found in the Thai hypertriglyceridemic group, which could potentially contribute to high triglyceride phenotypes in our population.

 

Nothing to Disclose: WK, WP, SM, SC, AK, SS, TS

11523 7.0000 SUN-0843 A A Common p.Gly185Cys Variant in APOA5 Is Prevalent in Thai Subjects with Severe Hypertriglyceridemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Meng Zhao*1, Xulei Tang2, Tao Yang3, Qingbo Guan1, Fuzhong Xue4 and Jiajun Zhao1
1Shandong Provincial Hospital affiliated to Shandong University, Jinan, China, 2The First Hospital of Lanzhou University, Lanzhou, China, 3The First Affiliated Hospital of Nanjing Medical University, Nanjing, China, 4School of Public Health, Shandong University, Jinan, China

 

Background Hypertriglyceridemia plays an important role in the pathogenesis of numerous noncommunicable chronic diseases, such as diabetes mellitus, metabolic syndrome and non-alcoholic fatty liver disease. The world faces a burden of thyroid disease that has reached epidemic proportions. Among them, subclinical hypothyroidism (SCH) has drawn intensive interest for its increasing prevalence and potential health effects, but it is unknown whether hypertriglyceridemia is associated with the increase in SCH. In this study we aimed to assess the association between serum triglyceride levels and the risk for SCH.

Methods This population-based case-control study was part of the REACTION study. A total of 24,100 subjects with similar and stable iodine nutrition status were recruited from the East, West and South of China. Cases of 5,033 SCH patients were identified and controls were matched 1 to 1 with the cases by age, gender and region. The association between serum triglyceride levels and the risk for SCH was estimated by the conditional logistic regression analysis among men and women, respectively.

Results Hypertriglyceridemia was associated with an increased risk for SCH in both men (odds ratio [OR], 1.578; 95% confidence interval [CI], 1.309-1.902) and women (OR, 1.444; 95% CI, 1.310-1.591). The positive association still existed after adjusting for potential confounders (OR, 1.325; 95% CI, 1.002-1.753 in men; OR, 1.397; 95% CI, 1.217-1.604 in women). Serum triglyceride levels were associated with the risk for SCH in a dose-response manner. Among men, compared with Quartile 1 of serum triglyceride levels (< 0.97 mmol/L), the risk for SCH increased approximately 1.4- (p = 0.027), 1.6- (p < 0.001), and 1.9-fold (p < 0.001) in Quartile 2 (0.97-1.36 mmol/L), Quartile 3 (1.37-1.99 mmol/L) and Quartile 4 (>1.99 mmol/L), respectively. A similar trend was observed among women.

Conclusion Elevated triglyceride levels were associated with an increased risk for SCH, suggesting a possible deleterious effect of hypertriglyceridemia on thyroid function. It indicates the necessity of understanding the extensive harm of hypertriglyceridemia.

 

Nothing to Disclose: MZ, XT, TY, QG, FX, JZ

14478 8.0000 SUN-0844 A Association Between Hypertriglyceridemia and Subclinical Hypothyroidism: A Large-Scale Population-Based Case-Control Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Rosalinda Posadas-Sanchez*1, Wendy Angelica Ocampo-Arcos1, Gilberto Vargas-Alarcon2, Teresa Villareal-Molina3, Janinne Ortega-Montiel2, Angel Rene Lopez-Uribe1, Xochitl Aida Medina-Urrutia2, Guillermo Cardoso-Saldaña1, Maria Carmen Gonzalez-Salazar1, Esteban Jorge-Galarza1 and Carlos Posadas-Romero1
1National Institute of Cardiology, Mexico, Mexico, 2National Institute of Cardiology "Ignacio Chavez", Mexico, Mexico, 3National Institute of Genomic Medicine (INMEGEN), Mexico, Mexico

 

Fatty liver (FL) has been considered as an independent risk factor for coronary artery disease (CAD). PNPLA3 gene variant (I148M) has been strongly associated with FL in several populations, including Hispanics. Coronary artery calcification (CAC) is a marker for early preclinical CAD. However, the association between I148M variant and subclinical atherosclerosis has not been described. The aim of this study was to examine the association of the I148M variant with FL and CAC in a Mexican adult population. A total of 1469 non related Mexican adults, aged 53.3+9.3 years were genotyped for the I148M variant. Anthropometric, clinical and metabolic parameters were collected from all subjects, and insulin resistance was assessed using the homeostasis model assessment (HOMA-IR). FL and CAC were assessed by computed tomography.The prevalence of FL was 33.2%, and the 148M allele frequency was 58.6% in the study. In logistic regression analysis, the M148M genotype was significantly associated with FL (OR= 2.41, 95%CI 1.7-3.3; p= 1.25x10-7), elevated ALT levels (OR=1.5, 95%CI 1.2-2.0; p=0.003), elevated HOMA-IR (OR= 1.5, 95%CI 1.2-2.1; p=0.005), and CAC>10 (OR=1.57, 95%CI 1.02-2.4; p=0.044), independently of age, gender, body mass index, and diabetes mellitus. In Mexican population, I148M/PNPLA3 variant was independently associated with higher hepatic enzyme levels, HOMA-IR, an increased risk for FL, and subclinical atherosclerosis (CAC>10).

 

Nothing to Disclose: RP, WAO, GV, TV, JO, ARL, XAM, GC, MCG, EJ, CP

14759 9.0000 SUN-0845 A Association of the I148M/PNPLA3 Variant with Fatty Liver Disease and Coronary Artery Calcium in Mexican Adult Population 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Jonathan SY Ti*, Poh Yong Tan, Edmond Lim, Gideon Tan and Yong Mong Bee
Singapore General Hospital, Singapore, Singapore

 

Background

Non-alcoholic fatty liver disease (NAFLD) is closely associated with visceral obesity, dyslipidaemia and type 2 diabetes (T2D). Ethnic differences in liver fat exist and this is closely linked to the fat storage capacity. Ethnicity with a lower capacity of body fat stores within subcutaneous adiposity in response to an increased energy influx will results in accumulation in non-adipose tissue such as liver, which is known as ectopic fat storage.

Objectives

We aim to (1) determine the liver fat content among Chinese and Asian Indian men with T2D in Singapore using regional computed tomography (CT) images and to (2) examine the correlations between liver fat and abdominal fat distribution.

Subjects

A total of 200 subjects (100 Chinese and 100 Asian Indian men) older than 50 years with T2D underwent regional unenhanced CT imaging. The median duration of diabetes was 10 years. Liver and spleen attenuation measurements from a single slice CT image at T12/L1 were taken with 5 regions of interests (ROIs) from the liver and 3 ROIs from the spleen. Hepatic attenuation indices (HAIs) were measured as follows: (1) hepatic parenchymal attenuation (CTLP); (2) liver to spleen attenuation ratio (LS ratio); and (3) difference between hepatic and splenic attenuation (LSdiff). Abdominal fat area was measured from a single slice CT image at the level of L2/3 using SliceOmatic (Tomovision). Abdominal fat was classified into visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT).

Results

Despite the similar BMI between Chinese and Asian Indian men, Chinese men had more liver fat (CTLP: 47.4 ± 10.8 for Chinese, and 51.8 ± 10.1 for Asian Indian; LS ratio: 0.83 ± 0.21 for Chinese, and 0.92 ± 0.20 for Asian Indian; LSdiff: -9.95 ± 11.87 for Chinese, and -4.72 ± 11.03 for Asian Indian; all P<0.01) and tended to have a greater disposition for fatty liver with an increase in BMI than Asian Indian men, indicating a clear difference between the two groups. There were significant negative correlations between CTLP, LS ratio and LSdiff with VAT but not SAT for both groups. The CTLP was better correlated with VAT (r=-0.342 and r=-0.315 for Chinese and Asian Indian men respectively; P<0.01 for both) than either LS ratio or LSdiff.

Conclusion

Chinese men with T2D had higher liver fat at a lower BMI compared with Asian Indian men. This suggests a reduced capacity to store fat among Chinese men with T2D and this is closely linked to ethnic difference in predisposition to NAFLD.

 

Nothing to Disclose: JST, PYT, EL, GT, YMB

15891 10.0000 SUN-0846 A Ethnic Differences in Liver Fat Content Among Chinese and Asian Indian Men with Type 2 Diabetes: A Cross-Sectional Observation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Michele Yuen*1, Sidney CF Tam2, Carol HY Fong3, Wing-Sun Chow2, Kathryn CB Tan4 and Karen SL Lam5
1Queen Mary Hospital, Hong Kong, Hong Kong, 2Queen Mary Hospital, Hong Kong, 3University of Hong Kong, Hong Kong, Hong Kong, 4University of Hong Kong, Hong Kong, 5The University of Hong Kong, Hong Kong

 

Background: Cerebrotendinous xanthomatosis (CTX) is a rare autosomal recessive disease characterized by the accumulation of cholestanol and cholesterol, leading to xanthomas and neurological symptoms. Genetic defect in CYP27A1 leads to a deficiency in sterol 27-hydroxylase and reduced chenodeoxycholic acid (CDCA) formation from cholesterol. The lack of negative feedback of CDCA on bile acid synthesis leads to increased production of cholestanol. Cholesterol production is also increased in CTX, but the role of statin therapy in these subjects is unclear.

Subject and methods: The records of all adult Chinese CTX patients managed at our center were retrieved from our computerized record system. Clinical and biochemical parameters and drug history were reviewed.

Results: Seven adult CTX patients (5 males, 2 females) from 4 unrelated, non-consanguineous families were identified. The mean age was 31.0+/-9.4 years at first symptoms, 36.0+/-10.9 years at diagnosis and 48.9+/-7.0 years at the time of study. Reported first symptoms were xanthomata (n=5) and motor abnormalities (n=2). At presentation, all patients had bilateral Achilles tendon xanthomata, 4 patients had cerebellar sign and 3 patients had subnormal intelligence.

Pre-treatment cholestanol level was 147.9+/-70.5 umol/l (reference range <13.0 umol/l), low-density cholesterol (LDL) level was 2.2+/-0.3 mmol/l, high-density cholesterol (HDL) level was 1.4+/-0.3 mmol/l and triglyceride (TG) level was 1.1+/-0.4 mmol/l.  CDCA, at 750mg daily in 3 divided doses, was started at diagnosis in 4 patients and at 4 years post-diagnosis in 3 patients. After 1 year of treatment, mean cholestanol level was reduced to 13.0+/-11.6 umol/l (p<0.05), while no significant changes were noted in LDL (2.8+/-0.5 mmol/l), HDL (1.4+/-0.2 mmol/l) or TG (1.2+/-0.7 mmol/l). Simvastatin 10mg nocte in addition to CDCA in 3 of the 7 patients at 3.3+/-2.2 years after diagnosis did not lead to any change in cholestanol, LDL, HDL or TG levels at 5 and 10 years post-treatment commencement. Six patients had stable intelligence and were engaged in meaningful employment. No improvement in demyelinating changes in the brain on MRI was observed with treatment (assessed serially in 3 patients). Xanthoma regressed partially in 3 patients, was excised with no recurrence in 2 patients and remained stable in 2 patients.

Conclusion: Our series is one of the largest of Chinese CTX patients, and possibly one of the longest longitudinally followed series of CTX patients, reported in the literature. Our data suggests that CDCA is effective in lowering cholestanol starting in the first year of treatment. Simvastatin at 10mg nocte seems to have no effect on circulating levels of cholestanol, LDL, HDL or TG at 5 and 10 years of follow-up. Further follow-up assessment may help to ascertain whether the reduction in cholestanol is associated with any clinical benefits.

 

Nothing to Disclose: MY, SCT, CHF, WSC, KCT, KSL

14753 11.0000 SUN-0847 A Cerebrotendinous Xanthomatosis in Seven Hong Kong Chinese 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Linda Kucane*1, Ingvars Rasa2, Zane Svikle3 and Laura Sviklane3
1Riga Stradins University, Riga East Clinical University Hospital, Riga, Latvia, 2Riga East Clinical University Hospital, Riga Stradins University, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia, 3The Latvian University, Riga, Latvia

 

Background: Many forms of inherited hyperlipoproteinemias (HLP) are common in population, based on world prevalences often underdiagnosed, can be multigenic and require secondary factors for expression and may be associated with cardiovascular disease. Materials and methods: This retrospective study was aimed to analyse patients (pts) with severe hyperlipidemia, admitted to RECUH Endocrinology Dpt. in past 3 years (yrs) Jan2011–Dec2013. Medical records of pts with total cholesterol (TC) ≥8.0mmol/L and/or triglycerides (TG) ≥5.6mmol/L were analysed to reach the study aim. Results: Number of pts was 168 (11 pts admitted repeatedly); 53.0% were female. Mean age - 52.9±14.1 yrs. 17.9% (n=30) didn’t have diabetes (DM), 58.3% had type 2 DM, 15.5% - type 1 DM, 4.8% pancreatogenic and 3.6% other types of DM. Mean duration of DM was 8.9±9.6 yrs, mean HbA1c - 10.5±2.6%; 91.6% (n=120) had it ≥8.0%. Other cardiovascular RF: 54.2 % was obese, 22.8% had high uric acid, 17.6% - GFR <60 ml/min, 76.2% - hypertension, 16.1% - coronary artery disease, 2.4% - peripheral artery disease, 10.7% - cerebrovascular events, 21.4% were smokers. In addition, 6.0% had 4-5 of RF, 41.1% had 2-3 and 37.5% only 1 of these 8 RF. 52 pts had a high TC while having TG <3.0mmol/L, out of these - 22 pts didn’t have DM, had normal thyroid and renal function. In this group mean age was 53.5±14.8 yrs, 50.0% male and female, mean TC was 8.4±0.5 mmol/L and 50.0% had steatosis on ultrasound. 45.4% (n=75) had a very high TG1 (≥ 5.64 mmol/L), 16.4% (n=27) had severe hypertriglyceridaemia2 (HTG) (>11.3mmol/L) and 4.8% (n=8) - very severe HTG2(>22.6mmol/L). 70 pts with a very high TG had elevated TC as well, in this group 20 pts had HDL cholesterol ≥1.0mmol/L while 32 pts had it diminished; 34 pts in this group had LDL cholesterol ≥3.0 mmol/L. Only 3 patients with very high TG had normal TC. 38.7% of pts with a very high TG had lactescent plasma; 10.7% had plasma exchanges as part of the treatment. Conclusion: Pts with high TC, LDLC and normal/close to normal TG, HDLC  may have heterozygous familial hypercholesterolemia. While pts with high TG, TC and low HDLC have possibility of HLP Type 2B or HLP type 4, which can deteriorate into HLP type 5 (modified Fredrickson3) as well. Many pts had obesity, DM or thyroid disease - secondary factors that can cause dyslipidemia or influence genetically susceptible pts for disease expression.

 

Nothing to Disclose: LK, IR, ZS, LS

14016 12.0000 SUN-0848 A Severe Hyperlipidemia As an Indicator of Possible Familial Lipid Disorders - Its Associated Metabolic Derangements and Cardiovascular Risk Factors (RF) in Riga East Clinical University Hospital (RECUH): 3 Years Retrospective Study in Latvia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Rashi Agarwal* and Girish Mour
St. Catherine Hospital, Garden City, KS

 

Background:

Nonalcoholic fatty liver disease (NAFLD) has been reported to be present in 10-46% of the general population. These numbers, however, have been primarily derived in urban and mixed populations. The prevalence of NAFLD in rural setting remains under reported.

Objective:To determine the prevalence of abdominal ultrasound diagnosed NAFLD and the associated co morbidities in a rural outpatient primary care (internal medicine and family practice) clinic in southwest Kansas.

Methods:

A retrospective analysis of ultrasound diagnosed fatty liver was conducted over a period of 21 months. Patients who received an abdominal ultrasound during the study period were included in the study.  Demographic and co morbidity data were collected and analyzed from our database for these patients. People with history of alcohol abuse and hepatitis C were excluded.

Results:

Of 242 patients who had an abdominal ultrasound, (13 excluded as mentioned above) 69 patients (30%) had NAFLD on ultrasound. 59% of whom were males. Median patient age was 51 years (21 - 83 years). Prevalence was significantly higher in obese patients (BMI >30kg/m2) at 75% as compared to 22% in overweight (BMI 25-29.9kg/m2) and 3% in normal weight (BMI:18.5-24.9kg/m2) patients. Of the obese patients, fatty liver disease was most prevalent in class I (BMI 30-34.9kg/m2) obesity at 29%, and similar at 23% in both class II (BMI 35-39.9 kg/m2) and III obesity (BMI >40kg/m2). Hypertension and dyslipidemia were the most common co morbidities associated at 53% each while diabetes type 2 was present in 42% patients. About 57% patients with NAFLD had normal transaminases.

Discussion:

NAFLD has emerged as a growing epidemic nationally and worldwide. NAFLD has the potential to progress to cirrhosis and currently, there is growing evidence suggesting that cardiovascular disease is the leading cause of death in patients with NAFLD. The possibility that NAFLD especially with its necroinflammatory variant (nonalcoholic steatohepatitis) may not only be a marker of cardiovascular disease but also may be involved in its pathogenesis. Additional research is required to draw a definitive conclusion.

Conclusion:

NAFLD is highly prevalent in the rural setting. Further larger prospective studies of the prevalence and associated co morbid conditions would be clinically relevant in this population to aggressively treat the co morbid conditions for better clinical outcomes.

 

Nothing to Disclose: RA, GM

16920 13.0000 SUN-0849 A Fatty Liver Disease in Rural Patients in Southwest Kansas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Samata Basani*1, Aliya Heylinger1, Zahid Ahmad2 and Abhimanyu Garg2
1UT Southwestern Medical Center, 2University of Texas Southwestern Medical Center, Dallas, TX

 

BACKGROUND: Type 5 Hyperlipidemia (T5HLP) is characterized by marked elevations in serum triglycerides (TG) associated with increased levels of very low density lipoproteins (VLDL) and chylomicrons.  The clinical presentation of T5HLP includes the presence of eruptive xanthomas, increased risk of coronary heart disease (CHD) and acute pancreatitis. Precise contribution of various predisposing factors for T5HLP is not well understood and there is paucity of data form the United States, especially in multi-ethnic patients. Therefore, we recruited a multi-ethnic T5HLP cohort from Dallas metropolitan area lipid specialty clinics. All patients were identified using the following criteria: serum TG > 1000 mg/dL (11.1 mmol//L) and/or history of acute pancreatitis. Patients with disease-causing mutations in the known T1HLP genes, LPL, GPIHBP1, APOA5, APOC2 and LMF1 were excluded.

RESULTS: A retrospective analysis was performed on102 T5HLP patients, mean ± SD age 46 ± 12 years and BMI 32 ± 9 kg/m2. Of these, 68 patients were male and 34 were female. A total of 53 patients were Caucasians, 34 Hispanic, 13 African-Americans, and 2 were of other ethnicity. Untreated median TG levels were 1711 mg/dL (25th- 75th quartile,1116 - 2650 mg/dL). Of these patients, 62% had uncontrolled diabetes, 26% had excessive ethanol use, 6% were on estrogen therapy and 6% had various types of lipodystrophy. Acute pancreatitis was a frequent complication in 29 %, hepatomegaly in 22 % and eruptive xanthomas were noticed in 10 % of patients. Upon improvement of glycemic control in patients with diabetes (HbA1C declined from 9.3 ± 3% to 7.7 ± 2%), moderation/discontinuation of alcohol, discontinuation of estrogen and treatment with lipid lowering agents, median serum TG improved to 610 mg/dL (301-1234 mg/dL).

CONCLUSIONS: We conclude that uncontrolled hyperglycemia and heavy ethanol use are the major contributors to T5HLP in North American patients. Besides these, estrogen use in women, severe obesity and lipodystrophies can further induce the phenotype. Even though marked reductions in serum TG are observed upon initiating lipid-lowering drugs and improvement of diabetes control, many patients still continue to have severe hypertriglyceridemia. This raises the possibility that some of these patients may have underlying genetic dyslipidemia which is exacerbated by other risk factors. It also justifies the need for developing additional targeted therapies to reduce the risk of acute pancreatitis and CHD in patients with T5HLP.

 

Disclosure: ZA: Speaker, Sanofi, Speaker, Genzyme Corporation. AG: Advisory Group Member, Bristol-Myers Squibb, Speaker, Merck & Co., Advisory Group Member, Pfizer, Inc.. Nothing to Disclose: SB, AH

16964 14.0000 SUN-0850 A Underlying Mechanisms of Extreme Type 5 Hyperlipoproteinemia in a North American Cohort 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Paul Tejera*1, Dean Karalis2, Barbara Simon1, Gary Xiao1 and Renee E Amori1
1Drexel University College of Medicine, Philadelphia, PA, 2University of Pennsylvania/Penn Cardiology CCP, Philadelphia, PA

 

Introduction: Lipoprotein X (Lp(x)) is a lipoprotein similar in density to low-density lipoprotein (LDL) and may accumulate in patients with biliary cirrhosis and other forms of cholestatic liver disease.  However, there are very few documented cases of Lp(x) after liver transplantation.

Clinical Case: A 58 year old Hispanic male without a history of hypercholesterolemia received an orthotopic liver transplant for hepatitis C infection, cirrhosis, and hepatocellular carcinoma.  He developed abnormal liver function tests and declining mental status two months after transplantation.  The initial anti-rejection regimen included glucocorticoids, calcineurin inhibitors, and mycophenolate mofetil.  Liver enzymes were elevated with alkaline phosphatase 2,130 U/L (n 40-129U/L), aspartate aminotransferase (AST) 95U/L (n 5-35U/L), alanine aminotransferase (ALT) 85 U/L (n < 40U/L), total bilirubin 20.65 U/L (n 0.10-1.5 mg/dL), and direct bilirubin 12.09 U/L (n < 0.3mg/dL).  A fasting lipid panel drawn to determine if vascular disease contributed to his declining mental status showed extremely elevated lipid levels with peak total cholesterol 1,390mg/dL (n < 200 mg/dL), direct LDL 1,300mg/dL (n < 130mg/dL), high-density lipoprotein (HDL) 7mg/dL (n >40mg/dL), and triglycerides 465mg/dL (n <150mg/dL). Apolipoprotein B (ApoB) levels were 11nmol/L (n < 90nmol/L).  Xanthomas were absent on physical exam.  A lipid profile done six months prior to the transplant was normal with total cholesterol 82 mg/dL, LDL 57 mg/dL, HDL 9mg/dL, and triglycerides 82mg/dL.  He was started on atorvastatin and ezetimibe.  No improvement was seen with pharmacotherapy, and plasmapharesis was initiated.  After two plasmapharesis treatments, the lipid profile improved significantly with total cholesterol 193mg/dL, LDL 131mg/dL, HDL 22mg/dL, and triglycerides 93mg/dL.  The cholesterol re-accumulated two weeks after plasmapharesis despite continued pharmacotherapy.  Given the cholestasis and new hypercholesterolemia, the presence of Lp(x) was suspected.  A qualitative electrophoresis performed at the Lipoprotein Metabolism Section of the National Institute of Health was positive for Lp(x).

Conclusion: This case illustrates Lp(x) as a cause of severe hypercholesterolemia in the setting of cholestatic liver disease after liver transplantation.   This case is unusual because of the swift development of hypercholesterolemia and development of Lp(x) post-liver transplant. The key clinical feature of this case is low ApoB with very high LDL, and this combination of findings in a patient who develops cholestatic liver disease after liver transplant should alert the physician that the cause of the hyperlipidemia may be Lp(x).  Since Lp(x) is not thought to be atherogenic, lipid-lowering therapy may not be required. 


[1]Remaley, A. Senior Investigator, Lipoprotein Metabolism Section of National Institutes of Health

 

Nothing to Disclose: PT, DK, BS, GX, REA

12928 15.0000 SUN-0851 A Severe Hypercholesterolemia and Cholestatic Liver Disease after Liver Transplant a Case of Lipoprotein X 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Abhimanyu Garg*1, Zahid Ahmad1 and Sara Monaghan2
1University of Texas Southwestern Medical Center, Dallas, TX, 2UT Southwestern Medical Center, Dallas, TX

 

Background:  Sitosterolemia (also known as phytosterolemia) is a rare autosomal recessive disorder characterized by increased intestinal absorption of cholesterol and plant sterols due to mutations in genes encoding ATP-binding cassette, subfamily G5 (ABCG5) or G8 (ABCG8). Nearly all patients present with hypercholesterolemia, elevated plant sterol levels, accelerated atherosclerosis and xanthomas. Primary presentation with anemia and thrombocytopenia is extremely unusual. 

Clinical case: A 58-year-old Hispanic female presented with anemia and thrombocytopenia for the last two years. She had no bleeding diathesis. Physical examination revealed bilateral xanthelesmas especially on the lower eyelids. She had a grade 2/6 systolic ejection murmur with normal S1 and S2 and prominent splenomegaly.

Laboratory work up revealed normal WBC count 4,900/µL (normal range: 3,800-10,800/µL), low hemoglobin 8.2 g/dL (11.7-15.5 g/dL) and hematocrit 26.2% (35%-45%), normal MCV 88.2 fL (80-100 fL) and low platelet count of 61,000/µL (140,000-400,000/µL). Absolute reticulocyte count varied from slightly elevated to normal, but serum bilirubin and haptoglobin were normal.  Peripheral smear revealed stomatocytes and many large and occasional giant platelets. A bone marrow evaluation showed mild hypercellularity, no morphologic dysplasia, and no abnormalities by flow cytometry or cytogenetic studies. She was taking no lipid lowering medications. A lipid panel revealed total cholesterol, 217 mg/dL (120 – 199 mg/dL), triglycerides, 120 mg/dL (50 – 150 mg/dL), LDL-cholesterol, 139 mg/dL (<130 mg/dL) and HDL-cholesterol, 54 mg/dL (45 – 65 mg/dL). There was no consanguinity among her parents and she had 3 brothers with hypercholesterolemia with one having coronary artery bypass graft at age 56 years.  Serum sitosterol levels were markedly elevated at 16.17 mg/dL (0.3-1.7 mg/dL). Genotyping for ABCG8 revealed a homozygous p.W536* mutation in exon 11.

Conclusions: This case highlights the importance of suspecting sitosterolemia in patients with anemia and thrombocytopenia when other common causes have been ruled out.  Presence of stomatocytes and giant platelets should be considered an atypical presentation of sitosterolemia. Why there is a marked heterogeneity in clinical presentation among patients with sitosterolemia remains unclear.

 

Disclosure: AG: Advisory Group Member, Pfizer, Inc., Speaker, Merck & Co., Advisory Group Member, Bristol-Myers Squibb. ZA: Speaker, Sanofi, Speaker, Genzyme Corporation. Nothing to Disclose: SM

15203 16.0000 SUN-0852 A Unusual Presentation of Sitosterolemia with Anemia and Thrombocytopenia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Pablo Rodrigues Costa-Alves1, Erika Cesar de Oliveira Naliato*2, Margarete Domingues Ribeiro1, Filipe Augusto Carvalho Paula1, Ana Cristina Moreira Jorge Ghazali1, Mariana Tayt-Sohn Martuchelli Moço1 and Maria de Fatima Moreira Silva Jorge1
1UNIFESO (Serra dos Orgaos University Center), 2UNIFESO (Serra dos Orgaos University Center), Teresopolis, Brazil

 

The introduction of antiretroviral therapy (ART) significantly reduced mortality in patients with HIV/AIDS. However, ART has been shown to produce important adverse effects, including metabolic alterations that increase atherosclerosis and cardiovascular risk. This prospective interventional study was based on data collection of 50% of the adult HIV/AIDS patients on Highly Active Antiretroviral Therapy (HAART) for at least one year, registered in the Program of STD/AIDS of Teresópolis/Brazil (n = 129) and aimed to analyze the lipid profile (total cholesterol - TC, HDL, and triglycerides), identify the prevalence of dyslipidemia, and implement statin therapy for those with a higher cardiovascular risk. Patients were evaluated at study entry and after a 2-year intervention period. At study entry, patients had a mean age of 45.0 ± 10.5 years with a predominance of females (56.5%) and the mean duration of HAART was 6.6 ± 4.3 years. At that time, the prevalence of dyslipidemia was 68.9%. Only 1% of the patients had been previously diagnosed with dyslipidemia. Most patients (27.4%) had TC levels below 160 mg/dL, 26.4% had levels from 160 to 199 mg/dL, 17% from 200 to 239 mg/dL, 18% from 240 to 279 mg/dL, and 11.2% ≥ 280 mg/dL. The majority (41.5%) also had low HDL levels (< 40 mg/dL), 37.8% had levels from 40 to 49 mg/dL, and 15% from 50 to 59 mg/dL, while 5.7% had high levels (≥ 60 mg/dL). Most patients (59.4%) had triglycerides levels < 150 mg/dL, 12.3% from 150 to 199 mg/dL, 20.8% from 200 to 499 mg/dL, and 7.5% ≥ 500 mg/dL. Simvastatin was prescribed to the patients with a high cardiovascular risk (5.7% of the patients) and to those whose triglycerides levels were ≥ 500 mg/dL (3.7%). At the 2-year folow-up evalution, there were reductions in the mean serum total cholesterol and triglycerides, but this decrease was not statistically significant. However, the elevation of HDL after the intervention had statistical significance (p = 0.01). By that time, 36% of patients had indication of pharmachological therapy: atorvastatin was prescribed to 94% of them, rosuvastatin to 3%, and fenofibrate to 3%. The present study demonstrates the high prevalence of dyslipidemia and the importance of routine lipid profile evaluation of Brazilian HIV patients, specially those on HAART.

 

Nothing to Disclose: PRC, ECDON, MDR, FACP, ACMJG, MTSMM, MDFMSJ

13416 17.0000 SUN-0853 A Brazilian HIV Patients Treated with Antiretroviral Therapy Present a High Prevalence of Dyslipidemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Saumya Kumar*1, Rahul Ravilla2 and Monica Agarwal3
1University of Arkansas for Medical Sciences, Little Rock, AR, 2University of Arkansas for Medical Sciences, 3Univ of Arkansas for Med Sciences, Little Rock, AR

 

Introduction

Cholestatic liver disease is a well-known cause of hyperlipidemia. Lipoprotein X (LpX) is the major contributor to elevated lipid levels in obstructive jaundice (1).  LpX is an abnormal serum lipoprotein which is a sub-fraction of low density lipoproteins (LDL). We report a case of obstructive jaundice with highly elevated LDL cholesterol (LDL-C) level that normalized after resolution of obstruction.

Clinical Case

A 42 year old man presented with jaundice. The past medical history was significant for chronic pancreatitis, diabetes mellitus related to pancreatitis and partial gastrectomy. Family history was positive for dyslipidemia in mother but negative for premature coronary artery disease(CAD) or familial hypercholesterolemia (FH). He had history of heavy tobacco and alcohol use. The physical exam was significant for BMI of 12.8 kg/m2 and icteric sclera. There was no tendon or eruptive xanthoma, xanthelesma or hepatospenomegaly. Biochemical evaluation was significant for total bilirubin 12.6 (0.2-1.2 mg/dl), AST 69 (15-41 IU/L), ALT 118 (5-45 IU/L), GGT 1357 (7-50 IU/L), alk phos 1126 (32-91 IU/L). Computed Tomography (CT) of abdomen showed intrahepatic and extrahepatic biliary obstruction. Fasting Lipid panel was measured by Beckman Synchron DXC analyser which is a homogenous assay. Results showed total cholesterol (TC) 942 mg/dl, triglycerides (TGL) 167 mg/dl, HDL-C 12 mg/dl and LDL-C 897 mg/dl. Vertical Auto Profile (VAP) showed total cholesterol 593 (< 200 mg/dl), HDL-C 43 (> 40 mg/dl), VLDL 33 (< 30 mg/dl), TGL 141 (< 150 mg/dl), apoB 100 of 331 (< 109 mg/dl), Lp(a) 26 (< 10 mg/dl) and LDL-C 517 (< 130 mg/dl).  Although the agarose gel electrophoresis showed an abnormal band in the pre-beta region suggestive of LpX but the polyacrylamide gel electrophoresis did not show a characteristic pattern for LpX.  CT guided percutaneous biliary drain relieved the obstruction.  The follow up biochemistry showed total bilirubin 0.7 mg/dl, AST 20 IU/L, ALT 17 IU/L, Alk phos 213 IU/L and GGT 105 IU/L. Repeat lipid panel showed TC 63 mg/dl, TGL 86 mg/dl, HDL-C 23 mg/dl, LDL-C 23 mg/dl.

Conclusion

Our patient presented with very high LDL-C which led to the initial suspicion of familial hypercholesteremia (FH). Due to concomitant obstructive jaundice, no CAD and no significant family history the suspicion for FH was low. LpX is rarely discovered in normal population due to quick catabolism but reaches very high levels in cholestatic jaundice (2). It differs from LDL particle due to absence of Apo B and high content of unesterified cholesterol (3).  Due to absence of Apo B it is not taken up by hepatocytes and cannot cause feedback inhibition of HMG Co A synthase, hence causing elevated levels of cholesterol. In our patient, the clinical presentation strongly supported the presence of LpX.  The best treatment is to relieve the obstruction.  Expedited management with LDL apheresis may be considered (4).

 

Nothing to Disclose: SK, RR, MA

13549 18.0000 SUN-0854 A The Mystery of Lipoprotein X in Liver Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Robina Iftikhar Rana*1, Robert Alexander Hegele2 and Adam D McIntyre2
1Schulich School of Medicine and Dentistry, Western University, London, ON, Canada, 2Robarts Research Institute, London, ON, Canada

 

Background:  Determinants of high density lipoprotein (HDL)-cholesterol (C) levels are multifactorial, including both genetic and environmental factors along with their complex interaction. Genetic determinants include rare large-effect mutations in single genes, multiple small-effect common single nucleotide polymorphisms (SNPs) and environmental factors such as alcohol and oral estrogen.  However, the relationship between markedly elevated HDL-C levels and risk of atherosclerotic vascular disease in individual patients is not clear.

 Case report: We report a 64 year old retired female teacher with history of heavy alcohol use and no history of coronary heart disease who was referred with elevated total cholesterol (TC) and HDL-C concentrations of 8.91 mmol/L ( normal <5.20 mmol/L) and 4.44 mmol/L (normal 1.30 – 1.55 mmol/L) , respectively, which were detected on routine lipid profile.  The ratio of TC to HDL-C was 2.0 (normal <4.0). Fasting plasma triglycerides and low-density lipoprotein (LDL)-C levels were 1.16 mmol/L (normal <1.70 mmol/L) and 3.94 mmol/L (normal <2.0 mmol/L), respectively.  Using a next-generation sequencing panel for dyslipidemia genes (LipidSeq, Illumina), we found that this patient: 1) was heterozygous for a rare premature termination mutation in the CETP gene, namely p.Q326X; and 2) had a high genetic risk score of comprised of common SNPs that genome-wide association studies (GWAS) had reported as being strongly associated with increased HDL-C.

Discussion:  The extraordinarily elevated HDL-C levels in this patient were thus multifactorial and associated with the concurrent presence of a heterozygous rare large-effect mutation, an assortment of common small-effect SNPs together with heavy alcohol use.  Typically HDL-C may be increased by 50-80% with any single one of these factors.  However, together, these factors appeared to have a synergistic effect to raise HDL-C.  Despite the remarkable biochemical deviation, this patient appeared to have neither disproportionate protection from, nor disproportionate susceptibility to atherosclerotic CVD.  Studying rare patients with extreme lipid phenotypes may be one approach to understand underlying mechanisms, their interactions and their relationship with clinical end points.

 

Nothing to Disclose: RIR, RAH, ADM

12405 19.0000 SUN-0855 A Multifactorial Basis for Dramatically Elevated HDL Cholesterol Levels 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Jianmei Yang*1, Xu Zhang2, Chunxiao Yu3, Jin Xu3, Chao Xu4, Ling Gao2 and Jiajun Zhao2
1Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan, Shandong, 2Shandong Provincial Hospital affiliated to Shandong University, Jinan, China, 3Provincial Hospital affiliated to Shandong University, China, 4Shandong Provincial Hospital affiliated to Shandong University, Department of Endocrinology and Metabolism, China ;, Jinan, Shandong

 

Background

Previous studies reported excessive lipid accumulation in organs was detrimental to health. But it has been not clear whether there is association between elevated serum lipid and adenohypophysis hormones. Here, we explored the effects of hyperlipidemia on adenohypophysis function.

Methods

This study had two parts. Part 1 was a cross-sectional of epidemiological investigation from 11,000 subjects. All participants were stratified according to age, blood gulcose and blood pressure. According to the study criteria, 95 men were selected including healthy control (n=61) and patients with hyperlipidemia (combine hypercholesterol-hypertriglyceridemia together, n=34). Their anthropometric parameters and serum were gained. Part 2 was an animal study, 40 male rats were randomized into normal control diet (100% Basic feed, n=20) or high fat diet (HFD) (83.7% Basic feed +1% Cholesterol +15% Lard +0.3% Cholate, n=20). At the end of 0 th, 4 th and 28 thweek of treatment, serum was collected. Serum lipid profile was measured using enzymatic method and TSH, FSH, LH and ACTH (Human normal ranges: 0.27-4.2 mIU/L, 1.5-12.4 mIU /mL, 1.7-8.6 mIU/mL and 7.2-63.3 pg/mL, respectively.) were detected using ELISA.

Results

(1) Epidemiological investigation showed the serum levels of TSH, FSH and LH increased while serum ACTH level was decreased in patients with hyperlipidemia (TSH, increased 50%, p<0.05). The results showed an association of hyperlipidemia with adenohypophysis hormones, especially TSH.

(2) To explore progressive effects of hyperlipidemia on adenohypophysis hormones, we set up HFD model of rats. There was no differences of both serum lipid and adenohypophysis hormones at 0 th week between control and HFD rats. However, serum lipid levels became an increase at the end of 4 th week. The total cholesterol and triglycerides increased about 1.6- and 1.5-fold in HFD rats at 28 thweek, respectively. Presenting an elevation of serum lipid levels in a time-dependent manner.

(3) For TSH (µIU/ml), the serum TSH levels of HFD rats were higher than those in the control group (4 th week:1.34±0.18 vs. 0.65±0.39, p<0.01; 28 th week: 1.95±0.32 vs. 0.68±0.17, p<0.01). Interesting, the dramatic change of TSH level was detected at 4 thweek.

(4) For FSH (mIU/ml) and LH (µIU/ml), they increased in HFD rats relative to the control. (4 th week FSH: 22.81±8.15 vs. 11.96±7.68, p>0.05; 28 th week FSH: 33.11±4.37 vs. 14.06±2.24, p<0.05; 4 th week LH: 15.07±0.44 vs. 14.89±0.10, p>0.05 and 28 th week LH: 17.48±0.59 vs. 16.58±0.37, p<0.01). It did not test the obvious change until 28thweek.

(5) For ACTH (pg/ml), similar to human, the serum ACTH levels presented a mild fluctuate under the study process. (4 th week: 7.52±0.16 vs. 7.34±0.12, p>0.05; 28 th week: 7.33±0.19 vs. 7.39±0.28, p>0.05).

Conclusions

Hyperlipidemia could affect adenohypophysis function. The serum TSH level was affected firstly, then FSH/LH and ACTH at last.

 

Nothing to Disclose: JY, XZ, CY, JX, CX, LG, JZ

13532 20.0000 SUN-0856 A Effects of Hyperlipidemia on Adenohypophysis Function 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Leslie Mae Kimura*1, Griselda Alvarez2, Anna Pawlikowska-Haddal3, Jacqueline Casillas4 and Kuk-Wha Lee5
1UCLA Mattel Children's Hospital, Los Angeles, CA, 2Mattel Children's Hospital UCLA, Los Angeles, CA, 3UCLA Mattel Children's Hospital, Los Angeles, 4UCLA Mattel Children's Hospital, 5Mattel Children's Hosp - UCLA, Los Angeles, CA

 

Background: Lipodystrophy is often accompanied by severe insulin resistance and diabetes (1). High insulin doses are needed to achieve euglycemia and self-resolution of diabetes has not been previously reported. There has been a recent case series by Adachi et al that suggested stem cell transplant including total body irradiation is a new etiology for acquired partial lipodystrophy [2]. 

Clinical Case: 10-year-6-month old girl with history of Acute Lymphoblastic Leukemia (ALL) with stem cell transplantation complicated by chronic-graft-versus-host disease presented with hyperglycemia and hypertriglyceridemia, and was diagnosed with diabetes. Her physical appearance was consistent with acquired partial lipodystrophy (APLD) with little subcutaneous fat on her extremities and gluteal region, and lipohypertrophy of her face and abdomen. Initial tests showed hemoglobin A1c of 9.2% (4.4-5.9%), c-peptide 29.3ng/mL (1.9-4.3 ng/mL), and triglycerides  3090 mg/dL (39-120 mg/dL). Her insulin requirement was quite severe at nearly 10 units/kg/day.  Additionally, she was treated with fenofibrate and metformin. Insulin was able to be discontinued for a period for 6 months, however was restarted 1 month prior to her unfortunate demise.

Conclusion: This is the first case in which a patient with APLD with a tremendously high daily insulin requirement was able to discontinue insulin completely and maintain euglycemia for several months without additional or alternative therapies such as leptin or IGF-1.

 

Nothing to Disclose: LMK, GA, AP, JC, KWL

15888 21.0000 SUN-0858 A Resolution of Insulin Requirement in Acquired Partial Lipodystrophy Related to Graft-Versus-Host Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Rashi Agarwal*1, Rudruidee Karnchanasorn2 and Girish Mour1
1St. Catherine Hospital, Garden City, KS, 2The University of Kansas Medical Center, Kansas City, KS

 

Background:

Vitamin D deficiency (VDD) has been associated with several metabolic, musculoskeletal, immunologic, inflammatory, infectious and liver diseases. The presence of VDD and nonalcoholic fatty liver disease (NAFLD) has become more prevalent in the general population independent of each other as well as concomitantly where patients with NAFLD have significant VDD. The prevalence of this association has not been reported in rural population.

Objective:

To determine the prevalence of VDD in patients with NAFLD diagnosed on abdominal ultrasound in a rural outpatient primary care clinic in southwest Kansas over a 21 month period, and assess co morbidities associated with both conditions.

Methods:

A retrospective analysis of ultrasound diagnosed fatty liver disease was conducted over a 21 month period. Patients who had ultrasound findings of NAFLD and had the 25 (OH) D levels measured were included in the study. Demographics data and co morbidities were collected and analyzed. People with history of alcohol abuse and hepatitis C were excluded.

Results:

Of 242 patients who had abdominal ultrasound, 13 were excluded. 69 patients (30%) had NAFLD on ultrasound of which 20 patients (29%) had their 25(OH) D concentrations measured.

Prevalence of VDD defined as 25(OH) D levels < 30 ng/ml in patients with NAFLD was 95%. 60% were males. Prevalence of 25(OH) D levels <10, 11-20, 21-29 ng/ml was 26%, 32% and 42% respectively. Median patient age was 62 years. Prevalence of NAFLD and VDD was significantly higher in obese patients (BMI>30kg/m2)) at 79%. Of the 79% obese patients, NAFLD and VDD were most prevalent in class I obesity (BMI 30-34.9kg/m2) at 37% followed by class II (BMI 35-39.9kg/m2) and class III (BMI >40kg/m2) obesity at 21% each. Hypertension was the most common co morbidity in 74%, while both diabetes type 2 and dyslipidemia were present in 58% patients with NAFLD and VDD. 63% patients with NALFD and VDD had normal transaminases.

Conclusion:

VDD was highly prevalent in patients with NAFLD in rural setting. Obesity and hypertension were the most commonly associated co morbidities. Previous studies have shown high prevalence of VDD in NAFLD and suggested a possible causal association. Detection and treatment of VDD in patients with NAFLD may be a simple and cost-effective adjunct to weight loss which is the only effective evidence based treatment of NAFLD at this time. However, further studies are needed to confirm these findings.

 

Nothing to Disclose: RA, RK, GM

16512 22.0000 SUN-0859 A Fatty Liver Disease and Vitamin D Deficiency…Evident? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Ahmed Ziada*
University of Western Ontario, London, ON

 

Management of very severe hypertriglyceridemia with and without plasma exchange.

Ahmed Ziada, Robert A. Hegele

Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada N6A 5B7

 

Background:  Acute pancreatitis (AP) is a potentially life-threatening complication of severe hypertriglyceridemia (HTG), which is some case series is the third most common cause of AP. The risk of AP markedly increases with very severely increased triglyceride (TG) levels > 22.6 mmol/L (normal < 1.7 mmol/L), but can be largely prevented by maintaining TG < 11.3 mmol/L. Usual management of HTG-induced AP includes: 1) cessation of oral intake; 2) fluid replacement; and 3) correction of secondary factors that predispose to HTG.  Plasma TG levels typically fall (half-life 48-72 hours) with these conservative measures and patients typically stabilize and survive.  Recently, several anecdotal reports of plasmapheresis or plasma exchange (PLEx) in the early stages of HTG-induced AP have demonstrated dramatic TG reductions, prompting some clinicians to recommend this intervention in the acute setting. 

Description: We report three patients consecutively admitted to our hospital in 2013 with very severe HTG-induced AP: cholesterol and TG levels at baseline were: patient #1 - 17.4 (normal < 5.2) and >62.2 mmol/L; patient #2 -10.8 and 44.0 mmol/L; and patient #3 - 41.7 and >62.2 mmol/L respectively.  Partial lipoprotein lipase deficiency was demonstrated molecularly in patient #3.  Patients #1 and #2 received no PLEx, while patient #3 received a single course of PLEx within 24 hours of admission.  By 72 hours, plasma TG was reduced by 68%, 77% and 73% in patients #1, #2 and #3, respectively.  Dynamics of TG reduction followed a similar for trajectory over the next week for all three patients.  All three patients were eventually discharged with essentially normal profiles, with dietary restrictions and on fibrate therapy.

Conclusion:  The clinical course in these three patients with severe HTG-induced pancreatitis suggests that PLEx is not necessary even in very severe cases, and that TG levels will correct rapidly with conservative measures and control of secondary factors.  The role of PLEx in this situation should be addressed more formally in a clinical trial format.

 

Nothing to Disclose: AZ

14320 23.0000 SUN-0860 A Management of Very Severe Hypertriglyceridemia with and without Plasma Exchange 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Mohammad Saeed Alkhatib* and Anzar Haider
Cleveland Clinic Childrens Hospital, Cleveland, OH

 

DKA is an acute metabolic complication of insulin deficiency, characterized by acidosis, hyperglycemia, and ketosis.  It may occur in  30% of patients with new onset type I diabetes(T1DM).  Insulin deficiency leads to derangement in lipid metabolism resulting in lipolysis with excess production of fatty acid from adipose tissue and increased  synthesis of triglyceride (TG).  Elevated TG can cause pancreatitis and pseudo hyponatremia.  Typically, TG level  is not significantly elevated (>500 mg/dl) in the majority of patients presenting in DKA. We describe  an adolescent who presented with DKA and severe hypertriglyceridemia at the onset of T1DM. The elevated TG resolved with only insulin and IVF hydration without any antilipid agent.

Case report:  A previously healthy 14 year old adolescent presented in DKA with a six week history of polyuria, polydipsia , 10 lbs weight loss and two week history of nocturia.   Except for moderate dehydration, exam did not reveal any Kussmal breathing, sensorial changes,  zanthomas or lipemia retinalis. A family history was negative for  T1DM and dyslipidemia.  A chemistry profile drawn at the time of presentation  revealed a sodium  of 121 mmol/L, bicarbonate 15 mmol/L,  glucose 514 mg/dl, moderate ketonuria  and A1C of 17.8%. A lipid panel drawn because of lipemic blood revealed a total cholesterol of 972 mg/dl, TG of 11,224mg/dl. LDL could not be calculated due to extremely elevated TG level. Pancreatic and liver enzymes were normal. TSH was also normal. He was treated with IVF and subcutaneous insulin injection with glargine and lispro.  LDL started declining with resolution of DKA and normalization of electrolytes. He was discharged on day 4. A lipid profile obtained at 3 weeks after discharge revealed normal TG of 89 mg/dl, LDL of 106 mg/dl, VLDL of 18 mg/dl and HDL of 60 mg/dl.

 Conclusions:  Insulin is a potent antilipolytic agent and can reverse the process of lipolysis by stimulating lipoprotein lipase. Unless TG and LDL fail to resolve, statin and fibrate (antilipid agents) are not needed if adequate therapy with insulin and rehydration are achieved.

 

Nothing to Disclose: MSA, AH

15069 24.0000 SUN-0861 A Severe Hypertriglyceridemia in a Patient with Diabetic Ketoacidosis (DKA) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Narmada Movva*1, Paula Butler2 and Janice L Gilden3
1Rosalind Franklin University of Medicine and Science/Chicago Medical School, North Chicago, 2Mt Sinai Hosp Med Ctr, Chicago, IL, 3RFUMS/Chicago Med Schl, North Chicago, IL

 

Background: Severe hypertriglyceridemia is a common cause of acute pancreatitis, followed by gallstones and alcohol, and accounts for about 10% of cases in the general population. Lipid profile changes in normal pregnancy are characterized by marked elevations of total plasma cholesterol and triglyceride (TG) levels. This is due to estrogen-induced increase in TG rich lipoprotein production and decrease in clearance of TG due to suppression of lipoprotein lipase activity in liver and adipose tissue. Hypertriglyceridemia-induced pancreatitis is associated with greater severity and higher mortality. About 50% of cases with acute pancreatitis in pregnancy are caused by high TG levels.

Clinical case: A 32 year old woman, 38weeks pregnant (G5 P4), presented with severe abdominal pain and vomiting.  She was admitted to the Hospital for evaluation and management. Previous pregnancies were full-term normal vaginal deliveries. Initial laboratory: Amylase=1,617 u/l (reference range16-96), Lipase=1,330 u/l (reference range 22-51), Triglycerides=12,570 mg/dl, Total cholesterol=1,067 mg/dl, HDL=74 mg/dl, and LDL not calculated (lipemic specimen); TSH=0.32(reference range 0.34-5.60 uIU/ml), Free T4=0.98(reference range 0.58-1.64ng/dl),normal transaminases. A diagnosis of acute pancreatitis was made.  An emergency cesarean section with intubation, was performed, due to acidosis and worsening pain of mother with both fetal and maternal distress (tachycardia).  Abdominal/pelvic CT scan showed significant peripancreatic inflammation and fluid within the pelvis, with possible hemorrhage, but no appreciable necrosis. Plasmapheresis was performed. After one session, TG decreased > 95% (from 12,570 to 471 mg/dl). The sepsis, left-sided pleural effusion, and ascites all improved following Plasmapheresis. The above complications continued to improve and by post-op day 3, she was extubated.  Fenofibrate treatment was then started, along with dietary restriction of calories and fat. TG continued to improve and was 398mg/dl at the time of hospital discharge (day 14). 

Conclusion: Hypertriglyceridemia is common during pregnancy, and although rare, severe elevations can occur and cause acute pancreatitis. The general treatment measures include: dietary restriction, lipid lowering drug treatments (such as fibrates, omega 3 fatty acids, medium chain triglycerides, heparin, insulin, and even plasmapheresis in difficult to manage cases. This case highlights the importance of early recognition, so that appropriate and aggressive treatment of hypertriglyceridemia-induced pancreatitis can be achieved with a decrease of morbidity and mortality in both the mother and baby.

 

 

Nothing to Disclose: NM, PB, JLG

13907 25.0000 SUN-0862 A Severe Hypertriglyceridemia-Induced Acute Pancreatitis in Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Omar Salim1, Kern Chaudhry2, Mashood Qadri3, Humza Salim4 and Mohamad Hosam Horani*5
1Midwestern University, AZ, 2Mercy-Gilbert Hospital, 3Desert Kidney, Phoenix, AZ, 4Midwestern University, AZ, 5Alsham Endocrinology, Chandler, AZ

 

 Case presentation : A 44 year old female presented with a 24 hour history of abdominal pain radiating to the back,lethargy, nausea, vomiting, and a fever of 103.7. Past medical history is significant for lipodystrophiy,  diabetes mellitus, hypertriglyceridemia, previous episode of pancreatitis, psoriatic arthritis. The patient does not smoke,drink, or use any non-prescription drugs. The patient was noncompliant in taking fenofibrate, methotrexate, andlevemir. The physical exam was significant for abdominal distension in the epigastric region. Vital signsshowed a blood pressure of 143/74, pulse 101. Respirations 16, pulse ox of 99, and a temperature of 38.1.
Laboratory findings revealed Hgb of 15.5, platelet count of 246, and WBC of 11.3. Sodium was 131, chloride97, potassium 3.6, bicarbonate 5 mEq/L , Cr  0.73, glucose level of 321, and . Lipase was 1,228U/L and amylase was 90 U/L. Lipid panel showed cholesterol at 632 mg/dL, triglycerides at 4,502 mg/dL,
patient received fluids,intravenous   insulin  , and IV antibiotics. The day after, serum glucose was 167 mg/dL, lipase decreased to 769, sodium was down to 127, triglycerides were still 4,500 mg/dL, and the bicarbonate dropped to 3 mEq/L . Patient  was kept on DKA  protocol for extra day because of persistant Anion gap acidosis

The endocrinology consult was obtained for hard to treat DKA , ABG was ordered and showed normal PH 7.39 with Bicarb of 20 while concomitant serum Bicarb  3 mEq/L .  and it was concluded that
hyponatremia and low bicarbonate were due to dilutionional effect of severe hypertriglyceredimia.  plasmapheresis  was intitated with normalization of serum bicarbonate after significant improvement in tryiglyceride level .

Discussion: Insulin deficiency in DKA enables the increase release of free fatty acids, which increases the formation of VLDL. Less VLDL is removed from the plasma due to reduced activity of lipoprotein lipase, which results in hypertriglyceridemia. This can decrease electrolyte measurements and bicarbonate via the dilutional effect of high amounts of serum lipids. This causes falsly high anion gap , so the arterial blood Gas measurement was necessary. Another etiology   if the serum is separated and left exposed to the air for more than 1 h, then bicarbonate concentration will be spuriously low, thereby elevating the anion gap .

  Conclusion :  If  metabolic acidosis persists despite appropriate treatment of diabetic ketoacidosis Serum Triglycerides level should be abtain,  and spuriously  low serum  bicarobanate secondary to dilutional effect of hypertriglyceredimia should be considred.

 

Nothing to Disclose: OS, KC, MQ, HS, MHH

13255 26.0000 SUN-0863 A Pseudo DKA Secondary to Severe Hypertriglyceridemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Usman H Malabu*1, Moe Thuzar2, Vasant V Shenoy2, Ryan Schrale3 and Kunwarjit Singh Sangla4
1The Townsville Hospital, Douglas, Australia, 2Townsville Hospital, Australia, 3Townsville Hospital, Townsville, 4Townsville Hospital, Townsville QLD, Australia

 

Extreme hypertriglyceridemia defined as serum triglyceride (TG) level >50 mmol/l (4425 mg/dl) can lead to acute pancreatitis (1). Rapid lowering of plasma TG is necessary in order to prevent such life threatening complications. However, there is no established guideline on the acute/immediate management of severe hypertriglyceridemia in clinical practice (2). The aim of the study was to review acute management and clinical course of patients with extremely high serum TG at a regional hospital. Ten cases of extreme hypertriglyceridemia admitted at the Australia’s Townsville Hospital between January 2010 and October 2013 were retrospectively reviewed. Age range: 24-55 years. Nine out of the 10 subjects were patients with type 2 diabetes, 3 of them were newly diagnosed. Mean haemoglobin A1C was 12% (108 mmol/mol) and mean random blood glucose at presentation was 324 mg/dl (range: 184-533). Five patients presented with acute pancreatitis. Mean TG at presentation was 100.5 mmol/l (8894 mg/dl). Plasma TG levels decreased by about 80% in the first 24 hours in those patients who were managed with nil per oral (NPO) and intravenous (IV) insulin infusion (n=4) and by about 40% in those treated with IV insulin infusion alone without NPO (n=4). Furthermore, mean daily serum TG was lower in subjects on insulin + NPO compared to patients on insulin alone 9.5 vs 33.8 mmol/l (841 vs 2991 mg/dl), p=0.0002; CI: 13.0-38.3. The clinical course was uncomplicated in all except one patient who subsequently developed a pancreatic pseudocyst. Thus, poorly controlled type 2 diabetes is a common trigger for extreme hypertriglyceridemia. Combination of NPO and IV insulin is an effective, simple and safe treatment strategy in immediate management of severe hypertriglyceridemia. Further prospective studies on a larger population are needed to confirm our findings.

  1. Ewald N, Hardt PD, Kloer H. Severe hypertriglyceridemia and pancreatitis: presentation and management. Curr Opin Lipidol 2009;20:497-504.

  2. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486-97.

Nothing to disclose: UHM, MT, VS, RS, KSS

Source of research support: James Cook University Australia research grant JCU/MRU 092010/528.

 

Nothing to Disclose: UHM, MT, VVS, RS, KSS

15843 27.0000 SUN-0864 A Extreme Hypertriglyceridemia Managed with Intravenous Insulin with or without Nil per Oral: Is There a Difference? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Chase D Hendrickson* and Sushela S Chaidarun
Dartmouth-Hitchcock Medical Center, Lebanon, NH

 

Background:  Both Niemann-Pick disease (NPD) and, to a lesser extent, subclinical hypothyroidism have been associated with dyslipidemia. While treating subclinical hypothyroidism has been shown to have only a minimal effect on dyslipidemia, investigations did not focus on patients with preexisting causes for dyslipidemia, particularly in the sphingomyelin-cholesterol lipidosis known as NPD.

Clinical Case: A 52-year-old lady with short stature and hepatosplenomeagly had been diagnosed with NPD type B many years before. She had longstanding dyslipidemia, with a recent fasting lipid panel showing a total cholesterol of 323 mg/dl (normal ≤ 199 mg/dl), a direct LDL of 266 mg/dl (normal ≤ 99 mg/dl), an HDL of 20 mg/dl (normal ≥ 40 mg/dl), and triglycerides of 403 mg/dl (normal ≤ 149 mg/dl). Her dyslipidemia was attributed to her NPD, and she refused treatment due to intolerance of medications and fear of liver injury, as she had mildly abnormal liver biochemical tests. She began to experience a decline in her functional status that had also been attributed to her NPD, with a workup for other causes showing only subclinical hypothyroidism. A recent TSH was 5.05 µIU/ml (normal 0.27 – 4.20 µIU/ml), with a total T4 from several years before of 6.6 µg/dl (normal 4.0 – 10.0 µg/dl) along with a TSH of 5.62 µIU/ml at that time.

In an attempt to improve any contributing factor to her declining functional status, her subclinical hypothyroidism was treated with levothyroxine 50 mcg daily, with a decrease in her TSH to 3.34 µIU/ml. With this change, her functional status improved, and her repeat fasting lipid panel was as follows: total cholesterol 266 mg/dl, LDL 183 mg/dl, HDL 21 mg/dl, and triglycerides 308 mg/dl.

Conclusion: The patient described above improved her dyslipidemia significantly with levothyroxine therapy for her subclinical hypothyroidism. Treatment of subclinical hypothyroidism has not been shown to significantly impact dyslipidemia, though it perhaps does when the LDL is significantly elevated. (1) The dyslipidemia in NPD type B is proposed to be related to the sphingomyelinase deficiency that is the hallmark of this disease. (2) In rat studies, levothyroxine therapy has been shown to increase the activity of sphingomyelinase. (3) Thus, treatment of subclinical hypothyroidism in patients with additional causes for dyslipidemia, such as NPD, may be particularly beneficial in terms of the lipid profile.

 

Nothing to Disclose: CDH, SSC

11844 28.0000 SUN-0865 A Treatment of Subclinical Hypothyroidism in Niemann-Pick Disease Causing Significant Improvement in Dyslipidemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Jean Abigaile Romero Castro-Caringal*1 and Leilani Basa Mercado-Asis2
1University of Santo Tomas Hospital, Manila City, Philippines, 2University of Santo Tomas, Manila City, Philippines

 

We have reported that inspite low fat diet and statin treatment, triglyceride (TG) and very low-density lipoprotein (VLDL) levels still peaked and plateaued postprandially.

Our objective is to determine if brachial artery flow-mediated dilatation (FMD) changes occur during postprandial peaking and plateauing of TG and VLDL on patients with cerebro- and cardiovascular diseases inspite of low fat diet and statin treatment.

Five subjects with normal fasting lipid levels (total cholesterol <200mg/dL, TG <150 mg/dL, and LDL <100mg/dL), were given low fat diet (30kcal/kg divided into 3 meals) given at time 0800H, 1200H, 1800H and 2 snacks at 1000H and 1600H, and their lipid levels and FMD were determined at 0, 2nd, 4th, 6th, 8th, 10th hour. All were taking atorvastatin daily for at least 6 months.

FMD was found to be consistently inversely correlated with triglyceride and VLDL for all patients.  Comparison of average values across the five patients showed that there is a significant inverse relationship between FMD and triglyceride (p<0.01) and between FMD and VLDL (p<0.01). 

Decrease in brachial artery FMD occurs at the same time the triglyceride and VLDL levels peaked in the high risk patients with cerebro- and cardiovascular diseases inspite of low fat diet and statin treatment.

 

Nothing to Disclose: JARC, LBM

16504 29.0000 SUN-0866 A Flow-Mediated Dilatation of Brachial Artery Is Inversely Correlated with the Postprandial Peaking of Triglyceride and Very Low-Density Lipoprotein in Patients with Cardio- and Cerebrovascular Diseases Despite Low Fat Diet and Statin Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Iram Hussain*, Zahid Ahmad and Abhimanyu Garg
University of Texas Southwestern Medical Center, Dallas, TX

 

Background: Pseudohyponatremia is typically seen in hyperglycemia, hypertriglyceridemia and hyperparaproteinemia, but its association with severe hypercholesterolemia is not well known.

Clinical case: A 43-year-old African-American woman with refractory primary biliary cirrhosis – diagnosed 8 months ago by biopsy and elevated anti-mitochondrial antibodies – was admitted for evaluation of low serum sodium (121 mmol/L; normal range: 135 – 145 mmol/L) and complaints of increasing fatigue, jaundice and itching. Her serum sodium levels were normal for the last 3 years; with slight reductions noted 3 months (133 mmol/L) and 1 month (131 mmol/L) before presentation.  She was taking azathioprine, cholestyramine, fenofibrate, hydroxyzine, prednisone, ranitidine, sertraline, trazodone, ursodiol, zofran, promethazine, prochlorperazine, losartan and amlodipine; and reported no recent changes in medications.

Her physical examination was significant for scleral icterus. She had no hepatosplenomegaly, xanthelasmas or xanthomas. Her AST was 120 U/L (10 – 35 U/L), ALT 107 U/L (10 – 35 U/L), alkaline phosphatase 507 U/L (35 – 104 U/L) and total bilirubin was 10.2 mg/dL (0.2 – 1.3 mg/dL). She was given intravenous fluids that were discontinued when a lipid panel revealed total cholesterol level of 2415 mg/dL (120 – 199 mg/dL), triglycerides of 299 mg/dL (50 – 150 mg/dL) and HDL-cholesterol of 42 mg/dL (45 – 65 mg/dL). Two years ago her total serum cholesterol was 322 mg/dL. This suggested a rapid progression of primary biliary cirrhosis resulting in accumulation of lipoprotein-X, and development of pseudohyponatremia secondary to lipoproteinemia.

The diagnosis of pseudohyponatremia was confirmed by measurement of serum osmolality (296 mOsm/kg H2O; normal range: 270 – 300 mOsm/kg H2O) and direct measurement of serum sodium (140 mmol/L; normal range: 135 – 145 mmol/L). Lipoprotein electrophoresis confirmed major presence of lipoprotein-X. Serum apolipoprotein B was only slightly elevated at 218 mg/dL (48 – 124 mg/dL). Her serum sodium for the next two days ranged from 120 – 125 mmol/L and she was discharged.

Conclusion: This case shows that extreme hypercholesterolemia from elevations of lipoprotein-X particles in cholestasis can be a rare cause of pseudohyponatremia. It highlights the need to consider this possibility prior to initiating treatment of hyponatremia.

 

Disclosure: ZA: Speaker, Sanofi, Speaker, Genzyme Corporation. Nothing to Disclose: IH, AG

15243 30.0000 SUN-0867 A Extreme Elevation of Lipoprotein-X in Primary Biliary Cirrhosis Presenting with Pseudohyponatremia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Pimjai Anthanont*1, John S. Millar2, Jeffrey Billheimer3, Marina Cuchel3, Daniel J. Rader3 and Ernst John Schaefer1
1JM USDA HNRCA at Tufts university, Boston, MA, 2Perelman School of Medicine, University of Pennsylvania School of Medicine, 3University of Pennsylvania School of Medicine

 

Clinical case: A 68 year old man had a long history of marked HDL deficiency and CHD. He was initially diagnosed with CHD at age 54 years when he developed angina, and coronary angiography revealed high grade stenoses of > 80% in coronary arteries. He underwent quadruple coronary bypass grafting surgery. He had a history of hypertension and no history of diabetes or smoking. Physical examination revealed normal except corneal arcus and diminished peripheral pulses. The patient had the following plasma lipid concentrations: total cholesterol 104, triglyceride 127, LDL-C 62, HDL-C, apoA-I 57 (normal >120 mg/dL) and Lp(a) 94 mg/dL (normal < 30 mg/dL). Liver, thyroid and renal function tests were normal. His father died of CHD at age 54 years. His paternal grandmother died of CHD in their 50s or 60s. His mother, age 88 years, was of Greek origin. She had no history of CHD. However, his mother did have a history of low HDL-C as well as his two brothers. DNA sequencing revealed the proband, his mother, and his youngest brother were found to be heterozygous for a C→T substitution at nucleotide 718 (c.718C >T, p.Gln216*). This mutation results in an apoA-I containing only the initial 215 of 243 amino (truncated apoA-I). We carried out the kinetic study in this proband. The data showed the apoA-I production of the proband was only 59% of that observed in the controls. His apoA-I fractional catabolic rate was 95% of control values. Cholesterol efflux capacity was assessed. The proband had low normalized efflux at 65% of the control values. This level of efflux was commensurate with the low HDL-C and apoA-I values observed in the proband's serum, similar to what was observed in two other subjects with low HDL-C.

Conclusion: We report a kindred in which a novel heterozygous apoA-I truncation results in decreased levels of HDL-C, apoA-I, very large HDL particles, and normalized cellular cholesterol efflux, associated with decreased apoA-I production. The association of this truncation with premature CHD remains uncertain, since two other familial lipoprotein disorders, namely familial Lp(a) excess and familial combined hyperlipidemia, were also observed in this kindred.

 

Nothing to Disclose: PA, JSM, JB, MC, DJR, EJS

11548 31.0000 SUN-0868 A A Novel Apolipoprotein A-I Truncation (ApoA-IMytilene) Associated with Decreased ApoA-I Production and Cholesterol Efflux 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0837-0868 4791 1:00:00 PM Clinical Aspects of Lipid Metabolism and Disease Poster

Chelsea N McMahon*1, Kathy Petoumenos2, Karl Hesse1, David A Cooper1, Andrew Carr3 and Katherine Samaras3
1St Vincent's Hospital, Sydney, Australia, 2Kirby Institute, Sydney, Australia, 3St Vincent's Hospital, Sydney NSW, Australia

 

Background: Treated HIV infection is associated with insulin resistance, metabolic syndrome and increased risk of diabetes in the short to medium-term. The long-term risk and predictors of glucose disorders are not clear. We hypothesized that (i) baseline %body fat, central obesity and insulin resistance predicted incident glucose disorders in treated-HIV infection and (ii) baseline glucose predicted mortality.

Methods: Data on participants in a longitudinal cohort study of 144 HIV-infected men attending a tertiary referral hospital and receiving combined anti-retroviral therapy were analyzed for long term glucose status. Glucose status was available in 108 (75%) after a mean 11.1 ± 1.4 years. Diabetes and prediabetes (impaired fasting glucose or impaired glucose tolerance) were ascertained by fasting glucose or oral glucose tolerance test.1 All-cause mortality was ascertained by medical record examination. Longitudinal estimates of visceral fat by dual-energy Xray absorptiometry were available in a subset at baseline and 12 months.

Results: The mean age at follow-up was 58 ± 8 years. Diabetes increased from 2% at baseline to 12% after mean follow-up of 11.1 ± 1.4 years. Pre-diabetes increased from 11% to 37%. Incident glucose disorders occurred in 49% (diabetes 11.5% and prediabetes 37.5%). Incident glucose disorders were associated with higher baseline C-peptide (2.9±0.2 vs. 2.2±0.1 µg/L, p=0.009) but similar baseline age, CD4 count, total and visceral fat, fasting glucose and insulin resistance compared to those who maintained normal glucose levels. In preliminary analyses of the subset with longitudinal body composition, incident glucose disorders were associated with early gains in visceral fat (p=0.02). Incident diabetes was associated with higher baseline insulin resistance (2.8±0.6 vs. 1.7±02, p=0.01), C-peptide (3.4±0.4 v 2.2±0.1 µg/L, p=0.001) and increased visceral fat at 12 months (p=0.05).

All-cause mortality was 14% over the observation duration. Mortality was 9% in those with incident glucose disorders vs 16% in those without (p=0.18). This compares to the general Australian population mortality rate of 4.62% for men aged 45-64 years.2 In logistic regression analysis, no association between mortality and baseline glucose was found, with age, AIDS, CD4 count, BMI or body composition as covariates.

Conclusion: Treated HIV is associated with high rates of incident glucose disorders at 10-15 years, with diabetes predicted by high baseline C-peptide and early visceral fat gain. Measures to prevent diabetes in this high risk group are warranted.

 

Nothing to Disclose: CNM, KP, KH, DAC, AC, KS

14327 1.0000 SUN-0998 A Incident Glucose Disorders and All-Cause Mortality at 15 Years in Treated HIV-Infection 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Isadora C Furigo*1, Jose Donato Jr.2, Miriam F Suzuki3, Thais T Zampieri1, João AB Pedroso1, Angela MR Lobo1, Amanda Alencar1, João E Oliveira3, Paolo Bartolini3 and Carlos RJ Soares3
1University of Sao Paulo, Sao Paulo, Brazil, 2University of Sao Paulo, Sao Paulo - SP, Brazil, 3IPEN-CNEN/SP

 

The quick release bromocriptine mesylate (Cycloset®) was recently approved as a drug to treat type 2 diabetes mellitus. Although several studies have shown beneficial effects of bromocriptine to reduce hyperglycemia in diabetic rodents and humans, the exact mechanism of action of the anti-diabetic effects of bromocriptine remains unknown. In the present study, we hypothesized that the anti-diabetic effects of bromocriptine is due to reductions in basal prolactin levels. Thus, we studied 4 groups of genetically obese and diabetic (ob/ob) mice for 16 days: 1) control (one daily ip injection of vehicle), 2) prolactin (mini-osmotic pumps infusing ovine prolactin; 18 µg/day), 3) bromocriptine (one daily ip injection of bromocriptine mesylate; 12 µg/g), and 4) bromocriptine+prolactin. Bromocriptine group exhibited a reduction in serum prolactin levels compared to other groups. No changes in food intake were observed among the groups; however, bromocriptine and bromocriptine+prolactin groups showed a reduced weight gain along the experiment. To determine whether glucose homeostasis was affected by the treatments we performed glucose and insulin tolerance tests. Bromocriptine group exhibited an improved glucose tolerance and insulin sensitivity compared to other groups, including bromocriptine+prolactin group. Serum insulin levels were also decreased only in bromocriptine group. In conclusion, prolactin replacement did not change the energy balance of bromocriptine-treated ob/ob mice, but it blunted most of the improvements observed on their glucose control. Our findings suggest a possible mechanism of action of the anti-diabetic effects of bromocriptine.

 

Nothing to Disclose: ICF, JD Jr., MFS, TTZ, JAP, AML, AA, JEO, PB, CRS

14894 2.0000 SUN-0999 A Uncovering the Mechanism of Action of the Anti-Diabetic Effects of Bromocriptine: The Role of Prolactin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Jenny Pena Dias*1, Toshiko Tanaka2, Olga D. Carlson3, Chee W. Chia2 and Josephine Mary Egan4
1NIA/NIH, Baltimore, MD, 2National Institute on Aging, Baltimore, MD, 3NIH/NIA, Baltimore, MD, 4National Institute on Aging/National Institutes of Health, Baltimore, MD

 

Testosterone (T) and Estrogen (E) levels decline with age in men. It is not clear if restoring T levels with long-term T replacement is beneficial or detrimental. In addition, the role lack of E plays in age-related changes in older men is not well studied. In a 12 month randomized, double-blind, placebo-controlled study, we restored T levels in older men (age ≥ 65 years) using T gel (5gm) or anastrazole (1mg), an aromatase inhibitor (AI) that decreases T to E conversion, in order to study the physiological consequences of T vs T+E replacement. Non-diabetic men were randomized into 3 groups: Placebo (P)-group (n=11, age = 71±1 years, T levels (ng/dl)=301.5±13.9, E levels(ng/dl)= 1.7±0.1); T-group (n=10, age=71±1years, T levels =331.5±22 and E levels =2.0±0.2) and AI-group (n=10, age=70±1 years, T levels =318.0±29, E levels = 1.6±0.2). Glucose and insulin levels during 2-hr OGTT, leptin (ng/ml), IGF-1(ng/ml) and fasting lipid levels cholesterol, triglyceride , HDL, LDL were measured at baseline and at 3, 6 and 12 months during treatment. Oral glucose insulin sensitivity (OGIS) index was derived from the OGTT. By 6 months, values of T and E levels in the 3 groups were as follows, P-group: T=400.5±49.1, E=1.8±0.2; T-group: T=653.6±96.2, E=2.5±0.5; AI-group: T=536.0±31.7, E=0.9±0.1. Using intent to treat analysis, no significant change in OGIS was noted between any of the groups.  Baseline leptin and IGF-1 levels were: P-group (leptin 7.4 ± 1.1, IGF-1 = 113.0±9.4); T-group (leptin = 7.7 ± 1.5, IGF-1 = 112.1±10.5); AI-group (leptin = 7.0±1.9, IGF-1=109.2±9.8). By 3 months, there was a significant difference between the two treatment groups (P<0.05) with an increase in leptin levels in the T-group (Δleptin = 1.6±1.4) and a decrease in the AI-group (Δleptin = -1.7±1.1), and the levels remained similar through subsequent months.  IGF-1 levels significantly increased in the T group (but not AI group) and peaked at 6 months (ΔIGF-1 = 15.3±10.3). For lipid levels, a significant decrease in HDL levels in the T-group was noted when compared to the placebo group with the largest decrease at 6 months (baseline HDL (mg/dl): P-group=51.7±3.8, T-group= 44.1±2.4, AI-group=47.5±2.5; ΔHDL at 6 months: P-group =0.9±2.2, T-group=-5.9±1.2, AI-group= 1.7±2.2).  No significant changes in lipid levels were noted over time in P-group or the AI-group. Restoring T levels to physiological range does not change insulin sensitivity in elderly men with borderline T levels. However, restoring T impacted IGF-1, HDL and leptin levels; increases in IGF-1 and decreases in HDL are due to combined T and E effects while decreases in leptin are mediated by E effects.

Acknowledgement:  This research was supported entirely by Intramural Research Program of NIH, NIA.

 

Nothing to Disclose: JPD, TT, ODC, CWC, JME

16245 3.0000 SUN-1000 A Effects of One Year Testosterone Versus Anastrazole Treatment on Physiological Functions in Hypogonadal Older Men 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Riddhi Das Gupta1, Akankasha Tiwari*2, Veena Nair3, V Padmanaban3, Mercy Inbakumari3, Ron Thomas3, Flory Christina3, Sylvia Kehlenbrink4, Michelle Carey5, Nihal Thomas6 and Meredith Hawkins7
1Christian Medical College, 2Montefiore Medical Center, New York, NY, 3Christian Medical College, 4Albert Einstein College of Medicine, 5Albert Einstein College of Medicine, Bronx, NY, 6Christian Medical College, Vellore, Vellore, India, 7Albert Einstein College of Med, Bronx, NY

 

Fibrocalculous pancreatic diabetes (FCPD) is a unique form of diabetes affecting millions of lean people in developing countries, characterized by chronic non-alcoholic calcific pancreatitis, insulin-requiring but ketosis-resistant diabetes, and fat malabsorption (1). To optimize therapeutic strategies for FCPD patients, it is imperative to conclusively assess their insulin secretion and sensitivity using gold-standard methodologies. Comprehensive tests were undertaken in n=9 South Indian males with FCPD (age 31±2 yrs, BMI=19±1 kg/m2, HbA1c=11.4±1.3%), compared with age, BMI, and ethnicity matched non-diabetic (ND, n=10) and type 1 diabetes subjects (T1D, n=13, HbA1c= 9.5±0.3%) and in n=10 subjects with type 2 diabetes (T2D, age 37±2, BMI= 25.0±0.3 kg/m2, HbA1c = 10.2±0.6%). On consecutive days, following correction of hyperglycemia for >12 hours, mixed-meal tolerance tests (MMTT) were performed to assess beta-cell function, and stepped euglycemic, hyperinsulinemic (~30 and 80 mU/m2/min) clamp studies were performed using M-value (constant glucose infusion rate) and 6,6-deuterated glucose to assess insulin sensitivity.

Glucose and C-peptide responses to MMTT suggested that FCPD subjects had similarly impaired insulin secretion to T1D, vs. ND (p=0.001) and T2D subjects (p<0.001).  Prehepatic insulin secretion rate (ISR) by Insulin SECretion deconvolution method (2) was markedly lower in FCPD (7.9±1.0 pmol/kg/min) relative to ND (36.0±4.6; p=0.0002) and T2D subjects (40.0±10.0; p=0.005), but similar to T1D (12.9±4.9; p=0.1). Hepatic insulin sensitivity (M value during low insulin phase) was comparably impaired in the FCPD (4.4±0.2) and T1D (3.6±0.3) vs. ND (7.2±0.7 mg/kg.min, both p<0.002), but most impaired in T2D (2.4±0.4 mg/kg.min, p<0.001 vs. ND). Peripheral insulin sensitivity (M-value at high insulin phase) was also comparably impaired in FCPD (9.0±0.4) and T1D (9.1±0.5) relative to ND subjects (13.5±1.4 mg/kg.min; both p<0.01), but less impaired than in T2D (5.6±1 mg/kg.min; p<0.001 vs. ND). Insulin-stimulated glucose uptake did not differ between T1D and FCPD subjects (p>0.99) and suppression of endogenous glucose production was comparable in both groups (p>0.99). Thus, we report the first C-peptide deconvolution and insulin clamp studies showing that FCPD patients have impaired insulin secretion and insulin resistance  (both comparable to T1D) despite correction of hyperglycemia, highlighting the need for both insulin replacement and sensitization.

 

Nothing to Disclose: RD, AT, VN, VP, MI, RT, FC, SK, MC, NT, MH

17006 4.0000 SUN-1001 A Fibrocalculous Pancreatic Diabetes Is Characterized By Insulin Resistance and Impaired Insulin Secretion 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Pratik Shah*1, Clare Gilbert2, Kate Morgan2, Louise Hinchey2, Syeda Alam2, Hannah Levy2, Roberta Button2, Niamh Landy2, Rebecca Margetts2, Senthil Senniappan3 and Khalid Hussain4
1Great Ormond Street Hospital for Children and UCL Institute of Child Health, London, United Kingdom, 2Great Ormond Street Hospital for Children, London, United Kingdom, 3Alder Hey Childrens Hospital, Liverpool, United Kingdom, 4Sidra Medical & Research Center, Qatar

 

Congenital hyperinsulinism (CHI) is one of the most common causes of hypoglycemia in infancy. Treatment of diazoxide unresponsive patients includes the use of somatostatin analog (octreotide) given either as subcutaneous injections three to four times daily or via a pump. We aimed to evaluate the use of a long acting somatostatin analog (lanreotide) in children with CHI, changing them from daily oral diazoxide or subcutaneous octreotide injections to 4 weekly lanreotide injections. We also studied the pharmacokinetics of lanreotide in children with congenital hyperinsulinism.

Children with diffuse CHI either on high dose diazoxide (causing side effects) or daily octreotide injections were recruited. Initial dose of lanreotide administered was 30mg injected via deep subcutaneous route and the daily diazoxide/octreotide was weaned after the first dose of lanreotide as per standard protocol. Lanreotide was administered every 4 weeks and blood glucose was monitored very closely when weaning their current medications. Each patient had height/weight, baseline USS abdomen, TFT, IGF1/IGFBP3, liver function, HbA1c and continuous glucose monitoring pre and post-lanreotide therapy. Quality of life questionnaires were completed.

14 children with CHI were recruited in the ongoing study (7 boys and 7 girls) and started on lanreotide. The median age is 6 years (3.5-15 years). 3 children had to stop lanreotide treatment (1 had atypical diffuse disease, 1 had profuse diarrhea and 1 showed partial response and developed hypoglycemic episodes on increasing the dose of lanreotide to 60mg). Out of the 11 patients on lanreotide, 8 were on daily octreotide injections and 3 on diazoxide. 7 patients came off their current treatment within 4 weeks of administering first lanreotide injection. However, one patient took more than 12 weeks to come off current treatment and needed a lanreotide dose of 60mg.  6 patients had underlying genetic mutation (ABCC8/KCNJ11). 2 children have come off their continuous overnight feeds and 3 of them are currently being weaned off their overnight feeds. The pharmacokinetic levels of lanreotide are currently being analysed. The preliminary data on the quality of life suggests that both parents and children are very satisfied with the response.

Lanreotide is a safe and effective alternative to octreotide/diazoxide therapy in patients with CHI, offering an improved quality of life. However, some children may not show complete response and monitoring of side effects is equally important. Also, long term follow up is necessary in this group of children with such a complex condition.

 

Nothing to Disclose: PS, CG, KM, LH, SA, HL, RB, NL, RM, SS, KH

15862 5.0000 SUN-1002 A Use of Long Acting Somatostatin Analog (Lanreotide) in Children with Congenital Hyperinsulinism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Antje Körner*1, Scheuermann Dittrich1, Madlen Neef1, Elena Sergeyev1, Mandy Vogel1, Jürgen Kratzsch2 and Wieland Kiess1
1University of Leipzig, Dept. of Women´s & Child Health, Leipzig, Germany, 2Univ of Leipzig, Instit of Lab, Leipzig, Germany

 

Rationale: Evaluation of glucose metabolism is currently based on 2h plasma glucose during an oral glucose tolerance test (oGTT) or fasting plasma glucose and insulin, as these are the only parameters where cutoff values exist. This does, however, not adequately reflect the degree of hyperinsulinemia due to insulin resistance, which needs to be assessed in obese children.

Objective: From frequent glucose and insulin levels during an oGTT of 64 healthy lean children (aged 7.7-18.8 years, BMI SDS ‑0.25±0.76) we aimed i) to established reference values for insulin secretion in normal children. ii)We compared insulin and glucose dynamics with data of 99 obese children (aged 6.1-17.9 years, BMI SDS 2.43±0.50). iii) We then applied these reference data to assess the prevalence of insulin resistance in an extended cohort of 1085 obese children.

Results:

i) From the healthy lean controls, we defined the maximal observed peak insulin (986 pmol/L) and minimal Matsuda ISI (3.154) as cutoffs. In lean children, pubertal status significantly affected fasting plasma (FPI) and Matsuda ISI.

ii) Integral and 2h glucose levels were significantly increased in obese children independent from age, gender and pubertal stage. However, particularly insulin parameters were markedly elevated, with peak and integral insulin levels doubled in obese compared to lean controls. The puberty effect seen in lean controls was overridden by BMI SDS when obese peers were included, which explained 36.5% (peak insulin), 43.8% (FPI), 43.8% (Matsuda ISI) of variance.

iii) Applying the obtained reference values to our large obesity cohort, 47.3% of obese children had hyperinsulinemia and 49.2% were insulin resistant based on peak insulin and Matsuda ISI, respectively, while prevalence rates of impaired glucose tolerance (13.8%) and impaired fasting glucose (18.2%) were much lower.

Conclusion: We provide reference values of insulin secretion during an oGTT from healthy lean children. Compared to lean children, insulin secretion is doubled in obese children and almost 50% of obese children already present hyperinsulinemia as a sign of insulin resistance.

 

Nothing to Disclose: AK, SD, MN, ES, MV, JK, WK

15713 6.0000 SUN-1003 A Pediatric Reference Values for Insulin from Ogtt in Normal Children and Prevalence of Hyperinsulinemia in Obese Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Adegbenga BOLANLE Ademolu*1, Abiola Olanike Ademolu2, Anthonia Ogbera3 and Olufemi Adetola Fasanmade4
1Lagos State University Teaching Hospital (LASUTH), Ikeja, Nigeria, 2Olabisi Onabanjo University Teaching Hospital, Ogun, Nigeria, 3Lagos State University, Nigeria, 4Lagos University Teaching Hospital, Lagos, Nigeria

 

Hypoglycaemia is a random blood sugar of 70mg/dl (3.9mmol/L) or less or a fasting blood sugar of 55mg/dl(3.1mmol/L).The geographical distribution of hypoglycaemia knows no boundary,It also has no ethnic,gender or age exception.It was noticed that the rate of sudden collapse was on the increase in a rural community in ikorodu with some resulting in death,hypoglycaemia was entertained as one of the  possible causes amongst others  since hypoglycaemia is a well  documented cause of sudden collapse in the public.This raises the question what is the frequency of hypoglycaemia in this community and what is the level of its severity if present?Does it occur among people living with diabetes or non diabetics in this community?The random blood sugar of 49 participants was checked using a brand new  accu-chek glucometer which was coded with the code key.The glucometer was calibrated in mg/dl.The glucometer strip was inserted to the glucometer till the glucometer is ready for use by showing a blinking drop of blood on the screen,then a participant had a finger prick using a sterile needle after cleaning the thumb with a spirit swab,the oozing blood is then applied to the orange area(the dermacated spot on the strip ment for a drop of blood) of the glucometer strip.The reading was then taken after which the strip was removed and discarded and reading was recorded.The procedure was repeated with each participants taking turns.The exercise lasted about three hours. The screening was done  after obtaining consent from each participant through their opinion leader.  The participants were randomly selected.A total number of 49 participants with age range 25-75years were recruited into the study,of these 26(53.06%)were male while 23(46.94%)were female.Only 2(4.08%)cases of hypoglycaemia was recorded and both were male.In the study population 2(4.08%)were known diabetics one male,one female but none were hypoglycaemic. Of the two male hypoglycaemic  participants,one was a 27years old youngman whose glucometer reading displayed low!(that is less than 10mg/dl!) and he was asymptomatic.Asymptomatic hypoglycaemia of random blood sugar of less than 10mg/dl can occur in the community setting.

 

Nothing to Disclose: ABA, AOA, AO, OAF

13003 7.0000 SUN-1004 A Hypoglycaemia in Ikorodu 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Chee W. Chia*1 and Josephine Mary Egan2
1National Institute on Aging, Baltimore, MD, 2National Institute on Aging/National Institutes of Health, Baltimore, MD

 

Diabetes affects more than a quarter of persons older than 65 years, with progressively higher prevalence in older men and women.  Interestingly, patients with type 2 diabetes and their first-degree relatives have impaired sweet taste, suggesting that impaired taste may play a role in the pathogenesis of diabetes. This hypothesis is consistent with recent findings from animal studies suggesting that tongue fungiform papillae, which contain sweet taste receptors, produce hormones such as GLP-1 and glucagon which are important for glucose metabolism and modulate taste sensitivity. In addition, taste bud size, taste cell number, taste precursor cell number, and taste modulating factors have been shown to decrease with age in rodents. Therefore, we hypothesized that fungiform papillae density declines with aging and is associated with metabolic dysregulation in humans. In a cross-sectional analysis, 353 (male = 170, 48%) participants from the Baltimore Longitudinal Study of Aging had data on fungiform papillae density, fasting plasma glucose (FPG), fasting insulin and adiponectin levels. Fungiform papillae density measurement was obtained using two clear hole reinforcements (diameter of 7mm) placed between median sulcus and apex of the tongue. The fungiform papillae present within the two 7mm holes were counted and normalized to the area of the hole. The participants have the following characteristics: age 70.2 ± 0.7 years, BMI 27.2 ± 0.3 kg/m2, FPG levels 98.5 ± 0.7 mg/dL, adiponectin levels 23.4 ± 0.9 µg/mL, fasting insulin levels 7.6 (IQR 4.2-12.8, µU/mL), and fungiform papillae density 22.0 ± 0.6 N/cm2. Multiple linear regression analysis adjusted for sex and BMI revealed a strong negative, independent association between fungiform papillae density and age (β = -0.28, P < 0.001), and between fungiform papillae density and FPG (β = -0.11, P = 0.042). A positive association was found between fungiform papillae density and adiponectin levels (β = 0.12, P = 0.029), but no association with fasting insulin was noted. These results support the hypothesis that fungiform papillae density may play a role in glucose metabolism during the aging process.  These findings suggest that taste receptors on fungiform papillae influence dietary habits, and decline in these receptors with aging may ultimately lead to obesity and alter carbohydrate metabolism. This hypothesis should be tested in longitudinal studies.

 

Nothing to Disclose: CWC, JME

14044 8.0000 SUN-1005 A Fungiform Papillae Density Is Associated with Age and Markers of Glucose Metabolism in the Baltimore Longitudinal Study of Aging 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Ali Iranmanesh*1, Donna Marie Lawson1, Monica Y Plazarte1 and Johannes D Veldhuis2
1VA Medical Center, Salem, VA, 2Mayo Clinic, Rochester, MN

 

Background: Being secreted equimolarly with insulin, circulating C-peptide concentrations could provide a more accurate estimation of pancreatic ß-cell function considering the significant first pass hepatic uptake of insulin.

Objective: To assess C-peptide secretory parameters in normal men during short-term fasting and after oral glucose intake.

Subjects: 68 men ages 18-78 yrs and BMIs 18-37 kg/m2

Study design: Each man was studied on 2 separate occasions after an overnight fast.

Intervention:  Ingestion of either 75 grams of dextrose solution or equal volume of water. Sessions were 6.5 hrs long; starting at of 0800-0900 hr. Blood was collected at 10-min intervals for glucose and C-peptide measurements. Deconvolution and ApEn statistics were used to assess C-peptide secretory properties and regularity of C-peptide secretory bursts, respectively.

Results: Deconvolution analysis identified basal and episodic release of C-peptide in both settings, with predominantly basal release in the fasting state (˜ 88%). Compared with water ingestion, oral dextrose intake caused significant increases in C-peptide (1) pulse frequency (3.9 ± 0.17 v 3.3 ± 0.2; P=0.03); (2) pulsatile release (60 ± 2.9 v 4.8 ± 0.3 ng/mL/6.5 hr; P < 0.0001), total secretion ( 93 ± 4.1 v 39 ± 2.0 ng/mL/6.5 hr; P<0.0001); and burst mass (17 ± 1.2 v 1.8 ± 0.2 ng/mL/6.5 hr; P<0.0001), without any effect on basal secretion (32 ± 1.9 v 34 ± 1.8 ng/mL/6.5 hrs; P=0.23). Nutrient intake improved regularity of C-peptide pulses per se (ApEn 0.32 ± 0.005 v 0.74 ± 0.04; P < 0.0001), and C-peptide correlation with circulating glucose concentrations (0.52 ± 0.02 v 1.1 ± 0.03; P < 0.0001).

Summary and conclusion:  Circulating C-peptide concentration is the sum of basal and pulsatile release. While being mostly basal during fasting, only the pulsatile secretory component is augmented by nutrient intake. We hypothesize therefore that in healthy men, pancreatic ß-cell functional mode in glucose homeostasis is mostly tonic during fating and primarily pulsatile in response to nutrients. Future studies are needed to verify these findings with consumption of mixed meals.

 

Nothing to Disclose: AI, DML, MYP, JDV

14795 9.0000 SUN-1006 A C-Peptide Secretory Dynamics after Overnight Fasting and in Response to Oral Dextrose Administration in Healthy Men 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Ilhan Satman*1, Yildiz Tutuncu2, Selda Celik2, Fulya Turker2, Nevin Dinccag1, Kubilay Karsidag1, Beyhan Omer2, Sibel Kalaca3, Aysegul Telci2, Sema Genc2, Temel Yilmaz1 and Jaakko Tuomilehto4
1Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey, 2Istanbul University Istanbul Medical Faculty, Istanbul, Turkey, 3Marmara University Medical Faculty, Istanbul, Turkey, 4Danube University, Krems, Austria

 

Altered circulating levels of IGF1 and its binding protein (IGFBP3) are associated with metabolic parameters and involved in glucose metabolism. However, data from studies investigating the role of IGF1 and IGFBP3 in pre-diabetes and new-onset diabetes defined by different diagnostic methods are sparse.

To further evaluate these associations, we measured serum levels of IGF1 and IGFBP3 and calculated molar ratio of IGF1/IGFBP3 in subjects with previously undiagnosed (new) diabetes and pre-diabetes based on fasting plasma glucose (FPG), OGTT and HbA1c from a recently completed large population-based study (TURDEP-II) including 26,499 Turkish adults (1). IGF1 and IGFBP3 levels were adjusted for age, gender, BMI, waist, blood pressure, living environment, smoking and alcohol use.

Compared to new diabetes groups diagnosed with FPG and OGTT criteria, subjects with new diabetes based on HbA1c criterion had poorer anthropometric and metabolic profile (more men and higher age, more family history of diabetes, heavy alcohol use; higher BMI, waist, triglycerides, non-HDL-cholesterol and HOMA-IR; but lower eGFR and HDL-cholesterol. A similar pattern was observed for high risk subjects identified by HbA1c as compared to subjects with IFG or IGT.

In general, mean levels of IGF1 and IGFBP3, and the molar ratio of IGF1/IGFBP3 in subjects with new diabetes were lower than in the pre-diabetic subjects (mean ± SD in new diabetes vs. pre-diabetes; IGF1: 110.1 ± 60.0 vs. 129.8 ± 64.2 ng/mL, IGFBP3: 3.76 ± 1.31 vs. 3.82 ± 1.21 ng/mL, IGF1/IGFBP3: 0.111 ± 0.057 vs. 0.127 ± 0.065).  IGF1 levels in new diabetes groups based on FPG, OGTT and HbA1c criteria were found close to each other (p=0.840). However, mean levels of IGFBP3 in HbA1c based new diabetes group was higher than those diagnosed with FPG and OGTT criteria (mean; 95%CI in A1C group: 3.99; 3.89-4.09 ng/mL, FPG group: 3.53; 3.42-3.64 ng/mL; OGTT: 3.76; 3.67-3.86 ng/mL, p<0.001). Similarly, IGF1/IGFBP3 in HbA1c based new-diabetes group was lower than the other two groups (p<0.001).

The trend for pre-diabetic states was comparable as well. HbA1c based high risk group had lower IGF1 (p=0.014) and higher IGF1BP3 levels (p=0.009) than IFG group, and lower IGF1/IGFBP3 than IFG (p<0.001) and IGT (p=0.031) groups.

We concluded that people identified with pre-diabetes or new diabetes based on HbA1c criterion are in more advanced stages than those diagnosed with FPG or OGTT criteria. These individuals may be more prone to develop complications due to further metabolic impairments such as IGF1/IGFBP3 system.

 

Nothing to Disclose: IS, YT, SC, FT, ND, KK, BO, SK, AT, SG, TY, JT

15773 10.0000 SUN-1007 A The Role of IGF1/IGFBP3 System in Pre-Diabetes and New-Onset Diabetes Diagnosed with Different Criteria 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Mehmet Sargin*1, Sakin Tekin2, Buket Tekin1, Tülay Karabayraktar1, Sule Temizkan1, Aysenur Ozderya1 and Kadriye Aydin1
1Kartal Training and Research Hospital, Istanbul, Turkey, 2Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey

 

Aim: The diagnosis of prediabetes has been made according to the measurements of fasting blood glucose level or using the oral glucose tolerance test (OGTT). Recent years HbA1c is therefore being considered as a diagnostic tool. But there are discordant results between HbA1c and OGTT. The aim of this study was to find the correlation between the results OGTT and HbA1c for the diagnosis prediabetes and compare with the results of continuous glucose monitoring system (CGMS).

Methods: A total of 92 consecutive patients (female/male:52/40, 45.2±11.2 years old) who have risk of diabetes were performed HbA1c (at least two measurements), 75 gr OGTT and CGMS concurrently, in order to diagnose dysglycemia according to ADA criteria. Firstly, we compared the prevalence of prediabetes in subjects who have risk of diabetes based on either HbA1c or OGTT. Secondly, we searched the correlation between HBA1C and OGTT with CGMS results

Results: We detected that 20 patients(21.7%) had impaired glucose tolerance using OGTT, 39(42.4%) patients had HbA1c between 5.7-6.4%. 45(48.9%) patients had prediabetes according to OGTT and/or A1C, 13(28.9%) patients had both according to HbA1c and OGTT.

According to CGMS results, 60(65.2%) of subjects had at least two glucose levels between 140-200 mg/dl during 6 day measurements. Of this 60 patients 8(13.3%) had IGT according OGTT and 23(38.3%) had A1C between 5.7-6.4%.

A total of 79(85.9) patients had abnormal glucose metabolism according to one of three methods and only five(6.3%) patients had dysglycemia when all three methods were taken into account.

 Conclusion: We found discordance between HbA1c and OGTT for detecting prediabetes. Dysglycemia and glucose variability were higher in CGMS.

 

Nothing to Disclose: MS, ST, BT, TK, ST, AO, KA

16258 11.0000 SUN-1008 A Diagnosis of Prediabetes: Comparison the Concurrent Results of OGTT, HbA1c and CGMS 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Mehmet Calan1, Ozge Dokuzlar1, Kemal Aygun1, Pinar Yesil2, Tugba Arkan1, Sinem Burcu Kocaer1, Mehmet Asi Oktan1, Guntug Gungor1, Nihan Karaosman1, Olgu Aygun1, Tuncay Kume1 and Firat Bayraktar*1
1Dokuz Eylul University Medical School, Izmir, Turkey, 2Ege University, Izmir, Turkey

 

OBJECTIVE­-Betatrophin, a newly identified hormone, is secreted by liver and fat into circulation, as a potent stimulator of  beta cell proliferation in mice. Insulin resistance causes upregulation of  betatrophin expression. The purpose of this study was to determine the serum levels of betatrophin in prediabetic subjects and to investigate the relationship between betatrophin and metabolic parameters. 

RESEARCH DESIGN AND METHODS-The research was designed as a case-control study, in which 42 subjects with prediabetes and 37 subjects with normal glucose tolerance (NGT) were consecutively recruited, in an attempt to match the groups for age, sex and body mass index (BMI). Serum betatrophin, insulin, C-peptide, fasting blood glucose, A1C, high sensitivity C-reactive protein (hs-CRP), and lipids levels were measured. Insulin resistance was evaluated using the homeostasis model assessment of insulin resistance (HOMA-IR) index.

RESULTS-Serum betatrophin levels were significantly higher in prediabetic subjects compared with NGT subjects (P<0.001). Betatrophin levels were positively correlated with HOMA-IR (r=0.746, P<0.001), BMI (r=0.426, P<0.001), waist circumference (r=0.486, P<0.001), insulin (r=0.786, P<0.001), C-peptide (r=0.759, P<0.001), 2 h plasma glucose (r=0.259, P=0.021), A1c (r=0.222, P=0.049) and low density lipoprotein cholesterol (LDL-C) (r=0.348, P=0.002). Multiple regression analysis showed that HOMA-IR (β=0.699, 95% CI=2.953-5.766, P<0.001) and LDL-C (β=0.213, 95% CI=0.016-0.009, P=0.009) levels were directly related to betatrophin levels independently from other factors including age, BMI, waist circumference and hs-CRP.

CONCLUSIONS-In humans, betatrophin may play a crucial role in the compensatory overproduction of insulin in insulin resistance state and control β cell replication, which, in turn, would open the door to the development of new treatments for diabetes.

 

Nothing to Disclose: MC, OD, KA, PY, TA, SBK, MAO, GG, NK, OA, TK, FB

15205 12.0000 SUN-1009 A Relationship Between Circulating Betatrophin Levels and Insulin Resistance in Prediabetic Subjects 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Dirk Jan Stenvers*1, Sadaf Atiqi1, Eelkje J Limonard1, Eric Fliers2, Andries Kalsbeek3 and Peter H Bisschop1
1Academic Medical Center, Amsterdam, Netherlands, 2Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands, 3Netherlands Institute for Brain Research, Amsterdam, Netherlands

 

The circadian timing system consists of molecular clocks in the brain and in metabolic tissues including liver, pancreas and adipose tissue. This timing system has been implicated in the pathophysiology of obesity and type 2 diabetes. Indirect evidence suggests that the daily rhythm in glucose tolerance is altered in patients with type 2 diabetes, but this has never been compared directly to the rhythm in healthy controls.

Therefore, we determined the daily rhythm in glucose tolerance in 6 obese males with type 2 diabetes and in 6 age-matched healthy lean males. Participants ingested 3 identical liquid meals (54E% carbohydrates, 29E% fat, 17E% protein) per day at 5.5 hours intervals for 3 days. Glucose tolerance was determined by the postprandial incremental area under the curve (AUC) for glucose. The first two days, glucose concentrations were measured in an ambulant setting by a continuous subcutaneous glucose monitoring system. On the third day, patients were admitted to the clinical research unit (CRU) to determine glucose and insulin concentrations in venous blood samples.

Under ambulant conditions, glucose tolerance improved during the day in type 2 diabetes (glucose AUC: morning 846 ± 113, noon 343 ± 108, evening 468 ± 125 mmol·min/L), whereas glucose tolerance decreased during the day in healthy controls (glucose AUC: morning 148 ± 22, noon 263 ± 50, evening 267 ± 48 mmol·min/L; interaction effect P=0.002). At the CRU on day 3, we observed the same pattern of glucose tolerance. In patients with type 2 diabetes the AUC of plasma glucose decreased after the morning (morning 1271 ± 279, noon 1007 ± 168, evening 1181 ± 218), whereas it increased over the day in healthy controls (morning 306 ± 188, noon 567 ± 211, evening 767 ± 292 mmol·min/L; interaction effect P=0.010). The diurnal rhythm in postprandial insulin excursions did not differ between groups (p=0.132).

Thus, our data show that the daily rhythm of postprandial glucose excursions is inversed in patients with type 2 diabetes compared to healthy controls. Our findings support the notion that the circadian timing system is involved in the pathophysiology of type 2 diabetes.

 

Nothing to Disclose: DJS, SA, EJL, EF, AK, PHB

12639 13.0000 SUN-1010 A The Daily Rhythm of Glucose Tolerance Is Inversed in Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Jing Sui*1, Lingshuang Sun1, Wei Cui1, Hui Guo1 and Bingyin Shi2
1First Affiliated Hospital of Xi’an Jiaotong University, School of Medicine, Xi’an, 2First Affiliated Hospital, Xi'an

 

Objective: To define the circadian effect of high-dose of methylprednisolone on blood glucose concentration and to optimise management of methylprednisolone-induced hyperglycemia.

Methods: 14 Graves' Ophthalmopathy patients were admitted to hospital and classified into two groups: 5 with pathoglycemia (Group 1) and 9 without pathoglycemia (Group 2). All patients were treated with high-dose methylprednisolone. Dynamic blood glucose concentration was monitored by using a continuous glucose monitoring system. Data were analyzed using SPSS 19.0 for Windows. P value <0.05 was considered statistically significant. Unless otherwise stated values represent mean±standard deviation.

Results: All patients' mean blood glucose and post-treatment (≥7.8mmol/L,≥11.1mmol/L) were significantly increased after glucocorticoid therapy (P value <0.05). It was revealed by continuous glucose monitoring system that the climax of glucose level occurred 6-10h and  18-19h after methylprednisolone administration for all patients. The mean blood glucose concentration and the increased value of average blood glucose between 0-24h after methylprednisolone administration in Group 1 was significantly higher than Group 2(P value<0.05), and mean blood glucose concentrations between 24-48h after methylprednisolone administration in Group 1 was also significantly greater than Group 2 (P value<0.05).

Conclusions: Methylprednisolone pulse therapy may result in hyperglycemia which predominantly occurs 0-24h after using methylprednisolone.Screening and resulting treatment for methylprednisolone-induced hyperglycemia should be directed at this period. Glucose-lowering therapy should not be necessary with the patients who has no pathoglycemia.

 

Nothing to Disclose: JS, LS, WC, HG, BS

13793 14.0000 SUN-1011 A Circadian Impact of High-Dose Methylprednisolone Pulse Therapy on the Acute Phase of Glucose 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

John Stephens Melish*
John A Burns Sch of Med, Honolulu, HI

 

Pharmacokinetic studies of glucose tolerance treat the volume of glucose distribution (Vd) as a constant (mL or dL/kg body weight) although isotope labeled glucose studies suggest that Vd varies in and among individuals (1). Vd has ben related to vascular reactivity (VR). Both increase with insulin, exercise, and GLP-1; both responses are blunted in Type 1 and Type 2 diabetes and with insulin resistance. The fractional rate of dietary glucose disposal/time, Kd*Vd, equals the clearance (mL/min) of post-hepatic dietary and endogenous glucose. The decrease in endogenous glucose due to peripheral uptake and decreased hepatic glucose secretion amplifies Kd to a higher value Ka. The peak and duration in glucose concentration above baseline depends on rate of dietary glucose appearance, rate of hepatic glucose secretion, and changes in Vd as well as Kd and Ka. This dynamic process returns glucose concentrations to baseline (BL). A model proposed by Melish, 2012 (2) quantitates each aspect of glucose appearance (Ra) and removal (Rd), in part by converting the oral glucose concentration curve to an i.v. curve. The model is applied to meal-related frequently sampled data from a study (3) comparing a mixed meal containing 75 g glucose in a group of 16 Type 2 diabetic patients treated randomly and sequentially with placebo (P), metformin (M), sitagliptin S), and sitagliptin-metformin (M+S).  The model estimates changes in Vd (dL) from dietary glucose remaining after first pass hepatic glucose uptake (g) and the impact on clearance of the increasing Vd. 

Results: Vdfinal:Vdinitial:%change: P(130;108;120); M(128:119:108); S(140:119:118); M+S(161:135:118). Kd: P(-0.0052); M(-0.0051); S(-0.0051); M+S(-0.0052). Ka: P(-0.0074); M(-0.0074); S(-0.0074); M+S(-0.0074). Ka*Vfinal: P(96); M(94); S(104); M+S(119). Glucose remaining after hepatic first pass: P(59.2); M (59.0); S (59.6); M+S (60.2)

Conclusions: Both the original study and the model show that glucose Ra and Rd and first pass hepatic fraction removed were about the same in each treatment mode. Thus differences in the height-duration of glucose curves and clearance in each study are due to BL glucose concentrations and increases in Vd with P<M similar to S<M+S attributable to Ka amplifying rates of exogenous and endogenous glucose disappearance. This model is consistent with the original study findings and conclusions on the effects of M, S, and M+S on endogenous glucose changes. Apparent Vd at rest depends on combined exogenous and endogenous glucose uptake and hepatic glucose suppression; not fluid changes. This physiologic and pharmacokinetic model is useful in interpreting frequently sampled glucose concentrations after glucose challenges and may be helpful in the education and management of patients on intensive lifestyle and medication regimens. The analysis is accomplished without isotopes and the calculations are straightforward.

 

Nothing to Disclose: JSM

12942 15.0000 SUN-1012 A Dietary Glucose, Glucose Clearance, and the Glucose Volume of Distribution 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Mustafa Aydemir1, Sebila Dokmetas*2 and Ahmet Altun3
1cumhuriyet university endocrinology department, sivas, Turkey, 2Medipol University, Istanbul, Turkey, 3Cumhuriyet University, Sivas, Turkey

 

The evidence obtained from observational studies indicates that certain drugs used to treat hyperglycemia can lead to an increase or decrease in the risk of cancer. In this in vitro study performed with breast cancer cell cultures we investigated the effects of medication used for the treatment of diabetes on the proliferation of cancer cells.

We used estrogen positive human breast cancer cells MCF-7 and estrogen negative breast cancer cells MDA-MB-231. Metformin, pioglitazone, insulin, exetanid alone at increasing doses and combinations thereof with metformin and Paclitaxel were used to compare cytotoxic effects. Cytotoxic effects of the drugs were compared after 96 hours. ‘‘Cell Proliferation Kit’’, XTT (2,3-Bis-(2-Methoxy-4-Nitro-5-Sulfophenyl)-2H-Tetrazolium-5-Carboxanilide)  test and Tripan blue dye test were used for viable cell count.

Metformin alone has a strong cytotoxic effect on the breast cancer cells like an anticancer drug (at concentrations of 2.5 mM, 5 mM, 10 mM, 15 mM, 20 mM cytotoxic effect was respectively 75.4%, 64.2%, 54.76%, 33.2%, 11.2%, p<0.001) and can increase the effect of paclitaxel. We determined that Pioglitazone doesn’t cause the breast cancer cell proliferation at physiological doses (0.1 µM, 1 µM, 25 µM, 50 µM p>0.005) and has cytotoxic effect at suprapharmacological doses (100 µM cytotoxic effect 43% p<0.05). We observed that the proliferative effects of insulin on cancer cells decrease when they are used in combination with metformin (p<0.05). We observed that exanatide has proliferative effect on breast cancer cells (at concentrations of 5 nM, 10 nM and 15 nM respectively 120.76%, 133.32%, 152.20% proliferation p<0.05) and that this proliferative effect disappears when it is used in combination with metformin (p<0.05).

We demonstrated that metformin alone is an anticancer agent as effective as paclitaxel and it potentialize the effect of paclitaxel in combination.

 

Nothing to Disclose: MA, SD, AA

16231 16.0000 SUN-1013 A In Vitro Comparison of the Effects of Metformin, Pioglitazone, GLP1 Analogue, Insulin That ARE USED in Treatment of Diabetes and Anticancer Agent, on Breast Cancer CELL Culture 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Carlos Dominguez-Reyes*1, Sara Davila-Valnezuela2 and Concepcion Gonzalez-Cruz2
1CENTENARIO HOSPITAL MIGUEL HIDALGO, AGUASCALIENTES, Mexico, 2HOSPITAL GENERAL TERCER MILENIO, AGUASCALIENTES, Mexico

 

Alternative titration algorithm fot the initiation of basal insulin for unskilled patients and health providers: A initiative for the real wealth-limited world.

The appropriate and well-timed use of insulin in type 2 DM is often restrained in many parts of the world by primary-care physician´s experience or patient´s resources. A tritation algorithm should facilitate both patient´s and health care provider´s participation in the use of basal insulin and optimize resources. We evaluated an alternative initiation and titration algorithm for basal insulina in patients uncontrolled on oral anti-diabetic agents (OAD) based on a higher initial dose and less frequent dose adjustments compared to standard treat-to target algorithm, in a real-life setting of limited insulin experience. Type 2 diabetics were eligible if were on stable dose for OAD for at least 3 months, had HbA1c ≥7.5% ≤11% and never used insulin before. Participant primary-care physicians had little or none experience with the use of basal insulin, although they were treating and caring individuals with DM. Two different algorithm were used for initiation and for titrating insulin Glargine as basal insulin to achieve a target of FPG ≤100 mg/dL (5.56 mmol/L). Alternative algorithm (AA) started an initial dose of 0.3 UI/kg with dose adjustments every week. Treat-to-target algorithm (TT) had an initial dose of 0.2 UI/kg and adjustments every 3rd day. Study endpoints were change in HbA1c and 7-point plasma glucose from baseline. Hypoglycemic events were reported and patient adherence, satisfaction (DQST) and use of glucose strips were assesed. Seventy-three patients were included and randomized to both groups. Diabetes care was provided in 3 primary-care centers by 6 different physicians. The trial lasted 3 months. 

There were no significant differences in patients demographic and clinical characteristcs among groups. Compared to baseline both algorithm were associated with similar reductions in HbA1c (AA -1.8% vs TT -1.6%). Final weight-adjusted insulin dose were 0.45 IU/kg for AA and 0.53 IU/kg for TT (p=ns). Both algorithm showed significant reductions in FPG and 7-point measurements from baseline to endpoint. The percentage of hypoglycemic events and rates were similar in both groups (22.8% vs 26.3%). Individuals in AA used 45% less glucose trips than TT. Our data sugges that a simpler and less resource-consuming titration algorithm achieved similar glycemic control to the more complex and expensive standard algorithm. The safety and user´s satisfaction was similar among the two groups. These results could help diabetes care systems to improve glycemic control in a setting where resource and clinical experience are limited. The limited number of participants would benefit from validation through studies powered sufficiently to evaluate efficacy, safety and adherence of the algorithms in longer terms.

 

Nothing to Disclose: CD, SD, CG

17029 17.0000 SUN-1014 A Alternative Tritation Algorithm for the Initiation of Basal Insulin for Unskilled Patients and Health Providers: A Initiative for the Real Wealth Limited World 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Lynn Kessler*1, Fabiana Araujo2, Yannis Sergio Guerra1 and Leon Fogelfeld3
1Stroger Hospital of Cook County, Chicago, IL, 2Stroger Hospital of Cook County, 3Stoger Hospital of Cook County, Chicago, IL

 

Physiologic factors predicting glycemic control among patients with longstanding Type 2 diabetes on insulin therapy.

Context:

Defects in insulin secretion and insulin resistance are the two major components contributing to the pathophysiology of Type 2 diabetes (T2DM). Declining beta cell function has been shown to be a central contributor to disease progression and glycemic control in newly diagnosed diabetes(1). The relative importance of beta cell function and insulin resistance in patients with longstanding disease is uncertain.

Objective:

To determine if endogenous insulin secretion or insulin sensitivity are associated with glycemic control in a group of T2DM patients on multiple daily insulin injections (MDII) with long disease duration .

Methods:

A cross-sectional analysis of data from 27 T2DM patients in the endocrinologist-run diabetes clinic at a large, urban safety-net hospital. All patients were on MDII and have been followed regularly in the diabetes clinic for at least one year.  Insulin sensitivity was evaluated by HOMA%S using C peptide; beta cell function was assessed by DC-peptide(30min-0min)/Dglucose(30min-0min)  (DC30/DG30) during oral glucose tolerance testing (OGTT). All short acting insulin was held prior to testing. Median fasting glucose at the time of OGTT was 144mg/dl (intraquartile range (IQR)113-200.5).

Results:

Mean A1c was 8.0% (standard deviation (SD) 1.2); median diabetes duration was 16 years (range 5-43). C peptide levels were detectable in all subjects, with a mean of 2.5 (SD 1.4) ng/ml.

In bivariate analysis, both diabetes duration (r=-0.356, p=0.04) and DC30/DG30 (r=-0.603, p=0.01), but not HOMA%S, correlated with A1c. In multivariate analysis, DC30/DG30 was the only variable of the three that emerged as a statistically significant independent predictor (r=-0.674, p=0.006) of A1c.

Conclusions

In patients with long-standing diabetes on multiple daily insulin injections, glycemic control is significantly associated with beta cell function but not insulin resistance.

 

Nothing to Disclose: LK, FA, YSG, LF

12827 18.0000 SUN-1015 A Physiologic Factors Predicting Glycemic Control Among Patients with Longstanding Type 2 Diabetes on Insulin Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Saad Sakkal*1 and Mohamed loutfy Sakkal2
1Pikeville Medical Center, Pikeville, KY, 2Metabolic care center, Mason, OH

 

Introduction: Insulin pump therapy is an effective technology to treat insulin dependent Diabetes. Yet, any tecnology could be misused. But little is published about its misuse in private practice. 

Methods: Patients: We analyzed prospectively data for the first 25 consecutive patients who came in for first evaluation, upon starting a new practice. These patients were started on insulin pump therapy previously by non-endocrinologist practitioners, but wanted to seek an endocrinologist service at present , with their concern follow up was uncertain ,or fully self-managed . All data were taken from the Medtronic’s pump download sheets during the first visit.

Data: we tabulated the full data set including Adherence parameters(Number of BGSM, wizards bolus use, frequency of set changes, priming) sensor/meter overview parameters(glucose readings number , average glucose results, above and below targets ratios, averages at breakfast ,lunch, dinner , bedtime and nighttime ,daily CHO and insulin/CHO bolus ratios, total daily insulin dose, daily basal to bolus ratios) , settings parameters (insulin sensitivity, CHO/Insulin ratio , number of basal rates)and daily profiles. Expense was estimated

Definition of misuse: any use incompatible with accepted standards of pump therapy for adherence  and settings including inadequate BGSM , or lack of entry by patients, inappropriate wizard override, inadequate set changes ,priming, inappropriate rate settings. We have space to present only first two factors (BGSM, Gl entry).

Results:female were 18(%72) ,age 18-60 , number of daily infusion rates 1-6 ,insulin sensitivity 10-75 ,CHO/I ratio 5-18, Daily total insulin 17-106 U.CHO intake 61-145 Gm , basal rates 8.2-78 U/Day and its ratio to total insulin %40-90 ,patients expense including pump price was estimated at $7400 in the first year,$2000 the following years.

Patient’s adherence to BGSM was a major variable ranging from 0.2-9 daily: doing only one test daily was recorded by 8/25, 2 tests by 5/25, 3 tests by 3/25, 4 tests by 6/25, and › 4 tests daily by 3/25. The total number for patients doing the required 4 or more tests were 9/25 (%36) which represent “good users”, but less than adequate testing was found in 16/25 or %64, which represent “misusers”.

Impact of daily BGSM on outcome was apparent between good and misusers :misusers has higher average glucose 218±108 mg/dl when compared to good users 93± 22 mg/dl, has higher %50 above target glucose : 14/16(%87) compared to good users 3/9 (%33),as well as %100 above target glucose :4/16 (%25) compared to good users 0/9 (%0). In misusers 3 has glucose average more than 300 mg/dl(one 420 mg/dl). Expense was higher in "misusers" (data not shown)

Conclusion:Misuse pf insulin pump therapy is common in practice, reaching % 64 when care is delivered by non-endocrinologist, or only self -managed, leading to poor glucose control.It may endanger life and waste $2000- $7400/year.

 

Nothing to Disclose: SS, MLS

13437 19.0000 SUN-1016 A How Common Is Misuse of Insulin Pump Therapy ? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Sudha K Yalamanchi*1, Yuval Eisenberg2, Irina Ciubotaru1, Arfana Akbar3, Nathan Chertok3, Emily Lelchuk3, Hiba Mohiuddin3, Hassan Zaidi3, Karthik Cherukupally3, Subhash C Kukreja1 and Elena Barengolts1
1UIC Section of Endocrinology, Chicago, IL, 2University of Illinois at Chicago, Chicago, IL, 3Jesse Brown VAMC, Chicago, IL

 

INTRODUCTION: There is a growing number of randomized, controlled trials (RCT) that observed no effect of vitamin D on glycemic control. This double-blind RCT evaluated whether high doses of vitamin D2 for 1 year affect glucose homeostasis.

METHODS: A total of 205 African American male veterans 35-85 years old, with BMI 28-39 kg/m2, dysglycemia (A1C 5.7-6.9%) and vitamin D insufficiency (25OHD 5-29 ng/mL) were randomized to receive placebo (PL) or 50,000 IU vitamin D2 supplementation (DS) for 1 year. Doses were adjusted with the goal of maintaining circulating 25OHD =/>40 ng/ml. The 180 minute frequently-samples intravenous glucose tolerance test (FSIVGTT) was performed at baseline and after 1 year in 50 participants. The data were then analyzed using the Minmod Millenium program to obtain the parameters of insulin sensitivity (Si, min-1/(μU/mL), acute insulin response (AIR, μU/(mLmin)), disposition index (DI), and glucose effectiveness (Sg, min-1). Data are reported as Mean [Standard Deviation] unless otherwise specified.

RESULTS: Average 25OHD levels rose from 14 to 52 ng/mL after D2 supplementation with a mean dose of about 75,000 IU per week. We have data for N=18 and N=12 for PL and DS groups, respectively. Average age (59 years) and BMI (32 kg/m2) were similar in both groups. Serum 25OHD levels varied in PL (8-25 ng/ml) and even more so in DS (21-73 ng/ml) subgroups.

There was high variability of the data and no significant differences in FSIVGTT-based glucose homeostasis indices including Si (PL 0.9424 [1.794] vs DS 0.4582 [0.3829], p=0.59); AIR (PL 3581 [3451] vs DS 1777 [1029], p=0.11); DI (PL 3432 [9487] vs DS 850 [743], p=0.17), and Sg (PL 0.0597 [0.1917] vs DS 0.0130 [0.0061], p=0.18). In addition, fasting plasma glucose (FPG) was not different in the two groups (PL 93 [12] vs DS 99 [15] mg/dl, p=0.28) while A1C levels tended to be higher after D2 supplementation (PL 6.2 [0.2] vs DS 6.4 [0.4], p=0.09).

DISCUSSION: These data added to the controversy surrounding the role of vitamin D in glucose homeostasis. In this subgroup analysis A1C levels tended to be higher suggesting possible worsening of glycemia in vitamin D supplemented group. This unexpected result could be explained by small number of subjects as well low and variable serum 25OHD levels in some subjects suggesting non-adherence or poor D2 absorption. In the entire group vitamin D supplementation had no effect on progression from prediabetes to diabetes or A1C levels. However, there was a trend in proportion of subjects whose A1C returned from diabetes to prediabetes, from prediabetes to normal or remained at the lowest prediabetes value of 5.7% (p=0.08).

CONCLUSION: In AAM with dygsycemia and vitamin D deficiency vitamin D2 supplementation for 1 year did not affect FSIVGTT-based indices of insulin sensitivity and secretion.

 

Nothing to Disclose: SKY, YE, IC, AA, NC, EL, HM, HZ, KC, SCK, EB

17007 20.0000 SUN-1017 A Fsigtt-Based Insulin Sensitivity and Secretion Are Not Improved By High-Dose Vitamin D2 Supplementation in African-American Male Veterans with Pre Diabetes with Hypovitaminosis D 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Joshua Lowndes*, Stephanie Sinnett and James Marshall Rippe
Rippe Lifestyle Institution, Celebration, FL

 

Fructose is metabolized differently than other monosaccharides.  Research in recent years has focused on fructose’s potential to induce impairments in glucose metabolism and insulin resistance.  However, studies that have shown such an effect have used experimental models that are drastically different than how fructose is typically consumed by humans – either using amounts far in excess of even the highest consumers and/or supplying it in isolation from other sugars or macronutrients.  Therefore, a more real world investigation of how fructose is typically consumed is needed.  

136 weight-stable (weight change <3% in previous 30 days) individuals aged 20-60 years old drank daily  sugar-sweetened low fat milk  for 10 weeks as part of their usual diet.  The amount of milk consumed was individualized for each participant based on the estimated number of calories required to maintain body weight (Mifflin St Jeor equation) and random group assignment: Groups 1 and 2 – 9% estimated caloric intake from fructose (50th percentile of American consumption) or glucose respectively added to low fat milk.  Groups 3 and 4 – 18% of estimated caloric intake from HFCS or sucrose (the typical source of fructose) respectively added to the milk.  Participants performed an Oral Glucose Tolerance Test following standard procedures before and at the end of the ten-week intervention period and 2 hour area under the curve (AUC) was calculated for glucose and insulin using the trapezoidal method.

Over the course of the ten weeks there was a small, but statistically significant increase in body weight in the entire cohort (162.2 ±27.3 vs 164.1 ± 28.1 lbs, p<0.001), but there was no effect on the type of sugar consumed.   However, there were no changes in either the glucose (13.3 ± 2.5 vs 13.2 ± 2.6 min*g/dl, p>0.05) or insulin (2.5 ±1.3 vs 2.5 ± 1.6 min*mU/ml, p>0.05) AUC.  Furthermore, the type of sugar consumed had no effect (interaction p>0.05)

These data suggest that chronic consumption of fructose when consumed in amounts typical in the American diet does not impair glucose tolerance regardless of the source of that fructose.

 

Nothing to Disclose: JL, SS, JMR

12047 21.0000 SUN-1018 A No Change in Oral Glucose Tolerance Tests As a Result of Ten Weeks of Consumption of Various Fructose Containing Sugars or Glucose 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Oluwarotimi Bolaji Olopade*1, Olufemi Adetola Fasanmade2, Michael Olawale Ajala3, Patience onyinyechi Chimah4 and Augustine E Ohwovoriole5
1Lagos Univ Teaching Hosp, surulere, lagos, Nigeria, 2Lagos University Teaching Hospital, Lagos, Nigeria, 3Lagos State Ministry of Hlth, Ate, Nigeria, 4Lagos University Teaching Hoaspital, Surulere, Lagos, Nigeria, 5University of Lagos, Yaba Lagos, Nigeria

 

BACKGROUND Proper feeding is a main pillar in the management of diabetes mellitus (DM). Beans are recommended for its richness and salutary effect on blood glucose. Inter-species differences exist in the way legumes impact blood glucose. What appears to be unknown is whether differences exist in the way members (referred to as varieties) of the same species of beans {Vigna unguiculata (Linn) Walp} have differential effects on blood glucose when equal amounts are consumed. OBJECTIVE To perform proximate analysis and compare the glycaemic effect on consumption of Vigna unguiculata (Linn) Walp species. RESEARCH HYPOTHESIS There are no differences among the glycaemic indices of the three varieties of Vigna unguiculata (Linn) Walp bean meals commonly consumed by Nigerians. METHODOLOGY Twelve consenting participants (eight females and four males) in good health without family history of DM took part in this study. Anthropometric measurements were measured using standard techniques. Vigna unguiculata (Linn) Walp varieties ‘oloyin’, ‘drum’ and ‘sokoto white’ were purchased from same market and boiled until it became edible for consumption devoid of ingredients. Participants were randomly allotted to bean meals of 50g and 50g glucose challenge tests and administered to the participants on weekly basis. Results of plasma glucose level were determined using standard methods and the GI determined using the trapezoid rule. Statistical analysis was done using SPSS version 20. Variable are expressed as mean [±standard deviation (SD)], median [95% confidence interval (CI)] and percentages. Inferential statistics used were Friedman test, Wilcoxon Signed Ranked test with Bonferroni correction. P < 0.05 was considered to be significant. RESULTS The median age of the study participants were 50.5 (45.5 – 55.5) years with female and male participant’s ages being 50.5 (44-56) years and 51 (46 – 57) years respectively. The mean (±SD) crude fibre content of Vigna unguiculata (Linn) Walp varieties ‘oloyin’, ‘drum’ and ‘sokoto white’ are 2.75 (± 0.00) %, 2.64 (± 0.14)% and 2.94 (± 0.17)% respectively. The median (95% CI) GI of Vigna unguiculata (Linn) Walp variety ‘oloyin’ was 12.10 (6.0 – 16.31)%, variety ‘drum’ 17.64 (9.22 – 48.93)% and variety ‘sokoto white’ 12.04 (5.54 – 28.94)% respectively. There was statistically significant different among the GI of the bean meals with Fridman’s test (x2 (2) = 6.500, p = 0.039). These statistical difference in the GI of variety ‘oloyin’ and ‘drum’ bean meal respond remained (Z = -2.667, p = 0.008) after post-hoc analysis with Bonferroni correction. CONCLUSION The fibre content of intra-species beans with their GI differs. ‘Drum’ bean meal has the least fibre content and highest glycaemic response while ‘sokoto white’ bean meals produce the best response. ‘Oloyin and ‘sokoto white’ bean meals are thus recommended for persons at risk or with DM.

 

Nothing to Disclose: OBO, OAF, MOA, POC, AEO

15781 22.0000 SUN-1019 A Some Beans ARE More Diabetes Friendly THAN Others 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Jordan Sinclair Wilson* and Michael Elliott
College For Public Health and Social Justice

 

In 2011, about 25.8 million individuals were believed to be affected by diabetes and of these 7 million were said to be undiagnosed cases. The health belief model suggests that intention to obtain screening may be a result of an individual’s perceived seriousness of and susceptibility for disease.”  Individuals form risk perceptions for diabetes through what they read, see, or hear. Limited research has been conducted on the demographic variation of doctors informing patients of being diagnosed with diabetes, and how this translates to individual perceived risk. Data was obtained from the National Health and Nutrition Examination Survey (NHANES) from 2011-2012 to determine if demographic variation exists (n=5053). Logistic regressions were performed to examine the relationship between dependent variables perceived risk, informed risk and diagnosis of diabetes and independent demographic variables such as education level, gender, and age. Results from the regressions found that risk perception was not concordant with reality. Individuals with less than a 9th grade education compared to individuals with a college degree or higher were less likely to perceive themselves at risk (odds ratio [OR]:0 .63; P=0.0045; confidence interval [CI]: 0.46, 0.87) and being informed of risk (OR: 0.48; P=0.0020; CI:0 .30, 0.76) but were more likely to be diagnosed (OR: 1.81; P=0.0004; CI: 1.30, 2.50). A similar difference was observed in 9-11th grade (includes 12th grade with no diploma) individuals; perceived risk (OR:0 .75; P=0.0186; CI: 0.59, 0.95) and being informed of risk (OR:0 .71; P=0.0355; CI:0 .51,0 .98) was less likely but being diagnosed (OR: 1.36; P=0.0448; CI: 1.01, 1.84) was more likely that individuals with a college degree or higher. Females perceived risk (OR: 1.37; P<0.0001; CI: 1.19, 1.58) and being informed of risk (OR: 1.55; P<0.0001; CI: 1.29, 1.88) was more likely but being diagnosed (OR: .83; P=0.0440; CI: 0.70, 0.99) compared to males was less likely. Variation in risk perception for race and BMI categories were consistent with diagnosis. Future research should investigate the role of health insurance status, type of health professional seen, frequency of physician interaction, and health literacy level. In addition future research should explore demographic variation in time to seek medical care once individuals perceive they are at risk for diabetes.

 

Nothing to Disclose: JSW, ME

16941 23.0000 SUN-1020 A Demographic Variation in Perceived Risk, Informed Risk and Diagnosis of Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Pedro Marques1, Margarida da Silva Vieira*1, Florbela Barata Ferreira2, Ana Aguiar3, Sandra Sousa3, Joaquim Nunes3, Ana Paula Soares3 and Carlos Calhaz-Jorge3
1Portuguese Institute of Oncology, Lisbon, Portugal, 2Hosp de Santa Maria, Loures, Portugal, 3Hospital Santa Maria, Lisbon, Portugal

 

Introduction: Polycystic ovary syndrome (PCOS) affects 5-8% of reproductive-age women. Obesity has been associated with metabolic abnormalities. We aimed to evaluate the prevalence and the impact of obesity in clinico-laboratorial features, focusing on glucose abnormalities, of women with PCOS.

Methods: We reviewed clinical records of PCOS women (Rotterdam criteria, 2003) surveilled at Hospital Santa Maria, between 2004-2013. Overweight and obese PCOS were (Body Mass Index ≥25 kg/m2) compared with non-obese for several clinico-biochemical features. Insulin-resistance was assessed recurring to fasting plasma glucose (FPG), oral-glucose tolerance test (OGTT), insulinemia, ratio glucose/insulin (G/I), HOMA-IR and QUICKI indexes.

Results: We identified 263 PCOS women. The mean age was 30(±4) years; 156(59.3%) were overweight or obese, 193(80.4%) had waist circumference>80cm, 13(4.9%) were hypertensive and 84(31.9%) had T2DM familial history. Clinical and/or biochemical androgen excess was identified in 125(47.5%). Glucose abnormalities in OGTT, hypertriglyceridemia and low cholesterol-HDL were detected in 26(11.9%), 21(9.1%) and 105(45.5%), respectively. The indexes G/I, HOMA-IR and QUICKI identified an elevated number of insulin-resistant PCOS (around 41%), predominantly associated to overweight or obesity (accounting for approximately 88% of the insulin-resistant cases).

                Comparative analyses of overweight/obese vs non-obese PCOS revealed in the former group, with statistical significance: higher rates of insulin-resistance, androgen excess, hypertension, T2DM familial history; higher mean values of waist circumference, insulin, triglycerides, cholesterol-LDL, FPG; and lower mean values of cholesterol-HDL and SHBG.

Conclusion: Body weight status was proven as a decisive factor for glucose metabolism and tolerance, as well as for other metabolic features in PCOS. Obesity, as the major factor determining long-term health consequences, should have prompt management in PCOS women.

 

Nothing to Disclose: PM, MDSV, FBF, AA, SS, JN, APS, CC

14110 24.0000 SUN-1021 A Metabolic Abnormalities in a Cohort of 263 Portuguese Women with Polycystic Ovary Syndrome: The Relevance of the Body Mass Index 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Cristina Martinez-Berdeja*1, Ivette Cruz-Bautista2 and Carlos Alberto Aguilar-Salinas2
1National Institute of Medical Science and Nutrition Salvador Zubirán, Mexico City, Mexico, 2National Institute of Medical Science and Nutrition Salvador Zubirán

 

Bile acids regulate the hepatic metabolism of glucose and lipids, by activating specific nuclear receptors (FXR, farnesoid nuclear receptor) and intracellular pathways (insulin signaling pathway). Bile acids have been involved in multiple metabolic diseases such as dyslipidemia, atherosclerosis and malabsorption. We hypothesized that seric total bile acids would be associated to clinical (age, BMI, waist circumference) and biochemical parameters (glucose, HOMA–IR, triglycerides, total colesterol, HDL cholesterol) in adults. We asked whether there is an association between total bile acids in serum and metabolic parameters in Mexican adults. Also, which metabolic parameters correlate better with total bile acids in serum. We designed an observational, non experimental, transversal clinical study, with a descriptive-correlational scope. We included 655 adult patients from our diabetes and dyslipidemia clinics and other external sources. Patients completed a standardized questionnaire with personal information (age, sex), family history, past medical history (diabetes, hypertension, dyslipidemia, coronary heart disease) and actual medication. We obtained by standardized procedures weight, height, BMI, blood pressure, waist and hip measurements. We draw blood, with nine to twelve hours of fasting for glucose, basal insulin, complete lipid profile and total bile acids in serum. Our major results showed that obese women with central obesity had a significant increase in total bile acids (4.8 µmol/l, p<0.001). We found a positive and direct relation between BMI and total bile acids (p=0.030). We divided the total number of patients in subgroups. Patients with diabetes and with metabolic syndrome had the highest concentration of total bile acids (4.8 µmol/l and 4.7 µmol/l, respectively, p<0.001). Hipoalfalipoproteinemia group had the highest total bile acid concentration (8.5 µmol/l, p=0.029). We found a positive correlation between total bile acids and HOMA-IR (r=0.254, p<0.001), glucose (r=0.188, p<0.001) and insulin (r=0.182, p<0.001) and a negative correlation with HDL colesterol (r=-0.098, p=0.013). The major determinants in total bile acids in adults were glucose (B/ES 0.369, p<0.001), insulin (B/ES 0.246, p<0.001) and age (B/ES 0.012, p <0.001). We concluded that total bile acids measured in serum are significantly elevated in metabolic syndrome and diabetes. The major determinants in total bile acid concentration were glucose, insulin and age. Decreased bile acid clearance, may explain the high concentration in diabetes and metabolic syndrome.

 

Nothing to Disclose: CM, IC, CAA

16516 25.0000 SUN-1022 A Major Metabolic Determinants Associated with Total Bile Acids in Serum in Mexican Adults 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Rudolf Yuy Tsun-Shu*
Kazakh National Medical University, Almaty, Kazakhstan

 

Objectives.  The research was carried out to improve cytologic non-invasive technology of diagnostics and monitoring of type 2 diabetes mellitus effective treatment. Material and methods. The research included 22 healthy people and 41 sick ones with type 2 diabetes mellitus at sub compensational stage of an average age  64,5±2,3 with 7,4±1,8 year duration of a disease. Patients got antihyperglucemic drugs or were treated with insulinotherapy along with herbal medical product “Yuvelax”. Material for cytologic analysis were oral cavity mucous swabs, taken on the 2 and 12 days in hospital. Oral swabs were fixed in spirit-acetone and were McManus, May-Grunvald’s and Romanovsky-Himsa’s dyed. In swabs at the rate of 1000 cells the epithelial cells at various stages of differentiation were determined. To determine glycogen content in epithelial cells computer morphodencytometria was used. Differentiation and cornification indexes of epithelial cells (DI and KI) were calculated in the swabs according to cytograms. Moreover, blood glucose level was determined. For mathematical data processing correlation analysis and Student’s criteria were used. Results. In type 2 diabetes mellitus patients the glycogen content in oral cavity mucous epithelial cells of 3, 4, and 5 stages of differentiation considerably reduced. In the cells of the 3d stage of differentiation it was 0,081±0,66 vs 0,32±0,008 standard unit in norm (P<0,01), in the cells of the  4th stage – 0,073±0,004 vs 0,2±0,007 standard units in norm (P<0,01), and in the cells of the 5th stage –  0,054±0,007 vs  0,11±0,006 standard units in norm (P<0,01). DI and KI in cheek, lip, and tongue cells considerably increased (P<0,05).  DI and KI values in gum and hard palate in type 2 diabetes mellitus were not accurately different from the norm. Glycogen content in epithelial cells of the 3, 4, and 5 stages of differentiation, as well as DI and KI of epithelial cells of oral cavity practically normalized on the 12th day of treatment (P<0,01), but did not reach the norm. In this way carbohydrate metabolism disorder in epithelial cells causes changes in the process of differentiation towards orthokeratosis which causes sharp increase of DI and KI of the epithelium cytogram of oral cavity mucosa. Conclusion. Indexes of differentiation and keratinization of oral cavity mucous epithelial cells and glycogen content degree in epithelial cells at different stages of differentiation can be used as diagnostics criteria of type 2 diabetes mellitus.

 

Nothing to Disclose: RY

11768 26.0000 SUN-1023 A Cytologic Diagnostics Criteria of Type 2 Diabetes Mellitus in Elderly Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Melendres Tison Kristine Anne*
Chinese General Hospital and Medical Center, Manila, Philippines

 

Venous fasting blood sugar is the method of choice used to screen for type 2 diabetes mellitus (T2DM). Nonetheless, capillary fasting blood glucose measurements may constitute an alternative to venous blood glucose measurements, specifically during the screening phase, because they are easier, less expensive, and less invasive to obtain. This research explored the use of the fasting capillary blood glucose (cFBS) to screen for T2DM.

            From August until September 2013, after informed consent was obtained, 117 male and female charity patients consulting at the out-patient department (OPD) were included in the study. The subjects were asked to undergo an overnight fast of 8-12 hours. In the laboratory, on the next day, 0.5 µL of blood for capillary fasting blood sugar (cFBS) was drawn from the fingertip. Afterwhich, 3-5 ml of blood was drawn from the antecubital vein of the same patient to determine the venous fasting blood sugar (vFBS). Results were divided into normal, impaired fasting glucose, and type 2 diabetes according to the cut-offs set by the American Diabetes Association. Data processing and analyses were done in SPSS v18.

            The results showed that the sensitivity and specificity of the cFBS in the screening of T2DM was 100% and 91%, respectively. At a prevalence rate of 8.22%, a patient has 67% chances of being diagnosed with T2DM (PPV = 67%) using this screening method.

            This study showed that cFBS can be utilized to screen for T2DM because of its high accuracy (97%). It is a suitable alternative for patients because it is convenient, less invasive, and cost-effective.

 

Nothing to Disclose: MTK

12070 27.0000 SUN-1024 A The Utility of Fasting Capillary Blood Glucose in the Detection of Type 2 Diabetes Mellitus Among Patients at the Charity out-Patient Section, Department of Internal Medicine at Chinese General Hospital and Medical Center 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Mark Anthony Santiago Sandoval*1, Elizabeth Paz-Pacheco1, Elizabeth Paterno1, Noel Juban1, Cecilia A. Jimeno1, Frances Lina C. Lantion-Ang1, Perpetua Patal1 and Edwin Jadulco Cañete2
1University of the Philippines Manila, Manila, Philippines, 2University of Philippines Manila, Manila, Philippines

 

Background: A community-based diabetes prevention program is to be implemented in the agricultural town of San Juan, Batangas in the Philippines.  Prior to this, determining the baseline food intake and physical activity of its residents is necessary.

                                                     

Objectives:  To assess the baseline food intake and level of physical activity among adults in this rural agricultural town.

 

Study design:  Cross-sectional survey

 

Participants:  139 adults belonging to 12 different “barangays” or villages, allocated proportionately with respect to village population, age and sex.

 

Outcome measures:  Food intake was determined using 24-hour food recall on 2 separate weekdays.  From these, macronutrient and energy intake were determined.  Whether energy intake achieved the Philippine recommended energy and nutrient intake (RENI) was also determined.  Level of physical activity was estimated using the International Physical Activity Questionnaire (IPAQ). 

 

Results: The mean energy intake is 1547 ± 558 kcal/d.  Carbohydrates comprised 70% of this, while protein and fats contributed 15% each. Men had an average energy intake of 1741 ± 649 kcal/day while women had a lower intake at 1351 ± 358 kcal/day (p=0.00002).  Energy intake decreased with decreasing age: 1664 ± 630 kcal/day for the 20-39y age group, 1493 ± 461 kcal/day for the 40-59 y age group and 1308 ± 399 kcal/d for the 60+ y age group. (p=0.009 for 20-39y group vs. 60+ y group)  The average food intake was inadequate and was only 72% of the recommended energy and nutrient intake (RENI) for Filipinos.  Only 16 of the 139 respondents (12%) had an average food intake that met the RENI.

The mean level of physical activity is 4,829 MET-min/wk which is considered high level of physical activity.  Forty-seven percent were categorized as having a high level of physical activity while 44% had a moderate level of physical activity.  Only 9% had a low level of physical activity.  Men had a higher level of physical activity with a mean of 4,560 MET-min/wk compared to 3,076 MET-min/wk for females (p=0.0002).  Level of physical activity did not differ significantly between the various age groups.

 

 

Conclusion:  Adult residents in this rural agricultural town had inadequate calorie intake, reaching only a mean of 72% of the RENI.  Mean level of physical activity is considered high.  Majority had either a high or moderate level of physical activity. These need to be considered in the development of a diabetes prevention program in this locale.

 

Nothing to Disclose: MASS, EP, EP, NJ, CAJ, FLCL, PP, EJC

14598 28.0000 SUN-1025 A Food Intake and Physical Activity in a Rural Agricultural Town in the Philippines: Preliminary Phase of a Diabetes Prevention Program 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Akeem P Jimoh*1, Michael Ezebuenyi2, Evelyn Shade Ambush1, Patience O Obih2 and Summers Summers1
1Xavier University of Louisiana, New Orleans, 2Xavier University of Louisiana, New Orleans, LA

 

Diabetes mellitus is a well-known disease associated with increased morbidity, mortality and high health care cost. One of the therapeutic approaches for treating diabetes is to control postprandial hyperglycemia by inhibiting the intestinal absorption of glucose. Drugs like acarbose and miglitol with similar mechanism of action are currently used as antidiabetics. These drugs have attendant side effects. There is a dire need for alternative remedies that have little or no side effects. Garcinia kola is an edible fruit used locally to treat many diseases including diabetes, but with unknown mechanism of action. Our hypothesis is that Garcinia kola reduces postprandial hyperglycemia by inhibiting alpha-glucosidase. Our objective is to investigate the alpha-glucosidase inhibitory activities of Garcinia kola in an in vitro study. The inhibitory effect of various concentrations of aqueous extracts of blueberry on alpha-glucosidase was studied. The study was done in vitro using α-glucosidase obtained from Bacillus Stearothermophilus. The extracts obtained from bitter kola seeds showed inhibitory activities against α-glucosidase with EC50 value of 3.1mg/ml. This result has demonstrated that bitter kola can be considered for further study in order to determine its potential use for the treatment of type 2 diabetes.

 

 

Nothing to Disclose: APJ, ME, ESA, POO, SS

16119 29.0000 SUN-1026 A Investigation into the Antidiabetic Activity of Bitter Cola Via Alpha- Glucosidase Inhibition 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0998-1026 4796 1:00:00 PM Diabetes: Clinical Physiology and Treatment Poster

Carlos Ortega-Gonzalez*1, Enrique Reyes-Muñoz2, Alfredo Castillo-Mora3, Aurora Ramírez-Torres3 and Nayeli Martínez-Cruz3
1Inst Nacional de Perinatologia, Mexico DF, Mexico, 2Instituto Nacional de Perinatologia, Mexico City, Mexico, 3Instituto Nacional de Perinatología, México, D.F., Mexico

 

Risk of large for gestational age neonates in a group of Mexican women with mild gestational diabetes mellitus diagnosed by The International Association of Diabetes and Pregnancy Study Groups Criteria.

 

Carlos Ortega-González, Enrique Reyes-Muñoz, Alfredo Castillo-Mora, Nayeli Martínez-Cruz, Aurora Ramírez-Torres.

Department of Endocrinology. National Institute of Perinatology Isidro Espinosa de los Reyes, SSA. México City, México.

Objective: The primary aim of this study was to know the risk of large for gestational age (LGA) neonates in a group of Mexican women without treatment for mild gestational diabetes mellitus (GDM) diagnosed by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria. The secondary aim was to know the risk of adverse perinatal outcomes.

Methods: Historical cohort study. All patients were studied by one-step protocol for GDM with an Oral Glucose Tolerance Test (2 h-75 g, OGTT). All women had singleton pregnancies, received prenatal care and deliveries were attended in our Institute. For purposes of this study, women included were divided in two groups: Group 1: Untreated pregnant women with “mild GDM” by IADPSG criteria, arbitrarily defined as those women with one abnormal plasma glucose value during OGTT: fasting 92-94 mg/dL or 2-h 153-154mg/dl, Group 2: Healthy pregnant women with normal 2 h-75 g, OGTT: fasting < 92 mg/dL, 1-h < 180 mg/dL and 2-h < 153 mg/dl. We excluded women with one or more of following values during 2 h-75 g, OGTT: fasting ≥ 95 mg/dL, 1-h ≥ 180mg/dL and 2-h ≥ 155 mg/dL, any type of pregestational diabetes and/or with underlying disease. Relative risk with 95% confidence interval (RR 95% CI) was calculated for LGA and adverse perinatal outcome.

Results.  We included 188 and 376 women in groups 1 and 2, respectively.  Glucose values (mean + SD) during 2 h-75 g, OGTT, were (group 1 vs group 2): fasting 92.1 ± 3.07 vs 81.6 ± 5.8 (p = .0001); 1-h: 136.3 ± 25.2 vs 120.2 ± 26.7 (p = .0001) and 2-h: 118.2 ± 19.1 vs 105.7 ± 20.2 (p = .0001). The incidence of LGA neonates were 5.8% and 4.2 for groups 1 and 2 respectively, RR 1.37 (95% CI .63 - 3.1), p= 0.247. There were not differences between groups in the incidence of preeclampsia, gestational hypertension, preterm premature rupture of membranes, cesarean delivery and small for gestational age.

Conclusion: The risk of LGA and adverse perinatal outcomes were similar among mild GDM diagnosed by IADPSG criteria and healthy pregnant women. Randomized clinical trials are request before the adoption of a new diagnostic criteria proposed by de IADPSG in Mexican women.

Key words: gestational diabetes, Mexican women, large for gestational age, perinatal outcomes, IADPSG.

Conflict of interest

None of the authors have any conflict of interest to declare.

 

Nothing to Disclose: CO, ER, AC, AR, NM

16976 5.0000 SUN-1031 A Risk of Large for Gestational Age Neonates in a Group of Mexican Women with Mild Gestational Diabetes Mellitus Diagnosed By the International Association of Diabetes and Pregnancy Study Groups Criteria 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1027-1040 4797 1:00:00 PM Gestational Diabetes Poster

Madona Azar*1, Julie Stoner1, Jean Ricci Goodman2, Lancer Stephens1, Keith Goodman3 and Timothy Lyons4
1University of Oklahoma Health Sciences Center, Oklahoma City, OK, 2Loyola University Medical Center, Maywood, IL, 3Choctaw Nation Health Care Authority, Talihina, OK, 4Queen’s University of Belfast, Belfast, Ireland

 

The prevalence of Type 2 Diabetes (T2DM) has increased in recent years and reached epidemic proportions. T2DM is being diagnosed in younger individuals, specifically in women of childbearing age. Minorities, such as American Indians and Hispanics, may be more affected. Untreated hyperglycemia in pregnancy, even mild, may have significant adverse consequences on both mother and fetus and may promote long term development of T2DM in the offspring. Recent guidelines have emphasized the importance of early and universal screening for dysglycemia in pregnant women, but there is still no consensus on the timing of and optimal screening modality. In this study, we proposed to determine an estimate of the prevalence of overt T2DM and gestational diabetes (GDM) at the first trimester (9-13 weeks) of pregnancy in American Indian and Hispanic women utilizing a 75g, two-hour oral glucose tolerance test (OGTT) after an overnight fast, along with hemoglobin A1c (HbA1c).  In addition, we aimed to identify markers associated with dysglycemia including fasting insulin level, HOMA-IR, serum 1,5-anhydroglucitol (1,5-AG) (an index of short term antecedent glycemia), and skin advanced glycation end-products (SCOUT) measurements. The most recent Endocrine Society diagnostic thresholds were used for the diagnosis of overt T2DM and GDM at the first trimester. In addition, first trimester serum 25-hydroxyvitamin D and fasting lipid measures were obtained.

242 American Indian and Hispanic women were enrolled in the study. Of those, 0.4% (n=1) were found to have overt T2DM, while 22% (n=54) had GDM at the first trimester (i.e., fasting blood glucose 92-125 mg/dl). 77% had normal glucose tolerance. Using American Diabetes Association guidelines for diagnosis, 0.4% (n=1) had overt diabetes and 12% (n=28) had pre-diabetes or impaired glucose tolerance at the first trimester as defined by a fasting blood glucose of 100-125 mg/dL and/or 2-h BG 140-199 mg/dL during the OGTT, and/or HbA1c of 5.7-6.4%. Factors positively associated with GDM at the first trimester included: pre-pregnancy BMI, waist and hip circumferences, systolic blood pressure, and SCOUT score. Fasting insulin and HOMA-IR were also significantly higher in women with GDM, while there was no significant association of serum 1,5-anhydroglucitol (1,5-AG), vitamin D levels, or fasting lipids with glycemic status.

In conclusion, dysglycemia was highly prevalent in minority women at the first trimester of pregnancy. Early diagnosis and treatment may help improve pregnancy outcomes and reduce the long-term risk of diabetes development in the offspring.

 

Nothing to Disclose: MA, JS, JRG, LS, KG, TL

15169 6.0000 SUN-1032 A First Trimester Dysglycemia in Pregnant Oklahoma Minority Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1027-1040 4797 1:00:00 PM Gestational Diabetes Poster

Erick Sta. Rosa Mendoza* and Leilani Basa Mercado-Asis
University of Santo Tomas, Manila City, Philippines

 

Plasma Insulin Level Identifies Pre-Impaired Glucose Tolerance State and Diabetes Mellitus among High Risk Pregnant Women

Background: Pre-impaired glucose tolerance (pre-IGT) is a condition in which there is abnormally high insulin secretion even the fasting and postprandial glucose levels are still within normal range. Insulin resistance in gestational diabetes mellitus (GDM) is probably chronic in nature and the altered physiologic mechanism and detrimental effects of hyperinsulinemia may start before pregnancy among those with risk factors. It was the aim of the study to establish the association of pre-pregnancy risk factors with pre-IGT state determined by plasma insulin level. More so, the study would like to establish that pre-IGT state is significantly associated with subsequent development of GDM.

Methodology: Thirty-four pregnant women were included and divided into 2 groups: those without (n=19) and those with (n=15) risk factors for hyperinsulinemia. Plasma glucose 2 hours after 75-gram glucose load and plasma insulin was done to determine the existence of pre-IGT (<200 mg/dL and >30 uIU/mL respectively) upon the diagnosis of pregnancy. A 75-gram oral glucose tolerance test was done between 26 and 28 weeks of gestation to identify GDM. Fisher’s exact test was performed to identify whether pre-pregnancy risk factors are significantly associated with pre-IGT during the first trimester of pregnancy and whether the occurrence of pre-IGT is significantly associated with subsequent development of GDM.

Results: Baseline characteristics included maternal age (22 ± 3 years vs. 29 ± 4 years), height (1.53 ± 0.04 m vs. 1.55 ± 0.05 m), weight (54.56 ± 9.22 kg vs. 62.58 kg ± 9.94) and BMI (20.11± 3.24 kg/m2 vs. 25.45 ± 4.22). Pre-pregnancy risk factors were obesity (n=8), first-degree family history of diabetes mellitus (n=3), previous GDM (n=3) and polycystic ovarian syndrome (n=1). Ten out of fifteen (66.7%) pregnant women with risk factors and four out of nineteen (21.1%) pregnant women without risk factors had pre-IGT. The presence of any pre-pregnancy risk factor was associated with pre-IGT during early weeks of pregnancy (p < 0.05). Nine out of fourteen (64.3%) pregnant women with pre-IGT and three out of twenty pregnant women without pre-IGT (15.0%) proceeded to GDM. The presence of pre-IGT was significantly associated with development of subsequent GDM (p < 0.05).

Conclusion: Obesity, first-degree family history of diabetes mellitus, polycystic ovarian syndrome and previous GDM were significant pre-pregnancy risk factors for the development of hyperinsulinemia or pre-IGT in pregnancy despite initially normal glucose tolerance. The occurrence of pre-IGT could identify those at risk to develop subsequent GDM. Screening for risk factors and plasma insulin levels before or early in pregnancy should be considered in preconception and prenatal care.

 

Nothing to Disclose: ESRM, LBM

14904 7.0000 SUN-1033 A Plasma Insulin Level Identifies Pre-Impaired Glucose Tolerance State and Diabetes Mellitus Among High Risk Pregnant Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1027-1040 4797 1:00:00 PM Gestational Diabetes Poster

Pedro Marques1, Daniel Macedo*2, Maria Raquel Carvalho3, Luísa Pinto4 and Sílvia Guerra4
1Portuguese Institute of Oncology, Lisbon, Portugal, 2Portuguese Institute of Oncology, Lisbon, Lisbon, Portugal, 3Hospital Santa Maria, Lisboa, Portugal, 4Hospital Santa Maria, Lisbon, Portugal

 

Introduction: Gestational diabetes mellitus (GDM) and maternal obesity are associated with complications in both mother and offspring. GDM prevalence, of about 5% of all pregnancies, is increasing as pregnant women become older and more obese. We aimed to evaluate the features and obstetric outcomes in women with GDM and additionally investigate the impact of pre-pregnancy obesity in several obstetric outcomes.

Methods: We reviewed clinical records of pregnancies complicated with GDM surveilled at Hospital de Santa Maria, Lisboa, between 2011 and 2012. Obese GDM women (Body Mass Index≥30kg/m2) were compared with non-obese for different maternal and neonatal outcomes.

Results: We identified 186 GDM women. The mean age was 33.9(±5.5) years. Most were diagnosed at 2nd trimester (55.9%) and controlled with diet (65.1%). Seventy-nine (42.5%) had familial history of DM. We observed remarkable rates of pregnancy hypertension (17.7%), cesarean deliveries (33.3%) and neonatal intensive care unit (NICU) admissions (8.1%). The mean gestational age was 38.3(±2.0) weeks and prematurity estimated in 12.9%. A low rates of preeclampsia (2.7%), abortion (1.0%), macrosomia (2.2%), newborns small or large-for-gestational age (5.9 and 7.0%), birth malformations (0.5%) and neonatal injuries (2.2%) were detected. No perinatal deaths were reported. Reclassification post-partum oral-glucose tolerance test (OGTT) detected glucose abnormalities in 21 GDM women (11.3%).

From the 186 GDM women, 132 had complete data on pre-pregnancy BMI. The mean BMI was 28.4(±6.6)kg/m2 and 43 out of 132 GDM women (32.6%) were classified as obese. No statistical differences were detected between obese versus non-obese GDM women with regard to the neonatal and maternal outcomes analysed, except for neonatal birth injuries, significantly higher in the obese group (4.7vs0%; p=0.04). Obese GDM needed more frequently pharmacological treatment to achieve glycemic targets (46.5vs28.1%; p=0.025) and had a higher prevalence of hypertension (34.9vs18.0%; p=0.032) than non-obese GDM.

Conclusion: In this series, obesity was not associated with poorer obstetric outcomes in GDM women, except for birth injuries. Interventions for weight lose in obese GDM women should be implemented in order to improve glycemic control and to avoid potential adverse neonatal and maternal complications. Regardless obesity, GDM may be associated to some adverse pregnancy outcomes, and then should be properly managed.

 

Nothing to Disclose: PM, DM, MRC, LP, SG

14074 8.0000 SUN-1034 A Retrospective Analyses of a Cohort of Women with Gestational Diabetes Mellitus: Focus on the Impact of Obesity in the Obstetric Outcomes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1027-1040 4797 1:00:00 PM Gestational Diabetes Poster

Catherine Adam*1, Christine L'Abbé2, Johanne Lachapelle2, Sabrina Ourabah2, Agnes Rakel1, Michèle De Guise2, Marie-Josée Bédard2 and Ariane Godbout3
1Centre de Recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada, 2Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada, 3Centre de recherche du Centre hospitalier de l’Université de Montréal (CR-CHUM), Montreal, QC, Canada

 

INTRODUCTION: Prevalence of gestational diabetes mellitus (GDM) is dramatically increasing. Recommendations for its treatment include a diet controlled in carbohydrates and 150 minutes of moderate intensity physical activity (PA) per week.

OBJECTIVE: Determine if an individualized counselling and follow-up by a trained kinesiologist could 1) help to increase PA in GDM patients, 2) decrease insulin use and medical intervention during pregnancy.

METHODS: Women diagnosed with GDM were randomly assigned to individualized follow-up by a kinesiologist (group 1) or general counselling about PA (group 2). A control group (group 3) was designed based on a previous GDM cohort who did not received any particular PA advice. Primary outcome was the use of insulin. Secondary outcomes included excessive gestational weight gain (GWG) according to the IOM guidelines, evaluation of medical intervention (non stress test and induction) and a composite outcome of maternal and fetal complications (hypertension, preeclampsia, cesarean c-section, assisted delivery, macrosomia, prematurity, neonatal unit admission). To monitor PA, patients in groups 1 and 2 were asked to answer a standardized questionnaire about their daily PA (PPAQ) and to wear an accelerometer for 1 week at GDM diagnosis and at the end of pregnancy.

RESULTS: A total of 79 GDM patients were recruited in the first year of the study and were randomized either to group 1 (n=40) or group 2 (n=39). Each subject was matched for age, BMI and term at GDM diagnosis with a patient from our previous GDM cohort (group 3). Maternal characteristics were similar at baseline. Insulin use was comparable in the three groups in terms of rate of insulin therapy (38, 33 and 41% respectively: p=0.752), delay before insulin addition to standard treatment (27, 29 and 37 days: p=0.134), and mean dose of insulin required to achieve glycemic control (0.24, 0.27, 0.32 U/kg/day: p=0.617). Medical intervention as well as maternal and fetal outcomes were also similar. Proportion of patients with excessive GWG was also comparable between groups (respectively 30, 33  and 41%: p=0.489). No difference was noted in level of PA between groups 1 and 2. However, a great proportions of active women stayed very active in group 1 during pregnancy, vast majority of women were very satisfied by this service and no adverse events that could be related to PA was demonstrated in both groups.

CONCLUSION: At interim analysis, no clear impact of an individualized counselling by a kinesiologist in GDM women could be demonstrated. Those results could be related to actual lack of power. However, appropriate PA intervention and follow-up could be considered safe for pregnant women since no adverse event or maternal sports injury was reported. More subjects and further analysis are needed to evaluate impact of PA on medical intervention, maternal and fetal outcomes and its cost-effectiveness in GDM patients.

 

Nothing to Disclose: CA, CL, JL, SO, AR, MD, MJB, AG

15378 9.0000 SUN-1035 A Impact of an Individualized Counselling on Physical Activity in Women with Gestational Diabetes: Interim Analysis of a Randomized Control Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1027-1040 4797 1:00:00 PM Gestational Diabetes Poster

Subhash B Yadav*1, Eesh Bhatia2, Vignesh G3 and Renu Singh4
1Sanjay Gandhi Post Grad Inst, Lucknow UP, India, 2Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India, 3Sanjay Gandhi Post Grad Inst, Lucknow, India, 4Queen Mary hospital, King George Medical, University, Lucknow, India

 

Objective: The criteria for gestational diabetes, as applicable to the south Asian population, are not well studied. We studied the prevalence of gestational diabetes mellitus (GDM) in north India by International Association in Diabetes and Pregnancy Study Group (IADPSG) and World Health Organization (WHO) criteria

 Methods: We conducted a cross-sectional study of 332 pregnant women, who were screened for GDM between 24-28 weeks of gestation by a 75g oral glucose tolerance test. Maternal antenatal history and parameters were recorded. Prevalence of GDM was calculated by both IADPSG and WHO (1999) criteria. Association of various maternal parameters with GDM by both of above mentioned criteria were analyzed.

 Results: The prevalence of GDM was 41.9% (CI, 36.6-47.2) and 17.4% (CI, 13.3-21.5) by IADPSG and WHO criteria respectively. The prevalence was 2.4 times higher by IADPSG criteria when compared with WHO criteria. By IADPSG criteria, 91% had abnormal fasting plasma glucose whereas all (100%) patients diagnosed as GDM by WHO criteria had 2hr post glucose value above the cut-off of 140 mg%. There was positive association of maternal weight [p=0.05] with GDM diagnosed by IADPSG. There was no association of maternal factors with GDM by WHO criteria. By IADPSG criteria, fasting glucose levels were associated with weight [p=0.006] of the patient and 1 hour post glucose levels were associated with weight [p=0.01] and number of gravid [p=0.006]. Birth weight of child was not affected by either gestational diabetes diagnosed by either criterion.

Conclusions: There is very high increase in the prevalence rate of GDM by using IADPSG criteria in north Indians. Further studies are needed to assess the cost-effectiveness of applying this criterion in limited resource settings.

 

Nothing to Disclose: SBY, EB, VG, RS

13246 10.0000 SUN-1036 A Comparison of Prevalence of Gestational Diabetes Mellitus By International Association of Diabetes and Pregnancy Study Group Criteria (IADPSG) and Older WHO Criteria– a Study from North India 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1027-1040 4797 1:00:00 PM Gestational Diabetes Poster

Emily J. Jones*1, Michael Peercy2, Hannah Fraley3 and Ellen W. Seely4
1University of Massachusetts Boston, Boston, MA, 2Chickasaw Nation Department of Health, Ada, OK, 3University of Massachusetts Boston, 4Brigham & Women's Hospital, Boston, MA

 

Background: American Indians experience twice the US population prevalence of CVD with earlier onset and increased morbidity and mortality. Excess CVD burden is partially attributable to the increase of type 2 diabetes (T2D), with prevalence recently increasing most alarmingly in American Indian women (AIW) of childbearing age. Gestational diabetes mellitus (GDM) is considered a unique risk factor for T2D and CVD. Women can lower risk for T2D by reducing weight and increasing physical activity. Recognizing the significant risk GDM poses in AIW, early intervention in the childbearing years is crucial.

Purpose: To describe the perspectives of Oklahoma AIW with previous GDM related to the barriers and facilitators to healthy lifestyle changes postpartum and specific intervention approaches that would facilitate participation in a postpartum lifestyle program.

Methods: We conducted a descriptive mixed methods study with 28 AIW who obtained care in a tribal health system in Oklahoma. Focus groups and informant interviews allowed women to describe barriers and facilitators to enacting postpartum lifestyle changes and explore various approaches to facilitate participation in a postpartum lifestyle program. Inductive content analysis with open coding was used to explore qualitative transcripts and categorize data by themes. Descriptive statistics were used to analyze data from demographic and technology feasibility surveys.

Results: Of 28 interested AIW (32 + 5 years; documented GDM) invited to participate in focus groups, only 12 could attend; 15 participated in informant interviews, and one completed surveys only. Influenced primarily by family history, the majority of AIW believed they would inevitably develop T2D and/or CVD; however, they were optimistic to delay onset or decrease severity of disease with lifestyle change. Barriers to preventive behaviors included a knowledge-behavior gap, competing priorities, time, financial, and geographic constraints, exhaustion, and childcare duties. Suggested facilitators of lifestyle change included the perceived value of role modeling healthy behaviors in the family, social support, nutritional education, and access to gyms with childcare. All reported regular text messaging and use of internet, either by PC or smart phone. The majority expressed enthusiasm for a lifestyle change program after pregnancy incorporating facilitators and utilizing the internet and/or text messaging. Many felt a face-to-face approach would be particularly motivating but stated numerous barriers to attending.

Conclusions: To resonate with AIW’s belief that T2D and CVD can be delayed with lifestyle changes, an intervention that utilizes the internet and/or text messaging and emphasizes the benefits of delaying disease onset should be tested as a novel, culturally relevant approach to reduce rates of T2D and CVD in this high risk population.

 

Nothing to Disclose: EJJ, MP, HF, EWS

14619 11.0000 SUN-1037 A Identifying Postpartum Intervention Approaches to Reduce Incidence of Type 2 Diabetes and Cardiovascular Disease in American Indian Women with Previous Gestational Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1027-1040 4797 1:00:00 PM Gestational Diabetes Poster

Jéssica Karina Vázquez*1, Martha Eugenia Fajardo2, Juan M Malacara3, Joel Ramírez4, Elva L Pérez4 and Herlinda Aguilar4
1Universidad de Guanajuato, León, Mexico, 2Universidad de Guanajuato, Leon GTO, Mexico, 3Univ de Guanajuato, Leon Gto, Mexico, 4Universidad de Guanajuato

 

BACKGROUND: Gestational Diabetes Mellitus (GDM) can lead to the development of type 2 diabetes mellitus (DMT2) in both mother and child. Peroxisome proliferator-activated receptors (PPARs) are major regulators of glucose and lipid metabolism.

AIMS/HYPOTHESIS: Placental PPAR-γ expression has been reported to be significantly lower in GDM patients compared to normal patients, yet it is unknown whether PPAR-γ expression could extend to an influence on early growth (which is largely mediated by insulin). Therefore, the aim of this study was to investigate if a relationship exists between PPAR-γ expression in placenta and newborn physical and metabolic characteristics in women with gestational diabetes mellitus (GDM).

METHODS: Fetal side placental tissue and cord blood samples were obtained from 14 GDM patients and 14 normal patients. Gene and protein expression levels were measured using quantitative real-time RT-PCR and Western-blot, respectively. Leptin and insulin levels were measured using a radioimmunoassay method. Differences between groups were analyzed using an independent Student t test, and correlations were analyzed using Pearson and Spearman rank correlation.

RESULTS: PPAR-γ gene (P<0.0001) and protein (P<0.00008) expression levels were significantly diminished in GDM patients compared to normal patients. PPAR-γ gene expression was negatively correlated with newborn weight (P<0.009) and abdominal perimeter (P<0.01), and cord blood leptin levels (P<0.05) in GDM patients. In addition, PPAR-γ protein expression was negatively correlated with cord blood triglyceride (P<0.03) levels in GDM patients, and with cord blood cholesterol levels (P<0.05) in normal patients.  

CONCLUSIONS: These results show that PPAR-γ expression altered in GDM may predispose early in life to hypertriglyceridemia and thus may be at greater risk of developing metabolic diseases later in life.

 

Nothing to Disclose: JKV, MEF, JMM, JR, ELP, HA

16987 12.0000 SUN-1038 A Placental PPAR-Gamma Expression Correlates with Cord Blood Triglyceride in Gestational Diabetes Mellitus Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1027-1040 4797 1:00:00 PM Gestational Diabetes Poster

Lynn M Yee*, Jamie M McGuire, Shaneah M Taylor, Charlotte M Niznik and Melissa A Simon
Northwestern University Feinberg School of Medicine, Chicago, IL

 

Objective: Diabetes in pregnancy is a significant problem for low-income, minority women. Successful management requires optimization of health services while aiming to improve women’s engagement in care. Cognitive load theory addresses this intersection and explains that high mental demand imposes barriers to success. Given the complexity of self-care requirements during a pregnancy affected by diabetes, we sought to prospectively evaluate barriers and protective factors that affect underserved women’s diabetes cognitive load in pregnancy.

Methods: Using mixed methods, 30 prospective semi-structured, in-depth interviews on diabetes barriers to care were performed with 10 diabetic pregnant women at three time points. Questionnaires using standardized scales assessed cognitive load moderators: health literacy and numeracy, social hassles, and diabetes self-efficacy. Qualitative analysis of longitudinal interview data used grounded theory techniques.

Results: 50% of this cohort of minority, low-income, public aid-supported women (median age 28.5) had pregestational diabetes. 50% had inadequate health literacy/numeracy using the Newest Vital Sign. Qualitative analysis identified 6 barriers and 4 protective factors. Diabetes self-care barriers included: diabetes novelty or lack of prior experience; outcome expectation and disbelief in treatment efficacy; social instability; limited nutrition comprehension and inability to carry out nutritional changes; psychological stressors; and the burden of disease management. Outcome expectation barriers included disbelief that treatment would enable success and fatalistic attitudes. Protective factors included: diabetes self-efficacy and familiarity; external motivation; supportive social and physical environment; and ability to self-regulate. Self-regulatory behaviors included recognition, behavioral modification and sustained change when goals were achieved. Lastly, inadequate health literacy was a common overarching influence on ability to effectively manage diabetes.

Conclusions: Pregnant women face multiple barriers to successful diabetes self-care. Ability to achieve diabetic goals in pregnancy is negatively influenced by several social, cognitive and knowledge-based factors. Protective factors can ameliorate these demands. Interdisciplinary teams including endocrinologists and obstetricians can assess patient barriers to diabetes success and use this framework to develop patient-centered interventions at this intersection between health services, health disparities, and behavior. Providers may benefit by understanding this complex interplay of social and medical factors that affect diabetes management in order to partner with their pregnant patients in achieving healthy pregnancies and successful postpartum transition.

 

Nothing to Disclose: LMY, JMM, SMT, CMN, MAS

15328 13.0000 SUN-1039 A “I Was Tired of All the Sticking and Poking”: Using Cognitive Load Theory to Identify Determinants of Diabetes Self-Care Among Low-Income Pregnant Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1027-1040 4797 1:00:00 PM Gestational Diabetes Poster

Ramaz Kurashvili*, Natalia Asatiani and Elena Shelestova
Georgian Union of Diabetes and Endocrine Associations

 

Background : Type 1/2 Diabetes Mellitus (T1/T2 DM) is increasing worldwide, it is  unequally affecting women  through pregnancy and threat posed to mother/child. T2DM has become a generation younger; 60 million of reproductive age (RA) women have T2DM. Number of women  starting  pregnancy with DM (PGDM) has  doubled since 1999. St.Vincent Declaration/SVD (1989) put as one of its targets “to approximate pregnancy outcomes  in women with DM to those of background population”. To achieve SVD goals Twinning movement was initiated in Europe. Discussion: Georgian Diabetes Federation (IDF  member since 1994) and Israeli Diabetes Association initiated Twinning  in 1992. False concepts on diabetes in pregnancy –  heritage of the past - resulted in high mortality/morbidity rates  and  discrimination of women with  DM. In existing situation Diabetes in Pregnancy (DiP) was selected as main  target and effective tool to show  State that changes are possible and can be substantial. As a part of  Program Dr. P.Segal, Prof. M. Hod and a  group of Israeli specialist came to Georgia;  an  EASD Postgraduate Course was held;  later 2   Georgian doctors were trained in Israel. As a result  Program was written, it received  full support, was sponsored by Novo  Nordisk and  initiated in 1996; 1st results were presented at  IDF Congress in 1997. Strong partnership between endocrinologists and obstetricians - main condition for success, was  another huge achievement. During past 17 yrs  309 women with PGDM were enrolled in  Program. Preconception care,  education, surveillance during pregnancy/ labor are provided to all women. Today almost 100% of RA women  with T1DM who plan pregnancy are enrolled in Program. Totally, 341 children were born to diabetic mothers. In 2008 Manual Diabetes in Pregnancy was prepared, published and distributed to specialists  from   CIS countries. In 2012 blocks on various aspects of Diabetes in Pregnancy  were prepared/ submitted to  Public Health Ministry  to be included in  State Program on NCDs.  Conclusion:   Program is still actively working. Over 70 presentations were made at various International Congresses. According to experts’ opinion it is  one of the most successful Twinning Programs. We confirm that in our Program  mentioned above SVD target  was achieved. Program showed that similar Programs can be initiated in any place even with minimal  resources and sustainable results and   success could be achieved. We hope new Government of Georgia will adopt State Strategy  on NCDs, where management of Diabetes in Pregnancy and universal screening for gestational diabetes will occupy appropriate  place.

 

Nothing to Disclose: RK, NA, ES

16155 14.0000 SUN-1040 A “Diabetes in Pregnancy” - Israeli-Georgian Twinning Program That Provides Care to Women with Diabetes in Georgia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1027-1040 4797 1:00:00 PM Gestational Diabetes Poster

Muneera abdulmalik Alshareef*
king fahad military hospital, Jeddah, Saudi Arabia

 

 

Background:

Type 1 Diabetes Mellitus (T1DM) is known to be associated with other autoimmune disorders.  The prevalence of celiac disease (CD) in patients with T1DM varies from 4.4 to 11.1% worldwide with limited data in Saudi Arabia. In this study, we report the prevalence of CD in patients with T1DM in the western region of Saudi Arabia.

Methods:

A cross sectional study of patients with T1DM whom were followed at the diabetic centre of King Fahad military Hospital in Jeddah, Saudi Arabia. Demographic data were obtained. Blood samples were collected for anti- tissue transglutaminase antibodies IgA (Anti-TTG)    Patients with positive serology for Anti-TTG underwent endoscopy for duodenal biopsy . Patients were divided to age groups (< 17, 17-23 and > 23 years old) and according to diabetes duration ; (< 4 , 4-9  and > 9 years) .  

Results:

Total of 218 patients ( 42% male and 58% female ) with T1DM . Anti-TTG was found in 7.3%. Histological features of CD was found in 63% of the positive Anti-TTG . They were 12 females and 4 males with sex ratio of male/female 1:3.  CD patients were significantly shorter; 154 cm vs 160 cm with ( p=0.01); lower weight, 51kg vs 61kg with (p= 0.03),  had  non significant lower 25-hydroxy Vitamin D level    and significant higher parathyroid hormone  (p=0.001 ). There were no significant difference between the prevalence of CD and the different age or the diabetes duration groups.

Conclusion:

This study showed similar prevalence of CD in patients with T1DM worldwide and the data lend support to recommend regular screening for CD in all patients with T1DM.

 

Nothing to Disclose: MAA

11281 1.0000 SUN-0947 A The Prevalence of Celiac Disease in Patients with Type 1 Diabetes Mellitus in Saudi Population. Cross Sectional Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Larry A Fox*1, Emilie Balkman1, Kim Englert1, Jobayer Hossain2 and Nelly Mauras1
1Nemours Children's Clinic, Jacksonville, FL, 2Alfred I duPont Hospital for Children, Wilmington, DE

 

Background: Many children and adolescents have poorly controlled T1D in part because of noncompliance with home blood glucose (BG) monitoring. Continuous glucose monitors (CGM) are an attractive option, but are only FDA-approved to be used in conjunction with fingerstick glucose for therapeutic decisions. We designed a pilot study that explores whether using sensor glucose (SG) data generated in real-time for treatment decisions would be safe in children/adolescents with poorly controlled T1D.

Study design: 10 adolescents with A1c ≥9% on insulin pump therapy were admitted to the Clinical Research Center after lunch. A CGM sensor (MiniMed Paradigm® Revel™) was inserted. Calibration fingerstick BGs were performed as per manufacturer recommendations. Reference plasma glucose values were measured at least hourly using Yellow Springs Instrument Glucose Analyzer (YSI). Beginning with dinner, SG was used for treatment decisions unless any of the following criteria were met: (1) YSI <70; (2) SG <70 and YSI >250; (3) absolute difference between SG and YSI was greater than the patient’s insulin sensitivity factor (ISF) or >100; (4) rate of change of YSI or SG was <60 but the other was ≥60 mg/dL/hr; (5) change in YSI and SG were in opposite directions (i.e., one was decreasing, the other increasing). All mealtime and high BG insulin doses and symptoms of hypoglycemia were logged. The participant was discharged after lunch the following day; 3 meals and 1-2 snacks were provided during the admission while using CGM.

Results: 9 patients (7 males; 15.2-17.8 yrs old) completed the study. Mean (±SE) absolute difference (MAD) and mean absolute relative difference (MARD) for SG compared to YSI were 29.6±4.5 mg/dL and 16.0±1.8%, respectively (range 14.0-53.3 mg/dL and 9.4-25.6%).  A total of 28 (range 1-4/patient) high BG correction doses were given during CGM use, 8 of which (0-2/patient) used YSI glucose for correction because one of the above criteria were met (6 because absolute difference between SG & YSI was >ISF; 2 because rate of change of YSI <60 and that of SG was ≥60 mg/dL/hr). There were 5 episodes of mild hypoglycemia occurring in 3 patients (2 with YSI <70, 1 with SG <70); 2 episodes in 1 patient were symptomatic (YSI 61-68), 1 patient with SG of 47 had symptoms but concurrent YSI was 148. The remaining low BGs were asymptomatic. Two of 5 lows BGs occurred after using SG for insulin dose calculations. There was no BG <55. Four insulin doses using SG for calculations (1 in each of 4 patients) resulted in an increase of BG by >100 (range 102-122) within 3 hours, none up to ≥350.  

Conclusion: Use of real-time CGM for treatment decisions in this pilot study was safe. Correction and mealtime doses using SG data did not result in significant over- or under-treatment with insulin. The use of SG for treatment decisions under supervised inpatient conditions may be an alternative to repeated fingerstick BGs, but further studies are needed.

 

Disclosure: LAF: Principal Investigator, Medtronic Minimed, Principal Investigator, Merck & Co., Advisory Group Member, Tandem Diabetes Care, Principal Investigator, Johnson &Johnson. NM: Principal Investigator, Medtronic Minimed. Nothing to Disclose: EB, KE, JH

13306 2.0000 SUN-0948 A An Inpatient Pilot Study Assessing the Safety of Using Real-Time Sensor Glucose Values for Treatment Decisions in Adolescents with Poorly-Controlled Type 1 Diabetes Mellitus (T1D) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Aurore Pecheur1, Thierry Barrea2, Valérie Vandooren2, Veronique Beauloye3, Annie Robert2 and Philippe A Lysy*3
1Université Catholique de Louvain, Bruxelles, 2Université Catholique de Louvain, 3Université Catholique de Louvain, Brussels, Belgium

 

Aims: To evaluate the characteristics, determinants and influences on disease control of partial remission (PR) in Belgian children with type 1 diabetes (T1D). Methods: We retrospectively analyzed records from our center of 242 children diagnosed with T1D (1994-2008). Clinical and biological features were collected at diagnosis and during follow-up. PR was defined using the insulin dose–adjusted A1C definition.Results: PR occurred in 56.2% of patients and lasted 9.2 months [0.5 to 56.6]. 25.6% of patients entered T1D with DKA, which correlated with lower incidence of PR (17.6%, vs 82.3% when no DKA). At diagnosis, lower A1C and higher C-peptide levels were associated with higher PR incidence in all patients while initial A1C levels correlated with longer PR only for young children (0-4 yr). Early A1C levels were predictive of PR duration since 34% of patients had long PRs (>1 year) when A1C levels were ≤6% after 3 months, whereas with higher A1Cs incidence of long PR decreased. Initial antibody titers did not influence PR except for anti-IA2 titers that correlated with A1C levels after 2 yr. Presence of 2 vs 1 anti-islet antibodies correlated with shorter PR. PR duration did not influence occurrence of severe hypoglycemia or diabetes-related complications but was associated with lower A1C levels at 18 months after PR. Conclusions: We show that at diagnosis, parameters associated with b-cell mass reserve (A1C, C-peptide, DKA) correlate with PR, which affected short-term A1C levels. Further research is needed to determine if PR influences diabetes long-term evolution.

 

Nothing to Disclose: AP, TB, VV, VB, AR, PAL

14412 3.0000 SUN-0949 A Partial Remission of Type 1 Diabetes: Determinants and Influences on Disease Outcome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Ana C Uribe-Wiechers*1, Paloma Almeda-Valdes2, Marcela Janka3, Joel Lopez-Gutierrez3 and Francisco Javier Gomez-Perez2
1Instituto Nacional de Nutricion y Ciencias Medicas Salvador Zubiran, Mexico City, Mexico, 2Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico, 3Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran

 

Introduction. Development of metabolic syndrome (MS) has been observed in some patients with type 1 diabetes (T1D) as the disease progresses over time. The association between MS and the occurrence of microvascular complications has not been established. The aims of this study were to determine the prevalence of MS in T1D and to evaluate its association with diabetic nephropathy.

Methods. Cross-sectional study that included patients with T1D of more than 10 years of evolution treated at the Diabetes Clinic of the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran in Mexico City. The presence of the MS was determined using the modified criteria proposed by the National Cholesterol Education Program-Adult Treatment Panel III.

Results. The overall prevalence of MS was 18.5% (n=15). Neither age (P=0.6) nor the time of T1D diagnosis (P=0.8) were different among the groups. While BMI (P=0.05), systolic blood pressure (SBP) (P=0.03), creatinine (P=0.04), AST (P=0.04) and A1C (P=0.05) were greater in the group with MS. Microalbuminuria (MA) was greater in subjects with MS (34.9 [8.3-169.3] vs those without MS 9.0 [5.0-27.0], P=0.02). When stratifying the population by the number of MS criteria, we found a progressive increase in MA when adding more MS criteria (P=0.008). We found a significant correlation between MA and A1C values, SBP and triglycerides (P<0.05). In the regression analysis the number of MS criteria was an independent factor associated with MA, after adjusting for the associated variables (R2=0.11, P=0.03).

Conclusion. The MS was present in 18.5% of the population studied, which is inferior to what has been previously reported by other studies including the DCCT (22%) and the FinnDiane (39%). The addition of MS criteria has a significant association with the presence of MA.

 

Nothing to Disclose: ACU, PA, MJ, JL, FJG

14716 4.0000 SUN-0950 A Diabetic Nephropathy in Patients with Type 1 Diabetes Mellitus. Contribution of the Metabolic Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Raphael Del Roio Liberatore Jr.*1, Maria Estela Bellini Ribeiro2, Carlos Eduardo Martinelli Jr.3 and Rodrigo Custodio4
1Faculty of Medicine from Ribeirão Preto-USP, Brazil, 2FAMERP, 3Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil, 4Faculty of Medicine from Ribeirão Preto-USP

 

SUMMARY

To compare multiple insulin doses (MID) and continuous insulin infusion therapy (CIIT) as treatment for type 1 diabetes, 40 type 1 diabetic patients (21 female) with ages between 10 to 20 years (mean=14,2) and mean time of diabetes of 7 years used MID for at least 6 months and after that, CIIT for at least 6 months. Each one of the patients have used MID and  CIIT. For analysis of HbA1c, mean glycated hemoglobin (mGH) was obtained during each treatment period (MDI and CIIT). Although mGH levels were lower during CIIT the difference was not statistically significant. During MDI, 14.2% had mGH values below 7.5%, versus 35.71% CIIT demonstrating better glycemic control with the use of CIIT. During MDI, 15/40 patients have severe hypoglycemic events versus 5/40 CIIT. No ketoacidosis were recorded. As we know, this is the first study with this design comparing MDI and CIIT showing better metabolic control and reduction of severe hypoglycemic events with CIIT.

 

Nothing to Disclose: RDRL Jr., MEBR, CEM Jr., RC

14939 5.0000 SUN-0951 A Multiple Insulin Injections Versus Insulin Pump Therapy to Diabetes Mellitus Type 1 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Gabriela H Teló*, Carly E Dougher, Michelle L Katz and Lori M Laffel
Joslin Diabetes Center, Boston, MA

 

With onset of puberty, insulin requirements increase in youth with type 1 diabetes (T1D) due to physiologic insulin resistance. Despite increased doses, glycemic control (A1c) generally deteriorates from the pubertal years until the 3rd decade of life. To describe trajectories of U/Kg/D in youth with T1D, we evaluated a dynamic cohort of 629 youth (46% male) with T1D ≥1 year, insulin dose ≥0.5 U/Kg/D at entry and ≥1 year of follow-up from 1993-2013. Mean U/Kg/D analysis by age consisted of the insulin dose closest to each birthday (±6 months). Longitudinal multivariate modeling included all U/Kg/D observations and adjustments for age, sex, pump use, weight status, baseline insulin dose, and age at T1D diagnosis. At 1st observation, mean age was 9.8±3.1 years, T1D duration 2.7±2.2 years, and A1c 8.9±1.7%; 5% of youth were pump treated and 31% were overweight/obese. Baseline age, T1D duration, A1c, and weight status did not differ by sex. Mean follow-up was 10.8±2.3 years and included 29±13 U/Kg/D assessments/patient with a mean interval of 4.7±4.0 months between U/Kg/D observations; U/Kg/D range 0.5-2.5. At last observation, mean age was 20.6±3.6 years, T1D duration 13.4±4.6 years, and A1c 9.0±1.7%; 35% were pump treated and 33% were overweight/obese. Final A1c differed by sex; A1c was 9.2±1.7% for females and 8.7±1.6% for males (p<.001). A1c was lower for pump vs. injections users at ages 10 (8.1 ± 1.0 vs. 8.7 ± 1.2, P =.02) and 20 (8.6 ± 1.2 vs. 9.0 ± 1.6, P =.008). Mean U/Kg/D analysis by age and stratified by sex revealed that females had higher U/Kg/D than males between the ages of 8-14 years (p<0.01) while males had higher U/Kg/D than females between ages 16-21 years (p<0.05). Insulin dose analysis by age and stratified by regimen revealed pump therapy yielded lower U/Kg/D versus injection therapy throughout childhood and adolescence (p<0.05); dose analyses by weight status revealed that overweight/obese youth had higher U/Kg/D only in the early pubertal teen years, ages 9-13 (p≤0.04). In longitudinal multivariate analysis, pump use was associated with a 0.13 U/kg/D lower insulin dose vs. injection therapy (p<.0001). Further study is needed to evaluate the interaction of sex, puberty, regimen, and weight status on daily insulin requirements and resulting glycemic control. Improved understanding of expected dose adjustments during childhood and adolescence may improve A1c outcomes in youth with T1D.

 

Disclosure: LML: Consultant, Sanofi, Consultant, Eli Lilly & Company, Consultant, Novo Nordisk, Consultant, Roche Pharmaceuticals, Consultant, Dexcom, Consultant, Johnson &Johnson, Consultant, Bristol-Myers Squibb, Consultant, Menarini, Consultant, Boehringer Ingelheim Pharmaceuticals. Nothing to Disclose: GHT, CED, MLK

16014 6.0000 SUN-0952 A Dynamic Changes in Total Daily Insulin Dose (U/kg/D) during Childhood and Adolescence in Youth with Type 1 Diabetes (T1D): Impact of Age, Sex, Regimen, and Weight Status 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Fred Cavallo Aita*1, Adriana Yock-Corrales1, Mariela Gonzales-Volio2 and Roberto Bogarin3
1Hospital Nacional de Niños, San José, Costa Rica, 2Caja Costarricense de Seguro Social, Costa Rica, 3Hospital Nacional de Niños, San Jose, Costa Rica

 

Introduction: Children with diabetic ketoacidosis (DKA) present frequently to the emergency department (ED) (1).  Most children recover when treated with insulin, intravenous fluids, and electrolyte replacement; however, infrequent complications, such as cerebral edema may occur (2).  We describe the presentation in the ED of children with DKA in Costa Rica.

Objectives: The aim of this study was to describe clinical presentation, complications and outcomes of diabetic ketoacidosis.

Methodology: We conducted a retrospective case series of consecutive patients aged 1 month to 15 years presenting to a single-center tertiary ED with DKA during a 5-year period.

Results:  61 patients were identified.  Mean age was 7,9 years (SD 3,76) and 64% were female. Median time from onset of symptoms to ED presentation was 8 days (IQR 2-15 days).  Twenty-one of the patients were previously healthy. 77% of the patients had a previous consult to a physician.  Precipitating factor was identified in 19 (31%) and 12 (19,7%) were DM 1 with poor control.  Most presented with progressive onset of symptoms (73,8%). Vomiting (54%), weight loss (55.7%), polydipsia (73.8%) and polyuria (69%) were the most frequent symptoms.  On examination, dry oral mucosa 46 (75.4%), lethargy 17 (28%) and tachypnea (23%) were the most common signs.  The degree of dehydration on arrival was mild in 19 (31%), moderate 14 (23%) and severe 16 (26.2%).  Laboratory findings on arrival: mean pH 7.14 (SD 0,13); bicarbonate 8.4 mmol/L (SD 4.14); PCO2 23.6 (SD 7.6); sodium 133.15 mEq/L (SD 6.4) and potassium 4.68 mEq/L (SD 0,89).  Twentytwo (36%) patients had severe DKA with a mean age of 7,7(SD 3.7).  Seven patients were treated for cerebral edema and all had severe DKA (P value 0.044), 16 had hypokalemia and 5 hypoglycemia during management.  Risk factors for cerebral edema were identified in 17 patients.  No mortality was found.

Conclusion: DKA poses significant risks of morbidity and mortality. It must be suspected in patients who present with polyuria, polydipsia, vomit and abdominal pain. Treatment with fluids, insulin infusion, and careful monitoring is necessary for better outcomes.

 

Nothing to Disclose: FC, AY, MG, RB

16492 7.0000 SUN-0953 A Pediatric Diabetic Ketoacidosis in a Tertiary Children's Hospital 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Jemma Jay Angela Anderson1, Catherine Leggett2, Jenny Couper3 and Alexia S Pena*3
1University of Adelaide, 2Women's and Children's Hospital, North Adelaide, Australia, 3University of Adelaide, North Adelaide, Australia

 

Introduction

Limited data exist regarding the rate of medication adherence in adolescents.

Aim

To use two different methods for assessing medication adherence using an electronic monitoring system and tablet count in adolescents with Type 1 Diabetes (T1D) participating in an RCT.

Method

Medication adherence was assessed in 49 T1D adolescents (age 14±2.3y, 23 males, duration T1D 6.1±4.3y, HbA1c 8.5±1.1, 22 using insulin pumps) enrolled in a 1 year RCT to receive metformin or placebo (ACTRN126110001148976)1. Adherence was assessed by means of a tablet count and prospective electronic monitoring using Medication Event Monitoring System caps (MEMS, AARDEX group, LTD Sion, Switzerland), which recorded episodes of bottle opening for each participant. These data were then compared to prescribed doses.

Adherence was assessed after allowing a 3-month run-in period; from 3-6 months (short-term) and from 6-12 months (long-term). Adequate adherence was defined as a value of ≥80% of prescribed doses taken over a defined period.

Results

MEMS adherence data for short and long-term use was available for 49 and 39 participants respectively. Adequate adherence using MEMS was 45% (22/49) short-term and 38% (15/39) long-term. Median adherence was 79% (short-term) and 67% (long-term).

Tablet count adherence data for short and long-term use was available for 30 and 33 participants respectively. Adequate adherence using tablet count was 67% (20/30) short-term and 42% (14/33) long-term. Median adherence was 86% (short-term) and 76% (long-term).

There was no statistically significant difference in adherence between the two methods, p = 0.11 (short-term) and p = 0.13 (long-term).

Conclusion

Adolescent adherence to metformin and placebo in this clinical trial was suboptimal as shown by both electronic monitoring and tablet count.

 

Nothing to Disclose: JJAA, CL, JC, ASP

16552 8.0000 SUN-0954 A Adherence Is Suboptimal in Adolescents with Type 1 Diabetes Participating in a Clinical Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Kalpana Dash*1 and Chiranjit ROY2
1Apollo Hospital, Bilaspur, India, 2Apollo Hospitals Bilaspur, Bilaspur, India

 

Type 1 diabetes is the most common form of diabetes in children and adolescence.  World wide there are 490,000 children under age 15 with type 1 diabetes.  This number is rising between 3-5% per year [1]. Several studies have shown that there is an increased prevalence of type 2 diabetes mellitus among adults with low socioeconomic status [2]. This is also true for type 2 diabetes mellitus children because, pediatric obesity is also more common in low socioeconomic status. However on the contrary type 1 diabetes is more common among wealthy population [3]. There is paucity of data about the distribution of type 1 diabetes among various communities and socioeconomic status in India. In this study we tried to find out the mean age, age distribution and distribution of diabetes among various communities and socioeconomic status. We analyzed 103 type 1 diabetes mellitus patients. Among 103 patients, 57 (55.33%) were male and 46 (44.66%) were female having no sex preponderance. The mean age of these patients was 21.81 years. Higher incidence of diabetes was found in the peri-pubertal period that is age group of 10-20 years (n = 48, 46.6%) and lowest was found in 11 (10.6%) cases in the age group less than 10 years. Between 21-30 years and more than 30 years had 24 (23.3%) and 20 (19.4%) cases respectively.  In order to explore the distribution of type 1 diabetes mellitus among different communities and socioeconomic status, we reviewed the records of 103 type 1 diabetes patients from 2002 to 2013 visiting at Endocrine clinic based in a tertiary care hospital in Central India. We classified all patients in to four classes as A, B, C and D depending on community and socioeconomic status. Group A patients belonged to poor socioeconomic status, group B belonged to business community with moderate to high socioeconomic status, group C all service class population with medium socioeconomic status and group D belonging to Mohammedan community. Number of patients belonging to various groups are A (n = 38, 36.9%), B (n = 43, 41.8%), C (n = 13, 12.6%) and D (n = 9, 8.7%). Our finding did not show a significant difference in the prevalence of type 1 diabetes among low socioeconomic status (A) and high socioeconomic status (B) which was also demonstrated by many studies [3]. It is very interesting to find that type 1 diabetes in our study was very low among certain communities like Hindu Brahmins (n=6, 5.8%), Srivastava (7=7, 6.8%) and Indian Mohammedans (n=9, 8.7%).   We have found a distinct accumulation of type 1 diabetes among business class people who belong to high SES. It suggest that probably physical inactivity, altered food habits, rapid urbanization and other environmental factors related to development of type 2 diabetes, probably plays a major role in the pathogenesis of type 1 diabetes. However, our series consists of a very small number of patients which needs further extension.

 

Nothing to Disclose: KD, CR

16739 9.0000 SUN-0955 A Prevalence of Type 1 Diabetes Mellitus Among Different Socioeconomic Groups & Communities in Chhattisgarh, India 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Anita Saha* and Indrajit Majumdar
University at Buffalo, State University of New York and Women and Children's Hospital of Buffalo, Buffalo, NY

 

Awareness of glycemic control is essential for long term management of youth with diabetes. However, youth show poor understanding of the glycemic control goals. Further, comprehensive diabetes care, a largely under-recognized entity in adults with diabetes, is often neglected in youth in the absence of visible clinical complications.

Aims: 1) Study the changes in awareness of most recent HbA1c and American Diabetes Association (ADA) recommended HbA1c targets in youth with diabetes following initiation of a quality improvement (QI) initiative at Women and Children’s Hospital of Buffalo, diabetes center (WCHOB-DC). 2) Study current level of comprehensive care in youth with diabetes.

Methods: As part of QI initiative at the WCHOB-DC, families of youth with diabetes, followed every 3-4 months, completed a comprehensive questionnaire at each clinic visit, since August 2012. Families were asked to indicate their most recent HbA1c and ADA recommended age appropriate HbA1c targets. At the end of the visit, families were also given a handout about their current HbA1c and ADA recommended target HbA1c. Data were collected retrospectively from electronic medical records before and after introduction of the QI process between August 2012 and April 2013. Additional data collected included blood pressure (BP), annual eye examination, cholesterol levels and influenza immunization. Data is presented as mean + SD and percentage. Wilcoxon Sign Rank Test was used for data comparison.

Results: Data collected from 338 records of youth with diabetes (13.7 + 4.2 years, 52.7% male; 90% non-hispanic whites, 92% type 1 diabetes) at their first clinic visit after QI projects initiation, was used as baseline. HbA1c of 32.1% subjects were at or below ADA recommended targets. BP and cholesterol levels were normal in 79.4% and 65.7% subjects, respectively. Annual eye examination and influenza immunization was completed in 91% and 83% subjects, respectively. Following initiation of the QI initiative, awareness of most recent HbA1c improved from 23% (n=315) to 33% (n=277, P=0.007) and HbA1c target awareness improved from 20% (n=315) to 29% (n=277, P=0.02) over 6 months.  

Conclusion: Intensive education resulted in improved awareness of glycemic control among families of youth with diabetes. Additional initiatives are needed to improve comprehensive care, which remains poor in this group.

 

Nothing to Disclose: AS, IM

11566 10.0000 SUN-0956 A Are Youth with Diabetes Aware of Glycemic Control and Comprehensive Diabetes Care? What Can We Do? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Shabana Kalladi*1, Bernard M Degnan2 and Susan Szpunar3
1Virginia Commonwealth University, Richmond, VA, 2St John Hospital, Detroit, MI, 3St John Hospital and Medical Center, Grosse Pointe Woods

 

In 2012, over 30,000 children attended diabetes camps in North America. In general, children who attend diabetes camp will be more active at the camp than they are at home. The association between increased activity and increased frequency of hypoglycemic events is well known, so it is general practice for medical staff to reduce insulin dosage at the very beginning of the camp session to avoid severe hypoglycemic events. Despite these measures, the frequency of hypoglycemic events at these camps is fairly high, often higher than the frequency of events reported at home. These events can occur at any time during the day, but the frequency at night is particularly high. At Camp Midicha, medical staff observed that the frequency of nocturnal hypoglycemia detected by standard protocol was quite high on the first night of camp even though the level of activity on the first day was fairly low. 

This prospective study investigates whether episodes of hypoglycemia in the early days of camp are due to higher activity level or to persistence of unrecognized hypoglycemic episodes that are occurring at home before camp. We examined this question using data from camp records as well as data from a group of campers who agreed to wear a Continuous Glucose Monitoring System (CGMS) for 2 days prior to camp through the first 2 days of camp.

Potential participants were recruited during the annual camp enrollment period; 46 campers agreed to have the CGMS placed approximately 48 hours prior to camp and to wear it through the first 48 hours of camp (CGMS group).  In addition, using camp records, blood glucose logs and insulin dosages were reviewed for the 46 subjects and for 209 campers who did not wear a CGMS device. For the analysis, each camper served as his or her own control. Due to the skewed nature of the data, analysis was done using the Wilcoxon Signed Ranks test.

Results: For the entire study group (n=252), 60% (153) were female, 68.9% (173) used insulin pumps, and the mean age was 12.4±2.4 years.  There were no significant differences between the campers who wore a CGMS device and those who did not except that CGMS users had a higher mean weight (CGMS 122.8±28.4 vs. 110.2±38.7 lbs., p=0.05). Data were first analyzed for the entire study group using camp records. The median percent of blood glucose measurements <70 did not differ significantly pre-camp to during camp (pre-camp median 0%, IQR 0; camp median 0%, IQR 9.1, p=0.08).  

Of the 46 campers who wore an iPro device, only 35 had valid iPro data.  From the iPro data, the median percent of BG measurements <70 prior to camp was 0.92% (IQR 5.7) compared to 1.67% (IQR 5.3) in the first two days of camp, p=0.93,showingthat the difference between the time periods was not statistically significant.

Conclusion: Episodes of hypoglycemia in the first 48 hours of camp that are usually attributed to increased activity may in fact be the result of persistent unrecognized hypoglycemic events occurring at home prior to camp.


 

Nothing to Disclose: SK, BMD, SS

13080 11.0000 SUN-0957 A Frequency of Hypoglycemic Events before and during Diabetes Camp: Use of a Continuous Glucose Monitoring System 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Zohreh Shoar*, Andrea Zivot, Shaida Nasiri, Nandita Mandhani and Barbara A Kelly
Albert Einstein Medical Center, Philadelphia, PA

 

BACKGROUND:

The prevalence of obesity is constantly increasing and more women during child bearing age are diagnosed as obese. Maternal obesity is considered to be a risk factor for abnormal carbohydrate metabolism and developing Gestational Diabetes (GD). Diabetes during pregnancy is known to be associated with significant maternal and neonatal complications.

OBJECTIVES:

The purpose of this study is to investigate the comorbid effects of maternal obesity and GD on neonatal outcome in an inner city population. In addition, we intend to compare the different modes of treatment for GD.

METHODS:

This is a retrospective chart review study; singleton mothers with a new diagnosis of GD and their infants born at Albert Einstein Medical Center, Philadelphia, during a 3 year period, were included in the study. Maternal data such as race, age, type of treatment for GD (diet, insulin, medications), and obesity status were collected and their association with neonatal variables such as birth weight, congenital anomalies, diagnosis of sepsis, feeding difficulties, admission to NICU,  bilirubin, hemoglobin, calcium, and glucose levels was examined. 

RESULTS:

Preliminary data from 91 women with the diagnosis of GD were analyzed:  ages 18 to 48 years (mean 30.33±0.69); 54.9% Black, 12% Hispanic, 12% Caucasian, 9.9% Asian, and 11% other/unknown; 67% with Medicaid insurance, 27.2% with private insurance, the rest with other/no insurance. Of these mothers 53% were obese (mean BMI of 34.78±0.72) and 47% were non-obese (mean BMI of 25.17±0.5).  There was no statistical difference between obese and non-obese mothers in regard to their age, insurance type , mode of delivery, gestational age, and treatment for GD. Maternal complications of pregnancy including poly/oligohydramnios, preeclampsia/eclampsia, and chorioamnionitis were equally observed in both groups, but hypertension was more significant in obese mothers (p=0.025). Similarly, we did not observe any difference in gestational age, birth weight, congenital anomalies, NICU admissions, diagnosis of sepsis, feeding difficulties, glucose, hemoglobin, and bilirubin levels based on obesity status or obesity status divided by treatment for GD. Only calcium was significantly lower in normal weight vs. obese mothers (8.73 ±0.28 vs. 9.92±0.24, p=0.012). Using correlation statistics, we did not observe any association between neonatal outcome and mode of treatment for GD and these associations remained non-significant after controlling for maternal age, race, and insurance type.

CONCLUSION:

While maternal obesity is a known risk factor for the development of gestational diabetes, its effect as an independent variable in neonatal outcome is less well defined.  Future larger experimental studies may provide better understanding of these risk factors on both maternal and infant health and well-being.

 

Nothing to Disclose: ZS, AZ, SN, NM, BAK

14201 12.0000 SUN-0958 A Maternal Obesity, Maternal Gestational Diabetes, and Neonatal Outcome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Mandana Moosavi*1 and Constantin Polychronakos2
1University of British Columbia, Vancouver, BC, Canada, 2McGill Univ/Montrea Child Hosp, Montreal, QC, Canada

 

Background: The honeymoon phase is the period shortly after initiation of insulin therapy in type 1 diabetes (T1DM) patients, in which there seems to be a portion of the beta cell mass still functional. During this phase patients tend to require less insulin because of endogenous production. This phase varies widely in duration in every patient and can last anywhere from one week to years. The exact mechanisms and immune pathways involved in initiation and maintenance of the honeymoon phase is not well known. It is possible that various variables including presence of genetic risk alleles determine the variation in depth and duration of the honeymoon phase in each patient. 

Objective: To test the hypothesis that some non-HLA T1D loci that modulate T1DM susceptibility, also determine the duration of the “honeymoon” phase by altering the rate of autoimmune beta cell destruction.

Methods:From a database of pediatric-onset T1DM patients,  we selected 177 subjects for whom we also had genome-wide genotyping data. From insulin doses and hemoglobin A1c values, we calculated the time spent in honeymoon phase.  Honeymoon was defined as a value <10 of a previously established metric calculated as A1c+4 x D, where D is daily insulin dose in U/kg (e.g. maintaining A1c <8 with 0.5 U/kg/day). This was multiplied by the duration of the <10 value to obtain the “area over the curve” as a quantitative trait. Using the allelic association option in PLINK software, we then examined the association between the quantitative trait and nine T1DM risk loci. 

Results: Out of the 9 SNPs ( Single Nucleotide Polymorphisms) representing the strongest associations with T1DM, we found two, rs3757247 on chromosome 6 (BACH2) and rs689 on chromosome 11 (insulin), that were shown to approach statistical significance with p= 0.059 and 0.088 respectively. Risk alleles at these two variants could therefore determine the duration of honeymoon period  in T1DM patients. 

 Conclusion: We have preliminary evidence that the presence of SNPs associated with T1DM risk may also affect the remission phase seen in these patients. Although our data did not reach statistical significance, two variants came very close to the threshold. This is a preliminary study that indicated that these data need to be validated in a larger sample size. More similar studies should be done to determine more variables that can contribute to the variation seen in the honeymoon phase.

 

Nothing to Disclose: MM, CP

14209 13.0000 SUN-0959 A Effect of Type 1 Diabetes Risk Loci on Duration of Honeymoon Phase in Type 1 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Natalie Hecht Baldauff*1, Hala Mounir Tfayli2, Wenxiu Dong3, Vincent Arena3, Dorothy J Becker4 and Ingrid Libman1
1Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, 2American Univ of Beirut, Beirut, Lebanon, 3University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, 4Children's Hosp/Univ of Pittsb, Pittsburgh, PA

 

Adiponectin correlates with insulin resistance (IR) and leptin is associated with adiposity. Racial differences in adipokines have been described in overweight adults and children and may explain differences in IR between African Americans (AA) and Caucasians (C). Limited data are available in children with TID, where the prevalence of obesity has increased significantly in the last decades.

Objective: (1) to assess racial differences in adiponectin, leptin, and their ratio (ALR) (2) to evaluate the relationship between the adipokines and anthropometric data within each race. 

Design: AA children with new onset T1D (48% M, age 11.1±3.8 yrs) were individually matched by sex, age, and diagnosis year with C. Sera were available for 156 subjects (77 AA, 79 C) for assays of adiponectin (RIA) and leptin (ELISA) prior to, 3-5 days, and 2-4 months (M3) after insulin therapy.  There were no significant differences in adiponectin levels on days 0-3 and leptin levels on days 0-5 so values were averaged (D0). β-cell autoantibodies (GAD, IA2, insulin, and ICA) were measured. 

Results:  At diagnosis, AA were more often overweight than C (Median [IQR]: 89.8 [23.8-97.6] vs. 35.9 [7.28-75.6] percentile, p<.001) and had fewer positive antibodies (72% vs. 87%, p=.05). At D0, adiponectin levels were lower in AA than in C (11.7 [7.5-17.4] vs. 16.4 [10-23.7 µg/mL], p=.008) but this difference did not persist after adjusting for BMI. By M3, adiponectin levels did not differ between AA and C (19.1 [11.2-30.8] vs. 18.5 [15-23 µg/mL], p=0.8). A negative correlation between adiponectin levels and BMI% at D0 only reached statistical significance in C (AA: r=-0.22, p=0.1 vs. C: r=-0.45, p-<0.001). Leptin levels were not significantly different between AA and C at D0 (1.7 [0.7-4.4] vs. 1.4 [0.8-2.8, p=0.6). By M3 leptin increased significantly in both groups, but higher levels in AA did not reach significance (10.1 [2.1-24.3] vs. 3.6 [1.6-16.2 ng/mL], p=0.08).   In AA, leptin correlated with BMI% at D0 (r=0.33, p=.007), but did not quite reach significance in C (r=0.24,p=0.06). ALR was not significantly different between AA and C at either D0 or M3.  D0 ALR negatively correlated with BMI% in both groups (AA: r= -0.38, p=0.002, C: r=-0.4, p=0.001). Age was related to ALR at D0 and M3 only in AA (r= -0.28, p<0.03 and r= - 0.56,p=0.003) and this negative correlation persisted after adjusting for BMI only at M3 (r= -0.46, p=0.02). In contrast, there were no significant relationships between age and ALR in C.

Conclusion: In children with new onset T1D, adiponectin, leptin, and their ratio were related to BMI.  After adjustment for BMI there were no racial differences in adipokines indicating that body composition rather than race determines adipokine levels. The differences in the relationships of ALR with age, only seen in AA, requires further exploration to assess potential differences in influences of factors such as pubertal IR and glucotoxicity.

 

Disclosure: HMT: attendee ISPAD scientific meeting, Medtronic Minimed, Speaker, Novo Nordisk. Nothing to Disclose: NH, WD, VA, DJB, IL

14514 14.0000 SUN-0960 A Racial Differences in Adiponectin and Leptin in Children with New Onset Type 1 Diabetes (TID) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Jonathan Henricks1, Edward Gratz2 and Berrin Ergun-Longmire*3
1University of Maryland, College Park, Baltimore, MD, 2The Herman and Walter Samuelson Children's Hosp at Sinai, Baltimore, MD, 3The Herman and Walter Samuelson, Baltimore, MD

 

Background: Autoantibodies to glutamic acid decarboxylase isoform 65kDa (GAD65) are common at the time of clinical diagnosis of T1D and are present in various autoimmune and neurological disorders such as stiff-man syndrome (SMS), cerebellar ataxia, and epilepsy. It has been observed that high levels of GAD65 antibodies in patients with idiopathic general epilepsy (IGE) may serve as a causative link to T1D, however this has yet to be proven.

Objective: The aim of this study is to investigate the incidence of neurological disorders in children with T1D who have elevated GAD65 antibodies. 

Methods: We conducted a retrospective chart review, identifying serum GAD65 levels and history of neurological disorders in patients who diagnosed with T1D between January 1, 1997 and December 31, 2013.  We used the MATLAB R213b statistical software for data analyses.

Results: Data were available for 82 children (33 males, 49 females) who were tested for GAD65.  The mean age, in years, was 13.65 ± 4.43. The mean duration of T1D was 4.03 ± 2.78 years.  

Of these 82 children, only 60 were positive for GAD65.  There was only one patient who had a seizure disorder in GAD65 positive group and none in GAD65 negative group.  The incidence of neurological disorders and GAD65 antibodies was insignificant when compared against GAD65-negative patients (p = 0.54). The patient who had a seizure disorder and GAD65 positive (GAD65 = 4.9 U/ml) was diagnosed with benign myoclonic absence seizure at the age of 4, and was diagnosed with T1D at 12 years old. The patient’s familial medical history was significant for both T1D and T2D, however, it was not positive for any seizure disorder.

Conclusion: Notwithstanding the limited data, our results do not indicate that the presence of GAD65 antibodies has an effect on the patients' risk of developing epilepsy or other neurological disorders.

 

Nothing to Disclose: JH, EG, BE

14655 15.0000 SUN-0961 A The Incidence of Neurological Disorders in Children with Type 1 Diabetes (T1D) and Positive GAD65 Antibodies 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Dara Eckerle Mize*1, Howard B A Baum1, Bonnie Slovis2, Joshua C Denny2, Lisa Bastarache2, Jacqueline Kirby2, Nida Safdar3, Alvin C Powers4 and Adam Seegmiller2
1Vanderbilt University Medical Ce, Nashville, TN, 2Vanderbilt University Medical Center, Nashville, TN, 3Vanderbilt University School of Mediciine, Nashville, TN, 4Vanderbilt Univ Med Ctr, Nashville, TN

 

Cystic fibrosis related diabetes (CFRD) confers reduced survival and affects 40-50% of adult cystic fibrosis (CF) patients.  CFRD represents a distinct disease process with incompletely understood pathophysiology.  Synthetic Derivative, a de-identified electronic medical record at Vanderbilt University Medical was used to conduct a retrospective review of individuals diagnosed with CFRD from 1996 to 2013.  Initial search for CF ICD-9 diagnosis codes (277.0, 277.01, 277.02, 277.03 and 277.09) revealed 953 subjects.  Final analysis included 151 subjects after exclusion of subjects for whom date and setting of CFRD diagnosis or criteria for CF diagnosis were unavailable.  The population was 53% female and 92% Caucasian, with a mean age at CFRD diagnosis of 27.8 years (range 5 to 59 years), and average duration of CFRD at last follow-up was 3.76 years. Exocrine pancreatic insufficiency was present in 99.3% of patients.  Diagnosis of CFRD was made in healthy outpatients 56% of the time and during hospitalization 38% of the time.  The remaining subjects were diagnosed as part of screening for gestational diabetes (n=5), in the setting of symptomatic hyperglycemia (n=2), and with outpatient screening tests during CF exacerbation (n=2).  Of 117 subjects who underwent genotype evaluation, DF508 had an allele frequency of 77%, with 66% (74) being homozygous for DF508.  Other allele frequencies were 3% for G551D; 2.1% for G532X; 1.3% for 1717-1G>A, 621>T, 2184insA and R533X; 0.9% for R117H, 3272-26 A>G, G85E, N1303K and Q493X; and 0.4% for 2184delA, W1282X, 2184, 1898>A, 2585delT, dI507, F508C, R1066C, R709x, R1158X, R1162X and V520F.  There was no correlation between genotype and age of onset of CFRD.  However, increasing age of onset of CFRD tended to be associated with increased BMI.  Average BMI for individuals diagnosed in the 1st decade was 14.3 kg/m2, followed by 18.8 kg/m2 for 2nd decade diagnosis, 20.5 kg/m2 for 3rd decade diagnosis, 20.2 kg/m2 for 4th decade diagnosis, 22.4 kg/m2 for 5th decade diagnosis and 25.9 kg/m2 for the 6th decade diagnosis.  Neither the duration of diabetes, nor the age of diabetes onset correlated with need for insulin therapy.  This is the first study to demonstrate a positive correlation between age of onset of CFRD and BMI and a lack of correlation between duration of diabetes and outpatient use of insulin therapy. These findings distinguish CFRD as a distinct form of diabetes and underscore the need for larger, confirmatory studies.

 

Disclosure: HBAB: Principal Investigator, Novo Nordisk. ACP: Ad Hoc Consultant, Boehringer Ingelheim Pharma GmbH & Co. KG, Ad Hoc Consultant, GNF/Novartis. Nothing to Disclose: DE, BS, JCD, LB, JK, NS, AS

16428 16.0000 SUN-0962 A The Association Between Age of Onset and Duration of Cystic Fibrosis-Related Diabetes with Insulin Use and BMI 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

In Ah Jung*1, Won Kyoung Cho2, Yeon Jin Jeon1, Min-Ho Jung1, Jae Wook Lee1, Nak Gyun Chung2, Bin Cho1 and Byung-Kyu Suh1
1College of Medicine, The Catholic University of Korea, Seoul, Korea, Republic of (South), 2College of Medicine, The Catholic University of Korea, Korea, Republic of (South)

 

Development of diabetes mellitus after hematopoietic stem cell transplantation for childhood leukemia

Purpose : We investigated clinical features of newly diagnosed diabetes mellitus (DM) after hematopoietic stem cell transplantation (HSCT) for treatment of childhood leukemia.

Methods : Between April 1999 and March 2013, total 112 patients (63 males, 49 females) were visited the clinic of pediatric endocrinology for routine follow-up check after HSCT for leukemia. Among them, four patients developed DM (3 males, 1 female). We retrospectively reviewed medical charts including laboratory findings.

Results :. Three patients were diagnosed as acute lymphoblastic leukemia who received total body irradiation and chemotherapy. The other one patient diagnosed as acute myeloblastic leukemia received only chemotherapy for conditioning. The mean age at HSCT was 7.75 ± 4.21 years. All four patients developed chronic graft-versus-host disease (GVHD) and treated with steroid. The mean age at diagnosis of DM was 16.25 ± 1.48 years and the time interval between HSCT and DM was 8.5 ± 4.2 years. Three patients showed obesity depend on body mass index (> 95th percentile for sex and age). No one showed antibodies related with pancreatic β-cell. The mean fasting insulin levels at diagnosis was 13.24 ± 9.17 μIU/mL and the mean homeostasis model assessment indexes of patients was 4.5 ± 2.0. Three patients who showed obesity were treated with metformin only or metformin and insulin injection, and the other one was treated with insulin injection only. After the treatment, the diabetic control of all patients was improved.

Conclusion : GVHD, long-term steroid treatment and insulin resistance seem to be close related to develop of DM after HSCT for treatment of childhood leukemia

Key words : Diabetes mellitus, Hematopoietic stem cell transplantation, Leukemia, Insulin resistance

 

Nothing to Disclose: IAJ, WKC, YJJ, MHJ, JWL, NGC, BC, BKS

13584 17.0000 SUN-0963 A Development of Diabetes Mellitus after Hematopoietic Stem Cell Transplantation for Childhood Leukemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Jung Soo Lim*1, Young Ju Choi2, Byoung Wook Huh2, Eun Jig Lee3 and Kap Bum Huh2
1Yonsei University Wonju College of Medicine, Wonju, Korea, Republic of (South), 2Huh’s Diabetes Center and the 21C Diabetes and Vascular Research Institute, Seoul, Korea, Republic of (South), 3Yonsei University College of Medicine, Korea, Republic of (South)

 

Background Double diabetes is generally defined as type 1 diabetes mellitus (DM) with insulin resistance (IR). This combination can lead to inadequate glycemic control even with higher insulin doses, thereby increasing risk of cardiovascular (CV) complications. The phenotype of double diabetes may be related to the genetic and lifestyle factors, weight gain caused by intensive insulin therapy, and the route of administration of exogenous insulin. The aim of this study is to investigate metabolic parameters according to the degree of IR in Korean double diabetes.

Methods We evaluated 203 patients with type 1 DM (men 100, women 103) whose fasting C-peptide was ≤0.6 ng/mL and who were treated with insulin. Insulin sensitivity was assessed by the rate constant of plasma glucose disappearance (Kitt%/min) using an insulin tolerance test in all patients; the low tertile of kitt was considered relatively insulin-resistant group. Moreover, visceral fat thickness (VFT) and carotid intima-media thickness (CIMT) were measured using ultrasonography.

Results In both genders, fasting glucose and HbA1c levels were significantly higher in the low tertile group than in the high tertile one. However, there were no differences in VFT and CIMT, as well as DM duration, body-mass index, waist circumference, and lipid profiles between the two groups.

Conclusions Contrary to expectations, the influence of IR on metabolic parameters in Korean double diabetes was not clear, except for factors related to glycemic control. Larger studies for relationship between IR and incident CV events in type 1 DM would be needed.

 

Nothing to Disclose: JSL, YJC, BWH, EJL, KBH

14400 18.0000 SUN-0964 A Clinical Characteristics of Korean Double Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Ilia Davidenko*1, Natalya Volkova2, Julia Rudakova3, Maria Antonenko4, Igor Reshetnikov5 and Irina Dzherieva6
1Rostov State Medical University, Rostov-on-Don, Russia, 2Rostov state medical university, Rostov on Don, 3Ros, Rostov-on-Don, Russia, 4Rostov State Med Univ, Rostov-on-don, Russia, 5Rostov State Medical University, Rostov-on-Don, Russia, 6Rostov State Medical University, Rostov on Don, Russia

 

Lipohypertrophy (LH) is a chronic complication of diabetes mellitus that is caused by frequent subcutaneous injections of insulin. (1). Nowadays, visual appearance of LH is less obvious due to good quality insulin and expansion their concentration. As a result, some difficulties of it’s diagnostics have been appeared (2). The aim of this study has been to develop the estimation risk model of insulin induced lipohypertrophy (LH) in diabetic patients. This study was done on 140 diabetic patients (89 females and 51 males) who had been under the treatment with insulin a mean 8 years. Observation and palpation techniques, as well as ultrasonography of subcutaneous fat were used in assessing LH in these diabetics. All patients were divided into two groups. First group included 117 patients with LH, second – 23 diabetics without pathologic areas of subcutaneous fat. Further, all known as well as additional LH risk factors were statistically processed using Spearman`s, Kendall tau, Gamma rank correlation coefficients and binary logistic regression. Results were statistically significant when p<0,05. Also measure area under curve (AUC) was determined. All risk factors were analyzed using Spearman`s, Kendall tau, Gamma rank correlation coefficients on first stage. Statistically insignificant parameters were eliminated (p>0,05). 10 factors from 23 were remained after first stage. Further, 10 parameters were subjected to ROC-analysis. Measure AUC was determined. All risk factors had high predictive value (AUC > 0,5). So, they were used for development the estimation risk model. On the basis of binary logistic regression the estimation risk model was created. Efficacy of  estimation risk model were tested on 34  diabetic patients. Predictive value of model was 86%  taking into account threshold cut-off 0,3 and confidence interval 95%. Nowadays, LH remains severe insulinotherapy complication. Since there is no any LH treatment, its early diagnostics is absolutely necessary for diabetic patients. Thus, we developed new noninvasive painless method of LH diagnostic with good quality and high predictive value (86%) for patients who are under the treatment with insulin.

 

Nothing to Disclose: ID, NV, JR, MA, IR, ID

16794 19.0000 SUN-0965 A Insulin Induced Lipohypertrophy Diagnostics in Diabetic Patients: Estimation Risk Model 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0947-0965 4799 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Daniela Jakubowicz*1, Julio Wainstein2, Yosepha Bar-Dayan3, Hadas Rabinovitz4 and Oren Froy5
1Wolfson Medical Center, Tel Aviv, Israel, 2E. Wolfson Medical Center. Tel Aviv University, Holon, Israel, 3Wolfson Medical Center, Holon, Israel, 4The Hebrew University of Jerusalem,, Rehovot, Israel, 5The Hebrew University of Jerusalem, Rehovot, Israel

 

Previously we have shown in type 2 diabetic (T2D) individuals that a diet with high-calorie (HC) breakfast (B) or morning meal with reduced dinner (D) or evening meal, resulted in a significant decrease in HbA1c, and was more beneficial than isocaloric diet with HC-B and reduced D in improving glucose, lipids and hunger. Whether it is related to a potential diurnal pattern of incretin secretion and β-cell responsiveness to incretins after HC meal ingestion in the morning vs. in the evening has however, not been studied in T2D

We assessed postprandial early 30, late 60-180 and 180 min plasma insulin, glucose, intact (i) and total (t) glucagon–like peptide-1 (GLP-1) and VAS hunger scores responses after HC 700 kcal B vs. after isocaloric and identical meal at D.

In a randomized crossover design 18-T2D (8 males, 10 females), aged 57.8 ± 4.7 yrs; BMI: 26.37 ± 1.69 kg/m2; HbA1c: 7.55 ± 0.42 %, were randomly assigned to 700 Kcal meal challenge ingested in the morning 8:00 h, or in the evening at 19:00 h. The morning or HC-B meal test  were performed on the 7th day in subjects being scheduled to seven days on HC-B diet, consisted in 1500 Kcal; CH:Prot:Fat: 50:30:20 %; with B:700; lunch:600 and D:200 Kcal. Thereafter the evening or HC-D meal test was performed on the 7th day in the same subjects but scheduled to seven days on isocaloric diet with the inverse meal timing distribution with B:200; lunch:600 and D:700 Kcal.

Compared to HC-D, the HC-B induced lower glucose peak: 252 ± 30.2 vs.295 ± 15.4 mg/dl, (p<0.001), lower AUC180 for glucose: 96575 ± 6311 vs.127001 ± 2571 mg/dl.180 min, (p< 0.001) and  significantly greater AUC30 for early insulin response (almost 2-fold): 2033 ± 139 vs.1124 ± 596 mIU/ml.30 min, (p< 0.001).

AUC180 in HC-B vs HC-D was higher by 22 ± 6% for tGLP-1, (p<0.001), by 24.5 ± 8% for iGLP-1, (p<0.001) and reduced by 44.2 ± 1% for hunger scores, (p < 0.001)

AUC30 for tGLP-1 and iGLP-1 were strongly and positively associated with AUC30 for early insulin response (r=0.32, p< 0.0001); whereas negatively associated with the postprandial AUC180 for plasma glucose (r= 0.18, p< 0.0001)

Conclusion: We have found in T2D subjects a higher and faster 30-min insulin secretion in response to identical meal challenge in the morning than in the evening, which was associated with a higher 30 and 180 min, total and intact GLP-1, lower glucose excursions and greater hunger suppression after HC-B. It supports the potential diurnal pattern of incretin secretion and of β-cell response to incretins, suggesting also that high caloric intake in the breakfast with reduced intake at dinner, might be a beneficial alternative for the management of type 2 diabetes

 

Nothing to Disclose: DJ, JW, YB, HR, OF

11530 1.0000 SUN-1058 A Differential Morning Vs. Evening Insulin and Glucagon–like Peptide-1 (GLP-1) Responses after Identical Meal in Type 2 Diabetic Subjects 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1058-1073 4804 1:00:00 PM Regulatory Peptides Other Than Insulin, Pediatric Cardiovascular Risk Poster

Daniela Jakubowicz*1, Oren Froy2, Mona Boaz3, Zohar Landau4, Tali Ganz3, Yosepha Bar-Dayan5, Maayan Barnea6, Miriam Menaged5 and Julio Wainstein3
1Tel Aviv University, Tel Aviv, Israel, 2The Hebrew University of Jerusalem, Rehovot, Israel, 3E. Wolfson Medical Center. Tel Aviv University, Holon, Israel, 4Wolfson Med Ctr, Holon, Tel Aviv-Yafo, Israel, 5Wolfson Medical Center, Holon, Israel, 6The Hebrew University of Jerusalem,, Rehovot, Israel

 

Impaired glucagon-like peptide (GLP-1) secretion or increased degradation by the enzyme dipeptidyl peptidase 4 (DPP-4) may contribute to ineffective insulin release and hyperglycemia in type 2 diabetes (T2D).

Therefore has been much recent interest in developing methods by which GLP-1 secretion can be enhanced in T2D. One approach might be a direct stimulation of GLP-1 secretion from intestinal L-cells.

Recently we reported that Whey protein (Whey) has insulinotropic and glucose lowering effect in T2D subjects. Whether it is related to a corresponding change of incretin secretion or degradation, however, has not been studied in T2D

To search the influence of Whey on postprandial GLP-1 secretion, degradation and DPP4 plasma activity, we assessed in T2D subjects, the effect of Whey preload 30 min before high glycemic Index (HGI) breakfast (B) on postprandial,  early 30-min, late 60 -120 min and 180 min, plasma insulin, glucose, intact GLP-1, total GLP-1 and  DPP4 plasma activity.

In a randomized crossover design 19-T2D (10 males, 9 females), aged 58 ± 5.5 yrs; BMI: 27.2 ± 5.3 kg/m2; HbA1c: 7.2 ± 0.8 %; duration of T2D: 8.2 ± 4.0 yrs;  consumed on separate days  50 gr Whey + 250 ml water or Placebo (P) (250 ml water), followed 30 min later by HGI-B. 

Whey vs placebo induced significantly higher early insulin secretion (AUC30) 2803 ± 250 vs.1324 ± 150 mIU/ml · 30 min (p < 0.003). Similarly AUC180 in Whey vs P was higher by 51.4 ± 2% for insulin (p < 0.003); 42 ± 4 % for  total-GLP-1 (p < 0.001); 74.5 ± 3% for intact-GLP-1 (p < 0.001), and reduced by 31 ± 4 % for plasma glucose. Peak of glucose in Whey was: 208 ± 43 vs. P: 301 ± 54 mg/dl (p <0.001).

In Whey AUC180 for total-GLP-1 and intact-GLP-1 responses were strongly and positively associated with AUC180 for insulin response (r=0.82, p < 0.0001); whereas negatively associated with the postprandial AUC180 for plasma glucose (r= 0.12, p < 0.0001) and the coefficient intact-GLP-1/ total-GLP-1 as surrogate of non degraded GLP-1, was significantly higher in Whey vs placebo (r=0.07, P < 0.0001).

Conclusion: Whey protein preload before HGI-B enhanced prandial intact-GLP-1 and total-GLP-1 secretion that occurred in a parallel fashion and strongly associated with the insulinotropic effect. These findings suggest that Whey protein may contribute to the improvement of the impaired function of GLP-1 as a transmitter in the enteroinsular axis and may represent a novel approach for incretin-based therapy, stimulating GLP-1 and  prandial insulin release limiting postprandial glycemia in type 2 diabetes.

 

Nothing to Disclose: DJ, OF, MB, ZL, TG, YB, MB, MM, JW

11613 2.0000 SUN-1059 A Pre-Meal Consumption of Whey Protein Enhances Intact and Total Glucagon–like Peptide-1 and Insulin Postprandial Responses in Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1058-1073 4804 1:00:00 PM Regulatory Peptides Other Than Insulin, Pediatric Cardiovascular Risk Poster

Patric Delhanty*1, Martin Huisman1, Michel Julien2, Patrick Brune3, Karine Mouchain3, Axel P.N. Themmen1, Thierry Abribat2 and Aart Jan van der Lely1
1Erasmus MC, Rotterdam, Netherlands, 2Alizé Pharma, Écully, France, 3Bertin Pharma, Montigny-le-Bretonneux, France

 

Ghrelin is the most potent known circulating orexigen. It occurs in the circulation in two isoforms, acylated (AG) and unacylated (UAG), whose interaction has important effects on metabolism. The AG/UAG ratio has been reported to range from 0.02-0.3, suggesting biologically relevant independent regulation of each isoform. However, AG is rapidly converted to UAG through deacylation by esterases in blood samples meaning that esterase inhibition is critical for accurate measurement of each isoform. We think that part of the reason for variation in reported AG and UAG values is caused by inconsistency in methods used to stabilize these peptides following blood collection. Indeed, a recent report has suggested that UAG is an artefact of the method of blood sampling. The aim of this study was to re-evaluate AG and UAG levels in stabilized blood samples from fasted healthy subjects. Venous blood samples were collected from 8 healthy subjects (4 male) who had been fasted overnight. Plasma samples were prepared with or without the protease/esterase inhibitor 4-(2-aminoethyl)benzenesulfonyl fluoride (AEBSF, 2 mg/ml) and stored frozen at either -20°C or -80°C from 0 to 6 months. AG and UAG were analyzed using ELISAs specific for the two isoforms. Blood collected without immediate AEBSF treatment contained predominantly low to undetectable levels of AG and high levels of UAG (>270 pg/ml) indicating rapid conversion of AG to UAG. Plasma from AEBSF treated blood, stored at -80°C and measured at 0, 1, 3 and 6 months contained AG and UAG in the ranges of 12-350 and 17-170 pg/ml, respectively. Mean (SEM) AG/UAG ratios were 1.7(0.3), 1.2(0.2), 1.5(0.3) and 1.8(0.5) at each time point with no significant effect of storage period.  In conclusion, re-evaluation of AG and UAG levels in AEBSF-stabilized plasma from fasting healthy adults indicates the AG/UAG ratio is markedly higher than previously described and that UAG is a real component of the circulation. This study highlights the importance of immediately stabilizing blood samples on collection for determination of both AG and UAG concentrations and provide a valuable tool for measurement of blood AG and UAG in physiological and interventional studies.

 

Nothing to Disclose: PD, MH, MJ, PB, KM, APNT, TA, AJV

12979 3.0000 SUN-1060 A The Acylated (AG) to Unacylated (UAG) Ghrelin Ratio in Esterase Inhibitor Treated Blood Is Higher Than Previously Described 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1058-1073 4804 1:00:00 PM Regulatory Peptides Other Than Insulin, Pediatric Cardiovascular Risk Poster

Ravi Nistala*1, Annayya R. Aroor1, James R. Sowers2, Javad Habibi1, Melvin R Hayden3, William Knight4, Tamara Hancock4, Thomas Klein5, Vincent G. DeMarco1 and Adam T Whaley-Connell1
1University of Missouri, Columbia, MO, 2Harry S Truman VA Hospital and University of Missouri, Columbia, MO, 3Univ of Missouri Columbia, Camdenton, MO, 4University of Missouri, 5Boehringer Ingelheim Pharmaceuticals

 

Obesity-related glomerulopathy is characterized initially by glomerular hyperfiltration with hypertrophy and then development of proteinuria.  Putative mechanisms include endothelial dysfunction and filtration barrier injury due to oxidant stress and immune cell activation.  There has been recent interest in targeting DPP4; however, the role that DPP4 has on oxidant stress, glomerular function and progression of obesity-related glomerulopathy is unknown. 

We utilized the Zucker Obese (ZO) rat, (aged 8 weeks) fed a normal chow or diet containing the DPP4 inhibitor linagliptin for 8 weeks (83mg/kg body weight).  Compared to lean controls, there were increases in plasma DPP4 activity along with proteinuria in ZO rats.  ZO rats further displayed increases in glomerular size and ultrastructural evidence of podocyte foot process effacement.  These findings occurred in parallel with decreased endothelial stromal-derived factor-1α, increased oxidant markers, and serine phosphorylation of the mammalian target of rapamycin.  DPP4 inhibition improved proteinuria and glomerular filtration barrier remodeling, circulating and kidney tissue DPP4 activity, increased active GLP1 as well as SDF-1α, and improved oxidant markers and the podocyte-specific protein nephrin.  These data support a role for DPP4 in glomerular filtration function and targeting DPP4 with inhibition improves obesity-related glomerulopathy due to oxidant stress.

 

Disclosure: TK: Employee, Boehringer Ingelheim Pharmaceuticlas. Nothing to Disclose: RN, ARA, JRS, JH, MRH, WK, TH, VGD, ATW

14140 4.0000 SUN-1061 A DPP4 Inhibition Attenuates Filtration Barrier Injury and Oxidant Stress in the Zucker Obese Rat 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1058-1073 4804 1:00:00 PM Regulatory Peptides Other Than Insulin, Pediatric Cardiovascular Risk Poster

Nusret Yilmaz, Ramazan Sari*, Sabahat Ozdem and Gultekin Suleymanlar
Akdeniz University, School of Medicine, Antalya, Turkey

 

Incretin system hormones such us glucagon-like peptide-1 have an important role in the pathogenesis of diabetes mellitus. Post-transplant diabetes associated with antirejection medications especially including calcineurin inhibitors and is a major problem affect graft survival. Immunosuppressive drugs used in transplantation patients, may contribute to the development of post-transplant diabetes mellitus through their possible adverse effects on incretins. In this study, we aimed to compare the effects of different immunosuppressive drugs used in renal transplantation patients on glucagon-like peptide -1 level.

15 cyclosporine-treated and 15 tacrolimus-treated renal transplant patients, and 15 healthy volunteers as a control group, a total of 45 people with no history of diabetes were enrolled in the study. Oral glucose tolerance test with 75 gr glucose was performed to all patients.  Glucagon-like peptide 1 levels were measured at 0, 30, 60, 90, 120 minutes by ELISA method.

Among three groups, at 0, 30 and 120 minutes statistically significant difference on glucagon-like peptide-1 levels were observed (p<0.001, p=0.026 and p<0.001, respectively). Baseline glucagon-like peptide-1 levels in both cyclosporine-treated and tacrolimus-treated groups was higher than the control group (p<0.001 and p=0.033, respectively). Baseline glucagon-like peptide-1 levels were significantly higher in cyclosporine-treated group compared to the tacrolimus-treated group (p=0.003). At 30 and 90 minutes, glucagon-like peptide -1 levels were significantly higher in tacrolimus-treated group compared to the cyclosporine-treated group (p=0.009 and p=0.042, respectively). Glucagon-like peptide-1 levels at 120 minutes were significantly higher in the cyclosporin-treated group compared to the tacrolimus-treated group (p=0.01). While reaching peak glucagon-like peptide-1 levels at 30 minutes in the tacrolimus-treated and control group, the highest levels of glucagon-like peptide -1 in cyclosporine-treted group was achieved at 120 minutes.

These findings showed that tacrolimus-treated renal transplant patients had preserved glucagon-like peptide-1 response to oral glucose load and cyclosporin-treated ones had higher baseline glucagon-like peptide -1 levels and atrophied and temporally impaired glucagon-like peptide -1 response to the oral glucose load.

 

Nothing to Disclose: NY, RS, SO, GS

14393 5.0000 SUN-1062 A Effects of Different Immunosuppressive Drugs on Glucagon-like Peptide-1 Levels in Renal Transplant Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1058-1073 4804 1:00:00 PM Regulatory Peptides Other Than Insulin, Pediatric Cardiovascular Risk Poster

Daisuke Yabe*, Hitoshi Kuwata, Masahiro Iwasaki, Ryota Usui, Takeshi Kurose and Yutaka Seino
Kansai Electric Power Hospital, Osaka, Japan

 

Despite accumulating evidence of enhancement of GLP-1 and GIP secretion by various nutrients, few findings have been applied to clinical practice for management of postprandial glucose levels in patients with type 2 diabetes (T2DM). Here, we investigate the effects of fish or meat intake before and after rice intake on postprandial glucose excursions as well as incretin secretion. In experiment A, untreated T2DM patients　(n=11, 57.6±4.3 year old, BMI 27.1±1.1kg/m2, HbA1c 7.0±0.2%) were subjected to 2 way-crossover tests on two separate days, in which they received, with a 15-min interval, steamed rice (240 kcal; protein 4.0g, fat 0.0g, carbohydrate 65.8g) before or after canned mackerels in brine (220 kcal; protein 15.1 g, fat 17.7g, carbohydrate 0g). Postprandial glucose was significantly reduced when they received mackerels before rice. Strikingly, GLP-1 was significantly elevated when they received the mackerels before the rice, while GIP was hardly affected by changing the order of intake. In experiment B, untreated T2DM patients (n=12, 56.1±17.1 year old, BMI 26.0±6.9kg/m2, HbA1c 6.8±1.1%) were subjected to 3 way-crossover tests on three separate days, in which they received, with a 15-min interval, rice before or after grilled beef (220 kcal; protein 16.4 g, fat 17.1g, carbohydrate 0.2g) or rice after mackerels. Postprandial glucose was significantly reduced when they received beef before rice. GLP-1 was significantly elevated when they received beef before rice. The profiles of postprandial glucose and GLP-1 were similar when they received beef or mackerels before rice. Interestingly, GIP secretion was significantly elevated when the patients received the beef, but not the mackerels, before the rice. Experiment C, a nutrition component analysis, revealed that the beef was rich in oleate and stearate, strong enhancers of GIP secretion, while the mackerels were rich in eicosapentaenoic acid and docosahexaenoic acid, which are poor enhancers of GIP secretion. The analysis found no distinct difference in amino acid composition in the beef and the mackerels. Our results show that meal-sequence can play an important role in controlling postprandial glucose and incretin secretion. While eating meat before rice in T2DM might ameliorate postprandial glucose and enhance GLP-1 secretion in a fashion similar to eating fish before rice, beef’s concomitant enhancement GIP secretion could promote obesity when such meal sequence is taken chronically.

 

Nothing to Disclose: DY, HK, MI, RU, TK, YS

15477 6.0000 SUN-1063 A Comparison of Fish or Meat Intake before and after Rice on Postprandial Glucose Excursions and Incretin Secretion in Type 2 Diabetes: Meal-Sequence As a Novel Target in Dietary Therapies for Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1058-1073 4804 1:00:00 PM Regulatory Peptides Other Than Insulin, Pediatric Cardiovascular Risk Poster

Yoshiyuki Hamamoto*1, Sachiko Honjo1, Kanta Fujimoto1, Hisato Tatsuoka1, Shinsuke Tokumoto2, Yoshiharu Wada1, Hiroki Ikeda3 and Hiroyuki Koshiyama2
1Kitano Hospital, The Tazuke Kofukai Foundation, Medical Research Institute, Osaka, Japan, 2Kitano hospital, The Tazuke Kofukai Foundation, Medical Research Institute, Osaka, Japan, 3Kitano Hospital The Tazuke Kofukai Foundation, Medical Research Institute, Osaka, Japan

 

The secretion patterns of incretin hormones such as glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) in patients with inflammatory bowel syndrome who have an inflammation at the lower ileum and colon, where L cells distribute and is the site of GLP-1 secretion, are not known. Therefore, in this study, we investigated the secretion patterns of incretin hormones in patients with Crohn’s disease (CD) and with ulcerative colitis (UC).  Subjects included 7 patients with CD and 6 patients with UC both without history of operation, and 7 healthy controls. Plasma glucose (PG), insulin (IRI), glucagon, as well as active GLP-1 (aGLP-1) and GIP levels measured with specific immunoassay, in response to 75g oral glucose load were determined. Insulin resistance and insulin secretion were also determined using the homeostasis model assessment (HOMA-R) and the insulinogenic index (IGI).  There was no significant difference in PG response, insulin sensitivity (HOMA-R; CD 1.4±1.1, UC 1.0±0.3, and control 1.4±0.5, n.s.) and insulin secretion (IGI; CD 0.9±1.0, UC 1.1±0.4, and control 1.1±0.7, n.s.) among the groups. Although the peak stimulated aGLP-1 values were not significantly different, aGLP-1 values at 60 minutes were significantly higher in the patients with CD and UC than controls (4.53±2.17, 3.86±1.14, and 2.73±0.65 pM/L, respectively. p<0.05).  GIP values at fasting and 60 minutes were significantly higher in patients with CD (49.2±22.1 and 274.1±90.7 pg/ml) than controls (27.4±7.6 and 178.7±58.7 pg/ml, p<0.05) while there was no difference in the patients with UC. There was no difference in glucagon response among the groups. In summary, in patients with CD, increased GLP-1 and GIP response to oral glucose load, and in patients with UC, increased GLP-1 response were observed. No difference of PG response, insulin sensitivity and insulin secretion was detected in either of CD and UC.

 

Nothing to Disclose: YH, SH, KF, HT, ST, YW, HI, HK

15696 7.0000 SUN-1064 A Enhanced Response of Incretin Hormones to Oral Glucose Tolerance Test in Patients with Crohn's Disease and with Ulcerative Colitis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1058-1073 4804 1:00:00 PM Regulatory Peptides Other Than Insulin, Pediatric Cardiovascular Risk Poster

Byung-Joon Kim*1, Young Sil Eom2, Kwang-Won Kim1 and Kang-Woo Lee3
1Graduate School of Medicine, Gachon University of Medicine and Science, Incheon, Korea, Republic of (South), 2Gachon University Gil Medicial Center, Incheon, Korea, Republic of (South), 3Sun hospital, Daejeon, Korea, Republic of (South)

 

Glucagon like peptide-1 (GLP-1) secreting enteroendocrine L cells has fatty acid receptor, GPR 120. Gamma-linolenic acid (GLA) is omega 6 fatty acid that prevents diabetics polyneuropathy. However, the effects of GLA on hyperglycemia and insulin sensitivity in type 2 diabetes through GPR120 are not yet elucidated. The present study investigated whether administration of GLA improves glycemic control, insulin sensitivity and pancreatic beta cell mass, and alters levels of GLP-1, an incretin hormone involved in glucose homeostasis. Male LETO and OLEFT rats were maintained with standard chow or chow containing 360 mg/kg GLA from 16 weeks until 24 weeks. In 16 week, all animals performed oral glucose tolerance test (OGTT) and showed the increased blood glucose and insulin levels suggesting the development of insulin resistance. The administration of OLETF rats with GLA improves glycemic control and insulin sensitivity, and recovers the reduced beta cell mass and increased islet fibrosis. Moreover, administration of GLA significantly increased serum active GLP-1 in OLETF rats. These data demonstrate that administration of GLA improves glycemic control, insulin sensitivity and pancreatic beta cell mass and fibrosis. Also, this improvement was accompanied by increments of serum active GLP-1 levels, suggesting that GLP-1 may play a role in the GLA-mediated beneficial effects

 

Nothing to Disclose: BJK, YSE, KWK, KWL

16351 8.0000 SUN-1065 A Gamma-Linolenic Acid Improves Glycemic Control and Insulin Sensitivity through Glucagon-like Peptide-1 in Oletf Diabetic Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1058-1073 4804 1:00:00 PM Regulatory Peptides Other Than Insulin, Pediatric Cardiovascular Risk Poster

Hugo R Boquete*, Gabriel Fideleff, Hugo L Fideleff, Gabriela Ruibal, Martha Suárez and Miriam Azaretzky
Hospital Alvarez, Buenos Aires, Argentina

 

Recent evidences highlight that melatonin rhythmicity may influence the cardiovascular system and some cardiovascular pathophysiological processes, but the ontogeny of these effects are still not completely evaluated. In previous studies, we have shown that correlations between melatonin excretion and some metabolic abnormalities associated with obesity and metabolic syndrome became apparent only in the final stages of puberty. Aim: to study further correlations between melatonin with different components of metabolic syndrome and other cardiovascular risk factors in late puberty. Patients and methods: We evaluated 42 obese pubertal patients (Tanner IV and V): 15 males; 27 females, with BMI >2SDS. Metabolic syndrome was defined using Cook’s criteria. We measured urinary 6-SM (radioimmunoassay, Stockgrand Ltd, Guildford, UK) in nocturnal (6-SMn: 6PM to 8AM) and diurnal samples (6-SMd: 8AM to 6PM). Levels of 6-SM were expressed as µg excreted per time interval and delta 6-SM as the difference between nighttime and daytime values. Measurement of waist circumference, blood pressure, insulin, glucose, total, HDL, LDL, non-HDL cholesterol, triglycerides and uric acid were performed in all patients. HOMA-IR and HDL/triglycerides ratio were calculated. Family history of cardiovascular risk factors was registered. Results (Spearman Rank order correlation): Regarding biochemical parameters, in males the following correlations were found: 6-SMd and total cholesterol (Rs= -0.58, p=0.0245); 6-SMd and non-HDL cholesterol (Rs= -0.6, p=0.0174); delta 6-SM and uric acid (Rs=0.89, p=0.0476). As regards females, a positive correlation was found between 6-SMn and insulin levels (Rs=0.42, p=0.0274). No correlations were found between melatonin excretion and the rest of biochemical markers or indexes evaluated. No associations were found between melatonin secretion and the presence of abdominal obesity, hypertension, metabolic syndrome or family history of cardiovascular risk in either gender. Conclusions: Associations between melatonin secretion and some alterations of metabolic biochemical parameters were different in both genders, reinforcing evidences of sexual dimorphism during puberty. Our results also suggest that some neuroendocrine abnormalities associated with cardiovascular disease become apparent from the end of pubertal development and, perhaps, it might be an indirect evidence of the first steps of the dyssynchrony between circadian clocks and different tissues.

 

Nothing to Disclose: HRB, GF, HLF, GR, MS, MA

11564 9.0000 SUN-1066 A 6-Sulfatoxymelatonin (6-SM) Excretion during Final Stages of Puberty in Obese Patients: Correlation with Different Components of Metabolic Syndrome and Other Cardiovascular Risk Factors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1058-1073 4804 1:00:00 PM Regulatory Peptides Other Than Insulin, Pediatric Cardiovascular Risk Poster

Anshu Gupta*, Edmond P. Wickham III and Daniel H Conrad
Virginia Commonwealth University, Richmond, VA

 

Background: Obesity in childhood is associated with an increased prevalence of diabetes and other traditional cardiometabolic risk factors, suggesting a looming epidemic of premature cardiovascular disease among today’s youth. Glycotoxins, known as advanced glycation end products (AGE’s), activating via the membrane-bound receptors (mRAGE), have been implicated in the pathophysiology of insulin resistance and vascular dysfunction in adults, but the role of RAGE in the early stages of metabolic disorders is unknown. As a result, we investigated the relations between RAGE levels and cardiometabolic risk factors (RF) in a cohort of obese adolescents.

Methods: Twenty obese adolescents [body mass index (BMI) ≥95th percentile],11-16 years of age, were admitted following a 12-hour overnight fast for anthropometric measurements, fasting peripheral blood sample collection, and a 2-hour, 75 gm,  oral glucose tolerance test (OGTT). The presence of the following additional cardiometabolic RF was determined: fasting triglyceride (TG) ≥110 mg/dL, HDL cholesterol < 40 mg/dL, fasting glucose ≥100 mg/dL, 2-hour glucose during OGTT ≥140 mg/dL, and blood pressure (BP) > 90th percentile. Peripheral blood mononuclear cells were isolated from a fasting venous sample and the proportion of CD14+monocytes positive for mRAGE (from Abcam) was quantified using flow cytometry. Univariate analyses were conducted for the entire group to test associations between %mRAGE positive monocytes and subject age, sex , BMI Z-score and other cardiometabolic RF outlined above. The %mRAGE positive monocytes were compared between adolescents with obesity alone, 1 RF and those with 2 or more additional RF.

Results: The mean age of twenty subjects studied was 13 ±1.31 years and 56% subjects were females. In univariate analyses, % mRAGE monocytes showed a significant positive correlation with fasting TG levels (r=0.6, p=0.01). The median %mRAGE positive monocytes were also significantly different between the three groups (Kruskal Wallis test, p=0.04), with a trend toward higher %mRAGE monocytes in both groups of obese adolescents with additional cardiometabolic RF compared to those with obesity alone after adjusting for multiple comparisons.

Conclusion: Adolescents with obesity and multiple cardiometabolic RF manifest increased mRAGE positive monocytes compared with adolescents with obesity alone. Moreover, the %mRAGE positive monocytes correlate significantly with fasting TG levels, despite most subjects having TG levels in the normal range. These preliminary findings suggest that mRAGE levels may be a useful biomarker to identify high-risk adolescents and are being confirmed with larger sample size to allow for more rigorous analyses. Additional studies are also warranted to determine if RAGE is mechanistically involved in the early pathogenesis of metabolic dysfunction resulting from obesity in childhood.

 

Nothing to Disclose: AG, EPW III, DHC

12013 10.0000 SUN-1067 A Monocytic RAGE Reflects Cardiometabolilc Risk in Adolescents with Obesity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1058-1073 4804 1:00:00 PM Regulatory Peptides Other Than Insulin, Pediatric Cardiovascular Risk Poster

Ramin Alemzadeh*1 and Jessica Kichler2
1Univ of Illinois at Chicago, Chicago, IL, 2Cincinnati Children's Hospital, Cicinnati, OH

 

Background: Elevated circulating uric acid (UA) level is strongly associated with prevalence of metabolic syndrome (MS) and its components in adults and children. Hyperuricemia has also been found to be associated with elevated parathyroid hormone (PTH) levels and vitamin D insufficiency in adults.  This study examined the relationship among UA, 25-hydroxyvitamin D [25(OH)D], PTH and indices of MS and inflammation in obese adolescents.

Methods: Body mass index (BMI), body composition, 25(OH)D, PTH, fasting lipids, glucose, high sensitivity c-reactive protein (hs-CRP), UA, HbA1c, insulin and the homeostatic model assessment for insulin resistance (HOMA-IR) were evaluated in 152 obese adolescents. 

Results: Hyperuricemia [SUA≥6.0 mg/dL (357 umol/L)] was present in 54.6% of entire cohort without significant ethnic/racial differences. While UA was negatively correlated with HDL-C and 25(OH)D (r=-0.35; p<0.01), it was positively correlated with fat mass (FM) (r=0.33; p<0.0001), systolic and diastolic blood pressure (SBP and DBP) (r=0.29; p<0.001 and r=0.21, p<0.01), PTH (r=0.60; p<0.001), PTH:25(OH)D (r=0.46; p<0.0001), TG: HDL-C ratio (r=0.23; p<0.01)  and hs-CRP (r=0.32, p<0.0001). Vitamin D deficiency [25(OH)D <50 nmol/L] was present in 51.3% of all patients, with higher prevalence in African American (AA) and Hispanic (H) than Caucasian (C) subgroups (72.1% and 62.5% vs. 32.7%; p<0.025). PTH and 25(OH)D were inversely correlated (r=-0.45; p<0.0001), with AA displaying higher PTH: 25(OH)D ratio than H and C subgroups (p<0.05).  While FM was negatively correlated with 25(OH)D (r=-0.29; p<0.001), it was positively correlated with PTH levels (r=0.35; p<0.0001). MS was identified in 53.3% of cohort with higher FM, UA, hs-CRP, HOMA-IR, PTH and PTH: 25(OH)D ratio compared to non-MS subgroup (p<0.001) without any difference is 25(OH)D levels.  Multiple regression analyses demonstrated that PTH:25(OH)D ratio mediated the relationship between UA and hs-CRP (β = 0.19, p <.05 to β = 0.15, p = 0.19), even after controlling for FM, but did not mediate the relationship between UA and blood pressure.

Conclusions: Hyperuricemia is strongly associated with components of MS, PTH levels and low grade inflammation independent of vitamin D status. The relationship between UA-induced low grade inflammation is mediated by the PTH: 25(OH)D ratio in obese adolescents.

 

Nothing to Disclose: RA, JK

13095 11.0000 SUN-1068 A Uric Acid-Induced Low Grade Inflammation Is Mediated By Parathyroid Hormone: 25-Hydroxyvitamin D Ratio in Obese Adolescents 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1058-1073 4804 1:00:00 PM Regulatory Peptides Other Than Insulin, Pediatric Cardiovascular Risk Poster

Swati Dave-Sharma*1, Shahnawaz Amdani2, Amir Navaei3 and Jayendra Sharma4
1Weill Cornell Medical College/ Cornell University, NY, NY, 2Lincoln Medical And Mental Health Center, Bronx, NY, 3Lincoln Medical and Mental Health Center, Bronx, NY, 4NUMC, NY, NY

 

Background: Cardiovascular disease (CVD) is the leading cause of mortality in the USA, the process begins in pediatrics. As the prevalence of childhood obesity is increasing, more and more pediatric patients are at risk for early atherogenesis and metabolic dysfunction. There is a well-established correlation between high LDL-C , low HDL-C and CVD. Studies have shown that the ratio of TG to HDL-C (Atherogenic Index- AI) is a strong predictor of CVD in adults, however the data from pediatric studies is lacking.

Objective: To evaluate the prevalence of abnormal AI in overweight and obese pediatric patients in a community hospital of South Bronx and its correlation with BMI, waist circumference (WC), Insulin Resistance Index (IRI), pre hypertension and hypertension in this population.

Design/Methods: In this cross-sectional study, data were collected from EMR of overweight and obese pediatric patients for age, sex, ethnicity, BMI, WC, blood pressure, fasting glucose, insulin and lipid profile. BMI was calculated using standard formula. HOMA-IR formula: [fasting glucose (mmol/l) x fasting insulin (mU/L)]/22.5 and AI formula log [TG(mg/dl)/HDL-C(mg/dl), low risk AI (<0.11), high risk AI (>0.21). Mc Nemar's t-test and Pearson's correlation test were used for statistical analysis.

Results: The mean age for 82 males was 13 ± 2 and 65 females was 14 ± 3 years. Mean BMI was 33.3 ±6.5 (32.6 ± 5.9 males, 34.3± 7 females). Adverse AI was found in 82% of patients (85% males, 80% females). Males had 8 times higher odds of having AI as compared to females (p<0.0001). Prehypertension was present in 13% (7% males, 20% females (BP: 90-95th percentile) and Hypertension in 23% (20% males, 26% females (BP: >95thpercentile). Prevalence of metabolic syndrome (WHO criteria) was 26% (22% males, 30% females). Males with high risk AI had 13 times and females 34 times higher odds of having hypertension as compared to those with low risk AI (p<0.0001). 100% (12/12) males and 94% (17/18) females with adverse IRI had adverse AI. There was a linear correlation of adverse AI with WC.

Conclusions: Atherogenic index is a simple and great tool in assessing the risk of CAD. High risk atherogenic index is associated with abdominal obesity, hypertension and insulin resistance in pediatric obese patients. Further prospective studies are required to evaluate the progression of CVD in patients with high risk atherogenic index.

 

Nothing to Disclose: SD, SA, AN, JS

14620 12.0000 SUN-1069 A Prevalence of Atherogenic Index and Its Relationship to Abdominal Obesity, Hypertension and Insulin Resitance in Obese Pediatric Patients of South Bronx 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1058-1073 4804 1:00:00 PM Regulatory Peptides Other Than Insulin, Pediatric Cardiovascular Risk Poster

Cigdem Binay1, Ayse B.Turhan1, Enver Simsek*1, Ozcan Bor1 and Meltem Akay2
1Osmangazi University School of Medicine, Eskisehir, Turkey, 2Eskisehir Osmangazi University School of Medicine, Eskişehir, Turkey

 


Background: Type 1 diabetes mellitus (T1DM) is associated with increased risk of hypercoagulable state. There are several well-known factors responsible for this enhanced risk, involving various clotting factors or pathways. The aim of the study was to assess the pro-coagulant condition in children with T1DM, with using rotation thromboelastography (ROTEM).

Methods: Forty-three patients (20 girls, 23 boys; age range were 2-18 years) and 30 non-diabetic control subjects with age- and sex-matched were enrolled in the study. ROTEM assays (intrinsic TEM-INTEM, extrinsic TEM-EXTEM) were used to measure the coagulation time (CT), clot formation time (CFT), maximum clot firmness (MCF) and traditional coagulation parameters (platelet count, prothrombin time, activated partial thromboplastin time and fibrinogen) were analysed in the study group.

Results: The mean HbA1c level was 8,94±1,88 % and the mean duration of diabetes was 3,15±2,49 years. None of the patients had macrovascular complications. As a microvascular complication, nephropathy was present in five patients. EXTEM-CT was significantly lower, EXTEM-MCF and INTEM-MCF were significantly higher in the diabetic group compared with the controls (p=0,00, p=0,02 and p=0,00, respectively). The duration of type 1 diabetes and the degree of metabolic control had no influence on these parameters. Platelet count, prothrombin time, activated partial thromboplastin time and fibrinogen were comparable between patients and control subjects.

Conclusion: This study has shown that decreased levels of CT and increased levels of MCF in patients with T1DM suggest a procoagulant state compared with controls. Further studies are needed to confirm our findings on a larger number of patients with T1DM and to determine the value of this analysis for predicting the vascular complications.

 

Nothing to Disclose: CB, AB, ES, OB, MA

15216 13.0000 SUN-1070 A Evaluation of Coagulation Profile with Using Thromboelastography in Children and Adolescents with Type 1 Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1058-1073 4804 1:00:00 PM Regulatory Peptides Other Than Insulin, Pediatric Cardiovascular Risk Poster

Deep Shikha*1, Rachna Walia2, Natia Potter3, Arlene Basa Mercado4 and Nathaniel Winer5
1SUNY Downstate Medical Center, Brooklyn, NY, 2SUNY downstate medical center, Norwich, CT, 3SUNY Downstate Med Ctr, Brooklyn, NY, 4SUNY Downstate Medical Center, 5SUNY Hlth Science Ctr Brooklyn, Brooklyn, NY

 

TITLE: PARADOXICAL INCREASE IN VASCULAR COMPLIANCE IN OBESE AND DIABETIC CHILDREN

Background: In adults, both obesity and Type 2 diabetes are positively correlated to cardiovascular disease mortality and arterial stiffness. Several studies of adults have shown that both obesity and Type 2 diabetes are independently associated with increased arterial stiffness. However, little is known about the relationship between arterial compliance and cardiovascular disease risk in children.We assessed whether large and small arterial compliance is impaired in obese and diabetic pubertal children.

Methods: One hundred Caribbean African children, aged 14-16 years including 21 lean children(between 25 and 75 percentile), 40 obese children (>95th percentile) and 39 children with diabetes mellitus type 2 (DM) diagnosed by American Diabetes Association criteria were studied. Arterial compliance of the large and small vessels were measured using the radial arterial diastolic pulse wave contour analysis.

Results: Large artery compliance did not differ significantly between lean, Obese, and DM subjects. Small vessel compliance was significantly greater in Obese (10.9± 1 mL/mm Hg x 100mL) and DM (10.4±0.7) subjects when compared individually with lean subjects (7.8±0.8; P<0.05). Small vessel compliance was significantly greater in DM subjects receiving antihypertensive drug therapy, compared to DM subjects not on antihypertensive treatment.

Interpretation: In our patient cohort, small vessel elasticity was significantly increased in obese and diabetic subjects compared to lean subjects but was similar in obese and diabetic subjects. Among diabetic subjects, it was significantly increased in patients on antihypertensive medications as compared to antihypertensive-naïve diabetic subjects.

Conclusion: The increase in compliance in diabetic and obese children as compared to lean subjects could be secondary to premature maturation of the vascular system; whether this can translate into early and increased incidence of cardiovascular events related to diabetes and obesity can only be known by long term follow up of these patients.

 

Nothing to Disclose: DS, RW, NP, ABM, NW

15551 14.0000 SUN-1071 A Paradoxical Increase in Vascular Compliance in Obese and Diabetic Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1058-1073 4804 1:00:00 PM Regulatory Peptides Other Than Insulin, Pediatric Cardiovascular Risk Poster

Nabila Roohi*1 and Ateek Ahmad2
1Department of Zoology (Endocrinology), University of the Punjab, Lahore, Pakistan, 2Department of Pediatrics, Lahore General Hospital, Lahore, Pakistan

 

Background and aims: Type 1 diabetes during childhood is associated with significant morbidity and mortality in adult life. Dyslipidemia and inflammatory markers, as the critical determinants in disease prediction, can be employed as sensitive markers for early detection of comorbidities in type 1 diabetic children. 

Subjects and Methods: Participants were prepubertal boys (n=91; mean age: 10.24±0.31 years), diagnosed with type 1 diabetes, selected randomly from diabetic clinics at Lahore. Age and sex matched non diabetic healthy children (n=70; mean age: 10.55±0.49 years) served as controls of the study. Lipid profile, apolipoproteins (Apo) and inflammatory markers were measured by enzyme linked immunosorbent assay (ELISA) and automated clinical chemistry analyzer. Data was analyzed statistically using Graph Pad Prism (version 5.00).

Results: Type 1 diabetics had significantly higher (P<0.05) concentrations of total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), triglycerides (TG), ApoB-100, leptin, C-reactive protein (CRP), tumor necrosis factor-a (TNF-a) and interleukin-2 (IL-2), whereas, high density lipoprotein cholesterol (HDL-C), ApoA-I, ApoA-IV, ApoE and adiponectin were significantly lowered (P<0.05) indicating a clear association between cardiovascular risks, particularly, atherosclerosis and type 1 diabetes in these children.

Conclusions: Dyslipidemia, apolipoproteins responses and raised inflammatory markers characterize the low grade inflammation and atherosclerotic process in type 1 diabetic children. Precocious identification of these abnormalities during childhood is crucial to prevent or delay the process of atherosclerosis and associated cardiovascular complications in adulthood.

 

Nothing to Disclose: NR, AA

16242 15.0000 SUN-1072 A Dyslipidemia and Inflammatory Markers As Predictors of Cardiovascular Risk in Type 1 Diabetic Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1058-1073 4804 1:00:00 PM Regulatory Peptides Other Than Insulin, Pediatric Cardiovascular Risk Poster

Jemma Jay Angela Anderson1, Oana Maftei2, Athul John1, Jenny Couper3, Tim Olds4 and Alexia S Pena*3
1University of Adelaide, 2The University of Adelaide, 3University of Adelaide, North Adelaide, Australia, 4University of South Australia, Adelaide, Australia

 

Background: Modifiable cardiovascular risk factors, such as physical activity and sleep duration are important to address in children with type 1 diabetes (T1D). The Australian recommendation for physical activity in children is 60 minutes of activity per day. The mean sleep duration in healthy 14 year olds is 8.7 hours [1]. Data is limited on daily activity and sleep duration in T1D children.
Objective: To evaluate activity levels and sleep duration in T1D and healthy children.
Methods: 75 T1D children, no complications, age 13.9y (2.33), 36 male, T1D duration 5.5y, median HbA1c 8.7% (6.3-14) participated in RCT (ANTRN12611000148976). Baseline data (prior to intervention) was used for analysis. Moderate-vigorous activity duration (time spent in METs >3.0) and sleep duration over 5 days was determined using SenseWear physical activity monitor. Biochemical and clinical variables were obtained. 23 healthy controls [age 13.83(2.7), 12 male] had the same evaluation.Results: There was a significant difference between the daily physical activity duration of male and female T1D children (2h45m(1h27m)vs 1h55m(57m), p=0.006). There was no difference in the duration of daily physical activity in the T1D vs control group [2h20m (1h17m) vs 2h51m (1h30m), p=0.177]. There was no significant difference in sleep duration [7h20m(1h01m) vs 7h34m(57m) vs p= 0.17). Sleep duration in T1D and controls was shorter than published percentiles of sleep duration in age matched children [1].
Conclusion: Children with T1D meet physical activity standards based on time spent in METs >3.0. Sleep duration of children with T1D and their Australian peers is less than recommended for age. Promotion of longer sleep duration may be important in children with T1D to modify cardiovascular disease risk.

 

Nothing to Disclose: JJAA, OM, AJ, JC, TO, ASP

16538 16.0000 SUN-1073 A Children with Type 1 Diabetes Meet Recommendations for Physical Activity but Not Sleep Duration 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1058-1073 4804 1:00:00 PM Regulatory Peptides Other Than Insulin, Pediatric Cardiovascular Risk Poster

Vladislava Paharkova1, Griselda Alvarez*2, Hiromi Nakamura1 and Kuk-Wha Lee3
1UCLA, Los Angeles, CA, 2Mattel Children's Hospital UCLA, Los Angeles, CA, 3Mattel Children's Hosp - UCLA, Los Angeles, CA

 

Abnormal mitochondrial function has been documented in insulin resistance and diabetes progression. Attenuation of oxidative stress may potentially slow or halt progressive beta cell damage. Humanin (HN) is a 24 amino acid putative mitochondria-derived peptide (MDP) encoded within the open reading frame (ORF) of mitochondrial 16S ribosomal RNA. Multiple studies have revealed diverse cytoprotective effects of HN against various cellular stressors in several organ systems, and antagonism of oxidative stress has been suggested as a mechanism by which it exerts its effects. To investigate the potential of HN to directly attenuate mitochondrial oxidative stress we first sought to establish proof-of-principle for a MDP in cell biology. We performed subcellular fractionation studies of INS-1 rat insulinoma cells and identified rattin (rHN), the rat HN homologue, in mitochondrial subcellular fractions, co-localizing with its previously reported binding partner Bax. Additionally, we depleted mitochondrial DNA in INS-1 cells by chronic treatment with ethidium bromide (EtBr) and rHN was not detected in treated cells compared to controls. Previous work with mouse mitochondrial transcription factor A (TFAM) KO heterozygote fibroblasts has shown a depletion of mitochondrial DNA, and therefore we hypothesized that if mouse Humanin (mHN) is of mitochondrial origin then a significant reduction in mHN expression would be observed. Surprisingly, we found that mHN expression is increased in these cells. These findings suggest mitochondrial origin and translation for rHN and a nuclear origin and cytoplasmic translation for mHN. To investigate the effects of HN on mitochondrial ROS production, HNG, an ultrapotent analogue of HN, was incubated with isolated mitochondria from INS-1 cells. A 55% reduction in hydrogen peroxide production compared to untreated controls was demonstrated. This is the first direct evidence for a MDP functioning as a local antioxidant.   In summary, we show proof-of-principle for a MDP and suggest its biologic function as a local antioxidant.

 

Nothing to Disclose: VP, GA, HN, KWL

15119 1.0000 SUN-1041 A Rodent Humanin Homologues Originate from the Nucleus and Mitochondria, and a Humanin Analogue Attenuates Hydrogen Peroxide Production from Mitochondria of Rat Insulin-Producing Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

InSug O-Sullivan*1, Kang Li2, David H Wasserman2, C. Ronald Kahn3, Michael W. Schwartz4 and Terry G Unterman1
1University of Illinois at Chicago & Jesse Brown VAMC, Chicago, IL, 2Vanderbilt University, Nashville, TN, 3Joslin Diabetes Ctr, Boston, MA, 4University of Washington, Seattle, WA

 

Regulation of hepatic glucose production by insulin is critical for the maintenance of glucose homeostasis.  FoxO proteins are important targets of insulin action and contribute to the regulation of gluconeogenic, glycolytic and lipogenic gene expression in the liver (JBC 281:10105, 2006).  To better understand the role of insulin and FoxO proteins in regulating hepatic gene expression and metabolism, we created liver-specific insulin receptor knockout (LIRKO) mice and insulin receptor/FoxO1 double knockout (LIRFKO) mice using the Cre lox system.  Initial studies confirmed that insulin receptor expression and signaling (phosphorylation of Akt) are disrupted in both LIRKO and LIRFKO mice.  Overnight (18 hr) fasting glucose levels are not altered in LIRKO or LIRFKO mice, yet fasting and post-prandial insulin levels are markedly elevated in LIRKO (but not in LIRFKO) mice compared to controls, suggesting that 1) LIRKO mice are insulin resistant and 2) disrupting FoxO1 in the liver is sufficient to restore insulin sensitivity in mice lacking the hepatic insulin receptor.  GTT studies (dextrose 2 g/kg i.p.) show that whereas glucose tolerance is markedly impaired in LIRKO mice, consistent with previous studies (Mol Cell  6:87, 2000), glucose tolerance is entirely normal in double knockout (LIRFKO) mice.   Similarly, insulin tolerance testing (Humulin, 1 Unit/kg i.p.) indicates that the severe insulin resistance of LIRKO mice is dramatically ameliorated by selective disruption of hepatic FoxO1.  Hyperinsulinemic euglycemic clamp revealed that LIRKO mice require reduced glucose infusion to maintain euglycemia during hyperinsulinemia, indicating that LIRKO mice are insulin resistant.  Tracer studies demonstrate that insulin is unable to fully suppress hepatic glucose output in LIRKO mice, consistent with previous studies. In contrast, insulin fully suppresses hepatic glucose output in double knockout (LIRFKO) mice despite the absence of hepatic insulin receptor signaling.  Insulin-stimulated 2-deoxyglucose uptake by skeletal muscle, white and brown fat, and brain were similar in LIRKO and LIRFKO mice, indicating that the major differences in the metabolic phenotype in LIRKO vs. LIRFKO mice predominantly reflect effects in hepatic glucose metabolism.  Together, these studies demonstrate that FoxO1 plays a major role in mediating effects of insulin on hepatic glucose metabolism.  Further, genetic disruption of FoxO1 is sufficient to restore the ability of insulin to fully suppress hepatic glucose production in the absence of insulin receptor signaling, providing strong support for the concept that extrahepatic targets of insulin (e.g. brain and/or adipose tissue) play a critical role in regulating glucose metabolism in the liver.

 

Disclosure: CRK: Principal Investigator, Sanofi, Scientific Board Member, Ember Therapeutics, Scientific Board Member, Catabasis, Scientific Board Member, CohBar, Scientific Board Member, FivePrime Therapeutics. Nothing to Disclose: IO, KL, DHW, MWS, TGU

16485 2.0000 SUN-1042 A Disruption of FoxO1 Restores the Ability of Insulin to Regulate Hepatic Glucose Production in Liver-Specific Insulin Receptor Knockout (LIRKO) Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

Weiqin Chen*1, Hongyi Zhou2, Pradip K Saha3, Luge Li4 and Lawrence C Chan5
1Medical College of Georgia at Georgia Regents University, Augusta, GA, 2Georgia Regents University, 3Baylor College of Medicine, Houston, TX, 4Baylor College of Medicine, 5Baylor Coll of Med, Houston, TX

 

Bscl2-/- mice recapitulate many of the major metabolic manifestations in Berardinelli-Seip Congenital Lipodystrophy type 2 (BSCL2) individuals, including lipodystrophy, insulin resistance and hepatic steatosis. Here we determined the mechanisms underlying the perplexing but novel metabolic disorders and fasting dependent hepatic insulin sensitivity in Bscl2-/- mice. Bscl2-/- mice had increased de novo lipogenesis, decreased β-oxidation and elevated lipoprotein clearance which lead to severe hepatic steatosis but hypotriglyceridemia. Mice with liver-specific inactivation of Bscl2 had no changes in liver and whole body glucose and lipid homeostasis. However, global Bscl2-/- mice exhibited improved glucose tolerance partially due to increased muscle mass. Interestingly, liver insulin signaling was impaired after a short-term fast; but became comparable after an overnight fast; and even further accentuated under hyperinsulinemic-euglycemic clamp in overnight fasted Bscl2-/- mice. Notably, such changes were not associated with liver diacylglyceride and ceramide contents, but correlated to the expression of hepatic insulin signaling receptor and substrates. Moreover, liver glucose and lipid metabolism in Bscl2-/- mice were differentially impacted by prolonged fasting. Overall, our results offered new insights into the metabolic disorders in Bscl2-/- mice and uncovered a novel fasting dependent regulation of hepatic insulin signaling through modulation of hepatic expression of crucial insulin signaling molecules.

 

Nothing to Disclose: WC, HZ, PKS, LL, LCC

13292 3.0000 SUN-1043 A Novel Metabolic Disorders and Fasting Moderated Hepatic Insulin Sensitivity in Lipodystrophic Bscl2/Seipin-Deficient Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

Minqian Shen*, Jieming Shi and Haifei Shi
Miami University, Oxford, OH

 

Obesity-associated low-grade inflammation at white adipose tissue (WAT) leads to metabolic defects. Sex steroid hormone estrogen may be protective against high-fat diet (HFD)-induced obesity and insulin resistance. This has been tested by many previous studies utilizing rodent models of ovariectomy (OVX) and/or treatment of estradiol (E2), the major biologically active form of estrogen. Body weight and adiposity are increased by OVX and reduced following E2 treatment however. Thus, the protective roles of E2 may be secondary effects to the changes of body weight and adiposity. We hypothesize that E2 directly maintains insulin sensitivity via acting on its receptor at adipose tissue independent of energy status. Mice with similar body weights and adiposity were used to test this hypothesis.  First, the short-term effects of E2 were tested using four groups of female C57BL/6 mice, including sham-operated mice treated with vehicle for E2 and fed with either a low-fat diet (LFD; Sham-Veh-LFD) or a HFD (Sham-Veh-HFD), and HFD-fed OVX mice with cyclic subcutaneous injections of either vehicle (OVX-Veh-HFD) or E2 (OVX-E2-HFD). All four groups were pair-fed with equal amounts of calories for a period of four days.  Their body weight and abdominal parametrial WAT mass, insulin signaling and expression levels of genes related to low-grade inflammation at WAT were compared. Body weights and WAT mass were similar among all four groups. OVX-Veh-HFD mice had impaired insulin signaling associated with rapid activation of inflammation at WAT, whereas OVX-E2-HFD group maintained insulin sensitivity without showing inflammation at WAT. Therefore, E2 directly contributed to the maintenance of insulin sensitivity during early phase of development of metabolic dysfunction, possibly via preventing low-grade inflammation at WAT. Second, the long-term effects of E2 were tested using four groups of HFD-fed OVX mice subcutaneously implanted with pellets filled with control vehicle (OVX-CON), physiological dose of E2 (OVX-E2), or low-doses of  selective agonists for estrogen receptor alpha (ERα) PPT (OVX-ERα) or ERβ DPN (OVX-ERβ) for a period of 12 weeks. Due to low-dose usage of the specific agonists for ERα and ERβ, body weights and adiposity were similar among OVX-CON, OVX-ERα, and OVX-ERβ groups. OVX-CON and OVX-ERβ groups had impaired insulin signaling at WAT, whereas OVX-E2 and OVX-ERα groups maintained insulin sensitivity in a similar manner. Therefore, E2 contributed to the maintenance of insulin sensitivity via acting on its ERα. To summarize, estrogen is a protective agent in regulating glucose homeostasis via decreasing inflammatory effects and sensitizing insulin signaling at adipose tissue during the development of diet-induced obesity.

 

Nothing to Disclose: MS, JS, HS

13853 4.0000 SUN-1044 A Estrogen and Its Receptor Alpha Regulate Insulin Signaling at Adipose Tissue 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

Mayumi Inoue*1, Yibin Jiang2 and Tae-Hwa Chun1
1Univ of Michigan, Ann Arbor, MI, 2Universityof Michigan

 

The exocyst complex is a large protein complex composed of Exo70, Exo84, Sec3, Sec5, Sec6, Sec8, and Sec10. The biological significance of the exocyst complex in regulating the tethering and docking of secretory vesicles was first discovered in the yeast. In mammalian cells, we have demonstrated that exocyst complex directs insulin-stimulated glucose uptake of adipocytes by accelerating the exposure of glucose transporter (GLUT4) to outside of the plasma membrane (Inoue et al, Nature. Inoue et al, Mol Biol Cell). Upon insulin stimulation, Free Fatty Acids (FFAs) in the circulation are also incorporated by adipocytes and several receptors and transporters have been shown to regulate cellular FFA uptake.  However, the molecular mechanism that regulates the protein trafficking necessary for FFA uptake of adipocytes has been undefined. To elucidate the molecular mechanism of FFA uptake in adipocytes, we explored the role of exocyst complex in adipocyte FFA uptake.

[Methods/Results] To assess the lipid uptake by differentiated 3T3-L1 adipocytes, we first examined the time course of LCFA uptake after insulin stimulation by monitoring the cellular uptake of fluorescent-labeled LCFA, BODIPY-dodecanoic acid (C12:0). The insulin-dependent LCFA uptake demonstrated the linear increase of LCFA uptake during 2 hours of monitoring (~ 400% increases in relative fluorescent unit (RFU) per well compared to time 0). Insulin stimulated LCFA uptake of adipocytes was inhibited by Akt inhibitor (Akt1/2I; 10mM) in a dose-dependent manner but not by phosphatidylinositol 3 (PI3)-kinase inhibitor (Wortmannin; 0.1mM), MAP kinase (MEK) inhibitor (U0126; 10mM), or mTOR inhibitor (Rapamicin; 0.1mM). The expression of exocyst complex in 3T3L1 adipocytes was silenced by the knock-down of each gene using RNAi oligo. Sec8 knock-down led to 87% reduction of insulin-induced increase in LCFA uptake (control: 16377 +/- 326.1 RFU, Sec8 KD 2103 +/- 152.2 RFU). When the expression of alternative component of the exocyst complex, i.e., Exo70, was silenced, the LCFA uptake of adipocytes was similarly suppressed. Under the condition wherein Exo70 expression was suppressed, Akt inhibitor did not exert inhibitory effect on LCFA uptake, suggesting Akt-dependent LCFA uptake was mediated by the exocyst complex.

[Conclusion]  Our data suggest that the exocyst complex regulates LCFA uptake of adipocytes in the Akt-dependent signaling pathway. Our findings shed new light on the novel mechanism by which insulin regulates adipocyte FFA handling. The exocyst complex can be the novel molecular target for the treatment of obesity.

 

Nothing to Disclose: MI, YJ, THC

15434 5.0000 SUN-1045 A The Exocyst Complex Regulates Akt-Dependent Long Chain Fatty Acid Uptake of Adipocytes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

Yan Jun Liu*1, Chaoying Yan2, Ying Wang3, Hanze Du3, Winnie Fan1, Michael Mangubat1, Allison Zhong2 and Theodore C Friedman1
1Charles R. Drew Univeristy of Medicine and Science, Los Angeles, CA, 2Charles R. Drew Univeristy of Medicine and Science, Los Angeles, 3Charles R. Drew University of Medicine and Science, Los Angeles, CA

 

Long-term glucocorticoid (GC) exposure is associated with insulin resistance and type 2 diabetes, but the underlying molecular mechanisms remain poorly understood. 11ß-hydroxysteroid dehydrogenase type 1 (11ß-HSD1) regulates tissue glucocorticoid action at the pre-receptor level and requires hexose-6-phosphate dehydrogenase (H6PDH) to maintain its activity. Here, we examined whether pre-receptor modulation of 11ß-HSD1 and H6PDH affects glucocorticoids action on insulin signaling in adipose tissue of mice. We show that corticosterone treatment induced expression of 11ß-HSD1 and H6PDH and caused insulin resistance in abdominal adipose tissue of C57BL/6J mice, as evidenced by a reduction in insulin receptor (IR) and insulin receptor susbstrate-1 (IRS-1) expression with corresponding decreases in adipose Thr308 AKT/PKB phosphorylation. Treatment of corticosterone-exposed mice with GC antagonist RU486 markedly reduced adipose 11β-HSD1 and H6PDH expression and reduced weight gain, hyperglycemia, and insulin resistance. The improvement of insulin resistance was accompanied by RU486-induced activation of IR mRNA and protein expression with a concomitant increase in pThr308 AKT/PKB activity in the adipose tissue. These findings suggest that the pre-receptor augmentation of 11β-HSD1 and H6PDH expression within central fat may contribute to exogenous glucocorticoid-induced local insulin resistance. RU486 exerts some of its beneficial effects, at least in part, by inhibiting adipose 11β-HSD1 and H6PDH expression.

 

Nothing to Disclose: YJL, CY, YW, HD, WF, MM, AZ, TCF

14257 6.0000 SUN-1046 A Regulatory Effects of RU486 on Glucocorticoid Metabolism and Insulin Signaling in Adipose Tissue from Corticosterone-Exposed Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

Kathryn Hinchee-Rodriguez*, Martin L Adamo, Bettie Sue Masters and Linda J Roman
Univ of Texas Hlth Sci Ctr, San Antonio, TX

 

Type 2 Diabetes (T2DM) is a major cause of death in the United States, and has become a global pandemic. T2DM results from reduced insulin sensitivity coupled with a relative failure of insulin secretion. Reduced insulin sensitivity is associated with reduced nitric oxide synthase (NOS) activity and impaired glucose uptake in human T2DM skeletal muscle. Upon insulin stimulation, nitric oxide synthesis increases in normal adult skeletal muscle, whereas no such increase is observed in T2DM adults, which is significant given that nitric oxide stimulates glucose uptake in skeletal muscle. We have shown that neuronal NOS (nNOS) is phosphorylated at Ser1446, resulting in its activation, in response to insulin in skeletal muscle, but it remains unknown which kinase(s) in the insulin signaling cascade is/are responsible. Immunoblot analyses indicate that in C2C12 myotubes, insulin-stimulated nNOS phosphorylation is dependent on one or more AKT isoforms, as the pharmacological inhibitor AKTi, which prevents AKT1/2 activation, inhibited nNOS phosphorylation. Moreover, the AKT2-specific inhibitor, AKT2i, also attenuated nNOS phosphorylation, implicating this isoform specifically. These results are consistent with the essential role of AKT2 in mediating glucose uptake in skeletal muscle and show, for the first time, that C2C12 myotube nNOS phosphorylation, and its associated increase in activity, are dependent on insulin signaling-activated AKT2.

 

Nothing to Disclose: KH, MLA, BSM, LJR

11439 7.0000 SUN-1047 A Insulin-Stimulated Neuronal Nitric Oxide Synthase Phosphorylation Is AKT2-Dependent in C2C12 Skeletal Muscle Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

Simona S. Ghanem*1, Garrett Heinrich2, Payal Patel3 and Sonia Michael Najjar4
1University of Toledo College of Medicine, Toledo, OH, 2Columbia University, New York, NY, 3University of Massachusetts Medical School, Worcester, MA, 4University of Toledo College of Medicine and Life Sciences, Toledo, OH

 

The carcinoembryonic antigen-related cell adhesion molecule 2 (CEACAM2) is a transmembrane glycoprotein that is mostly produced in the hypothalamus, epithelia of intestinal tissue, testis, spleen and kidney. While much is known about the function of CEACAM1, there is little known about that of CEACAM2. Using a global Cc2–/– mouse, we have shown that CEACAM2 regulates insulin action by playing an important role in the central regulation of energy balance (food intake and expenditure), and spontaneous physical activity. It also appears to regulate brown adipogenesis and insulin secretion via its action on GLP1 release. These functions are consistent with CEACAM2 expression in the ventromedial nucleus of the hypothalamus (VMH). While Ceacam2 deletion caused an increase in food intake in both males and females (in part due to elevated fatty acid synthase activity), only female mice developed obesity, elevated fat mass and insulin resistance due to reduced energy expenditure and spontaneous physical activity, starting at about 2 months of age. On the other hand, males remained insulin sensitive and lean until about 7-8 months of age, owing to increased sympathetic nervous system activity to adipose tissue. Future studies will aim to identify the mechanisms underlying the sexual dimorphic effect of Ceacam2 deletion on energy expenditure and peripheral insulin action.

 

Nothing to Disclose: SSG, GH, PP, SMN

15949 8.0000 SUN-1048 A Sexual Dimorphic Regulation of Insulin Action By CEACAM2 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

Saja S. Khuder*1, Lucia Russo1, Sadeesh Kumar Ramakrishnan2, Qusai Al-Share3, Garrett Heinrich4, Sang Jun Lee5, Terry D Hinds Jr.1, Brahma Raju Mopidevi1, Yatrik Madhukar Shah2, Edwin Ramon Sanchez1 and Sonia Michael Najjar1
1University of Toledo, College of Medicine, Toledo, OH, 2University of Michigan, 3Med Univ of Ohio Metab & Cardi, Toledo, OH, 4Columbia University, New York, NY, 5University of Cincinnati College of Medicine

 

The Carcinoembryonic Antigen-related Cell Adhesion Molecule (CEACAM1) is a transmembrane glycoprotein that regulates insulin action by promoting receptor-mediated insulin endocytosis and degradation, a key mechanism of insulin clearance, which occurs mostly in liver, but to a lower extent in kidney. Mice with null deletion of Ceacam1 exhibit impairment of insulin clearance and consequently, hyperinsulinemia, insulin resistance, hepatic steatosis and visceral obesity. Obese humans exhibit insulin resistance with associated decrease in CEACAM1 levels. High-fat feeding causes insulin resistance by reducing CEACAM1 before inflammation develops. Together with the finding that CEACAM1 is metabolically regulated; being markedly reduced at fasting and elevated in parallel to acute rise in insulin in response to refeeding, these data provided the impetus to investigate the mechanisms leading to decreased Ceacam1 expression in obesity, at fasting and in response to high-fat feeding. One of the shared common biochemical mechanisms between these conditions is elevated fatty acid (FA) entry to the liver to be cleared via β-oxidation. This is attained by activating the Peroxisome Proliferator Activated Receptor α  (PPARα), a nuclear receptor that forms heterodimers with retinoid x receptor alpha (RXRα) to bind to DNA at sites of target genes. Our preliminary data strongly suggest that FA-induced PPARα activation results in direct transcriptional inhibition of Ceacam1. We have shown that PPARα activation by WY-14,643 selective PPARα agonist causes PPARα binding to Ceacam1 promoter in rat and mice hepatoma cells and in the liver of wild-type, but not PPARα knockout mice, fed a Wy-supplemented diet for 3 days. Deletion and block mutation analyses identified a main site of PPARα/RXRα binding to Ceacam1 promoter. Further studies are underway to investigate the mechanisms involved in Ceacam1 regulation. With CEACAM1 playing a key role in maintaining insulin action and fat metabolism, these studies can potentially identify CEACAM1 as a tractable drug target to combat metabolic insulin resistance, fatty liver disease and obesity.

 

Nothing to Disclose: SSK, LR, SKR, QA, GH, SJL, TDH Jr., BRM, YMS, ERS, SMN

16017 9.0000 SUN-1049 A Regulation of CEACAM1 By Pparα-Dependent Mechanisms 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

Annie E Newell-Fugate*1, Monica Jarboe1, Corinne Bromfield1, Sherrie G Clark2, Robert L Rosenfield3, Janice M Bahr1 and Romana A Nowak1
1University of Illinois at Urbana-Champaign, Urbana, IL, 2Virginia-Maryland Regional College of Veterinary Medicine, Blacksburg, VA, 3The University of Chicago, Chicago, IL

 

Whereas the role of insulin resistance in the development of hyperandrogenemia is well established, it is unclear whether hyperandrogenemia itself can disrupt insulin signaling. Pigs and humans have similar adipose tissue composition and lipoprotein profiles. Therefore, the pig may be an appropriate animal model to examine the relationship of androgens and insulin signaling. We hypothesized that administration of depot-testosterone (cypionate) (DT) to female pigs would reduce insulin signaling. DT-treated females (n=5) were given intramuscular DT (100 mg/m2) every 6 days, with the first of three doses administered on the day of estrus (day 0). Four age-matched, cycling females were controls (C). Fasting blood was collected on days 0, 3, 7, 11 and 13 of the estrous cycle and was assayed for serum total testosterone (TT), insulin and glucose. Liver, skeletal muscle, visceral adipose, and subcutaneous adipose tissues were collected after euthanasia for real time PCR of INSR and IRS1 on D13-15 of the cycle. Data were assessed for normality and logarithmically transformed as needed. Serum TT, insulin, and glucose were analyzed by repeated measures ANOVA. Gene expression was analyzed relative to quantitation of the housekeeping gene HRPT1 by ANOVA. TT was significantly higher in the androgen treated group on days 3, 7, 11 and 13 of the estrous cycle (p<0.0001; DT0: 0.15 ± 0.83 ng/ml; C0: 0.17 ± 0.93 ng/ml; DT3: 5.21 ± 0.83 ng/ml; C3: 0.09 ± 1.10 ng/ml; DT7: 6.98 ± 0.92 ng/ml; C7: 0.13 ± 1.1 ng/ml; DT11: 7.45 ± 0.83 ng/ml; C11: 0.15 ± 0.93 ng/ml; DT13: 13.42 ± 0.83 ng/ml; C13: 0.09 ± 0.93 ng/ml). There was no significant difference in serum glucose between the two groups during treatment (p=0.2). Serum insulin was significantly higher in DT-treated than control females on D3, but significantly lower in DT-treated than control females on D13 (p<0.01; DT0: 6.00 ± 3.12 μU/ml; C0: 8.00 ± 3.49 μU/ml; DT3: 16.14 ± 3.12 μU/ml; C3: 3.36 ± 3.49 μU/ml; DT7: 2.68 ± 3.12 μU/ml; C7: 3.78 ± 3.49 μU/ml; DT11: 3.20 ± 3.12 μU/ml; C11: 7.14 ± 3.49 μU/ml; DT13: 2.50 ± 3.12 μU/ml; C13: 9.83 ± 3.49 μU/ml). INSR and IRS1 expression were significantly up-regulated in subcutaneous adipose tissue from DT pigs (p<0.01; INSR-DT: 2.52 ± 0.34 fold change; C: 1.00 ± 0.38 fold change; IRS1-DT: 2.75 ± 0.41 fold change; C: 1.00 ± 0.46 fold change). INSR expression was significantly up-regulated in visceral adipose tissue from DT pigs (p<0.001; DT: 2.83 ± 0.34 fold change; C: 1.00 ± 0.53 fold change). There was no significant difference in the fold change of either INSR or IRS1 in skeletal muscle or liver (p=0.6). In conclusion, administration of DT to female pigs causes dose-related changes in serum insulin concentrations and, at high doses, differentially up-regulates INSR and IRS1 gene expression in adipose tissue. These unexpected results suggest that prolonged masculinizing testosterone levels selectively increase insulin sensitivity of adipose tissue.

 

Nothing to Disclose: AEN, MJ, CB, SGC, RLR, JMB, RAN

16843 10.0000 SUN-1050 A Testosterone Administration to Female Pigs Causes Dose- and Time-Related Changes in Serum Insulin and Differentially up-Regulates Insr and IRS1 Gene Expression in Adipose Tissue 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

Yacir Benomar1, Gili Solomon2, Hassina ould-Hamouda3, Hamza Amine3, Ahlem Othmane3, Arieh Gertler4 and Mohammed Taouis*5
1University of Paris-Sud, France, 23Faculty of Agricultural, Food and Environmental Quality Sciences, The Institute of Biochemistry, Food Science, and Nutrition, The Hebrew University of Jerusalem, Rehovot, Israel, 3University Paris-Sud, 4Hebrew Univ Inst of Biochemist, Rehovot, Israel, 5CNRS CNPS UMR8195, Chilly Mazarin, France

 

Novel human resistin antagonist (monomeric C6A mutant) reduced body weight gain and restored insulin responsiveness in mice fed high fat diet.

Yacir Benomar1,2, Gili Solomon3, Hassina Ould-Hamouda             1,2, Hamza Amine 1,2, Ahlem Othmane1,2,  Arieh Gertler3*, Mohammed Taouis1,2*.


Resistin promotes both inflammation and insulin resistance associated with energy homeostasis impairment. Resistin, a cysteine-rich polypeptide, is secreted by adipose tissue and macrophages, but its mechanism of action remained unknown because its receptor was not characterized. We have recently identified Toll Like 4 receptor as the binding site for resistin in the hypothalamus and neuronal cells and showed that central resistin led to overall insulin resistance and inflammation (1).

Here, we aimed to block resistin action in mice fed high fat diet that are prone to obesity and inflammation, and attempt to reverse these metabolic disorders. For this purpose, we have developed and purified to homogeneity recombinant human resistin mutant (C6A) that does not form the dimeric molecule of resistin and acts as resistin antagonist (RA). The quality and purity of RA has been verified by SDS-PAGE and SEC analysis. We have tested the efficacy of RA in human neuroblastoma cell line SH-SY5Y and in mouse hypothalamic cell line mHypo 280. Firstly, we showed that resistin (100 ng/mL) induced the phosphorylation of Akt, while RA had no such activity in both cells. Importantly, we demonstrate that RA (10 mg/mL) completely and in lower doses gradually abolished resistin-dependent Akt phosphorylation. Once, the efficacy of RA demonstrated, we attempted to reverse the high fat-dependent insulin resistance by RA treatment in vivo. For this purpose, we have fed male C57BL/6 mice with HFD for 6 weeks and then mice received for 14 days daily injection of RA (0.3 mg/day/mice). A control group was also conducted that received chow diet. We clearly show that RA leads to a significant decrease in body weight of HFD mice (-2.5 g as compared to HFD mice treated with placebo) mainly due to loss of visceral fat.  Importantly, RA treatment completely restored glucose tolerance as evidenced by glucose tolerance test and also restored insulin-responsiveness as estimated by insulin tolerance test. In conclusion, we demonstrate that the blockade of resistin action reduced body weight gain, visceral fat content and restored insulin responsiveness of mice fed high fat diet.

(1) Benomar Y, Gertler A, De Lacy P, Crépin D, Ould Hamouda H, Riffault L, Taouis M. Central resistin overexposure induces insulin resistance through Toll-like receptor 4. Diabetes. 2013, 62:102-14.

*: equally contributed.

 

Nothing to Disclose: YB, GS, HO, HA, AO, AG, MT

13755 11.0000 SUN-1051 A Novel Human Resistin Antagonist (monomeric C6A mutant) Reduced Body Weight Gain and Restored Insulin Responsiveness in Mice Fed High Fat Diet 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

Hamza Amine1, Yacir Benomar2, Nadia Meskini3 and Mohammed Taouis*4
1University Paris-Sud, 2University of Paris-Sud, France, 3University HassanII, 4CNRS CNPS UMR8195, Chilly Mazarin, France

 

Odontella aurita-enriched high-fat diet prevents high-fat diet induced insulin resistance.

Hamza Amine1,2, Yacir Benomar1,2, Nadia Meskini3, Mohammed Taouis1,2

1Unité Mixte de Recherche 8195, University Paris-Sud, Orsay, Franc;,2Centre National de la Recherche Scientifique, Center of Neurosciences Paris-Sud, Unité Mixte de Recherche 8195, Orsay, France ; 3 Biochemistry and Environment Laboratory. University Hassan II, Morocco.

Omega-3 polyunsaturated fatty acids modulate the risk factors for metabolic syndrome via multiple mechanisms. However, their underlying mechanisms on insulin resistance and type 2 diabetes are still unknown.

Here, we report that Odontella aurita, a microalga rich in the omega-3 polyunsaturated fatty acid eicosapentaenoic acid (EPA), prevents High saturated fat diet induced insulin resistance and inflammation in the liver of Wistar rats. High fat diet (HFD), given for 8 weeks, increased plasma insulin levels associated with the down-regulation of insulin receptor (IR) and the impairment of insulin-dependent IR phosphorylation. Furthermore, HFD increased toll-like receptor 4 (TLR4) expressions. Indeed, we have recently reported that TLR4 is implicated in resistin-induced inflammation and insulin resistance in the hypothalamus (1). We also show that TLR-4 up-regulation is concomitant with the activation of c-Jun N-terminal kinase (JNK) and p38 mitogen-activated protein kinase (p38).

Importantly, Odontella aurita enriched HFD (HFOA, 12%) normalized body weight and plasma insulin levels, and restores IR expression at both protein and mRNA levels. In addition, HFAO improves insulin responsiveness as estimated by in vitro phosphorylation of hepatic plasma membrane IR. Furthermore, HFOA decreased TLR4 expression and JNK /p38 phosphorylation.

In conclusion, we demonstrate, for the first time to our knowledge, that omega-3 fatty acids brought by Ondontella aurita overcomes HFD-induced insulin resistance through the inhibition of TLR4/JNK/p38 MAP kinase signaling pathways.

(1) Benomar Y, Gertler A, De Lacy P, Crépin D, Ould Hamouda H, Riffault L, Taouis M. Central resistin overexposure induces insulin resistance through Toll-like receptor 4. Diabetes. 2013, 62:102-14.

 

 

Nothing to Disclose: HA, YB, NM, MT

13767 12.0000 SUN-1052 A Odontella Aurita-Enriched High-Fat Diet Prevents High-Fat Diet Induced Insulin Resistance 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

Yacir Benomar1, Arieh Gertler2 and Mohammed Taouis*3
1University of Paris-Sud, France, 2Hebrew Univ Inst of Biochemist, Rehovot, Israel, 3CNRS CNPS UMR8195, Chilly Mazarin, France

 

Resistin induces insulin resistance through Toll-Like Receptor 4 in SH-SY5Y human neuronal cells.

Yacir Benomar1,2, Arieh Gertler 3 and Mohammed Taouis1,2

 1Unité Mixte de Recherche 8195, University Paris-Sud, Orsay, Franc;,2Centre National de la Recherche Scientifique, Center of Neurosciences Paris-Sud, Unité Mixte de Recherche 8195, Orsay, France ; 3Faculty of Agricultural, Food and Environmental Quality Sciences, The Institute of Biochemistry, Food Science, and Nutrition, The Hebrew University of Jerusalem, Rehovot, Israel.

Obesity is linked to common metabolic diseases including insulin resistance, which constitutes a principal risk factor for type 2 diabetes. Increasing evidence indicates that changes in adipose-secreted factors in obesity, including release of inflammatory cytokines, dramatically affect insulin sensitivity. Among these adipokines, resistin is described as a key factor in obesity-mediated both inflammation and insulin resistance. More recently, it has been shown that central resistin induces neuro-inflammation through Toll like receptor 4 and inhibits insulin responsiveness by the down-regulation of insulin receptor (1). Another adipokine has been described to increase insulin responsiveness, adiponectin. Here, we aim to investigate the impact of resistin on adiponectin in human neuroblastoma cell line SH-SY5Y. We show that adiponectin leads to the phosphorylation of Akt and ERK1/2.Interestingly, resistin pretreatment completely abolished adiponectin-dependent Akt phosphorylation whereas ERK1/2 was not affected. The differential effect of resistin on ERK1/2 and Akt could be attributed to the direct effect of resistin on ERK1/2 phosphorylation. Importantly, SH-SY5Y cells resistin pretreatment induced the down-regulation of APPL1. This has been confirmed in vivo. Indeed, in Wistar rats, ICV resistin chronic infusion (14 days) leads to a significant down-regulation of hypothalamic APPL1. Furthermore, the knock-down of APPL1 by siRNA strategy completely abolished adiponectin action. In order to verify whether resistin action is mediated by TLR4, SH-SY5Y cells were transfected by siTLR4 construct. The knock-down of TLR4 completely abrogates resistin effect on adiponectin responsiveness.

In conclusion, resistin inhibits adiponectin-dependent Akt phosphorylation and down-regulates APPL1 through TLR4 receptors.

(1) Benomar Y, Gertler A, De Lacy P, Crépin D, Ould Hamouda H, Riffault L, Taouis M. Central resistin overexposure induces insulin resistance through Toll-like receptor 4. Diabetes. 2013, 62:102-14.

 

Nothing to Disclose: YB, AG, MT

13761 13.0000 SUN-1053 A Resistin Induces Insulin Resistance through Toll-like Receptor 4 in SH-SY5Y Human Neuronal Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

Rifat Emral*1, Azad Azarmir2, Ozgur Demir2 and Demet Corapcioglu3
1Ankara University School of Medicine, Ankara, Turkey, 2ankara university, 3Ankara Univ Schl of Med, Ankara, Turkey

 

Compared to healthy controls, diabetic humans show a defect not only in insulin but also in glucagon secretion. Glucagon has an important and critical role in the glucose homeostasis. The high glucagon levels in type 2 DM cases are mostly responsible for the high basal hepatic glucose secretion. Hyperglucagonemia may predispose hyperglycemia and even diabetes mellitus.

This experimental study was designed to find out if exogenous glucagon administration and hyperglucogonemia causes diabetic fenotype in rats or not. For this purpose, serum glucose and insulin levels, muscle insulin receptor counts and pancreas beta cell reserves of the hyperglucagonemic and control rats were determined at basal conditions and after hyperglucagonemia was established. Our study was performed on euglycemic male rats. 30 male, euglycemic rats were kept at 21oC ambient temperature at 12/24-hour natural lighting conditions and fed standard rat food. The study period was accepted as 14 days. The study group was also divided into two groups and the differentiator was the glucagon level given to the study group. Half the rats in the study group (10 rats) received glucagon 35 µg/kg/day (group 1) while the other half (10 rats) received 70 µg/kg/day (group 2) by infusion. The 10 rats assigned as the control group (group 3) received physiological saline infusion throughout the study.

            When compared with the hyperglucagonemic rats with the controls, glucose and insulin levels were not significantly different. Besides none of the hyperglucagonemic rats developed diabetes mellitus. The mean insulin receptor level was 1.70±0.67 in group 1, 1.50±0.52 in group 2 and 1.50±0.85 in group 3. There was no difference between the groups for basal insulin receptor levels. The insulin receptor measurements did not show a significant change at the end of the study in group 1, one of the experimental groups, and group 3, the control group, with mean values of 1.30±0.48 (median 1.00) in group 1 and 1.40±0.69 (median 1.00) in group 3. Compared to basal, higher dose glucagon infusion caused up regulation in insulin receptors comparing with the control rats. The mean number of cells in this analysis based on the staining of insulin-secreting cells was 68.42±18.18 for whole rats; 72.48±21.25 for group 1, 59.44±16.48 for group 2, and 73.34±14.40 for group 3. There was no statistically significant difference between the three groups for these observed levels (p>0.05) Although not statistically significant, insulin levels tended to decrease in the glucagon infusion group.

In conclusion, these data suggests that hyperglucagonemia, frequently seen in diabetes mellitus, is not a causative condition but maybe the result of the diabetes mellitus.

 

Nothing to Disclose: RE, AA, OD, DC

16217 14.0000 SUN-1054 A Possible Role of Experimental Hyperglucagonemia in the Development of Insulin Resistance and Diabetes Mellitus in Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

Glenn K Mcconell1, Gunveen Kaur1, Filippe Falcao-Tebas1, Yet H Hong1 and Kathryn L Gatford*2
1Victoria University, Melbourne, Australia, 2University of Adelaide, Adelaide, Australia

 

Insulin-stimulated glucose uptake is reduced in people with type 2 diabetes (T2D), especially in skeletal muscle, which accounts for >70% of insulin-stimulated whole-body glucose uptake. Importantly, increases in insulin sensitivity with regular exercise training are normal in T2D, providing an attractive target to improve glucose homeostasis in T2D. Acute exercise also improves subsequent insulin sensitivity and glucose uptake into muscle in humans and rodents, but this has not yet been demonstrated in any large animals. A large animal model would be useful for investigation of longitudinal changes during exercise and responses to different training regimes including underlying mechanisms by repeated biopsies of insulin-sensitive target tissues. We therefore measured insulin sensitivity and expression and activation of insulin signaling proteins in skeletal muscle of six non-pregnant mature adult Border Leicester × Merino female sheep, before and 18 h after an acute exercise bout. Animals were catheterized under general anesthesia and asepsis and whole-body insulin sensitivity was measured by hyperinsulinemic euglycemic clamp (HEC,120 min, 2 mU insulin.min-1.kg-1). Animals then underwent 10 days of familiarization to treadmill walking and an acute exercise bout (30 minutes at 50-60% VO2 max) was performed on the 11th day, with a second HEC conducted 18 h after the acute exercise. M. semimembranosus biopsies were collected under local anesthesia (1% Lignocaine) before and immediately following each HEC. All procedures were approved by the University of Adelaide Animal Experimentation and Ethics Committee. Compared to pre-exercise values in the same animals, glucose infusion rate during the clamp increased by 40% (P = 0.003) and insulin sensitivity increased by 32% (P = 0.028) on the day after acute exercise. Insulin increased phosphorylation of Akt Ser473 in muscle, indicative of proximal insulin signaling activation, by ∼5-fold (P < 0.001), with no effect of exercise, consistent with findings in humans and rodents. Muscle GLUT4 and PGC1α, protein and muscle glycogen content and citrate synthase activity were similar before and after exercise, consistent with an acute exercise response rather than an effect of the familiarization exercise. Improved insulin sensitivity and unchanged proximal insulin signaling on the day after acute exercise in sheep are consistent with responses in humans, suggesting that sheep are a suitable large mammal model to investigate underlying mechanisms for the beneficial effects of exercise on insulin sensitivity.

 

Nothing to Disclose: GKM, GK, FF, YHH, KLG

16542 15.0000 SUN-1055 A Acute Exercise Increases Whole-Body Insulin Sensitivity in Adult Sheep 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

Eric E Niederkofler*1, Amanda Leber1, Kwasi Antwi1, Tara Schroeder2, Kemmons A Tubbs1, Bryan Krastins3, Amol Prakash3, Mary Lopez3 and Scott Peterman3
1Thermo Fisher Scientific, Tempe, AZ, 2Thermo Fisher Scientific, Somerset, NJ, 3Thermo Fisher Scientific

 

Measurement of Insulin has been identified as a paramount metric for specific clinical research, therapeutic development, forensic and sports doping. Conventional insulin assays are plagued by the simple inability to differentiate endogenous from insulin analogs.  While LC-MS has demonstrated the ability to overcome this shortcoming, these methods have lacked the sensitivity demanded by the field.  Complicated by the presence of high plasma background, highly selective sample interface workflows are required for proper LC-MS detection/quantitation.  To satisfy all the listed capabilities, a Mass Spectrometric Immunoassay (MSIA) was developed for high-throughput, highly sensitive quantification of insulin and its analogs from human donor plasma. A series of research samples consisting of insulin mixes were prepared both neat and in donor plasma.  Individual analogs were prepared independently and applied at different levels to characterize the method employed.  For MSIA, targeted selection using MSIA D.A.R.T.’S technologies derivatized with a pan-anti insulin ab were employed as the sample interface.  MSIA detection and quantitation were performed using LC-MS on a Q Exactive.  Full MS scans were utilized for detection of intact insulin analogs, enabling simultaneous measurement of multiple analogs from a single sample.  Samples were prepared for LC-MS using a 30 minute pre-analytical protocol and analyzed by a 10 minute LC-MS method. Primary limitations to routine, high-throughput quantitation of insulin and its analogs have been limited by inefficient sample preparation resulting in lack of sensitivity and robustness.  Development/application of the Insulin MSIA facilitated capture of all variants, while significantly decreasing background matrix.  Efficiency afforded through the use of Ab target selection permitted development of a 10 minute method.  Versatility of the displayed MSIA resides in the ability of the pan-Ab to recognize a common epitope conserved across all of the analyzed variants.  Top-down HR/AM detection of intact insulin simplified the pre-analytical phases by removing the need for time consuming reduction/alkylation steps. Utilizing full scan MS enabled simultaneous detection of multiple insulin analogs, while providing the ability to screen for unsuspecting insulin analogs post-acquisition. Further confirmation of analogs was provided by fragmenting intact insulin and monitoring unique PRM transitions for each variant. Heavy insulin was used as an internal standard and spiked into each sample. AUCs for each analog were normalized to the heavy insulin AUC. Using standard curves, normalized AUCs were converted to amount of each analog. Results demonstrated an LLOQ of 15 pM (87 pg/mL) and an LOD of < 7.5pM (~47 pg/mL) for intact variants.  In addition, studies demonstrated inter- and intra-day CV’s of < 3% and recoveries of 96-100%.

 

Disclosure: EEN: Employee, Thermo Fisher Scientific. AL: Employee, Thermo Fisher Scientific. KA: Employee, Thermo Fisher Scientific. TS: Employee, Thermo Fisher Scientific. KAT: Employee, Thermo Fisher Scientific. BK: Employee, Thermo Fisher Scientific. AP: Employee, Thermo Fisher Scientific. ML: Employee, Thermo Fisher Scientific. SP: Employee, Thermo Fisher Scientific.

15599 16.0000 SUN-1056 A A Simple and Robust Targeted Quantitative Method for Insulin and Its Therapeutic Analogs 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

Elisa Vergari*1, Reshma Ramracheya2, Albert Salehi3, Melissa Brereton2, Anne Clark2, Frances M Ashcroft4 and Patrik Rorsman1
1University of Oxford, Oxford, United Kingdom, 2University of Oxford, 3Department of Clinical Science, Division of Endocrine Pharmacology, the Malmö University Hospital (UMAS), Malmö, Sweden, 4University of Oxford, United Kingdom

 

Background and Aim

Hypoglycemia is a major complication of insulin therapy in diabetic patients. This is a potentially fatal condition and is attributed to impaired counterregulation of glucagon secretion. The underlying mechanism remains unknown. Here we investigated the insulin-induced effects on pancreatic islet hormone release.

Methods

Islet hormone release was measured in static incubations of groups of 10-20 size matched human or mouse pancreatic islets. Changes in cytosolic calcium concentration ([Ca2+]i) were monitored by confocal microscopy. Capacitance measurements were used to measure exocytosis from delta cells within intact islets.

Results

Glucagon secretion was strongly inhibited by insulin (100 nM) and by increased glucose levels (from 1 to 6 mM). The insulin receptor blocker s961 reversed the suppressing effect of insulin on glucagon secretion. However, insulin also stimulated somatostatin secretion. This effect occurred at low glucose concentrations (1-4 mM) and was as strong as that evoked by high glucose.  Interestingly, the inhibitory effect of insulin on glucagon secretion could be prevented by the SSTR2 antagonist CYN154806. Immunohistochemistry showed that insulin receptors are expressed in somatostatin-releasing delta cells. Moreover, in a small subset of cells recorded within human intact islets, insulin evoked [Ca2+]i oscillations at low glucose level. A similar stimulation by insulin was seen in delta cells from SST-RFP mice (delta cells identified by delta cell-specific expression of the fluorescent protein RFP). Recordings made using both perforated patch and standard whole-cell technique showed that insulin stimulates exocytosis in mouse delta cells (identified by RFP expression). In vivo administration of the SSTR2 antagonist led to almost complete abrogation of insulin’s hypoglycaemic action.

Conclusion

This study suggests that life-threatening hypoglycaemic events in insulin-treated diabetic patients may be mediated by insulin-induced somatostatin secretion that suppress glucagon secretion by a paracrine effect. These findings endorse the significance of paracrine signaling in pancreatic islets, and underpin a potential role of somatostatin receptor antagonists in controlling insulin-induced hypoglycemia.

 

Nothing to Disclose: EV, RR, AS, MB, AC, FMA, PR

15063 17.0000 SUN-1057 A Insulin Induced Hypoglycemia: Shedding Light on the Role of Somatostatin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 1041-1057 4806 1:00:00 PM Insulin and Endocrine Metabolic Action Poster

Nujen Colak Bozkurt*1, Ferda Alparslan Pinarli1, Zehra Firat1, Bekir Ucan1, Umit Bagriacik2 and Tuncay Delibasi1
1Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey, 2Gazi University Faculty of Medicine, Ankara, Turkey

 

Background:It has recently been demonstrated that various extra-thyroidal tissues express thyrotrophic hormone receptors (TSHR) including the immune system, peripheral blood cells, bone marrow mesenchymal cells, adipose tissue, gonads, kidney, epidermis, bone and orbital fibroblasts. The exact functional roles of TSHR at extra-thyroidal tissues are controversy but growing evidence focus on differentiation, proliferation and synthesis functions. However, there has been no data about TSHR expression in pancreatic beta cells.

Materials-Methods: Islets were isolated from pancreata of male Wistar albino rats by enzymatic digestion and purified according to a certain protocol. Isolated islets were later administered trypsin. Beta cells were purified from islet suspension by magnetic-activated cell sorting (MACS). Isolated beta cells were incubated and immune-precipitated with anti-human TSH receptor antibody. Chemi-luminescent TSHR bents were visualized after performing gel electrophoresis and Western-blotting and also analyzed by flow cytometry.

Results: Approximately 950 ± 45 islets were isolated from 200 gr of pancreas of two rats (Fig1) and 855,000 beta cells were obtained by MACS. The purity of beta cells was found to be 90.2% by flow cytometry. After incubated with anti-TSHR antibodies, TSHR bents were shown by western blotting. Flow cytometric analyses revealed that 36% percent of beta cells demonstrate TSHR (Fig 2). There was no TSHR demonstrated on the remnant cell suspension after removal of beta cells 

Discussion: Beta cells play crucial role in glucose metabolism and pathogenesis of diabetes. We showed that isolated beta cells of pancreas demonstrate TSH receptors as a novel site. Our findings can lead to further studies about potential functions of those receptors, which may improve the aspects on prevention, or cure of diabetes.

 

Nothing to Disclose: NC, FA, ZF, BU, UB, TD

15211 7.0000 SUN-0972 A Pancreatic Beta Cells Have Thyroid Stimulating Hormone Receptors (TSHR) in Rat 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Deepthi Rao*1, Saleh Aldasouqi2, Mamata Ojha3, Richa Tikaria4 and Tiffany Burns5
1Michigan State University, Okemos, MI, 2Michigan State University, East lansing, MI, 3Michigan State University, East Lansing, MI, 4MSU, MI, 5Michigan State University

 

Background:

Exogenous insulin combined with blood glucose monitoring has been the mainstay of treatment for Type 1 diabetes mellitus (T1DM). However, this cannot effectively substitute the ability of the native pancreas in maintaining glucose homeostasis and is less than optimal in those with extreme glycemic lability. Whole organ pancreatic transplantation, while ideal carries the risk of major surgery. Islet cell transplantation has been developed as an alternative and is less invasive and associated with lower peri-procedural morbidity. However, long term studies after islet transplantation have showed disappointing results. We report the case of an islet cell transplant recipient who remains insulin independent after 8 years.

Case:

We present a 43 year old female with T1DM and history of islet cell transplant done in 2006. Her other medical problems include hypertension, papillary carcinoma of the thyroid, hypothyroidism and dyslipidemia. Family history is significant for hypothyroidism, type 2 diabetes mellitus and hypertension. She is a nonsmoker and denied alcohol or other drug abuse.

She was diagnosed with T1DM at age 10 and was being treated multiple daily insulin injection therapy initially and continuous subcutaneous insulin infusion later. She had retinopathy from DM and underwent laser photo coagulation. In 2006 she underwent allogeneic islet cell transplantation from a single donor through percutaneous portal vein approach and has been on a corticosteroid free immunosuppressive regimen with Tacrolimus and Mycophenolate. She is currently on Sitagliptin 100 mg daily. Her retinopathy has been stable since the transplant and she has remained insulin independent as of currently with normal home blood glucose levels and a glycated hemoglobin less than 6.5 %

Conclusion:

Our case demonstrates that islet cell transplantation remains a promising therapy for T1DM with a minimally invasive procedure as opposed to pancreatic transplant. There is room for significant improvement in organ procurement and development of safer and well tolerable immunosuppressive regimens. However, current studies showing the ability of non-islet cells to differentiate into islet cells offer a beacon of hope for patients with type 1 DM.

 

Nothing to Disclose: DR, SA, MO, RT, TB

17012 8.0000 SUN-0973 A A Case of Continued Insulin-Independence 8 Years after Islet Cell Transplantation: A Promising Remedy for Type 1 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Naweed Alzaman*1, Richard D Siegel2 and Ernst John Schaefer3
1Tufts Med Ctr, Boston, MA, 2Tufts Medical Center, Medford, MA, 3JM USDA HNRCA at Tufts university, Boston, MA

 

Background: Type 1 Diabetes Mellitus (DM) is caused by a progressive autoimmune destruction of the beta cells of the pancreas. This destruction begins years before the clinical manifestations of the disease become apparent. In newly diagnosed type 1 diabetic patients, the natural course of the disease is often characterized by transient restoration of beta cell function following initiation of insulin therapy. This period, often referred to as the “Honeymoon Period”, is characterized by a striking fall in the exogenous insulin requirements while good metabolic control is maintained. A few cases have been described where patients remain healthy without any insulin for an extended period of time.  Factors favoring this period include absence of diabetic ketoacidosis (DKA) at initial presentation, short duration of symptoms and older age at presentation. We report a 34 year old male patient who has been in remission for four years while he is maintaining minimal carbohydrate intake and exercising five times a week.

Clinical Course:A 34 year old male patient presented with a one month history of fatigue, weight loss of 20 pounds, polyuria and polydipsia. He was diagnosed with Type 1 DM based on his initial weight, age and positive glutamic acid decarboxylase antibodies (GAD Ab) 0.43 nMol/L (Normal < 0.02 nMol/L). He was not in DKA.   He was started on basal/bolus regimen of insulin on which his hemoglobin A1C (HbA1C) trended down from 14% to 6.3% in five months and he was taken off Insulin. Two months later his fasting glucose was 107 mg/dl with C-Peptide level of 0.9ng/ml (normal 0.8-3.1ng/ml). Two hours after ingesting 200 grams of carbohydrates, his glucose rose to 215 mg/dl and his C-Peptide was 5.6ng/ml. Over the next 3 years, he continued to keep his carbohydrate intake around 30 to 50 grams per day and his HbA1C was maintained between 5.7 to 6.3 % without insulin treatment. GAD Ab was repeated and remained positive (18.6u/ml).

Clinical Lesson: The pathophysiology of the honeymoon phase is poorly defined. It may occur more frequently with an older age of onset of autoimmune diabetes. Restored beta cell function and C-Peptide secretion have been reported to last up to two years. We report a patient with a prolonged honeymoon phase for four years while maintaining low carbohydrate intake and healthy life style habits. As type 1 DM is an autoimmune disease, reducing insulin secretion through a low carbohydrate diet and optimizing insulin sensitivity through exercise in this case may reduce antigen exposure to the immune system. This could play a role in maintaining a longer honeymoon period than usual.

 

Nothing to Disclose: NA, RDS, EJS

14957 9.0000 SUN-0974 A Prolonged Honeymoon Period in Type 1 Diabetic Patient with Low Carbohydrate Intake 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Ruchita Patel*1, Farah Akhtar Hasan2, Tahira Yasmeen3 and Charles Berkelhammer1
1UIC/Advocate Christ Medical Center, 2University of Illinois at Chicago, Advocate Christ Medical Center, Oak Lawn, IL, 3The University of Illinois/Advocate Christ Medical Center

 

Background: In the treatment of Autoimmune Pancreatitis (AIP), hyperglycemia is an important side effect of corticosteroid therapy. One must be cautious of exacerbating any pre-existing history of glucose intolerance and/or diabetes mellitus (DM) when starting treatment. Ironically, steroid-responsive AIP also has shown to cure hyperglycemia.

Clinical Case: 56 yo Egyptian male with recent diagnosis of AIP and diabetes mellitus presents for optimizing blood glucose levels prior to the initiation of corticosteroids for treatment of AIP.  The patient was diagnosed with AIP by computerized tomography, endoscopic ultrasound, and an elevated IgG4 level 181 mg/dL (7-89 mg/dL). Laboratory work included a hemoglobin A1C (HbA1C) 7.9%, 8.3% (4.5-5.9%) on two separate occasions one week apart. He also had an elevated fasting glucose level of 109.2 mg/dL (65-99 mg/dL). Also, a 2 Hour Oral Glucose Tolerance Test resulted: fasting glucose 185 mg/dL (65-99 mg/dL), 1 hour glucose 374 mg/dL (<180 mg/dL), 2 hour glucose 463 mg/dL (<155 mg/dL), and 3 hour glucose 382 mg/dL (<140 mg/dL). The patient was started on Glimepiride 1 mg PO TID with meals. However, he developed postprandial hypoglycemia.  He was switched to Repaglinide 0.5 mg PO TID with meals with a plan to increase the dose if hyperglycemia was exacerbated with use of corticosteroids for treatment of AIP.  He was also started on Metformin 500mg ER once daily.  The patient was started on an initial dose of prednisone 20 mg daily with a gradual taper to 5 mg daily over two months.  At the time the patient was on prednisone 5 mg daily, his HbA1c was 5.5%. The patient had revealed hypoglycemic episodes at two month and three month follow up visits. Accordingly, Repaglinide was discontinued at two months for postprandial hypoglycemia and then, Metformin discontinued at three months. Subsequent monitoring of HbA1C’s revealed values of 5.2% and 5.3% six and eleven months post treatment with corticosteroids.

Conclusion: We believe the patient had developed DM secondary to chronic AIP.  The exact mechanism of resolution of DM and AIP with steroids has not been clearly defined. It is proposed that exocrine and endocrine portions of the pancreas are improved with inactivation of inflammatory cells and fibroblast function by steroid therapy.  This is a case of AIP treated with steroids, which led to resolution of diabetes. Since around 60% of DM associated with AIP is responsive to steroids in the short and long-term period; marked DM in AIP appears to be an additional indication for steroid therapy.

 

Nothing to Disclose: RP, FAH, TY, CB

15523 10.0000 SUN-0975 A Steroids Curing Hyperglycemia in a Case of Chronic Autoimmune Pancreatitis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Amparo de la Peña*1, Jenny Y Chien2, Xuewei Cui3, Ronan Kelly4, Christoph Kapitza5 and Corina Loghin2
1Eli Lilly and Company, Indianapolis, IN, 2Lilly, Indianapolis, IN, 3inVentiv Health, 4Lilly, Singapore, Singapore, 5Profil Institute for Metabolic Research, Neuss, Germany

 

Dulaglutide is a long-acting glucagon-like peptide 1 receptor agonist developed to improve glycemic control in adults with type 2 diabetes mellitus (T2DM) following once-weekly administration.

The effects of dulaglutide on 1st- and 2nd-phase insulin secretion in response to an intravenous (IV) glucose bolus challenge were evaluated at the therapeutic dose (1.5 mg) in healthy subjects and patients with T2DM. 

In a randomized, double-blinded, placebo-controlled, 2‑period crossover study, subjects received a single subcutaneous injection of either dulaglutide 1.5 mg or placebo on Day 1 of each period. Two days later, at the maximum dulaglutide concentration, subjects underwent a 6-hour insulin infusion titrated to normalize blood glucose to a target range of 79 to 101 mg/dL, followed by a 0.3 g/kg IV glucose bolus. Areas under the curve and maximum concentrations for the 1st- (AUC 0-10 minutes: AUC1; Cmax1) and 2nd-phase secretion (AUC 10-180 minutes: AUC2, Cmax2) were calculated for insulin, glucose and C-peptide. The glucose disappearance constant (Kg) and the Homeostasis Model Assessment for β‑Cell Function (HOMA-B) were assessed.

In T2DM subjects, dulaglutide increased the mean (95% confidence interval) insulin AUC1 and Cmax1 7.92 (4.82, 13.0) and 5.40 (4.09, 7.13) times, respectively, over placebo, while the insulin AUC2 and Cmax2 were increased 2.44 (1.71, 3.47) and 3.78 (2.99, 4.78) times, respectively. C-peptide values were consistent with those observed in insulintropic responses. Subjects with T2DM on dulaglutide showed a mean glucose AUC1 16% greater and a mean AUC2 29.3% lower than after placebo administration; glucose Cmax1 and Cmax2 were not statistically different between treatments. Statistically significant increases of 0.337 in mean Kg (p-value=.006) and of 30% in mean HOMA-B (p-value=<.001) were estimated following dulaglutide compared to placebo in T2DM subjects. Gastrointestinal events were the most commonly reported type of related adverse events in T2DM subjects during the study.

Dulaglutide restored the 1st-phase insulin secretion in response to an IV glucose bolus in subjects with T2DM, and increased the 2nd-phase insulin response. The dulaglutide‑induced enhancement of insulin secretion was accompanied by changes in glycemic measures in subjects with T2DM. A single dose of 1.5 mg dulaglutide enhanced β‑cell function in subjects with T2DM, compared to placebo. Dulaglutide was well tolerated in T2DM and healthy subjects.

 

Disclosure: AD: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. JYC: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. RK: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. CK: Owner, Eli Lilly & Company, Owner, Johnson &Johnson, Owner, Novartis Pharmaceuticals, Owner, Novo Nordisk, Owner, Roche Pharmaceuticals, Owner, Sanofi, Owner, Servier. CL: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. Nothing to Disclose: XC

11713 11.0000 SUN-0976 A Once Weekly Dulaglutide 1.5 Mg Restores Insulin Secretion in Response to Intravenous Glucose Infusion 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Jad G Sfeir*1, Kristina I Rother2 and Violeta Botea Popii3
1Lankenau Med Center, Wynnewood, PA, 2National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD, 3Main Line Health, Wynnewood, PA

 

Background: In several recent clinical trials the addition of GLP-1 analogues or DPP-4 inhibitors to insulin therapy has been tested in patients with type 1diabetes.  Herein we report our experience on gradually replacing insulin treatment with liraglutide.

Case presentation: A 26 year-old Caucasian man was evaluated in the emergency department for polyuria, polydipsia and nocturia of 2 weeks duration. He reported a 20-pound weight loss over 2 months (BMI 27.4 kg/m2 at presentation). He had a history of Graves' disease, diagnosed at the age of 12, treated with methimazole, with subsequent remission. His plasma glucose was 356 mg/dL with mild ketoacidosis. HbA1C was 12%, and C-peptide was 0.58 ng/mL (normal 0.70 - 4.10). GAD65 autoantibodies were positive (11.9 U/mL; normal <1.0). In addition, his TSH was elevated (10.03 mIU/L; normal 0.34 - 5.6) and thyroid peroxidase antibodies were present (467 U/mL; normal <100).  The patient was diagnosed with type 1 diabetes and Hashimoto’s thyroiditis.

The patient was started on thyroid hormone replacement and a basal-bolus insulin regimen. At the 4-weeks follow-up, he was started on liraglutide at 0.6 mg daily. Immediately following initiation of liraglutide the patient started having recurrent hypoglycemic episodes. Over the next 4 weeks, his insulin requirements decreased from 0.6 units/kg/day to 0.075 units/kg/day. Continuous glucose monitoring over a 6-day period was conducted during which he used only 1-2 units of aspart insulin with meals in the first 3 days and no insulin in the last 3 days of the study. His fasting glucose ranged between 85 – 120 mg/dL (average 102); his post-prandial glucose ranged between 69 – 159 mg/dL (average 104). The study also recorded asymptomatic hypoglycemia at 58 mg/dL two days after the last dose of insulin.

Clinical Relevance: Upon initiation of insulin therapy, this patient had decreased beta-cell function as identified by a low C-peptide level and ketosis. Shortly after initiation of liraglutide he achieved fasting, then post-prandial glycemic control without any supplemental insulin administration. This case report illustrates an important role of GLP-1 agonists in the management of autoimmune diabetes after resolution of acute insulin deficiency. Whether the improvement in beta-cell function is quantitative or qualitative, temporary or long-term is yet to be determined.

 

Nothing to Disclose: JGS, KIR, VBP

14232 12.0000 SUN-0977 A Liraglutide: An Alternative to Insulin for New Onset Type 1 Diabetes in Adults? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Ilknur Ozturk Unsal*1, Zeynep Ginis1, Ferda Alparslan Pinarli1, Aynur Albayrak1, Erman Cakal1, Mustafa Sahin2 and Tuncay Delibasi1
1Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey, 2Ankara University School of Medicine, Ankara, Turkey

 

Aim:Although, pancreas islet call transplantation is a new, promising method for type 1 diabetic patients, it remains as an experimental procedure applied in selected patients. Success of islet cell transplantation has been found to be associated with donor characteristics and transplanted cell mass. In addition to islet cells, identification of a second cell type that would help to prolong life of islet cells is one of the studies aimed to prolong survival. Mesencymal stem cell (MSC) is the most studied cell group as the second cell type. The present study aimed to investigate effect of pancreatic MSC transplantation simultaneous with islet cell transplantation on islet liveliness and thus on the treatment of diabetes in type 1 diabetic rats.

Method:The study used Wistar Albino Rats aged 3-3.5 months and was performed in a total of four groups [control (G1), mesenchymal stem cell (G2), islet (G3) and islet + MSC (G4)] each including 8 rats. Blood glucose level of the rats, in which diabetes model has been created using streptozotocin, was measured after 72 hours. The rats having a blood glucose level exceeding 350 mg/dl were considered diabetic and included in the study. After 10-day follow-up period, phosphate buffer saline was given to G1 through portal vein, 600.000 islet-origin MSCs were transplanted into G2, 1500 islets were transplanted into G3, and 1500 islet and 600.000 islet-origin MSCs were transplanted into G4. Blood samples were obtained from the rats 30 days after transplantation and then, their livers and pancreases were kept in 10% formaldehyde and the experiment was ended. Following staining with Hematoxylin&Eosin, they were morphologically evaluated under a light microscope.

Results:Change in mean blood glucose level was statistically significant in G3 and G4 versus control and mesenchymal stem cell groups (p=0.001, p<0.001, p<0.001, and p<0.001 respectively). Change in blood glucose level did not statistically significantly differ between G1 and G2 as well as between G3 and G4 (p=0.485 and p=0.575 respectively). In the control group, decrease in mean C-peptide level 30 days after transplantation versus before transplantation was statistically significant (p=0.036). Histological examination revealed that mean number of islet cells in the pancreases of the rats was higher in G4; difference between the groups was statistically significant (p<0.001).

Discussion:In conclusion, the present study revealed that mesenchymal stem cells alone are not capable of reversing streptozotocin-induced diabetes. However, transplantation of islet cells together with mesenchymal stem cells showed beneficial effects in terms of prolonging survival of islet grafts suggesting that transplantation of mesenchymal stem cells together with islet cells during clinical islet transplantation may be beneficial in increasing the number of noninsulin-dependent patients in Type 1 diabetes.

 

Nothing to Disclose: IO, ZG, FA, AA, EC, MS, TD

12660 13.0000 SUN-0978 A Comparison of Therapeutic Characteristics of Islet Cell Transplantation Simultaneous with Pancreatic Mesenchymal Stem Cell Transplantation in Rats with Type 1 DM 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Marisa M Fisher*, Farah Meah, Renecia A Watkins, Sarah A Tersey, Tamara S Hannon, Janice Blum, Carmella Evans-Molina, Kieren J. Mather, Linda A DiMeglio and Raghavendra G Mirmira
Indiana University School of Medicine, Indianapolis, IN

 

Background/Hypothesis:Early detection of β cell death in persons at risk for type 1 (T1D) and 2 diabetes (T2D) would allow for prompt initiation of therapies to prevent or mitigate disease. Preproinsulin (PPI) DNA is unmethylated at CpG(-69) in human β cells, but methylated in this position in all other human cells. Released from β cells during apoptosis it may serve as a biomarker of clinically-silent disease. We have previously shown this to be a predictor of diabetes in murine models of diabetes. To test the hypothesis that β cell death is detectable and increases in human T1D and T2D, we developed a multiplex, dual-fluorescence probe-based Taqman PCR assay to detect methylated and unmethylated CpG(-69) in a single reaction.  We expressed the resultant values as an “unmethylation index” (where higher numbers indicate greater unmethylation and therefore β cell death).

Methods:  We validated the assay using DNA from isolated cadaveric human islets and our results show low background signals and linearity over multiple orders of magnitude. We then analyzed serum from 17 lean adult controls without T2D, 21 overweight/obese adult subjects without T2D and 23 overweight/obese adult subjects with T2D, as well as 36 pediatric subjects at T1D diagnosis, 8 weeks after diagnosis, and 6 pediatric controls without T1D.

Results:  Lean adult controls had a greater unmethylation index than overweight/obese subjects without T2D (0.81±1.8 [mean±SD] vs. 0.37±0.1, p=0.02). Lean adult subjects without T2D showed a trend towards higher unmethylation indices than subjects with T2D (0.81±1.8 vs. 0.17±0.3, p=0.09). There was no correlation between the unmethylation index and BMI (r2=0.02, p=0.28) or fasting blood glucose (r2=0.01, p=0.42). Unmethylation indices from pediatric subjects at T1D diagnosis were low and not different from pediatric subjects without T1D (p=0.99). Eight weeks after diagnosis, unmethylation indices did not change (p=0.51).

Conclusions:  Our results suggest a complex relationship between the unmethylation status of the PPI gene and diabetes. Lower unmethylation indices in overweight/obese individuals suggest a lower β cell death rate, consistent with known increases in β cell mass in obesity.  Additionally, lower unmethylation indices in T2D subjects compared to lean controls is consistent with reduced β cell mass in T2D secondary to β cell death prior to diagnosis. In T1D, the lack of methylation status differences between groups suggests that the loss of β cell mass at the time of diagnosis might have been extensive enough such that differences in β cell death were undetectable. These results indicate that β cell death measurements will be most valuable in phases of diabetes pathogenesis reflecting active ongoing cell death and that future studies should focus on the pre-diabetes state.

 

Nothing to Disclose: MMF, FM, RAW, SAT, TSH, JB, CE, KJM, LAD, RGM

14072 14.0000 SUN-0979 A Detection of Beta Cell Death in Serum of Persons with Type 1 and 2 Diabetes Using Multiplex PCR Analysis: Evaluation of a Potential Circulating Beta Cell Death Biomarker 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Hye Soon Kim*1, Mikyung Kim2, Namkyeong Kim3 and Inwook Song4
1Keimyung University Dongsan Hosp, Daegu, Korea, Republic of (South), 2Keimyung Univ Dongsan Med Ctr, Daegu, Korea, Republic of (South), 3Keimyung University Dongsan Medical Center, Daegu, Korea, Republic of (South), 4Keimyung University DongSan Medical Center, Daegu, Korea, Republic of (South)

 

Fibroblast growth factor 21 (FGF21) is a cytokine produced by the liver, adipose tissue, skeletal muscle, and the pancreas. Recently, FGF21 is suggested as a key metabolic regulator in glucose and lipid metabolism and its level in serum is higher in the patients with metabolic syndrome, type 2 diabetes and non-alcoholic steatohepatitis. On the other hand, diminished expression of FGF21 is shown in type 1 diabetes and latent autoimmune diabetes in adult (LADA). Type 2 diabetes is a heterogenic disease entity and patients with type 2 diabetes have diverse insulin secretory dysfunction. So, we investigated the association of serum FGF21 and insulin secretory function in patients who admitted our institute for poorly controlled blood glucose and needed insulin therapy. We reviewed personal history including drug history, anthropometric parameters, serum adiponectin, other metabolic parameters. We recruited 154 patients (men 52; women 152) with type 2 diabetes from January 2011 to July 2013, who admitted Keimyung University Dongsan Medical Center, retrospectively. Mean age was 55.4±14.0 in men and 61.4±14.1 in women and body mass index was 24.2±4.7 kg/m2 in men and 25.0±4.2kg/m2 in women. There was no significant difference in hemoglobin A1c (10.4% in men; 10.3% in women). Fasting C-peptide, insulin and homeostasis model assessment of insulin secretion (HOMA-IS) were used as assessment of insulin secretory function. Serum FGF21 level shows correlations with HOMA-IS and fasting insulin in men, but not in women. In addition, serum FGF21 level shows correlations with serum triglyceride, insulin and homeostasis model assessment of insulin resistance (HOMA-IR) in men, however, shows correlations with urine albumin/creatinine and HOMA-IR in women. As a result of multivariate linear regression analysis, only HOMA-IS has a significant correlation with serum FGF21 level. Serum adiponectin level shows negative correlations with duration of diabetes, BMI, total cholesterol and low density lipoprotein in men and shows negative correlation with BMI, waist circumference, total cholesterol and triglyceride, high density lipoprotein in women. Consequently, this study exhibits a positive correlation of serum FGF21 level with an index of insulin secretory function in men with type 2 DM and supports the result of another study with type 1 diabetes and LADA.

 

Nothing to Disclose: HSK, MK, NK, IS

13601 15.0000 SUN-0980 A The Association of Serum Fibroblast Growth Factor 21 with Insulin Secretory Function and Metabolic Parameters in Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Rochelle N Naylor*1, Jazzmyne T Dickens2, Louis H Philipson1 and Siri Atma W Greeley1
1University of Chicago, Chicago, IL, 2University of Chicago

 

Background: Monogenic diabetes is due to mutations in genes important to beta cell function. It is a rare but important cause of diabetes accounting for 1-2% of all diabetes cases. Clinical phenotypes include neonatal diabetes and maturity-onset diabetes of the young (MODY). Encountering variants of uncertain significance (VUS) during genetic testing for monogenic diabetes is a frustrating scenario for ordering providers and patients, leading to uncertainty about potential changes in therapy.  The best approach to VUS in monogenic diabetes is not clear. Here we present the impact of cascade genetic testing of family members to interpret a VUS and establish a genetic etiology for their diabetes.

Clinical Case: The proband presented with diabetes at 9 weeks of age. Family history noted diabetes onset at 4 months in her mother and 4 years in her maternal grandmother (MGM). Commercial sequencing of common neonatal diabetes genes was negative (KCNJ11, ABCC8, GCK, INS, PDX1). This prompted research testing of genes typically associated with a MODY phenotype. A novel variant was found in the HNF1A gene (G288W). The modified amino acid residue was highly conserved between species, and the mutation was predicted to be damaging by several prediction programs. The mutation was also present in the mother and MGM making this variant a plausible explanation for diabetes in the family. However, HNF1A-diabetes does not typically present in infancy or very early childhood and often is very sensitive to sulfonylureas (SU), to which the family showed a very limited response. Therefore, we encouraged cascade testing of additional family members, which revealed the presence of the VUS in the maternal great grandmother and maternal great aunt, both of whom had late-onset diabetes after age 50 years. This suggested that the HNF1A VUS was very unlikely to be the cause of early-onset monogenic diabetes, though it may contribute to risk for type 2 diabetes.

Additional genetic testing revealed an intronic mutation in the INS gene (c.188-31G>A) that had been described subsequent to the original gene testing to be a relatively common cause of neonatal diabetes due to deleterious effects on splicing. This mutation co-segregated with early onset diabetes in the mother and MGM but was not present in other family members. Interestingly, this family demonstrated modest C-peptide production in response to mixed meal testing that was enhanced by SU administration. In addition, the mother and MGM demonstrated clinical response to incretin-related therapies.

Conclusion: Cascade genetic testing in relatives helped to clarify the novel HNF1A VUS (G288W) as non-causal for monogenic diabetes and also prompted additional testing that led to a conclusive genetic diagnosis. To our knowledge, response to non-insulin drugs and demonstration of preserved endogenous insulin production has not been reported previously with this INS mutation.

 

Disclosure: RNN: Advisory board meeting participant., Quest Diagnostics. Nothing to Disclose: JTD, LHP, SAWG

17027 18.0000 SUN-0983 A Cascade Genetic Testing of Family Members Helps to Clarify the Unlikely Causality of a Novel HNF1A Variant and Establishes an Intronic Ins Mutation As the Cause for Neonatal Monogenic Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Marconi Abreu*1 and Ildiko Lingvay2
1UT Southwestern, Dallas, TX, 2University of Texas Southwestern Medical Center, Dallas, TX

 

Background: It is estimated that up to 5% of patients with diabetes have a form of monogenic diabetes, or Maturity Onset Diabetes of the Young (MODY). Although testing is expensive and often not covered by third party payers, the high degree of clinical suspicious prompting the correct diagnosis can have significant therapeutic implications and allows for informed family planning or screening of family members. For instance, most MODY 3 patients have great response to sulfonylureas, while most patients with MODY 2 do not require any treatment. Due to its high correlation with progressive renal disease, the diagnosis of MODY 5 reveals the need for further screening tests and close renal monitoring.  We present the case of a patient with a novel HNF1B mutation (MODY5) who was initially misdiagnosed as type-1 diabetes.

Clinical case: A 34 year old male presented with one year history of polyuria, polydipsia, nocturia, blurred vision, weight loss and fatigue. He also noted an increase in the frequency of infections of his chronic perianal fistula and decreased in his exercise performance. His past medical history is remarkable for HTN and hypercholesterolemia. His paternal grand-mother was diagnosed with diabetes at age 83. His exam is significant for BMI of 22.6 kg/m2, and otherwise a normal physical exam. A diagnosis of type-1 diabetes was made based on the clinical findings (age, lean, no signs of insulin resistance) and a HbA1c of 13% (3.2-5.6 %). His lab showed Anti-GAD 1.52 (<= 0.02 nmol/L), IA-2 Ab 0.07 (<= 0.02 nmol/L), negative Islet Cell Cytoplasmic Ab and c-peptide 0.5 (1.1 - 4.4 ng/mL). Although his Anti GAD antibody was positive, the level was lower than expected for newly diagnosed type 1 diabetes. His low BMI, young age, and sub-acute presentation supported the possibility of an alternative diagnosis of MODY.  Genetic testing demonstrated a G244A heterozygous missense mutation in the HNF1B gene.

Discussion:   MODY5 is linked to pancreatic atrophy, abnormal renal development, renal cysts, early renal impairment, insulin resistance, retinopathy, elevated transaminases, gout, hypospadias, epididymal cysts and infertility. End stage renal disease develops in approximately 50% of subjects before age of 45 years. The diagnosis of MODY5 does not change his diabetes treatment, but alerts us to further screen for other associated medical problems and provide family planning counseling. The G244A mutation is a novel mutation without an established phenotype. This case provides information regarding the clinical phenotype of this mutation.

 

Disclosure: IL: Investigator, Novo Nordisk, Investigator, Novo Nordisk, Advisory Group Member, Novo Nordisk. Nothing to Disclose: MA

12820 19.0000 SUN-0984 A A Novel HNF1B Mutation and Its Associated Clinical Presentation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Moina Uddin*1, David Carmody1, Megan Scott1, Nancy Devine1, Daniela L Sima2, Shannon Comley-Sood2 and Siri Atma W Greeley1
1University of Chicago, Chicago, IL, 2Albany Medical College, Albany, NY

 

Background: Neonatal diabetes mellitus occurs in approximately 1:100,000 births, with heterozygous activating mutations in the ATP-sensitive potassium (KATP) channel genes KCNJ11 and ABCC8 being the most common monogenic causes. KATP mutations usually allow for treatment with oral sulfonylureas (SU) instead of insulin injections and many of these patients also exhibit a spectrum of neurodevelopmental problems, from mild learning disorders and visuo-motor dis-coordination to more severe mutations causing cognitive dysfunction or rarely intractable seizures. Reports of response to SU therapy are sometimes conflicting for certain mutations and the potential beneficial effects of SU treatment on neurodevelopmental outcome are incompletely understood. 

 Clinical case: Through the University of Chicago Monogenic Diabetes Registry (http://monogenicdiabetes.uchicago.edu/), we identified a family with neonatal diabetes in three successive generations. The proband was diagnosed with diabetes within a week of birth, his father, paternal grandmother and great uncle were diagnosed at 8, 4 and 7 weeks of age respectively. The proband was treated successfully with glyburide (<1 mg/kg/day) soon after his diagnosis and was subsequently found to have the R201C mutation in KCNJ11, which was also confirmed in the father. The grandmother and great uncle are presumed to have inherited this mutation from an unaffected parent with germline mosaicism. Given reports of unsuccessful transfer from insulin to SU in older patients with this mutation, the father (who had been exclusively insulin-treated for 24 years) was reluctant but eventually agreed to a research-based treatment attempt in Chicago. Mixed meal testing revealed undetectable C-peptide levels at all timepoints before starting glyburide, and detectable but low levels (0.12-0.2 pmol/mL) by the fifth day of treatment (on 1 mg/kg/day). His dose was increased further to 2 mg/kg/day over week 2 and by week 3 he was able to discontinue basal insulin. By week 6 all insulin therapy was discontinued. Comprehensive neuropsychological testing revealed generally average to low average neurocognitive abilities with specific areas of significant weaknesses in fine motor speed, dexterity, visual perceptual skills, and visual motor integration, with scores falling in the borderline impaired to impaired range on these tasks.

 Conclusion: Previous studies have reported inconsistent response to SU and a variable degree of neurodevelopmental impairment in those with KCNJ11 mutations such as R201C. Our study of this family supports our hypothesis that SU treatment can still be successful in older patients even if they require a very high dose. Specific targeted neuropsychological testing may reveal deficiencies that are not necessarily clinically obvious and use of such tests will be critical for tracking potential beneficial effects of SU treatment.

 

Nothing to Disclose: MU, DC, MS, ND, DLS, SC, SAWG

14723 20.0000 SUN-0985 A A Three-Generation Family with Neonatal Diabetes Due to R201C Mutation in KCNJ11: Characterization of Specific Neuropsychological Impairments and Successful Transition to High Dose Sulfonylurea Monotherapy after 24 Years of Insulin Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Federica Ortolani*1, Albina Tummolo1, Valeria Grasso2, Francesco Papadia1, Marcella Vendemiale3, Maristella Masciopinto1, Rita Fischetto1, Fabrizio Barbetti2 and Elvira Piccinno1
1Pediatric Hospital "Giovanni XXIII", Bari, Italy, 2Pediatric Hospital "Bambino Gesù", Rome, Italy, 3Pediatric Hospital "Giovanni XXIII"; Bari, Italy

 

Case description: first born on term female, spontaneous delivery, SGA (2500g), non consanguineous parents. No gestational diabetes, no familiarity for type 1 and 2 diabetes. Normal glycaemia was detected the day after birth (72 mg/dl). Breastfed, normal weight gain in the first two weeks. Hospitalysed at 24 days for irritability and mild jaundice: blood glucose 509 mg/dl, normal venous hemogasanalysis (pH 7,420, BE -3 mmol/mol, Na concentration of 131 mEq/L, K concentration of 6,2 mEq/L). After being transferred to the Centre of “Metabolic Diseases, Clinical Genetics and Diabetology” of Pediatric Hospital Giovanni XXIII (Bari), she started rehydration and parenteral insulin therapy (regular insulin, starting dose 0,02 IU/kg/h) (IDF/ISPAD guidelines for Diabetes) (HbA1c: 3,9%).

Diagnosis and therapy: Since the beginning of rehydration, we positioned continuous glucose monitoring system (CGMS Medtronic Enlite 27 Gauge 6 mm), glycaemic range 80-200 mg/dl, in order to maintain a stable glycemic trend, to prevent acute hypoglycemia and hyperglycemia and to allow non-invasive frequent monitoring of blood glucose levels. After 6 days, we positioned insulin pump (Paradigm Veo, model 554C) and started therapy with Insulin Lispro (basal dose: 0,025 UI/h - 0,1 UI/h, pre-prandial bolus 0,025-0,1 UI with automatic suspension of basal insulin delivery for glycaemia <80 mg/dl). Since exclusive breastfeeding was continued, CHO calculation could never be performed and insulin dose was always very variable. Laboratory exams underlined: negative IAA, GAD e IA2; C-peptide: 1,4 ng/ml – after few days 0,73 (range 0,46-3,5 ng/ml); normal thyroid function, cholesterol and triglycerides, slight increase of AST/ALT. Normal abdominal ultrasonography. Molecular analysis underlined a de novo heterozygous mutation c.A149->G TAC (Tyrosin)>TGC (Cysteine), (p.Tyr50Cys; position 50 of proinsulin), described as INS/Y50C, never reported before in literature. Discharged, after 38 days of hospitalization, with CGMS and insulin pump (total basal insulin: 2,1 UI/day; 0,7 UI/kg/day) with lower night basal dose and pre-prandial bolus (0,025 UI before every meal when glycaemia>150mg/dl). After 6 months of follow up, normal weight gain, good metabolic control (HbA1c: 6,4%). Cognitive development assessment: QI 141/100, age equivalent score 8 months and ¾ (GMDS-R scale – Griffiths Mental Development Scale Revised 0-2). Positive parents’ adaptation to disease and therapy, good perception of social and familiar support.

Conclusions: The integrated system  (CGMS-insulin pump) is an elective therapy model for neonatal diabetes allowing to personalize insulin therapy, to plan therapy modifications studying the glycaemic trend in real time, reducing glycaemic variability and avoiding psychological burden correlated to hypoglycaemia.

 

Nothing to Disclose: FO, AT, VG, FP, MV, MM, RF, FB, EP

13203 21.0000 SUN-0986 A Neonatal Permanent Diabetes Caused By Mutation Ins/Y50C: Integrated System CGMS and Insulin Pump 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Foram Gandhi*, Carmen Torrado-Jule and Sharone Sheffer-Babila
Staten Island University Hospital, Staten Island, NY

 

Introduction: Maturity onset diabetes of the young is a monogenic, autosomal dominant form of DM generally presenting in children and young adults.  Often misclassified as either Type 1 or Type 2 diabetes, a correct diagnosis of MODY has significant therapeutic, prognostic and genetic counseling implications. The MODY subtypes identified to date involve glucokinase and various nuclear transcription factors which play a role in beta cell development and function. Of particular interest are mutations in the HNF1A and HNF4A genes which are highly responsive to treatment with sulfonylureas.  Here we report a novel mutation in HNF4A as a cause of monogenic diabetes.

Clinical Case: A 16 year old male was admitted for new onset Type 1 DM without DKA.  Family history is significant for father believed to have Type 1, paternal uncles with DM on insulin, paternal grandmother with diabetes onset with GDM, and paternal grandfather with recent onset of Type 2 DM.  On physical exam the patient had normal BMI and no acanthosis nigricans. Initial tests revealed serum glucose of 232mg/dL (n75-125 mg/dL), serum insulin <2uIU/mL (n5-29.0 uIU/mL), and HgA1c 10.0 % (n4-7%). Anti-insulin antibodies and islet cell antibodies were negative. Testing for anti-GAD antibodies was not done. He was discharged home on a total daily insulin dose of 0.39u/kg/day.  One year after diagnosis his glycemic control was optimal despite admitting to taking basal insulin but only rarely rapid acting insulin. The patient was then reevaluated.  Serum glucose was 91 mg/dL (n75-125 mg/dL) with a detectable c-peptide level (0.59 ng/mL, n0.8-3.9ng/mL). He tested negative for anti-GAD antibodies.  Genetic testing for MODY revealed a novel heterozygous missense mutation in the HNF4A gene, c.314 A>G (p.ASP105Gly), of unknown clinical significance.  On basis of clinical suspicion, treatment was initiated with a sulfonylurea.  The patient was responsive to a small dose and was immediately able to discontinue insulin therapy with excellent subsequent glycemic control.

Conclusion:  Genetic testing for MODY has prognostic and therapeutic value in the proband as well as family members. In addition, a confirmed genetic diagnosis of MODY in a patient previously presumed to have Type 1 DM has important implications in the ability to safely withdraw insulin therapy without risk for DKA. This case illustrates the importance of reporting mutations confirmed to result in clinical disease to facilitate identification, optimal treatment, and quality of life of future affected individuals.  Furthermore, we present evidence of a previously unreported mutation of HNF4A causing monogenic diabetes.

 

Nothing to Disclose: FG, CT, SS

13528 22.0000 SUN-0987 A Novel HNF4A Mutation As a Cause of Monogenic Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Ekaterina Sorkina*1, Anatoly N Tiulpakov2, Marina Kalashnikova3, Galina A Melnichenko4 and Vyacheslav Pronin1
1I.M. Sechenov First Moscow State Medical University, Moscow, Russia, 2Endocrinology Research Center, Moscow, Russia, 3I.M.Sechenov Moscow State Medical University, Moscow, 4Endocrinology Research Centre, Moscow, Russia

 

Background: Familial partial lipodystrophy type 2 (FPLD2) is a rare genetic condition, associated with different metabolic disorders, like insulin resistant diabetes mellitus, dyslipidaemia, hepatic steatosis, cardiovascular disease, PCOS and reproductive problems.

Clinical case 1: A 20 y.o. woman first presented with abnormal subcutaneous fat redistribution, acanthosis nigricans, diabetes since 18 y.o., with significant insulin resistance (insulin daily dosage up to 200 U and combined therapy with no effect). Despite different therapeutic strategies, glycemic control was poor: HbA1c 15.4% (< 6.5%), glycemic levels during the day 13.0-25.0 mmol/l (3.9-6.1); ALAT 222 U/l (10-40), ASAT 149 U/l (10-40), total cholesterol 452 mg/dl (<175), triglycerides 953 mg/dl (<150), insulin 49 mcm/ml (5-25), leptin 6.4 ng/ml (3.7-11.1). US-scan: hepatic steatosis, hepatomegaly, splenomegaly. Total fat% (by total body DXA) - 23,3% . Menstrual cycle was regular, with ovulation, and no US-signs of PCO.Hypercortisolism and acromegaly were excluded.  Clinical signs and family history of specific changed appearance, diabetes and PCOS in aunt and cousins led us to the clinical diagnosis of FPLD2, which was confirmed genetically by sequencing of LMNA gene: heterozygous missense mutation R482W, previously described in FPLD2 (1).

Clinical case 2: A 29 y.o. woman presented with similar changes in appearance as Patient 1, since 13 y.o. Since the age of 18 she had dysmenorrhea due to PCOS, impaired glucose tolerance, non-alcoholic steatohepatitis, mild arterial hypertension. In the age of 26 ovarian wedge resection was performed successfully, and in 28 y.o. patient delivered a healthy baby. During the pregnancy she developed gestational diabetes, controlled with diet and insulin in 3d trimester. A year after delivery: HbA1c 6.0% (<6.5%), starving glycemia 5.7 mmol/l (3.9-6.1), after OGTT – 8.1 mmol/l (<7.8); ALAT 35 U/l (10-40), ASAT 31 U/l (10-40), total cholesterol 246 mg/dl (<175), triglycerides 2120 mg/dl (<150), insulin 68.6 mcm/ml (5-25), leptin 3.9 ng/ml (3.7-11.1). US-scan: hepatic steatosis, hepatomegaly. Total fat% (by total body DXA) - 23,3%. Like in case 1, the clinical diagnosis of FPLD2 was confirmed genetically by revealing the very same LMNAmutation R482W.

In both cases, symptomatic combined hypolipidemic and antihyperglycemic treatment showed not enough efficiency, so we plan to start metreleptin therapy, recently approved for inherited lipodystrophies treatment by FDA, as soon as it will be registered in Russia.

Conclusion: These cases show how clinical manifestations of one inherited disease due to the very same gene mutation may vary and lead to different metabolic disorders in young age. These are the first 2 families with FPLD2 due to LMNA mutation described in Russian population, which provides a key for further studies of this pathology in Russia, correct diagnostics and treatment.

 

Nothing to Disclose: ES, ANT, MK, GAM, VP

14593 23.0000 SUN-0988 A Unusual Cases of Diabetes Mellitus As a Result of Heterozygous Missense Mutation R482W in Lmna Gene in 2 Unrelated Families, Described for the First Time in Russian Population 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Simmi Krishnan*, Jonathon Schofield, S Leigh Atkinson, Jennifer Beynon, Anjali Ahluwalia, Diane McKenna, Sheena Cottam and Basil George Issa
University Hospital of South Manchester, Manchester, United Kingdom

 

Introduction : With the development of Cystic Fibrosis (CF) centres and improved multidisciplinary care of this group of patients, pregnancy outcome has also improved significantly. Our aim was to assess the maternal and foetal outcome in women with cystic fibrosis related diabetes (CFRD) in a regional cystic fibrosis unit in the UK.

Study:  Retrospective review of case notes for pregnant women with CFRD attending Manchester Adult Cystic Fibrosis Centre during the period from 2004 to 2013.

Result :  There were twenty six pregnancies in twenty women during the period from 2004 to 2013 with twenty two singleton pregnancies and two twin pregnancies. All women with CF in our centre were asked to monitor their capillary glucose concentrations during pregnancy. Women included in the analysis had either diabetes related cystic fibrosis diagnosed prior to pregnancy or developed dysglycaemia during pregnancy as defined by persistently raised capillary glucose concentrations of >5 mmol/l on fasting samples and/or >7 mmol/l 1 hour post prandial. The age of women during the pregnancies ranged between 19 to 40 years of age. The mode of delivery was planned Caesarian section in twenty three pregnancies (88.4%) and normal delivery in three pregnancies (11.5%).  44% babies were delivered at 38 weeks of gestation. Preterm deliveries ( <37 weeks of gestation according to WHO definition ) were as follows: 28% were born at 36 weeks of gestation, 8% each were delivered at 28 and 37 weeks gestation respectively. 4% babies were delivered at 32, 33 and 34 weeks gestation respectively. Mean birth weight was 2.64 Kg (ranging between 0.5 – 3.83 Kg). There was no foetal loss recorded. Three babies were cared for in the Special Care Baby Unit (SCBU). The number of dietetic review outpatient appointments during the pregnancy ranged between two to eleven (mean of 5). Mean maternal weight gain during this pregnancy was 8.3 Kg.

Conclusion :  Successful and viable pregnancies in women with CFRD can be achieved when cared for by a multidisciplinary team in specialist centres with expertise in looking after these high risk pregnancies. This data shows that preterm deliveries in women with CFRD is quite common and perhaps explains the higher incidence of delivery by Caesarian section in this group of patients. They also demand regular, frequent specialist review and input especially with regards to improving and maintaining their nutritional status during the pregnancy.

 

Nothing to Disclose: SK, JS, SLA, JB, AA, DM, SC, BGI

14955 24.0000 SUN-0989 A Pregnancy Outcome in Women with Cystic Fibrosis Related Diabetes (CFRD) - a Single Centre Experience 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Vorawan Ummaritchot*1 and Richard D Siegel2
1Tufts Medical Center, Boston, MA, 2Tufts Medical Center, Medford, MA

 

Introduction: Non-autoimmune fulminant type 1 diabetes are more common among Japanese and Korean populations, but rare in other ethnicities. The onset of this subtype of diabetes has been noted to occur frequently during a pregnancy and the postpartum state. Fetal demise has been reported in pregnancy-related fulminant type 1 diabetes who developed the disease during pregnancy.

Clinical Case: A 42-year-old previously healthy Chinese woman who immigrated to the United States 10 years ago, presented abruptly with severe diabetic ketoacidosis within 2 weeks after uncomplicated normal delivery. There was no family history of diabetes. She had normal oral glucose tolerance test during pregnancy. There was an episode of glycosuria at gestational age 28 weeks with normal random glucose. On physical examination, her BMI is 24.7 kg/m2. Investigation revealed hemoglobin A1c level of 6.4%, fasting C-peptide level of <1.0 ng/mL, and negative GAD antibody. Her clinical course, biochemical, and immunological profiles were consistent with fulminant type 1 diabetes. The patient was treated with insulin therapy and antibiotics for urinary tract infection although blood and urine cultures were negative. There was no honeymoon period observed and she continued to require insulin therapy for diabetes control. Eleven months after the diagnosis, she had a spontaneous abortion at gestational age 11 weeks.

Conclusion: Fulminant type 1 diabetes is an important subtype of the disease in the young adult Asian population. Study of the association of fulminant type 1 diabetes with pregnancy is warranted for better understanding of the pathophysiology of the disease and maternal-fetal outcome.

 

Nothing to Disclose: VU, RDS

13585 25.0000 SUN-0990 A Postpartum Fulminant Type 1 Diabetes Followed By Fetal Loss, an Uncommon Presentation and Review Literature 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Luriza Glynn*1 and Vitaly Kantorovich2
1University of Connecticut Health Center, 2University of Connecticut Health Center, Farmington, CT

 

Case: 31 year old female with uncontrolled DM1 complicated by recurrent hypoglycemic seizures. Patient was diagnosed at age 12, treated with MDI insulin dose between 20-30 units a day, home records showing glucose levels ranging between 40 and 600. Her disease complicated by proliferative retinopathy, microalbuminuria, hypercholesterolemia and hypoglycemia unawareness, and her HbA1C was 10.2%. Patient had multiple prior admissions for severe hyperglycemia and hypoglycemic seizures and was started on continuous glucose monitoring (CGM) in attempt to eliminate hypoglycemias and decrease the degree of glucose fluctuation.  Unfortunately, patient’s follow up was poor in part because of financial hardship and in part because of clear lack of compliance and possible attention seeking behavior.  Despite intensive follow up, her HbA1C was 8.9% and a fructosamine 297 (range 170-285 umol/L), suggesting poor control in face of persisting severe hypoglycemias. In the fall of 2013, patient reported being approximately 6 weeks pregnant. She underwent aggressive counseling, but this time the main point of the need for better control was targeted to fetal wellbeing and patient expressed willingness to comply. The team decided to use CGM together with insulin pump, but faced long processing time for Medicaid paperwork and inability of patient to come for frequent visits because of remote residence and lack of transportation. The first issue was addressed through direct arrangements with insulin pump company, so the pump therapy was initiated right away. The second issue was resolved in less conventional way. For the purpose of close assessment patient and CDE developed a system in which patient sent in screen shots of her blood glucose history on pump meter, bolus activity, and continuous glucose monitor tracings 1-2 times per week, which allowed rapid adjustments of pump settings. Already after 6 weeks on insulin pump, her HbA1C improved down to 7.8% with a fructosamine of 226.  At the time of writing this abstract patient is in her 28th week gestation and she has followed closely with her OB/GYN and has had numerous ultrasounds reflecting normal fetal development. Her hypoglycemias are mild and very rare. Discussion: Combined CGM/insulin pump therapy is a powerful and effective tool in treatment of DM1, but usually reserved for compliant patients showing ability to follow up closely in order to make appropriate adjustments in pump settings. In our case, use of this treatment modality was felt to allow maximum efficiency and flexibility in management of uncontrolled pregnant DM1 patient. Although the team felt significant anxiety about possible noncompliance and lack of the efficient follow up because of patient’s inability to physically come for frequent visits, the system that we developed proved to be efficient and highly successful and could be considered to use in similar cases in the future.

 

Nothing to Disclose: LG, VK

17060 26.0000 SUN-0991 A Use of Cgm-Based Insulin Pump in Pregnant Patient with Uncontrolled DM1 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Madeline Candelario*1, Erwyn Chua Ong2 and Barnett Zumoff3
1Beth Israel Medical Center, New York, NY, 2Mount Sinai Beth Israel, New York, NY, 3Beth Israel Med Ctr, New York, NY

 

Background: Gestational Diabetes Mellitus (GDM) presenting with Diabetic Ketoacidosis (DKA) is highly unusual.  We present a patient with GDM complicated with DKA.

Case: A previously healthy 37 year-old African American female, gravida 7, para 4, spontaneous abortion 2, presented at 32 weeks of gestation with two-day history of nausea/vomiting, weakness, and drowsiness.  Patient denied abdominal discomfort, polydipsia and polyuria.  She was diagnosed with GDM one month previously which was treated with dietary modification only.  She is a non-alcoholic, with no known family history of diabetes.  There was no prior intake of steroids or beta-2 agonists.  On examination, patient was alert and oriented, dehydrated, not in acute respiratory distress, with normal vital signs.  Rest of physical examination was unremarkable.  Laboratory studies showed serum glucose 175 mg/dL (n 74-106 mmol/L), sodium 136 mmol/L, potassium 4.1 mmol/L, chloride 104 mmol/L, bicarbonate 9 mmol/L (n 22-30 mmol/L), anion gap 23 mmol/L (n 7-16 mmol/L). Leukocytes 16 K/uL (n 4.5-10.8 K/uL), lactate 1.7 mmol/L.  Arterial blood gas: pH 7.36, pCO2 23 mm Hg (n 35-45 mm Hg), pO2 116 mm Hg, bicarbonate 12 mEq/L (n 21-28 mm Hg).  HbA1c was 7% (n <5.9%).  Urinalysis revealed > 150 mg/dL ketone bodies and > 1000 mg/dL glucose, with no pyuria/bacteriuria/hematuria.  Imagings showed no signs of acute infection.  Islet-cell and GAD-65 antibodies were negative, with normal C-peptide level.  DKA protocol was instituted with IV fluids, insulin drip, and electrolyte replacement, which corrected the metabolic abnormalities.  Patient was subsequently treated with daily basal/bolus subcutaneous insulin through the rest of her pregnancy until the time of delivery at 39 weeks of gestation.  She gave birth via repeat cesarean section to a healthy normal-weight baby boy without any complications.  After delivery, patient achieved normoglycemia without any insulin requirement.

Discussion:  DKA during pregnancy can cause significant maternal mortality (5-15%), and is a leading cause of fetal loss with 30-90% mortality rate.  It occurs more commonly in patients with Type 1 DM, occasionally in patients with Type 2 DM, and unusually in patients with GDM.  It occurs in either undiagnosed Type 1 DM, GDM complicated by stress (from prolonged labor or infection), or in patients treated with corticosteroids for fetal lung maturity or beta-2 agonists for tocolysis.  Pregnancy itself, because of the associated insulin resistance induced by counter-regulatory hormones (i.e., human placental lactogen, prolactin, and cortisol), as well as the state of dehydration induced by nausea/vomiting during pregnancy can also precipitate DKA in patients with GDM. No precipitating factors were identified in our patient.  Awareness, early recognition and aggressive management of the possibility of DKA in patients with GDM are of utmost importance to reduce high perinatal mortality.

 

Nothing to Disclose: MC, ECO, BZ

13104 27.0000 SUN-0992 A Unusual Case of Gestational Diabetes Mellitus Presenting with Diabetic Ketoacidosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Natalia Branis*1 and Steven David Wittlin2
1University of Rochester Medical Center, Rochester, NY, 2Univ of Rochester Sch of Med &, Rochester, NY

 

Introduction

Obesity is a challenging clinical problem in patients with type 1 and type 2 diabetes. Many patients opt for prescription weight loss medications with amphetamine-like analogues being the most popular class (1). Our case report explores safety of this medical practice in patients with diabetes mellitus type 1. 

Clinical case

34-year old female with a history of type 1 diabetes, dyslipidemia and obesity class III was prescribed Diethylpropion 75 mg daily for the purpose of weight loss. She had been using an insulin pump for two years prior to presentation. Her last HbA1C was 9.2%. Ten days after starting Diethylpropion, the patient developed nausea, non-bloody vomiting and severe, cramping, periumbilical pain. At home blood glucose was ≈400 mg/dl (fasting target 70-130 mg/dl), despite switching her pump site and taking multiple insulin boluses through the pump. Upon arrival to the hospital, blood work revealed glucose of 718 mg/dl, pH 7.32 (7.35-7.45), bicarbonate 16 mmol/l (22-29 mmol/l) and anion gap 19 mEq/l (8-16 mEq/l). Urine analysis demonstrated large amount of ketones. She was hospitalized and successfully treated for DKA. Diethylpropion was discontinued.

Conclusion

Amphetamine-like analogues comprise the most popular class of weight loss medications (1). Their mechanism of action involves norepinephrine release from the lateral hypothalamus which results in the appetite suppression. Norepinephrine is also known to stimulate adipocyte lipolysis thereby increasing availability of NEFA. Furthermore, it promotes β-oxidation of NEFA to ketone bodies and increases levels of circulating glucose (2, 3). β-hydroxybutyrate concentration increases most significantly compared to other ketone bodies, while metabolic clearance rate of ketones diminishes under the influence of norepinephrine (4). In the setting of acute insulin deficiency, as demonstrated by simultaneous infusion of somatostatin, ketogenic effect of norepinephrine is augmented (4).  Gender differences are exhibited, with females being more sensitive to norepinephrine effects compared to males (5). 

In conclusion, amphetamine-like analogues lead to a release of norepinephrine which can result in a clinically significant ketosis, especially in the setting of insulin deficiency. Female patients can be especially vulnerable to these effects. This class of medications should be used with great caution in patients with type 1 diabetes.

 

Nothing to Disclose: NB, SDW

16453 28.0000 SUN-0993 A Amphetamine-like Analogues in Diabetes: Speeding Towards Ketogenesis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Hwal Rim Jeong*1, Young Seok Shim2, Hae Sang Lee1, Young Bae Kim3, Jungsub Lim4 and Jin Soon Hwang5
1Ajou University School of Medicine, Suwon, Korea, Republic of (South), 2Ajou University Hospital, Suwon, Korea, Republic of (South), 3Ajou University School of Medicine, 4Korea Cancer Ctr Hosp, Seoul, Korea, Republic of (South), 5Ajou Univ School of Med, Suwon City, Korea, Republic of (South)

 

Type 1 DM is characterized by severe insulinopenia, and dependence on exogenous insulin to prevent ketosis and to preserve life1). The incidence of the disease continues to increase worldwide, and this has serious short- and long-term implications2). Glycogenic hepatopathy (GH) is a rare complication of Type 1 DM, presenting as hepatomegaly and elevated serum transaminase levels in patients whose blood sugar levels are poorly controlled. In such patients, the fact that hepatomegaly may be caused by glycogen accumulation may appear to be strange, because glycogenesis is activated by insulin in response to high glucose levels, and insulinopenia is the principal pathophysiology of Type I diabetes. Also, recurrent hypoglycemia is common in glycogen storage disease, and persistent hyperglycemia is a presenting symptom of diabetes. In the literature, GH is recognized as common in Type I DM patients, but the underlying mechanism of development remains unclear. We present a case of GH in a Korean girl with poorly controlled Type I DM.

 

Nothing to Disclose: HRJ, YSS, HSL, YBK, JL, JSH

11642 29.0000 SUN-0994 A Glycogenic Hepatopathy in a Korean Girl with Poorly Controlled Type I Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Christel Marie Keefe*1 and Sarah Lawson2
1Cincinnati Children's Medical Center and the University of Cincinnati; Cincinnati, OH, USA, Cincinnati, OH, 2Cincinnati Children's Hospital Medical Center and University of Cincinnati School of Medicine, Cincinnati, OH

 

Introduction:  Hypertriglyceridemia is a known complication of uncontrolled diabetes.   Severe hyperlipidemia, resulting from an underlying genetic disorder, causing lipemic serum and electrolyte abnormalities in acute onset DKA in childhood is under-reported.

Clinical Case:  An 11 year old male, ZC, presented with new onset, Type 1 Diabetes (T1DM) in Diabetic Ketoacidosis (DKA), following a 3-4 month history of polyuria and polydipsia with 25lbs weight loss.  Initial laboratory evaluation confirmed diabetes mellitus, with serum sodium of 131mmol/L (corrected for glucose 135), Glucose level of 482mg/dL, and blood pH of 7.21.  ZC was started on intravenous hydration (IVF) of 3000mL/m2 -½normal saline (NS) over 24 hours and an insulin infusion (0.1U/kg/h) prior to transfer to the diabetes floor.  Overnight, despite correction of blood glucose, serum sodium began to fall to a nadir of 119mmol/L.  With this decrease in serum sodium, ZC remained stable without mental status changes.  Upon routine laboratory evaluation, bedside nursing noted thick and milky serum.  Lipid levels were drawn; serum cholesterol was 336mg/dL (normal 155-220), LDL 85mg/dL (45-120), HDL was 33 mg/dL (28-76) and Triglycerides of 1755mg/dL (22-131).  Serum sodium corrected for triglyceride elevation was 123mmol/L. ZCs low sodium was managed with continued IVF, though transitioned to NS, and a decreased rate of insulin infusion (0.05U/kg/h) to maintain glucose levels.  ZC was transitioned to subcutaneous insulin following resolution of his acidosis (bicarbonate of >20mmol/L).  Serum sodium improved without further intervention.

Testing for ApoE mutations revealed a heterozygous mutation for Apo e3/Apo e4 allelic variant, which has been associated with increased cardiovascular risk. [1]  Repeat testing of a cholesterol panel once patient was discharged from the hospital and glucose levels were well controlled showed a cholesterol level of 198mg/dL, LDL of 108mg/dL, HDL of 81mg/dL and Triglyceride level of 41mg/dL.   

Conclusion:  This is a case demonstrating electrolyte abnormalities and significant hypertriglyceridemia in a new onset T1DM in DKA.  It is assumed that the variation in his ApoE proteins on lipoprotein within his serum is the cause for the elevated triglyceride levels during a state of insulin insufficiency.

 

Nothing to Disclose: CMK, SL

13785 30.0000 SUN-0995 A Hypertriglyceridemia in an Adolescent with New Onset Type 1 Diabetes in DKA 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Armand Rosaurus Andador Labitag*1 and Roberto Cachola Mirasol2
1St. Lukes Medical Center, Quezon City, Quezon City, Philippines, 2St. Luke's Medical Center, Quezon City, Philippines

 

BACKGROUND:

Diabetes Mellitus and Autoimmune Thyroid Disease are among the most common endocrine diseases. While Diabetic Ketoacidosis (DKA) is an important trigger for thyroid storm, simultaneous development of DKA and thyroid storm is rare.

CLINICAL CASE:

A 29 year old Filipina, diagnosed with uncontrolled Type I DM and Grave's Disease, was admitted at the Emergency Department due to severe abdominal pain and palpitations. She was diagnosed with Type I DM and Grave's disease for 3 years and was non-compliant with her insulin.  Recently, the patient was tapered off from her Methimazole. Five days prior to consult, the patient's Hemoglobin A1c was 12.5% (4.1-6.5%) and her TSH was 0.00 (0.55-4.78 uIU/ml) with an elevated FT4 of 2.13 (0.89 – 1.76 ng/dL).   She presented with severe abdominal pain, palpitations, nausea and vomiting. She was conscious, with BP of 130/60 mmHg, CR 168 bpm, RR 25 cpm, and Temperature of 38.6 Celsius. She had critically high blood sugar level, a high anion gap metabolic acidosis, and + 3 serum ketones.  Burch-Wartofsky score was 50 which was interpreted as thyroid storm.  

She was diagnosed as a case of DKA complicated by simultaneous Thyroid Storm.   Diagnostic parameters on admission include critically high CBG; ABG with pH= 7.14 (7.35-7.45), PCO2= 19.1 (35-45 mmHg), HCO3= 6.3 (22-26 mmol/L); Anion Gap of 32  (8-16 meq/L); serum ketone +3 (Normal Value= Negative); Serum osmolality of 307 (275-295 mosm/kg).  She was hydrated with physiologic saline solution and started on Glulisine insulin drip. Loading dose of Prophylthiouracil 600 mg was started and was then given 300 mg every 6 hours. Propranolol was given at 40 mg twice a day. 

The patient was discharged on the third hospital day on a Basal- Bolus Insulin regimen with Methimazole 20 mg TID and Propranolol 10 mg TID.  On follow up after 1 month, she had a Glycohemoglobin of 6.9% (4.1-6.5%) and normal TSH at 0.85 (0.55-4.78 uIU/ml).  The patient was offered RAI for her Grave’s Disease.On the first hospital day, the patient’s hyperglycemia and symptoms improved and she was deemed out of Diabetic Ketoacidosis and Thyroid Storm.  Insulin drip was transitioned to basal bolus regimen.  Prophylthiouracil was also shifted to Methimazole 20 mg thrice daily.  

CLINICAL LESSONS: 

In this case, the history of uncontrolled Type 1 DM and worsening Grave’s Disease was of great help to the clinicians in considering the possibility that a simultaneous Thyroid Storm can manifest with the DKA.  The diagnostic parameters and criteria for both Thyroid Storm and DKA were also met.  Treatment for both disease entity was initiated immediately which lead to the speedy recovery of the patient from a potentially life-threathening situation.

The possibility of simultaneous Diabetic Ketoacidosis and Thyroid Storm should always be considered especially in patients with history of Diabetes Mellitus and Hyperthyroidism.

 

Nothing to Disclose: ARAL, RCM

14531 31.0000 SUN-0996 A Simultaneous Diabetic Ketoacidosis and Thyroid Storm in a 29 Year Old Filipina with Uncontrolled Type I Diabetes Mellitus and Grave's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Nurdan Gul*1, Tuba Yuce2, Nevin Dinccag3, Kubilay Karsidag3, Temel Yilmaz3, Murat Kose2 and Ilhan Satman3
1Istanbul Faculty of Medicine, Istanbul, Turkey, 2Istanbul University, Istanbul Faculty of Medicine, 3Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey

 

Presentation of Type I diabetes at onset  can be different and some of the patients may mimic abdominal catastrophs. We herein present a case presented with ketoacidosis, acute pancreatitis due to hypertriglyceridemia and possible hemolysis.

Case Report. A 22-year-old man admitted to accident and emergency department with severe abdominal pain, nausea and vomiting. He had a two month history of polyuria, polydipsia and significant weight loss. He was hospitalized with the diagnosis of acute abdomen possibly due to  acute apendicitis. During his preoperative investigations, plasma glucose level was found 345 mg/dl, and arterial pH was 7.0, bicarbonate was 8.3 mmol/L. Urinalysis showed 4+ glucose and 4+ ketones which confirmed the diagnosis of diabetic ketoacidosis. His blood chemistry also showed an increase in pancreatic enzymes (amylase 288 U/L and lipase 1097 U/L) as well as an increase in triglycerides (4070 mg/dl). Abdominal CT imaging showed diffusely swollen and edematous pancreas with peripancreatic fluid collection and heterogenous peripancreatic fat tissue compatible with the diagnosis of acute pancreatitis. Therefore, his treatment was planned for diabetic ketoacidosis, severe hypertriglyceridemia, and acute pancreatitis. He was given fluid and electrolyte replacement and intravenous insulin therapy. Fenofibrate and omega 3 therapy was also added to his treatment. On the fifth day he was admitted to endocrinology ward. His HbA1c was %15.9, C-peptide level was 0.329 ng/ml, triglycerides 155 mg/dl. He was positive for islet cell cytoplasmic antibodies (ICA 80 JDFu). Detailed history also showed a family history for type 2 diabetes and hypertriglyceridemia. However, no evidence of dyslipidemia was noted in his laboratory investigations during the evaluation of acute anterior uveitis one year before the admission. He was also previously evaluated for microcytosis, but he was not investigated further for thalassemia traits. During the initial treatment, findings compatible with hemolysis, such as increased plasma LDH, decrease in hematocrit levels, and schistocytes in the peripheral blood smear, were also noted. However, full hematological examination is being awaited for thalassemic traits and G6PD deficiency to be completed after full recovery from endocrine abnormalities.

Conclusion. Abdominal catastrophe is generally considered to be resulting from diabetic ketoacidosis in patients with type I diabetes. However, other possible causes of acute abdomen, such as pancreatitis due to hypertriglyceridemia may also contribute to the clinical picture, and early intervention may be life-saving in these complex conditions with multiple causes.

 

Nothing to Disclose: NG, TY, ND, KK, TY, MK, IS

16765 32.0000 SUN-0997 A An Uncommon Cause of Abdominal Catastrophe in a Patient with Type I Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Sunday, June 22nd 3:00:00 PM SUN 0966-0997 4807 1:00:00 PM Diabetes Pathophysiology and Treatment; Glucose Metabolism Poster

Fatma M Abdel-Maksoud, Patrick Riley, Kyla Wilkinson, Chad D Foradori, Tim D Braden and Benson T Akingbemi*
Auburn University, Auburn, AL

 

The incidence of reproductive diseases has increased in concert with the use of industrial chemicals in the last 40 years.   Daily phthalate exposure levels in the population are estimated at 30 µg/kg body weight (bw), which increased to 10-20 mg/day in preterm infants undergoing blood transfusions.  Di (2-ethylhexyl) phthalate (DEHP) is the most abundant phthalate in the environment.   Similarly, over 90% of the population has detectable bisphenol A (BPA) concentrations in their body, and estimates have shown that humans have 0.2-20 ng/ml of unconjugated BPA in serum. Because the early period of development is a sensitive window of exposure to environmental factors, we investigated the effects of two classical environmental endocrine disruptors (EEDs), namely, DEHP and BPA, in the developing male reproductive axis.  Timed-pregnant Long-Evans female rats were administered DEHP by gavage at 5 and 50 or BPA at 2.5 and 25 µg/kg bw (4 dams/group) during the prenatal period, i.e., gestational day 12 to parturition on day 21.  Development of steroidogenic capacity in testis was assessed in cohorts of male offspring at 21, 35 and 90 days of age (4-6 animals/treatment group).   Serum testosterone (T) concentrations (ng/ml) were similar in all animals at 21 days of age but were decreased at 35 days (P<0.05) in DEHP-exposed groups (0.57 ±0.1 and 0.58 ± 0.05) and in animals from the smaller BPA dose group (0.5± 0.02) compared to control unexposed male rats (1.3 ± 0.04).  However, serum T concentrations (ng/ml) at 90 days of age were paradoxically elevated (P<0.05) in male rats exposed to the greater DEHP (11±0.6) and BPA doses (12±0.4) compared to control (6±0.6).  Similar to observations at 35 days, serum T concentrations were linked to testicular T production (ng/g testis) in adult animals and were 214±11 and 248±5.5 in animals exposed to the greater DEHP and BPA doses, respectively, compared to control (161±10).  Although DEHP is considered a classical anti-androgen and BPA a xenoestrogen, both chemicals caused elevations (P<0.05) in serum 17β-estradiol concentrations (ng/ml), which measured 0.47±0.007 and 0.43±0.004 in 90 day-old animals from the greater DEHP and BPA dose groups compared to control (0.33±0.004). Data demonstrate that developmental exposure of male rats to EEDs interferes with differentiation of steroid hormone secretion capacity, which persists in the adult testis.  Also, it is likely that both DEHP and BPA have capacity to affect estrogen signaling pathways regulating testicular development.  The findings are important because identification of mechanisms of action associated with EED effects will facilitate the process of risk assessment of the population.  Results may also facilitate development of intervention and prevention strategies that reduce effects of exposures to hazardous substances in the environment.

 

Nothing to Disclose: FMA, PR, KW, CDF, TDB, BTA

14138 1.0000 SUN-0363 A Comparative Assessment of the Effects of Prenatal Exposures to Di (2-ethylhexyl) Phthalate (DEHP) and Bisphenol a (BPA) on Development of Testicular Steroid Hormone Secretion Capacity in Male Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 3:00:00 PM SUN 0363-0376 4811 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Shane M Regnier*1, Xiaojie Zhang2, Essam El-Hashani2, Andrew Kirkley2, Ayanna Williams3, Wakanene Kamau2, Celeste C. Thomas2 and Robert M Sargis1
1University of Chicago, Chicago, IL, 2The University of Chicago, Chicago, IL, 3Kennedy-King College, Chicago, IL

 

The last several decades have witnessed a dramatic deterioration in global metabolic health with the burgeoning worldwide epidemics of obesity and diabetes.  While recent changes in diet and physical activity are central drivers of metabolic disease, increasing attention has turned to contributing factors that may potentiate the effects of lifestyle changes; this includes exposure to endocrine disrupting chemicals (EDCs), exogenous chemicals with the capacity to modulate endogenous hormonal and metabolic signaling pathways.  Tolylfluanid (TF) is a phenylsulfamide fungicide widely used on agricultural crops outside of the United States as well as a booster biocide in marine paints.  Prior work has implicated TF as an environmental glucocorticoid, with the capacity to promote adipocyte differentiation in the 3T3-L1 cell line, and to induce insulin resistance in human and murine adipose tissue through a specific downregulation in insulin receptor substrate-1 (IRS-1).  While these effects suggest a potential role for TF in promoting diabetes, whether cellular effects are recapitulated after in vivo exposure is not known. Furthermore, while adipose tissue plays a central role in metabolism, the ultimate metabolic phenotype is governed by crosstalk between a network of metabolic tissues.  To investigate the hypothesis that TF disrupts metabolic homeostasis in vivo, male C57BL/6 mice were exposed to a diet fortified with TF at 100 ppm for 12 weeks.  Compared to control-fed animals, TF-treated mice had a 23% increase in adiposity that was most pronounced in the perigonadal fat pad.  This augmentation in adiposity was confirmed by DEXA scan where the effect was observed by eight weeks of exposure.  Metabolic cage analysis also revealed a reduction in the diurnal variation in energy usage suggesting some loss of metabolic flexibility.  Interestingly, the effects of TF on adipocyte physiology recapitulated findings obtained ex vivo.  Specifically, dietary supplementation with TF resulted in a significant 30% reduction in adipocyte IRS-1 levels; in addition, adiponectin gene expression was significantly reduced by 31%.  In a related study, C57BL/6 dams were exposed to TF-supplemented diet throughout pregnancy and lactation, and the perinatally exposed pups were then followed to adulthood.  Both male and female pups exhibited reduced body weight at weaning (13% and 11%, respectively), with males exhibiting impaired glucose tolerance in adulthood as measured by intraperitoneal glucose tolerance tests.  These findings suggest that exposure to TF throughout the life span has the capacity to disrupt energy homeostasis in a manner that could contribute to metabolic derangements, including obesity and diabetes.  Moreover, the current data supports efforts to characterize human exposure to TF and its potential metabolic consequences.

 

Disclosure: RMS: Advisory Group Member, CVS Caremark. Nothing to Disclose: SMR, XZ, EE, AK, AW, WK, CCT

PP18-3 14235 3.0000 SUN-0366 A Effects of the Endocrine Disruptor Tolylfluanid on Global Energy Metabolism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 3:00:00 PM SUN 0363-0376 4811 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Alina Marie Hamilton*1 and Robert K Dearth2
1University of Texas Rio Grande Valley, Edinburg, TX, 2University of Texas-Pan American, Edinburg, TX

 

Manganese (Mn) is an essential nutritional element readily available in the diet and required for normal physiological processes. Mn has been shown to be associated with signaling pathways in the breast that also play important roles in promoting carcinogenesis. Previously we showed that rats exposed to manganese (Mn) have increased serum estradiol (E2) levels accelerating mammary gland development resulting in adult hyperplasia.  However, it is not known whether Mn can directly impact E2 regulated pathways within the breast resulting in a more aggressive cancer. We used the estrogen receptor- α positive (ERα+) human breast cancer cell line, MCF-7, to determine the impact dietary levels of Mn have on cancer growth, invasion, and resistance to tamoxifen (TAM).  To determine the effects of Mn on breast cancer cell growth, MCF-7 cells were cultured and treated with either 25nM of MnCl2 or 17β-estrodiol (E2) as a stimulating control for 5 days. Mn treatment significantly (p<0.01) increased cell proliferation at 5 days compared to non-treated controls.  A scratch wound healing assay was used to characterize the cellular migration of cells treated with Mn. Mn treatment significantly (P<0.01) increased cell migration; as indicated by a rapid closing of the gap compared to non-treated cells at 96 hours. Thus, suggesting an increase in cell motility and aggressive behavior due to Mn. To determine if Mn could contribute to chemotherapy resistance, MCF-7 cells were treated with either 25nM of MnCl2, E2, E2 + the selective estrogen receptor inhibitor TAM or Mn + TAM. Interestingly, Mn attenuated the ability of TAM to effectively kill breast cancer cells compared to TAM alone.  Western blot analysis revealed Mn increased phosphorylation (p) of p42/44 MAPK (p<0.01) and pERα (ser118), both previously shown to be elevated in breast cancer cell lines resistant to endocrine therapy. Thus, while our data is preliminary, it suggests exposure to Mn increases cell proliferation, migration, and resistance in ERα+ breast cancer cells through activation of MAPK and subsequent phosphorylation of ERα. Thus suggesting that excess daily intake of Mn may contribute to a more aggressive breast tumor that is resistant to treatment.

 

Nothing to Disclose: AMH, RKD

16463 4.0000 SUN-0367 A Manganese Promotes a More Aggressive Phenotype in ER-Positive Breast Cancer through Phosphorylation of MAPK and ERα in Vitro 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 3:00:00 PM SUN 0363-0376 4811 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Shyama Majumdar*1, Wen Yang Hu1, Hung-ming Lam2, Andrew Schuster3, Nicole Ortogero3, Guang Bin Shi1, Yu Wen Liu4, Mario Medvedovic2, Kevin P White4, Wei Yan3, Shuk-Mei Ho2 and Gail S. Prins1
1University of Illinois at Chicago, Chicago, IL, 2University of Cincinnati College of Medicine, Cincinnati, OH, 3University of Nevada School of Medicine, Reno, NV, 4University of Chicago, Chicago, IL

 

There is compelling evidence that estrogens play roles in prostate development and cancer. We previously showed that human prostate stem and progenitor cells express estrogen receptors (ERα, ERβ and GPR30) and exhibit a proliferative response to estradiol-17β (E2) and to bisphenol A (BPA), suggesting that E2/BPA directly targets this cell population1,2. Importantly, brief developmental BPA exposure of these cells at environmentally relevant doses increases their carcinogenic susceptibility in vivo 2.  However, the downstream signaling targets of E2/BPA are yet to be defined. Small non-coding RNAs (sncRNAs) have been implicated in prostate cancer. In addition to widely studied miRNAs, increasing evidence suggests that small nucleoloar RNAs (SNORDs/SNORAs) may have malfunctioning roles in human malignancy. To evaluate whether E2 or BPA may target sncRNAs, we herein utilized human prostate stem/progenitor cells enriched from primary prostate epithelial cells (PrEC) of young, disease-free donors using 3-D prostasphere (PS) culture. Small RNA-seq was used for the initial sncRNAs screening of 0.1 nM E2 or 10 nM BPA treated PS cells from pooled cells of 3 different donors. Although no effect was seen on small non coding rRNAs or tRNAs, E2/BPA treatment down-regulated 37 miRNAs, 2 endo-siRNA, 13 mito-sRNA clusters, 31 SNORDs, 42 SNORAs and 8 scaRNAs and up-regulated other sncRNAs including 87 miRNAs, 21 mito-sRNA clusters and 22 SNORDs. These results were validated in a separate treatment set by Affymetrix gene array, DNA and histone methylation analyses on 0.1 nM E2, 10, 200, or 1000 nM BPA treated PS cells from three individual donors. Microarray and global hierarchical clustering analysis identified a unique block of 26 transcripts downregulated by all E2/BPA treatments across 3 donors.  Of these, 15 were SNORDs or SNORAs. While, a 5’CpG island was identified at 0.2-5kb upstream of several SNORDs, bisulfite sequencing analysis found no change in DNA methylation at these regions. Global histone methylation analysis by ChIP-seq revealed an increase or gain of H3K4M3 activation marks by both E2 and BPA treatment in 5 genes while a decrease or loss of H3K4M3 marks was observed with E2 and BPA treatments for 59 genes including 4 SNORDs. Amoung the SNORDs with loss of H3K4M3 activation marks was SNORD116-6, the most down regulated SNORD transcript in the Affymetrix gene array.  These data suggest that reprogrammed histone methylation marks by E2 or BPA treatments may be proximal events in modifying SNORD transcription in prostate stem/progenitor cells. Together, the present findings indicate  that sncRNAs are reprogrammed by E2 and BPA exposures in human prostate stem/progenitor cells and that interactions between epigenetic mechansisms may underpin altered stem cell memory leading to increased prostate cancer risk throughout life.

 

Nothing to Disclose: SM, WYH, HML, AS, NO, GBS, YWL, MM, KPW, WY, SMH, GSP

17023 5.0000 SUN-0368 A Role of Small Non-Coding RNAs in Estradiol and Bisphenol A Reprogramming of Human Prostate Stem/Progenitor Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 3:00:00 PM SUN 0363-0376 4811 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Viktoria Y Topper*1, Deena M Walker2 and Andrea C Gore1
1University of Texas at Austin, Austin, TX, 2Univ of Texas - Austin, Austin, TX

 

Endocrine-disrupting chemicals (EDCs) are ubiquitous environmental contaminants, detectable in virtually all humans. Exposures to low doses of EDCs during the critical period of brain sexual differentiation cause latent physiological and reproductive abnormalities, and changes in hypothalamic gene and protein expression. The goal of current work was to investigate the underlying molecular changes caused by prenatal PCB exposure, through measures of microRNA and associated genes in hypothalamus of adult rats. MicroRNAs, which are evolutionarily conserved small noncoding RNAs, undergo developmental changes in expression, affect hormone signaling pathways, and have been recently implicated in organizational effects of hormones on the brain. I hypothesize that developmental exposure to a mixture of PCBs with estrogenic activity causes alterations in the levels of hypothalamic estrogen-responsive microRNAs, with downstream effects on target gene expression. Male and female Sprague-Dawley rats were exposed to Aroclor 1221, an estrogenic PCB (A1221, 1mg/kg); Estradiol Benzoate, an estrogenic control, (EB, 50ug/kg), or vehicle (DMSO) through administration to the pregnant dam on gestational days 16 and 18. The experimental subjects were euthanized on postnatal (P) day P15, P30, P45, and P90, and the expression of select microRNAs (let-7a, let-7b, mir-124a, mir-145, mir-7a, mir-219, mir-132, mir-9, sno-202) was analyzed in the medial preoptic nucleus (MPN) and ventromedial nucleus (VMN). Initial results in the MPN indicate that prenatal PCBs affect microRNA expression in a sex and age specific manner. Notably, compared to control, treatment with EB or A1221 increases circadian mir-219 and mir-132 expression during pubertal development in males (P45) and decreases their expression in females (P30). Robust age effects were found for mir-7, mir-219, sno-202, and mir-132, all peaking in P15 rats. Also, mir-9 expression increased through development. Developmental markers, body and endocrine tissue weights, gene expression of the microRNAs/associated gene targets (circadian genes, nuclear hormone receptors, growth factors), and serum hormone assays (testosterone, estrogen, LH) will be used in bionetwork analysis to show region-specific changes and sexual dimorphisms in MPN and VMN. These initial results suggest that prenatal EDCs change developmental patterns of microRNA expression in the hypothalamus.

 

Nothing to Disclose: VYT, DMW, ACG

15475 8.0000 SUN-0371 A Fetal Exposures to Environmental Endocrine Disruptors Cause Long-Term Microrna Reprogramming of the Hypothalamus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 3:00:00 PM SUN 0363-0376 4811 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Pheruza Tarapore*1, Jun Ying1, Bin Ouyang2, Barbara Burke2, Bruce Bracken2 and Shuk-Mei Ho1
1University of Cincinnati College of Medicine, Cincinnati, OH, 2University of Cincinnati, Cincinnati, OH

 

Human exposure to bisphenol A (BPA) is ubiquitous. Animal studies found that BPA contributes to development of prostate cancer, but human data are scarce. Our study examined the association between urinary BPA levels and Prostate cancer and assessed the effects of BPA on induction of centrosome abnormalities as an underlying mechanism promoting prostate carcinogenesis. The study, involving 60 urology patients, found higher levels of urinary BPA (creatinine-adjusted) in Prostate cancer patients (5.74 g/g [95% CI; 2.63, 12.51]) than in non-Prostate cancer patients (1.43 g/g [95% CI; 0.70, 2.88]) (p = 0.012). The difference was even more significant in patients <65 years old. A trend toward a negative association between urinary BPA and serum PSA was observed in Prostate cancer patients but not in non-Prostate cancer patients. In vitro studies examined centrosomal abnormalities, microtubule nucleation, and anchorage-independent growth in four Prostate cancer cell lines (LNCaP, C4-2, 22Rv1, PC-3) and two immortalized normal prostate epithelial cell lines (NPrEC and RWPE-1). Exposure to low doses (0.01-100 nM) of BPA increased the percentage of cells with centrosome amplification two- to eight-fold. Dose responses either peaked or reached the plateaus with 0.1 nM BPA exposure. This low dose also promoted microtubule nucleation and regrowth at centrosomes in RWPE-1 and enhanced anchorage-independent growth in C4-2. These findings suggest that urinary BPA level is an independent prognostic marker in Prostate cancer and that BPA exposure may lower serum PSA levels in Prostate cancer patients. Moreover, disruption of the centrosome duplication cycle by low-dose BPA may contribute to neoplastic transformation of the prostate.

 

Nothing to Disclose: PT, JY, BO, BB, BB, SMH

16923 9.0000 SUN-0372 A Exposure to Bisphenol a Correlates with Early-Onset Prostate Cancer and Promotes Centrosome Amplification and Anchorage-Independent Growth in Vitro 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 3:00:00 PM SUN 0363-0376 4811 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Satoshi Takahashi*1, Hiroko Okinaga1, Maiko Murakami1, Yamato Mashimo1, Yuko Fujimaki1, Koji Morita1, Makoto Kinoshita1, Shin Fujimori1, Tamio Teramoto2 and Toshio Ishikawa1
1Teikyo University School of Medicine, Tokyo, Japan, 2Teikyo University Academic Research Center, Tokyo, Japan

 

Background: Aryl hydrocarbon receptor (AhR, a.k.a. dioxin receptor), is a transcription factor activated by xenobiotics (e.g. tetrachlorodibenzo-p-dioxin (TCDD)), dietary constituents (e.g. indole-3-carbinol), endogenous substances (e.g. bilirubin), etc. We have recently discovered that serum samples obtained from Graves’ disease patients taking methimazole (MMI) robustly induce AhR activation, due to an MMI metabolite 3-methyl-2-thiohydantoin (MTH). Because some studies suggested inhibitory effects of AhR ligands on breast cancer cell proliferation, we asked how MTH could affect the growth of MCF-7 cells. Also, because of the controversial issue regarding the crosstalk between AhR and estrogen receptor (ER)-α, we tested whether MTH and TCDD could alter ERα activity in MCF-7 cells, in the experimental setting where possible confounding factors that might interfere with AhR and ERα activities were minimized.

Methods: MCF-7 cells were maintained in Dulbecco’s modified Eagle’s medium containing fetal bovine serum (FBS) and antibiotics, but during the following experiments cells were cultured in either charcoal-stripped FBS or adult human serum. In the proliferation assay using 3,[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide (MTT), cells were treated with 1 μM TCDD or 80 μM MTH. Six days later, 1 mg/mL MTT was added for 3 hr and the amount of formazan was colorimetrically quantified. In the reporter gene assays, cells were transfected with a firefly luciferase reporter plasmid bearing AhR-response elements, ER-response elements, or neither of these elements, along with an internal control Renilla luciferase gene, and treated with the AhR ligands or 1 nM 17β-estradiol (E2). Twenty hours later, normalized firefly luciferase activity (firefly/Renilla luciferase luminescence) was measured.

Results: In the MTT proliferation assay, MTH as well as TCDD inhibited proliferation of MCF-7 cells. In the reporter gene assays performed under our experimental setting, MTH and TCDD induced AhR activation as expected but neither of them changed ERα-mediated transcription, whereas E2 enhanced ERα-dependent transcription as anticipated but did not alter AhR activity.

Discussion and Conclusions: MTH and TCDD exhibited antiproliferative effects on MCF-7 cells in vitro, presumably independent of ERα activity. Of note, the MTH concentration that we used in our experiments can actually be observed in the serum of MMI-treated patients, suggesting that MTH (or MMI) might be used as a drug against breast cancer. Because MMI has been clinically used for decades relatively safely despite its occasional adverse effects, our findings imply that the block and replacement regimen, in which a large dose of MMI and a sufficient amount of levothyroxine are co-administered to maintain euthyroidism, might be useful against breast cancer, although further studies are definitely needed.

 

Nothing to Disclose: ST, HO, MM, YM, YF, KM, MK, SF, TT, TI

15840 10.0000 SUN-0373 A Antiproliferative Effects of 3-Methyl-2-Thiohydantoin, a Methimazole Metabolite That Activates Aryl Hydrocarbon Receptor, on MCF-7 Breast Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 3:00:00 PM SUN 0363-0376 4811 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Vinothini Janakiram*1, Yuet-Kin Leung2 and Shuk-Mei Ho1
1University of Cincinnati College of Medicine, Cincinnati, OH, 2University of Cincinnati, Cincinnati, OH

 

Exposure to environmental endocrine disruptors such as bisphenol A (BPA) has been shown to increase breast cancer risk and alter the window of cancer susceptibility. A number of studies have also suggested that lifestyle, especially adopting high fat diet, could predispose to higher breast cancer (BCa) risk. Though BPA and high-fat diet exposure have been independently investigated, the synergistic action of both factors in breast cancer has not been determined. The objective was to investigate whether a specific high fat diet has differential action on potentiating the BPA effects in elevating the breast cancer risk. Cancer risk was evaluated using the postnatal day (PND) 50-DMBA induced mammary tumorigenesis Sprague-Dawley rat model. Based on the previous study we confirmed in utero exposure to 25 µg/kg/BW of BPA dose with HFB background was most effective in reprogramming the mammary gland to mammary tumor risk in adult life. To investigate whether a specific high fat diet have differential action on potentiating the BPA effects in elevating the breast cancer risk we tested 3 different high fat diets, high fat olive oil (HFO), high fat butter (HFB) and high fat safflower oil (HFS)  with or without 25 µg BPA/kg/BW. Non-monotonic BPA dose 25 µg BPA/kg/BW on different high fat diet background did not affect sex ratio of live birth, time of vaginal opening in daughters and serum concentrations of estradiol or progesterone in daughters on PND21. Interestingly, HFB and HFS with 25 µg BPA/kg/BW exposed day 21 wholemount showed significant increase in number of terminal end buds (TEB) compared to the control. There are no significant changes in terms of epithelial area, epithelial outgrowth, ductal length, ductal out growth & interductal fat pad area. Highest tumor incidence (76.9%) was found in HFB + BPA group. In terms of tumor multiplicity, latency, no significant difference was found between each of the HFD (high fat diet) and HFD + BPA groups. Most interestingly we found high fat butter diet has lowest tumor incidence (20%) among groups. In utero exposure to BPA under a high butter-fat background resulted in a non-monotonic enhancement of cell proliferation and TEB development that was associated with increased incidence of DMBA-induced mammary tumor in adulthood. Based on our results, though HFB alone has protective against breast cancer risk, when combine with BPA it modify the impact to higher breast cancer risk in adult life.

 

Nothing to Disclose: VJ, YKL, SMH

17024 11.0000 SUN-0374 A In Utero Exposure of Non-Monotonic Dose of Bisphenol a and High Fat Diets: High Fat Butter; High Fat Olive Oil; High Fat Safflower Oil on Breast Cancer Risk 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 3:00:00 PM SUN 0363-0376 4811 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Neeraj Kumar*
Shri Ramswaroop Memorial University, Barabanki, India

 

Objective: To investigate the effects of BPA on oxidative damage in terms of antioxidant enzymes activity level in different regions of the rat brain. 

Background: The ever increasing uses of electronic gadgets are becoming a widespread source of Bisphenol-A accumulation. As studies have been reported that low level BPA accumulation may produce neurological effects but still limited studies have re-examined for its adverse effects in terms of acute exposure from electronic devices.

Methodology: In this study, BPA migration was estimated through physio-chemical parameters and leachate (equivalent to 4mg/kg body weight) was used for animal dosing. Three groups of Albino Wister rats (190+20grm) were used for control, sham, and treated. The antioxidant enzymes including superoxide dismutase (Mn-SOD), catalase (CAT), glutathione peroxidase (GPx) and reduced glutathione level (GSH) were measured in different brain regions i.e. corpus striatum, frontal cortex, thalamus and midbrain.

Results: No significant changes were observed in most of the brain regions yet the level of GPx activity in corpus striatum (29.65±0.98 nmoles/min/mg protein) and level of GSH activity in frontal cortex (2.33±0.12 µmoles/g protein) was found to decrease significantly (p<0.05) when compared to controls. In addition, no significant effects were observed for the oxidative damage in brain regions of sham group when compared to control group.

Conclusion: Thus study suggests that acute exposure (4mg/kg body weight per day up to 28 days) of BPA does not induce significant oxidative damage in the rat’s brain. Furthermore, study might re-examine before affirm the final remark for subscribers and regulatory bodies at similar doses.

 

Nothing to Disclose: NK

11255 12.0000 SUN-0375 A Acute Exposure of BPA from Electronic Gadgets Does Not Induce Oxidative Stress in the Rat's Brain 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 3:00:00 PM SUN 0363-0376 4811 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Young Ah Lee*1, Seung Joon Chung2, Haewoon Jung3, Gyung Min Lee3, Hwa Young Kim3, Jieun Lee3, Juyoung Yoon3, Sanghyuk Bae4, Jin Hee Kim5, Yun-Chul Hong6, Choong Ho Shin7 and Sei Won Yang7
1Seoul Ntl Univ Childrens Hospita, Seol, Korea, Republic of (South), 2Seoul National University Children's Hospital, 3Seoul National University Children’s Hospital, 4Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 5Environmental Health Center, Seoul, Korea, Republic of (South), 6Institute of Environmental Medicine, Seoul National University Medical Research Center, Seoul, Korea, Republic of (South), 7Seoul National University Children's Hospital, Seoul, Korea, Republic of (South)

 

Introduction: Perfluorinated compounds (PFCs) have been widely used in a variety of consumer products such as fabrics, carpets, surfactants, paper coatings, and cosmetics. Concerns of the potential health consequences of these compounds have been raised. The aim of this study was to investigate the relationship between exposure level of PFCs and growth parameters in Korean 2-year old children.

Methods: Three hundred sixty children (189 boys, 171 girls) aged 1.9 to 2.2 years, who were born as appropriate for gestational age infants, were enrolled. Height and weight Z-scores at 2years of age, birth weight Z-score, midparental height (MPH), and maternal or paternal body mass index (BMI) Z-scores were assigned on the basis of the 2007 Korean National Growth Charts. Bone age was assessed using the Greulich and Pyle method. Fifteen kinds of PFCs were measured in blood serum.

Results: Four compounds including perfluorooctanoic acid (PFOA), perfluorononanoic acid (PFNA), perfluorohexane sulfonic acid (PFHxS), and perfluorooctane sulfonic acid (PFOS) were detected in more than 99% of the samples. Perfluorodecanoic acid (PFDA), perfluoroundecanoic acid (PFUnDA), perfluoroheptanoic acid (PFHpA), perfluorobutanesulfonic acid (PFBS), and perfluorododecanoic acid (PFDoDA) were detected in more than half of the samples with detection rates of 92.8, 89.7, 78.6, 66.9, and 52.5%, respectively. Among the five compounds (PFOA, PFNA, PFHxS, PFOS, and PFDA) detected in more than 90% of the samples, each compound was significantly correlated with all the other four compounds (all P < 0.001). Height Z-scores were negatively associated with log PFOA (P < 0.001), log PFNA (P = 0.020), log PFDA (P = 0.004), log PFHxS (P < 0.001), and log PFOS (P = 0.001). Weight Z-scores were negatively associated with log PFNA (P < 0.001) and log PFDA (P = 0.005). Interestingly, log PFBA (P = 0.033), log PFHxA (P = 0.047), log PFHpA (P = 0.021), log PFOA (P = 0.024), log PFNA (P = 0.024), log PFDA (P = 0.024), and log PFOS (P = 0.019) were significantly related to the decrease in weight Z-scores from birth to 2 years of age. After adjusting for bone age, birth weight, and MPH, higher exposure to log PFOA (P = 0.001), log PFDA (P = 0.008), log PFHxS (P = 0.001), and log PFOS (P = 0.002) were significantly related to shorter height at 2 years of age. After adjusting for bone age, birth weight, and paternal BMI, and duration of breast feeding, higher exposure to log PFDA (P = 0.022) was significantly related to lower weight at 2 years of age.

Conclusions: Two-year-old children with higher PFOA, PFDA, PFHxS and PFOS levels appear to be smaller, after adjusting for birth weight and genetic height potential. Further longitudinal studies are needed to elucidate the putative casual relationships between PFCs and growth in childhood. The mechanism leading to adverse outcomes after exposure to PFCs also needs to be elucidated.

 

Nothing to Disclose: YAL, SJC, HJ, GML, HYK, JL, JY, SB, JHK, YCH, CHS, SWY

14347 13.0000 SUN-0376 A Inverse Relationship Between Perfluoroalkyl Compounds Concentrations and Growth in 2-Year-Old Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Sunday, June 22nd 3:00:00 PM SUN 0363-0376 4811 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Madiha M Alvi*1, Aaron L. Klein2, Alison Schneider3, Matthew P. Gilbert1, Joel J Schnure1, Muriel H Nathan1, Michael J. DeSarno4, Scott R. Anderson5 and Annis M. Marney1
1The University of Vermont College of Medicine, South Burlington, VT, 2Good Samaritan Regional Health Center, Mount Vernon, IL, 3McKayDee Hospital, Ogden, UT, 4The University of Vermont College of Medicine, VT, 5The University of Vermont College of Medicine, Burlington, VT

 

Background: The incidence of thyroid nodules has risen to 19-67% in United States, and fine needle aspiration (FNA) remains the procedure of choice for further evaluation. This indicates a critical need to provide Endocrinology and Cytopathology fellows in training with comprehensive educational experience for managing thyroid nodules in practice. The Endocrine Division and the Pathology Department collaborated to design a novel Multidisciplinary Thyroid Biopsy Clinic (MTBC) to provide Rapid on-site assessment (ROSA) of FNA specimens, to improve the fellows’ educational experience, and to provide high quality care to our patients at a lower cost. The aim of this study was to evaluate the clinical outcomes effect of this novel MTBC which began in July, 2009.

Methodology: We performed a retrospective chart review of patients 2 years before (07/2007-06/2009) and 2 years after (07/2009-06/2011) instituting the MTBC. Since patients undergoing FNA of thyroid nodules at outpatient radiology always had ROSA of specimens for adequacy available from 2007-2011, we used this group as our control. Secondary analysis of surgical rates, financial cost and time required were also estimated.

Results: After implementation of MTBC and ROSA, we observed the following. 1) The number and percent of total thyroid nodules biopsied at the MTBC increased compared to radiology (from n=215 (46.5%) to n=320 (61%)). 2) Rates of non-diagnostic thyroid FNA biopsies in Endocrinology fell from 43% prior to ROSA to 13% after (p value <0.001). There was a concordant increase in benign nodules from 46% to 74% (p value < 0.001). 3) The size of nodules biopsied in the MTBC was smaller compared to before (mean size 19.94 mm as compared to 23.63 mm, p value < 0.001). 4) There was a decrease in surgical referrals after non-diagnostic cytopathology (from n=20 (21%) to n=0). An important limitation to our study is that the change/update in Bethesda classification system implemented during our study period (2009) may have reduced non-diagnostic and atypical results. In addition we did not analyze biopsy results from surgical clinics.

Conclusions: Implementation of a MTBC for Endocrinology and Cytopathology fellows in training improved the educational experience and confidence of the physicians-in-training while improving patient outcomes. On average our Endocrine and cytopathology fellows perform biopsy of approximately 50 nodules independently per year, or 100 over a 2 year fellowship.  Our comprehensive thyroid educational experience includes hands on thyroid ultrasound, FNA procedure with ROSA of specimens by pathologists, biopsy slide review at thyroid biopsy conference with pathologists, and review and discussion of patients’ cases at once monthly Radiology, Endocrinology, Pathology, Surgery (REPS) conference.  Most importantly, ROSA leads to better patient experience by reducing repeat FNA and unnecessary surgery.

 

Nothing to Disclose: MMA, ALK, AS, MPG, JJS, MHN, MJD, SRA, AMM

14641 1.0000 SUN-0453 A Multidisciplinary Thyroid Biopsy Clinic at the University of Vermont – a Comprehensive Educational Initiative and Experience 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0453-0460 4812 1:00:00 PM Quality Improvement Research/Patient or Provider Education Poster

Lena Shalem*1, Jonah Feldman1, Gary Rothberger1, Virginia Peragallo-Dittko2 and Sarah Walmsley2
1Winthrop University Hospital, Mineola, NY, 2Winthrop-University Hospital, Mineola, NY

 

Excessive laboratory testing is a well-known problem in medical practice, particularly in the inpatient setting(1).  The high incidence of wasteful HbA1c testing has been attributed to the implementation of HbA1c based performance measures(2).  In 2009, our 591-bed teaching hospital began a quality improvement process that culminated in February 2013 when the hospital was awarded Joint Commission Accreditation in Advanced Inpatient Diabetes Care.  One of the requirements was that all patients with diabetes have a HbA1c test on admission unless there was another HbA1c available from the previous 90 days.  The hospital embarked on multiple electronic and educational performance improvement activities to meet this requirement.  Our goal was to study the influence of quality improvement on wasteful laboratory testing by examining the change in the rate of unnecessary repeat HbA1c tests over this four-year period. 

We performed a retrospective analysis using data from our institution’s computerized laboratory system.  We obtained all HbA1c results from tests performed on inpatients from 2009 through 2012.  Our primary outcome measure was the repeat rate, or the proportion of total HbA1c tests that were performed less than 90 days from a previous test.  Over this period, 17.7% of the total testing was unnecessary.  Notably, there was a trend toward a decrease in the monthly repeat testing rate from the baseline period to the culmination of the quality improvement process.  In the beginning of 2009, 21.44% of the HbA1c tests were performed less than 90 days from a previous test, with that number decreasing to 13.04% (p< .0001) by the end of 2012, just prior to the Joint Commission site visit.  This decrease occurred without any interventions intentionally targeting the reduction of wasteful ordering.   

Our results are compatible with previously published reports that have shown a similarly high rate of unnecessary repeat HbA1c testing. However, contrary to published speculation, we found that quality improvement did not increase the rate of wasteful HbA1c testing; in fact there was a statistically significant decrease in wastefulness.  Though quality improvement processes tend to penalize the underutilization of resources without rewarding the avoidance of overutilization, we believe that in this case the efficiency and reliability introduced by the quality improvement process led to an overall decrease in the rate of unnecessary testing.  

 

Nothing to Disclose: LS, JF, GR, VP, SW

11262 2.0000 SUN-0454 A Quality Improvement in Inpatient Diabetes Care Decreases Wasteful HbA1c Testing 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0453-0460 4812 1:00:00 PM Quality Improvement Research/Patient or Provider Education Poster

Ploutarchos Tzoulis*1 and Pierre-Marc Gilles Bouloux2
1Royal Free Hospital, London, United Kingdom, 2UCL Medical School, London, United Kingdom

 

Introduction: Hyponatraemia is the most common electrolyte disorder encountered in hospitalised patients. There is paucity of data about the efficacy of current management of hyponatraemia in hospitalised patients in a real-life clinical setting.

Methods: This observational study was conducted in a large teaching hospital in London and included all adult inpatients with serum sodium (sNa) ≤ 128 mmol/l at any point during hospitalisation over a 3-month period (1st March 2013 – 31st May 2013). A retrospective case notes review was conducted with the aim of evaluating the effect of the current management of hyponatraemia on correction of sNa. All variables were analysed as median (interquartile range; IR) values.

Results:139 patients (69 males, 70 females) aged 74 (59-82) years developed sNa ≤ 128 mmol/l over the study period. The aetiology of hyponatraemia was recorded only in 58 cases (41.7%) with 25 patients being classified as having hypovolaemic hyponatraemia, 21 as SIADH and 12 as hypervolaemic hyponatraemia. The admission sNa was 130 (126-134) mmol/l, the nadir sNa during hospitalisation was 125 (122-127) mmol/l and sNa on discharge 132 (128-136) mmol/l. The in-hospital mortality rate was 17.3% and median length of hospital stay was 12 days. 

At 24 hours after development of sNa ≤ 128 mmol/l, sNa concentration was measured in 78.4% of patients with a change in sNa levels of +2 (0 to +4.5) mmol/l. A decrease in sNa levels was recorded in 20.2% of patients, while 8.2% of patients had sNa corrected by > 8 mmol/l, either due to treatment with normal saline in 2/3 of cases or due to haemodialysis in 1/3 of cases.

At 48 hours after development of sNa ≤ 128 mmol/l, sNa was measured in 77.7% of patients with a change of +3 (0 to +6) mmol/l. Reduction in sNa was recorded in 22.2% of cases with no cases of correction by > 18 mmol/l. Among hypovolaemic patients, the 48-hour change in sNa was +3 (0 to +8) mmol/l with reduction of sNa in 16% of cases. Among patients with SIADH, the 48-hour change was +1 (-1.5 to +5) mmol/l with reduction in sNa levels in 33.3% of cases.

With regards to sNa levels ≥ 132 mmol/l, 69.8% of patients reached this target with required time being 3 (2-6) days. Among hypovolaemic patients, the time period needed to reach sNa threshold of 132 mmol/l was 3 (1.5 - 5) days with an estimated rate of sNa change of 3 (1 –7.5) mmol/l/day. Among patients with SIADH, the required time to reach the cut-off of 132 mmol/l was 6.5 (3-10) days with an estimated rate of sNa change of 1.2 (1 - 2.5) mmol/l/day.

Discussion: This study demonstrated a slow rate of correction of sNa, especially in SIADH, with one third of patients with SIADH having further reduction in sNa concentration during the first 48 hours. Hyponatraemia was frequently undertreated, especially in cases of SIADH. Therefore, this study highlights the need for more intensive management of hospitalised patients with hyponatraemia.

 

Nothing to Disclose: PT, PMGB

13443 3.0000 SUN-0455 A Efficacy of Current Management of Hyponatraemia in Hospitalised Patients: Results from an Observational Study in a UK Teaching Hospital 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0453-0460 4812 1:00:00 PM Quality Improvement Research/Patient or Provider Education Poster

Timothy W. Bodnar*, Jennifer J. MacDonald, Preethi V. Patil and Roma Yogesh Gianchandani
University of Michigan Health System, Ann Arbor, MI

 

Background: Glycemic control is an important quality care initiative and patient safety issue in hospitals.  However, optimal management of diabetes and hyperglycemia in the inpatient setting is difficult to achieve.  Lack of appropriate knowledge has been identified as a key barrier to improved management among trainees.  Necessary knowledge and skills are not being developed in medical school and these deficits can persist into residency training and beyond. We hypothesized that adding an interactive seminar in hospital diabetes management to the third-year medical student (M3) curriculum (which previously had no such formal training) would improve knowledge and comfort in managing diabetes in the inpatient setting in a durable way.

Methods: A comprehensive seminar was developed for the M3 Seminar Series, a weekly mandatory lecture for all M3 students.  This seminar included a didactic portion on the fundamentals of inpatient diabetes and hyperglycemia management, followed by real-world interactive cases presented using an electronic audience response system.  Multiple choice questions were reviewed with the students at the end of the session to highlight key learning objectives. To assess durability of knowledge gained, students were given a 15-item multiple-choice quiz several months later as fourth-year (M4) students.  They were also asked to rate their comfort with inpatient diabetes management on a 4-point Likert scale.  Responses were compared to the same questions given to the previous class of M4s at the same point in the academic year (the previous class did not receive any formal inpatient diabetes training during their M3 or M4 years).  At the time of the quiz/survey, both groups had received the same experiential training in inpatient diabetes management during their clinical rotations.

Results: 175 students completed the voluntary, anonymous quiz/survey, 100 students from the control group (who had not received the seminar training) and 75 students from the experimental group (who had received the seminar training).  This represented a 60% response rate for the control group and a 44% response rate from the experimental group.  The mean number of correct answers (out of 15 questions) in the control group was 8.76 ± 2.53 compared to 9.15 ± 2.31 in the experimental group (p=0.30).  There was no significant difference in student-reported comfort in managing diabetes in the inpatient setting.

Conclusion: Adding a single seminar on hospital diabetes and hyperglycemia management in the M3 year may not durably improve medical student knowledge or change comfort level in this important subject.  Repeated interactions and greater focus on this topic during clinical rotations may be required.  More sustained methods of exposure to this subject need to be evaluated.

 

Nothing to Disclose: TWB, JJM, PVP, RYG

14612 4.0000 SUN-0456 A Improving Knowledge of Hospital Diabetes Management Requires More Than a Seminar 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0453-0460 4812 1:00:00 PM Quality Improvement Research/Patient or Provider Education Poster

Gloria Wu*1, Vinna Nam2, Kimberly D. Pham3, Byongdo Kim4 and Stephanie Tang5
1Stanford Hospital & Clinics, San Jose, CA, 2University of California, Berkeley, San Jose, CA, 3University of California, Berkeley, Berkeley, CA, 4University of California, Berkeley, 5Stanford University

 

Diabetes affects 26 million Americans but 96 million in China.  Prediabetes affects approximately 80 million Americans.  Obesity characterizes a majority of Type 2 diabetics in the US. 30-35% of Americans have Metabolic Syndrome which is a risk factor for diabetes. Asians are particularly at risk for the Metabolic Syndrome.  In 2013, $660 billion was spent in the US for fast food.  Approximately $1.7 B was spent on Asian fast food in the US.

Purpose: To create a smart phone app for Asian fast food with descriptions about calories, glycemic index and BMI indicator.   

Methods: Using Asian fast food take out menus via Google, we created a list of 100 Asian fast foods. Java was the programming language used.  For the "Asian Diet Watch" app, we used the Asian fast food industry norm of 8 ounces per serving. Using Google, we averaged the calorie count from the top four Asian menus per menu item. Glycemic Index was determined using Google search engine data for each food item. Body mass index was calculated if the user inputs height and weight.  There is a screen for activity score as well.  The user’s BMI is linked to obesity score using World Health Organization statistics.  No paid advertising was used.

Results: "Asian Diet Watch" was generated.  This was uploaded on Google Play using a gmail account and password.  Uploaded August 20, 2013, the app generated increasing numbers with each month.  Google analytics show that a total of 472 downloads were generated in 5 months. Information about number of "non-upload visitors " is unavailable.  Our downloads showed: US 33.05%,  Malaysia 10.17%, Singapore 9.96%, United Kingdom 4.24%, Philippines 3.60%. This is in contrast to the number of visitors on health and fitness apps: US 16.96%,  South Korea 5.10%, Japan 4.73%,  Germany 3.83%, United Kingdom 2.88%.

Discussion: To our knowledge, this is the only Asian food diet app available on Google Play. Androids are more widely sold in Asia than Apple iPhones, thus Android apps may be more common in Asia than in the US. Google is the predominant search engine in the world and US.  This app is easily found on Google Play.  While American interest in this app is the majority, the combined Asian interest is 2/3 of the US.  Android apps are written with Java programming language taught in high school whereas Apple iOs platform software language requires college or more advanced programming skills.  Thus Android apps are easier to create than Apple apps.  Thus Android Apps may be an accessible and  inexpensive tool for  international outreach for patients and the public.

 

Nothing to Disclose: GW, VN, KDP, BK, ST

16055 5.0000 SUN-0457 A New Asian Diet Smartphone App to Target Patients with Metabolic Syndrome and Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0453-0460 4812 1:00:00 PM Quality Improvement Research/Patient or Provider Education Poster

Amy Larkin*1, Anne Le1, Rob Bartel2, Anne L Peters3, Carol H Wysham4 and Lawrence Blonde5
1Medscape Education, 2The Endocrine Society, Chevy Chase, MD, 3Keck School of Medicine of the University of Southern California, Los Angeles, CA, 4University of Washington, 5Ochsner Medical Center, New Orleans, LA

 

Introduction:Despite major recent advances in type 2 diabetes (T2D) care, many patients do not achieve targeted glycemic targets. There is a need for treatments that offer effective glucose control with a low risk for hypoglycemia while addressing comorbid conditions associated with T2D. Incretin agents have been shown to be safe and effective in the treatment of patients with T2D, are included in recognized treatment algorithms, and are therefore an option for some patients. A study was conducted to determine if online educational interventions could improve knowledge about and/or appropriate use of incretin agents in patients with T2D by primary care clinicians (PCPs) in the United States (US) and outside the US (OUS).

Methods:  A cohort of US- and OUS-practicing PCPs participated in an online certified medical educational intervention (a CME activity) consisting of an expert panel discussion on the practical use of incretin agents. The educational activity was designed to address knowledge and practice gaps in the care of patients with T2D. The outcomes survey method, previously validated to measure performance-level outcomes, included knowledge- and case-based, multiple-choice questions focused on current evidence-based recommendations for the use of incretin agents in the management of patients with T2D. Participants were presented with a pre-assessment survey before the CME activity and a post-assessment survey with the same questions upon completion of the CME activity. These 2 data sets were compared to assess the impact of the educational intervention.

 

Results:200 PCPs (100 US and 100 OUS) were included in the assessment. Significant improvements were found as a result of participation in the educational intervention. The effect size was 1.08 for US PCPs and 0.72 for OUS PCPs (>0.8 is considered a large effect size; 0.4-0.8 is considered a medium effect size). PCPs (US and OUS) who participated in the CME activity were more likely to make evidence-based practice choices after participation in the educational activity, including:

  • Both US (70% pre vs 89% post; P < .001) and OUS (74% pre vs 84% post; P = .03) PCPs were significantly more likely post-education to recognize that in addition to improving glycemic control, GLP-1 receptor agonists are associated with a low risk for hypoglycemia.
  • US PCPs were significantly more likely post-education than pre-education (66% vs 54%; P = .004) to recognize that GLP-1 receptor agonists work in a glucose-dependent manner.
  • Both US (76% pre vs 90% post; P = .001) and OUS (81% pre vs 95% post; P < .001) PCPs were significantly more likely post-education to appropriately select a DPP-4 inhibitor as therapy for a patient with T2D and a moderately elevated A1c.

Conclusion: This study demonstrated the success of a targeted educational intervention on improving knowledge, competence, and performance of US and OUS PCPs in the use of incretin agents in patients with T2D.

 

Disclosure: ALP: Ad Hoc Consultant, Abbott Laboratories, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Astra Zeneca, Advisory Group Member, Eli Lilly & Company, Advisory Group Member, Bristol-Myers Squibb, Advisory Group Member, Jansen Pharmaceuticals, Advisory Group Member, Medtronic Minimed, Speaker Bureau Member, Novo Nordisk, Advisory Group Member, Sanofi, Ad Hoc Consultant, Medscape. CHW: Speaker, Novo Nordisk, Speaker, Lilly USA, LLC, Consultant, Jansen Pharmaceuticals, Speaker, Jansen Pharmaceuticals, Speaker, Boehringer Ingelheim Pharmaceuticals, Consultant, Boehringer Ingelheim Pharmaceuticals, Consultant, Bristol-Myers Squibb, Speaker, Bristol-Myers Squibb, Speaker, Merck & Co., Speaker, Sanofi, Consultant, Sanofi, Speaker, Astra Zeneca, Consultant, Astra Zeneca. LB: Speaker, Sanofi, Speaker, Novo Nordisk, Speaker, Merck & Co., Speaker, Jansen Pharmaceuticals, Speaker, Bristol-Myers Squibb, Speaker, Amylin Pharmaceuticals, Investigator, Sanofi, Investigator, Novo Nordisk, Investigator, Lilly USA, LLC, Consultant, Sanofi, Consultant, Quest Diagnostics, Consultant, Novo Nordisk, Consultant, Merck & Co., Consultant, Jansen Pharmaceuticals, Consultant, GlaxoSmithKline, Consultant, Eisai, Consultant, Astra Zeneca. Nothing to Disclose: AL, AL, RB

15406 6.0000 SUN-0458 A Success of Educational Interventions on Use of Incretin Agents in the Management of Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0453-0460 4812 1:00:00 PM Quality Improvement Research/Patient or Provider Education Poster

Amy Larkin*1, Anne Le1 and Zachary T Bloomgarden2
1Medscape Education, 2Mount Sinai School of Medicine, New York, NY

 

Introduction: Despite widespread dissemination of the evidence for better outcomes with improved glycemic control, a significant proportion of patients with type 2 diabetes (T2D) do not achieve A1c goals. We studied the effect of educational activities designed to help clinicians implement strategies for a patient-centered approach to T2D management. We sought to overcome attitudinal and performance barriers by improving clinicians’ ability to develop safe and effective treatment plans in the context of understanding the American Diabetes Association (ADA)/European Association for the Study of Diabetes (EASD) position statement(1). We measured the impact of the education on self-reported physician practice related to the management of T2D via a follow-up Planned Change Assessment® (PCA) of performance outcomes.

Methods: Educational need and clinical performance gaps related to T2D management were identified and used in developing content. Two sets of educational activities, each comprising 6 interviews with experts in the field of T2D management, focused on practical use of the ADA/EASD guidelines through case scenarios. A PCA survey was utilized immediately post-education to assess planned changes and 8 weeks later to measure self-reported changes in practice.

 

Results: 399 physicians completed the survey following the first set of activities, with 98% indicating an average of 3.2 intended changes. When re-engaged with the follow-up survey, 81% reported having made an average of 5.6 changes in practice; 178 completed the survey following the second activity, with 99% indicating an average of 3.6 intended changes. The follow-up survey showed 90% of physicians reporting having made an average of 4.1 changes in practice. Changes in practice were reported in the following areas: increased consideration of basal insulin + GLP-1 therapy as an option for patients who have elevated PPG or concerns about weight (as opposed to basal-bolus regimens), practicing more individualized therapy in T2D, using the ADA/EASD algorithms in practice, and more aggressively treating patients with T2D when appropriate. The percentage of those making changes and the number of changes is very high compared with data from similar 2012 outcomes activities(2).

 

Conclusion: The educational metrics gathered in this assessment are a strong indicator that these activities prompted changes in clinical performance, showing that education on practical application of guidelines in practice is a useful way to effect changes in practice.

 

Disclosure: ZTB: Consultant, Dainippon Sumitomo Pharma America, Speaker, Novo Nordisk, Consultant, Johnson &Johnson, Consultant, Boehringer Ingelheim, Consultant, Astra Zeneca, Consultant, Bristol-Myers Squibb, Speaker, Santarus, Speaker, Merck & Co., Consultant, Novartis Pharmaceuticals, Consultant, Merck & Co., Consultant, Forest Laborities, Consultant, Medtronic Minimed, Speaker, Boehringer Ingelheim, Stockholder, Baxter International, Stockholder, CVS Caremark, Stockholder, Roche Holdings, Stockholder, Novartis Pharmaceuticals. Nothing to Disclose: AL, AL

15384 7.0000 SUN-0459 A Planned Changes in Type 2 Diabetes Management: Effectiveness of CME in Practice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0453-0460 4812 1:00:00 PM Quality Improvement Research/Patient or Provider Education Poster

Tara Rashid1, Tariq Hasoon1, Sharaf Aziz2, Waleed Ansari2, Agron Ferati3, Rabih T Torbay4, Michael W. Brennan5, Majeed Jawad6, Gerald E Evans4, Ross I Donaldson7 and Robert J Ferry Jr.*8
1International Medical Corps, Baghdad, Iraq, 2Iraqi Ministry of Health, Baghdad, Iraq, 3International Advisory, Products and Systems, Alexandria, VA, 4International Medical Corps, Washington, DC, 5Alamance Eye Center, Burlington, NC, 6East Surrey Hospital, Surrey, United Kingdom, 7Harbor-UCLA Medical Center, Torrance, CA, 8University of Tennessee, Memphis, TN

 

Importance: Active conflict zones present the greatest challenges to delivery of medical care (1-5). This report describes the first national implementation of continuous professional development (CPD) by volunteer faculty for medical professionals working in an active conflict zone.

Objective: To implement Continuing Medical Education (CME) for medical professionals in Iraq after decades of restricted access to high quality, updated, and formally accredited CPD.

Design: Prospective design and implementation of comprehensive CPD program delivered in Iraq from August 20, 2007 – August 3, 2010.

Setting: Training was conducted in hospitals and new CME Centers across Iraq by diverse faculty representing 19 medical disciplines.

Participants: Three physician–coordinators based in Iraq and 27 volunteer physician faculty from rest of world.

Main Outcome: Strengthen the Iraqi health system, retain physicians in Iraq, and optimize patient outcomes through CPD at the national level within Iraq.

Results: Three CME Centers were established at Arbil, Baghdad, and Basrah, where over 2,857 Iraqi medical professionals received direct training via 39 face-to-face courses, conferences, and seminars. Telemedicine stations enabled two international CME/CPD events to be conceived and delivered in Iraq. Donated effort by all volunteer faculty exceeded $500,000. Participants displayed improved fund of knowledge after most CME events and expressed high levels of satisfaction with these experiences. Timely execution of key steps with the host government were identified for program success. No participant or faculty was injured during travel or attendance, despite a high state of conflict in Iraq during this period.  Although average post-test scores were universally higher than pre-test scores, many post-test raw scores were relatively low (<70% correct) consistent with adverse impact from decades of professional isolation.

Conclusions and Relevance: To our knowledge, this is the first CME/CPD program safely established across a nation in active conflict. Although CME/CPD is essential for optimal healthcare delivery, its impact on healthcare disparities is difficult to quantify when government infrastructure is rapidly changing. Additional studies are required to determine the long-term impact of structured CME/CPD in active conflict zones.

 

Disclosure: AF: , International Advisory, Products and Systems. RJF Jr.: Principal Investigator, Bristol-Myers Squibb, Principal Investigator, Eli Lilly & Company, Principal Investigator, Novo Nordisk, Principal Investigator, GlaxoSmithKline, Principal Investigator, Takeda, Editor, Up To Date. Nothing to Disclose: TR, TH, SA, WA, RTT, MWB, MJ, GEE, RID

14078 8.0000 SUN-0460 A Continuous Professional Development in Iraq (2007-10): Peacebuilding By Volunteer Physicians in an Active Conflict Zone 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0453-0460 4812 1:00:00 PM Quality Improvement Research/Patient or Provider Education Poster

Wei-An Andy Lee*1, Andrew Curtis2, Jennifer Ito3, Kristin Childress3, Miriam Del Carmen Padilla4, Manuel Pastor3 and Astrid Heger5
1Univ of Southern CA, Los Angeles, CA, 2Kent State, 3University of Southern California, 4LAC/USC, Van Nuys, CA, 5Violence Intervention Program, CA

 

Management of chronic diseases for disparate populations within Los Angeles County is extremely challenging due to the socio-economic issues that affect them.  These barriers are generally difficult for clinicians within the safety-net clinics to truly appreciate.  Our aim was to pilot the use of a web-based platform to allow community members to self audit their health perspectives within their local neighborhoods and to allow those contextual health perspectives be used to inform clinicians.  We designed this platform  to perform four essential functions.  Capture, Review, Evaluate and Teach (CREaTe).  

Our objective is to share our initial results of piloting this tool for communities within Boyle Heights, Los Angeles.

The first step involved the challenge of capturing information that had a contextual location-based perspective.  We built a fast, mobile GIS platform, allowing community members to audit their neighborhood perspective of health.  Reviews allowed different disciplines (medical, community, and sociology members) to screen the information for accuracy and merit.  The dataset was then analyzed by a GIS specialist.  From this information, we displayed the data in a platform that provided the best promise to inform patients or community members about their health assets within their respective neighborhoods. 

We partnered with Las Fotos Project, a community-based photography program for young girls in East Los Angeles, to pilot this platform.    Four girls in this group were given the platform to audit the Boyle Heights neighborhood for health assets over a 8 week period.

Results:

89 sites within Boyle Heights with photos and narratives were obtained on the platform.

100% of the sites were then reviewed by committees consisting of clinicians, sociologists, and community members without any technical issues.

The following were the summary of the site audits.

  • 24% Social(21), 20% Exercise(18) , 19% nutrition(17), 18% Education(16), 6% Transportation(5), 4% Medical(4), 3% Housing(3), 3% art(3), 2% Safety(2). 

The platform allowed users to quickly understand health perspectives from the community with direct links to physical location-based attributes. This limited pilot demonstrated that social, physical, nutritional and educational aspects of health were the dominant areas of health interest for high school girls in Boyle Heights.

100% of the results of the health audits were available within clinics using a standard web-based browser with internet access.  Clinicians were able to use this platform to provide context for patients within Boyle Heights, East Los Angeles.

Conclusion:  This pilot demonstrated the feasibility of using a MobileHealth, Web-based GIS platform to bridge the community-clinical gap through providing location-based community perspectives of health.  Future works will be to expand this approach to more communities and clinics.

 

Nothing to Disclose: WAAL, AC, JI, KC, MDCP, MP, AH

15567 2.0000 SUN-0440 A A Novel, Mobile Health GIS Platform to Build a Community-Clinical Partnership within Boyle Heights, Los Angeles 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0439-0452 4813 1:00:00 PM Health Outcomes Poster

Monika Bullinger*1, Rachel Sommer1, Julia Hannah Quitmann1, Nelly Mauras2, Kim Englert2, Judith L. Ross3, Lawrence A. Silverman4, Ron S Newfield5, Janet L. Fox6 and Andreas M. Pleil7
1University Medical Center Hamburg-Eppendorf, Hamburg, Germany, 2Nemours Children's Clinic, Jacksonville, FL, 3Jefferson Med Coll, Philadelphia, PA, 4Goryeb Children's Hospital, Morristown, NJ, 5UCSD/Rady Children's Hospital, San Diego, California, 6Pfizer Inc, New York, NY, 7Pfizer Inc., San Diego, CA

 

Objectives: The QoLISSY questionnaire is a multi-dimensional instrument, originally developed in 5 European countries, to evaluate the health-related quality of life (HrQoL) in short statured youth, from the patient and parent perspective. In order to make this tool available for use in the US, its validation for American-English speaking children, adolescents (8-18 yrs.) and parents (of children 4-18 yrs.) is needed.

Methods: After a multi-professional adaptation-process of the UK-English version into American-English, content validity and acceptance of the questionnaire was examined in focus group discussions combined with a cognitive debriefing session. Participants included 28 clinician-referred patients diagnosed with growth hormone deficiency (GHD) or idiopathic short stature (ISS) and their parents. In the subsequent field- and re-test, 51 children/adolescents (mean age 12.4 +/- 2.89 years), with a history of short stature (current height SDS -1.6 +/- 1.04, treated 45/untreated 6) and their parents completed the QoLISSY and additional questionnaires (e.g. KIDCSREEN, SDQ). Psychometric properties of the American-English QoLISSY version were examined and compared with the original European dataset.

Results: Focus groups and cognitive debriefing results support the content validity and acceptability of the questionnaire. Field-test results yielded good internal consistencies with Cronbach’s Alpha ranging from 0.84 to 0.96 (self-report) and from 0.87 to 0.97 (parent – report), as well as high test-re-test reliabilities. Discriminant validity based on score differences between subgroups categorized by current height was satisfactory. Correlations with the generic KIDSCREEN QoL Index measure support the construct validity. Psychometric properties of the American-English QoLISSY were comparable with the results from the original European study. The QoLISSY questionnaire measures impairment in the American-English speaking sample (n = 50; QoL total M = 73.30; SD = 21.33) similarly like in the European sample (n =268; QoL total M = 73.10; SD = 21.39), therefore no significant differences were found (QoL Total score p = 0.954).

Conclusion: The American-English version of the QoLISSY questionnaire is a psychometrically sound, short stature specific questionnaire for the assessment of HrQoL from the children’s, adolescents’ and their parents’ perspectives.

 

Disclosure: MB: Principal Investigator, none. NM: Principal Investigator, Medtronic Minimed. JLF: Employee, Pfizer, Inc.. AMP: Employee, Pfizer, Inc.. Nothing to Disclose: RS, JHQ, KE, JLR, LAS, RSN

14519 3.0000 SUN-0441 A Validation of the American-English Quality of Life in Short Stature Youth (QoLISSY) Questionnaire in the US 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0439-0452 4813 1:00:00 PM Health Outcomes Poster

Annie Guerin*1, Yaping Xu2, Robert Hiscock1, Susan M. Begelman2, Yunming Mu2, Reza Alaghband1 and Eric Q. Wu1
1Analysis Group, Inc., Boston, MA, 2Genentech Inc., San Francisco, CA

 

Purpose: Acromegaly (AC) is a chronic disease often diagnosed in its later stage when patients have already incurred a high comorbidity burden. The objective of this study was to estimate the incremental comorbidity burden of AC patients compared with that of AC-free patients.

Methods: AC and AC-free patients were identified from the Truven Health Analytics MarketScan®database (Q1 2008 to Q4 2012). AC patients were defined as having ≥2 independent diagnoses of AC (ICD-9-CM: 253.0x), or 1 diagnosis of AC and 1 claim for either a medical procedure or medication for AC. The index date for AC patients was defined as the earliest of the aforementioned AC occurrences.  AC patients were ≥20 years old as of the index date. AC-free patients had no AC diagnoses or claims for AC procedures or medications during the entire period covered by the database. AC and AC-free patients were exactly matched 1:1 based on age as of the index date, gender, region of residence, type of health plan coverage, and pre-index eligibility duration. AC-free patients were attributed the same index date as the matched AC patients. All patients had ≥1 year of eligibility following the index date. The study period was defined as the 1-year period following the index date. Prevalence of comorbidities as measured by medical claims recorded any time prior to the end of the study period was measured and compared for AC patients and AC-free patients using McNemar tests; risk ratios (RR) were also calculated.

Results: A total of 3356 AC patients and AC-free patients were matched. Patients were on average 49.7 years old and 53.1% of patients were female. Compared with AC-free patients, AC patients had a significantly higher prevalence of hypertension (43.7% vs 27.2%; P<0.001; RR: 1.61), arthropathy/arthralgia/synovitis (33.1% vs 20.0%; P<0.001; RR: 1.66), diabetes or impaired glucose tolerance (30.8% vs 13.6%; P<0.001; RR: 2.27), osteoarthritis (18.5% vs 8.5%; P<0.001; RR: 2.18), sleep apnea (17.5% vs 4.4%; P<0.001; RR: 3.97), hypopituitarism (15.5% vs 0.03%; P<0.001; RR: 520.00), menstrual abnormality (12.1% vs 6.7%; P<0.001; RR: 1.80), cardiac dysrhythmia/arrhythmia (11.7% vs 4.7%; P<0.001; RR: 2.51), colon polyp (10.2% vs 4.7%; P<0.001; RR: 2.17), myopathy/myalgia (9.4% vs 3.8%; P<0.001; RR: 2.45), and valvular heart disease (9.3% vs 4.0%; P<0.001; RR: 2.31).

Conclusion: The comorbidity burden of AC patients is substantial.

 

Disclosure: AG: Consultant, Genentech, Inc.. YX: Employee, Genentech, Inc., Employee, Genentech, Inc.. RH: Consultant, Genentech, Inc.. SMB: Employee, Genentech, Inc.. YM: Employee, Genentech, Inc.. RA: Consultant, Genentech, Inc.. EQW: Consultant, Genentech, Inc..

15128 4.0000 SUN-0442 A Comorbidity Burden Among Acromegaly Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0439-0452 4813 1:00:00 PM Health Outcomes Poster

Annie Guerin*1, Yaping Xu2, Robert Hiscock1, Susan M. Begelman2, Yunming Mu2, Reza Alaghband1 and Eric Q. Wu1
1Analysis Group, Inc., Boston, MA, 2Genentech Inc., San Francisco, CA

 

Purpose: Acromegaly (AC) is a chronic disease associated with higher morbidity and mortality if not treated appropriately, and often requires rigorous medical management that may add to the healthcare resource utilization (HRU) and cost burden of the disease. The objective of this study was to estimate and compare the incremental HRU and cost burden for AC and AC-free patients.

Methods: Patients were extracted from the Truven Health Analytics MarketScan®database (Q1 2008 to Q4 2012). AC patients were defined as having ≥2 independent diagnoses of AC (ICD-9-CM: 253.0x) or 1 diagnosis of AC and 1 claim for either an AC medical procedure or medication. The index date for AC patients was defined as the earliest of the above-mentioned AC incidents. AC-free patients had none of the aforementioned AC occurrences. AC and AC-free patients were exactly matched 1:1 based on age, gender, region of residence, type of health plan coverage, and pre-index eligibility duration. AC-free patients were attributed the same index date as their corresponding matched AC patients. All patients were ≥20 years of age as of the index date and had ≥12 months of eligibility following the index date. HRU and costs were evaluated over the 12-month study period following the index date. Incident rate ratios (IRRs) for HRU and cost differences (measured from a payer’s perspective; inflated to 2013 USD) between AC and AC-free patients were estimated using regression analyses and Wilcoxon signed-rank tests, respectively.

Results: A total of 3356 matched pairs of AC and AC-free patients were selected. Patients were on average 49.7 years old and 53.1% were female. Compared with AC-free patients, AC patients had almost 4 times more inpatient admissions (0.333 vs 0.085; P<0.001; IRR: 3.92), 2.65 more outpatient visits (21.506 vs 8.103; P<0.001; IRR: 2.65), and 2.24 more emergency room visits (0.499 vs 0.223; P<0.001; IRR: 2.24). Annual average total healthcare costs were $32,283 and $5,877 (P<0.001) for the AC vs AC-free patients, respectively. Compared with AC-free patients, AC patients incurred $19,327 incremental medical service costs ($24,047 vs $4,721; P<0.001) and $7,079 incremental pharmacy costs ($8,236 vs $1,157; P<0.001). Among AC patients, acromegaly-related healthcare costs accounted for approximately 38% of total healthcare costs, 27% of medical service costs, and 71% of pharmacy costs.

Conclusion: There is a significant HRU and cost burden associated with AC.

 

Disclosure: AG: Consultant, Genentech, Inc.. YX: Employee, Genentech, Inc., Employee, Genentech, Inc.. RH: Consultant, Genentech, Inc.. SMB: Employee, Genentech, Inc.. YM: Employee, Genentech, Inc.. RA: Consultant, Genentech, Inc.. EQW: Consultant, Genentech, Inc..

15528 5.0000 SUN-0443 A High Healthcare Resource Utilization and Costs Among Acromegaly Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0439-0452 4813 1:00:00 PM Health Outcomes Poster

Cynthia Plunkett*1 and Ariel L Barkan2
1University of Michigan, Ann Arbor, MI, 2Univ of Michigan, Ann Arbor, MI

 

Patients with acromegaly (a condition of chronic growth hormone hypersecretion by a pituitary adenoma) often require pharmacological treatment. Somatostatin analogs (SSAs) such as lanreotide and octreotide are often used as first-line medical therapy. Pasireotide, a novel multireceptor-targeted SSA, was recently approved for the treatment of Cushing’s disease and is currently in Phase 2 and Phase 3 clinical trials in patients with acromegaly. Because SSAs are delivered by subcutaneous or intramuscular injection, they can result in injection-related pain or anxiety. When combined with the prolonged, debilitating psychological complications associated with acromegaly, these administration challenges can negatively impact compliance, adherence, and quality of life. Proactively managing patients’ expectations and providing appropriate, timely guidance is crucial for maximizing adherence and, ultimately, optimizing the treatment experience. As part of ongoing clinical research since 1997, our team at the University of Michigan has used SSAs to treat 30 patients with acromegaly. Based on our clinical experiences with multiple SSA administration regimens (long-acting intramuscular, long-acting deep subcutaneous, and twice-daily subcutaneous) and a survey of related scientific literature, we generated a ‘dialog map’ that guides healthcare professionals through the many sensitive and complex patient communication issues surrounding this treatment process. Beginning with diagnosis, the dialog map includes discussion of treatment options, instruction on proper drug administration technique, and ensuring appropriate follow-up care. At each step, we provide talking points that address: the patient’s clinical situation; their geographic, economic, and psychological concerns; and their inclination to communicate with clinicians. We have found that involving patients, nurses, and physicians as equal partners in the treatment process optimizes treatment adherence in acromegaly. By using this dialog map to bridge the gap between physicians and patients, informed nurses can support clinical choices that, from a patient’s perspective, are manageable, logical, and will lead to the best possible outcome.

 

Disclosure: ALB: Advisory Group Member, Genentech, Inc., Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Ipsen. Nothing to Disclose: CP

14659 6.0000 SUN-0444 A The Care Continuum in Acromegaly: How Collaboration Between Patients, Nurses, and Physicians Can Optimize Treatment Experience 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0439-0452 4813 1:00:00 PM Health Outcomes Poster

Michael Goodman*1, Craig Sineath2, Travis Sanchez2, Shawn Giammattei3, Theresa Gillespie4, Monica Helms2, Enid Hunkeler5, Ashli Owen-Smith6, Douglas Roblin7, Jennifer Slovis8, Robert Stephenson2, Patrick Sullivan2, Virginia Quinn9, Cory Woodyatt2 and Vin Tangpricha4
1Rollins School of Public Health, Emory University, Atlanta, GA, 2Rollins School of Public Health, Emory University, 3The Rockway Institute, 4School of Medicine, Emory University, 5Division of Research, Kaiser Permanente, 6Center for Health Research Southeast, Kaiser Permanente, 7School of Public Health, Georgia State University, 8Kaiser Permanente, East Bay Medical Center, 9Kaiser Permanente Southern California

 

Background:  Despite demonstrable efficacy of medical gender reassignment therapy (MGRT) in alleviating gender dysphoria, access to qualified health care professionals who know how to administer hormonal therapy (HT) or perform appropriate surgical procedures remains a major problem in many countries including the United States.  The purpose of the current study is to examine the frequency and predictors of MGRT in persons who consider themselves transgender or gender non-conforming.

Methods:  Data were obtained from the "Transgender Health Priorities Survey" that was distributed on-line among attendees of a regional transgender support meeting held annually in Atlanta, GA.  Only responders whose self-identified gender was different from the one assigned at birth were included in the study.  The main outcome variables in the current analyses were self-reported receipt of various MGRT modalities.  Unadjusted and multivariable logistic regression analyses were performed to assess how receipt of any MGRT, ever HT, current HT, genital sex reassignment, or chest surgery were related to participants’ age, race, insurance status, education and MTF/FTM status.

Results:  A total of 479 transgender persons responded to the survey.  Of those, 351 (73%) were MTF and 128 (27%) were FTM.  Genital sex reassignment was reported in only 11 participants; all of them MTF, and for this reason multivariable analyses only evaluated predictors of HT or chest surgery.  The respective percentages of persons with reported current and ever HT use were 39% and 31% for MTF, and 23% and 20% for FTM.  Chest surgery was three times more common in FTM (9%) than in MTF (3%) study participants.  The MTF-FTM differences in receipt of different MGRT modalities were statistically significant after controlling for age, race, education and insurance status.  Having health insurance was independently associated with greater probability of current or ever HT, but not chest surgery.  Participants with at least college education were more likely to report previous chest surgery and current HT than persons who did not indicate having a college degree.  None of the GRT categories were associated with age or race.

Conclusion:  This study shows that frequencies of various MGRT modalities differ in MTF and FTM persons.  The data also show the importance of socioeconomic status and health insurance in providing access to MGRT.  Further studies with higher statistical power and greater geographical representation are needed to better understand barriers and facilitators of adequate care among transgender and gender non-conforming individuals.

 

Nothing to Disclose: MG, CS, TS, SG, TG, MH, EH, AO, DR, JS, RS, PS, VQ, CW, VT

14664 7.0000 SUN-0445 A Frequency and Determinants of Gender Reassignment Therapies Among Transgender and Gender Non-Conforming Persons 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0439-0452 4813 1:00:00 PM Health Outcomes Poster

William Polonsky1, Louise Traylor2, Ling Gao3, Wenhui Wei2, Barbara Ameer4, Andreas Stuhr*2 and Aleksandra Vlajnic2
1University of California San Diego, Del Mar, CA, 2Sanofi US, Inc., Bridgewater, NJ, 3Analysta Inc., Somerset, NJ, 4Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ

 

Treatment satisfaction is critical in improving patient-centered outcomes, yet comparative data for different insulins are lacking among patients with type 1 diabetes mellitus (T1DM).

We used patient-level data pooled from 2 RCTs in patients with T1DM previously treated with intermediate-acting insulin for ≥ 1 year, randomized to neutral protamine Hagedorn (NPH) insulin once or twice daily (n = 378), or insulin glargine once daily (n = 393) for 28 weeks; prandial insulin was continued. Treatment satisfaction improvement was measured by change in Diabetes Treatment Satisfaction Questionnaire status (DTSQs) scores from baseline to Week 28, and compared between insulin glargine and NPH insulin groups using multivariate models.

Data from 771 patients were analyzed; baseline mean age 39.4 years, women 48.1%, body mass index 25.2 kg/m2, glycated hemoglobin A1C (A1C) 7.8%, and fasting plasma glucose 217 mg/dL. Baseline DTSQs scores were 28.6 for insulin glargine vs 28.4 for NPH insulin. Week 28 A1C levels were 7.9 vs 7.8%, and weight gain 0.36 vs 0.31 kg for insulin glargine and NPH insulin patients, respectively (both P > 0.05). Treatment satisfaction increased significantly at Week 28 with insulin glargine vs NPH insulin (adjusted mean DTSQs change 1.02 vs −0.16; P = 0.005). When limited to patients not at ceiling at baseline (DTSQs < 30) a greater difference was observed (3.78 vs 1.68; P < 0.001). In a fixed effects model, treatment with insulin glargine (P = 0.005), a lower baseline DTSQs (P < 0.001), study (P = 0.011), and higher baseline A1C (P = 0.015) predicted treatment satisfaction improvement. Positive change in treatment satisfaction was linked to greater A1C reductions (Pearson correlation coefficient −0.11; P = 0.047) and less weight gain (marginally; 0.10; P = 0.067), but for the NPH insulin group only.

These data suggest that initiation of insulin glargine is associated with greater improvement in treatment satisfaction than NPH insulin in patients with T1DM. Treatment satisfaction improvement with insulin glargine not being significantly linked to A1C or weight change (as seen with NPH insulin) suggests other factors may have moderated these contributors and, thus, be of greater influence on insulin glargine satisfaction. Reduced rates of hypoglycemia or reduced injection frequency may be key; further investigation is warranted.

 

Disclosure: WP: Ad Hoc Consultant, Novo Nordisk, Speaker, Sanofi, Speaker, Novo Nordisk, Research Funding, Sanofi, Ad Hoc Consultant, Eli Lilly & Company, Ad Hoc Consultant, Sanofi. LT: Employee, Sanofi, Employee, Sanofi, Spouse employee, Bristol-Myers Squibb. LG: Consultant, Sanofi. WW: Employee, Sanofi, Employee, Sanofi. BA: Advisory Group Member, CSL Behring, Consultant, Sanofi. AS: Stock ownership, Roche Pharmaceuticals, Employee, Sanofi, Employee, Sanofi. AV: Employee, Sanofi, Employee, Sanofi.

15757 8.0000 SUN-0446 A Improved Treatment Satisfaction in Patients with Type 1 Diabetes Mellitus Treated with Insulin Glargine Vs Neutral Protamine Hagedorn Insulin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0439-0452 4813 1:00:00 PM Health Outcomes Poster

Ploutarchos Tzoulis* and Pierre-Marc Gilles Bouloux
Royal Free Hospital, London, United Kingdom

 

Introduction:Hyponatraemia is associated with significant morbidity and mortality. There is limited data about the efficacy of various therapeutic modalities for hyponatraemia outside the clinical trial setting.

Methods: This observational study included all adult patients with serum sodium (sNa) ≤ 128 mmol/l at any point during hospitalisation in a teaching hospital in London over a 3-month period (1st March 2013 – 31stMay 2013). The aim of this study was to examine the efficacy of management of hyponatraemia with various therapeutic measures. All variables were expressed as median (interquartile range; IQR).

Results:139 patients (69 males, 70 females) aged 74 (59-82) years were included in the study. 50 patients (36%) did not have any treatment for hyponatraemia. Among the remaining 89 patients, 69 patients had 1 episode of treatment, while 20 required sequential treatment. Drugs with the potential to contribute to hyponatraemia were discontinued in 39 cases; the most common were loop diuretics in 19 cases, ACE inhibitor or angiotensin receptor blockers in 16 cases, spironolactone in 12 cases and thiazide diuretics in 7 cases.

Overall, there were 100 episodes of treatment, including normal (0.9%) saline in 42 cases; fluid restriction in 26 cases; other intravenous fluids, mainly Hartmann’s solution, in 14 cases; haemodialysis in 8 cases; tolvaptan in 5 cases and other therapeutic measures in 5 cases. No patient was treated with hypertonic saline.

Among 42 patients treated with normal saline, sNa increase after 24-hour treatment was 4 (1.5 – 7.5) mmol/l. Correction of sNa by > 8 mmol/l and by > 12 mmol/l over the first 24 hours was recorded in 16.6% and 7.1% of cases respectively.

Fluid restriction, 1000 - 1500 ml/day in 17 cases and 500 - 750 ml/day in 9 cases, was prescribed for 26 patients. After 24-hour fluid restriction, sNa concentration changed by +2 (0 to +4) mmol/l with no increase in sNa in 34.6% of cases. Among 14 patients receiving fluid restriction for at least 72 hours, the 72-hour change in sNa was +2 (-1.5 to +5.7) mmol/l. 28.6% of individuals had reduction in sNa, 50% had change in sNa by 0-5 mmol/l and 21.4% had increase of sNa levels by > 5 mmol/l.

Tolvaptan, prescribed in 3 cases as second line and in 2 cases as third line therapy, led to a 24-hour change in sNa concentration by +3, +4, +6, +9 and + 14 mmol/l.

With respect to sNa increase by > 8 mmol/l and by > 12 mmol/l over the first 24 hours of treatment, this was documented in 15% (9% intravenous fluids, 3% haemodialysis, 2% tolvaptan, 1% fluid restriction) and 5% of therapeutic episodes respectively.

Discussion: A significant percentage of patients did not receive any treatment for hyponatraemia. Fluid restriction was often ineffective, while overcorrection of hyponatraemia most commonly occurred in patients treated with normal saline. This study demonstrated that treatment of hyponatraemia is frequently suboptimal in a real-life clinical setting.

 

Nothing to Disclose: PT, PMGB

13908 9.0000 SUN-0447 A Efficacy of Different Treatment Modalities for Hyponatraemia: An Observational Study in a UK Teaching Hospital 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0439-0452 4813 1:00:00 PM Health Outcomes Poster

Joseph G. Verbalis*1, Susan Boklage2, Joseph Chiodo III2 and Richard D Pollack3
1Georgetown University Medical Center, Washington, DC, 2Otsuka America Pharmceutical, Inc., Princeton, NJ, 3Advanced Analytic Solutions, Newtown, PA

 

INTRODUCTION: Hyponatremia (HN) is the most common electrolyte disorder and an independent predictor of increased mortality in hospitalized patients (pts). Fluid restriction (FR) is often the first line of therapy for HN; however, data assessing its effectiveness is limited.

HYPOTHESIS: Although a large number of demographic and clinical characteristics exist for pts with HN, a relatively small number of variables will discriminate pts responses to FR.

METHODS: Medical records of pts meeting the HN registry (ClinicalTrial.gov #NCT01240668) entry criteria for SIADH (age ≥18 yrs, euvolemic, serum sodium ([Na+]) ≤130 mEq/L) were abstracted. Pts treated with only FR on the first day a pt‘s [Na+] was ≤130 mEq/L (baseline [BL]), and who had a follow-up [Na+] within an 18-36 hour window of the first [Na+] were included. Response to FR was defined as a change from BL to follow-up [Na+] within 24 hours of at least: 2 mEq/L, 3 mEq/L, or 4 mEq/L. Exhaustive CHAID (CHi-squared Automatic Interaction Detection) was chosen as the segmentation method due to its ability to detect and evaluate both linear and non-linear relationships. Each change in response was modeled separately.

RESULTS:  365 pts were included in the final analysis. Pt demographics at admission and baseline lab results at the time of HN diagnosis were included in the model. By design, all variables included in each of the final segmentations were significant (p<0.05). Four variables were the most significant in each of the 3 models: serum [Na+], urine osmolality (UO), urine [Na+] and serum creatinine. The cutoff of UO (mOsm/kg H2O) for predicting response was <500 for pts with [Na+] 120-125 and <350 for [Na+] <120 (i.e., pts with UOs greater than these cutoffs had a higher probability of not responding).

CONCLUSIONS:  HN pt response to FR is associated to a relatively small number of parameters that differ slightly with the desired response in [Na+]. For pts with [Na+] >125, no variables predicted a response >50%. For pts with [Na+] ≤125, UO was the most critical factor in determining responses from 2-4 mEq/L; this is consistent with clinical experience that pts with lower free water clearances are less likely to respond to FR. Yet in this population, only 43% of physicians recorded UO at initial diagnosis. These results confirm the importance of easily measured laboratory parameters as predictors of response or lack of response to FR, and indicate a general deficiency of appreciation for these important clinical associations and how they can be utilized to enhance the management of HN pts.

 

Disclosure: JGV: Consultant, Cornerstone Therapetics, Consultant, Ferring Pharmaceuticals, Consultant, Otsuka, Principal Investigator, Otsuka, Speaker, Otsuka, Advisory Group Member, Otsuka. SB: Employee, Otsuka. JC III: Employee, Otsuka. RDP: Consultant, Otsuka.

13087 10.0000 SUN-0448 A Clinical Characteristics of Patients with Siadh Who Respond to Fluid Restriction in the Management of Hyponatremia from a Global Registry 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0439-0452 4813 1:00:00 PM Health Outcomes Poster

Ploutarchos Tzoulis*1, Emmanouil Bagkeris2, Ranjana Raj3, Prina Rajani3, Alexander Gallagher3 and Pierre-Marc Gilles Bouloux1
1Royal Free Hospital, London, United Kingdom, 2University College London, 3University College London Medical School

 

Introduction: Hyponatremia is associated with increased inpatient mortality. However, whether hyponatremia by itself can contribute to mortality or merely represents a surrogate marker for the severity of the underlying diseases remains a contentious issue. Our hypothesis was that if hyponatremic patients had highly significant excess mortality compared to controls despite no difference in factors such as age, gender, comorbidities, nature of underlying illness and provider of health care, this would demonstrate an independent association of hyponatremia with excess inpatient mortality.  

Methods: This was a single-centre, case-control study. Cases were all adult inpatients with sNa (serum Na) ≤ 128 mmol/l over a 3-month period, from 1st March 2013 to 31st May 2013, at a major UK teaching hospital. Controls were individuals with sNa > 128 mmol/l matched for age and gender who stayed in the same hospital ward as cases. The aim of this study was to compare the inpatient mortality rate of cases vs. controls.

Results:139 cases (69 males, 70 females) with a median age of 74 years had an inpatient mortality rate of 17.3% and a median length of hospital stay of 12 days. Among cases, 46.6% had hypovolemic hyponatremia, 34.5% euvolaemic hyponatremia and 18.9% hypervolemic hyponatremia. 254 controls (131 males, 123 females) with a median age of 72 years had an inpatient mortality rate of 5.9% and a median length of hospital stay of 15 days. Cases and controls had no statistically significant difference with respect to age, gender, presence of 17 comorbidities, use of 13 common drugs, serum creatinine, ICU admission rate and length of hospital stay. However, cases were more than 3 times more likely to die during their hospital stay compared to controls (OR 3.33, 95% CI 1.68 to 6.58, p<0.01).

Only 45.7% of controls remained constantly normonatremic (sNa 135-145 mmol/l) throughout hospitalization. Normonatremic controls had an inpatient mortality rate of 1.7% and a median length of hospital stay of 8 days. Cases were almost 12 times more likely to die during admission than normonatremic controls (OR 11.89, 95% CI 2.75 to 51.51, p< 0.01).

Discussion: This study, by minimising the effect of the most potential confounding variables, demonstrated hyponatremia as an independent predictor of inpatient mortality. Thus, hyponatremia per se is likely to contribute to excess mortality. Further studies are needed to examine if correction of hyponatremia can improve patient outcomes and reduce mortality.

 

Nothing to Disclose: PT, EB, RR, PR, AG, PMGB

11139 11.0000 SUN-0449 A Hyponatremia Is an Independent Predictor of Inpatient Mortality 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0439-0452 4813 1:00:00 PM Health Outcomes Poster

Jill Apel*1, Sirimon Reutrakul2 and David Baldwin3
1Rush University Medical Center, Chicago, IL, 2Ramathibodi Hospital, Bangkok, Thailand, 3Rush University, Chicago, IL

 

Hypoglycemia is common in patients with end stage renal disease (ESRD). We identified the incidence and timing of hypoglycemia and its risk factors in hospitalized patients with ESRD after the treatment of hyperkalemia with insulin. We conducted a retrospective study of all hospitalized adult patients treated with hemodialysis who received intravenous insulin to treat hyperkalemia between January 1, 2011 and December 31, 2011. We identified patients who became hypoglycemic (blood glucose < 60 mg/dl) after insulin administration. Of the 221 episodes of hyperkalemia treated with insulin, 29 episodes resulted in hypoglycemia (13%). Factors associated with a higher risk of hypoglycemia included no prior diagnosis of diabetes [odds ratio (OR) 2.3, 95% CI 1.0-5.1, p = 0.05], no use of diabetes medication prior to admission [OR 3.6, 95% CI 1.2-10.7, p = 0.02] and a lower pre-treatment glucose level (mean 104 ± 12 mg/dl vs. 162 ± 11 mg/dl, p = 0.04). Hypoglycemia occurred at a median of 2 hours after insulin administration and persisted for a median of 2 hours.

Our data supports the following protocol for the administration of insulin and dextrose and the monitoring of serum glucose:

  1. Check blood glucose prior to insulin administration. If blood glucose is less than 70 mg/dl, give 24 grams oral glucose gel or if NPO 25 grams IV dextrose prior to insulin.
  2. Give insulin 10 units IV along with 24 grams oral glucose gel or dextrose 25 grams IV.
  3. Re-check blood glucose 60 minutes after insulin and dextrose administration, and give 24 grams oral gel or dextrose 25 grams IV irrespective of blood glucose level.
  4. Re-check blood glucose 120 and 180 minutes after insulin administration. Give 24 grams oral glucose gel or dextrose 25 grams IV if blood glucose is less than 70 mg/dl.

The treatment of hyperkalemia with insulin in hospitalized patients with ESRD may be complicated by hypoglycemia. Patients with a history of diabetes are less susceptible to this complication. Our data supports the use of a protocol to provide dextrose support and blood glucose monitoring for at least 3 hours after insulin treatment of hyperkalemia.

 

Nothing to Disclose: JA, SR, DB

13424 12.0000 SUN-0450 A Hypoglycemia in the Treatment of Hyperkalemia with Insulin in Patients with End-Stage Renal Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0439-0452 4813 1:00:00 PM Health Outcomes Poster

Monika Bullinger*1, Rachel Sommer1, Julia Hannah Quitmann1, Y Miles Yu2, Priscila C. Gagliardi3, Ximena Carolina Gaete4, Maria Veronica Mericq5, Judith L. Ross6, Joseph Permuy7 and Nelly Mauras3
1University Medical Center Hamburg-Eppendorf, Hamburg, Germany, 2Nemours Children's Clinic, Orlando, FL, 3Nemours Children's Clinic, Jacksonville, FL, 4University of Chile, Santiago, Chile, 5Hosp San Borja-Arriaran, Santiago, Chile, 6Jefferson Med Coll, Philadelphia, PA, 7Nemours Children’s Clinic, Jacksonville, FL

 

Background: We are conducting a three arm comparator, open label randomized controlled trial (RCT) on the use of growth hormone (GH), aromatase inhibitors (AI), alone and in combination in 77 adolescent boys with ISS. The Quality of Life in Short Stature Youth (QoLISSY) Questionnaire was used to assess the impact of short stature in this cohort prior to any intervention, and QoLISSY baseline data was examined regarding instrument performance.

Methods: Data are available in 51 English speaking (USA) and 24 Spanish speaking (Chile) 13 to 18 years old pubertal patients, diagnosed with ISS. One of their parents also completed the questionnaire. QoL was assessed within physical, emotional and social domains and via the QoLISSY total score. Psychometric testing involved inspection of scale properties, including reliability (internal consistency) and validity (correlation with a generic QoL instrument). Differences in QoLISSY total and subscale scores were examined within child-parent dyads and across countries.

Results: High reliabilities with Cronbach’s alpha coefficients ranging from .76 to .93 (child-report) and from .76 to .95 (parent – report) were found in the total data set and for the two language versions. Person correlations of QoLISSY scores with the generic instrument varied around r=.35. Children reported a mean QoL total score of 63 ± 18 within the score range from 0 to a 100 maximum (higher score better functioning), while parents gave them a significantly lower mean score of 54 ± 19. Social and emotional QoL domains were rated low by both respondent groups. T-tests revealed score differences according to countries, with lower scores reported for the sample from Chile, both in child-self and in parent-observer report.

Conclusion: The instrument appears to be a promising tool for the cross cultural assessment of quality of life in children with ISS. Baseline results suggest that children with ISS have measurable deficits in social, emotional and physical quality of life domains. The impact of different interventions on QoL will be assessed longitudinally.

 

Disclosure: MB: Principal Investigator, none. NM: Principal Investigator, Medtronic Minimed. Nothing to Disclose: RS, JHQ, YMY, PCG, XCG, MVM, JLR, JP

14606 13.0000 SUN-0451 A Assessing Quality of Life in Patients with Idiopathic Short Stature (ISS) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0439-0452 4813 1:00:00 PM Health Outcomes Poster

Barbara Gisella Carranza Leon*, Marius N Stan, Pravin Thapa, Rebecca S Bahn and Elizabeth A. Bradley
Mayo Clinic, Rochester, MN

 

Background: Graves’ ophthalmopathy (GO) is a disfiguring and sight threatening disease that causes discomfort and decreased health-related quality of life (HRQOL). Despite progress in the understanding of its pathogenesis, current treatment is often not satisfactory. We have recently completed a trial of rituximab (RTX), an anti-CD20 monoclonal antibody, in the treatment of patients with GO. As a part of this study, we assessed each patient’s perception of how they feel and function in daily life using the Thyroid Eye Disease Patient Reported Outcome (TED-PRO) questionnaire (a disease-specific HRQOL questionnaire).

Objective: To assess the change in HRQOL of patients in a trial of RTX vs. placebo for the treatment of GO.

Methods:  This is a prospective, randomized, double blind, placebo-controlled trial of RTX in patients with active GO [clinical activity score (CAS) ≥4] and moderate to severe disease. Patients received 2 RTX infusions (1000 mg each) or saline 2 weeks apart. The patients answered the TED-PRO questionnaire at baseline, weeks 24 and 52.  The scores ranged from 0 to 100 with 0 meaning “severe problem” and 100 “not a problem at all”. The minimal clinically important difference was defined as a difference of more than half of the standard deviation.

Results: are specific to HRQOL data; the clinical data were presented separately. 13 patients were randomized to RTX and 12 patients to placebo.  24 patients completed the questionnaire at baseline, 23 at 24 weeks and 18 at 52 weeks. Mean (SD) HRQOL scores were 35.5 (20.7) at baseline, 52.9 (22.4) at 24 weeks and 66.8 (19.1) at 52 weeks for the RTX group and 32.6 (15.7) at baseline, 45.3 (17.2) at 24 weeks and 55.2 (14.6) at 52 weeks for the placebo group. There was no statistically significant difference between groups. HRQOL at 24 weeks increased from baseline with no difference between groups [mean TED-PRO change (standard deviation) 14.9 (24.3) for RTX vs. 11.4 (16.6) for placebo p=0.62]. A similar result was seen at 52 weeks (32.7(22.9) for RTX vs. 24.6 (13.6) for placebo, p=0.63).

Discussion: Both groups had improved HRQOL at 24 weeks. While this improvement continued up to 52 weeks, no difference between groups was noted. These results are similar to the clinical data (e.g. CAS, NOSPECS, proptosis, diplopia) which also showed no difference between groups.

Conclusion: RTX conferred no benefit over placebo in health related quality of life in patients with Grave’s ophthalmopathy.

 

Nothing to Disclose: BGC, MNS, PT, RSB, EAB

12027 14.0000 SUN-0452 A Quality of Life Assessment in Patients with Graves' Ophthalmopathy Randomized to Treatment with Rituximab Vs. Placebo 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Sunday, June 22nd 3:00:00 PM SUN 0439-0452 4813 1:00:00 PM Health Outcomes Poster

Scott Jeffrey Sauer*1, John B Davis2, H Kim Lyerly3, Imran Shah4, Kevin P Williams5 and Gayathri R Devi6
1Duke Univ Med Ctr, Durham, NC, 2Duke University, 3Duke University Medical Center, 4Environmental Protection Agency, 5North Carolina Central University, 6Duke University Med Ctr, Durham, NC

 

Bisphenol A (BPA), a known endocrine disrupting agent and ubiquitously found plasticizer has recently been identified to interact with G-protein-coupled receptor 30 (GPR30/GPER), an alternate estrogen receptor (ER). GPER overexpression has been observed in breast cancer with particularly high levels in an aggressive and commonly hormone-independent subtype, inflammatory breast cancer (IBC). In the current study, screening the EPA Tox Cast I library of environmental chemicals using a high-throughput cell proliferation assay identified  BPA to be one of the top toxicants that increased proliferation in IBC cells, irrespective of ER status.  This is supported by recent evidence that BPA can induce proliferative effects in ER-negative breast cancer cells via GPER. Further, GPER has the ability to activate downstream ERK signaling via cross-talk with the epidermal growth factor receptor (EGFR) pathway. Therefore, we sought to determine BPA’s effect on the anticancer efficacy of EGFR tyrosine kinase inhibitors (TKIs) used clinically for the treatment of breast cancer. Using normal and breast cancer cells with differential expression of ERa, GPER and EGFR, proliferation was measured using an MTT assay to assess the effect of BPA alone and in combination with EGFR TKIs lapatinib and gefitinib. Clonogenic, anchorage-independent growth, Annexin-V/7-AAD flow cytometry and signaling assays were also used to assess the functional effect of BPA on lapatinib action. Our results reveal that breast cancer cells with either EGFR-activation or ER-positivity were highly responsive to BPA-mediated proliferative effects. BPA increased pEGFR and pERK levels along with expression of antioxidants (SOD1/2, GSTP1) in EGFR-activated breast cancer cells. Further, we observed that lapatinib in addition to inhibiting pEGFR levels decreased GPER expression. BPA attenuated the cancer cell growth inhibitory effect of EGFR-TKIs and abrogated the lapatinib-mediated inhibition of pEGFR, GPER and downstream pNFkB signaling. In conclusion, understanding BPA’s effect on drug resistance is a new paradigm that has immediate implications in treatment regimens.

 

Nothing to Disclose: SJS, JBD, HKL, IS, KPW, GRD

16911 1.0000 SUN-0345 A Bisphenol a Interacts with Gper, Activates EGFR and ERK Signaling and Antagonizes Efficacy of Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors in Breast Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Xiaozhao Lu*, Guodong Yang and Zifan Lu
The Fourth Military Medical University, Xi'an, China

 

Deacetylation of RNA binding protein QKI by SIRT1 under fasting conditions controls the adaptive hepatic energy metabolism

 Abstract  The oxidized nicotinamide adenine dinucleotide-dependent deacetylase SIRT1 plays an essential role in hepatic fatty acid and glucose metabolism, which is related to steatosis and glucose intolerance in obese mice. Up to now, the detailed underlying mechanism is largely unknown. RNA binding protein QKI is a recently identified important molecule in cell growth and metabolism. Here we first found that hepatic QKI was acetylated under feeding conditions, while it was deacetylated by SIRT1 under fasting conditions. Knockdown of QKI under fasting conditions resulted in compromised gluconeogenesis and fatty acid oxidation, while the effects on metabolism under feeding conditions were much milder, indicating that QKI plays an essential role in metabolism under fasting conditions. Compared with acetylated QKI, deacytelated QKI had higher affinity with the downstream targets, such as PPARα and FOXO1. Interaction between QKI and PPARα/ FOXO1 in turn increased the expression of these target genes both at mRNA and protein levels. Accordingly, the downstream metabolism related genes of PPARα and FOXO1, such as G6P (Glucose-6-phosphatase), PEPCK2 (Phosphoenolpyruvate carboxykinase 2), ACADM (acyl-Coenzyme A dehydrogenase, C-4 to C-12 straight chain), CPT1A (Carnitine palmitoyltransferase I A ), HMGCS2 (3-hydroxy-3-methylglutaryl- CoA synthase 2) were increased by QKI expression, with the trend much more obvious under fasting conditions or by directly forced expression of the acetylated analogue. Taken together, our study here reveals that deacetylation of RNA binding protein QKI by SIRT1 under fasting conditions controls the adaptive hepatic energy metabolism.

 

Nothing to Disclose: XL, GY, ZL

11790 2.0000 SUN-0346 A Deacetylation of RNA Binding Protein Qki By SIRT1 Under Fasting Conditions Controls the Adaptive Hepatic Energy Metabolism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Maria Florencia Gottardo1, Maria Laura Magri2, Sandra Zárate2, Jimena Ferraris2, Guadalupe Eijo2, Mariela Moreno Ayala2, Marianela Candolfi1, Daniel Pisera2, Gabriela Jaita2 and Adriana Seilicovich*2
1Institute of Biomedical Research, University of Buenos Aires-CONICET, Buenos Aires, Argentina, 2University of Buenos Aires-CONICET, Buenos Aires, Argentina

 

Humanin (HN) is a 24-aminoacid peptide originally isolated from a cDNA library of surviving neurons of familial Alzheimer´s disease. HN has a cytoprotective action in several cell types such as neurons, lymphocytes and testicular germ cells. Rattin (HNr), an homologous peptide of HN in rat, has also a neuroprotective action.

In the present study, we evaluated the action of HN on apoptosis of anterior pituitary cells from male Wistar rats. Since TNF-α induces apoptosis of anterior pituitary cells in an androgen-dependent manner, we determined the effect of HN on apoptosis of anterior pituitary cells from gonadectomized (GNX) rats incubated with TNF-α (50 ng/ml) in the presence of dihydrotestosterone (DHT, 10-8M). The percentage of apoptotic cells was determined by TUNEL assay and pituitary subpopulations were identified by immunofluorescence. HN (5 µg/ml) inhibited the apoptotic effect of TNF-α on anterior pituitary cells (C: 0.7 %; TNF-α: 3.0 %; HN: 1.0 %; HN-TNF-α: 0.9 %, p< 0.05, χ2), lactotropes (C: 1.0 %; TNF-α: 3.3 %; HN: 1.3 %; HN-TNF-α: 1.2 %, p< 0.05, χ2) and somatotropes (C: 2.0 %; TNF-α: 5.9 %; HN: 2.3% HN-TNF-α: 1.7 %, p< 0.05, χ2).

We have previously shown that HNr expression in the anterior pituitary gland from male rats is higher than in females. In order to evaluate whether gonadal steroids modulate HNr expression in anterior pituitary cells from male rats, we evaluated the expression of HNr in pituitary cells from GNX rats incubated with 17β-estradiol (E2) or DHT by flow citometry (FACS). E2 decreased the percentage of anterior pituitary cells expressing HNr (C: 78.8 ± 10.5 %; E2: 44.7 ± 3.5 %, p< 0.05, Student´s t test) whereas DHT had no effect on this expression. 

Our results suggest that HN exerts an antiapoptotic action against proapoptotic stimuli in anterior pituitary cells and could be involved in tissue homeostasis in this gland. Alterations in HNr expression may affect cell turnover and play a role in the development of anterior pituitary tumors.

 

Nothing to Disclose: MFG, MLM, SZ, JF, GE, MM, MC, DP, GJ, AS

12021 3.0000 SUN-0347 A Antiapoptotic Action of Humanin in Anterior Pituitary CELLS from Male RATS 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Nikolaj Kulahin*1, Christopher J. Watson2, Waseem Sajid1, Gerd Schluckebier1, Claus Kristensen1, Asser Sloth Andersen1, Ole Kristensen3, Matthias Norrman1, Pierre De Meyts1 and Andrzej Marek Brzozowski2
1Novo Nordisk A/S, Maaloev, Denmark, 2University of York, York, United Kingdom, 3University of Copenhagen, Copenhagen, Denmark

 

The insulin/IGF signalling system is highly conserved throughout the evolution of multicellular organisms, where it plays a crucial role in metabolism, growth, reproduction and longevity. The Drosophila Melanogaster genome contains seven genes for insulin-like peptides (ILPs) that are expressed in neurosecretory cells in a highly tissue- and stage-specific pattern, DILP1-7. There is however only one insulin-like receptor tyrosine kinase (dIR). We reported in 2011 the crystal structure of Drosophila insulin-like peptide 5 (DILP5) (expressed in Saccharomyces Cerevisiae) at 1.85Å resolution, as well as its biological and receptor binding properties (1). DILP5 shares the canonical fold of the insulin peptide family and form dimers that differ from the mammalian and hagfish insulin dimers.

Drosophila Melanogaster also has a circulating ILP binding protein, called imaginal morphogenesis protein-Late 2 (IMP-L2), with no equivalent in mammals but with orthologues in other insects. It was cloned, expressed and purified in 2000 and was shown to bind human insulin and insulin-like growth factors (2). We showed in 2011 that it also binds DILP5 (1). We now report the solution of the crystal structure of IMP-L2 in the free form as well as bound to DILP5 and to human insulin-like growth factor-I (hIGF-I). Recombinant IMP-L2 was expressed in a Baculovirus expression system, purified and crystallized with selenium as heavy atom. IMP-L2 showed a bilobed structure with two IgG beta sheet modules folded together into a "baseball glove". The structure is very different from the known partial structures of IGFBPs and dispels the concept that IMPL-2 is an orthologue of a human IGFBP. The complex of IMP-L2 with DILP5 showed a multimeric structure with two DILP5 molecules bound into the grooves between the beta sheets of two distinct IMP-L2s in a symmetrical tetrameric IMPL-2. In contrast, the IMPL-2 complex with hIGF-I was monomeric and revealed a novel conformation of IGF-I not seen in previous structures of IGF-I, reminiscent of the R conformation of human insulin.

 

Nothing to Disclose: NK, CJW, WS, GS, CK, ASA, OK, MN, PD, AMB

12082 4.0000 SUN-0348 A The Crystal Structure of Human IGF-I Bound to Drosophila Imaginal Morphogenesis Protein-Late 2 (IMP-L2) Reveals a Novel Conformation of IGF-I 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Joseph P Tiano*, Danielle A Springer and Sushil G Rane
National Institutes of Health, Bethesda, MD

 

Beige adipose cells are a distinct and inducible type of thermogenic fat cell that express the mitochondrial uncoupling protein-1 (UCP-1) and thus represent a powerful target for treating obesity. Mice lacking the transforming growth factor-beta (TGF-beta) effector protein SMAD3 are protected against diet-induced obesity due to browning of their white adipose tissue (WAT) leading to increased whole body energy expenditure. However, the role TGF-beta/SMAD3 plays in WAT browning is not clearly understood. Irisin, a new exercised-induced skeletal muscle hormone, was recently discovered and found to induce WAT browning similar to that observed in SMAD3 deficient mice. To explore whether TGF-beta/SMAD3 negatively regulates irisin production and/or secretion we used C2C12 myoblasts and lean and obese mice subjected to an exercise regime. Using TGF-beta and pharmacological inhibition of TGF-beta receptor 1 we found that SMAD3 binds the FNDC5 (irisin precursor) promoter in cultured skeletal muscle cells associated with a suppression of FNDC5 mRNA and protein levels. Obese sedentary mice showed increased skeletal muscle SMAD3 phosphorylation (pSMAD3) compared to lean mice. Exercise increased serum irisin and decreased serum TGF-beta and skeletal muscle pSMAD3 in obese mice but not in lean mice. Thus, TGF-beta is only negatively associated with irisin in exercised obese mice. These data suggest TGF-beta may only negatively regulate irisin production and/or secretion under conditions of metabolic stress such as obesity. These findings demonstrate a novel association between irisin and TGF-beta/SMAD3 signaling and suggest that targeting skeletal muscle SMAD3 may represent a therapeutic approach to treating obesity.

 

Nothing to Disclose: JPT, DAS, SGR

12202 5.0000 SUN-0349 A Transforming Growth Factor-Beta Is Negatively Associated with Irisin in Exercised Obese Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Sarina Lim*1, Chris D McMahon2 and John V Conaglen3
1Endocrine Research Unit, Hamilton, New Zealand, 2Developmental Biology Group, Hamilton, New Zealand, 3Waikato Clinical School, University of Auckland, Hamilton, New Zealand

 

Myostatin is a well-established inhibitor of skeletal muscle development. However, the role of myostatin in cardiac muscle is less clear. In the current study, we investigated whether absence of myostatin was associated with an improvement in cardiac function following an acute myocardial infarction (MI), and if so, the potential mechanism(s). Using a murine model with a constitutive deletion of the myostatin gene (Mstn‑/-), acute MI was induced by ligation of left anterior descending (LAD) artery in adult Mstn-/- and wild-type (WT) mice. Sham-operated mice with thoracotomy alone were used as controls. Body weight (BWT), heart rate (HR), mean arterial pressure (MAP) and ejection fraction (EF) were measured at baseline, days 1 (EF only) and 28 post-surgery. At 28 days post-MI, mice were injected with BrdU, then euthanized and their hearts were excised and weighed, followed by histological examination and immunohistochemistry. Mstn-/- mice were larger than WT mice (39.21±0.57g vs 24.66±0.37g, P<0.001) and remained so during the study period. Ligation of the LAD artery resulted in a similar infarct size in both the Mstn-/- and WT mice (9.9±1.9% vs 12.5±1.7%, P=0.38). EF was similar at baseline between the genotypes (61.5±1.2% vs 60.6±1.3%, P=0.15) and following MI, a similar degree of reduction in EF resulted (-8.6±2.2% vs -7.3±2.7%, P=0.6). However, at 28 days post-MI, EF was restored to baseline in Mstn-/- but not in the WT mice (61.8±1.1% vs 57.1±2.3%, P<0.01). The mortality rate in Mstn-/- mice was lower compared to WT mice (0% vs 20%, P<0.05). Induction of MI did not alter the BWT in Mstn-/- mice, but BWT increased of almost 7% in WT mice post-surgery (P<0.001). Mstn-/- mice had a lower mean increase in HR post-surgery compared with WT mice (+23.6±13.7bpm vs +109.5±14.3bpm, P<0.01). Induction of MI resulted in a lower increase in MAP in Mstn-/- mice compared with WT mice (-7±3.9mmHg vs +4.4±3.9mmHg, P<0.05). There was no difference in the number of BrdU positive cells, the percent of apoptotic cardiomyocytes, and the size of cardiomyocytes between Mstn-/- and WT mice. However, a reduction in the extent of collagen deposition in the peri-infarct region was observed in Mstn-/- mice compared with WT mice (41.9±2.8% vs 54.7±3.4%, P<0.05). We concluded that absence of myostatin confers a possible survival advantage post-MI and better recovery in cardiac function by inhibiting the extent of fibrosis.

 

Nothing to Disclose: SL, CDM, JVC

12262 6.0000 SUN-0350 A Absence of Myostatin Improves Cardiac Function Post-MI Via a Reduction in the Extent of Cardiac Fibrosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Roberta Malaguarnera1, Alaide Morcavallo1, Antonella Sacco1, Maria Luisa Nicolosi1, Andrea Morrione2 and Antonino Belfiore*1
1University Magna Graecia of Catanzaro, Catanzaro, Italy, 2Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA

 

The insulin-like growth factor-I receptor (IGF-IR) plays a key role in regulating mammalian development and growth by binding IGF-I and IGF-II with high affinity. IGF-IR and its ligands are frequently deregulated in cancer and may contribute to cancer progression in dependence to microenvironmental cues. Discoidin domain receptor 1 (DDR1) is a collagen receptor tyrosine kinase, which is activated by collagen binding. It is also frequently overexpressed in cancer and implicated in cancer progression and metastasis.

We aimed to investigate whether IGF-IR signaling and pro-oncogenic functions may be modulated by DDR1.

We employed mouse fibroblasts, R- cells, which express low levels of DDR1 and lack endogenous IGF-IR. Cells were transfected with IGF-IR and DDR1 constructs in various combinations. We also studied human breast cancer cells lines with various IGF-IR and DDR1 expression profiles, after DDR1 transfection or silencing. The functional relevance of IGF-IR-DDR1 cross-talk was evaluated by signaling studies, by analyzing IGF-IR trafficking, and by the measurement of biological effects in response to IGF-I.

We found that DDR1 overexpression increased anchorage-dependent and independent growth of R-cells in response to IGF-I. The effect of exogenously expressed DDR1 required the presence of a functional IGF-IR and was associated with enhanced ERK1/2 and p70S6K activation, while the PI3K/Akt pathway was less affected. DDR1 was critical in regulating IGF-IR trafficking as in fact co-internalized with the IGF-IR upon IGF-I stimulation and protected the IGF-IR from degradation. In particular, DDR1 depletion experiments by siRNA indicated that DDR1 is important in promoting IGF-IR internalization. Accordingly, in breast cancer cell lines, DDR1 silencing inhibited IGF-I dependent protumoral effects including proliferation, cell cycle progression, and invasion.

In conclusion, these results suggest that IGF-IR-dependent protumoral effects are modulated by DDR1, which affects IGF-IR trafficking and signaling. Therefore, DDR1 could be considered a new valuable target for those cancers showing over-activation of the IGF-IR axis.

 

Nothing to Disclose: RM, AM, AS, MLN, AM, AB

12603 7.0000 SUN-0351 A Insulin-like Growth Factor-I Receptor Trafficking and Biological Functions Are Affected By Discoidin Domain Receptor 1 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Yewei Xing*1, Miguel Ganuza2 and Gary D Hammer3
1University of Michigan, Ann Arbor, MI, 2St. Jude Children’s Research Hospital, Memphis, TN, 3Univ of Michigan, Ann Arbor, MI

 

Background: Cyclin-dependent kinase (CDK) 7 is a dual functional molecule that works both in cell cycle control and transcription initiation. It is present in adrenal gland, with high expression directly under the adrenal capsule. Previous work has shown that CDK7 can phosphorylate Sf1- a key nuclear receptor in both adrenal development and differentiation (steroid production), suggesting a potential role of CDK7 in steroidogenesis and cell proliferation in the adrenal gland.

Method: In the current study, we crossed Sf1-Cre mice with CDK7-floxed mice to determine the role of CDK7 in Sf1-expressing cells using immunofluorence (IF) and realtime qPCR methodology.

Results: As early as P1, CDK7-knockout mice show adrenal hypoplasia and significant decreases in Sf1-positive adrenocortical cells number. However apoptosis rates were not changed in CDK7-knockout mice compared to wild type, consistent with a defect in adrenal development and cell proliferation rather than cell death. Later in life, CDK7 knockout mice display phenotypes that include: smaller adrenal gland, less adrenocortical cells, lower cell proliferation rate and dislocation of medulla accompanied by loss of fetal zone. In accordance with the immuno-fluorescence data, realtime qPCR showed that both 3 week-old and 7-week-old CDK7-knockout mice have decreased Sf1 and PCNA expression in the adrenal cortex. Surprisingly, although cyp11b1 was 30% lower in the CDK7 knockout mice (consistent with the deceased adrenocortical cell number observed), the mRNA level of cyp11b2 was increased compared to wild type littermates, suggesting CDK7 or its downstream targets (for example Sf1) may regulate the balance between ZG and ZF cell phenotypes.

 

Nothing to Disclose: YX, MG, GDH

12875 8.0000 SUN-0352 A CDK7 Regulates Adrenal Development and Steroidogenesis in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

James McTague*1, Meghan Ferguson1, Robyn N Dickner1, Constance L Chik2 and Anthony-K Ho2
1University of Alberta, Edmonton, AB, Canada, 2Univ of Alberta, Edmonton, AB, Canada

 

The shuttling of salt-inducible kinase 1 (SIK1), a member of the AMP-activated protein kinase family, between the nucleus and the cytoplasm appears to play an important role in the regulation of the CRE-dependent gene expression.  In rat pinealocytes, we have shown that SIK1 can function as an endogenous repressor of CREB-target genes and that the transcription of Sik1 is under adrenergic control.   In the present study, we focus on the SIK1 protein directly and investigated the importance of Thr475 and Ser577, two established protein kinase A phosphorylation sites, in the stability and nuclear entry of SIK1 in the rat pineal gland.  Using rats housed under a 24 h light/dark cycle, we found an increase in SIK1 protein within 3h after the onset of darkness.  In cultured rat pinealocytes, we found that norepinephrine (NE) stimulation, by acting through the β-adrenergic / cAMP /PKA pathway, resulted in an increase in the SIK1 protein level within 2h that peaked at 4h.  Surprisingly, fractionation of pinealocytes into the nuclear and cytoplasmic fractions revealed no significant nuclear entry of SIK1 even after NE stimulation.  Studies using pinealocytes with over-expressed SIK1 or mutated SIK1 indicated that blockade of protein degradation with MG132 caused a large increase in the T475A-SIK1 and S577A-SIK1 levels under both basal and NE-stimulated conditions, suggesting the absence of phosphorylation at Thr475 or Ser577 on SIK1 led to a rapid degradation of the protein.  Interestingly, fractionation studies showed that, under both basal and NE-stimulated conditions, the addition of MG132 resulted in T475A-SIK1 and S577A-SIK1 being detectable in the nuclear fraction but not the wild-type SIK1.  This suggests that dephosphorylated Thr475 or Ser577 is required for the accumulation of SIK1 in the nucleus.  However, because of the rapid degradation of dephosphorylated SIK1, this can only be demonstrated when protein degradation is inhibited.  Hence, our results indicate that although NE stimulation leads to the induction and stabilization of SIK1 through phosphorylation, the same phosphorylation also prevents the nuclear localization of SIK1.  This challenges the current concept of SIK action and unraveling  the mechanism whereby SIK1 performs its repressor role in the absence of nuclear localization in the rat pineal gland warrants further investigation.

 

Nothing to Disclose: JM, MF, RND, CLC, AKH

12905 9.0000 SUN-0353 A Adrenergic Regulation of the Synthesis, Cellular Distribution and Degradation Salt-Inducible Kinase in the Rat Pineal Gland 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Juilee Rege*1, Hiromi Koso Nishimoto1, Koshiro Nishimoto2, Michael Edwards3, Raymond J Rodgers4 and William E. Rainey1
1University of Michigan, Ann Arbor, MI, 2Univ of Michigan, Ann Arbor, MI, 3Georgia Regents University, Augusta, GA, 4University of Adelaide, Adelaide, Australia

 

Introduction: Bone morphogenetic proteins (BMPs) comprise one of the largest subgroups in the transforming growth factor-β (TGF-β) ligand superfamily. In the present study, we identified a functional BMP system in the human adrenal gland and have characterized BMP4 as a potential adrenal paracrine regulator of adrenal androgen synthesis.

Methods: Zona fasciculata (ZF) and zona reticularis (ZR) were microdissected from ten human adrenals. Total RNA was extracted from ten ZF/ZR pairs and hybridized to an Illumina microarray chip to identify the transcript differences. Zone-dominant expression of BMP4 was confirmed by quantitative RT-PCR (qPCR) and immunohistochemistry.  The H295R adrenal cell line was used for functional studies involving BMP4. Individual experiments were repeated at least three times.

Results: Human adrenal microarray analysis confirmed the expression of a complete BMP system equipped with the ligand (BMP4), receptors (BMP type-II receptor, activin receptor-like kinase receptors 2, 3 and 4; also called as ALK2, ALK3 and ALK4 respectively) and the signaling proteins (SMADs 4 and 5). Microarray, qPCR and immunohistochemistry confirmed that BMP4 expression was highest in the zona glomerulosa (ZG) followed by the ZF and ZR.  BMP4 production by the H295R cell line was also confirmed by enzyme immunoassay. A profound decrease was seen in dehydroepiandrosterone (DHEA) and androstenedione (A4) when the H295R cells were treated with increasing amounts of BMP4 (0.3-100ng/ml). BMP4 (30ng/ml) inhibited DHEA and A4 by 60% and 50% (p<0.001), respectively. Administration of BMP4 to H295R cells also caused a significant time and concentration-dependent decrease in the mRNA levels of CYP17. BMP4 (30ng/ml) abrogated CYP17 mRNA levels by 75% (p<0.001). On the contrary, the mRNA levels of cholesterol side-chain cleavage cytochrome P450 (CYP11A1) or type 2 3β-hydroxysteroid dehydrogenase (HSD3B2) transcripts remained unchanged. Cotreatment with noggin (60ng/mL), a BMP signaling inhibitor, reversed the inhibitory effects of BMP4 on the expression of CYP17 and production of DHEA and A4.

Conclusion: The present study demonstrates a functional BMP4 system in the human adrenal and the H295R cell line. We also establish that BMP4 acts as a negative regulator of adrenal CYP17 expression and thereby C19 steroid synthesis in the H295R cells, thus suggesting that BMP4 may play a paracrine role in the human adrenal.

 

Nothing to Disclose: JR, HKN, KN, ME, RJR, WER

12914 10.0000 SUN-0354 A Bone Morphogenetic Protein-4 (BMP4): A Paracrine Regulator of Human Adrenal C19 Steroid Synthesis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Audrey Loumaye1, Fanny Noel1, Pascale Lause1, Olli Visa-pekka Ritvos2 and Jean-Paul Mathieu Thissen*1
1Univ Catholique de Louvain, Brussels, Belgium, 2Univ of Helsinki, Helsinki, Finland

 

Myostatin (Mstn) is a negative regulator of skeletal muscle mass. Mstn inhibition, by gene invalidation or by administration of a soluble Activin type IIB receptor (sActRIIB), markedly increases muscle mass. This increased muscle mass is thought to mainly result from stimulated protein synthesis. Amino acid availability, and hence dietary protein intake, controls muscle protein synthesis.

To evaluate the role of amino acid availability in the hypertrophy caused by Mstn inhibition, we investigate whether dietary protein restriction blunts the hypertrophy caused by Mstn inhibition. For that, we analysed the muscle impact of dietary protein restriction in two models of Mstn inhibition:

In a first experiment, male FVB Mstn(-/-) and WT mice were fed ad libitum during 14 days an isocaloric diet: normal diet (20% protein (P20)) or low protein diet (5% protein (P5)). Dietary protein restriction in WT mice caused muscle atrophy (gastrocnemius [Gc] -17%, p<0.001; P5 vs P20). As expected, Mstn(-/-)mice were characterized by muscle hypertrophy (Gc +59%, p<0.001; KO vs WT). However, this hypertrophy was blunted by dietary protein restriction (Gc +49% vs +59%, p<0.05; P5 vs P20). This observation indicates that dietary protein restriction attenuates the muscle hypertrophy caused by Mstn KO.

In a second experiment, male FVB mice were fed ad libitum for 14 days the P20 and P5 diets. The sActRIIB was injected IP at the dose of 10 mg/kg twice a week. Dietary protein restriction caused also muscle atrophy (Tibialis anterior [TA] -8% and Gc – 15%, p<0.001; P5 vs P20). Treatment with the sActRIIB caused muscle hypertrophy as illustrated by TA weight (+ 25%, P<0.001; sActRIIB vs PBS) and fiber cross-sectional area (CSA) (+ 23%, p<0.05; sActRIIB vs PBS). The hypertrophy caused by sActRIIB was again severely blunted by dietary protein restriction based on TA weight (+11% vs +25%, p<0.001; P5 vs P20) and CSA (+12%, NS vs +23%, p<0.05; P5 vs P20). Since increased protein synthesis is mainly responsible for the muscle hypertrophy induced by sActRIIB, we tested the hypothesis that dietary protein restriction blunts protein synthesis signaling. Our results showed that expression of REDD-1 and KLF-15, two factors inhibiting mTOR activity, is increased in muscles of P5 mice (respectively, + 243% and +152%, both p<0.001; P5 vs P20) suggesting an inhibition of protein synthesis. Markers of muscle proteolysis such as LC3b mRNA for autophagy and Murf-1 mRNA for ubiquitine-proteasome proteolytic pathway were not induced by protein restriction.

In conclusion, our data indicate that the muscle hypertrophic effect of Mstn inhibition is blunted by dietary protein restriction. This attenuation appears more related to reduced protein synthesis than accelerated proteolysis. Further research will test whether supplementation of leucine, a stimulus of mTORC1, might restore the full anabolic effect of sActRIIB in protein-restricted animals.

 

Nothing to Disclose: AL, FN, PL, OVPR, JPMT

13005 11.0000 SUN-0355 A Muscle Hypertrophy Induced By Myostatin Inhibition Is Blunted By Dietary Protein Restriction 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Shin Ichiro Takahashi*1, Kumiko Fujieda2, Yosuke Yoneyama2, Akihiro Ito3, Minoru Yoshida3, Kazuhiro Chida1 and Fumihiko Hakuno1
1Graduate School of Agriculture and Life Sciences, The University of Tokyo, Tokyo, Japan, 2The University of Tokyo, Graduate School of Agriculture and Life Sciences, Tokyo, Japan, 3RIKEN, Saitama, Japan

 

Binding of insulin/insulin-like growth factors (IGFs) to their specific receptors, causes activation of receptor tyrosine kinase, followed by tyrosine phosphorylation of insulin receptor substrates (IRSs). This event triggers activation of the downstream signaling pathways for mediating various activities of insulin/IGFs. IRSs are reported to undergo posttranslational modifications including acetylation, resulting in modulation of insulin/IGF signaling and bioactivities. The present study is undertaken to identify histone acetyltransferases (HATs) and histone deacetylases (HDACs) that act on IRSs and the physiological significance of IRS acetylation.

HEK293T cells overexpressing IRS-1 or IRS-2, two isoforms of IRSs were cultured in the presence of HDAC inhibitors (trichostatin A and nicotinamide) and IRSs immunoprecipitated from cell lysates were immunoblotted using anti-acetyllysine antibody. We found acetylation of IRS-1, not IRS-2.  The lysine residue, number 315 (K315) was shown to be the primary target of acetylation in the above cell lysates as determined by LC-MS/MS and acetylation analysis of IRS-1 mutants [deletion of the various regions or point mutation(s) of lysine residue(s) to arginine residues(s)]. We then overexpressed various HATs and IRS-1 in HEK293T cells and measured acetylation of IRS-1. Overexpression of CBP (CREB-binding protein) or p300 (E1A binding protein p300) induced IRS-1 acetylation. In addition, RNAi-mediated knockdown of each HAT repressed acetylation of K315 IRS-1 in L6 myoblasts stably overexpressing IRS-1. To determine the HDACs that modify IRSs, we co-transfected HEK293T cells with plasmids expressing various HDACs, CBP and IRS-1. When HDAC6 or SIRT1 (Sirtuin1) was overexpressed, IRS-1 acetylation was remarkably decreased. Addition of a HDAC6 inhibitor (tubastatin A) increased its acetylation, confirming that HDAC6 is involved in IRS-1 deacetylation. Finally, we analyzed the effects of acetylation of IRS-1 on IGF signaling. Tubastatin A treatment of L6 myoblasts decreased IGF-I-dependent tyrosine phosphorylation. We then treated L6 myoblasts stably overexpressing IRS-1 with IGF-I and immunoprecipitated using anti-acetylated K315 IRS-1 antibody, followed by immunoblotting using an anti-phosphotyrosine antibody. IRS-1, whose K315 was acetylated, was not tyrosine-phosphorylated in response to IGF-I treatment, suggesting that acetylation of K315 negatively regulates IGF signaling.

Based on these results, we concluded that IRS-1 acetylation is regulated by HATs such as CBP and p300, and by HDACs such as HDAC6 and SIRT1 at least in part and may decrease IRS-1 tyrosine phosphorylation by insulin/IGF-I receptor, and its downstream signaling followed by repression of their bioactivities.

 

Nothing to Disclose: SIT, KF, YY, AI, MY, KC, FH

13520 12.0000 SUN-0356 A Mechanisms for Regulation of Acetylation of Insulin-Receptor Substrate (IRS)-1, Regulating Insulin-like Growth Factor (IGF) Signaling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Kishio Toma*, Fumio Otsuka, Naoko Tsukamoto-Yamauchi, Eri Nakamura, Kanako Ogura-Ochi, Takeshi Hosoya, Takayuki Hara, Tomohiro Terasaka, Kenichi Inagaki and Hirofumi Makino
Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan

 

Hypothalamic GnRH and local factors expressed in the pituitary play key roles in induction of gonadotropins secretion by gonadotrope.  It was recently reported that pituitary gonadotropinomas express different patterns of somatostatin receptor (SSTR) subtypes depending on the tumor condition and aggressiveness, leading to varied reactions to the treatments with somatostatin (SS) analogs.  We previously reported that bone morphogenetic proteins (BMPs) expressed in the pituitary are involved in the regulation of FSH secretion by gonadotropes.  For instance, BMP-6 and GnRH mutually augmented FSH transcription, while GnRH-induced FSH transcription was negatively regulated by BMP-7 in LβT2 gonadotrope cells.  However, the regulatory mechanism of LH secretion by BMPs has yet to be elucidated.  Here we investigated the effects of SS analogs and roles of BMP-6 in the regulation of LH secretion by gonadotrope LβT2 cells.  All the receptor subtypes for SS, including SSTR-1, -2, -3, -4 and -5, were found to be expressed in LβT2 cells.  LH mRNA expression and LH secretion induced by GnRH were significantly suppressed by treatments with SS analogs, pasireotide: an agonist for SSTR-1, -2, -3 and 5, and octreotide: an agonist for SSTR-2, in LβT2 cells.  Of note, the inhibitory effects of SS analogs on LH secretion were enhanced in the presence of BMP-6 treatment.  Based on the finding that BMP-6 increased the expression levels of SSTR-5 mRNA, it was suggested that BMP-6 upregulates SSTR actions leading to an effective reduction of GnRH-induced LH secretion by LβT2 cells.  In addition, GnRH-induced phosphorylation of MAPK pathways including ERK and JNK, but not P38, was suppressed by SS analog treatments.  Given that each inhibitor for ERK, JNK or P38 signaling suppressed GnRH-induced LH transcription, MAPKs are individually involved in the induction of LH secretion in LβT2 cells.  This trend was different from the effects on FSH secretion predominantly regulated by ERK signaling.  Moreover, SS analogs also impaired Smad1/5/8 phosphorylation induced by BMP-6.  Collectively, SS analogs have dual effects on modulating GnRH-induced MAPK signaling and BMP-6 activity.  Thus, a functional link between the BMP system and GnRH-induced LH transcription was uncovered.  The pituitary BMP system may play a regulatory role in GnRH-induced LH secretion by modulating the responsiveness to SS analogs in gonadotrope cells.

 

Nothing to Disclose: KT, FO, NT, EN, KO, TH, TH, TT, KI, HM

13581 13.0000 SUN-0357 A Involvement of BMP-6 in the Effect of Somatostatin Analogs on GnRH-Induced LH Secretion By Gonadrotrope Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Kieun Kim*1, Hiromi Nakamura2, Gyunho Kim3, Irina Kramerova4 and Kuk-Wha Lee5
1CHA Gangnam Medical Center CHA University, Seoul, Korea, Republic of (South), 2UCLA, Los Angeles, CA, 3Mattel Children's hospital, Los Angeles, CA, 4University of California Los Angeles, Los Angeles, 5Mattel Children's Hosp - UCLA, Los Angeles, CA

 

The rat Humanin homologue is translated in mitochondria and a Humanin analogue (HNG) potentiates differentiation in rodent myoblasts

Neuromuscular disease is characterized by progressive muscular weakness and lack of muscle mass. Humanin (HN) is a peptide putatively transcribed from an opening reading frame within the 16S rRNA region of mitochondrial genome. It protects against neuronal cell death secondary to various insults. However, the mitochondrial origin of Humanin remains unproven. The rat HN homologue (rattin) does not have nuclear coding sequence. In addition, the effect of Humanin modulation of myoblast differentiation has not been studied. We hypothesized that a HN analogue (HNG) promotes differentiation of myoblasts without effecting proliferation in the presence and absence of serum.

Rat L6 myoblasts were incubated with cycloheximide, chloramphenicol, and puromycin in a time course experiment. Cell lysates were subjected to Western blot analysis for Rattin expression. Cycloheximide ( cytoplasmic translation inhibitor ) treatment had no effect on rattin expression. Chloramphenicol ( mitochondria translation inhibitor ) treatment resulted in a dramatic decrease of rattin expression and puromycin ( non-specific translation inhibitor ) treatment also resulted in a decrease of rattin expression. These results suggest that rattin is translated in the mitochondria. Mouse C212 myoblasts were treated with HNG and differentiated. Increasing HNG doses resulted in a significant increase in cell nuclei and myotube count in a dose-dependent manner. Quantified nuclear distribution index was also increased. To analyze whether differentiation effects could be secondary to increases in cell number, we performed cellular proliferation assays using CCK8 assay in growth media. Treatment with similar doses of HNG did not result in an increase in cell proliferation in the presence or absence of serum.

In summary, the rat HN homologue is translated in mitochondria and supports proof-of-principle for a mitochondrial-derived peptide. In addition, a Humanin analogue (HNG) treatment enhanced C2C12 differentiation in a dose-dependent manner but was not associated with proliferation. We suggest that the present study supports a potential therapeutic role for Humanin in muscle dysfunction.  

 

Nothing to Disclose: KK, HN, GK, IK, KWL

14084 14.0000 SUN-0358 A The Rat Humanin Homologue Is Translated in Mitochondria and a Humanin Analogue (HNG) Potentiates Differentiation in Rodent Myoblasts 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Xinggang Wu1 and Yin Xia*2
1The Chinese University of Hong Kong, Hong Kong, China, 2The Chinese University of Hong K, Hong Kong

 

Mutations in HFE are the most common cause of hereditary hemochromatosis (HH). HFE mutations result in reduced expression of hepcidin, a hepatic hormone, which negatively regulates iron absorption from the duodenum and iron release from macrophages. However, the mechanism by which HFE regulates hepcidin expression in hepatocytes is not understood. It is known that the bone morphogenetic protein (BMP) pathway plays a central role in controlling hepcidin expression in the liver. Here, we show that HFE increased Smad1/5/8 phosphorylation and hepcidin expression, and inhibition of BMP signaling abolished HFE-induced hepcidin expression in Hep3B cells. HFE interacted with ALK3, inhibited ALK3 ubiquitination and proteasomal degradation, and increased ALK3 protein expression and its cell surface accumulation. The two HFE mutants associated with HH, HFE C282Y and HFE H63D, differently regulated ALK3 protein ubiquitination and trafficking, but both failed to increase ALK3 cell surface expression. Deletion of Hfe in mice resulted in a decrease in hepatic ALK3 protein expression. Our results provide evidence that HFE induces hepcidin expression via the BMP pathway: HFE interacts with ALK3 to stabilize ALK3 protein and increase ALK3 expression at the cell surface.

 

Nothing to Disclose: XW, YX

14336 15.0000 SUN-0359 A HFE Interacts with the BMP Type I Receptor ALK3 to Regulate Hepcidin Expression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Taek-Jeong Nam, Su-Jin Park*, Min-Kyeong Lee, Mi-Hye Kang, Young-Min Kim, In-Hye Kim, JinA Ryu, Jung-wook Choi and Youn-Hee Choi
Pukyong National University, Busan, Korea, Republic of (South)

 

Seaweeds have received a great deal of attention in recent years because they contain high amounts of proteins, vitamins, and minerals. Several polysaccharides in seaweeds have diverse biological activities, including effects on the immune system and cancer. Porphyra yezoensis is an intertidal marine red alga that has received increasing attention as a model organism owing to its important role in biological research. Although several studies have examined the polysaccharides found in extracts of P. yezoensis, the effect of specific proteins has not been reported. Therefore, this study examined this alga’s peptide activity on metastasis.

   The TGF-β1 signaling pathway induced cell apoptosis after P. yezoensis peptide (PPY) treatment, which may be related to a specific apoptosis pathway mediated by decreased Smad expression. These results suggest that restoration of Smad expression in MCF-7 cells is crucial for TGF-β1 to inhibit cell growth. Our results demonstrate that PPY inhibits Wnt/β-catenin signaling. In this study, we also examined the effect of cell–cell adhesion mechanisms (especially β-catenin) on specific pathways. We focused on cell inhibition, cell motility, and proliferation through decreased β-catenin by downregulation of Wnt, and explored whether PPY activates the Ras/Mek/Elk pathway in MCF-7 cells. Ras protein levels, as well as Raf or Mek levels, significantly decreased after MCF-7 cell exposure to PPY. These signaling pathways are known to be important for cell differentiation and proliferation. The antitumor and metastatic effect of PPY is known to be mediated by inhibiting the activation of TGF-β1 and Wnt/β-signaling, accompanied by decreased Ras signaling in MCF-7 cells.

 

Nothing to Disclose: TJN, SJP, MKL, MHK, YMK, IHK, JR, JWC, YHC

14522 16.0000 SUN-0360 A Inhibition of Metastasis By the Porphyra Yezoensis Peptide in MCF-7 Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Melissa A Riddle*, Luis Angel Leandry and Ronald Wayne Matheny Jr.
US Army Research Institute of Environmental Medicine, Natick, MA

 

The role of phosphoinositide 3-OH kinase (PI3K) in skeletal myogenesis is well-established; however, the contributions of individual PI3K catalytic subunits are much less well defined.  To study the role of the 110 kDa PI3K catalytic subunit β (p110β) in skeletal muscle differentiation, C2C12 murine myoblasts were treated with the p110β inhibitor TGX-221 or vehicle and allowed to differentiate for periods up to 96 hours.  Immunoflourescence analysis of fixed cells revealed that TGX-221-treated cells possessed ~38% less myogenin-positive nuclei than control cells 24h after onset of differentiation (P<0.001).  Additionally, the fusion index of TGX-221-treated myotubes was decreased by ~29% (P<0.01), myotube length was decreased by ~25% (P<0.001), and myotube diameter was decreased by ~14% (P<0.01) as compared to control cells 72h following onset of differentiation.  To define molecular mechanisms that regulated these observations, we next established protein and RNA transcript abundances of muscle-specific transcription factors and structural components.  As determined by Western blot, the abundance of myogenin and myosin heavy chain proteins were reduced by ~50% and ~40% at 24h and 48h following initiation of differentiation, respectively, in TGX-221-treated cells as compared to control cells (P<0.05 for both).  Forty-eight hours following onset of differentiation, TGX-221-treated cells showed a reduction in Ckm transcripts of ~40% (P<0.001), as well as reductions in expression of Myh3, and Myh8 of ~35%, and ~53%, respectively (P<0.01 for all) as compared to vehicle-treated control cells.  Seventy-two hours following onset of differentiation, TGX-221 treatment was associated with significant reductions in expression of Ckm (~28%), Myh2 (~32%), Myh3 (~26%), Myh7 (~31%), and Myh8 (~41%) (P<0.05 for all) as compared to control; and ninety-six hours following onset of differentiation, TGX-221 treatment was associated with significant reductions in expression of Ckm (~41%), Myh1 (~24%), Myh2 (~40%), Myh3 (~31%), Myh4 (~34%), Myh7 (~21%), and Myh8 (~42%) (P<0.05 for all) compared to vehicle control cells.  These findings indicate that inhibition of p110β catalytic activity represses expression of early myogenic transcripts (Ckm, Myh3, Myh8), which may lead to reduced expression of fast and slow myosin heavy chain transcripts (Myh1, Myh2, Myh4, and Myh7) and ultimately, myotube formation.  Overall, these data reveal that p110β regulates myogenesis in C2C12 cells.

 

Nothing to Disclose: MAR, LAL, RWM Jr.

14537 17.0000 SUN-0361 A Pharmacological Inhibition of PI3K p110beta Suppresses Myoblast Differentiation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Kelly Louise Walton*1, Justin L Chen1, Sara Layla Al-Musawi2, Paul Gregorevic3 and Craig Anthony Harrison4
1MIMR-PHI Institute of Medical Research, Clayton, VIC, Australia, 2MIMR-PHI Institute of Medical Research, Clayton VIC, Australia, 3Baker IDI Heart and Diabetes Institute, Melbourne, Australia, 4MIMR-PHI Institute of Medical Research, Clayton, Australia

 

Cancer cachexia is a state of severe frailty and fatigue, associated with pronounced loss of skeletal muscle and fat mass. In models of cancer cachexia, pharmacological blockade of the activin type II receptor, ActRIIB, not only prevents muscle wasting, but also restores previous muscle loss.  ActRIIB is a receptor for multiple TGF-β ligands; of these, we have shown that activins A and B are the most potent negative regulators of muscle mass. We used recombinant serotype 6 adeno-associated virus (rAAV6) vectors to increase circulating activin levels in C57BL/6 mice. Mice injected with control virus gained 10% of their starting-body mass over a 10 week period, whereas mice injected with activin encoding virus lost up to 12% of their body mass. Importantly, removal of activins completely restored body mass, highlighting the potential to target activin signalling in the treatment of cachexia.  To address this, we generated an activin specific antagonist by modification of the native activin B propeptide. Propeptides mediate the biosynthesis of all TGF-β ligands and, for some family members (e.g. TGF-β1), bind the mature growth factor with high enough affinity to confer latency. Based on the structure of Pro-TGF-β1, we designed specific activin propeptide-based antagonists. To increase stability, we fused the activin propeptide B to the Fc regions of a mouse IgG2A antibody. To enhance potency, the residues that confer latency to Pro-TGF-β1 were incorporated into the activin B propeptide by site-directed mutagenesis. The newly formed activin propeptide-Fc chimera inhibited activin A (IC50 1.5 nM) and activin B (IC50 3.5 nM) in vitro activity, with potency comparable to the activin antagonists, follistatin and ActRIIA/B (IC50 range 0.2-2 nM). Excitingly, the modified activin propeptide did not inhibit the closely related TGF-β ligands, myostatin and GDF-11, making it the first specific activin antagonist.  We used our adeno-associated viral model to assess the in vivo potential of the modified activin B propeptide. Injection of the tibialis anterior muscle of C57BL/6 mice with rAAV6:propeptide resulted in a significant increase (13%) in muscle mass, indicating that activin A and B contribute to the negative regulation of muscle mass. Next we injected the TA muscles of mice with rAAV6:activin (A or B) ± rAAV6:propeptide. As anticipated, mice injected with the activin viruses exhibited a marked reduction (35%) in muscle mass. Importantly, co-injection with the propeptide virus completely attenuated the activin-induced wasting in these mice. These results emphasise the in vivo potential of the modified activin B propeptide in the reversal of activin-induced muscle wasting.

 

Nothing to Disclose: KLW, JLC, SLA, PG, CAH

16684 18.0000 SUN-0362 A Reversal of Activin-Induced Muscle Wasting Using a Modified Activin B Propeptide 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Sunday, June 22nd 3:00:00 PM SUN 0345-0362 4816 1:00:00 PM Growth Factor/ Tyrosine Kinase signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Nicoleta C Olarescu*1, Lara A Householder2, Ellen R Lubbers2, Darlene E Berryman2, Edward O List2, Fabian Benencia2, John J Kopchick2 and Jens Bollerslev1
1Oslo University Hospital, Oslo, Norway, 2Ohio University, Athens, OH

 

Adipose tissue-derived mesenchymal stem cells (AT-MSC) are pluripotent stem cells with the ability to differentiate into adipocytes and osteoblasts, among other cells. Growth hormone (GH) has been shown to effect adipocyte differentiation, but the effect is highly dependent on the cell culture model used. That is, GH is found to stimulate the proliferation and inhibit differentiation of primary preadipocytes cell cultures while the opposite effects are described in clonal cell lines (1). Moreover, GH increases osteoblasts’ proliferation and differentiation (2). Additionally, activation of Wnt/β catenin signaling pathway leads to commitment of MSC towards osteoblasts on the expense of adipocytes (3).

The aim of this study was to elucidate the role of GH on AT-MSC differentiation using cells isolated from male GH receptor null (GHRKO), bovine GH transgenic (bGH) and wild-type (WTs) littermate control mice. AT-MSC from subcutaneous (Sc), epididiymal (Epi), and mesenteric (Mes) adipose tissue depots were isolated by flow cytometry (CD45- TER119- SCA1+ PDGRF+ cells). Their adipogenic and osteogenic differentiation capacity in vitro was determined by cell morphology and real-time RT-PCR.

Adipogenic differentiation of AT-MSC was only achieved in the Sc depot. Using identical in vitro conditions, the Epi and Mes depots did not accumulate lipids and expression of PPARγ and adiponectin genes, two markers of adipogenic differentiation, did not increase. Notably, we observed an increased differentiation capacity of Sc-GHRKO compared with Sc-WT cells. In contrast, an impaired differentiation was observed in Sc-bGH cells. Axin2 was increased in Sc-bGH adipocytes suggesting that Wnt/β catenin signaling pathway activation may be responsible for the decreased adipogenesis observed in these cells.

When cells were cultured under osteogenic conditions, bGH cells differentiated better compared to WT cells as estimated by determining the levels of RUNX2 and Osteocalcin gene expression. The Epi depot achieved the best differentiation, followed by the Sc and Mes depots in bGH cells. However, Sc-GHRKO cells did not differentiate.

In conclusion, we demonstrated that 1) the differentiation capacity of AT-MSC isolated by flow cytometry varies from depot to depot regardless genotype; 2) the lack of GH signaling increased the adipogenic but impaired osteogenic differentiation in AT-MSC from Sc depot; 3) GH effect on AT-MSC may be mediated by activation of the Wnt/β catenin signaling pathway.

In addition to the well described lipolytic effect, our results suggest that GH may diminish the amount of adipose tissue and increase bone mineral density by altering the fate of MSC towards osteoblastogenesis at the expense of adipogenesis.

 

Nothing to Disclose: NCO, LAH, ERL, DEB, EOL, FB, JJK, JB

14653 1.0000 SUN-0626 A Growth Hormone Signaling Influences the Fate of Adipose Tissue-Derived Mesenchymal Stem Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Edward O List*, Darlene E Berryman, Kevin Ray Funk, Adam Jara, Elizabeth A Jensen, Ross Comisford, Wenjuan Zhang, Jesse Kowalski and John J Kopchick
Ohio University, Athens, OH

 

In the mid 1990’s, our laboratory generated global GH receptor knockout mice (GHRKO).  Since then, these mice have proven to be an invaluable tool for uncovering the diverse actions of GH.  Many of these studies have pointed out the importance of GH in various tissues, such as liver and adipose tissue.  However, the specific contributions of these tissues to GH’s effect on physiology are difficult to discern in vivo since indirect actions of GH in other tissues can confound observations obtained in the global GHRKO mice.  Thus, we selectively disrupted GHR in adipose and liver tissue producing fat-specific GHR knockout mice (FaGHRKO) and liver-specific GHR knockout mice (LiGHRKO) to better clarify the effects of GH on these two tissues in vivo.  Many important findings were discovered in these lines.  We have recently published that FaGHRKO mice have significantly increased adiposity, yet are otherwise healthy with normal glucose metabolism (1). Recent data from LiGHRKO mice indicate that these animals are lean with a significant decrease in body fat and body size, and have impaired glucose metabolism.  Analysis of male and female LiGHRKO mice reveals a sex-specific development of fatty liver in males only but not in females.  One of the most interesting findings in our analyses of these two tissue-specific mouse lines is the serum adipokine profiles.  Unexpectedly, LiGHRKO mice have significantly increased levels of leptin, resistin, and adiponectin in circulation.  This adipokine profile is similar to global GHRKO mice despite the fact that global GHRKO mice are obese while LiGHRKO mice are lean with decreased adiposity compared to controls.  Thus, there appears to be a disconnect between adiposity measures and adipokine output by adipose tissue when the GHR is disrupted in liver, which suggests that hepatic GH signaling influences adipokine production in vivo.  Furthermore, FaGHRKO mice (which are expected to have a similar adipokine profile to global GHRKO mice since both lack GHR in adipose tissue and both are obese) show minimal changes to adipokines.  Taken together, these data suggest that GH stimulates crosstalk between liver and adipose tissue for adipokine production.

 

Nothing to Disclose: EOL, DEB, KRF, AJ, EAJ, RC, WZ, JK, JJK

14663 2.0000 SUN-0627 A GH Action in Liver but Not Adipose Tissue Influences Adipokine Production: Comparison of Fat-Specific and Liver-Specific GH Receptor (GHR) Knockout Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Yue Zhang*, Ashiya Buckels, Jing Jiang and Stuart J Frank
University of Alabama at Birmingham, Birmingham, AL

 

Melanoma is one of the most aggressive and treatment-resistant form of human cancers. It causes the ~75% of deaths related to skin cancer. In 60 human cancer cell lines from the National Cancer Institute (NCI) drug-screening panel (NCI-60 panel), melanoma cells have been found to have higher growth hormone receptor (GHR) than other type of cancer cell lines, such as colon, ovarian, renal, and prostate cancer cells.  In a recent study (1), metastatic melanoma samples were examined and GHR expression was found to be higher in more advanced stage samples.  This and other evidence suggest growth hormone (GH) signaling might play important roles in human melanoma biology.  GH, a 22kDa polypeptide hormone present in most vertebrates, is an important regulator of somatic growth and metabolism.  GH signals by interacting with GH receptor (GHR) to activate downstream signaling molecules, including JAK2 and STAT5.Using our anti-GHR and anti-JAK2 antibodies, as well as other immunochemical reagents, we have characterized several human melanoma cell lines, including SK-MEL-5 (MEL5) cells, which harbor the V600E BRAF oncogene mutation. In MEL5 cells, GH induced tyrosine phosphorylation of GHR, JAK2, and STAT5 in both dose-dependent (2-500 ng/ml) and time-dependent manners (2-60 min).  ERK was basally tyrosine phosphorylated, as anticipated with oncogenically-driven constitutive activation of upstream ERK pathway activators (Ras and Raf). GHR is a member of the cytokine receptor superfamily, which also includes prolactin receptor (PRLR). Human GH can activate both GHR and PRLR. Our previous studies demonstrate that monoclonal antibody, anti-GHRext-mAb, was able to block GH-induced signaling in several GHR-expressing cell lines by inhibiting GH-induced GHR conformational change. However, in human T47D breast cancer cells, PRLR expression resulted in diminished GH-induced GHR activation, and anti-GHRext-mAb, failed to inhibit GH-induced signaling in these GHR/PRLR co-expressing cells. PRLR was detected in MEL5 cells, and both GH and prolactin induced tyrosine phosphorylation of PRLR. In contrast to T47D breast cancer cells, pretreatment with either anti-GHRext-mAb or B2036, a GHR-specific GH antagonist, was able to inhibit GH-induced acute tyrosine phosphorylation of JAK2 and STAT5.  These results suggest the balance of GHR/PRLR in a particular cancer cell line might dictate GHR vs. PRLR utilization in response to GH, which could determine whether/which GHR-specific vs. PRLR-specific antagonists might be effective.

 

Nothing to Disclose: YZ, AB, JJ, SJF

13307 3.0000 SUN-0628 A Growth Hormone Signaling in Human Melanoma SK-MEL-5 Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Sara Siebel1, Sonia Rocha1, Javier Chaparro-Riggers1, Edward Pascua1, Kevin Lindquist1, Jeanette Dilley1, Zea Melton1, Nina Camacho-Hubner*2 and John Lin1
1Rinat, Pfizer Inc., San Francisco, CA, 2Pfizer Inc, New York, NY

 

Introduction: The pharmacological GH/GHR signaling blocker, Pegvisomant (Somavert®), has been shown to decrease serum levels of IGF-I, IGF-binding protein-3 (IGFBP-3) and acid labile subunit (ALS) in human and non-human primates, and is used to treat patients with acromegaly. The objective of this study was to develop and characterize antagonist antibodies targeted to human GHR and evaluate their pharmacodynamic properties in non-human primates.

Methods: Antibodies to human GHR were produced using hybridoma technology and screened by ELISA.  The antibodies’ ability to block the GH/GHR interaction was then assessed using biosensor technology. The murine antibody 13F10 and a humanized, affinity-matured version of 13F10 (RN172), were further characterized in cell signaling assays, using HEK293 cells overexpressing full length human or cynomolgus monkey GHR. GHR overexpressing cells were stimulated with 4.5nM human GH in the presence of anti-GHR antibodies, and inhibition of STAT5 phosphorylation was used as an indicator of blocking activity. GHR transfected cells were also used to test internalization of the RN172 antibody, as assessed by flow cytometry and confocal microscopy. To test the pharmacodynamic properties of the RN172 antibody in vivo, a dose response study was carried out in female cynomolgus monkeys. Baseline serum samples were collected from naïve animals, followed by a single IV injection of RN172 at a dose of 3, 10, or 30 mg/kg (n=2).  Serum samples were collected over the next two weeks and the serum was analyzed by ELISA for changes in IGF-I, IGFBP-3, and ALS.

Results: In cell-based assays, RN172 inhibited STAT5 phosphorylation in a dose-dependent manner in both cynomolgus and human GHR-transfected cell lines. Internalization of RN172 was also shown in these cell lines. In vivo, a single IV dose of RN172 was shown to lower serum IGF-I, IGFBP-3 and ALS levels in a dose-dependent manner in cynomolgus monkeys.

Conclusions: We have developed a humanized agonist antibody (RN172) targeting human GHR and shown it to block the GH/GHR interaction on biosensor, inhibit the phosphorylation of STAT5 in cell based assays, and down-regulate IGF-I secretion in vivo in cynomolgus monkeys.  Our in vitro characterization of RN172 shows inhibition of signaling in both cynomulgus and human GHR-overexpressing cells and internalization in GHR-transfected cells.  Since the RN172 antibody has been shown to inhibit IGF-I secretion in cynomolgus monkeys in vivo, we hypothesize that the RN172 would inhibit IGF-I production in humans as well. Such an antibody could provide an alternative to other therapeutic inhibitors of the GH/IGF-I axis in patients suffering from acromegaly.

 

Disclosure: SS: Employee, Pfizer, Inc.. SR: Employee, Pfizer, Inc.. JC: Employee, Pfizer, Inc.. EP: Employee, Pfizer, Inc.. KL: Employee, Pfizer, Inc.. JD: Employee, Pfizer, Inc.. ZM: Employee, Pfizer, Inc.. NC: Employee, Pfizer, Inc.. JL: Employee, Pfizer, Inc..

14936 4.0000 SUN-0629 A Humanization and Characterization of a Human Growth Hormone Receptor (GHR) Antagonist Antibody RN172 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Alona O Nakonechnaya*1, Christopher Pagano1 and Cynthia Gates Goodyer2
1McGill University, Montreal, QC, Canada, 2MUHC-MCH Rsrch Inst, Montreal, QC, Canada

 

Human growth hormone (GH) effects on target cells are exerted via a dimer of the growth hormone receptor (GHR) expressed on the cell membrane. Besides the full length form of the receptor (FL GHR), two truncated isoforms (TR GHR1-279 and TR GHR1-277) are produced from the same gene by alternative splicing at exon 9, resulting in receptors that bind GH but lack >97% of the intracellular domain. Relative amounts of the truncated isoforms are tissue-specific and can comprise up to 10% of the FL GHRmRNA produced (1,2). Following translation, TR GHRs are able to dimerize with the FL GHRs and are considered to serve as a dominant negative, as previously shown by inhibition of STAT5 phosphorylation (3). We have now examined the effect of TR GHR1-279 on JAK2, STAT5, SRC, ERK(1/2) and Akt pathways.

We transfected varying amounts (0-500ng) of a TR GHR1-279 expression vector in HEK293 cells followed by 250ng/ml GH stimulation for 0-60 min. We found that JAK2 and STAT5 activation by GH (0 vs. 10 min: p<0.01, p<0.001) was decreased to non-significance by 500 ng TR GHR1-279 in a dose-dependent manner. GH also induced phosphorylation (p) of ERK(1/2) (0 vs. 10 min: p<0.05) but, in this case, TR GHR1-279  had no effect. In contrast, GH decreased the high background levels of pSRC (0 vs. 10 min: p<0.01) and pAkt (10 vs. 30 min: p<0.05) in the wild-type HEK293 cells; the presence of TR GHR1-279 abolished the effect of GH on pSRC and pAkt levels were moderately altered.  

To understand how the TR GHR1-279 was able to interfere with multiple signaling pathways, we crosslinked HEK293 cells following transfection with 0-500ng of the TR GHR1-279 expression vector and 250 ng/ml GH for 15 min and analyzed the components of complexes with and without DTT using gradient SDS gels. Without DTT, we identified high molecular weight complexes (180kD to >500kD) that immunoreacted with antibodies for FL GHR, TR GHR1-279, SRC and JAK2. With DTT, the complexes dissociated into the individual components.

These results suggest that the FL and TR GHRs as well as the initial signaling components are localized together in the plasma membrane. Surprisingly, neither JAK2 nor SRC activation could provide a rationale for unchanging GH effects on ERK(1/2) stimulation in the presence of increasing amounts of  TR GHR1-279. Ongoing research is focused on alternative mechanisms of GHR pathway activation.

 

Nothing to Disclose: AON, CP, CGG

15011 5.0000 SUN-0630 A Effects of the Truncated Human Growth Hormone Receptor (GHR) on Downstream Signaling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Lara A Householder*1, Ozan Yigit Suer1, Kevin Ray Funk2, Kathleen Black1, Jesse Kowalski1, Vivian Lesende1, Edward O List1, John J Kopchick1 and Darlene E Berryman1
1Ohio University, Athens, OH, 2Ohio University, Edison Biotechnology Institute, Athens, OH

 

Reduction of growth hormone (GH) signaling with concomitant reduction in serum IGF-1 has been associated with extended lifespan and improved metabolism in a number of mutant mouse strains including Snell, Lit/Lit, Ames, and GH receptor knockout (GHR-/-) mice. Another strain of mice that expresses a GH receptor antagonist (GHA) also experiences a reduction in GH signaling but has not yet been fully characterized. Though aspects of their phenotype mirror those of the other models, they do not experience extended longevity. A recent study followed a cohort of GHA and WT mice, measuring body composition and serum glucose, insulin, leptin, and adiponectin levels from 6 to 82 weeks of age1. The study revealed GHA mice have a large spike in insulin levels at older age as well as significantly higher leptin and adiponectin levels indicating metabolic dysfunction with advancing age. The study failed to measure mouse length at any time point and only measured glucose tolerance and tissue weights at older time points. This project aims to more fully characterize GHA mice as they age by examining measures of body size, length and composition as well as tissue weights, glucose metabolism and plasma hormone levels in four different cohorts of mice, each at different age points: 6, 12, 18, and 24 months. Results confirmed that GHA mice are dwarf with significantly reduced weight and length at all age points. They also had reduced lean mass and increased fat mass at all time points compared to WT controls. When four main adipose tissue depots (subcutaneous, perigonadal, retroperitoneal, and mesenteric) were measured at dissection, the results showed that the higher fat mass in GHA mice was primarily due to expansion of the subcutaneous depot. Fasting blood glucose was also measured though few significant differences were found due to genotype, similar to the previous study1. Additionally, we found that GHA mice developed glucose and insulin intolerance earlier than WT mice with significant differences observed as early as 6 months. Our results demonstrate that GHA mice may be caught between two conflicting metabolic states: (1) obesity and (2) decreased GH action. While other mice with a reduction in GH action are considered “healthy obese” animals, GHA mice do not seem to enjoy the same metabolic benefits and are unable to override the detrimental effects of their obesity. Thus, they maintain a similar lifespan to their WT controls.

 

Nothing to Disclose: LAH, OYS, KRF, KB, JK, VL, EOL, JJK, DEB

14115 6.0000 SUN-0631 A Reduction of Growth Hormone (GH) Action in GH Antagonist Mice Results in a Dwarf and Obese Phenotype with Impaired Glucose Metabolism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Ozan Yigit Suer*1, Silvana Duran-Ortiz1, Riia Karoliina Sustarsic2, Callie Wood1, Edward O List1, Darlene E Berryman1 and John J Kopchick1
1Ohio University, Athens, OH, 2Medizinische Klinik und Poliklinik IV, Munich, Germany

 

The GH/IGF-1 axis is a key component of growth, metabolism, and lifespan. While the role of GH in the aging process is not fully understood, in humans, GH/IGF-1 levels naturally decrease with age and approach a nadir by 60 years of age. Previously, our laboratory created a murine germ line deletion in the GH receptor (GHR) gene that disrupted GHR signaling from conception. These mice, termed the GHR knockout mice (GHR-/-), are obese and dwarf with low IGF-1, low insulin, and high GH levels. They also have a low cancer incidence and an extended lifespan compared to littermate controls.

We further investigated the role of GH in the aging process by disrupting the GHR in adult mice. Mice with a ‘floxed’ GHR gene were crossed with mice that express a tamoxifen (TAM)-inducible ubiquitous Cre recombinase gene, ROSA26-Cre-ERT2. The GHR disruption was induced at 6 weeks of age via TAM administration, while control mice received an equal volume of vehicle, peanut oil (PO). Body composition, insulin sensitivity, and growth parameters were assessed. A subpopulation of the mice was dissected at 37 weeks of age to verify GHR disruption and to assess tissue weights.

These GHR knockdown mice showed a significant reduction in GHR expression within all examined tissues (liver, white adipose tissue depots, kidneys, gastrocnemius, and quadriceps) except in the heart. TAM mice displayed decreased growth and increased adiposity; mouse length as well as total and lean mass were significantly lower and relative fat mass was significantly higher in both female and male TAM mice compared to PO controls. As expected, the TAM mice demonstrated decreased IGF-1 and elevated GH levels. Insulin tolerance tests showed improved insulin sensitivity among TAM mice regardless of sex.

In conclusion, we generated a mouse with TAM-inducible knockdown of GHR. When inducing the knockdown at 6 weeks of age, these mice show reduced GHR expression in all tissues examined with exception of the heart. Similar to GHR-/- mice, these mice are small in size, obese, and insulin sensitive compared to controls. Additional investigations are ongoing to further characterize the effect of adult GHR gene disruption on long-term physiological parameters including longevity.

 

Nothing to Disclose: OYS, SD, RKS, CW, EOL, DEB, JJK

16219 7.0000 SUN-0632 A Characterization of Adult-Inducible Growth Hormone Receptor Gene Disrupted Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Ross Dobie*1, S F Ahmed2, Vicky E MacRae1 and Colin Farquharson3
1The Roslin Institute, Edinburgh, United Kingdom, 2Developmental Endocrinology Research Group, School of Medicine, University of Glasgow, UK, 3Roslin Institute, Edinburgh, United Kingdom

 

Growth hormone (GH) is a critical regulator of post-natal linear growth.   Although growth promoting therapy with recombinant human GH (rhGH) is effective in treating the majority of children with GH deficiency many children respond poorly to rhGH. Thus, it is unclear how we should manipulate the GH/IGF-1 axis to gain maximum and robust post-natal linear growth?  To develop such strategies we require a greater understanding of how GH dictates the pace of bone growth. The suppressor of cytokine signalling 2 (Socs2) knockout mouse has unregulated GH signalling and a gigantism adult phenotype despite no elevations in systemic GH or IGF-1 levels. However, a more detailed inspection of the Socs2-/- phenotype reveals that these mice are indistinguishable from wild-type (WT) littermates mates until 3-4 weeks of age.  These mice are therefore a unique animal model to understand better the regulatory mechanisms that control GH actions in early post-natal growth.

Two week-old male and female WT and Socs2-/- mice were administered (s.c) rhGH (3mg/kg) or vehicle twice daily for 14 days and growth was assessed by determining body weight gain.

From days 14-20 (phase 1) WT and Socs2-/- male mice were unresponsive to GH treatment. Whilst WT mice continued to be unresponsive, from days 21-27 (phase 2) the growth of Socs2-/- mice increased in response to GH and by day 27 the body weight and length of Socs2-/- mice was increased by (17%; p<0.05) and (6%; p<0.05), respectively compared to vehicle treated Socs2-/- male control mice. Female WT and Socs2-/- mice were also unresponsive to GH treatment during phase 1, however during phase 2 the body weights of both increased in response to GH when compared to their respective vehicle treated controls (WT: 36%; p<0.05, Socs2-/-:38%; p<0.05). Growth analysis of WT mice throughout the study period revealed a change in the growth rate between phase 1 and 2, independent of GH treatment.  During phase 1, male and female mice increased in weight 26% and 23% respectively whereas during phase 2, male and female mice increased their body weight by 45% and 28%, respectively. Having identified two distinct phases of growth, phase 1: GH and sex independent and phase 2: GH and sex dependent, we further aimed to determine the factors responsible for these changes. Local (bone) and systemic (liver) samples were analysed from day 17 (phase 1) and day 24 (phase 2) male and female WT mice. The expression of ghr and Igf1 mRNA were similar in bone and liver samples from 17 and 24 day-old male. Similarly, no differences in ghr and Igf1 expression were noted in bone and liver samples from male and female mice at 24 days.

These studies emphasise the critical role played by SOCS2 in regulating GH anabolic effects on body weight and bone length. Furthermore, age and sex specific factors are involved in regulating GH action and further studies are required to identify the precise factors and mechanisms involved.

 

Nothing to Disclose: RD, SFA, VEM, CF

16768 8.0000 SUN-0633 A Determining the Efficacy of GH Treatment: The Importance of Gender and Age 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Melody L. Allensworth-James*, Angela K. Odle, Anessa C. Haney, Mohsin M Syed, Noor Akhter and Gwen V. Childs
University of Arkansas for Medical Sciences, Little Rock, AR

 

Leptin is an important regulator of somatotrope function. Mice with somatotrope-specific deletion of exon 1 of LEPR showed reduced percentages of immunolabeled growth hormone (GH) cells and GH deficiency (GHD), with consequential metabolic problems and obesity.(1, 2) In studies of hormones affected by leptin, mutant females had mRNA levels reduced to 75% of control levels for GH (Relative Quantitation (RQ): 1.07±0.08 controls vs 0.7±0.04 mutants; p=<0.009, n=7) and to 50% for thyroid stimulating hormone (TSH) (RQ:1.0 ±0.17 controls vs 0.5±0.06 mutants; p=<0.02). Mutant males had 82% reductions in % cells with GH proteins and growth hormone releasing hormone receptors (GHRHR), but normal GH and TSH mRNA levels. Both sexes had normal mRNA levels for follicle stimulating hormone, luteinizing hormone, prolactin, GHRHR, and ghrelin. We next identified regulatory pathways activated by leptin in control cells exposed to 3 μM Actinomycin D (Act D) or 0.1 and 1 μM STAT3 Inhibitor Peptide (Millipore, STAT3i) for 1 h followed by 100 nM leptin for 3 h. Leptin alone stimulated 1.65X more GH storing cells: 26±9% to 43±1% (p<0.0001) of pituitary cells. Both Act D and STAT3i had no affect on %GH cells alone, but inhibited the stimulatory actions of leptin. We then tested ghrelin’s restorative actions on mutant cells. Ghrelin did not restore basal or GHRH-stimulated GH secretion from LepR exon 1 null somatotropes, as it did from LepR exon 17 null somatotropes (3), reflecting the more severe deletion; i.e., loss of exon 1 removes all isoforms of LepR, whereas ablation of exon 17 removes only the JAK binding site. Ghrelin alone or with 1 nM GHRH stimulated GH stores, bringing the %GH cells to basal control levels [from 15.9±0.8% to 24±1% (p<0.0001)]. Ghrelin and 3 nM GHRH stimulated levels that were higher than controls (33±2%, p<0.0001), but not as high as values seen in somatotrope LepR exon 17 null mice.(3) We used L-NAME with control cells to confirm that ghrelin requires activation of the nitric oxide pathway to stimulate GH stores.(4) L-NAME had no effect alone, nor did it affect leptin stimulation. To summarize, ablation of LepR exon 1 in somatotropes does not affect pituitary mRNA levels in males; however, it does reduce TSH and GH mRNA levels in females, suggesting that leptin has sex-specific regulatory effects on GH and TSH cells. These studies also show that leptin increases %GH cells above resting control levels through transcription using the JAK/STAT pathway. This explains the lower GH mRNA levels seen in female LepR exon 1 null somatotropes. However, in male LepR-null somatotropes, GH protein levels are reduced while GH mRNA levels are not, suggesting post-transcriptional action. Ghrelin’s ability to restore somatotrope function following LepR exon 17 deletion, but not after LepR exon 1 deletion, suggests that the receptor isoforms remaining after the LepR exon 17 ablation may be able to signal through another pathway.

 

Nothing to Disclose: MLA, AKO, ACH, MMS, NA, GVC

15319 9.0000 SUN-0634 A Exploring Mechanisms Underlying Leptin Actions on Somatotropes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Camilla AM Glad*1, Per-Arne Svensson2, Fredrik H Nyström3, Peter Jacobson2, Lena MS Carlsson2, Gudmundur Johannsson4 and Johanna C Andersson-Assarsson2
1Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and The Department of Endocrinology-Diabetes-Metabolism, Sahlgrenska University Hospital, Gothenburg, Sweden, 2The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden, 3Division of Cardiovascular Medicine at Linköping University, Linköping, Sweden, 4Sahlgrenska University Hospital, Gothenburg, Sweden

 

Growth hormone (GH) is a well-known regulator of energy metabolism and body composition. In healthy adults, both spontaneous and stimulated GH secretion is strongly and inversely associated with visceral adiposity, independent of age and sex. In fact, the adipose tissue is one of the major response tissues of GH action and GH efficiently stimulates lipolysis. GH receptors (GHR) have been shown to be abundantly expressed; however GHR mRNA expression in human adipose tissue in response to nutritional cues is less defined. To characterize GHR mRNA expression levels in human adipose tissue we used DNA microarray profiles from four different  studies on human adipose tissue, namely 1) expression profiles from a set of 65 human tissues acquired from the GEO database (data set GSE3526), 2) a set of 180 genetically unrelated obese men and women, 3) a set of 40 obese adult subjects subjected to a 16 week 450kcal/day very-low calorie diet (VLCD) study and finally 4) a 4 week over-feeding study on six healthy subjects subjected to a fast-food (FF) diet rich in proteins and saturated fat. In all four studies, Affymetrix U133Plus2.0 DNA microarrays were used, and GHR mRNA expression was analyzed using probe-set 205498_at. We found that 1) GHR gene expression was specifically high in GH responsive tissues (adipose tissue, muscle and liver), with the highest expression found in omental adipose tissue, 2) GHR gene expression and body mass index (BMI) was strongly and  inversely correlated, such that subjects with high BMI had lower GHR gene expression (p<0.0001), 3) adipose tissue GHR gene expression was significantly increased after 8 and 16 weeks of VLCD as compared to baseline (p=0.03 and p=0.01, respectively). Between week 16 and 18 when regular food was gradually introduced, the average body weight was unchanged but GHR gene expression decreased (p=0.06), indicating that caloric intake is indeed an important regulator of GHR gene expression in adipose tissue. In accordance with the VLCD findings we found that 4) GHR gene expression was significantly decreased in response to a 4 week FF diet (p=0.03). Collectively, these data show that GHR mRNA is highly expressed in human adipose tissue and that the expression is inversely correlated to BMI. In addition, we show that adipose tissue GHR gene expression is highly responsive to nutritional cues.

 

Disclosure: GJ: Speaker, Pfizer, Inc., Speaker, Novo Nordisk, Speaker, Otsuka, Consultant, Viropharma, Consultant, Astra Zeneca. Nothing to Disclose: CAG, PAS, FHN, PJ, LMC, JCA

15788 10.0000 SUN-0635 A Characterization of Growth Hormone Receptor (GHR) Gene Expression in Human Adipose Tissue 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Jessica M. Adams*1, Veronica Otero-Corchon2, Johannes D Veldhuis3, Nathan Qi2 and Malcolm James Low2
1University of Michigan, Ann Arbor, MI, 2University of Michigan Medical School, Ann Arbor, MI, 3Mayo Clinic & Graduate School of Medicine, Rochester, MN

 

We previously found using intensive random blood sampling that mice of both sexes lacking SST (Sst-KO) had elevated nadir and median GH levels, however somatic growth and sexual dimorphism in body size were unaffected (1). Based on the altered liver expression profile in these mice of a few assayed genes that are influenced by sex differences in GH secretion, we hypothesized that SST is necessary to produce the typical male pulsatile GH pattern. To test this hypothesis, we collected blood using a Culex (BASi, Inc.) automated sampling system from unrestrained, freely behaving wild-type (WT) and Sst-KO male and female mice implanted with carotid artery cannulas (n = 5-8). 10 ul blood samples were collected serially every 15 min over 11 h during the night. Mouse GH was assayed using a commercial ELISA (Millipore). We also performed an Affymetrix microarray analysis of mRNA isolated from liver to measure global gene-expression profiles. Deconvolution analysis of the GH data revealed no sex or genotype differences in the total amount of GH secreted or the length and number of secretory bursts during the collection period. However, the fraction of GH that was secreted in bursts, as opposed to basal release, was significantly lower in Sst-KO males than in WT males (32.7 ± 6.3% vs. 76.3 ± 15.3%, means ± SD, t-test, P < 0.0001) and more closely resembled WT and Sst-KO females (58.7 ± 31.9% and 58.6 ± 25.9%). The sex-biased effect of SST-deficiency on GH secretory dynamics in male, but not female mice, was largely paralleled by the hepatic gene expression data, although two nonconforming groups of genes emerged. Of the 115 most significantly differentially regulated and annotated genes among the 4 groups (FDR < 0.05 and fold change > 4), 86 were feminized in the Sst-KO males, 2 of which have been confirmed by qPCR to date. There were no genotype differences in females for 65 of those 86 genes, 18 of them were ultra-feminized and only 3 were masculinized in the Sst-KO females. Another group of 10 autosomal genes showed either male or female predominant expression in WT mice that was retained in the Sst-KO mice. Finally, 19 genes were differentially regulated in Sst-KO mice regardless of sex and in the absence of a sexually dimorphic expression pattern in WT mice, suggesting an alternative GH-independent role of SST in the regulation of these genes. Our data are consistent with a model whereby phasic inhibition of pituitary GH secretion by SST is essential for generating the prolonged inter-pulse nadirs of circulating GH in WT males compared to females. However, the retention of GH secretory bursts in Sst-KO mice suggests that SST is not required for the intrinsic pulsatility of hypothalamic GHRH release in either sex. The pattern of GH secretion in Sst-KO males closely resembles that of WT females leading to wide-spread, but not universally predictable, alterations in sexually dimorphic hepatic gene expression.

 

Nothing to Disclose: JMA, VO, JDV, NQ, MJL

15914 11.0000 SUN-0636 A Somatostatin Is Essential for the Expression of Sexually Dimorphic GH Secretion in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Kirsten Mense*, Marie Meyerholz, Hendrike Knaack, Martina Hoedemaker and Marion Piechotta
University of Veterinary Medicine, Hannover

 

It was previously described that IGF-I and GH blood concentrations increase during estrus in dairy heifers. Recent findings suggest that the hepatic GHR signaling pathway may be suppressed by the induction of suppressors of cytokine signaling (SOCS) through estrogenes. The aim was to examine GH, IGF-I and IGF-II blood concentrations and mRNA expression of the signaling pathway components during follicular phase (FP; estrogene dominated) and luteal phase (LP; progesterone dominated). Ovarian ultrasound was performed during physiological cycles (n=56) of 30 Holstein Friesian heifers to determine FP (24-60 h after appearance of clinical estrus signs) and LP (Day 12 ± 1 after ovulation). Blood samples and liver biopsies were taken and estrogen, P4, IGF-I, IGF-II and GH blood concentrations were measured. In liver biopsies, the mRNA expression of ERα, GHR, JAK2, STAT5B, SOCS2, SOCS3, IGF-I, IGF-II was determined by qPCR. In retrospect, FP samples were sub divided into samples taken ante- (ante-ov; n=7) vs. post-ovulationem (post-ov; n=49). Estrogen concentrations were higher ante-ov (34.7 ± 5.3 pg/ml) than post-ov (14.7 ± 0.8 pg/ml; P=0.002). IGF-I and GH concentrations were higher during FP (333.0 ± 73.6 and 11.9 ± 12.7 ng/ml) compared to LP (260.1 ± 59.8 and 5.8 ± 4.9 ng/ml) (P<0.0001). The IGF-II concentrations were lower in FP (49.2 ± 8.1 ng/ml) compared to LP (56.3 ± 9.4 ng/ml) (P<0.0001). No differences in GH, IGF-I or IGF-II blood concentrations were observed when comparing ante-ov with post-ov (P>0.05). The hepatic GHR expression tended to be higher in FP (69. 9 ± 31.4) compared to LP (61.6 ± 30.7) (P<0.1). The GHR was higher expressed in biopsies obtained ante-ov (98.8 ± 45.8) compared to post-ov (65.8 ± 27.1) (P<0.05). Interestingly, the SOCS2 expression was higher in FP (15.0 ± 9.7) compared to LP (12.5 ± 9.7; P<0.05). Moreover, SOCS2 was significantly higher expressed ante-ov (25.7 ± 12.9) than post-ov (13.5 ± 8.3; P<0.01). The data suggest that estrogen may have a positive effect on GHR expression. But in contrast to the supposed inhibitory effect of SOCS2, an increased hepatic SOCS2 expression during the estrogen dominated FP correlates with higher IGF-I serum concentrations. Parallel to high IGF-I serum concentrations, the hepatic IGF-I mRNA was not increased and it can be speculated that SOCS2 expression already inhibited the IGF-I expression but plasma concentrations were still high due to a prolonged half-live through binding proteins.

 

Nothing to Disclose: KM, MM, HK, MH, MP

14691 12.0000 SUN-0637 A Hepatic Ghr and SOCS2 Expression Is Influenced By Physiological Cycle Stages in Dairy Heifers 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Yan Bai1, Nicholas Silva1, Takeshi Akama1 and Cunming Duan*2
1University of Michigan, 2Univ of Michigan, Ann Arbor, MI

 

Human colon cancer cells proliferate when cultured in low extracellular Ca2+ levels ([Ca2+]) and form colonies in soft agar. When the extracellular [Ca2+] level is increased to 1 mM or higher, monolayer growth slows and colony formation is suppressed. The mechanistic basis underlying these [Ca2+]-induced changes is poorly understood. Here we report that extracellular [Ca2+] alter colon cancer cell responses to IGFs. While human colon cancer cells underwent proliferation in response to IGF stimulation in low [Ca2+] media, this mitotic response was not observed in cells grown in normal [Ca2+] media. When stimulated by IGF-2, cells in the normal [Ca2+] group showed significantly reduced pAkt activation compared to those in the low [Ca2+] group. Likewise, IGF treatment caused a highly significant increase in p85 and PDK1 phosphorylation in the low [Ca2+] group, whereas it had limited effect in the normal [Ca2+] group. In contrast, IGF treatment caused similar increases in the pIGF1R levels in the normal and low [Ca2+] groups. These results suggest that IGF signaling is suppressed in colon cancer cells under normal [Ca2+] condition and this regulation occurs at a step downstream of the IGF1R but at or above PI3K. We next examined the possible effects of [Ca2+] on the levels of p85 and IRS proteins. No difference was detected in the levels of p85. Compared to those of the low [Ca2+] group, the IRS-2 levels cells in the normal [Ca2+] group were significantly lower. RT-PCR analysis showed no significant difference in IRS-2 mRNA levels, suggesting that the changes in IRS-2 protein levels are due to post-transcriptional regulation. To determine whether the Ca2+-dependent calpains are involved in this regulation, the calpain inhibitor ALLN was added. ALLN treatment resulted in a marked increase in the IRS-2 levels in the presence or absence of IGF-2. Addition of ALLN resulted in a notable increase in basal and IGF-2-induced pAKT levels. These findings suggest that the calpain-mediated IRS-2 degradation may be part of the mechanisms by which IGF signaling is suppressed in colon cancer cells under normal [Ca2+] condition.

 

Nothing to Disclose: YB, NS, TA, CD

15086 13.0000 SUN-0638 A Suppression of IGF Signaling By Extracellular Ca2+ Via Calpain-Mediated IRS-2 Degradation in Colon Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Thomas Berton*1, Isabel Lambertz1, Claudio Conti1 and Robin S L Fuchs-Young2
1Texas A&M Health Science Center, College Station, TX, 2Texas A&M University Health Science Center, College Station, TX

 

Insulin-like growth factor 1 (IGF-1) plays a critical role in breast cancer (BrCa) development, due to its mitogenic and anti-apoptotic effects on mammary epithelium, which stimulate terminal end bud (TEB) formation and ductal elongation.  Although still controversial, some epidemiological studies have shown that high circulating levels of IGF-1 correlate to increase BrCa risk. Elevated levels of IGF-1 in African American (AA) women have also been identified as a possible contributor to BrCa outcome disparities. Interestingly, young, pre- and peripubertal AA girls have significantly higher circulating levels of IGF-1 than their age-matched Caucasian counterparts. These higher levels of IGF-1 in AA girls may account for accelerated development and attainment of larger stature, as well as the increased incidence of early onset and aggressive BrCa subtypes in AA women. To investigate the effect of IGF-1 on mammary tumorigenesis, our lab has characterized the BK5.IGF-1 transgenic (Tg) model, which recapitulates the paracrine/juxtacrine effects of IGF-1 exposure on mammary epithelium. Our studies have shown that Tg glands have an increased number and size of TEBs and are more susceptible to both carcinogen-induced and spontaneous mammary tumorigenesis. Molecular analyses revealed that Tg glands from prepubertal mice have increased PI3K/Akt activation and cell proliferation compared to WT glands, while postpubertal glands do not, leading us to hypothesize that exposure to elevated IGF-1 during early mammary gland development elevates BrCa risk though the expansion of mammary stem cell (MaSC) population. To investigate this, we conducted flow cytometric analysis of the MaSC population in glands from Tg and WT littermates at 4.5 and 9 weeks of age and assessed mammosphere-forming potential. Pre- and postpubertal glands from Tg mice had 2.3-fold and 1.6-fold more CD24low+/CD29hi/Sca-1-/CD49fhi cells compared to age-matched WT mice, respectively, indicating that Tg IGF-1 increased the number of MaSCs during development and maintained this population after puberty.  Our data also show that the frequency of mammosphere formation by Tg mammary epithelial cells (MECs) was 3.0-fold greater than WT MECs, suggesting that IGF-1-signaling stimulated growth and/or survival of sphere forming cells. These results indicate that elevated IGF-1 levels during early development contribute to the expansion and maintenance of MaSCs, increasing the proportion of self-renewing pluripotent cells that are potential carcinogen targets/cancer initiators. Furthermore, these data reveal a novel mechanism for the increased likelihood of AA women to develop aggressive, early onset and treatment refractory BrCa, and suggest the need to revisit the correlation of IGF-1 levels at the time of diagnosis, because IGF-1-mediated risk is determined during early breast development.

 

Nothing to Disclose: TB, IL, CC, RSLF

16557 14.0000 SUN-0639 A Exposure to Elevated IGF-1 during Early Mammary Gland Development Expands the Mammary Stem Cell Population and Increases Tumor Susceptibility 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Amer Youssef*1 and Victor Khin Han2
1Children's Health Research Institute - Western University, London, ON, Canada, 2Children's Hlth Rsrch Inst, London, ON, Canada

 

Placental mesenchymal stem cells (PMSCs) are readily available multipotent stem cells for use in regenerative therapies. The microenvironment of PMSCs is dynamic throughout gestation and determines changes in cell fate.  For optimal stem cell identity and fate manipulation, PMSCs must be maintained in culture conditions that mimic the in vivo microenvironment.  In vivo, PMSCs develop in low oxygen tension and varying insulin-like growth factor (IGF, IGF-I and IGF-II) concentration that increase gradually as pregnancy progresses. However, the signaling of IGF-I or IGF-II in low oxygen tension microenviroenment in stem cells is not well investigated. Therefore, we hypothesize that IGF-I and IGF-II signal via distinct signaling pathways to maintain PMSC multipotency under low oxygen tension. PMSCs from early human placentae were used to investigate the role of IGF-I and IGF-II on proliferation, multipotency and signaling through ERK1/2 and AKT pathways. we found that low oxygen tension enhanced the expression of IGF-II greater than IGF-I, which was reduced. IGF-I simulated higher phosphorylation of IGF-IRβ, ERK1/2 and AKT that were reduced in low oxygen tension. Proliferation was increased by IGFs and was enhanced further by low oxygen tension. Neutralization of IGF-IR inhibited PMSC proliferation in room air, whereas in low oxygen tension, PMSCs utilized IR to mediate IGF actions. We observed that low oxygen tension increased IR expression level. We conclude that maintaining PMSCs under low oxygen tension and appropriate IGF concentrations will maintain stem cell characteristics in vitro, that are mediated cooperatively between the IGF-IR and the IR. Therefore, understanding the in vivo microenvironment of stem cells can improve their use for in vitro application in tissue regenration therapy.

 

Nothing to Disclose: AY, VKH

16126 15.0000 SUN-0640 A Low Oxygen Tension Modulates the Insulin-like Growth Factor Signaling Via Insulin-like Growth Factor-I Receptor and Insulin Receptor to Maintain Stem Cell Identity in Placental Mesenchymal Stem Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Andrea L Jones*1, Elisavet Aikaterini Agathou1, Roberto Salvatori1, Andrew Wolfe1, Sally Radovick2 and Christopher Joseph Romero1
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins School of Medicine, Baltimore, MD

 

Introduction:     GHRH and somatostatin are produced in the hypothalamus and are thought to be the primary positive and negative regulators of the somatotroph in the GH axis, respectively. Other factors, such as IGF-1, are also known to provide feedback regulation. Our laboratory has previously demonstrated the importance of direct pituitary IGF-1 negative feedback with a mouse model in which the IGF-1 receptor (IGF-1R) was selectively ablated in the somatotroph.  The model also suggested that IGF-1 feedback may indirectly affect somatotroph regulation via the hypothalamus. Little is known, however, about the importance of IGF-1 feedback to the hypothalamus and its relative importance in regulation of the GH axis. We developed a knockout mouse in which the IGF-1R was selectively ablated from the GHRH-expressing neurons (GIGFRKO) to allow for the study of the mechanism and role of IGF-1 feedback at the level of the hypothalamus.

Methods and Results:   We used the Cre/loxP strategy, crossing a transgenic female mouse bearing a Cre recombinase gene inserted downstream from the mouse GHRH promoter (cloned in our laboratory) to a male mouse bearing loxP sites flanking exon 3 of the IGF-1R. The presence of the recombinant allele was confirmed by PCR. Sera from fasting three week-old female GIGFRKO and control mice were obtained for measurement of GH, PRL, LH, and FSH using the Milliplex Map Mouse Pituitary Panel (Millipore). The mean serum GH was lower in GIGFRKO than in control mice (1.04 ± 0.615 vs. 6.24 ± 0.971 ng/ml, P < 0.01). Serum PRL, LH, and FSH were not significantly different between the control mice and the GIGFRKO mice. Measurement of relative gene expression showed that GIGFRKO mice had a 2.1-fold increase in pituitary GH mRNA and a 0.55-fold decrease in hypothalamic somatostatin mRNA levels as compared with control littermates.

Conclusions:      We have developed a new mouse model to study the significance of IGF-1 negative regulation on the GH axis at hypothalamic level. GIGFRKO mice demonstrated lower levels of serum GH, but higher pituitary GH mRNA levels and lower hypothalamic somatostatin levels. We hypothesize that the primary role of GHRH neurons is as a GH set point regulator that acts by controlling the release of GH, and that the ablation of the IGF-1R interrupts the ability of the GHRH neurons to respond to low serum GH levels. Intact IGF-1 signaling in the somatostatin-expressing neurons may contribute to the increased GH production, but is unable to modulate its release. This mouse model further validates in vivo that IGF-1 feedback plays a physiologically important role in the GH regulatory pathway.

 

Disclosure: RS: Advisory Group Member, Ipsen, Investigator, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Pfizer, Inc.. Nothing to Disclose: ALJ, EAA, AW, SR, CJR

15196 16.0000 SUN-0641 A Targeted Disruption of GHRH Neuron Insulin-like Growth Factor-1 Signaling in a Cell-Specific Knockout Mouse Model 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Ajay Kumar*1, Bhanu Kalra1, Koushik Chowdavarapu1, Shivani Shah1, Gopal Savjani1 and Claus Oxvig2
1Ansh Labs, Webster, TX, 2Aarhus University, Aarhus, Denmark

 

Relevance: Insulin-like growth factor-1 (IGF-1) is a 7.6kDa, 70aa residue peptide. IGF-1 is primarily produced by the liver and circulates in the blood as an endocrine hormone. It is also produced locally by various tissues as a paracrine/ autocrine factor. IGF-1 found in circulation is primarily in a high molecular weight tertiary complex with IGF-binding protein-3 and acid-labile subunit. The unbound or free portion of IGF-1 in circulation is considered as the bioactive part as it is not inhibited by any binding proteins. Beyond its well-established mitogenic and metabolic functions, studies have shown the importance of IGF-1 and its use as a biomarker in detecting acromegaly and gigantism. Epidemiological studies have also linked elevated IGF-1 levels to increased cancer risk.

Methodology:  Bioactive and Total IGF-1 ELISAs were developed to measure unbound, total (acidified and neutralized) IGF in serum in 1.5 hours. Multiple mAbs were selected based on their high affinity and specificity to unbound full-length IGF-1 and no binding affinity to IGFBP-complexes. The antibody pair used in the bioactive IGF-1 assay measures >99% of unbound IGF-1 and does not cross-react with IGF-II and IGF-1-BPs. The same antibody pair measures Total IGF-1 levels by way of acidification and neutralization of samples, which dissociates the various IGF-1 and IGF-1-BP complexes, prior to assaying. In addition, a Mouse/Rat IGF-1 kit has been developed using a different pair of mAbs and measures Total IGF-1.

Validation: The analytical sensitivity of the Total and Bioactive assays, as calculated by the interpolation of mean plus two standard deviations of 20 replicates of zero calibrator and calibrator B (0.48 ng/mL) was 0.025 ng/mL. Total imprecision calculated on four samples, run in duplicates over six runs was 6.35% at 2.087 ng/mL, 5.97% at 8.191 ng/mL, 6.39% at 1.708 ng/mL and 5.17% at 4.794 ng/mL Inhibition up to 97% was observed when IGFBP-3 was spiked into IGF-1 in excess. The Bioactive IGF-1 and Total IGF-1 ELISAs did not correlate when measured in serum (R² = 0.186) or ascites from ovarian cancer (R² = 0.026) indicating to be an independent biomarker. Potential interferents hemoglobin (1.35mg/mL), triglycerides (5mg/mL) and bilirubin (0.5mg/mL) yielded average interference of 8.0%, 5.2%, and 12.1% respectively in the Bioactive IGF-1 assay and -4.8%, 10.5%, and -3.0%, respectively, in the Total IGF-1 assay.

Conclusion:  Highly reproducible Bioactive and Total IGF-1 ELISAs have been developed to measure total and free IGF-1 in serum and other biological fluids. Use of same antibody pair and identical calibrators (standardized to WHO code 91/554) enables researchers to measure the true ratio of unbound IGF-1 and total IGF-1 levels in circulation by means of differential sample treatment. Mouse/Rat IGF-1 ELISA provides researchers an additional tool to study circulating IGF-1 in mouse/rat model.

 

Nothing to Disclose: AK, BK, KC, SS, GS, CO

16089 17.0000 SUN-0642 A Development of IGF-1 ELISA Assays to Measure Free and Total Circulating IGF-1 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Hitoshi Nishizawa*1, Genzo Iguchi2, Hidenori Fukuoka2, Michiko Takahashi1, Kentaro Suda1, Hironori Bando1, Ryusaku Matsumoto1 and Yutaka Takahashi1
1Kobe University Graduate School of Medicine, Kobe, Japan, 2Kobe University Hospital, Kobe, Japan

 

Background

Recently, we have reported that nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are frequently observed in patients with adult GH deficiency (AGHD) and GH replacement therapy ameliorates these conditions (1, 2). Intriguingly, GH-deficient rat exhibits NASH and IGF-I improves steatosis and fibrosis (3), indicating that IGF-I plays an important role in the liver and may have a therapeutic application for a treatment of NASH and liver cirrhosis. It is well known that activation of hepatic stellate cells (HSCs) exerts a pivotal role in the progression of fibrosis. Recently, it has been reported that cellular senescence of those cells inhibits the activity and protects from fibrosis. P53 is an essential protein in cellular senescence and in p53-null mice (p53KO), activation of HSCs is impaired and the fibrosis was limited (4). The aim of this study was to explore the effect of IGF-I on general NASH and cirrhotic animal models and to clarify the underlying mechanisms.

Methods

Methionine-choline-deficient diet-fed db/db mice (MCD) and Dimethylnitrosamine-administered mice (DMN) were used as a NASH and cirrhotic animal model, respectively. Methionine-choline-deficient diet-fed p53-null mice (p53) were used for analysis of the involvement of cellular senescence. We also examined the effect of IGF-I on the liver and primary rat HSCs.

Results

IGF-I decreased visceral adiposity and improved insulin sensitivity in MCD. IGF-I significantly ameliorated steatosis (liver TG content; 1047.8±53.8 vs. 822.1±106.3 mg/tissue, p<0.05) and fibrosis (relative fibrotic area 100±7 vs. 30±3 (%), p<0.05) in MCD. Furthermore, IGF-I significantly ameliorated fibrosis (relative fibrotic area 100±15 vs. 57±9 (%), p<0.05) in DMN. In a mechanistic insight, IGF-I treatment restored mitochondrial function in hepatocytes concomitant with a reduced oxidative stress in the liver. Intriguingly, IGF-I receptor was strongly expressed in HSCs and IGF-I induced cellular senescence of HSCs in vitro (MCD) and in vivo (primary hepatic stellate cells). Convincingly, IGF-I did not improve fibrosis in p53KO, demonstrating that the action of IGF-I is p53-dependent.

Conclusion

These results suggest that IGF-I is efficacious for the treatment of general NASH and liver cirrhosis. IGF-I improved visceral obesity, enhanced oxidative stress, and impaired mitochondrial function. In addition, we have shown a novel underlying mechanism, in which IGF-I induce cellular senescence of HSCs and protects from fibrosis.

 

Nothing to Disclose: HN, GI, HF, MT, KS, HB, RM, YT

14323 18.0000 SUN-0643 A IGF-I Ameliorates Hepatic Fibrosis in Mouse Models of Nonalcoholic Steatohepatitis and Cirrhosis By Inhibiting the Hepatic Stellate Cell Activity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Marie Meyerholz*1, Kirsten Mense1, Matthias Linden2, Hendrike Knaack1, Elisa Wirthgen3, Andreas Hoeflich4, Michael Steufmehl5, Olivier Sandra6, Christoph Richard6, Martina Hoedemaker1 and Marion Piechotta1
1University of Veterinary Medicine, Hannover, 2Leibniz University Hannover, Hannover, 3Ligandis GbR, 4Leibniz Institute for Farm Animal Biology, Dummerstorf, 5University of Veterinary Medicine, 6INRA - Centre de Jouy-en-Josas, Jouy-en-Josas, France

 

The somatotropic axis plays an important role for embryonic growth and development. However, less is known about the effect of early pregnancy (embryo signaling) on the maternal GH-IGF-system. The aim was to investigate endocrine endpoints of the somatotropic axis in pregnant vs. non-pregnant dairy heifers until d18 of pregnancy. Blood samples of Holstein Friesian heifers (n=30) were taken on d0 (day of ovulation, defined by ultrasonography) and days 7, 14, 16 and 18 in repeated consecutive pregnant (p) and non-pregnant (np) periods. Additionally, liver biopsies were taken on d18. Heifers received artificial insemination or embryo transfer and pregnancy was verified either on d18 (P4 >2.0 and successful recovery of a conceptus [n=12]) or retrospectively on d42 (detection of embryonic heart beat [n=21]). The cows were defined as non-pregnant on d18 if P4 was <2.0 and no conceptus was recovered (n=29). Out of 62 periods, 38 were selected to build 19 pairs (np-p or p-np) for analysis by ANOVA as repeated measurements. Concentrations of progesterone, estrogens, GH, IGF-I and IGF-II were measured by the use of validated immunoassays. The blood concentration of IGFBP-2 to -4 at d0, d14 and d18 was determined using a quantitative western ligand blot. Hepatic mRNA expression of GHR, IGF-I, IGF-II, IGFBP-2 to -4 was detected by qPCR. At d18 the IGF-I [ng/ml] serum concentration tended to be lower in pregnant compared to non-pregnant heifers (284.9±82.6 vs. 321.8±81.6; P=0.082). In both groups IGF-I decreased from d0 to d16 (P<0.001) and increased towards d18 in pregnant (P<0.05) and in non-pregnant (P<0.001) heifers. The IGF-II [ng/ml] concentrations between pregnant and non-pregnant were comparable and increased in both groups between d0 and d14 (P<0.05). At d18, the IGFBP-4 [µg/ml] blood concentration was lower in pregnant (0.44±0.26) compared to non-pregnant heifers (0.75±0.36) (P=0.012). In liver biopsies IGFBP-3 expression tended to be lower in pregnant compared to non-pregnant cows (P<0.1). The reduced maternal serum IGFBP-4 may be due to enhanced proteolytic activity and as IGFBP-4 can inhibit IGF-I action, these data propose, that it may also lead to increased free IGF-I levels, potentially useful for local action at the cellular level e.g. in the endometrium of pregnant individuals.

 

Nothing to Disclose: MM, KM, ML, HK, EW, AH, MS, OS, CR, MH, MP

14945 19.0000 SUN-0644 A Maternal IGFBP-4 Concentration Is Lower in Pregnant Than in Non-Pregnant Dairy Heifers at Day 18 of Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0626-0644 4818 1:00:00 PM GH and IGF action Poster

Ryota Terashima1, Titaree Laoharatchatathanin1, Shiro Kurusu2, Ernst Pöschl3, Bent Brachvogel4 and Mitsumori Kawaminami*2
1Kitasato Univ, Aomori, Japan, 2Kitasato University, Aomori, Japan, 3University of East Anglia, Norwich, United Kingdom, 4University of Cologne

 

Annexin A5 (Anxa5) is a member of the multifunctional annexin protein family and is characterized by its calcium dependent high affinity to phosphatidylserine. Anxa5 has been supposed to work both inside and outside cells. Recently, we have demonstrated as an outside cell action its anticoagulation effects in mouse placenta on the surface of syncytiotrophoblast (1). On the other hand, we also found as inside cell function that GnRH stimulates the expression of Anxa5 in the pituitary gonadotropes and Anxa5 is involved in GnRH enhancement of gonadotropin secretion (2, 3). We found the pituitary expression of FSHβ was low in the pituitary gland of Anxa5 knockout mouse (Anxa5KO) (4). In the present study, we used global expression analysis to study the consequences of the loss of Anxa5 for the gene expression profile in the pituitary gland of Anxa5KO to identify novel molecular links of the Anxa5 and GnRH axis. Compared to C57BL/6J, there were 8 genes decreased and 5 genes increased in the pituitary gland of Anxa5KO. Nr4a3 (NOR1), a member of Nr4a orphan nuclear receptors, was one of upregulated genes in Anxa5KO mice. We found that this gene was increased in the pituitary gland of C57BL/6J after administration of a GnRH agonist. In addition, the expression of Nr4a3 was upregulated in the pituitary upon ovariectomy. We, then, showed that GnRH agonist stimulated the expression of Nr4a3 in LβT2 gonadotrope cells and that Nr4a3 was an immediate early response gene of GnRH receptor. GnRH agonist stimulated the expression of Nr4a3 in the primary culture of Anxa5KO pituitary cells but not in wild type. RNA interference of Nr4a3 in LβT2 cells resulted in the augmentation of FSHβ expression. Finally the effect of pulse frequency of GnRH agonist on the expression rate of Nr4a3 and gonadotropin subunits was examined. GnRH agonist was given in pulses with interval of 30 min or two hour for ten hours in perfusion culture of LβT2 cells. As reported repeatedly by others, LHβ mRNA expression was stimulated by higher frequency of GnRH agonist administration and FSHb was augmented by low frequency in the perfusion culture. Nr4a3 was stimulated by both frequencies of GnRH agonist administration. This sensitive response of Nr4a3 mRNA expression to GnRH and suppressive effect of Nr4a3 on FSHβ expression would explain, at least, that only LHβ subunit mRNA was augmented by higher frequency of GnRH pulses. Nr4a3 is suggested to be a novel Anxa5 related nuclear factor of gonadotropes and is involved in at least the regulation of FSHβ expression.

 

Nothing to Disclose: RT, TL, SK, EP, BB, MK

13154 1.0000 SUN-0645 A GnRH Stimulation of Nr4a3 (NOR1) mRNA Expression in LβT2 Gonadotropes, a Gene Augmented in the Anterior Pituitary Gland of Annexin A5 Knockout Mouse (Anxa5KO) and Suppression of Fshβ Expression By Nr4a3 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Maria Manfredi-Lozano1, Juan Roa1, Francisco Ruiz-Pino1, Aurora Zamora1, Silvia Leon1, David Garcia-Galiano1, Miguel Angel Sanchez-Garrido1, Antonio Romero-Ruiz2, Rafael Pineda3, Carlos Dieguez4, María J. Vázquez1, Allan E. Herbison5, Leonor Pinilla1 and Manuel Tena-Sempere*1
1University of Cordoba, Cordoba, Spain, 2Department of Cell Biology, Physiology and Immunology, University of Córdoba; CIBER Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III; Instituto Maimónides de Investigación Biomédica de Córdoba/Hospital Universitario Reina Sofia, Cordoba, Spain, 3University of Edinburgh, Edinburgh, United Kingdom, 4University of Santiago de Compostela/CIBERobn, Santiago de Compostela, Spain, 5University of Otago, Dunedin, New Zealand

 

POMC neurons in the hypothalamic arcuate nucleus (ARC) play an essential role in energy homeostasis, partially via the release of α-MSH that acts through MC3R and MC4R to suppress food intake and mediate the anorectic effects of leptin. Alpha-MSH pathways seem to be involved also in the central control of reproduction and bidirectional interplay with kisspeptins, ligands of Gpr54 and indispensable elements of the reproductive brain, has been suggested. Yet, the role of α-MSH in the regulation of puberty onset remains virtually unexplored. We document here the function of α-MSH signaling in the control of the gonadotropic axis at puberty and explore potential leptin/α-MSH/kisspeptin interactions. Activation of central α-MSH signaling, likely via MC4R, elicited robust LH responses in pubertal male and female rats, even against unfavorable metabolic conditions, but not in infantile rats. Chronic blockade of MC3/4R during the pubertal transition delayed the normal timing of puberty. In addition, the permissive effect of leptin on puberty onset, as evidenced in female rats subjected to chronic sub-nutrition, was blunted by central inhibition of MC3/4R. Exploration of α-MSH/kisspeptin interactions revealed that blockade of MC3/4R or selective elimination of kisspeptin receptor, Gpr54, in POMC neurons did not affect LH responses to kisspeptin; POMC-Gpr54 null mice did not display overt alterations of puberty either. In contrast, net LH responses to α-MSH were markedly attenuated, although not totally eliminated, in Gpr54-deficient mice, while blockade of α-MSH signaling suppressed Kiss1 expression and direct appositions between α-MSH fibers and Kiss1 neurons were observed in the ARC of pubertal female rats. Overall, our data document the essential role of α-MSH pathways in the physiological control of puberty and in transmitting the permissive effects of leptin. While α-MSH signaling seems dispensable for the reproductive effects of kisspeptins, our findings suggest that the reproductive/pubertal actions of α-MSH are, at least partially, mediated via modulation of kisspeptin pathways.

 

Nothing to Disclose: MM, JR, FR, AZ, SL, DG, MAS, AR, RP, CD, MJV, AEH, LP, MT

15659 2.0000 SUN-0646 A Essential Role of &alpha-MSH Signaling in Mediating the Permissive Effects of Leptin on Puberty Onset and Its Interplay with Kisspeptin Pathways 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Sheng Wu*1, Yi Chen1, Temi Fajobi1, Sara A DiVall1, Chawnshang Chang2, Shuyuan Yeh3 and Andrew Wolfe1
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Univ of Rochester Med Ctr, Rochester, NY, 3Univ of Rochester, Rochester, NY

 

Polycystic ovary syndrome (PCOS) is the major cause of infertility in reproductive aged women. PCOS is associated with high circulating levels of androgens and impaired metabolic function including insulin resistance. It is unclear whether insulin and androgen contribute to infertility independently or collaboratively in a vicious cycle. Female mice with chronic diet-induced obesity display increased circulating LH and testosterone levels.  Elevated levels of androgen have been shown to be correlated with increased insulin resistance, increased insulin secretion and elevated LH secretion, which can contribute to further elevation of circulating androgens and infertility. The goal of this study is to understand how androgen signaling via the androgen receptor (AR) impacts reproductive function.  We used the Cre-LoxP system to knock out the AR gene specifically in pituitary gonadotrope cells (PitARKO) to explore the role of androgen on the development of reproductive function and the development of infertility in hyperandrogenic female mice. Initial reproductive phenotyping in lean female mice indicated that there was no difference in the age of puberty between control and PitARKO littermates which was assessed by the age of vaginal opening and the age of first estrus.  Cyclicity and fertility were also studied in mice (between 2 and 5 months of age) and there was no significant difference between control and PitARKO mice. We observed a significant decrease in basal serum FSH levels with no corresponding change in serum LH levels. Similarly, the expression of the FSHβ gene was significantly reduced in pitARKO mice compared to WT mice with no observed difference in LHβ expression.  While the numbers of litters born to WT and PitARKO females was the same, the litter size was significantly smaller for PitARKO mice (11.5 versus 5 pups/litter for WT and PitARKO, respectively). LH and FSH response to ovariectomy were altered with reduced LH/FSH hormone and mRNA level in PitARKO females. This reduction may partially be due to reduced expression of activin A (p<0.05).  Preovulatory surge levels of LH were dramatically lower in PitARKO mice compared to control littermates. The number of corpora lutea was decreased while the number of unhealthy antral follicles was increased in PitARKO mice. Overall the pituitary androgen receptor contributes to the elaboration of the LH surge and for antral follicle development and normal reproductive function by regulating LH/FSH expression and secretion.

 

Nothing to Disclose: SW, YC, TF, SAD, CC, SY, AW

16491 3.0000 SUN-0647 A Crucial Role of the Pituitary Androgen Receptor in FSH Synthesis and Gonadotropin Surge 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Bruna Kalil*1, Suresh Ramaswamy2 and Tony M. Plant3
1University of Sao Paulo, Ribeirão Preto, Brazil, 2University of Pittsburgh School of Medicine and Magee Womens Research Institute, Pittsburgh, PA, 3University of Pittsburgh School of Medicine, and Magee-Womens Research Institute, Pittsburgh, PA

 

A subset of kisspeptin (KP) neurons in the arcuate nucleus (ARC) of the mediobasal hypothalamus (MBH) co-synthesizing neurokinin B (NKB) and dynorphin, and termed KNDy neurons, represent the major component of contemporary models of GnRH pulse generation.  Recently, substance P (SP), a tachykinin like NKB, was reported to be expressed in KNDy neurons in human hypothalamus [1] and to enhance KNDy neuron excitability in slices of a transgenic mouse hypothalamus [2]. We therefore examined the interactions of immunoactive SP and KP in MBH of castrated postpubertal male monkeys, in which GnRH pulsatility is enhanced.  Four orchidectomized monkeys, 39-51 mo old, were perfused transcardially with 4% PFA. Double fluorescence immunohistochemistry for KP (GQ2; 1:120,000) and SP (Dr. Robert Eskay, 1:15,000) was performed in 25µm coronal MBH sections.  A few SP cell bodies in close proximity to the third ventricle were observed in ARC.  In contrast, a more defined cluster of periventricular SP cells was found in areas corresponding to the ventromedial (VMH) and dorsomedial  (DMH) nuclei. As expected intensely stained KP cells were found throughout the ARC.  KP was not co-localized in SP perikarya. Intensely stained SP fibers densely innervated the ARC nucleus where they were found in close apposition with KP perikarya and fibers.  Beaded SP axons projected to the median eminence (ME) where they terminated in the external layer after intermingling with beaded KP axons. Double labeled fibers were not observed.  The distribution of SP in the present study was similar to that previously reported for the castrate monkey using DAB [3].  However, in contrast to the recent report in humans, KP neurons in the ARC of agonadal monkeys do not appear to co-express SP, a situation very different from the relationship between KP and NKB, which are co-localized.  The close apposition between SP axonal beads and KP neurons in the ARC is indicative of SP signaling on KNDy soma suggesting a role for SP in modulating the activity of the GnRH pulse generator.  In rodents [2,4], stimulatory effects of NKB signaling on electrical activity of KP neurons are partly dependent on NK1 (SP receptor) activation. Whether NK1 is expressed by KNDy neurons in monkey is unknown. While it is not possible to identify the origin of SP fibers in the present study, the intimate intermingling of SP and KP axonal projections in ME is similar to that previously reported for KP and GnRH, suggesting that SP may also modulate GnRH release directly. In summary, we provide evidence in the monkey of structural interactions between SP and KNDy neurons in ARC and ME: a finding consistent with the notion that this tachykinin may be involved in regulating pulsatile GnRH release either at the ARC or at ME.  However, the apparent lack of expression of SP in KNDy neurons indicates that this tachykinin is unlikely to be an additional component of the KNDy model of GnRH pulse generation.

 

Nothing to Disclose: BK, SR, TMP

16792 4.0000 SUN-0648 A Interactions Between Kisspeptin and Substance P in the Mediobasal Hypothalamus of the Male Rhesus Monkey 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Smita Salian-Mehta*1, Mei Xu2, Timothy A McKinsey3, Stuart Allen Tobet4 and Margaret E Wierman5
1Univ of Colorado - Denver, Aurora, CO, 2University of Colorado School of Medicine, Aurora, CO, 3University of Colorado Denver, 4Colorado State University, Fort Collins, CO, 5University of Colorado School of Medicine and Research Service VAMC, Aurora, CO

 

Premature death or mis-targeting of GnRH neurons during development leads to lack of sexual maturation and reproductive failure in mice and humans. Using microarray analysis of mouse GT1-7 differentiated compared to NLT undifferentiated GnRH neuronal cell-lines; we identified a unique molecular footprint of increasing expression of Class II HDAC members in GT1-7 cells. We showed that the Class IIa HDAC9 which can shuttle from cytoplasm to nucleus in presence of a stimulus can promote neuron survival and impair neuronal migration (1). HDAC6, a member of HDAC Class IIb is also upregulated at the transcript (3.5-fold), mRNA (3.4-fold) and protein levels (1.8-fold) as well as HDAC6 specific-activity (5.7-fold) in GT1-7 compared to NLT cells. HDAC6, with 2-deacetylase domains, is a cytoplasmically localized protein that can modulate rates of cell death via trafficking misfolded ubiquinated proteins and can foster cell movement via acetylation of α-tubulin and cortactin. In the current set of studies, co-immunoprecipitation assays demonstrated the novel finding that HDAC6 associates with the Class IIa HDAC9 but not 4 or 5 in GT1-7 cells. To test the functional role of HDAC6, it was silenced alone or in combination with HDAC9 in GnRH neuronal cells and we tested the downstream effects on cell survival using growth factor withdrawal to trigger cell death and on rates of migration in a transwell chamber. Silencing of HDAC6 (88%), HDAC9 (89%) or both in GT1-7 neurons augmented caspase-3 cleavage (3.4-fold, 4.4-fold and 7.1-fold respectively, p=0.02) compared to control, suggesting HDAC6 and 9 have additive effects to promote neuronal survival. Silencing of HDAC6 (86%) resulted in an activation of movement of GT1-7 cells (2.3-fold, p<0.01) similar to effects with silencing HDAC9 (2.6-fold, p<0.001). Inhibition of both HDAC6 and HDAC9 resulted in an additive effect (5-fold, p<0.001) to significantly increase cell movement, suggesting they may both contribute to the timed cessation of GnRH neuronal migration during development. Testing of WT, N- and C- terminal truncated HDAC9 mutants suggest that effects on survival require both cytoplasmic and nuclear localization whereas the effects on migration require a cytoplasmic site of action. Taken together our studies identify for the first time that Class IIb HDAC6 interacts with Class IIa HDAC9 to mediate both cell survival and timing of GnRH neuronal cell movement. Studies using HDAC9, HDAC6 and 9/6 null mice will define the impact of deletion of class II HDACs on reproductive phenotype and GnRH neuronal development.

 

Nothing to Disclose: SS, MX, TAM, SAT, MEW

15315 5.0000 SUN-0649 A Novel Interaction of Class IIb Histone Deacetylase (HDAC) 6 with Class IIa HDAC9 Controls GnRH Neuronal Cell Survival and Migration 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Horacio Novaira*1 and Sally Radovick2
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins School of Medicine, Baltimore, MD

 

Introduction: Kisspeptins (Kiss), as well as their G-protein coupled receptor 54 (Gpr54/Kiss1r), have been shown to be key components in the regulation of gonadotropin-releasing hormone (GnRH) secretion in several mammalian species, including humans. In addition, in vitro studies have demonstrated an increase in GnRH gene expression associated with an elevated secretory response to kiss administration, suggesting that kiss mediates GnRH expression at both the secretory and pretranslational levels. We have shown that the transcription factor, Otx-2, is regulated by kiss and may play a role in mediating the transcriptional response of the mouse GnRH (mGnRH) gene. However, the intracellular mechanisms and the dynamic chromatin modifications mediating kiss effects in the central reproductive axis are unclear. Aims: 1) To identify the modulation of chromatin structure and histone modifications of the mGnRH promoter that mediate kiss action. 2) To evaluate the role of Otx-2 in GnRH regulation by kiss.

Methods and results: In this study, we described specific histone acetylation, as associated with actively transcribed genes, on the mGnRH promoter induced by kiss. Chromatin immunoprecipitation (ChIP) assay followed by qPCR, demonstrated that 45 min of 10-9M kiss treatment significantly increased histone 3 acetylation (H3Ac) at the kisspeptin response element (KsRE) contained between -3446 and -2806 bp of the mGnRH promoter in GT1-7 cells (2.5-fold, n=3, p≤0.05), while no changes were observed in the neuron specific element (NSE) of the GnRH promoter.  Moreover, using specific H3Ac-lysine 9 (K9), -lysine 14 (K14) and -lysine 27 (K27) antibodies, kiss specifically induced acetylation of H3AcK14 at the KsRE (3-fold, n=3, p≤0.05). In addition, kiss induced trimethylation of H3 lysine 4 (K4), a marker of active chromatin (2.5-fold, n=3, p≤0.05); and no changes were observed in dimethylation of H3K9, a marker associated with gene repression. Chromatin conformational changes of the GnRH gene in GT1-7 cells were analyzed by the chromosome conformation capture (3C) assay. An interaction between the NSE and the KsRE via a chromatin loop in the mGnRH promoter in the presence of kiss was observed, indicating that the 5’ region enhances the induction of kiss-dependent mGnRH promoter activity. siRNA against Otx-2 mRNA was performed to silence the constitutive expression of Otx-2 in GT1-7 cells. The knock-down of Otx-2 in GnRH neuronal cell lines reduced GnRH mRNA expression and blocked expression and secretion of GnRH in response to kiss.

Conclusion: Taken together, these results demonstrate that kiss induces histone acetylation/methylation and consequently enhances the formation of a chromatin loop in the mGnRH promoter, resulting in an increase in kiss-dependent mGnRH expression. In addition, we demonstrated the key role of Otx-2 in mediating the transcriptional response of the mGnRH gene to kiss.

 

Nothing to Disclose: HN, SR

14921 6.0000 SUN-0650 A Kisspeptin Induces Dynamic Chromatin Modification to Control GnRH Gene Expression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Philippa Melamed*1 and Lilach Pnueli2
1Technion Israel Institute of Technology, Haifa, Israel, 2Technion-Israel Institute of Technology, Haifa, Israel

 

A distal enhancer element for the alpha subunit gene (GSU) of the gonadotropin hormones was previously described that determines its cell-specific expression. In this study, using chromatin conformation capture (3C) assay, we show that several regions including this previously reported enhancer, are in contact with the gene's proximal promoter. Our chromatin immunoprecipitation assays revealed that the enhancer has largely characteristic histone modifications, including H3K4 monomethylation and H3K27 acetylation. Moreover, two bidirectional non polyA RNAs (eRNAs) are transcribed whose levels, like those of the GSU mRNA, are increased following GnRH treatment. However they do not appear to be intrinsically linked to GSU transcription, as forskolin increased GSU mRNA levels 4-fold, without affecting the eRNA levels. This suggests that production of the eRNA is not merely a consequence of the proximity of this region to the active promoter. In order to clarify whether the eRNAs play a role in determining the activity of the proximal promoter, we knocked-down their levels using siRNA. This caused a dramatic drop in the levels of GSU mRNA, although it was still responsive to GnRH. We carried out 3C assays after stable transfection of the siRNAs, and in these cells the enhancer-promoter interactions were no longer apparent, while interactions on the control gene were unaltered. The siRNA-mediated eRNA knockdown also dramatically altered the histone modifications and chromatin compaction at the proximal promoter: there was a noticible drop in trimethylation of H3 at K4, and an apparent replacement of K27 acetylation with the repressive K27 trimethylation, while nucleosome occupancy was also increased. Our findings suggest that this eRNA plays a crucial function in determining the chromatin structure at the proximal promoter to facilitate GSU expression which likely plays a central role in determining the basal cell-specific expression of this gene.

 

Nothing to Disclose: PM, LP

16634 7.0000 SUN-0651 A Non-Coding RNA Determines Chromatin Structure at the Gonadotropin α Subunit Gene Promoter 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Erik Hrabovszky*1, Katalin Skrapits2, Beáta Á. Borsay3, László Herczeg3, Philippe Ciofi4, Stephen R Bloom5, Mohammad A Ghatei6, Waljit S Dhillo7 and Zsolt Liposits1
1Institute of Experimental Medicine, Budapest, Hungary, 2Institute of Experimental Medicine, 3Faculty of Medicine of the University of Debrecen, Debrecen, Hungary, 4INSERM U862, Neurocentre Magendie, Bordeaux, France, 5Imperial College London, United Kingdom, 6Imperial College London, London, United Kingdom, 7Imperial College NHS Healthcare Trust, London, United Kingdom

 

Neurons synthesizing kisspeptin (KP) and neurokinin B (NKB) in the hypothalamic arcuate nucleus (ARC) play pivotal roles in sex steroid feedback and the regulation of pulsatile gonadotropin-releasing hormone (GnRH) secretion. Unlike in rodents and the sheep, the analogous KP and NKB neurons in the human infundibular region rarely express dynorphin- but often exhibit Substance P (SP) immunoreactivity, indicating remarkable species differences in the neurochemical phenotype of these cells. In search for additional neuropeptides in human KP and NKB neurons, we carried out immunohistochemical experiments on hypothalamic sections obtained from five postmenopausal women. In immunofluorescent studies, 47.9±6.6% of the KP-IR and 30.0±4.9% of the NKB-IR perikarya co-contained immunoreactivity for cocaine- and amphetamine-regulated transcript (CART); CART signal occurred in 17.0±2.3% of KP-IR and 6.2±2.0% of NKB-IR axon varicosities. 24.0±4.1% of (KP and/or NKB)-IR perikarya and 4.8±1.4% of (KP and/or NKB)-IR axon varicosities were triple-labeled for KP, NKB and CART. CART-IR KP and NKB neurons established contacts with other peptidergic cells, including GnRH-IR neurons and also sent abundant projections to the infundibular stalk. KP and NKB fibers with CART often contained SP as well, while being distinct from CART fibers expressing immunoreactivity for the orexigenic peptide agouti-related protein. Presence of CART in human, but not rodent, KP and NKB neurons represents a new example of species differences in the neuropeptide compliment of mediobasal hypothalamic KP and NKB neurons. Target cells, receptor sites and physiological effects of CART in the efferent communication of KP and NKB neurons in primates require clarification.

 

Nothing to Disclose: EH, KS, BÁB, LH, PC, SRB, MAG, WSD, ZL

16955 8.0000 SUN-0652 A Cocaine- and Amphetamine-Regulated Transcript in Human Kisspeptin and Neurokinin B Neurons 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Mohsin M Syed, Noor Akhter, Angela K. Odle, Anessa C. Haney, Melody L. Allensworth-James and Gwen V. Childs*
University of Arkansas for Medical Sciences, Little Rock, AR

 

Leptin, an important regulator of appetite and metabolism, is also permissive for fertility. Its importance to gonadotrope function was seen when selective loss of the JAK binding site of LepR (exon 17) in gonadotropes impaired fertility in females.(1) Continuing studies focus on cellular mechanisms underlying the reproductive deficits. Most mutants lacking LepR in gonadotropes have normal numbers of immunolabeled gonadotropes, indicating that leptin is not needed to maintain this cell population. The one exception is mutant estrous female mice, which have 2.3-fold more LH cells (16.7±1%) than controls (7±0.3%; p<0.001), suggesting that mutant LH cells had not degranulated during surge secretion the day before, [which normally renders them invisible to immunolabeling and reduces percentages (2)].  To determine if this was due to reduced expression of gonadotropin releasing hormone receptors (GnRHR), we detected biotinylated GnRH (bio-GnRH) binding. Normally bio-GnRH binds to 73±2% of LH cells or 83±4.6% of FSH cells in diestrous controls. Diestrous mutants showed an 83-87% reduction in bio-GnRH binding to 13±1% of LH cells or 10±2% of FSH cells (p<0.0001; n=6). These mutant females also had reduced FSH and LH mRNAs to 37% or 73% of controls, respectively [Relative quantitation (RQ) values FSH: 1.2±0.16 controls vs 0.45±0.1 mutants; p=0.018; n=6; LH: 1.2±0.08 controls vs 0.86±0.1 mutants; p=0.04, n=5]. Serum estrogen was significantly elevated (2.25-fold) in diestrous female mutants (126±15 pg/ml) over controls (56±7 pg/ml; p=0.0008, n=12).  GH, prolactin, growth hormone releasing hormone receptor (GHRHR), or GnRHR mRNAs were normal.  Nearly all (99±0.5%) LH and FSH gonadotropes in control males express binding sites for bio-GnRH. Mutant males showed a 31-37% reduction to 62.5±6% of LH cells or 68.4±7% FSH cells binding bio-GnRH (p<0.001). Mutant males also had reductions in GnRHR mRNA to 76% of controls (RQ values: 1.17±0.08 controls vs 0.89± 0.04 mutants; p=0.02). GHRHR mRNA was reduced, as well, in mutant males to 64% of controls (RQ values: 1.15±0.1 controls vs 0.74±0.04 mutants; p=0.01) and GH mRNA was reduced to 76% of control values (RQ values 1±0.08 controls vs 0.77±0.01 mutants, p=0.03; n=5). Mutant males had no reductions in LH or FSH mRNAs and serum testosterone was normal. The loss of the JAK binding site of LepR in gonadotropes has sex specific effects on the reproductive system.  Both sexes show significant losses in GnRHR binding, but the magnitude of the reduction is much greater in females. This loss in GnRHR binding in females is associated with lower LH and FSH mRNAs, serum FSH and, ultimately, lower numbers of pups.(1) This may have significance to food supply and population growth.  When food is plentiful, leptin signals will optimize responses to GnRH and permit larger litters.  However, when food is scarce, lower serum leptin may limit GnRHR to reduce numbers of offspring.

 

Nothing to Disclose: MMS, NA, AKO, ACH, MLA, GVC

14685 9.0000 SUN-0653 A Leptin As a Gateway to Fertility Permitting Reproduction By Regulating Gonadotropin Releasing Hormone Receptors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Danalea V. Skarra*
University of California, San Diego, La Jolla, CA

 

The gonadotropins luteinizing hormone (LH) and follicle stimulating hormone (FSH) are required for human fertility. The gonadotropins are produced exclusively by gonadotrope cells located within the anterior pituitary. The transcription factor FOXO1 is expressed in murine pituitary gonadotropes and LβT2 cells, an immortalized gonadotrope cell line. We have previously reported that in LβT2 cells, FOXO1 represses basal and GnRH-induced synthesis of luteinizing hormone beta (Lhb) and follicle stimulating hormone beta (Fshb) subunits. Yet, it is unknown what signaling pathways regulate FOXO1 in gonadotropes. Here we investigate the regulation of FOXO1 in pituitary gonadotropes. We began with the PI3K/AKT pathway, which mediates the inhibitory effects of insulin, insulin like growth factor 1 (IGF1) and other growth factors on FOXO1. This pathway has also been implicated in the induction of gonadotropin synthesis and secretion. In primary murine pituitary cells and LβT2 cells, activation of the PI3K pathway with insulin or IGF1 resulted in AKT and FOXO1 phosphorylation. Insulin and IGF1 induced the phosphorylation of FOXO1 at Thr24, Ser256 or Ser319, all AKT sites which inhibit FOXO1 activity. AKT phosphorylation of FOXO1 induced FOXO1 shuttling from the nucleus to the cytoplasm in LβT2 cells, and shuttling was blocked by the inhibition of AKT or PI3K. In vivo, gonadotropes are exposed to GnRH along with signaling factors that regulate FOXO1, such as IGF1. Thus, the effects of GnRH on FOXO1 were also investigated. GnRH alone did not alter FOXO1 phosphorylation at Thr24, Ser256 or Ser319, but did cause a subcellular shift in FOXO1 from the nucleus to the cytoplasm. This GnRH-induced shift of FOXO1 was blocked by the PKC inhibitor BIM, but not by inhibition of AKT, implicating PKC signaling in FOXO1 regulation in addition to the PI3K/AKT pathway. GnRH co-treatment of LβT2 cells with IGF1 or insulin for 30 minutes significantly attenuated AKT phosphorylation at Thr308 and Ser473, but did not reduce FOXO1 phosphorylation at Thr24, Ser256 or Ser319 during the same time period. Our results indicate that insulin and IGFI regulate FOXO1 activity through the canonical insulin & IGF/PI3K/AKT pathways. Although GnRH can attenuate AKT signaling, GnRH inhibition of FOXO1 appears to occur through an independent pathway, possibly PKC mediated. In metabolic tissues, AMP-activated protein kinase (AMPK) stimulates FOXO1 activity, and AMPK is reportedly a negative regulator of Fshb synthesis, so we next investigated the AMPK pathway. Our preliminary studies indicate that AMPK activation does not alter FOXO1 Ser256 phosphorylation in LβT2 cells. Experiments are in progress to fully characterize AMPK effects on FOXO1 phosphorylation and subcellular localization.

 

Nothing to Disclose: DVS

14960 10.0000 SUN-0654 A Insulin/IGF and GnRH Regulate FOXO1 through PI3K/AKT and PKC Signaling Pathways in Gonadotropes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Taeshin Kim*1 and Mark A Lawson2
1University of CA San Diego, La Jolla, CA, 2University of California-San Diego, La Jolla, CA

 

Neuroendocrine control of reproduction requires appropriate pituitary response to GNRH stimulation to correctly modulate gonadotropin synthesis and secretion.  Multiple pathological conditions such as inflammation, obesity, and stress are known to limit pituitary responses to GNRH and these are known to via stress signaling that includes production of reactive oxygens.  The nicotinamide adenine dinucleotide phosphate (NADPH)-oxidase (NOX) family is a major source of intracellular reactive oxygen species, which regulates cell signaling and homeostasis. The role of NADPH oxidase has not been examined in the gonadotropes. GNRH stimulation elevates intracellular reactive oxygen species via NADPH oxidase in both mouse primary pituitary and LβT2 cells. Mouse pituitary and LβT2 cells have abundant Nox2 mRNA, and its protein level is increased in response to GNRH stimulation in LβT2 cells. Furthermore, the related family members Nox1, Duox1 and Duox2 mRNA are also detected in LβT2 cells as well as p67phox, p47phox, p40phox, Noxo1, Rac 1/2, and p22phox. Both GNRH-activated MAPK1/3 and JNK were significantly diminished by the NADPH oxidase inhibitor diphenyleneiodonium and the antioxidant N-acetyl-L-cysteine, but p38 was unaffected. Down-regulation of protein kinase C by overnight phorbol ester treatment or diphenyleneiodonium significantly inhibits GNRH- and PMA-mediated MAPK1/3 activation, but activation of MAPK1/3 by epidermal growth factor is unaffected, showing a ROS-dependent pathway of MAPK1/3 activation by GNRH receptor. Nuclear translocation of phosphorylated MAPK1/3 by GNRH treatment was also diminished by diphenyleneiodonium. Activation of Fshb and Lhb promoters and mRNAs by GNRH are also diminished by inhibition of NOX or by antioxidant treatment, as are the immediate early genes Atf3, Egr1, c-Fos, and c-Jun. These results suggest that NOX/DUOX-mediated ROS generation potently regulates function of gonadotropes and provides a link between PKC activation and downstream control of MAP kinase signaling.  Overall the dependence of GNRH on Reactive Oxygen Species for signal propagation provides a link between reproductive and metabolic or inflammatory signaling in a key cell type necessary for governance of reproductive function.

 

Nothing to Disclose: TK, MAL

15198 11.0000 SUN-0655 A Gnrh Regulates Gonadotropin Gene Expression through NADPH Oxidase-Derived Reactive Oxygen Species 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Jeremy D Cantlon, Lisa M Fernholz, Dilyara Murtazina, Christianne Magee, Alejandro Arreguin-Arevalo, Lindsey N Goetzmann and Colin M Clay*
Colorado State University, Fort Collins, CO

 

The preovulatory surge of LH is partially due to heightened sensitivity of gonadotropes to GnRH, caused by increased expression of GnRH receptors.  During the preovulatory period, estradiol (E2) from the developing preovulatory follicle dramatically increases transcription of GnRH receptor mRNA, inducing approximately a 25-fold induction of GnRH receptor mRNA in dissociated cultured sheep gonadotropes.  Recently, we discovered that fenofibrate (FEN), a peroxisome-proliferator activated receptor alpha (PPARA) agonist, is capable of eliminating the E2-induced increase in GnRH receptor mRNA in cultured sheep gonadotropes.  Pituitaries from ovariectomized sheep were enzymatically dissociated, and pituitary cells were cultured overnight.   The next day, groups of cells were treated with either, vehicle (DMSO), 10 nM E2, 50 μM FEN, or 10 nM E2 with 50 μM FEN.  Following 24 hours of treatment, total RNA from cells was harvested, and a reverse transcriptase reaction was performed to generate cDNA for qPCR analysis.  Starting quantities of ovine GnRH receptor and GAPDH mRNA were determined by qPCR, using validated primer sets to generate standard curves, and GnRH receptor mRNA quantities were normalized to GAPDH mRNA quantities. Treatment with E2 resulted in a 25-fold increase in normalized GnRH receptor mRNA (p < 0.01).  However, GnRH receptor mRNA quantity in cells treated with E2 plus FEN was not significantly different from DMSO (p < 0.01), indicating that activated PPARA is capable of eliminating the E2-induced increase in GnRH receptor expression.   To confirm the in vitro data, we have applied a similar experimental paradigm in transgenic mice harboring a transgene containing the ovine GnRH receptor promoter linked to luciferase.  In our previously published data from these mice, we observe a 22-fold increase in luciferase expression with E2 treatment.  In our initial studies, we see an approximately 85% attenuation of the E2 induced increase in pituitary luciferase expression when the transgenic mice were treated with both E2 and FEN.  The physiological role of PPARA is largely to regulate cholesterol and lipid metabolism, activating transcription of genes involved in fatty acid beta-oxidation and gluconeogenesis.  However, our data indicates that, in gonadotropes, PPARA may also play a unique role in regulating estradiol-induced expression of GnRH receptor during the preovulatory period.

 

Nothing to Disclose: JDC, LMF, DM, CM, AA, LNG, CMC

16047 12.0000 SUN-0656 A The Peroxisome Proliferator-Activated Receptor Alpha Agonist Fenofibrate Attenuates the Estradiol Mediated Increase in GnRH Receptor Expression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Pasha Grachev*1, Vincent Goffin2 and Kevin O'Byrne3
1West Virginia University, Morgantown, WV, 2Faculté de Médecine, Université Paris Descartes, Paris cedex 14, France, 3King's College London, London, United Kingdom

 

Prolactin (PRL) synthesized by pituitary lactotropes is known to enter the CNS via receptor-mediated transport in the choroid plexus. There is also evidence of de novo PRL synthesis within the CNS. Although PRL is classically associated with lactation, circulating PRL levels increase in response to (a) elevated estradiol, (b) acute stress exposure and (c) long-term antipsychotic treatment. Notably, the PRL receptor (PRLR) is expressed by, amongst others, hypothalamic neuropeptidergic neurons involved in (a) the generation of the preovulatory luteinizing hormone (LH) surge (periventricular kisspeptin neurons), (b) stress-induced suppression of the gonadotropin-releasing hormone pulse generator (parvocellular corticotropin-releasing hormone neurons) and (c) hyperprolactinemic amenorrhea (tuberoinfundibular dopamine neurons). However, whether these manifestations are sensitive to changes in central PRL levels has, until recently, been difficult to demonstrate experimentally. In this study we subjected ovariectomized (OVX) estradiol-primed rats, intracerebroventricularly administered with a PRLR antagonist, to frequent blood sampling in order to establish whether central administration of PRL is involved in the regulation of (a) the steroid-induced LH surge, and the suppression of pulsatile LH secretion induced by (b) acute immunological stress (intravenous lipopolysaccharide challenge), or (c) hyperprolactinemia due to chronic antipsychotic (sulpiride) treatment. Our data indicate, for the first time, that blockade of central PRLR (a) augmented the LH surge, (b) attenuated LPS-induced suppression of the LH pulse without affecting the concomitant release of corticosterone, and (c) had no effect on the deregulation of pulsatile LH secretion or hyperprolactinemia due to chronic exposure to sulpiride.

 

Nothing to Disclose: PG, VG, KO

13941 13.0000 SUN-0657 A Novel Insights into the Roles of Central Prolactin Signaling in the Regulation of the Gonadotropin-Releasing Hormone Pulse Generator in the Female Rat 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Darwin Omar Larco*1, Madelaine J Cho-Clark1, Shailaja K Mani2 and Tao-Yiao John Wu3
1Uniformed Services University, Bethesda, MD, 2Baylor College of Medicine, Houston, TX, 3The Uniformed Services Universit, Bethesda, MD

 

Reproductive function require the proper establishment of the Gonadotropin-Releasing Hormone (GnRH) neuronal population within the central nervous system (CNS). GnRH neurons originate outside the CNS in the nasal placode where their migration to the basal forebrain is dependent on their ability to respond to multiple signaling cues during development. The endopeptidase EP24.15 is expressed along the migratory path of GnRH neurons and may cleave the full-length GnRH peptide to generate the metabolite GnRH-(1-5). Using the immortalized GnRH-secreting cell line, the GN11 cell, as a model of GnRH neuronal migration, we recently demonstrated that GnRH-(1-5) inhibits cellular migration in a wound closure assay by binding the orphan G protein-coupled receptor 173 (GPR173). GnRH-(1-5) activating GPR173 initiates the formation of a complex with β-arrestin 2 to subsequently inhibit the signal transducer and activator of transcription 3 (STAT3) pathway to regulate migration. In this study, we determined the effect of GnRH-(1-5) on the migration of GN11 cells in the presence of an extracellular matrix (ECM) environment using a matrigel invasion assay (BD biosciences, San Jose, CA). This particular assay likely reflects the composition of the extracellular milieu (eg. Growth factors and ECM proteins) present along the migratory path of GnRH neurons. We found that GN11 cells exposed to 100 nM GnRH-(1-5) significantly (p < 0.05) inhibited the percent cell invasion through the matrigel barrier relative to vehicle (VEH)-treated cells (VEH = 107.4% +/- 8.9% vs GnRH-(1-5) = 53.3% +/- 7.2 %).  Cells invading through the matrigel were normalized to cells exposed to control inserts, which do not have the matrigel layer to account for potential changes in proliferation. These results parallel our previous findings that GnRH-(1-5) indeed inhibits GN11 cellular migration. Furthermore, the ability of GnRH-(1-5) to decrease cellular invasion though an in vitro ECM indicates that the responsiveness of migrating GnRH neurons to GnRH-(1-5) may be regulated by the extracellular environment. Next, we implemented a high-throughput PCR array (Qiagen) in cells treated with GnRH-(1-5) for 30 min to elucidate potential genes involved in the intracellular mechanism of GnRH-(1-5). Acute GnRH-(1-5) treatment significantly decreased members of the cytokine signaling pathway such as IL-1α (0.62 relative to 1.0) and IL-4Rα (0.73 relative to 1.0), which correlates with our previous finding that GnRH-(1-5) inhibits the normally cytokine-activated STAT3 pathway. Collectively, our studies demonstrate that GnRH-(1-5) binding GPR173 to inhibit the migration of GN11 cells is regulated by their ability to respond to extracellular cues.

 

Nothing to Disclose: DOL, MJC, SKM, TYJW

16044 14.0000 SUN-0658 A GnRH-(1-5) Inhibits the Migration of GN11 Cells in the Presence of an Extracellular Matrix Envionment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Alexander N Comninos*1, Jelena Anastasovska2, Meliz Sahuri-Arisoylu2, Channa N Jayasena3, Mohammad A Ghatei3, Stephen R Bloom2, Paul Matthews2, Jimmy D Bell2 and Waljit S Dhillo1
1Imperial College NHS Healthcare Trust, London, United Kingdom, 2Imperial College London, United Kingdom, 3Imperial College London, London, United Kingdom

 

Kisspeptin is a crucial activator of reproductive function. The role of kisspeptin has been studied extensively within the hypothalamus but little is known about its extra-hypothalamic functions.

The amygdala has roles in stress and reproductive behaviour amongst others. Furthermore, there exist extensive neuronal projections between the amygdala and hypothalamic regions regulating reproductive function. Amygdala lesioning results in hypersexuality and increased gonadotrophins. Conversely, stimulation of the amygdala delays puberty. Hence the amygdala has predominantly inhibitory roles in reproductive function. Taking this together with recent observations of kisspeptin gene expression in the amygdala, we hypothesised that kisspeptin may modulate amygdala input to hypothalamic regions regulating reproductive function.

To test this hypothesis, we employed the manganese ion as an activity-dependent paramagnetic agent to detect neuronal activation by magnetic resonance imaging (MRI) in adult male mice. Mice were administered either intraperitoneal kisspeptin or vehicle and signal intensity (SI) was measured by MRI for 120min. Regions of interest were pre-determined. Increased SI represented overall increased neuronal activation and vice versa. Linear regression analysis was performed to compare SI between kisspeptin and vehicle-treated groups.

A marked decrease in SI in both the right and left amygdala was observed following kisspeptin administration compared to vehicle (right decrease 22.4%, p<0.01 vs. vehicle; left decrease 20.4%, p<0.05 vs. vehicle, n=7-8). Plasma kisspeptin levels and serum LH increased at the same time-points as the observed decrease in amygdala SI (p<0.0001 vs. vehicle, n=6-8). Peak LH increase occurred at 120min after kisspeptin administration (kisspeptin +3.7±0.5ng/ml, vehicle +0.6±0.2ng/ml, p<0.0001 vs. vehicle). No significant differences in SI in the arcuate or anteroventral periventricular nuclei were observed after kisspeptin administration compared to vehicle.

We demonstrate for the first time that kisspeptin can reduce neuronal activity within the amygdala. The amygdala has established inhibitory physiological and behavioural effects on reproductive function. Hence, these data suggest that kisspeptin, by decreasing neuronal activity within the amygdala, may reduce these inhibitory effects on reproductive function and therefore contribute to the observed gonadotrophin rise. This suggests a novel model for the integrated regulation of physiological and behavioural aspects of reproductive function between the amygdala and hypothalamus by kisspeptin.

 

Nothing to Disclose: ANC, JA, MS, CNJ, MAG, SRB, PM, JDB, WSD

14161 15.0000 SUN-0659 A Kisspeptin Inhibits Neuronal Activity in the Amygdala of Male Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Shany Mugami*1 and Zvi Naor2
1Tel Aviv University, 2Tel Aviv Univ, Tel Aviv, Israel

 

Gonadotropin releasing hormone (GnRH) is a hypothalamic decapeptide that serves as a key regulator of the reproductive system in vertebrates and stimulates pituitary gonadotropes to synthesize and release luteinizing hormone (LH) and follicle stimulating hormone (FSH). Interaction of GnRH with its cognate receptor (GnRHR) leads to intracellular mechanism that includes activation of Mitogen-activated protein kinase (MAPK) cascades. One of the MAPKs is p38MAPK. Here we describe the role of PKC isoforms in GnRH-stimulated p38MAPK in αT3-1 and LβT2 gonadotrope cell lines. Incubation of the cells with GnRH resulted in a protracted activation of p38. By using the PKC activator, phorbol-12-myristate-13-acetate (PMA) we found that PKC is involved in the activation phase of p38 by GnRH. The gonadotrope cell lines aT3-1 and LbT2 express PKCa, bII, d, e, q, h, i/l and z, that represent members of all groups of the PKC isoforms. The pan PKC isoform inhibitor, GF109203X reduced GnRH- and PMA-stimulation of p38. The use of PKC antagonist peptide of the various PKCs has revealed that PKCα, PKCδ and PKCε mediate p38 activation by GnRH in αT3-1 while PKCα, PKCβII and PKCδ and PKCε are involved in p38MAPK activation by GnRH in LβT2 cells. In addition, stimulation by PMA has shown that PKCa, PKCβII and PKCδ are involved in p38MAPK activation in aT3-1 cells. Furthermore, unlike the dogma that p38 is localized in the nucleus of various cells, we localized p38 to the plasma membrane. Upon activation by GnRH, we noticed blebs formation, apparent migration and relocation of p38 to the blebs. We suggest that the activated p38 may be involved in gonadotropes migration. The physiological significance of gonadotropes migration is under investigation.

 

Nothing to Disclose: SM, ZN

14527 16.0000 SUN-0660 A Activation Mechanism of P38MAPK By GnRH and PMA in Pituitary Gonadotropes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Ekaette F. Mbong*1, Denise T McKee1 and Mark A Lawson2
1University of California, San Diego, La Jolla, CA, 2University of California-San Diego, La Jolla, CA

 

The presence of increased circulating free fatty acids (FFA), characteristic of obese individuals, causes cellular stress that can be measured within the ER of many cell types. Under cellular stress the unfolded protein response (UPR), a protective process that maintains proper protein folding and ER integrity, is activated to help restore homeostasis. There are three signaling branches in the UPR including the ATF6 pathway, which uses UPR-triggered proteolysis to activate and regulate UPR gene expression; the EIF2AK3 pathway, which acts as a translation control by modulating protein import into the ER lumen; and the ERN1 pathway, which utilizes unconventional mRNA splicing to activate an extensive adaptive transcriptional program regulating ~70 genes. We are focused on the ERN1 branch in which transcription factor Xbp1 mRNA is spliced by ERN1 in the cytoplasm during cellular stress to generate the active form. Our previous data indicated pulsatile stimulation of the gonadotrope by GNRH also induces the UPR (1), suggesting the gonadotrope utilizes the UPR to maintain cellular homeostasis under secretory demand of GNRH stimulation. The induction of the UPR by GNRH in the gonadotrope along with our findings that BMI inversely correlates with LH levels (2) led us to hypothesize that increased FFA, a result of obesity, may have an effect on the hypothalamo-pituitary-gonad axis. We hypothesized that chronic exposure to FFA desensitizes the gonadotrope to GNRH, resulting in the decreased secretion of the gonadotropin hormones LH and FSH. LβT2 and primary pituitary cells were treated with GNRH, oleate (FFA), both, or PBS (vehicle) and total RNA was harvested for use in qPCR analyses. Surprisingly, we found untreated levels of Xbp1 mRNA when cells were treated with oleate alone or in combination with GNRH. Moreover, we found gene expression of several housekeeping, reporter, and gonadotropin genes did not vary between different treatments in LβT2 cells. Interestingly, while several housekeeping and reporter genes remained at untreated levels in primary pituitary cells treated with oleate, a reduction in Lhb mRNA levels was seen, suggesting increased FFA disrupts gonadotropin gene expression. Thus, we may see reduced levels of gonadotropin secretion. As such, we are investigating the impact of FFA on gonadotropin secretion in primary pituitary cells.

 

Nothing to Disclose: EFM, DTM, MAL

15155 17.0000 SUN-0661 A FFA Modulation of Gonadotropin Gene Expression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Kathleen Yip*, Pamela L Mellon and Kellie M Breen
University of California, San Diego, La Jolla, CA

 

Stress is known to act at multiple levels of the reproductive neuroendocrine axis and we sought to investigate mechanisms of central gonadotropin-releasing hormone (GnRH) suppression as a result of elevated glucocorticoids. GnRH is released by specialized neurons in the hypothalamus and acts upon the pituitary gland to promote release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which in turn act on the gonads to promote steroidogenesis and development of gametes, making GnRH a key regulator of reproduction. Previous studies have shown that the presence of dexamethasone, a synthetic glucocorticoid, binds to glucocorticoid receptor, which is tethered to Oct-1, a transcription factor. The complex has been shown to bind to a negative glucocorticoid receptor element in the mouse GnRH promoter (1). Dexamethasone has also been shown to decrease GnRH mRNA in GT1-7 cells, an immortalized cell line representative of the mature GnRH neuron (2). Therefore, we sought to understand whether glucocorticoid suppression of the GnRH gene was mediated by modulation of the epigenetic status of the GnRH promoter. We used a DNase I hypersensitivity assay to determine whether dexamethasone promoted formation of a more condensed state of DNA. We found that 2-hour and 6-hour treatments with dexamethasone did not decrease the digestion of the GnRH promoter by DNase I, suggesting that suppression of GnRH did not result from this change in chromatin structure and an alternative mechanism may be responsible for diminished function of the GnRH gene by treatment with dexamethasone. Further studies are ongoing to clarify the mechanism by which glucocorticoids repress the GnRH gene since increasing levels of stress in contemporary society makes it important to elucidate the mechanism by which stress negatively affects reproductive function.

 

Nothing to Disclose: KY, PLM, KMB

16273 18.0000 SUN-0662 A Investigation of Chromatin Dynamics of the Mouse Gonadotropin-Releasing Hormone (GnRH) Promoter By Dexamethasone 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Kathleen Elizabeth Whitlock*1, Christian Cortés-Campos1, Joaquín Letelier1 and Stephanie Westmilller2
1Universidad de Valparaiso, Valparaiso, Chile, 2Cornell University

 

Gonadotropin-releasing hormone (GnRH) is a hypothalamic decapeptide essential for fertility in vertebrates.  Male patients lacking GnRH and treated with hormone therapy can remain fertile after cessation of treatment suggesting that new GnRH-neurons can be generated during adult life. We have confirmed the presence of hypothalamic GnRH cells in the preoptic area in adult zebrafish. We showed that we can obtain and trigger the differentiation of neural stem cells from the adult hypothalamus in vitro, and that these hypothalamic-derived neural stem cells are capable of differentiating into neurons and glia. Adult derived neural stem cells gave rise to GnRH cells, whose number increased with hormone treatment. Our results have confirmed a non-olfactory origin for hypothalamic GnRH cells, and demonstrated the presence of stem cells capable of producing GnRH in the adult.

 

Nothing to Disclose: KEW, CC, JL, SW

14081 19.0000 SUN-0663 A Adult Hypothalamic Neural Stem Cells Generate Gonadotropin-Releasing Hormone (GnRH) Neurons 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0645-0663 4820 1:00:00 PM GnRH & Gonadotroph Biology & Signaling Poster

Simina M Popa*1, Paige Haas1, Lee Wohlen Organick1, Donald K Clifton2 and Robert A Steiner3
1University of Washington, Seattle, WA, 2Univ of Washington, Seattle, WA, 3University of Washington

 

Kisspeptin (Kiss1), encoded by the Kiss1 gene, is essential for fertility in humans and mice. In female rodents, Kiss1 neurons in the anteroventral periventricular (AVPV) and periventricular nuclei (PeN) generate the preovulatory surge of GnRH and LH. The apparent number of Kiss1 neurons and the degree of Kiss1 expression in the AVPV/PeN are sexually differentiated, with females exhibiting greater expression than males. Exposure of females to testosterone (T) during the neonatal critical period masculinizes Kiss1 expression— causing the apparent disappearance of Kiss1 neurons in the AVPV/PeN in adulthood. The molecular basis for sexual differentiation of Kiss1 expression in the AVPV/PeN remains a mystery. However, apoptotic cell death or silencing of Kiss1 expression by epigenetic imprinting in the male could be at work. We hypothesized that Kiss1 neurons in the AVPV/PeN of the male survive neonatal exposure to T but simply lose their ability to express the Kiss1 transcript in adulthood. If every neuron that expressed Kiss1 during development could be tagged with a reporter, we could track its lineage and determine its fate in adulthood. To permanently mark the inception of Kiss1 expression, we tagged Kiss1 neurons with a bright Kiss1Cre-inducible reporter and compared expression profiles of this reporter in the AVPV between adult male and female mice. Mice expressing Cre and GFP under the control of the endogenous Kiss1 promoter were mated to mice that express tdTomato (tdT) under a Cre-inducible, constitutively active promoter. Thus, as soon as Kiss1 was expressed during development— even at low levels— these cells were permanently labeled with tdT. We observed that the number of tdT-labeled cells in the AVPV of the adult was indistinguishable between the sexes (34.1± 3.6 neurons per section in males and 35.3 ± 2.4  in females), testifying to the survival of Kiss1 neurons in the AVPV of the male. We observed tdT-labeled cells in the AVPV as early as post-natal day 12 in both sexes. These observations argue against apoptotic cell death as a mechanism for sexual differentiation of Kiss1 neurons in the AVPV.  Finally, adult males had greater numbers of tdT-labeled cells in the medial preoptic nucleus than females (p < 0.05). We suggest that in the neonatal male, testosterone initially stimulates Kiss1 expression (thus inducing tdT) but subsequently masks its expression in the AVPV of the adult through epigenetic silencing.

 

Nothing to Disclose: SMP, PH, LWO, DKC, RAS

13602 1.0000 SUN-0664 A Kiss1 Footprints Reveal Ghost Neurons in the Avpv of the Male Mouse 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Erica L Schoeller*1, Daniel D Clark2 and Pamela L Mellon3
1University of California, San Diego, La Jolla, CA, 2UCSD, San Diego, CA, 3Center for Circadian Biology, University of California, San Diego, La Jolla, CA

 

The circadian clock is comprised of a set of proteins that are regulated by a transcriptional feedback loop, a critical component of which is BMAL1. Elimination of BMAL1 results in abnormal circadian rhythms and a loss of fertility in both males and females. Female BMAL knockout (KO) mice are infertile due to dysregulation in the LH surge, and hormonal defects preventing embryo implantation. Male BMAL KO mice exhibit decreased steroidogenesis and testosterone levels, but the complete infertility displayed by these mice is not entirely explained by these mechanisms. We hypothesized that BMAL1 is required for male fertility on both the behavioral and neuroendocrine levels.

To examine this, we investigated mating behavior as well as reproductive hormone regulation. We found that BMAL KO males failed to mount estrous female mice. We also found that BMAL1 KO testosterone levels were decreased compared to WT littermates (42.2 +/- 9.3 vs 487.1 +/- 269 ng/dL). To determine whether this decrease in T was responsible for the absence of mounting behavior, we castrated and implanted testosterone capsules into BMAL KO mice and WT controls. Mating assays showed that BMAL KO males failed to mount female mice even after T replacement. Analysis of chemoinvestigatory behavior showed that BMAL KO males spent less time sniffing the ano-genital region of estrous females than WT over a 5-minute trial period (6 +/- 3.6 sec vs 81 +/- 26.3 sec). To determine whether defects in olfaction might be responsible for abnormal mating behavior, we performed the Buried Food Test and found that BMAL1 KO males have the ability to uncover food hidden from view, demonstrating an intact ability to smell. This indicates that the disruption of the peripheral clock gene, BMAL1, impairs the ability of mice to display appropriate male sexual behavior.

To examine neuroendocrine defects in these mice, we performed GnRH and kisspeptin challenges, measuring LH response 10 minutes after administration of GnRH or 20 minutes after administration of kisspeptin. LH response to GnRH was higher in BMAL KO compared to WT (12.09 +/- 0.76 vs 5.68 +/- 0.52 ng/mL), and response to kisspeptin was also higher in BMAL KO compared to WT (7.4 +/- 1.1 vs 2.2 +/- 0.31 ng/mL). These data suggest that LH storage and release is dysregulated in BMAL KO mice. Future studies will further investigate the hypothalamic and pituitary peptides involved in generating LH release and characterize the role of BMAL1 in neuroendocrine regulation of fertility.

In this study, we have found that the circadian protein, BMAL1, is required for male mating behavior and also has an important role in the neuroendocrine control of reproduction.

 

Nothing to Disclose: ELS, DDC, PLM

13152 2.0000 SUN-0665 A The Role of Circadian Clock Protein, BMAL1, in the Behavioral and Neuroendocrine Control of Male Reproduction 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Jose Cordoba-Chacon*1, Manuel D. Gahete2, Anabel Pozo-Salas2, Luis de Lecea3, Justo P Castano4 and Raul M. Luque4
1University of Córdoba; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC); Hospital Universitario Reina Sofia, and CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn) / University of Illinois at Chicago, Córdoba, Spain, 2University of Córdoba; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofia, and CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn), Córdoba, Spain, 3Stanford University School of Medicine, Stanford, CA, 4Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofia, CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn) and ceiA3, Córdoba, Spain

 

Cortistatin (CORT) shares high structural/functional similarities with somatostatin (SST), but displays unique pituitary actions, which are cell type- and gender-dependent. Specifically, female CORT-knockout (CORT-KO) mice showed enhanced GH expression/secretion, POMC expression and circulating ACTH/corticosterone/ghrelin levels, whereas male CORT-KO only displayed increased plasma GH and corticosterone levels (1). Changes in peripheral (i.e. stomach ghrelin and SST) rather than hypothalamic factors seem to account for the regulation of GH/ACTH axes in CORT-KO mice under fed conditions. Since GH and ACTH axes are altered in fasting, and thereby provide important adaptive mechanisms during the response triggered in this metabolic state (2,3), we sought to determine whether the absence of CORT influences GH/ACTH axes regulation during fasting. To this end, fed and fasted male/female CORT-KO mice were compared with littermate controls (CORT +/+). Fasting increased circulating GH levels in male/female CORT+/+, whereas this rise was not observed in CORT-KO, suggesting that CORT might be critical in the control of GH secretion during fasting. However, GH levels were higher in CORT-KO than in CORT+/+ mice in the fed state, which might preclude a further elevation in GH levels by fasting in CORT-KO. Interestingly, whereas fasting-induced rise of GH expression was observed in male/female controls, an increase in GH expression was only observed in the fasted female CORT-KO mice (24h), which might be attributed to changes in key factors associated with somatotrope responsiveness (i.e. higher GHRH-R/GHS-R and reduced sst2/5 expression). Fasting increased corticosterone levels in CORT+/+ and CORT-KO mice; however, those levels were higher in fasted CORT-KO (24h) than in controls, which might be associated with a higher expression of key factors involved in corticotrope responsiveness (i.e. pituitary CRF-R1 in males and hypothalamic CRF in females). Of note, elevated plasma ghrelin levels observed in female CORT-KO mice under fed and fasting conditions may also contribute to the gender-dependent differences in the GH/ACTH axes found in CORT-KO mice. Altogether, our data suggest that CORT is a key player in the gender-dependent regulation of the adaptive response on the GH and ACTH axes triggered by fasting in mice.

 

Nothing to Disclose: JC, MDG, AP, LD, JPC, RML

14925 3.0000 SUN-0666 A Cortistatin Is a Key Factor Regulating the Gender-Dependent Response of the Growth Hormone (GH) and Adrenocorticotropin (ACTH) Axes to Fasting in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Efthymia Karagianni*1, Olga Rassouli1, Andrew N Margioris2 and Maria Venihaki3
1School of Medicine, Heraklion, Greece, 2Univ of Crete School of Medicine, Heraklion, Greece, 3University of Crete, Medical School, Heraklion, Greece

 

Hypothalamic CRH is the principal mediator of stress response via stimulation of pituitary proopiomelanortin (POMC), precursor of ACTH and beta-endorphin, the former being inducer of adrenal cortisol. CRH and POMC-derived peptides are also present at inflammation sites, produced by innate immunity cells, where they exert modulatory effects. During inflammation, locally produced CRH stimulates beta-endorphin production from immune cells which induces analgesia via binding to opioid receptors on peripheral sensory nerves. Based on the above, we hypothesized that CRH plays a crucial role in inflammatory pain. In the present project we tested this hypothesis and the molecular pathways involved. To accomplish our aim, wildtype (Crh+/+) and Crh deficient (Crh-/-) mice were injected with 20 μl of CFA (Complete Freund΄s Adjuvant) into the right hind paw under mild anesthesia. Pain response was estimated using the Hargreaves Plantar Test Apparatus. The reaction time to a thermal stimulus was measured at specific time points (3, 6 and 24hrs) following the injections. At the same time points, paw edema was evaluated with a Plethysmometer.  At the end of the experiments blood was collected by the retroorbital route, mice were sacrificed and tissues were rapidly frozen for further analysis. Our results showed that the pain response to a thermal stimulus applied to the inflamed paw was faster in Crh-/- mice compared to their Crh+/+ littermates, while no differences were observed between the non-inflamed paws of the two genotypes. This result was accompanied by higher paw edema formation few hours after the induction of inflammation in Crh-/- mice. Surprisingly, cytokine production (IL6 and IL1beta) from the inflamed paw tissues were similar in both genotypes. As expected, plasma glucocorticoid levels were significantly reduced in Crh-/- mice 6 and 24 hrs post-CFA injection. Corticosterone replacement of Crh-/- mice in their drinking water did not alter their pain response although it significantly reduced their paw edema. Our findings a propos the lower inflammatory pain threshold in Crh-/- mice most probably reflect the significantly reduced tissue POMC mRNA levels in Crh-/- vs the Crh+/+ mice, as measured with Real Time PCR which lead to decreased levels of opioids at the inflammation sites. Our study provides data that will put the basis for the understanding of the mechanisms underlying the effect of CRH on inflammation-related analgesia.

 

Nothing to Disclose: EK, OR, ANM, MV

15251 4.0000 SUN-0667 A Inflammation-Induced Analgesia: Is Local Crh an Important Regulator? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Hiranya Pintana, Wanpitak Pongkan, Jirapas Sripetchwandee, Wasana Pratchayasakul, Nattayaporn Apaijai, Nipon Chattipakorn and Siriporn C Chattipakorn*
Chiang Mai University, Chiang Mai, Thailand

 

Previous study showed that testosterone deficiency is associated with obese-insulin resistant condition.(1) In addition, our previous studies demonstrated that obesity induced by long-term high-fat diet (HFD) consumption caused not only peripheral insulin resistance and brain insulin resistance as indicated by the impairment of brain insulin receptor function (insulin-induced long term depression; LTD) in male rats, but also brain mitochondrial dysfunction.(2-3)  However, the effects of testosterone deprivation with or without obesity on brain insulin receptor function and brain mitochondrial function have not been investigated.  In the present study, we hypothesized that testosterone deprivation alone causes brain insulin resistance and brain mitochondrial dysfunction, and obesity aggravates those deleterious effects in testosterone-deprived rats.  Seventy-two male Wistar rats were divided into 2 groups, sham-operated (Sham; S) or bilateral orchiectomy (ORX; O).  A week after the surgery, rats in each group was divided into 2 subgroups and fed with either normal (ND) or HFD for 4, 8 and 12 weeks.  At the end of each time point, blood samples were collected from all rats (sham-operated ND rats (NDS), orchiectomized ND rats (NDO), sham-operated HFD rats (HFS) and orchiectomized HFD rats (HFO)) to determine the levels of glucose, insulin, cholesterol, testosterone, malondialdehyde (MDA) and HOMA index.  Brains were rapidly removed for determining brain insulin-induced LTD and brain mitochondrial function.  We found that at week 8, HFS and HFO rats, but not NDO rats, developed only the peripheral insulin resistance as indicated by hyperinsulinemia with euglycemia and increased HOMA index.  At week 12, HFS and HFO rats showed significantly increased plasma MDA and brain MDA levels, compared to those of NDS and NDO rats.  In addition, peripheral insulin resistance, brain insulin resistance, as shown by impaired insulin-induced LTD, and brain mitochondrial dysfunction, as indicated by increased brain mitochondrial ROS production, increased brain mitochondrial membrane depolarization, and brain mitochondrial swelling, were observed at week 12 in HFS and HFO rats.  No differences in the impairment of brain insulin receptor function and brain mitochondrial function were found between HFS and HFO rats.  Interestingly, testosterone-deprived rats without obesity did not have any changes on peripheral insulin sensitivity, brain insulin receptor function and brain mitochondrial function, compared to NDS rats.  Our findings indicated that obesity, but not testosterone deprivation, caused peripheral insulin resistance, brain insulin resistance and brain mitochondrial dysfunction.

 

Nothing to Disclose: HP, WP, JS, WP, NA, NC, SCC

11736 5.0000 SUN-0668 A Testosterone Deprivation without Obesity Does Not Cause Brain Insulin Resistance and Brain Mitochondrial Dysfunction in Orchiectomized Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Jennifer F Thorson*1, Ligia D Prezotto2, Richard B. McCosh3, Elane C Wright1, Kendall C Swanson2, Brett R White4, Brad A Freking1, William T Oliver1, Stanley M. Hileman5 and Clay A Lents1
1USDA, ARS, USMARC, Clay Center, NE, 2North Dakota State University, Fargo, ND, 3West Virginia University School of Medicine, Morgantown, WV, 4University of Nebraska-Lincoln, Lincoln, NE, 5West Virginia University, Morgantown, WV

 

In most mammals, the RF-amide related peptide (RFRP) pre-pro-protein contains cleavage sites for 2 peptides (RFRP1 and RFRP3). Our laboratory did not observe RFRP3-induced suppression of LH secretion in gilts. However, the porcine sequence encodes an additional peptide (RFRP2) with an amidated C-terminus identical to avian gonadotropin-inhibitory hormone (GnIH). Moreover, a selective antagonist for the neuropeptide FF (NPFF) receptors (RF9) has been shown to potently induce a release of LH in mammals, thus providing an additional approach for studying the RFRP system in the pig. We hypothesized that RFRP2 reduces secretion of LH in the prepubertal gilt, while RF9 stimulates the release of LH. Prepubertal gilts were fitted with indwelling catheters to allow for intravenous treatment and collection of serial blood samples (10-minute intervals over 8 hours) for analysis of LH. In experiment 1, ovariectomized gilts (n = 9) were used in a replicated 3×3 Latin Square design with 6 days between treatment crossover. Treatments were saline and RFRP2 administered at 0.01 or 0.1 mg/kg BW. The RFRP2 was administered in a loading dose (25% of entire dose) followed by 11 repeated injections at 10-minute intervals. Two hours after treatment concluded, a GnRH antagonist (SB75; 10 µg/kg BW) was administered. In experiment 2, intact gilts (n = 7) were randomly assigned to 1 of 2 treatments (saline or 0.5 mg/kg BW of RF9) administered as a bolus injection and repeated over 2 replicates with 1 week between replicates. Four hours after RF9 treatment, GnRH (100 µg) was administered. Treatment with RFRP2 failed to suppress LH pulse frequency (1.16 ± 0.07 pulses/hour; P > 0.78), pulse amplitude (3.06 ± 0.45 ng/mL; P > 0.55), inter-pulse interval (53.97 ± 4.32 minutes; P > 0.68), or mean concentration (2.39 ± 0.27 ng/mL; P > 0.27). Treatment with SB75 reduced mean concentration of LH (P < 0.0001), but the suppressive effect did not differ between treatments (P > 0.53). Administration of RF9 stimulated a pulse-like release of LH that is comparable to an endogenous LH pulse. Treatment with RF9 increased (P = 0.003) mean concentrations of LH (0.51 ± 0.05 ng/mL) during the subsequent 4-hour period when compared to saline (0.26 ± 0.05 ng/mL) treated gilts. The GnRH-stimulated LH secretion following treatment with either saline or RF9 did not differ (4.34 ± 1.42 ng/mL; P = 0.82). While a direct suppressive effect of RFRP2 on LH secretion in the prepubertal gilt was not demonstrated, RF9-induced secretion of LH provides indirect evidence of RFRP involvement in the reproductive neuroendocrine axis of the pig. USDA is an equal opportunity provider and employer.

 

Nothing to Disclose: JFT, LDP, RBM, ECW, KCS, BRW, BAF, WTO, SMH, CAL

12811 6.0000 SUN-0669 A Effects of RFRP2 and RF9 on Secretion of Luteinizing Hormone in Prepubertal Gilts 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

David Garcia Galiano*1, Yun-Hee Choi2, Jean Zhao3 and Carol F Elias1
1University of Michigan, Ann Arbor, MI, 2University of Texas Southwestern Medical Center, 3Harvard Medical School, Boston

 

Phosphatidylinositol 3-kinase (PI3K) pathway plays an essential role in cellular function, mediating leptin and insulin actions mainly at the hypothalamic level through unknown mechanisms. The use of genetic models with conditional deletion of PI3K p110α or p110β catalytic subunits in various neuronal hypothalamic populations has revealed distinct or complementary roles of PI3K subunits in energy homeostasis. For instance, a role in metabolic regulation has been described for PI3K p110α or p110β subunits in POMC, AgRP or SF1 neurons. Nevertheless, only a fraction of these neuronal populations are responsive to leptin or insulin. To evaluate the role of PI3K p110α subunit mediating leptin effects in energy homeostasis, we generated mouse models carrying deletion of PI3K p110α catalytic subunit selectively in leptin receptor (LepR)-expressing cells. In adult male mice, metabolic analysis has shown that complete deletion of PI3K p110α catalytic subunit in LepR cells (LepRcre/crep110α-floxed) was associated with reduced body weight (23.05 ± 0.4 g, n=14) compared to controls (LepR-/-p110α-floxed: 26.2 ± 0.48 g, n=33; p<0.01), and with a significant decrease in lean and fat mass. Interestingly, the decrease in body weight was not associated with any change in daily food intake. Indeed, calorimetric measurements demonstrated that LepRcre/crep110α-null male had higher energy expenditure, showing an enhanced nutrient oxidation (higher O2 consumption and CO2 production). Additionally, to explore if PI3K p110β isoform has a compensatory, opposite or additive role in mediating leptin’s effects on energy homeostasis, we generated a mouse model with complete deletion of both PI3K p110α and p110β catalytic subunits in LepR-expressing cells (LepRcre/crep110α+β-floxed). Analysis of the metabolic parameters of adult males has shown that LepR p110α+β-null mice had reduced body weight (21.4±0.35g, n=14) compared to controls (LepR-/-p110α+β-floxed: 23.4±0.54g, n=25; p<0.05), significant decrease in lean and fat mass and no difference in food intake. Similar to LepR p110α-null male, LepR p110α+β-null mice exhibited higher O2 consumption and CO2 production. In conclusion, our data support the model that PI3K catalytic subunits in LepR cells are required for normal progression of body weight resultant from actions on energy expenditure.

 

Nothing to Disclose: DG, YHC, JZ, CFE

15575 7.0000 SUN-0670 A Male Mice with Deletion of PI3K Subunits in Leptin Receptor Cells Display Higher Energy Expenditure 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Koichi Adachi*1, Motomitsu Goto1, Takeshi Onoue1, Taku Tsunekawa1, Miyuki Shibata1, Shigeru Hagimoto1, Yoshihiro Ito1, Ryoichi Banno1, Hidetaka Suga1, Yoshihisa Sugimura1, Hiroshi Arima1 and Yutaka Oiso2
1Nagoya University Graduate School of Medicine, Japan, 2Nagoya Univ Grad Schl of Med, Nagoya, Japan

 

MAPK phosphatase-1 (MKP-1) is shown to negatively regulate MAPK signaling in peripheral tissues, although the role of MKP-1 in MAPK signaling in the hypothalamus remains to be clarified. In this study, we investigated whether MKP-1 regulates MAPK signaling activated by inflammation in the hypothalamus, and if so, which MAPKs are dephosphorylated by MKP-1 in mouse hypothalamic organotypic cultures. We also examined MKP-1 expression in the hypothalamus induced by inflammation in vivo. Sixteen-day-old C57BL6/J mice were sacrificed by decapitation, and hypothalamic organotypic cultures were performed. The hypothalamic explants were incubated with TNFα, and proteins are extracted and analyzed by Western blotting. TNFα (100 ng/ml) significantly increased MKP-1 protein levels at 1 h in hypothalamic organotypic cultures. TNFα also increased phospho-Erk (p-Erk), phospho-JNK (p-JNK), phospho-p38 MAPK (p-p38) and phospho-NFκB p65 (p-p65) at 0.5 h, while p-Erk and p-JNK returned to basal levels, and p-p38 and p-p65 declined at 1 h when MKP-1 protein levels were increased. To determine in which nuclei of the hypothalamus TNFα induces MKP-1 activation, TNFα (1 μg) was injected intraperitoneally (ip) into three-month-old male C57BL6/J mice, and MKP-1 gene expression in the hypothalamus was examined by in situ hybridization. MKP-1 is highly expressed in the suprachiasmatic nucleus in basal conditions. Although ip injection of TNFα did not affect MKP-1 mRNA expression in the suprachiasmatic nucleus, it significantly increased MKP-1 mRNA levels in the paraventricular and arcuate nuclei. To see the effect of MKP-1 inhibition on MAPK signaling, hypothalamic explants were treated with the MKP-1 inhibitor (triptolide) or its siRNA. Triptolide significantly blocked TNFα-induced upregulation of MKP-1 protein levels and increased TNFα-induced p-Erk, p-JNK and p-p38 in hypothalamic organotypic cultures. MKP-1 siRNA successfully reduced MKP-1 mRNA levels by 40%, and significantly blocked TNFα-induced upregulation of MKP-1 protein levels and increased TNFα-induced p-Erk, p-JNK, p-p38 and p-p65. These data demonstrate that MKP-1 is activated by TNFα and that it negatively regulates all three MAPK pathways in the mouse hypothalamus.

 

Nothing to Disclose: KA, MG, TO, TT, MS, SH, YI, RB, HS, YS, HA, YO

12475 8.0000 SUN-0671 A MAPK Signaling Is Inhibited By Mitogen-Activated Protein Kinase Phosphatase 1 in Mouse Hypothalamus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Cadence True*, Yee-Ming Chan and Stephanie Beth Seminara
Massachusetts General Hospital, Boston, MA

 

Humans with Neurokinin B (NKB) pathway mutations have idiopathic hypogonadotropic hypogonadism (IHH), characterized in part by a failure to undergo puberty, and are typically counseled that they will need life-long steroid hormone treatment.  However, a large percentage of patients lacking NKB signaling show activation of their hypothalamic-pituitary-gonadal axis later in life, a phenomenon called reversal of IHH.  It is currently unknown whether steroid hormone therapies used to treat hypogonadism in these patients might trigger the reversal of their IHH.  To address this question, mice bearing deletions in the gene encoding the NKB receptor, Tacr3, were treated with estradiol (n=8) or oil (n=9) capsules for two weeks.  Tacr3-/- females have previously documented impairments in estrous cycling, ovulation and uterine weights paralleling the phenotype of hypogonadotropism in their human counterparts.   Capsules were implanted in mice near the normal period of sexual maturation (PND 28) to mimic the time course of steroid therapy in IHH individuals, which is typically initiated soon after delays in puberty are noted. Capsules were removed after two weeks and elevated estradiol levels disappeared within three days, as evidenced by an exit from estrus.  After implant removal, estrous cycling was monitored for four weeks before ovaries and uteri were collected.  Tacr3-/- females receiving estradiol capsules spent significantly more time in estrus compared to oil-treated females (estradiol 14.8 ± 2.8%, oil 6.9 ± 1.4%; t-test p<0.05).  However, the overall number of cycles in the four week period was not significantly different between treatment groups.  Furthermore, only one animal in the estradiol-treated group had corpora lutea present in the ovaries and none were observed in oil-treated animals, indicating ovulation was still impaired in Tacr3-/- females.   Estradiol-treatment seemed to modestly increase Tacr3-/- uterine weight compared to oil treatment, although this was not statistically significant. These data indicate that steroid hormone treatment may improve activity of the hypothalamic-pituitary gonadal cascade but this treatment alone is not sufficient to completely rescue reproductive deficits in mice lacking the NKB receptor.

 

Nothing to Disclose: CT, YMC, SBS

16740 9.0000 SUN-0672 A Estradiol Treatment Improves Estrous Cycling but Does Not Rescue All Reproductive Defects in Neurokinin B Receptor Deficient Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Damien Lanfray*, Alexandre Caron, Marie-Claude Roy and Denis Richard
Quebec Heart and Lung Institute Research Centre, Quebec, QC, Canada

 

Endozepines are endogenous GABA-A receptor allosteric modulators derived from diazepam-binding inhibitor/acyl-CoA-binding protein (DBI/ACBP). Endozepines act centrally as potent anorexigenic signals. However, disruption of DBI/ACBP does not induce obesity in mice, suggesting that other endogenous endozepines could be involved in energy homeostasis maintaining. In this context the aim of our study was to evaluate the potential of the Acyl-Coa binding domain containing 7 (ACBD7), a paralogous gene of DBI/ACBP on energy homeostasis.

In situ hybridization and immunohistochemical experiments on mice indicated that ACBD7 was expressed and produced in hypothalamic neuronal cells, including the arcuate nucleus neurons (ARC). In vivo experiments on mice indicated that acute fasting decreased ACBD7 mRNA levels in the ARC (0.44 +/-0.07, p=0.0019, n=8) and in ventromedial hypothalamic nucleus (VMH) (0.62 +/-0.17, p=0.032, n=8). Our data also indicate that intracerebroventricular (icv) injection of the ACBD7 central fragment, that we called neuronal endozepines member (NEM), in fasting mice has strong anorexigenic effects (5pmol, 0.28+/-0.05 after 2h, p=0.022, n=6). Moreover, in vivoexperiments also indicated that the anorexigenic effects of NEM were totally blocked (0.94 +/-0.13 after 2h, p=0.022, n=6) by a co-injection with a MC4R antagonist (HS024).

Our data indicate that ACBD7, more specifically its central fragment NEM, is produced in the hypothalamus by neuronal cells and act as a potent anorexigenic compound via a MC4R-dependent mechanism. Finally, this study suggests that ACBD7 producing neurons could be a relay between peripheral signals including leptin and POMC neurons of the ARC.

 

Nothing to Disclose: DL, AC, MCR, DR

16910 10.0000 SUN-0673 A Neuronal Endozepines Member (NEM) Producing Neurons Are Potentially Involved in Hypothalamic Control of Energy Homeostasis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Emily Rose England*1, Ling Gan2, Diane L Hartzell1, Colette N Miller1, Jeong-Yeh Yang1, Suresh Ambati1, Natalie M Hohos1, Mary Anne Della-Fera1, Richard B Meagher1 and Clifton A Baile1
1University of Georgia, Athens, GA, 2Southwest University, Chongqing, China

 

The hippocampus is well established as the major brain region involved in memory, particularly episodic and spatial memory.  However, the hippocampus is a heterogeneous structure with multiple projections to other areas of the brain involved in emotional motivation and feeding behaviors, including the amygdala and hypothalamus.  Lesion studies show that hippocampal damage alters the self-regulation of appetitive behavior, promotes obesity and alters meal patterning, where meal duration becomes shorter and meal timing more frequent.  Although the effects of chronic high fat diet consumption show a negative impact on cognitive function, many who consume a generally healthy diet but indulge on the weekends or holidays may be priming their brains for continued fat consumption.  Eight to 10-week old male Long Evans rats were fed a high fat (45% kcal; n=10) or low fat (10% kcal; n=10) diet for 72 hours. Serum was collected after a two-hour fast when the animals were sacrificed.  Brains were removed and rapidly frozen.  Hippocampal punches were taken from frozen slices and gene expression was measured using qRT-PCR.  High fat diet resulted in significant increase in calorie intake (p<0.0001), with high-fat diet fed rats consuming over 25% more calories without a difference in food intake in grams. Serum leptin levels were significantly increased in the high fat group (p<0.05) after a 2-hour fast, while blood glucose and serum insulin did not differ between groups. qRT-PCR results showed no change in expression of leptin receptor in the hippocampus, potentially indicative of hippocampal leptin resistance after only 72 hours on a high-fat diet.  mRNA levels of the orexigenic neuropeptide galanin were found to be upregulated by 25% in hippocampal tissue from rats fed a high fat diet for 72 hours (p<0.05).  Galanin negatively impacts hippocampal-based working memory, but its effect on hippocampal control of eating behavior has not been reported.  Hypothalamic galanin is known to be upregulated in response to high fat diet and administration of galanin increases the preference for high fat diet in rodents.  We propose a similar mechanism at work in the hippocampus and a potential mechanism by which high fat diet can lead to an increased fat-craving and obesogenic phenotype.

 

Nothing to Disclose: ERE, LG, DLH, CNM, JYY, SA, NMH, MAD, RBM, CAB

14207 11.0000 SUN-0674 A A 72-Hour High Fat Diet Promotes Orexigenic Gene Expression in the Hippocampus of the Rat 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Anderson On-Lam Wong*1, Mu-Lan He2 and Ting Chen1
1University of Hong Kong, Hong Kong, China, 2University of Hong Kong, Hong Kong

 

Leptin is a potent anorexic factor in mammals and known to be widely expressed at the tissue level.  Although its function in feeding control is well conserved during vertebrate evolution, its protein sequence is highly variable from fish to mammals.  Unlike leptin, somatolactin (SL) is a pituitary hormone unique to fish species.  It is a member of the GH/PRL gene family and plays a functional role in background adaptation, lipid metabolism, acid-base balance, reproduction and immune responses.  Although leptin regulation of pituitary hormones has been reported, little is known regarding its pituitary actions on SL expression.  Recently, two SL isoforms, namely SL alpha and SL beta, have been cloned in grass carp and their expression have been confirmed to be under the control of central (e.g., PACAP), peripheral (e.g., IGF-I) and pituitary signals (e.g., SL itself).  To shed light on the functional interactions between leptin and pituitary SL in fish model, the structural identity of leptin expressed in grass carp, namely leptin A and leptin B, have been established by molecular cloning.  The two forms of leptin share a low level of a.a. sequence homology (only 23.9%) but their 3D protein structures with four helices arranged in the typical “up-up-down-down” topography are highly comparable to that of mammalian leptin.  In grass carp, leptin A and B are single-copy genes, ubiquitously expressed in various tissues, and have high levels of transcript expression in the liver with leptin A as the dominant form.  Recombinant proteins of grass carp leptin A and B were produced and found to inhibit both basal and NPY-induced food consumption and feeding behavior in goldfish.  In primary culture of grass carp pituitary cells, leptin A and B treatment could markedly increase SL alpha mRNA levels but with a minor stimulatory effect on SL beta transcript expression.  Using a pharmacological approach, SL alpha mRNA expression induced by the two leptin isoforms were shown to be mediated by JAK2/STAT5, MAPK and PI3k/Akt cascades.  Similar cascades, except for the PI3K/Akt pathway, were also involved in the signal transduction for SL beta gene expression induced by leptin A and B, respectively.  These findings, as a whole, provide evidence that leptin can exert direct effects at the pituitary cell level to up-regulate SL alpha and SL beta gene expression in carp species via overlapping and yet distinct post-receptor signaling mechanisms.  (Project supported by GRF Grant, Research Grant Council, Hong Kong.)

 

Nothing to Disclose: AOLW, MLH, TC

14714 12.0000 SUN-0675 A Signal Transduction for Leptin-Induced Somatolactin Gene Expression in Grass Carp Pituitary Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Amrita Basu* and John J Kopchick
Ohio University, Athens, OH

 

The presence of growth hormone (GH) and growth hormone receptor (GHR) in various regions of the mammalian brain (e.g. cerebral cortex, hippocampus, choroid plexus, amygdala, etc.) indicate possible effects of GH induced signaling in development and function of the central nervous system. Experimental and/or physiological alteration of GH signaling, as in acromegaly (increased GH action), GH defilciency (reduced GH action) and Laron Syndrome (disrupted GH signaling due to non-functional GHRs), have been shown to influence neuronal cell proliferation, myelination, post-traumatic neuroprotection, cognition, memory retention, behavior and aging in humans and animals. Detailed understanding of GH action in the brain, as a diabetogenic hormone (due to anti-insulin action) and as a primary regulator of insulin like growth factor-1 (IGF-1) production, will help in elucidating role of the hormone in the normal brain as well as in Alzheimer’s disease (AD), a neurodegenerative condition associated with perturbed glucose metabolism and insulin/IGF-1 signaling in the brain. The present study aimed at quantitative estimation of eight genes (GH, GHR, IGF-1, IGF-1 receptor, insulin, insulin receptor, monoamine oxidase A and B) in six months old, male, transgenic giant bovine growth hormone (bGH) mice with respect to wild type littermates (n=7). Following total RNA isolation, cDNA synthesis, quantitative real time polymerase chain reaction (qPCR) and data analysis, up-regulated expression of GH and IGF-1 and down-regulation of GHR, IGF-1 receptor, insulin and insulin mRNA transcript abundance were observed in various brain regions in these mice. Reduced expression of MAO-A and B in brain areas indicate possible alteration of neurochemistry by modified GH action in bGH mice. In a Barnes Maze test for spatial memory and cognitive performance, 12 months old ( n=10) bGH mice showed increased latency and path length to reach target than the age and sex-matched controls, indicating altered memory function in bGH mice since both the groups performed similarly when monitored for general locomotor activity. Further,  western blot analysis of these proteins in the brain of these animals will be performed for a better understanding of the molecular effect of GH in the brain as well as to identify potential therapeutic targets in GH signaling pathway relevant to AD and other neuronal diseases.

This work was supported by NIH grant P01AG031736, by the State of Ohio’s Eminent Scholar Program that includes a gift from Milton and Lawrence Goll, by the AMVETS, and by the Diabetes Institute at Ohio University.

 

Nothing to Disclose: AB, JJK

15956 13.0000 SUN-0676 A Comparative Analysis of Gene Expression and Spatial Memory Performance Between Transgenic Bgh and Wild Type Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Victoria Lynn Nutsch*1, Ryan Gregory Will2, Margaret R Bell1, Weiling Yin1, Juan M Dominguez2 and Andrea C Gore1
1University of Texas at Austin, Austin, TX, 2University of Texas at Austin

 

Studies on reproductive aging in males have usually focused on the age-related decline in testosterone. However, in males of many species, including humans and rats, serum estradiol (E2) levels have been shown to increase, decrease or remain the same. Relatively little is known about functional outcomes of changes in E2 in males, including actions on the nervous system where estrogen receptors are widely expressed in the male brain. Our goal was to examine the effects of E2 on expression of a suite of genes selected for their roles in masculine reproductive physiology, behavior, and other neuroendocrine functions. Young (5 m.o.) and middle-aged (18 m.o.) sexually experienced Sprague-Dawley male rats were castrated, implanted with either vehicle or estradiol (E2) subcutaneous capsules, and sacrificed one month later. Bilateral punches were taken from the bed nucleus of the stria terminalis (BnST), posterodorsal medial amygdala (MePD) and the preoptic area (POA). RNA was extracted, and expression of 48 genes analyzed by qPCR using Taqman low density arrays (TLDA). Estrogenic regulation was both age and region specific. While all three regions showed changed in gene expression with estradiol administration, estrogenic regulation of individual genes was both age and region specific. In some cases, Only genes in the BnST and MePD showed age-related changes. These genes were associated with a variety of functions, including steroid hormone receptors [Esr1, Oxtr, Kiss1r, Gper], neurotransmitters [Grin2b, Nos1] and homeostasis [Ntrk2, Npy]. The MePD in particular had a larger number of genes with interactions between age and hormone treatment. Some genes were upregulated by estradiol in young animals, but downregulated in middle-aged ones (Kiss1r, Tac3, Trh), while others were regulated by estradiol in only one of the age groups (Esr1, Npy, Nr3c1, Ntrk2, Oxtr). Oxtr was the only gene to show changes as a result of age and/or hormones across all three regions, and was upregulated by estradiol. Serum levels of hormones were also measured. T4 was higher in young than old animals in vehicle but not E2 males. Cortisol increased with age but decreased with E2 treatment. Progesterone and T3 did not change with age or E2. These results support the idea that estrogenic regulation of gene expression changes with age, and that these changes are region specific. Ongoing work is correlating hormone levels with gene expression results to identify relationships between and among neurobiological and hormonal markers.

 

Nothing to Disclose: VLN, RGW, MRB, WY, JMD, ACG

16083 14.0000 SUN-0677 A Estrogenic Regulation of Gene Expression in the Amygdala, Preoptic Area and Bnst during Aging in Male Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Yan-He Lue*1, Xinmin Li2, Christina Wang3 and Ronald S. Swerdloff4
1Harbor-UCLA Med Ctr/LA Biomed, Torrance, CA, 2UCLA, Los Angeles, CA, 3Harbor - UCLA Med Ctr, Torrance, CA, 4Harbor- Univ of California Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA

 

Klinefelter syndrome (KS) is the most common sex chromosome aneuploidy in men. Besides the reproductive defects, KS males exhibit learning and behavioral abnormalities. We have demonstrated that adult XXY mice have learning and memory and social behavioral impairments. By comparing MRI images of mice brains, we found that adult XXY mice had relative reduction of hippocampus volume as compared with their XY littermates. The hippocampus is responsible for memory, spatial navigation and behavioral inhibition. To determine the underlying molecular mechanisms of neurobehavioral deficit in XXY aneuploidy, the whole hippocampus were dissected out from 3 adult XXY and 3 littermate XY mice respectively. The RNA deep sequencing analysis was performed with RNA samples isolated from whole hippocampus. Total RNA was extracted and the integrity of RNA was evaluated. The cDNA libraries from total RNA samples were prepared and sequenced using the Illumina HiSeq2500 sequencer. The base call files were generated and converted to fastq files and mapped to the mouse reference genome using NextGENe (SoftGenetics). Partek Genomics Suite was used for identifying differentially expressed genes. We found 7 gene expression were statistically signicant difference (>2-fold) in hippocampus between XXY and XX mice. X-inactive specific transcript (Xist) was upregulated by 14.81-fold in XXY hippocampus, indicating extra X chromosome inactivation. As compared XXY vs. XY, Aldo-keto reductase family 1E1 (Akr1e1) expression was increased by 2.96-fold, Small nucleolar RNA, H/ACA Box26 (Saora26) by 3.15-fold, Diazepam binding inhibitor-like 5 (Dbil5) by 2.08-fold, and Eukaryotic translation initiation factro 1A-like 2 pseudogene (Gm2056) by 2.14-fold. In contrast, Small necleolar RNA, C/D Box16 (Snord16a) was down-regulated by 2.32-fold. Interestingly, microRNA Mir25 was down-regulated by 2.62-fold in XXY hippocampus as compared with littermate XY mice. Thus, the findings from this study provide evidence suggesting that the differential gene expression in hippocampus may be involved in the impaired learning and memory in XXY aneuploidy. We speculate that the interplay of testosterone and extra X chromosome in XXY aneuploidy may be the cause of the differential gene expression in hippocampus. The signaling pathways governed by these genes in the XXY brain and its relationship with neurobehavioral impairments remain to be determined.

 

Nothing to Disclose: YHL, XL, CW, RSS

15663 15.0000 SUN-0678 A Differential Gene Expression in Hippocampus Between Adult XXY and XY Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Luis Miguel Rendon Sr.*1, Emmanuel David Lopez2, Carlos Jesús Terrón Sr.3 and Tatiana Fiordelisio4
1Science Faculty UNAM, Mexico DF, Mexico, 2Faculty of Science, México, Mexico, 3Faculty of Science, Mexico City, Mexico, 4Facultad de Ciencias, Universidad Nacional Autonoma de México, México, Mexico

 

The hypothalamic hormones TRH and DA trigger and/or inhibit, respectively, synthesis and secretion of prolactin in lactotrophs, this hormone has an important role in lactogenic activity, lipid metabolism among others.

It has been propose that lactotrophs response to stimulus in a heterogeneous way depending on its localization in the pituitary. However, these studies were done in primary culture conditions, where the cells lose their interaction with others cells types (paracrine and autocrine communication) and their natural physiologic environment.

In this work we use acute pituitary slices from lactating mouse and intracellular Ca2+ imaging to examine the spatial distribution of lactotrophs and their Ca2+ signalling patterns elicited by different TRH concentrations and dopamine. Thereby, to elucidate how the cells are regulated both in their intracellular signalling pathways such as hormone secretion when these are located in the tissue, and the importance of tissue context in the endocrine, paracrine and autocrine regulation.

Lactating Balb-c Mice females were used. Pituitary gland was removed and embedded in agar 3% and coronal slices of 130 µm of thickness were obtained. Slices were incubated with fluo-4 AM (22 μM for 30 min at room temperature and perfused (1 ml/ min)) with saline saturated with 95% O2 and 5% CO2 during recording. Image sequences at 510 nm emission were obtained (300 ms exposure; 250 ms interval) with a stereomicroscope (Leica) and cooled camera CCD (Sensys). TRH was bath-applied for 30s at concentrations 0.1 nM to 100 nM, and washed for > 15 min between applications finally, separately dopamine 2 μM and high potassium solution, to evaluate viability, were applied.

The responsive cells to TRH and DA were counted in central and lateral region of the gland and their patterns of response of [Ca2+]I were plotted and analyse individually. 

With this protocol, we found that the number of cells responding to TRH in both regions of the adenohypophysis (central and lateral) of suckling mouse is similar, being different to male mouse, according to previous studies of our working group; The analysis of the area under the curve from the fluorescence response to TRH in the lactotrophs of the two regions of the adenohypophysis show no differences between them, at almost all TRH concentrations, except for TRH 10nM were a bigger increase is seen, especially in lactotrophs at the lateral region.

Finally, in comparison with previous studies in males, we find that in lactating mice, lactotrophs show a more homogeneous distribution in the anterior lobe, suggesting increased cell proliferation of lactotrophs and a plasticity of the pituitary gland because of physiological.

Financed by CONACyT

 

Nothing to Disclose: LMR Sr., EDL, CJT Sr., TF

13293 16.0000 SUN-0679 A Characterization of Lactotrophs Intracellular Calcium Response to Trh and Dopamine in Acute Pituitary Slices from Lactating Mouse 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Martina Rodie*1, Michelle Welsh2, William Holmes2, Stefan A Wudy3, Michaela F Hartmann3, I Mhairi Macrae2 and S Faisal Ahmed2
1University of Glasgow, Glasgow, United Kingdom, 2University of Glasgow, Glasgow, Scotland, 3Justus Liebig University, Giessen, Germany

 

Background: Magnetic resonance spectroscopy (MRS) can provide a non-invasive, functional insight into brain metabolism and alterations may predict long-term neurocognitive impairment. A sexually dimorphic pattern of spectroscopy has been reported in humans but there is a need to investigate this further in rodents.

Methods: Male and female Sprague Dawley rats (n=32, 16) were treated on postnatal days 1-5 with an antiandrogen (flutamide, 50mg/kg) or corn oil SC and scanned at 6wks and 10wks of age using a small animal 7T MRI scanner. Water-suppressed hydrogen MR spectra were acquired from a voxel placed in the frontal cortex using PRESS sequence and metabolites measured using the LC Model software. Serum testosterone (T) was measured by GCMS. Results were analysed with a repeated measures nested general linear model. Full width at half maximum (FWHM) of the water peak was used as a marker of reliability and was within the optimal range (12-18Hz).

Results: Male anogenital distance (AGD) was significantly reduced in the treatment group when compared to controls at both 6 and 10 weeks (p=0.003, p=0.02) and this remained significant when corrected for weight (p=0.001, p=0.02).  Phallus length was reduced in the treatment group at both ages (p=0.05, p=0.001). Serum T was higher in the control and treated males at 10 weeks (median 1.9ng/ml, 2.05ng/ml) when compared to the same animals at 6 weeks (0.56ng/ml, 0.61ng/ml, p<0.001). T levels were <0.1ng/ml in all female animals. T levels showed a positive correlation with AGD (p<0.001). On MR spectral analysis, glucose, glutamine, phosphocholine and myo-inositol levels were higher in the treated males compared to control males (p=0.05, p=0.03, p=0.01, p=0.01); these levels were similar to those in age-matched female controls (ns). N-acetylaspartylglutamate(NAAG) levels were lower in older animals from all groups (p=0.05) and glutamine, glutamate and GABA also declined over time (ns). Phosphocholine and myo-inositol increased with age (p=0.05, p=0.01). T levels showed a negative correlation with glutamate (p=0.01) and female animals tended to have higher glutamate levels (ns).

Conclusions: MRS based assessment shows that brain metabolites have an age and sex dependency. In addition to undermasculinisation of the male external genitalia, early postnatal androgen blockade alters the pattern of these metabolites. The functional effects of these alterations need further study.

 

Nothing to Disclose: MR, MW, WH, SAW, MFH, IMM, SFA

15827 17.0000 SUN-0680 A Early Androgen Blockade Influences Longer-Term Brain Metabolism As Assessed By Magnetic Resonance Spectroscopy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Keiichi Ikeda*1, Kouki Fujioka2, Toshiaki Tachibana3, Yoshinnobu Manome2 and Katsuyoshi Tojo4
1Jikei Univ Sch Med, Tokyo, Japan, 2Inst DNA Med, Jikei Univ Sch Med, Tokyo, Japan, 3JIkei Univ Sch Med, Tokyo, Japan, 4Jikei University School of Medicine, Tokyo, Japan

 

Corticortropin-releasing factor (CRF) and its family peptides, e.g., urocortins (UCNs), are ubiquitously expressed in normal central and peripheral tissues and play a critical role in stress-response against various cellular strress through CRF type 1 and type 2 receptors in normal cells.  And it is also reported that UCN I is expressed in various malignant cells, such as, human glioblastoma cells, gastric cancer cells, clear renal cell carcinomas, and so on.  But, due to the poor knowledge on the mechanism of UCN I secretion, we investigated the expression profiles and secretory pathway of UCN I in human neural stem cells (HNSCs) and two glioblastoma cell lines, e.g., A172 and U-138 MG glioblastoma cells by RT-PCR and immunocytochemistry.  Immunereactivities of CRF receptors are detected in A172 glioblastoma cells, but not HNSCs and U-138 glioblastoma cells, and UCN I immunorecativity is detected in A172 and U-138 MG glioblastoma cells by both light field and electron microscopy.  Interestingly, electron microscopy revealed UCN I immunoreactivtiy in vesicle-shaped area on cell surface of those glioblastomas.  Blockade of protein synthesis by cycloheximide (100μg/ml) revealed dramatic decrease in UCN I immunoreactivity at 2 and 4 hours after cycloheximide treatment in light field microscopy.  But the immunestaining under electron microscopy also revealed that UCN I immunoreactivity also decreased but still remained on plasma membrane, indicating that secretion of UCN I may not be interfered by inhibition of protein synthesis and its secretion may be via the constitutive secretory pathway.  Based on the results of the present study, UCN I may be secreted by the exocytosis through constitutive secretory vesicles from human glioblastoma cells.

 

Nothing to Disclose: KI, KF, TT, YM, KT

16311 18.0000 SUN-0681 A Expression Profile and Secretory Pathway of Urocortin I in Human Glioblastoma Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Nicole C Woitowich*1, Keith D Philibert2, Randy J Leitermann2, Mary R DeJoseph2, Marc J Glucksman2 and Janice H Urban1
1Rosalind Franklin University of Medicine and Science, North Chicago, IL, 2Rosalind Franklin University of Medicine and Science

 

Reproductive function is maintained by the coordinated efforts of the hypothalamic-pituitary-gonadal (HPG) axis along with peripheral metabolic and environmental cues. These cues are conveyed through additional neuropeptide inputs, such as kisspeptin and neurokinin B (NKB), which relay information to GnRH neurons. Neuropeptides, unlike classical neurotransmitters, do not employ a reuptake mechanism. Instead, endopeptidases cleave neuropeptides to modulate their signal. It is well established that the metalloendopeptidase, EC 3.4.24.15 (EP24.15), is responsible for the cleavage and subsequent signal modulation of GnRH both in vitro and in vivo. The goal of this current experiment was to determine if EP24.15 is co-expressed with kisspeptin and NKB in regions of the brain relevant to reproductive function. Double-label immunohistochemistry was used to visualize regions of immunoreactivity between kisspeptin or NKB, and EP24.15 in the hypothalamus of female rats. Colocalization or close apposition of EP24.15, kisspeptin, and NKB immunoreactive neurons and fibers supports the hypothesis that EP24.15 cleaves kisspeptin and NKB. Immunohistological data demonstrates colocalization of EP24.15 with kisspeptin and NKB in the arcuate nucleus of female rats. Taken together this data suggests that EP24.15 may cleave kisspeptin or NKB in vivo and represents an additional regulatory mechanism of mammalian reproduction.  Understanding the regulation of neuropeptide processing by EP24.15 may provide insight into the development of novel therapeutic targets for the treatment of infertility.

 

Nothing to Disclose: NCW, KDP, RJL, MRD, MJG, JHU

16930 19.0000 SUN-0682 A Colocalization of Novel Reproductive Endocrine Peptides and the Neuropeptide Processing Enzyme, EP24.15, in the Arcuate Nucleus of Female Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Rabia Mahmood*1, Ebony Gilbreath2, Sheba M J MohanKumar3 and Puliyur S MohanKumar4
1Michigan State University, E. Lansing, MI, 2Tuskegee University, Tuskegee, AL, 3MICHIGAN STATE UNIV, East Lansing, MI, 4Michigan State Univ, Okemos, MI

 

Aging in female rats is associated with increases in serum prolactin levels that lead to mammary and pituitary tumor formation.  This is associated with reduction in hypothalamic dopamine levels.  However, the mechanisms behind this phenomenon have remained unclear.  Since aging rats also have persistent increases in circulating estrogens, we hypothesized that chronic exposures to estrogen would decrease hypothalamic dopamine.  Using female Sprague Dawley rats, we have previously found that chronic exposures to low levels of estradiol 17 beta (E2) induces inflammatory changes in the hypothalamus to decrease dopamine synthesis in tuberoinfundibular dopaminergic (TIDA) neurons in the hypothalamus that leads to hyperprolactinemia.  In the present study we hypothesized that E2 affects glial cells in the hypothalamus to produce an increase in inflammatory mediators such as interleukin-1 beta and nitric oxide-related free radicals leading to effects on TIDA neurons.  To test this, we used a primary hypothalamic mixed neuronal glial cell culture and treated it with different doses of soluble estradiol 17 beta (0, 25, 50 and 75 uM) for 12, 24, 48 and 72 hours.  At the end of the exposure, we performed immunohistochemistry and western blotting for glial fibrillary acidic protein a marker for activated astrocytes, interleukin-1beta,  c-fos and nitric oxide synthase.  We found that there was a dose-dependent increase in all these markers.  These results indicate that E2 exposure is capable of producing inflammatory changes primarily mediated through astrocytes that could lead to increases in nitric oxide-related free radicals that results in a reduction in dopamine synthesis.  Supported by NIH AG027697.

 

Nothing to Disclose: RM, EG, SMJM, PSM

17045 20.0000 SUN-0683 A Estradiol-17beta Increases Inflammatory Mediators in Mixed Neuronal Glial Cell Culture 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Takeshi Onoue*1, Motomitsu Goto1, Taku Tsunekawa1, Miyuki Shibata2, Koichi Adachi1, Yoshihiro Ito1, Ryoichi Banno1, Hiroshi Arima1 and Yutaka Oiso3
1Nagoya University Graduate School of Medicine, Japan, 2Nagoya University Graduate School of Medicine, Nagoya, Japan, 3Nagoya Univ Grad Schl of Med, Nagoya, Japan

 

It is reported that NADPH oxidase-derived reactive oxygen species (ROS) play a pivotal role in insulin signaling in peripheral tissues such as the liver or adipose tissues.  Insulin is one of the key molecules which act on the hypothalamus to suppress food intake, and intracerebroventricular injection of NADPH inhibitor, diphenyleneiodonium (DPI), reportedly blocked the insulin-induced suppression of food intake in mice. In the current study, we investigated whether NADPH oxidase-derived ROS affect insulin signaling in the mouse hypothalamic explants, which maintain the intrinsic properties. Sixteen-day-old C57BL6/J mice were sacrificed by decapitation, and hypothalamic organotypic cultures were performed. The hypothalamic explants were treated with hydrogen peroxide (H2O2), DPI, N-Acetyl-L-cysteine (NAC, antioxidant) or vehicle, and proteins were extracted and subjected to analyses with Western blotting. Our data showed that insulin (10-7 M) as well as H2O2 (10-7-10-3 M) significantly increased phospho-Akt (p-Akt) levels, although there were no additivity in the effects of insulin and H2O2 on p-Akt levels. NAC (5 x 10-3 M) or DPI (10-6 M) did not affect p-Akt levels by itself. However, insulin-induced increases in p-Akt levels were significantly attenuated in the presence of NAC or DPI. These data suggest that insulin-induced phosphorylation of Akt is mediated via NADPH oxidase-derived ROS in the mouse hypothalamus.

 

Nothing to Disclose: TO, MG, TT, MS, KA, YI, RB, HA, YO

13677 21.0000 SUN-0684 A Insulin-Induced Phosphorylation of Akt Is Mediated Via NADPH Oxidase-Derived Reactive Oxygen Species in the Mouse Hypothalamic Organotypic Cultures 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Chad D Foradori*1, Valeria M Tanco2, Melaney Jones3, Robyn R Wilborn3, Terry D Brandebourg1 and Brian K Whitlock4
1Auburn University, Auburn, AL, 2College of Veterinary Medicine, University of Tennessee, Knoxville, TN, 3College of Veterinary Medicine, Auburn University, Auburn, AL, 4College of Veterinary Medicine, The University of Tennessee, Knoxville, TN

 

Gonadotropin-Releasing Hormone (GnRH) secretion into the hypophysial portal circulation is the final common pathway for the neural control of luteinizing hormone release. The episodic release of GnRH is essential for normal reproductive function. Moreover, the transfer of the organism’s internal status (energy stores, gonadal hormone levels, etc.) and the external environment (day length, stress, etc.) onto GnRH output is dependent on stimulatory and inhibitory afferent inputs. While there is evidence that GnRH neurons have the inherent capacity to produce episodic release, the mechanism of synchronization of anatomically scattered GnRH neurons remains unclear. Given this, the immunoreactive (-ir) distribution of GnRH and three neuropeptides previously implicated in the control of GnRH release [kisspeptin (Kp), RF-amide related peptide 3 (RFRP3) and dynorphin (DYN)] were evaluated and compared in estrus and diestrus bovine. Six intact bovine were perfused during the estrus or diestrus phase of the ovarian cycle. Tissue was collected for immunohistochemical analysis. Terminal plasma estrogen and progesterone levels were assayed. GnRH-ir cell bodies were found primarily in the medial preoptic area (mPOA), diagonal band of broca and medial septum. RFRP3-ir cell bodies were distributed in a continuum from the dorsomedial hypothalamic nucleus (DMH) to the paraventricular nucleus (PVN) of the hypothalamus. Kp-ir cells were localized in the medial-dorsal region of the arcuate nucleus (ARC) and to a lesser extent in the periventricular region of the mPOA. DYN-ir cell bodies were found in the PVN, supraoptic nucleus and ARC with a large number in the medial DMH. There were no differences in GnRH-ir or RFRP3-ir cell number or distribution between diestrus or estrus animals. By contrast, in diestrus animals there was an increase in DYN-ir and a decrease in Kp-ir cells in the ARC compared to estrus animals. Dual labeling immunofluorescence demonstrated that a proportion of GnRH-ir cells possessed close oppositions with Kp-ir (42.1%) or RFRP3-ir (32.2%) fibers. These proportions did not change between estrus and diestrus animals. In summary, the distribution of GnRH and several other neuropeptides (both inhibitors and stimulators) was characterized in the bovine hypothalamus and preoptic area. In addition, these mediators of GnRH release display neuroanatomical connectivity to GnRH and regulation through gonadal hormones/estrous status.

 

Nothing to Disclose: CDF, VMT, MJ, RRW, TDB, BKW

16310 22.0000 SUN-0685 A Distribution of Gonadotropin-Releasing Hormone, Kisspeptin, RF-Amide Related Peptide 3 and Dynorphin in Diestrus and Estrus Bovine 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Meenakshi Bose*1, Wayne C Glasgow2 and Himangshu S Bose3
1Eastside High School, Gainesville, FL, 2Mercer University School of Medicnie, Savannah, GA, 3Mercer Univ Schl of Med, Savannah, GA

 

Alzheimer’s Disease (AD) is characterized by the loss of neurons and synapses, resulting in gross atrophy of affected brain regions. AD is a protein-misfolding disease, caused by aggregation of abnormally folded Beta-Amyloid (ABeta). My goal  is to find how to degrade ABeta and its application in treatment for AD.  First, I identified that monkey kidney (COS-1) cells have a mechanism degrading ABeta that brain (SH-SY5Y) cells don’t.  Next, Mass Spectrometric analysis of Amyloid-Beta-associated-native complex, I identified many proteins including Ubiquilin1 (UBQLN1), Heat Shock Protein 56 (HSP56), and Heat Shock Protein 70 (HSP70).  Now, I hypothesize these 3 proteins may have a potential role in degrading ABeta and that, alongside chemicals like Nicotine and Genistein, their expression should increase, in turn decreasing expression of ABeta. To test my hypothesis, I performed protein-protein interaction by Co-Immunoprecipitation (Co-IP) of SH-SY5Y Cells Stably Expressing Amyloid-β targeting UBQLN1, HSP70, HSP56, and ABeta. I then treated SH-SY5Y cells with Nicotine/Genistein at various concentrations.  Nicotine, a nicotinic acetylcholine receptor antagonist, increases the activities of acetylcholine, and Genistein, an isoflavone, has neuroprotective effects.  I analyzed all samples on western blot using ABeta, UBQLN1, and HSP70 as well as Acetylcholinesterase and Glutamate Receptor antibodies to better understand the activity of Acetylcholine and Glutamate.  Because abnormal levels of these neurotransmitters may be behind many symptoms of AD.  I observed that ABeta was associated with UBQLN1 and HSP70 and that HSP70 was associated with UBQLN1 and ABeta. With both sets of experiments with Nicotine and Genistein, I observed decreased expression of ABeta as well as increased expression of HSP56 and HSP70 with Nicotine, while UBQLN1 expression also decreased. Nicotine and Genistein were able to regulate levels of the neurotransmitters Acetylcholine and Glutamate by inhibiting Acetylcholinesterase and Glutamate Receptors. In summary, I found that HSP56 and HSP70 are both possibly beneficial to the degradation of Amyloid-β and that Nicotine and Genistein, able to not only degrade Amyloid-β but also regulate levels of the neurotransmitters Acetylcholine and Glutamate, and are beneficial to possibly slowing the progression of Alzheimer’s Disease.

 

Nothing to Disclose: MB, WCG, HSB

15848 23.0000 SUN-0686 A Role of Nicotine and Genistein in Brain Cell Activity Regulating Alzheimer's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Carlos Jesús Terrón Sr.*1, Luis Miguel Rendon Sr.2, Emmanuel David Lopez3 and Tatiana Fiordelisio4
1Faculty of Science, Mexico City, Mexico, 2Science Faculty UNAM, Mexico DF, Mexico, 3Faculty of Science, México, Mexico, 4Faculty of Science, UNAM, DF, Coyoacan, Mexico

 

TRH stimulates pituitary thyrotrophs to synthetize and release the Thyroid Stimulating Hormone (TSH), this hormone causes the release of T3 and T4 from the thyroid, constituting the Hypothalamus-Pituitary-Thyroid (HPT) axis. The correct functioning of this axis is very important for different physiological process in the organism, like lipid metabolism and tissue growth. Recent studies have reported that in females, there is a great influence of the estrous cycle over the physiological dynamic and hormonal secretion of thyrotrophs, modifying among other things structure and size.

Nowadays it is well established that anatomical and physiological attributes of some endocrine cell populations are related with their distribution in the gland and the importance of tissue integrity. Our research group has characterized in previous works the intracellular calcium response in the thyrotroph population of male mice, showing the relevance of the maintenance of integrity and tissue structure. In this work we used pituitary slices to identify and differentiate the characteristics of the tyrotroph population in the central and lateral region of the adenohypophysis at different stages of the mouse estrous cycle. Slices were incubated with Fluo-4 AM (22 μM for 30 min at room temperature) and perfused (1 ml/ min) in saline saturated with 95% O2 and 5% CO2. Image sequences at 510 nm emission were obtained (300 ms exposure; 250 ms interval) with a stereomicroscope (Leica) and cooled camera CCD (Sensys). TRH was bath-applied for 30s at concentrations 0.1 nM to 100 nM, and washed for > 15 min between applications; finally, dopamine 2 μM and high potassium solution, were applied separately to evaluate viability.

The tyrotroph calcium response from pituitaries of different estrous cycle stages, show important variations among them, particularly in the diestrous when cells present an increased calcium response. An important change on the distribution and number of responsive thyrotrophs was seen being bigger on the proestrus stages. These dynamic changes on tyrotrophs show a possibly important mechanism of adaptation to a different physiological situation, implying a compensation mechanism to maintain tissue and organism homeostasis, in spite of the hormonal changes which are present during the estrous cycle.

 

Nothing to Disclose: CJT Sr., LMR Sr., EDL, TF

16111 24.0000 SUN-0687 A Characterization of the Intracellular Calcium Response to Trh in Thyrotrophs of Pituitary Slices during the Mouse Estrous Cycle 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Tatiana Fiordelisio1, Paulina Ocampo*2, Luis Miguel Rendon Sr.3, Gabriela Xóchitl Ayala4, Adriana Hernández4 and Adriana Aparicio4
1Facultad de Ciencias, Universidad Nacional Autonoma de México, México, Mexico, 2Faculty of Science, Mexico, Mexico, 3Science Faculty UNAM, Mexico DF, Mexico, 4Instituto de Fisiología Celular, UNAM

 

Dopamine has been recognized as the physiological inhibitor of lactotrophs. Until now, five types of dopamine receptors (D1, D2, D3, D4 y D5) are known; depending on their pharmacological properties they have been divided in two families, D1 which activates the adenylyl cyclase pathway and the D2 which inhibits the same route. The D2 receptor family has been located in both the pituitary and the brain, while the D1 receptor family has been located in several regions in the brain but not in the pituitary. Unpublished results by our work group have shown that applying dopamine to pituitary slices inhibits calcium entry by blocking L-type calcium channels in most responding cells, while in some minority cells it increases intracellular calcium. In this work, we used transgenic mice from the DrD1-EGFP (1Gsat/Mmnh) and DrD2-EGFP (118Gsat/Mmnc) line to identify D1 and D2 positive cells. We fixed pituitary male, cycling (proestrous, estrous and diestrous) and lactating female mice glands by intracardiacal perfusion of PFA 4% and processed 20mm cryostat pituitary slices for immunohistochemistry to PRL, TSH and CD31; image analysis and D1 and D2 reconstruction was made with Image-J and shows certain degree of regionalization in the distribution of D2 receptors, expressed mainly by lactotrophs, in the different physiological conditions evaluated.

 

Nothing to Disclose: TF, PO, LMR Sr., GXA, AH, AA

14129 25.0000 SUN-0688 A Characterization of the Location of Dopamine Receptors Type 1 (D1) and 2 (D2) in the Mouse Pituitary 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Avelino Guardado*1, Vladimir Ovando2 and Tatiana Fiordelisio3
1Universidad Nacional Autónoma de México, D.F., Coyoacán, Mexico, 2National Institute for Medical Sciences and Nutrition, D.F., Tlalpan, Mexico, 3Facultad de Ciencias, Universidad Nacional Autonoma de México, México, Mexico

 

NEURONAL MARKER (NF68) QUANTIFICATION IN ANTERIOR PITUITARIES FROM RATS WITH DIFFERENT PHYSIOLOGICAL DEMANDS

Being the systemic hormonal regulator, the anterior pituitary needs a complex regulation system that allows it to identify and integrate signals from different origins, besides being able to make all the necessary adjustments in secretion rates and endocrine cell population, required to make an effective response to the perceived stimuli. In response to these signals, endocrine cells in the anterior pituitary react with a series of changes which include cytoskeletal arrangements that control, among other processes, hormonal synthesis and release, as well as cell division. There is plenty of evidence for the role of intermediate filaments in the rearrangement of other cytoskeletal components (like actin filaments and microtubules), regulation of vesicular transport, and DNA repair in non-neuronal cells. Previous studies by our work group have shown the presence of neurofilaments (NF) in subpopulations of somatotropes, lactotropes, tyrotropes and gonadotropes; furthermore we have seen that the proportion of these NF positive cells varies in response to an increase in the demand for a particular hormone. In order to quantify total NF68 expression in the anterior pituitary, we made Western blots for NF68 with anterior pituitary homogenates of two months old male and female rats which were adrenalectomized, tyroidectomized, gonadectomized, or lactating (with and without suction stimuli) in order to provoke a physiological demand for certain hormones; all females were in estrous. Monoclonal mouse anti-NF68 and polyclonal rabbit anti-actin as a loading control were used for all Western blot essays; all images were analyzed using an Image J plugin for densitometric analysis. Our results shows a twofold to threefold increase in total NF68 expression for all experimental conditions (with the exception of lactating females without suckling stimuli); they also show the presence of two different NF68 isoforms, both different from neuronal NF68 but sharing a common epitope recognized by our monoclonal antibody. The increase in total NF68 seen in the experimental conditions as well as our previous results with increasing NF+ cell proportions in the same conditions seems to suggest the presence of a functionally different population of NF+ endocrine cells in the anterior pituitary. We will continue evaluating the possible effects in secretion and mitotic index of these NF+ cells in an attempt to determine if they are indeed functionally different from NF- cells.

 

Nothing to Disclose: AG, VO, TF

16218 26.0000 SUN-0689 A Neuronal Marker Expression (NF68) Quantification in Anterior Pituitaries from Rats with Different Physiological Demands 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Héctor Solís-Chagoyán*
Instituto Nacional de Psiquiatria

 

Circadian rhythm in melatonin release as a mechanism to maintain the circadian system organization in crayfish

Héctor Solís-Chagoyán1, Leonor Mendoza-Vargas2, Armida Baez-Saldaña3, Beatriz Fuentes-Pardo4

1Departamento de Neurofarmacología, Instituto Nacional de Psiquiatría, México

2Departamento del Hombre y su Ambiente, Universidad Autónoma Metropolitana, México

3Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, México

4Facultad de Medicina, Universidad Nacional Autónoma de México, México

Melatonin (MEL) is a highly conserved molecule respect to its circadian rhythm of release and functions. In crayfish, MEL concentration increases at night and this indoleamine synchronizes the circadian rhythm of electroretinogram amplitude (ERG), which is expressed by retinas and likely controlled by the cerebroid ganglion. The aim of this study is to determine whether MEL concentration change on the eyestalks, cerebroid ganglion and hemolymph during a 24 h cycle as well as to test whether MEL is detected by the cerebroid ganglion. MEL concentration was quantified by an ELISA assay and MEL effect on cerebroid ganglion was evaluated recording for the spontaneous electrical activity from it. Both experimental procedures were conducted maintaining crayfish in constant darkness, a suitable condition to study the intrinsic properties of circadian systems. Results showed that MEL is released into the circulatory system following a circadian rhythm and its content in retina and cerebroid ganglion peaks at the same circadian time. A MEL-dose injected into crayfish reduced the level of spontaneous electrical activity of the cerebroid ganglion. Evidence suggests that circadian increase in MEL concentration is detected by the cerebroid ganglion and this indoleamine may acts as a periodical signal to temporally organize the circadian system of crayfish.

 

Nothing to Disclose: HS

16398 27.0000 SUN-0690 A Possible Role of Melatonin Circadian Rhythm in Crayfish 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Emmanuel David Lopez*1, Carlos Jesús Terrón Sr.2, Luis Miguel Rendon Sr.3 and Tatiana Fiordelisio4
1Faculty of Science, México, Mexico, 2Faculty of Science, Mexico City, Mexico, 3Science Faculty UNAM, Mexico DF, Mexico, 4Faculty of Science, UNAM, DF, Coyoacan, Mexico

 

Hipothalamic Tirotropic Releasing Hormone (TRH) promotes the synthesis and secretion of Tirotropin Stimulation Hormone (TSH) in pituitary thyrotropes and stimule the production of thyroid hormones (THs), T3 and T4, involved in the control of cellular metabolism, in the thyroide gland; THs function as negative feedback in the pituitary and hypothalamus, this interaction is known as the hypothalamus -pituitary- thyroid axis.

When activated by ligand binding TRH, the receptors coupled to G proteins present in thyrotropes, trigger different signaling of intracellular calcium (Ca2+i) involved in the mobilization and release of secretory granules to the plasma membrane. To understand the physiology of this cells, must of the studies has been performed in primary cultures, condition that compromise functional and anatomical cell relations. Our working group has realized the importance of maintaining tissue structure for the study of the anterior pituitary gland using slices of adenohypophysis to study the activity of [Ca2+]i of thyrotroph.

Female mice under  pentobarbital (1mL/2.5Kg) anesthesia were sacrificed by decapitation. The pituitary was extracted and immediately embedded in agar of high melting point 3% (Invitrogen; Carllab Cal , USA) . Once cooled, agar cube was placed on the stage of a vibratome (Leica VT1000S) and coronal sections of 130μm were performed. During this process, the slices were kept submerged in normal saline ( NaCl 125mM, KCl 2.5mM, CaCl2 2mM, MgCl2 1mM, NaH2PO4 1.25mM, NaHCO3 10mM and glucose) at ambient temperature and with continuous bubbling with carbogen (O2  95%, CO2 5%). Slices were incubated for 30 min at room temperature with fluorescent intracellular calcium indicator Fluo 4 AM 2μM (Teflabs, Austin, USA) and 0.5 % pluronic acid (Sigma, St Louis MO, USA). Fluctuations in [Ca2+]i were recorded and Imaging with fluorescence stereomicroscope (Leica); Sequences fluorescence image, in the absence and presence of agonist, were obtained from excitation with a wavelength of 480nm excitation and 510nm emission, during an exposure of 300 ms and an interval 300 ms between each image . The acquisition was performed with a cooled CCD digital camera (RS Photometrics Sensys) and Image Pro Express software version 4.5.1.3.

TRH agonist (Sigma -Aldrich) via bath perfusion was applied during the first 30s of each experiment, in concentrations of 0.1, 1, 10 and 100nM, with washes of 15 min between doses to avoid the cumulative effects of TRH; at the end of the experiment a solution of KCl 140mM was administered to verify the viability of the cells.

 

Nothing to Disclose: EDL, CJT Sr., LMR Sr., TF

16375 28.0000 SUN-0691 A Intracellular Calcium Paterns of Thyrotroph in Response to Trh and DA Stimulation of Lactating Mouse Pituitary Slices 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Kyriaki S Alatzoglou*1, Mark J McCabe2, Louise C Gregory3, Emanuela Spadoni3, Juan Pedro Martinez-Barbera3, Mohamad Maghnie4 and Mehul Tulsidas Dattani5
1Chelsea and Westminster Hospital, London, United Kingdom, 2UCL Institue of Child Health, London, United Kingdom, 3UCL Institute of Child Health, London, United Kingdom, 4University of Genoa, Genoa, Italy, 5UCL GOS Institute of Child Health, London, United Kingdom

 

Background: OTX2 (NM172337.2) is a transcription factor implicated in pituitary, ocular and craniofacial development. In mice, it is expressed in the ventral diencephalon and Rathke’s pouch and then restricted to the posterior lobe. Although more than 30 heterozygous mutations have been described in humans, the pituitary phenotype has only been reported in detail in a few cases (n=10) and ranges from isolated GH deficiency (IGHD) to combined pituitary hormone deficiency (CPHD) with or without an ectopic posterior pituitary (EPP).

Objective and hypotheses: OTX2 mutations have so far been reported in single cases or in heterogeneous series, leading to the assumption that they are a rare cause of congenital hypopituitarism. We aimed to establish the contribution of OTX2 mutations in the etiology of congenital hypopituitarism in a well-defined patient cohort, investigate their functional consequences and identify if any genotype-phenotype correlations

Patients and Methods: We screened 125 patients from national (n=101) and international centres (n=24) with the diagnosis of septo-optic dysplasia (SOD) or its variants and at least one pituitary hormone deficiency. 27 patients had additional eye abnormalities (micro/anophthalmia, retinal  dysplasia, coloboma)  and  33 had an ectopic posterior pituitary on MRI. All were negative for mutations in HESX1, SOX2, SOX3, or PROKR2. Functional assays were performed in HEK293T cells with wild type and mutant OTX2 constructs and reporters included the HESX1 promoter and OTX2 consensus binding sites.

Results: Heterozygous OTX2 changes were identified in 6 patients (4.8%). They were chromosomal deletions including OTX2 (n=2), point mutations (n=3) and insertion-deletion (n=1) leading to frameshift or premature termination.W e identified the previously reported p.S138X mutation in a patient with retinal dystrophy, EPP and GHD, and three novel mutations:  (i) p.C170X in a patient with retinal dystrophy, EPP and GHD (ii) p.E79X in association with anophthalmia/microphthalmia, EPP and CPHD (iii) insertion-deletion (p.Ser168Argfs6*) in a patient with microphthalmia, GHD, EPP with a dual signal of the posterior pituitary and a bulky anterior pituitary. In vitro functional studies showed that mutations resulted in significant reduction/loss of transactivation compared to wild type.

Conclusions: Loss of function OTX2 mutations are not uncommon in patients with ocular, retinal and structural pituitary defects. GHD is the commonest endocrinopathy, although others may evolve, necessitating close monitoring of these patients.

 

Nothing to Disclose: KSA, MJM, LCG, ES, JPM, MM, MTD

15928 30.0000 SUN-0693 A Contribution of OTX2 Mutations in the Etiology of Congenital Hypopituitarism: Novel Changes and Functional Consequences 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Sebahattin Sari*1, Ediz Yesilkaya2, Erkan Sari3, Veysel Akgun3, Emrah Ozcan3, Selami Ince3, Mehmet Saldir3, Oguzhan Babacan3, Cengizhan Acikel3, Gokalp Basbozkurt3, Salim Ozenc3, Sirzat Yesilkaya3, Cenk Kilic3, Kemal Kara3, Sebahattin Vurucu3 and Murat Kocaoglu3
1Gulhane Military Medical Academy, Ankara, 2Gülhane Military Medical Academy, ANKARA, Turkey, 3Gulhane Military Medical Academy

 

Background: Pituitary imaging is important for the evaluation of the hypothalamo-pituitary axis defect but data about normal pituitary gland diameters and stalk are limited especially in children. Structure and the measurements of pituitary gland and pituitary stalk may change due to infection, inflammation or neoplasia.

Objective: The aim of this study is to provide normative data about pituitary diameters in pediatric population.

Material and Methods: Among 14854 cranial/pituitary gland magnetic resonance imaging performed between 2011-2013, 2755 images of Turkish children aged between 0-18 were acquired. After exclusions 517 images were left. Four radiologists were educated by an experienced pediatric radiologist for the measurement and assessment of the pituitary gland and pituitary stalk. Twenty cases were measured by all radiologists for pilot study and there was no interobserver variability.

Results: There were 10-22 children in each age group. The maximum median height of pituitary gland was 8.48±1.08 and 6.19±0.88 for girls and boys respectively. Volumes were also correlated with gender like height. Minimum median height was 3.91±0.75 for girls and 3.81±0.68 for boys. The maximum and minimum pituitary stalk basilar artery ratios for girls were 0.73±0.12 and 0.59±0.10. The ratios for boys were 0.70±0.12 and 0.56±0.11.

Conclusion: Our study demonstrated the pituitary gland and stalk size data of children in various age groups from newborn to adolescent. It is thought that these data can be applied in clinical practice. Future prospective follow up studies with larger samples also correlating the structural findings with the clinical and laboratory results are awaited.

 

Nothing to Disclose: SS, EY, ES, VA, EO, SI, MS, OB, CA, GB, SO, SY, CK, KK, SV, MK

11506 31.0000 SUN-0694 A Measures of Pituitary Gland and Stalk; From Neonate to Adolescence 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Brad Pogostin*, Richard A Noto and Michael Tenner
New York Medical College, Valhalla, NY

 

Background:

The incidence of pituitary cyst (PC) is not different than those found in autopsy findings. The sequential changes in cyst volume (CV) have not been reported.

Objectives:

In this study, we analyzed the change of pituitary cyst volume (PCV) in short children on GH therapy.

Subjects:

Brain MRIs of 618 GHD and ISS patients were reviewed. 56 patients were found to have a PC. 31 of these patients with multiple MRIs for analysis are the subjects of this abstract. Mean time between follow-ups was 1.25 years, the median was 0.70 years, and the range was 0.07 years to 4.20 years.

Methods:

MRI imaging with post-gadolinium contrast with particular attention to the pituitary gland were analyzed for the presence of PC, CV, pituitary volume (PV), and the percentage of the pituitary gland occupied (POGO) were measured and calculated. Large cysts (LPC) were considered to be when more than 15% of the PV was occupied by cyst.

Results:

Of the 31 patients, 19 (61%) patients’ original MRI showed a small cyst (SPC) and 12 (39%) patients’ original MRI showed a LPC. The mean and median change in CV for all patients was +3.82% (±20.99%) and -10.81% respectively, and changes varied between -80.27% and +176.13%. The mean and median change in POGO by the cyst for all of the patients was -7.66% ±15.56% and -17.28% respectively, and changes varied between -81.88% and +88.05%. The mean and median change in CV for patients with a SPC was -0.94% ±45.87% and -10.81% respectively, and changes varied from -80.27% to +97.70%. The mean and median change in POGO by the cyst for patients with a SPC was -5.37% ±44.59% and -16.32% respectively, and varied between -81.88% and +88.05%. The mean and median change in CV for patients with a LPC was +11.35% ±73.42% and -7.01% respectively, with a range of -70.43% to +176.13%. The mean and median change in POGO by the cyst for patients with a LPC was -11.30% ±40.35% and -18.90% respectively, with a range of -66.98% to +60.44%. For patients with two sequential MRIs, analysis of change in POGO in time demonstrated that none of the 19 patients with SPCs developed into LPCs and three of the 12 patients with LPCs diminished in size into SPCs. Statistical analysis showed no significant change in CV percentage change, or percentage change of POGO when comparing males vs. females, SPCs vs. LPCs, GHD vs. ISS, and post- vs. pre-pubertal patients.  

Of the 31 patients, 9 had three sequential MRIs. Five of these patients had a SPC, while four had a LPC. None of the patients with a SPC developed into a LPC. The percentage change in CV from the first to second MRI in patients with a LPC was between -20.5% to +40.3%. From the second to third MRI, the range was -34.7% to +77.9%

Conclusion:

PCV can change greatly in time. Patients with a SPC over short periods of time will unlikely develop into a LPC. However, patients with a LPC can show major changes and should be tracked for CV change in time. CV change seems to be independent of GH treatment and other variables.

 

Nothing to Disclose: BP, RAN, MT

13177 32.0000 SUN-0695 A The Growth of Pituitary Cysts in Patients with Growth Hormone Deficiency and Idiopathic Short Stature 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0664-0695 4822 1:00:00 PM Neuroendocrinology Poster

Zulma Dueñas*1, Gonzalo Martinez de la Escalera2 and Carmen Clapp3
1Universidad Nacional de Colombia, Bogota, Colombia, 2Universidad Nacional Autonoma de Mexico (UNAM), Querétaro, Mexico, 3National University of Mexico (UNAM), Queretaro, Mexico

 

Prolactin (PRL) is present in milk from which it reaches the circulation of the offspring. Ocular tissues incorporate systemic PRL and proteolytically process it to vasoinhibins, a family of peptides with antiangiogenic properties that promote the apoptosis-mediated regression of the ocular hyaloid vessels. Here, we investigated whether a deficiency of PRL in milk reduces the levels of intraocular vasoinhibins and the apoptosis of the hyaloid vasculature in neonatal rats. On postpartum days 4 to 18, lactating rats were injected with bromocriptine, an inhibitor of pituitary PRL secretion, with bromocriptine and ovine PRL (delivered via an osmotic minipump), or with vehicle. Serum PRL levels in lactating mothers and pups were measured by the Nb2 cell-bioassay. Apoptosis and vasoinhibin levels were measured in pups’ eye extracts, by ELISA and Western blot, respectively. Bromocriptine reduced serum PRL by 75% in mothers and pups and was associated with a significant decrease of offspring body weight at postnatal days (PND) 16 and 18. Treating the bromocriptine-injected mothers with PRL increased by two-fold the circulating levels of the hormone in both mothers and pups, and it reversed the loss of offspring body weight. Moreover, bromocriptine lowered the levels of retinal vasoinhibins in the nursing young. Consistent with the expected times for the apoptosis of the ocular hyaloid vasculature, eye apoptosis increased three-fold between PND 8 and 12, and declined on PND 18. Bromocriptine significantly reduced ocular apoptosis on PND 8 and 12, and this reduction was prevented by exogenous PRL. These findings are consistent with PRL in milk entering the circulation of the nursing young and contributing to the physiological involution of the hyaloid vasculature via its intraocular conversion to vasoinhibins. We speculate that these findings could help explain the observation that breastfeeding protects against retinopathy of prematurity, perhaps via milk PRL promoting vasoinhibin-mediated regression of the retinal neovessels.

 

Nothing to Disclose: ZD, GM, CC

12702 1.0000 SUN-0710 A Maternal Prolactin Regulates the Hyaloid Vasculature By Promoting the Generation of Intraocular Vasoinhibins in the Nursing Young 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Ryojun Nakajima*, Tsukasa Watanabe, Eri Nakamura, Naoya Ikoma, Michiyo Ishida and Toshio Harigaya
Meiji University, Kawasaki Kanagawa, Japan

 

Vasoinhibins (Vi) are 11-18 kDa N-terminal fragments of growth hormone/prolactin (PRL) family, which have an anti-angiogenic function.  Especially in recent years, Vi derived from PRL which cleaved by cathepsin D has been studied widely on its function of vascular diseases in many different organs.  However, there are not enough reports on Vi receptor that plays a key role of Vi function in target tissues.  Although Vi derived from PRL had weakly bound to PRL receptor, specific Vi receptor, which strongly bound to Vi, is still unclear.  In this study, we tried to detect Vi binding substances in endothelial cells, and obtained a result that integrin α5β1 had bound to Vi.  Integrin is well known as cell adhesion molecule and has α and β subunits.  In addition, integrin plays roles for cell migration and proliferation, and binds extracellular matrix such as fibronectin or collagen. Recently, it was reported that integrin also bound endostatin.  Endostatin is anti-angiogenic factor and a fragment of collagen XVIII cleaved by cathepsin E.  By binding integrin α5β1, endostatin inhibits cell migration and proliferation and induces apoptosis in endothelial cells.  Vi is similar to endostatin in terms of cleavage by cathepsin family, cell signaling pathways and anti-angiogenic function.  Therefore, we studied on the hypothesis that Vi could bind integrin α5β1 to mediate its function.  In this study, recombinant Vi (rVi) containing 1-145 amino acids of mouse PRL was used.  In order to determine the effects of rVi on endothelial cells, we performed a human umbilical vein endothelial cell (HUVEC) culture with rVi.  MTS assay, BrdU incorporation assay and TUNEL assay were used to detect cell viability, cell proliferation and apoptosis, respectively.  Moreover, a binding assay for rVi against integrin β1 monomer or integrin α5β1 was performed.  HUVEC culture under the addition of rVi indicated decreases of cell viability and proliferation, and an increase of apoptosis.  These effects of rVi were attenuated in cultured cells after integrin β1 antibody blocking.  In binding assay, rVi bound integrin β1 monomer and integrin α5β1, and its affinity to integrin α5β1 was higher than that of fibronectin, used as a positive control.  This result suggests that integrin α5β1 plays a role of Vi receptor and possibly mediates Vi functions.

 

Nothing to Disclose: RN, TW, EN, NI, MI, TH

12936 2.0000 SUN-0711 A Effects of Vasoinhibin on Endothelial Cells through Integrin α5β1 Binding 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Anne Victoria McNamara*1, Karen Featherstone2, David Spiller1, Alan S McNeilly3, John Mullins4, Julian Richard Davis1 and Michael R White1
1University of Manchester, Manchester, United Kingdom, 2The University of Manchester, Manchester, United Kingdom, 3Queen's Medical Research Institute, Edinburgh, United Kingdom, 4The University of Edinburgh, Edinburgh, United Kingdom

 

The transcriptional activity of the human prolactin (hPRL) gene is highly dynamic and pulsatile. Time lapse observations of hPRL reporter gene expression in pituitary cell lines and dispersed primary cells have found asynchronous, ultradian cycles of hPRL transcription, which we have proposed to be caused by chromatin remodelling processes generating binary ‘on’ and ‘off’ stochastic cycles of transcription (1).

Dopamine is a critical regulator of prolactin expression in-vivo, binding to type-2 dopamine (D2) receptors expressed on the cell surface of pituitary lactotrophs to acutely inhibit both prolactin transcription and secretion. To investigate the potential role of dopamine in co-ordinating or modulating cycles of hPRL transcription, we have evaluated the transcriptional timing of hPRL promoter activity following treatment with dopamine agonists in dispersed primary pituitary cell cultures and tissue slices prepared from transgenic BAC reporter rats that express either luciferase (Luc) or destabilised GFP (d2EGFP) under the control of the hPRL locus. 

Population analysis of dispersed hPRL-Luc pituitary cell cultures treated with increasing concentrations of the dopamine agonists bromocriptine (1-1000nM) or cabergoline (0.01-10μM) over a 24 hour period, demonstrated a significant reduction in reporter gene activity with a progressive decrease observed over time. Real-time bioluminescence imaging showed a significant reduction in hPRL transcriptional activity in individual lactotroph cells after dopamine agonist treatment, but asynchronous cycles of prolactin transcription persisted, albeit in a reduced percentage of cells and at a lower amplitude compared to untreated cells. In addition, Ex-vivo fluorescence imaging of cabergoline treated hPRL-d2EGFP 250μm pituitary slices confirmed a dramatic reduction in reporter gene expression. Single cell analysis from tissue slices revealed that cycles of hPRL transcription were maintained in individual living cells at a lower amplitude compared to untreated cells. 

In summary, cycles of prolactin transcription in individual lactotroph cells persist at a low level under dopaminergic suppression in both enzymatically dispersed cells and intact tissue. This indicates that cyclical behaviour is a fundamental property of transcription for this endocrine gene, and that dopaminergic suppression is likely to be mediated by reduction in amplitude of pulses of transcription, rather than by abolition of cyclical promoter activation.

 

Disclosure: JRD: Principal Investigator, HRA Pharma. Nothing to Disclose: AVM, KF, DS, ASM, JM, MRW

16687 3.0000 SUN-0712 A Effect of Dopaminergic Suppression on Cyclical Dynamics of Prolactin Promoter Activity in Living Pituitary Cells and Tissue 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Evgenia Korytnaya*1, Jiayan Liu2, Stephen E. Sullivan2, Sandra Ines Camelo-Piragua2, Richard J. Auchus3 and Ariel L Barkan1
1Univ of Michigan, Ann Arbor, MI, 2University of Michigan, 3University of Michigan, Ann Arbor, MI

 

Background: Ectopic prolactin secretion in patients with ectopic pituitary glands, ovarian teratomas and some malignancies has been a) suggested by hyperprolactinemia despite normal pituitary MRI, and b) immunochemically confirmed by tissue analysis.  No case of a malignant solid tumor fulfilling both criteria had been described.

Clinical case: A 47-year old woman presented with a 20-year history of hyperprolactinemia.  Amenorrhea and galactorrhea developed 3 years previously.  Her only medications were losartan and hydrochlorothiazide.  Physical examination revealed nodular goiter, normal cranial nerve function, and normal visual fields but abundant bilateral galactorrhea.  Serum prolactin ranged from 300 to >900 ng/ml, and other pituitary and thyroid indices were normal, including testing for macroprolactinemia.  Pituitary MRI revealed a partially empty sella but no tumor.  Cabergoline 0.5 mg twice weekly did not affect her prolactinemia (1700 to 1900 ng/ml) and the medication was stopped.  In the meantime, she developed abdominal pain and a computed tomography scan showed a 17.0 x 12.6 x 7.6 cm mass abutting the distal stomach, proximal duodenum, and right colon. After the tumor was excised, her galactorrhea resolved, menstrual periodicity resumed within the first month and serum prolactin fell to 5 ng/ml.  Pathological examination revealed epithelioid neoplastic tumor cells strongly positive for HMB45 and weakly positive for CD117, while negative for S100, MART-1, desmin, actin, EMA, cytokeratin AE1/AE3, and CD34—a pattern consistent with perivascular epithelioid cell tumor (PEComa).  Between 5-10% of the tumor cells were strongly positive for prolactin on immunohistochemistry.  RT-PCR detected prolactin mRNA in the tumor cell extract confirming the diagnosis of ectopic prolactin secretion.

Conclusion: Ectopic prolactin secretion is an extremely rare cause of hyperprolactinemia.  Described sources of ectopic prolactin included ectopic pituitary glands, mesenchymal tumors such as PEComas, gonadoblastoma, hematologic malignancies and teratomas (with ectopic development of pituitary tissue within embryologically aberrant tumor).  We present the first example of massive and symptomatic hyperprolactinemia due to ectopic prolactin production by a solid mesenchymal tumor confirmed with both mRNA analysis and immunohistochemistry.  Ectopic prolactin secretion should be suspected in patients with a prolactin >200 ng/ml and negative sellar MRI.

 

Nothing to Disclose: EK, JL, SES, SIC, RJA, ALB

12675 4.0000 SUN-0713 A Ectopic Prolactin Secretion from a Perivascular Epithelioid Cell Tumor (PEComa) Causing Amenorrhea and Profuse Galactorrhea 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Katherine Harrington*1 and Charles V. Clevenger2
1Northwestern University, Chicago, IL, 2VCU/MCV, Richmond, VA

 

The polypeptide hormone prolactin (PRL) is increasingly recognized as contributing to the development and progression of human breast cancer. This is supported by epidemiologic studies that found women with high levels of serum PRL are at an increased risk for developing breast cancer (1). Activation of the prolactin receptor (PRLr) by PRL contributes to the growth, survival and motility of human breast cancer cells. The PRL/PRLr complex activates multiple signaling pathways, including the serine/threonine kinase, Nek3 (NIMA-related kinase 3). In vitro studies have implicated a role for Nek3 in the regulation of breast cancer cell migration/invasion, apoptosis, and cytoskeletal reorganization (2, 3). Additionally, it was found that Nek3 expression is increased in malignant human breast tissue compared to normal tissue. Given the role of Nek3 in breast cancer it is important to better understand its regulation and function. Therefore, to begin to understand the mechanism of PRL-dependent regulation of Nek3 kinase activity, we focused on determining whether Nek3 activity is regulated by phosphorylation and to identify the potential sites(s) of autophosphorylation. Many kinases, including the Nek family of protein kinases, are positively regulated by phosphorylation in the activation loop segment. The putative activation loop of Nek3 (residues 145-172) contains five potential regulatory phosphorylation sites: Thr-161, Tyr-162, Thr-165, Tyr-167 and Tyr-168. These residues were mutated by site-directed mutagenesis and the effect on the catalytic activity of Nek3 was measured by non-radioactive in vitro kinase assay. Non-phosphorylatable Nek3 mutants T165V and Y168F showed a complete loss of catalytic activity (equivalent to kinase-dead Nek3), and therefore may represent the major regulatory phosphorylation sites of Nek3. A phosphospecific antibody to pT165-Nek3 was generated and characterized. This antibody was subsequently used to confirm that Nek3 specifically autophosphorylates at residue T165, and this phosphorylation event is regulated by residue Y168 Nek3. Additionally, we have found that inhibition of the MAPK pathway by using the MEK inhibitor, U0126, suppresses the PRL-induced activation of Nek3 in human breast cancer cell lines. Current studies focus on deciphering the functional importance of these phosphorylation events in breast cancer cells, in particular in the regulation of cell migration and invasion. Ultimately these studies should provide further mechanistic insight as to how Nek3 contributes to the pathogenesis of breast cancer.

 

Nothing to Disclose: KH, CVC

15421 5.0000 SUN-0714 A PRL-Induced Nek3 Kinase Activity Is Regulated By Phosphorylation of the Activation Loop 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Guangyuan Li*, Isaac Newton Hayward, Amy Marie Navratil and Brian D Cherrington
University of Wyoming, Laramie, WY

 

Peptidylarginine deiminases (PADs) are a family of Ca2+ dependent enzymes that post-translationally convert positively charged arginine amino acids into neutral citrulline residues. Major targets for PAD catalyzed citrullination are arginine and methyl–arginine residues on histone tails which causes epigenetic changes in gene expression. Recently, PAD3 expression was detected in the mouse mammary epithelial CID-9 cell line and in the lactating mouse mammary gland with highest expression on lactation day 2. Highest expression of PAD3 in the lactating mammary gland coincides with elevated serum prolactin which is critical to initiate high volume milk production, a process termed secretory activation. Given the coincident timing of increased PAD3 and elevated prolactin, our current studies investigate if increased PAD3 expression is mediated by prolactin activation of the JAK/STAT signaling pathway culminating at the PAD3 gene promoter. To test this, CID-9 cells were treated with a JAK2 inhibitor (SD-1029, 1uM) for 24 hours, followed by 5ug/ml of prolactin for 24 hours. Western Blots revealed that CID-9 cells treated with the JAK2 inhibitor decreased pJAK2 and blocked the prolactin induced increase in PAD3 expression suggesting that JAK2 is required for upregulation of PAD3 expression. At the promoter level, -657/+41 and -276/+41 base pairs of the human PAD3 gene promoter were amplified from genomic DNA and cloned into pGL3-Luciferase.  In CID-9 cells, both constructs had significant basal activity compared to empty pGL3 and showed approximately a 3-fold increase in luciferase activity when stimulated with 5ug/ml of prolactin for 24 hours. Immunofluorescent examination of PAD3 expression in the CID-9 cell line demonstrated that PAD3 partially localizes to the nucleus. Thus, PAD3 may citrullinate histones to decondense chromatin organizing lactation related genes allowing access for transcriptional machinery. To examine this possibility, CID-9 cells were treated with vehicle or 5ug/ml of prolactin for 30 or 60 minutes, followed by histone purification and Western Blot analysis to examine levels of citrullination of histone H3 arginine residues 2, 8, 17. Prolactin treatment increased PAD catalyzed histone tail citrullination suggesting that this epigenetic mechanism may promote expression of milk related proteins in the lactating mammary gland. Taken together, upregulation of PAD3 is mediated by prolactin induction of the JAK/STAT signaling pathway and increased PAD3 may facilitate epigenetic changes in lactation gene expression by mammary epithelial cells.

 

Nothing to Disclose: GL, INH, AMN, BDC

16963 6.0000 SUN-0715 A Upregulation of Peptidylarginine Deiminase 3 Expression Is Mediated By Prolactin Induction of the JAK/STAT Signaling Pathway 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Jimena Ferraris*1, Sandra Zárate1, Gabriela Jaita1, Florence Boutillon2, Marie Bernadet3, Julien Auffret4, Adriana Seilicovich1, Nadine Binart5, Vincent Goffin6 and Daniel Pisera1
1University of Buenos Aires-CONICET, Buenos Aires, Argentina, 2Inserm U1151 - Institut Necker Enfants Malades (INEM), Paris, France, 3INSERM, Unit 1151, PARIS, France, 4Université Paris-Sud, Le Kremlin Bicêtre, France, 5Unité Inserm 693, Le Kremlin-Bicêtre, France, 6Faculté de Médecine, Université Paris Descartes, Paris cedex 14, France

 

In females, anterior pituitary (AP) cell turnover is hormone- regulated along the estrous cycle.  In the rat, the proestrus surge of PRL coincides with the highest apoptosis and the lowest proliferation rates [1].  As PRL acts as a proapoptotic and antiproliferative factor in the male AP [2], we hypothesized that PRL is involved in the control of AP cell turnover along the estrus cycle. PRL administration to ovariectomized (OVX) rats (1 mg/Kg, i.p, 6 h) increased the percentage of hypodiploid cells (C: 10.0 ± 1.1, PRL 21.9 ± 5.3, p<0.05, t test),  decreased the percentage of BrdU- positive cells (C: 6.5 ± 0.3, PRL: 3.3 ± 0.2 p<0.05, t test) and decreased the percentage of cells in G2/M phase of the cell cycle (C: 9.4± 1.6, PRL: 5.0 ± 0.6, p<0.05, t test). This effect was observed specifically in the lactotrope subpopulation (C: 1.8 ±0.3, PRL: 2.8±0.2, p<0.05t test). Hyperprolactinemia induced by a DA receptor antagonist, sulpiride (5 mg/kg, i.p. 6h), in OVX rats increased apoptosis (C: 5.6 ± 0.7, SULPIRIDE: 13.5 ± 2.5, p<0.05, t test) and inhibited BrdU-incorporation (C: 6.2 ± 0.6, SULPIRIDE: 3.4 ± 0.8, p<0.05, t test) of AP cells from OVX rats, indicating a direct effect of PRL independent of DA action. To evaluate if the proestrus surge of PRL is involved in the induction of apoptosis, PRLR knockout (KO) mice and wild type (WT) mice were euthanized at proestrus or diestrus. Apoptosis was higher at proestrus (p) with respect to diestrus (d) in total AP cells and lactotropes but not in non- lactotrope cells. In PRLRKO those differences were abolished and basal apoptosis at diestrus was also decreased.  (Total AP cells WTd: 0.50 ± 0.07 WTp: 1.40 ± 0.50, KOd 0.10 ± 0.05, KOp: 0.03 ± 0.02; p<0.05 ANOVA. Lactotropes: WTd: 0.03 ± 0.01 WTp: 1.2 ± 0.50, KOd 0.00 ± 0.00, KOp: 0.06 ± 0.04 p<0.05, ANOVA).  We observed that PRLR blockade in female mice expressing constitutively the PRLR antagonist Δ1–9-G129R-hPRL (TG) [2] resulted in increased pituitary weight (WT: 1.6±0.07, TG: 2.19±0.01, p<0.05, t test).

In conclusion, our results suggest that PRL induces apoptosis of lactotropes at proestrus participating in the control of AP cell turnover during the estrous cycle. The chronic lack of physiological proapoptotic and antiproliferative actions of PRL, could contribute to alterations in cell renewal, leading to pituitary hyperplasia and tumor development.

 

Nothing to Disclose: JF, SZ, GJ, FB, MB, JA, AS, NB, VG, DP

12094 7.0000 SUN-0716 A Prolactin Induces Apoptosis of Lactotropes Regulating Anterior Pituitary Cell Turnover Along the Estrous Cycle 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Peter Oladimeji*1 and Maria Diakonova2
1University of Toledo, Toledo, OH, 2Univ of Toledo, Toledo, OH

 

Breast cancer is the second leading cause of cancer-related deaths among females, and yet the molecular basis of breast cancer progression remains poorly understood.  Prolactin (PRL), a hormone important in lactation and mammary gland development, contributes to breast cancer progression. Furthermore, PRL and estrogen (E2) have a synergistic effect on breast cancer cells proliferation, although the mechanism underlying the interaction of PRL and E2 signaling is not clear. In the present study we have shown that PRL and E2 exert their synergistic effects through p21-activated serine-threonine kinase (PAK1), a common node in both PRL and E2 signaling. We have previously shown that PRL-activated JAK2 tyrosine kinase phosphorylates tyrosines 153, 201 and 283 on PAK1. We have shown herein that overexpression of PAK1 WT significantly amplified proliferation of MCF7 and T47D cells in response to PRL and E2, while overexpression of phospho-tyrosyl-deficient mutant of PAK1 (PAK1 Y3F) eliminated this effect. In an attempt to understand the mechanism of pTyr-PAK1-dependent regulation of breast cancer cell proliferation, we have shown that PRL with E2 activated PAK1 WT but not PAK1 Y3F, much stronger than either PRL or E2 alone. This increased PAK1 kinase activity caused increased phosphorylation of S305 of estrogen receptor alpha (ERα) that led to enhanced phosphorylation of Ser118, presumably due to an intramolecular conformational changes in ERα. Amplified activation of ERα and PRL receptor/JAK2/PAK1 pathway resulted in maximum activation of estrogen responsive elements (ERE) and cyclin D1 promoter activity in PAK1 WT but not in PAK1 Y3F clones of MCF7 and T47D cells and subsequent increase in cell proliferation. Silencing of endogenous PAK1 inhibited ERE activation in response to E2 while PAK1 re-expression restored the response. It has been previously suggested that PAK1 contributes to tamoxifen (TAM) resistance by ligand independent phosphorylation of S305 on ERα. To confirm it, we have shown that PRL induces decreased TAM response in PAK1 WT but not PAK1 Y3F cells. These data suggest that pTyr-PAK1 plays an important role in the synergistic effect of PRL and E2 on breast cancer cell proliferation, and in TAM resistance.

 

Nothing to Disclose: PO, MD

12890 8.0000 SUN-0717 A The Role of Prolactin-Dependent PAK1-Tyrosyl Phosphorylation in the Potentiation of Estrogen Action and Tamoxifen Resistance 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Jennifer Jay*1, Alan Hammer1 and Maria Diakonova2
1University of Toledo, Toledo, OH, 2Univ of Toledo, Toledo, OH

 

Janus-activated kinase 2 (JAK2), a non-receptor tyrosine kinase, binds to different cytokine receptors and is activated upon ligand binding. Even though JAK2 plays an important role in cytokine signaling, JAK2 subcellular localization is still under debate. We have demonstrated that both endogenous inactive JAK2 and active JAK2 (pJAK2) localize to one of the two centrioles in T47D cells. In synchronized HeLa cells stably expressing GFP-centrin, a centriole marker, we found pJAK2 partially co-localized with ninein, a mother centriole marker. Ninein is involved in microtubule nucleation and anchoring to the centrosome. Therefore, we hypothesized that JAK2 may play a role in microtubule anchorage. Using the microtubule regrowth assay, we demonstrated in COS-7 JAK2-depleted cells and γ2A (JAK2-null) cells that JAK2 is required for microtubule anchorage. To assess whether JAK2 can interact and phosphorylate ninein, we demonstrated that endogenous ninein was able to co-IP with endogenous JAK2. Using an in vitro kinase assay we have shown that JAK2 phosphorylates the N-terminus of ninein while the C-terminal end of ninein (C-ninein) is able to inhibit JAK2 auto-phosphorylation in vitro. These data were confirmed by in vivo experiments. We demonstrate that cytokine (prolactin (PRL) and IFNγ) -activated JAK2 phosphorylation is decreased upon C-ninein overexpression. Furthermore, endogenous ninein knockdown leads to increased cytokine-activated JAK2 phosphorylation. To determine whether this decrease in JAK2 auto-phosphorylation causes a decrease in JAK2 kinase activity we tested phosphorylation of STAT5, downstream target of pJAK2. We found that PRL- and IFNγ-dependent STAT5 phosphorylation decreased upon overexpression of C-ninein and increased upon ninein knockdown.  Additionally, since pJAK2 only partially co-localizes with ninein, we hypothesized that JAK2 may play a role in other centrosome functions. Indeed, the absence of JAK2 causes a decrease in centrosome cohesion and an increase in mitotic defects. These results indicate that JAK2 is a novel member of centrosome associated complex and that this localization regulates both centrosomal function and JAK2 kinase activity.

 

Nothing to Disclose: JJ, AH, MD

12907 9.0000 SUN-0718 A JAK2 Plays a Role on the Centrosome and Is Negatively Regulated By Centrosomal Protein Ninein 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Divya Yogi-Morren*, Georgiana Alina Dobri and Krupa Doshi
Cleveland Clinic Foundation, Cleveland, OH

 

Introduction/Background:

We report a male with large bilateral adrenal masses, secondary hypogonadism and elevated DHEA-S. While it is commonly recognized that hyperprolactinemia may result in hypogonadism, the association of increased prolactin (PRL) levels with elevation of DHEA-S is not commonly made. We describe the effect of normalization of PRL levels with dopamine agonist treatment on suppression DHEA-S into the normal range.

Clinical case:

A 60 year old male presented with long-standing bilateral adrenal masses [Rt-1.2 x 2.7 cm, 19 HU and Lt - 4.6 x 3.9 cm, 25 HU]. His only complaint was fatigue and physical exam was unremarkable, except for mildly elevated BP. Screening tests excluded hypercortisolism, hyperaldosteronism and pheochromocytoma. Given large bilateral adrenal masses, sex-steroid workup was included, and showed a marked elevation of DHEA-S at 751.3 ug/dL(10.0 - 204.0 ug/dL) and hypogonadism with total testosterone of 142 ng/dL (220 - 1000 ng/dL). Non classical congential adrenal hyperplasia was ruled out via ACTH stimulation test with a basal 17-hydroxyprogesterone of 1.3 ng/mL (0.4 - 1.8 ng/mL) and a 60 minute value of 5.2 ng/mL. Hypogonadism and elevated DHEA-S prompted measurement of FSH (4.1mU/mL; Nl: 1-10), LH 2.3 mU/mL; nl:1-7) and PRL which was found to be elevated 683 ng/mL (2 - 14ng/mL). Pituitary MRI revealed a 0.9 x 1.5 x 0.6-cm left sided pituitary macroadenoma causing deviation of the gland and stalk to the right and abutting but not encasing the left cavernous sinus with no mass effect on the optic chiasm. The patient was started on cabergoline 0.25 mg orally twice per week and titrated up to 0.5 mg orally twice per week. He had an excellent response to cabergoline with a decrease in his PRL level from 683 ng/mL to 0.9 ng/mL. Concurrently, his DHEA-S also decreased from 751.3 ug/dL to 186.6 ug/dL while testosterone levels increased from 142 ng/dL to 528 ng/dL.

Conclusion:

The current guidelines for work-up of individuals with adrenal incidentalomas do not recommend checking for production of sex steroids unless the patient has obvious clinical stigma. While women with elevated androgens may readily provide symptoms of hyperandrogenism such and acne, hirsutism and menstrual irregularities, thereby prompting biochemical evaluation, there is a frequent delay in diagnosing men with similar problems, given lack of specific symptoms. We therefore suggest that clinicians should have a low threshold to measure androgens in the presence of adrenal incidentomas, especially in men, to exclude tumorous androgen production. Furthermore, clinicians should recognize that besides secondary hypogonadism,  hyperprolactinemia may also be associated with elevation of DHEA-S and that normalization of PRL levels can suppress DHEAS levels into the normal range, while restoring eugonadism.

 

Nothing to Disclose: DY, GAD, KD

14799 10.0000 SUN-0719 A An Unusual Presentation of Prolactinoma in a Male with Bilateral Adrenal Masses 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Saba Wasim Aziz* and Michael G Jakoby IV
Southern Illinois University School of Medicine, Springfield, IL

 

Background:  Somatotroph adenomas are typically diagnosed after insidious onset of the morphological and metabolic manifestations of acromegaly.  However, clinically silent somatotroph adenomas that do not induce the classical clinical features of acromegaly are increasingly recognized.  We present a case of a somatomammotroph macroadenoma without stigmata of acromegaly discovered incidentally during evaluation of amenorrhea.

Clinical case:  A 25-year-old woman was referred for evaluation and management of a pituitary mass.  The patient initially presented to her gynecologist after several months of amenorrhea and intermittent, low volume galactorrhea when wearing tight fitting brassieres.  Serum prolactin was modestly elevated (45.4 ng/mL, 1.4-24.2), prompting MRI of the sella turcica that demonstrated a 13 x 8 mm cystic macroadenoma of the right hemipituitary adjacent to the right cavernous sinus but not compressing the optic chiasm.  Gonadotropin (LH 6.1 mIU/mL, FSH 5.2 mIU/mL) and estradiol (54 pg/mL) levels were consistent with secondary amenorrhea.  No breast masses, nipple discharge, or manifestations of either Cushing’s syndrome or acromegaly were appreciated on examination by a senior endocrinology fellow and attending endocrinologist.  Subsequent evaluation of thyrotroph and corticotroph function was unremarkable, but IGF-1 was unequivocally elevated at 787 ng/mL (87-368), and GH was not suppressed during a 75 g oral glucose tolerance test (baseline: 3.26 ng/mL, 1hr: 2.45 ng/mL, 2 hr: 3.12 ng/mL, suppressed < 1 ng/mL).  The patient underwent transphenoidal resection of the macroadenoma, and the majority of cells showed immunohistochemical staining for GH.  Approximately 10% of cells also stained positively for prolactin, indicating a somatomammotroph adenoma.  Two weeks after surgery, IGF-1 level fell to 70 ng/mL, and GH suppressed to 0.1 ng/mL and 0.2 ng/mL at 1 hr and 2 hr, respectively, on a repeat oral glucose tolerance test obtained 10 weeks after surgery.  IGF-1 and GH results were consistent with surgical cure of GH excess. 

Conclusion:  Clinically silent somatotroph adenomas with biochemical and immunohistochemical evidence of growth hormone excess but absence of clinical features of acromegaly were first described nearly 30 years ago.  A recent series of 100 consecutively resected pituitary adenomas documented 24% somatotroph adenomas of which one-third, or 8% of all adenomas, were clinically silent somatotroph tumors.  There were no significant biochemical or histological differences between clinically active and clinically silent somatotroph adenomas.  This case and the recent peer-reviewed literature illustrates the importance of screening patients with pituitary masses for GH excess even in the absence of acromegalic findings on examination.

 

Disclosure: MGJ IV: Advisory Group Member, Sanofi, Speaker Bureau Member, Sanofi. Nothing to Disclose: SWA

16328 11.0000 SUN-0720 A Clinically Silent Somatomammotroph Macroadenoma: Case Report and Review of the Literature 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Shashank Rameshchandra Joshi1, Manasi Shah*2, Shilpa Joshi2 and Sanjiv Shah3
1Joshi Clinic, Mumbai, Maharashtra, India, 2Joshi Clinic, Mumbai, India, 3Diabetes Action Center, Mumbai

 

Aim: To prospectively evaluate etiology and management of prolactin excess in a tertiary care endocrine setting. To establish a screening and therapy based protocol in a cost effective way for a resource limited setting.

Method and materials:

At a tertiary care endocrine setting, 374 patients referred by primary care physicians and gynaecologists for prolactin excess were evaluated from 2008 to 2013. For each case, pooled prolactin assays, thyroid function tests and in select patients, other appropriate endocrine tests were performed. Most cases had an MRI scan of the head (sella) already performed. Detailed history of medications was taken, especially of prokinetics and antipsychiatric class of drugs, which are known to increase prolactin levels. Only those patients found to have prolactin excess after stoppage of medication and whose pooled prolactin was elevated, were started on cabergoline therapy.

Results:

Of the 374 patients with excess prolactin levels, only 299 (79.9%) patients had elevated pooled prolactin. Medications were found to be responsible for prolactin excess in 104 (27.8%) patients. Appropriate therapeutic modulation was done to normalize their prolactin levels. MRI scans were already performed in 118 (31.5%) patients out of the 374 patients referred, which were mostly not warranted. This study highlights the need of a cost effective protocol for eliminating unnecessary investigations like expensive endocrine assays and MRI scans.

Conclusion:

In a resource limited country like India, where patients pay out of pocket, there is a need for a cost-effective evidence based strategy to evaluate prolactin disorders. A simple list of medications which increases prolactin levels and pooled assays can eliminate the need for unnecessary MRI scans as well as other endocrine assays.

 

Nothing to Disclose: SRJ, MS, SJ, SS

16102 12.0000 SUN-0721 A Prolactin Disorders in Tertiary Care Endocrine Setting in India: Cost-Effective Audit 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Wonjin Kim*1, Cheol Ryong Ku1, Jae Won Hong2 and Eun Jig Lee3
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Inje University Ilsan Paik Hospital, Korea, Republic of (South), 3Yonsei University College of Medicine, Korea, Republic of (South)

 

Prolactinoma predominantly occurred in young women of reproductive age. But there are limited data about the effect of pregnancy and lactation on prolactinoma progression. We evaluated the safety of dopamine agonists including bromocriptine and cabergoline and pregnancy outcome in prolactinoma patients. Patients diagnosed with prolactinoma who experienced pregnancies were included. Sellar MRI and serum prolactin levels were performed before and after pregnancy and lactation. Total 46 patients with 62 pregnancies were included. Among 62 pregnancies, spontaneous pregnancies analyzed 61 (98.3 %) and only one pregnancy was made by in vitro fertilization. Live births were in 51 (82.3 %), while spontaneous abortions occurred in 11 (17.7%). Twenty-one were treated with cabergoline at the time of conception, whereas twenty-eight with bromocriptine. We divided patients into two groups by their changes of adenoma size after delivery; increased (n = 22) or decreased (n = 15). Patients with bigger adenoma size before pregnancy showed significantly increased after childbirth. However, the enlarged adenoma did not cause any clinical problems. Of all, breast-feeding was performed in 38 pregnancies. Mean duration of lactation was 4.9 ± 4.4 months. Among those 38, 16 patients had done MRI follow-up after the lactation. There were decreased adenoma sizes in 9 patients, no changes in 5 patients, while increased only in two patients. In conclusion, breast-feeding is not contraindicated in patients with prolactinoma, especially those who had smaller adenoma.

 

Nothing to Disclose: WK, CRK, JWH, EJL

13204 13.0000 SUN-0722 A The Effect of Pregnancy and Lactation on Prolactinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Luciana Pinto Brito1, Helena Panteliou Lima Valassi*2, Cassia Regina Mazi1, Berenice B Mendonca3 and Marcelo Cidade Batista4
1Laboratório de Hormônios e Genética Molecular- LIM/42, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 2Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, Brazil, 3Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular, LIM 42, Hospital das Clínicas, Faculdade de Medicina, São Paulo University, São Paulo, Brazil, São Paulo, Brazil, 4Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Percentage of prolactin recovery after PEG precipitation is used to evaluate with prolactin isoform is predominant, monomeric (PRLm) or macroprolactin (bbPRL). Our goal is to establish the absolute post-PEG prolactin reference range and validate its use for screening of macroprolactin in Cobas e601.

Total PRL (PRLt) was measured before and after precipitation with PEG 6000 25 % (PRLm) by Prolactin II assay (Roche) on Cobas E601 in 122 healthy women and 84 female patients selected because their PRLt was >30 ng / mL by IFMA assay DELFIA (PerkinElmer). In this method, the presence or absence of bbPRL was defined as the % recovery of PRL after PEG > 65% (65 patients, Group 1) or <30% (11 patients, Group 2), respectively. Samples with inconclusive values (recovery ranged between 30 and 65%) were subjected to gel filtration chromatography (8 patients, Group 3).

The reference range of PRLt and PRLm in the PRL II assay was 4.2 to 24 and 4.1 to 20 ng/mL, respectively (2.5 and 97.5 percentiles). In this assay, PRLt and PRLm in patients of Group 1 ranged from 41 to 366 and from 38 to 344 ng/mL, respectively. All PRLm results were above the post-PEG reference range, suggesting the predominance of PRLm. In Group 2, the PRLt and PRLm ranged from 18 to 37 and 2.6 to 17.7 ng/mL, respectively. All PRLm results were within the post-PEG reference range, suggesting the predominance of bbPRL . In Group 3, all results were above the PRLm post-PEG reference range (PRLt from 40 to 148 ng/mL and PRLm from 24 to 103 ng/mL), but there was a predominance of bbPRL (45 to 63%) in all samples in chromatography, suggesting the concomitant presence of bbPRL and PRLm.

In conclusion, reference range of post- PEG PRL in PRL II assay defined in this work; allow the correct identification of patients with predominant monomeric or macroprolactin.

 

Nothing to Disclose: LPB, HPLV, CRM, BBM, MCB

14532 14.0000 SUN-0723 A Validation of Reference Range of Prolactin after Precipitation with Polyethyleneglycol (PEG) for Hyperprolactinemia Evaluation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Fabio Rotondo*1, David G Munoz1, Jason Karamchandani1, Juan Bilbao2, Vladimir Iakovlev1, Michael D Cusimano1, Antonio Di Ieva1 and Kalman Kovacs1
1St. Michael's Hospital, Toronto, ON, Canada, 2University of Toronto, Toronto, ON, Canada

 

Introduction Several different lesions, most frequently pituitary adenomas, can be located in the sella turcica. In most cases the clinical, biochemical and imaging results provide the correct diagnosis. Few cases are, however, exceptions and the proper diagnosis can be achieved only by detailed morphologic study. We present here the case of an intrasellar melanocytic tumor which mimicked pituitary adenoma and was misdiagnosed.

 Clinical case A 74 year old man with a history of hypertension and blurred vision. An MRI of the brain revealed a 12-mm macroadenoma at the level of the pituitary which was subsequently diagnosed as a clinically non-functioning pituitary adenoma. He was neurologically intact, but his retinal nerve fiber thickness was 73 on the right and 72 on the left.  His visual fields were full.  Blood levels showed a hemoglobin of 139, TSH: 2.08, free T4: 9, cortisol in the morning: 519, growth hormone: < 0.1, LH: 6.7, FSH: 8.8, free testosterone: 28.7, prolactin: 19.2 (upper limit 13.1), IGF-1: 124. The intrasellar mass was removed by the endoscopic transsphenoidal approach.

Pathology The tumor was composed of spindle shaped, diastase resistant PAS positive cells containing cytoplasmic granules. It did not consist of adenohypophysial cells and was not a pituitary adenoma. Immunohistochemistry using the streptavidin-biotin-peroxidase complex method demonstrated immunopositivity for vimentin, S-100 protein, epithelial membrane antigen and Hmb45, a melanin marker. Immunostainings were negative for synaptophysin, chromogranin, GFAP, neurofilament antigen, SOX-10, progesterone receptor and the adenohypophysial hormones. Electron microscopy documented the presence of melanin granules in the cytoplasm of many tumor cells. Based on the morphologic findings, the diagnosis of intrasellar melanocytic tumor was made.

Intrasellar melanocytic tumors may originate in leptomeningeal melanocytes or may be metastatic deposits of an extrasellar primary malignant melanoma. In our case, the Ki67 nuclear labeling index was approximately 20% indicating rapid cell proliferation rate and raising the possibility that the intrasellar mass was a metastasis. In some cases primary malignant melanomas are very small and difficult to find but they can lead to widespread metastases. In our case, so far the primary tumor was not identified.

 Conclusion Various intrasellar lesions (thyrotroph hyperplasia, hypophysitis, primary and metastatic tumors, etc) may mimic pituitary adenoma. The correct and in some cases unexpected diagnosis can be made only by detailed morphologic investigation. The proper diagnosis is of crucial importance because it affects prognosis and therapy. 

 

Nothing to Disclose: FR, DGM, JK, JB, VI, MDC, AD, KK

14713 15.0000 SUN-0724 A Intrasellar Melanocytic Tumor Mimicking Pituitary Adenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Thomas James Upton*1 and Penelope Jane Hunt2
1Christchurch Hospital, Christchurch, New Zealand, 2Christchurch Hosp, Christchurch, New Zealand

 

Background: Pituitary metastases are uncommon and clinically may mimick symptoms and signs of a primary sellar lesion.

Clinical case: A 72-year-old woman presented with weight loss, headache and blurred vision. History included metastatic renal cell cancer (nephrectomy at 63, relapse at 70 with pulmonary metastases stable over 2 years). Clinically she was well with no discernible visual loss and normal thirst. MRI brain revealed a 25mm contrast enhancing pituitary mass with suprasellar extension, infundibular thickening and early optic chiasm compression. Automated visual field testing showed generalised peripheral constriction. Pituitary assessment showed significantly raised prolactin (6544 mIU/L (50-550)) with FSH 3.2 IU/L (>20), LH 0.2 IU/L (>15), free T4 9 pmol/L (10-24), TSH 4.54 mIU/L (0.4-4.0), IGF-1 116 ug/L (SDS +0.1) and cortisol after Synacthen 363 nmol/L (>550). She was commenced on hydrocortisone, thyroxine and cabergoline (0.5mg weekly). Prolactin rapidly normalised. The pituitary mass remained unchanged on serial imaging at 1 and 3 months. Five months after initial assessment she developed a bitemporal hemianopia and reduced visual acuity. Imaging confirmed growth of the tumour as well as intraventricular nodular enhancing lesions consistent with metastatic disease. The pituitary mass was debulked via transphenoidal approach; histology confirmed metastatic renal cell carcinoma. Vision improved following surgery with further recovery after pituitary radiotherapy.  The tyrosine kinase inhibitor sunitinib was commenced.

Conclusion: The differential diagnosis was macroprolactinoma or pituitary metastasis. Pituitary metastases are uncommon with renal cell metastases extremely rare (1). The degree of prolactin elevation supported the initial decision to treat as macroprolactinoma and the lack of tumour progression on close follow-up imaging was initially reassuring. In retrospect, involvement of the infundibulum may have been a clue to the correct diagnosis. In a series of 152 pituitary stalk lesions (2) almost one-third (n=49, 32%) were neoplastic. Of these, the majority were malignant (n=36, 74%) and most metastases (25/36, 69%). This case illustrates a challenging differential diagnosis and an important clinical point: a patient with a pituitary mass and history of malignancy is at high clinical suspicion for metastatic disease, regardless of other findings, especially if there is involvement of the pituitary stalk.

 

Nothing to Disclose: TJU, PJH

11365 16.0000 SUN-0725 A Renal Cell Pituitary Metastasis Masquerading As a Prolactinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Omar Manlapaz*1, Jeena Mary Varghese2, Neel L Shah3 and Kelly L Wirfel4
1Univ of Texas Med Sch at Houston, Houston, TX, 2University of Texas at Houston, Houston, TX, 3UT Med School - Houston, Houston, TX, 4The University of Texas Health Science Center at Houston

 

Background:

Dopamine agonist-resistant prolactinoma (DARP) is seen in patients who have a failure of achieving normal prolactin levels and/or in reduction of tumor size by at least 50% with maximal conventional doses of medication (bromocriptine 7.5 mg per day or cabergoline 2.0 mg per week). Treatment approaches to DARP include switching to another dopamine agonist, raising the dose of the dopamine agonist above conventional doses, surgical resection, radiation therapy, and other experimental treatments. Previous studies have suggested the role of selective estrogen receptor modulators (SERMs) in decreasing prolactin levels in DARP.  

 Clinical case:

A 33-year-old woman was initially evaluated for a seven-year history of secondary amenorrhea. Her prolactin level was 17,777 ng/mL (normal 2.8 – 29.2 ng/mL); and MRI of the brain showed a 4.5 cm suprasellar mass. She was initially started on bromocriptine but was later switched to cabergoline due to intolerance. With medical treatment, her prolactin level decreased to 4,989 ng/mL and a follow-up MRI of the head showed that the suprasellar mass decreased in size to 2.7 cm. She remained on cabergoline 0.5 mg once daily for another year. However, her subsequent prolactin levels plateaued, ranging from 4,900 to 6,300 ng/mL. Other treatment modalities were entertained, and she declined surgical resection of her prolactinoma. Her dose of cabergoline was increased, and she underwent radiation therapy with 52.2 Gy. Subsequently, four annual MRIs of the brain showed a stable 1.3 cm suprasellar mass; and her prolactin levels once again plateaued, ranging from 1,200-2,000 ng/mL. A trial of Raloxifene 60 mg once daily was started in addition to cabergoline 5 mg per week. A subsequent MRI of the brain showed a reduction in size of the suprasellar mass to 0.8 cm and her prolactin levels were below 1,000 ng/mL.

 Conclusion:

This case demonstrates a potential role of Raloxifene in decreasing prolactin level and tumor size in patients with prolactinoma that is refractory to dopamine agonist therapy and other modalities including radiotherapy. Further studies have yet to be done to establish this effect.

 

Nothing to Disclose: OM, JMV, NLS, KLW

14812 17.0000 SUN-0726 A Dopamine Agonist-Resistant Prolactinoma: A Potential Role of Raloxifene 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

David Sionit*1 and Lawrence E Shapiro2
1Winthrop Univeristy Hospital, Mineola, NY, 2Winthrop Univ Hosp, Garden City, NY

 

Title:

Resistant and Recurring Prolactinoma

Introduction/background:

 Prolactinomas rarely require ablative therapy because they respond to treatment with dopamine agonists by suppression of serum prolactin and decrease in tumor size.  However, in some cases these tumors are resistant to medical treatment

Clinical Case:

A 48 year-old man presented with a history of prolactinoma treated with dopamine agonists over the last 7 years. He was initially evaluated for infertility and found to have an elevated prolactin in the range of 100ng/dl.  An initial MRI showed a “normal” pituitary gland and he was placed on bromocriptine.  When prolactin levels failed to respond to typically effective levels of bromcriptine he was switched to carbergoline at progressively increasing dosages. Subsequent MRI in 2008 described 0.4 x 0.5 x 0.6 cm microadenoma causing right stalk deviation. Despite maximally tolerated cabergoline doses, the tumor grew to 2cm with encroachment on the optic chiasm and extension into the left cavernous sinus and he was referred for neurosurgery.  Immunohistology confirmed a prolactin secreting macroadenoma. Immediate post-operative  imaging showed minimal residual tumor.  However, despite continued cabergoline therapy, an MRI seven months post-op showed a 1.9 x 1.8 x 1.6 cm sellar mass consistent with recurrent/residual tumor without chiasmal compression. Serum prolactin levels were greatly increased to >1000 ng/dl (less than 10% macroprolactin), despite increasing dosages of cabergoline to a maximally tolerated 3.5 mg/week. He was then referred to neurosurgery for repeat transphenoidal tumor resection and post-operative radiotherapy.

Discussion:

Prolactinomas are the most common secretory pituitary tumor with an annual incidence of 30 per 100,000. Men tend to have larger tumors at presentation and more invasive/rapid growth. They are typically very sensitive to dopamine agonist therapy though rarely, as in our case, resistance can occur. Though there is no exact definition of resistance, it has been described as an inability to lower prolactin to normal limits and a 50% reduction in tumor mass with maximal tolerated dose of a chosen agent. A discordant response may occur where in there is a reduction of tumor size without prolactin normalization or vice versa. Possible mechanisms of dopaminergic resistance include decreased expression of dopamine sensitive D2 receptors or reduced D2 receptor affinity in tumor cells. In cases of failure of medications to control the size and function of prolactinomas treatment options include surgery, radiotherapy and newer agents such as the alkylating drug temozolomide.

Conclusion:

Rarely prolactinomas are resistant to dopaminergic medications and but in the instances they are they require ablative treatment.

 

Nothing to Disclose: DS, LES

11833 18.0000 SUN-0727 A Resistant Prolactinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Jose T Kuzhively*1 and Ambika Amblee2
1John H Stroger Hospital-Cook County, Chicago, IL, 2J Stroger Hosp-Cook County, Chicago, IL

 

Background

Resistance to dopamine agonists in prolactinomas (Pro) is rare and in such cases surgery (Sx) and radiation therapy (RT) can be considered. Complications post-RT like radiation necrosis (RN) is rare.

Case

66 yo male with Pro (3.1 cm) was started on cabergoline (C) 0.5 mg 2/week and titration to 2 mg daily over 12 months (m). Due to persistent symptoms and increase in tumor size (3.4 cm), patient (pt) underwent transphenoidal  Sx. Inadequate response lead to craniotomy 6 m later with pathology confirming a Pro with high Ki67 index (>10%). Repeat MRI, 2 m later showed residual tumor of 2.4 cm with Prl of 257ng/ml (2.6-13.1) and C dose was increased to 3 mg daily. After discussion with neuroSx, pt received external beam RT 1.8 Gy in 30 fractions. Post RT due to increase in tumor size to 4 cm, a 2nd craniotomy was done while maintaining a daily dose of 4 mg of C. Post sx he had a good response and his C dose was decreased to 0.5 mg 2/week. At 13 m post-RT he developed an ischemic stroke.  At 20 m post RT he had altered mental status, worsening left sided weakness, 4.7 cm frontal mass and MRI Spect confirmed the lesion as RN.  Pt responded to high dose steroids (S) and we plan to start Bevacizumab (B).

Conclusion

The incidence of RN reported in pituitary tumors is approximately 17%.  Risk factors include volume of brain irradiated, older age, total and fractionated RT dose, diabetes and Cushing’s disease. In 46 pituitary adenomas there were 4 cases of RN and 3 of 4 had Cushing’s disease. RN is a late complication with a mean onset of 22 m post RT. It is secondary to fibrinoid necrosis of small arterial vessels leading to necrosis and death of brain parenchyma. It is usually located at the site of the original tumor and can present with generalized seizures, cognitive decline, dementia and motor deficits. The risk increases with higher total RT dose and with fraction dose > 2.5 Gy. However the incidence varies in different centers and makes toxicity-risk predictions unreliable. RN usually ends with death or severe disability.

The 3 modalities of treatment are Sx, S, and B. High dose S reduce edema and mass effects and are usually needed upto 12 m post diagnosis. Results are better with early detection and treatment. Sx is indicated for large necrotic masses, lesions worsening with S and if hemorrhage or abscess develops. Sx provides immediate symptomatic relief and prevents further progression, with a median survival of 6 years with good Karnofsky performance score in 67%. B is a monoclonal antibody which is well tolerated and showed radiological and clinical improvement in 23/24 pts (96%) with RN. Side effects are arterial/venous thrombosis and risk of anaphylaxis (<1%).

RT can be a last resort for aggressive pituitary tumors like our pt as indicated by his Ki67 index. To prevent RN doses above 45-50 Gy and fractions of > 2 Gy need to be avoided. Post RT close surveillance and follow up imaging will catch the earliest signs to prevent morbidity and mortality.

 

Nothing to Disclose: JTK, AA

15998 19.0000 SUN-0728 A Radiation Necrosis Following External Beam Radiation for Dopamine Agonist Therapy Resistant Macroprolactinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Buthaina Almahmeed*1 and Jeannette M Goguen2
1University of Toronto, Toronto, ON, Canada, 2St Michaels Univ Hosp, Toronto, ON, Canada

 

Abstract: Prolactin secreting carcinoma

Background: Pituitary carcinoma is a very rare cancer and is seen in 0.1-0.2% of all pituitary tumors. It arises from the adenohypophysis. It has no clinical, radiological or histological features that distinguish it from benign pituitary adenomas. Most pituitary carcinomas are functioning, producing ACTH or prolactin. They are accompanied by craniospinal and/or systemic metastases. Most cases represent invasive macroadenomas at initial presentation.

Case: A 56 year old man presented in January 2004 with left sided visual failure. Physical examination confirmed the presence of left temporal hemianopsia. Imaging with CT scan and MRI revealed a 3 x 2.2 x 2.6cm macroadenoma with extension to the suprasellar cistern and left cavernous sinus and displacement of the left optic nerve. His pre-operative prolactin was 887. Due to visual deterioration he was admitted for urgent decompression. Pathology revealed a sparsely granulated pituitary adenoma which did not stain heavily for prolactin, with rare mitotic figures. He was started on Cabergoline post-operatively as repeat MRI showed a residual tumor of 1.1cm and his prolactin was high at 338. Triple bolus test confirmed panhypopituitarism. He was started onlevothyroxine and topical testosterone. He responded very well to cabergoline and remained asymptomatic with an undetectable prolactin until 2009, when cabergolin was stopped. Prolactin remained undetectable until 2012 then started rising gradually, reaching 20. in early 2013 it reached 202. A follow-up MRI of the pituitary revealed multiple new intracranial lesions which were suspicious for metastatic disease. Spine MRI was negative.  Excisional biopsy of one of the lesions was consistent with dissiminated pituitary carcinoma, prolactin secreating, with a high Ki-67 index of 10%. Surgery was not indicated given the dissiminated lesions. The decision was to proceed with medical treatment instead of radiation. Cabergoline was restarted and the dose was gradually increased, reaching 0.5mg BID. The patient responded very well to treatment and his prolactin started gradually decreasing. His most recent prolactin level was 30 in January 2014. He tolerated cabergoline very well.

Conclusion: Prolactin secreting carcinomas are rare tumors. They are defined by craniospinal or systemic metastatic spread. Incomplete suppression or a rising prolactin may indicate malignant transformation of an adenoma. Treatment options include surgery, dopamine agonists and radiation therapy. The prognosis is poor with a mean survival of 2-2.4 years.

 

Nothing to Disclose: BA, JMG

17030 20.0000 SUN-0729 A Prolactin Secereting Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Patamaporn Lekprasert*1, Nissa Blocher2 and Arthur Chernoff3
1Albert Einstein Medical Center, Elkins park, PA, 2Albert Einstein Medical Center, Philadelphia, PA, 3EINSTEIN MEDICAL CENTER, Philadelphia, PA

 

Epstein-Barr virus-associated nasopharyngeal cancer and pituitary prolactinoma are rare in adolescents. We report the first case of simultaneous nasopharyngeal carcinoma and pituitary macroprolactinoma.

Our case is an 18-year-old Dominican male who presented to the hospital with worsening neck pain. He started having right-sided neck mass one year ago while he was in his country. He was prescribed multiple pain medications without relief. The mass biopsy was performed and reported as invasive epidermoid carcinoma.  He was consequently sent to the US for further care.

On physical examination, he had a large mass, extending from his right-sided soft palate to his neck with cervical lymphadenopathy. Cervical lymphadenopathy was noticed. He did not have an evidence of secondary sexual characteristics. His testes were descended but small (4 cc.). His height was 160 cm, and his weight was 44 kilograms. Both were less than the third percentile. He had stable vital signs and intact neurologic examination.

Head and neck CT and MRI revealed 5.7x6.1x8.9 cm invasive mass centered at the right skull base and nasopharynx with intracranial extension to the right orbital apex, and sellar floor.  Brain MRI showed an enhanced 16.9x12.2 mm sellar mass, and the pituitary stalk was deviated to the right. The nasopharyngeal mass was re-biopsied. The pathology revealed non-keratinizing nasopharyngeal carcinoma of undifferentiated subtype. An Epstein-Barr virus DNA was more than 5,200 copies/ml. He was also found to have hyperprolactinemia at 1,445 ng/ml, and secondary hypogonadism with total testoterone of 158 (348-1197) ng/dL. His free thyroxine, moring cortisol and ACTH stimulation test were normal normal. His bone age was 15 years. His visual field evaluation was normal. He eventually was diagnosed with stage IVa nasopharyngeal carcinoma, and pituitary macroprolactinoma.

He underwent tracheostomy to establish an alternate airway, and percutaneous gastrostomy for nutrition support. He received concurrent chemo-radiation with Cisplatin followed by consolidation therapy with Cisplatin and 5-fluorouracil. He tolerated the treatment well, but later developed secondary adrenal insufficiency requiring Hydrocortisone 20 mg in the morning. Due to his nausea and vomiting during initial treatment, Bromocriptine 2.5 mg/day was initiated four months later. After finishing his chemo-radiation, the repeat MRI showed significant decrease of his nasopharyngeal cancer, but the sellar mass remained unchanged.  The prolactin at that time was 463 ng/mL.  His Bromocriptine was subsequently increased to 5 mg/day. The most recent prolactin was 33 ng/mL after two months of higher dose Bromocriptine. His total testosterone increased to 414 ng/dL. Patient reported overall improvement. We continued his Bromocriptine, and planned to repeat prolactin, total testosterone, and pituitary MRI in the near future.

 

Nothing to Disclose: PL, NB, AC

16253 21.0000 SUN-0730 A An Interesting Case of Synchronous Nasopharygeal Carcinoma and Pituitary Macroprolactinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Muyesser Sayki Arslan*1, Mustafa Sahin2, Esra Tutal1, Melia Karakose3, Oya Topaloglu1, Bekir Ucan1, Taner Demirci1, Mustafa Caliskan4, Seyda Sahingoz1, Erman Cakal5, Mustafa Ozbek6 and Tuncay Delibasi1
1Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey, 2Ankara University School of Medicine, Ankara, Turkey, 3Diskapi Yildirim Beyazit Teaching and Research Hospital, Ankara, Turkey, 4Diskapi Training and Research Hospital, Ankara, Turkey, 5Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey., Ankara, Turkey, 6Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey.

 

OBJECTIVE:

High prolactin induced hypogonadism and increased bone resorption in prolactinoma patients. We aimed to assess the level of fibroblast growth factor 23 (FGF 23), osteoprotegerin (OPG), receptor activator of nuclear factor κB ligand (RANKL) in prolactinomas according to control.

MATHERIALS  and METHODS:

We analyzed 50 premenopausal women with prolactinoma (29 with new diagnosis (group 1), 21 with biochemical controls (group 2)) and 27 healthy controls. We excluded the participants who have any condition that effect bone metabolism. According to pituitary imaging 6 of the patients had macroadenoma and 44 had microadenoma. Only 1 patient had hypogonadism. We investigated serum levels of FGF-23, parathyroid hormone (PTH), vitamin D, calcium, phosphorus, osteocalcin and deoxihydroxyproline (DOP) levels were measured in patients with prolactinoma.  Bone mineral density was evaluated by dual-energy RX absorptiometry.

RESULTS: Body mass index (BMI) and fat percentage were similar in patients and controls. Hip neck and lumbar spine measurements were significantly lower in patients with group 1 than group 2 (p<0.05).  None of the patients had osteoporosis in patients with controls. Only 2 patients had osteoporosis in patients with macroadenoma. Lumbar spine  (LS) was the most affected, as LS T-score was <-2 SD in 16% (n=8) of the patients.  Somatomedin C, growth hormone, thyroid stimulating hormone, vitamin D, calcium, phosphorus levels did not differ between groups. We found significant differences between DOP  and RANKL levels in group 1 and controls. However, there were no significant differences between OPG, FGF 23 and  osteocalcin levels.

CONCLUSIONS: Based on the results of this study, high prolactin level has no effect on FGF-23 and OPG levels. Further larger studies are needed to clarify bone metabolism  in patients with prolactinoma particularly in hypogonad patients.

 

Nothing to Disclose: MS, MS, ET, MK, OT, BU, TD, MC, SS, EC, MO, TD

12874 22.0000 SUN-0731 A The Relationship Between Fibroblast Growth Factor 23, Osteoprotegerin, Receptor Activator of Nuclear Factor κB Ligand and Osteoporosis in Patients with Prolactinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Anne Marie Hannon* and Antoinette A Tuthill
Cork University Hospital, Cork, Ireland

 

Prolactinomas are the most common hormone-secreting pituitary tumors. They occur with an incidence of approximately 44 per 100,000 and account for 40% of all pituitary adenomas. They typically present with infertitity, irregular menstrual cycles and galactorrhea in women and hypogonadism, decreased libido, infertility, erectile dysfunction and gynecomastia in men.

We present the case of a 19 year old male who presented to clinic with visual disturbance and delayed puberty. On examination he was noted to have delayed secondary sexual characteristic development. He had marked bitemporal hemianopia. Visual perimetry testing confirmed bitemporal visual loss. MRI pituitary revealed a 31 x 48mm pituitary mass extending into the suprasellar region. His prolactin was markedly elevated at 248,358mIU/L. His thyroid function tests showed a T4 of 9pmol/L and TSH of 2.29mIU/L. His IGF-1 was low at 55ng/ml and his testosterone was also low at 13.7nmol/L.

He was commenced on cabergoline therapy. After one month of therapy his prolactin level decreased significantly to 8973mIU/L and his vision improved. His repeat MRI showed a substantial reduction in size to 23 x 21mm with decompression of the suprasellar cistern.  Repeat TFTs showed a T4 of 5.7pmol/L and TSH of 1.44mIU/L.

He was further evaluated with a TRH stimulation test, his TSH was 4.39mIU/L after 30 minutes and 5.02mIU/L after 60 minutes, confirming central hypothyroidism, with a lack of response to TRH. Insulin Tolerance testing determined he was growth hormone and ACTH deficient. He was commenced on hydrocortisone and levothyroxine therapy.

We wish to highlight the deterioration in thyroid function tests from presentation in spite of tumour shrinkage, this an unusual occurence as hypothyroidism and hypoadrenalism usually improve with normalisation of the prolactin in macroprolactinomas. We postulate that this may be as a result of somatomammothyrotroph suppression with a dopamine agonist due to  their similar embryological origin. This effect has previously been described in one other case report of a giant prolactinoma.

 

Nothing to Disclose: AMH, AAT

16377 23.0000 SUN-0732 A Central Hypothyroidism As a Consequence of Cabergoline Treatment in a Macroprolactinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Corina Galesanu*1, Andra Loghin1, Alexandru Florescu1, Ilinka Grozavu1, Didona Ungureanu1 and Mihail Romeo Galesanu2
1University of Medicine and Pharmacy, Iasi, Romania, 2Romanian Academy of Medical Sciences, Iasi, Romania

 

Beckground : Prolactinomas are rare in childhood and adolescence, representing a half of pituitary adenomas (1% of intracranial tumors). Macroadenomas are more frequent than microadenomas.The signs and symptoms depend on age, sex, tumor size and prolactin level. Tumor size correlates positively with serum PRL levels; PRL level greater than 200 ng/mL strongly indicates pituitary tumor PRL-secreting. Due to a higher frequency of macroadenomas in boys, they present more often neuro-ophthalmologic findings (impaired vision, headache).

Clinical case : We present a man of 25-years-old diagnosed at age 13  with giant prolactinoma. He came to our observation after neurosurgery for symptoms of tumor expansion : headache , bitemporal hemianopia and decreased visual acuity.Elements of sella turcica were not recognizable on the pituitary X-Ray .The CT described a giant tumor of the pituitary gland (after partial removal tumor). PRL level greater 250 ng/mL. Treatment of choice was dopamine-agonist drug = bromocriptine in high dose 25 mg/day. After two years PRL level decresed to 15 mg/mL and the tumor have shrunk. The treatment was changed from bromocriptine at cabergoline 1 mgx2/week. No pituitary insufficiency was observed after surgery. The pacient developed normal puberty, reaching a final high=172cm. After 7 years of prolactin level control and no IRM signs of recidive  under medical therapy, the treatment was stoped. After 12 years at current evaluation the PRL level was high.Clinical and biological signs of pituitary insufficiency were absent . Ophtalmological consult : normal visual field. Pituitary X-Ray revealed a raised intrasellar volume, undefined sellar walls and a deeply declined sellar floor in the sphenoidal sinus. IRM described a 2/1.3/2.5 cm tumor residue with extension in the right cavernous sinus. Cabergoline therapy was reinitiated :1 mgx2/week.

Conclusions : The pacient had severe symptoms at diagnosis. Neurosurgery was performed before endocrinological evaluation and was not curative. Dopamine-agonists were needed postoperatively.When a patient has macroprolactinoma and PRL level greater 200 ng/ml, it is prudent to first treat medically; dopamine-agonists drugs should lower PRL levels and shrink the tumor.Generally bromocriptine lowers elevated PRL levels,shrinks prolactinomas and restores clinical abnormlities and the tumors that have shrunk during bromocriptine therapy do not enlarge following drug withdrawal. Also cabergoline lowered PRL in a dose-related manner. Cabergoline was more effective than bromocriptine in tumor size decreased. Higher doses of dopamine-agonists have been reported to further normalize PRL levels. In giant prolactinomas medical therapy are better than those of surgery; patients with prolactinomas that are resistant to dopamine-agonists therapy are particularly well suited for surgery.

 

Nothing to Disclose: CG, AL, AF, IG, DU, MRG

13349 24.0000 SUN-0733 A Giant Prolactinomas – Recidive after 12 Years (Case Report) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Antonio Selman-Geara*1, Antonio Selman-Almonte1 and Antoine Selman-Fermin2
1Universidad Central del Este, Santo Domingo, Dominican Republic, 2Einstein Medical Center Philadelphia, Philadelphia, PA

 

INTRODUCTION: Prolactinomas are the most common functioning pituitary tumors accounting for almost 40% of all adenomas (1). These tumors are more frequently diagnosed in women during childbearing 20-40 years of age (2), probably due to an early effect of elevated prolactin causing menstrual irregularity. Hyperprolactinemia is responsible for a third of all cases of female infertility (3), but with adequate management the majority of such women are expected to achieve successful pregnancies (4). CASE: a female born on Mar 29, 1957 came to her first visit on May 11, 1982 with menstrual irregularity, amenorrhea since Nov 23, 1981 (6mo before), inability to conceive, loss of orgasm, breast discharge since 1980 (2yrs before), loss of memory, hemianopia, and left hemicranias crisis of four days duration. Patient left and returned on Dec 2, 1985 with same complaints. LABORATORY TEST FINDING: PRL (RIA) 59.4 ng/ml (NV 0-20 ng/ml) (Jan 31, 1986). Total T3 27.6 ng (NV 24-34 ng), Total T4 6.0 ug (NV 5-13 ug) (Mar 4th, 1986). TSH 1.7 mIU/ml (NV 0-4 mIU/ml), FSH 11.7 mUI/ml (NV 0-20 mIU/ml), LH 10.4 mIU/ml (NV 0-25 mIU/ml), urinary 24/hs 17CO 10.0 mg/24hs (NV 6-14 mg/24hs), urinary 17OH 4.0 mg 24/hs (NV 2-6 mg/24hs), total oestrogen 51.1 pg/ml (NV 1-10 days 22-120 pg/ml – 11-20 days 120-237 pg/ml -21-30 days 110-220 pg/ml). Nov 13, 1986 PRL 460 ng/ml (NV 7-21 ng/ml). June 9, 1987 PRL 200 ng/ml (NV 15 ng/ml). May 16, 1989 PRL 115 ng/ml (NV 8-24 ng/ml) FSH 20 mIU/ml. LH 8.0 mIU/ml. Total oestrogen 28 pg/ml (NV post-menopause less than 40 pg/ml). Oct 15, 1989 PRL 60 ng/ml (NV 8-24 ng/ml). Mar 25, 1994 PRL 192.0 ng/ml (NV 0.3-27 ng/ml). Jan 4, 1995 PRL 200 ng/ml (NV 0.3-27 ng/ml), Mar 13, 1995 PRL 194.6 ng/ml (NV 0.3-27 ng/ml). IMAGE FINDING: X-ray of the skull shows sella turcica enlargement, partial destruction of anterior side of posterior clinoids & sella's floor and increase diffuse density inside the sella turcica (Oct 21, 1985). Cefalic CAT Scanner: sella turcica growth, floor sinkage and intrasellar calcification (Nov 13, 1985). X-ray: sella turcica enlargement reduction (May 5, 1986). Ophthalmologic evaluation: non pathologic (Feb 10, 1986). Retropharyngeal biopsy: rhinopharyngeal connective tissue inflammation (Mar 14, 1986). CERVICAL SMEAR: mature superficial squamous cell as premature menopause (May 1990). CONCLUSION: patient complains with symptoms of reproductive disorder and main condition of pituitary macroadenoma PRL secretion tumor (hyperprolactinemia). Long-term treatment with a low dose of dopamine agonist (Bromocriptine) 5 mg/daily. She starts to menstruate on Dec 23, 1990 until May 26, 1991 the time she became pregnant. Pregnancy, being the major concern, resulted in a total success. Partum by normal means, delivered a baby on Feb 26, 1992. Last check was on Mar 27, 2007 with menopause.

 

Nothing to Disclose: AS, AS, AS

12801 25.0000 SUN-0734 A Pregnancy during Active Macroprolactinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Mostafa Alfishawy*1 and Ahmed Daoud2
1Icahn School of Medicine at Mount Sinai/Queens Hospital Center, New york, NY, 2Cairo University School of Medicine, Cairo, Egypt

 

CONTEXT:Hyperprolactinemia without an obvious Central nervous system, Drug induced or Physiologic cause is termed Idiopathic Hyperprolactinemia. We describe 3 patients with Idiopathic Hyperprolactinemia who presented to Reproductive Endocrinology clinic with Hyperprolactinemia which was resistant to ordinary doses of Cabergoline and had abnormal Adrenocorticotropic hormone (ACTH) levels either high or Low and Prolactin level was normalized with low dose of steroids alone

CASE PRESENTATIONS: A 41-year-old male with Infertility, 45-year-old male with impotence and a 32-year-old female with amenorrhea presented with Hyperprolactinemia and normal Magnetic resonance imaging of the pituitary and hypothalamus. ACTH was high in the first two patients and was undetectable in the third. Low dose Prednisone was given for patients with subsequent normalization of Prolactin.

CONCLUSIONS: Corticotropin-releasing hormone may stimulate the release of Prolactin exactly as Thyrotropin-releasing hormone does

 

Nothing to Disclose: MA, AD

14254 26.0000 SUN-0735 A Case Series Demonstrating Role of Steroids in Treatment of Patients with Idiopathic Hyperprolactinemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

David Lawrence Levitt, Hillary Barnes Loper* and Kashif M. Munir
University of Maryland School of Medicine, Baltimore, MD

 

Introduction: 
Acute neurologic changes associated with a prolactinoma can be concerning for pituitary apoplexy, a life threatening complication of pituitary adenomas.  Other etiologies, including cavernous sinus thrombosis, need to be considered in this patient population.  It is important to keep a wide differential diagnosis when evaluating potential prolactinoma complications.

Case presentation:
A 55-year-old Caucasian man presented with slurred speech and headache.  Brain MRI/MRA demonstrated multiple left sided acute infarcts and a homogeneously enhancing 2.8 x 2.8 x 2.2cm sellar mass with extension into the right cavernous sinus and encasement of the cavernous right internal carotid artery without significant narrowing of this vessel.  Biochemical evaluation revealed a serum prolactin level of 2560ng/ml (reference range 4.0 -15.2), confirming the diagnosis of prolactinoma.  Additional hormone levels were unremarkable, with the exception of a total testosterone level of 27ng/dl (reference range 250-1100).   Therapy with cabergoline 0.5mg three times per week was initiated.   After one dose of cabergoline, severe headache, neck stiffness, eyelid swelling, and diplopia all developed, prompting immediate emergency care.  Intravenous hydrocortisone was initiated out of concern for pituitary apoplexy.  Brain MRI showed a stable pituitary macroadenoma, 2.4 x 2.4 x 2.7cm, without bleeding.  Subsequently, new left partial 3rd and 6th cranial nerve palsies were noted.  Repeat brain MRI showed interval development of left cavernous sinus thrombosis, left superior ophthalmic vein thrombosis, interval cystic changes within the pituitary adenoma, and diffuse sinus opacification.  The patient’s mental status continued to deteriorate, with development of ventilator-dependent respiratory failure.  Serial imaging visualized hyperdense lesions within bilateral occipital horns, concerning for basilar meningitis, and interval development of multiple acute infarcts.  Shortly thereafter, the patient expired from cardiac arrest.

Discussion: 
Pituitary apoplexy is often the most feared complication in a patient with known pituitary adenoma who develops new neurologic symptoms, such as headache. Though a rare occurrence, dopamine agonists have been reported to predispose to apoplexy, generally after weeks to months of therapy (1). Cavernous sinus thrombosis must also be considered in the setting of acute neurologic changes in patients with a large sellar mass (2).

 

Nothing to Disclose: DLL, HBL, KMM

14689 27.0000 SUN-0736 A Acute Prolactinoma Complications: Pituitary Apoplexy and Cavernous Sinus Thrombosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0710-0736 4824 1:00:00 PM Prolactin Biology and Signaling; Prolactinoma Diagnosis and Management Poster

Esra Hatipoglu*1, Baris Ikitimur1, Nuri Topsakal2, Oya Erkut Atilgan2, Asiye Filiz Camliguney2, Mutlu Niyazoglu3, Serdal Ugurlu4, Hasan Birol Cotuk2 and Pinar Kadioglu5
1Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey, 2Marmara University School of Physical Education and Sports, Istanbul, Turkey, 3Istanbul Teaching and Research Hospital, Istanbul, Turkey, 4Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey, 5Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey

 

Introduction: Physical exercise, maintains overall health and wellness with improving cardiovascular and metabolic status. It also promotes positive self-esteem and helps prevent depression. In this study we addressed the effect of exercise on metabolic and cardiovascular complications of acromegaly.

Methods: Patients with acromegaly were stratified into two groups according to their participation in a prescheduled program of exercise. Participants in the study group performed exercise for 75 minutes a day for 3 days a week during cosecutive 3 monthes. Warming, cardio, strength, balance and stretching moves applied in every course. Physical examination, laboratory and echocardiographic evaluation of the cases were performed before the beginning of the exercise program and after the completion of the program.

Results: After completion of exercise period exercise group had lower diastolic blood pressure (DBP) (80 [IQR: 80-84] mmHg) levels in comparison to control group (CG) (90 [IQR: 84-106]) (p= 0.004). Also after 3 months of exercise period, within the exercise group there was a significant decrease in diastolic blood pressure from 90 [IQR:88-103] mmHg to 80 [IQR:80-84] mmHg (p=0.04) and tendency towards decreament in body mass index (BMI) (p=0.08). GH was positively correlated with DBP (r=0.4, p=0.07). As the delay in time between initiation of symptoms and diagnosis of acromegaly prolonged, the ultimate BMI of the cases increased (r=0.6, p=0.01). Also the delay in time between initiation of symptoms and diagnosis tended towards having a negative correlation with early filling velocity (E) and the ratio of the early to late ventricular filling velocities (E/A) (r= -0.4, p=0.08 and r= -0.4, p=0.08).  This shows the tendency towards persistance of diastolic dysfunction in cases with delayed diagnosis.

Conclusıon: Short term regular exercise may improve DBP and BMI in cases with acromegaly. With a prolonged duration of exercise, metabolic and cardiovascular changes may be more prominent. Also increased GH levels are associated with increased DBP, so in this way it may also have an indirect contribution in cardiovascular mortality. Additionally, late diagnosis of acromegaly may have certain irrversible metabolic and cardiovascular consequences, and early diagnosis may have a preventive effect on progression of these complications.

 

Nothing to Disclose: EH, BI, NT, OEA, AFC, MN, SU, HBC, PK

12623 6.0000 SUN-0594 A Metabolic and Cardiovascular Changes in Cases with Acromegaly after Regular Short-Term Exercise 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Muzaffer Ilhan*1, Saime Turan2, Seda Turgut3, Gurbet Korkmaz2, Nazli Ezgi Ozkan2, Ozcan Karaman1, Ilhan Yaylim2 and Ertugrul Tasan1
1Bezmialem University, Istanbul, Turkey, 2The Institute of Experimental Medicine,Istanbul University, Istanbul, Turkey, 3Faculty of Medicine, Bezmialem University, Turkey

 

Acromegaly is a rare disease characterized with growth hormone hypersecretion generally arising from pituitary adenomas. It’s poorly understood causes underlying different behaviours of these tumors and useful prognostic markers are lacking. Survivin, an inhibitor protein of apoptosis, plays an important role in cell cycle regulation. Survivin leads to negative regulation of programmed cell death by acting as an inhibitor of caspase activation. Although survivin expression was recently shown to be expressed in normal pituitary tissue, less is known about pituitary tumors secreting growth hormone. In this study, our aim was to investigate possible association between survivin gene promoter -31 G/C genotypes and also serum survivin level and clinical prognostic factors in acromegaly. 68 acromegalic (Mean age 45±1,73)  patients and 171 controls (Mean age 42,92±2,11) were enrolled in the study. Survivin -31 G/C gene polymorphism was performed by using A PCR-restriction fragment length polymorphism method. Blood GH and IGF-I levels were assayed using a chemiluminescence immunometric assay. Serum survivin levels were determined by ELISA . We found no significant association between acromegaly patients and controls for the distribution of the survivin gene promoter -31 G/C genotype and allele frequencies. Acromegaly patients had significantly higher serum survivin levels than controls (p<0,05). In acromegaly patients with ≥2 cm pretreatment tumor size, GG genotype frequency was significantly higher than the patients with < 2cm tumor size (p=0.026; OR=1,988; 95%CI=1,085-3,641). Also it was found that, 5 of the 19 patients who had no pituitary mass after treatment, was carrying GC genotype and patients carrying GC genotype had a 2 fold increased risk for pituitary mass remaining after treatment (p=0,048; OR=2,046; 95%CI= 0,913-4,584).Our study suggested that survivin -31 G/C polymorphism do not modify individual susceptibility to acromegaly but this polymorphism and serum survivin levels might be associated with the prognosis of acromegaly in Turkish population.

 

Nothing to Disclose: MI, ST, ST, GK, NEO, OK, IY, ET

11959 7.0000 SUN-0595 A A Possible Relation Between Survivin Gene Polymorphism and Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Muzaffer Ilhan*1, Bahar Toptas-Hekimoglu2, Ilhan Yaylim2, Seda Turgut3, Saime Turan2, Ozcan Karaman1 and Ertugrul Tasan1
1Bezmialem University, Istanbul, Turkey, 2The Institute of Experimental Medicine,Istanbul University, Istanbul, Turkey, 3Faculty of Medicine, Bezmialem University, Turkey

 

Acromegaly is a chronic disease generally arising from growth hormone-secreting pituitary tumors. Monoclonal origin of these tumors suggests that intrinsic genetic alterations can play an important role for possible tumorigenic initiating mechanisms. The genetic structural alterations in majority of somatotroph adenomas are not clarified and the seeking for novel candidate genes is still a challenge. Vitamin D plays a crucial role in a broad variety of hormonal regulations including bone metabolism, immune response, cell proliferation and differentiation. 1.25-Dihydroxyvitamin D3, the most active form of the vitamin D binds to a corresponding intranuclear receptor (VDR) and interacts with various cell cycle regulators identified in numerous genes involved in cellular growth, differentiation, apoptosis and invasion of tumor cells. In present study we aimed to investigate possible associations between VDR polymorphisms, 25 (OH) vitamin D levels, acromegaly and also disease characteristics. 52 acromegalic patients (Mean age 45.7±1.9) and 75 controls (Mean age 42.2±3.5) were recruited to the study. VDR polymorphism was performed by polymerase chain reaction-based restriction fragment length polymorphism (RFLP). Blood GH and IGF-1 levels were assayed using a chemiluminescence immunometric assay and 25 (OH) vitamin D serum levels were measured by ELISA. VDR Fok-I ff genotype was significantly decreased in acromegaly patients (9.6%) compared with controls (26.7%) (OR: 0.361, 95% CI: 0.145-0.899; p=0.017) and carriers of Fok-I Ff genotype had a 1.6-fold increased risk for acromegaly disease (OR: 1.592, 95% CI: 1.114-2.274; p=0.011). Vitamin D haplotypes ( TaqI, FokI, Apa) were evaluated for association with acromegaly. Haplotype analysis revealed that there was  no  relationship  between VDR polymorphisms and  acromegaly cases. In acromegaly patients 25 (OH) vitamin D serum levels were significantly lower than controls (5.5±1.1 vs 29.1±2.6 ng/mL; p<0.001).  Pretreatment GH levels were significantly lower in acromegaly patients carrying Taq-I homozygote genotypes (TT and tt) comparing patients with heterozygote genotype (p<0.01).  There was no other correlation between acromegaly disease characteristics and VDR genotype distribution. Our study suggests that VDR Fok-I genotypes might affect the development of acromegaly disease. However, further studies are needed to confirm these findings.

 

Nothing to Disclose: MI, BT, IY, ST, ST, OK, ET

15175 8.0000 SUN-0596 A Investigation of the Vitamin D Receptor Polymorphisms in Acromegaly Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Donna King*1, Julie M Silverstein2, Kashif M. Munir3, Erin Dunnigan Roe4, Jack P Rock5, Janet L. Fox6, Maria Kouznetsova4, Andrew L Masica4, Laura A Puzniak7 and Lois E Lamerato5
1Pfizer Inc, New York City, NY, 2Washington University School of Medicine, St Louis, MO, 3University of Maryland Medical Center, Baltimore, MD, 4Baylor Scott & White Health, Dallas, TX, 5Henry Ford Health System, Detroit, MI, 6Pfizer Inc, New York, NY, 7Pfizer Inc., New York, NY

 

Rationale: There is a paucity of published data describing the epidemiology and outcomes for patients with acromegaly in the USA1. Advances in health information technology provide the opportunity to evaluate this area of unmet need using electronic health record data.  This study describes the development of a multi-institutional consortium and an acromegaly electronic data repository.

Methods: AcroMEDIC is a research consortium formed in 2013 to build a clinical data repository from multiple and diverse academic medical centers in the USA. Partnering institutions are Baylor Scott & White Health, Henry Ford Health System, University of Maryland Baltimore, Washington University School of Medicine, and Pfizer. The participating centers accessed their local information systems to identify cohorts of in-patients and out-patients with the acromegaly ICD9 code (253.0) for the most recent 6-11 years, as well as to determine the accessibility and validity of administrative, laboratory, prescription, and outcome data. This study was submitted to each institution’s Institutional Review Board and follows strict data transfer security requirements, including de-identification of patient data.

Results: There were 455 unique patients identified with acromegaly based on ICD-9 code. Of these, 127 underwent pituitary surgery at the consortium hospitals. Approximately 59% of patients were female.Prevalent comorbidities were hypertension (49%) followed by diabetes/impaired glucose tolerance (34%), sleep apnea (20%), osteoarthritis (19%), cardiac arrhythmia/dysrhythmia (12%), and heart failure (7%).

Discussion: Acromegaly is a rare disease with an estimated prevalence between 13,000 and 26,000 in the USA. Due to the low prevalence, it is often difficult to find suitably sized cohorts with which to perform statistically meaningful analyses. Preliminary data suggest the development of AcroMEDIC provides a robust data set to perform comparative analyses using patient level data related to demographics, treatment  modalities, comorbidities, and outcomes for patients with acromegaly.

Conclusion: The MEDIC platform is an innovative collaborative approach that can address data gaps in clinical knowledge of acromegaly treatment and other rare diseases in the USA.

 

Disclosure: DK: Employee, Pfizer, Inc.. JMS: Clinician, Pfizer, Inc.. KMM: Principal Investigator, Pfizer, Inc., Consultant, Pfizer, Inc., Investigator, Novartis Pharmaceuticals. EDR: Investigator, High Value Healthcare Collaborative , Principal Investigator, Pfizer, Inc.. JPR: Investigator, Pfizer, Inc.. JLF: Employee, Pfizer, Inc.. MK: Investigator, Pfizer, Inc.. ALM: Investigator, Pfizer, Inc.. LAP: Employee, Pfizer, Inc.. LEL: Principal Investigator, Pfizer, Inc., Investigator, Pfizer, Inc..

12004 9.0000 SUN-0597 A Utilizing Health Information Technology to Study Clinical Aspects of Diagnosis and Treatment of Patients with Acromegaly: Developing the Acromedic (Acromegaly Multi-site Electronic Data Innovative Consortium) Database 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Katja Kiseljak-Vassiliades*1, Nichole E Carlson2, Manuel T Borges3, BK Kleinschmidt-Demasters3, Kevin Lillehei4, Janice M. Kerr3 and Margaret E Wierman1
1University of Colorado School of Medicine and Research Service VAMC, Aurora, CO, 2University of Colorado Denver, Aurora, CO, 3University of Colorado, Aurora, CO, 4University of Colorado School of Medicine, Aurora, CO

 

Acromegaly, the constellation of clinical sequelae of a growth hormone (GH) pituitary tumor, is associated with significant morbidity and mortality. The diagnosis also carries a substantial financial burden associated with surgical and medical therapy, imaging and follow up visits.  Current treatment modalities including surgical resection, medical therapy with somatostatin analogues (SSA) and/or GH receptor antagonist, result in disease remission in approximately half of the patients.  Clinical and genetic predictors of GH tumor behavior and response to different therapies have been incompletely defined. The goal of this study was to examine clinical, radiologic and hormonal parameters of the different histological GH tumors subtypes (densely (DG), sparsely (SG) and intermediate (DG/SG) granulated) and correlate to response to surgical and medical therapies.  A retrospective chart review was performed of 112 patients with a diagnosis of acromegaly operated by a single neurosurgeon, and radiographic and pathology evaluated by a single neuroradiologist and neuropathologist, respectively.  Clinical, radiologic and biochemical data were correlated with histologic GH tumor subtype and remission as defined by normalization of IGF-1 levels in response to surgery and/or medical therapies. Compared to DG or intermediate subtypes, SG tumors occurred in younger patients (p=0.0012) and were 3-fold larger (p=0.0031). There were no differences in tumor invasion characteristics.  DG and intermediate tumors had dramatically higher rates of remission in response to surgery compared to SG, 67.9% and 57.1% respectively, vs. 14.3% (p<0.0001). In addition, SG tumors were significantly less responsive to medical therapy with SSAs, 50% for DG and 100% for intermediate and 28.6% for SG tumors (p=0.033).  SG tumors not responsive to SSAs, consistently responded to a switch to or addition of the GH receptor antagonist.  We conclude that histological subtyping of GH pituitary tumors implicates a differential clinical phenotype and biologic behavior, and provides prognostic significance for surgical and choice of medical therapies. Histologic subtyping should be consistently obtained and evaluated for prognoses in larger prospective trials with an ultimate goal of more personalized treatment approach to patients with acromegaly.

 

Disclosure: KK: Research Funding, Pfizer, Inc.. MEW: Research Funding, Pfizer, Inc.. Nothing to Disclose: NEC, MTB, BK, KL, JMK

14184 10.0000 SUN-0598 A Histological Subtyping of Growth Hormone Pituitary Tumors Predicts Response to Surgical and Medical Therapy in Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Gokcen Kocabas*1, Ilgin Simsir2, Banu Pinar Yurekli3, Nilufer Kutbay4, Emine Kartal Baykan5, Ilker Altun4, Murat Aksit1, Giray Bozkaya1 and Fusun Saygili2
1Bozyaka Training and Research Hospital, Izmir, Turkey, 2Ege University School of Medicine, Izmir, Turkey, 3Ege University Hosp, Bornova, Turkey, 4ege university hospital, Izmir, Turkey, 5Ege University Hospital, Izmir, Turkey

 

Osteoprotegerin (OPG) is expressed in vascular smooth muscle cells. OPG is implicated in inflammation, and is associated with diabetes, silent myocardial ischemia, acute myocardial infarction and subclinical atherosclerosis. Cardiovascular disease and several cardiovascular risks are increased in acromegaly.

MATERIALS AND METHOD

44 acromegaly patients (n=25 Female;n=19 Male)  and 32 age and gender matched controls (n=20 Femal;n=12 Male) were recruited.Control patients had no known history of cardiovascular disease, diabetes mellitus, hypertension and inflammatory disease. OPG levels were quantified by ELISA method.

RESULTS

Of the 44 acromegaly patients 43,2 % (n=19) were in remission according to GH and/or IGF-1 criteria. OPG levels were 415,3 ±113,9 (mean  ± SD) in acromegaly patients and 360 ± 97,8 in controls(p=0,03) In the acromegaly group OPG levels were not significantly different between patients  who were in remission and active (p=0,427) OPG levels were not correlated with IGF-1 levels (p=0,35)

CONCLUSIONS

Elevated OPG levels are associated with coronary artery disease, subclinical atherosclerosis and increased cardiovascular morbidity and mortality. OPG levels were significantly higher in acromegaly patients. OPG could be a marker for cardiovascular disease in acromegalics.

 

Nothing to Disclose: GK, IS, BPY, NK, EK, IA, MA, GB, FS

13369 11.0000 SUN-0599 A Osteoprotegerin Levels in Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

IIonka Kreitschmann-Andermahr*1, Sonja Siegel2, Johannes Kohlmann3, Daniel Starz3, Rolf Buslei3, Sven-Martin Schlaffer3, Renata Weber Carneiro3 and Michael Buchfelder3
1University of Duisburg-Essen, Essen, Germany, 2University Hospital Essen, Essen, Germany, 3University Hospital Erlangen, Erlangen, Germany

 

Despite the distinct clinical manifestations of acromegaly and the wide availability of well-trained health-care professionals and modern medical facilities in Western Europe, it still takes several years from symptom onset to diagnosis of acromegaly. The paucity of structured information on the course of the diagnostic process and the role of the involved health care professionals prompted us to investigate the patients’ perspective on this matter by conducting a postal survey on the process of diagnosing acromegaly during the last decade.

165 patients with acromegaly, operated between 2000 and 2012 in a large tertiary neurosurgical referral center in Germany, completed a standardized self-developed questionnaire on the course of the diagnostic process. It contained questions on the kind and number of medical professionals visited  from the onset of acromegaly-associated symptoms until the diagnosis was established as well as the specific complaints brought forward by the patient at the particular visit. For each medical specialty all presented complaints were categorized and counted by category.

After symptom onset patients waited on average 1.47 years until seeking medical advice, another 2.85 y elapsed until the right diagnosis was established. Patients visited on average 3.35 (range 1-20) doctors before receiving the diagnosis. They consulted all different kinds of medical professionals, most often general practitioners (GPs) (67.5%), orthopedists (35.6%) and neurologists (27%). The presented symptoms were various and often vague (e.g. “general discomfort”(5.5%) at GPs) or very common in the field of specialty visited (e.g. “headache”(7.9%) in neurology, ”feet problems”(8.5%) in orthopedics). None of the symptoms was presented in any medical field by more than 11% of the patients. The diagnosis of acromegaly was most often made by endocrinologists (48.8%; GPs 11%; neurologists 10.4%; orthopedists 3%).

The survey shows that GPs are consulted early in the diagnostic process by patients with acromegaly, but often with unspecific symptoms. Our data imply that patients then selectively tell specialists those parts of the symptomatology for which they regard the respective specialist as being competent for. This and a symptom-oriented medical approach may prevent “the larger picture” of being put into place earlier and explain some aspects of the long diagnostic delay.

 

Nothing to Disclose: IK, SS, JK, DS, RB, SMS, RW, MB

14695 12.0000 SUN-0600 A Who Diagnoses Acromegaly and When? – Experiences of 165 Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Cheol Ryong Ku*1, Jae Won Hong2, Wonjin Kim1, Young Duk Song3, Woo Kyung Lee4, Sun Ho Kim1 and Eun Jig Lee5
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Inje University Ilsan Paik Hospital, Korea, Republic of (South), 3NHIS Ilsan Hospital, Ilsan, Korea, Republic of (South), 4Yonsei Univ Coll of Medicine, Seoul, Korea, Republic of (South), 5Yonsei University College of Medicine, Korea, Republic of (South)

 

Objective: Impaired GH secretion usually accompanied in cured patients with functioning pituitary adenoma after transsphenoidal adenomectomy (TSA). Although surgery itself could induce the GH deficiencies, preoperatively over-secretion of pituitary hormones might influence on the secretory function of GH axis after TSA. However, there had been no studies about the role of over-secreted hormone from functioning pituitary adenoma on GH axis after achieving biochemical remission. In this study, we evaluated the change of GH axis after TSA in functioning pituitary adenoma.

Research Design and Methods: From the cohorts of Severance Hospital Pituitary Tumor Clinic, GH axis had been evaluated in cured patients after TSA. GHD was defined when the peak serum GH level was less than 3.0 ng/mL in insulin tolerance tests (ITT) which were conducted before TSA and at least 2 times at 1.5 years intervals after TSA.

Results: Three hundred and sixty five patients had been followed up for 8.36±4.21 years and the axis of GH had been evaluated 2.81±1.51 times with ITT for 5.52±6.62 years. The enrolled patients were consisted of 253 in GH secreting pituitary adenoma, 28 in Cushing disease, 73 in prolactinoma, and 11 in TSH secreting pituitary adenoma. There were no differences in sex ratio, age, Hardy classification, number of ITT and follow up duration between patients with each functioning pituitary adenoma. The frequency of preoperative GHDs was significantly higher in patients with Cushing disease (21/28; 75.0%) than subjects with prolactinoma and TSH secreting pituitary adenoma (26/73; 35.6%, and 3/11; 27.3%, respectively) (P < 0.001). After TSA, newly developed GHDs were diagnosed in 25/253 (9.9%) in GH secreting pituitary adenoma, 2/28 (7.1%) in Cushing disease, and none in both prolactinoma and TSH secreting pituitary adenoma. Among the patients with GHD before TSA, the recovery rates of GH axis were 6/21 (28.6%) in Cushing disease, 16/26 (61.5%) in prolactinoma, and 2/3 (66.7%) in TSH secreting pituitary adenoma.

Conclusions: These data provide the first clinical evidence that differentiating evaluations for GHD should be applied in patients with functioning pituitary adenoma according to the species of over-secreting pituitary hormones.

 

Nothing to Disclose: CRK, JWH, WK, YDS, WKL, SHK, EJL

15295 13.0000 SUN-0601 A Changes of GH Axis after Transsphenoidal Adenomectomy in Cured Patients with Functioning Pituitary Adenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Duan Lian*1, Huang Minqiang2, Yan Hua3, Zhang Yuhui4 and Gu Feng5
1Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China, 2Nanfang Hospital, 3The third affiliated hospital of southern medical university, 4China National Health Development Research Center, 5Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing

 

Aim/objective:  Acromegaly is a chronic disorder caused by hypersecretion of growth hormone, usually from a tumor of the pituitary gland. Transsphenoidal surgery and/or preoperative treatment with somatostatin analogs are two primary treatment options. Studies analyzing the relative efficacy of these two treatment strategies alone or in combination are limited. The objective of this study was to assess the cure rate, life-years gained and cost-effectiveness of these two therapeutic strategies for acromegaly. 

Methods: A total of 168 cases of acromegaly were retrospectively investigated for a head-to-head comparative evaluation of a) surgery and b) preoperative medical therapy. A Markov model was constructed to simulate the cost-effectiveness and progression of acromegaly. In addition, we analyzed several combinations of surgery, medical therapy and radiotherapy as second treatment options. 

Results: Among these patients, the ratio of males and females was 1:1.15, the mean age of disease onset was 33.1 years (range, 15 to 61 years), and the mean age of disease diagnosis was 38.2 years (range, 17 to 71 years). The cure rate of preoperative medical therapy was 100% for microadenoma and 61.1% for macroadenoma, while for surgical treatment the cure rate was estimated at 59.1% for microadenoma and 34.1% for macroadenoma. Our data indicates that life-years gained were slightly higher for the preoperative medical therapy group (4.7 years) compared with the initial surgery group (4.25 years) when these patients received surgery as a second treatment option. However, both the preoperative medical therapy and surgery group had a significant overall increase in life expectancy（5.21 years and 5.07 years） when they received long-term medical therapy as a second treatment option. These findings further indicate that preoperative medical therapy is more effective for increasing life expectancy of patients with macroadenoma, particularly when administered as a long-term treatment option. In the present study, our results demonstrated that costs of medical treatment were higher in the preoperative medical therapy group ($6636.95) than in the initial surgery treatment group ($5935.70) when comparing the results from the patients who received surgery as a secondary treatment option. However the preoperative medical therapy group had a significantly lower cost than the initial surgery group where radiotherapy plus medical therapy ($10994.26 Vs $13955.31) or long-term medical therapy ($54957.97 Vs $86054.21) was administered as a secondary treatment option.

Conclusion: Comparing estimates of the cost-effectiveness of therapeutic strategies provides insight that can help to improve individual and population based healthcare assessments. This study provides a framework on which policy makers, health professionals and patients can base decision-making about therapy for acromegaly.

 

Nothing to Disclose: DL, HM, YH, ZY, GF

13411 14.0000 SUN-0602 A Markov Modeling and Retrospective Statistical Analysis of the Effectiveness of Two Therapeutic Schemes at Clinically Targeting Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Alexander Karageorgiadis1, Evgenia Gourgari2, Charalampos Lyssikatos3, Constantine A Stratakis4 and Maya Beth Lodish*5
1NICHD, NIH, 2Georgetown University Hospital, Washington, DC, 3Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 4National Institutes of Health (NIH), Bethesda, MD, 5National Institutes of Health, Bethesda, MD

 

Carney complex (CNC) is a familial multiple neoplasia and lentiginosis syndrome associated with endocrine overactivity, including growth hormone (GH) excess. Data from 269 patients evaluated at the NIH Clinical center between 1989 and 2013 for potential CNC were retrospectively reviewed; 257 underwent screening in order to detect possible GH excess. This was achieved by measurement of insulin-like growth factor-1 (IGF-1), 24-hour GH sampling, and GH levels after oral glucose tolerance test (OGTT). In a subset of patients, GH response to thyrotropin-releasing hormone (TRH) test was measured. Increased IGF-1 levels were detected in 43 patients, while the inability to suppress serum GH during an OGTT was observed in 41 patients. The 24-hour GH test was abnormal in 13 patients and the GH levels of 21 patients were increased by >50% after TRH stimulation. In 79 patients out of the total 257 assessed, at least one of the abnormalities indicating GH excess was present.  The age at which GH excess was first identified ranged from 1.6-62.6 years (average 27.2 ± 14.7 yrs). Serial prolactin (PRL) levels were also measured; from the 148 patients who underwent screening, increased average serial PRL levels were detected in 52 individuals. GH excess along with PRL excess was found in 29 of these 52 patients (55.8%). Clinical features of acromegaly such as increased size of hands and feet, broadened nasal bridge or widening of mandible were the presenting symptoms in 16 patients, while other individuals were identified with GH excess via screening alone. Medication for treatment of GH excess, such as somatostatin analogues and dopamine agonists, was administered to 19 patients; 24 underwent transsphenoidal surgery (TSS). The association between mutations of the PRKAR1A gene and GH excess was also evaluated by assessing the PRKAR1A mutational status in 110 patients. Interestingly, out of the 69 patients who were found to have mutations, 37 presented with GH excess (53.6%), whereas out of the 41 patients who had no PRKAR1A gene mutation, 11 had GH excess (26.8%), a difference that was statistically significant (p=0.0061). Our study is the largest report of the clinical presentation of growth hormone excess in patients with CNC. In addition, in this large cohort we are able to clearly show the association of GH excess with the patients’ genetic background.

 

Nothing to Disclose: AK, EG, CL, CAS, MBL

12864 15.0000 SUN-0603 A Growth Hormone and Prolactin Secretion in Patients with Carney Complex 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Francesca Dassie1, Andrea Grillo2, Renzo Carretta2, Bruno Fabris2, Loredana Macaluso2, Moreno Bardelli2, Andrea Rebellato1, Chiara Martini3, Agostino Paoletta4, Roberto Vettor3, Nicola Sicolo3, Francesco Fallo3 and Pietro Maffei*3
1Padova University Hospital, Padova, Italy, 2Trieste University Hospital, Trieste, Italy, 3Padua University Hospital, Padua, Italy, 4Cittadella Civic Hospital, Padova, Italy

 

AIM: Short term blood pressure variability (BPV) has been recently shown to represent an additional correlate and possibly a causal factor of hypertension related cardiovascular complications. The aim of this study was to investigate short term systolic and diastolic variability indexes in 116 patients with active acromegaly (GH 20.07 ug/l; IGF1 691ug/l) in comparison with 82 age and 24-hour blood pressure matched control subjects.

PATIENTS AND METHODS: Patients underwent 24-hour ambulatory blood pressure monitoring (ABPM) and BPV was calculated as follows: systolic and diastolic standard deviation of 24 hour (SD_S, SD_D), day-time (SD_S1, SD_D1) and night-time (SD_S2, SD_D2) systolic and diastolic standard deviation; weighted SD of 24-hour systolic and diastolic (wSDS, wSDD) and systolic and diastolic average real variability (ARV_S, ARV_D). According to 2013 ESH-ESC Guidelines for the management of arterial hypertension on the basis of 24-h ABPM derived blood pressure values acromegalic patients (ACRO) and controls (CTR) were divided into two groups, normotensive (NT: ACRO n=74, CTR n=42) and hypertensive (HYP>130/80 mmHg: ACRO n=42, CTR n=40). In acromegalic patients anthropometric and biochemical profiles were collected.

RESULTS: Acromegalic patients, either normotensive or hypertensive, had higher SD_S, SD_S1, SD_D1, wSDS, wSDD, ARV_S and ARV_D when compared with controls (all variables of ACRONT and ACROHYP vs CTRNT and CTRHYP, P<0.05). SD_D, SD_S2 and SD_D2 were higher only in ACRONT in comparison with CTRNT.

CONCLUSION: Short term BPV is increased in acromegaly population independently from hypertension. Short term BPV may represent an additional cardiovascular risk factor in acromegaly. The role of GH/IGF-I axis has to be further clarified.

 

Nothing to Disclose: FD, AG, RC, BF, LM, MB, AR, CM, AP, RV, NS, FF, PM

13741 16.0000 SUN-0604 A Short Term Blood Pressure Variability in Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Ryusaku Matsumoto*1, Hidenori Fukuoka2, Genzo Iguchi3, Hironori Bando1, Kentaro Suda1, Hitoshi Nishizawa1, Michiko Takahashi1, Shozo Yamada4 and Yutaka Takahashi1
1Kobe University Graduate School of Medicine, Kobe, Japan, 2Kobe University Hospital, Kobe-Shi, Japan, 3Kobe University Hospital, Kobe, Japan, 4Toranomon Hospital, Tokyo, Japan

 

Background: Although patients with acromegaly demonstrate a reduced life expectancy associated with the over-secretion of growth hormone (GH) and insulin like growth factor-I (IGF-I), the pathophysiology has not been fully understood. A shortened telomere length has reportedly been strongly associated with a presence of age-related diseases and reduced life expectancy.

Aim: To examine whether the telomere length is shortened in patients with acromegaly. Furthermore, to explore the underlying mechanism.

Patients and Methods: Forty-six patients with acromegaly and age- and sex-matched 19 patients with non-functioning pituitary adenoma as a control were recruited. Relative telomere length of peripheral leukocyte was measured using quantitative PCR technique. In addition, we investigated the effect of GH or IGF-I stimulation on the telomere length in cultured human skin fibroblast.

Results: Patients with acromegaly exhibited significantly shorter telomere length than control subjects (0.62 ± 0.23 vs. 0.75 ± 0.35, p= 0.047*). In vitro analysis revealed that GH or IGF-I treatment decreased telomere length, which was normalized by the number of cell division, in the human fibroblasts. Furthermore, GH or IGF-I treatment enhanced senescence markers including senescence-associated β-galactosidase activity. 

Conclusion: Patients with acromegaly exhibited a shortened telomere length. In addition, GH and IGF-I treatment decreased telomere length and induced cellular senescence in human fibroblasts. These results may explain the increased prevalence of age-related disease such as cardiovascular disease and reduced life expectancy in acromegaly.

 

Nothing to Disclose: RM, HF, GI, HB, KS, HN, MT, SY, YT

13524 17.0000 SUN-0605 A Acromegaly Is Associated with a Shortened Telomere Length 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Dave Nellesen*1, Hong Truong1, Debora Oh1, Maureen P Neary2 and William H Ludlam2
1Analysis Group, Inc., Menlo Park, CA, 2Novartis Pharmaceuticals Corporation, East Hanover, NJ

 

Background: Real-world evidence is an emerging research priority. Specifically, stakeholders demand evidence that is generalizable to real-world patient populations. This systematic review of evidence from real-world studies of acromegaly patients assessed treatment patterns, clinical and economic outcomes.

Methods: A search was conducted using MEDLINE, EMBASE and abstracts from the International Pituitary Congress, ENDO, ICE, and ISPOR. Search terms were designed to identify studies that provide real-world evidence including health surveys, medical chart reviews, registries, and administrative database studies. Inclusion criteria were: English language, primary publication of results, included acromegaly patients (n ≥ 50), and real-world data.

Results: Of 844 unique citations, 63 publications (40 articles, 23 abstracts) met inclusion criteria. More than half (40/63) were recently published (2011-2013). Data sources included health surveys (25), medical chart reviews (19), registries (11) and administrative data (8). Geographic representation was broad, including Italy (8), United Kingdom (6), Netherlands (6), United States (6), Germany (5), Canada (4), and Spain (4). Publications reported treatment patterns (56), clinical outcomes (40), health-related quality of life (14) and economic outcomes (8).

Treatments included surgery, radiotherapy, octreotide, lanreotide, pegvisomant, cabergoline and bromocriptine. Line of therapy was reported in 34 publications. Disease control was reported in 40 publications. Definitions of disease control varied widely and included IGF levels alone (27 publications), GH levels alone (10), and both IGF and GH (16). Among studies measuring both IGF and GH, a range of 0-75% (median 36.8%) of patients had controlled disease, with the definition of biochemical control based on normal IGF and GH<1µg/L (4), normal IGF and GH < (or ≤) 2µg/L (3), normal IGF and GH < 2.5µg/L (2), and other (8). In later lines of therapy, 8 publications reported disease control ranging from 23 to 96%.

Conclusions: Real-world data on treatment of acromegaly are emerging, with a majority of studies identified in this search published in the previous 3 years. Only 6 US-based studies were identified, all published in the previous 2 years. Although definitions of disease control varied, this study demonstrates that in real-world settings, approximately half of acromegaly patients have uncontrolled disease, suggesting that additional treatment options may be needed.

 

Disclosure: DN: Researcher, Novartis Pharmaceuticals, Employee, Analysis Group, Inc. HT: Researcher, Novartis Pharmaceuticals, Employee, Analysis Group, Inc. DO: Consultant, Novartis Pharmaceuticals, Consultant, Analysis Group, Inc. MPN: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. WHL: Employee, Novartis Pharmaceuticals.

16399 18.0000 SUN-0606 A Systematic Review of Real-World Evidence on Treatment of Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Vania Santos Nunes*1, Julia Martins Simões Correa1, Maria Eduarda Silva Puga2, Edina Mariko Koga Silva2 and Cesar Luiz Boguszewski3
1Botucatu Medical School - State University/UNESP, Botucatu, Brazil, 2Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil, 3Sempr Fed Univ Parana, Curitiba, Brazil

 

Transsphenoidal surgery (TSS) is the primary treatment for most acromegaly patients. However, 40-60% of macroadenomas are unlikely to be controlled with surgery alone; thus, in these cases, a somatostatin analogue (SA) may be prescribed 3-6 months postoperatively for long-term use. We hypothesized that presurgical SA may improve outcomes in acromegaly patients. Objective: We conducted a systematic review of randomized, controlled trials that compared preoperative SA with direct TSS for the treatment of newly-diagnosed acromegaly patients. Methodology: The data sources were the following electronic databases: Embase, Pubmed, Lilacs, and Central Cochrane. The primary patient outcome measures were: no need for SA three months postoperatively and improvement of quality of life (both determined by laboratory results three months postoperatively (GH nadir after OGTT< 1 µg/L or random GH < 2.5 µg/L, and normal IGF-1 for age and gender); and mortality. Secondary patient outcome measures were: decrease in acromegaly complications; tumour shrinkage; costs; duration of hospital stay; and surgical complications. The included trials were analyzed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Risk of bias, inconsistency of results, indirectness of evidence, imprecision, and publication bias were deemed to be factors that decreased the quality of evidence. Results: A total of 2,099 references were identified and two reviewers independently screened the titles and abstracts to identify the studies. Twenty articles were potentially eligible for inclusion in the review; four were included, while 16 were excluded due to lack of randomization, different outcomes, or because they were only controlled studies. A pool of 261 patients (96% with macroadenomas) was randomly assigned to preoperative treatment with SA (lanreotide: n = 80; octreotide: n = 51) or to direct TSS (n = 130). The meta-analysis of normalization of IGF1 showed a significant difference in favour of the pre-treatment group (RR: 2.47 ;( 95% CI: 1.66, 3.77)). When adding a GH nadir during an OGTT ≤ 1 µg/L, the meta-analysis evidenced   a RR of 2.15 (95% CI: 1.39, 3.33) and a risk difference of 22%, also favouring the pre-treatment group. The effect was inconclusive for patients with microadenomas, due to their small number. Two studies assessed the duration of hospital stay and the results were similar between both groups. Mortality was not evaluated. According to the GRADE approach, the quality of evidence for lack of need for SA three months postoperatively was moderate, while the quality of evidence for improving quality of life was very low. Conclusions: In regard to the need for SA three months postoperatively, this review offers evidence that favors preoperative SA rather than proceeding directly to transphenoidal surgery for the treatment of newly-diagnosed acromegaly patients.

 

Disclosure: VSN: Speaker, Novartis Pharmaceuticals, Participant, Novartis Pharmaceuticals, Participant, Ipsen. CLB: Speaker, Novartis Pharmaceuticals, Participant, Novartis Pharmaceuticals. Nothing to Disclose: JMSC, MESP, EMKS

14778 19.0000 SUN-0607 A Presurgical Somatostatin Analogue Versus Direct Surgery for Newly-Diagnosed Acromegaly Patients: A Systematic Review and Meta-Analysis, Assessing Clinical Evidence Using the GRADE System 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Vania Santos Nunes*1, Julia Martins Simões Correa1, Maria Eduarda Silva Puga2, Edina Mariko Koga Silva2 and Cesar Luiz Boguszewski3
1Botucatu Medical School - State University/UNESP, Botucatu, Brazil, 2Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil, 3Sempr Fed Univ Parana, Curitiba, Brazil

 

Transsphenoidal surgery is the primary treatment for most acromegaly patients. However, 40-60% of macroadenomas are unlikely to be controlled with surgery alone; thus, in these cases, a somatostatin analogue may be prescribed for long-term use. Octreotide and lanreotide are the current somatostatin analogues used in the treatment of Acromegaly. They are effective in controlling GH/IGF1 hypersecretion and in reducing tumor size. Objective: We conducted a systematic review of randomized, controlled trials that compared octreotide with lanreotide for acromegaly patients with active disease and who had not previously been treated with somatostatin analogues. Methodology: The data sources were the following electronic databases: Embase, Pubmed, Lilacs, and Central Cochrane. The outcome measures included GH nadir after OGTT< 0, 4 (using sensitive assays) or < 1 µg/L (using RIA); random GH < 1 ng/mL (using sensitive assays) or < 2.5 ng/mL(using RIA); normal IGF-1 for age and gender; tumour shrinkage, quality of life and adverse events. Results: 2099 references were identified and two reviewers independently screened the titles and abstracts to identify the studies. Nineteen articles were potentially eligible for inclusion in the review, however only one study met the eligibility criteria of the review. Therefore a meta-analysis could not be performed. Eighteen studies were excluded due to lack of randomization, different outcomes or because included patients had been previously treated with octreotide. In the included study, no statistical differences were observed between these two drugs in tumour shrinkage and number of patients attaining normal IGF1 levels. Conclusion: Octreotide and lanreotide might have comparable effects in acromegaly disease control. However, more randomized clinical trials are required, with the aim of confirming the data presented herein.

 

Disclosure: VSN: Speaker, Novartis Pharmaceuticals, Participant, Novartis Pharmaceuticals, Participant, Ipsen. CLB: Speaker, Novartis Pharmaceuticals, Participant, Novartis Pharmaceuticals. Nothing to Disclose: JMSC, MESP, EMKS

14976 20.0000 SUN-0608 A Systematic Review of Octreotide Versus Lanreotide in the Treatment of Acromegaly Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Stephan Petersenn*1, John S Bevan2, Daniel Flanagan3, Antoine Tabarin4, Gaetan Prevost5, Pascal Maisonobe6, Caroline Sert6 and Philippe Caron7
1ENDOC Center for Endocrine Tumors, Hamburg, Germany, 2Aberdeen Royal Infirmary, Aberdeen, Scotland, United Kingdom, 3Derriford Hospital, Plymouth, United Kingdom, 4Universite de Bordeaux II/Hopital Haut Leveque, Pessac, France, 5CHU de Rouen, Bois-Guillaume, France, 6Ipsen Pharma, Boulogne-Billancourt, France, 7CHU Larrey, TOULOUSE, France

 

Introduction: Acromegaly is associated with impaired QoL. While treatment may improve biochemical control, it does not necessarily lead to recovery in QoL. As there is currently limited information on QoL changes accompanying primary LAN therapy, we present here QoL data from the PRIMARYS study.

Methods: PRIMARYS was an international open-label study of 90 treatment-naïve acromegalic patients with pituitary macroadenomas receiving primary LAN 120 mg/28 days for 48 wks (NCT00690898). The primary endpoint was % patients with significant (≥20%) tumor volume reduction (TVR) at wk 48/last post-baseline value available (LVA). Secondary endpoints included TVR at other timepoints, GH and IGF-1 changes, acromegalic symptoms, and QoL scores. QoL was based on patient-reported data from 7/9 countries that had a validated translation of the AcroQoL questionnaire (lower scores indicating worse QoL). Post hoc analyses were also conducted to compare AcroQoL score changes for patients with and without biochemical control (GH ≤2.5 ng/mL and normal IGF-1 at LVA).

Results: Significant TVR was achieved by 54% of patients at 12 wks and 63% at 48 wks/LVA (primary endpoint). Early and sustained improvements also occurred in GH and IGF-1, and acromegalic symptoms. The global AcroQoL score improved most between baseline (mean [SD]: 56.2 [16.1]) and wk 12 (64.5 [15.7]; change, 7.8 [9.3], 95% CI 5.7, 9.8) and was then stable at wks 24 (64.2 [17.6]) and 48 (66.5 [16.6]). A similar pattern was apparent for physical (baseline, 55.1 [19.7]; wk 12, 63.9 [17.9]; change, 8.2 [12.4], 95% CI 5.5, 11.0) and psychological dimension scores (baseline, 56.9 [17.1], wk 12, 64.4 [17.7], change, 7.5 [9.7], 95% CI 5.4, 9.6). For the psychological subdimensions, improvements were more marked for appearance, which was more impaired at baseline, than personal relationships. Post hoc analyses showed that the biochemically controlled patients had lower baseline QoL scores on all scales and consistently greater improvements than the uncontrolled patients, so scores were similar at wk-48 for the two groups.

Conclusions: In treatment-naive acromegalic patients with macroadenomas, early and sustained improvements in QoL occurred concurrently with improvements in TV, GH and IGF-1 levels, and acromegalic symptoms among patients receiving primary LAN 120 mg. Improvements related to appearance were particularly marked. QoL scores at study end were in the range of published scores for patients with treated disease.

 

Disclosure: SP: Advisory Group Member, Pfizer Global R&D, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Ipsen, Speaker, Pfizer, Inc., Speaker, Novartis Pharmaceuticals, Speaker, Ipsen. JSB: Advisory Group Member, ViroPharma, Advisory Group Member, Novartis Pharmaceuticals, Study Investigator, Ipsen, Consultant, Ipsen. DF: Consultant, Novartis Pharmaceuticals, Researcher, Ipsen, Speaker, Ipsen. AT: Speaker, HRA Pharma, Speaker, Novartis Pharmaceuticals, Consultant, HRA Pharma, Consultant, Novartis Pharmaceuticals, Consultant, Ipsen. PM: Employee, Ipsen. CS: Employee, Ipsen. PC: Advisory Group Member, Ipsen, Speaker, Novartis Pharmaceuticals, Speaker, Ipsen, Consultant, Novartis Pharmaceuticals, Consultant, Ipsen. Nothing to Disclose: GP

15929 21.0000 SUN-0609 A Improved Quality of Life (QoL) after Lanreotide Autogel/Depot (LAN) 120 Mg in Treatment-Naïve Acromegalic Patients: Data from the Primarys Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Antonio Pico*1, Eva Venegas2, Tomás Lucas3, Cristina Álvarez-Escolá4, Juan Antonio García Arnes5, Mónica Marazuela6, Peter J. Jonsson7, Nuria Mir8, Roy Gomez9, Spanish Acrostudy Group10 and Ignacio Bernabeu11
1Hospital General Universitario de Alicante, Alicante, Spain, 2Instituto de Biomedicina de Sevilla (IBiS), Consejo Superior de Investigaciones Científicas, Endocrinology Unit of Virgen del Rocío University Hospital, University of Seville, Sevilla, Spain, 3Hospital Universitario Puerta de Hierro, Majadahonda, Spain, 4La Paz University Hospital, Madrid, Spain, 5Hospital Universitario Carlos Haya, Málaga, Spain, 6Hospital Universitario de La Princesa, Instituto de Investigacion Princesa. Universidad Autonoma, Madrid, Spain, 7Endocrine Care, Pfizer Health AB, Sollentuna, Sweden, 8Pfizer Medical Affairs, Madrid, Spain, 9Pfizer Medical Affairs Europe, 10Acrostudy Centers Spain, Spain, 11Complejo Hospitalario Universitario de Santiago de Compostela, Universidad de Santiago de Compostela, Santiago de Compostela, Spain

 

Context: ACROSTUDY is a global non-interventional safety surveillance study designed to evaluate long-term safety and treatment outcomes of pegvisomant (PEG) treatment. ACROSTUDY was started in Spain in 2006.

Objective: The main objective is to report long-term efficacy of PEG therapy in the Spanish cohort of ACROSTUDY.

Main outcome Measure: Long-term monitoring of IGF-I levels.

Methods: We report a descriptive analysis of data from Spanish cohort enrolled in the study, using a database freeze as of July 1, 2013.

Results: 199 PEG treated patients from 41 centers were enrolled in the study, age 45.9 ± 11.9 years (mean±S.D), median 44.2 (25.6-68.4) years in males and 53.1 (21.2-83.8) years in females.  90.9% of patients had already received other medical treatment before the start of PEG. 48.2% of patients received PEG monotherapy. 97.5% of patients took daily PEG at PEG start. Mean follow-up was 4.9±1.0 years, and the mean time on PEG therapy was 6.7±2.1 years. Response to PEG (IGF-I normal or < LLN) ranged from 60.2 % of patients assessed after 12 months (n=113) of start PEG treatment to 67.9 % of patients assessed after 60 months (n=112). 15 patients have follow-up visits at year 9 with 66.7% of IGF-I normalization. The proportion of patients with an IGF-I sample showing normal or <LLN at any time point after PEG start was 85.5% (165 of 193 patients). At the last observation, the mean daily PEG dose was 15.2 mg for the group with normal IGF-I levels (n=107) and 17.6 mg for the uncontrolled group (n=77). Serious AEs (SAEs) were described in 31 patients (15.6%), and in 3 cases (1.5%) the SAEs were considered related to treatment.

Conclusions: In this non interventional study of the Spanish cohort previously unresponsive to surgical, medical therapy with Somatostatin analogs and/or radiation treatments, long term data for up to 9 years showed that Pegvisomant is a safe and effective medical treatment for acromegaly. Normalization of IGF-I was reported in 85.5% of patients at any time point after start of therapy.

 

Disclosure: AP: Investigator, Pfizer, Inc.. MM: Principal Investigator, Pfizer, Inc.. PJJ: Employee, Pfizer, Inc.. NM: Employee, Pfizer, Inc.. RG: Employee, Pfizer, Inc.. IB: Clinician, Ipsen, Clinician, Pfizer, Inc., Clinician, Novartis Pharmaceuticals, Clinician, Pfizer, Inc.. Nothing to Disclose: EV, TL, CÁ, JAG, SAG

14450 22.0000 SUN-0610 A Long-Term Pegvisomant Treatment Outcomes in Patients with Acromegaly: Spanish Acrostudy Data 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Claudia Ramirez*1, Ana Laura Espinosa de los Monteros2, Ernesto Sosa2, Juan Manuel Franco2, Guadalupe Vargas2, Baldomero Gonzalez2 and Moises Mercado2
1Hospital Especialidades CMN, Mexico City, Mexico, 2Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, Mexico, Mexico

 

Background: Adding cabergoline (CBG) to acromegalic patients with incomplete responses to somatostatin analogues is a relatively common practice.  However, few studies have evaluated its long-term efficacy.

Objective: To evaluate the long-term efficacy of CBG as adjunctive therapy for acromegalic patients partially responsive to octreotide LAR (OCT).

Design and methods: Retrospective study of acromegalic patients with partial response to OCT (20 mg monthly dose) in whom CBG (median dose 2 mg/week, range 0.5-3) was added for 6 or more months (mean follow up 28.9 ± 19.7 months).  Biochemical control was evaluated based on the achievement of different GH and IGF-1 targets.

Results: 66 patients (mean age 43.4 ± 19.9 years, 66.7% with macroadenomas). Prior to OCT therapy, median GH and IGF-1 levels were 17.4 ng/mL (IQR 8.1-59.9) and 3.36 x ULN (IQR 2.62-4.00), respectively and decreased to 2.8 ng/mL (IQR 1.7-4.7) and 1.9 x ULN (IQR 2.6-4), respectively, after OCT therapy.  The addition of CBG resulted in a further drop of GH and IGF-1 to 1.6 ng/mL (IQR 1-2.9) and 1.57 x ULN (IQR 1.19-2.17), respectively.  73% of the patients achieved a GH < 2.5 ng/mL, 34% an IGF-1 < 1.2 x ULN and 30.2% reached both biochemical goals.  A GH < 1 ng/mL and an IGF-1 < 1.2 x ULN was achieved by 11%.  No serious adverse effects were recorded.

Conclusion: Addition of CBG to ongoing OCT therapy is an effective strategy for patients who are not fully controlled on the SA alone.

 

Nothing to Disclose: CR, ALE, ES, JMF, GV, BG, MM

12653 23.0000 SUN-0611 A Long- Term Efficacy of Cabergoline Addition to Ongoing Octreotide LAR Therapy in Patients with Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Giuseppe Reimondo*1, Maura Arosio2, Paola Berchialla3, Elena Malchiodi4, Annamaria Colao5 and Massimo Terzolo1
1Medicina Interna 1 - AOU San Luigi, Orbassano (TO), Italy, 2Univ of Milan, Milano, Italy, 3Dpto di Scienze Cliniche e Biologiche - Università di Torino, 4Endocrinology and Diabetology Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy, 5Federico II Univ of Naples, Naples, Italy

 

Context: Whether acromegaly is associated with increased incidence of cancer has been debated for several years. The rarity of the disease and the reduced life expectancy of acromegalic patients till the era of somatostatin analogues (SSA) hampered the analysis of large series with a meaningful number of cancers.

Objective: To assess cancer incidence in a nationwide survey of Italian acromegalic patients.

Design: Data of 1512 patients who were proactively followed at 24 tertiary referral centers in Italy were collected retrospectively. Epidemiological, patient and tumor characteristics were analyzed at baseline and during  a mean follow-up of 120 months. Cancer diagnoses were coded using the International Classification of Diseases and data of acromegalic patients were compared to the general Italian population using the cancer registry AIRTUM. The expected number of cancers was calculated by multiplying the number of person-years by the appropriate national, gender-, age-, calendar year-, and site-specific cancer incidence rates for each five-year age group and calendar year of observation. Risks of cancer were estimated by computing the standardized incidence ratios (SIRs).

Results: 124 patients with acromegaly who had a diagnosis of cancer were identified. In women, incidence of all malignancies was increased (SIR 1.51; 95% CI 1.2-1.91) in particular colorectal (1.86, 1.06-3.28) and thyroid cancer (3.22, 1.61-6.44). In men, incidence of all malignancies was borderline increased (1.29, 0.99-1.7). The most striking increase was found for thyroid (6.51, 2.71-15.65) and kidney cancer (3.73, 1.78-7.83). In multivariate analysis the risk factors for all malignancies were familiarity, age and fractionated radiotherapy. No correlation with hormonal parameters either at diagnosis or at the last follow-up was found.

Conclusions: in acromegalic patients cancer risk is increased with a gender-related difference. Although GH and IGF-I levels were not correlated with cancer incidence, it should be considered that hormone measurements at discrete time points may not represent adequately the overall exposure to GH and IGF-I excess.

 

Disclosure: AC: Scientific Board Member, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals. MT: Advisory Group Member, HRA PHARMA. Nothing to Disclose: GR, MA, PB, EM

14860 24.0000 SUN-0612 A Increased Incidence of Cancer in Acromegalic Patients: An Italian Nationwide Survey 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

James M W Robins*1, John Ayuk2, UK National Acromegaly Investigators 20143 and John Newell-Price4
1Sheffield Teaching Hospitals NHS Trust, 2University Hospital Birmingham, Birmingham, United Kingdom, 3The Society for Endocrinology, UK, 4University of Sheffield and Department of Endocrinology, Sheffield Teaching Hospitals, Sheffield, United Kingdom

 

Background                                                                                

Pituitary tumors causing acromegaly are treated primarily by surgical resection.  If not curative, further treatment is needed.  ‘Gamma Knife’ stereotactic radiosurgery enables delivery of highly focused radiation in a single fraction to a pituitary target.

Hypothesis and underlying question

To assess the effectiveness of gamma knife radiosurgery for acromegaly

Experimental design and methodology

Data was retrospectively collected from 35 patients followed in eight regional centers, via the National Acromegaly Register. All patients had undergone neurosurgery and depending on time of treatment, a Nucletec RBS 5000, Nucletec C or Perfexion Gamma Knife (Elekta, Stockholm) was used for radiosurgery at a single institution (Sheffield, UK). The mean peak dose administered was 53Gy. Results were analyzed using Microsoft Excel.

Results

Biochemical: Of thirty-five patients, 66% achieved a normal age and sex-adjusted IGF-1 at a median follow up of 65 months after gamma knife radiosurgery.  Of thirty-two patients who were tested, 72% achieved a controlled (<2.5ug/L) nadir GH level, median follow up of 60 months; of these patients 35% (n = 8) were also receiving medical therapy. The mean IGF-1 before and after gamma knife was 777ug/L and 436ug/L, respectively (p = 0.015).  Mean GH level before gamma knife in 24 patients was 5.62ug/L and after was 1.25ug/L (p = 0.0051).  The probability of control of IGF-1 and GH levels was not found to correlate with dose of radiation delivered.

Radiological: Post gamma knife MRI demonstrated pituitary tumor size unchanged or reduced in 100% of 24 patients with evaluable imaging at a median follow up of 50.5 months. 

Endocrine Side Effects: 17% (6/35) developed new endocrine disturbances. Of these three were being treated with medical therapy.

Other side effects: No patient suffered any visual disturbance on follow-up

Conclusions

Gamma knife radiosurgery for acromegaly after neurosurgery is a safe and effective long-term adjunctive treatment for acromegaly, with an acceptable incidence of hypopituitarism, that compares favorably to fractionated radiotherapy, at least with this length of follow-up.

 

Disclosure: JA: Medical Advisory Board Member, Novartis Pharmaceuticals, Medical Advisory Board Member, Ipsen. JN: Principal Investigator, HRA Pharma. Nothing to Disclose: JMWR, UN

13034 25.0000 SUN-0613 A Effectiveness of Stereotactic Gamma Knife Radiosurgery for the Treatment of Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Sean H.P.P. Roerink*1, Margreet A.E.M. Wagenmakers2, Femke Wessels3, Rosalie Sterenborg4, Johannes W.A. Smit2, Ad RMM Hermus5 and Romana T. Netea-Maier2
1Radboud University Medical Center Nijmegen, Netherlands, 2Radboud University Nijmegen Medical Center, Nijmegen, Netherlands, 3Radboud University Nijmegen Medical Center, 4Radboud University Nijmegen medical center, 5Radboud University Medical Center, Nijmegen

 

Context: Acromegaly is associated with an impaired quality of life (QoL). Next to increased morbidity and mortality acromegaly causes anatomical disproportions, which may contribute to the decreased QoL after successful treatment. The Derriford appearance scale 59 (DAS59) is a validated questionnaire to objectively measure the spectrum of psychological distress and disruptions to everyday life that are associated with self-consciousness of appearance.

Objective: To investigate the psychological distress and dysfunction related to self-consciousness of appearance in patients in long-term remission of acromegaly and the effect on QoL using the Derriford Appearance Scale 59.  

Patients, design and methods: All patients (>18 years old) who were treated for acromegaly at the Department of Endocrinology of the Radboud University Nijmegen Medical Centre were invited to participate in this study. A gender, age and BMI matched control group was provided by the patients themselves.  Participants were asked to complete the Derriford appearance scale-59 (DAS59), RAND-36, AcroQoL, a visual analogue scale (VAS) and a sociodemographic questionnaire. Differences between patient- and control group and correlations between questionnaire scores and clinical data on diagnosis, remission time and treatment collected from medical records were analyzed.

Main outcome measures: Scores on the DAS59, RAND-36, AcroQoL and VAS.

Results:  Of the 120 respondents, 73 agreed to participate in the study [all cured or under biochemical control, median remission time 10.5 years (range 41.3 years)]. Of these, 34 (46.6%) reported self-consciousness about their appearance. Twenty-nine of these patients (85.3%) pointed out their face to be the most prominent source of discontent. Fifty-seven matched control subjects were included in this study as well. Significant correlations were found between the scores of the DAS59 and the AcroQoL, RAND-36 and VAS.

Conclusions:  Even after long-term remission of acromegaly, a significantly larger number of patients are self-conscious about their appearance, leading to psychological distress and disruptions to everyday life. The facial features turn out the be the most important source of this self-consciousness. This study shows a significant correlation between self-consciousness of appearance and QoL. This stresses the importance for physicians to address self-consciousness of appearance and the need for additional support in this regard during follow-up.

 

Nothing to Disclose: SHPPR, MAEMW, FW, RS, JWAS, ARH, RTN

12481 26.0000 SUN-0614 A Self-Consciousness of Appearance after Acromegaly: A Cross-Sectional Study to Investigate Self-Consciousness about Appearance after Long Term Biochemical Remission of Acromegaly Using the Derriford Appearance Scale 59 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Herbert A Schmid*1, Thierry Brue2, Annamaria Colao3, Mônica Gadelha4, Ilan Shimon5, Karen Kapur1, Lisa D'Amato1, Alberto M Pedroncelli1 and Maria Fleseriu6
1Novartis Pharma AG, Basel, Switzerland, 2Centre de Recherche en Neurobiologie et Neurophysiologie de Marseille, France, 3Università Federico II, Naples, Italy, 4Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, 5Rabin Medical Center and Sackler School of Medicine, Tel-Aviv University, Petah-Tiqva, Israel, 6Oregon Health & Science University, Portland, OR

 

Background: PAOLA was a multicenter, randomized, 24-week study in patients with inadequately controlled acromegaly, which assessed the efficacy and safety of pasireotide LAR versus continued treatment with octreotide LAR and lanreotide Autogel. One exploratory objective was to measure changes in various associated biomarkers, including insulin-like growth factor 1 (IGF-1), IGF binding protein 2 (IGFBP-2; released from white fat cells and known to prevent insulin resistance), glucose and HbA1c.

Methods:Eligible patients: adults with growth hormone (GH) levels >2.5μg/L and IGF-1 levels >1.3xULN, who had received octreotide LAR 30mg/lanreotide Autogel 120mg monotherapy for ≥6 months. Patients were randomized to pasireotide LAR 40mg (n=65) or 60mg (n=65) or continued treatment with octreotide LAR/lanreotide Autogel (n=68; active control). Blood samples for biomarker assessment were taken before each drug administration.

Results: Pasireotide LAR 40 and 60mg dose-dependently decreased average GH, IGF-1 and IGFBP-3 levels without tachyphylaxis of response. Baseline glucose and HbA1c levels were significantly (P<0.05) higher in patients who received antidiabetic medication during pasireotide treatment (54% of population) than those who did not (glucose: 114 [95% CI: 110, 119]) versus 95.8mg/dL [92.8, 98.9]; HbA1c: 6.2 [6.1, 6.4] versus 5.6% [5.5, 5.7]). Peak glucose and HbA1c levels in patients who did not receive antidiabetic medication were lower than in those receiving antidiabetic medication (glucose: 115 [110, 120] versus 155mg/dL [143, 168]; HbA1c: 5.9 [5.8, 6.0] versus 7.5% [7.1, 8.0]). IGFBP-2 levels increased from baseline to week 24: 42.4 [37.0, 48.6] to 62.2ng/mL [51.9, 74.5] and 45.3 [39.0, 52.5] to 60.1ng/mL [49.8, 72.4] in patients who received and did not receive antidiabetic medication, respectively.

Discussion:Elevated GH causes insulin resistance; therefore, patients with inadequately controlled acromegaly may be particularly sensitive to developing pasireotide-induced hyperglycemia. Given the increased glucose levels, the increase in IGFBP-2 levels was an unexpected observation.

Conclusions: The effects of pasireotide LAR on glucose homeostasis may be attenuated by increased insulin sensitivity due to the compensatory increase in IGFBP-2. The ~50% of the population who did not receive antidiabetic medication had significantly lower baseline glucose levels than those who did, and pasireotide-induced hyperglycemia was mild and decreased over time.

 

Disclosure: HAS: Employee, Novartis Pharmaceuticals. TB: Investigator, Pfizer, Inc., Investigator, Sandoz, Speaker, Sandoz, Advisory Group Member, Viropharma, Speaker, Viropharma, Consultant, Ipsen, Advisory Group Member, Ipsen, Speaker, Ipsen, Investigator, Ipsen, Speaker, Merck Serono, Consultant, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Investigator, Novartis Pharmaceuticals, Investigator, Novo Nordisk, Speaker, Novo Nordisk, Consultant, Pfizer, Inc., Advisory Group Member, Pfizer, Inc., Speaker, Pfizer, Inc., Investigator, Pfizer, Inc., Investigator, Sandoz, Speaker, Sandoz, Advisory Group Member, Viropharma, Speaker, Viropharma. AC: Scientific Board Member, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Advisory Group Member, Novartis Pharmaceuticals. MG: Advisory Group Member, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Speaker, Ipsen, Speaker, Pfizer, Inc., Principal Investigator, Novartis Pharmaceuticals, Coinvestigator, Novartis Pharmaceuticals, Coinvestigator, Pfizer, Inc.. IS: Advisory Group Member, Novartis Pharmaceuticals, Coinvestigator, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Consultant, Pfizer, Inc., Coinvestigator, Pfizer, Inc., Speaker, Pfizer, Inc., Advisory Group Member, Novo Nordisk, Advisory Group Member, Neopharm. KK: Employee, Novartis Pharmaceuticals. LD: Employee, Novartis Pharmaceuticals. AMP: Employee, Novartis Pharmaceuticals. MF: Principal Investigator, Novartis Pharmaceuticals, Ad Hoc Consultant, Novartis Pharmaceuticals, Ad Hoc Consultant, Ipsen, Principal Investigator, Ipsen, Ad Hoc Consultant, Genentech, Inc., Principal Investigator, Corcept, Consultant, Novartis Pharmaceuticals.

14658 27.0000 SUN-0615 A Exploratory Data Evaluating the Effect of Pasireotide on GH, IGF-1, IGFBP-2, IGFBP-3, HbA1c and Glucose in Patients with Inadequately Controlled Acromegaly Enrolled in a 24-Week Study (PAOLA) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Verónica Perea1, Eugenia Resmini2, Purificación Martínez de Icaya3, Anna Aulinas4, Victoria Alcázar3, Pablo Fernández-Catalina5, Fernando Calvo6, Carmen Fajardo7, Mónica Marazuela8, Concepción Blanco9, Cristina Alvarez-Escola10, Juan J. Díez11, Conxa Páramo12, Javier Riveiro13, Pedro Iglesias11, Marcel Sambo14 and Gemma Sesmilo*1
1Hospital Universitari Quiron-Dexeus, Barcelona, Spain, 2IIB- Sant Pau y Servicio de Endocrinología, Departamento de Medicina, Centro de Investigación Biomédica en Enfermedades Raras (CIBER-ER Unidad 747), Hospital Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain, 3Hospital de Leganés, Madrid, Spain, 4Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII,IIB- Hospital Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain, 5Complejo Hospitalario de Pontevedra, Pontevedra, Spain, 6Hospital Clínico Miguel Servet, Zaragoza, Spain, 7Hospital Universitario La Ribera, Alzira. Valencia, Spain, 8Hospital Universitario de La Princesa, Instituto de Investigacion Princesa. Universidad Autonoma, Madrid, Spain, 9Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Spain, 10La Paz University Hospital, Madrid, Spain, 11Hospital Ramón y Cajal, Madrid, 12Hospital Xeral-Cíes, Vigo, Spain, 13Hospital de La Princesa, Madrid, Spain, 14Hospital Gregorio Marañón, Madrid, Spain

 

Acromegaly is a rare disease with an insidious presentation that usually takes years of symptoms before the diagnosis. It has an estimated prevalence of 40-125 cases per million, however, some screening studies have found a much higher prevalence, suggesting that this figure could be underestimated. Acromegaly symptoms are non-specific but acral enlargement is almost universally present at diagnosis. Aim: we aimed at investigating the prevalence of acromegaly in a population of patients with symptoms of sleep apnea and/or hoarseness who attended for a first visit in Hospital sleep referral units and had symptoms of acral enlargement. Methods: multicenter Spanish study involving 15 Hospital sleep referral units. Patients who were seen in first visit for sleep apnea symtoms and/or hoarseness were offered to participate.  Participants were asked about symptoms of acral enlargement including: increase in ring size or shoe size, enlargement of the tongue, lips or jaw, paresthesiae in hands or carpal tunnel syndrome and widening of tooth spaces. They were also questioned about a list of typical acromegaly symptoms including headaches, hoarse voice, arthralgia, diabetes, hypertension, fatigue, excessive sweating, menstrual disturbances in women and erectile dysfunction in men.  A physical examination including height, weight and ring circumference was performed. Only in those patients who answered “yes” to any of the symptoms of acral enlargement, a serum IGF-1 was measured; if elevated, it was repeated and if confirmed, an oral glucose tolerance test was performed to rule out acromegaly. The project is still ongoing, we present preliminary data. Results: from 675 patients included in the study, one case of acromegaly was diagnosed.

Conclusions: In a population of patients with sleep apnea symptoms and acral enlargement, we found an acromegaly prevalence of 1.5 cases per 1000 patients screened. It is important that sleep specialists beware of the disease and recognize its symptoms in order to perform an early diagnosis

 

Nothing to Disclose: VP, ER, PM, AA, VA, PF, FC, CF, MM, CB, CA, JJD, CP, JR, PI, MS, GS

17105 28.0000 SUN-0616 A Acromegaly Screening in Patients with Sleep Apnea Symptoms 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Guoxiang Shen*1, Christelle Darstein2, Karina Hermosillo Reséndiz1, Yanfeng Wang1 and Ke Hu1
1Novartis Pharmaceuticals Corporation, East Hanover, NJ, 2Novartis Pharma AG, Basel, Switzerland

 

Introduction: Pasireotide LAR was superior to octreotide LAR at providing biochemical control (GH andIGF-1) in patients with medically naïve acromegaly in a 12-month study. The PK/PD of pasireotide and octreotide in these patients is reported here.

Methods: Patients were randomized to receive either pasireotide LAR 40mg/28d (n=176) or octreotide LAR 20mg/28d (n=182) for 12 months. A non-linear inhibitory Emaxmodel and logistic regression models were used to analyze the relationship between pasireotide and octreotide concentration and efficacy (GH and IGF-1). Exposure and safety (FPG, ECG and liver function parameters) were also evaluated.

Results: Trough concentrations of both drugs reached steady state after three monthly injections and were approximately dose proportional. Gender, baseline GGT levels and body weight were statistically significant PK covariates for pasireotide, with no clinically meaningful impact on PK exposure; findings were similar for octreotide except for body weight. With the non-linear Emaxmodel, the effective concentrations (mean±SE) for pasireotide and octreotide to suppress GH were 6.3±1.1 and 1.9±0.6ng/mL, respectively. The effective concentration for pasireotide to suppress IGF-1 was 13.5±2.4ng/mL; however, this could not be estimated for octreotide because of insufficient suppression of IGF-1. The maximum suppression (mean±SE) of GH was similar for pasireotide (85.3±1.7%) and octreotide (84.1±1.7%), whereas pasireotide achieved stronger suppression of IGF-1 than octreotide (73.6±1.9% and 57.6±2.2%, respectively). Octreotide did not result in normalization of IGF-1 even at higher doses. Logistic regression analysis indicated a 36.6% increase in odds of IGF-1 normalization with a 50% increase in pasireotide exposure; the corresponding odds increase was only 26.1% for octreotide. The odds of hyperglycemia occurring increased with pasireotide exposure but to a lesser extent than the odds of clinical response, supporting a positive benefit-to-risk ratio for pasireotide within the dose range tested. There was no clinically significant relationship between exposure to either drug and QTcF/QTcB or liver function parameters.

Conclusions: Pasireotide LAR had a superior effect on suppressing IGF-1 compared with octreotide LAR; this PK/PD analysis confirms that higher doses of octreotide LAR would not result in greater IGF-1 suppression. Besides hyperglycemia, no other safety parameters had relevant associations with pasireotide exposure.

 

Disclosure: GS: Employee, Novartis Pharmaceuticals. CD: Employee, Novartis Pharmaceuticals. KH: Employee, Novartis Pharmaceuticals. YW: Employee, Novartis Pharmaceuticals. KH: Employee, Novartis Pharmaceuticals.

14707 29.0000 SUN-0617 A Pharmacokinetic and Pharmacodynamic Analyses of Pasireotide LAR and Octreotide LAR Support the Efficacy Results of a Randomized, Double-Blind, Phase III Study in Patients with Medically Naïve Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Marie Jagot1, Emmanuel D Sonnet*1, Brigitte Delemer2, Christine Cortet3 and Veronique Kerlan4
1CHU Brest, Brest, France, 2Hop Robert Debre, Reims, France, 3Lille University Hospital, Lille cedex, France, 4CHRU BREST, BREST, France

 

The prevalence of sleep apnea (SA), defined by polysomnography (PSG), had only been evaluated in small cohorts in acromegaly. Few studies tried to identify risk factors and complications associated with SA in acromegaly.

The aim of our work was to evaluate the modalities of screening of SA in acromegaly, its prevalence, among those who had a PSG and finally to identify risk factors and complications associated with SA in acromegaly in a large cohort.

We retrospectively reviewed the data of acromegalic patients before or at the time of the diagnosis from 3 French teaching hospitals (Brest, Lille, Reims). Modalities of screening of SA were evaluated, looking for the patients who underwent PSG. We determined the prevalence of SA (defined by an Apnea Hypopnea Index ≥ 5). We defined two groups of acromegalic patients : those with SA : SA+ and those without SA : SA-. Every possible risk factor or complication of SA was assessed in our population and their prevalence compared between the two groups.

Among the 266 acromegalic patients of our cohort, 101 underwent a PSG (38%). 67% of them showed SA (68 patients). SA+  had higher BMI (31.4 kg/m2 vs 25.5; p<0.0001) and were more often than male SA- patients (75.3% vs 33.3 , p<0.0001). No difference was found  in age at diagnosis, tobacco use. IGF1 (% of the upper normal range for age) was higher in SA+: (322 vs 245%, p=0,002). No difference was found in GH (mean, nadir during OGTT), duration of acromegaly. Prevalence of goiter (echography) was higher in SA+ : 83% (45/54) vs 39% (11/28), p<0,001. No difference was found regarding presence of nodules, hypothyroidism. SA+ were more often diagnosed with hypertension: 61% vs 28%, p=0,002, and with left ventricular hypertrophy (LVH) (echography): 67% (33/49) vs 33% (9/27), p=0,004. No significant association was found in prevalence of dyslipidemia and diabetes in our cohort, but SA+  showed higher HbA1c at the diagnosis of acromegaly : 6,9% vs 6,1%, p=0,02.

In conclusion, in our population of 266 patients, only 38% had appropriate SA screening. The prevalence of SA was 67% among our large cohort of 101 patients who underwent PSG. We confirmed some expected risk factors for SA : male gender, BMI, IGF1 levels and showed an association between goiter and SA, which was never found before. Concerning complications, SA was associated with hypertension, modifications in glucose metabolism. and LVH.

 

Nothing to Disclose: MJ, EDS, BD, CC, VK

15785 30.0000 SUN-0618 A Sleep Apnea, Defined By Polysomnography, Is Highly Prevalent in Acromegaly and Is Associated with Several Risk Factors and Complications 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Günter K. Stalla*1, Diego Ferone2 and Annamaria Colao3
1Max Planck Institute of Psychiatry, Munich, Germany, 2IRCCS AOU, San Martino-IST, University of Genoa, Genoa, Italy, 3Università Federico II di Napoli, Naples, Italy

 

Introduction: Current acromegaly treatment guidelines recommend GH<1.0µg/L and IGF-1≤ULN to reduce morbidity and normalize mortality. Recent studies suggest many patients remain inadequately controlled, despite several available treatments. In collaboration with Novartis, the European Neuroendocrine Association (ENEA) conducted a survey to collect information on the perceived definition of biochemical control and real-world treatment decision making.

Methods: A 19-question multiple-choice online survey was sent to members of ENEA in November 2013, as well as to attendees of an international pituitary meeting in Stockholm, Sweden in October 2013 (total recipients, N=629).

Results: 179 respondents (28.5% of recipients) (Europe, n=118) from 45 countries (European, n=23/45) completed the survey; 120 considered themselves pituitary specialists. All respondents treated ≥1 patient with acromegaly; 114 treated >10/year (mean, 27/year). 58% of all respondents’ patients were on medical therapy. Of those patients, 61% were considered biochemically controlled (range, 0–100%). 74% of all respondents measure both GH and IGF-1 to determine biochemical control; a further 21% measure GH only if IGF-1 is ambiguous. Interestingly, 56% consider it acceptable for a patient to have IGF-1>ULN; the most common reasons were levels within the assay error range (61%), no symptoms present (35%), and if GH is normal (28%). 32% of respondents consider IGF-1≥1.3xULN as the threshold for taking action; 18% wait until IGF-1≥1.5xULN. 51% of all respondents (55% vs 44% specialist vs non-specialist) base their treatment decision on signs and symptoms if biochemical markers are slightly elevated. 58% of all respondents reported barriers to changing medical therapy in patients with inadequate biochemical control, the most prevalent of which were increased cost (53%) and reimbursement issues (49%); 29% responded that IGF-1 assay variability is a barrier.    

Conclusions: Although guidelines for the treatment of acromegaly recommend control of both GH and IGF-1, 56% of the physicians responding to this survey consider it acceptable for a patient to have IGF-1>ULN, and 18% consider IGF-1≥1.5xULN acceptable. Although this lack of urgency to treat may reflect challenges in clinical practice, it suggests that many patients with acromegaly remain on the same treatment despite being inadequately controlled, which may impact on long-term patient outcomes, as well as on the cost of disease management.

 

Disclosure: DF: Advisory Group Member, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Investigator, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals, Advisory Group Member, Ipsen, Speaker, Ipsen, Investigator, Ipsen, Consultant, Ipsen, Advisory Group Member, Eli Lilly & Company, Speaker, Eli Lilly & Company, Investigator, Eli Lilly & Company, Consultant, Eli Lilly & Company, Advisory Group Member, Pfizer, Inc., Speaker, Pfizer, Inc., Investigator, Pfizer, Inc., Consultant, Pfizer, Inc.. AC: Advisory Group Member, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Scientific Board Member, Novartis Pharmaceuticals. Nothing to Disclose: GKS

15712 31.0000 SUN-0619 A Is Clinical Practice Reflective of Acromegaly Treatment Guidelines? Results from a Survey of Treating Physicians in 45 Countries 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Mazhar Muslum Tuna*1, Ersen Karakilic2, Mehtap navdar Basaran2, Bercem Aycicek Dogan3, Narin Nasiroglu Imga3, Ayse Arduc4, Yasemin Tutuncu5, Tuba Unal6, Dilek Berker3 and Serdar Guler7
1Ankara Numune Education and Research Hospital, Ankara, Turkey, 2Ankara Numune Education and Training Hospital, Ankara, Turkey, 3Ankara Numune Education and Research Hospital, Ankara, Turkey, 4National Institute of Diabetes and Digestive and Kidney Diseases, Diabetes, Endocrine and Obesity Branch, National Institutes of Health, Bethesda, Maryland 20892, 5Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey, 6ankara numune education and research hospital, 7Hitit University, Faculty of Medicine, Corum, Turkey

 

Introduction: The aim of this study was to evaluate association between clinical behaviour of growth hormone(GH) secreting tumor and  analysis of immunohistochemical(IHC) staining.

Material and methods: Records of  clinical data and analysis of IHC were obtained for 67 of 110 subjects who were undergone transsphenoidal surgery between June 2008 and May 2013 at Ankara Numune Education and Research Hospital. Remission statement was evaluated at three month after operation according to GH, IGF-1 level and oral glucose supression test. Analysis of IHC in adenoma tissue were performed by the staining of the antibody  GH(A0570, Dako), PRL(PRL-02, Neomarkers) ,TSH(0042, Dako), ACTH(AH26,Thermo), FSH(N1539,Dako), LH(LH01, Neomarkers), Ki-67(Mib-1, Dako) and p53(D07, Dako).

Results:  Mean age of the 67 patients was 42,5 ± 10,1(23-63) and  %63 of patients were women.While staining of GH were positive of post operative specimens for all subjects,including  %44 were pure  GH positive, %38  were PRL positive, %13 were ACTH positive and %8 were FSH-LH positive. Ki -67 index was ≤1 in 21 of 32 patients(%65) and was  ≥2 in 11 of 32 patients(%35) . P 53 mutation was determined in 5 of 17 patients (%29).  

Remission rate of acromegaly was significantly higher in the patients who had plurihormonal staining than  monohormonal staining of specimens(p=0.008).Futhermore, the patients who had GH and PRL positive co-stainýng of specimens were  better than the other plurihormonal staining regarding remission rate of the acromegaly( p= 0.002).

Conclusions: Our study revealed that immunohistochemical profile may be an indicator for clinical behaviour of GH secreting tumor.

 

Nothing to Disclose: MMT, EK, MNB, BAD, NNI, AA, YT, TU, DB, SG

17064 32.0000 SUN-0620 A Evaluation of Immunohistochemical Staining Features in Acromegaly Patients- Comparing with Clinical Findings 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Aart-Jan van der Lely*1, Vyacheslav Pronin2, Inga Balcere3, Moon-Kyu Lee4, Liudmila Ya Rozhinskaya5, Marcello D Bronstein6, Mônica Gadelha7, Pascal Maisonobe8 and Caroline Sert8
1Erasmus Medical Center, Rotterdam, Netherlands, 2IM Sechenov First Moscow State Medical University, Moscow, Russia, 3Pauls Stradins Clinical University Hospital, Riga, Latvia, 4Samsung Medical Center, Sungkyunkwan University, Seoul, Korea, Republic of (South), 5Endocrinology Research Centre, Moscow, Russia, 6University of São Paulo Medical School, São Paulo, Brazil, 7Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, 8Ipsen Pharma, Boulogne-Billancourt, France

 

Introduction: EDIs with lanreotide Autogel may help improve the burden associated with long-term acromegaly treatment. The LEAD study evaluated the efficacy and safety of switching patients receiving conventional octreotide LAR doses to lanreotide Autogel EDIs.

Methods: LEAD was a multinational open-label non-comparative study (NCT00701363). Patients with acromegaly and normal IGF-1 after octreotide LAR 10 or 20 mg every 4 weeks for ≥6 months were switched to lanreotide Autogel 120 mg at an EDI. In phase 1, patients received lanreotide Autogel every 6 weeks for 24 weeks. IGF-1 levels at the end of phase 1 determined dose intervals during the 24 weeks of phase 2 (group A: IGF-1 levels >100% to ≤130% ULN received lanreotide Autogel 120 mg every 4 weeks; group B: >50 to ≤100% ULN, every 6 weeks; group C: ≤50% ULN, every 8 weeks); patients with IGF-1 levels >130% ULN were withdrawn from the study. The primary endpoint was the % patients maintaining normal IGF-1 with an EDI of 6 or 8 weeks at week 48. An ANCOVA was performed on the IGF-1 level change from baseline (week 0) during the study with treatment as a main factor and IGF-1 level and baseline IGF-1 as covariates.

Results: The intention-to-treat (ITT) population comprised 124 patients entering phase 1 and receiving ≥1 dose of treatment (baseline mean age, 54.4 years, time since diagnosis, 8.7 years, octreotide LAR treatment duration, 2.5 years); 109 entered phase 2 (group A, 12%; group B, 64%; group C, 24%); and 107 completed the study. At week 24 (end of phase 1), 89% [95% CI: 83–94%] of the ITT population maintained normal IGF-1 on a 6-week EDI. At week 48 (end of phase 2), 76% [95% CI: 68, 83%] maintained normal IGF-1 levels on a 6- or 8-week EDI (primary endpoint). Observed treatment effect estimates [95% CI] for IGF-1  change from baseline (week 0) to week 48 were 18.7% [7.5, 29.9] for group A vs group B,
–24.0 % [–32.1, –15.8] for group C vs group B, and 42.7% [29.5, 55.8] for group A vs group C; all were statistically significant at 0.01 level. Over 48 weeks, treatment-emergent AEs (TEAEs) occurred in 91 (73%) patients, treatment-related AEs in 54 (44%), and TEAEs leading to withdrawal in 8 (6%). Gastrointestinal disorders were the most common events (39 [31%]).

Conclusions: These data suggest acromegalic patients controlled on conventional octreotide LAR doses can maintain IGF-1 control when switching to lanreotide Autogel 120 mg EDIs.

 

Disclosure: IB: Investigator, Ipsen. LYR: Speaker, Merck Sharp & Dohme, Speaker, Amgen, Speaker, Eli Lilly & Company, Speaker, Servier, Researcher, Ipsen, Researcher, Novartis Pharmaceuticals, Researcher, Amgen, Researcher, Merck Sharp & Dohme, Researcher, Eli Lilly & Company, Researcher, Servier, Speaker, Novartis Pharmaceuticals, Speaker, Ipsen. MDB: Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Pfizer, Inc., Advisory Group Member, Chiasma, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Principal Investigator, Ipsen, Principal Investigator, Novartis Nutrition, Inc., Advisory Group Member, Ipsen. MG: Advisory Group Member, Novartis Pharmaceuticals, Researcher, Novartis Pharmaceuticals, Researcher, Ipsen, Speaker, Pfizer, Inc., Speaker, Novartis Pharmaceuticals, Speaker, Ipsen. PM: Employee, Ipsen. CS: Employee, Ipsen. Nothing to Disclose: AJV, VP, MKL

16052 33.0000 SUN-0621 A Extended Dosing Intervals (EDIs) with Lanreotide Autogel/Depot 120 Mg Can be Effective in Acromegalic Patients Biochemically Controlled with Octreotide LAR 10 or 20 Mg: The Lead Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Whitney W Woodmansee*1, Kathleen Graham Lomax2 and Roberto Salvatori3
1Brigham and Women's Hospital/ Harvard Medical School, Boston, MA, 2Ipsen Biopharmaceuticals, Inc, Basking Ridge, NJ, 3Johns Hopkins University School of Medicine, Baltimore, MD

 

Introduction: The Somatuline® Depot (lanreotide) Injection for Acromegaly (SODA) study is an ongoing, multi-center, observational, post-marketing study of Somatuline Depot (SD)-treated patients (pts) with acromegaly.  Patients may enroll at any point before or during SD treatment. This registry is reflective of “real world” experience. This is an analysis of the 2-year data on the frequency with which pts underwent assessments of comorbidities as recommended in acromegaly management guidelines (1, 2).

Methods: Pts diagnosed with acromegaly were treated with SD. Demographics, efficacy data, targeted adverse events (TAE), and serious adverse events (SAE) were collected. Data were collected regarding the performance of oral glucose tolerance tests (OGTT), HbA1c levels, MRIs, sleep studies, echocardiograms, colonoscopies, and gallbladder ultrasounds.

Results: By Feb 28, 2013, of 202 pts enrolled in SODA, 50% were female, average age was 49.9 years, 75% had previously undergone pituitary surgery, and 19% had received radiation therapy. Of 45 pts with available IGF-I levels at 2-years from enrollment, 30 (68.2%) were normal/low for age. 99/202 (49%) reported at least one TAE and 21/202 (10%) pts reported SAEs.  28% of pts had OGTT data at diagnosis, 9% 1-year after enrollment, and 13% at 2 years. HbA1c data was recorded in 40 patients at baseline (20% of population) and ever recorded in 82 patients (41%).  95% had MRIs documented at study enrollment (of which 73% were abnormal), 13% at 1-year, and 14% at 2-years.  28% had sleep studies at enrollment (with 84% showing sleep apnea), 1 pt had a sleep study at year 1 and 2 at year 2.  46% had echocardiograms at enrollment (of which 51% were abnormal) and <5% had repeat studies at 1- and 2-years.  50% of pts had colonoscopy data at enrollment (of which 46% demonstrated abnormalities, mostly polyps), and <6% had repeat data recorded at 1- and 2-years.  19% of pts at enrollment had gallbladder ultrasounds (of which 59% were abnormal), and <4% had repeat data at 1- and 2-years.

Conclusions: At 2 years, a majority of pts had IGF-I levels reflecting biochemical control of acromegaly.  The safety data is consistent with the known safety profile of lanreotide. Despite guideline recommendations to screen and monitor acromegalic patients for comorbidities, 50% or fewer of the patients have exam results from tests such as echocardiograms, colonoscopies, or sleep studies, reported during study enrollment.

 

Disclosure: WWW: Principal Investigator, Pfizer, Inc., Principal Investigator, Ipsen, Medical Advisory Board Member, Corcept, Medical Advisory Board Member, Genentech, Inc., Medical Advisory Board Member, Eli Lilly & Company. KGL: Employee, Ipsen. Nothing to Disclose: RS

14571 34.0000 SUN-0622 A Screening for Comorbid Conditions in Patients Enrolled in the Soda Acromegaly Registry 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Masaaki Yamamoto*1, Hidenori Fukuoka2, Genzo Iguchi2, Ryusaku Matsumoto1, Michiko Takahashi1, Hitoshi Nishizawa1, Kentaro Suda1, Hironori Bando1 and Yutaka Takahashi1
1Kobe University Graduate School of Medicine, Kobe, Japan, 2Kobe University Hospital, Kobe, Japan

 

Objective: Although colorectal neoplasms are well known as one of the complications in acromegaly, there have been few data regarding the prevalence and predictor in Asian patients with acromegaly. We aimed to clarify the prevalence and associated factors of colorectal neoplasms in Japanese patients with acromegaly in a single center.

Methods: We screened 109 consecutive patients with acromegaly and enrolled 57 patients who had undergone complete colonoscopy at the diagnosis at Kobe University Hospital between 1986 and 2012. 

Results: Among 57 patients, hyperplastic polyps, adenoma, and adenocarcinoma were diagnosed in 22 (40.7%) patients, 15 (27.8%) patients, and 3 (5.6%) patients, respectively, which were more prevalent than previous report. The prevalence of adenocarcinoma was significantly higher in the patients with acromegaly than in Japanese historical control subjects (P <0.0001). The presence of colorectal polyps or adenocarcinoma was positively associated with disease duration (P <0.05). Intriguingly, the area under the growth hormone (GH) concentration-time curve during oral glucose tolerance test (GH AUC) was significantly increased in patients with adenocarcinoma than in those with no lesion or hyperplastic polyps.

Conclusion: Japanese patients with acromegaly exhibited an increased risk of colorectal neoplasms. Increased GH AUC can be used as a predictor for colon adenocarcinoma in patients with acromegaly.

 

Nothing to Disclose: MY, HF, GI, RM, MT, HN, KS, HB, YT

13325 35.0000 SUN-0623 A The Increased Area Under the Growth Hormone Concentration-Time Curve during Oral Glucose Tolerance Test Is Associated with Colorectal Adenocarcinoma in Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Zhaoyun Zhang*1, Yiming Li2, Yao Zhao2 and Shiqi Li3
1Huashan Hospital, 2Huashan hospital, Shanghai, China, 3Huashan Hospital, Shanghai

 

Acromegaly is related to increased mortality and morbidity. This study aimed to analyze the clinical features of patients with growth hormone (GH)-secreting pituitary adenomas who underwent surgery and to compare the clinical characteristics of GH adenomas with mixed GH and prolactin (PRL) adenomas. Between 2004 and 2012, 634 patients with GH-secreting pituitary adenomas (M/F, 196/338, 20-78 years) were admitted to our hospital for surgery. The initial symptoms, biochemical markers, hormone levels, MRI of pituitary and pathological results were collected and analyzed. The mean age of first diagnosis was 42 ± 12 years. The most common clinical manifestations or complications were acromegaly (71.45%), coarse facial features (54.57%), and hypertension (37.79%). According to BMI, 33.2% of patients were normal and 43.3% of patients were overweight, while 23.5% were obese. 256 patients (40.37%) presented with IFG/IGT or diabetes. 90% of patients had macroadenomas. There were significant correlations between the tumor size and the GH level (r = 0.27, p = 0.002), IGF-1 (r = 0.26, p = 0.027), and PRL (r = 0.23, p = 0.012). Surgery reduced the excessive secretion of GH, IGF-1, and PRL (85.52 ± 99.52 µg/L vs. 15.03 ± 36.36 µg/L, 740.74 ± 282.13 ng/ml vs. 526.89 ± 263.93 ng/ml, and 36.69 ± 58.1 ng/ml vs. 9.56 ± 17.36 ng/ml, respectively; p < 0.05). 468 patients (73.8%) had GH adenomas while 166 patients (26.3%) had mixed GH and PRL adenomas. Compared with patients with GH adenomas, patients with mixed GH and PRL adenomas had higher prevalence of diabetes (33.13% vs 23.19%, p=0.013). In all acromegalic patients with diabetes, the duration of diabetes was much longer in patients with mixed GH and PRL adenomas than those with GH adenomas (10.08±8.23 vs 6.55±6.26 years, p<0.05). The tumor size, random GH and IGF-1 between GH adenomas and mixed GH and PRL adenomas were not different. Our study showed that Chinese acromegalic patients had high prevalence of hypertension, glucose abnormalities, and overweight/obesity, and PRL may affect glucose metabolism.

 

Nothing to Disclose: ZZ, YL, YZ, SL

11690 36.0000 SUN-0624 A Analysis of 634 Cases of Growth Hormone-Secreting Pituitary Adenoma from One Chinese Medical Center Between 2004 and 2012 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Weiwei Zhao*, Yehong Yang, Hongying Ye, Zhaoyun Zhang, Yongfei Wang, Yao Zhao and Yiming Li
Huashan hospital, Shanghai, China

 

Objectives Octreotide is effective in treating TSHoma, while octreotide shows no potential benefits in treating PRTH (1). Acute octreotide suppression test was used as adjunct diagnostic test for TSHoma in some cases. There is no explicit standard program for carrying out the acute octreotide suppression test (2). The study intends to evaluate the efficiency of acute octreotide suppression test with different approaches, and investigate the value of acute octreotide suppression test in diagnosing TSHoma and PRTH.

Methods 12 patients with TSHoma and 3 patients with PRTH were enrolled in the study. Patients with TSHoma were randomly divided to 3 groups with 3 men and 1 woman in each group. Each group was set differently. For example, octreotide 0.1mg at 8am, 16pm, and 20pm subcutaneously for group A; octreotide 0.1mg at 8am, 16pm, and 24pm subcutaneously for group B; octreotide 0.1mg at 8am and 16pm subcutaneously for group C. The PRTH patients were treated as octreotide 0.1mg tid subcutaneously (group D). Serum TSH, FT3 and FT4 were evaluated at 8am, 10am, 12am, 14pm, 16pm, and the next 8am during the tests. The suppression efficiencies of thyroid function were compared between the four groups.

Results The patients of TSHoma aged from 17 to 73 years old, and the patients of PRTH aged from 25 to 49 years old. The average age of A, B, C, D groups were 41.5, 56, 32.3 and 33 years old respectively. The values of TSH were all normalized after acute octreotide suppression test in group A, B, and C. The inhibition rate of TSH, FT4, and FT3 were 60.0%~90.2%, 9.0%~22.1%, and 15.4%~40.2% in group A. The inhibition rate of TSH, FT4, and FT3 were 47.7%~94.1%, 5.3%~28.8%, and 16.4%~25.7% in group B. The inhibition rate of TSH, FT4, and FT3 were 81.5%~85.5%, 9.11%~28.4%, and 28.2%~38.3% in group C. The values of TSH in group D were still above the normal limits after test. The inhibition rates of TSH, FT4, and FT3 were 21.1%~57.5%, 4.3%~27.7%, and 2.0%~19.2% in group D. The inhibition rates of TSH were significantly higher than FT4 and FT3 in all the 4 groups (P＜0.05). There are no significant differences for the inhibition rates of TSH among the group A, B, or C, as well as FT4 and FT3. The inhibition rates of TSH and FT3 in group A, B, and C were significantly higher than that of group D, while FT4 were not.

Conclusions The dynamic assessment of TSH is essential in acute octreotide test for diagnosing and assessing the efficiency of TSHoma. For acute octreotide test, the program of three times a day is not superior than the program of twice a day. Whether the TSH level can reach normal level after acute octreotide test is essential in diagnosing TSHoma and PRTH, while the inhibition rate of TSH has limited value.

 

Nothing to Disclose: WZ, YY, HY, ZZ, YW, YZ, YL

14669 37.0000 SUN-0625 A The Value of Acute Octreotide Suppression Test in Diagnosing Thyrotropin-Secreting Pituitary Adenoma (TSHoma) and Pituitary Resistance to Thyroid Hormone (PRTH) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0589-0625 4831 1:00:00 PM Acromegaly 1 Poster

Mariana F Guzzo*1, Luciani R S Carvalho2 and Marcello D Bronstein3
1HC FMUSP, Sao Paulo, Brazil, 2University of São Paulo, Hospital das Clinicas, São Paulo, Brazil, 3University of São Paulo Medical School, São Paulo, Brazil

 

Ketoconazole (KTC), an antifungal agent proved to be a potent inhibitor of adrenal steroidogenesis, is used in the management of Cushing's syndrome. The literature shows conflicting results regarding ACTH levels during KTC treatment for Cushing´s disease (CD), pointing to decreased or increased ACTH plasma levels at basal and unchanged ACTH plasma levels after stimulus with CRH. Previous in vitro studies have shown a decreased ACTH secretion in the presence of KTC in normal and tumor pituitary cells in culture. In order to characterize the direct effect of KTC in immortalized pituitary cell lines such as AtT-20 cells (secreting ACTH), GH3 cells (secreting GH and PRL) and  αT3.1  cells (secreting alpha-subunit), they were cultured in the presence and absence of KTC. We evaluated KTC role, in vitro, on ACTH hormone secretion, cell viability and expression of apoptosis and cell cycle markers. The ACTH levels in AtT-20 cells were measured by commercial immunoassay AutoDELFIA in the supernatant media collected at 30 minutes in the presence of KTC and 3h after its removal. The cell titerassay was used to analyze cell viability at 6, 12 and 24h in the presence of 20, 40 and 60 µM KTC concentration and also 48h after KTC removal. The expression of apoptosis and cell cycle markers were evaluated after 6h in the presence of 40 µM KTC concentration by RT-qPCR, using relative quantification. The ACTH levels were reduced only after KTC removal in AtT-20 cells (about 70% in 50 µM and 10% in 100 µM, p<0.05 x control), suggesting cell death. It was observed a dose dependent effect on pituitary cell viability. The highest KTC concentration (60µM) was related to the lowest level of viability at 24h as follow: AtT-20 cells (10.88 ± 5.7% of the control, p<0.001); GH3 cells (17.2 ± 3.6% of the control, p<0.001); αT3.1 cells (11.2 ± 1.3% of the control, p<0.001) and it was also seen a partial recovery of cell viability at 48h after KTC removal in all cell lines. It was noticed an increased expression of cell death receptors (ex. Fas, TNFR), caspases (ex. -6,-7,-9) and cell cycle inhibitors markers (p21 and p27 in GH3 cells and p21 only in αT3.1 cells) in the presence of KTC compared to 48h after its removal, which suggests an activation of apoptosis pathway and cell cycle arrest. In conclusion, our findings suggest that ketoconazole have the potential to reduce cell viability and increase the expression of genes related to apoptosis and cell cycle regulation leading to arrest in pituitary cell lines.

 

Nothing to Disclose: MFG, LRSC, MDB

13314 1.0000 SUN-0696 A The Inhibitory Effects of Ketoconazole in Immortalized Pituitary Cell Lines Leading to Decreased Cell Viability Are Due to an Increase of Apoptosis Markers and Cell Cycle Inhibitors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0696-0709 4833 1:00:00 PM Pituitary Tumors-Basic Poster

Henriett Butz*1, Peter M Szabo2, Peter Igaz3, Sandor Czirjak4, Sayka Barry5, Istvan Liko6, Márta Korbonits7, Karoly Racz3 and Attila Patocs8
1Hungarian Academy of Sciences, Budapest, Hungary, 2Hungarian Academy of Sciences, Budapest, 3Semmelweis Univ, Budapest, Hungary, 4National Institute of Neurosurgery, Budapest, Hungary, 5William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom, 6Richter Ltd, Budapest, Hungary, 7Barts and the London School of Medicine, London, United Kingdom, 8MTA TKI, Budapest, Hungary

 

Background. Clinically non-functioning pituitary adenomas (NFPAs) are common intracranial tumors. Despite several investigations, the background of their pathogenesis has not been clearly revealed.

Aim. To assemble genomic, transcriptomic, proteomic, and mirNome data in order to identify mechanisms involved in the pathogenesis of pituitary adenoma.

Methods. For integrative analysis, expression data of 207 NFPA and 41 normal pituitary (NP) samples were studied. Publicly available datasets of (i) DNA loss and gain by comparative genomic hybridization, (ii) gene and (iii) protein expression data, and (iiii) our own novel mRNA and microRNA expression data were collected and analysed. Complex bioinformatics analysis by using GeneSpring, Gene Set Enrichment Analysis, Ingenuity Pathway Analysis and network analysis was carried out. For validation of the results of integrative analysis quantitative real-time polymerase chain reaction (qRT-PCR) was applied on a sample set consisting from 52 NFPA and 10 NPs.

Results. Several members of aryl hydrocarbon receptor (AHR) signaling were found to be altered and their correlations with interacting partners suggested its involvement in the pathogenesis of NFPAs. Other developmental pathways revealed by our analysis included Notch and Hedgehog signaling both showing down-regulation in NFPAs compared to healthy pituitary tissues.

Conclusions: Integration of high-throughput datasets obtained from different platforms and from different levels may be a useful method for recognizing new, putative pathogenic factors and potentially may reveal novel therapeutic targets.

 

Nothing to Disclose: HB, PMS, PI, SC, SB, IL, MK, KR, AP

15913 2.0000 SUN-0697 A Integrative Analysis of Chromosomal, Trancriptome, Proteomic and Mirnome Data Reveals Involvement of Impaired Developmental Processes in Clinically Non-Functional Pituitary Adenoma Formation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0696-0709 4833 1:00:00 PM Pituitary Tumors-Basic Poster

Roberto Salvatori*1, Plamena Gabrovska2, Astrid Weber3, Richard Quinton4, Elizabeth C Crowne5, Valentina Corazzini1, Serban Radian6, Kumar Sinha7, Anne-Lise Lecoq8, Philippe Chanson9, Mark G Thomas10, Atik Baborie11, Olaf Ansorge12, Marie Bussel13, Karen Stals13, Sian Ellard14, Peter James Trainer15 and Márta Korbonits16
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Barts and The London School of Medicine, London, United Kingdom, 3Royal Liverpool Children's Hospital, LIverpool, United Kingdom, 4Newcastle-upon-Tyne Hospitals, Newcastle Upon Tyne, United Kingdom, 5Bristol Royal Hospital for Children, Bristol, United Kingdom, 6Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom, 7Walton Centre NHS foundation trust, Liverpool, United Kingdom, 8Hosp Bicetre, Le Kremlin-Bicetre, Le Kremlin-Bicêtre, France, 9Univ Paris-Sud, UMR-S693, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France, 10University College London, London, United Kingdom, 11The Walton Centre for Neurology and Neurosurgery, Liverpool, United Kingdom, 12University of Oxford, Oxford, United Kingdom, 13Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom, 14University of Exeter Medical School, Exeter, United Kingdom, 15Department of Endocrinology, Manchester, United Kingdom, 16William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom

 

About 20% of FIPA patients carry a heterozygous AIP mutation. A small segmental duplication in exon 6 of AIP (c.805-825dup, p.F269_H275dup) has been previously reported in a UK family and in an apparently sporadic French giant. We report here 6 additional kindreds (3 from UK and 3 from USA) harbouring affected subjects carrying the same AIP duplication. All individuals share the same ethnic background and geographical origin (Caucasians, with known family link to England), but are not known to be related; they live in France, different UK counties, or US states. Out of 24 carriers, 14 patients (10 males) presented with signs/symptoms of pituitary macroadenoma: 9 gigantism, 3 acromegaly, 2 clinically non-functioning pituitary adenomas (one of which had 5-10% cells staining for GH). One additional patient was identified on prospective screening (microadenoma, IGF-1 1.5x ULN).  The average age of onset of symptoms was 19.1 years (range 9-34, median 18.5). One subject affected by gigantism had dilated cardiomyopathy, aortic dilatation and history of infantile psychosis. Another subject had a gastrointestinal stromal tumor. As comprehensive genotyping of unaffected family members has not been carried out, we cannot comment on the penetrance of disease in these families. Haplotype analysis showed a 2.1 Mb-long area common to all 8 kindreds, suggesting that they originate from a single ancestor. The steady flow of immigration from the British Isles to North America in the last few centuries, and the close proximity of England and France support the presence of a founder effect. The cause of the spreading of this allele is unknown. Because the penetrance of the pituitary phenotype in carriers of AIP mutations is ~10-30%, the mutation does not prevent reproduction in the majority of carriers. Furthermore, even patients who develop pituitary adenomas may maintain normal fertility until the adenoma is large enough to cause hypopituitarism (or hypogonadism in the case of prolactinomas). Whether the mutated allele may confer some kind of survival advantage is unknown, and overall unlikely. There are a few "hotspot" AIP point-mutations identified in the gene affecting CpG sites, but this segmental duplication is not a typical recurrent mutation type, and therefore it is unlikely to be arising independently in these families.

In summary, we report the same AIP mutation occurring in 8 apparently unrelated kindreds from 3 different (but potentially linked) countries, and show that all the affected subjects share a common ancestor. The majority of affected subjects are males suffering from young-onset GH-producing adenomas.

 

Disclosure: RS: Advisory Group Member, Ipsen, Investigator, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Pfizer, Inc.. MK: Advisory Group Member, Pfizer, Inc., Investigator, Pfizer, Inc., Investigator, Novartis Pharmaceuticals. Nothing to Disclose: PG, AW, RQ, ECC, VC, SR, KS, ALL, PC, MGT, AB, OA, MB, KS, SE, PJT

11463 3.0000 SUN-0698 A Founder Effect in Recurring AIP Mutation Causing Familial Isolated Pituitary Adenoma Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0696-0709 4833 1:00:00 PM Pituitary Tumors-Basic Poster

Federica Guaraldi*, Mirko Parasiliti Caprino, Alessandro Berton, Nunzia Prencipe, Stellina Valentina Di Giacomo, Valentina Gasco, Guglielmo Beccuti, Roberta Giordano, Ezio Ghigo and Silvia Grottoli
University of Turin, Turin, Italy

 

Background: some studies have demonstrated an increased prevalence of anti-pituitary antibodies (APAs) in patients with acromegaly compared to the general population, although reported rates are highly variable among studies depending on the examined sample and the method applied for their identification. Indirect immunofluorescence (IFI), considered the gold standard technique for APA assessment, presents technical limitations that significantly impact on its reproducibility and reliability. Moreover, APAs target antigens are still to be determined, and their clinical significance has never been investigated.

Aims of this pilot study were to: 1) assess the reliability of an optimized IFI method for APAs detection; 2) define the prevalence of APAs and anti-GH secreting cells (GHAs), and 3) their clinical significance in acromegaly.

Materials and methods: APAs were evaluated by IFI optimized through significant reduction of background and non-specific Ig bindings, definition of signal localization (cytoplasm vs nucleus) and pattern, and improvement of image resolution. Serum samples from 86 acromegaly patients (M:F=30:56; mean age at diagnosis 48 ± 14 yr, range 17-78; mean age at evaluation 60 ± 15.2 yr, range 17-84), treated with surgery/radiotherapy/drugs. Family history of pituitary adenoma, typical manifestations, co/morbidities (metabolic/neoplastic/autoimmune diseases), and disease activity were recorded. APAs-positive samples were also evaluated for GHAs.

Results and conclusions: the optimization process significantly increased IFI reliability, mainly reducing false positive results and identifying intracellular signal localization and patterns. Our results, derived from the largest study performed in acromegaly, confirmed the prime involvement of autoimmunity in acromegaly (33.7% of the patients developed APAs; the IFI pattern was nuclear-perinuclear in 15, and cytoplasmic in 14 patients). Differently from other autoimmune disorders, dopamine-agonists and somatostatin-analogues combination therapy does not seem to suppress antibodies production. GHA were present in 62% of APAs-positive patients, suggesting its role as a potential immune target. No correlations were found between APAs and gender, family history of pituitary disease, disease activity, comorbidities or treatment outcome. Larger studies are warranted to standardize IFI method and define the mechanisms underlying antibodies production, target antigens and their clinical significance.

 

Nothing to Disclose: FG, MP, AB, NP, SVD, VG, GB, RG, EG, SG

14573 4.0000 SUN-0699 A Clinical Significance of Anti-Pituitary and Anti-GH Secreting Cells Antibodies Assessed By an Optimized Method in Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0696-0709 4833 1:00:00 PM Pituitary Tumors-Basic Poster

Anne-Lise Lecoq*1, Say Viengchareun2, Jérôme Bouligand3, Jacques Young4, Audrey Boutron Corriat5, Anne Guiochon-Mantel6, Marc Lombes2, Philippe Chanson7 and Peter Kamenický8
1INSERM U693 - Faculté de Médecine Université Paris Sud, Le Kremlin Bicêtre, France, 2INSERM U693, Le Kremlin Bicêtre, France, 3Hôpital Bicêtre Assistance Publique Hôpitaux de Paris, Le Kremlin Bicêtre, France, 4University Paris Sud, Department of Endocrinology, Bicetre Hospital, INSERM U693, Le Kremlin-Bicêtre, Fance, Le Kremlin Bicêtre, France, 5Hôpital Bicêtre-Assistance Publique Hôpitaux de Paris, Le Kremlin Bicêtre, France, 6Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France, 7Univ Paris-Sud, UMR-S693, Le Kremlin Bicêtre, France, Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Service d’Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, Paris, France, Le Kremlin-Bicêtre, France, 8Hôpital Bicêtre-Assistance Publique Hôpitaux de Paris-Université Paris Sud, Le Kremlin Bicêtre, France

 

Germline mutations in the Aryl hydrocarbon receptor Interacting Protein (AIP) occur in approximately 20% of patients with familial isolated pituitary adenomas and 4% of patients with sporadic pituitary adenomas. The molecular mechanisms by which AIP mutations lead to pituitary tumorigenesis are unclear. The best-known interacting partner of AIP is the Aryl hydrocarbon Receptor (AhR), a transcription factor mediating the effects of xenobiotics, implicated in carcinogenesis. Considering that 75% of AIP mutations disrupt the physical or functional interaction with AhR, we hypothesize that the tumorigenic potential of AIP mutations could potentially result from altered AhR signaling. The aim of this study was to evaluate the impact of AIP mutations on AhR signaling pathway.

First, we used fibroblasts from 4 patients with growth hormone- or prolactin-secreting pituitary adenomas, harboring heterozygous AIP mutations: a missense mutation in the translation initiation codon ATG (p.M1?), a frameshift mutation with premature stop codon (p.G117AfsX39), a duplication of 21 nucleotides (p.F269_H275dup) and a nonsense mutation (p.R304X). We observed a 50% decrease of AIP protein level in the mutated cells compared to fibroblasts of 3 healthy subjects, without detection of truncated proteins on Western blots. The expression of [35S]-methionine-radiolabeled mutant AIP proteins was confirmed by in vitro translation assays. Gene expression studies demonstrated significant variations in the basal and kynurenine-induced expression of AhR target genes. Interestingly, AIP mutations disrupting AhR interaction (p.R304X and p.G117AfsX39) led to a 50% decrease of CYP1B1 expression and a 50% increase of TIPARP expression in the fibroblasts.

The impact of AIP mutations on AhR transcriptional activity was further studied in pituitary GH3 cells. Overexpression of AIP mutants compared to wild-type AIP resulted in a 50% increase in the basal and kynurenine-induced CYP1B1 and AhRR expression. Whether AIP mutations also alter the nucleo-cytoplasmic trafficking of AhR and/or AhR binding to Dioxin Response Elements in the promoters of target genes is currently investigated by High Throughput Microscopy and Chromatin Immunoprecipitation.

In sum, we show in human fibroblasts bearing heterozygous AIP mutations and in transfected pituitary GH3 cells, that AIP mutations affect AhR transcriptional activity. Altered AhR signaling could contribute to the tumorigenic potential of AIP mutations.

 

Nothing to Disclose: ALL, SV, JB, JY, AB, AG, ML, PC, PK

13735 5.0000 SUN-0700 A AIP Mutations Differentially Impair AhR Signaling in Fibroblasts of Patients with Pituitary Adenomas and in Pituitary GH3 Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0696-0709 4833 1:00:00 PM Pituitary Tumors-Basic Poster

Clarissa Silva Martins*, Renata Costa Camargo, Fabiano Pinto Saggioro, Luciano Neder, Helio Rubens Machado, Ayrton C. Moreira and Margaret De Castro
Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil

 

Introduction The molecular bases of pituitary tumorigenesis remain not completely understood. In sporadic tumors, mis-expression of genes and proteins involved in cell cycle regulation, such as P27KIP1 (CDKN1B) underexpression has been observed. However, if translational control of CDKN1B underlies this phenomenon is yet an unexplained question. To clarify p27 translational regulation in pituitary tumors, this study evaluates gene expression of CDKN1B, its targets (CCNE1, CDK2) and CDKN1B interacting translational regulators (DKC1, RPS13, miR221, miR222) in ACTH-, GH- secreting and non functioning pituitary adenomas (NFPA) compared to normal pituitaries (NP). In these different subtypes of tumors, we also have sequenced the DKC1 gene.

Subjects Samples obtained during transsphenoidal surgery from 51 patients presenting pituitary tumors: 12 ACTH-secreting, 18 GH-secreting and 21 NFPA. The control group comprises seven NP tissues obtained during autopsies.

Methods RNA and DNA were isolated by TRIzol. Gene expression was assessed by qPCR. In 35 tumors, all 15 exons and intron/exon boundary regions of DKC1 were amplified and sequenced. Kruskall-Wallis test was used for continous variables.

Results CDKN1B underexpression was observed in somatotropinomas vs NP (fold change= -1.8) (p=0.03), CCNE1 overexpression was observed in NFPA vs NP (fold change= 4.4) (p=0.02). A tendency towards higher CDK2 expression was observed in tumors vs NP (p=0.07). No differential gene expression among groups were observed in CDKN1B translational regulators RPS13 (p=0.19) and DKC1 (p=0.2). The expressions of miR221 and miR222 were similar between tumors and NP, but were higher in NFPA vs ACTH-secreting adenomas (p<0.001 and p=0.003). No DKC1 polymorphisms (SNPs) or mutations were found in exons 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12 and 13. In exon 9, a NFPA exhibited the missense mutation c.776A>C, p.His259Pro. According to SIFT this mutation may be potentially deleterious. However, accordingly to PolyPhen it may be benign. In exon 14, the synonymous SNP rs1127051 (c.1461C>T, p.Ala487=) was found with genotypic frequency (%): CC: 0.91/ CT 0.06/ TT: 0.03. This frequency is similar to those found in NCBI-dsSNP databases for Europeans, Asiatics and Mexican descendants. In intron 14-15, the mutation g.18972G>T was found in heterozygosis in a GH-secreting tumor and in homozygous in a NFPA. In exon 15, the inframe deletion c.1492_1494delAAG, p.K505delK, described in one intestinal cancer sample, was found. In the 3’UTR, the SNP rs1800533 (g.19118G>A) was found with  frequency GG: 0.744/ GA 0.17/ AA 0.086, which is similar to those found in NCBI databases for Europeans and Mexican descendants.

Conclusion In pituitary tumors, CDKN1B underexpression is not explained by mis-expression of its translational regulators - DKC1, RPS13, miR221, miR222. In addition, DKC1 mutations are not frequent events in pituitary adenomas.

 

Nothing to Disclose: CSM, RCC, FPS, LN, HRM, ACM, MD

14770 6.0000 SUN-0701 A The Role of P27 (CDKN1B) Interacting Translational Regulators in Pituitary Tumorigenesis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0696-0709 4833 1:00:00 PM Pituitary Tumors-Basic Poster

Renata Kikuchi Foltran*1, Ericka Barbosa Trarbach2, Felipe HG Duarte3, Raquel S Jallad4 and Marcello D Bronstein5
1University of São Paulo Medical School, São Paulo, Brasil, Sao Paulo, Brazil, 2Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 3Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Sao Paulo, Brazil, 4Hosp das Clinicas Univ of Sao Pa, Sao Paulo SP, Brazil, 5Disciplina de Endocrinologia e Metabologia, Unidade de Neuroendocrinologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil.

 

Screening of AIP (aryl hydrocarbon receptor-interacting protein) gene mutations in patients with sporadic pituitary gigantism.

Renata K Foltran, BS1, Ericka B. Trarbach, MS, PhD1,Felipe H. G. Duarte, MD, PhD2, , Raquel S. Jallad, MD, PhD1,2.Marcello D. Bronstein, MD, PhD2 ,

1Laboratório de Endocrinologia Celular e Molecular LIM/25, HCFMUSP, São Paulo, Brasil.

2 Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Brasil.

Recent reports suggest that aryl hydrocarbon receptor interacting protein (AIP), a tumor suppressor gene that plays a positive role in AHR-mediated (aromatic hydrocarbon receptor) signaling, has an involvement in the development of GH-secreting tumors, mainly in children and adolescents. Here, we evaluated the presence of germline AIP mutations in apparently sporadic pituitary adenomas causing gigantism. Seven patients (6 males) were included in this study. In all cases, clinical evidence of GH hyper secretion were observed before the age of 18 years old with height above +2 SD for age and gender. High serum GH and IGF-I levels and invasive macroadenoma were observed in all cases. No patients had familial  history and laboratory evidence for MEN1. Three cases were diagnosed with McCune Albright syndrome. Four patients were submitted to a transsphenoidal pituitary adenomectomy and two underwent radiotherapy. Mutational analysis of AIP (ENST00000279146) was performed by PCR amplification of coding regions and automatic sequencing, using genomic DNA extracted from peripheral blood. We identified a heterozygous p.Gln217* AIP stop codon mutation in one male with sporadic gigantism. Previously, the p.Gln217* (CM071537) was only described in a patient with gigantism resulting from a familial isolated pituitary adenoma(1). In the remaining cases, only polymorphic variants, already reported in NCBI SNP database, were detected: a missense p.Gln228Lys and an intronic c.468+111C>T, in 7/7 and 3/7 cases, respectively. However, the relevance of the p.Gln228Lys needs to be clarified, since it is located in functionally relevant domain inside the AIP protein. In conclusion, pathogenic AIP gene mutation was not very frequent in our cohort of gigantism patients. Additional studies are necessary to establish the prevalence of AIP mutations and polymorfisms in sporadic pituitary gigantism and their role in pituitary tumorigenesis.

There is no conflit of interest

1. Cai F, Zhang YD, Zhao X, Yang YK, Ma SH, Dai CX, Liu XH, Yao Y, Feng M, Wei JJ, Xing B, Jiao YH, Wei ZQ, Yin ZM, Zhang B, Gu F, Wang RZ.Screening for AIP gene mutations in a Han Chinese pituitary adenoma cohort followed by LOH analysis. Eur J Endocrinol. 2013 169(6):867-84

 

Nothing to Disclose: RKF, EBT, FHD, RSJ, MDB

14788 7.0000 SUN-0702 A Screening of AIP (aryl hydrocarbon receptor-interacting protein) Gene Mutations in Patients with Sporadic Pituitary Gigantism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0696-0709 4833 1:00:00 PM Pituitary Tumors-Basic Poster

Toru Tateno*1, Karen Gomez-Hernandez2, Tae Tateno1, MawMaw Hlaing3, Lei Zheng4, Sylvia L. Asa4 and Shereen Z Ezzat2
1Ontario Cancer Institute, Toronto, ON, Canada, 2University Health Network, University of Toronto, Toronto, ON, Canada, 3University Health Network, 4University Health Network, Toronto, ON, Canada

 

Background: Fibroblast growth factor receptor 4 (FGFR4) is a member of a family of transmembrane receptors which have been implicated in pituitary tumors. A single nucleotide polymorphism (SNP) at codon 388 of FGFR4 (Gly388Arg), which encodes an amino acid in the transmembrane part of the FGFR4 gene, has been linked with increased cancer progression. We reported that this SNP can influence cellular metabolism through STAT3 serine translocation to the mitochondria resulting in enhanced proliferation (Tateno et al. PLoS Genetics 2011).  Here we examined the impact of altered pituitary cell mitochondrial respiration on the therapeutic action of different somatostatin analogs.

Methods and Results:  Using pituitary GH4 or AtT20 cells stably expressing the human FGFR4 Gly388 (G388) cDNA or the polymorphic Arg388 (R388) cDNA variant, we compared the ability of octreotide and pasireotide to influence hormone and cellular functions.  Introduction of either FGFR4 isoform had no influence on endogenous somatostatin receptor levels including SSTR2 and SSTR5 levels.  While octreotide and pasireotide were equally effective in reducing hormone secretion and diminishing oxygen consumption rates in cells expressing the wild type FGFR4-G388, only pasireotide could influence these actions in cells expressing the FGFR4-R388 polymorphic variant.  Pharmacologic inhibition studies confirmed that the phosphatase inhibitor pervanadate can abrogate this impact of pasireotide on STAT3 serine dephosphorylation.  The phosphatase 2B inhibitor cyclosporine A, however, was ineffective in rescuing the effect of pasireotide.  In contrast, the phosphatase 2A inhibitor okadaic acid effectively diminished Src and STAT3 dephosphorylation induced by pasireotide, providing evidence for involvement of this phosphatase in mediating this drug’s action.

Conclusions: Our data suggest that FGFR4 polymorphic isoforms mediate signaling that converges on mitochondrial respiratory function providing important therapeutic targets for selective somatostatin analog actions.

 

Nothing to Disclose: TT, KG, TT, MH, LZ, SLA, SZE

14915 8.0000 SUN-0703 A The FGFR4-G388R Transmembrane Polymorphism Modulates Mitochondrial Function Providing a Target for Selective Somatostatin Receptor Action in Pituitary Tumors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0696-0709 4833 1:00:00 PM Pituitary Tumors-Basic Poster

Karen Gomez-Hernandez*1, Sonia Cheng2, Toru Tateno3, Sylvia L. Asa4 and Shereen Z Ezzat1
1University Health Network, University of Toronto, Toronto, ON, Canada, 2University of Alberta, 3Ontario Cancer Institute, Toronto, ON, Canada, 4University Health Network, Toronto, ON, Canada

 

Introduction: A single nucleotide polymorphism (SNP) in fibroblast growth factor receptor 4 (FGFR4) in which arginine is substituted for glycine at codon 388 (FGFR4-G388R) occurs in up to 50% of the population and has been associated with aggressive tumor behavior in some cancers (Mete, Ezzat, & Asa, 2012). We reported that this SNP can change mitochondrial functions through STAT3 serine translocation to the mitochondria resulting in enhanced cell proliferation, and hormone production in pituitary GH4 cells (Tateno et al., 2011). Based on these findings we hypothesized that acromegalic patients with this SNP would tend to have higher pre-treatment levels of IGF-1 than those with the prototypic form of the gene as well as an altered response to somatostatin analogues (SSAs).

Patients and methods: Consecutive patients with acromegaly followed at University Health Network, Toronto, Canada that were treated with SSAs, had no previous history of pituitary radiation, and in whom all the relevant clinical information was available were included. Using hard copy charts and electronic medical records reviews, all relevant clinical information was recorded including: gender, IGF-1 level, FGFR4 status, sensitivity or resistance to SSAs. Genotyping for FGFR4 Arg388Gly was performed in a subset of the cases.

Preliminary results: 89 cases were assessed. Of these, 40 were women (44.9%) and 49 were men (54.1%). Genotyping has been completed on 27 (67.5%) women and 32 (65.3%) men. Forty four percent of women and 46.8% of men had the SNP. Within the SSAs resistant subgroup, the FGFR4 variant status was associated with a higher initial IGF-1 (1236.4 ug/L ± 457.5 ug/L) when compared to patients with wild-type status (vs. 887.6 ug/L ± 229.8 ug/L; p=0.044) Moreover, female subjects harboring the FGFR4 variant were more frequently sensitive (9/12 sensitive) to SSA therapy compared to their wild-type counterparts (vs. 4/15 sensitive; p=0.017).  This effect appeared to be gender specific, as it was not found amongst male subjects (FGFR4 variant = 9/15 sensitive vs.WT 10/17 sensitive; p = NS).  

Discussion: These preliminary results provide evidence for the involvement of FGFR4-G388R polymorphism in determining IGF-1 production in patients with acromegaly. Additionally, a gender/genotype interaction may portend therapeutic responsiveness to SSA.

 

Nothing to Disclose: KG, SC, TT, SLA, SZE

14950 9.0000 SUN-0704 A FGFR4 Genetic Status and Sensitivity to Somatostatin Analogues in Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0696-0709 4833 1:00:00 PM Pituitary Tumors-Basic Poster

Kirstine Stochholm*1, Agnethe Berglund2, Jens Sandahl Christiansen3, Svend Juul4 and Claus H. Gravholt2
1Aarhus University Hospital, Aarhus C, Denmark, 2Aarhus University Hospital, Aarhus, Denmark, 3Aarhus University Hospital, Denmark, 4Section of Epidemiology, Aarhus, Denmark

 

Socio-economic Factors do not and Growth Hormone Treatment may affect Mortality in Adult Onset Growth Hormone Deficiency

Context: GHD is associated with changes in body composition, increased cardiovascular risk markers, and reduced bone mineral density. There seems to be multiple causes of the reported increased morbidity and mortality.

Objective: The objective was to study the socio-economic status in patients with adult onset GHD, and its impact on mortality.

Design: This is a nationwide registry study where the socio-economic status in a cohort of adult onset GHD patients was identified in the Danish nationwide registries and compared with controls matched on age and sex. The patients were diagnosed in 1980-1999, and  mortality and socio-economic status was followed until 2007. The socio-economic status included cohabitation, education, income, parenthood, convictions, and retirement.

Patients and controls: All patients had adult onset GHD and were born in 1950 or later. Two-hundred and seventy-six patients (54% men; 48% treated with growth hormone ) and 25,717 controls were included. The patients were divided into six categories according to the primary cause of the deficiency.

Results: In patients, the incidence of cohabitation, parenthood and convictions was significantly reduced, whereas education was unaffected. The incidence of early retirement was significantly increased. Mortality was significantly increased in total and in three out of six diagnostic groups, and this increase remained after adjustment for cohabitation and education. Overall, the mortality was only increased in  patients not treated with growth hormone.

Conclusions: The patients had an impaired socio-economic profile on most parameters compared to controls. The socio-economic outcome was closely related to the primary cause of the deficiency. Mortality was unaffected by the socio-economic status.

 

Disclosure: JSC: Research Funding, Novo Nordisk, Board Member, Novo Nordisk, Board Member, The name is Merck Serono, lectures, Novo Nordisk, lectures, Pfizer, Inc., fees, Eli Lilly & Company. Nothing to Disclose: KS, AB, SJ, CHG

15197 10.0000 SUN-0705 A Socio-Economic Factors Do Not and Growth Hormone Treatment May Affect Mortality in Adult Onset Growth Hormone Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0696-0709 4833 1:00:00 PM Pituitary Tumors-Basic Poster

Robert Y Osamura*1, Midori Matsuda2, Chie Inomoto3, Shozo Yamada4, Kenichiro Asano5, Hidetoshi Ikeda6, Kazunori Arita7, Shingo Fujio7, Toshio Hirohata8, Shigeyuki Tahara9, Akira Matsuno10 and Akira Teramoto11
1Intl Univ of Health and Welfare, Tokyo, Japan, 2International University of Health and Welfare, Tokyo, Japan, 3Tokai University School of Medicine, Isehara, Japan, 4Toranomon Hosp, Tokyo, Japan, 5Hirosaki University Hospital, hirosaki, Japan, 6Research Institute for Pituitary, Koriyama, Japan, 7Graduate School of Medical and Dental Sciences Kagoshima University, Kagoshima, Japan, 8The University of Tokyo, Tokyo, Japan, 9Nippon Medical School, Tokyo, Japan, 10Teikyo Univ Ichihara Hosp, Ichihara-Shi, Japan, 11Tokyo Rosai Hospital & Nippon Med Sch, Tokyo, Japan

 

Background:Pituitary carcinoma is very rare in the pituitary tumors(0.5%) and exhibits invasion and/or metastases. In addition to temozolomide(TMZ) therapy or ratioation therapy, molecular targeted therapies such as somatostatin analogue and anti-mTOR(everolimus) are available. This study is aimed at to elucidate the immunohistochemical expression of somatostatin receptor2a(SSTR2a), SSTR5 and p-mTOR for the possible treatment with somatostatin analogue and everolimus.

Design: Paraffin embedded tissue of the pituitary carcinoma from 11 patients(5 ACTH producing, 2 PRL producing and 3 null cell ”immunonegative for hormones”) were subjected to immunohistochmical staining of SSTR2a, SSTR5 and p-mTOR. Four cases revealed liver metastasis and 9 cases revealed intracranial and/or spinal spread. Immunohistochemical staining  was done by anti-SSTR2a and anti-SSTR5 rabbit monoclonal antibodies(Epitomics Inc.) and anti-p-mTOR rabbit monoclonal antibody(Phospho-mTOR (Ser2448) antibody,  Cell Signaling Technology Inc.) were. The results of SSTR2a staining was evaluated according to Volante M et al(Mod.Pathol 2007).

Results:Positive staining for SSTR2a, score 2 and 3 by Volante , was observed in two cases(1 null cell carcinoma, sccore 3, and 1 ACTH produdinng carcinoma, score 2)  The former case showed systemic spread of spinal meninges and invasion to anterior pons, and the latter revealed the metastasis in the liver. No cases exhibited SSTR5. Five cases were positive for p-mTOR in the cytoplasm of the tumor cells with various intensity and various proportion(from 1+30% to 3+90%)

Conclusions:The positive cases for SSTR2a were noted in two cases, one null cell and one ACTH), suggesting its aberrant, not Pit-1 related, expression. P-mTOR expression was noted in 5 cases. Even though the numbers of cases are limited, immunohistochemical detection of SSTR2a and p-mTOR may provide therapeutic information for further therapy of he pituitary carcinoma when the primary and metastatic tumors do not respond to other therapies such as TMZ.

 

Nothing to Disclose: RYO, MM, CI, SY, KA, HI, KA, SF, TH, ST, AM, AT

16771 11.0000 SUN-0706 A Immunohistochemical Detection of Therapeutic Biomarkers(SSTR2a, SSTR5 and p-mTOR) in Pituitary Carcinomas Analysis of Total 11 Cases 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0696-0709 4833 1:00:00 PM Pituitary Tumors-Basic Poster

Maria Chiara Zatelli*1, Mauro Di Ruvo2, Federico Tagliati3, Erica Gentilin4, Teresa Gagliano4, Natalia Pellegata5, Maria Rosaria Ambrosio4 and Ettore Ciro degli Uberti6
1Univ. of Ferrara, Ferrara, Italy, 2Section of Endocrinology, University of Ferrara, Ferrara, Italy, 3Section of University of Ferrara, Ferrara, Italy, 4University of Ferrara, Ferrara, Italy, 5Helmholtz Zentrum München, Neuherberg, Germany, 6Section of Endocrinology, University of Ferrara, Italy

 

CDKN1B gene encodes a cyclin-dependent kinase (Cdk) inhibitor, regulates G1 to S cell cycle progression, and may display loss-of-function germinal mutations that cause MEN4 syndrome.

The aim of the study is to characterize a new 4 bp deletion in CDKN1B 5’-UTR region, identified in a patient with acromegaly due to a pituitary adenoma.

Functional promoter characterization was developed in human (MCF-7), murine (AtT20/D16V-F2) and rat (GH3) cell lines. Total mRNA and proteins were extracted from peripheral blood of the patient and control subjects to analyze CDKN1B/p27Kip1 expression. In addition, p27Kip1 expression was evaluated by immunohistochemistry in tissue sections of the patient’s GH-secreting pituitary adenoma. We found that the transcriptional activity of the deleted promoter (heterozygous  deletion in CDKN1B 5 '-UTR region extending from nucleotide -29 to -26 from the translation start site) is significantly decreased (~ 30-60% vs. wild type; p <0.01). CDKN1B/p27Kip1 expression  analysis of patient’s circulating leukocytes showed a significant reduction (~ 72%) in mRNA levels, while p27Kip1 protein levels are similar to wild-type controls. Immunohistochemistry shows a reduced p27Kip1 expression in the patient's pituitary adenoma compared to the control. Our data show that the identified deletion causes a significant reduction in promoter transcriptional activity and in CDKN1B mRNA expression, indicating a putative role of the deletion in the patient’s disease. Further studies are needed in order to understand whether the deletion could impact protein function.

 

Nothing to Disclose: MCZ, MD, FT, EG, TG, NP, MRA, ECD

13934 12.0000 SUN-0707 A Acromegaly Associated with a New Deletion in CDKN1B 5'-UTR Region: Functional Molecular Characterization 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0696-0709 4833 1:00:00 PM Pituitary Tumors-Basic Poster

Malgorzata Trofimiuk-Müldner*1, Anna Skalniak2, Jakub Piatkowski2, Grzegorz Sokolowski2 and Alicja Hubalewska-D1
1Jagiellonian University Medical College, Krakow, Poland, 2University Hospital in Krakow, Krakow, Poland

 

Germline AIP gene mutations have been linked with familial isolated pituitary adenomas (FIPA) and are responsible for about 15-30% of such cases. The inactivating mutations of AIP have also been reported in seemingly sporadic pituitary adenomas (in about 3-4% of all cases), particularly of early onset, aggressive, and growth hormone secreting.

Aim: to assess the frequency and type of germline AIP gene mutations in patients with apparently sporadic PMAs.

Material: The study included 31 consecutive patients with pituitary macroadenoma (17 males, 14 females; median age at diagnosis 43 years), followed in the Outpatient Clinic of  the Endocrinology Department, University Hospital in Krakow. 13 subjects have been diagnosed (based on hormonal results and, if feasible, on pituitary tumor histopathology) with non-functioning pituitary adenoma (NFPA), 10 – acromegaly, 4 – prolactinoma, 2 – Cushing’s disease, 1 – TSH-oma, and 1 with gonadotropinoma. Median tumor size at diagnosis was 30 mm.

Methods: DNA of all participants was isolated from whole peripheral blood. The 6 exons of the AIP gene were sequenced using sanger sequencing (ABI 3500). Sequences were compared to reference data at NCBI, accordingly: NM_003977.2 and NP_003968.2. Nucleotide conservativity was estimated by PhyoP. The mutation influence on protein was estimated by PROVEAN Protein.

Results: 2 patients (9,8%) have been suggested to harbor a germline missense mutation in exon 3 of the AIP gene c.[377A>T];[=], p.[Q126L]; [=] (patient 1 – a 53 year old female with suprasellar NFPA, operated due to pituitary apoplexy symptoms – harboring also SNP rs2276020/c.516>t/p.Asp= in exon 4-5; patient 2 – a 41 year old female with 17 mm ACTH-secreting macroadenoma). The mutation, to our knowledge so far unreported, is localized in a highly conservative region of the gene and the substitution of Gln with Leu at codon 126, most probably leads to abnormal  function of AIP suppressor gene.

Conclusions: As both mutation carriers would not be selected for AIP gene sequencing based on clinical features, it seems feasible to search for germline AIP gene mutations in every patient with PMA. The presented report is an initial one, the recruitment of patients is still pending.

 

Nothing to Disclose: MT, AS, JP, GS, AH

14383 13.0000 SUN-0708 A Germline Aryl Hydrocarbon Receptor Interacting Protein (AIP) Gene Mutations in Patients with Apparently Sporadic Pituitary Macroadenomas (PMA) – a Pilot Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0696-0709 4833 1:00:00 PM Pituitary Tumors-Basic Poster

YangJong Lee*1, Jin Mo Cho2, Cheol Ryong Ku3, Sun Ho Kim3 and Eun Jig Lee4
1Yonsei University, Seoul, Korea, Republic of (South), 2Ajou University School of Medicine, Korea, Republic of (South), 3Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 4Yonsei University College of Medicine, Korea, Republic of (South)

 

MicroRNAs (miRNAs) have been implicated in the pathogenesis of many human tumors. miRNAs act not only as a tumor suppressor but also as an oncogene in some malignancies. However, few studies have been reported on the role of miRNAs on pituitary adenoma. We performed miRNA microarray using total RNA extracted from 6 acromegalic tumors tissue. Among 6 patients, 3 were microadenomas (Hardy type I) and remaining 3 invasive adenomas (Hardy IV). Twenty five miRNAs were up-regulated and 20 ones were down-regulated in patients with invasive adenomas. Candidate transcripts from microarray were further explored with rat pituitary GH-producing (GH3) cells with estradiol (E2) treatment. Estrogen treatment highly elevated the expression of miR-338, suggesting that miR-338 might influence on the progression of pituitary adenoma in acromegalic patients.

 

Nothing to Disclose: YL, JMC, CRK, SHK, EJL

14250 14.0000 SUN-0709 A MiR-338 Correlates with the Invasiveness of GH Secreting Pituitary Adenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM SUN 0696-0709 4833 1:00:00 PM Pituitary Tumors-Basic Poster

Ryan J Bourgo*1 and Geoffrey L Greene2
1University of Chicago, Chicago, IL, 2Univ of Chicago, Chicago, IL

 

Chromatin architecture has become apparent as a key regulator in many aspects of cell biology.  Local chromatin structure has been shown to impact gene transcription, DNA repair processes, DNA replication, and even more long-term processes such as X-chromosome inactivation.  There are a host of enzymes, scaffolding proteins, and other factors that are responsible for ensuring that local chromatin architecture is a plastic environment that acts as a barrier-to-entry for the complex cellular processes noted above.  While it is quite clear that DNA conformation is a critical node of control within a cell, it has been traditionally difficult to study complex genomic architecture and its biological impact.  To this end we have developed a novel method of identifying loci of interacting chromatin called Simplified Chromatin Conformation Capture (S3C), which has a host of advantages over traditional 3C-based methodologies.  S3C, like traditional 3C, also relies on formaldehyde crosslinking to capture naturally occurring DNA-protein-DNA interactions.  However, S3C takes an unbiased approach to DNA shearing by using sonication, and then efficiently enriches for a specific genomic locus of interest through hybridization and subsequent purification by complimentary biotinylated oligo.  Here, we demonstrate the effectiveness of S3C by identifying a complex set of chromatin interactions at the SIAH2 gene. Furthermore, we show that these interactions are likely mediated by estrogen receptor, and promoted by estradiol treatment. 

 

Disclosure: GLG: Advisory Group Member, Pfizer, Inc.. Nothing to Disclose: RJB

14898 2.0000 SUN-0406 A Simplified Chromatin Conformation Capture (S3C) Identifies Plasticity in SIAH2 Gene Architecture 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Beth A. Russell*1, Dario M. Villamar2, Geoffrey L Greene3 and Swati Kulkarni1
1University of Chicago, Chicago, IL, 2Weill Cornell Medical College, New York, NY, 3Univ of Chicago, Chicago, IL

 

While hormone signaling in tumor cell lines and tumor samples has been well studied, the reciprocal experiments in tissue from normal individuals have not been performed due to the lack of sufficient sample quantity. Given this, it is difficult to study the impact of preventative measures or put tumor data in the context of their normal cellular environment. Nearly 75% of tumors are derived from luminal epithelial cells. 7% of the cells in normal breast and 10% of the luminal epithelial cells are estrogen receptor alpha (ESR1) positive. Given this context, a method to isolate specific pools of cells prior to chromatin immunoprecipitation (ChIP) experiments is required to accurately capture the cell-type specific response. We have developed fluorescence activated cell sorting mediated small sample chromatin immunoprecipitation (FACS-ssChIP) to isolate ESR1 positive nuclei from small tissue samples and isolate ESR1 bound DNA fragments using a modified ChIP protocol adapted for small samples. We have validated the FACS-ssChIP procedure with MCF7, ESR1 positive breast cancer cells, and MCF10a, ESR1 negative normal mammary cells, as positive and negative controls. FACS can be used effectively to isolate ESR1 positive fractions from mixed populations with a low false positive rate. Tissue from multiple individuals have been examined by FACS-ssChIP. Reproducibility is seen in replicate experiments with tissue samples from the same individual. FACS-ssChIP is an efficient method for ChIP on small human biopsy samples.  We have shown that the FACS process permits the isolation of nuclei from specific cellular populations for small sample ChIP experiments from small core biopsies. The FACS-ssChIP technique opens up the research options for prevention and developmental studies in normal individuals.

 

Disclosure: GLG: Advisory Group Member, Pfizer, Inc.. Nothing to Disclose: BAR, DMV, SK

PP21-3 16378 3.0000 SUN-0407 A FACS-ss ChIP Enables Mammary Estrogen Signaling Studies in Normal Individuals 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

J. David Furlow*1, Lucia N. Dobrawa1, Yuzhu Wei2, Mischa Streekstra2, Eric S. Neff1, Brenda J. Mengeling1 and Albertinka J. Murk2
1UC Davis, Davis, CA, 2Wageningen University, Wageningen, Netherlands

 

Thyroid hormones (THs) are critical regulators of vertebrate development, growth and metabolism. Identifying TH-modulating compounds, either agonists or antagonists of the thyroid hormone receptors (TRs), remains an important goal clinically and in environmental toxicology. Toward this end, we developed a stable luciferase based reporter assay using GH3 cells for TR active compounds that is adaptable for high throughput screening. Here, we test whether the cell-based results are relevant in a convenient and specific in vivo assay for TH action: induced metamorphosis of one week old Xenopus laevis tadpoles. We compared a set of natural and synthetic TR agonists (T3, T4, GC-1 and CO23), a synthetic antagonist (NH-3), and a set of brominated flame-retardants (BFRs: HBCD, BDE-47, and TBBPA), in both cells and tadpoles. After initial in vitro screening in cells, compounds were tested in vivo for specific morphological changes such as growth of the lower jaw, expansion of the brain, and loss of the gills, which represent reproducible and quantifiable endpoints of TH action. We augmented gross morphology with a whole mount immunocytochemical assay to quantify proliferating cells in a sensitive, three-dimensional assay for a known cellular response to TH in vivo. We further demonstrated that TRβ (a widely expressed direct target gene), aurora B kinase (in proliferating tissues), and collagenase-3 (in resorbing tissues) are strongly induced TH responsive genes that can be used as pathway specific biomarkers. In addition, we found that a transgenic, TH response element driven reporter gene assay is generally a convenient substitute for gene expression responses to TH. Overall, there was an excellent concordance among multiple assays for the tested known natural and synthetic agonists. Further, isotype-selective ligand effects suggested both overlapping and distinct roles for TR isotypes in GH3 cell and specific tadpole tissue responses. The antagonist NH-3 inhibited GH3 and tadpole responses to TH, except for proliferation in the brain where NH-3 showed partial agonist activity. Among the BFRs, BDE-47 mimicked T3 in some morphological changes yet also generally inhibited cell proliferation. BDE-47 did not affect TH target gene or transgenic reporter expression suggesting its actions are TR-independent. Lastly, TBBPA showed weak mixed agonist/antagonist activity in GH3 cells, but inhibited T3 induced morphological changes, cell proliferation, and target and reporter gene expression in vivo, thus likely acting as a TR antagonist. Tadpoles appeared to be more sensitive to TBBPA than in the cell based assay. Thus, the GH3 cell based assay has good predictive value for in vivo responses, but the one week induced metamorphosis assay may be more sensitive for some compounds while at the same time revealing potentially important cell type selective actions.

 

Nothing to Disclose: JDF, LND, YW, MS, ESN, BJM, AJM

16974 4.0000 SUN-0408 A In Vitro to in Vivo Screening for Thyroid Hormone Receptor Active Compounds 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Aleksandra Cvoro*1, Liani Devito2, Douglas Harold Sieglaff1, Dusko Ilic2 and Paul Webb1
1Houston Methodist Research Institute, Houston, TX, 2King’s College London, London, United Kingdom

 

Transcriptional factors (TFs) regulate distinct sets of genes depending on cell type and developmental or physiological context. However, biological processes are rarely initiated and regulated by individual TFs; rather, close cooperation of multiple TFs integrating different signals is responsible for the modulation of the cell response. The networking of thyroid hormone receptors (TR) and Kruppel-like factor 9 (KLF9) is well established in brain development where KLF9 mediates T3 actions on neuronal differentiation.  Here we examine if TR/KLF9 cooperation occurs in non-neuronal tissues. We first examined relations between these factors in a hepatocellular carcinoma cell line, HepG2. Microarray analysis in HepG2 cells expressing low levels of endogenous TRβ, as well as in TRα or TRβ stably transfected HepG2 cells, indicated that KLF9 is strongly activated by T3 which was confirmed by qPCR. To further explore the possibility of a TR/KLF9 network, we used a siRNA specific to KLF9 in TR stably transfected HepG2 cells. Microarray analysis to compare gene expression profiles with control and KLF9 siRNAs revealed 368 genes that displayed more than 2-fold change after KLF9 knock down. Further, our data revealed that KLF9 knockdown profoundly altered the pattern of T3 response. Pathway analysis revealed roles of TR/KLF9 axis in multiple processes, including regulation of key signaling pathways implicated in stem cell biology. To determine whether the TR/KLF9 axis is active in stem cells, we used human embryonic stem cell (hESC) line KCL034 and induced pluripotent stem cell (iPSC) lines iKCL004 and iKCL011. T3 treatment resulted in robust increase in KLF9 mRNA in all three cell lines. Thus, the TR/KLF9 axis is active in hESC and iPSC. Our studies suggest that the TR/KLF9 axis is active in multiple cell types and conceivably involved in regulation of differentiation and early stages of organogenesis as well as homeostasis in adult cells.

 

Nothing to Disclose: AC, LD, DHS, DI, PW

14916 5.0000 SUN-0409 A A Conserved Thyroid Hormone Receptor/KLF9 Axis Active in Multiple Cell Types 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Larissa C Faustino*1, Khatuna Gagnidze2, Tania Maria Ortiga-Carvalho3 and Donald W Pfaff4
1Icahn School of Medicine at Mount Sinai, New york, NY, 2The Rockefeller University, New York, NY, 3Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil, 4Rockefeller Univ, New York, NY

 

Estradiol (E2) and thyroid hormones (TH) are fundamental for animal development, physiology and behavior. Several evidences have shown that genomic actions as well as nongenomic actions of estrogen receptors (ER) and thyroid hormone receptors (TR) can be integrated. Interactions between TH and E2 on the brain influence reproductive physiology and sexual behavior (1). The progesterone receptor (Pgr) and oxytocin receptor (Oxtr) genes are stimulated by E2 within the ventromedial hypothalamus (VMH) and preoptic area (POA), two critical brain regions for sexual and maternal behaviour, respectively. In the present study, we investigated the impact of TH and E2 interactions on early molecular events associated with Pgr and Oxtr gene regulation. Six to eight week-old female mice were submitted to ovariectomy. After recovery, mice were induced to become hypothyroid (iodine deficient diet containing 0.15% PTU for 2 weeks) and hyperthyroid by a single injection of T3 (50 ug/100 g BW). Euthyroid animals were also used. All groups were further divided into 2 different groups, one injected with 20 ug of E2 and the other one with vehicle. First, we observed that hyperthyroidism abolished E2-induction of Pgr and Oxtr mRNA (evaluated by qPCR) in both brain areas 6 hours after injections of E2 and T3, indicating that high levels of T3 were able to interfere with E2 normal signaling. The excess of T3 was also able to suppress the up-regulation of the co-factors steroid-receptor coactivator 1 (SRC-1) and integrator complex p300/CBP (CBP) by E2. Aiming to investigate how TH could interfere with the E2-induced histone modifications that contribute to the expression of Pgr ad Oxtr in the VMH and POA, we evaluated by Chromatin Imunoprecipitation (ChIP) assay the association of H3Ac (acetylation of histone H3) and H3K4me3 (trimethylation of H3) with the promoters of these genes 3 hours after injections. Association of H3Ac and H3K4me3 with these two promoters was gene and brain-region specific. Next, we analyzed by ChiP assay the recruitment of ERalpha and TRalpha to putative regulatory sequences within Pgr and Oxtr promoters 3 hours after hormonal exposure. Hypothyroidism and hyperthyroidism affected E2-induced ERalpha recruitment to proximal and enhancer sites within Pgr promoter in the VMH in a similar fashion. E2 was able to recruit TRalpha to Pgr promoter, mimicking T3 action, however, when T3 was in excess and therefore TRalpha recruitment was high, E2 inhibited T3-induced TRalpha recruitment by 44% (p<0.05). Finally, to Oxtr promoter, E2 and T3 worked together to increase ERalpha and TRalpha recruitment in a synergic fashion. Our data indicate a cross-regulation between E2 and TH at an early molecular stage in the VMH and POA of female mice that is dependent on the brain region, gene analyzed, histone modification assayed, promoter/enhancer site and time after hormonal exposure.

 

Nothing to Disclose: LCF, KG, TMO, DWP

16336 6.0000 SUN-0410 A Impact of Thyroid Hormones on ER Alpha-Dependent Actions in Ventromedial Hypothalamus and Preoptic Area 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Manav Batra*1, Sandeep S Dhindsa2, Husam Ghanim3, Sanaa Abuaysheh4, Antoine Makdissi5, Ajay Chaudhuri6, Nitesh D Kuhadiya1 and Paresh Dandona7
1University at Buffalo, Buffalo, NY, 2Diabetes and Endocrinology Center of Western New York, Williamsville, NY, 3SUNY at Buffalo, Buffalo, NY, 4SUNY at Buffalo, 5State Univ of New York at Buffal, Buffalo, NY, 6SUNY at Buffalo, Williamsville, NY, 7State Univ of NY, Buffalo, NY

 

Our previous work has shown that one third of males with type 2 diabetes (T2DM) have hypogonadotropic hypogonadism (HH). These patients are more insulin resistant than eugonadal men with T2DM. Testosterone replacement suppresses inflammation, molecular mediators of insulin resistance, restores insulin sensitivity, decreases adipose tissue and increases lean body mass. In order to elucidate the underlying mechanisms further, we have now investigated whether males with HH have an alteration in the expression of androgen receptor (AR), estrogen receptor (ER)α and aromatase and whether testosterone replenishment restores these indices to normal. Fasting peripheral blood mononuclear cells (MNC) and adipose tissue biopsy samples were analyzed for AR, ERα and aromatase mRNA expression in HH and eugonadal diabetic males at baseline and after 26 weeks of testosterone administration in the HH group. AR expression was significantly lower in adipose tissue and MNC (by 27% and 25%, respectively; p<0.05) from HH patients compared to eugonadal T2DM patients (p<0.05). Testosterone administration in HH patients restored AR expression to that in eugonadal patients. The expression of ERα and aromatase in adipose tissue were also diminished in HH patients (by 29% and 33%, respectively, p<0.05) and they increased significantly to levels comparable to those in eugonadal T2DM patients (p<0.05). In the MNC, the expression of ERα was not different among eugonadal and hypogonadal men and did not change after testosterone treatment while aromatase expression was not detectable. We conclude that in HH patients there is a series of other defects including a diminution of AR, ERα and aromatase. Thus, not only do the HH patients suffer from the lack of testosterone, the ability to respond to testosterone is diminished. Similarly, the reduction of aromatase reduces the conversion of testosterone to estradiol, consistent with the observed reduction of estradiol in HH patients; this, in association with reduced ERα leads to a further reduction in estradiol effects. These novel observations are relevant to the pathogenesis and the treatment of insulin resistance, atherogenesis and possibly osteopenia in patients with HH.

 

Nothing to Disclose: MB, SSD, HG, SA, AM, AC, NDK, PD

15963 7.0000 SUN-0411 A Reduced Expression of Androgen and Estrogen Receptors and Aromatase in Patients with Hypogonadotropic Hypogonadism: Restoration Following Testosterone Administration 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Ping Gong*1, Zeynep Madak-Erdogan1, Jilong Li2, Jianlin Cheng3, Michael Greenlief2 and Benita S Katzenellenbogen1
1University of Illinois at Urbana-Champaign, Urbana, IL, 2University of Missouri, 3Universityo of Missouri

 

Botanical estrogens (BEs) are widely consumed by women as dietary supplements, but their activities, efficacies and safety are not fully understood. The aim of this study was to examine the genome-wide gene expression patterns (transcriptomes) of botanical estrogens (genistein, S-equol, liquiritigenin) and to compare their transcriptomes with each other and with that of estradiol (E2), in order to determine whether their activities were similar or different from each other and from the endogenously produced estrogen, estradiol.  Gene expression was examined by RNA-Seq in human breast cancer (MCF7) cells containing three different complements of estrogen receptors, estrogen receptor alpha only, estrogen receptors alpha plus beta, or estrogen receptor beta only, thereby mimicking the different ratios of these two receptors in different human breast cancers and in different estrogen target tissues. Cells containing each of these 3 complements of ERs were treated with control vehicle or botanical estrogen or E2 for 24h. We found that BEs up-regulated or down-regulated many of the same genes as did E2, but 25-40% of genes were uniquely regulated by BEs. Principal Component Analysis and other evaluations revealed that the overlap in regulated genes with E2 was greatest for the soy isoflavones genistein and S-equol, with the greatest difference from E2 in gene expression pattern being observed for the licorice root botanical estrogen liquiritigenin. The character of the ligand was found to depend on the cell background of ERs present, with the effects of BE and E2 depending critically on ERα and/or ERβ presence in the cell. However, the gene expression patterns of the 3 BEs more resembled each other than that of E2, even though genistein and S-equol clustered together more than they did with liquiritigenin or E2. The BEs and E2 regulated genes and signaling pathways controlling proliferation, antioxidant activities, anti-inflammatory activities, and cell motility. Notably, the BEs were less stimulatory of genes promoting proliferation and motility vs. E2, and were more pro-apoptotic in their gene regulations. Hence, the distinctive pattern of gene regulation by the individual BEs and E2 may underlie differences in their activities in estrogen target tissues containing different levels of the two ERs.

 

Nothing to Disclose: PG, ZM, JL, JC, MG, BSK

12892 8.0000 SUN-0412 A Transcriptome Analyses Reveal Distinct Patterns of Gene Regulation By Different Botanical Estrogens in Dietary Supplements 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Elliot R Cooper*1, Xiaohong Li1, Kristine McGrath1 and Alison Heather2
1University of Technology, Sydney, Australia, 2University of Otago, Dunedin, New Zealand

 

Nutritional sports supplements are often marketed to athletes claiming to help build lean muscle tissue, reduce body fat, and enhance endurance. The world-wide dietary supplement market is estimated to be worth $142.1 billion USD and is expected to reach $204.8 billion USD by 2017. The lack of good manufacturing practice and regulation in the production and sale of nutritional supplements has led to the covert fortifying of these supplements with anabolic steroids to better achieve the claimed benefits. It has been discovered that in some instances these additions are not declared on the product label. Therefore, the aim of the study was to screen a range of nutritional sports supplements from the Australian market for the presence of androgens using an in vitro yeast cell-based bioassay. Seventy four nutritional supplements were randomly purchased from Sydney-based stores that included protein powders, amino acids, creatines, fat metabolisers, ‘testosterone-boosters’, carbohydrates, and stimulant/nitric oxide ‘pre-workout’-based supplements. Steroid extracts were obtained using solid-phase extraction with a C18 column. The steroid extracts were then tested for androgenic activity using a yeast-based bioassay whereby Saccharomyces cerevisiae cells were co-transformed with a human androgen receptor (AR) expression vector and a β-galactosidase reporter vector under the control of tandem androgen response elements. Two supplements had relative potencies (RP) (defined as ‘extract receptor activity/receptor activity of testosterone (T)’) greater than T, 2.64 ± 0.33 (p-value 0.0197) and 7.20 ± 0.24 (p-value 0.0008), respectively. A third supplement had a RP less than, but not significantly different than,  T (0.79 ± 0.067, p-value 0.0504). Four supplements activated AR, however with lower RP values than T (supp. 4 RP = 0.21 ± 0.03, p-value 0.0066; supp. 5 RP = 0.43 ± 0.09, p-value 0.0162; supp. 6 RP = 0.27 ± 0.02, p-value 0.0053; and supp. 7 RP = 0.36 ± 0.04, p-value 0.0025). In summary, steroid extracts from 7 sports nutritional supplements from the Australian market had AR bioactivity, however, only 1 of these supplements declared the addition of an androgen.

 

Nothing to Disclose: ERC, XL, KM, AH

15386 9.0000 SUN-0413 A Steroidal Extracts from Nutritional Sports Supplements Sold in Australia Test Positive for Androgenic Activity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Nikolaou Nikolaos*1, Maryam Nasiri2, Laura Louise Gathercole1, Silvia Parajes1, Nils P. Krone3, George Valsamakis4, Georgios Mastorakos4 and Jeremy W Tomlinson1
1University of Birmingham, Birmingham, United Kingdom, 2University of Birmingham, 3University of Sheffile, Birmingham, United Kingdom, 4Athens Medical School, Athens, Greece

 

Non alcoholic fatty liver disease (NAFLD) is rapidly becoming the most common cause of hepatic dysfunction in the western world. It is a spectrum of disease, ranging from simple lipid accumulation within hepatocytes to steatohepatitis (NASH) with fibrosis and leading finally to cirrhosis and liver failure. Recent studies have shown an association between NAFLD and androgen deficiency, yet in the majority of patients with NASH, androgen levels are normal. In contrast, in patients with polycystic ovarian syndrome (PCOS) which is characterised by androgen excess, hepatic steatosis is prevalent. Our hypothesis is that androgen exposure may be a critical regulator of lipid flux within human hepatocytes.

C3A human hepatoma cells were cultured and treated with Testosterone [T] (5nM, 50nM) or the more potent androgen, Dihydrotestosterone [DHT] (1nM, 10nM) for 24h. Lipid accumulation was measured by C14 acetate incorporation and gene expression by real-time PCR. As an additional model of androgen excess, cells were transfected with an androgen receptor (AR) construct (pcDNA3.1+AR) or vector alone as a control.

FASN, ACC1, ACC2 and CPT1 mRNA expression was significantly increased after treatment with Testosterone in a dose-dependent manner (FASN: ctrl 13.9±2.0 vs. T 5nM 42.0±5.8 vs. T 50nM 60.4±3.3, ACC1: ctrl 1.1±0.3 vs. T 50nM 3.1±0.4, CPT1: ctrl 1.8±0.3 vs. T 50nM 4.2±0.9, p<0.05). Observations were similar following DHT treatment (FASN: ctrl 13.9±2.0 vs. DHT 1nM 60.6±11.0 vs. DHT 10nM 82.0±19.5, ACC1: ctrl 1.1±0.3 vs. DHT 10nM 4.5±1.1, ACC2: ctrl 0.5±0.1 vs. DHT 10nM 1.3±0.2, CPT1: ctrl 1.8±0.3 vs. DHT 1nM 3.3±0.1 vs. DHT 10nM 4.7±0.5, p<0.05). AR over-expression further increased lipid metabolism gene expression (FASN: ctrl 13.9±2.0 vs. AR 66.8±6.2, ACC1: ctrl 1.1±0.3 vs. AR 3.5±0.3, ACC2: ctrl 0.5±0.1 vs. AR 1.0±0.1, CPT1: ctrl 1.8±0.3 vs. AR 4.3±0.2, p<0.05). Changes in gene expression were paralleled by observations utilizing dynamic functional assays of lipid accumulation. Both Testosterone and DHT increased de novo lipogenesis and this was also increased following AR over-expression (ctrl 7002±259 vs. T 8748± 433, DHT 8970±330, AR 14193±755, p<0.05).

In conclusion, these data demonstrate that enhanced androgen action is able to stimulate lipid accumulation in human hepatocytes and this may be crucial in understanding the association between PCOS and NAFLD.

 

Nothing to Disclose: NN, MN, LLG, SP, NPK, GV, GM, JWT

15870 10.0000 SUN-0414 A Androgen Receptor Activation Stimulates Hepatic Lipid Accumulation in Human Hepatocytes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Ken-ichiro Takagi*1, Kyohei Horie1, Etsuko Fujita1, Michiharu Kageyama2, Shinnosuke Hosoda1, Hidekazu Watanabe1, Kousuke Sasaki1, Hiroyuki Sugiyama1, Yoshiaki Azuma1 and Tsuyoshi Kimura1
1Teijin Pharma Limited, Hino Tokyo, Japan, 2Teijin Pharma Limited

 

Androgens play vital roles in maintaining male phenotype. Steroidal androgens, such as Nandolone, oxandrolone and fluoxymesterone have beneficial effects on muscle and bone but are not widely used due to safety concerns. Selective androgen receptor modulators (SARMs) are androgen receptor (AR) ligands that induce anabolism while having reduced effects in reproductive tissues. We have identified different types of SARM with novel non-steroidal scaffold. TEI-SARM1 binds to AR with high affinity and exhibits high selectivity for androgen receptor. It showed strong transcriptional activity in HEK293 cells. TEI-SARM2 has excellent oral bioavailability and longer half-life in the blood at least than known SARMs including those under clinical trials. Anabolic activity and tissue selectivity of TEI-SARM2 were evaluated in castrated (ORX) rats by assessing the effects on the levator ani muscle (LA) and prostate. ORX rats were orally administrated TEI- SARM2 once, and then tissues were dissected and weighed 2 weeks later. Nandororone decanoate (ND) was used as a reference (once subcutaneous injection in oil).
In ORX rats, LA and prostate weight was decreased, and serum luteinizing hormone (LH) level was elevated. TEI- SARM2 treatment recovered LA weight to the level of that in sham-operated animals, while the influence on the prostate and serum LH were minimal. ND also increased LA weight without affecting prostate weight much. However, serum LH level was substantially suppressed. We conclude that TEI- SARM2 is a novel long-acting SARM. Its application to several disease conditions is expected by potent anabolic activity on muscle and bone, reduced androgenic side effects and hormonal perturbation, and improved dosing regimen (oral and lower frequency).

 

Nothing to Disclose: KIT, KH, EF, MK, SH, HW, KS, HS, YA, TK

14375 11.0000 SUN-0415 A Identification and Characterization of a Novel Long-Acting SARM 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Philip J Jensik*, Emily A. Perkins and Lydia A Arbogast
Southern Illinois University School of Medicine, Carbondale, IL

 

Progesterone and androgens may have physiological interactions in females and pathophysiological interactions in hyperandrogenic states.  These hormones can influence the activity of central catecholaminergic neurons, which have roles in diverse functions from reproduction to mental health.  We have previously shown that ligand-bound progesterone receptor (PR) B increases tyrosine hydroxylase (TH) promoter activity, whereas PRA has little influence but inhibits PRB-mediated transactivation.  Androgen receptor (AR) also increases TH promoter activity.  PR and AR actions map to the -1.6 to -1.3 kb region within the TH promoter.  The goal of this study was to determine the influence of PRA on AR-mediated transactivation of the TH promoter.  TH positive mouse neuronal CAD cells were transfected with -1.6 kb TH-LUC, -1.4 kb TH-LUC, 2xPRE-LUC, or Probasin-LUC promoter constructs with AR, and CMV-Renilla for 18 hours.  Cells were then treated with vehicle, 200 nM progesterone, 100 nM testosterone or both for 20 hours followed by dual luciferase assay.  Compared to vehicle, progesterone increased -1.4 and -1.6 kb TH promoter activity 1.5-2 fold.  Testosterone increased -1.4 and -1.6 kb TH promoter activity 2 and 3.5 fold, respectively.  In cells treated with both progesterone and testosterone, -1.4 and -1.6 kb TH promoter activity increased 4.5 and 6 fold, respectively.  Testosterone also increased both 2xPRE and probasin promoter activity, however progesterone co-treatment suppressed testosterone-induced transactivation of these promoters.  Cells were also treated with lower concentrations of progesterone (15 nM) and testosterone (15 nM).  At this concentration, progesterone had no effect on -1.4 kb TH promoter activity, and testosterone alone increased promoter activity 2 fold.  Co-treatment with both progesterone and testosterone further increased promoter activity to 3 fold.  Experiments were then performed using the progestin contraceptive norgestrel, which also has androgenic activity.  Cells were transfected with PRB, PRA, AR, or PRA with AR and were treated with vehicle, progesterone, or norgestrel.  Compared to vehicle, progesterone and norgestrel similarly increased TH- 1.6 kb promoter activity in cells transfected with PRB or PRA (5 and 1.5 fold, respectively).  In AR transfected cells, progesterone treatment had no effect, but norgestrel treatment increased promoter activity around 2.5 fold.  In cells transfected with both AR and PRA, progesterone had little effect on promoter activity but norgestrel increased promoter activity around 4 fold.  Taken together, these data indicate PRA increases AR-mediated TH promoter transactivation.  The stimulatory action of PRA on AR differs from both the inhibitory actions of PRA on AR-mediated transactivation of the 2xPRE and probasin promoters and also the inhibitory influence of PRA on PRB-mediated increases in TH promoter activity.

 

Nothing to Disclose: PJJ, EAP, LAA

16767 12.0000 SUN-0416 A Progesterone Receptor-Α Increases Androgen Receptor-Mediated Transactivation of the Tyrosine Hydroxylase Promoter 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Luca De Toni*1, Simone Tescari1, Diego Guidolin1, Giacomo Strapazzon2, Damiano Pizzol1, Vincenzo De Filippis1 and Carlo Foresta1
1University of Padova, Padova, Italy, 2EURAC Institute of Mountain Emergency Medicine, Bolzano, Italy

 

Testosterone (T) acts both through interactions with the nuclear receptor and through rapid, non-genomic pathway. The membrane-associated, G-protein coupled receptor GPRC6A has been suggested to represent the major effector of non-genomic actions of T.  GPRC6A is also the putative receptor for osteocalcin (OCN), a small protein from osteoblasts that modulates many metabolic and hormonal processes. Recent findings from our group showed that different degrees of γ-carboxylation of OCN significantly influence the affinity of OCN for Ca2+ and therefore the conformational status of the protein, justifying the major biological activity of the γ-carboxylated form. Androgens and OCN have strong chemical differences; therefore it could be hypothesized that the non-genomic effects of T on GPRC6A could be mediated by the T-SHBG complex. By a docking computational analysis on GPRC6A, we identified three peptide sequences on SHBG sequence that could represent candidates for being ligands of GPRC6A. Only the sequence corresponding to residues 145-161 had a significant OCN-decarboxylated similar structure. The data have been confirmed experimentally by displacing assays in cell models expressing GPRC6A. In fact, the incubation with an excess of SHBG induced a significant reduction of 37% and 85% in the signal for the carboxylated and decarboxylated OCN, respectively. Finally, the peptide 145-161 of SHBG has been in vitro synthetized, FITC-conjugated and evaluated for a possible binding on MA-10 murine Leydig cells, which express a functional GPRC6A. We observed a specific staining at the cell membrane and the incubation with an excess of non carboxylated-OCN led to a significant signal reduction. Furthermore, the quantification of T in the culture medium showed an increase in T production after stimulation with the peptide with respect to control. Ongoing studies are evaluating the effects of the 145-161 peptide of SHBG in cells and tissues expressing GPRC6A.

 

Nothing to Disclose: LD, ST, DG, GS, DP, VD, CF

16673 14.0000 SUN-0418 A Computational and Experimental Approach to Study the Interaction Between Human Osteocalcin, SHBG and GPRC6A 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Jana Malikova*1, Nuria Camats2, Mónica Fernández-Cancio3, Pilar Andaluz3, Laura Audí3 and Christa E Flueck4
12nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic, Prague 5, Czech Republic, 2University Children's Hospital Bern, Bern, Switzerland, 3Hospital Universitari Vall d'Hebrón, Barcelona, Spain, 4Pediatric Endocrinology and Diabetology, Bern, Switzerland

 

Steroidogenic factor 1 (NR5A1/SF-1) regulates adrenal and sex development and function. Patients with NR5A1 mutations present with disorders of sex development (DSD, 46,XY), ovarian insufficiency (46,XX) and rarely with adrenal insufficiency. Role of SF-1 deficiency in obesity has been described in mice. Brain-derived neurotrophic factor (BDNF) is important for central regulation of food intake and is linked to mouse and human obesity. Both genes are expressed in the hypothalamus of mouse and man.

            We hypothesized that human NR5A1 mutations may affect the metabolism and that this effect could be mediated in part through BDNF. Therefore, we performed in vitro functional studies and compared biometrical data of patients to study the relationship among SF-1, BDNF and obesity.

            Five 46,XY DSD patients from 4 families, one presenting adrenal insufficiency, were analysed for NR5A1 mutations. The detected mutations were analysed by checking their ability to activate 3 target steroidogenic enzymes (CYP17A1, CYP11A1, HSD3B2) in HEK293 cells. For the SF-1-BDNF study, we assessed the activity of SF-1 mutants on a human BDNF (hBDNF) promoter luciferase reporter construct in JEG3 cells. We also obtained metabolic parameters of 16 individuals harboring heterozygote NR5A1 mutations.

            Three NR5A1 (G7X, R313C and H408Pfs*159) mutations and 1 variant (T296M) were detected. Two of them were novel mutations: G7X and H408Pfs*159. The 46,XY DSD patient with adrenal insufficiency was compound heterozygote for G7X and T296M. R313C, located in a hot spot for NR5A1 mutations, was present in several patients and families with hypospadias. Promoter transactivation assays showed that all 3 mutations had significantly reduced transactivation activity on steroidogenic promoters whereas the variant was similar to the wild-type (WT).These results confirm that G7X, in the DNA binding domain, is a severe NR5A1 mutation which causes adrenal insufficiency and DSD.

            In the SF-1-BDNF study, all 3 mutants had significantly reduced transactivation activity on the hBDNF promoter I, whereas the variant was again comparable to the WT. This shows that SF-1 regulates human BDNF promoter I activity in vitro (which is thought to be associated with obesity), and that SF-1 mutations cause decreased promoter activation. Despite these results, clinical data of the subjects did not reveal a high obesity rate in our young, small population.

 

Nothing to Disclose: JM, NC, MF, PA, LA, CEF

13453 15.0000 SUN-0419 A New Insight into SF-1 Mutations and Possible Relationship to Obesity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Lisa Kate Philp*, Tanya K Day, Miriam S Butler, Shalini Jindal, Lisa Maree Butler and Wayne D Tilley
University of Adelaide, Adelaide, Australia

 

Small glutamine-rich tetratricopeptide repeat-containing protein α (SGTA) is an androgen receptor (AR) cochaperone which prevents nuclear translocation and activation of the AR until it is ligand-bound. In addition, SGTA binds to other growth mediators such as the growth hormone receptor (GHR) and myostatin. In vitro SGTA knockdown elicits mitotic arrest, but in vivo confers no abnormal phenotype in worm, yeast or fly. Here we aimed to determine the physiological effects of global Sgta ablation by Cre-lox gene deletion in C57BL/6 mice. Fertile Sgta+/- mice generated viable Sgta-/- offspring, but at less than Mendelian distribution (P=0.095). Sgta-/- exhibited significantly lower body weights and body length in both sexes (vs WT, Sgta+/- P<0.01). Body weight changes were observed from day 7 of age and were not a result of altered food intake. Gross muscle mass was reduced in Sgta-/- male and females (vs Sgta+/- M&F P<0.05), as tibialis, gastrocnemius and soleus masses were all decreased. Female, but not male, Sgta-/- mice had decreased white fat, as mesenteric fat was less (P<0.01); and femur mass was lower (P<0.05) than heterozygous littermates. Vital and visceral organs had normal morphology and histology. Sgta-/- mice, bred to assess fecundity, were subfertile, tending to have smaller litters and less live births (P≤0.13) while neonate death was markedly increased (P<0.01). Female sex organ morphology and histology was normal in Sgta-/- mice, although ovarian mass was decreased vs WT, despite all normal stages of follicular development being detected. Male contribution to subfertility is unknown, but Sgta-/- males were not effeminate, morphology and histology of sex organs was normal, and sperm was detected. Altogether, full, but not partial, SGTA ablation limits growth and fertility of mice in vivo. While myostatin defects may confer lower muscle mass, limited body and organ growth also implicates GHR-mediated defects, while the normal sex organ development observed infers intact AR signaling.

 

Nothing to Disclose: LKP, TKD, MSB, SJ, LMB, WDT

16733 16.0000 SUN-0420 A Full, but Not Partial, Sgta Ablation Confers Subfertility and Limits Offspring Viability and Growth in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Michael A Pearen*, Joel M Goode, Kelvin Z Tuong, Rebecca Lee Fitzsimmons, Emily Shao and George E.O. Muscat
The University of Queensland, Brisbane, Australia

 

Nor-1/NR4A3 is a member of the orphan nuclear receptor 4A (NR4A) subgroup. We have previously identified Nor-1 as a regulator of oxidative metabolism in cultured skeletal muscle cells (1,2). More recently we have developed a mouse line that over-expresses activated Nor-1 in skeletal muscle. This transgenic mouse line displays a transition towards a type IIX oxidative skeletal muscle fiber type, increased mitochondrial number, enhanced oxygen consumption, enhanced endurance (and glycogen accumulation), significantly improved glucose tolerance, and decreased body adiposity (3,4). Furthermore, we have identified increased expression of multiple genes involved in glycolysis, the tricarboxylic acid cycle, oxidative phosphorylation, fatty acid oxidation, and the malate-aspartate shuttle (4). In the current study we report that further characterization of the Nor-1 transgenic mouse has revealed that these mice display skeletal muscle hypertrophy and increased skeletal muscle vascularization. At the molecular level, these changes appear driven by myostatin/SMAD signaling and VEGF signaling pathways respectively. In general, the changes observed in the Nor-1 transgenic mouse line mimic the phenotypic and molecular changes observed following exercise, suggesting that Nor-1 mediates exercise signaling. In this context, we have shown that Nor-1 mRNA expression is induced following exercise and that this induction is dependent on the calcium/calcineurin signaling cascade.

 

Nothing to Disclose: MAP, JMG, KZT, RLF, ES, GEOM

16539 17.0000 SUN-0421 A The Orphan Nuclear Receptor Nor-1/NR4A3 Is Involved in Exercise-Dependent Signaling and Phenotypes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Barbara J Clark*1, Syed J Khundmiri1, Eleanor D Lederer2, Matt Cave3 and Banrida Wahlang4
1Univ of Louisville School of Medicine, Louisville, KY, 2Veterans Administration Medical Center, Louisville, KY, 3University of Louisville School of Medicine, Louisville, KY, 4University of Louisville, Louisville, KY

 

The nuclear receptor FXR has been proposed to play a protective role in the kidney, with FXR null mice displaying increased susceptibility to STZ-induced renal lipid dysregulation and diabetic nephropathy.  STARD5 is a soluble sterol transport protein that we previously reported to be specifically localized in the proximal tubules of the kidney and showed that expression was increased in kidneys from diabetic mice.  Recent reports revealed that STARD5 preferentially binds primary bile acids that are ligands for FXR.  Herein we examined whether STARD5 may serve as a bile acid sensor in kidney by measuring FXR-dependent transcriptional responses and how STARD5 modulates FXR transcriptional activity.  HKC-8 human proximal tubule cells were co-transfected with a FXRE-luciferase reporter and a human FXR expression plasmid and treated with chenodeoxycholic acid (CDCA) for 24 h.  A dose-dependent increase in FXRE-luciferase reporter gene activity was observed with the maximal increase detected at 25 mM CDCA.  siRNA silencing of STARD5 resulted in a 2-fold increase in CDCA-stimulated FXRE- luciferase reporter gene activity, suggesting STARD5 may suppress FXR-mediated responses, perhaps by sequestering CDCA.  We also investigated STARD5 expression in the small intestine as this is a major site of bile acid-FXR activity.  Immunohistochemistry and qRT-PCR data show that STARD5 is expressed in the small intestine of the rat and mouse.  C57BL6/J mice fed a high fat diet (HFD) for 12 weeks had elevated ABCA1 and FGF15 mRNA levels in the ileum while FXR and STARD5 levels remained unchanged.  FGF15 is a FXR target gene, indicating activation of FXR by the HFD.  Given that loss of STARD5 expression increased CDCA-stimulated FXR activation in HKC-8 cells, we propose that a decrease in the STARD5: FXR ratio in the intestine would enhance the FXR-FGF15 signaling pathway and reduce hepatic bile acid levels.

 

Nothing to Disclose: BJC, SJK, EDL, MC, BW

16404 18.0000 SUN-0422 A FXR Activation Is Suppressed By STARD5 in Hkc-8 Human Renal Proximal Tubule Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Sayeepriyadarshini Anakk*1 and Phil VanDuyne2
1University of Illinois, Urbana, IL, 2University of Illinois at Urbana- Champaign

 

Lipids play a crucial role in the development of obesity, diabetes and fatty liver. Nuclear receptors Farnesoid X Receptor (Fxr) and Small Heterodimer Partner (Shp) regulate cholesterol, bile acid, lipid and glucose homeostasis. Although, combined loss of Fxr and Shp led to excessive bile acid overload it protected these mice against metabolic dysfunction. Here we report that when challenged with 45% high fat diet, Fxr; Shp double knockout mice gained 70% less weight than the wild type animals and were protected against glucose intolerance. Further Fxr; Shp double knockout mice displayed increased fatty acid oxidation, increased adiponectin, decreased leptin and increased in vivo lipolysis, which clearly substantiate the dramatic decrease in the amount of visceral fat observed in these mice compared to wild type animals. This metabolically beneficial lean phenotype could be resultant of either loss of Fxr and Shp or subsequent to increase in bile acid levels. Currently, we are focusing on characterizing if and how increase in bile acid concentration regulates lipid droplet size and overall lipid metabolism. These findings may lead to potential targets for treating obesity and diabetes.

 

Nothing to Disclose: SA, PV

15057 19.0000 SUN-0423 A Combined Genetic Ablation of Fxr and Shp Protects Mice Against Obesity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Stéphanie Bilodeau*1, Amelie C Rodrigue-Way2, Véronique Caron2, Sarah Keil2, Emile Lévy2, Grant Mitchell2 and Andre Tremblay3
1Ste-Justine Hospital Research center - dpt Biochemistry Université de Montréal, Montréal, QC, Canada, 2Ste-Justine Hospital Research Center, Montréal, QC, Canada, 3Ste Justine Hosp-Univ of Montr, Montreal, QC, Canada

 

Metabolic syndrome is characterized by abdominal obesity, insulin resistance, and atherogenic dyslipidemias which increase the risk of cardiovascular diseases. Scavenger receptor CD36 is known to play a central role in lipid metabolism by promoting macrophage cholesterol efflux with potential to reduce atherosclerotic lesions. However, the role of CD36 on cholesterol de novo synthesis is not known. In this study, we describe the cellular mechanism by which CD36 activation exerts cholesterol depletion in HepG2 cells. Using CD36 ligand hexarelin, we found a rapid phosphorylation of HMG-CoA reductase Ser-872 in treated cells, resulting in inactivation of the rate-limiting enzyme in sterol synthesis. Proteasome-dependent degradation of HMG-CoA reductase was also induced through an increased recruitment of anchor proteins Insig-1 and Insig-2. Genes encoding key enzymes involved in cholesterol synthesis and under the control of transcription factor SREBP-2 remained unresponsive to the sterol depletion, due to retention of SREBP-2 escort protein Scap by Insig-1/2. Expression of Insig1 and Insig2genes was also increased with activation of nuclear receptor PPARγ by CD36. Recruitment of coactivator PGC-1a to activated AMPKα was also promoted, resulting in PGC-1α transcriptional activation through Sirt1-mediated deacetylation, increased recruitment of PPARγ, and upregulation of Insig-1/2. Our results reveal a regulatory role of CD36 on PGC-1α signaling and identify CD36 as a novel regulator of HMG-CoA reductase function and Insig-1/2 expression, two critical steps regulating cholesterol synthesis in hepatocytes.

 

Nothing to Disclose: SB, ACR, VC, SK, EL, GM, AT

15419 20.0000 SUN-0424 A Scavenger Receptor CD36 Regulates HMG-CoA Reductase and Insig-1/2 through a PPARγ /PGC-1α Pathway in Hepatocytes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Chihiro Ebihara*1, Ken Ebihara2, Megumi Aizawa Abe2, Yuji Yamamoto1, Sachiko Yamamoto Kataoka1, Mingming Zhao1, Valentino Milton Gumbilai1, Kiminori Hosoda2 and Kazuwa Nakao3
1Kyoto University Graduate School of Medicine, Kyoto, Japan, 2Kyoto University Hospital, Kyoto, Japan, 3Medical Innovation Center, Kyoto, Japan

 

Development of exquisite animal models for human diseases is essential in promoting translational medicine. However, it is critical to consider species differences in translating the findings of disease-model animals into human pathophysiology. Although much has been learned from mouse models, some flaws have been noted in mice as animal models for human obesity related diseases. While it has been reported that thiazolidinediones (TZDs) improve fatty liver in human, TZDs aggravate fatty liver in mice. To explore the mechanism by which TZDs exert differential effects between species, we treated genetically obese, leptin deficient ob/ob mice and Lepmkyo/Lepmkyo rats (Physiol Genomics 2013) with rosiglitazone or pioglitazone for 4 weeks. We also treated generalized lipodystrophy models, A-ZIP/F-1 mice and seipin KO rats (in submission). Both TZDs upregulated hepatic PPARg mRNA expression and aggravated fatty liver in ob/ob and A-ZIP/F-1 mice. On the other hand, TZDs did not affect hepatic PPARg mRNA expression in Lepmkyo/Lepmkyo and seipin KO rats. However, TZDs improved fatty liver in Lepmkyo/Lepmkyo rats while fatty liver in seipin KO rats was unchanged by TZDs. Furthermore, TZDs improved insulin sensitivity in ob/ob and A-ZIP/F-1 mice without the change of adiposity. On the other hand, TZDs improved insulin sensitivity in Lepmkyo/Lepmkyo rats accompanied by the increase of adiposity but did not in seipin KO rats. Taking the fact that TZDs generally improve fatty liver and increase adiposity in human patients, the present study indicates that TZDs improve fatty liver through adipose tissue and that adipose tissue is required for metabolic effects of TZDs in rats and humans.

 

Nothing to Disclose: CE, KE, MAA, YY, SYK, MZ, VMG, KH, KN

16334 22.0000 SUN-0426 A Improvement Effect of Thiazolidine on Fatty Liver and Type 2 Diabetes Requires Adipose Tissue: An Evidence from the Comparison Between Mice and Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Kelly T Dineley1, Jordan Jahrling1, Caternina Hernandez1, Raj Kumar2 and Larry Denner*3
1University of Texas Medical Branch, 2The Commonwealth Medical College, Scranton, PA, 3University of Texas Medical Branch, Galveston, TX

 

Hippocamapal cognitive impairment is a quintessential feature of Alzheimer’s disease (AD) and AD mouse models. The peroxisome-proliferator activated receptor gamma (PPARγ) agonist rosiglitazone improves hippocampus-dependent cognitive deficits in some AD patients and ameliorates deficits in the Tg2576 transgenic AD mouse model. Tg2576 cognitive enhancement occurs through the induction of a gene and protein expression profile reflecting convergence of the PPARγ signaling axis and the extracellular signal-regulated mitogen-activated protein kinase (ERK) cascade, a critical mediator of memory consolidation. We therefore tested whether PPARγ and ERK associated in protein complexes that subserve cognitive enhancement through PPARγ agonism. Co-immunoprecipitation of hippocampal extracts revealed that PPARγ and active ERK (pERK) associated in Tg2576 in vivo, and that PPARγ agonism facilitated recruitment of PPARγ to pERK during memory consolidation. These complexes are critical to consolidation since acute PPARγ antagonism, which blocks RSG memory enhancement, blocks the learning-induced increase in complexes. Furthermore, the amount of PPARγ recruited to pERK correlated with cognitive reserve in humans with AD and in Tg2576. We also found these proteins have intrinsic association properties since recombinant GST-pERK, but not unphosphorylated GST-ERK, bound recombinant PPARγ in an in vitro glutathione bead pull-down assay. Using far-UV circular dichroism, we found increase α-helical content in the binary complexes, potentially through structural stabilization of the intrinsically disordered N-terminal domain of PPARγ. Finally, partial proteolysis showed that both proteins undergo structural perturbations when complexed together compared to the individual proteins in solution. Our findings implicate a previously unidentified dynamic multiprotein complex that provides a molecular mechanism for the convergence of the PPARγ and pERK pathways during cognitive enhancement, thereby offering new targets for therapeutic development in AD.

 

Nothing to Disclose: KTD, JJ, CH, RK, LD

16973 23.0000 SUN-0427 A Pparã Recruitment to Active ERK during Memory Consolidation Is Required for Alzheimer's Disease-Related Cognitive Enhancement 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Laura Ann Bienvenu*1, Melissa Reichelt2, James Morgan1, Lea M.D Delbridge2 and Morag Jennifer Young3
1MIMR-PHI Institute of Medical Research, Melbourne, Australia, 2University of Melbourne, Melbourne, Australia, 3Hudson Institute of Medical Research, Melbourne, Australia

 

Cardiomyocyte mineralocorticoid receptor (MR) activation is involved in the development of cardiovascular disease. A number of important cell-specific roles for the MR signaling in driving cardiac pathology have now been described. Recent experimental studies have demonstrated that cardiomyocyte specific deletion of MR can ameliorate cardiac fibrotic and inflammatory responses induced by excess mineralocorticoids or tissue injury. Experimental and clinical evidence also suggests that sex differences observed in heart failure may have an MR-dependent mechanism. The sex specific role of cardiomyocyte MR in ischemia/reperfusion injury and recovery is unknown. To study the role of cardiomyocyte MR in cardiac function, male and female, wild type (WT) and cardiomyocyte MR knockout (myo-MRKO) mice (8 weeks of age) underwent uninephrectomy and were maintained on either (i) high salt (VEH: 0.9% NaCl, 0.4% KCl) or (ii) high salt plus deoxycorticosterone pellet (DOC: 0.3mg/day, 0.9% NaCl, 0.4% KCl). Following 8 weeks of treatment hearts were Langendorff-perfused, subjected to 20 minutes global ischemia and 45 minutes reperfusion (n=7-9 per group). Basal cardiac function was equivalent between all groups demonstrating that, under basal conditions, loss of cardiomyocyte MR signaling and mineralocorticoid status does not alter cardiac function regardless of sex and genotype. However, recovery of left ventricular developed pressure (LVDevP) post-ischemia/reperfusion was greater in male myo-MRKO hearts compared to WT (% basal LVDevP: male WT; VEH: 73±5 mmHg, DOC: 78±2 mmHg vs, male myo-MRKO; VEH: 88±6 mmHg, DOC: 90±3 mmHg, p<0.05) and female myo-MRKO hearts compared to WT (% basal LVDevP: female WT; VEH: 66±9 mmHg, DOC: 69±7 mmHg vs female myo-MRKO; VEH: 86±5 mmHg, DOC: 85±5 mmHg, p<0.05). During ischemia, mineralocorticoid excess increased peak contracture in male hearts regardless of genotype (male VEH; WT: 35±8 mmHg, myo-MRKO: 46±4 mmHg vs male DOC; WT:53±4mmHg, myo-MRKO: 53±4 mmHg, p<0.05). Interestingly, selective deletion of cardiomyocyte MR reduced peak contracture in female hearts even in the presence of excess mineralocorticoids (female WT; VEH: 35±5 mmHg, DOC: 42±3 mmHg vs female myo-MRKO; VEH: 22±4 mmHg, DOC: 33±6 mmHg, p<0.05). These data demonstrate that after acute ischemia/reperfusion, activation of cardiomyocyte MR reduces cardiac functional recovery in both sexes. During the ischemic period mineralocorticoid status modulated peak ischemic injury in male hearts; whereas in female hearts it appears that MR activation is critical for peak ischemic injury. This study highlights the critical role cardiomyocyte MR plays in sex-specific ischemic injury as well as cardiac function post-ischemia/reperfusion and provides evidence for the development of cardiac-and/or sex-specific MR therapies.

 

Nothing to Disclose: LAB, MR, JM, LMDD, MJY

16578 24.0000 SUN-0428 A Cardiomyocyte Mineralocorticoid Receptor Signaling Impairs Cardiac Functional Recovery Post Ischemia/Reperfusion and Modulates Sex-Specific Ischemic Injury Responses 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Timothy James Cole*1, Luke R Terella2, Morag Jennifer Young3 and Peter J Fuller4
1Monash University, Melbourne, Australia, 2Monash University, 3Prince Henry's Institute of Medical Research, Clayton VIC, Australia, 4MIMR-PHI Institute and Monash University, Clayton VIC, Australia

 

The mineralocorticoid receptor (MR) is unique amongst the steroid hormone receptors in that it has two physiological ligands, aldosterone and cortisol/ corticosterone. The classic role of MR is to promote ion/water homeostasis in epithelial tissues (kidney/colon) in response to aldosterone. The roles of the MR in non-epithelial tissues such as brain, fat and heart are not well defined and may reflect cortisol signaling. Given that the relative importance of key transcriptional mechanisms of action of the MR (classical genomic signaling via a hormone response element or transrepression of other transcription factors) or non-genomic signalling in specific tissues are not clear, the goal of the present study was to separate the functional role of classic genomic signaling, mediated by DNA-binding, from these other signaling mechanisms. We therefore generated mice containing a mutation, C603S which precludes DNA-binding by the MR (1), using gene-targeting. 50% of MRC603S mutant mice die at birth with the remainder failing to thrive, losing weight and dying between days 10-13, similar to mice with a complete null mutation for the MR gene (2). Renal expression of C603S MR mRNA and cellular localization of C603S MR by immunohistochemistry was equivalent to WT MR in day 7 postnatal kidneys with unexpected reduced expression of renin mRNA. Kidney mRNA from day 7 C603S mutant mice and littermate controls was subjected to microarray analysis. C603S MR mutant mice were rescued by twice daily 0.9% saline injections until weaning and thereafter with saline to drink. Mutant mice analysed at 4-5 weeks of age were 20-30% lighter than littermate controls and showed strikingly reduced adiposity. This unique mouse model for the MR demonstrates that DNA-binding is essential for the epithelial MR response and will provide the basis for analysis of non-classical signaling of the MR in non-epithelial tissues.

 

Nothing to Disclose: TJC, LRT, MJY, PJF

15594 25.0000 SUN-0429 A A C603S DNA-Binding Domain Mutation of the Mouse Mineralocorticoid Receptor in Vivo Cause Postnatal Renal and Adipose Deficits 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Jesus Banuelos*, SoonCheon Shin and Nick Z Lu
Northwestern University, Chicago, IL

 

Glucocorticoids are used in the treatment of a variety of diseases including inflammatory disorders and cancer although glucocorticoid resistance limits their benefits in subsets of patients.  We found that EL4 cells, a mouse thymoma cell line, harbored a point mutation in their glucocorticoid receptor (GR) gene and determined whether the mutant GR underlies glucocorticoid resistance. Western blot analyses showed that the expression level of total GR protein was comparable among EL4 cells and glucocorticoid-sensitive primary T cells and T cell lines. EL4 cells, in contrast to other cells tested, were resistant to glucocorticoid-mediated gene regulation. In the absence of ligands, the GR in EL4 cells localized predominantly in the cytoplasm and upon dexamethasone treatment underwent nuclear translocation, suggesting the ligand binding ability of the GR was intact. By sequencing the GR cDNA generated from the EL4 cells, we found that arginine 493 was mutated to a cysteine. Allelic discrimination analyses revealed that the R493C mutation occurred on both alleles. This conserved arginine residue adjacent to the second zinc finger in the DNA-binding domain is also mutated in human GR (R477H) in the glucocorticoid-resistant Jurkat leukemia cells. In transient transfection assays, the R493C mutant could not transactivate the MMTV-luciferase reporter. Site-directed mutagenesis to revert the R493C mutation restored the transactivation activity. Cotransfection experiments showed that the R493C mutant did not inhibit the activities of the wild-type GR. In addition, the transrepression activity of the GR was blunted by the R493C mutation as the mutant GR did not repress either the AP-1 or NF-kappaB reporters as effectively as wild-type GR. Furthermore, ectopic expression of the wild-type GR in the EL4 cells enabled glucocorticoid-mediated gene regulation (e.g., Bim). Thus, the conserved arginine in the DNA binding domain of the GR is necessary for the transcriptional activity of the GR and a hot spot for mutations that result in glucocorticoid resistance in both human and mouse leukemia cells.

 

Nothing to Disclose: JB, SS, NZL

17019 26.0000 SUN-0430 A A Hot Spot in the Glucocorticoid Receptor DNA-Binding Domain Susceptible to Loss of Function Mutation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Qiong Deng* and Greti Aguilera
National Institute of Child Health and Human Development, Bethesda, MD

 

Recent evidence suggests that rapid glucocorticoid feedback on HPA axis activity depends on ligand-induced association of the classical glucocorticoid receptor (GR) to membrane fractions. Membrane association of the estrogen receptor (ER) is known to involve palmitoylation of a cystein located within a 14 amino acid highly conserved region in the ligand binding domain of a number of steroid receptors. To determine whether a similar mechanism applies to the GR, we examined GR palmitoylation and corticosterone-induced GR trafficking of EGFP-rat GR constructs bearing mutations cysteine 686 to alanine (C683A GR), and leucines 687 to 690 to alanine (L687-690A GR) after transfection in the hypothalamic cell line, 4B.  GR immunoprecipitation in 4B cells preloaded with [3H] or [14C]palmitic acid, revealed marked immunoreactive GR by western blot but no corresponding autoradiographic bands, suggesting lack of GR palmitoylation.  Mutation of C683A, corresponding to the palmitoylation site of the ER, had no effect on corticosterone-induced membrane or nuclear localization of GR but L687-690A mutant GR remained in the cytoplasm following corticosterone exposure and was not found in membrane or nuclear fractions.  The lack of GR trafficking of this mutant was due to totally impaired ligand binding as shown by binding of [3H] dexamethasone to cytosolic proteins of Cos-7 cells transfected with wild type and mutant GR constructs. Concomitantly, western blot following GR immunoprecipitation showed decreased co-immunoprecipitation of heat shock protein 90 (HSP-90) in cell proteins from cells transfected with L687-690A GR compared with wild type. The data demonstrate that the leucine repeat, 687-690, plays a critical role in determining a GR conformation compatible with ligand binding and association with HSP90.

 

Nothing to Disclose: QD, GA

15424 28.0000 SUN-0432 A Leucine Repeat 687 to 690 of the Glucocorticoid Receptor (GR) Is Essential for Ligand Binding and GR Interaction with Heat Shock Protein 90 (HSP90) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Shigeru Suzuki* and Tomoshige Kino
NICHD/NIH, Bethesda, MD

 

Glucocorticoids have diverse actions on many important biological activities, such as intermediary metabolism in the liver, muscle and adipose tissues, by influencing metabolism of glucose, fatty acids, cholesterol and amino acids, whereas they also influence strongly the activity of the immune system. These actions of circulating glucocorticoids are transmitted to the nucleus of cells by an intracellular receptor molecule, the glucocorticoid receptor (GR). Glucocorticoid-bound GR in the nucleus regulates transcriptional activity of glucocorticoid-responsive genes through communication with cofactors, which attract other transcription factors/cofactors and the general transcription complex to DNA and change their accessibility to chromatin through enzymatic activities, such as acetylation and methylation of histone tails. We previously reported that the circadian transcriptional factor CLOCK acetylates GR and represses GR-induced transcriptional activity (1). The sirtuin family protein SIRT1 is a NAD(+)-dependent class III histone deacetylase and plays a key role in longevity, intermediary metabolism and regulation of circadian rhythms. SIRT1 deacetylates CLOCK and some nuclear receptors, and modulates their transcriptional activity. In this study, we examined the effect of SIRT1 on GR-mediated transcriptional activity. We found that knockdown of SIRT1 with its siRNA decreased dexamethasone-stimulated mRNA expression of the endogenous, glucocorticoid-responsive glucocorticoid-induced leucine zipper (GILZ) gene in HeLa and HepG2 cells (49 and 33% decrease, respectively), while overexpression of SIRT1 with its expression vector increased dexamethasone-stimulated GILZ mRNA expression in SIRT1-defective rat hepatoma HTC cells (57% increase). Interestingly, overexpression of a SIRT1 mutant defective in its deacetylase activity (H363Y) also enhanced GILZ mRNA expression (81% increase). Further, wild type or H363Y mutant SIRT1 overexpression both enhanced GR-induced transcriptional activity of the glucocorticoid-responsive mouse mammary tumor virus (MMTV) promoter in transient transfection-based reporter assays using HTC cells (70 and 58% increase, respectively) or HepG2 cells (104 and 154% increase). In a GST pull-down assay employing bacteria-produced GST-SIRT1 or GST-GR fusions, SIRT1 interacted with the DNA-binding domain of GR through its N-terminal portion enclosed in its amino acids 117-222 and its C-terminal portion spanning its amino acids 625-747. Taken together, these results suggest that SIRT1 directly interacts with GR and positively regulates its transcriptional activity in its deacetylase activity-independent fashion. Thus, SIRT1 is a coactivator of GR and possibly mediates its biological effects on longevity, intermediary metabolism and/or circadian rhythms to the transcriptome responsive to glucocorticoids/GR.

 

Nothing to Disclose: SS, TK

14833 29.0000 SUN-0433 A Sirt1 Enhances the Transcriptional Activity of the Glucocorticoid Receptor in Its Deacetylase Activity-Independent Fashion 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Anna Klopot1, Gleb Baida1, Pankaj Bhalla2, Guy Haegeman*3 and Irina Budunova1
1Northwestern University, Chicago, IL, 2Northwestern university, Chicago, IL, 3Ghent University, Gent, Belgium

 

Glucocorticoids are effective anti-inflammatory drugs widely used in dermatology. However, they induce serious adverse effects, including skin atrophy.  Glucocorticoids act via the glucocorticoid receptor (GR), a transcription factor that causes either gene activation, by binding as a homodimer to gene promoter, or transrepression (TR), via diverse mechanisms including negative interaction between monomeric GR and other transcription factors. As GR dimerization and transactivation are important for metabolic side effects of glucocorticoids, GR ligands that do not support dimerization have the potential for an improved benefit/risk profile. Compound A (CpdA) is a novel non-steroidal GR ligand that does not promote GR dimerization, retains anti-inflammatory potential, but induces fewer metabolic side effects compared to classical glucocorticoids. The topical effects of CpdA have not been well studied.  We report here that in mouse keratinocytes, CpdA did not activate GR-dependent genes, but mimicked closely the inhibitory effect of glucocorticoids on the expression of inflammatory cytokines and matrix metalloproteinases. When applied topically to the skin of mice, CpdA inhibited skin inflammation and hyperplasia induced by contact irritant 12-O-tetradecanoyl-phorbol-acetate. Unlike glucocorticoids, CpdA itself did not induce epidermal and subcutaneous fat atrophy which correlated with lack of induction of REDD1 (regulated in development and DNA damage response 1) ?,a new marker of steroid-induced skin atrophy. Overall, our results suggest that CpdA and its derivatives represent novel promising class of anti-inflammatory compounds with reduced topical side effects.

 

Nothing to Disclose: AK, GB, PB, GH, IB

12207 30.0000 SUN-0434 A Selective Activator of the Glucocorticoid Receptor (GR), Compound a, Dissociates Anti-Inflammatory and Atrophogenic Effects of GR Signaling in Skin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Nina M Patrick*1, Vineela Kadiyala1, Rosa Jaime-Frias1 and Catharine Lynn Smith2
1University of Arizona, 2Univ of Arizona, Tucson, AZ

 

Lysine deacetylases (KDACs) are known targets of a group of drugs being evaluated in clinical trials for use in the treatment of cancer and other diseases. It is essential to understand the role of KDACs in signaling and transcription to reveal the full cellular effects of KDAC inhibitors. The glucocorticoid receptor (GR) and other non-histone proteins are known to associate with class I and II KDACs but their role in GR action is largely undefined. We have recently shown that KDAC1, either alone or in cooperation with KDAC2, facilitates GR transactivation at 50% of glucocorticoid-activated genes in a hepatoma cell line [Kadiyala et al. (2013) J. Biol. Chem. 288, 28900-912].  The goals of the current study are to identify the KDAC complexes involved and define the mechanism by which KDACs cooperate with GR to activate transcription.  Because KDACs 1 and 2 are thought to be functionally-redundant, it is surprising that they do not play equivalent roles in GR transactivation.  Thus, we are investigating their interactions and the composition of their complexes in our hepatoma cell line.  The results show that KDACs 1 and 2 do interact but that there are distinct complexes that only contain KDAC2.  ChIP assays are being used to define the mechanism by which KDAC1 facilitates GR transactivation.  Additionally, we are focusing on the potential role of SRC (steroid receptor coactivators) acetylation on GR mediated transcription.  The p160 family of steroid receptor coactivators (SRC-1, SRC-2, and SRC-3), have been shown to promote nuclear receptor activity and are required for optimal receptor activation.  Acetylation of SRC proteins has been documented to inhibit their interaction with the estrogen receptor.  Therefore, current studies are focused on investigating SRC association with GR transcription complexes at target genes in the presence and absence of KDAC inhibitors and the effects of SRC knockdown on GR transactivation at target genes that are impaired in the presence of VPA.

 

Nothing to Disclose: NMP, VK, RJ, CLS

15257 31.0000 SUN-0435 A Defining the Role of Lysine Deacetylases in Glucocorticoid Receptor Mediated Transactivation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Sunday, June 22nd 3:00:00 PM SUN 0405-0435 4835 1:00:00 PM Metabolic Effects of Nuclear Receptors and Coregulators Poster

Mathias Schlögl*1, Susi Votruba2, Paolo Piaggi1, Mary F. Walter3, Jonathan Krakoff1 and Marie S Thearle2
1Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ, 2National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ, 3NIDDK, NIH

 

Background:

Fat free mass (FFM) is a major determinant of both energy expenditure (EE) and energy intake (EI). Irisin is secreted from muscle, an important component of FFM, in response to exercise and leads to an increase in EE. The association between food consumption and fasting plasma irisin concentrations (FPIC) in humans remains unknown.

Methods:

Sixty-six nondiabetic adults (34 NA/ 21 C/ 5 H/ 6 AA; 42M/ 24F; mean±SD: age 33.7±9.7 y; BMI 31.1±7.5 kg/m2; %body fat 31.0±9.1%, FPIC 349.5 ± 166.6 ng/mL) were admitted to a clinical research unit for a study of ad libitum energy intake (EI). EI expressed as both total daily kcal (CAL) or as a percentage of an individual’s calculated weight maintaining energy needs (%WMEN; [mean daily energy consumed/WMEN]*100), and macronutrient intake (PRO, CHO, fat) were determined. After 6 days of consuming WMEN, EI was assessed using a vending machine paradigm over 3 days. Physical activity was restricted to light activities. FPIC were measured on the morning of the second day of the vending machine period after an overnight fast using a highly sensitive commercial ELISA (Phoenix Pharmaceuticals, Belmont, CA, USA). Body composition was determined by DXA. FPIC data were right-skewed, and so, were log transformed (log10) to meet the assumptions of linear regression.

Results:

There were no significant correlations between FPIC and demographic and anthropometric parameters. On day 1, the subjects consumed, on average, 144±52% of their WMEN. After adjusting for age, sex and race, an increase of 500 CAL on day 1 was associated with a 3.4% decrease in FPIC the next morning (95% CI -6.2, -0.4%, P = 0.03). Results were similar if EI was expressed as %WMEN such that a 10% increase in WMEN was associated with a 1.9% decrease in FPIC (95%CI -3.7%, -0.1%; p=0.03). A 50 g increase in CHO consumption was associated with a 2.6% decrease in FPIC (95% CI -4.9, -0.2%, P = 0.04) and a 50 g increase in fat consumption was associated with a 5.8% decrease in FPIC (95% CI -10.7, -0.7%, p=0.03). After adjusting for age, sex, race, fat-mass index and fat-free mass index there was no association between FPIC and CAL, %WMEN, or macronutrient intake on day 2 of the vending paradigm (p=NS).

Conclusion: Higher 24h EI during ad libitum access to food is associated with lower FPIC the following morning. However, FPIC does not predict subsequent EI in humans. This association is consistent with the opposing metabolic effects of exercise and overeating.

 

Nothing to Disclose: MS, SV, PP, MFW, JK, MST

15029 1.0000 SUN-0875 A Higher 24h Ad Libitum Food Intake Predicts Lower Fasting Plasma Irisin Concentrations in Adult Humans 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0875-0890 4840 1:00:00 PM Adipocyte Biology-Clinical studies Poster

Jules Aljammal*1, Valerie L Reeves2, Munira Siddiqua Abbasi1, Bret Goodpaster3, Petra Kienesberger4, John Dube2 and Erin Elizabeth Kershaw2
1UPMC, Pittsburgh, PA, 2Universtiy of Pittsburgh, Pittsburgh, PA, 3Sanford Burnham Medical Research Institute,, Orlando, FL, 4Dalhousie Medicine New Brunswick, Saint John, NB, Canada

 

Background: Obesity and the metabolic syndrome are major public health problems. Adipokines serve as both pathogenic factors and potential therapeutic targets for these disorders. One such adipokine, Autotaxin (also known as ectonucleotide pyrophosphatase/phosphodiesterase family member 2 or ENPP-2), is an adipocyte secreted lysophospholipase D that generates the lipid signaling molecule lysophosphatidic acid (LPA). Adipose tissue expression of autotaxin has been linked with insulin resistance and glucose intolerance in both mice and humans. However, the relationship between serum autotaxin and features of the metabolic syndrome in humans remains poorly understood.

 

Objective: The goal of the present study was to determine the relationship between serum autotaxin concentrations and insulin resistance/metabolic syndrome in older obese human subjects.

 

Experimental Design: To achieve this goal, 64 human subjects (23 Male, 41 Female) age 60-76 years and BMI of 21-38 were phenotyped for features of the metabolic syndrome including the following: body mass index, body composition (fat mass, lean mass), waist circumference blood pressure, fasting serum lipids (total cholesterol, LDL, HDL, triglycerides), fasting glucose and insulin, serum glucose response to an oral glucose tolerance test, HbA1c, and insulin sensitivity by glucose infusion rate (GIR) during an hyperinsulinemic euglycemic clamp. Serum autotaxin was then determined by ELISA (R&D Systems).

 

Results: Serum autotaxin levels were higher in women than men (286.30 ± 16.52 vs 167.70 ±  10.25, p<0.0001). Serum autotaxin levels positively correlated with basal insulin in both genders (r = 0.559, p = 0.0009 in women, r = 0.584, p = 0.0068 in men). In addition, serum autotaxin levels inversely correlated with glucose infusion rate in both genders (r = -0.383, p = 0.019 in women, r = -0.514, p 0.012 in men). Finally, serum autotaxin levels were higher in females with metabolic syndrome than in females who did not have metabolic syndrome (339 ± 32.05 vs 259 ± 17.12, p = 0.02)

 

Conclusion: In conclusion, serum autotaxin levels positively correlated with basal insulin and negatively correlated with insulin sensitivity in both genders. Serum autotaxin levels were also increased in females with metabolic syndrome. Overall, these data support a relationship between serum autotaxin levels and insulin resistance/metabolic syndrome in humans. Additional studies are required to understand the underlying mechanisms linking LPA signaling to metabolic disease in humans.

 

Nothing to Disclose: JA, VLR, MSA, BG, PK, JD, EEK

12176 2.0000 SUN-0876 A Serum Autotaxin Levels Correlate with Insulin Resistance and Features of the Metabolic Syndrome in Humans 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0875-0890 4840 1:00:00 PM Adipocyte Biology-Clinical studies Poster

Gilberto J. Paz-Filho*1, Teresa Neeman2, Claudio Alberto Mastronardi2 and Alexander J. Rodriguez2
1Australian National University, Acton, Australia, 2The Australian National University, Canberra, Australia

 

Introduction: Lipodystrophy syndromes (LS) are characterized by generalized/partial absence of subcutaneous adipose tissue, which clinical manifestations consist of hypoleptinemia, hyperglycemia, elevated insulin resistance, dyslipidemia and hepatic steatosis. Leptin replacement therapy (LRT) is effective at improving glycemic control and liver injury, as well as restoring a normal lipid profile. Currently, no data exists that comprehensively and succinctly compiles the evidence from the literature, and demonstrates the effect of LRT on metabolic and hepatic parameters in LS patients.

Methods: A systematic review of the MEDLINE and Cochrane Library databases was conducted to identify studies assessing the effect of LRT on metabolic and hepatic endpoints of patients with lipodystrophy not associated with the use of HIV protease inhibitors. Standardized mean differences (SMD) and 95% confidence intervals of pooled results were calculated for overall changes in glucose homeostasis (fasting glycemia, insulin, HbA1c), plasma lipid profile (triglycerides, total cholesterol, HDL-cholesterol, LDL-cholesterol), and hepatic morphology/function (liver volume/fat, albumin, ALT and AST), using an inverse-variance random-effects model.

Results: After screening, 14 studies were included for review, out of 270 studies eligible for inclusion. Meta-analysis of results from clinical studies in 243 patients showed that LRT decreased fasting glucose [0.76 SMD units (range 0.40-1.12), p<0.0001], HbA1c [0.55 (0.23-0.86), p=0.0006], triglycerides [1.12 (0.81-1.43), p<0.00001], total cholesterol [0.62 (0.21-1.02), p=0.003), liver volume [0.98 (0.52-1.43), p<0.0001], liver fat [0.67 (0.44-0.89), p<0.0001], ALT [0.44 (0.07-0.80), p=0.02] and AST [0.45 (0.17-0.73) p=0.002].

Conclusion: In patients with LS not associated with the use of HIV protease inhibitors, LRT improves the outcome of several metabolic and hepatic parameters. Studies were limited by small populations and therefore large prospective trials are needed to validate these findings.

 

Nothing to Disclose: GJP, TN, CAM, AJR

12716 3.0000 SUN-0877 A A Meta-Analysis into the Effects of Leptin Replacement Therapy on Metabolic and Hepatic Endpoints of Patients with Lipodystrophy Syndromes Not Associated with the Use of HIV Protease Inhibitors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0875-0890 4840 1:00:00 PM Adipocyte Biology-Clinical studies Poster

Harriette Rosen Mogul*1, Ruth G Freeman2 and Philipp E Scherer3
1New York Med Coll, Valhalla, NY, 2Montefiore Med Ctr, Bronx, NY, 3University of Texas Southwestern Medical Center, Dallas, TX

 

BACKGROUND The leptin to adiponectin ratio (LAR) has been proposed as a useful and important measure of insulin resistance and adipogenesis in diabetic1 2 and non-diabetic adults,3 consistent with the central role of adipocyte dysfunction in insulin resistance and metabolic syndrome. LAR correlates with insulin sensitivity in large, population based studies of non-diabetic men and women3 and is a significant predictor of incident diabetes4 and cardiac abnormalities in high risk cohorts;5;6 adverse events in long term followup of myocardial infarction patients;7 and cardio-metabolic syndrome in multiple studies.6;8-10 We evaluated LAR at baseline and 6 months in EMPOWIR, our double blind, placebo controlled, randomized trial of carbohydrate modified diet (CMD) alone, and in combination with metformin (MF) 2000mg and MF + rosiglitazone (RSG) in women with Syndrome W—an early manifestation of insulin resistance, defined by the triad of Weight gain (≥20 lbs after the 20´s), Waist gain, and White Coat hypertension in normoglycemic hyperinsulinemic Women.11 The study was conducted to test the hypothesis that insulin sensitizers along with CMD could reduce fasting insulin and body weight (BW) as previously reported.12;13 The aim of this analysis was to assess the relationship of 6-month LAR with study treatment and other relevant correlates. METHODS We measured leptin (Millipore RIA, Quest Diagnostics Nichols Institute) and total adiponectin (Elisa, Millipore/ Linco in the laboratory of Dr. P. Scherer), and metabolic covariates at baseline and 6-months (n=38; 54.5% white, 22.7% black, 13.6% Hispanic, 9.1% other; mean age 47.0 ±6.4 years, BMI 30.4±2.9 kg/m2; normal GTT, mean AUC-insulin 161.0 μU/ml. Paired t-tests and multivariate models were used (SPSS 20). Participants attended 4 weekly nutrition workshops prior to randomization. RESULTS Significant BW reductions were observed in all groups (P´s=.049, .005, .017). Despite comparable weight loss in the 3 groups, mean basal LAR was unchanged in the diet and diet + MF arms (P’s 0.877, and 0.618 respectively), but declined significantly in the MF+RSG arm (2.50 →1.25, P=.011, with LAR reduction in 9 of 11 subjects). Multivariate models demonstrated that, as in other studies of obese subjects, 6 month LAR was significantly predicted by TZD use2 and white race14 (P’s= .032 and .028), but was independent of age or BMI. CONCLUSION These findings support the potential utility of LAR as an index of treatment response.  

  

 

Nothing to Disclose: HRM, RGF, PES

11488 4.0000 SUN-0878 A Modulation of Leptin to Adiponectin Ratio in EMPOWIR (Enhance the Metabolic Profile of Women with Insulin Resistance), a Randomized Clinical Trial of Normoglycemic Women with Midlife Weight Gain, Waist Gain, and White-Coat Hypertension (Syndrome W) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0875-0890 4840 1:00:00 PM Adipocyte Biology-Clinical studies Poster

Eu Jeong Ku*1, Kyong Yeun Jung1, Soo Lim1, Hak Chul Jang2 and Sung Hee Choi1
1Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 2Seoul National University Bundang Hospital and Seoul National University College of Medicine, Seoul, Korea, Republic of (South)

 

Objective: Adiponectin is the most abundant secretory adipocyte-derived protein, well known as insulin-sensitizing, anti-inflammatory and anti-atherogenic adipokine. Despite the inverse correlation with adiponectin and insulin resistance, several recent studies reported an association of higher adiponectin level with higher mortality. There are few longitudinal studies on the association between adiponectin and mortality focusing on elderly Asian people and results are still inconsistent. The objective of this study was to investigate the association between serum total adiponectin and all-cause, cardiovascular mortality in elderly Korean adults.

Methods: We recruited 1,000 subjects aged over 65 years performing basic activity of daily living by age- and sex-stratified random sample from Seongnam city in 2005-2006. The mean follow-up duration was 5.2 years. Total adiponectin levels were measured using an enzyme-linked immunosorbent assay. Body composition was measured by dual-energy X-ray absorptiometry and computed tomography. Study population had to complete questionnaires about comorbidities, medical histories and life styles. Vital status was ascertained through 31 December 2011 using the Cause of Death Statistics of the Korean National Statistical Office. Cardiovascular mortality was defined as coronary heart disease (i.e. fatal myocardial infarction, fatal cardiovascular heart disease) and cerebrovascular disease (stroke). We used Cox proportional hazards models to examine the longitudinal association between serum total adiponectin and all cause and cardiovascular mortality

Results:There were 222 deaths and 15% (33 of 222) were from cardiovascular disease. The unadjusted association between total adiponectin and all-cause and cardiovascular mortality showed an increased risk (HR 1.534, 95% CI 1.317-1.786 for all-cause mortality; HR 1.654, 95% CI 1.202-2.276 for cardiovascular mortality). After adjustment for age and sex, there was a trend toward increased risk of all-cause mortality with increasing standard deviation of adiponectin, 6.4 μg/ml (HR 1.272, 95% CI 1.101-1.469). The similar trend was observed after adjusting for age, sex, hip circumference, BMI, smoking history and alcohol consumption (HR 1.195, 95% CI 1.005-1.421 for all-cause mortality). After additional adjustment for covariates, confounders (i.e. HDL-cholesterol, history of diabetes mellitus, hypertension), Adiponectin remained associated with increased risk of all-cause mortality (HR 1.240, 95% CI 1.022-1.505) and showed a trend towards increased risk of cardiovascular mortality (HR 1.519, 95% CI 1.000-2.306).

Conclusion: Higher adiponectin level was associated with higher all-cause mortality in this study of community-based Korean elderly persons. This paradoxical relationship needs further study for underlying mechanisms that might explain the results.

 

Nothing to Disclose: EJK, KYJ, SL, HCJ, SHC

12741 5.0000 SUN-0879 A Association of Adiponectin with All-Cause and Cardiovascular Mortality in Korean Elderly Adults: The Korean Longitudinal Study on Health and Aging (KLoSHA) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0875-0890 4840 1:00:00 PM Adipocyte Biology-Clinical studies Poster

Dana Sheely*, Kevin Comerford, Rogelio Almario and Sidika Emine Karakas
University of California at Davis Medical Center, Sacramento, CA

 

Weight loss is the first line of treatment for metabolic syndrome (METS) as it can improve all of the major components of the syndrome. Recent research has shown that Wingless-type MMTV integration site family member (WNT) signaling pathways are an important regulator of adipogenesis; and may play a role in the pathogenesis of the disorders which constitute METS. However, further investigation is necessary to elucidate the effects of weight loss on the WNT signaling proteins and WNT inhibitors in human populations with METS. WNT signaling is initiated with the binding of a WNT protein to its receptors. In the adipose tissue, activation of WNT leads to production of WNT1 inducible signaling pathway 2 (WISP2) in the cytosol, which inhibits activation of peroxisome proliferator-activated receptor gamma (PPARγ) through downstream actions. The inactivation of PPARγ exerts an anti-adipogenic effect by limiting the storage function of adipose tissue and diverting lipids to ectopic storage sites such as liver and muscle -- leading to insulin resistance. Extracellularly, antagonists of WNT such as secreted frizzled-related protein 4/5 (SFRP4 and SFRP5) can bind and neutralize WNT and thus interfere with WNT signaling. The recent discovery that several of the WNT signaling and WNT inhibitory proteins are secreted into circulation has led to clinical studies linking these proteins to various metabolic disorders such as obesity and type 2 diabetes. Our lab conducted a 2-month weight loss program using a meal plan based on ideal body weight for height calculations in 29 women with METS.  Fasting blood samples were obtained at the beginning and end of the intervention to measure serum WNT signaling pathway proteins (WNT5 and WISP2); WNT-inhibitors (SFRP4 and SFRP5); and markers of inflammation and insulin resistance. On average, the participants lost 6.2 kg over 2 months. Serum WNT5 (baseline:1.05 ± 0.07 ng/ml) significantly decreased (-0.17 ± 0.08 ng/ml, p= 0.04) and serum SFRP5 (baseline: 5.44 ± 0.08 ng/ml) tended to decrease (-1.48 ± 0.72 ng/ml, p = 0.05).  Serum WISP2 (baseline: 234.20 ± 34.80 ng/ml) levels significantly increased (28.60 ± 41.10 ng/ml, p < 0.01). WNT5 levels correlated directly with fasting glucose (r = 0.453, p = 0.014), triglycerides (r = 0.395, p = 0.034) and IL-6 (r = 0.404, p = 0.030), while WISP2 levels correlated directly with TNFα (r = 0.696, p < 0.001).  SFRP5 levels tended to correlate inversely with IL-6 (r = -0.349, p = 0.064). These results demonstrate that during active weight loss, WISP2 levels increased, while WNT5 decreased, and SFRP5 trended towards a decrease. The contrasting changes in WNT5 and WISP2 suggest that WISP2 may be regulated by alternate mechanisms, outside of the downstream effects of WNT5. Taken together, these results suggest that WNT signaling pathways and WNT inhibitors are influenced by lifestyle measures in METS.

 

Nothing to Disclose: DS, KC, RA, SEK

15545 6.0000 SUN-0880 A Effects of Weight Loss on Serum WNT Signaling Proteins and WNT Inhibitors in Women with Metabolic Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0875-0890 4840 1:00:00 PM Adipocyte Biology-Clinical studies Poster

Ioannis Ilias*1, Dimitra A Vassiliadi2, Maria Theodorakopoulou2, Nikitas Nikitas2, Marinela Tzanela3, Sofia Apollonatou2, Stylianos Tsagarakis4 and Ioanna Dimopoulou2
1E Venizelou Hosp, Athens, Greece, 2University of Athens Medical School, Athens, Greece, 3Evangelismos Hospital, Athens, Greece, 4Evangelisnos Hospital, Athens, Greece

 

Introduction: Cortisol (F) is enmeshed in adipose tissue metabolism in many aspects (1). A positive association between plasma F and lipolysis has been observed. Critically ill patients show the “lipemia of sepsis”.

Aim: To study, in septic and non-septic ICU patients, adipose tissue lipolysis vs tissue F, using microdialysis (MD).

Subjects and methods: We studied 43 (24 men & 19 women, mean age±SD: 63±19 years) mechanically ventilated patients with a diagnosis of septic shock (n=21) or systemic inflammatory response syndrome/severe sepsis (n=22). Upon ICU admission a MD catheter was inserted under sterile conditions into the subcutaneous adipose tissue of the upper thigh. Excluding patients on steroid therapy, on day 2 (n=27), day 3 (n=24) and day 4 (n=21) MD samples were collected six times per day for MD glycerol (MD GLYC; used as an index of lipolysis) and tissue F. The mean of these 6 collections was used for analysis (normal values for adipose tissue GLYC glycerol < 200 μmol/L). Statistics were done with analysis of covariance (ANCOVA) and linear regression.

Results: Most samplings (44/72) indicated accentuated lipolysis with above-normal MD GLYC levels. MD GLYC was associated with MD F (ANCOVA p=0.022) and was not associated with age, day of sampling or presence of shock. MD GLYC was weakly correlated to MD F (r=+0.242, p=0.045).

Discussion: Changes in interstitial/tissue F may not be reflected in plasma (total) F concentration (2). Thus it is interesting that we observed an - albeit weak - association between tissue lipolysis (via MD GLYC levels) and MD F, verifying (though modestly so) the well-known association between lipolysis and F (3).

 

Nothing to Disclose: II, DAV, MT, NN, MT, SA, ST, ID

12172 7.0000 SUN-0881 A Tissue Lipolysis Vs Tissue Cortisol in Septic and Non-Septic Critical Illness 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0875-0890 4840 1:00:00 PM Adipocyte Biology-Clinical studies Poster

Michael William O'Reilly*1, Laura Louise Gathercole1, Wiebke Arlt1 and Jeremy W Tomlinson2
1University of Birmingham, Birmingham, United Kingdom, 2Univ of Birmingham, Birmingham, United Kingdom

 

Polycystic ovary syndrome (PCOS) is a clinical triad of anovulation, insulin resistance and androgen excess. Adipose androgen generation of testosterone from androstenedione by aldo-ketoreductase type 1C3 (AKR1C3) may contribute to hyperandrogenism, particularly in the setting of obesity and hyperinsulinaemia. We aimed to determine the effects of body mass index (BMI) and insulin on AKR1C3 expression in subcutaneous (SC) and omental (OM) fat depots in women. 

Paired SC and OM samples from 43 women undergoing elective abdominal surgery were analyzed (mean age 56.4±1.7 years; mean BMI 28.8±0.8kg/m2) and RNA extracted. After reverse transcription, AKR1C3 mRNA expression was determined by realtime quantitative PCR. Pearson’s correlation testing was used to determine relationships between variables. Additional studies using primary cultures of differentiated human adipocytes (in triplicate) explored the regulation of AKR1C3 expression by both insulin and androgens.

AKR1C3 expression (delta CT) was significantly higher in SC compared to OM fat (7.1±0.6 v 9.2±0.4, p=0.004), and in obese compared to non-obese women (6.4±1.1 v 8.9±0.4, p=0.01). BMI had a strong positive correlation with SC adipose AKR1C3 expression (R= - 0.51 for delta CT, p=0.006); this association was not observed in OM fat. Insulin treatment alone upregulated AKR1C3 expression in primary SC (p=0.04), but not OM adipocytes. However, in the presence of androgen excess (androstenedione, 20nM), insulin increased AKR1C3 expression in OM adipocytes (p=0.004).

Subcutaneous AKR1C3 expression is upregulated with increasing BMI and insulin exposure in females. This mechanism may contribute significantly to androgen generation in patients with PCOS and has the potential to represent a novel therapeutic target.

 

Nothing to Disclose: MWO, LLG, WA, JWT

12598 8.0000 SUN-0882 A Insulin and Obesity Upregulate AKR1C3 Expression in Female Adipose Tissue: Evidence for Adipose Androgen Generation in Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0875-0890 4840 1:00:00 PM Adipocyte Biology-Clinical studies Poster

Tung-Yueh Chuang1, Gloria Mabel Gamboa2, Lawrence C Layman1, Michael P Diamond1, Ricardo Azziz3 and Yen-Hao Chen*1
1Georgia Regents University, Augusta, GA, 2Georgia Rengents University, Augusta, GA, 3Augusta University, Augusta, GA

 

We previously reported that adipose tissue (AT) from women with PCOS or insulin resistance (IR) revealed a differentially expressed microRNA (miRNA) profile, including upregulated miR-93 in PCOS patients and in non-PCOS women with IR (1). Overexpressed miR-93 directly inhibited glucose transporter isoform 4 (GLUT4) expression thereby influencing glucose metabolism. We have now studied the role of miR-223, which is also abnormally expressed in the AT of IR subjects. Our data indicates that miR-223 expression is increased 2 fold (p<0.01) in the AT of IR women (n=18) compared to non-IR women (n=15), regardless of whether they had PCOS or not. MiR-223 expression in AT was positively correlated with HOMA-IR (r=0.64, p<0.01, n=23) and miR-93 (r= 0.41, p<0.05, n=23) expression, but was negatively correlated with GLUT4 gene (r=-0.64, p<0.01) expression. In conclusion, miR-223 was overexpressed in the AT of IR subjects regardless of PCOS status. miR-223 expression was negatively associated with GLUT4 but positively associated with HOMA-IR, and miR-93 expression. Together these data suggest that in AT miR-223 is an IR-related miRNA and may serve as a potential biomarker and a therapeutic target for the treatment of IR-related disorders.

 

Nothing to Disclose: TYC, GMG, LCL, MPD, RA, YHC

13819 9.0000 SUN-0883 A Micro RNA-223 Expression Is Upregulated in Human Adipose Tissue of Insulin Resistant Women with and without Polycystic Ovary Syndrome (PCOS) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0875-0890 4840 1:00:00 PM Adipocyte Biology-Clinical studies Poster

Vibha Singhal*1, Kathryn E Ackerman2, Hannah Clarke2, Meghan Slattery3, Lauren Weiner4, Gerald Kolodny5, Aaron Martin Cypess6 and Madhusmita Misra2
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Massachusetts General Hospital and Harvard Medical School, Boston, MA, 3Massachusetts General Hospital, Boston, MA, 4Joslin Diabetes Center and Harvard Medical School, 5Beth Israel Deaconess Medical Center/Harvard Medical School, 6Joslin Diabetes Center, Boston, MA

 

Background: Brown Adipose Tissue (BAT) is responsible for thermogenic energy expenditure, and imaging has revealed that adults have varying amounts of BAT. Children have higher BAT activity than adults, suggesting a greater impact on energy homeostasis. Recent studies have revealed estrogen receptors in BAT and suggested a role for estrogen in up-regulating BAT synthesis and activation. BAT activity has not been studied in athletes, especially young women who are oligo-amenorrheic and in a state of relative energy deficiency (indicated by low fat stores). Leptin and thyroid hormone have also been shown to increase the thermogenic potential of BAT and we have demonstrated lower leptin levels in AA than EU. We postulated that being hypoestrogenic, hypoleptinemic and in a state of relative energy deficiency, AA young women would have less BAT activity than EU controls.

Objective: Evaluate cold induced brown fat activity in oligo-amenorrheic athletes (AA) compared to eumenorrheic (EU) normal weight controls.

Methods: We evaluated 5 oligo-amenorrheic endurance athletes (weight-bearing aerobic activity more than 4 hrs/wk) and 6 eumenorrheic normal weight controls between 18-21 years of age for cold induced BAT activity. Subjects wore a cooling vest at 14 °C for 120 min before the PET/CT scan. BAT activity was quantified by 18F- FDG uptake in the cervical-supraclavicular depots. Body composition was assessed by DXA. We also measured resting energy expenditure (REE) and levels of serum irisin (a myokine that induces brown adipogenesis). JMP statistical software was used for analysis.

Results:  The AA and EU groups were similar for age (22.3±2.3 vs. 21.7±2.5 y), Tanner stage, BMI (21.1±2.6 vs. 21.9±1.1 kg/m2), total fat (14.2±5.2 vs. 16.4±4.4 kg), % body fat (24.4±6.3 vs. 27.6±6.2) and lean mass (40.6±2.7 vs. 40.7±4.6 kg). None of the AA had visible BAT and one third of the EU group had visible BAT. AA had significantly lower BAT volume and activity than EU (6.8±3.0 vs. 39.8± 46.4 ml; p=0.03; 16.6±6.7 vs. 155.1±199.3 mL*SUVmean*g*mL-1; p=0.03; Wilcoxon test). One AA was excluded as she was clearly an outlier (by Dixon Q test) (104.5 ml and 438.1 mL*SUVmean*g*mL-1BAT volume and activity). BAT volume and activity correlated inversely with age (Spearman Rho=-0.78 and -0.64; p=0.008 and 0.048) and duration of amenorrhea (Rho=-0.85 and -0.83; p=0.002 and 0.003), but not with BMI, %body fat, lean mass, REE or irisin levels. BAT volume correlated positively with total fat mass (Rho=0.64, p=0.048).

Conclusions: We conclude that AA have lower brown fat volume and activity than EU. This may be due to the hypoestrogenic state in AA, given that estrogen stimulates BAT, and BAT activity was inversely associated with duration of amenorrhea. Lower BAT activity may also imply an adaptive response to conserve energy in these young women who are already in an energy deficient state.

 

Nothing to Disclose: VS, KEA, HC, MS, LW, GK, AMC, MM

13368 10.0000 SUN-0884 A Cold Induced Brown Adipose Tissue Activity in Young Oligo-Amenorrheic Athletes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0875-0890 4840 1:00:00 PM Adipocyte Biology-Clinical studies Poster

Johanna C. van den Beukel*1, Aldo Grefhorst1, Jacobie Steenbergen1, Frank J.M.F. Dor2, Martin J. Hoogduijn2 and Axel P.N. Themmen1
1Erasmus MC, Rotterdam, Netherlands, 2Erasmus MC

 

In mammals, white adipose tissue (WAT) stores energy in the form of triglycerides, whereas brown adipose tissue (BAT) can oxidize triglyceride-derived fatty acids to generate heat, a process mediated by brown-adipocyte-specific uncoupling protein 1 (UCP1). Depending on its location and presence or absence of specific triggers, WAT depots can gain BAT-like properties such as presence of brown-like adipocytes with UCP1 expression. Studies suggest that human perirenal adipose tissue is a WAT depot with BAT-like properties, but it is not known which factors determine this browning. We performed a detailed investigation of human perirenal adipose tissue.

Perirenal and subcutaneous adipose tissue was obtained from 19 male and 23 female healthy live kidney donors, aged 27-81. Browning of the adipose tissue was studied by RNA analysis and immunohistochemistry. Mesenchymal stem cells (MSCs) were isolated from these depots to study the browning potential in vitro.

None of the collected subcutaneous adipose tissues showed presence of brown adipocytes or UCP1 gene expression. When the average outside temperature a week before harvesting was lower than 10 °C, brown adipocytes, i.e. cells with multiple small lipid droplets and positive for UCP1 staining, were present in perirenal adipose tissue of all women but in only 1 out of 10 men. UCP1 gene expression, in contrast, did not differ between men and women partly due to very high expression in 1 man (p=0.43). Subcutaneous-derived MSCs that were differentiated towards adipocytes did not express UCP1. Perirenal-derived MSCs differentiated towards adipocytes expressed significantly more UCP1 when they were from female origin compared to male origin (p=0.009).

Female perirenal adipose tissue has a higher potency to gain BAT-like properties than male perirenal adipose tissue. Thus, perirenal adipose tissue is a genuine beige adipose tissue depot, but its degree of browning depends on sex and environmental triggers such as temperature.

 

Nothing to Disclose: JCV, AG, JS, FJMFD, MJH, APNT

16905 12.0000 SUN-0886 A Women Have More Potential to Induce Browning of the Perirenal Fat Depot Than Men 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0875-0890 4840 1:00:00 PM Adipocyte Biology-Clinical studies Poster

Paul Lee*1, Sheila Smith1, Joyce D Linderman1, Amber B Courville2, Robert J Brychta1, William Dieckmann3, Charlotte D Werner1, Kong Chen1 and Francesco S. Celi4
1Diabetes Endocrinology Obesity Branch, NIDDK, NIH, Bethesda, MD, 2Clinical Center, NIH, Bethesda, MD, 3PET Department, NIH, Bethesda, MD, 4Virginia Commonwealth University, Richmond, VA

 

In addition to heat production during cold exposure, growing evidence suggests brown adipose tissue (BAT) may contribute to healthy metabolism in humans (1). Even a mild reduction in environmental temperature is sufficient to activate BAT (2) and induce hormonal changes (3). However, the long-term consequences of temperature acclimatization on BAT, and whether it impacts on whole body energy/substrate metabolism in humans, are unclear. 

In this study, we examined the impact of controlled temperature acclimatization on BAT and energy homeostasis in five men (21±2 years old, BMI: 22±1 kg/m2, body fat: 21±2%) over a 4-month period. Volunteers engaged in usual daytime activities but slept in a temperature-adjusted private room: 24°C (month 1) → 19°C (month 2) → 24°C (month 3) → 27°C (month 4). Personal temperature detectors monitored individual exposed temperature continuously for the entire 4-month period. At the end of each testing month, BAT was quantified by Positron Emission Tomography (PET)-CT scanning and energy metabolism by whole room indirect calorimetry, mixed meal test, blood hormonal/substrate profiling and adipose/muscle biopsies ex vivo analyses.

During the 4-month period, mean BAT volume and overall fat metabolic activity increased upon cold acclimatization (19°C) by 42±18% (p<0.05) and 10±11% (p<0.05), respectively; decreased after the thermoneutral month (24°C) to nearly baseline level, and completely muted at the end of one-month warm exposure (27°C). Room (p<0.05) and individually exposed temperatures (p<0.01), but not outdoor temperatures, correlated with BAT changes during study period. BAT-acclimatization was accompanied by diet-induced thermogenesis and post-prandial glucose metabolism enhancement, evident only after cold exposure. Mechanistically, BAT acclimatization was associated with reciprocal changes of circulating adiponectin and leptin levels, mirrored by corresponding transcriptosomal changes in adipose tissue ex vivo.

In summary, sequential monthly acclimatization modulated BAT reversibly, boosting and suppressing its abundance and activity in mild cold and warm conditions, respectively, independent of seasonal fluctuations. The inducibility and suppressibility of human BAT paralleling whole body metabolic changes suggests regulatory links between BAT thermal plasticity and glucose metabolism in humans. We propose BAT enhancement as a promising therapeutic strategy to improve glycemia in humans.

 

Nothing to Disclose: PL, SS, JDL, ABC, RJB, WD, CDW, KC, FSC

12533 13.0000 SUN-0887 A Impact of Chronic Cold Exposure in Humans (ICEMAN) Study: Evidence for Brown Adipose Tissue Plasticity Modulating Glucose Metabolism in Humans 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0875-0890 4840 1:00:00 PM Adipocyte Biology-Clinical studies Poster

Daniel Tews*1, Verena Schwar1, Theresia Weber1, Marc Scheithauer1, Thomas Barth1, Peter Möller1, Tobias Fromme2, Martin Klingenspor2, Pamela Fischer-Posovszky3 and Martin Wabitsch1
1University Medical Center Ulm, 2Technical University Munich, 3University of Ulm, Ulm, Germany

 

Introduction Studies in animal models revealed that brown and white adipocytes derive from different progenitor cells. Molecular characteristics of these cells have not been investigated in detail in humans. Here we sought to identify novel markers of human brown adipocyte progenitor cells.

Methods Paired deep neck and subcutaneous adipose tissue samples from n=52 subjects were taken and subdivided for analysis by immunohistochemistry (n=26) and quantitative real-time PCR (n=14), respectively. Progenitor cells were isolated from paired tissue samples of n=12 patients and were differentiated into adipocytes in vitro. Expression profile of progenitor cells was assessed by gene array analysis. Real-time PCR was performed to assess mRNA expression of selected genes.

Results Progenitor cells isolated from deep neck and subcutaneous adipose tissue show marked differences in gene expression pattern. In 355 differentially regulated (<1.5 fold) genes, we found genes encoding 32 transcriptions factors, 25 surface proteins and 14 receptor ligands. Validation by qPCR confirmed ADH1B as highest expressed in deep neck progenitor cells. In vitro differentiated adipocytes from the deep neck adipose tissue were characterized by elevated UCP1 and classical brown marker gene expression.

Conclusion The ability of human adipocyte progenitor cells to differentiate into brown-like adipocytes is depot-specific and is based on intrinsic differences in gene expression. Our data provide potential molecular targets involved in the genetic determination of brown adipocyte precursor cells.

 

Nothing to Disclose: DT, VS, TW, MS, TB, PM, TF, MK, PF, MW

14528 14.0000 SUN-0888 A Comparative Gene Array Analysis of Human Deep Neck and Subcutaneous Adipose Tissue Progenitor Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0875-0890 4840 1:00:00 PM Adipocyte Biology-Clinical studies Poster

Risa M Wolf*, Marcus M Seldin, Kimberley E Steele, Thomas H Magnuson, Michael A Schweitzer and G. William Wong
The Johns Hopkins University School of Medicine, Baltimore, MD

 

C1q/TNF-related protein3 (CTRP3), also known as cartonectin, is a novel adipokine that lowers blood glucose levels, reduces triglyceride synthesis, and is protective against liver steatosis in diet-induced obese mice. In this study, we hypothesized that higher levels of serum CTRP3 expression would be correlated with a more favorable metabolic profile in humans.

Fasting serum samples were obtained from 19 healthy patients. For each patient, serum was analyzed in the core laboratory for the following parameters: A1C, insulin, glucose, AST, ALT and lipid panel. Serum CTRP3 levels were measured by ELISA. Results were analyzed using the Student’s t-test and Pearson correlation testing.   

The cohort included 10 men and 9 women with a mean age of 32 ± 7 years (range 23-52), and mean BMI of 21.9 ± 2 kg/m2 (range 18.7-25.4). All patients were healthy, 17/19 had no past medical history and took no medications.  63% were white, and 37% identified as non-white. Baseline metabolic parameters were normal for all patients, with a mean fasting glucose of 74 ±10 mg/dL (range 56-95), mean AST 19 ± 5 IU/L (range 12-28), mean ALT 15 ± 7 IU/L (range 8-39), mean total cholesterol 167 ± 27 mg/dL (range 123-223), mean TGL 74 ±5 mg/dL (range 34-152), mean HDL 62 ± 15 mg/dL (range 30-88), and mean LDL 90 ±22 mg/dL (range 55-144). Mean CTRP3 was 190 ± 40 ng/mL (range 110-240). We found higher levels of CTRP3 expression in women vs. men (210 ± 30 vs. 160 ± 30 ng/mL, p<0.01), and in non-white vs. white patients (220 ± 30 ng/mL vs. 165 ± 30 ng/mL, p<0.001). Patients with higher blood sugars had lower CTRP3 levels, but this trend was not statistically significant (p=0.056). We did not find any other statistically significant correlations between CTRP3 level and any of the metabolic or demographic parameters.

In conclusion, circulating CTRP3 levels are significantly higher in women, suggesting the possibility of hormonal influence. Though CTRP3 levels in healthy adults are not correlated with metabolic parameters, individuals with higher fasting glucose levels have lower CTRP3, and therefore, glucose metabolism dysregulation may cause further abnormalities in circulating CTRP3 levels. Further studies are needed to investigate the relationship that may exist between CTRP3 and blood sugar levels.

 

Nothing to Disclose: RMW, MMS, KES, THM, MAS, GWW

15991 15.0000 SUN-0889 A Establishing Reference Ranges for C1q/TNF-Related protein3 (CTRP3) Levels in Healthy Adults 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0875-0890 4840 1:00:00 PM Adipocyte Biology-Clinical studies Poster

Risa M Wolf*, Marcus M Seldin and G. William Wong
The Johns Hopkins University School of Medicine, Baltimore, MD

 

Metformin is the first line therapy for hyperglycemia, but its mechanism is not well understood.  C1q/TNF-related protein3 (CTRP3) or cartonectin is a novel adipokine that lowers blood glucose levels by regulating gluconeogenesis and suppressing gluconeogenic enzyme expression (1). A recent study showed metformin increases CTRP3 expression in human tissue explants (2).  We sought to determine how metformin affects CTRP3 and other adipokine expression in adipose tissue using in vitro and in vivo loss-of-function technology. 

Mouse 3T3-L1 pre-adipocytes were cultured and differentiated until fully confluent, and treated with either vehicle or metformin for 6 and 24 hours. Quantitative RT-PCR was used to measure mRNA expression levels of adipokines, including CTRP3, CTRP9, CTRP12, adiponectin and leptin. Metformin treatment enhanced CTRP3 mRNA expression 3-fold at 6hours (p<0.01) and 2.5-fold at 24 hours (p=0.01). In contrast, other novel and important adipokines (Leptin, adiponectin, CTRP9 and CTRP12/adipolin) did not show significant changes in mRNA expression in response to metformin treatment.

Metformin specifically and significantly increases CTRP3 expression and does not increase other major adipokine expression. Further investigation into whether metformin functions through CTRP3 or is synergistic with CTRP3 will be performed using mice lacking CTRP3.  By better understanding the mechanism through which metformin functions, we can improve the prevention and treatment of diabetes and its associated comorbidities.

 

Nothing to Disclose: RMW, MMS, GWW

15279 16.0000 SUN-0890 A The Novel Adipokine CTRP3 Mediates Beneficial Effects Exerted By Metformin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0875-0890 4840 1:00:00 PM Adipocyte Biology-Clinical studies Poster

Nicole E De Long*1, Eric Barry1, Christopher Pinelli2, Geoffrey Wood2, Daniel B Hardy3, Katherine Mary Morrison1, Valerie H Taylor4, Hertzel C Gerstein5 and Alison C Holloway1
1McMaster University, Hamilton, ON, Canada, 2University of Guelph, Guelph, ON, Canada, 3The Univ of Western Ontario, London, ON, Canada, 4University of Toronto, Toronto, ON, Canada, 5Population Health Research Institute, McMaster University

 

Introduction: According to current estimates, 10-15% of women take antidepressant medications during pregnancy. The side effects of this class of medication during pregnancy have been extensively studied, but most studies examine teratogenic outcomes, not metabolic changes. A recent clinical study however has reported that the use of selective serotonin reuptake inhibitor (SSRIs) antidepressants during pregnancy is associated with an increased risk of postnatal obesity. In humans, obesity is often associated with fatty liver, dyslipidemia and inflammation.  However the effects of perinatal exposure to SSRIs on markers of fatty liver and inflammation have not been examined.

Objective: In this study, we examined the effect of fetal exposure to fluoxetine (Prozac®), a SSRI antidepressant, on hepatic lipid accumulation and markers of inflammation.

Methods: Female nulliparous Wistar rats were given vehicle (N=15) or fluoxetine hydrochloride (FLX 10 mg/kg/d; N=15) orally for 2 weeks prior to mating until weaning. We assessed liver histology, hepatic lipids and markers of inflammation in the offspring at 26 weeks of age.

Results: There was a significant increase in the number of offspring with mild to moderate NASH in FLX-exposed offspring relative to controls (p=0.04). The female offspring of FLX-treated dams had significantly higher levels of hepatic triglycerides and cholesterol (p<0.01); similar results were seen for male offspring although the cholesterol levels did not reach statistical significance (p=0.057).  There was also evidence of increased inflammation of the liver in FLX-exposed offspring; males had significant elevations in relative mRNA expression of TNFα (CON: 0.4 ± 0.22; FLU: 1.8 ± 0.58; p=0.02), IL-6 (CON: 0.2 ± 0.13; FLU 1.7 ± 0.52; p=0.003) and MCP1 (CON: 0.2 ± 0.13; FLU: 1.3 ± 0.45; p=0.008) whereas female offspring had higher expression of TNFα (CON: 0.8 ± 0.48; FLU: 2.5 ± 0.8; p=0.045), and increased macrophage infiltration (CD68; CON: 1.0 ± 0.09; FLU: 1.5 ± 0.06; p=0.01).

Conclusion: These data demonstrate that in this model fetal and neonatal exposure to FLX results in evidence of fatty liver and inflammation in both male and female offspring.  Since fatty liver and hepatic inflammation are associated with a number of metabolic abnormalities, these results raise concerns regarding the long term metabolic sequelae of fetal exposure to SSRIs.

 

Disclosure: HCG: Principal Investigator, Sanofi, Advisory Group Member, Sanofi, Consultant, Sanofi, Principal Investigator, Eli Lilly & Company, Advisory Group Member, GlaxoSmithKline, Advisory Group Member, Astra Zeneca, Advisory Group Member, Bristol-Myers Squibb, Principal Investigator, Roche Pharmaceuticals, Advisory Group Member, Novo Nordisk, Advisory Group Member, Boehringer-Ingelheim. Nothing to Disclose: NED, EB, CP, GW, DBH, KMM, VHT, ACH

16195 5.0000 SUN-0910 A Perinatal Exposure to the Selective Serotonin Reuptake Inhibitor Fluoxetine Results in Hepatic Lipid Accumulation and Inflammation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Kristell LE Mapihan1, Anne-Sophie Parent2, Samuel Boury2, Olivier Lascols3, Georges Lion2, Myriam Labalette2, Isabelle Wolowczuk4 and Marie-Christine Vantyghem*5
1Lille University hospital, Lille, France, 2Lille Nord de France University hospital, Lille, France, 3Saint-Antoine University Hospital, Paris, France, 4Pasteur Institute, Lille Nord de France University & E.G.I.D - FR3508 European Genomic Institute for Diabetes, Lille, France, 5Lille Nord de France University & E.G.I.D - FR3508 European Genomic Institute for Diabetes, Lille Cedex, France

 

Introduction: The diagnosis of non-HIV lipodystrophies is challenging, especially since borderline forms with type 2 diabetes have been described.

Objective: To identify the most specific anthropometric and immune-inflammatory parameters enabling to differentiate lipodystrophies from obese and control subjects.

Methods: This prospective study included 4 groups: 16 LMNA–mutated lipodystrophies (LDM), 16 non-LMNA mutated partial lipodystrophies (LDNM), 28 obese (O) and 14 normal-weighed healthy subjects (C). The anthropometric characteristics (DEXA, MRI), blood leptin, C-reactive protein (CRP) and lymphocytes (immunophenotype) levels were analysed. Three ratios were calculated to assess the fat and lean mass distribution and adipose tissue function: trunk fat/lean mass (FM/LM), intra-/whole abdominal fat (IAF/WAF), and leptin/WAF.

Results: The 3 ratios ranges in the 4 subgroups were as follows: IAF/WAF: increased around 0.5 in LDM (0.53±0.03) vs. around 0.25 in all other subgroups (LDNM: 0.33±0.03; O: 0.28±0.02; C :0.23±0.04; p<0.01 for the 3); trunk FM/LM: similar and close to 0.3 in LDM (0.39±0.05) and C (0.29±0.02), and increased above 0.5 in LDNM (0.57±0.05; p≤0.01 vs LDM, O and C) and O (0.81±0.04; p<0.001 vs LDM, LDNM and C); leptin/WAF: similar around 2.5 in LDM (2.3±0.2) and LDNM (2.7±0.5), compared to C (2.7±0.5), but increased around 5 in O (4.9±0.5; p<0.01 vs. LDM, LDNM and C). CRP was increased in LDM (1.9±0.4mg/L), LNDM (4.1±0.9) and obese (7.0±1.0) (p<0.01 for the 3 vs. C: 0.3±0.3mg/L). CRP differed significantly between LDM vs. C, O and LDNM (p≤0.05 for the 3 vs. LDM). CD3+CD4+ (935±24 vs. 800±69; p=0.03), CD4+ (1077±108 vs. 808±70; p=0.01), CD4+DR+ (90±9 vs. 53±5; p<0.01) and CD25+ (945±113 vs 603±75; p<0.05) were higher in respectively LDM compared to C, but not compared to O (851±65). CD25+ was the only marker different between LDM vs. LDNM (respectively 945±113 vs. 706±96; p=0.04).

Conclusion: Compared to controls, LMNA-mutated lipodystophies were characterized by increased intra/whole abdominal fat ratio, increased CRP, CD4+ and CD25 levels, and similar fat/lean mass and leptin/WAF ratios. Obese patients show increased fat/lean mass and leptin/WAF ratios, increased CRP, but normal intra/whole abdominal fat ratio, compared to controls. Non-LMNA mutated lipodystrophies are intermediate with increased IAF/WAF like LDM, increased FM/LM like obese subjects, increased CRP like both, compared to control, without any specific (CD4, CD25) immunophenotype anomalies, at the difference with LDM. These results suggest that LMNA-mutated lipodystophies are associated with normal trunk fat/lean mass ratio measured in DEXA and specific immunophenotype alterations, compared to non-LMNA mutated lipodystrophies, obese and normal-weighed control subjects.

 

Nothing to Disclose: KL, ASP, SB, OL, GL, ML, IW, MCV

13142 6.0000 SUN-0911 A Increased Intra/Whole Abdominal Fat Ratio and Blood CD4+ and CD25+ Levels, with Normal Fat/Lean Mass Ratio in Lmna-Mutated Lipodystophies, in Contrast with Obese Subjects, By Comparison with Controls 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Elena Parreño Caparrós*1, Fátima Illán Gómez2, Manolo Gonzálvez Ortega2, Isabel Orea Soler2, Maria Luisa Lozano Almela2, Elena Arjonilla Sampedro2 and Maria Soledad Alcaraz Tafalla2
1Hospital de la Vega Lorenzo Guirao, Murcia, Spain, 2Hospital Morales Meseguer, Murcia, Spain

 

INTRODUCTION: Resistin, a new adipokine belonging to the cysteine-rich proteins family known as RELMs (resistin-like molecules) (1) is also called ADSF (adipocyte-specific secretory factor) (2) or FIZZ3 (found in inflammatory zone) (3). Rodent Resistin is expressed predominantly in adipocytes (1-2) while human Resistin is mainly expressed in inflammatory cells (4-6). It has been suggested that human resistin is associated with insulin resistance by inflammation (7).

 Our aim was to study Resistin levels in patients with morbid obesity and lean subjects, as well as analyzing changes in Resistin levels in patients with morbid obesity after significant weight loss due to bariatric surgery. We also assessed other inflammatory and antiinflammatory cytokines and metabolic variables.

METHODS: No randomized clinical trial. A total of 71 patients with morbid obesity and 31 healthy subjects with normal weight were selected. The variables studied in all cases were: anthropometric and adiposity parameters (body mass index (BMI), fat mass, waist-hip ratio) and metabolic variables (glucose, hemoglobin A1c (HbA1c), insulin), inflammatory cytokines (high-sensitivity C-reactive protein (hs-CRP), interleukin 6 (IL-6)), antiinflammatory cytokines (adiponectin) and Resistin. Homoeostasis model assessment (HOMA) and quantitative insulin sensitivity check index (QUICKI) were calculated. Obese patients underwent gastric bypass surgery and, after 12 months and major weight loss, the same variables were reassessed.

RESULTS: Significant differences between Resistin levels among morbid obesity patients and healthy subjects have not been found (9’42 ± 3’81 nanogram/mililiter (ng/ml) and 9’38 ± 4’24 ng/ml), nor between obese patients before and after weight loss (9’42 ± 3’81 ng/ml and 9’46 ± 4’35 ng/ml). However, significant differences between glucose, insulin, HbA1c, HOMA, QUICKI, hs-CRP, IL-6 and adiponectin levels among morbid obesity patients and healthy subjects, and between obese patients before and after weight loss have been found. Resistin levels have not had any correlation with adiposity anthropometric measures, nor metabolic variables, hs-CRP, IL-6 and adiponectin.

CONCLUSION: No significant differences between plasma levels of Resistin in patients with morbid obesity and lean subjects have appeared, and these levels do not change after a significant weight loss after bariatric surgery. Resistin levels have not had any relation with inflammatory and antiinflammatory cytokines and metabolic variables. Our findings do not support that Resistin is associated with insulin resistance by inflammation.

 

Nothing to Disclose: EP, FI, MG, IO, MLL, EA, MSA

13704 7.0000 SUN-0912 A Resistin and Obesity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Paul J Davis*1, Sheng-Huei Yang2, Guei-Yun Cheng3, Heng Yuan Tang4, Hung-Yun Lin5 and Patricia Grasso6
1Albany College of Pharmacy and Health Sciences, 2Taipei Cencer Center, Taipei, Taiwan, 3Taipei Medical University, Taipai, Taiwan, 4Albany College of Pharmacy and Health Sciences, Rensselaer, NY, 5Signal Transduction, Inc, Rensselaer, NY, 6Albany Medical College, Albany, NY

 

Biologically active leptin-related synthetic peptides activate STAT3 via phosphorylation of ERK1/2 and     PI-3K. The similarity of the action of leptin-related synthetic peptide analogs [D-Leu-4]-OB3, OB3, and LEP 116-130 (95-101) on energy balance and glucose homeostasis in insulin-resistant db/db mice to the actions of leptin in ob/ob mice has been confirmed.  The molecular basis of the effects of these peptides, however, remains unclear.  In the present study, we examined the ability of these peptides to activate signal transduction pathways known to be involved in transduction of the leptin signal.   In a specific and concentration-dependent manner, [D-Leu-4]-OB3 induced serine phosphorylation of STAT3 primarily through activation of ERK1/2.  At 10 uM,   [D-Leu-4]-OB3 induced phosphorylation of ERK1/2, STAT3 Ser-727, STAT3 Tyr-705, and PI-3K by 5.57 + 1.24-fold,  3.45 + 0.49-fold,  3.31 + 0.11-fold, and 2.32 + 0.13-fold, respectively.  OB3 also induced activation of STAT3 via phosphorylation of ERK1/2, STAT3 Ser-727, STAT3 Tyr-705 and PI-3K, but to a lesser degree   Using  PD98059 and LY, specific inhibitors of MEK and PI-3K respectively, we were able to differentiate the signal transduction pathways involved in peptide-induced STAT3 activation.  We determined that [D-Leu-4]-OB3 induced serine phosphorylation of STAT3 primarily through activation of ERK1/2.  Tyrosine phosphorylation of STAT3, however, was induced primarily through activation of PI-3K.   Our data suggest that in db/db mice, [D-Leu-4]-OB3 binding to short isoforms of the leptin receptor may induce intracellular signaling cascades which do not require OB-Rb activation, and that these signals ultimately result in peptide-modulated transcriptional and translational events associated with its effects on energy balance and glycemic regulation.  In summary, as is the case for leptin, we have shown for the first time that biologically active leptin-related synthetic peptide analogs activate STAT3 via phosphorylation of serine and tyrosine residues by multiple signal transduction pathways.

 

Nothing to Disclose: PJD, SHY, GYC, HYT, HYL, PG

13748 8.0000 SUN-0913 A Biologically Active Leptin-Related Synthetic Peptides Activate STAT3 Via Phosphorylation of ERK1/2 and PI-3K 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Kathryn Elizabeth Berkseth*1, Eric D. Strachan1, Eric Turkheimer2, Carolyn J. Noonan1, Ally R. Avery1, Dedra S. Buchwald1, Niloo Afari3 and Ellen A. Schur1
1University of Washington, Seattle, WA, 2University of Virginia, Charlottesville, VA, 3University of California San Diego, San Diego, CA

 

Background: There is a clear association between obesity and chronic, low-grade peripheral inflammation.  We sought to determine the relative genetic and environmental contributions to obesity-associated peripheral inflammation through a cross-sectional twin study.

Methods: Same-sex monozygotic (MZ) and dizygotic (DZ) twin pairs, age 18-65 years were randomly selected from the University of Washington Twin Registry.  Subjects with major medical conditions, disability, pregnancy, neuropathy or taking long-term pain medication were excluded.  Anthropomorphic measures including body mass index (BMI) were collected along with blood for inflammatory markers including C-reactive protein (CRP) and interleukins 1a, 1b, and 6. Data were analyzed by using regression models to assess the overall association between BMI and inflammation and then by using bivariate structural equation models (SEM) to determine first the directionality of the association between BMI and inflammation and then the relative genetic and environmental contributions to the associations.

Results: Two hundred twin pairs were included in the final analysis (107 MZ and 93 DZ pairs; 53% female).  There was a significant association between CRP and BMI in the overall model (P<0.01) but no associations between BMI and other inflammatory markers. The magnitude of the BMI-CRP association was such that a 1-unit increase in BMI was associated with a 10.2% increase in CRP.  In the SEM analyses, BMI was strongly genetically determined (heritability=85%) as opposed to CRP (heritability=15%). In terms of directionality, the effect of BMI on CRP was significant (P<0.01) whereas the effect of CRP on BMI was not (P=0.94).  Finally, analysis of the significant BMI-CRP association showed no shared genetic component.

Conclusions: Analyses of MZ and DZ twins in this study demonstrate an association between BMI and CRP, which is the result of BMI affecting levels of CRP and not CRP affecting BMI.  In addition, the positive association between BMI and CRP is independent of genetics.

 

Nothing to Disclose: KEB, EDS, ET, CJN, ARA, DSB, NA, EAS

14146 9.0000 SUN-0914 A Twin Analyses Strongly Suggest That Elevated Body Mass Index Is Causally Related to Elevated C-Reactive Protein 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Annayya R. Aroor*1, Vincent G. DeMarco1, Guanghong Jia1, Zhe Sun2, Mona Garro1, Luis A. Martinez-Lemus2, Gerald A. Meininger2 and James R. Sowers3
1University of Missouri, Columbia, MO, 2University of Missouri, 3Harry S Truman VA Hospital and University of Missouri, Columbia, MO

 

Background Obese premenopausal women display increased risk for cardiac dysfunction in contrast to cardiovascular protection in premenopausal women without obesity. Endothelial dysfunction and arterial stiffness play a central role in the development and progression of diastolic dysfunction and increased arterial stiffness has also been reported in obese women. We examined whether feeding a high fat western diet (WD) mimics these finding in a mouse model of diet induced obesity.

Methods Four week old male and female C57Bl6/J mice were fed a high fructose/high fat western diet (WD) or control diet (CD) for 16 weeks.  2-D echocardiograms were used to evaluate diastolic function and atomic force microscopy was used to evaluate endothelial stiffness ex-vivo.   

Results   Diastolic dysfunction is evident in WD-fed male and female mice compared to age-matched mice fed a control diet (CD) as indicated by impaired LV wall motion (decreased, ratio of early septal motion, E’ to late septal motion, A’ [E’/A’ ratio], 31%  in male and 45% in female, *P<0.05 vs same sex control), prolonged relaxation (increased isovolumic relaxation time [IVRT], 66% in male and 36% in female, *P<0.05 vs same sex control), and abnormal myocardial performance (increased myocardial performance index [MPI], 66% in male and 30% in female, *P<0.05 vs same sex control).  Endothelial cell stiffness was significantly increased (5-fold, P<0.05 vs same sex control) in both male and female WD-fed mice.   

Conclusion These studies suggest a similar predisposition toward developing diastolic dysfunction in male and female mice exposed to a WD accompanied by increased endothelial stiffness.  Therefore the WD-fed mouse model provides a translational model that mimics abrogation of estrogen mediated cardiovascular protection in obese premenopausal women.

 

Nothing to Disclose: ARA, VGD, GJ, ZS, MG, LAM, GAM, JRS

15371 10.0000 SUN-0915 A Increased Endothelial Cell Stiffness and Impaired Diastolic Function in Western Diet Fed Female Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Masanori Tamaki*, Kazutoshi Miyashita, Masanori Mitsuishi, Shu Wakino, Koichi Hayashi and Hiroshi Itoh
School of Medicine, Keio University, Tokyo, Japan

 

Chronic kidney disease (CKD) decreases physical performance of the patients from an early phase of disease, and the physical inactivity constitutes an independent risk for cardiovascular diseases and renal prognosis. We have identified a decrease in muscle mitochondria and exercise endurance of 5/6 nephrectomized (5/6Nx) mice, an animal model of mild CKD, from an early phase. Thereafter muscles mass and power were decreased in aged 5/6Nx mice (1). To improve the physical performance of the CKD model mice, the effect of a gastric hormone, ghrelin, was examined, whose circulating concentration is reported to increase in CKD patients. C57bl/6 mice which had undergone 5/6 nephrectomy at 6 to 7 weeks old were examined for physical performance at 12 weeks. Exercise endurance and muscle power were measured as running distance and grip power by use of treadmill and dynamometer for mice. Ghrelin (0.3 µg/gBW) or IGF-1 (0.3 µg/gBW) was administered intra-peritoneally three times a week from 8 weeks old. C2C12 cultured myocytes were treated for 24 hours with ghrelin (100 nmol/l) and were examined for the effects on mitochondrial energy metabolism, with or without siRNA for PGC1 alpha, which promotes mitochondrial biogenesis. 5/6 nephrectomy decreased muscle mitochondria (100.0±5.3 vs. 75.4±2.3 %; p<0.01) and running distance (587±9.2 vs. 394±18.6 m; p<0.01) of the mice. Serum acylated and des-acylated ghrelin were both increased in 5/6Nx mice (47.7±7.0 vs. 76.8±10.1 fmlol/ml; p<0.05 and 430.3±53.6 vs. 1292.3±59.4 fmol/ml; p<0.01). Ghrelin increased muscle mitochondria (91.4±3.3 vs. 75.4±2.3 %; p<0.01) and running distance (487±15.7 vs. 394±18.6 m; p<0.01) compared with 5/6Nx mice. Either of ghrelin or IGF-1 treatment increased muscle mass (ghrelin: 0.165±0.004, IGF-1: 0.173±0.003 vs. 5/6Nx: 0.145± 0.002 mg; p<0.01) and the power (ghrelin: 262±4.2, IGF-1 273±9.3 vs. 5/6Nx: 247±4.2 mg; p<0.05). Increases in mitochondrial amount (140.3±3.81 vs. 100.0±3.8 %; p<0.01) and oxygen consumption (136.1±8.9 vs. 100.0±5.5 %: p<0.01) were identified in ghrelin-treated C2C12 myocytes, and the effects were suppressed by knocking down of PGC1 alpha gene (mitochondrial amount: 117.5±6.2 %; p<0.01, oxygen consumption: 115.8±3.1 %; p<0.05). We speculated that these results indicate that ghrelin plays a novel role in improvement of physical performance of CKD patients.

 

Nothing to Disclose: MT, KM, MM, SW, KH, HI

14660 11.0000 SUN-0916 A Exercise Endurance of 5/6 Nephrectomized Mice Was Improved By Gastric Hormone Ghrelin through PGC1 Alpha-Dependent Activation of Muscle Mitochondria 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Julio César Sanchez*, Oscar Alonso Pinzón, Diego Fernando López-Zapata and Juan Carlos Sepúlveda-Arias
Universidad Tecnológica de Pereira, Pereira, Colombia

 

Metabolic syndrome (MS), has become epidemic and causes increased morbidity and mortality in the general population. The objective of this study was to compare lymphocyte proliferation under mytogen stimulation with concanavalin A (conA) and insulin, in a group of patients with MS (Group 1) and a healthy group (Group 2). This was an analytical observational study.  Group 1 consisted of 53 patients who met the diagnostic criteria (1) for MS.  Group 2 consisted of 36 first-degree healthy relatives of Group 1 plus 27 healthy non-relatives.  All individuals were evaluated for lipid profile, glycemia, and lymphocyte extraction and culture.  Each subject was evaluated for lymphocyte proliferation by fluorescence emission.  P values <0.05 were considered significant. There was no gender difference among the study participants (p>0.05).  In terms of age, significant differences were found between Groups 1 and 2 (p<0.05).  It was found that when conA concentrations at 1 and 5 ug/ml were added, greater lymphocyte proliferation resulted in both groups compared with higher concentrations.  In contrast, when different concentrations of insulin were added, there was no associated variation in lymphocyte proliferation.  However, proliferation of lymphocytes was significantly higher in Group 1 compared to Group 2 under insulin stimulus, which did not happen under conA stimulus.  Even after age and gender correction, this difference was maintained. This study found an elevated lymphocyte proliferative response to insulin in patients with MS, suggesting an important role of lymphocytes and insulin in the pathophysiology of MS, and making this response a biological-immunological marker for MS.  According to the observed responses, it is necessary to evaluate the lymphocyte-insulin pathway in order to find early markers of MS.

 

Nothing to Disclose: JCS, OAP, DFL, JCS

17048 12.0000 SUN-0917 A Evaluation of Human Lymphocyte Proliferation Associated with Metabolic Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Mirna Bastos Marques1, Thomas Janssens1, Fabian Güiza Grandas2, Sarah Vander Perre1, Sarah Derde1, Greet Van den Berghe1 and Lies Langouche*1
1KU Leuven, Leuven, Belgium, 2KU Leuven, Belgium

 

Premorbid overweight and obese patients appear to have a survival benefit during critical illness, referred to as the ‘obesity paradox’. This could in part be explained by a protective role of excess adipose tissue during critical illness. We previously demonstrated that M2 macrophages accumulate in adipose tissue and more smaller adipocytes with higher storage properties are formed during critical illness, in human patients and in animal models. We hypothesized that these alterations may provide a larger storage depot which could protect against ectopic lipid deposition, predominantly in the fed state.

In a centrally catheterized mouse model of sepsis-induced prolonged (5 days) critical illness, the impact of premorbid obesity was assessed in the fasted and in the parenterally-fed state. Survival, body composition, ectopic lipid deposition, adipocyte size and macrophage accumulation were studied.

Obese and lean mice were generated by a 12 weeks diet of 45% fat versus 10% fat prior to the septic insult. Mice were then randomized to either fasting or parenteral nutrition. Fasted obese septic mice displayed a better survival (90%) than the 3 other septic groups (fed obese 56%, fasted lean 60%, fed lean 64%). After 5 days of illness, obese mice lost more fat mass than lean (p≤0.03), irrespective of nutrition, but maintained a higher body weight (p≤0.01) and more fat mass (p<0.0001). During critical illness, lean mice lost ectopic lipids (p≤0.03) and lean tissue (p≤0.04) whereas this did not occur in obese mice, irrespective of nutrition. The median size of adipocytes became smaller with illness in lean (p<0.05) but not in obese mice. During critical illness, obese mice maintained higher adipocyte leptin expression (p≤0.03) and showed a larger number of adipose tissue M2 macrophages (p≤0.05) producing anti-inflammatory cytokines and Arginase-1, which could theoretically play a role in the preserved lean tissue mass.

In conclusion, the survival benefit of obese critically ill mice was only present in the fasted, not in the fed state. The hypothesis that survival benefit would be attributable to prevention of ectopic lipid accumulation was not confirmed. Instead, premorbid obesity appeared to favor the use of lipids from the adipose tissue as metabolic substrate, hereby preventing loss of ectopic lipids. Most importantly, premorbid obesity, but not the nutritional regimen during critical illness, was able to totally prevent illness-induced lean tissue wasting.

 

Nothing to Disclose: MBM, TJ, FG, SV, SD, GV, LL

13638 13.0000 SUN-0918 A Premorbid Obesity, but Not the Nutritional Regimen during Critical Illness, Prevented Illness-Induced Lean Tissue Wasting in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Gabrielle Page-Wilson*1, Kana Meece1, Michael Rosenbaum2, Rudolph L Leibel2, Anne White3, Richard M. Smiley1 and Sharon L. Wardlaw1
1Columbia University College of Physicians & Surgeons, New York, NY, 2Columbia University College of P&S, New York, NY, 3University of Manchester, Manchester, United Kingdom

 

The brain melanocortin system is regulated by leptin and insulin and plays a critical role in maintaining energy balance. Physiological studies of this system in humans have been limited by the lack of reliable biomarkers for brain melanocortin activity. This study focuses on proopiomelanocortin (POMC) measurements in human cerebrospinal fluid (CSF) as studies in rodents show that levels of the intact POMC prohormone in CSF reflect hypothalamic POMC activity. CSF was collected by lumbar puncture and blood was collected in the morning after an overnight fast in 45 healthy subjects (21M, 24F) ages 19-50.  22 were lean (L), mean BMI 22.4 and 23 were overweight/obese (O), BMI 33.8. Leptin, soluble leptin receptor (sOB-R) and POMC were measured by sensitive ELISA and insulin by RIA. Mean plasma leptin (ng/ml) was 4.6 ± 0.85(SE) (L) vs 33 ± 5.7 (O); mean CSF leptin (pg/ml) was 119 ± 21 vs 332 ± 29 (O).  As expected plasma leptin correlated strongly with BMI, body fat (DXA) and plasma insulin. Plasma and CSF leptin levels were also strongly correlated (r=0.85; p<0.001).  However, the relative amount of leptin transported into CSF declined with increasing BMI, ranging from 4.5 to 0.52%, consistent with a saturable transport mechanism.  Plasma sOB-R correlated negatively with plasma and CSF leptin. CSF sOB-R was 100-fold lower than plasma and correlated negatively with plasma and CSF leptin (p=0.02). CSF levels of POMC were 14-fold higher than in plasma; CSF and plasma POMC were not correlated. CSF POMC was higher in L vs O subjects (269 ± 16.7 vs 197 ± 11.5 fmol/ml; p<0.001). There was a strong negative correlation between CSF POMC and CSF leptin (r= -0.60; p<0.001).  Significant negative correlations were also noted between CSF POMC and plasma leptin, insulin and BMI.  CSF POMC was higher in males than in females (262 ± 17.4 vs 206 ± 12.9 fmol/ml; p=0.01), however the negative correlation between CSF POMC and leptin remained when the genders were analyzed separately.  CSF POMC was also correlated with CSF sOB-R (r=0.63; p<0.001).  This study shows that high levels of POMC are present in human CSF and that there are significant differences related to adiposity and gender.  The striking negative correlation between CSF leptin and POMC may indicate that POMC plays a primary role in regulating body weight.  Alternatively, the lower level of POMC in obese subjects may be an indication of “leptin resistance” that is well documented in POMC neurons in obese animals.

 

Nothing to Disclose: GP, KM, MR, RLL, AW, RMS, SLW

12403 14.0000 SUN-0919 A Proopiomelanocortin and Leptin Measurements in Cerebrospinal Fluid of Lean and Obese Humans: Correlations with Plasma Leptin, Soluble Leptin Receptor and Insulin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Julia H Goedecke*1, Tommy Olsson2 and Ulf Riserus3
1South African Medical Research Council, Cape Town, South Africa, 2Umeå University, Umea, Sweden, 3Uppsala University, Sweden

 

Previously, we have shown that black South African (SA) women have a greater subcutaneous adipose tissue (SAT) inflammatory profile than white women. We hypothesise that this may be associated with altered metabolism of polyunsaturated fatty acids (PUFA), specifically the pro-inflammatory n-6 PUFA, arachidonic acid (AA). AA levels are dependent on dietary intake and metabolic processing of its precursor linoleic acid (LA) by the activity of desaturase enzymes. The aim of the study was to compare serum fatty acid composition and desaturase enzymes between black and white SA women. Serum fatty acid composition and gluteal SAT inflammatory gene expression was measured in 60 BMI-matched black and white SA women. Although LA tended to be higher (57.7±4.4 vs. 55.9±3.7%, P=0.079) in black compared to white women, its metabolites, γ-linolenic acid (GLA; 0.70±0.29 vs. 0.89±0.31, P=0.015) and dihomo-γ-linolenic acid (DGLA; 0.67±0.14 vs. 0.76±0.15, P<0.001) were lower, while AA (9.2±1.8 vs. 7.9±1.4, P=0.004) was higher. These differences may be explained by lower δ6 desaturase (D6D; 0.012±0.006 vs. 0.016±0.006, P=0.017), which catalyses the conversion of LA to GLA, and higher δ5 desaturase (D5D; 14.1±2.8 vs. 10.6±2.9, P<0.001), which catalyses the conversion of DGLA to AA, in black compared to white women. Lower LA, and higher DGLA and AA levels were associated with increased SAT expression of the inflammatory cytokine, tumour necrosis factor-α (TNFα) (LA: r=-0.49, P=0.007; DGLA: r=0.51, P=0.005; AA: r=0.39, P=0.03) in black, but not white women. In conclusion, we showed ethnic differences in desaturase activites and the associations with serum FA and SAT inflammatory profile in black and white women. The implications of altered PUFA metabolism for disease risk needs to be investigated, including the role of diet in these relationships.

 

Nothing to Disclose: JHG, TO, UR

12080 15.0000 SUN-0920 A Ethnic Differences in n-6 Polyunsaturated Fatty Acid Metabolism and the Association with Inflammatory Gene Expression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Rachana Dahiya*1, Sarah P. Shultz2, John Cardinal3, Nuala Byrne4, Andrew P. Hills5, Kristen Gibbons5, Louise S. Conwell6, Mark Harris7 and Gary Martin Leong8
1The University of Queensland, Herston, Australia, 2Massey University, Wellington, New Zealand, 3Pathology Queensland, Herston, Australia, 4Institute of Health and Biomedic, Brisbane, QLD, Australia, 5Mater Research - UQ, South Brisbane, Australia, 6Royal Children's Hospital, Brisbane, Australia, 7Mater Children's Hosp, South Brisbane, Australia, 8The University of Queensland and Mater Children's Hospital, St Lucia QLD, Australia

 

Background: Adolescent obesity is associated with inflammation, insulin resistance and prediabetes.  Resistance training (RT) may have anti-inflammatory effects and decrease the risk of Type 2 diabetes. Objective: To investigate whether resistance training (RT) improves the adipokine profile, body composition and insulin sensitivity of obese adolescents. Methodology: Fourteen obese adolescents (16.1+1.6 y; M:F 6:8; body mass index (BMI) SDS 2.01 + 0.31) were recruited for a 16-week RT intervention. Thirty-one lean youth (15.6+1.3 y; M:F 19:12; BMI SDS -0.03+0.07) had baseline anthropometric measurements and blood tests for comparison.  Participants completed 3 RT sessions per week with training load progressively increased from 60% to 85% of one repetition maximum (1-RM). The following parameters were examined pre- and post-intervention: 1) Height, weight, BMI; 2) High sensitivity C-reactive protein (hs-CRP) and adipokines including interleukin (IL)-1b, IL-6, tumor necrosis factor-alpha (TNF-a), adiponectin, soluble intercellular adhesion molecule (sICAM)-1, leptin and resistin; 3) Body composition by dual energy x-ray absorptiometry (DXA), and 4) Insulin sensitivity by homeostatic model assessment (HOMA-IR). Results: Obese youth had significantly higher IL-1b, leptin and resistin (all p<0.0001) and lower adiponectin and sICAM-1 (both p<0.0001) at baseline compared with lean youth. Post-intervention, a reduction in IL-6 (p<0.01), IL-1b (p<0.01) and resistin (p <0.001) was observed whereas adiponectin and sICAM-1 increased (p<0.05, p<0.001 respectively) in obese adolescents. HOMA and hs-CRP remained unchanged. IL-1b and sICAM-1 levels in obese youth normalised to levels comparable to lean youth post-intervention (p = 0.1 and p=0.2), whereas TNF- a  and resistin were significantly lower (p<0.05, p<0.01 respectively) post-intervention in the obese youth. Percent fat for the trunk, arm and total body (p<0.05) were reduced, while fat free mass (p<0.01) was increased after the intervention. Conclusions: RT is a feasible intervention to improve the adipokine profile and body composition of obese adolescents suggesting it may be a feasible intervention for improving metabolic health in obese youth at high risk of type 2 diabetes.

 

Nothing to Disclose: RD, SPS, JC, NB, APH, KG, LSC, MH, GML

13701 16.0000 SUN-0921 A Resistance Training Improves Metainflammation and Body Composition in Obese Adolescents 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Kanthi Bangalore Krishna*1, Robert o'Doherty2, Maja Stefanovic-Racic3, Ian Sipula2, Nikolaus Dedousis2 and Gabriele Schoiswohl4
1Children's Hospital of Pittsburgh, Pittsburgh, PA, 2University of Pittsburgh, 3Univ of Pittsburgh, Pittsburgh, PA, 4University of Pittsburgh, Pittsburgh, PA

 

Insulin resistance (IR) is present in ~50% of adults aged 65+ years. Aging is also associated with altered immune competence and a proinflammatory state. While myeloid and lymphoid immune cell infiltration of AT and liver play a role in the pathogenesis of the IR associated with obesity, their role in the IR of aging is unknown. Here, we evaluated the immunophenotype, using flow cytometry, of AT and liver of young (18 weeks, C57BL/6J) lean, insulin sensitive mice (low (11%) fat diet, YLIS), young obese insulin resistant mice (obesity induced by a high fat (41%) diet, YOIR), aged (17 months) lean insulin sensitive (ALIS), and aged obese insulin resistant (AOIR) mice (both aged groups were fed a low fat (11%) diet throughout their lives). AOIR compared to YLIS had significant increases (~150%) in total AT T-cells (CD3+NK1.1-). Both helper (CD3+CD4+) and effector (CD3+CD8+) T-cells contributed to these increases in AT (both >125%). In liver, only CD3+CD8+ cells were increased (>400%). The majority (~75%) of T-cells were CD62L-, suggesting that they were activated. Notably, however, the T-cell increases were also present in ALIS, despite similar IS compared to YLIS. Furthermore, AOIR mice had higher T-cell content in AT and liver compared to YOIR, despite being markedly less IR (~50%). There were no differences in B-cells between the four groups, and there were no differences in the macrophage (MAC) or dendritic cell (DC) content of AT or liver between AOIR, ALIS and YLIS. However, YOIR had significantly more MAC and DC compared to all other groups. Taken together, these data demonstrate an aging-associated increase in the infiltration of activated T-cells into AT and liver, which occurs independent of adiposity changes (compare AOIR vs ALIS) or diet exposure (compare AOIR vs YOIR). Importantly, this elevated infiltration does not negatively impact IS (compare AOIR vs ALIS, and AOIR vs YOIR).

 

Nothing to Disclose: KB, RO, MS, IS, ND, GS

13828 17.0000 SUN-0922 A Liver and Adipose Tissue (AT) T-Cells Do Not Contribute to the Insulin Resistance of Aging 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Holly Eugenia Sikes Resuehr*1, Amy Miskimon Goss1, Gordon Fisher2, Gary Hunter1, Richard Shelton1 and Barbara Ann Gower3
1University of Alabama at Birmingham, Birmingham, AL, 2University of Alabama at Birmingham, 3Univ of AL at Birmingham, Birmingham, AL

 

Objective: Depression has been linked to excess adiposity, intra-abdominal adipose tissue (IAAT), and inflammation.  However, the causative nature of these relationships remains unclear.  This study was designed to test the hypothesis that improvement in depressive symptoms with weight loss is due to a reduction in markers of inflammation (MOI), which occurs secondary to reduction in IAAT.  The specific associations tested were: 1) whether a decrease in depressive symptoms with weight loss is associated with decreases in both visceral fat and MOI; 2) whether reduction in IAAT is associated with reduction in MOI; and 3) whether  improvement in depressive symptoms with weight loss is associated with reduction in MOI independent of changes in IAAT.

Method: This was a longitudinal study designed to look at healthy, overweight (BMI 27-30 kg/m2), premenopausal women before and after weight loss through diet or diet plus exercise interventions.  Depressive symptoms were evaluated using the Beck Depression Inventory-II, (BDI).  Body composition was measured with DXA, and IAAT with CT scanning.

Results:  Total body adiposity, MOI, and BDI scores were all significantly reduced after weight loss. Change in BDI score was independently associated with change in IAAT after adjustment for change in total fat mass (Std β=-0.22, p<0.05).  Change in BDI score was  also independently associated with change in TNF-α after adjusting for the change in total fat and change in IAAT (Std β=-0.22, p<0.05).

Conclusions:  The improvement (decrease) in depressive symptoms with weight loss was significantly and independently correlated with reduction in both IAAT and TNF-α.  Thus, loss of body fat may relieve depressive symptoms through multiple mechanisms.

 

Nothing to Disclose: HESR, AMG, GF, GH, RS, BAG

15396 18.0000 SUN-0923 A Sad Fat: The Relationship Between Depression, Visceral Fat, and Markers of Inflammation before and after Weight Loss 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Gabriel Ángel Martos-Moreno*1, Andrea Bartucci2, Vicente Barrios3, Arturo Minguez4, Sara Sirvent5, Guillermo Martínez6, Federico G Hawkins6 and Jesús Argente7
1Hospital Nino Jesus.Instituto de Investigación La Princesa. UAM. ISCIII.., Madrid, Spain, 2Hospital Nino Jesus, Madrid, Spain, 3Hospital Infantil Universitario Niño Jesús. Universidad Autónoma de Madrid. CIBERobn, Instituto de Salud Carlos III, Madrid, Spain, 4Hospital Niño Jesus. Instituto de Investigación La Princesa, Madrid, Spain, 5Hospital Niño Jesús, Madrid, Spain, 6Hospital Universitario 12 de Octubre, Madrid, Spain, 7Hospital Infantil Universitario Niño Jesus, Universidad Autonoma de Madrid, CIBERobn Instituto Carlos III, Madrid, Spain

 

Liver steatosis (LS) is diagnosed in obesity even at very early ages, with insulin resistance (IR) and dyslipidemia involved in its pathophysiology.

We aimed to investigate the demographic, phenotypic and metabolic features of patients diagnosed between 2008 and 2013 with obesity (BMI>+2SDS) associated LS by ultrasonography (US) at baseline (B; n=88); their management strategy and evolution at their first US control (1C; n=25).

Analyzed variables were: Demographic: Age, race, sex, pubertal stage. Anthropometric: BMI-SDS, waist-SDS and body composition (DXA) and abdominal fat distribution (MRI) when available (n=27 at B). Metabolic: Baseline or after OGTT (1.75 g/kg, maximum 75g, n=54 at B) glucose and insulin levels and derived indexes (HOMA, WBISI, insulinogenic index); HbA1c; lipid profile, apoprotein-A1 and B, liver enzymes, uric acid. Adipokines: Leptin (RIA), leptin receptor (ELISA), total (RIA) and HMW-adiponectin (ELISA) (n=43 at B). Management: Achievement of BMI reduction, metformin use or no.

Mean age and BMI were 12.07±2.81 years and 4.60±2.81SDS, respectively; 71.6% males/29.4% females (61.2% pubertal). Caucasian (56.5%) and Hispanic races (41.2%) predominated, with no differences in age, BMI, sex or pubertal stage distribution between groups. LS was mainly diffuse (97.7%) and mild (65.9%). Patients with moderate-severe LS (31.8%) had lower WBISI and HDL (both p<0.05); higher AST (p<0.05), ALT (p<0.01), apoprotein-B (p<0.05) and LDL/HDL-ratio (p<0.05). Their trunk/lower-limb fat-ratio (Trunk/LL, DXA) and visceral/subcutaneous abdominal fat-ratio (Vis/Sq, MRI) were higher (p<0.05) than in mild LS. Serum liver enzymes were increased in 40.5% (in 14.3% both AST and ALT), with lower levels in females vs. males and prepubertal children vs. adolescents (p<0.05). These patients had higher glucose and insulin at 30 minutes in the OGTT (p<0.05 and p<0.01), cholesterol, apoprotein-B, cholesterol/HDL and LDL/HDL-ratios (p<0.05) and higher Trunk/LL and Vis/Sq ratios (p<0.05). IR prevalence was 65.8%, mean HOMA 4.62 and HbA1c was >5.7% in 35.9% patients. Over 30% of patients had dyslipidemia (mainly HDL decrease and VLDL increase) and 79.4% low vitamin D (<20 ng/ml), both alterations were more severe in Hispanics (p<0.05) as was acanthosis nigricans (p<0.01). At 1C (n=25; mean 1.88 years after B) 17 patients (68%) improved LS determined by US (10 resolved [40%]), with greater decreases in BMI-SDS, apolipoprotein-B and insulin (all p<0.05) than those not improving LS.

We conclude that greater severity of OB-LS as determined by US or AST/ALT elevation is associated with more intense visceral adiposity and metabolic impairment, which are also influenced by race, sex and pubertal stage. Weight reduction can reverse LS, resulting in an improved metabolic status.

 

Nothing to Disclose: GÁM, AB, VB, AM, SS, GM, FGH, JA

16697 19.0000 SUN-0924 A Liver Steatosis in Obese Children and Its Associated Metabolic Impairment Are Influenced By Gender, Race and Pubertal Status and Reversed after Weight Reduction 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Jacqueline Cavalcante Silva*1, Edson Mendes1, Marcela Frota Cavalcante1, Ivan da Rocha Pitta2 and Dulcineia Saes Parra Abdalla1
1University of Sao Paulo, Sao Paulo, Brazil, 2Federal University of Pernambuco, Pernambuco-PE, Brazil

 

Metabolic syndrome (MetS) can be defined as a group of conditions that increases cardiovascular diseases and diabetes risk, with obesity, dyslipidemia, arterial hypertension and insulin resistance or glucose intolerance as clinical features. People aged 20 to 70 years have a MetS prevalence of 24% in the world. Inflammation and insulin resistance, also triggered by obesity, are demonstrated in metabolic syndrome what qualify them as interesting targets to new therapeutic approaches. The anti-diabetic oral drugs class of thiazolidinediones (TZDs) can be appointed as an alternative treatment of MetS. During the last years, many groups are working in the development of new thiazolidine compounds, intending to identify more effective drugs with fewer adverse effects. The aim of this study was to evaluate the biological effects of some of these new compounds in MetS induced by diet in C57BL/6J and C57BL/6J LDLr -/- mice. A new thiazolidine compound, GQ-11, showed hypoglycemic and immunomodulatory effects in adipose tissue of treated mice. In fact, GQ-11 induced IL-10 upregulation in both strains of treated mice suggesting M2 macrophages recruitment with anti-inflammatory action. Moreover, GQ-11 modulated Mcp1, Pecam, Vcam and Vegf gene expression in epididymal white adipose tissue. The down-regulation of Mcp1, Vegf, Pecam and Vcam gene expression promoted by GQ-11 may decrease monocyte/macrophages recruitment to adipose tissue improving the pro-inflammatory state in diabetes.

 

Nothing to Disclose: JCS, EM, MFC, IDRP, DSPA

15212 20.0000 SUN-0925 A Immunomodulatory Effects of a New Thiazolidine Compound in C57BL/6J and C57BL/6J Ldlr -/- Mice with Metabolic Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Izabela Maciejewska-Paszek1, Elzbieta Grochowska-Niedworok2, Andrzej Siwiec3, Lechoslaw Dul4, Anna Gruenpeter3 and Tomasz Jerzy Irzyniec*1
1Medical University of Silesia, Katowice, Poland, 2Medical Univesity of Silesia, Katowice, Poland, 3The John Paul II Pediatric Center, Sosnowiec, Poland, 4Medical University of Silesia, Katowice

 

Background: In case of failure of a combination therapy of  Juvenile Idiopathic Arthritis (JIA) with at least two traditional drugs, etanercept is given to control the illness intensity and complications. Etanercept  is a receptor protein  p75 Fc  which reacts with human tumour  necrosis factor alpha (TNF α). It is proven, that leptin synthesis depends on ob gene. TNF α stimulate ob gene expression. Pharmacological influence leading to weakening TNF α activity may cause changes of synthesis, and physiological leptin activity.  Even though ghrelin may not be considered literally a leptin’s antagonist, its different influence on hunger, particularly in probable leptin activity decrease, suggests the research on ghrelin being worth starting.

Aim: The aim of our research was to assess leptin and ghrelin activity change caused by etanercept given to the children with JLA.

Patients  and methods: Leptin and ghrelin activity in the organisms of children between 4-18 y, ill of JLA treated with etanercept were examined. The examined group (IA) included 25 children. During the research, they received diversified doses of etanercept (60-332). The control group (IC) consisted of healthy children (n=16). The nutrition level of examined groups was assessed on a basis of  body mass index  (BMI).  In the serum leptin [L], total [Grel tot]  and acyl ghrelin [Grel ac ] was determined.

Results: In healthy children we observed positive correlation between [L] and [Grelac] Tau=0,62.  In ill children population the BMI growth caused also the [L] increase. The influence of BMI on [L] was average /moderate (rs.= 0,67). The BMI growth stimulates the [Grel tot] increase r=0,86 so the influence of BMI on [Greltot] is considerable. The dependence model between [Greltot] and BMI was found, also correlated with age, which means that both BMI and age of ill children influence the [Greltot]. For the ill children with BMI < 23 kg/m2, the growth of BMI decreases [Grelac], however the BMI influence on [Grelac] is slight (rs= - 0,49).

Conclusion: From data presented in this study it seems that etanercept treatment of Juvenile Idiopathic Arthritis may influence leptin and ghrelin secretion and/or activity.

 

Nothing to Disclose: IM, EG, AS, LD, AG, TJI

16225 21.0000 SUN-0926 A Leptin and Ghrelin Secretion in Children with Juvenile Idiopathic Arthritis Treated with Etanercept 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0906-0926 4843 1:00:00 PM Obesity and Inflammation Poster

Ja Hye Kim*1, Yoo-Mi Kim1, Beom Hee Lee2, Jin-Ho Choi2 and Han-Wook Yoo1
1Asan Medical Center Children's Hospital, Seoul, Korea, Republic of (South), 2Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea, Republic of (South)

 

Background: Management of congenital adrenal hyperplasia (CAH) during transition period from pediatric to adult life is still challenging and special attention should be given to achieve normal growth and puberty, minimize virilization of females, prevent metabolic syndrome, and optimize fertility. This study was aimed to characterize clinical course and long-term complications in adolescents and adults with CAH caused by 21-hydroxylase deficiency.

Methods: Forty-two CAH patients aged from 11.5-51 years were included (27 females with 9 salt-wasting (SW) form and 18 simple virilizing (SV) form; 15 males with 12 SW and 3 SV form). We reviewed growth, pubertal status, metabolic complications, and long-term morbidities.

Results: Twenty six of 42 patients (57.8%, 19 females and 7 males) reached their final adult height and the mean adult height was 153.3 ± 5.3 cm (-1.8 ± 1.2 SDS) in females and 162 ± 5.6 cm (-2.3 ± 1.0 SDS) in males. In 19 females who reached final adult heights, patients with SV form were significantly shorter than those with SW form (p=0.04). The mean age at pubertal onset was 9.5 ± 1.1 years in females and 10 ± 2.2 years in males, and central precocious puberty was documented in 7 patients (16.7%). The mean age at menarche was 12.2 ± 2.3 years and 52.6% of patients showed regular menstruations. Twenty one adolescents (age range, 11.2-17.5 years) revealed normal body mass index (BMI) (13 females, 20.9 ± 2.4 kg/m2; 8 males, 20.7 ± 3.3 kg/m2), however, BMI was elevated in 21 subjects in adult period (age range, 18-51 years) (14 females, 24.7 ± 4.2 kg/m2; 7 males, 24.1 ± 4.5 kg/m2)(p=0.002). Hypercholesterolemia was detected in 12 patients (28.6%) and hypertension in only 1 patient (2.4%). Hypercholesterolemia was more prevalent in adults (p = 0.004 by chi-square test), but it was not associated with type and dose of glucocorticoid. Four males with SW form (33.1%) were diagnosed with testicular adrenal rest cell tumor at median age 18.2 years (range, 6.5-24 years). Adrenal tumors were found in 4 patients at mean age 26.9 years (range, 6.5-50 years). Of 6 females of child-bearing age, 2 patients attempted to conceive, but failed to be pregnant spontaneously. Three genetic females raised as male, were diagnosed later in life (median 29.2 years, range 22-50 years) and they have been under regular testosterone injection therapy.

Conclusion: Reduced final adult height was prominent in females with SV form, which could be caused by delayed diagnosis and consequent advancement of bone age and early puberty. As BMI increased in adulthood, we should monitor metabolic profiles when they enter the adolescent period. In addition, regular testicular examination and ultrasonography should be performed. Other clinical consequences such as osteoporosis, cognitive function, and psychosexual development should be evaluated during transitional period.

 

Nothing to Disclose: JHK, YMK, BHL, JHC, HWY

12773 1.0000 SUN-0121 A Endocrine Consequences of Congenital Adrenal Hyperplasia (CAH) during Transition Period from Adolescent to Adult 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0121-0136 4848 1:00:00 PM Adrenal Pediatric Endocrinology Poster

Markus Bettendorf*, Daniela Choukair and Janna Mittnacht
University Hospital Heidelberg, Heidelberg, Germany

 

Introduction: In the last decades the majority of children with chronic endocrine diseases survive into young adulthood after receiving comprehensive medical care in pediatrics. 25-50% of pediatric patients are lost for follow-up visits in adult care. Therefore it seems imperative to establish a structured medical transfer from pediatric to adult health care. Consequently we established a standardized medical and psychological work-up in order to identify disease specific morbidity and to comprehend quality of life in adolescents with chronic endocrine diseases at the time of transition from pediatric to adult care as a basis to define individual needs for patient care in early adulthood.

Methods: Patients with chronic endocrine diseases were selected based on their prevalence in our outpatient cohort: Turner syndrome (TS), congenital adrenal hyperplasia (CAH), congenital hypopituitarism (HP), congenital primary hypothyroidism (CH) and small-for-gestational-age-children (SGA). The quality of life was examined by quality of life questionnaires KIDSCREEN and DISABKIDS in adolescence after reaching final height (girls: bone age ≥ 14 years and menarche; boys: bone age: ≥ 16 years and voice breaking). The KIDSCREEN is a generic instrument to measure health related quality of life in children and adolescents. The DISABKIDS is an instrument to assess health related quality of life in children and adolescents with chronic diseases. Scale scores are transformed into transformed raw scores (TRS) ranging from 0-100, with higher scores indicating better quality of life. Patients and parents gave informed consent to participate in this evaluation which was approved by the local ethics committee.

Results: In the period from May 2010 to October 2013 a total of 89 patients (54 females, 35 males) were eligible to participate in this study: TS (n=19), CAH (n=16), HP (n=3), CH (n=32), SGA (n=10) and others (n=9). Chronological ages ranged from 14.3 to 30.6 years. DISABKIDS mean TRS were 81.3 ± SD 14.7 (reference-TRS mean 76.9 ± SD 18.3 1) and similar in all patient groups. The self-reported mean TRS for the 10 different sub-scales of the quality of life questionnaire KIDSCREEN ranged between 70.9 ± SD 23.7 and 88.4 ± SD 17.3  (reference-TRS range  66.8 ± SD 19.3 and 90.3 ± SD 15.5 2). Again there was no significant difference between the patient groups.

Conclusion: The adolescents with chronic endocrine diseases showed an average quality of life in both quality of life questionnaires DISABKID and KIDSCREEN. The adolescents felt autonomous and no limitation in their life independent of individual diagnoses. The level of quality of life in these patients is encouraging but patients with chronic endocrine diseases still need to be sensitized for their specific morbidity and individual need for specialty care in adulthood. 

 

Nothing to Disclose: MB, DC, JM

14525 2.0000 SUN-0122 A Quality of Life in Adolescents with Chronic Endocrine Diseases at the Time of Transition from Pediatric to Adult Care 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0121-0136 4848 1:00:00 PM Adrenal Pediatric Endocrinology Poster

Marjorie C Golekoh*1, Manasa Mantravadi2, Lindsey Hornung3, Jane Khoury3, Maryam Fouladi2, Susan R Rose3 and Sarah Lawson2
1Children's Hospital of Michigan, Detroit, MI, 2Cincinnati Children's Hospital Medical Center and University of Cincinnati School of Medicine, Cincinnati, OH, 3Cincinnati Children's Hospital Medical Center, Cincinnati, OH

 

Adrenocorticotropic hormone deficiency (ACTHD) is a potentially life-threatening condition observed in many childhood survivors of intracranial malignancy treated with chemotherapy and /or radiation.  Time from tumor diagnosis and therapy to development of ACTHD cannot be ascertained from previous studies.  This lack of knowledge has led to annual surveillance using low-dose ACTH stimulation testing (LDST) for 10-15 years following completion of tumor therapy.  Objectives for this study were identification of incidence and timing to ACTHD onset to allow development of an effective screening strategy among brain tumor survivors. 

We performed a retrospective chart review of 77 children diagnosed with primary brain tumor in the optic (OP) or suprasellar (SS) regions, between 2002 and 2012.  The outcome of interest was ACTHD, defined as peak serum cortisol <18 µg/dL twenty minutes after intravenous administration of 1µg/m2 ACTH. Peak cortisol >20 µg/dL was defined as normal while 18 -20 µg/dL was indeterminate. For those whose evaluation only included random cortisol, ACTHD was defined as cortisol ≤12.9 µg/dL drawn between 0700-0900. Any level ≥13 at any time of the day was considered normal.   

Among this subset of 77 patients (52% female, mean age (±SD) 6.1 ± 4.5y), 69% (53) had OP (mean age 4.8 ± 3.9y) and 31% (24) had SS (mean age 9.0 ± 4.4y).  ACTHD was present in 6 (14.3 % of those who had any ACTH testing, 7.8% of all patients), however 43% (33) have not had any testing.  Two additional patients had indeterminate results.  Of those with ACTHD, 33% (2/6) had OP.  Among the 25% (19/77) who underwent cranial irradiation, 2 (11%) developed ACTHD. The time to onset of ACTHD from tumor diagnosis was 1.3 years (range: -0.02, 4.26) [n=6], and from irradiation -0.2 and 0.75 years [n=2].  Among those who underwent LDST, n=36, the time from diagnosis to initial test was 2.2 years (-0.1 to 8.2) and from therapy was 1.4 years (-3.3 to 6.1). Concurrent endocrinopathies were found in 83% of those with ACTHD vs. 61% of those without ACTHD. 

We conclude that, for patients with optic pathway or suprasellar tumors, monitoring for ACTHD should be done at the time of diagnosis, then annually thereafter.  A follow up screening for ACTHD should be done 4-6 months after completion of cranial irradiation therapy.

 

Nothing to Disclose: MCG, MM, LH, JK, MF, SRR, SL

13786 3.0000 SUN-0123 A Analysis of Prospective Annual Adrenocorticotropin Stimulation Testing Among Survivors of Intracranial Tumor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0121-0136 4848 1:00:00 PM Adrenal Pediatric Endocrinology Poster

Daniel Fiordelisio de Carvalho*1, Giselle Yuri Hayashi2, Claudia Faure3, Carla Gabriella Vallejos3, Vinicius N. Brito4, Berenice B Mendonca5 and Tania A Bachega1
1Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 2Laboratório da APAE SÃO PAULO, Brazil, Sao Paulo, 3Laboratório de Triagem Neonatal da APAE de São Paulo, Brazil, Sao Paulo, 4Laboratório de Hormônios e Genética Molecular-LIM42, Disciplina de Endocrinologia, Hospital das Clínicas, FMUSP, Sao Paulo, Brazil, 5Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular LIM/42, Disciplina de Endocrinologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

 

Congenital Adrenal Hyperplasia (CAH) is an eligible disease for newborn screening programs (NBS) as it is a frequent disorder and its clinical signs can be overlooked in newborns, leading to high mortality. Despite the efficacy of NBS to identify CAH newborns, a high false positive rate (FPR), mainly related to prematurity, is the main concern; whereas earlier sample collection tends to increase the false negative rate. Recently, the CAH diagnosis was included in our national NBS, in which neonatal (N) samples are collected after 72h of life in ~94% of newborns and between 48-72h in the remaining. Objective– To optimize CAH-NBS by adjusting N17OHP values according to birth-weight and sample collection time. Patients and methods– Data of 205,867 NBS tests were analyzed; initially, newborns were screened using a single cutoff (≥20 ng/mL). N17OHP levels were retrospectively evaluated according to sample collection time (G1:48<72h and G2:≥72h) and, simultaneously, to birth-weight (BW) groups (BW1:<1,500g, BW2:1,501-2,000g, BW3:2,001-2,500g and BW4:>2,500g). N17OHP levels were measured by immunofluorimetric assay (serum equivalent). Newborns with abnormal N17OHP levels underwent hormonal confirmatory tests. CYP21A2 sequencing was performed in those with persistently increased serum 17OHP levels. Non-parametric tests were used. Results– Median N17OHP levels significantly differed between G1 and G2 in all BW groups (p<0.05). The 99.8th percentile of N17OHP levels was the best cutoff to distinguish non-affected from CAH newborns, as follows in G1 (BW1:52.5; BW2:54.9; BW3:37.6; BW4:19.8 ng/mL) and G2 (BW1:152.1; BW2:74.7; BW3:60.8; BW4:25.4 ng/mL). The FPR was 5.2% using the single cutoff value ≥20 ng/mL (69% due to prematurity). N17OHP levels adjusted to birth-weight and age at sample collection significantly decreased the FPR to 0.037% and 0.035% in G1 and G2, respectively. Eighteen newborns (9 males, 16 salt-wasting form) disclosed hormonal and molecular CAH diagnosis, N17OHP levels ranged from 31-410 and from 379-480ng/mL in patients from G1 and G2, respectively. The CAH incidence was high (1:11,437) in this pilot study with proven genotyped patients. False negative results were not reported using all aforementioned cutoffs. Conclusion– N17OHP should be adjusted not only according to degree of prematurity, but also to age at sample collection. This standardization is important to optimize the NBS reducing the FPR and, thus, screening costs and parents anxiety.

 

Nothing to Disclose: DFDC, GYH, CF, CGV, VNB, BBM, TAB

16137 4.0000 SUN-0124 A Improving the Effectiveness of CAH Newborn Screening Adjusting 17OHP Levels According to Degree of Prematurity and Age at Sample Collection 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0121-0136 4848 1:00:00 PM Adrenal Pediatric Endocrinology Poster

Noriyuki Katsumata*1, Hidenori Sugawara2 and Etsuro Tokuhiro3
1Natl Res Inst for Child Hlth & Dev, Tokyo, Japan, 2Yokohama City University Medical Center, Yokohama, Japan, 3Odawara Municipal Hospital, Odawara, Japan

 

Context: Congenital adrenal hyperplasia due to steroid 21-hydroylase deficiency (21-OHD) is an autosomal recessive disorder caused by mutations in CYP21A2. Depending on the severity of the clinical manifestations, the disease phenotype is divided into three forms: the salt-wasting (SW) and simple virilizing (SV) forms, also known as the classic forms, and the nonclassic (NC) form, and the disease severity correlates well with the residual enzyme activity of mutant CYP21A2.

Objective: The aims of this study are to describe a novel CYP21A2 mutation in intron 6 (IVS6), and to elucidate functional consequences of the mutation.

Patient and Methods: A Japanese female patient with nonclassic 21-OHD was studied. She had normal female external genitalia and no symptoms and signs of adrenal insufficiency. We performed genetic analysis of CYP21A2 in the patient and parents, followed by transient functional expression studies of the novel mutant CYP21A2.

Results: The patient was a compound heterozygote having an IVS2-13A/C>G mutation in the maternal allele and a novel IVS6+76G>A mutation in the paternal allele. The expression studies indicated that the IVS6+76G>A mutation created a new alternative IVS6 splice donor site at 73 nucleotides downstream from the authentic site, and reduced the immunoreactive 21-hydroxylase protein and enzyme activity to 36% and 41% of the wild type, respectively.

Discussion: The IVS2-13A/C>G mutation is shown to almost completely abolish 21-hydroxylase activity. We have demonstrated that the novel IVS6+76G>A mutation only partially inactivates enzyme activity. Thus, we conclude that the IVS6+76G>A mutation is responsible for the NC phenotype in our patient.

Conclusions: The IVS6+76G>A mutation in CYP21A2 causes erroneous splicing and give rise to the NC form of 21-OHD.

 

Nothing to Disclose: NK, HS, ET

14261 5.0000 SUN-0125 A Novel Intronic Mutation in CYP21A2 Causes Nonclassic Steroid 21-Hydroxylase Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0121-0136 4848 1:00:00 PM Adrenal Pediatric Endocrinology Poster

Mimi S. Kim*1, Anna Ryabets-Lienhard2, Anh Dao-Tran2, Sheree Schrager2, Vicente Gilsanz1, Elana Davidowitz2, Eugene Nguyen2 and Mitchell E. Geffner1
1Children's Hospital Los Angeles, The Saban Research Institute, Los Angeles, CA, 2Children's Hospital Los Angeles, Los Angeles, CA

 

Background: Children with classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency are now developing cardiovascular disease (CVD) risk factors such as obesity and high blood pressure. Ultrasound measures of carotid intima-media thickness (CIMT) provide a graded marker of CVD risk. We examined whether CAH adolescents have increased CIMT when compared to matched controls, and the potential relations between CIMT, gender, androgens, body composition, and metabolic/inflammatory markers in CAH adolescents.

Methods: Twenty adolescents (Tanner IV-V) with CAH were rigorously matched for gender, age, ethnicity, BMI, and waist-to-hip ratio. Anthropometric measures, CIMT determinations (15L8 MHz transducer) and fasting serum lipids, insulin, glucose, androgens (testosterone, androstenedione), 17-hydroxyprogesterone (17-OHP), and inflammatory markers (PAI-1, hs-CRP, homocysteine, leptin, 25-OH vitamin D) were obtained. Whole body (WB) DXA (total, trunk, and arm %fat) was used to assess body composition, and single-slice CT was used to quantify visceral and subcutaneous abdominal fat. An additional 8 unmatched obese adolescent CAH cases were included in within-group analyses. Pearson correlations were used to test variable associations within cohorts, and t-tests were used to compare cases to controls. The criterion for significance was α = 0.05 in all analyses.

Results:Between adolescents with CAH (16 ± 3.3 y, 50% female, 35% obese) and matched controls (16.5 ± 2.4 y, 50% female, 30% obese), there was no significant difference in CIMT [0.34 ± 0.04 vs. 0.35 ± 0.04 mm: t(df) = -0.74, p = 0.46]. Among CAH (15.6 ± 3.2 y, 54% female, 50% obese), CIMT was greater in males than females [0.37 ± 0.04 vs. 0.33 ± 0.04 mm, t(df) = 2.49, p = 0.02], and correlated positively with androstenedione (r = 0.46, p = 0.01) and 17-OHP (r = 0.48, p = 0.01). There was no difference in CIMT between salt-wasting and simple-virilizing CAH types. Similar to controls, CIMT was greater in obese than non-obese CAH [t(df) = -2.65, p = 0.01], but did not correlate with waist-to-hip ratio, BMI %ile, WB DXA, abdominal fat, HOMA-IR, or inflammatory markers. Conversely, in controls, CIMT correlated positively with BMI %ile, WB DXA, leptin, and abdominal fat. HDL was inversely associated with CIMT in obese CAH (r = -0.4, p = 0.04) and controls (r = -0.47, p = 0.04).

Conclusion: We found no significant difference in CIMT between CAH adolescents and matched controls, despite power > 0.99 to detect previously published effects. We found a sex difference in CAH similar to large, normative CIMT populations; nonetheless, these measures were significantly related to androstenedione, 17-OHP, and obesity in adolescents with CAH.

 

Nothing to Disclose: MSK, AR, AD, SS, VG, ED, EN, MEG

11906 6.0000 SUN-0126 A Carotid Wall Thickness in Adolescents with Classical Congenital Adrenal Hyperplasia Is Not Different from Matched Controls 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0121-0136 4848 1:00:00 PM Adrenal Pediatric Endocrinology Poster

Dwaipayan Muhuri*, Mabel Yau, Ahmed Khattab, Christian Enrique Pina and Maria I New
Icahn School of Medicine at Mount Sinai, New York, NY

 

The long-term outcome of final height in 25 males with 21-Hydroxylase-Deficient Non-Classical Congenital Adrenal Hyperplasia (21-OHD NC-CAH) aged 6-34 years old who were all treated with glucocorticoids was evaluated.  For good hormonal control, glucocorticoid dosing was adjusted to keep 17-Hydroxyprogestorone (17-OHP) level less than 1000 ng/dL and D4-Androstenedione (D4) level less than 400 ng/dL. 

All 25 males satisfy the phenotypic-genotypic correlation commonly seen in 21-OHD NC-CAH patients by either having a V281L mutation in Exon 7 or a P30L mutation in Exon 1.  Interestingly, a greater prevalence of V281L mutation was observed in the 13 males of Ashkenazi Jewish descent where 9 were homozygous and the remaining 4 were carriers.  Four 21-OHD NC-CAH males with P30L Exon 1 mutation but no V281L Exon 7 mutation were Non-Jewish.

To evaluate height, these 25 males with 21-OHD NC-CAH were divided into two groups.  Group 1 consisted of 16 patients who had reached their final height after adolescence either by having a growth rate of less than 1 cm per year or with a bone age of greater than 17 years.  Final heights of 14 out of 16 patients either met or exceeded their respective target heights with a 2% margin of human error.  Group 2 consisted of 9 males with 21-OHD NC-CAH who were still growing at the time of data collection for whom the predicted final height was calculated before and after treatment.  Almost all had improved final height predictions with glucocorticoid treatment. 

Testicular sonograms in 6 of the 25 patients with 21-OHD NC-CAH were evaluated for the presence of testicular adrenal rest tumors (TART) with only one abnormal finding of TART.  This patient was in poor hormonal control as was evident by elevated levels of 17-OHP and D4.

Usually, advanced bone age owing to elevated adrenal androgen secretion results in poor height prediction, with un-treated patients frequently failing to reach their respective target heights.  Our data from Group 1 and Group 2 demonstrated slowing of bone age advancement in conjunction with improved height prediction, suggesting a therapeutic effect of cortisol in lowering androgen levels and thereby estrogen levels which have been documented to increase epiphyseal fusion.  The cortisol therapy also decreases chronic ACTH stimulation of testicular adrenal rests.  This prevents hypertrophy and destruction of the testicular parenchyma leading to improved fertility and normal testosterone levels in males.

 

Nothing to Disclose: DM, MY, AK, CEP, MIN

12877 7.0000 SUN-0127 A Improved Height Outcome and Decreased Prevalence Rate of Tarts in Males with Non-Classical Congenital Adrenal Hyperplasia Under Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0121-0136 4848 1:00:00 PM Adrenal Pediatric Endocrinology Poster

Martin J Whitaker*1, Dena Digweed2, Sarah Spielmann3, Hiep Huatan2, David Eckland2, Trevor Johnson4, Geoff Tucker4, Oliver Blankenstein5, Heiko Krude6 and Richard J Ross7
1University of Sheffield, 2Diurnal Limited, 3Charité Universitätsmedizen Berlin, Germany, Berlin, Germany, 4Simcyp, United Kingdom, 5Charité Universitätsmedizin Berlin, Berlin, Germany, 6Charité - Universitätsmedizin Berlin Campus Virchow, Berlin, Germany, 7University of Sheffield, United Kingdom

 

Background: Current treatment for adrenal insufficiency in neonates and infants is unsatisfactory as unlicensed adult formulations are used and the minimum unit dose available is a scored 5mg hydrocortisone tablet.  These are difficult to administer to neonates and give rise to inconsistencies in dose as content uniformity of crushed tablets cannot be verified. We have developed a new formulation, Infacort®, specifically designed for infants and neonates, and present results of an adult phase 1 study.

Methods:Infacort®is an immediate release formulation of hydrocortisone that is provided in capsules containing multi-particulate granules at appropriate doses of 0.5, 1, 2 & 5 mg. The granules are designed with a taste masking layer to permit compliant oral dosing. This study evaluated the pharmacokinetic performance of Infacort® and its safety.  Infacort® was compared to 10 mg adult immediate-release hydrocortisone tablets in an open-label, randomised crossover study in 16 dexamethasone suppressed healthy adults.

Results: The pharmacokinetic results for 10mg Infacort® vs 10mg hydrocortisone immediate release were: Cmax  LSmean 566 vs 598 nmol/l, ratio Infacort® to hydrocortisone (90% CI),  95 (84-107); AUC0-inf  LSmean 1602 vs 1576 hr*nmol/l, ratio Infacort® to hydrocortisone (90% CI), 101 (96-107); Tmax LSmean 0.75 vs 1.00 hr, mean difference Infacort® to hydrocortisone (95% CI), 0.0 (-0.5-0.3). Infacort® & hydrocortisone at a dose of 10 mg were bioequivalent, as reflected by geometric LSmean 90 % CI for ratios of Cmax, AUC0-t and AUC0-inf within 0.8 – 1.25. Infacort® was tested for dose-proportionality between 0.5 mg – 10 mg; Cmax, AUC0-t and AUC0-inf were shown to increase in a linear fashion and were dose-proportional when adjusted for protein binding. The majority of subjects described Infacort® as, “not good or bad”, for smell (81.3% to 87.5 % of subjects), feel in the mouth (68.8 % of subjects) and taste (68.8 % to 81.3 % of subjects).

Conclusions: Infacort® was safe, well tolerated and of neutral taste when administered as a single oral dose of 10 mg. Infacort® granules and hydrocortisone tablets were bioequivalent with respect to Cmax, AUC and  tmax and demonstrated dose-proportionality.  Infacort® provides a new formulation specifically designed for the treatment of infants and neonates with adrenal insufficiency.

 

Disclosure: MJW: Management Position, Diurnal. DD: Employee, Diurnal. HH: Employee, Diurnal. DE: Employee, Diurnal. GT: Employee, Diurnal. RJR: Other activities, please specify:, Asterion Ltd, Director, Diurnal Ltd. Nothing to Disclose: SS, TJ, OB, HK

15058 8.0000 SUN-0128 A Infacort®, Oral Hydrocortisone Granules with Taste Masking for the Treatment of Neonates and Infants with Adrenal Insufficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0121-0136 4848 1:00:00 PM Adrenal Pediatric Endocrinology Poster

Baris Ekici1 and Nurcan Cebeci*2
1Derince Training and Research Hospital, 2Derince Training and Research Hospital, Kocaeli, Turkey

 

Background: Subclinical hypothyroidism (SH) is defined as moderate thyroid dysfunction characterized by mildly elevated thyroid stimulating hormone (TSH) levels with normal serum free thyroxine (fT4) levels. The prevalence is reported around 2% in pediatric population. Migraine is a common cause of primary headaches and in a single study it was supposed that 24% of migraineur children had subclinical hypothyroidism. In the present study we aimed to evaluate the presence of subclinical hypothyroidism and associated endocrinological abnormalities in children with migraine naive to treatment. 

Methods: Children with migraine who were diagnosed in Pediatric Neurology Clinic based on the second edition of the International Classification of Headache Disorders between the dates March 2013-January 2014 and who did not receive any medication were recruited in this cross-sectional study. All patients were examined by the same pediatric endocrinologist and anthropometric measurements, systemic blood pressure, pubertal stages were recorded. Fasting serum levels of thyroid function tests, lipids, glucose and insulin were obtained.

Results: Ninety eight children (55 female) with a mean age of 11.45±3.1 years were evaluated. Of those, 39 were prepubertal and 59 were pubertal. No patient had hypertension. Subclinical hypothyroidism (TSH≥5.0 mIU/L with normal fT4) was detected in 5 patients (5.1%), none had positive thyroid antibodies. Other conditions were obesity (n=6), hirsutism (n=4), short stature (n=3), polycystic ovaries (PCO,n=3), precocious puberty (n=2) and gynecomastia (n=1). Of five patients with SH, only one had obesity. While no subject had dyslipidemia, 7 had insulin resistance associated with obesity and/or PCO. No significant differences were found between patients with and without SH.

Conclusion:  Our results revealed that the prevalence of SH in children with migraine is not as high as previously reported. Since no significant endorinologic disturbance was found in those children we suggest that the initial endocrinological evaluation or screening for SH is unnecessary.

 

Nothing to Disclose: BE, NC

13360 9.0000 SUN-0129 A Is Initial Endocrinological Evaluation Necessary for Children with Migraine? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0121-0136 4848 1:00:00 PM Adrenal Pediatric Endocrinology Poster

Michael John McPhaul*1, Michael Phillip Caulfield2, Ke Zhang3, Kyriakie Sarafoglou4 and Richard E Reitz2
1Medical Director, Endocrinology, San Juan Capistrano, CA, 2Quest Diagnostics Nichols Institute, San Juan Capistrano, CA, 3Quest Diagnostics Nichols Inst, 4Leo Fung Center for CAH and DSD, Minneapolis, MN

 

Mass spectrometry (MS) provides a method capable of measuring a wide range of steroids with high precision. The coupling of MS with high turbulence liquid chromatography has yielded methods that are compatible with a high throughput diagnostic testing laboratory. Previously, we have reported the validation of a multiplexed assay to measure 13 steroids simultaneously using serum sample volumes as small as 100 microliters, making it suitable for use in newborns. The application of this method to define disorders of steroidogenesis requires well established pediatric reference ranges for comparison.

To address this need, we analyzed samples from 1202 individuals, ages 1 month to 17 years (615 males and 585 females). After de-identification, the samples were analyzed to determine the concentrations of 13 individual steroids (11-deoxycortisol, 17-hydroxyprogesterone, 17-hydroxypregnenolone, 18-hydroxycorticosterone, cortisone, androstenedione, corticosterone, cortisol, DHEA, deoxycorticosterone, pregnenolone, progesterone, testosterone). The measured concentration of each steroid was examined individually and obvious outliers omitted from further analysis.

The non-excluded values for each assay were stratified by age in year increments. Data were transformed to the power of lambda and fitted against age using smooth curve fitting (spline smooth) for the mean using age as the sole independent variable and transformed steroid values as dependent variable. Either a fixed standard deviation was estimated using the residuals about the regression for the mean or a polynomial regression model against age was fitted to the standard deviations of the residuals. Reference ranges were expressed as M±2SD where data were back-transformed as appropriate (LOQ as lower bound if M-2SD below LOQ). (R.2.11.1 was used for all statistical analyses1,2).

The determination of specific age related pediatric reference ranges (1 month to 17 years) will permit the use of this test in evaluating patients for all forms of congenital adrenal hyperplasia (CAH) and other adrenal steroidogenic defects via the simultaneous measurement of 13 steroids in the steroidogenic pathway and the ability to assess the levels of precursor and products of the different CYP enzymes.

 

Disclosure: MJM: Employee, Quest Diagnostics. MPC: Employee, Quest Diagnostics. KZ: Employee, Quest Diagnostics. RER: Employee, Quest Diagnostics. Nothing to Disclose: KS

15164 10.0000 SUN-0130 A The Use of a Multiplexed Panel of 13 Steroids to Define Age-Specific Steroid Hormone Reference Ranges for Children and Adolescents 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0121-0136 4848 1:00:00 PM Adrenal Pediatric Endocrinology Poster

Marilza Leal Nascimento1, Anísia Nhelety Baptista Cristiano2, Tatiane Campos1, Masanao Ohira3, Genoir Simoni4, Edson Cechinel1, Rose Marie Linhares1, Juliana van de Sande Lee1 and Paulo Cesar Silva*1
1Joana de Gusmao Childrens Hospital, Florianopolis, Brazil, 2UFSC Faculty of Medicine, Florianopolis, Brazil, 3Santa Catarina Federal University, Florianopolis, Brazil, 4Joana de Gusmao Childrens Hospital, Florianopolis

 

Introduction: CAH is a family of inherited disorders of adrenal steroidogenesis. The steroid 21-hydroxylase deficiency (21OHD) accounts for approximately 95% of the cases of CAH. Newborn screening for CAH is justified by the sometimes difficult clinical diagnosis and the risks associated with missed diagnosis, particularly the life-threatening salt-wasting crisis. The incidence varies between 1:5.000 and 1:20.000 newborn. In Santa Catarina, Brazil, statewide screening for CAH by measuring 17-hydroxyprogesterone levels in dried blood spots was introduced in october, 2000.

Objectives: The aim of the study was to evaluate the screening program of the Santa Catarina Department of State Health- SCDS- (PTN-SES/SC) and provide subsidies to enable its completion.

Methods: Retrospective cohort study of 748,395 children screened between January 2001 and December 2010. Of patients were analyzed: prevalence, coverage PTN-SES/SC, the age of the first collection of the first sample of 17-hydroxyprogesterone (17-OHP), the average age of initiation of treatment as well as its main clinical manifestations.

Results: We diagnosed 50 cases of CAH, with a prevalence of 1:14.967. The average age at first sampling was 7.8 days and the average 17-OHP was 152.9 ng / ml. The most common manifestations were virilized genitalia without palpable gonads, clitoromegaly, labial fusion, weight loss, dehydration, genital hyperpigmentation, penile enlargement. In three girls error occurred in the establishment of gender at birth.  The salt wasting form occurred in 75%. No case of shock or death was verified. Mean age at start of treatment 21,6 days. All children diagnosed were treated with hydrocortisone, where the salt losing was associated 9-α-fludrocortisone.

 Conclusions:  The prevalence of CAH in the is 1:14.967 newborn screened. The collection of the first sample is outside the recommended time, resulting in delays to the start of treatment.

 

Nothing to Disclose: MLN, ANBC, TC, MO, GS, EC, RML, JVDSL, PCS

13451 11.0000 SUN-0131 A Ten Years Evaluation of a Neonatal Program Screening Test for Congenital Adrenal Hyperplasia (CAH) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0121-0136 4848 1:00:00 PM Adrenal Pediatric Endocrinology Poster

Mirela Costa de Miranda*1, Ricardo Paranhos Moreira2, Larissa Garcia Gomes2, Guiomar Madureira3, Berenice B Mendonca4 and Tania A Bachega3
1Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Sao Paulo, Brazil, 2School of Medicine, Sao Paulo University, Sao Paulo, Brazil, 3Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 4Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular LIM/42, Disciplina de Endocrinologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

 

Testicular Adrenal Rest Tumors in Patients with 21-Hydroxylase Deficiency

Laboratório de Hormônios e Genética Molecular-LIM42, Disciplina de Endocrinologia, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo - São Paulo, Brazil

Testicular adrenal rest tumors (TARTs) are one of the most frequent causes of infertility in males with 21-hydroxylase deficiency (CAH). Different TART prevalencerates have been reported in up to 94% of patients. It is thought that quality of disease control is one of the main pathogenic factors, acting through ACTH and angiotensin II stimulatory effects. However, there is still little information regarding the influence of long-term predictors involved in TARTs development. Objective: To evaluate TARTsprevalence in CAH patients and to correlate with the long-term predictors. Patients and methods: data of 25 males (15 salt wasters) were retrospectively evaluated.The mean age at diagnosis was 1.3 mos in salt wasting (SW) and 46 mos in simplevirilizing (SV) form. Hormonal control quality, assessed through long-term mean ACTH, 17OHP, androstenedione (D4) and renin levels were analyzed, as well as mean testosterone (T), inhibin B levels and spermogram. Mean glucocorticoid doses were evaluated and converted into cortisol equivalent. Genotypes, determined through CYP21A2 sequencing, were classified according to predicted impairment on enzymatic activity: null and severe groups. Data of patients with/without TARTs by scrotal ultrasound (US) were compared. Student’s t and Chi-square tests were used.Results: The mean age at the time of US was 21.7±6 yrs and TARTs were observed in 8 patients (bilateral in 7). Despite late diagnosis in SV patients, the frequency of TARTs was significantly higher in SW patients (40% vs 20%). Mean glucocorticoid doses did not differ in patients with and without TARTs as well as fludrocortisone doses in SW patients with and without TARTs (p>0.05 for both). During follow up, mean ACTH, 17OHP, D4 and T levels did not differ in both patient groups, except for mean renin levels, which were significantly higher in patients with TARTs than inthose without (21±9 vs 12±8 ng/mL, respectively, p=0.02) and for inhibin B, whosemean levels were 64±15 vs 152±70 ng/mL, respectively (p=0.004). Similar frequencies of genotype groups were observed in patient with/without TARTs. Frequency of oligospermia was significantly higher in TART patients (83%) than inthose without (38%); the latter were mainly related to hypogonadotrophichypogonadism. Conclusion: in this CAH series, a high frequency of TARTs wasobserved. An additive renin stimulatory effect, instead of long-term hormonal control,seems to be the major role in TARTs development.

 

Nothing to Disclose: MCDM, RPM, LGG, GM, BBM, TAB

15455 12.0000 SUN-0132 A Testicular Adrenal Rest Tumors in Patients with 21-Hydroxylase Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0121-0136 4848 1:00:00 PM Adrenal Pediatric Endocrinology Poster

Helmuth G. Doerr*1, Hartmut Wollmann2 and Berthold P Hauffa3
1University Hospital Erlangen, Erlangen, Germany, 2University Hospital Erlangen, Germany, 3Univ Children's Hosp, Essen, Germany

 

Adrenal crisis occurring during stress situations is especially feared in children with CAH and salt-wasting (SW); literature reports cases of death. Our aim was to collect data on CAH patients who died in Germany. On behalf of the German Working Group for Pediatric Endocrinology (APE) a questionnaire was sent out between 2002 and 2004 to the members of APE to record mortality in patients with severe CAH. The participating centres (n=88) reported 17 cases of death (10 f, 7 m). 13 patients had the SW form and 4 the uncomplicated form. All were on regular replacement with glucocorticoids, the SW forms with mineralocorticoids as well. Age of death varied between 6 weeks and 32 years (3 adult patients were reported). Most children died as toddlers (n=9). Almost all deceased patients had German parents and were presented regularly to a center with a pediatric endocrinologist. Most patients (n=10) died at home. Immediately before death, the patients suffered from high fever (n=14) in combination with vomiting (n=4), convulsions (n=4), diarrhea (n=1), dyspnea and/or upper respiratory tract infection (n=2), varicella (n=1) or without any other symptoms (n=2). Two had salmonella gastroenteritis and one had gastric bleeding. One child additionally suffered from a metabolic defect (medium-chain acyl-CoA dehydrogenase deficiency). One patient developed a salt-wasting crisis, five patients developed hypoglycemia and severe convulsions with cerebral edema.

In our view, the patients died due to the complete lack or the inadequate adaptation of glucocorticoid dosage to the acute stress situation, which triggered an Addisonian crisis in most cases. We assume that the caregivers (parents, GPs) underestimated the severity of symptoms due to different diseases and did not adapt the glucocorticoid dosage early enough and adequately to these stress situations. The results show that informing and advising of the parents/patients and the physicians involved must be improved, with the emphasis on improved communication and training.

 

Disclosure: HW: Employee, Pfizer, Inc.. Nothing to Disclose: HGD, BPH

14672 13.0000 SUN-0133 A Cases of Death in Children with Classical Congenital Adrenal Hyperplasia (CAH) Due to 21-Hydroxylase Deficiency in Germany 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0121-0136 4848 1:00:00 PM Adrenal Pediatric Endocrinology Poster

Ahmed Khattab*1, Mabel Yau1, Sorahia Domenice2, Dwaipayan Muhuri1, Elaine Maria Frade Costa2, Tony Yuen3, Christian Enrique Pina1, Mirian Y Nishi4, Amy C Yang5, Berenice B Mendonca6 and Maria I New1
1Icahn School of Medicine at Mount Sinai, New York, NY, 2Disciplina de Endocrinologia e Metabologia - Laboratório de Hormônios e Genética Molecular/ LIM42, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3Icahn School of Medicine at Mount Sinai, NY, 4Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Brazil, 5Icahn School of Medicine, New York, NY, 6Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular, LIM 42, Hospital das Clínicas, Faculdade de Medicina, São Paulo University, São Paulo, Brazil, São Paulo, Brazil

 

Genotype/ hormonal phenotype mismatch in the diagnosis of 17 β hydroxysteroid 3 dehydrogenase deficiency

 

Steroid 17β-hydroxysteroid Dehydrogenase 3 (17β-HSD3) deficiency is a rare autosomal recessive disorder that usually presents at birth with ambiguous genitalia in a patient with a 46, XY karyotype. Since the 17β-HSD3 enzyme converts delta-4 androstenedione (D4) to testosterone (T), an increased D4 to T ratio, when the patient undergoes a human chorionic gonadotropin stimulation (hCG) test, is expected in 17β-HSD3 deficiency. Two patients were studied with 17β-HSD3 deficiency in whom the diagnosis was confirmed genetically but demonstrated a normal ratio of D4 to T, not increased as expected.

The first patient is a 12 year old 46 XY Brazilian who was born with ambiguous genitalia and was assigned to the female sex.  Partial androgen insensitivity syndrome was ruled out by normal androgen receptor sequencing. Pelvic ultrasonography confirmed normal appearing testicles bilaterally. HCG stimulation test at 5 months of age revealed a low D4 to T ratio of 0.4. At 8 months of age, she underwent a feminizing genitoplasty and bilateral orchiectomy. Later on she was screened for mutations in the HSD17β3 gene. The patient was found to be a compound heterozygote for c.608 C>T (p.Ala203Val) and c.625 T>C (p.Ser209Prol) mutations.

The second patient is a 10 year old 46 XY Yemenite also born with ambiguous genitalia and assigned to the female sex. Pelvic ultrasonography revealed the absence of a uterus and the presence of bilateral inguinal structures, possibly testes.  The patient’s hCG stimulated D4 to T ratio was 0.4 and biochemical criteria for the diagnosis of 5 alpha reductase 2 deficiency were met. However, 5 alpha reductase 2 deficiency was ruled out after sequencing the SRD5A2 gene which did not demonstrate any mutations.  Further, genetic analysis confirmed homozygous mutation of c.608 C>T (p.Ala203Val) in the HSD17β3 gene. Both mutations are predicted to be deleterious by in silico analysis and were not found in the 1000 Genomes Project.

Discussion and conclusion: The diagnosis of 17β-HSD3 deficiency was not made in both patients based on increased D4 to T ratios. Our data indicate that genetic analysis is superior to hormonal tests for the diagnosis of 17β-HSD3 deficiency. We suggest that molecular genetic analysis was superior to hormonal tests for the diagnosis of 17β-HSD3 deficiency.

 

 

 

Nothing to Disclose: AK, MY, SD, DM, EMFC, TY, CEP, MYN, ACY, BBM, MIN

12219 14.0000 SUN-0134 A Genotype/ Hormonal Phenotype Mismatch in the Diagnosis of 17 â Hydroxysteroid 3 Dehydrogenase Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0121-0136 4848 1:00:00 PM Adrenal Pediatric Endocrinology Poster

Mariam Gangat*1, Ian Marshall2 and Sadana Balachandar3
1Rutgers - RWJMS, New Brunswick, NJ, 2Rutgers-RWJMS, New Brunswick, NJ, 3Rutgers - RWJMS

 

Introduction: Newborn screening for salt wasting congenital adrenal hyperplasia (SW CAH) due to 21-hydroxylase deficiency is performed in all 50 US states, as timely recognition of this disorder, especially in male infants, is critical for the prevention of a life-threatening adrenal crisis.

Clinical Case: A Caucasian male of mixed European ancestry was born at an outside hospital at 35 weeks via caesarean section for intrauterine growth restriction with a birth weight of 1,470 kg (~ SGA).  Mother received 4 antenatal steroid doses.  There was neither consanguinity nor family history of neonatal deaths.  Examination revealed descended testes within a normally developed scrotum, and a normal sized phallus. Patient remained hospitalized for 5 weeks during which time hyponatremia was first noted at 4 weeks of age with a nadir of 124 mmol/L (133-155), biochemically associated with hyperkalemia of 6.7 mmol/L (4.0-5.5), but without metabolic acidosis, hypoglycemia, or clinical features of salt wasting.  Hyponatremia was attributed to prematurity and resolved with sodium supplementation (4 mEq/kg/day); hyperkalemia also resolved.  Routine newborn screenings for CAH on day of life 2, 7, 14 and 39 were all negative. He was discharged home at 5 weeks of age on sodium supplementation only.

Patient was admitted to our hospital at 7 weeks of age for re-evaluation of hyponatremia.  He had remained clinically well in the interim without feeding or growth concerns.  Biochemical testing on admission showed normal electrolyte levels, however 17-OHP was elevated at 2,850 ng/dL. Sodium was discontinued for 36 hours resulting in the sodium concentration dropping to 131 mEq/L, without hyperkalemia, hypoglycemia, or metabolic acidosis. 17-OHP increased further to 10,900 ng/dL. Treatment for CAH was initiated with hydrocortisone and florinef, and sodium supplementation was re-started. 

At our request, the 4 original newborn screen samples were re-analyzed, and were essentially identical to the initial results. Genetic testing identified deletion of 1 allele of CYP21A2 and I172N mutation on the 2nd allele. 

Conclusion: We present a premature male infant with 4 normal newborn screens for CAH that presented with hyponatremia and hyperkalemia and was ultimately diagnosed with SW CAH.  Two possible contributors to his negative screening results are IUGR and antenatal steroid exposure, which are known negative predictors of 17-OHP levels in premature infants.  Interpretation of CAH newborn screening results should be done with caution particularly in male infants, and further workup for CAH should be undertaken if there is any clinical suspicion.  In this situation, despite the negative screening results, the presence of hyponatremia and hyperkalemia should have raised the possibility of SW CAH.  This also underlines the need for the involvement of pediatric endocrinologists in such cases.

 

Nothing to Disclose: MG, IM, SB

12104 15.0000 SUN-0135 A Case of Multiple Negative Newborn Screenings for Congenital Adrenal Hyperplasia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0121-0136 4848 1:00:00 PM Adrenal Pediatric Endocrinology Poster

Mouhammad Rateb Alwazeer*1, Oluyinka Olutoye2, Judith F Margolin2, Eumenia Castro2, Jennifer Williams2, Martha M Quezado3, Maya Beth Lodish4, Constantine A Stratakis5 and Andrea Erika Balazs6
1Texas Children's Hospital Baylor College of Medicine, 2Baylor College of Medicine, 3National Cancer Institute, Bethesda, MD, 4National Institutes of Health, Bethesda, MD, 5National Institutes of Health (NIH), Bethesda, MD, 6Baylor Coll of Med, Houston, TX

 

Background: In pediatric population, bronchial carcinoid is one of the most common sources of Cushing syndrome due to ectopic ACTH production. The prevalence of this condition is unknown. The diagnosis, localization of the carcinoid, and the treatment of hypercortisolism require multidisciplinary approach. Lymph node invasion is common at the time of presentation it appears to be unrelated to the histological type of the tumor and determines the surgical management.

Case presentation and clinical course: We describe a case of a 14-year-old girl with Cushing syndrome due to ACTH producing bronchial carcinoid tumor. She presented with signs and symptoms of severe hypercortisolism. Serial hormone studies confirmed cortisol excess due to increased ACTH production. Imaging studies including somatostatin scan revealed a right middle lobe tumor in the lung. She received medical therapy to modify adrenal hormone production to alleviate symptoms and in preparation for surgery. She underwent right middle lobe segmentectomy with a 1.5 mm clear margin. Histology confirmed a well differentiated, typical ACTH producing bronchial carcinoid. Despite the tumor resection the patient continued with hypercorticotropinemia and consequent hypercortisolism. A follow-up somatostatin scan 8 weeks after surgery showed increased uptake at the original tumor site with negative mediastinal lymph nodes uptake. Only the second surgery consisting of total lobectomy with mediastinal lymph node resection resulted in normalization of plasma ACTH and serum cortisol concentrations within 48 hours. Histology showed clear margins for the excised lung tissue but mediastinal lymph nodes involvement.

Conclusion: Localization of ACTH producing bronchial carcinoid and residual tumor tissue after incomplete resection can be challenging. Somatostatin scan post surgery can be misleading as it failed to localize the source of persistent hypercorticotropinemia and could not indentify the carcionid spread in the lung. Hormone therapy and modification of hormone production plays significant part in medical management throughout the acute and postoperative course. Although the treatment of choice for an ACTH producing bronchial carcinoid is surgery, complete resolution of Cushing syndrome post surgery is rare in pediatrics. 

 

Nothing to Disclose: MRA, OO, JFM, EC, JW, MMQ, MBL, CAS, AEB

11341 16.0000 SUN-0136 A Cushing Syndrome Secondary to Bronchial Carcinoid Tumor in a 14-Year- Old Female: Challenges in Diagnosis and Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0121-0136 4848 1:00:00 PM Adrenal Pediatric Endocrinology Poster

Andrea Granados*, Joyce Lee and Acham Gebremarian
University of Michigan, Ann Arbor, MI

 

Background: Descriptive data on the relationship between linear growth and pubertal development in a population based cohort of children and adolescents born after 1990’s has not been published to our knowledge.

Objective: To evaluate the relationship between timing of peak height velocity with puberty and to evaluate the percentage of growth attained across stages of puberty separately for boys and girls.

Methods: The National Institute of Child Health and Human Development Study of Early Child and Youth Development (SECCYD) was a longitudinal study of growth and development that followed children from infancy to 15 years of age starting in 1991.  We included 402 subjects with available data in yearly intervals. Height velocity was calculated by subtracting consecutive height measurements. Peak height velocity (PHV) was identified as the largest increase in height velocity after ages 6 for girls and after age 8 years for boys. Percentage of height attained by a given Tanner stage was calculated by dividing height at a given Tanner stage by final height at Tanner Stage 5 (for a subset who completed their growth by age 15). Tanner staging (breast development for girls and genitalia for boys) was performed by a pediatric endocrinologist or nurse practitioner using visual inspection and palpation. Menarche data was obtained by maternal report via questionnaire.

Results: Our results show that the percentage of girls who achieved PHV was 29.4% by Tanner stage 2, 69.1%, by Tanner Stage 3, 92.6% by Tanner Stage 4, and 95.1% by Tanner stage 5. We found that the percentage of boys who achieved PHV was 12.5% by Tanner Stage 2, 30.4% by Tanner Stage 3, 58.9% by Tanner Stage 4, and 70.7% by Tanner stage 5.  Only 70.6% of girls achieved their PHV by the time of menarche.

We also calculated the percentage of growth attained across stages of puberty. We found in girls that by Tanner Stage 2, 88.1% of growth in height was completed, by Tanner Stage 3, 95.4% was completed and by Tanner stage 4, 98.2% of growth in height was completed. We found in boys that by Tanner Stage 2, 85.2% of growth was completed, by Tanner Stage 3, 92.2% of growth in height was completed, and by Tanner Stage 4, 95.5% of growth in height was completed.

Conclusions: Previous studies have reported that PHV occurs between Tanner stage 2 and 3 in girls and Tanner stage 3 and 4 in boys. This is one of the first studies to examine the relationship between timing of PHV and pubertal stage in a recent cohort. Our finding of substantial variability in the timing of PHV, with PHV occurring beyond stages 3 in girls and stages 4 in boys, is important for pediatricians to recognize when assessing growth.  Percentage of growth attained across Tanner stages, is consistent with previous studies.

 

Nothing to Disclose: AG, JL, AG

11607 3.0000 SUN-0154 A Relationship Between Timing of Peak Height Velocity and Percentage of Growth with Pubertal Staging in Boys and Girls 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Hyun-wook Chae*1, Ah Reum Kwon2, Yejin Kim3, Jung Min Ahn1, Dae Ryong Kang4, Ha Yan Kim4, Hyeon Chang Kim4, Il Suh4, Duk-Hee Kim5 and Ho-Seong Kim6
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Severance Hospital, Seoul, Korea, Republic of (South), 3SEVERANCE CHILDREN'S HOSPITAL, SEOUL, Korea, Republic of (South), 4Yonsei University College of Medicine, 5Yonsei Univ Coll of Med, Seoul, Korea, Republic of (South), 6Severance Children's Hospita, Seoul, Korea, Republic of (South)

 

Purpose: The timing of the growth spurt and gender differences in physical growth can vary greatly, and it may contribute to the final height. However, there are few studies about height and height velocity of early/average/late maturing children because of the requirements of a population based longitudinal study. We investigated the height and height velocity according to growth tempo from the Kangwha cohort.

 Methods: The present study conducted as a part of a community-based prospective cohort study from 1986 to 1999 with 800 school children (359 males, 441 females). We calculated 2 standard deviation of peak height velocity(PHV) and the age of PHV, and then grouped the subjects into early/average/late maturing group. We compared the results of 3 groups and investigated the differences.

 Results: The age at PHV was 12 in boys and 10 in girls, and height velocity at PHV was 8.62 cm/yr in boys and 7.07 cm/yr in girls on average tempo growth. In boys, the age of PHV was 11 and PHV 9.82 cm/yr in early maturing group, and the age of 13 and 8.97 cm/yr in late maturing group. In girls, the age of PHV was 9 and PHV 9.75 cm/yr in early maturing group, however, in late maturing group, the difference was not significant compared with average tempo. Final height of each group was not different.

 Conclusion: Final height was similar between early/late and average tempo group. The PHV might be greater in early than in late maturing group, however the difference was significant only in boys. Further longitudinal studies including pubertal development would be needed.

 

Nothing to Disclose: HWC, ARK, YK, JMA, DRK, HYK, HCK, IS, DHK, HSK

14203 6.0000 SUN-0157 A Height and Height Velocity of Early/Average/Late Maturing Children and Adolescents from Longitudinal Study of the Kangwha Cohort 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Natalie D Shaw*1, James P Butler2, Tairmae Kangarloo3 and Janet E. Hall4
1Boston Children's Hospital, Boston, MA, 2Harvard School of Public Health, 3Massachusetts General Hospital, Boston, MA, 4Massachusetts General, Boston, MA

 

Context: The reactivation of the reproductive axis during puberty is marked by sleep-specific augmentation of pulsatile LH, a surrogate of pulsatile GnRH. We have previously demonstrated that LH pulses are most likely to occur during deep sleep (stage N3) in pubertal children suggesting that deep sleep may stimulate LH secretion (1). We therefore hypothesized that disruption of deep sleep would lead to diminished LH secretion relative to normal sleep in pubertal children.

Methods:  Healthy children were randomized to 2 overnight studies, spaced 2 months apart, consisting of frequent blood sampling (q10min x 8h) and polysomnography (PSG) during normal sleep or disrupted deep sleep. Deep sleep was interrupted and lighter sleep induced using acoustic and tactile stimuli, as previously described (2).  Pulsatile LH secretion was analyzed using a validated modification of the Santen and Bardin method of pulse detection (3). Estradiol (E2) and T were measured q4h. Mean LH, LH pulse frequency, LH pulse amplitude, E2, T, and all sleep parameters were compared using ANOVA controlled for subject and study order. 

Results: 14 subjects (7 boys, 7 pre-menarchal girls), 11.6-14.3 yrs-old, in Tanner breast stages II-IV or with testicular volumes 4-15cc, were studied. During the normal sleep night all subjects demonstrated normal sleep macroarchitecture for age with a sleep efficiency of 88.4±2.9% (mean ± SE) and sleep latency of 21.3±3.5 min.  An average of 68.1 (±10.7) auditory and/or tactile stimuli were delivered to interrupt deep sleep during the disruption night, resulting in a doubling of the arousal index (10.3±0.65 vs. 23.0±3.6 events/hr, p=0.006), a decrease in the amount of time spent in deep sleep (N3: 31.7±2.9 vs. 21.2±2.5%,p=0.003), and an increase in the amount of time spent in lighter sleep stages (N1: 4.6±0.6 vs 7.0±0.9 %, p=0.01 and N2: 37.2±2.8 vs. 43.7±2.9%, p=0.02) relative to the night of normal sleep, but no increase in the number of episodes of wakefulness following sleep onset.   Despite the success of this intervention in decreasing consolidated deep sleep, there were no differences in mean LH (normal: 3.2±0.4 vs. disrupted: 3.2±0.5 IU/L, p=1), LH pulse frequency (0.6±0.06 vs. 0.6±0.07 pulses/hr, p=0.4), LH pulse amplitude (2.8±0.4 vs 2.8±0.4 IU/L, p=1), or peak E2 (30.7±4.8 vs. 27.0±2.9 pg/ml, p=0.5) or T (355.4±70.5 vs. 347.6±73.7 ng/dl, p=0.7) levels between normal and disrupted sleep nights. 

Conclusion:  Disruption of deep sleep in pubertal children over the course of one night does not decrease nocturnal LH secretion.  This suggests that either: 1) sleep-active neurons induce deep sleep and GnRH secretion through contemporaneous but independent pathways; or 2) complete abolition of deep sleep is required to prevent deep-sleep related GnRH secretion.

 

Nothing to Disclose: NDS, JPB, TK, JEH

14093 7.0000 SUN-0158 A Deep Sleep Disruption Does Not Diminish Pulsatile LH Secretion in Pubertal Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Ben WR Balzer*1, Gurmeet KS Singh2, Patrick J Kelly1, Karen Paxton1, Catherine I Hawke1, David J Handelsman2 and Katharine S Steinbeck3
1The University of Sydney, Australia, 2ANZAC Research Institute, Sydney NSW, Australia, 3The Children's Hospital at Westmead, Sydney NSW, Australia

 

The gonadotropin and sex steroid (testosterone (T) and estradiol (E2)) changes that drive the external manifestations of puberty are well described using cross-sectional data according to age or Tanner staging. Longitudinal data describing the interactions between the changing hormonal milieu and adolescent growth is lacking. Previous studies relied upon older sex steroid immunoassay techniques lacking the sensitivity and specificity of mass spectrometry-based steroid assays.

Our aims were to (a) establish and validate liquid chromatography-tandem mass spectrometry (LC-MS/MS) assays for urine T and E2 and an immunoassay for urine LH for a longitudinal study of adolescents (the Adolescent Rural Cohort, Hormones, Health, Education, Environment and Relationships (ARCHER) study (1)) involving frequent (3 monthly) sampling; (b) describe hormone changes over the first year in the first 104 (57 F) participants (of 342 total cohort); (c) describe relationships between changes in urine and serum hormones with standard measures of puberty (anthropometry, Tanner stage).

Participants underwent annual physical assessment (height, weight, BMI, foot length), provided self-rated Tanner staging and annual fasting blood samples as well as quarterly urine samples. Urine T and E2 were measured by LC-MS/MS and LH by immunoassay (Immulite) in a single batch and corrected for specific gravity (SG).

At baseline, mean ages (SD) were 12.5 (0.93) years for males and 11.8 (0.98) for females. Most scheduled samples were collected (93% serum, 92% urine) with a low participant attrition rate (<3% per annum). Urine E2, T and LH increased according to chronological age and Tanner stage from baseline to 1-year follow-up. Urine and serum hormones correlated with self-rated Tanner stages at both baseline and 1-year follow-up (p<0.01 for all). However, change in self-reported Tanner stage did not exhibit a significant association with change in urine or serum hormones. Changes in foot length were more strongly correlated with urine hormone changes than were other anthropometric or self-rated Tanner stage changes.

These preliminary findings demonstrate the feasibility of intensive collection of urine samples together with validated urine assays for sex steroids and LH. These will allow a more accurate and sensitive, individual assessment of puberty timing and tempo. The preliminary findings related to foot length are of potential clinical interest.

 

Nothing to Disclose: BWB, GKS, PJK, KP, CIH, DJH, KSS

12459 8.0000 SUN-0159 A Urinary Sex Steroids, Luteinising Hormone and Anthropometric Markers of Puberty: Preliminary Results from an Intensive Longitudinal Cohort Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Sara Vandewalle*1, Youri Taes1, Tom Fiers2, Kaatje Toye2, Jean De Schepper3 and Jean-Marc Kaufman2
1Ghent University Hospital, Ghent, Belgium, 2Ghent University Hospital, Gent, Belgium, 3Brussels University Hospital, Brussels, Belgium

 

Background: Although both testosterone (T) and estradiol (E2) are considered essential in the regulation of the male skeleton, there are few data concerning the relative contribution of T  and E2 on bone mineral density (BMD), bone geometry, body composition and bone maturation in healthy boys.

Objective: To analyze the relationship between T and E2 and BMD, bone geometry, skeletal maturation and body composition.

Methods: This is a cross-sectional study in 199 healthy boys (aged 6-19 y). T and E2 were determined by liquid chromatography tandem mass spectrometry. Whole body and lumbar areal bone mineral density  (aBMD) and bone area, lean mass and fat mass were determined by  dual-energy X-ray absorptiometry. Trabecular (distal site) and cortical (proximal site) volumetric BMD (vBMD) and bone geometry were assessed at the non-dominant forearm  using peripheral QCT. Skeletal age was determined by X-ray of the left hand. Multivariable-adjusted analyses (including age, height and weight) were used to study the associations between T and E2 and BMD, bone geometry, body composition and skeletal maturation.

Results: T was positively associated with lean mass (p<0.001), lumbar and whole body bone area (p<0.001), trabecular and cortical area (p<0.01) and periosteal circumference (p<0.01) at the radius. The associations remained significant after inclusion of E2 in the model (p<0.05), however associations between T and bone area parameters were no longer present after inclusion of lean mass in the model.  E2 was positively associated with lumbar and whole body aBMD (p<0.001), trabecular vBMD at the radius and tibia (p<0.01) and cortical thickness at the radius (p<0.05). E2 was an independent negative predictor of the endosteal circumference (p<0.01). Moreover, E2 was positively associated with bone age advancement (p<0.001). The associations remained significant after inclusion of T in the model (p<0.05).   

Conclusion: Circulating E2 is positively associated with bone maturation and areal and volumetric BMD and negatively with endosteal circumference in healthy boys, whereas T is a determinant of lean mass and  bone size. We hypothesize that T leads to an increase in muscle mass which causes a larger bone size due to an increase in strain exerted on the bone. Due to the cross-sectional design however, we are not able to draw causative conclusions and a direct effect of T on bone size cannot be fully excluded. Moreover, our findings underscore the important role of E2 in skeletal development in boys, which needs further confirmation by a longitudinal study.    

 

Nothing to Disclose: SV, YT, TF, KT, JD, JMK

12584 9.0000 SUN-0160 A Relative Contribution of Testosterone and Estradiol on Bone Mineral Density, Bone Geometry, Body Composition and Bone Maturation in Healthy Boys 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Christine M. Burt Solorzano*1, Jessicah S. P. Collins2, Ruchi Bhabhra1, Amy Denise Anderson1, John C. Marshall1 and Christopher R. McCartney1
1University of Virginia, Charlottesville, VA, 2Augusta Health, Fishersville, VA

 

During early puberty, LH (GnRH) pulses first occur during sleep. Daytime LH pulses gradually increase, leading to a mature pattern of high daytime pulse frequency with nighttime slowing. In adult women, testosterone (T) impairs progesterone (P) negative feedback on LH pulses, but mechanisms regulating day-night differences in LH pulse secretion across puberty are unclear. We reported in young girls (Tanner 1-3) that short-term oral P (25-50 mg at 16:00 and 20:00 h; P 5.1 ± 1.4 [mean ± SEM] ng/mL) suppressed LH pulsatility when awake (19:00-23:00 h) but not during sleep (23:00-07:00 h)(1). We aimed to assess if differential day-night sensitivity of the GnRH pulse generator to P suppression is evident in peri-pubertal girls receiving long-term (7 d) P and estradiol (E2).

We studied 25 normal weight (NW) and 20 obese (OB, BMI%-ile >95) girls ages 8-17. LH was sampled every 10 min and pulse frequency was assessed while awake (19:00-23:00 h) and during sleep (23:10-07:00 h). Girls then received oral P (0.5 mg/kg at 07:00, 15:00, and 23:00 h) and E2 (0.5-1 mg/d) for 7 days, after which LH frequency was reassessed. Day 7 plasma P was 8.2 ± 0.4 ng/mL; E2 was 143 ± 11.4 pg/mL.

Several young NW girls (Tanner 1-3) had no daytime pulses before P, making daytime comparisons difficult. However, contrary to results after short-term oral P, 7 d of P (P 5.0 ± 0.8 ng/mL) suppressed nighttime pulses by 66% in this group. In late pubertal (Tanner 4-5) NW girls, similar P levels (7.3 ± 0.8 ng/mL) suppressed overnight LH pulses to a lesser degree (42%). When GnRH pulse generator sensitivity to P (“P sensitivity”) is expressed as % fall in LH pulses (Day 1 vs. Day 7) divided by Day 7 P level, nighttime P sensitivity was higher in early vs. late pubertal girls (13.2 vs. 5.8), possibly reflecting lower T levels (6.4 ± 1.1 vs. 19.8 ± 2.2 pmol/L).

In NW late pubertal girls, 7 days of P suppressed day and night LH pulses to a similar degree (38% vs. 42%). Compared to NW girls, OB girls had higher LH pulse numbers (per 4 h) before P (day = 3.7 ± 0.2 vs. 3.2 ± 0.2; night = 2.7 ± 0.2 vs. 2.3 ± 0.2). After P, day and night LH pulses were similarly suppressed (28% and 32%), but to a lesser degree compared to NW. Likewise, OB girls had similar degrees of impaired P sensitivity during day and night (OB P sensitivity: day 2.7, night 3.0; NW P sensitivity: day 5.3, night 5.8). Impaired P sensitivity in OB girls may reflect higher plasma T vs. NW girls (48.4 ± 7.3 vs. 19.8 ± 2.2 pmol/L).

This study suggests that, after 7 days of E2/P, nighttime GnRH pulse generator sensitivity to P decreases across puberty. Day-night differential suppression was not observed in this study. The discordance with previous findings in early pubertal girls may reflect (a) more effective suppression of sleep-related LH frequency with longer-term (7 d vs. < 1 d) P administration, higher P concentrations, or the addition of E2; and/or (b) less effective suppression of daytime LH pulses in late pubertal girls (related to higher T).

 

Nothing to Disclose: CMB, JSPC, RB, ADA, JCM, CRM

15204 10.0000 SUN-0161 A Day-Night GnRH Pulse Generator Sensitivity to Suppression after Extended Administration of Progesterone in Girls Across Puberty 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Sara A DiVall*1, Bonnie Sklar2, Sheng Wu3, Fredric Edward Wondisford4, Sally Radovick5 and Andrew Wolfe3
1Johns Hopkins Univ, Baltimore, MD, 2Johns Hopkins University, Baltimore, MD, 3Johns Hopkins University School of Medicine, Baltimore, MD, 4Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, 5Johns Hopkins School of Medicine, Baltimore, MD

 

Physical and hormonal changes marking the onset of human puberty such as breast development or changes in serum LH levels can be difficult to differentiate from non-pubertal variances.  Because changes in metabolism accompany puberty, we hypothesized that there are puberty-specific changes in the serum metabolome independent of weight and age that potentially more accurately mark the initiation and/or progression of puberty.  We assessed the serum metabolome in female C57BL/6J mice at postnatal day (PND) 18 (prepubertal), 30 (midpubertal), or 38 (post-pubertal).  As age and weight-matched non-pubertal controls, we also studied gonadotropin-releasing hormone receptor null (GnRH-Rko) mice at the same ages (n=6 in each group).  Using chromatography with tandem mass spectroscopy, 335 metabolites were measured in extracted serum (Metabolon Corp, Raleigh NC).  Data were log transformed and imputed with minimal observed values.  For comparison between groups, a Welch’s two sample t-test was performed and a false discovery rate (q value) was calculated to account for multiple comparisons.  Levels of the branched chain amino acid (BCAA) metabolites leucine, alpha-hydroxyisovalerate, and valine were higher in PND 39 wild type mice than in PND 18 wild type mice (1.5, 1.1, and 2.0 fold difference respectively with q value < 0.1) and higher than GnRH-Rko mice at pubertal ages (each metabolite 1.3, 1.5, and 1.4 fold higher, respectively with q value < 0.05).  Lysine metabolites (2-aminoadipate and pipecolate) were lower in PND 39 wild type mice than in PND 18 mice (1.8 and 2.3 fold lower respectively with q value 0.25) and lower than GnRH-Rko mice at pubertal ages (4.0 and 1.6 fold lower, respectively with q value 0.16).  Of the 32 serum lysophospholipids assessed, the levels of 10 were lower in ko mice at pubertal ages (varying from1.14 to 1.65 fold higher with q values 0.16 or less).  These results suggest that lysine and BCAA metabolism is altered during puberty; these metabolites have been shown to be associated with obesity and insulin resistant states.  Differences in lysophospholipids suggest that phospholipase A2 activity may also be altered upon puberty.  In conclusion, amino acid metabolites and lysophospholipids differ between pubertal and non-pubertal states, and may be serve as biomarkers of puberty.

 

Nothing to Disclose: SAD, BS, SW, FEW, SR, AW

16899 11.0000 SUN-0162 A Serum Metabolites Associated with Pubertal Progression in Female Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Martha D Bardsley*1, Karen Kowal2, Rhae Ana Gamber3, Najiba Lahlou4 and Judith L. Ross2
1Nemours/A.I.DuPont Hospital for Children, 2Thomas Jefferson University/duPont Hospital for Children, Philadelphia, PA, 3Thomas Jefferson University/Nemours, Philadelphia, PA, 4Hopital Cochin-Université Paris-Descartes, Paris, France

 

Objective: To describe the influence of androgen replacement in childhood on the testicular phenotype of prepubertal boys with 47,XXY Klinefelter syndrome (KS).

Background: KS has a characteristic physical phenotype of testicular failure (androgen deficiency), ranging from nearly complete early androgen deficiency and gonadal failure to mild androgen deficiency and azoospermia in adulthood. The testicular function results presented here are from a 2-year, randomized clinical trial to study the effects of childhood androgen replacement on the KS cognitive and physical phenotypes.

Methods: Double-blind, placebo-controlled clinical trial (2005-2011, NCT00348946). Evaluation included clinical assessment and measurement of testosterone and gonadotropin levels every 6 months over 2 years in a cohort of boys with KS, ages 4-12 years. Results are presented as mean standard deviation scores (SDS)±SD. Analyses included t-tests, ANCOVA, and Fisher's exact test.

Results: 93 boys, ages 4-12 yrs, were randomized to 2 groups: oxandrolone (Ox)(N=46, 0.06 mg/kg/day) or placebo (Pl)(N=47).  At baseline (BL), the Ox group was significantly younger than the PL group (7.0±2.2 vs 8.4±2.6 years, P<0.001). Penile length and mean testicular volume SDS were significantly reduced at BL (–1.7±0.8 and -1.2±1.4) and were similar in both groups.  All boys had prepubertal testicular volume (≤4 ml).  81/93 had Tanner 1 pubic hair (PH) and 12/93 had Tanner 2 or 3 pubic hair (ages 10-12 years).  From BL to 2 years, testicular volume SDS change was greater in the Ox (-1.4±1.4  to 2.1±2.4) versus Pl (-1.1±1.5  to 0.0±2.2) groups, with increasing differences over the study duration.  Over 2 years, pubic hair development (Tanner I to II and I to III) occurred at younger ages in Ox versus Pl groups (ages 8.3-11.5 vs. 9.5-14.7 years), and there was no difference in frequency of Tanner IV or V. Testosterone, LH and FSH levels were similar in both groups throughout the study. However, in boys <10 years, testosterone levels were in the highest quartile for age in 6/24 Ox vs. 0/21 Pl boys (P=0.01) at the 2-year point, with similar LH and FSH levels. In boys >10 years,  testosterone, LH, and FSH levels were similar in both groups at all visits, as were the percent with castrate gonadotropin elevations.

Conclusions: In this 2-year clinical trial in boys with KS, ages 4-12 years, Ox treatment was associated with earlier pubic hair development and subtle testicular enlargement.  In boys less than 10 years, testosterone levels were increased in the Ox group, without a group difference in gonadotropins. Oxandrolone is known to have dose-related virilization, which was seen in this study as earlier onset of pubic hair development. Increased testicular volume for age, along with elevated testosterone values in the Ox group (<10 years) may imply a direct Ox effect on Leydig cells. Future studies will help define the underlying mechanism of these observations.

 

Nothing to Disclose: MDB, KK, RAG, NL, JLR

11296 12.0000 SUN-0163 A Androgen Replacement in Boys with 47,XXY Klinefelter Syndrome: Influence on the Testicular Phenotype 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Michele Gortakowski*, Luisa Aguiar, Holley F Allen, Rushika Conroy and Edward O Reiter
Baystate Medical Center, Springfield, MA

 

Background: Hypoandrogenism is an important feature of Klinefelter Syndrome (KS), the most frequent type of sex chromosomal abnormality in males. Conversely, children with 3β-Hydroxysteroid Dehydrogenase (3β-HSD) deficiency, a rare cause of CAH, tend to have elevated androgen levels. To our knowledge, two case reports show a coexistence of 21 hydroxylase deficiency and KS. We describe a child with KS and impaired 3β-HSD function.

Clinical Case:  A 6 yo male born SGA at 26 weeks with history of developmental delay presented to our clinic for evaluation of short stature (Z score=-2.83) and premature pubarche (onset at 4yo). PE showed prepubertal testes and Tanner 2 (T2) pubic hair. Initial investigation was consistent with premature adrenarche showing advanced bone age (+3.3SD; BA=9y0m/CA=6y5m), DHEAS 365 μg/dL (42 – 109 μg/dL), 17OHP 42 ng/dL (<116 ng/dL) and testosterone 43 ng/dL (18 – 150 ng/dL). He was lost to follow-up and returned at 8 yo, when GH therapy was initiated due to history of SGA with poor catch-up growth (Z score=-2.91). He had an ACTH stimulation test which showed the following stimulated levels (1 h after IV cosyntropin 250 mcg): elevated 17-OH pregnenolone at 1,979 ng/dl (88-675 ng/dL), elevated 17-OH pregnenolone/17OHP ratio of 35.3 (0.5-6.3), suggestive of a 3β-HSD dysfunction, and cortisol 36.7 μg/dL (15-36 μg/dL).  The stimulated 17-OH pregnenolone (nmol/L)/cortisol (μmol/L) ratio was normal at 58.9 (Lutfallah et al criteria for 3β-HSD CAH ≥363) (1). As he had a normal cortisol response, glucocorticoid was not initiated. At 9 yo he was diagnosed with KS when evaluation for developmental delay showed a 47 XXY karyotype.  At his last visit (age 9y11mo) his testicular size had increased to 4 cc and gonadotropins were at the pubertal levels of 2.5 mIU/mL (LH) and 6.8 mIU/mL (FSH), with a testosterone of 42 ng/dL.

Conclusion:  This case describes the consequences of the unusual coexistence between KS and 3β-HSD impaired function. This is an uncommon combination that clinicians should acknowledge, as the evolving testicular failure will influence the clinical management. Prepubertally, the adrenal androgen excess predominated in this patient but, as puberty progresses, we speculate that the expected hypoandrogenism from KS will have a greater impact on his phenotypic features. This case illustrates how the interplay between two disorders with opposing effects on androgen levels can create diagnostic and therapeutic challenges.

 

Nothing to Disclose: MG, LA, HFA, RC, EOR

13108 13.0000 SUN-0164 A Premature Pubarche in a Child with Abnormal 3ß-Hydroxysteroid Dehydrogenase Function and Klinefelter Syndrome: The Intriguing Relationship Between Androgen Deficiency and Excess 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Hae Woon Jung*1, Shin Mi Kim2, Hwa Young Kim3, Kyung Min Lee3, Young Ah Lee3, Choong Ho Shin1 and Sei Won Yang3
1Seoul National University Children's Hospital, Seoul, Korea, Republic of (South), 2Seoul Red Cross Hosp, Seoul, Korea, Republic of (South), 3Seoul Natl Univ College of Med, Seoul, Korea, Republic of (South)

 

Background:A large proportion of the increased mortality in Turner syndrome (TS) is related to cardiovascular complications. Increased arterial stiffness may be an important predictor related to cardiovascular complications in TS patients. A novel method of evaluating arterial stiffness, which is relatively independent of changes in blood pressure (BP), is the cardio-ankle vascular index (CAVI). The aim of this study was to compare arterial stiffness using CAVI between TS patients and healthy controls and to evaluate for possible factors affecting arterial stiffness within the patient group.

Subjects and Methods:Known TS patients (n=24) with confirmed karyotypes were recruited from the outpatient clinic of Seoul National University Children’s Hospital between August, 2010 and June, 2013. Patients with type 2 diabetes and/or hypertension requiring medication were excluded. There were 5 patients with one or more combined congenital heart anomalies (aortic coarctation (n=2), bicuspid aortic valve (n=2), aortic stenosis (n=3)). Anthropometric data, fasting blood lab and measurements of CAVI and pulse wave velocity were collected. A healthy control group (n=23) matched for age and body mass index (BMI) were recruited for comparison.

Results: The mean age and BMI of the TS patients were 27.0 years and 22.8 kg/m2 respectively while that of the control were 28.2 years and 22.04 kg/m2. CAVI was significantly higher in the TS patients compared to controls (6.05 vs. 6.65, P < 0.001), while there was no significant difference in pulse wave velocity. Univariate analysis for factors affecting CAVI within the TS patient group showed that CAVI was associated with waist circumference (P = 0.04) and systolic BP (P = 0.045). There were no significant factors related to CAVI using multivariate regression analysis including age, systolic BP, waist circumference, HOMA-IR and presence of cardiac anomalies.

Conclusion: TS patients showed an increased arterial stiffness compared to age- and BMI-matched controls using CAVI measurement. Further prospective studies in larger TS patient group are mandatory in order to find significant factors related to increased arterial stiffness.

 

Nothing to Disclose: HWJ, SMK, HYK, KML, YAL, CHS, SWY

14359 14.0000 SUN-0165 A A Study of Arterial Stiffness in Turner Syndrome Patients Using Cardio-Ankle Vascular Index 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Flora Bacopoulou*1, Maria-Evangelia Rodanaki2, Sophia Markantonis2, Evgenia Stergioti3, Ioanna Andreadou4, Vassiliki Efthymiou5, Efthimios Deligeoroglou3 and George Chrousos6
1University of Athens Medical School, Athens, Greece, 2Laboratory of Biopharmaceutics-Pharmacokinetics, School of Pharmacy, University of Athens, 3Division of Pediatric-Adolescent Gynecology and Reconstructive Surgery, Second Department of Obstetrics and Gynecology, University of Athens, ‘Aretaieion’ Hospital, 4Department of Pharmaceutical Chemistry, School of Pharmacy, University of Athens, 5Center for Adolescent Medicine and UNESCO Chair in Adolescent Medicine and Health Care, First Department of Pediatrics, University of Athens, Children's Hospital 'Aghia Sophia', Athens, Greece, 6University of Athens, Children's Hospital 'Aghia Sophia', Athens, Greece

 

Kisspeptin peptides are the most powerful stimulators of GnRH secretion and consequently gonadotropin release from anterior pituitary. Kisspeptin is considered critical in regulating reproductive function in relation to metabolic and environmental cues. Reproductive function is gated by the energy reserves and stress of the individual (1); conditions of energy insufficiency and stress such as the eating disorders, often disturb reproductive function and fertility. In this context we studied serum levels of kisspeptin-1, LH, FSH and estradiol in adolescents diagnosed, according to DSM V criteria, with Anorexia Nervosa (AN), Other Specified Eating Disorders (OSED) and healthy age matched controls, in order to assess circulating kisspeptin-1 levels, correlations with gonadotropins and estradiol as well as potential differences among study groups. A total of 37 adolescent girls participated in the study, 17 AN patients (mean age±SD: 15.8±1.6 years, mean BMI±SD: 15.7±0.9 kg/m2), 5 OSED patients (mean age±SD: 14.8±1.4 years, mean BMI±SD: 18.7±2.7 kg/m2) and 15 controls (mean age±SD: 14.5±1.7 years, mean BMI±SD: 20.2±1.8 kg/m2). Serum Kisspeptin-1 concentrations were measured using the Human Kisspeptin 1 (KISS-1) Elisa Kit, (Emelca Bioscience). The assay range was 20 ng/l-1500 ng/l with a sensitivity of 12.14 ng/l, intra-assay and inter-assay precision CV <10% and <12% respectively. The mean±SD kisspeptin-1 levels were 249.2±136.7 ng/l for the anorectic patients, 450.9±185.2 ng/l for the OSED patients and 308.7±194.1 ng/l for the control group. There were no statistically significant differences in kisspeptin-1 levels among the three groups studied. Furthermore when amenorrhoeic patients and participants with normal menstruation were compared, statistically significant differences were found for LH and estradiol (p=0.05) but not for kisspeptin-1. For all study participants, statistically significant correlations were found between LH and FSH (r=0.535), LH and estradiol (r=0.409), BMI and estradiol (r=0.429). More studies are needed to evaluate further the regulatory role of serum kisspeptin-1 in patients with eating disorders.

 

Nothing to Disclose: FB, MER, SM, ES, IA, VE, ED, GC

16991 15.0000 SUN-0166 A Kisspeptin-1 Serum Levels in Adolescents with Anorexia Nervosa and Other Specified Eating Disorders 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Jacob Gerner Lawaetz*, Casper P. Hagen, Martin Blomberg Jensen and Anders Juul
University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark

 

Context: A testicular volume < 4 ml or genital stage 1 (G1) ≥ 14 years is the classical diagnostic criteria for delayed puberty in boys. An alternative criteria is the Pubertal Stage Line Diagram (PSLD)(1) which is an age-conditional reference diagram for tracking pubertal development using testicular volume or genital stage < -2 SD for age as diagnostic of delayed puberty.

Objective: To evaluate the different diagnostic criteria’s for the diagnosis of Constitutional Delay of Growth and Puberty (CDGP).

Design and Participants: A retrospective evaluation of clinical, auxological and biochemical data, based on 451 consecutive boys who were evaluated for delayed puberty in a single tertiary centre between 1990 and 2013. Of the 451 boys evaluated, 164 were excluded due to missing data, reclassification and associated comorbidities. In the 287 remaining patients we applied classical – and PSLD criteria to diagnose CDGP.

Main Outcome Measures: Baseline measurements of chronological age, bone age, height, testis size, genital stage, LH, FSH, testosterone and inhibin B. Longitudinal measurements of LH before and after start of treatment with testosterone undecanoate (TU).

Results: 78/287 boys were in G1 ≥ 14 years old, 43/287 had a testicular volume < 4 ml ≥ 14 years old, whereas 162/287 boys were in a genital stage < -2 SD for age, and 115/287 boys had a testicular volume < -2 SD for age. In the group of 162 boys with a genital stage < -2 SD for age, chronological age at first visit was on average 15.2 years (25th , 75th percentile : 14.1 , 16) and bone age was 12.5 years (11.5 , 13.2), [bone age delay of 2.6 years (1.8 , 3.4)]. Height at first visit was 154.5 cm (146 , 161.4) [HSDS -1.6 SD (-2.1 , -1.1)]. Testis size at diagnosis was 4 ml (3 , 6). LH, FSH, testosterone and inhibin B levels were subnormal for age or clustered in the lower part of the reference range. 105/162 boys with CDGP were treated with peroral TU for an average of 0.88 years (0.55 , 1.34). 39/105 responded to TU treatment with a significant decrease in LH from 0.85 IU/l (0.37 , 1.43) to 0.03 IU/l (0.03 , 0.29) and were classified as “LH-dippers”. Other 17/105 responded with an increase in LH from 0.77 IU/l (0.4 , 1.14) to 1.03 IU/l (0.77 , 2.14) and were classified as “non-LH-dippers”. No significant differences in clinical, auxological or biochemical data were found between LH-dippers and non-LH-dippers.

Conclusions: Diagnosis of CDGP strongly depends on the selected diagnostic criteria, and we suggest using Pubertal Stage Line Diagram criteria, which enables an age specific evaluation of pubertal development.  Boys with CDGP constitute a heterogeneous group and vary markedly in phenotype. Thus, a subpopulation of CDGP boys are very sensitive in their pituitary feedback upon TU treatment to induce puberty, but it remains to be seen if the short-term LH change to TU is predictive of long-term response to puberty induction. ClinicalTrails.gov identifier: NCT02034487.

 

Nothing to Disclose: JGL, CPH, MBJ, AJ

15653 16.0000 SUN-0167 A Clinical, Auxological and Biochemical Findings in 451 Consecutive Boys Evaluated for Delayed Puberty in a Single Tertiary Referral Center 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Havva Iscan1, Daniela Polansky1, Nils Lehmann2, Corinna Grasemann1 and Berthold P Hauffa*1
1Universität Duisburg - Essen, Kinderklinik II, Essen, Germany, 2Universität Duisburg - Essen, Essen, Germany

 

Introduction: The distinction of hypogonadotropic hypogonadism (HH) from severe constitutionally delayed puberty (CD) remains difficult in clinical practice. Early diagnosis is important, because patient management differs. The test most frequently proposed to distinguish between both conditions is the GnRH agonist (GnRH-A) test. It has been evaluated for various agonists in small series only, mostly in boys. Objective: To assess the diagnostic performance of the GnRH-A test in boys and girls with various degrees of pubertal delay. Methods: All 303 GnRH-A (buserelin 10 μg/kg BW sc) tests performed in 279 patients (30 female; age 14.9±1.3 yrs [mean±1 sd] from 1.12.1996 to 31.7.2012 were reevaluated after a mean (range) follow-up of 2.7 (0-11.6) yrs by two observers. 158 patients were identified in whom diagnoses could be confirmed by independent diagnostic means. 121 patients were not included into the analysis (n= 93 no clinical follow-up data, n=3 test technically incomplete, n=25 diseases with varying responsiveness of the hypothalamo-pituitary-gonadal axis, e.g. Prader-Willi-, Bardet-Biedl syndromes, anorexia nervosa, others). Patients were rated according to the stringency of external confirmation as "diagnosis confirmed" (group A: n=112) or "diagnosis highly probable" (group B: n=46). To establish the influence of age and pubertal development on test performance, testing was considered "early" at an age of (females/males) <13/<13.5 yrs, "average" at 13-≤15.5/13.5-≤16 yrs or "late" at >15.5/>16 yrs. Patients were rated as prepubertal, early pubertal and pubertal using Tanner staging (and testicular volume in boys). Delta LH (IU/L) in serum 4 h post injection was selected to discriminate between HH and CD. Performance was assessed  by ROC curve analysis, cutpoints were calculated using the Youden Index. Results: In group A sensitivity for the diagnosis of HH was 94.7 %, specificity was 87.8 %. If less stringently confirmed patients were added (groups A+B), sensitivity was 91.8 %, specificity was 90.7 %. ROC AUC was 0.96 in both settings with no difference in discriminatory power. Cutpoint for delta LH in group A (groups A+B) was 4.4 IU/L (3.4 IU/L) with an odds ratio per 1 unit increase of 0.62 [CI 0.49-0.77, P<0.0001] (0.60 [CI 0.50-0.73, P<0.0001]). For group A (groups A+B), the positive predictive value (PV) was 0.80 (0.86), the negative PV was 0.97 (0.95) using prevalences derived from the tested population. No differences in test performance became apparent, if sex, age or pubertal stage at test were entered into the model. Conclusion: The GnRH (buserelin) test appears to be a robust test under real life conditions with stable performance over long periods of time with a good ability to distinguish between HH and CD in young adolescents with pubertal delay, with similar performance in boys and girls.

 

Nothing to Disclose: HI, DP, NL, CG, BPH

14477 17.0000 SUN-0168 A Diagnostic Performance of the GnRH Agonist (Buserelin) Test in 158 Children and Adolescents with Pubertal Delay Assessed By Long-Term Follow-up 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Zhihong Liao*1, Nana Yan1, Wen Ji1, Jia Deng2, Yu Wang1, Yiming Wang2 and Yanbing Li3
11st Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China, 2Zhongshan Medical College, Guangzhou, China, 3First Affiliated Hospital, Sun Yat-sen University, China

 

Idiopathic hypogonadotropic hypogonadism (IHH) is a rare disease defined by absent or incomplete puberty due to insufficient gonadotropin without pituitary tumor or other deficiencies. IHH commonly appears in a sporadic form, but several familial cases have also been reported. Known genes mutations can be detected in some patients. As IHH has a complex pathogenesis and is fivefold less prevalent in females, the amount of literatures linked with affected females is relatively less. To explore relationship between the genotypes and related clinic features, all coding exons and exon-intron boundaries of twelve selected genes in six affected females by extracting DNA from peripheral-blood samples, which are KAL1, FGF8/FGFR1, PROK2/PROK2R, GnRH1/GnRHR, TAC3/TACR3, KISS1/KISS1R and NELF, were amplified by PCR. The PCR products were sequenced and analyzed by prediction programmes(SIFT&Polyphen-2).  We collected the clinical characters for all the six cases with IHH, including clinical manifestations, karyotype, thyroid function, adrenal, pituitary secretion, glucose and lipid metabolism, GnRH stimulation test, imaging examination of the pituitary, olfactory system, genital system. Four gene mutations were observed in three of them. Case four had Two detected mutations  simultaneously that were c.1419G>A (p.Gly474Arg) of KAL1 and c.991G>A (p.Val331Met) of PROKR2. Case two showed a TACR3 gene mutation of c.692C>T(p.Thr231Ile), whose karyotype showed 46，XX，t（2，11）（q11；q25). Case five was found a FGF8 gene mutation of c.493G>A(p.Glu165Lys). Non detected mutations were identified in other cases. No abnormality were seen for the remaining genes. Four missense mutations were identified here. PROKR2 (c.991G>A) was reported before. The other three mutations were newly reported here. Since the digenic mutations did not present collaborative effect in clinic futures, we concluded that the digenic mutations may mediate certain overlapping functions. We haven’t performed functional experiments associated with the signaling passway. No outstanding clinical findings that was differential from other female patients has been noticed among the three patients. Our finding had contributed to the IHH gene spectrum.

 

Nothing to Disclose: ZL, NY, WJ, JD, YW, YW, YL

13234 18.0000 SUN-0169 A Molecular Genetic Study of Female Patients with Idiopathic Hypogonadotropic Hypogonadism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Maria Veronica Mericq*1, Camila Corvalan2, Laura Prieto3 and Ricardo Uauy2
1Hosp San Borja-Arriaran, Santiago, Chile, 2Institute of Nutrition and Food Technology, University of Chile, Santiago, Chile, 3Institute of Nutrition and Food Technology (INTA), University of Chile, santiago, Chile

 

Premature adrenarche (PA) has been associated to increased adverse metabolic profile at diagnosis. We have recently shown, in a cross sectional analysis of longitudinal followed children of normal birth weight that different adiposity indicators at age 7 yr were positively and similarly associated with PA and these associations were only partially related to IGF-I and leptin at that age. Objective: to identify early predictors of high DHEAS in 7y Chilean children. Methods: longitudinal follow-up of 977 participants (48% girls) of the Growth and Obesity Chilean Cohort Study that represents low-middle income children, of birth weights 2500-4500g. In these children we have anthropometric information at birth and 4y, as well as maternal information: BMI (current and pre-pregnancy), pregnancy weight gain (IOM), height, schooling and age at menarche. In a subsample (n=269) we also determined IGF-I, adiponectin and insulin at 4 yr. Results: Obesity (BMI> 2 SDS WHO 2007,OR 1.67,1.13-2.49) larger waist circumference ( WC >p 90th ,NHANES III, OR 1.78,1.27-2.47), higher IGF-I ( > p75th sample, OR 1.78,0.93-3.39-1.5) at 4 yrs, as well as lower birth weight  (BW< 3 K,OR 1.74, 1.18-2.57 ) and a higher educated mother ( school yr> 12  OR 1.69, 1.21-2.36)  predicted those children who had higher DHEAS at 7y. Risks associated with combining obesity at 4y with one additional risk factor are as follows: Obesity at 4y+BW <3K , n=923 ,OR 3.80,1.29-11.16), Obesity at 4y + IGFI > p75 at 4y, n=236,OR 3.35,1.05-10.67), Obesity at 4y +WC > P90 at 4y , n=923 ,OR 2.70,1.48-4.92), Obesity at 4y + Maternal Schooling > 12y n=923 ,OR 1.76,1.11-2.81).All analyses were adjusted by age and sex (Interactions p >0.05). The associations were considered significant if P< 0.05. The analyses were conducted by using SAS (version 9.1; SAS Institute). *p<0.05. Conclusions: the identification of these early risk factors could allow establishing prevention strategies of PA in these children

 

Nothing to Disclose: MVM, CC, LP, RU

13000 19.0000 SUN-0170 A Identification of Early Risk Factors for Premature Adrenarche 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Shin-Hee Kim*1, In Ah Jung2, Won Kyoung Cho2, Kyoung Soon Cho2, So Hyun Park2, Min Ho Jung2 and Byung Kyu Suh2
1The Catholic University of Korea, Seoul, Korea, Republic of (South), 2College of Medicine, The Catholic University of Korea, Seoul, Korea, Republic of (South)

 

Objective Our aim was to evaluate the timing of menarche and the associated factors among patients with idiopathic central precocious puberty (CPP) or early-onset puberty (EP) who were treated with gonadotropin-releasing hormone agonists (GnRHa).

Methods. We analyzed clinical and laboratory data of 98 girls (75 CPP and 23 EP) who were treated with GnRHa. Cumulative incidence of menarche was calculated by Kaplan-Meier method. Clinical and laboratory parameters associated with time to menarche were determined using the Cox proportional hazards model.

Results. A total of 98 girls were followed for median 24.2 months (interquartile ranges [IQR], 14.3–32.2). At the initiation of treatment, the median chronological (CA) and bone age (BA) were 8.7 years (IQR, 8.2–9.3) and 12 years (IQR, 11.5–12), respectively. The median treatment duration for whole cohort was 2.9 years (IQR, 2.3–3.5). Of the 98 girls, 57 (58 %) reported menarche after completing GnRHa treatment. Among these 57 girls, median interval between end of treatment and onset of the menarche was 13.4 months (IQR, 9.4–18.5). Cumulative incidence rate of onset of menarche was 31% at 12 months, 51% at 15 months, 61% at 18 months, and 82% at 24 months after completing treatment. In univariate analysis, factors associated with the time to menarche included BMI SDS at start of treatment (hazard ratio [HR], 1.33; 95% confidence interval [CI], 1.003–1.77), LH/FSH ratio at start of treatment (HR, 1.34; 95% CI, 1.04–1.72) and BMI SDS at end of treatment (HR, 1.88; 95% CI, 1.34–2.64). Multivariate analysis indicated only one risk factor was BMI SDS at end of treatment (HR, 1.02; 95% CI, 0.99–1.04).

Conclusion. We found that onset of menarche was associated with BMI SDS at end of treatment. These results suggest that hormonal and auxological parameters at start as well as at end of treatment are related to time of menarche.

 

Nothing to Disclose: SHK, IAJ, WKC, KSC, SHP, MHJ, BKS

13376 20.0000 SUN-0171 A Time to Menarche after Completing Gonadotropin-Releasing Hormone Agonist in Girls with Central Precocious or Early-Onset Puberty 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Peter A. Lee*1, Margaret Luce2 and H. Peter Bacher2
1Penn State Univ Coll of Med, Hershey, PA, 2AbbVie, Inc, North Chicago, IL

 

Background: The recently developed microsphere-based 3-month leuprolide acetate (LA) formulations (non-weight-based dosing) for patients with central precocious puberty (CPP) triggered the question about the optimal transition from 1-month formulations (mainly weight-based dosing). Additionally, the efficacy assessment using GnRH analog stimulation tests is cumbersome and has been complicated by accessibility problems.

Objective: To provide a sub-analysis of patients who were pre-treated with 1-month LA prior to enrollment in a pivotal Phase III trial and then being randomized to 3-month depot formulations with either 11.25- or 30 mg and to investigate the use of basal LH as an alternative test for treatment monitoring.

Methods: This study was a retrospective post hoc analysis of a randomized, open-label, 6-month study in a total of 84 patients with CPP (42 were pre-treated monthly with either 7.5 mg-, 11.25 mg- ,or 15 mg of LA or another dose or GnRH agonist).

Results: Suppression was effectively maintained in 81% (11.25 mg dose) and 100% (30 mg dose) of patients. Independent of the monthly LA dose used prior to randomization, the maximum-stimulated LH levels remained well below the required cut-off of 4IU/ml. The adverse event profile was balanced and very similar among treatment groups regardless of the LA-dose used prior to randomization and between the 11.25- and the 30 mg 3-month formulations. Comparison of basal LH and maximum-stimulated LH to assess LH suppression will be provided

Conclusions: The dose of monthly LA formulations does not seem to effect the continuation of LH suppression when patients are switched to 3-month microsphere-based LA formulations, regardless whether patients were treated with 11.25- or 30 mg 3-monthly formulation. The 30 mg 3-month LA formulation achieved a more stringent LH suppression versus 11.25 mg dose.

 

Disclosure: PAL: Consultant, AbbVie, Speaker Bureau Member, AbbVie, Medical Advisory Board Member, Novo Nordisk, Consultant, Novo Nordisk. HPB: Employee, AbbVie, Inc. Nothing to Disclose: ML

15208 21.0000 SUN-0172 A Practical Considerations for the Treatment of Central Precocious Puberty with a 3-Month Leuprolide Acetate Formulation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Zeina Melhem Nabhan*1 and Erica A Eugster2
1Riley Hosp for Children, Indianapolis, IN, 2Indiana University School of Medicine

 

Most Children with McCune Albright Syndrome do not Require Treatment for Precocious Puberty.

Background: McCune Albright Syndrome (MAS) is a rare sporadic disorder typified by the classic triad of precocious puberty (PP), café au lait skin pigmentation and polyostotic fibrous dysplasia (FD) of bone. PP results from autonomous gonadal function and is characterized by the sudden onset of vaginal bleeding in girls and early secondary sexual development in boys. Although often the presenting feature, the frequency with which children with MAS need to be treated for PP has not been well described.

 Objective: To investigate the natural history of PP in children with MAS and determine the percentage of children requiring treatment.

 Method: Medical records of children with MAS followed at Riley Hospital for Children in the past 15 years (1998-2013) were reviewed. Variables analyzed included age, sex, presenting features, presence of café au lait macules, presence of fibrous dysplasia, presence of PP, treatment for PP, pelvic US, and episodes of vaginal bleeding in girls.       

 Results: Twenty children (12F: 8M) with MAS were identified. The average age at diagnosis was 5.19 ± 3.25 yrs (range: 0.66 - 12.75 yrs). Ninety five percent had FD and 85% had café au lait macules. PP was the presenting feature in 100% of the girls at an average age of 4.31 ± 2.52 yrs (range: 0.66 - 8.2 yrs), of whom 75% had vaginal bleeding and 25% had episodic breast development.  Of nine girls who had a documented pelvic US, 77% had unilateral large ovarian cysts and 22% had an enlarged uterus and ovaries. During an average of  7.6 years of follow-up,  16% of girls had no vaginal bleeding, 25% had one episode, 25% had 2 episodes, and 34% had >3 episodes. Three girls required medical therapy for PP consisting of progesterone (n=1), letrozole (n=1) and testolactone/spironolactone (n=1). Other than a trend toward a younger age at diagnosis (p = 0.07), no differences were seen between girls who had progressive PP compared with those who did not. Boys presented at an average age of 6.95 ± 4.03 yrs (range: 2.0 - 12.75 yrs). Craniofacial FD causing skeletal asymmetry was the presenting feature in 60% of boys whereas 40% presented with fractures of long bones. Boys were followed for an average of 3.9 years during which none had biochemical evidence of PP. However 25% had isolated unilateral or bilateral testicular enlargement. Thus, only 15 % of our cohort required medical therapy for PP.

 Conclusion: Although PP is arguably the most notorious manifestation of MAS, it occurs primarily in girls and is usually not progressive. Therefore, a minority of children with MAS will require treatment for PP. Our results support careful monitoring and provide important prognostic information for parents and healthcare providers.

 

Disclosure: EAE: Principal Investigator, Endo Pharmaceuticals, Investigator, Abbott Laboratories. Nothing to Disclose: ZMN

12857 22.0000 SUN-0173 A Most Children with Mccune Albright Syndrome Do Not Require Treatment for Precocious Puberty 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Mo Kyung Jung*1, Ah Reum Kwon2, Jung Min Ahn1, Hyun-wook Chae1, Duk-Hee Kim3 and Ho-Seong Kim4
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Severance Hospital, Seoul, Korea, Republic of (South), 3Yonsei Univ Coll of Med, Seoul, Korea, Republic of (South), 4Severance Children's Hospita, Seoul, Korea, Republic of (South)

 

Growth Outcome for girls with idiopathic Central Precocious Puberty during GnRH agonist therapy

Mo Kyung Jung, Ah Reum Kwon, Jung Min Ahn, Hyun Wook Chae, Duk Hee Kim and Ho-Seong Kim

Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea

Abstract

Purpose: GnRH agonist therapy is the treatment of choice for central precocious puberty (CPP). However controversy still exists about final height preservation of GnRH agonist therapy. We analyzed height preservation by comparing the final height (FH) with mid-parental height (MPH) and predicted adult height (PAH) before treatment.

Method: We retrospectively reviewed FH of 82 girls with idiopathic CPP who were treated with GnRH agonist. FH was measured at the time when height velocity was less than 1cm/yr, at least 2 years after menarche, and bone age (BA) was over than 15 years. BA was assessed by the Greulich-Pyle method, and PAH was predicted by the Bayley-Pinneau method. Growth parameters were expressed as standard deviation score (SDS), and we assessed the changes of height SDS during GnRH treatment. Considering the effect of growth hormone (GH) treatment, we divided the patients into two groups, one receiving GnRH agonist therapy alone (n=59) and the other receiving GnRH and GH combined therapy (n=23).  

Results: Mean current age was 14.16±1.44 years. At the start of treatment, mean chronologic age (CA) was 8.62±0.82 years, and mean BA was 10.39±0.86 years, which was 1.77±0.84 years older than CA. The length of treatment was average of 1.93±0.72 years. Menarche occurred after GnRH therapy discontinuation for 0.97±0.61 years and time span elapsed from menarche was 2.61±1.28 years.

In the group of GnRH agonist alone, height SDS for BA was increased during treatment, which was -0.40±0.81 at the start, -0.29±0.80 at the end of treatment, and 0.18±0.95 at final. Compared to initial PAH (156.61 ± 3.96 cm), FH (159.92 ± 4.64 cm) was statistically increased (p value<0.001), and was similar to MPH (159.90 ± 3.52 cm).

In the group of GH combined therapy, height SDS for BA was also increased during treatment. It was -0.95±0.53 at first, -0.49±0.82 at the end of treatment, and -0.03±1.05 at last. Also FH (158.94±5.11cm) has reached to MPH (158.07±3.31cm), and compared to initial PAH (154.63±2.55cm), it was also statistically increased (p value<0.001). Furthermore, height gain was slightly higher than GnRH agonist therapy alone.

Conclusions: In CPP girls treated with GnRH agonist, height SDS for BA was increased and the FH which had become higher than initial PAH, finally was close to MPH.

Keywords: Central Precocious Puberty, GnRH agonist, Final height

 

Nothing to Disclose: MKJ, ARK, JMA, HWC, DHK, HSK

14228 23.0000 SUN-0174 A Growth Outcome for Girls with Idiopathic Central Precocious Puberty during GnRH Agonist Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Se Young Kim*1 and Seung Joon Lee2
1Bundang Jesaeng Gen Hosp, Seongnam, Korea, Republic of (South), 2Bundang Jesaeng General Hospital, Daejin Medical Center

 

Purpose :The goal of treatment for true precocious puberty (TPP) and early puberty with gonadotropin-releasing hormone agonist (GnRHa) is to prevent loss of genetic potential of target height (TH). And to regress secondary sex characteristics appropriate for patient’s age. But some patient’s growth velocity (GV) after treatment would decline and suggest that final height (FH) was not improved. So, we investigated the effect of combined growth hormone (GH) and GnRHa treatment for near-final height (NFH) improvement.

Methods :In this retrospective study, we collected data on the 167 girls with TPP [139 treated with only GnRHa (Group 1); and 28 treated with GnRHa and combined GH over 1 year (Group 2)] who diagnosed with Luteinizing Hormone (LH) level over 5 IU/mL and two to three-fold increment compared basal level after GnRH stimulation test. NFH was investigated after menarche at least one year has elapsed from 32 patients. 22 patents with NFH treated with only GnRHa are included Group 3. And 8 patients with NFH treated with combined GnRHa and GH over 1 year are included Group 4.

Results :The chronological age at diagnosis were 8.25 ± 1.10 years in Group 1, 9.02 ± 1.45 years in Group 2. The height SDS at diagnosis were -1.76 ± 1.26 in Group 1, -0.59 ± 0.97 in Group 2, showed significant difference (p<0.05). The predicted adult height (PAH) SDS at diagnosis were -1.76 ± 1.26 in Group 1, -2.82 ± 1.53 in Group 2 with significant difference (p<0.05). After 1 year treatment , PAH SDS were -1.14 ± 1.17 in Group 1, -1.71 ± 1.29 in Group 2. After 2 year treatment, PAH SDS were -0.73 ± 1.01 in Group 1, -0.50 ± 1.40 in Group 2. After 3 year treatment, PAH SDS were -0.40 ± 1.13 in Group 1, -0.50 ± 1.05 in Group 2, appeared decreasing intergroup PAH difference. TH SDS at diagnosis were -0.50 ± 0.504 in Group 3, -0.97 ± 0.514 in Group 4, showed significant difference (p<0.05). After over 1yr treatment, NFH SDS of Group 3 and Group 4 were not statistically different.

Conclusion :The combined GH and GnRHa therapy in TPP and early puberty, whose PAH SDS or TH SDS were shorter than 5 percentile, could effective improving NFH in proportion to treatment duration.

 

Nothing to Disclose: SYK, SJL

11847 24.0000 SUN-0175 A The Effect of Combined Growth Hormone and Gonadotropin-Releasing Hormone Agonist Treatment for Near-Final Height Improvement in True Precocious Puberty and Early Puberty 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Natalie Hecht Baldauff1, Marcela Vargas*1, Kanthi Bangalore Krishna1, Melissa A Buryk2 and Selma Feldman Witchel1
1Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, 2Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA

 

Background:  Central precocious puberty (CPP) is the premature reactivation of the hypothalamic-pituitary-gonadal axis and is defined as the onset of secondary sexual characteristics before age 8 in females and 9 in males. The most common treatments are Leuprolide acetate depot and Histrelin implants.  Anecdotal reports suggest increased weight gain during treatment.  We compared the effects of Leuprolide (L) and Histrelin (H) on BMI, growth velocity, and skeletal maturation. 

Methods:  We reviewed charts of children diagnosed with idiopathic CPP between 2008 and 2013.  We included females diagnosed with CPP prior to the age of 8 years and males diagnosed prior to the age of 9 years and who began treatment with GnRH agonists prior to age 8.5 years and age 9.5 years respectively.   Patients with congenital adrenal hyperplasia, McCune Albright Syndrome, diabetes mellitus, intracranial pathology, and steroid secreting tumors were excluded.  We hypothesized that: 1) the increase in BMI would be greater in the L treated group than the H treated group and 2) there would be no difference in growth velocity or skeletal maturation between groups. 

Results:  A total of 37 patients fulfilled the inclusion criteria. Median age was 7.3 yrs, 60% caucasian and 97% female. Median BMI at baseline was 18 kg/m2 [16.8-19] and median bone age 1.5 years advanced at 8.8 years [7.8-10.5]. Mean follow up was 3.1 years (±0.8) with Tanner stage regressing in most cases (3% tanner stage 1 at start, 44% tanner stage 1 at end) and only 3 patients progressing, both to tanner stage 5 (2 L and 1 H). No differences in baseline age, BMI, bone age, midparental target height, and predicted height were found at start of treatment. There was no difference in age-adjusted change in BMI, +3.25kg/m2 (±1.8) in L and +4.3kg/m2 (±1.2) in H treated (p=0.3), nor was there a difference age-adjusted change in bone age, +2.6yrs (±1.8) L vs. +3yrs (±1.2) (p=0.6) over 3.1yrs of follow-up. Height velocities were similar between groups (5.4 cm/yr (±1.5) L vs. 5.6cm/yr (±1.2) H) (p=0.6). BMI change was different from the normal population based on CDC BMI data, +1.7kg/m2 over same age range (p<0.01).

Conclusions: Leuprolide and Histrelin had similar success in suppression of puberty with very few treatment failures in either group. Changes in BMI, bone age, and height were similar whether treated with Lupron or Histrelin. However, compared to healthy controls, there was a significant BMI increase in both treatment groups. Taken together, the data indicate that growth velocity, skeletal maturation and BMI changes as well as treatment efficacy were comparable between the two treatment groups.  Given that treatment outcomes were almost identical, we conclude that choice of treatment can be individualized based on patient preference.

 

Nothing to Disclose: NH, MV, KB, MAB, SFW

14569 25.0000 SUN-0176 A Leuprolide and Histrelin: A Comparison of Efficacy and Impact on BMI, Growth Velocity, and Skeletal Maturation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Amnon Zung*, Ella Burundukov, Mira Ulman, Tamar Glaser, Malka Chen and Zvi Zadik
Kaplan Medical Center, Rehovot, Israel

 

Objective GnRH analog (GnRHa) administration in girl with precocious puberty (PP) is aimed to suppress gonadotropin secretion and subsequently pubertal progression. The gold standard for effective hormonal suppression is attenuated serum LH levels in response to LHRH stimulation. We aimed to compare basal and post-GnRHa levels of LH to LHRH stimulation test, and to evaluate first-voided urinary LH (ULH) as a non-invasive alternative method for monitoring treatment.

Methods Seventeen girls with PP were followed over a period of 12 to 36 months during GnRHa (Decapeptyl Depot) treatment. ULH and serum LH levels were obtained every 4 months before and 24 hr after GnRHa administration respectively, along with clinical evaluation of pubertal staging, growth velocity (GV) and bone age (BA) advancement. LHRH stimulation test was performed 4 months after the first injection and annually thereafter. Pre-pubertal cutoff for ULH was 1.62 IU/L based on 2SD above the mean in 29 prepubertal girls. Based on historical data, adequate suppression of gonadotropins was defined by maximal basal and stimulated LH levels of 0.7 and 2.0 IU/L, respectively.    

Results A total of 36 LHRH stimulation tests demonstrated adequate suppression of gonadotropins with peak LH of 0.57 ± 0.33 (range 0.1-1.4 IU/L). Corresponding mean post-GnRHa LH levels was 0.59 ± 0.33 (range 0.1-1.6) and mean basal LH levels was 0.27 ± 0.16 (range 0.1-0.7 IU/L). Both tests were correlated with LHRH-stimulated LH: R=0.807 and R=0.696 for post-GnRHa and basal LH levels respectively (p<0.001 for both comparisons). Corresponding mean ULH levels was 1.12 ± 0.38 IU/L, and only once ULH level was above 1.62 IU/L.

Among 90 pair-tests of ULH and post-GnRHa LH measurements obtained over 380 patient-months, six ULH measurements levels were above the pre-pubertal cutoff (range 1.66 – 2.21) but none of post-GnRHa LH levels. In spite of adequate hormonal suppression, 21 episodes of clinical breakthrough were recorded: 10 episodes of GV SDS > 2, 8 episodes of BA advancement and three episodes of both GV and BA acceleration. ULH and post GnRH LH levels measured during these episodes were similar to levels obtained during clinical suppression. 

Conclusions Decapeptyl Depot treatment provides adequate suppression of the hypothalamic- pituitary-gonadal axis during PP. When in doubt, both pre-GnRHa basal and post-GnRHa LH levels can provide reliable data on hormonal suppression. Clinical breakthroughs during treatment do not reflect unsuppressed gonadotropins and therefore therapy intensification is not necessarily indicated.

 

Nothing to Disclose: AZ, EB, MU, TG, MC, ZZ

13007 26.0000 SUN-0177 A Monitoring Gonadotropin-Releasing Hormone Analog Treatment in Girls with Central Precocious Puberty: A Comparison of Four Methods 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Ayako Ozawa*1, Tomotaka Kono1, Katsuya Aizu1, Ichiro Miyata2 and Hiroshi Mochizuki1
1Saitama Children's Medical Center, Japan, 2Jikei University School of Medicine, Japan

 

Background: Precocious puberty (PP) is seen more frequently in girls, and is considered idiopathic for the majority of female cases. Furthermore, it is globally said that the proportion of cases of PP secondary to organic lesions is higher in boys than in girls. However, there is little information concerning clinical aspects of the male PP in Japan.

Objectives: In the present study, we analyzed the characteristics of male cases with PP at a single center.

Subjects and Methods: The subjects were 28 boys diagnosed as having PP at the Division of Endocrinology and Metabolism of Saitama Children’s Medical Center in Japan between April 1992 and July 2012. For these patients, we investigated clinical symptoms and laboratory findings retrospectively.

Results: Among 28 boys with PP comprising this study, GnRH-dependent PP (GDPP) was found in 23 (82.1%) cases, and GnRH-independent PP (GIPP) in five (17.9%) cases. In these 23 patients with GDPP, 13 (46.1%) cases were caused by organic lesions in the central nervous system (hypothalamic hamartoma in four cases, other brain tumors in four cases and brain damage with no tumors in five cases), and six (21.4%) cases were accompanied by chromosomal abnormality (Down syndrome in five cases and Williams syndrome in one case). The other four (14.3%) cases were idiopathic. On the other hand, two cases of hCG-producing germ cell tumor, one case of hepatoma and two cases of McCune-Albright syndrome were found in the GIPP patients. The mean age at diagnosis of all patients was 7.1±3.1 years (ranging from 0.7 to 11.1 years), but the age at diagnosis of idiopathic PP or GDPP with chromosomal abnormality was localized between 8.8 years and 10.8 years (10.0±0.6 years). Furthermore, GDPP with organic lesions was found in each age group of childhood.

Discussion: Our study demonstrated low incidence (14.3%) of idiopathic PP in boys as reported previously. All patients diagnosed as having PP before 8 years of age were accompanied by McCune-Albright syndrome or organic lesions, and therefore, it is especially important to identify underlying diseases in younger boys with PP. Additionally, since PP exists in approximately 20% of cases with damage of central nervous system or chromosomal abnormality, it is necessary to take care for the onset of PP in those patients.

 

Nothing to Disclose: AO, TK, KA, IM, HM

13547 27.0000 SUN-0178 A Clinical Aspects of 28 Boys with Precocious Puberty at Saitama Children's Medical Center in Japan 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Young-Jun Rhie*1, Hyo-Kyoung Nam2, Joon Woo Baek2 and Kee-Hyoung Lee2
1Korea University Ansan Hospital, Korea University College of Medicine, Ansan-si, Gyeonggi-do, Korea, Republic of (South), 2Korea University College of Medicine, Seoul, Korea, Republic of (South)

 

Kisspeptin-G-protein couple receptor-54 (GPR54) system plays a key role in the activation of the gonadotropic axis at puberty. Central precocious puberty (CPP) is caused by the premature activation of hypothalamic gonadotropin-releasing hormone secretion. Recently, an activating mutation of the GPR54 gene was identified in a girl with CPP, implicating GPR54 in the pathogenesis of CPP. This study was aimed to identify the GPR54 gene variations and to investigate the associations between the GPR54 gene variations and CPP. Korean girls with CPP (n=194) and their healthy controls (n=99) were included in this study. The GPR54 gene was directly sequenced in randomly selected CPP samples (n=30). The genetic variations identified were genotyped by SNaPshot assay in both groups. Seven polymorphisms were identified in the GPR54 gene. A novel polymorphism, 919667 T/G was identified for the first time. 920170 T/G and 920642 A/T showed meaningful differences in genotype and allele frequencies. Haplotype CAGTGTC was detected more frequently in CPP group. The genetic variation of GPR54 gene can be a contributing factor of development of CPP. The association between gene variation and CPP should be validated by further evidence obtained from large-scaled and functional studies.

 

Nothing to Disclose: YJR, HKN, JWB, KHL

15657 28.0000 SUN-0179 A GPR54 Gene Polymorphisms in Korean Girls with Central Precocious Puberty 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Francisca Grob*1, Carolina Mendoza1, Helena Poggi2, Claudia Godoy1, Marcela Lagos2 and Alejandro Martínez-Aguayo3
1Pontificia Universidad Católica de Chile, Santiago, Chile, 2Pontificia Universidad Católica de Chile, Santiago de Chile, Chile, 3Pontificia Universidad Catolica de Chile, Santiago, Chile

 

Background: Non Classical Congenital Adrenal Hyperplasia (NCAH) due to 21-hydroxylase deficiency can present with signs of hyperandrogenism, but phenotype is variable and sometimes patients have no apparent clinical symptoms, making diagnosis difficult. In such cases genetic analysis of CYP21A2, the gene encoding for 21-hydroxylase, has been proven to be useful.

Objective:To assess clinical, radiologic and biochemical features of patients under 18y with hyperandrogenism due to NCAH and compare them with those without NCAH.

Study design and subjects: A retrospective review of medical records of patients under 18 years referred to endocrinology between March 2006-2013 by hyperandrogenism was performed. The diagnosis of NCAH was performed using cut-offs of baseline 17-hydroxyprogesterone (17-OHP) ≥7 ng/ml or of ≥10 ng/ml after 0.25 mg of corticotropin stimulation test, and confirmed by CYP21A2 genetic analysis. Virilizing tumors were excluded. Clinical, anthropometric, radiologic and biochemical data were compared between groups with and without NCAH. Target and predicted height (Bayley Pinneau) were calculated by standard deviations (WHO 2005).

Results: (Median, [interquartile range]) 46 patients were evaluated, 54% were diagnosed with NCAH; the median age was 8y [7.2-9.75], and 64.5% were female.

Baseline and post stimulation 17-OHP levels (ng/mL) were higher in the NCAH group (9.55, [6.95-14.4]) and 30 [19-67]) compared to the non NCAH group (1.4 [0.7-2.1] and 5.1 [4.4-6.3]) (P< 0.0001).

Female patients with NCAH exhibited higher testosterone levels (ng/dl) than the group without NCAH (16, [8.6-46]) vs (5.9, [2.7-12.7], P = 0.048). Male patients with NCAH showed more advanced bone age (months) compared with the non NCAH group (35, [23-59]) vs (19, [16-9], P = 0.018).

Patients with NCAH compared with those without NCAH were taller than their target height (1.52 [0.92 to 1.93 SD] vs 1.0 [0.48 to 1.85 SD]) (P < 0.0001), their actual height was higher than predicted (1.83 [1.57 to 3.06 SD] vs 1.69 [1.28 to 2.63 SD];) (P < 0.0001) and their predicted height was smaller than their target height (-0.71 [-2.09 to 0.19 SD] v/s - 0.41 [- 1.7 to 0.22 SD]; P= 0.006).

Conclusion: Baseline and post stimulation 17-OHP levels are higher in patients with NCAH, but overlap significantly. Our results could suggest that the predicted final height (by Bayley Pinneau) of NCAH patients is lower than expected given their parental height. High testosterone levels in girls and advanced bone age in boys could suggest NCAH in pediatric patients referred by hyperandrogenism.

 

Nothing to Disclose: FG, CM, HP, CG, ML, AM

14582 29.0000 SUN-0180 A Genotypic, Phenotypic and Biochemical Evaluation of Children with Hyperandrogenism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Rinku Mehra1 and Paul B Kaplowitz*2
1Children's Natl Med Ctr, Washington, DC, 2Children's National Med Ctr, Washington, DC

 

Background:  It is known that signs of puberty in very young children are often benign but some studies suggest that premature thelarche (PT) often progresses to central precocious puberty (CPP).  There is even less information about the presentation and course of genital hair of infancy (GHI).

Objectives: 1.To analyze the frequency of different diagnoses made in children < 3 yrs referred for signs of early puberty. 2. To examine the usefulness of lab testing and follow-up in children with PT and GHI, and 3. To identify the red flags indicating a more serious diagnosis.

Methods: A list of all children < age 3 referred to a large urban children’s hospital for signs of early puberty (259.1) between 7/1/09 and 6/30/13 was generated from billing records.  Each chart was reviewed for age of visit, parent-reported age of onset of breast or pubic hair, length percentile, labs, initial diagnosis, whether there was a follow-up visit, and if the diagnosis changed.

Results: Of 278 patients, 155 (56%) were diagnosed with PT (mean age at visit 19 mo; mean age at onset 7 mo); 69 (25%) were Dx with GHI (56 F/13M; mean age at visit 12 mo, onset 6 mo) and 37 (13%, all F) had both breast and pubic hair and were labeled GHI/PT (mean age at visit 14 mo; onset 6.6 mo).  22% of all pts had had signs since the 1st month of life. One patient (large clitoris) was Dx with CAH, one was Dx with NCCAH and did not require treatment. One (breasts and vaginal bleeding) was Dx with McCune-Albright at 31 mo, and one with cerebral palsy (CP) and developmental delay presenting with GHI at age 10 mo was Dx with CPP at 32 mo.  This was the only one of 46 pts with a recorded f/u visit where the initial Dx changed, but all parents were instructed to return if there was either progression or new findings were noted. Hormone tests (usually DHEA-S, T and 17OHP for GHI; LH, FSH, estradiol for PT) were done in 35.3%.  Half of the GHI pts tested had elevated DHEA-S (20-100 µg/dl); the only other clearly abnormal values were in the cases mentioned.

Conclusions:  Very few children referred for puberty at <3 yrs have a serious underlying Dx; progression of PT to CPP was not identified. One child with GHI progressed to CPP but the child also had CP.  A surprising number had both GHI and PT, which has been little described in the literature but pts did not have a more worrisome outcome than either Dx alone.  Hormone testing is unlikely to be helpful in typical cases of PT, GHI, or GHI/PT.

 

Nothing to Disclose: RM, PBK

12419 30.0000 SUN-0181 A Clinical Characteristics of Children Under Age 3 Referred for Early Puberty 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Mikkel Grunnet Mieritz*1, Kaspar Sørensen1, Lise Aksglaede2, Annette Mouritsen2, Casper P. Hagen1, Linda Hilsted3, Anna-Maria Andersson4 and Anders Juul2
1University of Copenhagen, Faculty of Health and Medical Sciences, Rigshospitalet, Department of Growth and Reproduction, Denmark, Copenhagen, Denmark, 2University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark, 3Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark, 4University of Copenhagen, Faculty of Health and Medical Sciences, Koebenhavn Oe, Denmark

 

Objective. Pubertal gynaecomastia is a frequent phenomenon occurring in 20-40% of otherwise healthy adolescent boys. Little is known about the etiology of pubertal gynaecomastia. Markedly elevated thyroid hormones in adults with hyperthyroidism are associated with gynaecomastia.

 

Design. In a cross sectional cohort study we examined 446 healthy Danish school boys (28 of these with gynaecomastia). We evaluated TSH, T3, T4, free-T4 and free-T3 as well as pubertal development in boys with and without pubertal gynaecomastia.

 

Results. Boys with gynaecomastia had significantly higher serum concentrations of free-T3, whereas serum concentrations of TSH, T4, free-T4 and T3 did not differ significantly compared to a group of age matched pubertal boys. The differences in free-T3 between boys with and without gynaecomastia remained statistically significant even after additional correction for age (p=0.003), genital stage (p=0.003) and BMI (p=0.003), respectively. The statistical significance remained in a model with all three confounders (p=0.005). We have previously found IGF-I to be significantly associated with pubertal gynaecomastia (1) and when including IGF-I in the statistical model, the difference in free-T3 is no longer statistical significant (p=0.121).

 

Conclusions. Healthy boys with pubertal gynaecomastia had significantly higher serum levels of free-T3 compared to controls without gynaecomastia at the time of examination. However, this result did not remain statistically significant after adjustment for IGF-I, and we speculate that the GH/IGF-I axis and thyroid hormones interact, and may both influence the development of pubertal gynaecomastia.

 

Nothing to Disclose: MGM, KS, LA, AM, CPH, LH, AMA, AJ

15686 31.0000 SUN-0182 A Elevated Serum Levels of Free Triiodothyronine in Adolescent Boys with Gynaecomastia Compared to Controls 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Yoo-Mi Kim*1, Ja Hye Kim1, Beom Hee Lee2, Han-Wook Yoo1 and Jin-Ho Choi2
1Asan Medical Center Children's Hospital, Seoul, Korea, Republic of (South), 2Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea, Republic of (South)

 

Purpose: Central precocious puberty (CPP) is caused by the early activation and maturation of the hypothalamic-pituitary-gonadal (HPG) axis. This study investigated the effect of gonadotropin-releasing hormone agonist (GnRHa) treatment on final adult height (FAH) in girls with CPP.

Subjects and Method: Sixty Korean girls with CPP were included in this study. Seven of them had intracranial lesions including pilocytic astrocytoma, hamartoma, hydrocephalus, meningitis, acute disseminated encephalomyelitis, and Rathke’s cleft cyst. Patients who received human recombinant growth hormone or were diagnosed with syndromic disorder were excluded. The timing of final adult height (FAH) was defined by a growth velocity of less than 2 cm/year or a bone age (BA) greater than 15 years. During therapy, the dose of GnRHa was adjusted according to pubertal suppression, which was assessed by the Tanner stage, growth velocity, stimulated luteinizing hormone (LH) level, and BA every six months.

Results: The mean age of thelarche, BA, and chronological age (CA) at diagnosis were 7.3 ± 1.1,10.5 ± 1.1, and 8.3 ± 1.0 years. The basal and peak LH levels by GnRH stimulation tests were 1.8 ± 1.1 and 22.8 ±1.3 IU/L, respectively. Duration of therapy was 2.5 ± 0.8 years. CA, BA, and height at the end of GnRHa therapy were 10.9 ± 0.5 years, 11.8 ± 0.4 years, and 148.2 ± 4.5 cm, respectively. The age at menarche was 12.2 ± 0.6 years, and the mean interval between the interruption of therapy and menarche was 1.35 ± 0.45 years (range, 0.6 – 2.5 years). FAH significantly increased after therapy compared to PAH at diagnosis (160.9 ± 4.5 cm vs. 156.8 ± 7.1 cm, p < 0.001). Height gain was 4.1 ± 7.2 cm and subjects’ FAH was similar to their target height (159.5 ± 3.6 cm, p = 0.06). There were no significant differences in FAH and age at menarche between organic and idiopathic CPP (p = 0.24, 0.28, respectively). The FAH SDS was positively correlated with the midparental height (MPH) SDS (r = 0.441, p < 0.001), height SDS at the start of the treatment (r = 0.624, p < 0.001), height SDS at the endof the treatment (r = 0.733, p < 0.001) and PAH at theend of the treatment (r = 0.756, p < 0.001). Growthvelocity after discontinuation of the treatment was positively correlated with FAH (r = 0.323, p = 0.12), and negatively correlated with both BA (r = -0.333, p = 0.009) and CA (r = -0.389, p = 0.002) at the discontinuation.

Conclusion: This study demonstrated that GnRHatherapy is effective for height gain in patients with CPP when treatment commenced at age 8 years. FAH was significantly improved when MPH and PAH at the end of treatment were high. All patients showed menarche at the appropriate age.

 

Nothing to Disclose: YMK, JHK, BHL, HWY, JHC

12922 32.0000 SUN-0183 A The Effect of Gonadotropin-Releasing Hormone Agonist Treatment on Final Adult Height in Girls with Central Precocious Puberty 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Seung Yang*1 and Il Tae Hwang2
1Hallym University College of Medicine, Seoul, Korea, Republic of (South), 2Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea, Republic of (South)

 

Backgrounds: During puberty, secondary sex characteristics appear accompanied by growth spurts, which indicates the influence of sex hormones on growth hormone(GH) and insulin-like growth factor-I(IGF-I) secretion. Pubertal suppression with gonadotropin-releasing hormone agonist(GnRHa)  treatment in patients with precocious puberty may inversely affect IGF-I secretion. The results from the previous studies concerning GnRHa treatment and IGF-I secretion remain controversial. The aims of this study are to replicate the results of the previous studies and investigate effects of GnRHa treatment on serum IGF-I and IGFBP-3 concentrations.

Subjects and Methods: Total 60 girls (43 central precocious puberty and 17 early puberty) treated GnRHa were enrolled. Chronological age at GnRHa treatment and parental heights were obtained. Height, serum IGF-I and IGFBP-3 concentrations were measured before and after treatment. Standard deviation score(SDS) of height, serum IGF-I and IGFBP-3 concentrations for age before and after 1 year of treatment were compared. SDS are calculated using Cole's modified LMS method.

Results: Height SDS decreased significantly after 1 year of GnRHa treatment. IGF-I SDS, IGFBP-3 SDS and IGF-I:IGFBP-3 ratio did not show significant change after treatment. Subgroup with higher Δheight SDS showed higher ΔIGF-I SDS and IGF-I:IGFBP-3 ratio after treatment (p=.048 and .018 respectively). Subjects with higher mid-parental height(MPH) tended to be taller both before and after treatment(p=.000 respectively), but MPH did not correlate height velocity.

Conclusions: GnRHa treatment inversely affected height velocity. Results showed no clear relationship between GnRHa treatment and IGF-I, IGFBP-3 concentrations.

 

Nothing to Disclose: SY, ITH

15975 33.0000 SUN-0184 A Relationship Between Serum Insulin-like Growth Factor-I(IGF-I), Insulin-like Growth Factor Binding Protein-3(IGFBP-3) Concentrations and Body Height before and after Gonadotropin-Releasing Hormone Agonist(GnRHa) Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Jeesuk Yu*1, Ji Won Koh1, Jae-Sik Jeon1, Jaekyung Kim1 and Mina Ha2
1Dankook University Hospital, Cheonan, Korea, Republic of (South), 2Dankook University College of Medicine, Cheonan, Korea, Republic of (South)

 

Background: Both growth in height and gain of weight are accelerated during puberty. They are mainly affected by sex-hormones, growth hormone and IGF-1, and influenced by various factors either directly or indirectly.

Objective and hypotheses: We designed the study to find out the expression of various cytokines in the sera of female children with early- or precocious puberty and to analyze the association between the cytokines and the pubertal status.

Methods: Twenty-eight female children with breast budding before 9 years of age, who underwent the LHRH stimulation test as well as the cytokine analysis using their blood, were included in the study. The height, weight, and BMI were measured. We defined obesity as when the BMI was 95 percentile or more. We also defined pubertal response as when the maximum LH level was 5 IU/L or more on LHRH stimulation test. The blood levels of adiponectin, leptin, ghrelin, IL-1β, IL-6, IL-10, resistin, and TNFα were measured by Luminex multiple bead technology (Milliplex; Millipore Co., Billerica, MA, Bio-plex; Bio-Rad laboratories, Hercules, CA). Independent t-test was done using IBM SPSS Statistics 20.0 for the statistical analysis. P-value less than 0.05 was considered as statistically significant.

Results: Nineteen out of 28 children were categorized as having early- or precocious puberty. The mean IL-6 level was lower in pubertal children than that in prepubertal children (4.48 ± 4.77 vs. 19.56 ± 20.26 pg/mL, p=0.057). The leptin and resistin levels were significantly higher in the obesity group (n=6) than in the non-obesity group, while the ghrelin was significantly lower in the obesity group (p < 0.05). On the other hand, amongst female children with early- or precocious puberty, IL-1β and IL-6 levels were also increased as the peak LH level increased.

Conclusions: The female children younger than 9 years of age in early- or precocious puberty did not show the increment of leptin or resistin compared to female prepubertal children, although the obesity group showed significantly higher levels of leptin and resistin. The mean IL-6 level was lower in pubertal children, but it increased as the peak LH level increased.

 

Nothing to Disclose: JY, JWK, JSJ, JK, MH

13770 34.0000 SUN-0185 A Cytokine Profile in the Female Children with Early- or Precocious Puberty 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Jennifer Lynn Miller*1, Lisa Anne Roth2 and Donald Zimmerman3
1Ann & Robert H Lurie Children, Chicago, IL, 2Columbia University Medical College, New York, NY, 3Northwestern Feinberg School of Medicine

 

Background: Giant Axonal Neuropathy (GAN) is an autosomal recessive neurodegenerative disorder caused by mutations in the GAN gene producing central and peripheral neurodegeneration, due to structural impairment of neurofilaments (1). Early puberty and autonomic dysfunction have been reported, but not studied extensively in GAN patients.

Clinical Case: A 9.5 year old boy with GAN (progressive clumsiness, weakness and chronic respiratory insufficiency requiring nighttime BiPAP, diagnosed at age 5 years via EMG, gene test, and sural nerve biopsy) presented to pediatric endocrinology with PH at 7 years, acne at 8.5 years, AH at 9 years, without apocrine odor or genitalia change. He reported palpitations since age 6 years, occurring 3 times monthly, lasting 1-5 minutes, not associated with facial flushing, anxiety, tremor, or heat intolerance. There were no known neuromuscular or endocrine disorders in his biological family.
Physical examination: BP 96/61, HR 88, height 132.8 cm (29%ile), weight 32.4 kg (64%ile). Kinky hair, keratosis pilaris and resting nystagmus were present. Thyroid was normal. There was profound lower extremity weakness and atrophy, and absent patellar reflexes. Testes were 6 ml bilaterally, and pubic hair was T4.

Laboratory evaluation (8am) revealed pubertal gonadotropins and testosterone: LH 1.11 mciunits/ml (<0.3), FSH 1.6 mciunits/ml, testosterone 153.5 ng/dl (<10).

Thyroid studies, cortisol, prolactin, DHEA-S, 17OHP, plasma metanephrines and catecholamines were normal.
EKG, echocardiogram, and Holter monitor were normal, except sinus tachycardia during palpitations.
Brain MRI was normal.
Bone age was unable to be obtained due to patient’s clinical decline.

Discussion: The patient's kinky hair, keratosis pilaris, and neurologic findings were characteristic of GAN. Palpitations and sinus tachycardia were attributed to autonomic dysfunction sometimes associated with GAN. CPP was also likely attributable to GAN.

GAN is associated with peripheral and central nervous system changes such as positive Babinski sign and latency delay in the auditory brainstem response test in affected patients(2).  Brain MRI and proton MR spectroscopy have demonstrated white matter disease associated with evidence of axonal loss and demyelination.3

CPP has been described in patients with GAN4,5,6. This patient is the first reported to have CPP with a documented mutation in the GAN gene encoding gigaxonin.

Conclusion: This case emphasizes links between GAN and autonomic dysfunction as well as CPP. Although the mechanism linking CPP to GAN is not established, it is known that CPP occurs in children with cerebral palsy or shunted hydrocephalus possibly via a loss of GABA-ergic inhibitory tone to hypothalamic GnRH-secreting neurons. It is possible that GAN also affects GABA-ergic inputs to the hypothalamus, thereby prematurely disinhibiting GnRH secretion and triggering CPP.

 

Nothing to Disclose: JLM, LAR, DZ

13184 35.0000 SUN-0186 A Giant Axonal Neuropathy and Precocious Puberty 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Carolina Ivet Marín-Aragon*1, Elva L Perez-Luque2 and Juan M Malacara3
1Universidad de Guanajuato, Leon, Mexico, 2Univ de Guanajuato, Leon Guanajuato, Mexico, 3Univ de Guanajuato, Leon Gto, Mexico

 

Introduction: Precocious puberty in girls is the sexual development that initiates before nine year of age. Several determinants of idiopatic precocious puberty has been proposed, among them body composition, xenoestrogens, psychogenic and genetic factors. Recently the rs314276 polymorphism of the LIN28B gene has emerged as an important factor.

Objective: To compare groups of children with and without precocious puberty in order to identify somatometric and hormone differences and the possible association of the LIN28B gen polymorphism.

Materials and methods: In an epidemiologic design 2000 girls six to ten years old without congenital or chronic diseases growth or development, from elementary schools in León, Mexico, were examined, and 23 were identified with precocious puberty. As controls, 23 girls paired for age were also included for study. Cases and controls were examined for Tanner’s classification of puberty, anthropometry, as well as glucose, lipids, insulin, leptin, adiponectin, FSH, LH, and estradiol measurements. DNA was extracted for the typing of the LIN28B rs314276 (A/C) polymorphism by means of PCR- RFLP. Statistical analysis: we used Mann and Whitney U test, logistic regression analysis and generalized lineal model   

Results: In the group 2000 girls, 38.1% had obesity. Among them a total of 23 girls had precocious puberty, compared with the control groups they had increased BMI (p<.02) and stature (p<.001) as well as increased circulating glucose p<0.0001, leptin p=0.001 and marginally higher FSH p=0.048. The frequency of the C variant of the LIN28B rs314276 was significantly increased with respect to the controls (0.72 vs 0.48, X2 = 11.0; p = 0.0009).

Conclusions: In a population based study, we found a 1.15% frequency of precocious puberty in girls, with a strong association with C variant of LIN28B rs314276 gene.

 

Nothing to Disclose: CIM, ELP, JMM

14343 36.0000 SUN-0187 A Frequency of Precocious Puberty and Relationship with the LIN28B rs314276 Genetic Polymorphism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0152-0187 4851 1:00:00 PM Puberty and its Disorders: Pediatric Endocrinology Poster

Erika Cesar de Oliveira Naliato*1, Vanessa Tavares Oliveira2, Thiago Rezende Ferreira2, Claudia Fortes Mello2, Luana Rios Mangabeira Oliveira2, Larissa Brust Fernandes2, Valeria Dantas Alves2, Lucas Augusto Santos Ferreira2, Suzana Villela Moreira2, Roberta L M Pandini2, Sidia Sena2 and Luciana Maria Borges M Souza2
1UNIFESO (Serra dos Orgaos University Center), Teresopolis, Brazil, 2UNIFESO (Serra dos Orgaos University Center)

 

Over the last decades, children have been progressively gaining weight and the prevalence of obesity has consequently increased. Besides the instruments classically used for the evaluation of body fat, the value of other anthropometric measures, such as waist (WC) and neck circumferences (NC), has been recently emphasized. In order to investigate the usefullness of these measures in the evaluation of Brazilian children, we assessed WC and NC, and correlated them to data such as age, weight, height, hip circumference, and BMI in 522 children and adolescents (282 girls and 240 boys) followed at the Pediatrics Clinics of the Costantino Ottaviano Hospital in Teresópolis/Brazil. There was no statatistically significant difference between girls and boys when the following variables were compared: age (5.8 ± 3.8 vs. 6.0 ± 3.7 years, respectively; p = 0.8266), weight (22.6 ± 12.6 vs. 23.2 ± 12.5 kg, respectively; p = 0.6378), height (110.7 ± 26.8 vs. 112.8 ± 25.9 cm, respectively; p = 0.6033), BMI (18.17 ± 9.80 vs. 17.50 ± 5.26 kg/m², respectively; p = 0.5277), BMI percentile (51.7 ± 34.1 vs. 53.1 ± 33.1, respectively; p = 0.5061), WC (54.9 ± 10.4 vs. 56.0 ± 11.4 cm, respectively; p = 0.4921), hip circumference (61.3 ± 14.3 vs. 60.9 ± 13.5 cm, respectively; p = 0.9732), and NC (27.4 ± 3.3 vs. 27.8 ± 3.5 cm; p = 0.1125). Based on the BMI percentile (calculated for children aged 2 years or more), 37 patients were classified as underweight (BMI bellow the 5th percentile), 277 had a healthy weight (5th up to the 85th percentile), overweight (85th to less than 95th percentile), and 50 obese (equal to or greater than the 95th). Waist-to-hip ratio (WTH) was calculated by dividing waist circumference to hip circumference and waist-to-height ratio (WTHt), by dividing waist circumference to height. Weight, height, BMI, BMI percentile, NC, hip circumference, WTH, and WTHt were significantly correlated with WC (r = 0.9008, 0.8402, 0.5576, 0.6236, 0.6271, 0.9224, -0.2701 and -0.1722, respectively). In a similar way, weight, height, BMI, BMI percentile, hip circumference, WTH, and WTHt were significantly correlated with NC (r = 0.6777, 0.6105, 0.1698, 0.3883, 0.6694, -0.2781 and -0.1579, respectively). The present data suggest that simple and unexpensive clinical tools, such as WC and NC, can be important in the anthropometric evaluation of Brazilian children, contributing to the screening and follow-up of obesity and overweight.

 

Nothing to Disclose: ECDON, VTO, TRF, CFM, LRMO, LBF, VDA, LASF, SVM, RLMP, SS, LMBMS

12139 1.0000 SUN-0137 A The Use of Waist and Neck Circumferences in the Evaluation of Obesity in Children and Adolescents of Teresópolis/Brazil 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0137-0151 4852 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Simon Kayemba-Kay's*
Centre Hospitalier Victor Jousselin, DREUX, France

 

POLYCYSTIC OVARY SYNDROME IN OVERWEIGHT AND OBESE GIRLS: PELVIC MRI CONTRIBUTION TO THE DIAGNOSIS.

S. Kayemba-Kay’s.

Pediatric Endocrinology Section, Department of Pediatrics & Neonatal Medicine, Victor Jousselin Hospital, Dreux, France.  

Background: Polycystic ovary syndrome (PCOS) represents the most common reproductive endocrinopathy in women of childbearing age, it affects 5 – 10% women in this age group. Its cardinal features are hyperandrogenism, ovulatory dysfunction and/or polycystic ovary appearance. Gold standard diagnostic tool is pelvic ultrasound (PUS) whose performance is rather limited in overweight and obese adolescent girls. We report four cases of PCOS in whom pelvic MRI allowed diagnosis confirmation in three patients.

Patients & Methods: Adolescent girls seen for signs and symptoms of hyperandrogenism had biological testing (LH, FSH, testosterone, S-DHEA, delta-4 androstenedione, 17(OH)P, TSH, free T4 and lipid profile) and PUS and/or pelvic MRI performed. Other causes of hyperandrogenism were excluded.
Imaging: PUS performed with trans-abdominal transducer (Acuson© scanner, using 3.5 - 7.5 MHz transducer; pelvic MRI performed with phased array coil of 1.5 T Siemens MRI scanner, with T1 and T2-weighted axial and coronal images. The diagnosis of PCOS was made according to Rotterdam PCOS consensus Workshop (Hum Reprod 2004; 19: 41-7).

RESULTS: Four adolescent girls met the definition criteria. Mean age 14.5 years (14,25 ± 1,43), mean BMI 34,59 ± 7,36 Kg/m², menstrual irregularities were present in all four (mean age at menarche 12,02 ± 1,36 years), acanthosis nigricans present in three, clinical and biological characteristics (tables 1 & 2 respectively).

COMMENTS: Although PUS is gold standard diagnostic tool in PCOS patients, its limitations in overweight and obese girls are real and well known. US is performant with endo-vaginal transducer that can, however, not be utilized in virgin girls.
Pelvic MRI is useful and accurate method, it allows greater delineation of structural components of the ovary and better appreciation of its volume or structural alterations.

CONCLUSION: In adolescent obese girls suspect of PCOS, MRI is better alternative to PUS.

 

Nothing to Disclose: SK

12976 2.0000 SUN-0138 A Polycystic Ovary Syndrome in Overweight and Obese Girls: Pelvic MRI Contribution to the Diagnosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0137-0151 4852 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Waleed Janem*, Harvey Berman, Frank Scannapieco and Lucy D Mastrandrea
University at Buffalo, Buffalo, NY

 

Studies in adults show that chronic inflammation associated with obesity and dysglycemia correlates with prevalence of periodontal disease. Pro-inflammatory molecules produced by diseased periodontal tissue may enter the circulatory system to induce and/or exacerbate insulin resistance. Several studies have shown that aggressive treatment of periodontal disease improves glycemic control in adults with Type 2 diabetes. In addition, studies in children with Type 1 diabetes demonstrate increased rates of dental caries and gingivitis compared to those without diabetes. There is little information related to oral health in obese children with and without Type 2 diabetes. We hypothesize that obese children with Type 2 diabetes will have higher rates of oral disease and elevated salivary inflammatory markers compared to children without diabetes. To address this hypothesis, we recruited three study populations age 10-19 years ; normal weight (C; N=12), obese (Ob; N=9), and obese with type 2 diabetes (T2D; N=7). Subjects completed a dental health survey, received a clinical dental exam, and provided a salivary sample for measurement of inflammatory markers (pH, nitric oxide, C-reactive Protein (CRP), and Interleukin 1β (IL-1β)).  Salivary samples were assayed for acidity using short range pH paper (5.5 – 8.0; 0.2 increment), nitric oxide using Griess reagent, and CRP and IL-1β by ELISA. There was no difference in age between the groups. BMI Z-scores were 2.5±0.5 (T2D) vs. 2.2±0.7 (Ob) vs. -0.5±0.8 (C); p=0.000.  HbA1C (%) was 9.79±3.64 (T2D) vs. 5.28±0.16 (Ob); p=0.017.  There was no difference in number of carious lesions or restorations between the groups. There was a trend towards increasing gingival index in those with T2D (T2D 1.00±0.37 vs. Ob 0.61±0.44 vs. C 0.57±0.32; p=0.054). Salivary pH was 7.1±0.3 (T2D) vs. 7.2±0.2 (Ob) vs. 7.2±0.1 (C); NS.  Salivary levels of inflammatory markers including nitric oxide, CRP, and IL-1β were similar between the groups. Our results to date suggest that there is no difference in dental disease between children with Type 2 diabetes compared to age-matched obese and normal weight children.

 

Nothing to Disclose: WJ, HB, FS, LDM

13018 3.0000 SUN-0139 A Comparison of Oral Disease in Children of Normal Weight, Obesity or Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0137-0151 4852 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Bassem Dekelbab*1 and Amy Kakkannat2
1Beaumont Children Hospital and St John Providence hospital, MI, 2Beaumont Children's Hospital, Royal oak, MI

 

Background: Metformin therapy is a well-established treatment of type 2 diabetes in adults with increased use in obese children and adolescents with hyperinsulinemia, insulin resistance, type 2 diabetes and PCOS. Previous studies in adults reported that Metformin decreased serum vitamin B12 [vit B12] level by 14-30% due to its malabsorption. Deficiency of vit B12 can be detected by low serum of vit B12 or increased levels of homocysteine [Hcy] and methylmalonic acid [MMA]. No studies have examined this issue in the pediatric population.

Objective: Study the prevalence of vit B12 deficiency and the relationship between BMI and vit B12 levels in healthy and Metformin treated children and adolescents followed at two community hospital’s outpatient clinics.

Methods: Measurement of vit B12, Hcy and MMA in 90 Subjects [7-18 yr] who were divided into 3 groups; 22 Subjects with normal BMI, 55 Obese subjects [BMI ≥ 95%tile for age and gender], and 13 Metformin-treated subjects [for at least 6 months]. 12 of 13 Metformin-treated subjects had BMI ≥ 95th percentile.

Results: no subjects with low vit B12 level were identified. Vit B12 levels in obese and metformin groups were similar but normal BMI group tended to have higher vit B12 levels than the other two groups (P = 0.034). Hcy and MMA levels were not found to be statistically significant among the three groups (P = 0.088).

Conclusion: Children on metformin do not appear to have a higher incidence of vit B12 deficiency. However, there does appear to be a difference based on BMI, as normal weight children were more likely to have higher levels of vitamin B12 than obese children whether treated with metformin or not. More subjects enrollment will help further elucidate the relationship between vit B12 level, BMI , and metformin therapy in children.

 

Nothing to Disclose: BD, AK

14229 4.0000 SUN-0140 A Prevalence of Vitamin B12 Deficiency in Children and Adolescents Treated with Metformin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0137-0151 4852 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Chris Prestel*1, Shashidhar Pai2, Daynna Wolff2 and Remberto C. Paulo2
1Medical University of South Carolina, 2Medical University of South Carolina, Charleston, SC

 

Background

BWS is usually due to  dysregulation of imprinted genes in chromosome 11p15.  We report an unusual case of BWS with 3 mutations, and a novel mutation in ABCC8 gene, 1 of the 2 genes found in Chromosome 11p15.1 implicated in congenital hyperinsulinism, of unknown significance.  Difficulty with obtaining proper pancreatic imaging to determine definitive surgical management is also highlighted.

Clinical Case

Pt was born at 37 weeks gestation, Apgars 8 —> 9.  Initial exam revealed macrosomia and umbilical hernia. He developed hypoglycemia resistant to IV dextrose and feeding, even up to glucose infusion rate (GIR) of 15 mg/kg/min.   Hypoglycemia workup was negative, except for persistently elevated insulin levels (up to 11.5  uU/mL,  NL 2.6-11), with blood sugars <40 mg/dL. ‪ Diazoxide 15mg/kg/day, then Octreotide 15mcg/kg/day, failed to relieve hypoglycemia.  Pancreatic hyperplasia was suspected, and he was transferred out of state to where 18F-DOPA is available for use with PET scanning, under Investigational New Drug (IND).   18F-DOPA/PET scan confirmed pancreatic generalized hyperplasia, with no focal uptake. 60% pancreatectomy was performed.  Pathology showed enlarged islets, with the majority of cell nuclei organized in prominent trabecular pattern with a thin layer of exocrine cells at the periphery, consistent with BWS.  Post-op, he tolerated 12-hr fast with GIR at 4.6 mg/kg/minute via G-tube, which was completely weaned off a few weeks after discharge. 

SNP microarray analysis showed mosaicism for maternal UPD of 11p (arr 11p15.5p11.2(60,864-43,704,999)x2 hmz[25-30%]. Molecular analysis showed hypermethylation at IC1 (H19), and hypomethylation at IC2 (LIT1).  These 3 mutations are all consistent with BWS.   DNA sequence analysis revealed a novel mutation in ABCC8 (ABCC8 c.371 A>T). However, this mutation was inherited from mother and is of unknown significance.

Discussion

Our patient’s course illustrates how genetic testing is invaluable in diagnosing BWS.  Hemihypertrophy consistent with BWS was noted in retrospect. UPD in patients with BWS is usually of paternal origin.  Our patient has maternal UPD of 11p.  The novel mutation in the paternally expressed ABCC8 gene, 1 of the 2 known genes in Chromosome 11p15 causing PHHI, was maternal in origin as well, and hence is of unknown significance.  More studies are needed to elucidate this further.  Patients with severe PHHI must often be referred to one of a handful facilities in the country where 18F-DOPA is available under IND.  Transfer of care soley for this specialized imaging usually stretches patient resources.

Conclusion:

Emphasis on need for lower threshold for testing for BWS in patients with PHHI is made. Need for more accessible imaging techniques, or ready access to 18F-DOPA for PET scanning, to reliably elucidate pancreatic hyperplasia is highlighted

 

Nothing to Disclose: CP, SP, DW, RCP

17056 5.0000 SUN-0141 A Novel Mutations Leading to Beckwith Wiedemann Syndrome and Persistent Hypoglycemia of Infancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0137-0151 4852 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Anup Kumar1, William L Galanter1 and Diego Ize-Ludlow*2
1University of Illinois at Chicago, Chicago, IL, 2Univ of Illinois Med Ctr, Chicago, IL

 

Diabetic ketoacidosis (DKA) is the leading cause of mortality in childhood diabetes mellitus (DM). The mean annual medical expenditure for youth with DKA episodes in the US has been estimated to nearly twice that of those with DM and no episodes of DKA. Most of the excess expenditure is due to hospitalization. DKA is a preventable complication of diabetes and in the context of health care reform it could become a patient centered outcome measure targeted for cost reduction.

To assess the potential impact of an urban health system based intervention to decrease DKA, we performed a retrospective case study among pediatric DM patients. The Health System includes a 500-bed tertiary hospital, an outpatient facility, and 19 neighborhood clinics. Query of an enterprise wide electronic record including inpatients and outpatients from 7/1/2000 to 6/30/2010 identified 515 pediatric patients with DM corresponding to 1053 patient years.  There were 254 episodes of DKA among 144 patients; corresponding to 24 DKA episodes per 100 patient/years. 50.7% of the cases were Male, 54.8% were African American, 27.7% Hispanic, 15.9% white and 1.4% other.  41.7% (n=60) of the DKA episodes corresponded to the index diagnosis of diabetes.  Among those with newly diagnosed DM, 82% (n=41) had no previous contact with the health system. 53% (n=84) of the DKA episodes were among patients with previous diagnosis of DM, with 58% (n=49) of these being previously followed at the health system. 14 patients contributed to 30% of the episodes.

 

Fifty seven percent (n=82) of the DKA episodes would not have been accessible to a health system based intervention at the admitting hospital as those patients never had contact with the health system. Among the patients known to the health system, 107 DKA episodes were potentially preventable by interventions aimed towards avoiding an initial DKA in patients with known DM. 110 DKA episodes were potentially preventable by interventions directed to prevention of DKA recurrence. 13 DKA episodes were potentially preventable by interventions aimed at earlier diagnosis of DM within Health System patients.

Identification of medically high-risk populations and the development of interventions for risk mitigation is an important component for a successful transition to accountable care. These findings exemplify the challenge health systems will find in attempting to mitigate DKA risk, as well as factors that should be considered before considering some “preventable” complications as outcome measures. To fully realize the potential prevention of DKA, multi institutional, health plan or public health interventions would be required.  As a single organization our health system could only have attempted to prevent 50% of DKA episodes.

 

Nothing to Disclose: AK, WLG, DI

15081 6.0000 SUN-0142 A Is Diabetic Ketoacidosis Prevention at Reach for Single Health System Intervention? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0137-0151 4852 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Rita A Gomez-Diaz*1, Marco A Morales-Pérez2, Rafael Mondragón-González3, Adan Valladares-Salgado3, Renata Saucedo-García3, Carolina Bekker-Méndez3, Hanna R Pacheco-Ubaldo4, Rodrigo Barquera4, Elisa Nishimura-Meguro3, Eulalia Garrido-Magaña3, Blanca E Aguilar-Herrera3 and Niels Wacher3
1Instituto Mexicano del Seguro Social, Mexico, Mexico, 2Hospital General “Dr. Gaudencio González Garza,” Centro Médico Nacional “La Raza”, IMSS, Mexico City,, Mexico DF, Mexico, 3IMSS, Mexico, 4ENAH, Mexico

 

Hypothesis . The aim of the present study was to evaluate the association between HLA risk haplotypes (HLA-DRB1/-DQA1/-DQB1) with markers of  β-cell function, islet antibodies, HbA1c and lipid profile in well-defined groups of recent-onset type 1 diabetes patients and their healthy first degree family and controls.

 Design. This is an analytical cross-sectional study of pediatric patients recently diagnosed with type 1 diabetes (maximum 3 months evolution), first-degree relatives (parents and siblings) and healthy controls.  The study included analysis of antibodies (anti-GAD, anti-IA2, Anti-Insulin), HLA risk and protector haplotypes (by PCR-SSP) and β-cell function (plasma pro-insulin, insulin and C-peptides).  Haplotypes were obtained by maximum likelihood methods using the software Arlequin ver. 3.0. Means and standard deviations for each clinical measurement were calculated and compared between three different genotypic groups: patients with risk haplotypes in both chromosomes, patients with only one risk haplotype, and patients with no risk haplotypes in either chromosome, and also against their non-diabetic relatives.

Results. Patients (n = 46) and relatives (n = 71) were included. There were significant differences between patients and controls in haplotypic frequencies. DRB1*04/DQA1*03/DQB1*03:02  was found 95.7 % of patients (n = 44) vs 51.87% of controls (n = 83; p = 0.0073); 47.8 % of patients (n = 22) bearing DRB1*03:01/DQA1*05/DQB1*02 vs 8.12% (n = 13; p = 0.0024), and 2.2 % (n = 1) with DRB1*14/DQA1*05/DQB1*03:01 vs 20.0 % (n = 32; p = 0.0017). However, when compared against their relatives, this significance disappeared. Regarding progression and metabolic traits, anti-IA2, anti-insulin, and proinsulin (p < 0.02) showed differences between patient groups. Age at onset was significantly different from children carrying two risk haplotypes against those carrying none (10.3 vs 14.0 y, p = 0.0013), and both insulin (28.1 vs 15.0 µUI/mL) and C-peptide (0.56 vs 0.90 ng/mL) were also dissimilar between patients with two risk haplotypes against patients with one haplotype (p < 0.05).

Discussion and Conclusions. Patients carrying at least one risk haplotype are younger at the age of onset than those not carrying any risk haplotype. Lower insulin, proinsulin and C peptide levels between careers of two risk haplotypes is an evidence that genetic factor determines the severity of insulin deficiency in T1D.

 

Nothing to Disclose: RAG, MAM, RM, AV, RS, CB, HRP, RB, EN, EG, BEA, NW

16393 7.0000 SUN-0143 A The Number of HLA Risk Haplotypes ARE Associated with the Severity of Insulin Deficiency in Recent-Onset Type 1 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0137-0151 4852 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Lina Huerta Saenz*1, Stephen DeLurgio1, Nicole Knecht2, Stella Vergara-Bagby2, Susana R. Patton3 and Mark A Clements4
1The Children's Mercy Hospital/ University of Missouri-Kansas City, Kansas City, MO, 2The Children's Mercy Hospital, Kansas City, MO, 3University of Kansas, Kansas City, KS, 4Children's Mercy Hospital/University of Missouri-Kansas City, Kansas City, MO

 

Glycemic variability is a risk factor for severe hypoglycemia in children.  While evidence suggests that knowledge related to healthy eating and carbohydrate counting (CHO) correlates with mean glycemic control, the degree to which such knowledge  impacts levels of glycemic variability in children with T1D remains unknown. Therefore, we sought to determine if nutrition and carbohydrate counting knowledge, measured by a revised version of the NutriCarbQuiz (NCQ), correlates with glycemic variability measures including standard deviation of blood glucose (SDBG) and number of hypo/hyperglycemic excursions from a 14-day glucometer download. Correlation with HbA1c was also assessed. The NCQ is a previously validated self-administered nutrition questionnaire for youth with T1D that can be completed in 10 minutes. It has a 6th grade reading level and it incorporates CHO counting, healthy eating and nutrient density domains.

Youths with T1D for ≥6 months, age 1-21 years old, and their parents were enrolled. Our study objective was to determine whether glycemic variability indices correlate with NCQ scores.

75 families were enrolled with 58 youths and 70 parents completing the NCQ. Mean youth age was 12.5 ± 3.9 years, with 61% male, 82.6% White, and 86.6% on insulin pump. Youths’ mean diabetes duration was 4.6± 3.5 years. Youths had a mean HbA1C = 8.9 ± 1.9%, a mean blood glucose (MBG) = 218 ±70 mg/dL, a blood glucose SD (SDBG) 103 ± 34, and average number of hyperglycemic excursions of 35.8. Youths’ mean NCQ score was 26 [64% of 40.5 points].Youth NCQ scores were significantly negatively correlated with HbA1C and marginally with MBG (rNCQ, HbA1C: -.397, p=0.002, rNCQ, MBG= -.259, p=0.063) after controlling for age and duration of T1D. Youth NCQ CHO counting knowledge score was also significantly negatively correlated with both HbA1C and MBG (rNCQCHO, HbA1C: -.392, p=0.003, rNCQCHO, MBG= -.273, p=0.050). Youth NCQ total and CHO counting knowledge scores did not correlate significantly with SDBG (rNCQ, SDBG = -.119, p=0.417; rNCQCHO, SDBG = -.100, p=0.495). Paradoxically, youth NCQ score had a positive correlation with hypo/hyperglycemic excursion frequency (rHYPO-NCQ=.400, p=0.006; rHYPER-NCQ=.490, p=0.01).

The NutriCarbQuiz (NCQ) is a brief, valid measure of nutritional and carbohydrate counting knowledge, and correlates well with mean glycemic control (HbA1c), but not with the degree of glycemic variability (SDBG). Rather, increased knowledge paradoxically correlates with an increased number of hyper/hypoglycemic events. While this may be mediated by patients’ increased attempts to correct abnormal blood glucose, whether increased knowledge is associated with increased risk for severe hypoglycemia remains to be determined.  Dietary factors other than nutrition and carbohydrate counting knowledge may influence glycemic variability and further studies are needed.

 

Disclosure: MAC: Consultant, Medtronic Minimed. Nothing to Disclose: LH, SD, NK, SV, SRP

12707 8.0000 SUN-0144 A Glycemic Variability and Nutrition Knowledge Measured By the Nutricarbquiz (NCQ) in Youth with Type 1 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0137-0151 4852 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Shaathanaa Kalyanasundram1, Oana Maftei1, Alex Rowlands2, Adine Mayenburg1, Tim Olds2 and Alexia S Pena Vargas*1
1The University of Adelaide, 2University of South Australia, Adelaide, Australia

 

Background

There is limited data regarding physical activity levels and sedentary behaviour in children with type 1 diabetes (T1D). We aimed to evaluate activity levels and sedentary behaviour in T1D children and healthy children using a validated use of time instrument.

Methods

Thirty-two T1D children (aged 10.2-18.2 years, 18 boys, BMI z-score was 0.5±0.7) recruited consecutively  from the pediatric diabetes clinic at the Women's and Children's Hospital, South Australia, self-reported their 24-hour use-of-time (physical activity, sedentary behaviour, sleep and other daily activities), using the computerised instrument Multimedia Activity Recall for Children and Adolescents (MARCA), for four days (1). Each activity reported was linked to a compendium of energy expenditures, allowing the calculation of total daily energy expenditure (TDEE).

We compared physical activity and sedentary behaviour in children with T1D, according to sex, to an Australian representative sample of healthy children from the 2007 National Survey (n=1971, 10.2-17 year-olds, 985 boys) who had MARCA administered.  

Results

Children had T1D duration of 3.2 ±3.6 years and HbA1c 8.9 ± 1.8%. Their insulin dose was 0.8±0.2 units per kg/day and 14 children were using insulin pump.

There was no significant difference between T1D children and healthy children according to sex in their moderate-vigorous physical activity (MVPA), TDEE, sleep duration and total sitting time (all p>0.05). T1D children, particularly boys, spent significantly less time walking compared to healthy children (13.8±15 vs 31.5±31.2 minutes, p= 0.014 for boys and 24.9±17.4 vs 41.1±34.8 minutes, p=0.06 for girls).  Children with T1D spent 111.1±77.1 minutes per day in MVPA.

Conclusion

Children with T1D have similar physical activity levels and sedentary behaviour to healthy children.

 

Nothing to Disclose: SK, OM, AR, AM, TO, ASP

16659 9.0000 SUN-0145 A Children and Adolescents with Type 1 Diabetes Have Similar Activity Levels to Healthy Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0137-0151 4852 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Hyo-Kyoung Nam*1, Joon Woo Baek1, Young Jun Rhie2 and Kee-Hyoung Lee1
1Korea University College of Medicine, Seoul, Korea, Republic of (South), 2Korea University Ansan Hospital, Korea University College of Medicine, Ansan-si, Gyeonggi-do, Korea, Republic of (South)

 

Objectives: Occasionally, it might be difficult to determine which type of diabetes mellitus (DM) a patient has and to choose proper treatment. The aim of this study is to investigate the differences in clinical features and disease process according to the autoantibody expression and random serum C-peptide level obtained at diagnosis in children and adolescents with DM.

Patients and Methods: We retrospectively reviewed clinical characteristics and laboratory findings of 125 children aged below 20 years diagnosed with diabetes at the pediatric endocrinology clinics of Korea university hospital. They were subdivided into 4 groups based on the autoantibody (Ab) positivity and serum C-peptide (C) level (≥ 0.6 ng/mL, C+) at diagnosis as followings : Ab+/C-, Ab-/C+, Ab+/C+, Ab-/C-. Then we compared the characteristics at diagnosis and at 1 year after diagnosis among groups.

Results: There were 54 patients in Ab+/C-, 37 in Ab-/C+, 19 in Ab+/C+, 26 in Ab-/C- group. These four groups differed in age at diagnosis, BMI SDS, initial glucose, initial HbA1c, initial c-peptide level and positive number of autoantibodies. Among youth treated as type 1 DM, there were 54 (100%) patients in Ab+/C-, 4 (11%) in Ab-/C+, 11 (58%) in Ab+/C+, 13 (87%) in Ab-/C- group. In youth with type 1 DM, Ab-/C- group showed significantly longer honeymoon duration than Ab+/C- group. In Ab+/C+ group, both type 1 DM and type 2 DM showed higher percentage of insulin autoantibody positivity but type 1 DM showed rapidly decreased recent C-peptide level whereas type 2 DM showed preserved recent serum C-peptide level. All groups of type 1 DM showed similar blood glucose control irrelevant to positivity of antibodies and c-peptide level. Youth with type 2 DM in Ab-/C- group (n=2, 100%) had lower C-peptide level at diagnosis and higher HbA1c level at diagnosis and at 1 year after diagnosis than other groups.

Conclusions: These findings suggest that measurement of autoantibodies and serum C-peptide level at the initial diagnosis of diabetes and regular check-up are useful for predicting disease progression and providing appropriate management.

 

Nothing to Disclose: HKN, JWB, YJR, KHL

13519 10.0000 SUN-0146 A Characteristrics According to Autoantibodies and C-Peptide Level in Children and Adolescents with Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0137-0151 4852 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Shin-Hee Kim*1, In Ah Jung2, Won Kyoung Cho2, Kyoung Soon Cho2, So Hyun Park2, Min Ho Jung2 and Byung Kyu Suh2
1The Catholic University of Korea, Seoul, Korea, Republic of (South), 2College of Medicine, The Catholic University of Korea, Seoul, Korea, Republic of (South)

 

Purpose: Limited data on the relationship between glycemic control and dyslipidemia in patients with type 1 diabetes. We aimed to investigate the incidence of dyslipidemia and its association with glycemic control in adolescents and young adults with type 1 diabetes.

Methods: This cross-sectional study included 21 Korean patients with type 1 diabetes aged 11–25 years. Fourteen (67%) patients were female and median duration of diabetes was 8.5 years (range: 0.2–15.6). We compared the lipid profiles of patients with dyslipidemia and those of patients without dyslipidemia. In addition, correlations between glycosylated hemoglobin (HbA1c) and lipid profiles (total cholesterol [TC]; low-density lipoprotein cholesterol [LDL-C]; high-density lipoprotein cholesterol [HDL-C]; and triglyceride [TG]) were determined by linear regression analysis.

Results Of 21 patients with type 1 diabetes, 6 (28.6 %) had dyslipidemia. There were no statistically significant differences between dyslipidemia and non-dyslipidemia group regarding age, duration of illness, body mass index standard deviation score, and microalbuminuria. HbA1c level was positively correlated with TC (P = 0.009; R2= 0.306) and TG (P = 0.003; R2= 0.386). Patients with dyslipidemia were more likely to have the higher median values of HbA1c than those without dyslipidemia (10.6% [range: 7.5–13.3] vs. 7.8% [range: 6.6–9.9]; P = 0.01).

Conclusions: A substantial proportion of adolescents and young adults with type 1 diabetes had dyslipidemia. We found a correlation between poor glycemic control and poor lipid profiles in young patients with type 1 diabetes.

 

Nothing to Disclose: SHK, IAJ, WKC, KSC, SHP, MHJ, BKS

15725 11.0000 SUN-0147 A Incidence of Dyslipidemia and Its Association with Glycemic Control in Adolescents and Young Adults with Type 1 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0137-0151 4852 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Raphael Del Roio Liberatore Jr.*1, Carlos Eduardo Martinelli Jr.2, Gil Guerra Jr.3, Thais Della Manna4 and Ivani Nonato Silva Freire5
1Faculty of Medicine from Ribeirão Preto-USP, Brazil, 2Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil, 3Medical School, University of Campinas (FCM-UNICAMP), Brazil., São Paulo, Brazil, 4Sao Paulo Univ Child Hosp, Sao Paulo, Brazil, 5UFMG

 

Congenital hyperinsulinism (CH) is the most common cause of persistent hypoglycemia in neonatal period. The inadequate secretion of insulin leads to high morbidity and mortality in those newborns. Despite the recent progress in the diagnosis and management of CH, until recently, the situation in Brazil has been that of early 1990’s. The epidemiology is unknown and state-of-the art management has not been available. We proposed to review clinical and molecular data from the cases of Brazilian patients with CH. All centers of pediatric endocrinology were invited to participate, and except the north region of the country, all center sent clinical data and blood species. 61 cases of CH were reviewed, 36(59%) male, gestational age ranged between 32 and 41 weeks (M:37,6). Macrossomia occurred in 14 cases (28%) and the age at the diagnosis ranged from 1 to 1080 days (M:75.13) and more than 90 days in 28% of the cases. Glucose level at diagnosis range from 5 to 77 mg/dl (28.5) and insulin level 2.5 to 147 mU/ml. Cetone, ammonia and free fat acid levels were achieved in only 14% of the cases. Most part of the cases used prednisone as the first treatment although 40 cases used diazoxide. In 40% of the cases medical treatment was not effective and surgery was necessary. All histological forms were diffuse. Molecular analysis were made in 53/61 cases. ABCC8 mutations were found in 15/53 cases and KCNJ11 mutations in 6/53. Together, ABCC8 and KCNJ11 mutations occurred in 40% of the cases. Clinical and molecular correlations were impossible as 68% of the cases that used diazoxide the dosage were too small to check clinical response. Also all surgery cases were diffuse. GLUD 1 mutations were found in 9/53 cases, no one with result of ammonia level. GCK mutations were found in 3/53 cases, and none mutations were found at HADH, SLC16A1 and HNF4A genes. Mutations were found in 63% of the cases, but no clinical and molecular correlations were possible caused by a no patronization of the diagnostic exams and medical treatment.

 

Nothing to Disclose: RDRL Jr., CEM Jr., GG Jr., TDM, INSF

16348 12.0000 SUN-0148 A Congenital Hyperinsulinism: Clical and Molecular Data from a Brazilian Population 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0137-0151 4852 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Cassandra Corinne Brady*1, Andrew Anthony Palladino2, Thomas Andrew Burrow3 and Iris Gutmark-Little4
1Cincinnati Children's Hosp, Cincinnati, OH, 2The Childrens Hosp of Phildephia, Media, PA, 3Cincinnati Children's Hospital, Cincinnati, OH, 4Cincinnati Children's Hospital M, Cincinnati, OH

 

Introduction:Congenital hyperinsulinism (HI) leads to unregulated insulin secretion and hypoglycemia. Diagnosis is typically based on elevated insulin levels and low plasma β-hydroxybutyrate (BOHB) at the time of hypoglycemia. However, insulin levels can be misleading and genetic confirmation is important.

Case Description: An 11 month old female with hypoglycemia underwent a fasting evaluation lasting 5.5 hours with a final blood glucose of 32 mg/dL. Critical labs included an insulin of 0.2 μIU/mL (normal <2-13 fasting), BOHB of 4.3 mg/dL (0-3.0), free fatty acids (FFA) of 0.46 mmol/L (0.5-0.9), and growth hormone of 3 ng/mL (>7). Growth hormone therapy was initiated, but hypoglycemia persisted and a repeat fast was conducted. During the repeat fast, a detectable insulin level of 1.3 μIU/mL, low BOHB of 1.5 mg/dL, and low FFA of 0.38 mmol/L suggested HI. Diazoxide was started and genetic testing sent. Mutation analysis of ABCC8showed three variants (R1215W – paternal, pathogenic; W739C – maternal, variant of unknown significance; R1393L – maternal, variant of unknown significance). Failure of diazoxide prompted transfer to another facility where an 18-F-dopa PET scan showed no focal uptake. Management with octreotide and enteral dextrose was chosen over surgical exploration.

Clinical Lessons: Our case emphasizes that HI cannot be excluded based solely on a low insulin value and must be considered in the setting of low BOHB and FFA. Insulin levels may not be elevated due to periodic release, rapid hepatic clearance, or insulin degrading enzymes.

Diazoxide unresponsive HI suggests a KATPchannel defect and a potential need for surgery. Genetic testing of the child and parents is recommended to further delineate the type of HI. Children with a homozygous or compound heterozygous recessive mutation will have diffuse disease. Paternally inherited heterozygous recessive mutations with maternal loss of heterozygosity lead to paternal uniparental disomy and the development of focal disease.

Our patient had an uncommon combination of three mutations. The paternal recessive mutation is known to be pathogenic, but the pathogenicity of the maternal mutations is unclear. The genetic results in our patient could have suggested either focal or diffuse disease. Given the imaging results, medical management was chosen over surgery. With a diagnosis of diffuse disease, one or both maternal variants are suspected to be pathogenic. Understanding the genetics of congenital HI is crucial for evaluation and management of patients.

 

Nothing to Disclose: CCB, AAP, TAB, IG

11819 13.0000 SUN-0149 A The Inaccuracy of Insulin Levels in Congenital Hyperinsulinism and the Importance of Genetic Testing 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0137-0151 4852 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Shruti A. Fadia*, Tal Grunwald, Elizabeth A Suarez, Rita Ann Kubicky, Filippina Filia Dimitriadi, Francesco De Luca and Anita Azam
St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA

 

Background: Neonatal diabetes mellitus (NDM) is a rare condition, with an approximate incidence of 1:200,000 live births. Mutations of genes involved in pancreatic organogenesis, β-cell apoptosis, and insulin regulation/processing are implicated in the pathogenesis. NDM is classified as either transient or permanent. A major cause of transient NDM is the abnormal expression of imprinted genes at chromosomal region 6q24. Transient NDM typically occurs by the first month of life and resolves by 12 weeks, but it may recur later in life. Mutations in the insulin (INS) gene, which is located on chromosome 11, have been shown to cause permanent NDM.

Case: LC, a 40 3/7 week gestation female, was born via induced vaginal delivery due to suspected IUGR. Her birth weight was 1.98 kg (<3rd percentile), birth length 45 cm (<3rd percentile), and head circumference 32.5cm (<3rdpercentile). She was admitted to the NICU due to IUGR and suspected sepsis. On day of life 2, she had an elevated blood glucose (BG) of 225 mg/dL. BG was as high as 390 mg/dL on day of life 4 with insulin level of <2 uIU/mL (nl <23 uIU/mL), C-peptide level of 0.2 ng/mL (nl 0.8-3.1 ng/mL), pH 7.44, and bicarbonate of 21. Urinalysis revealed glycosuria without ketonuria. Hyperglycemia was initially managed with an intravenous insulin infusion. Additional insulin boluses were given intravenously at set intervals to provide carbohydrate coverage for feeds. At 3 weeks, she was transitioned to an insulin pump. Microarray analysis revealed uniparental disomy (UPD) of chromosome 6. On further testing, an autosomal heterozygous missense mutation in the INS gene at c.227 G>A (p.Ser76Asn) of unknown clinical significance was identified. Ultrasound of the pancreas showed normal anatomy. Insulin treatment was stopped at approximately 11 weeks of life due to episodes of mild hypoglycemia. Laboratory studies at that time showed a normal insulin level of 18.3 uIU/mL (nl 2.6-24.9 uIU/mL), C-peptide level of 1.6 ng/mL (nl 0.4-2.2 ng/mL), BG level of 113 mg/dL, and hemoglobin A1C of 5.2%. BG levels have remained stable off insulin therapy.

Conclusion:  The DM in our patient was transient in nature, which is expected given the finding of UPD of chromosome 6. Since INS gene mutations result in permanent NDM, the resolution of DM within the first 3 months of life indicates that the concurrent heterozygous missense INS gene mutation found in this patient may not be of clinical significance. However, close clinical follow up is warranted.

 

Nothing to Disclose: SAF, TG, EAS, RAK, FFD, FD, AA

16870 14.0000 SUN-0150 A Case of Neonatal Diabetes Mellitus Due to Uniparental Disomy of Chromosome 6 with Concurrent Insulin Gene Missense Mutation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0137-0151 4852 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

Shruti A. Fadia*, Francesco De Luca and Elizabeth A Suarez
St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA

 

Background: Congenital generalized lipodystrophy (CGL) is a rare form of familial lipodystrophy characterized by near total absence of subcutaneous adipose tissue and extreme muscularity from birth. Other clinical findings include acanthosis nigricans, acromegaloid features, severe hyperinsulinemia, dyslipidemia, and abnormal glucose metabolism during puberty.  Here, we present the case of an adolescent male diagnosed with CGL during infancy with resolution of the metabolic manifestations over time.

Case: At birth, AG was noted to have generalized decreased subcutaneous fat, large hands and feet, increased muscle bulk, and a protuberant abdomen with hepatomegaly. Laboratory workup obtained at 4 months of age revealed a serum glucose of 101 mg/dL, elevated insulin of 166.6 uIU/mL (nl <17 uIU/mL), elevated triglycerides of 379 mg/dL (nl 33-129 mg/dL), low HDL of 19 mg/dL (nl 38-76 mg/dL), low total cholesterol of 90 mg/dL (nl 125-170 mg/dL), and normal liver function tests. Based on the clinical and laboratory findings, he was diagnosed with CGL and treated with a low-fat diet. His lipid panel and insulin levels normalized at 8 months of age and remained normal until 5 years of age, after which he was lost to follow-up. He presented for endocrine re-evaluation at 14 years of age. On exam, his height was 179.7 cm (95th percentile), weight 64.5 kg (75th-90th percentile), and BMI 20 % (50th-75thpercentile). He was noted to have decreased subcutaneous fat on his face, extremities, and abdomen with prominent musculature on bilateral upper and lower extremities without associated hepatomegaly or acanthosis nigricans. He had Tanner stage V pubic hair with testicular volume of 25 ml bilaterally. Laboratory studies showed normal hemoglobin A1C of 4.6%, AST of 23 U/L (nl 12-32 U/L), ALT of 23 U/L (nl 7-32 U/L), slightly decreased total cholesterol of 103 mg/dL with normal HDL cholesterol of 45 mg/dL, LDL cholesterol of 51 mg/dL, and triglycerides of 33 mg/dL. Insulin level was <2 uIU/mL  and leptin level was 1.5 ng/mL (nl 0.6-24.9 ng/mL). Echocardiogram showed no cardiomegaly. Abdominal US showed no hepatomegaly.

Conclusion: Our patient presented with an unusual course of CGL with resolution of metabolic complications over time. Genetic testing to characterize the specific mutation and confirm the diagnosis of CGL is warranted.

 

Nothing to Disclose: SAF, FD, EAS

16824 15.0000 SUN-0151 A Absence of Typical Metabolic Manifestations of Congenital Generalized Lipodystrophy in an Adolescent Male 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0137-0151 4852 1:00:00 PM Diabetes, Hypoglycemia & Obesity: Pediatric Endocrinology Poster

David Kulak*1, Andrea Wojtczuk2, Gerson Weiss3 and Laura T Goldsmith2
1Rutgers-New Jersey Medical School, United States, NJ, 2Rutgers-New Jersey Medical School, Newark, NJ, 3Rutgers - New Jersey Medical School, Newark, NJ

 

Endometrial decidualization, the morphological and functional differentiation of endometrial stromal cells, is essential for successful blastocyst implantation and maintenance of pregnancy. Despite its functional significance, the biochemical mechanisms involved in decidualization are poorly understood.  Increased production of prolactin and IGFBP-1 are hallmarks of decidualization. Our prior data suggest that decidualization related changes in expression of vascular endothelial growth factor, interleukin 11, and interleukin 8 as well as alterations in cellular morphology are MAP kinase dependent.  We therefore hypothesized that decidual expression of prolactin and IGFBP-1 are MAP kinase dependent.  

A well characterized telomerase-immortalized line of human endometrial stromal cells which undergo characteristic decidualization response to increased intracellular cAMP was used as an in-vitro model. Replicate wells of cells were incubated for 14 days in phenol red-free media without (control) or with 8-br-cAMP (0.5mM) to decidualize the cells. To determine the role of MAP kinase in decidualization, cells were also incubated with 8-br-cAMP in the presence or absence of a selective MEK inhibitor (10uM UO126). Since PKA has been implicated in decidualization, cells were also incubated with 8-br-cAMP in the presence or absence of a PKA inhibitor (10uM Rp-cAMPs).  Medium was removed and replenished every 72 hours. Prolactin and IGFBP-1 concentrations in medium from each well were determined by specific human prolactin and human IGFBP-1 enzyme immunoassays. To determine the distribution of the data from all 4 experiments (each performed in triplicate), Kolmogorov- Smirnov tests were performed. Since the data were not normally distributed, differences between groups were assessed by non-parametric Mann-Whitney tests, and are herein expressed as median levels (pg/ml).

In medium from decidualized cells, median levels of prolactin were increased 45-fold compared to medium from the non-decidualized control group (p=0.001), and the median levels of IGFBP-1 were increased 350-fold (p=0.001). Inclusion of a MEK inhibitor reduced cAMP stimulated prolactin levels by 70% from median levels of 1,372 pg/ml (8-br-cAMP) to 465 pg/ml (8-br-cAMP+UO126) (p=0.002), and reduced IGFBP-1 levels by 60% from 115,820 pg/ml to 75,930 pg/ml (p=0.001). In distinct contrast, inhibition of PKA did not alter levels of prolactin (p=0.48) or IGFBP-1 (p=0.16).

These novel data demonstrate that the MAP kinase pathway plays an integral role in human endometrial stromal cell decidualization, including regulation of the hallmark indicators prolactin and IGFBP-1.

 

Nothing to Disclose: DK, AW, GW, LTG

11806 1.0000 SUN-0030 A A Role for Mitogen Activated Protein Kinase in Decidualization of Human Endometrial Stromal Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0030-0045 4855 1:00:00 PM Female Reproductive Tract Poster

Fenghua Bian*1, Fei Gao1 and Sanjoy K Das2
1Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, 2Cincinnati Children's Hospital Medical Center, Cincinnati, OH

 

Uterine stromal cell decidualization critically depends on the tight control of gene regulation through expression, as well as, repression at the site of implantation. Previously, we showed that Cbx4, a component of the polycomb repressive complex 1 (PRC1), exhibits DNA hypomethylation in the promoter region with the activation of expression during stromal cell decidualization. Epigenetic regulation via polycomb repressive complex 1 (PRC1) plays a major role in genetic repression, although its role during the progression of decidualization remains unknown. To elucidate this notion, we first examined the cell-specific expression of Cbx4 at mRNA and protein levels during decidualization in mice. Our results revealed that Cbx4 is increased primarily in the antimesometrial decidual bed in association with polyploidy. Additionally, other PRC1 members (Cbx2, Cbx6, Cbx7, Cbx8, Ring1A, Ring1B, Mel18, and Bmi1) were also detected during decidual progression. Because PRC1 contributes to DNA compaction for gene repression via monoubiquitination of histone H2A at lysine 119 (ubH2A-K119), and because H3K27me3 is also responsible for the onset of PRC1 function, we further analyzed the expression of these histone marks in conjunction with PRC1 complex regulators by dual immunofluorescence studies. We found that the co-localization of Ring1B/Bmi1 with ubH2AK119 and Cbx4/2 with H3K27me3 was revealed in polyploid cells, suggesting PRC1-dependent function is involved in terminal differentiation with polyploidy development during decidualization. More importantly, we found that the suppression of Cbx4 by siRNA or pharmacological inhibition of Bmi1/Ring1A in the PRC1 complex resulted in a failure of decidualization, development of polyploidy, and inhibition of ubH2AK119 levels. Furthermore, mice harboring Ring1B conditional knockout (Ring1Bfl/fl/PgrCre/+) demonstrated symptoms of sterility with severe decidualization defects in early pregnancy. These results suggest that PRC1-dependent control essentially contributes to the successful progression of decidualization in early pregnancy.

 

Nothing to Disclose: FB, FG, SKD

13124 2.0000 SUN-0031 A Polycomb Repressive Complex 1 (PRC1) Mediated Function Is Critical for Uterine Stromal Cell Decidualization 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0030-0045 4855 1:00:00 PM Female Reproductive Tract Poster

Mikihiro Yoshie*1, Kazuya Kusama1, Kazuhiro Tamura1, Takiko Daikoku2, Tsutomu Takarada1 and Eiichi Tachikawa1
1Tokyo University of Pharmacy & Life Sciences, Tokyo, Japan, 2Cincinnati Children's Hospital Medical Center, Cincinnati, OH

 

Embryo implantation and appropriate differentiation of uterine stromal cells (ESCs) into decidual cells are crucial events for the establishment of successful pregnancy in the rodent and human. We previously reported that activation of a cAMP signaling mediator, exchange protein directly activated by cAMP (EPAC), promotes ovarian steroid- or cAMP analog-induced decidualization in cultured human ESCs. In addition, siRNA-mediated knock-down of the EPAC subtypes, EPAC1 and EPAC2, or of Rap1, a downstream factor of EPAC signaling, abrogated functional and morphological decidualization of human ESCs. However, whether Epac and Rap1 play roles in decidualization has not been examined in vivo. In the present study, we showed that Epac1, Epac2 and Rap1 expression was up-regulated in decidual cells at implantation sites in pregnant rats. To examine whether the uterine expression of Epac1, Epac2 and Rap1 is associated with embryo implantation and decidualization, a delayed implantation model was used. In the progesterone-primed delayed implantation uterus, Epac1, Epac2 and Rap1 expression was up-regulated in decidual cells at the initiation of implantation induced by treatment with estradiol. However, any effects of estradiol and/or progesterone on the expression of Epac1, Epac2 and Rap1 were minor in ovariectomized non-pregnant rat. We used artificially induced decidualization model to explore the association of Epac1, Epac2 and Rap1 expression with decidualization. The expression of Epac1, Epac2 and Rap1 was enhanced during artificially induced decidualization in the pseudopregnant rat uterus. We further examined the functional roles of these factors during decidualization using an in vitro decidualization model. Treatment of cultured rat ESCs with both medroxyprogesterone and cAMP stimulated the expression of prolactin (Prl) and decidual/trophoblast prolactin-related protein (Dtprp), while knock-down of Epac1, Epac2 or Rap1 attenuated the expression of these decidual markers. These findings suggest that Epac1, Epac2 and Rap1 play key roles in decidualization.

 

Nothing to Disclose: MY, KK, KT, TD, TT, ET

15727 3.0000 SUN-0032 A Involvement of cAMP Signaling Mediators, Epac1, Epac2 and Rap1 in Decidualization of Rat Uterus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0030-0045 4855 1:00:00 PM Female Reproductive Tract Poster

Molly Bennette Moravek*1, Ping Yin1, Masanori Ono1, Matthew T Dyson2 and Serdar Ekrem Bulun1
1Northwestern University, Chicago, IL, 2Northwestern University

 

Recently, a small population of uterine fibroid cells with progenitor cell properties was found to be necessary for ovarian steroid-dependent growth of fibroids. Our lab discovered a novel way of isolating these progenitor cells using cell surface markers CD34 and CD49b, which avoids the pitfalls of the side population technique for isolating stem cells, and has revealed 3 populations of fibroid cells:  CD34+/CD49b+ (progenitor), CD34+/CD49- (intermediate), and CD34-/CD49b- (differentiated).  In order to determine differential gene expression between these cell populations and identify critical gene pathways that may explain the pathogenesis of uterine fibroids, fibroid tissue was collected from 8 premenopausal African American subjects at the time of surgery and cells sorted by flow cytometry based on CD34 and CD49b expression.  RNA was isolated and microarray performed using the Illumina Human HT-12 Expression BeadChip. Gene expression was analyzed using multiple t-tests, with differential expression defined as fold change >1.5 and false discovery rate <5%.  Functional pathway analysis using Kyoto Encyclopedia of Genes and Genomes indicated genes involved in inflammation, apoptosis, wound healing, TGF-β signaling, and extracellular matrix receptor interaction were highly differentially expressed in CD34+/CD49b+ cells. Gene expression profiling revealed that the three cell populations were molecularly distinct, with over 1000 genes differentially expressed between them. Genes involved in the TGF-β and IGF pathways, two pathways implicated in uterine fibroid pathogenesis, were differentially expressed between the different populations, validated by PCR.  TGF-β3 was upregulated in CD34+/CD49- cells, whereas TGF-β1 was upregulated in CD34-/CD49- cells.  Interestingly, the TGF-β receptors were upregulated in the CD34+/CD49+ cells.  Similarly, IGF-I and –II were upregulated in CD34+/CD49- cells, but most of the IGF binding proteins were upregulated in CD34+/CD49+ cells.  Additionally, estrogen and progesterone receptor (ER and PR) genes were downregulated in CD34+/CD49b+ cells. These results suggest that the CD34+/CD49b+ fibroid progenitor cells have a molecular signature unique from CD34+/CD49- and CD34-/CD49b- cells.  Interestingly, ligands, receptors, and binding proteins from the TGF-β and IGF signaling pathways showed differential expression in different cell types.  This information, combined with the lack of ER and PR, suggests paracrine interaction between the cell populations necessary for hormone-dependent fibroid growth. Further evaluation of these interactions may lead to the development of new treatment options. Treatments targeting fibroid progenitor cells and interactions with surrounding cells could not only treat current fibroids, but also prevent the growth of new tumors.

 

Nothing to Disclose: MBM, PY, MO, MTD, SEB

16371 4.0000 SUN-0033 A Differential Gene Expression in Fibroid Progenitor Cells: New Perspectives on Old Pathways 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0030-0045 4855 1:00:00 PM Female Reproductive Tract Poster

Antonia Navarro*1, Ping Yin2, Diana Monsivais3, Masanori Ono2 and Serdar Ekrem Bulun1
1Northwestern Univ, Chicago, IL, 2Northwestern University, 3Northwestern University, Chicago, IL

 

The Presence of 5-hmC is an Epigenetic Feature Promoting Growth in Uterine Fibroids

Uterine leiomyoma, or fibroids, represent the most common benign tumors of the female reproductive tract. They become symptomatic in 30% of all women and up to 70% of African American women of reproductive age. Epigenetic dysregulation of DNA methylation (5-mC) has been demonstrated at the genome-wide in leiomyoma tissues; however, the role of the newly identified epigenetic mark DNA hydroxymethylation (5-hmC) and its regulators the ten-eleven translocation (TET) proteins remain fully unexplored. In this study we used human uterine leiomyoma and normal myometrial tissues to characterize the role of 5-hmC and TET proteins in leiomyoma. We demonstrated higher 5-hmC levels in leiomyoma tissues than in normal myometrial tissues. In addition, we also observed that the increase in 5-hmC levels is due to the upregulation of TET1 and TET3 mRNA and protein levels in leiomyoma tissues. Functionally, we demonstrated that independent silencing of TET1 and TET3 by siRNA lead to a significant reduction in 5-hmC levels in leiomyoma. Moreover, silencing of TET1 and TET3 interestingly resulted in significant decreased in cell proliferation measured by PCNA levels and BrdU-incorporation. Finally, treatment with the oncometabolite 2-HG, a competitive inhibitor of TET proteins resulted in a significant decreased in 5-hmC, and it also lead to a substantial decrease in cell proliferation in leiomyoma. This study presents the first evidence for an epigenetic imbalance of the 5-hmC homeostasis in uterine leiomyoma due to the increase of 5-hmC through the upregulation of TET1 and TET3 proteins. Our data suggest a possible functional role of 5-hmC in the pathogenesis of this disease, and the identification of 5-hmC and its regulators could be potential diagnostic and therapeutic targets in uterine leiomyoma.

 

Nothing to Disclose: AN, PY, DM, MO, SEB

16995 5.0000 SUN-0034 A The Presence of 5-Hmc Is an Epigenetic Feature Promoting Growth in Uterine Fibroids 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0030-0045 4855 1:00:00 PM Female Reproductive Tract Poster

Masao Izawa*1, Fuminori Taniguchi2, Naoki Terakawa2 and Tasuku Harada2
1Tottori University Faculty of Medicine, Yonago, Japan, 2Tottori Univ/Fac of Med, Yonago, Japan

 

Background: DNA methylation provides a layer of epigenetic controls that has important implications for diseases including endometriosis. A marked up-regulation of aromatase gene associates with aberrant DNA hypomethylation leading to a high estrogen environment in endometriotic tissues (1, 2). However, it is unknown whether global alterations in DNA methylation profiles occur in endometriosis, and to what extent they are involved in the estrogen-dependent pathophysiology (3).

Objective: Using a genome-wide profiling of DNA methylation, we challenged an extraction of genes having aberrant DNA hypomethylation, and then evaluated their expressions in endometriotic cells.

 Patients: The Institutional Review Boards of Tottori University Faculty of Medicine approved this project. We obtained the informed consent from all patients. The chocolate cyst lining in ovaries of patients with endometriosis was the source of endometriotic tissue. As control, endometrial tissues were obtained from uteri of cycling premenopausal women who had uterine leiomyoma. These patients had received no hormonal treatment before surgery.

Methods: Stromal cells were prepared from endometrial and endometriotic tissues. DNA samples were isolated from 4 endometrial and 4 endometriotic cells. DNA methylation profiles were assayed using Illumina Infinium HumanMethylation450 BeadChip Array and GeneSpring GX 11.5.  Gene expression was evaluated using qRT-PCR, Western blots and immunocytochemistry.

Results:  1) The 857 GpG sites, which were differentially hypomethylated more than 10-fold in endometriotic cells, were extracted from 485,512 CpGs on an Array. 2) From these CpGs, the 317 CpGs were further extracted depending on the β cut-off value of 0.25. 3) We finally extracted GATA6 gene, which showed more than 90% hypomethylation within the gene body. 4) GATA6 mRNA was highly expressed in endometriotic cells, while in endometrial cells the expression was at a marginal level. 5) As anticipated, GATA4, which is under the control of GATA6, was highly expressed in endometriotic cells. 6) Within GATA4 gene, aberrant CpG methylation profile was not observed. 7) GATA6 and GATA4 expression were also demonstrated in endometriotic tissues on the peritoneum.

Conclusion: Although the overall methylation profile in endometriotic cells was highly similar to that in endometrial cells, we successfully extracted a series of hypomethylated CpGs within GATA6 gene body in endometriotic cells. GATA6 was highly expressed in endometriotic cells. The present finding along with our previous observations (1, 2) provides a facet of molecular basis of epigenetic disorder in endometriosis.

 

Nothing to Disclose: MI, FT, NT, TH

15391 6.0000 SUN-0035 A Hypomethylation of GATA6 Gene Body May Cause the up-Regulation in Endometriotic Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0030-0045 4855 1:00:00 PM Female Reproductive Tract Poster

Alina Peraza Montalbano*1 and Carole R Mendelson2
1UT Southwestern Med Cntr, Dallas, TX, 2Univ Texas Southwestern Med Ctr, Dallas, TX

 

Preterm birth is the leading cause of neonatal morbidity and mortality in developed countries and the second leading cause of death in children under the age of 5 yr worldwide. While ~30% of preterm labor is due to underlying infection, the majority of cases are of unknown etiology. Notably, both term and preterm labor are associated with increased levels of proinflammatory mediators (e.g. interleukin-1β (IL-1β), interleukin-6 (IL-6)), within fetal and maternal reproductive tissues, which activate inflammatory transcription factors (NF-κB, AP-1) and expression of genes encoding contraction-associated proteins (CAP) (e.g. oxytocin receptor (OXTR), connexin-43 (CX43), cyclooxygenase 2 (COX-2)). By contrast, uterine quiescence throughout most of pregnancy is maintained by increased circulating progesterone (P4) and enhanced progesterone receptor (PR) transcriptional activity, which silence expression of CAP genes and proinflammatory mediators. We propose that increased P4/PR inhibits CAP gene expression, in part, by blocking activation and DNA-binding of inflammatory transcription factors and by causing repressive changes in chromatin structure. The objective of this study was to define the epigenetic regulation of CAP genes during pregnancy and effects of P4 withdrawal, leading to preterm labor. Timed-pregnant ICR/CD1 mice at 16.5 days post-coitum (dpc) (19 dpc=term) were given a single injection of the PR antagonist, RU486, or vehicle; myometrial tissues were isolated 1 h, 3 h, and 8 h post-injection and during preterm labor. Using RT-qPCR, we observed that RU486 caused a rapid induction of OXTR (p=0.005) and CX43 (p=0.005) mRNA in myometrium, compared to vehicle-injected mice; this was evident within 3 h of treatment and sustained through labor initiation, 12-14 h after treatment. By contrast, IL-1β, IL-6 and TNF-α mRNA levels were significantly upregulated only 8 h (p=0.05) after RU486 injection, while COX-2 mRNA failed to increase until preterm labor occurred. Because the kinetics of activation of CAP genes in response to P4/PR withdrawal is mediated by transcription factor binding and collective histone modifications at their promoters, we suggest that the mechanisms for activation of IL-1β, and COX-2 genes differ markedly from OXTR and CX43 at the levels of transcription factor recruitment and chromatin modification. Analysis of the underlying epigenetic mechanisms will provide much needed insight into the pathogenesis of preterm birth.

 

Nothing to Disclose: APM, CRM

15950 7.0000 SUN-0036 A Differential Timing in Activation of Contraction-Associated Genes in Myometrium of Pregnant Mice with Preterm Labor Induction Suggests Distinct Epigenetic Mechanisms 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0030-0045 4855 1:00:00 PM Female Reproductive Tract Poster

Kazuhiro Tamura*1, Keiko Fumoto1, Masumi Otsu1, Mikihiro Yoshie1, Takeshi Kajihara2, Osamu Ishihara2, Keiichi Isaka3 and Eiichi Tachikawa1
1Tokyo University of Pharmacy & Life Sciences, Tokyo, Japan, 2Saitama Medical University, Saitama, Japan, 3Tokyo Medical University, Tokyo, Japan

 

The molecular mechanisms underlying the onset and progression of endometriosis are still poorly understood. Our previous study has shown that distinct endometriosis-like lesions were created by injecting a suspension of human endometrial cells into BALB/c nude female mice that underwent unilateral ovariectomy (uOVX) compared with control non-uOVX mice. We observed that the lesions in uOVX animals express high levels of IL-6 and prostaglandin (PG) E2, and that peritoneal bleeding may stimulate the expression of proinflammatory mediators partly through protease-activated receptor (PAR) activation. In the present study, alpha 1-antitrypsin (α1-AT) was identified as a protein that significantly decreased in the lesion of uOVX mice by 2-dimentional gel electrophoresis, followed by MALDI-TOF MS. To understand the biological significance of α1-AT in the endometriosis-like lesions, the lesions were harvested for immunohistochemical analysis and immunoblotting for several signaling pathways. The levels of phosphorylated Akt, mammalian target of rapamycin (mTOR), p70 ribosomal S6 kinase, and NFκB were higher in endometriosis-like lesions from the uOVX group than control. The lesions mostly comprised stromal cells. The bioactivity of α1-AT was assessed by investigating inflammatory factors expression in PAR-stimulated endometrial stromal cells in vitro. PAR promoted the expression of IL-8 and cyclooxygenase (COX)-2, and the phosphorylation of ERK and p38MAPK. Treatment with α1-AT (0.5 mg/ml) inhibited the IL-8 and COX-2 expression with no changes in the activation of Akt, NFκB, and MAPK signaling pathways. PGE2 (0.5 µM) and EGF (50 ng/ml) significantly enhanced PAR1 agonist (thrombin)-stimulated COX-2 and IL-8 expression, respectively, and α1-AT protein also blocked these expressions. These results suggest that α1-AT posseses the anti-inflammatory activity beyond its role as an antiprotease. Our results illustrate that exacerbated inflammatory reaction in the xenograft mouse model may be caused partly by the dysregulation of α1-AT, suggesting the possible involvement of α1-AT in the pathophysiology of endometriosis.

 

Nothing to Disclose: KT, KF, MO, MY, TK, OI, KI, ET

15443 8.0000 SUN-0037 A Inhibitory Action of alpha1-Anti-Trypsin on Proinflammatory Mediators Expression in Human Endometrial Stromal Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0030-0045 4855 1:00:00 PM Female Reproductive Tract Poster

Sara Sinha Morelli*, Pranela Rameshwar and Laura T Goldsmith
Rutgers - New Jersey Medical School, Newark, NJ

 

Cyclic replenishment of all cellular compartments of the human endometrium is absolutely required for successful reproduction.  The mechanisms involved in cyclic endometrial regeneration, including the cellular source of regenerative endometrial cells, remain poorly understood.  The current studies tested the hypothesis that bone marrow (BM) cells give rise to mature, endometrial parenchymal stromal cells, the predominant endometrial structural cell type.

          A murine BM transplant model was used, in which BM cells harvested from transgenic mice which express Green Fluorescent Protein (GFP) were injected via tail vein into syngeneic immature female mice.  Five mice with successful hematopoietic reconstitution were sacrificed at 12 months post transplant and hysterectomy was performed.  Immunohistochemistry using specific anti-GFP and anti-vimentin (parenchymal stromal cell marker) antibodies was performed to enable localization and quantitation of BM-derived and parenchymal stromal cell types in uterine tissue sections of recipient mice.  Confocal laser microscopy was used to identify GFP-positive cells, vimentin-positive cells and fluorescently stained nuclei in endometrial stromal compartments.  BM-derived parenchymal stromal cells were identified as those which were co-positive for GFP and vimentin.

          The proportion of total endometrial stromal compartment cells which was BM-derived in each animal was 15.3% (369 GFP+cells/2411 total stromal compartment cells), 10.8% (332/3066), 16.2% (327/2021), 12.2% (364/2973) and 5.9% (238/4004) [12.1% ± 4.1% (mean ± SD), n=5 animals]. Parenchymal stromal cells (not other cell types) comprised 29.4% (708/2411), 27.9% (854/3066), 20.3% (410/2021), 31.6% (938/2973) and 28.6% (1144/4004) of total endometrial stromal compartment cells in each animal [27.6% ± 4.3%  (mean ± SD), n=5 animals].  The proportion of endometrial parenchymal stromal cells which was BM-derived in each animal was 15.7% (111/708), 14.9% (127/854), 21.2% (87/410), 13.0% (122/938) and 7.3% (83/1144) [14.4%  ± 5.0% (mean ± SD), n=5 animals].

          These data definitively demonstrate that bone marrow gives rise to a critical structural component of the endometrium, since bone marrow is a long term source of mature endometrial parenchymal stromal cells. These findings significantly advance understanding of the mechanisms responsible for endometrial regeneration and implicate a novel role for bone marrow-derived cells in treatment of disorders of endometrial function.

 

Nothing to Disclose: SSM, PR, LTG

16447 9.0000 SUN-0038 A The Bone Marrow Is a Long Term Source of Murine Endometrial Parenchymal Stromal Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0030-0045 4855 1:00:00 PM Female Reproductive Tract Poster

Ikuko Sawada*1, Kae Hashimoto1, Kenjiro Sawada1, Tomoyuki Fujikawa2, Akiko Itai2 and Tadashi Kimura1
1Osaka Univ Med Schl, Suita-shi, Japan, 2IMMD. Inc., Tokyo, Japan

 

[Background]

Endometriosis is one of common gynecological diseases associated with chronic pelvic pain and infertility and severely compromises women’s quality of life. Mounting evidence have shown that nuclear factor-κB (NF-κB) pathway activates many of the target genes that are critical to the initiation and establishment of endometriosis. Therefore, we evaluated the therapeutic potential of targeting this pathway using a novel IKKβ inhibitor, IMD-0560 (IMMD. Inc. Tokyo, Japan).

[Methods]

Endometriotic stromal cells (ESCs) were isolated from ovarian chocolate cysts in 20 patients who underwent laparoscopic surgeries. The phosphorylation of IκB was confirmed by Western Blot and the expression of nuclear p65 protein was exampled by immunofluorescent analyses. The inhibitory effects of IMD-0560 on ESCs were assessed by in vitro cell proliferation assay (modified MTS assay), in vitro adhesion assay followed by Western Blots of integrins and quantitative ELISA of a representative inflammatory cytokine, interleukin-6 (IL-6).

[Results]

The treatment of tumor necrosing factor-α (TNF-α) induced IκB phosphorylation as well as a nucllear translocation of p65 protein in ESCs. The co-treatment of IMD-0560 almost abolished these effects. The treatment of IMD-0560 inhibited the proliferative and adhesive activities of ESCs followed by the down-regulation of β1-integrin. In addition, IMD-0560 attenuated the production of IL-6 in a dose-dependant manner.

[Discussion]

IMD-0560 significantly suppressed the proliferative, adhesive activities and a cytokine production of endometriotic cells. Targeting IKKβ may be a novel therapeutic option for endometriosis.

 

Nothing to Disclose: IS, KH, KS, TF, AI, TK

15456 10.0000 SUN-0039 A Targeting Inhibitor of NF-κb Kinase Beta (IKKβ) May Represent a Possible Novel Treatment for Endometriosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0030-0045 4855 1:00:00 PM Female Reproductive Tract Poster

Balazs Jori1, Marinus Blok2, Koen Vijver van De2, Bert Delvoux1, Bart de Koning2, Rick Kamps2, Toon Van Gorp1, Roy Kruitwagen1, Encarna Gomez-Garcia2 and Andrea Romano*1
1Maastricht University Medical Centre, 2Maastricht University Medical Centre, Maastricht, Netherlands

 

Women carrying a Lynch Syndrome (LS) mutation have increased lifetime risk to develop - among others - endometrial cancer (EC). LS mutations can occur in four different mismatch-repair (MMR) genes and screening of these genes in currently used for genetic counselling. However, cancer risk predictions are broad and inaccurate and some woman carrying one given mutation can develop EC some other not.

We hypothesised that EC risk is modified by additional germ-line variants besides the MMR gene mutations.

To identify novel germ-line variants, the peripheral blood DNA from 38 EC patients belonging to LS families was analysed by targeted sequencing. Per patient, 154 genes involved in endometrial carcinogenesis were captured (Agilent® Haloplex™ capture system) and subjected to massive parallel sequencing using Illumina® HiSeq™. Raw data were analysed with Softgenetics ® NEXTgene ™ and Agilent ® SureCall ™. The panel of 154 genes included genes involved in estrogen metabolism and signalling, besides onco- and tumour-suppressors

After excluding common variants and synonymous mutations, two protein-coding variants per patient were identified, corresponding to a mutation rate of 3.9/MB. Genes like APC, MLL, LEPR and NOTCH1 carried distinct mutations in 10% of the patients. In addition, genes involved in estrogen metabolism and signalling (CYP1A1, CYP19A1, COMT, NCOR1, NCOR2, NCOA2, STS) resulted mutated in 40% of the patients analysed. Extra genes where mutations occurred frequently were identified (RET, ATM). The tumour material of these patients is being currently analysed for loss-of-heterozygosity, for protein aberration, inactivation or overexpression analyses.

In conclusions, additional germ-line mutations can modify the EC risk of a MMR LS mutation. The high prevalence of these mutations in specific genes/pathways can be used for a better cancer risk prediction by analysing these genes in routine genetic testing of LS family members.

 

Nothing to Disclose: BJ, MB, KV, BD, BD, RK, TV, RK, EG, AR

15654 11.0000 SUN-0040 A Novel Germ-Line Mutations in Genes Controlling the Estrogen Metabolism in Lynch Syndrome-Related Endometrial Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0030-0045 4855 1:00:00 PM Female Reproductive Tract Poster

Madelaine J Cho-Clark*1, Darwin Omar Larco1, Maya Jane Sorini2, Shailaja K Mani3 and Tao-Yiao John Wu1
1Uniformed Services University, Bethesda, MD, 2Holton-Arms School, Bethesda, MD, 3Baylor College of Medicine, Houston, TX

 

GnRH is a decapeptide known for its key role in regulating the hypothalamic-pituitary-gonadal (HPG) axis.  While its major role in HPG regulation has been well characterized, its secondary level of regulation in peripheral tissues remains elusive.  GnRH is processed by zinc metalloendopeptidase EC 3.4.24.15 (EP24.15) that cleaves the hormone at the Tyr5-Gly6 bond to form a pentapeptide, GnRH-(1-5).  This pentapeptide’s actions differ from those of its parent peptide, GnRH, in both neural and peripheral cells.  We have previously shown that GnRH-(1-5) stimulates epidermal growth factor (EGF) release, increases the phosphorylation of EGFR, and promotes cellular migration in the Ishikawa endometrial cancer cell line.  We also demonstrated that the actions of GnRH-(1–5) are mediated by the orphan G protein-coupled receptor 101 (GPR101).  The down-regulation of GPR101 expression by antisense oligonucleotide and by siRNA blocked the GnRH-(1–5)-mediated transactivation of EGFR and increases in cellular migration.  Furthermore, the global MMP inhibitor, Batimastat, blocked GnRH-(1-5) mediated EGFR phosphorylation.  This suggests that activation of GPR101 may mobilize MMPs at the membrane level to release membrane bound EGF.  In this study, we investigated the effect of GnRH-(1-5) on cellular migration and invasion by examining its regulation of collagenases MMP2 and MMP9.  Using the matrigel invasion assay, we examined the effects of GnRH-(1-5) and its parental analogs on migration and invasion in the Ishikawa cell line and compared them to the vehicle (VEH) control. Treatment with GnRH-(1-5) (100nM) increased both migration and invasion into the matrigel by ~20% and 30% (p<0.05), respectively at t= 48h whereas treatment with 100nM GnRH had no effect (p>0.10) on either parameters. Interestingly, treatment with (D-Ser6)-GnRH (an agonist of GnRH), resulted in an anti-migratory effect (p<0.05), while having no effect on invasion.  Furthermore, treatment with GnRH-(1-5) increased (p<0.05) the levels of MMP9 in the crude membrane fraction, whereas treatment with 100nM GnRH or 100nM (D-Ser6)-GnRH had no effect (p>0.10).  No change (p>0.10) in MMP2 levels was observed in the lysate and crude membrane fractions with all treatments.  Our results suggest that GnRH-(1-5) regulate the recruitment of MMP9 to the membrane level to stimulate migration and invasion. 

 

Nothing to Disclose: MJC, DOL, MJS, SKM, TYJW

15999 12.0000 SUN-0041 A Gonadotropin-Releasing Hormone (GnRH) Metabolite, GnRH-(1-5), Mediates Cell Migration and Invasion in the Ishikawa Cell Line 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0030-0045 4855 1:00:00 PM Female Reproductive Tract Poster

Ping Yin*1, Antonia Navarro2, Molly B Moravek3, John S Coon V1, Matthew T Dyson3, Ranjani Sundar3 and Serdar Ekrem Bulun2
1Northwestern University, Chicago, IL, 2Northwestern Univ, Chicago, IL, 3Northwestern University

 

Progesterone exerts an overall tumorigenic effect on both uterine leiomyoma (fibroid) and breast cancer tissues, whereas the antiprogestin RU486 inhibits growth of these tissues through an unknown mechanism. Previously, using an unbiased ChIP-sequencing technique, we uncovered perilipin 2 (ADRP/ADPH/PLIN2) as a novel PR target gene in T47D breast cancer cells and primary human uterine leiomyoma cells. RU486 treatment induced PLIN2 gene expression via the same DNA regulatory region in both cell types. PLIN2, an adipose differentiation-related protein, is ubiquitous in non-adipose lipid droplet-containing cells and plays important roles in lipid droplet formation and stabilization, but its loss is linked to the expression of fibrogenic genes in hepatic fibrosis. Moreover, in clear cell renal carcinoma, higher PLIN2 expression is associated with better cancer-specific survival and cancer-free survival. Until now, little is known about the roles of PLIN2 in the regulation of the growth of human uterine leiomyomas or breast cancers. In this study, we examined the impact of PLIN2 on the function of uterine fibroid cells and T47D cells by depleting its expression via small inference RNA (siRNA). We found that knockdown of PLIN2 with siRNA dramatically increased protein levels of proliferating cell nuclear antigen (a marker for cell proliferation) in both cell types. In T47D cells, PLIN2 knockdown also significantly stimulated the expression of fibrogenic genes including TIMP1 (2-fold), collagen 1a1 (1.5-fold), and collagen 1a2 (3-fold). Furthermore, we discovered that 75% of subjects’ leiomyoma tissues expressed lower mRNA levels of PLIN2 compared to the adjacent myometrial tissues. Our conclusions suggest that PLIN2 regulates cell proliferation and extracellular matrix formation in human T47D breast cancer cells and primary uterine leiomyoma cells, and we predict that PLIN2 plays an important role in mediating the therapeutic effects of RU486 in uterine leiomyomas and breast cancers.

 

Nothing to Disclose: PY, AN, MBM, JSC V, MTD, RS, SEB

16949 13.0000 SUN-0042 A Novel Progesterone Receptor Target Gene Perilipin 2 Regulates Proliferation and Collagen Formation in Breast Cancer and Uterine Leiomyoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0030-0045 4855 1:00:00 PM Female Reproductive Tract Poster

Patricia Tereese Jimenez*1, Sarah White1 and Carole R Mendelson2
1University of Texas Southwestern Medical Center, Dallas, TX, 2UT Southwestern Med Ctr, Dallas, TX

 

Endometrial stromal cells are hormonally responsive and must undergo molecular, structural and functional changes for the uterus to become receptive for blastocyst implantation and to support embryo development. microRNAs (miRNA/miR) and their targets have been proposed to serve regulatory roles in implantation. To define miRNAs that are differentially regulated in endometrial stroma during implantation, we conducted miRNA microarray analysis of 1281 mature miRNAs in stromal cells of mouse uterus at 0.5 days post-coitum (dpc, prior to implantation) and from implantation sites at 4.5 dpc (during implantation). Intriguingly, we observed that all members of the evolutionarily conserved miR-200 family were downregulated more than two-fold at 4.5 vs. 0.5 dpc. TGFβ and transcription factors ZEB1 and ZEB2, confirmed targets of miR-200s, are known positive regulators of epithelial-to-mesenchymal transition (EMT) and stimulate metastasis and invasion of cancer cells. miR-200s and ZEBs exist in a double-negative feedback loop, whereas, ZEBs and TGF-β positively regulate one another. To confirm and extend results of the microarray, RT-qPCR of RNA from endometrial stromal cells isolated from a separate cohort of mice at 0.5, 2.5, 4.5 and 8.5 dpc revealed that between 0.5 and 2.5 dpc, miR-200a, -200b and -200c were significantly downregulated, while ZEB1/2 and TGF-β, were significantly, but transiently, upregulated. N-cadherin, a known mesenchymal marker, was expressed in a similar pattern as ZEB1/2 and TGF-β, while the epithelial marker, E-cadherin, was increased between 4.5 dpc and 8.5 dpc, in association with decidualization. These findings suggest that EMT and the reverse process, MET, may serve important roles in implantation, invasion and decidualization. To analyze hormonal regulation of the miR-200 family and targets, ovariectomized mice were subcutaneously injected with vehicle, 1 mg 17β estradiol (E2) or 1 mg progesterone (P4) for 1, 2 or 3 days. Endometrial stromal cells were isolated from whole uteri and analyzed by RT-qPCR. Notably, miR-200 family members were markedly upregulated by E2 at each time point. On the other hand, ZEB1 and ZEB2 were downregulated by E2 and upregulated by P4 following 2 days of treatment. Our collective findings suggest that miR-200s and their targets serve as hormonally-modulated mediators of the coordinated signaling pathways during embryo implantation. Furthermore, miR-200-ZEB-TGF-β regulation of EMT/MET within endometrial stroma may be critical to successful implantation and decidualization.

 

Nothing to Disclose: PTJ, SW, CRM

12856 14.0000 SUN-0043 A The Mir-200 Family and Their Targets Are Hormonally Regulated in Endometrial Stromal Cells and Likely Serve a Key Role in Blastocyst Implantation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0030-0045 4855 1:00:00 PM Female Reproductive Tract Poster

Sevim Yildiz Arslan*, Yanni Yu, Thomas H. Hope and Julie Kim
Northwestern University, Chicago, IL

 

Hormone fluctuation throughout the menstrual cycle contributes to changes in immune responses that render the upper female reproductive tract vulnerable to HIV infection. It is thought that HIV infection is more likely to occur during luteal phase because of dampening of protective immune responses. As it is becoming more evident that hormone production as well as function of immune cells are ideal candidates for HIV transmission, it is essential to understand the role of hormones on HIV infection in women. The objective of this study is to identify genes in endocervical tissues of women that are differentially expressed in the follicular versus the luteal phases of the menstrual cycle using gene expression profiling. Cervical tissue samples of different hormonal status were obtained from routine hysterectomies. A microarray using the IIlumina platform was performed with 8 tissues from follicular and 8 tissues from luteal phases of the menstrual cycle. Data analysis revealed 450 genes significantly different between the two phases, with a p-value < 0.05 and a fold change cutoff of 1.5. Categorization of these genes, using Ingenuity Pathway Analysis, GeneGo as well as DAVID revealed genes associated with collagen fibril morphology, differentiation, proliferation, dendritic cell (DC) and leukocyte migration, among others. We focused on genes associated with dendritic cell maturation and migration as well as hormone regulation by assessing their differential expression using real time PCR as well as IHC staining to examine protein expression. Both mRNA expression and protein levels of genes, such as COL3A1, SLPI, DC-SIGN, and IL-10 that may play a role in HIV-DC interaction, were significantly decreased in luteal as compared to follicular phase (p < 0.05).

In the endocervix, mature CD83+ DCs outnumber immature CD1a+ DCs throughout the menstrual cycle. IHC studies showed that protein levels of CD83+ DCs decreased from follicular to the luteal phase, indicating a tolerogenic phenotype that may be regulated by sex hormones. Overall, this is the first microarray analysis comparing gene expression in endocervical tissues in cycling women. This study identifies key genes of HIV-DC interaction and potentially novel mechanisms influenced by ovarian hormones which will significantly enhance our understanding of HIV infection in women.

 

Nothing to Disclose: SY, YY, THH, JK

15381 15.0000 SUN-0044 A Gene Profiling of Endocervical Tissues during the Menstrual Cycle 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0030-0045 4855 1:00:00 PM Female Reproductive Tract Poster

Junting Hu*
State Key Lab of Medical Neurobiology, Shanghai, China

 

Nitric oxide (NO) is highly unstable, with a half-life of seconds in buffer solutions. It regulates the contractility and relaxation of Fallopian tube, and is involved in gametes maturation, fertilization, early embryonic development and embryo transfer to the uterus[1, 2]. NO is synthesized by the action of NO-synthase (NOS) with three isoforms of NOS being identified: neuro nitric oxide synthase (nNOS), inducible nitric oxide synthase (iNOS) and endothelial nitric oxide synthase (eNOS).In the present study, we probed the expression and regulation of NOS in the mouse and human fallopian tube during the mouse estrous cycle and human menstrual cycle, together with NOS expression in the human tube after ectopic pregnancies as well as after lipopolysacharide (LPS) treated mouse. Studies were conducted using immunohistochemistry, immunofluorescence, quantitative real time polymerase chain reaction (qRT-PCR) and in vitro tissue cultures. The results showed that the presence of different NOS isoforms in the mouse and human fallopian tubes during different stage of estrous and menstrual cycle; ovarian steroid hormones regulate NOS expression in mouse fallopian tubes. iNOS expression increased in the fallopian tube of human ectopic pregnancies and LPS treated mouse. The results of present study provided morphological and molecular evidences that NOS in the human and mouse fallopian tube might participate in the tubal contractions and suggested that iNOS may be involved in ectopic pregnancies.

 

Nothing to Disclose: JH

11494 16.0000 SUN-0045 A The Similar and Distinct Regulation of Nitric Oxide Synthase Isoform Expression in Mouse and Human Fallopian Tubes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0030-0045 4855 1:00:00 PM Female Reproductive Tract Poster

Marie Jagot1, Emmanuel D Sonnet*1, marie-Therese le Martelot1, Isabelle Masse1, Genevieve Crouzeix1, Estelle Leclercq1 and Veronique Kerlan2
1CHU Brest, Brest, France, 2CHRU BREST, BREST, France

 

GH is important to female fertility. In vivo, GH is involved in oocyte maturation (1).  When added to gonadotrophins for IVF, GH enhances the live birth rates (2). Some women undergoing IVF are considered as poor ovarian responders. Poor response can be defined quantitatively (low previous ovarian response to stimulation protocol), or qualitatively : no pregnancy after several IVF. However, GH status has never been assessed in women considered as poor responders.

Our work aimed to determine the prevalence of GH deficiency (complete or partial) in a population of women considered as poor ovarian responders in IVF. We also studied the consequences of GH deficiency in IVF results : total amount of gonadotrophins required for stimulation, number of oocytes retrieved and embryos obtained, fecundation rates (number of embryos/number of oocytes).

Women who had no pregnancy after three IVF (or two IVF, when oocytes or embryos quality was seen as poor) were recruited in our clinic. Those with previous ovarian surgery or severe uterine malformation or abnormal BMI were excluded from the study. GH secretion was assessed by the highest value of GH obtained with glucagon test and insulin tolerance test (ITT). Criteria were : GH ≤ 9mUi/l : complete GH deficiency ; 10≤GH≤30mUi/l : partial GH deficiency, GH>30mUi/l : GH : normal.

32 women underwent the glucagon test, and 19 also underwent the ITT. One patient had a complete GH deficiency, and 8 were diagnosed with partial GH deficiency. In the course of the second IVF, women with GH deficiency had lower fecundation rates than women with normal GH secretion : 0,25 (n=8) vs 0,43 (n=16), p<0.05. The two groups did not differ for all other indicators.

 The prevalence of GH deficiency therefore seems to be high in women considered as poor responders to IVF, as this condition affected nearly one third (9 over 32) of the patients in our cohort.It was found that GH deficiency only impacted qualitative results of IVF (fecundation rates), with no impact on the number of oocytes retrieved or embryos obtained. The present study was the first to look for GH deficiency in poor ovarian responders in IVF, and to assess its consequences in fertility. This emphasizes the importance of GH upon qualitative parameters in women fertility, as suggested by its roles in oocyte maturation in vivo.

 

Nothing to Disclose: MJ, EDS, MTL, IM, GC, EL, VK

12107 1.0000 SUN-0001 A GH Deficiency Can be Encountered in Poor Ovarian Responders to IVF, 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Margaret C Garin*1, Samantha F Butts2, David B Sarwer1, Kelly C Allison1 and Anuja Dokras1
1Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, 2Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA

 

Background:  Ghrelin is an appetite stimulant and regulator of energy intake; however, its role in ovarian function is less well established.  Ghrelin may have central effects on fertility through suppression of the hypothalamic-pituitary-gonadal axis.  Additionally, ghrelin and its receptor have been localized in the human and rodent ovary suggesting a direct role for ghrelin in ovarian function. Polycystic ovary syndrome (PCOS) is associated with decreased serum ghrelin levels and elevated levels of anti-mullerian hormone (AMH), a biomarker of ovarian follicular function.  Regulation of AMH in PCOS is poorly understood.  We therefore examined the relationship between total ghrelin and AMH in obese women with PCOS.

Methods:  Fasting serum total ghrelin, AMH, insulin, glucose, and total testosterone were compared between 54 obese women with well-defined PCOS and 53 obese controls using t tests, simple correlation, and multiple linear regression controlling for age and BMI.  AMH levels were measured using the Gen II enzyme linked immunosorbent assay (Beckman Coulter) and total ghrelin was measured using a radioimmunoassay kit (Millipore). 

Results: The mean age of the cohort was 33 +/- 7 years and the mean BMI was 40.5 +/- 9.9 kg/m2.  Women with PCOS had higher AMH (4.96 +/- 3.31 ng/mL vs. 2.56 +/- 2.13 ng/mL; p<0.001), total testosterone (58.61 +/- 31.04 ng/dL vs. 34.10 +/- 17.13 ng/dL; p<0.001), insulin (23.91 +/- 13.55 uU/mL vs. 17.77 +/- 11.39 uU/mL; p=0.014), and homeostasis model assessment-estimated insulin resistance (HOMA-IR) (5.86 +/- 3.94 vs. 4.07 +/- 2.75; p=0.01) but lower total ghrelin (782.02 +/- 255.18 pg/mL vs. 901.50 +/- 355.75 pg/mL; p=0.051) compared to controls.  Total ghrelin inversely correlated with AMH (r= -0.3940; p=0.003), insulin (r= -0.274; p=0.05) and HOMA-IR (r= -0.314; p=0.022) in PCOS, and total ghrelin inversely correlated with HOMA-IR in controls (r= -0.322, p=0.024).  AMH inversely correlated with age (r= -0.649, p<0.001) and positively correlated with total testosterone (r=0.493, p<0.001) in controls.  In multivariate analysis, total ghrelin in women with PCOS was the best predictor of AMH (r2=0.155, p=0.003) and the significance of this association was not attenuated by the addition of HOMA-IR, total testosterone, age and BMI.  In contrast, age was the best predictor of AMH in controls (r2=0.422, p<0.001) with slight improvement in the model with the addition of total testosterone (r2=0.469, p=0.05).

Conclusions: In obese women with PCOS, total ghrelin levels correlated inversely with AMH independent of age, BMI, HOMA-IR, and total testosterone.  Ghrelin dysregulation reported in PCOS may play a role in AMH secretion independent of obesity, insulin resistance, or hyperandrogenemia.  Future studies are needed to determine the potential mechanisms that may explain the role of ghrelin in regulation of AMH in the polycystic ovary.

 

Disclosure: DBS: Consultant, BAROnova, Consultant, EnteroMedics. Nothing to Disclose: MCG, SFB, KCA, AD

12589 2.0000 SUN-0002 A Ghrelin Is Independently Associated with Anti-Mullerian Hormone in Obese Women with Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Joely A. Straseski*1, Jun Lu2, Christopher Holt3, Myung Choi3 and Kimberly Kalp2
1Univ of Utah School of Medicine, Salt Lake City, UT, 2ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, 3ARUP Laboratories, Salt Lake City, UT

 

Background: Anti-Müllerian hormone (AMH) is responsible for regression of the female ductal system during embryonic development. It is produced by the male testes until puberty and the female granulosa cells until menopause. A highly sensitive AMH assay is ideal for investigation of infertility, menopause, ovarian reserve or monitoring granulosa cell tumors post-therapy. The picoAMH ELISA kit (Ansh Labs, Webster, TX, USA) is a new quantitative immunoassay that detects ultra-low concentrations of AMH in human serum. Here, we describe the analytical performance of the picoAMH assay.

Methods: Imprecision studies used manufacturer’s controls (65 and 185 pg/mL) and patient pools (201 and 404 pg/mL) assayed in duplicate or triplicate once daily for 10 days. Dilution imprecision was tested using 1:10 and 1:100 dilutions of serum pools assayed in triplicate once daily for 5 days. Limit of blank (LOB) and limit of detection (LOD) were assessed using the blank and 6.3 pg/mL calibrators. Linearity was determined by serially diluting a high AMH serum sample in blank calibrator to create 5 samples tested in duplicate. Recovery was evaluated by adding the highest 2 calibrators to patient samples (84 and 202 pg/mL). Temperature stability was determined by storing 2 specimens (99 and 301 pg/mL) ambient for 24 hr, 4C for 7 days and -20C for 3 weeks. Effects of up to 3 freeze/thaw cycles were studied. Method comparison of 57 samples in the range of 80-181,000 pg/mL was performed using the Beckman AMH Gen II ELISA as the comparator method. Gender/age-specific reference intervals were established using fresh or biorepository serum specimens (6 mos-71 yrs, n=1,076).

Results: Imprecision and dilution imprecision studies showed total CVs ≤ 6.3 and ≤ 8.7%, respectively. LOB and LOD were 0.81 and 3.11 pg/mL, respectively. The assay was linear to 696 pg/mL. Recovery ranged 76-101%. AMH differed <18% at all storage temperatures and <5% after 3 freeze/thaw cycles. Deming regression of the method comparison yielded y = 0.999 x – 0.226, R² = 0.99. Eleven gender/age-specific reference intervals were established using non-parametric and robust statistics.

Conclusions: The AnshLabs picoAMH ELISA demonstrated performance close to the manufacturer claims and excellent correlation with the comparator method. This method lowered the LOD from the current 80 pg/mL to 3 pg/mL. We report gender/age-specific reference intervals for this assay that will be useful for clinical practice.

 

Nothing to Disclose: JAS, JL, CH, MC, KK

13035 3.0000 SUN-0003 A Analytical Evaluation of the Ansh Labs Pico-AMH ELISA Assay for Anti-Müllerian Hormone 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Betânia Rodrigues dos Santos* and Poli Mara Spritzer
Hospital de Clínicas de Porto Alegre and Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

 

Women with polycystic ovary syndrome (PCOS) frequently present insulin resistance and metabolic comorbidities, such as dyslipidemia, diabetes and hypertension. Variants on vitamin D receptor (VDR) gene have been associated with insulin resistance and diabetes in general population. Therefore, we aimed to investigate whether Apa-I polymorphism (rs7975232) in the VDR gene is associated with metabolic syndrome in PCOS and control women. A cross-sectional study including 190 PCOS (Rotterdam criteria) and 100 non-hirsute and ovulatory controls was performed. Endocrine and clinical measurements were assessed. Body mass index (BMI) was calculated. Genotypic analyses were evaluated by Real Time PCR. Women with PCOS were younger (22.9±6.7 vs. 25.2±7.7 years; p=0.013) and had significantly higher BMI (29.7±6.4 vs. 27.03±6.1 Kg/m2; p=0.001), total testosterone (0.90±0.40 vs. 0.54±0.17 ng/mL; p<0.001) and fasting insulin (16.87 (9.81-26.97) vs. 11.09 (7.34-15.44); p<001). The prevalence of metabolic syndrome in PCOS and controls were 26.5% and 4.8%, respectively. The genotypic distribution for Apa-I SNP did not differ significantly between PCOS (AA: 32.1%, AC: 46.3%, CC: 21.6%) and controls (AA: 36.0%, AC: 48.0%, CC: 16.0%). The genotype analyses among PCOS participants showed that individuals with CC genotype (CC vs. CA+AA) of Apa-I had higher risk for metabolic syndrome (OR: 2.133; 95% CI 1.020-4.464, p=0.042). The analyses among control participants showed that metabolic syndrome is more frequent in CC that CA+AA genotype (13.3% vs. 2.9%), but not significant, perhaps because of the low prevalence of metabolic syndrome in the control group. The CC genotype was also associated with higher systolic blood pressure (p=0.009), total cholesterol (p=0.040) and LDL (p=0.038) in both PCOS and control groups (two-way ANOVA). In conclusion, the present results suggest that variant Apa-I in VDR gene may be associated with metabolic syndrome in PCOS women from Southern Brazil.

 

Nothing to Disclose: BRDS, PMS

13737 4.0000 SUN-0004 A Apa-I Polymorphism in VDR Gene Is Related to Metabolic Syndrome in Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

David H Barad*1, Vitaly A Kushnir1, Pallavi Khanna2 and Norbert Gleicher3
1The Center for Human Reproduction, New York, NY, 2Icahn School of Medicine at Mount Sinai Program, Queens Hospital Center, 3Center for Human Reproduction, New York, NY

 

Age specific AMH testing is increasingly important in assessing functional ovarian reserve (FOR). Lower limits of detection (~0.16ng/mL), are, however, limiting in women with low FOR, who even at AMH levels below current limits of detection often still respond to ovulation induction.  More sensitive AMH tests, therefore, might improve clinical predictability of treatment outcomes in such patients.  We, therefore, compared AMH results of a currently widely utilized AMH assay (enzymatically amplified two-site immunoassay AMH Gen II ELISA ref A73818, (Beckman Coulter Brea, CA), to a new ultrasensitive AMH assay (picoAMH, Ansh Labs, Webster, TX, a three-step sandwich type immunoassay), in IVF, based on follicle, oocytes and embryo numbers and pregnancy rates. The analytical measurable range of the PicoAMH assay is 0.003 —14ng/mL with a limit of detection of 0.001ng/mL.  Between August - October 2013 serum was collected from 30 women with known abnormally low AMH (by standard test) and evidence of low age-specific FOR.  Only 28 results were, however obtained by the picoAMH assay and only 24 had a contemporaneous sample sent for routine AMH analysis (mean age 41.9 ± 2.4 years; range 38-43).  Mean AMH of the standard assay was 0.35ng/mL (0.22 to 0.56); of picoAMH assay 0.16ng/mL (0.07 to 0.34) (Paired T-Test, df = 23, p = 0.008).  With standard assay 12 patients had undetectable AMH but had detectable AMH with picoAMH assay. Their mean AMH was 0.043ng.mL  (95% CI, 0.014 to 0.128).  Among patients with undetectable AMH on standard assay, 4 did not continue in treatment, 8 attempted IVF and only 1 failed to retrieve oocytes. (4 women retrieved 1 oocyte, 1 patient 3 oocytes, 1 had 4 oocytes, and 1 as many as 7 oocytes). 5/8 women reached embryo transfer, though none conceived. The new picoAMH test is considerably more sensitive than currently routinely used AMH assays. It, therefore, likely better reflects FOR in women with very low FOR. Whether it also better reflects very low known pregnancy chances in such patients requires further investigations of a larger patient sample.

 

Nothing to Disclose: DHB, VAK, PK, NG

13917 5.0000 SUN-0005 A Clinical in Vitro Fertilization (IVF) Outcomes Based on Comparative Anti-Müllerian Hormone (AMH) Testing with a Standard and New Highly Sensitive Assay 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Sarantis Livadas*1, Anastasios Kollias1, Dimitrios Panidis2 and Evanthia Diamanti-Kandarakis1
1Athens University Medical School, Athens, Greece, 2Aristotle Univ Thessaloniki, Thessaloniki, Greece

 

Polycystic ovary syndrome (PCOS) represents a moving spectrum of hormonal towards metabolic abnormalities as women with the syndrome are ageing. Hormonal abnormalities, anovulation and hyperandrogenic signs dominate the picture during the early years of PCOS and fade away as years go by. Metabolic abnormalities and insulin resistance remain throughout the PCOS life cycle, however it is unclear how they change as women with the syndrome are ageing. We undertook the present study aiming to evaluate in a large cohort of women with PCOS and controls, as they are ageing, changes of insulin resistance, assesd with the use fo HOMA-IR index, and its associations with clinical, biochemical, hormonal and ultrasound findings. Data from 1345 women with PCOS (Rotterdam criteria) and 302 controls of Caucasian origin and Greek ethnicity were analyzed on a cross-sectional manner. In PCOS group, age (-0.045±0.008) was negatively and BMI positively (0.18±0.007) associated with HOMA-IR (R2=0.36). When data were stratified regarding BMI status, a negative association of age with HOMA-IR was found in lean, normal and overweight patients (r:-0.266, -0.233, -0.192, p<0.001), which was neutralized in obese patients (r:-0.009, p:ns). Free androgen index and BMI were positively associated with HOMA-IR in all age quartiles. When mean HOMA-IR values were plotted according to BMI subgroups at different age quartiles, a significant gradual decrease of HOMA-IR was observed in normal (p<0.001) and overweight (p:0.004), but not in obese women (p:0.202) across age quartiles. In conclusion, ageing deteriorates insulin resistance in obese but not in lean and overweight women with PCOS. Since BMI and androgens are positively associated with HOMA-IR and androgens decline through time, it appears that if women with PCOS do not become obese may exhibit a better metabolic profile during reproductive years.

 

Nothing to Disclose: SL, AK, DP, ED

14123 6.0000 SUN-0006 A Diverse Impact of Ageing on Insulin Resistance in Lean and Obese and Women with Polycystic Ovary Syndrome: Evidence from 1345 Women with the Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Matea Belan*1, Karine Duval1, Farrah Jean-Denis2, Youssef Ainmelk1, Marie-Helene Pesant1, Marie-France Langlois1, Belina Carranza-Mamane1 and Jean-Patrice Baillargeon1
1Université de Sherbrooke, Sherbrooke, QC, Canada, 2Research Center of the Centre hospitalier universitaire de Sherbrooke, Sherbrooke, QC, Canada

 

BACKGROUND: Adverse impacts of obesity on the reproductive function of young women are well known. In contrast, the repercussion of obesity on male fertility has been overlooked, even if some studies found impaired seminal quality, sexual endocrine profile and sexual function. Although it was reported that weight loss improve reproductive health in obese women, it is still unknown whether a lifestyle intervention in male partners improves couples’ fertility. In order to begin answering this question, we sought to assess characteristics of male partners of infertile couples whose spouse is obese and participates in a randomized-controlled trial evaluating the impacts of a lifestyle intervention on couples’ fertility outcomes.

METHODS: All interested male partners of obese women participating in the above-mentioned trial were recruited in this nested controlled prospective cohort study. Couples were referred to the Fertility Clinic of an Academic Center. Both partners were evaluated at baseline for their body mass index (BMI) and lifestyle, using a lifestyle questionnaire. Data is reported as median with [interquartile range]. Medians were compared between partners using Wilcoxon test and concordance between partners was tested using Spearman’s correlation.

RESULTS: Of the 55 participating male partners (age 33.9 ± 6.1 years), 49.1% were obese, compared to 13.3% in the general Canadian male population aged 20-44 years (Statistics Canada1). The lifestyle questionnaire revealed that ‰ ate in restaurants 2.0 [1.0-3.0]  times/week vs 1.5 [1.0-2.0] in Š (p=NS), in fast-food restaurants 56.9% vs 51.2% (p=NS) of the time; 58.2% of ‰ vs 47.3% of Š (p=NS) do not eat breakfast daily; 87.3% vs 85.5% (p=NS) eat less than 5 portions of fruits and/or vegetables daily; and 27.3% vs 5.5% (p=0.006) drink ≥1 regular soda beverages daily. Only 32.7% of ‰ vs 16.3% of Š (p=0.05) were active or moderately active. 24% of ‰ vs 27% of Š were smokers (p=NS) and ‰ consumed 2.0 [0.3-4.0] alcohol drinks/week vs 0.5 [0.0-2.0] for ‰ (p=0.003). Moreover, statistically significant correlations between partners were found for daily cereal products consumption (ρ=0.45; p=0.001), regular soda beverages consumption (ρ=0.40; p=0.003), restaurant frequentation (ρ=0.31; p=0.02), hours spent for sedentary screen activities (ρ=0.43; p=0.001) and tobacco use (ρ=0.50; p=0.001).

CONCLUSION: Our preliminary results suggest that in infertile couples referred to a fertility clinic, male partners of obese women are often obese themselves and display either similar or worst lifestyle habits than their spouse (except for activity level). Such adverse lifestyle could therefore contribute to their couple’s infertility. We thus suggest that in infertile couples, male partners of obese women should be included in the interdisciplinary lifestyle intervention indicated for their spouse, in order to optimize couples’ fertility.

 

Nothing to Disclose: MB, KD, FJ, YA, MHP, MFL, BC, JPB

14199 7.0000 SUN-0007 A Characteristics of Male Partners of Infertile Couples in Which the Wife Is Obese and Participates in a Clinical Trial on the Impacts of a Lifestyle Intervention 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Yacob Fattout*1, Lydia Usha1, Salman Waheed2 and Rasa Kazlauskaite1
1Rush University Medical Center, Chicago, IL, 2Rush University Medical Center, chicago, IL

 

Background: Fulvestrant is an estrogen receptor antagonist, used to treat postmenopausal women with hormone receptor positive metastatic breast cancer.  In some metastatic cancers, estradiol levels may occasionally be used to monitor treatment. However, the ability of estra-triene-diol moiety of the fulvestrant to cross-react in commercial estradiol assays remains largely unrecognized in clinical laboratory and practice.

Methods: In search for a clinical guidance regarding fulvestrant cross-reactivity in commercial estradiol assays, we reviewed the fulvestrant Federal Drug Administration (FDA)-approved package insert label, the FDA device and Clinical Laboratory Improvement Amendment (CLIA) databases pertaining to estradiol assays from April 2002 (the original date of fulvestrant approval) until January 2014.

Circulating estradiol levels were tested in a serum sample of a woman,  who underwent total hysterectomy with oophorectomy for treatment of her estrogen- and progesterone-receptor-positive breast cancer, and received monthly intramuscular fulvestrant for the previous 5 months.  Due to unexplained elevation of estradiol levels on the initial testing, the estradiol levels were compared using 3 different clinical laboratories. The woman tested negative for ovarian remnant syndrome.  

Results: The official package insert for fulvestrant does not include warning about the potential for false-positive results when testing for estradiol. We were not able to find information in the FDA and CLIA databases on estradiol assay cross-reactivity in fulvestrant-treated patients. We were able to identify one abstract comparing several estradiol assays for cross-reactivity in fulvestrant-treated post-menopausal women. The estradiol levels were undetectable using liquid chromatography-tandem mass spectrometry (LC-MS/MS), whereas immunometric assays tested false-positive for estradiol levels.  

Conclusions: The lack of clinical awareness for fulvestrant chemical similarity with estradiol may lead to unnecessary estradiol testing, erroneous interpretation of the results, and lead to false medical decisions. The regulator agency warnings should be introduced at multiple levels of clinical system. First, the package labeling for fulvestrant must include the warning about the fulvestrant’s potential to affect the hormonal testing. Second, the CLIA should consider requirement for providing the assay interference data of the new drugs on measurements of hormonal markers.

 

Nothing to Disclose: YF, LU, SW, RK

14237 8.0000 SUN-0008 A False Elevation of Serum Estradiol Due to Fulvestrant May Lead to Faulty Therapeutic Decisions: The Need for Medication Label Warning 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Tugba Arkan1, Mehmet Calan1, Mehmet Asi Oktan1, Dilek Cimrin2 and Firat Bayraktar*1
1Dokuz Eylul University Medical School, Izmir, Turkey, 2Dokuz Eylul University

 

Introduction: Maternal vitamin D deficiency is an important problem. Associations between maternal vitamin D status and fetal size have been published in small studies. The objective of this study was to determine the association between maternal 25-hydroxyvitamin D (25(OH)D) and newborn weight.

Method:  A retrospective cohort study was conducted. The medical records of Dokuz Eylul University Hospital Endocrinology division clinic were reviewed from october 2012 till March 2013. 75 pregnant women’s records were investigated, 25(OH)D measured at a gestation of 26 wk or less. Nobody had vitamin D supplemation. 

Results: Study subjects age average was 29.91 ± 5.00, BMI average 28.80  ± 5.07, vitamin D level average was 18.80 ± 9.51 and birth weight average was 3205.41 ± 517.02. In spearman’s correlation analysis we didn’t find any relationship between vitamin D levels and birth weights (r=-0.058, p=0.619).

Conclusions: Maternal vitamin D levels weren't associated with newborn weight. Adequately powered randomized controlled trials are needed to test whether maternal vitamin D supplementation may improve fetal growth.

 

Nothing to Disclose: TA, MC, MAO, DC, FB

15265 9.0000 SUN-0009 A Effect of Vitamin D Levels to Birth Weight 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Maria-Luisa Lazo-de-la-Vega-Monroy*1, Martha I. González-Domínguez1, Leonel Daza-Benitez2 and Gloria Barbosa-Sabanero1
1University of Guanajuato, Leon Campus, Leon, Guanajuato, Mexico, 2UMAE No. 48 IMSS, Leon, Gto., Mexico

 

Alterations in fetal growth do not only lead to pregnancy and neonatal health risks, but also favor metabolic diseases during adult life. Therefore, the study of birth weight determination and its modifications remains an important issue in metabolic diseases prevention, which represent a worldwide health problem. Placental growth is a crucial component in fetal growth, and it has been suggested that insulin and the IGF (Insulin-like growth factor) system play an important role in fetal growth and placental development and function. Although insulin and IGFs in the umbilical cord blood have been associated to birth weight, the roles of placental IGF1 and Insulin receptors (IGF1R and IR), as well as the PI3K/Akt signaling pathway, shared by both receptors, in placental function and birth weight are not fully elucidated. To study the expression of insulin/IGF and activation of the PI3K/Akt signaling pathway in relation to placental weight and birth weight, we performed a transversal comparative study in placentas from healthy mothers of SGA, AGA and LGA (small, adequate and large for gestational age) term newborns (n=20 per group). Insulin and IGF-I in cord blood were measured by ELISA, and placental protein expression of IR, IGF1R and phosphorylation of signaling molecules were analysed by Western Blot. A significant positive correlation between placental weight and birth weight was found (r=0.86, p<0.0001), together with a positive correlation between insulin and IGF-I umbilical cord blood concentrations and birth weight (r=0.48 and r=0.52 respectively, p<0.0001), in agreement to previous reports. IGF1R expression showed a significant decrease in the SGA group compared to control AGA (20%, p=0.03), and positively correlated with placental (r=0.37, p=0.02) and birth weights (r=0.46, p=0.003) within the SGA and AGA groups, while protein expression of IR was not modified in SGA or LGA compared to AGA. To evaluate the activation of PI3K/Akt signaling pathway we analysed the phosphorylation of PDK1, the main kinase for Akt activation. PDK1 phosphorylation showed a 30% decrease in both SGA (p=0.016) and LGA (p=0.028) groups compared to control. No changes in the kinase docking-associated phosphorylation Y980 IGF1R or in the pIGF1R Y980/total IGF1R ratio were found. Thus, modification of PI3K/Akt signaling pathway might be differentially regulated in SGA and LGA placentas, related to a decreased IGF1R expression in SGA and perhaps differences in IGF1R or other downstream kinase activation in LGA. These results suggest that changes in the IGF1R expression and/or activation of the PI3K/Akt pathway are possibly involved in altered human placental growth, consequently leading to abnormal fetal growth.

 

Nothing to Disclose: MLL, MIG, LD, GB

15282 10.0000 SUN-0010 A Changes in Placental IGF1R Expression and Activation of the PI3K/Akt Pathway in Small for Gestational Age (SGA) and Large for Gestational Age (LGA) Newborns 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Lucy-Ann Behan*, Hala Goma, Hend Ahmado, Sara Abdulwahab, Jihye Kim, Kihwan Choi, Aaron R Wheeler and Robert F Casper
University of Toronto, Toronto, ON, Canada

 

According to the Women’s Health Initiative (WHI) study, use of combined estrogen/progesterone hormone therapy is linked with increased risk of breast cancer (BC) in postmenopausal women. Breast cancer risk is increased with prolonged exposure to estrogen; however rather than a decrease in the incidence of BC after menopause, when circulating estrogen levels fall, rates of BC continue to rise with age. It is now accepted that the peripheral in-situ biosynthesis of estrogen through the aromatase pathway contributes to almost 100% of the total estrogen produced in postmenopausal women.

We hypothesised that due to the presence of aromatase in breast tissue, there is no difference in measured levels of estrogen in healthy female breast tissue in postmenopausal women on hormone therapy (HT) and postmenopausal women without HT, despite the peripheral decrease in estrogen. In a pilot study of 9 postmenopausal women on HT (Group 1) and 12 postmenopausal women without HT (Group 2) breast tissue Estradiol, Progesterone, Androstenedione, and Testosterone were extracted from fine needle breast biopsy samples. Results were analysed using a digital microfluidic based sample extraction technique, coupled with a highly sensitive high performance liquid chromatography (HPLC) - Mass Spectrometer (LTQ–Linear IT-Thermo Scientific, Waltman, MA).

There was no difference in mean age between Group 1, age 55 + 7 years and Group 2 , age 56 + 7 years p=0.8, nor was there a difference in duration of menopause at time of sampling, 7 + 6 and 8 + 7 years, respectively (p=0.6). Median breast estradiol levels were not different between the two groups: Group 1 estradiol 9.4fmol/mg (interquartile range, 5.7 to 11.9) and Group 2 at 9.7fmol/mg (IQR 6.4 to 22.5), p=0.6. Mean breast androstendione levels were not different between groups (p=0.4), however mean breast testosterone levels were significantly lower in group 1 compared to group 2 at 4.1fmol/mg ± 2.7 and 17.3fmol/mg ± 11.0 respectively (p<0.01), while median breast progesterone levels were non-significantly higher in women on HT, compared to those who were not (5.2 fmol/mg, IQR 3.6 to 8.1 v 2.3fmol/mg, IQR 0.9 to 4.0, respectively, p=0.05). 

This data suggests that there is no difference in breast estrogen levels in women on hormone therapy compared to those without and estrogen replacement therapy may not be the cause of increased breast cancer risk on HT. It is possible that the progestin component of HT may have an adverse impact and further analysis of breast tissue steroid hormone levels are being undertaken.

 

Nothing to Disclose: LAB, HG, HA, SA, JK, KC, ARW, RFC

15494 11.0000 SUN-0011 A Estradiol Levels in Breast Tissue Are Not Different Between Postmenopausal Healthy Women with or without Hormone Replacement Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Roisin Worsley*, Emorfia Gavrilidis, Caroline Gurvich and Jayashri Kulkarni
Monash University

 

Background: Schizophrenia is a debilitating chronic condition often associated with significant cognitive impairment. In men with schizophrenia, higher testosterone levels are associated with better cognition and more hostility.(1) Little is known about the effect of testosterone in women with schizophrenia.

Aim: to determine if there is an association between serum testosterone levels and cognitive and psychopathology scores in women with chronic schizophrenia.

Methods: baseline data was used from two randomised controlled trials of women with chronic schizophrenia.   Serum testosterone was measured on a single sample. Cognition was measured using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), on which a higher score equates to better cognition. Psychopathology was measured using the Positive and Negative Syndrome Scale (PANSS), with a higher score indicating more severe psychosis. As data were not normally distributed Spearman correlations were used to assess the associations between testosterone and cognitive and psychopathological variables. For variables in which a significant correlation was found, women with testosterone levels in the lowest quartile were compared to women with levels in the highest quartile using the Mann-Whitney U test.

Results: data on cognition were available for 165 women and for psychosis on 265 women, aged 19-51 with mean length of illness 11.8 years (±7.5). Mean testosterone was 1.45nmol/L (± 0.75), mean PANSS 77.71 (±59.35) and mean total RBANS score was 76.41 (±16.5) indicating marked cognitive impairment across the group. Significant correlations were seen between serum testosterone levels and RBANS measures of verbal memory (story recall [-0.19, p=0.016], immediate memory [-0.18, p=0.020], delayed memory [-0.195, p=0.012]), as well as total RBANS score (-0.155, p=0.047). Significant correlations were seen between testosterone and the following symptoms of psychosis: difficulty in abstract thinking (0.18, p=0.023), ‘lack of spontaneity and flow of conversation’ (0.022, p=0.005), motor retardation (0.18, p=0.023), lack of judgement and insight (0.20, p=0.01), preoccupation (0.16, p=0.04).

Significant differences between women with testosterone levels in the lowest quartile compared with the highest quartile were seen for delayed memory (p=0.05), story recall (p=0.039) and ‘lack of spontaneity and flow of conversation’ (p=0.01).

Conclusion: in women with chronic schizophrenia, higher testosterone levels are associated with poorer cognition, in particular, verbal memory. This is a new finding which has not been reported before in women with schizophrenia.

 

Nothing to Disclose: RW, EG, CG, JK

15534 12.0000 SUN-0012 A Higher Testosterone Levels Are Correlated with Poorer Verbal Memory in Women with Chronic Schizophrenia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Ajay Kumar*1, Bhanu Kalra1, Amita Patel1, Shivani Shah1, Gopal Savjani1, Axel P.N. Themmen2, Jenny A. Visser2 and David Mark Robertson3
1Ansh Labs, Webster, TX, 2Erasmus MC, Rotterdam, Netherlands, 3Prince Henry's Inst of Med Res, Clayton VIC, Australia

 

Objective: The aim of this study was to develop a well characterized human AMH ELISA that can accurately measure circulating levels of AMH in women with diminished ovarian reserve.

Relevance: AMH is reported to be strongly associated with age, antral follicle counts (AFC), FSH and generally thought to be relatively stable over the menstrual cycle compared to other markers of ovarian reserve. In females, AMH is produced by the granulosa cells of small growing follicles from 36 weeks of gestation onwards until menopause, when levels become undetectable. Current AMH immunoassays are not sensitive to detect circulating levels in women approaching menopause or with insufficient ovarian reserve. AMH has been a marker of interest in young breast cancer survivors as pre-chemotherapy AMH levels may predict post-chemotherapy ovarian function, and a rise in levels after chemotherapy may reflect ovarian recovery. Several studies have also used AMH to model age at menopause. However, due to limited sensitivity, it has not been possible to detect AMH five years prior to menopause until present.

Methodology: A three-step, sandwich-type enzymatic microplate assay has been developed to measure AMH levels in 100 µL of sample in less than 5 hours. The assay measures human AMH and uses stabilized recombinant human AMH as calibrators (6.0-1000 pg/mL). The antibodies used have been epitope mapped to the stable mid-pro and mature region of AMH. The assay measures the bioessential AMH and does not detect other TGFβ family members. A prospective preanalytical sample stability on serum specimens stored at various temperatures (room temperature, -20°C, 2-8°C) were studied up to 7 days.  

Validation: Ansh Labs picoAMH ELISA, when compared to Ansh Labs US AMH ELISA using 115 serum samples in the range of 0.0-13333 pg/mL yielded a correlation coefficient of >0.995 (p < 0.0001) and a slope of 0.92 with an intercept of -50.66 pg/mL. Total imprecision, calculated on 3 serum pools over 40 runs, 2 replicates per run, was 5.84% at 22.58 pg/mL, 3.15% at 86.51 pg/mL and 4.34% at 373.18 pg/mL. The functional sensitivity calculated at 20% CV was 3.9 pg/mL. Dilution and spiking studies showed an average recovery of 98-114% and 97-109%, respectively. Over 95% of AMH values were detectable using the picoAMH ELISA in the late reproductive age group. The AMH concentrations measured at different temperature conditions were very reproducible (CV <9%).

Conclusions: A highly sensitive, specific and reproducible AMH assay has been developed that measures human AMH levels in cycles with lower follicle number and at later reproductive age. Serum AMH levels may be an appropriate test to identify premature loss of ovarian reserve. The performance of the AMH assay is ideal for research investigation into onco-fertility, onset of menopause, diminished ovarian reserve screening and monitoring the recurrence of granulosa cell tumor in post-menopausal subjects.

 

Disclosure: APNT: Consultant, Ansh Labs. Nothing to Disclose: AK, BK, AP, SS, GS, JAV, DMR

16072 13.0000 SUN-0013 A Development of Stable Picoanti-Müllerian Hormone (AMH) ELISA: Sensitive, Reliable and Reproducible Results 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Yushu Li*1, Yingxi Xu1, Chenyan Li2, Zhongyan Shan3 and Weiping Teng4
1The First Affiliated Hospital, China Medical University, Shenyang, China, 21st Affiliated Hospital of China Medical University, Shenyan, China, 3Institute of Endocrinology, shenyang, China, 4The Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China

 

Graves’ disease (GD) is the most common cause of autoimmune hyperthyroidism in pregnancy, occurring in 0.1%–1% of all pregnancies. Gestational transient thyrotoxicosis (GTT) is the more frequent cause of thyrotoxicosis limited to the first half of pregnancy. Maternal thyroid dysfunction, especially in early pregnancy, may lead to pregnancy complications and adverse neonatal outcomes. Few population-based prospective studies have evaluated the effects of thyrotoxicosis on this issue. The data were from a prospective study in China which screened 4800 pregnant women in early pregnancy. Patients with thyrotoxicosis were diagnosed on specific FT4 and TSH criteria in pregnancy in the study. All 73 patients with GTT were without evidence of thyroid autoimmunity, with normal thyroid ultrasound  and resolving spontaneously by the end of the second trimester of pregnancy. There were 228 pregnant women with normal thyroid function in the control group. Thirty-six patients with newly diagnosed GD in the early pregnancy were further divided into two groups according to receiving anti-thyroid drug treatment (10 patients) or not (26 patients). Questionnaires, physical examination, thyroid ultrasound, and the measurement of serum TSH, FT4, FT3,TPOAb, and TRAb were conducted. All patients were followed up to postpartum, and their pregnancy and neonatal outcomes were recorded. Outcomes included miscarriage, gestational diabetes, gestational hypertension/preeclampsia, cesarean section, preterm delivery, low birth weight, and small-for-gestational-age neonates. Compared with the control group, GTT group had significantly higher prevalence of gestational diabetes [OR=2.88 (1.14-7.29), p < 0.05], however, the prevalences other neonatal or gestational complication in GTT group were similar to that in control group (p > 0.05). The incidence of the premature birth [OR=5.58 (2.00-15.60)], gestational hypertension [OR=5.05 (1.20-21.21)], gestational diabetes [OR=4.45 (1.28-15.50)], low birth weight [OR=5.92 (1.36-25.66)] and cesarean section [OR=7.58 (1.19-48.18)] was found to be distinctly higher in GD group without treatment compared to that in the control group ( all p < 0.05). Pregnancy outcomes in GD treatment group had no obvious statistical difference with those in the control group, although the TSH and FT4level in GD patients either with or without treatment were equal during the second and the third trimester. The prevalence of miscarriage, premature delivery,gestational hypertension, low birth weight and placental abruption was significantly higher in the group of TRAb positive pregnant women than that in TRAb negative group (p < 0.05). We concluded that in early pregnancy, either GTT or GD will have negative effect on pregnancy outcomes. It is very necessary to strengthen the management of gestational hyperthyroidism in early pregnancy.

 

Nothing to Disclose: YL, YX, CL, ZS, WT

16551 14.0000 SUN-0014 A Effects of Thyrotoxicosis in Early Pregnancy on Gestational Complications and Neonatal Outcomes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Kerri Ann Kissell*1, Enrique Schisterman1, Beom Seuk Hwang2, Zhen Seuk Chen2, Neil Perkins1, Jean Wactawski-Wende3 and Sunni Mumford4
1NIH/NICHD, Bethesda, MD, 2NICHD, Bethesda, 3University at Buffalo, SUNY, Buffalo, NY, 4Eunice Kennedy Shirver National Institute of Child Health and Human Development, Rockville, MD

 

Background/Objectives: While established as a marker of ovarian quantity, it remains less certain whether anti-Mullerian hormone (AMH) designates ovarian quality. Several studies have linked AMH level with aneuploidy rate and miscarriage in patients seeking infertility evaluations; however there is a lack of studies evaluating an association between maternal serum AMH and history of pregnancy outcomes in healthy women not seeking reproductive management.

Subjects/Methods: This was a subset analysis of the prospective BioCycle Study involving 78 women aged 18-44 years with history of gravidity and absence of diagnosed reproductive impairment. Pregnancy outcomes were obtained by questionnaire at baseline screening. Serum was taken at up to 8 time points throughout up to 2 menstrual cycles. Stored samples were later analyzed using Generation II enzyme linked immunoassay. Linear mixed models were used to evaluate associations across menstrual cycles (≤ 16 measurements) and adjusted for age and parity.

Results: Among women with history of gravidity, geometric mean maternal serum AMH was marginally higher in women with history of adverse pregnancy outcome (n=13), including spontaneous abortion and stillbirths, compared to women with healthy outcomes (1.56 ng/dL [95% CI: 0.90-2.71] vs 0.87 ng/dL [95% CI: 0.68-1.12] p=0.0616).

Conclusion: In a cohort of women without previously recognized pathology impacting reproductive capacity, marginally higher maternal serum AMH levels were found in those with a history of adverse pregnancy outcomes. Further study is required to determine if AMH may also serve as a marker of ovarian quality.

 

Nothing to Disclose: KAK, ES, BSH, ZSC, NP, JW, SM

16778 15.0000 SUN-0015 A History of Adverse Pregnancy Outcomes and Maternal Serum Anti-Mullerian Hormone Levels 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Allison Macbeth*1, G. William Mercer2 and Jerilynn C Prior3
1Centre for Menstrual Cycle and Ovulation Research, Vancouver, BC, Canada, 2Centre for Menstrual Cycle and Ovulation Research, Vancouver, BC, Canada, 3University of British Columbia, Vancouver, BC, Canada

 

Women experience midcycle peaks in estradiol and testosterone around the LH peak prior to ovulation; women’s sexual interest is believe to increase related to these changes. However, not only are the data inconsistent, they are in small datasets without sufficient power to explore potentially related additional variables. We examined the temporal relationship between “interest in sex” and the midcycle within ovulatory cycles; we also studied sexual interest relationships with women’s other experiences within a prospective 1-year study in 66 initially ovulatory, normal weight, healthy premenopausal women1. Ovulation was documented by validated quantitative basal temperature (QBT)2;3. Healthy women (n=61), mean age 33.9 ±5.4 years, provided diary data; after excluding anovulatory cycles and women with major missing diary data, 749 cycles remained. Menstrual Cycle Diary©4 data included 20-items scored on a 5-point scale for an average of 353 days/participant. The resulting 19,048 daily records were analysed by a principal component factor analysis and orthogonal rotation. Results showed that factor extraction of an eigenvalue of 1.0 produced five factors accounting for 60% of the total variance. To observe temporal relationships between the midcycle and interest in sex, data were plotted centred on the day before the temperature rise (QBT-1), about +1.5 days after the midcycle LH peak2. The variable “interest in sex”, showed no important temporal pattern across the cycle. Five factors were also documented: 1) Negative mood5; 2) Menstruation; 3) Breasts and Fluid6; 4) Interest in Sex; and 5) Physical Discomforts (headache, constipation, sleep problems). Variables of “feelings of self-worth” and “feelings of energy” were loaded on the Interest in Sex factor. This factor was plotted oriented to QBT-1 and again there was no temporal pattern. However Interest in Sex factor did inversely correlate with Negative Mood factor (r=-.22); it was unrelated to other factors (r<±.13). These data suggest that, although hormonal events at midcycle likely increase ovulatory women’s sexual interest, psychosocial and situational variables are also important and need to be considered when women seek assistance for low sexual desire. References: 1Prior J NEJM 1990;323:1221; 2Clin Invest Med 1990;13:123; 3Bedford J Eur J Ob-Gyn Repro Biol 2009;146:76; 4Prior JC in Repro Endo Surg Technology 1996;1077; 5Harvey A J Psychosom Ob-gyn 2007;30; 6White CP Obstet Gyn Int 2011;138451.

 

Nothing to Disclose: AM, GWM, JCP

15180 16.0000 SUN-0016 A Women's Sexual Interest Not Temporally Related to Midcycle Hormones within Ovulatory Cycles—Relationship with Feelings of Self-Worth and Energy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Amy Denise Anderson*, Ruchi Bhabhra, Christine M. Burt Solorzano and Christopher R. McCartney
University of Virginia, Charlottesville, VA

 

Early puberty is marked by low daytime LH (GnRH) pulse frequency with overnight (sleep-associated) increases. Daytime pulse frequency increases across pubertal maturation, but nocturnal frequency remains similar. We have reported that, in early/mid-pubertal girls, exogenous progesterone (P) may acutely abolish daytime pulse frequency without influencing nocturnal frequency. Androgens antagonize P negative feedback at the GnRH pulse generator. We have suggested that low levels of P preferentially suppress daytime LH (GnRH) frequency in early puberty, with rising T allowing an increase in daytime frequency across puberty.

We are pursuing a study to assess whether daytime vs. nighttime LH frequency is acutely sensitive to P suppression in late pubertal (postmenarcheal) girls. Subjects undergo two 18-h admissions (1800-1200 h) for frequent blood sampling, each during a late follicular phase. Subjects are randomized to receive either P (0.8 mg/kg at 0700, 1500, 2300 and 0700 h) or placebo prior to and during the first admission, with alternate treatment given during a subsequent cycle (cross-over design). Lights are extinguished from 2300 to 0700 h. LH pulse frequency is assessed as interpulse intervals (IPI) during evening wake, sleep (first to last sleep as determined by actigraphy), and morning wake. Treatment-related differences in IPI (IPI with progesterone vs. IPI with placebo) were assessed by Wilcoxon signed-rank tests. Note: higher IPI denotes lower LH frequency and vice versa.

To date we have studied 6 postmenarcheal subjects without hyperandrogenemia: age 14.7 ± 1.0 y (mean ± SD); Tanner breast stage 4.3 ± 1.2; BMI-for-age percentile 89 ± 17; free T 11 ± 3 pmol/L. Average IPI was 39 ± 27% (mean ± SEM) higher with P during evening wake (p=0.16); 17 ± 20% higher with P during sleep (p=0.44); and 29 ± 16% higher with P during morning wake (p=0.09). Average wake (morning and evening) IPI was 33 ± 18% higher with P (p = 0.06). 5 of 6 subjects exhibited higher wake IPIs with P (vs. placebo); 3 of 6 subjects had higher sleep IPIs with P (vs. placebo).

Preliminary data suggest a trend toward decreased LH pulse frequency during waking hours with acute P administration, although subjects exhibited variability in this regard. Continued study is required. P does not acutely abolish daytime pulse frequency in postmenarcheal girls, in contrast to available data in early/mid-puberty; this may reflect higher T levels in late puberty.

 

Nothing to Disclose: ADA, RB, CMB, CRM

16223 17.0000 SUN-0017 A Waking Vs. Sleep Associated LH Pulse Frequency Suppression in Response to Progesterone in Late Pubertal Girls 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Tomohiro Ishii*1, Ryuji Fukuzawa2, Takeshi Sato1, Koji Muroya3, Masanori Adachi3, Kenji Ihara4, Junko Igaki2, Yukihiro Hasegawa2, Seiji Sato5, Toshikatsu Mitsui1 and Tomonobu Hasegawa1
1School of Medicine, Keio University, Tokyo, Japan, 2Tokyo Metropolitan Children's Medical Center, Tokyo, Japan, 3Kanagawa Children's Medical Center, Yokohama, 4Graduate School of Medical Sciences, Kyushu University, Fukuoka, 5Saitama Municipal Hospital, Saitama, Japan

 

Context: Steroidogenic acute regulatory protein (StAR) transports cholesterol from the outer to the inner mitochondrial membrane, where it serves as a common precursor of adrenal or gonadal steroid hormones. Our previous study revealed the up-regulation of genes associated with inflammatory or immune response and macrophage infiltration in the adrenal cortex of knockout mice lacking StAR.

Objective: This study aimed at investigating macrophage infiltration in the gonads of individuals with congenital lipoid adrenal hyperplasia (lipoid CAH).

Patients and Methods: This study involved 7 patients with lipoid CAH who underwent gonadectomy: 2 female patients (22 and 40 years of age) and 5 male patients (0–1 years of age). Immunohistochemical analysis was performed to determine steroidogenic cells and macrophages by steroidogenic factor 1 and ionized calcium-binding adaptor molecule 1, respectively.

Results: Compared with the controls, the ovaries of lipoid CAH contained an increased number of macrophages that infiltrated clusters of lipoid and hyperplastic luteal cells or aggregated in the stroma. The number of macrophages in the testes did not differ between controls (95% confidence interval, 13.3–25.8 per 0.2 mm2) and patients (19.3–47.7) with lipoid CAH (p = 0.10).

Conclusions: These results demonstrate for the first time that macrophage infiltration is significantly enhanced in adult ovaries with lipoid and hyperplastic luteal cells, but not significantly increased in infant testes with lipoid and non-hyperplastic Leydig cells. These results imply the possible link between cholesterol accumulation and the inflammatory or immune response in steroidogenic tissues in cases of StAR deficiency.

 

Nothing to Disclose: TI, RF, TS, KM, MA, KI, JI, YH, SS, TM, TH

11473 18.0000 SUN-0018 A Ovarian Macrophage Infiltration in Adult Women with Congenital Lipoid Adrenal Hyperplasia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Selvarajan Ramkumar*1, Viveka Jyotsna2, Devasenathipathy Kandasamy3 and Aanchal Kakkar4
1AIIMS, chennai, India, 2All India Institute of Medical Sciences, New Delhi, India, 3AIIMS, New Delhi, India, 4AIIMS, new delhi, India

 

Background: Hyperandrogenism is commonly encountered in the reproductive age group. Hyperandrogenism occurring in a post-menopausal woman is rare. Virilising tumors are often suspected in this age group.

Objective: Our objective was to describe an uncommon benign cause of post-menopausal virilisation and bilateral ovarian mass

Case:65 years old postmenopausal woman presented to our Endocrine clinic with slowly progressive increase in terminal hair growth in face, chest, abdomen and back over 8 years. Her problems started 2 years after menopause. She also complained of hair loss but did not experience acne, voice change, galactorrhoea, abdominal pain, abdominal distension, vaginal bleeding, symptoms of raised intra-cranial tension, and change in appetite or weight. Ferriman-Galleway score was 12.  She was overweight with acanthosis nigricans and skin tags. There was mild temporal recession of hair. There was no clitoromegaly, hoarseness of voice, goiter, galactorrhoea, Cushingoid features or acromegaly.  Systemic examination was normal, no abdominal or pelvic mass was palpable.

Her hormonal profile showed: LH 29.9 (7.7-58.5 mIU/ml), FSH 60.3 (25.8 –134.8mIU/ml),  total testosterone 2.17 (0.029-0.408 ng/ml) and DHEAS 110 (33.6-249 µg/dl). Serum TSH, prolactin, Overnight dexamethasone suppression test, 17-OH progesterone and Insulin- like growth factor-1 were normal. Transvaginal ultrasonogram showed bilateral ovarian masses.  CT scan of abdomen and pelvis showed normal adrenals with bilateral ovarian masses. FDG-PET/CT scan did not show uptake in the bilateral ovarian masses. In the presence of normal DHEAS levels and normal appearing adrenals with bilateral solid mass lesions in both ovaries, virilizing ovarian tumor was considered. She underwent exploratory laparotomy and  bilateral salphingo-oophorectomy with hysterectomy. Her testosterone levels were normalized  to 0.161 ng/ml on 3rd post-operative day and 0.059ng/ml 7 days later.   Histological examination was suggestive of stromal leydig cell hyperplasia. Only one case of stromal leydig cell hyperplasia was reported before.

Conclusion: Stromal leydig cellhyperplasia is a benign entity which can present as bilateral ovarian masses with significant hyperandrogenemia in the postmenopausal women and should be considered in the differential diagnosis of postmenopausal hirsuitism. The differential diagnosis includes virilising ovarian tumors especially hilus cell tumors and fibroma-thecoma which present as slowly progressive hirsutism. The preoperative diagnosis is difficult. Surgical resection and histopathological examination is needed to confirm the diagnosis. Serum testosterone level normalized after bilateral oophorectomy in our case. To our knowledge, this is the second case report of postmenopausal hirsutism due to bilateral stromal leydig cell hyperplasia.

 

Nothing to Disclose: SR, VJ, DK, AK

11769 19.0000 SUN-0019 A Stromal Leydig Cell Hyperplasia Presenting As Virilising Ovarian Mass in Post-Menopausal Woman 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Ji Wei Yang*1, Barbara Duda2, Bi Lan Wo3, Marie-Josée Bédard3, Helene B Lavoie3 and Ariane Godbout4
1McGill University Health Center, Montreal, QC, Canada, 2Hopital du Sacre-Coeur de Montreal, Montreal, QC, Canada, 3Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada, 4Centre de recherche du Centre hospitalier de l’Université de Montréal (CR-CHUM), Montreal, QC, Canada

 

Introduction: The differential diagnosis of severe headache and sudden onset of endocrine dysfunction during pregnancy can be challenging. Rapid recognition and action are needed to ensure maternal and fetal well being. Clinical Case: A 30 year-old women presented at 30 weeks of gestation with a thunderclap headache, without visual or focal neurologic deficit. Blood pressure was transiently elevated (148/75 mmHg) but the workup for preeclampsia was negative. In hospital, the patient developed important polyuria (1L/hr) and hypernatremia (156 mmol/L). Initial CT scan of the head was negative for intracranial hemorrhage but showed an enlarged non-edematous pituitary gland. A lumbar puncture yielded CSF without xanthochromia. Subsequent MRI of the head revealed an enlarged pituitary gland measuring 16 mm with slight compression of the optic chiasm. Visual fields were normal however. Laboratory tests showed morning cortisol at 161 nmol/L (non pregnant range 119-618), TSH 2.94 mU/L (0.3-3.0), T3 3.4 pmol/L (3.5-6.0) and T4 13 pmol/L (10-23). Prolactin (83 ug/L) was normal for the 3rd trimester. Obstetrical history of this G3P2A0 woman was only significant for gestational diabetes mellitus requiring insulin therapy. There was no history of previous infertility or autoimmune disorders. The patient was initially treated with desmopressin, hydrocortisone and levothyroxine. Within 10 days, rapid regression of the pituitary enlargement was noted on MRI (11 mm) without signs of hemorrhage or ischemia. The concomitant findings of diabetes insipidus (DI), adrenal insufficiency and subclinical hypothyroidism as well as the absence of intracranial or pituitary hemorrhage led to the diagnosis of lymphocytic hypophysitis (LH). Remaining course of the pregnancy was marked by anti-C and anti-D alloimmunisations. At 38 weeks, a repeat cesarean C-section was planned due to alloimmunisation. The patient gave birth to a healthy baby girl weighing 3950g. At 3 weeks postpartum, the patient was breastfeeding normally and doing well under medication. At 6 months postpartum, hydrocortisone and desmopressin dosages were successfully reduced and further regression of pituitary enlargement was noted on MRI. Conclusion: Diagnosis of headache and hypopituitarism during pregnancy can be challenging since initial presentation can mimic conditions such as subarachnoid hemorrhage and pituitary apoplexy. LH is a rare autoimmune disease characterized by lymphocytic infiltration of the pituitary gland. To our knowledge, very few cases of LH with DI have been described in pregnancy or in the postpartum period (1-6). High clinical suspicion and proper hormone assessment are important to establish accurate diagnosis and treatment. A multidisciplinary approach involving endocrinologists and obstetricians can greatly reduce maternal and fetal morbidity resulting from pituitary dysfunction during pregnancy.

 

Nothing to Disclose: JWY, BD, BLW, MJB, HBL, AG

13449 20.0000 SUN-0020 A A Rare Case of Severe Headache and Sudden Onset Diabetes Insipidus during Pregnancy: Differential Diagnosis and Management 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Leyda Pennyna Callejas*1, Pamela Berens2 and Shahla Nader3
1University of Texas Health Science Center, Houston, TX, 2University of Texas Health Science Center, Houston, TX, 3University of Texas Health Science Center, Houston, TX

 

Introduction: The main role for prolactin (PRL) is in gestational breast growth and lactogenesis. PRL levels rise during pregnancy to values of 100-300 ng/ml in the 3rd trimester (TM). Its deficiency presents as failure to lactate. PRL deficiency can occur in association with deficiency of other pituitary hormones or in isolation. Only 7 cases of isolated PRL deficiency have been described, one with atrophic breasts. We present two cases of idiopathic isolated PRL deficiency, followed during pregnancy.

Case 1:  A 32 year old female presented for evaluation of irregular menses and desire for a 2nd child. Medical history was significant for self reported hypoplastic tubular breasts, supplemented by implants. Irregular cycles and acne lead to the diagnosis of PCOS. She took oral contraceptives, achieving pregnancy 2 months off the pill, on metformin.  Apart from lack of breast growth, pregnancy and delivery were normal. However, she reported lack of breast engorgement, impaired milk secretion, and inability to lactate.  On exam BMI 24, glandular breast tissue and implants were palpated bilaterally.  Her PRL level was 1.7 ng/ml (n 3-30 ng/ml), repeat level of 2.9 ng/ml and a normal TSH. She ovulated on clomiphene and became pregnant on a subsequent cycle while on metformin only.  A second TM PRL was 21.8 ng/ml and third TM PRL was 119.6 ng/ml.

Case 2: A 24 year old female without a significant medical history was seen for evaluation of amenorrhea. Menarche was at age 16 followed by infrequent menses. On exam BMI 22.5, with normal breast exam and mild hirsutism. Laboratory testing showed mildly elevated testosterone, high LH/ FSH ratio, consistent with PCOS. However her PRL was undetectable and on repeat testing was <0.1 ng/ml, with mildly elevated TSH and negative thyroid antibodies.  Further workup showed repeat normal TSH, normal free T4, growth hormone, cortisol, chemistry and another PRL of 1 ng/ml.  Patient was unsuccessful in achieving pregnancy despite follicular development with letrozole. In vitro fertilization resulted in singleton pregnancy. PRL was 3.6 ng/ml in first TM increasing to 8.7 ng/ml in second TM.  Repeat testing in third TM is pending.

Conclusions: Hypoprolactinemia is usually associated with other pituitary hormonal deficiencies. Etiologies include vascular, neoplastic, autoimmune, and infectious diseases. Only 7 cases of isolated PRL deficiency have been reported, one with abnormal breasts and one with a family history. We have identified 2 patients with PRL deficiency, followed during gestation. One had a low-normal PRL response to pregnancy and the second had minimal response. Lack of lactotroph hyperplasia during pregnancy may explain the blunted response in case 2. However, despite significant PRL response in case 1, she had abnormal breast development and experienced prior lactation difficulties. The relationship of low PRL and abnormal breast development remains largely unknown.

 

Nothing to Disclose: LPC, PB, SN

13504 21.0000 SUN-0021 A Idiopathic Isolated Prolactin Deficiency: Report of Two Cases Followed during Gestation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

David R. Saxon*1, Micol S. Rothman1, David W Russell2 and Jean D Wilson2
1University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, 2University of Texas Southwestern Medical Center, Dallas, TX

 

Background: Steroid 5α-reductase 2 deficiency results in dihydrotestosterone deficiency and the majority of patients have traditionally been raised as girls. Patient-initiated gender reassignment generally occurs around puberty or into the mid-twenties (1).

Clinical Case: A 45 y/o XY, gender-assigned female (s/p orchiectomy at age 8) with presumed partial androgen insensitivity syndrome presented to discuss transition to male gender. The patient reported having always identified as male, but had only recently decided to pursue gender transition. Initial tests performed included the following: total testosterone 23 (14-76 ng/dL, female), 5-α-dihydrotestosterone (5-DHT) 13.3 (24-208 pg/mL), elevated gonadotrophins, estradiol <20, 17-OH progesterone 10, and DHEA-S 193 (32-240 ug/dL). Genetic testing of the AR gene to diagnose androgen insensitivity syndrome was negative thereby calling the initial diagnosis into question. To reevaluate the genetic defect at hand, blood samples were sent to the Department of Molecular Genetics at UT Southwestern Medical Center for further analysis. Results indicated that the patient is a compound heterozygote for steroid 5α-reductase 2 deficiency (i.e., SRD5A2gene mutations) and harbors one previously recognized mutation and one novel mutation. The missense mutation in exon 3 (Arginine171Serine or R171S) has been previously described in patients from Turkey, Sicily, Malta, Cyprus, and Mexico (2). This mutation reduces the affinity of the enzyme for NADPH cofactor and shortens the half-life of the protein. The novel mutation is a deletion mutation (480, delC by the Andersson et al. (3) nomenclature) in exon 2, which would effectively remove the carboxyl-terminal 103 amino acids from the 254-amino acid protein and thus render the enzyme inactive. Based on a corrected diagnosis of steroid 5-reductase 2 deficiency, testosterone therapy was initiated with Androgel 1.62%, two pumps daily. At close follow-up, total testosterone was 249 (240-950 ng/dL, males, by LC-TMS) and 5-DHT was 128 (24-208 pg/mL, by TMS); the patient reported mild signs of virilization (increase upper lip hair growth), increased sense of well being, and slightly increased libido.

Conclusion: This case demonstrates a novel steroid 5α-reductase 2 gene mutation and is also unique given the initial misdiagnosis and the patient’s late change in gender role behavior.

 

Nothing to Disclose: DRS, MSR, DWR, JDW

13508 22.0000 SUN-0022 A Middlesex in Clinic: A Novel Steroid 5α-Reductase 2 Gene Mutation in a Patient Desiring Gender Reassignment at an Uncharacteristically Late Age 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Tomomi Yokozawa*1, Ryoko Asano1, Tomomi Nakamura2, Makiko Koyama2, Yoshiaki Kanda2, Hideya Sakakibara2 and Fumiki Hirahara2
1Yokohama City University School of Medicine, Japan, 2Yokohama City University School of Medicine, Yokohama, Japan

 

Background: Steroid cell ovarian tumors, not otherwise specified, are extremely rare. Such tumors can produce steroids, especially testosterone, and may cause amenorrhea, oligoamenorrhea, or virilization. We report a case of steroid cell ovarian tumor, not otherwise specified, with symptoms of primary amenorrhea and virilization.

Clinical case: A 16-year-old Japanese girl was referred to our hospital with primary amenorrhea. Physical examination revealed hoarseness, acne, clitoromegaly with a width of 8 mm and hirsutism with a Ferriman & Gallwey hirsutism score of 22. She was classified as Tanner stage II for breast and V for pubic hair. Magnetic resonance imaging of the pelvis revealed a normal-sized uterus and a left ovarian tumor measuring 4×4 cm. Total serum testosterone, free serum testosterone, and DHEA-S were 270 ng/dL (n11–47 ng/dL), 3.3 pg/mL (n<2.7 pg/mL), and 380.8 µg/dL (n51–321 µg/dL), suggesting ovarian-derived hyperandrogenism. CA125, CA19-9, and AFP levels were within normal limits. LH, FSH, estradiol, and progesterone levels were 2.7 mIU/mL (n1.76–10.24 mIU/mL), 7.4 mIU/mL (n3.01–350 mIU/mL), 33.7 pg/mL (n20–350 pg/mL), and 1.8 ng/mL (n<0.92 ng/mL), respectively. Since we suspected an ovarian androgen-producing tumor as the cause of primary amenorrhea, laparoscopic left ovarian tumorectomy was performed. The left ovarian tumor was tan-brown in color, and stony hard. The diagnosis by postoperative histopathology was ‘steroid cell tumor, not otherwise specified’. One month after surgery, the patient’s serum total testosterone level decreased to the normal range and menarche occurred. Seven months after surgery, her Ferriman & Gallwey hirsutism score decreased to 4, and hoarseness and acne also improved.

Conclusion: Ovarian steroid cell tumors are a type of ovarian stromal tumor, which may cause menstrual disorders with virilization. Incidences of primary amenorrhea due to these tumors are rare because the average age of onset is 43 years. Elevated total serum testosterone is an important sign of an ovarian steroid cell tumor. It may be difficult to diagnose these tumors as they are usually unilateral and small, so that only slight enlargement of an ovary may be detected by imaging. Surgical removal of these tumors is essential and effective in improving symptoms. In cases of primary amenorrhea, it is important to check for ovarian tumors as a possible source of hyperandrogenism.

 

Nothing to Disclose: TY, RA, TN, MK, YK, HS, FH

13700 23.0000 SUN-0023 A Primary Amenorrhea Due to a Steroid Cell Ovarian Tumor, Not Otherwise Specified, in an Adolescent Girl: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Fernanda de Azevedo Correa*1, Paulo H M Bianchi2, Marcela M Franca1, Aline P Otto1, Rodrigo J M Rodrigues2, Dani Ejzenberg2, Paulo C Serafini2, Ivo J P Arnhold1, Berenice B Mendonca1 and Luciani R S Carvalho3
1Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo FMUSP, São Paulo, Brazil, 2Unidade de Reprodução Assistida e Infertilidade, Disciplina de Ginecologia da FMUSP, São Paulo, Brazil, 3University of São Paulo, Hospital das Clinicas, São Paulo, Brazil

 

Background: GH deficiency can lead to subfertility and hypopituitarism is frequently associated with infertility. We present here 4 patients with congenital combined pituitary hormone deficiencies (CPHD) who had successful pregnancies after adequate hormonal replacement therapy prior to ovarian stimulation (OS). Clinical Cases: The four patients presented at childhood with severe short stature and after combined pituitary stimulation tests GH, TSH, LH and FSH deficiencies were diagnosed in all patients, ACTH and ADH deficiencies were diagnosed in 2. The patients were treated for all deficiencies and GH replacement was reinstituted in adulthood in all of them. By the time they asked to be referred to the fertility clinic they were in hormone replacement therapy including GH (1.5 to 2.0 IU daily) and estradiol valerate (2 mg)+levonogestrel (0.25 mg). Prior to follicular stimulation GH doses were titrated monthly accordingly to IGF1 to achieve normal values (median ± 1DP), at this moment uterine volumes varied from 20.6 to 63.3 cm3. OS was performed with variable doses and duration of menotropin. Since multiple pregnancies in women with hypopituitarism are associated with a poor outcome, when OS resulted in monofollicular growth, patients were elected to timed intercourse (TI)/intrauterine insemination (IUI), and when it resulted in multifollicular growth, IVF and elective single embryo transfer (eSET) was performed. Outcomes: Patients 1 (25 yrs) had a successful first attempt of OS and IUI resulted in a single pregnancy with live birth. Patient 2 (27 yrs) needed two attempts of OS which resulted in a single pregnancy and live birth after TI. Patient 3 (26 yrs) underwent 3 attempts of OS and TI that did not result in pregnancy. In the forth OS attempt, the cycle was converted to IVF due to multifollicular growth, but no pregnancy was achieved after 3 eSETs. In the fifth attempt (IVF), 1200 IU of recombinant FSH were consumed, resulting in 3 embryos, 1 was transferred (fresh) and resulted in a single ongoing pregnancy. Patient 4 (35 yrs) had also tubal abnormalities and IVF and eSET were promptly indicated. The OS resulted in 3 embryos. The first attempt of eSET did not result in pregnancy. The second attempt (frozen-thawed embryo) resulted in a single ongoing pregnancy. Conclusion: Adequate hormonal replacement therapy, including GH, may be an important step prior to fertility treatments in women with congenital hypopituitarism.

 

Nothing to Disclose: FDAC, PHMB, MMF, APO, RJMR, DE, PCS, IJPA, BBM, LRSC

14059 24.0000 SUN-0024 A Successful Pregnancies after Adequate Hormonal Replacement Prior to Ovarian Stimulation in Four Patients with Congenital Hypopituitarism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Sarantis Livadas*1, Ioannis Androulakis2, Nicholas G Angelopoulos2, Fotis Papagiannopoulos3 and Aristides Lytras4
1Athens University Medical School, Athens, Greece, 2Division of Endocrinology, Metabolism and Diabetes, Evgenideion Hospital, Athens, Greece, 3NovoNordisk, Greece, 4Biomedical Research Foundation, Academy of Athens, Athens, Greece

 

Background: HAIR-AN syndrome, namely the coexistence of hirsutism, insulin resistance and acanthosis nigricans is a very rare syndrome and it is characterized from clinical and biochemical hyperandrogenism accompanied with severe insulin resistance, chronic anovulation and metabolic abnormalities. Literally, HAIR-AN represents an extreme case of polycystic ovary syndrome (PCOS). In everyday practice the management of HAIR-AN constitutes a therapeutic challenge with the available pharmaceutical agents. Specifically, the degree of insulin resistance cannot be significantly ameliorated with metformin administration, whereas oral contraceptives chronic administration is associated with worsening of metabolic profile. Liraglutide, a GLP-1 analogue has been introduced with great success in the management of type 2 diabetes. However, regarding PCOS there are only two reports showing a significant improvement of hormonal/metabolic profile in significantly obese women with the syndrome (1,2).

Clinical case:  The impact of Liraglutide on hormonal /metabolic profile and ovarian function was evaluated in four (4) women with HAIR-AN. In one case metformin was co administered with Liraglutide. The mean age of women participating in this study was 29±2.4 years, with a mean BMI 31±3.5kg/m2 and the mean period of administration was 15.25±2.5 months. All participants accepted treatment without complaints and a modest weight loss (92,8±13,7 vs. 89,25±12,2kg, p:ns) was observed. However, a statistical significant improvement regarding insulin levels (39,2±9,6 vs. 22,4±10,7µIU/mL), the degree of IR calculated with HOMA-IR index (8,3±2,6 vs. 5,1±2,8) and the pattern of menstrual cycle (60.8 vs. 10,3±1,5 cycles per year, p<0.001) for all comparisons). Regarding androgen levels a trend to lower testosterone, SHBG and free androgen index was disclosed, but did not reach statistical significance.   Furthermore, one woman became pregnant during Liraglutide treatment giving birth to a healthy child.

Conclusion: This is the first case demonstrating the efficacy of Liraglutide in the management of women with HAIR-AN.

 

Disclosure: FP: Employee, Novo Nordisk. Nothing to Disclose: SL, IA, NGA, AL

14097 25.0000 SUN-0025 A Liraglutide Administration Improves Metabolic Profile and Reproductive Features in Women with Hair-an Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Emiko Ushio*1, Yoshiaki Kanda1, Mikiko Sato1, Reiko Numazaki1, Etsuko Miyagi1, Hideya Sakakibara2 and Fumiki Hirahara1
1Yokohama City University School of Medicine, Yokohama, Japan, 2Yokohama City Univ Schl of Med, Yokohama, Kanagawa, Japan

 

Background: Benign metastasizing leiomyoma (BML) is a markedly rare disease that develops distant metastases such as lung metastasis from pathologically benign leiomyoma of the uterus. Although it has been reported that BML develops after leiomyomectomy of the uterus or simple hysterectomy for leiomyoma of the uterus and results in metastasis to a variety of organs, its pathogenesis remains to be elucidated.

Case: An intrapelvic mass was detected during a medical check-up in a 41-year-old women who had undergone myomectomy and abdominal total hysterectomy for leiomyoma of the uterus. Since preoperative examinations showed multiple bilateral lung nodular shadows suggestive of lung metastasis of a malignant tumor, she was referred to our department for further examinations. Imaging modalities showed a solid mass with a longer diameter of 6.5 cm in the pelvis with multiple nodular shadows 1 cm in diameter in bilateral lungs. An intrapelvic tumor of unknown origin (ovarian, retroperitoneal, or gastrointestinal tumors) with multiple lung metastases was diagnosed, and the patient underwent tumor resection for exploration of the primary lesion. The tumor was elastic, hard and movable with no tendency to invade the adjacent tissue. A cross section revealed a white expanding tumor, which resembled the appearance of leiomyoma of the uterus. Pathohistologically, tumor cells with acid-fast cytoplasm and short spindle-shaped nuclei were growing in bundles in an intricate manner, which resembled the pathological findings of the previously resected uterine tumor. Immunohistochemistry showed that the tumor was ER (+) and PgR (+). Pathological findings showed no malignancy and were consistent with those of leiomyoma. Based on all these findings, the intrapelvic tumor was diagnosed as retroperitoneal recurrence of leiomyoma of the uterus. There was no clinical finding suggestive of any other malignant tumors and the multiple lung metastases were suspected to originate from the intrapelvic mass. The patient received GnRHa therapy to suppress estrogen and the multiple lung metastatic lesions tended to decrease in size.

Conclusions: We report a case of BML that exhibited intrapelvic recurrence and multiple lung metastases after hysterectomy. As treatment, extraction of the lesion, bilateral adnexectomy, and hormone therapy (GnRHa and progesterone analogues) have previously been reported. In general, the disease progresses slowly and is often followed up without treatment, in particular, in postmenopausal cases. In the present case, bilateral adnexectomy may be considered. When an intrapelvic tumor and distant metastasis such as lung metastasis are suspected in females after hysterectomy, it is necessary to take into account the possibility of BML in addition to malignant tumors.

 

Nothing to Disclose: EU, YK, MS, RN, EM, HS, FH

14421 26.0000 SUN-0026 A Benign Metastasizing Leiomyoma with Intrapelvic Recurrence and Bilateral Lung Metastasis after Hysterectomy: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Genzo Iguchi*1, Ryusaku Matsumoto1, Hironori Bando1, Kentaro Suda1, Hitoshi Nishizawa1, Michiko Takahashi1, Hidenori Fukuoka1, Yasuo Imanishi2, Hironobu Sasano3 and Yutaka Takahashi1
1Kobe University Graduate School of Medicine, Kobe, Japan, 2Osaka City University Graduate School of Medicine, Osaka, Japan, 3Tohoku University Graduate School of Medicine, Sendai, Japan

 

Background: A rare type of ovarian tumor produces androgens and manifests virilizaion.  Fibroblast growth factor 23 (FGF23) plays an important role in phosphate metabolism and an ectopic production by mesenchymal tumors causes tumor-induced osteomalacia associated with severe hypophosphatemia. The other type of FGF23-producing tumor is extremely rare.

Clinical case: A 43-year-old premenopausal woman presented rapidly progressive alopecia, amenorrhea, hirsuitism, and virilization with elevated testosterone (T) levels (14.6 ng/mL, n<0.9 ) and hypophosphatemia (1.8 mg/dL, n; 2.6–4.5). Serum FGF23 level was elevated at 64.5 pg/mL (n<50). In the screening for androgen-producing tumor, 18F-FDG PET/CT revealed increased uptake in the right ovary. Abdominal MR imaging showed a 26-mm solid mass in the right ovary. The adrenal glands appeared normal.

After right ovariectomy, serum level of T and FGF23 rapidly decreased (0.8 ng/mL and 47.4 pg/m/L, respectively), hypophosphatemia improved (2.8mg/dL), amenorrhea resolved in a month and alopecia gradually improved. Histological analysis of the resected tumor exhibited a steroid cell tumor that was positive for inhibin. Immunohistochemical analysis revealed that the tumor cells were positive for enzymes for steroid synthesis including Scc, 3βHSD, c17, and 17βHSD5, which was compatible with androgen-producing tumor. In addition, many FGF23-positive tumor cells were also detected. These results indicate that the ovarian tumor produced both testosterone and FGF23. 

A few reports demonstrated that serum FGF23 levels were increased in patients with advanced ovarian cancer and FGF23 expression was detected in the cancer cells, although no patients exhibited hypophosphatemia (1), and genetic variants in the FGF pathway were associated with ovarian cancer risk and prognosis (2), suggesting that FGF may play a role in the progression of ovarian cancer.

Conclusion: We present the first case of androgen- and FGF23-producing ovarian tumor. FGF23 may play a role in the development of ovarian tumor.

 

Nothing to Disclose: GI, RM, HB, KS, HN, MT, HF, YI, HS, YT

14461 27.0000 SUN-0027 A A Case of Androgen- and Fibroblast Growth Factor 23-Producing Ovarian Tumor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Laura Torchen*1, Ryan Sisk2, Margrit Urbanek2 and Andrea Dunaif2
1Feinberg School of Medicine, Northwestern University, Chicago, IL, 2Northwestern University Feinberg School of Medicine, Chicago, IL

 

Rapid virilization accompanied by markedly elevated testosterone (T) levels (≥200 ng/dL) raises suspicion of an androgen-secreting neoplasm. The non-invasive diagnosis of such ovarian tumors can be difficult. Accordingly, surgical exploration of the ovaries may be necessary.

A 12-year-old Kuwaiti girl presented with 2 years of progressive virilization, extensive acanthosis nigricans and secondary amenorrhea. The parents were first cousins. She was nonobese, Tanner V, Ferriman and Gallwey score 36, with clitoromegaly and acromegaloid changes of the nose and hands. Labs: T (LC/MS/MS) 832 ng/dL (n< 40), 17-hydroxyprogesterone (17OHP) 767 ng/dL (<169) without increase with ACTH stimulation, DHEAS 130 ng/dL (<148), fasting insulin 217 µIU/mL (1.9-23), fasting glucose 84 mg/dL (<100) and post-challenge glucose 200 mg/dL (n<140). MRI and PET scanning of the abdomen and pelvis showed no masses.

Although the patient had features of type A syndrome of extreme insulin resistance, there was a concern about an androgen-secreting neoplasm. Whole-exome sequencing was performed (BGI, Philadelphia, PA) as part of an IRB-approved research protocol with appropriate informed consent. Sequencing data were assembled via the Illumina pipeline (San Diego, CA) and aligned to the reference sequence using the Burrows-Wheeler Aligner (BWA, Cambridge, UK). SNPs and insertion-deletions were detected by the Genome Analysis Toolkit (Broad Institute, Cambridge, MA). ANNOVAR (Biobase, Wolfenbüttel, DE) annotated variant results. The patient was homozygous for an insulin receptor gene mutation, Arg145Cys in exon 2, domain L1. This domain is critical for insulin binding. Both parents were heterozygous for this mutation consistent with autosomal recessive inheritance. The sequencing and bioinformatic analyses were completed within 60 days.

Due to her genetic diagnosis, exploratory surgery was avoided. Leuprolide acetate depot 15 mg IM monthly was begun. T decreased to 145 ng/mL after 1 mon. Oral ethinyl estradiol 20 μg-norethindrone acetate 1 mg and metformin XR 1500 mg were added. After an additional mon, T declined to 70 ng/dL with normalization of 17OHP (92 ng/dL). This case illustrates that whole-exome sequencing can be a valuable tool in the identification of mutations in patients with suspected genetic disorders. Sequencing costs are rapidly decreasing making it feasible to use this approach in the clinic.

 

Nothing to Disclose: LT, RS, MU, AD

15931 28.0000 SUN-0028 A Genetic Diagnosis Using Whole Exome Sequencing in a Patient with Extreme Insulin Resistance and Hyperandrogenemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

Paulo H M Bianchi*1, Gabriela R F C A Gouveia2, Sorahia Domenice3, Elaine M F Costa4, Regina M Martin3, Luciane C Carvalho3, Tatiana S Pelaes3, Rodrigo R Codarin5, Maria Beatriz S Faria5, Rossana P V Francisco5, Edmund Chada Baracat2, Paulo C Serafini1 and Berenice B Mendonca6
1Unidade de Reprodução Assistida e Infertilidade, Disciplina de Ginecologia da FMUSP, São Paulo, Brazil, 2Unidade de Reprodução Assistida e Infertilidade, Disciplina de Ginecologia da FMUSP, Sao Paulo, Brazil, 3Hospital das Clínicas, Disciplina de Endocrinologia e Metabologia, Laboratório de Hormônios e Genética Molecular/LIM42, FMUSP, SP, Brazil, Sao Paulo, Brazil, 4University of São Paulo, Sao Paulo, Brazil, 5Disciplina de Obstetrícia da FMUSP, Sao Paulo - SP, Brazil, 6Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular LIM/42, Disciplina de Endocrinologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

 

Background: CAH due to 17α-hydroxylase deficiency in 46,XX patients is characterized by absence of sexual maturation due to inadequate biosynthesis of ovarian androgens and estrogens. This abnormal endocrine milieu is associated with an ovulatory dysfunction and inadequate endometrial development for embryo implantation. Although primary embryonic development were previously achieved, no successful pregnancy have been reported. Case report: A 24 years old patient with primary amenorrhea, delayed puberty and hypertension, look for treatment and the diagnosis of 17α-hydroxylase deficiency due to a compound heterozygote mutation (p.W406R/P428L) in the CYP17 gene was established. Treatment with DEX 0.5 mg/ day and HRT with conjugated estrogens 0.625 mg/day was started. The patient had an unsuccessful IVF and a new IVF was attempted after pituitary down-regulation with leuprolide acetate (long GnRHa protocol). Ovarian stimulation (OS) was performed with daily doses of 112.5 IU of recombinant FSH. Ultrasonographic criteria for oocyte pick up were achieved on the 12th day of OS. Four mature oocytes were harvested, fertilized with a fresh sample of spermatozoa and the resulting embryos were cultured for five days. Two embryos reached the morula stage. Since serum P levels >1.5 ng/mL at the end of OS are associated with lower pregnancy rates, all embryos were cryopreserved.  The patient received 10.8 mg of triptorelin acetate to down-regulation of gonadotropins and reducion of P levels. Three months later, when serum P level was <1.0 ng/mL and endometrial preparation for embryo transfer was initiated, with daily administration of 6 mg of E2 valerate orally. When endometrial thickness reached 8 mm (18th day of treatment) with serum P of 0.5 ng/mL, 200 mg of micronized P was added vaginally 3 times a day. Five days later, the embryo were thawed and transferred to the uterus. Serum βhCG tested positive 12 days after embryo transfer and a single pregnancy was confirmed, 21 days after embryo transfer. During early pregnancy the patient was treated with DEX 0.35 mg, 6 mg of topic 17 beta estradiol and 2 mg of E2 valerate orally and maintaining estradiol levels around 200 pg/ml. Estradiol levels were monitored twice a week and when placenta begin to produce estradiol, at 8 weeks of gestation, the exogenous estradiol was withdrawn and E2 levels until delivery varied from 350 to 800 pg/mL and P levels were >60 ng/mL. At 30 weeks of gestational age, signs of fetal distress were identified in cardiotocography and cesarean section was performed; a true knot of the umbilical cord and meconium-stained amniotic fluid was found. The male newborn weighed 1945 g (adequate for gestational age), with Apgar scores: 7/10/10. Conclusion: Successful live birth was achieved in a female with 17-hydroxylase deficiency through IVF, cryopreservation of embryo and frozen–thawed embryo transfer after adequate endometrial preparation.

 

Nothing to Disclose: PHMB, GRFCAG, SD, EMFC, RMM, LCC, TSP, RRC, MBSF, RPVF, ECB, PCS, BBM

16007 29.0000 SUN-0029 A Successful Live Birth in a Female with 17-Hydroxylase Deficiency through IVF Frozen–Thawed Embryo Transfer after Adequate Endometrial Preparation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0001-0029 4859 1:00:00 PM Female Reproductive Endocrinology II Poster

David J Handelsman*1, Lam P Ly2 and Ken Sikaris3
1ANZAC Research Institute, Sydney NSW, Australia, 2ANZAC Research Institute, Sydney, NSW, Australia, 3Melbourne Pathology, Collingwood, Melbourne, Australia

 

Introduction:It has been suggested that evaluation of “free” (protein unbound) testosterone may be useful in clinical practice. However, laborious direct laboratory measurement is rarely available so various formulae to calculate “free” testosterone (cFT) have been proposed. Widely used equilibrium binding equations involve multiple assumptions and plug-in constants (including incorrect stoichiometry for testosterone binding to SHBG) and were validated in only small samples whereas the assumption-free empirical formulae have been developed and validated in two studies involving over 6000 samples.

Aim: To investigate the comparative performance of alternative cFT formulae in a large sample from a major commercial pathology laboratory.

Methods:Coded data from the results of 123,572 consecutive blood samples requesting serum testosterone in the clinical practice of a large commercial pathology laboratory over 7 years (2007-13) were provided for analysis of blood testosterone and SHBG (Roche E170) and albumin (Roche BCG) together with patient gender and age. cFT was calculated in 106,941 samples (86%) with complete data according to published equilibrium binding (Sodergard (FTS), Vermeulen (FTV)) and empirical (Nanjee-Wheeler(FTN), FTA, FTZ) equations together with modified FTS and FTV formulae using the correct SHBG binding stoichiometry (FTS2, FTV2, respectively), FTV adjusted for individual albumin concentrations (FTV+a) and free androgen index (FAI). All calculation were compared with the best validated (FTZ) by Lin’s concordance correlation coefficient (CCC, NCSS v9 software) with estimates of slope and intercept.

Results:There were more (50.5%) samples from female (n=62,441, mean age 36.3 (SD 13.2, range 0-97 years) than male (n=61,131, 53.3 (17), 0-99 years) patients. Compared with FTZ (CCC, slope, intercept), conventional equilibrium binding formulae [FTS (0.767, 1.73, -30.0), FTV (0.846, 1.51, -21.8)] and another empirical formula [FTN (0.9801, 1.64, -4.9) displayed non-linear deviation which were progressively greater at higher concentrations. These deviations were improved by correcting stoichiometry [FTS2 (0.893, 1.13, -28.2), FTV2 (0.919, 1.02, -21.9)] but not by including correction for albumin [FTV+a (0.863, 1.49, -22.9)]. FAI was very poorly correlated with FTZ (0.323, 0.27, -7.41).

Conclusions: Using this large sample of clinical data, we conclude that (a) all cFT  formulae consistently and progressively (with concentration) overestimate cFT relative to the assumption-free, laboratory-validated FTZ formula, (b) deviations are greater for equilibrium binding than the best empirical formulae and (c) correcting erroneous stoichiometry of equilibrium binding formulae improves their performance to closer approximate the best empirical formula, (d) albumin adjustment makes little difference and (e) FAI is unrelated to cFT.

 

Nothing to Disclose: DJH, LPL, KS

12234 1.0000 SUN-0047 A Large Sample Evaluation of the Performance of Free Testosterone Calculations: Impact of Correct SHBG Binding Stoichiometry and Albumin Adjustment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Laura Owen*1 and Brian G. Keevil2
1University Hospital of South Manchester, Manchester, United Kingdom, 2Univ Hospital of South Manchester, Manchester, United Kingdom

 

Introduction

The measurement of male androgens in most laboratories is often limited to testosterone alone. To more accurately determine the androgen status in men the measurement of other androgens such as DHT and DHEA would be beneficial however these are difficult to measure without derivatisation. We report a combined LC-MS/MS assay for the measurement of testosterone, androstenendione, DHT and DHEA on a small sample volume.

 Methods

Zinc sulphate (100 µL) was added to 100 µL of sample. After mixing, acetonitrile containing internal standards was added and was further mixed. The samples were centrifuged before analysis. Samples were extracted using an automated on-line solid phase extraction on a C18 cartridge by a Waters Acquity/OSM and analytes were measure using a Waters TQS tandem mass spectrometer.

 Results

Chromatographic separation was achieved between all four androgens. The run time was 6.2 minutes per sample. The lower limit of quantitation was 0.2 nmol/L for testosterone, 0.3 nmol/L for androstenedione, 0.17 nmol/L for DHT and 2 nmol/L for DHEA. The CV of the assay for testosterone and DHT was <6%, androstenedione was <9% and DHEA was <5% The testosterone and androstenedione gave the following comparisions with the routine LC-MS/MS assay: Testosterone (combined) = 1.01 x existing assay + 0.07 nmol/L and androstenedione (combined) = 1.09 x existing assay - 0.29 nmol/L.

 Discussion

We have developed a rapid assay for the LC-MS/MS measurement of testosterone, androstenedione, DHT and DHEA in a routine clinical laboratory. The assay requires a small volume of sample and all analytes are measured simultaneously without derivitisation achieved by using a high sensitivity mass spectrometer. The assay is rapid and simple to prepare and has the potential for routine clinical use or for the analysis of large numbers of samples involved in clinical trials.

 

Nothing to Disclose: LO, BGK

14446 2.0000 SUN-0048 A A Method for Combined Androgen Measurement 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Maram Alkhatib*1, Michael Scott Irwig2 and Nikki Duong3
1George Washington University, Washington, DC, 2George Washington Univ, Washington, DC, 3George Washington University, Washington

 

Background: Tropical infectious diseases have been associated with abnormalities in endocrine function tests in both animal and human studies.

Objective: We sought to compare common endocrine function tests in subjects with tropical infectious diseases and controls.

Methods: We performed a literature search and included cases-control studies in adults and adolescents published in the English language. Nineteen studies were included in the analysis and the majority pertained to 3 tropical infectious diseases: malaria, leishmaniasis, trypanosomiasis.

Results: In both males and females, total testosterone levels were consistently lower among cases than controls in malaria, leishmaniasis and trypanosomiasis in five studies. Levels of DHEA and DHEA-S were also lower among cases than controls in 2 studies confined to leishmaniasis. Levels of TSH, free T4, free T3, cortisol, ACTH and PTH showed inconsistencies among studies.

Limitations: Small numbers of studies, small sample sizes in the majority of studies, variability in hormone assays and poor study design

Conclusions: In evaluating patients who live or have traveled to countries with tropical infectious diseases, clinicians should be aware that abnormal endocrine function test results may reflect active infection with one of these diseases. The most consistent finding was lower total testosterone levels among both males and females in malaria, leishmaniasis and trypanosomiasis. Additional studies with larger sample sizes and standardization are needed.

 

Nothing to Disclose: MA, MSI, ND

15041 3.0000 SUN-0049 A Endocrine Lab Abnormalities in Tropical Infectious Diseases 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Bethany Ann Jackson*1 and Max E. Stachura2
1Georgia Regents University, Augusta, GA, 2Georgia Regents University

 

Introduction:

    An elevated total thyroxine or total testosterone level can reflect an underlying increase of thyroid binding globulin (TBG) or sex Hormone Binding Globulin (SHBG), rather than an increased level of either active hormone. It is unusual to find both binding globulin-driven total hormone elevations in the same patient.

Clinical Case:

    A 56 y/o male was referred by his primary provider to the Endocrine Clinic for evaluation and management of both elevated total testosterone 1511 ng/dL (348-1197) and total thyroxine (T4) 14.8 mcg/dL (4.5-12) levels discovered during an evaluation for fatigue and erectile dysfunction. When repeated his total testosterone was again elevated at 1590 ng/dL (240-950) with normal Lutenizing Hormone (LH) 8.31 mIU/mL (1.5-9.3) and Follicle Stimulating Hormone (FSH) 3.88 mIU/mL (1.4-18.1). His total T4 was 16.3 mcg/dL (4.5-12) with normal Thyroid Stimulating Hormone (TSH) 1.082 mcIU/mL (0.4-4.7).  The corresponding free hormone levels were normal with elevated levels of the corresponding binding globulins. Free T4 was 1.19 ng/dl (0.58-1.76) with a TBG of 410 mcg/mL (12-26); free testosterone measured by equilibrium dialysis was 11 ng/dl (9-30) with SHBG of 177 nmol/L (10-57). Elevated TBG can be associated with hepatitis, elevated estrogen levels, certain drugs, acute intermittent porphyria, or can be hereditary due to increased production of TBG. Elevated levels of SHBG have been associated with hepatitis, elevated estrogen levels, age, certain drugs, iron overload within the liver, and acute psychosocial stress. The patient was taking none of the known causative drugs and his estradiol level was within normal limits.  Despite normal liver function tests, a screen for Hepatitis C viral infection revealed an elevated antibody level. Gastroenterology referral is pending for further evaluation.

Conclusion:

    The mechanism by which hepatitis causes increased levels of TBG and SHBG is unclear and literature on the subject is limited. Clinicians should be aware of the association of hepatitis with elevated hormone binding globulin levels and the effects increased binding globulins may have on measurement of hormone levels.  Free hormone levels should be obtained when total hormone levels do not correlate with clinical findings.

 

Nothing to Disclose: BAJ, MES

11802 4.0000 SUN-0050 A Elevated Total Thyroxine and Total Testosterone, an Unusual Combination 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Michael Scott Irwig*
George Washington University, Washington, DC

 

Background:Recent postmarketing studies have found that finasteride 1 mg for male pattern hair loss has been associated with persistent sexual and non-sexual side effects. Finasteride is also known to alter androgen levels and semen parameters in healthy younger men.

Objective:To assess the serum levels of androgens (testosterone and dihydrotestosterone) and semen parameters in former users of finasteride who developed persistent sexual side effects.

Methods:Otherwise healthy former users of finasteride (n=24) with persistent sexual side effects for ≥3 months were administered standardized interviews. Subjects were asked to obtain two sets of morning androgen measurements (testosterone and dihydrotestosterone) and two semen analyses performed at least one month apart.

Results:The mean serum levels of total testosterone (542 ng/dL) and dihydrotestosterone (48 ng/dL) were similar to baseline androgen levels in other studies. Nonetheless, 3 out of 24 subjects (13%) had two confirmed low testosterone levels and 3 out of 23 subjects (13%) had two confirmed low dihydrotestosterone levels. As compared to a reference sample of unscreened men, the median semen volume (2.7 mL) and total motility (50%) were lower in our population. Three out of 19 subjects (16%) had severe oligospermia (< 5 million/mL) and 4 out of 9 (44%) had two low motility values.

Limitations:Retrospective study design, small sample size, recall bias

Conclusions: Although mean levels of androgens were similar to those in healthy men, a subset of men with persistent sexual side effects associated with finasteride had severe oligospermia and low levels of serum androgens. Further research is needed on additional subjects.

 

Nothing to Disclose: MSI

11432 5.0000 SUN-0051 A Androgen Levels and Semen Parameters Among Former Users of Finasteride with Persistent Sexual Side Effects 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Leen Antonio*1, Frederick C Wu2, Terence W. O'Neill2, Stephen R. Pye3, Emma L. Carter2, Joseph D. Finn3, Ilpo T. Huhtaniemi4, Gianni Forti5, Gyorgy Bartfai6, Felipe F Casanueva7, Krzysztof Kula8, Margus Punab9, Aleksander Giwercman10, Frank A. Claessens11, Brigitte Decallonne1 and Dirk M Vanderschueren1
1KULeuven, Leuven, Belgium, 2The University of Manchester, Manchester, United Kingdom, 3University of Manchester, Manchester, United Kingdom, 4Imperial College London, London, United Kingdom, 5University of Florence, Florence, Italy, 6Albert Szent-György Medical University, Szeged, Hungary, 7Universidad de Santiago de Compostela, Santiago de Compostela, Spain, 8Medical University of Łódź, Łódź, Poland, 9Tartu University Hospital, Tartu, Estonia, 10Malmo University Hospital, Malmo, Sweden, 11KU Leuven, Belgium

 

Background: Both low total testosterone (T) and sex hormone binding globulin (SHBG) have been associated with an increased risk for metabolic syndrome (MetS) in men. However, serum concentrations of T are strongly linked to SHBG levels, and both are decreased in MetS.  Whether the risk for MetS associated with low T is independent of SHBG, remains unclear. Furthermore, T is aromatised to estradiol (E2). The potential impact of variations in E2 on the risk for MetS has not been investigated.

Objective: To study the longitudinal association of T and E2 and the risk for MetS in a large European cohort of healthy middle aged and elderly men and to assess if this risk is independent of SHBG.

Methods: The European Male Ageing Study (EMAS) included 2736 community-dwelling men from 8 European countries, aged 40-79 years at baseline, followed-up for 4.3 years (range 2.95-5.7 years). MetS was defined using the ATP III criteria. Serum total T and E2 levels were measured by respectively liquid and gas chromatography/mass spectrometry. The association between baseline SHBG and sex steroids and the development of incident MetS at follow-up was assessed using logistic regression with adjustments made for age, study centre, smoking status, physical activity and general health. Results were expressed as standardised odds ratios (OR) with 95% confidence intervals (CI).

Results: In the EMAS cohort, 282 men developed MetS between baseline and follow up, while 1387 men did not satisfy criteria for MetS at either time point. Men with a higher level of SHBG or total T had a significantly lower risk of developing MetS (OR 0.59 (CI 0.49-0.70, p˂0.001) and 0.58 (CI 0.50-0.68, p˂0.001), respectively). Calculated free T showed similar findings to total T. E2 was not associated with incident MetS (OR 0.99, CI 0.86-1.13, p=0.867). However, the T/E2 ratio was strongly inversely associated with incident MetS (OR 0.55, CI 0.46-0.66, p˂0.001). The inverse association between MetS and SHBG became non-significant if T was added to the model (OR 0.80, CI 0.64-1.01, p=0.064), while the association with T persisted after addition of SHBG (OR 0.67, CI 0.55-0.83). The association between E2 and incident MetS remained non-significant after adjustment for SHBG (OR 1.14, CI 0.99-1.32, p=0.074), but became significant after adjustment for T (OR 1.40, CI 1.20-1.64, p˂0.001). The T/E2 ratio remained strongly inversely associated with incident MetS even after SHBG was added to the model (OR 0.62, CI 0.51-0.75, p˂0.001).

Conclusions: In men, low T, independently of SHBG and E2, predicts the development of MetS. A higher T/E2 ratio, reflecting lower aromatisation of T into E2, is linked with a reduced risk for MetS.

 

Disclosure: FCW: Speaker, Bayer Schering Pharma, Clinical Researcher, Eli Lilly & Company, Speaker, Besins Healthcare. Nothing to Disclose: LA, TWO, SRP, ELC, JDF, ITH, GF, GB, FFC, KK, MP, AG, FAC, BD, DMV

12458 6.0000 SUN-0052 A Low Serum Testosterone and Its Aromatisation into Estradiol Increases Risk for Metabolic Syndrome in Men Independent of SHBG 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Stephen J Winters*, Jyothi Gogineni, Marjan Karegar, Charles R Scoggins, Richard Baumgartner and Dushan T Ghooray
University of Louisville, Louisville, KY

 

Sex hormone binding globulin (SHBG) is a circulating glycoprotein produced by hepatocytes that transports testosterone and other steroids in the blood. SHBG levels are influenced by genetic, hormonal, metabolic, and nutritional factors.  Low levels of SHBG are associated with adiposity, insulin resistance, and fatty liver, and convey an increased risk for type 2 diabetes and cardiovascular disease.  Hyperinsulinemia and intrahepatic fat content have been proposed as possible determinants of SHBG expression but so far no studies of SHBG mRNA in human liver have been published.  The nuclear receptor hepatocyte nuclear factor-4α (HNF4α) stimulates multiple genes that function in lipid metabolism, and activates SHBG gene transcription.  We examined SHBG in serum, and SHBG and HNF4α mRNAs by qRT-PCR, fasting insulin levels, insulin resistance by HOMA-IR, and hepatic triglyceride concentrations in 55 subjects with cancer, ECOG performance status 0, who were undergoing partial hepatectomy as treatment for their disease. Patients were aged 39 to 82 yrs (61.8±11.2 yrs), and weighed 43.1 -130 kg (84.5±20.2 kg) with a BMI of 16 - 45 kg/m2 (28.9±6.5 kg/m2).  Nineteen patients had T2DM and 18 were diagnosed with dyslipidemia. There was a strong positive relationship between SHBG mRNA in liver and serum SHBG levels (R2 = 0.40, p < 0.001) with higher levels in women than men.  Moreover, the level of HNF4α mRNA was a strong predictor of SHBG mRNA (overall R2 = 0.30, p < 0.001).  Hepatic triglyceride concentrations varied 30-fold from 134 to 2679 mg/dL, and increased with increasing body weight, but not all obese persons had hepatic steatosis.  When subjects were divided into two groups based on low (134-412 mg/dL) or high (415-2679 mg/dL) hepatic triglyceride levels, subjects with high levels were more insulin resistant (p<0.01) based on HOMA-IR (3.31±0.51 vs 1.60 ± 0.28) and had a higher fasting blood glucose level (122±9.5 vs 99±2.8 mg/dL; p=0.02).  There were significant inverse curvilinear relationships between the hepatic triglyceride concentration and the levels of both serum SHBG (R2=0.16, p=0.02) and SHBG mRNA (R2=0.23, p=0.003). These associations did not differ by gender, and were independent of HNF4α, age, BMI, HOMA and the diagnosis of T2DM. There was a statistically significant curvilinear association between HNF4α and hepatic triglycerides in men (R2 = 0.23, p=0.04) but not women (R2=0.09, n.s.). Furthermore, SHBG and HNF4α expression levels were significantly inversely associated with insulin and HOMA in men (r’s > 0.05, p< 0.05) but not women.  There was no relationship between HbA1c (n=28) and hepatic triglycerides (R2=0.003) or SHBG mRNA (R2=0.01). Our findings reveal that SHBG gene expression is a major determinant of the level of SHBG in plasma, and support the notion that hepatic triglycerides are one factor that regulates circulating SHBG through a mechanism involving HNF4α and SHBG expression.

 

Nothing to Disclose: SJW, JG, MK, CRS, RB, DTG

12014 7.0000 SUN-0053 A SHBG Gene Expression in Human Liver and Hepatic Steatosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Esperanza Beatriz Berensztein*1, Tony M. Plant2, Paula Aliberti1, Maria Sonia Baquedano1, Roberto Ponzio3, Diego Chirico1, Marco A. Rivarola1 and Alicia Belgorosky1
1Garrahan Pediatric Hospital, Buenos Aires, Argentina, 2University of Pittsburgh Medical School and Magee-Womens Research Institute, Pittsburgh, PA, 3School of Medicine, University of Buenos Aires, Buenos Aires, Argentina

 

The role of estrogen (E) in primate testis development and function is poorly understood. The rhesus monkey is a good model for the human because, in contrast to rodents, this macaque has an extended period of testicular quiescence during prepuberty (PP).  In human testis (HT) and monkey testis (MT) we have found minimal expression of either androgen receptor (AR) or ERalpha (ERα) in Sertoli cells (SC) or germ cells (GC) during PP.  At puberty, marked upregulation of AR in SC and of ERα in GC has been reported in both monkey and human (1). High expression of ERbeta (ERβ) in HT during early PP  has been also reported (2), as well as that of two isoforms, ERβ1 and ERβ2, (the last without E binding function) (3). The present study examined using immunohistochemistry: 1) postnatal expression of ERβ in HT and MT, and 2) LH and FSH stimulation, either alone or in combination, on ERβ expression in juvenile MT. HT tissue was collected at necropsies or from biopsies of patients without endocrine or metabolic diseases. HT (n=23) was classified as: neonatal (age < 1 month [mo], n=4), infantile (1-7 mo, n=5), juvenile (1 year to puberty, n=8), pubertal (14 -15 years old, n=5) and adult (20 years-old, n=1).  MT was classified as: neonatal (age 1-2 d), infantile (4-5 mo), juvenile (14-19 mo), pubertal (38-51 mo) and adult (60 mo) (n=6 for each group). Juvenile MT (16-19 mo) that received vehicle (Veh), FSH, LH or LH+FSH for 11 days was also studied (n=4) (4). Positive nuclei for ERβ were counted, and percentage of positive cells (GC or SC) was calculated. In MT GC, ERβ expression was robust and similar at all ages (X±SD = 60±12.1% of GC), while in HT GC overall expression (X±SD=51.1±31.4% of GC) was similar to MT but increased with age (r=0.826, p=0.001). In both species, expression of ERβ was found mostly in spermatogonia and also in primary spermatocytes and  immature spermatids. ERβ expression in SC in MT (X±SD=24.2 ±21.2% of SC) and HT (X±SD=47.6±30.7% of SC) increased significantly with age (r=0.829, p=0.006) in SC of MT, as well as of HT (r= 0.40 p= 0.001 n=23). Under gonadotropin treatment, expression of ERβ showed no significant differences in GC (Veh=65.9, FSH=76.3, LH=74.9, FSH+LH=67.1% of GC) or in SC (Veh= 33, FSH= 26.7, LH= 14.2, FHS+LH=11.8% of SC). Our data demonstrate high ERβ expression in primate GC and SC further suggesting that these cells might be potential targets for E action, and indicate that expression of this receptor is gonadotropin independent.

 

 

Nothing to Disclose: EBB, TMP, PA, MSB, RP, DC, MAR, AB

13811 8.0000 SUN-0054 A A Comparative Study of Expression of Estrogen Receptor Beta in Testes of Rhesus Monkey and Man 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Jeanette Wahlberg*, Yvonne Lood, Elisabet Aardahl-Eriksson, Carolina Webe, Arne Eklund, Johan Ahlner and Bertil Ekman
Linköping University, Linköping, Sweden

 

In this study we investigated the relationships between total testosterone, calculated bioactive testosterone, salivary testosterone and urinary testosterone during treatment with intramuscular injections of 1000 mg testosterone undecanoate every 12th week for a year. Males with primary or secondary hypogonadism (n= 22), transsexuals with male identity (n=13), and for comparison a healthy control group of men (n= 32) were investigated. Total serum testosterone was analysed with the Roche Elecsys testosterone II assay, and bioactive testosterone was calculated using the law of mass action. Salivary testosterone was collected via Salivette tubes and measured with enzyme immunoassay on Tecan Freedom EVOlyzer. Urine testosterone was analysed with liquid chromatography–tandem mass spectrometry LC-MS/MS. Results are presented as mean ± SD. Reference values were calculated from the control group: serum testosterone <50 yrs. 20.1 + 4.8 nmol/l vs. >50 yrs. 13.9 + 3.1 nmol/l, salivary testosterone <50 yrs. 0.52 + 0.17 nmol/l vs. >50 yrs. 0.40 + 0.10 nmol/l, urine testosterone <50 years 11.1 ± 10.1 nmol/mmol creatinine vs. >50 years 7.4 ± 5.3 nmol/mmol creatinine. Through values were measured in all patients after four injections: serum testosterone: 16.1 ± 5.8 nmol/l vs. urine testosterone 14.8 ± 8.9 nmol/mmol creatinine. Both in patients and controls, salivary and urinary testosterone showed high correlations with serum testosterone. Salivary testosterone correlated even better with calculated free testosterone and the serum testosterone/SHBG ratio. Serum testosterone, salivary testosterone and urinary testosterone showed in general comparable kinetic pattern over time. However in several patients’ discrepancies between the serum testosterone levels and salivary and/ or urinary testosterone levels were found. In conclusion, both salivary and urinary testosterone seems to be additional tools to monitor long term testosterone replacement therapy and gives further information, especially if serum testosterone values are inappropriate high or low.

 

Nothing to Disclose: JW, YL, EA, CW, AE, JA, BE

16197 9.0000 SUN-0055 A Pharmacokinetics and Pharmacodynamics of Intramuscular Testosterone Undecanoate: Serum, Salivary and Urinary Levels of Testosterone in Transsexuals with Male Identity and in Men with Hypogonadism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Ronald S. Swerdloff*1 and Jonathan S. Jaffe2
1Harbor- Univ of California Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, 2Antares Pharma Inc., Ewing, NJ

 

Topical treatments for males with hypogonadism (HGM) result in physiologic testosterone (T) concentrations but require daily administration, dose titration, and carry risk of transfer to women and children, leading to abnormal development of male sexual characteristics. T for IM injection (IMT) does not carry this risk, but may be painful, inconvenient, and typically cannot be self-administered. IMT may also be associated with T level peaks and troughs leading to mood swings. The pharmacokinetic (PK) profile of subcutaneous T enanthate (TE) administered with the Jet-Injector™ (JT), a novel, pre-filled, self-administration system for T, were studied.  

Twenty adults (age 31-69) with HGM (T <300 mg/dL at two screening visits with documented clinical symptoms received 50 mg (n=10) or 100 mg (n=10) JT weekly for 6 weeks in clinic administered by a healthcare professional. Mean baseline T was 301 ng/dL for patients in the 50 mg group and 214 ng/dL in the 100 mg group. At week 1, both doses produced normal mean total T concentrations 24 h post-dose (433 ng/dL in the 50 mg group [range 197-821 ng/dL] and 545 ng/dL in the 100 mg group [range 388-833 ng/dL]). Pre- and post-dose T levels rose with successive doses and plateaued at week 5. At week 6, 24 h post-dose mean T was 421 ng/dL in the 50 mg group (range 263-640) and 1042 ng/dL in the 100 mg group (range 526-1420).  In the 50 mg group, T Cmin was generally unchanged. In the 100 mg group, T Cminincreased through week 5.

Steady state Cavg[0-168h] T levels at week 6 were higher in the 100 mg group vs. the 50 mg group (927 vs. 420 ng/dL; 2.21-fold higher). In the 50 mg group at week 6, Cmax was 624 ng/dL (range 388-825 ng/dL) and Tmax was 46.2 h; Cmin was 286 ng/dL (range 211-372 ng/dL). In the 100 mg dose at week 6, Cmax was 1427 ng/dL (range 662-2120 ng/dL) and Tmax was 33.9 h; Cmin was 584 ng/dL (range 236-860 ng/dL). Mean AUC(0-168h) at week 6 was 704.96 and 1556.94 ng*h/ml for the 50 and 100 mg doses, respectively. Serum estradiol and dihydrotesterone rose proportionately with T levels. JT injection took 3-4 seconds per patient and consistently provided the precise dose.

JT rapidly restored and maintained steady, physiologic Cavg[0-168h]  levels of T with attenuated peak to trough fluctuations relative to that seen with higher doses of TE administered on a 1-2 times per month schedule. This may be clinically important in avoiding treatment-related mood swings observed with IM TE. These PK data suggest that JT may represent an alternative to daily topical T that decreases risks associated with secondary exposure while delivering T replacement weekly via a self-administration option.

 

Disclosure: RSS: Ad Hoc Consultant, Antares Pharma Inc.. JSJ: Employee, Antares Pharma Inc..

14028 10.0000 SUN-0056 A Pharmacokinetic Profile of 50 Mg and 100 Mg Doses of Subcutaneous Testosterone Enanthate Administered with the Novel Jet-InjectorTM 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Gurmeet KS Singh*1, Leo Turner2, Reena Desai1, Mark Jimenez1 and David J Handelsman1
1ANZAC Research Institute, Sydney NSW, Australia, 2Concord Hospital, Sydney NSW, Australia

 

Introduction: Testosterone (T) and nandrolone (N) esters in an oil vehicle usually require deep intramuscular injections by skilled medical personnel. As intramuscular injections often deposit injectate into subdermal fat, more convenient self-administered subcutaneous injections of androgen esters may be feasible.

Aim: To investigate the (a) pharmacokinetics and pharmacodynamics of subcutaneous injection of N decanoate (ND) in healthy volunteer men using DBS for time intensive blood sampling without frequent clinic visits and (b) feasibility of subcutaneous injections of androgen ester in an oil vehicle.

Methods: Healthy eugonadal men (n=8, age 31 ± 10 (SD) year, height 175 ± 7 cm, weight 80.7 ± 0.8 kg, BMI 26.3 ± 3.0 kg/m2) were administered 100 mg ND in 2 mL arachis oil vehicle (MSD, Australia) by subcutaneous injection into a single abdominal site. Capillary blood obtained by finger prick was dried onto filter paper, recording the exact sampling time, before and daily for 21 days. Venous blood was sampled before and at weekly intervals to also store serum and spot onto filter paper. After storage at room temperature, DBS were eluted and extracted for assay of N and T by LC-MS/MS (tandem triple quadrupole API5000) in a single batch run. Serum N and T concentrations were estimated with adjustment for capillary blood sample volume and hematocrit to define peak (N) or nadir (T) time and concentration from the individual daily measurements.

Results: From the daily measurements, serum N rose to a peak concentration of 2.50 ± 0.25 (SEM) ng/mL at a median (range) of 6 (4-13) days causing a reduction in serum T from 3.50 ± 0.57 ng/mL at baseline to a nadir of 0.38 ± 0.13 (SEM) ng/mL representing 89 ± 3% maximal suppression at a median (range) of 8 (5-16 hr). In simultaneously sampled capillary and venous blood, there was a high correlation with serum N (Passing-Bablok r=0.956 & 0.964, respectively) as well as for serum T (r=0.948 & 0.992) respectively. There were no complaints of discomfort following the injections.

Conclusions: This study demonstrates that (a) DBS sampling coupled with LC-MS steroid assays can achieve intensive time sampling for PK/PD studies in the community without requiring clinic visits, venesection or frozen serum storage and (b) androgen esters in an oil vehicle can be delivered effectively by subcutaneous injection avoiding the need for medically supervised deep intramuscular injections.

 

Nothing to Disclose: GKS, LT, RD, MJ, DJH

12227 11.0000 SUN-0057 A Pharmacokinetic-Pharmacodynamic Study of Subcutaneous Injection of Nandrolone Decanoate in an Oil Vehicle Using Dried Blood Spots (DBS) Blood Sampling Coupled with Ultra High Pressure Liquid Chromatography, Tandem Mass Spectrometry (LC-MS) Assays 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Kerri L Melehan*1, Camilla M Hoyos1, Garun S Hamilton2, Keith K Wong3, Brendon J Yee3, Robert I McLachlan4, Ronald R Grunstein1 and Peter Y Liu5
1Woolcock Institute of Medical Research, Sydney, Australia, 2Monash Medical Centre, Melbourne, Australia, 3Royal Prince Alfred Hospital, Sydney, Australia, 4Monash Medical Centre, Clayton, Australia, 5Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA

 

Introduction:  Erectile Dysfunction (ED) and reduced libido are reported to be common in men with Obstructive Sleep Apnea (OSA), possibly due to endothelial dysfunction and impaired hypothalmo-pituitary testicular regulation, respectively. Continuous positive airway pressure (CPAP) and phosphodiesterase type 5 (PDE-5) inhibitors are first line therapies for OSA and ED, respectively.  No randomized sham-controlled study has tested the efficacy of CPAP in improving sexual function or the effects of PDE-5 inhibitors on sleep disordered breathing in men with OSA and ED.

Methods: 61 men with at least moderate OSA (apnea hypopnea index>20) and ED (IIEF-ED<26) were randomized to 12 weeks of CPAP or Sham CPAP, as well as 10mg daily Vardenafil or placebo in a 2-by-2 factorial design study. Erectile and sexual function, and quality of life, were assessed by questionnaires including International Index of Erectile Function (IIEF), Self-Esteem & Relationship Scale (SERS), SF-36 and Functional Outcomes of Sleep Questionnaire. Sleep related erections (SRE’s) were measured using nocturnal penile tumescence monitoring. Overnight blood sampling every 10 minutes for 8 hours, followed by mathematical deconvolution, assessed pulsatile luteinizing hormone and testosterone secretion.

Results: 55 men completed the trial (age=54.1±9.2years, BMI=32.8±4.9kg/m2, serum testosterone levels=10.1±3.7nmol/L.  CPAP eliminated OSA and improved overall sexual satisfaction (p=0.04).  CPAP increased the number of SRE’s (p<0.01) and improved quality of life domains of vigilance (p=0.01) and vitality (p=0.03). Improvements in erectile function (p=0.04) and sexual desire (p=0.03) were seen but only in those adherent (>4 hour use/night) to CPAP compared to sham. These adherent participants also improved in the domains of self-esteem, sleepiness, social function, mental health and had reductions in depression and stress (all p<0.05).  Vardenafil improved SRE quality, self-esteem and relationship satisfaction and reduced distress due to sexual dysfunction (all p<0.05). Vardenafil did not worsen OSA in those who were allocated to sham CPAP. Overnight pulsatile hormone secretion is being calculated in a subset of men assessed at baseline and after 3 months.

Conclusion:  CPAP improves traditional quality of life measurements, and also sexual satisfaction and function, particularly in those with OSA who are adherent to CPAP.  Daily 10mg vardenafil did not worsen OSA and improved social function and mood in relation to sexual function. Hormonal mechanisms and changes in endothelial function may be responsible.

 

Disclosure: RIM: Advisory Group Member, Eli Lilly & Company. Nothing to Disclose: KLM, CMH, GSH, KKW, BJY, RRG, PYL

12889 12.0000 SUN-0058 A Adherent CPAP Improves Erectile and Sexual Function and Quality of Life in Men with OSA and Erectile Dysfunction (ED): A Randomised Sham Controlled Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Nagendar Jakka* and Ramesh Jayanthy
osmania general hospital, hyderabad, India

 

Premature ejaculation (PE)  is a common form of sexual dysfunction (SD) in diabetic males.We did a cross sectional study to know the various factors  associated with PE in men with Type 2  diabetes mellitus (DM). 60 consecutive male type 2 diabetic patients aged 30 to 60 years, who attended endocrinology department were included in the study.These subjects were compared with 38  BMI matched diabetic males without PE . PE was diagnosed with history, clinical examination and premature ejaculation diagnostic tool (PEDT). Anxiety was assessed with Generalized Anxiety Disorder 7-item (GAD-7) scale.

Prevalence of  PE was 36.66 % ( n=22). Anxiety (1.364 ± 0.105 vs. 1.100 ± 0.069 ; P= 0.046 ) was associated with PE. The mean age  (47.727  ± 1.546  vs. 49.350 ± 1.705 years; P= 0.484 ), duration of  DM (4.083 ± 0.832 vs. 3.999 ± 0.731 years ; P= 0.940 ), HbA1c (9.586  ± 0.450 vs. 8.630 ± 0.380 % ; P=0.116 ), peripheral neuropathy (1.636 ± 0.105 vs. 1.700 ± 0.105 ; P=0.671),autonomic neuropathy (1.364 ± 0.105 vs. 1.250  ± 0.099 ; P=0.439 ), serum testosterone level (345.450  ± 31.403  vs. 350.577 ± 34.066 ng/dl ; P=0.912 ) and luteinizing hormone (LH) level (5.272 ± 0.490 vs. 6.702 ± 0.863 IU/L; P= 0.148 ) were not statistically significant in patients  of diabetics  with PE.

We conclude  that anxiety is the most significant factor associated with PE in diabetic males. However, the metabolic ,hormonal and complication status of patient  did not correlate with PE .

 

Nothing to Disclose: NJ, RJ

16063 13.0000 SUN-0059 A Premature Ejaculation in Type 2 Diabetic Males – Focus on the Contributing Factors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

George Mskhalaya*1, Elena Zakharova1, Victoria Zaletova1, Elena Kasatonova2, Yaroslav Melnik2 and Evgeniy Efremov2
1Center for Reproductive Medicine MAMA, Moscow, Russia, 2Research Institute for Urology, Moscow, Russia

 

Primary spermatogenic failure has different aetiologies and is a common cause of severe oligozoospermia and non-obstructive azoospermia (NOA).  In case of NOA different sperm retrieval techniques are applied. Microdissection testicular sperm extraction (micro-TESE) is considered to give the biggest sperm retrieval rate. But the question is whether testicular sperm retrieved by micro-TESE can provide necessary fertilization and pregnancy rate.

Materials and methods: 81 men with NOA due to primary spermatogenic failure were included in the study.  All patients underwent hormonal analysis (serum FSH, inhibin B, Testosterone and LH levels) and genetic analyses including; AZF deletions and karyotype. Testicular sperm extraction and oocyte retrieval were performed simultaneously. Data is presented as a median and quartile range.

Results: Median age of the patients was 31 years [27; 36]. Most of the patients had elevated FSH level - 12.8 [6.13;19.73] IU/l, low inhibin B level - 47.6 [11.1;101.1] pg/ml, normal LH 6.12 [3.75; 8.34] IU/l and testosterone 13.95 [11.6; 18.34] nmol/l levels. Normal FSH levels in part of the patients with NOA can be explained by the presence of maturation arrest at the spermatocyte or spermatid level, but normal number pf spermatogonia. Sperm retrieval rate (SRR) was 37%, fertilization rate 67%, pregnancy rate (PR) – 39%.

Conclusion: Micro-TESE in patients with NOA is characterized by high SRR. Testicular sperm, retrieved by micro-TESE can provide PR that can be compared to PR when using semen spermatozoa.

 

Nothing to Disclose: GM, EZ, VZ, EK, YM, EE

15764 14.0000 SUN-0060 A Micro-Tese Technique in Patients with Azoospermia Due to Primary Spermatogenic Failure: Sperm Retrieval, Fertilization and Pregnancy Rate 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Mara Yvonne Roth*1, Grace Shih1, Niloufar Ilani2, Christina Wang3, Stephanie T. Page4, William J Bremner1, Ronald S. Swerdloff5, Regine Sitruk-Ware6, Diana Lynn Blithe7 and John K. Amory1
1University of Washington, Seattle, WA, 2Harbor - UCLA Med Ctr and Los Angeles Biomedical Research Institute, Torrance, CA, 3Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, 4University of Washington and Harborview Medical Center, Seattle, WA, 5Harbor- Univ of California Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, 6The Population Council, New York, NY, 7National Institute of Child Health and Human Development, Bethesda, MD

 

Unintended pregnancies account for 50% of pregnancies in the United States despite the numerous contraceptive methods available to women.  The only contraceptive methods available to men are vasectomy and condoms, used by 10% and 16% of couples respectively (1).  While prior studies have shown efficacy of male hormonal contraceptives in development, few have evaluated patient acceptability and potential use if commercially available.

A 6-month randomized controlled trial of T gel plus Nestorone gel (NES), a potent non-androgenic progestin, was performed at two academic medical centers, University of Washington, Seattle, WA, and Harbor-UCLA Medical Center, Torrance, CA (2).  As part of this study, a previously published questionnaire was administered to subjects to assess the acceptability and likelihood of using the transdermal gel-based contraceptive regimen (3).   A total of 99 men were randomized to one of three treatment arms with equivalent doses of 10gm 1% T gel daily to skin, and either a placebo gel or 2 different doses of NES gel: 8mg daily or 12mg daily to skin.  Seventy-nine men completed the acceptability questionnaire, including 17 men who dropped-out early from the drug treatment phase. 

Overall, 58% of men enrolled in this study were satisfied or very satisfied with this gel-based method of contraception.  A majority reported they would recommend this method to others, and 34% of subjects reported they would use this as their primary method of contraception if it were commercially available.

A majority of men were satisfied with this transdermal male hormonal contraceptive and would use this method of contraception if commercially available.  This method of male contraception could provide an easily reversible, effective method of contraception that is appealing to a greater proportion of men than use other currently available methods of male contraception.  Future studies will combine the active hormones into a single gel applied daily and may further improve overall acceptability.

 

Disclosure: CW: Investigator, Clarus, Speaker, Lilly USA, LLC, Investigator, Besins Health Care, Investigator, Lipocine. WJB: Consultant, Repros Pharmaceuticals. RSS: Investigator, Clarus, Investigator, Novartis Pharmaceuticals. JKA: Investigator, Clarus. Nothing to Disclose: MYR, GS, NI, STP, RS, DLB

11829 15.0000 SUN-0061 A High Acceptability of a Combination of Nestorone® and Testosterone Gels for Male Hormonal Contraception in a Randomized Controlled Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Laura Torchen*1, Ajay Kumar2, Bhanu Kalra2, Gopal Savjani2, Ryan Sisk3, Richard S Legro4 and Andrea Dunaif3
1Feinberg School of Medicine, Northwestern University, Chicago, IL, 2Ansh Labs, Webster, TX, 3Northwestern University Feinberg School of Medicine, Chicago, IL, 4Penn State University, Hershey, PA

 

PCOS is a highly heritable complex genetic disease. Male as well as female first-degree relatives (FDRs) have reproductive phenotypes characteristic of the syndrome. Elevated AMH levels suggestive of altered Sertoli cell function were found in the sons of women with PCOS during infancy and childhood, but not in adulthood. Further, adult male prenatally androgenized sheep have reduced sperm counts and germ cell number consistent with abnormal Sertoli cell function. These findings suggest that intrauterine androgen excess could program changes in testicular function in male PCOS FDRs. We performed this study to test the hypothesis that Sertoli cell function is altered in adult male PCOS FDRs.

Early morning T, LH, AMH and Inhibin B levels were measured in 64 PCOS fathers (PCOS-F) and 38 control men (CON-F) 40-60 yo, and in 77 PCOS brothers (PCOS-B) and 90 control men (CON-B) 20-50 yo. The PCOS probands were diagnosed by NIH criteria. Data from PCOS-B within the same family were averaged to yield one mean value per family, resulting in 60 PCOS-B family units. Two-tailed t-tests or nonparametric tests were applied, as appropriate, for 2 group comparisons. ANCOVA adjusted for age was used for PCOS-F comparisons when the endpoint was significantly correlated with age.

PCOS-F were older than CON-F (53±4 [SD] PCOS-F v 49±5 CON-F y, P<0.0001) but BMI (P=0.09) did not differ. Neither age nor BMI differed in PCOS-B and CON-B. AMH levels were significantly higher in PCOS-F (4.99±3.92 PCOS-F v 3.49±2.42 CON-F ng/mL, P=0.04 by ANCOVA) and in PCOS-B (9.18±5.88 PCOS-B v 6.99±5.60 CON-B ng/mL, P=0.02). LH levels were increased in PCOS-F (5.3±3.7 PCOS-F v 3.3±1.2 CON-F ng/mL, P=0.0009) and in PCOS-B (4.4±1.6 PCOS-B v 4.2±4.4 CON-B ng/mL, P=0.001). There was no correlation between LH and age in the PCOS-F. Inhibin B, FSH, and T did not differ in male FDRs and their respective controls.

Increased AMH levels suggest male PCOS FDRs have altered Sertoli cell function. Inhibin B levels, another marker of Sertoli cell function, did not differ in male FDRs. Intratesticular T levels are a major regulator of Sertoli cell AMH production, however, there was no evidence for alterations in T production or action in male PCOS FDRs. Elevated LH levels in male FDRs may reflect altered regulation of gonadotropin secretion as is seen in women with PCOS. These changes could result from intrauterine programming or from PCOS susceptibility genes.

 

Disclosure: RSL: Speaker, Ferring Pharmaceuticals. Nothing to Disclose: LT, AK, BK, GS, RS, AD

13112 16.0000 SUN-0062 A Brothers and Fathers of Women with PCOS Have Altered Testicular Function 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Alex J. Polotsky*1, Amanda Ashleigh Allshouse2, Peter Raymond Casson3, Christos Coutifaris4, Michael P Diamond5, Gregory M Christman6, William D Schlaff7, Ruben Alvero1, JC Trussell8, Stephen A Krawetz9, Nanette Santoro1, Esther Eisenberg10, Heping Zhang11, Richard S Legro12 and Reproductive Medicine Network (RMN)13
1University of Colorado-Denver, Aurora, CO, 2University of Colorado-Anschutz Medical Campus, Aurora, CO, 3University of Vermont, Burlington, VT, 4Hosp of Univ of PA, Philadelphia, PA, 5Georgia Regents University, Augusta, GA, 6Shands Hospital, University of Florida, Gainesville, FL, 7Jefferson University, Philadelphia, PA, 8SUNY Upstate Medical University,, Syracuse, NY, 9Wayne State Univ Sch of Medici, Detroit, MI, 10Vanderbilt Univ Med Ctr, Nashville, TN, 11Yale University, New Haven, CT, 12Penn State University, Hershey, PA, 13NIH/NICHD

 

Obese men with normal semen parameters exhibit diminished fertility in both natural and assisted conception but little prospective data is available.

Objective: To determine the impact of male phenotype and body mass on the chance of pregnancy and live birth among the Pregnancy in Polycystic Ovary Syndrome II (PPCOS II) participants (1,2).

Methods: This is a secondary analysis of a randomized clinical trial. 750 women with polycystic ovary syndrome (PCOS) were randomized to ovulation induction with either letrozole or clomiphene citrate (mean BMI of 35.1 kg/m2).  PCOS was defined by Rotterdam Criteria.  Females were 18-39 years old, had at least 1 patent fallopian tube and normal uterine cavity and a male partner with sperm concentration of at least 14 million/mL who consented to regular intercourse.  Couples were followed up to 5 treatment cycles to determine ovulation and pregnancy.  International index of erectile function (IIEF) was obtained to assess sexual activity.  Analysis was limited to subjects for whom complete male partner information was available (n=710).  Logistic regression was conducted with live birth as the outcome with adjustment for age, BMI, and smoking of each partner as well as sperm concentration and intercourse frequency.

Results: 245 couples achieved pregnancy (34.5%) and 171 women had a live birth (24.0%) in our analytic sample.  Mean male BMI was higher in couples who failed to conceive (29.5 kg/m2 vs. 28.2 kg/m2, p=0.039) as well as those who did not have a live birth (29.5 kg/m2 vs. 28.1 kg/m2, p=0.047).  

Multivariable analysis indicated that the likelihood of live birth was increased in couples with ≥ 3 sexual intercourse attempts over the past 4 weeks (reported at baseline) as opposed to couples with lesser frequency (OR= 4.01, 95 % CI: 1.56-10.28), p<0.01].  After adjustment for female BMI, the association of male BMI with live birth was no longer significant (OR= 0.93, 95 % CI: 0.81-1.08), p=0.36.  Every 5 unit increase in female BMI decreased the chance of live birth by 17% (OR= 0.83, 95 % CI: 0.75-0.93), p<0.01].

Conclusions:  In this large cohort of obese women with PCOS, impact of male obesity was explained by female BMI.  Obesity, a potentially modifiable risk factor, is highly prevalent among women with PCOS and considerably decreases success of fertility treatment.  It is noteworthy that couples reporting frequent intercourse had a greater chance of success of fertility treatment.

 

Disclosure: CC: Board Member, NOVA Therapeutics . MPD: Board Member, Advanced Reproductive Care , Consultant, Halt Medical, Genzyme, Auxogyn, Actamax, and ZSX Medical , Investigator, Abbvie, Novartis, Boeringher Ingelheim, Ferring, EMD Serono, Biosante. JT: Owner, Pfizer, Inc., Owner, Merck & Co., Owner, Astellas, Owner, Johnson &Johnson. NS: Advisory Group Member, Menogenix, Principal Investigator, Bayer, Inc.. HZ: Ad Hoc Consultant, Sun Yat-Sen University, Heilongjiang University of Chinese Medicine, Tsinghua University, and Shangdong University, Ad Hoc Consultant, Sun Yat-Sen University, Heilongjiang University of Chinese Medicine, Tsinghua University, and Shangdong University. RSL: Speaker, Ferring Pharmaceuticals. Nothing to Disclose: AJP, AAA, PRC, GMC, WDS, RA, SAK, EE, RMN

11125 17.0000 SUN-0063 A Impact of Male Factors and Adiposity on Pregnancy and Live Birth in Pregnancy in Polycystic Ovary Syndrome II (PPCOS II) Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Claire Bouvattier*1, Laure Esterle2, Peggy Renoult-Pierre3, Véronique Pascal-Vigneron4, Delphine Drui5, Veronique Kerlan6, Sophie Christin-Maitre7, Jerome Yves Bertherat8, Jean Marc Kuhn9, Philippe J Caron10, Olivier Chabre11, Philippe A Touraine12, Didier R Dewailly13, Pierre Bougneres14, Veronique Tardy15 and Jacques Young16
1APHP Hôpital Bicetre -Université Paris Sud, Le Kremlin Bicetre, France, 2APHP Hôpital Bicêtre, Le Kremlin Bicetre, France, 3CHU Tours, Tours, France, 4CHU Nancy Hopital Brabois, Vandoeuvre Les Nancy, France, 5CHU Nantes - Hôpital Nord Laennec, Nantes, France, 6CHUBrest - Hopital De La Cavale Blanche, Brest, France, 7Hôpital St Antoine (AP-HP) UMPC Univ Paris 6, France, 8APHP - Hôpital Cochin Université Paris Descartes, Paris, France, 9CHU de Rouen, Rouen, France, 10CHU Larrey, Toulouse, France, 11Service d’Endocrinologie-Diabétologie-Nutrition, Grenoble Cedex, France, Grenoble, France, 12APHP hôpital Pitie Salpetriere, Paris, France, 13CHRU Lille Hopital Jeanne de Flandre et Université de Lille, Lille, France, 14APHP Hôpital Bicêtre Université Paris Sud, Le Kremlin Bicetre, France, 15CHU Lyon Université Claude Bernard Lyon 1, Lyon, 16Assistance Publique Hopitaux de Paris- Hôpital Bicêtre université Paris Sud, Le Kremlin Bicetre, France

 

Introduction : An increasing number of publications suggest that fertility in men born with congenital adrenal hyperplasia (CAH) due to 21OHD can be impaired.

Aims : We implement a French network in order to study the consequences of classic 21OHD on testicular functions, gonadotropic axis, and on sexual life, fertility, in a great representative sample of well genotyped men with CAH/21OHD. We collected relevant clinical, hormonal data and imaging from medical files and  recorded prospectively patient’s responses to questionnaires concerning personal life and sexual life.

Patients : From 2011 to date, 209 21OHD men with a median age of 30±11 yrs (18-50) have been already included in the study from 30 different French endocrinology department (in majority adult Endocrine units but also pediatric and liberal departments).

Results :  From the 209 genotyped 21OHD men included, 77% had a salt-wasting (SW) and 23% pure virilizing forms. Mean height (m±SD) was 168±8 cm and mean BMI was 26±5 kg/m2. An intermediate evaluation of couple life performed in January 2014 showed that 60% patients were living with a female partner. 42% had children and 4% have resorted assisted medical procreation. To date, 157/209 patients (69 %) underwent testicular ultrasound and 56/157 (36%) had testicular adrenal rest tumor. Surprisingly, a sperm count was performed in only 62/209 (30%) of 21OHD men. From these, 77% had abnormal sperm count which will be detailed. Hormonal evaluation of testicular functions and gonadotrope axis was performed in 172 of these patients. Different hormonal profiles were observed indicating either normal gonadotrope axis, gonadotrope deficiency or primary testicular insufficiency. Their mechanisms will be discussed. On the whole the patients received a mean dose of 28±9 mg of hydrocortisone/day. SW patients also received 100±68 μg/d of 9 alpha-fludrocortisone. Very high ACTH and 17OHP levels in the majority of them indicate poor therapeutic compliance. 

Conclusions : At the end of this program, a specific map of the centers taking care of CAH/21OHD men in France will be available. Genotype-phenotype relationship and patient care and their influence on personal life, sexuality and fertility will be established in what is the most important series of men suffering the disease reported to date. Thanks to this network an educational program will be implemented to explain the gaps detected and to improve the care of these patients in the field of fertility and sexuality.

 

Nothing to Disclose: CB, LE, PR, VP, DD, VK, SC, JYB, JMK, PJC, OC, PAT, DRD, PB, VT, JY

14386 18.0000 SUN-0064 A Testicular and Gonadotrope Axis Status and Sexual Life/Fertility in 209 Men Born with Classic 21 Hydroxylase Deficiency (21OHD) : Results of a French Multicentric Survey 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Reshmi Srinath*1, Kathryn A Carson2, Sherita Hill Golden1 and Adrian S Dobs1
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

 

Cardiovascular disease (CVD) is considered a leading cause of death in men more than women, with testosterone (T) potentially contributing to vascular risk. Cross-sectional studies in men have shown an association between low serum T and CVD, carotid atherosclerosis, metabolic syndrome, and mortality, with others suggesting a J-shaped association.  Carotid intima media thickness (cIMT) is considered a marker of atherosclerosis and predictor of future clinical cardiac events. We hypothesize that low T is independently associated with preclinical atherosclerosis, as defined by cIMT on ultrasound.

     The Atherosclerosis Risk in Communities (ARIC) study is a large prospective multicenter cohort of people aged 45-64 followed since 1987 to evaluate risk factors associated with incident CVD. We measured plasma total T by liquid chromatography mass spectrometry at visit 4(1996-1998) using samples obtained prior to 10:30 AM, in males without prevalent CVD including stroke, or prior T therapy. Cochran-Armitage test for trend and general linear models regression was used to assess the cross-sectional association of quartile of T with cardiovascular risk factors, 10 year coronary heart disease (CHD) risk, and mean cIMT obtained by B-mode ultrasound at visit 4. Multivariable regression analysis was adjusted for age, race, center, body mass index (BMI), waist circumference, smoking status, diabetes, hypertension, LDL and HDL. In 1558 males (mean (SD) age=63.1 (5.6) years, BMI=28.2 (4.3) kg/m2) mean plasma T was 402.3 (165.1) ng/dL with results divided into quartiles (288.4, 377.6, 480.1 ng/dL).  Lower T was significantly associated with higher BMI, greater waist circumference, presence of diabetes, hypertension, lower HDL,  never smoking , and greater 10 year CHD risk(p=0.01).  T was not associated with mean cIMT in unadjusted(p=0.47) or adjusted analyses(p=0.56), nor with mean cIMT>1.0mm (unadjusted p for trend=0.84, adjusted p for trend=0.56). Least squares mean cIMT values were 0.91, 0.89, 0.90, 0.88 mm across quartiles 1 through 4 of T, respectively. 

     Low plasma T in men is cross-sectionally significantly associated with CVD risk factors, including BMI, waist circumference, diabetes mellitus, low HDL and hypertension, which is reflected in a significant increased 10 year CHD risk. However, after controlling for key CVD risk factors, there was no cross-sectional association between T and mean cIMT or mean cIMT>1 mm.  These results are reassuring that neither low nor high T levels increase preclinical atherosclerosis.

 

Nothing to Disclose: RS, KAC, SHG, ASD

16067 19.0000 SUN-0065 A Association Between Endogenous Testosterone and Preclinical Atherosclerosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Reshmi Srinath*1, Kathryn A Carson2, Sherita Hill Golden1 and Adrian S Dobs1
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

 

Cardiovascular disease (CVD) is considered a leading cause of death in men more than women, with testosterone (T) potentially contributing to vascular risk. Cross-sectional studies in men have shown an association between low serum T and cardiovascular disease (CVD), carotid atherosclerosis, metabolic syndrome, and mortality, with others suggesting a J-shaped association. Testosterone levels decline in men with aging and chronic disease. We hypothesize that low T is independently associated with clinical atherosclerosis, as defined by incidence of cardiovascular outcomes.

     The Atherosclerosis Risk in Communities (ARIC) study is a large prospective multicenter cohort of people aged 45-64 years followed since 1987 to evaluate risk factors associated with incident CVD. We measured plasma total T by liquid chromatography mass spectrometry at visit 4(1996-1998) using samples obtained prior to 10:30 AM, in males without prevalent CVD including stroke or prior T therapy. Cochran-Armitage test for trend and general linear models regression was used to assess the cross-sectional association of quartile of T with cardiovascular risk factors and 10 year coronary heart disease (CHD) risk. Proportional hazard regression analysis was performed to assess the association of T quartiles with incident CHD and congestive heart failure (CHF) events. Multivariable regression analysis was adjusted for age, race, center, body mass index (BMI), waist circumference, smoking status, diabetes, hypertension, LDL and HDL. In 1558 males (mean (SD) age= 63.1 (5.6) years, BMI=28.2 (4.27) kg/m2) mean plasma T was 402.2 (165.1) ng/dL with results divided into quartiles (288.4, 377.6, 480.1 ng/dL).  Lower T was significantly associated with higher BMI, greater waist circumference, presence of diabetes, hypertension, lower HDL, never smoking, and greater 10 year CHD risk(p=0.01). Median follow-up was 12.8 yrs for incident CHD (287 events) and 13.1 yrs for incident CHF (140 events). Following multivariable adjustment, there was no association of quartile (Q) of T with incident CHD [hazard ratio (HR)=0.87 (95%CI=0.60-1.26) for Q1; 0.97 (95%CI=0.69-1.38) for Q2; 0.97 (95%CI=0.69-1.36) for Q3 compared to reference of Q4] or for incident CHF [HR=0.77 (95%CI=0.46-1.29) for Q1; 0.72 (95%CI=0.43-1.21) for Q2; 0.87 (95%CI=0.53-1.42) for Q3 compared to reference of Q4].

     Low plasma T in men is cross-sectionally significantly associated with CVD factors including BMI, waist circumference, low HDL, diabetes, and hypertension, which is reflected in a significant increased 10 year CHD risk. However, after controlling for key CVD risk factors, there was no association between T and future clinical cardiac events. Our results are reassuring that neither high nor low T levels increased clinical CVD events.

 

Nothing to Disclose: RS, KAC, SHG, ASD

16125 20.0000 SUN-0066 A Association Between Endogenous Testosterone and Cardiovascular Clinical Outcomes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Racha Dermesropian*1, Dana G. Mills1 and Vitaly Kantorovich2
1University of Connecticut Health Center, 2University of Connecticut Health Center, Farmington, CT

 

Case: 20-year-old male (P1) referred to endocrine clinic for work up of severe hypogonadism. P1 was the product of a twin gestation and born 1 month premature weighing about 5 lbs. His mother was unaware of number of placentas at delivery and twins’ monozygocity was assumed based on striking facial similarity and anosmia, which they developed in early childhood. Twin brother (P2) was diagnosed at birth and operated at age 6 weeks for atrioventricular septal defect, combined with patent ductus arteriosus and aortopulmonary window, as well vesicoureteral reflux. Apart from micropenis and small testicles in P1 and low body weight in both, twins had normal pre-pubertal development, reaching developmental milestones in timely manner. Starting at age 14 P2 underwent normal although delayed puberty, while P1 continued to grow in height with no signs of puberty. There was no family history of congenital disorders. On exam P1 was 177 cm tall with a BMI of 17.9. He had a micropenis, testes of 5-6 ml and minimal facial and body hair. His total testosterone level was 26 ng/dL (reference range 300-1080 ng/dL), FSH - 1.33 mIU/mL (1.27-19.26 mIU/mL) and LH - 1.1 mIU/mL (1.5-9.3 mIU/mL). Bone density test showed a T score of -3.4 at the lumbar spine and a -3.9 at the femoral neck. Bone age was assessed at 15 y.o. standard. P1 also had a severe vitamin D deficiency. P2 was 175 cm tall with a BMI of 16.1. He had normal size penis, testes of 10-12 ml and normal body hair distribution, normal testosterone and FSH/LH levels. While his bone age was appropriate, bone density showed a T score of -3.2 at the femoral neck. P1 was treated with aggressive vitamin D replacement prior to testosterone replacement. Discussion: Kallmann syndrome is defined as hypogonadotropic hypogonadism with anosmia. Five genes have been identified so far in relation to Kallmann syndrome (KS): KAL1, FGFR1, FGF8, PROKR2, PROK2. Mutations in all 5 genes account for about 30% of all KS cases raising possibility of additional, yet unidentified genes to be involved. Our P1 tested negative for commercially available KAL1 and FGF1R gene mutations. While our patients presumed to be monozygotic and both have anosmia, the rest of their phenotype is significantly discordant by severe hypogonadotrophic hypogonadism in one and cardiac and GU malformations in the other. This heterogeneity suggests additional mechanisms - epigenetic factors or modifier genes – to affect expression of KS-related gene mutation. Polygenic or oligogenic inheritance could also explain the incomplete penetrance of the disease. Patients carrying different KS-related gene mutations have been shown to have variability in the degree of hypogonadism and anosmia as well as variability in the associated, non-olfactory and non-reproductive disorders. This variability depends on the particular KS gene involved and suggests significant complexity of the genetics of KS that is still to be fully understood.

 

Nothing to Disclose: RD, DGM, VK

11622 21.0000 SUN-0067 A Differential Phenotypic Features of Kallmann Syndrome in Twins 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Joana Menezes Nunes*1, Elisabete Rodrigues2, João Magalhães3, João Silva4, Francisco Cruz5 and Davide Carvalho6
1Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar São João. Faculty of Medicine, University of Porto. Portugal, Porto, Portugal, 2Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar São João. Faculty of Medicine, University of Porto, Porto, Portugal, 3Pathology Department, Centro Hospitalar São João., 4Urology Department, Centro Hospitalar São João, Porto, Portugal, 5Urology Department, Centro Hospitalar São João, Porto. Faculty of Medicine, Porto University, Porto Portugal, 6Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João. Faculty of Medicine, Porto University. Portugal, Porto, Portugal

 

Introduction: Gynecomastia is common, may occur in all ages and although most cases have benign and self-limited causes, it may be a sign of underlying systemic disease or drug toxicity. Anamnesis, physical exam and diagnostic evaluation remain the cornerstone. Case report: Male, 47 years-old, referred to Endocrinology for bilateral breast enlargement within the past 3 years without relation to weight. He complained of decreased libido, without erectile dysfunction. Past history of renal lithiasis, arterial hypertension, dyslipidemia, obesity, stable angina and Meniére's disease, treated with diltiazem 240mg id, telmisartan 40mg id, rosuvastatin 20mg id and aspirin 150mg id. No ethyl and smoking habits, a healthy 11 years-old daughter and no family history of breast/testicular cancer. On physical exam, BMI=33Kg/m2, asymmetric bilateral gynecomastia (left > right) without palpable nodules, breast tissue moderately tender, without skin / nipple retraction neither ulceration. Left testicular volume was reported as 6cm3 and right one 5cm3. Remaining physical exam was normal. Laboratory results showed normal renal, hepatic and thyroid function and hypergonadotropic hypogonadism. Karyotype was normal. The breast ultrasound confirmed gynecomastia and testicular ultrasound revealed a left hypoechoic nodule measuring 18mm and a right one with 10mm. Serum β-hCG and α-fetoprotein were normal. The patient underwent bilateral orchiectomy and histology revealed bilateral Leydig cell tumor with benign characteristics. He maintains gynecomastia 11months after surgery. Conclusion: In men with an identifiable cause for gynecomastia, its treatment often ameliorates the breast enlargement, at least partially. However, if it presents for more than 1year, complete regression is unlikely due to predominance of fibrotic tissue. Leydig cell tumors represent up to 3% of testis neoplasms. Malignant variants have been reported only after puberty and account for 10%. We present this case because of its rarity, especially being bilateral and to underline that the etiological study of gynecomastia should not be neglected neither its psychological burden.

 

Nothing to Disclose: JMN, ER, JM, JS, FC, DC

16367 22.0000 SUN-0068 A Gynecomastia Caused By Bilateral Leydig Cell Tumor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Ali Aldibbiat*, Paul Peter, Praveen Partha and Giridhar Tarigopula
Darlington Memorial Hospital, Darlington, United Kingdom

 

Background: Several genetic defects can lead to primary male hypogonadism including Klinefelter syndrome, Noona Syndrome and Y chromosome defects. The clinical phenotype and biochemical state vary depending on the genetic defect in each condition. Kinefelter syndrome (46,XXY) remains the most common phenotype.

Clinical case: A 28 male referred by his general practitioner to the endocrine clinic due to erectile dysfunction which has been going on for few years but got worse recently. This concerned him as he was in a relationship and intends to father children. He had good libido and was able to get erections but these do not last long enough to enable penetration. He often has premature ejaculation. He reached puberty at age of 15. He enjoys good energy levels and worked as a chef. He shaves his face once every two weeks. He was not a smoker but drinks alcohol in excess on occasions. He had no family history of note. On examination his height was 188 cm with a BMI of 28kg/m2. He had scanty facial and chest hair but normal pubic and axillary hair. His genital examination showed normal penis but small testes measuring 10ml bilaterally with normal consistency. Biochemical work up demonstrated raised FSH (19.5 iu/L) and LH (14.0 iu/L) with normal testosterone (11.4 nmol/L) measured at 10.30AM with SHBG at 34 nmol/L and a calculated free androgen index at 33.5%. His haematology, renal, liver, bone and thyroid panels were all normal. Klinefelter syndrome was suspected therefore genetic analysis was requested. This revealed an abnormal karyotype with 46.XY.ish psu idic(Y)(q11.22)(SRY++)[37]/45.X[2]. Almost 95% of the cells contained pseudoisodicentric Y chromosome, a mutated form of Y chromosome due to a palindrome preserving crossover mutation leading to deletion of a significant segment of the long arm. The missing segment from the long arm contained the azoospermia factor (AZF) leading to infertility. A cell line with 45,X karyotype was detected in 5% of the cells, likely developed secondary to early instability in the recombinant Y chromosome. The level of mosaicism in patient’s somatic cells isn't clear but likely to vary between different tissues similar to the variability in the secondary sexual phenotype seen in the patient. This mutation is a de novo event and not an inherited condition. The patient was offered genetic and andrology counselling. Testosterone replacement was offered but patient stopped taking following a trial period due to lack of benefit.   

Conclusions: Genetic defects in Y chromosome can lead to primary hypogonadism with a clinical phenotype similar to that of Klinefelter syndrome but with variations depending on severity of mutation, level of mutation penetrance and mosaicism. Testosterone replacement may not be necessary if adequate endogenous testosterone production is achieved. Genetic and fertility counselling are important steps in addressing patients’ concerns.

 

Nothing to Disclose: AA, PP, PP, GT

16736 23.0000 SUN-0069 A De Novo Mutation Leading to Klinefelter-like Phenotype of Male Hypogonadism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

Latrice Doreen Faulkner*1, Ronald Stuart2, Eduardo A. Nillni2 and Jennifer Wootton Hill3
1Univerisity of Toledo, Toledo, OH, 2The Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI, 3University of Toledo School of Medicine, Toledo, OH

 

Melanocortins are a family of peptides that are derived from proteolytic cleavage of pro-opiomelanocortin (POMC) by prohormone convertases. POMC products, like a- melanocyte-stimulating hormone (MSH) dramatically improve hepatic insulin sensitivity and regulate glucose production. Reduced melanocortin activity may contribute to hyperglycemia in T2D; indeed, melanocortin pathways have recently been implicated in mediating the reversal of T2D following gastric bypass surgery.

Erectile Dysfunction (ED) is highly prevalent in men with both Diabetes mellitus (DM) and obesity. While the primary therapy for men with ED is phosphodiesterase type 5 (PDE5) inhibitors like Viagra, half of male patients with T2D are unresponsive to this treatment. Melanocortinergic agents are currently being investigated for a possible therapeutic role in male and female sexual dysfunction. These investigations were initially sparked by findings that systemic administration of a synthetic analog of alpha-MSH, MT-II, causes penile erections in humans.  Subsequent studies demonstrated α-MSH signaling promotes erectile activity and copulatory behavior in male mice.

We have previously shown that male rodents lacking both insulin and leptin receptors in POMC neurons (LepR/IRPOMC mice) exhibit a T2D-like phenotype, which includes increased in body weight, hyperglycemia, hyperinsulinemia, and systemic insulin resistance. Here we show that LepR/IRPOMC males are sub-fertile due to dramatic alterations in sexual behavior and erectile function. Remarkably, these reproductive changes were accompanied by a dramatic decrease in POMC gene expression and aMSH production by POMC neurons. These results are compatible with reduced endogenous a-MSH production driving both T2D and erectile dysfunction. Thus, the melanocortinergic system may prove a particularly effective pharmacological target for the treatment of ED in patients with T2D.

 

Nothing to Disclose: LDF, RS, EAN, JWH

16971 24.0000 SUN-0070 A Disrupted Melanocortin Signaling Facilitates Type 2 Diabetes Associated Erectile Dysfunction 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0046-0070 4864 1:00:00 PM Hormone Measurements, Pharmacokinetics, Sexual Dysfunction, Genetic Andrology Poster

David Muram*1 and Simin Baygani2
1Eli Lilly and Company, 2Eli Lilly and Company, Indianapolis, IN

 

Introduction: Efficacy of any topical testosterone replacement therapy is established in clinical trials by determining the portion of men with average plasma concentration (Cavg) of testosterone in the normal range. However, in clinical practice, dose adjustment and monitoring are based on serum total testosterone (TT) levels assessed from a single morning blood draw—a strategy that assumes consistency among measurements. This post-hoc analysis assessed the likelihood that men receiving a maintenance dose of testosterone 2% solution (Axiron®) have normal serum TT levels as determined by a single draw on different days.

Methods: An open-label, multi-center, titration trial was conducted in androgen-deficient men (N=155) who started on a daily dose of 60 mg of testosterone 2% solution applied in the morning to axillae (30 mg/axilla). Blood samples were drawn for evaluating serum TT levels 2, 4, 8, 12, 16, 20, and 24 hours post treatment. If necessary, the dose was adjusted on days 45 and 90 to maintain the normal physiological range (300-1050 ng/dL) of TT serum levels based on the calculated 24-hour Cavgon days 15 and 60, respectively. The post-hoc analysis study group comprised 105 patients who had serum TT levels measured on at least 2 separate days and who remained on the 60-mg starting dose throughout the study. The portion of men with normal serum TT levels was determined at 2, 4, and 8 hours after application (times most relevant to clinical practice) on days 15, 60, and 120.

Results: Of the patients who had blood samples from days 15, 60, and 120 (n=97), 63.9% had normal TT serum levels 2 hours post treatment on all 3 days, 90.7% on at least 2 of the 3 days, and 95.9% on at least 1 of the 3 days. Of patients who had blood samples taken on days 15 and 60 (n=100) or on days 15 and 120 (n=97), 77% and 71.1%, respectively, had serum TT levels in the normal range on both days, and 95% and 94.8% had normal levels on at least 1 of the 2 days. Similar results were seen at 4 and 8 hours after application.

Conclusions: In a group of men whose Cavg was known to be within the normal physiological range, testosterone levels from single measurements on separate days were not consistently in this range. These findings suggest that single measurements do not always reflect the calculated Cavg on the same day and indicate a potential drawback of monitoring and adjusting doses of testosterone 2% solution based on measurement of a single serum TT level.


 

Disclosure: DM: Employee, Eli Lilly & Company. SB: Employee, Eli Lilly & Company.

11165 1.0000 SUN-0071 A Consistency of Serum Testosterone Levels in Patients Using Axiron 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

David Muram*1, Craig Donatucci2, Zhanglin Lin Cui2, Yujun Zhu2 and Yun Fang2
1Eli Lilly and Company, 2Eli Lilly and Company, Indianapolis, IN

 

Introduction: Testosterone replacement therapy (TRT) is prescribed to treat hypogonadism (HG). However, most patients only use TRT for a short time, with nearly half discontinuing after 3 months.  The aim of this study was to assess whether the use of parenteral TRT (defined as short-acting injectable, P-TRT) in men with HG has similar utilization patterns. 

Materials and Methods: 517 men ≥18 years-old from the Truven MarketScan® Database with HG and P-TRT initiated in 2009 were followed for 12 - 30 months. Treatment discontinuation was defined as a medication gap of >30 days. A restart was defined as a refill of the P-TRT after a medication gap. Patients with one medication gap only were classified as continuous users. Patients with more than one medication gap were classified as intermittent users.

Results: For continuous users, only 58 patients (31.2%) continued P-TRT 3 months after initiation. With time, the number of treated patients reduced: 23 (12.4%) at 6 months and 9 (4.8%) at 12 months. By the end of 2.5 years, none remained on therapy.

Duration of P-TRT was longer for many of the intermittent users. 3 months after initiation of therapy, 131 patients (39.6%) received P-TRT. With time, the number of treated patients declined: 95 (28.7%) at 6 months and 84 (25.4%) at 12 months. By the end of 2.5 years, 48 (14.5%) patients received P-TRT.

Some intermittent users had multiple medication gaps followed by a restart. The mean duration of P-TRT was 2-3 months (median 1 month) followed by a mean gap in P-TRT of about 2-5 months (median 2-3 months). At each of the pre-specified time points, some intermittent patients were off P-TRT, but restarted P-TRT at a later date. When considering these patients as being in active therapy, 330 (99.7%), 301 (90.9%) and 257 (77.6%) patients received P-TRT at 3, 6 and 12 months, respectively.

After the first discontinuation, 59 patients (11.4%) switched to using topical testosterone and were removed from this study.

Conclusions: The results suggest that high discontinuation rates may be due to the disease state rather than cost, dosing, daily use, or application method. Looking beyond adherence, many men who discontinued P-TRT displayed episodic use. We hypothesize that patients use P-TRT when they are symptomatic and discontinue therapy when symptoms abate. After discontinuation, it’s our assumption that patients who remain asymptomatic stay off P-TRT whereas those whose symptoms recur reinitiate P-TRT.

 

Disclosure: DM: Employee, Eli Lilly & Company. CD: Employee, Eli Lilly & Company. ZLC: Employee, Eli Lilly & Company. YZ: Employee, Eli Lilly & Company. YF: Ad Hoc Consultant, Eli Lilly & Company.

11535 2.0000 SUN-0072 A Utilization Patterns of Parenteral Testosterone Preparations in Hypogonadal Men 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Larry Ma*1, Kent H Summers2, Steve B Camper1 and Neil H Shusterman1
1Endo Pharmaceuticals Inc., Malvern, PA, 2Former Employee of Endo Pharmaceuticals Inc.

 

Objective:

Intramuscular (IM) testosterone injections have been available since 1953 but significant immediate adverse reactions have not been well documented. The objective was to estimate the rate of anaphylaxis associated with IM testosterone injections using a large claims database. Data from the FDA Adverse Event Reporting System (FAERS) were also presented.

Methods:

This retrospective analysis utilized a large commercial claims database, with annual enrollment between 30 and 50 million lives. Study sample consisted of males who received office-based IM testosterone injection(s) between 2007 and 2011. Anaphylaxis cases were selected from medical claims based on the ICD-9-CM 995.0 (other anaphylactic reaction), occurring on the same day of the testosterone injection. The relationship between testosterone injections and anaphylaxis were classified as “likely, probably, possible, unlikely” based on the clinical review of patient’s medical history, treatment for anaphylaxis and existence of confounding diagnoses. The outcomes were the number of patients with anaphylaxis per 10,000 patients and the number of anaphylaxis cases per 10,000 person-years.

Results:

Between 2007 and 2011, 989,778 IM testosterone injections were identified for a total of 120,402 male patients (mean age: 49.1 years). A total of 232 patients were identified having at least one anaphylaxis claim within 365 days of receiving an IM testosterone injection. Among 40 same-day anaphylaxis cases (39 patients) as IM testosterone injections, there were 8 cases (8 patients) with anaphylaxis classified as “likely” or “probable”, which represents a rate of 0.7 patient per 10,000 patients, or 1.0 cases per 10,000 person-years. There were 11 cases (11 patients) with anaphylaxis classified as “likely”, “probable”, or “possible”, representing a rate of 0.9 patients per 10,000 patients, or 1.4 cases per 10,000 person-years.  In comparison, injectable testosterone annual sales were between 1.6 and 5.2 million doses in the US from 2008 to 2012, but there were only 19 cases of anaphylaxis identified from FAERS from 1969 to 2013 (44 years).

Conclusion:

Our study showed that, although rare, anaphylaxis-related events have been documented to occur following IM testosterone injections. Given the limitations of spontaneous reporting of adverse events for marketed products, claims databases can be utilized to complement FAERS in identifying safety signals for drugs, especially older products.

 

Disclosure: LM: Employee, Endo Pharmaceuticals, Employee, Endo Pharmaceuticals, Employee, Endo Pharmaceuticals. KHS: Employee, Endo Pharmaceuticals, Employee, Endo Pharmaceuticals, Employee, Endo Pharmaceuticals. SBC: Employee, Endo Pharmaceuticals, Employee, Endo Pharmaceuticals, Employee, Endo Pharmaceuticals. NHS: Vice President, Endo Pharmaceuticals, Vice President, Endo Pharmaceuticals, Vice President, Endo Pharmaceuticals.

16194 3.0000 SUN-0073 A Rate of Anaphylaxis Associated with Intramuscular Testosterone Injections 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Bu Beng Yeap*1, Helman Alfonso2, Paul Chubb3, David J Handelsman4, Graeme J Hankey1, Osvaldo P Almeida1, Jonathan Golledge5, Paul E Norman1 and Leon Flicker1
1University of Western Australia, Perth, Australia, 2Curtin University, Perth, Australia, 3Fremantle Hospital, Fremantle, Australia, 4University of Sydney, Sydney NSW, Australia, 5James Cook University, Townsville, Australia

 

Background

Older men have lower testosterone (T) levels compared with younger men but whether differences in circulating T, or its metabolites dihydrotestosterone (DHT) or estradiol (E2) are markers or causal contributors to ill-health in this setting remains controversial. Several studies have reported associations of sex hormones with mortality in men however fewer studies have included analyses of non-fatal cardiovascular events.

Hypothesis

We tested the hypothesis that plasma T, DHT and E2 are differentially associated with occurrence of non-fatal and fatal ischaemic heart disease (IHD) and stroke events in older men.

Methods

Plasma total T, DHT and E2 were assayed using liquid chromatography-tandem mass spectrometry in early morning samples collected in 2001-04 from 3,690 community-dwelling men aged 70-89 years living in Perth, Western Australia [1]. Outcomes of first hospital admission or death due to IHD or stroke from recruitment until December 2010 were ascertained by data linkage. We used Cox proportional hazards regression to assess associations of sex hormones with IHD and stroke events, adjusting for age, and additionally for education, smoking, BMI, waist-hip ratio, hypertension, dyslipidemia, diabetes, creatinine, prevalent cardiovascular disease and cancer.

Results

Follow-up duration was (mean±SD) 5.9±2.4 years for IHD and 6.6±1.9 years for stroke events. Incident IHD occurred in 921, incident stroke in 310 and neither in 2,435 men. In age-adjusted analyses lower plasma T or DHT were associated with IHD events (quartiles Q4:Q1 T hazard ratio [HR]=0.80, 95% confidence interval [CI]=0.67-0.97; DHT HR=0.77, 95% CI=0.64-0.91), but these associations were attenuated after adjustment for other risk factors. In age- and fully-adjusted models, higher plasma T predicted lower incidence of stroke (Q4:Q1 fully adjusted HR=0.68, 95% CI=0.48-0.97) as did higher DHT (fully adjusted HR=0.61, 95% CI=0.43-0.87). Plasma E2 was not associated with either IHD or stroke.

Conclusions

Apparent associations of higher T or DHT with lower incidence of IHD events may be modulated via conventional cardiovascular risk factors. Higher DHT levels predicted lower IHD mortality in this cohort [2], thus DHT may protect against death from rather than incidence of IHD events. Both higher plasma T or DHT are robust biomarkers for lower incidence of stroke. Randomised clinical trials are needed to clarify the impact of modifying T or DHT levels on health in ageing men.

 

Nothing to Disclose: BBY, HA, PC, DJH, GJH, OPA, JG, PEN, LF

13605 4.0000 SUN-0074 A In Older Men, Higher Plasma Testosterone or Dihydrotestosterone Are Independent Predictors for Reduced Incidence of Stroke but Not Ischaemic Heart Disease Events 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Gideon Sartorius*1, Lam P Ly1 and David J Handelsman2
1ANZAC Research Institute, Sydney, NSW, Australia, 2ANZAC Research Institute, Sydney NSW, Australia

 

Introduction:Male sexual function is highly androgen dependent but whether aromatisation of testosterone is required remains contentious. Recent evidence from administration of an aromatase inhibitor to younger men (Finkelstein et al NEJM 369:1011-1022, 2013) suggested partial dependence on aromatisation.

 Aim: To investigate the effects selective estrogen deficiency induced by a non-aromatizable androgen, DHT, on sexual function of healthy middle-aged and older men.

 Methods, Outcome Measures and Analysis:Randomized clinical trial of daily transdermal DHT (70 mg) or placebo gel treatment for 24 months in 114 healthy middle-aged and older (>50 yr) men without known prostate disease (Idan et al Ann Intern Med 153:621-632, 2010). The endpoints were responses to a validated psychosexual and mood questionnaire completed before, at 3 months, then at 6 monthly intervals during and 3 months after study. Data were analyzed by mixed model analysis of variance for repeated measures using age and body mass index (BMI) as covariates and including interactions of treatment with age and time-on-study.

 Results:Serum DHT was increased with complete suppression of serum LH, FSH and estradiol throughout the 24 month study resulting in reduced spinal bone density and hormonal recovery post-study. There were no spontaneous complaints or discontinuations for adverse changes in sexual function during the study. DHT administration had no effects on any measure of sexual function, apart from a mild decrease in overall sexual desire, more prominent in younger men and reversible after cessation of treatment. Increasing age and, less often increasing BMI, were associated with significant decreases in most aspects of sexual function.

Conclusions:We conclude that aromatization may not be required to maintain male sexual function in healthy eugonadal middle-aged or older men but age and obesity are significantly associated with decreases in most aspects of self-reported sexual function and satisfaction. The apparent dependence of young male sexual function on aromatisation may be conditional on age and obesity and can be overcome by a non-aromatizable androgen.

 

Nothing to Disclose: GS, LPL, DJH

12225 5.0000 SUN-0075 A Male Sexual Function Can be Maintained without Aromatization: Randomized Placebo-Controlled Trial of Dihydrotestosterone (DHT) in Healthy, Older Men 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Benjumin Hsu*1, Robert G Cumming1, Fiona M Blyth2, Vasi Naganathan2 and David J Handelsman3
1University of Sydney, Sydney, Australia, 2Concord Hospital & University of Sydney, Sydney, Australia, 3University of Sydney, Sydney NSW, Australia

 

Objectives

To identify relationships between circulating reproductive hormones and decline in of functional ability over two-years of follow-up in older men; and to examine whether muscle strength explains any of the observed relationships.

Methods

1318 men aged 70 years and older from the Concord Health and Ageing in Men Project (CHAMP) were assessed at both baseline (2005-2007) and 2-year follow-up (2007-2009). At baseline, testosterone (T), dihydrotestosterone (DHT), estradiol (E2), and estrone (E1) were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS), and SHBG, LH, and FSH by immunoassay. The calculated free testosterone (cFT) was computed using an empirical formula derived from the measured TT and SHBG. Functional disability was assessed by self-report using a basic Activities of Daily Living (ADL) scale (Katz) at both time points. Functional decline was determined by change in ADL stages, defined by specific threshold definitions ranging from no difficulty in Stage 0 to complete difficulty in Stage IV. Grip and quadriceps strength were measured using dynamometers.

Results

All reproductive hormones were significantly associated with functional decline in univariate analyses. However, only T, E2, E1, and cFT remained significantly associated after adjusting for age, BMI, smoking status, and number of comobidities. In the multivariable analyses, compared to men in the highest T quartile, men in the lowest T quartile had an increased risk of functional decline (OR: 1.96, 95%CI: 1.01-3.82). The associations with E2, E1, and cFT were similar to T. When muscle strengths were added into the multivariable model, the associations between T, E2, E1, and cFT and functional decline were no longer statistically significant.

Conclusion

Low circulating T, E2 and E1 in older men were associated prospectively with functional decline over two years and this relationship is mediated by decreased muscle strength.

 

Disclosure: RGC: Speaker, Eli Lilly & Company. Nothing to Disclose: BH, FMB, VN, DJH

11377 6.0000 SUN-0076 A Longitudinal Relationships of Circulating Reproductive Hormone Levels and Functional Disability in Community-Dwelling Older Men: The Concord Health and Ageing in Men Project 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Molly M. Shores*1, Alexandra E. Fox2, Kathryn P. Moore3, Alvin M. Matsumoto4, Christopher W. Forsberg3, Nicholas L. Smith5, Susan R. Heckbert6, Mary Lou Thompson6 and Thomas J. Walsh7
1VA-Puget Sound/University of Washington, Seattle, WA, 2Seattle VA Epidemiology Research and Information Center (ERIC), 3Seattle VA ERIC, 4VA Puget Sound Hlth Care Syste, Seattle, WA, 5University of Washington and VA Puget Sound Health Care System, Seattle, WA, 6University of Washington, 7University of Washington, Seattle, WA

 

Introduction.  Low serum testosterone (T) is common, occurring in approximately 40% of older men, while male hypogonadism (repeated low T levels plus clinical signs and symptoms of low T) is less frequent, with an estimated prevalence of 2-6%.  Over the past decade, T prescriptions (particularly T gels) have increased greatly in the context of intensive marketing of T.  However, in an integrated health care system with formulary restrictions, patterns of T use and characteristics of treated and untreated men with low T are not clear.

Objectives.  To characterize T-treated and untreated men with low T levels and describe patterns of T-use within the VA Health Care System, one of the largest integrated health systems in the United States, providing care to a large number of older men.

 Methods.  We used a national VA clinical database to identify men ages 40-89 who received VA health care from 2002 to 2011 and had a low T level as indicated by the testing laboratory.  We excluded men with a history of T-treatment in the year prior to the low T level or with any history of prostate or breast cancer.  T-treatment duration was defined as the interval between the dates of the first and the last T prescription fill.  Co-morbid conditions were assessed by ICD-9 codes.

Results.  From 2002-2011, there were 226,170 men who had a low T level and met the study criteria.  Of these men, 39.6% (89,493) were treated with testosterone.  Compared with untreated men, T-treated men were younger (mean 59.8 vs. 62.0 yrs.), less likely to be African-American (12.2% vs. 15.0%), had a greater BMI (mean 32.6 vs. 31.4 m2/kg), more sexual dysfunction (19.8% vs. 17.1%), less cardiovascular disease (21.9% vs. 24.2%) and a similar prevalence of diabetes (34.5% vs. 34.4%).  T-treated men were less likely to be hospitalized (12.5% vs. 15.3%) than untreated men in the year before the low T level.  The most common T-formulations were patches (50.2%) and intramuscular (IM) T (47.6%).  T-gel was infrequently prescribed (2.2%).  The median time to treatment after T measurement was 1.2 months (mean of 6.3 (SD=13.6) months).  The median treatment duration was 10.3 months (mean 21.0(26.0)).  The median number of prescriptions filled was 6 (mean 12.3 (16.5)).  A considerable number of men filled only one prescription (14.4%, n=12,918).    

Conclusions.  Compared to untreated men, those treated with T were slightly younger, had greater BMI, more sexual dysfunction and similar rates of diabetes, but appeared healthier, as they had less cardiovascular disease and were hospitalized less.  T-treatment duration was highly variable, but was typically not chronic, as the median duration of treatment was less than one year.  Finally, T-treatment patterns within the VA health care system differ from national patterns as most men within the VA system are treated with IM or patch; while within the US the most commonly prescribed T formulation is T-gel.

 

Disclosure: AMM: Clinical Researcher, Abbott Laboratories, Clinical Researcher, GlaxoSmithKline, Consultant, Abbott Laboratories, Consultant, Endo Pharmaceuticals, Consultant, Lilly USA, LLC, Consultant, GTX, Consultant, Forendo. Nothing to Disclose: MMS, AEF, KPM, CWF, NLS, SRH, MLT, TJW

14365 7.0000 SUN-0077 A Characteristics of Treated and Untreated Middle-Aged and Older Men with Low Testosterone and Testosterone Use in a National Veterans Affairs (VA) Cohort 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Ilpo T. Huhtaniemi*1, Emma L. Carter2, Joseph D. Finn3, Stephen R. Pye3, Terence W. O'Neill2, Gyorgy Bartfai4, Felipe F Casanueva5, Gianni Forti6, Aleksander Giwercman7, Thang S Han8, Krzysztof Kula9, Michael E. J. Lean10, Neil Pendleton3, Margus Punab11, Dirk M. Vanderschueren12 and Frederick C Wu2
1Imperial College London, London, United Kingdom, 2The University of Manchester, Manchester, United Kingdom, 3University of Manchester, Manchester, United Kingdom, 4Albert Szent-György Medical University, Szeged, Hungary, 5Santiago de Compostela, Santiago Compostela, Spain, 6University of Florence, Florence, Italy, 7Malmo University Hospital, Malmo, Sweden, 8Royal Holloway University of London (ICR2UL) and Ashford and St Peter's NHS Foundation Trust, Surrey, United Kingdom, 9Medical University of Łódź, Łódź, Poland, 10University of Glasgow, Glasgow, United Kingdom, 11Tartu University Hospital, Tartu, Estonia, 12UZ Gasthuisberg/Catholic Univ, Leuven, Belgium

 

A state of compensated hypogonadism (CHG) has recently been defined in ageing men as elevated serum concentration of  LH (> 9.5 IU/L) in the face of normal testosterone (T > 10.5 nmol/L). CHG can be regarded as a transitional state during the progression from eugonadism (EUG) (T > 10.5 nmol/L, LH < 9.4 IU/L) to primary hypogonadism (PHG) (T < 10.5 nmol/L, LH > 9.4 IU/L).  We sought to identify the hormonal and phenotypic characteristics associated with the progression of CHG during a follow-up of 4.3 yr. Community-dwelling men (n = 3,369) aged 40-79 yr in 8 European countries participated in EMAS, a prospective observational cohort survey.  Of 279 men with CHG at baseline, 47 (16.8%) were lost to follow-up. Of the remaining men 36 (15.5%) died, 132 (56.9%) remained in CHG and 15 (6.5%) progressed to PHG. Differences in characteristics amongst the defined gonadal status were investigated using descriptive statistics and linear and logistic regression models.  At baseline, men with CHG had a 10-fold increased risk of developing PHG as compared with EUG men, after adjusting for age, BMI, smoking status and comorbidity. When compared with persistent CHG at baseline, men progressing to (i.e. incident) PHG had similar age and BMI, but their total T (13.3 + 2.6 [SD] vs 19.1 + 5.6 nmol/L), free T (188 + 58 vs 268 + 74 pmol/L), and FSH (39.0 + 24.3 vs 22.5 + 15.1 IU/L), but not LH, differed significantly (p< 0.01). Moreover, they demonstrated significantly lower (p< 0.03 or less) physical function, higher prevalence of low moods and prostate disease.  During follow-up, the annualised change  were significantly greater in men with incident PHG compared with persistently EUG men in haemoglobin (-1.3 ± 3.1 vs. 0.0 ± 2.2 g/litre, p=0.05), Reuben’s Physical Performance Test scores (-0.5 ± 0.7 vs -0.1 ± 0.5, p<0.001) with higher incidence of physical symptoms: limited walking (22.2 vs. 4.1%, p=0.01), decreased physical activity (42.9 vs. 12.5%, p=0.02), fatigue (14.3 vs. 3.0%, p=0.02), > 1comorbidity (60.0 vs. 23.3%, p=0.05) and sexual symptoms: decreased morning erections (50.0 vs. 16.3%, p=0.03), frequency of sexual thought (50.0 vs. 16.1%, p<0.001) and erectile dysfunction (66.7 vs. 16.2%, p<0.001). Similar differences (to a lesser extent) were found between men with incident PHG and persistent CHG. At follow-up, incident PHG men also had higher SHBG levels (67.8 ± 59.5 vs. 45.3 ± 18.5 nmol/L, p<0.001) than EUG men. The proportion of men with CHG who died, 15.5%, was significantly higher than for EUG men (5.2%, p<0.05 after adjustment for age, BMI and smoking status). In conclusion, CHG is a preferential path for the development of PHG in EUG ageing men. Baseline hormones (T, free T and FSH) but not age predict the accelerated transition from CHG to PHG in surviving men. Progression to PHG is associated with deterioration of features compatible with androgen deficiency.  Men with CHG are at an increased risk of dying compared with persistent EUG.

 

Disclosure: FCW: Speaker, Bayer Schering Pharma, Clinical Researcher, Eli Lilly & Company, Speaker, Besins Healthcare. Nothing to Disclose: ITH, ELC, JDF, SRP, TWO, GB, FFC, GF, AG, TSH, KK, MEJL, NP, MP, DMV

14694 8.0000 SUN-0078 A Natural History of the Progression of Compensated Hypogonadism to Primary Hypogonadism in Ageing Men: Hormonal and Phenotypic Characteristics – Longitudinal Data from the European Male Ageing Study (EMAS) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Eelkje J Limonard*1, Natasja M van Schoor2, Renate T de Jongh2, Paul Lips2, Eric Fliers3 and Peter H Bisschop1
1Academic Medical Center, Amsterdam, Netherlands, 2VU University Medical Center, Amsterdam, Netherlands, 3Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands

 

Background Mice lacking osteocalcin or its receptor are subfertile with low testosterone and high luteinizing hormone concentrations.(1) In humans, loss of function mutations of the osteocalcin receptor are associated with hypergonadotrophic hypogonadism.(2) Besides its recently discovered hormonal function, osteocalcin is also a well-known marker of bone formation.
Objective To determine the association between physiological variations in osteocalcin and the pituitary-gonadal axis.
Design and Participants Data were used from the Longitudinal Aging Study Amsterdam (LASA), an ongoing cohort study in a representative sample of the older Dutch population.
Measurements Levels of total testosterone (T) and bioavailable T (bioT),  luteinizing hormone (LH) and osteocalcin were measured in 614 men. Data were analyzed using linear regression analyses and adjusted for age, body mass index (BMI), vitamin K antagonist use and 25-hydroxyvitamin D (25(OH)D), parathyroid hormone (PTH), LH and (bio)T concentrations.   
Results The median age 75.4 (interquartile range 69.8-81.2) years and the median osteocalcin level was 1.80 (interquartile range 1.34-2.40) nmol/l. Serum osteocalcin levels were inversely associated with bioT (adjusted B = -0.26, P < 0.01), but not with total T. Men in the highest quartile (Q4) of osteocalcin had significantly lower levels of bioT as compared with men in the lowest quartile (Q1) (adjusted B = -0.70, P < 0.01). Furthermore, serum osteocalcin levels were positively associated with LH levels (adjusted B = 0.09, P < 0.01). Men in Q4 of osteocalcin had higher levels of LH than those in Q1 (adjusted B = 0.28, P < 0.01). 
Conclusions Serum osteocalcin levels were negatively associated with bioavailable testosterone levels and positively with luteinizing hormone levels in elderly men. These data are more compatible with an effect of testosterone on bone turnover than an effect of osteocalcin on the gonadal axis.

 

Nothing to Disclose: EJL, NMV, RTD, PL, EF, PHB

13038 9.0000 SUN-0079 A Osteocalcin and the Pituitary-Gonadal Axis in Elderly Men: A Population-Based Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Thomas W Storer*1, Joseph Mosholder2, Ayan Elmi2, Renee Miciek3, Thomas G Travison4, Shehzad Basaria2 and Shalender Bhasin1
1Brigham and Women's Hospital - Harvard Medical School, Boston, MA, 2Brigham and Women's Hospital-Harvard Medical School, Boston, MA, 3Harvard School of Public Health, Boston, MA, 4Harvard Medical School, Boston, MA

 

BACKGROUND: Testosterone (T) replacement unequivocally increases skeletal muscle mass and strength but previous trials have not shown consistent improvements in physical function. We have shown that T stimulates mitochondrial biogenesis, increases red cell mass, 2,3 BPG, and tissue capillarity, all of which would be expected to increase tissue O2 delivery and aerobic performance. However, the effects of testosterone on aerobic performance in older men have not been evaluated.  To determine whether T supplementation improves measures of aerobic function [peak oxygen uptake (VO2peak) and the gas exchange lactate threshold (LTGE)], men aged ≥65yrs with mobility limitation (ML) and low total or free T levels were randomized to receive 10 mg of T (n=28) or placebo gel (n=36) daily for 6-mo (these participants comprise a subset of men participating in the Testosterone in Older Men with Mobility Limitation (TOM) Trial). We also determined the effects of T therapy on the age-related decline in VO2peak, which in the sedentary male population is expected to be approximately 0.4 mL/kg/min/year.†  METHODS: Subjects performed symptom limited cycle exercise using a 10-15 watt ramp protocol and breath-by-breath measures of oxygen uptake to determine VO2peak and LTGE.  VO2peak was selected from the last 15 sec of exercise and the V-slope method was used to detect LTGE. Changes in VO2peak within and between groups were compared using paired and unpaired t-tests, respectively. The change between groups for VO2peak vs. its expected change over treatment was examined with an unpaired t-test. RESULTS:  Baseline VO2peak and LTGE [mean (SD)] as well as their 6-mo changes [mean (SE)] are displayed in the table. VO2peak and LTGE improved slightly in the T arm while decreases were seen in the P group. The decrease in LTGE was significantly smaller for the T compared to P group. The 6-mo increase in VO2peak in the T arm represented 3.4 fold attenuation of the expected age-related decline, whereas men in the P group experienced accelerated decline at nearly twice the expected rate. CONCLUSION: Testosterone therapy in mobility-limited older men was associated with improved VO2peak and attenuated its age-related decline. Long-term intervention studies are needed to determine the durability of this effect and whether T affects fatigue.

                                          Testosterone                       Placebo                  Difference        

                                   Baseline       Change       Baseline       Change         in change         P

VO2peak(mL/kg/min) 20.5 (4.2)   0.68 (0.50)   19.2 (2.9)   -0.36 (0.43)     1.04 (0.66)     0.12

 LTGE(mL/kg/min)       13.7 (2.5)   0.0 (0.41)     14.0 (3.2)   -1.61 (0.49)    -1.49 (0.66)     0.03

 

Disclosure: SB: Investigator, Abbott Pharmaceuticals , Clinician, Eli Lilly & Company. SB: Principal Investigator, Abbott Laboratories, Principal Investigator, Eli Lilly & Company. Nothing to Disclose: TWS, JM, AE, RM, TGT

13848 10.0000 SUN-0080 A Testosterone Replacement Improves Aerobic Function in Mobility Limited Older Men with Low Testosterone 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

James Calvin Larocque*1 and Jawad Mohammad Khan2
1Eastern Virginia Medical School, Chesapeake, VA, 2Endocrinology and Diabetes Center, Portsmouth, VA

 

Hypogonadotrophic hypogonadism is common in men with obesity and in men with type 2 diabetes. Treatment usually involves testosterone replacement administered either trans-dermally or intramuscularly. Both methods predictably lead to side effects of testicular shrinkage, reduction in sperm count, and, at times gynecomastia. The gels and injections are also at times aversive to patents, and thus lead to discontinuation of treatment .  Aromatase inhibitors have been used to raise sperm counts in infertile men by raising FSH secretion. We undertook, analogously, to treat low testosterone levels by raising LH secretion by use of the aromatase inhibitor anastrozole. Fourteen male patients presenting with low testosterone due to pituitary dependent hypogonadism were selected in a clinical context for treatment with anastrozole.   BMI for the diabetic group was 36.3 +/-  4.1.  BMI for the obese group was 35.6 +/- 6.2.  Average LH level for the group of six diabetic men was 6.2 +/- 2.86 ng/dl. Average LH level for the group of eight obese non-diabetic men was 6.0 +/- 2.27 mIU/ml. Total testosterone under treatment  in the diabetic group rose from 324.8 +/- 67.21 to 506.3 +/- 106.9 ng/dl.  Total testosterone in the obese group rose from from 274.6 +/-  31.1 ng/dl to 480.0 +/- 110.2 ng/dl.  Free testosterone in the diabetic group rose from 6.3 +/- 1.6 to 10.5 +/- 1.5 ng/dl, and, in the obese group, from 7.2 +/- 1.7 to 11.7 +/- 3.9 ng/dl. Total estrogen in the diabetic group level dropped from 121.0 +/- 20 to 72.4 +/- 29.7 pg/ml, and in the obese group from 105.4 +/- 22.3 to 79.9 +/- 29.3 pg/ml.  Testosterone/estrogen ratio in the diabetic group rose from 2.9 +/- 0.8 to 8.5 +/- 3.4, and in the obese group from 2.7 +/- 0.6 to 7.0 +/- 4.0.  Clinical improvement was noted to some degree in all patients, whether in energy, libido, or motivation. No side effects of the anastrozole were seen. These observations demonstrate clinically significant rises in testosterone levels, both total and free, accompanaied by symptomatic improvement. The effect was equally robust for the non-diabetic obese and the diabetic men.  Body mass index did not affect the result in either group, the less obese patients having proportional increases in testostosterone. The most important effect seen, in both groups  was the marked increase in the testosterone/estrogen ratio. Since this ratio may correlate with clinical improvement, it is suggested that such clinical improvement can be seen with relatively small increments of testosterone itself. Though these findings need to be confirmed by clinical studies with larger numbers of subjects, the possiblity is here presented that aromatase inhibition may represent an alternative treatment modality to testosterone replacement in a large number of obese and diabetic men with testosterone deficiency. Such a method may be both more advantageous and acceptable to patients than testosterone administration itself.

 

Nothing to Disclose: JCL, JMK

14126 11.0000 SUN-0081 A Aromatase Inhibition for Hypogonadotrophic Hypogonadism in Men 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Michael Zitzmann*1 and Farid Saad2
1University Clinics Muenster, Muenster, Germany, 2Bayer Pharma AG, Berlin, Germany

 

Background

The intramuscular injection of the long-acting ester testosterone undecanoate (TU) offers a convenient modality for testosterone substitution. The effects of such a therapy on body composition have been well documented but long-term effects and inter-patient variability remain to be elucidated.

Methods

We report data from 422 patients (188 with primary [including 56 Klinefelter patients], 125 with secondary hypogonadism and 109 with late-onset (“mixed” or “metabolic” hypogonadism) aged 15 to 72 years (mean 41±12 years) receving intramuscular injections of 1000 mg of TU during a maximal treatment time of 17 years.

Results

Individual dosing intervals ranged from 10 to 14 weeks Serum T concentrations increased from 5.2 nmol/L to stable trough levels of 12.8 nmol/L within the first year of treatment and furtheron to levels between 15 and 16 nmol/l thereafter. The proportion of men fulfilling the new Harmonized Criteria for definition of the Metabolic Syndrome decreased from initially 86% to 68% within the first year and furtheron to 43% within 5 years (Chi-square for trend:p<0.001). During the maximal duration of treatment, an overall favorable change from baseline was visible for a multitude of parameters related to androgen effects/metabolic risk, especially lipid parameters (HDL-cholesterol, LDL-cholesterol, triglycerides), blood pressure and fasting glucose levels (all with p<0.001 in ANOVAs). Body weight decreased within the first year from 100.9±11.7 to 97.8±10.6kg and continued to decrease in a sustained manner to 86.6±9.3kg. Body mass index decreased in a similar fashion. Prostate size increased from 16.8±5.0 to max 21.2±5.4 ml (p<0.001), whilst PSA levels changed moderately (baseline 1.5±0.4 to max 2.3±0.6 µg/l, p=0.001). No case of prostate cancer was observed, possibly also due to the rather young age of patients. Haematocrit was significantly elevated during treatment but remained within the normal range (40.5±2.1% to max 47.2±2.5%, p<0.001), except for occasional measurements (maximal value 56.7%). One patient suffered from deep vein thrombosis, one from stroke, two from myocardial infarction. These events were considered unlikely to be directly related to testosterone replacement therapy, as the patients had a respective cardiovascular risk profile but haematocrit was not elevated.

Conclusion:

Intramuscular injections of testosterone undecanoate represent a feasible, safe and well tolerated modality of androgen substitution in hypogonadal men of a wide age-range, substantiated by a long experience, facilitating a decrement of metabolic/cardiovascular risk factors.

 

Disclosure: FS: Employee, Bayer Schering Pharma. Nothing to Disclose: MZ

12760 12.0000 SUN-0082 A Longterm-Treatment of Hypogonadal Men Using Intramuscular Testosterone Undecanoate: Experience of 17 Years 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Emily F Shortridge*1, Paula K Polzer1, Prina Donga2, Michael Marcus2 and Rolin L Wade2
1Eli Lilly and Company, Indianapolis, IN, 2IMS Health, Plymouth Meeting, PA

 

Purpose: To determine whether persistence to testosterone replacement therapy (TRT) was affected by TRT formulation and symptom response.

Methods: Men ≥18 years with hypogonadism (HG) were identified from the 2008-2010 Reliant electronic medical records database. Non-persistence was defined as a gap between prescription refills greater than twice the days supplied in the previous prescription. Surveys using validated instruments for measuring symptoms of HG were collected, and symptom reporting was evaluated based on persistence.

Results: A total of 488 men were diagnosed with HG in the period, and 408 of these initiated TRT at some point. Average patient age was 53.1 years (SD=13 years). Care was sought by 35% of patients at internal medicine practices (n=169), 28% at endocrinologists (n=134), 10% at urologists (n=49), and 8% at primary care practices (n=39). Overall 22% (n=89) of patients were persistent with TRT during the follow-up period; another 26% switched therapies (n=106). Patients using testosterone gels (n=64 [32%]) were more likely to be persistent than those using testosterone injections (n=16 [10%]; p<0.001). In addition, 28% (n=56) of men taking gels switched to another therapy, compared to 13% (n=21) of men using injections and 56% (n=28) of men using a patch (gel v. injection, p=0.0007; gel v. patch, p=0.0004).

Surveys were mailed to 133 men with HG identified in the database in 2012; 95 were included in the final analysis. Of those, 24 respondents were persistent on TRT and 63 were not. The most commonly reported symptoms for seeking treatment and the most bothersome at the time of survey were erectile dysfunction (ED), loss of energy or feeling tired, and decreased sex drive. At the time of the survey, men who had been persistent were slightly less likely to report loss of energy or decreased sex drive compared to men who were not persistent (NS); however, persistence appeared to have no effect on ED symptomology.   

Conclusions: In this health plan, persistence to TRT was low among men with HG, with slight differences found by therapy type. Factors that might influence persistence, such as treatment expectations, symptom improvement, and financial considerations, require further study.  

 

Disclosure: EFS: Employee, Eli Lilly & Company. PKP: Clinical Researcher, Eli Lilly & Company. PD: Researcher, Eli Lilly & Company. RLW: Researcher, Lilly USA, LLC. Nothing to Disclose: MM

13090 13.0000 SUN-0083 A Persistence with Testosterone Replacement Therapy (TRT) in a US Health Plan 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Glenn R Cunningham*1, Raymond C. Rosen2, Christina Wang3, Alisa Stephens4, Susan Ellenberg5, Alvin M. Matsumoto6, Shalender Bhasin7, Mark E Molitch8, John T Farrar9, David Cella10, Thomas M Gill11, Elizabeth Louise Barrett-Connor12, Jane A Cauley13, Denise Cifelli14, Jill P Crandall15, Kristine E Ensrud16, Laura Fluharty17, Evan Hadley18, Cora E Lewis19, Marco Pahor20, Susan M Resnick21, Sergei Romashkan18, Ronald S. Swerdloff22 and Peter J Snyder23
1Baylor Coll of Med, Houston, TX, 2New England Research Institutes, Inc., Watertown, MA, 3Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, 4University of Pennsylvania School of Medicine, 5Univ of Pennsylvania Schl of Me, Philadelphia, PA, 6VA Puget Sound Hlth Care Sys, Seattle, WA, 7Brigham & Women's Hospital, Boston, MA, 8Northwestern University Feinberg School of Medicine, Chicago, IL, 9University of Pennsylvania School of Medicine, Philadelphia, PA, 10Northwestern University Feinberg School of Medicine, 11Yale School of Medicine, New Haven, 12Univ of CA - San Diego, La Jolla, CA, 13University of Pittsburgh, Pittsburgh, PA, 14Perelman School of Medicine, University of Pennsylvania, Philadelphia, 15Albert Einstein College of Medicine, Bronx, NY, 16University of Minnesota, Minneapolis, MN, 17Perelman School of Medicine, University of Pennsylvania, 18National Institute on Aging, Bethesda, MD, 19Univ of Alabama at Birmingham, Birmingham, AL, 20University of Florida, Gainesville, FL, 21Natl Inst on Aging, Baltimore, MD, 22Harbor- Univ of California Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, 23Univ of PA, Philadelphia, PA

 

Background

The relationship between sex hormone levels and sexual function in older hypogonadal men is unclear. We tested the hypothesis that total and free testosterone (TT and FT) and estradiol (E2) levels are independently associated with sexual function in symptomatic older hypogonadal men.

Methods

We evaluated 470 hypogonadal men enrolled in the Sexual Function Trial of The Testosterone Trials. At entry, men were ≥65 years, had symptoms and objective evidence of sexual dysfunction, and 2 early morning TT values on separate days with an average of <275 ng/dL. They qualified for the Sexual Function Trial if they scored ≤20 on the Sexual Desire Domain of the Derogatis Interview for Sexual Function (DISF-SDD) and had a partner willing to have sexual intercourse at least twice a month. We investigated the cross-sectional association of baseline TT (LC-MS/MS), equilibrium dialysis FT and E2 (LC-MS/MS) levels with sexual desire assessed by the DISF-SDD, erectile function evaluated by the Erectile Function Domain of the International Index of Erectile Function (IIEF-EFD), and sexual activity determined by the Psychosexual Daily Questionnaire (PDQ4) using multivariable linear regression and adjusting for confounding factors.

Results

Men in the Sexual Function Trial had a mean±SD age of 71.6±5.3 years, BMI of 31.0±3.5 and waist circumference of 110±10.7 cm. Baseline TT was 238.2±69.0 ng/dL, FT 58.3±20.2 pg/mL and E2 22.6± 9.7 pg/mL. The sexual function scores were low: DISF-SDD 11.8±6.6, IIEF-EFD 8.0±8.2 and PDQ4 1.4±1.3. In unadjusted analyses, TT and FT but not E2 were associated with sexual function. However, only FT [partial regression coefficient (ß)] remained significantly associated with DISF-SDD score (ß=0.034, p=0.04), IIEF score (ß=0.054, p=0.01) and PDQ4 score (ß=0.007, p=0.03) after adjustment for age, BMI, waist circumference, gait speed, PHQ9 (depression) score, FACIT Fatigue (vitality) score, mean arterial pressure and hemoglobin A1c. Similarly, FT (p<0.005), but not TT or E2 was associated with measures of sexual function in all men (n=788) in The Testosterone Trials.

Conclusions

FT but not TT or E2 is independently associated with measures of sexual desire, erectile function and sexual activity in older hypogonadal men with symptoms and objective evidence of sexual dysfunction. These findings suggest that FT contributes more than TT or E2 to sexual dysfunction in older hypogonadal men.

 

Disclosure: GRC: Consultant, Repros Therapeutics, Consultant, Purdue Pharma, Consultant, Ferring Pharmaceuticals, Advisory Group Member, Endo Pharmaceuticals, Consultant, Clarus, Advisory Group Member, AbbVie. RCR: Principal Investigator, Lilly USA, LLC, Principal Investigator, Bayer, Inc., Principal Investigator, Boehringer-Ingelheim, Consultant, Lilly USA, LLC, Consultant, Allergan. CW: Investigator, Clarus, Speaker, Lilly USA, LLC. SE: Consultant, Bristol-Myers Squibb, Consultant, Jansen Pharmaceuticals, Consultant, Theravance, Consultant, Chelsea, Consultant, Endo Pharmaceuticals, Consultant, Otsuka, Consultant, Millenium, Consultant, Onyx, Consultant, Salix, Speaker, Amgen. AMM: Clinical Researcher, Abbott Laboratories, Clinical Researcher, GlaxoSmithKline, Consultant, Abbott Laboratories, Consultant, Endo Pharmaceuticals, Consultant, Lilly USA, LLC, Consultant, GTX, Consultant, Forendo. SB: Principal Investigator, AbbVie, Principal Investigator, Lilly USA, LLC. MEM: Investigator, Corcept, Consultant, Corcept, Investigator, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals. JAC: Consultant, Merck & Co.. KEE: Consultant, Merck & Co.. RSS: Investigator, Novartis Pharmaceuticals, Investigator, Clarus, Consultant, Clarus, Consultant, Endo Pharmaceuticals, Consultant, Antares, Consultant, Lawley Hormonal Sol, Clinical Researcher, Clarus, Clinical Researcher, Lipocine. PJS: Principal Investigator, AbbVie. Nothing to Disclose: AS, JTF, DC, TMG, ELB, DC, JPC, LF, EH, CEL, MP, SMR, SR

12367 14.0000 SUN-0084 A Free Testosterone but Not Total Testosterone or Estradiol Is Associated with Sexual Function in Symptomatic Older Hypogonadal Men in the Sexual Function Trial of the Testosterone Trials 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Farid Saad*1, Mahmoud Nasser2, Gheorghe Doros3, Winfried Kurtz4, Ahmad Haider5 and Louis J Gooren6
1Bayer Pharma AG, Berlin, Germany, 2University of Aleppo, Aleppo, Syria, 3Boston University School of Public Health, Boston, MA, 4Klinikum Bremerhaven, Bremerhaven, Germany, 5Private Urology Practice, Bremerhaven, Germany, 6VU University Medical Center, Amsterdam, Netherlands

 

Introduction: Anti-inflammatory effects of testosterone (T) have been demonstrated in numerous studies. Effects of T in auto-immune models have been studied experimentally (Fijak M et al., J Immunol 2011, 186: 5162-5172). We previously reported effects of two years of T treatment in a small group of hypogonadal men with Crohn’s disease (Haider A et al., Horm Mol Biol Clin Invest 2010; 2(3): 287–292).  

Methods: In a prospective, cumulative, observational registry study, 73 hypogonadal men with Crohn’s disease (n=71) and Colitis ulcerosa (n=2) with T ≤ 12 nmol/L from 2 centers in Bremerhaven, Germany and Aleppo, Syria received treatment with parenteral testosterone undecanoate every 12 weeks following an initial 6-week interval for up to 75 months. 12 hypogonadal men of similar age with Crohn’s disease did not receive T and served as control group (CTRL). In total, 73 men received T and 12 hypogonadal men remained untreated. The Crohn's Disease Activity Index (CDAI) was assessed every 3 months. Highly sensitive C-reactive protein (hsCRP) and leukocyte count were measured. The Aging Males’ Symptoms Scale (AMS) was used as a quality of life (QoL) instrument. 5 patients in the T group had osteoporosis. 

Results: T levels at baseline were 9.37 ± 1.08 nmol/L in the T group and 10.75 ± 0.36 in CTRL. During treatment, T increased to 15.72 ± 0.53 and slightly declined in CTRL. The CDAI decreased from 231.3 ± 35.96 to 75.0 in the T group and increased from 196.25 ± 7.11 to 210.0 in CTRL. hsCRP (mg/dl) levels at baseline were 14.01 ± 9.18 in the T group vs 7.3 ± 0.98 in CTRL. They decreased to 2.63 ± 1.91 after 72 months in the T group and increased to 13.7 in CTRL. Leukocyte count decreased from 12.42 ± 2. 46 to 5.97 ± 0.51 x 103 cells/µl in the T group and remained unchanged in CTRL (from 11.38 ± 1.29 to 12.7). AMS improved from 49.47 ± 8.11 in the T group to 17.33 ± 0.58. In CTRL, AMS remained unchanged from 47.17 ± 1.03 at baseline to 48 at the end of the observation period. 5 patients in the T group had osteoporosis. T-scores in these patients improved from approximately -2.9 to approximately -1.8. 

Conclusion: Normalisation of T in hypogonadal men with Crohn’s disease led to improvements of the CDAI, hsCRP , a reduction of leukocytes and an improvement of QoL. The mechanism of this improvement may be through anti-inflammatory and immunosuppressive effects of testosterone, reducing chronic inflammation of the intestinal wall in Crohn’s Disease.

 

Disclosure: FS: Employee, Bayer Schering Pharma. GD: Coinvestigator, Bayer Schering Pharma. AH: Speaker, Bayer Schering Pharma, Speaker, Takeda. Nothing to Disclose: MN, WK, LJG

13217 15.0000 SUN-0085 A Hypogonadal Patients with Crohn's Disease Benefit from Treatment with Testosterone – Data from an Ongoing, Long-Term, Observational Registry Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Ronald S. Swerdloff*1, Youngju Pak2, Christina Wang1, Peter Y Liu1, Shalender Bhasin3, Thomas M Gill4, Alvin M. Matsumoto5, Marco Pahor6, Prasanth Surampudi7, Sergei Romashkan8, Evan Hadley8 and Peter J Snyder9
1Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, 2Los Angeles Biomedical Research Insitute at Harbor-UCLA Medical Center, Torrance, CA, 3Brigham and Women's Hospital - Harvard Medical School, Boston, MA, 4Yale School of Medicine, New Haven, 5VA Puget Sound Hlth Care Sys, Seattle, WA, 6University of Florida, Gainesville, FL, 7Harbor - UCLA Med Ctr and Los Angeles Biomedical Research Institute, Torrance, CA, 8National Institute on Aging, Bethesda, MD, 9Univ of PA, Philadelphia, PA

 

Background: Older men have thinner skin and slower metabolic clearance that may affect the absorption of transdermal testosterone (T) and, hence, T concentrations.  We determined the 24h serum T PK after daily transdermal T gel in older men and evaluated whether ambulatory samples drawn 2h after gel application were reflective of Cavg over 24h during the PK day.

Subjects and Methods:  47 subjects in The T Trials (symptomatic men ≥65y with 2 early morning T values averaging <275 ng/dL enrolled in a double-blinded, placebo-controlled T replacement study) participated in a PK substudy after applying the gels for about 120 days. 27 men aged 71.6±5.6y (mean±SD) applied T gel, and 20 men aged 69.8±2.8y applied placebo gel. Height, weight, mean number of metered dose pump actuations were similar between the 2 groups. Dose adjustments occurred when serum T levels were measured to maintain serum T between 500-800 ng/dL. At 120±14 days, each participant had one inpatient PK day with serial samples drawn over 24h and ambulatory visits on two different days when serum T was measured 2h after supervised administration of the gels. Serum T(s) from each subject were measured in the same LC-MS/MS assay.

Results: Cavg, Cmax, Cmin and the Fluctuation Index (Cmax-Cmin )/Cavg) of serum T during the PK day were 452±178, 680±297, 281±143 ng/dl and 0.88±0.44 in the T gel group and 182±34, 229±40, 134±189 ng/dl and 0.52±0.17 in the placebo group. The within subject variability accounted for 54% and 53% of the total variance in the Cavg in T and placebo gel groups respectively. In the T gel group, only 22% of older men had Cavg within the target range of 500-800 ng/dl, while 81% had serum T between 300-1000 ng/dl. In those receiving T gel, serum T levels at 8h and 2 h alone accounted for 80% and 45% of the variability in Cavg.  2h ambulatory T levels on two different days did not correlate with Cavg on the PK day. The ambulatory levels correlated better with each other (r=0.67, p< 0.001) than with the 2h T levels during the PK day (r=0.22, and 0.20, both p=0.3) despite the same T dosage at all visits.

Conclusion: After T gel application, the within individual variations in the serum T levels are large. The 2h ambulatory serum T level post-application is not a good indicator of Cavg on another day.  In older men with low T, multiple dose adjustments may be needed to achieve serum T in the target range.  

 

Disclosure: RSS: Clinical Researcher, Abbott Laboratories. CW: Investigator, Clarus, Speaker, Lilly USA, LLC, Investigator, Besins Health Care, Investigator, Lipocine. SB: Principal Investigator, Abbott Laboratories, Principal Investigator, Eli Lilly & Company. AMM: Principal Investigator, Abbott Laboratories, Principal Investigator, GlaxoSmithKline, Consultant, Endo Pharmaceuticals, Consultant, Lilly USA, LLC, Consultant, GTx, Consultant, Forendo. PJS: Clinical Researcher, Abbott Laboratories. Nothing to Disclose: YP, PYL, TMG, MP, PS, SR, EH

13964 16.0000 SUN-0086 A Testosterone Pharmacokinetics (PK) in Older Men Participating in the Testosterone Trials (The T Trials) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Amit R Bodhani*1, Lindsay Parker2, Zarmina Khankhel3, Mahesh J Fuldeore4 and Adrian S Dobs5
1AbbVie Inc., North Chicago, IL, 2Evidera, Lexington, MA, 3Evidera, London, United Kingdom, 4AbbVie, North Chicago, IL, 5Johns Hopkins University School of Medicine, Baltimore, MD

 

Background and Objective: Hypogonadism (HG) adversely impacts sexual function and quality of life.  Limits of current detection and screening techniques may delay or hinder timely diagnosis and treatment and may lead to significant economic implications. We systematically reviewed research on diagnosis and real-world treatment of HG to better understand challenges in diagnosis, limitations of current diagnostic techniques, and HG diagnosis and treatment rates in the United States (US).

Methods: We searched MEDLINE, Embase (2002-2012), and government and professional organizations for literature related to HG diagnostic guidelines and techniques and US diagnosis and treatment rates. Publications were included if they met predefined criteria and were abstracted for relevant information.

Results: Out of the 65 articles retrieved, 24 were included based on our criteria. International, European, and US guidelines recommend basing HG diagnosis on persistent symptoms and consistently low T levels on ≥2 occasions. The standard diagnostic technique is serum total T (TT) measurement. However no age-specific low T values have been determined, and standards vary by laboratory; serum TT <300 ng/dL is commonly, though not universally, used to diagnose T deficiency. When TT levels are borderline low or clinical symptoms persist despite normal TT, guidelines recommend measuring free T and/or T bound to sex hormone-binding protein (SHBG). Available screening tools cannot replace biochemical diagnosis; they are highly sensitive (60%-90%) but lack specificity (30%-70%). Current guidelines advise against salivary T tests due to lack of standardized methodology and reference ranges for T, although they may reliably identify HG and correlate with serum T. Few studies examined diagnostic and treatment rates in the US. Diagnostic rates vary based on different techniques; biochemical HG diagnosis rates resemble older estimates at about 35%–41% among aging men screened in medical practices.

Conclusion: Limitations of current diagnostic guidelines and techniques contribute both to low HG recognition and low treatment rates once recognized. Screening tools are non-specific and can only be used as guides to interpret laboratory criteria. Standardized reference values for low TT are needed for consistent HG diagnosis. Additional guidance is needed on the optimal combination of techniques to improve the accuracy of diagnosis, and thus enable the identification and treatment of HG patients.

 

Disclosure: ARB: Employee, Abbott Laboratories, Employee, Abbott Laboratories. LP: Independent Contractor (including contracted research), Abbott Laboratories. ZK: Independent Contractor (including contracted research), Abbott Laboratories. MJF: Employee, Abbott Laboratories, Employee, Abbott Laboratories. Nothing to Disclose: ASD

13881 17.0000 SUN-0087 A Limitations of Hypogonadism Diagnosis and Rate of Treatment in Males in the US: A Systematic Literature Review 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Ronald S. Swerdloff*1, Wael A. Salameh2, Adrian S Dobs3, James A. Longstreth4, Sandra M. Faulkner2, Robert E. Dudley2, Gregory M. Flippo5, John K. Amory6, Jed C. Kaminetsky7, Theodore M. Danoff2 and Christina Wang1
1Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, 2Clarus Therapeutics, Inc, Northbrook, IL, 3Johns Hopkins University School of Medicine, Baltimore, MD, 4Longstreth & Associates, Mundelein, IL, 5Alabama Clinical Therapeutics, LLC, Pinson, AL, 6Univ of WA Med Ctr, Seattle, WA, 7Manhattan Medical Research, New York, NY

 

Introduction:  An oral route of administration for a testosterone (T) replacement therapy (TRT) has potential convenience, compliance and safety advantages over current therapies for  hypogonadism marketed in the US that are delivered by oral, transdermal or injectable routes. Outside the US, oral Testosterone Undecanoate (TU) is available and has a long history of safety but the short serum half-life and variable absorption results in low trough serum T levels.  A novel formulation of oral TU that utilizes a SEDDS (Self-Emulsifying Drug Delivery System) and that offers the possibility of better efficacy was evaluated in two Phase 3 trials.

Subject and Methods:  Both trials recruited hypogonadal men (serum T ≤ 300 ng/dL) age 18-75 years old into open-label, multicenter, dose-titration trials.  Trial I was a randomized, active-controlled, 2-arm, 12-month study in 325 hypogonadal men.  Participants were randomized to either oral TU (n=162) or 1% AndroGel® (n=163), a commonly prescribed TRT.  Trial II was a single-arm 114-day study with oral TU (n=144). The starting dose of oral TU (as T equivalents) in both studies was 200 mg BID dosed with food. There were up to 2 dose-titration opportunities, but the trials differed in: 1) Timing of the post-dose sample used for dose titration (Trial I: 4-6 h, Trial II: 3-5 h); 2) T concentration thresholds for dose adjustment (Trial I: 250-1100 ng/dL, Trial II 250-700 ng/dL); and 3) size of the dose adjustment (Trial I 100 mg, Trial II 50 mg T equivalent).  Efficacy was assessed on Day 90 in Trial I and Day 114 in Trial II based on T Cavg from serial serum samples collected over 24 hours for T assayed by LC-MS/MS.  

Results:  In Trial I, T Cavg value was 628 ± 342 ng/dL (mean ± SD) with oral TU and 485 ± 220 ng/dL with T-gel with 84% and 79% of oral TU and T-gel subjects, respectively, in the eugonadal range (defined as 300-1000  ng/dL).  In Trial II the T Cavg was 422 ± 171 ng/dL with 75% of subjects in the eugonadal range.  Serum T peak (Cmax) excursions occurred in both trials but with the revised dose-titration algorithm used in Trial II only 6% of subjects had a Cmax between 1800-2500 ng/dL and only 3% >2500 ng/dL. These Cmax excursions were infrequent, transient and inconsistent for any given subject.

Conclusions: Both trials demonstrated effective T replacement and with the revised dose-titration algorithm the Cmax was comparable to other TRTs.  This novel SEDDS formulation of TU fulfills an unmet need for an effective oral T replacement therapy in hypogonadal men.

 

Disclosure: RSS: Consultant, Clarus, Investigator, Novartis Pharmaceuticals, Consultant, Endo Pharmaceuticals, Investigator, Abbott Laboratories. WAS: Chief Scientific Officer, Clarus. JAL: Independent Contractor (including contracted research), Clarus. SMF: Employee, Clarus. RED: Employee, Clarus. JKA: Investigator, Clarus. TMD: Employee, Clarus. CW: Investigator, Clarus, Speaker, Lilly USA, LLC, Investigator, Besins Health Care, Investigator, Lipocine. Nothing to Disclose: ASD, GMF, JCK

11142 18.0000 SUN-0088 A Pharmacokinetics and Efficacy of a New S.E.D.D.S. Formulation of Oral Testosterone Undecanoate (TU) in Hypogonadal Men: Data from Two Phase 3 Trials with Different Dose-Titration Algorithms 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Ronald S. Swerdloff*1, Wael A. Salameh2, Adrian S Dobs3, Sandra M. Faulkner2, Robert E. Dudley2, Gregory M. Flippo4, Jed C. Kaminetsky5, John K. Amory6, Theodore M. Danoff2 and Christina Wang1
1Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, 2Clarus Therapeutics, Inc, Northbrook, IL, 3Johns Hopkins University School of Medicine, Baltimore, MD, 4Alabama Clinical Therapeutics, LLC, Pinson, AL, 5Manhattan Medical Research, New York, NY, 6Univ of WA Med Ctr, Seattle, WA

 

Introduction:  An oral testosterone (T) replacement therapy (TRT) would be the preferred choice for many hypogonadal men.  Currently the only oral TRT approved in the US is methyl-T which has hepatotoxicity concerns. The safety of a novel oral TU formulation utilizing a Self-Emulsifying Drug Delivery System (SEDDS) with improved T replacement characteristics was evaluated in two Phase 3 trials.

Subject and Methods:  Both were open-label, multicenter, dose-titration trials in hypogonadal men (serum T ≤ 300 ng/dL) age 18-75.  Trial I was a randomized, active-controlled, 2-arm, 12-month study. Participants were randomized to either oral TU (n=162) or 1% AndroGel® (n=163), which was included for safety comparison.  Trial II was a single-arm 114-day study with oral TU (n=144). The trials differed in their dose-titration algorithms for oral TU that resulted in a lower T Cavg in Trial II (422 ng/dL) v. Trial I: (628 ng/dL) and fewer high Cmax excursions in Trial II.  Safety was assessed through adverse event (AE) reporting, routine clinical laboratory and dihydrotestosterone (DHT) measurements.

Results: No deaths occurred in either trial.  In Trial I, the incidence of AEs was similar between T-gel (62%) and oral TU (68%) groups, while serious AEs were 4% and 7% (only 1% in oral TU deemed treatment related), respectively. A single case of prostate cancer occurred in the T-gel group. The most frequently reported classes of AEs for all subjects were infection, GI, reproductive system, breast, musculoskeletal and connective tissue disorders.  In Trial II the incidence of AEs was 49% with 1% considered serious but not treatment-related, and the pattern was similar to Trial I.  LFT elevations were rare and inconsequential in both trials. In Trial I, total and LDL cholesterol, triglycerides and PSA were not statistically significantly different between the two groups.  The HDL-C reduction from baseline (associated with all TRT to some degree) was greater in Trial I (T-gel 12% and oral TU 22%) than Trial II (oral TU only; 9%).  In Trial I no differences between oral TU and T-gel were observed for hs-CRP and Lp-PLA2. Hct increased in TU subjects by 3% but mean values remained within the normal range. DHT and DHT/T ratio rose in both groups but were greater with oral TU v. T-gel.  However, in Trial II the impact of oral TU was considerably less. The observed effect of oral TU on DHT and DHT/T ratio was deemed clinically neutral as it was less than reported with other TRTs.  Moreover, studies with DHT-gel have not revealed safety signals relative to Hct or prostate.

Conclusion: These two Phase 3 trials demonstrate that this novel SEDDS formulation of oral TU has a safety profile consistent with other TRTs and is well tolerated in hypogonadal men.  With the final oral TU dose-titration algorithm, HDL-C reduction (9%) was similar to that observed with T-gel (12% in Trial I). CV biomarkers did not indicate a T effect in either the TU or T-gel group.

 

Disclosure: RSS: Consultant, Clarus, Investigator, Novartis Pharmaceuticals, Consultant, Endo Pharmaceuticals, Investigator, Abbott Laboratories. WAS: Chief Scientific Officer, Clarus. SMF: Employee, Clarus. RED: Employee, Clarus. JKA: Investigator, Clarus. TMD: Employee, Clarus. CW: Investigator, Clarus, Speaker, Lilly USA, LLC, Investigator, Besins Health Care, Investigator, Lipocine. Nothing to Disclose: ASD, GMF, JCK

14196 19.0000 SUN-0089 A Safety of a New S.E.D.D.S. Formulation of Oral Testosterone Undecanoate (TU) in Hypogonadal Men: Data from Two Phase 3 Trials with Different Dose-Titration Algorithms 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Christina Wang1, Martin M. Miner*2, Yusong Chen3, Ronald S. Swerdloff1 and Adrian S Dobs4
1Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, 2Brown University and the Miriam Hospital, Providence, RI, 3Endo Pharmaceuticals Inc, Malvern, PA, 4Johns Hopkins University School of Medicine, Baltimore, MD

 

Background/Objective: Testosterone (T) treatment for male patients with hypogonadism can improve signs and symptoms. Guidelines from The Endocrine Society recommend raising T concentrations into the midnormal range for adult men, without reaching excessively high T concentrations. A US phase 3 study was conducted to evaluate the pharmacokinetics (PK) of intramuscular (IM) testosterone undecanoate (TU) in hypogonadal men using varying doses and dosing regimens to achieve (1) average T concentrations (Cavg) within the adult eugonadal range (300–1000 ng/dL) and (2) ≤5% of men with maximum T concentration (Cmax) ≥1800 ng/dL.

Methods: Dosing regimens – Part A (n=237): 750 mg (A-750) or 1000 mg (A-1000) TU IM every 12 weeks (max, 13 total injections). Part B (n=134): 1000-mg TU loading dose, then either 750 mg (B-750) or 1000 mg (B-1000) 8 weeks later, followed by the same dose every 10  weeks (750 mg) or 12 weeks (1000 mg) thereafter (max, 10 [B-750] or 8 [B-1000] injections). Part C (cohort 1 [n=130; published in (1)]; cohort 2 [n=23]): 750 mg (C-750) TU IM initial dose, 4 weeks later, and then every 10 weeks (max, 9 injections). Serum T intensive PK (IPK) was assessed after the second (part C, cohort 2), third (part B), or fourth (part A) injections. Adverse events (AEs) and tolerability were assessed.

Results: At screening, Cavg was 187.3, 189.1, and 197.6 ng/dL in parts A, B, and C (cohort 2), respectively. All dosing regimens produced mean Cmax within the eugonadal range and had similar IPK profiles. Mean Cmax was highest with the 1000-mg TU dose, regardless of dosing regimen. With all dosing regimens, most men had Cmax ≤1500 ng/dL (A-750: 115/119 [96.6%]; A-1000: 101/114 [86.3%]; B-750: 21/22 [95.5%]; B-1000: 95/112 [84.8%]; C-750: 22/23 [95.7%]). Cmax ≥1800 ng/dL occurred only in the A-1000 (7/114 [6.1%]) and B-1000 (9/112 [8.0%]) arms; none of the men receiving 750 mg TU in parts A or C had Cmax ≥1800 ng/dL. TU was well tolerated in all dosing regimens. The most common AEs in part C after injection 2 (cohort 2) were influenza-like illness and sinusitis (2 patients each); none were considered treatment related; no shortness of breath was reported. AEs for Part C (750 mg) injections 3 and 4 (cohort 1) were previously published and 1 patient experienced a pulmonary reaction event (mild coughing) after a single injection (received 6 additional injections), which resolved in 10 minutes (1).

Conclusions: TU 750 mg at baseline, 4 weeks, and then every 10 weeks (C-750) resulted in most men achieving eugonadal Cmax within the injection 2 interval and no men with Cmax ≥1800 ng/dL (unlike the other dosing regimens). Additional injections using the C-750-mg dosing regimen maintained Cavg (494.0 ng/dL) within the eugonadal range, indicating that this regimen provided the most physiologic T levels (1). All injections were tolerated without notable AEs.

 

Disclosure: CW: Investigator, Clarus, Speaker, Lilly USA, LLC, Investigator, Besins Health Care, Investigator, Lipocine. MMM: Consultant, Endo Pharmaceuticals, Researcher, Forest. YC: Employee, Endo Pharmaceuticals. RSS: Consultant, Endo Pharmaceuticals. Nothing to Disclose: ASD

14875 20.0000 SUN-0090 A The Pharmacokinetics of Different Doses and Dosing Regimens of Testosterone Undecanoate Injection for the Treatment of Male Hypogonadism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Emily F Shortridge*1, Paula K Polzer1, Prina Donga2, Michael Marcus2 and Rolin L Wade2
1Eli Lilly and Company, Indianapolis, IN, 2IMS Health, Plymouth Meeting, PA

 

Background: Men are diagnosed with hypogonadism (HG) based on low testosterone levels and self-reported symptoms. While HG is interrelated with type 2 diabetes (T2DM), there is little information about men’s experiences with HG, T2DM, and patterns of testosterone replacement therapy (TRT). This study examined symptoms and TRT use among HG men with and without T2DM who sought care in a single US health plan.

Methods: Men ≥18 years with HG with and without T2DM were identified from the 2008-2010 Reliant electronic medical records database. Surveys, including validated instruments for measuring symptoms of HG, were collected and results were compared by diabetic status using chi square or Wilcoxon Rank Sum tests.  

Results: A total of 93 men comprised the analysis (19 HG+T2DM, 74 HG-only). Median age at HG diagnosis was 50 years and was similar between the two cohorts. 28.4% of men with HG-only reported being treated for their HG by an endocrinologist compared to 52.6% of men with HG+T2DM (P=0.058). Men with HG+T2DM reported that their overall physical health was significantly worse than men with HG-only (P=0.029). Erectile dysfunction (ED) was the primary reason for seeking care among all men surveyed, although HG+T2DM men reported ED significantly more often (89.5%) than men with HG-only (60.8%; P=0.027). Additionally, men with T2DM reported experiencing ED (94.7%) more than men with HG-only (45.9%; P<0.0001) at the time of the survey. Other reasons for seeking care were similar among HG men with and without T2DM and included loss of energy and decreased sex drive. All men were less likely to report experiencing the symptoms of loss of energy and decreased sex drive at the time of the survey compared to when they initially sought care. Most men reported using TRT (89.5% T2DM, 87.8% HG-only), primarily as injection or gel formulations. TRT discontinuation was reported by 68.4% vs. 55.4% of HG+T2DM and HG-only men (P>0.05) due in part to lack of efficacy and/or cost of treatment.

Conclusions: This study provides information about symptoms and TRT utilization in HG men with and without T2DM. ED was the primary reason for all men seeking care. The proportion of men who continued to report ED remained high among men with HG+T2DM, while there were fewer reports of ED in men with HG-only.  The high proportion of HG+T2DM men who continued to report ED may underscore the need for research into the multiple factors that contribute to ED and efforts to improve treatment efficacy for this population.

Disclosures: EFS and PP are Lilly employees. PD, MM, and RLW are employees of IMS Health.

Funding: This study and preparation of this paper were funded in full by Eli Lilly and Company.

 

Disclosure: EFS: Employee, Eli Lilly & Company. PKP: Clinical Researcher, Eli Lilly & Company. PD: Researcher, Eli Lilly & Company. RLW: Researcher, Lilly USA, LLC. Nothing to Disclose: MM

11771 21.0000 SUN-0091 A Symptoms and Treatment Experiences of Hypogonadal Men with and without Type 2 Diabetes in a US Health Plan 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Arif Yonem*1, Eylem Cagiltay2, Ebubekir Baspinar2, Ahmet Seyit Ay3, Levent Ozsari4 and Ferhat Deniz1
1GATA Haydarpasha Training Hospital, Istanbul, Turkey, 2Haydarpasha Training Hospital, Gulhane Military Medical Academy, Istanbul, Turkey, 3GATA HAYDARPASHA Training Hospital, ISTANBUL, Turkey, 4Diyarbakir Military Hospital, Diyarbakir, Turkey

 

Androgen deficiency is a major health and social problem. It causes a number of metabolic disturbances, and has a role on quality of life and lifespan. Sirtuins have a role in many cellular events such as energy metabolism, stress response, oncogenesis, inflammation and especially lifespan(1). Effects of sirtuins on the reproductive system has not been studied much yet. In this study, our aim is to investigate the relationship between testosterone deficiency and sirtuins. Twenty-five male patients with hypogonadotropic hypogonadism and 30 healthy male volunteers were included in the study. Mean serum sirtuin 1 (SIRT1) levels of hypogonadotropic hypogonadism patients and healthy subjects were compared. Relationship between serum sirtuin-1 serum level and age, body mass index(BMI), testosterone, gonadotropin levels and insulin resistance were evaluated. Mean serum sirtuin-1 levels of patients and controls were 21,81±13,57 ng/ml and 17,58±13,24 ng/ml, respectively. There wasn’t any statistical difference between serum sirtuin-1 levels of two groups. (p>0,05). Additionally, serum sirtuin 1 level showed no relation to age, BMI, serum levels of testosterone, lipids, and insulin resistance. However, we concluded that more research should be done on this subject including different groups of age and sex, with different sirtuins, and measurements of tissue levels of sirtuins in addition to serum levels of sirtulins.

 

Nothing to Disclose: AY, EC, EB, ASA, LO, FD

13256 22.0000 SUN-0092 A Serum Sirtuin-1 Levels in Male Hypogonadotropic Hypogonadism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Mirjana Pavlic*1 and Richard Arthur Bebb2
1University of British Columbia, Vancouver, BC, Canada, 2Univ of British Columbia, Vancouver, BC, Canada

 

Obstructive sleep apnea (OSA) is a disorder characterized by repetitive apneic events resulting in hypoxia and hypercapnia affecting 4 to 25% of adult males. OSA is associated with obesity, hypertension, hypogonadism and increased cardiovascular morbidity. Testosterone (T) deficiency has multiple adverse effects on health, including loss of muscle, sexual dysfunction and impaired quality of life and has been associated with increased mortality. Continuous positive airway pressure therapy (CPAP) and weight loss increase T levels in men with OSA however, relative androgen deficiency may not be fully reversed, leading to long-standing hypothalamo-pituitary-gonadal (HPG) dysregulation. The role of T in men with OSA is controversial because concerns regarding respiratory safety. Additionally, exogenous T leads to suppression of the HPG axis with recovery lasting weeks to months following discontinuation of therapy, independent of OSA.

Clomiphene citrate (CC) is a weak estrogen receptor antagonist that competes with estradiol feedback at the pituitary and hypothalamic levels increasing LH, FSH, steroidogenesis and spermatogenesis in men, and inducing ovulation in women. CC in OSA has several potential benefits over T. Firstly, it does’t cause suppression of HPG axis, secondly it’s not associated with erythrocytosis and thirdly, it does’t suppress spermatogenesis. Use of CC in OSA induced hypogonadism has not yet been investigated and no retrospective trials have been preformed to assess efficacy of CC in OSA induced hypogonadism. 

We preformed a retrospective chart review to assess the effect of CC on HPA axis in patients with OSA induced hypogonadism. Charts at the Men’s Health Initiative in Vancouver dating from 1998 to 2013 were searched using keywords including CC, hypogonadism and OSA. Charts meeting criteria were reviewed and serum T, LH, FSH levels were analyzed at baseline and after initiating therapy to assess for efficacy of CC in restoration of HPG axis.

We hypothesized that CC is effective treatment of OSA induced hypogonadism. Our specific aims were to assess the effect of CC on HPG axis by analyzing T, LH and FSH in OSA patients with biochemically confirmed hypogonadism; assess effects on spermatogenesis and assess sustainability of restoration of HPG axis following discontinuation of CC.

Our preliminary results support this, as demonstrated by an increase in all three hormones following CC therapy. There was a 58.3%, 50.1% and 50.6% increase from baseline at 2 months in T, LH and FSH levels respectively, and this was maintained at 45.1%, 63.0% and 60.3% at 4 months (N=8).

This is the first larger retrospective case series to demonstrate benefit of CC in restoring HPG axis in OSA induced hypogonadism.

 

Nothing to Disclose: MP, RAB

12143 23.0000 SUN-0093 A Clomiphene Citrate in Treatment of Obstructive Sleep Apnea Induced Hypogonadism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Garineh Ovanessoff*1, Gaja Andzel1, John Matchette1 and Sherman Mitchell Harman2
1Phoenix VA Health Care System, Phoenix, AZ, 2Kronos Longevity Research Institute, Phoenix, AZ

 

Background:  Hypothalamic hypogonadism (HH) is common in patients in VA endocrine clinics. Usual treatment is injected or transdermal testosterone (T), modalities both inconvenient and expensive. In young veterans, fertility and testicular atrophy are often of concern, since T suppresses the hypothalamic-pituitary-gonadal (HPG) axis. Recently, clomiphene, a partial estrogen agonist/antagonist employed in female infertility, has been shown to increase LH and T production in male hypogonadism. We tested clomiphene citrate as a treatment for secondary hypogonadism in men without evident pituitary disease, some of whom had concomitant conditions that suppress the HPG axis.

Methods:  Subjects were recruited from the Phoenix VA Medical Center endocrinology clinic. Inclusion criteria were:  diagnosis of HH (T level < 250 ng/dl, no LH elevation, no significant pituitary abnormality on MRI or CAT), age 30-70 y, and able to communicate and provide informed consent. Exclusion criteria were pituitary tumor >5mm, chronic renal, liver or heart disease, chronic non-compliance, PSA ≥ 4.0 ng/ml, history of prostate, testicular or breast cancer, or cataracts limiting vision. Subjects were treated with oral clomiphene for 7 weeks, initially at 25 mg per day.  Dose was increased to 50 mg/day if T level after week 3 was <450 ng/dl.  The primary endpoint was total T by immunometric assay. Values were compared vs. week 0 by repeated measures ANOVA.  Physical exam was performed at baseline and week 7; laboratory tests were drawn at weeks 0, 3, and 7. We called subjects at weeks 2, 4, and 6 to assess adverse effects.

Results: Of 9 men recruited to date, 1 dropped out at 4 weeks and 8 completed.  Mean age of participants was 51±12 y. At week 3 only 2/9 men were at goal of 450 ng/dl, which increased to 7/8 at week 7.  Mean week 0 T was 184±67 ng/dl with LH of 3.6±2 mIU/ml. Mean T±SD at 3 weeks was 355±168 ng/dl (p=0.005); 7/9 patients required a dose increase. Mean week 7 T was 541±196 ng/d l (p<0.001), with LH of 10.3±5 mIU/ml (p=0.008). Mean Hct at week 7 was 45±4% (p=0.6) and PSA was 1.5±1.7 ng/dl (NS).  Adverse events included hot flashes (3), headache (2), and nausea (1), mainly transient. One patient had acute gout, likely not due to study medication.

Discussion: Clomiphene was well-tolerated and raised T levels to goal in most subjects, making it a promising alternative to T preparations. The study is still underway. Additional results to be reported will include effects on lipid profiles and a comparison of men previously treated vs. not treated with T.

 

Nothing to Disclose: GO, GA, JM, SMH

13125 24.0000 SUN-0094 A Testosterone Response to Clomiphene Citrate in Veterans with Hypothalamic Hypogonadism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Ersen Karakilic*1, Bercem Aycicek Dogan2, Mazhar Muslum Tuna3, Mehtap navdar Basaran1, Mustafa Unal4, Dilek Berker2 and Serdar Guler5
1Ankara Numune Education and Training Hospital, Ankara, Turkey, 2Ankara Numune Education and Research Hospital, Ankara, Turkey, 3Ankara Numune Education and Research Hospital, Ankara, Turkey, 4ankara numune training and education hospital, ANKARA, Turkey, 5Hitit University, Faculty of Medicine, Corum, Turkey

 

Introduction

Association of gonadotrophin and androjen hormones with thyroid volume has not been researched in young males yet. The present study aimed to evaluate difference of thyroid volume in patients with idiopathic hypogonadotrophic hypogonadism (IHH).

Material and Methods

We enrolled new diagnosed 34 patients with IHH (mean age: 28±9.6), and 20 healthy controls (mean age:31±6.2) who were admitted to Ankara Numune Training and Education hospital between 2011-2014 years. All subjects were lived in same country. The patients with thyroid diseases were excluded. FSH, LH, total testosterone, free testosterone, estradiole, free t4 (fT4), free t3 (fT3), TSH, anti-TPO, anti-TG, insulin, fasting blood glucose were evaluated. Thyroid volumes (TV) were measured by an experienced endocrinologist using a high-resolution ultrasound.

Results

There were not any differences regarding to age, BMI among the two groups (p>0.05). TSH, fT4, fT3, anti-TPO, anti-TG, insulin, fasting blood glucose were similar in two groups (p>0.05). Total testosterone was lower in patients with IHH than control subjects (p<0.05). Thyroid volume of patients with IHH (mean value of TV=10.8 ml±7.1) was significantly smaller than control subjects (mean value of TV=17.6 ml±8.1) (p=0.009). There was positive correlation only between total testosterone and thyroid volume in patients with IHH (p=0.001, r=0.604). 

Conclusion

 Our study revealed that thyroid volume was smaller in patients with IHH. If our ongoing prospective study will confirm this result, it can be said that testosteron is a hormon which is efficient on thyroid volume.

 

Nothing to Disclose: EK, BAD, MMT, MNB, MU, DB, SG

16873 25.0000 SUN-0095 A The Relationship Between Testosterone Levels and Thyroid Volume in Young Men with Idiopathic Hypogonadotropic Hypogonadism: Preliminary Results of a Prospective Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Jane A Cauley*1, Laura Fluharty2, Susan Ellenberg3, Thomas M Gill4, Kristine E Ensrud5, Elizabeth Louise Barrett-Connor6, Denise Cifelli7, Glenn R Cunningham8, Alvin M. Matsumoto9, Shalender Bhasin10, Marco Pahor11, John T Farrar12, David Cella13, Raymond C. Rosen14, Susan M Resnick15, Ronald S. Swerdloff16, Cora E Lewis17, Mark E Molitch18, Jill P Crandall19, Alisa Stephens20, Christina Wang16, Sergei Romashkan21, Evan Hadley21 and Peter J Snyder22
1University of Pittsburgh, Pittsburgh, PA, 2Perelman School of Medicine, University of Pennsylvania, 3Univ of Pennsylania Schl of Me, Philadelphia, PA, 4Yale School of Medicine, New Haven, 5University of Minnesota, Minneapolis, MN, 6Univ of CA - San Diego, La Jolla, CA, 7Perelman School of Medicine, University of Pennsylvania, Philadelphia, 8Baylor Coll of Med, Houston, TX, 9VA Puget Sound Hlth Care Sys, Seattle, WA, 10Brigham and Women's Hospital - Harvard Medical School, Boston, MA, 11University of Florida, Gainesville, FL, 12University of Pennsylvania School of Medicine, Philadelphia, PA, 13Northwestern University Feinberg School of Medicine, 14New England Research Institutes, Inc., Watertown, MA, 15Natl Inst on Aging, Baltimore, MD, 16Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, 17Univ of Alabama at Birmingham, Birmingham, AL, 18Northwestern University Feinberg School of Medicine, Chicago, IL, 19Albert Einstein College of Medicine, Bronx, NY, 20University of Pennsylvania School of Medicine, 21National Institute on Aging, Bethesda, MD, 22Univ of Pennsylvania, Philadelphia, PA

 

Background: Complex randomized clinical trials present recruitment challenges because of the many stringent inclusion and exclusion criteria.  We describe here the recruitment results of the TTrials, a coordinated set of 7 randomized trials to determine the efficacy of testosterone (T) treatment of symptomatic older elderly men with low testosterone. 

Methods:  Men were eligible if they were ≥ 65 years of age, had symptoms and objective evidence of sexual dysfunction, impaired mobility, or low vitality and 2 early morning total testosterone values that averaged  <275 ng/dl.  Men could enroll in more than 1 of the 3 main trials if they qualified.  We examined the yields at each of two screening visits (SV) and at randomization.  We also compared the characteristics of men in each trial and men enrolled in multiple main trials.

Results: Men were recruited primarily through mass mailings from population-based lists of age-eligible men in 12 US areas.  Men who responded were initially screened by telephone to ascertain symptoms and potential exclusions (e.g., history of prostate cancer): > 51,000 telephone screens were completed.  Overall, 53.5% of men were eligible at the telephone screen (45%, sexual function; 28%, physical function and 49%, vitality trials).  We completed 23,889 SV1: 4,700 (19.7%) men were eligible by T level; 7.5% were ineligible by high prostate cancer risk; 13.4% were excluded for other reasons; overall 2,781 (11.6%) were eligible for the SV2.  Of these, 2,261 (81.3%) completed SV2.   At SV2, 515 (22.8%) men did not meet objective criteria for impairment and another 8.6% were excluded for other reasons and 218 (9.6%) were excluded by T level.    

After SV2, 931 (41.2%) men were eligible for randomization and 789, (84.6%) were randomized; 99 (12.5%) in all 3 trials and 348 (44%) in 2 trials.  The mean age was 72 years and mean BMI 31.0 kg/m2.  Mean (SD) total T was 238.1 (68.9) ng/dl and free T, 58.2 (20.3) pg/ml.  Men in the Physical Function trial tended to be older than men in the other 2 trials, but there was no difference in total T across trials.  Men who qualified for all 3 trials tended to have the lowest physical and sexual function scores and more fatigue.

Conclusions:  We successfully met or exceeded our recruitment goals for each trial and randomized 789 older hypogonadal men with unequivocally low serum T and subjective and objective impairment, in spite of a screening/enrollment ratio of 64/1.

 

Disclosure: JAC: Consultant, Merck & Co.. SE: Consultant, Bristol-Myers Squibb, Consultant, Merck & Co., Consultant, Jansen Pharmaceuticals, Consultant, Johnson &Johnson, Consultant, Endo Pharmaceuticals, Consultant, Otsuka, Speaker, Amgen. KEE: Consultant, Merck & Co.. GRC: Advisory Group Member, AbbVie, Consultant, Clarus, Advisory Group Member, Endo Pharmaceuticals, Consultant, Ferring Pharmaceuticals, Consultant, Purdue Pharma, Consultant, Repros Therapeutics. AMM: Clinical Researcher, Abbott Laboratories, Clinical Researcher, GlaxoSmithKline, Consultant, Abbott Laboratories, Consultant, Endo Pharmaceuticals, Consultant, Lilly USA, LLC, Consultant, GTX, Consultant, Forendo. SB: Principal Investigator, Abbott Laboratories, Principal Investigator, Eli Lilly & Company. RCR: Principal Investigator, Lilly USA, LLC, Principal Investigator, Bayer, Inc., Principal Investigator, Boehringer-Ingelheim, Consultant, Lilly USA, LLC, Consultant, Allergan. RSS: Investigator, Clarus, Investigator, Novartis Pharmaceuticals, Consultant, Clarus, Consultant, Endo Pharmaceuticals, Consultant, Antares, Consultant, Lawley Hormonal Sol, Clinical Researcher, Clarus, Clinical Researcher, Lipocine. MEM: Investigator, Corcept, Consultant, Corcept, Investigator, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals. CW: Speaker, Lilly USA, LLC, Investigator, Clarus. PJS: Principal Investigator, AbbVie. Nothing to Disclose: LF, TMG, ELB, DC, MP, JTF, DC, SMR, CEL, JPC, AS, SR, EH

13039 26.0000 SUN-0096 A Screening and Recruitment for the Testosterone Trials (TTrials) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Aksam A Yassin*1, Ahmad Haider2, Gheorghe Doros3, Abdulmaged M Traish4 and Farid Saad5
1Institute of Urology and Andrology, Norderstedt, Germany, 2Private Urology Practice, Bremerhaven, Germany, 3Boston University School of Public Health, Boston, MA, 4Boston University School of Medicine, Boston, MA, 5Bayer Pharma AG, Berlin, Germany

 

Introduction: Improvements of metabolic parameters on long-term testosterone replacement therapy (TRT) from our registry studies have been reported in 2013 (Traish, Int J Clin Pract).  

Methods: 561 hypogonadal men from both registry studies were divided into age groups ≤65 (Group A, n=450) and >65 years (Group B, n=111). All men were treated with three-monthly TU injections for up to 6 years.  

Results: Total cholesterol (TC, mg/dl) decreased from 268.92±45.95 to 193.56±16.58 in Group A and from 268.44±52.69 to 191.69±21.8 in Group B, LDL (mg/dl) from 159.87±36.7 to 119.81±34.87 in Group A and from 162.48±31.63 to 120.86±33.56 in Group B, triglycerides (mg/dl) from 262.35±73.16 to 192.1±34.4 in Group A and from 266.9±84.37 to 192.27±32.16 in Group B. HDL (mg/dl) increased from 48.91±17.33 to 59.55±17.66 in Group A and from 51.64±16.56 to 61.99±16.87 in Group B.  

TC:HDL ratio improved from 6.15±2.42 to 3.54±1.04 in Group A and from 5.67±2.09 to 3.32±0.91 in Group B (p<0.0001 for all). 

Fasting glucose (mg/dl) decreased from 104.18±22.17 to 96.44±8.44 in Group A and from 119.07±40.01 to 101.74±19.37 in Group B. HbA1c (%) decreased from 6.64±1.32 to 5.66±0.65 in Group A and from 7.0±1.38 to 5.94±0.82 in Group B with mean changes from baseline of -1.15±0.04 and -1.37±0.09%, resp. (p<0.0001 for all). 

Systolic blood pressure (mmHg) decreased from 145.51±17.73 to 132.39±10.41 in Group A and from 147.01±15.78 to 132.13±10.53 in Group B. Diastolic blood pressure decreased from 87.33±11.69 to 78.47±5.36 in Group A and from 89.36±10.54 to 78.7±6.22 in Group B (p<0.0001 for all). 

Liver enzymes: AST (U/L) decreased from 35.8±16.04 to 22.83±6.43 in Group A and from 31.33±14.71 to 22.39±6.47 in Group B. ALT (U/L) decreased from 38.17±18.92 to 24.64±10.66 in Group A and from 37.5±22.77 to 24.73±9.52 in Group B (p<0.0001 for both). 

C-reactive protein (CRP, mg/L) declined from 4.04±6.34 to 0.75±1.06 in Group A and from 2.65±3.75 to 0.71±0.51 in Group B (p<0.0001 for all). 

Conclusions: TRT in hypogonadal men resulted in sustained improvements of all metabolic syndrome parameters independent of age. Reductions in liver enzymes suggest reductions in liver fat content, as observed by Hoyos et al. (Eur J Endocrinol 2012; 167: 531-541). Reductions in CRP confirm the anti-inflammatory properties of testosterone.

 

Disclosure: AAY: Speaker, Bayer Schering Pharma, Speaker, Ferring Pharmaceuticals. AH: Speaker, Bayer Schering Pharma, Speaker, Takeda. GD: Coinvestigator, Bayer Schering Pharma. FS: Employee, Bayer Schering Pharma. Nothing to Disclose: AMT

13210 27.0000 SUN-0097 A Metabolic Syndrome Parameters in Hypogonadal Men on Long-Term Treatment with Testosterone Undecanoate (TU) Injections Improve Independently from Age: Observational Data from Two Registry Studies 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Liudmila Ivanova*1 and Inna Korol2
1Kuban State Medical University, Krasnodar, Russia, 2Kuban State Medical University

 

Aim of our study was improvement schemes of pharmacotherapy in patients with heart dysplasia syndrome(HDS) and hypogonadism.25 (54.4 %) women and 21 (45.6 % ) men with HDS and hypogonadism with the average age  50 ± 3,4 years were investigated. All patients received magnesium preparations, vitamins B, C and E. In the presence of hyperinsulinemia patients received thioctic acid, hypocalcemia - calcium supplements and vitamin D. 21 people(group I) received hormone replacement therapy. The control group (25 people) did not receive sex hormones. Electrocardiography and echocardiography were performed before treatment and after 6 months of therapy. After 6 months of therapy the pacients of group I was marked by greater effectiveness of treatment compared with the control group. Thus, reducing the frequency of episodes of atrial arrhythmia or relief in the experimental group was higher 7.8% and 8.6% respectively, than in the control group. In the treatment of ventricular arrhythmia have also been reported better results in the group, where sex hormones were prescribed as compared to the control group its frequency decreased by 2.2%. High efficiency of treatment was achieved in arresting ventricular arrhythmia, and in the experimental group it was observed two times more (19.0% and 8.0% respectively). Disappearance of bundle-branch block in the experimental group was 3.8% higher, than in the control group. Inverse results were achieved in the treatment of extended interval QT - normalization of its duration in the experimental group was 4.2% less compared to the control group. After 6 months of treatment the depth of first-degree prolapse of mitral valve (PMV) and first-degree mitral regurgitation (MR) in the experimental group decreased by 9.3% in comparisonwith the group, where sex hormones were not prescribed. In some cases, even the disappearance of mitral valve prolapse was observed  and the frequency of this phenomenon was also 3.0% higher in the group, where sex hormones were prescribed. According to our research the best treatment results were observed in the group, where treatment of pathology of connective tissue as well as of hypogonadism was performed. Comprehensive medical approach (magnesium preparations, vitamins, thioctic acid and calcium supplements and vitamin D, in case of hypogonadism (hormone replacement therapy estrogen-gestagen medicines in women and testosterone in men) gives greater reduction in frequency of episodes of arrhythmias and conduction of the heart, reducing the depth of prolapse of the mitral leaflets or even arresting PMV and MR.

 

Nothing to Disclose: LI, IK

15061 28.0000 SUN-0098 A Pharmacotherapy of Hypogonadism and Heart Dysplasia Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Toshihiro Fujiwara*1, Noriko Watanabe1, Teruaki Iwamoto2, Chisa Tabata1, Takako Kurosawa1, Maki Kusumi1, Momo Noma3, Hiroki Onoue4 and Osamu Tsutsumi1
1Sanno Hospital, Tokyo, Japan, 2International University of Health and Welfare, 3Sanno Hospita, Tokyo, Japan, 4Sanno Hospital

 

Background: Hypogonadotropic-hypogonadism male has impaired gonadal function both in spermatogenesis and androgenesis. Its cause varies wide and hemochromatosis(HC) is among them, which is very rare disease in Japan. This disease induces structual and functional disorder in pituitary by excess deposition of iron, leading to insufficient production of gonadotropin. Thus HC causes infertility, for which intensive gonadotropin treatment is required.  Clinical case: A 36-year Japanese man suffered from hereditary hemochromatosis with loss of libido as well as azoospermia. Hormonal data showed decreased gonadotropin (FSH: 4.1 IU/L, LH: 1.5 IU/L) and low testosterone (70.9 ng/dL), while serum iron level was high (286 μg/dL). Initially hCG was administered (5,000 IU x 3 /week), which activated androgenesis, serum testosterone being 753.9 ng/dL after two weeks. This confirmed the Leydig cells were functional. Then human recombinant FSH (150 IU x 3/week) was co-administered with hCG and production of spermatozaoa was confirmed after three months, which revealed both Sertoli cell function and potential of spermatogenesis were conserved. Though concentration of spermatozaoa was not high (0.4-0.5 x 106/ml), several specimen was cryopreserved. Thereafter controlled ovarian stimulation of the patient’s wife was underwent and a total of 14 oocytes was retrieved. Using both fresh and cryopreserved spermatozoa intracytoplasmic sperm injection was applied and five of them were fertilized, followed by acquisition of three good morphological embryos, which were cryopreserved. Then cryo-thaw embryo transfer was attempted. The first cycle showed marginal increase of serum hCG but clinical pregnancy was not established. In the second trial using blastocyst positive serum hCG was confirmed and course of pregnancy was uneventful. She delivered healthy baby.

Conclusion: By careful and intensive treatment with gonadotropin both androgenesis and spermatogenesis was successfully achieved in a hypogonadotropic-hypogonadism male due to HC . HC may affects testicular tissue and impairs efficacy of treatment. In our case Leydig cell function was well conserved and both Sertoli cell function and spermatogenesis system was at least partially conserved. Like other cause of hypogonadotropic-hypogonadism male successive gonadotropin treatment with hCG and FSH to HC male is effective.

 

Nothing to Disclose: TF, NW, TI, CT, TK, MK, MN, HO, OT

16400 29.0000 SUN-0099 A Successful Induction of Androgenesis and Spermatogenesis Using Hcg-Human Recombinant FSH to a Hypogonadotropic –Hypogonadism Male Caused By Hemochromatosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Giuseppe Grande*1, Domenico Milardi2, Federica Vincenzoni3, Antonella Giampietro3, Irene Messana4, Massimo Castagnola3, Laura De Marinis5 and Alfredo Pontecorvi3
1Catholic University School of Medicine, Rome, Italy, 2Catholic University of the Sacred Heart, Rome, Italy, 3Catholic University, Rome, Italy, 4University of Cagliari, Cagliari, 5Università Cattolica del Sacro Cuore, Rome, Italy

 

The male reproductive accessory organs, comprising the epididymis, vas deferens, seminal vesicles and prostate are androgen-dependent organs which have important roles in mediating androgen effects on the final structural development of sperm, as well as the acquisition of sperm function in the excurrent ducts of the post-testicular reproductive tract. Bioinformatics is capable of supporting proteomics in the interpretation of the data analysis, in the identification of the proteins of clinical interest and in the development of functional interattomic models by means of statistical analysis and use of algorithms. The objective of this study was to identify the putative proteic networks absent in the seminal plasma of hypogonadic patients.

Seminal plasma samples from 20 patients affected by secundary hypogonadism and 10 normogonadal controls were analyzed by an LTQ Orbitrap XL hybrid mass spectrometer and data were evaluated using bioformatic tools to functionally annotate the panel of androgen-dependent proteins. The interaction network of the differentially expressed proteins was built in silico, including the androgen receptor (AR).

A lower number of proteins was identified in hypogonadic patients compared with normogonadal men. Among the 61 proteins identified in normogonadal men, 33 proteins were absent in hypogonadic patients. Functional annotation analysis revealed that binding and enzymatic activities are mainly deficient in male hypogonadism.

7 absent proteins can fall into one large protein-protein interaction network, which directly involves the AR. In details filamin A, prolactin inducible protein (PIP) and prostatic acid phosphatase (PAP) are directly linked with AR; PIP is in network both with zinc-alpha-2-glycoprotein and with lactotransferrin, which is also functionally linked with cystatin-C. Myeloperossidase is in network with lactotransferrin and  PAP. The association of an high resolution mass spectrometry–based proteomic approach and an in silico-interattomic approach was firstly used to identify a seminal proteic network mainly involved by male hypogonadism. These proteins might represent putative physiological in vivo targets in androgen deficiency for diagnosis, prognosis and therapy.

 

Nothing to Disclose: GG, DM, FV, AG, IM, MC, LD, AP

16140 30.0000 SUN-0100 A Identification of a Functional Proteic Network Absent in Male Hypogonadism from Seminal Plasma Profiling Using High-Resolution Mass Spectrometry and "in silico" Interattomics 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Leena Nahata*1, Richard N. Yu1, Shalender Bhasin2 and Laurie E. Cohen1
1Boston Children's Hospital, Boston, MA, 2Brigham and Women's Hospital - Harvard Medical School, Boston, MA

 

Objective: Male hypogonadism is a common endocrine disorder that is often associated with low bone density, poor muscle mass, anemia, and sexual dysfunction.  The Endocrine Society has recently published a Clinical Practice Guideline for testosterone therapy in androgen-deficient men.  Because testosterone treatment is frequently initiated in adolescence, the goal of this quality improvement initiative was to evaluate the extent to which pediatric endocrinologists at a large tertiary care center followed these guidelines, and to identify potential opportunities for improvement.

Design: We performed a retrospective chart review at Boston Children’s Hospital.  Inclusion criteria were: current age ≥16 years, diagnosis of hypogonadism, and testosterone replacement therapy.  The following data were collected: current age, age at initiation of testosterone therapy, underlying medical diagnoses, pre- and on-treatment testosterone levels, route of testosterone administration and dose, whether a DXA scan and hematocrit had been done, and adherence with therapy. 

Results: 59 patients were included.  14 (24%) were prescribed lower testosterone doses than those recommended in the Clinical Practice Guideline.  7 (12%) had no pre-treatment testosterone levels recorded and 10 (17%) had no on-treatment testosterone levels.  In 49 patients with on-treatment testosterone levels, 36 had at least one value that was lower than the adult reference range.  In 12 of these 36 men (33%) in whom testosterone levels were low, the dose was not adjusted.  37 of the 59 patients (63%) did not have bone density scans and 20 (34%) did not have hematocrit levels checked.

Conclusions: Pediatric endocrinologists in this review did not consistently follow clinical practice guidelines for testosterone therapy in hypogonadal men.  Strategies that improve adherence to guidelines could be helpful in maximizing benefits of therapy and minimizing treatment-associated risks.

 

Disclosure: SB: Principal Investigator, Abbott Laboratories, Principal Investigator, Eli Lilly & Company. Nothing to Disclose: LN, RNY, LEC

12492 31.0000 SUN-0101 A Management of Testosterone Therapy in Pediatric Patients with Hypogonadism: Are We Following Clinical Practice Guidelines? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Lourdes Ibanez*1, Marta Diaz2, Abel Lopez-Bermejo3 and Francis E de Zegher4
1Hospital Sant Joan de Déu, University of Barcelona, Esplugues, Spain, 2Hospital Sant Joan de Déu, University of Barcelona, Spain, 3Dr. Josep Trueta Hospital, and Girona Institute for Biomedical Research, Spain, 4University of Leuven, Leuven, Belgium

 

Hyperinsulinemic androgen excess is the most common cause of hirsutism, acne, seborrhea and menstrual irregularity in adolescent girls. The ovarian androgen excess originates most often from an absolute or relative excess of fat in adipose tissue and from the ensuing elevations in insulinemia and gonadotropin secretion.

There is no approved therapy for androgen excess in adolescent girls. The prime recommendation is to reduce body adiposity with lifestyle measures. The addition of an oral estro-progestagen contraceptive (OC) is a standard approach endorsed by an Endocrine Society Clinical Practice Guideline (Legro et al, JCEM 2013). An alternative approach is to add an insulin-sensitizing medication for those hyperandrogenic girls who are not sexually active. The sole studies hitherto comparing these two approaches in girls with androgen excess were of limited relevance because they explored medications (such as flutamide and cyproterone acetate) not readily available in many countries. Here we report the preliminary results of a first comparison between the effects of a widely prescribed OC (20 mcg  ethinylestradiol plus 100 mcg levonorgestrel) and the effects of a novel low-dose insulin-sensitizing combination of pioglitazone (Pio, only 7.5 mg/d), spironolactone (Spi, 50 mg/d) and metformin (Met, 850 mg/d) in adolescents with hyperinsulinemic androgen excess and without need for contraception. Over 6 mo, PioSpiMet had more normalizing effects than OC, in particular on hirsutism score, on visceral and hepatic adiposity, on carotid intima-media thickness and on circulating C-Reactive Protein, LDL-cholesterol and GGT. None of the girls dropped out of the study; there were no particular side-effects in either study subpopulation.

In conclusion, preliminary evidence over 6 mo suggests that PioSpiMet confers more benefit than OC to adolescent girls with hyperinsulinemic androgen excess and without risk of pregnancy.

 

Nothing to Disclose: LI, MD, AL, FED

15149 32.0000 SUN-0102 A Oral Contraception Versus Low-Dose Pioglitazone-Spironolactone-Metformin (PioSpiMet) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Sunday, June 22nd 3:00:00 PM SUN 0071-0102 4866 1:00:00 PM Male Reproduction: Hypogonadism and Reproductive Aging Poster

Zhongyan Shan*1, Le Zhang2 and Weiping Teng3
1Institute of Endocrinology, shenyang, China, 2Institute of Endocrinology, Shenyang, China, 3The Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China

 

Marginal iodine deficiency is a very common iodine nutritional status, which is easy to be ignored. Previous studies have reported that it could lead to the alteration of neurodevelopment related proteins. The aim of study is to explore whether marginally maternal iodine deficiency produces more subtle changes in cell migration and cognitive function of the progeny, and the optimal time of giving intervention to minimize the adverse effects. In the present study, female Wistar rats maintained on low-iodine grain were randomly assigned to three groups based on iodated water concentration: low iodine (L group, 1.2 μg/d), normal iodine (N group, 5–6 μg/d), and marginal iodine (M group, 3 μg/d). M group was treated with normal iodine supplement from one month before pregnancy (PP group), Gestational (G) day 13 (G13 group), and Postnatal (P) day 0 (P0 group) till P21. Maternal and pup thyroid hormone was measured. Nissel stain was used to observe the morphology and immunohistochemistry was used to measure BrdU, Reelin and Tenascin-C expression in the somatosensory cerebral cortex. Finally, Morris Water Maze (MWM) was used to measure spatial performance. On G17, FT4 levels of M group and P0 group were decreased by about 10% compared to that of pre-pregnancy, while FT4 levels of PP, G13, N groups were descended within 5%. There were changes in the cytoarchitecture of the somatosensory cortex of M and L group, whereas the gross cytoarchitecture of PP, G13 and P0 pups was similar to that of N pups. The percentage of BrdU-labeled cells were decreased in layer II-III for the L and M pups (4.01±0.19%, 5.17±0.33% VS 9.54±0.26, P<0.05), and increased in layer VI for the L, M and P0 pups (57.63±1.36%, 56.04±2.74%, 54.92±5.16% VS 42.45±2.01, P<0.05), whereas no differences were found in any layer among PP, G13 pups and N pups. The Reelin and Tenascin-C expression in the cerebral cortex of P0, M and L groups was significantly lower and higher than the N group on P7, respectively (Reelin 35.2±3.5, 25.5±3.9, 10.7±1.9 VS 74.2±3.5 *105; P<0.05 all; n=6); (Tenascin-C 77.9±3.7, 65.2±3.5, 87.6±6.6 VS 33.3±2.3 *105; P<0.05 all; n=6). In MWM, our data showed that PP, G13 and P0 pups took less time than the M group on the second day (61.1±2.0, 59.1±2.4, 60.9±1.6 VS 67.7±2.3 s; P<0.05 all; n=10). On the third day, the latency of the pups from the PP and G13 groups were shorter than the M group pups (37.3±2.4, 36.1±1.9 VS 41.4±1.7 s; P<0.05 all; n=10). There was a statistical difference between the PP and the M group pups on the fourth day (17.3±1.1 VS 23.2±2.1 s; P<0.05 all; n=10). These results showed that iodine supplement in early stage of pregnancy (before G13) could improve the cerebral cortex cytoarchitecture and the cell migration in the developing brain of the progeny whose mother with marginal iodine deficiency. The mechanism was related with the lower Reelin and higher Tenascin-C restored in the early stage of cerebral cortex development.

 

Nothing to Disclose: ZS, LZ, WT

PP25-3 15841 4.0000 SUN-0466 A Treatment with Iodine in Pregnant Rats with Marginal Iodine Deficiency Improves Cell Migration in the Developing Brain of the Progeny 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

Yosuke Ono*1, Masanori Fujita2, Mieno Shiraishi1, Yoritsuna Yamamoto2, Shoichi Tachibana2 and Yuji Tanaka1
1National Defense Medical College, Tokorozawa, Japan, 2National Defense Medical College Research Institute, Tokorozawa, Japan

 

Background: Myxedema  Coma (MC)  is  severe,  life-threatening  hypothyroidism,  with  a  high  mortality  rate.  Currently,  the  most  common  approach  to  treating  MC  is  the  replacement  of  thyroid  hormone.  However  it  is  yet  to  be  established  whether  MC  should  be  treated  by  administering  T4  alone,  with  conversion  to  T3  depending  on  the  deiodinase  activity  in  the  patient;  or  by directly  administering  both  T4  and  T3, simultaneously.  Secondary  concerns  include  dose,  frequency,  and  route  of  administration  (of  either  hormone).  Although  there  have  been  several  reports  about  the  rabbit  model  of  thyroidectomy,  no  study  has  focused  on  the  success  of  inducing  MC  or  its  treatment(1-3).  The  distinct  advantage  of  using  rabbits  is  that,  unlike  other  species  whose  parathyroid  glands  are  embedded  in  the  thyroid,  rabbit  parathyroids  are  found  both  within  and  outside  the  thyroid (1).  Therefore,  even  after  removing  the  thyroid,  the  calcium  homeostasis  of  the  rabbit  is  stable.

Objectives: The  purpose  of  the  present  research  was  to  establish  a  rabbit  model  of  MC  by  total  thyroidectomy  under  a  microscope,  and  to  evaluate  the  effects  of  thyroid  hormone  therapy  on  the  model.

Method: The  research  protocol  was  approved  by  the  Animal  Research  Committee  of  the  National  Defense  Medical  College,  Saitama,  Japan.  Ten  male  New  Zealand  White  Rabbits  weighing  2.5  to  3.0  kgs  were  anesthetized  with  35 mg/kg  of  ketamine  and  5 mg/kg  of  xylazine  administered  intramuscularly.  Eight  rabbits  were  completely  thyroidectomized  under  a microscope,  and  the  other  2  rabbits  underwent  sham  operations (control  group).  We  monitored  the  thyroidectomized  animals  without  thyroid  hormone  replacement  for  15  weeks.  Immediately  prior  to  thyroidectomy,  and  2  and  4  weeks  after  the surgery,  heart  rate (HR),  blood  pressure (BP),  body  temperature (BT),  and  electrocardiograms (ECG)  were  recorded,  and,  at  the  same  time,  blood  samples  were  taken  from  the  jugular  vein  under  anesthesia.

Results: The  animal  model  in  the  present  study  showed  remarkable  reduction  of  serum  thyroxine  levels  at  4  weeks  after  surgical  procedure  vs. controls  (0.50±0.10 vs. 3.5±0.70 µg/dL). Additionally,  thyroidectomized  rabbits  compared  to  control  group  rabbits  exhibited  a  number  of  signs  of  hypothyroidism,  such  as  hypothermia (BT : 38.5±0.2 vs. 39.5±0.2°C), hypotension (systolic BP : 84.5±15.3 vs. 128±18.4 mmHg),  bradycardia (HR : 139.6±18.9  vs. 183±2.8)  and  low voltage indications on ECGs.  The 7 / 8 rabbits  with  hypothyroidism  died,  possibly  due  to  heart  failure,  from 5 to 14 weeks  after  thyroidectomy,  since  histopathologic  examination  revealed  myxedema  heart,  that  is  hydropic  vacuolation  of  muscle  fibers,  branching  and  loss  of  striation.

Conclusion: To  the  best  of  our  knowledge,  we  are  the  first  researchers  to  have established  a  new  rabbit  model  of  MC,  which  may  facilitate  pathophysiological  and  molecular  investigations  on  MC,  and  evaluations  of  new  therapeutic  interventions.

 

Nothing to Disclose: YO, MF, MS, YY, ST, YT

12711 5.0000 SUN-0467 A A New Rabbit Model of Myxedema Coma Induced By Total Thyroidectomy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

Keiko Takeshige*1, Takashi Sekido2, Jun-ichirou Kitahara3, Yuki Kobayashi4, Shin-ichi Nishio5, Mitsuhisa Komatsu5 and Satoru Suzuki6
1Shinshu University School of Medicine, Matsumoto-shi, 2Shinshu University Schoolo of Medicine, Matsumoto-shi, Japan, 3Shinshu University Schoolo of Medicine, Matsumoto-shi, 4Shinshu University School of Medicine, Matsumoto-shi, Japan, 5Shinshu University, Schoolo of Medicine, Matsumoto-shi, Japan, 6Fukushima Medical University, Fukushima-shi, Japan

 

μ-Crystallin (CRYM) is also known as NADPH-dependent cytosolic T3-binding protein. A study using CRYM-null mice suggested that CRYM stores triiodothyronine (T3) in tissues. We previously established CRYM-expressing cells derived from parental GH3 cells. To examine the precise regulation of T3-responsive genes in the presence of CRYM, we evaluated serial alterations of T3-responsive gene expression by changing pericellular T3 concentrations in the media. We estimated the constitutive expression of three T3-responsive genes, growth hormone (GH), deiodinase 1 (Dio1), and deiodinase 2 (Dio2), in two cell lines. Subsequently, we measured the responsiveness of these three genes at 4, 8, 16, and 24 h after adding various concentrations of T3. We also estimated the levels of these mRNAs 24 and 48 h after removing T3. The levels of constitutive expression of GH and Dio1 were low and high in C8 cells, respectively, while Dio2 expression was not significantly different between GH3 and C8 cells. When treated with T3, Dio2 expression was significantly enhanced in C8 cells, while there were no differences in GH or Dio1 expression between GH3 and C8 cell lines. In contrast, removal of T3 retained the mRNA expression of GH and Dio2 in C8 cells. These results suggest that CRYM expression increases and sustains the T3 responsiveness of genes in cells, especially with alteration of the pericellular T3 concentration. The heterogeneity of T3-related gene expression is dependent on cellular CRYM expression in cases of dynamic changes in pericellular T3 concentration.

 

Nothing to Disclose: KT, TS, JIK, YK, SIN, MK, SS

13302 6.0000 SUN-0468 A Cytosolic T3-Binding Protein Modulates Dynamic Alteration of T3-Mediated Gene Expression in Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

Sebastian G Hönes1, Anita Boelen2, Sigrun Horn3, Eddy Rijntjes4, Josef Köhrle5, Dagmar Führer1, Heike Heuer3 and Lars C Moeller*1
1University Duisburg-Essen, Essen, Germany, 2Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands, 3Leibniz Institute for Age Research/Fritz Lipmann Institute, Jena, Germany, 4Charite - Universitätsmedizin Berlin, Berlin, Germany, 5Charité - Universitätsmedizin Berlin Campus Virchow, Berlin, Germany

 

Introduction: Hypothyroidism is often a prerequisite to study thyroid hormone (TH) action in mice. We aimed to evaluate the efficacy of various protocols to induce hypothyroidism by measuring not only serum TSH and TH levels, but also TH dependent gene expression in liver and heart.

Methods: Mice were rendered hypothyroid with either low iodine diet (LoI) + 0.15% propylthiouracil (PTU), addition of 0.5% perchlorate and 0.02% methimazole+sacharine (MMI) to the drinking water, LoI diet + 0.15 % PTU + perchlorate/MMI or MMI/perchlorate treatment alone. TSH, FT4, FT3, TT4 and TT3 levels were measured by (radio)immunoassays. Gene expression in liver and heart was measured by real-time PCR after three weeks of treatment (n=5 mice per treatment). Untreated mice served as control.

Results:With all treatments hypothyroidism could be induced as TSH increased more than hundredfold. FT4 was reduced to levels below our limit of detection (< 6% FT4 of control mice). TT4 levels also decreased to less than 10% with all treatments compared to untreated mice. In contrast, FT3 was reduced to only 50 - 25% and TT3 levels were even less reduced (72 - 116% of control mice). The expression of genes used for normalization (liver: 18S, Ppia, RPL13a; heart: 18S, Gapdh) was not influenced by treatment or TH levels. With all treatments hepatic expression of DIO 1 was reduced to 1% compared to untreated mice. Conversely, mRNA expression of TBG, normally repressed by TH in adult mice, was significantly increased in hypothyroidism (MMI: 558%, LoI+MMI: 1086%, LoI+PTU+MMI: 783%, LoI+PTU: 689%). In the heart, Myh6 mRNA expression was significantly reduced (MMI: 12%, LoI+MMI: 1%, LoI+PTU+MMI: 2%, LoI+PTU: 2%).

Conclusion: All protocols worked well as demonstrated by markedly elevated serum TSH levels. Furthermore, reduced expression of TH-responsive genes and induction of TBG, negatively regulated by TH, demonstrated tissue hypothyroidism in liver and heart. Interestingly, FT3 was less reduced than FT4 and in contrast to TT4, TT3 levels remained almost normal with all treatments. This finding may be explained by physiology defending T3 levels and increased TBG expression in hypothyroidism.

 

Nothing to Disclose: SGH, AB, SH, ER, JK, DF, HH, LCM

13591 7.0000 SUN-0469 A Protocols for Induction of Hypothyroidism in Mice Validated By Gene Expression in Liver and Heart 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

Xiaochun Teng*1, Xiao-na Hu2, Zhongyan Shan3 and Weiping Teng4
1Department of Endocrinology and Metabolism, Institute of Endocrinology, the first Hospital of China Medical University, Shenyang, China, 2Institute of Endocrinology,the first hospital of China Medical University,Shenyang, China, 3Institute of Endocrinology,The First Hospital of China Medical University, Shenyang, China, 4The Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China

 

Both maternal hypothyroxinemia and maternal iron deficiency (ID) are associated with poorer neurodevelopment of the offspring (1, 2). Iron is an important component of thyroid peroxidase, a key enzyme in the synthesis of thyroid hormone (TH). Maternal ID can cause brain defects, which has a direct role (decreased iron levels in the brain), and indirect role (hypothyroxinemia) (3). In this study, we found that the effect of hypothyroxinemia is a dominant early event that impairs brain development and reduced brain iron level may be later event.

We established two rat models to imitate the two common types of maternal ID [mild ID with anemia (ID+A) and ID without anemia (ID-A)]. Iron limitation was initiated two weeks before pregnancy. We analyzed maternal TH level from gestation day 13 (G13) to postnatal day 10 (P10). At G13, the maternal serum TT4 were significantly decreased compared to controls, 2.43±0.40 μg/ml vs 3.28±0.53μg/ml (P < 0.05) in mild ID+A dams and 2.61±0.50μg/ml vs 3.28±0.53μg/ml (P < 0.05) in ID−A dams. Maternal hypothyroxinemia lasted from G13 to P10 in both ID dams. 

We, next, determined TT3 level in neonatal brain at P10. In ID−A pups, TT3 level is reduced in cerebral cortex (6.01 ± 0.28 ng/g vs 7.25 ± 0.20 ng/g, P <0.05), and in hippocampus (13.39± 1.32 ng/g vs 17.07 ± 1.13 ng/g, P < 0.05). Similar results were found in mild ID+A pups. The data demonstrated maternal ID-induced hypothyroxinemia impaired neonatal brain TH level. Consistent with low TH level, the mRNA expression TH-responsive genes (mbp, rc3, camk4 and reelin) were significantly reduced in neonatal cerebral cortex and hippocampus in both ID rat models at P10. Furthermore, both ID rat models had thinner cortical layers compared to control at P10. Vibrissae-evoked forelimb placing test (sensorimotor skills) showed significantly motor retardation in ID pups.

We determined iron concentration in neonatal brain using graphite furnace atomic absorption spectroscopy and the density of iron granules using iron (III) histochemical staining at P10, and no significant difference was found between the control and the ID pups. The mRNA expression of iron-responsive genes, such as transferrin receptor (tfr) and divalent metal transporter (dmt1) had no significant difference in ID-A group compared to control group, but had higher in ID+A group. The results indicated that maternal ID did not affect the iron level in neonatal brain including cerebral cortex or hippocampus in ID groups compared to control group at P10. But after P10, the brain iron concentration decreased in both ID pups.  

Taking together, this study demonstrated that maternal ID-induced hypothyroxinemia is sufficient to impair the early brain development, regardless neonatal brain iron level is normal. Therefore, maternal ID is an indicator for low TH level. Monitoring thyroid hormone level is recommended in iron deficient pregnant women.

 

Nothing to Disclose: XT, XNH, ZS, WT

14160 8.0000 SUN-0470 A Maternal Iron Deficiency-Induced Hypothyroxinemia Impairs Early Brain Development Regardless Normal Iron Level in Neonatal Brain 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

Chen-Che Jeff Huang* and Douglas Forrest
National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD

 

Many hormone disorders of the adrenal cortex, such as adrenocortical carcinoma and steroid hormone deficiency are results of overgrowth or underdevelopment of the adrenal gland. At embryonic stages, the fetal adrenal cortex already has the ability to synthesize and secrete steroid hormones that are critical for fetal development. These functional fetal cortical cells then undergo regression and are replaced by continuously renewing adult-like cortical cells after birth. The continuously renewing adult cortical cells grow from the most outer layer of the cortex and form the “adult zone”, whereas fetal cortical cells stay in the inner portion of the cortex and form the “fetal zone”. During subsequent development, the fetal zone (also called the x-zone in mice) regresses while the adult zone grows. However, the mechanisms that regulate the differential development and the regression of the adrenal cortical layers remain unclear. Here, we report that thyroid hormone signaling is active in the adrenal cortex, especially in the adrenal x-zone. We identified specific expression of thyroid hormone receptor TRβ1 in the x-zone by qPCR analysis of mRNA and by analysis of X-gal staining in a newly-derived knockin mouse strain carrying lacZ fused into a TRβ1-specific N-terminal exon of the Thrb gene. To study functions of thyroid hormone in the x-zone, we administered ectopic triiodothyronine (T3) to wild type mice or mice lacking different TR isoforms. In wild type mice, T3 induced pronounced hypertrophy of the x-zone, altered expression of 3β-hydroxysteroid dehydrogenase and zona fesciculata markers in the x-zone. These T3-mediated changes were impaired in TRβ1-deficient mice. Our results identify TRβ1 as a specific marker in the adrenal x-zone and point to a novel role of thyroid hormone in determining the fate of adrenal cortical cells during developmental remodeling of the adrenal gland.

 

Nothing to Disclose: CCJH, DF

14670 9.0000 SUN-0471 A Thyroid Hormone Receptor β1-Mediated Adrenal Remodeling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

Shaker A. Mousa*1, Sudha Thangirala1, Hung-Yun Lin2, Heng Yuan Tang1, Gennadi V. Glinsky3 and Paul J Davis4
1Albany College of Pharmacy and Health Sciences, Rensselaer, NY, 2Taipei Medical University, Taiwan, 3Stanford University, 4Albany College of Pharmacy and Health Sciences

 

Tetraiodothyroacetic acid (tetrac) is a deaminated L-thyroxine (T4) analogue that initiates anti-proliferative and anti-angiogenic actions at the thyroid hormone-tetrac receptor site on plasma membrane integrin αvβ3.  The integrin is largely expressed on tumor cells and dividing endothelial cells.  Within cells, tetrac is thyromimetic; at αvβ3, it is a thyroid hormone antagonist.  We have covalently bound tetrac to a poly(lactic-co-glycolic acid) nanoparticulate to limit its effects to αvβ3 and prevent its cellular uptake.  The anticancer actions at αvβ3 of Nanotetrac (NT) include downstream disruption of transcription of genes in cancer cell survival pathways and actions on cyclins, catenin-dependent pathways and suppression of expression of anti-apoptosis genes (1).  NT blocks T4 and T3 actions at the integrin.  YH Huang et al. (2) have recently shown that thyroid hormone enhances hepatoma cell migration/invasion by a microRNA-21 (miR-21)-dependent mechanism.  In the present studies, we isolated miRNA from tetrac- and NT (2 mM)-treated ‘triple negative’ human breast cancer (MDA-MB-231) cells and quantitated miR-21 and  miR-15A by qPCR with the specific primers (Qiagen).  miR-21 has oncogenic (proliferative) activity and miR-15A is pro-apoptotic.  Exposure to the hormone analogues was for 24 h.  NT reduced miR-21 expression by 50%, whereas unmodified tetrac was without effect.  Tetrac and NT both increased miR-15A by more than 10-fold.  Activation (phosphorylation) of NFκB is a downstream step in miR-21-induced cancer cell proliferation.  We quantitated NFκB mRNA in MDA-MB-231 cells exposed to tetrac and NT and obtained a 45% decrease in NFκB mRNA in NT-treated cells; tetrac did not significantly reduce abundance of this mRNA.  Chemokine CCL20 interacts with miR-21 and both may be upregulated in cancer cells.  We measured CCL20 mRNA in MDA-MB-231 cells and found that tetrac or NT decreased this mRNA by 3-fold.  In summary, oncogenic miR-21 is downregulated by NT in MDA-MB-231 cells, whereas pro-apoptotic miR-15A is upregulated by NT and tetrac.  mRNAs for NFκB and CCL20 proteins that are targets of miR-21 action are decreased in NT/tetrac-exposed cells.  Thus, NT interferes with miR-21 at multiple points in its functional pathways in breast cancer cells. 

(1) PJ Davis et al., Annu Rev Pharmacol Toxicol 51:99-115, 2011                                  (2) YH Huang et al., Cancer Res 73:2505-2517, 2013

 

Nothing to Disclose: SAM, ST, HYL, HYT, GVG, PJD

14837 10.0000 SUN-0472 A Microrna-21 and microRNA-15A Expression in Human Breast Cancer (MDA-MB-231) Cells Exposed to Nanoparticulate Tetraiodothyroacetic Acid (Nanotetrac) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

Toshiharu Iwasaki*1, Lu Yu1, Ming Xu1, Ronny Resmana1, Yu Xiong2, Noriaki Shimokawa1 and Noriyuki Koibuchi1
1Gunma Univ Grad Sch of Med, Maebashi, Japan, 2Gunma Univ Grad Sch of Health Sci, Maebashi, Japan

 

Thyroid hormone (TH) deficiency during the fetal and early postnatal periods results in severe mental and physical retardation, known as cretinism in humans.  However, the molecular mechanism underlying TH action in the developing brain has not yet been fully understood.  We have generated a transgenic mouse line expressing a dominant-negative TH receptor (TR) in cerebellar Purkinje cells to study the role of the TH in cerebellar development.  A mutant human TRβ1 (G345R), which binds to the TH-response element but cannot bind to T3, was subcloned into exon 4 of the full-length L7/ Pcp-2 gene, which is specifically expressed in Purkinje and retinal rod bipolar cells.  There is no significant retardation in general growth or cerebellar weight in the transgenic mice.  The motor coordination of transgenic mice was significantly disrupted at P15 and P30 by Rotarod test.  Purkinje cell dendrite arborization was markedly delayed in the male and female transgenic mice by immunohistochemistry.  To our surprise, disappearance of external granule cell layer is also retarded as a result of delayed migration of granule cells to the internal granule cell layer.  We confirmed that the transgene was specifically expressed in Purkinje cells in the postnatal cerebellum.  In the primary cerebellar culture, TH-induced Purkinje cell dendrite arborization was also suppressed.  We examined the changes in the expression levels of TH-responsive genes by using semi-quantitative RT-PCR analysis.  The expression levels of inositol trisphosphate  (IP3) receptor type1 and retinoic acid receptor-related orphan receptor (ROR)α mRNAs, which are mainly expressed in Purkinje cells, and brain-derived neurotrophic factor (BDNF) mRNA, which is expressed in both Purkinje and granule cells were significantly decreased.  Furthermore, the expression levels of neurotrophin (NT)-3 mRNA, which is mainly expressed in granule cells were also decreased.  The expression levels of myelin basic protein (MBP) mRNA, which is mainly expressed in oligodendrocytes were not altered.  These results indicate that the development of Purkinje cells is directly regulated by TH through its binding to TR, whereas TH action through TR in Purkinje cells is important for development of other subsets of cerebellar cells such as granule cells.

 

Nothing to Disclose: TI, LY, MX, RR, YX, NS, NK

15716 11.0000 SUN-0473 A 2. Role of Thyroid Hormone in Cerebellar Development ~ Analysis of Transgenic Mice Expressing Dominant Negative Thyroid Hormone Receptor in Purkinje Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

Zhongyan Shan*1, yuan-Yuan Zhang2 and Weiping Teng3
1Institute of Endocrinology,The First Hospital of China Medical University, Shenyang, China, 2Department of Endocrinology and Metabolism, Shenyang, China, 3The Institute of Endocrinology, The First Hospital of China Medical University, Shenyang, China

 

Thyroid hormone is indispensable for fetal brain development and maternal thyroid hormone deficiency is thought to result in severe and irreversible brain impairments in offspring, such as learning and memory. Epidemiological studies and animal studies by our group have showed that maternal subclinical hypothyroidism may result in significant negative effects on fetal neurodevelopment. But the underlying mechanism responsible for these neurological alterations remains unclear. In the present study, we performed thyroidectomy and L-T4 injection daily in Wistar rats to induce maternal subclinical hypothyroidism. Our data indicated that the pups from subclinical hypothyroidism group showed prolonged latencies during the learning process in the water maze compared with the control. The transcription factor CREB signaling pathway closely associated with synaptic plasticity and learning and memory. Consistent with behavior results, western blotting were also observed decreased activation of the CREB signaling pathway including three important upstream modulators: (1) phosphor- mitogen-activated protein kinases (P-ERK1/2) (0.447 ±0.032 vs 0.683±0.065;p=0.034,n=3 ); (2) phosphor-CaMKIV(0.114±0.008 vs 0.277±0.068;p=0.02,n=3); (3 )phosphor-AKT(0.56 ±0.0282 vs 0.7035 ±0.0282;p=0.036.n=3) and one downstream: total CREB (0.370±0.057 vs 0.564±0.0832;p=0.039,n=3) and phosphor-CREB (0.426±0.08 vs 0.587±0.172; p=0.042,n=3) compared with the control at postnatal day 7(P7) in hippocampus. Our findings suggested that decreased activation of the CREB signaling pathway in pups may contribute to impairments of cognitive function caused by maternal subclinical hypothyroidism.

 

Nothing to Disclose: ZS, YYZ, WT

15922 12.0000 SUN-0474 A The Impairment of Maternal Subclinical Hypothyroidism on Offspring Brain Development Is Mediated By CREB Signaling Pathway 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

David de Alba*1, Martha Mercado-Morales1 and Angelica Rueda2
1CINVESTAV-IPN, Mexico city, Mexico, 2Cinvestav-IPN, Mexico, Mexico

 

Ryanodine receptor-mediated (RyR) diastolic Ca2+ leak has been proposed as an important mechanism that may contribute to the appearance of cardiac arrhythmia in some pathologies. Another component in the regulation of this Ca2+ leak is the Sarco-Endoplasmic calcium ATPase pump (SERCA2a) activity; both proteins are mayor participants in the cytoplasm/luminal Ca2+ balance and therefore in the generation of delayed after depolarization (DAD´s) that may cause triggered activity and ventricular arrhythmia. The experimental model of hyperthyroidism in rat is induced by maintaining increased serum levels of the thyroid hormone 3,3´,5-triiodothyronine (T3). Hyperthyroid animals present mayor alterations in the cardiac function; for instance, arrhythmic activity in both whole hearts (extrasystoles) and isolated cardiomyocytes (automatic activity) and the molecular basis for those alterations are not fully understood. Due to the key participation of RyR and SERCA2a in maintaining the balance of intracellular Ca2+ fluxes, we sought to determine if RyR-mediated Ca2+ leak -evaluated as local Ca2+ sparks, and global Ca2+ waves- was modified by the condition of hyperthyroidism and may contribute to the automatic activity in isolated left ventricle cardiomyocytes by Ca2+ imaging (confocal microscopy). In addition, the Sarcoplasmic Reticulum (SR) Ca2+ load was evaluated by caffeine pulses. We also determined in vitro SERCA2a activity and both mRNA and protein expression levels of several proteins of interest.

Confocal image analysis of Fluo-3 loaded left ventricle cardiomyocytes from hyperthyroid rats showed that Ca2+ spark amplitude increased 39%, while spark-mediated Ca2+ flux and Ca2+ mass increased 39 and 64%, respectively, with no modifications of overall spark-mediated Ca2+ leak due to a slightly diminished Ca2+ spark frequency. In regard to Ca2+ waves, hyperthyroid condition leads to an augmented occurrence of this form of leak (30%) and also induces the appearance of abnormal wave-like events in the form of arrowhead-shaped Ca2+ releases (60%).

SR Ca2+ overload has been proposed as a possible mechanism for explaining increased diastolic Ca2+ leak, nevertheless, in the condition of hyperthyroidism the high incidence of abnormal Ca2+ release events in diastole cannot be explained by this model since neither SR Ca2+ load nor diastolic [Ca2+]i were modified. Finally, qPCR assays showed a significant augmentation of RyR and SERCA mRNA levels by 79% and 68% respectively. In this regard, Ca2+ uptake assays showed an augmented SERCA activity (162%). The changes found at protein expression levels and SERCA activity may participate in the generation of abnormal diastolic Ca2+ release events and can promote automatic activity in cardiac cells of hyperthyroid animals.

 

Nothing to Disclose: DD, MM, AR

16046 13.0000 SUN-0475 A Increased Diastolic Ca2+ Leak Is Associated with Automatic Activity and May Promote Cardiac Arrhythmia in Hyperthyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

Shigekazu Sasaki*, Akio Matsushita, Hiroko Misawa Nakamura, Naoko Hirahara and Yutaka Oki
Hamamatsu Univ Schl of Med, Hamamatsu, Shizuoka, Japan

 

The mutation in the ligand-binding domain (LBD) of T3-receptor (TR) β gene is known to cause the syndrome of resistance to thyroid hormone (RTH).  However, it is known that 15 to 30% of the patients with RTH have no mutation in the TRβ gene.  In these patients, no genetic abnormality has been identified in the p160 family co-activators or co-repressors (i.e., nuclear receptor co-repressor or silencing mediator for retinoid and thyroid hormone receptors).  This indicates the possibility that the factor other than TR, p160 family or co-repressors may be involved in the T3 signaling.  Recently accumulated lines of evidence suggest that, in addition to histone modification by p160 family or co-repressor, the RNA elongation step also plays a critical role in the gene expression.  Here, we investigated the involvement of positive elongation factor-b (P-TEFb), which is the dimer of cyclin-dependent kinase (CDK) 9 and T-type cyclins, in the transcriptional activation by T3.  Flavopiridol and 5,6-dichloro-1-beta-D-ribofuranosylbenzimidazole are the specific inhibitor against CDK9.  Treatment of the pituitary derived LβT2 cells with these compounds reduced the T3-induced expression of the genes for type-1 deiodinase and Spot14 to 10 to 50%.  Co-immunoprecipitation study using 293T cells transfected with the expression plasmid for TRβ1 fused with FLAG-tag revealed the in vivo interaction of TRβ1 with CDK9 but not with cyclin T1 in a T3-independent manner.  Identical results were observed when FLAG-tagged TRα1 and TRβ2 were used.  Deletion analysis using GST pull down assay indicated that N-terminal region of CDK9 including PITARE domain interacts with LBD of TRβ1, of which amino acid sequence is highly conserved among TR isoforms.  Finally, the expression level of the T3-sensitive Spot 14 and KLF9 genes in LβT2 cells were decrease by 30 to 50% when the expression of endogenous CDK9 gene was knocked down to 50% using RNA interference.  These results suggested that CDK9 is a novel member that mediates the T3 signal to the expression of its target genes.

 

Nothing to Disclose: SS, AM, HMN, NH, YO

16751 14.0000 SUN-0476 A Thyroid Hormone Receptor (TR) Interacts with Cyclin-Dependent Kinase 9, a Constituent of Transcription Elongation Factor P-TEFb 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

Sjoerd D. Joustra*1, Onno C. Meijer2, W. Oostdijk2, Charlotte A. Heinen3, Isabel M. Mol2, Gabriela Carreno4, Daniel J. Bernard5, Nienke R. Biermasz2, Ans M.M. van Pelt6, Geert Hamer6, Jan M. Wit1 and Gerry T.M. Wagenaar2
1Leiden University Medical Center, Leiden, Netherlands, 2Leiden University Medical Center, Netherlands, 3Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands, 4Institute of Child Health, London, United Kingdom, 5McGill University, Montreal, Canada, 6Academic Medical Center, Amsterdam, Netherlands

 

Loss-of-function of immunoglobulin superfamily, member 1 (IGSF1) results in a recently identified X-linked endocrine syndrome. Its features are central hypothyroidism and macroorchidism, and in some patients prolactin deficiency, GH deficiency, disharmonious pubertal development (normal timing of testicular growth but delayed rise of testosterone), or increased body mass index and fat percentage. IGSF1’s functional role in development and disease is unknown; therefore, we investigated the spatial and temporal expression of IGSF1 at the protein and mRNA levels in fetal, neonatal, and adult Wistar rats, using immunohistochemistry, in situhybridization, and real-time PCR.

In the adult brain, high levels of IGSF1 immunoreactivity were observed in various areas, including the hypothalamus. In the adult pituitary gland, IGSF1 is present in the Pit1-cell lineage comprising GH, TSH, and PRL-producing cells, but not in gonadotrophs and corticotrophs. In the adult testis, IGSF1 is present in the cytoplasm of Sertoli cells (during stages XIII to VI of the seminiferous epithelium) and Leydig cells. In adult females, IGSF1 is expressed at relatively low levels in the ovary in developing follicles and at relatively high levels in the oviduct. In the adult adrenal gland, IGSF1 is exclusively expressed in the zona glomerulosa. IGSF1 is strongly expressed in hepatocytes of the fetal liver, but decreases rapidly to background levels immediately after birth. In all cases, specificity of IGSF1 protein expression was corroborated by in situ hybridization and real-time PCR for the Igsf1 mRNA.

The results of this study represent the first comprehensive overview of the organ specific expression profile of IGSF1, and thereby enable the formulation of hypotheses about IGSF1’s role(s) in endocrine physiology. The expression pattern in the pituitary gland suggests a local role of IGSF1 in the autocrine or paracrine regulation of secretion of TSH, GH, and prolactin. In contrast, IGSF1 is not expressed in the gonadotrophs, indicating that the delayed puberty and macroorchidism in these patients is not likely caused by pituitary dysfunction, but rather by a local defect in the testis. This is consistent with our observations that IGSF1 is expressed in Sertoli cells (the number of which determines testicular size) and Leydig cells (which produce testosterone). The results of our study provide a framework that will facilitate future research on IGSF1 function in relevant cells and tissues.

 

Nothing to Disclose: SDJ, OCM, WO, CAH, IMM, GC, DJB, NRB, AMMV, GH, JMW, GTMW

11647 15.0000 SUN-0477 A Spatial and Temporal Expression of Immunoglobulin Superfamily, Member 1 (IGSF1) in the Rat 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

Paula Bargi-Souza*, Francemilson Goulart-Silva and Maria Tereza Nunes
University of Sao Paulo, Sao Paulo, Brazil

 

Introduction: Our previous study has reported that triiodothyronine (T3) acts on posttranscriptional steps of TSH synthesis and reduces its secretion when acutely administered to thyroidectomized rats (1, 2). In this study we investigated the T3 effects on posttranscriptional steps of beta TSH in TalphaT1 cells, a tumor thyrotrophic cell line, and on TSH secretion in primary culture of anterior pituitary cells in the presence of RGD peptide, a competitive agent for the integrin site recognized by T3 at the plasma membrane.

Methods: TalphaT1 cells were seeded on matrigel-coated plates and cultured in medium containing 10% FBS depleted of thyroid hormones by treatment with AG1X-8 resin for 48h (Hypothyroid group - H). After this, 5,6-dichloro-1-β-D-ribobenzimidazole (DRB - 50 mM / 2h) or RGD (100 µg/mL – 50 min) were administered to inhibit the gene transcription or the binding of T3 to αvβ3 integrin located at the plasma membrane, respectively. Afterwards, T3-treatment was performed in the doses of 10 nM or 0.1 nM for 30 min or 0.1 µM for 4h. Total RNA was extracted for the investigation of Tshb mRNA by RT/qPCR and the degree of adenylation by RACE-PAT assay, as well as TshbmRNA content on polysome fraction. Primary anterior pituitary cells were isolated and cultured with FBS treated with charcoal in the presence or absence of T3 (10 nM) and/or RGD for 30 min. The intracellular and extracellular TSH content were analyzed by Western blotting and in the T3-treated groups the TSH content in the extracellular medium was evaluated by ELISA assay.

Results: The results obtained with TalphaT1 cells showed that T3 rapidly decreased the total content of Tshb mRNA even in the presence of DRB, an effect that was abrogated by RGD treatment. Moreover, it was shown that T3 (0.1 nM) specifically decreased the poly(A) tail length of Tshb mRNA and its association with ribosome, which indicates that the translational rate of TSH synthesis was also reduced. In parallel, T3 increased the intracellular content of TSHB while reduced the amount of TSH in extracellular medium, effects that were abolished by previous RGD administration.

Conclusions: These results led us to conclude that T3 down-regulates TSH synthesis and secretion at several posttranscriptional steps by mechanisms triggered at the plasma membrane through αvβ3 integrin, characterizing novel actions of T3 on its own regulatory axis.

 

Nothing to Disclose: PB, FG, MTN

13469 16.0000 SUN-0478 A Inhibitory Effects of T3 on TSH Synthesis and Secretion Are Triggered By αvβ3 Integrin in TalphaT1 Cell Line and in Primary Culture of Anterior Pituitary Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

Tania Weber Furlanetto*1, Ana Paula Santin Bertoni2, Ana Caroline Hillebrand3 and Ilma Simone Brum3
1Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil, 2Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, 3Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil

 

Thyroid cancer and thyroid nodules are more prevalent in women than men, so sex hormones may have an etiological role in these conditions. There are no data about direct effects of progesterone on thyroid cells, so the aim of the present study was to evaluate progesterone  effects  in the sodium iodide symporter (NIS), thyroglobulin (TG), thyroperoxidase (TPO) and Ki-67 gene expression in follicular cells derived from normal human thyroid tissue cultured in monolayer. Thyroid follicular cells viability and differentiation were assessed by its characteristic morphology, and by positive staining for TG and TPO proteins by immunocytochemistry. TSH (20 μUI/mL) increased Ki-67 (p<0.0001), TG (p=0.01), NIS (p=0.0003), and TPO (p<0.0001) mRNA expression. When 10nM progesterone was added to TSH, there was a further significant increase in mRNA expression of  KI-67 (p<0.0001), TG (p<0.04) and NIS (p<0.0001); the increase in TPO mRNA expression was non-significant (p<0.07). All these effects were abolished by mifepristone, an antagonist of the progesterone receptor, suggesting that genes involved on thyroid cell function and proliferation are up regulated  by progesterone through the genomic pathway. Thus, based on these results, we suggest a positive effect of progesterone on thyroid follicular cells treated with TSH, increasing its proliferation, while maintaining their differentiated phenotype.

 

Nothing to Disclose: TWF, APSB, ACH, ISB

14752 17.0000 SUN-0479 A Progesterone Increases Proliferation While Maintaining Differentiated Phenotype in Normal Human Thyroid Follicular Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

Anita Boelen*1, Emmely M. de Vries1, Joan Kwakkel2, Leslie Eggels2, Andries Kalsbeek2, Perry Barrett3 and Eric Fliers1
1Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands, 2Academic Medical Center, Amsterdam, Netherlands, 3University of Aberdeen, Aberdeen Scotland, United Kingdom

 

Non thyroidal illness syndrome (NTIS) is associated with decreased TRH expression in the paraventricular nucleus (PVN) of the hypothalamus. This is probably due to increased local  production of T3 by type 2 deiodinase (D2), an enzyme that is expressed in tanycytes lining the wall of the third ventricle. Administration of lipopolysaccharide (LPS), an established model of NTIS in rodents, increases D2 expression in tanycytes by a mechanism that is poorly understood at present. Several studies suggest the involvement of NFκB inflammatory signal transduction. We therefore evaluated the involvement of NFκB in the LPS-induced up-regulation of D2 in tanycytes using an in vivo and in vitro approach.

In a mouse model for acute inflammation we studied the effects of LPS on mRNA expression of D2 and RelA (the p65 subunit of NFκB) in the periventricular (PE) area and the arcuate nucleus-median eminence region (ARC-ME) of the hypothalamus. We next investigated LPS-induced D2 expression in primary cell cultures of tanycytes isolated from PN10 rat pups. The identity of tanycytes in the culture was confirmed by qPCR for DARPP-32, nestin, vimentin and GFAP and by immunostaining for vimentin and GFAP. Finally, we stimulated D2-expressing InkArf-/- glioma cells with LPS.

LPS increased D2 mRNA expression in the PE as well as RelA mRNA expression in the ARC-ME. Likewise, LPS increased D2 and RelA mRNA expression in primary tanycytes and in InkArf-/- glioma cells. Phosphorylation of RelA was increased both in tanycytes and in InkArf-/- glioma cells 15-60 min after LPS stimulation, confirming activation of RelA mediated transcription. Blocking RelA signaling in primary cultures of tanycytes by sulfasalazine or JSH-23 (inhibitors of nuclear internalization of NFκB) prevented the LPS-induced D2 increase. The same was observed in InkArf-/- glioma cells using siRNA knock down of RelA.

We therefore conclude that NFκB is essential for the up-regulation of D2 in tanycytes during inflammation.

 

Nothing to Disclose: AB, EMD, JK, LE, AK, PB, EF

14796 18.0000 SUN-0480 A NfκB Is Essential for the Lipopolysaccharide-Induced Increase of Type 2 Deiodinase in Tanycytes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

Kenji Ohba*1, Melvin Khee Shing Leow2, Brijesh Kumar Singh1, Rohit Anthony Sinha1, Junya Kohari1, Xiao-Hui Liao3, Samuel Refetoff3, Judy Chia Ghee Sng4 and Paul Michael Yen1
1Duke-NUS Graduate Medical School, Singapore, Singapore, 2Tan Tock Seng Hospital, Singapore, Singapore, 3The University of Chicago, Chicago, IL, 4Singapore Institute for Clinical Sciences, A*STAR, Singapore, Singapore

 

In the clinical setting, both the onset and recovery of hyperthyroidism can last several weeks. Although the time courses of several thyroid hormone (TH)-responsive target genes have been studied, the timepoints usually have been relatively short, ranging from several hours to a few days. In addition, little is known about the changes of target gene expression when transitioning from the hyperthyroid to euthyroid state. Therefore, we studied in mice the patterns of target gene expression in various tissues during the transition between euthyroidism and hyperthyroidism, and the recovery from hyperthyroidism. 8-week-old C57BL6 male mice were injected with 5μg/mouse of L-T3 daily for 14 days. Elevated serum T3 and suppressed TSH levels were confirmed 6 h after the last injection. Tissues were harvested at 6 h and on days 1,3,5, and 10 during L-T3 treatment, and at 6 h and days 1,3,5,7, and 10 after the last injection. Serum T3 and TSH returned to their basal levels 10 d after the last injection. Relative mRNA levels of genes positively- and negatively-regulated by T3 were analyzed by qRT-PCR. In liver, Dio1 mRNA expression was continuously increased throughout L-T3 treatment. In contrast, Thrsp (Spot 14), Me1, Cyp7a1, ACC1, and Fas mRNA showed only transient increases, with their maximum inductions occurring 6 h to 3 d after the initial injection. In kidney, a similar pattern was observed for Dio1; however, Thrsp showed a rapid increase that could still be detected 6 h after the last injection. After L-T3 withdrawal, hepatic Thrsp and Me1 mRNA rapidly returned to their basal levels. In contrast, Dio1 mRNA transiently decreased, and ACC1 and Fas transcripts transiently increased after L-T3 withdrawal. Hepatic SREBP1c and renal Cyp27b1 genes were negatively-regulated during hyperthyroidism. However, L-T3 withdrawal unexpectedly induced their transcription above basal levels. Our findings show that different genes in the same tissue can have different temporal expression patterns during the transition from euthyroidism to hyperthyroidism and during their return to euthyroidism. Moreover, the same gene can have different expression patterns in different tissues. Currently, we are studying the epigenetic mechanisms that likely account for these differences. In conclusion, there are different gene- and tissue-specific responses to the induction of hyperthyroidism and its recovery that may contribute to the variable symptoms reported by hyperthyroid patients before and after treatment, even when serum TH and TSH levels have been normalized.

 

Nothing to Disclose: KO, MKSL, BKS, RAS, JK, XHL, SR, JCGS, PMY

13324 19.0000 SUN-0481 A Gene- and Tissue-Specific Differences in the Temporal Expression Patterns of T3-Regulated Genes during Induction of Hyperthyroidism and Recovery 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

Kenneth Bruce Ain*1, Charles D Smith2, Richard C Grondin2, William B LeMaster2, Barbara J Martin2 and Brian T Gold2
1VA Medical Center & University of Kentucky, Lexington, KY, 2University of Kentucky, Lexington, KY

 

Cognitive and motor impairments have long been associated with hypothyroidism; however, the precise character of cognitive change remains controversial. Despite widespread anecdotal clinical recognition of impaired driving of hypothyroid patients, there is a paucity of data on motor impairment and vehicular safety that would validate precautions for hypothyroid patients. To evaluate neurological, psychological, and vehicular operation parameters altered by hypothyroidism, we performed sequential assessments in euthyroid, hypothyroid, and euthyroid hormone-replaced states in thyroid cancer patients who underwent thyroid hormone withdrawal for radioiodine scanning. Recruitment, informed consent (Univ. of Kentucky IRB), and initial phase of study evaluation were obtained while euthyroid.  Inclusion criteria included: age 18-70 years, ≤ 2 years driving experience, valid driver’s license, and normal corrected visual acuity. Exclusion criteria included: cognitive impairment or impairing psychoactive medications, interfering neurologic disorders (epilepsy, head injury with >5 minute loss of consciousness), or disabilities affecting assessment of driving and motor performance (e.g., stroke, spinal disease or Parkinson’s disease). Target recruitment was reached at 32 subjects (drop-out replacement resulted in 40 recruited subjects). Assessments used: ThyDQoL and ThySRQ measures, Human Motor Assessment Panel, and a psychometric test battery (including: National Adult Reading Test, Boston Naming Test, Mini-Mental State Exam, Wechsler Adult Intelligence Test-Revised, Letter Fluency FAS, and Beck inventory). A driving simulator (STISIM Drive, M400, Hawthorne, CA) assessed vehicular skills. Experimental design used within-subject longitudinal “A-B-A” with each subject tested at 3 visits in the same sequence: euthyroid, hypothyroid, and euthyroid. We showed that, in hypothyroidism, fine motor performance of hands and reaction times in emergency braking tests were slowed, as well as subjective slowing reported on structured clinical scales. Depression was present, typified by vegetative and mood alterations, but lacking reported guilt and lowered self-esteem seen in other types of depression. Cognitive impairment was characterized by declines on speeded executive tests. In contrast, episodic memory performance improved over time regardless of thyroid hormone status. Braking times increased in hypothyroidism by 8.5%, equivalent to reports of effects from a blood alcohol level of 0.082 g/100 mL (above legal driving limit in USA). These data represent new empirical evidence supporting avoidance of complex activities requiring rapid responses, such as operating motor vehicles, in hypothyroidism. We did not observe reduced global mental function or a decline in episodic memory, distinguishing hypothyroidism from amnestic states.

 

Nothing to Disclose: KBA, CDS, RCG, WBL, BJM, BTG

14316 20.0000 SUN-0482 A Quantified Cognitive, Motor and Driving Impairments in Hypothyroidism and Their Reversibility 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

David M Strich*1, Gilad Karavani2, Shalom Edri3 and David Joseph Gillis4
1Shaare Zedek Medical Center and Clalit Health services, Jerusalem, Israel, 2Hadassah-Hebrew University Medical Center, Jerusalem, Israel, 3Clalit Health services, Jerusalem, Israel, 4Hadassah University Hospital, Jerusalem, Israel

 

Introduction: About 80% of triiodothyronine (T3) production is due to extra thyroidal conversion of thyroxine (T4) to T3 by two deiodinases (D1 and D2). Thyrotropin (TSH) has been shown to enhance deiodinase activity in thyroid cell cultures. It is not known if this effect is significant in-vivo.

Methods:  free T3 (FT3), free T4 (FT4) and TSH levels from 3,305 sera taken from children and adolescents (age 1- 20 yr.) without any known thyroid disease were studied. TSH results greater than 7.5 mIU/l were excluded, and FT4 and FT3 levels were within the normal range. This enabled us to investigate the relations between TSH, FT4 and FT3 levels in the euthyroid, or near-euthyroid state.  

Results: There was a significant positive linear correlation of TSH with FT3 (R= 0.12; p<0.0001), but not with FT4.  For each increasing TSH quartile, FT3 and FT3/FT4 increased significantly (for both FT3 and FT3/FT4 ratio, p<0.05 for every TSH quartile when compared with the1st quartile)

Conclusion:  Increasing TSH levels are expected to increase both FT4 and FT3 levels, however within the euthyroid range, as TSH increases FT3 levels increase but FT4 levels do not. Since T3 is produced mostly from T4, this paradox can be explained by TSH driving increased deiodinase activity that converts T4 to T3 so that extra T4 production is not reflected in higher serum FT4 but instead is associated with higher serum FT3. Thus our study provides novel in-vivo evidence supporting the known in-vitro effect of TSH on thyroid deiodinases.

 

Nothing to Disclose: DMS, GK, SE, DJG

15601 21.0000 SUN-0483 A Euthyroid Humans Thyrotropin Enhances Throxine Conversion to Triiodothyronine 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0463-0483 4868 1:00:00 PM HPT Axis Biology and Thyroid Hormone Action Poster

Alessandro Antonelli*, Silvia Martina Ferrari, Andrea Di Domenicantonio, Alda Corrado, Ilaria Ruffilli and Poupak Fallahi
University of Pisa, Pisa, Italy

 

Drug malabsorption is a potential concern in patients with autoimmune atrophic gastritis. In this study we report reversible normalisation of serum TSH levels in three patients with autoimmune atrophic gastritis switched to the therapy with L-Thyroxine (L-T4) in oral liquid formulation, previously treated with L-T4 in tablet formulation. The change from tablets to oral liquid formulation normalised serum TSH levels, while the switch back to tablets caused thyrotropin levels to worsen. These results lead us to believe that absorption of thyroxine is greater with oral liquid formulations in these patients. In conclusion, our results suggest that the L-T4 oral liquid formulation could circumvent the pH alteration resulting from autoimmune atrophic gastritis.

 

Nothing to Disclose: AA, SMF, AD, AC, IR, PF

12583 1.0000 SUN-0499 A Reversible Normalisation of Serum TSH Levels in Patients with Atrophic Gastritis Who Received L-T4 in Tablet Formulation after Switching to an Oral Liquid Formulation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0499-0514 4878 1:00:00 PM Thyroid Autoimmunity Poster

Alessandro Antonelli*, Silvia Martina Ferrari, Alda Corrado, Andrea Di Domenicantonio, Ilaria Ruffilli and Poupak Fallahi
University of Pisa, Pisa, Italy

 

L-Thyroxine (L-T4) absorption is a crucial step in the management of substitutive therapy in patients with autoimmune thyroiditis and subclinical hypothyrodism. Here, we show the reversible normalisation of serum TSH levels in 15 patients with autoimmune thyroiditis and subclinical hypothyrodism (in absence of other causes of L-T4 malasorption) who received L-T4 in tablet formulation after switching to the same dosage of an oral liquid formulation. Serum TSH levels normalised after the change from tablets to liquid oral formulation while the switch back to tablet formulation in 8 among the 15 considered patients caused thyrotropin levels to worsen. This fact leads us to believe that absorption of thyroxine was greater with oral liquid formulations in these patients. In conclusion, these results suggest that the L-T4 oral liquid formulation could circumvent some problems related to the use of high L-T4 doses in the substitutional treatment of hypothyroidism.

 

Nothing to Disclose: AA, SMF, AC, AD, IR, PF

12591 2.0000 SUN-0500 A Reversible Normalisation of Serum TSH Levels in Patients with Subclinical Hypothyroidism Who Received L-T4 in Tablet Formulation after Switching to an Oral Liquid Formulation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0499-0514 4878 1:00:00 PM Thyroid Autoimmunity Poster

Donald SA Mcleod*1, David S. Cooper2, Paul W Ladenson2, David C Whiteman1 and Susan J Jordan1
1QIMR Berghofer Medical Research Institute, Herston, Australia, 2The Johns Hopkins University School of Medicine, Baltimore, MD

 

Background: Race may be a newly recognized risk factor for Graves’ disease. We examined prevalence of thyrotoxicosis by race in Americans aged 12-49 years using three National Health And Nutritional Examination Surveys (NHANES).

Methods and findings: We analyzed data from 17,937 participants in NHANES III (1988-1994), NHANES 1999-2002, and NHANES 2007-2010. We defined thyrotoxicosis as a serum thyroid-stimulating hormone (TSH) ≤0.1 mU/L or subjects taking methimazole or propylthiouracil, and overt thyrotoxicosis (NHANES III only) as high serum total thyroxine and serum TSH ≤0.4 mU/L. We performed logistic regression accounting for the complex sampling design of NHANES and combined results from all three NHANES surveys using a random-effects model. There were 67 study participants with point prevalent thyrotoxicosis. The odds ratio (95% confidence interval) for thyrotoxicosis in the primary analysis was 2.89 (1.48-5.65) for non-Hispanic blacks and 1.18 (0.59-2.35) for Mexican Americans, compared to non-Hispanic whites (I2 for heterogeneity=0% for both). For overt thyrotoxicosis, the odds ratio (95% confidence interval) was 3.75 (1.02-13.78) for non-Hispanic blacks and 2.39 (0.72-7.98) for Mexican Americans, compared to non-Hispanic whites.

Conclusions: Our results suggest there are race differences in the prevalence of thyrotoxicosis. Future studies should address whether these race differences are due to genetics, environmental exposures, or a combination of both.

 

Nothing to Disclose: DSM, DSC, PWL, DCW, SJJ

14521 3.0000 SUN-0501 A Race and the Prevalence of Thyrotoxicosis in Young Americans 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0499-0514 4878 1:00:00 PM Thyroid Autoimmunity Poster

Celestino Neves*1, César Esteves2, Oksana Sokhatska2, Carmo Palmares2, José Luís Medina3, Luís Delgado2 and Davide Carvalho2
1São João Hospital, Faculty of Medicine, University of Porto, Porto, Portugal, 2Centro Hospitalar São João, Faculty of Medicine, University of Porto, Portugal, 3Faculty of Medicine, University of Porto, Porto, Portugal

 

Background: Besides their effects on the cardiovascular system, thyroid hormones are also a key metabolic regulator. So, it is possible that the higher cardiovascular risk in Graves’ disease may be due not only to hemodynamic changes induced by the hyperthyroid state, but also to alterations in the cardiovascular risk factor profile.

Aim: To evaluate the association between thyroid function and cardiovascular risk factors profile in patients with Graves’ disease.

Patients and Methods: We recorded thyroid function tests, BMI, insulin resistance markers comprising the Homeostasis Model Assessment for insulin resistance (HOMA-IR), the Quantitative Insulin Sensitivity Check Index (QUICKI), HISI (Hepatic Insulin Sensitivity Index), WBISI (Whole-Body Insulin Sensitivity Index), IGI (Insulinogenic Index) and the levels of total cholesterol (TC), HDL, LDL-cholesterol, triglycerides (TG), apolipoprotein B (ApoB), ApoA1, lipoprotein(a) (Lp[a]), homocysteine, CRP (C-reactive protein), folic acid and vitamin B12 levels in 104 subjects with Graves’ disease (94% female): 55 euthyroid patients and 49 patients with hyperthyroidism. Mann-Whitney test, logistic regression and Spearman correlations were used for statistical analysis. Results were adjusted for age and BMI. A two-tailed p<0.05 was considered statistically significant.

Results: Significantly higher median levels of TRAb [1.25 (1.05-1.45) vs 1.03 (0.90-1.14) IU/L, p<0.001] were found in the hyperthyroid patients. On the other hand, levels of folate [5.1 (3.6-6.5) vs 6.9 (5.1-9.4) ng/mL, p<0.001] and WBISI [4.39 (2.49-6.15) vs 5.50 (4.08-7.79), p=0.015] were significantly lower in the hyperthyroid group. It was observed that patients with higher levels of TRAb (OR=1.166, p=0.004) or CRP (OR=3.064, p=0.042) had a higher risk of being hyperthyroid. The same observation was established for subjects with higher values of HOMA-IR (OR= 1.613, p=0.025) or IGI (OR=2.933, p=0.046). On the other hand, patients with higher levels of folate had a lower risk of being hyperthyroid (OR=0.797, r=0.004). In the hyperthyroid group, FT3 levels were positively correlated with levels of Lp(a) (r=0.367, p=0.020) and with HOMA-IR (r=0.384, p=0.017). In this group, FT3 levels correlated negatively with QUICKI (r=-0.379, p=0.019) and HISI (r=-0.384, p=0.017). A negative correlation between the levels of TSH and TRAb (r=-0.304, p=0.033) was also established in the hyperthyroid group. In the euthyroid group, TSH levels were positively correlated with WBISI values (r=0.291, p=0.047) and the levels of FT3 were negatively correlated with vitamin B12 (r=-0.358, p=0.010).

Conclusion: In the present study, we found that patients with higher levels of TRAb, CRP, HOMA-IR or IGI had a higher risk of being hyperthyroid. On the other hand, patients with higher folate levels had a lower risk of being hyperthyroid.

 

Nothing to Disclose: CN, CE, OS, CP, JLM, LD, DC

15425 4.0000 SUN-0502 A Graves' Disease and Cardiovascular Risk Factors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0499-0514 4878 1:00:00 PM Thyroid Autoimmunity Poster

Hernando Vargas-Uricoechea*1, Hernando David Vargas-Sierra2, Julián Ñáñez-Paz3, Karina Agredo-Reyes3 and Magda Rangel-Bahamón3
1Universidad del Cauca, Popayán-Colombia, Popayán-Cauca, Colombia, 2Corporación Universitaria Rafael Núñez, Cartagena-Bol, Colombia, 3Universidad del Cauca, Popayán, Colombia

 

Background: Hemodynamic and cardiac effects of SH are not considered in all patients; moreover, they are not assessed systematically or adequately in this group of individuals. 

Objective: To determine the cardiac effects of SH in women with GBD.

Methods: 62 women with SH due to GBD, selected on the basis of TSH levels <0.4 mUI/mL, normal levels of FT3-FT4, ultrasonographic criteria and nuclear imaging with radioiodine uptake (131-I) were matched with 62 healthy women. All of them underwent the following tests: Transthoracic echocardiography, 24-h holter ECG and 24-h ambulatory blood pressure monitoring. Women with SH who were receiving antihypertensive and/or beta-blocker drugs were not included.

Results: Echocardiography showed diastolic dysfunction, defined as E/A reduction in women with SH compared to healthy women: 0.86 [0.79-0.94] vs. 1.32 [1.16-1.48] (p=0.026). Of the women with SH, 17 (27.4 %) met criteria for ventricular hypertrophy when compared to healthy women. The heart rate average in women with SH was 95 bpm and 71 bpm in healthy women (p=0.018). Differences in diastolic blood pressure levels were not found, but differences in systolic blood pressure were found both day and night –those with SH had a mean systolic daytime pressure of 140 mmHg and mean night pressure of 142 mmHg (p=0.023).

Conclusion: Women with GBD manifest significant and relevant hemodynamic and cardiac changes, which should be investigated at the time of diagnosis. Intervention studies should be performed to assess the impact of modifying these cardiac alterations in order to achieve proper treatment of SH.

 

Nothing to Disclose: HV, HDV, JÑ, KA, MR

15451 5.0000 SUN-0503 A Hemodynamic and Cardiac Effects of Subclinical Hyperthyroidism (SH) in Women with Graves-Basedow Disease (GBD) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0499-0514 4878 1:00:00 PM Thyroid Autoimmunity Poster

Yun Cai1, Qingfang Hu1, Xiaoyun Liu*1, Heng Chen1, Liping Yu2, John C Hutton2, George S Eisenbarth2, Tao Yang3 and Jiawei Chen1
1The First Affiliated Hospital of Nanjing Medical University, Nanjing, China, 2University of Colorado Denver, Aurora, CO, 3the First Affiliated Hospital of Nanjing Medical University, Nanjing, China

 

Patients with type 1 diabetes (T1D) often develop other autoimmune diseases, of which autoimmune thyroid disease (AITD) is the most frequent. Many studies have revealed an association between thyroid autoantibodies and islet autoantibodies in patients with T1D. However, few studies have reported about the islet autoantibodies and none reported about the zinc transporter 8 autoantibody (ZnT8A) in patients with AITD. To investigate the anti-islet autoimmune status in patients with AITD and the association between islet autoantibodies and autoantibodies against thyroid peroxidase (TPOAb) and thyroglobulin (TGAb), we performed this cross-sectional study. 740 AITD (377 Graves’ disease (GD) and 363 Hashimoto’s thyroiditis (HT), 600 female and 140 male, aged 40.4±14.0), 787 T1D (384 female and 403 male, aged 28.0±14.7), 172 non-autoimmune thyroid disease (nAITD) patients (141 females and 31 male, aged 50.3±13.7) and 115 healthy controls (87 female and 28 male, aged 44.7±12.8) were recruited. Autoantibodies against zinc transporter 8 (ZnT8A), glutamic acid decarboxyase (GADA) and insulinoma-associated protein-2 (IA-2A) were detected by radioligand assay. Islet autoantibody relative value= Islet autoantibody index/cut-off index. The results showed (1) the prevalence of ZnT8A in AITD group was significantly higher than that in healthy controls (15.00% vs 1.74%, P<0.01). Similarly, the prevalence of IA-2A in AITD group was higher than that in healthy controls (4.19% vs 0%, P<0.05). The differences between ZnT8A or IA-2A positive rate in the AITD group and the nAITD group (15.00% vs 9.30%, P>0.05 and 4.19% vs 2.91% P>0.05) were not statistically significant. The prevalence of GADA in AITD group was significantly higher than that in healthy controls (7.97% vs 0.87%, P<0.01) and in nAITD group (7.97% vs 2.33%, P<0.01). However, any of the three islet autoantibodies positive rate in AITD group was significantly lower than that in T1DM group (ZnT8A: 15.00% vs 43.33%, P<0.01; IA2A: 4.19% vs 27.32%, P<0.01; GADA: 7.97% vs 49.81%, P<0.01). (2) the differences between any of the islet autoantibodies positive rate in the GD subgroup and the HT subgroup (ZnT8A: 13.79% vs 16.25%, P>0.05; IA2A: 4.51% vs 3.86%, P>0.05; GADA: 8.49% vs 7.44%, P>0.05) were not statistically significant. (3) Analysis of multivariable linear regression suggested that ZnT8A relative value was associated with GADA relative value (b=0.352, P<0.01) and TPOAb titer (b=0.002, P<0.01) and GADA relative value was associated with ZnT8A relative value (b=0.183, P<0.01). It is clear that the prevalence of ZnT8A, IA-2A and GADA were relatively high in patients with AITD and the results suggest the disease pattern has no influence on anti-islet autoimmunity. The analysis of multivariable linear regression indicates a potential link between thyroid autoimmunity and anti-islet autoimmunity in the immunological pathogenesis.

 

Nothing to Disclose: YC, QH, XL, HC, LY, JCH, GSE, TY, JC

15746 6.0000 SUN-0504 A Relatively High Prevalence of Islet Autoantibodies in Autoimmune Thyroid Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0499-0514 4878 1:00:00 PM Thyroid Autoimmunity Poster

Ceyla Konca Degertekin, Metin Arslan*, Ozlem Turhan Iyidir, Banu Aktas Yilmaz, Sehri Elbeg, Hatice Pasaoglu and Nuri Cakir
Gazi University Faculty of Medicine, Ankara, Turkey

 

Thyroid hormones are necessary for a healthy skeletal growth and bone remodelling. Hypothyroidism causes slowing of bone turnover and an increase in  the fracture risk by adversely affecting bone quality. A new body of evidence suggests that autoimmune disorders as well, are associated with a disturbed bone turnover. Hashimoto’s thyroiditis is an autoimmune disorder in origin and the impact of autoimmunity and the resultant hypothyroidism on bone turnover in Hashimoto’s thyroiditis is not known. Osteoprotegerin(OPG)/Receptor activator nuclear kappa B ligand (RANKL) pathway is known to play a major role in bone remodelling and interleukin-6 (IL-6), which is an osteoclastogenic cytokine, may exert its inhibitory effect on bone formation indirectly by influencing the balance between OPG/RANKL. In this study, we assessed the levels of OPG, RANKL and IL-6 along with markers of bone formation as osteocalcin (OC), procollagen type I N propeptide (PINP) and markers of bone resorption as type 1 collagen C telopeptide (CTX) and tartrate resistant acid phosphatase isoform 5b (TRAcP 5b) in 30 hypothyroid and 30 euthyroid premenopausal Hashimoto’s thyroiditis patients and 20 healthy premenopausal controls. We found that TRAcP 5b [1.5(1.2) vs 1.9(1.0) vs 2.0(0.8) U/l for hypothyroid, euthyroid and control groups, respectively; p=0.006], CTX [4.02(2.39) vs 5.84(4.49) vs 6.37(3.80) ng/ml; p=0.01] and OC [2.5(2.7) vs 4.3(3.5) vs 4.2(2.2) ng/ml; p=0.017) levels were lower and PINP [147.26(32.55) vs 127.25(36.45) vs 128.51(28.23) pg/ml; p=0.001) was higher in hypothyroid compared to euthyroid Hashimoto patients and controls. OPG levels were higher [323.0(364.8) vs 251.6(338.0) vs 107.5(131.7) pg/ml; p<0.001] and RANKL levels were lower [461.50(336.75) vs 439.50(359.00) vs 695.00(445.62) pmol/l; p=0.021] in hypothyroid and euthyroid Hashimoto patients compared to controls. OPG was positively correlated with serum TSH (ρ=0.248, p=0.029). Hypothyroid Hashimoto patients had lower IL-6 levels compared to euthyroid Hashimoto and control groups [5.2(8.3) vs 11.3(8.4) vs 15.2(12.0) pg/ml; p<0.001]. RANKL/OPG ratio was independently associated with the presence of Hashimoto’s thyroiditis (p<0.001) and markers of bone turnover (p=0.038). In conclusion, bone turnover is adversely affected in hypothyroidism in premenopausal patients with Hashimoto’s thyroiditis and thyroid autoimmunity per se, may potentially contribute to the problem through the OPG/RANKL pathway.

 

Nothing to Disclose: CK, MA, OT, BA, SE, HP, NC

15766 7.0000 SUN-0505 A Osteoprotegerin/RANKL System and Bone Turnover Is Disturbed in Hasmimoto's Thyroiditis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0499-0514 4878 1:00:00 PM Thyroid Autoimmunity Poster

Banu Pinar Sarer Yurekli*1, Gokcen Unal Kocabas2, Aysegul Akkaya2, Cem Mirili2, Serkan Unal2, Guray Guvercin2 and Mehmet Erdogan3
1Ege University Hosp, Bornova, Turkey, 2Bozyaka Education and Research Hospital, 3Ege University Hospital

 

Serum Dehydroepiandrosterone sulfate levels in premenopausal women with chronic lymphocytic thyroidtis

Aim

Dehydroepiandrosterone (DHEA) and its sulfated metabolite, dehydroepiandrosterone sulfate (DHEAS), has previously been reported to decrease hyperglycemia, obesity, cancer, and autoantibody generation in a number of animal models. DHEAS has been shown to exert potent effects on both humoral and cellular immune response. However, their physiological role in the immune system is unkonown. DHEAS could have immunmodulatory effects. Chronic lymphocytic thyroidtis is a disease that has a immunological pathogenetic basis.

Material-Methods

We included 93 premenopousal women for this cross-sectional study. Forty-six patients who were seropositive for thyroglobulin autoantibodies (AntiTg) and/or thyroperoxidase autoantibodies (AntiTPO) were taken as study group. Forty-seven patients who were age metched and seronegative for Antitg and AntiTPO autoantibodies were accepted as control group. All patients were euthyroid. In both group, none of the cases were taking estrogen/progesterone medication and had no polycystic ovary syndrome and hirsutism. All cases enrolled into study had regular menstruation periods and no problem of adrenal insufficiency.

Results

Mean age of antibody positive (+) group was 37 years of old and 33 years fort he control group (p=0,056). No statistical difference in DHEAS serum concentration was found between antibody positive chronic lymphocytic thyroiditis patients and antibody negative control group (mean DHEAS 178 µg/dL versus 172µg/dL, respectively, p=0,76).  There was no correlation between DHEAS levels and thyroid autoantibodies.

Conclusion

In the present study, we did not observe any significant differences in serum concentration of DHEAS between study and control group. DHEAS may have immunomodulatory effect. There is limited study in the literature related to DHEAS and autoimmune thyroiditis occurence. In this perspective, further studies are needed.


 

Nothing to Disclose: BPS, GU, AA, CM, SU, GG, ME

15779 8.0000 SUN-0506 A Serum Dehydroepiandrosterone Sulfate Levels in Premenopausal Women with Chronic Lymphocytic Thyroidtis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0499-0514 4878 1:00:00 PM Thyroid Autoimmunity Poster

Sena Hwang*1, Woo Kyung Lee2, Dong Yeob Shin3 and Eun Jig Lee4
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Yonsei Univ Coll of Medicine, Seoul, Korea, Republic of (South), 3Yonsei University College of Med, Seoul, Korea, Republic of (South), 4Yonsei University College of Medicine, Korea, Republic of (South)

 

Background: Graves’ disease (GD) is caused by autoantibodies stimulated to thyroid-stimulating hormone receptor (TSHR). Two frequent assays were compared in relations to the diagnostic accuracy for GD. One is an inhibition assay using the monoclonal antibody (M22) closely mimicking the binding to TSH (M22-TRAb), and one is a bioreporter assay using the chimera transfected cell (Mc4-TSAb) and measuring stimulation of cyclic adenosine monophosphate (cAMP) production.

Methods: This cross-sectional study examined 216 sera from thyrotoxicosis patients (including 67 subclinical thyrotoxicosis); 94 sera from GD diagnosed within one month and 120 sera from transient thyrotoxicosis (TT). We compared the diagnostic performance of two TSHRAb assays.

Results: The M22-TRAb assay and Mc4-TSAb assay were positive in 96.1 and 92.2% of the GD patients, whereas they were negative in 92.5% and 91.7% of the TT patients. We found the cut-off values of the two tests for GD diagnosis were 2.00 IU/L and 158.0 %. However, 7 of 94 GD (7.4%) showed discordant results and 2 of them were treated with antithyroid drug that could have effects on the TSHRAb titer. In GD patients with subclinical thyrotoxicosis, the specificities for GD diagnosis of both assays were decreased to 82.1% and the proper cut-off levels of M22-TRAb and of Mc4-TSAb were 2.56 IU/L and 217%.  M22-TRAb showed stronger correlations with T3 level (P=0.026) and thyroid I-131 uptake (P=0.025) than that of Mc4-TSAb in untreated GD.

Conclusion: Similar and high diagnostic accuracy was shown for Mc4-TSAb and M22-TRAb in GD patients. However, considering a 7.4% discordance rate between two tests, we suggest a combination of both assays can reduce the presence of TSHRAb-seronegative GD, especially for those under the therapy. Higher cut-off values of both assays should be considered for diagnosis of early GD.

 

 [½Å1]¼öÄ"° ¸Â³ªzä?

 

Nothing to Disclose: SH, WKL, DYS, EJL

15834 9.0000 SUN-0507 A High Diagnostic Performance of TSH Receptor Antibody Assays in Graves' Disease with Different Cut-off Values in Early GD 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0499-0514 4878 1:00:00 PM Thyroid Autoimmunity Poster

Miguel Walter Vasquez Cayoja*1, Javier Mauricio Farias2, Karina Miragaya2, Ana Paula Lisdero2, Mariangeles Ruffini3, Gabriela Jimenez3 and Cecilia Goldaracena2
1CEDIR, Montero, Bolivia, 2Sanatorio Güemes, Buenos Aires, Argentina, 3Sanatorio Guemes

 

Thyroid autoimmunity in patients with subclinical hypothyroidism helps us to determine etiology, prognosis and treatment. However, in some economic, geographic situations it is difficult to have this determination.

Along time many sonographic parameters have been proposed to establish the diagnosis of thyroid autoimmunity, however these parameters are limited by operator dependence.

Objective: to evaluate the association between thickness of thyroid isthmus by ultrasound and the presence of TPO-Ab.

Material and methods

A total of 880 patients and thyroid ultrasound were evaluated, they came to our service from July to November’s 2012. We evaluated size of the isthmus, echo patterns and presence of nodules by ultrasound, additionally TSH levels and TPO-Ab were evaluated.

We excluded patients who had not data about size of the isthmus, and those without TSH and TPO-Ab levels realized within 3 months around date of ultrasound. Remaining 535 patients to analysis.

We analyzed groups according Thyroid Status, each group was divided into quintiles according size of the isthmus in milimeters (less than 2, 2 to 4, 4 to 6, 6 to 8 and greater than 8), We performed the analysis about of patients with positive antibodies (TPO-Ab).

TSH values and the size of the isthmus were expressed in mean an SD, Each quintile represent the percent of patients with positive TPO-Ab, for analysis of RR and OR We compared Q2 vs anothers groups Qx(Q3+Q4+Q5). Statistical analysis was evaluated by ANOVA and Fisher´s Test performed by software INSTAT 3.01.

Results.

The mean size of the isthmus for Q1, Q2, Q3, Q4, Q5, were 1.52, 2.82, 4.53, 9.95, 12.39 mm respectively. The TSH means were not significantly different (means ± SD) Q1 = 5.97 ±1.49, Q2 = 6.2 ± 1.33, Q3 = 6.76 ± 1.48, Q4 = 5.73 ± 0.56, Q5=5.39 ± 9.4 (P = 0.38) among groups.  No statistically significant differences were found when the echo pattern and the presence of nodules were evaluated.

The proportion  of TPO-Ab positive by quintiles according to the size of the isthmus for all levels of TSH was Q1=48%, Q2=55%, Q3=80%, Q4=82%, Q5=69%, p values Q2 vs Qx<0.0001; RR=1.42 (IC95% 1.24 to 1.63); OR=3.03 (IC95% 1.82 to 5.04).

In group of euthyroid patients TPO-Ab positive was: Q1=43%, Q2=50%, Q3=72%, Q4=73%, Q5=67%; The risk of positive TPO-ab on Qx compared with Q2 was RR=1.43 (IC95% 1.18 to 1.74); OR=2.54 (IC95% 1.44 to 4.49).

In Sub Clinical Hypothyroidism group TPO-Ab positive was: Q1=64%, Q2=67%, Q3=100%, Q4+Q5=88%. The risk of positive TPO-ab on Qx compared with  Q2 was RR=1.40 (IC95% 1.13 to 1.72); OR=8.27 (IC95% 1.01 to 67.16).

Finally the accuracy of this method to predict the association between antibodies and isthmus size greater than 4 mm was: S=27%; E=95%; PPV=94%, NPV= 33%; Odds Ratio 8.5 (95% CI 1.06 to 68.12) p=0.018

Conclusions

Independently of TSH values isthmus size ticker than 4 mm are associated with APTO positive antibodies. This association was strongly specific but poor sensibility.

 

Nothing to Disclose: MWV, JMF, KM, APL, MR, GJ, CG

16405 10.0000 SUN-0508 A Measurement of Thyroid Isthmus By Ultrasound Can Predict Presence of TPO-Ab 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0499-0514 4878 1:00:00 PM Thyroid Autoimmunity Poster

Shakir Zhuraev*1, Yerbol Shaikhiyev2, Adil Shokebaev2, Baurzhan Ormanov2, Arman Aliev2, Nurmakhan Imammirzaev1, Yerzhan Rakhimov2 and Anton Lee1
1National Scientific Center of Surgery named after AN Syzganov, Almaty, Kazakhstan, 2A.N. Syzganov,s National scientific center of surgery, Almaty, Kazakhstan

 

Introduction.

Radical surgical treatment of diffuse toxic goiter (Graves' disease), characterized by quick achievement of euthyroid state, is widespread and recognition in our country. However, the problem of postoperative complications today remains quite relevant. In this regard, there is a need to develop and implement advanced minimally invasive treatments for Graves' disease.

 Materials and methods.

SETA as independent method of treatment of Graves' disease, introduced in our clinic since 2012. Following this procedure, 45 patients received treatment from the beginning of 2012 till 2014. Diagnosis was confirmed on the basis of studies of hormonal status. The patients were divided into 2 groups. Main group consisted of 45 patients using SETA as independent method, was 15 (33%) men and 30 (67%) women aged 21 to 58 years old, and in the control group, in which 45 patient performs subtotal strumectomy, was 12 (26.6%) men and 23 (73.3%) women aged 25 to 64 years.

 Results.

Confirmed the effectiveness of SETA by color Doppler ultrasound scanning of the thyroid gland , hormonal control study in the dynamics of 3 -10-30 -th day after embolization. During this time achieved compensation phenomenon of hyperthyroidism , thyroid volume reduction , reduction of blood flow in the thyroid tissue , intensification of thyrostatic therapy.Complications after SETA at  8 cases was moderate pain syndrome.Thyroid hormones in the dynamics decreased. TTG increased gradually. On 5 and 30 days after SETA held needle aspiration biopsy of the thyroid gland. At the same time revealed necrosis of glandular epithelium and interstitium, and then fibrosis. The duration of treatment ranged from 5 till 7 days.

CONCLUSIONS:

SETA is an effective treatment for Graves' disease. Can be used in severe forms of Graves' disease, with complications of the underlying disease, severe comorbidities. Promotes rapid relief of thyrotoxicosis phenomena, reduce the volume of the thyroid gland. After SETA determined characteristic pathological changes in thyroid gland, testifying the effectiveness of the treatment.

 

Nothing to Disclose: SZ, YS, AS, BO, AA, NI, YR, AL

16864 11.0000 SUN-0509 A Selective Embolization of Thyroid Arteries (SETA) As Independent Method of Treatment in Patients with Graves' Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0499-0514 4878 1:00:00 PM Thyroid Autoimmunity Poster

Felipe Rodrigues Noronha1, Isabel Cristina de Mello Guazzelli2, Veronica Carneiro Borges Mioto3, Nicolau Lima Neto3 and Suemi Marui*1
1Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 2Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 3Faculdade de Medicina da Universidade de São Paulo, Brazil

 

Graves´ disease (GD) is usually characterized by thyrotoxicosis, goiter and ophtalmopathy. Genetic background has important role in thyroid autoimmune tolerance and consequently may influence clinical presentation. Several polymorphism, especially in CTLA4 gene  (1) and recently the -1626A/G (rs180195) in promoter region of thyroglobulin gene (TG) were associated with GD (2). To study the frequencies and genetic background potential impact on clinical picture, we retrospectively evaluated 153 patients (116 females) with GD diagnosed at our Institution. Clinical, hormonal and treatment data were obtained from medical records from 2006 to 2013. DNA of all patients and 78 normal controls was extracted from peripheral leukocytes and rs3087243 (CT60-CTLA4) and rs180195 (TG) were genotyped by Real-time PCR (Taqman®). Both polymorphisms were in Hardy-Weinberg equilibrium. The mean age of GD diagnosis was 40.2±15.4 ys (5 to 74), ophthalmopathy was clinical diagnosed in 47.4%, smoking was referred in 32%, presence of autoimmune nonthyroid disorder was reported in 10% and only 8.8% had negative TSH receptor antibody (TRAb). Relapse was reported in 68% after drug treatment (mean duration of treatment = 24 months) and mostly received radioiodine therapy (total 24±12.2 mCi). We did not find association of GD with risk allele and risk genotype of both polymorphisms. No association with risk alleles and risk genotypes and age at GD diagnosis, ophthalmopathy, goiter, TRAb concentrations and GD relapse were found. We conclude that the CT-60 CTLA4 and TG polymorphisms here studied were not associated with GD in our cohort and had no impact on GD clinical presentation in our Institution.

 

Nothing to Disclose: FRN, ICDMG, VCBM, NL, SM

11998 12.0000 SUN-0510 A CTLA-4 (CT60) and Thyroglobulin Promoter Polymorphisms Are Not Associated with Graves′ Disease: Experience of a Single Academic Institution-Sao Paulo-Brazil 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0499-0514 4878 1:00:00 PM Thyroid Autoimmunity Poster

Roberto Vita*1, Maria Le Donne2, Salvatore Settineri2 and Salvatore Benvenga3
1University of Messina, Messina, Italy, 2University of Messina, 3University of Messina Policlinico G. Martino; University of Messina School of Medicine;University Hospital Policlinico G. Martino, Messina, Italy

 

Very few studies have investigated in the EPP whether emotional disturbances other than depression are associated with thyroid dysfunction and autoimmunity. Six affective mood states are measured by the POMS questionnaire: anger-hostility (A), confusion-bewilderment (C), depression-dejection (D), tiredness-fatigue (S), tension-anxiety (T), vigor-activity (V). Except for V (abnormal score at ≤40), the other mood states are negative (abnormal score at ≥61). We wished to test if these mood states could be linked to changes in thyroid function and/or thyroid autoimmunity.

On day 3 PP, in 74 women with no family/personal history of psychiatric disorders/thyroid diseases, we measured serum TSH, FT3, FT4, thyroperoxidase antibodies [TPOAb], thyroglobulin antibodies [TgAb] and administered the POMS questionnaire. Data are mean±SD. Statistics handled by ANOVA and linear regression.

The rates of abnormal POMS-A, -C, -D, -S, -T or -V scores were 13.5%, 16.2%, 13.5%, 23.0%, 25.7% or 20.3%. Women with abnormal POMS-T or POMS-D scores had higher TSH levels than women with normal POMS-T or POMS-D scores (3.35±2.1 vs. 2.42±1.7 m/UL, P=0.05, or 3.71±2.1 vs. 2.49±1.7, P<0.10). Women with abnormal POMS-A, -D and -S scores had higher TPOAb levels than women with correspondingly normal scores (22.9±23.5 vs. 12.3±26.1 U/ml, P=0.04; 36.6±48.7 vs. 10.1±18.4, P=0.004; 25.5±39.2 vs. 10.2±19.4, P=0.02). Serum TSH correlated positively with POMS-A, -C and -D scores. Serum TPOAb correlated positively with POMS-A, -C, -D, -S, -T scores.

In summary, the rate of POMS-D (13.5%) is comparable to that of -A and -C, but lower than that of -S, and -T (23 and 26%). The first three moods correlate directly with serum TSH, and all five correlate directly with serum TPOAb.

 

Nothing to Disclose: RV, ML, SS, SB

11930 14.0000 SUN-0512 A Abnormal Scores of the Profile of Mood States Scale (POMS) Correlate with Thyroid Dysfunction and Thyroid Autoimmunity in the Early Postpartum Period (EPP) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0499-0514 4878 1:00:00 PM Thyroid Autoimmunity Poster

Ana Carolina de Castro Nassif Gomes Monteiro1, Verônica Carneiro Borges Mioto1, Sérgio Kobayashi1, Cheila Portela Silva2, Maria Cristina Chammas1 and Suemi Marui*3
1Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 2Sociedade Beneficente Israelita Brasileira Albert Einstein, Sao Paulo, 3Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil

 

During pregnancy, thyroid physiology undergoes several changes in order to adapt to the metabolic and hormonal modifications experienced by the maternal organism. Thyroid vascularization and thyroid volume appear to increase diffusely as thyroid hormone production need to be higher in pregnancy. Our aim was to evaluate the morphological changes undergone by the maternal thyroid gland during the three trimesters of pregnancy.

Methods: Ultrasonography was performed with color Doppler ultrasound scanner (Philips IU-22) equipped with a 7.5-12 MHz broadband linear transducer in pregnant women with low risk and without known thyroid disease in each trimester. Thyroid volume, echotexture and echogenicity were determined as cm3, homo or heterogenous and hypoechogenic or normal, as previously described (CHAMMAS). Vascularization pattern was classified as normal, slightly increased, moderately increased, or highly increased according to color pixels density. The inferior thyroid artery was identified outside the thyroid parenchyma in the sagittal plane, maintaining the Doppler angle less than 60˚ and flow was measured in cm/s.

Results: From May-2011 to November-2013, 179 pregnant women were prospectively evaluated, 53 (29.6%) in the first trimester, 76 (42.4%) in the second trimester and 50 (28%) in the third trimester.  The mean maternal age was 27.8±7.2 years and BMI was 26.4±5.2 kg/m2. Eighty-four women (46.9%) were in their first pregnancy. Thyroid nodule was found in 21.2 %. During the first trimester, the mean thyroid volume was 9.7±2.9 cm³, moderately increased vascularization pattern was found in 35.8% and mean peak systolic velocity was 26.2±8.6 cm/s. During the second trimester, mean thyroid volume was 9.8±2.9 cm³, moderately increased vascularization pattern was found in 54% of pregnant women and mean peak systolic velocity was 25.6±8.8 cm/s. During the third trimester, mean thyroid volume was 9.8 ± 2.9 cm ³, moderately increased vascularization pattern was found in 54% and mean peak systolic velocity was 25.9±8.7 cm/s. No significant differences according to thyroid volume (p=0.452, 0.146 and 0.318), echotexture (p=0.133) and echogenicity (p=0.840) were found among the trimesters. Diffusely increased vascularization of thyroid parenchyma was observed but with no statistical difference among the trimesters (p=0.400). In contrast, the peak systolic velocity of inferior thyroid artery (PSV-ITA) was higher in the first trimester than the third trimester (p=0.002).

Conclusion: We found no significant difference in thyroid volume, echotexture and echogenicity, as well as the thyroid vascularization pattern along pregnancy. It was noteworthy that the PSV-ITA was significantly higher in the first trimester of pregnancy.

 

Nothing to Disclose: ACDCNGM, VCBM, SK, CPS, MCC, SM

12479 15.0000 SUN-0513 A Ultrasonography of the Thyroid Gland during Pregnancy: Comparison Among Trimesters 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0499-0514 4878 1:00:00 PM Thyroid Autoimmunity Poster

Uma Kaimal Saikia*1 and Dipti Sarma2
1Gauhati Medical College, Guwahati, Assam, India, 2Gauhati Medical College, Guwahati, India

 

Maternal and fetal health is known to be affected by the thyroid status of the mother during pregnancy. In addition the presence of thyroid autoantibodies has been reported to be associated with adverse pregnancy outcomes. The present study was done to assess the prevalence of thyroid peroxidase antibodies (TPO Ab) among pregnant women and its relationship to maternal and fetal parameters including pregnancy induced hypertension (PIH), fetal loss, need for cesarian section, preterm delivery, low birth weight and neonatal jaundice requiring phototherapy. A total of 542 women attending the antenatal clinic of Gauhati Medical College irrespective of gestational age, without any known thyroid disorder or on any drugs known to alter thyroid function were screened for thyroid dysfunction by estimation of FT4 and TSH and TPO Ab. Treatment was given as required to maintain TSH in the trimester specific reference range. Subjects were followed up and outcomes were recorded.

Among the 542 women screened  subclinical hypothyroidism (SCH) was seen in 21.58%, overt hypothyroidism (OH) in 5.35%, hyperthyroidism in 2.39% and 1.47% had gestational thyrotoxicosis. Normal thyroid function was seen in 69.18%. The overall prevalence of positive TPO Ab was 18.08%. Among women with normal thyroid function TPO Ab  were present in 16.8%. Follow up data were available for 516 women of whom 361 were euthyroid with TPO positivity of 17.45%. Comparison between TPO positive and negative euthyroid subjects revealed a significant increase in fetal loss in the former group (7.93% vs 0.33%) though other parameters did not differ between them.  Though SCH and OH were found to be associated with adverse end points including PIH, preterm delivery and neonatal jaundice, the presence or absence of thyroid autoimmunity did not alter outcome in these patients. In view of the association of thyroid autoimmunity with pregnancy loss in euthyroid pregnant women, thyroid autoantibody screening may be advocated in pregnancy.

 

Nothing to Disclose: UKS, DS

13194 16.0000 SUN-0514 A Thyroid Autoantibodies Interfere with Pregnancy Outcome in Euthyroid Women - an Indian Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0499-0514 4878 1:00:00 PM Thyroid Autoimmunity Poster

Raul Ruiz-Esponda*, Val J Lowe and Diana S. Dean
Mayo Clinic, Rochester, MN

 

Background: A palpable thyroid nodule is found in about 5% of the general population. It is estimated that of all thyroid nodules, only about 5% are malignant (1; 2).  Incidentally found non-palpable thyroid nodules (thyroid incidentalomas) are increasing with the extensive use of different imaging techniques including positron emission tomography (PET). The prevalence of incidental thyroid fluorodoxyglucose (FDG) uptake on PET ranges from 0.1 to 4.3% in the literature. Focal uptake on FDG PETCT carries a higher risk of malignancy, ranging from 14-57% in some studies (3-6). 11C-Choline PET/CT is an imaging technique that is being widely used for the evaluation, staging and surveillance of different malignancies, particularly prostate cancer (7).  A case of a benign thyroid incidentaloma detected by 18F-choline has been reported (8). There have been case reports on which 18F-FDG PET/CT negative thyroid cancer lesions are positive on11C-Choline PET/CT (9).

Objective: Our objective was to evaluate our institutional experience with the prevalence of incidental thyroid uptake and thyroid malignancy in patients undergoing 11C-Choline PET/CT for prostate cancer.

Methods: A retrospective review of all men who underwent 11C-Choline PET/CT studies for prostate cancer from September 2005 to August 2013 at the Mayo Clinic in Rochester MN was performed. A total of 1697 studies were performed during this time period, but men with more than one examination during the study period were counted only once, so a total of 1197 men were reviewed. The etiology of these thyroid incidentalomas was determined by cytology and/or histopathology. The patients were classified into three groups: benign, malignant, and no follow up. Data on age, neck ultrasound findings, thyroid stimulating hormone levels (TSH) and cytology/histopathology results was also obtained.

Results: Incidental high uptake in the thyroid gland was found in 30/1197 (2.5%) of patients. Because of advanced primary disease, poor prognosis and/or advanced age, 14/30 (46.7%) patients had no follow-up. An adequate follow-up was performed in 16/30 (53.3%). Of those with adequate follow-up, a benign etiology was determined in 14/16 (87.5%) based on US and cytology. Of this benign group, one patient was found with a follicular adenoma and one patient with a Hurthle cell adenoma. Their mean age was 69.9 +/- 7.7 (SD) and TSH 2.29 +/- 1.28 (SD).  Of the patients with adequate follow up, 1/16 (6.1%) was found with papillary thyroid cancer and one with a non-diagnostic fine needle aspiration (FNA). 

Conclusions: Thyroid incidentalomas on 11C-choline PET/CT may carry a lower likelihood of being malignant compared to those found on FDG PET/CT. In this study, a primary thyroid malignancy was confirmed in only 6.1% of the patients who had adequate follow-up which is less than the 14-57 % of those found on FDG PET/CT.

 

Nothing to Disclose: RR, VJL, DSD

13118 1.0000 SUN-0515 A Clinical Significance of Incidental Thyroid Uptake on 11C-Choline PET/CT 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Rita Joana Santos*, Margarida da Silva Vieira, Pedro Marques, Edward Limbert and Valeriano Leite
Portuguese Institute of Oncology, Lisbon, Portugal

 

Background: Focused on the molecular pathogenesis of differentiated thyroid cancer (DTC), emphasizing the role of MAP kinase signaling pathway, interest rose on tyrosine kinase inhibitors (TKI) in the treatment of radiodine refractory DTC. We describe our clinical experience with Sorafenib and Sunitib in patients with refractory DTC who were not eligible for clinical trials.

Patients and methods: Patients with progressive and metastatic radiodine refractory DTC received Sorafenib 400 mg orally twice a day and were treated for a minimum of 12 weeks. Both baseline and at least one follow up scan were required for restaging purposes. The primary endpoint was radiographic response and progression free survival (PFS). The secondary endpoints were thyroglobulin correlation with response and toxicity assessment. If a patient had progressive disease (PD) under treatment with Sorafenib, treatment with Sunitinib (50 mg daily for 4 weeks followed by 2 weeks off drug) could be initiated if clinically indicated.

Results: Seventen patients were treated (9 women, 8 men) with a median age of 61 yr (range 39-77 yr). 15 patients begun treatment with Sorafenib and 2 with Sunitinib. Four patients with PD with Sorafenib switched therapy to Sunitinib. All patients had PD in the 12 months prior to theraphy. Best response in target lesions with Sorafenib was: partial response (PR) in 4 (26%) and stable disease (SD) > 6 months in 7 (46%). The median PFS was 13 months. Best response with Sunitinib was: PR in 3 (50%) and SD in 1 (16%). PR were mainly achieved  at 3 months of theraphy, with a good correlation between radiographic and thyroglobulin response. All PR were  observed in lung and lymph nodes. Pleural disease and non-irradiated bone metastases demonstrated PD. Common adverse events included diarrhea, hand-foot skin syndrome and cutaneous rash. No treatment related deaths were seen. Dose reduction was required in 70 and 50% of the patients under Sorafenib and Sunitinib, respectively. Three out of 4 patients who were previously refractory to Sorafenib achieved PR with Sunitinib.

Conclusions: Sorafenib and Sunitinib appears to be effective in patients with metastatic progressive DTC, especially within the first months of treatment. Failure of a previously given thyrosine kinase inhibitor does not predict lack of response of a different TKI in the same patient.

 

Nothing to Disclose: RJS, MDSV, PM, EL, VL

14930 2.0000 SUN-0516 A Tyrosine Kinase Inhibitors in the Treatment of Differentiated Thyroid Cancer: Efficacy and Tolerability in 17 Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Ayman A. Zayed1, Moaath K. Mustafa Ali*2, Omar Mohammed Jaber3, Moh’d Jaber Suleiman4, Ashraf Azzam Ashhab5, Munther Suleiman Momani1, Maha Suliaman Shomaf5, Salah Mohammed AbuRuz5 and Wajdi Mohammed Al_Shweiat4
1The University of Jordan / Jordan University Hospital, Amman, Jordan, 2King Hussein Cancer Center, Amman, Jordan, 3University of Iowa Hospitals and Clinics, Iowa City, IA, 4The University of Jordan/Jordan University Hospital, Amman, Jordan, 5University of Jordan, Amman, Jordan

 

Background and Objective: The etiology of medullary thyroid carcinoma (MTC) remains unknown. The aim of this study was to determine whether there is a significant association between MTC and Hashimoto’s thyroiditis (HT) in the histopathologic material of thyroidectomized patients.

Methods: In this retrospective cross-sectional study, we reviewed the medical records of all patients who underwent total thyroidectomy for different thyroid-related complaints between January 2000 and January 2012 at Jordan University Hospital - Amman, Jordan. In order to highlight relevant previously-published studies addressing this topic, a literature search was conducted for English-language studies reporting “MTC” or “C-cell hyperplasia” (CCH) in patients with HT.

Results: Of the 863 patients with a mean age of 47.2 ± 12.3 years who underwent total thyroidectomy during the study period, 78 (9.04%) were diagnosed with HT, and 15 (1.74%) had MTC, 3 (20%) of whom had coexistent HT. A total of 683 (79.1%) patients had BTD, 67 (9.8%) of whom had HT. The difference between these rates was not statistically significant (p=0.19). When examined by gender, 9 females had MTC, 3 (33.3%) of whom had coexistent HT; by contrast, of 560 females with BTD, 62 (11.1%) had HT (p=0.04)

Conclusions: Although this study population represents a small and single-institution experience, our results suggest that there might be an association between HT and MTC only in female patients who undergo total thyroidectomy. If this finding is confirmed by larger studies, more aggressive surveillance for MTC may be indicated in female patients with HT.

 

Nothing to Disclose: AAZ, MKM, OMJ, MJS, AAA, MSM, MSS, SMA, WMA

11410 3.0000 SUN-0517 A Is Hashimoto's Thyroiditis a Risk Factor for Medullary Thyroid Carcinoma? Our Experience and a Literature Review 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Juan J. Díez*, Pedro Iglesias, Teresa Alonso and Enrique Grande
Hospital Ramón y Cajal, Madrid

 

Background. Sunitinib, a tyrosine kinase inhibitor (TKI), has been used in clinical trials in patients with progressive differentiated thyroid carcinoma refractory to radioiodine (RAI) therapy.

Aim. Our aim was to evaluate the efficacy of sunitinib in patients with advanced, RAI-refractory differentiated thyroid carcinoma outside of clinical trials.

Design. Retrospective analysis of patients treated in the setting of daily clinical practice in a University General Hospital.

Methods. Eleven patients (5 women, mean age 63.0±12.9 yr) with papillary (n=7) or follicular (n=4) thyroid carcinoma were studied. Initial therapy consisted on thyroidectomy with (n=6) or without (N=5) lymph node neck dissection followed by RAI therapy (mean activity 480±274 mCi). One or more surgical procedures after initial thyroidectomy were performed in 6 patients. Two patients were treated with one line of TKI before sunitinib therapy. All patients had evidence of objective progressive disease (PD) and fulfilled criteria of resistance to RAI before starting sunitinib therapy.

Results. Initial dose was 50 mg/day (n=7) or 37.5 mg/day (n=4) in a 4-week on/2-week off schedule. Dose reduction was necessary in 6 patients (54%). Median duration of treatment with sunitinib was 11.5 (IQR, 5.2-32.5) months. Complete response was achieved in 1 patient (9%) and partial response (PR) in 2 patients (18%). Five patients (45%) had stable disease (SD). Therefore, overall response rate was 27% and disease control rate was 72%. Median progression free survival (PFS) was 32.5 (95% confidence interval, 0-73.2) months. Median PFS was similar in patients with papillary and follicular thyroid carcinoma, in patients with and without initial lymph node dissection, and in patients receiving high (>400 mCi) or low (≤400 mCi) activities of RAI. Patients with and without lung and bone metastases had similar PFS. However, median PFS was significantly (P<0.05) longer in men than in women, in patients who did not need surgery after initial thyroidectomy, and in patient in whom sunitinib was used as first line TKI therapy. PFS in the two patients who received sunitinib after other multitargeted agent were 5.2 and 4.7 months. Most frequent grade 1 and 2 adverse events were fatigue, mucositis, hand-and-foot syndrome, hyporexia, rash, hypertension, and edema. Grade 3 toxicities were observed only in two patients.

Conclusion. In routine clinical practice, sunitinib appears to be effective and feasible in patients with advanced, RAI-refractory differentiated thyroid carcinoma. Most patients achieved SD or PR, despite having PD at the start of treatment, and safety profile was consistent with that reported in previous clinical trials.

 

Nothing to Disclose: JJD, PI, TA, EG

12691 4.0000 SUN-0518 A Activity and Safety of Sunitinib in Patients with Advanced Radioactive Iodine-Refractory Differentiated Thyroid Carcinoma in Clinical Practice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Lucas Leite Cunha*1, Suely Nonogaki2, Elaine Morari3, Fernando Soares4, José Vassallo5 and Laura Sterian Ward6
1University of Campinas, Brazil, 2Adolfo Lutz Institute, 3Laboratory of Cancer Molecular Genetics, Faculty of Medical Sciences – University of Campinas (Unicamp), 4Department of Pathology, A. C. Camargo Cancer Center, 5Laboratory of Investigative and Molecular Pathology (Ciped), Faculty of Medical Sciences – University of Campinas (Unicamp)., 6University of Campinas, Campinas,SP, Brazil

 

Thyroid cancer incidence has been increasing all over the world and 60,220 new patients are estimated to be diagnosed during 2013 in the USA. The cyclooxygenases (COX) are a group of enzymes that catalyses the formation of prostaglandins from arachidonic acid, that is essential for recruitment of immune cells. COX-2 activity has been implicated in carcinogenesis and demonstrated to stimulate angiogenesis, inhibit apoptosis, increase cell invasion, sti­mu­late cell proliferation, besides promoting inflammation. We previously described a mixture of immune cells infiltration that was associated to phenotype of differentiated thyroid carcinoma (DTC). The present investigation aimed to evaluate if markers of the immune system response and of tumor associated inflammation may predict outcome of patients with DTC. We studied 399 consecutive patients with differentiated thyroid carcinoma. Papillary thyroid carcinoma was diagnosed in 325 patients whereas the remaining 74 patients presented follicular thyroid carcinomas. Immune cell markers included tumor associated macrophages (CD68) and tumor infiltrating lymphocytes (TIL) subsets, such as CD3, CD4, CD8, CD16, CD20, CD45RO, GRANZYME B, CD69 and CD25 always evaluated in intraepithelial infiltrating cells located within cancer cell nests. We also investigated the expression of COX2 in tumor cells. Among all the immunological parameters evaluated, only enrichment of CD8+ lymphocytes (p=0.001) and expression of COX2 (p=0.01) were associated to recurrence. The multivariate model identified CD8+ TIL/COX2 as independent risk factor for recurrence. A multivariate analysis using Cox’s proportional-hazards model adjusted for the presence of concurrent chronic thyroiditis, observed in 29% of the cases demonstrated that the presence of concurrent chronic thyroiditis had no effect on prognostic prediction mediated by CD8+ TIL and COX2. Others immunohistochemical markers failed to predict prognosis. This relatively simple pathology tool may help clinicians select cases that may benefit of a more aggressive approach sparing the majority of patients from unnecessary procedures.

 

Disclosure: LSW: Board Member, Abbott Laboratories, Board Member, Sanofi. Nothing to Disclose: LLC, SN, EM, FS, JV

13278 5.0000 SUN-0519 A Expression of COX2 and Infiltration of CD8+ Lymphocytes May Predict Outcome of Patients with Differentiated Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Kimberley Jane Edwards*, Matei Alexandru Dordea and Vijayakumar Kurup
University Hospital of North Tees, United Kingdom

 

Background:

International data has shown increased prevalence of differentiated thyroid cancer (DTC), particularly papillary thyroid cancer (PTC).  In addition, the expanding use of sonography to detect and guide fine-needle aspiration (FNA) of thyroid nodules has led to significant advances in diagnosis and treatment of thyroid cancer.  Consequently, The American Thyroid Association is preparing further guidelines on thyroid nodules and DTC for publication in 2014 incorporating new evidence.

Since 2009, many UK endocrinology centers have adopted the Royal College of Pathologists’ (RCPath) Thyroid FNA Classification system, which is similar to the Bethesda System for Reporting Thyroid Cytopathology. The system aims to provide a numerical cytology category in addition to a full prose report to improve clarity and communication as part of a multidisciplinary team discussion regarding treatment for suspected thyroid cancer.

This single centre study aims to examine the cytologic-histologic correlation using the RCPath system since its introduction 3 years ago.

Methodology:

Single surgeon, retrospective study of 106 thyroidectomy/hemi-thyroidectomy patients between 2009 and 2013. Ultrasound guided FNA performed by a specialist endocrine radiologist. Cytology samples were reported using the RCPath system and compared with final histological diagnosis.

Results:

Of 106 FNAs, 23 were reported as non-diagnostic (Thy1), 28 as non-neoplastic (Thy2) and the remaining 55 were reported as abnormal: 5 as Thy3a, 39 as Thy3f, 5 as Thy4 and 6 as Thy5.  All Thy4/5 (n=11) correlated to an underlying malignancy.  20.5% (n=8) of Thy3f aspirates also preceded a histological diagnosis of thyroid cancer. The PPV of identifying a neoplasm with Thy3f was 74%.  

Conclusion:

The Thy5 and Thy3f diagnostic categories corresponded with the 97-100% and 15-30% risks of malignancy suggested by RCPath.  The Thy3a and Thy4 categories were deemed too small to allow statistically significant results. The recommendation to incorporate the system into the MDT setting may prove beneficial in planning management for clinically worrying lesions.

 

Nothing to Disclose: KJE, MAD, VK

16193 6.0000 SUN-0520 A The UK Royal College of Pathologists' Thyroid Fine-Needle Aspiration Classification System: Cytologic-Histologic Correlations Since Introduction 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Joanne Ngeow*1, Gurkan Bebek2, Rita Tohme1, Fusong Chen2, Ying Ni2 and Charis Eng1
1Cleveland Clinic, Cleveland, OH, 2Cleveland Clinic

 

Context: RASAL1 has recently been identified as an important tumor suppressor for sporadic thyroid tumorigenesis particularly for follicular thyroid cancer (FTC) and anaplastic thyroid cancer. Thyroid cancer is an important component of Cowden syndrome (CS). Patients with germline PTEN mutations have an overrepresentation of FTC over other histological subtypes.

Objective: To determine the prevalence of germline RASAL1 mutations in PTEN mutation positive and wildtype CS patients.

Design and participants: We reviewed our prospective database review of >3000 CS/CSL patients and identified a subset of patients who presented with thyroid cancer for RASAL1 mutation analysis. TCGA sporadic PTC database with germline data for RASAL1 mutations.

Main Outcome Measures: Prevalence of germline RASAL1 mutations in CS-related thyroid cancer patients.

Results: We scanned 155 CS/CS-like patients with thyroid cancer for germline RASAL1 mutations. Of the 155, 39 patients had known germline pathogenic PTEN mutations (PTENmut+) and 116 were PTEN mutation negative (PTENWT). Amongst these 155 patients, we identified RASAL1 germline alterations suspected as being deleterious in 2 patients. Both were PTENWT patients who had FTC (2/48; 4.1%). This was in contrast to PTENmut+ patients with thyroid cancer (0/39). Of 339 sporadic PTC patients from the TCGA study, 62 (18%) had germline RASAL1 variants predicted to be deleterious. TCGA patients with follicular variant PTC were statistically overrepresented (21/62; 34%) amongst patients with deleterious RASAL1 variants compared to those without (57/277; 21%).

Conclusions: Germline RASAL1 alterations are uncommon in CS patients but may not be infrequent in apparently sporadic FvPTC patients.

 

Nothing to Disclose: JN, GB, RT, FC, YN, CE

12943 7.0000 SUN-0521 A Germline Alterations in RASAL1 in PTEN Wildtype Cowden Syndrome Patients Presenting with Follicular Thyroid Cancer and in Individuals with Apparently Sporadic Epithelial Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Hernando Vargas-Uricoechea*1, Ivonne Meza-Cabrera2, Karina Agredo-Reyes3, Julián Ñáñez-Paz3 and Magda Rangel-Bahamón3
1Universidad del Cauca, Popayán-Colombia, Popayán-Cauca, Colombia, 2Hospital Universitario San José, Popayán-Cauca, Colombia, 3Universidad del Cauca, Popayán, Colombia

 

Background

Thyroid cancer is uncommon, but it is the most frequent malignant tumor of the endocrine system.  Isolated cytology findings do not necessarily correlate with those found on ultrasound, and vice-versa.  

Method:

Descriptive study of subjects over 18 years of age with a clinical history of eufunctional thyroid nodule. All patients included in the study underwent ultrasound-guided fine needle aspiration of the nodule.  The primary objective was to determine the validity between the cytological findings in relation to eight ultrasound variables suggestive of thyroid cancer.

 Results

The analysis included 31 cases ranging between 19 and 87 years of age, the majority of them females (n=28); the most common clinical characteristic was a firm nodule (87.1%) and a nodule larger than 4 cm (22.6%). Regarding thyroid cancer, 22.6% of cases were positive, and 77.4% were negative.  Cytological findings suggestive of malignancy were the following: presence of nuclear overlap, 22.6% (Sensitivity: 100%), presence of vacuole and nuclear bar, 16.1% (Sensitivity: 71.43%), cell crowding, 12.9% (Sensitivity: 57.14%), ground glass nucleus (Sensitivity: 42.8%), papillae (9.7%) and microfollicle (6.5%) formation. The ultrasound findings most frequently associated with the presence of cancer were: Microcalcifications: Sensitivity 85.71% and Specificity 91.67%; Positive Predictive Value (PPV) 75%; Negative Predictive Value (NPV) 95.65%; and solitary nodule: Sensitivity 100%; Specificity 66.67%; VPP 46.67% and NPV 100%.

 Discussion

The most frequent cytological findings suggesting malignancy were intracellular vacuole and nuclear bar.  They have already been reported as noted in the Bethesda System, but this review showed two characteristics that have not been mentioned previously, namely, nuclear overlap and nuclear crowding, with good sensitivity and specificity. Microcalcifications and the presence of a solitary nodule seen on ultrasound showed the highest sensitivity, specificity and NPV.

 

Nothing to Disclose: HV, IM, KA, JÑ, MR

15480 8.0000 SUN-0522 A Validity of Ultrasound Criteria for Malignancy and FINE Needle Aspiration (FNA) in Eufunctional Thyroid Nodule 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Saira Furqan*1, Asma Ahmed2, Zain Ali Bhutta3, Uzma Majid4, Safia Awan4 and Najmul Islam4
1AGA KHAN UNIVERSITY HOSPITAL,KARACHI,PAKISTAN, KARACHI, Pakistan, 2Aga Khan Univ Hosp, Karachi, Pakistan, 3Aga Khan University Hospital, Karachi, 4Aga Khan University Hospital, Karachi, Pakistan

 

Background: Thyroid carcinoma has a better overall survival rate in comparison to other malignancies. Outcome of patients with thyroid malignancy largely depends upon different prognostic factors at presentation. In this study we have evaluated different factors at initial presentation in patients with thyroid carcinoma and their significance in predicting the outcome in our population. Methods: Retrospective review of patients with thyroid cancer at our hospital from 1999 to 2011 was done. Results: Mean age at presentation was 44±17 years with female to male ratio of 2.1:1. Mean follow up period was 6.45 years. Out of 206 patients, 158 had differentiated thyroid carcinoma. Most common variant was papillary (n=130, 63.10%) followed by follicular carcinoma (n=22, 8.73%). 6 (2.91%) had hurthle cell variant of follicular carcinoma. 18 (8.73%) had medullary and 10 (4.85%) had anaplastic carcinoma. 20 (9.70%) had other causes like carcinoma of undetermined significance, thyroid lymphoma, metastatic carcinoma etc.

Patients having DTC, 70(44.3%) were diagnosed at stage 1, 17 (10.8%) at stage 2, 12 (7.6%) at stage 3 and 29 (18.3%) at stage 4. 2 (14.3%) patients with medullary carcinoma were diagnosed at stage 1, 4 (28.6%) at stage 3 and 8 (57.1%) at stage 4. All patients with anaplastic carcinoma had stage 4 disease. Overall cure rate was 33.5%, persistence rate 26.6%, recurrence was 8.2% and thyroid cancer related mortality was 8.9%.

By univariate analysis age, cancer types, distant metastasis, type of surgery and thyroglobulin levels were significant prognostic factors. By multivariate analysis age ≥ 45 years (p=0.04), distant metastasis at the time of presentation (p=0.04), thyroglobulin levels ≥ 8 right after surgery (p=<0.001) were found to be independent prognostic factors.  Factors like gender and thyroglobulin doubling time did not show any association with the prognosis of thyroid carcinoma. Conclusion: The current study demonstrated an assessment of prognostic factors in this cohort. Age at diagnosis, distant metastasis and thyroglobulin levels were found to be strong prognostic factors for thyroid carcinoma.

 

Nothing to Disclose: SF, AA, ZAB, UM, SA, NI

13550 9.0000 SUN-0523 A Prognosis and Outcome Analysis of Thyroid Cancer: Experience from a Tertiary Care Centre in Pakistan 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Sarah C. Clement*1, Leontien C. Kremer1, Thera P Links2, Renee L. Mulder1, Cecile M. Ronckers1, Berthe L.F. van Eck-Smit3, Rick R. van Rijn4, Heleen J.H. van der Pal4, Wim J.E. Tissing5, Geert O. Janssens6, Marry M. van den Heuvel-Eibrink7, Sebastian J.C.M.M. Neggers8, E.J.M. Nieveen van Dijkum4, Robin P. Peeters9 and H.M. van Santen10
1Emma Children’s Hospital/Academic Medical Center, Amsterdam, Netherlands, 2University of Groningen, University Medical Center Groningen, Groningen, Netherlands, 3Academic Medical Center Amsterdam, Amsterdam, Netherlands, 4Academic Medical Center, Amsterdam, Netherlands, 5University Medical Center Groningen, Groningen, Netherlands, 6Radboud University Nijmegen Medical Center, Nijmegen, Netherlands, 7Erasmus MC University Medical Center - Sophia's Children's Hospital Rotterdam, 8Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands, 9Erasmus Univ Rotterdam, Rotterdam, Netherlands, 10Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, Netherlands

 

Purpose: There is lack of international consensus on surveillance strategies for differentiated thyroid cancer (DTC) after radiation exposure in childhood cancer survivors (CCS). Screening can be done by either neck palpation or ultrasonography. Ultrasonography could allow for early identification of DTC, although it remains unclear whether early detection impacts prognosis or morbidity. In this study we addressed the evidence for the question: ‘Does early identification of DTC influence outcome?’

Methods: A Dutch national multidisciplinary working group was convened to answer the following clinical sub-questions for children and adults: ’Does early identification of DTC diminish recurrence or mortality rates and, if early identification of DTC results in less aggressive treatment, does it contribute to a decline in surgical complications or severe adverse effects of radioiodine treatment?' All literature was systematically identified and reviewed, evidence summaries were developed and final conclusions were formulated based on the level of evidence.

Results: In children, little evidence (level C) was found that early identification of DTC is associated with lower recurrence or mortality rates. No clear evidence was found that early identification influences occurrence of adverse events after surgery or radioiodine. In adults, clear evidence was found that early identification of DTC is a favorable prognostic factor with respect to recurrence (level B) and mortality rates (level A). Also, clear evidence was found that more extensive surgery increases the risk to develop transient hypoparathyroidism (level A) and that the use of higher doses of radioiodine increases the risk to develop second primary malignancies (level B).

Conclusion: There is some suggestion that early identification of DTC in children may be associated with better outcome. For adults, there is clear evidence that early identification of DTC is associated with favorable outcome. These results are an important cornerstone for the future international surveillance guideline for DTC in CCS. Before recommendations for screening can be made, however, the benefits and harms of screening for DTC should be further evaluated.

 

Nothing to Disclose: SCC, LCK, TPL, RLM, CMR, BLFV, RRV, HJHV, WJET, GOJ, MMV, SJCMMN, EJMN, RPP, HMV

14374 10.0000 SUN-0524 A Clinical Relevance of Early Identification of Differentiated Thyroid Carcinoma in Childhood Cancer Survivors: State of the Evidence 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Fumihiko Furuya*1, Kazuya Takahashi1, Hiroki Shimura2, Sayaka Ichijo1 and Tetsuro Kobayashi1
1University of Yamanashi, Chuo, Yamanashi, Japan, 2Fukushima Medical University, Fukushima-shi, Japan

 

Thyroid hormone receptor (TR) mediates the crucial effects of the thyroid hormone (T3) on cellular growth, development, and differentiation. Decreased expression or inactivating somatic mutations of TRs have been found in human cancers of the liver, breast, lung, and thyroid. We analyzed the expression profile of TRβ in 24 human thyroid cancer tissues. The abundance of TRβ mRNA was significantly decreased in thyroid cancer tissues and cell line as compared to intact thyroid tissues. We constructed a recombinant adenovirus vector, AdTRβ, which expresses human TRβ cDNA driven by the cytomegalovirus promoter, and analyzed the effects of AdTRβ on the cell cycle or proliferation of thyroid cancer cells. The AdTRβ-infected cells showed expression of phosphorylated stress-activated protein kinase/Jun-amino-terminal kinase (SAPK/JNK) and an activated SAPK/JNK signaling pathway. Induction of phosphorylated SAPK/JNK led to expression of RhoB, a member of the Ras superfamily, along with p21-associated cell-cycle arrest in the G0/G1 phase and inhibition of cell proliferation. Conversely, lowering cellular RhoB by small interfering RNA knockdown in AdTRβ-infected cells led to downregulation of p21 and inhibited cell-cycle arrest. The growth of thyroid cancer cell tumor xenografts in vivo was significantly inhibited by AdTRβ injection as compared to control virus-injected tumors. These results indicate that TRβ prevents thyroid cancer cell proliferation via activation of the SAPK/JNK signaling pathway

 

Nothing to Disclose: FF, KT, HS, SI, TK

14370 11.0000 SUN-0525 A Ligand-Bound Thyroid Hormone Receptor β Induces Cancer Cell Cycle Arrest 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Oya Topaloglu1, Bekir Ucan1, Mustafa Sahin2, Muyesser Sayki Arslan1, Taner Demirci1, Tugba Taskin Turkmenoglu3, Mustafa Caliskan4, Erman Cakal1, Mustafa Ozbek1 and Tuncay Delibasi*1
1Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey, 2Ankara University School of Medicine, Ankara, Turkey, 3Department of Pathology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey, 4Diskapi Training and Research Hospital, Ankara, Turkey

 

Background: Fine-needle aspiration (FNA) is the gold standard method in evaluation of thyroid nodules. FNA must be done with ultrasound guidance from the solid part of the thyroid nodule containing both solid and cystic components. However, nondiagnostic results are more common in complex thyroid nodules. Alternative techniques are needed for the evaluation of these thyroid nodules.   In this study we aimed to determine the value of elastosonography in differential diagnosis of malignant and benign thyroid nodules containing both cystic and solid components.

Materials and Methods: A total of 100 consecutive patients with complex thyroid nodules who were referred to our clinic were enrolled to this prospective study. All of the patients were evaluated with conventional B-mode ultrasound (US)  and elastosonography (Hitachi EUB 7000 HV) by 12 mHz linear probe. Elastosonographic evaluation was performed mainly from the solid part of the complex nodule. FNA was also performed from the solid component with ultrasound guidance. Elastosonographic, conventional ultrasonographic features and cytological results were compared and evaluated statistically.    

Results: Cytological examination of 100 complex thyroid nodules were determined as follows; benign  (n=74), nondiagnostic (n=22), malignant (n=2) , suspicious for malignancy (n=1), atypia of undetermined significance (n=1). Seventy-four nodules, which were evaluated as benign constituted Group 1 and remainder 26 nodules, constituted Group 2. However, in Group 1 sixty-four nodules had elastosonography score (ES) as 2, 10 nodules had ES as 3. In Group 2, ES for 14 nodules were evaluated as 2 and 11 nodules were evaluated as 3. Elastosonographic scores were statistically significant between two groups (p<0.01). Conventional US features such as parenchymal heterogenicity, nodule number, color flow doppler pattern, presence or absence of halo were similar between two groups.  Mean strain index was 2.13±0.34 in Goup 1 and 2.44±0.5 in Group 2 (p>0.05).  

Conclusion: Value of the elastosonographic evaluation for complex thyroid nodules has not been adequately assessed. This study has demonstrated that elastosonography does not seem superior to the conventional US for the evaluation of complex thyroid nodules.

 

Nothing to Disclose: OT, BU, MS, MS, TD, TT, MC, EC, MO, TD

16282 12.0000 SUN-0526 A Is Elastosonography Helpful in Differential Diagnosis of Benign and Malignant Thyroid Nodules with Complex Features? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Daria Gazizova*, Dmitry Beltsevich and Alexander Ilyin
Endocrine Research Center, Moscow, Russia

 

The management of patients with MTC is based on absolute values and dynamics of calcitonin (Ct) and carcinoembryonic antigen (CEA) levels. About 0,83% of MTC cases reported to be nonsecretory (1), thus making detection of the disease and postoperative management difficult. Other markers of MTC were also described (2), but there are scarce data on the serum levels of gastrointestinal tumor marker carbohydrate antigen 19 –9 (Ca 19 –9). Recently, several cases of patients with MTC secreting Ca 19-9 were reported. Majority of these patients had rapid disease progression, some of them had an inappropriately low serum Ct levels. 

Materials and methods: Сa 19-9 was investigated by immunofluorescence assay (Fujirebio Diagnostics) in 25 patients with newly diagnosed or recurrent MTC, 7 of them had aggressive MTC (Ct doubling time (DT) <6 months and distant metastasis). High serum level of Ca19-9 - 48,5 U/ml (normal range: 0–29 U/ml) was found in the case of 53-year-old woman with sporadic MTC. This patient had high and progressively increasing levels of Ct and CEA (DT <6 months), multiple cervical lymph nodes and liver metastasis, confirmed somatic M918T mutation. The production of Ca 19-9 by MTC was confirmed by strong cytoplasmic immunoreactivity for Ca 19-9 antibody in lymph node metastasis.

Conclusions: To date Ca 19-9 secretion was observed only in MTC cases with aggressive behavior. Its determination in particular could be helpful in patients with nonsecretory MTC. But additional data are needed to make any recommendations for Ca 19-9 estimation in aggressive or nonsecretory MTC.

 

Nothing to Disclose: DG, DB, AI

14406 13.0000 SUN-0527 A Carbohydrate Antigen 19–9 Secretion By Medullary Thyroid Cancer - Is It a Marker of Disease Aggressiveness? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Sean Raj1, Rohit Ramanatham1, David Sabbag1, Rebecca Matejowsky2 and Mark A Sultenfuss*2
1Baylor College of Medicine, 2MEDVAMC, Houston, TX

 

Introduction:  Thyroid nodules are common, with prevalence in 50-60% of the general population. Fine Needle Aspiration (FNA) for thyroid nodules in the Veteran population is common, and in our experience, these nodules are almost always benign in etiology. Previously published strategies and proposed criteria are utilized to assess imaging features of thyroid nodules in an effort to guide biopsy referral.  However, these criteria are derived from a predominantly younger female patient population. This study evaluates and identifies imaging features of benign and malignant thyroid nodules in the Veteran population, which represents an incompletely studied, predominantly older and male demographic.

Results:  A total of 346 consecutive patients with sonographically evaluated thyroid nodules who were referred to Interventional Radiology for FNA between April 2009 and August 2012 were retrospectively reviewed. The average age of the patient was 65.6 years, and 82% were male. Multiple sonographic criteria were evaluated, including: lesion size, presence of microcalcifications, multiplicity of nodules, association of lymph node involvement, vascularity, echogenicity, morphology, acoustic enhancement, and borders. Pathological evaluation of the biopsy specimen yielded 295 benign (85%), 23 malignant (7%), and 28 indeterminate (8%) etiologies.  Benign nodules averaged 2.6 cm in size, whereas malignant nodules were 3.4 cm. Characteristics of benign nodules versus malignant lesions, include: microcalcifications 11% benign and 30% malignant, abnormal lymphadenopathy 3% benign and 26% malignant, intranodular vascularity 34% benign and 43% malignant, and amorphous morphology 19% benign and 39% malignant. Features which showed no difference between the benign and malignant etiology include: echogenicity, acoustic enhancement, and multiple nodules.

Conclusions:  These results suggest that utilizing previously proposed criteria to differentiate benign versus malignant thyroid nodules might not apply in a similar way to this predominantly older and male Veteran population. Further characterization of salient sonographic patterns of benign and malignant thyroid nodules may assist the endocrinologists, radiologists, and surgeons in avoiding unnecessary thyroid biopsies, while further optimizing patient care and allocation of clinical resources.

 

Nothing to Disclose: SR, RR, DS, RM, MAS

14524 14.0000 SUN-0528 A Sonographic Features of Thyroid Nodules Undergoing Fine Needle Aspiration in the Veteran Population 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Hyemi Kwon*1, Won Gu Kim2, Tae Yong Kim3, Dong Eun Song1, Jung Hwan Baek1, Jin-Sook Ryu1, Suck Joon Hong1, Won Bae Kim1 and Young Kee Shong1
1University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea, Republic of (South), 2Asan Medical Center, Seoul, Korea, Republic of (South), 3Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea, Republic of (South)

 

Serum calcitonin (CA) levels may be used to identify patients with medullary thyroid carcinoma (MTC), but there are imperfect cut-off levels to optimize sensitivity and specificity. If basal serum CA exceeds 10 pg/mL, the measurement of pentagastrin stimulated serum CA levels was known to be useful for diagnosis of MTC. However, pentagastrin is not available for stimulation test in many countries. This study aims to identify cut-off value of basal serum CA to discriminate MTC from other conditions of hypercalctoninemia. This retrospective study enrolled patients with hypercalcitoninemia (≥ 10 pg/mL) between 2000 and 2013 at Asan Medical Center in Korea. We evaluated the levels of basal serum CA in four groups; pathologically proven MTC (group 1, n=93), pathologically proven non-MTC after thyroid surgery (group 2, n=57), benign thyroid nodules according to the results of fine needle aspiration cytology (group 3, n=68), and patients with no thyroid nodule on ultrasonography (group 4, n=25). The median CA level of group 1 (409 pg/mL) was significantly higher than other groups (group 2 : 13.6 pg/mL, group 3 : 12.95 pg/mL, group 4 : 12.8 pg/mL, P<0.001). The proportion of patients whose basal serum CA levels above 65 pg/mL were 68% in group 1, 0% in group 2, 0% in group 3, and 8% in group 4. When we applied 65 pg/mL of CA level as cut-off value to diagnosis MTC, the sensitivity and specificity were 77.4%, and 98.7%, respectively. The positive and negative predictive values were 97.3% and 87.6%, respectively. When the tumor size of MTC was ≥ 1 cm, serum CA levels in 56 of 61 patients (92%) were above 65 pg/mL. In the micro-MTC, serum CA level in a half of patients was lesser than 65 pg/mL. Common factors associated with hypercalcitoninemia in non-MTC groups were autoimmune thyroiditis, chronic kidney disease, use of proton pump inhibitors, and other malignancies. Basal serum CA levels above 65 pg/mL could be useful to discriminate MTC from other conditions of hypercalcitoninemia.

 

Nothing to Disclose: HK, WGK, TYK, DES, JHB, JSR, SJH, WBK, YKS

12930 15.0000 SUN-0529 A Usefulness of Basal Serum Calcitonin Levels in Patients with and without Medullary Thyroid Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Dashamir Xhemal Gjergji*
Poliklinika Qendrore e Specialiteteve, Tirane, Albania

 

Actualities in the diagnosis and treatment of thyroid cancer in Albania

Dashamir Gjergji MD 1,Mehdi Alimehmeti PHD2,Xheladin Dracini PHD2,,Thanas Fureraj PHD2,Irfan Ahmeti MD3, Adrian Kristo MD2, 

 

1)   Central Policlinic of Specialities, Tirana, Albania

2)   Mother Theresa University Hospital center Tirana,Albania

3)   University Hospital Center ,Skopje,Macedonia

Introduction. Thyroid cancer is a relatively rare disease;Generally clinically apparent thyroid nodules are present in 4 – 7 % of the adult population,with malignancy rates from 3 – 12%. The aim of this communication is to present the actual status of diagnosis and treatment of thyroid cancer in Albania.

Patients and Methods. In our study we have analysed the preoperative clinical database of 262 patients, divided in 206 (79%) females and 56 (21%) males, admitted in the Clinic of General Surgery, UHC “Mother Theresa” in Tirana and the Registry of the Department of Pathology in the timeframe 2004 - 2011. The data comprised age, sex, age distribution, signs and symptoms, imaging, functional tests, preoperative FNA,postoperative histopathology results All patients data were analysed using SPSS package, version 15.

Results. The average age was 34,5 +/- 12,6 (16 – 71) years, the M : F ratio was 1 : 3,7. From the study emerged that the thyroid patologies resulted benign in 220 (84%) patients and malignant in 42 (16%) patients, diagnosed as thyroid cancer. The histologic types of thyroid cancer were as follows: papillary 28 (67%) patients; follicular 10 (24%) patients, medullary 3 (7%) and anaplastic 1 (2%) patient. The overall morphopathology of thyroid gland resulted multinodular in 153 (58%) patients and uninodular in 109 (42%) patients, the percentage of cancer in uninodular goiters was greater than in multinodular (23% vs 13%). FNAB was accurate in determination of the correct diagnosis in 80% of cases. The sensitivity of FNAB was 94%, meanwhile specificity was 96%. Specific accuracy of FNAB in detecting cancer was ca. 97%. Overall prevalence of cancer in nodular goiters was 16%. Among the signs and symptoms related to thyroid cancer we found that 40 and 33% of these patient presented dyspnea and dysphagia, respectively. The physical examination in thyroid cancer patients revealed apparent nodular growth of the thyroid gland in 81% and hard nodular consistency in 79% of cases.

Discussion. Thyroid cancer was more common in patients aged > 65 years. The most affected gender,were females. From the study emerged that solid nodules have the greater percentage of thyroid cancer. Thyroid cancer was found more frequently in ‘cold’ nodules, in comparison with other nodular patologies included in the study (21% vs 11% and 5% in ‘hot’ and iso-uptake types).

Conclusion. FNA is an important tool in evaluation of  thyroid nodules. Although FNA   is much specific than sensitive ,remains useful  technique in detection of thyroid cancer,especially in uninodular goiters.

 

Nothing to Disclose: DXG

14113 16.0000 SUN-0530 A Actualities in the Diagnosis and Treatment of Thyroid Cancer in Albania 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Kyeong Hye Park1, Kwang Joon Kim2, Young Ki Lee3, Seonhyang Jeong3, Dong Yeob Shin*3 and Eun Jig Lee4
1Yonsei University College of Med, Seoul, Korea, Republic of (South), 2Severance Hospital, Seoul, Korea, Republic of (South), 3Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 4Yonsei University College of Medicine, Korea, Republic of (South)

 

Background

Papillary thyroid cancer (PTC) with Hashimoto’s thyroiditis (HT) shows the lower frequency of BRAFV600E than without HT. It is still unclear whether the presence of serum anti-thyroid antibody itself is related with BRAFV600E in PTC with lymphocytic thyroiditis.

Methods

Total 2002 PTC patients who underwent thyroid surgery were enrolled. BRAFV600E status and clinicopathological parameters were analyzed according to the presence of lymphocytic thyroiditis and TPOAb.

Result

1511 (75.3%) patients had BRAFV600E mutation. Compared with BRAF wild type group, the pathological lymphocytic thyroiditis was less frequently observed (36.6% vs. 26.5%, p<0.001) and TPOAb titer was lower in BRAFV600E group (9.37 vs. 8.6, p=0.029).

Subgroup analysis showed that the prevalence of BRAFV600E is lower in patients with both pathological lymphocytic thyroiditis and positive TPOAb than lymphocytic thyroiditis alone.  (77.4% vs. 65.2%, p=0.001).

Conclusion

Not only the pathological lymphocytic thyroiditis, the presence of serum TPOAb is related with the low prevalence of BRAFV600E in PTC concomitant HT.

 

Nothing to Disclose: KHP, KJK, YKL, SJ, DYS, EJL

14485 17.0000 SUN-0531 A The Frequency of BRAFV600E Is Dependent on the Presence of Anti-TPO Antibody in Papillary Thyroid Cancers with Lymphocytic Infiltration 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Ana María Sequera*1, Marta Torres2, Patricia Glikman2, Maria Paula Esteban2, Graciela Astarita2, Viviana Mesch3, Andrea Kozak2, Mónica Melmann1, Graciela Mosquera Filoso2, Mirta Gurfinkiel2, Patricia Pagano2, María José Iparraguirre2, Natalia Blanco2, Monica Saavedra2, Isabel Teres2 and Patricia Otero1
1Argentine Society for Endocrinology and Metabolism, CABA, Argentina, 2Argentine Society for Endocrinology and Metabolism, Caba, Argentina, 3School of Pharmacy and Biochemistry, University of Buenos Aires, Argentina

 

Serum Tg during Levothiroxyne treatment and after TSH stimulation in the follow up of patients with DTC usually correlates with studies indicating persistence of disease, such as I131 total body scan (TBS). However, some cases of discordant Tg and TBS results have been reported. Clinical utility of Tg is linked to the specificity(Sp), functional sensitivity(FS) and precision of the assay used. Aim: To compare five assays for Tg in samples from DTC patients and their concordance with active disease. Materials and methods: 136 samples from DTC patients under follow up after thyroidectomy, thyroglobulin antibodies negative were evaluated. Recurrence of disease was determined by TBS, Positron Emision Tomography (PET), Tg in fine needle aspirates, cytology or any other study indicating persistence (PDIS) or absence (ADIS) of disease (DIS). Tg < FS was considered Tg -, based on the FS from the methodology used in the Center providing the sample. We defined four groups (G) according to Tg value and recurrent DIS: G1(n=45): patients with Tg - and ADIS, G2 (n= 35): Tg+ and ADIS; G3 (n=15): Tg – and PDIS and G4 (n=41): Tg+ and PDIS. A control G (n=20) corresponding to healthy subjects (normal palpation and thyroid profile) was included. Serum Tg was measured in aliquots from all samples by five assays (methodology / FS)= Cobas-Elecsys (CEl)/1.0 ng/ml; Access (ACC)/0.30 ng/ml; Immulite 1000(IM1)/ 0.90 ng/ml; Immulite 2000 (IM2)/ 0.60 ng/ml and RSR/1.0 ng/ml. Results: Tg (ng/ml) value in median and (range) were: G1= CEI:1.0(1.0-1.8); ACC: 0.3(0.3-1.1); IM1: 0.9(0.6-1.2); IM2: 0.60(0.9-1.9); RSR: 1.0(1.0-1.3).G2= CEI:3.4(1.0-47.5); ACC: 2.0(0.3-27.6); IM1: 2.5(0.9-39.9); IM2: 2.4(0.6-44.5); RSR: 1.0(1.0-1.3). G3= CEI:1.0(1.0-1.3); ACC: 0.4(0.3-0.7); IM1: 0.9(0.6-1.1); IM2: 0.60(0.6-0.63); RSR: 1.0(1.0-1.5).G4=CEI: 8.8(1.0-290); ACC: 5.8(1.0-186); IM1: 5.7(0.9-174); IM2: 6.6(0.6-205); RSR: 7.0(1.0-190). CG= CEI: 11.8(2.5-59.2); ACC: 9.1(1.2-36.1); IM1: 7.2(0.9-34.8); IM2: 9.1(1.5-37.4); RSR:11.7(1.3-34.0). Every method showed significant difference with at least one another in all groups (p< 0.01, Friedman, Dunn test). ACC showed the higher % of samples with Tg <2 ng/ml in G2 and G4. None assay showed coincident results with PDIS in G3. Tg levels using CEI were higher in all groups. CONCLUSIONS: a)Tg measurement by different methods have different ability to suggest persistence of disease. b)A lower FS does not necessary means a better specificity to detect persistence of disease. c)The use of a unique cut off for Tg in DTC should be revised.

 

Nothing to Disclose: AMS, MT, PG, MPE, GA, VM, AK, MM, GM, MG, PP, MJI, NB, MS, IT, PO

14966 18.0000 SUN-0533 A Measurement of Serum Thyroglobulin (Tg) By Five Assays during Follow-up of Differentiated Thyroid Cancer (DTC): Functional Sensitivity Vs Specificity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Aamna Hassan*, Saima Riaz, Humayun Bashir, M Khalid Nawaz, Raza Hussain, Amina Khan, Aamir A Syed, Mazhar A Shah and Ahmad Murtaza
Shaukat Khanum Memorial Hospital and Cancer Research Center

 

Objective: To evaluate the impact of F-18 FDG PET/CT scan in Differentiated Thyroid Cancer (DTC) patients with elevated Thyroglobulin (Tg) and negative I-131 scan. To correlate stimulated Tg levels with Standardized Uptake Value (SUV) of lesions detected on PET/CT scan.

Methods: Retrospective analysis of PET/CT scan performed from September 2009 and January 2014 at Shaukat Khanum Memorial Cancer Hospital, Pakistan, in DTC patients with stimulated Tg level above 10 ng/ml and a negative I-131 NaI whole body scan. All patients had undergone thyroidectomy and radioactive iodine remnant ablation. We classified our patients as low, intermediate and high based on the American Thyroid Association Guidelines for risk of recurrence.

Results: 82 scans were performed in 69 patients. 60 had papillary carcinoma and 9 follicular. 62 scans were positive, indicating a sensitivity of 75%. 20 showed no uptake or morphologic abnormality. There was no correlation between Tg level and scan negativity and no association between SUV and Tg levels in positive scan. 21 patients with positive scans had histopathologic evaluation; 20 proved malignant while 1 showed false positive uptake in a reactive node. No geographic distribution based on disease severity was seen.

23 patients were excluded due to insufficient information on disease grade. We report 57 scans in 46 patients. The average age was 44 years, range 9 – 75.

The low risk group had 9 patients, 66% female and 34% males. All except 1 patient became I-131 negatice after the first therapy. Average time to negativity was 3.2 years; range of 1 - 4 years.  Mean stimulated Tg levels was 201 ng/ml; range 10.9 – 1144. Areas of FDG uptake included the thyroid bed, lymph nodes in the neck, mediastinum. FDG SUV range was 2 – 7; average 4.6.

The intermediate group had 38 scans in 26 patients. Mean stimulated Tg was 284 ng/ml; range 21 to 1401. Average time to I-131 negativity was 2.4 years; range 1 – 5 years. Areas of FDG uptake included the thyroid bed, lungs, lymph nodes in the neck, mediastinum. FDG SUV range was 1.8 – 16; average 6.4.

12 patients were classified as high risk. 75% female and 25% males. Average time to I-131 negativity was 3.3 years. Mean stimulated Tg level was 395 ng/ml; range 49 to 1500. Areas of FDG uptake included the thyroid bed, lung, bone, lymph nodes in the neck, mediastinum. SUV range was 3 – 22; average 9.6.

4 patients had elevated thyroglobulin antibody levels. These patients belonged to all risk categories and all were found to have hypermetabolic foci with positive histology.

Surgery and radiation therapy were opted where possible. 31 patients received empiric high dose I-131 therapy. Overall, PET/CT led to a change in management in 33% of patients.

Conclusion:

PET/CT has an established role in I-131 negative, DTC patients with elevated Tg level. In our population F-18 FDG PET/CT scan resulted in change of management in a significant number of patients.

 

Nothing to Disclose: AH, SR, HB, MKN, RH, AK, AAS, MAS, AM

16757 19.0000 SUN-0534 A Management Impact of F-18 FDG PET/CT Scan in Differentitated Thyroid Cancer Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Annie Mary Sawka*1, Lauren Bresner2, Rita Banach3 and Asima Naeem4
1University Health Network/University of Toronto, Toronto, ON, Canada, 2University of Toronto Medical School, Toronto, ON, Canada, 3Thyroid Cancer Canada, Toronto, ON, Canada, 4University Health Network, Toronto, ON, Canada

 

Background:  One of the most common concerns and unmet needs of cancer survivors is fear of cancer recurrence.  However, little is known about the extent to which thyroid cancer survivors worry about their cancer or general health.

Objective:  Our objective was to quantify worry relating to cancer and general health, in a sample of Canadian thyroid cancer survivors.

Design, Setting, and Participants:  We performed a cross-sectional, self-administered survey of thyroid cancer survivor members of Thyroid Cancer Canada (TCC) patient support group, in January of 2012.  The questionnaire included demographic and medical history questions, in addition to the Assessment of Survivor Concerns (ASC) questionnaire.  The ASC includes cancer worry questions – ie. worry about future cancer diagnostic tests, second primary malignancy, and recurrence, as well as general health worry questions – ie. dying, health, and children’s health.  ASC worry responses were scored on a Likert Scale (ranging from 1=not at all to 4=very much), and the sum of responses was used to calculate the overall questionnaire score.  Item response means were compared to published general oncology survivor data.  Independent predictors of the overall ASC score were identified using backwards conditional linear regression analysis.

Results:  The effective survey response rate was 60.0% (940/1567), excluding 47 who were not eligible due to no personal history of thyroid cancer and 20 with an invalid mailing address.  Key demographic characteristics included a preponderance of the following: women (88.9%, 836/940), married/common-law marital status (76.2%, 716/940), having children (72.4%, 681/940), age <50 years (53.9%, 507/940); and the time since thyroid cancer ≥3 years (62.1%, 584/940).  The respective means and standard deviations for worry questions were as follows:  diagnostic tests – 2.46 (0.97), second primary - 2.65 (0.95), recurrence 2.60 (0.98), dying – 2.12 (0.99), health – 2.77 (0.92), children’s health – 2.74 (0.97) (N=939 for the ASC data).  Thyroid cancer survivors had significantly greater health worries (all 3 health-related questions), but not significantly different levels of cancer worries, relative to published general oncology population data.  Independent predictors of increased ASC score in thyroid cancer survivors included:  negative thyroid cancer disease status (ie. disease persistence or suspicion of persistence on tests) and having children, whereas older age and increasing time since diagnosis of thyroid cancer were negatively associated with ASC score. 

Conclusions:   Young adults, particularly parents, who are relatively recently diagnosed with thyroid cancer, or in whom there is evidence or suspicion of residual disease, may experience heightened cancer-related health worry.  More research is needed to confirm these findings, and to explore possible explanatory factors and consequences.

 

Nothing to Disclose: AMS, LB, RB, AN

14469 20.0000 SUN-0535 A Assessment of Survivor Concerns: A National Survey of Thyroid Cancer Canada Support Group Members 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Maria Soledad Librizzi*1, Sonsoles Guadalix1, Jorge Ferrero1, Eduardo Ferrero1, Guillermo Martínez Díaz-Guerra1 and Federico G Hawkins2
112 de Octubre University Hospital, 2Hospital Universitario 12 de Octubre, Madrid, Spain

 

Objectives: Prognosis of differentiated thyroid carcinoma (DTC) is usually good, but even so a proportion of the patients develop recurrences and eventually die of the disease. The aim of this study was to evaluate the utility of three staging systems for predicting disease-specific mortality in our patients.

Patients and methods: We reviewed, retrospectively, 213 patients (184 females, 29 males, mean age 48.8 years, range 19-86) with DTC (192 papillary, 21 follicular carcinoma) treated in our hospital  from 1992 up to 2012. Patients were classified according to MACIS, AGES and AMES systems. Total thyroidectomy was performed in 186 patients (87.3%), near total thyroidectomy in 9 of them (4.2%) and hemithyroidectomy in 18 patients (8.4%). Lymphadenectomy was carried out in 80 patients  (37.5%).  The mean follow-up period  was 6.83 years (1-20 years). Survival probability was calculated using Kaplan-Meier analyses. Prognostic factors were analyzed using a univariate log rank test and a multivariate Cox regression analysis model.

Results: According to MACIS system, 16 patients (7.58%) corresponded to high risk (score >7), 168 patients (79.72%) to low risk (score <6) and 27 patients (12.8%) were classified as intermediate risk with score 6-7. There were significant differences (p 0.026) in the overall survival among patients at high, intermediate and low risk and also when we compared high-risk patients with low plus intermediate risk (p<0.01). According to AGES, 45 patients (21.3%)  were high risk patients (score >4) and 166 patients (78.67%) corresponded to low risk (score ≤4), with significant differences regarding overall survival (p<0.01). Classifying patients with AMES system, 66 patients (31.28%) corresponded to high risk and 145 were classified as low risk patients (68.72%) without significant differences between the two groups (p 0.9095) in terms of overall survival.

Conclusions: Of the prognostic classification systems analyzed in this study, the AGES and MACIS systems perform best and are therefore the most suitable for predicting outcome in our DTC-patients.

 

Nothing to Disclose: MSL, SG, JF, EF, GM, FGH

15698 21.0000 SUN-0536 A Usefulness of Current Staging Systems in Differentiated Thyroid Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Joanne Chang*1, Maria Papaleontiou2, Mousumi Banerjee2 and Megan R Haymart2
1University of Michigan, School of Public Health, Ann Arbor, MI, 2University of Michigan, Ann Arbor, MI

 

Well-differentiated thyroid cancer is rising in incidence with the fastest growth in older patients (1). Although patient age is associated with worse prognosis, whether this is secondary to thyroid cancer specific deaths or competing causes of death associated with older age remains unclear. We obtained data from 43,139 patients diagnosed between 1998 and 2005 with well-differentiated thyroid cancer in the Surveillance, Epidemiology, and End Results (SEER) Program. The importance of age in relative survival (RS), overall survival (OS), and disease-specific survival (DSS) by stage was assessed.  Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) were used to assess the impact of age, after adjusting for sex, race, stage, and tumor size on OS and DSS. Patients’ age at diagnosis was the most important predictor of survival, both for DSS and OS (HRs=91.9; 95% CI: 51.7-163.1 and 79.9; 95% CI: 62.1-102.7, for >80 years, respectively). In the multivariable model, female gender was significantly associated with improved OS (HR=0.6; 95% CI:0.6-0.6), follicular histology had a small association with worse survival (DDS HR=1.4; 95% CI:1.2-1.6 and OS HR=1.2; 95% CI: 1.1-1.3) and larger tumor size was associated with worse outcome (DSS HR=1.7;95% CI: 1.4-1.9 and OS HR=1.0; 95% CI: 0.9-1.1 for tumor size > 4 cm).  Patients with regional disease and distant metastases had a worse outcome than those with localized disease but the importance of disease severity on outcome was much greater for DSS than OS (HRs=44.8; 95% CI: 36.5-55.1 and 4.9; 95% CI: 4.4-5.3, respectively). Older patient age was associated with poorer survival regardless of disease severity. Patients with localized and regional disease were dying of other causes as OS was worse than DSS and RS. In contrast, in patients with distant metastases the DSS, RS and OS were very similar. In conclusion, age is the most important determinant of death in thyroid cancer patients. Older age is associated with both increased death from thyroid cancer and increased death from competing causes. Distant metastases are associated with a high likelihood of death from thyroid cancer whereas with lower risk disease, other causes of death may be more important to outcome. 

 

Nothing to Disclose: JC, MP, MB, MRH

11225 22.0000 SUN-0537 A Impact of Age on Disease-Specific and Overall Survival of Patients with Carcinoma of the Thyroid 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Mónica Santiago*1, Jose Hernan Martinez2, Coromoto Palermo2, Carlos Rafael Figueroa3, Rafael Trinidad1, Madeleine Gutierrez2, Alfredo Sanchez4 and Michelle M Mangual1
1San Juan City Hospital, 2San Juan City Hospital, San Juan, PR, 3San Juan City Hospital, Caguas, PR, 4San Juan City Hospital, PR

 

The Prevalence of Coexistence Thyroid Carcinoma and Thyroid Nodules in Hyperthyroid Patients of San Juan City Hospital

Mónica Santiago MD, José Hernán Martinez MD FCAP, Coromoto Palermo MD,

Carlos Figueroa MD, Rafael Trinidad MD, Michelle Mangual MD, Madeleine Gutierrez MD, Alfredo Sanchez MD, Eva Gonzalez MD , Maria de Lourdes Miranda MD

Department of Endocrinology, Metabolism, and Diabetes; San Juan City Hospital

Abstract

Hyperfunctional nodules of the thyroid are rarely associated with thyroid cancer, for these reason are rarely biopsied. Although multiple theories have being proposed, the relationship is still uncertain. After performing a MEDLINE literature search, we found in multiple retrospectives analysis, that patients with hyperthyroidism with hyperfunctional nodules have an estimated of 0.3% to 16.3% prevalence of malignancy. In our study forty-eight hyperthyroid cases were prospectively investigated to provide information about the association between hyperthyroidism and thyroid cancer. Historical, biochemical and radiological characteristics of the case subjects and their nodules were also analyzed. All nodules greater than 1cm in diameter, nodules 5-10 mm size diameter if they had calcification were fine-needle biopsied (FNAB) under ultrasound guidance. The biopsy samples were cytologically asses (by the BETHESDA classification) and we found 77% of benign nodules, 2% of nodules presented with atypia of undetermined significance or follicular lesion of undetermined significance, 8.3% were malignant nodules, and 10.4% were nondiagnostic or unsatifactory.  All patients with a biopsy diagnosis of malignant underwent surgery. Thyroid malignancy (micro- or macrocarcinoma) diagnosed pre-operatively in all 4 cases by US-guided FNAB was confirmed by the pathology obtained after the surgery. Papillary thyroid carcinoma was identified in 2 patients (4.17%), and Follicular thyroid carcinoma was found in 2 patients (4.17%). These data demonstrate a higher than expected incidental cancer rate in hyperthyroid patients compared with euthyroid subjects with nodular goiter. Our purpose is to stress the point that, although hyperfunctioning thyroid nodules are rarely described as malignant in the literature, FNAB should not be restricted to cold nodules, in view of our data and others published reports.

 

Nothing to Disclose: MS, JHM, CP, CRF, RT, MG, AS, MMM

12602 23.0000 SUN-0538 A The Prevalence of Coexistence Thyroid Carcinoma and Thyroid Nodules in Hyperthyroid Patients of San Juan City Hospital 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Anna Wojcicka*1, Malgorzata Czetwertynska1, Michal Swierniak1, Joanna Dlugosinska2, Monika Maciag1, Agnieszka Czajka1, Kinga Dymecka1, Rafal Ploski1, Albert de la Chapelle3 and Krystian Jazdzewski1
1Medical University of Warsaw, Warsaw, Poland, 2Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland, 3Comprehensive Cancer Center, Ohio State University, Columbus Ohio, United States of America, Columbus, OH

 

Background: The risk of developing papillary thyroid carcinoma (PTC), the most frequent thyroid malignancy, is elevated up to 8.6-fold in the first-degree relatives of PTC patients, what could be explained by polygenic action of low-penetrance alleles. Among the etiological culprits, exposure to ionizing radiation during childhood is a known risk factor for thyroid cancer. The mechanisms in which ionizing radiation promotes carcinogenesis consist mainly in its ability to induce DNA double-strand breaks. In mammalian cells, double-strand DNA breaks activate the ataxia-teleanagiectasia-mutated (ATM) kinase, which phosphorylates and activates checkpoint yeast homolog (CHEK2). Subsequently, CHEK2 phosphorylates breast cancer 1 gene (BRCA1) and triggers DNA repair or, if failed, leads to cellular apoptosis. Functionality of the ATM-BRCA1-CHEK2 pathway is affected by polymorphisms and mutations within the involved genes, underlying inefficient DNA repair and leading to tumorigenic changes within the cells.

The aim of this study was to identify low-penetrance susceptibility alleles for PTC by genotyping deleterious SNPs in genes involved in DNA damage-response and cell-cycle control pathways: ATM, BRCA1 and CHEK2.

Methods and results: Sequenom iPLEX technology was employed to genotype polymorphisms: rs1801516 in ataxia telangiectasia mutated (ATM), rs17879961 in CHEK2 checkpoint yeast homolog (CHEK2), and rs16941 in breast cancer 1 gene (BRCA1) in 1781 PTC patients and 2081 healthy controls. We identified CHEK2 rs17879961 (OR=2.2, P=2.37e-10) and BRCA1 rs16941 (odds ratio [OR]=1.16, P=0.005) and as the risk alleles for PTC. ATM rs1801516 variant modifies the risk associated with BRCA1 variant by 0.78 (P=0.02). Both ATM and BRCA1 variants modify the impact of male gender on clinical variables: T status (P=0.007), N status (P=0.05), and stage (P=0.035).

Conclusion: The study shows the complex association between genetic variants of ATM-CHEK2-BRCA1 axis and the predisposition to PTC. Furthermore, the study supports previous findings on the importance of age and gender on the clinical outcome of the disease and showed that this effect is significantly altered by the minor alleles of the analysed genes, emphasizing their importance in the pathogenesis of PTC.

 

Nothing to Disclose: AW, MC, MS, JD, MM, AC, KD, RP, AD, KJ

13678 24.0000 SUN-0539 A Variants in the ATM-CHEK2-BRCA1 Axis Determine Genetic Predisposition and Clinical Presentation of Papillary Thyroid Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Mustafa Sahin*1, Bekir Ucan2, Müyesser Sayki Arslan2, Mustafa Ozbek2, Seyda Ozdemir3, Nujen Colak Bozkurt4, Oya Topaloglu2, Esra Tutal5, Taner Demirci6, Mustafa Caliskan7, Erman Cakal8 and Tuncay Delibasi2
1Ankara University School of Medicine, Ankara, Turkey, 2Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey., 3Diskapi Training and Research Hospital, Ankara, Turkey., 4Ankara Training and Research Hospital, Ankara, Turkey, 5Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey., Ankara, Turkey, 6Diskapi Training and Research Hospital, Ankara, Turkey, 7Diskapi Yildirim Beyazit Teaching and Research Hospital, Ankara, Turkey, 8Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey

 

To investigate the role of ghrelin and PAI-1 (plasminogen activator inhibitor-1) in occurrence and size of cancer. We aimed to evaluate plasma ghrelin and PAI levels in patients with thyroid cancer and compare with age, sex and body mass index (BMI) matched controls. Fifty-four thyroid  cancer patients (7 male, 47 female) and 24 healthy controls (6 male, 18 female) were included in our study. There was no significant difference in age between thyroid cancer patients (42,4 ±10.1 ) and controls (42,5±8.9). There were no significant difference in BMI, TSH (thyrotropin) levels, insulin resistance (HOMA-IR), PAI-1 levels are found to be significantly lower in thyroid cancer patients [240,0 (7.1-489,9)] according to controls[(332,3 (74.7-695)]. There was no significant difference in ghrelin levels between patients and controls. But plasma ghrelin levels were significantly higher in tumors larger than 1 cm diameter according to microcarcinomas. Plasma ghrelin levels are also found to be correlated with tumor size (r=0.499; p<0.0001). PAI-1 levels may be lower in thyroid carcinomas and ghrelin levels may be important in prognosis of thyroid carcinoma.

 

Nothing to Disclose: MS, BU, MSA, MO, SO, NCB, OT, ET, TD, MC, EC, TD

15856 25.0000 SUN-0540 A Plasma Ghrelin and PAI-1 Levels in Patients with Thyroid Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Ana Reyes Romero Lluch, Juan Ignacio Cuenca Cuenca, Raquel Guerrero Vázquez, Antonio Jesús Martínez Ortega, Ignacio Jiménez Varo, Beatriz González Aguilera, Noelia Gros Herguido and Elena Navarro González*
Virgen del Rocio University Hospital, Seville, Spain

 

Surgery is the only curative treatment available for recurrent medullary thyroid cancer, but tumor localization is often difficult. Therefore, we studied the potential value of 18-dihydroxiphenylalanine PET and 18-FDG PET as a valid localization method. Our objectives were to evaluate the utility of 18F-DOPA PET scan for identification of lesions in patients with suspected recurrence of MTC and to compare the usefulness of this technique over 18F-FDG PET scan. We also studied the correlation between the calcitonin and CEA levels and calcitonin doubling time and PET positivity. To perform this study we prospectively examined, between november 2011 and december 2012, 17 patients with MTC diagnosis and suspicion of recurrence either by imaging techniques (n=2), or by biochemical evidence (elevated calcitonin or CEA levels; n = 15). Each patient underwent a 18F-FDG PET scan first and then a 18F-DOPA PET with an interval of 15 days between both. Sex, age, type of MCT, number and location of the lesions were studied. The correlation between calcitonin, CEA levels and calcitonin doubling time and the positivity of PET was analyzed. Results: Please note that quantitative variables are defined as mean ± standard deviation. Total simple: n= 17 (12 women, 71%); age 48.1 ± 12.8 years. 10 patients had sporadic MTC and 7 patients had multiple endocrine neoplasia syndrome type 2 (MEN 2A). Abnormal uptakes were detected with 18F-DOPA in 10 patients and only in 8 patients with 18F-FDG (sensitivity of 60% versus 46.6 %). 24 total lesions were detected with 18F-DOPA versus 13 total lesions with 18F-FDG. None of our patients showed additional lesions with 18F-FDG in comparison with 18F-DOPA. 7 patients had negative results with both scans. We did not found significant differences between the maximum Standard Uptake Value (SUV) of lesions detected using 18F-FDG compared with 18F-DOPA (4.2± 2.7 vs 3.7± 2.6). Calcitonin levels were significantly higher in patients (n=10) with positive PET (524.09 ± 406.51 pg/ml vs 95.48 ± 72.68 pg/ml; p=0.02). Only 2 patients with calcitonin levels > 150 pg/ml and/or CEA > 4.5 ng/mL showed negative results. In all patients with calcitonin levels >260 pg/ml, 18-FDOPA PET was able to demonstrate persistent disease. In patients with abnormal test results, there were no significant differences in calcitonin levels between 18F-DOPA and 18F-FDG (524.09 ± 406.51 pg/ml vs 481.50 ± 415.58 pg/ml;p=0.82). No correlation between calcitonin doubling time and PET positivity was found. Histological confirmation was obtained in 7 patients. In 3 patients the diagnosis was confirmed using other imaging techniques. Conclusions: 18F-DOPA PET seems to be superior to 18F-FDG PET in detecting and locating lesions in patients with recurrent MTC. This technique tends to be especially useful in patients with negative results in other morphologic imaging techniques and calcitonin levels ≥150 pg/mL or CEA ≥4.5 ng/mL.

 

Nothing to Disclose: ARR, JIC, RG, AJM, IJ, BG, NG, EN

13068 26.0000 SUN-0541 A Utility of 18F-Dihydroxyphenilalanine PET in Patients with Recurrent Medullary Thyroid Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Anna Wojcicka*, Wojciech Gierlikowski, Marta Kotlarek, Lukasz Koperski and Krystian Jazdzewski
Medical University of Warsaw, Warsaw, Poland

 

Objectives:Apical iodide transporter (AIT) is essential for thyroid homeostasis, functioning both as iodide transporter and a potent tumor suppressor. Its decreased levels observed in thyroid cancer underlie its progression and inefficiency of radioactive iodine treatment, used for ablation of post-operative and metastatic thyroid cancer cells. Mechanisms leading to downregulation of AIT in thyroid cancer are largely unknown, but we and other teams have reported that thyroid cancers are accompanied by significant upregulation of numerous microRNAs. MicroRNAs (miRs) are short, approx. 22-nt long non-coding RNAs that posttranscriptionally regulate expression of protein-coding genes. Binding of a miR to 3’UTR (UnTranslated Region) of mRNA results in inhibition of further steps of protein synthesis. Increased expression of miRs, observed in cancers, leads to their enhanced binding with target mRNAs, causing severe downregulation of their expression and resulting in deregulation of numerous cellular pathways.

The aim of this study was to elucidate the impact of microRNAs on regulation of AIT expression and to assess the role of deregulation of this process in thyroid carcinogenesis.

Methods and results: MicroRNAs targeting AIT were identified in silico and their interaction with AIT was confirmed in luciferase assay in cell lines transfected with synthetic microRNAs and a reporter plasmid with 3’UTR of AIT cloned downstream of luciferase. In this system, binding of a microRNA to the 3’UTR results in decreased synthesis and activity of luciferase. Significant reduction of luciferase activity was obtained for miR-181a-5p (20%, p=0.02), miR-182-5p (18%, p=0.05) and miR-494-3p (15%, p=0.01), indicating binding of these microRNAs to 3’UTR of AIT. SQ-PCR analysis in 48 PTC and non-tumorous paired tissue samples revealed a 67-fold decrease of AIT (p=2x10-7) in PTC and a concomitant upregulation of miR-181a-5p (1.67-fold, p=0.001) and miR-182-5p (2.03-fold, p=0.002). AIT expression was additionally 4.79-fold lowered (p=0.001) in presence of BRAFV600F mutation. AIT levels negatively correlated with tumor size (r=-0.29, p=0.03, n=54). SQ-PCR analysis of 19 thyroid adenomas showed a 2.24-fold decrease of AIT, accompanied by upregulation of miR-181a-5p (1.8-fold, p=0.02), miR-182-5p (5.4-fold, p=0.05) and miR-494-3p (6.1-fold, p=0.01). Downregulation of AIT was correlated with upregulation of its downstream effector, antiapoptotic survivin (r=-0.45, p=0.055).

Conclusions: This is the first study showing microRNA-dependent regulation of AIT expression and its aberrances in thyroid malignancies. Modulating the levels of miR-181a-5p, miR-182-5p and miR-494-3p could be used for restoration of AIT and reversal of carcinogenic process, as well as to reestablishment of radioiodine uptake by thyroid cells.

 

Nothing to Disclose: AW, WG, MK, LK, KJ

15923 27.0000 SUN-0542 A Apical Iodide Transporter (AIT) and Its microRNA – Induced Silencing in Thyroid Malignancies 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Amit Mehta*, Lisa Zhang, Myriem Boufraqech, Dhaval Patel, Naris Nilubol and Electron Kebebew
National Cancer Institute, NIH, Bethesda, MD

 

Anaplastic thyroid cancer (ATC) is one of the most aggressive human malignancies with a median survival of 5 months. Currently there is no effective therapy for ATC. The ubiquitin – proteasome pathway plays an integral role in cancer initiation and progression, and is a promising target for cancer therapy. The aim of the present study was to investigate the anticancer effects of a second generation, irreversible proteasome inhibitor, Carfilzomib, in ATC. We treated ATC cell lines (SW1736, 8505c and C643) with different concentrations of Carfilzomib (0nM - 296.0nM) within the clinically achievable serum concentration. Treatment effect on cell proliferation, cell cycle progression, and apoptosis were then analyzed. Protein expression of target genes was determined by Western blot analysis. Carfilzomib treatment significantly inhibited cellular proliferation, which was dose and time-dependent in all ATC cell lines. This effect was observed at concentrations up to 1000 fold lower than the achievable plasma concentration (Cmax = 5878.0 nM) in human – the concentration at which most of the drugs short term side effects are likely to occur. Carfilzomib treatment also induced caspase-dependent apoptosis, G2/M cell cycle arrest, and decreased expression of N-cadherin, a marker for the epithelial-mesenchymal transition (EMT). Analysis of cell cycle regulatory proteins such as p21, p27, and p53 were not altered by Carfilzomib treatment, suggesting that Carfilzomib induces G2/M arrest in ATC cells by a CdkI independent mechanism. Our data shows that Carfilzomib is a promising anticancer agent for the treatment of ATC. Further investigation into the potential of Carfilzomib as a new therapeutic agent for anaplastic thyroid cancer is warranted.

 

Nothing to Disclose: AM, LZ, MB, DP, NN, EK

14034 28.0000 SUN-0543 A Carfilzomib, a Second Generation Proteasome Inhibitor, Has Anticancer Activity in Anaplastic Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Teresa Rago*1, Maria Scutari1, Francesco Latrofa1, Valeria Loiacono1, Paolo Piaggi2, Ivo Marchetti1, Rossana Romani1, Fulvio Basolo1, Paolo Miccoli3, Massimo Tonacchera4 and Paolo Vitti5
1University of Pisa, Italy, 2Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ, 3University of Pisa, Pisa, Italy, 4University of Pisa, Pisa (PI), Italy, 5University Hospital, Pisa, Italy

 

Context. The clinical management of patients with thyroid nodules which are indeterminate at fine needle aspiration (FNA) cytology is still unsettled. 1520 consecutive patients with indeterminate cytology among 100,065 patients who underwent FNA between January 2000 and December 2010 were investigated retrospectively. We evaluated the clinical outcome of patients with indeterminate thyroid nodules and we identified the features associated with malignancy.

Results: 371/1520 (24.4 %) patients with indeterminate thyroid nodules had thyroid cancer at histology, the follicular variant of papillary cancer being the most frequent histotype. 342 patients with cancer were free of disease after thyroidectomy and 131-I remnant ablation, while 29 needed further treatment because of persistent disease. Among them only 12 had persistence of disease at the end of follow-up. Atypias at cytology (p=0.001), blurred nodule margins (p=0.005) and spot microcalcifications (p=0.003) at thyroid ultrasound (US) were significantly associated with malignancy. A clinical score including cytology and US characteristics was calculated; the lowest value showed a high negative predictive value (83.9%) for the presence of malignancy and even higher (99.5%) for the presence of a more cumbersome cancer disease, only 4 out of  the 29 patients who needed further treatment being included in the group with the lowest risk score.

Conclusions: Patients with indeterminate cytology and histology of thyroid cancer had an overall good prognosis. A clinical risk score including the results of cytology and US features is helpful in the management of patients with indeterminate thyroid nodules.

 

Nothing to Disclose: TR, MS, FL, VL, PP, IM, RR, FB, PM, MT, PV

14737 29.0000 SUN-0544 A The Large Majority of 1520 Patients with Indeterminate Thyroid Nodule at Cytology Have a Favourable Outcome and a Clinical Risk Score Has a High Negative Predictive Value for a More Cumbersome Cancer Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Thomas VIZHALIL PAUL V*1, Nitin Kapoor III2, Sahana Shetty1, Nihal Thomas3, Simon Rajaratnam V1, Deepak Thomas Abraham1, M J PAUL1, Pooja Ramakant4 and Marie Therese4
1CHRISTIAN MEDICAL COLLEGE, VELLORE, India, 2Christian Medical College, Vellore, India, 3Christian Medical College, Vellore, Vellore, India, 4CHRISTIAN MEDICAL COLLEGE

 

Primary hyperparathyroidism and non-medullary thyroid cancer are common endocrine conditions seen in day to day clinical practice and several reports of their co-existence have been cited in medical literature.   We hereby report a series of 5 patients of primary hyperparathyroidism who were diagnosed of non-medullary thyroid malignancies.

We conducted a retrospective study of histologically proven cases of primary hyperparathyroidism between the year 2007 - 2012. Data of one hundred sixty five subjects (74 male, 91 female) were analyzed.  Three percent (n=5) of these patients with primary hyperparathyroidism had non medullary thyroid malignancies. Mean age was much higher in patients with non-medullary thyroid malignancies (57 yrs. vs. 41 yrs).  All patients with thyroid malignancies were women. All but one patient were asymptomatic for their thyroid illness and were detected incidentally during evaluation of hyperparathyroidism and were operated simultaneously.  None of these patients had family history of thyroid malignancies.

The average size of the thyroid tumor was 12 mm and none of these patients had any extra capsular invasion, lymph node or distant metastasis. Three out of 5 patients had papillary thyroid carcinoma(PTC) and two had a follicular variant of papillary thyroid carcinoma(FVPTC). Those with PTC had total thyroidectomy and   FVPTC patients had hemi thyroidectomy initially followed by completion thyroidectomy. All patients were successfully cured of their thyroid and parathyroid illness.

Thyroid malignancy has been described to occur at an increased frequency in primary hyperparathyroidism compared to general population. An early diagnosis in this regard will help to reduce the morbidity associated with another surgery.  The pathogenesis of this concurrence is not fully established. Careful thyroid evaluation should be considered for all patients with primary hyperparathyroidism and looked for in follow up especially in elderly women.

 

Nothing to Disclose: TVP V, NK III, SS, NT, SR V, DTA, MJP, PR, MT

15070 30.0000 SUN-0545 A Non Medullary Thyroid Malignancies in Primary Hyperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Joanna Klubo-Gwiezdzinska*1, John Costello2, Kirk Ernest Jensen3, Aneeta Patel2, Douglas Van Nostrand4, Kenneth Burman4, Leonard Wartofsky4 and Vasyl Vasko2
1Washington Hospital Center, Washington, DC, 2Uniformed Services University of the Health Sciences, Bethesda, MD, 3USUHS, Rockville, MD, 4MedStar Washington Hospital Center, Washington, DC

 

Introduction

Amifostine is a potent scavenger of reactive oxygen species that efficiently reduces the extent of DNA-damage caused by free radicals. In patients with differentiated thyroid cancers amifostine is clinically used to prevent salivary gland damage after treatment with radioiodine. 

Objective

We hypothesized that  amifostine may affect  thyroid cancer cells response to treatment with DNA damaging agents. 

 Material and Methods

Amifostine's active free thiol WR-1065 was investigated in human thyroid cancer cell lines derived from follicular (FTC133), papillary (TPC1 and BCPAP) and anaplastic (C643) cancers, and in fibroblasts (NIH3T3 cells). DNA damage was induced by cell exposure to H2O2(100 mM) or by treatment with radiomimetic neocarzinostatin (NCS-250 ng/ml). DNA damage was determined by Comet Assay. Cell viability was examined using Vi-CELL Cell Analyzer. Western blot analysis with anti-phospho-H2AX, anti-phospho-Chk1 and anti-phospho-p53 was performed to examine the effects of WR1065 on activation of DNA damage/repair signaling. Apoptosis was evaluated by detection of cleaved caspase 3 and cleaved PARP. Expression of thyroid specific genes (TTF1, PAX8, Tg, NIS and Pendrin) and stem cell markers (Nanog, OCT4, BMI-1, EZH2, SUZ12) was examined by real time PCR. 

Results

Treatment with WR-1065 (1mM) did not protect thyroid cancer cells from DNA damage after exposure to H2O2 (100 mM). Western blot analysis with anti- phospho-Chk1, phospho-p53 and phospho-H2AX demonstrated that WR-1065 did not prevent H2O2– inducible activation of DNA damage/repair signaling in thyroid cancer cells. Comet assay demonstrated that in thyroid cancer cell lines WR-1065 did not prevent DNA breaks induced by the treatment with radiomimetic NSC. WR-1065 did not prevent NSC-inducible cleavage of caspase-3 in any of examined thyroid cancer cell lines. Chronic exposure to WR-1065 (1 mM for 24 hours) was toxic for all thyroid cancer cells, but not for fibroblasts (NIH3T3 cells). ATC-derived C643 cells were more resistant to WR-1065 than TPC or FTC-derived cell lines. Treatment with low doses of WR-1065 (0.1 mM for 24 hours) decreased the number of viable cells by 8%, 47%, 92% and 82% in C643, TPC-1, BCPAP and FTC-133 cells respectively. The cytotoxic effects of WR1065 on thyroid cancer cells were not associated with caspase-3 or PARP cleavage, suggesting necrotic rather than apoptotic mechanism of cell death. Real time PCR analyses have shown that WR1065 did not affect expression of genes controlling radio-iodine uptake in thyroid cells and had no effect on mRNA level of genes coding for cancer stem cell markers. 

 Conclusion

Our study  suggests that amifostine does not attenuate the efficacy of radio-iodine treatment in patients with thyroid cancer. Results demonstrating WR-1065 cytotoxicity suggest it's potential utility as the adjunct treatment of thyroid cancer.

 

Nothing to Disclose: JK, JC, KEJ, AP, DV, KB, LW, VV

15883 31.0000 SUN-0546 A Amifostine Used Clinically for Salivary Gland Protection during Therapy with Radioiodine Is Cytotoxic for Thyroid Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Seong Jin Lee*1, Si Hyoung Kim2, Dong-Sun Kim3, Sung Hoon Yu2, Jun Goo Kang1, Chul Sik Kim1, Eun Gyung Hong1, Doo-Man Kim1, Jae Myung Yoo1, Sung-Hee Ihm1, Moon Gi Choi1 and Hyung Joon Yoo1
1College of Medicine, Hallym University, Seoul, Korea, Republic of (South), 2College of Medicine, Hallym University, Korea, Republic of (South), 3College of Medicine, Hanyang University, Korea, Republic of (South)

 

Herbimycin A (HMA), a heat shock protein 90 inhibitor, has a cytotoxic effect on cancer cells. We evaluated the effect of HMA on cell survival and cadherin/catenin complex in anaplastic thyroid carcinoma cells. When 8505C, CAL62 and FRO cells were treated with HMA, the percentage of cell numbers decreased, and that of dead cells increased in a time- and concentration-dependent manner. After treatment with HMA, cleaved PARP protein levels increased in 8505C, CAL62 and FRO cells, whereas cleaved caspase-3 protein levels increased only in FRO cells. After treatment with HMA, in 8505C and CAL62 cells, we did not detect E-cadherin protein, while FRO cells showed significant increases in E-cadherin protein levels. In all cells, β-catenin protein levels were enhanced. When FRO cells were treated with HMA, there was an increase in immunoprecipitated β-catenin, suggesting increased formation of E-cadherin/β-catenin complex with HMA treatment in FRO cells. After treatment with HMA, the protein levels of E-cadherin and β-catenin were enhanced, and those of N-cadherin and vimentin were diminished in a time- and concentration-dependent manner. As for the influence of HMA on the nuclear and cytoplasmic protein levels of E-cadherin, α-catenin, β-catenin and γ-catenin, HMA treatment enhanced both nuclear and cytoplasmic protein levels of E-cadherin and β-catenin, while it enhanced the cytoplasmic, and diminished the nuclear, protein levels of α-catenin and γ-catenin. In pretreatment with LY294002 or transfected with PTEN siRNA before HMA treatment, the protein levels of p21 and p27 increased, and p53 protein levels decreased. Compared to cells treated with HMA alone, in LY294002-pretreated cells, the protein levels of E-cadherin, α-catenin, β-catenin, γ-catenin and p21 further increased, and those of N-cadherin and p53 further decreased, and those of vimentin and p27 were not changed. In PTEN siRNA-transfected cells, the protein levels of vimentin and p53 further increased, and those of E-cadherin, p21 and p27 further decreased, and those of N-cadherin, α-catenin, β-catenin and γ-catenin were not altered. In E-cadherin siRNA-transfected FRO cells, the protein levels of N-cadherin, vimentin, Akt and p53 were elevated, and those of p21 and p27 were reduced. As for β-catenin, the total protein levels were not altered, and the nuclear protein levels were elevated, and the cytoplasmic protein levels were reduced. In β-catenin siRNA-transfected FRO cells, the percentage of dead cells, and the protein levels of cleaved PARP and cleaved caspase-3 were diminished without change in the percentage of cell numbers. The protein levels of p21 and p27 were enhanced, and those of Akt, ERK1/2 and p53 were not altered. In conclusion, our results suggest that HMA has a cytotoxic effect with a concomitant increase in formation of E-cadherin/β-catenin complex mediated by PI3K/Akt signaling in FRO cells.

 

Nothing to Disclose: SJL, SHK, DSK, SHY, JGK, CSK, EGH, DMK, JMY, SHI, MGC, HJY

13206 32.0000 SUN-0547 A Herbimycin Α Induces Cell Death with Formation of E-Cadherin/b-Catenin Complex Mediated By PI3K/Akt Signaling in Anaplastic Thyroid Carcinoma Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Sirin Pandey*1 and Juan Carlos Jaume2
1University of Wssconsin, Madison, WI, 2University of Wisconsin - Madison, Madison, WI

 

Background: Inflammatory conditions have been associated with different types of malignancies however Hashimoto thyroiditis as a risk for thyroid cancer remains controversial.  We have encountered patients with Hashimoto thyroiditis (HT) on FNA cytology who are completely euthyroid (normal thyroid function biochemically).  We termed them as having euthyroid Hashimoto thyroiditis (EHT) henceforward.  We hypothesized that of patients with EHT, TPO antibody positive patients will develop full blown hypothyroidism (true HT) while TPO antibody negative patients (true EHT) will have an increased risk of thyroid cancer over time.

Methods: We prospectively followed patients with EHT.  We checked all EHT patients for TPO autoantibodies and divided them in 3 categories depending on their TPO autoantibody status: negative, low (<1:1000) and high (>1:1000) titer. We followed them from 2007 to 2013.

Results: 46 patients with EHT (42 females and 4 males) were consecutively identified and followed for 6 years.   14/46 had negative TPO titer, 10/46 had low TPO titer, 9/46 had high TPO titer, 2/46 had negative to positive seroconversion, 11/46 antibody status was unknown. 

4/46 patients developed hypothyroidism (true HT) over time (2 were from low titer group, 1 was from unknown status group and 1 was from seroconversion group who developed high TPO titer).

13/46 underwent thyroidectomy (10 total and 3 partial).  8/46 (17%) were found to have differentiated thyroid cancer (DTC) on final pathology (1/14 negative TPO titer, 4/10 low TPO titer, 2/9 high TPO titer and 1/11unknown TPO status).  None had hypothyroidism prior to surgery (true EHT). 

Conclusion:  Our study demonstrates that Euthyroid Hashimoto thyroiditis (EHT) is prospectively linked to differentiated thyroid cancer (DTC).  DTC was also significantly associated with low/negative titer of TPO antibodies.  Although our study group size is small, at this point the association is quite significant.  We have ~500 patients with EHT being followed prospectively, if the association continues to be present, we may have uncovered the highest risk factor for thyroid cancer.

 

Nothing to Disclose: SP, JCJ

16534 33.0000 SUN-0548 A Risk of Thyroid Cancer in Prospectively Followed Euthyroid Hashimoto Thyroiditis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Mustafa Ozbek*1, Bekir Ucan2, Mustafa Sahin3, Askin Gungunes2, Zeynep Ginis4, Müyesser Sayki Arslan2, Taner Demirci5, Esra Tutal6, Melia Karaköse2, Ahmet Yesilyurt2, Oya Topaloglu2, Erman Cakal4 and Tuncay Delibasi2
1Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey., Turkey, 2Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey., 3Ankara University School of Medicine, Ankara, Turkey, 4Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey, 5Diskapi Training and Research Hospital, Ankara, Turkey, 6Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey., Ankara, Turkey

 

Objective : The most common thyroid malignancy are papillary and follicular thyroid carcinomas. They are accounting for approximately 85-90 % of all thyroid cancers. Recent studies have been reported the relevance of COX-2 in human carcinogenesis. The aim of this study to investigate the relationship between the thyroid carcinoma and COX-2 gene polymorphism in Turkısh population.

Materials and methods : We included a total of 96 differentiated-thyroid cancer patients ( mean age 46.9 ± 10.3 years ; 14 males, 82 females ) and 83 healthy control subjects ( mean age 46.0 ± 10.6 years ; 39 males, 44 females ). The frequency of -765G>C, -8473T>C and 1195A>G gene polymorphisms in the COX-2 promoter region was investigated in the thyroid cancer patients and control group using the high resolution melting ( HRM ) method. The data were analysed with χ² or Fisher’s exact test. A two-tailed  p  value below 0.05 was considered statistically significant.

Results : No difference was determined with respect to COX-2(-765G>C) and COX-2(-1195A>G) gene polymorphisms between thyroid cancer patients and control group. There was statistically significant differences between COX-2(-8473T>C) gene polymorphism in the thyroid cancer and control group ( p =0.012).

Conclusion : Single nucleotide gene polymorphism (SNP) COX-2(- 8473T>C) was significantly associated with the occurence of the differentiated thyroid( especially papillary) cancer. The SNP COX-2 (-8473T>C ) gene polymorphism may contribute to genetic susceptibility of thyroid papillary carcinoma in Turkısh population.

 

Nothing to Disclose: MO, BU, MS, AG, ZG, MSA, TD, ET, MK, AY, OT, EC, TD

13926 34.0000 SUN-0549 A Cyclooxygenase-2 ( COX-2 ) Gene Polymorphism in Patients with Differentiated Thyroid Carcinomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Hongjun Lv*, Jiao Fu, Meiju Ji, Peng Hou and Bingyin Shi
The First Affiliated Hospital of Xi’an Jiaotong University School of Medicine, Xi'an, China

 

It is well known that many cancer cells rely more on aerobic glycolysis to generate ATP and metabolic intermediates for cell proliferation than oxidative phosphorylation. 3-bromopyruvate (3BP) is a small molecular, specific anticancer agent targeted hexokinase II, which plays a critical role in the course of aerobic glycolysis. In this study, we observed that 3BP, in both dose- and time-dependent manner, inhibited growth of all the thyroid cancer cells used in this study, including K1, BCPAP, C643, FTC133, IHH4, 8305C, with an IC50 concentration of 31.64μg/mL, 8.56μg/mL, 32.23μg/mL, 26.68μg/mL, 4.53μg/mL and 8.56μg/mL respectively. In-depth experiments revealed that 3BP induced cell apoptosis in a dose- and time-dependent manner. When treated with 3BP of 4, 8, 12 μg/mL for 6 hours, the apoptotic C643, K1, FTC133, BCPAP cells raised from 5.44% to 7.91%, 12.7%, 54.3%, from 3.08% to 3.62%, 8.11%, 23.0%, from 15,5% to 13.4%, 34.7%, 79.2%, from 5.71% to 8.08%, 12.9%, 41.1% respectively. When the cells were treated with 3BP of 12 μg/mL for 0, 1, 2, and 4 hours, the apoptotic C643, K1, FTC133, BCPAP cells raised from 5.99% to 7.10%, 10.7%, 15.8%, from 3.18% to 3.70%, 6.00%, 5.09%, from 15,2% to 14.6%, 20.6%, 24.7%, from 3.86% to 4.93%, 9.10%, 13.1% respectively. 3BP treatment also altered cell cycle distribution, mainly resulting in G2/M arrest. When treated with 3BP of 5, 10 μg/mL for 6 hours, the G2/M phase cells of C643, FTC133 and BCPAP cells raised from 11.17% to 9.11%, 18.94, from 12.39% to 13.15%, 13.72%, from 5.44% to 11.36%, 14.56%, respectively. Then the C643 cells were injected subcutaneously to form xenogenous tumors in nude mouse, and then 3BP were administered intraperitoneally at a dose of 0, 5, 10mg/kg for 12 days respectively. The results confirmed the pronounced antitumor effects of 3BP. The tumor load was decreased by 58.3% when 3BP was administered. Then the xenogenous tumors were preceded for immunostaining of Ki67, a criterion for cell proliferation. We found that the tumors treated with 3BP showed a significantly weakened signaling of Ki67. These results indicated that 3BP is an effective, potential approach for thyroid cancer.

 

Nothing to Disclose: HL, JF, MJ, PH, BS

14234 35.0000 SUN-0550 A 3-Bromopyruvate (3BP) Inhibits Growth of Thyroid Cancer Cells in Vitro and in Vivo 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Maria Eleni Nikita*1, Wen Jiang2, Robert Owen Newbury3, Susan Alexandra Phillips4, Richard E Reitz5, Frederic M Waldman6, Feras M. Hantash6 and Ron S Newfield4
1Rady Children Hospital, San Diego, CA, 2Rady Children's Hospital, San Diego, CA, 3Rady Children's Hospital, san diego, CA, 4UCSD/Rady Children's Hospital, San Diego, California, 5Quest Diagnostic Inc, San Juan Capistrano, CA, 6Quest Diagnostics Nichols Institute, San Juan Capistrano, CA

 

Background: Well-differentiated thyroid cancer (WDTC) incidence is increasing per SEER data. Most pediatric WDTC is papillary (PTC). Several mutations are commonly associated in adults with TC, but the type and frequency of those mutations in pediatric WDTC patients have not been well studied.

Hypothesis: The prevalence of different mutations underlying WDTC may differ between children and adults. Specific mutation classes may correlate with the clinical phenotype at presentation or response to therapy.

Methods: We retrospectively analyzed 40 consecutive tissue blocks from pediatric TC cases (2001-2012). The protocol was IRB approved to analyze these blocks at Quest Diagnostics for commercially available BRAF, NRAS, HRAS and KRAS mutations, and RET/PTC rearrangements (ReAr) in PTC and PAX8/PPARγ fusions in follicular thyroid carcinoma (FTC) or follicular variant of PTC (FVPTC), using validated molecular methods. No subject had radiation exposure.

Results: Of 40 samples, 37 (28 F, 9 M) were successfully genotyped. Mean age at diagnosis (Dx) was 15 (range 8-21) yrs, most being Hispanic (70.3%) or Caucasian (21.6%). Mutations were noted in 20/37 (54.1%). Only 1/3 with FTC had a mutation-NRAS(Q61K). 3/7 females with FVPTC had PAX8/PPARγ fusions. Of 27 subjects with typical PTC, 16 (59.2%) subjects (12 F) had mutations: BRAF V600E in 10/27 (37%), 5 (18.5%) with RET/PTC ReAr (4 RET/PTC1+ and 1 RET/PTC3+), and 1 (3.7%) NRAS(Q61K).  80% of BRAF mutations were in Hispanics, 20% in Caucasians. 90% of BRAF mutations were in 15-20 year olds, and 10% in <15 yrs. All subjects with RET/PTC ReAr were ≤15 yrs. No significant differences were noted in tumor size, lymph nodes or distant metastasis at Dx, based on presence or type of mutation, though 68.4% of PTC with + mutation had affected lymph nodes at Dx vs 37.5% without mutations. Correlations of genotype with response to therapy await longer follow-up.

Conclusions: In our pediatric WDTC cohort, BRAF V600E was the most prevalent mutation in PTC, especially in older adolescents of Hispanic descent, and with a higher rate than other pediatric data (1). RET/PTC ReAr were less prevalent in this cohort versus prior US pediatric studies (2,3). More advanced molecular analysis will likely reveal other types of mutations/ReAr/fusions that can also help evaluate indeterminate FNA specimens. A larger, ethnically varied pediatric cohort followed long-term is needed to better study genotype-phenotype correlations in TC at Dx and beyond.

 

Disclosure: RER: Employee, Quest Diagnostics. FMW: Employee, Quest Diagnostics. FMH: Employee, Quest Diagnostics. Nothing to Disclose: MEN, WJ, RON, SAP, RSN

12447 36.0000 SUN-0551 A Genotype-Phenotype Analysis in 40 Pediatric Thyroid Cancer Cases 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Elena Izkhakov*1, Orli Sharon2, Ester Knoll3, Asaf Aizic1, Dan Fliss1, Rona Limor3, Naftali Stern1 and Dalia Somjen3
1Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, 2Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel, 3Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

 

Background: Estrogen Receptors (ERs), Vitamin D Receptors (VDR) and 1a -hydroxylase 25- hydroxy vitamin D (1OHase) are expressed in various normal and cancer cells.

Aims: To assess whether the ERß  mimetic agent Carboxy-Daidzein-tboc (cDtboc) and vitamin D metabolites (VDMs)  such as 1,25D, 24,25D and 25D modulate the cell proliferation (CP) and mRNA expression of ERs, 1OHase and VDR  in human Papillary Thyroid Carcinoma (PTC) cells.

Methods: ERa, ERß, VDR, 1OHase expression and CP were determined by rtPCR and by direct measurement in 7 PTC and normal thyroid specimens harvested during thyroidectomy from the same patients.

Results: ERa, VDR and 1OHase mRNA was more abundantly expressed in normal than cancer cells, whereas ERß mRNA expression was similar in both cell types. In cancer cells VDMs increased mRNA expression of ERa, ERß and  VDR, but not of 1OHase, whereas in normal cells VDMs elicited an increase in the mRNA expression of all genes of interest, with the exception of ERß. High concentration of VDMs dose dependently inhibited CP in cancer cells, while CP of normal cells was reduced by high concentration of 1.25D only. The effect of 1,25D was more potent in cancer compared with normal thyroid cells. cDtboc also inhibited CP in a dose-related fashion, and cancer cells were more sensitive than normal cells to this inhibitory action. Low concentration of VDMs reduced CP in cancer cells, while this effect was not observed in normal thyroid cells.  Most importantly, 1,25D amplified the inhibitory effect of cDtboc on CP in cancer cells; such that not only was the maximal inhibition larger (-78% vs. 65%), but it was attained at a 100 fold lowerconcentration of cDtboc (0.3umol/l).

 Conclusions: This is the first report that 1,25D markedly amplifies the inhibitory effect of cDtboc on the growth of human thyroid cancer cells derived from patients. We suggest that this is exerted, at least in part, by vitamin D-induced increase in ERß expression, thus allowing accentuating the  cytotoxic effect exerted by cDtboc alone reported previously from our group (1). This finding might form the basis for the use new strategy in the therapy in human thyroid cancer.

 

Nothing to Disclose: EI, OS, EK, AA, DF, RL, NS, DS

14933 37.0000 SUN-0552 A Vitamin D Amplifies the Growth Inhibitory Effect of the Estrogen Receptor ß Agonist Carboxy-Dtboc in Human Thyroid Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Alessia Sagazio*, Ines Bucci, Marilena Olivieri, Giulia Di Dalmazi, Alberto Carpenito, Cesidio Giuliani and Giorgio Napolitano
University of Chieti-Pescara, Chieti, Italy

 

Thyroid nodules are a very common disorder in endocrinology practise. Thyroid nodules are detected by palpation in 3–7% and by ultrasound  (US) in 20–76% of the general population. However sensitivity and specificity of US criteria  are not sufficient to predict thyroid malignancy and FNAC (Fine Needle Aspiration Cytology) remains the best single test to differentiate benign from malignant  thyroid lesions. US Elastosonography (USE) has recently emerged as a sonographic method which measures the tissue hardness/elasticity and aids in the differentiation of benign from malignant nodules. Thyroid cancer generally presents as a stiff lesion compared to elasticity of benign thyroid lesion. The aim of our study was to evaluate diagnostic role of real time USE comparing USE score (S1-S4) to cytologic results after FNAC. The study included 149 thyroid lesions at first clinical observation in 136 patients (108 F and 98 M, mean age 50, range 22-84). We assessed thyroid lesions in 4 decreasing elasticity score  (S1-4) and then correlated to cytology results (THY1-4). After FNAC we excluded thyroid nodules with non diagnostic cytologic results (THY1). Our results show that amongst 129 nodules, 113 had benign cytologic diagnosis THY2. Of this 113 nodules 75 (66.4%) had S1-S2 elastosonographic pattern and 38 (33.6%) S3-S4 pattern. Amongst 13 thyroid nodules with a FNA result of indeterminate lesion (THY3), 5 (38.7%) had S1-S2 pattern and 8 (61.5%) S3-S4 score. Finally, out of three nodules with suggestive malignant cytologic results (THY4), 1 had S2 (33.3%) and 2 S3-S4 (66.6%) pattern. Evaluating our results by USE score we observed that  81 lesions had a S1-S2 USE score; 75 (92%) had FNA result of benign lesion (THY2), 5 had an indeterminate (THY3, 6.1%) and 1 had a suspecious malignant (THY4, 1.2%) nodule. Out of 48 thyroid nodules with S3-S4 USE score, 38  (79.1%)   had benign cytologic results (THY2), 8 indeterminate (THY3, 16.6%) and 2 suspicious (THY4, 4.1%)pattern. Our study show that 92% of thyroid lesions with low USE score S1-S2 are correlated to FNA result of benign lesion (THY2);on the contrary, higher USE pattern S3-S4 which are supposed to be suggestive for malignant and inderminate nodules are not correlated with the cytologic result. In conclusion, this study seems to indicate that USE might be an helpful tool for the diagnosis of benign thyroid lesions.

 

Nothing to Disclose: AS, IB, MO, GD, AC, CG, GN

15850 38.0000 SUN-0553 A Real Time Elastosonography Versus Cytology: Diagnostic Role in Thyroid Lesions 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Shih-Min Cheng*, Cindy Barlan, Feras M. Hantash, Raul G. Simental-Pizarro, Fariba Payandeh, Kevin Qu, Zhong J. Zhang, Anthony D. Sferruzza, Richard E Reitz and Frederic M Waldman
Quest Diagnostics Nichols Institute, San Juan Capistrano, CA

 

BACKGROUND: Fine-needle aspiration (FNA) cytology provides a definitive diagnosis of benign or malignant disease in the majority of thyroid nodules. However, ~25% of nodules have indeterminate cytomorphology. The American Thyroid Association noted that molecular markers may help guide management in patients with indeterminate FNA cytology. We investigated mutation patterns in a panel of 7 genes (BRAF, RAS [K-, N-, H-], RET-PTC, Pax8/PPARγ) in thyroid FNA samples submitted for molecular testing at a reference laboratory.

METHODS: A total of 533 patient samples were analyzed (smears, Cytolyt, ThinPrep slides, and FFPE blocks). Cytopathology diagnosis was categorized according to the Bethesda System for Reporting Thyroid Cytopathology (BSRTC). DNA and RNA were extracted and tested for BRAF mutations using allele-specific PCR (V600E and K601E); for RAS (H-, K-, N-) mutations using pyrosequencing (codons 12, 13, & 61); and for RET/PTC1 and RET/PTC3 rearrangements and PAX8-PPARγ translocations using RT-PCR.

RESULTS: Atypia/follicular lesions of undetermined significance (AUS/FLUS, BSRTC-III) were the predominant  specimen type (230/533, 43.2%), followed by follicular neoplasm/suspicious for follicular neoplasm (FN/SFN, BSRTC-IV; 127/533, 23.8%), benign (38/533, 7.1%), malignant (36/533, 6.8%), and suspicious for malignancy (SFM, BSRTC-V; 18/533, 3.4%). 63 (11.8%) samples had invalid molecular results and were excluded from further analysis. Molecular analysis identified gene alterations in 82 (25.1%) of 327 indeterminate nodules (BSRTC III-V). For AUS/FLUS samples, NRAS Q61 (14/194, 7.2%), BRAF V600E (13/194, 6.7%), and HRAS Q61 (12/194, 6.2%) were the predominant mutations. For FN/SFN samples, NRAS Q61 (11/118, 9.3%) was the most frequent mutation, followed by BRAF V600E and HRAS Q61 (5/118 each, 4.2%). BRAF V600E was the most frequent mutation in both SFM (3/15, 20%) and malignant (10/31, 32%) samples, as was BRAF K601E (2/7,  29%) in follicular variant-papillary thyroid cancer. RET/PTC rearrangements were detected in 2 PTC and 1 AUS specimens. PAX8/PPARγ was detected in 1 FLUS and 1 FN/SFN specimen. Interestingly, 4/37 (11%) cytologically benign samples had mutations in NRAS Q61, BRAF V600, and KRASG12. Overall, the presence of mutations in the 7-gene molecular panel was mutually exclusive in all but 2 AUS samples. In 17 cases, multiple specimens from different nodules were submitted from the same patient; in 10 (59%) of these patients, results varied between nodules.

CONCLUSION: In our reference laboratory experience, roughly 25% of indeterminate nodules exhibited gene alterations on molecular analysis. Interestingly, some samples already had a morphologic diagnosis of benign or malignant nodules (74/533; 13.9%); a larger dataset and clinical follow up information would be beneficial to determine the utility of molecular screening of these nodules.

 

Disclosure: SMC: Employee, Quest Diagnostics. CB: Employee, Quest Diagnostics. FMH: Employee, Quest Diagnostics. RGS: Employee, Quest Diagnostics. FP: Employee, Quest Diagnostics. KQ: Employee, Quest Diagnostics. ZJZ: Employee, Quest Diagnostics. ADS: Employee, Quest Diagnostics. RER: Employee, Quest Diagnostics. FMW: Employee, Quest Diagnostics.

16384 39.0000 SUN-0554 A Molecular Testing of Indeterminate Thyroid Nodules: A Reference Laboratory Experience 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Qi Yang*, Meiju Ji, Peng Hou and Bingyin Shi
The First Affiliated Hospital of Xi’an Jiaotong University School of Medicine, Xi'an, China

 

Shikonin is an active naphthoquinone extracted from roots of Chinese herbal Zi Cao. It has been widely used as an antitumor agent in cancers. In our previous study of thyroid cancer, shikonin also showed effective proapoptosis and invasion preventive ability. However, the mechanisms underlying antitumor effects of shikonin is still unclear enough. The aim of this study was to further test the therapeutic potential of shikonin for thyroid cancer and explore the signal regulating modes of shikonin. We observed the effects of shikonin on proliferation, cell cycle, apoptosis, migration, invasion and xenograft tumor growth in thyroid cancer cell lines and the effect of shikonin on proliferation of primary thyroid cancer and normal epithelial cells. Shikonin inhibited thyroid cancer cell proliferation, promoted apoptosis, redistributed the cell cycle, and prevented cell invasion. But normal epithelial cells were not sensitive to shikonin. Moreover, all the antitumor effects of shikonin was through reactive oxygen species (ROS) regulated signaling pathways. Our data showed that shikonin induced ROS markedly repressed the phosphorylation of Erk and Akt, activated the p16/Rb pathway, elevated the amount of p53 in wild type thyroid cancer cells. Further elucidation of the mechanisms involved revealed that extra ROS dramatically inhibited thyroid cancer cell migration and invasion by suppressing epithelial-mesenchymal transition (EMT) and downregulating expression of Slug, MMP-2, -9 and -14. Growth of xenograft tumors derived from thyroid cancer cell line FTC133 in nude mice was significantly inhibited by shikonin. Importantly, we did not find the effect of shikonin on liver function in mice. We for the first time demonstrated that shikonin is a potentially effective antitumor agent for thyroid cancers.

 

Nothing to Disclose: QY, MJ, PH, BS

13567 40.0000 SUN-0555 A Antitumor Effects of Shikonin, a Chinese Herbal Extract, Are through Reactive Oxygen Species Regulated Signaling Pathways 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Sapna Nagar*1, Nicole A. Cipriani1, Sharone P. Kaplan1, Peter Angelos2, Edwin Kaplan3 and Raymon H Grogan3
1University of Chicago, Pritzker School of Medicine, Chicago, IL, 2Univ of Chicago, Chicago, IL, 3University of Chicago Medicine, Chicago, IL

 

Introduction

In 1995 we published a retrospective study of 49 patients with follicular thyroid carcinoma (FTC) or Hurthle cell carcinoma (HCC) diagnosed and treated at our academic tertiary care institution and followed for a mean of 10.7 years. Mortality from cancer was 16% and all deaths occurred within 13 years. Long-term follow-up studies on these cancers are lacking. The purpose of the present study was to extend the follow-up of these patients to determine long-term recurrence and survival.

Methods

Eighty-two patients diagnosed with FTC and HCC between 1965 and 1997 (including the 49 previously reported) were identified. Data on demographics, pathologic diagnosis, recurrence, and survival were collected. In addition, all available pathology slides were reviewed to confirm the diagnosis of FTC or HCC. Recurrence and survival data were computed using the Kaplan-Meier method.

Results

Of 82 patients diagnosed with FTC or HCC on routine postoperative pathology, repeat analyses of histology were possible in 53 (65%) patients. Upon histologic review, only 14 (26%) patients were confirmed to have FTC and 4 (8%) had HCC. Twenty-three patients (43%) were reclassified as papillary thyroid cancer (PTC) and 12 (23%) were benign adenomas. Eighty-six percent (30 of 35) of these reclassified cases were diagnosed prior to 1990. None of the reclassified PTC patients died of disease, and none of the benign patients demonstrated metastatic disease or died of disease. Mean follow-up of patients with confirmed FTC and HCC was 20.8 years. Recurrence of disease occurred in 22%, death from FTC or HCC was 29% and overall death was 61% at 48 years. All deaths from cancer occurred within 16 years of tumor diagnosis.

Conclusion

Upon review of our cohort, 66% of FTC or HCC cases were reclassified as either benign adenomas or PTC using modern pathology definitions.  After reclassification, FTC and HCC diagnosed decades ago were found to be more aggressive than previously reported. These data suggest that caution should be exercised when evaluating FTC and HCC in large retrospective databases, for they may be “contaminated” by alternate diagnoses as well.

 

Nothing to Disclose: SN, NAC, SPK, PA, EK, RHG

16387 41.0000 SUN-0556 A Follicular Thyroid Cancer in Long-Term Retrospective Studies: A Need for Caution 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Maija Mukane*1, Ingvars Rasa2 and Maksims Mukans3
1Riga East Clinical University Hospital; Riga Stradins University; Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia, 2Riga East Clinical University Hospital, Riga Stradins University, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia, 3Riga Stradins University, Riga East Clinical University Hospital, Riga, Latvia

 

Background: Thyroid nodules are a common disorder affecting 500 to 600 million people worldwide, and often are the source of diagnostic and management dilemmas. Qualitative evaluation of multinodular goiter is necessary because 5 to 10% of nodules are malignant. The aim of the study was to compare pre- and postoperative diagnoses in biggest hospital, in Latvia. Materials and methods: Retrospective study of patients' (pts) medical records who had thyroid nodules with different etiology and admitted to Riga East Clinical University Hospital in 2 year period (2009 Jan–2010 Dec). All pts included in the study underwent surgery and had histological examination of operation material. Comparison between pre- and postoperative diagnoses was made using SPSS 20. Results: A total of 454 pts medical records were analysed, mainly females (87.4%). There was no age difference between genders (p=0.447), and median age in the study population was 54 (interquartile range 64–43) yrs. Preoperatively diagnosed benign nodular goiter (87.4%, n=380) was proved histologically with high accuracy (85.2%, n=324), but in the rest of the cases it was autoimmune thyroiditis (6.8%, n=26), missed thyroid cancer (4.7%, n=18, mostly papillary carcinoma n=14, follicular carcinoma n=3, medullar carcinoma n=1), thyrotoxic follicular adenoma (3.2%, n=12). Pts with suspected thyroid cancer (4.2% of all pts, n=19) in majority underwent total thyroidectomy (n=11), but in the rest of the cases subtotal thyroidectomy (n=3), hemithyroidectomy (n=4) and partial resection of lobe (n=1). Only in half of the cases (52.6%, n=10, mostly papillary carcinoma n=7, follicular carcinoma n=1, medullar carcinoma n=2) thyroid cancer diagnosis pre- and postoperatively concurred. In 6 cases, surgeon made the decision re-operate because of histologically proved thyroid cancer, and in 3 cases it was validate (histologically proved papillary carcinoma). Conclusion: Coincidence of pre- and postoperative diagnosis was high in benign nodules but inadequate in malignant nodules in the study population. It is important to confirm thyroid nodule etiology before surgery, what helps to make right decisions about the extent of operation and avoid re-operations.

 

Nothing to Disclose: MM, IR, MM

12974 42.0000 SUN-0557 A Quality of Thyroid Nodule Preoperative Care: Data from Latvia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Maria Chiara Zatelli*1, Daniela Molè2, Raul M. Luque3, Erica Gentilin4, Teresa Gagliano4, Federico Tagliati5, Alejandro Ibanez Costa6, Roberta Rossi2, Mariarosa Pelizzo7, Giancarlo Pansini4, Ettore Ciro degli Uberti2 and Justo P Castano3
1Section of Endocrinology, University of Ferrara, FERRARA, Italy, 2Section of Endocrinology, University of Ferrara, Ferrara, Italy, 3Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofia, CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn) and ceiA3, Córdoba, Spain, 4University of Ferrara, Ferrara, Italy, 5Section of University of Ferrara, Ferrara, Italy, 6Section of Cell Biology, University of Cordoba, Cordoba, Spain, 7Univ of Padova, Italy

 

The truncated somatostatin receptor subtype 5 receptor variant (sst5TMD4) characterizes more invasive and aggressive forms of breast cancer and has shown a dominant negative action towards sst2 agonists. We previously found that sst5 counteracts sst2 selective agonists in a Medullary Thyroid Carcinoma (MTC) cell line, the TT cells. We here investigate sst5TMD4 expression in human MTCs and the effects of its over-expression in TT cells. In our hands, sst5TMD4 expression correlates with disease stage, is higher in MTC metastases vs. primary tumors and in sporadic vs. familial cases. Overexpression of sst5TMD4 in TT cells enhances cell proliferation, antagonises sst2-induced antiproliferative effects, confers an enhanced invasiveness and induces epithelial to mesenchymal transition (mirrored by decreased E-cadherin and phosphorylated b-catenin levels, as well as by increased vimentin, total b-catenin and phosphorylated GSK3B levels). Therefore, sst5TMD4 expression in human MTC correlates with disease stage and invasive behaviour. Its over-expression in TT cells confers a greater aggressiveness, suggesting that sst5TMD4 may represent a negative prognostic marker in MTC. Moreover, our data are in line with a dominant negative activity of sst5TMD4 towards sst2.

 

Nothing to Disclose: MCZ, DM, RML, EG, TG, FT, AI, RR, MP, GP, ECD, JPC

15853 43.0000 SUN-0558 A The Truncated Somatostatin Receptor Variant sst5TMD4 Influences Medullary Thyroid Carcinomas Aggressivity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Deva Boone*1, Edward Wang1, Alexandra E Reiher2, David J Winchester1, Richard A Prinz1 and Tricia A Moo-Young2
1NorthShore University HealthSystem, Evanston, IL, 2NorthShore University Health System, Evanston, IL

 

Background: Anaplastic thyroid cancer is associated with very poor prognoses. Surgical resection has been shown to improve survival, but less than half of newly diagnosed patients undergo an operation. In this study we identify those factors associated with undergoing surgical intervention.

Methods:  The National Cancer Database (NCDB) was queried from 1998 to 2011, identifying 3185 patients with anaplastic thyroid cancer. Clinicopathologic, demographic, and socioeconomic variables were analyzed to determine their relationship to surgical intervention.

Results: The mean age was 70, and 60% of patients were female. Forty-nine percent received surgical intervention; 62.7% interventions were subtotal or total thyroidectomies. Patients who received an operation were younger (69±12 years vs. 72±12, p<0.001) and had smaller tumors (60±30mm vs. 68±38, p=0.001). Demographic factors including patient income, ethnicity, race, education level, and urban vs. rural location did not affect likelihood of operation.  The presence of comorbidities (Charlson/Deyo score) and positive lymph nodes also did not affect operation rates, but distant metastatic disease was associated with fewer surgical interventions (35% vs. 59%, p<0.001). Those receiving operations were more likely to have health insurance (97% vs. 95%, p=0.005).  Private insurance was associated with higher rates of surgical intervention: 55.9% of patients with private insurance received an operation, compared to 44.5% of patients with Medicaid and 47.5% of patients with Medicare (p<0.001).

Conclusions:  Fewer than half the patients presenting with anaplastic carcinoma underwent surgical intervention.  Younger patients, those with smaller tumors, and those without distant disease were more likely to undergo surgical intervention.  Socioeconomic factors, except for health insurance status, were not predictive of surgery.

 

Nothing to Disclose: DB, EW, AER, DJW, RAP, TAM

16241 44.0000 SUN-0559 A Factors Influencing Surgical Intervention for Anaplastic Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Roy Lirov*1, Michael Howard Roh2, Megan R Haymart2, Mark S Cohen2, Paul G. Gauger3 and Barbra Miller4
1University of Michigan Health System, Ann Arbor, MI, 2University of Michigan, Ann Arbor, MI, 3University of Michigan Health Systems, Ann Arbor, MI, 4University of Michigan, Ann Arbor

 

Background

The predictive value of malignancy within a thyroid nodule classified as atypia of undetermined significance/follicular lesion of undetermined significance (FLUS) is estimated to be 5-15%.  Gene expression classifier (GEC) analysis can be informative but has limitations.  We hypothesize that ultrasound (US) characteristics of cytologically indeterminate nodules can add value to the decision making process and reduce unnecessary operations.

Methods

Retrospective review of FLUS cases with US imaging evaluated between July 2009 and November 2013. US characteristics using strict criteria for overall appearance (benign or indeterminate) of each FLUS nodule were reviewed by a single blinded reviewer with extensive US experience and compared with final histopathologic diagnosis.  Site of malignancy (within FLUS nodule or elsewhere) was recorded.  GEC results, when available, were compared with final pathology and US characteristics. Descriptive methods of analysis are used.

Results

237 patients with FLUS diagnoses were identified by review of pathology and thyroid surgery databases.  64 patients (9 males) had complete data and images available for review.  Median age was 54 years (range 15-80).  54 underwent surgery. Median nodule size was 2.45cm (range 0.5-5cm).  38 (70%) had benign disease on final pathology.  4/54 (7%) FLUS nodules were malignant, having a median size of 2.9cm (range 2.4-3.2cm).  The remaining 12 cancers were microcarcinomas unrelated to the FLUS nodule.  1/20 (5%) of the FLUS nodules categorized by US as benign was malignant on final pathology.    Mild to moderate vascularity was the only identifiable feature that may have suggested malignancy. 3/34 (8.8%) FLUS nodules categorized by US as indeterminate were malignant. GEC was used in 24 additional cases with 11 categorized as suspicious.  Of 5 undergoing surgery, 3 had benign US findings and all had benign final pathology. 

Conclusion

Careful observation of FLUS nodules with benign characteristics is reasonable in those without other reasons for operation.  Limiting the use of GEC analysis to FLUS lesions with indeterminate US characteristics may optimize use of resources. The incidence of malignancy found outside the FLUS nodule, albeit only microcarcinomas in this series, can be substantial and could influence management.

 

Nothing to Disclose: RL, MHR, MRH, MSC, PGG, BM

16712 45.0000 SUN-0560 A Ultrasound Characteristics As a Factor in Determining Utility of Surgery for Patients with Thyroid Nodules Classified As “Follicular Lesions of Undetermined Significance” on Cytology 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

A Wayne Meikle*1, Mark M Kushnir2 and Alan L Rockwood3
1Univ of UT Med Sch, Salt Lake City, UT, 2ARUP Laboratories, Salt Lake City, UT, 3University of Utah, Salt Lake City, UT

 

Background: Measurement of thyroglobulin (Tg) in serum and plasma is used to monitor patients after treatment for differentiated thyroid carcinoma (DTC). Difficulty in using Tg as a biomarker of the recurrence of DTC is related to the presence in many patients of endogenous anti-Tg autoantibodies (Tg-AAb), which can interfere with immunoassay (IA) measurements and cause false-negative results. To date there were no comparative studies supporting better utility of the LC-MS/MS methods for measurement of Tg in Tg-AAb positive samples, as compared to commercial immunoassays.

Methods: Recently we developed LC-MS/MS method for measurement of Tg in serum and plasma samples (Clin Chem 2013 59:982–990). The lower limit of quantification is 0.5 ng/mL (0.76 fmol/mL); total imprecision of triplicate measurements in serum samples over five days below 10%. Comparison with a commercial IA using serum samples free of Tg-AAb (n=73) showed Deming regression equation IA= 1.00*LC-MS/MS-2.35, r=0.982, Sy,x=9.52. In a set of Tg-AAb positive samples that tested negative for Tg using IA (n=71), concentrations determined by LC-MS/MS method were at or above 0.5 ng/mL in 23% of samples (median 1.2, range 0.7-11 ng/mL).  Tg concentrations determined with commercial IA agreed well with LC-MS/MS for Tg-AAb negative samples, but underestimated Tg concentrations in Tg-AAb positive samples. We reviewed data of analysis of Tg in Tg-AAb positive samples using Beckman AccessTM IA (n =1367) and LC-MS/MS (n = 6180) methods and compared distributions of concentration and Tg positivity rate for the assays.

Results: Both assays used the same calibration standards. Mean Tg concentrations at ranges of 0.5-1, 0.5-2, 0.5-5 ng/mL were 0.70, 1.00 and 1.86 ng/mL for the IA; and 0.76, 1.19 and 2.06 ng/mL for the LC-MS/MS. Higher positivity rate was observed in the results of analysis by the LC-MS/MS method as compared to the IA. Differences in the positivity rate between LC-MS/MS and IA at concentrations >0.5, >1.0 and >2.0 ng/mL were 5.4%, 6.9% and 6.3%. 

Conclusions: In agreement with our earlier data (Clin Chem 2013 59:982–990), IA was shown to underestimate Tg concentrations in Tg-AAb positive samples, especially at Tg concentrations below 2 ng/mL (determined with LC-MS/MS). The underestimation of the concentrations is likely caused by interference of Tg-AAb with the IA.

 

Nothing to Disclose: AWM, MMK, ALR

16914 46.0000 SUN-0561 A Observational Study of Data on Analysis of Thyroglobulin in Autoantibody Positive Samples Using Commercial Immunoassay and LC-MS/MS Method 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Teresa Martins*, Teresa Azevedo, Jacinta Santos, Nuno Cunha, Frederico Valido, Olga Ilhéu and Fernando Rodrigues
Oncology Institute of Coimbra, Coimbra, Portugal

 

Lymph node metastasis are frequent in medullary thyroid cancer. Fine-needle aspiration cytology is occasionally non-diagnostic, but calcitonin measurement in fine–needle washout may provide an important contribution for the diagnosis. However, the available studies on this topic are sparse, unlike those based on the well-established method of thyroglobulin measurement in fine needle washout.

We report our experience at identifying lymph node MTC metastasis using calcitonin measurement in specimens obtained by ultrasound guided fine-needle aspiration biopsy (FNAB) of suspicious cervical lymph nodes.

Seventeen patients with ages ranging from 39 to 91 years with MTC diagnosis or suspicion of the disease were submitted to FNAB of suspicious cervical lymph nodes and subsequent CT washout measurement. We performed 37 FNAB with CT washout measurement using the IMMULITE 2000 immunoassay, and considered as positive CT values greater than 10 pg/ml.

CT values were positive in 19 of the 37 FNAB’s performed, with values ranging from 28 to 201396 pg/ml, and was negative in the remainders. From the 19 positive results, cytological samples were non-diagnostic in 8 patients, CMT metastasis in 9 cases, and benign in 2. From the 8 patients with non-diagnostic cytology, 4 had the presence of metastasis confirmed by histological study. In the remainders, surgery was not performed due to advanced age, disseminated disease, and multiple surgeries. From the 9 patients with CMT metastasis, the histological studies revealed the presence of disease in 9. From the 2 patients with benign cytology, 1 is under surveillance and the other was operated and MTC metastasis were confirmed.

From the 18 patients with negative CT washout, 6 had non-diagnostic cytology, 10 benign cytology, 1 parotid gland, and the other was a submaxillary gland. In spite of the absence of histological confirmation in all cases, no false positive or negative results were detected. Sensibility was of 100% in the patients with positive histological study.

In this study, we demonstrated that FNAB CT washout may be regarded as a complementary approach to the conventional cytological study, aiming at obtaining an accurate diagnosis of suspicious lymph nodes in MTC, especially when serum calcitonin and FNAB cytology cannot reach a definitive diagnosis.

 

Nothing to Disclose: TM, TA, JS, NC, FV, OI, FR

14112 47.0000 SUN-0562 A Calcitonin Measurement on Fine Needle Washout of Neck Lymph Node Metastasis in Patients with Medullary Thyroid Cancer: Our Experience 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Veronica Ilera*, Silvina Roxana Pozniak, Maria Valeria Premrou and Laura Elena Maffei
Centro Médico Dra Laura Maffei, Buenos Aires, Argentina

 

Background: In pregnancy, many factors have a stimulatory effect on thyroid growth. Pregnancy may stimulate thyroid cancer cell growth leading to cancer recurrence or progression.

Objective: To study pregnancy impact on outcome of patients previously treated for differentiated thyroid cancer (DTC).

Methods: retrospective descriptive study. Inclusion criteria: women of childbearing age followed at a private endocrinology center, who gave birth after complete thyroid-cancer treatment and had ≥1 year follow up after delivery. We evaluated type of treatment, AJCC-TNM staging and ATA risk of recurrence classification. Outcome evaluation was performed before pregnancy, 1 year after delivery and at the end of follow up. They were categorized as: no evidence of disease (NED): TSH-stimulated thyroglobulin (Tg) <2 ng/ml, Tg on L-thyroxine (LT4) <1 ng/ml and negative neck ultrasound; biochemical evidence of disease (BED): TSH-stimulated Tg ≥2 ng/ml and/or under LT4 ≥1 ng/ml and negative imaging studies; structural evidence of disease (SED): TSH-stimulated Tg ≥2 ng/ml and/or under LT4 ≥1 ng/ml and positive imaging studies. If anti-Tg antibodies present, imaging studies and antibody titers were considered.

Results: 142 patients with DTC evaluated between years 2000-2012, 6 met inclusion criteria. Mean age at surgery: 28,3 years. 6/6 had total thyroidectomy, 2/6 required central neck dissection. Histology was papillary in 5/6 and follicular carcinoma in 1/6. All were TNM stage I; 5/6 were ATA low risk and 1 intermediate risk. All underwent radioactive iodine (RAI) ablation, mean dose 120 mCi. 2/6 required additional RAI treatment, none were reoperated. The mean interval from diagnosis to pregnancy was 74 months. At time of conception 6/6 had NED. All gave birth at term, mean age 33,8 years. No pregnancy or postpartum complications were observed. 7/7 newborn had appropriate weight and no congenital malformations. One year after delivery, 6/6 patients were NED. One gave birth twice, and was considered NED after each pregnancy. No patient required new surgery or RAI treatment after delivery, with a mean follow up of 36 months. 0/6 were considered BED or SED at final evaluation.

Conclusions: In this cohort, pregnancy did not have a negative impact on outcome of DTC. According to the literature, in women previously treated for DTC with no structural or biochemical evidence of persistence disease at conception, pregnancy does not seem to cause thyroid cancer recurrence.

 

 

Nothing to Disclose: VI, SRP, MVP, LEM

16104 48.0000 SUN-0563 A Pregnancy Impact on Outcome of Differentiated Thyroid Cancer: A Descriptive Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Borami Kang*1, Kwanhoon Jo1, Min Hee Kim1, Dong Jun Lim1, Si Luo2, Sun Hee Ko1, So-Lyung Jung1 and Yongmin Kim3
1Seoul St. Mary’s Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea, Republic of (South), 2University of Washington, Seattle, WA, 3Pohang University of Science and Technology Pohang, Pohang, Korea, Republic of (South)

 

When calcifications, frequently found in both benign and malignant nodule, are present in thyroid nodules, the noninvasive differentiation with ultrasound (US) becomes challenging. This study is to evaluate the utility of elastography in differentiating calcified thyroid nodules. Consecutive fine needle aspiration (FNA) referral patients (165 patients with 196 nodules) who had both US elastography and B-mode examinations were analyzed retrospectively. Among them, 45 benign and 20 malignant nodules had calcifications. On 65 calcified nodules, elastography showed 95%, 51.1%, 46.3% and 95.8% of sensitivity, specificity, positive predictive value, and negative predictive value of detecting malignancy, respectively. With elastography, 23 out of 45 benign calcified nodules were correctly diagnosed compared to 4 out of 45 using US B-mode. While it is difficult to differentiate benign and malignant calcified thyroid nodules solely with US B-mode, elastography shows the potential of reducing the number of FNA biopsies performed on calcified nodules.

 

Nothing to Disclose: BK, KJ, MHK, DJL, SL, SHK, SLJ, YK

14656 49.0000 SUN-0564 A Elastography Can Effectively Decrease the Number of Fine Needle Aspiration Biopsies on Patients with Calcified Thyroid Nodules 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Francesco Latrofa*1, Debora Ricci2, Eleonora Sisti1, Lucia Montanelli1, Paolo Piaggi3, Teresa Rago1, Emilio Fiore1, Michele Marino2 and Paolo Vitti2
1University of Pisa, Italy, 2University Hospital, Pisa, Italy, 3Phoenix Epidemiology and Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, AZ

 

Context. Serum thyroglobulin autoantibodies (TgAb) induce an underestimation of the values of thyroglobulin (Tg), the marker of differentiated thyroid carcinoma (DTC), when assessed by immunometric assays (IMA). The level of TgAb that interferes with Tg measurement is unsettled.  

Design. Sera were obtained from 177 patients with papillary thyroid carcinoma after total thyroidectomy, before thyroid remnant ablation (off L-T4), when Tg is supposedly detectable. Tg was measured by an IMA (functional sensitivity 0.1 ng/ml), TgAb by three IMAs and three radioimmunoassays (RIA)s [functional sensitivities and positive cut-offs: 8.0-30 IU/ml (IMA1), 20-40 (IMA2), 1.2-4 (IMA3), 96-150 (RIA1), 40-60 (RIA2), 49-70 (RIA3)]. TgAb levels that best correlated with undetectable Tg values in the 177 patients were calculated by ROC curve analysis. The recovery of Tg was calculated by incubating the sera of 67 patients with borderline or positive TgAb (by IMA1) with 4 sera with high levels of Tg, diluted to final Tg concentrations between 0.1 and 300 ng/ml. The samples of Tg1, Tg2, Tg3 and Tg4 were incubated with the sera of 5, 24, 21 and 17 patients, respectively. The number of detectable Tg and TgAb levels were compared by the χ2 test. Tg concentrations were compared by Kruskal-Wallis test.

Results. Tg values were correlated with the results of TgAb (undetectable, borderline or positive) by the six assays. Tg was detectable in 128 and undetectable in 49 patients. In the group of patients with detectable Tg, TgAb were undetectable in 60.9-92.2%, borderline in 0-30.5% and positive in 7.0-9.4% of subjects (p<0.001). Among patients with undetectable Tg, TgAb were undetectable in 14.3-61.2%, borderline in 8.2-24.5% and positive in 30.6-63.3% of subjects (p<0.001). Tg values were higher in subjects with undetectable TgAb (from 7.0-19.1 to 10.9-21.4 ng/ml) then in those with borderline TgAb (from 0.0-0.0 to 5.3-14.2 ng/ml) and positive TgAb (from 0.0-0.0 to 0.0-0.8 ng/ml) (p<0.001). An undetectable Tg value correlated with the following TgAb cutoff levels: >9.3 IU/ml (IMA1), >41.0 (IMA2), >1.3 (IMA3), >52.0 (RIA1), >0.0 (RIA2) and >0.0 (RIA 3) (p<0.001 for all). TgAb interfered significantly with Tg recovery (Spearman correlations from -0.47 to -0.69) (p<0.001). The interference (underestimation in most samples) was more common for lower Tg concentration (in 62/67 samples of Tg 0.1 and 0.33 ng/ml). Positive, but not borderline TgAb levels interfered significantly with Tg recovery. An underestimation of Tg values was always observed in presence of TgAb ≥100 and in most cases of TgAb <100, an underestimation of Tg values in few cases with TgAb <100. The recovery of Tg1-4 was similar.

Conclusions. Borderline TgAb levels interfere with Tg measurement but to a lesser degree than positive TgAb levels. The interference is higher for low Tg concentrations and high TgAb levels.

 

Nothing to Disclose: FL, DR, ES, LM, PP, TR, EF, MM, PV

13410 50.0000 SUN-0565 A Evaluation of the Level of Thyroglobulin Autoantibodies Interfering with Thyroglobulin Measurement in Patients with Differentiated Thyroid Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Yejee Lim*1, Min Hee Kim2, Kyunghee Kim3, Kwanhoon Jo2, Ihn-Suk Lee4, Ja-Seong Bae5, Dong Jun Lim6, Ki-Hyun Baek7, Jong-Min Lee4, Moo-Il Kang6 and Bong-Yun Cha2
1The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea, Republic of (South), 2Seoul St. Mary’s Hospital, The Catholic University of Korea, College of Medicine, Seoul, Korea, Republic of (South), 3Division of Endocrinology & Metabolism, 4The Catholic University of Korea, 5The Catholic University of Korea, Seoul St. Mary’s Hospital, 6Seoul St Mary's Hosp/Cath U, Seoul, Korea, Republic of (South), 7Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeouido St. Mary’s Hospital, Seoul, Korea, Seoul, Korea, Republic of (South)

 

The measurement of stimulated thyroglobulin (Tg) after total thyroidectomy and remnant radioactive iodine (RAI) ablation is the gold standard for monitoring disease status in patients with papillary thyroid carcinomas (PTCs). However, the measurement of stimulated Tg (sTg) levels via thyroid hormone withdrawal or the use of recombinant human thyroid-stimulating hormone (rhTSH) can cause patient discomfort and represents a significant cost. The aim of this study was to determine whether sTg measurement during follow-up can be avoided in intermediate- and high-risk PTC patients.

A total of 346 patients with PTCs with an intermediate or high risk of recurrence were analysed. All of the patients underwent total thyroidectomy performed by the same surgeon as well as remnant RAI ablation. The patients were followed with sTg measurements with or without whole-body scans after initial treatment. Preoperative and postoperative parameters were included in the analysis.

Among the preoperative parameters, age below 45 years and preoperative Tg above 19.4 ng/ml were significant risk factors for predicting detectable sTg during follow-up. Among the postoperative parameters, thyroid capsular invasion, lymph node metastasis, and ablative Tg above 2.9 ng/ml were independently correlated with a detectable sTg range (OR: 4.293, 7.496, and 18.433, respectively). The combination of ablative Tg less than 2.9 ng/ml with pre- and postoperative independent risk factors for detectable sTg increased the negative predictive value for detectable sTg up to 98.5%.

Based on pre- and postoperative parameters, a substantial proportion of patients with PTCs in the intermediate- and high-risk classes could avoid aggressive follow-up measures.

 

Nothing to Disclose: YL, MHK, KK, KJ, ISL, JSB, DJL, KHB, JML, MIK, BYC

14303 51.0000 SUN-0566 A Identification of Intermediate- to High-Risk Papillary Thyroid Carcinoma Patients Who May Benefit from Stimulated Thyroglobulin Measurements after Radioactive Iodine Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Hye Jeong Kim*1, Hyeong Kyu Park1, Dongwon Byun1, Kyo-Il Suh1, Myung Hi Yoo1, Sun Wook Kim2 and Jae Hoon Chung2
1Soonchunhyang University Hospital, Seoul, Korea, Republic of (South), 2Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, Republic of (South)

 

Objective Multifocality is associated with aggressive pathologic features and an increased risk of poor outcomes in papillary thyroid carcinoma (PTC). If multifocality represents the burden of tumours, multifocal tumours may be characterised by different behaviours according to the number of tumour foci. Here we investigated the clinicopathologic characteristics of patients with PTC according to the number of tumour foci.

Patients and Methods A retrospective analysis of 2,095 patients with PTC was performed. The study population was divided into four groups according to the number of tumour foci: N1 (one tumour focus), N2 (two foci), N3 (three foci), and N4 (four or more foci). Logistic regression models were used to assess the relationships between the number of tumour foci and pathologic features of PTC.

Results Patients with solitary tumour (n=1,423; 68%) were classified into the N1 group. Patients with multifocal tumours were classified into the N2 (n=463; 22%), N3 (n=140; 7%), or N4 (n=69; 3%) groups. An increasing number of tumour foci was significantly associated with more aggressive features, such as older age at diagnosis (p=0.006), cervical lymph node metastasis (p<0.001), and advanced TNM stage of disease (p=0.001) at initial surgery. There was a significant dose-dependent relationship between the number of tumour foci and the frequency of ≥5 metastatic nodes in the lateral neck (p for trend<0.001). The multivariate-adjusted ORs (95% CI) for the N2, N3, and N4 groups compared to the N1 group for lateral lymph node metastasis were 1.53 (1.05-2.22), 2.57 (1.50-4.42), and 2.88 (1.42-5.84), respectively. There were no significant differences in gender, primary tumour size, or distant metastasis among the four studied groups.

Conclusions An increase in the number of tumour foci was strongly associated with older age at diagnosis, cervical lymph node metastasis, and advanced TNM stage of PTC. The number of tumour foci independently predicted lateral lymph node metastasis.

 

Nothing to Disclose: HJK, HKP, DB, KIS, MHY, SWK, JHC

14431 52.0000 SUN-0567 A Number of Tumor Foci Predicts Lateral Lymph Node Metastasis in Papillary Thyroid Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Rudruidee Karnchanasorn*, Kristine Grdinovac, Nicole Renee Downing, Bhairvi Jani and Guoqing John Chen
The University of Kansas Medical Center, Kansas City, KS

 

Background: Thyroid nodules are very common with an estimated prevalence of 3-7% by palpation and a 20%-76% detection rate by ultrasonography. Fine-needle aspiration (FNA) biopsy is the standard of care for work-up of thyroid nodules. The American Thyroid Association (ATA) suggested that serum TSH should be assessed prior to FNA. If the serum TSH is suppressed, a radionuclide thyroid scan (I scan) should be obtained. FNA is not necessary in hyperfunctioning nodule due to very low risks of malignancy. Few studies reported how patients with thyroid nodules are managed according to the clinical guidelines. The objective of this study was to examine use of  TSH and I scan exams  prior to FNA.
Methods: This was a retrospective chart review study. There were 833 ultrasound-guided FNA (UGFNA) cases performed at a Midwest academic medical center from January 2010 to January 2012. We randomly selected 200 patients among the 833 cases. The clinical measures were selected according to the ATA guideline, including TSH values, radioactive iodide scan, and other measures.
Results: Of the 200 patients, many with multiple thyroid nodules, 273 USFNAs were performed. The majority of patients were female (82%), of Caucasian race (71%), and had no significant co-morbidities. TSH was documented in 75%. TSH values range from 0.02 to 73.19. TSH values < 0.35 mg/dl were considered suppressed.  21 patients had suppressed TSH, while 181 had normal TSH, and 3 had TSH greater than 5.00 mg/dl. There were 22  patients who had I scan. Hyperfunctioning nodules were found in 4 cases.  6 cases had nonfunctioning nodules and  12 cases had isofunctioning nodules. Of the 21 patients with suppressed TSH, only 10 (47.62%) patients had I scan, while, 12 patients underwent I scan had normal TSH. Among 22 patients with I scan, 16 had benign cytology, and 6 were found to have indeterminate cytology. All 4 patients with hyperfunctioning nodules had benign cytology.
Discussion: According to ATA guideline, TSH should be checked to screen for hyperfunctioning nodules that wouldn’t require FNA due to very low risks of malignancy. Our data showed that 25% of patients didn’t have TSH values prior to FNA. Among those with low TSH, 11 (52.38%)  didn’t receive I scan. Some patients with normal TSH had unnecessary I scan. FNA were performed in 4 patients with functioning nodules which could have been avoid if the guidelines were followed.
Conclusion: It appears there is a gap between current patient care and clinical practice guidelines recommended care for management of thyroid nodules, which could reflect physicians’ unfamiliarity with clinical practice guidelines. As thyroid nodules are extremely common, improvement of knowledge of the current guidelines could be highly beneficial. Further studies are needed to examine for factors associated with the rate of compliance with clinical guidelines in management of thyroid nodules.

 

Nothing to Disclose: RK, KG, NRD, BJ, GJC

13279 53.0000 SUN-0568 A TSH Assessment Prior to Fine Needle Aspiration Biopsy of Thyroid 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Jee Hee Yoon*1, Hee Kyung Kim2, Soo Jeong Kim1 and Ho-Cheol Kang1
1Chonnam National University Medical School, Gwangju, Korea, Republic of (South), 2Chonnam National University College of Medicine, Gwangju, Korea, Republic of (South)

 

BACKGROUD: Follicular-variant papillary thyroid cancer (FV-PTC) is the most common variant type of papillary thyroid cancer. Considering that low frequency of BRAF mutation and more benign clinical course, FV-PTC is one of non-aggressive PTC. The aim of our study is to compare classic PTC and FVPTC and to find the relationship between ultrasonographic findings and clinical behavior in patients with FVPTC.

METHODS: One hundred thirty one patients with FVPTC and 131 patients with classic PTC who are age and sex matched between 2004 and 2012 were reviewed retrospectively. Clinical, histopathological, and ultrasonographic features were compared.

RESULTS: Pre-operative thyroglobulin (Tg) was higher (p=0.033) and mean tumor size was larger (p=0.002) in FVPTC group. Tumor multiplicity, malignancy detection rate by fine needle aspiration (FNA), and recurrence rate were significantly higher in classic PTC group (P=0.003, <0.01 and 0.036). In ultrasonographic findings, FVPTCs had lower rate of hypoechogenicity (P=0.019), irregular margin (<0.01) and microcalcifications (p=0.001). The patients with FVPTC reported as follicular neoplasm by FNA had larger size (P <0.01), more benign ultrasonographic features including isoechogenicity, the presence of halo, and smooth margin than patients with FVPTC diagnosed as PTC by pre-operative FNA (P= 0.053, 0.023, 0.006) and low tendency of remission due to distant metastasis (P=0.051) .

CONCLUSIONS: FVPTC show more benign ultrasonographic findings and good clinical outcome than classic PTC even though the size of tumor is larger. Subgroup of FVPTC reported as follicular neoplasm pre-operatively has similar ultrasonographic and clinical characteristics to follicular carcinoma, so more careful work up to find distant metastasis is needed. The cytological result by FNA and ultrasonographic findings could help to predict clinical and pathological characteristics of FVPTC.

 

Nothing to Disclose: JHY, HKK, SJK, HCK

15706 54.0000 SUN-0569 A Ultrasonography Only May be Misleading in Follicular-Variant of Papillary Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Kyong Yeun Jung*1, Ye An Kim1, Eu Jeong Ku1, Jae Hoon Moon1, Kyung Won Kim2, Ka Hee Yi3, Do Joon Park1, Seong Yeon Kim1, Seok-Mo Kim4, Hang-Seok Chang4 and Young Joo Park1
1Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 2Seoul National Univ Hosp, Seoul, Korea, Republic of (South), 3Seoul National University College of Medicine, 4Yonsei University College of Medicine, Seoul, Korea, Republic of (South)

 

Background: Medullary thyroid carcinoma (MTC) is known to be 3-4% of thyroid neoplasm. Recently, the genetic screening for germline mutation in the RET gene has been extensively used for the diagnostic screening of hereditary MTC patients and their relatives. There was a relative paucity of study with regard the genetic and clinical feature of MTC in Korea. Here, we present a genetic, clinicopathologic feature and prognosis of MTC.

Methods: We retrospectively reviewed the data of 331 MTC patients who were followed from 1982 to 2013 in Seoul National University Hospital and Yonsei University Hospital. We analyzed clinicopathologic feature and RET mutation type, and prognosis. The patients with positive RET mutation were divided into index and non-index case. We defined the non-index case as the MTC patients who were early detected by familial screening or whose age was in under 20.

Results: The mean age at diagnosis was 47.3 years and 63% were female, with the median follow-up duration was 57.2 months (10-226 months). Distant metastasis at the time of diagnosis was found in 8.1% of the patients. The 5-year overall survival rate was 93% and the 5-year disease free survival rate was 88%. The poor prognostic factors for survival was tumor size >2cm (hazards ratio [HR], 7.097), distant metastasis (HR 5.479), age >40years (HR3.916) and male (HR 2.554) by multivariate analysis. Of 172 MTC patients who were screened for RET gene test, the RET mutations were confirmed in 45 index cases and then identified in 12 non-index cases (36 families). The most common codon of mutation was the codon 634 (n=13) and then 918 (n=5), 618 (n=4) and 804 (n=4). In the non-index cases, the tumor size was smaller (1.1 ± 1.2cm vs 2.0 ± 1.5cm) and the proportion of biochemical remission was higher compared to the index case (75.0% vs 48.9%).

Conclusion: A better knowledgement of clinicopathologic feature of MTC and the screening of RET mutation for hereditary MTC has led to earlier diagnosis and excellent prognosis for MTC.

 

Nothing to Disclose: KYJ, YAK, EJK, JHM, KWK, KHY, DJP, SYK, SMK, HSC, YJP

15565 55.0000 SUN-0570 A Genetic and Clinicopathologic Feature of Medullary Thyroid Cancer in Korea 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Jun Hwa Hong1, Jung Uee Lee2, Min Hee Lee3, Minho Shong4 and Young Suk Jo*5
1Chungnam National University School of Medicine, Daejeon, Korea, Republic of (South), 2Daejeon St. Mary's Hospital, The Catholic University of Korea, Daejeon, Korea, Republic of (South), 3Chungnam National University School of Medicine, 4Chungnam National University Hospital, Daejeon, Korea, Republic of (South), 5Yonsei University College of Medicine, Seoul, Korea, Republic of (South)

 

The oncocytic variant of papillary thyroid cancer (PTCov) is relatively uncommon but is occasionally related to aggressive features and increased mortality compared with other differentiated thyroid malignancies. Recent epidemiologic data have presented the relationship between excessive adiposity and thyroid carcinogenesis. However, the histologic subtypes of papillary thyroid cancer according to anthropometric parameters have never been elucidated.

 In this study, we observed the proportion of oncocytic tumor cells (OTC) in papillary thyroid cancer (N=142) and analyzed the relationship between the clinico-pathological features and the proportion of OTC. The obese patients with PTC show a tendency to have large tumor size (p=0.023). In addition, the proportion of OTC increased in over-weight and obese patients (p=0.009). Remarkably, this proportion of OTC is a strong positive risk predictor for tumor recurrence (OR=7.357, p=0.008).

 In conclusion, PTCov is one of aggressive risk factors and might be a major hisotological change in the obese patients with PTC.

 

Nothing to Disclose: JHH, JUL, MHL, MS, YSJ

15614 56.0000 SUN-0571 A Comparisons of Prognostic Features and Body Weight By the Proportion of Oncocytic Tumor Cells in Papillary Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Jacqueline Jonklaas*
Georgetown University Medical Center, Washington, DC

 

Background and Objective

Radioactive iodine therapy is associated with side effects caused by damage to non-thyroid tissues. Salivary and lacrimal side effects of radioiodine therapy are well documented. However, nasal side effects are rarely described. The objective of this study was to document the frequency of nasal side effects in comparison to lacrimal side effects, and to determine, in a preliminary analysis, whether contributing factors could be identified.

Methodology

A retrospective review of the charts of patients with a diagnosis of thyroid cancer and documentation of radioiodine therapy was performed. The frequency of both nasal and lacrimal sides was ascertained. Factors that may have contributed to patients sustaining nasal damage after radioiodine therapy were also documented. These included RAI dose, method of preparation for receiving radioiodine therapy, and patient characteristics.

Results

Forty patients (9.7%) and 43 patients (10.5%) were deemed to have suffered lacrimal and nasal side effects from their radioiodine treatment respectively. The mean time of onset of lacrimal symptoms was 10 months. The mean time of onset of nasal symptoms was 11 days. Both radioiodine dose and body mass index were significantly positively correlated with sustaining lacrimal and nasal side effects (p values 0.01-0.04). Being prepared for treatment using a withdrawal protocol was associated with increased risk of both lacrimal and nasal side effects, with odds ratios (95% CI) being 0.37 (0.18-0.76) and 0.22 (0.11-0.44) respectively.

Conclusions and Relevance

Transient nasal dysfunction appears to occur at a rate of approximately 10%. This rate is similar to the rate of occurrence of lacrimal dysfunction. Although we cannot determine whether these acute nasal side effects were followed by long term or permanent ramifications, these consequences of radioiodine add to the reasons to carefully evaluate the benefits and risks of radioiodine therapy for patients with thyroid cancer on an individual basis.

 

Nothing to Disclose: JJ

14719 57.0000 SUN-0572 A Nasal Dysfunction after Radioiodine Therapy: A Rarely-Recognized Side Effect with Similar Frequency to Lacrimal Dysfunction 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Rodis Paparodis*1 and Juan Carlos Jaume2
1University of Wisconsin School of Medicine and Public Health, Madison, WI, 2University of Wisconsin - Madison, Madison, WI

 

Title: Thyroid Cancer Features in the Setting of Graves Disease.

Affiliations: Endocrine Autoimmunity Unit, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI1. Veterans Affairs Medical Center, Madison, WI2.

Background: Graves disease (GD) is believed to be associated with clinically more aggressive differentiated thyroid cancers (DTC), compared to the DTCs identified in the unaffected population. Our clinical observations argued against that hypothesis, and we performed this study to address this controversy.

Methods: We investigated the potential for an association between GD and more aggressive forms of DTC, by reviewing our prospectively collected database of patients referred for thyroid surgery at the Univ. of Wisconsin Hospital - Madison, WI, for the last 19 years. Hashimoto’s thyroiditis on pathology was an exclusion criterion.

We collected data for tumor size, focality, extra-thyroidal extension (ETE), lymphatic or distant metastases and need for reoperation. We compared the frequency of coexistence of these findings with DTC in GD and the non-GD population using χ2-test. We compared the tumor size between the two groups using student’s t-test.

Results: Out of 2168 subjects, 207 were affected by GD. 16 GD subjects were found to harbor DTC. Controls harbored 623 DTCs. GD was found to harbor smaller tumors (0.71±0.39 vs. 1.90±1.72cm), p=0.0012. GD trended to be associated with less risk for ETE (OR 0.15, 95%CI 0.009-2.56, p=0.08) and need for reoperation (OR 0.20, 95% CI 0.01-3.46, p=0.24). Lymphatic involvement and distant metastases were not significantly different due to the small number of affected subjects in the Non-GD population.

Conclusions: Graves disease seems to be associated with a less aggressive form of differentiated thyroid cancer in our series. Larger studies in the future will need to look into this question further.

 

Nothing to Disclose: RP, JCJ

16213 58.0000 SUN-0573 A Thyroid Cancer Features in the Setting of Graves Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Rodis Paparodis*1 and Juan Carlos Jaume2
1University of Wisconsin School of Medicine and Public Health, Madison, WI, 2University of Wisconsin - Madison, Madison, WI

 

Title:High Titers of Thyroid Peroxidase, Thyroglobulin and TSH-Receptor Antibodies Appear Protective for Thyroid Cancer in Patients with Graves Disease.

Affiliations: Endocrine Autoimmunity Unit, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI1. Veterans Affairs Medical Center, Madison, WI2.

Background: Inflammation is associated with cancer in multiple organs. In the thyroid gland autoimmunity has been linked to differentiated thyroid cancer (DTC) by some scholars, but this association was discounted by others. With this study we attempted to address this debated issue.

Methods: We investigated the potential for an association between humoral autoimmunity and DTC in patients with Graves disease (GD), by reviewing our prospectively collected database of patients who were referred for thyroid surgery at the Univ. of Wisconsin Hospital - Madison, WI, for the last 19 years. Subjects with a preoperative diagnosis of DTC were excluded. We collected data for thyroid pathology and antibodies titers against thyroglobulin (Tg-Abs), thyroid peroxidase (TPO-Abs), TSH-receptor (TR-Abs) and thyroid stimulating immunoglobulin (TSI-Abs). For Tg-Abs we compared the serum concentrations. The TPO-Abs titer was considered either high (TPO+++) if >1:1000, low (TPO+/-) if <1:1000 or undetectable.  For TR-Abs and TSI-Abs we compared the titers as a percentage of maximal normal titers and the ratios between subjects with elevated vs. normal titers. We compared the frequency of DTC in GD patients as a function of antibodies’ titers using χ2-test and compared the different autoantibody titers, using student’s t test.

Results: Out of 2828 subjects studied, 207 were affected by GD. 16 subjects were found to harbor DTC. The odds ratio (OR) for DTC in TPO+/- GD compared to TPO+++ subjects was 3.60 (1.07-12.33). The OR was not significant for Tg-Abs, but the Tg-Abs titer was significantly higher in the DTC compared to the non-DTC subjects (111.0±27.8 vs. 35.3±12.0. TSI-Abs and TR-Abs titers were not associated with the risk for DTC, but subjects with DTC had almost significant lower TR-Abs titers than non-DTC subjects (718±720 vs. 296±347) p=0.17.

Conclusions: The presence of a strong humoral autoimmune response in the form of high TPO-Abs, Tg-Abs and TR-Abs titers appear to be protective from DTC in patients with GD as judged by this epidemiological observation. To the contrary, the absence of high autoantibody titers confers a risk for DTC in the setting of Graves disease.

 

Nothing to Disclose: RP, JCJ

16239 59.0000 SUN-0574 A High Titers of Thyroid Peroxidase, Thyroglobulin and TSH-Receptor Antibodies Appear Protective for Thyroid Cancer in Patients with Graves Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

San Thida*1, Natsurang Chongkrairatanakul2 and Juan Carlos Jaume3
1UW Hospital and Clinics, Madison, WI, 2University of Wisconsin, Madison, WI, 3University of Wisconsin - Madison, Madison, WI

 

Background: 

The Bethesda system for reporting fine needle aspiration (FNA) specimens of thyroid nodules has been established as a standard cytological classification to stratify the risk of malignancy.  Thyroid specimens reported as follicular Lesion of undetermined significance (FLUS) have been a major challenge for clinicians to direct patients for repeated biopsy, surgery or continuous monitoring.  The rate of malignancy in FLUS specimens is thought to be 5-15% but the probability of malignancy varies among institutions.  Based on data from several reports, the risk of malignancy with this cytological diagnosis ranges from 5 to 38 %.  Clearly this is too wide of a range for decision making.


Methods:

Our objective was to determine the risk of malignancy and outcome of FLUS cytological diagnosis at our institution.  We reviewed all data from our prospectively collected thyroid FNA database from July 2011 to June 2013. The original FNA cytology results from target nodules were matched to the cytology results of repeated FNAs, or pathology results of subsequent diagnostic lobectomies or total thyroidectomies.

Results:

Among the 1420 nodules biopsied, 127 nodules were diagnosed as FLUS on FNA.  We subdivided all patients diagnosed with FLUS into 3 groups - 1) patients who had a repeated FNA (N=15/127); 2) patients who directly underwent surgery (N=79/127); and 3) patients who had only a follow up ultrasound for monitoring (25/127).  Repeated FNA cytology revealed: benign cytology (9/15), FLUS again (4/15), and non-diagnostic (1/15).  Among all FLUS diagnosed nodules that underwent surgery, pathology revealed: differentiated thyroid cancer (30/79), benign nodule (47/79), parathyroid (1/79), and no final pathology report due to surgery done at another hospital (1/79).  In our cohort, the overall rate of FLUS on initial FNA was 8.9% and the incidence of thyroid cancer was 27% of patients who underwent thyroid surgery.  Most common reason for choosing surgical option was size >4 cm and patient’s preference. 


Conclusion: 

The malignancy rate of thyroid nodules with initial FLUS diagnosis is higher than expected (5 –15%) at our institution.  Our study highlights that different incidences of thyroid cancer in FLUS category likely exist among institutions, so decision for management of FLUS diagnosis should be made based local experiences.  National guidelines for management of this cytological diagnosis are inaccurate at least in our setting.  We suggest other institutions do similar analyses as described here to generate more accurate local guidelines for management of FLUS diagnosis.

 

Nothing to Disclose: ST, NC, JCJ

16346 60.0000 SUN-0575 A The Risk of Malignancy and Outcome in Thyroid Nodules Categorized As Follicular Lesion of Undetermined Significance 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Gayatri Jaiswal*1, Victor Joseph Bernet2, John C Morris III3 and M. Regina Castro3
1Mayo Clinic, Jacksonville, FL, 2Mayo Clinic Jacksonville, Jacksonville, FL, 3Mayo Clinic, Rochester, MN

 

Background: The incidence of thyroid cancer is 5-7 fold higher in transplanted than non-transplanted patients. However there is limited information on the actual characteristics and outcomes of this particular cancer in different solid organ transplant groups. To the best of our knowledge, only 2 studies have described thyroid cancer characteristics and outcomes in the transplant population with majority of patients being kidney transplant recipients.

Objective: We aim to describe features of thyroid cancer unique to solid- organ transplant recipients.

Methods: We identified 33 patients who have received solid organ transplantation at Mayo Clinic Jacksonville and Mayo Clinic Rochester, who have a diagnosis of thyroid cancer pre- or post-transplant in the study period of 2007-2013.  A retrospective chart review was performed to collect data with respect to clinical history, diagnosis, pathology/stage, management and treatment outcomes of thyroid cancer in this group of patients.

Results: Out of 33 patients (median age 56) with a history of thyroid cancer and organ transplantation, 51.5% (17) were male. Our study group included 17 Kidney, 11 Liver, 1 Kidney- Pancrease, 1 Heart, 1 Lung, 1 Heart-Lung and 1 Heart-Kidney Transplant recipients. Average follow up time since transplant was 133 months.

Pathology results classified patients as: 30 Papillary (93%), 1 Follicular, 1 Hürthle cell and 1 Medullary Thyroid cancer. Average tumour size was 1.6 cm in maximum dimension .Thyroid cancer had been diagnosed before transplantation in 14 (42%) patients. Most (63 %) thyroid cancers were found incidentally; often during transplant evaluation. All except 1 patient had either total or subtotal thyroidectomy. One patient was observed with serial imaging due to underlying comorbidities. Only 12 (36%) received radioactive iodine treatment.

Twenty one patients (64%) had Stage 1 Thyroid cancer. Persistent disease was present in 3 patients. Four (12%) patients had recurrence during follow up, three of whom had initially presented with intermediate/high risk tumors. One of these patients, with Hürthle cell carcinoma, presented with adrenal metastasis 4 years after thyroidectomy and radioactive iodine treatment. There were 2 deaths, not related to thyroid cancer.

Conclusion: It is unclear if the higher incidence of thyroid cancer in transplant population is due to effects of immunosuppressant therapy or incidental to extensive testing in this population. Never the less, our preliminary data indicate that there may not be a significantly higher recurrence rate or worse prognosis of thyroid cancer in transplant recipients. If larger, prospective trials in the future also indicate the same, then alternate management strategies may not be necessary in this group as compared to the general population .With completion of our data analysis, we may achieve more validity to our conclusion.

 

Nothing to Disclose: GJ, VJB, JCM III, MRC

13301 61.0000 SUN-0576 A Thyroid Cancer in Solid Organ Tranplant Recipients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Rohit Jain*1, Roberto Emilio Izquierdo2, Mary McGrath1 and Paula Rosenbaum1
1SUNY Upstate Medical University, Syracuse, NY, 2Joslin Ctr for Diab, Syracuse, NY

 

Background: There is uncertainty of benefit in treating patients with radio active iodine (RAI) with persistent or recurrent differentiated follicular- cell derived thyroid cancer on biochemical or anatomical assessment but show negative diagnostic scans. In this area of study, there are no RCTs or prospective studies(1) and a review of literature suggests no improvement(2).

Hypothesis: We attempted to answer the question if empiric therapy with RAI with a negative diagnostic scan has any impact on the outcome.

Methods: We report a retrospective assessment of patients treated with empiric RAI between 1990-2007 at our medical center diagnosed with differentiated follicular cell- derived thyroid cancer, biochemical or structural evidence of recurrent or persistent disease and a negative DxWBS.
Patients were followed up for at least 6 months or till 2012. RAI dose was >100 mCi.
Disease activity (RECIST criteria) and mortality were evaluated as outcomes. Biochemical parameters were thyroglobulin and/or antibody levels. Structural disease was based on imaging or corresponding exam/surgical report.

Analyses included descriptive statistics, Kaplan Meier and Cox proportional hazard modeling.

Results: We studied 15 patients, 80 % were white, 53% females, with a mean age of 46.3 years.
All cancers were well differentiated with 73% cases being papillary, and the remainder follicular variant. 60% were stage III or higher and 53% had nodal disease at the time of diagnosis. All received initial ablative doses of RAI with a mean follow up of 9.5 yr. All survived to the end of the study; 13% were stable, 27% cured and 60% had progression.

There was a persistent lack of activity on the scan post empiric RAI dose, regardless of progression or stable/cure status. While time between initial diagnosis and detection of persistent/recurrent disease was not a significant predictor, older age at diagnosis and male sex were significantly associated with disease progression. The only subject, a 21 yr old male, with distant metastasis (pulmonary) at the time of diagnosis was cured.

Conclusion: 60% of the cases progressed despite empiric RAI.
Benefit was less likely for the older male. This warrants continued scrutiny of outcome data using this modality or early alternative treatments.

 

Nothing to Disclose: RJ, REI, MM, PR

13412 62.0000 SUN-0577 A Poor RAI Treatment Outcomes in Persistent/Recurrent Follicular Cell- Derived Thyroid Cancer with Negative Diagnostic Whole Body Scans (DxWBS) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Syed zubair Hussain*1, Maseeh uz Zaman2, Sarwar Malik3, Nanik Ram2, Ali Asghar2, Unaib Rabbani2, Nida Aftab4 and Najmul Islam2
1Aga Khan University hospital, Karachi, Pakistan, 2Aga Khan University Hospital, Karachi, Pakistan, 3Aga Khan University Hospital, Pakistan, 4Dow Medical College ,Karachi,Pakistan, karachi, Pakistan

 

Background

Thyroid cancer is the most common endocrine cancer. About 90% of these are differentiated thyroid cancers (DTC). Treatment options are total thyroidectomy followed by radioactive I131remnant ablation(RRA) and thyroid stimulating hormone (TSH) suppression with thyroxine. Unsuccessful ablation drastically affects the prognosis of patients with DTC particularly high risk individuals, therefore identifying the factors that affect the success of ablation is important in the management of patients with DTC. Stimulated thyroglobulin(sTg)is a good predictor of successful ablation in DTC.Its levels can be influenced by tumor staging and TSH values, as well as other factors. Therefore we did this study using TSH to correct the predictive value of sTg in success of RRA. Our objective was to ascertain whether sTg/TSH ratio can be a used as a good predictor of successful RRA and to compare its predictability with sTg.

Methods

We retrospectively reviewed the records of 75 patients with DTC,who underwent total thyroidectomy followed by RRA and TSH suppression.We assessed preablationsTg, preablation sTg/TSH ratio, age, gender, histopathology, capsular invasion, tumor size, nodal involvement, distant metastasis,TNM staging, I131 ablative dose and ETA risk as predictors of successful RRA. Results

Preablation sTg and sTg/TSH ratio are significantly associated with ablation outcome. Cutoff value for sTg to predict successful and unsuccessful ablation was 18ng/mL with 76.7% sensitivity and 79.1% specificity while for sTg/TSH cutoff was 0.35 with 81.4% sensitivity and 81.5% specificity(P<0.001). Association was stronger for sTg/TSH ratio with adjusted odd’s ratio (AOR) 11.64 (2.43-55.61) than for sTg with AOR 5.42(1.18-24.88). Conclusions

Our study adds to the value of preablation sTg and establishes the role of preablation sTg/TSH ratio in predicting the ablation outcome. Preablation sTg/TSH ratio can be considered as better predictor of ablation outcome than sTg, tumor size and capsular invasion. Therefore we suggest to use sTg/TSH ratio for risk stratification too

 

Nothing to Disclose: SZH, MUZ, SM, NR, AA, UR, NA, NI

16719 63.0000 SUN-0579 A Preablation Stimulated Thyroglobulin/TSH Ratio As a Predictor of Successful I131remnant Ablation in Patients with Differentiated Thyroid Cancer Following Total Thyroidectomy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Sann Yu Mon*1, Jeffrey D Borrebach2, Shane Otto LeBeau3, Christopher Coyne4, Sally E Carty5, Linwah Yip2, Kelly L McCoy2, Michael T Stang2, Robert L Ferris6, Umamaheswar Duvvuri2, Judith Joyce2, Mitchell Tublin2, Marina N. Nikiforova2, Yuri E Nikiforov7 and Steven Paul Hodak4
1University of Pittsburgh School of Medicine, Pittsburgh, PA, USA, PIttsburgh, PA, 2University of Pittsburgh Medical Center, 3Univ of Pittsburgh Med Ctr, Pittsburgh, PA, 4University of Pittsburgh Medical Center, Pittsburgh, PA, 5University of Pittsburgh, Pittsburgh, PA, 6University of Pittsburgh Cancer Institute, 7Univ of Pittsburgh, Pittsburgh, PA

 

Controversy exists over use of radioactive iodine (RAI) therapy following total thyroidectomy (TT) in low-risk (LR) well-differentiated thyroid cancer (WDTC) patients.  The American Thyroid Association (ATA) recommends RAI activities of 30-100 mCi for remnant ablation in LR and RAI for selected patients with AJCC stage I and II. However, the characteristics of these “select” cases are poorly defined1. Data also continue to emerge suggesting LR WDTC, and specifically those patients who are low risk by MACIS criteria (distant metastasis, age, completeness of resection, local invasion, tumor size score <6) may not benefit from RAI2-5 and when RAI is necessary, lower activities are equally effective6-7. A recent meta-analysis showed that a wide variation in RAI use after TT is common in US for both LR and high risk (HR) WDTC8. 

To determine practice patterns and the degree to which providers vary in their use of RAI, we performed a retrospective analysis of 218 WDTC that underwent TT in our academic center between 2009 and 2012: mean age (47.4±14.1 yrs), 86.2% females, AJCC Stage I (71.6%), Stage II (8.3%), Stage III (18.7%), Stage IV (1.4%).  We excluded those with distant metastases.  Among 128 LR, the majority (45.3%) received RAI approximately (≈) 50 mCi whereas 33.6% received no RAI, 16.4% received ≈100 mCi and the remaining 4.7% received >110 mCi.   In multivariate analysis, tumor size (>1 cm), lymph nodes metastasis (LNM) and the presence of a BRAFV600E mutation were all statistically significant factors that favored higher activities of RAI (p<0.001).  Among HR group, the majority (44.4%) received RAI ≈ 100 mCi, 41.7% received > 110 mCi and the rest ≈ 50 mCi.  Our multivariate analysis showed that those without LNM, BRAFV600E mutation, extra-thyroidal extension and those with tumor size (<1 cm) tend to receive RAI ≈ 50 mCi or less (p<0.001). Among 190 patients who were LR by MACIS criteria: 22.1% received no RAI whereas 63.7% received between 30 and 100 mCi. The remaining 14.2% of MACIS LR received RAI >100 mCi and were more likely to have tumor size (>1cm), LNM and/or multiple tumor foci (p<0.001). 

Our data suggest the majority (95%) of LR received appropriate RAI following current ATA guidelines, however, treatment heterogeneity was more prevalent for patients with HR disease and those LR by MACIS criteria. This results in low risk disease that is sometimes over treated and conversely, in high-risk cases that may be undertreated. Heterogeneity of RAI use by different providers is perhaps due to lack of sufficiently defined clinical guidelines.  Implementation of thyroid management pathway in our institution may be a feasible strategy for reducing heterogeneity in RAI therapy.

 

Nothing to Disclose: SYM, JDB, SOL, CC, SEC, LY, KLM, MTS, RLF, UD, JJ, MT, MNN, YEN, SPH

12921 64.0000 SUN-0580 A Heterogeneity and Controversies in Radioactive Iodine Use: Are We Near a Consensus? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Zhiheng Henry He1, Vivek Bansal2 and James Vincent Hennessey*3
1Beth Israel Deaconess Med Center, Boston, MA, 2University Hospitals Case Medical Center, Cleveland, OH, 3Beth Israel Deaconess Medical School, Boston, MA

 

Successful treatment of differentiated thyroid cancer (DTC) often relies on a complete total thyroidectomy and subsequent radioactive iodine ablation (RAI) therapy. However, an objective measure of surgeon’s proficiency in performing total or near total thyroidectomy is lacking. We hypothesized that post-surgical, pre-ablation thyroid I-123 uptake, adjusted for the urinary iodine excretion might be an index reflective of the completeness of surgery and may be a good predictor for disease outcome. Methods: We retrospectively reviewed 226 patients with DTC undergoing thyroidectomy and initial RAI at Beth Israel Deaconess medical Center from 2007 to 2012. This cohort had a mean age of 49.6±15.1 years. One hundred and sixty were females (79.8%) and 66 were males (29.2%). They all underwent total thyroidectomy by local surgeons who were identified as #1, #2, and #3. Most of the surgeries were done by surgeon #1 (93) and surgeon #2 (93). All other surgeons involved were pooled and designated as #3 due to the low volume for individual surgeons (36). All patients were instructed to follow a low iodine diet for 2 weeks prior to RAI. Measurements of TSH, FT4, Urine iodine and creatinine on spot samples were obtained prior to the administration of the ablative I-131 dose. The outcome measure of disease freedom was defined, based on available data as a basal serum (LT4 treated) thyroglobulin (Tg) of <1 ng/ml or a thyrogen-stimulated Tg <2 ng/ml along with an unremarkable/ inconspicuous neck ultrasound and/or negative I-123 scan, all which were performed together or in close proximity of each other 6-18 months after the initial RAI).  Results: Pre-ablation thyroid uptake was not different between surgeon #1 v #2 (3.85%±4.22% v 2.95%±4.1%, p>0.05). However, surgeon #2 was significantly lower that of #3 (2.95%±4.1% v 6.29%±9.2%, p=0.005). After being normalized for the urinary iodine/creatinine ratio, surgeon #1 and #2 remained similar (0.12±0.15 %/mcg/g v 0.13±0.24 %/mcg/g, p>0.05) and both were significantly lower than that of #3 (0.32±0.55 %/mcg/g, p<0.01 for both). Further, 90.6% (87) of surgeon #1’s and 92.6% (87) of surgeon #2’s patients were disease free. This was significantly higher than the 72.2% (26) of patients operated on by the surgeons designated as #3 after a mean follow up of 378±141 days post RAI (p<0.01). Our results suggested a post-surgical thyroid uptake to urinary iodine/creatinine ratio might be used as an index to measure surgeon’s proficiency and can potentially predict disease outcomes in patients with DTC.

 

Nothing to Disclose: ZHH, VB, JVH

11952 65.0000 SUN-0581 A Thyroid Uptake to Urinary Iodine/Creatinine Ratio May be a Predictor of Disease Outcomes for Differentiated Thyroid Cancer (DTC) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Rupendra T Shrestha*1 and James Vincent Hennessey2
1BIDMC-MILTON, Milton, MA, 2Beth Israel Deaconess Medical School, Boston, MA

 

Introduction:

The Atypia of Undetermined Significance (AUS) category in the Bethesda System of reporting thyroid fine needle aspiration (FNA) includes various cytological findings considered to have a low risk of malignancy. It is unclear if any particular subset of the cytological findings within this category carries a higher risk for malignancy requiring a more aggressive treatment plan.

Materials and methods:

We reviewed 210 AUS FNAs that were performed between October of 2007 and May of 2012. Of these 18 FNAs were repeats of the same nodule leaving 192 distinct nodules. Histopathological data from surgery was available in 91 nodules and characteristics of these nodules were analyzed.

We compared the initial cytology report and subclassified the nodules into one of four groups: Architectural Atypia (includes abnormal follicular arrangement but no cellular abnormalites), Cellular Atypia ( Atypical cellular findings) with or without architectural atypia, Hurthle cells only and otherwise unspecified AUS categories. The surgical pathology confirmed  malignancy rate for each group was calculated.

Results:

Papillary thyroid carcinoma was the most common malignancy identified (26/30 [87%]). We found that in the Architectural Atypia only category,  3/18 (17%) nodules were malignant, whereas when Cellular Atypia with or without architectural atypia was present, 19/55 (35%) were malignant . There were 10 nodules which eventually were referred for surgery where the AUS status was based predominantly on Hurthle cells seen on cytology, half of these were malignant (5/10, [50%]). The malignancy rate in AUS cases which were not otherwise specified was 3/8 (38%).

Conclusion:

Cellular atypia with or without architectural atypia seen on initial AUS had a higher malignancy rate compared to Architectural Atypia only in our study group. Further research may be required to consider subclassification of this category to assign appropriate risk of malignancy for AUS nodules.

 

Nothing to Disclose: RTS, JVH

13178 66.0000 SUN-0582 A Cytologic Subclassification of Atypia of Uncertain Significance May Predict Lesions More Likely to be Malignant at Surgery 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0515-0582 4880 1:00:00 PM Thyroid Neoplasia Poster

Sean T Butterbaugh*, Sarah A Andres, Mary Ann Sanders and James L Wittliff
University of Louisville, Louisville, KY

 

Measurements of estrogen (ER) and progestin receptors (PR), as well as HER-2/neu proteins, are related to a patient’s prognosis and therapy selection with limited use in deciphering histopathologies of breast cancer.  Comparative genomic hybridization indicated invasive lobular carcinoma (ILC) is closely related to low grade invasive ductal carcinoma (IDC), and is genetically unrelated to intermediate and high grade carcinomas. Patients with ILC had improved response to aromatase inhibitors (AI) compared to low grade IDC (BIG 1-98 Trial). Our goal is to identify clinically relevant genes that distinguish subtypes and predicts response to AIs rather than relying solely on histomorphology and/or immunohistochemistry for pathologic diagnosis of ILC. Using an IRB-approved biorepository and database, total RNA was extracted from breast carcinoma cells procured by laser capture microdissection of 247 de-identified tissue biopsies to perform microarray analyses to identify expression signatures associated with breast cancer behavior.  Of these, 16 were ILC, 13 were low grade IDC, 55 were intermediate grade IDC and 85 were high grade IDC, and 107 of these were hormone receptor positive. Gene candidates were differentially expressed between ILC and low grade IDC (luminal A) and exhibited similar levels between ILC and high grade IDC (luminal B). Quantified results of protein biomarker analyses and gene expression did not identify differences in levels of either ER, PR or HER-2/neu oncoprotein nor of expression of either ESR1, PGR, ERBB2 or EGFR genes in ILC (n= 90) compared to those of low grade IDC (n=85). However, comparison of microarray data from hormone receptor positive cancers revealed 299 genes that were differentially expressed (p<0.01) between ILC and low grade IDC (luminal A-like), and 99 of these were not differentially expressed (p>0.01) between ILC and high grade IDC (luminal B-like). These genes were associated with key molecular and cellular functions, e.g., cell-to-cell signaling, cell morphology, cell death and survival, cellular assembly and organization and carbohydrate metabolism using Pathway analysis software (Ingenuity®). qPCR validated expression of BRWD1, CAPSL, CHRNA, CMTM7, CRMP1, GSKIP, HBEGF, PAPPA, and LRBA was evaluated in intact tissue sections of 22 ILC, 24 low grade IDC and 18 high grade IDC tumors. Despite genetic evidence suggesting close relationships of ILC and low grade IDC, we predict a clinically relevant gene set underlies a cancer’s biologic features and response to AI. Of the candidate genes, heparin-binding EGF-like growth factor (HBEGF) and collapsin response mediator protein 1 (CRMP1) expression appear to be genomic markers for defining subtypes as an alternative to relying solely on histologic classification of invasive carcinomas as lobular or ductal.

 

Nothing to Disclose: STB, SAA, MAS, JLW

15131 2.0000 SUN-0327 A Microgenomic Features of LCM-Procured Cells Discriminate Invasive Lobular from Invasive Ductal Carcinomas of the Breast to Complement Endocrine Biomarkers 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0326-0339 4882 1:00:00 PM Tumor Progression; Endocrine Neoplasia Poster

Tomomi Yoda*1, Keely M McNamara1, Yasuhiro Miki2, Kiyoshi Takagi3, Takanori Ishida1, Takashi Suzuki3, Noriaki Ohuchi1 and Hironobu Sasano1
1Tohoku Univ Sch of Med, Sendai, Japan, 2International Research Institute of Disaster Science, Tohoku University, Sendai, Japan, 3Tohoku University Graduate School of Medicine, Sendai, Japan

 

Prostaglandins are group of lipid compounds enzymatically derived from fatty acids and their importance in cancer progression has been well documented. In breast cancer, an inhibition of cyclooxygenase-2, which is a host enzyme producing various types of prostaglandins, has been reported to suppress breast cancer but the function of the great majority of COX-2 mediated prostaglandins have not been elucidated. Therefore in this study, we focused on the actions of 11β-Prostaglandin F2α (11β-PGF2α) and its cognate receptor, the Prostaglandin F receptor (FP receptor). 11β-PGF2α is produced by the actions of aldo-keto reductase family 1 member C3 (AKR1C3), a multifunctional enzyme, expressed in both non-neoplastic and neoplastic breast tissues which acts not only as a steroid hormone metabolizing enzyme, but also as prostaglandin synthesizing enzyme catalyzing the reduction of the prostaglandin precursor, PGD2 to 11β-PGF2α. Therefore we focused on the possibility that some effects of AKR1C3 could be mediated by its actions as 11β-PGF2α synthase. We examined FP receptor expression in 56 breast cancer cases using immunohistochemistry and analyzed the functions of AKR1C3-produced 11β-PGF2α in breast carcinoma cell lines. FP receptor and AKR1C3 immunoreactivity was detected in the cytoplasm of tumor cells, and 87.7% and 65.7% of breast cancer cases were classified as positive, respectively (defined as >10% tumor cells of immunoreactivity for both AKR1C3 and FP receptor), and 62.5% of cases were double positive for both FP receptor and AKR1C3. These cases trended to be correlated with high proliferative activity (defined positive as Ki-67 >10%) but the correlation did not reach statistical significance (χ2-test, p = 0.07). In subsequent in vitro analysis, breast carcinoma cell lines harboring the endogenous expression of both FP receptor and AKR1C3 (MDA-MB-231 and SUM185PE) were used. AKR1C3 inhibitor significantly decreased 11β-PGF2α production and suppressed cell proliferation. We also demonstrated that FP receptor selective antagonist AL8810 significantly inhibited cell proliferation via phosphorylation of mitogen-activated protein kinase (MAPK). Furthermore 11β-PGF2α stimulated FP receptor dependent phosphorylation of MAPK and cell proliferation in FP receptor stably expressed MCF-7. These results indicated that AKR1C3 actions as 11β-PGF2α synthase did promote tumor progression via FP receptor-MAPK signaling in breast carcinoma cells.

 

Nothing to Disclose: TY, KMM, YM, KT, TI, TS, NO, HS

13703 3.0000 SUN-0328 A 11β-Prostaglandin F2α Produced By AKR1C3 Stimulates FP-Receptor and Contributes to Breast Cancer Progression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0326-0339 4882 1:00:00 PM Tumor Progression; Endocrine Neoplasia Poster

Minako Sakurai*1, Yasuhiro Miki2, Kiyoshi Takagi3, Takashi Suzuki4 and Hironobu Sasano3
1Tohoku University, Graduate School of Medicine, Sendai, Japan, 2International Research Institute of Disaster Science, Tohoku University, Sendai, Japan, 3Tohoku University Graduate School of Medicine, Sendai, Japan, 4Tohoku Univ Sch of Hlth Sci, Sendai, Japan

 

Mammary epithelial cell development is partly dependent on adjacent adipose tissues. Mature adipocytes have been recently demonstrated to act as an endocrine organ producing and secreting various signaling molecules such as hormones, cytokines and adipokines. In invasive breast carcinoma tissues, carcinoma cells are well known to interact with surrounding adipocytes, also termed cancer-associated adipocytes (CAA). CAAs have modified biological features and phenotypes compared to normal adipocytes. However, key regulators mediating an interaction between carcinoma and cancer-associated adipocytes remains unclear.

   Using 2D co-culture system, we performed DNA microarray analysis of both primary human subcutaneous adipocytes (Lonza) and human breast carcinoma cell lines (ATCC), MCF7 (ER-positive) and MDA-MB-231 (ER-negative). Mature adipocytes cocultivated with carcinoma cells exhibited lower expression of adipocyte specific markers, while cytokines, chemokines, and Serum Amyloid A (SAA) family were markedly elevated (> 2-Fold). Among these genes above, subsequent qRT-PCR analysis confirmed that mRNA expression of IL-6 (9.3-fold), IL-8 (26.9-fold), SAA1 (2.5-fold), SAA2 (2.7-fold), and SAA4 (4.3-fold) were significantly increased in adipocytes cocultivated with MDA-MB-231. In addition, there were 435 genes up-regulated in MCF7, and 212 genes in MDA-MB-231 with more than 2-fold increase by co-culture with mature adipocytes. qRT-PCR analysis also confirmed marked increment of several genes; Lipocalin-2 (LCN2; 64.7-fold), SAA1 (99.8-fold), and S100 calcium binding protein A7 (179.2-fold) in MCF7 cocultivated with adipocytes, while LCN2 was also up-regulated by 4.5-fold in MDA-MB-231. LCN2 and S100A7 were previously reported to be positively associated with breast cancer progression. Therefore, an activation of these neoplastic molecules may be directly influenced by the presence of CAAs, especially among the breast cancer patients with increased body fat mass.

 

Nothing to Disclose: MS, YM, KT, TS, HS

11497 4.0000 SUN-0329 A Identification of Signaling Factors Involved in an Interaction Between Human Breast Carcinoma and Adipocytes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0326-0339 4882 1:00:00 PM Tumor Progression; Endocrine Neoplasia Poster

Elaine Carol Maggi*1, Jyothi Vijayaraghavan2 and Judy S Crabtree2
1LSU Health Science Center, New Orleans, LA, 2LSUHSC, New Orleans, LA

 

Neuroendocrine tumors (NETs) are a form of cancer that arises from neuroendocrine tissue of the endocrine pancreas (pNETs), stomach, intestines, lungs or colon (carcinoids). These tumors have a high metastatic potential and the 5 year survival of some types of NETs is as low as 4%. Aside from surgical removal of the tumor prior to metastasis, there are no curative medical therapies for NETs. Although there have been recent therapeutic gains with mTOR inhibitors, there is still a vital need for more therapeutic targets. One such biological target is the retinoblastoma binding protein 2 (RBP2).

RBP2 is an important cell cycle regulator with multiple links to cancer development and prognosis.  It is upregulated in several different forms of cancer including gastric and non-NET lung cancers, and in some cases has been linked to the development of drug resistance and metastasis.  RBP2 directly activates cell growth through its demethylase activity and indirectly effects cell cycle arrest through various roles in protein complexes, the most studied of which is the interaction with retinoblastoma (RB). Recent literature demonstrates that inhibiting RBP2 production in a pancreatic NET mouse model halts tumor formation, suggesting the viability of RPB2 as a potential therapeutic target. However, this paper did not address RBP2 overexpression as a causative role of tumor formation or the effect of RBP2 on other NET types or the role in metastasis.  Therefore, the purpose of our research is to investigate the relationship between RBP2 levels and NET formation and metastasis. To do this we have evaluated the levels of RBP2 in both human and mouse tissue samples by RT-PCR and/or protein analysis and performed proliferation, invasion and migration assays in NET cell lines in the presence or absence of RBP2 or an enzymatically dead RBP2.  We have demonstrated regulation of selected downstream targets involved in cell cycle progression.  From these data, we conclude that RBP2 is elevated in human and mouse NETs and that this elevation is impacting proliferation and other metastatic properties by modulating the production of downstream targets. Therefore, RBP2 plays a critical role in NET tumorigenesis and may be a putative target for future drug development.

 

Nothing to Disclose: ECM, JV, JSC

16224 6.0000 SUN-0331 A RBP2 Overexpression in Neuroendocrine Tumors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0326-0339 4882 1:00:00 PM Tumor Progression; Endocrine Neoplasia Poster

Francesca Lugli*1, Donato Iacovazzo1, Paola Lanza2, Frediano Inzani2, Chiara De Waure2, Guido Rindi1 and Laura De Marinis2
1Università Cattolica del Sacro Cuore, Rome, Italy, 2Catholic University, Rome, Italy

 

Endocan has been reported as specific of endothelial tumor cells and was shown to be expressed by tip cells during angiogenesis process.

The principal aims of the study are the assessment of immunohistochemical VEGF and Endocan expression in functioning and non functioning pNETs and the comparison of these markers with clinical features, Ki67 and TNM staging.

We collected a total number of 79 pNETs surgical specimens for immunohistochemestry (IHC). The population chosen has been classified according to type of diagnosis, sex, age, grading and staging.

We report the preliminary results of IHC for VEGF and Endocan performed on 46 patients. The expression of Endocan is limited to endothelial cells within neoplastic tissue. VEGF is expressed in the cytoplasm of tumoral cells. VEGF and Endocan expression is strictly connected, considering that Endocan expression upon endothelial cells is stimulated by VEGF production by neoplastic cells (P <0,001). The grading is directly correlated to the stage and in our series this finding is confirmed (P 0.001). We  correlated Endocan and VEGF expression to Ki67 and TNM classification. We found a significant correlation between Endocan and VEGF expression and metastatic disease (P 0.005 and <0.001 respectively).

These preliminary data seem to show that Endocan and VEGF immunohistochemical expression in pNETs may be predictive markers of aggressiveness.

 

Nothing to Disclose: FL, DI, PL, FI, CD, GR, LD

16185 7.0000 SUN-0332 A Evaluation of VEGF and Endocan/Esm-1 Expression in Pnets and Correlation with Ki-67 and Prognosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0326-0339 4882 1:00:00 PM Tumor Progression; Endocrine Neoplasia Poster

Francesca Marciello*1, Roberta Modica1, Michela Del Prete1, Vincenzo Marotta1, Valeria Ramundo1, Anna Chiara Carratù1, Chiara de Luca di Roseto1, Pasqualina Buonomano1, Ester Picillo1, Annamaria Colao2 and Antongiulio Faggiano3
1University "Federico II" of Naples, 2University, Naples, Italy, 3University, Napoli, Italy

 

Introduction: Recent data suggest that metformin has antineoplastic properties in different type of cancer. Effects of metformin have never been investigated in neuroendocrine tumors (NET).

We aim to determine the role of metformin on recurrence-free survival (RFS) in NET patients.

Patients and methods: A retrospective analysis was conducted by comparing NET patients under treatment with metformin (group A) and without metformin (group B). These groups had comparable clinical and pathological characteristics. To rule out the effect of hyperglycemia on tumor outcome, only subjects with mild type 2 diabetes mellitus (fasting glycemia≤140 mg/dl and HbA1c≤7% at the diagnosis) and of recent diagnosis (< 12 months) were considered. Metformin therapy was performed at standard doses for at least 6 months. A Kaplan-Meier analysis was performed.

Results: We analysed data from 12 patients in group A (5 F, 7 M; mean age: 63 years) and 20 patients in group B (10 F, 10 M; mean age: 59 years). G1 and G2 NET were 5 and 7 in group A, 10 and 10 each in group B. Primary NET was in bronchi (1 in group A, 2 in group B), gastrointestinal tract (4 in  group A, 6 in group B), pancreas (7 in group A, 12 in group B). Five patients in group A and 4 in group B had liver metastases at diagnosis. Recurrence rate was lower in group A than in group B (8% vs 40%). Median RFS was not reached in group A, while it was 87 months in group B (95%CI:13.14-160.86, p<0.05). There were no statistically significant differences in RFS between the two groups according to grading, metastases, NET therapies, other anti-diabetic drugs in association with metformin.

Conclusion: Metformin therapy seems to be associated with improved RFS in NET patients. Prospective studies are needed to better define the anti-neoplastic role of metformin in NET.

 

Nothing to Disclose: FM, RM, MD, VM, VR, ACC, CD, PB, EP, AC, AF

15784 8.0000 SUN-0333 A Role of Metformin on Recurrence-Free Survival in Neuroendocrine Tumors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0326-0339 4882 1:00:00 PM Tumor Progression; Endocrine Neoplasia Poster

Jong Ho Kim*1, Kang Hee Ahn1, Park Su Bin1, Ji Ryang Kim1, Won Jin Kim1, Yun Kyung Jeon1, Sang Soo Kim1, Bo Hyun Kim1, In Joo Kim1, Byung Joo Lee1 and Yong Ki Kim2
1School of Medicine, Pusan National University, Busan, Korea, Republic of (South), 2Kim Yong Ki Internal Medicine Clinic, Busan, Korea, Republic of (South)

 

Background: In addition to a typical role of calcium and bone homeostasis, recently vitamin D attracts attention because of its relation to cancer. Lower level of vitamin D was associated with the prevalence and aggressiveness of several cancers. The objective of our study is to evaluate the relationship between preoperative serum 25(OH) vitamin D level and poor clinicopathologic characteristics in female patients with papillary thyroid cancer (PTC).

Materials and Methods: A total of 638 patients who diagnosed and underwent total thyroidectomy for PTC from June 2012 to May 2013 were included. Blood samples were obtained within two weeks prior to total thyroidectomy. Patients were categorized into 4 quartiles by preoperative serum 25(OH) vitamin D level. We analyzed clinicopathologic features of PTC retrospectively.

Results: Preoperative vitamin D was significantly lower in patients with tumor size more than 1cm (P=0.041) and in those with lymph node metastasis (LNM) (P=0.007). As increasing of the serum vitamin D concentration, there were no significant trends of several clinicopathologic features except decreasing of PTC size (P=0.010). Simple linear regression analysis between PTC size and 25(OH) vitamin D showed inverse relationship (r=-0.111, P=0.009). The patients in 2nd quartile had more T stage 3/4 (odds ratio [OR], 2.028 [95% Confidence Interval [CI]: 1.194-3.443]; P=0.009), lymph node metastasis (OR, 2.028 [95% CI: 1.194-3.443]; P=0.009), lateral neck metastasis (LNeM) (OR, 5.029 [95% CI: 1.655-15.281]; P=0.004) and extrathyroidal extension (ETE) (OR, 1.946 [95% CI: 1.150-3.293]; P=0.013) than those in 4th quartile. Multivariate analysis showed that the patients in 2nd quartile compared with those in 4th quartile had more T stage 3/4 (OR, 1.888 [95% CI: 1.081-3.300]; P=0.026), LNM (OR, 2.037 [95% CI: 1.195-3.473]; P=0.009), LNeM (OR, 5.117 [95% CI: 1.679-15.591]; P=0.004) and ETE (OR, 1.807 [95% CI: 1.038-3.145]; P=0.036). When we recategorized into two groups by median of 25(OH) vitamin D, the lower half was significantly higher risk for T stage 3/4, LNM, LNeM, stage III/IV and ETE. All values except ETE were sustained significance after adjusting for several clinicopatholoic factors.

Conclusion: Lower preoperative serum 25(OH) vitamin D level is associated with advanced clinicopathologic features in female patients with PTC

 

Nothing to Disclose: JHK, KHA, PSB, JRK, WJK, YKJ, SSK, BHK, IJK, BJL, YKK

12303 10.0000 SUN-0335 A Low Serum 25(OH) Vitamin D Is Associated with Poor Clinicopathologic Characteristics in Female Patients with Papillary Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0326-0339 4882 1:00:00 PM Tumor Progression; Endocrine Neoplasia Poster

Xiaoyun Liu*1, Lijun Zhu2, Dai Cui1, Zhixiao Wang1, Huanhuan Chen1, Yu Duan1, Meiping Shen1, Zhihong Zhang1, Xiaodong Wang1, Erik Karl Alexander3, Tao Yang4 and Jiawei Chen1
1The First Affiliated Hospital of Nanjing Medical University, Nanjing, China, 2Nanjing Maternity and Child Health Care Hospital Affiliated to Nanjing Medical University, Nanjing, China, 3Brigham & Women's Hospital, Boston, MA, 4the First Affiliated Hospital of Nanjing Medical University, Nanjing, China

 

There exists a possible but uncertain association between Hashimoto’s thyroiditis (HT) and papillary thyroid carcinoma (PTC). However, PTC lies on a spectrum of disease, ranging from microcarcinoma to overt disease, with or without lymph node metastasis. Notably, most previous studies only evaluated classic PTC (with maximum diameter more than 10 mm). There have been few investigations concerning the relationship between HT and different stages of PTC, from occult or micro papillary thyroid carcinoma (mPTC) with maximum diameter no more than 10 mm, to clinical PTC (cPTC), to locally metastatic PTC. The aim of this study was to evaluate whether the presence of HT was associated with PTC at any stage, in a large tertiary hospital of eastern China. We conducted a retrospective, observational study of all archival thyroidectomies ranging from unilateral to bilateral partial, subtotal, near total and total thyroidectomies with or without central lymph node dissection (CLND) and/or lateral lymph node dissection (LLND) in a 6-year period from January 2008 to December 2013 in The First Affiliated Hospital of Nanjing Medical University. We evaluated 6,487 thyroid surgery specimens over this period. In total, 1,338 specimens were diagnosed histologically as demonstrating HT. The prevalence of PTC in the HT cohort was 43.7%. This was significantly higher than the prevalence of PTC in the non-HT group (23.0%; P=0.000). After adjustment of gender and age, the prevalence of PTC was still higher in HT group than in non-HT group. The same trend was similarly discovered for mPTC and cPTC significanctly as well. The prevalence of PTC was also higher in HT group than in non-HT group significantly among patients with unilateral thyroidectomies (36.6% vs. 17.9%, P=0.000) and bilateral thyroidectomies (55.1% vs. 34.3%, P=0.000). In contrast, no relationship was identified between HT and other cancer types. Notably, local lymph node metastasis in PTC was less frequent in HT group than in non-HT group with statistical significance (53.4% vs. 62.3%, P=0.008). Similar tendency was found for mPTC and cPTC groups (38.3% vs. 47.%, P =0.066 and 65.6% vs. 71.0%, P=0.195). Specially in PTC group with maximum tumor diameter between 6-10mm, lymph node metastasis was significantly lower in HT than in non-HT group (56.8% vs. 64.8%, P=0.010). This trend was revealed also in patients receiving unilateral thyroidectomies (48.0% vs. 64.6%, P=0.001), while no significance was discovered in bilateral thyroidectomies. We speculate that histologic HT was associated with an increased prevalence of PTC, independent of tumor size, gender, age and surgical methods. Local lymph node metastasis, however, was less frequent when HT was present, especially in unilateral lesion with maximum diameter 6-10 mm. These data suggest an association of HT to low risk stage of PTC, and/or a protective effect from further disease progression.

 

Nothing to Disclose: XL, LZ, DC, ZW, HC, YD, MS, ZZ, XW, EKA, TY, JC

16583 11.0000 SUN-0336 A Coexistence of Hashimoto's Thyroiditis with Different Stages of Papillary Thyroid Carcinoma in a Consecutive Chinese Cohort 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0326-0339 4882 1:00:00 PM Tumor Progression; Endocrine Neoplasia Poster

Nazanene H Esfandiari*1, Ka Kit Wong1 and Anca Mihaela Avram2
1University of Michigan, Ann Arbor, MI, 2Univ of Michigan Med Ctr, Ann Arbor, MI

 

AIM: To assess the contribution of pre-ablation 131-I scans with SPECT-CT (Dx scan) to risk stratification in patients with differentiated thyroid cancer (DTC).

MATERIALS AND METHODS:

Using clinical and histopathology information an endocrinologist performed ATA risk stratification in 320 patients (pts) (219F; 101M, mean age 47.3 ± 16.4, range 10 - 90) with DTC (289 papillary, 22 follicular and 9 Hurthle cell tumors). Dx scans were interpreted by 2 nuclear medicine physicians as showing thyroid remnant, cervical nodal, or distant metastases. The endocrinologist then re-assessed the risk stratification incorporating the findings from Dx scans and stimulated thyroglobulin levels.

RESULTS:

The mean tumor size was 2.4 ± 1.8 cm. Tumor staging (pT) was: 48 T1a, 68 T1b, 60 T2, 109 T3, 29 T4a, 3 T4b and 3 Tx. Pathology nodal staging (pN) was:  65 N0, 87 N1a, 62 N1b and 106 Nx.  Initial ATA risk stratification was low-risk in 97/320 pts (30%); medium-risk in 190/320 pts (60%) and high-risk in 33/320 pts (10%). Dx scans detected regional metastases in 112/320 pts (35%) and distant metastases in another 24/320 pts (8%) of patients.  After review of Dx scan information, the re-assigned ATA risk categories were as follows: low-risk: 66/320 pts (20%); medium-risk: 201/320 pts (63%) and high-risk 53/320 pts (17%).  Detection of unsuspected distant and regional metastases resulted in changes in ATA risk stratification to the high-risk category in 20 pts (upgrading 17 previously medium-risk pts and 3 previously low-risk pts), and to the medium-risk category in 28 previously low-risk pts.

CONCLUSION:

ATA risk stratification is a robust instrument for defining the extent of disease as ascertained on diagnostic 131-I SPECT-CT. However, 48/320 pts (15%) will have an underestimation of recurrence risk when assessment is based on histopathology alone. Preablation 131-I scintigraphy contributes to risk stratification by defining nodal and metastatic disease in addition to histopathology-based predictions.

 

Nothing to Disclose: NHE, KKW, AMA

12381 12.0000 SUN-0337 A What Is the Contribution of Pre-Ablation 131-I Scintigraphy with SPECT/CT to Risk Stratification of Differentiated Thyroid Cancer? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0326-0339 4882 1:00:00 PM Tumor Progression; Endocrine Neoplasia Poster

Hui-Ju Lee*, Jun Qin, San-Pin Wu, Shih-Chieh Lin, Rainer B. Lanz, Chad J. Creighton, Francesco J. DeMayo, Ming-Jer Tsai and Sophia Y Tsai
Baylor College of Medicine, Houston, TX

 

Androgen deprivation is the most common treatment strategy for prostate cancer (PCa). However, PCa progresses from an androgen dependent to an androgen refractory state subsequent to androgen ablation therapy, resulting in castration resistant prostate cancer (CRPC). Unfortunately, how CRPC is achieved remains largely undefined. Steroid receptor coactivator-2 (SRC-2) also known as TIF2, GRIP1 and NCOA2, is a member of the p160 SRC family, which is frequently amplified or overexpressed in metastatic prostate cancer patients, suggesting it may play a critical role in PCa progression, metastasis and CRPC. In this study, we used genetically engineered mice, expressing SRC-2 specifically in the prostate epithelium as a mouse model to examine the role of SRC-2 in prostate tumorigenesis. Over-expression of SRC-2 in the mouse prostate epithelium causes neoplasia, indicating the oncogenic role of SRC-2 in prostatic neoplasia. Over-expression of SRC-2 in PTEN heterozygous mice accelerates PTEN mutation induced tumor progression and develops a metastasis-prone cancer. Androgen deprivation has been shown to induce aggressive CRPC tumors in the PTEN null mutants. Interestingly, such aggressive tumors are absent in SRC-2/PTEN deficient mice, indicating a critical role of SRC-2 in CRPC. Further studies showed that SRC-2 expression is repressed by androgen signaling and SRC-2 promotes tumor progression and metastasis through hyperactivation of PI3-kinase/AKT and MAPK signaling pathways. The biological significance of the signaling cascade of SRC-2 is substantiated by analysis of patient data. Finally, SRC-2 signaling is tightly correlated with disease progression and tumor recurrence. Our results establish a conceptual framework for SRC-2 mediated AR deprivation in CRPC development, with potential implications for prostate cancer therapy.

 

Nothing to Disclose: HJL, JQ, SPW, SCL, RBL, CJC, FJD, MJT, SYT

14831 13.0000 SUN-0338 A SRC-2 Is an Oncogene for Prostate Cancer and Plays an Essential Role in Metastatic CRPC Development 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0326-0339 4882 1:00:00 PM Tumor Progression; Endocrine Neoplasia Poster

Naifa L Busaidy*1, Maria E Cabanillas1, Ramona Dadu2, Camilo Jimenez1, Mouhammed Amir Habra1, Ara Vaporciyan3, Lilah Morris4, Nancy D Perrier1 and Ana Oliveira Hoff5
1The University of Texas MD Anderson Cancer Center, Houston, TX, 2Baylor College of Medicine, Houston, TX, 3The University of Texas - MD Anderson Cancer Center, Houston, TX, 4University of Arizona, AZ, 5ICESP/University of Sao Paulo, Sao Paulo, Brazil

 

Background: Systemic therapy is not effective in parathyroid carcinoma and the resultant hypercalcemia can be recalcitrant to traditional treatments.  Parathyroid tumors demonstrate increased angiogenesis.  Sorafenib is an anti-angiogenic agent (inhibition against VEGFR, PDGFR, BRAF and  kit) recently approved for thyroid cancer, but not yet investigated in parathyroid carcinoma.

Clinical Case:  A 59-year-old gentleman who had elevated calcium levels (13mg/dL (nl =8.4-10.2)) and iPTH=298pg/mL (10-80pg/mL), underwent surgical resection, left inferior parathyroidectomy and lobectomy for a presumed adenoma.  A large parathyroid adenoma (1160mg) was removed with no malignant transformation. 

7 months later, hypercalcemia recurred and he underwent surgical resection and was found to have a parathyroid adenoma (8931 mg).  Postoperatively his calcium never normalized after the 2nd surgery. Sestamibi scan showed no evidence of parathyroid adenoma.  A 3rd surgery was performed (neck exploration) 8 months later without success.

The patient remained hypercalcemic and developed renal insufficiency (creatinine 2.4mg/dL (nl-0.7-1.3)).  His calcium remained in the 12 to 17 mg/dL range so he was initiated on several doses of pamidronate and fluids with no decrease in his calcium.  Sensipar 90mg was initiated with some decrease in his calcium, but never in the normal range.

Patient then transferred care to our institution.  Staging studies identified pulmonary metastases, largest (2.2cm mass right lower lobe), and small neck disease.  He was treated with zolendronic acid with some decrease in his calcium 12-14mg/dL.  Patient was referred for debulking of the largest lung lesion to control the calcium.  After a right thoracotomy with right lower lobe segmentectomy and multiple wedge resection of his parathyroid carcinoma, the patient had excellent control of his calcium down to 9 for about 8 weeks.

 Next generation sequencing was performed on his metastatic tumor specimen with no targetable mutations found.

His calcium climbed to 13mg/dL again, thus sensipar was re-initiated at 90mg daily.  Denosumab was not approved for financial coverage by insurance.  Given no identifiable targetable mutations on the resected lung tumor resected and reports of increased expression of angiogenesis in parathyroid ca, sorafenib was added at 400mg po BID.  Within one month of initiating sorafenib, his calcium fell from 15mg/dL to 7mg/dL.  Sensipar was stopped and sorafenib continued. The calcium remains in the normal range after 6 months on therapy.  His pulmonary metastases have decreased in size and his creatinine has improved from 2.6 to 1.5mg/dL.  His only adverse events are grade 1 hypertension and alopecia.

Conclusion:  Sorafenib may be a good therapeutic alternative for patients with parathyroid carcinoma refractory to traditional therapies.  Further studies are needed to elucidate mechanism of action and efficacy.

 

Disclosure: NLB: Investigator, GlaxoSmithKline, Investigator, Bayer, Inc., Consultant, Novartis Pharmaceuticals. AOH: Advisory Group Member, Bayer, Inc.. Nothing to Disclose: MEC, RD, CJ, MAH, AV, LM, NDP

14952 1.0000 SUN-0279 A Metastatic Parathyroid Carcinoma and Hypercalcemia Responds to Treatment with Sorafenib 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Antonio M Lerario*1, Regina M Martin2, Ana Oliveira Hoff3, Marilena Nakaguma4, Gilberto Castro Jr.3, Carlos Henrique Teixeira3, Marcos Menezes5, Vanessa Dalalio6 and Berenice B Mendonca7
1ICESP/University of Sao Paulo, São Paulo, Brazil, 2Hospital das Clinicas, University of Sao Paulo School of Medicine, Sao Paulo, Brazil, 3ICESP/University of Sao Paulo, Sao Paulo, Brazil, 4Hospital das Clinicas, University of São Paulo Medical School, São Paulo, SaoPaulo, 5ICESP/University of Sao Paulo, São Paulo, 6Uberaba, Brazil, 7Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular, LIM 42, Hospital das Clínicas, Faculdade de Medicina, São Paulo University, São Paulo, Brazil, São Paulo, Brazil

 

Background: Parathyroid carcinoma (PTCA) is a rare tumor that responds poorly to therapies other than surgery. When surgery is not curative, patients usually die as a result of hypercalcemia. In this setting, cytoreductive procedures, immunotherapy and drugs targeting calcium metabolism may temporarily improve the control of hypercalcemia. Chemotherapy is associated with severe toxic symptoms and few clinical benefits. Kinase inhibitors (KIs) have emerged as attractive therapeutic options for endocrine tumors. A recent study has shown that parathyroid tumors have high expression of VEGFR and PDGFR, providing a rationale for considering KIs for refractory PTCA. Case-report: A 50 year-old female patient presented with a palpable thyroid nodule 6 years ago that was surgically removed. Pathological findings were consistent with PTCA. At that time, calcium and PTH levels were normal. Since her sister had primary hyperparathyroidism, the HRPT2 gene was sequenced and an inactivating germline mutation was identified. In the next 2 years, the patient developed local recurrences that were treated with surgery. In Dec/2009, she developed bilateral pulmonary nodules and PTH-dependent hypercalcemia which subsequently became refractory to calcium lowering agents (zoledronic acid (ZA) and denosumab) and multiple cytoreductive procedures (either transthoracic radiofrequency termoablation (RFTA) and thoracotomy for mediastinal and pleural metastases). After presenting episodes of acute pancreatitis (Dec/2012 – Mar/2013), the patient underwent a new RFTA for a pleural nodule and surgical removal of a thoracic subcutaneous nodule. Ten days after (Apr/2013), reduction of total calcium (tCa) from 12.6 to 10.2 [N:8.6-10.2 mg/dL], ionized calcium (iCa) from 7.1 to 6.3 [N: 4.6-5.3 mg/dL] and PTH from 3,167 to 1,001 [N:15-65 pg/mL] were achieved. After a multidisciplinary discussion, we opted for a therapeutical trial with sorafenib, a KI that targets VEGFR and PDGFRs in a dose of 400 mg twice a day. One week later, a decrease of tCa (8.6), iCa (4.5) and PTH (264) was observed. Despite of a progressive elevation of PTH levels observed in the following 9 months (up to 4,505), tolerable calcium levels (tCa=10.3 and iCa=6.1) were reached combining ZA, denosumab and sorafenib. Of note, the patient presented weight recovery and improvement of muscle weakness and fatigue. Discussion: This is an illustrative PTCA case characterized by an atypical initial clinical presentation and long-term survival. To our knowledge, it is the first report of sorafenib therapy in metastatic PTCA and its effect on bone metabolism has been suggested by targeting PDGFR and decreasing osteoclast function. In our patient, hypercalcemia handling was facilitated after sorafenib intake and we suggest that KIs may have therapeutic effects in metastatic PTCA, supporting further studies.

 

Nothing to Disclose: AML, RMM, AOH, MN, GC Jr., CHT, MM, VD, BBM

16604 2.0000 SUN-0280 A Sorafenib Treatment Improves Refractory Hypercalcemia in a Patient with Metastatic Parathyroid Carcinoma: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Anne Marie Hannon*1, Deirdre Fitzgerald1, David Tuite1, Patrick Sheehan2 and Antoinette A Tuthill1
1Cork University Hospital, Cork, Ireland, 2South Infirmary/ Victoria University Hospital, Cork, Ireland

 

Parathyroid cancer is a rare disease, occurring with an annual incidence of approximately 1.25 cases per 10,000,000 persons. Persistent or recurrent disease frequently occurs, reoperation success rates increase significantly with pre-operation localisation techniques. Survival rates vary widely in the literature, with 5-year survival ranging from 20-85% and 10-year survival from approximately 15-80%. Data from the US National Cancer Data Base showed a 5-year survival of 88.5% and a 10-year survival of 49.1%

We present the case of a 29 year old man who presented with symptoms of hypercalcaemia in 2008. His Ca and PTH were significantly elevated at 2.99 mmol/l and 1299ng/l respectively. He underwent a MIRP with single gland resection of his left lower parathyroid gland. His histology revealed parathyroid carcinoma with extension of cells through the capsule and focal vascular invasion. His PTH fell to 19ng/l following surgery, however it began to rise within two months. He had a CT Neck, a sestamibi scan, neck ultrasound and PET scan which did not demonstrate any residual parathyroid tissue. His Ca was persistently elevated at 2.71 – 3 mmol/l and his PTH had risen to 273ng/l. On discussion with the MDT, he was referred for selective venous sampling.  The venous sampling clearly demonstarted an increased level of PTH in the proximal internal jugular vein in comparison to the peripheral sample (711ng/l vs  249ng/l).  He underwent a left thyroid lobectomy and central neck dissection. Histology revealed recurrent parathyroid adenocarcinoma with nodular infiltration, one of the nine lymph nodes that were resected contained metastatic parathyroid adencarcinoma. His PTH fell to 28ng/l and his calcium normalised at 2.36mmol/l. Due to the rare occurence of this disease there is limited data available on localisation techniques in recurrent disease. This case demonstrates the importance of considering selective venous sampling in patients with biochemical recurrence of parathyroid carcinoma, particularly when radiological screening does not reveal residual parathyroid tissue.

 

Nothing to Disclose: AMH, DF, DT, PS, AAT

15140 3.0000 SUN-0281 A The Role of PTH Sampling in the Treatment of Recurrent Parathyroid Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Richmond Gyamfi*1, David Sloan2 and Prasanna Santhanam1
1Marshall University School of Medicine, Huntington, WV, 2University of Kentucky College of Medicine, Lexington, KY

 

Introduction

Primary hyperparathyroidism is the third most common endocrine disorder but in pregnancy, it’s a rare diagnosis (1-3).  Most of the information obtained are from case reports and a few retrospective studies (1).  We present a 33 year old female seen with hypercalcemia and primary hyperparathyroidism at 33 weeks gestation.

Clinical Case

 A 33 year old woman G3 P1 A1 with asymptomatic hypercalcemia for more than 2 years was referred to our clinic for expert opinion during pregnancy.  Past medical history was significant for GERD and hypercalcemia.  Patient had no known family history of hyperparathyroidism, hypercalcemia or nephrolithiasis. She was on prenatal vitamins, ferrous fumarate and Vitamin D 50,000units weekly.

On examination, vitals were stable except a BP of 146/84mmHg.  All other examination findings were normal for her age and gestation.  Patient had the diagnosis of hyperparathyroidism before pregnancy but that was managed conservatively.   On presentation, patient was asymptomatic with calcium of 11.0mg/dl and an intact PTH of 145.8pg/mL. Repeat labs at 35 weeks showed corrected calcium of 11.3mg/dl and intact PTH of 95pg/mL. At this point, after extensive review of literature, it was decided that surgery was the most suitable option even in late pregnancy. Patient was referred to an endocrine surgeon where parathyroidectomy was done at 36 weeks.  A 3cm parathyroid adenoma was removed with a significant decrease in PTH intraoperatively. Hypercalcemia resolved and the PTH was normalized to 32. Baby was delivered by cesarean section at 39 weeks without any complications.

Discussion

Diagnosis of primary hyperparathyroidism in pregnancy can be a challenge. Imaging for localization is limited to only ultrasound since sestamibi scan is contraindicated in pregnancy.  

Hypercalcemia in pregnancy is associated with maternal and fetal complications. Maternal complications include pancreatitis, hyperemesis gravidarum, hypercalcemic crisis, and nephrolithiasis. Fetal complications are mainly due to suppression of neonatal PTH. These include neonatal hypocalcaemia with associated tetany.  Other complications include low birth weight, preterm delivery and intrauterine death (2-6). Management algorithms are based on severity of the hyperparathyroidism induced hypercalcemia, symptoms of the patient and the gestational age. Management is conservative in most cases but surgical management (parathyroidectomy) is preferred in certain situations (4).  Patients with primary hyperparathyroidism who plan to get pregnant should undergo evaluation for parathyroidectomy before conception (7).

Conclusion

Untreated Primary Hyperparathyroidism in pregnancy can cause significant mortality and morbidity for both mother and fetus. Obstetricians should seek expert endocrinology opinion early and in most cases, complications can be avoided by timely pre-pregnancy management.

 

Nothing to Disclose: RG, DS, PS

12983 4.0000 SUN-0282 A A Case of Primary Hyperparathyroidism in Pregnancy-Challenges in Management in Late Third Trimester 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Olesya Krivospitskaya*1, Sarah Nielsen1, Ronald N Cohen1 and David H Sarne2
1University of Chicago, Chicago, IL, 2The University of Chicago, Chicago, IL

 

Introduction

MEN1 is an autosomal dominant disorder secondary to mutations in the tumor suppressor gene MEN1. We report a patient who presented with recurrent hypercalcemia and galactorrhea, and was diagnosed with MEN1 based on clinical criteria. A novel mutation in MEN1 gene was discovered

Clinical case

A 38 year-old female with a history of primary hyperparathyroidism treated with partial parathyroidectomy presented with recurrent hypercalcemia. The patient also had oligomenorrhea and bilateral galactorrhea since age 13. Her calcium was found to be 10.2 (8.4 - 10.2 mg/dL), PTH  109 (15 - 75 pg/mL) and prolactin 79.7 (4.8 - 23.3 ng/mL). MRI of pituitary revealed 5x5 mm non-enhancing lesion along the left lateral superior aspect of the pituitary gland. NM parathyroid imaging revealed a focus of increased and persistent activity highly compatible with a parathyroid adenoma along the posterior aspect of the left thyroid gland. The patient underwent CT chest, abdomen and pelvis, which did not reveal any other tumors. Fasting gastin, insulin, proinsulin, C-peptide, vasoactive intestinal peptide, glucagon, chromogranin A levels were all within the normal limits.

The patient was started on cabergoline 0.25mg twice per week for presumed prolactinoma. Her menstrual cycles became regular and galactorrhea subsided. The patient underwent subtotal parathyroidectomy with removal of a total of 2.6gms of parathyroid tissue and her calcium levels and PTH returned to normal.

Based on clinical criteria the patient was diagnosed with MEN1 syndrome. In addition, the patient reported a strong family history of MEN1-related tumors, further supporting the diagnosis: maternal uncle with parathyroid tumor at age 32, maternal grandmother with a pancreatic tumor at age 34, one maternal cousin with a parathyroid tumor at age 39 and one maternal cousin with a pituitary tumor at age 34 and a parathyroid tumor at age 35.

Genetic testing revealed a novel c.1350 G>C nucleotide change in MEN1 gene. The NHLBI ESP Exome Variant Server reports c.1350 G>C was not observed in approximately 6,000 samples from individuals of European and African American backgrounds, indicating that it is not a common benign variant in these populations. The nucleotide occurs at the last nucleotide position of exon 9 and multiple in silico models predict that this sequence alters the natural donor splice site, leading to abnormal gene splicing; however, the actual effect of the c.1350 G>C sequence change in vivo is unknown in the absence of RNA and functional studies. If c1350 G>C does not alter splicing, then it would be expected to lead to a Q450H missense change at a position that is well conserved across species. Therefore, this sequence change is a strong candidate for a disease-causing mutation.

Conclusion

We report a novel mutation in MEN1 gene in a patient presented with recurrent primary hyperparathyroidism and hyperprolactinemia.

 

Nothing to Disclose: OK, SN, RNC, DHS

15124 5.0000 SUN-0283 A 38 Year-Old Female with Recurrent Hypercalcemia and Hyperprolactinemia with a Novel Mutation in MEN1 Gene 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Sarah Berend*1, Antoine Bennet2, Alexandre Buffet2, Delphine Vezzosi2, Solange Grunenwald2 and Philippe Caron1
1CHU Larrey, TOULOUSE, France, 2CHU Larrey, Toulouse, France

 

Background
Multiple endocrine neoplasia type 2B (MEN2B) combines a medullary thyroid carcinoma (MTC), pheochromocytoma, a marfanoid habitus, and mucosal and/or intestinal ganglioneuromatosis. Unlike in multiple endocrine neoplasia type 2A, primary hyperparathyroidism has, to our knowledge, never been reported in MEN2B patients. We report herein, the case of primary hyperparathyroidism in a woman with a MEN2B and carrying a germ-line mutation in the codon 918 of RET gene.

Clinical case

In a 50-year old MEN2B woman with asthenia and constipation, biochemical evaluation revealed an increased serum calcium level (2.89 mmol/L, N: 2.2-2.6 mmol/L) associated with an inappropriate elevation of parathormone (152 pg/mL, N< 85 pg/mL) and high urinary calcium (307 mg/day). The patient had been previously followed in our department for an MTC treated by total thyroidectomy and bilateral neck dissection at the age of twelve (last evaluation serum calcitonin 743 pg/mL, CEA 23.7 ng/mL), a bilateral pheochromocytoma treated by bilateral adrenalectomy at the age of thirty, and a mucosal and digestive ganglioneuromatosis. Hyperparathyroidism was complicated by radial, femoral and lumbar osteoporosis whereas the patient has never had nephrolithiasis and serum creatinine concentration was normal (55 µmol/L, N< 90 µmol/L). Cervical ultrasound and MIBI tomoscintigraphy revealed a right inferior parathyroid adenoma. Medical treatment by Cinacalcet (45 mg per day) was started and improved clinical symptoms and normalized serum calcium level (2.5 mmol/L).

Conclusion

We report the first case of primary hyperparathyroidism in a 50-year old woman with MEN2B. Cinacalcet improved clinical and biochemical signs of hyperparathyroidism. Long-term follow-up of patients with MEN2B should include serum calcium and PTH monitoring in order to diagnose primary hyperparathyroidism in such patients.

 

Nothing to Disclose: SB, AB, AB, DV, SG, PC

15046 6.0000 SUN-0284 A Primary Hyperparathyroidism in a Patient with Multiple Endocrine Neoplasia Type 2B 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Angela Lee* and Stephen Morris Twigg
Royal Prince Alfred Hospital, Sydney, Australia

 

Background

There are multiple mechanisms by which tumors can cause hypoglycemia, and it is imperative to distinguish the underlying cause so that directed management strategies can be used to prevent and treat hypoglycemia, to enhance patient quality of life when the cancer cannot be cured.

Clinical Case

A 74 year old man who had a 15 year history of incurable metastatic low grade hemangiopericytoma and was previously living independently at home, presented with recurrent episodes of fasting hypoglycemia with neuroglycopenic symptoms. Episodes were resolved with the intake of oral carbohydrate provided by his partner (grade 1 hypoglycemia by US Endo criteria (1)). Blood tests to investigate Whipple’s triad showed a low insulin (<6pmol/L, RR: 10-96pmol/L), and low c-peptide (<33pmol/L, RR 200-1200pmol/L) during morning fasting spontaneous hypoglycemia (2.2mmol/L, RR 3.5-5.4mmol/L). Adrenal insufficiency was excluded with a normal morning cortisol (428nmol/L, RR 200-600nmol/L). Further investigation of his non-insulin mediated hypoglycemia showed a high ratio of serum IGF-II (80nmol/L, RR 47-94nmol/L) to IGF-I (3.6nmol/L, RR8.3-24.4nmol/L) consistent with non-islet cell tumour hypoglycemia (NICTH) mediated by IGF-II (2). Initial treatment with regular carbohydrate intake, and high dose dexamethasone at 2mg twice daily was used to prevent recurrent hypoglycemia, and he underwent palliative chemotherapy. On attempts to wean the dexamethasone due to glucocorticoid side-effects, hypoglycemia recurred, and he was commenced on concurrent recombinant human growth hormone therapy (rhGH), to help reduce bioavailable IGF-II. Subsequently, the combination of lower dose dexamethasone 1mg twice daily and rhGH was found to improve his quality of life ongoing across many months, through resolution of his fasting including nocturnal hypoglycemia, enabling him to be managed in ambulatory care, living at home. He appears to have tolerated the rhGH well.

Conclusions

This case raises key learning points: (i) even after a long duration of indolent malignancy, new episodic hypoglycemia due to NICTH can occur which may cause morbidity and mortality; (ii) it is important to identify if NICTH is caused by IGF-II because specific treatment with glucocorticoids and growth hormone can significantly improve patient quality of life; (iii) the minimum lab dataset required for diagnosis of NICTH being caused by IGF-II, especially utility of the molar IGF-II:IGF-I ratio when a ‘big IGF-II’ assay is not available, is exemplified; (iv) whether palliative rhGH is a viable long term treatment in lower grade incurable malignancies causing NICTH, is explored.

 

Nothing to Disclose: AL, SMT

11795 7.0000 SUN-0285 A Non-Islet Cell Tumor Hypoglycemia in Incurable Low-Grade Malignancy: Confirming IGF-II As the Cause Aids Palliative Care Outcomes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Jessie Teng*1, Sally K. Abell1, Nirupa Sachithanandan2, Michael S Hofman3 and Richard James MacIsaac2
1St Vincent's Hospital, Fitzroy, Australia, 2St Vincent's Hospital Melbourne, Australia, 3Peter MacCallum Cancer Centre, Melbourne, Australia

 

Background

Metastatic functioning neuroendocrine tumours (NETs) can present with refractory hormonal syndromes causing significant morbidity. Recent advances in therapy include the use of peptide receptor radionuclide therapy (PRRT).

Clinical Case

A 69-year-old man was admitted with an unconscious collapse and undetectable blood glucose levels several weeks after 1st dose of octreotide LAR for an insulin and gastrin co-secreting NET. He was initially diagnosed with a metastatic gastrinoma (pancreatic tail and hepatic lesions), after presenting with Zollinger-Ellison syndrome eight years ago. He subsequently underwent extensive surgery with normalisation of gastrin levels post-operatively. Histopathology confirmed a well-differentiated NET.

Three years later, he had intra-abdominal nodal recurrence, with hypergastrinaemia and new-onset hyperinsulinaemic hypoglycaemia (fasting glucose 1.7mmol/L; insulin 73mU/L; C-peptide 1.76pmol/L). He underwent another surgical resection; interestingly, the tumour stained positive for gastrin but negative for insulin. Over the ensuing five years, he developed multiple hepatic, nodal and osseous metastases. Due to the recurrence of symptomatic hypoglycaemia, he was commenced on glucocorticoids and octreotide therapy prior to his current presentation.

This time, however, his hypoglycaemia remained refractory despite aggressive management with continuous dextrose infusions, dexamethasone, diazoxide, glucagon therapy and enteral feeding. Given limited therapeutic options, PRRT was administered. His 2nd cycle of PRRT was complicated by catastrophic gastrointestinal bleeding despite oral PPI therapy, requiring emergency resuscitation. This hormonal crisis was likely caused by acute cell lysis and release of stored peptide hormones within tumour cells. Gradually, his hypoglycaemia resolved and he was able to maintain euglycaemia with only low dose dexamethasone. 

In total, our patient has now undergone four cycles of PRRT with a decrease in anatomical tumour burden as demonstrated by recent imaging. He remains asymptomatic and his gastrin, insulin and chromogranin levels have reduced significantly.

 

Clinical Lessons:

1)      PRRT is an effective therapeutic option for severe refractory hypoglycaemia due to insulin oversecretion in NETs, despite failure of conventional management. Early referral should be considered for patients with metastatic functional NETs.

2)      Although PRRT is generally well-tolerated, vigilance for peptide storm and worsening secretory symptoms is necessary post-PRRT, with supportive therapy.

3)      Response to hormonal oversecretion syndromes following PRRT can take several cycles of therapy.

4)      Hypoglycaemic collapse post-octreotide LAR is a well-described adverse effect, although this can be delayed and unpredictable, as in our case.

 

Nothing to Disclose: JT, SKA, NS, MSH, RJM

11574 8.0000 SUN-0286 A Peptide Receptor Radionuclide Therapy Is Effective for Refractory Hypoglycaemia in an Insulin and Gastrin Co-Secreting Metastatic Neuroendocrine Tumour 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Seng Kiong Tan* and Cherng Jye Seow
Tan Tock Seng Hospital, Singapore, Singapore

 

Introduction

Endogenous hyperinsulinemia in adults is commonly caused by insulinoma. We report a case of insulinoma localized by ASVS and review existing and emerging localization modalities.

Case Presentation

A 30 years old lady with absence seizure since childhood presented with syncope. A random capillary blood glucose was 2.7mmol/L (49mg/dL). A neurologist was consulted and the EEG was normal. Systemic history was unremarkable. She had no liver or renal impairment. She denied taking traditional herbal supplements or illicit drugs. There was no suggestion of hypocortisolism.

Physical examination was unremarkable. BMI was 19.6 kg/m2.

A 72 hour fast was performed and she became hypoglycemic 6 hours into fasting. Her venous glucose was 2.0mmol/L (36mg/dL). C-peptide was elevated at 403pmol/L (RI:<200pmol/L), insulin 3.9mU/L (RI:<3mU/L). Toxicology was negative for sulphonylurea. Serum calcium was normal. CT pancreas  and endoscopic ultrasound (EUS) were normal. ASVS was performed and insulin measured from the gastroduodenal artery increased 60x from 7mU/L at 0s to 422mU/L at 120s, localizing the insulinoma to the head of pancreas.

Discussion

Localizing insulinomas is challenging as 90% are <2cm. Many centers have compared non-invasive studies (CT, MRI, Octreotide scintigraphy) versus invasive studies (EUS, ASVS), with MRI being the most sensitive non-invasive study (MRI 25-71%, CT 32-64%, Octreotide scintigraphy 33-50%), and ASVS the most sensitive invasive study (ASVS 84-100%, EUS 65.4-86%).(1,2,3,4) Factors affecting the sensitivity of EUS include tumor size <0.75cm and those located in the tail of pancreas.(5) The suboptimal sensitivity of Octreotide scintigraphy is due to variable expression of sst2A and sst5 receptors in insulinoma.(6) 18F-FDOPA PET imaging is accurate in diagnosing congenital hyperinsulinism, but results are not replicable in adults due to increased expression of aromatic amino acid decarboxylase.(7,8) GLP-1R imaging showed promising results and allowed the use of intra-op gamma probe to aid surgical removal,(9) but studies found it useful in benign insulinomas and poor in malignant cases due to lack of GLP-1R expression in malignant insulinoma.(10) New tracers such as N-5-[(18)F]fluoropentylmaleimide are developed to improve the sensitivity of non-invasive localization modalities.(11)

Conclusion

ASVS remains the most sensitive modality for localization, while new tracers are developed  to improve the sensitivity of non-invasive techniques.

 

Nothing to Disclose: SKT, CJS

11532 9.0000 SUN-0287 A Endogenous Hyperinsulinemia Secondary to Insulinoma: A Review of Current and Emerging Localization Modalities for Pre-Operative Evaluation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Yang Guoqing*1, Dou Jingtao1, Zang Li2 and Mu Yiming1
1Chinese PLA General Hospital, Beijing, China, 2Chinese PLA General Hospital, beijing, China

 

Background: Insulin-producing tumors of the pancreas are the most frequent cause of pancreatic hyperinsulinemic hypoglycemia (PHH) in adults. They are usually solitary benign neoplasms , and some are MEN-1 associated insulinomas. There is a special form of pancreatic hyperinsulinemic hypoglycemia presented as recurrent, not MEN-1 associated multicentric insulinoma, is defined as insulinomatosis .

Clinical case: A 43-year-old female complained confusion and fatigue in the morning since March 1995. On her first admission(1996) to the PLA General hospital, the biochemical tests showed fasting hyperinsulinemic hypoglycemia, insulinoma was suspected, but the imaging studies were negative, during exploratory laparotomy, a red round mass, 0.2cm in diameter, was detected in the pancreatic body and another red mass, 0.4cm in diameter, was detected at the tail of the pancreas. After the operation, symptoms were alleviated , and fasting plasma glucose levels returned to normal. But 6 months later, above symptoms recurred again and worsened gradually. On her second admission in 2001, the results of biochemical tests indicated insulinoma again, distal pancreatectomy was performed . Intraoperative exploration detected multiple nodules between the central body to the tail of the pancreas. Pathological findings showed multiple grey, medium solid nodules, with various dimensions from 1×1×1cm to 0.3×0.3×0.3cm. HE staining showed that multiple microadenomas (< 5mm) and insulin-expressing monohormonal endocrine cell clusters were distributed inside the pancreatic tissue. After several years of remission, the patient was admitted for the third time because of severe symptoms of hypoglycemia. Clinical findings were similar with those of the second admission. The remnants of pancreas were removed, pathologic showed similar results with the second operation. MEN1 gene sequencing analysis was negative. Conclusion: Here is a case report of insulinomatosis described first time in China. Recurrent hypoglycemia, multicentric multiple microadenoma secreting insulin and insulin-expressing monohormonal endocrine cell clusters may be the clinical and pathological features of insulinomatosis.

 

Nothing to Disclose: YG, DJ, ZL, MY

14730 10.0000 SUN-0288 A A Special Form of Pancreatic Hyperinsulinemic Hypoglycemia ---Insulinomatosis: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Viveka Jyotsna*1, Selvarajan Ramkumar2, C J Das2, C Bal2, Amlesh Seth2 and M C Sharma2
1All India Institute of Medical Sciences, New Delhi, India, 2All India Institute of Medical Sciences, Delhi, Delhi, India

 

Background: Hypoglycemia secondary to non-pancreatic ectopic insulin secretion of is rare. Of the 48 cases of insulinoma treated by us in the last 20 years, this is the first case of ectopic insulin secretion arising from kidney. This lady presented with recurrent hypoglycaemia which turned out to be due to ectopic insulin secretion from neuroendocrine tumor in kidney. To the best of our knowledge, this is the first report of neuroendocrine tumor located in kidney proven to produce insulin and leading to hypoglycemia. All previously reported cases of ectopic insulinoma have been reviewed and tabulated.

Clinical case: A forty four year old lady presented with recurrent hypoglycemic episodes for 3 years. She had complains of forgetfulness, altered behaviour, headache, palpitation, sweating and giddiness. Most of her symptoms occurred in the early morning and improved spontaneously. She consulted various physicians including neurologist and psychiatrist and had been diagnosed as pseudo-seizure, panic attacks or conversion disorder.

 Diagnostic evaluation:

After admission, she had persisted hypoglycemia and required continuous infusion of 10% Dextrose at the rate of 75 – 100ml/hr in addition to 1-2 hourly feeds. Her hemogram, electrolytes, renal and liver functions were normal. HbA1c was 4.5%. Hormonal assay showed thyroxine (T4) 5.67(5.1 – 14.1mcg/dl), TSH 4.42(0.27 – 4.2 mIU/ml), Insulin like Growth Factor- I(IGF-1) - 165.90(62 – 205 ng/ml), growth hormone 1.20 ng/ml and cortisol 15.78 mcg/dl. Results of critical samples collected during hypoglycemia had high insulin and high c-peptide during hypoglycemia confirming endogenous hyperinsulinemic hypoglycemia. 

Both multi-phase CT abdomen and contrast enhanced MRI abdomen demonstrated a mass lesion arising from upper- mid pole of right kidney. No lesion was identified in the pancreas. Endoscopic ultrasound also did not demonstrate any pancreatic lesion. 68Gallium DOTANOC scan and 99mTc-HYNICTOC nuclear scan did not demonstrate any  uptake in the pancreas but both demonstrated intense uptake in the mass lesion in the kidney indicating a neuroendocrine tumor.

Treatment and follow up:

She underwent abdominal exploration and right nephrectomy. Post-operative period was uneventful and she became euglycemic without need for dextrose infusion. Her glucose values were maintained between 120 – 160 mg/dl thus confirming clinically the right sided mass near renal hilum to be the source of ectopic insulin secretion. 

 Ultra-structural examination revealed insulin secreting neuroendocrine tumor, positive on staining for insulin. Hypoglycemia disappeared after tumour resection.

 Clinical lessons/Conclusion: This is the first case of ectopic insulin secretion from neuroendocrine tumor of the kidney. It proves that ectopic origin of insulin from kidney exists and is cured on resection.

 

Nothing to Disclose: VJ, SR, CJD, CB, AS, MCS

14897 11.0000 SUN-0289 A Ectopic Insulin Secreting Neuroendocrine Tumor Arising from Kidney: A Diagnostic Dilemma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Radhika R. Narla*1, Kathleen Kelly2 and Anthony P Heaney2
1UCLA David Geffen School of Medicine, Los Angeles, CA, 2University of California (UCLA), Los Angeles, CA

 

Background: 72 hour fasting protocol remains an important diagnostic tool in evaluation of complex hypoglycemia cases.

Clinical Case: A 52-year old male with 15 year history of T2DM complicated by retinopathy, neuropathy and End stage renal disease (ESRD). He had been on Hemodialysis since 2011 and following gastric bypass in 2009, he stopped all insulin and oral diabetic medications. In July 2013, he developed hypoglycemia and at presentation to us was having daily seizures with blood glucose levels 30-40 mg/dL. Workup at an outside hospital had suggested endogenous hyperinsulinemia but despite treatment with diazoxide and octreotide he continued to have hypoglycemia and seizures requiring frequent hospitalizations.

Review of his home blood glucose monitoring logs indicated the patient was having both fasting as well as post prandial hypoglycemic episodes. The case was further complicated by presence of an insulin antibody and interpreting his insulin levels in the setting of his ESRD.  To better understand the mechanism of his hypoglycemia, the patient was admitted for a 72hour fast.

Within 48 hours, the patient demonstrated fasting hypoglycemia with blood glucose ≤45mg/dL.  Concomitant insulin level was 111uU/ml (3-25 uU/ml), proinsulin was 28.7 pmol/L (n<28.9 pmol/L), C-peptide was 1.2 ng/ml (1.1-4.3 ng/ml) and beta hydroybutrate was 2.10mmol/L (n<0.4mmol/L) confirming hyperinsulinemic hypoglycemia.  Sulfonylurea screen was negative. Given the discordance in insulin and C-peptide levels and known insulin antibody, free insulin levels were measured after PEG-precipitation of serum samples. Free insulin was also inappropriately elevated. Imaging with CT and Endoscopic Ultrasound (EUS) showed a homogeneous hypoechoic lesion in the pancreatic tail. Sonographic features were consistent with a neuroendocrine tumor (PNET) which was further supported by an EUS guided fine needle aspiration biopsy revealing neuroendocrine tumor cells. Following distal spleen sparing pancreatectomy, PNET was confirmed histopathologically and the patient was euglycemic during 72 hours of inpatient post-operative monitoring.

Conclusion: This complex patient had 3 distinct etiologies for hypoglycemia. He exhibited postprandial symptoms which pointed to his gastric bypass as the main etiology.  He also had significant titers of an insulin antibody raising the possibility of autoimmune mediated hypoglycemia. Ultimately his 72 hour fast documented fasting hyperinsulinemic hypoglycemia which prompted careful evaluation for an insulin secreting NET that was ultimately resected from his pancreas. This case highlights several key teaching points in the assessment of the hypoglycemic patient and demonstrates the importance of the 72 hour fast even in cases where other etiologies are at first considered more likely.

 

Nothing to Disclose: RRN, KK, APH

15915 12.0000 SUN-0290 A The Importance of the 72 Hour Fast in a Patient with Multiple Etiologies for Hypoglycemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Ashley Ann Thorsell* and Matthew Jason Levine
Scripps Clinic, La Jolla, CA

 

Insulinomas represent a rare subtype of pancreatic neuroendocrine tumors, with a reported incidence of 4 cases per 1 million patient-years. The average age of diagnosis is 47 years, with women accounting for 59% of the cases. Surgical excision is the treatment of choice, and usually curative.

A 48 year-old female presented to the hospital in an unresponsive state, and was found to have a blood glucose (BG) level <30mg/dL. For four months prior, she recalled having symptoms of sleepiness, perioral paresthesia, “feeling drugged”, confusion and “spotty vision” with prolonged fasting. Her symptoms resolved with food and normalization of her BG, confirming Whipple's Triad. During her hospitalization, she had confirmed low BG with inappropriately elevated insulin and C-peptide levels. An MRI with multiplanar imaging showed no evidence of a pancreatic mass or inflammation. An abdominal CT scan with and without contrast was also negative for any pancreatic abnormalities. Her pituitary, thyroid, and adrenal function were all normal. When she presented to me, low BG in the setting of elevated insulin and C-peptide levels were again confirmed as an outpatient, after an overnight fast. Her Beta-Hydroxybutyrate level was normal at 0.06mmol/L (reference 0.28 or less) during an episode of hypoglycemia. Her insulin antibody level and sulfonylurea screen were both negative. Her proinsulin level was elevated at 99.7pmol/L (reference 18.8 or less). She finally had an endoscopic ultrasound, which was suspicious for a 10mm x 8mm lesion at the head of the pancreas near the bile duct; four fine-needle aspiration biopsies showed results consistent with a neuroendocrine tumor, which stained positive for chromogranin and synaptophysin. Calcium and prolactin levels were normal, making MEN type 1 less likely. Her symptoms were controlled with conservative dietary measures and Diazoxide. She underwent a laparoscopic enucleation of a solitary 1.5cm x 1.4cm x 0.9cm ovoid insulinoma, confined to the pancreas and without metastases. The pathology confirmed a benign, well-differentiated, grade I neuroendocrine tumor (Ki-67 labeling index <2%). One month postoperatively, she had complete resolution of her hypoglycemia, with an average BG of 93mg/dL (range 78-119mg/dL).

We report a case of a 48 year-old female who presented with classic neuroglycopenic symptoms, and found to have an insulinoma at the head of the pancreas that was successfully cured with surgical resection.

 

Nothing to Disclose: AAT, MJL

11517 13.0000 SUN-0291 A Case Report of an Insulinoma in a 48 Year-Old Female 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Aditya Varnam Shreenivas*1 and Vivien Leung2
1Bronx Lebanon Hospital, Bronx, 2Bronx Lebanon Hospital Center, New York, NY

 

INTRODUCTION: Although historically, fasting hypoglycemia has been considered the hallmark of an insulinoma, postprandial hypoglycemia has also been occasionally reported as the predominant feature.  We report a rare case of an insulinoma diagnosed in an individual presenting without fasting hypoglycemia and instead, with postprandial hypoglycemia.

 CASE REPORT: A 47year-old Hispanic female with medical history of migraine, depression, hypercholesterolemia, iron deficiency anemia and peptic ulcer disease presented with complaints of frequent episodes of dizziness, blurring of vision and anxiety over the past four months.  These episodes usually occurred 1-2 hours after eating and resolved with ingestion of sugary foods.  Home glucometer readings during typical symptoms ranged from 47-64 mg/dL.  She denied any prior history of type II diabetes, gastric bypass surgery, and had no family history of diabetes. Physical exam revealed a healthy appearing middle-aged female with BMI of 28.  Bloodwork after an overnight fast showed serum blood glucose 77mg/dL, 8am cortisol 9.6 (5-25 µg/dl).  Hemoglobin A1C, thyroid function tests, IGF-1, liver function tests and renal function were in normal range.  She was instructed to bring a typical meal to clinic for monitoring of postprandial fingerstick sugar level.  3 hours after ingestion of the meal, she developed typical adrenergic symptoms during which point-of-care testing showed a glucose level of 49.  Bloodwork drawn during the episode revealed a serum glucose level of 44 mg/dL, C-peptide of 2.9(0.8-3.1ng/ml) and insulin level of 32(0-17 µIU/lt).  Sulfonylurea screen and insulin antibodies were negative. After bloodwork was drawn, she was given 15gm of oral glucose following which symptoms resolved.  Medical therapy with acarbose was attempted, but did not lead to significant reduction in her hypoglycemic events.  MRI abdomen/pelvis confirmed the presence of two tumors in the tail of the pancreas.  Patient subsequently underwent partial pancreatectomy, splenectomy and lymph node resection. Pathologic analysis revealed three tumors resected from pancreatic body and tail measuring 0.8 cm, 1 cm and 1.2 cm in greatest dimensions respectively. Histologically the tumors were neuroendocrine in nature, and were consistent with insulinoma.  Post-operatively, her hypoglycemic symptoms resolved completely. 

CONCLUSION: Insulinoma is frequently associated with fasting hypoglycemia.  We present a rare case of an insulinoma in the setting of verified postprandial hypoglycemia with elevated insulin and C-peptide levels  Although insulinomas typically present with fasting hypoglycemia, it is important to consider insulinoma in the differential of patients presenting with postprandial hypoglycemia as well.

 

Nothing to Disclose: AVS, VL

11309 14.0000 SUN-0292 A A Rare Case of Insulinoma Presenting without Fasting Hypoglycemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Jayme A. Aschemeyer, Mohammad Kawji* and Wael Taha
Wayne State University, Detroit, MI

 

Background:  The Warburg hypothesis postulates that cancer cells observed in vivo and in vitro exhibit glycolysis with lactate secretion, even in the presence of sufficient oxygen.

Clinical case:  We report a 42 year old HIV+ male who was referred to our consultation service for hypoglycemia.  Physical examination demonstrated cachectic appearing male with bilateral leg edema.  He had no clinical manifestations of neuroglycopenia despite serum glucose of 36mg/dl. His serum lactate was 8.5 mmol/L (normal range, 0.4-2.0 mmol/L).  Cosyntropin stimulation testing showed an adequate morning response with a peak cortisol of 19.8 mcg/dL.  C-peptide and insulin levels were obtained during hypoglycemic conditions; 0.4 ng/mL and <0.1 µIU/mL respectively. 

Bone marrow biopsy defined 100% cellular bone marrow with 50% involvement by Burkitt-like lymphoma with a leukemic phase.  Flow cytometry report analysis showed abnormal CD10 positive and CD4 positive B cell neoplasm with partial retention of CD19 and no light chain expression.  Examination of peripheral blood slide shows large lymphoma.  Burkitt lymphoma is known to have loss of B cell markers including light chains and to acquire abnormal markers such as CD4. 

He had improvement of his hypoglycemic episodes during his initial diagnosis with chemotherapy, however, he was readmitted two months later with recurrent hypoglycemia and lactic acidosis. He opted to forgo further treatment and was placed on hospice.

Conclusion:  This case indicates that Warburg effect improves by treating the etiologic malignancy. And the excess lactate possibly serves as the energy source for the brain, as evidenced by lack of neuroglycopenic symptoms.

 

Nothing to Disclose: JAA, MK, WT

13566 15.0000 SUN-0293 A Improvement of Asymptomatic Hypoglycemia and Lactic Acidosis after Chemotherapy in a Patient with Burkitt's Lymphoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Jaisri Maharaj* and Devaprabu Abraham
University of Utah, Salt Lake City, UT

 

Title: Spontaneous amelioration of type 2 diabetes in a patient with large insulinoma. 

Background: Insulinomas can occur in type 2 diabetics but are very rare. Development of insulinoma in type 2 diabetic patients leads to the delay in its diagnosis due to the relative protective effects of hyperglycemia and the inherent risk of hypoglycemia induced by oral agents. We report a patient with insulinoma in a patient treated for Type 2 diabetes and performed a review of the literature.

Case report: A 55 year old male with a five year history of Type 2 diabetes mellitus and hypertension was hospitalized for acute exacerbation of heart failure. He was noted to have recurrent episodic hypoglycemia with sugars as low as 35mg/dL. Episodes were accompanied by anxiousness, weakness and dizziness with increasing frequency over the preceding 6 months. Symptoms were relieved by eating. There was no apparent progressive loss of memory. His diabetes was treated with linagliptin 5 mg and glyburide 5 mg per day. His HbA1C was 6.1%, (n 4.0-5.6%). Due to the recurrent hypoglycemia, his diabetic medications were gradually discontinued. Glyburide was discontinued 4 months ago, and then the linagliptin. Imaging of the spine was performed for the evaluation of chronic back pain, which revealed an incidental mass within the tail of the pancreas measuring 4.7 x 2.6 cm. FNA was performed under endoscopic-guided ultrasound of this mass to rule out pancreatic adenocarcinoma. The pathology was reported as findings consistent with islet cell neuroendocrine tumor. No masses in the liver or lymphadenopathy were evident by imaging. During the hospital stay, a skin biopsy for migratory rash on his back did not reveal skin findings of glucagonoma. Results:

Biochemical testing during a hypoglycemic episode revealed the following findings:

blood glucose of 45 mg/dL, serum C-peptide of 5.6 ng/ml (n 0.8-3.0 ng/ml), serum insulin of 20 microIU/ml (n 3-19 microIU/ml), proinsulin of 6 pmol/L (n <\ 28.9 pmol/L) and serum free cortisol of 2.54 mcg/dL (n 0.15- 0.94 mcg/dL). His serum chromogranin A level was 1261 ng/ml (0-95 ng/ml).  Patient is awaiting surgical removal of the pancreatic tumor.

Conclusion: A review of the literature reveals that rarely, insulinoma can develop in type 2 diabetic subjects. To our knowledge, this case is unique in the spontaneous improvement of blood sugar control requiring complete cessation of all anti-diabetic agents. This case also emphasizes the importance of considering insulinoma as a cause of recurrent hypoglycemia in diabetic patients.

 

Nothing to Disclose: JM, DA

15458 16.0000 SUN-0294 A Spontaneous Amelioration of Type 2 Diabetes in a Patient with Large Insulinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Laura Joan McCreight*, James G Boyle and Russell S Drummond
NHS Greater Glasgow and Clyde, Glasgow, United Kingdom

 

Introduction

This case highlights the variable presentation of carcinoid tumours according to their primary site – in this case an ovarian primary.

Clinical Case

Our patient is a 76 year old female who is physically active, still playing badminton, referred in March 2012 with two months of increasing peripheral oedema, and episodes of light-headedness. She has a past medical history of hypertension, cerebrovascular disease, diverticular disease and a previous left oopherectomy (1965) for an ovarian cyst. On initial assessment she was found to have both a pansystolic and diastolic murmur and marked bilateral pitting oedema. Clinically, she had tricuspid regurgitation with prominent “v” waves, a pulsatile liver, and peripheral oedema. Initially, right-sided heart failure secondary to valvular heart disease was suspected.

Investigations

An echocardiogram confirmed tricuspid and pulmonary valve destruction with significant regurgitation, consistent with carcinoid heart disease. On further questioning, she described flushing episodes with triggers including spicy foods and alcohol, and a two year history of intermittent diarrhoea. A diagnostic urinary 5-HIAA level of 769umol/L (reference range 0-50umol/L) confirmed the diagnosis of carcinoid. Abdominal ultrasound showed normal upper abdominal organs with neither liver metastasis, nor inferior vena cava thrombosis, but a large right ovarian mass (44x54x30mm) was identified and confirmed on CT scanning.

Results / treatment

Surgical resection was scheduled, with pre-operative octreotide given to prevent carcinoid crisis. Histopathology demonstrated an insular ovarian carcinoid tumour. Post-op, urinary 5-HIAA levels were undetectable. Our patient has recovered well and has returned to badminton. She awaits cardiac surgery for valve replacement.

Conclusions

This patient presented with carcinoid syndrome and carcinoid heart disease secondary to an ovarian carcinoid tumour. Primary ovarian carcinoid tumours account for 0.3 – 1% of all carcinoid tumours, and for <0.1% of ovarian tumours 1,2. Up to 33% of insular ovarian carcinoid tumours will be associated with carcinoid syndrome3, and carcinoid heart disease affects approximately one third of those with carcinoid syndrome4. GI carcinoid tumours develop carcinoid syndrome after liver metastasis prevents serotonin metabolisation within the liver, and therefore allow serotonin to be released into the systemic circulation. As the ovarian vein drains directly into the inferior vena cava, carcinoid syndrome manifests independent of liver dysfunction in ovarian carcinoid5. An important consideration for this patient was pre-operative planning – the suspicion of carcinoid allowed appropriate pre-operative treatment with octreotide to prevent carcinoid crisis i.e. the sudden and dramatic release of excess mediatory substances causing shock and circulatory collapse5.

 

Nothing to Disclose: LJM, JGB, RSD

12369 17.0000 SUN-0295 A An Ovarian Carcinoid Tumour Presenting with Carcinoid Heart Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Kristina Linder Ekberg*1, Henrik Ullen2 and Kjell E Oberg3
1Dep of Endocrinology, Metabolism and Diabetes, Stockholm, Sweden, 2Dep. of endocrine oncology, Uppsala, Sweden, 3University Hospital, Uppsala, Sweden

 

Background: Hyperammonemia in tumor patients with liver metastases but normal liver function has been described precipitating hepatic encephalopathy. The mental symtoms vary from mild lack of awareness through disorientation to coma and death.

Clinical case: At the time of diagnosis 57 year old caucasian woman with a history of hypertension, hysterectomy (myoma) and vascular headache.
Intermittent flushing since a couple of  years.

Diagnostic evaluation: In Dec 2008 the patient underwent CT and MRI because of an abdominal lump. Eight hepatic lesions were found, a pan-creatic tumor and a metastase in the spleen, fine needle biopsy of the liver showed neuroendocrine cells and Chromogranin A and urinary excretion of 5-HIAA was increased. A liver biopsy disclosed a neuroendocrine tumor with proliferation rate 3% according to Ki67. Somatostatin analogue (SSA) was initiated in March 2009 and interferon added in May the same year.

In July 2009 the patient complained of a slight ataxia, tiredness, headache, dizziness and slowness in activity. She acted weard according to her hus-band. IFN was omitted.

She was hospitalized three episodes autumn 2009 during which several investigations were performed including  EEG which showed hepatic en-cephalopathy but INR and Albumin were normal. CT and MRI of the brain was normal and liver ultrasound verified normal blood flow in portal and liver veins. CT abdomen: stable disease.
There was two episodes where she became comateuse and was treated at the intensive care unit (ICU). Diagnostics initially didn´t give any clues to her coma. Ammonia in serum was elevated (121 and 194) µmol/L and treatment with sodium benzoate was initiated. The patient woke up after a week.

A suspicion of a hepatic porto-systemic shunt was raised and liver transarterial chemoembolization (TACE) was performed. The mental status of the patient was restored efter a few days and the ammonia levels dropped instantly postembolisation to normal levels.

Follow up: Due to a successive biocemical progression in ammonium ions and chromogranin A during 2010 despite clinically and radiological stable disease  Temozolamide and Bevacizumab was started in Oct 2010.
The  patient is now in excellent general condition 54 months after her he-patic encephalopthy and is followed on an out-patient basis with ammoni-um levels within the normal range.

Since neuroendocrine tumors are often slowly progressing with a fairly long life expectancy, one has to take particular considerations if these pa-tients develop hyperammonemia. Even in generalized disease with exten-sive liver metastases the life gain of treating hyperammonemia can be several years.

In conclusion it is important to diagnose this condition in patients with advanced NET to prevent fatal outcome as well as to improve quality of life. All NET pat with advanced disease and bizarre symptoms should be checked for ammonium levels despite normal liver function.

 

Nothing to Disclose: KLE, HU, KEO

16401 18.0000 SUN-0296 A Hyperammonemic Encephalopathy in a Patient with Hepatic Metastases of Neuroendocrine Tumor. a Report on a Case Successfully Treated with Hepatic Artery Embolization 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Maija Mukane*1 and Ingvars Rasa2
1Riga Stradins University, Riga East Clinical University Hospital, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia, 2Riga East Clinical University Hospital, Riga Stradins University, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia

 

NF pNEC represents 2-5% of all pancreas malignancies and have an incidence of 1 case per 100 000 individuals per year, but the incidence of Hodgkin lymphoma is 2.8 cases per 100 000 individuals per year. Case report shows patient with two rare diseases developed simultaneously. A 66–year–old man with no alcohol abuse presented with cystic tumor in pancreas tail, which caused mild acute pancreatitis. In further evaluation CT scan was made and no signs of malignancy were found, in fine needle aspiration biopsy no atypical cells were found (2010). In next two years patient had follow-up visits. Comparison abdominal CT scan was made in April, 2013. Pancreas tumor enlargement, mediastinal, hilar, para-aortic, para-rectal, infraclavicular and axillary lymphadenopathy and single focus in spleen (metastasis?) were found. Basing on mentioned findings there was differential diagnosis between pancreas tumor with metastasis and lymphoproliferative disorder. Distal pancreas resection and splenectomy was made in May, 2013. Histologically NF pNEC Grade 1 (CKAE1/AE3, chromogranin, Ki67 positive), Hodgkin lymphoma in spleen and lymph nodes (60% T lymphocytes CD3+) were proved. After surgery in June, 2013 neuron-specific enolase level was increased (27.95 ng/ml), but in October, 2013 – in reference interval (15.49 ng/ml). Till now patient have regular chemotherapy because of Hodgkin lymphoma, no metastasis of NF pNEC were found in comparison CT scans. As in case of this patient presentation of NF pNEC has no specific signs, currently CT scans are the studies most used for detection. Although NF pNEC and Hodgkin lymphoma are rare diseases, they can combine.

 

Nothing to Disclose: MM, IR

12529 19.0000 SUN-0297 A Non Functioning Pancreas Neuroendocrine Carcinoma (NF pNEC) and Hodgkin Lymphoma Simultaneously:Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Anne E Bantle*1 and Sidney A Jones2
1University of Minnesota Medical School, 2Ridgeview Medical Center, Chaska, MN

 

Introduction:

Evaluation of patients with elevated gastrin levels can be challenging. We present the case of a patient with significant elevations in serum gastrin and suspected gastrinoma. The case illustrates the importance of an expanded differential diagnosis in the workup of hypergastrinemia.

Clinical Case:

A 39 year old woman with history of hypothyroidism presented to the endocrine clinic for evaluation of diaphoresis, hot flashes, and fatigue. Thyroid function was within the normal range on a replacement dose of 112 mcg levothyroxine per day.  She reported a history of an elevated gastrin level several years prior at another institution. Endocrine workup included fasting gastrin level, which was elevated on two separate occasions (2371 and 3122 pg/ml; normal range <100 pg/ml after 8 hour fast). Chromagranin A level was also elevated (472 and 410 ng/ml; range <93 ng/ml). Workup for gastrinoma was pursued. This included computed tomography scan of the chest, abdomen and pelvis, which revealed a small ovarian cyst but was otherwise normal. A 24 hour whole body indium 111 pentetreotide scan (Octreoscan) was negative. Esophagogastroduodenoscopy was performed and showed localized erythema in the area of the pylorus with no esophageal, gastric or duodenal ulcers.  Biopsy specimens were negative for Heliobacter pyloriinfection, though biopsy of gastric mucosa revealed mild active gastritis and mild atrophy. Gastric pH obtained by gastric probe was >7.0, in the absence of treatment with antacids or proton pump inhibitors. Parietal cell antibodies were positive (109.0 units; range <20.0 units). There was no vitamin B12 deficiency (518 pg/ml; range 239-931 pg/ml), and hemoglobin was normal at 13.4 g/dl (range 12.0-16.0 g/dl) though with low mean corpuscular volume of 79 fl (range 80-98 fl). 

Conclusion:

Autoimmune gastritis is a chronic inflammatory disease of the stomach that is often silent until its late stages. Prevalence estimates range from 7.8 to 19.5% (1), but despite high prevalence the diagnosis can be overlooked prior to development of late manifestations, especially B12 deficiency and anemia. One of the biochemical markers for autoimmune gastritis and gastric atrophy is elevation in serum gastrin. A diagnosis of chronic autoimmune gastritis with achlorhydria should be considered in the differential of a patient with an elevated gastrin level.

 

Nothing to Disclose: AEB, SAJ

14252 20.0000 SUN-0298 A Cryptogenic Gastrin Elevation: The Search Is on 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Maija Mukane*1 and Ingvars Rasa2
1Riga Stradins University, Riga East Clinical University Hospital, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia, 2Riga East Clinical University Hospital, Riga Stradins University, Riga, Latvia

 

NF pNEC represents 2-5% of all pancreas malignancies and have an incidence of 1 case per 100 000 individuals per year, but the incidence of Hodgkin lymphoma is 2.8 cases per 100 000 individuals per year. Case report shows patient with two rare diseases developed simultaneously. A 66 – year–old man with no alcohol abuse presented with cystic tumor in pancreas tail, which caused mild acute pancreatitis. In further evaluation CT scan was made and no signs of malignancy were found, in fine needle aspiration biopsy no atypical cells were found (2010). In next two years patient had follow-up visits. Comparison abdominal CT scan was made in April, 2013. Pancreas tumor enlargement, mediastinal, hilar, para-aortic, para-rectal, infraclavicular and axillary lymphadenopathy and single focus in spleen (metastasis?) were found. Basing on mentioned findings there was differential diagnosis between pancreas tumor with metastasis and lymphoproliferative disorder. Distal pancreas resection and splenectomy was made in May, 2013. Histologically NF pNEC Grade 1 (CKAE1/AE3, chromogranin, Ki67 positive), Hodgkin lymphoma in spleen and lymph nodes(60% T lymphocytes CD3+) were proved. After surgery in June, 2013 neuron-specific enolase level was increased (27.95 ng/ml), but in October, 2013 – in reference interval (15.49 ng/ml). Till now patient have regular chemotherapy because of Hodgkin lymphoma, no metastasis of NF pNEC were found in comparison CT scans. As in case of this patient presentation of NF pNEC has no specific signs, currently CT scans are the studies most used for detection. Although NF pNEC and Hodgkin lymphoma are rare diseases, they can combine.

 

Nothing to Disclose: MM, IR

12534 21.0000 SUN-0299 A Non Functioning Pancreas Neuroendocrine Carcinoma (NF pNEC) and Hodgkin Lymphoma Simultaneously: Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Hui Peng*1, W Tabb Moore2 and Lynt Johnson3
1Georgetown University Hospital, DC, 2Georgetown University, Washington, DC, 3Goergetown university

 

VIPoma is a rare neuroendocrine tumour first described by Priest and Alexander in 19571.The incidence is 1 in 10 million per year2. Most cases arise within the pancreas, while others reported in the lungs, colon, liver, adrenals, and neuroganglia3. The diagnose is often delayed because of its rarity. Patient usually suffers from multiple episodes until the diagnosis is made. We have one case and the diagnose was made after patient had five severe diarrhea episodes in one year.

45 year old Female with history of meningoma and diabetes was transferred from outside hospital with intermittent persistent watery diarrhea,  hypokalaemia, acidosis of one years’ duration of intermittent multiple episodes (January, September, November, December and multiple episodes in the following January).  The diarrhea did not stop with fasting, and serum potassium required multiple cycles of intravenous potassium replacement. Physical examination and routine blood investigations were normal. An abdominal CT showed there is soft tissue prominence in the region of the pancreas head and uncinate process. However follow up MRI indicates that the previous described soft tissue prominence in the region of the pancreatic head and uncinate process may simply represent pancreatic tissue. At that time, octreotide was empirically started as VIPoma was strongly suspected. Patient responded to octreotide very well. Laboratory tests were not back at that time. The team proceeded EUS guideline biopsy even MRI was negative and found a 3.6X2.2 cm pancreatic head mass.  Biopsy results showed: Epithelial neoplastic proliferation, most consistent with tumor of neuroendocrine origin. The neoplastic cells demonstrate diffuse and intense immunoreactivity with synaptophysin, and pan-keratin and focal reactivity with CD56. The chromogranin and tryptase immunostains are negative. The beta-catenin stain highlights cell membrane instead of nuclei. This immunohistochemical profile confirms the diagnosis of neuroendocrine tumor of the pancreas.Laboratory results came back as: VIP 182pg/ml (20-42), gastrin 231 pg/ml ( 0-115), 5-HIAA 4.5 mg /24 h (0.0-14.9). Glucagon 49 pg/ml (<=80). Patient was diagnosed with VIPoma and had Whipple procedure and pathology showed: Pancreatic endocrine neoplasm, well-differentiated, measuring 4.5 cm in greatest diameter involving head of pancreas .

 Conclusion: The diagnosis is the key of treatment of rare disease as VIPoma.  Our case compexity was high due to the rarity of disease and follow up MRI was negative. With diligence and strong suspicion, our case was finally diagnosed after one year.

 

Nothing to Disclose: HP, WTM, LJ

17050 22.0000 SUN-0300 A Diarrhea and Vipoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Cherng Jye Seow*, Seng Kiong Tan, Kar Mun Eu, Dao Ming Gerard Lim, Kok Seng Melvin Lee, Wen Yang Benjamin Ho and Pei Shan Yeo
Tan Tock Seng Hospital, Singapore, Singapore

 

Introduction: Management of patients with Multiple Endocrine Neoplasia 1 (MEN1) is challenging as tumors are frequently multiple and can recur. We present a case of MEN1 and discuss the challenges involved.

Case report: A 32 years old chinese man with 3 young children was first seen at the neurology clinic with a 3 years history of intermittent syncopal episodes. An imaging of the brain and an electroencephalogram was normal. Physical examination was unremarkable. A random glucose of 2.5 mmol/L promoted an Endocrinological consult. A 72 hour fast confirmed the diagnosis of endogenous hyperinsulinemic hypoglycaemia. Toxicology screen was normal. Imaging of the pancreas as well as an endoscopic ultrasound revealed a solitary 2.8 x 2.5 x 2.3 cm hypervascular lesion in the body of the pancreas. Diazoxide was started prior to surgery. Laparoscopic resection of the body and tail of the pancreas was performed and revealed multiple microadenomas scattered throughout the resected specimen. Postoperatively, he had impaired glucose tolerance managed with lifestyle interventions. In addition, PTH-mediated hypercalcemia was noted with an adjusted calcium level consistently above 2.8mmol/L (RI:2.15-2.58). Parathyroid scan showed a sestamibi-avid extra-thyroidal mass inferior to the right thyroid lower pole measuring 0.8 x 1.1 x 0.8 cm. In view of possible multi-glandular involvement, bilateral neck exploration was performed which showed all 4 parathyroid glands to be hyperplastic. Total parathyroidectomy and thymectomy followed by implant of part of the parathyroid gland into the sternocleidomastoid muscle was performed. This was complicated by transient hypoparathyroidism. Anterior pituitary hormone assessment and imaging of the pituitary gland was normal. Genetic screen identified a mutation consistent with the diagnosis of MEN1. The patient will require life-long follow up for tumor recurrence. His family members have also been counselled regarding genetic screening.

Discussion: MEN1 syndrome should be suspected in any young patient with endogenous hyperinsulinemic hypoglycaemia and/or primary hyperparathyroidism. Diagnostic screening in individuals known to have MEN1 leads to detection of tumours approximately 10 years earlier than those without screening. The aim of screening is to detect abnormalities at a presymptomatic stage, when they are most treatable, with the potential to reduce the morbidities associated with longstanding hormone excess. Predictive genetic testing for children at risk of inheriting MEN1 has been recommended as early as age 5 though there is no proof that screening children from a young age actually reduces morbidity and mortality. Resection of the underlying tumors are recommended but unfortunately MEN1 is associated with a high risk of recurrence and patient will require lifelong surveillance for recurrence.

 

Nothing to Disclose: CJS, SKT, KME, DMGL, KSML, WYBH, PSY

13546 23.0000 SUN-0301 A Challenges Associated with the Management of Multiple Endocrine Neoplasia 1 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Mala Ramnaraine* and Hilary Whitlatch
Alpert Medical School of Brown University/Rhode Island Hospital, East Providence, RI

 

Background:

MEN-1 is an autosomal dominant syndrome resulting in parathyroid, pancreatic neuroendocrine, and anterior pituitary tumors. One fifth of MEN-1 deaths are due to malignant neoplasms, most notably pancreaticoduodenal endocrine tumors (PET). The optimal extent and frequency of biochemical/imaging surveillance is debated. Some guidelines recommend an aggressive surveillance protocol starting at an early age, with biochemical screening annually and imaging every 1-3 years. Prospective studies using this strategy have not strongly shown an associated reduction in mortality. This, along with the associated cost and risk of accumulated radiation exposure, has led others to recommend more limited biochemical and radiologic surveillance.

Clinical Case:

A 44 year old man with MEN -1, diagnosed at age 32, presented to the hospital with a 1 year history of weight loss and progressive abdominal pain. Family history is notable for a mother and two brothers with MEN-1. He was diagnosed with primary hyperparathyroidism in 2004; he had removal of 3.5 parathyroid glands. He was then lost to follow-up, but re-established care three months prior to hospital admission. At that time, biochemical workup included PTH 22 pg/ml (14-72 pg/ml); Ca 10 mg/dl (8.5-10.5 mg/dl); IGF-1 99 ng/ml (n2-328 ng/ml) Z score -0.8; LH 1.3 mIU/ml ( 1.5-9.3 mIU/ml); FSH 5 mIU/ml (1.4-18.1 mIU/ml); total testosterone 158 ng/dl (270-1070 ng/dl); SHBG 97.3 nmol/l (17.3-65.8 nmol/l); random cortisol 28 ug/dl; ACTH 5 pg/ml (6-50 pg/ml); 24hr urine metanephrines <25 pg/ml (≤ 57 pg/ml); 24 hr urine normetanephrines 93 pg/ml (≤ 148 pg/ml); 24hr total metanephrines 93 pg/ml (≤205 pg/ml); TSH 1.682 uIU/ML (0.35-5.5 uIU/ml); prolactin 4.0 ng/ml (2-17 ng/ml); A1c 13.4% (4.3-5.8%). He was diagnosed with diabetes and started on insulin.

On presentation to the hospital, a CT abdomen showed multiple pancreatic, hepatic and bony lesions concerning for metastatic disease. Biochemical testing included chomogranin 158 ng/ml (1.9-15.0 ng/ml); 5HIAA 315.5 mg/24Hr (2.0-8.0 mg/ 24Hr); gastrin 30 pg/ml (<101 pg/ml); glucagon<134 pg/ml (≤ 134 pg/ml); ACTH 5 pg/ml (6-50 pg/ml); C-peptide <0.10 ng/ml (0.8-3.10 ng/ml). A brain MRI revealed multifocal areas of osseous metastasis with dural extension. A CT chest showed diffuse osseous metastatic disease in the thoracic spine, ribs and sternum. His liver biopsy revealed metastatic well-differentiated neuroendocrine tumor, TTF-1 and CDX-2 negative, likely pancreatic in origin, staining for chromogranin A and synaptophysin. Oncology recommended palliative radiation therapy and induction into a therapeutic trial.

Conclusion:

Although MEN-1 associated PET is often aggressive, further long-term prospective trials are needed to determine the optimal imaging surveillance strategy that will both reduce associated mortality and be clinically feasible and cost-effective.

 

Disclosure: MR: Clinical Researcher, Novo Nordisk. HW: Coinvestigator, Takeda, Coinvestigator, Novo Nordisk.

16392 24.0000 SUN-0302 A Case of Aggressive Neuroendocrine Tumor in MEN1: What Is the Optimal Radiologic Surveillance Strategy? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Nathalie Oliveira Santana*1, Raquel S Jallad2, Felipe HG Duarte3, Rachel Simoes Pimenta Riechelmann4, Veronique Raverot5, Jacqueline Trouillas6, Gerald Raverot7 and Marcello D Bronstein8
1University of Sao Paulo, Sao Paulo, Brazil, 2Hosp das Clinicas Univ of Sao Paulo Medical School, Sao Paulo SP, Brazil, 3Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Sao Paulo, Brazil, 4Instituto do Câncer do Estado de São Paulo (ICESP), São Paulo, Brazil, 5Hospices Civils de Lyon, Lyon, France, 6Groupement Hospitalier Est, Bron, France, 7Hospices Civils de Lyon, Lyon Cedex 03, France, 8University of São Paulo Medical School, São Paulo, Brazil

 

Background: Ectopic source of GH/GHRH occurs in less than 1% of the acromegalic patients. As a rule, at the time of diagnosis, the absence of typical pituitary adenoma and a thoracic/abdominal lesion indicate that an ectopic source should be ruled out.

Clinical case: A 35-year-old female with a five-year history of typical acromegalic features, bilateral galactorrhea and oligomenorrhea was referred to our service for pituitary surgery. Baseline laboratory tests were: GH = 33.5 ng/mL, IGF-1 = 1290 ng/mL [normal value (nv): 115-307 ng/mL)] and prolactin = 79 ng/mL (nv: 2.8-29.2 ng/mL). Acute octreotide suppression test demonstrated a reduction of 97.6% in GH level in 6 hours. Other pituitary axes were intact. MRI showed an intra- and supra-sellar lesion (2.4 cm), suggestive of pituitary macroadenoma.

The patient also had a history of a mass in the inferior lobe of the right lung, found elsewhere in a routine chest X-ray two years before, not previously investigated, which remained stable in the meantime. CT scan depicted a 6.1 cm mass in the referred lobe, compatible with neuroendocrine tumor, corroborated by the 99mTc-octreotide scintigraphy and confirmed by bronchial biopsy. 18F-FDG PET showed high glycolytic activity (SUV = 8.4). Moreover, GHRH baseline level was 844 ng/L (nv < 30 ng/L).

The patient underwent surgical resection of the lung tumor and blood samples were collected before and up to 360 minutes after removal, in order to assess serum GH and GHRH levels. GH and GHRH levels progressively decreased from baseline 53 ng/mL and 844 ng/L to a nadir of 0.9 ng/mL and 165 ng/L, respectively. IGF-1 level one week after surgery was 180.5 ng/mL (nv: 103-322 ng/mL). Acromegalic features improved shortly after surgery.

Pathologic examination revealed a 7.2 cm atypical carcinoid, 3 mitosis per 10 HPF, invasion of vascular structures and absence of necrosis. Stage pT3 pN0, free surgical margins. Immunohistochemistry analysis: positive for chromogranin, synaptophysin, TTF-1 and 35BH11, Ki-67 < 1%. The lung tumor was also positive for anti-GHRH antibodies, and expressed SSTR2 and SSTR5.

Pituitary MRI three months after surgery depicted a significant mass shrinkage. The lowest GH level after oGTT was 0.4 ng/mL, GHRH level was normal (30 ng/L), but IGF-1 level increased to 576 ng/mL, suggesting residual disease, not confirmed by CT and octreoscan, or pituitary autonomy.

Clinical lesson: Even if there is an image suggestive of pituitary adenoma in MRI, the presence of a thoracic or abdominal mass should not be overlooked. Plasma GHRH assay, in addition to an impressive GH suppression on acute octreotide test and a positive octreoscan result, are accurate tools for differential diagnosis between GH-secreting pituitary adenoma and ectopic GHRH secretion.

 

Disclosure: RSPR: Speaker, Pfizer, Inc., Speaker, Novartis Pharmaceuticals. Nothing to Disclose: NOS, RSJ, FHD, VR, JT, GR, MDB

15168 25.0000 SUN-0303 A Acromegaly Due to Ectopic Secretion of GHRH Mimicking a GH-Secreting Pituitary Adenoma: The Role of Imaging and GHRH Assay 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Eduarda Resende*1, Joana Oliveira Couto2, Raquel Martins3, Maritza Sá1, Margarida Ferreira1, Ana Paula Santos3, Isabel Torres3 and Silvestre Abreu1
1Hospital Central do Funchal, Funchal, Portugal, 2Portuguese Institute, Porto, Portugal, 3Portuguese Institute of Oncology, Porto, Portugal

 

Introduction: Acromegaly is usually caused by a pituitary adenoma; ectopic or eutopic secretion of Growth-Hormone Releasing Hormone (GHRH) is a rare condition, responsible for less than 1% of the cases.

Case Report: A 34-year-old woman was referred to the Endocrine Clinic with a multinodular goiter. However, on physical examination there were some signs of acromegaly: coarsening of facial features, protusion of the lower jaw and  thick,oily skin. In her past medical history there was a right lung lower lobectomy with a histologic diagnosis of a typical carcinoid. Laboratory investigation showed a seric concentration of  IGF-1 of 826 ng/ml (136-449), and a fine-needle aspiration of a thyroid nodule revelead a cytologic diagnosis suspicious of papillary carcinoma. A random GH level was 7,7 ng/dl, and after a 75 g oral glucose load the GH was 9,4 ng/dl. The pituitary MRI, however, didn´t show a tumour, which raised the possibility of ectopic acromegaly. Since our patient had an history of a pulmonary carcinoid, she was asked a chest and abdominal CT, which showed “ eight nodules in the liver, highly suspicious of metastatic involvement by the primary neuroendocrine tumour”. She had a discrete elevation of chromogranin A and no elevation of 5-hydroxyindoleacetic acid. A Ga68 – PET – DOTANOC revealed an increased captation in the hepatic lesions, and a biopsy was performed, confirming the neuroendocrine origin of the metastasis; immunohistochemical staining was positive for GHRH. The patient was initiated on monthly intramuscular octreotide, and was submitted to radioembolization of the hepatic lesions, with a notable reduction in the size of the metastasis. At the moment the IGF-1 levels are dramatically reduced – 54 ng/dl -  and a total thyroidectomy confirmed the diagnosis of papillary carcinoma.

Clinical Lessions: The diagnosis of ectopic acromegaly may be suspected in any case of bichemically proven acromegaly with no pituitary adenoma. GHRH hypersecretion must be confirmed to avoid unneccessary pituitary surgery. The incidence of papillary carcinoma of the thyroid is increased in acromegalic patients.

 

Nothing to Disclose: ER, JOC, RM, MS, MF, APS, IT, SA

16389 26.0000 SUN-0304 A Ectopic Acromegaly Caused By Hepatic Metastasis of a Pulmonary Neuroendocrine Tumour 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Zsuzsanna Valkusz*1, Krisztian Sepp2, Gabriella Uhercsak2, Andras Voros2, Andras Palko2 and Miklos Toth3
1University of Szeged, Szeged, Hungary, 2University of Albert Szentgyorgyi, Szeged, 3Semmelweis University, Budapest, Hungary

 

Background: Adrenocortical carcinoma (ACC) is a rare tumor accounting for < 0.2 % of all malignancies. Non-islet cell tumor hypoglycaemia (NICTH) is a syndrome defined by the presence of a solid tumor and fasting hypoglycaemia, which is caused by an insulin-independent pathway. Big insulin-like growth factor (IGF)-II secreted from the tumor is thought to be the primary hormonal mediator of NICTH.

Clinical case: A 34-year-old woman after finishing the breastfeeding of her 1,5- year old child  was diagnosed with  Cushing syndrome and  the examination revealed  an abdominal mass 10 cm diameter in 2011. The tumor was resected within 3 weeks with her right adrenocortical gland; histology showed high grade adrenocortical carcinoma (ACC) KI 67 was 25-30% (pT3).  After the surgery and local adjuvant radiotherapy all of the Cushing symptoms and signs disappeared. Despite surgery and chemotherapy with mitotane, the ACC progressed with metastases to the lymph nodes and lung in 2012. Initially she developed adrenal insufficiency and was treated with hydrocortisone. After an additional long row of other cytotoxic chemotherapy the ACC progressed and in 2013 it produced superabundant cortisol, testosteron, DEA-S, 17-OH progesteron. At this time she first exhibited symptoms of hypoglycaemia and progressively became more severe without any signs of hepatic metastases. Serum insulin concentration was 0.2 uU/ml, C peptide was 0.12 ng/ml,and blood glucose was 20 mg/dl. The somatostatin analogue octreotide did not stop the hypoglcycaemia but could reduce significantly the frequency of the hypoglycaemic episodes and her quality of life is improved. It is believed that insulin-like growth factor II produced by tumors is the primery hormonal mediator of NICTH although other possible mechanisms have been proposed.

Conclusion: here we report a patient who presented with adrenal failure, Cushing’s syndrome and hypoglcaemia during the course of ACC progression. Only in 2010 was described the first case demonstrating the role of big IGF-II and no other cases in the literature.

 

Nothing to Disclose: ZV, KS, GU, AV, AP, MT

12290 27.0000 SUN-0305 A Cushing's Syndrome and Unknown Hypoglycaemia in a Patient with Adrenocortical Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Salvatore Maria Corsello*1, Paola Senes1, Roberto Iezzi1, Maria Vittoria Rufini2, Maria Teresa Congedo1, Rosa Maria Paragliola1 and Alfredo Pontecorvi3
1Catholic University School of Medicine, Rome, Italy, 2Catholic University School of Medicine, Rome, Italy, Rome, Italy, 3Endocrinologia e Malattie del Metabolismo, Università Cattolica del Sacro Cuore, Rome, Italy, Italy

 

Introduction: The ectopic production of ACTH is responsible for approximately 10% of cases of Cushing's syndrome. Whenever possible, once hypercortisolemia is under control with medical therapy, the final treatment consists of surgical excision of the tumor. We report a case of a patient with high surgical risk and poor response to medical therapy in which hypercortisolemia has been successfully treated with radio frequency ablation of the bronchial carcinoid tumor.

Clinical case:  A 43 old woman came to our hospital because of severe and rapidly worsening signs and symptoms of hypercortisolism over the previous three months. Hormonal tests suggested the presence of Cushing's syndrome due to ectopic ACTH-production. Imaging studies detected an 8 mm pulmonary nodule with fluorine- 18-fluorodeoxyglucose (FDG) uptake localized in the middle right lobe. The patient started therapy with ketoconazole with poor response. Middle right lobectomy was indicated but, due to the patient's very high surgical risk, a thermal ablation with radiofrequency of the bronchial nodule was performed. After the procedure, ACTH and cortisol levels dropped and FDG positron emission tomography (PET) showed complete response to treatment. Clinical conditions progressively improved and, six weeks later, the patient underwent middle lobectomy without complications. Histology showed a 0.7 cm ACTH-producing typical bronchial carcinoid tumor.

Conclusions: Thermal ablation with radiofrequency allows to achieve a rapid control of hypercortisolism with subsequent improvement of symptoms.  This procedure should, therefore, be considered as viable therapeutic option in those cases of bronchial ACTH-secreting tumors in which the surgical approach is initially contraindicated.

 

Nothing to Disclose: SMC, PS, RI, MVR, MTC, RMP, AP

15722 28.0000 SUN-0306 A Ectopic Cushing's Syndrome Due to a Bronchial ACTH-Secreting Carcinoid Successfully Treated with Radio Frequency Ablation (RFA) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Thomas Jensen*1, David R. Saxon2 and Marc-Andre Cornier1
1University of Colorado School of Medicine, Aurora, CO, 2University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO

 

Background: To describe a rare case of cortisol-secreting adrenocortical carcinoma (ACC) with plausible aldosterone secretion.

Clinical Case: A 54-year-old woman with recent onset of T2DM, HTN, and refractory hypokalemia presented with weakness and weight loss of 25lbs over the past month. Diabetes was diagnosed within in the past three months (A1c 7.0%), hypertension was being treated with lisinopril 40mg daily and spironolactone 25mg daily (only for past 3 days), and hypokalemia was being treated with 60mEq KCL daily. On initial exam she had bruising, violaceous striae, and proximal muscle wasting with a blood pressure of 168/84. Potassium was 2.1 mmol/L, glucose was 467 mg/dL, and HbA1c was now 11.6%. On CT scan she was found to have a 10 cm left adrenal mass with multiple liver lesions consistent with metastases. A random cortisol was 45.9 ug/dL with an ACTH of 12 pg/mL (6-58 pg/mL). Her renin was 1.1 ng/mL (0.5-4.0 ng/mL) with an AM aldosterone of 344 ng/dL (4-31 ng/dL) and a potassium of 2.3 mmol/L. Her 24-hour urine cortisol was 1470 ug/d (<45ug/d). Pheochromocytoma work-up was negative. Repeat aldosterone was 257 ng/dL. She was started on ketoconazole 200mg TID and underwent left adrenalectomy with left lateral hepatectomy. Final pathology revealed an ACC. Post-op cortisol remained elevated at 36.4 ug/dL, but aldosterone fell to 88.8 ng/dL despite a higher dose of spironolactone (150mg daily). She was discharged on ketoconazole 200mg BID. Shortly after discharge, she was readmitted for new seizures and found to have cryptococcal meningitis. Given a poor prognosis, she was made comfort care.

Clinical Lesson: ACC is a rare tumor with estimated incidence of 0.5-2 cases per million per year. 60% of these tumors are hyperfunctioning. In a review series of 202 cases of ACC, of secreting tumors, 47% secreted cortisol and androgens, 27% cortisol only, 15% aldosterone only and 6% androgens only (1). Tumors co-secreting cortisol and aldosterone are extremely rare with only 27 case reports to literature search. Our patient had a very elevated aldosterone though her renin was not completely suppressed, but this may occur in primary hyperaldosteronism (2,3), our patient had been on lisinopril, and imaging suggested that tumor was compressing her renal artery. The workup for suspected ACC includes, imaging with MRI or CT along with biochemical workup for excess adrenal hormones.  Management depends upon staging at the time of diagnosis (4).  Stage 1-3 disease usually involves surgical resection followed by mitotane and in many cases with the addition radiation therapy in Stage 3. In Stage 4, palliative therapy is offered with either surgical resection, radiation, and chemotherapy or chemotherapy alone. Excess hormones are treated with medications to suppress secretion or block effect. This is an example of a case with definitive ACC secreting cortisol and likely co-secretion of aldosterone.

 

Nothing to Disclose: TJ, DRS, MAC

15552 29.0000 SUN-0307 A A Curious Case of a Secreting Adrenocortical Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Milena Caccelli*1, Maria Candida B V Fragoso2, Ludmila Malveira3, Marcello D Bronstein4 and Marcio Carlos Machado5
1Unidade de Neuroendocrinologia da Disciplina de Endocrinologia e Metabologia, HC-FMUSP, Sao Caetano do Sul -SP, Brazil, 2University of Sao Paulo, Sao Paulo-SP, Brazil, 3Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil, 4University of São Paulo Medical School, São Paulo, Brazil, 5University of Sao Paulo Medical School, Sao Paulo, Brazil

 

Background: The treatment of hypercortisolism in ectopic ACTH syndrome (EAS) is commonly performed by bilateral adrenalectomy for severe cases and for those with no detectable source of ACTH production (occult cases). Otherwise, some particularly carcinoid tumors may express somatostatin and dopamine subtype 2 (DRD2) receptors and be responsive to treatment in vivo with somatostatin analogues and dopamine agonists, respectively. The objective of this study is to report a patient with occult EAS in control of hypercortisolism with prolonged use of cabergoline for 88 months.

Clinical Case: Male patient, 29 years, 24 months history of weight gain with fat centripetal accumulation, moon face, proximal muscle weakness, large purplish skin striae, headache, hypertension, diabetes mellitus, hypokalemia and reduced bone mass. The ACTH-dependent Cushing syndrome was confirmed by cortisol (F) levels after 1 mg dexamethasone (24 μg/dL), urinary free cortisol/24h (UFC, 6201 μg/24h, RV: 30-300) and plasma ACTH (153 pg/mL, RV <46). MRI scanning of pituitary showed heterogeneous contrast enhancement in the left side of the pituitary parenchyma suggesting the presence of microadenoma. Underwent transsphenoidal pituitary surgery when no tumor was visualized with biopsy revealing neurohypophysis. The inferior petrosal sinus sampling (IPSS) with desmopressin confirmed absence of central to peripheral ACTH gradient, establishing the diagnosis of EAS. In investigating the source of ACTH, chest and abdomen CT scan, cervical ultrasonography, tumor markers, OctreoScan® and FDG-PET were negative. The acute test with octreotide 50 μg SC showed significant reduction (78%) in plasma ACTH concentrations. With two weeks of use of octreotide SC 300 μg/day presented with adrenal insufficiency treated by reducing the dosage of octreotide and concomitant oral replacement of cortisone acetate. After a brief period of UFC increase, the octreotide was replaced by cabergoline 1.5 mg/week. Evolved again with control of hypercortisolism (UFC) presenting clinical remission and peeling skin. Following, patient remains asymptomatic and improved bone mass using cabergoline 1.5 mg/week for 88 months. EAS remains occult with annual screening image during the follow-up.

Conclusions: Cabergoline is one of the most widely used drugs in Cushing's disease due to frequent expression of DRD2 receptor in corticotroph tumors. In a few cases studied, was also demonstrated the expression of dopamine receptor in carcinoid tumors and EAS explaining the response to cabergoline in a few short-term patients, alone or with somatostatin analog. We present a case of occult EAS with excellent answer to octreotide and also to cabergoline at the long term, being an alternative to bilateral adrenalectomy even in a severe case of hypercortisolism.

 

Nothing to Disclose: MC, MCBVF, LM, MDB, MCM

16638 30.0000 SUN-0308 A Long-Term Follow-up of Cabergoline Treatment in Occult Ectopic Acth Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Noah Aaron Bloomgarden*1 and Martin I Surks2
1Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY, 2Montefiore Med Ctr, Bronx, NY

 

Background: Cushing’s disease is often an indolent syndrome characterized by gradually progressive physical findings that may take months to many years to manifest.  This patient illustrates the importance of recognizing physical findings and laboratory abnormalities in a rapidly progressive disease of profound cortisol excess.

A 68-year woman with obesity and HTN, presented with complaint of progressive weakness, sent from her PMD for profound hypokalemia.  Two weeks prior she had noted significant progressive proximal muscle weakness, accompanied by generalized fatigue.  She was given a five-day course of prednisone and antihistamines for a "facial rash" seven days before admission; her blood pressure medication was changed from an ACE inhibitor to hydrochlorothiazide.   Review of symptoms was significant for several weeks of diarrhea accompanied by early satiety and decreased PO intake for the past 3 months.  Physical exam was significant for abdominal distension, proximal muscle weakness, lower extremity edema and diffuse skin pigmentation, attributed to tanning in Florida.  Exam was negative for abdominal striae, elevated blood glucose, buffalo hump, moon facies, central obesity and buccal hyperpigmentation.  Patient was noted to have a metabolic alkalosis  (serum  bicarbonate, 38 mEq/L),  and critically low potassium (2.0 mEq/L).  Serum potassium remained low in spite of 7 days of vigorous replacement and withdrawal of hydrochlorothiazide.  AM cortisol was found to be markedly elevated (96 ug/dL, 5.0-25.0 ug/dL), supported by elevated 24HR urine free cortisol (1470 ug/24 hr, 4-50 ug/24 hr). 

Confirmatory testing for the cause of cortisol excess was undertaken.  Administration of Dexamethasone 1 mg (AM cortisol 83 ug/dL, 5-25.0 ug/dL) and 8 mg (AM cortisol 88 ug/dL, 5-25.0 ug/dL) failed to suppress cortisol.  ACTH was markedly elevated (81 pg/mL, 5-27 pg/mL) while DHEA-S was notably low (36 ug/dL, 35-430 ug/dL).  CT imaging of her abdomen and pelvis demonstrated an ill-defined 2.8 cm hypoenhancing mass in the pancreatic tail with multiple hypoenhancing masses in the liver suggestive of metastatic disease.  Liver biopsy demonstrated a high-grade neuroendocrine tumor, consistent with small cell carcinoma; the pathology stained negative for ACTH and somatostatin.  In spite of initial improvement in cortisol with ketoconazole and octreotide, patient’s cortisol remained markedly (>100 ug/dL) elevated.  Patient received a single cycle of chemotherapy (carboplatin/etoposide) with rapid deterioration complicated by tumor lysis and renal failure.  The patient became dialysis dependent and was transferred to hospice care 45 days after her initial presentation.

Conclusion: This case highlights the importance of early recognition of signs and symptoms of acute and marked cortisol excess as well as the rapid morbidity and mortality associated with ACTH release in this small cell tumor subtype.

 

Nothing to Disclose: NAB, MIS

15481 31.0000 SUN-0309 A Rapid Progression of a Small Cell Ectopic ACTH Secreting Tumor of the Pancreas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Liesl Altus*1 and Peak Mann Mah2
1Lyell McEwin Hospital, Elizabeth Vale, Australia, 2Lyell McEwin Hosp, Elizabeth Vale, Australia

 

Introduction: Small cell lung cancer causing severe Cushing’s syndrome due to ectopic ACTH production, with bilateral adrenal and pituitary metastases is rare.

Clinical Case: A 65-year old female presented with lethargy after a recent diagnosis of metastatic poorly differentiated carcinoma from a subcutaneous biopsy. CT scan revealed a left hilar mass, bilateral enlarged adrenal glands and multiple subcutaneous and intraperitoneal nodules. Clinical and biochemical features of hypercortisolaemia were present.  Random cortisol was 2297 nmol/L  at 23:00 (n<200). ACTH-dependent Cushing’s syndrome was confirmed with UFC 17998 nmol/24h (n 50-350) and ACTH 224 ng/L (n 10-60). Secondary hypothyroidism and hypogonadism were present. Pituitary MRI revealed a right-sided pituitary mass, without clear distinguishing features of metastases or adenoma.

Ectopic ACTH production was favoured over a functioning pituitary adenoma given the rapid onset of clinical features, the degree of hypercortisolaemia and lack of suppression with high dose dexamethasone. Further dynamic testing could not be performed as the patient rapidly deteriorated with progressive generalised oedema, proximal myopathy, hypotension and persistent hypokalaemia despite replacement. She was commenced on ketoconazole in an attempt to control hypercortisolism to permit palliative chemotherapy. She developed pneumonia and died, only 4 weeks after receiving the initial diagnosis. Neuroendocrine carcinoma was diagnosed post-mortem. Metastases were present in hilar lymph nodes, bilateral adrenals, pituitary, subcutaneous and intra-abdominal tissue. Immunoprofile was consistent with pulmonary origin. They showed no staining for ACTH.

Conclusion:  This case was a dramatic demonstration of the aggressive behaviour that neuroendocrine carcinomas can display. Although the post mortem ACTH stain was negative, there was no evidence of additional pituitary pathology and the clinical course and biochemistry were consistent with ectopic ACTH production. This case is unusual in that despite bilateral adrenal metastases, there was such severe hypercortisolaemia. A recent case report explores the possibility of enhanced corticosteroid biosynthesis in peritumour adrenal tissue suggesting that ACTH-producing adrenal metastasis have greater capacity for inducing severe hypercortisolism1. This case also highlights the high morbidity and mortality that can be associated with endocrine manifestations of cancer.

 

Nothing to Disclose: LA, PMM

14243 32.0000 SUN-0310 A Severe Cushing's Syndrome Due to Ectopic ACTH Production in a Patient with Bilateral Adrenal and Pituitary Metastases from Pulmonary Small Cell Lung Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Jamila Carpin1, Miro Popescu2, François Delanoe3, Lyonel Belia3, Amandine Berdelou4 and Fritz-Line Velayoudom-Cephise*5
1Centre Hospitalier Universitaire de Pointe-à-Pitre, Endocrinology, Guadeloupe, 2University Hospital of Pointe a Pitre/Abymes, France, 3Centre Hospitalier Universitaire de Pointe-à-Pitre, 4Institut Gustave Roussy, Villejuif, France, 5Centre Hospitalier Universitaire de Pointe-à-Pitre, Pointe-à-Pitre, Guadeloupe

 

Introduction: Ectopic secretion of adrenocorticotrophin (ACTH) is generally described in Bronchial or Thymic carcinoid with clinical or biological presentation of Cushing syndrome. Some cases of paraneoplastic Cushing have been reported with pancreatic neuroendocrine tumors (NET) which often secrete Insulin or IGFII. Nephrotic syndrome (NS) defined by proteinuria ≥3g, low serum protein <60g/L and edemas, is generally caused by primary idiopathic glomerular disease (membranous nephropathy). We report the case of NS revealing a pancreatic NET with paraneoplastic Cushing.
Clinical case: A 56-year-old woman was referred in our institute for evaluation of edemas and hypokalemia. A weight gain with high blood pressure and diabetes were noticed. Biology found hyperglycemia, hypokalemia and proteinuria >3g/24h. Diagnosis of NS was confirmed with Cushing syndrome linked to ectopic secretion of ACTH, associated with thyrotropin, and gonadotropin insufficiency. CGA was increased: 1247ng/mL. Abdominal ultrasonography showed a multinodular liver and CT-scan found a pancreatic tumor of 4 cm with splenic thrombosis. Hepatic Biopsy confirmed metastases of moderately differentiated endocrine carcinoma of grade 2 (mitoses: 3 per mm2, Ki67: 8%). Contrary to hepatic metastases, the pancreatic tumor was In-111 octreotide scintigraphy negative and 18-FDG-PET positive. After treatment of Cushing syndrome by Ketokonazole, Metyrapone and Mitotane, NS decreased. Anticortisolic treatment was reduced due to side effects but evolution was fatal because of an acute hepatorenal failure.
Conclusion: this case underlines that edemas of NS could hide ectopic secretion of ACTH linked to neuroendocrine tumors. Early treatment of Cushing syndrome could improve NS but control of the balance between efficacy and tolerance of anticortisolic drugs determines prognosis.

 

Nothing to Disclose: JC, MP, FD, LB, AB, FLV

15517 33.0000 SUN-0311 A Nephrotic Syndrome Revealing an Ectopic Secretion of ACTH By a Pancreatic Neuroendocrine Tumor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Amrita Banerjee*1, Umasuthan Srirangalingam1, Emad George2, Daniel Berney1, Prasad Patki1, John Peters1, Maralyn Druce1, Mona Waterhouse1, Shern L Chew3, Anju Sahdev1, William Drake1 and Scott Alexander Akker1
1St Bartholomew's Hospital, London, United Kingdom, 2The Queen Elizabeth Hospital, King's Lynn, United Kingdom, 3London Clinic, London, United Kingdom

 

Bladder paragangliomas (PGLs) are chromaffin cell tumours arising from
within the bladder wall. Succinate dehydrogenase B (SDHB)
germline mutations are associated with the development of
predominantly extra-adrenal paragangliomas, high rates of
metastatic disease and additional neoplasms including renal cell
carcinoma, gastro-intestinal stromal tumours and pituitary adenomas.1,2
Identifying clinical disease phenotypes associated with SDHB mutations
are essential to guide disease surveillance regimens and influence
outcomes.

We present a retrospective case series of 5 subjects with SDH associated
bladder PGLs from a total cohort of 7 subjects with bladder PGLs (71%).
Genetic testing identified the following SDHB mutations: c.292T>C,
c.406delA, and c.590C>G in two subjects, while loss of SDHB
immunohistochemical staining was identified in one subject (genetic
analysis pending).    Median age at first diagnosis was 24 years
(range 18 - 68) and 60% of patients presented with micturition related
symptoms of catecholamine excess. Plasma and/or 24hr urine
catecholamines/ metanephrines were raised in 4/5 (80%) subjects. A positive
family history was apparent in 2/5 (40%).  Surgical resection
was undertaken in 4 subjects and one subject awaits surgery. Histopathological analysis identified extension through the lamina propria in 3/4 (75%) subjects.   The only non-invasive case of bladder PGL was identified at an early stage through our annual surveillance program, as a 5.4mm lesion on diffusion weighted MR imaging. Metastatic bladder PGLs were noted in 3/5 (60%) subjects. One subject had an invasive PGL at presentation through the muscularis propria of the bladder wall with frank extension into perivesical fat while two further subjects developed metastases within 4 years of the initial tumour diagnosis.  One subject died from metastatic paraganglioma 7 years after the initial diagnosis, following surgery and chemotherapy (MIBG non-avid). Another subject with metastasis received 6 cycles of adjuvant I131 MIBG therapy and has since remained in remission for 7 years.

Currently, disease surveillance regimes for detecting occult PGLs in
asymptomatic carriers of SDHB mutations are in place but there remains
debate about modality and frequency of surveillance. This case series
highlights: i. The bladder as a 'hot-spot' for SDHB associated
paragangliomas ii. The high rate of malignancy associated with SDH
associated bladder paragangliomas iii. Intensive surveillance regimes,
with particular attention to the bladder region can allow early
identification and intervention for these lesions with the aim of
improving the prognosis of subjects with SDH associated bladder PGLs.

 

Disclosure: WD: Principal Investigator, HRA Pharma. Nothing to Disclose: AB, US, EG, DB, PP, JP, MD, MW, SLC, AS, SAA

16000 34.0000 SUN-0312 A Clinical Manifestations of SDH Associated Bladder Paragangliomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Masayasu Iwabuchi*
Seirei Mikatahara Hosp, Hamamatsu, Japan

 

Background: Malignant paraganglioma is a rare tumor with a poor prognosis because its excess production of catecholamines leads to potentially lethal complications.  Elevated catecholamines can cause pulmonary edema by increased pulmonary capillary permeability and peripheral vasoconstriction, leading to a shift of extracellular fluid. In addition, catecholamines reduce bowel motility, leading to paralytic ileus.  Several chemotherapy regimens have been reported to be effective against this tumor, but a standard form of chemotherapy has not been established.  The chemotherapeutic regimen, consisting of cyclophosphamide, vincristine, and dacarbazine (CVD), has been reported to be effective against malignant pheochromocytoma.  Iwabuchi reported palliative chemotherapy with cytosine arabinoside for malignant pheochromocytoma (1).

Case report:  A woman with schizophrenia suffered from paralytic ileus caused by paraganglioma. Her retroperitoneal lesion was resected and histological diagnosis of paraganglioma was confirmed. She recovered from paralytic ileus after the operation, which reduced catecholamines levels. Next year, the diagnosis of malignant paraganglioma was confirmed by examinations of CT, MIBG and PET, indicating metastases to rib in her chest wall and lumbar vertebrae. After she made a decision of chemotherapy under informed consent.   We have continued the CVD treatment for 33 months until her psychiatric condition worsened.  Because of delusion, she could not share any medical information.  We decided to discontinue CVD therapy.  During the discontinuation, metastasized tumor turned worse causing bone pain. She hoped cytoreductive treatment but did not agree to re-start the CVD because of the side effects of the chemotherapy. She chose palliative chemotherapy of subcutaneous administration of 20 mg of cytosine arabinoside twice a week. The chemotherapy discontinued again because of delusion of pregnancy.  During the discontinuation of the treatment, paralytic ileus and pulmonary edema and bone pain worsened with the increase of cathecholamines suggesting the progression of the disease. Because of paralytic ileus, morphine was not administered. Abdominal pain, dyspnea and bone pain made her decide to re-start the palliative chemotherapy. One week after re-starting the treatment, her bowel movement, respiratory condition improved and bone pain was controlled. 24hr urinary Norepinephrine secretion after re-starting the chemotherapy reduced from 14,759 to 6,708 microgram/day (normal range: 26-121 microgram/day). No adverse effect of chemotherapy has been observed. For efficacy and avoidance of adverse effect, the chemotherapy was optimized from the viewpoint of cell kinetics.

Clinical Lesson: Palliative chemotherapy with cytosine arabinoside controlled the potentially lethal complications of malignant paraganglioma.

 

Nothing to Disclose: MI

13337 35.0000 SUN-0313 A Palliative Chemotherapy Controlled Lethal Complications of Malignant Paraganglioma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Ruth Casey*, Aoife Garrahy, Mary Casey, Paula o'Shea and Marcia Bell
Galway University Hospital, Galway, Ireland

 

The SDHAF2 gene is associated with familial head and neck paragangliomas (PG)1. The role of the SDHAF2 gene is to regulate flavination of SDHA which is essential for a functional succinate dehydrogenase complex.2 Phenotypic characterisations of this gene are believed to include exclusivity to head and neck paragangliomas, multifocality within the head and neck, low risk of malignancy and a predominant normetanephrine secretory pattern.1, 3 One known pathogenic SDHAF2 mutation, GLY78ARG , has been identified in a Dutch and Spanish kindred and predisposes to head and neck paragngliomas.2 To date there are no published reports of either somatic or germline mutations in SDHAF2 linked with hereditary phaeochromocytoma. We present two cases of patients with unilateral phaeochromocytoma attending our centre with evidence of a heterozygous mutation of SDHAF2 on genetic analysis of both patients. Neither patient has a known positive family history and these patients are not related. These cases suggest that the phenotype associated with these newly identified genes are varied and further advances may only be made as genetic screening for this rare tumour group becomes more common place.

1.Kunst HP, Rutten MH, de Mönnink JP,et al. SDHAF2 (PGL2-SDH5) and hereditary head and neck paraganglioma.lin Cancer Res. 2011 Jan 15;17(2):247-54. 

2. Hao HX, Khalimonchuk O, Schraders M, et al. SDH5, a gene required for flavination of succinate dehydrogenase, is mutated in paraganglioma. Science 2009; 325: 1139-1142

3. Bayley JP, Kunst HP, Cascon A,et al.SDHAF2 mutations in familial and sporadic paraganglioma and phaeochromocytoma.Lancet Oncol. 2010 Apr;11(4):366-7

 

Nothing to Disclose: RC, AG, MC, PO, MB

12677 36.0000 SUN-0314 A SDAHF2: A Novel Mutation in Phaeochromocytoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Mohamad Hosam Horani*1, Omar Salim2, Mahmood Shahlapour3, Anuja Choure4 and Khalid Salim2
1Alsham Endocrinology, Chandler, AZ, 2Midwestern University, AZ, 3Mercy Gilbert Hospital, 4Chandler hospital

 

Case presentation: A 32 year old morbidly obese female with a history of hypertension and hypothyroidism
presented to the ER after a sporadic syncopal episode at home. She complained of a four month history of
intermittent episodes of blurry vision, headache, dizziness, and neck pain. She went to the ER after an episode
three months ago and was found to be hypotensive, which was attributed to her medication. After discontinuing
them, she continued to have episodes. Her family history is significant for neck masses in her father, sister, and
paternal grandfather, as well as hypertension and diabetes. There was no family or personal history of MEN
syndrome, thyroid cancer, skin lesions, pancreatic tumors, nor pheochromocytomas.
The physical exam was significant for tenderness to palpation on the left neck. Vital signs showed
borderline hypotension with systolic in 90-100s, otherwise normal. Hgb/Hct was 12.6/38.3, platelets were 244,
and WBC was 7.6. Sodium was 137, potassium was 3.7, chloride was 105, bicarbonate was 23, and BUN/Cr
was 12/.66.
A head CT was negative. A neck CTA showed heterogenously enhancing mass lesions in the carotid
sheath bilaterally between the internal and external carotid arteries suggestive of paragangliomas. A neck MRI
confirmed 2.5 x 1.7 cm masses bilaterally. Soft tissue U/S of head/neck/thyroid revealed diffuse heterogenous
enlargement consistent with diffuse multinodular thyroid goiter and nodules. Genetic testing revealed one
amino acid mutation at Proline-81-Leucine in the SDHD gene, consistent with paragangliomapheochromocytoma
syndrome type 1.
An electrophysiology consult placed a dual-chamber pacemaker, alleviating syncopal episodes. An
endocrinology consult ruled out a secretory paraganglioma and pheochromocytoma by checking catecholamines,
metanephrines, dopamine, and chromogranin A. Calcitonin and CEA markers returned normal, ruling out
thyroid cancer. The patient followed up with neurosurgery, who recommended bilateral excision.
Background/discussion: Hereditary paraganglioma is an autosomal dominant disorder involving mutations
involved in at least 4 genes SDHD, SDHAF2, SDHC, and SDHB, which correspond to paraganglioma type 1, 2,
3, and 4 respectively. These genes modify the enzyme succinate dehydrogenase which, if dysfunctional, leads to
succinate accumulation causing abnormal, yet benign cell growth. This can manifest into parasympathetic
nerve cell bunches found on head, neck, trunk, or sympathetic bundles on the adrenals as a pheochromocytoma.
The patient had bilateral nonsecretory parasympathetic neuroendocrine masses on the carotid bodies, causing
symptomatic bradycardia secondary to vagal symptoms related to paranglioma compression. A thorough family
history greatly assists an accurate diagnosis. Excision is the definitive treatment for secondary symptoms.

 

Nothing to Disclose: MHH, OS, MS, AC, KS

12931 37.0000 SUN-0315 A Familial Paraganglioma Type 1 Presenting with Sncope in Young Female 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Mine Adas*1, Bora Koc2 and Gokhan Adas3
1Okmeydani Training Hospital, Istanbul, Turkey, 2Bakirkoy Dr. Sadi Konuk Training and Research Hospital, istanbul, Turkey, 3S.B. Sadi Konuk Research Hospital

 

Introduction: Pheochromocytomas are chromaffin cell tumors typically arising in the adrenal glands and characterized by excessive production of catecholamines. Secretion of catecholamines in pheochromocytoma can be episodic or biochemically silent and therefore can present difficulty in diagnosis; however, failure to diagnose pheochromocytoma can have fatal consequences. Here, we report 7 different interesting cases that have pitfalls and mistakes during diagnosis.   

Cases: Between 2000 and 2013, we investigated retrospectively 26 patients with  diagnosis of pheochromocytoma. Among them, we found 7 patients with pitfalls and mistakes at diagnosis. One case had undiagnosed pheochromocytoma presenting with hypertensive crisis during nonrelated surgical procedure. Two cases misdiagnosed to have kidney masses (preop diagnosis, renal cell cancer and hypernephroma) and operated by urology department. The pathology revealed that patients had pheochromocytoma. Two patients were thought to have retroperitoneal masses and sent to radiology for biopsy with CT. The biopsy results were pheochromocytoma. One patient with breast cancer found to have adrenal mass with a suv-max 3.2 on FDG-PET-CT consisted with metastases. After adrenalectomy the diagnosis was pheochromocytoma. The last patient with left adrenal incidentaloma was operated for non-adenoma findings on MRI. 24-hour metabolites were unremarkable. But the diagnosis was pheochromocytoma.

Conclusion: Every crisis may be the last one for a pheochromoytoma patient. The fine-needle aspiration biopsy of a pheochromoytoma may result in haemorrhage and hypertensive crisis. Therefore, the possibility of pheochromoytoma should always be ruled out by biochemical testing before fine-needle aspiration biopsy is undertaken.  Given the strong association between the imaging features and pheochromoytoma, some advocate treatment with α- and β-adrenergic blockade and tumor resection in patients with imaging phenotype of pheochromoytoma, even when the results of biochemical testing for pheochromoytoma are normal. Mistakes in diagnosis and treatment of pheochromoytoma may be resulted perniciously. Therefore adrenal masses should be managed attentively with experienced endocrinology and radiology departments.

 

Nothing to Disclose: MA, BK, GA

13364 38.0000 SUN-0316 A Pitfalls in Diagnosis of Pheochromocytoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Maria Laarni Subang*, Rana Malek and Henry Richard Alexander Jr.
University of Maryland Medical Center, Baltimore, MD

 

Bilateral Paragangliomas in the Presence of the p.C68Y variant of the SDHB Gene

Background: Pheochromocytoma (PCC) and paraganglioma (PGL) are neuroendocrine (NE) tumors that are mainly sporadic but can also occur as part of inherited disorders, like MEN2, VHL and NF1. Ten to 30% are metastatic, and identification of germline mutations in the succinate dehydrogenase subunit B (SDHB) gene is predictive of metastasis and poor prognosis.

Clinical case: A 26 year old female  diagnosed with hypertension at age 23, maintained  on hydrochlorothiazide, developed night sweats and chest pain for 2 months. Chest x-ray, 2D echocardiogram, and exercise stress test were normal. She then started suffering from headaches on most days of the week with worsening blood pressure (BP) control despite titration of medication. A renal ultrasound showed right adrenal mass (3.6 cm at the greatest diameter). Labs from the primary care provider's office showed elevated 24-hour urine vanillylmandelic acid (VMA)  (17.3 ng/24 hrs, nl 0-7.5 ng/dl). She was referred to surgical oncology and endocrinology. Physical exam did not reveal café au lait spots, inguinal or axillary freckling, or neurofibromas. MRI of the abdomen showed bilateral adrenal masses (2.9 cm at the greatest diameter bilaterally). Further work-up showed elevated plasma fractionated (PF) normetanephrines (1,137 pg/ml, nl 0-145 pg/ml) and normal PF metanephrines (38 pg/ml, 0-62 pg/ml). There in no known family history of NE tumors. The patient was started on phenoxybenzamine 2 weeks before planned surgery. Surgery revealed bilateral paragangliomas with the right mass showing capsular and vascular invasion, increased mitotic rate (3-4 mitoses/10 high power field), and focal architectural disarray. Post-operative normetanephrines normalized to112 pg/ml (nl 0-145 pg/ml), associated with resolution of hypertension, night sweats, and headaches.  She proceeded to have genetic testing for familial paraganglioma syndrome type 4 (FPL4) that revealed the SDHB variant p.C68Y (also known as c.203G>A).  This variant has only been documented in one case report in a 59 year old with a right adrenal pheochromocytoma metastatic to the lymph nodes (1).

Conclusion: In a patient presenting with bilateral paragangliomas, physical findings and biochemical profile should support a focused and cost-effective genetic testing.  Features that were highly suggestive of FPL4 were age of onset, excessive normetanephrine production with normal metanephrine levels, extra-adrenal location, absence of physical findings suggestive of other inherited disorders, and aggressive histopathologic features.

 

Nothing to Disclose: MLS, RM, HRA Jr.

15006 39.0000 SUN-0317 A Bilateral Paragangliomas in the Presence of p.C68Y Variant of the Succinate Dehydrogenase Subunit B (SDHB) Gene 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Maria Batool*1, Lynn A Burmeister2 and John P Bantle2
1University of Minnesota Medical Center, Minneapolis, MN, 2University of Minnesota, Minneapolis, MN

 

Introduction:

The majority of  adrenal incidentalomas are non-secretory adenomas, although they can occasionally be malignant neoplasms and functional adenomas.

Adrenal ganglioneuromas are rare tumors that can mimic adrenal malignancies, metastases and pheochromocytomas.

Clinical case:

A 25 year old Vietnamese male with schizophrenia was seen in consultation for a 3.8 cm left adrenal mass, discovered incidentally on a CT scan of the abdomen and pelvis that was obtained as part of an evaluation for abdominal pain.

Biochemical testing was done to determine if the mass was hormonally active and ruled out a pheochromocytoma, Cushing's syndrome and primary hyperaldosteronism.

A dedicated adrenal CT was obtained which showed the lesion with a precontrast density of 36 Hounsfield units, increased enhancement  post- contrast of 44 Hounsfield units with further enhancement on delayed imaging of 71 Hounsfield units.

The size of the mass, paucity of fat and high density on the CT was worrisome for malignancy.

Given these findings, a PET CT was done which showed a hyperattenuating, heterogeneously enhancing, non- fluorodeoxyglucose (FDG) avid left adrenal mass. Findings were deemed indeterminate for malignancy as metabolically active malignant lesions trap FDG intracellularly, whereas most benign lesions do not.

Subsequently , the patient underwent  a left unilateral adrenalectomy without complication. The specimen submitted to pathology weighed  28.4 grams and was 6.1 x 4.9 x 2.9 cm in size . It was identified as a mature ganglioneuroma.

Conclusion:

Ganglio neuromas of the adrenal gland are extremely rare with approximately 230 cases reported in the literature (1).

They are benign,  well-differentiated tumors of the sympathetic nervous system composed of Schwann cells and ganglion cells that arise from the great sympathetic chains extending from the base of the skull to the neck ( 8%-9%), mediastinum (39%-43%) and retroperitoneum  (35%-52%) (2).

They preferentially affect young people and are are usually asymptomatic and hormonally silent. When symptomatic, they present with nonspecific symptoms related to their size or location with compression of neighboring structures. 

Ganglioneuroma may be found as a composite tumors with pheochromocytomas and may secrete catecholamines in that situation. They have also been reported to secrete VIP and even testosterone. Malignant transformation has been rarely reported (3).

About 67 % of ganglioneuromas are misdiagnosed as malignant adrenal lesions prior to surgery because of their size, presence of calcifications and density on imaging (4).

Histo pathological examination is currently the only tool to definitely diagnose this pathology. Complete surgical excision with negative margins is the therapy of choice and prognosis with such treatment is excellent.


 

Nothing to Disclose: MB, LAB, JPB

15014 40.0000 SUN-0318 A Adrenal Ganglio Neuroma – the Great Mimic? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Ravi Iyengar*1, Audrey Haywood1, Semil B Mehta1, Tricia A Moo-Young2, Deva Boone1, Richard A Prinz1, William D Kerr Jr.1 and Liana K Billings1
1NorthShore University HealthSystem, Evanston, IL, 2NorthShore University Health System, Evanston, IL

 

Background: The timing of surgical resection for patients presenting with pheochromocytoma crisis is controversial.

Clinical case: A 32 year-old healthy women presented to the emergency room complaining of abdominal pain and vomiting followed by chest pain and palpitations.

On exam she was pale and diaphoretic with blood pressure (BP) 140/90 and heart rate 140 beats/min. EKG showed ST elevations and sinus tachycardia with periodic VT/SVT. Troponin was elevated consistent with acute MI. Abdominal/pelvic CT ruled out aortic dissection and revealed a 7.1 cm hemorrhagic left adrenal mass. An emergent angiogram revealed normal coronary arteries with LV ejection fraction (LVEF) 30%. During the procedure, her BP rose to 193/113.

In the ICU, phentolamine and IV fluids were given. She developed flash pulmonary edema requiring intubation. She was resuscitated following two subsequent PEA arrests. A phentolamine infusion was given transiently, but was stopped because dopamine infusion was required to maintain systolic BP >90.

During the following 48 hours, she suffered from cardiogenic shock presumed to be secondary to a catecholamine-induced cardiomyopathy. She had tachycardia, hypotension requiring pressors, acute renal failure, pulmonary edema, transaminitis, fever, and ischemic digits.

By Day 4, the patient’s status stabilized. By Day 5, acute renal failure, tachycardia, fever, and pulmonary edema had resolved. BP tolerated a nicardipine infusion. Repeat echocardiogram showed LVEF of 25%. Day 1 plasma normetanephrine and metanephrine were 145 nmol/L (<0.90) and 66 nmol/L (<0.50), respectively.

A successful laparoscopic left adrenalectomy was performed on Day 8 followed by an uncomplicated post-operative hospital course. Pathology revealed a 9.9 cm pheochromocytoma. A post-surgical echocardiogram revealed an EF of 42%. Plasma fractionated metanephrine was undetectable after one week.

Conclusion: Early in this patient’s hospital course, the healthcare team struggled to determine the best timing of surgical resection in the absence of alpha blockade and the setting of a presumed pheochromocytoma and multi-organ failure. Much of the evidence provided on this topic is based on case series.

A recent study of the management of pheochromocytoma crisis concluded stabilization of the acute crisis and sufficient alpha-blockade prior to surgery leads to lower post-operative complication and mortality rates (1). Others have argued that emergency resection is indicated when attempts at alpha blockade fail to reverse the deterioration of the patient’s condition (2). Furthermore, it remains unknown whether removing the tumor may improve cardiomyopathy acutely or this resolves over a longer period (3).

We show that stabilizing multi-organ failure, initiation of nicardipine in pre-surgical preparation, and urgent, not emergent, adrenalectomy resulted in full recovery of this patient.

 

Nothing to Disclose: RI, AH, SBM, TAM, DB, RAP, WDK Jr., LKB

15137 41.0000 SUN-0319 A Determining the Timing of Surgery for the Best Clinical Outcome in Pheochromocytoma Crisis Resulting in Multi-Organ Failure and Catecholamine-Induced Cardiomyopathy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Christine Jane Orr*1 and William Louis Harper2
1McMaster University, Hamilton, ON, Canada, 2McMaster Univ, Hamilton, ON, Canada

 

Background: Multifocal pheochromocytoma is a rare disorder which may present with cardiac manifestations, including sudden death. This condition has complex diagnostic and management considerations, often requiring multidisciplinary care. 

Case: A 50 year old man presented with PEA arrest. History was significant for Grave’s Disease and cardiomyopathy NYD. He was admitted to the ICU for cooling. 12 days later he suffered a second arrest; resuscitation included 40 minutes of CPR. Following this he required a CT scan of his head. This showed a pharyngeal mass. CT neck showed the mass was actually the tongue. An incidental 3.3 x 4.5 cm mass in the carotid body was seen (Fig 1).  Cardiac cath showed normal coronaries. A 24 hour urine collection for metanephrines was positive at 37.7 nmol/dL (<11 nmol/dL). Fractionated metanephrines were positive for norepinephrine 3008 nmol/dL (<660 nmol/dL).  MIBG scan showed abnormal tracer activity in the right adrenal gland only.  Octreotide scan was completed to further assess potential neck paraganglioma. This showed octreotide accumulation in the right carotid body and the right adrenal, consistent with right pheochromocytoma and right carotid paraganglioma. (Fig 2) CT abdo showed a 6 mm nodule in the right adrenal gland and a 6 cm mass in the left adrenal (Figure 3.) Adrenal washout studies showed delayed washout >50% consistent with left sided pheochromocytoma. The patient was diagnosed with right carotid body paraganglioma and bilateral adrenal pheochromocytomas.

Management began with implantation of ICD and initiation of beta-blockade. Initiation of alpha-blockade occurred after diagnosis. Pre-op carotid body tumor embolization with onyx was done in IVR. This procedure required peri-op phentolamine and intra-op norepinephrine. Despite two weeks of pre-op phenoxybenzamine, the blood pressure did respond to intra-op norepinephrine.  Carotid artery balloon occlusion testing showed delayed crossflow with whole brain perfusion time of > 2 s. This test demonstrated that any carotid occlusion at the time of paraganglioma surgery would likely result in a large stroke.

Tumor removal took place 6 days following embolization.  Bilateral adrenalectomy was complicated by prolonged hypotension with episodes of hypertension requiring phentolamine. Post-op hydrocortisone was converted to oral therapy. The patient was discharged well to the brain injury ward.

Conclusion: Manifestations of neuroendocrine tumours are variable. Diagnostic challenges include multifocal disease and non-conciliatory imaging. Medical management with alpha-blockade may be clinically adequate in non-stressful conditions however additional stress may require dose adjustment or addition of another agent. In cases of paraganglioma balloon occlusion tests are useful for surgical planning. Communication between multiple medical subspecialties is challenging but crucial.

 

Nothing to Disclose: CJO, WLH

15409 42.0000 SUN-0320 A Diagnostic and Management Challenges with Multifocal Pheochromocytoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Salvatore Maria Corsello*1, Rosa Maria Paragliola1, Rosa Maria Lovicu1, Vincenzo Di Donna1, Angelo Minucci2, Ettore Capoluongo2 and Alfredo Pontecorvi1
1Catholic University School of Medicine, Rome, Italy, 2Catholic University School of Medicine, Rome

 

Introduction: Pheochromocytomas (PHEOs) and paragangliomas are neural crest-derived tumors that produce, store, metabolize, and secrete catecholamines. PHEO is generally a sporadic tumor, but recent population based studies suggest that up to 32 % of patients have a germline mutation in one of the known common susceptibility genes. In particular, mutations of VHL, NF1 and RET cause well characterized cancer susceptibility syndrome (von Hippel Lindau, Neurofibromatosis Type 1 and MEN 2 respectively).

Clinical case: We recently evaluated a 62 years old man, affected by hypertension, who came to our attention for a incidentally discovered 5 cm adrenal mass. His medical and family history was negative for endocrine disease. Abdominal CT scan confirmed a 5 cm adrenal adenoma, which did not show the typical radiological characteristic of pheochromocytoma. Laboratory evaluation ruled out cortical and medullary adrenal hyperfunction. Due to the size of the lesion, the patient was referred to surgery. Unfortunately, during adrenal manipulation, a severe intraoperative hypertensive crisis occurred, which was successfully treated with verapamil. During post-operative period patient was treated with copious idration to avoid hypotension and anti-hypertensive therapy was withdrawn. Final histology revealed the diagnosis of PHEO. Laboratory screening for MEN 2 was performed, showing elevated basal and stimulated calcitonin levels (basal 20 pg/ml, after i.v. calcium 296 pg/ml). Neck ultrasound showed bilateral thyroid micronodules and FNAB confirmed the suspicious of medullary thyroid cancer. Patient underwent total thyroidectomy and lymphadenectomy: final histology showed C-cell hyperplasia (CCH). Genetic test for protoncogene RET was performed and a missense mutation on exon 2 (c.166C>A, p.Leu56Met) was found. This mutation has previously been reported in association with Hirschsprung’s disease (HSCR), the congenital absence of ganglion cells in the submucosal and myenteric plexi of the gut. RET is the main gene implicated in this condition while in turn HSCR can represent a rare manifestation of MEN 2A. However, our patient was not affected by HSCR.

Conclusions: This unique case of MEN 2A is characterized by non-secreting PHEO and CCH associated with RET L56M mutation. To our knowledge, this is the first case of MEN 2 A reported in association with this mutation.

 

Nothing to Disclose: SMC, RMP, RML, VD, AM, EC, AP

15801 44.0000 SUN-0322 A A Case of MEN2A Associated to Leu56Met RET Mutation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Anne Marie Hannon*1, Patrick Sheehan2, Adrian Brady3 and Antoinette A Tuthill1
1Cork University Hospital, Cork, Ireland, 2South Infirmary/ Victoria University Hospital, Cork, Ireland, 3Mercy University Hospital, Cork, Ireland

 

MEN 2a is an autosomal dominant disease characterised by medullary thyroid carcinoma, pheochromocytoma, and primary parathyroid hyperplasia. It has an estimated prevalence of 1 per 30,000 in the general population.

Hereditary Haemorrhagic Telangiectasia is an autosomal dominant condition which is characterised by abnormal vascular structures resulting in epistaxis, gastrointestinal bleeding, iron deficiency anaemia, mucocutaneous telangiectasia, and arteriovenous malformations. It occurs with a prevalence of between 1 in 5000 and 8000. 

We present an unusual case of two distinct autosomal dominant conditions occurring in one patient. Firstly, MEN2a which was inherited paternally and HHT which was inherited maternally.

Our patient presented at age 24 with neck swelling. She underwent a near total thyroidectomy and central node dissection, the histology of which showed medullary carcinoma of the thyroid. A subsequent review of her family history revealed a positive family history for thyroidectomy in her father. Genetic analysis confirmed the presence of Cys611 Tyr RET oncogene missense mutation. Three out of five siblings and her father also tested positive for the gene.

Routine post-operative screening revealed a large upper left lobe pulmonary AVM.  On questioning she also complained of frequent episodes of epistaxis and she had characteristic facial telangiectasia. She was diagnosed with HHT and she was referred for embolization of the AVM. Her mother and two sisters have also been diagnosed with HHT.

This case demonstrates an unusual occurrence, where two distinct autosomal dominant conditions are inherited by a single patient. It highlights the importance to be vigilant that there may be multiple pathologies present when screening for disease recurrence in MEN2a.

 

Nothing to Disclose: AMH, PS, AB, AAT

16352 45.0000 SUN-0323 A MEN2A and Hereditary Haemorrhagic Telangiectasia – an Unusual Finding in Post-Operative Screening 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Asha Kallianpur*, Joanne Ngeow, Rita Tohme, Jessica Mester and Charis Eng
Cleveland Clinic, Cleveland, OH

 

Cowden syndrome (CS), one of several clinically overlapping autosomal dominant disorders, is characterized by frequent mutations in the Phosphatase and TENsin homolog (PTEN) gene and a marked predisposition to breast, thyroid and other cancers. CS is associated with loss-of-function germline PTEN mutations, which hyperactivate the cell-survival-promoting PI3K/AKT (mTOR) pathway and increase levels of phospho-AKT (pAKT). Significant unexplained variation in cancer risk in CS patients suggests a role for other genetic modifiers, however. We hypothesized that common variants in PI3K/AKT pathway genes and in genes that regulate iron transport and complement activation modify breast cancer (BC) susceptibility in women with CS.

Women with (cases) or without a history of invasive BC (controls), who met relaxed International Cowden Consortium operational criteria for CS, were evaluated in this unique, single-institution study. Genomic DNA extracted from peripheral blood leukocytes was genotyped by the SequenomTM method at candidate loci in 3 pathways comprised of functionally interdependent genes: regulation of iron transport (HFE, TMPRSS6, PCSK7, TFRC, TF, ACO1), mTOR (PIK3CA, AKT1, AKT2, MET, FRAP1, PHLPP2), and complement activation (complement factor H, CFH). PTEN mutations or deletions were detected by a combination of denaturing gradient electrophoresis, high-resolution melting curve analysis, Sanger sequencing, and multiplex ligation-dependent probe amplification assay. Intracellular PTEN and pAKT levels were measured by immunoblotting. Genetic associations with BC risk were assessed in multivariable regression models adjusted for age and stratified by PTEN status. A multiple testing correction for the number of independent genes rather than SNPs was applied to minimize Type I error in this exploratory study.

Among 628 women with CS (mean age 51±14 years), 340 (54%) had BC; 46 (13.5%) of cases and 81 (28.1%) of controls had germline PTEN mutations. Overall genotyping efficiency was >99%. Mutations in CFH (rs1061170) and PIK3CA (rs7640662) were associated with reduced risk of BC regardless of PTEN status [multivariable-adjusted odds ratio (OR) 0.70, p=0.05 and OR 0.63, p<0.05, respectively]. PCSK7 (rs236918) was significantly associated with reduced BC risk in all models, even following multiple-testing correction (OR 0.54, p=0.003). Levels of PTEN and pAKT did not differ significantly by genotypes at the studied loci. Interaction effects of CFH rs1061170 and PCSK7 rs236918 or between either of these variants and PTEN status were not observed. There were no genetic associations with thyroid cancer.

Variants in CFH, PIK3CA and particularly PCSK7 genes independently attenuate BC risk in women with CS, but measurable effects on PTEN or pAKT do not explain these associations.  Further studies are indicated to confirm these findings and elucidate underlying mechanisms.

 

Nothing to Disclose: AK, JN, RT, JM, CE

15166 46.0000 SUN-0324 A Polymorphisms in Complement Factor H (CFH) and Proprotein Convertase Subtilisin/Kexin Type 7 (PCSK7) Genes Reduce Breast Cancer Risk in Women with Cowden Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Bert M. Bieler*1 and Susan Marie Gerber2
1Cooper University Hospital, Camden, NJ, 2Cooper University, Cherry Hill, NJ

 

Background: Pure Leydig cell ovarian tumors comprise less than 0.5% of all ovarian neoplasms. These tumors contain testicular elements that may produce testosterone and other androgens if not functionally inactive. Leydig cell tumors may be either benign or malignant depending on degree of differentiation. The majority of these tumors occur in women younger than 40, although they can occur in women of all ages. If excess androgens are present, patients present with virilization, including hirsutism, breast atrophy, voice deepening, clitoromegaly, androgenic alopecia, acne, and menstrual disturbances. Diagnosis is initially based upon signs of virilization plus elevated testosterone with or without the presence of adnexal mass. Treatment is normally surgery alone. Final histologic diagnosis is confirmed via surgical pathology.

Clinical case: We report the case of a 64-year-old female with past medical history of type 2 diabetes, hypertension, hyperlipidemia, peptic ulcer disease, low back pain, cataracts, and tobacco abuse, who initially presented to endocrinology for toxic multinodular goiter. Upon questioning, she reported two years of worsening facial hirsutism, voice deepening, clitoromegaly, and increased libido. Laboratory testing revealed normal FSH, LH, DHEA-S, IGF-1, and 8 a.m. cortisol. Total testosterone was elevated at 443 ng/dl (10 times the normal value). Repeat total testosterone was 515 ng/dL. She underwent ovarian ultrasound, but the ovaries were not well-identified. Subsequent CT abdomen/pelvis revealed normal-appearing adrenals and ovaries. An incidental 2.9 cm right renal lesion was noted. Follow-up MRI showed similar findings. Patient was referred to urology and gynecology and underwent right nephrectomy as well as bilateral oophorectomy to rule out the ovaries as the source of abnormal testosterone production.  Pathology demonstrated a right renal cell cancer and a benign 1.5 cm right ovarian Leydig cell tumor.  Only 4 days after the surgery, the patients’ total testosterone had dropped from 515 ng/dl to <1 ng/dl.

Conclusion: This case demonstrates the importance of a thorough history, which led to the discovery of virilization. Additionally, suspicion for the presence of either adrenal or ovarian tumor as the source of very elevated testosterone levels in a virilized female patient should guide further management even in the presence of apparently normal imaging.

 

Nothing to Disclose: BMB, SMG

13183 47.0000 SUN-0325 A Virilization in a Post-Menopausal Female: A Leydig Cell Ovarian Tumor Presenting As Hyperandrogenism in a Patient with Normal Ovaries on Imaging 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Sunday, June 22nd 3:00:00 PM SUN 0279-0325 4885 1:00:00 PM Endocrine Neoplasia Case Reports Poster

Caroline T. Nguyen* and Jonathan S. Lopresti
Keck School of Medicine, University of Southern California, Los Angeles

 

Background: Hereditary Vitamin D-Resistant Rickets (HVDRR) is a rare autosomal recessive disease most often presenting in infancy. Mutations in the Vitamin-D-Receptor (VDR) gene lead to partial or total hormone resistance to 1,25(OH)2D3.

Clinical Case: A 24-year-old woman of average body habitus and height with a 5-year history of Graves’ disease, a diffusely large goiter (5x normal), Graves’ exophthalmos, and intolerance to methimazole underwent total thyroidectomy.  10 days post-op she develops symptomatic hypocalcemia 7.2 mg/dL (8.6-10.2 mg/dL) with normal albumin.  Aggressive oral calcium, ergocalciferol, and magnesium oxide supplementation is initiated. Two months after thyroidectomy she is re-admitted for symptomatic hypocalcemia with cramping, muscle spasms, and tingling in the extremities. Calcium 5.6 mg/dL, albumin 4.8 g/dL (3.5-5.5 g/dL), phosphorus 4.8 mg/dL (2.4-4.1mg/dL), magnesium 1.9 (1.7-2.4mg/dL), PTH 24 (10-65pg/mL), and QTc 438ms (n<440ms) were present.  She is treated for iatrogenic hypoparathyroidsim with IV calcium and calcitriol 0.5mcg PO BID with stabilization of calcium at 6mg/dL and resolution of symptoms.

However, over the next month she is admitted multiple times with persistent symptomatic hypocalcemia (Ca 5.1 mg/dL to 6mg/dL) with prolonged QTc up to 492ms. Calcitriol is eventually titrated up to 3mcg PO BID and calcium to 3gm PO TID in addition to IV calcium as needed with no significant improvement in her hypocalcemia. At this point, Vitamin-D-resistance is suspected.  1,25-dihydroxy-Vitamin-D is elevated at 99pg/mL (15-60pg/mL), consistent with a VDR dysfunction. 

Pre-thyroidectomy calcium of 9.1mg/d was likely an elevated calcium from longstanding uncontrolled hyperthyroidism.  Pre-thyroidectomy alkaline phosphatase was elevated at 286 IU/L (44-147 IU/L) in the setting of otherwise normal LFTs, consistent.  After total thyroidectomy with resolution of her hyperthyroidism and iatrogenic hypoparathyroidism, the patient lost her PTH-mediated compensation and developed persistent hypocalcemia.  In order to maximize her Vitamin-D-independent calcium regulation, she was started on Teriparatide, a parathyroid hormone analog, with resolution of her symptoms and improvement in her calcium to 8.4mg/dL.

Conclusion: Hypocalcemia unresponsive to aggressive standard therapy with an elevated 1,25-dihydroxy-Vitamin-D is consistent with Vitamin-D Resistance due to a receptor defect.  If hypoparathyroidism is also present, treatment with parathyroid hormone analog should be considered.

 

Nothing to Disclose: CTN, JSL

16304 1.0000 SUN-0236 A Hereditary Vitamin D-Resistance Diagnosed in Adulthood Masked By Hyperthyroidism and Unmasked By Iatrogenic Hypoparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0236-0245 5053 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Amy M DeGueme*1, Marconi Abreu2, Markey Carden McNutt II3, Ildiko Lingvay4 and Perry E Bickel3
1UT Southwestern Medical Center, Dallas, TX, 2UT Southwestern, Dallas, TX, 3UT Southwestern Med Ctr, Dallas, TX, 4University of Texas Southwestern Medical Center, Dallas, TX

 

Background: Primary hyperparathyroidism is a rare disorder presenting during pregnancy, however, if managed appropriately, it represents a preventable cause of fetal and maternal morbidity and mortality.

Clinical Case: A 16-year old, previously healthy, woman who was 20 weeks pregnant presented with 4 weeks of progressive generalized weakness and body aches as well as significant nausea and vomiting. She was found to have hypokalemia (<1.5 mmol, n=3.6-5.0 mmol/L), hypomagnesemia (1.4 mg/dL, n=1.6-2.6 mg/dL), elevated CPK (9801 units/L, n=26-192 units/L), preserved renal function (GFR>60), and hypercalcemia (13.1 mg/dL, n=8.4-10.2 mg/dL). Admission EKG showed QT prolongation. Electrolytes were aggressively replaced while hypercalcemia was treated with intravenous fluids. Further workup revealed an elevated PTH (126.7 pg/mL, n=15-65 pg/mL) with normal PTHrP (<0.2 pmol/L, n=<2.0 pmol/L) and low vitamin D 25-OH (13 ng/mL, n=25-80 ng/mL). Neck ultrasound identified an abnormal parathyroid gland abutting the left inferior thyroid pole. Her perioperative course was complicated by a non-obstructing, right 6 mm renal calculus with a urinary tract infection. Testing for other endocrine abnormalities was obtained, but screening labs revealed normal thyroid function tests, plasma metanephrines, fasting gastrin, aldosterone, renin, 8 am cortisol, and 24 hour urine cortisol.

Due to continued need for intravenous fluids (200cc/hr) to maintain normal calcium level and limited medical therapies available while pregnant, she underwent left inferior parathyroid adenoma removal with appropriate intra-operative drop in PTH (5.6 pg/mL at 20 minutes post removal). Pathology confirmed diagnosis of adenoma (weight 330 mg). Follow up calcium and PTH was 8.9 mg/dL and 39.9 pg/mL, respectively, two weeks after surgery, while off calcium supplements.

Conclusion: This case illustrates the importance of having a high clinical index of suspicion for diagnosis when patients present with typical, yet severe, non-specific symptoms of pregnancy as well as appropriate management of PHP during pregnancy. Persistent PTH elevation from the mother can lead to fetal hypocalcemia and parathyroid gland suppression. Left untreated, this can lead to significant hypocalcemia and tetany in the newborn as well as increased risk for nephrolithiasis, severe electrolytes abnormality, pre-eclampsia, pre-term delivery and miscarriage in the mother. Ultrasonography is the preferred modality for localization during pregnancy, although its sensitivity is around 69%. Minimally invasive parathyroidectomy can be performed during the second trimester, when the risk of anesthesia-induced pre-term delivery is the lowest and organogenesis is complete. The ability to perform intra-operative serial PTH monitoring allows for confirmation of successful adenoma resection and reduction of surgical time.

 

Nothing to Disclose: AMD, MA, MCM II, IL, PEB

16924 2.0000 SUN-0237 A Management of Severe Primary Hyperparathyroidism (PHP) during Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0236-0245 5053 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Kristen Anne Hyland* and Thomas Joseph Weber
Duke University Medical Center, Durham, NC

 

Background:  Milk alkali syndrome is an important etiology of hypercalcemia.

Clinical Case:  A 41 year old female status post bilateral lung transplantation (BOLT) for cystic fibrosis was admitted for abdominal pain. She rapidly decompensated, requiring transfer to the ICU and vasopressor administration, and was ultimately diagnosed with a small bowel obstruction.  Laboratory evaluation was significant for: acute renal insufficiency (creatinine 2.0 mg/dL (0.4-1.0) from a baseline of 1.0), calcium of 12.6 mg/dL (8.7-10.2), ionized calcium 1.77 mmol/L (1.15-1.32), phosphorus 6.5 mg/dL (2.3-4.5) and CO2 of 34 mmol/L (21-30). Medications at admission included a daily vitamin D supplement, tacrolimus, mycophenolate mofetil, trimethoprim-sulfamethoxazole and gancyclovir.  She was initially treated with IV furosemide and calcitonin 200 mcg s.q. every 6 hours with worsening of her hypercalcemia. She was given another dose of IV furosemide, but additional IV fluids were held because of recent BOLT.  She was then given 4mg IV zoledronic acid on hospital day 2.  Endocrinology was consulted on hospital day 4 for continued hypercalcemia.

Upon further elicitation of her medical history, patient stated that she had poor appetite, had been drinking up to 3 gallons of milk daily and also had had severe worsening of reflux symptoms over the previous 2 weeks.  She had been started on esomeprazole, but had also started taking over-the-counter calcium carbonate (Tums) up to 6 times per day. A diagnosis of milk-alkali syndrome (MAS) was made. She was closely monitored for development of hypocalcemia, which developed on hospital day 8 (6 days post IV bisphosphonate administration). Nadir ionized calcium was 0.89 mmol/l. 25 OH D level was low at 21 mg/mL (30-100), with a 1,25 (OH)2 D of <8 pg/mL (18-78). She required initiation of calcitriol 0.5mg twice daily, calcium carbonate 1500mg three times daily and cholecalciferol 2000 units daily. Calcium supplementation and calcitriol were continued post-discharge and could only be weaned 5 months post-discharge.

Conclusion:   This case demonstrates MAS secondary to increased dairy intake and over-the-counter anti-reflux treatment. Hypercalcemia, metabolic alkalosis, renal impairment and hyperphosphosphatemia, especially with a history of increased dairy or calcium intake, should trigger consideration of this diagnosis. This case illustrates how IV bisphosphonate, although potentially indicated for severe hypercalcemia, can complicate the management of patients with MAS.

 

Nothing to Disclose: KAH, TJW

16934 3.0000 SUN-0238 A Unrecognized Milk-Alkali Syndrome with Hypocalcemia Following Bisphosphonate Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0236-0245 5053 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

So-Young Kim*1, Oksana Davydov1 and Richard S Bockman2
1Weill Cornell New York Presbyterian, New York, NY, 2Weill Cornell Medical College

 

Introduction:

Prolonged glucocorticoid excess from Cushing’s disease can result in severe skeletal deterioration that does not self-repair after successful surgical treatment.

Clinical Case:

A 34-year-old man presented with a tibial stress fracture after minor trauma.  He subsequently developed avascular necrosis of the left femoral head. On physical exam, he had truncal obesity and a protuberant abdomen with large purple striae. Labs revealed elevated AM cortisol (21.6 ug/dl, nl 8-19 ug/dl) and urinary free cortisol (561 ug/24hrs, nl<250 ug/24hrs).  After 1mg dexamethasone, AM Cortisol remained elevated (27.2 ug/dl, nl<1.8 ug/dl) and ACTH did not suppress (84 pg/mL, nl<48 pg/mL). Patient also had elevated bone resorption, NTX (65 nM BCE/mM, nl 3-51 nM BCE/mM), low vitamin D 25(OH) (24.8 ng/ml, nl 30-100 ng/ml) with intact PTH (54 pg/ml, nl 15-65 pg/ml).  The DXA showed severely low BMD at lumbar spine (L-spine) 0.763 g/cm2 with a Z-score -3, and at total right hip 0.588 g/cm2 with a Z-score -2.8. Pituitary MRI revealed a focal lesion in the sella turcica consistent with microadenoma. This region was resected and pathology described a pituicytoma. One-year post resection, AM cortisol and ACTH normalized (9.3 ug/dl and 21 pg/ml respectively). A repeat DXA obtained 9-months post-surgery showed no significant change in BMD in L-spine 0.753 g/cm2 (Z-score -3.1); a 15% improvement in BMD at the right total hip, 0.686 g/cm2 (Z-score -2.3).  At that point, the patient was started on Teriparatide (TPTD).  After 2 years, a repeat DXA revealed a 53.9% increase in BMD at L-spine (1.154 g/cm2, Z-score 0.7); 50% increase at the total right hip (0.977 g/cm2, Z-score -0.2). Trabecular bone structure analyses at the start of TPTD and at completion showed an 11% increase, far less than the change in BMD. The patient received 5mg dose of zolendronate upon completion of TPTD.  Repeat DXA 3 years later showed BMD that continued to improve at spine and hip. In summary, successful surgical therapy in Cushing’s disease resulted in little improvement in osteoporosis. Subsequent treatment with TPTD restored BMD to above average skeletal mass that was associated with a much smaller increase in trabecular bone structure.

Conclusion: Restoration of skeletal mass and correction of osteoporosis after successful surgical treatment of the Cushing’s disease required anabolic therapy with TPTD. The principle deficit in the trabecular bone may be in the mineral, not the structural components.

 

Nothing to Disclose: SYK, OD, RSB

11837 4.0000 SUN-0239 A A Mechanism of Teriparatide-Induced Skeletal Repair in Cushing's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0236-0245 5053 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Karyne Lima Vinales*1, James Deer2 and Sherman Mitchell Harman3
1Phoenix VA health Care system, Phoenix, AZ, 2Phoenix VA Health Care System, Phoenix, AZ, 3Kronos Longevity Research Institute, Phoenix, AZ

 

Background:  The mechanism of hypercalcemia in coccidioidomycosis, a granulomatous fungal infection, is uncertain. Prior case reports of this rare complication do not document increased 1,25(OH)2 Vitamin D levels concomitant with hypercalcemia.

Clinical case: A 50 year old African-American female with a history of HIV was admitted for worsening cough, fever, and fatigue. She had stopped her anti-retroviral therapy a few months prior to admission. The patient was hypoxic with O2 saturation of 75%. CT scan demonstrated a miliary consolidation pattern with lymphadenopathy. Cocciodioides immitis was cultured from bronchoscopic washings. She also had CNS lesions consistent with disseminated coccidioidomycosis. CSF was serologically positive for Cocciodioides. The patient was treated with amphotericin and fluconazole. Within one week of admission, serum Ca increased from 9.0 to 12.1 mg/dL with normal limits (NL) of 8.4 - 10.4. The patient denied nausea/vomiting, abdominal pain, or altered mental status. On further evaluation total Ca levels were 9.3 and 11.3 mg/dL with corresponding PTH values of 23 and 6 pg/mL (NL = 10 – 65 pg/mL). Calcium levels corrected for a low albumin level of 2.7 g/dL (NL=3.5 - 5.1 g/dL) were 10.3 and 12.9 mg/dL. Ionized calcium was increased at 1.35 and 1.4 mmol/L (NL = 1.12 - 1.32 mm/L). Differential diagnosis of PTH independent hypercalcemia included disseminated coccidioidomycosis, adrenal insufficiency secondary to fluconazole, multiple myeloma or other malignancy.  A cosyntropin stimulation test was normal and UPEP/SPEP was negative. PTHRp was low-normal (14 pg/mL; NL= 14-27 pg/mL), and 25(OH) Vitamin D was mildly increased at 60.4 ng/mL (NL=30 – 60 ng/mL). TSH was 3.0 uIU/mL (NL= 0.5 - 5.0). However, the 1,25(OH)2 vitamin D was elevated at  92 pg/mL (NL = 18-72 pg/ml). The patient’s Ca level peaked at 12.4 (albumin corrected 14.8) mg/dL. Hypercalcemia was not controlled with hydration, and she received one dose of pamidronate 60 mg intravenously to which she responded well within 3 days. Nadir Calcium was 8.7 mg/dL (corrected 10.1), 10 days after administration.

Conclusion: In a case of proven disseminated coccidioidomycosis with hypercalcemia, we demonstrated significantly increased 1,25 (OH)2 vitamin D and no other proximate cause of high calcium levels, suggesting granulomatous production of 1 alpha-hydroxylase as the cause of hypercalcemia, similar to the mechanism reported in sarcoidosis.

 

Nothing to Disclose: KLV, JD, SMH

13261 5.0000 SUN-0240 A Hypercalcemia Secondary to Disseminated Coccidioidomycosis with Increased 1,25 Dihydroxy Vitamin D 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0236-0245 5053 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Kim Thien Nguyen*1, Dorothy A Fink1, Mishaela Ruth Rubin2, Sharon L. Wardlaw3 and John P Bilezikian1
1College of Physicians and Surgeons, Columbia University, New York, NY, 2Columbia University College of Physicians and Surgeons, New York, NY, 3Columbia University College of Physicians & Surgeons, New York, NY

 

Background: Osteitis fibrosa cystica (OFC) is a form of severe bone remodeling that occurs in the secondary hyperparathyroidism of chronic kidney disease (CKD) and most often affects the spine, ribs, long bones, and skull.  Rarely, OFC can affect the jaws and maxillofacial bones causing marked facial deformities, a complication called leontiasis ossea.

Clinical Case:  A 21-year old Latina woman with Alport syndrome and Stage 5 CKD received a renal transplant at the age of 14, but at age 17 developed rejection requiring hemodialysis.  Three years later, she noted swelling and disfigurement of the face with protrusion and widening of the jaw leading to difficulty with speech and swallowing.

Evaluation confirmed probable brown tumor of the mandible and maxilla.  The PTH was 5,116 pg/mL (nl: 8-51), phosphorus 5.9 mg/dL (nl: 2.5-4.3), 25(OH)D 11.9 ng/mL (nl: 30-80), and alkaline phosphatase 1,869 U/L (nl: 33-96).  Except for one high serum calcium of 10.4 mg/dL (nl: 8.7-10.2), she was normocalcemic.  Ultrasound of the neck showed 1.2 cm nodules near the inferior poles of both thyroid lobes, likely enlarged parathyroid glands.  Head and neck CT revealed diffuse hyperostosis with expansion of the medullary spaces of the mandible and skull and of the facial bones, cervical vertebrae, and calvarium.  Despite institution of cinacalcet (30 mg/d), sevelamer hydrochloride (800 mg tid), and ergocalciferol (50,000 IU/wk), facial deformities worsened over 7 months.

She was referred to our institution for total parathyroidectomy with forearm autotransplantation of parathyroid tissue.   The intraoperative PTH level fell from over 3000 pg/mL to 221 pg/mL.  ‘Hungry bone syndrome’ developed with undetectable PTH (<3 pg/mL) and hypocalcemia (6.5 mg/dL). Intravenous calcium replacement at a rate as high as 2.5 mg/kg/hr was required for 10 days before successfully transitioning to oral calcium repletion. Discharge medications were calcitriol (1 ug/d), ergocalciferol (50,000 IU/wk), and calcium carbonate (5 gm/d).

The autotransplanted parathyroid tissue is functional 10 months postoperatively with mean PTH level of 40 pg/mL, but is insufficient to maintain normal serum calcium. Despite a second renal transplant 4 months after parathyroidectomy, she requires large amounts of calcium and calcitriol. Nevertheless, marked regression of her jaw hypertrophy and improved facial appearance has occurred with control of the severe hyperparathyroidism, even in her relative hypoparathyroid state.

Conclusion:  This case of leontiasis ossea illustrates a rare complication of the secondary hyperparathyroidism of uremic osteodystrophy.  While few patients have complete normalization of their facial bone abnormalities and may need surgery, residual PTH in this patient led to improvement of facial bone abnormalities and demonstrates that partial skeletal healing is possible with correction of the severe hyperparathyroid state.

 

Nothing to Disclose: KTN, DAF, MRR, SLW, JPB

13825 6.0000 SUN-0241 A Uremic Leontiasis Ossea: A Rare Disorder of Skeletal Remodeling Due to Severe Renal Osteodystrophy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0236-0245 5053 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Jessica S Tanenbaum*1, Dorothy A Fink1, Kim Thien Nguyen1, Mishaela Ruth Rubin2 and John P Bilezikian1
1College of Physicians and Surgeons, Columbia University, New York, NY, 2Columbia University College of Physicians and Surgeons, New York, NY

 

Background: Hypercalcemia caused by increased bone resorption due to increased osteoclast activity is seen in acute and lymphomatous subtypes of Adult T-Cell Lymphoma/Leukemia. Reported osteoclast activators in these situations include parathyroid related hormone (PTHrP) and macrophage inflammatory protein-1α (MIP-1α).

Clinical Case: A 48 year-old woman presented with marked hypercalcemia of 15.4 mg/dL (8.7-10.2), fatigue, and shortness of breath. Two months prior to admission, she had noted neck swelling and on exam there were multiple enlarged lymph nodes up to 3 centimeters in the anterior cervical, posterior occipital, and supraclavicular regions.

Laboratory studies: PTH was undetectable <3 pg/mL (nl: 8-51); marked hypercalciuria of 542 mg/24 hours (nl: 150-300) was noted. The 25-hydroxyvitamin D (25-OH D) was low 19 ng/mL (nl: 30-80) while the 1,25-dihydroxyvitamin D (1,25 (OH)2D) was elevated 77 pg/mL (nl: 15-75). The PTHrP level was at the upper limit of normal 25 pg/mL (nl: 14-27). HTLV-I and HTLV-II tests were positive. Imaging by CT and PET-CT revealed diffuse FDG-avid lymphadenopathy, several necrotic nodes along the right internal jugular vein, and heterogeneous marrow FDG uptake. Excisional biopsy of an enlarged right cervical node revealed malignant lymphoma. The tissue's morphologic and immunophenotypic characteristics, combined with the HTLV-1 positivity, confirmed a diagnosis of Adult T-Cell Lymphoma.

Course: Hypercalcemia was managed successfully with intravenous hydration, zoledronic acid, and calcitonin. The lymphoma was treated with cycles of bortezomib and raltegravir. Whole body PET-CT scans prior to the third and fifth cycles of chemotherapy showed interval reduction in the size and FDG avidity of the lymphadenopathy. By the fifth cycle, serum calcium level was 8.6 mg/dL. However, 1,25 (OH)2D was two times the normal range (132 pg/mL) and the 25-OH D remained low (18 ng/mL). The PTHrP declined to 15 pg/mL.

Conclusion: While it is possible that the PTHrP was responsible for the increase in 1,25 (OH)2D, it is unlikely. The paradoxical increase in 1,25 (OH)2D in association with a reduction in PTHrP and unchanged 25-OH D suggests 2 mechanisms for the hypercalcemia associated with the T-Cell Lymphoma: production by the tumor of both PTHrP and 1,25 (OH)2D.

 

Nothing to Disclose: JST, DAF, KTN, MRR, JPB

13878 7.0000 SUN-0242 A Dual Mechanisms of Hypercalcemia in a Patient with Adult T-Cell Leukemia/Lymphoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0236-0245 5053 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Niralee Vaishnav*1 and Leland Graves2
1University of Kansas Medical Center, Kansas City, KS, 2The University of Kansas Medical Center, Kansas City, KS

 

Background:  Hypovitaminosis D is a common clinical problem following malabsorptive weight loss procedures as well as other malabsorption disorders and often requires ongoing, aggressive replacement therapy. On occasion, replacement with high dose cholecalciferol or ergocalciferol fails to correct hypovitaminosis D.  As parenteral vitamin D is no longer available in the US, this leaves little alternative therapy.  UV light therapy has been used successfully in similar cases but may be difficult for some patients to obtain regularly.  Profound vitamin D deficiency may result in symptoms of myalgia, bone pain and muscle cramping.  In addition, it may lead to bone loss with increased fracture risk and has been associated with conditions such as insulin resistance, autoimmune disorders and potentially increased malignancy risk. 

Clinical Case:  A 41-year-old African American female presented with severe chronic hypovitaminosis D associated with bone pain and myalgias.  She had undergone biliary pancreatic diversion for weight reduction ten years prior to presentation. Her initial 25-OH vitamin D was very low (3 ng/dL, n = 30-80 ng/mL). Despite compliance with aggressive vitamin D2 and D3 therapy regimens of up to 200,000 international units (IU) daily, including tablet, liquid and wafer formulations, she remained vitamin D deficient (level <15 ng/dL). Hypovitaminosis D secondary to malabsorption from biliary pancreatic diversion was the diagnosis and alternative treatments including UV light therapy were discussed. However, due to cost constraints, this was not feasible. Since fat soluble vitamins such as vitamin D are often deficient in patients with pancreatic exocrine dysfunction and potential inadequate bile and pancreatic enzyme delivery may occur in patients with pancreatic biliary diversion due to reduced post meal fat absorption, a trial of pancreatic enzyme replacement was proposed.  We started our patient on weight based Creon (48,000 units) to be taken at the time of her daily high dose Ergocalciferol treatment of 200,000 IU. Repeat testing four months later revealed a 2 fold increase in her vitamin D level to 24 ng/dL. 

Conclusion:  Hypovitaminosis D related to malabsorption may be particularly difficult to treat.  For patients at risk for pancreatic exocrine insufficiency, a trial of vitamin D replacement with pancreatic enzyme supplementation may be considered.

 

Nothing to Disclose: NV, LG

14017 8.0000 SUN-0243 A An Alternative Treatment Approach for Malabsorption Related Vitamin D Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0236-0245 5053 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Afreen Idris Shariff*1, Jennifer Laura Stahl1 and Fiona J Cook2
1Brody School of Medicine, East Carolina University, Greenville, NC, 2Brody School of Medicine, Greenville, NC

 

A 27 year old G1P0 female presented with symptoms of abdominal pain, nausea, vomiting, altered mental status and findings of ataxia and intranuclear ophthalmoplegia at 17.3 weeks gestation. As part of the evaluation for altered mental status an MRI of the brain was done with findings of central pons and medial thalami demyelination.  Serum thiamine level was severely low at <7nmol/L  [normal 8-30]. Wernicke’s Encephalopathy was diagnosed and was attributed to malnutrition exacerbated by hyperemesis gravidarum. Alcohol use was denied. Thiamine was replaced with significant neurological recovery by day 3. At 19.2 weeks gestation the patient had intrauterine fetal demise. Pathological examination of placenta and fetus did not reveal any histological abnormality.

Despite no longer being pregnant, the patient continued to have nausea and vomiting. Post-partum, she developed progressive hypercalcemia with highest serum calcium 14 mg/dL [when corrected for low albumin], compared to corrected serum calcium 10.5 mg/dL on admission. Intact parathyroid hormone level was 518.3 pg/ml [normal 10-65] and 25-hydroxy vitamin D level was 5 ng/ml [normal 30-100]. A Sestamibi scan suggested a left parathyroid adenoma, following which the patient underwent excision of a 2.7 gm parathyroid adenoma. She was at high risk for hypocalcemia due to hungry bone syndrome but did well post op with high doses of oral calcium and vitamin D.

The literature suggests that the diagnoses of primary hyperparathyroidism in pregnancy (<100 reported cases) and Wernicke’s Encephalopathy from hyperemesis in pregnancy (<50 reported cases) are rare.  Our patient was severely malnourished as evidenced by low albumin, along with severe vitamin D and thiamine deficiency. We propose that our patient had pre-existing severe primary hyperparathyroidism, which was masked, not only by vitamin D deficiency, but also by pregnancy related changes in calcium and PTH physiology. The fetal-placental unit rapidly extracts calcium from the maternal blood stream to meet the needs of the fetal skeleton. Post partum, when fetal calcium demand was removed, the patient became severely hypercalcemic. This case raises the concern that primary hyperparathyroidism during pregnancy may be easily overlooked and more common than reported. Screening for this problem would be important in any pregnant patient who presents with signs of poor nutrition, hyperemesis, and high normal serum calcium.

 

Nothing to Disclose: AIS, JLS, FJC

14105 9.0000 SUN-0244 A An Instructive Case of Hyperemesis Gravidarum, Wernicke's Encephalopathy, and Primary Hyperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0236-0245 5053 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Lívia Grimaldi Abud Fujita*1, Thaís Helena Monteiro de Oliveira1, Gustavo Rocha Dissenha1, Letícia Alarcão Maxta1, Evandro S Portes2 and Ricardo A Guerra2
1Hospital do Servidor Público Estadual, São Paulo, Brazil, 2Hospital do Servidor Publico Estadual de Sao Paulo

 

Introduction: hypoparathyroidism, regardless of cause, is characterized by serum levels of low calcium, high phosphorus and low or inappropriately normal levels of parathyroid hormone (PTH). Calcifications may occur, especially in the central nervous system (basal ganglia and cerebellum), in about twenty percent of the patients with chronically untreated hypoparathyroidism. However, calcifications in other parts of the body are very rare, with few reports in the literature.

Case report: a female patient, aged 56, during hospitalization for myasthenic crisis, was diagnosed with hypoparathyroidism (total calcium 6.5 mg/dl; ionized calcium 1.14 mmol/L; phosphorus 6.2 mg/dl and PTH < 3 pg/ml).

Regarding hers personal history, the patient presented at 15 year of age of Grave’s disease and underwent total thyroidectomy because there was treatment failure with oral antithyroid medication and radioiodine. She presented postoperative hypoparathyroidism, but used calcium carbonate and calcitriol for only two months. Thus, the patient had an untreated hypoparathyroidism for about 40 years.

Concomitant diagnosis of hypoparathyroidism at age 56, the patient also complained of the onset of severe pain, limited movement, and hardened tumors in joints (shoulders, knees, knuckles, elbows) and other regions of the body as in the paraspinal musculature of the neck, jaw, arms and thighs, progressively worsening. Plain radiographs showed extensive calcification of these structures, with hyperostosis of some bony prominences. Biopsy of one of these calcifications was performed on the dorsum of the first right finger; pathology report was of calcinosis cutis.

Paradoxically, the patient had no calcifications in central nervous system in computadorizad tomography scans.

Besides the prescription of calcitriol, cholecalciferol and calcium carbonate for the treatment of hypoparathyroidism, was also prescribed phosphate binder (Renagel) at a dose of 800 mg, in the three main meals of the day. The purpose of this approach is to reduce the calcium X phosphorus product and thus prevent progression of calcifications.

Conclusion: there is almost no description in the literature of calcification in extra central nervous system structures. However, we believe that the exposure to a high product calcium X phosphorus for a long period in this patient caused coarse calcifications in various structures of the body, leading to an atypical presentation of hypoparathyroidism and serious damages to her.

 

Nothing to Disclose: LGAF, THMDO, GRD, LAM, ESP, RAG

14163 10.0000 SUN-0245 A Hypoparathyroidism Associated with Coarse Calcification in Various Parts of the Body: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0236-0245 5053 1:00:00 PM Metabolic Bone Disease - Genetic Causes and Management Poster

Naira Baregamian*1, Patricia Donovan1, Karl Insogna2 and Robert Udelsman3
1Department of Surgery, Section of Endocrine Surgery, Yale University School of Medicine, New Haven, CT, 2Endocrinology & Metabolism Section, Yale University School of Medicine, New Haven, CT, 3Miami Cancer Institute, Miami, FL

 

In nearly 5% of patients with a presumptive diagnosis of primary hyperparathyroidism (PHPT), borderline or “normal” intact parathyroid hormone (iPTH; normal: 10-69 pg/mL) levels can be demonstrated. The utility of mid-molecule PTH (mmPTH, 10-25 nLEq/mL), a diagnostic adjunct, has not been established in this small but challenging subset of symptomatic patients. Review of an HIC-approved prospective database identified 373 patients who underwent surgery from May 2010 to October 2013 for PHPT, and in 36 patients (81% female), a mmPTH was obtained pre-operatively. Symptoms, signs, biochemical, imaging, operative, pathologic and follow-up data were reviewed. They had neurocognitive symptoms (72%), bone disease (78%: 50% osteoporosis, 28% osteopenia; 22% with fractures), nephrolithiasis (19%) and gastrointestinal symptoms (25%). Two patients with recurrent and one with persistent PHPT had undergone initial surgery elsewhere. Eight (22%) had both normal iPTH (47±14, range 27-60) and mmPTH (21±4, range 13-25) values; 7 (19%) had normal iPTH (53±13, range 29-67) and elevated mmPTH (35±6, range 30-46) values; 20 (56%) had elevated values of both iPTH (121±33, range 75-201) and mmPTH (46±13, range 30-68) and 1 (3%) had an elevated iPTH with a normal mmPTH value. The correlation between iPTH and mmPTH was 0.67 (p=<0.0001). Abnormal parathyroid glands were identified and resected in all patients. All 36 patients achieved an intra-operative biochemical cure (iPTH fell by >50% and was in the normal range). Nineteen (53%) had multi-gland hyperplasia and underwent subtotal parathyroidectomy, whereas, 17 (47%) had a single adenoma resected via a minimally invasive approach. In the hyperplasia group, 3 (16%) had positive, 12 (63%) had partially localizing and 4 (21%) had non-localizing imaging.  In the adenoma group, 8 (47%) had positive and 9 (53%) had negative imaging. Thirty five of 36 (97%) of these patients maintained a normal calcium and low-normal iPTH in post-operative follow up, whereas, 1 had persistent disease in spite of removing a 125 mg adenoma. Importantly, all 7 patients of the target group with “normal” iPTH and elevated mmPTH values were cured, thus demonstrating the efficacy of mmPTH as a diagnostic adjunct in patients with a borderline PHPT biochemical profile. These symptomatic patients demonstrate a high probability of multi-gland hyperplasia, and can be cured by surgery.

 

Nothing to Disclose: NB, PD, KI, RU

13476 1.0000 SUN-0193 A Mid-Molecule Parathyroid Hormone Is a Useful Adjunct in Establishing the Diagnosis of Primary Hyperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Aysenur Ozderya*1, Omer Kocak2, Sule Temizkan1, Kadriye Aydin3, Gulgun Arslan4 and Mehmet Sargin2
1Kartal Training and Research Hospital, Istanbul, Turkey, 2Div of Family and Community Medicine, Kartal Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey, 3Div of Endocrinology, Kartal Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey, 4Div of Internal Medicine, Kartal Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey

 

OBJECTIVE: Normocalcemic hyperparathyroidism (NCPHPT) is a comperatively newer clinical presentation of primary hyperparathyroidism which has been described over the past decade. It is well defined  that many metabolic disturbances accompany classic hypercalsemic form of hyperparathyrodism. Alterations in the glucose metabolism is one of them but data is limited  in NCPHPT patients.  To address this issue we aimed to determine whether insulin resistance accompanies this early stage of  primary hyperparathyroidism.

SUBJECTS AND METHODS: The study was conducted at endocrinology outpatient clinic in Kartal Lutfi Kýrdar Training and Research Hospital. Twenty-five patients aged 18-65 years with normocalcemic hyperparathyroidism and 25 age, gender and body mass index matched controls were included the study. Patients were diagnosed NCPHPT if their serum calcium (Ca) concentrations and  ionized serum Ca were in the normal range but whom the parathyroid hormone (PTH)  level inappropriately persisted high. Subjects with 25(OH)D levels over 20 ng/dl were included the study.  The upper limit of the PTH was calculated with the nomogram (calculated max PTH=120-[6xCa] - [½ x Vit D3] - [¼ x Age] for each subject. Patients and controls underwent a standard 75 gram  oral glucose tolerance test (OGTT). Insulin resistance was assessed by the homeostasis model assessment (HOMA-IR) and insulin sensitivity index (ISOGTT).

RESULTS: There were no difference between the demographic features of NCPHPT patients and the control group. NCPHPT patients were  overweight/obese (mean body mass index (BMI) 30,3 ± 4,9 kg/m2).  Nefrolithiasis was more common in NCPHPT patients than controls but the difference was not statistically significant (p=0.16). HOMA-IR tended to be higher and the ISOGTT tended to be lower in NCPHPT patients  but  the  difference was not statistically significant (respectively p=0.17 and p =0.22). We did not find any correlation between PTH and glucose metabolism markers HOMA-IR, ISOGTT, HBA1C and BMI. ISOGTT tended to be lower in increasing Ca levels but the correlation was not statistically significant (p=0.06). 25(OH)D had statistically significant negative correlation with HBA1C and CRP (respectively p<0.01 and p<0.01). ALP was in normal range in both groups,  but it was statistically higher in NCPHPT patients than controls (p=0.02).

CONCLUSION: The results of this study indicate that insulin resistance is not more common in NCPHPT patients and PTH is not related to ISOGTT and HOMAIR but limited number of patients may hinder the possible association. Hypercalcemia, 25(OH)D insufficiency and obesity may be responsible for insulin resistance in hyperparathyroidic patients. There is an increased bone turnover in this early stage of the disease.

 

Nothing to Disclose: AO, OK, ST, KA, GA, MS

13778 2.0000 SUN-0194 A Insulin Resistance and Normocalcemic Hyperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Manige Konig1, Yasaman Mohtasebi*2, Lisa Davidoff3 and Elizabeth A. Streeten4
1Bay West Endocrinology, 2Univ of Maryland Med Ctr, Baltimore, MD, 3University of Maryland Medical Center, 4Univ of Maryland Hosp, Baltimore, MD

 

Renal safety is similar in patients with hypoparathyroidism treated chronically with high dose vitamin D2 compared to calcitriol

 

Background: Ergocalciferol(vitamin D2) was the first treatment used for hypoparathyroidism, but is now used in <20% of patients due to concern for potential renal toxicity because of its long half–life.  High doses of D2 are needed to promote production of 1,25(OH)2D and maintain eucalcemia, in the absence of PTH, but in our experience, toxicity from D2 occurs far less often than with calcitriol. The purpose of this retrospective study was to compare serum calcium (Ca), serum creatinine (Cr), hospitalizations for calcium disturbance, kidney stones and quality of life in hypoparathyroid patients chronically treated with D2 vs calcitriol.

Methods: After IRB approval, billing records containing ICD9 codes for hypoparathyroidism were used to identify patients treated for hypoparathyroidism at the University of Maryland over the past 10 years. After review of electronic medical records, 30 patients with confirmed hypoparathyroidism were identified, 16 treated chronically with D2 and 14 with calcitriol.  We compared clinical characteristics, mean serum Ca corrected for serum albumin and serum Cr in the 2 groups.  Analyses of hospitalizations for calcium imbalance and quality of life questionnaires are ongoing.

Results: There was no significant difference in the etiology of hypoparathyroidism in those treated with calcitriol vs D2. Mean age of D2 group was 58.9±16.7 yrs vs 50.9±22.6 yrs in calcitriol group (p=0.28) and although treatment duration tended to be longer in those on D2: 17.8±14.2 yrs vs 8.5±4.4 yrs in calcitriol group, there was no significant difference in mean corrected serum Ca or Cr between 2 groups. Mean corrected serum calcium was 8.6±0.6mg/dl in D2 group vs 8.39±0.74mg/dl in calcitriol group (p=0.37). Mean serum creatinine/GFR was 0.91±0.32/76 in D2 vs 1.04±0.34/55 in calcitriol group (p=0.29). Mean daily dose of vitamin D2 was 41.326±30,198 IU and for calcitriol, 0.58±0.31mcg. Doses of D2 used in our study were well below those shown to cause toxicity in the late 1970s (100,000-150,000 IU/day).

Conclusions: We found no evidence of greater renal toxicity in patients with hypoparathyroidism treated chronically with high dose vitamin D2 compared to those treated with calcitriol.  Chronic treatment with vitamin D2 should be considered more often in patients with hypoparathyroidism.

 

Nothing to Disclose: MK, YM, LD, EAS

13779 3.0000 SUN-0195 A Renal Safety Is Similar in Patients with Hypoparathyroidism Treated Chronically with High Dose Vitamin D2 Compared to Calcitriol 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Catherine Massart*1, Jean-Claude Sourberbielle2 and Philippe Chanson3
1CHU Rennes, Rennes, France, 2Hôpital Necker-Enfants malades, Paris, France, 3Univ Paris-Sud, UMR-S693, Le Kremlin Bicêtre, France, Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Service d’Endocrinologie et des Maladies de la Reproduction, Le Kremlin Bicêtre, Paris, France, Le Kremlin-Bicêtre, France

 

Introduction : Third generation (3G) parathyroid hormone (PTH) assays are new generation methods that recognize only bio-intact PTH 1-84 without any cross-reaction against 7-84  PTH fragments.

Objective: To study the analytical performances and reference range of the new 3G-PTH assay performed on the LIAISON XL ®  according to vitamin D status.

Patients and methods: Reference intervals were obtained from 911 healthy subjects (441 men, 470 women) from different areas of  France, aged 18-85 yr. Only subjects with normal blood and urinary routine biochemical parameters were included. Serum 3G-PTH and 25 hydroxyvitamin D (25OHD) were measured using the automated 3G-PTH and 25OHD LIAISON XL® (DiaSorin SA, Antony, France). Intra- and inter-assay variability were evaluated for each parameter. Comparison between different groups of 3G-PTH classified according to 25OHD values (≥ 75 nmol/l or between 50 and 75 nmol/l ) was performed with the non-parametric Mann-Whitney test.

Results: Intra- and inter-assay CVs were ≤ 10 % or ≤ 7.1 % for 3G-PTH or 25OHD, respectively. The concentrations (3rd-97th percentile) obtained in the whole group ranged from to 10.5 to 39.1 ng/L and from 22 to 102.3 nmol/l for 3G-PTH and 25OHD, respectively. Considering only the 177 subjects with 25OHD ≥ 75 nmol/l, 3G-PTH values ranged from 9.3 to 33 ng/L. These 3G-PTH concentrations were statistically different (Z=-2.611; p=0.009) with those obtained (range: 10.6- 37 ng/L) in the 454 subjects with 25OHD levels between 50 and 75 nmol/l . Conclusion These results confirm that vitamin D status should be taken into account when establishing reference values for serum 3G-PTH. By doing that, we found that the upper normal limit was significantly lower than what is indicated in the manufacturer notice. Whether other determinants of PTH secretion such as age, renal function, or calcium intake should also be taken into account deserves further study.

 

Nothing to Disclose: CM, JCS, PC

13888 4.0000 SUN-0196 A Analytical Performances and Reference Values of the Third-Generation Parathyroid Hormone Assay Obtained on the Liaison XL® Immunoassay System 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Steven J Bowlin*1, Tara Sadowski2, Tamara J. Vokes3, John P Bilezikian4, Bart Lyman Clarke5, Michael Mannstadt6, Dolores M. Shoback7 and Hjalmar Lagast8
1NPS Pharma, Bedminster, NJ, 2NPS Pharmaceuticals, Inc., Bedminster, NJ, 3University of Chicago Medicine, Chicago, IL, 4College of Physicians and Surgeons, Columbia University, New York, NY, 5Mayo Clinic E18-A, Rochester, MN, 6Massachusetts General Hospital and Harvard Medical School, Boston, MA, 7University of California - San Francisco VA Medical Center, San Francisco, CA, 8NPS Pharmaceuticals, Bedminster, NJ

 

Chronic hypoparathyroidism is a rare endocrine disorder. Emerging data indicate significant complications from the disease and its treatment. There is a limited amount of long-term clinical and epidemiology information available because published data frequently originate from single centers involving a relatively small number of patients. To address this gap, a voluntary, observational patient registry called PARADIGHM™, sponsored by NPS Pharmaceuticals, Inc., was initiated; its primary goal is to characterize the epidemiology, natural history, and clinical features of a large cohort of patients with hypoparathyroidism under normal clinical practice conditions.

PARADIGHM will prospectively collect data arising from routine medical care of patients. Patients with hypoparathyroidism of any age and etiology are eligible regardless of treatment. Patients will be recruited over a 7-year period with a goal sample size of 900. Follow-up data collection is planned for a minimum of 10 years. Patients are recruited through any physician at investigator sites. Data collected will include (1) clinical and treatment data documented in medical records, (2) patient-reported outcomes and health care use, and (3) mortality.

The registry began enrolling in the United States in July 2013 and will start enrolling in the European Union in 2014. In addition to patient demographics, family and medical history, and etiology of the disease, we will capture clinically relevant data such as patients’ symptoms and quality of life, as well as the impact of the disease on the patient’s professional life. Results of laboratory and imaging testing, details of treatment, emergency room visits and hospital admissions, and mortality will also be collected.

PARADIGHM will provide long-term, prospective, clinically relevant data from the largest cohort of patients with hypoparathyroidism. Findings are expected to contribute to a better understanding of the natural history of hypoparathyroidism, and have the potential to assist the medical community in clinical, evidence-based decision making.

 

Disclosure: SJB: Employee, NPS. TS: Employee, NPS. TJV: Advisory Group Member, NPS. JPB: Advisory Group Member, NPS, Research Funding, NPS. BLC: Advisory Group Member, NPS, Research Funding, NPS. MM: Advisory Group Member, NPS. DMS: Advisory Group Member, NPS, Research Funding, NPS. HL: Employee, NPS.

13925 5.0000 SUN-0197 A Paradighm™: A Natural History Registry for Patients with Chronic Hypoparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Marcela Janka Zires*1, Paloma Almeda-Valdes2 and Francisco Javier Gomez-Perez2
1Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico, 2Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico

 

Introduction

Hypercalcemia is a rare but well established cause of acute and chronic pancreatitis. Hypercalcemia-related pancreatitis is mainly secondary to primary hyperparathyroidism (HPT). The prevalence of pancreatitis in HPT varies widely; most studies have reported an increased prevalence while others report a frequency around 1.5%, similar to the normal population. These contradictory findings suggest that additional disease-modifying factors may play a role in the development of pancreatitis in HPT. It has been described that abnormal increase of cytosolic calcium triggers acute pancreatitis. In addition, there are studies showing that a combination of both hypercalcemia and variants in the SPINK1 or CFTR genes, increase the risk to develop pancreatitis in HPT. In 1988 the prevalence of pancreatitis secondary to HPT at the Instituto Nacional de Ciencias Mee﷽﷽﷽﷽﷽﷽﷽﷽s

 Methods

n. Nutritio dicas y ﷽﷽ador Zubiran. Nutritio dicas y ﷽﷽ador Zubiran. Nutritio dicas y ﷽﷽ador Zubiran. Nutritio dicas Salvador Zubiran (INCMNSZ) in Mexico City was 12.1%.

Objective

To describe the current prevalence of pancreatitis secondary to HPT at the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran.dicas y ﷽﷽ador Zubiran. Nutritio dicas y ﷽﷽ador Zubiran. Nutritio dicas y ﷽﷽ador Zubiran. Nutritio

Material and methods

Retrolective cross-sectional study of 390 patients diagnosed with HPT between 1987 and 2012.

Results

Among 390 cases of HPT, 30 (7.69%) cases with acute or chronic pancreatitis were documented. 73% were male, 33% had history of alcoholism, 36% had history of cholecystectomy, 40% had history of ureteral calculi, and 36% had more than one episode of pancreatitis. The average calcium level was 14.18 mg/dL (9.3 to 18.6), the mean parathyroid hormone level was 269 pg/mL (72 to 594), and the average vitamin D level was 18 ng/mL (7 to 38).

Conclusions

We found a decrease in the prevalence of pancreatitis in patients with primary hyperparathyroidism from 12.1% to 7.69%. This is probably due to an early diagnosis of asymptomatic hyperparathyroidism as a result of routine measurement of calcium in recent years.

 

Nothing to Disclose: MJ, PA, FJG

14247 6.0000 SUN-0198 A Decreased Prevalence of Pancreatitis Secondary to Primary Hyperparathyroidism. Experience at the Instituto Nacional De Ciencias Medicas Salvador Zubiran, Mexico City 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Thomas VIZHALIL PAUL V*1, Sahana Shetty1, Nitin Kapoor III1, Nihal Thomas2, Simon Rajaratnam V1, Deepak Thomas Abraham1, M J PAUL1, Pooja Ramakant3, Regi Oommen3, Nylla Shanthally3 and Marie Therese3
1CHRISTIAN MEDICAL COLLEGE, VELLORE, India, 2Christian Medical College, Vellore, India, 3CHRISTIAN MEDICAL COLLEGE

 

Primary hyperparathyroidism is potentially treatable metabolic bone disorder, however, its presentation is very different in Indian population as compared to the west with respect to age and severity of disease. Preoperative localization of abnormal parathyroid gland results in good surgical results with minimum exploration. Hence we attempted to look at the clinical and biochemical profile, preoperative localization by ultrasound and sestamibi parathyroid scintigraphy  and the concordance between them.

             We conducted a retrospective study of histologically proven cases of primary hyperparathyroidism between the year 2007 - 2012. Data related to 165 subjects (74 males, 91 females) was analyzed. Mean( + SD) age was 42(+13) years. Most of them were symptomatic(84 percent) with predominant presentation being renal calculi (58%), bone pain (43.6%), fracture (13.4%), pancreatitis (9.2%).  Hypercalcemia was seen in 81%, hypophosphatemia in 76% and a high alkaline phosphatase in two third of them. Vitamin D deficiency (<20 ng/ml) was seen in about half  of the subjects. The median PTH at diagnosis was 362( 88-3720pg/ml). The median size of the parathyroid adenoma was 2cm.The tumor size correlated well with preoperative PTH level (r =0.47, p <0.000). In ten subjects, primary hyperparathyroidism was a part of multiple endocrine neoplasia( MEN syndrome) of which eight were MEN 1 and two were MEN 2.

Total number of abnormal parathyroid glands found on surgical exploration were 186 (158 single adenoma, 24 multiple, 4 in ectopic sites), among which 142(76%) were detected on a neck ultrasound and 148(85%) on a sestamibi parathyroid scintigraphy. Among the single adenomas, 70% were correctly lateralized on ultrasound and 68.5% on sestamibi as confirmed on surgical exploration. Ultrasound and parathyroid scintigraphy were concordant in lateralizing unilateral parathyroid adenomas in 64 % of subjects showing  a moderate agreement(kappa=0.61,p=0.001) This study demonstrated the more symptomatic presentation of the primary hyperparathyroidism with a higher prevalence of pancreatitis,  skeletal disease and MEN 1 in our study as compared to published literature. Majority of parathyroid adenomas were localized by ultrasound and sestamibi scan with moderate agreement between them.

 

Nothing to Disclose: TVP V, SS, NK III, NT, SR V, DTA, MJP, PR, RO, NS, MT

15003 7.0000 SUN-0199 A Primary Hyperparathyroidism: An Experience from a Tertiary Care Centre in South India 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Beatriz Lecumberri Santamarí*, Diego Meneses, Laura Pérez, Cristina Álvarez-Escolá, Antonio Torrijos, Ángel Sanz, Juan José Cornejo and Luis Felipe Pallardo
La Paz University Hospital, Madrid, Spain

 

Cinacalcet hydrochloride (CI), an allosteric CaSR modulator that increases sensitivity to extracellular calcium and downregulates PTH secretion, was approved by the European Medicines Agency (EMA) in June 2008 to treat hypercalcemia in patients with primary hyperparathyroidism (PH) in whom parathyroidectomy (PT) would be indicated based on serum calcium levels (Ca) but surgery is clinically inappropriate or contraindicated. CI effectively reduces Ca in PH but there are still few reports on biochemical and densitometric long-term outcomes. We have retrospectively revised 15 patients (11 women and 4 men) with PH treated with CI in the last 5 years in a tertiary Hospital in Madrid. We have recorded their main clinical and biochemical data at baseline, 6 months and at the end of the follow-up or at CI withdrawal, as well as daily doses used, dose titrations and side effects. Their mean age, BMI and follow-up time were 78.79 ± 8.91 years (56-88), 26.06 ± 4.78 (18-35.8), and 15 ± 16 months (1-48), respectively. All patients met EMA CI indications; 2 showed ectopic mediastinal parathyroid adenomas, 67% had hypertension, 67% multinodular goiter, and 5 had been previously diagnosed with cancer: 4 were cured (2 kidney, 1 breast and 1 colon) and 1 (with a MEN1 PY307X mutation) had a neuroendocrine metastatic pancreatic cancer. CI was withdrawn in 2 patients after PT and subsequent cure of their PH. Vitamin D treatment was used by 9 patients and bisphosphonates by 2. Initial daily CI doses were 60 mg in 9 patients, and 30 mg in 6. Although CI was usually well tolerated (80%), 3 patients required dose reductions due to gastrointestinal side effects that were mild and disappeared in 2 cases, but led to CI withdrawal in the MEN1 patient. Final daily doses ranged between 30-60 mg and all patients became normocalcemic. Ca significantly decreased at 6 months (mean reduction = 1.94 mg/dL) and remained stable afterwards (11.66 ± 0.46, 9.72 ± 0.92 and 9.87 ± 1.2 mg/dL; p < 0.0001). There were no differences between mean baseline PTH levels and levels at 6 months, but a significant decrease was detected when comparing PTH at 6 months with final values (213.63, 256.11 and 111.73 pg/mL; p = 0.045). A similar but not significant trend was observed for alkaline phosphatase (128.86, 127.33, and 89.27 UI/L; p = 0.09). Serum phosphorus (sp) significantly increased (2.76, 2.9, 3.48 mg/dL; p = 0.02), and 24h-urinary calcium levels remained stable. No significant changes were found globally between basal and final bone mineral density (BMD) but 2 patients showed a marked improvement in their total lumbar spine and hip T-scores. In our series, the early and significant Ca reduction induced by CI lasted until the end of the follow-up. CI also increased sp in a significant and progressive manner and had a slower but significant effect on reducing PTH. The stabilization of BMD during CI treatment suggests a mild beneficial long-term effect on bone in patients with PH.

 

Nothing to Disclose: BL, DM, LP, CÁ, AT, ÁS, JJC, LFP

15121 8.0000 SUN-0200 A Characteristics and Outcomes of Patients with Primary Hyperparathyroidism Treated with Cinacalcet and Followed in a Tertiary Hospital: A Five-Year Retrospective Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Benjamin Christopher James*1, Edwin Kaplan1, Raymon H Grogan1 and Peter Angelos2
1University of Chicago Medicine, Chicago, IL, 2Univ of Chicago, Chicago, IL

 

Background

In recent years “minimally invasive parathyroidectomy” (MIP) has become the procedure of choice for many surgeons, but the meaning of the term MIP is unclear. This is confusing for both the medical community and patients. We hypothesize that because the definition of MIP in the literature is so variable this term has little meaning. Our aim was to create a standardized taxonomy and terminology for MIP.

Methods

We performed a Pubmed search using the terms:  parathyroidectomy, minimally invasive, localized, focused, unilateral, radio-guided, video-assisted, and endoscopic. Review articles, and publications that did not comment on parathyroidectomy were excluded. Data were collected for: author, journal title, year published, and all described aspects of parathyroidectomy.  Histograms of all descriptive terms were analyzed for frequency of use and time trends.

Results

We identified 1,010 articles, and analyzed 443 (44%) after applying the exclusion criteria. We found 18 words used in 75 different combinations to describe MIP.  Publication time trends showed a non-parametric distribution between 1982 and 2013, with a median publication year of 2006. We established four categories that encompassed all 75 definitions of MIP, namely:  1. operative approach (open describing incision size, or endoscopic, robotic, video-assisted), 2. number of glands explored, 3. operative adjuncts (ioPTH, radio-guided, fluorescence-guided), and 4. anesthesia type. The words “focused”, “targeted” and “directed” are unclear and were replaced with actual gland number explored. Operative approach was the most commonly described attribute and was mentioned in 47% (n=207) of the articles (mean incision size = 2.2 cm), followed by number of glands explored (blank % of articles), operative adjuncts [(overall %)(iopth, radioguided, fluorescence guided), and finally anesthesia type [36% of articles (general [27% (n=120)] vs. local [9% (n=42)].

Conclusion

The finding that there are 75 different definitions for MIP confirms that this term is too generic to be useful. We propose a new, taxonomic format for describing MIP based on the four descriptive categories we identified in this study: [operative approach], [# of glands explored], parathyroidectomy using [operative adjuncts] under [anesthesia type]. For example, “2cm, single gland parathyroidectomy using ioPTH under general anesthesia”.

 

Nothing to Disclose: BCJ, EK, RHG, PA

15225 9.0000 SUN-0201 A What's in a Name? : A Taxonomy for the Definition of Minimally Invasive Parathyroidectomy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Kerstin Landin-Wilhelmsen*1, Georgios Kontogeorgos1, Penelope Trimpou2, Christine Laine1, Göran Oleröd3, Anders Harald Lindahl3 and Lars Wilhelmsen4
1Section for Endocrinology, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden, 2Sahlgrenska University Hospital, Gothenburg, Sweden, 3Department of Clinical Chemistry, Gothenburg, Sweden, 4Institution of Medicine, Gothenburg, Sweden

 

Context: There is limited knowledge about the prevalence of and morbidity due to normocalcemic hyperparathyroidism (HPT).

Objective: The aim was to study the prevalence and natural history of normocalcemic HPT and its relation to cardiovascular risk factors, fractures and other hormonal aberrations in the population.

Design: Cross-sectional and retrospective study.

Setting:  Sahlgrenska University Hospital, Gothenburg, Sweden.

Subjects: A random population sample of men and women (n=608, age 25-64 years) was studied in 1995, as a part of the World Health Organization MONItoring of trends and determinants for CArdiovascular disease (WHO MONICA) study, and reinvestigated 13 years later (n=412, age 38-78 years), participation rate 68%.

Main Outcome Measures: Fasting blood samples were taken in the morning for analysis of calcium and hormonal variables. A serum intact parathyroid hormone level (S-PTH) > 60 pg/ml (60 ng/l) was considered as HPT and a serum calcium level of 8.60 mg/dl - 9.96 mg/dl (S-Ca 2.15 mmol/l - 2.49 mmol/l) as normocalcemia. Blood pressure and medication were recorded. Data on fractures, myocardial infarction, stroke and death were retrieved from hospital records until 2012.

Results: Normocalcemic HPT was present in 6.4% of the subjects in 1995 and in 19.4% at follow-up in 2008-2009. Primary HPT was found in 2.3% and 1.0%, and secondary HPT with hypocalcemia in 0% and 0.2% respectively. S-PTH was positively correlated with age and body mass index. After adjustment for these variables, a high S-PTH level >60 pg/ml (60 ng/l) was associated with lower S-Ca and S-25(OH)D, higher serum osteocalcin and cortisol, previously high S-PTH and currently treated hypertension. No relation was seen with creatinine, cystatin C, vitamin B12, homocystein, thyroid hormones, glucose, insulin, blood lipids or calcaneal bone mass. There was no increase in the hard end points of fractures, myocardial infarction, stroke or death after 17 years.

Conclusions: Normocalcemic HPT was common in the population and no subject had progressed to primary HPT during the 13-year follow-up period. No increase in hard end points was seen over the 17-year period.

 

Nothing to Disclose: KL, GK, PT, CL, GO, AHL, LW

15710 10.0000 SUN-0202 A Normocalcemic Hyperparathyroidism - High Prevalence and Low Morbidity in the General Population, a 13-Year Follow-up Study, the WHO Monica Project, Gothenburg, Sweden 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Yosra Moria*1, Balsam Saeed Bohlega2 and Ali Saeed Alzahrani3
1University Hospitals Cleveland Medical Center, Cleveland, 2King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia, 3King Faisal Specialist Hospital, Riyadh, Saudi Arabia

 

Introduction:

Transient hypocalcemia is common following parathyroidectomy for primary hyperparathyroidism (PHP). The two main underlying causes are removal of the abnormal parathyroid adenoma with damage to other normal glands and hungry bone syndrome (HBS). HBS is a transient and severe hypocalcemia (Ca <2.1 mmol/l) presumed to be secondary to influx of Ca to the Ca-deficient bones in which hypocalcemia is expected to lead to a feedback increase in PTH level.

In the past, the standard surgical approach for PHP was a four-gland exploration and removal of the most abnormally looking gland. When low Ca develops and PTH remains low,the cause was usually explained by the inadvertent damage of the normal glands during surgery. Recently, Minimally invasive surgery directed to the parathyroid adenoma is widely practiced and post operative hypocalcemia is due to HBS. Surprisingly, we observed that PTH is frequently subnormal, inappropriately normal or slightly elevated in the face of significant hypocalcemia. This suggests that the long-held belief that simple influx of calcium to the bone is the main mechanism of hypocalcemia in HBS is not totally accurate and that secondary parathyroid suppression due to the previously chronic hypercalcemia  is an important mechanism.

Methods:

We retrospectively reviewed the medical records of 48 consecutive cases of PHP who underwent minimally invasive parathyroidectomy during the years 2007-2011. Demogarphic and biochemical data were collected and analyzed. Pre operative abnormal gland(s) was radiologically localized. Intraoperative PTH was measured in 39 cases, the median PTH pre and intraoperatively were 440 (91-3588 ng/l) and 65 (16-562 ng/l) with a decrement ranging from 47% to 99%. The duration of HBS ranged between 2-75 days.

Results:

During postoperative period, 39 patients developed hypocalcemia, 21 patients required calcium infusion. Concomitant PTH levels were measured in 15 patients and was either low or inappropriately normal for the level of hypocalcemia. This strongly suggests that the remaining parathyroid glands are suppressed.

The following parameters were analyzed as potential predictive factors for the development of HBS: age, sex, preoperative S.Ca, PTH, ALP, Vitamin D level and presence of bone disease. Although PTH, ALP and vitamin D were significantly associated with HBS in univariate analysis (P values, 0.009, 0.016, 0.013, respectively), only S.PTH remained significantly associated with HBS in multivariate logistic regression analysis (P=0.006).

Conclusion:

These data shows that one of the main mechanisms of hypocalcemia in HBS is secondary parathyroid deficiency due to long-term suppression of parathyroid glands in a situation reminiscent of secondary adrenal suppression following surgery for Cushing syndrome. In our analysis, the preoperative S. PTH level was the most important predictive factor of HBS.

 

Nothing to Disclose: YM, BSB, ASA

15980 11.0000 SUN-0203 A Secondary Parathyroid Gland Suppression Is a Major Mechanism for Hypocalcemia in Hungry Bone Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Ulku Aybuke Tunc1, Tevfik Demir*1, Merve Yilmaz1 and Arzu Gedik2
1Dokuz Eylul University Medical School, Izmir, Turkey, 2Dokuz Eylul Universitesi Tip Fak, Izmir, Turkey

 

Anemia prevalence is reported between 5% and 31.8% in patients with PHPT. Anemia in PHPT shows correlations with serum calcium, PTH, alkaline phosphatase levels, severity of the bone disease and PHPT duration. In this study we compared pre-operative and post-operative hemogram parameters of patients with PHPT who received a parathyroidectomy at our department. We determined the prevelans of pre-operative anemia, thrombocytopenia, neutropenia and observered if any of this parameters were recovered after the surgery. We excluded patients with systemic diseases which may interfere with cytopenias. Likewise, we determined pre-operative and post-operative variations of  some parameters such as RDW, MPV, neutrophile/lymphocyte rates, that are often disregarded in hemogram reports but related to chronical inflammation. Out of 157 patients with PHPT, 127(80,9%) were women and 30(19,1%) were men. There was no significant difference in terms of prevelance of cytopenia before and after the surgery for PHPT. Correlation analysis didn’t reveal any significant differences between studied parameters except that there was a moderate-weak relation between PTH level and neutrophile/lymphocyte rate. Mean RDW was high in patients with PHPT before the surgery, however it didn’t improve after the operation significantly. There are no studies in the literature evaluating RDW, MPV values and neutrophile/lymphocyte rates that are related to primary hyperparathyroidism (or secondary, tertiary hyperparathyroidism). Our study has the feature of being the first study in this field, more significant data is expected to be obtained as the number of included patients increase.

 

Nothing to Disclose: UAT, TD, MY, AG

16024 12.0000 SUN-0204 A Comparison of the Pre-Operative and Post-Operative Hemogram Parameters of the Patients with Primary Hyperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Kimberley Jane Edwards*, Rachel French, Matei Alexandru Dordea, Rudra Maitra and Vijayakumar Kurup
University Hospital of North Tees, United Kingdom

 

Background:

Technetium-99m sestamibi scintigraphy is frequently used to localize parathyroid adenomas in sporadic primary hyperparathyroidism and discriminate between single and multi-glandular disease.  Accurate pre-operative localization therefore facilitates minimally invasive approaches to parathyroidectomy and the avoidance of morbidity associated with bilateral neck exploration.

A variety of studies have cited sensitivities ranging from 80-100% when sestamibi scintigraphy is used pre-operatively. However, the use of sestamibi scintigraphy, particularly for first-time explorative parathyroid surgery, remains controversial and highly variable between centers.

This study evaluates the use of sestamibi scintigraphy to predict intra-thyroidal parathyroid adenomas and considers whether hemi-thyroidectomy is justifiable in cases of positive pre-operative sestamibi scintigraphy when subsequent neck exploration has failed to identify a parathyroid adenoma.

Methodology:

A retrospective analysis was conducted of 126 parathyroidectomies performed by a single surgeon over an 8-year period (2005-2013). Pre-operative localization with sestamibi scintigraphy was conducted on all patients presenting with primary hyperparathyroidism prior to progression to minimally invasive parathyroidectomy.  Failure to identify a parathyroid adenoma on bilateral neck exploration was succeeded by immediate hemi-thyroidectomy of the lobe corresponding to the side of increased tracer uptake on scintigraphy.

Results:

126 patients with primary hyperparathyroidism were included in this study; 98 had a positive scintigram.  Surgical neck exploration identified 87 parathyroid adenomas, confirmed by histology.  The remaining 11 patients progressed to immediate hemi-thyroidectomy; in 8 cases an intra-thyroidal parathyroid adenoma was demonstrated on histological examination, in 1 case a hyperplastic intra-thyroidal parathyroid gland was identified and in 2 cases histology was suggestive of a subcapsular hyperplastic or benign parathyroid gland.  Overall, sestamibi scintigraphy had a positive predictive value of 96.9% for a parathyroid adenoma.

Conclusion:

When neck exploration fails to identify a parathyroid adenoma, a positive scintigram may justify immediate progression to hemi-thyroidectomy increasing chances of successful localization, treatment and avoidance of further investigations and/or surgery.

 

Nothing to Disclose: KJE, RF, MAD, RM, VK

16212 13.0000 SUN-0205 A Is Sestamibi Guided Hemi-Thyroidectomy Justified When Neck Exploration Is Negative? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Raluca Alexandra Trifanescu1, Mara Carsote1, Andrei Goldstein2, Dan Hortopan2, Anda Dumitrascu2, Cristina Popa2, Livia Procopiuc2 and Catalina Poiana*1
1Carol Davila University of Medicine and Pharmacy, Bucharest, Romania, 2C. I. Parhon National Institute of Endocrinology, Bucharest, Romania

 

Background:For preoperative localization of parathyroid adenomas in patients with primary hyperparathyroidism, parathyroid ultrasonography, technetium 99m Sestamibi scintigraphy and computed tomography are used.

Aims: to assess the usefulness of preoperative imaging methods in localization of parathyroid adenomas in patients with primary hyperparathyroidism undergoing parathyroidectomy.

Patients and methods:64 consecutive patients (4M/60F) with primary hyperparathyroidism were retrospectively reviewed. 34 patients (2M/32F) with symptomatic primary hyperparathyroidism, aged 57.2 ± 12.6 years, underwent parathyroidectomy and had pathology report available; 3 patients are waiting for scheduled parathyroidectomy; one patient was treated with cinacalcetum. Serum intact PTH was measured by immunoradiometric assay and 25 OH vitamin D by radioimmunoassay. Parathyroid ultrasonography, computed tomography scan and technetium 99m Sestamibi parathyroid scintigraphy were used for preoperative localization of parathyroid adenoma.

Results:In patients submitted to parathyroidectomy (n=34), average total calcium serum levels at diagnosis was 11.5 ± 1.5 mg/dL, median PTH level was 254 pg/mL (range 64.2-1982.3). Average 25 OH vitamin D levels were 16.4 ± 8.7 ng/mdL (range 4-31.9). Ultrasonography correctly identified the localization of parathyroid adenoma in only 16 out of 34 cases (47%) operated on. Localization of parathyroid adenoma was superior for computed tomography scan (23 out of 29 cases, 79.3%) and technetium 99m Sestamibi scintigraphy (12 out of 15 cases, 80%). Pathology findings were: 27 solitary parathyroid adenomas, 3 cases with double adenomas, one case with parathyroid hyperplasia and one parathyroid carcinoma. In two cases, parathyroidectomy was unsuccessful despite using all three localization methods and surgical exploration.

Conclusion: for correct preoperative localization, a combination of at least two methods should be considered in patients undergoing parathyroidectomy.

 

Nothing to Disclose: RAT, MC, AG, DH, AD, CP, LP, CP

16379 14.0000 SUN-0206 A Preoperative Localization of Parathyroid Adenomas in Patients with Primary Hyperparathyroidism: Is It Sufficient One Imaging Method? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Teresa Bonanséa*1, Cynthia Alvares Brandão1, Monique Nakayama Ohe1, Marise Lazaretti-Castro2, Claudia M.A.F. Ferrer3 and Jose Gilberto Vieira4
1Universidade Federal de São Paulo UNIFESP, São Paulo, Brazil, 2Universidade Federal de São Paulo UNIFESP, Sao Paulo SP, Brazil, 3Grupo Fleury, São Paulo, Brazil, 4Grupo Fleury, Sao Paulo, Brazil

 

Parathyroid Hormone (PTH) in circulation is quite heterogeneous and this observation translates in real challenges in its laboratory measurement. The introduction of immunometric (second generation) assays based on two distinct antibodies directed against amino-terminal and carboxyl-terminal portions of the PTH molecule have, in part, simplified the issue. However, recent studies suggest that these second generation assays measure long PTH fragments (7-84), besides the intact biological active PTH (1-84). Third-generation assays (Bio-PTH) were developed using amino terminal specific antibodies directed against the first four amino acids, restricting the measurement to the putative biological active molecular forms (1-84). Previous studies have shown that the proportion of carboxy-terminal fragments of PTH vary highly depending on several factors, including renal function and serum calcium levels. In this study we evaluated the use of a third generation assay (Bio-PTH 1-84) in the initial  diagnosis of primary hyperparathyroidism. Thirty one PHPT patients (3 men and 28 women), aged 61.8 ± 29.8yr (mean ± SD)  were studied and had PTH levels measured with two different methods using the same immunochemiluminescent assay plataform (Elecsys 2010 System, Roche). We compared a second-generation assay (I-PTH) with a third generation PTH assay (Bio-PTH). Two populations of 423 and 108 healthy adults with serum 25-OHD levels above 25ng/ml were used to define normal values in the I-PTH and Bio-PTH assays, respectively, and they were 24.2-78.0 ng/L for the I-PTH assay and 19.9-58.5ng/L for Bio-PTH assay. In PHPT patients, PTH values ranged from 67 to 553ng/L (median: 170ng/L) using the intact assay and from 55 to 328ng/L (median: 111ng/L) using the bio-PTH assay. Results obtained with the Bio-PTH assay were significantly lower (p<0,0001, Wilcoxon). In general I-PTH and Bio-PTH showed highly significant correlation (r= 0,977, p <0,0001). In the present study, the use of Bio-PTH in PHPT patients does not significantly improve diagnostic sensitivity and specificity compared to I-PTH assays. Lower results with Bio- PTH tests are expected in function of the assay specificity determined by the amino terminal antibody used. Our results demonstrate that both second and third generation PTH methods are strongly correlated in PHPT patients and control subjects.

 

Nothing to Disclose: TB, CAB, MNO, ML, CMAFF, JGV

16466 15.0000 SUN-0207 A Experience with an BIO-PTH (1-84) ASSAY in the Diagnosis of Primary Hiperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Rachel L McKenney*1, Rebecca S Sippel2, David Schneider3 and Sarah Oltmann4
1University of Wisconsin Hosital and Clinics, Madison, WI, 2University of Wisconsin, Madison, WI, 3University of Wisconsin School of Medicine and Public Health, 4University of Wisconsin

 

Introduction: Primary hyperparathyroidism (PHPT) is a common endocrinopathy that can have a devastating impact on bone density.  All patients who demonstrate abnormal bone mineral density should be screened for this treatable secondary cause.  Our primary objective was to evaluate the frequency of screening for PHPT in patients diagnosed with osteoporosis or osteopenia.   

Methods: Patients who had a CPT code for a DEXA scan and an ICD-9 diagnosis of osteopenia or osteoporosis in 2011 at a single academic institution were identified.  A random sample of every 5th patient with a primary care physician in our health system was chosen for an in depth chart review.  Patients were considered adequately screened for PHPT if serum calcium was drawn within 6 months of the diagnostic bone density scan.  We also evaluated the frequency of parathyroid hormone (PTH) testing and the extent of work-up for abnormal labs.

Results: 450 patients were included in the analysis and 90.9 % were female (n=409).    The mean age was 50.5± 10.9 years and the mean T score was -1.91± 0.03.  Osteoporosis was present in 19.3% (n=87) of patients and the remaining 80.7%( n=363)had osteopenia.  Serum calcium levels were checked within 6 months of diagnosis in 52% (n=234) of patients and were significantly more likely to be checked in patients with osteoporosis versus osteopenia (71.2 % vs. 47.6%, p<0.001). Calcium levels were available at any timepoint after diagnosis in 91.8% (n=413) of patients and were found to be elevated above 10.2 mg/dL in 7.7% (n=32) of patients. Of the 32 patients with documented hypercalcemia and bone disease, PTH levels were obtained in only 17 (53%) of the patients.  12 had confirmed hyperparathyroidism and 4 were referred to endocrine surgery for parathyroidectomy. 

The vast majority of patients had their bone disease managed by their PCP, with only 8.4% (n=38) of patients referred to an endocrinologist.  Patients seen by an endocrinologist were significantly more likely to have a calcium level (100%  vs. 18.7%,p <0.001) and a PTH level (84.2% vs. 21.3% p<0.0001).  PCP were significantly more likely to draw a PTH when there was a diagnosis of osteoporosis versus osteopenia (32.3% vs. 19.1% p = 0.0167), but this difference was not seen in the endocrinologist group. 

Conclusion: Screening for PHPT occurs in only about half of patients with documented bone disease at our institution, although patients diagnosed with osteoporosis or those seen by an endocrinologist for their bone disease were significantly more likely to be screened.   However osteopenia accounted for the majority of patients with bone disease and most of patients were managed solely by their PCP.  Consequently, improved education targeting primary care providers is needed to improve screening for primary hyperparathyroidism in patients with osteopenia and osteoporosis.

 

Nothing to Disclose: RLM, RSS, DS, SO

16710 16.0000 SUN-0208 A Screening for Primary Hyperparathyroidism in Patients Diagnosed with Osteopenia or Osteoporosis in a Tertiary Care Center 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Montana Suwannasarn*1, Wallaya Jongjaroenprasert1, Ronnarat Suvikapakornkul1, Palapong Chayangsu1 and Chutintorn Sriphrapradang2
1Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, 2Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

 

Background: Postoperative hypocalcemia is the most common complication that is observed in patients who undergo bilateral thyroid resection, reported incidence up to 30%. Despite hypocalcemia is usually transient but symptomatic hypocalcemia can be fatal. Postoperative inpatient monitoring of serum calcium level usually requires 48 hours or longer. This study aimed to find predictor of immediate postoperative hypocalcemia and permanent hypoparathyroidism by using early postoperative parathyroid hormone (PTH) level and percentage of intact PTH (%iPTH) decline.

Methods: This is a prospective study of 65 patients who underwent total or subtotal thyroidectomy with measuring preoperative and 4-hour postoperative PTH testing (iPTH4hr). The specificity, sensitivity, positive predictive value (PPV) and negative predictive value (NPV) for the iPTH4hr and %iPTH decline were calculated.

Results: Fifty-six (86.2%) of 65 subjects were female. Mean age was 43 ± 15 years. Most of the cases, 39 (60%) were diagnosed of papillary thyroid carcinoma, the rest were multinodular goiter (N=14, 21.5%) and Graves’ disease (N=5, 7.7%). Significant hypocalcemia was observed in 25 (38.5%) patients. Eight patients (16%) experienced hypocalcemic symptoms. Level of iPTH4hr less than 12.5 pg/ml and %iPTH decline from baseline greater than 72% could accurately predict immediate postoperative significant hypocalcemia and permanent hypoparathyroidism. The sensitivity, specificity, PPV and NPV for iPTH4hr were 92%, 87.5%, 82.1% and 94.6% respectively. The %iPTH decline was equally in accuracy with the sensitivity, specificity, PPV and NPV were 84%, 90%, 84% and   90% respectively. At the end of the study, 9(18%) of 49 patients were permanent hypoparathyroidism, iPTH4hr less than 12.5 pg/ml and %iPTH decline from baseline greater than 72% could also predict permanent hypoparathyroidism with the sensitivity, specificity, PPV and NPV for iPTH4hr were 100%, 90%, 72.7% and 97.4% respectively and 88.9%, 92.5%, 69.2% and 100% for %iPTH decline greater than 72% respectively.

Conclusions: Single iPTH4hr levels less than 12.5 pg/ml or %iPTH decline greater than 72% could be helpful in identifying patients at risk of immediate postoperative significant hypocalcemia that need early treatment of calcium and vitamin D and facilitate early discharge of patients from hospital. In addition, either single iPTH4hr or %iPTH decline accurately predicted permanent hypoparathyroidism.

 

Nothing to Disclose: MS, WJ, RS, PC, CS

12757 17.0000 SUN-0209 A Postoperative Intact Parathyroid Hormone Levels after Thyroidectomy As a Predictor of Postoperative Hypocalcemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Michael Mannstadt*1, Tamara J. Vokes2, Nelson B Watts3, Douglas S. Denham4, Dolores M. Shoback5, Bart Lyman Clarke6, Hjalmar Lagast7 and John P Bilezikian8
1Massachusetts General Hospital and Harvard Medical School, Boston, MA, 2University of Chicago Medicine, Chicago, IL, 3Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, 4Clinical Trials of Texas, Inc., San Antonio, TX, 5University of California - San Francisco VA Medical Center, San Francisco, CA, 6Mayo Clinic E18-A, Rochester, MN, 7NPS Pharmaceuticals, Bedminster, NJ, 8College of Physicians and Surgeons, Columbia University, New York, NY

 

In hypoparathyroidism, low PTH levels lead to hypocalcemia, hypercalciuria, and hyperphosphatemia.  Current management with high doses of oral calcium (Ca) and active vitamin (Vit) D does not adequately control mineral ion homeostasis and can lead to complications in many patients. The phase III REPLACE study (Mannstadt M, et al. Lancet Diabetes Endocrinol. 2013;1(4):275-283) demonstrated that 50–100 µg/day of rhPTH(1-84) is efficacious and well tolerated as PTH replacement therapy over 24 weeks. Oral Ca and Vit D supplements were reduced by ≥50% while serum Ca was maintained (primary endpoint) in 53% of patients on rhPTH(1-84) vs 2% of patients on placebo (P<0.001). The subsequent RELAY study showed that, in some patients, 25 μg/day of rhPTH(1-84) is adequate.

The ongoing, open-label RACE study is assessing long-term safety and effectiveness of subcutaneous rhPTH(1-84) therapy at 25, 50, 75, and 100 µg/day. rhPTH(1-84) was titrated from 25 or 50 μg/day with up-titration to 50, 75, and 100 μg/day if active Vit D and oral Ca could be further reduced and serum Ca level remained at or above baseline. Long-term efficacy is based on the composite endpoint of ≥50% reduction in oral Ca (or ≤500 mg/day) and ≥50% reduction in active Vit D (or ≤0.25 μg/day), while maintaining serum Ca ≥7.5 mg/dL.

The results of the planned interim 52-week analysis of the RACE study include data for 53 patients (83% female; mean age, 48±10 years; mean duration of disease, 16±13 years) who were enrolled at 13 US centers. 49 patients continued through 52 weeks; none discontinued due to adverse events (AEs). 4 (8%) patients experienced serious AEs (not deemed treatment related). The 52-week AE profile was similar to that of the REPLACE study. 51 (96%) patients reported ≥1 AE. The most common AEs (>15% of patients) were muscle spasm, hypocalcemia, paresthesia, nausea, headache, arthralgia, and constipation. 36/49 patients (74% [95% CI, 59–85]) met the efficacy endpoint. Mean dose of oral Ca was 2203±1708 mg/day at baseline and decreased by 67%±34% by Week 52. Mean dose of Vit D was 0.7±0.5 μg/day at baseline and decreased by 73%±44% by Week 52. Serum phosphate levels were uniformly lower than baseline throughout the 52 weeks: mean change was −0.73±0.79 mg/dL.

rhPTH(1-84) was well tolerated and efficacious throughout 52 weeks. Ca and Vit D supplements were markedly lower than baseline while serum Ca levels were maintained and phosphate levels were reduced. These results confirm and extend our experience with rhPTH(1-84) as an effective treatment for hypoparathyroidism.

 

Disclosure: MM: Advisory Group Member, NPS. TJV: Advisory Group Member, NPS. NBW: Research Funding, NPS. DSD: Research Funding, NPS. DMS: Research Funding, NPS, Advisory Group Member, NPS. BLC: Advisory Group Member, NPS, Research Funding, NPS. HL: Employee, NPS. JPB: Advisory Group Member, NPS, Research Funding, NPS.

13891 18.0000 SUN-0210 A Long-Term Safety and Efficacy of Recombinant Human Parathyroid Hormone (rhPTH[1-84]) for the Treatment of Adults with Hypoparathyroidism: Interim Data from the Race Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Sunday, June 22nd 3:00:00 PM SUN 0193-0210 5054 1:00:00 PM FGF23 & Phosphate Disorders; Parathyroid Hormone & Disorders; Osteoporosis Poster

Dat Ha*1, Madhia Shahid2 and Donald Ray McClellan3
1Phoenix VA Health Care System, Phoenix, AZ, 2Phoenix Children's Hospital, 3Phoenix Children's Hospital, Gilbert, AZ

 

BACKGROUND:

Thyrotoxic periodic paralysis (TPP) is a sporadic, common complication of hyperthyroidism in Asian men, usually 20-40 yr of age, but increasingly seen in Western countries. This potentially fatal condition is characterized by muscle paralysis and hypokalemia due to massive intracellular potassium shift.

CASE:

17 year-old Hispanic male with no PMHx was admitted for episodic bilateral lower extremity weakness and pain that recurred over the past week, resulting in inability to stand up or ambulate. These episodes resolved spontaneously. He did heavy lifting at the gym and reported increased sugar intake a few weeks prior to onset of symptoms.  He also endorsed heat intolerance but no other thyrotoxic symptoms.

Initial labs showed K 2.7 (which was repleted), CK 737 (39-308 U/L), TSH <0.01 (0.52-5.08 mIU/L), FT4 3.52 (0.59-1.17 ng/dL), TPO 91 (<35 IU/mL0, TSI 338% (<140%). Thyroid uptake scan: 57% at 4 hr, 70% at 24 hr. The patient was ablated with 8.5 mCi of I-131, with resolution of his symptoms and hypokalemia. Two months post ablation, his TSH is <0.006, FT4 2.4.

DISCUSSION:

TPP is characterized by recurrent, transient episodes of muscle weakness ranging from mild weakness to complete flaccid paralysis. Respiratory paralysis is a rare but serious complication. Attacks are commonly precipitated by ingestion of carbohydrate-rich meals or sweet snacks, alcohol, or strenuous exercise.

The hallmark of TPP is hypokalemia, with serum K usually < 3.0 mmol/L.  Hypokalemia occurs due to a massive shift of potassium into the cells (mainly myocytes) rather than net loss from the body.  This is believed to be due to increased Na/K-ATPase pump activity in the hyperthyroid state, as well as enhanced insulin response.  Thyroid hormone-responsive elements (TREs) are present in the upstream region of the Na/K-ATPase subunits, and thyroid hormones increase the Na/K-ATPase activity via transcriptional and posttranslational mechanisms. Catecholamines can also stimulate Na/K-ATPase activity, and may explain why non-selective beta blockers can abort paralytic attacks.  Serum CK of muscle origin is elevated in about two thirds of patients, especially when precipitated by exercise. This episodic paralysis will remit with definitive control of hyperthyroidism.

 

Nothing to Disclose: DH, MS, DRM

15592 1.0000 SUN-0484 A Paroxysmal Limb Paralysis with Hypokalemia and Elevated CK: Thyrotoxic Periodic Paralysis in a Pediatric Patient with Grave's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0484-0498 5059 1:00:00 PM Non-neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Sonika Gupta*1, Constance L Fry2, Maria Luis Policarpio-Nicolas2 and Jan M Bruder1
1University of Texas Health Science Center at San Antonio, San Antonio, TX, 2University of Texas Health Science Center at San Antonio

 

Background: The prevalence of Graves’ opthalmopathy in euthyroid/hypothyroid patients ranges between 1.6 and 8.6%. About 5% of opthalmopathy seen in patients with active Graves’ disease is severe, but severe disease in euthyroid/hypothyroid patients is rare.  Other diagnoses must be considered in these patients. Case: 63 year old man with PMH of stable ocular myasthenia gravis not requiring treatment, controlled Type 2 Diabetes and chronic lymphocytic leukemia (stable, not on treatment) who presents with severe opthalmopathy causing acute vision loss, chemosis and proptosis. He denied eye pain but felt pressure and fatigue. He could see outlines of people and hand movement but could not recognize facial features.  He was euthyroid clinically. Physical exam revealed an afebrile Caucasian male with pulse 82 and BP 167/87. No goiter or nodules were found on thyroid exam. Eye exam showed bilateral lid lag, proptosis, stare, impaired abduction and adduction, chemosis and conjunctival injection along with superotemporal visual field defect in right eye and normal bilateral intraocular pressure. Portable slit lamp exam revealed no anterior chamber defects. Luedde exopthalmometer measurements were 23 mm on left and 24 mm on right (normal 19-21mm for Caucasians). Lung, heart, abdominal, skin and extremities exams were normal. MRI showed infiltration of extraocular muscles and CT orbit was suspicious for Graves’ orbitopathy with significant thickening of the bilateral extraocular muscles and internal fatty infiltration, resulting in compression of the optic nerves at the bilateral orbital apex. Lab work revealed normal electrolytes and liver function. Hemoglobin 13g/dl, platelet count 279 k/ul, white count  23,000 k/ul which were unchanged from previous WBC. TSH 0.693 uIU/ml,  free T4 1.2ng/dl. Patient was treated with pulse high dose steroids (IV methylprednisone weekly x 12 weeks) and had symptomatic improvement. Subsequent results were normal: TPO antibody <10 IU/ml, thyroglobulin antibody <20 U/ml, thyroid stimulating immunoglobulin 92 %. A right eye lateral rectus muscle biopsy showed involvement by chronic lymphocytic leukemia/small lymphocytic leukemia which was confirmed by flow cytometric immunophenotyping: Clonal B cell expressing CD19, CD5 and surface kappa light chains. Conclusion: We report a case of a patient suspected to have euthyroid Graves’ opthalmopathy with “classic” features of Graves’ eye disease as well as CT findings. CLL eye involvement was thought to be extremely unlikely as patient did not have any other extravascular involvement. Diagnosing GO is usually straightforward, but other diagnoses have to be considered in patients with normal thyroid tests. Determination of thyroid-specific antibodies contributes to the diagnosis of underlying thyroid disease.  A muscle biopsy was needed in this case to make the correct diagnosis.

 

Nothing to Disclose: SG, CLF, MLP, JMB

14009 2.0000 SUN-0485 A Opthalmopathy: Severe Euthyroid Graves or Extravascular CLL? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0484-0498 5059 1:00:00 PM Non-neoplastic Thyroid Disorders-Clinical and Case Reports Poster

David Marc Gorson*
Southwestern Vermont Medical Center, Bennington, VT

 

A 52 year old female had a total thyroidectomy in 2005 for a 1.6 cm follicular thyroid carcinoma.  Three removed lymph nodes were negative. 105 mCi of radioiodine were subsequently administered, and there was no uptake outside of the neck on the post-treatment scan. Recombinant hTSH stimulated serum thyroglobulin (TG) was  0.1 subsequently, and TSH suppressed TG levels were undetectable over the next 7 years. In December, 2012, the TSH was 0.82 on levothyroxine 0.2 mg, and the TG was undetectable with negative anti-TG antibodies.  Annual neck ultrasounds were negative for recurrent tumor.

In July, 2013 after seeing a Dr. Oz television program, the patient obtained via the internet and ingested “green coffee bean  extract” tablets for weight loss . After the sixth day she felt acutely ill, with nausea and vomiting, tachycardia with exertion, and generalized weakness and malaise. She stopped the tablets and saw her primary care physician who obtained a TSH which was suppressed.  Medication for nausea was provided but the symptoms continued.  She was seen by the author 2 weeks after discontinuation of the tablets. She was acutely ill with nausea and dry heaves, and appeared clinically dehydrated. The resting pulse was 96 and supine blood pressure was 110/68 with mild orthostatic change. She was admitted to the hospital where her Free T4 was >7.0 (0.8-2.2 ng/dl), with an undetectable TSH. With IV hydration and bedrest, the patient improved sufficiently to be discharged after 48 hours. Levothyroxine was withheld. The free T4 declined to 6.2 the following day and was 4.7 by discharge.  Two and a half weeks later the free T4 was 0.6 and the TSH was 0.05. Levothyroxine was resumed and three months later the free T4 was 1.1 and the TSH was 1.89.

This case suggests the patient ingested thyroxine, which may have been part of the green coffee bean extract and which was obtained via the internet. Clinicians should be aware of this as a potential cause of hyperthyroidism.

 

Nothing to Disclose: DMG

12256 3.0000 SUN-0486 A Green Coffee Bean Extract Associated with Exogenous Hyperthyoidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0484-0498 5059 1:00:00 PM Non-neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Adriana Gonzalez*, Tiffany Marie Cortes and Ali Atef Zaied
University of Texas Medical Branch, Galveston, TX

 

Background: Apathetic hyperthyroidism typically manifests in patients over 50 years of age. This case report is rare because it involves a 35-year old female with apathetic hyperthyroidism.

Case Report:  A 35-year old African American female presented with chief complaint of fatigue, palpitations and dyspnea. She had been started on levothyroxine 25 mcg daily, and a mediastinal mass was found on radiographic testing. Patient denied history of weight loss, diarrhea, heat intolerance, anxiety or increased appetite. On initial exam vital signs were: P 138, RR 25, BP 105/71, and T of 36.6 C.  Patient was alert, oriented and in no acute distress. Positive findings included pale conjunctivae, icterus, brisk tendon reflexes; thyroid gland was minimally enlarged. She had no ocular compromise, skin changes, or tremor of outstretched hands. EKG showed sinus tachycardia. Laboratory findings were pertinent for anemia, Hb7.9 g/dL (n 11.5-15 g/dL), undetectable TSH, FreeT4>7ng/dL (n 0.78-2.20ng/dL),T3:643 (n 97-170ng/dL). Elevated LFTs>2000 U/L (n AST <40U/L; ALT<51U/L). CT body with contrast showed thymus hyperplasia; axillary, retroperitoneal and pelvic adenopathy; and no adrenal masses. Levothyroxine was stopped. Given lack of findings on history and exam suggestive of overt hyperthyroidism and her high transaminases, patient was started only on metoprolol; thionamides were held. Total T4, free T4 by equilibrium dialysis and TRAb were ordered. Thyroid scan and uptake could not be done due to recent study with iodinated dye. Patient’s tachycardia improved. Due to history of fatigue, adrenal reserve was assessed. Cortisol level 1 hour after 250 mcg ACTH was 13.3ug/dL (n ≥ 20ug/dL), indicative of adrenal insufficiency. Patient was started on hydrocortisone.  On day 5, given persisting elevation of total T4, methimazole 5 mg a day was started. FreeT4 of 10.7 ng/dL (n 1.1-2.4ng/dL) by equilibrium dialysis confirmed hyperthyroidism. Patient‘s energy level and appetite improved substantially during hospitalization. TPO antibodies and TRAb returned positive; she was diagnosed with Grave’s disease and apathetic hyperthyroidism. Liver enzymes improved and methimazole was increased to 10 mg a day. There was concern for underlying cancer. Lymph node excisional biopsy was performed. Patient was discharged in stable condition stable, Free T4 of 4.12ng/dL.

Conclusion: Apathetic hyperthyroidism may present in adults under the age of 50 in the presence of severe underlying illness.

 

Nothing to Disclose: AG, TMC, AAZ

12238 4.0000 SUN-0487 A Apathetic Hyperthyroidism in a 35-Year Old Woman 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0484-0498 5059 1:00:00 PM Non-neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Marina Goldis*1, Evan Graber1, Michelle Klein2, Elizabeth Wallach3, Lindsey Waldman3, Dennis Jay Chia2, Molly Oliver Regelmann1 and Robert Rapaport3
1Icahn School of Medicine at Mount Sinai, New York, NY, 2Ichan School of Medicine at Mount Sinai, New York, NY, 3Pediatric Endocrinology and Diabetes, Icahn School of Medicine at Mount Sinai, New York, NY, New York, NY

 

Introduction:  ATA guidelines recommend routine Tg screening and periodic 131I scan and/or US depending on recurrence risk (1).   Improvements in ultrasound (US) techniques and technology have increased the sensitivity of this imaging modality.  We describe 2 youths diagnosed with papillary thyroid carcinoma (PTC) who had noted recurrences on US after normal 131I scans.

Patient 1: 16 yo female presented with a neck mass for 6-9 months.  FNA consistent with PTC.  She underwent total thyroidectomy (TT) and lymph node (LN) dissection; staging was pT1N1bMX.  2 months postoperatively, whole body 131I scan showed residual thyroid bed tissue without distant metastases.  131I ablative therapy followed.  131I scan 9 months later revealed no uptake in the neck.  Thyroglobulin (Tg) increased from 0.3 ng/mL to 2.3 ng/mL after rhTSH stimulation (negative Tg antibodies).  TSH remained suppressed after ablation (0.01-0.26 µIU/mL).  2 years post-ablation, US revealed a 1.7 x 0.6 x 1.5 cm heterogeneous, hypoechoic vascular structure without normal LN architecture below surgical bed.  Follow-up US 3 and 6 months later remained unchanged.  131I scans performed 2 and 3 years after ablation showed no uptake in the area of concern.  PET imaging revealed a 1.3 x 0.6 cm mildly hypermetabolic focus consistent with the area of concern on US.  FNA consistent with PTC.  Patient had surgical resection and pathology confirmed PTC within a cervical LN.

Patient 2: 13 yo female presented with goiter for 2 years.  She was euthyroid with negative thyroid antibodies.  US revealed a multinodular goiter with dominant hypervascular lobulated nodule occupying the isthmus of the gland. 131I scan had normal 24 hr uptake of 28.5% (10-30%) with a cold nodule.  She had TT with central LN dissection.  Pathology confirmed PTC, stage pT3N1MX, with involvement through the capsule and 10 perithyroid LN.  She had 131I ablation 1 month after TT.  TSH remained suppressed after ablation (0.01-0.9 uIU/mL).  Tg increased from <1-1.7 ng/mL to 10-14 ng/mL after rhTSH stimulation (negative Tg antibodies).  Subsequent 131I scans and PET imaging were normal.  2 yr following ablation, US revealed a 1.6 x 0.5 x 1.0 cm hypoechoic structure with hypervascularity and non-shadowing echogenic foci suspicious for calcifications.  Pathology of the concerning LN was consistent with recurrent PTC. 

Discussion: In the patients presented, US detected recurrence of PTC in the setting of multiple negative 131I scans, as well as negative PET imaging (case 2).  The patients demonstrate the benefit of US over 131I scan in 2 non-iodine-avid recurrences.  This suggests that in patients with initial metastases localized to the neck, US may be the ideal imaging modality for follow up and should be used in the setting of elevated Tg and negative 131I scan.

 

Nothing to Disclose: MG, EG, MK, EW, LW, DJC, MOR, RR

14090 5.0000 SUN-0488 A Thyroid Ultrasound Is More Sensitive Than 131I Imaging in Detecting Recurrence of Papillary Thyroid Cancer in Youth 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0484-0498 5059 1:00:00 PM Non-neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Vishnu Vardhan Garla*1 and Angela R Subauste2
1University of Mississippi Medical center, jackson, 2University of Mississippi Medical Center, Jackson, MS

 

Thyroid storm and methimazole induced agranulocytosis in a patient: A treatment conundrum.

Objective: To report and elucidate a rare case of thyroid storm and methimazole induced agranulocytosis in a patient and detail the treatment dilemmas it poses.

Methods: We present Patient’s clinical history, physical findings, diagnostic work up and treatment along with the literature review.

Patient presentation: A 30 year old female presented to the emergency department with shortness of breath and a productive cough. She also complained of losing weight since 3 years. Past history was significant for preeclampsia resulting in a still birth 4 months ago. There was no significant family history. She smoked 6 cigarettes/day but had no history of alcohol or drug use. Vitals revealed a blood pressure of 206/112 and a heart rate of 150/min. Examination showed a cachetic woman who was confused. A prominent apical impulse was noted but no goiter. The TSH was measured and was found to be <0.01 (0.93-1.7 ng/dL) and free T4 of 3.72 (0.27-4.2 mcIU/ml). Patient was started on methimazole 20 mg tid, propranolol 60 mg every 6 hours, hydrocortisone 50 mg every 8 hours. Thyroid stimulating immunoglobulin was positive confirming the diagnosis of grave’s disease. Three days after starting the methimazole the patient’s WBC count dropped from 10.5 to 1.9. Methimazole was stopped, the patient was given 1 dose of neupogen and the wbc count rose from a nadir of 1.0 to 31.2. The free T4 slowly trended up again reaching a peak of 2.46. Surgery was consulted and the patient underwent a total thyroidectomy. One month later upon follow up the patient’s weight was stable and her free T4 was normal on 75 micrograms of levothyroxine.

Conclusion: Thyroid storm complicated by methimazole induced agranulocytosis pose an enormous challenge as antithyroid medications are the mainstay of treatment. The role of Granulocyte colony stimulating factor in the treatment of agranulocytosis remains to be studies further.

 

Nothing to Disclose: VVG, ARS

14301 6.0000 SUN-0489 A Thyroid Storm and Methimazole Induced Agranulocytosis in a Patient: A Treatment Conundrum 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0484-0498 5059 1:00:00 PM Non-neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Ruchi Gaba* and Nalini Ram
Baylor College of Medicine, Houston, TX

 

INTRODUCTION

Struma ovarii is a rare monodermal teratoma composed predominantly of mature thyroid tissue (>50%). Malignancy varies from 5 to 37 % in these tumors, with papillary carcinoma being the most common. The V 600E amino acid substitution accounts for 90% of all oncogenic BRAF mutations and has typically been detected in classic PTC but less often in the follicular variant PTC. It is seen in two-thirds of malignant struma ovarii (MSO) with classic  papillary features. The BRAF V600E mutation in papillary thyroid carcinoma (PTC) has been demonstrated to be a poor prognostic factor.  We report a case of follicular variant of PTC (FVPTC) with a BRAF V600E mutation arising in struma ovarii.

CLINCIAL CASE

A 42-year-old multiparous woman presented with 10 months of progressive pelvic pain and abdominal distension. CT abdomen demonstrated a 24.8 x 23.8 x18.6 cm hypo dense mass with multiple septations arising from the left ovary. Tumor markers were elevated: CA125: 61.2 U/ml (0-31 U/ml) and CA 19-9: 1213.36 U/ml (0-35 U/ml). CEA, Inhibin B, LDH and AFP levels were normal. She underwent a total abdominal hysterectomy and bilateral salpingo- oophorectomy. Intra operative frozen section showed a left ovarian cystic teratoma with thyroid tissue. Histology revealed a 2.5 cm papillary thyroid carcinoma with follicular architecture arising in the 28 cm struma ovarii. There was no capsular or lymphovascular invasion. Genetic analysis revealed a V600E amino acid substitution BRAF mutation.

Thyroid ultrasound revealed a 2 cm complex cystic and solid heterogeneous nodule in the right thyroid lobe. Fine needle aspiration of the nodule was indeterminate with rare follicular groups showing irregular nuclear contours and nuclear overlapping. Hence patient underwent total thyroidectomy. Histology revealed a 1.2 cm right adenomatous nodule and the rest of the thyroid was normal.

After surgery the patient received ablative radioiodine treatment (150 mCi 131-I), given the positive BRAF mutation. I-131 post-therapeutic whole-body scintigraphy showed no uptake. She was started on levothyroxine suppressive therapy with periodic monitoring of thyroglobulin levels. The patient is recurrence free for about 2 years now.

DISCUSSION

There are difficulties in the management of MSO because of the absence of uniform consensus with the rarity of the disease. The optimum management should be the same as in the case of differentiated thyroid carcinoma. BRAF V600E mutation has not been reported before in FVPTC arising in struma ovarii. Our management was aggressive due to the presence of BRAF V600E mutation. Long-term follow-up for the detection of persistent or recurrent disease is required. The molecular markers that are applied to primary thyroid lesions may be helpful in the diagnosis and risk stratification of malignant struma ovarii.

 

Nothing to Disclose: RG, NR

15971 7.0000 SUN-0490 A Follicular Variant Papillary Thyroid Cancer with BRAF V600E Mutation Arising in Struma Ovarii: Challenges in Management 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0484-0498 5059 1:00:00 PM Non-neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Saba Wasim Aziz* and Carmel Maria Fratianni
Southern Illinois University School of Medicine, Springfield, IL

 

Background: Diffuse Sclerosing Variant of Papillary thyroid cancer (DSVPTC) is a rare variant of PTC with aggressive tumor biology & increased propensity for invasiveness & distant metastasis.  It is also more common in young patients. We present an unusual case of DSVPTC in association with cardiac and lingual neurofibromas. While PTC has very rarely been reported in association with Neurofibromatosis- 1(NF1), DSVPTC with neurofibroma has never been reported prior.

Clinical Case: A 12 yo female presented with dysphagia. She had previously required hemi-glossectomy at age 2.5 years for a lingual neurofibroma.  At age 12 she was diagnosed with Stage II DSVPTC after total thyroidectomy & neck dissection. Her Right lobe was entirely replaced by DSVPTC & metastatic adenopathy at Left levels IIA and III & Right paratracheal region noted. Initial TG (thyroglobulin) was 2147. Pulmonary metastases were noted which were successfully treated with 144 mCi of RAI. After a clinical recurrence in the R paratracheal region she received a second dose of RAI 218 mCi.  Although she has evidence of persistent disease she has maintained TG levels in the 2-3 range on thyroid hormone suppression. Because of persistently detectable TG without focal lesion on Whole Body Scan, PET CT Scan was done which surprisingly disclosed an asymptomatic cardiac lesion of soft tissue density overlying the left ventricle (LV). Cardiac MRI defined a 4x2 cm lesion encasing portion of the Left main coronary artery & Left Anterior Descending Coronary Artery. CT Angiogram better delineated this large mass which coursed along the superior aspect of the LV, encasing but not narrowing the Left main coronary artery and proximal LAD and partially encasing the Left Circumflex artery.  As the lesion was suspicious for a pericardial metastasis, biopsy was performed. The biopsy was variably interpreted at 2 tertiary hospitals as either a low grade Malignant Peripheral Nerve Sheath Tumor (MPNST) arising in a neurofibroma, or an atypical neurofibroma.  The cardiac lesion was not felt to be safely resectable. She has not met diagnostic criteria for NF1 (no Lisch nodules, axillary freckling, café au lait spots, skeletal abnormality or positive Family hx etc.) although she does have relative macrocephaly.  MRI of brain was unremarkable.

Conclusion: DSVPTC is an aggressive thyroid neoplasm which can occur in association with isolated neurofibromas without definitive diagnosis of NF as in this case. Of interest, there is in vitro evidence that MPNST can be inhibited by Sorafenib. Should she evolve anatomic progression of her DSVPTC and/or her MPNST this agent may be of therapeutic interest for both entities.  Although both NF1 and NF2 can be associated with abnormal tumor formation, the specific genetic alteration(s) underlying the constellation of metastatic DSVPTC and neurofibroma in this case remain to be elucidated.  Sequencing of the NF gene will be recommended.

 

Nothing to Disclose: SWA, CMF

16313 8.0000 SUN-0491 A Diffuse Sclerosing Variant of Papillary Thyroid Cancer Associated with Cardiac and Lingual Neurofibromas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0484-0498 5059 1:00:00 PM Non-neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Dorothy A Fink*1, Kim Thien Nguyen2, Jessica Furst3, Salila Kurra4, Susana A Ebner5 and John P Bilezikian2
1Columbia University, New York, NY, 2College of Physicians and Surgeons, Columbia University, New York, NY, 3Columbia Unviersity College of Physicians and Surgeons, 4Columbia Univ Med Cntr, New York, NY, 5Columbia Presbyterian Med Ctr, New York, NY

 

Background:  Hyperthyroidism is a rarely reported complication of parathyroid surgery.  Possible mechanisms include release of thyroid hormone during prolonged surgery.  Even more uncommon is the development of atrial fibrillation in this context.

Clinical Case:  A 66-year-old woman presented with palpitations 2 days following subtotal parathyroidectomy.  Her history includes stage 1 breast cancer treated with lumpectomy on anastrozole, hypertension, nontoxic multi-nodular goiter, and primary hyperparathyroidism.  Parathyroid surgery, performed under general anesthesia, was prolonged because of multiglandular disease.  After removal of all or portions of 3 hypercellular parathyroid glands, the PTH fell from 121 pg/mL (nl: 8-51) to 14 pg/mL.  On exam, heart rhythm was irregular at 124 beats per minute.  The anterior neck was swollen and erythematous but the surgical incision was clean and closed with no palpable goiter.  There was no proptosis, lid lag, fine tremor, fine skin, abnormal reflexes or other stigmata of hyperthyroidism.  There was no prior personal or family history of thyroid disease.  No recent exposure to iodinated contrast, lithium, or amiodarone was reported.  The TSH was suppressed at 0.25 mIU/L (nl: 0.32-4.05); FT4 was elevated at 1.48 ng/dL (nl: 0.7-1.24) as was the T3 at 193 ng/dL (nl: 58-159); and the total T4 was normal at 10.97 μg/dL (nl: 5.41-11.66).  Thyroid antibodies were not detected.  The thyroglobulin was 650 ng/mL (nl: 1.3-31.8) and the TSI was normal. The pre- and post-operative calcium values were 10.0 and 9.8 mg/dL respectively (nl: 8.9-10.3).  Electrocardiogram confirmed atrial fibrillation.  Prior cardiac echocardiogram showed normal function with mild tricuspid regurgitation and mild pulmonary hypertension.  The atrial fibrillation was managed with metoprolol.  The patient spontaneously converted to normal sinus rhythm overnight.  Follow-up TSH remained low at 0.14 μIU/mL, but the free T4 decreased to normal range.

Conclusion:  To our knowledge, this is only the second case report to document atrial fibrillation occurring in the setting of hyperthyroidism within days after parathyroidectomy.  Extensive surgical exploration of the neck, as was the case in this patient, may have led to temporary release of thyroid hormone and incited the atrial arrhythmia. While other factors may have contributed to the atrial fibrillation, the transient hyperthyroidism is likely to have been a major factor.

 

Disclosure: JPB: Principal Investigator, Amgen. Nothing to Disclose: DAF, KTN, JF, SK, SAE

14307 9.0000 SUN-0492 A Hyperthyroidism and Atrial Fibrillation after Parathyroidectomy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0484-0498 5059 1:00:00 PM Non-neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Stanley Chen Cardenas*1 and Henry G Fein2
1Sinai Hospital of Baltimore, Baltimore, MD, 2Sinai Hospital and Johns Hopkins School of Medicine, Baltimore, MD

 

Background: Elevated TSH is frequently seen in patients with Hashimoto thyroiditis as the gland becomes atrophic and hypothyroidism occurs.  However, extremely high TSH levels in the absence of Macro-TSH or endogenous heterophilic human antimouse antibodies are  rare.  We report a patient with very high TSH that responded to thyroxine replacement. 

Clinical Case:  53 year old woman with cardiomyopathy (ejection fraction <10%), end stage renal disease (secondary to focal segmental glomerulosclerosis, requiring hemodialysis) and tertiary hyperparathyroidism (serum calcium 10.1-11.0) was admitted in December 2012 with symptoms of fluid overload. She had first been diagnosed with Hashimoto thyroiditis and hypothyroidism in June 2004 with Free T4 0.82 ng/dL (nl: 0.82-1.77) and TSH 45.3 mIU/L(nl: 0.45-4.50),  During treatment with levothyroxine (LT) 125 mcg, TSH was 0.72 in December 2009 and 0.29 in January 2012 (Free T4 1.34). LT dosage was apparently then decreased by other physicians over the next year to 25 mcg orally.

Upon hospital admission, TSH was 632, total T4 1.2mcg/dL (nl: 4.5-12.0) and Free T4 0.34. She reported mild fatigue only. LT was increased immediately to 50 mcg/day orally. She had a negative anti-mouse heterophile antibodies, positive thyroid peroxidase and antithyroglobulin antibodies. After hospital discharge, she was followed at 6-8 week intervals with stepwise 25 mcg increases in the dose of oral LT with periodic measurements of TSH. One month later on 50 mcg LT, TSH was 387 and Free T4 0.44. After six months, on 100 mcg LT, TSH was 39.3 and FT4 0.94.  However, one month later, with no change in dosage or adherence by her report, TSH was 60.6. LT was increased to 125 mcg.  When TSH again rose to 88.6 at ten months, LT dosage was increased to 150 mcg and two months later TSH was 12.4 and Free T4 1.2.  The patient continues to deny any change in symptoms.  Her cardiomyopathy did not improve and an implantable defibrillator was installed.

Conclusion: In some hypothyroid patients, extraordinarily high serum TSH can be noted.  This does not appear to be related to renal clearance since, with no change in renal function or dialysis frequency, TSH levels generally appeared to inversely correlate with LT dose.  Unlike several reports in the literature, restoration of normal thyroid hormone levels has not improved cardiac function.

 

Disclosure: HGF: Speaker Bureau Member, Corcept. Nothing to Disclose: SCC

15302 10.0000 SUN-0493 A Dramatically Elevated Serum TSH Responsive to Treatment in a Patient with Hashimoto Thyroiditis, Renal Failure and Cardiomyopathy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0484-0498 5059 1:00:00 PM Non-neoplastic Thyroid Disorders-Clinical and Case Reports Poster

César Esteves1, Celestino Neves*2, Fernando Silveira3 and Davide Carvalho1
1Centro Hospitalar São João, Faculty of Medicine, University of Porto, Portugal, 2São João Hospital, Faculty of Medicine, University of Porto, Porto, Portugal, 3Centro Hospitalar São João

 

Introduction: It is well known that thyroid autoimmunity frequently occurs in association with other autoimmune disorders, more frequently of the skin or endocrine organs. There are previous reports in the literature of a rare association between Hashimoto thyroiditis and a form of autoimmune neuropathy – CIPD (chronic inflammatory demyelinating polyneuropathy). Objective: To report the case of a patient with autoimmune thyroid disease and a variant of CIDP – MADSAM (multifocal acquired demyelinating sensory and motor neuropathy). Clinical case: Female, 53 years old, sent to Endocrinology appointment due to the detection of subclinical hyperthyroidism (TSH 0.16 µUI/mL, T4L 1.15 ng/dL) during the investigation of a nodular goiter and dysphonia. She had positive anti-peroxidase antibodies and slightly positive TRABs levels. Thyroid ultrasound showed the presence of 2 solid nodules with 25 mm in the left lobe and a diffuse heterogeneous appearance of the thyroid gland. The 2 largest nodules were biopsied and the cytology revealed that they were colloid. She did a thyroid scan showing a diffusely increased uptake. She initiated propylthiouracil 50 mg bid. She was referred to Neurology to investigate dysphonia due to bilateral vocal cord palsy and left arm numbness and strength loss. The electromyography was suggestive of acquired demyelinating neuropathy, affecting the upper limbs. The superficial peroneal nerve biopsy revealed diminished density of fiber density. She did not respond to immunoglobulin therapy but had a good response to glucocorticoids. A MADSAM diagnosis was established. Due to the airway compromise, the definitive treatment of the hyperthyroidism was achieved with administration of radioactive iodine, after which the titer of TRAB increased. Conclusion: The association with autoimmune thyroid disease and autoimmune neuropathy is rare. We describe the association of a case of MADSAM with thyroid autoimmune disease, previously undescribed in the available literature.

 

Nothing to Disclose: CE, CN, FS, DC

16039 11.0000 SUN-0494 A Autoimmune Thyroid Disorder and Neuropathy: A Rare Association 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0484-0498 5059 1:00:00 PM Non-neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Sarah El Yaman*1, Kenneth H Hupart2 and Renee Bargman1
1Nassau University Medical Center, East Meadow, NY, 2Nassau Univ Med Ctr, East Meadow, NY

 

Background:

Non-traumatic hematoma of a previously normal thyroid gland is a very rare condition. We report a case of a thyroid hematoma that presented as an acute neck mass suspicious for neoplasm and subsequently resolved.

Case Report:

5-year-old boy presented with a neck mass that appeared suddenly. He had a fever and URI symptoms 2 weeks prior which have since resolved and denied any neck trauma or other symptoms. His exam was significant for a 1.5 x 1.5 cm, firm, fixed, tender neck mass on left of the midline and slightly tender 1 cm lymph nodes in the right submandibular, bilateral posterior cervical and left supraclavicular regions.

Initial thyroid function tests showed low TSH at 0.010 uIU/ml (0.36-3.74), elevated T4 at 19.4 ug/dl(4.5-12.1) and free T4 at 2.34 ng/dl (0.76-1.46) with normal T3, elevated ESR (68 mm/hr), and slightly elevated CRP (0.9 mg/dl).

Thyroid ultrasound showed a heterogeneous mass on the left side of the neck that is inseparable from the left thyroid lobe, and compressing it. The mass appeared solid and extended laterally to the great vessels with an overall measurement of 4.8 x 2.6 x 3.1 cm.  A Technetium Thyroid scan showed no uptake.  MRI of the neck revealed a left neck mass arising from the thyroid, with possibility of a thyroid carcinoma. FNA under general sedation was being arranged but by hospital day 4 the mass appeared to be decreasing in size and repeat thyroid ultrasound then showed a decrease in size of the mass to 2.99 x 1.38x 1.06 cm. TFT showed low but normalizing TSH (0.012 uIU/ml), elevated but normalizing T4 (17.4 ug/dl) and freeT4 (2.21 ng/dl).  Thyroglobulin was within normal range (26.1 ng/ml), and thyroglobulin antibody was negative.  The child was discharged without further invasive tests with close follow up.   On day 26 the mass decreased further to 3.1x1.4x1 and a third set of TFT showed normalizing thyroid hormone levels with a TSH of (0.013 uIU/ml), T4 (13.8 ug/dl), FT4 (1.54 ng/dl).   By 3 months the mass resolved entirely and the TFTs were completely normalized. 

Conclusion:  This is a case of a child with a likely non-traumatic thyroid hematoma that presented as a mass that was suspicious for neoplasm.  Waiting for clinical progression before attempting invasive tests may be reasonable in such cases.

 

Nothing to Disclose: SE, KHH, RB

16084 12.0000 SUN-0495 A Non-Traumatic Thyroid Hematoma in a Child 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0484-0498 5059 1:00:00 PM Non-neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Myrto Eliades*1, Sarada Jaimungal1, Yasaman Mohtasebi1, Kashif M. Munir2 and Komal Patil-Sisodia1
1University of Maryland School of Medicine, Baltimore, MD, 2University of Maryland Medical Center, Baltimore, MD

 

Introduction: Thyroid storm is usually precipitated by endogenous or exogenous critical events such as: illness, injury, acute iodine load, or surgery. No previous report to our knowledge exists of thyroid storm induced by an electrical injury.

Clinical case: A 23-year old African American man was admitted to the ICU with symptoms of acute pulmonary edema, tachycardia and altered mental status. Prior to admission he had suffered two electrical shocks to the back and upper torso delivered by a Taser gun, after being pursued by the police. Vital signs on initial presentation were Tmax 39.1°C, BP 151/69, HR 134-190 bpm, RR 22-26 and SatO2 80%. Chest x-ray showed bilateral pulmonary infiltrates. The patient was intubated for hypoxic respiratory failure. History revealed 60 lb unintentional weight loss over a 3 month period. Clinical exam was notable for diaphoresis, tachypnea, tachycardia and thyromegaly with an audible bruit. No exophthalmos was present. Thyroid storm was suspected based on the Burch-Wartofsky score which exceeded 45 (80).  Laboratory results were consistent with thyroid storm: TSH < 0.01 mIU/L (0.47 – 4.68), Free T4 >7 ng/dl (0.6-2.5) and Free T3 31.4 pg/ml (2.4-4.0). Thyroid stimulating immunoglobulin (TSI) was elevated at 563% (normal 1-139%) indicative of underlying Graves’ disease.

Medical treatment with IV hydrocortisone 100mg IV q8h, propranolol 60mg PO q8h, Propylthiuracil (PTU) 200mg PO q8h and SSKI 200mg PO q6h was initiated. Extubation occurred on hospital day 3; however tachycardia, agitation, and diaphoresis persisted despite very high doses of oral PTU (300mg q8h). Lithium 300 mg PO q8h was initiated on day 4 without any subsequent improvement in clinical status. Plasmapheresis on hospital day 6 resulted in a dramatic improvement in symptoms. The patient was discharged after 15 days on methimazole 30mg PO daily and propranolol 30mg PO q8h with plan for outpatient follow up for radioactive iodine ablation. 

Conclusion: This is the first reported case to our knowledge of thyroid storm after Taser exposure. This case illustrates the harmful potential of Taser guns in otherwise healthy young individuals and adds to the recently reported safety concerns associated with their use (1)

 

Nothing to Disclose: ME, SJ, YM, KMM, KP

13499 13.0000 SUN-0496 A Thyroid Storm Induced By Electrical Shock Delivered By a Taser Gun 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0484-0498 5059 1:00:00 PM Non-neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Alexander V Dreval1, Olga Nechaeva2, Irina V Komerdus*3, Tamara Mamedova3, Tatyana Shestakova1 and Yulia N Bardeeva4
1Moscow Regional Research & Clinical Institute, Moscow, Russia, 2Moscow Researcher Clinical Ins, Moscow, Russia, 3Moscow Regional Research Clinical Institute, Moscow, Russia, 4Moscow Regional Research & Clinical Institute n.a.M.F.Vladimirskiy, Moscow, Russia

 

Introduction. The combination of papillary carcinoma and Grave's disease (GD) is extremely rare. We are presenting a clinical case of combination of GD and ophthalmopathy with papillary cancer in patient injected of GH to increase his muscle mass.

Clinical case. Man, 36 y. o., BMI 32 kg/m2 due to prominent muscle mass, has hereditary hemochromatosis and nonalcoholic steatohepatitis. Previously he was successfully treated for chronic viral hepatitis C by standard antiviral therapy. He simultaneously introduced growth hormone for increasing his muscle mass in a dose of 12 IU. Several months later, in September 2012 he complained for palpitations, weight loss (7 kg)  and weakness. The patient took metoprolol in total daily dose 900 mg without clinical effect. In October 2012 GD was diagnosed (TSH - 0 , 003 mIU/l, f T4 - 40.0 pmol /l, TSH Ab - 38 U/L (normally less than 1.5), thyroid volume 56 ml). Euthyroidism restored in 10 weeks on methimazole’s dose 40 mg per day. Since November 2012 active severe ophthalmopathy was diagnosed (CAS 4 points, proptosis - 28 mm in both eyes, permanent double vision, decreased visual acuity). Parenteral glucocorticoid therapy was prescribed in total dose of methylprednisolone 1750 mg. In March 2013 due to the large dose of thyreostatics (40 mg) that was required to maintain euthyroidism and symptoms of hypercortisolism on glucocorticoids, thyroidectomy was made. He was replaced by levothyroxine at dose of 150 mg /day. Histologically microfocuses of papillary carcinoma (adenocarcinoma ) and follicular variant of papillary carcinoma with diffuse expression of cytokeratin 19, galectin 3 and NVME -1, over on the rest of colloid goiter with signs of functional activity were seen. Suppression of TSH to 0.9 mIU/l was achieved at a L-T4 dose of 225 mg / day only 5 months later, but after 4 months an increase of the  thyroglobulin level to 10 ng/ml, with a normal level of antibodies to thyroglobulin <3 , and  still very high level of antibodies to the TSH receptor - 38.9 U / L . There was no data on relapse of goiter on neck ultrasound. During postoperative period opthalmopathy  remained active and severe and parenteral glucocorticoid therapy was prescribed again in total dose of 1250 mg . In 6 months after thyreoidectomy total body scan with 123 I on rhTSH-stimulation showed hyperfixation of 123I in the thyroid. Ablative dose of 131 I - 3521 MBq was given. In 6 weeks after RIT the level of TG was decreased to 0,6, CAS of ophthalmopathy -2 points,  intermittent diplopia and a high level of TSH Ab -35.1 U / l  were persisted.

Conclusion. Large muscle mass of the patient required high doses of medication (thyreostatics, beta -blockers, levothyroxine). In case of administration of GH in patients without growth hormone deficiency should be remember the possible development of malignancies including thyroid cancaer. Completely total thyroidectomy should be performed in this case.

 

Nothing to Disclose: AVD, ON, IVK, TM, TS, YNB

15620 14.0000 SUN-0497 A Unexpected Papillary Carcinoma Coexisted with Graves' Disease and Ophthalmopathy in Patient Previously Received Growth Hormone Injections without Confirmed GH Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0484-0498 5059 1:00:00 PM Non-neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Farheen Kassim Dojki1, Beatriz Tendler2, Robert Udelsman3, Sidra Azim*4 and Patricia Donovan5
1University of Connecticut, Meriden, CT, 2University of Connecticut, 3Miami Cancer Institute, Miami, FL, 4University of Connecticut School, Hartford, CT, 5Department of Surgery, Section of Endocrine Surgery, Yale University School of Medicine, New Haven, CT

 

Background: Medullary thyroid carcinomas (MTC) are tumors that arise from the neural crest–derived parafollicular C cells and represent 5% of all thyroid neoplasms.

Clinical Case: A 55-year-old lady presented with complaints of flushing and night sweats of 2 years duration. She was also concerned about her constipation, weight gain and hot flashes, which were different for her since she was 3 years post-menopausal. Physical exam was unremarkable and thyroid gland appeared normal size with no supraclavicular lymph nodes or dorsal cervical fat pad. Laborotary workup showed normal levels of TSH 3.89 (0.3 and 5.5), ACTH 18 (6-58), 24-hour urine free cortisol 18.3 mcg/day (upper range 45), calcitonin 433pg/mL (0-5) and CEA 80.1ng/mL (0-5). IGF-1, plasma free metanephrines, calcium and PTH were within normal limits. Normetanephrines were borderline elevated and MIBG (Meta-Iodo-Benzyl-Guanidine) scan only showed activity on the right thyroid bed where the thyroid nodule also showed up on ultrasound. She underwent total thyroidectomy and right central neck dissection finding a 1.2 cm medullary thyroid carcinoma on the right thyroid lobe which was well circumscribed and encapsulated with 13 lymph nodes showing no carcinoma. Calcitonin and CEA immunostains supported the diagnosis. No C-cell hyperplasia was identified on the rest of the thyroid, which had a background of lymphocytic thyroiditis. RET mutation was not detected hence it was likely sporadic. Post-op calcitonin was less than 2pg/mL and CEA 0.8ng/mL. She was started on thyroid replacement and did well on follow-up.

Conclusion: Flushing is a common presenting complaint to physicians and results from changes in cutaneous blood flow triggered by multiple conditions. Common benign diseases cause majority of the cases, however in some cases it may be a symptom of something more serious. MTCs occur sporadically or 25% of the time as hereditary forms associated with tumor syndromes (MEN 2 and familial MTC) due to RET oncogene mutation, which are autosomal dominant. Secretory diarrhea is the most prominent hormone-mediated clinical feature. Hence our patient presenting with constipation was unusual. There have been some case reports in pediatric patients and some adolescent who present with constipation and on workup for ruling out Hischsprungs disease are found to have MEN2B. Constipation in these cases is likely due to colonic dysfunction. Flushing of the face and upper extremities, discoloration and telangiectasia is also a symptom commonly seen with hormone overproduction in MTC, which can be an early predictor and easily missed. Rarely, ectopic production of ACTH and/or CRH may cause paraneoplastic Cushings syndrome that was ruled out in our patient. It is important to remember that flushing though mostly benign may point towards more serious diseases and should not be overlooked.

 

Nothing to Disclose: FKD, BT, RU, SA, PD

16979 15.0000 SUN-0498 A Flushing: Often a Forgotten Symptom for Medullary Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Sunday, June 22nd 3:00:00 PM SUN 0484-0498 5059 1:00:00 PM Non-neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Alice Pik-shan Kong1, Kai Chow Choi2, Ruth Chan2, Risa Ozaki3, Ronald C Ma4, Kitty Kit Ting Cheung*5, Andrea O Luk4, Wing Yee So4, Jean Woo4 and Juliana CN Chan4
1The Chinese Univ of HK, Hong Kong, 2The Chinese University of Hong Kong, Hong Kong, Hong Kong, 3Prince of Wales Hosp, Yuen Long, 4The Chinese University of Hong Kong, 5Prince of Wales Hospital, N.T., Hong Kong

 

Background: Epidemiological studies suggest a role for a low GI diet in the management of childhood and adolescence obesity (1). We aimed to study the changes in body mass index (BMI) and other obesity indices in obese adolescents randomized to a 12-month low GI diet versus a conventional Chinese diet.

Methods: Obese adolescents of Chinese ethnicity aged 15-18 years were identified from population-recruited, territory-wide surveys. Obesity was defined as BMI ≥95th percentile of Hong Kong local age- and sex-specific reference(2). Eligible subjects were randomized to either a 6-month intervention with low GI diet (45-50% carbohydrate and 30-35% fat with the remainder from protein) or conventional Chinese diet as control (55-60% carbohydrate and 25-30% fat with the remainder from protein). We used mixed effects model to compare the changes across the time point at baseline, month 6 and month 12 between the 2 groups.

Results: 281 obese adolescents were recruited (139 in low GI group and 142 in control group). Mean age was 17.2±1.2 years and 17.3 ±1.3 years in low GI and control group respectively. The respective BMI at baseline was 30.7±4.4 kg/m2 in low GI group and 30.8±4.3 kg/m2 in control group. 59% subjects completed 6-month study and 30% completed 12-month study. After adjustment for age and sex, subjects in low GI group had significant reduction in obesity indices including BMI, body weight and waist circumference compared to subjects in the control group at 6 month (all p <0.05). At 12-month, there was a non-significant trend of reduction of obesity indices.  

Conclusion: A low GI diet may be an alternative to conventional diet in obese adolescents. High attrition rate remains to be the challenge of dietary intervention especially in the youth population.

 

Nothing to Disclose: APSK, KCC, RC, RO, RCM, KKTC, AOL, WYS, JW, JCC

16528 1.0000 SUN-0892 A A 12-Month Randomized Controlled Trial to Investigate the Impact of a Low Glycemic Index (GI) Diet on Obesity Indices in Adolescents 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0891-0905 5061 1:00:00 PM Human Obesity: Targets and Therapies Poster

Amy Miskimon Goss*1, Paula C Chandler-Laney2 and Barbara Ann Gower3
1University of Alabama at Birmingham, Birmingham, AL, 2Univ of Alabama at Birmingham, Birmingham, AL, 3Univ of AL at Birmingham, Birmingham, AL

 

Introduction:Glucagon, a counterregulatory hormone to insulin, has a primary role in maintaining glucose homeostasis, and may also exert effects on appetite and satiety by suppressing ghrelin.  Studies have shown a reduced-carbohydrate (CHO) diet increases circulating glucagon; however, whether this dietary approach promotes satiety through this mechanism in women with PCOS has not been studied.  The objectives of this study were to 1) compare the effects of habitual consumption of a reduced-CHO vs standard (STD) diet on glucagon and other hormones with documented effects on hunger in a postabsorptive state and in response to a solid meal challenge, and 2) identify the hormonal determinants of hunger following an overnight fast in women with PCOS.

Methods:In a crossover diet intervention, 30 women with PCOS consumed a reduced-CHO diet (41:19:40 % energy from CHO:protein:fat, resp.) for 8 weeks and a standard (STD) diet (55:18:27) for 8 weeks. All food was provided for both diet phases. After 4 weeks of acclimation to the diets, participants underwent a meal test during which circulating glucose, insulin, glucagon, ghrelin, GLP-1, PYY, and cortisol were measured before and after consumption of breakfast from their assigned diets. Self-reported hunger and satiety were measured using a visual analogue scale following a 12-hr fast.

Results:A significant diet effect was observed for fasting glucagon and glucagon area-under-the-curve (AUC). During the reduced-CHO diet arm, glucagon was significantly greater following a 12-hr fast and following consumption of the reduced CHO breakfast meal compared to the STD breakfast meal.  Fasting and AUC ghrelin, GLP-1, PYY, cortisol, glucose, and insulin were not significantly different between the diet arms after 4 weeks.  Hunger rating from the visual analogue scale was inversely associated with fasting glucagon and cortisol. However, a threshold effect occurred for the relationship between glucagon and hunger, such that in women with glucagon >90 mg/dL there was no detectable relationship with perceived hunger. During the reduced-CHO meal test, glucagon AUC was inversely associated with ghrelin AUC (Std Β=-46, p=0.05).

Conclusion: Among women with PCOS, a reduced CHO/higher fat diet may reduce hunger by elevating circulating glucagon.  Further studies are needed to determine the precise mechanisms through which glucagon may affect perceived hunger and whether elevated glucagon from a reduced CHO/higher fat diet impacts ad libitum food intake.

 

Nothing to Disclose: AMG, PCC, BAG

14756 2.0000 SUN-0893 A Elevated Glucagon Following Habitual Consumption of a Reduced Carbohydrate Diet May Reduce Perceived Hunger in Women with PCOS 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0891-0905 5061 1:00:00 PM Human Obesity: Targets and Therapies Poster

Jung Hwan Park*1, Dong-Sun Kim2, Sangmo Hong3, Chang-Bum Lee4, Yongsoo Park5, Woong Hwan Choi6 and You Hern Ahn7
1College of Medicine, Hanyang University, Seoul, Korea, Republic of (South), 2Hanyang Univ Hosp, Seoul, Korea, Republic of (South), 3Hanyang University, Gyeonggi, Korea, Republic of (South), 4Hanyang Univ, Guri, Korea, Republic of (South), 5Hanyang Univ.,, Seoul, Korea, Republic of (South), 6Hanyang Univ Hospital, Seoul, Korea, Republic of (South), 7Hanyang University Hospital

 

Objective Bariatric surgery can rapidly improve glycemic control and cardiovascular risk factors in severely obese patients with type 2 diabetes. However, there is no data in non-obese patients. This observational study was designed to compare the changes of body weight and lipid profiles in obese and non-obese patients after gastric bypass surgery.

Methods In this study, 116 patients, who received laparoscopic gastric bypass surgery due to early gastric cancer and were not treated with chemotherapy, were included. Number of patients with body-mass index (BMI) of < 25 was 75 (64.7%). Body weight and lipid profiles at baseline (pre-operatively) and at follow-up (3, 6, 9, and 12 months) after surgery were collected.

Results In total patients, mean age was 59.57 ± 13.27 years old and mean BMI was 23.50 ± 3.44. The majority was male (72.4%). There were significant reductions in the body weight at 3, 6, 9, 12 months after surgery (P < 0.01). In the lipid profiles, triglyceride levels significantly decreased after surgery. Total cholesterol and LDL cholesterol levels also decreased after surgery. However, there were no statistical differences at 9 and 12 months after surgery in total cholesterol, and at 6, 9, and 12 months after surgery in LDL cholesterol. HDL cholesterol levels significantly increased at follow-up after surgery. However, there was no statistical difference at 3 months after surgery. In patients with BMI of < 25, mean age 59.72 ± 14.11 years old and mean BMI was 21.48 ± 2.28. Body weight significantly reduced after surgery (P < 0.01). Triglyceride levels significantly decreased after surgery. LDL cholesterol levels also decreased after surgery. However, there were no statistical differences. Reductions in total cholesterol levels after surgery had statistical significance at 6 months after surgery. Increments in HDL cholesterol levels after surgery had statistical significance at 9 and 12 months after surgery. In patients with BMI of ≥ 25, mean age was 59.29 ± 29 years old and mean BMI was 27.19 ± 1.65. There were significant reductions in body weight and triglyceride levels after surgery. Total cholesterol and LDL cholesterol levels decreased after surgery. However, there were statistical differences only at 3 months after surgery in total cholesterol and LDL cholesterol. Same as patients with BMI of > 25, increments in HDL cholesterol levels after surgery had statistical significance at 9 and 12 months after surgery.

Conclusion In this study, we observed that changes of body weight and lipid profiles in obese and non-obese patients after gastric bypass surgery were similar.

 

Nothing to Disclose: JHP, DSK, SH, CBL, YP, WHC, YHA

15881 3.0000 SUN-0894 A Comparison of Changes in Obese and Non-Obese Patients after Gastric Bypass Surgery 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0891-0905 5061 1:00:00 PM Human Obesity: Targets and Therapies Poster

Ahmad Haider*1, Aksam A Yassin2, Gheorghe Doros3, Abdulmaged M Traish4 and Farid Saad5
1Private Urology Practice, Bremerhaven, Germany, 2Institute of Urology and Andrology, Norderstedt, Germany, 3Boston University School of Public Health, Boston, MA, 4Boston University School of Medicine, Boston, MA, 5Bayer Pharma AG, Berlin, Germany

 

Introduction: Studies show inverse associations between testosterone and the MetS. 

Methods: 362 men with obesity grade I (BMI 30-34.9), grade II (BMI 35-39.9) and grade III (BMI ≥ 40 kg/m2) from two prospective, cumulative registry studies of 561 hypogonadal men received TU injections for up to 6 years.   

Results:

Grade I (n=185, mean age: 58.4±8.0 years): Fasting glucose (mg/dl) decreased from 107.22±30.2 to 97.87±14.42, change from baseline -8.37±1.83 mg/dl, HbA1c (%) from 6.58±1.24 to 5.6±0.76, change from baseline -1.05±0.06%. Total cholesterol (TC; mg/dl) decreased from 268.43±44.24 to 191.47±16.8, LDL (mg/dl) from 158.75±32.82 to 116.26±34.65, triglycerides (TG; mg/dl) from 257.49±62.1 to 193.23±29.01. HDL (mg/dl) increased from 46.53±15.93 to 56.09±15.71. The TC:HDL ratio declined from 6.39±2.41 to 3.64±0.87. Systolic blood pressure (SBP; mmHg) decreased from 143.96±15.09 to 130.11±8.95, diastolic blood pressure (DBP) from 85.54±10.84 to 78.23±5.82. C-reactive protein (CRP, mg/L) declined from 2.11±2.36 to 0.58±0.46 (p<0.0001 for all).

Grade II (n=131, 60.6±5.6 years): Fasting glucose (mg/dl) decreased from 114.17±27.04 to 99.3±11.49, change from baseline -14.83±2.19 mg/dl, HbA1c (%) from 7.63±1.31 to 5.9±0.73, change from baseline -1.69±0.07%. TC (mg/dl) decreased from 292.23±41.07 to 196.78±19.85, LDL (mg/dl) from 174.5±28.46 to 125.86±35.8, TG (mg/dl) from 292.12±61.15 to 194.19±20.66. HDL (mg/dl) increased from 57.35±19.17 to 67.41±18.82. The TC:HDL ratio declined from 5.86±2.76 to 3.2±1.12. SBP (mmHg) decreased from 159.15±14.71 to 135.26±10.97, DBP from 95.02±11.86 to 79.66±4.96. CRP (mg/L) declined from 3.34±4.6 to 0.69±0.97 (p<0.0001 for all).

Grade III (n=46, 60.3±5.4 years): Fasting glucose (mg/dl) decreased from 115.48±23.85 to 96.54±2.9, change from baseline -18.48±2.96 mg/dl, HbA1c (%) from 7.57±1.38 to 6.08±0.5, change from baseline -1.61±0.13%. TC (mg/dl) decreased from 306.76±43.03 to 192.23±9.17, LDL (mg/dl) from 190.57±36.6 to 136.24±28.07, TG (mg/dl) from 326.87±60.21 to 194.4±12.59. HDL (mg/dl) increased from 62.76±18.7 to 72.55±13.34. The TC:HDL ratio declined from 5.47±2.57 to 2.75±0.59. SBP (mmHg) decreased from 161.04±14.3 to 142.05±9.57, DBP from 97.07±10.91 to 80.89±6.76. CRP (mg/L) declined from 3.96±4.31 to 0.57±0.59 (p<0.0001 for all).

Conclusions: All changes were meaningful and sustained for the full observation time. TRT seems to be effective to improve MetS and cardiovascular risk profile in obese hypogonadal men.

 

Disclosure: AH: Speaker, Bayer Schering Pharma, Speaker, Takeda. AAY: Speaker, Bayer Schering Pharma, Speaker, Ferring Pharmaceuticals. GD: Coinvestigator, Bayer Schering Pharma. FS: Employee, Bayer Schering Pharma. Nothing to Disclose: AMT

13212 4.0000 SUN-0895 A Improvement of Metabolic Syndrome (MetS) Parameters in 362 Obese Hypogonadal Men upon Long-Term Treatment with Testosterone Undecanoate (TU) Injections: Observational Data from Two Registry Studies 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0891-0905 5061 1:00:00 PM Human Obesity: Targets and Therapies Poster

Yonit Marcus*1, Jessica Sack2, Elad Segev3, Brurya Tal2, Galina Shenkerman2, Rona Limor4, Karen Michele Tordjman2, Gabi Shefer5 and Naftali Stern2
1Tel Aviv Medical Center, Tal Aviv, Israel, 2Tel Aviv Medical Center, Tel Aviv, Israel, 3Holon Institute of Technlogy, Holon, Israel, 4Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, 5Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel

 

Background: Recommended treatment for metabolic syndrome (MetS) patients is a combination of proper diet with exercise. Most attempted weight loss periods terminate in subsequent weight regaining. Muscle loss during diet occurs often, thus repeated weight loss attempts could lead to increasing sarcopenia, frailty and disability. Here we assessed the effect of a 1-year multidisciplinary intensive intervention program on body composition and metabolic outcome.

Methods: Thirty-eight patients that completed 1 year of intervention involving frequent interaction with physicians, a dietician and physiologist. Patients' ages were 19-71 years, median age ~53. Nine men and 8 women were above and 12 men and 6 women below median age. Body composition was determined based on DEXA scans done at the beginning and the end of 1-year intervention.

Results: Women and men younger than 53 years lost 11 and 10% of their body weight, respectively, while older than 53-year-old subjects lost only about 6% of their body weight. Younger women and men lost about 17% of their fat mass but only 10 and 15%, respectively, at older age. As for lean mass loss, younger men lost less than women (1% vs. 5%), where both older men and women lost 3% of their lean mass. Strikingly all subjects that gained or lost less than 2.9% lean (median value of % lean loss) were exclusively those engaged in physical activity prior to intervention, and continued throughout this year (χ², p<0.001).

Conclusions: During intensive weight-loss supervised by a multidisciplinary team according to current "best practice" guidelines: a) young and older men can lose weight without obligatory lean mass loss; b) young and older women tend to lose lean mass (muscle), along with fat loss, unless they engaged in physical activity prior to the attempted weight loss. We submit that to preserve muscle in MetS, irrespective of age, exercise should precede the initiation of weight loss and not be started coincident with diet.

 

Nothing to Disclose: YM, JS, ES, BT, GS, RL, KMT, GS, NS

13347 5.0000 SUN-0896 A Exercise First, Diet Later: Exercise Prior to Diet Protects Subjects with the Metabolic Syndrome from Muscle Loss, Independent of Age/Gender 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0891-0905 5061 1:00:00 PM Human Obesity: Targets and Therapies Poster

Arne Astrup1, Mette Kristensen1, Lucio Gnessi2, Mikiko Watanabe2, Stepan Svacina3, Martin Matoulek3, Pavol Hlubik4, Hana Stritecka5, Franco Contaldo6, Fabrizio Pasanisi6, Hassan M Heshmati*7, Yishai Zohar7, Eyal S Ron7, Alessandro Sannino8, Christian Demitri8 and Cosimo Saponaro8
1University of Copenhagen, Frederiksberg C, Denmark, 2Policlinico Umberto I, Rome, Italy, 3General Hospital in Prague, Prague, Czech Republic, 4Nutrition Disorder Center, Hradec Kralove, Czech Republic, 5Faculty of Military Health Sciences, Hradec Kralove, Czech Republic, 6Federico II University Hospital, Naples, Italy, 7Gelesis, Boston, MA, 8Gelesis, Lecce, Italy

 

The effect on body weight of chronic oral administration of Gelesis100, a novel hydrogel, was assessed in 128 non-diabetic overweight and obese subjects randomized to two Gelesis100 arms (2.25 g twice daily, n = 43 and 3.75 g twice daily, n = 42) and a placebo arm (n = 43). Treatment was administered in capsules with 500 mL of water before lunch and dinner, in a double-blind, parallel-group fashion, over 12 weeks, in subjects on hypocaloric diet (-600 kcal/day). Statistical analysis used analysis of covariance model with baseline weight, gender, and body mass index (BMI) as covariates, comparing Gelesis100 arms to placebo arm. One hundred twenty-five subjects had at least one post-baseline body weight assessment (intention-to-treat “ITT” population). The ITT population included 40 males and 85 females, with a mean age ± standard deviation (SD) of 44 ± 12 years and a mean BMI ± SD of 31.7 ± 2.4. One hundred ten subjects completed the treatment. Dropout rates were 5%, 24%, and 21%, with Gelesis100 2.25 g, Gelesis100 3.75 g, and placebo, respectively. One hundred twenty-six subjects provided safety data. In the ITT population, the mean ± SD body weight percent changes from baseline to the end of treatment were -6.1 ± 5.1%, -4.5 ± 4.5%, and -4.1 ± 4.4%, with Gelesis100 2.25 g, Gelesis100 3.75 g, and placebo, respectively. Weight loss was statistically significant with Gelesis100 2.25 g (P = 0.026). Lower tolerability and compliance may explain the observed efficacy result with Gelesis100 3.75 g. The extent of weight loss was more pronounced in subjects on Gelesis100 2.25 g with high fasting glucose (> median, 5.15 mmol/L) at baseline (-8.2 ± 5.3%; P = 0.006), especially in those with impaired fasting glucose at baseline (-10.9 ± 4.3%; P = 0.019). There was a significant negative correlation between fasting glucose at baseline and change in body weight in Gelesis100 2.25 g arm (r = -0.50; P < 0.001) contrasting with a lack of correlation in placebo arm (r = -0.06; P = 0.708). The most common adverse events (AEs) were bloating, flatulence, abdominal pain, and diarrhea, with lower prevalence in Gelesis100 2.25 g arm compared to placebo and Gelesis100 3.75 g arms. Serious AEs were observed in 3 subjects on placebo (gallstone and abdominal pain). In conclusion, chronic administration of Gelesis100 (2.25 g twice daily) to overweight and obese subjects significantly decreases the body weight, especially in subjects with impaired fasting glucose at baseline. The treatment is safe and well tolerated. Gelesis100 can be considered as a promising new therapy for obesity and a tool for weight management. If confirmed in subsequent studies, Gelesis100 has also the potential to induce dramatic weight loss in overweight and obese subjects with type 2 diabetes.

 

Disclosure: AA: , Gelesis. HMH: Consultant, Gelesis. YZ: Founder, Gelesis. ESR: Management Position, Gelesis. AS: Researcher, Gelesis. CD: Researcher, Gelesis. CS: Management Position, Gelesis. Nothing to Disclose: MK, LG, MW, SS, MM, PH, HS, FC, FP

13676 6.0000 SUN-0897 A Oral Administration of Gelesis100, a Novel Hydrogel, Significantly Decreases Body Weight in Overweight and Obese Subjects 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0891-0905 5061 1:00:00 PM Human Obesity: Targets and Therapies Poster

Jay Toulany*1, Yan Wang1, Catherine Brown2, Kathryn Slayter3, Shelly McNeil2 and Kerry B Goralski1
1Dalhousie University, Halifax, NS, Canada, 2IWK Health Centre, Halifax, NS, Canada, 3Capital District Health Authority Halifax Infirmary, Halifax, NS, Canada

 

Background: Prochemerin is an inactive adipokine precursor that is released from fat cells and cleaved by extracellular proteases to active chemerin, which exerts effects on inflammation, metabolism and cell differentiation, proliferation, and migration via binding to the chemokine-like receptor 1(CMKLR1). Plasma and serum total chemerin (prochemerin + active chemerin) is increased in obese humans suggesting that chemerin may contribute to obesity-associated diseases. The effect of obesity on the production of active chemerin is unknown, given a lack of assays that specifically measure active chemerin in biological fluids. 

Objectives: 1) To develop a cell-based biological assay to measure active chemerin in human plasma and serum and 2) to utilize this assay to determine if obesity specifically increases the formation of active chemerin in fasted and fed states

Methods: The pilot study was approved by the IWK Research Ethics Board and involved a clinical population comprised of two groups categorized by body mass index (BMI); normal weight (BMI 20-25, n=4) and obese (BMI >30, n=4). Blood samples were collected after an overnight fast at 07:00 and 08:00 AM and following breakfast at 8:30, 09:00, 9:30, 10:00, 11:00, 12:00 and 13:00. A cell-based CMKLR1 biological assay and ELISA were used, respectively, to determine the active and total chemerin concentrations in plasma and serum samples. 

Results: The average active chemerin concentration over all time points was higher (P<0.001) in obese vs. normal weight subjects in serum (8.50 ± 0.59 nM vs. 6.52 ± 0.34 nM) and plasma (6.28 ± 0.59 nM vs. 3.93 ± 0.71 nM). There were no significant changes in plasa and serum active chemerin  in the post-prandial period. The correlation between active chemerin and obesity was increased substantially in plasma and serum when subjects were categorized as obese or normal weight according to waist to hip ratio (r = 0.827 and 0.877) instead of BMI (r = 0.568 and 0.693). The ratio of active to total chemerin in the serum of the normal weight group was higher (P< 0.01) than the obese group (59.9 ± 4.4 % vs. 47.5 ± 3.5 %).

Conclusions: Based on the results of our study, we conclude that active chemerin is elevated in the plasma and serum of obese humans. The higher correlation between active chemerin and waist-to-hip ratio supports that increased active chemerin is strongly linked to central obesity. The difference in active/total chemerin ratios in serum supports the potential for modified chemerin signaling and function in obese individuals.

 

Nothing to Disclose: JT, YW, CB, KS, SM, KBG

11894 7.0000 SUN-0898 A The Plasma and Serum Concentrations of Active Chemerin Are Elevated in Obese Humans 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0891-0905 5061 1:00:00 PM Human Obesity: Targets and Therapies Poster

Yonit Marcus*1, Elad Segev2, Gabi Shefer3, Jessica Sack4, Brurya Tal4, Mariana Yaron5, Eliezer Carmeli6, Yael Sofer7, Miri Margaliot4 and Naftali Stern4
1Tel Aviv Medical Center, Tal Aviv, Israel, 2Holon Institute of Technlogy, Holon, Israel, 3Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel, 4Tel Aviv Medical Center, Tel Aviv, Israel, 5Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, 6University of Haifa, Haifa, Israel, 7Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

 

Background: Intentional weight loss induces favorable cardiovascular (CV) effects secondary to fat mass reduction. However, the CV impact of reduction in lean body mass, which often accompanies weight loss, has not been explored. Muscle disintegration could elicit inflammation with adverse systemic effects, potentially affecting the vasculature.

Aims: To examine the relationship between lean/ fat mass loss, blood pressure (BP) and intima-media thickness (IMT) during 1 year of exercise/diet treatment in patients with the metabolic syndrome (MetS).

Methods: Thirty-eight subjects with MetS participated in a multidisciplinary program targeting all known risk factors with emphasis on diet and exercise. Carotid intima media thickness (IMT), 24h ambulatory BP monitoring (ABPM), central BP and body composition by DEXA, were evaluated before the intervention and 1 year later.

Results: Predictably, men with larger fat mass reduction (>12.5%) enjoyed significant reduction in ABPM systolic pressure (-11 mmHg; p<0.03). However, compared to men showing good muscle preservation (gain or loss<2.9% in lean mass) men with notable lean mass depletion (>2.9%) showed (1) no decline in central systolic BP (+2mmHg vs. -21mmHg; p<0.0033); (2) no reduction in IMT (+54um vs. -29um; p<0.033). Likewise, women with significant lean mass loss showed no decline in mean ABPM diastolic pressure.

Conclusions: The loss of lean body mass during treatment of the MetS is associated with negative effects on BP and IMT, particularly in men. This novel association should draw attention to the possibility that muscle preservation may be important for cardiovascular outcome during intentional weight loss.

 

Nothing to Disclose: YM, ES, GS, JS, BT, MY, EC, YS, MM, NS

13352 8.0000 SUN-0899 A Lean Mass Loss during the Metabolic-Syndrome Treatment Has Unfavorable Cardiovascular Effects Negating Benefits Attained By Fat Mass Loss 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0891-0905 5061 1:00:00 PM Human Obesity: Targets and Therapies Poster

Guanghui Li*1, Li Zhang2, Lijun Kong1, Ling Fan1, Weiyuan Zhang3 and James C Rose4
1Beijing Obstetrics and Gynecology Hospital,Capital Medical University, Beijing, China, 2Beijing Obstetrcis and Gynecology Hospital,Capital Medical University, Beijing, China, 3Beijing Obstetrics and Gynecology Hospital,Capital Medical University, 4Wake Forest School of Med, Winston Salem, NC

 

ABSTRACT

Background: Maternal obesity is associated with higher risks of adverse maternal and fetal complications, but the effect of dietary and lifestyle interventions for obese pregnant women on gestational weight gain(GWG) and pregnancy outcomes is unclear.

Objective: This study examined whether an intensive dietary and lifestyle intervention in the early pregnancy performed in obese pregnant women could effectively decrease GWG,and prevent relevant adverse pregnancy outcomes.

Methods: 258 obese pregnant Chinese women were enrolled in the randomized controlled trial at 6-12 weeks of gestation. Participants were randomly assigned to the standard care (n=72) or the intervention groups(n=141). The intervention focused on restricting energy intake combined with behavioral lifestyle modification through participation in group sessions and individual counseling. Obese pregnant women in the intervention group were advised to record in a dietary diary, physical activity and weekly weight gain. They met the obstetrician at least 5 times face to face including 3 or more times before OGTT was performed at 24-28weeksof gestation. The primary outcomes were gestational weight gain and the incidence of GDM, pregnancy hypertensive disorders,large-for-gestational-age(LGA) infants, macrosomia and the rate of caesarian section.

Results: Adherent participants(n=68) had a significantly decreased total GWG compared with the non-adherent and the control groups(10.83Kg in the adherence group,14.13Kg in the non-adherence group,14.10Kg in the standard care group,p=0.001). The GWG before OGTT was preformed was less in the adherence group(4.79Kg) than in the non-adherent group(6.9kg) and the standard care group(6.7kg ) p=0.005. Mild pre-eclampsia was reduced in the adherence group(0.0%), compared to  the non-adherence group(2.7%), and the standard group(6.9%),p=0.031.The incidence of macrosomia  was  decreased in the adherence group. ( 7.4% in the adherence group, 27.4% in the non-adherence group,25.0% in the standard care group,p=0.006).A significant lower incidence of LGA infants was also detected in the in the adherence group.(10.3% in the adherence group, 32.9% in the non-adherence, 25.0% in the standard care group,p=0.006).No significant difference was observed in other maternal and fetal complications.

Conclusions: The study showed that the intensive dietary and lifestyle intervention performed from the first trimester in obese women could significantly decrease total GWG, and reduce  the risk of developing mild pre-eclampsia, macrosomia, and LGA infants. The intervention did not result in adverse effects on fetal growth and maternal and fetal complications.

Key words:pregnancy; obesity; dietary intervention; lifestyle intervention; weight gain;pregnancy outcomes

 

Nothing to Disclose: GL, LZ, LK, LF, WZ, JCR

15059 9.0000 SUN-0900 A Effects of Dietary and Lifestyle Intervention in Obese Pregnant Women on Gestational Weight Gain and Pregnancy Outcomes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0891-0905 5061 1:00:00 PM Human Obesity: Targets and Therapies Poster

Daria Gusakova*1, Svetlana Kalinchenko2, George Mskhalaya3, Yuliya Tishova4 and Armais Kamalov5
1Research Institute of Urology, Moscow, Russia, 2People's Friendship University of Russia, Moscow, Russia, 3Center for Reproductive Medicine MAMA, Moscow, Russia, 4People`s Friendship University, Moscow, Russia, 5Moscow State University, Moscow, Russia

 

Background and aims: In recent years there is an increasing number of studies paying attention to the relationship of metabolic syndrome (MS) and urolithiasis. Components of MS such as abdominal obesity, hypertension, hyperglycemia and diabetes mellitus (DM) type 2 are independently associated with an increased risk of urolithiasis. Testosterone deficiency treatment in men with MS may also have an impact on the risk factors of urolithiasis associated with MS.

Methods: 65 men with MS and hypogonadism (20 – 65 years old) were included in this study. All patients were divided into 2 groups: the treatment group (40 men), who received i/m testosterone injections (testosterone undecanoate 1000 mg or testosterone esters 250 mg) and the control group (25 men). pH of morning urine sample, serum concentration and 24-hour excretion of uric acid, calcium, magnesium, and phosphate were measured before the treatment and after 24 weeks of therapy.

Data is presented as a median and quartile range. Statistical analysis was made using Wilcoxon test.

Results: Normalization of testosterone levels was achieved in all patients in the treatment group - total testosterone - 18.0 [15.3 ; 20.8] nmol/l , p <0,001. In the control group total testosterone remained below normal limit - 9.0 [7.1, 10.5] nmol/l , p = 0,92. There was a significant decrease in serum uric acid concentration from 440.0 [389.4 , 515.0] to 403.0 [382.0 , 465.0] mmol/l (p <0,001) and uric acid excretion from 4.9 [4.0 , 5.7] to 4.2 [4.0 , 5.1] mmol/day (p = 0.009 ) in the treatment group as well as an increase in  pH of morning urine sample from 5.5 [5.0 , 5.5] to 6,0 [5,8; 6,4] (p <0,001). There was also a slight but significant increase of serum magnesium concentration in the treatment group from 0.89 [0.83, 0.99] to 1.00 [0.89, 1.02] mmol/l (p = 0,018) without any changes of its excretion. No significant changes in the study parameters were observed in the control group. Serum calcium and phosphate levels as well as their excretion with the urine did not change.

Conclusion: Testosterone treatment in hypogonadal men with MS may not only improve the basic anthropometric parameters of MS, but may also be the key to solving the problem of urolithiasis in these patients considering pathogenetic relationship of these conditions.

 

Nothing to Disclose: DG, SK, GM, YT, AK

16689 10.0000 SUN-0901 A Effects of Testosterone Supplementation on Laboratory Risk Factors of Urolithiasis in Hypogonadal Men with Metabolic Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0891-0905 5061 1:00:00 PM Human Obesity: Targets and Therapies Poster

Maria Victoria Marcos1, Nuria Sanz*2, Juan Manuel Rodriguez3, Consol Sanchez4, Lourdes Ibáñez5, Corpus Marzo6, Angeles Buj7 and M.Jesus Asencio7
1Hospital de Terrassa, Terrassa, Spain, 2Hospital Sant Joan de Deu, Barcelona, 3ICS CAP Creu Alta, Terrassa, Spain, 4Hospital de Terrassa, Terrassa, 5Hospital Sant Joan de Deu, Barcelona, Spain, 6ICS CAP Creu Alta, 7CAP Sant Llàtzer

 

Background: 

Infantile obesity is nowadays a pandemic disease and needs a paediatrician interventional attitude. Since 1990 until 2010 it has trebled and the World Health Organization  recommens prevention “as soon as possible” even during the first year of life. A spanish study (Aladino 2011) stimated the prevalence of overweight in boys as a 26,3% and in girls a 25,9% and the prevalence of obesity as a  22% and  a 16,2% respectively. Our aim was to set up a new SCORE to be applied to the newborn at birth, calculating risk of obesity,  and to be correlated with the obesity/overweight future outcomes. There is not a precedent of using this kind of tool in the spanish population. Our hypothesis is that the child’s background can predict obesity during infancy and consequently adulthood. 

Patients and methods:  

The study population consisted of healthy newborns recruited at two healthcare centres of two districts in the area of Barcelona. The SCORE was calculated adding  the punctuation obtained in three sections: 1) family background [4-27 points] (social, job state, career education, toxic habits and obesity in parents) , 2) prenatal [1-7 points] ( ponderal gain and complications during pregnancy)  and 3) neonatal [1-4]  determinants (birthweight adjusted for sex and gestational age). The highest SCORE possible is 38 points,  meaning higher risk of obesity in the future and the lowest 6 points.  The patients are planned to be followed in clinics 10 times over the 4 years of life and will  be divided at random into two groups: one receiving usual care advices  and the other receiving gradually additional information about a healthy lifestyle to prevent obesity.

Preliminary Results:

A total of 96  healthy newborns have been already recruited ( 59.8 % male) during a period of six months with a birthweight mean of 3323 gr (+/- 0.416). The total mean SCORE was 11.4 (+/-3.4)  and if we consider the different sections of the SCORE the results expressed by mean +/- standard error of the mean are: Family background 8.7 (+/-3.1), Prenatal factors 2.2 (+/-0.08) and Neonatal factors 0.6 (+/-0.1) . In this sample there was no association found between the total SCORE either the Family Background section and birthweight. 

Conclusion

This study is the first relating a new SCORE with birthweight, pointing that infantile obesity is not programmed at birth, but is built during the firsts years of life. So on, following up these children and offering some interventions will help us to better understand the origins of this new pandemic. 

 

Nothing to Disclose: MVM, NS, JMR, CS, LI, CM, AB, MJA

14748 11.0000 SUN-0902 A From the Need of Preventing Infantile Obesity As Soon As Possible: A New Score at Birth 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0891-0905 5061 1:00:00 PM Human Obesity: Targets and Therapies Poster

Mohammed S Albadah1, Hafedh Dekhil1, Shaffi Ahamed Shaik1, Mohammed A Alsaif2, Mustafa Shogair1 and Assim A Alfadda*1
1College of Medicine, King Saud University, Riyadh, Saudi Arabia, 2College of Applied Medical Sciences, Riyadh, Saudi Arabia

 

Background

Weight loss improves metabolic fitness and reduces morbidity and mortality associated with obesity. Although the mechanism of this remains unclear, evidence suggest that adipokines may play a role. Recently, it has been shown that skeletal system also plays a role in the regulation of body energy and glucose metabolism.

Objectives

To determine the effect of weight loss on circulating osteocalcin and its association with serum adipokines and other metabolic risk factors.

Subjects and Methods

A prospective study of 49 obese non-diabetic male subjects (mean age 32.3 ± 8.7 years) was conducted at the Obesity Research Center, King Saud University, Riyadh. Each subject gave their written informed consent and the project was approved by the local Ethics Committee. Subjects were given instructions folder listing different combinations of meals and snacks that collectively would provide 1,500 Kcal/day. They then used their food lists to self-select three meals and two snacks a day during the sixteen-week duration of the study. Follow up telephone calls were made once every two weeks to ensure compliance. Subjects were also advised at the first visit to maintain a healthy lifestyle in general, but they did not participate in any organized physical activity programs. Selected serum adipokines, several metabolic parameters,  and total, undercarboxylated and carboxylated osteocalcin were measured before and after intervention.

Results

Subjects had lost significant weight with the dietary intervention (BMI 39.72 ± 7.58 pre-intervention vs. 37.83 ± 7.61 kg/m2 post-intervention, P=0.000). There was significant reduction following weight loss in waist circumference, total cholesterol, LDL-cholesterol, fasting blood glucose, HOMA-IR, bone specific alkaline phosphatase, and serum resistin levels. On the other hand, serum adiponectin levels had increased significantly following weight loss. There was no significant changes in the levels of CRP, HDL-cholesterol, triglycerides, vitamin D, total, carboxylated, and undercarboxylated osteocalcin, and undercarboxylated to total osteocalcin ratio.      

Conclusions

Although, modest weight reduction after a dietary program was associated with significant improvement in several metabolic parameters, this seems not to affect different forms of circulating osteocalcin (total, undercarboxylated, and carboxylated) nor the undercarboxylated to total osteocalcin ratio.

 

Nothing to Disclose: MSA, HD, SAS, MAA, MS, AAA

13582 12.0000 SUN-0903 A The Effect of Weight Loss on Serum Osteocalcin and Its Association with Serum Adipokines in Obese Adults 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0891-0905 5061 1:00:00 PM Human Obesity: Targets and Therapies Poster

Mithat Bahceci1, Mustafa Demirpence1, Pelin Tutuncuoglu*2, Nesil Gören3, Hüsnü Yilmaz3 and Gonca Oruk1
1Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey, 2Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey, 3Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey

 

Background and aims: GLP-1 receptor agonists were associated with significant weight loss in diabetic patients, raising the question of whether these agents could be used for weight loss in patients without diabetes. We aimed to determine the effect of exenatide on body weight during 12 monthly treatment period.

Subjects and methods: Newly diagnosed obese (BMI≥35kg/m2) 34 type 2 diabetic patients (47.8±12.6 yr) were included. Exenatide therapy was started with 5μg b.i.d in addition to metformin (2 gr/day). At the 1st month of treatment an additional visit was scheduled  to verify the compliance to drug prescription and the occurrence of possible side effects. Exenatide dosage was increased to 10 μg b.i.d (20 μg/day) in appropriate patients at the end of 1st month of treatment. Serum fasting and postprandial glucose, HbA1c, lipid levels; and body weight and body mass index (BMI) were measured in four visits (baseline, 3rd, 6th and 12th month of treatment).

Statistical analysis: All result were expressed is mean ±standard deviation. Paried Samples test was used in the comparison of control in patient. Relationships between variables were evaluated with Paried Samples test. P<0,05 values were accepted as statistically significant.

Results: Mean  A1c levels (from 8,17± 1,83%    to 6,75± 1,08), fasting (from 186,84± 59,7 mg/dL to118,93 ± 16,74 mg/dL and postprandial glucose levels showed significant decrements (from 254,30±86,6 to141,77 ± 19,9). In addition,  body weight (from 126,2±28,9 kg to112,4±28,1   and BMI values showed significant improvements (from 48,1± 9,88 kg/m2 to43,8± 9,39) with a yearly exenatide treatment. During the treatment  period we did not observe and significant hepatic dysfunction, pancreatitis or  increment in serum calcitonin levels.

Conclusion: Exenatide  treatment restores not only glyceamic control, but also it leads to significant weigt loose  type 2 diabetic patients .  It can be used as a anti-obesity drug in suitable cases.

 

Nothing to Disclose: MB, MD, PT, NG, HY, GO

14556 13.0000 SUN-0904 A The Effect of Exenatide Body Weight and Glycaemic Control: It MAY be an ANTI-Obesity Drug 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0891-0905 5061 1:00:00 PM Human Obesity: Targets and Therapies Poster

Daniela Georgina Aguilar-Velázquez*1, Tania Guadalupe Gómez Peralta2, Isela Esther Juárez Rojop3, Telma González Castro4, Lilia López Narváez5, MarÍa ANTONIA Jiménez Santos6, Carlos ALFONZO Tovilla ZÁrate7, Deysi Yadura Bermúdez Ocaña7, Idemi Aguilar Mariscal7 and Esdras Arjona MagaÑa7
1UNIVERSIDAD JUÁREZ AUTÓNOMA DE TABASCO, 2UJAT, México, Mexico, 3UJAT, Mexico, Mexico, 4UJAT, COMALCALCO, Mexico, 5Hospital General de Yajalón. Secretaría de Salud, Yajalón, Chiapas, México, COMALCALCO, Mexico, 6UJAT, VILLAHERMOSA, Mexico, 7UJAT

 

Introduction. Childhood obesity is a public health problem that is increasing worldwide, especially in developed countries. The major risk health problems of childhood obesity are cardiovascular disease (dyslipidemia, hypertension), endocrine dysfunction (type 2 diabetes, glucose intolerance, and insulin resistance) and pulmonary complications (obstructive sleep apnea syndrome, asthma, and exercise intolerance). Mexico is not an exception. Approximately 70% of the Mexican adult population has excessive body weight. The prevalence of obesity and overweight in Mexican school children aged 5–11 is also high: one child in four is overweight. This prevalence represents about 5,664,870 overweight and obese children in school-age at national level. Many studies have indicated an association between increased obesity and short sleeping time. Obesity is a prime factor for lifestyle-related diseases, and leads to the occurrence of heart disease and stroke. Enough sleeping time may be also required for the prevention of obesity.

Objective: The aim of this research was to assess the association between the time of sleep and obesity in middle school students in a Mexican Population.

Methodology: This study was conducted in Comalcalco Tabasco, México from February to November 2013. This cross-sectional study was performed on 841 children enrolled in the six public secondary schools of the city. All students completed a questionnaire administered by trained interviewers focusing on health behaviors related to obesity, such as physical activity, time spent watching TV and time of sleep. A lineal regression was performed to examine the association between BMI and time of sleep. Multivariate analysis was performed for adjusted the OR. 95% confidence intervals were calculated.

Results: Sleeping hours were significantly less in obese children than in non-obese children. Multivariate analysis showed that BMI increased as sleeping time became shorter in the order ≥10, 9-10,8-9, <8. (OR 95% CI 0.06, 0.07 0.10).

Conclusion: This study showed an association between short sleeping time and more obesity in student of secondary school in a Mexican population.

The Author(s) Warrants That the Work in Its Entirety Is Original Except for Those Parts That Are Reproduced or Adapted with Permission from Other Sources and Acknowledged As Such within the Work, That It Has Not Been Published, That All the Facts It Contains Are True and Accurate, and Has Not Been Published Other Than As an Abstract in Any Language or Format and Has Not Been Submitted Elsewhere for Print or Electronic Publication Consideration. the Author(s) Further Warrant That the Work Does Not Contain

 

Nothing to Disclose: DGA, TGG, IEJ, TG, LL, MAJ, CAT, DYB, IA, EA

14923 14.0000 SUN-0905 A Association Between Short Sleeping Time and Obesity in Secondary School Children in Mexico 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM SUN 0891-0905 5061 1:00:00 PM Human Obesity: Targets and Therapies Poster

Matthias Kroiss*1, Silviu Sbiera1, Martin Fassnacht1, Ellen Leich2, Andreas Schirbel1, Laura Wiemer1, Silke Matysik3, Felix Gardill1, Gerhard Liebisch3, Gerd Schmitz3, Andreas Rosenwald2 and Bruno Allolio1
1University Hospital Wuerzburg, Wuerzburg, Germany, 2University of Wuerzburg, Wuerzburg, Germany, 3University Hospital Regensburg, Regensburg, Germany

 

Background: Mitotane is an orphan drug for treatment of adrenocortical carcinoma (ACC). Mitotane leads to frequent and serious adverse effects with a narrow therapeutic window. Despite clinical use for more than 5 decades, its exact molecular mechanism of action is unknown.

Methods and Findings: In NCI-H295 ACC cells, I125-labeled mitotane was rapidly internalized and distributed to endomembranes and mitochondria. Genome-wide gene expression data after treatment of NCI-H295 cells for 6h with 50 µM and 100 µM mitotane showed profound alterations of genes implicated in sterol metabolism and apoptosis. Pathway analyses by MetaCore software revealed significant alterations of 22/53 genes involved in endoplasmic reticulum (ER) stress response. Mitotane dose dependently led to strongly increased expression of ER-stress marker C/EBP homologous protein (CHOP) as demonstrated by immunoblotting and quantitative PCR (fold change 50 µM: 9.5±1.5, 100 µM 13.3±4.1) in NCI-H295R cells. In HeLa epithelial cells similar to most other cell lines tested, CHOP induction was only 2.2±0.1 (50 µM) and 4.4±0.5 fold (100 µM, each p<0.0001 vs. NCI-H295R), in liver HepG2 cells 2.0±0.8 (50 µM, p<0.0001) and 12.5±1.8 fold (100 µM, n.s. vs. NCI-H295R) by quantitative PCR. CHOP-activation was partially blocked by ER-stress inhibitor salubrinal in NCI-H295R cells. Experimental induction of ER-stress with thapsigargin reduced steroid hormone synthesis. With carboxy-H2DCFDA as a tracer, we found time and concentration dependent increase of reactive oxygen species (ROS) in NCI-H295R cells treated with 50 µM (fold change 1.65±0.07) and 100 µM mitotane (2.13±0.10, each p<0.001 vs. control). Using mass spectrometry, we found a dose-dependent increase of free cholesterol in NCI-H295R cells after 6 h mitotane treatment from 50.0±0.92 nmol/mg (control) to 84.9±3.1 nmol/mg at 50 µM and 102.0±7.2 nmol/mg at 100 µM mitotane (each p<0.0001 vs. control). 7β-hydroxycholesterol increased disproportionally from 55±7 pmol/mg to 162±10 pmol/mg at 50 µM and 143±4 pmol/mg at 100 µM mitotane, respectively (p<0.0001 each vs. control, n.s. 50 µM vs. 100 µM). Cholesterol esters were decreased at 0.5 and 2 h of mitotane incubation but increased after 6 h of 100 µM mitotane. No significant alterations of lipid homeostasis by mitotane were observed in the liver HepG2 cell line.

Conclusions: Mitotane induces ER-stress by increasing free cholesterol and oxysterols in adrenocortical NCI-H295 cells which leads to apoptosis and decreased steroid hormone synthesis. This effect appears to be relatively specific for adrenocortical cells since mitotane induced alterations of lipid metabolism and induction of CHOP were less pronounced in most other cell types. This mechanism of action might pave the way for treatment of ACC, e.g. by inhibition of cholesterol esterification.

 

Disclosure: BA: Consultant, Boehringer-Ingelheim, Coinvestigator, HRA-Pharma, Committee Member, Ipsen. Nothing to Disclose: MK, SS, MF, EL, AS, LW, SM, FG, GL, GS, AR

17901 1.0000 LBSU-0819 A Mitotane Blocks Steroidogenesis and Triggers Apoptosis in Adrenocortical Carcinoma Cells through Induction of Endoplasmic Reticulum Stress Via Toxic Lipids 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM LBSU 0819-0823 5237 1:00:00 PM Adrenal/HPA Axis Poster

Stephanie MJ Fliedner*1, Uma Shankavaram2, Abdel Elkahloun3, Hendrik Lehnert1 and Karel Pacak4
1University Medical Center Schleswig-Holstein, Luebeck, Germany, 2National Cancer Institute, National Institutes of Health, 3National Human Genome Research Institute, National Institutes of Health, 4National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD

 

Within the last five years, the number of gene mutations associated with paragangliomas (PGLs) has more than tripled. Strong genotype-phenotype associations have been recognized, indicating the need for identification of individualized treatment approaches.

On the expression level, two main groups of PGLs have been identified, those showing increased expression of hypoxia related genes (pseudo hypoxic PGLs, cluster 1) and kinase signaling genes (cluster 2). The latest addition to the list of gene mutations predisposing to pseudo hypoxic PGLs are stabilizing mutations of hypoxia inducible factor 2 alpha (HIF2A or EPAS1). HIF2A-PGLs are most often multifocal, produce noradrenaline (and adrenaline if adrenal) and metastatic cases have been reported. The afflicted patients often show a syndromic presentation with paragangliomas at young age, duodenal somatostatinomas and polycythemia from early childhood, although in the majority of cases the mutations were found to be somatic.

In order to understand if and how HIF2A PHEOs/PGLs differ from other pseudo hypoxic PGLs on the molecular level we performed a differential gene expression analysis. Six HIF2A PGLs were compared to normal adrenal medulla (n=8) and PGLs with von Hippel-Lindau (VHL, n=13), succinate dehydrogenase B (SDHB, n=18) and D (SDHD, n=14) gene mutations. Significance analysis of microarray with two class option at a false discovery rate below or equal to 0.1 revealed 875 differentially expressed genes in HIF2A PGLs compared to the other pseudo hypoxic PGLs after normalization to adrenal medulla. Unsupervised hierarchical clustering showed that HIF2A PGLs make up a separate cluster from other pseudo hypoxic PGLs. As previously described, SDHB and SDHD abdominal and thoracic PGLs clustered together while SDHD head and neck PGLs and VHL PHEOs fell into separate sub clusters. Prediction analysis of microarray allowed correct classification of all HIF2A samples based on as little as 3 genes (TRHDE, LRRC63, IGSF10) with only one misclassification of a none-HIF2A PGL. A list of 10 most significantly differentially expressed genes was identified and confirmatory qRT-PCR for this HIF2A expression signature was performed. Interestingly, none of these genes have been previously described as HIF2A target genes.

In conclusion, while HIF2A-PGLs clearly qualify as members of the pseudo-hypoxic PGL group, they show a characteristic expression signature that separates them from other pseudo hypoxic PGLs. Unexpectedly, the most significantly differentially expressed genes have not been previously described as HIF target genes.

 

Nothing to Disclose: SMF, US, AE, HL, KP

17998 2.0000 LBSU-0820 A Characteristic Expression Signature of Hypoxia Inducible Factor 2 Alpha Mutation-Related Paragangliomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM LBSU 0819-0823 5237 1:00:00 PM Adrenal/HPA Axis Poster

Guilherme Asmar Alencar*1, Madson Q. Almeida2, Antonio M Lerario3, Gabriela Resende4, Mirian Y Nishi1, Maria Adelaide Albergaria Pereira5, Berenice B Mendonca1 and Maria Candida B V Fragoso5
1Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 2Hospital das Clínicas & Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 3University of São Paulo, Hospital das Clinicas, Brazil, 4Hospital das Clínicas, University of Sao Paulo Medical School, 5Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil

 

Background: Primary macronodular adrenal hyperplasia (PMAH) is considered a rare cause of Cushing's syndrome (CS), but its frequency has been increased lately. A recent report referred that all patients with PMAH harboring ARMC5 mutations presented severe CS and suggested a more aggressive management such as bilateral adrenalectomy for this condition1.Objective: Our aim is to describe the spectrum of CS presentation in a large cohort of Brazilian patients with PMAH due to ARMC5 mutations. Methods: A total of  24 PMAH patients from five non–related Brazilian families and 28 potentially sporadic patients underwent a clinical, hormonal, biochemical analysis, adrenal imaging (CT scan or MRI and/or 18F-FDG PET/CT) and ARMC5 genotype evaluation. The familial cases were actively investigated due to indices cases, and the sporadic cases due to the incidentaloma finding. All patients who had no catabolic signs but only abnormal serum cortisol after DST were classified as having subclinical CS. Results: Ten different ARMC5 inactivating germline mutations (c.2423A>C,p.His808Pro;c.1094T>C,p.Leu365Pro;c.170_171insG,Ile58Asnfs45;c.952C>G,p.Leu318Val;c.1181T>C,p.Leu394Prol;c.1158G>A,p.Trp386*; c.2336C>G,p.Ser779*; c.280_281delTC,p.Ser94Valfs*8;c.1960C>T,p.Arg654;c.476-1G>C) were confirmed in 3 families (21 familial members) and in 7 out of 28 sporadic cases (25%)2. All mutations were considered possible damaging, in three different prediction sites2. The genealogy of the largest family showed that PMAH was inherited in an autosomal dominant pattern, with incomplete penetrance and variable clinical expressivity2. Seven familial cases and four potentially sporadic cases presented with overt Cushing´s syndrome. The other patients (n=17) carriers of ARMC5 mutation had subclinical CS (60 %). The patients with overt CS were treated with total adrenalectomy of the larger adrenal gland and with partial adrenalectomy of the contralateral adrenal (2/3 of the adrenal gland). This approach avoids adrenal insufficiency and until now, no recurrence was observed on follow-up up to 5 years. Conclusion: Subclinical CS is the most common clinical presentation of PMAH due to ARMC5 mutations and incomplete penetrance was also found in familial cases. Therefore, a conservative treatment is more adequate to treat patient’s carriers of ARMC5 mutations than systemic bilateral adrenalectomy.

 

Nothing to Disclose: GAA, MQA, AML, GR, MYN, MAAP, BBM, MCBVF

18028 3.0000 LBSU-0821 A High Frequency of Subclinical Cushing's Syndrome in the Inherited Autosomal Dominant Primary Macronodular Adrenal Hyperplasia Due to ARMC5 Mutations 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM LBSU 0819-0823 5237 1:00:00 PM Adrenal/HPA Axis Poster

Styliani Ourailidou*1, Sevasti Karaliota1, Katia/Catherine P Karalis2, Claire Bastie3 and Dimitris Grammatopoulos4
1Biomedical Research Foundation of the Academy of Athens, Greece, Athens, Greece, 2Biomedical Research Foundation of the Academy of Athens, Greece, Boston, MA, 3Warwick Medical School, coventry, 4Univ of Warwick Biomed Res Inst, Coventry, United Kingdom

 

Corticotropin-Releasing Hormone (CRH) is the master regulator of mammalian stress responses, mediated via activation of the hypothalamic-pituitary-adrenal (HPA) axis. Emerging evidence suggests a critical role of this system in the maintenance of energy balance and homeostasis in response to external and/or internal challenges and CRH appears to regulate, both, energy intake and energy utilization (1). However, the CRH-driven molecular pathways and effectors are not well defined. We hypothesized that CRH actions might involve Fyn kinase, a member of the Src family of non-receptor tyrosine kinases; Fyn has been implicated in a variety of biological processes, such as oligodendroglial development and myelination, T-cell survival and activation of metabolic processes. The latter is supported by the close relationship of Fyn kinase and the insulin signaling pathway and the metabolic phenotype of the Fyn knockout (KO) mice (2). Furthermore, Fyn kinase might also play a critical role in HPA axis function since Fyn KO mice show altered behavioral responses.

We investigated putative CRH – Fyn kinase interactions using the CRH -/-  mouse as an experimental model, which is characterized by glucocorticoid deficiency and blunted response to basal and stress conditions (3).  Fyn mRNA and protein expression was determined with qPCR and immunoblotting in various metabolic tissues. Although similar levels of Fyn expression were detected in white adipose tissue, skeletal muscle and liver, a significant decrease in Fyn expression was identified in the brown adipose tissue (BAT) and the spleen of CRH -/- mice compared to wild-type littermates. Interestingly, corticosterone level normalization in CRH -/- mice did not reverse but further decreased Fyn kinase expression, suggesting a direct inhibitory role for CRH.  Moreover, conditions of BAT activation and increased fat oxidation such as cold exposure, resulted in a 50% decrease in BAT Fyn expression in CRH -/-  mice compared to wild-type littermates. In order to characterise the role of Fyn kinase in brown adipocytes, we used the T37i cell line as an in vitro cellular model of brown adipocyte. Morphological characterisation of cells treated with SU6656 (10nM) during differentiation identified larger cells with increased number of lipid droplets,  suggesting that pharmacological inhibition of Fyn kinase enhanced brown adipocyte differentiation. Previous studies showed that Fyn kinase is necessary for white adipocyte differentiation, therefore this finding might identify  divergent roles for Fyn  in the regulation of white and brown adipocyte differentiation. In conclusion, these findings identify  CRH as an upstream regulator of Fyn kinase expression in brown adipose tissue and this interaction might be important for the control of  brown adipocyte differentiation.

 

Nothing to Disclose: SO, SK, KPK, CB, DG

17994 4.0000 LBSU-0822 A The Crh Knockout Model Identifies Novel Roles for Crh-Mediated Fyn Kinase Pathways in the Control of Brown Adipocyte Biology 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM LBSU 0819-0823 5237 1:00:00 PM Adrenal/HPA Axis Poster

Eva Boonen*, Lies Langouche, Thomas Janssens, Philippe Meersseman, Hilke Vervenne and Greet Van den Berghe
KU Leuven, Leuven, Belgium

 

Introduction: Adrenal insufficiency is considered to be prevalent among critically ill patients, although the pathophysiology, diagnostic criteria and optimal therapeutic strategy remain controversial. During critical illness, reduced cortisol breakdown contributes substantially to elevated plasma cortisol and low plasma corticotrophin (ACTH) concentrations.1 Considering the trophic impact of ACTH on the adrenal cortex, we hypothesized that with longer duration of critical illness, subnormal ACTH adrenocortical stimulation may occur, which may predispose to adrenal insufficiency.

Methods: Adrenal glands were harvested ≤24h of death from 13 patients who died after a long ICU-stay [median 16 IQR (13-21) days], from 27 patients who died after a short ICU-stay [2 (1-5) days] and from 13 control subjects who died suddenly out-of-hospital. Prior glucocorticoid treatment was excluded. Microscopic adrenocortical zonational structure was evaluated by H&E staining. The amount of adrenal cholesterol-esters was determined by Oil-Red-O staining and mRNA expression of ACTH-regulated steroidogenic enzymes was quantified after mRNA quality control.

Results: The adrenocortical zonational structure assessed by H&E staining was disturbed in patients as compared with controls (P<0.0001), with indistinguishable adrenocortical zones only present in long ICU-stay patients (P=0.003 vs. controls). Adrenal glands from long ICU-stay patients, but not those of short ICU-stay patients, contained 21% less protein (P=0.03) and 9% more fluid (P=0.01) than those from controls, while they tended to weigh less for a comparable adrenal surface area.  There was 78% less Oil-Red-O staining in long ICU-stay patients than in controls (P=0.03) and also 78% less than in short-stay patients (P=0.03), the latter similar to controls (P=0.31). The mRNA expression of MC2R, SCARB1, HMGCR, STAR and CYP11A1 was at least 58% lower in long ICU-stay patients than in controls (all P≤0.03), and of MC2R, SCARB1, STAR and CYP11A1 at least 53% lower than in short ICU-stay patients (all P≤0.04), whereas gene expression in short-stay patients was similar to controls.

Conclusion: Depletion of adrenocortical cholesterol esters and reduced expression of ACTH-regulated steroidogenic genes in prolonged, but not acute, critical illness suggest that sustained lack of ACTH-effect may contribute to risk of adrenal insufficiency in long-stay ICU patients.

 

Nothing to Disclose: EB, LL, TJ, PM, HV, GV

17913 5.0000 LBSU-0823 A Impact of Duration of Critical Illness on the Adrenal Glands of Human Intensive Care Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Sunday, June 22nd 3:00:00 PM LBSU 0819-0823 5237 1:00:00 PM Adrenal/HPA Axis Poster

Michael Højby Rasmussen*1, Jurgita Janukonyté2, Marianne C Klose3, Djordje Marina4, Mette H Tanvig5, Lene Finnerup Nielsen1, Charlotte Höybye6, Marianne Andersen7, Ulla Feldt-Rasmussen8 and Jens Sandahl Christiansen9
1Novo Nordisk, 2Aarhus University Hospital, 3Rigshospitalet , University of Copenhagen,, Koebenhavn Oe, Denmark, 4Rigshospitalet , University of Copenhagen,, 5Odense University Hospital, 6Karolinska University Hospital, Stockholm, Sweden, 7Odense University Hospital, Odense C, Denmark, 8Rigshospitalet , University of Copenhagen,, Copenhagen, Denmark, 9Aarhus University Hospital, Aarhus C, Denmark

 

Recombinant human GH (rhGH) replacement therapy in children and adults currently requires daily sc. injections for several years or lifelong, which maybe both inconvenient and distressing for patients. NNC0195-0092 is a reversible albumin-binding growth hormone derivative, developed with the aim of reducing clearance and as consequence of a reversible binding to circulating serum albumin prolonging the pharmacodynamic (PD) effect.

The trial was a randomised, open-labelled, active-controlled, multiple dose, dose-escalating, sequential dose group trial investigating the safety, tolerability, pharmacokinetic (PK) and PD of weekly NNC0195-0092 compared to once daily rhGH. Four (4) cohorts of 8 adults with GHD in each cohort were investigated (in total, 32 AGHD subjects). The subjects enrolled into the trial were on stable GH replacement therapy, either male or female with a BMI between 18.0 to 35.0 kg/m2, age 20 to 70 years, Fourteen days before being randomized the AGHD subjects discontinued their GH replacement therapy. Four escalating doses of NNC0195-0092 were tested; 0.02, 0.04, 0.08 and 0.12 mg kg/week and in each dose-group 8 AGHD subjects were dosed with a subcutaneous administration of NNC0195-0092 (n=6) or daily rhGH (n=2). After 1st and 4th dosing at each dose level the pharmacokinetics and PD (IGF-I, IGFBP-3) were evaluated.

Multiple doses of NNC0195-0092 administered sc. to AGHD subjects were well tolerated at all doses investigated, with no serious safety issues identified. No positive test results for anti NNC0195-0092 antibodies, anti hGH antibodies, or local tolerability issues were observed at any dose level tested. A significant dose-dependent IGF-I response was induced, with elevated IGF-I levels at all dose levels of NNC0195-0092 investigated (0.02, 0.04, 0.08, 0.12 mg/kg). The IGF-I and IGFBP-3 levels were significantly greater for the 0.12mg/kg dose compared to rhGH and 0.02−0.08 mg/kg doses based on comparison of AUC0-168h and Cmax. A clinically relevant IGF-I response was induced by doses up to 0.08 mg/kg.

In conclusion, multiple dosing of NNC0195-0092 administered sc. to adult patients with GHD was well tolerated at all doses investigated. No antibodies or local tolerability issues were observed at any dose level tested. A clear dose-dependent PD response was observed with elevated IGF-I levels at all dose levels. The IGF-I profiles indicate that NNC0195-0092 possesses a very promising sustained once-weekly treatment profile in AGHD.

 

Disclosure: MHR: Employee, Novo Nordisk. JJ: Researcher, Novo Nordisk. LFN: Employee, Novo Nordisk. CH: Coinvestigator, Novo Nordisk. MA: Coinvestigator, Novo Nordisk. UF: Principal Investigator, Novo Nordisk, Principal Investigator, Novartis Pharmaceuticals, Speaker, Pfizer, Inc., Speaker, Novo Nordisk, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Advisory Group Member, Pfizer, Inc.. JSC: Research Funding, Novo Nordisk, Board Member, Novo Nordisk, Board Member, The name is Merck Serono, lectures, Novo Nordisk, lectures, Pfizer, Inc., fees, Eli Lilly & Company. Nothing to Disclose: MCK, DM, MHT

17848 1.0000 LBSU-0377 A A Novel Reversible Albumin-Binding Growth Hormone Derivative Possesses a Promising Once-Weekly Treatment Profile in Aghd 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM LBSU 0377-0378 5242 1:00:00 PM Growth Hormone Signaling Poster

Ki Goosens*, Barbara Gisabella and Jessica Brophy
McGovern Institute, Massachusetts Institute of Technology, Cambridge, MA

 

Growth hormone (GH) exerts pronounced trophic effects in many tissues throughout the body. Although GH is synthesized by the pituitary gland, where it is released into the circulating bloodstream, it is also synthesized within limbic brain areas including the amygdala and the hippocampus, two brain regions that regulate emotional memory. However, very little is known about the role of locally synthesized GH in regulating emotional processing.  Recent studies show that GH expression is enhanced in the amygdala by chronic stress, and is both necessary and sufficient for chronic stress-related enhancement of fear memory in rodents, an animal model of post-traumatic stress disorder (PTSD)1. Despite our understanding of GH signaling in the periphery, it is not clear how GH acts in the amygdala to enhance associative fear learning. One possibility is that, just as GH produces trophic effects in the periphery, it may exert similar trophic effects in the brain.  

To explore the hypothesis that GH produces neurotrophic effects in the adult brain, we used an adeno-associated viral vector to overexpress GH with green florescent protein (GFP) or GFP alone in the basolateral complex of the amygdala (BLA) in rats. Dendritic spines were quantified by combining confocal imaging with three-dimensional dendritic analysis.  We found that growth hormone overexpression significantly enhanced density of dendritic spines on both primary and secondary branches of pyramidal neurons in the BLA.

This suggests that GH potently promotes dendritic spinogenesis in neurons, illuminating a novel role for GH in the adult brain, and provides a potential mechanism by which chronic stress, which enhances GH in the amygdala, could contribute to stress-induced alterations in amygdala morphology and function.

 

Nothing to Disclose: KG, BG, JB

18053 2.0000 LBSU-0378 A Growth Hormone Enhances Amygdala Spine Density and Fear Memory 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Sunday, June 22nd 3:00:00 PM LBSU 0377-0378 5242 1:00:00 PM Growth Hormone Signaling Poster

Francisco J Pasquel1, Priyathama Vellanki*1, Saumeth Cardona2, Isabel Anzola1, Maya Fayfman3, Limin Peng4, Dawn Smiley1 and Guillermo E Umpierrez1
1Emory University, Atlanta, GA, 2Emory University School of Medicine, Atlanta, GA, 3Emory Univeristy, Atlanta, GA, 4Emory Univeristy Rollins School of Public Health

 

Peri-operative hyperglycemia and diabetes (DM) are associated with increased inflammation and higher rates of hospital complications in surgical patients. This prospective randomized trial analyzed the association between glucose control, peri-operative complications and the inflammatory/oxidative state in patients with DM and without history of DM (nonDM) undergoing CABG surgery. Complications were measured by a composite score, which included mortality, wound infection, pneumonia, bacteremia, respiratory failure, acute renal failure and any major cardiovascular events.  Inflammatory and oxidative stress marker levels were measured peri-operatively (preoperative, 3, 5 and 30 days postoperative). Markers of oxidative stress and inflammation included C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), cortisol, 2’-7’-dicholorofluorescin (DCF) and thiobarbituric acid-reactive substances (TBAR).

A total of 302 patients undergoing CABG were randomized to intensive (BG 100-140 mg/dl, n=151) and conservative (BG 141-180 mg/dl, n=151) glucose control.  Of these, 152 patients had DM. Mean ICU daily glucose levels were 132±14 mg/dL for the intensive and 154±16 mg/dl (P<0.001) for the conservative group. There were no differences in the primary outcome, with a similar number of patients in the intensive and conservative groups experiencing ≥ 1 complications (42% vs. 52%, P=0.08). There were no differences in inflammatory and oxidative stress marker levels between the intensive and conservative groups. Preoperative CRP (33.9±56 vs 10.3±15 ug/dl, p=0.002) and TNF-α (13.0±11 vs 8.8±4 pg/ml, p=0.015) were higher in DM compared to nonDM. Preoperative cortisol levels were similar between DM and nonDM groups; however, in the postoperative period, cortisol levels were lower in DM compared to nonDM (22.7±11 vs 27.7±13ug/dl, p=0.012). Day 3 TNF-α levels (11.6±7, vs 9.3±4 pg/ml, p=0.025) and day 30 TNF-α levels were significantly higher in DM (12.8±12 vs 9.7±6 pg/ml, p=0.034).  Preoperative and postoperative IL-6 levels were increased in patients with complications compared to no-complications (Preoperative: p<0.05; postoperative: p<0.001).  Postoperative cortisol and DCF levels were higher in patients with complications ( p<0.05) compared to no-complications. There were no differences in TBAR levels in patients with DM compared nonDM and in patients with complications compared to no-complications.

In summary, we observed no differences in the rate of hospital complications or in the concentration of inflammatory/oxidative stress markers between intensive (100-140 mg/dl) and conservative (141-180 mg/dl) glucose control. Patients with DM or with hospital complications had higher glucose and inflammatory/oxidative stress marker levels compared to those without DM and complications.

 

Disclosure: DS: Principal Investigator, Sanofi, Advisory Group Member, Sanofi. GEU: Principal Investigator, Merck & Co., Principal Investigator, Sanofi, Principal Investigator, Boehringer Ingelheim , Advisory Group Member, Sanofi. Nothing to Disclose: FJP, PV, SC, IA, MF, LP

17902 5.0000 LBSU-1078 A Association of Glycemic Control, Inflammatory Markers and Peri-Operative Complications in Patients Undergoing CABG 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM LBSU 1074-1087 5251 1:00:00 PM Diabetes & Obesity Poster

Elena Barengolts*1, Arfana Kouser2, Subhash C Kukreja3, Yuval Eisenberg1, Irina Ciubotaru3 and Buvana Manickam3
1University of Illinois at Chicago, Chicago, IL, 2Jesse Brown VAMC, Chicago, IL, 3UIC Section of Endocrinology, Chicago, IL

 

Introduction: Minority populations including African American men (AAM) are among those at increased risk for T2DM and are underrepresented in RCT. Addressing disparities in health care research is a mission of the Veterans Health Administration (VHA). This double-blind RCT evaluated vitamin D efficacy for treating early stages of glucose intolerance.

Methods: AAM veterans with dysglycemia (A1C 5.7-6.9% and no anti-T2DM drugs) and hypovitaminosis D (25OHD 5-29 ng/ml) were randomized to receive weekly placebo (PL, N=102) or vitamin D (VD, ergocaciferol 50,000 IU, N=103). All subjects received 400 IU VD. Indices of glucose tolerance were derived from oral glucose tolerance test (OGTT) done at 0 and 12 months; A1C was measured at 0, 6 and 12 months. The OGTT-derived indices were: OGIS=Oral Glucose Insulin Sensitivity (http://webmet.pd.cnr.it/ogis); ISIcom=ISI composite (f=fasting, m=mean: 104/(IfGfImGm)^0.5); ISIif (if=insulin fasting: 1/if); ISIpeak (30=at 30 min, p=peak: 105/((I30*G30)*(Ip*Gp))^0.5); IGIig=Insulinogenic index (I30-If)/(G30-Gf); IGIcg (C=C-peptide: (C30-Cf)/(G30-Gf); GDOGIS= Glucose Disposition: (OGIS)*(IGIcg); GDISIpeak (auc=area under the curve: (ISIpeak)*(IGIauc). Groups were compared in intention-to-treat (ITT) and per-protocol analyses (PPA) (NCT 01375660).

Results: Average 25OHD levels rose from 14 to 20 and 50 ng/ml with average weekly dose of 2,800 and 70,920 IU/week for PL and VD groups, respectively. In ITT changes in indices of insulin sensitivity (Δ-OGIS), insulin secretion (Δ-IGIcg) and glucose disposition (Δ-GDOGIS) were positive in VD and negative in PL with difference reaching significance for Δ-GDOGIS (p=0.04) and marginally significant for Δ-OGIS (p=0.08) and Δ-IGIcg (p=0.07). In PPA, changes in almost all indices were significant or marginally significant; Sensitivity: Δ-OGIS, Δ-ISIcom, Δ-ISIfi, and Δ-ISIpeak, p=0.01, 0.06, 0.09, and 0.07, respectively; Secretion: Δ-IGIcg, p=0.07; Disposition: Δ-GDOGIS and Δ-GDISIpeak, p=0.03 and 0.04, respectively.

There was a small improvement of A1C at 6 months in VD vs PL in ITT (p=0.067), reaching significance in PPA: Δ-A1C +0.06% (PL) vs -0.04% (VD), p=0.02. This change did not persist at 12 months. The proportion of subjects changing from prediabetes to T2DM did not differ, 10% (PL) vs 11% (VD). In impaired fasting glucose (IFG) subgroup, 8% (1/13) and 32% (6/19) subjects in PL vs VD, respectively, reverted from IFG to normal glucose tolerance suggesting that VD mostly affected early stage of T2DM development. Four subjects, 2 in PL and 2 in VD group, had elevated calcium.

Conclusion: Vitamin D in high doses was beneficial and safe for treating early stages of glucose intolerance in AAM with hypovitaminosis D and dysglycemia. Further studies are warranted to confirm that the observed small albeit significant changes would translate into clinically relevant improvement in glycemic status.

 

Nothing to Disclose: EB, AK, SCK, YE, IC, BM

17957 6.0000 LBSU-1079 A High Dose Vitamin D Supplementation for 12 Months Improves Insulin Sensitivity and Glucose Disposition Indices in African American Men with Hypovitaminosis D and Dysglycemia: Results of the D-Vitamin Intervention in Veteran Administration (DIVA) Randomized Clinical Trial (RCT) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM LBSU 1074-1087 5251 1:00:00 PM Diabetes & Obesity Poster

Christopher Simon Kovacs1, Veeraswamy Seshiah2, Ludwig Merker3, Anita Vedel Christiansen4, Flavien Roux5, Afshin Salsali*6, Gabriel Kim6, Peter Stella6, Hans-Juergen Woerle6 and Uli C Broedl6
1Mem Univ of Newfoundland, St John's, Canada, 2Diabetes Care and Research Institute, Chennai, India, 3Diabetes- und Nierenzentrum, Dormagen, Germany, 4Boehringer Ingelheim Danmark A/S, Copenhagen, Denmark, 5Boehringer Ingelheim France SAS, Reims, France, 6Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany

 

Objective: A Phase III double-blind trial, EMPA-REG EXTENDTM PIO (NCT01289990), assessed the long-term safety and efficacy of EMPA as add-on to pioglitazone ± metformin versus placebo in patients with T2DM.

Methods: Of 498 patients randomized and treated with EMPA 10 mg, EMPA 25 mg, or placebo (all as add-on to pioglitazone alone or pioglitazone plus metformin) in a 24-week study (reported as EMPA-REG PIOTM; NCT01210001, reference 1), 61.2% of patients continued in a double-blind extension for ≥52 weeks. Patients were treated until the last patient to enter had completed the trial. Safety was assessed for ≥76 weeks (in all patients who received ≥1 dose of study drug), while efficacy was assessed at week 76. Exploratory efficacy endpoints were changes from baseline (of EMPA-REG PIOTM) in HbA1c, body weight, systolic and diastolic blood pressure (SBP and DBP). The difference between the adjusted means in the placebo and treatment groups was assessed using ANCOVA in patients who received ≥1 dose of study drug and had a baseline HbA1c value, using LOCF.

Results: At week 76, EMPA significantly reduced HbA1c versus placebo, with placebo-adjusted mean changes (95% CI) of ‑0.59% [-0.79, -0.40; p<0.001] and ‑0.69% [-0.88, -0.50; p<0.001] for EMPA 10 mg and 25 mg, respectively; as well as body weight (‑2.0 kg [-2.7, -1.2; p<0.001] and ‑1.7 kg [-2.4, -1.0; p<0.001], respectively). EMPA led to clinically meaningful reductions in BP versus placebo, with placebo-adjusted mean changes (95% CI) in SBP of ‑2.0 mmHg (‑4.5, +0.4) and ‑3.7 mmHg (‑6.1, ‑1.3; p<0.01) for 10 mg and 25 mg, respectively, and in DBP of ‑1.5 mmHg (‑3.0, +0.0) and ‑2.2 (‑3.7, ‑0.7; p<0.01). Adverse events (AEs) were reported in similar proportions of patients on EMPA 25 mg (82.1%) and placebo (82.4%) but a lower proportion on EMPA 10 mg (76.4%). Hypoglycemic AEs (glucose ≤70 mg/dL and/or requiring assistance) were reported in a higher percentage of patients on placebo (4.2%) than EMPA 10 mg (1.8%) or 25 mg (3.0%); 1 patient each on placebo and EMPA 25 mg required assistance. AEs consistent with urinary tract infection were reported in a higher proportion of patients on placebo (26.7%) than EMPA (10 mg, 22.4%; 25 mg 22.0%). AEs consistent with genital infection were reported in more patients on EMPA (10 mg, 10.3%; 25 mg, 4.2%) than placebo (3.0%).

Conclusion: EMPA 10 mg or 25 mg as add-on to pioglitazone ± metformin for ≥76 weeks were well tolerated and reduced HbA1c and weight compared with placebo.

 

Disclosure: CSK: Investigator, Boehringer Ingelheim. LM: Consultant, Boehringer Ingelheim, Investigator, Boehringer Ingelheim, Speaker, Boehringer Ingelheim. AVC: Employee, Boehringer Ingelheim. FR: Employee, Boehringer Ingelheim. AS: Employee, Boehringer Ingelheim. GK: Employee, Boehringer Ingelheim. PS: Employee, Boehringer Ingelheim. HJW: Employee, Boehringer Ingelheim. UCB: Employee, Boehringer Ingelheim. Nothing to Disclose: VS

17992 7.0000 LBSU-1080 A Empagliflozin (EMPA) for ≥76 Weeks As Add-on to Pioglitazone with or without Metformin in Patients with Type 2 Diabetes (T2DM) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM LBSU 1074-1087 5251 1:00:00 PM Diabetes & Obesity Poster

Michael W. Roden1, Jianping Weng2, Ludwig Merker3, Anita Vedel Christiansen4, Flavien Roux5, Afshin Salsali*6, Gabriel Kim6, Peter Stella6, Hans-Juergen Woerle6 and Uli C Broedl6
1German Diabetes Center, Leibniz Center at Heinrich Heine University Düsseldorf, German Center for Diabetes Research (DZD), Düsseldorf, Germany, 2The Third Affiliated Hospital of Sun Yat-sen University, Canton, China, 3Diabetes- und Nierenzentrum, Dormagen, Germany, 4Boehringer Ingelheim Danmark A/S, Copenhagen, Denmark, 5Boehringer Ingelheim France SAS, Reims, France, 6Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany

 

Objective: A Phase III double-blind trial, EMPA-REG EXTENDTM MONO (NCT01289990), assessed the long-term safety and efficacy of EMPA monotherapy versus placebo (PBO) and sitagliptin (SITA) in patients with T2DM.

Methods: Of 899 patients randomized to EMPA 10 mg, EMPA 25 mg, PBO or SITA 100 mg in a 24-week study (reported as EMPA-REG MONOTM, NCT01177813, Ref 1), 68.4% of patients continued in a double-blind extension for ≥52 weeks. Patients were treated until the last patient to enter completed the trial. Safety was assessed for ≥76 weeks (in all patients who received ≥1 dose of study drug), while efficacy was assessed at week 76. Exploratory efficacy endpoints were changes from baseline (of EMPA-REG MONOTM) in HbA1c, body weight, systolic and diastolic blood pressure (SBP and DBP). The difference between the adjusted means in the placebo and treatment groups was assessed with ANCOVA in patients who received ≥1 study drug dose and had a baseline HbA1c value, using LOCF.

Results: At week 76, EMPA 10 mg and 25 mg significantly reduced HbA1c and weight (placebo-adjusted mean change [95% CI]: HbA1c -0.78% [-0.94, -0.63] and -0.89% [-1.04, -0.73], respectively, both p<0.0001; weight -1.8 kg [-2.4, -1.3] and -2.0 kg [-2.6, -1.5], both p<0.0001). EMPA led to clinically meaningful and sustained reductions in SBP vs placebo (placebo-adjusted mean change [95% CI]: -3.4 mmHg [-5.5, -1.2] and -3.4 mmHg [-5.6, -1.2]; both p<0.01). The difference vs SITA in HbA1c at week 76 for EMPA 10 mg and 25 mg [95% CI], respectively, was -0.12% [-0.28, 0.04] and -0.22% [-0.38, -0.07], p<0.01 for 25 mg dose; for weight it was -2.3 kg [-2.9, -1.8] and -2.6 kg [-3.1, -2.0], both p<0.0001; for SBP -3.7 mmHg [-5.9, -1.6] and -3.8 mmHg [-6.0, -1.6], both p<0.001); and for DBP -1.5 mmHg (-2.8, -0.2) -1.6 mmHg (-2.9, -0.2), both p<0.05. AEs were reported in similar proportions of patients on EMPA (76.8–78.0%), PBO (76.4%) and SITA (72.2%). Hypoglycemic AEs (glucose ≤70 mg/dL and/or requiring assistance) were reported in 2 patients (0.9%) in each treatment group; 1 patient on EMPA 10 mg required assistance. AEs consistent with urinary tract infection were reported in similar proportions of patients on EMPA (9.0–9.4%), PBO (10.9%) and SITA (9.0%). AEs consistent with genital infection were reported in more patients on EMPA (5.8–6.3%) than PBO (1.7%) or SITA (0.9%).

Conclusion: EMPA 10 mg or 25 mg as monotherapy for ≥76 weeks were well tolerated and reduced HbA1c, weight and SBP compared with PBO.

 

Disclosure: MWR: Advisory board/speaker's honoraria, Eli Lilly & Company, Investigator, Boehringer Ingelheim. JW: Investigator, Eli Lilly & Company. LM: Consultant, Boehringer Ingelheim, Investigator, Boehringer Ingelheim, Speaker, Boehringer Ingelheim. AVC: Employee, Boehringer Ingelheim. FR: Employee, Boehringer Ingelheim. AS: Employee, Boehringer Ingelheim. GK: Employee, Boehringer Ingelheim. PS: Employee, Boehringer Ingelheim. HJW: Employee, Boehringer Ingelheim. UCB: Employee, Boehringer Ingelheim.

17999 8.0000 LBSU-1081 A Empagliflozin (EMPA) Monotherapy for ≥76 Weeks in Drug-Naïve Patients with Type 2 Diabetes (T2DM) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM LBSU 1074-1087 5251 1:00:00 PM Diabetes & Obesity Poster

Ludwig Merker*1, Hans-Ulrich Haering2, Anita Vedel Christiansen3, Flavien Roux4, Afshin Salsali5, Gabriel Kim5, Thomas Meinicke5, Hans-Juergen Woerle5 and Uli C Broedl5
1Diabetes- und Nierenzentrum, Dormagen, Germany, 2University of Tuebingen, Tuebingen, Germany, 3Boehringer Ingelheim Danmark A/S, Copenhagen, Denmark, 4Boehringer Ingelheim France SAS, Reims, France, 5Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany

 

Objective: A Phase III double-blind trial, EMPA-REG EXTENDTM MET (NCT01289990), assessed the long-term safety and efficacy of EMPA as add-on to metformin versus placebo (PBO) in patients with T2DM.

Methods: Of 637 patients randomized and treated with EMPA 10 mg, EMPA 25 mg, or PBO (all as add-on to stable metformin) in a 24-week study (EMPA-REG METTM; NCT01159600; Reference 1), 72.7% of patients continued in a double-blind extension for ≥52 weeks. Patients were treated until the last patient to enter had completed the trial. Safety was assessed for ≥76 weeks (in all patients who received ≥1 dose of study drug), while efficacy was assessed at week 76. Exploratory efficacy endpoints were changes from baseline (of EMPA-REG METTM) in HbA1c, body weight, systolic and diastolic blood pressure (SBP and DBP). The difference between the adjusted means in the placebo and treatment groups was assessed using ANCOVA in patients who received ≥1 dose of study drug and had a baseline HbA1c value, using LOCF.

Results: At week 76, EMPA 10 mg and 25 mg significantly reduced HbA1c and body weight vs placebo (placebo-adjusted mean change [95% CI]: HbA1c -0.61% [-0.75, -0.46] and -0.73% [-0.88,-0.58], respectively, both p<0.001; weight -1.9 kg [-2.5, -1.3] and -2.2 kg [-2.8, -1.6]; both p<0.001). EMPA led to clinically meaningful and sustained reductions in SBP vs PBO (placebo-adjusted mean change [95% CI]: -4.4 mmHg [-6.6, -2.3] and -3.7 mmHg [-5.9, -1.5] for 10 mg and 25 mg, respectively, both p<0.001). For DBP, empagliflozin led to placebo-adjusted mean changes (95% CI) of -2.0 mmHg (-3.4, -0.5) and -1.4 mmHg (-2.8, 0.1). Adverse events (AEs) were reported in a higher proportion of patients on EMPA 10 mg (80.2%) than PBO (77.7%), but a lower proportion on EMPA 25 mg (72.0%). Hypoglycemic AEs (glucose ≤70 mg per dL and/or requiring assistance) were reported in similar proportions of patients on EMPA (4.1–4.2%) and PBO (3.4%); 1 patient on EMPA 10 mg required assistance. AEs consistent with urinary tract infection were reported in similar proportions of patients on PBO (13.6%) and EMPA 10 mg (14.3%) but a lower proportion on EMPA 25 mg (10.3%). AEs consistent with genital infection were reported in more patients on EMPA (8.3–9.3%) than PBO (0.5%).

Conclusion: EMPA 10 mg or 25 mg as add-on to metformin over a treatment period of ≥76 weeks were well tolerated and reduced HbA1c, weight, and SBP compared with PBO.

 

Disclosure: LM: Consultant, Boehringer Ingelheim, Investigator, Boehringer Ingelheim, Speaker, Boehringer Ingelheim. HUH: Advisory Group Member, Boehringer Ingelheim. AVC: Employee, Boehringer Ingelheim. FR: Employee, Boehringer Ingelheim. AS: Employee, Boehringer Ingelheim. GK: Employee, Boehringer Ingelheim. TM: Employee, Boehringer Ingelheim. HJW: Employee, Boehringer Ingelheim. UCB: Employee, Boehringer Ingelheim.

17996 9.0000 LBSU-1082 A Empagliflozin (EMPA) for ≥76 Weeks As Add-on to Metformin in Patients with Type 2 Diabetes (T2DM) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM LBSU 1074-1087 5251 1:00:00 PM Diabetes & Obesity Poster

Zheng Chen*1, Robert Brink2 and Liangyou Rui1
1University of Michigan Medical School, Ann Arbor, MI, 2Garvan Institute of Medical Research

 

Obesity is associated with chronic, low-grade inflammation. Pro-inflammatory cytokines inhibit insulin signaling, thus contributing to insulin resistance under obesity conditions. Myeloid cells, including macrophages, are the primary source of proinflammatory cytokines in obesity, and macrophage activation is believed to play an important role in the pathogenesis of obesity-associated metabolic disease. TRAF3 is an adaptor molecule mediating cell signaling in response to a variety of cytokines, however, its metabolic function has not been explored. In this work, we demonstrate that TRAF3 in myeloid cells is a novel regulator of systemic insulin sensitivity and glucose metabolism.  We deleted TRAF3 in myeloid cells using TRAF3flox/flox/ lysM-cre approaches. TRAF3-deficient mice had normal body weight and blood glucose; however, they were protected from high fat diet (HFD)-induced insulin resistance, hyperglycemia, and glucose intolerance. In both liver and skeletal muscle, insulin-stimulated phosphorylation of Akt (pSer473 and pThr308) was significantly higher in TRAF3-deficent than in control mice fed a HFD. The expression of hepatic glucose-6 phosphatase, a key gluconeogenic gene, was lower in TRAF3-deficient mice.  Moreover, myeloid cell-specific deletion of TRAF3 significantly decreased the expression of proinflammatory cytokines in the livers and white adipose tissue from mice fed a HFD. Taken together, our data suggest that TRAF3 mediates HFD-induced inflammatory response in macrophages which in turn promotes insulin resistance in obesity.

 

Nothing to Disclose: ZC, RB, LR

17766 10.0000 LBSU-1084 A Deletion of TRAF3 in Myeloid Cells Ameliorates Dietary Insulin Resistance and Glucose Intolerance in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM LBSU 1074-1087 5251 1:00:00 PM Diabetes & Obesity Poster

Frank K Huynh* and Matthew D Hirschey
Duke University Medical Center, Durham, NC

 

Sirtuins are a family of highly conserved NAD+-dependent deacylases that have a wide range of biological functions. There are seven mammalian sirtuins (SIRT1-7) and reduced sirtuin 1 (SIRT1) and SIRT3 activity have been shown to be correlated with the development of type 2 diabetes and the metabolic syndrome. Intriguingly, reduced expression of the mitochondrial sirtuin, SIRT4, is associated with increased fatty acid oxidation and a protection from diet-induced obesity. However, several key aspects of glucose and lipid metabolism under different environmental stresses have not yet been performed in SIRT4 knockout (SIRT4KO) mice.  Thus, we obtained SIRT4KO mice and performed several in vivo assays to further investigate the metabolic effects resulting from a loss of SIRT4.  SIRT4KO mice on a regular chow diet had slightly decreased body weight as well as mild fasting hyperglycemia and increased glucose-stimulated insulin secretion. Further, while younger mice showed normal insulin sensitivity, as male mice aged, they began to develop insulin resistance. When put on a high carbohydrate, low protein diet, male SIRT4KO mice had exacerbated fasting hyperglycemia, impaired glucose tolerance, and had a trend towards insulin resistance even at a younger age. In terms of lipid metabolism, male SIRT4KO mice had elevated fasting plasma triglycerides while females had decreased fasting triglycerides.  However, both male and female mice had normal lipid tolerance.  Remarkably, even though previous data show that SIRT4KO mice are protected against diet-induced obesity, our data suggest that the lack of SIRT4 may result in insulin resistance especially with aging or a high carbohydrate diet.

 

Nothing to Disclose: FKH, MDH

18038 12.0000 LBSU-1086 A Loss of Sirtuin 4 Leads to Insulin Resistance in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM LBSU 1074-1087 5251 1:00:00 PM Diabetes & Obesity Poster

Wataru Nishimura*1, Nobuaki Funahashi1, Haruhide Udagawa1, Miho Kawaguchi1, Takao Nammo1, Hisashi Oishi2, Satoru Takahashi2 and Kazuki Yasuda1
1Research Institute, National Center for Global Health and Medicine, Tokyo, Japan, 2Faculty of Medicine, University of Tsukuba, Ibaraki, Japan

 

Dynamic imaging of pancreatic β-cells contributes to the better understanding of diabetes pathology, developmental biology and regenerative medicine. Our research has been focusing on the visualization of functional β-cells mass in mice using the luciferases and fluorescent proteins.

Insulin gene transcription factors Pdx1 and MafA are critical for development, maintenance and regeneration of β-cells. Pdx1 and MafA are indispensable for expression of the molecules critical for function of β-cells, such as insulin or Glut2. Reduction in the expression of these factors results in β-cell dysfunction. Inducing the expression of these factors in compromised β-cell line leads to the increased promoter activity and the expression of insulin. Thus, these factors can be markers for β-cell function. It is also known that the expression of MafB, another large Maf factor usually observed in adult α-cells, is increased in immature β-cells during development and in compromised β-cells of diabetes.

To monitor Pdx1 promoter activity in vivo, we generated Pdx1 promoter-secreted Gaussia luciferase (Pdx1-GLuc) reporter mice. Analysis of Pdx1-GLuc mice revealed that plasma GLuc activity was significantly increased compared to wild-types, and GLuc expression and activity were exponentially higher in pancreatic β-cells than in pancreatic non-β-cells, the duodenum and other organs. GLuc activity secreted into the culture medium from the islets isolated from Pdx1-GLuc mice correlated with the number of islets. The transplantation of Pdx1-GLuc islets into SCID mice elevated their plasma GLuc activity. Conversely, a partial pancreatectomy in Pdx1-GLuc mice reduced the plasma GLuc activity.

We also generated BAC-MafA promoter-Kusabira Orange (MafA-KOr) mice to visualize MafA promoter activity in vivo. The expression of KOr was restricted to the β-cells in pancreas. The reduction in KOr fluorescence induced by hydrogen peroxide was observed over time in the cultured islets isolated from MafA-KOr mice. Moreover, crossing MafA-KOr mice with MafB-GFP mice enabled simultaneous monitoring of changes in both MafA and MafB expressions in the isolated islets, demonstrating mutually exclusive expression of these factors in the islet cells.

These results suggest that the expression of Pdx1, MafA and MafB in the pancreatic islets can be successfully monitored using these systems. The islets isolated from these reporter mice would be the powerful tools to identify small molecules that can activate Pdx1 or MafA promoter in the islets, and the identified chemicals may improve function of β-cells. Because overexpression of these factors converts pancreatic acinar or liver cells into β-cells, chemicals to activate Pdx1 and MafA promoters may also induce transdifferentiation of somatic cells into β-cells.

 

Nothing to Disclose: WN, NF, HU, MK, TN, HO, ST, KY

17797 13.0000 LBSU-1087 A Generation and Characterization of Reporter Mice to Monitor Pdx1 and Mafa Promoter Activity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Sunday, June 22nd 3:00:00 PM LBSU 1074-1087 5251 1:00:00 PM Diabetes & Obesity Poster

Kathryn Lisa Hackman*1, Gregory Snell2 and Leon Bach3
1Monash University, Melbourne, Australia, 2The Alfred Hospital, Melbourne, Australia, 3The Alfred, Melbourne, Australia

 

Background

Diabetes mellitus (DM) is common following lung transplant (LTx) and is an independent risk factor for mortality. No studies to date have prospectively determined the incidence or prevalence of DM using the oral glucose tolerance test (OGTT) pre and post LTx. Further, changes in metabolic parameters following LTx and risk factors for persistent DM following LTx have not been comprehensively studied.

Methods

Prospective, longitudinal study of all LTx recipients aged ≥16y at a quaternary institution, comparing DM status before and 3, 12 and 24 months after LTx, using the OGTT. Incidence and prevalence of DM and dysglycaemia, and changes in metabolic control, including glucose and insulin levels, HbA1c and BMI, were determined. Risk factors for persistent new onset DM after transplant (NODAT) were assessed by univariate logistic regression analysis. The effect of DM status on survival was assessed.

 

Results

Between 1/8/2010 – 1/12/2012, 156 consecutive patients underwent first LTx. Baseline DM prevalence was 25%, increasing to 47%, 43% and 33% at 3, 12 and 24 months respectively. Impaired glucose tolerance &/or impaired fasting glucose was present in a further 15% at baseline and 20%, 13% and 14% at 3, 12 and 24 m. NODAT incidence amongst patients at risk was 31%, 29% and 17% at 3, 12 and 24 m.

PreTx DM was the strongest predictor of persistent DM post Tx. Risk factors for NODAT at 2 years were 1 and 2 h glucose levels on preTx OGTT (OR 1.67 (95% CI 1.14 – 2.46), p= 0.008 and OR 2.23 (1.34 – 3.76), p = 0.002 respectively). Age, sex, underlying lung disease, family history of DM, preTx BMI, BMI change, HbA1c, insulin levels on OGTT, HOMA scores and fasting glucose were not predictive.

35 patients died, of whom 17 (49%) had DM (7 NODAT, 10 DM pre&post). Four required redo LTx of whom 2 had NODAT and 1 had IGT. Estimated mean survival in patients with DM at study end or time of death or redo LTx was 959 (859 - 1059) d vs 1132 (1061 – 1203) d in normoglycemic patients, p= 0.02. PreTx DM status did not significantly affect survival.

 

Conclusion

In this prospective, longitudinal study, most patients had DM or IGT in the first year after LTx. By 3 months, 1/3 of patients at risk had NODAT. The only risk factors for persistent NODAT were elevated 1 and 2 h glucose on preTx OGTT. Survival was reduced in patients with DM. We suggest all patients waitlisted for LTx undergo OGTT for diagnosis and risk stratification. We also recommend DM screening post Tx, as early detection and management may reduce morbidity and mortality. Further studies to determine the effect of early treatment of DM following LTx are urgently needed.

 

Nothing to Disclose: KLH, GS, LB

PP40-2 12426 1.0000 MON-0951 A Prevalence and Predictors of Diabetes after Lung Transplant - a Prospective, Longitudinal Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 11:30:00 AM PP40 4896 11:15:00 AM Diabetes Clinical Care; Genetics & Epidemiology Poster Preview

Andrea Mari*1, Stefano Del Prato2, Bernhard Ludvik3, Amparo de la Peña4, Linda Shurzinske4 and Valeria Pechtner5
1Institute of Biomedical Engineering, National Research Council, Padova, Italy, 2University of Pisa, Pisa, Italy, 3Medical University of Vienna, Vienna, Austria, 4Eli Lilly and Company, Indianapolis, IN, 5Eli Lilly and Company, Neuilly-sur-Seine Cedex, France

 

In the Phase 3 double-blind AWARD-3 study, efficacy and safety of once weekly dulaglutide (DU), a GLP-1 receptor agonist, were assessed as monotherapy in early stage T2DM patients in comparison to metformin (MET). In a subset of patients, effects on model-estimated β-cell function and insulin action in response to a meal challenge were evaluated.

A standard mixed meal with 75 g of carbohydrates was administered at baseline, 26 wk (primary time point), and at 52 wk to patients treated with DU 1.5 mg (n=133), DU 0.75 mg (n=136), or MET (n=140). Plasma glucose, insulin, and C-peptide concentrations were determined prior to and 15-, 30-, 60-, 120- and 180-min post meal. β-cell function was assessed by empirical parameters and by a validated mathematical model describing the relationship between insulin secretion rate (ISR) and glucose concentrations.

 Baseline patient demographics (Mean±SD) were comparable across treatment arms: age 55±10 yr, duration of diabetes 2.6±1.8 yr, A1C 7.6±0.9 %, and weight 93±19 kg. LSM (SE) changes from baseline at 26 wk for A1C: DU 1.5 mg -0.88 (0.10) %, DU 0.75 mg -0.80 (0.09) % and MET -0.65 (0.09) %, and for weight: DU 1.5 mg -2.08 (0.38) kg, DU 0.75 mg -0.91 (0.36) kg and MET -2.09 (0.36) kg. At 26 wk, while decreases in postprandial area under the glucose curve (AUCg) were not different, increases in postprandial insulin (AUCi) and C-peptide (AUCcp) were greater in patients treated with DU 1.5 mg or DU 0.75 mg compared to MET (AUCi: p<0.001, both comparisons; AUCcp: p<0.001 and p=0.004, respectively). Additionally, compared to MET at 26 wk, DU 1.5 mg and DU 0.75 mg increased AUCi/AUCg (p<0.001 and p=0.005, respectively), as well as model-based parameters of β-cell function: ISR at a fixed glucose concentration of 162 mg/dL (ISR162; p<0.001 and p=0.04, respectively) and glucose sensitivity (only DU 1.5 mg, p=0.004). At 52 wk, changes in AUCi, AUCcp, AUCi/AUCg, and ISR162 were generally sustained with DU 1.5 mg compared to MET (p<0.001, all comparisons). Overall, effects were less marked with DU 0.75 mg. Matsuda’s insulin sensitivity index increased to a greater extent with metformin in comparison to DU 1.5 mg and DU 0.75 mg at 26 wk (p=0.005 and 0.004, respectively) and at 52 wk (p=0.04 and 0.01, respectively).

In conclusion, results from empirical and model-based parameters consistently indicated that DU 1.5 mg improves postprandial glycemic control and enhances β-cell function compared to MET.

 

Disclosure: AM: Researcher, Eli Lilly & Company, Consultant, Eli Lilly & Company. SD: Advisory Group Member, Sanofi, Advisory Group Member, Novo Nordisk, Speaker, Novartis Pharmaceuticals, Advisory Group Member, Merck & Co., Advisory Group Member, Jansen Pharmaceuticals, Speaker, Bristol-Myers Squibb. AD: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. LS: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. VP: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. Nothing to Disclose: BL

PP40-3 12490 2.0000 MON-0953 A Once Weekly Dulaglutide Enhances ß-Cell Function Compared to Metformin in Patients with Type 2 Diabetes (T2DM) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 11:30:00 AM PP40 4896 11:15:00 AM Diabetes Clinical Care; Genetics & Epidemiology Poster Preview

Patrick M. O'Neil*1, Kathie L Hermayer1, Peter Tuerk1, Lynne Becker1, Stephanie Rost2, Jan Veliko2 and Karen Miller-Kovach2
1Medical University of South Carolina, Charleston, SC, 2Weight Watchers International, Inc, New York, NY

 

Moderate weight loss (e.g., 5%) improves glycemic control among people with Type 2 diabetes (T2DM).  Weight Watchers (WW), a community-based program, has been shown to produce weight loss in this range, but effects among participants with T2DM are not known and the standard program does not address T2DM-specific issues.  We report here the 6-month results from a 12-month trial examining the effects for participants with T2DM of the WW program combined with diabetes counseling, relative to a control group receiving standard diabetes education.

Enrollment for this 12-month prospective, randomized, controlled, parallel-group, multicenter clinical trial occurred May 2012 through April 2013.  Subjects were 563 overweight/obese adults with T2DM, from 16 US sites (BMI 27 to 50; HbA1c 7% to 11%; 70%/30% female/male; 44% white/36% black/10% Hispanic/10% other), on any or no diabetes medications including insulin.  They were randomized 1:1 to either the WW program tailored for diabetic participants or to standard diabetes care (SC). WW subjects received unlimited access to weekly community WW meetings and use of the online WW tools. This was supplemented with individual telephonic counseling with a WW-trained registered dietitian/certified diabetes educator to individualize the WW program in light of their T2DM status.  SC subjects received one session of in-person diabetes-related nutritional counseling with a registered dietitian and follow-up educational materials. The primary endpoint was change from baseline in HbA1c. Secondary endpoints included changes in fasting plasma glucose  (FPG) and weight (% of baseline weight lost).

Groups did not differ at baseline on HbA1c (M = 8.32%, SD 1.0), FPG (M = 165.63 mg/dL, SD 47.36), BMI (M=37.19, SD 5.69), or age (M = 55.10, SD 9.12). Three-month follow-up data were obtained on 502 subjects and 6-month data were obtained on 481 subjects.  Changes in HbA1c, FPG, and weight were analyzed using hierarchical linear modeling.

Significant time by treatment interactions revealed differences between groups in changes in HbA1c, FPG, and weight (ps < .0001).  Mean 6-month changes in HbA1c for WW and SC subjects were, respectively, -0.64% (95%CI: -0.48, -0.80) and -0.01 (95%CI: -0.17, +0.15).  Similarly, 6-month changes in FPG were -14.07 mg/dL (95%CI: -6.85, -21.30) for WW and +5.88 mg/dL (95%CI: +12.86, -1.11) for SC.  WW subjects lost significantly more weight than did SC subjects (M % of baseline weight lost = 4.3% and 1.7%, respectively). At six months, 32.8% of WW subjects and 12.6% of SC subjects attained HbA1c <7.0%.

These six-month results suggest that the tailored WW program produces significantly greater improvement in glycemic control and weight loss compared to standard diabetes nutrition education. If longer-term follow-up data support the durability of these results, this program may represent a new option in the management of T2DM.

 

Disclosure: PMO: Principal Investigator, Weight Watchers International, Researcher, Vivus, Inc., Speaker, Eisai, Speaker, Novo Nordisk, Advisory Group Member, Fleishman-Hillard, Principal Investigator, Novo Nordisk, Principal Investigator, Orexigen Therapeutics, Principal Investigator, Arena Pharmaceuticals. KLH: Principal Investigator, Novo Nordisk, Consultant, Sanofi. PT: Researcher, Weight Watchers International. LB: Researcher, Weight Watchers International. SR: Employee, Weight Watchers International, Employee, Weight Watchers International, Employee, Weight Watchers International. JV: Employee, Weight Watchers International, Employee, Weight Watchers International, Employee, Weight Watchers International. KM: Employee, Weight Watchers International, Employee, Weight Watchers International, Employee, Weight Watchers International.

PP40-4 13096 3.0000 MON-0955 A Effects on Glycemic Control and Weight of a Widely Available Weight Control Program Tailored for People with Type 2 Diabetes: Six-Month Results 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 11:30:00 AM PP40 4896 11:15:00 AM Diabetes Clinical Care; Genetics & Epidemiology Poster Preview

Ikuyo Kusaka*1, Hotaka Yamada2, Masashi Yoshida2, Tomoko Asano2, Atsushi Aoki2, Aki Ikoma2, Hideo Toyoshima2, Masafumi Kakei2 and San-e Ishikawa2
1Jichi Medical University Saitama Medical Center, Saitama, Japan, 2Jichi Med Univ Saitama Med Ctr, Saitama, Japan

 

Cathepsin K(CatK) belongs to a family of cysteine protease. CatK is predominantly expressed in osteoclasts, and is responsible for the degradation of bone matrix. Recent studies have showen that CatK may be involved in development of atherosclerosis. The present study was undertaken to determine whether CatK is associated with atherosclerosis and microangiopathy in diabetic patients. Forty-five patients with diabetes mellitus were enrolled. There were 34 males and 11 females, with the mean age (± SD) of 66 ± 8 years. Serum levels of CatK, VEGF, HMGB-1 and CD146 were measured by ELISA. Vascular calcification, Intima Media Thickness(IMT) and flow-mediated dilation (FMD) were measured by ultrasound sonogram. Serum CatK levels ranged from 0.16 to 10.0 ng/ml (mean value: 3.0). Serum CatK had a negative correlation with FMD(r=-0.405, P=0.006), but did not correlate with IMT and vascular calcification. Also, serum CatK levels positively correlated with VEGF(r=0.368, P=0.013) and CD146(r=0.430, P=0.006). Serum CatK levels were elevated in parallel with the progression of nephropathy, because serum CatK positively correlated with serum Creatinine(r=0.408, P=0.005), and negatively correlated with eGFR(r=-0.292, P=0.052). Also, serum CatK levels were significantly higher in the diabetic patients with retinopathy than those without retinopathy(3.9 vs 2.9ng/ml, P=0.003). These findings indicated that an increase in serum CatK levels is associated with vascular endothelial dysfunction, and progression of microangiopathy in patients with diabetes.

 

Nothing to Disclose: IK, HY, MY, TA, AA, AI, HT, MK, SEI

PP34-1 12738 1.0000 MON-1044 A Close Association of Cathepsin K with Macro- and Microangiopathy in Diabetic Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 11:30:00 AM PP34 4897 11:15:00 AM Predictors and Mediators of Cardiovascular Risk: Clinical Research Poster Preview

Nicole R Kitos*, Melanie M Mott, Devina Luhur Willard, Monica Ursino-Toraldo and Andrea D Coviello
Boston University School of Medicine, Boston, MA

 

Cardiovascular disease (CVD) is the leading cause of death in women, with typical onset of disease post-menopause.  There are race-ethnic (RE) disparities in some CVD risk factors (CVD RFs) such as obesity and diabetes (DM), with Black and Hispanic women being at disproportionately high risk of both.  Objectives: 1) To determine if there are RE differences in the burden of CVD RFs in premenopausal women from a diverse, high risk urban population; and 2) To determine if differences in CVD RFs vary with the presence of polycystic ovary syndrome (PCOS).  Methods:  The presence of CVD RFs including obesity, DM, Hypertension (HTN), hyperlipidemia (HL), metabolic syndrome (MetS), and fatty liver disease (NAFLD) were determined from the eMR problem list by ICD9 code in 23,313 premenopausal women (18-50 yrs) seen at Boston Medical Center in 2011.  RE was self-reported and classified as:  Asian/Pacific Islander, Black, Hispanic, Middle Eastern, Native American, White, and Other.  Analyses were stratified by PCOS status given the associated high rates of metabolic disease. Comparisons were by Chi2, alpha<0.05, SASv9.2. Results:  CVD RFs varied significantly by RE. Blacks had the most obesity (30%), DM (10%), and HTN (21%) while Hispanics had the most MetS (10%) and Other women had the most HL (12%); p<0.0001, for all. Hispanic (1%) and Middle Eastern (1%) women had the most NAFLD (p=0.003). PCOS status was associated with some but not all CVD RFs. Women without PCOS (n=22,218) had higher rates of HTN (16% vs. 12%, p=0.0004) than women with PCOS.  MetS was higher in women without PCOS (7% vs. 0%, p<0.0001) and likely under-coded. Women with PCOS (n=1095) had higher rates of obesity (41% vs. 24%, p<0.0001) and NAFLD (1.2% vs. 0.6%, p=0.01). There was no difference in DM (10% vs 8%, p=0.2) or HL (8% vs. 10%, p=0.06).  Among women without PCOS, Black and Hispanic women had the most obesity (29% and 29%, p<0.0001). Blacks also had more HTN (21%, p<0.0001) and DM (10%, p<0.0001). Hispanics had the most MetS (10%, p<0.0001) and Other women had the most HL (13%, p<0.0001). Among women with PCOS, Blacks had more obesity (48%, p<0.0001) and HTN (18%, p=0.004).  Conclusions:  Cardiovascular risk varied by race-ethnicity in premenopausal women.  Overall, Black and Hispanic women had the most CVD RFs.  Women with PCOS had higher rates of some but not all CVD risk factors, suggesting that PCOS did not account for the high CVD risk observed in this young, diverse population of women.

 

Nothing to Disclose: NRK, MMM, DLW, MU, ADC

PP34-2 12683 2.0000 MON-1043 A Race-Ethnic Disparities in Cardiovascular Risk in Premenopausal Women from a High-Risk, Underserved, Urban Population 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 11:30:00 AM PP34 4897 11:15:00 AM Predictors and Mediators of Cardiovascular Risk: Clinical Research Poster Preview

Danit Ariel* and Gerald M Reaven
Stanford University, Stanford, CA

 

Background: It is well accepted that impaired fasting glucose (IFG) is a significant predictor of type 2 diabetes risk, but whether it is a risk for cardiovascular disease (CVD) is less clear. We hypothesized that the inconsistent link between IFG and CVD risk is due to the marked heterogeneity of peripheral insulin resistance amongst individuals with IFG.

Methods: We defined normal glucose tolerance (NGT) and impaired fasting glucose (IFG) in a nondiabetic population using fasting glucose values, and we measured several CVD risk factors. We directly quantified insulin sensitivity by determining the steady state plasma glucose (SSPG) concentration during an insulin suppression test. We compared CVD risk factors between the NGT and IFG groups as a whole. Then, using the tertiles of SSPG concentrations in the NGT group, we stratified the NGT and IFG individuals as insulin resistant (IR) (SSPG > 151) or insulin sensitive (IS) (SSPG < 151); and we compared CVD risk factors between these subgroups. Lastly, we defined the proportion of individuals in the IFG group who are insulin sensitive.

Results: CVD risk factors (BMI, SBP, TG, TC, LDL-C, HDL-C, nonHDL-C) were significantly worse in the IFG group (n=94) compared to the NGT group (n = 315) (p<0.0001). When we subdivided each group based on insulin sensitivity, the IR subgroups demonstrated higher CVD risk than the IS subgroups within both the NGT and IFG individuals. Finally, 30% of the entire IFG group was insulin sensitive, and these individuals had a normal cardiometabolic profile, based on conventional classification.

Conclusion:  Our results confirm that individuals with IFG, as a whole, are more insulin resistant and have higher CVD risk factors than individuals with NGT. We also show that in a nondiabetic population, the presence of insulin resistance results in greater CVD risk factors and marked heterogeneity within each category of fasting glucose. Finally a substantial number of individuals with IFG are insulin sensitive and these individuals have a normal cardiometabolic profile. Such differences may explain why prior studies of IFG individuals have only inconsistently found an increase in their CVD risk profile. To better risk stratify individuals with IFG for CVD risk, we advocate for assessment of their peripheral insulin resistance.

 

Nothing to Disclose: DA, GMR

PP34-3 13563 3.0000 MON-1045 A Insulin Resistance As the Determinant of Cardiovascular Disease Risk in Individuals with Normal Glucose Tolerance or Impaired Fasting Glucose 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 11:30:00 AM PP34 4897 11:15:00 AM Predictors and Mediators of Cardiovascular Risk: Clinical Research Poster Preview

Sara Klinepeter Bartz*1, Maria Claudia Caldas2 and Fida F Bacha3
1Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 2Texas Children's Hospital, Houston, TX, 3Children's Nutrition Researc, Houston, TX

 

Endothelial dysfunction may be an early manifestation of subclinical atherosclerosis. Urine microalbumin to creatinine ratio (UACR) has been associated with vascular inflammation and is a useful predictor of cardiovascular (CV) events in adults (1).  In children, elevated UACR has been associated with obesity and impaired glucose metabolism (2).  We investigated whether UACR was related to endothelial dysfunction in adolescents across the spectrum of glucose regulation.

52 adolescents: 9 normal weight with normal glucose tolerance (NW-NGT), 19 overweight NGT (OW-NGT), 14 OW with prediabetes (OW-PreD), and 10 with type 2 diabetes (T2DM) underwent: oral glucose tolerance test (OGTT) with calculation of whole body insulin sensitivity index (WBISI), endothelial function assessment by peripheral arterial tonometry with determination of reactive hyperemia index (RHI), body composition (DEXA).  UACR was measured. Results are Mean ±SE.

The 4 groups did not differ with respect to age (15.4±0.4 years), tanner stage, sex or racial distribution.  The NW-NGT had significantly lower BMI (21.7±0.7 vs. 29.4±1.1, 32.5±1.1, and 33.4±1.8 kg/m2, p=<0.001) and % body fat (23.3±2.1 vs. 33±2.2, 35.7±1.8, and 37.7±2.3 %, p=0.001), compared with OW-NGT, OW-PreD and T2DM, respectively.  RHI (1.7±0.1, 1.6±0.1, 1.5±0.1, and 1.6±0.1), UACR (4.0±0.8, 4.9±0.9, 5.6±1.3, and 5.1±0.7 mg/g), triglycerides, total cholesterol levels and blood pressure were not significantly different in NW-NGT, OW-NGT, OW-PreD and T2DM groups, respectively.  HbA1C was higher in T2DM and PreD compared with the other groups (6.1±0.2 % T2DM, 5.7±0.1 PreD vs. 5.6±0.1 NW-NGT and 5.4±0.1 OW-NGT). WBISI decreased from NW to OW to T2DM and was lowest in OW-PreD (4.0±0.4, 2.2±0.3, 1.2±0.2, and 1.6±0.4, respectively).  UACR was related to RHI (r=-0.40, p=0.003), % body fat (r=0.29, p=0.04) and SBP (r=-0.34, p=0.01), with no significant relationship between UACR and lipids, BMI, or WBISI.  In a multiple regression analysis with UACR as the dependent variable and RHI, %body fat, group (or HbA1c), age, sex, race, SBP, cholesterol and WBISI as independent variables, RHI (β=-0.495, p=0.003) and gender (β=0.429, p=0.014) together and independently contributed to the variance in UACR (R2=0.417, p=0.014).

The UACR is an early marker of endothelial function in youth along the spectrum of glucose regulation, independent of adiposity or insulin sensitivity. This test is an easily obtainable measure, suitable in the office setting and for clinical studies aiming at assessment of CV risk in children.

 

Nothing to Disclose: SKB, MCC, FFB

PP34-4 14107 4.0000 MON-1046 A Urine Microalbumin to Creatinine Ratio: A Marker of Early Endothelial Dysfunction in Youth 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 11:30:00 AM PP34 4897 11:15:00 AM Predictors and Mediators of Cardiovascular Risk: Clinical Research Poster Preview

Susmeeta T. Sharma*1, Ninet Sinaii2 and Lynnette K. Nieman2
1Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 2National Institutes of Health, Bethesda, MD

 

Context: Severe hepatic impairment may limit the use of ketoconazole (KTZ) in Cushing’s syndrome (CS). Both the European Medicines Agency and the FDA have recommended against the use of KTZ for fungal infections and it has been withdrawn from the market in the European Union (1-2).

Objective: Evaluate the safety of KTZ treatment (Rx) in CS.

Methods: Retrospective study (1982-2012) of all CS patients (pts) on KTZ Rx. Alkaline phosphatase (AP), AST, ALT levels before initiation and dose change and on the final dose were characterized as percentage of upper limit of normal (%ULN). Pre- to post-KTZ change was analyzed using Wilcoxon signed rank test. Logistic regression modeling was used to identify variables (age, gender, type of CS, KTZ dose, Rx duration, baseline AP/AST/ALT, alcohol use, concomitant use of other agents to decrease cortisol levels) that may predict the development of severe transaminitis (AST and/or ALT ≥3xULN) with KTZ Rx in CS.

Results: 150 pts (68 Cushing’s disease, 53 proven and 26 occult ectopic ACTH secretion, 1 ACTH-dependent CS, unclear etiology, 2 adrenal) received KTZ Rx; 65 were on combination Rx. Mean age was 40±15 years, 97 were women. Median initial, max and final KTZ doses were 600, 1100 and 800 mg/day, respectively. Median duration on KTZ was 43 days (range=4-3169). Adverse events (AE) on KTZ occurred in 102 (68.5%) pts. AP (P=0.0001) and AST (P=0.005), but not ALT, increased significantly on KTZ. AEs included hepatic dysfunction (43%), gastrointestinal symptoms (24%), adrenal insufficiency (18%), rash/pruritis (n=3) and fatigue (n=5). Severe transaminitis occurred in 26 (17%) pts (KTZ discontinued in 18, dose decreased in 8). Only 2 of these pts were on drugs with independent hepatic toxicity or strong CYP3A4 inhibition. None developed fulminant hepatic failure. Likelihood of developing of severe transaminitis was higher in pts ≤30 years at presentation (OR=5.4, 95%CI [1.6, 18.2]; P=0.006) and those on a max KTZ dose ≥1200 mg/d (OR=5.2, 95%CI [1.3, 20.5]; P=0.02); odds decreased with longer duration of KTZ Rx (>30 vs. ≤30 days, OR=0.2, 95%CI [0.1, 0.7]; P=0.008). 12 pts were treated more than once (gap≥1 year) with KTZ. Severe transaminitis was consistently present or absent in both Rx episodes for 8 (67%) pts.

Conclusions: KTZ can cause hepatic dysfunction in a large number of pts. Liver function should be monitored closely, especially in pts on doses ≥1200 mg/d or those with a prior history of hepatic dysfunction on KTZ.

 

Nothing to Disclose: STS, NS, LKN

PP27-1 16509 1.0000 MON-0772 A Factors Predicting the Development of Severe Transaminitis with Ketoconazole Treatment in Cushing's Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 11:30:00 AM PP27 4901 11:15:00 AM Adrenal Tumors & Pheochromocytomas; Adrenal Case Reports Poster Preview

Takumi Kitamoto*1, Sachiko Suematsu2, Yoko Matsuzawa2, Masao Omura2, Jun Saito2 and Tetsuo Nishikawa2
1Graduate School of Medicine, Chiba University, Chiba, Japan, 2Yokohama Rosai Hosp, Yokohama, Japan

 

Aldosterone-producing adenoma (APA) is a common disease of surgically curable hypertension and aldosterone plays a crucial role on inducing cardiovascular complications. Our objective was to evaluate the cardiovascular complications before and after unilateral adrenalectomy in APA-patients with and without KCNJ5 gene mutations

We compared the clinical characteristics and laboratory findings with cardiovascular complications among 88 APA patients with or without KCNJ5 and ATPase gene mutations. Sixty-two cases (70.5 %) among all subjects possessed somatic mutations of KCNJ5 (p.G151R or p.L168R). There were 3 (3.4%) cases who exhibited ATPase gene mutations (p.L104R or p.L425_V426del) without any KCNJ5 gene mutations. The KCNJ5 mutated and wild type groups demonstrated similar advances in left ventricular hypertrophy before surgery, although the mutated group was significantly younger with higher plasma and urine aldosterone levels than the wild type group. Both of these groups displayed postoperative improvements in hypertension although smaller numbers of anti-hypertensive drugs were needed in each group. Moreover, the LV mass index (LVMI) of the mutated group was significantly improved after surgery, while the wild type group was not. Multiple linear regression analysis showed improvement of LVMI was independently associated with plasma aldosterone level, age and BMI in this order.

In conclusion, the present study clearly demonstrated that KCNJ5 mutations are common among Japanese APA patients (frequency: 70.5%), although ATPase mutations show the same incidence as those in western countries. The KCNJ5 gene mutations apparently induce strong autonomous aldosterone production, and the KCNJ5 mutated group demonstrated significant postoperative improvement in LVMI due to marked reduction of aldosterone. Thus, we need to precisely diagnose younger APA-patients possessing strong ability of aldosterone production due to KCNJ5 gene mutations, since those cases may have worsen cardiovascular complications.

 

Nothing to Disclose: TK, SS, YM, MO, JS, TN

PP27-2 13187 2.0000 MON-0770 A Comparative Study on Cardiovascular Complications before and after Surgical Treatment for Aldosterone-Producing Adenomas with KCNJ5 or ATPase Gene Mutations 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 11:30:00 AM PP27 4901 11:15:00 AM Adrenal Tumors & Pheochromocytomas; Adrenal Case Reports Poster Preview

Vitaly Kantorovich*1, Andrew E Arai2, Victoria L Martucci3, Karen T Adams3, James C Reynolds4 and Karel Pacak5
1University of Connecticut Health Center, Farmington, CT, 2NHLBI, 3Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 4National Institutes of Health, Bethesda, MD, 5National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD

 

Background: Pheochromocytomas (PHEO) and paragangliomas (PGL) are rare catecholamine (CAT)-secreting tumors, associated with significant cardiovascular (CV) morbidity and mortality, including hypertension (HTN), arrhythmias, cardiomyopathy (CMP), congestive heart failure (CHF) and myocardial infarction (MI), and structural myocardial changes - hypertrophy, myocarditis, necrosis, and fibrosis. Acute and severe rise in CAT levels frequently result in HTN crisis, MI, CHF, arrhythmia or multiorgan failure. Chronic disease usually presents with resistant HTN, while subacute cases resemble stress CMP. Secretory profile of HCAT - epinephric, norepinephric, dopaminergic or mixed - defines phenotype of the CV target damage because of the different affinity of the above hormones to different types and subtypes of vascular and myocardial adrenergic receptors. On the other hand, clinical experience suggests that some patients seem to avoid significant CV morbidity despite prolonged course of the disease and/or significant hypercatecholaminemia (HCAT). Objective: To better understand structural and functional cardiac abnormalities, we evaluated 17 patients with metastatic PHEO/PGL and significant HCAT by cardiac functional magnetic resonance imaging (FMRI) and assessment of heart intensity on MIBG imaging, using either Nakajo’s (visible heart intensity in comparison to left lobe of the liver) or Somsen’s (heart to mediastinum ratio of MIBG uptake on SPECT images) methods. Results: The study included 7 patients with sporadic PHEO/PGL, 5 with SDHB, 2 with MEN2A, 1 with either MEN2B, VHL or SDHD mutation-related disease. Patients vary significantly in age at diagnosis (35.5±16.1 years, 9-62 for mean±SD, range) and overall length of the disease (9.7±8.4, 0.5-22). At the time of the workup, all patients were clinically asymptomatic and showed HCAT (12.1± 14.6, 2.6-61.3 times upper limit of normal plasma value of either tested CAT). Nine patients (52.9%) were on CAT action-blocking therapy, while the rest was on no treatment or low dose unrelated antihypertensives. On FMRI, all patients were found to have normal LVEF (64.4±4.7, 59-75) with mild anatomical abnormalities – valvular regurgitation in 52.9%, dilatation of atrias or ventricles in 52.9%, lipomatous hypertrophy of atrial septum in 17.7%. The heart intensity studies showed no visible intensity in 5 patients (29.4%) and low visible intensity in another 6 patients (35.3%), while on SPECT images the ratio was 1.58±0.22, compared to 1.93±0.16 for healthy controls. None showed strong correlation with length of disease or levels of CAT. Conclusions: In patients with long standing metastatic PHEO/PGL and prolonged and significant HCAT, extensive in-depth evaluation shows little structural or functional cardiac damage, while heart MIBG uptake suggested at least some degree of functional desensitization of adrenergic receptors.

 

Nothing to Disclose: VK, AEA, VLM, KTA, JCR, KP

PP27-3 12843 3.0000 MON-0769 A Functional and Structural Cardiac Abnormalities in Patients with Metastatic Pheochromocytomas and Paragangliomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 11:30:00 AM PP27 4901 11:15:00 AM Adrenal Tumors & Pheochromocytomas; Adrenal Case Reports Poster Preview

Mathilde Lafont1, Cedric Fagour2, Tristan Wagner3, Guy Darancette3, Alexandre Rault4, Magalie Haissaguerre3, Marie Laure Nunes5, Alexandre Ouattara3, jean-Benoit Corcuff3 and Antoine Tabarin*6
1University Bordeaux 2, Pessac, France, 2CHU Fort de France, Fort de France, France, 3University Bordeaux 2/Hopital Haut Leveque, Pessac, France, 4chirurgie géneral et digestive, 5Hopital Haut Leveque, Pessac, France, 6University hospital of Bordeaux, Pessac, France

 

Background: A number of incidentally discovered pheochromocytomas are silent and not associated with permanent or paroxystic hypertension. Little is known about hemodynamic (HD) instability during surgical removal of normotensive incidental pheochromocytomas (NIP) and wether these tumors require the standard of care for pheochromocytoma anesthesia is unknown.  

Objectives: to compare the intraoperative hemodynamic features and immediate postoperative outcomes between patients with NIP, patients with hypertensive pheochromocytomas (HP) and normotensive patients operated for benign non-pheochromocytoma adrenal incidentalomas (AI).

Design: Retrospective cohort study.

Methods: 50 patients (10 NIP, 24 HP and 16 AI) were anesthesized and operated by the same team using laparoscopy in 78% of cases. 60% of NIP and 87.5% of HP received pretreatment with alpha-receptors or calcium-channel blockers prior to surgery. All patients underwent the same intraoperative hemodynamic monitoring including continuous direct intra-arterial pressure recording. HD was assessed by the following features: extreme high and low arterial pressure, number of hypotensive and hypertensive episodes, extreme high and extreme low heart rates, number of episodes of tachycardia and bradycardia, fluid and vasoactive drugs requirement. The features of HD were compared between groups using ANOVA. The patients’ records were also reviewed for immediate postoperative course.

Results: As expected, features of HD differed significantly between HP and non-pheochromocytoma AI. On the opposite, most of the features of HD during excision of NIP were similar to that observed in HP. the only differences between NIP and HP were a reduced nadir of hypotension (39.7 ± 12.6 mm Hg  vs 30.0 ± 11.3 mm Hg; p < 0.05) and a reduced fluid requirement (1.7 ± 0.7 L vs 2.3 ± 1.3 L; p < 0.05) respectively. No patient died and all side effects were mild (Grade ≤ 3) and reversible. The frequency and intensity of immediate post-operative complications did not significantly differ between NIP and HP.

Conclusions: Despite the lack of spontaneous abnormal hemodynamic features, NIP are roughly comparable to HP in terms of hemodynamic instability during surgical resection and differ markedly from non-pheochromocytoma AI. Therefore, it is crucial to identify NIP amongst adrenal incidentalomas that are scheduled for surgery and the standard of care for pheochromocytoma anesthesia must be used for surgical excision of NIP.

 

Nothing to Disclose: ML, CF, TW, GD, AR, MH, MLN, AO, JBC, AT

PP27-4 13363 4.0000 MON-0771 A Hemodynamic Instability during Surgical Resection of Normotensive Incidentally Discovered Pheochromocytomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 11:30:00 AM PP27 4901 11:15:00 AM Adrenal Tumors & Pheochromocytomas; Adrenal Case Reports Poster Preview

Matthew J Biehl* and Lori T Raetzman
University of Illinois at Urbana-Champaign, Urbana, IL

 

The arcuate nucleus of the hypothalamus (ARC) is widely considered to be one of the most important regulators of energy homeostasis. Its direct link to the endocrine systems allows it to respond to circulating hormones and alter feeding behavior by releasing the antagonistic peptides proopiomelanocortin (POMC), an anorexigenin, and neuropeptide y (Npy), an orexigenin. Along with maintaining energy homeostasis, the ARC also plays a role in reproduction which remains to be fully understood. Neurons producing Kisspeptin interact with gonadotropin releasing hormone (GnRH) neurons in the rostral hypothalamus to directly stimulate circulating LH and FSH levels during sexual maturation. Despite the central function of these neurons, the factors regulating their development remain poorly characterized. It is important to investigate these neuronal populations, as defects in their development have been shown to lead to obesity and infertility.

  We have previously shown that Notch signaling in hypothalamic progenitor cells controls the generation of both Pomc and Npy neurons. In our current study, we hypothesized that Notch signaling would similarly impede Kisspeptin neuronal differentiation, whereas loss of Notch signaling would lead to an overabundance of neurons, in parallel to what was previously reported for the other two populations. To address this hypothesis, mice with a conditional deletion of Rbpj-κ, an essential cofactor in canonical Notch signaling (LOF) or constitutively active Notch1 (GOF) in Nkx2.1 positive cells of the ventricular zone of the ventral hypothalamus were used. By means of in situ hybridization, immunohistochemistry, and qRT-PCR, we have shown a significant reduction in Kisspeptin neuron number and Kiss1 mRNA in the hypothalamus of both LOF and GOF mice. Another early marker of Kisspeptin neurons, PDyn, was reduced by qRT-PCR in the LOF transgenic model, but showed no significant difference in the GOF model. Preliminary data suggested that loss of ARC Kisspeptin neurons may also affect sexual maturation and gonadal size at 8 weeks of age, indicating a persistent effect well into the reproductive life of affected mice.

  These data would suggest that Notch signaling may be acting as a branch point during proneural differentiation. Notch expression needs to be extinguished from hypothalamic progenitors to allow neuronal differentiation in the ARC. However, a loss of Notch signaling requiring Rbpj-κ will lead to an imbalance of feeding circuit and reproductive neurons. These data also suggest that the pathways controlling differentiation of Kisspeptin neurons or the timing of their generation may be distinct from Pomc and Npy neurons.

 

Nothing to Disclose: MJB, LTR

PP33-1 16087 1.0000 MON-0698 A Rbpj-κ Dependent Notch Signaling Differentially Modulates Development of Neurons of the Murine Arcuate Nucleus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 11:30:00 AM PP33 4904 11:15:00 AM Pituitary Development and Function Poster Preview

Angela K. Odle*, Melody L. Allensworth-James, Anessa C. Haney and Gwen V. Childs
University of Arkansas for Medical Sciences, Little Rock, AR

 

Leptin, an appetite-suppressing hormone produced largely by white fat cells, signals energy stores to the brain via receptors in the hypothalamus and is produced in several extra-adipocyte tissues, including the brain and the pituitary gland (1). By deleting the long-form of leptin receptor on somatotropes, we demonstrated that the leptin signal optimizes the somatotrope population and growth hormone secretion (2). As all pituitary cell types produce some leptin, we hypothesize that pituitary leptin, in the absence of adipocyte leptin, is important for the production and secretion of various pituitary hormones and receptors. To test our hypothesis, we created tissue-specific leptin knockout animal models: a pituitary-specific lep KO mouse (GHRHr-Cre), an adipocyte-specific lep KO mouse (Adipoq-Cre), and a global lep KO mouse (EIIa-Cre). Pituitaries from 6-month old male and female pituitary-lep-null and adipocyte-lep-null mutants and controls were collected and processed for qPCR. We also collected hypothalami from adipocyte- and global-lep-null mutants and controls. Sera from pituitary and adipocyte leptin KO animals were collected and used for pituitary hormone assays. There were no significant differences in any of the pituitary-lep-null male or female pituitary transcripts measured. However, pituitary-lep-null female mutants have significantly decreased serum prolactin levels (DEL: 8116pg/mL ± 1156, CTL: 34148pg/mL ± 9174; n=7, n=7, p=0.03).  The adipocyte-lep-null female mutants also had significantly decreased serum prolactin (DEL: 5177pg/mL ± 2046, CTL: 44150pg/mL ± 16659; n=5, n=5, p=0.04) as well as decreased LH (DEL: 734.5pg/mL ± 181.5, CTL: 2552pg/mL ± 663.5; n=5, n=5, p=0.03).  Adipocyte-lep-null male mutants have significantly decreased FSH (DEL: 7195pg/mL ± 495.1, CTL: 11062pg/mL ± 1335; n=6, n=6, p=0.02). qPCR showed that adipocyte-lep-null females have significant decreases in pituitary GHRH (p<0.005), GHS-R (p<0.05), LH (p<0.01), and prolactin (p<0.05) transcripts, as well as significant increases in GHRHr (p<0.01), POMC (p<0.01), and TSH (p<0.05) transcripts. Adipocyte-lep-null males also have decreased pituitary prolactin transcripts (p<0.005) and increased POMC (p<0.0001) and GHRHr (p<0.01) transcripts. Both male and female Adipocyte-lep-null mutants have decreased hypothalamic GHRH mRNA (p<0.05).  We thus used tissue-specific leptin knockout animal models to investigate the relative importance of pituitary and adipocyte leptin. While deletion of pituitary leptin led to decreased prolactin, deletion of adipocyte leptin caused several additional changes in mRNA and proteins. Most notably, a decrease in hypothalamic GHRH mRNA occurs, a change not seen in either the ob/ob mouse (3) or our own global leptin KO mouse. Both adipocyte and pituitary leptin appear to play a role in the production of pituitary hormones and receptors.

 

Nothing to Disclose: AKO, MLA, ACH, GVC

PP33-2 14848 2.0000 MON-0699 A Investigating Sources of Leptin Important to the Regulation of Pituitary and Hypothalamic mRNA Production and Pituitary Hormone Secretion 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 11:30:00 AM PP33 4904 11:15:00 AM Pituitary Development and Function Poster Preview

Andrew James Lessey*, Samantha Mary Mirczuk, Ashleigh Clarke, Imelda Mary McGonnell and Robert C Fowkes
The Royal Veterinary College, London, United Kingdom

 

C-type natriuretic peptide (CNP), the predominant natriuretic peptide in the pituitary, is associated with neuroendocrine development and function. Our previous studies show that genes encoding CNP (nppc2, cnp3, nppc4, nppcl) are expressed during pituitary development in humans and zebrafish (Danio rerio), however a precise role for CNP in the pituitary has yet to be elucidated. Using the versatile zebrafish, we explored in vivo effects of exposing developing embryos to exogenous CNP. Wild-type Tupfel long fin (TL) zebrafish embryos were collected from staged matings and exposed to 100nM CNP-22 for 24, 48 or 72 hours post-fertilisation (hpf). Biometric analyses revealed a significant reduction in body length in embryos exposed to CNP across the developmental time course, along with a delayed onset of melanosome aggregation compared to untreated controls. Total RNA was subsequently extracted from treated and control embryos and simultaneous gene expression of the natriuretic peptide system in zebrafish (nppa (ANP), nppb (BNP), nppc2, cnp3, nppc4, nppcl (CNPs), npr1a, nprA (GC-A), nprB (GC-B), nprC (NPR3) corina (corin), furina and furinb (furins)) and phenotypic indicators of pituitary cell lineage (cga (alpha-subunit), gh1 (growth hormone), pomca (proopiomelanocortin), pou1f1 (pit-1), smtlβ (somatolactin) and tshβ (thyroid-stimulating hormone)) were examined using a multiplex qRT-PCR assay and GenomeLab GeXP analysis system. nppc4 was significantly decreased at 24hpf (P<0.05) but increased at 48hpf (P<0.01), whereas, nppcl was decreased at 48 and 72hpf (P<0.01 and P<0.05, respectively). Both npra and pomca were reduced at 48hpf (P<0.05 and P<0.01, respectively). To investigate the effects of elevated CNP exposure on cGMP accumulation, dispersed primary zebrafish embryo cultures were exposed to 100nM CNP or ANP for up to 60 minutes. Both CNP and ANP increase cGMP accumulation over 60 minutes. Collectively, these data suggest that CNP has a role in the regulation of growth and pituitary gene expression during zebrafish development.

 

Nothing to Disclose: AJL, SMM, AC, IMM, RCF

PP33-3 14720 3.0000 MON-0696 A C-Type Natriuretic Peptide Regulates Growth and Pituitary Development in Embryonic Zebrafish (Danio rerio) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 11:30:00 AM PP33 4904 11:15:00 AM Pituitary Development and Function Poster Preview

Hanne M Hoffmann*1, Anika Tamrazian1 and Pamela L Mellon2
1Univ of California San Diego, La Jolla, CA, 2Center for Circadian Biology, University of California, San Diego, La Jolla, CA

 

Sexual maturation and fertility are regulated by the hypothalamic pituitary gonadal (HPG) axis. Improper development or disruption of the HPG axis leads to reduced fertility or complete infertility. In this study, we show that the homeodomain transcription factor Ventral Anterior Homeobox1 (Vax1) is expressed in adult mouse male and female pituitary, hypothalamus, and testis. We hypothesize that Vax1 is required for normal fertility by regulating the HPG axis in mice. Since Vax1-/- mice die soon after birth, we conducted a fertility study in Vax1+/- mice. We found both Vax1+/- males and females produced fewer pups/litter and females produced fewer litters as compared to wild type. To determine the origin of this subfertility, we analyzed gene expression patterns from the hypothalami and pituitaries from 2-5 month old male and diestrus female Vax+/- mice. Vax1 mRNA levels were reduced, as expected. Males exhibited a 69% decrease in GnRH transcript levels and females an 80% reduction. Furthermore, there was a ~70% reduction in GnRH neuron numbers in both male and female mice as determined by IHC. Interestingly, qRT-PCR from the pituitary showed that LH, FSH and GnRH receptor transcript levels were reduced in females only. To establish if the altered transcript levels affected circulating hormone levels, we measured LH and FSH in sera collected from these same animals. Once more, only females were affected and presented high circulating LH levels. As both LH and FSH are required for proper maturation and release of follicles, we evaluated the number of corpora lutea in diestrus Vax1+/- females. H&E staining found fewer corpora lutea in the Vax1+/-, indicating a reduction in ovulated oocytes, which is in agreement with the reduced litter size of these females. We propose that Vax+/- females are subfertile due to a reduction in GnRH transcript level and GnRH neuron numbers along with a reduction of pituitary GnRH receptor mRNA. These changes would result in a blunted GnRH signal to the pituitary leading to abnormal LH levels possibly resulting in fewer corpora lutea and reduced fertility. In contrast, Vax1+/- male subfertility did not appear to have a central origin as all of the studied pituitary and hypothalamic transcripts, as well as circulating LH, FSH and T levels were comparable to controls. While H&E stained testis revealed normal morphology, Vax1+/- mice had an 88% reduction of motile sperm. Staining for LacZ in Vax1-LacZ mice showed that the elongated spermatids in the testis activate the Vax1 promoter, though Vax1 mRNA expression was absent in epididymal sperm as determined by qRT-PCR. Our data support that Vax1, expressed in sperm, is required for normal sperm generation, though it is still unclear what role Vax1 plays in sperm generation and maturation. In conclusion, reduced expression of Vax1 is associated with sub-fertility in adulthood of both male and female mice.

 

Nothing to Disclose: HMH, AT, PLM

PP30-2 12693 2.0000 MON-0604 A Vax1 Heterozygous Mice Exhibit Male and Female Subfertility: Central Versus Peripheral Origins 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 11:30:00 AM PP30 4905 11:15:00 AM GnRH & Gonadotrope Biology & Signaling Poster Preview

Brian P Kenealy*, Kim L Keen, James P Garcia, Joseph R Kurian and Ei Terasawa
University of Wisconsin-Madison, Madison, WI

 

Recently we discovered that estradiol (E2), synthesized and released in the stalk-median eminence (S-ME) of ovariectomized female rhesus monkeys, plays a role in regulation of GnRH release. Specifically, using a microdialysis method, we found that a brief infusion (20 min) of estradiol benzoate (EB) into the S-ME promptly stimulated GnRH release. This EB-induced GnRH release was mediated by local neuro-E2 release, as 1) EB induced neuro-E2 levels in microdialysate samples reaching 700-1500 pg/ml and 2) infusion of an aromatase inhibitor, letrozole, into the S-ME blocked EB-induced GnRH release (Kenealy et al., 2013, PMID:24305803). In comparison, we previously showed that systemic administration of EB induces negative feedback effects on GnRH release (Mizuno and Terasawa, 2005, PMID:15842235). While direct EB infusion to the S-ME induces a stimulatory effect within 60 min, systemic injection results in an inhibitory effect with a latency of ~2h. Although there are several distinct differences between the two modes of EB administration, the dose and exposure period may be the main determining factors. We hypothesized that a longer EB infusion period and/or a larger dose of EB to the S-ME would result in an initial increase followed by a suppression (negative feedback effect) of GnRH release. To test this hypothesis, we infused EB (0.1 µM) for a 2 h, 4 h, or 6 h period directly into the S-ME while dialysates were collected. GnRH levels in dialysates were measured by RIA. The results indicate that in all groups (regardless of the infusion period) EB induced an initial GnRH increase within the first 1 h. However, in ~50 % of the cases of the 4 and 6 h groups, EB infusion resulted in additional repeated GnRH increases with a high amplitude. In the remaining cases, EB infusion either suppressed or had no effect on GnRH release. In several experiments, we also examined the dose effect (a low 1 nM and a high 1 µM dose) with a fixed infusion period of 6 h. Both EB doses failed to suppress GnRH release and also induced stimulatory effects similar to the 0.1 µM dose. These data suggest that direct EB infusion into the S-ME does not consistently suppress GnRH release and it often stimulates GnRH release. It is concluded that in female rhesus monkeys the S-ME is not the site of negative EB feedback action and perhaps the negative feedback action requires input from the arcuate nucleus, where kisspeptin neurons are present.

 

Nothing to Disclose: BPK, KLK, JPG, JRK, ET

PP30-4 16361 4.0000 MON-0608 A Effects of Dose and Duration of Estradiol Benzoate Infusion into the Stalk Median Eminence on GnRH Release in Female Rhesus Macaques 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 11:30:00 AM PP30 4905 11:15:00 AM GnRH & Gonadotrope Biology & Signaling Poster Preview

Raul M. Luque*1, Alejandro Ibañez-Costa2, Jose Cordoba-Chacon3, Manuel D. Gahete2, Justo P Castano1 and Rhonda D. Kineman3
1Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofia, CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn) and ceiA3, Córdoba, Spain, 2University of Córdoba; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofia, and CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn), Córdoba, Spain, 3University of Illinois at Chicago/Jesse Brown VA Medical Center, Chicago, IL

 

Melatonin, the main product of the pineal gland, exhibits a striking circadian rhythm in its release. The anterior pituitary hormones are also known to show clear daily patterns and rhythms of secretion. However, the relationship between melatonin and pituitary function remains controversial, and studies focusing on the potential direct role of melatonin in normal pituitary cells are limited to non-primate species.Therefore, in the present study we used primary pituitary cell cultures from normal adult primates (female baboons; Papio anubis), as a model that closely resembles humans at the physiologic and genomic levels.  The direct impact of melatonin on the gene expression and release of the major pituitary hormones was assessed by real-time-PCR and ELISA, respectively. Melatonin increased GH and PRL expression and release in a dose- and time-dependent fashion, a response that was completely blocked by somatostatin. However, melatonin did not affect the expression/release of ACTH, FSH or TSH, and tended to decrease LH (p=0.09).  The actions of ghrelin or GHRH (established stimulators of GH and/or PRL release; 10nM) were not altered by co-admistration of melatonin (10nM), suggesting that melatonin might activate similar intracellular signaling pathways as ghrelin/GHRH to induce GH and PRL secretion, respectively. Use of inhibitors to block the AC/PKA or PLC/PKC intracellular signaling pathways completely abolished melatonin-induced GH release. In contrast, only the inhibition of AC/PKA activity completely abolished melatonin-induced PRL release. The actions of melatonin in the pituitary were not only confined to the stimulation of GH and PRL synthesis/release but also included the regulation of the expression of other key regulatory components of somatotrope, lactotrope and gonadotrope cell function (i.e. the receptors for GHRH, ghrelin and somatostatin/cortistatin and kiss-1). Melatonin receptors were found to be expressed in the baboon pituitaries. These results, show for the first time in a primate model, that melatonin directly regulates GH and PRL expression/release in a dose- and time-dependent manner through common (AC/PKA) and distinct (PLC/PKC) intracellular signaling pathways. Therefore, it is possible that the direct actions of melatonin on the function of somatotropes and lactotropes (and possibly of gonadotropes) contribute to the daily patterns of hormonal release observed in these pituitary cell types.

 

Nothing to Disclose: RML, AI, JC, MDG, JPC, RDK

PP35-2 15820 2.0000 MON-0695 A Melatonin Stimulates GH and PRL Release through Common (AC/PKA) and Distinct (PLC/PKC) Intracellular Signaling Pathways in Primary Baboon Pituitary Cell Cultures 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 11:30:00 AM PP35 4907 11:15:00 AM Neuroendocrinology: Clinical and Translational Research Poster Preview

Christopher J Child*1, Daniel Conroy2, Alan G Zimmermann3, Whitney W Woodmansee4, Eva Marie Erfurth5 and Leslie L Robison6
1Eli Lilly and Company, Windlesham, United Kingdom, 2inVentiv Health Clinical, Burlington, MA, 3Eli Lilly and Company, Indianapolis, IN, 4Brigham and Women's Hospital/ Harvard Medical School, Boston, MA, 5Skåne University Hospital, Malmo, Sweden, 6St. Jude Children's Research Hospital, Memphis, TN

 

Speculation remains that GH treatment (trt) may increase risk of neoplasia. While studies in GH-treated (GHtx) childhood cancer survivors showed an increase in second neoplasms (1,2), those in GHtx adults have been equivocal. Previous data from the HypoCCS observational study (3) showed no increased risk of primary (1°) cancer in 6840 GHtx adults [mean follow-up of 3.7 years (y)]. Here we present an update of 1° cancer cases at study close, & comparison between GHtx & untreated (Utx) patients (pts) for 1° cancers & recurrences of pituitary adenoma (PA) & craniopharyngioma (CP) - the most prevalent intracranial tumors that lead to hypopituitarism.

Observed 1° cancer rates reported during study were compared to expected cases from SEER (USA; 4) & GLOBOCAN (all other countries; 5). Recurrence & 1° cancer rates in GHtx vs Utx pts were analyzed after adjustment of baseline (BL) trt group imbalances using propensity scores (prop scr; 6). Pts were stratified into prop scr quintiles (7,8), derived from a logistic regression model of 27 covariates chosen due to BL trt group imbalances or likely impact on neoplasm occurrence. Neoplasm rates were compared using the Cochran-Mantel-Haenszel test, controlling for the prop scr quintiles. 1° & recurrent cases were ascertained from study data & serious adverse event reports from pts with ≥1 follow-up visit. Main study populations were: all-sites 1° cancer analysis: GHtx N=8418, Utx 1268; history of PA: GHtx, 3668, Utx 720; history of CP: GHtx 956, Utx 102. Mean±SD follow-up times were 4.8±3.8 y for GHtx (40575 person y [PY]) & 3.5±3.2 y for Utx (4476 PY) for 1° cancer analysis, & 5.2±4.0 & 3.6±3.2 y respectively for PA, & 5.1±4.0 & 3.7±3.3 y for CP for recurrence analyses.

The standardized incidence ratio (SIR) [95% confidence interval (CI)] for all-sites 1° cancers in GHtx pts (225 cases) was 0.82 [0.71-0.93] for all countries combined. The most common cancers in GHtx pts were prostate (PR; N=40), malignant melanoma (22), breast (BR; 21), & colorectal (CR; 20). Due to specific concerns regarding PR, BR & CR cancers, cases for these sites were analyzed separately; for all countries combined SIR [95% CI] for GHtx pts were 0.80 [0.57-1.10] for PR, 0.59 [0.36-0.90] for BR, & 0.62 [0.38-0.96] for CR cancers. After adjusting for the prop scr quintiles, the risk of 1° cancer was not statistically different between the GHtx & Utx pts (relative risk=1.00 [95% CI: 0.70-1.41] p=0.98). Incidence rates [95% CI] of tumor recurrences were 14.2 [12.6-16.0]/1000 PY for PA (268 cases) & 13.2 [10.2-16.9]/1000 PY for CP (64 cases). Using the prop scr, relative risk was 0.91 [0.68-1.22] p=0.53 for PA & 1.32 [0.53-3.31] p=0.55 for CP recurrences.

In summary, no increased risk relative to the general population for all-sites, BR, CR, or PR 1° cancers was found for adult GHtx pts in HypoCCS. Likewise, prop scr adjusted analysis of GHtx vs Utx pts showed no significant difference in rates of 1° cancer or PA & CP recurrences.

 

Disclosure: CJC: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. AGZ: Employee, Eli Lilly & Company, Employee, Eli Lilly & Company. WWW: Principal Investigator, Pfizer, Inc., Principal Investigator, Ipsen, Medical Advisory Board Member, Corcept, Medical Advisory Board Member, Genentech, Inc., Medical Advisory Board Member, Eli Lilly & Company. Nothing to Disclose: DC, EME, LLR

PP35-3 11111 3.0000 MON-0622 A Assessment of Incidence of Primary Cancers and Intracranial Tumor Recurrences in Growth Hormone (GH)-Treated Adult Hypopituitary Patients: An Analysis of the Hypopituitary Control and Complications Study (HypoCCS) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 11:30:00 AM PP35 4907 11:15:00 AM Neuroendocrinology: Clinical and Translational Research Poster Preview

Jaydira Del Rivero*1, Zhengping Zhuang2, Chunzhang Yang3, Josef T Prchal4, Ronald M Lechan5, Arthur S Tischler6, Tito Fojo7, David Taieb8, Vera Popovic9, Felipe Lorenzo10, James A Young11, Joan Nambuba1, Karen T Adams1, Ivana Jochmanova1, Maria Merino7, Constantine A Stratakis12, Electron Kebebew13 and Karel Pacak14
1Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 2National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, 3National Institutes of Health, Bethesda, MD, 4University of Utah School of Medicine and VAH, Salt Lake City, UT, 5Tufts Medical Center, Boston, MA, 6Tufts Univ Sch of Medicine, Boston, MA, 7National Cancer Institute, National Institutes of Health, Bethesda, MD, 8CHU de la Timone, Marseille Cedex 05, France, 9Clinical Centre of Serbia, Belgrade, Serbia, 10University of Utah Health Sciences, 11Rocky Mountain Cancer Centers, 12National Institutes of Health (NIH), Bethesda, MD, 13National Cancer Institute, NIH, Bethesda, MD, 14National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD

 

Introduction: Pheochromocytomas (PHEOs) and paragangliomas (PGLs) are neuroendocrine tumors (NETs) derived from neural crest cells. Currently, germline mutations can be identified in up to 35% of PHEOs and PGLs. New somatic and germline mutations in the hypoxia inducible factor 2 alpha (HIF2A) have recently been found to be the cause of a syndrome consisting of multiple and recurrent PHEOs or PGLs associated with polycythemia and, in some, multiple duodenal somatostatinomas (1).

Methods: Seven patients were investigated with a detailed clinical evaluation. Plasma and/or urinary catecholamines and metanephrines were measured. Anatomic and functional imaging studies were performed for tumor(s) visualization. Genomic DNA was extracted from either tumor tissue or blood for the detection of HIF2A mutations.

Results: Patients were found to have multiple PHEOs/PGLs, solitary/several duodenal somatostatinomas, and polycythemia with somatic gain-of-function mutation HIF2A. All patients were females with an average age of 27 years. All developed polycythemia and PHEO/PGL at a mean age of 4 and 21 years, respectively; four patients presented with duodenal somatostatinomas (1 refused duodenal examination despite elevated plasma somatostatin levels) at an average age of 33.5 years. All patients showed an increase in plasma and urine norepinephrine and normetanephrine but none showed elevated plasma and urinary metanephrine or epinephrine. All patients with somatostatinoma presented with cholecystitis or cholelithiasis.

Discussion: The present findings establish the existence of a new neuroendocrine tumor syndrome presenting with multiple PGLs/PHEOs and somatostatinomas, associated with polycythemia (2). Notably, these tumors share a common genetic denominator (HIF2A mutations) that contributes to polycythemia and tumor pathogenesis due to upregulation of the HIF2A signaling pathway. The study further suggests that patients with high or inappropriately normal erythropoietin with elevated hemoglobin concentration associated with polycythemia could be screened for the presence of NETs or, conversely, patients with multiple, apparently sporadic PGLs with polycythemia, should be screened for the presence of somatostatinomas (perhaps other NETs as well) and HIF2A mutations. Finally, these findings reveal a new avenue for PGL research by a recent proposal that the pathogenesis of hereditary and other sporadic tumors are indeed interconnected via the HIF signaling pathway, calling for the use of new therapeutic options targeting this specific pathway (3).

 

Nothing to Disclose: JD, ZZ, CY, JTP, RML, AST, TF, DT, VP, FL, JAY, JN, KTA, IJ, MM, CAS, EK, KP

PP35-4 15303 4.0000 MON-0767 A The NIH Experience of Seven Somatic HIF2A Patients Presenting with Multiple Paragangliomas and/or Duodenal Somatostatinomas Associated with Polycythemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 11:30:00 AM PP35 4907 11:15:00 AM Neuroendocrinology: Clinical and Translational Research Poster Preview

Carolyn M Klinge*1, Russell A Prough2 and Barbara J Clark3
1Univ of Louisville Schl of Med, Louisville, KY, 2Univ. of Louisville School of Medicine, Louisville, KY, 3Univ of Louisville Sch of Med, Louisville, KY

 

Although oncomiR miR-21 is one of the most highly expressed miRNAs in liver and is overexpressed in hepatocellular carcinoma (HCC), its transcriptional regulation in HCC is uncharacterized.  We examined the effect of physiologically relevant nM concentrations of dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEA-S) on miR-21 expression in HepG2 human hepatoma cells and found that 10 nM DHEA increases pri-miR-21 transcription and mature miR-21 expression in a biphasic manner with an initial peak at 1 h followed by a second, sustained response from 3-12 h.  Dietary DHEA increased miR-21 in vivo in mouse liver.  siRNA, antibody, and inhibitor studies suggest that the first temporal peak involves a GPER/GPR30, estrogen receptor α-36 (ERα36), epidermal growth factor receptor (EGFR) -dependent, pertussis toxin-sensitive pathway requiring activation of c-Src, ERK1/2, and PI3K, and plasma membrane lipid raft structure.  Knockdown of ERα and ERβ did not inhibit the initial increase in pri-miR-21.  The second phase of miR-21 induction involves DHEA metabolism to androgen and estrogen receptor (AR and ER) ligands.  Indeed, activation of ERβ and AR by DHEA and its metabolites androst-5-ene-3,17-dione (ADIONE), androst-5-ene-3β,17β-diol (ADIOL), dihydrotestosterone (DHT), and 5α-androstane-3β,17β-diol (3β-Adiol) increased miR-21 transcription resulting in increased cell viability and decreased Programmed Cell Death 4 (Pdcd4) protein, a bona fide target of miR-21.  Knockdown of ERβ or AR ablated DHEA-induced pri-miR-21 transcription at the 6 h time point and chromatin immunoprecipitation studies showed that DHEA increased ERβ and AR recruitment to the miR-21 promoter within the VMP1/TMEM49 gene at this time.  These data suggest a mechanism for DHEA stimulation of miR-21 transcription with possible significance in hepatocellular carcinoma.

 

Nothing to Disclose: CMK, RAP, BJC

PP37-1 13870 1.0000 MON-0406 A Dehydroepiandrosterone Induces Biphasic miR-21 Transcription in HepG2 Cells through GPER/GPR30, Estrogen Receptor β, and Androgen Receptor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 11:30:00 AM PP37 4911 11:15:00 AM Steroid Hormone Receptors and Epigenetic Control Poster Preview

Cynthia L Bethea*1, Arubala P Reddy1, Matthew T Flowers2, Robert A Shapiro2, David H Abbott3 and Jon E Levine2
1Oregon National Primate Research Center, Beaverton, OR, 2University of Wisconsin-Madison, Madison, WI, 3Univ of Wisconsin & Wisconsin National Primate Research Center, Madison, WI

 

The administration of estradiol-17b (E) to animal models after loss of ovarian steroid production has many beneficial effects on neural functions.  E also has anorexic effects, although the mechanism of action is not well defined. In the US, obesity has reached epidemic proportions, and blame is directed at the western style diet, which is high in fat and sugar. This study examined the interaction of E and diet in surgically menopausal nonhuman primates with a 2 X 2 block design. Marmosets (n=4/group) were placed on control-low fat diet (LFD; 14%kcal from fat) or high fat diet (HFD; 28%kcal from fat) 1 month prior to ovariectomy (Ovx). Empty (placebo) or E-filled Silastic capsules were implanted s.c. during Ovx surgery. Treatments extended 6 months. The established groups were: placebo+LFD; E+LFD; placebo+HFD, or E+HFD. At necropsy, the brain was flushed with saline and harvested. The midbrain was dissected and processed for qRT-PCR using Evagreen (Biotinum). Genes previously found to impact serotonin neural functions were examined. Results were analyzed using 1-way ANOVA and Neuman-Keuls for pairwise comparsions. There was a significant difference in TPH2 across the groups (p=0.011) and HFD prevented E-stimulated TPH2 expression. MAO-A was different between the groups (p=0.01) and it was increased in the E+HFD group. MAO-B was also different between the groups (p=0.035). E increased MAO-B in the raphe and this was prevented by HFD. There was a significant difference between treatments in CRF-R2 expression (p=0.005). E increased CRF-R2 and this stimulatory effect was blocked by HFD. Regardless of diet, there was a trend toward E-induced decreases in SERT and CRF-R1 expressions (p=0.1). 5HT1A, UCN1, estrogen receptor beta and progestin receptor expressions were not different between groups. Estrogen receptor alpha was undetectable. In summary, HFD can interfere with E-regulation of some genes that are pivotal for optimum serotonin neural function. Together, the actions of HFD in the presence of E appear highly anxiogenic as HFD could decrease serotonin synthesis, increase serotonin degradation, decrease norepinephrine degradation, and decrease the expression of CRF-R2. This suggests that the beneficial actions of hormone therapy may be lost in the serotonin system in the context of a HFD.

Supported by MH68542 to CLB, HD44405 to JEL, ONPRC P51 OD11092, WNPRC P51 OD11106.

 

Disclosure: DHA: Ad Hoc Consultant, Viamet Pharmaceuticals Inc.. Nothing to Disclose: CLB, APR, MTF, RAS, JEL

PP37-2 16187 2.0000 MON-0408 A High Fat Diet Alters Estrogen-Responsive Serotonin-Related Gene Expression in the Dorsal Raphe Nucleus of Marmoset Monkeys 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 11:30:00 AM PP37 4911 11:15:00 AM Steroid Hormone Receptors and Epigenetic Control Poster Preview

Cody Lee Shults*1, Elena Pinceti1, Yathindar Satya Rao2 and Toni R Pak3
1Loyola University Chicago, Maywood, IL, 2Loyola University Chicago, Forest Park, IL, 3Loyola Univ Stritch Schl Med, Maywood, IL

 

Recent observations in the aging brain of both healthy and neurodegenerative individuals revealed global increases in alternative gene splicing (AS). To further compound the effects of aging is the loss of estrogen associated with menopause in females, and these increases in age-related AS events have not been studied in females. The loss of the major circulating estrogen, 17β-estradiol (E2), contributes to the loss of cognitive function, including mood disorders and memory impairment observed in postmenopausal women. The nuclear steroid receptors through which E2 mediates its actions, ERα and ERβ, are both subject to AS. Recent studies have shown that the dominant negative ERα delta7 splice variant, which alters ERα signaling, increases in the aged female brain in both healthy and neurodegenerative patients. Other recent studies have linked increased expression of the dominant negative ERβ2 splice variant to decreased hippocampal neurogenesis and depressive-like behaviors in female rats. This form of the receptor has decreased affinity for ligand, which may result in an alteration in E2 signaling pathways. Furthermore, ERβ splice variants are expressed in a tissue-specific manner throughout the brain. Based on these findings, we hypothesized that ERβ splice variant expression increases with longer periods of hormone loss. In our model of surgically-induced menopause, animals were ovariectomized (OVX) to remove endogenous ovarian production of E2 and were then deprived of E2 for increasing amounts of time from 1 to 12 weeks (1 wk, 4 wks, 8 wks, 12 wks). After varying deprivation periods, animals were treated with either vehicle or 2.5ug/kg E2 for 3 consecutive days, and then sacrificed 24 hours after the last treatment for tissue collection and data analysis. Our E2 deprivation studies have shown that ERβ splice variant expression increases with longer periods of E2 deprivation, up to 12 weeks post-OVX in these aged female rats. However, treatment with E2 was still effective on attenuating the increases observed in ERβ splice variant expression. This observed increase in ERβ splice variant expression may be the result of altered splicing kinetics, which favors inclusion of alternatively spliced exons flanked by a short intron upstream of it’s 5’ splice site. Treatment with a topoisomerase inhibitor camptothecin, which slows down splicesome kinetics, in hypothalamic-derived GT1-7 cells results in an increase in ERβ2 expression. These data suggest that loss of hormone may contribute to the alternative splicing of ERβ, which may be due to changes in E2 signaling pathways and splicing kinetics associated with attenuating its normal expressional profile in the brain.

 

Nothing to Disclose: CLS, EP, YSR, TRP

PP37-3 16863 3.0000 MON-0409 A Loss of Circulating 17β-Estradiol Result in an Increase in the Alternative Splicing of Estrogen Receptor β in Aged Female Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 11:30:00 AM PP37 4911 11:15:00 AM Steroid Hormone Receptors and Epigenetic Control Poster Preview

Lan N. Tu*1, Kanako Morohaku1, Pulak R. Manna2, Susanne H. Pelton1, W. Ronald Butler1, Douglas M. Stocco2 and Vimal Selvaraj1
1Cornell University, Ithaca, NY, 2Texas Tech University Health Sciences Center, Lubbock, TX

 

Translocator protein (TSPO), previously known as the peripheral benzodiazepine receptor (PBR) is a mitochondrial outer membrane protein implicated in cholesterol import to the inner mitochondrial membrane, the rate-limiting step in steroid hormone biosynthesis. Although TSPO is portrayed as a critical factor in regulating steroidogenesis, previous research on TSPO was based entirely on in vitro experiments. This model was indirectly reinforced by an early report that claimed TSPO knockout mice were embryonic lethal, underscoring both a putative vital role and the inability to conduct in vivo experiments. In a recent publication, using Leydig cell specific TSPO conditional knockout mice, we demonstrated that TSPO was not required for testosterone production or fertility in vivo. This raised several questions regarding TSPO, including functional inadequacies that lead to embryonic mortality in TSPO deficient mice. In order to further examine developmental deficits due to the loss of TSPO and reaffirm our findings on steroidogenesis, we used germ cell specific Ddx4-cre mediated recombination in TSPO floxed (TSPOfl/fl) mice to generate a global TSPO null (TSPO-/-) genotype. Contrary to the previous report, the TSPO-/- mice survived with no apparent phenotypic abnormalities, were fertile and produced litters that were identical in number to TSPOfl/fl controls. Examination of adrenal and gonadal steroidogenesis (physiological and stimulated) did not show significant differences between TSPOfl/fl and TSPO-/- mice. Adrenal transcriptome shotgun sequencing comparison of gene expression profiles and validation by quantitative PCR showed that genes involved in the steroid hormone biosynthesis pathway, such as (StAR, HSD3B1 and CYP11A1) were unchanged in TSPO-/- mice. Ultrastructural examination illustrated no morphological alterations in adrenocortical cells and mitochondria in TSPO-/- mice. These results directly refute a role for TSPO in steroid hormone biosynthesis and also demonstrate that TSPO is dispensable for viability. In an attempt to correlate our in vivo findings to previously used in vitro models, we determined that siRNA-knockdown of TSPO in different steroidogenic cell lines (MA-10, MLTC, Y-1 and R2C) had no effect on steroidogenesis. Together, these findings provide solid evidence that disproves the previous assertion that TSPO has an essential role in steroid hormone biosynthesis.

 

Nothing to Disclose: LNT, KM, PRM, SHP, WRB, DMS, VS

PP37-4 12769 4.0000 MON-0405 A Steroid Hormone Biosynthesis: TSPO Function Directly Challenged in Viable Null Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 11:30:00 AM PP37 4911 11:15:00 AM Steroid Hormone Receptors and Epigenetic Control Poster Preview

Janelle E Mapes*1, Quanxi Li2, Athilakshmi Kannan2, Lavanya Anandan1, Mary Jo Laws2, Indrani C Bagchi2 and Milan K Bagchi1
1University of Illinois at Urbana-Champaign, Urbana, IL, 2Univ of IL at Urbana-Champaign, Urbana, IL

 

In the mammary gland, genetic circuits controlled by the hormones, estrogen, progesterone and prolactin (PRL), act in concert with pathways regulated by the epidermal growth factor (EGF) family to control the growth and morphogenesis of this tissue during puberty, pregnancy and lactation.  However, the precise molecular mechanisms that integrate these signaling pathways are unclear.  In this study, we identifed CUZD1 (CUB and zona pellucida-like domain containing protein- 1) as a novel mediator of PRL signaling in steroid hormone-primed mouse mammary gland and undertook an examination of its role in growth and differentiation of this tissue during pregnancy.  CUZD1 expression is markedly induced in steroid-primed mammary epithelial cells in response to PRL treatment. Cuzd1-null mice exhibited a striking impairment in ductal branching and alveolar development during pregnancy, resulting in a subsequent defect in lactation.  Administration of PRL, which induces proliferation and differentiation of mammary ductal and alveolar epithelium in wild type mice, failed to do so in Cuzd1-null mice.  Interestingly, phosphorylation and activation of STAT5, a transcription factor that mediates PRL signaling, was absent in Cuzd1-null mammary tissue during pregnancy and lactation. We also noted that the expression of epiregulin (EREG), an EGF family growth factor regulated directly by STAT5, is suppressed in Cuzd1-null mammary gland. Protein interaction studies, using flag-tagged CUZD1 expressed in HC11 mouse mammary epithelial cells, revealed that CUZD1 is an integral component of a multi-protein complex containing JAK1/JAK2 and STAT5. Elevated expression of CUZD1 in HC11 cells stimulated phosphorylation and nuclear translocation of STAT5. This led to increased expression of EREG, which acts via the cell surface EGF receptors, ERBB1 and ERBB4, to promote cell proliferation. Collectively, our findings suggest that CUZD1 plays an important role in mammary epithelial cell proliferation and differentiation by facilitating JAK-STAT5 signaling and subsequent production of growth factors, such as EREG. CUZD1, therefore, emerges as a critical mediator of PRL action that controls mammary alveolar development during pregnancy and lactation.

 

Nothing to Disclose: JEM, QL, AK, LA, MJL, ICB, MKB

PP28-1 14736 1.0000 MON-0022 A CUZD1 Is a Critical Component of the JAK-STAT5 Pathway That Mediates Prolactin Signaling in Mammary Gland Development during Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 11:30:00 AM PP28 4918 11:15:00 AM Female Reproductive Endocrinology Poster Preview

Suman Rice*1, Ken Laing2, Ruth Burton3, Kamal Ojha4 and Helen Diane Mason1
1St George's Univ of London, London, United Kingdom, 2St Georges University of London, London, United Kingdom, 3Oxford Gene Technology, Begbroke, Oxfordshire, United Kingdom, 4St Georges Hospital, London, United Kingdom

 

The underlying principle regarding female reproduction is the growth and development of ovarian follicles, but our knowledge regarding initiation of follicle growth or the genes involved in preantral follicle progression in the human ovary is very poor. Our aim was to identify differentially expressed genes at different stages of human preantral folliculogenesis by expression profiling. Follicles were isolated from ovarian tissue obtained from cortical biopsies (n=17 subjects) and oophorectomies (n=3 subjects), staged according to Gougeon’s classification1. Same stage follicles were pooled & lysed but kept patient specific. The extracted RNA was subject to 2 rounds of T7-based linear amplification, labelled and co-hybridised against a similarly amplified and labelled reference RNA pooled from ovarian stromal tissue, onto 44k human high-density oligonucleotide microarrays (Agilent Technologies). Raw data was extracted, subject to Loess smoothing, intensity dependent normalisation and averaged by follicle stage.

612 genes were up-regulated and 104 down regulated at initiation, most strikingly those involved in cell cycle reactivation eg. E2F- family of cell-cycle transcription factors and PTEN2. Apart from well-known genes and pathways like HIF1alpha, which are up-regulated substantially, there are novel ones like ACE-3 & DND1 (which controls miRNA expression), which have never been shown to be expressed in follicles. Progression from the transitional to primary stage resulted in decreased expression of 834 genes and up-regulation of 194. This is characterised by a switching off of cell cycle genes and a substantial attenuation of KITLG expression, which supports the suggestion that granulosa cells at the early stages of follicle growth can enter and leave the cell cycle3. Intriguingly expression of FSHβ was up-regulated 47-fold as follicles initiated growth and then switched off as the follicle progressed from the transitional to the primary stage.

Growth from the primary to the multi-laminar stage saw a preponderance of the genes changing being up-regulated again, though the fold-change was not as marked as when the follicles emerged from the quiescent stage. The importance of DNA repair and chromosomal breakage, which accumulate with age in PFs, is shown by the significant increase in expression of BRAC14 and FANCI genes. There is also significant up-regulation of HSD17B1, which converts oestrone to oestradiol. Expression of IGF2 and IGFBP-6,-3 are also markedly changed at this stage. In conclusion, analysis of the genes and signalling pathways involved at each stage of preantral folliculogenesis has allowed us to establish for the first time the human preantral follicle transcriptome. This will provide valuable benchmark information which can be used to improve in vitro preantral follicle culture after ovarian cryopreservation for fertility management.

 

Nothing to Disclose: SR, KL, RB, KO, HDM

PP28-2 14580 2.0000 MON-0038 A Unravelling the Preantral Follicle Genome: The First Comprehensive Gene Expression Profiling of Human Preantral Follicles 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 11:30:00 AM PP28 4918 11:15:00 AM Female Reproductive Endocrinology Poster Preview

Masa-aki Hattori*1, Huatao Chen2, Guiyan Chu3, Makoto Kumazawa1 and Nobuhiko Yamauchi1
1Fac of Agric/Kyushu Univ, Fukuoka, Japan, 2Kyoto University, Kyoto, Japan, 3Northwest A&F University, Shaanxi, China

 

The peripheral circadian oscillator plays an essential role in synchronizing local physiology via regulation of the expression of clock-controlled genes (CCGs). Ovarian growth is involved in follicular development and luteinization accompanied by biosyntheses of steroids, prostaglandins (PG), and heme in granulosa cells and luteal cells. Although the granulosa cells lack the functional cellular clock at the immature stage, FSH promotes the development of the granulosa cell clock machinery by increasing the expression of a gap junction channel gene (1) and LH resets the cellular clock of matured granulosa cells (2). The core clock proteins entrain rhythmic expression of numerous genes through binding to an E-box, RORE, and D-box at their promoters. Ovarian oscillators directly drive the expression of numerous ovarian CCGs as well as the secretion of hormones in response to LH surges. In the present study using the clock gene RNA interference and the agonist of Rev-erba, we investigated if the rate-limiting steps in the metabolic pathways of P4 (genes: Star, Cyp11a1), PG (Ptgs2), and heme (Alas1) are controlled under cellular clock machinery. Mature granulosa cells were prepared from mouse Per2-destabilized luciferase (dLuc) reporter gene transgenic rats, pretreated with eCG. A real-time monitoring system of Per2 promoter activity was employed to detect Per2-dLuc oscillations. During monitoring Per2 promoter activity, total RNA were isolated and subjected to RT-qPCR for measurements of gene transcripts. Mature granulosa cells exposed to LH treatment displayed apparent Per2-dLuc oscillations and a diurnal rhythmic expression of core clock genes (Bmal1, Per1, Per2, Rev-erbα, and Dbp). The examined ovarian genes such as Star, Cyp11a1, Ptgs2, and Alas1 showed rhythmic transcript profiles, indicating that these genes may be CCGs. Bmal1 siRNA treatment significantly decreased both the amplitude of Per2-dLuc oscillations and Bmal1 mRNA levels compared to non-silencing RNA treatment in mature granulosa cells. Furthermore, Bmal1 siRNA treatment significantly inhibited the transcript levels of clock oscillator genes and ovarian clock-related genes. Bmal1 interference also inhibited the synthesis of P4 and PGE2. In addition, the natural ligand and synthetic agonist of Rev-erba, heme and GSK4112, respectively, decreased both the expression of Ptgs2 and Alas1 and the diurnal rhythmic expression of core clock genes, indicating that Rev-erba has an inhibitory role in the expression of Ptgs2 and Alas1. Ovarian enzymes such as cytochrome P450 and NO synthase are heme-binding proteins. Collectively, these results suggest that the ovarian cellular clock machinery controls various metabolic pathways, especially in the rate-limiting steps, associated with fertility. Our data also provide new evidence that Bmal1 and Rev-erba play multiple physiological roles in ovarian granulosa cells.

 

Nothing to Disclose: MAH, HC, GC, MK, NY

PP28-3 12325 3.0000 MON-0039 A Rate-Limiting Steps in the Metabolic Pathways of Steroids, Prostaglandins, and Heme Are Controlled Under Cellular Circadian Clocks in Ovarian Granulosa Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 11:30:00 AM PP28 4918 11:15:00 AM Female Reproductive Endocrinology Poster Preview

Marina Augusto Silveira*1, Tabata Mariz Bohlen1, Regina P Silva1, Jose Donato Jr.2 and Renata Frazao1
1University of Sao Paulo, Sao Paulo, Brazil, 2University of Sao Paulo, Sao Paulo - SP, Brazil

 

The Kiss1 gene encodes a family of neuropeptides called kisspeptins which are essential for the onset of puberty and fertility. Most Kiss1 expressing neurons in the anteroventral periventricular nucleus (AVPV), the anterior periventricular nucleus (PeN) and the arcuate nucleus (ARC) of the hypothalamus co-expresses prolactin receptors (PRL-R), suggesting that kisspeptin neurons mediate prolactin negative feedback on GnRH neurons. JAK/STAT5 is the most important signaling pathway recruited by prolactin. Kiss1-expressing neurons are target of prolactin activation as demonstrated by phosphorylation of STAT5 (pSTAT5) in ovariectomized and ovariectomized E2-primed rats. The goal of the present study was to evaluate the percentage of kisspeptin neurons activated by prolactin in intact female mice and whether Stat5 inactivation of kisspeptin neurons would interfere with the timing of puberty and reproduction. To determine the percentage of kisspeptin neurons activated by prolactin we used transgenic mice expressing Cre-recombinase driven by Kiss1 regulatory elements. These mice were crossed with Rosa26GFP mice, which express the green fluorescent protein (GFP) in a Cre-dependent manner. The Kiss1-Cre/GFP female received a single dose of ovine prolactin (i.p.,10 mg/g) or vehicle 2 h before brain collection. Brain sections were processed for double immunohistochemistry detection of GFP and pSTAT5. To further evaluate whether the Stat5 deletion of Kiss1-Cre expressing neurons would interfere with female reproductive development, Kiss1-Cre mice were crossed with Stat5fl/fl mice, genes encoding mouse Stat5a and Stat5b were flanked by loxP sites (1). Body weight and three pubertal events (vaginal opening, first estrus and cyclicity onset) were evaluated daily. The results showed that acute administration of prolactin induced pSTAT5 expression on 33% of AVPV/PeN Kiss1-Cre neurons and 64% Arc Kiss1-Cre neurons in intact female mice. Interestingly, the age of first estrus and age of onset of cornification were advanced in Kiss1-Cre/STAT5fl/fl mice (P<0.05), despite no changes on age of vaginal opening and body weight. Female Kiss1-Cre/STAT5fl/fl produced normal littermates compare to control group (P>0.05) and had no apparent problem to support their litters during lactation. The results suggest that even under low levels of gonadal steroids, as expected in female mice in diestrus-estrus, prolactin exert transcriptional effects on Kiss1 neurons. In addition, Stat5 expression on kisspeptin neurons seems to be necessary for normal puberty timing but not require for normal development of pregnancy and lactation. Whether compensatory pathways were activate on kisspeptin neurons due to Stat5 deletion needs to be further investigated.

 

Nothing to Disclose: MAS, TMB, RPS, JD Jr., RF

PP28-4 15161 4.0000 MON-0023 A Stat5 Inactivation of Kisspeptin Neurons Leads to Early Onset of Puberty 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 11:30:00 AM PP28 4918 11:15:00 AM Female Reproductive Endocrinology Poster Preview

Paula Aliberti*1, Roxana Marino1, Nora Isabel Saraco2, Matias Juanes1, Marco A. Rivarola1, Alicia Belgorosky1 and Esperanza Beatriz Berensztein1
1Garrahan Pediatric Hospital, Buenos Aires, Argentina, 2Hospital de Pediatria Garrhan, Buenos Aires, Argentina

 

The octamer binding transcription factor OCT3/4 is specifically expressed in all germ cell (GC) tumors with pluripotent potential (1). The testis-specific protein Y-encoded (TSPY) gene is the putative gene for the gonadoblastoma locus on the Y chromosome (GBY). GBY is hypothesized to serve a normal physiological function in GC proliferation but could predispose incompatible GCs in dysgenetic testis to tumorigenesis(2). TSPY, together with OCT3/4, are used as biological markers for GC tumor development in patients with dysgenetic gonads. Nonetheless the expression of TSPY in normal prepubertal children is scarcely known. We decided to study the expression of TSPY and OCT3/4 in testes of prepubertal and pubertal control patients. Testis tissues obtained from necropsy or biopsy of pediatric patients without metabolic or endocrinology diseases were used. TSPY mRNA expression was analyzed by RT-PCR in 17 prepubertal testes, median (M) chronological age 1 year (y), range 1 day-7.9 y. mRNA integrity was verified by a positive β-actin band in RT-PCR. TSPY and OCT3/4 protein expression was studied in 15 paraffin-embedded testis samples from 14 prepubertal (M 0.33 y, range 1day-12.8 y) and 3 pubertal (M 12.5 y, range 12 y-13.8 y) control patients by immunohistochemistry (IHC). It was regarded as positive seminiferous tubules (ST) if at least one GC stained for TSPY (cytoplasm) or OCT3/4 (nucleus); and as positive sample: > 5% positive STs. Thirteen of the 17 samples (76%) resulted positive by RT-PCR to TSPY mRNA expression (M 1 y, range 6 days–7y) while 4 resulted negative (M 4.5 y, range 54 days–7.9 y). No significant difference was found between age M. While 8 of the 15 prepubertal samples (53.3%) stained positively for TSPY by IHC, 7 resulted negative, with no significant difference in the age ranges and Ms. The 3 pubertal samples (100%) stained positively for TSPY. We found a wide variability in the distribution of positive STs in prepubertal testes (M 40%, range 20-86.4%), as well as in pubertal testes (M 63.6%, range 48-90%).  In both groups there were testes with more than 80% of their STs staining positively for TSPY. On the contrary to previously published data (3), we observed great variability within patients of the same age. None of the 18 control samples stained positively for OCT3/4. Thus, in contrast to OCT3/4, special care should be taken when using TSPY as premalignant marker for GC tumors.

 

Nothing to Disclose: PA, RM, NIS, MJ, MAR, AB, EBB

PP36-1 13751 1.0000 MON-0004 A Is Tspy a Suitable Germ Cell Premalignant Marker in Prepubertal Testis? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 11:30:00 AM PP36 4920 11:15:00 AM Male Germ Cells: Translational Studies Poster Preview

Alex David Ridgeway* and Dolores J Lamb
Baylor College of Medicine, Houston, TX

 

INTRODUCTION:  Non-obstructive azoospermia (NOA) results from spermatogenic failure, however, the mechanisms involved are incompletely understood.  Since spermatogenesis requires prolific cellular division and meiosis, repair systems (i.e. mismatch repair - MMR) are needed to correct cellular insults or to commit the cell to apoptosis.  Deficiencies in MMR can arise via epigenetic modifications, specifically aberrant DNA methylation. Given that MMR deficiencies in mice can cause sterility, we sought to investigate the role of DNA methylation in the MMR pathway of NOA men.

METHODS: We examined the global DNA methylation profile of testicular fibroblasts from NOA men (n=21) and fertile controls (n=5) using the Infinium HumanMethylation450 BeadChip. Bisulfite clonal sequencing was used to validate microarray results as well as to screen additional patients (10 NOA and 9 controls). MSH5, a key component of the MMR pathway, was found to be hypermethylated in NOA versus control samples. To determine the effect of MSH5 methylation on its expression, patient cells harboring MSH5 methylation were treated with the global demethylating agent 5-aza-2-deoxycytidine (5-Aza). In opposite effect, control cells (gonadal stromal fibroblasts - GSF) not harboring MSH5 methylation were treated with RNAi directed DNA methylation (RdDM) so as to replicate aberrant marks. MSH5 gene expression was quantified by qPCR and Western blot. 

RESULTS: We identified significantly increased DNA methylation within 5 CpG sites of MSH5 exon 2 in a cohort (6 out of 31) of NOA men.   This cohort also exhibited downregulation of MSH5 gene expression and reduced MSH5 protein when measured by qPCR and Western blot. Furthermore, removal of the aberrant MSH5 hypermethylation from NOA fibroblasts using 5-Aza resulted in an increase in MSH5 expression.  Discontinuing 5-Aza treatment lead to the reemergence of MSH5 hypermethylation, suggesting a potential driving cis element/trans factor. Manipulation of MSH5’s endogenous DNA methylation signature via specific CpG site RdDM in GSF cells resulted in a similar loss of MSH5 gene expression.  This data shows that hypermethylation of CpG sites within exon 2 of MSH5 downregulates MSH5’s gene expression.

CONCLUSIONS: Decreased MSH5 expression as a result of DNA methylation may lead to defective DNA recombination, impaired spermatogenesis, and decreased genetic stability, which may ultimately contribute to a NOA phenotype.

FUNDING: Supported by a Male Reproductive Health Research Career (MHRH) Development Physician Scientist Award (K12) (HD073917-01) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Program and by NIH grants P01HD36289 from the Eunice Kennedy Shriver NICHD and 1R01DK078121 from the National Institute of Kidney and Digestive Diseases.

 

Nothing to Disclose: ADR, DJL

PP36-2 13914 2.0000 MON-0001 A Hypermethylation of Discrete CpG Sites within MSH5 Deleteriously Affect Its Expression in Non-Obstructive Azoospermic Men 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 11:30:00 AM PP36 4920 11:15:00 AM Male Germ Cells: Translational Studies Poster Preview

Anders Rehfeld*1, Christian Schiffer2, Astrid Müller2, Dorte Louise Egeberg1, Hanne Frederiksen3, Steen Dissing4, Kristian Almstrup1, Timo Strünker2 and Niels Erik Skakkebaek5
1University of Copenhagen, Faculty of Health and Medical Sciences, Rigshospitalet, Copenhagen, Denmark, 2Center of Advanced European Studies and Research, Bonn, Germany, 3Copenhagen University Hospital, Copenhagen, Denmark, 4University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark, 5University of Copenhagen, Faculty of Health and Medical Sciences, Rigshospitalet, Denmark, Copenhagen, Denmark

 

Background:

Ultraviolet filters (UV filters) are widely used in personal care products, including sunscreens. The utilization of UV filters is increasing worldwide. UV filters are rapidly absorbed from the skin and some UV filters are found in >95% of urine samples in the US, Spain, France and Denmark. Experimental studies have indicated that several UV filters have endocrine disruptive effects.

Hypothesis:

We hypothesized that UV filters may mimic the physiological action of progesterone on the sperm-specific CatSper Ca(2+)-channel (cation channel of sperm). Previous studies have shown that in vitro, the human CatSper channel is promiscuously activated by structurally diverse synthetic chemicals.

Methods:

In this study, we chose to test a large group of the 37 UV filters allowed in cosmetics in the EU. We used Ca(2+) fluorimetry to screen these chemicals for their ability to induce Ca(2+) influx in human sperm. Using specific CatSper inhibitors we examined whether the induced Ca(2+) signals involve CatSper. By patch-clamp recordings we studied the direct action of a subset of these chemicals on CatSper currents in human sperm. Finally, we examined a number of the UV filters for their effect on motility and acrosomal exocytosis in human sperm.

Findings:

The first results from our study showed that several UV filters at physiologically relevant concentrations evoke an increase of intracellular Ca(2+). Furthermore, we found that surprisingly many of the UV filters (4-MBC, 3-BC, BP-3, OD-PABA, and HMS) evoke the increase in intracellular Ca(2+) by directly activating the CatSper channel. Some of these UV filters were in addition found to evoke both a motility response and acrosomal exocytosis. Worryingly, we discovered that UV filters compete with progesterone for CatSper activation and desensitize sperm for its physiological ligand. Moreover, in complex low-dose mixtures reflecting physiologically relevant exposure levels, UV filters cooperated to elevate intracellular Ca(2+) in sperm.

Conclusions:

We conclude that many UV filters directly activate the CatSper channel and thereby mimic the effect of progesterone on human sperm. These UV filters therefore interfere with essential sperm functions and, thereby, might impair human fertilization.

 

Nothing to Disclose: AR, CS, AM, DLE, HF, SD, KA, TS, NES

PP36-3 15828 3.0000 MON-0002 A Ultraviolet Filters Mimic the Action of Progesterone on Human Sperm 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 11:30:00 AM PP36 4920 11:15:00 AM Male Germ Cells: Translational Studies Poster Preview

Raghuveer Kavarthapu*1, Chon-Hwa Tsai Morris2 and Maria L Dufau3
1National Institutes of Health, Bethesda, MD, 2national institutes of health, Bethesda, MD, 3NIH-NICHD, Bethesda, MD

 

Gonadotropin-regulated testicular RNA helicase (GRTH/DDX25) is a testis specific member of the DEAD-box protein family which is essential for round spermatid elongation and completion of spermatogenesis (1, 2). Previous studies using transgenic (Tg) mice with GFP as reporter gene demonstrated that the distal 5’ flanking region of GRTH (-6.4 Kb/-3.6 Kb) is responsible for specific expression exclusively in germ cells (3). We showed an indirect action of androgen on GRTH expression in the germ cells of Tg mice carrying this specific 5’ flanking sequence (-6.4 Kb/-3.6 Kb). An inhibitory effect of the androgen receptor antagonist, flutamide (F, in vivo administration) on -6.4kb/-3.6kb-directed GFP expression was observed in the round spermatids of Tg mice, suggesting a regulatory action of androgen on GRTH expression through these GC specific upstream sequences.  A putative cis-binding element for a specific nuclear factor (GCNF/RTR), predominantly expressing in the developing GCs and required to direct gene expression in the postmeiotic phase of GC of the testis, was identified on -5270/-5252 bp region of GRTH gene.  The present study explores the potential androgen action through GCNF on GRTH gene transcription in GC.  Western blot analysis showed GCNF protein expression was significantly decreased in the testis of Tg mice carrying -6.4 kb/-3.6 kb upon F treatment suggesting the presence of a regulatory network for androgen-GCNF-upstream 5’ GRTH sequence to direct GRTH expression in the GC. A marked reduction of GCNF level was also noted in the purified round spermatids from wild type mice treated in vivo with F but not in the spermatocytes. ChIP analysis further demonstrated the association of GCNF with GRTH sequence spanning the GCNF binding site in both round spermatids and spermatocytes. This interaction was abolished by F treatment in the round spermatids only. Our study provides evidence for androgen indirect action on GCNF regulation of GRTH specific expression in GC. We propose an indirect participation of yet to be defined androgen induced factor(s) required to trigger GRTH expression by GC during spermatogenesis. This study provides insights for elucidation of intrinsic mediator (s) by androgen specific function in Sertoli cells which would in turn impact on GCNF-induced expression of GRTH in the GC.

 

Nothing to Disclose: RK, CHTM, MLD

PP36-4 12209 4.0000 MON-0003 A Androgen Modulation of Germ Cell Nuclear Factor (GCNF) Regulates GRTH/DDX25 Specific Expression in Germ Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 11:30:00 AM PP36 4920 11:15:00 AM Male Germ Cells: Translational Studies Poster Preview

Essi Ryödi*1, Jorma Salmi1, Pia Jaatinen2, Heini Huhtala3, Rauni Saaristo1, Matti Välimäki4, Anssi Auvinen5 and Saara Metso2
1Tampere University Hospital, Tampere, Finland, 2Tampere Univ Hosp, Tampere, Finland, 3University of Tampre, Tampere, Finland, 4Helsinki University Hospital, Finland, 5University of Tampere, Tampere, Finland

 

Cardiovascular morbidity and mortality in hyperthyroidism treated  with RAI or thyroidectomy– a nation-wide comparative cohort study with a long-term follow-up

OBJECTIVE In our previous study on 4334 hyperthyroid patients treated with thyroidectomy1, the risk of hospitalization due to cardiovascular diseases (CVD) started to increase before the thyroidectomy and by the time of the operation it was 1.50-fold in the hyperthyroid patients compared to the controls. After the thyroidectomy, the hospitalizations due to all CVDs remained more frequent among the patients up to 20 years after thyroidectomy (1.15). However, there was no increase in cardiovascular mortality (RR 0.91). The aim of this study was to compare the effect of two different treatment modalities, i.e. radioactive iodine (RAI) and surgery, on cardiovascular morbidity and mortality in hyperthyroid patients.

PATIENTS AND MEASUREMENTS A population-based cohort study was conducted among 1819 hyperthyroid patients (median age 59 years) treated with RAI in 1986-2007 in Tampere, Finland, 5441 age- and gender matched  reference subjects, and among  4334 hyperthyroid patients (median age 46 years) treated with thyroidectomy. Firstly, the hospitalizations due to CVDs were analyzed until the treatment with RAI. Secondly, the hazard ratios for any new hospitalization due to CVDs after the administration of RAI were estimated in a Cox regression analysis adjusted with the prevalent CVDs at the time of RAI therapy. Thirdly, hospitalization and mortality rates were compared between the patients treated with RAI and those treated surgically, adjusted with the prevalent CVDs, age and gender.

RESULTS The risk of hospitalization due to CVDs increased years before the RAI treatment and by the time of the tretament it was 1.81-fold in the patients compared to the controls (p< 0.001). After the RAI therapy, the hospitalizations due to all CVDs (HR 1.23), hypertension (HR 1.26), heart failure (HR 1.25), arrhythmias (1.18), valvular diseases or cardiomyopathies (HR 1.68) and cerebrovascular diseases (1.34) remained more frequent among the patients up to 20 years after RAI therapy. Cardiovascular mortality was also higher in the patients compared to the control group (1.24). In a Cox regression analysis including the patients treated with RAI for hyperthyroidism and the patients treated surgically, the RAI-treated patients had a higher risk of CVDs (RR 1.14, 95 % CI 1.03-1.26) and atrial fibrillation (RR 1.28, 95% CI 1.08-1.53) after treatment compared to thyroidectomy-treated, when adjusted for age, gender and prevalent CVDs.

CONCLUSIONS The present study shows that hyperthyroidism increases the risk of hospitalization due to CVDs before the treatment, and the risk is sustained up to two decades after treatment with RAI.  In long-term follow-up, patients treated with RAI remain at a higher CVD risk compared to patients treated with thyroidectomy.

 

Nothing to Disclose: ER, JS, PJ, HH, RS, MV, AA, SM

PP29-1 14738 1.0000 MON-0468 A Cardiovascular Risk in Hyperthyroidism Treated with RAI or Thyroidectomy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 11:30:00 AM PP29 4922 11:15:00 AM Non-Neoplastic Thyroid Disorders; Thyroid Case Reports Poster Preview

Danilo Villagelin*1, Roberto Bernando Santos2, Marilia Bortolotto Felippe2, Rebeca Barbosa Carbinatto2, Jakeline Neves Giovanetti2, Heloisa Neumann Nogueira2, Larissa Campos Silva2, Laura Sterian Ward3 and Joao Hamilton Romaldini4
1Pontificia Universidade Catolica de Campinas and University Campinas Laboratory of Cancer Molecular Genetics, Brazil, 2Pontificia Universidade Catolica de Campinas, Brazil, 3University of Campinas, Campinas,SP, Brazil, 4Pontificia Universidade Católica de Campinas and HSPE-IAMSPE, Sao Paulo, Brazil

 

There is no consensus regarding the best therapy for Graves' disease (GD) or GD ophthalmopathy (GO), especially for the more than 50% patients that relapse after antithyroid drugs (ATD). Prolonging the use of methimazole (MMI) could be interesting not just for euthyroidism restoration, but also because ATD interfere with the mechanism of immune disease. This effect could be particularly beneficial for patients with GO.

The aim of this study was to evaluate the effectiveness, safety and quality of life in patients treated with long-term low MMI doses, compared with patients treated with radioiodine (RAI) after GD relapse.

Two hundred e thirty three out of an initial group of 418 GD patients older than 18 years treated with MMI for 12-24 months relapsed after discontinuation of ATD. They were divided into two groups: group A was treated with RAI (10-15mCi) and group B was treated with low MMI doses (2.5-5 mg / day) for 12-240 months (median: 92 months, 98 ± 43 months). Serial measurements of thyroid function and Active Clinical Score (CAS) were performed every three months during the first year and every six months. In addition patients who had been euthyroid for at least 6 months were submitted to a quality of life assessment using Short Form Health Survey questionnaire.

The groups were similar concerning age, gender, ethnicity, body mass index, smoking, antithyroid antibodies, TRAb, thyroid volume, initial concentrations of TSH, free T4 and CAS values. Group B patients showed better GO improvement than group A patients. CAS at 12 month: 0.86 ± 1.03 vs. 1.86 ±1.59, p<0.001; CAS 24 month: 0.60 ± 0.88 vs. 2.47 ± 1.57 p<0.0001; CAS 36 month: 0.53 ± 0.74 vs. 2.38 ± 1.57 p <0.0001; CAS 48 months: 0.23 ± 0.44 vs. 2.73 ± 1.45 p<0.001, respectively. Concerning thyroid status, group B patients had a higher number of periods in euthyroidism (57% vs. 40%, p <0.0001) and less periods of overt or subclinical hypothyroidism (6% vs. 18%, p <0.001 and 4% vs. 10%, p=0.003, respectively) than group A patients. There was no difference in the quality of life of the two groups.

We demonstrated that continuing treatment with low doses of MMI does not affect the quality of life, induces a greater frequency of euthyroidism and produces better results in terms of eye disease than treating GD patients who relapsed with RAI. We conclude that the long-term use of low doses of MMI can be an interesting option for GD patients who had a recurrence, especially concerning GO evolution.

 

Disclosure: LSW: Board Member, Abbott Laboratories, Board Member, Sanofi. Nothing to Disclose: DV, RBS, MBF, RBC, JNG, HNN, LCS, JHR

PP29-2 13500 2.0000 MON-0470 A The Prolonged Use of Low Doses of Methimazole Is an Interesting Therapeutic Alternative for Relapsed Graves' Disease Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 11:30:00 AM PP29 4922 11:15:00 AM Non-Neoplastic Thyroid Disorders; Thyroid Case Reports Poster Preview

Na Zhang*, Lingyan Wang, Qi Duan, Uzair Khan and Xiaomei Yao
Department of Pathophysiology, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China, 300070.

 

AIM: Epidemiological studies showed that iodide excess may lead to hypothyroidism, hyperthyroidism, euthyroid goiter and thyroid autoimmunity. Oxidative stress has been one of the underlying mechanisms. Metallothioneins are regarded as scavengers of reactive oxygen species (ROS), including superoxide. Mitochondria are the primary site of action of thyroid hormones and the major intracellular source of ROS. We aim to understand the effect of high concentrations of iodide on mitochondrial superoxide production in the thyroid of metallothionein I/II knockout (MT-I/II KO) mice.

METHODS: Eight-week-old 129S7/SvEvBrd-Mt1tm1BriMt2tm1Bri/J(MT-I/II KO) mice and 129S7/Sv (Wildtype, WT) mice were used. In vitro study, thyroid cell suspension were prepared and exposed to high concentrations of KI or H2O2 for 2 hours. In vivo study, MT-I/II KO and WT mice were randomly divided into control groups and 100 times high iodide groups (100 HI). Control groups received deionized water and normal diet (daily iodide uptake is 1.5μg /d). In 100 HI groups, KI 150μg /d was added to the deionized water for 14 days before sacrifice. MitoSOX Red was used to measure intramitochondrial superoxide production by flow cytometry. Cell viability and lactate dehydrogenase (LDH) activity were measured.

RESULTS: In vitro study, following 100μM, 1 mM, 10 mM of KI, or 1 mM H2O2 exposure for 2 hours, the mitochondrial superoxide production exhibited a significantly increased MitoSOX Red fluorescence intensity, with increased LDH activity and decreased relative cell viability in both MT-I/II KO and WT groups. More significant increase of mitochondrial superoxide production can be detected in MT-I/II KO groups than in WT groups. Besides, we demonstrated that 6-propyl-2-thiouracil (PTU, 300μM), or perchlorate (KClO4, 30μM) can inhibit 100μM KI induced strong mitochondrial superoxide production in both MT-I/II KO and WT groups. In vivo study, significantly higher concentrations of urinary iodine level can be detected in MT-I/II KO mice than in WT mice. Compared to control groups, the mitochondrial superoxide production were significantly increased in 100 HI groups in the thyroid of both MT-I/II KO and WT mice, with significantly increased LDH activity and decreased relative cell viability, more significant changes can be detected in MT-I/II KO mice than in WT mice.

CONCLUSIONS: High concentrations of iodide may lead to significant increase of mitochondrial superoxide production in both vitro and vivo study. MT-I/II may potentially protect the thyroid against high concentrations of iodide induced oxidative stress. KClO4 (the competitive inhibitor of iodide transport) or PTU (the inhibitor of thyroid peroxidase) may relieve the effect of high concentrations of iodide induced significantly increased mitochondrial superoxide production.

 

Nothing to Disclose: NZ, LW, QD, UK, XY

PP29-3 12565 3.0000 MON-0464 A Effect of High Concentrations of Iodide on Mitochondrial Superoxide Production of Metallothionein I/II Knockout Mice in Thyroid 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 11:30:00 AM PP29 4922 11:15:00 AM Non-Neoplastic Thyroid Disorders; Thyroid Case Reports Poster Preview

Amanda Shinzato*1, Antonio M Lerario2, Debora Lucia Seguro Danilovic3, Chin Jia Lin4, Suemi Marui5 and Ericka Barbosa Trarbach6
1Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 2Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 3FMUSP, Sao Paulo, Brazil, 4Univ of Sao Paulo, Sao Paulo SP, Brazil, 5Faculdade de Medicina USP, Sao Paulo SP, Brazil, 6Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Previous results demonstrated a high proliferative status of thyroid follicular cells and goiter in tissue-specific mutants mice with Pten loss or Dream overexpression(1;2). In humans, a large percentage of patients with Cowden disease have goiters or other thyroid abnormalities associated with germ-line PTEN mutations. The aim of this study was to investigate the tissue expression of PTEN and DREAM, as well as germ-line and somatic PTEN mutations and somatic DREAM mutations, in patients with multinodular goiter (MNG). We evaluated 60 MNG patients (55 females). Genomic DNA and/or RNA were extracted from both patients' hyperplastic thyroid tissue and peripheral blood. Relative quantification of PTEN and DREAM mRNA was evaluated using 2-ΔΔCt method, normalized to GAPDH expression, on data produced by real-time PCR. PTEN and DREAM over and lower expression were respectively defined by value 2.0-fold (or greater) and 0.5-fold (or smaller) relative to a commercial pool of normal human thyroid RNA. Mutations analyses were performed by amplification of PTEN and DREAM coding region by PCR followed by automatic sequencing. RQ = relative quantification; M = median; SD = standard deviation. We observed a high expression of PTEN in 56.7% of MNG patients with RQ M of 3.3 (SD = 1.4), and only one case with lower expression (RQ = 0.27). In the remaining cases (41.7%), PTEN expression was normal (RQ M = 1.30; SD = 0.33). In fact, PTEN had been shown to be overexpressed in benign proliferative and typical endometrium hyperplasia(3), with PTEN loss of expression related only to carcinomas and earliest precancerous lesions(4). For the DREAM gene, the most cases of MNG (63.4%) had normal expression with RQ M of 1.21 (SD = 0.37). Over and lower expression of this gene were observed in 28.3% (RQ M = 3.5; SD = 5.7) and 10% (RQ M = 0.4; SD = 0.14) of the cases, respectively. Regarding PTEN and DREAM mutations analysis, only previously described intronic polymorphisms were observed in DNA from blood and/or thyroid hyperplastic tissue. In conclusions, our results demonstrated that PTEN expression is higher in MNG suggesting that this gene is overregulated (or at least has its expression maintained) in this benign hyperplastic thyroid lesions. No evidence for the correlation of DREAM overexpression and pathogenesis of human goiters was observed in our cohort of MNG patients. In addition, no mutations or new rare variants in DNA sequence of DREAM and PTEN were detected.

 

Nothing to Disclose: AS, AML, DLSD, CJL, SM, EBT

PP29-4 14801 4.0000 MON-0466 A Molecular Investigation of PTEN and DREAM Genes in Patients with Multinodular Goiter 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 11:30:00 AM PP29 4922 11:15:00 AM Non-Neoplastic Thyroid Disorders; Thyroid Case Reports Poster Preview

Donato Iacovazzo*1, Patrick J. Morrison2, William Foulkes3, Douglas S Ross4, Francesca Lugli5, Plamena Gabrovska1, Emanuela Lucci-Cordisco6, Laura De Marinis5 and Márta Korbonits7
1Barts and The London School of Medicine, London, United Kingdom, 2Belfast City Hospital, Belfast, United Kingdom, 3McGill University, Montreal, Canada, 4Mass General Hospital, Boston, MA, 5Università Cattolica del Sacro Cuore, Rome, Italy, 6Catholic University, Rome, Italy, 7William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom

 

Familial medullary thyroid carcinoma (MTC) accounts for approximately 25% of MTC cases, and can occur either as part of MEN2-syndrome or as isolated familial MTC (fMTC), defined as more than 10 carriers in the kindred, or multiple carriers or affected members over the age of 50 with an adequate medical history excluding pheochromocytoma. Most MEN2 families (98%), as well as fMTC kindreds (88%), harbour a mutation in the proto-oncogene RET. Moreover, about 7% of apparently sporadic MTC cases carry a RET mutation. Somatic RET mutations in sporadic MTC tumour samples have been identified in 40-50% of cases, while more recently somatic RAS mutations have been identified in 13% of cases from different studies. There are very few reports about RET mutation-negative fMTC. An Italian study analysed 250 families with hereditary MTC and 6 families (2.4%) were RET mutation-negative (Romei C. et al, EJE 2010).

Here we report 4 families with RET mutation-negative fMTC-like phenotype: an Italian family with 11 affected members, a Greek family with 5 affected, a family from Northern Ireland with 3 affected and an Italian-Argentinian family with 2 affected subjects. Several affected members in these families underwent genetic testing, but no mutations have been found of germline DNA at direct sequencing of the whole-coding sequence of RET. Moreover, somatic hotspot RET (M918T, C634, A883F) and RAS mutations (HRAS, KRAS, NRAS – codons 12, 13, 61) have been searched in an MTC tissue sample from the Italian family, but no mutations have been identified. In these families an autosomal dominant inheritance pattern was observed together with high penetrance. The mean age at diagnosis in these patients is 37 yrs (SD 16.4), and interestingly only 2 out of 21 patients presented with distant metastasis at diagnosis, suggesting a possibly better prognosis compared to RET-related fMTC.

Identification of the disease causing mutations in these families might reveal a novel pathway and drug target in MTC.

 

Disclosure: DSR: Consultant, Novo Nordisk, Consultant, Bayer, Inc.. MK: Advisory Group Member, Pfizer, Inc., Investigator, Pfizer, Inc., Investigator, Novartis Pharmaceuticals. Nothing to Disclose: DI, PJM, WF, FL, PG, EL, LD

PP39-1 16663 1.0000 MON-0546 A Four Families with RET-Mutation Negative Familial Medullary Thyroid Carcinoma: What Lies Beyond RET? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 11:30:00 AM PP39 4925 11:15:00 AM Thyroid Neoplasia Poster Preview

Alessandro Antonelli*, Silvia Martina Ferrari, Guido Bocci, Concettina La Motta, Gabriele Materazzi, Andrea Di Domenicantonio, Romano Danesi, Federico Da Settimo, Paolo Miccoli and Poupak Fallahi
University of Pisa, Pisa, Italy

 

Anaplastic thyroid carcinoma (ATC) is an endocrine malignancy, rare and rapidly fatal and the mean survival is approximately 6 months. The most effective therapy for ATC is multimodal treatment protocol that include surgery, chemotherapy (doxorubicin and cisplatin), and hyperfractionated accelerated external beam radiotherapy, with a median patient survival of 10 months. An increase in the effectiveness of the treatment could be made possible testing the sensitivity of “primary anaplastic thyroid cancer cells” (pATC) from each subject to different drugs, avoiding the administration of inactive therapeutics. In this study, we tested the antineoplastic effect of two new “pyrazolo[3,4-d]pyrimidine” compounds (CLM3, CLM29) in pATC obtained both from biopsy (biop-pATC), or from fine needle aspiration (FNA-pATC). Primary biop-pATC or FNA-pATC cultures were both established from 5 patients. The concentrations of CLM29 and CLM3 used in the in vitro experiments were 1, 10, 30, 50 µM. A significant reduction of proliferation was shown in FNA-pATC, or biop-pATC, cells by WST-1 assay respect to the control, in particular with CLM29, and slightly with CLM3. Both compounds increased the percentage of apoptotic cells in FNA-pATCs, or biop-pATC, dose-dependently. Our results demonstrate no significant differences in sensitivity to CLM29 or CLM3 between the tested ATC cells from FNA, or biopsy. In conclusion: 1) primary FNA-pATC cells have a sensitivity to tyrosine kinase inhibitors (TKIs) agents quite similar to that observed in primary cells from biopsy (biop-pATC), and for this reason the use of primary FNA-pATC cells for the tests can reduce the time needed for biopsy; 2) CLM29 and CLM3 are effective in reducing cell growth, increasing apoptosis in ATC; 3) the possibility to test senitivity to different TKIs in each patient is able to increase the efficacy of treatments, avoiding the administration of ineffective drugs.

 

Nothing to Disclose: AA, SMF, GB, CL, GM, AD, RD, FD, PM, PF

PP39-2 12600 2.0000 MON-0554 A Evaluation of the Antineoplastic Activity of Two Tyrosine Kinase Inhibitors, CLM29 and CLM3, in Primary Cultures from Anaplastic Thyroid Cancer, Obtained from Fine Needle Aspiration 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 11:30:00 AM PP39 4925 11:15:00 AM Thyroid Neoplasia Poster Preview

Nikita Pozdeyev*1, William M Wood1, Laura A Pike2, Kelsey Wuensch3, Hiroyuki Shibata4 and Bryan R Haugen1
1University of Colorado, Aurora, CO, 2University of Colorado Medical School, Aurora, CO, 3University of Colorado Anschutz Medical Campus, Aurora, CO, 4Akita University, Akita, Japan

 

Docetaxel chemotherapy and external beam radiotherapy are used for the treatment of advanced forms of thyroid cancer not amenable to surgical excision, radioactive iodine therapy or TKI therapy. The efficacy of these treatment modalities is limited by the development of chemo- and radioresistance by tumors. It was shown that, in non-endocrine cancers, NF-κB signaling is increased by chemo- and radiotherapy contributing to tumor survival and escape from the treatment. In the current study we tested whether a similar effect is observed in thyroid cancer cell lines. For this purpose we constructed a lentiviral vector containing a Renilla luciferase reporter driven by a minimal c-fos promoter just downstream of four NF-κB response elements and transduced this into thyroid cancer cells already expressing firefly luciferase driven by a constitutive CMV promoter as a non- NF-κB-regulated control. We showed that docetaxel treatment for 48 hrs or longer increases NF-κB activity (Renilla luciferase/Firefly luciferase) in papillary (BCPAP) and anaplastic (8505C) thyroid cancer cell lines in vitro in a dose dependent manner. A 3.4- and 1.8-fold increase in reporter activity in BCPAP and 8505C cells, respectively, was observed after they were exposed to 5 nM of docetaxel for 48 hrs (p<0.005). This effect was abrogated by the NF-κB pathway inhibitors bortezomib (≥10 nM) and GO-Y030 (≥0.25 µM). Ionizing radiation at a dose of 2 and 5 Gy also activated the NF-κB pathway in thyroid cancer cells. A 1.4- and 1.5-fold increase in reporter activity was demonstrated at 72 hrs after a 5 Gy dose of ionizing radiation in BCPAP and 8505C cells, respectively (p<0.01). This finding was confirmed in irradiated BCPAP cells by showing an increased binding of nuclear p65 to NF-κB binding sites using an ELISA assay. These effects were blocked by an overexpression of a mutated form of IκBα which, as a result of impaired degradation, retains p65 in the cytoplasm. Finally, we have demonstrated that the dual luciferase reporter activity is measurable in a mouse orthotopic model of anaplastic thyroid cancer (8505C cells) allowing monitoring of tumor NF-kB activity in vivo. These in vitro and in vivo models will allow testing of our hypothesis that transient inhibition of NF-κB pathway will prove to be a useful combination therapy with radiation and chemotherapy in advanced thyroid cancer.

 

Nothing to Disclose: NP, WMW, LAP, KW, HS, BRH

PP39-3 15228 3.0000 MON-0544 A The NF-κb Pathway Is Activated By Chemotherapy and Radiation in Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 11:30:00 AM PP39 4925 11:15:00 AM Thyroid Neoplasia Poster Preview

WanMing 2164442714 Zhang1, Manjula K Gupta*2, Eren Berber1, Christian E Nasr1, Allan E Siperstein1 and Kresimira M Milas3
1Cleveland Clinic, Cleveland, OH, 2Cleveland Clin Fndn, Cleveland, OH, 3Oregon Health Science University, Portland, OR

 

Background:  While thyroid nodules are remarkably common, there is still considerable diagnostic challenge to accurately identify which nodules are malignant lesions. We have previously reported an effective use of the  relative quantitative real-time RT-PCR assay for TSH receptor mRNA (TSHR) as a marker of circulating cancer cells in blood that utilized thyroid cancer tissue total mRNA as reference preparation[JCEM 92:468, 2007]. We have revalidated this assay using synthesized mRNA copy number for absolute quantitation of TSHR mRNA. The performance of this test in routine clinical practice is reassessed for preoperative diagnosis of thyroid cancer and compared to FNAb results. We also attempted to correlate TSHR mRNA levels with BRAF mutation detected in surgical specimens.

Patients and Method:  TSHR mRNA levels in peripheral blood mononuclear cells were measured by a real-time RT-PCR (qRT-PCR) assay. Complemented RNA (cRNA) for TSHR was synthesized and used for calibration and results were expressed as copy number per reaction. Total of 70 patients (thyroid cancer 38, benign controls 32) who underwent thyroid surgery and had final pathologic diagnosis were analyzed by both relative and absolute qRT-PCR methods. Among these 70 patients, 54 had FNAb prior to surgery and 26 had BRAF mutation analyzed post-surgery. TSHR mRNA results from thyroid cancer patients were compared with controls using non-parametric method.  Clinical sensitivity and specificity was analyzed using receiver operating curve (ROC) analysis.

Results:The absolute copy number of TSHR showed excellent correlation with the relative qRT-PCR assay using cancer tissue total RNA as standard [R=0.99;P<0.0001]. Copy number had analytical linearity over 100-7000000 copy per reaction. The intra- and inter-assay variations were 7 and 16%, respectively. The patients with thyroid cancer had significantly higher copy number than those of benign controls (median 1212 vs. 534, P=0.0001). Using a cutoff level of 918 copy/microliter, TSHR mRNA showed a 68% sensitivity and 78% specificity [PPV=79%; NPV=68%] in differentiation of malignant nodules from benign nodules with overall accuracy of 73%. In contrast FNAb only correctly classified 39% of patients [PPV=100%; NPV 54%] and 42% patients had indeterminate results. Furthermore, TSHR mRNA correctly classified 65% of indeterminate FNA (15 out of 23) and may have prevented some unnecessary surgeries. TSHR mRNA copy numbers were not correlated to pathological stages (P=0.095) or B-RAF mutation status(P=0.68 in tumor tissue.

Conclusions: TSHR qRT-PCR assay showed considerable pre-operative diagnostic accuracy for thyroid cancer, the copy number of TSHR mRNA is a sensitive indicator of cancer detection. The copy number of TSHR mRNA in blood is not correlated to pathological stage and to BRAF status of tumor.

 

Nothing to Disclose: WZ, MKG, EB, CEN, AES, KMM

PP39-4 16092 4.0000 MON-0545 A Clinical Performance of Absolute Quantification of TSH Receptor mRNA As a Diagnostic Marker for Circulating Thyroid Cancer Cells: Comparison with FNA Biopsy for Thyroid Cancer Detection 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 11:30:00 AM PP39 4925 11:15:00 AM Thyroid Neoplasia Poster Preview

Ali Naderi*
University of Iowa, Iowa City, IA

 

Prolactin-Induced Protein (PIP), also known as GCDFP-15, is widely expressed in breast cancer and has been used as a characteristic biomarker for the diagnostic evaluation of this disease. Recent studies have revealed that PIP is highly expressed in luminal A and molecular apocrine subtypes of breast cancer and is one of the best biomarkers for the immunohistochemical identification of molecular apocrine tumors (1-3). It is known that PIP expression is regulated by prolactin and androgen hormones (4, 5). In particular, androgen receptor (AR) engages in a transcriptional cooperation with prolactin-activated Stat5 and Runx2 to regulate PIP expression. Although, it has been shown that purified PIP promotes growth of breast cancer cells and PIP expression is necessary for the proliferation of T-47D and MDA-MB-453 cell lines (1, 5, 6), the molecular mechanisms of PIP function in breast cancer have remained largely unknown. In this study, we carried out a comprehensive investigation of PIP function in breast cancer using PIP-silencing in seven breast cancer cell lines that encompassed luminal A, luminal B, and molecular apocrine subtypes. In addition, we carried out analysis of expression microarray data, performed proteomic analysis using mass spectrometry to identify PIP-binding partners, and studied correlation of PIP expression with various biomarkers in primary breast tumors. We discovered that PIP is required for the progression through G1 phase, mitosis, and cytokinesis in luminal A, luminal B, and molecular apocrine breast cancer cells. In addition, PIP expression is associated with a transcriptional-signature enriched with cell cycle genes and regulates key genes in this process including Cyclin D1, Cyclin B1, BUB1, and FOXM1. Importantly, we have identified novel PIP-binding partners in breast cancer and shown that PIP binds to β-tubulin and is necessary for microtubule polymerization in breast cancer cells. Furthermore, PIP interacts with actin-binding proteins including Arp2/3 and is needed for inside-out activation of integrin-β1 mediated through talin. This study suggests that PIP is required for cell cycle progression and regulation of cytoskeletal proteins in breast cancer with a significant function in proliferation and motility of breast cancer cells. Our findings provide a rationale for exploring PIP inhibition as a therapeutic approach in breast cancer that can potentially target microtubule polymerization.

 

Nothing to Disclose: AN

PP32-1 12300 1.0000 MON-0289 A Prolactin-Induced Protein Regulates Key Phases of Cell Cycle in Breast Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 11:30:00 AM PP32 4927 11:15:00 AM Hormone Dependent Tumors Poster Preview

John Mark P Pabona, Alexander F Burnett, Frank A Simmen, Rebecca Stone, Charles M Quick, Rosalia CM Simmen and Maria Theresa E Montales*
University of Arkansas for Medical Sciences, Little Rock, AR

 

Endometrial cancer (EC) is the most commonly diagnosed gynecologic malignancy. Early stage disease has a 5-year survival rate of 90%, but prognosis is worsened with increasing stage. Other than surgical removal of the uterus, there is no current definitive treatment for EC. Impaired glucose tolerance and diabetes are risk factors for EC development. In limited epidemiological studies, the oral biguanide metformin (Met) commonly used for the treatment of Type 2 diabetes was shown to lower mortality rate in diabetic EC patients. Nevertheless, a direct effect of Met to inhibit EC development or growth has not been fully elucidated. We previously reported the loss of expression of transcription factor KLF9 in endometrial tumors relative to adjacent uninvolved endometrium of women with EC. KLF9 is a PGR co-regulator in uterine cells; we and others have reported attenuated PGR and/or KLF9 expression in a number of uterine pathologies (e.g. endometriosis, infertility, EC) associated with progesterone (P) resistance. To understand the mechanism of Met action for its potential application in EC chemoprevention and therapy, we treated human Ishikawa EC cells with Met (5 μg/ml; physiologically relevant) and evaluated the temporal expression of PGR, KLF9 and other endometrial genes (PTEN, KLF4, cFOS, TERT, p53) shown to be dysregulated in EC. Met temporally increased KLF9 transcript levels (2.4X, 2h; 4.5X, 48h) coincident with those of total PGR and PGR-B (4.5X and 2X, respectively; 48h), relative to untreated cells. Met similarly increased PTEN (2X, 48h), KLF4 (3.5X, 2 h), cFOS (3X, 48h) and TERT (6X, 48 h) but not p53 transcript levels. To determine if KLF9 mediates Met effects, siKLF9 targeting was used to knockdown KLF9 (by 80%) and the expression of these same genes was evaluated. Total PGR and PGR-B transcript levels were higher in cells treated with Met+siKLF9 than with Met+control siRNAs. By contrast, the expression of all other genes did not differ between the treatment groups. Our results suggest that Met administration maintains PGR expression and hence, PGR sensitivity in EC even after the loss of KLF9 expression. A randomized pilot study to test the efficacy of short course Met vs. No Therapy on uterine proliferation and P-sensitivity in the period prior to hysterectomy in non-diabetic EC patients is ongoing (NCT01877564). These findings may have significant implications for use of Met in chemoprevention of EC and other P-resistant uterine pathologies.

 

Nothing to Disclose: JMPP, AFB, FAS, RS, CMQ, RCS, MTEM

PP32-2 16036 2.0000 MON-0307 A Metformin Induces Progesterone Receptor (PGR) and PGR Co-Regulator Krüppel-like Factor 9 (KLF9) Gene Expression in Endometrial Carcinoma Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 11:30:00 AM PP32 4927 11:15:00 AM Hormone Dependent Tumors Poster Preview

Suman Rice*1, Laura Pellatt2, Arba Ahmetaga3, Helen Diane Mason1 and Saffron Ann Whitehead3
1St George's Univ of London, London, United Kingdom, 2Bromley College of F&HE, Bromley, United Kingdom, 3St Georges University of London, London, United Kingdom

 

Evidence has been accumulating for an anti-cancer role for metformin and that it reduces breast cancer risk in post-menopausal women1. It inhibits growth of breast cancer cells both in vivo and in vitro and, whilst several different mechanisms have been investigated, the greatest focus has been on the AMPK/mTOR signalling pathway2,3. Another possible protective mechanism is by metformin’s ability to inhibit aromatase activity in breast adipose tissue. The aim of this study was two-fold: firstly to investigate the effects of metformin on the basal growth of MCF-7 cells, after stimulation with oestradiol and subsequently after inhibition of mTOR with rapamycin.  Secondly, to investigate the action of metformin on the mRNA expression and activity of a number of steroidogenic enzymes. High doses of metformin (10-2 and 5×10-3M) significantly inhibited both basal and oestrogen-stimulated cell division (p<0.001, 0.01, Tukeys Multiple Comparison Test). Surprisingly addition of rapamycin (10-10M) to doses of metformin that on their own were not inhibitory, did induce a significant (p<0.05) reduction in growth. As expected rapamycin at a higher dose (10-8M) inhibited growth (p<0.003), but again the addition of metformin produced a further attenuation. This highlights a potential therapeutic role for metformin in conjunction with rapamycin analogues in the inhibition of growth of breast cancer cells. Exposure to low dose metformin (10-7M) for 7-10 days significantly (p<0.005) reduced the conversion of androstenedione and testosterone (both requiring aromatase), but not the conversion of oestrone or oestrone sulphate (via 17b-HSD/sulphatase) to oestradiol. A similar reduction in aromatase activity was seen with the higher dose of 10-4M metformin though the inhibition was more marked and occurred after 3 days exposure. This attenuation was via a down-regulation in promoter II mRNA expression, which is aberrantly switched on in malignant breast cells4. In conclusion, metformin at achievable plasma levels could have a dual therapeutic action in the prevention of breast cancer. First, by inhibition of cell growth via enhancement of the inhibition of the mTOR signalling pathway and attenuation of oestrogen-stimulated growth. Secondly, by inhibition of aromatase synthesis/activity that is pivotal to the local conversion of androgens to oestrogens in breast tissue, which drives hormone-responsive tumour growth.

 

Nothing to Disclose: SR, LP, AA, HDM, SAW

PP32-3 14475 3.0000 MON-0298 A The Dual Inhibitory Effect of Metformin on Growth and Oestradiol Production in Breast Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 11:30:00 AM PP32 4927 11:15:00 AM Hormone Dependent Tumors Poster Preview

Megan E Zavorka*, Christopher M Connelly and Richard G MacDonald
Univ Nebraska Med Ctr, Omaha, NE

 

Insulin-like growth factor II (IGF-II) binds and activates the IGF-I receptor (IGF1R), leading to increased metabolism, proliferation and survival.  IGF-II is often over-expressed in many IGF-dependent cancers, such as in the liver, prostate, and pancreas.  IGF-II also binds to the mannose 6-phosphate/IGF-II receptor (M6P/IGF2R).  M6P-based ligands bind to repeats 3 and 9 of the M6P/IGF2R ectodomain and mediate lysosomal enzyme trafficking, while exogenous IGF-II binds to domain 11 and is internalized to the lysosome.  Cross-bridging the M6P/IGF2R into a dimeric structure by bivalent M6P-based ligands increases the receptor’s internalization rate; therefore, we hypothesize that increased internalization of M6P/IGF2R caused by bi- or multivalent M6P-ligands induces cross-bridging and increases degradation of the passenger ligand IGF-II, resulting in inhibition of cell proliferation by reducing bioavailability of IGF-II for IGF1R.  Our goal is to synthesize new bivalent M6P-based ligands that bind with high affinity in a bi- or multivalent way that will stimulate internalization of IGF-II, acting as a tumor suppressor and serving as a novel treatment option for IGF-dependent cancer.  Various multivalent M6P-based ligands were synthesized by coupling pentamannosyl 6-phosphate (PMP) to ovalbumin and the tripeptide Ser-Tyr-Lys by reductive amidation.  These PMP-ligands were studied to determine the smallest ligand that can bivalently bind the M6P/IGF2R with high affinity.  Using radioligand displacement assays, PMP- ovalbumin and PMP-Ser-Tyr-Lys bound with high affinity (IC50 values of 21 nM and 52 nM, respectively) to soluble bovine M6P/IGF2R when compared to the monovalent M6P (IC50= 8 µM).  Promising proof-of-principle studies in several cancer cell lines show that cell proliferation can be inhibited by 10 nM PMP-ovalbumin or PMP-Ser-Tyr-Lys.  Furthermore, this inhibition of cellular growth can be abrogated by add back of 10 mM M6P, which we have shown in vitro competitively displaces the PMP-ligands from the M6P/IGF2R.  Gel-shift assays reveal that these PMP-ligands are able to dimerize two M6P/IGF2Rs, revealing that the M6P moieties on the PMP-ligands are spaced far enough apart to span the necessary distance (~30 Å) to cross-bridge the receptor.  The mechanism of cellular growth suppression appears to be due to depletion of IGF-II from the culture medium, since add back of recombinant IGF-II to a concentration of 10 nM rescues the effect.  We can conclude that targeting the M6P/IGF2R with bi- and multivalent M6P-based ligands inhibits IGF-induced proliferation in several cancer cell lines, and may serve as a novel therapeutic option for IGF-dependent cancers by a modified ligand-trap type mechanism.

 

Nothing to Disclose: MEZ, CMC, RGM

PP38-2 12020 2.0000 MON-0328 A Mannose 6-Phosphate (M6P)-Based Ligands for the M6P/Insulin-like Growth Factor II Receptor Inhibit IGF-II-Dependent Growth of Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 11:30:00 AM PP38 4928 11:15:00 AM Therapies for Cancer Poster Preview

Tony Antakly*1, Emil Toma2 and Jose Menezes1
1Univ of Montreal, Montreal, QC, Canada, 2U Montreal, Montreal, QC, Canada

 

The urine contains known compounds that play important roles in key physiological functions and it may contain as yet undiscovered molecules with potential therapeutic properties. In previous studies, we have isolated small molecular weight factors called HIP from human urine which potently block the growth of several types of cancers including AIDS-Kaposi’s sarcoma (Nature Biotechnol 15, 1228). Subsequently, we and others have attempted to purify HIP to homogeneity. To date, the chemical identity as well as the exact signaling mechanisms have remained elusive. In order to efficiently characterize this molecule, we undertook a systematic approach to decipher the molecular components of HIP.  Chromatographic purification and high-resolution fractionation showed that the active moiety comprises more than one molecular species, two of which are required for full biological activity.  Using proteomics, metabolomics and nuclear magnetic resonance spectroscopy (NMR), we have now identified these components and tested their anti-cancer activity using a bioassay platform. Characterization was done by proteomics (QTOF-2, LC mass spectrometer (LC)-QTOF liquid chromatography) and NMR (950 MHz). Results indicate that the active moiety of HIP is a small metabolite. This small molecule binds to a hydrophilic “pocket” of a small peptide. The situation of HIP is not unique, since recently accumulating data indicate that small molecular weight molecules, which otherwise do not possess functional activity, can be turned into potent bioactive molecules once metabolized or following their binding with other molecules. This study allowed us to synthesize HIP in an attempt to use it as a therapeutic anti-cancer product. To this end, our recent preliminary HIP human clinical trial data suggest the active agent is well tolerated and effective.

 

Nothing to Disclose: TA, ET, JM

PP38-4 17039 4.0000 MON-0329 A Small Molecules from Human Urine Bound to HCG Display Potent Anti-Cancer Activity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 11:30:00 AM PP38 4928 11:15:00 AM Therapies for Cancer Poster Preview

Samuel Zuber*1, Robert Wesley2, Graeme Eisenhofer3, Karel Pacak4 and Vitaly Kantorovich5
1Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 2National Institutes of Health, Bethesda, MD, 3University Hospital Carl Gustav Carus, Dresden, Germany, 4National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, 5University of Connecticut Health Center, Farmington, CT

 

Background: Adrenal pheochromocytomas (PHEO), diffuse sympathetic paragangliomas (sPGL), and parasympathetic head and neck paragangliomas (HNPGL) related to mutations in genes encoding subunits B and D of the succinate dehydrogenase complex (SDHB/SDHD) represent a unique subgroup among hereditary catecholamine-secreting tumors. These tumors are frequently clinically asymptomatic, biochemically silent and display immature secretory profile - dopamine rather than norepinephrine. While SDHB-related tumors are inherently more aggressive and prone to malignancy, tumors associated with SDHD mutations affect multiple parasympathetic ganglia and show little secretory activity. Measurement of plasma/urinary catecholamine metabolites, especially normetanephrine, represents a gold standard in biochemical detection of these tumors, although silent biochemical presentation, suboptimal diagnostic sensitivity, occasional cost prohibition, delay or lack of availability suggests the need of readily available backup biomarker. Chromogranin A (CgA) levels can raise several fold in neuroendocrine tumors and have been suggested as valuable in workup of sporadic and hereditary forms of PHEO/PGL. Objective: To test this hypothesis, we compared performance of CgA and NMN in the NIH cohort of most challenging diagnostic groups - 41 patients with SDHB-related PHEO/PGL, 18 patients with SDHB/D - related HNPGL and a large cohort of healthy SDHB mutation carriers. Results:  In the SDHB group, CgA showed sensitivity of 73.2% and specificity of 95.9%, while for NMN they were 70.7% and 98.6%, respectively. Elevations in CgA and NMN were complementary in 92.7% of patients with proven tumors. Both tests performed well on receiver operating characteristic (ROC) curve analysis. CgA levels were elevated in 76.9% of SDHB patients and in 80% of patients with metastatic disease and normal NMN levels. On the other hand, CgA and NMN values in patients with HNPGL were significantly lower than in patients with PHEO/sPGL. Conclusion: CgA is a valuable complementary biomarker in work-up of SDHB-related PHEO/sPGL. In combination with plasma NMN, CgA further enhances tumor detection by 22.0% with minimal loss in specificity. Although non-specific for PHEO/PGL, CgA may well supplement plasma NMN to facilitate diagnostic evaluation of SDHB-related PHEO/sPGL, especially where the measurement of plasma metanephrines could otherwise be delayed by decreased availability or cost restriction. CgA levels should be included in biochemical workup of any neuroendocrine tumor that could represent PHEO/PGL, as well as could be used for follow up of the recurrent disease if shown to parallel NMN on initial diagnostic evaluation or decrease significantly after initial surgery. Diagnostic value of CgA in management of parasympathetic HNPGL remains questionable.

 

Nothing to Disclose: SZ, RW, GE, KP, VK

OR27-1 11621 1.0000 A Clinical Utility of Chromogranin a in Sdhx-Related Paragangliomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 1:00:00 PM OR27 4717 11:30:00 AM Adrenal Tumors & Endocrine Hypertension Oral

Masanori Murakami*1, Takanobu Yoshimoto1, Kyoichiro Tsuchiya1, Isao Minami1, Masatomo Mihara1, Hajime Izumiyama1, Koshi Hashimoto1, Takayoshi Suganami2, Yasuhisa Fujii1, Kosei Abe3, Kazuhiko Nakabayashi3, Kenichiro Hata3, Kazunori Kihara1 and Yoshihiro Ogawa4
1Tokyo Medical and Dental University, Tokyo, Japan, 2Tokyo Med and Dental University, Tokyo, Japan, 3National Research Institute for Child Health and Development, Tokyo, Japan, 4Tokyo Medical and Dental University and AMED, CREST, Tokyo, Japan

 

Primary aldosteronism (PA) is the most common endocrine hypertension comprising 10% of hypertensive patients. A recent series of transcriptome analyses using DNA microarray has shown that numerous genes are differentially expressed between aldosterone-producing adenoma (APA) and its adjacent adrenal gland (AAG) tissue from the same patient. However, the molecular mechanism(s) of pathogenesis of APA has not yet been fully clarified. Although growing body of evidence has shown that epigenetic abnormalities including DNA methylation play a key role in tumorigenesis, there are few studies with regard to DNA methylation in APA. In the present study, to elucidate the pathogenic relationship between gene expression and DNA methylation in PA, we conducted an integrated analysis of transcriptome and methylome data for paired APA-AAG samples from the same patient. Adrenal specimens were obtained from 7 Japanese patients with APA, who underwent adrenalectomy at Tokyo Medical and Dental University. RNA and DNA samples were extracted from those 7 paired APA and AAG tissues. Gene expression and genome-wide DNA methylation profiles were obtained using SurePrint G3 Human GE 8x60K Microarray (Agilent) and Infinium HumanMethylation450 Beadchip (Illumina), respectively. Transcriptome analysis identified 244 significantly (2 fold<) upregulated genes in APA compared to AAG. The upregulated genes include the previously studied genes such as PCP4, ALDH1A2, and CYP11B2, and other genes that have not been previously studied. Gene ontology (GO) analysis for these upregulated genes identified the calcium signaling pathway to be most significantly enriched with the upregulated genes (8 genes). Methylome analysis revealed that APA was globally hypomethylated compared to AAG regardless of gene feature groups, namely, TSS1500, TSS200, 5’UTR, 1stExon, gene body, and 3’UTR. GO analysis for the genes showing hypomethylation at TSS1500/TSS200 regions in APA identified the term “cytokine-cytokine receptor interaction” to be most significantly enriched with hypomethylated genes (37 genes). Integrated analysis of gene expression and genome-wide DNA methylation profiles identified 18 genes that are upregulated and whose TSS1500/TSS200 regions are hypomethylated in APA compared to AAG. In conclusion, this is the first genome-wide study for PA that integrated transcriptome and methylome data. Global DNA hypomethylation in APA and concordant transcriptional up-regulation of some key genes may play crucial roles in the pathophysiological significance in PA.

 

Nothing to Disclose: MM, TY, KT, IM, MM, HI, KH, TS, YF, KA, KN, KH, KK, YO

OR27-2 13752 2.0000 A Integration of Transcriptome and Methylome Analyses to Dissect Molecular Pathogenesis of Primary Aldosteronism: Comparison Between Aldosterone-Producing Adenomas and Adjacent Adrenal Glands 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 1:00:00 PM OR27 4717 11:30:00 AM Adrenal Tumors & Endocrine Hypertension Oral

Merve Kutahyalioglu*1, Khaled M Elsayes2, Rafael Andres Vicens2, Kanishka Sircar2, Tarek Jazaerly2, Levent Ozsari2, Camilo Jimenez2, Steven G Waguespack2, Naifa L Busaidy2, Maria E Cabanillas2, Elizabeth G Grubbs2 and Mouhammed Amir Habra2
1The University of Texas Health Science Center at Houston, Houston, TX, 2The University of Texas MD Anderson Cancer Center, Houston, TX

 

Background: Adrenal incidentalomas (AIs) are found in about 5% of the population, and current guidelines recommend imaging follow-up for 2 years after their discovery to assess malignant potential. One type of AI, adrenocortical carcinoma (ACC), is a rare and aggressive malignancy that is often diagnosed in advanced stages. This report describes clinical and radiological characteristics seen in ACC patients preceding the confirmation of malignancy. The recognition of suspicious AIs could lead to earlier diagnosis of ACC that could improve prognosis by allowing earlier surgical resection.

Patients and Methods: We retrospectively reviewed the records and images of patients with ACC who had been evaluated at The University of Texas MD Anderson Cancer Center between 1998 and 2013 to identify those who had undergone preexisting imaging studies at least 90 days before receiving their diagnosis of ACC. Images were independently reviewed by two radiologists. Clinical and pathological data were also reviewed and summarized for these patients.

Results: Of the 392 patients, 18 (4.6%; 10 women and 8 men) had available images before their ACC diagnosis. The median age (range) at ACC diagnosis was 56 years (32-82 years). Preexisting imaging studies included CT (17 patients with various CT protocols) and MRI (1 patient). The median time (range) between the first available imaging and ACC diagnosis was 385 days (92-2324 days). Hormonal overproduction was documented in 9 of 18 patients at the time of ACC diagnosis.

On the first available imaging, 2 of 18 patients (11%) had normal adrenal glands (Two women [46 and 63 year-old] with ACC measuring 1 cm and 7.5 cm respectively. The time intervals between the first available imaging and ACC diagnosis were 1564 and 748 days respectively). The remaining 16 had preexisting adrenal mass with a median size of 2.7 cm (range, 1.4-9 cm). Pre-contrast density was available in 14 of these 16 patients, ranging from 17 to 49 (median, 36) Hounsfield units. At the time of ACC diagnosis, the median size of adrenal masses was 9 cm (range, 1-18 cm), and the number of patients at each disease stage were as follows: stage I: 2, stage II: 6, stage III: 4, and stage IV: 6 patients. The reasons contributing to delayed diagnosis in these 16 patients included missed adrenal mass (n=2), referral delay (n=3), and prolonged monitoring for presumed adenoma based on size criteria (n=11).

Conclusions: In our series, all ACC patients with a preexisting adrenal mass had radiological features that were not compatible with benign lipid-rich adenomas. It remains unclear if these lesions represent atypical adenomas or ACC upon their initial radiographic discovery. Therefore, patients with AIs and pre-contrast density >10 HU should be carefully monitored both hormonally and via imaging, regardless of tumor size. If such a mass demonstrates growth, early surgery should be considered due to the possibility of ACC.

 

Disclosure: NLB: Investigator, GlaxoSmithKline, Investigator, Bayer, Inc., Consultant, Novartis Pharmaceuticals. MEC: Researcher, Roche Pharmaceuticals, Researcher, Genentech, Inc., Researcher, Eisai, Researcher, Exelixis, Inc., Consultant, Eisai, Consultant, Exelixis, Inc.. MAH: Investigator, Eisai. Nothing to Disclose: MK, KME, RAV, KS, TJ, LO, CJ, SGW, EGG

OR27-3 13948 3.0000 A Preexisting Adrenal Masses in Patients with Adrenocortical Carcinoma: Beyond Size Alone 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 1:00:00 PM OR27 4717 11:30:00 AM Adrenal Tumors & Endocrine Hypertension Oral

Martin Fassnacht*1, Eric Baudin2, Michael J Demeure3, Tanya Fleege4, Srinivasu Poondru4, David I Quinn5, Ramona Rorig4 and Gary D Hammer6
1University Hospital Wuerzburg, Wuerzburg, Germany, 2HRA Pharmacy, Paris, France, 3Dept Surgery, Milwaukee, WI, 4Astellas Pharma US, Inc., Deerfield, IL, 5USC Norris Cancer Hospital, Los Angeles, CA, 6University of Michigan, Ann Arbor, MI

 

Background: ACC is an uncommon but frequently fatal cancer. For pts with metastatic or recurrent nonoperable ACC, there are very limited treatment options. Insulin-like growth factor 2 (IGF2) overexpression occurs in >90% of ACC, hence the IGF pathway is a potential therapeutic target. We assessed the activity of a potent IGF-1 receptor TKI linsitinib in ACC.

Methods: In a double-blind phase III trial accruing over 21 months, pts with measurable locally advanced or recurrent ACC following 1st- or 2nd-line treatment were randomly assigned to linsitinib 150mg BID orally or best supportive care & placebo (P), in a 2:1 ratio, respectively. The primary endpoint was overall survival (OS; power 80% for ↑OS from 9 to 15.6 months); secondary endpoints: PFS,

disease-control & objective response rate (blinded central review by RECIST 1.1), QoL & safety/toxicity

(CTCAEv4.02).

Results: 139 pts (median age 50yrs, 67% female, ECOG 0/1: 44.6, 51.1%) were enrolled with

90 assigned to linsitinib & 49 to P. Prior therapies included surgery: 90.6%; radiotherapy: 30.9%; mitotane: 100% & cytotoxic chemotherapy: 73.4%. The median time from diagnosis to trial initiation was 26.5 months. There was no difference between linsitinib and placebo in overall survival (median 323 days (10.8 months) vs 356d (11.8); p=0.77, HR 0.94); PFS (44 vs 46d; p=0.3, HR 0.83) & DCR (32.2 vs 34.7%). However, 3 pts on linsitinib experienced PR and 8 had prolonged PFS >100d (4 on drug >400d), whereas these events did not occur with placebo. Dose modification: L: 43.3, P 29.2%. Treatment-emerged adverse events (TEAEs) occurred in 97.8 vs 93.8%, grade 5: 5.6 vs 10.4%, gr 4: 10.1 vs 2.1%, gr 3: 45.6 vs 31.3% for L vs P respectively. Common TEAEs: fatigue (33.3 vs 22.9%), nausea (26.7 vs 31.3%), vomiting (20.0 vs 20.8%), abdominal pain (20.0 vs 20.8%), QTc prolonged (20 vs 6.3%) for L vs P.

Conclusions: Targeting the IGF pathway with linsitinib did not improve overall or progression-free survival in adrenocortical cancer patients, although a small subgroup of patients seemed to benefit from this drug. Timely and efficient accrual to phase III trials in rare cancers is internationally feasible.

 

Disclosure: EB: Research Funding, HRA Pharma. TF: Employee, Astellas Pharma US. SP: Employee, Astellas Pharma US. RR: Employee, Astellas Pharma US. Nothing to Disclose: MF, MJD, DIQ, GDH

OR27-4 16248 4.0000 A International Randomized, Double-Blind, Placebo-Controlled, Phase 3 Study of Linsitinib (OSI-906, L) in Patients (pts) with Locally Advanced or Metastatic Adrenocortical Carcinoma (ACC) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 1:00:00 PM OR27 4717 11:30:00 AM Adrenal Tumors & Endocrine Hypertension Oral

Vasileios Chortis*1, Kassiani Skordilis2, Wiebke Arlt3 and Rachel K Crowley4
1Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and and Experimental Medicine, University of Birmingham, Birmingham, United Kingdom, 2University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom, 3University of Birmingham, Birmingham, United Kingdom, 4Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, United Kingdom

 

New adrenal lesions discovered during cross-sectional abdominal imaging pose an increasingly common diagnostic challenge; their initial management should focus on the exclusion of malignancy and autonomous hormone excess. The role of adrenal biopsies in this context is limited and pathologists often struggle to differentiate benign from malignant adrenal tissue even when analysing the entire tumour specimen. Guidelines recommend that adrenal biopsy should only be considered if two criteria are met: firstly, history of extra-adrenal malignancy and an isolated new adrenal lesion with suspicious imaging criteria; secondly, biochemical exclusion of phaeochromocytoma. We reviewed all cases of adrenal biopsies performed at University Hospital Birmingham (UHB) in the time period from January 2004 to October 2013, with a view to assessing compliance with standards of best practice, reviewing histopathology and clinical medical records.  We identified 18 UHB patients with adrenal biopsies in the defined 10-year period. The decision for adrenal biopsy was taken in accordance with guideline recommendations in only 3 patients; an additional 12 fulfilled the clinical criterion only and in the remaining 3 none of the required criteria was fulfilled. Multidisciplinary team review prompted biopsy in 7 of 18 but only three patients underwent endocrine review. In 10 of the 14 patients with underlying history of malignancy the histopathology result was informative, prompting chemotherapy in six of them. All but two patients died within a year of biopsy (median 2 months, range 3 days to 12 months). In one patient with a recent history of melanoma the biopsy indicated adrenocortical adenoma; the adrenal mass was removed surgically three years later due to significant growth and histopathology revealed a melanoma metastasis embedded in a large phaeochromocytoma. In conclusion, patients undergoing adrenal biopsies are frequently managed haphazardly, with only the minority receiving MDT and endocrine review. Histopathology is regularly non-informative and can be misleading.

 

Nothing to Disclose: VC, KS, WA, RKC

OR27-5 14418 5.0000 A Jumping the Gun – an Audit of Adrenal Biopsies in a Tertiary Referral Centre 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 1:00:00 PM OR27 4717 11:30:00 AM Adrenal Tumors & Endocrine Hypertension Oral

Alexander R Opotowsky1, Lilamarie Moko1, Yuli Kim2, Jonathan Ginns3, Matthias Greutmann4, Jamil Aboulhosn5, Jasmine Grewal6, Ghadeera Almansoori7, Erwin Oechslin7, Ali Zaidi8, Michael Earing9, Michelle Gurvitz10, Michael Landzberg10, Michael Singh10, Anne Marie Valente10, Fred Wu10 and Anand Vaidya*11
1Boston Children's Hospital, MA, 2Hospital of the University of Pennsylvania, PA, 3Columbia University, NY, 4University Hospital Zurich, Switzerland, 5UCLA Medical Center, CA, 6St. Paul’s Hospital, University of British Columbia, Canada, 7University of Toronto, Canada, 8Ohio State Medical Center, OH, 9Children's Hospital of Wisconsin, OH, 10Boston Children's Hospital, 11Brigham and Women’s Hospital/Harvard Medical School, Boston, MA

 

Context: Tissue hypoxia and aberrant cellular oxygen sensing are leading theories for the development of pheochromocytoma (PHEO)-paraganglioma (PGL) syndromes (PPS), supported by the discovery of several susceptibility genes that are involved in hypoxia regulation and in the pathogenesis of PPS.  Case reports anecdotally suggest an association between cyanotic congenital heart disease (CCHD) and PPS; however, there are no existing cohort or population level epidemiologic data. 

Hypothesis/Aims: We hypothesized that exposure to chronic hypoxia in CCHD could increase incidence of PPS.  We tested our hypothesis in 2 studies: 1) We developed an international consortium to identify and characterize cases of CCHD with PPS; 2) We analyzed a nationalhospitalization dataset to determine whether the incidence of PPS was higher with CCHD.

Methods:  Study 1) A consortium of 9 tertiary care centers from North America and Europe was established. CCHD patients with PPS diagnosed by pathology, or biochemistry and imaging, were retrospectively identified.  Study 2) Data from the 2000-2009 Nationwide Inpatient Survey were analyzed to determine the population-based frequency of hospitalization for CCHD and PPS.  PPS was defined as PHEO (ICD-9 194.0, 227.0, 255.6), PGL (194.5/6, 237.3), or carotid body tumor (194.5, 227.5). CCHD was defined as CHD plus one of the following: cyanosis, hypoxemia, or secondary erythrocytosis.  Logistic regression was performed to adjust for age, sex, and established PPS genetic syndromes (e.g. MEN, VHL, NF). Sampling weights were used to produce national estimates. 

Results: Study 1) We identified 18 CCHD patients with PPS.  Cases were 50% male, age at PPS diagnosis 35 ± 4 y, and a duration of cyanosis 24 ± 5 y.  11/18 had a single tumor (7 unilateral PHEO; 4 PGL) and 7/18 had multiple tumors (2 bilateral PHEO; 6 multi-focal PGL).  PGL sites included head and neck (n=2) and intra-abdominal (n=18) (including peri-aortic and organ of Zuckerkandl).  There was one malignant PHEO. All patients had 2-8x elevations in blood and urine norepinephrine metabolites, two also had <2x elevation in epinephrine metabolites, and 1 had 2x elevation in dopamine.  All patients described new or worsening adrenergic symptoms; none had clinical signs of genetic syndromes associated with PPS.  Genetic testing results for known PPS genes are pending.  Study 2) Over the study, there were >196 million admissions in the US, 108,464 ± 3,120 had PPS, 16,823 ± 689 had CCHD, and 51 ± 22 had both PPS and CCHD.  The adjusted odds of PPS with CCHD was OR=6.0 (95% CI 2.6-13.7, p<0.0001), whereas the odds of PPS in non-cyanotic CHD was the same as the overall population (OR 0.9, p=0.48).

Conclusions: Our findings implicate a strong link between CCHD and PPS.  Whether these rare diseases co-associate due to a single common pathogenic factor, or the result of hypoxic stress superimposed on a genetic susceptibility, should be further investigated.

 

Nothing to Disclose: ARO, LM, YK, JG, MG, JA, JG, GA, EO, AZ, ME, MG, ML, MS, AMV, FW, AV

OR27-6 15035 6.0000 A Pheochromocytoma-Paraganglioma Syndromes and Cyanotic Congenital Heart Disease: An International Multicenter Case Series and Population-Based Epidemiologic Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 1:00:00 PM OR27 4717 11:30:00 AM Adrenal Tumors & Endocrine Hypertension Oral

Corey Cain*1, Joel Valencia2 and Edward C. Hsiao1
1University of California, San Francisco, San Francisco, CA, 2University of California, San Francisco

 

Purpose:  Osteoporosis and obesity are significant medical conditions that contribute to morbidity and mortality. Although obesity is traditionally associated with increased bone mass, large studies show that obese patients are not protected from fractures. One feature common to diseases with bone fragility such as diabetes, obesity, and aging is increased bone marrow adiposity. Although marrow adiposity is thought to contribute to bone fragility, our understanding of skeletal changes in metabolic disease is limited by an incompletely described pathway of osteoblast-adipocyte communication and a paucity of complementary models with high bone mass and low marrow fat mass. In this study, we hypothesize that osteoblastic Gs-G protein coupled receptor signals can influence marrow adiposity by changing bone metabolism and directing bone marrow cell fate.

Methods: We used the ColI(2.3)+/Rs1+ transgenic mouse model where an engineered G-protein coupled receptor Rs1 activates Gs signaling in osteoblastic cells. We previously showed that these mice have 5-15 fold increases in trabecular bone formation resembling fibrous dysplasia of the bone. O2 consumption, CO2 production, movement, food, and water consumption were measured. Additionally, total body and bone marrow fat content were measured by EchoMRI, and blood was analyzed for glucose, insulin, and triacylglyceride levels after fasting. qPCR on whole bone was used to determine mRNA levels of genes involved in adipogenesis and osteoblast development. Seahorse metabolic stress tests were used to characterize the respiration capacity of bone marrow cells from control and ColI(2.3)+/Rs1+  mice. 

Results: We found an unexpected 15% loss of total body fat and a 90% loss in tibial fat, as well as a 73% loss of blood triglyceride levels. Furthermore, ColI(2.3)+/Rs1+ mice showed decreased movement, food, and water consumption without alterations to energy expenditure. Seahorse mitochondrial stress test analysis on ColI(2.3)+/Rs1+ hematopoietic cells revealed a 50% decrease in basal respiration. qPCR indicated a decrease in genes expressed by mature adipocytes including Adiponectin and PRDM16. We also found increased levels of Wnt expression in ColI(2.3)+/Rs1+ bones. 

Conclusions: ColI(2.3)+/Rs1+ mice show increased bone formation but decreased marrow adiposity, in contrast to other conditions of decreased bone formation and increased marrow adiposity. In addition, the ColI(2.3)+/Rs1+ bones showed decreased expression of mature adipocyte markers, possibly caused by a non-cell autonomous mechanism from the Rs1-expressing osteoblasts. Our findings suggest that osteoblasts may influence the metabolic homeostasis of bone through both changes in bioenergetics and cellular differentiation.

 

Nothing to Disclose: CC, JV, ECH

OR31-1 14315 1.0000 A Transgenic Mice with Induced Gsá Signaling in Osteoblasts Have Alterations to Bone Marrow Adipocyte and Metabolic Homeostasis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 1:00:00 PM OR31 4720 11:30:00 AM Novel Signaling Mechanisms and Bone Cell Biology Oral

Sisi Liu*1, Saloustros Emmanouil1, Edward Mertz2, Paraskevi Salpea1, Jenna Shapiro1, Sergey Leikin2 and Constantine A Stratakis3
1Section on Endocrinology and Genetics, NICHD, NIH, Bethesda, MD, 2Section on Physical Biochemistry, NICHD, NIH, Bethesda, MD, 3National Institutes of Health (NIH), Bethesda, MD

 

PRKAR1A, the gene for type-I regulatory subunit of protein kinase A (PKA) is mutated in Carney complex, a disease associated with bone tumors. A mouse model of Prkar1a haploinsufficiency (Prkar1a+/-) developed bone lesions due to bone stromal cell (BSC) expansion; when haploinsufficiency of Prkaca, the gene coding for PKA type I catalytic subunit was introduced onto the Prkar1a+/- background to generate Prkar1a+/-Prkaca+/- mice, more vertebral lesions were found, along with increased PKA-II to PKA-I ratio. We now report two mouse models heterozygous for PKA regulatory subunits 2a or 2b in the Prkar1a+/- background. They developed similar lesions with later time of onset and lower aggressiveness. In double heterozygous vertebrae, Raman microscopy revealed better bone organization and mineralization levels, indicating a partial rescue of lesion phenotype; calcein staining indicated higher new bone formation rates. Immunohistochemistry showed higher expression of osteogenic markers (runx2, osteocalcin, osterix and Dmp1) in double heterozygous lesions; FACS supported such findings. Inverted osteons, which is an abnormal pattern of new bone formation without an existing bone surface, were found in these mice; this can be responsible for new bone formation inside lesion area. Higher percentages of Type I collagen homotrimers were also found (8%-25% compared with 0%-6% in wide type). PKA activity and PKA subunits expressions were analyzed. Decreased PKA-II to PKA-I ratios were found in Prkar1a+/-Prkar2a+/- (PKA-II: PKA-I =1.62) and Prkar1a+/-Prkar2b+/- (PKA-II: PKA-I = 1.32) bones compared with Prkar1a+/- ones (PKA-II: PKA-I = 1.82).We have also found increased Cβ subunit expression transcriptionally (3.6 and 2.3 folds respectively) and translationally (2.5 and 3.7 folds respectively) in double heterozygous lesions. In conclusion, decreased PKA-II to PKA-I ratios and increased Cβ subunit expression may contribute to higher osteogenic activity, resulting in better bone organization, mineralization and new bone formation in adult mice.

 

Nothing to Disclose: SL, SE, EM, PS, JS, SL, CAS

OR31-2 15946 2.0000 A Abnormal cAMP-Dependent Protein Kinase Activity Leads to Bone Tumors in Adult Mice but This Depends on the PKA Subunit Expressions 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 1:00:00 PM OR31 4720 11:30:00 AM Novel Signaling Mechanisms and Bone Cell Biology Oral

Sherwin S. Yen*, William R. Thompson, Gunes Uzer, Zhihui Xie, Buer Sen, Maya Styner, Keith Burridge and Janet E Rubin
University of North Carolina Chapel Hill

 

Exercise loading of the skeleton promotes bone formation through biasing marrow MSC toward osteoblasts and away from adipocytes. We have shown that application of mechanical strain suppresses adipogenesis in marrow derived MSC in part by enhancing cytoskeletal structure and stiffness through activation of RhoA. The proximal steps leading to mechanical RhoA activation involve a Fyn-FAK-mTORC2-Akt cascade initiated in the focal adhesion mechanosome. Exchange of GDP for GTP is the crucial last step governing RhoA activity and is regulated by Guanine nucleotide Exchange Factors (RhoA activators) and GTP-ase Activating Proteins (RhoA deactivators). We asked if strain activates RhoA by GEF stimulation and/or by GAP inhibition. We selected ARHGAP18 as a RhoA specific GAP candidate because it has been shown in previous reports to downregulate RhoA and decrease actin stress fiber formation in fibroblasts. ARHGAP18 deficient marrow derived MSC were generated through stable shRNA knockdown. ARHGAP18 deficient MSCs demonstrated increased basal RhoA activation measured by RhoA bead binding assay. This suggested that ARHGAP18 might function as a tonic inhibitor of RhoA in MSC. Imaging showed the actin cytoskeleton to be increased in the ARHGAP18 deficient MSC compared to controls. Application of 200 cycles x 2% strain using the Flexcell system induced a further increase in RhoA activation compared to controls and, strain-induced cytoskeletal reorganization (increased actin bundling and connectivity) was more robust in the ARHGAP18 KO cells. As the actin cytoskeleton not only responds to dynamic mechanical input, but also to the static substrate stiffness, we reasoned that a loss of ARHGAP18 might influence MSC differentiation due to enhanced cytoskeletal structure. After 4 d in adipogenic medium, ARHGAP18 deficient MSC resisted adipogenesis as compared to control MSC, assessed by Oil-Red-O lipid stain and measures of fat markers by immunoblot analysis. Furthermore, when cultured in 7 d of osteogenic media, ARHGAP18 deficient cells displayed accelerated osteogenesis with increased alkaline phosphatase staining and osteogenic gene expression. These data demonstrate that ARHGAP18 is a primary negative regulator of RhoA activity in MSCs, and alternate GAPs do not compensate for its absence. The stiffer cytoskeleton results in an anti-adipogenic, pro-osteogenic lineage bias. Our data suggest that MSC lineage is exquisitely sensitive to factors that alter cytoskeletal dynamics. By identifying the key regulators of RhoA activity during mechanical strain we aim to further elucidate how a dynamic physical environment can control MSC fate.

 

Nothing to Disclose: SSY, WRT, GU, ZX, BS, MS, KB, JER

OR31-3 14643 3.0000 A The RhoA Gtpase Activating Protein ARHGAP18 Regulates Mesenchymal Stem Cell Lineage Commitment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 1:00:00 PM OR31 4720 11:30:00 AM Novel Signaling Mechanisms and Bone Cell Biology Oral

Anne Gingery*1, John R Hawse1, Kevin S. Pitel1, Muzaffer Cicek1, Jordan M Reese1, Sarah A Grygo1, Urszula T. Iwaniec2, Russell Thomas Turner2, Malayannan Subramaniam1 and Thomas C Spelsberg1
1Mayo Clinic, Rochester, MN, 2Oregon State University, Corvallis, OR

 

TGF-β Inducible Early Gene-1 (TIEG), a member of the kruppel family of transcription factors (KLF10), plays important roles in regulating bone physiology.  We have previously demonstrated that TIEG knockout (KO) mice exhibit a gender specific osteopenic phenotype in female mice.  Ovariectomy and estrogen (E2) replacement studies in these animals demonstrate that TIEG expression is essential for maximal estrogenic activity in the skeleton as the response to E2 was halved in KO mice.  Furthermore TIEG has been identified in clinical studies as one of a handful of genes whose altered expression are associated with decreased bone mass and osteoporosis in humans.  Gene expression studies of the cortical shells of long bones revealed that sclerostin, a potent Wnt inhibitor of bone formation, exhibits a 12-fold elevation in expression in KO relative to WT littermates.  Transient transfection and luciferase assays revealed that TIEG expression resulted in a 3.5 fold decrease in sclerostin promoter activity.  The ability of TIEG to regulate canonical Wnt signaling through the Tcf/Lef enhancer elements using a TopFlash reporter construct was also explored.  TIEG expression was shown to increase TopFlash activity and to further enhance the Lef1 and β-catenin mediated induction of this reporter construct in osteoblasts.  Co-immunoprecipitation studies revealed that TIEG also interacts with Lef1 and β-catenin.  Since nuclear localization of β-catenin is essential for activation of the canonical pathway, we examined TIEGs role in mediating this process.  Over-expression of TIEG in U2OS cells resulted in enhanced nuclear localization of β-catenin, which was confirmed using WT and TIEG KO calvarial osteoblasts.  Enhancement of β-catenin nuclear localization by TIEG appears to be mediated by TIEG’s activation of AKT and subsequent inhibition of GSK3-β.  In addition, use of the TOPGAL reporter mouse demonstrated that loss of TIEG expression resulted in decreased canonical Wnt pathway activity by 40% in the skeleton relative to WT mice. Taken together, these data demonstrate that TIEG regulates canonical Wnt signaling through dual mechanisms which include the suppression of SOST expression, enhancement of β-catenin nuclear localization and transcriptional activity.   Our next goal was to determine whether TIEG plays a role in the cross-talk between E2 and Wnt signaling in bone.  Increased TIEG expression and decreased sclerostin expression was observed following treatment of osteocytes with E2. These effects were blocked by anti-estrogen ICI, revealing a direct role for E2 receptors in regulating the expression of these genes.  In summary, these data reveal important roles for TIEG in regulating E2 signaling in bone and in mediating cross-talk between these two pathways.

 

Nothing to Disclose: AG, JRH, KSP, MC, JMR, SAG, UTI, RTT, MS, TCS

OR31-4 16478 4.0000 A Tieg Regulates Estrogen and Canonical Wnt Signaling in Bone 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 1:00:00 PM OR31 4720 11:30:00 AM Novel Signaling Mechanisms and Bone Cell Biology Oral

Gary Hattersley*1, Thomas Dean2 and Thomas J Gardella2
1Radius Health, Inc, Waltham, MA, 2Massachusetts General Hospital, Boston, MA

 

PTH and PTHrP share some sequence homology, and may have arisen from a common ancestral gene, but each plays a distinct role in bone physiology. PTH, secreted by the parathyroid glands, acts in a classical endocrine manner to preferentially promote bone resorption over bone formation and regulate calcium homeostasis. In contrast, PTHrP functions as paracrine regulator of bone formation. This difference in function is highlighted by the contrasting skeletal phenotypes of mice in which these genes are disrupted. Interestingly, the actions of both PTH and PTHrP are mediated by the same receptor, the G- protein-coupled parathyroid hormone receptor type 1 (PTHR1). Recent studies have now provided a basis for the divergent actions of PTH and PTHrP in bone, that have shown marked differences in PTHR1 conformation selectivity, subcellular localization of ligand-receptor complexes and persistence of intracellular cAMP signaling. Abaloparatide (ABL), a novel analog of PTHrP(1-34), is currently being developed as a treatment for osteoporosis. ABL was selected for enhanced bone anabolic activity while possessing a more limited effect on bone resorption and calcium mobilization, than seen with PTH(1-34). In completed clinical studies, this activity was manifested by earlier and greater bone mineral density gains compared to teriparatide (rhPTH(1-34)). This study evaluated the binding of ABL to two distinct PTHR1 conformations, R0 and RG. Competition binding studies were performed in membranes prepared from transiently transfected COS-7 cells to assess binding to the two PTHR1 conformations. As found previously, PTH(1-34) and PTHrP(1-36) each bound to the RG conformation with similarly high affinities (IC50 = 0.46 and 0.65 nM, respectively), but PTHrP bound with markedly lower affinity to R0 (IC50 = 2.6 and 31 nM, respectively). Like PTH and PTHrP, ABL displayed high affinity for RG (0.75 nM), but bound to R0 with an affinity (135 nM) even lower than that of PTHrP. Thus, ABL exhibited even greater selectivity to differentially bind to the two PTHR conformations than did PTHrP. Previous studies have suggested that stronger binding to R0, as seen with PTH(1-34), leads to a more sustained intracellular cAMP response and hence a greater effect to stimulate bone resorption, whereas selective binding to RG, as seen with PTHrP, results in a more transient cAMP signal and less bone resorption and hence a greater bone-anabolic response. The current findings thus suggest that the enhanced bone anabolic activity of abaloparatide, as compared to PTH(1-34), may arise from a more selective binding to the RG PTHR conformation.

 

Disclosure: GH: Employee, Radius Health. Nothing to Disclose: TD, TJG

OR31-5 15816 5.0000 A Differential Binding Selectivity of Abaloparatide (BA058) Compared to PTH and PTHrP for PTH Type 1 Receptor Conformations 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 1:00:00 PM OR31 4720 11:30:00 AM Novel Signaling Mechanisms and Bone Cell Biology Oral

Weirong Xing1, Shaohong Cheng1, Jon Wergedal2 and Subburaman Mohan*1
1VA Loma Linda Healthcare System, Loma Linda, CA, 2JL Pettis VA Med Ctr, Loma Linda, CA

 

We recently demonstrated that thyroid hormone (TH) is indispensable for the prepubertal rise in IGF-I expression and bone mass accretion in mice.  Accordingly, we found that the rapid increase in TH levels that occurs during the second week of postnatal life in mice is obligatory for initiation and progression of the second ossification center (SOC).  The severely compromised bone volume in the epiphysis of TH deficient Tshr-/- mice is completely rescued by TH replacement during postnatal day 5-14. In this study, we focused on the signaling pathways by which TH regulates formation of the SOC. Expression levels of key regulators responsible for endochondral ossification were evaluated by quantitative RT-PCR using RNA extracted from the epiphyses of 7 day old Tshr-/- mice treated with TH or vehicle and heterozygous littermates treated with vehicle. Expression levels of transcription factors (Runx2, Osx, β-catenin, Sox, Gli2 and Mef2C) and extracellular signaling molecules (Ihh, IGF-I, RANKL) that are responsible for chondro-osteoblast differentiation were dramatically down regulated in the SOC of Tshr-/- mice compared to euthyroid Tshr-/+ mice that were rescued by TH treatment of Tshr-/- mice. Immunohistochemistry double staining found that the Col2 expressing cells at the edge of the SOC expressed high levels of Osx, Col10, and ostecalcin at day 10 while the ossification center was forming bone matrix. To determine the TH effect on Osx expression in vivo, we evaluated the effect of TH on cherry reporter expression in Osx-cherry reporter mice.  TH injection of osterix-cherry reporter mice caused robust expression of the cherry reporter at day 7 and 10. To determine if Ihh signaling is involved in regulating TH induction of Osx expression, we examined the effects of cyclopamine, a known inhibitor of hedgehog signaling,  on Osx expression in epiphyseal chondroctyes. Cyclopamine treatment not only blocked the TH-induced increase in Osx, but also the TH effects on ALP, and Col10 mRNA levels.  Consistent with the in vitro studies, treatment of Tshr-/+ heterozygous mice with cyclopamine reduced bone volume, trabecular number, but increased trabecular spacing of the tibial epiphyses. In conclusion, our data support that TH regulates the SOC initiation and progression via differentiating chondrocytes into bone matrix producing osteoblasts by stimulating Ihh and subsequently Osx expression in epiphyseal chondrocytes.

 

Nothing to Disclose: WX, SC, JW, SM

OR31-6 17003 6.0000 A Thyroid Hormone Regulates Secondary Ossification Formation Via Activation of Indian Hedgehog and Osterix Signaling in Chondrocytes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 1:00:00 PM OR31 4720 11:30:00 AM Novel Signaling Mechanisms and Bone Cell Biology Oral

Shruti Mahendra Gandhi*1, Peter Kokkinos2, Lauren Korshak2, Joseph Powell2 and Eric S Nylen2
1Washington DC VA Medical Center, DC, 2VA Medical Center, Washington, D.C.

 

Introduction:  Diabetes is the most common cause of end-stage kidney disease. Fitness status and increased physical activity are essential for diabetic health. Their impact, however, on CKD outcomes and renal function have not been extensively investigated.

Objectives:  The primary objective was to assess the exercise capacity-progression to CKD- mortality association. A secondary objective was to assess the effect of a 12-week exercise program on eGFR. 

Methods: We identified 2,007 type 2 diabetics (mean age: 61±10.3 years) with normal kidney function who completed an exercise stress test at the VA Medical Center, Washington, DC. Cox proportional hazard model with spline function of MET was used to define the MET level associated without increased risk of progression to CKD (HR=1.0). This MET level (7.5 METs) was used to form four fitness categories based on intervals of 2 METs above and below this threshold: Least-Fit (<5.5 METs); Low-Fit (5.5-7.5 METs) Moderate-Fit (7.6-9.5 METs) and High-Fit (>9.5 METs). Cox proportional hazard analysis, adjusted for age, BMI, cardiac risk factors, sleep apnea, alcohol dependence and cardiac medications, was used to assess the risk of progression to CKD or death. The Least-Fit category was used as the referent.

We also assessed the effects of exercise on renal function in 67 type 2 diabetics. All completed a 12-week aerobic/resistance supervised exercise program. Peak exercise capacity (METs) metabolic panel and blood pressure were evaluated at baseline and after the completion of the program. Patients were classified into 2 groups based on baseline eGFR >60 mL/min/1.73m2 (n=52) and eGFR 30-60 mL/min/1.73m2 (n=15). The effect of exercise was compared within groups using a paired samples t-test.

Results: In the CKD outcomes cohort (mean f/u=7.3 ±5.1 years), the combined events (CKD/death) were 572 (39 deaths/1000 person-years). The mortality risk and rate of progression to CKD were progressively lower with increased fitness. More specifically, the rate was lower by 41% (HR=0.59; CI: 0.49-0.72; p<0.001) for Low-Fit; 51% (HR=0.49; CI: 0.372-0.633; p<0.001) for the Moderate-Fit and 68% (HR=0.32; CI: 0.172-0.6; p<0.001) for High-Fit individuals.

No significant change in eGFR was noted for the group with eGFR>60 mL/min/1.73m2 despite significant improvement in METs (p<0.001), HbA1c (p=0.009) and plasma glucose level (p=0.032).  However, patients with eGFR 30-60 mL/min/1.73m2 had significant improvement in both exercise capacity (7.22±1.85 METs vs 8.56±2.3 METs, p=0.042) and eGFR (53.0±4.2 vs 61.5±9.9; p=0.002) at baseline and post intervention, respectively.

Conclusions: Exercise capacity amongst diabetics was inversely associated with the rate of progression to CKD and mortality. In addition, renal function improved in CKD Stage 3 diabetics following the exercise program with 53% patients improving to CKD Stage 2.

 

Nothing to Disclose: SMG, PK, LK, JP, ESN

OR40-1 15459 1.0000 A Fitness Impact on Renal Function and Chronic Kidney Disease in Type 2 Diabetics 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 1:00:00 PM OR40 4729 11:30:00 AM Type 2 Diabetes: Beta Cell Function and Novel Interventions Oral

Su Ann Ding*1, Donald C Simonson2, Florencia Halperin2, Marlene Wewalka1, Kathleen Foster1, Katherine Kelly1, Jennifer Panosian1, Ann Goebel-Fabbri1, Osama Hamdy1, Kerri Clancy3, David Lautz3, Ashley Vernon2 and Allison B Goldfine1
1Joslin Diabetes Center, Boston, MA, 2Brigham and Women's Hospital, Boston, MA, 3Emerson Hospital, Concord, MA

 

To compare effectiveness for cardiometabolic outcomes of bariatric surgery to intensive medical weight management, we randomized 38 obese T2D (15M/23F; weight 104±16 kg; BMI 36.3±3.4 kg/m²; age 52±6 years; HbA1c 8.5±1.3%; 61% on insulin) to laparoscopic Roux-en-Y gastric bypass (RYGB; n=19) or intensive medical diabetes and weight management (IMWM; n=19) with follow up for up to 18-24 months. At 12 months, there was greater reduction in weight (-28±2 vs -7±2 kg; RYGB vs IMWM, P<0.0001) and fat mass by bioelectrical impedance (-23±1 vs -6±2 kg, P<0.0001) post-RYGB; and at 18-24 months, weight loss (-29±2 vs -5±2 kg, P<0.0001) and loss of fat mass (-23±2 vs -2±2 kg, P<0.0001) were sustained post-RYGB.  HbA1c reduction was greater post-RYGB (-2.0±0.4 vs 0.0±0.4, P<0.001) at 12 months and maintained at 18-24 months (-1.7±0.4 vs -0.2±0.3, P<0.01).  Reductions in systolic blood pressure (BP) (-12±3 vs -1±3, P<0.05) and triglycerides (-47±9 vs -5±9, P<0.001) and increase in HDL (10±2 vs 0±2, P<0.001) were greater post-RYGB at 12 months.  At 18-24 months improvement in systolic BP (-10±5 vs 7±3, P<0.01) and HDL (15±4 vs 2±2, P<0.05) were maintained, and reduction in diastolic BP (-9±3 vs 1±2, P<0.05) emerged only post-RYGB. Changes in UKPDS cardiometabolic risk scores from baseline of 10.3±8.2% for coronary heart disease (-2.8±1.2 vs 0.3±1.0%, P<0.05), 6.7±6.4% for fatal coronary heart disease (-2.1±1.0 vs 0.7±0.7%, P<0.05), 4.0±3.3% for stroke (0.23±0.25 vs 1.04±0.25%, P<0.05) and 0.54±0.49% for fatal stroke (-0.04±0.06 vs 0.19±0.05%, P<0.01) were all more favorable at 18-24 months following RYGB than IMWM. In summary, RYGB produces greater weight loss,  sustained improvements in HbA1c, and greater improvements in BP and lipids at 18-24 months compared to medical management. UKPDS risk scores are more favorable post-RYGB for coronary heart disease and fatal coronary heart disease, and in lesser magnitude for stroke and fatal stroke at 12 months, and persist over 18-24 months, which parallel the improvement of cardiometabolic risk factors and HbA1c. Over intermediate duration of follow-up, these findings support that RYGB is an acceptable therapeutic option for cardiovascular risk reduction in obese patients with diabetes in whom surgical risk is not excessive.

 

Disclosure: OH: Advisory Group Member, Abbott Nutrition, Advisory Group Member, Merck & Co., Researcher, Neurometrix. AV: Coinvestigator, Covidien. Nothing to Disclose: SAD, DCS, FH, MW, KF, KK, JP, AG, KC, DL, ABG

OR40-2 15237 2.0000 A Comparative Effectiveness for Cardiometabolic Outcomes of Roux-En-Y Gastric Bypass with Intensive Diabetes and Weight Management in Obese Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 1:00:00 PM OR40 4729 11:30:00 AM Type 2 Diabetes: Beta Cell Function and Novel Interventions Oral

Donald C Simonson*1, Su Ann Ding2, Florencia Halperin1, Marlene Wewalka2, Kathleen Foster2, Katherine Kelly2, Jennifer Panosian2, Ann Goebel-Fabbri2, Osama Hamdy2, Kerri Clancy3, David Lautz3, Ashley Vernon1 and Allison B Goldfine2
1Brigham and Women's Hospital, Boston, MA, 2Joslin Diabetes Center, Boston, MA, 3Emerson Hospital, Concord, MA

 

Weight loss improves patient-reported outcomes (PRO) in obese type 2 diabetes (T2D) patients; however, differences between surgical and medical weight management, and the durability of their effects, are not well established.  We randomized 38 obese T2D (15M/23F; weight 104±16 kg; BMI 36.3±3.4 kg/m²; age 52±6 yrs; HbA1c 8.5±1.3%; 61% on insulin) to laparoscopic Roux-en-Y gastric bypass (RYGB; n=19) or intensive medical weight management (IMWM; n=19) with follow-up for 18-24 mos.  At baseline, subjects had moderately reduced SF-36 physical health (PH) (65±17) and mental health (MH) (64±14), high Impact of Weight on Quality of Life (IWQOL) (75±23), and high Problem Areas in Diabetes (PAID) (54±15) health status scores.  At 10% weight loss or 3 mos (if 10% loss was not achieved), RYGB resulted in greater weight loss (-11±1 vs. -7±1 kg; P<0.001), but a similar decline in HbA1c (-1.7±0.2 vs. -1.6±0.2%) vs. IMWM.  SF-36 PH (12±3 vs. -2±3; P<0.01) and MH (15±3 vs. 1±3; P<0.001) improved more in IMWM vs. RYGB.  Improvements in IWQOL and PAID were similar between groups.  At 12 mos, RYGB had much greater weight loss (-28±2 vs. -7±2 kg; P<0.0001) and lowering of HbA1c (-2.0±0.4 vs. 0.0±0.4%; P<0.001) vs. IMWM, both of which persisted at 18-24 mos (-29±2 vs. -5±2 kg, P<0.0001; -1.7±0.4 vs. -0.2±0.3%, P<0.01, respectively).  IWQOL improved more in RYGB (-32±4 vs. -17±4; P<0.01), and correlated with greater weight loss at 12 mos (r = 0.70, P<0.001) and 18-24 mos (r = 0.67, P<0.001).  Change in PAID score did not differ between groups at 12 mos (-20±2 vs. -15±2), but RYGB trended toward greater improvement at 18-24 mos (-20±3 vs. -12±3, P=0.06) consistent with sustained lowering of HbA1c.  In contrast, improvements in SF-36 PH (4±4 vs. 7±4) and MH (5±4 vs. 11±4) did not differ between RYGB and IMWM at 12 mos, and did not substantively change further at 18-24 mos.  Thus, in obese T2D, 1) RYGB produces greater weight loss, sustained improvements in HbA1c, and improvement in the impact of weight on quality of life up to 24 mos compared to medical management, 2) both treatments reduce problems associated with diabetes management, although the long-term effect is somewhat greater after RYGB, and 3) IMWM improves general physical and mental health more than RYGB up to 3 months, but both groups had similar moderate improvements in the longer term.  These outcomes should be considered in therapeutic decisions for weight loss strategies in obese T2D.

 

Disclosure: OH: Advisory Group Member, Abbott Nutrition, Advisory Group Member, Merck & Co., Researcher, Neurometrix. AV: Coinvestigator, Covidien. Nothing to Disclose: DCS, SAD, FH, MW, KF, KK, JP, AG, KC, DL, ABG

OR40-3 16128 3.0000 A Changes in Patient-Reported Outcomes up to Two Years after Roux-En-Y Gastric Bypass Vs. Intensive Medical Weight Management in Obese Patients with Type 2 Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 1:00:00 PM OR40 4729 11:30:00 AM Type 2 Diabetes: Beta Cell Function and Novel Interventions Oral

Sheetal Malhotra*1, Namita Gupta2, Sneha Galiveeti1, Bojana Milekic1 and Pietra Dale Greenberg3
1JJ Peters VA Medical Center, Bronx, NY, 2University of Nebraska Medical Center, Omaha, NE, 3James J Peters VA Med Ctr, Bronx, NY

 

The link between obesity and type 2 diabetes is clearly established with weight loss resulting in improvement in insulin sensitivity and glycemic control.  Laparoscopic sleeve gastrectomy involves the removal of the greater curvature of the stomach, and is now a common low-morbidity surgical technique for weight loss. Previous cohort studies have shown improvement in obesity in patients undergoing sleeve gastrectomy. However, there have been no studies comparing long term diabetes outcomes in patients undergoing surgical intervention as compared to controls who are on nonsurgical diabetes care. 

Research question: To compare long term diabetes outcomes in patients undergoing sleeve gastrectomy as compared to controls who undergo nonsurgical diabetes care.

Methods: We reviewed medical records of veterans between 18 and 80 years of age with type 2 diabetes undergoing sleeve gastrectomy at a VA medical center in a major metropolitan area.  Primary study outcomes included measures of diabetes control including HbA1C and BMI. Secondary outcomes such as total and LDL cholesterol, hospitalizations and mortality were also assessed. Data from surgery patients were compared to data from diabetic controls that did not undergo surgery using  descriptive analyses, t-tests , and repeated measures ANOVA.

Results: Data from charts of 30 surgery patients and 23 controls were analyzed from 2010 to 2013.  Most of the subjects enrolled were males (96%) with an average age of 57 years (range 29-80 years) .  The median BMI at baseline was 41 (range 36-60) kg/m2 and median Hba1c was 7.3.  There was a significant improvement in BMI and Hba1c in surgery patients over one year follow up; improvements were sustained through the end of two years after surgery. Mean BMI decreased from 41 to 34 over two years ( P<0.001) and mean Hba1c decreased from 7.25 to 5.98 (P<0.001).  Similar outcomes were not seen in controls during the study period. Differences in these outcomes between surgery patients and controls were significant over short term and long term follow up (P<0.001).   No changes were seen in total cholesterol or LDL cholesterol for surgery patients.  However, it was noted that the changes in outcomes plateau after the first year of surgery.

Discussion:  It is interesting to note that sleeve gastrectomy may offer better diabetes control and improved outcomes compared to patients who follow medical care only. However,  the improvement in outcomes in surgery patients may not be a permanent solution for diabetes outcomes.

Conclusion: Sleeve gastrectomy is effective in improving diabetes outcomes in veterans as compared to those receiving nonsurgical diabetes care.

 

Nothing to Disclose: SM, NG, SG, BM, PDG

OR40-4 15872 4.0000 A Sleeve Gastrectomy Outcomes in Veterans with Type II Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 1:00:00 PM OR40 4729 11:30:00 AM Type 2 Diabetes: Beta Cell Function and Novel Interventions Oral

Mark Louis Heiman*1, Jeffrey H Burton2, Elena Deych3, William D Shannon4 and Frank Lyons Greenway III5
1MicroBiome Therapeutics, Indianapolis, IN, 2Pennington Biomedical Research Center, Baton Rouge, LA, 3Washington Univ, St. Louis, St. Louis, MO, 4BioRankings, LLC, St. Louis, MO, 5Pennington Biomed Res Ctr, Baton Rouge, LA

 

People living in wealthy cultures are inflicted with metabolic diseases, in part, because of over eating processed food.  Human physiology has limited ability to adapt to these modern dietary habits. In contrast, the ecosystem of the intestines; containing bacteria, fungi, undigested- and partially digested- foods, quickly adapts.  For example, shifts in the GI microbiome are documented for T2D when compared to the microbiome of healthy individuals (1,2).  The first microbiome modulator designed to treat dysbiosis in T2D is NM504.  A trial was done to test if NM504 improves the oral glucose tolerance of prediabetics and untreated T2D by modulating the GI microbiome.  Thirty subjects were enrolled in the double-blind, randomized, placebo-controlled trial for 28 days (14 subjects completed each arm).  NM504 was administered twice a day prior to either breakfast or lunch and prior to dinner.  The microbiome modulator was well tolerated and improved (p < 0.05, n=14) the serum glucose levels during an oral glucose tolerance test at both 120 - and 180 - min when compared to those values in subjects assigned to the placebo (n=14).  Insulin levels were similar between the 2 groups during the oral glucose tolerance testing.  The improved glucose tolerance was associated with decreased circulating levels of ALK phosphatase (p=0.06, n=14), hsCRP (p=0.012, n=14), and total cholesterol (p=0.01, n=14).  NM504 treatment also decreased the desire to eat (p=0.03, n=14), increased stool IgA levels (p=0.03, n=14), and decreased stool pH (p=0.03, n=14). We think that NM504 attenuates absorption of glucose and bile salts.  Other possible mechanisms of action in the lower gut include maintenance of the mucosal barrier, increased luminal exposure to antioxidants, increased viscosity within the lumen.  Individual changes in microbiota abundance and short chain fatty acid production were evident but were not different when grouped by treatment.  A tendency for increased GLP-I levels and decreased ocatanoyl ghrelin levels in response to a meal tolerance test during week 3 was also observed.  In conclusion, NM504 is the first therapeutic to directly modulate the GI microbiome in prediabetics and in T2D to improve oral glucose tolerance with decreased markers of inflammation and blood lipids.  Moreover, this improved metabolic state occurred without change in dietary habits. Follow-up studies will include more subjects and longer trials.

 

Disclosure: MLH: Chief Scientific Officer, MicroBiome Therapeutics, Chief Scientific Officer, MicroBiome Terapeutics, Chief Scientific Officer, MicroBiome Therapeutics. ED: Collaborator, BioRankings. WDS: Chief Scientific Officer, BioRankings. FLG III: Advisory Group Member, MicroBiome Therapeutics. Nothing to Disclose: JHB

OR40-5 14546 5.0000 MON-0957 A Improved Oral Glucose Tolerance in Prediabetics and Type 2 Diabetics (T2D) in a Pilot Clinical Trial Testing a Novel Gastrointestinal (GI) Microbiome Modulator 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 1:00:00 PM OR40 4729 11:30:00 AM Type 2 Diabetes: Beta Cell Function and Novel Interventions Oral

Lalitha Gudipaty*1, Nora K Rosenfeld1, Carissa S. Fuller1, Marina Cuchel2 and Michael R. Rickels3
1Hospital of the University of Pennsylvania, PA, 2University of Pennsylvania School of Medicine, 3University of Pennsylvania Perelman School of Medicine, Philadelphia, PA

 

The two main pathophysiologic abnormalities in Type 2 Diabetes (T2D) are impaired tissue sensitivity to insulin action (i.e. insulin resistance) and impaired pancreatic β-cell function.  While obesity plays a pivotal role in insulin resistance, this alone does not typically result in abnormal glucose tolerance and must be accompanied by a defect in β-cell insulin secretion.  We hypothesized that in nonobese T2D, insulin sensitivity may be normal but β-cell defects would predominant with impaired insulin synthesis and/or secretion compared to obese T2D.  As part of a study designed to investigate the role of incretin-based therapy vs. sulfonylurea therapy in early type 2 diabetes (T2D), we recruited T2D subjects with fasting glucose between 110-159 mg/dl off all anti-diabetic agents and measured β-cell function and secretory capacity using glucose-potentiated arginine (GPA) test during which acute insulin responses to arginine (5 g) were determined under fasting (AIRarg) and 230 mg/dl (AIRpot) and 340 mg/dl (AIRmax) hyperglycemic clamp conditions.  Subjects were classified as nonobese (BMI ≤ 28; N=12) or obese (BMI > 28; N=26) and compared with normal controls (N = 12) that were weight and race matched to the nonobese T2D subjects. 

Results: Analysis of baseline data revealed that while the nonobese and obese T2D subjects were similar in age, both groups were older than the normal control group (58.8 ± 2.5 vs. 54.5 ± 1.6 vs. 32.2 ± 2.5; P < 0.0001 for both vs. normal).  The acute insulin response to arginine was significantly lower in the nonobese T2D under 230 mg/dl hyperglycemic clamp conditions than the normal group (AIRpot 79.6 ± 15.5 vs. 136.9 ± 17.9 μU/mL; P <0.05).   Acute proinsulin responses to arginine (APRpot) were (APRpot: 17.9 ± 2.9 vs. 15.1 ± 1.0 vs. healthy 25.0 ± 2.7 pmol/L; P <0.01).  Fasting proinsulin:insulin ratios were greater by statistical trend across the groups (27.7 ± 5.2 vs. 20.8 ± 2.1 vs. 16.3 ± 2.9%; P <0.1).  Acute proinsulin/insulin ratios (PISR) to estimate the contents within the secretory granules of the β-cell reveal that nonobese T2D have a higher PISR than obese T2D subjects and healthy subjects under 230 mg/dl glucose conditions (4.7 ± 1.2 vs 2.2 ± 0.2 vs. 2.9 ± 0.3 %; P < 0.05).  Non-obese T2D subjects had decreased β-cell sensitivity to glucose compared to the normal controls (210 ± 20 vs. 193 ± 11 vs. 155 ± 8 mg/dl; P <0.05). Obese T2D subjects were insulin resistant (P < 0.001) while non-obese subjects had insulin sensitivity that was comparable to normal subjects. 

Conclusions: In nonobese T2D, β-cell defects predominate with impaired β-cell sensitivity to glucose and proinsulin processing compared to obese T2D and normal controls in the absence of insulin resistance.

 

Nothing to Disclose: LG, NKR, CSF, MC, MRR

OR40-6 14754 6.0000 A Impaired B-Cell Secretory Capacity in Nonobese Compared to Obese Early Type 2 Diabetes and Healthy Controls 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 1:00:00 PM OR40 4729 11:30:00 AM Type 2 Diabetes: Beta Cell Function and Novel Interventions Oral

Rene Baudrand*1, Anand Vaidya2, Patricia C Underwood3, Amanda Elizabeth Garza3, Jonathan S Williams4, Gail K. Adler5, Gordon H Williams5 and Luminita H Pojoga6
1Pontificia Universidad Catolica de Chile, Santiago, Chile, 2Brigham and Women’s Hospital/Harvard Medical School, Boston, MA, 3Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, 4Brigham & Women's Hospital, Harvard Medical School, Boston, MA, 5Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 6Brigham & Women's Hosp, Boston, MA

 

Background: Cardiometabolic disorders are highly prevalent and associated with increased mortality in both obese and non-obese subjects. These observations suggest that BMI alone is not an accurate predictor of risk and that individual risk profiling is needed for non-obese subjects. Caveolin-1 (cav-1) modulates cell surface signaling and interacts with multiple receptors which may have a pathogenic role in cardiometabolic dysfunction.

Preliminary results: We previously reported that cav-1 gene variants associate with insulin resistance (IR) in two ethnically different cohorts. We also described that cav-1KO mice have an abnormal glucose profile and dyslipidemia despite their lean phenotype.

Aim: Herein, we describe analyses revealing a cav-1 variant capable of predicting cardiometabolic risk factors with an emphasis on non-obese individuals (BMI <30).

Methods/Results: We genotyped 735 Caucasian adults for the cav-1 rs926198 polymorphism. When analyzed by a dominant inheritance model and by WHO criteria, 57% were minor allele carriers and presented higher prevalence of diabetes (10.7% vs 5.7%, p=0.016), low HDL (49.3% vs 39.6%, p=0.018), IR (44.3% vs 35.1%, p=0.022) and metabolic syndrome (MetS, 33% vs 20.5%, p<0.001). Minor allele carriers exhibited significantly higher Framingham risk score, circulating PAI-1 and IL-6 levels, when compared to major allele carriers, which were not explained by differences in BMI. Also, minor allele carriers, even when adjusted for age, gender and BMI, presented higher odds of diabetes (OR 1.98, CI: 1.10-3.57, p=0.022), low HDL (OR 1.57, CI: 1.11 – 2.22, p =0.010) and MetS (OR 2.49, CI: 1.66-3.78, p=<0.001). These effects in cardiometabolic outcomes were modulated by a significant interaction between the cav-1 variant and BMI as a categorical variable. Thus, minor allele carrier status strongly predicted MetS in non-obese subjects (OR 3.56, CI: 2.05-6.19, p< 0.001); in contrast the effect of cav-1 variant to predict MetS was blunted in obese individuals (OR 1.63, CI: 0.86-3.08, p= 0.134). Consistently, we observed that non-obese minor allele carriers had significant higher odds for both diabetes (OR 2.26 CI: 1.07 – 4.77, p =0.032) and low HDL risk (OR 1.78, CI: 1.17 – 2.69, p =0.007).

Conclusion: A prevalent cav-1 variant was associated with IR, cardiovascular risk and inflammation, and predicted several cardiometabolic risk factors in Caucasians. Notably, in non-obese subjects, this cav-1 variant predicted higher odds of diabetes, dyslipidemia and MetS. Therefore, this particular genotype may improve individual risk profiling and screening by detecting metabolically unhealthy non-obese subjects. Future prospective studies are needed to confirm the clinical implications of our results.

 

Nothing to Disclose: RB, AV, PCU, AEG, JSW, GKA, GHW, LHP

OR34-1 16168 1.0000 A A Prevalent Caveolin-1 Gene Variant Predicts Cardiometabolic Risk in Non-Obese Subjects 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 1:00:00 PM OR34 4731 11:30:00 AM Predictors and Mediators of Cardiovascular Risk: Clinical Research Oral

Irina Ciubotaru*1, Stefan J Green2, Arfana Akbar3, Karthik Cherukupally3, Hassan Zaidi3, Subhash C Kukreja1 and Elena Barengolts2
1UIC Section of Endocrinology, Chicago, IL, 2University of Illinois at Chicago, Chicago, IL, 3Jesse Brown VAMC, Chicago, IL

 

INTRODUCTION: The gut Gram-negative bacteria Prevotella and its relative abundance over Bacteroides increase energy extraction possibly contributing to obesity and type 2 diabetes (T2D), while Akkermansia is associated with weight loss and may be protective (1). This study evaluated associations between dietary composition, gut microbiota, and serum 25OHD level in a cohort of African American men (AAM) with prediabetes and hypovitaminosis D.

METHODS: 24h dietary recalls were obtained from AAM participants in a clinical trial of D vitamin Intervention at VA (DIVA, NCT01375660). Gut (fecal) microbiota was analyzed using high-throughput next-generation sequencing of microbial rRNA genes and data processed using established bioinformatics pipelines. Dietary data are reported as mean±SD and % RDA. The effects of BMI, A1C, dietary intake, and serum 25OHD on microbiota at genus level were assessed.

RESULTS: Participants (n=104) had age 59±8 yrs, BMI 32±3 kg/m2, A1C 6.1±0.3%, serum 25OHD 18.5±18 ng/dL. They consumed daily 2167±111 kcals (69.5±29%), 89±37g proteins (117.3±66%), 90±49g fat (91.8±52%), 28±16g (89.3±52%) saturated fat, 251±140g (58.5±34%) carbohydrates (CHO), and 16±10g fiber (37.3±25). Significant differences between bacterial populations of extreme quartiles of total calories (p<0.002), saturated fat (p<0.02), CHO (p=0.05), fiber (p<0.05), and protein (p<0.03) were observed. A decrease in the Bacteroides (B) and an increase in Prevotella (P) abundance were observed with increased quartiles of caloric intake (B/P ratios: 12.5, 5.25, 2.37, and 1.66, respectively). Akkermansia abundance was inversely correlated with caloric intake. There was no significant association between BMI and A1C and microbiota makeup, while increasing serum 25OHD level was associated with dramatic decrease in Prevotella.

DISCUSSION: Positive association of caloric and macronutrient intake with Prevotella abundance (B/P ratio) and inverse association of caloric intake with Akkermansia are in agreement with previous studies (1). Negative association between serum 25OHD level and gut Prevotella is novel and suggests possible contribution of vitamin D to changes in gut microbiota via vitamin D receptor signaling (2-3). Alternatively, increased caloric intake may favor proliferation of Prevotella resulting in increased intestinal vitamin D clearance (4) and lower circulating 25OHD level. In the same cohort we observed possible vitamin D role in delaying T2D development due to improved insulin sensitivity. Taken together these results suggest novel interactions between microbiota, vitamin D, nutrient intake, and glucose homeostasis.

CONCLUSION: In AAM with prediabetes and hypovitaminosis D relative abundance of Prevotella correlated positively with caloric and macronutrient intake and negatively with serum 25OHD level.

 

Nothing to Disclose: IC, SJG, AA, KC, HZ, SCK, EB

OR34-2 16237 2.0000 A Vitamin D May Play a Role in Obesity and T2DM Via Modulation of Gut Microbacteria As Evidenced By Novel Negative Correlation Between Fecal Prevotella Abundance and Serum 25OHD Level and Positive Correlation of Prevotella with Caloric and Macronutrient Intake 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 1:00:00 PM OR34 4731 11:30:00 AM Predictors and Mediators of Cardiovascular Risk: Clinical Research Oral

Subramanian Kannan*1, Simone Matsuda Torricelli2, Kevin M Pantalone3, Brian J Wells3, Matthew Karafa2 and Robert S Zimmerman3
1Narayana Health City, Bangalore, India, 2Cleveland Clinic, Cleveland OH, Cleveland, OH, 3Cleveland Clinic, Cleveland, OH

 

Background: Controversy still surrounds the selection of anti-diabetic agents for the treatment of type 2 diabetes mellitus (DM-2) once the first line agent, Metformin, fails.  Recently, the focus in management of DM-2 has shifted to the adverse effects of the anti-diabetic agents, largely the risk of adverse cardiovascular (CV) outcomes and mortality. A prospective trial found an increased risk of hospitalization for congestive heart failure in subjects treated with saxagliptin. A recent re-analysis of the RECORD trial by the US-FDA noted no increase in CV risk with the use of rosiglitazone. Large-scale clinical trials investigating the long-term CV safety of glucagon like peptide-1 agonists (GLP-1a) are ongoing.

Aim: To assess the risk of overall mortality, coronary artery disease, and congestive heart failure in patients with DM-2 treated with dual drug therapy including metformin and an additional anti-diabetic agent. 

Methodology: A retrospective cohort study was conducted using an academic health center enterprise-wide electronic health record (EHR) system to identify 13,185 patients with DM-2 who received a prescription for (Metformin (MF) in combination with a Sulfonylurea (SFU) (N=9,419), Thiazolidinedione (TZD) (N=1,846), DPP4-inhibitor (DPP4-I) (N=1,487), or a GLP-1 receptor agonist (N=433), seen in the outpatient clinics, ≥ 18 years of age, and not on insulin or undergoing dialysis at baseline.  The patients were followed for mortality, coronary artery disease, and congestive heart failure by documentation in the EHR and Social Security Death Index.  Cox multiple regression models were used to compare cohorts. Combination therapy with MF+SFU served as the comparator group.

Results: Baseline characteristics for the entire cohort include mean (+ SD) age 60.6 + 12.6 years, 54.6% male and 75.8% Caucasian.  The median follow-up was 4 years.  There were a total of 1,077 deaths, 1,733 CAD events, and 528 CHF events in 55,110.76 person years of follow-up.  No statistically significant difference in the risk of overall mortality or CAD was observed among the different drug combinations. There was a trend towards improved overall survival with users of MF+TZD [HR 0.86 (0.74-1; p=0.05)] and MF+GLP-1a [HR 0.569 (0.30 - 1.07; p=0.08)] users. A higher risk of CHF was observed with MF+DPP4-I use [HR 1.104 (1.04-1.17; p=0.001)] and a trend towards a statistically significant increased risk with other combinations, MF+TZD [HR 1.024 (0.98-1.07)] and MF+GLP-1a [HR 1.1 (0.99-1.22)]. A sub-analysis of the MF+TZD cohort after excluding rosiglitazone demonstrated similar risks of mortality, CAD, and CHF.  

Conclusions: It does not appear that the SU and MF combination confers increased cardiac or mortality risk compared to the other drug combinations. However, an increased risk of CHF was noted with MF+DPP4-I use, as well as a strong statistical trend towards an increased risk with other combinations.

 

Disclosure: KMP: Consultant, Novo Nordisk, Consultant, Sanofi, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Eli Lilly & Company. RSZ: Speaker Bureau Member, Novo Nordisk, Speaker, Jansen Pharmaceuticals, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Merck & Co., Speaker Bureau Member, Santarus. Nothing to Disclose: SK, SMT, BJW, MK

OR34-3 11354 3.0000 A The Risk of Overall Mortality and Cardiovascular Events in Patients with Type 2 Diabetes on Dual Drug Therapy Including Metformin: A Large Database Study from Cleveland Clinic 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 1:00:00 PM OR34 4731 11:30:00 AM Predictors and Mediators of Cardiovascular Risk: Clinical Research Oral

Nora Alghothani*1, Trudy R. Gaillard2, Lianbo Yu3 and Kwame Osei1
1The Ohio State University, Columbus, OH, 2Ohio State University, 3The Ohio State University

 

Ethnic disparities in CVD outcomes exist among AAW & WAW women. The significantly higher mortality in AAW occurs despite higher HDL-C & lower TG. AAW manifest increased insulin resistance, oxidative stress burden, & proinflammatory markers as well as HDL dysfunctionality (1). ASA therapy has been recommended to reduce subclinical atherosclerosis & CVD outcomes such as stroke. Although its anti-platelet effects are well established, additional anti-inflammatory benefits of ASA in the prevention of CVD & its risk factors in AAW is unknown. Thus, it remains uncertain whether AAW equally benefit from ASA.

To explore the anti-inflammatory response to ASA therapy in AAW compared to WAW, we examined the subclinical proinflammatory markers hsCRP & IL-6. We conducted a placebo-controlled, double blind randomized study for 6 mos duration of 42 nondiabetic postmenopausal AAW & WAW (mean age 57.2 ± 3.6 years) with subclinical atherosclerosis by CIMT (mean in AAW 0.6911 ± 0.0509 vs. WAW 0.6113 ± 0.0525 mm). Subjects received either daily enteric coated ASA 325 mg or identical placebo. Fasting blood samples & anthropometric parameters were obtained at baseline & 6 mos later. AAW (n=21) were more obese than WAW (BMI 32.8 ± 6.5 vs. 27.8 ± 5.0 kg/m2, P = 0.007). We found no significant differences between AAW & WAW in fasting glucose, insulin, C-peptide, HOMA-IR, LDL-C, HDL-C, apoB, or blood pressure at baseline & 6 mos. At baseline, AAW had lower TG (62.2 ± 23.4 vs. 88.3 ± 46.5 mg/dL, P = 0.02) & higher apoA1 (185.2 ± 29.7 vs. 159.7 ± 46 mg/dL, P = 0.03). Compared to WAW, AAW also had higher baseline hsCRP (3.96 ± 3.7 vs. 2.2 ± 2.5 mg/L, P = 0.07), but no significant difference in IL-6 (0.77 ± 0.411 vs. 2.05 ± 4.20 pg/mL, P = 0.171). Although when using ANOVA models to assess treatment & race effect as well as their interaction, no statistically significant difference was concluded, AAW did appear to have an overall blunted response to the antinflammatory properties of ASA when compared to WAW. While hsCRP increased from baseline to 6 mos in placebo AAW (n=10, 3.34 ± 2.42 vs. 8.36 ± 12.83 mg/L) & placebo WAW (n=10, 2.19 ± 2.82 vs. 2.69 ± 3.24 mg/L), it remained essentially unchanged in ASA treated AAW (n=11, 4.53 ± 4.69 vs. 4.62 ± 3.84 mg/L). In contrast, hsCRP decreased by 25% in ASA treated WAW (n=11, 2.13 ± 2.41 vs. 1.60 ± 2.44 mg/L). IL-6 increased in both placebo groups at 6 mos (in AAW was 0.58 ± 0.28 vs. 2.97 ± 3.41 pg/mL & in WAW 0.99 ± 1.02 vs. 2.31 ± 2.47 pg/mL). We found IL-6 also increased in ASA treated AAW (0.93 ± 0.45 vs. 2.56 ± 0.95 pg/mL). On the other hand, ASA reduced IL-6 by 48% in WAW (2.69 ± 5.43 vs. 1.39 ± 0.51 pg/mL).

In summary, our pilot study demonstrated that AAW appear to be more resistant than WAW to anti-inflammatory properties of ASA. We conclude that there are ethnic differences in response to ASA mediated anti-inflammatory benefits, & speculate that perhaps a higher dose of ASA may be required in AAW to achieve better CVD outcomes & lessen disparities.

 

Nothing to Disclose: NA, TRG, LY, KO

OR34-4 17051 4.0000 A African American Nondiabetic, Postmenopausal Women (AAW) Are More Resistant to Anti-Inflammatory Effect of Aspirin Therapy Than White Women (WAW) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 1:00:00 PM OR34 4731 11:30:00 AM Predictors and Mediators of Cardiovascular Risk: Clinical Research Oral

Katherine Samaras*1, Jackie Curtis2, Andrew Watkins3, Simon Rosenbaum2, Scott Teasdale3, Megan Kalucy3 and Philip B. Ward4
1St Vincent's Hospital, Sydney NSW, Australia, 2University of New South Wales, Sydney, Australia, 3South Eastern Sydney Local Health District, Bondi Junction, Australia, 4South Western Sydney Local Health District, Liverpool BC, Australia

 

Youth with first episode psychosis (FEP) receiving antipsychotic medications (APMs) are at risk of obesity, metabolic syndrome and diabetes. APM initiation induces a rapid deterioration in metabolic health within 12 weeks, with up to 77% experiencing clinically significant (>7%) weight-gain within the first year (1,2).

Aim: To determine whether a multi-disciplinary, 12-week early intervention in youth with psychosis can attenuate the expected weight gain and decline in metabolic health.

Methods: Young people aged 15-25 with FEP admitted from January 2013 were eligible to enroll in a 12-week multidisciplinary intervention, the Keeping the Body in Mind Program. Weekly individualized dietetic monitoring and education were provided, in addition to group education sessions. Individualized exercise prescriptions were provided by an exercise physiologist, along with optional use of a supervised on-site gym. Controls were youth with FEP attending another Sydney service with similar socio-demographic characteristics that did not offer lifestyle interventions. Outcomes were weight, waist and fasting lipids and glucose exercise capacity (VO2 max) and energy intake at baseline and 12 weeks.

Results: 16 participants (7 males, 9 females, mean age 20.0 (SD 2.3) years undertook the intervention. Controls (n=11, males, one female, mean age 21.7 SD 2.0) were similar in age (p=0.6) and APMs prescribed. Weight gain was substantially less in the intervention group compared to controls (1.2 kgs ± 0.7 versus 7.3 kgs ± 1.3, p < 0.001). In the intervention group, contrary to the expected deterioration in metabolic parameters, there was no significant increase in waist circumference (p=0.84), systolic or diastolic blood pressures (p=1.0 & p=0.1), HDL (p=0.2), LDL (p=0.9), triglycerides (p=1.0), total cholesterol (p=0.5), and fasting blood glucose (p=0.2). Clinically significant changes were observed in aerobic fitness (VO2 max; p=0.01) and energy intake (p<0.001) in the intervention group.

Conclusions: Multidisciplinary early lifestyle intervention can abrogate the negative metabolic outcomes associated with anti-psychotic medication in this vulnerable population of young people. This could contribute to reducing the disparity in life expectancy in young people with first episode psychosis.

 

Nothing to Disclose: KS, JC, AW, SR, ST, MK, PBW

OR34-5 15804 5.0000 A Early Lifestyle Intervention Abrogates Antipsychotic-Induced Weight Gain in First Episode Psychosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 1:00:00 PM OR34 4731 11:30:00 AM Predictors and Mediators of Cardiovascular Risk: Clinical Research Oral

Seoyoung C. Kim1, Robert Glynn1, Jun Liu1, Brendan M. Everett1 and Allison B Goldfine*2
1Brigham and Women's Hospital, Boston, MA, 2Joslin Diabetes Center, Boston, MA

 

Dipeptidyl peptidase-4 inhibitors (DPP4i), such as linagliptin, saxagliptin, and sitagliptin, are oral glucose-lowering drugs for type 2 diabetes mellitus (T2D). While two recent large clinical trials of T2D patients with cardiovascular disease (CVD) at baseline showed no risk of ischemic cardiovascular events associated with DPP4i, one trial showed an increased risk of hospitalization for heart failure (HF) in the saxagliptin group. The objective of this study was to evaluate the risk of CVD including myocardial infarction (MI), stroke, coronary revascularization, and HF associated with DPP4i in T2D patients with and without baseline CVD.

We conducted a population-based cohort study using commercial insurance claims data (2005-2012). Among patients aged 40 years and older with T2D, two mutually exclusive exposure groups were selected: 1) DPP4i combotherapy (DPP4i plus metformin) and 2) non-DPP4i combotherapy (metformin plus other non-DPP4i drugs) initiators. Patients with cancer, end-stage renal disease, dialysis, or use of insulin-containing drugs or glucagon-like peptide 1 agonists at baseline were excluded. The primary endpoint was a composite CVD outcome including MI, stroke, coronary revascularization and HF, defined with a hospital discharge diagnosis or procedure code. The secondary endpoints were the individual components of the primary endpoint. To control for baseline confounders such as demographic factors, comorbidities, medications, and health care utilization, propensity score (PS) matching method was used. PS-matched Cox regression models compared the risk of CVD in DPP4i initiators compared to non-DPP4i initiators with and without baseline CVD. Sensitivity analysis compared initiators of DPP4i monotherapy versus non-DPP4i monotherapy.  We included a total of 32,419 (5,573 pairs with baseline CVD and 26,746 without) PS-matched pairs of DPP4i and non-DPP4i combotherapy initiators. Among patients with baseline CVD, the IR per 1,000 person-years for composite CVD was 86.2 (95%CI 77.2-96.2) in DPP4i and 100.5 (95%CI 89.8-112.6) in non-DPP4i. The PS-matched HR for composite CVD was 0.90 (95%CI 0.77-1.06) for DPP4i vs. non-DPP4i combotherapy initiators in patients with baseline CVD. Among patients with no baseline CVD, the IR per 1,000 person-years for composite CVD was 15.9 (95%CI 14.2-17.9) in DPP4i and 17.0 (95%CI 15.0-19.3) in non-DPP4i. The PS-matched HR for composite CVD was 0.95 (95%CI 0.80-1.13) in patients with no baseline CVD for DPP4i vs. non-DPP4i initiators. The PS-matched HR for hospitalization for HF was also not increased with DPP4i. Similarly, the sensitivity analysis showed no increased CVD risk in DPP4i monotherapy initiators with and without baseline CVD.  

In conclusion, in this large cohort of T2D patients, initiating DPP4i was not associated with an increased or decreased risk of CVD including HF compared to those initiating non-DPP4i.

 

Disclosure: SCK: Investigator, Pfizer, Inc.. ABG: Principal Investigator, Daiichi Sankyo, Principal Investigator, Novo Nordisk, Principal Investigator, Mercodia, Nestle, Amneal Pharmaceutical, Lifescan Provide Supplies for NIH funded studies. Nothing to Disclose: RG, JL, BME

OR34-6 15311 6.0000 A Dipeptidyl Peptidase-4 Inhibitors Do Not Increase the Risk of Cardiovascular Events in Type 2 Diabetes: A Population-Based Cohort Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 1:00:00 PM OR34 4731 11:30:00 AM Predictors and Mediators of Cardiovascular Risk: Clinical Research Oral

Yugong Ho*1, Nancy E Cooke2 and Stephen A Liebhaber3
1Univ of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 2Univ of PA Schl of Med, Philadelphia, PA, 3Univ of PA - Clinical Res Bldg, Philadelphia, PA

 

Pit-1, a pituitary specific POU homeodomain transcription factor, plays an essential role in the process of anterior pituitary differentiation. Abolishing the expression of Pit-1 results in the combined loss of somatotropes, lactotropes, and thyrotropes in the anterior pituitary. Prior studies have revealed that the initial activation of Pit-1 occurs at embryonic day 14 (E14) in the developing mouse pituitary.  This activation is mediated by the binding of transcription factor Atbf1 at an ‘early enhancer’ of Pit-1, located -5.8 kb upstream of the Pit-1 promoter. The subsequent maintenance phase of Pit-1 expression is initiated and  sustained at E16.5 by an auto-regulatory mechanism in which Pit-1 binds to its own promoter and to a distal enhancer (‘late enhancer’) located 10 kb upstream of the Pit-1 promoter. Despite the identification of these regulatory elements, the accompanying changes in chromatin architecture at the Pit-1 locus during the pituitary development remains undefined. In the current study, we investigate the chromatin configuration of the mouse Pit-1 locus at different developmental stages. Our chromatin conformation capture (3C) analysis reveals that the early enhancer is positioned proximal to the Pit-1 promoter at the time of initial Pit-1 activation (E14.5). We detect an accompanying acetylation of histone H3 at this stage that is restricted to the early enhancer and the promoter. The maintenance phase of Pit-1 expression is marked by a switch in the locus conformation, with positioning of the distal enhancer in proximity to the promoter. Furthermore, ChIP-3C analysis suggests that the interaction between the distal enhancer and the promoter in the maintenance phase is mediated by Pit-1 and CBP.  The long-range chromatin interaction in the maintenance phase is associated with a broad hyperacetylated chromatin domain throughout the entire locus. Taken together, our studies demonstrate that the regulation of Pit-1 expression is accompanied by the dynamic alternation of the chromatin conformation when the Pit-1 gene switches from transcriptional activation to the maintenance phase of gene expression.  These data support a model in which chromatin architecture plays an important role in activation and maintenance of gene expression in the pituitary.

 

Nothing to Disclose: YH, NEC, SAL

OR33-1 14069 1.0000 A Dynamic Chromatin Interactions at the Pit-1 Locus during Pituitary Differentiation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR33 4738 11:30:00 AM Pituitary and Growth Hormone Oral

Amanda Helen Mortensen*1, Vanessa Schade2, Thomas Lamonerie3 and Sally A Camper4
1University of Michigan, Ann Arbor, MI, 2University of Michigan, 3Equipe Neurodéveloppement, France, 45704 Med. Sci II, 1241 Catherine St., Ann Arbor, MI

 

Mutations in a variety of transcription factors cause pituitary insufficiency in mouse and man.  OTX2 is a particularly intriguing example because the phenotypic consequences cover a broad spectrum, and the penetrance is incomplete.  Clinical manifestations include craniofacial structures, eye development, and/or pituitary insufficiency associated with ectopic or undescended posterior lobe and anterior lobe hypoplasia (reviewed in [1]).  HESX1 mutations also produce a spectrum of effects, influencing definition of the midline and many of the same tissues as OTX2.  The spatial and temporal expression patterns of both genes in the anterior visceral endoderm (AVE) and molecular epistasis analyses led to the realization that OTX2 regulates HESX1 expression in the developing forebrain.  During organogenesis of the mouse pituitary gland, Otx2 and Hesx1 are both expressed transiently in the oral ectoderm, but Otx2 is also expressed strongly in the ventral diencephalon tissue fated to become the infundibulum.  To determine the relative contributions of these two sites of Otx2 expression to pituitary gland development, we used the cre-loxP system to selectively inactivate Otx2.  Deletion of Otx2 in the AVE and rudimentary Rathhke’s pouch using Foxg1-cre causes a variable pituitary phenotype that includes anterior pituitary dysmorphology and bifurcations.  This suggests that Otx2 could play a role in the activation and/or maintenance of Hesx1 expression in both the AVE and the rudimentary pouch.  Deletion of Otx2 in the developing ventral diencephalon using Nkx2.1-cre led directly to posterior lobe hypoplasia and reduced FGF signaling, which secondarily caused anterior pituitary hypoplasia, independent of Hesx1.  These data suggest that Otx2 expression in the developing ventral diencephalon and oral ectoderm are both important for normal hypothalamic-pituitary axis function.  Thus, the mechanism underlying posterior lobe and pituitary stalk defects in human patients is likely to be due to the failure of OTX2 to activate FGF signaling in the ventral diencephalon.  While this contributes secondarily to the anterior lobe hypoplasia, the failure of OTX2 to activate HESX1 expression in the AVE and rudimentary Rathke’s pouch are also likely to be contributing factors to poor anterior pituitary growth and multiple pituitary hormone deficiencies.  In conclusion, our studies in genetically engineered mice suggest two mechanisms that underlie disrupted pituitary development and function in patients with OTX2 mutations.

 

Nothing to Disclose: AHM, VS, TL, SAC

OR33-2 16918 2.0000 A Tissue Specific Disruption of OTX2 Causes Pituitary Hypoplasia By Different Mechanisms 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR33 4738 11:30:00 AM Pituitary and Growth Hormone Oral

Yash Chhabra*1, Ho Yi Wong2, Andrew James Brooks3 and Michael John Waters4
1University of Queensland, Brisbane, Australia, 2University of Queensland, St. Lucia, Australia, 3The University of Queensland, Brisbane QLD, Australia, 4Univ of Queensland, Brisbane QLD, Australia

 

Growth Hormone (GH) is essential for the regulation of growth and the homeostatic control of intermediary metabolism. GH actions are mediated by the Growth Hormone Receptor (GHR); a member of the cytokine receptor super family that signals through the JAK2/STAT5, PI-3K and MAPK pathways. Target tissue responsiveness to GH is under regulatory control to avoid excessive GHR activation. Numerous loss-of-function mutations in GHR associated with idiopathic short stature and GH insensitivity have been described and these confer protection against cancer. The P495T (Proline to Threonine) GHR variant, has been reported in two separate GWAS population studies linking it with increased lung cancer susceptibility (OR= 12.98 (1) and 2.04 (2) respectively). Here we have studied the potential bases for this action. We find that P495T GHR increases STAT5 and AKT signalling in a cell-dependent manner. Although not constitutively active by itself this variant results in prolonged downstream signalling and proliferation after GH stimulation due to delay in GHR degradation at the cell surface. This appears to be the direct result of steric hindrance to SOCS2 ubiquitin ligase binding at Y487 that lies in close proximity to P495T in GHR. Additionally, the P495T variant is less prone to the ligand-independent constitutive endocytosis that remains unaffected by proteasomal and/or γ-secretase inhibitors. This is the first time a polymorphism in GHR has been associated with cancer and highlights the importance of GHR turnover in tumour promotion.

 

Nothing to Disclose: YC, HYW, AJB, MJW

OR33-3 13698 3.0000 A The First Cancer-Associated Variant of the Growth Hormone Receptor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR33 4738 11:30:00 AM Pituitary and Growth Hormone Oral

Michelle L. Brinkmeier*, María Inés Pérez Míllan, Leonard Cheung and Sally A Camper
University of Michigan, Ann Arbor, MI

 

Proper size and composition of the mouse anterior pituitary is achieved through two waves of pituitary growth (1,2).  Early proliferation, migration, and differentiation of progenitor cells between embryonic day 12.5 (e12.5) and e14.5 in mice is required to establish the initial pools of anterior pituitary cells.  A subset of these cells retain their proliferative capacity and drive a second wave of pituitary growth after birth, expanding the populations of differentiated cells to their proper proportions.  Both Prop1df/df and Pou1f1dw/dw mutants lack anterior pituitary somatotropes, thyrotropes, and lactotropes resulting in dwarfism and hypothyroidism, but the pituitaries of Prop1 mutants exhibit a unique dysmorphology and earlier onset hypopituitarism relative to Pou1f1 mutants (3).  This may be explained by the differentially regulated genes unique to Prop1 and Pou1f1 mutants (4).  We hypothesized that Prop1 regulates the transition of progenitors to differentiated cells.  To explore this idea we examined the effect of both mutations on expression of selected transcription factors, cell cycle regulators and signaling pathways from e12.5 Rathke’s Pouch through postnatal day 7 (P7) pituitary.  We discovered a second wave of Prop1 expression after birth suggesting it plays a role during both embryonic and postnatal growth.  During embryogenesis expression of Notch2 (5) and the transitional cell marker cyclin E (6), are reduced in Prop1 mutants, but they do not appear to depend on Prop1 or Pou1f1 postnatally.  Pituitary stem cells or progenitors are marked by several transcription factors including the SOXB family member SOX2.   A modest increase (~2 fold) in postnatal Sox2 expression is evident in Prop1 mutants, consistent with the idea of a transitional block.  Another SOXB transcription factor exhibits dramatically increased expression (~50-100 fold), specifically in Prop1 mutants between P3 and P7.  Normally this gene is silenced before birth, in contrast to the essentially uniform expression of Sox2 throughout wild type embryonic and postnatal pituitary development.  Dynamic regulation of SOXB genes can influence the transition from progenitor to differentiated cells in other organ systems (7).   In summary, we have discovered a potential role for Prop1 in postnatal expansion of the pituitary gland associated with elevated expression of progenitor markers and reduction in expression of transitional cell markers.  In addition we identified a potential Prop1 target that may regulate the transition between progenitor proliferation and differentiation.  

 

Nothing to Disclose: MLB, MIPM, LC, SAC

OR33-4 16769 4.0000 A Postnatal Expression of PROP1 Regulates the Transition of Progenitors to Differentiating Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR33 4738 11:30:00 AM Pituitary and Growth Hormone Oral

Angus M. MacNicol*, Melanie C. MacNicol, Melody L. Allensworth-James, Anessa C. Haney, Angela K. Odle and Gwen V. Childs
University of Arkansas for Medical Sciences, Little Rock, AR

 

The appetite regulatory hormone, leptin stimulates growth hormone (GH) production and secretion from somatotropes. We recently demonstrated the importance of leptin to somatotrope function, showing that the selective ablation of leptin receptors (LepR) in somatotropes causes GH deficiency (GHD) with consequential metabolic problems and adult-onset obesity.[1, 2]  Studies of mutants lacking the JAK binding site in LepR (exon 17) revealed a 60% reduction in number of GH protein-containing cells and cells that express growth hormone releasing hormone receptors (GHRHR), [1, 3] but no reduction in number of cells with GH mRNA, suggesting a posttranscriptional role for leptin in optimizing GH stores.[3] We thus began in silico and molecular assay studies to determine candidate regulatory factors that specifically target GH mRNA. An important clue was discovered in ob/ob mice in a report that showed upregulation of inhibitory miRNAs (miR-103 and miR-107) in the absence of leptin signaling, which contributed directly to insulin resistance.[4] A comparative analysis of the GH mRNA 3’ untranslated region (3’ UTR) revealed that the murine GH mRNA 3’-UTR (but not the human GH mRNA 3’-UTR) contains complete seed sequences for miR-103 and miR-107 suggesting these miRNAs as candidate regulators of murine GH mRNA translation. The 98-nucleotide murine GH 3’-UTR contains additional predicted miRNA-binding sites two of which, miR-590-3p and miR-1197, are also conserved in all 3’-UTRs of the human GH1 mRNAs.[5, 6] We examined pituitaries from our somatotrope LepR exon-1-null mutant mice for expression of these candidate miRNAs. qPCR analysis indicated that while GH mRNA levels were unchanged in mutant vs control males, GH mRNA levels were slightly reduced to 75% of control values in mutant females (p=0.01). Pituitary GHRHR and ghrelin mRNA levels were normal in both male and female mutants, in spite of the lower levels of binding to GHRHR (This suggests leptin posttranscriptional regulation of GHRHR mRNA as well). Mutant pituitaries from both sexes had significantly higher levels of miR590 and miR103 over controls (miR590; mutants 169% ± 3% vs control; p=0.02, n=8 and miR103; mutants 126% ± 4% vs controls p=0.0004, n=7). Mutant females, but not mutant males, had a 2-fold higher expression of miR1197 (198% ± 3% p=0.04 vs controls, n=4). miR107 was higher in control females than control males (211% ± 2% females, p=0.02, n=4) and mutant males showed an 84% upregulatory trend in miR107 (p=0.06, n=4). These data indicate that loss of LepR selectively in somatotropes upregulates miRNA levels for those miRNAs predicted to bind and inhibit translation of GH mRNA. The findings support a model in which leptin optimizes somatotrope GH protein stores by preventing a sex-specific block in GH mRNA translation by key miRNAs.

 

Nothing to Disclose: AMM, MCM, MLA, ACH, AKO, GVC

OR33-5 13971 5.0000 A Does Leptin Optimize Somatotrope GH Stores Via Post-Transcriptional Mechanisms? Selective Ablation of Leptin Receptors in Somatotropes Upregulates Micro-RNAs Predicted to Bind and Inhibit Translation of GH mRNA 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR33 4738 11:30:00 AM Pituitary and Growth Hormone Oral

Maria Ines Perez-Millan*1, Michelle L. Brinkmeier2, Claudia Veiga Chang3, Luciani R S Carvalho4 and Sally A Camper5
1University of Michigan, Ann Arbor, MI, 2Univ of Michigan, Ann Arbor, MI, 3Universidade de Sao Paulo, Sao Paulo, Brazil, 4University of São Paulo, Hospital das Clinicas, São Paulo, Brazil, 55704 Med. Sci II, 1241 Catherine St., Ann Arbor, MI

 

Multiple pituitary hormone deficiency (MPHD) can be caused by mutations in several pituitary transcription factor genes in mouse and man, including Prop1, Pou1f1, Hesx1, Sox2 and other genes.  Prop1 is expressed briefly during embryonic development and early postnatal life in mice, and it is necessary for repression of Hesx1 expression and activation of Pou1f1 (1).  PROP1 mutations cause progressive hormone deficiency in humans, affecting all lineages, while POU1F1 mutations cause MPHD involving TSH, GH and PRL production exclusively.  We hypothesize that PROP1’s role is in progenitor transition to differentiation and POU1F1 has a later role restricted to lineage-specific cell specification.  To test this hypothesis we examined the effect of both mutations on expression of stem cell markers and on the quantity of progenitor colony forming cells (PCFC) (2).  Prop1 mutant mice have elevated expression of Sox2 in the postnatal pituitary gland, while similar levels of expression were detected in Pou1f1 mutants, supporting the hypothesis.  Both mutants can generate PCFCs in culture that express stem cell markers including Sox2, Sox9 and Gfra2.  Surprisingly, pituitaries from either mutant contain more PCFC than wild types, and they proliferate at a more rapid rate.  Both mutations exert effects on the developmental profile of PCFC.  Normally PCFC decrease as animals develop after birth, but PCFC peak in Prop1 mutants between P7 and 13, and Pou1f1 mutant PCFC accumulate at later ages during adulthood.  This is consistent with the fact that Prop1 is upstream of Pou1f1 in the genetic hierarchy and several days earlier than Pou1f1, and these results imply that Pou1f1 has an unexpected role in PCFC development and/or function.  PCFC from Prop1 mutant mice have a different morphology than Pou1f1 mutants and wild type derived colonies. RNA-Seq experiments identify genes unique to each mutant genotype and suggest candidate genes to explain the differences in PCFC numbers, morphology, and proliferation rates.  These results support the idea that Prop1 is necessary to promote the transition of progenitors to differentiation and reveal an unexpected role for Pou1f1 in PCFC.  Understanding the molecular mechanisms that underlie PCFC development and function is an important starting point for considering effective therapeutic treatments for MPHD.

 

Nothing to Disclose: MIP, MLB, CVC, LRSC, SAC

OR33-6 16454 6.0000 A Unique Effects of PROP1 and POU1F1 on Pituitary Progenitor Development, Proliferation and Differentiation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR33 4738 11:30:00 AM Pituitary and Growth Hormone Oral

Sharon Lauretta Dubois*1, Andrew Wolfe2, Sally Radovick3, Ulrich Boehm4 and Jon E Levine1
1University of Wisconsin-Madison, Madison, WI, 2Johns Hopkins University School of Medicine, Baltimore, MD, 3Johns Hopkins School of Medicine, Baltimore, MD, 4University of Saarland School of Medicine, Homburg, Germany

 

The kisspeptin signaling pathway is an integral component of neuroendocrine systems governing fertility in humans and rodents. Kisspeptin is mainly expressed in the anteroventral periventricular nucleus (AVPV) and the arcuate nucleus (ARC) in the rodent brain, the majority of which co-express estrogen receptor α (ERα). In females, estradiol (E2) activation of ERα stimulates kisspeptin expression in the AVPV while suppressing kisspeptin expression in the ARC. Thus, it has been proposed that E2 activation of ERα in AVPV kisspeptin neurons mediates release of ovulatory GnRH/LH surges (positive feedback), while ERα activation in ARC kisspeptin neurons maintains basal GnRH/LH secretion (negative feedback). To test these hypotheses, we generated mice bearing kisspeptin cell-specific deletion of ERα (KERαKO) and challenged them with E2 regimens that evoke either positive or negative feedback effects. To induce an LH surge, KERαKO mice and wild-type (WT) littermates were ovariectomized (OVX) and treated with low dose E2 capsules. Mice were then injected s.c. with vehicle or estradiol benzoate (EB) 6d post-OVX and euthanized the following evening. As expected, 75% of WT mice treated with EB exhibited an LH surge; however, none of the KERαKO mice exhibited LH surges. Thus, ERα activation in kisspeptin neurons is required for E2-mediated positive feedback. Next, WT and KERαKO mice were OVX, received oil or E2-filled capsules, and euthanized at 3wk post-OVX. In both WT and KERαKO mice, E2 treatment significantly decreased LH levels to those seen in intact mice, demonstrating that E2-mediated negative feedback remains intact in long-term OVX KERαKO mice. Finally, to test whether pituitary sensitivity to E2 was altered in KERαKO mice, WT and KERαKO mice were OVX, treated with E2 capsules, and injected s.c. with GnRH or saline. GnRH treatment significantly elevated LH to a similar degree in WT and KERαKO mice, indicating no differences in pituitary responsiveness. These experiments clearly demonstrate that ERα signaling in kisspeptin neurons is required for the expression of positive, but not negative feedback actions of E2 on GnRH/LH secretion. It remains to be determined if the obligatory involvement of these receptors in positive feedback reflects their role in the development and maturation of kisspeptin neurons, or in the active signaling processes leading to release of GnRH/LH surges, or both.

 

Nothing to Disclose: SLD, AW, SR, UB, JEL

OR30-1 13489 1.0000 A Absence of Estradiol-Induced LH Surges in Kisspeptin Cell-Specific ERα Knockout (KERαKO) Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR30 4739 11:30:00 AM GnRH & Gonadotrope Biology & Signaling Oral

Jones B Graceli*1, Silvia Capellino2, Andrew Schoeffield3, Horacio Novaira2, Fredric Edward Wondisford4, Andrew Wolfe2 and Sally Radovick5
1Federal University of Espirito Santo, Vitoria, Brazil, 2Johns Hopkins University School of Medicine, Baltimore, MD, 3Loyola University Maryland, Baltimore, MD, 4Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, 5Johns Hopkins School of Medicine, Baltimore, MD

 

The effect of estrogen on the differentiation and maintenance of reproductive tissues is mediated by two nuclear estrogen receptors (ERs), ER alpha (ERα) and beta (ERβ). Lack of functional ERα and ERβ genes in vivo significantly affects reproductive function, however, the target tissues and signaling pathways in the hypothalamus are unclear. Here, we describe the generation and reproductive characterization of a GnRH neuron-specific ERβ knockout mouse model (GERβKO), as well the development of a specific antisera for mouse ERβ (mERβ). GERβKO mice displayed a delay in vaginal opening (WT: 27.0±0.3 vs GERβKO: 29.6±0.4 d; p≤0.05, n=4-8) and first estrus (WT: 28.4±0.3 vs GERβKO: 32.5±0.8 d; p≤0.05, n=4-8). They also had differences in cycle length, with GERβKO mice having a longer proestrus phase (WT: 1.5±0.1 vs GERβKO: 2.0±0.1d, p≤0.05, n=4-8). Female GERβKO mice had lower serum LH (WT: 0.6±0.03 vs GERβKO: 0.37±0.05 ng/ml; p≤0.01, n=4-10) and FSH (WT: 4.9±0.9 vs GERβKO: 1.6±0.8 ng/ml; p≤0.01, n=4-10) levels.  Further, impaired development of ovarian follicles was noted with reduced number of antral follicles and corpora lutea (p≤0.05, n=3) in the GERβKO mice. In males, there were no differences in the timing of the onset of puberty or the LH and FSH levels between WT and GERβKO mice. In order to confirm deletion of ERβ in GnRH neurons, we developed a novel antisera for mERβ since discrepancies in immunoreactivity have been reported for ERβ antibodies. The antisera was developed using 18 specific amino acids (CSTEDSKSKEGSQNLQSQ) in the C-terminus of the mERβ conjugated to keyhole limpet hemocyanin protein. Wistar rats were immunized and antisera characterized by western blot analysis in tissue panels from WT and mice genetically modified to lack ERβ (CERβO). The size of the detected ERβ protein isoforms was consistent with the predicted molecular size in protein extracts obtained from the hypothalamus, uterus, ovary and mammary gland of WT mice but was absent in CERβO female mice. Male WT mice expressed ERβ in the hypothalamus, testes and epididymus, which was not present in CERβO mice. The pattern of ERα expression was similar in CERβO and WT mice. This novel ERβ antisera confirmed ERβ deletion in GnRH neurons of GERβKO mice. Thus, deletion of ERβ of GnRH neurons in vivo results in a delay of pubertal development and impaired gonadotropin secretion disrupting periodic reproductive cycling. This work supports the hypothesis that the ERβ in GnRH neurons has an important function in the modulation of the reproduction axis.

 

Nothing to Disclose: JBG, SC, AS, HN, FEW, AW, SR

OR30-2 15917 2.0000 A Reproductive Axis Disruption of Mice Lacking Estrogen Receptor β in GnRH Neurons 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR30 4739 11:30:00 AM GnRH & Gonadotrope Biology & Signaling Oral

Katarzyna M M Glanowska*1, Laura L Burger2 and Suzanne M Moenter2
1University of Virginia, Charlottesville, VA, 2University of Michigan, Ann Arbor, MI

 

The central nervous system exerts control over reproduction through pulsatile release of GnRH. In this context, puberty is defined as a sequence of developmental changes leading to an organized pattern of GnRH release that is capable of inducing pituitary synthesis and secretion of gonadotropins. Our understanding of the central events of the early prepubertal period is poor because of an inability to measure GnRH in very young animals. We used fast-scan cyclic voltammetry (FSCV) to monitor changes in GnRH concentration in brain slices; GnRH release frequency in the median eminence (ME) of slices from adults matches LH pulse frequency in vivo. Using FSCV, we showed that GnRH release in the ME is observed well before the onset of outward pubertal signs, and also that the frequency in 1wk old male mice is much greater than in adults. Here we studied the mechanisms of high frequency GnRH secretion at this age. First, we hypothesized that frequent GnRH release was due to stimulatory kisspeptin drive to the GnRH system. The frequency of GnRH release in kisspeptin knock out mice, however, was the same as in controls (5.0±0.4, n=5, vs 5.0±0.6, n=6 events/hr), suggesting high frequency GnRH release at 1wk is kisspeptin-independent. We next asked if high frequency GnRH secretion could be inhibited by steroid feedback or inhibitory neuromodulators. To test steroid feedback, 1wk old intact male mice were injected sc with 50µg/g T or vehicle 4h before brain slice preparation and spontaneous GnRH release monitored. T reduced release frequency compared to vehicle (0.6±0.2, n=7, vs 4.3±0.7, n=3, events/hr, p<0.05). Bath application of the inhibitory neuromodulator GnIH to the slices from control mice also reduced GnRH release frequency (2.2±0.5 vs 5.3±0.8, events/hr, n=6, p<0.05). GnIH neurons have been reported to be steroid sensitive so we tested if the GnIH receptor (GPR147) inhibitor RF9 could reverse the effect of testosterone. RF9 restored GnRH frequency in slices from T-injected mice (4.6±0.7 events/hr, n=5). This suggests testosterone acts at least in part via activation of GPR147. Finally, we examined LH release in vivo in response to GnRH (150 ng/kg). GnRH failed to increase serum LH at 15 min in 1wk old mice, but did in mice aged ≥2wk, which is after cessation of the high frequency spontaneous release observed at 1wk of age. These data indicate high frequency GnRH release in early prepubertal male mice is kisspeptin-independent and appears to result from lack of endogenous inhibition of the GnRH network, since the hypothalamic circuitry is mature enough to respond to testosterone feedback when it arrives. We postulate the high endogenous GnRH frequency at 1wk results from GnRH neuronal activity needed for proper synaptogenesis, and that the shut down of the pituitary by this high frequency protects the downstream reproductive system from premature development while this critical neuronal maturation proceeds.

 

Nothing to Disclose: KMMG, LLB, SMM

OR30-3 12676 3.0000 A Regulation of High Frequency GnRH Release in Early Prepubertal Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR30 4739 11:30:00 AM GnRH & Gonadotrope Biology & Signaling Oral

James P Garcia*1, Kathryn A Guerriero1, Kim L Keen2, Brian P Kenealy1, Joseph R Kurian1 and Ei Terasawa1
1University of Wisconsin-Madison, Madison, WI, 2Univ of Wisconsin, Madison, WI

 

The KNDy network formed by kisspeptin, neurokinin B (NKB) and dynorphin neurons in the arcuate nucleus (ARC) has been implicated for the mechanism of GnRH pulse-generation in non-primate species. However, the role of KNDy neurons in the ARC in non-human primates is unclear. In this study, we investigated the interaction between kisspeptin and NKB neurons in pubertal female rhesus monkeys using microdialysis. We infused the kisspeptin agonist (KP-10) or antagonist (peptide 234) and the NKB agonist (senktide) or antagonist (SB222200) into the stalk-median eminence (S-ME), while dialysates were continuously collected at 20-min intervals. Agonists were infused for 20 min and antagonists were infused for 60 min (starting 40 min before and through agonist infusion). GnRH and kisspeptin levels in dialysates were measured by RIA. In Experiment 1, we found that senktide significantly stimulated both GnRH and kisspeptin release. This suggests that NKB stimulates GnRH release directly or indirectly though kisspeptin neurons, as KP-10 stimulates GnRH release in pubertal female monkeys (Guerriero et al., 2012, PMID:22166978). To assess whether NKB signals to GnRH neurons are mediated by kisspeptin neurons or kisspeptin signals are mediated by NKB neurons, we next examined the effects of peptide 234 on senktide-induced GnRH release (Experiment 2) and the effects of SB222200 on KP-10 induced GnRH release (Experiment 3). The results indicated that peptide 234 blocked senktide-induced GnRH release. Surprisingly, SB222200 also blocked KP-10 induced GnRH release. In experiments 2 and 3, we were not able to assess kisspeptin release, as both peptide 234 and KP-10 interfere with the kisspeptin RIA. These results suggest that there is a reciprocal relationship between kisspeptin and NKB signaling, both of which ultimately result in GnRH release. Although our finding that SB222200 blocked KP-10 effects on GnRH release contradicts an earlier report by Ramaswamy et al. (2011, PMID:21832818) in prepubertal male monkeys, there are considerable differences in approaches and methodologies. Considering a recent report in humans showing that there is a low degree of overlap between kisspeptin, NKB and dynorphin expressing neurons in the ARC (Hrabovszky et al., 2012, PMID:22903610), we speculate that there is considerable interaction between NKB, kisspeptin and GnRH neuroterminals in the S-ME. The role of dynorphin in this network remains to be investigated.

 

Nothing to Disclose: JPG, KAG, KLK, BPK, JRK, ET

OR30-4 14797 4.0000 A Interaction Between Kisspeptin and Neurokinin B Neurons in Pubertal Female Rhesus Monkeys 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR30 4739 11:30:00 AM GnRH & Gonadotrope Biology & Signaling Oral

Sekoni D. Noel*1, Cecilia Martin2, Titilayo Muyide2, Serap Simavli2, Joy N. Liang3, Victor M. Navarro4, Rona S. Carroll2 and Ursula B Kaiser2
1Brigham and Women's Hospital/Harvard Med School, Boston, MA, 2Brigham and Women's Hospital and Harvard Medical School, Division of Endocrinology/Diabetes, Boston, MA, 3Brigham and Women's Hospital/Harvard Medical School, Boston, MA, 4Harvard Medical School and Brigham and Women's Hospital, Boston, MA

 

Pulsatile GnRH released from the hypothalamus binds to its receptors (GnRHR) on gonadotropes in the pituitary to stimulate the pulse frequency-dependent synthesis and secretion of LH and FSH.  This pulsatile GnRH release also regulates gonadotrope Gnrhr expression, with the highest receptor levels associated with faster GnRH pulse frequencies (e.g., every 30 minutes) and greater LH release, whereas slower GnRH pulse frequencies (e.g., every 2 hours) are associated with lower GnRHR levels and greater FSH release.  Our group previously identified an AP-1 element in the Gnrhr gene promoter necessary for full GnRH induction of GnRHR expression in vitro.  In the current study, we generated a knock-in (KI) mouse model with a point mutation in the AP-1 site of the Gnrhr gene promoter that eliminates AP-1 binding and blocks GnRH induction of Gnrhr transcription in vitro, with the goal of confirming the disruptive effects of this mutation on GnRHR expression and assessing the resulting physiological consequences in vivo.  Reproductive phenotypic analysis demonstrated that female homozygous KI mice displayed abnormal pubertal development, with significant delays in vaginal opening, first day of estrus, and mean age of onset of estrous cyclicity, compared to wild-type (WT) littermate controls. These mice also displayed disrupted estrous cycles, with significantly more time spent in diestrus, and produced smaller litters, compared to WT female controls.  Serum gonadotropin (LH and FSH) levels were similar for intact WT and KI females in diestrus. Strikingly, the KI mice showed no significant increase in serum LH levels after ovariectomy, in contrast to WT females.  RT-qPCR analysis further demonstrated that female KI mice had significantly lower pituitary Gnrhr, Lhb and Fshb mRNA levels than WT females after ovariectomy, suggesting that these KI mice had impaired post-gonadectomy induction of gonadotropin secretion.  Collectively, our data support an important role for the AP-1 site in the Gnrhr gene promoter in the regulation of GnRHR expression levels in vivo, and further demonstrate that properly coordinated regulation of GnRHR is critical for pubertal development and for reproductive cyclicity in female mice.

 

Nothing to Disclose: SDN, CM, TM, SS, JNL, VMN, RSC, UBK

OR30-5 16862 5.0000 A A Proximal AP-1 Site in the Gnrhr Gene Promoter Is Critical for Normal Pubertal and Reproductive Development in Female Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR30 4739 11:30:00 AM GnRH & Gonadotrope Biology & Signaling Oral

Jerome Fortin*1, Ulrich Boehm2, Chuxia Deng3, Mathias Treier4 and Daniel J. Bernard1
1McGill University, Montreal, QC, Canada, 2University of Saarland School of Medicine, Homburg, Germany, 3NIH, Bethesda, MD, 4Max Delbruck Center for Molecular Medicine, Berlin, Germany

 

Follicle-stimulating hormone (FSH) is an essential regulator of gonadal function and fertility in humans and mice. Gonadotropin-releasing hormone (GnRH) and activins stimulate FSH synthesis; yet, their relative roles and mechanisms of action in vivo are incompletely understood. In cell lines, activins signal through the receptor-regulated SMAD proteins, SMAD2/3, the obligatory co-SMAD, SMAD4, and the SMAD-interacting, cell-restricted factor, forkhead box L2 (FOXL2), to stimulate transcription of the FSHβ subunit gene (Fshb). Consistent with these observations, mice with gonadotrope-restricted deletions of Smad4 (S4cKO) or Foxl2 (F2cKO) are FSH-deficient and subfertile. Based on in vitro observations, we predict that SMAD4 can partially mediate activin-induced Fshb transcription in the absence of FOXL2 (and vice versa), potentially explaining the residual FSH synthesis and fertility in S4cKO or F2cKO mice. To test this idea, we generated mice lacking both factors in gonadotropes (S4F2cKO), by crossing mice carrying “floxed” alleles of Smad4 and Foxl2 with GnrhrIRES-Cre (GRIC) mice. In striking contrast with the effects of the single gene knockouts, S4F2cKO mice displayed severe hypogonadism. S4F2cKO females had small ovaries (devoid of antral follicles and corpora lutea), thread-like uteri, and were acyclic and sterile. Male S4F2cKO mice had small testes, but were fertile. Thus, S4F2cKO mice phenocopy Fshb-deficient animals. Indeed, male and female S4F2cKO mice were profoundly FSH- and Fshb-deficient. FSHβ immunoreactivity was absent in LHβ-positive pituitary gonadotropes of S4F2cKO mice, but retained in a small population of “FSHβ-only” cells. S4F2cKO animals had elevated pituitary expression of the luteinizing hormone β subunit gene (Lhb), possibly as a result of reduced negative feedback by gonadal sex steroids. In females, this resulted in elevated circulating LH levels. In contrast, serum LH was diminished in males, likely due to a sex-specific downregulation of the gonadotropin α subunit (Cga). Collectively, these results establish SMAD4 and FOXL2 as master regulators of Fshb expression in vivo, and suggest that activins may be more important regulators of FSH synthesis than GnRH.

 

Nothing to Disclose: JF, UB, CD, MT, DJB

OR30-6 14012 6.0000 A Follicle-Stimulating Hormone Synthesis and Fertility Require the Independent and Complementary Activities of SMAD4 and FOXL2 in Gonadotropes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR30 4739 11:30:00 AM GnRH & Gonadotrope Biology & Signaling Oral

Caroline M Gorvin*1, Paul J Newey2 and Rajesh V Thakker1
1University of Oxford, Oxford, United Kingdom, 2Ninewells Hospital & Medical School, University of Dundee, Dundee, Scotland

 

The prolactin receptor (PRLR) is a member of the class I cytokine receptor family that signals predominantly through the JAK2-STAT5 pathway. PRLR is expressed on a number of cell types including mammary epithelial cells, adipocytes, and pancreatic beta cells and has been implicated in an array of physiological processes including fertility, lactation, and metabolic regulation. However, understanding of the role of PRL/PRLR signalling is incompletely defined, and progress is hampered by a lack of reported mutations in PRL and/or PRLR. To date, two common PRLR variants (I76V, I146L) are reported to demonstrate constitutive activity in vitro, with one of these (I146L) overrepresented in benign breast disease, whilst we recently identified a loss-of-function PRLR mutation, H188R, which was associated with familial hyperprolactinaemia1. We hypothesised that additional rare PRLR variants, identified in recent large-scale sequencing projects may be associated with altered in vitro activity. We therefore identified previously uncharacterised non-synonymous, germline PRLR variants from existing databases. Variants for analysis were selected based on their proximity to known functional domains, and using protein prediction algorithms. Two extracellular domain (ECD) and eight intracellular domain (ICD) variants were evaluated by a phospho-STAT5 assay (AlphaScreen) and a STAT5-dependent gene expression assay utilising a cytokine-inducible Src homology-2 domain containing protein (CISH) luciferase reporter in HEK293 cells treated with prolactin (0-1000ng/mL). Five of the ten variants were associated with altered responses when compared to the wild-type receptor. Thus, the ECD variant E155K was associated with reduced pSTAT5 but normal CISH activity. Of the ICD variants, F255S resulted in a significant decrease in activity equivalent to that of H188R, whilst G263D and E554Q demonstrated a significant but less pronounced reduction in pSTAT5 activity. One variant in the ICD, R327Q, was associated with constitutive activity using AlphaScreen assays and a gain in CISH reporter activity.  These studies give further insight into PRLR structure-function and highlight that rare variants may be associated with alterations in receptor signalling. Further investigation of such rare coding variants in association with phenotypic data is required to elucidate their in vivo significance.

References

1.         Newey PJ, Gorvin CM et al. (2013) Mutant prolactin receptor and familial hyperprolactinemia. The New England journal of medicine 369(21):2012-2020.

 

Nothing to Disclose: CMG, PJN, RVT

OR35-1 13718 1.0000 A Functional Evaluation of Rare Genetic Variants in the Prolactin Receptor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR35 4741 11:30:00 AM Prolactin and Vasopressin: Genes to Receptor Signaling in Physiology and Disease Oral

Dana C Borcherding*1, Eric M Jacobson2, Eric R Hugo1, Matthew D Wortman1, William L Seibel3, Chris R Evelyn3 and Nira Ben-Jonathan1
1University of Cincinnati, Cincinnati, OH, 2Avecia, Cincinnati, OH, 3Cincinnati Children Hospital, Cincinnati, OH

 

Prolactin (PRL), acting via its receptor (PRLR), enhances tumor growth, reduces apoptosis, and increases resistance to chemotherapy in both breast and prostate cancer. In spite of the growing evidence for the role of PRL signaling in the pathophysiology of these cancers, the PRLR has not been adequately exploited as a therapeutic target. Our objective was to use high throughput screening (HTS) to identify small molecule inhibitors of PRL signaling that could be used as oral medications. Screening was conducted at the University of Cincinnati Drug Discovery Center, which has a small molecule library of 340,000 drug-like compounds and a state-of-the-art HTS facility. A three-dimensional virtual representation of the library, docked against an X-ray crystallographic model of the PRLR, identified 1000 compounds, predicted to interfere with PRL binding to the receptor. A set of 50,000 diverse compounds was also selected. Three PRL-dependent, cell-based assays with different sensitivities and complementary properties were adapted for HTS. The very sensitive Nb2 rat lymphocyte bioassay was used to screen 51,000 small molecules, initially at 10 µM each.  Compounds that inhibited PRL-induced cell growth were retested in triplicate with and without PRL to confirm findings. After several rounds of screening, 128 ‘hits’ were selected as effective inhibitors of PRL-stimulated cell growth, but not as general suppressors of cell viability. A 10-point dose curve was used to calculate IC50 values for each inhibitor. The latter were also retested with two additional cell-based assays: murine Ba/F3 cells stably transfected with human PRLR, and T47D breast cancer cells stably expressing a luciferase reporter for Jak2/Stat5 activation by PRL. Seven PRL antagonists, active at an IC50 of 2 μM or less, were selected for further characterization. Binding of these inhibitors to the extracellular domain of the PRLR was determined by microscale thermophoresis. Three of these inhibitors bound to the receptor with a Kd of 1-3 µM, while the other four did not bind to the PRLR and likely inhibit PRL signaling downstream of the receptor. Ongoing studies are using medicinal chemistry to generate structural modifications of the best inhibitors. The modified compounds will be subjected to extensive in vitro and in vivo studies before they can progress into clinical trials to establish their suitability as novel medications in the treatment of breast and prostate cancer.

 

Nothing to Disclose: DCB, EMJ, ERH, MDW, WLS, CRE, NB

OR35-2 14908 2.0000 A Identification and Binding Characterization of Small Molecule Inhibitors of Prolactin Signaling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR35 4741 11:30:00 AM Prolactin and Vasopressin: Genes to Receptor Signaling in Physiology and Disease Oral

Suzanne M Schauwecker*1, Jonathan D Licht1 and Charles V. Clevenger2
1Northwestern University, 2VCU/MCV, Richmond, VA

 

The polypeptide hormone prolactin (PRL) is essential for normal breast tissue growth and maturation; however, this hormone also contributes to breast cancer development. PRL binds to and activates the transmembrane PRL receptor (PRLr). The PRLr signals from the cell surface to the nucleus both by activating canonical signals, such as the Jak2/Stat5 pathway, and by directly translocating to the nucleus. We have previously shown that nuclear PRLr binds to the chromatin-modifying protein high-mobility group N2 (HMGN2), recruiting HMGN2 to the promoter of the PRL-responsive gene CISH (cytokine-inducible SH2-containing protein). At this promoter, HMGN2 stimulates transcription, but the mechanism by which HMGN2 does so is unknown. One potential mechanism previously identified is that HMGN2 binds to nucleosomes and induces chromatin decompaction by competition with chromatin-compacting proteins. Given this, we hypothesized that HMGN2 causes chromatin decompaction at promoters of PRL-responsive genes, allowing the transcriptional machinery to access the promoter DNA and initiate transcription. In these studies, the CISH promoter was examined by chromatin immunoprecipitation for factors regulating chromatin compaction, such as histone H1. Prior to PRL stimulation, the CISH promoter was found to exhibit low histone H3 density only near the binding site of the necessary transcription factor Stat5a. Following PRL stimulation, a decrease in H3 density across the CISH promoter was observed. PRL stimulation also resulted in the loss of H1 at the CISH promoter. Following HMGN2 knockdown, the loss of H1 was attenuated. Therefore, HMGN2 may compete with H1 for binding to the CISH promoter. Consistent with transcriptional activation, PRL stimulation also resulted in increased RNA Polymerase II (Pol II) bound at the CISH promoter; knockdown of HMGN2 resulted in less bound Pol II. These data suggest that HMGN2 facilitates PRL-induced transcription by competing with H1 for binding to the promoter DNA, thus promoting chromatin decompaction to allow the transcriptional machinery to better access the promoter DNA.

 

Nothing to Disclose: SMS, JDL, CVC

OR35-3 12133 3.0000 A Prolactin-Induced Transcription Is Facilitated By Competition Between HMGN2 and Histone H1 in Breast Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR35 4741 11:30:00 AM Prolactin and Vasopressin: Genes to Receptor Signaling in Physiology and Disease Oral

David R Grattan*1, Ilona C. Kokay2, Rosemary S. E. Brown2, Caroline M. Larsen2, Amanda Wyatt2 and Paul R. Le Tissier3
1University of Otago, New Zealand, 2University of Otago, Dunedin, New Zealand, 3Institute of Child Health, London, United Kingdom

 

Prolactin receptors are widely expressed in the hypothalamus. When prolactin (or placental lactogen) levels are elevated, during pregnancy and lactation, prolactin may exert a range of actions in the maternal brain to help the mother adapt to the demands of these reproductive states, including effects on maternal behaviour, appetite and food intake, stress responses, and adult neurogenesis. This hypothesis has been difficult to test, however, because blocking prolactin secretion in rodent’s leads to termination of the pregnancy, due to loss of the luteotrophic action of prolactin in the ovary. To circumvent this problem, we have developed a mouse line allowing conditional deletion of the prolactin receptor (PRLR) gene in the brain, using a Cre-LoxP strategy. Mice with LoxP site flanking the PRLR gene (PRLRflox ) were crossed with mice expressing Cre-recombinase under the control of the neuron-specific calcium-calmodulin-dependent Kinase-2α (CamK2α ) promoter. Cre-mediated recombination could be detected through activation of a green fluorescent protein (GFP) construct within the transgene. Female mice homozygous for the PRLRflox and expressing Cre, and control mice that lacked Cre, were monitored over several estrous cycles. Groups of animals were then perfused, and brains processed for immunohistochemistry for GFP and phosphorylated STAT5 (a marker of prolactin action), and in situ hybridisation for PRLR mRNA. Blood samples were also collected, and serum prolactin levels measured by radioimmunoassay. Cre-expressing mice had abnormal estrous cycles, characterised by long periods in diestrus. Prolactin levels were significantly elevated. GFP could be detected throughout the hypothalamus, suggesting that Cre-mediated recombination had occurred in many regions known to contain the PRLR. Interestingly, we also observed GFP in the hippocampus, an area where we do not detect PRLR mRNA. Levels of pSTAT5 and PRLR mRNA were markedly reduced compared to control animals, in particular, in the tuberoinfundibular dopamine neurons that normally regulate prolactin secretion. Together, these data suggest that deletion of the PRLR in CamK2α−positive neurons impaired negative feedback, resulting in hyperprolactinemia and consequent pseudopregnancy. These mice provide a valuable tool for investigating prolactin action in the brain.

 

Nothing to Disclose: DRG, ICK, RSEB, CML, AW, PRL

OR35-4 16432 4.0000 A Conditional Deletion of the Prolactin Receptor to Identify Brain-Specific Actions of Prolactin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR35 4741 11:30:00 AM Prolactin and Vasopressin: Genes to Receptor Signaling in Physiology and Disease Oral

Ferhat Deniz*1, Emel Saglar2, Arif Yonem1, Eylem Cagiltay3, Ahmet Seyit Ay3, Levent Ozsari4 and Hatice Mergen2
1GATA Haydarpasha Training Hospital, Istanbul, Turkey, 2Hacettepe University, Ankara, Turkey, 3GATA HAYDARPASHA Training Hospital, ISTANBUL, Turkey, 4The University of Texas MD Anderson Cancer Center, Houston, TX

 

Central Diabetes Insipidus (DI) is caused by a deficiency of antidiuretic hormone arginine vasopressin and characterized by polyuria, polydipsia and inability to concentrate urine. We present the results of the molecular analyses of AVP-NPII gene in a large FNDI pedigree. We report a male patient in whom central DI is associated with heterozygous three base pair deletion at codon 69-70 (207_209delGGC), leads to deletion of alanine amino acid, and heterozygous six base pair insertion between codon 83 and 84 (255_256insCCGTCG) in exon 2 of the AVP-NPII gene, leads to insertion of proline and serine amino acids respectively. Mutations are combined in the cis position. Family members of the proband patient were analyzed and the prospective clinical data were collected. The proband patient applied to our hospital for eligibility to be a recruit in Armed Forces. Central DI was confirmed with water deprivation-desmopressin test according to increase in urine osmolality from 162 mOsm/kg to 432 mOsm/kg after desmopressin acetate enjection. He had severe polyuria (20 L/day), polydipsia (20.5 L/day), fatique, and deep thirstiness. His condition was worse than all other family member on history, physical examination, and laboratory findings. The coding regions of AVP-NPII gene were amplified by polymerase chain reaction and submitted to direct sequence analysis. Direct sequencing of the AVP-NPII gene showed that father of the proband patients and some of the other family members have three base pair deletion, but none of them have six base pair insertion in exon 2 of the gene. Results were revealed that six base pair insertion mutation is a de novo mutation for the proband patient. Three-dimensional protein structure prediction was shown for both deleted AVPNPII gene and combined deleted and inserted form of the AVP-NPII gene and compared with wild type of the gene. The combined deletion and insertion mutation was predicted to yield an abnormal AVP precursor in neurophysin moiety.  We suggested that this compound mutation in proband patient is in an important portion of the neurophysin peptide since the mutations most probably lead to conformational change.

 

Nothing to Disclose: FD, ES, AY, EC, ASA, LO, HM

OR35-5 15656 5.0000 A Identification of a Novel Deletion of the AVP–NPII Gene in a Patient with Central Diabetes Insipidus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR35 4741 11:30:00 AM Prolactin and Vasopressin: Genes to Receptor Signaling in Physiology and Disease Oral

Katharina Timper1, Wiebke Kristin Fenske2, Mira Katan3, Felix Kuehn4, Birsen Arici5, Nica Frech1, Jonas Rutishauser6, Peter Kopp7, Bruno Allolio8, Christoph Stettler9, Beat Mueller10 and Mirjam Christ-Crain*1
1University Hospital Basel, Basel, Switzerland, 2Leipzig University Medical Center, Leipzig, Germany, 3University Hospital Zurich, Zuerich, Switzerland, 4University Hospital Bern, Bern, Switzerland, 5Hospital Rheinfelden, Rheinfelden, Switzerland, 6Hospital Bruderholz, Bruderholz, Switzerland, 7Northwestern Univ, Chicago, IL, 8University of Wuerzburg, Wuerzburg, Germany, 9Univ Hosp Inselspital Bern, Bern, Switzerland, 10Kantonsspital Aarau, Aarau, Switzerland

 

Background: In polyuria-polydipsia syndrome, primary polydipsia (PP) must be distinguished from central and nephrogenic diabetes insipidus (DI). A correct discrimination is mandatory since inadequate treatment may lead to serious complications. The diagnostic gold standard is the water deprivation test (WDT) with direct or indirect measurement of arginine vasopressin (AVP). However, test interpretation is problematic, and direct measurement of AVP is hampered by methodological difficulties. The aim of this study was to evaluate the diagnostic accuracy of copeptin in the differential diagnosis of DI.

 Design: Prospective multicenter study in four tertiary referral centers in Switzerland and Germany.

 Methods: The ‘CoSIP-Study’ included 55 patients >18 years with a history of polyuria in the presence of polydipsia. All participants underwent a WDT. The test started at 8 am without prior fluid restriction with a baseline blood and urine sampling and was terminated as soon as serum sodium levels increased >147mmol/L. If this cutoff was not reached by fluid deprivation alone a 3% saline infusion was administered. At baseline and hourly during the water deprivation test, a serum sample was obtained for measurement of copeptin and AVP.

 Results:We present data from all 55 patients enrolled (complete central DI 11 patients, partial central DI 16 patients, PP 18 patients, nephrogenic DI 10 patients). 32 were women, 23 were men. Mean (± SD) age was 45 ± 15.9 years. Baseline copeptin levels ranged from 21.4-117 pmol/L in patients with nephrogenic DI, from 0.7-5.1 pmol/L in patients with central DI (complete: 0.7-3.4 pmol/L; partial: 0.9-4.1 pmol/L) and from 1.1-13.5 pmol/L in patients with PP. Without prior thirsting, a single baseline copeptin level of >20 pmol/L perfectly differentiated nephrogenic DI from all other etiologies with a sensitivity and specificity of 100%, rendering a WDT unnecessary. Furthermore, a delta copeptin (difference between baseline copeptin and copeptin upon osmotic stimulation, i.e. at a plasma sodium (PS) level >147 mmol/L) >2.8pmol/L differentiated patients with PP from patients with central DI with a specificity of 96.3% and a sensitivity of 88.9%. Thereby, a delta AVP >0.9pg/ml (difference between baseline AVP and AVP at a PS level >147 mmol/L) differentiated patients with PP from patients with central DI with a specificity of 96.3% and a sensitivity of 77.8%.  Interestingly, a maximal copeptin (copeptin upon osmotic stimulation, i.e. at a PS level >147 mmol/L) >4.9pmol/L differentiated between patients with primary polydipsia and those with central DI with a specificity of 96.3% and a sensitivity of 94.4%, while a maximal AVP >1.8pg/ml (AVP at a PS level >147 mmol/L) differentiated between these entities with a specificity of 96.3% and a sensitivity of 83.3%.

Conclusion: Copeptin is a promising new tool in the complex diagnosis of polyuria-polydipsia syndrome.

 

Disclosure: BA: Committee Member, Ipsen, Coinvestigator, HRA-Pharma, Consultant, Boehringer-Ingelheim. BM: Speaker, Thermo Fisher AG. MC: Speaker, Thermo Fisher AG. Nothing to Disclose: KT, WKF, MK, FK, BA, NF, JR, PK, CS

OR35-6 12758 6.0000 A Copeptin in the Diagnosis and Differential Diagnosis of Diabetes Insipidus - the ‘Cosip-Study' 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 1:00:00 PM OR35 4741 11:30:00 AM Prolactin and Vasopressin: Genes to Receptor Signaling in Physiology and Disease Oral

Maryam Nasiri*1, Nikolaos Nikolaou1, Silvia Parajes2, Iwona Bujalska3, Laura Louise Gathercole1 and Jeremy W Tomlinson1
1University of Birmingham, Birmingham, United Kingdom, 2Univ of Birmingham, Birmingham, United Kingdom, 3University of Birmingham, United Kingdom

 

Patients with GC excess (Cushing’s syndrome) develop central obesity, insulin resistance and hepatic steatosis. The A-ring reductases (5α-reductase type 1 [5αR1] and 2 [5αR2]) generate dihydrotestosterone from testosterone, but importantly also inactivate cortisol and are highly expressed in human liver. We propose that 5αR may regulate GC exposure and therefore may modulate metabolic phenotype in human liver.

Primary human hepatocytes and the C3A human hepatoma cell line were incubated with cortisol (0-1000 nM), alone or in combination with the selective 5αR2 inhibitor, Finasteride (500 nM) or non-selective inhibitor, Dutasteride (500 nM) for 24h. In addition, C3A cells (which express 5αR1, but not 5αR2), were transfected with a plasmid containing either wild type, or inactivated mutant (R246Q) 5αR2. The functional impact of these manipulations was assessed through real-time PCR based gene expression, enzyme activity assays using both gas and liquid chromatography / mass spectrometry and functional assessments of de novo lipogenesis (DNL).

Cortisol decreased DNL in a dose-dependent manner (e.g. 85.6 6.6% [100nM], 73.5 7.9% [250nM], 55.04 5.6% [1000nM], p<0.05). 5αR2 over-expression increased DHT generation and cortisol clearance and in the absence of cortisol, did not alter rates of DNL. However, in the presence of cortisol, 5αR2 restored DNL to levels observed in untreated controls (e.g. 61.9±7.6% [cortisol] vs. 103.8±8.8% [5αR2+cortisol], p<0.05, control=100%). Complementary experiments using the R246Q 5αR2 construct did not alter cortisol-mediated suppression of DNL. Furthermore, both Finasteride and Dutasteride augmented the action of cortisol to supress DNL in primary cultures of human hepatocytes (e.g. 88.3±5.3 vs. 76.9± 5.2%, cortisol vs. cortisol + finasteride, p=0.05).

We have demonstrated that manipulation of 5αR activity can regulate metabolic phenotype in human liver. Further clinical studies are now warranted, but this may have significant clinical implications for those patients with mutations in 5αR2 and those prescribed 5αR inhibitors.

 

Nothing to Disclose: MN, NN, SP, IB, LLG, JWT

OR37-1 15825 1.0000 A 5 Alpha-Reductase Is a Regulator of Glucocorticoid Action and Metabolic Phenotype in Human Liver 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 1:00:00 PM OR37 4747 11:30:00 AM Steroid Hormone Receptors and Epigenetic Control Oral

Edwin Cheung*
University of Macau, Macau, China

 

An aberrant androgen receptor (AR) transcriptional network underpins prostate cancer development. While the binding of AR to chromatin has been extensively studied in prostate cancer, information pertaining to how the spatial architecture of chromatin influences the AR transcriptional circuitry remains limited. To gain a better understanding of how chromatin structure impacts the AR transcriptional process, we performed chromatin interaction analysis by paired-end tag (ChIA-PET) sequencing to globally profile AR-associated and ERG-associated long range chromatin interactions in an ERG fusion positive prostate cancer cell line. We integrated the structural information together with transcriptomes generated by GRO-Seq and RNA-Seq. Our findings show ERG-associated long range chromatin interactions as an elemental component in the AR-associated chromatin interactome, acting in concert, to achieve coordinated regulation of AR target genes. In addition, using our AR and ERG interactome data we identify a complex network of transcriptional hubs that is important in regulating the androgen induced transcriptional output. Taken together, our results revealed the presence of an AR-ERG defined higher order chromatin structure exploited for driving prostate cancer progression.

 

Nothing to Disclose: EC

OR37-2 16503 2.0000 A An AR-ERG Co-Associated Chromatin Interactome Defines the Transcriptional Network in Prostate Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 1:00:00 PM OR37 4747 11:30:00 AM Steroid Hormone Receptors and Epigenetic Control Oral

Neal D Andruska*, Xujuan Yang, Xiaobin Zheng, Chengjian Mao, Mathew M Cherian, Lily Mahapatra, William Helferich and David J Shapiro
University of Illinois, Urbana, IL

 

Although endocrine therapy is initially successful, recurrent estrogen receptor α (ERα) positive breast cancers develop resistance. Many therapy-resistant breast and gynecologic tumors contain ERα, suggesting the presence of novel modes of ERα action potentially targetable with small molecule biomodulators. High-throughput screening identified BHPI, a non-competitive small molecule ERα inhibitor with novel modes of action. At low concentrations BHPI inhibited proliferation and ultimately killed ERα positive breast cancer cells resistant to antiestrogens. In a mouse xenograft model, BHPI induced rapid and substantial tumor regression. BHPI is so effective because it acts via ERα to regulate multiple nuclear and extranuclear pathways. BHPI rapidly inhibits 17β-estradiol-ERα mediated induction and repression of gene expression by inhibiting recruitment of ERα to gene regulatory regions. Unexpectedly, BHPI elicits near-quantitative inhibition of protein synthesis in ERα positive cancer cells, with no effect in ERα negative cells. BHPI does not inhibit protein synthesis in ERα negative MCF10A cells, gains the ability to inhibit protein synthesis when ERα is stably expressed in isogenic MCF10AERIn9cells and loses the ability to inhibit protein synthesis when the ERα is knocked down with siRNA or degraded by ICI 182,780. Also, increasing the level of ERα in MCF7ERαHA cells, progressively increased BHPI inhibition of protein synthesis. Thus, expression of ERα in cancer cells is necessary and sufficient for BHPI inhibition of protein synthesis.  BHPI acts by linked activation of two extranuclear pathways important in cancer. In ERα containing cells, BHPI rapidly acts by a novel mechanism to activate the metabolic sensor, AMPK, leading to phosphorylation and inactivation of eEF2, inhibiting protein synthesis. The pathways identified by analyzing BHPI’s action emerged as important in both the estrogen-ERα cell proliferation program and the pathology of cancer. Analysis of patient data from more than 1,000 ERα positive breast cancers identified a powerful prognostic marker that is tightly correlated with subsequent resistance to tamoxifen therapy, reduced time to recurrence and poor survival.

    Current endocrine therapies focus on inhibiting the action of ERα, and are therefore usually ineffective in ERα positive cancer cells that do not depend on estrogens or ERα for proliferation. BHPI is fully effective in these cells because it uses an alternative anticancer strategy of hyperactivating a pathway in ERα positive cancer cells. This work demonstrates the potential of a novel approach to endocrine therapy based on hyperactivating extranuclear ERα-linked pathways in cancer cells.

 

Nothing to Disclose: NDA, XY, XZ, CM, MMC, LM, WH, DJS

OR37-3 13600 3.0000 A A Non-Competitive Estrogen Receptor α Inhibitor Activates AMPK, Inhibits Protein Synthesis and Induces Tumor Regression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 1:00:00 PM OR37 4747 11:30:00 AM Steroid Hormone Receptors and Epigenetic Control Oral

Vanessa Dubois*1, Michaël R. Laurent1, Mieke Sinnesael1, Nele Cielen1, Christine Helsen2, Liesbeth Clinckemalie3, Lien Spans1, Ghislaine Gayan-Ramirez1, Louise Deldicque1, Peter Hespel1, Geert Carmeliet1, Dirk M. Vanderschueren4 and Frank A. Claessens3
1University of Leuven, Belgium, 2KU Leuven, Belgium, 3KU Leuven, Leuven, Belgium, 4Katholieke Universiteit Leuven, Leuven, Belgium

 

Androgens have well-established anabolic actions on skeletal muscle, although the direct effects of the androgen receptor (AR) in muscle remain unclear. We generated mice in which the AR is selectively ablated in satellite cells (satARKO), the muscle precursor cells. Total-limb maximal grip strength is decreased by 7% in satARKO mice, with soleus muscles containing about 10% more type I fibers and 10% less type IIa fibers than the corresponding control littermates. The weight of the perineal levator ani muscle is markedly reduced (-52%). Thus, muscle AR is involved in fiber type distribution and force production of the limb muscles, while it is a major determinant of the perineal muscle mass. Surprisingly, myostatin (Mstn), a strong inhibitor of skeletal muscle growth, is one of the most androgen-responsive genes (6-fold reduction in satARKO) through direct transcription activation by the AR. Consequently, muscle hypertrophy in response to androgens is augmented in Mstn knockout mice. Our finding that androgens induce Mstn signaling to restrain their own anabolic action has implications for the treatment of muscle wasting disorders.

 

Nothing to Disclose: VD, MRL, MS, NC, CH, LC, LS, GG, LD, PH, GC, DMV, FAC

OR37-4 12991 4.0000 A A Satellite-Cell Specific Knockout of the Androgen Receptor Reveals Myostatin As a Direct Androgen Target in Skeletal Muscle 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 1:00:00 PM OR37 4747 11:30:00 AM Steroid Hormone Receptors and Epigenetic Control Oral

Gwendolyn I Humphreys*, Yvonne S Ziegler and Ann M Nardulli
University of Illinois at Urbana-Champaign, Urbana, IL

 

17β-estradiol (E2) plays critical roles in a number of target tissues, including the brain, mammary gland, reproductive tract, and bone. The importance of E2 in the female brain becomes especially apparent during menopause, when E2 production dramatically declines. Cognition and memory deficits as well as an increased incidence of stroke during menopause can be attributed, in part, to the decline in E2. The cerebral cortex is critical to cognitive function and is particularly sensitive to ischemic stroke damage. However, little is known about how E2 exerts its effects in the cerebral cortex.

To provide some insight into the effect of E2 replacement in postmenopausal women, we examined the cortical transcriptome using a mouse model system. Female adult mice were ovariectomized and implanted with silastic tubing containing oil or E2. After 7 days, the cerebral cortices were dissected and RNA was isolated and analyzed using RNA-Seq. Analysis comparing oil- and E2-treated animals revealed that E2 treatment significantly increased or decreased the transcript levels of 88 genes.

To further understand the role of E2 in the cerebral cortex, we identified biological processes and pathways associated with the E2-responsive genes. Several processes identified were of particular relevance in the brain: long term synaptic potentiation, myelination, inactivation of mitogen activated protein kinase activity, phosphoprotein phosphatase activity, and phosphatidylinositol 3-kinase activity. We also identified several biological processes involved in lipid synthesis and metabolism, including fatty acid elongation and triglyceride biosynthesis. Vasoconstriction and vasodilation, cell-cell communication, and histone modification were also E2 responsive. Our findings demonstrate the far-reaching and diverse effects of E2 in the cerebral cortex and provide valuable information on the cortical processes that may be altered in postmenopausal women.

 

Nothing to Disclose: GIH, YSZ, AMN

OR37-5 12685 5.0000 A Gene Expression Modulation By Estrogen in the Female Mouse Cerebral Cortex 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 1:00:00 PM OR37 4747 11:30:00 AM Steroid Hormone Receptors and Epigenetic Control Oral

Ayesha A Shafi*1, James Michael Arnold1, Vasanta Putluri1, William Charles Krause2, Zheng Xia1, Wei Li1, Nagireddy Putluri1, Arun Sreekumar1 and Nancy L Weigel1
1Baylor College of Medicine, Houston, TX, 2University of California San Francisco

 

Prostate cancer (PCa) is the second leading cause of cancer-related death in American men. Androgen ablation therapy is the most common therapy for advanced PCa. Within two years, tumors become resistant to therapy and develop castration-resistant prostate cancer (CRPC). There is no effective treatment for CRPC, which is androgen-depletion resistant, but androgen receptor (AR)-dependent. AR is a hormone-activated transcription factor that mediates androgen action. Recent studies have shown that constitutively active AR splice variants that lack hormone-binding domains are expressed in CRPC. Reports of the actions and contributions of variants to CRPC relative to full-length AR are conflicting. To address this question, we have generated derivatives of androgen-responsive LNCaP and VCaP cell lines with inducible expression of AR-V7, a variant containing exons 1, 2, and 3 of AR and a small amount of unique sequence from exon 3b. AR-V7 stimulates expression of some AR target genes, induces cell growth, and increases cell migration. We performed RNA-Seq to compare the transcriptomes of AR and AR-V7. RNA-Seq analysis reveals a common subset of genes regulated by both receptors and more intriguingly genes uniquely regulated either by AR or by AR-V7 suggesting isoform specific actions. Pathway analysis showed significant regulation of metabolic pathways. Cancer cells frequently become more dependent on the glycolytic pathway than normal cells. Using liquid chromatography-mass spectrometry (LC-MS), we examined the effect of AR or AR-V7 activation on the levels of metabolites involved in energy metabolism and proliferation. The changes in metabolite levels suggest that AR-V7 preferentially enhances glycolysis, increases fatty acid synthesis, and increases rates of glutamine metabolism (i.e. glutaminolysis). Consistent with this, a Seahorse metabolic flux assay showed that AR-V7 preferentially increases extracellular acidification rates (ECAR), a measure of glycolytic activity. We have confirmed that AR-V7 regulates genes that regulate these metabolites not only in our inducible LNCaP-V7, but in the VCaP-V7 cell model. The previously reported metabolic profile in 22Rv1 cells, which endogenously express full-length AR and AR-V7, is consistent with our findings. This study suggests that AR-V7 does not simply substitute for AR, but exhibits gains of function that may include the ability to grow more efficiently in an oxygen poor environment.

 

Nothing to Disclose: AAS, JMA, VP, WCK, ZX, WL, NP, AS, NLW

OR37-6 16206 6.0000 A The Androgen Receptor Splice Variant, AR-V7, Reprograms Metabolism Towards a More Bioenergetic Phenotype Consistent with Aggressive Prostate Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 1:00:00 PM OR37 4747 11:30:00 AM Steroid Hormone Receptors and Epigenetic Control Oral

Victor M. Navarro*1, Serap Simavli2, Iain Robert Thompson3, Caroline Maguire4, John C Gill5, Rona S. Carroll6 and Ursula B Kaiser2
1Harvard Medical School and Brigham and Women's Hospital, Boston, MA, 2Brigham and Women's Hospital and Harvard Medical School, Division of Endocrinology/Diabetes, Boston, MA, 3Brigham and Women's Hospital and Harvard Medical School, Division of Endocrinology/Diabetes, Boston, MA, Boston, MA, 4Brigham and Women’s Hospital and Harvard Medical School, 5Brigham & Womens Hospital/Harvard, Boston, MA, 6Brigham and Women's Hospital/Harvard Med School, Boston, MA

 

Puberty onset is an exquisitely regulated process in which the awakening of pulsatile gonadotropin-releasing hormone (GnRH) secretion occurs, leading to reproductive competence. However, the underlying mechanisms controlling the proper time of puberty onset remain ill-defined. A number of human and rodent studies suggest that the neuropeptides kisspeptin and neurokinin B (NKB), co-expressed in a subpopulation of arcuate neurons (KNDy neurons) in the hypothalamus, play a role as gatekeepers of GnRH release during puberty.  NKB belongs to the tachykinin family of peptides that also includes substance P (SP) and neurokinin A (NKA); however, the role of SP and NKA in the control of puberty onset has remained unexplored. We have recently demonstrated that the activation of the receptors of these tachykinins (NK1R and NK2R, respectively) induces gonadotropin release in adult mice in a kisspeptin-dependent manner. Here, we aimed to assess whether the SP/NK1R and NKA/NK2R systems may also play a role in the timing of puberty onset, through a series of functional and expression studies in the female mouse. First, acute central administration to prepubertal females of a specific NK1R agonist, but not of an NK2R agonist, elicited luteinizing hormone (LH) release, suggesting that SP/NK1R may play a role in the activation of the gonadotropic axis prepubertally. Therefore, in our second aim, the effects on pubertal maturation of twice daily intraperitoneal administration of the NK1R agonist from postnatal day 22 to 32 was tested. This treatment induced a clear advancement in puberty onset, as determined by the timing of vaginal opening, serum LH levels and gonadal weights, compared to vehicle-treated controls. In addition, to determine the likely involvement of endogenous SP (and NKA) in the control of puberty onset, the expression of the genes encoding both ligands (Tac1) and their respective receptors (Tacr1 and Tacr2) was assessed in the arcuate nucleus of infantile, juvenile, prepubertal and adult (diestrous) female mice by RT-qPCR. We found that Tac1 and Tacr1, but not Tacr2, mRNA levels were higher prior to puberty onset, suggesting an elevation of the tachykinin tone and increased number of SP receptors prepubertally. In summary, we document a role for SP, through the stimulation of its receptor, in the activation of the gonadotropic axis prior to puberty onset, positioning this system as a potential novel regulator of kisspeptin/GnRH release in the maturation of the gonadotropic axis.

 

Nothing to Disclose: VMN, SS, IRT, CM, JCG, RSC, UBK

OR28-1 16475 1.0000 A Substance P As a Novel Regulator of Puberty Onset 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 1:00:00 PM OR28 4756 11:30:00 AM Female Reproduction: Puberty Onset, Folliculogenesis, and Metabolic Responses Oral

Arnon Gal*1, Po-Ching Patrick Lin1, Joseph A Cacioppo1, Patrick R Hannon1, Megan M Mahoney1, Andrew Wolfe2, Rodrigo Cesar Fernandez-Valdivia3, John P Lydon4, Carol F Elias5 and Chemyong Ko6
1University of Illinois at Urbana-Champaign, Urbana, IL, 2Johns Hopkins Univ Schl of Med, Baltimore, MD, 3Wayne State University, Detroit, MI, 4Baylor Coll of Med, Houston, TX, 5University of Michigan, Ann Arbor, MI, 6University of Illinois at Urbana, Urbana, IL

 

Ovarian steroids play a central role in regulating the female reproductive axis. They act as both positive and negative regulators of GnRH secretion in the hypothalamus. Recent studies have identified Kisspeptin neurons of the hypothalamus as the target of estrogenic regulation of GnRH secretion. In this study, we aimed to determine if Kisspeptin neurons are a target of progesteronic regulation of GnRH secretion in the hypothalamus. To this end, the progesterone receptor gene (Pgr) was selectively ablated in the Kisspeptin neurons in mice (K-PgrKO), and their serum gonadotropin concentrations, fertility, cyclicity and pubertal onset were compared with those of wild type (WT) controls as proxies for kisspeptin-mediated GnRH secretion. Mutant mice displayed advanced pubertal onset (vaginal opening day of 29 ± 1.0 d vs. 32.4 ± 3.1 d, n=10, p < 0.01), had low serum LH (0.12 ng/ml, n=4 vs. 0.46 ng/ml, n=6, p = 0.019), severely impaired fertility (22% vs. 66% at 3.5 months, n=9, and 14% vs. 71% at 5 months of age, n=7, p = 0.03) and irregular estrous cyclicity. Consistently, the adult mutant mouse ovary had histopathological defects characterized by smaller numbers of corpora lutea (2.6 ± 1.51 vs. 9.4 ± 5.03, n=5, p = 0.026). Examination of the pituitary gland and ovaries of the mutant mice revealed that these organs maintained a normal range of responsiveness to GnRH and gonadotropin challenges, respectively. K-PgrKO mice had a similar increase in serum LH after GnRH stimulation (1.34 ± 0.49 ng/ml vs. 1.66 ± 0.71 ng/ml) and were able to ovulate after ovarian hyperstimulation with PMSG and hCG. Nevertheless, mutant mice ovulated significantly less oocytes (21.5 ± 4.7, n=6 vs. 43 ± 9.64, n=3, p < 0.01). Given the poorer ovulatory response to gonadotropin stimulation in the mutant mice, the basal FSH/LH ratio was measured and found to be significantly higher in the mutant mice (3.4 ± 1.3 vs. 1.1 ± 0.6, n=5, p = 0.007). To determine the mode of Pgr regulation of kisspeptin, Kiss1 mRNA and Kisspeptin protein levels were evaluated in mutant mice and controls. There was no differences in the raw cell number of Kisspeptin positive cells between 5 month-old WT mice (36.7 ±17.0 cells per 0.1 mm2) and mutant mice (49.3 ± 13.5 cells per 0.1 mm2) (p=0.259), or in Kiss1 mRNA expression levels in the anteroventral periventricular nucleus from 6-7 month old WT and K-PgrKO mice (WT, 2.5 ± 3.6 AU; KO, 2.2 ± 2.6 AU. Our results indicate that the loss of Pgr in the Kisspeptin neuron impairs GnRH secretion and that Kisspeptin neurons serve as the target, and Pgr as a mediator, of the progesteronic regulation of GnRH secretion.

 

Nothing to Disclose: AG, PCPL, JAC, PRH, MMM, AW, RCF, JPL, CFE, CK

OR28-2 16892 2.0000 A Loss of Progesterone Receptor in Kisspeptin Neurons Causes Premature Pubertal Onset and Infertility 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 1:00:00 PM OR28 4756 11:30:00 AM Female Reproduction: Puberty Onset, Folliculogenesis, and Metabolic Responses Oral

Kristen P Tolson*1, Christian J Garcia1, Jeremy Troy Smith2 and Alexander S Kauffman1
1University of California, San Diego, La Jolla, CA, 2The University of Western Australia, Perth, Australia

 

Kisspeptin regulates reproduction by stimulating GnRH neurons via the receptor, Kiss1r. Kiss1r is also expressed in non-GnRH brain areas and peripheral tissues, suggesting additional functions for kisspeptin outside of reproduction. However, this has not been closely examined. Here, we studied the energetic and metabolic phenotype in mice lacking kisspeptin signaling (Kiss1r KO mice). Compared to WT littermates, KO females displayed dramatically higher body weights after 8 weeks of age, along with higher leptin, increased fat levels, and strikingly impaired glucose tolerance. Conversely, male KOs had normal body weights and glucose regulation. Surprisingly, despite their obesity, KOs ate less than their control littermates. However, KO females displayed dramatically reduced locomotor activity and metabolism which was not due to impaired thyroid hormone secretion. Comparing ovariectomized (OVX) KO and OVX controls, we determined that over half of the excess body weight of KO females is due to gonadal sex steroid-independent mechanisms. This was true whether OVX occurred before or after puberty (2 weeks old and 5 weeks old, respectively), showing that the obesity phenotype is not simply due to the KO’s lack of sex steroids during puberty or adulthood. We also examined the body weights of female hypogonadal (hpg) mice, which lack GnRH and gonadal sex steroids throughout postnatal development. We found that hpg females display the same mild body weight phenotype as OVX WT females, but do not have the additional obesity seen in Kiss1r KO females. OVX Kiss1r KO females also still developed lower metabolism and glucose intolerance compared to OVX WTs. Additional studies in younger cohorts have allowed us to determine the developmental onset of the various aspects of the metabolic phenotype in Kiss1r KO females. Our findings demonstrate that, aside from regulating reproduction, kisspeptin signaling serves previously-uncharacterized functions of regulating body weight and glucose homeostasis, primarily in females, in sex steroid-independent manner. Alterations in kisspeptin signaling could therefore be a novel component contributing to some facets of obesity, diabetes, and/or metabolic dysfunction.

 

Nothing to Disclose: KPT, CJG, JTS, ASK

OR28-3 13176 3.0000 A Kisspeptin Signaling Is a Novel Player in Obesity, Metabolism, and Glucose Homeostasis in Female Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 1:00:00 PM OR28 4756 11:30:00 AM Female Reproduction: Puberty Onset, Folliculogenesis, and Metabolic Responses Oral

Jeffrey Hoek, E. Leonie A.F. van Houten, Piet Kramer, Anke McLuskey, Bas Karels, Axel P.N. Themmen and Jenny A. Visser*
Erasmus MC, Rotterdam, Netherlands

 

Polycystic ovary syndrome (PCOS) is a disorder associated with infertility and metabolic disturbances. Ovaries of PCOS women contain an increased number of growing follicles. Such an ovarian phenotype is also observed in mice lacking the ovary-specific growth factor anti-Müllerian hormone (AMH). To determine the interaction between ovarian and metabolic function, we studied the metabolic phenotype of mice lacking AMH signaling as a model for an altered profile in ovarian growth factors.

In the first experiment, female mice lacking AMH (AMHKO) or its specific type II receptor (MRKI) and wild type littermates (WT) were analyzed at 4, 5 and 8 months of age. In the second experiment, 4-month-old female AMHKO, MRKI, and WT mice were fed a high fat diet (HFD) for one month. In both experiments body weight was measured, an intraperitoneal glucose tolerance test (IPGTT) was performed, morphology of white adipose tissues (WAT) was analyzed and serum hormone levels were determined.

Body weight did not differ between genotypes. However, at 5 months of age, AMHKO and MRKI mice had a better glucose tolerance than WT mice (P=0,002), who displayed a worsening in glucose tolerance with increasing age. At 5 months, WAT depots of AMHKO and MRKI mice contained smaller adipocytes (P<0.001). In agreement, leptin levels were strongly reduced in AMHKO and MRKI mice compared to WT mice (40-80%, P<0.001). At 8 months, AMHKO mice continued to have smaller adipocytes (P<0.001), lower leptin levels (P<0.05), and tended to have an improved glucose tolerance (P<0.07) combined with 2-fold lower insulin levels (P<0.05) compared to WT mice.

HFD treatment resulted in a nearly 5% gain in body weight of WT mice (P<0.05), which was reflected by a significant increase in WAT depot weights (P<0.05). In contrast, AMHKO and MRKI mice fed a HFD maintained similar body and WAT depot weights as mice on control chow. Glycerol levels tended to increase in WT mice upon HFD, but were unaffected in AMHKO and MRKI mice. Morphological analysis of WAT depots showed that adipocyte size in AMHKO and MRKI mice did not change upon HFD, while in WT mice adipocyte size increased significantly (P<0.001). HFD-fed WT mice had a normal glucose tolerance in the presence of nearly 2-fold increased insulin levels. In contrast, AMHKO and MRKI mice became glucose intolerant (P<0.05), while insulin levels were not affected in these mice upon a HFD.

In conclusion, mice lacking AMH signaling are protected against metabolic aging but become glucose intolerant upon HFD treatment. The lack of compensatory hyperinsulinemia upon HFD in these mice suggests impaired insulin secretion. Furthermore, the lack of adipocyte size increase upon HFD suggests that storage of excess energy in the form of lipids in adipocytes is impaired. Combined, these results suggest that an altered profile in ovarian growth factors affects metabolism.

 

Disclosure: APNT: Consultant, Ansh Labs. Nothing to Disclose: JH, ELAFV, PK, AM, BK, JAV

OR28-4 12572 4.0000 A Analysis of the Metabolic Phenotype of Female Mice Lacking Anti-Müllerian Hormone Signaling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 1:00:00 PM OR28 4756 11:30:00 AM Female Reproduction: Puberty Onset, Folliculogenesis, and Metabolic Responses Oral

Jenny Lisa Wilson*1, Ekaterina Salimova1, Gregory A Dissen2, Sergio R Ojeda3, Michael A Cowley4, Nadia Rosenthal1, Pablo Jose Enriori5 and Maria Cecilia Garcia Rudaz6
1Monash University, Melbourne, Australia, 2OR Natl Primate Res Ctr/OHSU, Beaverton, OR, 3Oregon National Primate Research Center/Oregon Health and Science University (ONPRC/OHSU), Beaverton, OR, 4Monash Univ, Clayton Vic, Australia, 5Monash University, Clayton, VIC, Australia, 6Monash Medical Centre, Monash Ch, Clayton, Australia

 

PCOS, the most common female endocrine disorder of unknown etiology is characterized by reproductive abnormalities and associated metabolic conditions comprising insulin resistance, Type 2 diabetes mellitus and dyslipidemia. We previously reported that transgenic overexpression of NGF, a marker of sympathetic hyperactivity, directed to the ovary by the mouse 17α-hydroxylase promoter (17NF mice), results in ovarian abnormalities similar to those seen in PCOS women (1). To investigate whether ovarian overproduction of NGF also induces common metabolic alterations of PCOS we assessed glucose homeostasis by glucose tolerance test, plasma insulin levels and body composition by Dexa scan in young female 17NF mice compared with WT mice. 17NF mice exhibited increased body weight and alterations in body fat distribution with a greater accumulation of visceral fat compared to subcutaneous fat (p<0.01). 17NF mice also displayed glucose intolerance (p<0.01) and hyperinsulinemia (p<0.05), which, similar to PCOS patients, occurred independently of body weight. Since we have previously established that 17NF mice exhibit increased extrinsic sympathetic input to the ovary (1) we went on to determine whether overexpression of ovarian NGF is capable of altering systemic sympathetic outflow by measuring interscapular brown adipose tissue temperature (iBAT-T) and UCP1 expression. We found that 24h iBAT-T was higher in 17NF mice than WT mice and was significantly different when just the dark period (19:00-07:00) was considered (p<0.05). Interestingly, 17NF mice also exhibited cardiac dysfunction similar to what has been reported in chronic hypertensive subjects. Echocardiography revealed left ventricular enlargement (p<0.01),) and left ventricular posterior wall thinning (p<0.01). Moreover, the internal diameter of the right common carotid artery (RCCA) was increased during systole and diastole (p<0.001). Systolic-diastolic changes in the diameter of the RCCA and area of the left ventricle were decreased (p<0.001) compared to WT mice. These findings suggest an overexpression of NGF in the ovary may be sufficient to cause both reproductive and metabolic alterations that are characteristic of PCOS and are in support of the hypothesis that sympathetic hyperactivity may play a primary pathological role in the development and/or progression of PCOS. Most importantly, this new animal model could therefore allow for the exploration of new treatments of PCOS.

 

Nothing to Disclose: JLW, ES, GAD, SRO, MAC, NR, PJE, MCG

OR28-5 15544 5.0000 A Transgenic Mice Overexpressing Nerve Growth Factor (NGF) in the Ovary Exhibit Both Reproductive and Metabolic Alterations Characteristic of PCOS and a State of Sympathetic Hyperactivity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 1:00:00 PM OR28 4756 11:30:00 AM Female Reproduction: Puberty Onset, Folliculogenesis, and Metabolic Responses Oral

So-Youn Kim*1, Katy Ebbert1, Marilia Cordeiro1, Jie Zhu1, Vanida Serna2, Kelly A Whelan3, Megan Romero1, Takeshi Kurita1 and Teresa K Woodruff3
1Northwestern University, Chicago, IL, 2Northwestern University, Chicago, 3Feinberg School of Medicine, Northwestern University, Chicago, IL

 

The maturation of the follicle is initiated by the AKT-mediated phosphorylation of FOXO3A in oocytes, which is triggered by an increase in the phosphatidylinositol (3,4,5)-trisphosphate (PIP3) level. Oocyte PIP3 levels are maintained by the balance between phosphatase and tensin homolog (PTEN) and phosphoinositide 3-kinase (PI3K) activities. However, the events that tip the balance towards PI3K to initiate the activation of immature follicles are not fully understood. To study the role of PI3K activity in oocyte development, we generated transgenic mice that express constitutively active PI3K in the primordial oocytes. The ovaries of Cre+ transgenic mice at neonatal stage had an excess number of primordial follicles showing that the elevation of PIP3 level promotes oocyte survival after follicle formation. Surprisingly, perinatal activation of PI3K in the oocyte did not initiate the maturation of primordial follicles in neonatal ovaries. The primordial oocyte of Cre+ mice demonstrated a nuclear accumulation of PTEN, indicating the presence of a PTEN-mediated protective mechanism against premature activation. Oocytes within the supernumerary primordial follicles activated without granulosa cell maturation and were cleared from the initial pool, resulting in an identical number of primordial follicles to Cre- mice at puberty. This observation suggests that an intrinsic mechanism controls size of ovarian reserve. Finally, PI3K activity did not affect normal follicle activation. Thus, antral follicles with meiotically competent oocytes accumulated in Cre+ ovaries. Our current study has highlighted the importance of PI3K signaling in follicle survival, and the dominant role of PTEN in the maintenance of female reproductive lifespan.

 

Nothing to Disclose: SYK, KE, MC, JZ, VS, KAW, MR, TK, TKW

OR28-6 11744 6.0000 A Cell Autonomous Phosphoinositide 3-Kinase Activation in Oocytes Promotes Survival but Not Premature Loss of Primordial Follicles 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 1:00:00 PM OR28 4756 11:30:00 AM Female Reproduction: Puberty Onset, Folliculogenesis, and Metabolic Responses Oral

Panneerdoss Subbarayalu*1, Suryavathi Viswanadhapalli1, Santosh Timilsina1, Tabrez Mohammad1, Yidong Chen1, Michael Drake1, T. Rajendra Kumar2 and Manjeet Rao1
1University of Texas Health Science Center at San Antonio, San Antonio, TX, 2Kansas Univ Med Ctr, Kansas City, KS

 

Introduction: It is well established that androgen is essential for normal spermatogenesis and male fertility; however, the mechanism of its action is not completely understood. In part this is because very few androgen-regulated genes have been definitely identified so far. We show that small non-coding RNAs “miRNAs” are one group of androgen-dependent trans-acting factors in the testis. Using androgen suppression mouse models, we have shown that a number of miRNAs are upregulated and their gene targets are down-regulated in the absence of androgen. Of these miR-471 is of particular interest as its expression begins to peak at day 12 in the Sertoli cells, the postnatal stage when androgen levels starts to rise and androgen-dependent spermatogenic events begins to set in the mouse testis. These findings prompted us to evaluate the functional role of androgen-responsive miR-471 expression in spermatogenesis and male fertility in vivo.

Methods: We generated transgenic mice expressing miR-471 driven by the Sertoli cell-specific promoter Rhox5Pp. We performed fertility, histological, germ cell apoptosis and phagocytosis assays to characterize reproductive phenotype of miR-471 mice.

Results: Using an in vivo transgenic mouse model, we demonstrate that expression of androgen responsive miR-471 in the Sertoli nurse cells is critical for adjacent male germ cell development and differentiation. Mice overexpressing miR-471 suffered from increased germ cell apoptosis, abortive germ cell meiotic progression, impaired spermatid differentiation, compromised Sertoli cell-Sertoli cell adhesion at the blood-testis barrier and impaired fertility.  Importantly, our analysis revealed that miR-471 regulates Sertoli cell phagocytosis of apoptotic germ cells in an androgen-dependent manner. Our results indicate that miR-471 influences these spermatogenic events by regulating expression of key androgen-responsive Sertoli cell-specific genes.  Taken together, this study establishes miRNAs as a new class of regulatory molecules in the testicular physiology that control key androgen dependent events essential for male fertility.

Conclusion: miR-471 transgenic mice represent the first genetic model for studying the function of specific miRNAs in Sertoli cells and miR-471 is the first androgen-regulated miRNA proven to be important for male fertility. Furthermore, our study is first to show that Sertoli cell phagocytosis is an androgen–dependent event.

 

Nothing to Disclose: PS, SV, ST, TM, YC, MD, TRK, MR

OR36-1 15489 1.0000 A Androgen-Responsive Mir-471 Expression in Sertoli Cells Is Essential for Phagocytosis of Apoptotic Germ Cells, Germ Cell Development and Complete Male Fertility 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 1:00:00 PM OR36 4759 11:30:00 AM Regulatory Mechanisms in Testicular Cells Oral

Joseph Patrick Moore Jr.*, Stephen J Winters and Rong Qiang Yang
University of Louisville, Louisville, KY

 

There is accumulating evidence that pituitary adenylate cyclase- activating polypeptide (PACAP) differentially regulates FSH and LH production, and may be especially important in the endocrine function of the fetus and newborn. Pituitary PACAP expression is high during fetal life, and declines dramatically at birth at which time follistatin decreases and FSH is significantly and selectively increased. To further evaluate the paracrine role of PACAP as a developmental regulator of FSH and LH production, we utilized a Cre/lox approach to selectively ablate PACAP in murine gonadotrophs. Conditional knockout mice (pitPAC-KO) were phenotypically normal and were fertile. FSH-ß expression levels were significantly elevated in pitPAC-KO mice from E17 (12-fold) to PN1 (3-fold) whereas, LH-ß mRNA levels were normal. Throughout postnatal development (P1 to P40), FSH expression levels remained significantly higher (2- to 15-fold) in pitPAC-KO mice while LH-ß expression levels were slightly but not significantly elevated,  FSH-ß- and LH-ß mRNA levels were similar in adult (PN50 and PN90) pitPAC-KO mice and controls. Our previous studies showed that testicular maturation is delayed by pituitary PACAP overexpression (1).  In pitPAC-KO mice, by contrast, testes were significantly larger from postnatal day 20 through adulthood, and markers of immature Sertoli (AMH) and Leydig (TSP2) cells declined 10 and 5 days earlier, respectively, when compared to wild-type. Moreover, markers of adult Sertoli (Fshr) and Leydig (17ßHSD III) cells increased 5 days earlier in pitPAC-KO mice. The spermatogenesis marker, c-kit, was also increased 5 days earlier in the pitPAC-KO mice. This is the first model for tissue-specific deletion of PACAP expression, and reveals that pituitary PACAP delays the expression of FSH beginning in fetal life, and regulates testicular development.  Further studies of the gonadotroph-specific knockout mice should provide insight into the role of pituitary PACAP in reproductive development and other biological functions.

 

Nothing to Disclose: JPM Jr., SJW, RQY

OR36-2 16043 2.0000 A Premature Testicular Maturation and FSH Synthesis in Gonadotroph-Specific PACAP Knockout Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 1:00:00 PM OR36 4759 11:30:00 AM Regulatory Mechanisms in Testicular Cells Oral

Emmi Rotgers*1, Sonia Bourguiba-Hachemi2, Adolfo Rivero-Müller3, Mirja Nurmio3, Noora Kotaja3 and Jorma Toppari3
1Institute of Biomedicine, University of Turku, Turku, Finland, 2Arabian Gulf University, Manama, Bahrain, 3University of Turku, Turku, Finland

 

Sertoli cells (SC) are a highly differentiated somatic testicular cell type that is essential for spermatogenesis. SC control germ cell differentiation via several signaling pathways, supply the developing sperm with nutrients and form the blood-testis-barrier (BTB). Defects in SC differentiation are thought to be a driving force behind male reproductive health problems such as male factor infertility.

 Retinoblastoma tumor suppressor protein (RB) is a controller of key cellular events such as G1/S-phase cell cycle progression, DNA damage responses, apoptosis and differentiation. RB, and the related p107 and p130, are collectively called the pocket protein family. RB controls cell cycle progression through several mechanisms: one of the best illustrated is its interaction with the E2F family and the control of E2F-regulated gene expression.

 RB is expressed in Sertoli cell and spermatogonia in the mouse testis. In the present study we dissected the role of RB in Sertoli cell proliferation, differentiation and function by creating a Sertoli cell-specific knock-out mouse line (SC-RbKO) through cross-breeding Amh-cre and Rb floxed-mice. The SC-RbKO mice showed a severe progressive testicular phenotype on both macroscopic and histological level that led to infertility. The normal progression of the first wave of spermatogenesis and the unaltered histology in the young animals suggested that the Rb-deficient SCs initially differentiated normally. However; by the age of 1 month, the SCs gradually re-entered the cell cycle, which was shown by the appearance of BrdU-positive SCs. As a sign of loss of SC polarity, the distribution of tight-junction and ectoplasmic specialization markers was severely altered in the adult SC-RbKO. Concomitantly, the mutant SCs regained the expression of cytokeratin 18, a marker for immature SCs. This was accompanied by a nuclear accumulation of activated ATM, which is a central player in DNA damage repair, and finally apoptosis of SCs.

 Of the E2F-family members, E2F3 is the only one expressed in mouse Sertoli cells. Using co-immunoprecipitation assay on testicular tissue from juvenile and adult mice, we showed that E2F3 interacts with RB during the mouse testicular development. Moreover, p107 and p130 attempted to compensate RB in the control of E2F3 in the SCRbKO testis. Lastly, to test the contribution of the deregulated E2F3 to the SC-RbKO phenotype, we performed an in vivo knock-down of E2F3 with shRNA, introduced by testicular microinjection and transfection by jetPEITM, which resulted in a partial rescue of the SC-RbKO phenotype.

Taken together, in this study we show that RB is required to control the E2F3 transcription factor in the maintenance of terminal differentiation in mouse Sertoli cells.

 

Nothing to Disclose: ER, SB, AR, MN, NK, JT

OR36-3 15886 3.0000 A RB/E2F-Pathway Controls Terminal Differentiation of Mouse Sertoli Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 1:00:00 PM OR36 4759 11:30:00 AM Regulatory Mechanisms in Testicular Cells Oral

Eva Szarek*1, Leticia F. Leal2, Malgorzata Kotula-Balak3, Barbara Bilinska3 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2School of Med of Ribeirao Preto, Ribeirao Preto-SP, Brazil, 3Jagiellonian University, Krakow, Poland

 

Phosphodiesterases (PDEs) play a critical role in regulating cAMP levels and signaling. Among them PDE8B, a cAMP-specific PDE, is highly expressed in the testis. Genetic aberrations in cAMP-signaling predispose to endocrine tumors but they are also known to affect reproduction. We examined testes isolated from wild-type (WT) and Pde8b-/- or knock-out (KO) mice at 6, 9, and 12 months (n=3-8/group). Pde8b-/- testis revealed regressive changes in seminiferous tubules (ST), containing increased numbers of atrophied tubules by 12 months (WT: 0±0.001% vs. KO: 11±0.012%) with ST diameter significantly decreased (WT: 209.3±6.65um vs. KO: 169.6±4.22um). Atrophied tubules resembled Sertoli-cell only (SCO) syndrome. Using Sox9 immunostaining we examined Sox9+ cell numbers, revealing a significantly higher number of Sertoli cells (SC) in Pde8b-/- testes (KO: 27.68±0.15 vs. WT:19.20±0.05 Sox9+ cells/tubule); SC in Pde8b-/- testes are maintained in an immature state. Since spermatogonial differentiation or accumulation of spermatogonia in ST has been shown to induce germ cell death, we hypothesized that germ cell loss resulted from increased apoptosis due to accumulation of spermatogonia undergoing defective spermatogenesis. We performed TUNEL to assess cell death and observed significantly higher numbers of TUNEL+ cells in Pde8b-/- testes (6mo: WT 4±1.0 vs KO 30±8.2 cells/tubules; 12mo: WT 9±1.9 vs KO 64±5.4 cells/tubules). Examination of junctional proteins, Cx43 and N-Cadherin, revealed a failure to establish junctional characteristics of the blood testis barrier, a likelihood substantiated by the abnormal localization of germ cells. Evaluation of blood biochemistry revealed a significant increase in LDH in Pde8b-/- mice (KO: 265.5±81.33 vs WT: 182.50±7.50U/L; P<0.05); LDH is known to be elevated in non-seminomatous germ cell tumors. Serum estradiol was elevated, but there was no difference in serum testosterone. In our further analysis of the hypothalamic–pituitary–gonadal axis in Pde8b-/- mice, it is evident that there are fertility issues in both males and females, the causes of which are currently under investigation. We conclude that PDE8B has a previously unknown role in SC function and proliferation; its wider role in fertility remains poorly characterized. PDE8B may be a therapeutic target for male infertility, especially that related to SC dysfunction.

 

Nothing to Disclose: ES, LFL, MK, BB, CAS

OR36-4 15924 4.0000 A A cAMP-Specific Phosphodiesterase, Phosphodiesterase 8B (PDE8B), Affects Sertoli Cell Proliferation in Adult Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 1:00:00 PM OR36 4759 11:30:00 AM Regulatory Mechanisms in Testicular Cells Oral

Rohini Bose1, Kin Lam Fok1, Kai Sheng2, Xiaotong Liang2, Hsiao C Chan3, Martine G Culty4, Wenming Xu2 and Simon Sipen Wing*1
1McGill University & McGill University Health Centre Research Institute, Montreal, QC, Canada, 2West China Second University Hospital, Sichuan University, Chengdu, China, 3Chinese Univ of Hong Kong, Shatin Hong Kong, 4Rsrch Inst of MUHC, Montreal, QC, Canada

 

Maintenance and differentiation of stem cells require precise regulation of protein expression. The ubiquitin (Ub) system mediates protein degradation and so is involved in this regulated protein expression. Spermatogonial stem cells (SSCs) are one of the most active stem cell systems in the body, in which the SSCs self-renew and differentiate to sustain the production of millions of sperm daily. In our previous studies, we identified a Ub ligase, Huwe1, which is able to ubiquitinate histones in the testes and undergoes a cytoplasm to nucleus shuttle during the transition from gonocyte to SSC. However, its exact role in SSC homeostasis remains elusive. Therefore, we inactivated  Huwe1 (Huwe1flox/Y) in the primordial germ cells (PGC) using Ddx-4 (Huwe1flox/Y Ddx4-Cre+) promoter-driven Cre recombinase.  Huwe1flox/Y Ddx4-Cre+ mice were infertile and showed complete depletion of germ cells in adult Huwe1flox/Y Ddx4-Cre+ testes.  Immunostaining of the germ cell marker, Ddx4, in different developmental stages of Huwe1flox/Y Ddx4-Cre+ testes revealed the progressive degeneration of germ cells from 6 dpp onwards. Gene expression profiling by microarray and real time PCR showed decreases in self-renewal markers (Gfra1, c-Ret, Plzf, and Ngn3) and differentiation markers (c-Kit, Stra8, Sall4) in 6 dpp but not in 3 dpp Huwe1flox/Y Ddx4-Cre+testes.  Brdu labeling of mice on 3 dpp revealed that there was a marked decrease in the number of proliferating germ cells in the testis.  There was no significant change in the number of TUNEL positive cells. Patients (204) with azoospermia and 247 fertile controls were genotyped for 27 different SNPs in the Huwe1 gene region.  Three SNPs were significantly associated with azoospermia and one of these was located in the promoter region ~672 bp upstream of the transcriptional start site.  Thus Huwe1 is essential for development and maintenance of the SSC pool and mutations in this gene may cause human azoospermia.

 

Nothing to Disclose: RB, KLF, KS, XL, HCC, MGC, WX, SSW

OR36-5 15510 5.0000 A The HUWE1 Ubiquitin Ligase Is Required for Establishment and Differentiation of Spermatogonial Stem Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 1:00:00 PM OR36 4759 11:30:00 AM Regulatory Mechanisms in Testicular Cells Oral

Sajad Salehi*1, Ikeoluwa Adeshina1, Rachel Massalee1, Fredric Edward Wondisford2, Mehboob Ali Hussain1, Andrew Wolfe1 and Sally Radovick3
1Johns Hopkins University School of Medicine, Baltimore, MD, 2Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, 3Johns Hopkins School of Medicine, Baltimore, MD

 

Kisspeptin, encoded by the Kiss1 gene, binds to a specific G-protein coupled receptor (GPR54 or Kiss1R) to regulate the central reproductive axis. Kisspeptin is localized to specific neurons located in the arcuate (ARC) and anteroventral periventicular (AVPV) nuclei of the hypothalamus and controls GnRH-mediated pubertal maturation and reproduction. Kisspeptin has also been reported to be expressed in peripheral tissues including the testes. However, the factors regulating testicular kisspeptin and its role in reproduction are unknown.

We performed a series of experiments to demonstrate kisspeptin expression in the testes. Q-RT-PCR on a murine tissue panel showed 17-fold higher kisspeptin mRNA levels in testes as compared to the ARC nucleus. (ARC: 1, AVPV: 1.12, Testes: 17.59, P<0.05). Immunohistochemical analysis using a validated kisspeptin antibody (Millipore AB9754) localized kisspeptin immunoreactivity to testicular Leydig cells. A developmental time course of kisspeptin mRNA expression revealed testicular kisspeptin mRNA levels escalating during development with peak levels reached after puberty (P<0.05), and consistent with temporal changes in kisspeptin mRNA levels in the ARC nucleus during reproductive maturation. Similarly, kisspeptin protein levels in Leydig cells were also found to increase during pubertal development reaching their peak after puberty.

A series of experiments were performed to determine whether testicular kisspeptin was regulated by the central reproductive axis. Intraperitoneal injection of 0.2 mg/kg LHRH agonist increased testicular kisspeptin mRNA 1.73±0.19 fold while 0.05 mg/kg LHRH antagonist decreased the expression to 0.65±0.15 fold as compared to a saline injection (p<0.05 for both).

These data show that kisspeptin is expressed at significant levels in mouse Leydig cells and is regulated by changes in reproductive neuroendocrine function. Further experiments will be performed to define the role for testicular kisspeptin in the reproductive axis.

 

Nothing to Disclose: SS, IA, RM, FEW, MAH, AW, SR

OR36-6 14802 6.0000 A Developmental and Endocrine Regulation of Kisspeptin Expression in the Leydig Cells of the Mouse Testes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 1:00:00 PM OR36 4759 11:30:00 AM Regulatory Mechanisms in Testicular Cells Oral

Carla M Moran*1, Maura Agostini2, Edward Visser3, Erik Schoenmakers2, Nadia Schoenmakers2, Odelia Rajanayagam2, Amaka Offiah4, Greta Lyons2, David Halsall5, Mark Gurnell6, Simon J B Aylwin7 and V Krishna K Chatterjee1
1University of Cambridge & Addenbrooke's hospital, Cambridge, United Kingdom, 2University of Cambridge, 3Erasmus Medical Ctr, Rotterdam, Netherlands, 4Sheffield Children's NHS Trust, 5University of Cambridge & Addenbrooke's Hospital, United Kingdom, 6University of Cambridge & Addenbrooke's Hospital, Cambridge, United Kingdom, 7King's College Hospital, London, United Kingdom

 

Background

Alternative splicing at the THRA locus generates transcripts encoding thyroid receptor alpha1 (TRα1) or a non hormone-binding splice variant (α2) whose function is unknown. Hitherto, four cases of Resistance to Thyroid Hormone (RTH) with highly deleterious, frameshift/premature stop mutations in the carboxyterminal transactivation domain of TRα1 have been recorded. Here, we describe a family with a missense mutation involving both TRα1 and α2 products of the THRA locus; comparison of their phenotype and the functional properties of missense TRα1/α2 mutants with patients harbouring only defective TRα1, delineates the relative roles of these two proteins. 

Findings

A 61 y.o female (P1), presented in childhood with growth failure, developmental delay, constipation, a prominent tongue and macrocephaly. Despite normal protein bound iodine levels, a clinical diagnosis of hypothyroidism was made and she was treated with thyroxine from age 3yrs. Similar features were identified in two of her sons (P2, 30 y.o, P3, 26 y.o), who were also thyroxine-treated from early childhood with an improvement in development, growth and constipation.

 Results

All three individuals exhibit similar clinical (macrocephaly, broad facies and skin tags, constipation, motor dyspraxia and dysarthric slow speech), biochemical [subnormal FT4/FT3 ratio (P1 2.14, P2 1.68, P3 1.43, RR 2.07 to 3.51); low reverse T3 (P1 5, P2 & P3 <5, rr 8-25 ng/dl); raised CK; mild anaemia] and radiological (thickened calvarium and long bones) features similar to patients with defective TRa1 alone; however, P2 is tall (91st centile) and cognitive impairment is mild, with all three patients achieving a third level qualification.

They are heterozygous for a missense mutation in a highly conserved residue (A263V) of THRA, affecting both TRa1 and a2 products. In transfection assays, transactivation by A263V mutant TRα1 is impaired at low, but comparable to WT receptor at higher T3 concentrations (WTTRa1 EC50 1nM; A263VTRa1 EC50 100nM); concordant with this, dominant negative inhibition of WT receptor function by A263V mutant TRa1 is reversible at higher T3 levels. In contrast, the properties of A263V mutant α2 are similar to WT a2, with both proteins localising predominantly to cell cytosol and only inhibiting TRa1 function when coexpressed at very high levels (Ratio of TRa1/a2 1:50).

 Discussion

We have identified three individuals with a missense THRA mutation, affecting both TRa1 and a2 transcripts. Their clinical phenotype resembles cases with defective TRa1 alone, with no added features; the properties of A263V mutant a2 are similar to WT a2 protein. Together, these findings suggest that TRa1 is the major functional product of the THRA locus. As observed in vitro, thyroid hormone treatment of patients with missense receptor defects may reverse dominant negative inhibition by mutant TRa1, resulting in a milder clinical phenotype.

 

Disclosure: MG: Principal Investigator, Ipsen, Advisory Group Member, Novartis Pharmaceuticals. SJBA: Principal Investigator, HRA Pharma. Nothing to Disclose: CMM, MA, EV, ES, NS, OR, AO, GL, DH, VKKC

OR29-1 15800 1.0000 A Resistance to Thyroid Hormone Mediated By a Missense Mutation in Thyroid Receptor Alpha 1 and Alpha 2 Splice Variant 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 1:00:00 PM OR29 4763 11:30:00 AM Genetics of Thyroid Development, Regulation and Thyroid Hormone Action Oral

Theodora Pappa*1, Alfonso Massimiliano Ferrara1, Jiao Fu1, Xiao-Hui Liao1, Alexandra M Dumitrescu1, Christopher D Brown2, April Peterson1, Lars C Moeller3, Kathleen Wyne4, Kevin P White5, Roy E Weiss1 and Samuel Refetoff1
1The University of Chicago, Chicago, IL, 2University of Pennsylvania, Philadelphia, PA, 3University Duisburg-Essen, Essen, Germany, 4Weill Cornell Medical College, The Methodist Hospital, Houston, TX, 5University of Chicago, Chicago, IL

 

Background: Familial TBG deficiency is an X-chromosome linked condition, caused by mutations of the TBG gene. Affected males present with low serum total T4 and T3 with normal TSH values, whereas females have only mildly reduced total serum T4 and T3.

Clinical Case: Out of 72 families with X-linked TBG deficiency tested in our laboratory, 68 had coding exon mutations in the TBGgene. In the remaining four, sequencing of all TBG gene exons, introns, minimal promoter and 2,500bp upstream region failed to identify any abnormalities. Affected individuals had low serum TBG concentration with normal properties.

To test the hypothesis that the families with uncharacterized TBG deficiency carry a mutation in a long-range cis-regulatory element, we re-sequenced 1Mb flanking the TBGlocus in ten individuals from these families. In three families, of Arab origin, we found a novel single nucleotide variant (G to A) in a predicted liver-specific enhancer co-segregating with the phenotype. This variant was not found in dbSNP, the one thousand genomes project data, or in 150 control X chromosomes of Arab ethnicity.

To assess whether this region functions as an enhancer of the TBG gene, and the possible attenuating effect of the mutation, we cloned 2,200bp from each putative enhancer genotype upstream of the TBG minimal promoter and firefly luciferase. The empty vector and a construct with the minimal promoter lacking the enhancer served as controls. Constructs were transfected into HepG2 cells, which express TBG. Results were normalized for renilla luciferase activity. Compared to the minimal promoter alone, the wild-type enhancer induced luciferase activity by 42-fold, whereas the mutant enhancer only by 14-fold. These results confirm that the cis-regulatory region has the predicted enhancer properties and that the mutation reduces its activity on the TBGpromoter.

Although the enhancer contains several hepatic nuclear factors (HNF) binding sites, an HNF1alpha site ~55bp downstream and an HNF3beta site ~35bp upstream of the mutation, they are not directly interrupted by the mutation. Gel shift experiments were performed to identify the factor responsible for this effect of the mutation on the TBG function, however this question remains unanswered. It is possible that a complex interaction of several factors is needed for the proper effect of the enhancer on TBG expression.

As the three families harboring this mutation are of Arab origin, the possibility of inheritance identical by descent was investigated. Preliminary data indicate that three affected individuals from these families share a 6.3Mb region surrounding the mutation locus. The shared haplotype is being further characterized.

Conclusion: To our knowledge, this is the first demonstration of a congenital endocrine disorder caused by a mutation in a long-range cis-regulatory element.

 

Nothing to Disclose: TP, AMF, JF, XHL, AMD, CDB, AP, LCM, KW, KPW, REW, SR

OR29-2 16057 2.0000 A A Mutation in a Liver-Specific Transcription Enhancer As a Novel Mechanism for X-Chromosome Linked TBG Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 1:00:00 PM OR29 4763 11:30:00 AM Genetics of Thyroid Development, Regulation and Thyroid Hormone Action Oral

Jiao Fu*1, Samuel Refetoff2, Alexandra M Dumitrescu2 and Roy E Weiss2
1The First Affiliated Hospital of Xi’an Jiaotong University School of Medicine, Xi'an, China, 2The University of Chicago, Chicago, IL

 

Background: The monocarboxylate transporter (MCT) 8 is an active and specific thyroid hormone cell-membrane transporter. Most patients with MCT8 gene mutations display severe psychomotor defects, including truncal hypotonia, cognitive retardation, spastic quadriplegia; the inability to walk or speak; and have characteristic thyroid abnormalities of high serum T3, low rT3, low normal to reduced T4, and normal or slightly elevated TSH concentrations. To date, more than 100 families harboring more than 70 different mutations have been described. Here we report a patient harboring a novel MCT8gene mutation and manifesting a mild phenotype.

Clinical case: The proband, a 12 year-old boy, was conceived in vitroby intracytoplasmic sperm injection (ICSI) and was born at 38 weeks by C-section to a 41 year-old woman after an uneventful pregnancy. By 2 months of age, he was noted to have decreased tone compared to his brother, excessive tongue thrusting, back arching, difficulty holding his head and regurgitation. The proband’s motor and intellectual development were slightly delayed, he started walking at 14 months and had poor language skills. No clinical thyroid phenotype was noted and thyroid function tests (TFTs) were normal. Neurological evaluation demonstrated that the child had dyspraxia and dyslexia. From age 3 y, he received extensive PT/OT 2-3h/day and major improvement was noted. He learned to ride a bike, swim and to ski, although with some difficulty. He is left-handed and is able to write with some apraxia.

His fraternal twin brother also conceived by ICSI was on the autism spectrum and parents arranged for whole-exome sequencing of the family. This was performed by deCODE genetics and revealed a de novo hemizygous missense mutation of the MCT8 gene in the proband leading to the amino acid substitution arginine to glutamine in position 388 (R388Q) located in the fourth intracellular domain of MCT8. This was not found in 2,230 Icelanders who were whole-genome sequenced, in 1000 Genomes or in the  Exome Sequencing Project (EVS6500). This aminoacid change is predicted to be benign using the PolyPhen-2 algorithm with a score of 0.074. Functional analysis using skin fibroblasts from the patient or by transfecting the R388Q MCT8 mutant in vitrowill be done to understand the effect of this mutation on MCT8 function.

Conclusion: We report a de novo R388Q mutation in MCT8 gene identified by whole-exome sequencing in a child with mild cognitive, motor and behavior abnormalities, different from most patients reported with MCT8 deficiency. This case illustrates that mild MCT8 mutations exist, and they could be missed if only patients with abnormal TFTs are evaluated. The investigation of this mutation is relevant, as it seems to dissociate the neurological manifestations from the thyroid abnormalities, and might reflect a role of MCT8 other than thyroid hormone transport.

 

Nothing to Disclose: JF, SR, AMD, REW

OR29-3 16078 3.0000 A Whole-Exome Sequencing Identified a Novel MCT8 Gene Mutation in a Child with Mild Cognitive, Motor and Behavior Abnormalities 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 1:00:00 PM OR29 4763 11:30:00 AM Genetics of Thyroid Development, Regulation and Thyroid Hormone Action Oral

Kiyomi Abe*1, Satoshi Narumi2, Junko Nishioka3, Shuichi Yatsuga3, Tateo Kuno4, Kaori Kameyama1 and Tomonobu Hasegawa5
1Keio University School of Medicine, Tokyo, Japan, 2National Research Institute for Child Health and Development, Tokyo, Japan, 3Kurume University School of Medicine, Fukuoka, Japan, 4Saga University, Saga, Japan, 5School of Medicine, Keio University, Tokyo, Japan

 

Background: Congenital hypothyroidism (CH) is the most common congenital endocrine disorder with a prevalence of 1 in 3,000 to 4,000 newborns. PAX8 is a thyroid-specific transcription factor, which regulates the proliferation and differentiation of thyroid follicular cells. Heterozygous inactivating PAX8 mutations cause CH that follows autosomal dominant inheritance. To date, 53 mutation-carrying patients belonging to 22 families have been reported, though no family with incomplete penetrance has been shown.

Objective: The aim of this study was to report clinical and molecular findings of a four-generation family that harbored a PAX8 mutation.

Subjects and Methods: Three probands were second cousins. They shared common great grandmother, who had had a thyroid nodule and received thyroidectomy at age 75 years. The probands were diagnosed as having CH in the frame of newborn screening (serum TSH levels: 94.0, 407.8, 438.7 mU/L). One of them had a high serum thyroglobulin level (2520 ng/mL). For three probands and 17 family members, we sequenced PAX8. The effect of the mutation on the interaction between PAX8 and target DNA was predicted based on structural data of PAX6-DNA complex.  

Results: We identified a novel heterozygous PAX8 mutation (G56S) in the three probands and seven family members, including the great grandmother. The seven apparently healthy family members had variable serum TSH levels, including five with a normal level (TSH levels: 1.2, 1.4, 1.4, 2.6, 2.7, 25.2, 30.0 mU/L). Elderly mutation carriers (age: 64, 66, 75 years) had adenomatous goiter on ultrasonography. Regarding the histological examination, the great grandmother’s thyroid had multi-nodular mass, of which size of follicles were variable ranging from fetal-like extremely small to slightly small. The structural analysis predicted that G56S had a defect in target DNA binding.

Conclusions: We reported the largest PAX8 mutation-harboring family with 10 carriers in four generations. Three novel findings were provided: (1) Mutation carriers can have high serum thyroglobulin levels, resembling dyshoromonogenetic goiter, in the neonatal period; (2) The phenotype of PAX8 mutation can be subject to incomplete penetrance; (3) Thyroid tissue morphology can be variable even within a single mutation carrier.

 

Nothing to Disclose: KA, SN, JN, SY, TK, KK, TH

OR29-4 15699 4.0000 A Clinical and Molecular Characterization of the Largest Family with Congenital Hypothyroidism Due to a PAX8 Mutation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 1:00:00 PM OR29 4763 11:30:00 AM Genetics of Thyroid Development, Regulation and Thyroid Hormone Action Oral

Lip Min Soh1, Maralyn Druce*1, Ashley B Grossman2, Ann-Marie Differ3, Liala Rajput4, Maria Bitner-Glindzicz5 and Márta Korbonits6
1Centre for Endocrinology, William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom, 2Oxford Centre for Diabetes, Endocrinology & Metabolism, 3North East Thames Regional Genetics Service Laboratory, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom, 4Cochlear Implant Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom, 5Clinical Genetics Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom, 6William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom

 

The diagnosis of Pendred syndrome is based on the clinical triad of deafness, goiter and an iodide organification defect. Deaf children undergo inner ear imaging, and those with enlarged vestibular aqueducts undergo perchlorate discharge test (PDT) and genetic testing for the Pendred gene SLC26A4. If any of these tests is abnormal, the patients are often subjected to lifelong monitoring and repeated investigations, which may pose significant psychological distress for this young population group. We conducted a large retrospective study of 50 patients to determine if any of these investigations could be avoided.

In our cohort, 33 patients had biallelic SLC26A4 mutations, 11 had monoallelic and 6 had no mutations. The 11 patients with monoallelic mutation had normal PDT. Of the 33 patients with biallelic mutation, 26 underwent a PDT. Twelve patients had >30% PDT, nine (all >20yrs) developed hypothyroidism, while the three younger ones were euthyroid. All patients with PDT <30% are euthyroid. There was a significant correlation between PDT and size of goiter (R=0.61, P=0.0009) and the age of onset of hypothyroidism (R=-0.62, P=0.04). A positive PDT result in the absence of biallelic mutations was related to false positivity from other conditions such as Hashimoto’s thyroiditis. In our population, the hazard of becoming hypothyroid increased by 7% per percentage point increase in PDT (P=0.001).

Forty-one different mutations were detected, among which 9 had not been previously described: c.73C>A (p.Pro25Thr), c.284G>C (p.Gly95Ala), c.454delG (p.Val152Phefs*2), c.1252G>A (p.Gly418Arg), c. 1511T>C (p.Phe504Ser), c.1920G>A (p.Trp640*), c.2118C>A (p.Cys706*), c.2174insTATC (p.Ala725Alafs*30) and c.2186T>C (p.Leu729Pro). Data from our cohort suggests that there is a correlation between SLC26A4 genotype and thyroid phenotype, and that thyroid dysfunction is dependent on the residual functional activity of mutated alleles.

Conclusions: Our results suggest that performing PDT in patients with monoallelic mutations is no longer clinically justifiable. On the other hand, for patients with biallelic mutations, a PDT discharge of >30% may signify high risk of developing goiter and hypothyroidism, and hence this subset of patients should have lifelong monitoring and follow-up.

 

Nothing to Disclose: LMS, MD, ABG, AMD, LR, MB, MK

OR29-5 13497 5.0000 A Strong Genotype-Phenotype Correlation in Pendred Syndrome Allows Reduced Endocrine Follow-up in Suitable Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 1:00:00 PM OR29 4763 11:30:00 AM Genetics of Thyroid Development, Regulation and Thyroid Hormone Action Oral

Pia Hermanns*1, Cherise Klotz2, Robert M Couch3, Norma Leonard2 and Joachim Pohlenz4
1Children's Hospital of Mainz, Mainz, Germany, 2University of Alberta Hospital, Edmonton, Canada, 3Univ of Alberta, Edmonton, AB, Canada, 4Universitaetsklinkum Mainz, Mainz, Germany

 

A 6-week-old male was admitted for investigation of prolonged jaundice. The pregnancy was unremarkable with a normal at term delivery. The neonatal screening was unremarkable. The boy was born to consanguineous parents of Turkish descent.

At presentation serum levels of thyrotropin, T4 and T3 were low and prolactin slightly elevated. Venous TSH was undetectable low. Central hypothyroidism was diagnosed and a TSH beta gene mutation was hypothesized.

Using different PCR protocols, we were unable to amplify both coding exons of the boy’s TSHbeta gene, which suggested a deletion of the coding sequence. An array comparative genomic hybridization (aCGH) was performed using specific probes around the TSHbeta gene locus on chromosome 1. The propositus was homozygous for a 6 kb deletion spanning all exons, as well as parts of the 5’ untranslated region of the TSHbeta gene. Both parents were heterozygous for this deletion.

This is the first report of a large deletion in the TSH beta gene. Isolated congenital secondary hypothyroidism (ICSH) is rare but important, since most patients with ICSH are diagnosed later in life, which results in severe growth failure and intellectual disability. Our study shows again that neonatal screening for both, fT4 and TSH is desirable. It would help to prevent symptoms of hypothyroidism in affected individuals.

 

Nothing to Disclose: PH, CK, RMC, NL, JP

OR29-6 13006 6.0000 A Homozygous Deletion of the TSH Beta Subunit Gene Causes Congenital Secondary Hypothyroidism in a Consanguineous Family of Turkish Descent 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 1:00:00 PM OR29 4763 11:30:00 AM Genetics of Thyroid Development, Regulation and Thyroid Hormone Action Oral

Ming Li*1 and David Largaespada2
1Univ of Minnesota, Minneapolis, MN, 2University of Minnesota, Minneapolis, MN

 

Well-differentiated thyroid cancer is one of the most indolent types of cancer, even though a small number of them do recur, metastasize or become locally invasive, leading to excessive morbidity and mortality. Unfortunately there are currently no reliable methods for predicting biological behaviors of this group of tumors, or effective treatments for those truly invasive ones. As a result, many patients are over-treated according to standard therapy, with unclear benefits but significant suffering and economic cost. In this research, we aim to study the genetic basis of aggressiveness of thyroid cancer by carrying out a forward genetic screen using random insertional mutagenesis by sleeping beauty transposon in thyroid gland. Thyroid-specific over-expression of the BRAF V600E mutant was shown to lead to typical indolent papillary thyroid cancer with 100% penetrance, setting stage for further study on metastasis and invasiveness. In this cancer-prone background, we have successfully created a cohort of transgenic mice that harbor additional transgenes to allow random insertional mutagenesis by sleeping beauty transposon in follicular cells of thyroid gland. The transgenes carried by the cohort include: a tandem array of oncogenic sleeping beauty transposons known as t2/onc, sleeping beauty transposase in one ROSA26 locus that could be activated by Cre recombinase, BRAF V600E mutant in another ROSA26 allele that could similarly be activated by Cre, and finally CreERT2 fusion protein under the control of the thyroid-specific thyroglobulin promoter. Upon activation of Cre recombinase by tamoxifen treatment, we were able to show extensive mobilization of the t2/onc transposons leading to random insertional mutagenesis within the mouse genome specifically in thyroid follicular cells. Ongoing research is focused on harvesting of thyroid cancers and their metastases in these mice and identification of driver mutations responsible for carcinogenesis, metastasis and local invasiveness. Identification of genes involved in these processes promises better molecular markers for risk stratification and potential treatment targets for invasive thyroid cancers.

 

Nothing to Disclose: ML, DL

OR39-1 15570 1.0000 A A Mouse Model for Forward Genetic Screening of Genes Involved in Carcinogenesis, Metastasis and Invasiveness of Well-Differentiated Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 1:00:00 PM OR39 4765 11:30:00 AM Thyroid Neoplasia Oral

Sun Wook Cho*1, Hyun Jin Sun1, Young A Kim2, Sun Kyoung Han2, Byung-Chul Oh3, Ka Hee Yi2, Do Joon Park2 and Young Joo Park2
1National Medical Center, Seoul, Korea, Republic of (South), 2Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 3Gachon University, Incheon, Korea, Republic of (South)

 

Tumor-associated macrophages (TAMs) have been recognized as important players in the tumorigenesis of many cancers, including advanced thyroid cancer. We investigated a role of TAM in human PTC. First, immunohistochemical staining of CD163 (macrophage marker) and CD31 (endothelial cell marker) was performed using tissue microarray including normal thyroid tissues (n=7), follicular adenoma (n=57), and PTC (n=148). The density of CD163+ TAMs was significantly higher in PTCs, compared with benign follicular adenomas or normal tissues. Moreover, a higher density of CD163+ TAMs was significantly associated with bigger tumor size, initial LN metastasis, and vascular invasion (CD31+ cell density). Next, human PTC (BHP10-3M), monocyte/macrophage (THP-1), and endothelial (HUVEC) cell-lines were used to explore the effects of TAMs in PTC tumorigenesis in vitro and in vivo. MTT assay demonstrated that coculture with BHP10-3M and THP-1 cells significantly increased tumor cell survivals compared to BHP10-3M cell alone. Cell migration and invasion potentials were enhanced in BHP10-3M/THP-1 than BHP10-3M. Furthermore, conditioned medium (CM) of BHP10-3M amplified cell migration and invasion potentials of HUVEC cells. In nude mice, cotransplantation with BHP10-3M and THP-1 cells showed significant increases of tumor growth than BHP10-3M cell alone, and treatment of clodronate liposomes, which inhibited the activation of macrophage by inducing apoptosis, attenuated the promoted tumor growth in BHP10-3M/THP-1 cotransplanted group. Finally, BHP10-3M/THP-1-cocultured CM showed strong expression of CXCL16, a ligand of CXCR6, while it did not expressed in BHP10-3M alone CM in cytokine array analysis. Recombinant human CXCL16 (rhCXCL16) treatment did not changed BHP10-3M cell viability, but enhanced cell migrations. Furthermore, anti-CXCL16 inhibited supporting effects of TAMs on PTC cell migrations. In angiogenesis, rhCXCL16 stimulated tubule formation of endothelial HUVEC cells and anti-CXCL16 inhibited stimulatory effects of TAMs on angiogenesis. Collectively, the effects of TAMs on PTC tumor invasion and angiogenesis were, in part, mediated by CXCL16 signaling. In conclusion, TAMs may potentiate tumor promoting microenvironment and play a functional role in tumor growth, invasion and angiogenesis of human PTC, partly via CXCL16 signaling.

 

Nothing to Disclose: SWC, HJS, YAK, SKH, BCO, KHY, DJP, YJP

OR39-2 14348 2.0000 A Tumor-Associated Macrophages Support Tumor Growth, Invasiveness and Angiogenesis in Papillary Thyroid Carcinoma Via CXCL16 Signaling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 1:00:00 PM OR39 4765 11:30:00 AM Thyroid Neoplasia Oral

Jennifer Anne Morrison*1, Jill J Severson2, William M Wood3 and Bryan R Haugen4
1University of Colorado Anschutz Medical Campus, Denver, CO, 2University of Colorado Anschutz Medical Campus, 3Univ of Colorado Anschutz Medical Campus, Aurora, CO, 4University of Colorado, Aurora, CO

 

Thyroid cancer is the most common endocrine malignancy and is responsible for >1850 deaths per year in the U.S.  The mechanisms which underlie the development of aggressive poorly differentiated and anaplastic thyroid cancer (ATC), which are refractory to conventional therapies, are incompletely understood.  We recently reported that thioredoxin interacting protein (TXNIP) is a tumor suppressor in thyroid cancer.  TXNIP is highly expressed in differentiated thyroid cancer (DTC) but its expression is low/absent in ATC.  Forced TXNIP expression in the ATC cell line HTh74 resulted in slowed in vitro growth, and TXNIP overexpression in the ATC cell line T238 resulted in attenuated tumor growth and reduced pulmonary metastatic burden in an in vivo orthotopic thyroid cancer mouse model.  As upregulation of TXNIP might serve as a pharmacologic intervention in advanced thyroid cancer, we sought to identify therapeutic agents that result in elevated TXNIP levels in order to enhance our understanding of the mechanisms and pathways involved in TXNIP regulation and also to facilitate the development of novel pharmacotherapies.  Employing an assortment of signaling pathway inhibitors, including those that inhibit Src (dasatinib), BRAF (sorafenib), MEK1/2 (selumetinib), and phosphoinositide 3-kinase (PI3K) pathways (LY294002, rapamycin) as well as a peroxisome proliferator-activated receptor gamma (PPARγ) agonist and antagonist (Pioglitazone and GW9662, respectively), we identified the PI3K inhibitor LY294002 as a potent inducer of TXNIP protein expression in a panel of ATC cell lines (HTh74, C643, and T238) as analyzed by immunoblot analysis.  Treatment with LY294002 also resulted in statistically significant inhibition of proliferation of these ATC cell lines in culture.  Interestingly, however, treatment with other PI3K inhibitors Wortmannin and BKM120 resulted in little or no TXNIP induction.  Furthermore, treatment of ATC cells with LY294002 did not consistently inhibit phosphorylation of the PI3K target Akt, implying a PI3K-independent mechanism of TXNIP induction by LY294002.  LY294002 has been shown in other systems to increase intracellular calcium concentrations independently of PI3K pathway inhibition.  Therefore, we investigated whether the LY294002-mediated calcium increase could be affected by the calcium channel blocker verapamil.  Cotreatment with verapamil blunted the induction of TXNIP by LY294002 in the ATC cell lines, suggesting that TXNIP expression and/or stability is regulated, at least in part, through calcium flux.  These data uncover a previously unidentified and potentially druggable target for TXNIP regulation in thyroid cancer cells and highlight the potential for exploiting these pathways in the treatment of select patients with advanced thyroid cancer.

 

Nothing to Disclose: JAM, JJS, WMW, BRH

OR39-3 13073 3.0000 A Pharmacologic Upregulation of the Tumor Suppressor Thioredoxin Interacting Protein (TXNIP) Results in Inhibition of Anaplastic Thyroid Cancer Cell Growth 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 1:00:00 PM OR39 4765 11:30:00 AM Thyroid Neoplasia Oral

Magdalena Rudzinska*1, Damian Gawel1, Kamila Maria Karpinska1, Miroslaw Kiedrowski2, Katarzyna Arczewska1, Justyna Sikorska1, Tomasz Stepien3, Magdalena Marchlewska3 and Barbara Czarnocka1
1The Center of Postgraduate Medical Education, Warszawa, Poland, 2Maria Sklodowska -Curie Memorial Cancer Center, Warszawa, Poland, 3Copernicus Memorial Hospital, Lodz, Poland

 

The differentiated thyroid carcinomas (DTC), disseminate by two major routes: papillary carcinoma (PTC) usually by the lymphatics, and follicular cancer (FTC) mainly through the circulatory system. Recently, several studies have highlighted the significance of lymphangiogenic factors in the progression of diverse human tumors, and a number of regulatory molecules specific to lymphatic cells and lymphangiogenesis have been identified. One of the key lymphangiogenic molecules is podoplanin (PDPN), a mucine type transmembrane glycoprotein specific to lymphatic system. PDPN was recently demonstrated to be expressed in a variety of human tumors, and in some of them, it is regarded as a factor promoting tumor progression. The purpose of the current study was to elucidate the molecular role of PDPN in the biology of thyroid cancer cells.

We evaluated the PDPN RNA and protein expression levels in thyroid carcinoma cell lines (TPC1, BcPAP, FTC133, CGTH-W-1) and primary thyroid tumors by quantitative RT-PCR, Western blot, ICC and IHC methods. The effect of PDPNsilencing on the malignant cell features, such as: proliferation, migration, invasion and adhesion, was studied in TPC1 cells. Then, PDPN expression and cellular localization was examined in a series of frozen PTC samples and archived PTC, FTC, follicular adenoma (FA) and normal thyroid tissues.

We found that PDPN gene and protein expression was upregulated in PTC derived TPC1 and BCPAP, and significantly down-regulated in FTC derived cell lines.  PDPN silencing with specific siRNA significantly (~15 fold) decreased cellular invasion, modestly cell migration and motility (2-fold lower than that of control cells), and had no effect on proliferation and adhesion. Podoplanin was not detectable  in normal and peritumoral tissues, where the PDPN antibody solely stained lymphatic vessels of different size and shape. In a series of archived DTCs, podoplanin was negative in FTCs and FAs, while in 40% of PTCs PDPN was solely expressed in cancer cells with uniformly distributed but  variable labeling intensity. Cytoplasmic PDPN expression was not associated with tumor size (pT) or histological (FvPTC vs classic PTC) subtype but was significantly correlated with patient’s age (P<0.001).

This is the first study analyzing expression and function of PDPN in thyroid cancer.

Our results demonstrate that PDPN is expressed in papillary thyroid carcinoma cell lines and in a fraction of PTCs. Moreover, we reveal podoplanin involvement in the regulation of  the invasive potential of  papillary thyroid carcinoma cells, suggesting that it might be implicated in thyroid papillary carcinoma progression.
This work was supported by grant 2012/07/B/NZ5/02444 from The National Science Center, Poland

 

Nothing to Disclose: MR, DG, KMK, MK, KA, JS, TS, MM, BC

OR39-4 14607 4.0000 A Podoplanian a Lymphangiogenesis Regulator and Its Role in Differentiated Thyroid Cancer Biology 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 1:00:00 PM OR39 4765 11:30:00 AM Thyroid Neoplasia Oral

Thomas C Beadnell*1, Katie M Mishall1, Qiong Zhou1, Alexander A Strait1, Maia L Corpuz1, Jihye Kim1, Guoliang Wang1, Aik Choon Tan2 and Rebecca E Schweppe1
1University of Colorado Anschutz Medical Campus, Aurora, CO, 2University of Colorado Medical School, Aurora, CO

 

There is currently a dearth of therapies for patients with anaplastic and advanced stages of papillary thyroid cancers. In addition to frequent MAPK pathway mutations, our lab has recently identified Src as an alternative, clinically relevant target in thyroid cancer (1,2). However, like many targeted therapies, long term efficacy of targeting Src using a single-agent approach is naïve, due to the presence of multiple potential escape mechanisms. To identify mechanisms of resistance to Src inhibitors, we generated a panel of four thyroid cancer cell lines that are resistant to the Src inhibitor, dasatinib (BMS-354,825). We chose two BRAF-mutant (BCPAP; SW1736) and two RAS-mutant (C643; Cal62) cell lines, and cultured cells continuously with increasing concentrations of dasatinib (50 nM to 2 μM), or alongside with control cells treated with vehicle (DMSO) for up to 9 months. We first calculated relative resistance for each dasatinib-resistant cell line in comparison to their respective control cell line. All four of the resistant cell lines exhibited a >10 fold increase in IC50 in response to dasatinib treatment, as well as the Src inhibitor, saracatinib (AZD0530), but were relatively sensitive to the Src inhibitor bosutinib (SKI-606), with only 1.5-3 fold increases in IC50 values for growth. Of note, three out of four of the cell lines (BCPAP, C643, and Cal62), demonstrated sustained resistance to dasatinib upon release of treatment for 1 to 2 months. To uncover resistance mechanisms on a genome-wide scale, we performed high-throughput RNA-sequencing (RNA-seq) on the control and resistant cell lines. Both RAS-mutant cell lines acquired Src gatekeeper mutations (SRC T341M), which was confirmed by SANGER sequencing. Interestingly, the RNA-seq analysis also demonstrated the MAPK pathway was enriched in the resistant cell lines, which we validated by Western blotting, observing increased levels of ERK 1/2 phosphorylation. In accordance with this, our preliminary data suggests increased BRAF and CRAF dimerization as a mechanism driving MAPK pathway activation. We therefore tested the effects of the MEK inhibitor, selumetinib (AZD6244) on cell growth, and found increased resistance in the BRAF-mutant cell lines (2.8-4.5 fold), yet increased sensitivity in the RAS-mutant C643 cell line (2.8 fold). Consistent with increased sensitivity to MEK inhibition in the RAS-mutant C643 cells, the RNA-seq data suggests a subpopulation of the resistant C643 cells has acquired a BRAF-V600E mutation. Taken together, our data indicate important roles for the Src gatekeeper mutation in RAS-mutant cells, and the MAP kinase pathway in both BRAF- and RAS-mutant cells, in regulating resistance to the Src inhibitor, dasatinib. In summary, these results provide important information on how to target the Src and MAPK pathways and counter potential mechanisms of resistance in the clinic.

 

Nothing to Disclose: TCB, KMM, QZ, AAS, MLC, JK, GW, ACT, RES

OR39-5 14283 5.0000 A Elucidating Mechanisms of Resistance to Src Inhibition in Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 1:00:00 PM OR39 4765 11:30:00 AM Thyroid Neoplasia Oral

Anthony Joseph Recupero*1, Kirk Ernest Jensen2, Aneeta Patel2, John Costello1, Oleksandr Sergiyovych Larin3, Victoria Hoperia3, Yevgeniya Kushchayeva4, Kenneth Burman4 and Vasyl Vasko1
1Uniform Service University of the Health Sciences, Bethesda, MD, 2Uniformed Services University of the Health Sciences, Bethesda, MD, 3Center for Endocrine Surgery, Kyiv, Ukraine, 4MedStar Washington Hospital Center, Washington, DC

 

Introduction

Medullary thyroid cancers (MTCs) harboring RET mutations are characterized by early metastatic spread. Reprogramming of tumor cell metabolism contributes to disease progression and aberrant expression of mitochondrial genes are demonstrated in metastatic cancers.

Objective

The objective of this study was to examine expression of mitochondrial respiratory chain molecules in MTC-derived cell lines and in human MTC tissue.

Material and Methods

The mRNA level of 86 genes coding for the mitochondrial electron transport chain was evaluated in two MTC cell lines (TT and MZ-CRC-1) using “mitochondrial energy” PCR arrays. RNA from normal thyroid was used as a control. Western blot analysis was performed to determine the protein expression of mitochondrial molecules in MTC cell lines. MTC samples from 62 patients were used for immunostaining. Statistical analysis was carried out to correlate results of staining with clinico-pathological characteristics.

Results

Both MTC-derived cell lines demonstrated increased expression of genes coding for mitochondrial complex I (NADH dehydrogenases: NDUFA5, NDUFA10, NDUFB2 and NDUFAB), complex II (Succinate dehydrogenase: SDHB), and complex V (ATP synthase: ATP5C1 and ATP5I) when compared to the normal thyroid. Increased expression of mitochondrial carrier (SLC25A25) was specific for the RET643 positive TT cells. RET918 positive MZ-CRC-1 cells were characterized by overexpression of genes coding for complex IV (COX4, COX6 and COX7) when compared to the normal thyroid and to TT cells. Western blot with anti-NDUFA5, anti-SDHB, anti-COX4 and anti-ATP5B showed expression of mitochondrial proteins in MTC-derived cells. In human MTC samples staining with anti-NDUFA5, anti-COX4 and anti-ATP5B was detected in 8/62 (12.9%), 36/62 (58%) and 56/62 (90%) examined tumors respectively. Normal C cells were negative with anti- NDUFA5 and anti-COX4, but demonstrated cytoplasmic staining with anti-ATP5B. There were no associations between the level of expression of mitochondrial molecules and patient’s age, gender or tumor size. The level of NDUFA5 and ATP5B was not significantly different between MTCs presenting with and without metastases. In contrast, expression of COX4 was significantly associated with the presence of metastases at the time of surgery. Positive immunostaining with anti-COX4 was detected in 22/28 (78.5%) MTCs presenting with lymph nodes metastases versus 14/34 (41.1%) tumors without metastases (p=0.004).

Conclusion

Increased expression of mitochondrial molecules in MTC-derived cell lines and human MTC suggest the role of enhanced mitochondrial respiration in development of MTC.  Over-expression of COX4 may be involved in the metastatic progression of MTCs, perhaps representing a biomarker for tumor aggressiveness.

 

Nothing to Disclose: AJR, KEJ, AP, JC, OSL, VH, YK, KB, VV

OR39-6 13777 6.0000 A Expression of Mitochondrial Respiratory Chain Molecules in Human Medullary Thyroid Cancers 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 1:00:00 PM OR39 4765 11:30:00 AM Thyroid Neoplasia Oral

Marc B Cox*1, Cheryl Lynne Storer2, Ji Ho Suh3, Arundhati Chattopadhyay4, Robert Fletterick5, Anders Mikael Strom6 and Paul Webb3
1Univ of Texas at El Paso, El Paso, TX, 2Border Biomed Res Ctr, El Paso, TX, 3Methodist Hosp Res Inst, Houston, TX, 4Methodist Res Hosp Ctr, Houston, TX, 5Univ of CA - San Francisco, San Francisco, CA, 6Univ of Houston, Houston, TX

 

FKBP52 has been shown to be an important positive regulator of AR in cellular and whole animal models and represents an attractive target for the treatment of prostate cancer. To this end, we previously identified and characterized a novel class of AR inhibitors that specifically inhibit FKBP52-regulated AR signaling. The lead inhibitor, termed MJC13, prevents hormone-dependent dissociation of the AR-FKBP52-Hsp90 complex, ultimately preventing AR from entering the nucleus. MJC13 is predicted to act through binding the AR BF3 surface, which is hypothesized to be an FKBP52 interaction/regulatory surface. Additionally, the BF3 surface overlaps with the predicted β-catenin binding site on AR. Here we demonstrate that FKBP52 and β-catenin interact directly in vitro and act in concert to promote a synergistic up-regulation of both hormone-independent and dependent AR signaling. Our data demonstrate that FKBP52 promotes β-catenin interaction with AR and is required for β-catenin coactivation of AR activity in prostate cancer cells. Co-regulation of AR by FKBP52 and β-catenin does not require FKBP52 PPIase catalytic activity. However, the FKBP52 proline-rich loop that overhangs the PPIase pocket is critical for synergy. The degree of FKBP52/ β-catenin co-regulation varies depending on which promoter is present on the reporter construct, suggesting regulation at the level of transcription. Finally, the FKBP52-specific inhibitor, MJC13, effectively blocks the synergistic up-regulation of AR by FKBP52 and β-catenin. In summary, we have identified a novel, functional interaction between FKBP52 and β-catenin, which has clear implications in prostate cancer progression to the hormone refractory state.

 

Nothing to Disclose: MBC, CLS, JHS, AC, RF, AMS, PW

OR32-1 12231 1.0000 A FKBP52 and β-Catenin Directly Interact to Regulate Androgen Receptor Activity in Prostate Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 1:00:00 PM OR32 4768 11:30:00 AM Nuclear Receptors in Hormone-Dependent Tumors: Regulation, Interactions and Therapeutic Targets Oral

Theresa E Hickey*1, Jessica L L Robinson2, Nicole L Moore1, Roslin Russell2, Luke Selth1, Oscar Rueda2, Carlos Caldas2, Jason S Carroll2 and Wayne D Tilley1
1University of Adelaide, Adelaide, Australia, 2University of Cambridge, Cambridge, United Kingdom

 

Unprecedented interest in targeting the androgen receptor (AR) in women with breast cancer has arisen in recent years, with multiple clinical trials currently underway. While the goal of most trials is to inhibit AR activity, clinical and scientific evidence to date supports context-specific tumour suppressive or oncogenic effects of AR signaling in breast cancer cells, highlighting the need to better define AR expression and function in this disease1. Analysis of AR mRNA expression in the Metabric Cohort comprised of 2,000 breast tumours2 revealed that AR expression was evident in all 10 molecular subtypes of breast cancer classified by integrated analysis of copy number aberrations and transcriptome profiling.  Even integrated cluster 10, largely comprised of cancers with a basal phenotype and very low or no AR expression as a group, had multiple cases with AR mRNA expression tantamount to that in the other clusters. Assessment of relative AR mRNA expression on breast cancer specific survival indicated that a high level of AR defined by recursive partitioning of the dataset significantly predicted a good outcome in women with estrogen receptor alpha (ERα) positive disease but not in women with ER negative disease. To define the molecular mechanisms that underpin the apparent beneficial effect of AR signalling in ERα positive breast cancers, ChIP-seq analyses were performed in ZR-75-1 breast cancer cells stimulated with 10nM 17β-estradiol (E2) or 5α-dihydrotestosterone (DHT), either alone or in combination. Simultaneous activation of AR and ERα resulted in chromatin binding sites that overlapped by at least 1 base pair in 35-40% of the total binding events for each receptor. Depletion of AR via treatment with multiple siRNAs resulted in significant enrichment of ERα binding at these loci, indicating that the presence of AR restricts the amount of ERα binding at select sites co-occupied by these receptors when simultaneously activated by their cognate ligands. Motif analysis revealed that these common AR and ERα binding sites were enriched for FOXA1, a pioneer factor for both receptors in breast cancer3. Depletion of FOXA1 more robustly hindered the binding of AR than ERα, but depletion of AR and FOXA1 resulted in a dramatic loss of ERα binding and chromatin accessibility.  Treatment with E2+DHT also resulted in a loss of approximately 20% of ERα chromatin binding events stimulated by treatment with E2 alone. The presence of AR at nearly half of these sites indicated that it was able to displace or outcompete ERα for DNA binding. The latter common AR and ERα binding sites were enriched in the promoter region of genes that regulate apoptosis. Collectively these data suggest that the beneficial effect of AR expression in ERα positive breast cancers may be due to the ability of AR to restrict ERα DNA binding.

 

Nothing to Disclose: TEH, JLLR, NLM, RR, LS, OR, CC, JSC, WDT

OR32-2 16144 2.0000 A The Androgen Receptor Restricts Estrogen Receptor Alpha DNA Binding in Breast Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 1:00:00 PM OR32 4768 11:30:00 AM Nuclear Receptors in Hormone-Dependent Tumors: Regulation, Interactions and Therapeutic Targets Oral

Keely M McNamara*1, Shota Nakamura1, Tomomi Yoda1, Alif Meem Nurani2, Yasuhiro Miki3, Takanori Ishida1, Noriaki Ohuchi1 and Hironobu Sasano4
1Tohoku Univ Sch of Med, Sendai, Japan, 2Tohoku Univ Sch of Med, Miyagi, Japan, 3International Research Institute of Disaster Science, Tohoku University, Sendai, Japan, 4Tohoku University Graduate School of Medicine, Sendai, Japan

 

FOXA1 has been demonstrated to play a pivotal role in hormone dependent cancers. Transcriptional profiling in breast cancer specimens revealed that, in certain estrogen receptor alpha (ERα) negative samples, FOXA1 can interact with the androgen receptor (AR) to replicate a luminal gene expression profile through FOXA1-AR interactions at estrogen responsive elements. This profile is termed molecular apocrine in reference to their characteristic high AR expression also seen in histologically identified apocrine carcinoma. We previously examined AR in an overlapping but non synonymous class of ER- breast cancers, triple negative breast cancer (TNBC), and the presence of AR was found to be associated with the androgen synthesising enzymes (5αR1 and 17βHSD5) and lower proliferation. This association was more marked in luminal-like compared than in basal-like TNBC, suggesting a possible FOXA1 involvement. Therefore, in this study, we evaluated immunoreactivity of FOXA1, AR and androgen synthesizing enzymes in order to understand their interactions in 176 cases of TNBC. In these samples FOXA1 status was significantly associated with that of AR (>10%LI cutoff, AR+, 72% FOXA1+; AR-, 23% FOXA1+ AR vs.FOXA1 χ2 p<0.01), FOXA1 positive TNBC cases were also significantly associated with higher AR H score (Wilcoxian p<0.01 Range; FOXA1+ 0-294 FOXA1-0-149) and FOXA1 LI was lower in carcinomas positive for the basal marker CK5/6 (Wilcoxan p<0.08). When examining its relationship to androgenic enzymes, the FOXA1 LI increased in proportion to 5αR1 and 17βHSD5 prevalence (ANOVA, p<0.05). When Ki67 LI of carcinoma cells was compared among FOXA1/AR groupings,  FOXA1+/AR+ cases had the lowest Ki67 labelling index (15.7%) and FOXA1-/AR+  the highest labelling index (41.7%) with these difference being statistically significant (ANOVA, Tukey Kramer HSD +/+ vs -/+ p<0.01).  We then examined the interactions between FOXA1 and AR in the AR+TNBC cell line, MDA-MB-453 in order to evaluate whether there was any direct correlation between these two factors. DHT treatment decreased FOXA1 expression in a dose dependent manner (ANOVA n=3 p<0.01) and FOXA1 knockdown via siRNA increased the expression of AR (ANOVA n=3 p=0.03), suggesting a negative regulatory loop between FOXA1 and AR expression. These findings suggest that the maintenance of the molecular apocrine phenotype could be partially dependent on the cross talk between AR-FOXA1 signalling pathways and enzyme expression in TNBC.

 

Nothing to Disclose: KMM, SN, TY, AMN, YM, TI, NO, HS

OR32-3 12742 3.0000 A The Interaction of Androgen Pathways with the Pioneer Factor FOXA1 in Triple Negative Breast Cancers 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 1:00:00 PM OR32 4768 11:30:00 AM Nuclear Receptors in Hormone-Dependent Tumors: Regulation, Interactions and Therapeutic Targets Oral

Irida Kastrati*, Marton Siklos, Gregory Thatcher and Jonna Frasor
University of Illinois at Chicago, Chicago, IL

 

Nearly 75% of breast tumors express estrogen receptor (ER) and will be treated with endocrine therapy, such as tamoxifen or aromatase inhibitors. Yet, about 50% of these tumors fail to respond and eventually recur as aggressive, metastatic cancers. Coincidently, these same characteristics also define cancer stem cells (CSCs). According to the CSC hypothesis, the bulk of the tumor responds to treatment, while CSCs are a subset within the tumor that are resistant to conventional therapies, tumor initiating, metastatic, and responsible for tumor recurrence. Therefore, targeting breast CSC promises to sensitize to therapy even resistant, aggressive tumors, and prevent future recurrence and metastasis. However, to develop new therapies against CSCs, it is essential to understand factors and pathways that drive their survival and propagation.

In order to study CSCs from ER+ breast cancers, MCF-7 mammospheres (MS) were grown from single cells, in an anchorage-independent manner, under de-differentiating conditions. Consistent with previous reports, we find that MS cells express multiple CSC markers, and are more tumorigenic than standard adherent culture cells. Gene expression profiling reveals that estrogenic stimulus and inflammatory response are the top associated gene networks expressed in MS. Indeed, we find intrinsic activation of ER in the absence of ligand and elevated endogenous nuclear factor κB (NFκB) activity. This is demonstrated by increased expression of ER- and NFκB- target genes, which are suppressed by the ER antagonist, ICI182780 (ICI), or by the NFκB inhibitor, IKK7, respectively. Increased ER and p65 DNA binding activity are also observed. In addition, our findings indicate that ER and the NFκB pathway are not only active but also required for MS growth, since treatment with either ICI or IKK7 significantly attenuated the number and size of MS that form.

Activation of either ER, or the NFκB pathway, individually, was previously implicated in breast CSC biology. However, we find that co-treating with both ER and NFκB inhibitors at sub-optimal, ineffective doses, results in enhanced inhibition on MS growth compared to either inhibitor alone. The left hand-shift of MS growth inhibition curve by ICI in the presence of IKK7, or by IKK7 in the presence of ICI, suggests that activation of ER and the NFκB pathway in MS might be interdependent. Yet, ICI had no effect on NFκB-target genes, or IKK7 on ER-target genes in MS. This indicates that ER and the NFκB pathway are converging on specific factors to promote MS growth. Based on these findings, we synthesized novel co-targeting agents that simultaneously inhibit both ER and the NFκB pathway, and found them to be effective at inhibiting MS growth. Taken together, our findings show that active ER and NFκB work together to drive CSCs, and that co-targeting them can be successfully exploited to treat aggressive ER+ breast cancers.

 

Nothing to Disclose: IK, MS, GT, JF

OR32-4 16561 4.0000 A Co-Targeting ER and the NFkB Pathway Provides a New Therapeutic Approach for Aggressive ER+ Breast Cancers 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 1:00:00 PM OR32 4768 11:30:00 AM Nuclear Receptors in Hormone-Dependent Tumors: Regulation, Interactions and Therapeutic Targets Oral

Xiaobin Zheng*, Neal D Andruska and David J Shapiro
University of Illinois, Urbana, IL

 

Although 30-70% of ovarian cancers are estrogen receptor α (ERα) positive, endocrine therapy for ovarian cancer using agents developed to treat ERα positive breast cancer are largely ineffective. Recurrent ovarian tumors are treated with combination chemotherapy using taxanes and platinum. After several treatment cycles tumors recur as resistant ovarian cancer. Therapeutic options for these resistant tumors are poor and approximately two thirds of ovarian cancer patients die within 5 years. Using high-throughput screening we identified a non-competitive small molecule ERα inhibitor, which is effective in therapy-resistant ovarian cancer cells. The inhibitor interacts with ERα as judged by its ability to alter the fluorescence emission spectrum of purified ERα and to alter the sensitivity of purified ERα ligand-binding domain (LBD) to protease digestion. In ERα positive ovarian cancer cells, the inhibitor acts on multiple ERα-dependent pathways, one of which is inhibition of 17β-estradiol (E2)-ERα mediated gene expression.  The inhibitor selectively blocks proliferation of ERα positive ovarian cancer cells resistant to antiestrogens (4-hydroxytamoxifen and ICI 182,780/Fulvestrant/Faslodex), cisplatin, and paclitaxel, and blocks anchorage-independent growth in soft agar of ERα positive PEO4, BG-1, and Caov-3 ovarian cancer cells. At 1 μM, the inhibitor completely blocks proliferation of multidrug resistant OVCAR-3 cells that are resistant to ICI 182,780, taxanes, cisplatin and other anticancer drugs. Importantly, in multiple cell models, the inhibitor restores sensitivity of resistant ovarian cancer cells to killing by therapeutically relevant concentrations of cisplatin and paclitaxel. Our studies comparing the actions of the inhibitor and standard antiestrogens provide new insights that help explain why antiestrogens are usually ineffective in ERα positive ovarian cancer cells. To our knowledge, this is the first small molecule ERα inhibitor to successfully target ovarian cancer cells resistant to antiestrogens and chemotherapeutic drugs.

 

Nothing to Disclose: XZ, NDA, DJS

OR32-5 14931 5.0000 A A Noncompetitive Small Molecule ERα Inhibitor Blocks Proliferation of Therapy-Resistant Ovarian Cancer Cells and Restores Sensitivity to Taxanes and Cisplatin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 1:00:00 PM OR32 4768 11:30:00 AM Nuclear Receptors in Hormone-Dependent Tumors: Regulation, Interactions and Therapeutic Targets Oral

Fabio Stossi*1, Michael J Bolt1, Radhika D Dandekar1, Vasanta Putluri1, Akash K Kaushik1, Ching-yi Chang2, Maureen M Mancini1, Arun Sreekumar1, Donald P McDonnell2 and Michael Alan Mancini1
1Baylor College of Medicine, Houston, TX, 2Duke University School of Medicine, Durham, NC

 

Prostate cancer is still a deadly disease especially when patients become resistant to drugs that target the Androgen Receptor (AR) ligand binding domain.  At this stage patients develop recurring castrate-resistant prostate cancers (CRPCs).  Interestingly, CRPC tumors maintain dependency on AR for growth; moreover, in CRPCs, constitutively active AR splice variants (e.g., AR-V7) begin to be expressed at higher levels. These splice variants lack the ligand binding domain, rendering them insensitive to current endocrine therapies. Thus, it is of paramount importance to understand what regulates the expression of AR and its splice variants to determine new therapeutic strategies in CRPCs.  In support of this idea, reduction of AR levels has been shown to diminish growth of CRPC tumor xenografts.  As part of a larger NIEHS-funded project, our customized high throughput microscopy and quantitative image analysis platform (1 and Szafran and Mancini, ’14, in press) was used to evaluate effects of endocrine disruptors on steroid receptor activities. We sought to specifically identify novel modulators of AR levels in multiple breast and prostate cancer cell lines.  We identified Bisphenol AP (BPAP), a Bisphenol A (BPA) analog and endocrine disruptor used in chemical and medical industries, as a down-regulator of both full length AR and the AR-V7 splice variant.  We validated its activity by performing time-courses, dose-responses, Western blot and qPCR analysis.  We found that, uniquely in 22RV1 cells, BPAP is capable of reducing AR and AR-V7 protein and target genes mRNAs (and proteins) by >50%.  Interestingly, through BiFC analysis experiments, BPAP does not appear to bind directly to AR, distinguishing it from another BPA derivative (EPI-001) that is currently being evaluated as a novel therapeutic agent (2-3).  BPAP also caused reduction of cell in S phase, as measured by EdU labeling, which was accompanied with ~80% loss in cell numbers and colony formation in anchorage-independent growth assays. Moreover, it greatly affected the carbon usage as measured by Biolog™ analysis.  To begin understanding BPAP mechanism(s) of action, next we performed a nuclear receptor RNAi library screen in 22Rv1 cells and identified two targets (ESRRA and NR4A1) as potential modulators of BPAP activity.  We found that a complex interplay between AR, ESRRA and NR4A1 exists at the receptor level (i.e. BPAP down-regulates also ESRRA but not NR4A1), target gene and phenotypic level and we are exploring this phenomenon with additional experiments.  Further validation of these networks and in vivo xenograft studies are ongoing.  

In summary, via high throughput microscopy, we have identified a novel AR down-regulator, Bisphenol AP, which has potential as a novel lead compound for CRPC treatment.  Moreover, BPAP appears to act through interference with a nuclear receptor network that has AR, NR4A1 and ESRRA as central nodes.

 

Nothing to Disclose: FS, MJB, RDD, VP, AKK, CYC, MMM, AS, DPM, MAM

OR32-6 17108 6.0000 A Bisphenol AP Is a Novel AR Down-Regulator in Castrate Resistant Prostate Cancer Cells Via Modulation of Nuclear Receptors' Networks 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 1:00:00 PM OR32 4768 11:30:00 AM Nuclear Receptors in Hormone-Dependent Tumors: Regulation, Interactions and Therapeutic Targets Oral

Lacey M Litchfield*, Mohammed Habis, Nadia Ismail, Alyssa Johnson, Ernst Lengyel and Iris L Romero
University of Chicago, Chicago, IL

 

While there is a surge of interest in the anti-cancer effects of the diabetic biguanide metformin, it is unclear whether pre-clinical findings will translate into a protective effect in patients. Nearly all in vitro studies to date used doses of metformin not attainable in patients and have not taken into account experimental glucose levels. In the present study, we tested the hypothesis that hyperglycemia inhibits the anti-cancer effects of metformin.  Using ovarian cancer (OvCa) as a model system, we determined that low doses of metformin (0.5-1 mM) resulted in cytotoxic effects at physiological glucose levels (5.5 mM) but not in standard cell culture conditions (25 mM glucose). AMPK is a central mediator of metformin response, with effects on glycolysis, glucose uptake, and synthesis of fatty acids and proteins. We noted AMPK activation in OvCa cells with doses as low as 0.5 mM metformin when cells were cultured at physiological glucose levels.  Next, we sought to understand the mechanism of the suppression of metformin response in high glucose conditions.  We hypothesized that cells cultured in high glucose had a compensatory increase in glycolysis making them less sensitive to the energetic stress induced by metformin.  To test this we evaluated induction of glycolysis via AMPK-mediated activation of the 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase isoform PFKFB3. Co-administration of a glycolytic inhibitor (3PO- PFKFB3 inhibitor) and metformin led to a synergistic reduction in cell viability and glycolysis as measured by ATP production. Finally, we tested whether our in vitro findings could be recapitulated in vivo. We developed a syngeneic mouse model of OvCa with a type II diabetic phenotype by feeding C57BL/6J female mice a 60% kCal fat diet for 12 weeks. Mice on high fat diet developed a statistically significant increase in body weight and decreased glucose tolerance, as measured by glucose tolerance tests, compared to lean controls. We then tested the effect of metformin on OvCa tumor burden in hyperglycemic versus normal glycemic mice. Metformin treatment significantly decreased tumor burden in normal glycemic mice (mean tumor weight: placebo 40 mg + 4.5, metformin 23.2 mg + 3.5, p=0.01).  In contrast, metformin did not significantly reduce tumor burden in hyperglycemic mice (placebo 48 mg + 9, metformin 40 mg + 7, p=0.5).  Clinically, these findings are provocative because some argue that metformin will not work as a cancer therapeutic in patients without diabetes.  Our findings suggest metformin may actually have a greater impact on OvCa in the absence of diabetes and, in fact, poorly controlled diabetes may promote cancer to a degree that metformin is unable to counteract.  Further investigation of the relationship between hyperglycemia, glycolytic activation, and metformin sensitivity will inform both future in vitro studies and appropriate cancer therapeutic dosing in humans.

 

Nothing to Disclose: LML, MH, NI, AJ, EL, ILR

OR38-1 16121 1.0000 A Hyperglycemia Inhibits the Anti-Cancer Effects of Metformin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 1:00:00 PM OR38 4769 11:30:00 AM Therapies for Cancer Oral

Valerie Nicole Barton*, Nicholas D'Amato and Jennifer K Richer
University of Colorado Anschutz Medical Campus, Aurora, CO

 

Triple negative breast cancer (TNBC) constitutes 15-20% of invasive breast carcinomas and has the lowest five-year survival rate. Currently, there are no targeted therapies for TNBC. Recent studies demonstrate that the androgen receptor (AR) is expressed in up to a third of TNBC. AR is highly expressed in the luminal AR (LAR) TNBC subtype but is also present in other TNBC subtypes and may present an opportunity for targeted therapy. We hypothesized that AR+ TNBC critically depend on AR and that AR inhibition will decrease tumor burden in preclinical models of breast cancer. To determine the extent to which AR+ TNBC depend on AR, we inhibited AR activity with enzalutamide (enza) and shRNAs in multiple TNBC subtypes. Treatment with enza significantly reduced baseline proliferation (p<0.05) and prevented AR nuclear localization in response to DHT in multiple TNBC cell lines. Likewise, AR knockdown significantly reduced proliferation (p<0.001) and increased apoptosis (p<0.001) compared to cells transduced with a non-targeting control. Microarray profiling and ELISA of TNBC lines treated with DHT and enza suggested that AR regulation of amphiregulin (p<0.05) is a mechanism by which AR influences proliferation in TNBC. In addition to reduced proliferation, AR knockdown or treatment with enza altered cellular morphology from stellate to round and significantly decreased migration (p<0.05) and invasion (p<0.001) of TNBC cell lines spanning multiple subtypes. In vivo, enza significantly decreased tumor volume (85%), increased apoptosis (60%), and reduced AR nuclear localization (50%) in a MDA-MB-453 xenograft model. Our findings suggest that AR influences both proliferation and invasion of AR+ TNBC cells regardless of TNBC subtype and provide promising preclinical data on the efficacy of enza in AR+ TNBC. Inhibition of AR by anti-androgens such as enza may represent an effective new opportunity for targeted therapy in TNBC.

 

Nothing to Disclose: VNB, ND, JKR

OR38-2 11599 2.0000 A Targeting Androgen Receptor Decreases Proliferation and Invasion in Preclinical Models of Triple Negative Breast Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 1:00:00 PM OR38 4769 11:30:00 AM Therapies for Cancer Oral

Ali A Pedram*1, Mahnaz Razandi2, Suzanne A Fuqua3, Ramesh Narayanan4, James Dalton5 and Ellis R Levin6
1Univ of CA-Irvine, Long Beach, CA, 2Long Beach VAMC, Long Beach, CA, 3Baylor Coll of Med, Houston, TX, 4GTX Inc, Memphis, TN, 5GTx, 6University of California-Irvine and the Long Beach VAMC, Long Beach, CA

 

Estrogen receptor beta (ERb) has been reported present in many human breast tumor specimens, both ERa positive and ER, PR, and ErbB2 triple negative cancers. We have found that endogenous ERb is mainly present in the mitochondria of several breast cancer epithelial cell lines. In mitochondria, ERb mediates the cell survival effects of estrogen when the sex steroid binds this receptor as an agonist in the setting of radiation (Mol Biol Cell, 2006) or the response to tamoxifen in animal models (Oncogene, 2013). Tamoxifen is effective as a cytotoxic agent in this malignancy when binding mitochondrial ERb as an antagonist, activating the intrinsic apoptotic pathway. We therefore investigated whether a selective ERb antagonist could cause cytotoxicity in Tamoxifen resistant MCF-7 cells and augment the cytotoxic actions of chemotherapy in breast cancer models. GTx 921 shows ~45-fold selective activity to compete off binding of labeled estradiol at ERb compared to ERa transfected/expressing CHO cells. In vitro, tamoxifen-resistant MCF-7 cells underwent a 10-fold increase in apoptosis upon culture with GTx921 compared to control or tamoxifen-incubated cells, with 70% of the cells dying by 48 hours. Cell death correlated to GTx921 causing a 5-fold increase in superoxide production (oxidative stress) compared to control, while Tam had no effects.  Upon inserting Tam-resistant cells into matrigel along with saline (control) or GTx921 (1nM) and then injecting into the flanks of nude mice, the control tumors grew to be 7-fold larger at 3 weeks, compared to the GTx21-exposed tumors. Only the latter tumors showed extensive TUNEL staining , Annexin V expression, and Caspase-7 cleavage. In additional experiments, exposing cultured MCF-7 cells to the chemotherapeutic agent, Taxol (0.1-1uM) produced significant apoptotic death, augmented ~50% by co-incubation with GTx921. Cell death seen with taxol at 0.1uM +GTx921 was equivalent to cell death from taxol 0.5uM, seen throughout the dose-response. The GTX921 effects were prevented by exposure to an ERb agonist (DPN) but not by an ERa agonist (PPT), indicating functional receptor specificity of GTx921. Thus, we conclude that an ERb antagonist has the potential to induce the death of tamoxifen-resistant breast tumors and also to augment the cytotoxic effects of established chemotherapy in malignant cells. The latter may allow lowering the dose of chemotherapy but maintaining cytotoxicity for this cancer.

 

Disclosure: RN: Researcher, Employee of GTx. JD: Researcher, Genentech, Inc.. Nothing to Disclose: AAP, MR, SAF, ERL

OR38-3 11604 3.0000 A A Selective Estrogen Receptor Beta Antagonist Reverses Tamoxifen Resistance and Augments Chemotherapy-Induced Cytotoxicity in Breast Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 1:00:00 PM OR38 4769 11:30:00 AM Therapies for Cancer Oral

Jordan M Reese*1, Vera J Suman1, Malayannan Subramaniam1, Xianglin Wu1, Vivian Negron1, Anne Gingery1, Kevin S. Pitel1, Sejal S Shah1, Heather E Cunliffe2, Ann E McCullough3, Barbara A Pockaj3, Fergus J Couch1, Janet E Olson1, Carol Reynolds1, Wilma L Lingle1, Thomas C Spelsberg1, Matthew P Goetz1, James N Ingle1 and John R Hawse1
1Mayo Clinic, Rochester, MN, 2Translational Genomics Research Institute, Phoenix, AZ, 3Mayo Clinic, Scottsdale, AZ

 

Estrogen receptor beta (ERβ), unlike ERα, classically functions as a tumor suppressor in vitro.  However, ERβ’s biological functions in vivo and predictive/prognostic value in breast cancer are controversial.  To begin to address these issues, we utilized a well characterized and validated ERβ specific monoclonal antibody to examine the expression profiles and prognostic value of this receptor in the following 3 cohorts: 1) a cohort with all breast cancer subtypes (n=184), 2) a prospective NCCTG adjuvant tamoxifen trial for postmenopausal women with ERα positive breast cancer with long-term follow-up (n=177) and 3) a cohort of 71 triple negative breast cancers (TNBCs).  These analyses revealed that about one-third of all breast tumors, regardless of sub-type, express nuclear ERβ and this expression was independent of ERα or HER2.  In the NCCTG 89-30-52 cohort, prolonged recurrence free interval was significantly associated with nuclear, but not cytoplasmic, ERβ protein expression.  Interestingly, in TNBCs, nuclear ERβ was expressed in approximately 24% of tumors.  Based on these data, we sought to further elucidate the biological functions of ERβ in breast cancer using multiple novel ERβ expressing cell model systems.  In the triple negative MDA-MB-231 cell line, expression of ERβ alone led to inhibition of proliferation and induction of apoptosis in response to estrogen and multiple ERβ specific agonists.  Similar effects were also observed in ERβ expressing triple negative Hs578T cells.  Conversely, these same treatments induced proliferation of ERβ-expressing MCF7 cells which endogenously express ERα.  However, ERβ expression did sensitize MCF7 cells to the anti-proliferative effects of anti-estrogens.  Microarray analysis and RT-PCR profiling of MDA-MB-231-ERβ cells revealed that estrogen and ERβ agonists markedly induced the expression of multiple cystatins, a family of small secreted cysteine protease inhibitors which function as tumor suppressors, and potently inhibited canonical TGFβ signaling.  Conditioned media isolated from estrogen or ERβ agonist treated MDA-MB-231-ERβ cells suppressed the proliferation rates and inhibited TGFβ signaling in other TNBC cell lines, effects that were completely reversed following the depletion of cystatins from the conditioned media.  Taken together, these data demonstrate that ERβ likely has value as a predictive and/or prognostic biomarker in breast cancer and suggest that therapeutic targeting of ERβ will have clinical benefit in multiple breast cancer sub-types.  However, the specific drug of choice is likely to vary based on ERα status.

 

Nothing to Disclose: JMR, VJS, MS, XW, VN, AG, KSP, SSS, HEC, AEM, BAP, FJC, JEO, CR, WLL, TCS, MPG, JNI, JRH

OR38-4 16912 4.0000 A Estrogen Receptor Beta: A Prognostic Biomarker and Novel Therapeutic Drug Target in Breast Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 1:00:00 PM OR38 4769 11:30:00 AM Therapies for Cancer Oral

Dana C Borcherding*, David F Barnard, Eric R Hugo, Sejal R Fox, Kathleen LaSance and Nira Ben-Jonathan
University of Cincinnati, Cincinnati, OH

 

Patients with advanced breast cancer often fail to respond to anti-hormonal treatment and/or to chemotherapy, creating an incentive to develop novel and effective treatments. Dopamine (DA) binds to five receptors (DAR), classified by the ability to increase (D1R and D5R) or decrease (D2R, D3R and D4R) cAMP levels. Fenoldopam (Fen) is a D1R agonist which does not penetrate the brain and is FDA-approved to treat renal hypertension.  The objectives were: 1) to determine if D1R is expressed in breast cancer cells (BCC) and carcinomas, and whether D1R expression correlates with disease severity, 2) to analyze effect of D1R agonists on cell viability and determine the signaling pathway(s) involved, and 3) to examine if Fen inhibits tumor growth in mice with xenografts. We discovered D1R expression, determined by PCR and western blotting, in aggressive BCC and primary tumors. Scoring of tissue microarrays by immunohistochemistry revealed moderate to strong D1R expression in 30% of 751 primary breast carcinomas. Such expression was associated with larger tumors, higher grades, and lymph node metastasis; D1R expression was undetected in 30 normal breast tissues.  Patients with D1R-expressing tumors had significantly shorter survival and recurrence-free survival. DA and three selective D1R agonists, but not a D2R agonist, reduced cell viability and inhibited cell invasion. The reduced cell viability was due to apoptosis, as determined by flow cytometry and TUNEL assay.  Unexpectedly,  Fen decreased intracellular cAMP while increasing cGMP. The role of the cGMP/protein kinase G (PKG) as mediators of D1R activation was supported by using PKG activators and inhibitors.  Fen induced rapid and dramatic suppression of tumor growth in mice with MDA-MB-231 xenografts. Tumor suppression was due to a combined effect of Fen on apoptosis and necrosis. Fluorescence imaging, following injection of anti-D1R antibody conjugated to a fluorescent marker, revealed location of tumors and metastases in mice with xenografts. In conclusion, D1R overexpression in breast cancer is associated with advanced disease and poor prognosis. The D1R agonist Fen induced apoptosis in vitro through the cGMP/PKG pathway, and caused marked inhibition of tumor growth in mice. These data suggest that D1R analysis in tumor biopsies could serve as a prognostic biomarker for advanced breast cancer. Fen should be exploited as a novel therapeutic agent in patients who do not respond to standard therapy.

 

Nothing to Disclose: DCB, DFB, ERH, SRF, KL, NB

OR38-5 15163 5.0000 A Expression and Therapeutic Targeting of Dopamine Receptor Type-1 in Breast Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 1:00:00 PM OR38 4769 11:30:00 AM Therapies for Cancer Oral

Kerstin Knoop1, Andrea Maria Mueller1, Kathrin A Schmohl2, Nathalie Schwenk1, Janette Carlsen2, Marcus Hacker2, Burkhard Göke2, Ernst Wagner3, Peter J Nelson2 and Christine Spitzweg*1
1University Hospital of Munich, Germany, 2University Hospital of Munich, Munich, Germany, 3Ludwigs-Maximilians-University, Munich, Germany

 

The tumor-homing property of mesenchymal stem cells (MSCs) has lead to their use as delivery vehicles for therapeutic genes. The application of the sodium iodide symporter (NIS) as reporter and therapy gene allows non-invasive imaging of MSC biodistribution and functional transgene expression by 123I-scintigraphy or PET-imaging, as well as therapeutic application of 131I. Hypoxia-inducible factor 1 (HIF-1) is a key mediator of the cellular response to hypoxia and therefore highly expressed in solid malignancies. Placing NIS under the control of the HIF-1-promoter should consequently allow tumor-specific NIS expression after MSC-mediated delivery.

We stably transfected human MSCs with NIS driven by the HIF-1 promoter (HIF-NIS-MSCs) and analyzed functional NIS expression by iodide uptake assay, Western blot and FACS analyses. We further investigated distribution and tumor recruitment of HIF-NIS-MSCs by 123I-scintigraphy and 124I-PET imaging in subcutaneous and intrahepatic HCC (Huh7) xenograft models.

After hypoxia was simulated in vitro by treatment of HIF-NIS-MSCs with 300 µM of the hypoxia simulating agent CoCl2, a 48-fold increase in perchlorate-sensitive iodide uptake was observed compared to HIF-NIS-MSCs under normal conditions. Western blot and FACS analyses confirmed CoCl2-induced NIS expression in HIF-NIS-MSCs. After establishment of subcutaneous and intrahepatic HCC xenografts in nude mice, HIF-NIS-MSCs were injected i.v. three times in four day-intervals and MSC distribution was analyzed by γ-camera imaging and 124I-PET imaging 48 hours after the last MSC injection. Injection of 18.5 MBq 123I resulted in a tumor-selective iodide accumulation showing active MSC recruitment and tumor-specific promoter activation in both tumor models. To increase the resolution in the intrahepatic xenografts, 124I-PET imaging was performed. 48h after the last HIF-NIS-MSC injection, 12 MBq 124I were applied and iodide accumulation was detected in the area of the primary tumor which confirmed the data of the γ-camera imaging.

Our results demonstrate selective recruitment of HIF-NIS-MSCs into HCC tumors resulting in tumor-specific iodide accumulation, opening the exciting prospect of NIS-mediated radionuclide therapy of extrathyroidal tumors after MSC-mediated gene delivery.

 

Nothing to Disclose: KK, AMM, KAS, NS, JC, MH, BG, EW, PJN, CS

OR38-6 16868 6.0000 A In Vivo Imaging of Mesenchymal Stem Cell Recruitment into the Tumor Stroma of Hepatocellular Carcinoma (HCC) Using a HIF-Specific Sodium Iodide Symporter (NIS) Gene System 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 1:00:00 PM OR38 4769 11:30:00 AM Therapies for Cancer Oral

Wann Jia Loh*1, Lih-Ming Loh1, Xiao Li Zhao2, Dawn Shao Ting Lim1 and Peng Chin Kek3
1Singapore General Hospital, Singapore, Singapore, 2Singapore General Hospital, 3Singapore General Hosp, Singapore, Singapore

 

Adrenal venous sampling (AVS) is the gold standard procedure for lateralisation of aldosterone hypersecretion in primary aldosteronism. As there is scant literature of the experience of AVS in South East Asia, we reviewed the results in our hospital. The records of all patients who underwent AVS in Singapore General Hospital from January 2003 to November 2013 were reviewed retrospectively.

Adrenal vein cannulation was regarded as successful if adrenal-peripheral cortisol ratio was >5.   Positive lateralisation was defined as lateralised ratio (LR) ≥ 4 and/or contralateral ratio (CR) of <1. ACTH infusion was used in 79/81 (97.5%) patients. Baseline characteristics, indication for testing, number of antihypertensives used, radiological and laboratory results were recorded.  Clinical improvement was defined as resolution of hypertension or reduction of antihypertensives.

All 81 patients who underwent AVS were included. Indications were hypertension with hypokalemia (76.5%), adrenal incidentaloma (14.8%), young hypertensives (4.9%), and poorly controlled hypertension (3.7%).   Mean age was 54±8.3 years. Computed tomography showed adrenal mass at left (64.2%), right (24.7%), and bilateral (4.9%). Cannulation success rate was 45/81(55.6%) for bilateral, 46/81(57.8%) for right, and 76/81(93.8%) for left.

Forty out of 80 patients underwent unilateral adrenalectomy with one lost to follow up. Complete resolution of hypertension was seen in 16/39(41.0%) and reduction of antihypertensives in 37/39 (94.9%). Post-adrenalectomy, renin-aldosterone biochemistry normalized in 23/25(92%) of patients. Resolution of hypokalemia occurred in all except one.

Patients with bilateral successful cannulation were analyzed: Group A with positive LR and CR (n=20); Group B with positive CR but negative LR (n=8); Group C with positive LR but negative CR (n=1); Group D with negative LR and CR (n=5); Group E with invalid LR or CR because aldosterone assayed was not diluted to absolute levels (n=11). In Group A, 100% had clinical improvement in blood pressure post-adrenalectomy. In Group B, 4/8 patients underwent surgery with clinical improvement in 3/4(75%).  In this group, CR <1 was used to aid decision for surgery, with LR between 2 and 4. Patients in Group C and D did not undergo surgery. In Group E, 5/6 patients underwent surgery, with 100% clinical improvement.

Of those with unsuccessful AVS, 17/36 (47.2%) patients underwent surgery. Clinical improvement was seen in all except one patient who had cavernous hemangioma on histology. Among them, six with failed right sided cannulation underwent surgery guided by positive CR. Clinical improvement post-surgery was seen in 5/6 (83%).

Bilateral cannulation was met with moderate success in our single center at 55.6%. However, in patients suitable for surgery, there was a good clinical improvement rate in 94.9%, with complete resolution of hypertension in 41%.

 

Nothing to Disclose: WJL, LML, XLZ, DSTL, PCK

14242 2.0000 MON-0768 A Results of Adrenal Venous Sampling for Primary Aldosteronism and Clinical Outcomes after Adrenalectomy in Singapore : Ten Years' Experience in a Tertiary Hospital 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Juan Pablo Brito*1, Noor Asi2, Michael R. Gionfriddo1, Catalina Norman1, Aaron Leppin2, Claudia Zeballos-Palacios2, Chaitanya Undavalli2, Chaitanya Undavalli2, Zhen Wang1, Juan P. Domecq2, Gabriela Prustsky2, Tarig A Elraiyah2, Larry L Prokop2, Victor M Montori1 and Mohammad Murad1
1Mayo Clinic, Rochester, MN, 2Mayo Clinic

 

Background:  Computed tomography (CT) and magnetic resonance imaging (MRI) are the major imaging modalities used for the localization of catecholamine –producing tumors (pheochromocytoma and paraganglioma). Functional imaging (FI) offers an alternative approach to localize, evaluate, and stage these tumors.

Objective: Our objective was to describe the additive benefit of FI studies for patients with pheochromocytoma and paraganglioma (PPGs) who have undergone MRI or CT scan evaluation.

Methods: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus through June 2012 for  studies that included patients with biochemically proven PPGs who underwent CT or MRI and additional FI for the localization of PPGs.

Results: We included 32 studies enrolling a total of 1264 patients with a mean age of 43 years old. The studies were uncontrolled and evaluated six FI modalities.  FI tests provided small additive value to CT/MRI aiding in the localization of only 24/1445 primary cases (1.4%) and 28/805 metastatic cases (3.5%). In metastatic cases, 6-[F-18]Fluoro-L-Dihydroxyphenylalanine (DOPA) and Flurodopamine-PET (FDA) were the FI tests  most successful at identifying disease missed by CT/MRI, providing additional benefit in 6/60(10%) and 5/78(6.4%) cases, respectively. No clinically significant findings were observed in any of the predefined subgroups. No study evaluated the impact of FI on the completeness of surgical resection or other patient-important outcomes.

Conclusions: Observational evidence suggests that FI tests have limited additional role in patients with PPGs who have undergone CT/MRI evaluation. However, the role of FI tests in specific subgroups of patients with atypical presentations (metastatic, extra-adrenal) should be explored. Further research should also evaluate the impact of FI tests in achieving outcomes that matter to patients.

 

Nothing to Disclose: JPB, NA, MRG, CN, AL, CZ, CU, CU, ZW, JPD, GP, TAE, LLP, VMM, MM

14587 7.0000 MON-0773 A The Incremental Benefit of Functional Imaging in Pheochromocytoma/Paraganglioma: A Systematic Review 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Zakariae Bram*1, Estelle Louiset2, Bruno Ragazzon3, Sylvie Renouf1, Marthe Risk-Rabin4, Rossella Libe5, Jacques Young6, Marie-Christine Vantyghem7, Antoine Martinez8, Constantine A Stratakis9, Jerome Yves Bertherat10 and Herve Lefebvre11
1INSERM U982, Institute for Biomedical Research and Innovation, University of Rouen, Mont Saint Aignan, France, Mont Saint Aignan, France, 2Normandie University, UNIROUEN, INSERM U982, Laboratoire Différenciation et Communication Neuronale et Neuroendocrine, ROUEN, France, 3INSERM U 1016, CNRS 8104, Institut Cochin, Paris Descartes University, Paris, France, 4INSERM U1016, University Paris V, Cochin Institute, Paris, France, Paris, France, 5INSERM Unité 1016, Centre National de la Recherche Scientifique Unité Mixte de Recherche 8104, Institut Cochin, Paris, France, 6University Paris Sud, Department of Endocrinology, Bicetre Hospital, INSERM U693, Le Kremlin-Bicêtre, Fance, Le Kremlin Bicêtre, France, 7Department of Endocrinology, Lille Regional University Hospital, INSERM U859, Lille2 University, Lille, France, Lille Cedex, France, 8CNRS UMR6247, INSERM U931, Gred, Clermont Université, Aubière, France, Aubiere, France, 9National Institutes of Health, Bethesda, MD, 10INSERM U 1016, Cochin Institute, Paris Descartes University, Paris, France, 11Institute for Biomedical Research and Innovation, University Hospital of Rouen, Rouen, France

 

In the normal adrenal gland like in some macronodular adrenal hyperplasia tissues, serotonin (5-HT) stimulates cortisol secretion through a paracrine mechanism. The aim of the present study was to investigate in vitro the role of 5-HT in the physiopathology of cortisol hypersecretion in PPNAD. Thirty-five PPNAD tissues were studied by using molecular, immunohistochemical and pharmacological approaches. RT-PCR revealed overexpression of the genes encoding tryptophan hydroxylase (TpH), the key enzyme of 5-HT synthesis, and the 5-HT4, 5-HT6 and 5-HT7 receptors in comparison with normal adrenals. 5-HT was detected in hyperplastic nodules and in the medium of PPNAD cultured cells. Incubation of tissue fragments with a TpH inhibitor significantly reduced cortisol secretion. 5-HT dose-dependently increased cortisol production by PPNAD cells derived from 7 patients, with higher potency and efficacy than in normal adrenocortical cells. 5-HT was also able to increase expression of the CYP11B1 gene, which encodes the steroidogenic enzyme 11alpha-hydroxylase, in PPNAD cells. The PKA inhibitor H-89 and 5-HT4, 5-HT6 and 5-HT7 receptors antagonists inhibited the stimulatory effect of 5-HT on cortisol production. 5-HT4 and 5-HT7 receptor expression was positively regulated by the PKA pathway in the PPNAD cell line CAR47.01. In most patients, PPNAD results from inactivating mutations of the PRKAR1A gene which cause enhancement of the PKA pathway. In the adrenocortical cell line H295R, inhibition of PRKAR1A gene expression by use of PRKAR1A shRNA markedly stimulated expression of tryptophan hydroxylase, 5-HT4, 5-HT6 and 5-HT7 receptors at mRNA and protein levels. The stimulatory effect of PRKAR1A shRNA on gene expression was blocked by H-89. We have investigated the role of the transcription factor Sp1 in the stimulation of TpH and 5-HT receptor expression by PKA in PPNAD cells. Sp1 mRNA was expressed in PPNAD tissues and the phosphorylated form of the Sp1 protein was detected in the adrenal micronodules. In H295R cells, the stimulatory effect of PRKAR1A shRNA on TpH and 5-HT receptor expression was inhibited by Sp1-interfering RNA (Sp1 siRNA). Taken together, our results show that, in PPNAD tissues associated with Cushing’s syndrome, activation of the PKA pathway triggers formation of an illicit serotonergic regulatory loop through transcriptional mechanisms involving the transcription factor Sp1.

 

Nothing to Disclose: ZB, EL, BR, SR, MR, RL, JY, MCV, AM, CAS, JYB, HL

14780 8.0000 MON-0774 A Role of Sp1 in cAMP-Dependent Transcriptional Regulation of the Serotonergic Signaling Pathway in Primary Pigmented Nodular Adrenal Disease (PPNAD) Tissues Associated with Cushing's Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Paola Chrysostomou1, Maya Beth Lodish*2, Evrim Turkbey2 and Constantine A Stratakis3
1NICHD, NIH, 2National Institutes of Health, Bethesda, MD, 3National Institutes of Health (NIH), Bethesda, MD

 

Primary pigmented adrenocortical disease (PPNAD) is a rare ACTH-independent cause of Cushing’s syndrome (CS). PPNAD may be an isolated condition, or it may be associated with Carney’s complex (CNC), a multiple endocrine neoplasia syndrome characterized by spotty skin pigmentation, myxomas, and endocrine overactivity. Accurate assessment of adrenal gland volume has been difficult due to the gland’s convoluted structure and overall small size in PPNAD. 3-D volumetric imaging can potentially be useful to assess adrenal pathology, especially in PPNAD. Previous radiologic description of the adrenals in PPNAD have ranged from normal size to a combination of nodular and atrophic glands with occasional macronodules. We aimed to further characterize the radiologic phenotype in patients with PPNAD using 3D CT volumetric analysis, comparing adrenal volumes in individuals with and without CS in the context of PPNAD, as well as in normal controls.  We hypothesized that patients with active CS would have larger adrenal gland volume.  Forty-eight patients  (26 females, average age 28.4 ± 18.2 years) and 8 controls (19± 3 yr) were evaluated via 1-2.5 mm slice thickness adrenal CT for possible PPNAD based on clinical suspicion and/or family history between 1/2007 to 7/2013. Nineteen were pediatric patients (< 18). Thirteen (27%) harbored a mutation in PRKAR1A on 17q22-4. CT scans were used to create 3-dimensional models of each adrenal gland by contouring the adrenal gland in each slice using Vitrea Core Fx v6.3software (Vital Images, Minnetonka, Minnesota). The software calculated the total adrenal gland volume by multiplying the total area by slice thickness. Biochemical diagnosis of CS was performed with diurnal cortisol, ACTH measurements, and a 6-day low and high dose dexamethasone suppression test (Liddles test) measuring 24-hour urinary free cortisol (UFC) and urinary 17-hydroxysteroids (17-OHS). Criteria for CS included a paradoxical increase in UFC and/or 17-OHS between baseline and day 6 of the Liddle’s test, loss of diurnal variation of cortisol, elevated UFC, and/or midnight cortisol ≥4.4 μg/dl in children and ≥7.5 μg/dl in adults.  Thirty-nine patients met the diagnostic criteria for active CS. The total adrenal volume in those patients was 7.9cc ± 4.1. The mean adrenal volume for patients without florid CS was 5.4cc ± 2.6 (p value = 0.023). Mean adrenal volume in 8 normal controls was not statistically different, at 8cc ± 1.6. The mean total adrenal volumes were corrected for body surface area (BSA); for the patients with CS, the mean was 10.2cc/m2 ± 4.5 compared to 6.8cc/kg/m2 ± 2.9 for those without CS (p value = 0.037). We conclude that adrenal volume in patients with CS and PPNAD is larger than those with PPNAD alone, even when corrected for BSA. Although adrenal volume in PPNAD may be normal, volumetric CT may be useful in the detection of individuals with PPNAD associated with active CS.

 

Nothing to Disclose: PC, MBL, ET, CAS

12881 9.0000 MON-0775 A Use of 3-Dimensional Volumetric Modeling of Adrenal Gland Size in Patients with Primary Pigmented Nodular Adrenocortical Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Ikki Sakuma*, Akina Shiga, Seiichirou Higuchi, Tomoko Takiguchi, Hidekazu Nagano, Naoko Hashimoto, Sawako Suzuki, Hisashi Koide, Tomohiko Yoshida, Koutaro Yokote and Tomoaki Tanaka
Chiba University Graduate School of Medicine, Chiba, Japan

 

Context

 123I-metaiodobenzylguanidine (MIBG) scintigraphy and 18F-fluoro-2-doxy-D-glucose (FDG) positron emission tomography (PET) are useful for the localization of pheochromocytoma. Uptake of radioisotopes might be mediated by expression of transporters correlated with tumor cell differentiation.

Objective

We investigated correlation functional imaging results with the expression profiles of several transporters and transcription factors related to development of chromaffin cells in pheochromocytoma.

Methods

Sixty-two patients had confirmed pheochromocytoma. Endocrinological findings and functional imaging results were collected for all subjects. Resected tumors were examined by real time PCR for expression of transporters and other markers.

Results

Sensitivities of MIBG and FDG-PET were 90% and 73% respectively. The norepinephrine transporter (NET) expression in MIBG-negative tumors significantly lower than that in MIBG-positive tumors. The glucose transporter 1 (GLUT1) in FDG-PET-negative tumors significantly lower than that in FDG-PET-positive tumors. The expression of phosphatidylethanolamine N-methyltransferase (PNMT) correlated with the ratio of urinary metanephrine excretion (UMN)/ urinary normetanephrine excretion (UNMN). The expression of tyrosine hydroxylase (TH) correlated with the UMN+UNMN. The expression of glucocorticoid receptor (GR) correlated with NET, catecholamine synthases and some transcription factors related to development of chromaffin cells. Gene expression analysis of primary culture cells demonstrated that the dexamethasone treatment markedly increased the induction of NET, catecholamine synthases and insulinoma associated-1 (INSM1) which regulated chromaffin cells differentiation.

Conclusions

Uptake of MIBG and FDG-PET in pheochromocytomas correlated with the expression of NET and GLUT1 respectively. Combination of MIBG and FDG-PET contribute to increase of sensitivity for localizing pheochromocytoma. Our investigation also suggested that the expression of NET might correlated with the expression of GR and INSM1.

 

Nothing to Disclose: IS, AS, SH, TT, HN, NH, SS, HK, TY, KY, TT

15267 10.0000 MON-0776 A Characterization of Transporter Expression in Pheochromocytomas: A Correlation with MIBG Scintigraphy and FDG-PET 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Susmeeta T. Sharma*1, Ninet Sinaii2 and Lynnette K. Nieman2
1Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 2National Institutes of Health, Bethesda, MD

 

Background: Ketoconazole (KTZ) and Metyrapone (MET) can treat hypercortisolemia in Cushing’s syndrome (CS). We evaluated the long-term efficacy and safety of combination treatment (Rx) with KTZ and MET (K+M) in CS.

Methods: Retrospective study of all CS patients (pts) treated at some point with K+M (1982-2012). Pts with ACTH-dependent CS were classified as ectopic ACTH syndrome (EAS) or Cushing’s disease (CD) based on pathology, or as ‘occult’ if testing suggested EAS but no tumor was found. Urine free cortisol (UFC), morning serum cortisol (F), alkaline phosphatase (AP), AST and ALT values before initiation and dose change and on the final dose were characterized as percentage of upper limit of normal (%ULN). Change in variables (before and on final K+M dose) was analyzed using Wilcoxon signed rank, McNemar or paired Student’s t-test. Eucortisolemia was defined as a normal UFC or F ≤48%ULN (≤12 mcg/dl).

Results: 59 CS pts (CD=12, EAS=31, Occult=14, Adrenal=2) received K+M, 8 (13.6%) were on block and replace Rx. Mean age at presentation was 42.4±14.3 years, 33 (56%) were females and 47 (80%) were non-hispanic whites. Baseline median (IQR) UFC was 1317.4 %ULN (523.2-5088.9), AP 69.8 %ULN (48.3-86.2), AST 75.0 %ULN (50.0-126.5) and ALT 112.2 %ULN (61.0-198.7). Median final KTZ dose was 1200 (range 200-1800) mg/day, final MET dose was 1500 (range 500-4000) mg/day and median duration of Rx was 24 (range 3-1503) days. UFC (P=0.008) and F (P<0.0001) levels decreased on K+M Rx. 32 (54%) pts were eucortisolemic at some point (on any K+M dose combination) and 26 (45%) were eucortisolemic on the final K+M combination dose. Systolic blood pressure (BP) (P=0.0002) and fasting plasma glucose (P=0.046) decreased and fewer pts had diabetes (P=0.025) or required ≥ 2 anti-hypertensive medications (P=0.046) on K+M. Weight, diastolic BP, potassium, total cholesterol, AP, AST and ALT levels and the proportion of pts with hypertension remained unchanged (P=NS). There was no difference in KTZ and MET dose (initial, max or final) or the type of CS between responders (pts eucortisolemic on final dose) and non-responders. Adverse events occurred in 28 (48%) pts and included adrenal insufficiency (n=6), gastrointestinal symptoms (n=9), hepatic dysfunction (n=12), new/worsening HTN (n=2), and hypokalemia (n=1).

Conclusion: K+M combination Rx effectively decreases cortisol levels in CS. A substantial number of pts may require additional Rx modalities to achieve eucortisolemia.

 

Nothing to Disclose: STS, NS, LKN

16532 11.0000 MON-0777 A Combination Treatment with Ketoconazole and Metyrapone in Cushing's Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Kiyotaka Itcho*1, Kenji Oki1, Kazuhiro Kobuke1, Rui Kishimoto1, Shusaku Maeda1, Haruya Ohno1, Masayasu Yoneda2 and Nobuoki Kohno1
1Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan, 2Institute of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan

 

Background: Somatic mutations of KCNJ5, ATP1A1, ATP2B3, or CACNA1D were found in some aldosterone producing adenomas (APAs). Each mutant stimulates different intracellular signal cascade which influence cell volume, cell proliferation, tumor progression or aldosterone production. Therefore, the aims of our study were to clarify pathological findings such as ZG and ZF like cells and compare aldosterone production levels among different genotypes.

Methods: We evaluated 39 patients with APA who were operated at Hiroshima University Hospital. Tumor DNA from APA tissue and peripheral DNA were extracted, and PCR based direct sequence of KCNJ5, ATP1A1, ATP2B3, and CACNA1D was performed. We measured basal aldosterone levels and plasma renin activity. mRNA and protein levels of CYP11B2 in APA were detected by real-time PCR and immunohistochemistry.

Results: 26 and 5 patients with APA had KCNJ5 and ATP1A1 somatic mutation, respectively. No patient showed ATP2B3 or CACNA1D mutation. In 26 APA with KCNJ5, the pathological findings of 21 were primarily composed of ZF-like cells, whereas those of 5 had similar percentage composition of ZF-like cells and ZG-like cells. The pathological findings of 4 APA with ATP1A1 mutation were primarily composed of ZG-like cells, whereas the other was similar percentage composed of ZF-like cells and ZG-like cells. No mutations were obtained in 8 APA. 4 APA were primarily composed of ZF-like cells, 2 APA were primarily composed of ZG-like cells and 2 APA had similar percentage composition of ZF-like cells and ZG-like cells. The basal plasma aldosterone levels, plasma renin activity, mRNA and protein levels of CYP11B2 had no differences among the 3 group such as mutant KCNJ5, mutant ATP1A1 and no mutation.

Conclusion: We identified that APA with ATP1A1 mutation was mainly composed of ZG like cells, and had higher ratio of ZG like cells compared to APA with KCNJ5 mutation or without any mutations. In addition, we found that higher ratio of ZF like cells in APA with KCNJ5 than that with other type of cells. On the other hand, no relationship of plasma aldosterone levels, or CYP11B2 expression were observed among genetic variations of APA.

 

Nothing to Disclose: KI, KO, KK, RK, SM, HO, MY, NK

16605 12.0000 MON-0778 A The Relationship Between Tumor Genotype and Clinical or Pathological Characteristics in Patients with Aldosterone Producing Adenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Rene Baudrand*1, Linda Wiinberg2, Gail K. Adler2, Justine Barletta2, Jennifer Chan3, Toni Choueiri3, Robert G Dluhy2, Aymen Elfiky4, Ole-Petter Riksfjord Hamnvik5, Matthew Kulke6, Irene Rainville4, Huma Q Rana4, Daniel T Ruan2, Aditi Saxena7, Ellen W. Seely7, Paul Shyn8, Amy E Steele2, Gordon H Williams2 and Anand Vaidya9
1Pontificia Universidad Catolica de Chile, Santiago, Chile, 2Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 3Dana-Farber Cancer Institute, Boston, MA, 4Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 5Brigham and Women's Hospital, Boston, MA, 6Dana-Farber Cancer Institute, 7Brigham & Women's Hospital, Boston, MA, 8Brigham and Women's Hospital, Harvard Medical School, MA, 9Brigham and Women’s Hospital/Harvard Medical School, Boston, MA

 

Context:Our Center for Adrenal Disorders includes a team of endocrinologists, oncologists, surgeons, interventional radiologists, pathologists, and geneticists. Our mission is to offer patients integrated, expert, and compassionate care for their specific disease. 

Aim: We evaluated patients with adrenal diseases for reductions in quality of life (QoL) and/or mood-related symptoms and for potential benefit from our integrated multi-disciplinary care model.

Methods:We administered validated instruments to assess QoL (CDC-HRQoL, CARES, SF12) and well-being (PHQ9) to all patients in our Center: every 6-12 months for patients with benign disorders, and every 3 months for patients with malignant diseases. We categorized patients into 3 groups: 1) Benign Non-Functional tumors (BNF); 2) Actively treated Benign Hormonal Disorders (BHD) (ie: primary hyperaldosteronism, Cushing’s syndrome, congenital adrenal hyperplasia [CAH], Addison’s, adrenal insufficiency); and 3) Malignant or metastatic diseases (MALIG) (ie: adrenal cortical carcinoma [ACC], metastatic pheochromocytoma-paraganglioma syndromes [PPS], metastases to the adrenal gland). We evaluated the relationship between diagnosis category and QoL outcomes using regression models adjusted for age, race, and gender.

Results:160 patients were evaluated with questionnaires over 1.5 years with the following distribution per category: BNF=36%, BHD=43%, MALIG=21%. The distribution of overall diagnoses included 107 adrenal masses (65 < 4cm; 42 > 4cm), 28 primary hyperaldosteronism, 20 Cushing’s syndrome, 32 PPS, 22 ACC, 11 CAH, 40 Addison’s/adrenal insufficiency, and 9 metastases to the adrenal. BNF and BHD had similar numbers of unhealthy days assessed by CDC-HRQoL (8±10 d vs 10±12 d, p=0.61) whereas the MALIG group had significantly more (20±12 d, p<0.001). Cancer related QoL score (CARES) showed similar results between BNF and BHD groups, but scores in MALIG were 50% higher (p<0.001). Consistently, well-being assessed by PHQ9 showed similar scores between BNF and BHD (4.0±4.2 vs 4.6±5.5, p=0.97) while the MALIG group had many more mood-related symptoms (8.0±4.9 p=0.013) and a higher odds of depressive symptoms (PHQ9>5) compared to BNF (OR=5.3 [1.4-21.1], p=0.017). Patients in all 3 groups self-reported improvements in their mood and confidence (+20-30%) post-evaluation by physicians in our Center (p<0.001).

Conclusion: In an integrated multidisciplinary adrenal center, patients with actively treated benign adrenal functional disorders have similar QoL and well-being as those with non-functional adrenal tumors. Malignant adrenal diseases significantly worsen QoL and mood; however, patients with adrenal disorders across the entire spectrum of neoplastic and hormonal diseases perceive benefit from a specialized multi-disciplinary center.

 

Nothing to Disclose: RB, LW, GKA, JB, JC, TC, RGD, AE, OPRH, MK, IR, HQR, DTR, AS, EWS, PS, AES, GHW, AV

13020 13.0000 MON-0779 A Evaluation of Quality of Life and Well-Being of Patients with Adrenal Disorders in the Setting of an Integrated Multi-Disciplinary Care Model 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Donovan Tay*1 and Joan J C Khoo2
1Changi General Hospital, Singapore, Singapore, 2Changi General Hospital, Singapore

 

Primary aldosteronism is associated with higher risk of cardio- and cerebrovascular events,. In Caucasian populations, aldosterone excess results in a 4-fold risk of stroke, 6- fold risk of myocardial infarction and 12-fold risk of atrial fibrillation1 and that cardiovascular complications are more prevalent in the hypokalemic variant.2 We aimed to identify risk factors associated with vascular complications in adults in a multi-ethnic Asian population in Singapore. 

This is a retrospective study of 73 patients (51± 11 years, range 17 to 77) with primary aldosteronism who presented to our hospital between 1998 to 2012 and were followed up with a mean duration of 3.8 ± 3 years. Clinical and biochemical data were obtained at baseline and the latest visit. The population was 67% male (n = 49), and predominantly Chinese (78%) with 19% Malays and 2% of other races. 37.0% had an aldosterone producing adenoma who underwent adrenalectomy, 15.1% were treated medically for bilateral adrenal hyperplasia, while 47.9% remained unclassified and treated medically. 

The overall prevalence of vascular events was 34.2% (n =  25). Cardiovascular events (angina pectoris, myocardial infarction, coronary angioplasty) occurred in 13.7%, atrial or ventricular arrhythmias in 13.7 %, ischaemic or haemorrhagic stroke in 20.5%, and aortic dissection in 2.7%.

Patients having vascular complications were significantly older at presentation as compared to those without (57 ± 10 vs 48 ± 11 years, p=0.002), and were more likely to be  male (odds ratio OR = 2.57; 95% confidence interval [CI] 0.99 to  6.66) and of Malay ethnicity (OR = 2.37; 95% CI 1.34 to 4.20). Serum creatinine was higher at diagnosis (101 ± 43 vs 81 ± 20 umol/L, p=0.037), and duration of hypertension longer (12.2 ± 8.1 vs. 7.3 ± 6.5 years), in patients with complications compared to those without. Pretreatment systolic (169 ± 30 vs 158 ± 28 mmHg) and diastolic (91 ± 12 vs 8 ± 18 mmHg) blood pressure, aldosterone (956 ± 649 vs 888 ± 696 pmol/L) and serum potassium (2.93 ± 0.86 vs. 2.79 ± 0.62 mmol/L) were not significantly different between patients with and without complications. Age, gender and Malay race were significant (p < 0.01) risk factors for vascular complications in multivariate analysis. Malay ethnicity was a significant predictor of complications when corrected for age and gender based on logistic regression models.

Greater vigilance for vascular complications may be advisable in Malay patients with primary aldosteronism during follow up.

 

Nothing to Disclose: DT, JJCK

13213 14.0000 MON-0780 A Cardio and Cerebrovascular Complications in Patients with Primary Aldosteronism from an Asian Perspective 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Juan Pablo Brito*1, Noor Asi2, Irina Bancos3, Michael R. Gionfriddo1, Claudia Zeballos-Palacios2, Chaitanya Undavalli2, Zhen Wang1, Juan P. Domecq2, Gabriela Prustsky2, Tarig A Elraiyah2, Larry L Prokop2, Victor M Montori1 and Mohammad Murad1
1Mayo Clinic, Rochester, MN, 2Mayo Clinic, 3Mayo Clinic, MN

 

Background:  The presence of germline mutations in patients with sporadic pheochromocytoma and paraganglioma (SPP) may change the management of both index cases and family members. However, the frequency of germline mutations in sporadic SPP is still unknown.

Objective: To describe the frequency of germline mutations in SPP and determine the value of testing the index patient and their family members for these mutations.

Methods: We searched databases through June 2012 for observational studies of patients with sporadic and biochemically proven pheochromocytoma (PCC) or paraganglioma (PG) who underwent germline genetic testing. The criteria to define sporadic tumors was: the absence of a family history of PCC/PG, syndromic features, bilateral or metastatic disease.

Results: We included 31 uncontrolled case series including 5031 patients (mean age 44). These patients received tests for any of these ten mutations: SDHAF2, RET, SDHD, SDHB, SDHC, VHL, TMEM127, MAX, IDH, and NF1. The frequency of germline mutation in SPP was 552/5031 or 11%; when studies with patients fulfilling 4 criteria for sporadic tumors were used the frequency was 171/1332 or 13%. The most common germline mutation was SDHB 167/3611 (4.6%), followed by SDHD 125/3738 (3.3%). Minimal outcome data were available regarding the benefits of testing in index cases and family members. One study found 2 new cases of PCC/PG in 37 family members of the index cases. Another study was able to identify syndromic lesions in 31 of the 66 patients with SPP and germline mutations.

Conclusions:  The prevalence of germline mutations in SPP is approximately 11-13% with the most common mutations affecting less than 1 in 20 patients. The value of testing for germline mutations in patients with SPP and their family members is unknown, as the balance of potential benefits and harms, remains unclear.

 

Nothing to Disclose: JPB, NA, IB, MRG, CZ, CU, ZW, JPD, GP, TAE, LLP, VMM, MM

14621 15.0000 MON-0781 A Testing for Germline Mutation in Sporadic Pheochormocytoma/Paraganglioma: A Systematic Review 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Agostino De Venanzi*1, Geneviève Oligny-Longpré2, Isabelle Bourdeau3 and Andre Lacroix4
1Centre hospitalier de l'Universite de Montreal, Montreal, QC, Canada, 2Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada, 3Centre hospitalier de l’Université de Montréal (CRCHUM), Montreal, QC, Canada, 4Centre hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada

 

Background: Several aberrant G-protein coupled receptors (GPCR) can regulate cortisol secretion in primary bilateral macronodular adrenal hyperplasia (BMAH) and unilateral adenomas (CSA). The criteria utilized for response to in vivo tests were arbitrarily based on the % of maximal cortisol increase: partial: 25-49%, positive: >50% following stimulation. It is unclear if the same criteria are appropriate for patients with Cushing’s syndrome (CS) or with sub-clinical CS (SCS defined as normal UFC but subnormal suppression of cortisol post dexamethasone). 

Objective: Retrospective analysis of data from patients with primary BMAH or CSA either with CS or SCS tested for aberrant GPCR. 

Patients and Methods: 70 patients (54 F, 16 M) with primary causes of CS (n: 21) or SCS (n: 49) with unilateral (n: 14) or bilateral (n: 56) lesions were studied. A systematic in vivo screening protocol was performed under dexamethasone suppression in SCS patients. Plasma cortisol and ACTH were measured basally and every 30 min during upright posture, mixed meal, or stimulation with ACTH 1-24, GnRH, TRH, arginine-vasopressin (AVP), glucagon and metoclopramide. Additional tests were performed in specific cases. 

Results: Based on cortisol increase ≥25%, at least one aberrant GPCR (excluding plasma ACTH increase and response to ACTH 1-24) was present in 89.8% of SCS (95% bilateral and 66.7% unilateral) and in 66.7% of CS (81.2% bilateral and 20% unilateral). Cortisol increase following 250 mcg ACTH iv was higher in SCS than in CS (539%±392 vs 231%±208 (p=0.002), while peak cortisol level was similar (1040±416 vs 932±767; p=0.56). In CS, patients with cortisol increase ≥25% always had a minimal increase of cortisol > 100 nmol/l. In SCS, an increase in cortisol ≥ 100 nmol/l was coupled with at least 100% increase, irrespective of basal hormone value. The use of ≥50% cortisol cut-off increase for SCS resulted in 77.6% positivity (87.5% bilateral and 44.4% unilateral); the overall number of positive tests fell from 101 to 66. SCS displayed one, two or three positive responses in 44.8%, 34.2% and 21%; 35.7% of CS showed one, 28.6% two or three, and 7.1% four responses. The maximal plasma cortisol value during positive tests were on average 30.6% (range 10-99) in SCS and 64% (range 21-245) compared to peak following ACTH 1-24 injection. Responses to AVP (61%) and metoclopramide (43.6%) were the most prevalent in SCS, while in CS it was AVP (42.8%) and upright posture (35%).  Among the additional tests, the most prevalent positive were insulin induced hypoglycemia, LH/hCG and isoproterenol. 

Conclusions: Aberrant GPCRs are widely prevalent in CS and SCS, mostly in BMAH. Percent cortisol increase differs between CS and SCS groups.  In SCS, addition of a ≥100 nmol/l cortisol increase cut-off appears necessary to validate a positive result.  Identification of aberrant GPCR contributes to confirm BMAH diagnosis for bilateral lesions.

 

Nothing to Disclose: AD, GO, IB, AL

14973 16.0000 MON-0782 A Criteria of Response to in Vivo Tests to Identify Aberrant Hormone Receptors in Primary Cortisol-Secreting Adrenal Lesions 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Bernardo Dias Pereira*1, Sofia Carrilho Vaz2, Henrique Vara Luiz3, Teresa C. Ferreira2, Jorge Ralha Portugal4 and Lucília Salgado2
1Hospital Garcia de Orta, E.P.E., Almada - Setœbal, Portugal, 2Instituto Português de Oncologia de Lisboa, Francisco Gentil, E.P.E., Lisboa, Portugal, 3Hospital Garcia Orta. E.P.E., Lisbon, Portugal, 4Garcia de Orta Hospital, Almada, Portugal

 

123Iodine-metaiodobenzylguanidine scintigraphy is usually recommended preoperatively to localize occult adrenal pheochromocytomas or when larger primary tumors raise concerns related to distant metastasis (1). Our objective was to analyze the clinical utility of 123Iodine-metaiodobenzylguanidine scintigraphy in the preoperative evaluation of adrenal pheochromocytomas. We performed a two institution, retrospective analysis of the clinical experience (1993-2012) with 123Iodine-metaiodobenzylguanidine scintigraphy in the preoperative investigation of histologically confirmed adrenal pheochromocytomas. Thirty four patients (pts) (male, n/%: 19/55.9%) were suitable for analysis. Median age at diagnosis was 46.5 years (min.-max.: 8-70). Paroxystic symptoms were the main presenting feature (n/%: 23/67.6%) and hypertension occurred in 24 pts (70.6%; grade I hypertension, n/%: 10/29.4%). Thirteen patients (38.2%) had genetic mutations (RET, n/%: 10/29.4%; NF1, n/%: 2/5.9%; SDHB, n/%: 1/2.9%). Mean total urinary metanefrines were 4.83 ug/24h (SD: ±7.28; reference: <1). In all pts the primary tumor was detected by CT or MRI (median diameter: 4.5 cm, min.-max.: 0.9-7.2). Five pts (14.7%) had bilateral lesions with imaging features suggestive of pheochromocytomas which were confirmed histologically (MEN2A: 4 pts; 1 pt with no genetic mutations). 123Iodine-metaiodobenzylguanidine scintigraphy detected the primary tumor in 30 pts (88.2%) and in 3 of the 5 cases of bilateral disease. Four pts (11.8%; MEN2A: 2 pts; NF1: 2 pts, 1 with a malignant pheochromocytoma) had false-negative scintigraphy (median diameter: 4.0 cm, min.-max.: 1.3-4.6). Malignant pheochromocytoma was documented in five pts (14.7%): 1 pt had distant metastasis detected preoperatively (MEN2A; dimension of the primary tumor: 3 cm) and 4 pts developed metastasis (MEN2A: 1 pt; NF1: 1 pt; SDHB mutation; 1 pt; 1 pt without genetic analysis) during the postoperative follow-up period (mean: 6.3 years, SD: ±5.52 years). In our cohort 123Iodine-metaiodobenzylguanidine scintigraphy added little to the preoperative evaluation of adrenal pheochromocytomas when these tumors were detected by CT or MRI. The value of this study may be limited to pts with identified genetic syndromes who have a higher frequency of bilateral disease or distant metastasis.

 

Nothing to Disclose: BDP, SCV, HVL, TCF, JRP, LS

16309 17.0000 MON-0783 A Preoperative Utility of 123Iodine-Metaiodobenzylguanidine Scintigraphy in Patients with Adrenal Pheochromocytoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Catherine Ann Barrett*1, Stan Van Uum1 and Jacques W.M. Lenders2
1Western University, London, ON, Canada, 2Radboud University Medical Center, Nijmegen, Netherlands

 

Background: Certain medications are well known to affect the synthesis and or release of catecholamines by pheochromocytoma (PH) cells. Administration of exogenous corticosteroids for diagnostic or therapeutic purposes has been reported to carry an increased risk of a catecholaminergic crisis (CC) in patients harboring a PH.

Objective: To assess the characteristics of patients with catecholamine-producing tumors that were reported to have suffered from CC or death after administration of a steroid, CRH or cosyntropin.

Methods: Pubmed was searched using combinations of the following search terms: PH, paraganglioma, adrenal incidentaloma, dexamethasone suppression test (DST), glucocorticoid, hypertensive crisis, CRH and cosyntropin. From all published case reports (1962-2013) we retrieved information on medical history, presenting symptoms, dose and route of steroid administration, location and size of adrenal mass, biochemical phenotype and outcome.   

Results: We identified a total of 22 cases. Eight patients died. The tumor size was over 2 cm in the 13 patients in whom tumor size was provided. Tumor site: right adrenal 10; left adrenal 6; extra-adrenal 2; unknown 4. Incidentalomas: Three patients with an incidentaloma were reported to suffer from a CC after a high dose two day DST (fatal in one patient). Adrenal diameter was > 4 cm in all and density was > 28 HU in two. In two patients biochemical tests of serum catecholamines, total metanephrines or VMA were falsely normal and one of them died. In the other patient the high dose DST was done despite elevated urine total metanephrines. There are no reports of a CC in incidentaloma patients undergoing a low dose DST (1 mg). Steroid treatment: In 15 patients, therapeutic steroid doses were administered orally, parenterally, intramuscularly or intra-articular for a variety of clinical indications. Three patients died. There were preexistent symptoms compatible with PH in 5 patients. In one patient with a fatal CC there was an undiagnosed adrenal mass at the time of steroid administration. CRH and cosyntropin: CC occurred in 1 patient following CRH administration and in 3 patients following cosyntropin. All cases were fatal. One patient had symptoms compatible with PH.

Conclusions: In patients with a large adrenal incidentaloma (>4 cm), biochemical testing for PH should be carried out before doing a high dose DST. There is no evidence however that biochemical screening for PH is necessary prior to a low dose DST in patients with an incidentaloma.

 

Nothing to Disclose: CAB, SV, JWML

12694 18.0000 MON-0784 A Risks of Catecholaminergic Crisis Following Steroid Administration in Patients with an Adrenal Mass: A Literature Review 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Sandi-Jo Galati*1, Sarah M Hopkins2, Khadeen C Cheesman3, Rachel A Zhuk2, Chelsey Amer4, Michael K Boyajian5, Emilia Bagiella3, William B Inabnet III3 and Alice C Levine6
1Mt Sinai School of Med, Fairfield, CT, 2Icahn School of Medicine at Mount Sinai, 3Icahn School of Medicine at Mount Sinai, New York, NY, 4Sackler School of Medicine, 5Columbia University, 6Mt Sinai Med Ctr, New York, NY

 

Background: Primary aldosteronism (PA) is the leading cause of identifiable endocrine hypertension (HTN).  The potential cardiovascular and renal benefits of hormone directed therapies or surgery underlie the importance of early case detection. Initially, the prevalence of PA was accepted to be 1-2% of patients with hypertension. However, studies over the past 20 years suggest that the prevalence of PA may be greater than originally suspected, with rates varying between 5-12% in patients with hypertension, and even higher rates described in patients with diabetes and HTN (13-14%), resistant HTN (19-20%), and HTN with obstructive sleep apnea (34%).  The prevalence of PA has not previously been studied in an urban primary care population within the United States.

Hypothesis: We hypothesized that the prevalence of PA in our urban population of patients with HTN exceeds the initially estimated prevalence rate of 1%. We recruited patients with HTN from our adult primary care clinic, with creatinine less than 1.5mg/dL, no prior systemic glucocorticoid or mineralocorticoid-receptor antagonist use, and no prior work-up for PA to be screened for PA with an aldosterone-to-renin ratio (ARR).  ARR > 20 ng/dL per ng/mL/hour in concordance with a plasma aldosterone concentration (PAC) > 10 ng/dL and a suppressed renin was considered a positive screening test for PA and was followed with a confirmatory oral sodium loading test (OSLT).

Results: A total of 296 patients were screened, of which 61.5% were female, 52% were Latino, and 39.9% were Black. Fourteen patients screened positive for PA, leading to an overall screening prevalence of 4.7% (14/296).  Patients with a positive screening test were more likely to have resistant HTN (p=0.0334), require more medications for treatment of HTN (p=0.0289), and demonstrated a trend towards lower potassium values that was not significant (p=0.758).  Six patients completed the OSLT and 2 patients were confirmed positive for PA. Of the remaining 8/14 patients who screened positive, 7 patients refused further testing and one patient expired prior to confirmatory testing. These results suggest that the prevalence of PA in our population is less than in other reports worldwide over the past 20 years.

Conclusions: Our results indicate that PA is less prevalent in our urban US primary care population than in other recent studies worldwide. This difference might be explained by the ethnic diversity of our population as well as the inclusion of all hypertensive patients from our primary care clinic, irrespective of severity or hypokalemia.  Consistent with previous findings, our study found the rate of a positive screening test for PA to be higher in patients with resistant HTN but there was no statisically significant correlation with the presence of hypokalemia. Our data suggest that screening for PA in an urban hypertensive population should be limited to those patients with resistant HTN.

 

Nothing to Disclose: SJG, SMH, KCC, RAZ, CA, MKB, EB, WBI III, ACL

12823 19.0000 MON-0785 A Prevalence of Primary Aldosteronism in an Urban Hypertensive Population 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Norio Wada*
Sapporo City General Hospital, Sapporo, Japan

 

Hyperkalemia is a complication of adrenalectomy for aldosterone producing adenoma (APA). Recently, several reports showed high frequency of postoperative hyperkalemia in patients with APA. Addition of mineralocorticoid receptor antagonists (MRA) before surgery is considered for control of blood pressure and serum potassium. The aim of this study is to investigate the effect of preoperative MRA for development of hyperkalemia in patients with APA.

The medical records of 42 patients with primary aldosteronism adrenalctomized in Sapporo City General Hospital from 2007 to 2013 were analyzed retrospectively. The pathological diagnosis as cortical adenoma was confirmed in all patients. They were followed-up for at least 6 months after surgery. Twenty-three patients were added MRA before surgery (group A), 19 patients were not (group B). In group A, 17 patients received eplerenone, 6 patients received spironolactone. The duration of taking MRA ranged from 11 to 336 days (mean 61 days, median 35 days). The mean dosage of eplerenone and spironolactone was 82 mg and 58 mg, respectively. There were no significant differences in plasma renin activity, plasma aldosterone concentration (PAC), renal function and other clinical characteristics at diagnosis between group A and B. In all patients, hyperkalemia (serum potassium > 5.0 mmol/L) was observed in 12 patients (28.6 %), persistent hyperkalemia (continued more than 3 months) in 4 patients (9.5 %), transient hyperkalemia in 8 patients. Hyperkalemia was developed in 8 patients (34.8 %) of group A, in 4 patients (21.1 %) of group B, persistent hyperkalemia was developed in 3 patients (13.6 %) of group A, in 1 patient (5.3 %) of group B, the rates were not significantly different between group A and B, respectively. Immediately after surgery, the mean PAC was higher (71 vs. 47 pg/mL), the frequency of hypoaldostreronism (PAC < 35 pg/ml) was lower (4.3 % vs. 36.8 %) in group A than group B (p < 0.05 in both).

In conclusion, the preoperative administration of MRA did not prevent postoperative hyperkalemia in patients with APA, although decreased hypoaldosteronism immediately after surgery.

 

Nothing to Disclose: NW

13333 20.0000 MON-0786 A Effect of Preoperative Mineralocorticoid Receptor Antagonists for Postoperative Hyperkalemia in Patients with Aldosterone Producing Adenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Kanako Nakao*1, Mika Tsuiki1, Yusuke Hirokawa2, Hiroshi Okuno1 and Mitsuhide Naruse1
1National Hospital Organization Kyoto Medical Center, Kyoto, Japan, 2Kyoto Medical Center, Kyoto, Japan

 

[Background] Adrenal Venous Sampling (AVS) is considered a gold standard for lateralization in patients with primary aldosteronism (PA). However, the criteria for interpretation of its result have not been standardized and the postsurgical outcome of following each criterion has not been well investigated. [Objective] We aim to evaluate the AVS criteria from post-surgical outcome in patients with PA. [Methods] Twenty-two patients with PA who underwent unilateral ADX at Kyoto Medical Center from Jan 2008 to Dec 2012 following AVS were included. We included only those patients with successful AVS catheterization to both adrenal veins. We excluded PA with subclinical Cushing syndrome. Diagnostic indices analyzed were; Plasma aldosterone concentration ≥1400ng/dl, Lateralized ratio ≥2.6, and Contra-lateral ratio <1.0 during cosyntropin stimulation. Post-operative data analyzed were; 6 mo post-operative blood pressure, plasma potassium, and Aldosterone to renin ratio (ARR). [Result] Sixteen patients (72.7%) met all the three diagnostic indices, followed by 5 patients (22.7%) with only one index and 1 patient (4.5%) with two indices. Eight out of 16 patients (50%) with 3 positive indices showed hypertension cure post-operatively, while all of the patients with only 1 positive index showed persistent hypertension post-operatively. Plasma potassium normalized in all the patients. The rate of ARR normalization didn’t correlate with number of positivity or type of index. Using univariate analysis, pre-operative serum creatinine was shown to predict hypertension cure (P=.0145). [Conclusion] Patients with only one diagnostic index showed low hypertension cure rate, suggesting that bilateral PA may have been included. Pre-operative serum creatinine level may predict hypertension cure. PA is benign disease with effective medication, and we have to be prudent not to make patients suspicious of bilateral disease to undergo surgery.

 

Nothing to Disclose: KN, MT, YH, HO, MN

15347 21.0000 MON-0787 A Validation of Adrenal Venous Sampling Criteria from Post-Operative Outcome in Primary Aldosteronism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Takuya Toki*1, Masao Omura2, Kohzoh Makita3, Seishi Matsui1, Maki Nagata1, Yoko Matsuzawa2, Jun Saito2 and Tetsuo Nishikawa2
1Yokohama Rosai Hospital, Yokohama, Japan, 2Yokohama Rosai Hosp, Yokohama, Japan, 3Hikarigaoka Hospital, Tokyo

 

Introduction: Cases with subclinical Cushing’s syndrome (SCS) due to adrenal adenoma often demonstrate hypertension, glucose intolerance and osteoporosis, while it is obscure whether or not mild excess of cortisol involves pathogenesis of hypertension. SCS had been recently reported to complicate primary aldosteronism (PA). Therefore, we tried to prospectively study the prevalence of PA and hypertension in cases with SCS.

Methods: 36 cases with adrenal SCS or 14 with overt Cushing’s syndrome (OCS) diagnosed by overnight dexamethasone suppression test were enrolled into this study from 2008 to 2012. PA was suspected when maximal aldosterone concentration was > 20ng/dl after 250μg of ACTH stimulation. Hyperaldosteronism was diagnosed when concentration of aldosterone was >1400ng/dl in effluent sampled at various intra-adrenal tributary veins after ACTH stimulation (selective segmental AVS: SS-AVS). We evaluated remission of hypertension one year after unilateral adenomectomy for SCS and OCS or aldosterone-producing adenoma (APA).

Results: Aldosterone-renin ratio was < 20 ng/dl per ng/ml/h in 31 among 50 cases with SCS and OCS, however, 31 cases of SCS and 9 of OCS were suspected to complicate PA, which was screened by ACTH-stimulation test. There were 30 hypertensives among 31 with SCS simultaneously associating PA. Moreover, we could make differential diagnosis of various subtypes of PA in those patients with SCS and OCS by SSAVS. The results of SSAVS clearly demonstrated that there were 8 cases with cortisol+aldosterone-producing adenoma (CAPA), 15 cases of SCS or OCS simultaneously showing APA in the opposite side of adrenal and 17 cases of SCS or OCS associated with bilateral hyperaldosteronism (IHA). All of 14 cases with OCS became hypotensive after adenomectomy for OCS. All of 7 cases with CAPA and 2 with SCS complicating APA in opposite side of adrenal became normotensive after removing CAPA and APA. 4 cases among 5 with SCS complicating APA in opposite side of adrenal and 4 cases among 5 with SCS associated with IHA still persisted hypertension even though hypercortisolemia was cured one year after adenomectomy for SCS.

Conclusion: We would like to emphasize the usefulness of SSAVS for detecting PA in SCS or OCS cases. The present data also clearly demonstrated that prevalence of PA is 80% among SCS and OCS-patients, and we should consider the possibility of association of PA when the patients with SCS and OCS are presenting hypertension.

 

Nothing to Disclose: TT, MO, KM, SM, MN, YM, JS, TN

14363 22.0000 MON-0788 A Frequently Missing Primary Aldosteronism Among Patients with Subclinical Cushing's Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Shoichiro Izawa*, Kazuhiko Matsuzawa, Keisuke Sumi, Youhei Fujioka, Naoya Yamamoto, Hideki Shiochi, Risa Nakanishi, Tsuyoshi Ohkura, Hiroko Ohkura, Masahiko Kato, Shin-ichi Taniguchi and Kazuhiro Yamamoto
Tottori University Faculty of Medicine, Yonago, Japan

 

Objectives: 123I-Metaiodobenzylguanidine (MIBG) is widely used for imaging pathology of the adrenal medulla. Having a molecular structure similar to that of norepinephrine, it is concentrated, released, and stored in the chromaffin granules. Pheochromocytoma (Pheo) is a catecholamine-secreting neoplasm arising from adrenal or extra-adrenal chromaffin tissue. Most publications on 123I-MIBG imaging of pheochromocytoma reported its diagnostic sensitivity and specificity were between 80% and 100%. However, widespread use of imaging modalities brought us increasing number of tumors mimicking Pheo. We evaluated preoperative management of 123I-MIBG positive tumors to minimize catecholamine-related pre-, intra-, and postoperative adverse events associated with Pheo.

Patients and Methods: We carried out a retrospective study of 123I-MIBG positive tumors diagnosed between April 1, 2009 and December 31, 2013. Nineteen patients (15 with pheochromocytoma and 4 with other tumors), aged 63±14 years, were enrolled. We studied their 24-h urinary metanephrines (MN), catecholamines (CA), computed tomography (CT), magnetic resonance image (MRI), and surgical treatment. 123I-MIBG scintigraphy was evaluated by planar and selected SPECT 24 h after the administration of 123I-MIBG. All patients underwent surgery with preoperative administration of doxazocin.

Results: Mean greatest diameter of Pheo was 44±19 mm. Other 4 tumors included a non-functioning adrenal adenoma (greatest diameter 19mm), a schwannoma (25mm), a ganglioneuroma (60mm), and an adrenocortical carcinoma (80mm).

    All patients with Pheo showed elevated 24-h urinary MN and/or CA. The quantity of MN (r=0.82, p<0.001) and CA (r=0.51, p=0.044) had positive correlation with greatest diameter of Pheo. However, the difference between Pheo and other tumors was not significant among small tumors less than 30mm. All patients with Pheo also showed both early phase strong staining on contrast-enhanced CT (CE-CT) and high signal intensity of T2 weighted image (T2WI) on MRI. However, 3 of 4 with other tumors did not show early phase strong staining on CE-CT, though all of them were positive on high signal intensity of T2WI.

    In their surgery, 14 of 15 with Pheo required intravenous administration of phentolamine and catecholamine, unless they were treated by sufficient dose of doxazocin (8-16mg/day). No significant associations were observed between tumor size and adverse events. Other tumors, treated by doxazocin (4 -12mg/day), did not require phentolamine and catecholamine.

Conclusion: 123I-MIBG has some limitations for the differential diagnosis of small tumors mimicking Pheo. We strongly recommend preoperative administration of alpha-adrenoceptor antagonists to small tumors mimicking Pheo, because radiological and hormonal assessments do not clearly differentiate Pheo and other 123I-MIBG positive tumors.

 

Nothing to Disclose: SI, KM, KS, YF, NY, HS, RN, TO, HO, MK, SIT, KY

14535 23.0000 MON-0789 A Preoperative Management of 123I-Metaiodobenzylguanidine Positive Tumors Mimicking Pheochromocytoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Yasutaka Baba*, Sadao Hayashi and Kohei Nagasato
Kagoshima University, Kagoshima, Japan

 

Previous reports suggested that mixing blood sample derived from non-adrenal vein might affect the assessment of both selectivity of catheterization and laterality of aldosterone producing adenoma (APA) during adrenal venous sampling (AVS). To overcome the bias as mentioned above, we aimed to investigate whether blood sampling of central adrenal vein (CAV) could influence on the assessment of both selectivity and laterality by the step-up of cortisol (plasma cortisol concentrations, PCC) or aldosterone value (AV) between the adrenal vein and the CAV. We determined the selectivity index (SI) and laterality index (LI) in samples obtained sequentially from conventional bilateral adrenal veins and bilateral CAVs before and after IV administration of cosyntropin in 28 consecutive patients with primary aldosteronism. We then calculated the SI with PCC obtained using four different cut-off values [PCC(side)/PCC(IVC) > = 3.0, 2.0, 1.36 or 1.1] before cosyntropin stimulation. Receiver operating characteristics (ROC) analyses were conducted to determine the best LI, in which PCC and AV -derived index for lateralization of the aldosteronoma-bearing adrenal gland. On both APA and contralateral sides before and after cosyntropin stimulation, there was no statistically significant difference of PCC, SI(PCC APA/IVC), and LI(AV/PCC APA/contra) between conventional AVS and central AVS except AV in central AVS at APA side before cosyntropin stimulation (P = 0.0407). At each cut-off values, there was no statistically significant difference of SI between conventional AVS and central AVS. Meanwhile, the ratio of AV to PCC of conventional AVS between dominant and non-dominant sides after cosyntropin stimulation was the most reliable index [area under the curve (AUC), 0.776±0.088; 95 % confidence interval (CI): 0.629 to 0.886 ]. Although samples from CAV revealed an increase in aldosterone release after cosyntropin stimulation, central AVS could not show an advantage of assessment of both selectivity and laterality in patients with primary aldosteronism.

 

Nothing to Disclose: YB, SH, KN

15202 24.0000 MON-0790 A Is Central Adrenal Venous Sampling Useful for Judging Selectivity and Laterality in Patients with Primary Aldosteronism? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Tiago Lopes Nunes da Silva*1, Bernardo Dias Pereira1, Henrique Vara Luiz2, Ana Catarina Matos1 and Jorge Ralha Portugal1
1Garcia de Orta Hospital, Almada, Portugal, 2Garcia Orta Hospital, Portugal

 

Primary Hyperaldosteronism (PHA) is a common form of endocrine hypertension in which aldosterone production is inappropriate and partially autonomous from the renin-angiotensin system. A recent study that compared cardiovascular events, in patients with PHA and essential hypertension, showed a significantly higher number of events in PHA patients, emphasizing the importance of early diagnosis and targeted treatment. In our center, a critical assessment of PHA patients has not yet been made.

To evaluate and characterize the diagnostic workup, treatment and follow up of confirmed PHA patients.

The data was retrospectively extracted from the case files of the 24 confirmed PHA patients, from 1992 to 2013.

The inclusion criteria were patients with aldosterone/renin ratio (ARR)>5,7/30 and a positive confirmatory test. The data was analyzed with SPSS 21®.

The 24 patients had a median age of 63 years and 63% (15) were females. Hypertension had been diagnosed at a median age of 44 years and 39% (7) were younger than 40 years of age. The diagnosis of PHA was made at the age of 56. Approximately 58% (14) had resistant hypertension with 53%(13) being treated with 4 or more anti-hipertensive drugs.

All patients were screened with ARR and serum K+. Median Aldosterone/Direct Renin Concentration ratio was 32 (<5,7), Aldosterone/Plasma Renin Activity ratio was 192(<30), Aldosterone was 26 ng/dL and a K+2,9 mmol/L (3,5-5,5 mmol/L). Just 17%(4) had normokalemic PHA.

To confirm PHA, 63% (15) did a saline infusion test with median aldosterone of 40 ng/dL and 16% (3) did the captopril challenge test with a median aldosterone increase of 25%. Both had a low number of negative results, 12% (1) and 14% (1), respectively.

The subtype classification was performed by: CT in all patients with unilateral nodules in 82% (20); Iodocholesterol scintigraphy (NP59) in 37,5% (9) and arterial venous sampling (AVS) with cosyntropin infusion in 25% (6). The CT and NP59 agreed in 33% (3), but in another 33% (3) there was no tracer uptake. This nodules ranged in size from 15 to 20 mm. All AVS were unsuccessful.

The treatment consisted in adrenalectomy in 30% (8) and medical therapy in 48% (11). 24%(6) were loss during follow-up. Adrenalectomy versus medical therapy normalized K+in 100%(8) vs 86%(10), improved hypertension in 75%(6) vs 29%(3) and normalized hypertension in 25%(2) vs 27%(3).

This study shows that the detection of PHA was greatly under evaluated with only the most severe variants diagnosed: high prevalence of resistant hypertension, a median aldosterone value of 40 ng/dL and 83% of hypokalemia. It is also worth taking notice of the median time until diagnosis -12 years- increasing the risk of cardiovascular morbidity. The absence of successful AVS has probably led to more patients being medically treated. In spite of this, the therapeutic options lead to good outcomes in treating hyperkalemia and hypertension.

 

Nothing to Disclose: TLN, BDP, HVL, ACM, JRP

16175 25.0000 MON-0791 A Primary Hyperaldosteronism: A Real World Experience of 21 Years 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Zanariah Hussein*1, Anilah Abdul Rahim2, Johan Poole-Johnson3 and Rozaimi Razali3
1Hospital Putrajaya, W P Putrajaya, Malaysia, 2Hospital Putrajaya, Putrajaya, Malaysia, 3Sengenics Sdn Bhd

 

Pheochromocytoma(PHEO) and paraganglioma(PGL) are rare tumors arising from chromaffin cells in the adrenal medulla and autonomous ganglia. Multiple genes have been implicated in PHEO/PGLs such as RET, VHL, NF1, TMEM127, MAX, KIF1B, SDHA, SDHB, SDHC, SDHD, SDHAF2 and EGLN1/PHD2. Several European series have reported that up to 25% of apparently sporadic PHEO/ PGL patients harbor germline mutations in these PHEO susceptibility genes. There are only few publications reporting genetic analysis of PHEO/ PGL patients from Asia. Identification of underlying genetic predisposition may facilitate personalized care. The objective of this study was to identify pathogenic germline mutations in a cohort of Malaysian patients with non-syndromic PHEO / PGL using exomes sequencing technique. Eighty patients with a confirmed diagnosis of PHEO/PGL treated at Hospital Putrajaya from January 2000 to February 2013 were identified from the hospital database, of which thirteen patients with family history or syndromic features (MEN2, NF1 and VHL) were excluded. Patients with the following features: metastatic PHEO/PGLs, bilateral adrenal involvement, multifocal, extra-adrenal or early onset of disease below age 50 were invited to participate. Twenty four patients consented, their DNA were extracted from peripheral blood leucocytes and genetic analysis for RET, VHL, SDHA, SDHB, SDHD, SDHAF2, TMEM127, MAX, KIF1B, PHD2/EGLN, KIF1B, RAK/FRK, ERK and RAS were performed using exome sequencing (Illumina HiSeq2000). Median age at diagnosis was 29.5 years (range 11-52). Fifty percent of patients had unilateral PHEO, 8% bilateral PHEO, 12.5% PGL and 29% had metastatic PHEO/PGLs. Four patients (16.7%) had mutation in RET (3 unilateral PHEO and 1 metastatic PHEO), two (8%) in VHL (both had bilateral PHEO), two in SDHB (both had unilateral PHEO), one in SDHA (unilateral PHEO) and in KIF1B gene (abdominal paraganglioma). Four patients (16.7%) were detected to have polymorphism (G691S) in RET gene. One patient with a functional abdominal PGL had combined SDHB and RET mutations and remains disease free seven years after tumor removal. Among those with malignant disease, one (14%) had mutation in SDHB gene and another had RET gene mutation. We also found high frequency of variants of uncertain significance (VUS) in EGLN1, RAK/FRK, ERK genes in this cohort. No SDHD, SDHC, SDHAF2 or TMEM127 mutations were detected in our cohort. In conclusion the overall incidence of germline mutations in known susceptible genes for PHEO / PGL amongst this Malaysian cohort was 42.7% with 16.7% having polymorphism (G691S) of RET gene. This finding is more frequent than that reported in Western literature and emphasizes the importance of germline mutation testing for each patient with PHEO / PGL with or without a positive family history.

 

Nothing to Disclose: ZH, AA, JP, RR

16927 26.0000 MON-0792 A Genetic Mutation Screening in a Malaysian Cohort with Non-Syndromic Pheochromocytoma /Paraganglioma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Yerong Yu*1, Yanyan Li2, Yuping Liu2 and Jianwei Li2
1West China Hospital, Sichuan University, Chengdu, China, 2West China Hospital, Sichuan University

 

For the diagnosis of primary aldosteronism (PA), confirmatory testing is mandatory and different function tests such as saline infusion test (SIT) can be employed. There are, however, sparse data evaluating the diagnostic significance of SIT in Chinese hypertension patients. The aim of the study was to assess the serum aldosterone response after SIT in Chinese subjects with primary aldosteronism (PA), essential hypertension (EH) and healthy volunteers (C). 77 hypertensive patients who had positive case detection using the aldosterone to rennin ratio (ARR) and 21 health volunteers were subjected to a standard SIT. Hypertensive agents were stopped or replaced for at least 2wk before testing with calcium channel antagonists or a-blockers. The plasma rennin activity and aldosterone concentration at baseline and after 2 liter 0.9% NaCl infusion were tested. 48 hypertensive patients were differentiated as having PA based upon adrenal venous sampling and/or adrenal surgery, among them 29 were aldosterone-producing adenomas (APA), 19 were bilateral idiopathic hyperaldosteronism(IHA). The average blood pressure were 162.8±20.0/98.1±13.8mmHg (APA), 156.8±23.7/98.2±15.1 mmHg (IHA), 152.4±20.2/95.7±13.2 mmHg (EH), and 110.8±9.6/67.9±8.5mmHg(C). The serum aldosteron concentration and ARR were much higher in PA subjects: 32.9±12.7 ng/dl and 326.3±239.0 ng/dl:ng/ml.h (APA), 23.9±9.4 ng/dl and 166.5±198.4 ng/dl:ng/ml.h (IHA), 13.0±3.9 ng/dl and 35.3±29.6 ng/dl:ng/ml.h (EH), 13.3±3.3 ng/dl and 20.0±11.8 ng/dl:ng/ml.h respectively. The values for ARR after SIT were 453.3±761.8 in APA, 381.0±645.1 in IHA, 52.8±53.9 in EH, and 25.9±20.7 in C. The values for aldosteron concentration after saline infusion were 25.9±11.7 in APA, 16.1±7.0 in IHA, 8.5±2.4 in EH, 8.3±1.8 in C. The optimal aldosterone cutoff value of post-SIT for diagnosis PA is 10.18ng/dl, which sensitivity and specificity is 95.8% and 86%. Post-SIT aldosterone levels were >10ng/dl in all PA patients, but > 5ng/dl in all EH and C subjects except one, there were 8/29 EH patients whose Post-SIT aldosterone levels greater than10ng/dl.  In conclusion, the best Post-SIT aldosterone cut-off values for identifying PA was 10.18ng/dl in Chinese patients. However, the serum aldosterone response after SIT is lower in Chinese essential hypertensive subjects and healthy volunteers, even at the optimal cut-offs the diagnostic significance were moderate because of values overlapping between patients with and without the disease. 

 

Nothing to Disclose: YY, YL, YL, JL

14360 27.0000 MON-0793 A The Response to Saline Infusion Test in the Chinese Subjects with Primary Aldosteronism, Essential Hypertension and Healthy Control 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Ana Paula Marques*1, Isabel Paiva2, Inês Sapinho3, Fernando Rodrigues4, Maria Pereira5, Sandra Belo6, Joana Oliveira Couto7, Maria João Oliveira8, Helder Simões9, Márcia Alves10, Marta Ferreira11, Isabel Manita12 and Ricardo Manuel Rangel13
1Hospital Pedro Hispano, Porto, Portugal, 2Hosp de Univ de Coimbra, Coimbra, Portugal, 3Hospital Fernando Fonseca, Lisboa, 4Oncology Institute of Coimbra, Coimbra, Portugal, 5Hospital Braga, 6Serviço de Endocrinologia, Diabetes e Metabolismo, Centro Hospitalar de São João, 7Portuguese Institute, Porto, Portugal, 8Hospital Gaia, Vila Nova de Gaia, 9Hospital de Egas Moniz- CHLO EPE, Lisboa, Portugal, 10Coimbra’s University Hospital, Coimbra, Portugal, 11Endocrinology, Diabetes and Meta, Porto, Portugal, 12Garcia de Orta Hospital, Almada, Portugal, 13Hospital Curry Cabral, Lisboa, Portugal

 

Objective: Pheochromocytomas are rare tumors from adrenal chromaffin tissue. The Portuguese Study Group of Adrenal Tumors  performed a multicentric retrospective evaluation of patients with pheochromocytomas

Material and methods:  Twelve endocrine departments participated, reviewed the data of 176 patients, between 1986 and 2011. A questionaire included data on epidemiological, clinical , laboratory , radiological , genetic study , preoperative treatment , surgery and follow up .  

Results: 105 female and 70 male , with 51,9 ± 15,2 years. The clinical presentation of 172 patients were:  31% discovered incidentally; 10 % had the  typical spells; 18% had persistent hypertension and 5,2 %  discovered in a genetic screening; other clinical symptoms like lost weight, abdominal pain , headache , sweating were present in  11% of the cases and 25% had  a mixture of more than one clinical presentation. The most often laboratory assays evaluated were the urinary catecholamines and their metabolites. Using HPLC method, the sensivity for the diagnosis was 62% for metanephrine(97 patients) and 82% normetanephrine(85 patients).

In 154 patients,  the localization was by CT  in 84% , MR in 41% and MIBG scintigraphy in 55%. The mean dimension of the tumor was 55,3 ± 33,7mm,  56%  at the right adrenal, and 7% bilateral.   

The preoperative treatment  in 126 cases was : phenoxybenzamine in 65% of the patients, and associated to a β blocker in 29,3%.

In 170 patients, the surgical approach was laparotomy in 91(54%) and laparoscopy in 74(44%); 5 patients were not submitted to a surgery.

9 patients had the  diagnosis of malignant pheochromocitoma: at the diagnosis in 3 cases, or during the follow up (after 6 to 192 months) in 6. Four of these patients died after a mean of 59,7 months(2-111).

In 19 patients a genetic syndrome was found: 10 patients of MEN 2A, two cases of a mutation in SDHB, four a NF1 and three a VHL disease. 

Conclusions: 

Due to the fact of being  retrospective  and for a long period of time ,  this study has some limitations . Specially the hormonal studies were diverse and different along the years and among the several centers .  31% of the patients  were discovered as a  incidentallomas. The right adrenal was  more affected than the left one . The  genetic screening was scarce, only 11% diagnosed as a  familiar disease. Given that the malignancy in a pheochromocitoma can be a late finding  life-long follow-up is mandatory.

 

Nothing to Disclose: APM, IP, IS, FR, MP, SB, JOC, MJO, HS, MA, MF, IM, RMR

14526 28.0000 MON-0794 A Pheochromocytomas: Retrospective Multicentric Clinical Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Chen Chen, Zhiqiang Lu*, Jiachao Chen, Jing Cheng, Xiaomu Li, Haiying Zeng and Xin Gao
Zhongshan Hospital, Fudan University, Shanghai, China

 

Objectives  

Primary aldosteronism is one of the most reason for symptomatic hypertension,The clinical manifestation of primary aldosteronism is high blood pressure,hyperaldosteronemia,and hypokalemic. The most common clinical subtypes of primary aldosteronism are aldosterone-producing adenoma(APA) and adrenal cortical hyperplasia(or idiopathic hyperaldosteronism,IHA).Although the prevalence of APA may be as high as 60%-90% in PA,the pathophysiological mechanisms resulting in APA  are still not well understood. According to the literatures, Dopamine receptor D2 (DRD2) plays a key role in the aldosterone secretion of APA. The expression of DRD2 was different between APA and normal adrenal cortex.So we explore the mechanism of aldosterone-producing adenomas by using technology of DNA methylation.

Methods

Real-time PCR and Methylation-specific PCR were used to test the expression of Dopamine receptor D2 and the level of DNA methylation by screening of 15 APA which were clinically diagnosed and histologically confirmed, and 3 normal adrenal cortex.

Rusults

We found the mRNA levels of DRD2 in APA were significantly lower than  the normal adrenal cortex (¢C(t)13.13±2.16vs.9.44 ± 1.96, P=0.002 ). Then the methylation of Dopamine receptor D2 were tested.9 cases out of 15 APA were rmethylated , and the left 6 cases were demethylated and the normal adrenal cortex  were all demethylated. Interestingly, there was a decrease tendency in mRNA levels of DRD2 from demethylated cases to methylated cases of APA  (¢C(t)12.77±2.39 vs 13.37±2.10 P=0.480) . The mRNA levels of DRD2 in methylated  and demethylated cases were significantly lower than normal adrenal(P=0.009 and 0.024 ,respectively ).

Conclusions

 1.  The expression of DRD2  in APA was significantly lower than NA.

 2.  The methylated DRD2 played a partial role in the expression of APA.

 

Nothing to Disclose: CC, ZL, JC, JC, XL, HZ, XG

11339 29.0000 MON-0795 A Different Dopamine Receptor D2 Expression and Methylation Level Between Aldosterone-Producing Adenoma and Normal Adrenal Cortex 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Yeong Bok Lee*1, Jin Kyeong Shin1, Hee sun Kwon1, Jang Won Son1, Seong Su Lee1, Sung Rae Kim1, Chung Ho Kim2 and Soon Jib Yoo1
1The Catholic University of Korea, Bucheon St. Mary’s Hospital, Bucheon, Korea, Republic of (South), 2The Catholic University of Korea

 

Backgound: The functional imaging technique of choice for diagnosis of pheochromocytoma is currently scintigraphy with metaiodobenzylguanidine (MIBG). Recently, positron emission tomography (PET) is increasingly used in evaluating pheochromocytoma and may play a complementary role. The present study is aimed to evaluate the usefulness of a FDG-PET/CT in diagnosis of pheochromocytoma when compared to MIBG scan.   

Methods: We retrospectively reviewed 7 patients who underwent FDG-PET/CT and MIBG scan for evaluation of adrenal tumors suspected of being pheochromocytoma in biochemical study and/or dynamic contrast enhanced computed tomography between 2010 and 2013. The patients with adrenal tumors underwent various screening tests, including the measurement of the baseline adrenocorticotropic hormone (ACTH), cortisol, 24-hour urine collection for analysis of catecholamines (vanillylmandelic acid, metanephrine, normetanephrine), and  evaluation of the ratio of the plasma aldosterone concentration to the plasma renin activity (ARR), in addition to 1 mg overnight dexamethasone suppression tests (DST). The degree of FDG uptake on PET was scored by maximum standarized uptake values (SUVmax) for the lesion with the most intense FDG uptake was recorded.

Results: According to the pathological findings, in 3 of 7 patients was confirmed pheochromocytoma and the rest 4 of the patients were non-hormone-secreting adenomas. The mean 24-hour urinary vanillymandelic acid (normal range 0-8.0mg/day), metanephrine (normal range 52.0-341.0ug/day), normetanephrine concentrations (normal range 88.0-444.0ug/day) of the pheochromocytoma (26.26mg/day, 5926.96ug/day, 6018.3ug/day) were higher than that of the non-hormone-secreting adenomas (2.77mg/day, 181.0ug/day, 332.67ug/day). The size (mean, range) of the pheochromocytoma (5.62cm, 3.0-7.2cm) was larger than non-hormone-secreting adenomas (2.77cm, 1.5-4.0cm). All pheochromocytoma concentrate MIBG, however, 2 of 4 non-hormone-secreting adenomas had false positive results. The maximum standarized uptake values (SUVmax) (mean, range) of the pheochromocytoma (8.84, 4.70-17.98) was higher than that of the non-hormone-secreting adenomas (2.68, 0-4.69).

Conclusion: FDG-PET/CT was sensitive and specific for differentiating pheochromocytoma from non-hormone secreting adenomas. Therefore, additional FDG-PET/CT is recommended when MIBG-avid adrenal adenoma who had borderline result in biochemical study and/or dynamic contrast enhanced computed tomography.

 

Nothing to Disclose: YBL, JKS, HSK, JWS, SSL, SRK, CHK, SJY

15433 30.0000 MON-0796 A Adrenal Imaging: The Value of Additional Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography(FDG-PET/CT) in Pheochromocytoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0767-0796 4778 1:00:00 PM Endocrine Hypertension & Cushing's Poster

Matthew D Taves*1, Adam W Plumb2, Daniel T Patton2, Chunqi Ma2, Ninan Abraham2 and Kiran K Soma2
1University of British Columbia, Vancouver, BC, Canada, 2University of British Columbia

 

Glucocorticoids are synthesized in the adrenal glands and circulate through the blood to coordinate organismal physiology. In early life, glucocorticoids can impair growth and neural development, but are also critical for maturation of the immune system and other organs. To avoid harmful glucocorticoid effects, neonates experience a stress hyporesponsive period (SHRP), during which circulating glucocorticoids are minimal (1). While the SHRP deprives other organs of blood-borne glucocorticoids where they are needed, this apparent conflict could be resolved by tissue-specific production of glucocorticoids. Glucocorticoids may be locally produced in extra-adrenal tissues, such as the thymus, where they are critical for the production of immunocompetent T cells (2) responsible for cell-mediated adaptive immunity. We found that in developing mice, endogenous glucocorticoid levels are much higher in lymphoid organs (thymus, bone marrow, and spleen) than in circulating blood. However, the mechanism and functions of local glucocorticoid elevation in bone marrow and spleen are unknown. To determine whether glucocorticoids are locally synthesized, we cultured bone marrow and spleen in the presence of metyrapone, which blocks glucocorticoid production from upstream precursors, or carbenoxolone, which blocks glucocorticoid production through reactivation of downstream metabolites. Only metyrapone inhibited glucocorticoid production, indicating that synthesis occurs primarily from upstream precursors. Glucocorticoid production was even higher in adults than in neonates, indicating that tissue-specific glucocorticoid regulation is important not only in early life, but also in adulthood. We then looked for steroidogenic enzyme gene expression, and found mRNA for all glucocorticoid-synthetic enzymes in both bone marrow and spleen. Our findings show that these organs, the sites of B cell development (3), can locally synthesize glucocorticoids. Developing B cells have especially high glucocorticoid receptor expression (4), further indicating a glucocorticoid role in B cell development. Together, these data suggest that bone marrow- and spleen-synthesized glucocorticoids may be critical for production of immunocompetent B cells, and resultant antigen-specific humoral immunity.

 

Nothing to Disclose: MDT, AWP, DTP, CM, NA, KKS

11483 1.0000 MON-0797 A Glucocorticoid Synthesis By Mouse Bone Marrow and Spleen 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Dirk van Moorsel*1, Nicolaas Schaper1, Ronald M.A. Henry2, Marleen van Greevenbroek2, Charlotte Geelen1, Elisabeth F.C. van Rossum3, Giel Nijpels4, Leen M. 't Hart5, Casper G. Schalkwijk1, Carla van der Kallen2, Hans P. Sauerwein6, Jacqueline M. Dekker4, Coen D.A. Stehouwer2 and Bastiaan Havekes2
1Maastricht University Medical Center, Maastricht, Netherlands, 2Maastricht University Medical Center, 3Erasmus MC, Rotterdam, Netherlands, 4VU University Medical Center Amsterdam, 5Leiden University Medical Center, 6Maastricht University Medical Center, Netherlands

 

Background: Glucocorticoids are known to have vascular effects. The BclI glucocorticoid receptor (GR) polymorphism increases glucocorticoid sensitivity and is associated with adverse metabolic effects. Whether the BclI polymorphism also affects cardiovascular variables, remains to be elucidated.

Objective: To investigate the association of the BclI polymorphism with blood pressure, atherosclerosis and cardiovascular disease (CVD).

Design and Setting: We conducted an observational cohort study, combining data from 2 cohort studies designed to investigate genetic and metabolic effects on CVD.

Patients and Methods: 1228 participants (mean age 64.7 years ± 8.5) from the Cohort study on Diabetes and Atherosclerosis Maastricht (CODAM) and the Hoorn Study were genotyped for the BclI polymorphism. Blood pressure was measured. Atherosclerosis was assessed by measuring ankle-brachial index (ABI) and carotid intima-media thickness (IMT). Prevalent CVD was assessed with questionnaires, hospital records and ECG.

Results: We identified 519 non-carriers (CC), 540 heterozygous (CG) carriers and 169 homozygous (GG) carriers of the G-allele of the BclI polymorphism. Homozygous carriers had higher mean arterial pressure (MAP) (103.8 ± 12.4 vs. 101.6 ± 12.2 mmHg [mean ± SD]; p<0.05) compared with non-carriers. In addition, homozygous carriers had lower ABI compared with heterozygous carriers (1.08 ± 0.13 vs. 1.11 ± 0.14; p<0.05). Associations remained significant after adjustment for sex, age and smoking status. Additional adjustment for BMI attenuated the association of BclI with blood pressure by 21% (MAP; GG vs. CC), suggesting that this association is (at least partly) mediated by BMI.

Conclusion: Homozygous G-allele carriers of the BclI polymorphism of the GR gene have higher MAP and lower ABI. Our findings support the hypothesis that genetic variations in the GR, which are known to alter GC sensitivity, can have cardiovascular implications.

 

Nothing to Disclose: DV, NS, RMAH, MV, CG, EFCV, GN, LM, CGS, CV, HPS, JMD, CDAS, BH

12334 2.0000 MON-0798 A Bcli Glucocorticoid Receptor Polymorphism Is Associated with Higher Blood Pressure and Lower Ankle-Brachial Index, but Not with Carotid Intima-Media-Thickness or Cardiovascular Disease: The Hoorn and Codam Studies 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Zaki K Hassan-Smith*1, Stuart Andrew Morgan1, Mark Sherlock2, Beverly Hughes3, Gareth Geoffrey Lavery1, Jeremy W Tomlinson1 and Paul M Stewart4
1University of Birmingham, Birmingham, United Kingdom, 2Beaumont Hospital / RCSI Medical School, Dublin, Ireland, 3Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, UK, 4University of Leeds, Leeds, United Kingdom

 

Background: 11β-HSD1 expression and activity increases with age in fat, bone, and skin, with local tissue generation of glucocorticoids implicated in associated diseases. We have previously shown that mice with global deletion of 11β-HSD1 are protected from age-associated muscle weakness. We hypothesized that 11β-HSD1 expression/activity is upregulated with age in humans and that this contributes to sarcopenia and other conditions associated with senescence.

Experimental Design: 135 healthy subjects (women n=77, men n=58, aged 20-80 years) in total were recruited to the study. Global assessment of 11β-HSD1 activity was performed by GC/MS analysis of 24-hour urine collections. Muscle-specific expression of 11β-HSD1 was assessed as part of a microfluidic gene expression array of 92 genes in vastus lateralis biopsy samples (n=79 of total cohort). Analysis of body composition (DEXA), muscle function (jump-plate mechanography, grip strength) and serum biochemistry were also performed. Spearman correlations between 11β-HSD1 expression/activity and functional parameters/potential regulators were carried out.

Results: Skeletal muscle expression of 11β-HSD1 was increased with age in women (x2.3-fold increase in those aged >50 vs. <50 years, p=0.0007). No changes in GR or H6PDH were observed. 11β-HSD1 expression did not change with age in men, however H6PDH was increased (x1.66-fold increase in those aged >50 vs. <50 years, p=0.002). Genes involved in response to cell stress (GADD45a, HSP90B1, CDKN1A, HIF-1a) and regulation of muscle proteolysis (PSMA2, PSMD4) were also differentially expressed with age. Muscle 11β-HSD1 expression correlated negatively with grip strength (r =-0.37, p<0.05), bone mineral density (r=-0.43, p<0.01) and IGF-I (r=-0.38, p<0.05), and positively with fat mass (r=0.32, p<0.05) LH (r=0.50, p<0.001) and FSH (r=0.56, p<0.001), in women. Furthermore urine (THF+5aTHF)/THE ratios were increased in women aged >70 compared to those in their 20s (median 0.94, IQR 0.87-1.02 vs 0.77, IQR 0.69-0.87). No changes in global 11β-HSD1 activity were observed with age in men.

Conclusions: Skeletal muscle 11β-HSD1 expression is upregulated with age in women and this phenomenon may be driven by the menopause. Our results highlight associations between muscle 11β-HSD1 and sarcopenia, osteoporosis and obesity and set the scene for interventional studies of selective 11β-HSD1 inhibitors in elderly and post-menopausal cohorts.

 

Nothing to Disclose: ZKH, SAM, MS, BH, GGL, JWT, PMS

16364 3.0000 MON-0799 A Skeletal Muscle 11beta-HSD1 Is Increased with Age in Women in Association with Reduced Grip-Strength and an Adverse Body Composition Profile 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Roland H Stimson*1, Murat Akyol2, Lynne E Ramage1, Alison M Fletcher1, Rod N Carter1, John L Forsythe2, Edwin J van Beek1, Nicholas M Morton1 and Brian R Walker1
1University of Edinburgh, Edinburgh, United Kingdom, 2Royal Infirmary of Edinburgh, Edinburgh, United Kingdom

 

The recent discovery of functional brown adipose tissue (BAT) in adult humans has generated great interest in activating BAT thermogenesis to increase energy expenditure to treat obesity, however the regulation of this tissue is still poorly understood. Glucocorticoids (GC) are powerful suppressors of BAT activity in rodents. We hypothesized that GCs suppress BAT activity in humans and tested this both in vivo and in vitro.

6 healthy lean men (age 23±2 y, BMI 22.0±0.9kg/m2) attended after overnight fast on two occasions in a randomised double-blind design, one after 24h of prednisolone 10mg BD and the other following placebo. Deuterated glucose was infused to measure whole body glucose uptake. Subjects were placed in a room cooled to 17 degrees Celcius for 2h, after 1h a 75MBq IV 18F-fluorodeoxyglucose (FDG) bolus was administered. PET/CT was performed to measure glucose uptake by BAT in vivo. In separate experiments, paired explants of human BAT and WAT, obtained from the supraclavicular region from subjects undergoing elective neck surgery (n=4), were cultured in 0, 100 and 1000nM cortisol for 24h. Basal and maximal (using the uncoupler FCCP) oxygen consumption (OCR) was measured using a Seahorse XFe24 analyser. In addition, paired human brown and white adipocytes obtained from the stromal vascular fraction (n=6) were cultured in 0, 100 and 1000nM cortisol for 24 and 48h to assess regulation of mRNA levels.

In the in vivo experiment, prednisolone decreased whole body glucose uptake (0.18±0.02 vs 0.24±0.04 L/min, P<0.05), but substantially increased FDG uptake by BAT during cold exposure (413±167 vs 225±102 grams/L, P<0.05) and tended to increase volume of active BAT (71±25 vs 50±25 grams, P=0.07). In vitro, cortisol suppressed basal and FCCP-stimulated OCR in BAT explants (35±15 (0nM) vs 17±9 (100nM) vs 14±6 (1000nM) pmol/min/mg tissue, P<0.05 0nM vs 1000nM) but not in WAT (10±4 vs 10±2 vs 9±3 pmol/min/mg). In the primary brown adipocytes, cortisol suppressed UCP-1 mRNA levels after both 24 and 48 h (1.0±0.0 (0nM) vs 0.97±0.13 (100nM) vs 0.52±0.7 (1000nM) AU, P<0.01 1000 vs 0/100nM). Cortisol increased GLUT-1 and fatty acid synthase mRNA (P<0.05 1000 vs 0nM).

GCs increase in vivo glucose uptake by BAT in humans as measured using FDG PET, however GCs decrease mitochondrial oxidation and suppress UCP-1. These results suggest that GCs may increase glucose transport and lipogenesis in BAT, and highlight that FDG PET is not a direct measure of energy expenditure by BAT.

 

Nothing to Disclose: RHS, MA, LER, AMF, RNC, JLF, EJV, NMM, BRW

15268 4.0000 MON-0800 A Glucocorticoids Increase Glucose Uptake By Human Brown Adipose Tissue in Vivo but Decrease Oxidative Phosphorylation and Inhibit Uncoupling Protein 1 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Takuhiro Sonoyama*, Masakatsu Sone, Kyoko Honda, Daisuke Taura, Katsutoshi Kojima, Megumi Inuzuka, Naotetsu Kanamoto, Naohisa Tamura and Kazuwa Nakao
Kyoto University Graduate School of Medicine, Kyoto, Japan

 

Stem cells are gaining attention as promising tools in the field of regenerative medicine and developmental biology especially after the establishment of human ES cells and human iPS cells. Although there have been reports of the differentiation of mesenchymal stem cells and mouse ES cells into steroid-producing cells, the differentiation of human ES/iPS cells into steroid-producing cells has not been reported. The purpose of our present study was to establish a method for inducing differentiation of human ES/iPS cells into steroid-producing cells. In this study, we used two human ES cell lines, named H9 and KhES1, and one human iPS cell line, named B7. The first approach we tried was embryoid body (EB) formation and further culture on adherent plates. The resultant differentiated cells expressed mRNAs encoding the steroidogenic enzymes StAR, HSD3B, CYP11A1, CYP17A1, and CYP19, and secreted progesterone was detected in the cell medium. However, expression of human chorionic gonadotropin (hCG) was also detected, suggesting the differentiated cells were trophoblast-like. Then, we next tried a multi-step approach, in order to differentiate human ES/iPS cells into steroid-producing cells that are not trophoblast-like, but instead exhibit the characteristics of adrenal cortical cells. As a first step, human ES/iPS cells were induced to differentiate into the mesodermal lineage. After 7 days of differentiation induced by BIO (a GSK 3β inhibitor), the human ES/iPS cells had differentiated into Flk1- and PDGFRa-expressing mesodermal lineage cells. As a second step, plasmid DNA encoding SF-1, a master regulator of the development of adrenal cortex and gonads, was introduced into these mesodermal cells. The forced expression of SF-1 and subsequent addition of 8-Br-cAMP induced the mesodermal cells to differentiate into the steroidogenic cell lineage, and gene expression of CYP21A2 and CYP11B1, in addition to StAR, HSD3B, CYP11A1 and CYP17A1, was detected. Moreover, secreted cortisol was detected in the medium, but hCG was not. These findings indicate that the steroid-producing cells obtained through the described multi-step method are not trophoblast-like; instead, they exhibit characteristics of adrenal cortical cells. Our method will open a new avenue to the elucidation of the molecular mechanisms underlying the development/differentiation of the adrenal cortex, and to the future possibility of cell therapies for patients with adrenal insufficiency.

 

Nothing to Disclose: TS, MS, KH, DT, KK, MI, NK, NT, KN

12171 5.0000 MON-0801 A Differentiation of Human Embryonic Stem Cells and Human Induced Pluripotent Stem Cells into Steroid-Producing Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Dawn EW Livingstone*, Catherine Sykes, Lyam M Hollis, Brian R Walker and Ruth Andrew
University of Edinburgh, Edinburgh, United Kingdom

 

Topical steroids are the main treatment for inflammatory skin conditions including eczema, but their use is limited by adverse effects, both locally on skin integrity and systemically on metabolic function. Novel steroid treatments are needed which dissociate anti-inflammatory from metabolic effects. We previously identified 5alpha-tetrahydrocorticosterone (5aTHB) as a novel glucocorticoid receptor ligand with dissociated effects in vitro.  Here, we determine anti-inflammatory efficacy of 5aTHB in vivo compared with hydrocortisone (HC), along with pharmacokinetics and potential adverse effects.

Inflammation was induced in adult male C57Bl6 mice by topical croton oil (300ug) administration to the ear, and swelling assessed after 24 hr by ear weight. Dose-responses to 5aTHB and HC (0-100ug) were determined by co-administration of steroid with croton oil. Oral and intravenous pharmacokinetics of 5aTHB and HC were determined.  To assess potential adverse effects, 5aTHB or HC was applied to ears of mice daily for 4wks; dosage was informed by dose response studies as efficacious (25ug), high therapeutic (100ug) and supra-therapeutic (200ug). Body weight and ear skin thickness were measured biweekly. At cull; treated and control ears and adrenals were weighed. Plasma insulin was analysed by ELISA and RNA abundance by qPCR. Data are mean±SEM, *p<0.05, (n=6-12).

The anti-inflammatory IC50s for 5aTHB and HC were 23.3 and 12.7ug, respectively. 5aTHB had 17% oral bioavailability, and was cleared 15x faster than HC. Daily treatment with HC caused significant ear skin thinning by day 6, with maximum effect by day 13: 20±3*, 22±2* and 17±2*% thinning at 25, 100 and 200ug HC respectively. HC dose-dependently reduced ear weight (at cull) by 23±5%* 39±3%* and 43±12*%, and reduced abundance of collagen RNA at even the lowest dose of HC by 76±5%*(Col1a1), 79%±5*(Col1a2) and 84±4%*(Col3a1). By contrast, 5aTHB caused only slight and transient skin thinning; there was no difference in ear weight at cull or in any of the collagen subtypes (p>0.1 at all doses). HC had systemic effects: the contralateral (untreated) ear was lighter at the two higher doses (33±5%* and 41±5%*), and body weight was reduced at all doses (p<0.001).  The two higher doses of HC reduced adrenal weight (by 50±7%* and 42±7%*), and increased plasma insulin (by 3.5* and 5.2*fold) indicating systemic effects on HPA axis activity and glucose metabolism. All systemic effects were absent at even the highest dose of 5aTHB (p>0.2 for all comparisons).

In summary, 5aTHB is equivalently efficacious to HC in the croton oil mouse model of skin inflammation. Crucially, 5aTHB has low systemic availability and chronic treatment does not result in the negative skin or systemic (HPA axis or metabolic) effects induced by hydrocortisone. 5aTHB therefore has potential for development as a novel topical anti-inflammatory agent with improved therapeutic index.

 

Nothing to Disclose: DEL, CS, LMH, BRW, RA

13772 6.0000 MON-0802 A 5alpha-Tetrahydrocorticosterone: A Novel Topical Anti-Inflammatory Agent with Improved Therapeutic Index 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Christine Jewell*1, Lisa Murphy2, Crystal Cannon2, Stavros Garantziotis2 and John A Cidlowski3
1NIEHS/NIH, Research Triangle Park, NC, 2Natl Inst Env Hlth Sci/NIH, Research Triangle Park, NC, 3NIEHS/NIH, Research Triangle Pk, NC

 

Glucocorticoids are important mediators in the pathogenesis of cardiovascular disease and metabolic syndrome. They exert their effects through glucocorticoid receptors (GR), which are expressed in most cells of the body and regulate the expression of multiple downstream genes.  Glucocorticoids are widely used to treat immunological and inflammatory diseases such as asthma and rheumatoid arthritis; however, not all patients respond equally to glucocorticoid treatment.  This has led to the classification of patients as steroid resistant or steroid sensitive, and in turn, to the identification of many single nucleotide polymorphisms (SNPs) in the GR gene.  One SNP that has been linked to glucocorticoid sensitivity as well as coronary artery disease, obesity and Type II diabetes (metabolic syndrome) is N363S (1220A-G) (rs6195). To investigate the functional relevance of the N363S GR SNP, we utilized samples from the NIEHS Environmental Polymorphism Registry (EPR) which is a racially diverse DNA repository of over 15,000 participants. Our primary goals were:  1) to examine a racially diverse population for the N363S SNP, 2) to examine the responsiveness of N363S carriers to glucocorticoids using a modified dexamethasone suppression test, and 3) to investigate the role of genes involved in metabolic syndrome in macrophages from N363S carriers and matching wild type controls exposed ex vivo to glucocorticoids.  Clinical data on genotyped age and sex matched wild type GR and N363S GR participants revealed that N363S GR carriers have significantly increased levels of insulin suggesting they are insulin resistant, a condition that is associated with the chronic inflammation induced by central adiposity and metabolic syndrome. To further examine the insulin resistance phenotype at a molecular level, we compared RNA extracted from macrophages treated ex vivo with or without 100nM dexamethasone from wild type GR and N363S GR EPR participants and performed quantitative RT-PCR on known gene players in the insulin, inflammation and metabolic pathways.  Genes including HSD11B1, IRS1 and GLUT4 showed a significant difference in regulation between wild type GR and N363S GR.  Thus, this data delineates a potential molecular mechanism for the insulin resistance phenotype observed in N363S GR carriers.

 

Nothing to Disclose: CJ, LM, CC, SG, JAC

13911 7.0000 MON-0803 A The Role of Glucocorticoid Receptor N363S Single Nucleotide Polymorphism in Receptor Function and Metabolic Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Nicolas C. Nicolaides*1, Eliza B. Geer2, Dimitrios Vlachakis3, Amalia Sertedaki4, Ioanna Bakopoulou4, Sophia Kossida3, George P. Chrousos5 and Evangelia Charmandari4
1Biomedical Research Foundation of the Academy of Athens, Athens, Greece, 2Mt Sinai School of Medicine, New York, NY, 3Biomedical Research Foundation of the Academy of Athens, Greece, 4Athens University, School of Medicine, Athens, Greece, 5University of Athens, School of Medicine, Athens, Greece

 

Primary Generalized Glucocorticoid Resistance is a rare familial or sporadic disorder characterized by generalized, partial, target-tissue insensitivity to glucocorticoids. The molecular basis of this condition has been ascribed to inactivating mutations in the human glucocorticoid receptor (hGR) gene. We have previously reported a novel heterozygous mutation in the hGR gene in a patient with the condition, which resulted in histidine (H) to arginine (R) substitution at amino acid position 726 in the ligand-binding domain of the receptor. In the present study, we investigated the molecular mechanisms through which the mutant receptor hGRαH726R impairs glucocorticoid signal transduction. In transient transfection assays, hGRαH726R demonstrated reduced ability to transactivate the glucocorticoid-inducible MMTV promoter in response to increasing concentrations of dexamethasone and did not exert a dominant negative effect upon the wild-type receptor (hGRαWT). The hGRαH726R displayed decreased ability to transrepress the NF-κB signaling pathway compared with the hGRαWT. Western blot analysis revealed equal protein expression of hGRαWT and hGRαH726R. Dexamethasone-binding assays showed that the affinity of the mutant receptor hGRαH726R for the ligand was 2-fold lower than that of the hGRαWT (Kd=20.7 ± 3.25 nM vs. 9.2 ± 3.82 nM). Subcellular localization and nuclear translocation studies confirmed predominantly cytoplasmic localization of both hGRαH726R and hGRαWT in the absence of ligand; exposure to dexamethasone (10-6 M) induced a slower translocation of hGRαH726R (60 min) into the nucleus compared with the hGRαWT (15 min). In GST pull-down assays, the mutant receptor hGRαH726R demonstrated impaired interaction with the LXXLL motif of the GRIP1 coactivator through its defective AF-2 domain. Finally, a 3D molecular modeling study of the H726R mutation revealed a significant structural shift in the rigidity of helix 10 of the receptor. Indeed, His726 was loosely bound via hydrophobic interactions through the side chain of the imidazole ring, while the longer arginine side chain established strong hydrogen bonding interactions with the core of the structure. The latter resulted in reduced flexibility of helix 10 and decreased affinity of the mutant receptor for binding to the ligand. We conclude that the natural mutant receptor hGRαH726R impairs multiple steps of glucocorticoid signal transduction, thereby decreasing tissue sensitivity to glucocorticoids.

 

Nothing to Disclose: NCN, EBG, DV, AS, IB, SK, GPC, EC

14895 8.0000 MON-0804 A A Novel Point Mutation of the Human Glucocorticoid Receptor Gene Causes Primary Generalized Glucocorticoid Resistance through Reduced Flexibility of Helix 10 of the Ligand-Binding Domain of the Receptor and Decreased Affinity for the Ligand 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Krystle Anne Frahm* and Stuart Allen Tobet
Colorado State University, Fort Collins, CO

 

Neurons of the paraventricular nucleus of the hypothalamus (PVN) integrate peripheral signals and coordinate responses that are important for maintaining homeostasis, vasomotor tone, energy balance, stress responses and behavioral functions.  In addition to the density of its cytoarchitecture, the PVN also contains 3-fold more blood vessels than surrounding brain regions.  Previously, exposure to excess glucocorticoids during fetal development resulted at postnatal day (P)20 in increased blood-brain barrier (BBB) permeability and area of desmin immunoreactive (ir) pericytes on a significantly smaller blood vessel network within the PVN (Frahm & Tobet, 2013; Endocrine Abstracts FP03-4/SAT-5).  To further define the temporal parameters of these effects, mice were exposed to either vehicle (veh) or the synthetic glucocorticoid dexamethasone (dex; 0.1mg/kg) during embryonic days 11-17 and on P50 male and females were perfused with the low molecular weight dye fluorescein isothiocyanate (FITC).  Brains were then examined for ir-GFAP for astrocytes and ir-desmin as a marker for pericytes.  Results showed that veh-treated females had more total ir-GFAP than dex-treated females in the PVN (p < 0.05).  Astrocyte associations with blood vessels were estimated by examining GFAP-ir fluorescent overlap with FITC labeled vasculature. There was a similar pattern of decreased ir-GFAP covering blood vessels in dex-treated females compared to veh-treated females (P < 0.05).  For ir-desmin pericytes in the PVN, there was a significant increase in ir-desmin normalized to blood vessel density in dex-treated compared to veh-treated males (p < 0.05).  There were no significant differences observed for dex treatment or sex in extravascular FITC leakage or blood vessel density. In our previous study at P20, exposure to excess glucocorticoids during fetal development decreased the blood vessel network and BBB competency.  The current results demonstrate that at P50 the BBB is functional even though the components of the BBB were altered (in a sex-specific manner). We hypothesize that these alterations in BBB components in combination with environmental or physiological challenges may result in sex-related changes in BBB competency.

 

Nothing to Disclose: KAF, SAT

13835 9.0000 MON-0805 A Prenatal Dexamethasone Alters the Composition of the Blood-Brain Barrier within Paraventricular Nucleus of the Hypothalamus at Postnatal Day 50 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Rene Baudrand*, Cristian A Carvajal, Carmen Campino, Carmen A Carrasco, Jose Miguel Dominguez, Fidel Allende, Sandra Solari, Carlos F Lagos, Carolina P Valdivia, Andrea Vecchiola, Alejandra Tapia and Carlos E Fardella
Pontificia Universidad Catolica de Chile, Santiago, Chile

 

BACKGROUND/AIM: Obesity and the metabolic syndrome (MetS) are associated with higher glucocorticoid metabolites (GCM) and inappropriate aldosterone levels. While body mass index (BMI) may correlate with cardiometabolic risk factors, it cannot quantify body fat content or distribution. Therefore, we aimed to assess whether body composition could be a better predictor of dysregulated adrenal secretion and  metabolic disorders.

METHODS: We recruited 103 adults (18-81 years, BMI 29.6 ± 4.4 kg/m2, 65% female, 48% MetS by ATPIII). Body composition (fat and muscle mass) and visceral adipose tissue (VAT) were estimated with a previously validated monitor1. We measured in plasma: aldosterone, cortisol, adiponectin and leptin. Cortisol production was estimated as the sum of free urinary GCM (tetrahydrocortisol, allo-tetrahydrocortisol and tetrahydrocortisone, assessed by LC-MS/MS).

RESULTS: Body fat mass was correlated with leptin levels (r=0.82, P<0.001) and negatively to muscle mass (r=-0.89, P<0.001). When adjusting for age and gender, GCM levels were better correlated with VAT estimation (partial-r=0.38, P=0.006) than BMI (partial-r=0.25, P=0.008) or abdominal circumference (partial-r=0.20, P=0.047) and were inversely correlated with muscle mass (partial-r=-0.31, P=0.046). In addition, fat mass but not BMI, was associated with higher plasma aldosterone (r=0.21, P=0.048). Both fat mass and VAT estimation were better predictors of MetS than BMI or muscle mass in a backward-stepwise logistic regression. Moreover, a multivariate predictive model showed highly discriminative capacity for MetS (ROC curve 0.933, Sensitivity 85%, Specificity 92%). Selected variables in this model not included in MetS criteria were: age, gender, fat mass, GCM (all of them increasing the risk) and adiponectin (with a protective effect).   

CONCLUSIONS: We observed that body composition and fat distribution differences correlate better than BMI with GCM and aldosterone. These findings suggest that fat mass may modulate the synthesis of adrenal hormones, such as cortisol and aldosterone that are associated with cardiovascular risk and MetS. Furthermore, including fat mass estimation rather than BMI to other well known risk factors improved a clinical model that accurately predicts MetS status.

 

Nothing to Disclose: RB, CAC, CC, CAC, JMD, FA, SS, CFL, CPV, AV, AT, CEF

15426 10.0000 MON-0806 A Body Composition Rather Than BMI Is Related to Adrenal Hormone Dysregulation and Metabolic Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Irit Hochberg*1, Sophie Petropoulos2, Nhu Quynh T. Tran3, Ariel L Barkan4, Alan R Saltiel4, William F Chandler5, Moshe Szyf6 and Dave Bridges3
1Rambam Health Care Campus, Haifa, Israel, 2McGill University, Montreal, Canada, 3University of Tennessee, Memphis, TN, 4Univ of Michigan, Ann Arbor, MI, 5University of Michigan, Ann Arbor, MI, 6McGill University

 

Context: Excess glucocorticoids have many clinically important effects in adipose tissue, including redistribution of adipose tissue mass and insulin resistance.   

Aim: To determine the effect of chronic exposure to endogenous cortisol on gene expression and DNA methylation in human adipose tissue.

Experimental design: We compared global gene expression in subcutaneous fat biopsies from Cushing's disease patients undergoing transsphenoidal pituitary adenomectomy with that of controls undergoing a similar surgery for non-functioning pituitary adenoma. mRNA was analyzed by next-generation sequencing and bioinformatic analysis of transcript expression was performed by DeSeq2 and GOseq package. Genomic DNA Illumina Infinium HumanMethylation450 BeadChip sequencing was analyzed in GenomeStudioâ. 

Results: RNAseq was analysed from 6 Cushing’s disease patients and 11 controls. DNA methylation was analyzed from 4 Cushing’s disease patients and 8 controls. We identified 532 genes (199 genes downregulated and 333 upregulated) that had significantly different expression in adipose tissue from Cushing's disease patients. Among these, several key genes in glucose metabolism (LDHB, GYS2, GBE1), lipogenesis (ME1, , DGAT2, LEP, ACACA  ) and cholesterol synthesis (DHCR7 , DHCR24)  were expressed at higher levels (1.5 to 2.9 fold, Padj<0.05) in Cushing's patients. CIDEA, an important regulator of lipid metabolism, had a 2 fold lower expression in Cushing's patients (Padj<0.05). Goseq analysis identified one significantly different KEGG pathway (glycolysis /gluconeogenesis) and two significantly different GO terms for biological processes (glucose catabolic process and monosaccharide catabolic process. Genome-wide DNA methylation found 1808 CGs (corresponding to 1031 unique genes, 541 methylated and 450 demethylated) that were significantly differentially methylated in adipose tissue derived from patients with Cushing’s disease compared to control (P<0.001 and delta beta value of ± 15%).  Interestingly, many of the top 40 genes found to be significantly methylated or demethylated are involved in cellular metabolic processes. Of the differentially methylated genes, 17 also had a significantly different mRNA expression.

Conclusions: We have identified the glucocorticoid gene expression and methylation signatures in human adipose tissue. It is likely that changes in expression of key enzymes in glucose and lipid metabolism contribute to the effects of excess glucocorticoids on adipose tissue metabolism.

 

Nothing to Disclose: IH, SP, NQTT, ALB, ARS, WFC, MS, DB

15084 11.0000 MON-0807 A The Cushing's Disease Gene Expression and DNA Methylation Signature in Human Adipose Tissue Reveals Novel Mechanisms for the Metabolic Effects of Excess Glucocorticoids 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Johanna C. van den Beukel*1, Mariëtte R. Boon2, Jacobie Steenbergen1, Onno C. Meijer2, Axel P.N. Themmen1 and Aldo Grefhorst1
1Erasmus MC, Rotterdam, Netherlands, 2Leiden University Medical Center, Leiden, Netherlands

 

Mammals have two distinct types of adipose tissue. White adipose tissue (WAT) stores energy as triglycerides (TGs) and brown adipose tissue (BAT) oxidizes TG-derived fatty acids to produce heat, a process in which uncoupling protein 1 (UCP1) is essential. Active BAT is considered beneficial for metabolism. Cold exposure is a common method to induce BAT activity in laboratory animals. Chronic glucocorticoid treatment is accompanied by metabolic side effects such as central obesity and hypertriglyceridemia. We questioned whether induction of BAT activity by cold exposure corrects glucocorticoid-induced metabolic disturbances in mice.

Mice were implanted with 50-mg corticosterone or control pellets and housed for 24 h at 23 °C or 4 °C one week later. Animals were sacrificed after these 24 hours and their faeces, blood and BAT were collected for analysis. An additional group of mice was injected with 14C-deoxyglucose after the 24-h 23 °C or 4 °C to measure glucose uptake by BAT as a proxy for BAT thermogenesis.

As expected, corticosterone treatment resulted in ~4-fold induction of 24-h fecal corticosterone excretion. Cold exposure enhanced 24-h fecal corticosterone excretion, remarkably even in corticosterone treated mice. Corticosterone treatment worsened metabolism as was evident from increased blood glucose (p=0.006) and plasma TG concentrations. Cold exposure corrected both blood glucose and plasma TG concentrations of corticosterone treated mice. BAT activity was inhibited by corticosterone: BAT Ucp1 expression was reduced by 75% (p=0.008) and BAT depot weight was 3.5-fold increased due to lipid accumulation making the BAT almost indistinguishable from WAT. Independent of the treatment, cold exposure induced BAT Ucp1 expression and reduced BAT lipid content. In mice kept at 23 °C, corticosterone treatment reduced BAT glucose uptake by 75% (p=0.003). Upon cold, BAT glucose uptake did not differ between control and corticosterone-treated mice (p=0.11).

In conclusion, corticosterone treatment reduces BAT activity, but this is rescued by cold exposure. Cold not only activates BAT but also corrects corticosterone-induced metabolic disturbances such as elevated blood glucose and plasma TG concentrations.

 

Nothing to Disclose: JCV, MRB, JS, OCM, APNT, AG

16937 12.0000 MON-0808 A Cold Exposure Corrects Glucocorticoid-Induced Metabolic Disturbances in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Alfonso Leal-Cerro*1, Juan Antonio García-Arnés2, Juan Antonio Lillo-Muñoz3, Mauro Boronat4, Ana Maria Sanchez-De Abajo4, Anna Aulinas5, Eulàlia Urgell-Rull6, Carmen Fajardo7, Mario Ortuño-Alonso8, Cristina Lamas-Olivera9, Isabel Salinas-Vert10, Elena Torres-Vela11, Antonia Blazquez-Ortiz12, Javier Salvador13, Silvia Maraver-Selfa14, Ana Peña-Aguera14, Pilar Sánchez-Mártinez15, Natividad González-Rivera16, Anna Casteras-Roman17, Rosa Camara18, Ignacio Bernabeu19 and Antonio Leon-Justel20
1Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío Seville, Sevilla, Spain, 2Carlos Haya Hospital, Málaga, Spain, 3Hospital Carlos Haya, Malaga, Spain, 4Hospital Universitario Insular, Las Palmas de Gran Canaria, Spain, 5Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII,IIB- Hospital Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain, 6Hospital de Sant Pau, Barcelona, Spain, 7Hospital Universitario La Ribera, Alzira. Valencia, Spain, 8Hospital de la Ribera, Alzira. Valencia, Spain, 9Hospital general Universitario de Albacete, Albacete, Spain, 10Hospital Universitari Germans Trias i Pujol, Barcelona, Spain, 11Hospital San Cecilio, Granada, Spain, 12Hospital San Cecilio, Granada, 13Clínica Universitaria de Navarra. Universidad de Navarra, Pamplona, Spain, 14Hospital Clinico Universitario Virgen de la Victoria, Malaga, Spain, 15Virgen Macarena University Hospital, Sevilla, Spain, 16Unidad de Gestión de Endocrinología y Nutrición. Hospital Universitario Virgen Macarena, Sevilla, Spain, 17Hospital Universitario Vall d'Hebrón, Barcelona, Spain, 18Hospital la Fe, Valencia, Spain, 19Complejo Hospitalario Universitario de Santiago de Compostela, Universidad de Santiago de Compostela, Santiago de Compostela, Spain, 20Hospital Universitario Virgen del Rocío, Sevilla, Spain

 

Diagnostic screening for Cushing's syndrome has been proposed for patients with multiple, severe or progressive conditions associated with hypercortisolism. However, information about the performance of routine diagnostic work-up in this type of population is scant. In addition, measurement of urinary free cortisol excretion, probably the most often employed initial test to diagnose Cushing's syndrome, has limitations in high-risk populations because of its low specificity and reproducibility. Determination of midnight salivary cortisol levels (MSC) is considered an easy and inexpensive alternative to assess patients with suspected hypercortisolism. Here we report the preliminary results of a Spanish multicentre study, CRISALIDA (CRIbado en SALIva De Alteraciones del cortisol), a survey aimed to evaluate the effectiveness of MSC as a screening method for hypercortisolism in a high-risk population. In addition, we also aimed to calculate the prevalence of Cushing syndrome in this settting.

Methods/design

Multicentre (19 centers in Spain) cross-sectional study. Sample size will be 609 patients with at least two of the following manifestations: obesity (BMI>30 kg/m2), uncontrolled hypertension in spite of medical treatment (SBP>140 and DBP>90 mmHg, >2 drugs), poorly controlled diabetes (HbA1C>7,0%), osteoporosis (T score -2.5) or hyperandrogenism in women. Two MSC samples are measured (at 22:30 and 23:00 h). In addition, an overnight 1 mg dexamethasone suppression test is performed (DST) the following morning. In this test, both serum and salivary cortisol levels are measured.

Results

As of January 2014, out of 609 patients to be included, 272 have been included in the study and results have been obtained for 201. Hypercortisolism was excluded in 141 (70.1%) and was confirmed in 22 cases (10.9%). In 38 cases (18.9%), the results were inconclusive and need to be re-evaluated. In the hypercortisolism group, 81.8% of the patients were women, 93.5% were obese (BMI 34,32 ± 6.10 kg/m2), 59.1% showed uncontrolled hypertension, 36.1% had poorly controlled diabetes (HbA1c 6.2 ± 1.19 %), 27.3 % had been diagnosed with osteoporosis and 40,9% of the female patients showed hyperandrogenism. No differences in MSC levels were found between the 22:30h (82.99 ± 221.80 nmol/l) and the 23:00h (61.05±167.00 nmol/l) measurements (p=0.274) in the hypercortisolism group, values for the DST were 38.14 ± 50.87 nmol/l for salivary cortisol and 311.15 ± 309.02 nmol/l for serum cortisol. In the group in which hypercortisolism was excluded, no differences in cortisol levels were found between the 22:30h (5.27 ± 2.09 nmol/l) and the 23:00h (6.39 ± 2.69 nmol/l) measurements (p= 0.881), and values for the DST were 6.70 ± 5.30 nmol/l for salivary cortisol and 27.69 ± 23.52 nmol/l for serum cortisol.

Conclusion

MSC is a valuable and convenient alternative for the screening of hypercortisolism in high-risk populations.

 

Nothing to Disclose: AL, JAG, JAL, MB, AMS, AA, EU, CF, MO, CL, IS, ET, AB, JS, SM, AP, PS, NG, AC, RC, IB, AL

14489 13.0000 MON-0809 A Multicentre Evaluation of the Efficacy of Midnight Salivary Cortisol As a Screening Test for the Diagnosis of Hypercortisolism within an at-Risk Population: Crisalida Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Roland H Stimson*, Anna J Anderson, Lynne E Ramage, Ruth Andrew and Brian R Walker
University of Edinburgh, Edinburgh, United Kingdom

 

Acute glucocorticoid (GC) excess is thought to increase lipolysis, however chronic GC excess paradoxically increases fat mass. Most previous studies examining the lipolytic effects of GCs have been performed ‘in vitro’, while the ‘in vivo’ studies have mostly used very high GC doses and/or not clamped counter-regulatory hormone levels. We tested whether the effects of GCs on lipolysis are dependent on the prevailing insulin and adrenaline concentrations.

20 healthy men (age 33±3 y, BMI 23.8±0.3 kg/m2) attended after overnight fast on 3 occasions, randomised in a crossover design to 14 hours of either low GC (metyrapone plus placebo; plasma cortisol 165±11nM), medium GC (metyrapone plus low dose hydrocortisone (HC); cortisol 427±20nM) or high GC (metyrapone plus high dose HC; cortisol 1423±54nM). On each occasion, subjects received intravenous (IV) somatostatin for 345 mins with glucagon and growth hormone replacement, and deuterated glycerol and glucose infusions to measure whole-body lipolysis and glucose kinetics. Subjects were further randomised in parallel groups of 10 to receive 345 mins of either low or high dose insulin replacement (0.06 vs 0.20 mU/kg/min) with IV dextrose infused to maintain blood glucose at 8mM. IV adrenaline was infused during the final hour. Data are mean ± SEM.

In the absence of adrenaline, high GC prevented suppression of Ra glycerol (1.1±0.1 vs 0.9±0.1 vs 0.9±0.1 μmol/kg/min, P<0.05 vs medium/low) and plasma FFAs (64±12 vs 40±4 vs 33±6 μM, P<0.05) in the high but not low insulin group. In the presence of adrenaline, high GC increased FFAs in both low (681±80 vs 465±50 vs 486±59 μM, P<0.05) and high (322±54 vs 137±22 vs 110±21 μM, P<0.05) insulin groups, and increased Ra glycerol with high insulin (3.4±0.4 vs 2.5±0.3 vs 2.7±0.3 μmol/kg/min, P<0.05). Low GC was unchanged from medium GC, and GC had no effect on glucose kinetics in any conditions.

Acute changes in GC levels do not alter whole-body lipolysis in the presence of low insulin or low adrenaline. Supraphysiological levels of GCs substantially augment the pro-lipolytic effect of adrenaline and weakly antagonise the anti-lipolytic effect of insulin, however varying GC levels within the physiological range does not alter whole-body lipolysis. These results may partially explain the differential effects of hypercortisolaemia on fat storage with acute stress (with high adrenaline/ low insulin levels) versus chronic stress (characterised by hyperinsulinaemia/ low adrenaline).

 

Nothing to Disclose: RHS, AJA, LER, RA, BRW

14760 14.0000 MON-0810 A The Acute Lipolytic Effects of Glucocorticoids in Humans Are Dependent on Insulin and Adrenaline 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Carlos F Lagos*1, Andrea Vecchiola1, Cristobal A Fuentes1, Fidel Allende1, Alejandra Tapia1, Carolina P Valdivia1, Sandra Solari1, Rene Baudrand1, Gareth Ivor Owen1, Mariana Cifuentes2, Cristian A Carvajal1 and Carlos E Fardella1
1Pontificia Universidad Catolica de Chile, Santiago, Chile, 2Universidad de Chile, Santiago, Chile

 

The enzyme 11-beta hydroxysteroid dehydrogenase type 1 (11β-HSD1), regenerates cortisol (F) from inactive cortisone in liver and adipose tissue, and is a therapeutic target for central obesity, insulin resistance and hypertension. Selectivity for the reductase activity of 11β-HSD1 and over 11β-HSD2 isoform has been suggested as critical issues for successful clinical efficacy.

Aim. To identify novel selective non-steroidal 11β-HSD1 inhibitors using structure and ligand-based virtual screening and in vitro assays in human adipose cell-line.

Methods. The crystal structures of human 11β-HSD1 were retrieved from the Protein Data Bank database. Protein preparation and editing, atom typing (protein, ligand and cofactors), protein–ligand complexes structural alignment, and ligand clustering were performed using Accelrys Discovery Studio. Ligands were clustered using ECFP fingerprints, and structure-based pharmacophore models for each protein in the cluster were generated with LigandScout v3.1. The three-dimensional alignment of the ligands for each cluster was used to construct the shape-based queries with vROCS. The OpenNCI database (~260,000 compounds) was retrieved and filtered by ADME/Tox constraints with FILTER, and the conformers generated by OMEGA . Virtual screening of the conformer database was performed with ROCS v3.2 (shape-queries) and further scored and ranked by accomplishment with the obtained pharmacophore model for each cluster. Compounds were obtained from the Developmental Therapeutic Program (NCI DTP), and 11β-HSD1 activity assays performed in differentiated LS-14 cells using 18β-glycyrrhetinic acid as control inhibitor. Cortisone (E) and Cortisol (F) production were quantified by LC-MS/MS.

Results. A set of 25 11β-HSD1-ligand complexes was structurally aligned. The RMSD for the superimposition of all proteins was less than 2Å. Ligand clustering results in 5 main groups, one of them containing only steroidal molecules. Enrichment rates for the shape-query and pharmacophore models were higher than 75%. The top 1000 hits from shape-based query virtual screening filtered with the pharmacophore models render the best 100 hits. Of these, a final selection of 40 compounds was obtained from the NCI DTP and biologically assayed, showing no effect over cellular viability. Inhibition assays identified 2 novel hits compounds displaying enzyme inhibitory activities in the low micromolar range in cell-based assay.

Conclusion. Virtual screening experiments and subsequent in vitro evaluation of promising hits revealed several selective inhibitors. Efficient inhibition of human 11β-HSD1-mediated cortisol production in LS-14 adipocytes was demonstrated for 2 compounds. Our results suggest that ligand and structure-based approaches in combination with cell-based activity assays are useful for the identification of 11β-HSD1 inhibitors.

 

Nothing to Disclose: CFL, AV, CAF, FA, AT, CPV, SS, RB, GIO, MC, CAC, CEF

16854 15.0000 MON-0811 A Novel 11β-HSD1 Inhibitors Identified through Structure-Based Pharmacophore Modeling and Shape-Based Virtual Screening 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Owen R Vaughan*1, Miles J De Blasio2, Janelle W Ward1 and Abigail L Fowden1
1Centre for Trophoblast Research, University of Cambridge, United Kingdom, 2University of Adelaide, Adelaide, Australia

 

Background and Aims

Fetal cortisol concentrations rise naturally before birth and during adverse conditions earlier in gestation. In both situations, fetal growth and nutrient demand are reduced. This study examined whether the effects of cortisol on ovine feto-placental glucose metabolism are sex linked.

Methods

Studies were conducted under the Animals (Scientific Procedures) Act 1986. After recovery from catheterisation under general anaesthesia, sheep fetuses were infused with either cortisol (1.38 ± 0.04 mg/kg/day i.v.; n=10 females, F & n=11 males, M) or saline (0.9% w/v, n =10F & n=8M) for 5 days from ≈125 days of gestation (term ≈145 days). On day 5 of infusion, net feto-placental glucose uptakes and transplacental clearance of non-metabolisable 3H-methyl-D-glucose were measured using antipyrine infusion to quantify blood flow. After euthanasia (Na pentobarbitone 200mg/kg), placental tissue was collected for gene expression analyses. Effects of treatment (Pcort), sex (Psex) and their interaction (Pinter) were analysed by two-way ANOVA. Values are mean ± SEM.

Results

On day 5 of infusion, plasma cortisol concentration was significantly greater in cortisol (78±8 ng/ml) than saline infused fetuses (17±1 ng/ml; Pcort<0.0001) and was unaffected by sex (Psex & Pinter>0.05). Fetal blood glucose concentration was also higher in cortisol (1.10 ± 0.06 mM) than saline infused animals (0.83 ± 0.03 mM; Pcort<0.0001; Psex, Pinter>0.05) with no change in maternal glycaemia (P>0.05, all cases).  Materno-fetal plasma glucose concentration gradients were, therefore, reduced by cortisol infusion and, moreover, were lower in males than females, independent of treatment (saline; F, 2.6±0.1 mM, M, 2.3±0.1 mM; cortisol; F, 2.3±0.1mM M, 2.2±0.1mM; Pcort=0.011, Psex=0.021, Pinter>0.05).  Umbilical glucose uptake was significantly lower in cortisol (25 ± 2 µmol/min/kg fetus, n=19) than saline infused fetuses (31 ± 2 µmol/min/kg, n=17, Pcort<0.035) but was not sex-linked (Psex & Pinter>0.05). As uterine glucose uptake was not affected by either factor (P>0.05 all cases), utero-placental glucose consumption was higher in cortisol (600±86 µmol/min/kg placenta, n=17) than saline infused fetuses (381 ± 69 µmol/min/kg, n=19, Pcort=0.049) and unaffected by sex (Psex & Pinter>0.05). Transplacental tracer glucose clearance was greater in males (289±27 ml/min/kg placenta) than females (197 ± 25 ml/min/kg; Psex=0.022) and was unaffected by treatment (Pcort, Pinter>0.05). Placental expression of Slc2a1 and Slc2a3 glucose transporter genes did not differ with sex or treatment (n=4-5 per treatment per sex; P>0.05, all cases).

Conclusion

Actions of cortisol on feto-placental glucose metabolism were not sex-linked. However, there were sex differences in the mechanisms of transplacental glucose transport although these did not result in differences in net glucose uptake by male and female fetuses.

 

Nothing to Disclose: ORV, MJD, JWW, ALF

15182 16.0000 MON-0812 A Are the Effects of Cortisol on Feto-Placental Glucose Metabolism Sex-Linked? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Owen R Vaughan*1, Paul Cordero2, Maria Haro Garcia2, Miguel Constancia2 and Abigail L Fowden1
1Centre for Trophoblast Research, University of Cambridge, United Kingdom, 2Metabolic Research Laboratories, Cambridge Biomedical Research Centre, United Kingdom

 

Glucocorticoid excess during pregnancy reduces birth weight and programs abnormal adult phenotype in the offspring. In part, these effects are mediated via changes in placental size, nutrient transfer and endocrine function [1]. This study used a genome-wide approach to determine glucocorticoid-induced changes in placental gene expression, with particular focus upon imprinted genes that are known to influence materno-fetal resource allocation.

C57BL6/J mice (n=5) were treated with corticosterone (CORT, 76 µg/g/day, in drinking water) between day (D) 11 and D16 of pregnancy (term = D21). Controls (n=5) drank tap water throughout. Following euthanasia on D16, one male placenta from each litter was selected for RNA extraction and reverse transcription. cDNA was hybridized to the Affymetrix mouse gene 1.0ST array. Fluorescence data were analysed using GeneSpring GX software to generate a list of genes differentially expressed in corticosterone-treated versus control placentae. The technical and biological validity of the microarray analysis was confirmed by real-time PCR quantification of the 4 genes with the greatest expression fold-change (Aplnr, -4.08; Slc1a2, -1.83; Lcn2, +2.43; Psg22, +1.78; all P<0.05).

Relative to untreated controls, 290 genes were upregulated and 558 downregulated in corticosterone exposed placentae (fold-change >|1.25|, P<0.05, total 35557 genes analysed). Ingenuity pathway analysis of the differentially expressed set of genes was used to identify biological function categories affected by corticosterone-treatment. Corticosterone downregulated genes involved in cardiovascular and organismal development, cell cycling, cell-cell interaction and cellular assembly but upregulated genes involved in nervous system, connective tissue and musculoskeletal development, carbohydrate metabolism and cell death (all P<10-8). The list of differentially expressed genes was compared with specific gene sets from the Molecular Signatures Database (v4.0, [2]) to determine the effect of corticosterone on imprinted genes (set M2491, [3]) and genes containing a glucocorticoid receptor binding motif (M3647). Corticosterone treatment downregulated five paternally-expressed imprinted genes (Dlk1, Magel2, Mest, Ndn, Plagl1) and two maternally-expressed imprinted genes (Igf2r, Meg3) and upregulated only the paternally-expressed Ddc gene. Eight of the genes differentially expressed in corticosterone treated versus control placentae were known to contain a glucocorticoid receptor binding motif (upregulated, Fl1, Scnn1a, Gipc2, Mboat2; downregulated Slc7a11, Cdh2, Ets1, Gen1).

Overall, corticosterone has a predominantly downregulatory effect on placental gene expression, including the expression of imprinted genes. Persistent changes in these genes may alter fetal resource allocation and thus influence growth epigenetically.

 

Nothing to Disclose: ORV, PC, MH, MC, ALF

15230 17.0000 MON-0813 A Glucocorticoid-Induced Gene Expression Changes in the Mouse Placenta Identified By Microarray 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Owen R Vaughan*1, Miles J De Blasio2 and Abigail L Fowden1
1Centre for Trophoblast Research, University of Cambridge, United Kingdom, 2University of Adelaide, Adelaide, Australia

 

Background and aims

Glucocorticoids like cortisol have an important role in fetal development. In adults, they regulate metabolism and fetal cortisol is known to alter utilization of glucose and lactate in fetal sheep near term [1]. However, little is known about the effects of maternal cortisol on fetal metabolism. Therefore, we determined the effect of maternal cortisol administration during late gestation on the umbilical uptake of oxygen and nutrients in fetal sheep.

Methods

Studies were conducted under the Animals (Scientific Procedures) Act 1986. After catheterisation under general anaesthesia, pregnant ewes were infused with cortisol (1.19 ± 0.04 mg/kg/day, i.v., n=14) or saline (0.9%w/v, n=20) as a control for 5 days from ≈125 days of pregnancy (term ≈145 days). On day 5 of infusion, umbilical uptake of oxygen (O2), lactate and glucose was measured using Fick principle and antipyrine infusion to quantify umbilical blood flow. At the end of the study, ewe and fetus were euthanised for tissue collection (Na pentobarbitone, 200mg/kg). Mean ± SEM values are presented per kg fetal body weight and statistical significance assessed by Student’s t-test.

Results

There was no significant effect of maternal cortisol treatment on umbilical glucose uptake (saline, 30.6 ± 2.0 µmol/min/kg; cortisol, 26.4 ± 2.8µmol/min/kg, P>0.05). In contrast, umbilical uptake of lactate was higher in cortisol treated (26.2 ± 2.7µmol/min/kg) than control animals (17.6 ± 2.1 µmol/min/kg, P<0.015). Similarly, umbilical O2 uptake was 30% higher in cortisol than saline treated ewes (cortisol, 416 ± 31 µmol/min/kg; saline, 302 ± 13 µmol/min/kg, P<0.004). There was a significant positive correlation between the umbilical uptakes of O2 and lactate (r=0.489, P=0.008, n=28). There was no significant effect of cortisol treatment on umbilical blood flow (P>0.05). Neither did fetal arterial O2 content nor blood glucose and lactate concentrations differ with maternal treatment (P>0.05, all cases). Fetal body weight was similar in the two groups (P>0.05).

Discussion

Maternal cortisol treatment altered fetal metabolism. Since the lactate used by the fetus is produced primarily by the placenta, the results suggest that placental oxidative metabolism may be reduced leading to increased lactate production and O2 availability for onward transfer to the fetus.

 

Nothing to Disclose: ORV, MJD, ALF

15694 18.0000 MON-0814 A Maternal Cortisol Administration Alters the Fetal Nutrient Supply 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Giuseppe Reimondo*1, Marcella Coletta1, Daniela Giachino2, Iacopo Chiodini3, Darko Kastelan4, Valentina Morelli5, Salvatore Cannavo6, Alessandra Cuccurullo2, Paolo Beck-Peccoz7, Mario De Marchi8 and Massimo Terzolo1
1Medicina Interna 1 - AOU San Luigi, Orbassano (TO), Italy, 2Genetica Medica - AOU San Luigi, Orbassano (TO), 3Fondazione Policlinico IRCCS, milan, Italy, 4Department of Endocrinology, Zagreb, Croatia, 5University of Milan, Fondazione IRCCS Ca’ Granda-Ospedale Maggiore Policlinico, Milan, Italy, 6University of Messina, Messina, Italy, 7University of Milan, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy, 8Genetica Medica - AOU San Luigi

 

Context: Some variants of the glucocorticoid receptor (GR) gene have been found to alter glucocorticoid sensitivity and have been associated with worsen metabolic profiles.

Objective: The aims of the present study were: 1) to examine whether the prevalence of N363S, ER22/23EK and BclI variants was different in patients with adrenal incidentaloma (AI) with or without subclinical Cushing syndrome (SCS) than in the general population and 2) whether the presence of these gene variants may be linked to metabolic or hormonal abnormalities in patients with adrenal incidentalomas or subclincal cushing syndrome.

Design: The study included 411 patients with adrenal incidentalomas and 189 control subjects. Metabolic and hormonal parameters and GR gene variants (on genomic DNA by pyrosequencing assays) were determined. Patients were stratified in three groups by using cortisol after 1 mg DST (<1.8 mcg/dl, between 1.9 and 3 mcg/dl, >3 mcg/dl)

Results: When compared with control subjects, the carrier frequency for the three variants was similar (N363S 5.4% vs 9.1%, BclI  54% vs 44.6%, ER22/23EK 4.4% vs 3.8%) and we have not observed any difference between the three groups defined by cortisol after 1 mg DST. Only N363S carriers showed hypertension (86.4% vs 63.9%, p=0.03) and hyperlipidemia (63.4 vs 43.8%, p=0.05) more frequently than the remainders. In a multiple regression analysis including N363S, age, sex and BMI (R2=0.06, p<0.01), N363S was demonstrated to be an independent predictor of hypertension only in patients with non-secreting adenoma.

Conclusion: In our study the prevalence of the three variants is the same as reported in literature, without any differences related to the alteration of the HPA axis. We don’t found any correlation between ER22/23EK and BclI variants and metabolic parameters. Nevertheless, N363S could influence blood pressure levels, but the effect seems to be more evident in patients with normal cortisol secretion, while it is less apparent in subjects with an autonomous cortisol secretion. It should be considered that cortisol secretion outweights the effect of glucocorticoid receptor sensitivity on clinical phenothype.

 

Disclosure: PB: Committee Member, Sandoz. MT: Advisory Group Member, HRA PHARMA. Nothing to Disclose: GR, MC, DG, IC, DK, VM, SC, AC, MD

14775 19.0000 MON-0815 A Analysis of Bcli, N363S and ER22/23EK Polymorphism of the Glucocorticoid Receptor Gene in a Large Series of Patients with Adrenal Incidentaloma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Nick Z Lu*, Newton Li, Jesus Banuelos and Yun Cao
Northwestern University, Chicago, IL

 

Macrophages play a key role in the onset and resolution of inflammation and glucocorticoid responses of macrophages are not clearly understood. We found that toll like receptor ligands, interferon gamma, or tumor necrosis factor (TNF), but not interleukin 4, increased the level of glucocorticoid receptor (GR)-A translational isoforms while decreasing the level of the GR-D2 and -D3 isoforms within 8 h, which persisted up to 60 h. The total GR mRNA or protein was increased by these activating agents that also increased the potency of dexamethasone to inhibit proinflammatory cytokines such as TNF. In addition, the activation stimuli also reverted  glucocorticoid suppression of phagocytosis and blunted glucocorticoid suppression of nitrite production in the cells. The different glucocorticoid activities in resting and activated macrophages were blocked by RU486, indicating the role of GR isoforms in distinct glucocorticoid responses. Thus, conventionally activated macrophages express selective GR translational isoforms that alter the ability of glucocorticoids to regulate macrophage functions. 

 

Nothing to Disclose: NZL, NL, JB, YC

17043 20.0000 MON-0816 A Activation Alters Glucocorticoid Receptor Translational Isoforms and Glucocorticoid Responses in Macrophages 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Gita Avotina*1 and Ingvars Rasa2
1Riga East Clinical University Hospital, The University of Latvia, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia, 2Riga East Clinical University Hospital, Riga Stradins University, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia

 

Hypercortisolism causing thromboembolic complications is studied before, and it is considered a crucial factor predisposing pts with CS to thromboembolic events. The hypercoagulable state seen in these pts is related to cortisol excess that induces prothrombotic changes in blood. Pts with CS have been reported to have a more than 10 fold increased risk of developing venous thromboembolism. The aim of this study was to evaluate, whether pts with CS in tertiary care multi-profile Riga East Clinical University Hospital, have an impairment of thromboembolism factors. Study about coagulation factors in pts with CS is performed the first time in Latvia. This hospital based case control, retrospective study analyzes 16 medical records of CS occurring in 11 pts admitted 01.01.2009 – 06.30.2013 (4.5yrs) to The Department of Endocrinology of a tertiary care multi-profile Riga East Clinical University Hospital. All pts were analyzed, using ACTH, cortisol, urinary free cortisol and following coagulation factors: APTL, prothrombin, INR, fibrinogen, platelet count and clinical data about causes of thromboembolic complications, as well. The statistical data was processed using SPSS 16.0. All the data was presented in the mean value with a standard deviation. Normal range for APTL was defined 28.0–40.0s, prothrombin – 70.0–130.0%, INR – 0.9–1.1, fibrinogen – 2.0–4.0g/L, platelet count – 150,000–400,000, ACTH – 7.2–63.3pg/mL, cortisol – 3.7–19.4mkg/dL, urinary free cortisol – 4,3–176mkg/24h. Females were 81.8 % and males –18.2%. Females were younger than males, 54.6±11.6yrs vs 58.0±24.0yrs. ACTH was 669.2 ±1480.2pg/mL, cortisol – 17.6±9.5mkg/dL, urinary free cortisol – 195.7±143.6mkg/24h. Surgical therapy was performed for 63.6%, radiotherapy – 36.4%, medical treatment – 36.4%. APTL was 32.8 ±4.4s (n=7). Prothrombin level was 101.4±19.8% (n=10). INR was 1.0±0.1 (n=10). Fibrinogen was 4.4±1.8g/L (n=8). Platelet count was 320,300± 118,900 (n=11). Thromboembolic events occurred in 9.1% (n=1), cerebral infarctions – in 18.2% (n=2), and coronary infarctions – in 36.4% (n=4). There were a small number of pts during 4.5yrs, possibly because CS is rare and unrecognised disease. CS pts in this study have high normal levels of coagulation factors. CS pts are more prone to have coronary infarctions than cerebral infarctions and thromboembolic events. Evaluation of coagulation factor use in clinical practice and development of sensitive and early warning tests to early diagnose thromboembolism in CS pts should be done.

 

Nothing to Disclose: GA, IR

11827 21.0000 MON-0817 A Coagulation Factors in Patients (pts) with Cushing's Syndrome (CS) in Tertiary Care Multi-Profile Riga East Clinical University Hospital: 4.5 Years Data 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Masataka Kudo1, Fumitoshi Satoh*1, Sorama Aoki2, Ryo Morimoto1, Yoshitsugu Iwakura1, Yoshikiyo Ono1, Ken Matsuda1, Akira Sugawara3, Katsumi Yoshida4, Kenichi Sato2 and Sadayoshi Ito1
1Tohoku University Hospital, Sendai, Japan, 2Tohoku Pharmaceutical University, Sendai, Japan, 3Tohoku Univ Grad School of Med, Sendai, Japan, 4Tohoku Kosai Hospital, Sendai, Japan

 

Context: Cushing’s syndrome (CS) can be underdiagnosed in general practice. There are only a few reports on how to efficiently detect patients with CS before performing the specific tests.

Objectives: To establish a new method of analyzing predictors for CS using an appropriate set of routine clinical tests, which are used in general practice.

Setting, methods and subjects: This was a cross-sectional, case-control study. Thirty patients with CS and 49 healthy individuals were included in the present study. An optimal set of routine clinical tests (= a new effective marker) to screen patients with CS was discriminated and the association of those clinical tests with serum cortisol levels was established by using pattern recognition methods.

Results: Serum cortisol was highly associated with a combination of 8 characteristics (γ-GTP, LDH, Na, K, and counts of neutrophils, lymphocytes, eosinophils and monocytes) in patients with CS. The analyses using pattern recognition methods of these 8 characteristics before endocrine workups were found to be useful to discriminate the patients with hypercortisolemia who needed to undergo surgery.

Conclusions: The pattern recognition methods can be clinically useful to predict the patients with hypercortisolemia.

 

Nothing to Disclose: MK, FS, SA, RM, YI, YO, KM, AS, KY, KS, SI

15580 22.0000 MON-0818 A Usefulness of Novel Screening System Which Assists the Diagnosis of Cushing Syndrome By the Pattern Recognition Methods Using Combination of Routine Tests 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Matthew J Chapman*1, Nicola Argese2, Vijay Dabhi3, Dhanasekaran Mani3, Christopher Boot4, Rachel K Crowley5, Paul M Stewart6 and Jeremy W Tomlinson1
1Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and Experimental Medicine, University of Birmingham, United Kingdom, 2Sapienza University of Rome, 3University Hospital Birmingham NHS Foundation Trust, 4University Hospitals Birmingham NHS Foundation trust, 5Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, United Kingdom, 6University of Leeds, Leeds, United Kingdom

 

Up to 2-3% of the US and UK population are prescribed glucocorticoid (GC) therapy and their adverse effects contribute to a significant health burden. Suppression of endogenous GC secretion is a recognized complication of therapy, but the magnitude of the problem, together with its clinical consequences have not been determined. We conducted a retrospective study across all specialties in a large secondary-tertiary care center identifying 2782 patients who underwent 3666 250µg ACTH1-24 stimulation tests (CST) between 2008-2013. Patients were grouped according to indication and clinical and biochemical assessments made prior to CST were analyzed; a 30-minute cortisol of ³550nmol/L was considered indicative of adequate adrenal reserve.

497 (17.9%) patients failed the CST; failure rates were highest in those patients with underlying adrenal disease (60.8%). 693 patients had pituitary disease and 20.5% (n=142) failed the CST. 408 patients were taking oral, topical, intranasal or inhaled GC therapy (excluding those with pituitary, adrenal and central nervous system pathology) and 32.8% (n=134) of these patients failed. In this group, 30-minute cortisol response was positively associated with systolic blood pressure (p<0.05), and those patients with the lowest cortisol response had the highest number of hospital admissions in the preceding 2 years (3.7±0.5 vs. 2.6±0.2, p=0.05). In those patients taking inhaled corticosteroids (those with oral co-administration were excluded), Fluticasone treatment was associated with the highest CST failure rates (26.1%). However, in patients taking either inhaled Fluticasone or Beclometasone, there was a dose-dependent effect upon the cortisol response across the CST; those patients on the highest doses having both decreased basal and 30-minute cortisol values (e.g. Fluticasone 30-minute cortisol, <400mcg/day vs. >400mcg/day, 880±72 vs. 737±34nmol/L, p<0.05).

Suppression of adrenal reserve due to GC administration (oral, topical or inhaled) is both common and associated with adverse outcome. Future prospective studies need to define the clinical consequences and determine the optimal medical management of these patients.

 

Nothing to Disclose: MJC, NA, VD, DM, CB, RKC, PMS, JWT

14768 23.0000 MON-0819 A Adrenal Insufficiency Due to Prescribed Glucocorticoids Is Associated with Adverse Outcome: An Analysis of 3666 ACTH Stimulation Tests 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Vincent L. Wester*1, Sabine M. Staufenbiel2, Margriet A.B. Veldhorst2, Jenny A. Visser2, Laura Manenschijn2, Jan W. Koper2, Francoise J.M. Klessens-Godfroy3, Erica L.T. van den Akker1 and Elisabeth F.C. van Rossum2
1Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands, 2Erasmus MC, Rotterdam, Netherlands, 3Sint Franciscus Gasthuis, Rotterdam, Netherlands

 

Background: Obesity has been associated with relatively high cortisol output in urine. However, findings of cortisol levels in blood, saliva and urine in association with obesity have been inconsistent across studies, possibly due to the high variability in systemic cortisol levels. Cortisol levels measured in scalp hair provide a marker for long-term cortisol exposure and circumvents the limitations of time-point measurements. Using this relatively novel method, chronically increased cortisol has been linked to cardiovascular disease and disease course in Cushing’s disease. We examined whether obese patients of our academic obesity center, have higher hair cortisol concentration at intake than non-obese subjects.

Subjects and methods: Hair cortisol levels of 47 obese patients, 41 overweight and 87 normal-weight subjects were measured using an enzyme-linked immunosorbent assay (ELISA), reflecting the average systemic cortisol concentrations of the previous three months.

Results: Obese patients (median BMI 38.8, range 31.1 – 65.8) had higher hair cortisol levels than overweight and normal-weight subjects (30.8 vs 8.5 and 8.4 pg/mg hair, respectively, p<0.001). These results were independent of age and sex. Overweight and normal-weight subjects did not differ significantly in their hair cortisol levels (p>0.05). Within obese patients, hair cortisol levels did not significantly correlate with cardiometabolic risk factors.

Conclusion: For the first time, we have shown that obese patients have elevated long-term cortisol levels compared to normal weight and overweight subjects. This relative hypercortisolism may contribute to cardiovascular disease risk in obese patients, and may yield a novel treatment target.

 

Nothing to Disclose: VLW, SMS, MABV, JAV, LM, JWK, FJMK, ELTV, EFCV

13639 24.0000 MON-0820 A Elevated Long-Term Cortisol Levels in Scalp Hair of Obese Subjects, Compared to Normal-Weight and Overweight Subjects 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Katerina Simunkova*1, Kristian Lovas1, Marianne Oksnes1, Paal Methlie1, Espen Rostrup2, Hanne Henno1, Mira Tilseth1 and Eystein Sverre Husebye1
1University of Bergen, Bergen, Norway, 2Haukeland University Hospital, Bergen, Norway

 

The conventional glucocorticoid replacement therapy in primary adrenal insufficiency (Addison’s disease, AD) renders the cortisol levels unphysiological. Many patients take stress-doses during stressful physical or psychological events. However, the effect of such dosing has not been demonstrated. In this double blind cross-over trial we tested the effect of an extra dose of hydrocortisone on hormonal, metabolic and cardiorespiratory parameters in response to a maximal incremental exercise test determining the maximal aerobic capacity (V02max). Two hours after morning medication 10 women with AD and 10 healthy women matched for age and body fat were included and assigned to receive either an additional 10 mg of hydrocortisone (HC) or placebo (P) one hour prior to testing. The normal exercise-induced increase in cortisol was not observed in AD patients. Serum and saliva levels of cortisol increased 2-3 fold after extra hydrocortisone as compared to placebo; fasting and exercise-induced blood glucose, plasma adrenaline (A), growth hormone, insulin, lactate and free fatty acids did not differ. Only borderline differences were found in the plasma noradrenaline (NA) (p=0,042). In the women with AD the levels of NA increased during the exercise and peaked immediately after the end of the exercise unlike A that remained unchanged (NA:p<0,0001; A:p=0,47). Conversely, in healthy women both NA and A increased significantly during exercise and peaked immediately after the end of exercise. Maximal exertion measured as V02max, and duration of exercise was independent of the treatments. However, V02max, and duration of exercise were significantly lower in women with AD than healthy women p<0,005, p<0,005.We conclude that patients with AD did not benefit from additional HC during short–term, high-intensity exercise. Moreover, patients with AD have decreased adrenomedullary reserve, lower maximal aerobic capacity and lower exercise performance. Stress dosing in this setting does not seem to be justified.

 

Nothing to Disclose: KS, KL, MO, PM, ER, HH, MT, ESH

13896 25.0000 MON-0821 A Effect of Cortisol on Physical Exertion in Patients with Primary Adrenal Failure 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Irina Bancos*1, Jon Hazeldine2, Janet M Lord3 and Wiebke Arlt4
1Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and and Experimental Medicine, University of Birmingham, Birmingham, UK, 2MRC ARUK Centre for Musculoskeletal Ageing, School of Immunity and Infection, University of Birmingham, Birmingham, UK, 3MRC ARUK Centre for Musculoskeletal Ageing, School of Immunity and Infection, University of Birmingham, Birmingham, UK, Birmingham, United Kingdom, 4University of Birmingham, Birmingham, United Kingdom

 

Mortality in patients with primary adrenal insufficiency (PAI) is significantly increased, with respiratory infections reported as a major cause of death. We hypothesized that a defect in immune response to infection might be the underlying cause. To test this, we carried out a cross-sectional study in patients with PAI recruited from the out-patient clinic of a secondary referral center in comparison to age- and sex-matched healthy controls from the general population. After providing written informed consent all subjects underwent a comprehensive screen of the immune system including measurement of neutrophil phagocytosis, reactive oxygen species production  and number of circulating B, T and NK cells. NK cell cytotoxicity (NKCC) and degranulation towards the MHC Class I deficient K562 tumor cell line was measured by flow cytometry. We also studied the surface phenotype of peripheral NK cells by flow cytometry, recording the expression of NK cell activating receptors (NKp30, NKp46, NKG2D and CD16).

We recruited 27 patients (median (range) age 54(18-77) years; 23/27 women; BMI 23(19-37) kg/m2) with PAI due to autoimmune adrenalitis (n=25) and bilateral adrenalectomy (n=2); duration of disease was 13(0.5-48) years. Comorbidities in 19/27 patients included autoimmune thyroid disease (n=12), pernicious anemia (n=2), premature ovarian failure (n=2), type 1 diabetes (n=1), vitiligo (n=1), and asthma (n=2). Daily hydrocortisone dose was 22.5(10-30)mg; 26/27 patients received fludrocortisone (100(50-300)µg) and 8/23 women were on DHEA replacement (31.25(25-50)mg).

Neutrophil function and circulating frequencies of B, T and NK cells did not differ between PAI and controls. However, NKCC was significantly reduced in PAI (12.0±1.5% vs. 21.1±2.6% in controls, P<0.01). In addition, circulating NK cells in PAI patients contained significantly fewer cells expressing the activating receptors NKG2D (PAI vs. controls 76±3% vs. 92±1%, P<0.0001), NKp30 (56±3% vs. 74±6%, P< 0.01) and NKp46 (27±2% vs. 56±5%, P=0.0001) while NK cell CD16 expression did not differ. No relationship to glucocorticoid dose or DHEA replacement was noted.

Adrenal insufficiency is associated with severely impaired NKCC, thereby compromising early recognition and elimination of virally-infected cells. This marked impairment in anti-viral immune defense is likely to causally contribute to the increased rate of respiratory infections and ultimately mortality observed in PAI.

 

Nothing to Disclose: IB, JH, JML, WA

12789 26.0000 MON-0822 A Primary Adrenal Insufficiency Is Associated with Severely Impaired Natural Killer Cell Function – Causal Link to Increased Mortality? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Sigridur Bjornsdottir*1, Marianne Oksnes2, Magnus Isaksson3, Paal Methlie2, Roy Miodini Nilsen4, Olle Kämpe5, Anna-Lena Hulting6, Eystein Sverre Husebye2, Kristian Lovas2, Thomas Nystrom7 and Sophie Bensing8
1Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden, Sweden, 2University of Bergen, Bergen, Norway, 3Uppsala University, 4Haukeland University hospital, Bergen, Norway, 5Karolinska Institutet, Stockholm, Sweden, 6Karolinska Univ Hosp, Stockholm, Sweden, 7Karolinska Institutet, Department of Clinical Science and Education, Division of Internal Medicine, Södersjukhuset AB, Stockholm, Sweden., 8Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden

 

Background: Conventional glucocorticoid replacement therapy in patients with Addison’s disease (AD) is unphysiological with possible adverse effects on mortality, morbidity and quality of life. Physiological amounts of glucocorticoids are required for normal growth hormone (GH) production and release and a chronically raised cortisol level, suppresses the secretion of GH with possible metabolic and cardiovascular consequences. The diurnal cortisol profile can likely be restored by continuous subcutaneous hydrocortisone infusion (CSHI). The aim of this study was to compare circadian hormone rhythms in conventional thrice-daily regimen of glucocorticoid replacement therapy (OHC) with CSHI treatment in AD patients.

Design, Subjects, Measurements: An open, randomized, two-period, 12-wk crossover multicenter trial in Norway and Sweden. Ten AD patients were admitted for 24-h sampling of hormone profiles after 8-wk of CSHI and OHC. We measured the circadian rhythm of cortisol, adrenocorticotropic hormone [ACTH], growth hormone [GH], insulin-like growth factor-1, [IGF-1] and IGF binding protein-3 [IGFBP-3] in patients who underwent OHC and CSHI treatment. 

 

Results: The mean hydrocortisone dose was 0.34 mg/kg/d (0.10) and 0.30 (0.11) mg/kg/d for CSHI and OHC treatments, respectively. CSHI provided a more physiological circadian cortisol and ACTH curves including a late night cortisol surge. The expected nocturnal augmentation of GH release more pronounced for CSHI, which together with the higher IGF-1 and IGF-BP3 levels suggests a more anabolic status.

Conclusion: Replicating the circadian cortisol rhythm with CSHI treatment could have beneficial metabolic effects beyond the normalization of ACTH levels, which should lead to further research in this area. The important nocturnal GH peak was preserved in both treatment groups but more pronounced in the CSHI group. In addition, the consistently higher IGF-1 and IGF-BP3 levels during morning hours suggest that CSHI provides a more anabolic and physiological nighttime state.

 

Nothing to Disclose: SB, MO, MI, PM, RMN, OK, ALH, ESH, KL, TN, SB

11024 27.0000 MON-0823 A Circadian Cortisol and Growth Hormone Profiles in Patients with Addison's Disease: A Comparison of Continuous Subcutaneous Hydrocortisone Infusion with Conventional Glucocorticoid Replacement Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Adina F. Turcu*, Robert Chomic, James J. Shields, Kyung J. Cho, William E. Rainey and Richard J. Auchus
University of Michigan, Ann Arbor, MI

 

Background: Sulfotransferase type 2A1 (SULT2A1) is expressed in the cytoplasm of human adrenocortical cells, predominantly in the zona reticularis, where it sulfates the 3β-hydroxyl group of Δ5-steroids. Dehydroepiandrosterone sulfate (DHEAS) is the most abundant steroid in the circulation for most of adult life and the major product of the zona reticularis. Although other Δ5-steroids are SULT2A1 substrates, little is known about the adrenal production of other Δ5-steroid sulfates.

Objective: To characterize the production and cosyntropin responsiveness of the adrenal Δ5-steroid sulfates pregnenolone sulfate (PregS), 17-hydroxypregnenolone sulfate (17OHPregS), DHEAS, and androst-5-ene-3β,17β-diol sulfate (ADS).

Methods: Serum samples were collected before and 20 minutes after cosyntropin administration from the iliac vein (IV) and both adrenal veins (AV) of 4 patients with primary aldosteronism. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) was used to quantify serum concentrations of Δ5-steroid sulfates.

Results: DHEAS was the most abundant Δ5-steroid sulfate in AV and IV, both at baseline (means 62% and 67% of total Δ5-steroid sulfates, respectively) and after cosyntropin stimulation (means 43% and 62%, respectively), followed by ADS (means 31% and 30% at baseline; means 20% and 33% after cosyntropin stimulation, respectively). The percentages of PregS (means 3.5% and 1.3% in AV and IV, respectively) and 17OHPregS (means 2.5% and 1% in AV and IV, respectively) were low at baseline, but, in contrast to DHEAS and ADS, they rose sharply after cosyntropin stimulation (means 29.5 and 3% in AV and IV, respectively for PregS and means 6.5% and 3% in AV and IV, respectively for 17OHPregS). DHEAS and ADS rose only 1.3- to 2.9-fold after cosyntropin in the AV and <1.3-fold in the IV. Cosyntropin markedly stimulated AV PregS (10- to 44-fold) and AV 17OHPregS (4- to 12-fold) in 3 of 4 patients.

Conclusions:  In adults, DHEAS and ADS are the major adrenal Δ5-steroid sulfates, but their abundance is poorly responsive to acute cosyntropin stimulation, possibly because circulating concentrations are high. In contrast, PregS and 17OHPregS are minor adrenal products at baseline, but these steroids respond abruptly to ACTH stimulation, likely due to a sudden shift of proportions in SULT2A1 substrates. PregS and 17OHPregS might be useful markers of adrenal function and of AV cannulation.

 

Nothing to Disclose: AFT, RC, JJS, KJC, WER, RJA

14642 28.0000 MON-0824 A Liquid Chromatography-Tandem Mass Spectrometry Analysis of Human Adrenal Vein Δ5-Steroid Sulfates before and after ACTH Stimulation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Aikaterini Theodoraki*1, Lakshmi Jain2, Gill Rumsby3, Laura Jane Waters4 and Stephanie Baldeweg5
1UCL Hospitals, London, United Kingdom, 2CENTRAL AND NORTH WEST LONDON NHS FOUNDATION TRUST, London, United Kingdom, 3UCL Hospitals, London, England, 4CENTRAL AND NORTH WEST LONDON NHS FOUNDATION TRUST, London, 5UCL Hospitals, London

 

Background: Ritonavir, a protease inhibitor, potently inhibits CYP3A4, a key enzyme in glucocorticoid metabolism.   Iatrogenic Cushing’s syndrome (ICS) is therefore a potential problem with secondary adrenal failure in those HIV patients receiving concomitant ritonavir and glucocorticoids. A structured approach for identifying and managing potentially affected individuals has not been established. We aimed to describe the management of ICS in a large HIV cohort and develop practice guidelines.

Methods: Patients with ICS were systematically identified through the clinic letter database. Relevant search terms including cortisol, triamcinolone and fluticasone were employed. Additionally, all cortisol results from patients with HIV tested in the biochemistry department from 2012-2013 were reviewed. From a case note review we documented presenting features, investigations and subsequent management.

Results: Nine patients with features of ICS were identified. Six of these were secondary to inhaled fluticasone, of which two were in combination with salmeterol, and three secondary to triamcinolone use. Fluticasone was prescribed for asthma in five patients. The commonest presenting symptoms were weight gain and fatigue. Five patients had cortisol levels measured following which three had short synacthen testing (SST). Two patients had a SST without a prior cortisol measurement. Five patients with evidence of adrenal suppression were managed jointly with the Endocrinology team. In most cases fluticasone was stopped and, when required, substituted with beclomethasone, prior to hydrocortisone replacement. All patients seen in the Endocrinology clinic had repeat assessment of their ACTH reserve with gradual reduction in steroid replacement doses. In two patients the hypothalamic pituitary adrenal function recovered. Correspondence to the primary care physician was sent for all patients, however one patient did not disclose HIV status.

Conclusion: Using a systematic approach we identified patients with ICS and found heterogeneity in clinical practice. Increasing awareness among clinicians and educating patients with HIV regarding potential drug interactions is likely to prevent similar events in the future. To this end, we have produced a relevant patient information leaflet. Additionally, the HIV and endocrinology teams have developed clear guidelines for ICS management.

 

Nothing to Disclose: AT, LJ, GR, LJW, SB

16308 29.0000 MON-0825 A Ritonavir and Glucocorticoids: A Systematic Review of Cases of Iatrogenic Cushing's and Recommendations for Clinical Practice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Sabine M. Staufenbiel*1, Cornelie D. Andela2, Laura Manenschijn1, Alberto M. Pereira3, Elisabeth F.C. van Rossum1 and Nienke R. Biermasz2
1Erasmus MC, Rotterdam, Netherlands, 2Leiden University Medical Center, Netherlands, 3Leiden University Medical Center, Leiden, Netherlands

 

Primary and secondary adrenal insufficiency patients on hydrocortisone replacement therapy have increased hair cortisol concentrations and BMI

Patients with primary and secondary adrenal insufficiency (AI) need life-long cortisol replacement therapy with exogenous glucocorticoids such as hydrocortisone (HC). However, higher glucocorticoid doses have been associated with an unfavorable metabolic profile. A reliable biomarker to reflect optimal dosing is currently not available. Cortisol in scalp hair has been recently identified as a retrospective biomarker for long-term cortisol exposure in endocrine research. Hair provides the opportunity to measure mean cortisol concentrations of months to years in retrospect, in contrast to the short time frame covered by urine, serum and saliva cortisol. High long-term cortisol concentrations, measured in scalp hair, have also been associated with adverse metabolic features. We hypothesized that the patients that use HC have higher hair cortisol concentrations than patients that do not use HC or healthy controls. We aimed to investigate the association between pituitary and adrenal disease, HC doses and hair cortisol concentrations including metabolic features.

Hair samples were collected in 133 patients with primary or secondary AI confirmed by dynamic testing on chronic HC replacement (HC+), 45 patients with pituitary diseases without apparent AI (HC-), and 178 healthy controls. The proximal 3 cm of hair were used. Cortisol was extracted from the hair with methanol, and cortisol concentrations were measured using a competitive enzyme-linked immunoassay.

Hair cortisol concentrations between all patients and healthy controls varied significantly (p < 0.001; after adjustment for HC use: p = 0.03). HC+ patients showed significantly higher hair mean cortisol concentrations than HC- patients (75.93 pg/mg vs. 33.08 pg/mg, p < 0.001). Hair cortisol concentrations were not significantly different between HC- patients and healthy controls (M = 14.45 pg/mg). In HC+ patients, the dose of HC showed a trend correlation with hair cortisol concentrations (ρ = 0.16, p = 0.07). The body mass index (BMI) correlated significantly with hair cortisol concentrations in the whole group of participants (ρ = 0.2, p < 0.001). HC+ and HC- patients did not differ significantly in BMI (27.75 vs. 28.54) but had a significantly higher BMI than healthy controls (24.46), p < 0.001.

Patients with HC use for adrenal insufficiency have higher hair cortisol concentrations than patients with pituitary disease without HC use and healthy controls. These results suggest that some patients may be overtreated. The association between hair cortisol concentrations and BMI suggests that this relative overtreatment may lead to an increased body weight. Hair cortisol measurements may be a promising additional tool to monitor glucocorticoid replacement in AI.

 

Nothing to Disclose: SMS, CDA, LM, AMP, EFCV, NRB

16623 30.0000 MON-0826 A Primary and Secondary Adrenal Insufficiency Patients on Hydrocortisone Replacement Therapy Have Increased Hair Cortisol Levels and BMI 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Antonio Leon-Justel1, Ainara Madrazo-Atutxa2, Rocio Infante-Fontan1, Jovanna Castro- Luque1, Blanca Frances1, Ana Alvarez-Rios1, Juan Francisco Martin-Rodriguez2, Alfonso Manuel Soto-Moreno3, David A Cano4 and Alfonso Leal-Cerro*5
1Hospital Universitario Virgen del Rocío, Sevilla, Spain, 2Instituto de Biomedicina de Sevilla (IBiS), Consejo Superior de Investigaciones Científicas, Endocrinology Unit of Virgen del Rocío University Hospital, University of Seville, Sevilla, Spain, 3Unidad de Gestión de Endocrinología y Nutrición. Instituto de Biomedicina de Sevilla (IBiS), Consejo Superior de Investigaciones Científicas, Universidad de Sevilla. Hospital Universitario Virgen del Rocío, Sevilla, Spain, 4Endocrinology and Nutrition Unit, Institute of Biomedicine of Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, Seville, Spain, 5Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío Seville, Sevilla, Spain

 

Measurements of midnight salivary cortisol values (MSC) are increasingly used as a method to assess patients with suspected hypercortisolism. However, normal values that can be used as a reference has not been firmly established. In this study, we establish a specific normal range for midnight salivary cortisol values in a healthy population.

Subjects and Methods

A sample population of 120 healthy subjects aged 18-72 years old (42.3  ± 12.5) years and normal BMI (23.45 ± 2.65) were studied. Fifty-six (46.7%) were men and 64 (53.3%) women. These subjects had neither signs nor a history of acute or chronic illness. Ninty seven (80.8%) were non-smoker and 23 (19.2%) were smoker. Samples of saliva were obtained at 22:30 h and 23:00 h using a Salivette®. MSC was measured by a MODULAR ANALITIC E-170 Roche Diagnostic. Normal intervals were established by using nonparametric methods to determine the 0.025 and 0.975 fractiles.

Results

 

Eight patients were excluded from the analysis because their cortisol values were considered to be outliers. The median and IQR for MSC at 22:30 and 23:00 h were, 4.75 nmol/L [3.94-5.77] and 4.78 nmol/L [3.84-5.94], respectively. No significant BMI, sex-related or time-related differences were found for MSC. However, MSC was significantly higher in smokers (p=0.014) (6.50 nmol/L [4.84-7.33]) vs non-smoker (4.62 nmol/L [3.83-5.27]). Differences in MSC were obtained in relation with age, with significant differences in the oldest population (p=0.016) The distribution of MSC values regarding the age groups were 4.68 nmol/L [4.02-5.18] (< 30 years, n=20), 4.30 nmol/L [3.74-6.17] (31-40 years n=31), 4.12 nmol/L [3.40-5.34] (41-50 years n=31), 5.31 nmol/L [4.80-6.44] (51-72 years n=30). In order to establish the reference value, we considered two different age groups. Group 1: age <50, n=82 (MSC 4.29 nmol/L [3.72-5.52]) and group 2: age >51, n=30 (MSC 6.10 nmol/L [4.64-6.81]). Normal intervals for MSC were, group 1: 2.65-7.72 nmol/L and group 2: 3.08-9.21 nmol/L.

Conclusion

These data report the normal salivary cortisol values at midnight in a healthy population. We found that age and smoke are two variables that affect normal MSC values ranges.  The use of normal values for MSC is adequate to discriminate subjects with hiper- or hipocortisolism situations.

 

Nothing to Disclose: AL, AM, RI, JC, BF, AA, JFM, AMS, DAC, AL

13796 31.0000 MON-0827 A Normal Values of Midnight Salivary Cortisol in Healthy Population 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Xiaofan Mi*1, Erin Tobin1, Heidi Kane1, Daniel Saleh1, Elizabeth Secord1, Wayne Pierantoni2, Justin Carré3 and Richard Slatcher1
1Wayne State University, Detroit, MI, 2Grosse Pointe Allergy and Asthma Center, Grosse Pointe, MI, 3Nipissing University, North Bay, ON

 

Accumulated evidence from human and animal models establishes the hypothalamic-pituitary-adrenal (HPA) axis as a major biological pathway linking socio-emotional experiences and physical wellbeing.  HPA axis and cortisol dysregulation are associated with increased susceptibility to various diseases. With regard to the immune system, disrupting cortisol’s modulatory roles potentially augments the risk for inflammatory diseases such as asthma. The purpose of this study was to investigate asthma symptom measures to identify the predictive value of cortisol. 68 asthmatic adolescents aged 10-17 provided four saliva samples per day across four days. Additionally, participants completed baselines symptom reports, daily symptom diaries, and released medical records. Saliva samples were assayed for cortisol levels using Direct Salivary EIA ELISAs. Results revealed that higher salivary cortisol output predict greater asthma morbidity and daily asthma symptoms, particularly wheezing (p<0.05) across baseline reports and shortness of breath and chest pain (p<0.05) across daily symptom reports. Cortisol output and diurnal slope pattern were not significantly associated with pulmonary functioning or the frequency of clinic visits. These results are the first to our knowledge to demonstrate that salivary cortisol is associated with clinical health outcomes in adolescent children.

 

Nothing to Disclose: XM, ET, HK, DS, ES, WP, JC, RS

11238 32.0000 MON-0828 A Daily Salivary Cortisol Is a Predictor of Clinical Health Outcomes in Asthmatic Adolescents 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0797-0828 4779 1:00:00 PM Glucocorticoid Actions Poster

Ming Lu*, Hanna Kjellin, Omid Fotouhi, Linkiat Lee, Inga-Lena Nilsson, Anders Höög, Janne Lehtiö and Catharina Larsson
Karolinska Institutet, Stockholm, Sweden

 

The parathyroid glands which secrete parathyroid hormone are essential for the balance of serum calcium. Pathological enlargements of the parathyroids lead to hormonal over-secretion which affects most organs resulting in multiple clinic features. The parathyroid tissue contains two major types of cells, chief cells and oxyphilic cells. Based on histological differences, chief cells are categorized into conventional type chief cell and clear type chief cell. Chief cells are regarded as the functional cells secreting PTH from the normal gland, rather than oxyphilic cell. Oxphilic cell adenomas are often considered as non-functional tumors. However, serveral PTH secreting oxyphilic cell adenomas have recently been reported. In the Karolinska University Hospital, the proportion of pure functional oxyphilic cell adenoma is around 5% of all parathyroid adenomas, which is similar to previous reports of 3-8%. The molecular background behind different cell types in parathyroid has only been rarely investigated. In this study, we performed LC-MS/MS mass spectrometry to compare protein expressions in each type of parathyroid adenomas and normal parathyroids from normocalcemic individuals. Selected proteins were then verified in extended sample series using Western blot analysis and immunohistochemistry. Our studies have identified some novel proteins of interest which were differentiatly expressed between oxyphilic and chief adenomas e.g. LIM domain only 3 (LMO3), S100B, Testicular Receptor 4 (TR4) and Vitamin D receptor (VDR). Futhurmore, we found that TR4 and Tumor necrosis factor, alpha-induced protein 8-like 2(TNFAIP8L2) have different expression pattern between adenoma and normal rim, but not compared to normal parathyroid from normocalcemic individuals, which indicated that normal parathyroid undergo molecular changes under hypercalcemia. On the other hand, no difference was identified for known parathyroid specific protein, i.e. PTH, Calcium sensing receptor (CaSR), and Parathyroid hormone-related peptide (PTHrP). In conclusion, we report protein expression profiles of different types of parathyroid adenoma, which provide better understanding of the molecular background of parathyroid glands.

 

Nothing to Disclose: ML, HK, OF, LL, ILN, AH, JL, CL

15895 1.0000 MON-0256 A Molecular Differences Between Oxyphilic Cell and Chief Cell Parathyroid Adenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0256-0266 4782 1:00:00 PM Parathyroid and Bone Biology Poster

Sihoon Lee*, Hong Seok Choi, Seul Min Kim and Hyun Jin Kwon
Gachon University School of Medicine, Incheon, Korea, Republic of (South)

 

Parathyroid hormone (PTH) plays a critical role in maintaining blood ionized calcium levels within narrow limits. A significant amount of knowledge about the transcription factors and proteins involved in the organogenesis and the normal physiology of parathyroid gland has been gained from molecular analyses of the pathophysiology of idiopathic hypoparathyroidism cases. Specifically, hypocalcemia due to inadequate PTH production without additional developmental defects, is most frequently caused by heterozygous activating mutations in the calcium-sensing receptor (CaSR). Less frequent are homozygous or heterozygous mutations in the parathyroid-specific transcription factor GCM2 and exceedingly rare are mutations in the PTH gene itself. Our goal of this study was to isolate potential key players among parathyroid-specific genes and to identify direct targets for GCM2. Gene expression profiles of 3 functional parathyroid adenoma samples were analyzed using the human genome wide illumina bead microarrays. For the control 2 standard universal human RNA preparations were used. Briefly, total RNA was extracted from the fresh frozen samples, and then amplified, purified and labeled with biotin-NTP. Labeled cRNA was hybridized to each bead array and array signal was detected and then scanned. The comparative analysis between 3 functional parathyroid adenoma samples and 2 standard universal human RNA was carried out using fold-change. Forty seven differentially expressed genes (DEGs) emerged which showed 4 or greater fold increase of expression in parathyroid adenoma in all the 6 comparison combination sets (3 samples x 2 controls). When DEGs were listed in the downward numerical order of expression, well-known players such as PTH, CaSR, MafB and GCM2 were found at the top of the list, indicating this approach is sound and informative. This data suggest that there are novel potential candidate key players in this DEGs list other than those mentioned above. We performed genetic interaction analyses in silico, and validated their interactions in vitro with reporter constructs.  Further molecular genetic analyses regarding direct targeting by GCM2 and expression during parathyroid organogenesis are being pursued for these genes.

 

Nothing to Disclose: SL, HSC, SMK, HJK

15684 2.0000 MON-0257 A Microarray-Based Gene Expression Profiling of Functional Parathyroid Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0256-0266 4782 1:00:00 PM Parathyroid and Bone Biology Poster

Bekir Ucan*1, Mustafa Sahin2, Mustafa Ozbek3, Mustafa Caliskan4, Müyesser Sayki Arslan5, Gülfer Öztürk6, Askin Gungunes5, Nujen Colak Bozkurt7, Esra Tutal6, Taner Demirci8, Erman Cakal1 and Tuncay Delibasi5
1Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey, 2Ankara University School of Medicine, Ankara, Turkey, 3Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey., Turkey, 4Diskapi Yildirim Beyazit Teaching and Research Hospital, Ankara, Turkey, 5Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey., 6Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey., Ankara, Turkey, 7Ankara Training and Research Hospital, Ankara, Turkey, 8Diskapi Training and Research Hospital, Ankara, Turkey

 

Recent studies indicate that plasma Heart-type fatty acid binding-protein (H-FABP) concentration could be used as an early biochemical marker for macrovascular disease. Patients with primary hyperparathyroidism (PHT) have been reported to have increased cardiovascular risk factors. Our aim was to evaluate plasma H-FABP concentration in primary hyperparathyroidism in comparison with healthy controls.

We measured plasma H-FABP with commercial ELİSA kit. We also evaluated serum lipid levels, serum calcium, phosphorus, PTH, insulin resistance (HOMA-IR), carotid intima-media thickness (CIMT) in all patients with primary hyperparathyroidism and healthy  controls.

We studied 59 PHT patients (6 male, 63 female) and compared with 24 (4 male, 20 female) healthy controls. There was no significant difference in age between patients (51.7±12.9) and controls (53.7±9.8). There were no significant difference in CIMT, HOMA-IR, HsCRP , BMI between patients and controls. Unexpectedly patients with PHT showed significantly lower H-FABP levels 1271.9 pg/mL (298-3377) compared to healthy controls 2319(928-8767) (P < 0.001). Also we found that H-FABP is conversely correlated with PTH levels.  Further studies need for clarifying this interesting correlation.

 

Nothing to Disclose: BU, MS, MO, MC, MSA, GÖ, AG, NCB, ET, TD, EC, TD

16603 3.0000 MON-0258 A Primary Hyperparathyroidism Patients Have Low H-FABP Levels 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0256-0266 4782 1:00:00 PM Parathyroid and Bone Biology Poster

Nese Ersoz Gulcelik*1, Muge Keskin2, Cavit Culha3, Mehmet Senes1 and Yalcin Aral4
1Ankara Training Hospital, 2Ankara Training & Res Hosp, Ankara, Turkey, 3Ankara Training and Research Hospital, 4Ankara Training and Research Hospital, Ankara, Turkey

 

Objective: Primary Hyperparathyroidism (PHPT), is associated with decreased bone mineral density at cortical skeletal sites.  Fetuin- A (FETUA)  is a major liver-derived multifunctional plasma protein that play a role in bone remodeling, bone mineralization, insulin resistance and diabetes.  We therefore evaluated the association of preoperative and postoperative serum fetuin-A levels in female patients with PHPT.

Material And Method: We performed a prospective study of 60 female patients with asympthomatic PHPT and 20 controls.  Of the 60 patients, 10 symptomatic patients and 23 asympthomatic patients were surgically treated according to the guidelines. Fasting blood glucose, calcium, phosphate, plasma lipids, renal function tests, osteocalcin, bone specific alkaline phosphatase, ALP, LDH, 25OHD, PTH, FETUA levels and bone mineral densitometry were evaluated in 60 female patients.  At postoperative 6 th week  PHPT, 25OHD, PTH, FETUA levels were reevaluated in 33 patients.

Results: FETUA levels were higher in 60 patients with PHPT than control patients. FETUA levels were higher in patients who had gone to surgery than the nonsurgery group. After parathyroidectomy, FETUA, PTH, calcium levels were found to be significantly decreased. LDH, phosphate, 25OHD levels were increased in the postoperative period. There was no correalation between PTH and FETUA levels. Diabetic PHPT patients had higher FETUA levels than non-diabetic PHPT patients. FETUA levels were positively correlated with HbA1c.

Conclusion: In our study, FETUA levels significantly decreased after parathyroidectomy. FETUA levels can be a useful marker to detect the changes in bone metabolism in patients with PHPT and to detect the patients suitable for surgery.

 

Nothing to Disclose: NE, MK, CC, MS, YA

12970 4.0000 MON-0259 A Fetuin-a Levels in Patients with Primary Hyperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0256-0266 4782 1:00:00 PM Parathyroid and Bone Biology Poster

Alemu Fite* and Berhane Seyoum
Wayne State University

 

Vitamin D deficiency is associated with diverse disease types and the non-skeletal benefit of vitamin D is gaining wide scientific interest. The interaction of immune cells with adipocytes within the adipose tissue in obese and diabetic individuals may play a pathophysiological role in insulin resistance. We examined whether cholecalciferol (VD3) improve an impaired insulin signaling due to exposure of adipocytes to macrophages in an in vitro co-culture model. We differentiated 3T3-L1 murine cells into adipocytes (dif3T3) and exposed them to Raw 264.7 murine macrophage like cells (Raw) in a direct cell-to-cell contact at a cell-density ratio of 5:1 with and without VD3 at a dose concentration of 100 ng/ml and insulin at 100 nM concentrations. Treated and control cells were assessed for gene expression using real-time PCR and protein activity using Western protein analysis. VD3 increased transcription of genes involved in insulin signaling. In dif3T3/Raw co-cultures as compared to dif3T3 alone, adiponectin, Glut4 and AS160 mRNA were reduced by 4-fold, 5-fold and 2-fold, respectively in contrast to Glut1 mRNA that was increased by 2-fold. VD3 altered gene expression in dif3T3 but not as effectively in dif3T3 co-cultured with Raw cells. Spot density analysis of Western blots showed increased Akt phosphorylation in dif3T3 cells; 4-fold by VD3; 5-fold by insulin; and 3.6 fold by co-culturing with Raw cells. Akt phosphorylation in dif3T3 cells was further enhanced 10-fold by the combined effects of insulin and Raw cells; 3.6-fold by the combined effect of Raw cells and VD3. A synergistic Akt phosphorylation was found by the combined effects of all Raw cells, VD3 and insulin treatments resulting in over 17-fold increase. In addition to enhancing transcription and activity of insulin signaling molecules, VD3 was observed to increase IL-6 gene expression in a concentration dependent manner. Our co-culture system may mimic the inflammatory response resulting from the pathologic adipose tissue infiltration by macrophages in obese diabetic individuals. The potential mechanism how vitamin D is protective in insulin resistance/metabolic syndrome and weight gain may be through preventing the undesirable interaction of immunological and metabolic pathways.

 

Nothing to Disclose: AF, BS

12868 5.0000 MON-0260 A Cholecalciferol Improves Inflammation-Induced Impairments of Insulin Signaling in Vitro 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0256-0266 4782 1:00:00 PM Parathyroid and Bone Biology Poster

Rakhil Rubinova*1, Frank Akwaa1, Benjamin J. Frisch2, Mark LaMere3, Michael W Becker4 and Laura Maria Calvi1
1University of Rochester Medical Center, Rochester, NY, 2University of Rochester School of Medicine, Rochester, NY, 3James P. Wilmot Cancer Center, Rochester, NY, 4University of Rochester Medical Center

 

The role of osteoprogenitor (OP) populations derived from bone marrow (BM) in human skeletal disease is poorly understood. To date, studies using human whole bone marrow (WBM) derived OP cells have revealed variable age and gender-related changes.  Conventional methods of measuring OPs in BM discount the contribution of hematopoietic cells and rely upon cell adherence to tissue culture plastic, expression of alkaline phosphatase (AP+) and mineralization (Von Kossa +). We hypothesized OPs present on the surface of human bony spicules from BM aspirates better represent the osteoblastic lineage in humans. Based on murine models, this population of OPs may be important for bone anabolism and support of hematopoiesis. Once identified, we aimed to characterize normal adult human OPs and explore age and gender-related changes. We developed a protocol obtaining iliac crest BM aspirates from healthy volunteers ages 21 – 70 years. WBM was collected and filtered. Spicules were collagenase-digested and bone associated cells (BAC) were collected.  WBM cells and BACs were cultured in limiting dilutions (LD) in osteogenic media to form AP+ and Von Kossa + colonies, with the most primitive OPs being Von Kossa and AP positive (AP+ VK+ OPs), while AP+ colonies only represents a more differentiated osteoprecursors (AP+ VK- OPs), as others have described. Colony frequencies were scored at 28 days and quantified using LCalC software. AP+ VK+ OPs frequencies were increased in BACs as compared to WBM from 6 females (ages 26- 64) and 3 males (ages 23-54) at any age. We additionally observed a 3 to 6 fold decrease in frequency of AP+ VK+ OPs with increasing age in both BACs (1 in 2720 +/- 1,526 to 1 in 52,265 +/- 33,320) and WBM (1 in 17,755 +/- 10,037 to 1 in 160,222 +/-82,715). In contrast, with increasing age, AP+ VK- OPs were increased in WBM (1 in 10,670+/- 6,027 to 1 in 6,130 +/- 3,231) but overall unchanged in BACs (1 in 1,189 +/- 660 to 1 in 10,750 +/- 6,072). Therefore, bony spicules are enriched for osteoprogenitor activity compared to WBM.  Notably, there were unexpected site-specific changes is the relative abundance of immature to mature colonies, which may be due to the contribution of age-specific hematopoietic changes. We suspect that our LD analysis in BACs may indicate age-associated exhaustion of the osteolineage stem cell pool in favor of a more differentiated osteoprecursor. Therefore analysis of BACs may be a useful technique to enrich OPs and to define their role in human skeletal disease. Together these data suggest that BACs may be a useful but currently understudied cell population to study bone disorders in humans.

 

Nothing to Disclose: RR, FA, BJF, ML, MWB, LMC

14131 6.0000 MON-0261 A Enrichment of Osteoprogenitors from Human Trabecular Bone and Analysis of Age Related Changes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0256-0266 4782 1:00:00 PM Parathyroid and Bone Biology Poster

Xin-Hua Liu*1, Lauren Collier2, Risheng Ma3, Rauf Latif4, Terry F Davies5, William A Bauman6 and Christopher Pratt Cardozo2
1J.J. Peter VA Medical Center, Bronx, NY, 2James J. Peters Veteran Affairs Medical Center, Bronx, NY, 3Mt Sinai Schl of Med, Bronx, NY, 4Mount Sinai School of Medicine and the James J Peters VA Medical Center, New York, NY, 5Mount SInai School of Medicine, 6James J. Peters VA Medical Center, Bronx, NY

 

Androgen signaling via the androgen receptor (AR) is essential for normal fetal, neonatal, and postnatal development. Ample evidence demonstrates the anabolic effect of androgens in extragonadal settings such as skeleton muscle and bone. Effects of androgens on early embryogenesis, however, are not well delineated. Since both embryonic stem cells (ESCs) and induced pluripotent stem (IPS) cells express AR, the effects of dihydrotestosterone (DHT) on IPS cell differentiation were examined. IPS cells were derived from mouse embryonic fibroblasts using the STEMCCA vector containing Oct4, Sox2, cMyc and KLF4 genes expressed from a single polycistronic transcript. IPS cells were initially cultured in DMEM supplemented with 15% knockout serum replacement (KO-SR) and treated with or without DHT (10nM) for 7d before plating for EB formation. Gene expression was examined by real-time (Rt)-PCR. During the pre-treatment stage, DHT induced a significant increase in early myogenic transcriptional factors such as Pax3 (3.2-fold), Pax7 (2.5-fold), Myf5 (5.6-fold) and MyoD (3.3-fold) compared to the cells treated with vehicle only. EB formation was then induced in KO-SR medium in a suspension culture system. IPS cells pre-treated as above were plated in non-coated plates at day zero with or without DHT. Significant upregulation of mesendoderm markers, like Brachyury (5.7-fold) and MixL1 (4.7-fold), and downregulation of Naong and Oct4 (ESC markers) expression were induced by DHT at day 7 assayed by Rt-PCR. DHT also increased the levels of myocyte-committed markers, like NCAM (6-fold) and CD34 (2.5-fold). By extending the time of induction, the effects of DHT on post-EB-IPS cells were next evaluated. 7d-old EBs were allowed to adhere to gelatin-coated plates and were grown as a monolayer in DMEM containing 2% horse serum and continuously treated with DHT. By day 14, post-EB-IPS cells exhibited morphologies which were reminiscent of mesenchymal progenitor cells including spindle shapes, cuboidal morphology and round cells. Rt-PCR analysis of these cells demonstrated dramatic enhancement in Pax3 (23.9-fold) and Pax7 (36.7-fold) expression at day 21, accompanied by elevated levels of MyoD (6-fold), myogenin (4.5-fold) and NCAM (10.5-fold) at day 28. Moreover, the expression of vimentin, a critical mesenchymal marker, was markedly induced (53.6-fold) by DHT at day 21, and the levels remained constant thereafter. The other related genes that were significantly induced by DHT during this stage were Runx2 (32.3-fold) and Pitx2 (13.6-fold); both are Wnt-target genes that play critical roles in regulating bone and muscle development, respectively. These data demonstrate a novel role for androgens in stimulating terminal differentiation of IPS cells to mesenchymal progenitor cells, and suggest an ability of androgens to regulate early embryonic development.

 

Nothing to Disclose: XHL, LC, RM, RL, TFD, WAB, CPC

13832 7.0000 MON-0262 A Androgens Promote Differentiation of Induced Pluripotent Stem Cells to Mesenchymal Progenitor Cells through Embryoid Body Formation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0256-0266 4782 1:00:00 PM Parathyroid and Bone Biology Poster

Megan M Weivoda*1, Katharina Jaehn2, Matthew Prideaux2, Ming Ruan1, Christine Hachfeld1, Larry Pederson1, Rachel Ann Davey3, Sundeep Khosla4, Lynda F Bonewald5 and Merry Jo Oursler1
1Mayo Clinic, Rochester, MN, 2University of Missouri Kansas City, 3University of Melbourne, Heidelberg, Australia, 4Mayo Clinic College of Med, Rochester, MN, 5Univ of MO Sch of Dentistry, Kansas City, MO

 

Osteocytes express certain osteoclast genes including cathepsin K (Ctsk) to remodel mineralized matrix in response to lactation. The Ctsk promoter is commonly used to drive Cre recombinase (Cre) expression to knockdown genes specifically in osteoclasts. Activation of this promoter in osteocytes may lead to Cre expression and subsequent gene deletion in osteocytes, complicating the findings in osteoclast specific knockdown experiments. The goal of this study was to assess the tissue specificity of genes used to drive Cre expression in the osteoclast lineage and to identify novel gene candidates to selectively target osteoclasts. Expression of genes used to drive Cre recombinase expression in the osteoclast lineage (CD11b, Ctsk, LysM, Rank, and Vav1) was compared in osteocytes isolated from lactating and virgin female mice, bone marrow macrophages, and bone marrow-derived precursor and mature osteoclasts. Mice expressing Cre recombinase driven by a transgenic Ctsk promoter were crossed with YFP reporter mice to assess Cre activity in osteoclasts and tissues. Microarrays performed on virgin and lactating mouse osteocytes were analyzed in comparison to osteoclasts to reveal potential candidate genes for new osteoclast specific Cre models; identified targets were validated by qPCR. Osteoclast specificity of Cre driver genes and novel targets were assessed in a cDNA tissue library. Consistent with published data, lactation increased Ctsk expression in osteocytes. Osteoclasts expressed 7-fold higher levels of Ctsk as compared to osteocytes isolated from lactating mice. YFP reporter expression was evident in osteocytes isolated from Ctsk-Cre/YFP mice; however this activity was 5-times lower than the activity measured in mature osteoclasts. Additionally, YFP expression in osteocytes was not affected by lactation. Lactation did not significantly alter expression of CD11b, LysM, Rank, or Vav1. Analysis of osteoclast genes in a cDNA tissue library showed that Ctsk had the greatest specificity for osteoclasts. YFP reporter expression was found in the brains isolated from Ctsk-Cre/YFP mice; however, analysis of lox-P site excision showed minimal cleavage suggesting that the reporter activity may be coming from an infiltrating cell type. Microarray analysis identified Oscar and OC-Stamp as highly expressed in osteoclasts compared to virgin or lactating osteocytes. Validation by qPCR showed 20 and 54-fold increases, respectively, in comparison to lactating osteocytes. Moreover, Oscar and OC-Stamp were highly restricted to the osteoclast lineage. These data suggest that although lactation induces Ctsk expression in osteocytes, transgenic Ctsk-Cre remains a good model for gene knockdown in the osteoclast lineage in mice. This work also suggests that Oscar and OC-Stamp Cre models may be promising tools for highly specific gene deletion in the osteoclast lineage.

 

Nothing to Disclose: MMW, KJ, MP, MR, CH, LP, RAD, SK, LFB, MJO

16838 8.0000 MON-0263 A Comparative Analysis of Osteoclast Lineage Cre-Drivers and Identification of Novel Osteoclast Lineage Selective Genes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0256-0266 4782 1:00:00 PM Parathyroid and Bone Biology Poster

Akiko Yuno*1, Takeshi Usui1, Shigeki Koizumi2 and Akira Shimatsu1
1National Hospital Organization Kyoto Medical Center, Kyoto, Japan, 2Kin-i-kyo Chuo Hospital, Sapporo, Japan

 

Context: Recent advances in genetics and epigenetics have revealed an overlap between molecular and clinical features of pseudohypoparathyroidism(PHP) subtypes, broadening the previous spectrum of PHP genotype-epigenotype correlations and indicating limitations of the current classification of the disease.

Objectives: To clarify the underlying molecular alterations of PHP type I, we studied the phenotype, genotype, and epigenotype correlations in Japanese PHP type I patients.

Design:Retrospective case series.

Patients:Subjects were 32 Japanese patients (21 females and 11 males) from 22 nonrelated families with clinical diagnosis or suspicion of PHP type I or pseudo-PHP.

Measurements: Clinical data were obtained for 29 patients. We examined mutations in the coding region of GNAS by PCR-direct sequencing. The copy number alternations and methylation states of GNAS differentially methylated regions (DMRs) were evaluated using methylation-specific multiplex ligation-dependent probe amplification (MS-MLPA) assay.

Results: A total of 6 different structural mutations of GNAS were identified in 6 patients, of which 5 were novel. We investigated potential methylation alterations in all the patients, regardless of their clinical diagnosis (PHP-Ia or PHP-Ib) and found isolated loss of methylation in exon A/B in 16 patients distributed across different 7 families. They all had the 3kb microdeletion in STX16. In 8 patients overall complete methylation defects were identified. Clinical observations showed that height SDS was significantly lower in patients with PHP-Ia than those with PHP-Ib (-2.76±1.53 vs -0.44±1.44, P=0.005). Comparing clinical characteristics and the underlying genetic alteration, we observed that index cases with GNAS mutations were diagnosed earlier than those patients with epimutations (8.67±3.89 vs 26.0±14.6,P <0.001).

Conclusions: PHP-I patients negative for GNAS gene mutations should be considered for further molecular investigations to obtain useful genetic or epigenetic information for clinical management or genetic counseling. MS-MLPA allows precise and rapid analysis of the methylation status in GNAS DMRs as well as the detection of microdeletion mutations.

 

Nothing to Disclose: AY, TU, SK, AS

12249 9.0000 MON-0264 A Molecular Characterization of Genetic and Epigenetic Alterations in Japanese Patients with Pseudohypoparathyroidism (PHP) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0256-0266 4782 1:00:00 PM Parathyroid and Bone Biology Poster

Francesca Marta Elli*1, Paolo Bordogna2, Luisa de Sanctis3, Anna Spada4 and Giovanna Mantovani5
1University of Milan; Fond IRCCS Ca' Granda Policlinico, Milano, Italy, 2IRCCS Cà Granda H Maggiore Policlinico, Milano, Italy, 3University of Torino, Torino, Italy, 4IRCCS Cà Granda H Maggiore Policlinico, Milan, Italy, 5Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy

 

Pseudohypoparathyroidism (PHP) is a heterogeneous group of rare genetic metabolic disorders due to molecular defects at the GNAS locus, that encodes also for the α-subunit of the stimulatory G protein (Gsα), causing end-organ resistance to the actions of PTH.

The classification of the different subtypes of PHP is based on the presence of specific somatic and developmental abnormalities, referred to as Albright hereditary osteodystrophy (AHO), and the resistance to other hormones acting via GPCRs.

Recently, mutations in genes encoding proteins crucial for cAMP-mediated signalling different from Gsα and deletions of chromosome 2q37.2 have been detected in a small subset of patients with PHP with no GNAS defects, showing a phenotypic overlap with Acrodysostosis (ACRDYS)  and brachydactyly-mental retardation syndrome (BDMR), also called AHO-like syndrome.

Despite the high detection rate of genetic and epigenetic defects by currently available molecular approaches, about 30% of PHP patients still lack a molecular diagnosis, hence the need to screen patients negative for GNAS genetic or epigenetic defects also for chromosomal regions and genes associated to diseases that undergo differential diagnosis with PHP.

In this study, we screened by Sanger sequencing and multiplex ligand-dependent probe amplification (MLPA) our series of AHO/PHP patients negative for GNAS locus genetic and imprinting defects (sporadic or genetic-based), for the presence of mutations at PRKAR1A gene (n=58), PDE4D gene (n=18), as well as for deletions affecting the chromosome region 2q37 (n=38).

We detected 2 missense mutations at the PRKAR1A gene, 2 intronic mutations at the PDE4D gene and 2 heterozygous deletions of 2q37, overlapping with previously described rearrangements affecting this subtelomeric region. In silico analysis predicted a pathological effect for all genetic defects found in our patients.

In conclusion, our data further confirm the molecular and clinical overlap among these disorders and highlight the complexity in performing an accurate diagnosis of PHP, as well as the pivotal role of the cAMP pathway in the development of the AHO phenotype.

 

Nothing to Disclose: FME, PB, LD, AS, GM

14497 10.0000 MON-0265 A Screening of a Large Italian Series of Patients Affected with Albright Hereditary Osteodystrophy and/or Pseudohypoparathyroidism to Find Causative Genetic Defects Affecting the cAMP-Mediated Signalling Pathway 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0256-0266 4782 1:00:00 PM Parathyroid and Bone Biology Poster

Mariana Tenorio Antunes Reis*1, Bruno Ferraz-de-Souza1, Mirian Y Nishi2, Amaryllis Avakian3, Pedro Henrique S Correa1 and Regina M Martin4
1Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), Sao Paulo, Brazil, 2University of São Paulo, Hospital das Clinicas, Sao Paulo, Brazil, 3Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, Brazil, 4Hospital das Clínicas, Disciplina de Endocrinologia e Metabologia, Laboratório de Hormônios e Genética Molecular/LIM42, FMUSP, SP, Brazil, Sao Paulo, Brazil

 

Background: Classification of pseudohypoparathyroidism (PHP) and pseudopseudohypoparathyroidism (PPHP) has traditionally been made relying on phenotypic features. Recently, as the molecular bases of these conditions have been better understood, a shift towards a combined clinical-molecular classification has emerged, due to the considerable overlap of clinical features between PHP1a and PHP1b patients according to molecular analysis of GNAS.

Objective: To classify 28 patients with PHP (n=24) or PPHP (n=4) based on GNAS molecular defects and to correlate with phenotype.

Methods: Phenotypic characterization including stigmas of Albright Hereditary Osteodystrophy (AHO), hormonal resistance profile, CNS calcifications and ophthalmological examination. GNAS molecular defects were analyzed by automated sequencing and MLPA for the Gsα coding region and by MS-MLPA for the study of differentially methylated regions (DMRs).

Results: Patients’ age ranged from 1 to 65 years, 14 males and 14 females. AHO evaluation revealed: round face (n=17), brachydactyly (n=10), short stature (n=7), ectopic ossifications (n=5), dental abnormalities (n=4), cognitive impairment (n=3), overweight (n=9) and obesity (n=9). Hypocalcemia, hyperphosphatemia and high PTH levels were detected in 21 PHP patients at diagnosis. PHP patients also had hypothyroidism (n=15), cataract (n=8) and CNS calcifications (n=18). We found 8 mutations in the Gsα coding region in patients with PHP1a (n=10) and PPHP (n=4). Four distinct patterns of methylation at the DMRs led to the diagnosis of PHP1b in the remaining patients (n=14).

Discussion and conclusion:

GNAS tissue-specific imprinting and heterozygous mutations at Gsα coding region are the molecular basis of PHP1a/PPHP. Because the inheritance pattern is known, in our study, the detection of Gsα defects enabled: classification of 14 patients as PHP1a/PPHP; early identification of 2 of them and genetic counseling for 2 families.

On the other hand, alterations in DMRs of the GNAS regulatory region are common molecular findings in PHP1b patients, but the mechanisms that result in PHP1b and inheritance patterns are not well understood. From our 28 patients, 14 have PHP1b of which 12 show AHO stigmas. Without GNAS analysis, these 12 individuals would have been misdiagnosed as PHP1a leading to potential failure in genetic counseling.

Therefore, we believe that classification of PHP/PPHP based on GNAS analysis is more informative than the phenotype-based system.

 

Nothing to Disclose: MTAR, BF, MYN, AA, PHSC, RMM

14924 11.0000 MON-0266 A Analysis of GNAS Defects in 28 Patients with Pseudohypoparathyroidism or Pseudopseudohypoparathyroidism and Correlation with the Phenotype 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0256-0266 4782 1:00:00 PM Parathyroid and Bone Biology Poster

Elizabeth A. Lawson*1, Pouneh K. Fazeli2, Dean A. Marengi3, Ela Cross1, Mary L Bouxsein3, Karen K. Miller1, Alexander Terence Faje1 and Anne Klibanski1
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Neuroendocrine Unit, Massachusetts General Hospital/Harvard Medical School, Boston, MA, 3Massachusetts General Hospital, Boston, MA

 

Anorexia nervosa (AN), a psychiatric disorder characterized by self-induced starvation, predominantly affects young women and is associated with hypogonadism and severe bone loss. Animal data has shown that the neurohormone, oxytocin, is anabolic to bone and low oxytocin levels may mediate bone loss associated with estrogen deficiency. We have previously demonstrated that decreased nocturnal oxytocin secretion in AN is associated with low bone mineral density (BMD). The association between oxytocin secretion and  bone microarchitecture in AN is unknown. We hypothesized that low oxytocin levels would be associated with impaired bone microarchitecture. We studied 37 female AN and 46 healthy controls (HC) of similar age, mean 26.8±0.6 yrs. We assessed serum oxytocin levels (Enzo ELISA, unextracted); BMD (Hologic) at the spine, total hip and forearm; and in 21 AN and 25 HC, microarchitecture (high-resolution peripheral quantitative CT) and estimated bone strength (finite element analysis) at the radius and tibia. Mean %IBW was 79.2±1.1 in AN and 99.9±0.9 in HC (p<0.0001). Oxytocin levels were lower in AN than HC (1005±61 vs. 1261±66 pg/mL, p=0.003). BMD was lower in AN than HC at all sites (p≤0.02). At the radius, trabecular (Tb) volumetric BMD (vBMD) and Tb number (TbN) were lower and Tb separation (TbSp) was higher in AN than HC (p=0.06); total area, Tb thickness (TbTh), and cortical thickness (CtTh) did not differ; and stiffness and failure load were lower in AN than HC (p≤0.03).  At the tibia, TbN was lower in AN than HC (p=0.08); total area, Tb vBMD, TbTh, TbSp, and CtTh did not differ; and stiffness and failure load were lower in AN than HC (p=0.002). Across groups, oxytocin levels were associated with BMD at the forearm (R=0.25, p=0.02) and hip (R=0.23, p=0.04); and microarchitecture (radius: Tb vBMD R=0.43, p=0.003, TbN R=0.35, p=0.02, TbTh R=0.28, p=0.06, TbSp R=-0.34, p=0.02) and estimated strength  (radius: stiffness R=0.29, p=0.05, failure load R=0.33, p=0.03; tibia: stiffness R=0.34, p=0.02, failure load R=0.35, p=0.02). After controlling for BMI, relationships between oxytocin and forearm BMD (+), Tb vBMD (+) at the radius, and TbN (+) at the tibia (p<0.05), and TbN (+), and TbSp (-) at the radius and Tb vBMD (+) at the tibia (p<0.10) were found. Within HC only, oxytocin was associated with trabecular microarchitecture (radius: Tb vBMD R=0.53, p=0.006, TbN R=0.51, p=0.01, TbSp R=-0.58, p=0.002; tibia: Tb vBMD R=0.55, p=0.005, TbN R=0.41, p=0.04, TbSp R=-0.42, p=0.04), but not total area, CtTh or strength measures. There were no relationships between oxytocin levels and bone parameters in AN. Conclusion: Oxytocin is associated with trabecular bone parameters in healthy young women, but not in AN. Whether abnormal oxytocin secretion contributes to AN-associated bone loss merits further investigation.

 

Nothing to Disclose: EAL, PKF, DAM, EC, MLB, KKM, ATF, AK

14964 3.0000 MON-0228 A Oxytocin Levels Are Associated with Trabecular Microarchitecture in Healthy Women, but Not in Women with Anorexia Nervosa 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0226-0238 4783 1:00:00 PM Novel Mechanisms That Regulate Bone and Mineral Metabolism Poster

Pouneh K. Fazeli*1, Alexander Terence Faje2, Ela Cross2, Clifford J Rosen3, Mary Larsen Bouxsein4 and Anne Klibanski2
1Neuroendocrine Unit, Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Massachusetts General Hospital/Harvard Medical School, Boston, MA, 3Maine Medical Center Research Institute, Scarborough, ME, 4Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

 

Anorexia nervosa (AN) is a psychiatric disorder characterized by chronic starvation and low body weight with a lifetime prevalence of 2.2% in women.  Approximately 85% of young women with AN have bone mineral density (BMD) values more than one standard deviation below an age comparable mean and this bone deficit is associated with an uncoupling of bone formation and bone resorption, and a seven-fold increased risk of fracture.  Fibroblast growth factor (FGF)-21 is a hormone produced in the liver and by adipocytes.  In animal models, starvation markedly upregulates FGF-21 production in the liver.  In humans, a very low calorie diet and prolonged fasting result in increased levels of FGF-21.  FGF-21 transgenic mice have significant bone loss due to a decrease in bone formation and a marked increase in bone resorption.  We hypothesized that FGF-21 would be inversely associated with BMD and parameters of bone microarchitecture in women with AN.  We studied 46 women [20 with AN (mean age +/- SEM: 28.5 +/- 1.1 yrs) and 26 normal-weight controls (C) of similar age (26.4 +/- 0.7 yrs)].  We measured serum FGF-21 (ELISA, R&D Systems), BMD by dual energy x-ray absorptiometry, bone microarchitecture in the distal radius and tibia by high-resolution peripheral quantitative CT and estimated bone strength using finite element analysis. Median FGF-21 levels were similar in AN and C {median [interquartile range]: AN: 33.6 [18.1, 117] pg/ml vs C: 57.4[23.8, 107.1] pg/ml (p=0.54)}.  BMD was significantly lower in AN compared to C at the spine, hip and total body (p<0.0001 at all sites).  Bone volume fraction (BV/TV), trabecular number (TbN), trabecular thickness (TbTh), stiffness and failure load were lower in AN compared to C at the radius (p<0.03 for all values) and tibia [p<0.02 for all values except for TbTh (p=0.16)].  Trabecular separation (TbSp) was significantly higher in AN compared to C at both the radius and tibia (p<0.02 for both).  There were no associations between log FGF-21 and BMD by DXA in either AN or HC. In the AN group, there were significant inverse associations between log FGF-21 and BV/TV (R= -0.50, p=0.02), TbN (R= -0.57, p<0.01), stiffness (R= -0.50, p<0.03) and failure load (R= -0.50, p=0.02) at the radius and a positive association between log FGF-21 and TbSp (R= 0.50, p<0.03) at the radius.  There were no associations between FGF-21 and tibial parameters.  Therefore FGF-21, a hormone which increases during chronic starvation, may contribute to the decreased bone mass and strength in AN.

 

Nothing to Disclose: PKF, ATF, EC, CJR, MLB, AK

15033 4.0000 MON-0229 A FGF-21 Is Associated with Worsened Bone Microarchitecture and Decreased Bone Strength in Anorexia Nervosa 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0226-0238 4783 1:00:00 PM Novel Mechanisms That Regulate Bone and Mineral Metabolism Poster

Anne Gingery*1, Malayannan Subramaniam1, Kevin S. Pitel1, Laurence B. Lindenmaier2, James N Ingle1, Matthew P Goetz1, Russell Thomas Turner3, Urszula T. Iwaniec3, Thomas C Spelsberg1 and John R Hawse1
1Mayo Clinic, Rochester, MN, 2University of Oregon, Corvallis, OR, 3Oregon State University, Corvallis, OR

 

Endoxifen has recently been identified as the predominant active metabolite of tamoxifen and is currently being developed as a novel hormonal therapy for the treatment of endocrine sensitive breast cancer.  Endoxifen classically functions as an anti-estrogenic compound.  Since estrogen and estrogen receptors play critical roles in mediating bone homeostasis, and since endoxifen is currently being implemented as a novel breast cancer therapy, we sought to comprehensively characterize the effects of endoxifen on the skeleton.   Three month old ovariectomized (OVX) C57BL/6 mice were treated with vehicle control or 50mg/kg/day endoxifen hydrochloride via oral gavage for 45 days.  Dual-energy x-ray absorptiometry analysis revealed significant increases in bone mineral density and content throughout the skeleton following endoxifen treatment.  Increased trabecular density, cortical content, bone area and thickness were observed by peripheral quantitative computed tomography in the tibial metaphysis and diaphysis. Micro-CT analysis of the femoral metaphysis revealed significant increases in bone volume to tissue volume, trabecular number and thickness, as well as decreased trabecular spacing.  Serum markers of bone formation and resorption were increased in endoxifen treated animals indicating active bone turnover.   Cortical shells from endoxifen treated mice showed significant increases in osteoblast genes such as Runx2, osterix, alkaline phosphatase (AlkPhos) and osteoprotegerin (OPG).  In addition, the osteocyte genes, MEPE and DMP1, were significantly increased. Osteoblast and osteoclasts from endoxifen treated mice were also cultured and the expression profiles were examined.  Osteoclasts showed significantly increased expression of marker genes including NFATc1, RANK, c-Fms, Cathepsin K, and decreased expression of the osteoclast inhibitory lectin gene.  In concordance with the cortical shell data, adherent marrow stromal cell cultures derived from endoxifen treated mice showed significant increases in Runx2, osterix, and AlkPhos relative to vehicle treated controls.  In addition, human fetal osteoblasts with stably integrated estrogen receptor alpha exhibited significant increases in osteoblast Runx2, osterix, AlkPhos, and OPG following endoxifen treatment.  In order to further validate our work, a pre-clinical rat model using 4 month old OVX and intact Sprague Dawley rats were treated with placebo or endoxifen (10mg/kg/day) for 30 days and revealed significant protection against cancellous bone loss following estrogen depletion.  Interestingly, endoxifen treatment also enhanced cancellous bone formation in ovary intact animals.  These are the first studies to evaluate endoxifen’s effect on the skeleton and suggest that endoxifen may have utility as an osteoporotic treatment and prevention of bone loss in endocrine sensitive breast cancer patients.

 

Nothing to Disclose: AG, MS, KSP, LBL, JNI, MPG, RTT, UTI, TCS, JRH

PP31-3 16508 5.0000 MON-0230 A Endoxifen Protects Against Bone Loss in Post-Menopausal Models of Osteoporosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0226-0238 4783 1:00:00 PM Novel Mechanisms That Regulate Bone and Mineral Metabolism Poster

Masafumi Fukagawa*1, Yoshiko Iwasaki2, Hisae Tanaka3, Atsushi Yasuda1, Toshiro Seki1 and Junichiro James Kazama4
1Tokai Univ Sch Med, Kanagawa, Japan, 2Oita University of Nursing and health Sciences, Oita, Japan, 3Tokai University School of Medicine, Isehara, Japan, 4Niigata Univ, Niigata, Japan

 

Accumulation of uremic toxins contributes damages and abnormalities in various organ systems including bone in chronic kidney disease (CKD). We previously reported indoxyl sulfate, a major uremic toxin, evoked skeletal resistance to parathyroid hormone (PTH) in CKD. In this study, we examined the effects of another major protein-bound uremic toxin, p-cresyl sulfate (PCS) on the bone in vivo.  

Male Sprague Dawley rats, at 6-weeks of age, underwent a 5/6-nephrectomy or sham operation. After 9 weeks, the rats were randomly divided into two groups: CKD rats and PCS loaded CKD (CKD+PCS) rats. The CKD+PCS rats were treated with PCS (n=7) at a dose of 50mg/kg/ day for 4weeks by intra-peritoneal injection. The CKD rats (n=9) and sham-operated rats (n=4) received phosphate buffered saline.  

Before loading of PCS, there was no significant difference either in renal function or serum PCS level between CKD and CKD+PCS rats. After 4 weeks of loading, serum PCS concentration in CKD+PCS rats increased to approximately 7.7 fold higher than that in CKD group (4.5±5.0 vs 34.4±21.6 μmol/l; p<0.01). In addition, despite similar body weights, serum creatinine (1.4±0.2 vs 1.2±0.1 mg/dl; p<0.05) and phosphorus (7.5±0.6 vs 6.6±0.8 mg/dl; p<0.05) levels were higher in the CKD+PCS group than the CKD group. PTH level was trend increasing, but not significant (1026.6±353.3 vs 871.9±112.5 pg/ml; p=0.379).

Bone turnover was assessed by bone histomorphometry analysis in secondary trabecular of tibia. The CKD+PCS group showed increasing osteoblast surface (+67%; p<0.05), osteoid volume (+62%; p<0.05) compared with CKD group. However, the values of bone formation rate and bone resorption parameters were comparable with CKD group. Of note, Storage modulus at 1Hx (-16%; p<0.05) and tan delta (-18%; p<0.05), which represent mechanical properties, were significantly lower in CKD+PCS group compared with sham group despite of the comparable values of BMD. These data suggest that PCS aggravates not only osteoblastic and osteoclastic functions, but also bone mechanical properties in early stage of CKD. Further studies are required to clarify detailed mechanisms of PCS in deteriorating bone mechanical properties.

 

Nothing to Disclose: MF, YI, HT, AY, TS, JJK

12302 6.0000 MON-0231 A P-Cresyl Sulfate Aggravates Bone Mechanical Properties through Osteoblastic and Osteoclastic Dysfunction in Early Stage of Chronic Kidney Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0226-0238 4783 1:00:00 PM Novel Mechanisms That Regulate Bone and Mineral Metabolism Poster

Mohammadi Kaouass*1, El Bachir Affar2 and Andrew C Karaplis3
1Université Sainte Anne, Pointe de l'Église, NS, Canada, 2Centre de Recherche Maisonneuve-Rosemont, Montreal, QC, 3McGill Univ, Montreal, QC, Canada

 

Parathyroid hormone-related peptide (PTHrP) modulates cellular function in a dual mode of action: by activating G-protein-coupled receptor and, by direct intracellular mechanism following translocation to the nucleus. The absence of nuclear PTHrP has profound consequences on the biology of the organism in vivo leading to decreased cell proliferation, early senescence and apoptotic death. The overall objective of our study is to unravel the complexity of these PTHrP actions by identifying proteins associated with PTHrP at the level of the nucleus, and investigate the mechanism(s) by which these protein-protein interactions alter the proliferative and anti-apoptotic capacity of the cell. FLAG-HA Tandem Affinity Purification (TAP) followed by mass spectrometry was used to identify and analyze nuclear proteins associated with the intra-nuclear PTHrP. For this purpose, human PTHrP (1-141) missing the N-terminal signal peptide (PTHrPDSP) and tagged with HA and FLAG epitopes was generated by RT-PCR amplification and used in Hella cells. Several novel PTHrP-interacting proteins were found to be specifically associated with the tagged PTHrP whose identities were determined by mass spectrometry. The PTHrPDSP-associated proteins can be grouped into at least five classes based on their function, which include: (1) protein arginine methyltransfease 5 (PRMT5), shown to negatively regulate transcription and is required for cell-cycle progression; (2) RNA binding proteins represented by the DEAD-box helicase DDX15/Prp43, RNA-binding motif 10 (RBM10) and Matrin-3, involved in RNA splicing; (3) ribosome-associated proteins such as ribosomal LBP/p40 and DDX15/Prp43 shown to be involved in ribosome biogenesis; (4) Apoptosis Susceptibility protein (CAS, also known as Exportin-2 or CSE1) that mediates nuclear-to-cytosolic recycling of importin-α and possibly other proteins; and (5) heat shock proteins such as HSP7C, HSP71 and GRP78. Treatment with micrococcal nuclease did not disrupt the interaction of PTHrP with PRMT5 and LBP/p40, suggesting that the observed associations are not dependent on RNA. The proliferative effect of nuclear PTHrP might result from the modification of the activity of some components of the transcription machinery and/or translation

 

Nothing to Disclose: MK, EBA, ACK

15903 7.0000 MON-0232 A Novel Interacting Protein Partners of Nuclear Parathyroid Hormone-Related Peptide (PTHrP) As Identified By Tandem Affinity Purification 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0226-0238 4783 1:00:00 PM Novel Mechanisms That Regulate Bone and Mineral Metabolism Poster

Yingyu Feng*1, Lei Su2, Guohong Wei2, Haipeng Xiao3, Yanbing Li4 and Lingling Xiu1
1The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China, 2The First Affiliated Hospital of Sun Yat-sen University, 3The First Affiliated Hospital of Sun Yat-sen University, Guang Zhou, China, 4First Affiliated Hospital, Sun Yat-sen University, China

 

Background: Type 2 diabetes and osteoporosis have been found recently to be tightly correlated. New antidiabetic agents, glucagon-like peptide-1 receptor agonist exendin-4 was reported to play a positive role in bone metabolism: prevent osteopenia in aged ovariectomized rats, reverse the bone loss of diabetes and insulin resistant models. However, whether exendin-4 has direct effect on osteoblasts proliferation and differentiation and its cellular mechanisms is unkown.

Methods: We examined the effects of exendin-4 on the proliferation, differentiation, and mineralization of mice osteoblasts MC3T3-E1. Cell proliferation was assessed using MTT assay after exendin-4 treatment at different doses and time points. Cell differentiation was induced by 50mg ∕ L ascorbic acid and 10mM β-glycerophosphate in the absence or presence of exendin-4.  Alizarin red staining was used to measure the mineralization of MC3T3-E1 after 21-days induction of differentiation. Gene expression of differentiation markers (ALP, OCN, Collagen-I, and Runx2) were quantitated with fluorogenic quantitative PCR analysis on day 3, 7, 14 and 21. Western blot analysis was used for the detection of phosphorylation of p42 ∕ 44 (ERK1/2) which was the key protein of MAPK ∕ ERK1/2 pathway.

Results: Exendin-4 led to a dose- and time-dependent increase in cell proliferation (P<0.05). No significant effect was found on the mineralized nodule formation. Exendin-4 increased the mRNA expressions of ALP, OCN, and Collagen-I at 14 days of differentiation; and up-regulated the Runx2 mRNA expression at day 7 (P<0.05). Exendin-4 had no effect on total protein level of ERK1/2 but up-regulated the phosphorylation of ERK1/2 (p-ERK1/2), with the peak effect at 10-7 mol ∕ L and 15 mins (P<0.05). PD98059 (50 μM), the specific inhibitor of ERK1/2, could block the effects of exendin-4 on both cell proliferation and up-regulation of p-ERK1/2 in MC3T3-E1 osteoblasts (P<0.05).

Conclusions:  These findings suggest that exendin-4 might promote the proliferation and differentiation of osteoblasts MC3T3-E1 via the activation of MAPK ∕ ERK1/2 pathway.

 

Nothing to Disclose: YF, LS, GW, HX, YL, LX

13322 8.0000 MON-0233 A Exendin-4 Promote Proliferation and Differentiation of MC3T3-E1 Osteoblast By MAPK/ERK1/2 Activation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0226-0238 4783 1:00:00 PM Novel Mechanisms That Regulate Bone and Mineral Metabolism Poster

Jenna Shapiro1, Sisi Liu*1 and Constantine A Stratakis2
1Section on Endocrinology and Genetics, NICHD, NIH, Bethesda, MD, 2National Institutes of Health (NIH), Bethesda, MD

 

Carney complex (CNC) is a multiple endocrine neoplasia disease cause by an inactivating mutation in PRKAR1A, which encodes the Iα regulatory subunit (RIα) of Protein Kinase A (PKA).  Mouse models of CNC harboring mutations in PKA subunits develop vertebral bone tumors that feature abnormal type I collagen structure and deposition.  We hypothesize that changes in PKA expression directly affect the structure of collagen in the bone extracellular matrix (ECM), via changes in the osteogenic process.  In order to determine the effect of aberrant PKA activity on osteogenesis and subsequent ECM structure, MC3T3 murine pre-osteoblasts were transfected to alter expression of the regulatory or catalytic PKA subunits.  Stable transfection of MC3T3s yielded cells that expressed human RIα, as confirmed by qRT-PCR. MC3T3s expressing human RIα exhibited a more elongated morphology than their wild-type counterparts. In addition, these cells mineralized earlier (14 d vs. 21 d exposure to osteogenic media) and more extensively than the control cells, as qualitatively measured by Alizarin Red S staining.    No changes in PKA activity, or viability over 14 d were observed.  These results indicate that changes in RIα expression potentially direct mineralization of the ECM during osteogenesis.

 

Nothing to Disclose: JS, SL, CAS

15183 9.0000 MON-0234 A Alteration of PKA Subunit Expression on the Osteogenic Behavior of MC3T3 Murine Pre-Osteoblasts 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0226-0238 4783 1:00:00 PM Novel Mechanisms That Regulate Bone and Mineral Metabolism Poster

Tulio Fernandez1, Gilberto Olave2, Carlos H Valencia3, Sandra Arce4, Julian MW Quinn5, Paul Alter Komesaroff*6 and Qizhi Chen1
1Monash University, Clayton, Australia, 2University of Valle, cali, Colombia, 3University of Valle, Cali, Colombia, 4Autonomous University of the Occident, Cali, Colombia, 5Prince Henry’s Institute, Clayton, Victoria, Australia, 6Monash University Department of, Armadale, Victoria, Australia

 

Vascularisation of artificial grafts remains a major challenge in bone tissue engineering. Strategies for vascularising artificial scaffolds have been evaluated using osteoinductive calcium phosphates (CaP) in animals, raising two fundamental concerns: whether CaP can induce Haversian canal formation in rats and mice, which lack these structures; and the suitability of rodent models for studying the formation of heavily vascularised dense cortical bone. In this study, bone defects were created in the skulls of 4 month old male Wistar rats, filled with saline solution or a chitosan/ceramic paste with different β-TCP:CaO:ZnO and solid/(solid + liquid) ratios, and sacrificed at 20, 40 and 60 days. Samples were stained with H&E and Goldner’s trichome stain and examined using optical and electron microscopy and transmission electron microscopy. Formation of new bone occurred rapidly in all experimental sites implanted with the CaP-based biomaterial, with grafted biomaterial being largely replaced by avascular new cortical bone by 40 days. The bone regeneration process displayed three major phases: fibrovascular infiltration, in which rudimentary blood vessels formed; newly formed bone populated with many irregular-shaped cavities; and avascular, woven cortical bone. The bone remodelling mechanisms in CaP-grafted defects were the same as the well-recognised processes of natural remodelling in rats, although implanted CaP greatly accelerated the bone growth rate of the defects at the initial stage, with a growth rate of 60 mm/day, much higher than the bone growth rate (<5 mm/day) in non-implanted rats of the same age. The growth rate of new bone in the CaP-grafted defects was proportional to the degradation rate of the biomaterial. The grafted biomaterial was largely decomposed and replaced by new bone by 40 days of implantation, and the defects nearly filled by newly formed, poorly vascularised, dense bone cortical bone. Implanted CaP-based biomaterial neither induced Haversian remodelling in rat calvaria nor enhanced mineralisation of regenerated cortical tissue, showing that osteoinductive CaP does not have the capacity to induce ectopic formation of the Haversian system in rat calvaria. We conclude that while CaP effectively stimulate bone regeneration calvarial bones of rats are not suitable for the evaluation of bone tissue engineering strategies that are aimed at vascularisation, and nor are these models suitable for animal studies aimed at the engineering of thick bone for clinical applications in which vascularisation of the artificial bone matrix is critical.

 

Nothing to Disclose: TF, GO, CHV, SA, JMQ, PAK, QC

16706 10.0000 MON-0235 A Can Calcium Phosphate Induce Haversian Remodelling in Rats? Are Rats a Suitable Model for Scaffold-Based Bone Tissue Engineering? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0226-0238 4783 1:00:00 PM Novel Mechanisms That Regulate Bone and Mineral Metabolism Poster

Han-Hyuk Lim*
Chungnam National University School of Medicine, Daejeon, Korea, Republic of (South)

 

Introduction: The correlation between obesity and bone acquisition during adolescence remains to be elucidated. And the the role of weight change in the relationship between vitamin D and insulin resistance has not yet been fully studied. We aimed to determine the influences of bone mineral density (BMD) associated with serum vitamin D level and insulin resistance in growing obese mouse model. Materials & Methods: Postnatal day 28 female C57BL/6J mice (n=17) were randomly divided into 3 groups. Obese group (HF+VD-, n=6) received a high fat diet (HFD) for 9 weeks, obese with vitamin D group (HF+VD+, n=5) was kept on HFD with 25-(OH) Vitamin D3 supplement (400 IU/day), and control group (HF-VD-, n=6) was weaned low fat chow. Serum levels of fasting glucose, insulin, 25-(OH) vitamin D3, and bone marker concentration such as osteoprotegerin (OPG), cross-linking telopeptide of type 1 collagen (CTX), and osteocalcin (OC) were measured. In addition, tibia bone densitometry (BMD) was analyzed by micro–computed tomography. Results: The final body weight and weight gain were significantly elevated in HFD groups (P < 0.001). Vitamin D supplement reduced weight gain in HFD mice. BMD was the greatest in HF+VD+ (P < 0.001), and greater in HF+VD- than HF-VD- (P = 0.004). Serum insulin/glucose (I/G) ratio was significantly higher in HF+VD- than HF+VD+ and HF-VD-. Serum I/G ratio was inverse correlation with serum 25-(OH) vitamin D3 levels. The significant differences of OPG, CTX and OC among three groups were not showed. Conclusions: The vitamin D may reduce the excess weight gain and directly and/or indirectly increase BMD by reducing insulin resistance in high-fat-diet growing obese mice. The obese itself cannot be a low-risk factor for osteoporosis. Further studies for osteoblast and osteoclast activity in obese state were necessary.

Nothing to disclose: LIM HH

 

Nothing to Disclose: HHL

12358 11.0000 MON-0236 A 25-(OH) Vitamin D3 Improves Bone Acquisition in High-Fat-Diet Fed Young Female Mice By Reducing Insulin Resistance 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0226-0238 4783 1:00:00 PM Novel Mechanisms That Regulate Bone and Mineral Metabolism Poster

Christian M Girgis*1, Peter Houweling2, Nancy Mokbel3, Kuan Minn Cha3, Amit Lalwani3, Michael Robert Downes4, Roderick John Clifton-Bligh5 and Jenny Elizabeth Gunton6
1Westmead Millennium Institute, Sydney, Australia, 2Murdoch Childrens Research Institute, 3Garvan Institute of Medical Research, Sydney, Australia, 4Salk Institute, San Diego, CA, 5Royal North Shore Hospital, Sydney, Australia, 6Garvan Institute of Medical Research, Sydney NSW, Australia

 

Background: Vitamin D deficiency is associated with muscle weakness, myalgia and age-related sarcopenia. These features may result from defects in muscle repair. However, precise mechanisms are unclear. A central question is whether VDR is expressed and functionally active in skeletal muscle.

Methods: PCR, western blot and immunohistochemistry were used to examine VDR in quadriceps, tibialis anterior (TA) muscles and primary CD56+ muscle precursor cells. As VDR regulates muscle development, we examined its role in muscle regeneration, a process with similar features. To induce muscle injury, 100ug of Notexin (NTX), a purified venom from Australian tiger snake (Notechis scutatus), was injected in TA muscle of adult male mice. Saline was injected in the contralateral limb as control. VDR knockout (KO) mice on high-calcium/phosphorus rescue diet and WT littermates were used. Muscle histology and RT-PCR were assessed.

Results: VDR was detected in quadriceps and TA muscles and partly localized to myonuclei on DAPI counterstain. Five days post-NTX injection, extensive muscle damage and inflammatory infiltrates were seen in KO and WT mice. VDR mRNA and protein levels increased substantially in WT mice (ie 9.2-fold increase at day 5 versus saline, p<0.005). KO mice displayed differences in gene expression at day 5 compared to WTs, specifically an increase in the expression of IL-6, an anti-inflammatory myokine (1.4-fold, p<0.05), and reduced expression of TNF-alpha (0.6-fold, p<0.005). At day 10, while muscle recovery was seen in both groups, KO mice displayed significantly more fibers with central nuclei, a measure of muscle remodeling (77% vs. 36%, p<0.005). KO mice displayed higher Pax7 and PCNA mRNAs (both ~ 2-fold, p<0.005), markers of satellite cell proliferation, and of myogenic regulatory factors, myoD and myogenin (2.2 and 1.8-fold, p<0.005). Regenerating muscle fibers were smaller in KO mice (diameter: 24 vs. 35 µm, p <0.005) and myostatin, a negative regulator of muscle mass, was higher (1.5-fold, p<0.005).

Conclusion: VDR is expressed in murine skeletal muscle and is substantially upregulated following injury. VDR KO mice respond differently to NTX-induced muscle injury with earlier induction of myogenic regulatory factors, more fibers with central nuclei and smaller fibers.These data suggest that VDR plays a modulatory role in muscle regeneration.


 

Nothing to Disclose: CMG, PH, NM, KMC, AL, MRD, RJC, JEG

12332 12.0000 MON-0237 A The Vitamin D Receptor (VDR) Is Expressed in Murine Skeletal Muscle and Modulates Regeneration at This Site 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0226-0238 4783 1:00:00 PM Novel Mechanisms That Regulate Bone and Mineral Metabolism Poster

Dalia Somjen*1, Oleg Dolekart2, Sara Katzburg3, Orli Sharon4, Moshe Salai2, Naftali Stern5 and Eran Maman2
1Tel Aviv Med Ctr, Tel Aviv, Israel, 2Tel-Aviv med ctr, Tel-Aviv, Israel, 3Tel-Aviv Sourasky Med Ctr, Tel Aviv, Israel, 4Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, 5Tel Aviv Medical Center, Tel Aviv, Israel

 

Hormone therapy in orthopedic patients who might be at increased risk for tendon tearing was apparently never analyzed for its effects on tendon cell (tenocyte) proliferation, a potentially important determinant of tendon regeneration/healing. In the present study we studied the effect of a short term exposure (24h) of several hormones on cellular proliferation. Rat cultured tenocytes express the specific markers scleraxis (Scx) and collagen type 1 (Col1) as well as estrogen receptor α (ERα) and vitamin D receptor (VDR). Estradiol- 17β (E2), the phytoestrogen Biochainin A (BA), the selective estrogen modulator (SERM) raloxifene (Ral) and the less-calcemic vitamin D analog QW each stimulated significantly DNA synthesis (DNA), achieving a variable peak effect ( 130-240%) In contrast, parathyroid hormone 1-34 (PTH) and the phytoestrogens daidzein (D) and genistein (G) were ineffective. The ERβ specific analog DPN as well as the ERα specific analog PPT stimulated cell proliferation, but PPT's effect was more robust (170 vs 135%).  Moreover, only the ERα antagonist MPP and not ERβ antagonist PTHPP abolished the proliferative response to E2. E2, PTH and QW modulated the expression of Scx, Col1 and VDR. It is presently unknown whether or not human derived tendon cells are likewise sensitive to hormone. In conclusion, cultured rat tenocytes growth and metabolism is significantly affected by E2, some but not all phytoestrogens as well as by PTH. The implications and mechanisms underlying these effects remain to be elucidated.

 

Nothing to Disclose: DS, OD, SK, OS, MS, NS, EM

14346 13.0000 MON-0238 A Rat Tenocytes Are New Estrogen-, PTH- and Vitamin D Responsive Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0226-0238 4783 1:00:00 PM Novel Mechanisms That Regulate Bone and Mineral Metabolism Poster

Dorothy I Shulman*1 and Karen K Winer2
1Univ S FL Morsani Coll of Med, Tampa, FL, 2NICHD/NIH, Bethesda, MD

 

3 young women (ages 18-19) with hypoparathyroidism due to activating mutations of the CASR have been treated with rhPTH 1-34 (Forteo, Eli Lilly) delivered by an insulin pump (Animas, Medtronic, Omnipod) for 8-14 months. All were diagnosed in infancy or early childhood, initially treated with calcitriol and calcium supplementation, and had significant nephrocalcinosis, diagnosed in infancy or early childhood.  They subsequently received subcutaneous injections of synthetic PTH 1-34 through a research program at the NIH for 1.5-10 years, and had participated in a 6 month trial comparing PTH replacement therapy with injections vs. pump a year prior to the end of the NIH PTH program.  PTH injections reduced urine calcium excretion, which improved further when PTH was delivered through a pump.  All patients received magnesium supplementation and 1000 IU of vitamin D3. The patients were transitioned to a commercial source of rhPTH (Forteo) delivered via an insulin pump covered by their insurance (each patient was approved for a different pump). All subjects have been on treatment for nearly a year. Serum calcium was targeted between 7-8.5 mg/dL(1.75-2.1 mmol/L).  Mean ± SD serum calcium during pump was 8.2 ± 0.5 mg/dL (2.0 ± 0.1 mmol/L) and on the prior year of injections, 7.6 ± 0.6 mg/dL (1.9 ± 0.2 mmol/L) (p<0.01).  Mean daily rhPTH dose was reduced during pump therapy to 22.1 ± 6.1 compared to 28 ± 6.9 mcg/d on injections. 24 hr urine calcium was lower on pump (184 ±31 mg ; 4.6 ± 0.8 mmol) than on injections (259 ± 104 mg;  6.5 ± 2.6 mmol) (p=0.056). Ratio of 24 hr urine calcium (mg)/serum calcium (mg/dL) was significantly lower on pump (23.6 ±4.8 vs 33.4±15.5; p<0.05).  Bone density of the lumbar spine remains in the normal range and increased in 2 patients.  Serum alkaline phosphatase levels, a marker of bone formation, were normal during injection and pump therapy. On pump therapy symptomatic hypocalcaemia occurred just before menses or with intercurrent illness. There were 3 brief hospitalizations for tetany in two patients, one due to failed infusion site and another associated with menses and stress. All patients have learned to give a bolus, take extra calcium supplementation, or temporarily increase the pump rate for early tetany.  All wish to continue pump therapy.  Conclusions: rhPTH 1-34 delivered via insulin pump can result in sustained low -normal serum calcium levels with normalization of urinary calcium excretion over a 1 year period.  This therapy lowers urinary calcium excretion more effectively than calcitriol, and in some individuals, more than PTH injections.  It may provide the greatest long-term protection to the kidney in patients with hypoparathyroidism due to mutations of the calcium receptor who are at great risk of renal impairment.

 

Disclosure: DIS: Advisory Group Member, Vicrin, Consultant, Johnson &Johnson. Nothing to Disclose: KKW

11788 1.0000 MON-0193 A Results of One Year of Therapy with Recombinant Human Parathyroid Hormone 1-34 (rhPTH 1-34) Delivered By Insulin Pump in 3 Women with Activating Mutations of the Calcium Sensing Receptor (CASR) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Elaine W. Yu*, Mary L Bouxsein, Elizabeth Monis, Adam Roy, W. Scott Butsch and Joel S Finkelstein
Massachusetts General Hospital, Boston, MA

 

BACKGROUND: Substantial bone loss occurs after bariatric surgery, but the full extent and duration are unknown. We previously reported bone loss in the 1st year after Roux-en-Y gastric bypass (RYGB) as measured by quantitative computed tomography (QCT) and dual-energy x-ray absorptiometry (DXA).(1)  Because skeletal changes had not yet reached a steady state, we continued to monitor subjects for a 2ndyear.

METHODS: We evaluated 50 adults with severe obesity in a prospective 2-year study (30 undergoing RYGB surgery + 20 non-surgical controls). Bone mineral density (BMD) was measured at the lumbar spine and proximal femur by QCT and DXA at 0, 1 and 2 years. We measured serum calcium, 25(OH)-vit D, parathyroid hormone (PTH), amino-terminal propeptide of type I collagen (P1NP) and C-telopeptide (CTX) levels at these same time points. P-values are for comparisons between RYGB and controls.

RESULTS: Baseline age, weight, and BMD were similar in the RYGB and control groups. Weight loss plateaued 1 year after RYGB but remained greater than controls at 2 years (-30 ± 2% vs. -5 ± 4%, p<0.0001). BMD did not change in the controls over 2 years. In previous analyses, spine BMD from baseline to year 1 after RYGB declined 3.4% by QCT and 3.3% by DXA. In current analyses, spine BMD from year 1 to 2 after RYGB continued to fall by QCT (-1.7 ± 0.8%, p=0.045) and DXA (-2.2 ± 0.6%, p=0.009). We also previously noted the 1st year after RYGB led to an insignificant loss in QCT total hip BMD and decline of 8.9% in DXA total hip BMD. We now report that total hip BMD from year 1 to 2 after RYGB declined markedly by QCT (-4.2 ± 1.0%, p=0.001), with a similar trend observed by DXA (-2.6% ± 0.7%, p=0.061). QCT trabecular total hip BMD also declined in the 2nd year after RYGB (-3.4 ± 1.1%, p=0.018). In total, by 2 years after RYGB, spine BMD was 5 and 7% lower and total hip BMD was 7 and 10% lower than controls by QCT and DXA, respectively (p<0.001 for all). Bone turnover markers peaked at 6 months after surgery but remained markedly elevated above baseline 2 years after RYGB (CTX 149 ± 20%, P1NP 65 ± 13%, p<0.001 for both). Calcium and 25(OH)-vit D were unchanged in both groups. There were small increases in PTH in the 2ndyear after RYGB that were not different from controls. Changes in BMD, assessed by QCT or DXA, were not associated with weight loss or changes in PTH.

CONCLUSIONS: Bone loss persists in the 2nd year after RYGB, as evidenced by declining QCT and DXA BMD at the spine and hip, and persistently elevated bone turnover markers. Bone loss occurs despite stability of weight, calcium and PTH during the 2nd year after RYGB. The mechanisms underlying bone loss after RYGB remain to be elucidated.

 

Disclosure: EWY: Consultant, Amgen. WSB: Consultant, Eisai, Consultant, Coleman Group. Nothing to Disclose: MLB, EM, AR, JSF

12939 2.0000 MON-0194 A Bariatric Surgery Patients Have Continued Bone Loss for 2 Years after Surgery Despite Weight Stabilization 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Rachel L. Usala*1, Stephen J. Fernandez2, Laura Cowen3, Nawar M. Shara2, Julianna Barsony4 and Joseph G. Verbalis4
1Georgetown University School of Medicine, 2MedStar Health Research Institute, Washington, DC, 3MedStar Georgetown University Hospital, Washington, DC, 4Georgetown University Medical Center, Washington, DC

 

Several independent studies have shown increased bone fracture rates in patients with hyponatremia (HN). A likely major contributor to this finding is gait instability and increased falls in HN patients. Studies in experimental animals have also demonstrated HN-induced bone loss, and analysis of human subjects in the National Health and Nutrition Examination Survey (NHANES III) showed a significantly increased odds ratio for osteoporosis by hip DXA in the HN subjects in this database. To assess the potential clinical significance of these findings, we analyzed the clinical database of the MedStar Health system using the Explorys electronic health record (EHR) tool. Analysis of serum laboratory measurements and ICD-9 codes in >2.8 million unique patient EHRs accumulated as of April 2013 revealed a 2.6-fold increased prevalence of osteoporosis in HN patients (4.6%) versus non-HN patients (1.8%) and of vertebral or long-bone fragility fractures among HN patients (9.5%) versus non-HN patients (3.7%). Clinical factors including labs, medications, and diagnoses were selected for evaluation in groups with osteoporosis (n=43,176, mean age 76.0 years, 86.8% female), without osteoporosis (n=17,301, mean age 75.0 years, 87.1% female), with fragility fracture (n=63,603, mean age 59.6 years, 56.9% female) and without fragility fracture (n=28,920, mean age 57.9 years, 54.1% female). Hyponatremia was defined as [Na+]<135mmol/L. Univariate analysis using a logistic regression model demonstrated increased risk of osteoporosis among patients with well-established risk factors such as glucocorticoid use and increased risk of fracture among patients with clinical characteristics such as liver disease. The model also demonstrated increased risk of osteoporosis and fragility fracture in patients with HN. Relative to risk of osteoporosis with [Na+] >135mmol/L, the risk of osteoporosis increased as the severity of average HN before osteoporosis increased ([Na+] 130-135mmol/L,OR 1.48[95% CI, 1.38-1.6]; 125-130mmol/L, OR 1.88[95% CI, 1.53-2.31]; <125mmol/L, OR 4.13[95% CI, 2.00-8.54]). Relative to risk of fracture with [Na+]>135mmol/L, the risk of fracture also increased as the severity of average HN prior to fracture increased ([Na+] 130-135mmol/L, OR 1.66[95% CI, 1.55-1.77]; 125-130mmol/L, OR 1.92[95% CI, 1.57-2.35]; <125mmol/L, OR 3.24[95% CI, 1.67-6.28]). A chronically hyponatremic patient cohort has been identified for further analysis. Multivariate modeling to investigate independent risk factors is ongoing. The results of this study support the hypothesis that HN is a significant and clinically important risk factor for both osteoporosis and bone fractures in inpatients and outpatients in the U.S.

 

Disclosure: JGV: Consultant, Cornerstone Therapetics, Consultant, Ferring Pharmaceuticals, Consultant, Otsuka, Principal Investigator, Otsuka, Speaker, Otsuka, Advisory Group Member, Otsuka. Nothing to Disclose: RLU, SJF, LC, NMS, JB

15146 3.0000 MON-0195 A Hyponatremia Is Associated with Increased Osteoporosis and Bone Fragility Fractures in a Large Health System Population 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Aliya Aziz Khan*1, John P Bilezikian2, Henry G Bone3, Andrey Gurevich4, Peter Lakatos5, Waldemar Misiorowski6, Liudmila Ya Rozhinskaya7, Marie-Louise Trotman8 and Miklos Toth9
1McMaster University, Hamilton, Canada, 2Columbia Univ Coll of P & S, New York, NY, 3Michigan Bone and Mineral Clinic, Detroit, MI, 4Amgen (Europe) GmbH, Zug, Switzerland, 5Semmelweis Univ Med Sch, Budapest, Hungary, 6Rheuma Medicus Interdyscyplinarne Centrum Reumatologiczne, Warszawa, Poland, 7Endocrinology Research Centre, Moscow, Russia, 8Amgen Inc., Thousand Oaks, 9Semmelweis University, Budapest, Hungary

 

Primary hyperparathyroidism (PHPT) is characterized by hypercalcemia and elevated or non-suppressed parathyroid hormone (PTH) levels. It is associated with increased risk of renal stones and nephrocalcinosis as well as increased bone remodeling, decreased bone mineral density and, in some studies, increased risk of fragility fracture. Surgery is usually curative and recommended as a first-line approach, but some individuals are unable or unwilling to undergo surgery. Surgery, moreover, is not always curative. Cinacalcet (Cin) increases the sensitivity of the calcium sensing receptor to extracellular calcium and can normalize calcium and PTH in patients (pts) with PHPT in a series of phase 2 and open-label studies. We sought to demonstrate the efficacy and assess the safety of Cin to correct hypercalcemia in pts with PHPT for whom parathyroidectomy is indicated on the basis of an elevated corrected total serum calcium, but who are unable to undergo surgery.

The phase 3, double-blind, randomized, placebo-controlled study consisted of a 30-day screening phase, a 12-week dose-titration phase, and a 16-week efficacy-assessment phase (EAP). The primary endpoint was achievement of a mean corrected total serum calcium concentration (Ca) of ≤10.3 mg/dL during the EAP. Secondary endpoints were achievement of a ≥1.0-mg/dL reduction in Ca, mean plasma PTH change, and absolute change in Medical Outcomes Study Cognitive Functioning (MOS-CF) scale.

Of 67 pts randomized, 33 received Cin and 34 placebo (PBO). At baseline, mean (SD) age was 72.3 (11.4) years, median (Q1; Q3) plasma intact PTH was 164.0 (131.0; 211.0) pg/mL and mean (SD) Ca was 11.77 (0.46) mg/dL.

The primary endpoint (Ca ≤10.3 mg/dL) was met by 25 pts (75.8%) in the Cin group vs. none in the PBO group (p <0.001). Ca was reduced by ≥1.0 mg/dL in 84.8% of the Cin group vs. 5.9% of the PBO group (p <0.0001). Mean (SD) percentage change in plasma PTH from baseline was ‑22.9% (27.3%) with Cin vs. +1.8% (17.4%) with PBO (p <0.001). Mean (SD) change in MOS-CF from baseline was not statistically different in the Cin and PBO groups: 7.6 (18.3) and -3.8 (17.5), respectively. Most frequent adverse events (AEs) were nausea (30% Cin, 18% PBO) and muscle spasms (18% Cin, 0% PBO). Serious AEs were observed in 3 (Cin) and 4 (PBO) pts; no events were reported in more than one pt.

This phase 3 study demonstrates that cinacalcet is effective in reducing the serum calcium concentration in this PHPT population.

 

Disclosure: AAK: Principal Investigator, Amgen. JPB: Principal Investigator, Amgen. HGB: Principal Investigator, Amgen, Consultant, Amgen, Principal Investigator, Merck, Consultant, Merck, Principal Investigator, Novartis, Consultant, Novartis. AG: Employee, Amgen, Employee, Amgen. PL: Advisory Group Member, Amgen, Speaker, Servier, Speaker, Roche. WM: Principal Investigator, Amgen. LYR: Principal Investigator, Amgen. MLT: Employee, Amgen, Employee, Amgen. MT: Principal Investigator, Amgen.

12166 4.0000 MON-0196 A Cinacalcet Normalizes Serum Calcium in a Randomized, Placebo-Controlled Clinical Study in Patients with Primary Hyperparathyroidism Unable to Undergo Parathyroidectomy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Catherine Mary Kelly*1, Afshan Zahedi2, Rosario Briones2 and Abtin Jafroodifar3
1University of Toronto, 2Women's College Hospital, Toronto, ON, Canada, 3Women's College Hospital

 

Delayed-onset Mild Primary Hypoparathyroidism Post Thyroidectomy for Thyroid Cancer: a case series

Transient hypoparathyroidism with hypocalcemia is reported in up to 20% of cases post total thyroidectomy,but permanent hypoparathyroidism persists in much smaller numbers ranging from 0.8 to 3.0%. 

In our Thyroid Cancer Program at Women’s College Hospital , we noted cases of hypoparathyroidism that were first documented more than one year after total thyroidectomy for well differentiated thyroid cancer (WDTC) and previous normal calcium levels.These patients presented with mild hypocalcemia (2.0-2.19 mmol/L) despite documented eucalcemia postoperatively. To ascertain the prevalence of delayed onset mild primary hypoparathyroidism (DOPH) post total thyroidectomy for WDTC,we instituted routine measurements of serum calcium at all annual follow-up visits.We then performed a retrospective chart analysis of thyroid cancer cases to determine the prevalence and clinical description of DOPH cases.

Methods:We reviewed medical charts for all WDTC patients in the WCH Thyroid Program who received total thyroidectomy between 2000-2012,with documented serum calcium levels that normalized within 3-6 months postoperatively.Patients were excluded if they had ≥3 parathyroid glands removed had prior parathyroid disease,were on calcitriol,had incomplete or inadequate documentation of thyroid cancer pathology, or whether radioactive iodine (RAI)treatment was administered.We defined DOPH as new hypoparathyroidism at least one year post initial thyroid cancer surgery with normal calcium levels documented in the first year.Data was abstracted from the medical records and analyzed.

Results:Among the 406 cases of WDTC included, 45.6% were T1 and 21.9% were T2, 17% were T3 and 3.2% were T4. The average tumour size was 1.61 ± 0.69 cm in the WDTC cohort and 1.71 ±1.2cm in the DOPH case series. We identified 25 cases of DOPH within the WDTC cohort of 406 patients (6.16%).The mean age at diagnosis of WDTC in our DOPH cases was 39 ± SD 16.6 years (range: 8.6 – 78.7 years) compared to 44.8 ± 14.2 years in the overall cohort. Among the DOPH cases, the mean serum calcium concentration was 2.13 ± 0.03 mmol/L (2.2-2.6)and the mean PTH level was 3.2 ± 1.6 pmol/L (1.4-7.6).The median time of diagnosis of the delayed onset hypoparathyroidism was 3.49 years from total thyroidectomy(range: 1.27 to 16.9 years).

Conclusions:In our cohort of WDTC patients, we found that 6.16% developed DOPH more than one year post-thyroidectomy despite postoperative eucalcemia.  Nineteen of 25 patients with DOPH (76%) received RIA therapy. Currently, the 2009 ATA Thyroid Cancer recommendations do not include annual surveillance of serum calcium in follow up of WDTC.Our case series is the first to identify this potential long-term complication of thyroid cancer treatment.

 

Nothing to Disclose: CMK, AZ, RB, AJ

12284 5.0000 MON-0197 A Delayed Onset Mild Primary Hypoparathyroidism in Post Thyroidectomy for Thyroid Cancer: A Case Series 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Jenning Nuguid1, Peter Simm2, Jeremy Freeman2, Mark MacKay2, Alexandra Gorelik3, Ashwini Kale4, Sandra Petty3 and John D Wark*4
1University of Melbourne, Parkville, Australia, 2Royal Children's Hospital, 3Royal Melbourne Hospital, 4The University of Melbourne / Royal Melbourne Hospital, PARKVILLE, Australia

 

People receiving long term antiepileptic drug (AED) therapy are at high risk for reduced bone mineral density (BMD) and fractures. The pathogenesis of this problem is likely to be multifactorial and to include drug-induced bone fragility and increased falls risk. Some evidence suggests that the bone disorder may particularly affect patients who commence AED therapy at a young age before skeletal maturity.

We therefore obtained questionnaire information, BMD measurements (dual energy Xray absorptiometry; peripheral quantitative computed tomography, QCT; anthropometry; bone age; serum 25 hydroxyvitamin D  (25 OHD) levels and lower limb muscle strength and balance tests (Leonardo ground reaction force platform; GRFP) in same-sex, AED therapy-discordant twin and sibling pairs aged 5 – 18 years. Paired analyses were conducted and within-pair differences calculated.

Fourteen pairs (7 male/7 female; 5 twin/9 sibling pairs) were recruited. Chronological age (12.9 ± 2.5 (mean ± SD), 12.8 ± 3.1 years) and bone age (13.0 ± 3.5, 13.0 ± 3.0 years) did not differ between AED users and non-users, respectively. The duration [median (IQR)] of AED therapy was 3.5 (2-10) years. AED therapy included enzyme-inducing drugs in 50 % of users and 50 % of users had a history of AED polytherapy. Physical activity, pubertal status, anthropometry and serum 25 OHD (users - 58.9 ± 28.4; non-users - 46.3 ± 13.2 nmol/L; P = 0.21) did not differ between groups; 6 AED users and 7 non-users had 25 OHD levels < 50 nmol/L (20 ng/mL). AED users had more fractures than non-users (e.g., 9 versus 1 forearm fractures; P = 0.013). Areal BMD adjusted for bone age was lower at the femoral neck in AED users (within-pair difference, user – non-user:  - 0.9 %; P = 0.04), but not at the lumbar spine (- 1.0 %; P = 0.20), total hip (- 0.85 %; P = 0.12) nor whole body (- 0.4 %; P = 0.34). Peripheral QCT bone measures did not differ between groups (all P > 0.05); nor did tibial muscle cross-sectional area (users – 4911 ± 1607; non-users – 5800 ± 1521 mm2; P = 0.14). On the multiple one leg jump test, maximal force on the weight bearing leg (F max) was 15 % lower in AED users compared with non-users when adjusted for body weight (P = 0.04). Balance testing on the GRFP revealed no differences between groups.

This study using a powerful twin and sibling discordant-pair design demonstrated reduced areal BMD at the femoral neck site and reduced maximal muscle force in the lower limb in young AED users compared with matched healthy twin and sibling controls. Vitamin D status did not appear to play a role in the demonstrated deficits. These findings suggest possible mechanisms affecting the muscle-bone unit contributing to the increase in fracture risk in long term AED users, and indicate the need for larger, longitudinal and mechanistic studies.

 

Nothing to Disclose: JN, PS, JF, MM, AG, AK, SP, JDW

15342 6.0000 MON-0198 A Bone and Muscle Health Deficits in Children and Adolescents Treated Long Term with Antiepileptic Medications: A Twin and Sibling Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Donald SA Mcleod*1, Peter Justin Donovan2, Naomi Achong3, Katherine Adele Scott4, John Galligan5 and Carel J Pretorius6
1QIMR Berghofer Medical Research Institute, Herston, Australia, 2Royal Brisbane and Women's Hospital, Brisbane QLD, Australia, 3University of Queensland, Brisbane QLD, Australia, 4Gold Coast Hospital, Southport QLD, Australia, 5Pathology Queensland, Brisbane QLD, Australia, 6Pathology Queensland, Queensland Health, Brisbane QLD, Australia

 

Background: Hypercalcemia is a common complication of cancer with parathyroid hormone related peptide (PTHrP) an important etiology.  Literature on the underlying causes of PTHrP-mediated hypercalcemia, in both malignant and benign conditions, is limited to small case series and case reports.

Objective: To systematically identify a large series of cases of PTHrP-mediated hypercalcemia, to document differences in demographics and clinical course between malignant and benign etiologies.

Design, Setting, Patients:Hospital-based, retrospective case series that identified subjects from 1999 to 2010 in the Australian state of Queensland.  Included subjects had persistent hypercalcemia with simultaneously elevated PTHrP.

Results: A total of 138 cases were identified. Solid organ malignancies made up 82.6% (n=114) of cases, with squamous cell carcinoma (SCC) 56 (40.6% of total).  Squamous cell and other non-small cell carcinoma of the lung was the single mostly commonly identified etiology (n=33, 24.0%).  Hematological malignancy and benign conditions made up 8.7% (n=12) each.  Etiologies that had previously not been identified as being associated with PTHrP-mediated hypercalcemia were myxoid sarcoma, primary amyloid, plasma cell leukemia, duodenal adenocarcinoma, metastatic merkel cell carcinoma and epitholioid haemangiendothelioma.  Median survival was markedly different between groups of etiologies (52 days (21-132) for solid organ malignancy, 362 days (18-652) for hematological malignancy, 906 days (16-undefined) for benign/no apparent malignancy group (p <0.0001)).  There were no differences in PTHrP between the three groups and although mean peak corrected calcium was lower in the benign group (3.11 ± 0.44mmol/L) compared to the solid organ and haematological malignancy groups (3.41 ± 0.48and 3.69 ± 0.71, respectively), it was not a useful discriminator.

Conclusion: PTHrP-mediated hypercalcemia is most frequently caused by solid organ malignancy and it portends a poor prognosis.  If hematologic malignancy or no cause is identified, prognosis is substantially better.

 

Nothing to Disclose: DSM, PJD, NA, KAS, JG, CJP

12895 7.0000 MON-0199 A PTHrP-Induced Hypercalcaemia: A Series of 138 Cases 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Alexis Jamie Feuer*1, Ashley Thai2, Ryan T Demmer2 and Maria George Vogiatzi3
1New York Presbyterian Hospital Weill Cornell Medical Center, New York, NY, 2Mailman School of Public Health, Columbia University Medical Center, NY, NY, 3Weill Cornell Medicine New York Presbyterian, New York, NY

 

Background: Serotonin is a neurotransmitter that regulates bone mass in animal studies. Selective serotonin reuptake inhibitors (SSRI's) increase systemic and CNS serotonin levels, which may lead to bone loss. Limited adults studies link SSRI's to decreased bone mineral density (BMD). A similar effect in pediatrics has not been examined.

Objective: To determine associations between SSRI use and bone mass in adolescents.  

Methods: Data from the 2006-2010 National Health and Nutrition Examination Study (NHANES) was analyzed. All subjects aged 12 to 20 years who had complete demographic, anthropometric, DEXA and prescription medication information were included.

Results: Of a total 4303 subjects, 62 individuals (1.4%) took an SSRI [Males: 20 (32%); Females: 42 (67%)]. Of SSRI users, 47 (75%) were Caucasian, 5 (8%) were African American and 9 (15%) were Hispanic. Socioeconomic status was higher among SSRI users, and it was taken into account in our analysis.

SSRI use was an independent predictor of bone mass after adjusting for age, gender, height and BMI z scores, socioeconomic status and physical activity. Specifically, total femur bone mineral content (BMC) and BMD were negatively associated with SSRI use after adjusting for the above factors (p=0.0006 and 0.007 respectively). Similar negative associations were observed for femur neck BMC and BMD after adjusting for the same variables (p=0.02 and 0.017 respectively). Among SSRI users, total femur BMC was decreased by 2.2 g/cm2 (+/0.95 g/cm2) and BMD by 2.0 g/cm2 (+/- 0.02 g/cm2). 

Lumbar spine BMC and BMD were also negatively associated with SSRI use after adjusting as above (p=0.03 and 0.05 respectively). Among SSRI users, lumbar spine BMC was decreased by 3.6 g/cm2 (+/0.004 g/cm2) and BMD by 2.8 g/cm2 (+/- 0.002 g/cm2). 

25-hydroxyvitamin D (25OHD) concentrations were available in a small number of subjects and could not be included in the analysis. However, 25OHD concentrations were higher among SSRI users (29+11.6ng/mL vs. 21+8.5ng/mL, SSRI vs. non-SSRI, p<0.05).

Conclusion: SSRI use correlates with a decrease in femoral neck, total femur and lumbar spine BMD and BMC in adolescents and young adults. These findings suggest a role of serotonin on bone and support monitoring of bone mass in adolescents treated with SSRIs.

 

Nothing to Disclose: AJF, AT, RTD, MGV

12826 8.0000 MON-0200 A SSRI Use in Adolescents Is Associated with Decreased Bone Mass: An Nhanes Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Naoki Edo*1, Hisanori Suzuki1, Megumi Miyakawa1, Akira Takeshita1, Noriaki Fukuhara1, Hiroshi Nishioka2, Daishu Miura1, Shozo Yamada1 and Yasuhiro Takeuchi1
1Toranomon Hosp, Tokyo, Japan, 2Toranomon Hospital, Tokyo, Japan

 

<Background and Aim> Primary hyperparathyroidism (PHPT) is a common endocrinopathy that deteriorates bone integrity and increases fracture incidence. GH and IGF-1 are critically involved in skeletal development in concert. It is, however, yet uncertain how GH/IGF-1 excess affects bone metabolism in adult, although it may have anabolic effects on bone. Elderly women with asymptomatic PHPT and osteoporosis are sometimes treated with anti-bone resorptive drugs without parathyroid surgery.  Currently, only available bone anabolic agent is teriparatide that is contraindicated to PHPT. GH may be another bone anabolic agent, although its effect on bone mineral density (BMD) in primary osteoporosis is modest. To clarify effects of GH/IGF-1 on bone in patients with PHPT, we analyzed clinical data of patients with PHPT and acromegaly in comparison with those with PHPT alone.

<Methods> A case-control study was carried out with the patients in a single hospital. Cases were eight patients (2 males, 6 females) with PHPT coexistent with acromegaly, and for each case 2 age- and sex-matched controls whose serum intact PTH levels were similar to the case were enrolled. Laboratory data, bone markers and BMD were retrospectively collected.

<Results> Z-score of lumbar BMD was significantly higher in cases (p <0.05). Serum phosphate (s-P), tubular maximum reabsorption of phosphate (Tmp/GFR), daily urinary excretion of calcium, bone markers [bone alkaline phosphatase (BAP), osteocalcin (OC) and urinary type I collagen cross-linked N-telopeptide (u-NTx)] were significantly higher in cases (p <0.05). Lumber BMD was correlated with s-P (r = 0.53, p <0.02) but not with intact PTH, BAP, OC or u-NTx. Univariate analysis showed that s-P was the independent factor associated with lumber BMD (p <0.02). Besides, each of BAP and OC was correlated with s-P (BAP: r = 0.50, p <0.02, OC: r = 0.49, p <0.02), and s-P was shown to be independent factor in univariate analysis (BAP p <0.05, OC p <0.05).

<Discussion and Conclusion> Data shown here suggest that GH/IGF-1 excess increases serum phosphate level and accelerates bone metabolism that might be a determinant of BMD in patients with PHPT. Since a possible major determinant of BMD was serum phosphate level, GH/IGF-1 excess may contribute to the increase in BMD in patients with PHPT due to anabolic phosphate metabolism.

 

Nothing to Disclose: NE, HS, MM, AT, NF, HN, DM, SY, YT

13186 9.0000 MON-0201 A Effects of GH/IGF-1 Excess on Bone Metabolism in Patients with Primary Hyperparathyroidism Coexisting with Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Eelkje J Limonard*1, Michael W Tanck1, Annemieke C Heijboer2, Erik Endert1, Eric Fliers3 and Peter H Bisschop1
1Academic Medical Center, Amsterdam, Netherlands, 2VU University Medical Center, Amsterdam, Netherlands, 3Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands

 

Background Inhibition of sympathetic signalling to bone by osteoblast specific knockout of the beta2-adrenergic receptor leads to a high bone mass phenotype.(1) In contrast, mice with sympathetic hyperactivity due to a double knock-out of alpha2A- and alpha2C-adrenoceptor also have a high bone mass phenotype.(2)
Objective To determine the role of alpha2-adrenoceptors in human bone metabolism in vivo.
Methods In a randomized cross-over design, we determined the acute effect of a single oral dose of 0.3mg clonidine (a selective alpha2-adrenoceptor agonist) versus no intervention on bone turnover in twelve healthy volunteers. Repetitive blood samples were drawn for six hours (9:00 A.M.-3:00 P.M.). Bone formation and resorption were determined by measurement of procollagen type 1 amino-terminal propeptide (P1NP) and carboxy-terminal collagen crosslinks (CTx), respectively. Data were analyzed with a linear mixed model. The study was approved by the Medical Ethics Committee.
Results Four men, three postmenopausal women and five premenopausal women (median age 26.5; range 19-68 years) were included. CTx increased after clonidine treatment, whereas a tendency to decrease was observed during control (time*intervention effect, p = 0.035). The difference was most evident two hours after the intervention, with CTx concentrations of 568.5 ± 43.6 ng/L versus 474.9 ± 41.3 ng/L [mean±SEM] (p = 0.004). P1NP concentrations were not affected by clonidine (p = 0.520).
Conclusion Pharmacological alpha2-adrenergic stimulation increases CTx, indicating increased bone resorption in humans.

 

Nothing to Disclose: EJL, MWT, ACH, EE, EF, PHB

13265 10.0000 MON-0202 A The Role of alpha2-Adrenergic Receptors in Human Bone Remodeling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Arun Krishna*1, Ravi Sadasivan2, Kelly Olsson3, Jessica Papadopoulos Weaver1 and Shuvayu Sen1
1Merck & Co, Inc, NJ, 2Evidera Inc, United Kingdom, 3Evidera, Inc, Lexington, MA

 

BACKGROUND: Osteoporosis leads to increased risk of bone fracture and other morbidities. Recent studies indicate that 62.0%1 to 67.5%2of postmenopausal patients are not treated with prescription medications for osteoporosis. However, the reasons for non-treatment among recently diagnosed osteoporosis patients are not well understood. 

OBJECTIVE: To understand the physician perspective for not treating postmenopausal women who have been recently diagnosed with osteoporosis.

METHODS: An online physician survey comprising of patient chart reviews was conducted from August 16 to September 04 2013.  Physicians selected randomly at least 3 patient charts that met all of the following criteria: postmenopausal female;  diagnosed with osteoporosis within the past 3 to 12 months; not yet prescribed prescription osteoporosis medications. Patient clinical characteristics, osteoporosis risk factors, and reasons for non-treatment were collected for each chart reviewed. The online survey was developed via a targeted literature review and qualitative interviews with physicians, and tested prior to data collection.

RESULTS: 224 physicians completed the survey (103 primary care physician, 41 gynecologists, 40 rheumatologists, and 40 endocrinologists). Data from 811 untreated postmenopausal osteoporosis patients charts were obtained. The majority of untreated patients (71%) were 56-71 years; 90% were diagnosed via bone mineral density (BMD) scans (average t-score: -2.6) and had been diagnosed for an average of 6.3 months (median: 6 months). The primary reason for non-treatment was patient driven [patient pushed back on the recommended prescription (81%, n=657)], rather than physician driven, [physician decided not to prescribe (19%, n=154)]. The most frequently mentioned reasons for patient pushback included concerns of medication side-effects (63%),  consideration of non-prescription options before prescription medications (42%),  questioning the potential benefit of taking medication (32%), polypharmacy (26%), lack of understanding osteoporosis risks (25%), unwillingness to take medications for any condition (21%), and insurance status / lack of affordability (21%).  Physicians decided not to prescribe due to patients’ low calcium and / or vitamin D levels (32%), pre-existing gastrointestinal (GI) problems (27%), polypharmacy (25%), and risk of bisphosphonate side-effects (20%).  For 66% of untreated patients, physicians intended to address patient concerns during the next patient visit.

CONCLUSION:  

Physicians stated that 63% of patients resisted OP treatment due to concerns about medication related side effects. Clinical issues such as low calcium and / or Vitamin D levels (32%), pre-existing GI problems (27%), poly-pharmacy (25%), and risk of bisphosphonate side-effects (20%) are major physician-led reasons for non-treatment.

 

Disclosure: AK: Employee, Merck & Co., Employee, Merck & Co.. SS: Employee, Merck & Co., Employee, Merck & Co.. Nothing to Disclose: RS, KO, JPW

12342 11.0000 MON-0203 A Reasons for Non-Treatment of Osteoporosis Among Postmenopausal Patients in the United States – Physician Perspective 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Arun Krishna*1, Kelly Olsson2, Ravi Sadasivan3, Jessica Papadopoulos Weaver1 and Shuvayu Sen1
1Merck & Co, Inc, NJ, 2Evidera, Inc, Lexington, MA, 3Evidera Inc, United Kingdom

 

BACKGROUND: Osteoporosis is an under-treated condition; nearly 621-68%2of postmenopausal osteoporosis patients do not receive treatments for osteoporosis. Perceived barriers to receiving osteoporosis treatments need to be better understood to help reduce non-treatment rates.   

OBJECTIVE: To understand the post-menopausal osteoporosis patient perspective for not receiving osteoporosis medications.

METHODS: An online survey was conducted among postmenopausal patients who were newly diagnosed with osteoporosis within the past 3-12 months and who had not yet received prescription osteoporosis medication.  The online survey was developed via a targeted literature review and qualitative interviews with patients, and tested prior to data collection. The survey was fielded from August 19 to September 19 2013.

RESULTS: 165 untreated patients, age 56 and older completed the survey. The majority of patients (75%) were diagnosed via bone mineral density (BMD) scans. On average, patients had been untreated for 8.7 months (median: 9 months) post-diagnosis. The primary reason for non-treatment was patient driven [patient pushed back on the recommended prescription (52%, n=85)], rather than physician driven [physician decided not to prescribe (48%, n=80)].  Patients reported that they pushed back on the recommended prescription for the following reasons: concerns about medication side-effects (65%), consideration of non-prescription options and behavioral modifications before prescription medications (52%), questioning the potential benefit of taking medication (33%), polypharmacy (22%), unwillingness to take medications for any condition (21%), and lack of experiencing negative health issues due to osteoporosis (20%).  Patients reported that their physicians did not prescribe the medication for the following reasons: low calcium and / or Vitamin D levels (23%), risk of bisphosphonate side effects (21%), pre-existing gastrointestinal (GI) problems (20%), polypharmacy (19%), and contraindications with existing medications (18%).  After diagnosis, 56% of patients were not directed to additional sources of information on osteoporosis, its management, or treatment by their physician. However, if more information were provided by the physician, 37% of patients reported that they would be very likely to take the recommended osteoporosis medications.

CONCLUSION: Sixty-five percent of patients said that concerns about medication related side-effects are a major reason for non-treatment, 23% of patients reported that their physicians did not prescribe osteoporosis medication due to low calcium and / or Vitamin D levels, 21% said their physician did not prescribe due to risk of bisphosphonate side effects, and 20% stated their physician did not prescribe osteoporosis treatment due to pre-existing gastrointestinal (GI) problems.

 

Disclosure: AK: Employee, Merck & Co., Employee, Merck & Co.. SS: Employee, Merck & Co., Employee, Merck & Co.. Nothing to Disclose: KO, RS, JPW

12354 12.0000 MON-0204 A Reasons for Non-Treatment of Osteoporosis Among Postmenopausal Patients in the United States – Patient Perspective 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Anuradha Khadilkar*1, Neha Kajale2, Shashi Chiplonkar3, Zulf M Mughal4 and Vaman Khadilkar3
1Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India, 2Hirabai Cowasji Jehangir Medical Research Institute,, Pune, India, 3Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India, 4Royal Manchester Children’s Hospital, Manchester, United Kingdom

 

Lactation is associated with variable amount of bone mass loss at the spine, hip and femur during first 6-months of lactation and recovery by 1-year (1); however, losses at other sites have not been examined. Low dietary intake of calcium and low bone mass are prevalent in Indian women of the child bearing age. We hypothesized that in lactating women bone at all sites recovers completely at 1-yr post-partum. Thus, aim of present study was to examine changes in bone parameters and body composition with special reference to regional changes in urban middle class Indian women up to 1-yr post partum.

In this prospective study, 70, full term, apparently healthy post partum, primiparous women (27.8± 3.5 yr) were randomly selected and assessed within 7-days of delivery. Data on anthropometry, diet recall, body composition, bone mineral density (BMD) at total body (TB), AP spine (APS) and dual neck femur (DF) by Dual Energy X ray Absorptiometry (GE-Lunar DPX) was collected at baseline, 6-m and 1-yr post partum. Out of 70 women, data at 3 time points is presented here on 32 women.

Mean TBBMD decreased significantly (p<0.05) during initial 6-m by 2.1% despite consuming adequate calcium (1189 ± 411 mg/d). At 1-yr, mean TBBMD showed significant (p<0.05) improvement by 1 %   (1.109 ± 0.1 g/cm2) over the 6-m value (1.097± 0.1g/cm2) yet, it remained 1% below the baseline (difference not significant). Mean BMD at arms showed significant decrease of 1.4 % (0.806 ± 0.02g/cm2: p<0.05) over baseline at 6 months and 2.3 % decrease ( 0.785±0.022 g/cm cm2: p<0.05) over baseline at 1-yr. BMD at axial sites [trunk, ribs and spine] recovered almost to baseline at 1-yr ( -1.3 %, - 0.3 % , +2.5 %  respectively) with significant decrease at 6-m (-4.0%, -1.4 %, -1.2 % respectively ). Lean body mass (LBM) decreased around 9 % from baseline both at 6-m as well as 1-yr. Total fat percentage increased initially at 6-m (+ 2.3%) with further decrease from 6-m to 1-yr  (- 4.8 %). Android fat% showed increase of 11 % at 6-m over baseline which remained elevated (9 %) at 1-yr.  

In Indian post-partum women, changes in BMD and body fat were not similar at various sites.  The BMD at axial but not appendicular sites had recovered to baseline values at one year post-partum. Lactation was also accompanied by loss of LBM and increased risk for central obesity.

 

Nothing to Disclose: AK, NK, SC, ZMM, VK

14379 13.0000 MON-0205 A Variable Recovery in Bone Mass at Axial and Appendicular Sites in Indian Lactating Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Xiaoping Zhang*1, Erik Allen Imel2, Mary Denise Ruppe3, Thomas Joseph Weber4, Mark Klausner5, Takahiro Ito6, Maria Vergeire6, Jeffrey Humphrey6, Francis H Glorieux7, Anthony A Portale8, Karl Insogna9, Munro Peacock10 and Thomas O Carpenter11
1Kyowa Hakko Kirin Pharma Inc, Princeton, NJ, 2Indiana University School of Medicine, Indianapolis, IN, 3The Methodist Hospital, Houston, TX, 4Duke University Medical Center, Durham, NC, 5Kyowa-hakko Kirin Pharma Inc., Princeton, NJ, 6Kyowa Hakko Kirin Pharma Inc., Princeton, NJ, 7Shriners Hosp for Children, Montreal, QC, Canada, 8Univ of CA - San Francisco, San Francisco, CA, 9Yale University School of Medicine, New Haven, CT, 10Indiana Univ Sch Med/Univ Hosp, Indianapolis, IN, 11Yale Univ Schl of Med, New Haven, CT

 

Objectives: In XLH, abnormally elevated serum FGF23 results in low renal maximum threshold for phosphate reabsorption (TmP/GFR), low serum phosphorus (Pi), inappropriately normal 1,25 dihydroxyvitamin D [1,25(OH)2D] with subsequent development of rachitic deformities (1,2). In adults with XLH, a single subcutaneous (SC) or intravenous dose of KRN23 increased TmP/GFR, serum Pi, and 1,25(OH)2D (3,4). We report PK and PD of KRN23 following multiple-dose administration.

Methods: Up to 4 SC doses of KRN23 were given every 28 days to 28 adults with XLH. Pre-dose serum Pi guided the KRN23 dose in a stepwise dose escalation algorithm: 0.05, 0.1, 0.3 and 0.6 mg/kg. Blood and urine samples for assessing PK and PD variables were collected pre-dose and on days 3, 7, 12, 18 and 26 after each dose. Serum samples for KRN23 were analyzed using a validated assay and for PD using commercial methods. Results: Mean (±SD) KRN23 doses administered were: 0.05, 0.10±0.01, 0.28±0.06, and 0.48±0.16 mg/kg. The mean times to reach maximum serum KRN23 level were similar across four dosing intervals (7.0 to 8.5 days). The mean KRN23 maximum (Cmax,n),  minimum (Cmin,n) and area under the concentration-time curve (AUCn) in the n-th dosing interval increased proportionally with increase in mean dose. Mean KRN23 half-life was 16.4±5.8 days. Serum Pi and TmP/GFR increased from baseline at all subsequent samplings except the first-dose trough (P < 0.05). Serum 1,25(OH)2D increased from baseline except for first and second-dose troughs (P < 0.05). Bone markers increased significantly for BALP (bone alkaline phosphatase) and CTx (carboxy terminal cross-linked telopeptide of type I collagen) after 3 doses, osteocalcin after 2 doses and P1NP (procollagen type I N propeptide) after 1 dose (P < 0.05). Serum KRN23 and Pi concentrations changed in parallel throughout the dosing interval, supporting a direct PK-PD relationship. The AUCn for change from baseline in TmP/GFR, serum Pi and 1,25(OH)2D at each dosing interval increased linearly with increase in KRN23 AUCn. No PK-PD correlations were observed for serum calcium, parathyroid hormone, 25-hydroxyvitamin D, 2-hr urine calcium/creatinine ratio, or 24-h urine calcium.

Conclusion: The effects of KRN23 on serum Pi, TmP/GFR, and serum 1,25(OH)2D levels were sustained after each dose. PK dose proportionality and the linear PK-PD relationship between serum KRN23 concentrations and serum Pi concentrations support adjusting the dose based on serum Pi levels. KRN23 is a promising treatment for XLH patients.

 

Disclosure: XZ: Employee, Kyowa Hakko Kirin Pharma Inc.. EAI: Coinvestigator, Kyowa hakko Kirin Pharma Inc, Investigator, Merck & Co.. MDR: Investigator, Kyowa Hakko Kirin Pharma Inc.. TJW: Investigator, Kyowa Hakko Kirin Pharma Inc.. MK: Employee, Kyowa Hakko Kirin Pharma Inc.. TI: Researcher, Kyowa Hakko Kirin Pharma Inc.. MV: Employee, Kyowa Hakko Kirin Pharma Inc.. JH: Employee, Kyowa Hakko Kirin Pharma Inc.. FHG: Investigator, Kyowa Hakko Kirin Pharma Inc.. AAP: Investigator, Kyowa Hakko Kirin Pharma Inc.. KI: Investigator, Kyowa Hakko Kirin Inc. MP: Investigator, Kyowa Hakko Kirin Pharma Inc.. TOC: Data Safety and Monitoring, Alexion, Ad Hoc Consultant, Kyowa Hakko Kirin, Investigator, Kyowa Hakko Kirin.

12858 14.0000 MON-0206 A Pharmacokinetics (PK) and Pharmacodynamics (PD) Following Four Monthly Doses of a Human Monoclonal Anti-FGF23 (Fibroblast Growth Factor 23) Antibody (KRN23) in Adults with X-Linked Hypophosphatemia (XLH) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Nisha Bhavani*, Adlyne Reena Ashirvatham, RV Jayakumar, Harish Kumar, Vasantha Nair, Praveen V Pavithran, Arun S Menon and Usha V Menon
Amrita Institute of Medical Sciences, Cochin, India

 

INTRODUCTION: Tumor-induced osteomalacia (TIO) is a rare disease in which patients present with bone pain, fractures, and muscle weakness due to the production of FGF 23 usually  by benign mesenchymal tumors  which are typically very small and often located at obscure sites. Hence the main issue in management of such patients is proper tumor localization. We describe a series of 12 cases of TIO managed in a tertiary referral university teaching hospital in a developing country.

CASE PRESENTATIONS:12 patients were diagnosed with TIO during evaluation of long standing musculoskeletal symptoms and immobility. Out of the 12 patients, 10 were males and only 2 were females. Age ranged form 20 to 53 years.All of them had myopathy, and  9 out of 12 had stress fractures. The duration of symptoms ranged from  8 to 48 months. The serum phosphorous ranged between 0.8 mg/dl and 2.1 mg/dl (Normal: 2.5 to 4.5 mg/dl) with the lowest serum phosphorus measuring 0.8 mg/dl and a mean phosphorous of 1.35mg/dl. PTH ranged between 31.6 and 335 pg/ml. Tmp GFR was low in all patients ranging between 0.4mg/dl and 1.75 mg/dl with the lowest value being 0.4 mg/dl. FGF 23 was done in 10 patients and was high in all, ranging between 152 and 2323.5 RU/ml (Normal range: 10-150 RU/ml)

The implicating tumors in our patients were small tumors in the right fibula in 2 patients ,  left mandible in 1,  subarticular region of left femoral head in 1 , in right proximal femur for 1, in right femur neck in 1 , in right tibia in 1 , near right sciatic notch in 1, D4vertebral lesion in 1, mastoid lesion in 1 and mass within the nasal cavity in 2 patients.The tumors were detected by the Ga-DOTANOC PET scan in 10 patients, MDCT head in 1 and blood pool scan in 1. 

9 patients underwent surgical intervention(Tumor excision in 6 patients, bipolar hemiarthroplasty in 1 , Left segmental mandibulectomy in 1 and  D4 corpectomy in 1), 1 underwent Radiofrequency ablation of femur head and 2 did not follow up for surgery.Histopathological examination of the resected specimens showed benign mesenchymal tumor in 3 patients, spindle cell neoplasm of vascular origin in 1, hemangiopericytoma in 1 , myopericytoma in 1 , mesenchymal tumor mixed connective tissue variant in nasal cavity in 1, giant cell tumour of nasal cavity in 1  and necrotic bone in 1 patient.

Post-operatively, serum phosphorus had normalised in 7 of the 9 patients who had undergone excision. 2 who had incomplete resection are still on phosphate supplements. All patients who underwent surgery are mobile and are back to normal activities.

CONCLUSIONS: This series demonstrate that 1) serum phosphorous should be measured in patients with suspected metabolic bone disease and/or unexplained musculoskeletal symptoms 2) Functional imaging with Ga -DOTANOC PET  is a valuable tool in localisation of tumors causing TIO  and 3) serum FGF23 can be helpful in  diagnosis and monitoring treatment outcomes in TIO.

 

Nothing to Disclose: NB, ARA, RJ, HK, VN, PVP, ASM, UVM

14520 15.0000 MON-0207 A Tumor Induced Osteomalacia; A Single Centre Experience 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Enver Ciftel1, Fatih Kilicli*2 and Sebila Dokmetas3
1Cumhuriyet University, Campus, Turkey, 2Cumhuriyet University, Sivas, Turkey, 3Medipol University, Istanbul, Turkey

 

AIM: FGF-23 is a phosphatonin that regulates the mineral metabolism. We evaluated whether if there is an association between FGF-23, IGF-1, androgens, insulin resistance (IR) and bone mineral density in women with Polycystic Ovary Syndrome (PCOS), and healthy controls.

METHODS:  FGF-23, IGF-1 and HOMA-IR were evaluated in both the 47 women with PCOS and 26 healthy women, and also bone mineral density was evaluated in only patient group. Afterwards, patients were compared for these parameters according to the presence of IR and hyperandrogenemia.

FINDINGS: Mean FGF-23 was 137.55±75.42 and 414.81±53.02 (pg/ml) (p<0.05), and mean IGF-1 was 28.41±99.69 and 244.26±58.99 (ng/ml) (p>0.05) in PCOS patients and healthy controls, respectively. In PCOS patients FGF-23 values were 90.31±67.27 vs. 175.7±58.81 (pg/ml) (p<0.05), and IGF-1 values were 229.0±113.70 vs. 227.9±88.65 (ng/ml) (p<0.05), in IR and non-IR groups, respectively. T and Z scores of vertebrae and femur were higher in IR group when compared with the non-IR group, but the difference was insignificant. There was also an insignificant, poor and negative correlation between FGF-23, and vertebral T and femur Z scores in the patients with and without IR. FGF-23 and IGF-1 scores were 146.6±76.81 and 232.9±99.51 in patients with hyperandrogenemia, and 111.0±67.22 (pg/ml) and 214.0±103.7 (ng/ml) in patients without hyperandrogenemia. FGF-23 and IGF-1 levels were tend to be higher in hyperandrogenemia group, but the difference was not statistically significant.

CONCLUSION: Our results revealed that FGF-23 levels are decreased in patients with PCOS, and this decrease was particularly significant in patients with insulin resistance. According to our findings, decreases in FGF-23 levels are effective in protection of the bone density in patients with PCOS.

 

Nothing to Disclose: EC, FK, SD

15015 16.0000 MON-0208 A Association of Insulin Resistance and Hyperandrogenemia with Serum Levels of FGF-23, IGF-1, and Bone Mineral Density in Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Thomas O Carpenter*1, Elizabeth A Olear1, Jane H Zhang2, Bruce K Ellis1, Christine A Simpson1, David Cheng1, Caren M Gundberg1 and Karl Insogna1
1Yale University School of Medicine, New Haven, CT, 2VA Connecticut Healthcare System, West Haven, CT

 

XLH is characterized by low serum phosphorus (P), renal phosphate wasting, and inappropriately normal 1,25(OH)2D levels. Elevated serum PTH levels often occur, may exacerbate the phosphaturia and worsen bone disease. We therefore performed a randomized, placebo (PLB)-controlled, double-blind 1 yr trial of the vitamin D analog, paricalcitol (PC, Zemplar®) in children (> 9 yrs) and adults with XLH and elevated PTH. Patients with serum calcium (Ca) > 10.7 mg/dl, 25-OHD < 20 ng/ml, creatinine > 1.5 mg/dl, or pregnancy were excluded. At baseline, serial samples for serum PTH were obtained for 26hr and area under the curve for PTH (PTHauc) calculated. Fasting serum P, intact FGF23, total alkaline phosphatase activity (ALP), and renal phosphate threshold (TmP/GFR) were assessed.  99mTc-methylene diphosphonate bone scans (BoSc) were performed and scored by a radiologist masked to treatment arm. Patients were randomized 2:1 (PC:PLB), begun on 2 mcg daily, and titrated at 1 and 2 mos as tolerated (dose range: 1-4 mcg).  No changes were made in subjects’ usual medications.  The primary outcome was change in PTHauc over the treatment period. Urine and serum Ca were assessed every 1-2 mos.  Results:  Mean PTHauc decreased by 17% in the PC group, differing (P = 0.007) from the 20% increase in the PLB group. PTHauc decreased by 20-29% in 39% of PC treated subjects, 30-39% in 22%, and 40% or more in 11%, whereas PTHauc decreased by 20-29% in 25% of the PLB group, by 30-39% in 1 subject (12%), and by 40% or more in no PLB subject.  A 10% increase in TmP/GFR occurred in the PC group, compared to a 21% decrease in the PLB group (P<0.05).  Serum P increased by 12% with PC, and did not change with PLB, but the difference between groups in change from baseline was not significant.  Serum FGF23 increased by 176%, from 120 (95% CI: 72-203) pg/ml to 244 (145-411) pg/ml in the PC group (P < 0.05) compared to a non-significant 15% increase in those receiving PLB (from 93 pg/ml to 104 pg/ml).  In adults, PC decreased baseline ALP by 23% from 118 ± 34 IU/L to 96 ± 27 IU/L (P = 0.005), but no change occurred in PLB.  BoSc scores improved in 6/17 PC subjects, but in 0/8 PLB. Hypercalciuria developed in 32% of PC and persisted from baseline in 1 PLB subject. Both PTH and FGF23 were significant determinants of TmP/GFR at baseline, but after PC, only PTH remained significantly correlated with TmP/GFR.  Conclusions:  PC suppressed mean PTHauc by > 20% in twice as many PC subjects as those receiving PLB. BoSc improved in 35% of PC and in no PLB subject, and ALP corrected in PC adults.  A significant increase in serum FGF23 accompanied PC, despite a slight increase in TmP/GFR.  PTH remained a determinant of TmP/GFR, but FGF23 did not after PC exposure. Suppression of PTH appears to be a useful strategy for skeletal improvement in XLH patients with elevated PTH, and PC may be an effective adjunct to standard therapy in this setting. PC was well-tolerated but urine Ca should be carefully monitored with its use.

 

Disclosure: TOC: Investigator, Kyowa Hakko Kirin, Ad Hoc Consultant, Kyowa Hakko Kirin, Data Safety and Monitoring, Alexion. CMG: Consultant, Alexion, Consultant, Kyowa Hakko Kirin, Investigator, Kyowa Hakko Kirin. KI: Investigator, Kyowa Hakko Kirin Inc. Nothing to Disclose: EAO, JHZ, BKE, CAS, DC

12621 17.0000 MON-0209 A Paricalcitol Therapy Improves Hyperparathyroidism in Patients with X-Linked Hypophosphatemia: Results from a One-Year Randomized Controlled Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Mary Denise Ruppe*1, Xiaoping Zhang2, Erik Allen Imel3, Thomas Joseph Weber4, Mark Klausner5, Takahiro Ito6, Maria Vergeire6, Jeffrey Humphrey6, Francis H Glorieux7, Anthony A Portale8, Karl Insogna9, Munro Peacock10 and Thomas O Carpenter11
1The Methodist Hospital, Houston, TX, 2Kyowa Hakko Kirin Pharma Inc, Princeton, NJ, 3IN Univ School of Med, Indianapolis, IN, 4Duke University Medical Center, Durham, NC, 5Kyowa-hakko Kirin Pharma Inc., Princeton, NJ, 6Kyowa Hakko Kirin Pharma Inc., Princeton, NJ, 7Shriners Hosp for Children, Montreal, QC, Canada, 8Univ of CA - San Francisco, San Francisco, CA, 9Yale University School of Medicine, New Haven, CT, 10Indiana Univ Sch Med/Univ Hosp, Indianapolis, IN, 11Yale Univ Schl of Med, New Haven, CT

 

Objectives: In XLH, abnormally elevated serum FGF23 results in low renal maximum threshold for phosphate reabsorption, low serum phosphorus (inorganic, Pi), and inappropriately normal 1,25 dihydroxyvitamin D with subsequent development of rachitic deformities (1,2). In adults with XLH, a single subcutaneous (SC) dose of KRN23 increased levels of these 3 biomarkers (3,4). In the present study, effect of KRN23 on health-related quality of life (HRQL) was assessed. Methods: KRN23 was given SC every 28 days for 4 doses to 28 adults with XLH (26 completers). Pre-dose serum Pi guided the KRN23 dose in a stepwise dose escalation algorithm: 0.05, 0.1, 0.3, and 0.6 mg/kg. General HRQL was measured with SF-36v2 (5) and WOMAC (6) at baseline and Day 120 (end point). Eight SF-36v2 scales were obtained: Physical Functioning (PF), Role Limitations due to Physical Health (RP), Bodily Pain (BP), General Heath Perceptions (GH), Vitality (VT), Role Limitations due to Emotional Problems (RE), and Mental Health (MH). Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were derived. WOMAC scales included Pain, Stiffness and Physical Functioning. Significance was set at P < 0.05 for the paired t-test. Results:  At the end point, mean scores for all SF-26v2 domains increased and those for WOMAC decreased, indicating improvement in health status for all domains of both instruments. Five of these differences were significant: RP, BP, and PCS for SF-36v2 and Physical Functioning and Stiffness for WOMAC. RP retained significance after correction for multiplicity.  At baseline, mean BP, PF, RP, and PCS scores were far below that of the general US population, while scores for all other scales were not significantly different. At endpoint, the mean MH and MCS score became significantly higher than the US norm and RP became indistinguishable from the norm, while mean PCS, BP, and PF scores remained below the norm. Scores for the other domains remained comparable to the norm. At baseline, while GH, BP and SF scores for XLH patients were significantly higher than those of the osteoarthritis (OA) population, all other scores were not significantly different. At endpoint, all mean SF-23v2 scale scores were increased relative to those for OA patients, showing significance for all 8 SF-36v2 scales except PF and RE. Conclusions: Treatment with KRN23 for 4 months resulted in significantly improved patient self-perception of physical functioning using SF36v2 and WOMAC as HRQL instruments.

 

Disclosure: MDR: Investigator, Kyowa Hakko Kirin Pharma Inc.. XZ: Employee, Kyowa Hakko Kirin Pharma Inc.. TJW: Investigator, Kyowa Hakko Kirin Pharma Inc.. MK: Employee, Kyowa Hakko Kirin Pharma Inc.. TI: Researcher, Kyowa Hakko Kirin Pharma Inc.. MV: Employee, Kyowa Hakko Kirin Pharma Inc.. JH: Employee, Kyowa Hakko Kirin Pharma Inc.. FHG: Investigator, Kyowa Hakko Kirin Pharma Inc.. AAP: Consultant, Sanofi, Consultant, Abbvie. KI: Investigator, Kyowa Hakko Kirin Inc. MP: Investigator, Amgen, Investigator, NPS, Investigator, Lilly USA, LLC. TOC: Data Safety and Monitoring, Alexion, Ad Hoc Consultant, Kyowa Hakko Kirin, Investigator, Kyowa Hakko Kirin . Nothing to Disclose: EAI

12698 18.0000 MON-0210 A Effect of Four Monthly Doses of a Human Monoclonal Anti-FGF23 (Fibroblast Growth Factor 23) Antibody (KRN23) on Quality of Life in X-Linked Hypophosphatemia (XLH) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Sujin Lee*1, Jong-Chan Youn2, Seok-Min Kang3 and Yumie Rhee3
1Yonsei University College of Medicine, Seoul, 2Yonsei University College of medicine, Seoul, Korea, Republic of (South), 3Yonsei University College of Medicine, Seoul, Korea, Republic of (South)

 

Heart failure is associated with increased risk of hip fractures. However, the prevalence and predictors of hip fractures in patients with acute decompensated heart failure (ADHF) have not been well investigated.  

Fifty male patients with ADHF (60 ± 16 years, mean ejection fraction 28.0 ± 11.5%) were enrolled. Quantitative CT scans for bone mineral density (BMD), bone geometry, as well as   cardiopulmonary exercise tests (CPET) were evaluated. Sixteen patients (32%) had osteopenia (volumetric lumbar BMD of 80-120 mg/cm3) and six patients (12%) had osteoporosis (BMD < 80 mg/cm3). The percentage of ischemic patients was higher in osteoporosis group. Total hip BMD and femoral neck cortical thickness were lower (p=0.001 and p=0.019, respectively), and buckling ratio of the femoral neck was higher in ischemic patients than non-ischemic patients. Multivariate regression analysis revealed that peak VO2, which is a well-known prognostic marker in ADHF, independently predicted total hip BMD and femoral neck cortical thickness when controlled for age, BMI, etiology of heart failure (β=0.547, p=0.021 and β=0.590, p=0.011, respectively).

Hip fracture risk seems to be higher in ischemic patients whose buckling ratio of femoral neck is higher. Peak VO2, a surrogate marker for exercise capacity, independently predicted total hip BMD and femoral neck geometry in patients with ADHF. These findings may explain why hip fractures are increased in ADHF patients.

 

Nothing to Disclose: SL, JCY, SMK, YR

11841 19.0000 MON-0211 A Decreased Exercise Capacity Negatively Affects Hip Geometry in Patients with Acute Decompensated Heart Failure 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Narendra Kotwal*1, Aditi Dilip Pandit2 and M K Garg3
1Army Hospital Research & Referra, New Delhi, India, 2Army Hospital (R&R), New Delhi, India, 3Command Hospital (Southern), Maharastra, India

 

Bone health was studied in 26 patients  of HSCT over  one year. The mean age and BMI of the cohort was 24.4±16.4 years and 19.4±4.5 kg/m2. There were 17 males (65%) and 9 females (35%), of which 15 were adults (58%), 6 prepubertal children (23%) and 11 adolescents (42%). The bone mineral density (BMD) declined non-significantly from the baseline at the whole body (TBMD) (% change -2.8±5.5, p=0.748) and the lumbar spine (% change -4.6±8.7, p=0.130) at 6 months post transplant. There was a significant decline in BMD from the baseline at total hip (hipBMD) (% change -9.1±9.7; p<0.0001), femoral neck (FNBMD) (% change -4.0±9.6; p=0.003), femoral trochanter (FTBMD) (% change -4.7±10.4; p=0.001) and ward’s triangle (WBMD) (% change -11.4±10.7; p <0.0001) at 6 months post transplant.  From the 6 months post transplant to 12 months posttransplant there was significant improvement in TBMD (% change 3.9±5.1, p=0.014), hipBMD (% change 9.7±11.2, p=0.014), FNBMD (% change 5.1±5.1; p=0.002) and WBMD (% change 3.8±5.7; p=0.036). There was a trend towards recovery at lumbar spine and FTBMD. BMD decline at ward’s triangle  was statistically significant indicating persisting bone loss aat 12 months post transplant. There was a statistically significant rise in serum NTx from the baseline to the serum NTx levels at 3-6 months  and statistically significant drop in serum osteocalcin levels at baseline when compared to levels at 3-6 months post transplantation .

 Decrease in BMD negatively corelated  with age, BMI, and hypoadrenalism.. Allogenic BMD had more effect on hipBMD, FNBMD, FTBMD, and WBMD than autologous BMT at 6 months post HSCT. GVHD had no effect on bone loss at any site. The intake of immunosuppressive therapy had a statistically significant effect on the change in BMD at 6 months post HSCT. Steroid use had a significant effect on the WBMD  and hipBMD  at 6 months post HSCT with no significant effect on other sites. Patients with leukaemia had more significant change in FNBMD (-8.8±4.4%; p=0.002), WBMD (-13.0±7.0%; p=0.035) and FTBMD (-7.9±3.6%; p=0.040) when compared to patients with MM at 6 months post HSCT.

Conclusions

Maximum bone loss is observed at six months in patients with post-HSCT, which showed recovery at 12 months post HSCT. Bone loss was highest at ward’s triangle followed by femoral trochanter, femoral neck, total hip, lumbar spine and whole body. The bone loss is predominantly at cortical bone. Younger age, low BMI, hypoadrenalism, allogenic transplant, immunosuppressive therapy, and steroid use are all related to bone loss in patients undergoing HSCT.

BMD should be performed in all patients undergoing HSCT at one year post transplant to assess the bone health. Most patients who recover from bone loss may not require any therapy. Those patients with persistent low BMD may require long-term follow-up and anti-resorptive therapy.

 

Nothing to Disclose: NK, ADP, MKG

12304 20.0000 MON-0212 A BONE Loss in Patients Undergoing Hematopoietic STEM CELL Transplant (HSCT) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Myriam Lorena Partida Muñoz*1, Gonzalo Allo Miguel2, Maria Soledad Librizzi3, Sonsoles Guadalix Iglesias2, Guillermo Martínez Díaz-Guerra2, Alicia Serraclara Pla2 and Federico G Hawkins4
112 de Octubre University Hospital, Madrid, Spain, 212 de Octubre Hospital, 312 de Octubre University Hospital, 4Hospital Universitario 12 de Octubre, Madrid, Spain

 

INTRODUCTION: Patients with adulthood-onset GH deficiency (AGHD) show lower bone mineral density (BMD) and reduced health-related quality of life (HRQoL) than the general population. Short-term studies have described improvement in BMD after treatment with recombinant GH (rhGH). There are few long-term studies, reporting controversial results, including BMD plateau.

OBJECTIVE: The aim of our study was to evaluate in AGHD patients, the effect of long-term (7 years) treatment with rhGH in BMD and HRQoL.

MATERIAL AND METHODS: Prospective open label study in 17 AGHD patients (8 men and 9 women) treated with daily injection of rhGH during 7 years. The dose was adjusted to maintain serum IGF-1 levels within the normal range according to age and sex. BMD was measured with DXA at lumbar spine (LS) and femoral neck (FN) before starting the treatment and at years: 1, 2, 3, 5 and 7. Health status was assessed with the QoL-AGHDA validated for the spanish population. Statistical analysis was performed using the sign test between paired measurements. Results were stratified by sex and body mass index (BMI)

RESULTS: Mean age was 37.3±12.4 years. Before treatment, osteopenia was detected in the group at LS (T-score: -1.62 [-2.52, -0.85]) and CF (T-score: -1.28 [-2.04, -0, 20]). 3 women and 2 men had osteoporosis. After 7 years of rhGH treatment significant increase in BMD at LS was observed regarding basal data (p <0.05), first year of treatment (p <0.05), second year (p <0.01), third year (p <0.05) and fifth year (p <0.01). Female patients showed no significant differences in BMD at CL at 7 years. At FN no significant changes at 7 years were found in both genders. Patients showed significant improvement in HRQoL from the first year (p <0.01) until the seventh year (p <0.01) of rhGH treatment.

CONCLUSIONS: 7 years supplementation with rhGH in AGHD leads to a significant increase in BMD at LS but not in FN. BMD increase was significantly higher in males. Patients presented an early and sustained significant improvement in HRQoL.

 

Nothing to Disclose: MLP, GA, MSL, SG, GM, AS, FGH

12746 21.0000 MON-0213 A BONE Mineral Density and Quality of Life in Adults with Growth Hormone Deficiency Treated with Recombinant Human Growth Hormone Therapy during 7 YEARS 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Luciana Campanha-Versiani*1, Marta MS Sarquis2, Danielle Aparecida Gomes Pereira2, Adauto Versiani Ramos3, Maria de Fatima Haueisen Sander Diniz2 and Luiz De Marco4
1Centro Universitário de Belo Horizonte- Uni-BH, Belo Horizonte, Brazil, 2Universidade Federal de Minas Gerais, UFMG, Belo Horizonte, Brazil, 3Centro de Estudos do Hospital Felicio Rocho, Belo Horizonte, Brazil, 4Universidade Federal de Minas Gerais, UFMG, Belo Horizonte MG, Brazil

 

Bariatric surgery has been frequently used as an alternative for definitive treatment of obesity. However, the patients undergoing this type of procedure have changes in body composition and bone metabolism.

The aim of this study was to evaluate the impact of a supervised exercise program of muscle strengthening in total body composition and bone markers in 37 obese subjects patients (81.1% female, mean age=38.2±11.1, BMI=42.4±3.7 Kg/m2) preoperatively and one year after Roux-en-Y gastric bypass surgery.

The whole body densitometry (DXA) was used to evaluate BMD, total fat and lean body mass. Laboratory investigation consisted of serum calcium, PTH, 25-hydroxyvitamin D and bone remodeling markers (C-telopeptide of collagen type I- CTX and bone specific alkaline phosphatase - BAP). Muscle strength was determined by concentric 1-repetition maximum (1RM) test and hand grip dynamometer (JAMAR®).  Postoperatively, subjects were divided into two groups: training group (TG) - 18 volunteers who participated in a supervised exercise program of muscle strengthening, two nonconsecutive days per week, during 32 weeks. Each session lasted 1 hour and included eight exercises: seated chess press, lat pull down, standing biceps curl, standing triceps extension, fly machine, leg extension, leg press and leg curl. Subjects performed three sets of 10 repetitions at an intensity that was 75% of their 1RM for each exercise. The control group (CG) consisted of 19 volunteers who refused, for several reasons, the exercise program. Statistical analysis were done by Student's t-test and ANOVA, with a significance level of 5% (p <0.05).

There was no significant difference between groups in relation to bone markers or calcium metabolism. After one year, TG showed smaller decreases in total BMD than CG (0.07 ± 0.049 vs 0.140± 0.081 g/cm3, respectively) and greater bone mass at the lumbar spine compared to the CG (p <0.05). Furthermore, TG had a significant increase in arms lean mass relative to CG (p <0.05). The overall and specific muscle strength was statistically greater in the TG compared to the CG at the end of one year postoperatively (p <0.05).

In conclusion, the supervised exercise program did not influence bone remodeling markers, but attenuated spine bone loss and improved muscle mass in the arms and the overall muscle strength. Studies aiming fracture protection should be done to determine the real impact of this program.

 

Nothing to Disclose: LC, MMS, DAGP, AVR, MDFHSD, LD

14067 22.0000 MON-0214 A One Year Physical Training MAY Atenuate SPINE BONE Loss and Improve Muscle Strengh in Individuals Submitted to Bariatric Surgery 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Zerrin Orbak*1 and Handan Alp2
1Ataturk University Medical Facul, Erzurum, Turkey, 2ataturk university

 

In this study we investigated the relationship between BMD and serum levels 0f IGF-1 and IGFBP-3 in malnourished children without rachitic manifestations and compared with that in healthy children of the same community

The subjects were 26 children with malnutrition and 21 healthy controls. Using the Wellcome Classification, marasmus was diagnosed in 16 children, kwashiorkor in 10 children.

Malnourished children had lower IGF-1 and IGFBP-3 levels than controls matched for age and sex, and their BMD, BMC and BMAD were also low. Although BMD measurements of children with marasmus and kwashiorkor were similar, serum IGF-1 and IGFBP-3 levels in kwashiorkor were lower than those in marasmus. Positive relationships were noted between serum levels of IGF-1, IGFBP-3 and BMD and BMC of lumbar spine in each three group.

Malnutrition, particularly protein undernutrition, contributes to the occurence of lower bone mineral density. It is confirmed importance of IGF-1 and IGFBP-3 in bone metabolism in malnourished and healthy children.

 

Nothing to Disclose: ZO, HA

14441 23.0000 MON-0215 A Association Between Bone Mineral Density in Lumbar Spine and Serum IGF-1, IGFBP-3 Levels in Malnourished Children without Rachitic Manifestations 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Phillip Wong*1, Peter J Fuller2, Matthew T Gillespie1, Vicky Kartsogiannis1, Donald K Bowden3, Boyd J Strauss4, Eldho Paul5 and Frances Milat1
1Prince Henry's Institute of Medical Research, Clayton VIC, Australia, 2MIMR-PHI Institute and Monash University, Clayton VIC, Australia, 3Monash Health, Clayton VIC, Australia, 4Monash University, Clayton VIC, Australia, 5Monash University, Clayton, Australia

 

Thalassemia is an inherited disorder of ineffective erythropoiesis requiring chronic transfusion therapy in its most severe form. This leads to iron overload, marrow expansion and hormonal complications which are implicated in bone deformity and loss of bone mineral density (BMD). In this 19 year retrospective longitudinal study, the relationships between BMD (determined by dual energy X-ray absorptiometry) and risk factors for osteoporosis in 277 subjects with transfusion-dependent thalassemia were examined. The study cohort of 277 subjects, from a single academic center, is unique; it represents one of the largest and certainly longest follow-up of patients with transfusion-dependent thalassemia world-wide. The mean age at first review was 23.2 ± 11.9 years and 43.7% were male. Hypogonadism was present in 28.9% and fractures confirmed in 11.6% of subjects. Lumbar spine (LS), femoral neck (FN) and total body (TB) Z scores were derived. Patients with transfusion-dependent thalassemia had a significant longitudinal decline in BMD at the FN and TB. In the uni- and multivariate linear mixed model analysis of BMD and risk factors for bone loss, FN Z score was more consistently significantly compared to the LS and TB.  The rate of decline at the FN was 0.02 Z score per year and was 3.85 fold greater in males compared to females. The decline in FN Z score over the last 5 years (years 15-19) was 2.5 fold that of the previous 7 years (years 8-14) and coincided with a change in iron chelator therapy from intravenous desferrioxamine to oral deferasirox. Hemoglobin levels positively correlated with higher TB and LS Z scores. In conclusion, the FN is the preferred site for follow-up of BMD. Transfusing patients (particularly males) to a higher hemoglobin target may improve BMD. A role for deferasirox in bone loss is consistent with previous observations and warrants further study.

 

Nothing to Disclose: PW, PJF, MTG, VK, DKB, BJS, EP, FM

14515 24.0000 MON-0216 A Thalassemia Bone Disease: A 19 Year Longitudinal Analysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Telma Palomo*1, Maria Cristina Andrade2, Barbara S.E. Peters1, Fernanda A Reis3, João Thomas Carvalhaes3, Francis H Glorieux4, Frank Rauch4 and Marise Lazaretti-Castro5
1Universidade Federal de São Paulo UNIFESP, São Paulo, SP, Brazil, 2Universidade Federal de São Paulo UNIFESP, São Paulo, Brazil, 3Universidade Federal de São Paulo UNIFESP, São Paulo, 4Shriners Hosp for Children, Montreal, QC, Canada, 5Universidade Federal de São Paulo UNIFESP, Sao Paulo SP, Brazil

 

OI is a heritable connective tissue disorder that is mainly characterized by bone fragility. Intravenous (IV) pamidronate infusions are given to increase bone density and decrease fracture rates in children with OI. Infusion of IV pamidronate is associated with dose- and infusion-rate-dependent effects on renal function as evidenced by increases in serum creatinine. In the best-studied protocol (‘standard protocol’, SP), pamidronate is given at a dose of 1 mg per kg body weight given over 4 hours per day on 3 successive days. These infusion cycles are repeated every 4 months (annual pamidronate dose: 9 mg per kg body weight). The aim of this study was to evaluate renal safety and efficacy of a shorter and higher concentration per dose of IV pamidronate treatment during 1 year follow up and compare to SP. We believe that decreasing the infusion time, the average cost per treatment can be reduced, and may shorten the waiting list for treatment, rendering pamidronate therapy more feasible in smaller centres. In the present study, we assessed a new infusion protocol (‘modified protocol’, MP) where pamidronate was administered in 1-day cycles at a dose of 2 mg per kg body weight given in single infusions over 2 hours. Cycles were repeated every 4 months (annual pamidronate dose: 6 mg per kg body weight). We compared results in 18 patients with OI types I, III or IV receiving MP to 18 historic controls who had received SP and who were matched for age, OI type and pamidronate treatment status. No group differences were found with regard to percent change in serum creatinine concentration (ΔCr) during the first pamidronate infusion (+1.9% [SD: 21.0%]) with MP vs -3.4% [SD: 8.4%] with SP; p=0.32). In the MP, serum baseline creatinine levels at entry in the study were similar to creatinine levels after 1 yr of pamidronate treatment 0.40 [SD: 0.12] vs. 0.36 [SD: 0.09] mg/dL, n=14, P=0.06. Serum concentrations of total calcium and inorganic phosphorus decreased similarly in both protocols. After 12 months of therapy, lumbar spine bone mineral density z-scores had increased from -2.7 (SD: 1.5) to -1.8 (SD: 1.4) with MP and from -4.1 (SD: 1.4) to -3.1 (SD: 1.1) with SP. The bone density changes during the 12 month study interval were similar between groups (p=0.68). In conclusion, these results suggest that the modified pamidronate protocol was safe and had similar effects on bone density as the standard pamidronate protocol.

 

Disclosure: FHG: Investigator, Novartis. Nothing to Disclose: TP, MCA, BSEP, FAR, JTC, FR, ML

15935 25.0000 MON-0217 A Evaluation of a New Pamidronate Protocol for the Treatment of Osteogenesis Imperfecta 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Ruth Cruz-Soto*1, Analleli Manguilar-Leon2, Victoria Mendoza3, Mario Molina-Ayala4, Guadalupe Guadalupe2, Baldomero Gonzalez1, Aldo Ferreira5 and Moises Mercado6
1Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, Mexico, Mexico, 2Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, 3HECMN IMSS, Mexico City, Mexico, 4Hospital de Especialidades, Centro Médico Nacional Siglo XXI, IMSS, Mexico, 5Centro Medico Nacional Siglo XXI, Mexico, Mexico, 6Hospital de Especialidades Centro Medico Nacional S.XXI IMSS, Mexico

 

Background:  Type 1 diabetes mellitus (DM1) appears to be associated with a reduced bone mineral density and an elevated fracture risk.  The mechanisms behind this association are largely unknown.  Bone remodelling is regulated by systemic and local factors including proinflamatory and anti-inflamatory cytokines, which may be inherently altered in patiens with DM1.

Objective:  To determine if pro- and anti-inflamatory cytokines correlate with markers of bone turnover in patients with DM1 with varying degrees of metabolic control and diabetic complications.

Patients and methods:  Cross-sectional study of 62 patients with DM1.  Metabolic evaluation included fasting blood glucose, HbA1c levels and creatinine clearance.  Bone metabolism evaluation included the measurement of calcium, phosphorus, alkaline phosphatase and vitamin D3 levels.  sPINP and sCTX were determined (ELISA) as markers of bone formation and resorption, respectively.  Blood levels of proinflamatory (IL1, IL6 and TNFa) and anti-inflamatory (IL10) cytokines were measured by flow cytometry.  Data was analyzed using parametric and non-parametric statistics.

Results:  Median age of the patients was 33.5 years (IQR 24-46) and 80% were females, with a median HbA1c of 8.5% (IQR 7.7-10) and creatinine clearance of 69.5 mg/mL (IQR 61-89).  The prevalence of diabetic neuropathy, nephropathy and retinopathy was 15%, 30% and 31%, respectively.  Median sPINP and sCTX were 963 ng/mL (IQR 680-1990) and 402 pg/mL (IQR 296-709), respectively.  Median plasma concentrations of IL1beta, IL6, TNFa and IL10 were 7.4 pg/mL (IQR 6.2-17.5), 5.65 pg/mL (IQR 2.85-9.4), 5.5 (IQR 2.7-11.4) and 5.2 (IQR 2.85-9.4), respectively.  A positive correlation was found between IL6 and sCTX (r=0.48, p=0.037), whereas TNFa and sCTX correlated positively only in patients with HbA1c >7.5% (r=0.43, p=0.05).  Lineal regression analysis revealed a significant association only between sCTX and IL6 (β= 23.8, 95% CI 2-45.6, p=0.03); other factors such as renal function and the presence of diabetic complications did not appear to affect these associations.

Conclusions:  An increased state of bone resorption is associated with increased levels of proinflamatory cytokines, particularly in patients with poorly controlled DM1, independently of renal function and the presence of diabetic complications.

 

Nothing to Disclose: RC, AM, VM, MM, GG, BG, AF, MM

16246 26.0000 MON-0218 A Association of Pro- and Anti-Inflamatory Cytokines with Markers of Bone Turnover in Patients with Type 1 Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Ana Martínez Lira*, Karen Canchola Benitez and Herlinda Aguilar-Zavala
Universidad de Guanajuato, Celaya, Mexico

 

Introduction: Previous studies had showed that pregnancies are correlated with low bone mass (BM), its causing higher risk for fractures.

Objective: To compare BM levels in 60 women 21 to 35 years old, with one pregnancy only and with previous multiple pregnancies.

Material and methods: Direct measurements of parameters were performed with a Tanita body composition analyzer. The bioimpedance parameters we measured were body fat percentage (%BF), total body water percentage (%TBW), muscle mass (MM), bone mass (BM), and visceral fat (VF), furthermore BM was calculated by Alan Martin formula; we applied general data, food frequency (SNUT) and physical activity (GPAQ) questionnaires.

Results: We didn’t find difference in BM levels between women with one pregnancy only and with previous multiple pregnancies. However in this women BM was lower than normal average (2.4 vs 2.2±0.26 kg). But women with previous multiple pregnancies were smoker (3±1 cigarette/day, p<0.02), older (30±3 age years p<0.001), had more level of physical activity (2.1±0.8 METS, p<0.05) and lower time in arrest (186±160 min./day, p<0.005). BM by bioimpedance was positively associated with systolic pressure (r=.44, p<0.0005), IBM (r=0.8, p<.0001), %BF (r=0.68,p<0.0001), vigorous recreation  (r=0.36,p<0.006) and recreation activity (r=0.28,p<0.03); We found high correlation between BM by bioimpedance and formula (r=0.76,p<0.0001).

Conclusion: In this women BM levels was lower than normal average, BM by bioimpedance and by formula were similar, but not different between women with one pregnancy only and with previous multiple pregnancies, last one women showed more physical activity, and smock more cigarettes. BM by Tanita was higher correlated with BM by formula, BMI, %BF and systolic pressure.

 

Nothing to Disclose: AML, KCB, HA

16437 27.0000 MON-0219 A Bone Mass Levels Between Mexican Women with One Pregnancy Only and with Previous Multiple Pregnancies 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Amra Osmancevic*1, Taye Demeke2, Anne Lene Krogstad3, Håkan Sinclair4, Eva Angesjö5, Gamal El-Gawad6 and Kerstin Landin-Wilhelmsen7
1Department of Dermatology, Gothenburg, Sweden, 2Lärjedalen Primary Health Care, Gothenburg, Sweden, 3Section for Climate Therapy, Oslo, Norway, 4Department of Geriatric Medicine, Borås, Sweden, 5Brämhult Primary Health Care, Alingsås, Sweden, 6Gamlestadens Primary Health care, Gothenburg, Sweden, 7Section for Endocrinology, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

 

Background: Vitamin D deficiency is a common health problem among immigrants with dark skin and with reduced sun exposure in Northern European countries. Low vitamin D status has been linked to bone diseases and low bone mineral density (BMD).

Aim: The aim was to test the hypothesis that BMD in Somalian women living in Sweden was lower in comparison with the American white and the Afro-American reference population according to the manufacturer.

Subjects: In this cross-sectional study BMD was examined in 67 immigrant women from Somalia, median age 35.9 years  (min 18.1, max 56.0), latitude 0-10° North living in Gothenburg, Sweden, latitude 57° North, >2 years. All women have been wearing covering clothing due to their religious and socio-cultural reasons and they had skin photo-type V.

Methods: BMD was measured by DXA (Dual energy X-ray Absorptiometry) at the lumbar spine and the left and right hip. BMD results were recorded as the Z-score (difference in SD from the mean of a healthy, age- and sex-matched sample) and the T-score (SD from the mean peak value in young sex-matched adults) for each subject.

The BMD in Somalian women was compared both with BMD in white American women and BMD in African-American women using standard data provided by the DXA manufacturer (Lunar Prodigy enCORETM , GE Healthcare, LU44663). Body mass index (BMI) was calculated as a body weight (kg) divided by the height squared (m2). A fasting blood test was drawn for analysis of serum 25(OH)D (DiaSorin, Stillwater, MN, USA).

Results: The median BMI was 27.9 kg/m2(min 16.9, max 37.3). The majority, 70%, had vitamin D deficiency; serum 25(OH)D <10 ng/ml (25 nmol/l).

The median value of Z-score compared with the reference interval for the American white population was -0.9 SD (min -3.4, max 1.6) of the lumbar spine; 0.1 SD (min -1.7, max 2.1) of the left hip and 0.0 SD (min -2.0, max 1.7) of the right hip. The median value of T-score was -0.6 SD (min -3.2, max 2.0) of the lumbar spine; 0.0 SD (min -2.1, max 2.5) of the left hip and 0.1 SD (min -2.2, max 2.3) of the right hip.

The median value of Z-score compared with reference interval for the African-American population was -1.5 SD (min -4.0, max 0.9) of the lumbar spine; -0.9 SD (min -2.8, max 1.0) of the left hip and -0.9 SD (min -3.0, max 2.2) of the right hip. The median value of T-score was -0.7 SD (min -3.2, max 2.0) of the lumbar spine; 0.1 SD (min -1.9, max 2.5) of the left hip and 0.2 SD (min -2.2, max 2.3) of the right hip. No fractures were reported during life. The relation between BMD and the visual analogue scale (VAS) for pain scoring and the duration of years in Sweden, respectively, will be analyzed.

Conclusions: BMD was lower in these fairy young immigrant women from Somalia, living in Sweden, in relation to the African-American reference population. Vitamin D supplementation should be considered to prevent from osteomalacia and future fractures.

 

Nothing to Disclose: AO, TD, ALK, HS, EA, GE, KL

16621 28.0000 MON-0220 A Bone Mineral Density Is Low in Somalian Women Living in Sweden 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Nasser M. Rizk*1, Amina Saleh Fadel1, Nora Basem Younes2, Amrita Cheema3 and Mahmoud Zeiri2
1Qatar University, Doha, Qatar, 2Hammad medical coroprtaion, Doha, Qatar, 3George Town University, Washigton DC

 

Background:

Osteopenic fractures are major cause for morbidity among diabetic subjects 1. Previous reports of bone turnover markers in type 2 diabetes (T2DM) are scarce, and the results are conflicting2,3. Our aim was to assess the changes in bone turnover markers between T2DM and non-diabetes control subjects and its correlation with the glycemic control among diabetics.

Methods:

A Cross-sectional study was performed on 133 Arab subjects, resident in Qatar (87 T2DM, and 53 without diabetes used as a control). Bone turnover markers Osteopontin (OPN) ,  Osteocalcin (OC),  Osteopotegrin (OPG),  and PTH were determined in serum by multiplex Eliza with Luminex 200 . 25 hydroxy-vitamin D and HBA1C (%) were measured at the clinical chemistry lab at Hammad Medical Corporation, Doha-Qatar. Estimated average glucose (eAG) was calculated to assess the glycemic control. Data are expressed as mean value (with 95% confidence interval for mean), unless mentioned otherwise.

Results:

The mean ± SD of the age and BMI of the diabetic subjects were (52.5 ± 9.8 years) and  (31.3 ±5.05 kg/m2), and the age and BMI of the controls were (35.4± 10.4 years) and (28.9±5.04 kg/m2), respectively. The mean value of the serum level of bone resorption marker (OPN), was significantly lower in T2DM (79.4 [58.4-100.5] pg/ml), compared with non-diabetes subjects (132.3 [107.4-157.3] pg/ml), with p< 0.0001, and this p value was still significant (0.031) even after adjustments of age, gender and BMI. There was no significant differences in bone formation markers for (OC) ng/ml (3.36 [2.49-4.13] vs. (3.34 [2.54-4.41], with P=0.958),  and (OPG) pg/ml (224.3 [186.4-262.7] vs. 205.4 [188.1-201.6], with p=0.675), and this p value was still not significant (0.851, and 0.432), respectively even after adjustments of age, gender and BMI.  PTH serum levels pg/ml was significantly lower in T2DM (24.5 [21.5-27.6]) than control subjects (42.9 [38.3-47.7], with P< 0.041) and the p value was 0.025 after adjustments of age, gender and BMI. 25-hydroxy vitamin D level (ng/ml) was not significantly different between the diabetic (14.34 [11.64-17.03]) and the control subjects (16.95 [15.23-18.67], p=0.089). Moreover T2DM subjects with uncontrolled glycemic control (eAC >154 mg/dl ) had lower concentrations of (OPN) pg/ml (75.29 [46.1-104.5]) and PTH pg/ml (26.2 [22.3-28.4]) than T2DM subjects with better glycemic control (eAC ≤ 154 mg/dl ) for OPN (114.2 [93.8-134.4]) and PTH (39.8[34.3-45.1]) with p values = 0.013 and 0.001, respectively and this pvalue was still significant (0.042, 0.012) respectively, even after adjustments.

Conclusion

T2DM patients have lower levels of bone resorption marker OPN, and PTH compared with subjects without diabetes. The poor glycemic control and the lower levels of PTH may induce a low turnover state as reflected by lower level of bone resorption marker, and this situation may influence the higher risk of fracture of T2DM.

 

Nothing to Disclose: NMR, ASF, NBY, AC, MZ

16657 29.0000 MON-0221 A Circulating Osteopontin Level Is Reduced Among Type 2 Diabetes with Poor Glycemic Control 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Luiz Claudio Goncalves de Castro*1, Cinthia Araujo2, Andre Leite2, Paulo Yamaguti2, Heliana Mestrinho2 and Ana Carolina Acevedo2
1University of Brasilia, Brasilia - DF, Brazil, 2University of Brasilia, Brazil

 

Osteogenesis Imperfecta (OI) is a group of inherited bone disorders characterized by low bone mass, bone fragility and susceptibility to fractures, with a wide phenotypic variation. Those patients may also present dentinogenesis imperfecta, a hereditary dentin disorder. Bisphosphonates (BP) are commonly used as the symptomatic pharmacological approach attempting to reduce the frequency of fractures and improve clinical mobility for children with moderate or severe forms of OI.  Disodium pamidronate (PAM) is one of the most used BP in this situation, and it is administered in cyclic intravenous infusions. Studies with murine models have shown that BP, including PAM,  may delay or inhibit tooth development and eruption. To address this question in humans, we studied the effect of PAM on tooth formation and eruption of growing children with OI.  Tooth development was evaluated through dental panoramic radiographs from 45 children with OI (aged between 4 and 16.9 years; 20 females), receiving PAM for at least 2 years, and 90 healthy subjects (40 females) matched for age and sex.  Stages of development of the teeth of the left mandibular region were scored accordingly. The difference in temporal pattern of dental development between patients with OI and controls was not statistically significant for males (p=0.664) nor for females (p=0.567) independently when being evaluated as whole groups or by age ranges.  Mean differences between dental age and chronological age among patients and controls were, for males, 0.3±0.4 yr (4.0-6.9 yr age group; p=0.273); 0.7±0.8 yr (7.0-9.9 yr age group; p=0.228); 0.9±1.1 yr  (10.0-12.9 yr age group; p=0.084) and 0.6 yr (13.0-16.9 yr age group; p=0.381); and for females  0.5±0.5 yr (4.0-6.9 yr age group; p=0.311); 0.5±0.7 yr (7.0-9.9 yr age group; p=0.865); 0.1±0.7 yr (10.0-12.9 yr age group; p=0.708) and 0.4±0.9 yr (13.0-16.9 yr age group; p=0.401).   Similarly, there was no statistical difference in the period of dental exfoliation when radiographs were assessed by time of treatment with PAM.  The results evidenced that, for this sample of children with OI, treatment with PAM did not affect the temporal arrangement of tooth development and eruption.

 

Nothing to Disclose: LCGDC, CA, AL, PY, HM, ACA

16891 30.0000 MON-0222 A Pamidronate Does Not Impair Tooth Formation or Eruption in Children with Osteogenesis Imperfecta 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Gita Avotina*1 and Ingvars Rasa2
1Riga East Clinical University Hospital, The University of Latvia, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia, 2Riga East Clinical University Hospital, Riga Stradins University, Latvian Osteoporosis and Bone Metabolism Diseases Association, Riga, Latvia

 

PHPT characterises with uncontrolled parathyroid hormone (PTH) secretion resulting in hypercalcemia. This condition occurred at any age more commonly affects those older than 50yrs of age. Patients (pts) may have bone disease, renal manifestations, gastrointestinal symptoms, neuropsychiatric and cardiovascular manifestations.The aim of this study was to determine pts demographics, laboratory data, diagnostics and treatment of PHPT in tertiary care multi-profile Riga East Clinical University Hospital (RECUH). Hospital based case control retrospective study analyzed medical records of pts admitted to the hospital in 4.5yrs (01.01.2009–06.30.2013). The statistical data were processed using SPSS 16.0. All the data were presented in the mean value with a standard deviation. Normal range for calcium was defined 2.1–2.6mmol/L, for PTH – 12.0–72.0pg/mL, for phosphorus – 0.8–1.6mmol/L, for alkaline phosphatase – <117.0U/L. There was 176 medical records of 140 pts. Females were 87.1% (n=122). 12.9% (n=18) were males. Age was 60.2±13.3yrs. Calcium level in the study population was 2.8±0.4mmol/l. PTH level was 258.2±315.9pg/mL (n=130), phosphorus level was 0.9±0.2mmol/L (n=108), alkaline phosphatase level was 89.3 ±36.5U/L (n=68). 25(OH)D3 level was assessed for 37.1% of pts, and it was 15.5 ±8.9ng/mL. Total 25(OH) vitamin D2,D3 level was assessed for 20.7% of pts, and it was 23.6 ±11.7ng/mL. Ultrasound exams verified parathyroid adenoma in 49.2% (n=62) and suspected in 31.0% (n=39). In 37.6% (n=38), parathyroid adenoma was localised in the right side, in 57.4% (n=58) – in the left side, in 5.0% (n=5) – in both sides, 19.8% did not localise. CT scans with intravenous administration of contrast verified parathyroid adenoma in 52.1% (n=25) and suspected in 18.8% (n=9). In 41.2% (n=14) parathyroid adenoma, was localised in the right side, in 50.0% (n=17) – in the left side, in 5.9% (n=2) – in both sides, in 2.9% (n=1) it was atypically localised. Technetium (99mTc) sestamibi scans verified parathyroid adenoma in 57.8% (n=26) and suspected in 15.6% (n=7). In 46.9% (n=15) parathyroid adenoma was localised in the right side, in 40.6% (n=13) – in the left side, in 12.5% (n=4) – in both sides. SPECT/CT scans verified parathyroid adenoma in 60.0 % (n=6), suspected in 30.0% (n=3). In 11.1% (n=1) parathyroid adenoma was localised in the right side, in 55.6% (n=5) – in the left side, in 33.3% (n=3) – in both sides. DXA demonstrated osteoporosis in 70.7 % (n=29) and osteopenia – in 24.4% (n=10). Parathyroidectomy was treatment of choice for 47.1% (n=66) pts. Pts, whose parathyroid adenoma was not localised, proceed follow-up. Pts with PHPT in RECUH are more often females and mean age is older than described in the literature. More often parathyroid adenoma was localised in the left side. Parathyroidectomy is a treatment of choice for less than half of all pts included in this study.

 

Nothing to Disclose: GA, IR

11777 31.0000 MON-0223 A Primary Hyperparathyroidism (PHPT) in Tertiary Care Multi-Profile Riga East Clinical University Hospital: 4.5 Years Data 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Lev David Bubis*1, James A Lee2, Irene Epelboym2, Jennifer Hong Kuo2, John Chabot2 and John D Allendorf3
1Columbia University College of Physicians and Surgeons, 2Columbia University Medical Center, New York, NY, 3Winthrop-University Hospital

 

The ability of preoperative calcium and iPTH elevation to predict adenoma size and multifocality in primary hyperparathyroidism (PHPT) remains controversial. The purpose of this study is to investigate relationships between pre-operative biochemical profiles and adenoma weight and/or multifocality in PHPT. A single institution IRB-approved retrospective review of PHPT patients undergoing parathyroidectomy from 9/2008-8/2012 was conducted. Demographic, biochemical, and pathological data collected within 3 months prior to surgery were analyzed. Cases were stratified by preoperative biochemical variables into the following groups: ‘classic’ PHPT (Ca >1mg/dL above upper limit of normal, iPTH above upper limit of normal), ‘mild’ PHPT (Ca <1mg/dL above upper limit of normal, iPTH above upper limit of normal), ‘normocalcemic’ PHPT (Ca within normal limits, any iPTH), and ‘normohormonal’ PHPT (iPTH within normal limits, Ca above upper limit of normal). Statistical analysis assessed for differences amongst groups in mean gland weight and incidence of multifocality. 595 consecutive patients with PHPT were included in the study. Mean age was 59.5±0.5 years. 518 (86.5%) had single adenomas, 44 (7.35%) had multiple adenomas, and 33 (5.51%) had multigland hyperplasia. Patients with single gland disease had the highest mean preoperative Ca (10.7±0.03mg/dL), iPTH (121.1±4.3pg/mL), and gland weight (790±50mg). A Fischer’s exact test demonstrated a significant relationship between preoperative biochemical profile and multifocality (p=0.013), with post-hoc Bonferroni-adjusted pairwise analysis indicating a significantly higher proportion of multigland disease in the ‘normocalcemic’ profile [27.7%] vs ‘classic’ profile [7.1%] (p=0.004). When patients with single adenomas were stratified by biochemical profile, a Kruskal Wallis test revealed a significant association between preoperative biochemical profile and gland weight (p=0.0001). ‘Classic’ PHPT were the largest glands with mean weight of 1027+190mg (vs. 844+97mg for ‘mild’ PHPT, 462+108mg for ‘normocalcemic’ PHPT, and 321+31mg for ‘normohormonal’ PHPT. A post-hoc Mann-Whitney test with Bonferroni correction showed the significant differences were between ‘normocalcemic’ vs ‘mild’ profiles (p=0.0002); ‘normocalcemic’ vs ‘classic’ profiles (p<0.0001); ‘normohormonal’ vs ‘mild’ profiles (0.0001); and normohormonal vs ‘classic’ profiles (p<0.0001). This study demonstrates that preoperative biochemical profile can predict adenoma size and multifocality in PHPT.  This association may help guide intraoperative localization of parathyroid adenomas, especially in cases where adjunct imaging studies are unavailable or equivocal – with ‘classic’ PHPT profiles predicting large single adenomas, and ‘normocalcemic’ biochemical profiles predicting lower gland weight and/or multigland disease.

 

Nothing to Disclose: LDB, JAL, IE, JHK, JC, JDA

12392 32.0000 MON-0224 A Preoperative Biochemical Profile Predicts Gland Size and Multifocality in Primary Hyperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Marcio L Griebeler*1, Ann E Kearns1, Matthew A Hathcock2, Euijung Ryu2, L Joseph Melton III2 and Robert A Wermers1
1Mayo Clinic, Rochester, MN, 2Mayo Clinic Rochester, Rochester, MN

 

PURPOSE: The study evaluates the incidence of thiazide-associated hypercalcemia and clarifies its clinical features and natural history.

METHODS: This is a population-based descriptive study of Olmsted County, Minnesota. Residents with thiazide-associated hypercalcemia were identified through the Rochester Epidemiology Project and the Mayo Clinic Laboratory Information system from 1992-2010.Incidence rate was calculated per 100,000 person-years using age and sex distribution of the 2010 US white population.

RESULTS: 220 residents (190 women and 30 men; median age, 68 years) with thiazide-associated hypercalcemia were identified between 1992 and 2010.  The overall age and sex-adjusted incidence was 17.0 (95% CI, 14.7 – 19.2) per 100,000 person-years. There was an increase in incidence after 1996, peaking at 1999 with the overall incidence of 31.7. The highest rate was 314.3 per 100,000 in 65 - 74 year-old women.  Hypercalcemia was identified a median of 3.9 years after thiazide initiation, and the average highest serum calcium was 10.7 mg/dl.  A total of 139 (63%) patients continued thiazide and of these 7 patients developed primary hyperparathyroidism (PHP), 71 (51%) remained hypercalcemic and 68 (48.9%) patients had their calcium level normalized. Of the 81 (37%) patients who discontinued the thiazide, 49 (60.4%) patients had persistent hypercalcemia. Of this subgroup, 43 (88%) patients were subsequently diagnosed with PHP. Comparing the clinical and laboratory spectrum of patients with thiazide-associated hypercalcemia and the subset that later was found to have PHP, 86.3 % were female vs. 82% respectively, mean age of onset was 67.4 vs. 66.6 years, the mean serum calcium before thiazide use was 9.7 mg/dL in both groups, the maximum serum calcium on thiazides was 10.7 vs. 10.9 mg/dL, and the median years from thiazide start to hypercalcemia was 3.9 vs. 2.9 years. Comparing the subset of patients that thiazide was discontinued and the thiazide was continued without parathyroid surgery, 85.1 % were female vs. 88.9%, mean age of onset was 68 vs. 67 years, the mean serum calcium before thiazide use was 9.7 mg/dL in both groups, the maximum serum calcium on thiazides was 10.7 mg/dL in both groups, and the median years from thiazide start to hypercalcemia was 4 vs 3.7 years.

CONCLUSION:  The majority of patients remains on the thiazide diuretic despite hypercalcemia and about half of these patients will continue having high calcium levels. The persistence of hypercalcemia in patients discontinuing thiazides and the clinical similarities suggest that concomitant primary hyperparathyroidism is common in patients who develop hypercalcemia while taking thiazide diuretics.

 

Nothing to Disclose: MLG, AEK, MAH, ER, LJM III, RAW

13058 33.0000 MON-0225 A Incidence and Clinical Spectrum of Thiazide-Associated Hypercalcemia – a Population-Based Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0193-0225 4785 1:00:00 PM Diseases of Bone and Mineral Metabolism Poster

Kyeong Jin Kim*1, Sun Hwa Kim1, Yoon Jung Kim2, Jee Hyun An1, Nam Hoon Kim1, Hye Jin Yoo1, Hee Young Kim1, Ji A Seo1, Nan Hee Kim1, Kyung Mook Choi1, Sei Hyun Baik1, Dong Seop Choi1 and Sin Gon Kim1
1College of Medicine, Korea University, Seoul, Korea, Republic of (South), 2College of Medicine, Hallym University, Seoul, Korea, Republic of (South)

 

Background: Vitamin D deficiency is widespread in immigrants and refugees as well as general population. We investigated the prevalence of vitamin D deficiency and associated metabolic risk factors in North Korean refugees living in South Korea.

Methods: We examined 386 subjectss aged over 30 years from the North Korean refugee health in South Korea (NORNS) study. Vitamin D deficiency was defined as serum 25(OH)D level of below 20 ng/ml. Metabolic syndrome and its components were also assessed.

Results: The prevalence of vitamin D deficiency was 87%, and there was no one who had sufficient vitamin D level (25(OH)D ≥ 30 ng/ml) among North Korean refugees. Underweight subjects (body mass index (BMI) < 18.5 kg/m2) had significantly lower 25(OH)D levels compared with individuals with normal BMI (≥ 18.5 and < 23 kg/m2). In the multivariate logistic regression analysis, those with the lowest 25(OH)D levels (< 10 ng/ml) was significantly associated with metabolic syndrome (OR, 6.37, 95% CI, 1.34 – 30.33), high triglyceride (OR, 6.71, 95% CI, 1.75 – 25.68), and low high-density lipoprotein (OR, 5.98, 95% CI, 1.54 – 23.19) compared with thoese with 25(OH)D levels ≥ 20 ng/ml even after adjusting for confounding variables including BMI.

Conclusions: Vitamin D deficiency was very common among North Korean refugees in South Korea. In spite of low BMI, low vitamin D levels were associated with metabolic syndrome in this population.

 

Nothing to Disclose: KJK, SHK, YJK, JHA, NHK, HJY, HYK, JAS, NHK, KMC, SHB, DSC, SGK

13740 1.0000 MON-0239 A Vitamin D Status and Associated Metabolic Factors in North Korea Refugees in South Korea 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0239-0255 4788 1:00:00 PM Osteoporosis and Metabolic Bone Disease Poster

Aiji Yajima*1, Masaaki Inaba2, Yoshihiro Tominaga3, Ken Tsuchiya4, Kosaku Nitta4, Kazutaka Matsushita1, Motoko Tanaka1, Akemi Ito5 and Shigeru Satoh6
1Akebono Clinic, Kumamoto, Japan, 2Osaka City University Graduate School of Medicine, Osaka, Japan, 3Nagoya Second Red Cross Hospital, Aichi, Japan, 4Tokyo Women's Medical University, Tokyo, Japan, 5Ito Bone Histomorphometry Institute, Niigata, Japan, 6Akita University, School of Medicine, Akita, Japan

 

The dual energy of x-ray absorptiometry showed that the increase of bone mineral density after parathyroidectomy is smaller in cortical than in cancellous bone in patients receiving dialysis with high turnover bone disease. The present study was undertaken to investigate changes of histomorphometric parameters of cortical and cancellous bone together. Iliac bone biopsy was performed before and 1 week after parathyroidectomy in Group I (n=13, Age;56.1 ±6.9 years, Duration of Dialysis;18.7 ±6.5 years), and before and 4 weeks after in Group II (n=15, Age;54.3 ± 11.8 years, Duration of Dialysis;10.2 ± 7.1 years). Moreover, changes of histomorphometric parameters of the endocortical, intracortical and periosteal surfaces as well as in cancellous surface were monitored. Serum level of intact parathyroid hormone was measured simultaneously and decreased from 1125.4 ± 573.1 pg/ml to 15.7 ± 19.6 pg/ml after the neck surgery. In cancellous surface, osteoclast surface (Oc.S/BS) decreased to 0% within 4 weeks after parathyroidectomy, while osteoblast surface (Ob.S/BS) transiently increased at 1 week, followed by a reduction at 4 weeks to levels below the pre-surgical level. In cortical bone, Oc.S/BS was not reduced to 0%, but decreased significantly while a significant and temporary increase of Ob.S/BS was observed only on the endocortical (25.3 ± 11.3 to 43.6 ± 21.7 %) and intracortical surfaces (21.3 ± 13.5 to 36.3 ± 19.3 %) at 4 weeks, but not at 1 week. However, Oc.S/BS did not decrease and Ob.S/BS did not increase significantly on the periosteal surface at 1 and 4 weeks after the surgery. Namely, the improvement of high bone turnover on these two surfaces lagged behind that in cancellous surface. Lamellar bone volume significantly increased in cancellous bone, however, did not increase around the periosteal surface. As a result, the improvement of the high bone turnover of the endocortical surface and intracortical surface was obtained, but the degree of it was smaller than in cancellous surface although the growth of bone is mainly dependent of periosteal mineral apposition in the young subjects without chronic kidney disease. In addition, the increase of the normal lamellar bone could not be anticipated around the periosteal surface in these patients. In conclusion, the treatment for high bone turnover should be done at the early stage of renal hyperparathyroidism because both the reduction of bone volume and woven texture of bone are irreversible in cortical bone, especially, around the periosteal surface.

 

Nothing to Disclose: AY, MI, YT, KT, KN, KM, MT, AI, SS

15236 2.0000 MON-0240 A Irreversibility of High Bone Turnover Around the Periosteal Surface in Patients with Severe Renal Hyperparathyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0239-0255 4788 1:00:00 PM Osteoporosis and Metabolic Bone Disease Poster

Maria Elena Romero Ibarguengoitia*1, Arnulfo Gonzalez Cantu2, Judith Aparicio España3, Sergio Hernandez Jiménez4, Alfredo Reza Albarrán5 and Francisco Javier Gómez Pérez6
1Instituto Nacional de Ciencias Medicas y Nutrición Salvador Zubiran, UNAM, Mexico DF, Mexico, 2Endocrinology Research Gruop of Monterrey, San Pedro Garza García, Mexico, 3Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico, 4Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, UNAM, Mexico DF, Mexico, 5Instituto Nacional de Ciencias Médicas y Nutrición Salvadodr Zubirán, Mexico DF, 6Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, UNAM, Mexico DF, Mexico

 

Postmenopausal osteoporosis is a well known disease caused by increased bone remodeling resulting from estrogen deficiency. Indications for treatment are based on low areal bone mineral density (aBMD, T-score≤−2.5), typical fragility fractures (spine or hip), and more recently, an elevated 10-year fracture probability (by FRAX®). In contrast, there is no clear definition of osteoporosis nor intervention thresholds in younger individuals. True osteoporosis in the young can occur, which we define as a T-score below −2.5 at spine or hip. It is usually  associated with a chronic disease known to affect bone metabolism. In the absence of secondary causes, the presence of fragility fractures, such as in vertebrae, may point towards a genetic or idiopathic osteoporosis. Until today there are only case reports  of  patientes with very low aBMD (spine and/ or hip T-Score <-4) with very poor information about characteristics, treatment  and fracture prevalence, so the propose of these study was to describe a serie of patientes with very low  aBMD  in order to know  more information about this identidy. We did a retrolective, observational and transverse study. 654 densitometries (Hollogic QDR) of patients between 18-40 years done in our hospital between 2009-2013 were analyzed. 40 patients had very low aBMD. There where 27 men (23+/-6 years) and 13 women ( 26+/-8 years).  There were no difference between genders in serum calcium, phophorus, PTH, magnesium,  25 OH vitamine D and urinary calcium  (p>0.05). 8 patients (20%) smoked , 4 (10%) dranked more than 30g of alcohol/day. 14(35%)  had a BMI<18.5, 19(47.5%) BMI 18.6-24.9 and 7 (17.5%) BMI 25-30. 19 (47.5%) used steroids (13.74+/- 23 mg of prednisone), 10 (25%) omeprazol, 8(20%) antiepileptics, 7(17.5%) antidepressant drugs, 4 (10%) levotiroxine and 3(7.5%) diuretics (furosemide). The most frecuent diseases reported were: Hypogonadism in 11 patients (27.5%), hypothyroidism, ankylosin spondylitis and inflammatory bowel disease in 4 patients (10%) each. Diabetes type 2 and autoinmune hepatitis in 3 patients (7.5%) each. There was 1 case of Ehlers Danlos, 1 case of a dismorphic non specified syndrome, 1 case of Von Gierke syndrome and 1 imperfect osteogenesis. The most frecuent treatment used was calcium and vitamine D (47.5%). 15 patientes had T-score <-4 in the hip (-3.45+/-1.12), 15 in femoral neck (-3.4 +/- 1.2) and 36 in the spine (-4.47 +/-1.24). The fracture prevalence was 22.5% (9 patients), 5/9 had mayor osteoporotic fractures. The most important factors associated with fracture prevalence according to the multinomial logistic regression were: peak bone mass, steroid use, diuretic use and low BMI (p<0,001).  Conclusion. Secundary causes are the most frecuent in very low aBMD, even though genetic causes must be considerd. Fracture prevalence  is related to aBMD dependent and independent factors.

 

Nothing to Disclose: MER, AG, JA, SH, AR, FJG

14703 4.0000 MON-0242 A Osteoporosis in Young Patients (18-40 years) with Very Low Areal Bone Mineral Density (aBMD T- Score <-4). One of the Biggest Series Reported 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0239-0255 4788 1:00:00 PM Osteoporosis and Metabolic Bone Disease Poster

Eun Young Lee*1, Kyoung Min Kim2, Su Jin Kim1, Chang Oh Kim1, Yoosik Youm3, Hyeon Chang Kim1 and Yumie Rhee1
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Seoul National University Bundang Hospital, 3Yonsei University, Seoul, Korea, Republic of (South)

 

A recent study showed high prevalence of sarcopenia and its significant relation to osteoporosis in women with a fragility fracture of hip. Although sarcopenia is associated with a decline not only in muscle mass but also in muscle function, many studies were based on muscle mass, but not muscle strength. The aim of this study was to investigate the association between muscle strength/function measured by various tests and osteoporosis of hip in healthy elderly women. We recruited 487 healthy community-dwelling women aged 64 to 87 years. Whole body composition and bone mineral density (BMD) at hip were measured using bioelectrical impedance analysis and dual X-ray absorptiometry, respectively. Muscle strength or function was assessed by grip strength (GS), jumping mechanography (JM), timed-up and go (TUG), and chair rise test (CRT). There were significant differences in age, body mass index (BMI), thigh circumference, 25(OH)D, osteocalcin, skeletal muscle mass according to the category of femoral BMD. Muscle strength or function was significantly decreased in osteoporotic group. In correlation analysis, thigh circumference, skeletal muscle index, and muscle strength had positive correlation with femoral BMD. Total time during TUG and CRT was negatively associated with femoral BMD. Multiple logistic regression analysis demonstrated that body mass index, osteocalcin, and muscle strength measured by JM were significant predictors for osteoporosis of hip. Muscle strength measured by JM may be a useful marker for osteoporosis of hip in healthy elderly women.

 

Nothing to Disclose: EYL, KMK, SJK, COK, YY, HCK, YR

15979 5.0000 MON-0243 A Muscle Strength Measured By Jumping Mechanography Is Associated with Bone Mineral Density of Hip in Healthy Elderly Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0239-0255 4788 1:00:00 PM Osteoporosis and Metabolic Bone Disease Poster

Udaya Manohar Kabadi*
University of Iowa, Clive, IA

 

Background:Decline in BMD following chronic therapy with prednisone is attributed to osteoporosis induced by prednisone and hypogonadism caused by suppression of hypothalamic pituitary-gonadal axis. However, lack of circulating active 125 OH Vitamin D due to prednisone induced inhibition of hepatic 25 hydroxylase may also contribute to the decline in BMD.

Aim:Effect of administration of 125 OH vitamin D (Calcitriol) on BMD was examined in subjects with low BMD (T< -2.5) refractory to  therapy with Cholecalciferol, calcium and Risedronate

Subjects and Methods:17 women and 4 men with ages 45-56 years receiving prednisone ≥10 mg daily for  ≥3 years with declining BMD for 2 years while receiving daily Vit D3 (Cholecalciferol) 1200 units, Calcium carbonate (elemental calcium, 1200- 1500 mg) and Risedronate 5 mg were refered for assessment. The subjects divided into 2 groups. Both groups continued Calcium and Risedronate. In 8 women and 2 men(group 1), Cholecalciferol was increased to 2000 units daily while in group 2(9 women and 2 men), Cholecalciferol was substituted by Calcitriol, 0.5 mcg daily . Comprehensive metabolic panels(CMP) including serum calcium and alkaline phosphatase as well as 25 OH Vit D and 125 OH Vit D levels were determined by local laboratory every 6 months. BMD was determined by DEXA using same equipment at yearly interval. The subjects were followed every 3 months to ensure adherenceand compliance

 Results:CMP including serum calcium and alkaline phosphatase remained normal throughout observation. Serum 25 OH Vit D (<20 ng/ml) and 125 OH Vit D levels ( < 25 pg/ml) were subnormal prior to increasing the daily dose of Cholecalciferol in group 1 and prior to change over to Calcitriol in group 2 and remained unaltered in both groups at the end of observation period of 2 years. 125 OH Vit D normalized (53 ±6 pg/ml) in group 2 but remained subnormal in group 1.

BMD (T score) continued to decline in group1(-2.9±0.2 to -3.3±0.3) whereas BMD improved (-2.3± 0.2) significantly(p<0.01) from baseline (-3.1± 0.3) in group 2. Thus, BMD in group 2 was significantly greater at both year 1 and year 2 in comparison to group 1 (p<0.01).

Conclusion:In subjects receiving chronic therapy with prednisone,

1)Both serum 25 OH Vit d and 125 OH Vit D levels are decreased leading to osteomalacia, yet another factor in inducing decline in BMD

2)Contribution of osteomalacia in the decline in BMD in subjects receiving chronic prednisone therapy is  further confirmed by improvement in BMD by supplementation of Calcitriol.

3)Calcitriol appears to be a preferred Vit D formulation over Cholecalciferol in subjects receiving chronic therapy with prednisone for preserving and improving BMD while continuing adequate calcium supplementation and administration of Bisphosphonates.

 

Nothing to Disclose: UMK

13413 6.0000 MON-0244 A Improvement in Bone Density with Caclitriol Substitution for Vitamin D3 in Refractory Prednisone Induced Osteoporosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0239-0255 4788 1:00:00 PM Osteoporosis and Metabolic Bone Disease Poster

Shin Hye Kim* and Mi-Jung Park
Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea, Republic of (South)

 

Background: Normative data for bone mineral density (BMD) in Asian adolescents and youth are scarce.

Objective: We aimed to provide normative values and reference curves for BMD in Korean adolescents and youth.

Methods: Using the data from Korean Nutrition Health and Nutrition Examination Survey (KNHANES) in 2008~2011, a total of 3,352 subjects (1,635 males and 1,717 females aged 10-25 years), were included for this study. BMD were measured using dual X-ray absorptiometry at lumbar spine (LS), total body (TB), total body less than head (TBLH), total hip (TH), and femoral neck (FN). Age related reference curves for BMD were generated using the LMS statistical procedure.

Results: The BMD increased with age in both genders (P<0.0001), and reached a plateau at ages 16-17 in males and at age 15 in females. Peak BMD velocities occurred at ages 13-14 in males; at ages 11-12 in females. Peak bone mass (PBM) of all study regions was achieved by the age of 21 and 19 in males and females, respectively. BMD in LS, TB, and TBLH was maintained until the age of 25, whereas decrease in BMD was noted in TH and FN from the age of 23 and 22 in males and females, respectively.

Conclusions: This reference curves for BMD can be used to assess and monitor the bone health in Korean adolescents and youth.

 

Nothing to Disclose: SHK, MJP

14459 7.0000 MON-0245 A Reference Curves for Bone Mineral Density in Korean Adolescents and Young Adults Aged 10 to 25 Years: The Korea National Health and Nutrition Examination Survey, 2009~2011 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0239-0255 4788 1:00:00 PM Osteoporosis and Metabolic Bone Disease Poster

Amanda Miller1, Jenneth Cole2, Kara Thompson1 and Stephanie M Kaiser*1
1Dalhousie University, Halifax, NS, Canada, 2Capital Health, Halifax, NS, Canada

 

Introduction:  Previous studies have demonstrated that patients with osteoporosis (OP) have a poor understanding of their bone disease and that this negatively influences treatment decisions and medication compliance.

Objective:  The aim of this study was to determine if there is a discrepancy between perceived and objective disease knowledge (PK and OK, respectively) in patients with OP and whether this correlates with certain patient characteristics.

Design and Methods: After ethics approval, 121 patients of any age/gender referred to the Osteoporosis clinic were provided questionnaires to assess their PK and OK overall and in each of four domains: general OP, prevention and treatment, risk factors, and consequences of OP.  Overall correlation between PK and OK was assessed using the Spearman correlation coefficient.  Multivariate analysis was performed to look at association of demographic variables with PK and OK. Internal consistency for PK surveys overall and in each of the four domains was established using Cronbach’s alpha.  A Spearman correlation coefficient was calculated between our PK and OK surveys and results obtained using previously validated surveys addressing the same.

Results: There was a low-moderate correlation (Spearman coefficient 0.542) between PK and OK, with PK generally greater than OK (67.1% vs 51.7%).  PK was significantly increased by attendance at an osteoporosis educational session (p 0.0021) and by a prior visit at the osteoporosis clinic (p 0.0021).  Conversely, OK correlated positively with increasing education level (p 0.0002).  Internal consistency for overall PK was reasonable with a Cronbach’s alpha of 0.836, however was poor in the consequences of OP domain (Cronbach’s alpha of 0.547).  Spearman correlation coefficient showed a high-moderate correlation between survey results and those achieved with previously validated surveys.

Conclusion: Patients require further education regarding OP, focusing on minimizing the disparity between PK and OK.  This is perhaps best achieved through additional education sessions.  As a consequence of the results of this study, questionnaires have been modified to improve poor internal consistency noted in the consequences of OP domain and this study is ongoing using these modified questionnaires.

 

Nothing to Disclose: AM, JC, KT, SMK

14855 8.0000 MON-0246 A Perceived Versus Objective Knowledge in Patients with Osteoporosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0239-0255 4788 1:00:00 PM Osteoporosis and Metabolic Bone Disease Poster

Erik Allen Imel*1, Marc Rosenman2, Allison Nguyen3, Brian Decker2, Joel Martin4, Katie Allen4, Zangdong He5, Ziyue Liu5 and Siu Hui4
1Indiana University School of Medicine, Indianapolis, IN, 2Indiana University School of Medicine, 3Merck & Co, Inc., NJ, 4Regenstrief Institute, Inc., 5Indiana University Schools of Medicine and Public Health

 

Osteoporotic fractures contribute greatly to health care costs and individual morbidity and mortality. Patients with chronic kidney disease (CKD) are at increased risk for osteoporosis (OP) and fractures. Bisphosphonates (BIS) are the most commonly prescribed drugs for OP but are not recommended for patients with creatinine clearance <30 ml/min (risedronate and ibandronate) or <35 ml/min (alendronate and zoledronate). The objective of this analysis was to estimate the prevalence of CKD among patients who are potential candidates for BIS. Data from a large multi-system clinical care health information exchange network in Central Indiana from 2000-2012 were used to identify men and women age 50+ who had either bone mineral density (BMD) via DXA indicating OP (lowest T-score ≤-2.5) or osteopenia (T-score -1 to -2.5), documentation of dispensed BIS, ICD9 diagnosis of OP or osteopenia, or ICD9 evidence of a fracture (excluding sites not associated with OP or multiple concurrent fractures suggesting trauma). Patients with osteopenia plus a fracture were grouped with osteoporosis patients as potential treatment candidates. Patients with BMD T-score ≥ -1 were classified as normal. Estimated GFR was calculated by the CKD-EPI equation. CKD stages were based on stable levels for ≥90 days using the patients’ initial eGFR values (mL/min/1.73m2) during their first year in the cohort and were classified as: Normal, ≥90; Stage 2, 60-89; Stage 3, 30-59; Stage 4, 15-29; Stage 5, <15.

Results: Out of the full cohort (115,211 women, 32,991 men), 8,420 women and 635 men had normal BMD and 60,870 women and 10,423 men had either osteopenia plus a fracture or OP (regardless of fracture). The remainder had OP treatment alone, fracture alone, or osteopenia without fracture. The majority were white (88.5%) with 11.1% black and 0.4% other. The prevalence of CKD stages 3 to 5 increased with age. Of the women and men with normal BMD, 21.1% and 26.3% had CKD stages 3-5; and 1.4% and 5.0% had CKD stages 4-5. Of the women and men with osteopenia plus a fracture or OP, 32.9% and 28.8% had CKD stage 3-5; and 4.3% and 4.5% had CKD stage 4-5. Thus, BIS would not be recommended for more than 4% of the patients who otherwise might benefit from OP treatment. CKD is common in this large cohort of patients at risk for osteoporotic fractures, yet treatment with BIS is not recommended in this population. Appropriate treatment options to prevent fractures in patients with CKD are needed.

 

Disclosure: EAI: Coinvestigator, Kyowa Hakko Kirin, Investigator, Merck & Co.. MR: Coinvestigator, Merck & Co.. AN: Employee, Merck & Co., Employee, Merck & Co., Employee, Merck & Co.. Nothing to Disclose: BD, JM, KA, ZH, ZL, SH

13033 9.0000 MON-0247 A Prevalence of Chronic Kidney Disease in Patients Age 50 and Older Having Osteopenia and Osteoporosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0239-0255 4788 1:00:00 PM Osteoporosis and Metabolic Bone Disease Poster

Maria Marta Sarquis Soares*1, Marcio W Lauria2, Adriana Maria Kakehasi3, Michelle S Diniz4 and Jackson Machado-Pinto4
1Universidade Federal de Minas Gerais, Belo Horizonte MG, Brazil, 2FM/ Univ Fed de Minas Gerais, Belo Horizonte MG, Brazil, 3Universidade Federal de Minas Gerais, Belo Horizonte, Brazil, 4Santa Casa de Belo Horizonte, Belo Horizonte, Brazil

 

Psoriasis is a chronic inflammatory disease that leads to elevation in serum levels of TNF-α and other proinflammatory cytokines such as IL-6 and IL-17. Other organs and tissues may be affected by this chronic inflammatory disease. TNF-α may increase osteoclast precursors which could favor the onset of osteopenia and osteoporosis; in addition, IL-6 is a potent stimulator of bone reabsorption (1).

This study aims to determine and compare the body composition in patients with psoriasis and controls.

This is a case-control study with 36 adult patients (15 women) with cutaneous psoriasis without psoriatic arthritis and 37 controls (17 women). Total body composition including fat mass, lean mass and bone mineral density was obtained by Dual-energy X-ray absorptiometry (DXA). We performed a descriptive analysis of the variables. To compare cases and controls the chi- square test, Fisher's exact test and the nonparametric Mann- Whitney test were used.

There was no difference between groups regarding gender, age, waist circumference, body mass index (BMI), diabetes mellitus and hypertension. There was no statistically significant difference in lean body mass and percentage body fat between cases and controls. The cases showed a tendency to lower total bone mass (p = 0.059). The stratified analysis by gender showed that male patients with psoriasis had lower bone mass (p = 0.007) and lower total bone mineral density (p = 0.027) than controls. Studies that associate psoriasis with reduced bone mineral density are still controversial and limited (2). However, in a large population-based study psoriasis was associated with osteoporosis in men (3).

The identification of osteoporosis as a new comorbidity of psoriasis has consequences for the treatment of these patients. Currently, due to the lack of data there is no recommended screening for osteoporosis as well as supplementation with calcium and vitamin D for the prevention of osteoporosis in this group of patients

 

Nothing to Disclose: MMSS, MWL, AMK, MSD, JM

14816 10.0000 MON-0248 A Men with Psoriasis Have Lower Bone Mass Than Controls 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0239-0255 4788 1:00:00 PM Osteoporosis and Metabolic Bone Disease Poster

Sungwha Lee*1, Moon Gi Choi2 and Ohk Hyun Ryu3
1Hallym University College of Medicine, Chuncheon Sacred Heart Hospital, Chuncheon-si, Korea, Republic of (South), 2College of Medicine, Hallym University, Seoul, Korea, Republic of (South), 3Division of Endocrinology and Metabolism, Hallym University College of Medicine, Seoul, Korea, Republic of (South)

 

The recent trend is to make a diagnosis of osteoporosis based on the bone mineral density (BMD) of the femoral neck to overcome the discordance in bone loss according to the measuring site. However, the BMD of other sites is still clinically relevant, and their integration might be another approach for the discordance. The aim of this study was to determine the relationship between the number of osteoporotic sites as an integration factor and BMD. This study was based on data obtained from the Korea National Health and Nutrition Examination Survey 2008-2011, which is a nationwide cross-sectional study. Among postmenopausal women aged 50 years or older, 3,849 women whose BMD were measured at the lumber spine, femoral neck and total hip were included in the study. Only 39.2-59.0% of diagnosis were consistent with the diagnosis at each site. Lumbar spine T-score was reduced by -0.163 for 2 osteoporotic sites and by -0.462 for 3 osteoporotic sites, compared to 1 osteoporotic site. Femoral neck T-score was reduced by -0.609 for 3 osteoporotic sites compared to 1 and 2 osteoporotic sites. Our results confirmed that the discordance of BMD per site was considerably high among Korean women in their 50s, possibly due to the difference per site in the pattern of BMD reduction with age. The number of osteoporotic sites is a factor in which such a discordance is reflected, showing significantly lower BMD per site when more sites are diagnosed as osteoporosis.

 

Nothing to Disclose: SL, MGC, OHR

14156 11.0000 MON-0249 A The Number of Osteoporotic Sites As Adjusting Factor of Bone Mineral Density 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0239-0255 4788 1:00:00 PM Osteoporosis and Metabolic Bone Disease Poster

Quang Vutrong Ton*1 and Ismat Shafiq2
1University of Rochester School of Medicine & Dentistry, 2University of Rochester, Rochester, NY

 

Background: HIV-infected patients independent of anti-retroviral treatment have increased risk of osteopenia and osteoporosis. However, HIV infection is not commonly recognized as a risk factor for osteoporosis and there are no guidelines for management of osteoporosis in young HIV-infected patients. 

Clinical Case: A 29-year old male with a past history of methamphetamine use for two years presented with right hip pain after sustaining a fall on a wet restaurant floor. CT scan of pelvis revealed a right inferior pubic ramus and acetabular fracture leading to Endocrine consultation.

He had a right tibula-fibula fracture with subsequent surgery 6 months ago after a physical altercation. He then was diagnosed with HIV infection and started on anti-retroviral therapy two months after surgery. He also has 10 pack year history of smoking. There was no history of glucocorticoid use. Upon diagnosis of HIV, he quit methamphetamine and tobacco use. He has no family history of osteoporosis or fractures.

His physical examination was remarkable for poor dentition with multiple missing teeth and right lower extremity scar. His bone mineral density (BMD) scan showed a Z score of -4.0 at the spine, a Z score of -2.9 total left hip and a Z score of -4.1 total right hip. His laboratory values revealed a calcium of 9.6 mg/dL (normal range 9.0-10.3 mg/dL), an albumin of 4.3 g/dL (normal range 3.5-5.2 g/dL), a PTH of 42.3 pg/mL (normal range 15.0-65.0 pg/mL), a TSH of 1.48 uIU/mL (normal range 0.27-4.20 uIU/mL), a total testosterone of 758 ng/dL (normal range 249-836 ng/dL), a FSH of 7.3 mIU/mL (normal range 1.5-12.4 mIU/mL), a LH of 8.8 mIU/mL (normal range 1.7-8.6 mIU/mL),an estradiol of 28 pg/mL (normal range 8-43 pg/mL), a total 25-OH vitamin D of 69 ng/mL (normal range 30-80 ng/mL), an anti- transglutamine antibody IgA of 5.2 AB/units (normal range 0.0-19.9 AB/units), an alkaline phosphatase of 93 U/L (normal range 40-130 U/L), and a 24 hour urine calcium of 129 mg (normal range 100-240 mg/24 hr). He was treated with teriparitide 20 mcg subcutaneously daily and calcium citrate 1260 mg oral daily.

Conclusion: HIV infection and methamphetamine abuse are not commonly recognized as risk factors for osteoporosis. Numerous data show that individuals with HIV infection are at early and increased risk for osteoporosis. Limited data exist on methamphetamine inhalation and bone mineral density changes however it has been hypothesized that it can change skeletal structure notable in the periodontal region. Physicians should be aware of these two alternative risk factors when evaluating for osteoporosis until specific guidelines are created for management.

 

Nothing to Disclose: QVT, IS

15474 12.0000 MON-0250 A Osteoporosis in a Young HIV-Infected Male with History of Methamphetamine Use 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0239-0255 4788 1:00:00 PM Osteoporosis and Metabolic Bone Disease Poster

Sachin kumar Jain,1, Aadhaar Dhooria*2, Praphulla Deepankar3, Harish Gupta4 and Nishchint Jain4
1Lady Hardinge Medical College & Dr. R M L Hospital, New Delhi, India, 2Lady Hardinge Medical College &Dr. R M L Hospital, New Delhi, India, 3PGIEMR & Dr.R M L Hospital, New Delhi, India, 4PGIMER & Dr RML Hospital, New Delhi, India

 

Objective:  A case of bilateral fracture neck femur in an adolescent girl following generalized seizures.

16 yr old girl presented with pain both groins last 1 yr and an episode of generalised tonic-clonic seizure. Pain was insidious, dull aching, progressive, aggravated with movement, relieved with rest, no  morning stiffness or radiation. She had started limping  more on the left side in 3 months. An orthopaedic surgeon made a provisional diagnosis of tuberculosis of the left hip joint, started her on anti-tubercular therapy for last three weeks. There was no past h/o seizures or fever. Her scholastic performance was poor, she had minimal outdoor activities predating the illness, had achieved menarche at 13 years and normal menstruation.

On examination,  she was conscious & oriented, thin built, BMI of 15.9 kg/m². Vital signs stable. Grade 2 Chvostek’s and Trousseau’s signs noted. No skin pigmentation/ alopecia/ pallor/ icterus/ cyanosis/ pedal edema/ lymphadenopathy/ clubbing/ oral thrush. Fundus was normal. She had 2 episodes of GTCS during examination following which she was unable to move both lower limbs.

Investigations: Corrected S.Calcium = 5.1 mg/dl (8.5-10.5), Ionized Ca= 0.92mmol/l (1.12-1.32), S.Magnesium= 1.2 mg/dl (1.6-2.4 mg/dl), S.PO4 =2.1mg/dl (2.5-5.5). NCCT Head normal. ECG showed QT prolongation ( QTc= 0.519sec). S.ALP 3832 U/L (50-300). S.25 (OH) Vit D 3= ng/ml (30-100) and S.PTH 222.4 pg/ml (14-75). 24 hr urinary calcium excretion 10.4mg/day (100-300). Tissue transglutaminase antibody negative. Complete blood counts, Liver, Kidney & Thyroid functions normal.

X ray Pelvis showed bilateral fracture neck femur & deformed head of femur with osteopenia. MR imaging of the pelvis revealed only bilateral fracture neck of femur & no features suggestive of tuberculosis. Chest X-ray and X-ray skull were normal.

Diagnosis: Rickets-Osteomalacia, nutritional Vitamin D deficiency, secondary hyperparathyroidism, bilateral fracture neck femur secondary to hypocalcemic seizures. It is postulated that severe hypocalcemia leading to generalized seizures could be secondary to accelerated catabolism of vitamin D by rifampicin which is a known hepatic enzyme inducer.

Treatment: intravenous calcium gluconate, intravenous magnesium, intramuscular vitamin D injection (0.6million units once only) and oral calcium and vitamin D. Conservative management for femur fractures was done. Anti-tubercular therapy was stopped.

DISCUSSION: Femoral fractures caused by a seizure have been described in only a handful of case reports in older adults, patients with renal failure, multiple myeloma and skeletally immature patients. Bilateral fracture neck femurs are extremely rare in hypocalcemic seizures with vitamin D deficiency.  Physicians should carefully evaluate patients with seizures for secondary injuries, both at presentation and after the patient recovers from the post-ictal stage.

 

Nothing to Disclose: SKJ, AD, PD, HG, NJ

16633 13.0000 MON-0251 A Seizure Induced Bilateral Fracture Neck Femur in a Adolescent Girl 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0239-0255 4788 1:00:00 PM Osteoporosis and Metabolic Bone Disease Poster

Erick Sta. Rosa Mendoza* and Leilani Basa Mercado-Asis
University of Santo Tomas, Manila City, Philippines

 

Prevalent Fractures Occur at Relatively Younger Age and Higher Bone Mineral Density among Adult Filipino Men


Background: Osteoporosis in men is markedly underdiagnosed and undertreated even though the morbidity and mortality rates associated with fragility fractures are higher in men than in women. Data on osteoporosis and fractures among Asian males are lacking. The study aimed to identify predictors of osteoporosis and prevalent fractures among adult Filipino men. The result of the study may have important implications in our understanding on how the disease is varied by gender and ethnicity allowing better diagnosis, prevention and treatment.

Methodology: Retrospective chart review of 184 Filipino men with age of 50 years old and above screened for bone mineral density from 2007 to 2012 was performed. Age, weight, body mass index (BMI), Osteoporosis Self-Assessment Tool for Asians (OSTA) score, smoking status, family history of fracture, diabetes mellitus, oral steroid, thyroid hormone, anti-testosterone drugs, physical inactivity and T-score were considered. Test of proportions compared fragility fractures among normal, osteopenic and osteoporotic men. Logistic regression analysis, Hosmer-Lemeshow test and Wald test were used to determine significant predictors of prevalent fractures and osteoporosis.

Results: Of the 184 patients, 40.2 and 29.9% have osteopenia and osteoporosis, respectively. Sixteen (21.6%) and eighteen (32.1%) osteopenic and osteoporotic men have fragility hip, spine and forearm fractures at the time of screening. Men with age from 50 to 69 years have the same risk of osteoporosis and fractures as those with age of 70 years and above. While hip fractures are significantly higher in osteoporotic men (p < 0.05), vertebral fractures are increased in both osteopenic and osteoporotic men. The logistic regression models for both prevalent fractures and osteoporosis have acceptable fit. Even the mere presence of osteopenia predicts the presence of prevalent fractures (p < 0.05). A high risk OSTA score can predict fracture (p < 0.05). A BMI less than 21 kg/m2 (p < 0.05) and current smoking status (p < 0.05) are associated with increased risk of osteoporosis.

Conclusion: A significant fraction of Filipino men with osteopenia and osteoporosis have prevalent fractures. Our data suggest that fractures may occur in men younger than 70 years old and even at higher bone mineral density before osteoporosis sets in. A low BMI and high OSTA score are consistent risk factors for fracture even in men. Tobacco smoking may be an emerging principal risk factor of osteoporosis especially in men. The threshold for screening and treatment of osteoporosis and associated fractures must be lowered in men contrary to the usual knowledge and practice.

 

Nothing to Disclose: ESRM, LBM

14725 14.0000 MON-0252 A Prevalent Fractures Occur at Relatively Younger Age and Higher Bone Mineral Density Among Adult Filipino Men 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0239-0255 4788 1:00:00 PM Osteoporosis and Metabolic Bone Disease Poster

Clare Leung1, Mark Harris*2, Janet Warner3, Joshua Francis1, Amanda Scott1, Craig Dancer4 and Clare Nourse1
1Mater Children's Hospital, 2Mater Children's Hosp, South Brisbane, Australia, 3Mater Pathology, 4Ipswich Hospital

 

Introduction

Alterations in Vitamin D metabolism are a recognised effect of anti-tuberculosis treatment with rifampicin. This occurs via the induction of CYP3A4, a cytochrome P450 enzyme, which is involved in the catabolism of 25-hydroxyvitamin D and its active metabolite 1,25-hydroxyvitamin D.  The presented case suggests a threshold effect for rifampicin-induced hypovitaminosis D.

Case

A  12 year old boy presented with symptomatic hypocalcaemia (total calcium 1.59 mmol/L , NR 2.15 – 2.70) in association with elevated alkaline phosphatase (820 nmol/L , NR 70-250), increased PTH (39.0 pmol/L, NR 2.0 – 9.5) decreased 25OH Vit D (12 nmol/L, NR 50-150) and inappropriately normal 1,25 (OH)2 Vit D ( 52 nmol/L NR 40 - 150 nmol/L), eight months after commencing anti-tuberculosis therapy. There were no clinical or radiological signs of rickets.  Before commencing treatment and for the first 3 months after treatment with rifampicin and isoniazide was commenced his serum calcium, phosphate and alkaline phosphatase levels were in the normal range.  Review of his biochemistry however revealed a progressive increase in his alkaline phosphatase after his isoniazide was ceased and the rifampicin dose was increased from 300 mg daily to 600 mg daily.  Despite correcting his hypocalcaemia and reducing his rifampicin dose to 300mg daily his 25 OH Vit D level was slow to normalise

Conclusion

With increasing displacement of refugee populations the prevalence of tuberculosis in first world countires is likely to increase.  This paper highlights the potential adverse effects of rifampicin on Vit D metabolism, particularly at higher doses.  Serial monitoring of serum alkaline phosphatase may represent a simple and relatively inexpensive method of identifying individuals at risk of rifampicin-induced hypovitaminosis D.

 

Nothing to Disclose: CL, MH, JW, JF, AS, CD, CN

16505 15.0000 MON-0253 A Symptomatic Hypocalcaemia Secondary to Rifampicin-Induced Hypovitaminosis D 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0239-0255 4788 1:00:00 PM Osteoporosis and Metabolic Bone Disease Poster

Shintaro Yamaguchi*1, Tatsuya Maruyama1, Kazutoshi Miyashita1, Isao Kurihara1, Shu Wakino1, Hirobumi Tokuyama1, Akinori Hashiguchi1, Konosuke Konishi1, Koichi Hayashi1, Matsuhiko Hayashi2 and Hiroshi Itoh1
1School of Medicine, Keio University, Tokyo, Japan, 2Keio University School of Medicine, Tokyo, Japan

 

Background: Primary biliary cirrhosis (PBC) is an immune-mediated chronic cholestatic liver disease, characterized by increased concentrations of serum IgM and the presence of circulating anti-mitochondrial antibodies. Although bone diseases such as osteoporosis or osteodystrophy are commonly associated with PBC, osteomalacia, which is caused by abnormal vitamin D metabolism, is not recognized as a complication of PBC.

Clinical case: We report a case of 49-year-old female who had multiple pathological fractures. On admission, she had difficulty in walking because of strong pains in the hips. Osteomalacia was strongly suspected from the clinical course, hypophosphatemia, low serum level of 1,25-dihydroxyvitamin D3 (11.0 pg/dl) and high bone specific alkaline phosphatase (67.5 IU/l). Bone scintigraphy showed multiple hot spots in joints and ribs, which were compatible with osteomalacia. Arterial blood gas analysis showed metabolic acidosis with a normal anion gap, indicating renal tubular acidosis (RTA). Inappropriate alkaline urine (pH 6.0) indicated distal RTA but the bicarbonate loading test showed bicarbonate wasting, a pattern of proximal RTA (FEHCO3- 13.25%, U-Bpco2 50.1 mmHg). A 24-hour urine analysis showed a low renal fractional tubular reabsorption of phosphate (Tmp/GFR 0.91) and uric acid (FEUA 43.9%), normoglycemic glycosuria (12.83 g/day) and generalized aminoaciduria, resulting in the diagnosis of Fanconi syndrome. A renal biopsy was consistent with features of tubulointerstitial nephritis (TIN). High levels of alkaline phosphatase (663 IU/l), high serum IgM levels (1084 mg/dl) were found in a biochemical examination and the presence of anti-mitochondrial M2 antibody (1:10) indicated PBC. Sequential liver biopsy was compatible with a mild degree of PBC. Taken together, the patient was clinically diagnosed as osteomalacia concomitant with hypophosphatemia, vitamin D deficiency and RTA, which might be caused by TIN with Fanconi syndrome. This view was supported by the evidence that administration of 1,25 dihydroxyvitamin D3, neutral potassium phosphate, sodium bicarbonate for osteomalacia and predonizolone for TIN substantially relieved clinical features of fractures and renal dysfunction of the patient. Interestingly, the patient was accompanied with asymptomatic PBC, which was comfirmed by liver biopsy.

Conclusion: PBC should be sought in adult patients with unexplained osteomalacia caused by tubulointerstitial nephritis with Fanconi syndrome even in the absence of liver dysfunction.

 

Nothing to Disclose: SY, TM, KM, IK, SW, HT, AH, KK, KH, MH, HI

16799 16.0000 MON-0254 A Severe Osteomalacia Caused By Tubulointerstitial Nephritis with Fanconi Syndrome Accompanied with Asymptomotic Primary Biliary Cirrhosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0239-0255 4788 1:00:00 PM Osteoporosis and Metabolic Bone Disease Poster

Thiti Snabboon*1, Natnicha Houngngam2 and Lalita Wattanachanya3
1Chulalongkorn Univ, Bangkok, Thailand, 2Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, Thailand, Bangkok, Thailand, 3Chulalongkorn University

 

Background: Autosomal recessive type of osteogenesis imperfecta (OI) is caused by mutation in the gene encoding the intracellular collagen-modifying complex: cartilage-associated protein (CRTAP), prolyl 3-hydroxylase 1 (LEPRE1) and cyclophilin B (PPIB). The complex is responsible for one step in collagen post-translational modification, the prolyl 3-hydroxylation of specific proline residues at position 986 of type I collagen chains.

Clinical case: A proband, 37-year-old female from a consanguineous family, showed typical manifestations of OI: vertebral deformities, rhizomelia and fractures, deformities of long bones, severe osteoporosis and the presence of Wormian bone.  From the pattern of her inheritance, genetic study was analyzed for the mutation in genes responsible for recessive type of OI: CRTAP, LEPRE1 and PPIB. The defect in type I collagen of the patient was assessed with western blot, tandem mass spectrometry and immunofluorescent study.

Result: A novel homozygous mutation of CRTAP gene, c.1106 delA in exon 6, was identified. Its predicted protein was expected to premature stop codon 10-amino acid downstream. Her dermal fibroblasts showed a 37% decrease in 3-hydroxylation of a1(I)Pro986. In addition, lack of LEPRE1 staining on rER from immunofluorescent study of her primary dermal fibroblast was also demonstrated. With normal quantitative analysis and the expected deletion part located on the tail of the CRTAP protein, these may correspond with the less phenotypic severity of the patient.

Conclusion: Our study showed an unusual manifestation of the recessive type of OI with less severe than expected. Genotype and phenotype correlation of the prolyl 3-hydroxylation complex was proposed.

 

Nothing to Disclose: TS, NH, LW

16613 17.0000 MON-0255 A Functional Study of a Novel Mutation in Crtap Gene Causing Recessive Osteogenesis Imperfecta 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Monday, June 23rd 3:00:00 PM MON 0239-0255 4788 1:00:00 PM Osteoporosis and Metabolic Bone Disease Poster

Tetsurou Satoh*1, Satoshi Yoshino1, Masanobu Yamada2, Koshi Hashimoto1, Takuya Tomaru1, Akiko Katano-Toki1, Shuichi Okada1, Atsushi Ozawa1, Sumiyasu Ishii1, Kazuhiko Horiguchi1, Nobuyuki Shibusawa1, Tsutomu Sasaki3, Tadahiro Kitamura3 and Masatomo Mori4
1Gunma University Graduate School of Medicine, Maebashi, Japan, 2Gunma University, Graduate School of Medicine, Japan, 3Institute for Molecular and Cellular Regulation, Gunma University, Maebashi, Japan, 4Kitakanto Molecular Novel Research Institute for Obesity and Metabolism, Midori, Japan

 

Obesity arises from impairment of energy balance, which is centrally coordinated by an adipokine, leptin through activating the long form of leptin receptor (Leprb).  Obesity causes so-called central leptin resistance; however, whether enhanced peripheral leptin sensitivity could overcome central leptin resistance remains obscure.  A peripheral metabolic organ targeted by leptin is the liver with low Leprb expression.  We here show that mice fed a high-fat diet (HFD) and obese patients with non-alcoholic hepatosteatosis exhibit increased expression of hepatic Helz2 (helicase with zinc finger2) also known as PRIC285/PDIP1, which functions as a transcriptional coregulator for several nuclear receptors including peroxisome proliferator-activated receptorγ in vitro (1, 2).  To explore physiological importance of Helz2, we generated Helz2-deficient mice and analyzed their metabolic phenotypes.  Helz2-deficient mice showing hyperleptinemia associated with central leptin resistance are protected against HFD-induced obesity without altering food intake or locomoter activities and significantly upregulates hepatic Leprb expression.  Helz2-deficiency and adenovirus-mediated liver-specific exogenous Leprb overexpression in wild-type mice significantly stimulated hepatic AMP-activated protein kinase (AMPK) on HFD, whereas Helz2-deficient db/db mice lacking functional Leprb did not.  Fatty acid β oxidation was increased in Helz2-deficeint hepatocytes and Helz2-deficient mice revealed increased oxygen consumption and decreased respiratory quatinent in indirect calorimetry analyses.  The enhanced hepatic AMPK energy-sensing pathway in Helz2-deficeint mice ameliorates hyperlipidemia, hepatosteatosis and insulin resistance by reducing lipogenic gene expression and stimulating lipid burning gene expression.  These findings together demonstrate that Helz2-deficiency ameliorates HD-induced metabolic abnormalities by stimulating endogenous hepatic Leprb expression, despite central leptin resistance.  Hepatic HELZ2 might be a novel target molecule for the treatment of obesity with hepatosteatosis.

 

Nothing to Disclose: TS, SY, MY, KH, TT, AK, SO, AO, SI, KH, NS, TS, TK, MM

13715 1.0000 MON-0838 A Protection Against High-Fat Diet Induced Obesity in Helz2-Deficient Male Mice Due to Enhanced Expression of Hepatic Leptin Receptof 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0838-0849 4792 1:00:00 PM Lipid Biology and Disease- Basic and Translational Aspects Poster

Dean Paul Larner*1, Stuart Andrew Morgan1, Laura Louise Gathercole1, Jeremy W Tomlinson1, Paul M Stewart2 and Gareth Geoffrey Lavery1
1University of Birmingham, Birmingham, United Kingdom, 2University of Leeds, Leeds, United Kingdom

 

Non-alcoholic fatty liver disease (NAFLD) is characterised by intra-hepatocyte lipid accumulation in the absence of excessive alcohol consumption. Simple steatosis is a reversible condition; however progression to irreversible non-alcoholic steatohepatitis (NASH- characterised by inflammatory infiltrate) and ultimately cirrhosis is a major health burden. Glucocorticoid (GC) reactivation through the activity of the enzyme 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) may promote hepatic lipid accumulation and contribute to the potential to develop steatosis. To test this, 11β-HSD1 global KO (GKO), hepatocyte-specific KO (LKO) and C57BL/6 control mice (n=12) were fed the American life style induced obesity syndrome (ALIOS) diet, known to induce a metabolic syndrome including progression from NAFLD to NASH, for 16 weeks. No differences were found between the groups for a number of metabolic parameters including bodyweight, fasting glucose and insulin; and glucose and insulin tolerance. Neither was any change seen in the expression of genes involved in hepatic lipid metabolism.

Liver weights were no different between groups, with H&E stained sections blind scored for the degree of steatosis (0-absent, 3-severe) giving an average score of 1.8 for control, 2.3 for GKO and 1.9 for LKO liver, with liver triglyceride similar for each group. Thus, rather than being protected from steatosis, GKO and LKO mice have the same degree of hepatic lipid accumulation. We reasoned that 11β-HSD1 could mediate hepatic inflammation in NASH through modulation of local GC availability. We assessed the expression of inflammatory/fibrosis markers and show highly significant increases in hepatic mRNA for Tnfa (P<0.001), Col1a1 (P<0.01) and Fsp1 (P<0.001) only in GKOs. Histological analysis revealed an increased score for the presence of inflammatory foci, with 87 % of GKOs exhibiting >2 inflammatory foci per field of view, compared with 30 % in LKO and controls (p<0.01).

Finally, the elevated expression of Mac2 (p<0.002) and Ccl2 (p<0.05) suggests exaggerated macrophage cell activation and infiltration in GKO but not LKO or control liver, possibly as LKO and control mice retain normal macrophage and immune cell 11β-HSD1 activity. Together these data show that global depletion of 11β-HSD1 does not protect from ALIOS induced metabolic disease and steatosis and leads to accelerated progression to NASH through unrestrained immune cell activation and infiltration.

 

Nothing to Disclose: DPL, SAM, LLG, JWT, PMS, GGL

16026 2.0000 MON-0839 A Accelerated Progression to Steatohepatitis in 11â-Hydroxysteroid Dehydrogenase Type 1 Knockout Mice Fed a Steatogenic Diet 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0838-0849 4792 1:00:00 PM Lipid Biology and Disease- Basic and Translational Aspects Poster

Elahu Gosney Sustarsic*1, Maximilian Bielohuby1, Riia Karoliina Sustarsic1, Ayse Zengin1, Amon Horngacher2, Sarina Benedix1 and Martin Bidlingmaier3
1Medizinische Klinik und Poliklinik IV, Munich, Germany, 2Klinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany, 3Klinikum der Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany

 

Obesity and metabolic syndrome are frequently accompanied by non-alcoholic fatty liver disease (NAFLD). In Western countries, 20-40% of the general population is estimated to have NAFLD, and this number will increase as obesity and diabetes become more common. The influence of dietary components on fat accumulation in the liver are not completely understood. Low carbohydrate diets are frequently used as a weight-loss intervention and are also effectively utilized in the treatment of refractory epilepsy. Here, we investigated how changing the protein content of a low carbohydrate, high fat (LC-HF) diet affects liver steatosis. Male Wistar rats were placed on soy-based LC-HF diets at 12 weeks of age (n=5 rats per group). Rats were pair-fed daily based on the ad-libitum calorie consumption of the chow-fed animals. The normal protein diet was composed of 78.8% fat, 19.1% protein and 2.2% carbohydrate (LC-HF-NP) while the low protein diet was 92.8% fat, 5.5% protein 1.7% carbohydrate (LC-HF-LP). After four weeks, animals were sacrificed and livers were collected. Frozen livers were sectioned into 12 µM slices which were stained with Oil Red O in order to visualize lipids. During the study, the LC-HF-LP rats gained less weight compared to chow rats (21.3 g vs. 52.5 g; P<0.001), while weight gain in LC-HF-NP animals (39.9 g) was not significantly different. Chow-fed rats had a fasting glucose of 104.3 mg/dl while LC-HF-NP rats had a level of 95.9 mg/dl; LC-HF-LP rats, with 66.5 mg/dl, had significantly lower glucose than either group (P<0.01). Neigher absolute nor relative liver weights were different between diets. Based on the intensity of Oil Red O staining, LC-HF-LP fed rats exhibited severe intrahepatic lipid accumulation. On the other hand, livers from LC-HF-NP rats showed low levels of lipid staining. Similar results were obtained with rats fed beef-based diets that differed from the soy diets only in the source of dietary fat. Our findings suggest that the macronutrient composition of low carbohydrate diets can be an important determinant of liver fat accumulation. Future studies should further investigate the role of dietary protein and carbohydrate content on NAFLD in the context of high fat diets.

 

Nothing to Disclose: EGS, MB, RKS, AZ, AH, SB, MB

16947 3.0000 MON-0840 A The Amount of Protein in Low Carbohydrate High Fat Diets Determines the Effect on Lipid Accumulation in the Liver 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0838-0849 4792 1:00:00 PM Lipid Biology and Disease- Basic and Translational Aspects Poster

Melanie Penke1, Jonas Thue Treebak2, Susanne Schuster1, Theresa Gorski1, Antje Garten1 and Wieland Kiess*3
1University of Leipzig, Faculty of Medicine, Leipzig, Germany, 2University of Copenhagen, 3University of Leipzig, Dept. of Women´s & Child Health, Leipzig, Germany

 

Objective: Animal and human studies have shown that Nicotinamide phosphoribosyltransferase (NAMPT), the key enzyme of mammalian NAD biosynthesis from nicotinamide, is modified in non-alcoholic fatty liver disease. By regulating intracellular NAD levels NAMPT is thought to play important roles for cellular metabolism especially by regulating Sirtuins (NAD dependent deacetylases) which also play an important role in fatty acid metabolism. Here we investigated the effect of a high fat diet on hepatic NAD metabolism in mice.

Results: Mice fed a HFD gained weight (29.9±2.5 vs. 39.0±4.2g), store more hepatic triglycerides compared to chow fed animals and showed a significant impaired glucose tolerance. Acetylation status of p53 and phosphorylation status of eIF2α was decreased (-67.4% and -27.9%, respectively) as well as total protein level of Bax and Caspase3 (-63.1% and -43.0%, respectively) in mice fed a HFD compared to control mice. Nampt mRNA (2.0fold) and protein levels (2.2fold), Nampt activity (41.4±14.1 vs. 65.8±19.5 cpm/total proteinxh) and intracellular NAD concentration (1.6fold) were significantly higher in HFD compared with chow fed mice. Protein level of Sirt1 was up regulated, while mRNA expression level of Sirt1 and Sirt3 stayed stable.

Conclusion: HFD mice showed lower levels of marker for ER stress and apoptosis if fed a HFD for 11 weeks. This could be mediated by the „Nampt-Sirt1-p53“.Increasing Nampt (mRNA, protein, activity) and NAD levels resulting in an higher activity of Sirt1 which decreases acetylation status of p53 and thereby down regulates Bax and Caspase3.

 

Nothing to Disclose: MP, JTT, SS, TG, AG, WK

13747 4.0000 MON-0841 A Hepatic NAD Metabolism Is Dysregulated By an Excessive Supply of Lipids 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0838-0849 4792 1:00:00 PM Lipid Biology and Disease- Basic and Translational Aspects Poster

Hyun-Hwa Son*1, In-Hyuk Chung2, Abhimanyu Garg3, Bong Chul Chung1, Eun-Gyong Yoo4 and Man-Ho Choi1
1KIST, Seoul, Korea, Republic of (South), 2CHA University, Sungnam, Korea, Republic of (South), 3Univ Texas Southwest Med Ctr, Dallas, TX, 4College of Medicine, CHA University, Sungnam, Korea, Republic of (South)

 

Sitosterolemia is a rare autosomal recessive disorder characterized by increased plant sterol levels and accelerated atherosclerosis. The diagnosis is usually missed for lack of availability of clinical laboratories which can measure blood phytosterols. Early detection in childhood should prevent sequelae of the disease such as atherosclerotic vascular disease as well as anemia and thrombocytopenias. A gas chromatography-mass spectrometry (GC-MS)-based analysis have been developed to measure 20 sterols, including cholesterol and its metabolites as well as phytosterols, from a dried blood spot (DBS), which can be used for early diagnosis of sitosterolemia in childhood. It offers small and simple collection/storage and easier transfer, with a good stability, over conventional blood sampling. The optimized analytical conditions led to good chromatographic selectivity with a symmetric peak shape for all circulating sterols. The limit of quantification is 0.01~0.2 µg/mL for most sterols analyzed except for cholesterol and its fatty acid esters (0.1~50 µg/mL), while the precision (% CV) and accuracy (% bias) ranges from 1.4 to 16.4% and from 81.8 to 128.4%, respectively. We measured blood sterol levels in patients with sitosterolemia and healthy children after obtaining written informed consent from the parents. The ratios of sitosterol to cholesterol were 0.216 and 0.263 in two patients (5- and 7-year-old girls) with sitosterolemia harboring compound heterozygous disease-causing mutations in ABCG5, compared to 0.005±0.001 (mean±SD, n=23) in the healthy girls, age 5 to 12 years (P<0.0001 with a non-parametric Mann-Whitney U-test). Then, the method was applied to a 10-year-old hypercholesterolemic girl with 347 mg/dL total-cholesterol, which was normalized by low- fat/low-cholesterol diet (166 mg/dL). She had significantly increased serum level of sitosterol (14.93 mg/dL), against 0.08±0.05 mg/dL in the healthy girls (n=93), and the ratio of sitosterol/cholesterol in a DBS was 0.198. She was finally diagnosed as a new patient with sitosterolemia. As an alternative, the ratio of sitosterol/desmosterol was also increased (>25-folds, P<0.0001) in patients with sitosterolemia. We conclude that this novel GC-MS method for measuring blood sterols can be used for screening of sitosterolemia in young children especially those presenting with hypercholesterolemia. Further study in establishing the reference values of both relative concentrations and metabolic ratios of various blood sterols from this method are in progress.

 

Nothing to Disclose: HHS, IHC, AG, BCC, EGY, MHC

13388 5.0000 MON-0842 A A Novel GC-MS-Based Profiling of Sterols from a Dried Blood Spot for Diagnosis of Sitosterolemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0838-0849 4792 1:00:00 PM Lipid Biology and Disease- Basic and Translational Aspects Poster

Yisheng Yang*1, Chuanqi Chen2, Benny Chang1, Lan Li1, Mark W Sleeman3 and Lawrence C Chan4
1Baylor College of Medicine, Houston, TX, 2Shenzhen Shekou People's Hospital, Shenzhen, China, 3Monash University, Victoria, Australia, 4Baylor Coll of Med, Houston, TX

 

Lipid droplet proteins (LDPs) decorate LDs in essentially every tissue in the body. The 5-membered PAT family LDPs PLIN1-5 share sequence similarities, but individual PLINs have distinct functions. The action of Plin1 is well studied, but the actions/functions of the other Plins remain poorly understood. We previously showed that loss of Plin2 markedly reduces hepatic triglyceride (TG) and prevents fatty liver in mice. Plin3 was shown to replace Plin2 on LDs when Plin2 is missing. We have produced Plin3-knockout mice; they display improved fasting glucose and glucose tolerance with normal insulin sensitivity. Prolonged (48h) fasting elevates hepatic TG, downregulates VLDL secretion and plasma TG in Plin3-KO mice. Furthermore, the mice display marked increased PLIN2, PLIN5, ATGL and CGI-58 on hepatic LDs via a mostly posttranscriptional mechanism; the elevated PLIN5 interacts with ATGL, suppressing lipolysis. We conclude that PLIN3 and PLIN3/2 ratio modulate hepatic lipid homeostasis via PAT family proteins and their interactions with other PLINs and lipolysis-related enzymes/factors. The PAT LDPs are potential targets for the treatment of diabetes and fatty liver disease.

 

Nothing to Disclose: YY, CC, BC, LL, MWS, LCC

14718 6.0000 MON-0843 A Role of Lipid Droplet Proteins Plin2 and Plin3 in Glucose Homeostasis and Hepatosteatosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0838-0849 4792 1:00:00 PM Lipid Biology and Disease- Basic and Translational Aspects Poster

Melanie Marie Thomas*1, Michael John Haas2, Luisa M. Onstead-Haas1, Anna Szafran-Swietlik3, Hagop Kojanian4, Tim Davis5, Paul Armstrong5, Norman C W Wong6 and Arshag D Mooradian1
1University of Florida, Jacksonville, FL, 2Univ of Florida, Jacksonville, FL, 3University of FL, Jacksonville, FL, 4UF Shands Jacksonville, Jacksonville, FL, 5Biotechnology Laboratory Technology, Florida State College of Jacksonville, 6Univ of Calgary, Calgary, AB, Canada

 

Background. 

Phytochemicals such as flavonoids, vitamins, and polyphenols have been shown to have beneficial effects in metabolic disease. To determine if select flavonoids regulate hepatic apolipoprotein A-I (apo A-I) and high-density lipoprotein (HDL) synthesis, we examined the effects of quercetin, isoquercetin, and myrescetin on apo A-I gene expression in HepG2(hepatocytes) and Caco-2 (intestinal) cells.

Methods. 

Apo A-I gene expression was measured by Western blotting, quantitative reverse-transcription polymerase chain reaction, and transient transfection. Estrogen receptor  (ESR1)and estrogen receptor  expression were measured by Western blotting, and ESR1 expression was inhibited using ESR1-specific short inhibitory RNA (siRNA).

Results. 

Quercetin and isoquercetin, but not myrecetin, induced apo A-I protein and mRNA synthesis, and induced apo A-I promoter activity. Induction by quercetin required an estrogen-responsive region of the apo A-I promoter. Addition of estrogen receptor blocker ICI-182780 to quercetin-treated cells inhibited the effects of quercetin on apo A-I gene expression. Down-regulation of ESR1 with ESR1 siRNA had no effect on basal apo A-I gene expression, however it prevented quercetin-mediated induction of apo A-I gene expression.

Conclusions. 

We conclude that quercetin induces apo A-I gene expression at least in part through induction of ESR1 and may be useful in treating hypoalphalipoproteinemia.

 

Nothing to Disclose: MMT, MJH, LMO, AS, HK, TD, PA, NCWW, ADM

11471 7.0000 MON-0844 A Induction of Hepatic Apolipoprotein a-I Gene Expression By the Isoflavones Quercetin and Isoquercetrin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0838-0849 4792 1:00:00 PM Lipid Biology and Disease- Basic and Translational Aspects Poster

Su Hyeon Lee1, Eung Ju Kim2, John Kevin Leach3, Won-Yong Lee4, Bong Chul Chung1, Hong Seog Seo2 and Man-Ho Choi*1
1KIST, Seoul, Korea, Republic of (South), 2Korea University Guro Hospital, Seoul, Korea, Republic of (South), 3Shire Pharaceuticals, Lexington, MA, 4Yonsei University, Seoul, Korea, Republic of (South)

 

Statins reduce low-density lipoprotein cholesterol in the mevalonate pathway. Of the pleiotropic effects in statins, the anti-inflammations have been concerned with additional benefits of the clinical outcomes preventing cardiovascular events. Eicosanoids are oxygenated metabolites of membrane-released arachidonic acid through the cyclooxygenase (COX), lipoxygenase (LOX), cytochrome P450 ω-hydroxylase (CYP ω-hydroxylase) and non-enzymatic free radicals. In contrast to the conventional circulating inflammation markers, evaluating the broad spectrum of lipid signaling mediators may give better understanding the biological functions of inflammation. A liquid chromatography-mass spectrometry (LC-MS)-based metabolic profiling in the liver microsomal S9 fractions have been developed to measure 33 eicosanoids to allow “in vitro eicosanoid signatures”. The limit of quantification is 0.5~20 ng/mg proteins, while the precision (% CV) and accuracy (% bias) ranges from 4.7 to 10.8% and from 88.4 to 110.9%, respectively. Eicosanoid signatures resulted in the COX metabolites were increased in inflammation-induced model rabbits against the control rabbits, whereas 20-HETE catalyzed by CYP ω-hydroxylase was significantly decreased. Then, five statins, such as simvastatin, pravastatin, mevastatin, atorvastatin and rosuvastatin, have been evaluated their anti-inflammatory effects on eicosanoid metabolism from the liver S9 fractions obtained from the model rabbits. All statins showed no significant alterations in eicosanoids catalyzed by COXs and LOXs, but simvastatin increased 20-HETE significantly (9.33- and 11.85-folds in response to 50 and 100 μM treatments, respectively; P<0.001). Statins induce cytochrome P450 4F2 and 4F3 mRNA, protein and gene expression in human liver and may control lipid metabolism through 20-HETE-dependent activation of peroxisome proliferator activated receptor-α (PPAR-α). Because 20-HETE could be a PPAR activator, statins might be considered as PPAR ligands in fat-dependent energy and lipid metabolisms related to CYP enzymes. The  devised method shows a new insight of anti-inflammation mechanism of statins and could be a useful tool for evaluation of drug efficacies and physiological changes in inflammation.

 

Nothing to Disclose: SHL, EJK, JKL, WYL, BCC, HSS, MHC

13396 8.0000 MON-0845 A Mevalonate Pathway-Independent Anti-Inflammations of Statins Evaluated By a Novel in-Vitro Quantitaive Eicosanoid Signature 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0838-0849 4792 1:00:00 PM Lipid Biology and Disease- Basic and Translational Aspects Poster

William Kurban*1, Hagop Kojanian2, Anna Szafran-Swietlik3, Luisa M Onstead-haas4, Michael John Haas5 and Arshag D Mooradian6
1University of Florida College of Medicine-Jacksonville, Jacksonville, FL, 2UF Shands, Jacksonville, FL, 3University of FL, Jacksonville, FL, 4University of Florida College of Medicine-jacksonville, 5Univ of Florida, Jacksonville, FL, 6University of Florida, Jacksonville, FL

 

Background. Statins have favorable effects on endothelial function partly because of their capacity to reduce oxidative stress. However, antioxidant vitamins, unlike statins, are not as cardio-protective and this paradox has been explained by failure of vitamin antioxidants to ameliorate endoplasmic reticulum (ER) stress.

Methods. To determine if statins prevent dextrose-induced ER stress in addition to their anti-oxidative effects, human umbilical vein endothelial cells (HUVEC) and HepG2 hepatocytes were treated with 27.5 mM dextrose in the presence of simvastatin (lipophilic statin that is a pro drug) and pravastatin (water-soluble active drug) and oxidative stress, ER stress, and cell death were measured. Superoxide (SO) generation was measured using 2-methyl-6-(4-methoxyphenyl)-3,7-dihydroimidazo[1,2-A]pyrazin-3-one hydrochloride. ER stress was measured using the placental alkaline phosphatase assay and Western blot of glucose-regulated protein 75, c-jun-N-terminal kinase, phospho-JNK, eukaryotic initiating factor 2a and phospho-eIF2a, and X-box binding protein 1 mRNA splicing. Cell viability was measured by propidium iodide staining.

Results. Superoxide anion production, ER stress, and cell death induced by 27.5 mM dextrose was inhibited by therapeutic concentrations of simvastatin and pravastatin.

Conclusions. The salutary effects of statins on endothelial cells in reducing both ER stress and oxidative stress observed with pravastatin and the pro-drug simvastatin suggest that the effects may be independent of cholesterol lowering activity.

 

Nothing to Disclose: WK, HK, AS, LMO, MJH, ADM

11388 9.0000 MON-0846 A Statins Prevent Dextrose-Induced Endoplasmic Reticulum Stress and Oxidative Stress in Endothelial and HepG2 Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0838-0849 4792 1:00:00 PM Lipid Biology and Disease- Basic and Translational Aspects Poster

Colette N Miller*1, Jeong-Yeh Yang1, Tucker Avra1, Suresh Ambati1, Natalie M Hohos1, Diane L Hartzell1, Emily Rose England1, Mary Anne Della-Fera1, Srujana Rayalam2 and Clifton A Baile1
1University of Georgia, Athens, GA, 2Philadelphia College of Osteopathic Medicine, Suwanee, GA

 

Non-alcoholic fatty liver disease (NAFLD) is characterized by the two-hit theory which involves accumulation of hepatic lipid (hit 1) and lipotoxicity which damages the liver (hit 2). Some anti-obesity compounds that promote lipolysis of adipose stores result in increased hepatic lipid storage and subsequent hepatic damage. Because of this, it is imperative that anti-obesity compounds be tested for their effects in the liver. Phytochemicals like resveratrol (R) have demonstrated anti-obesity effects by regulating the adipocyte lifecycle and causing lipolysis in mature adipocytes. Furthermore, such compounds are often anti-inflammatory and may prevent lipotoxic effects. In the current study, ovariectomized (OVX) rats were fed diets containing varying doses of phytochemicals (diet 1: 1000 mg/kg genistein (G); diet 2: 500 mg/kg G, 200 mg/kg R, and 1000 mg/kg quercetin (Q); diet 3: 1000 mg/kg G, 400 mg/kg R, and 2000 mg/kg Q). After 16 weeks, rats were euthanized and various adipose depots and the liver was removed and weighed. Hepatic and adipose tissue lipid and triglycerides were extracted and assayed. To be expected OVX resulted in a significant increase in retroperitoneal lipid content which was reversed with phytochemical treatment (p<0.05). Total hepatic lipid and triglycerides were also increased with diets 2 and 3 compared to all other groups (p<0.05). To confirm that phytochemical treatment increased lipid mobilization to the liver, serum free fatty acid was measured and found to be significantly increased in diets 2 and 3 (p<0.10). Hepatic apoptotic and fibrotic gene expression was then measured to assess if the increased hepatic lipid resulted in liver damage. Phytochemical treatment did not produce increases in caspase 2, BCL-2 binding component 3, or osteonectin gene expression. Serum alanine amino-transferase was also not significantly increased in the high dose phytochemical treatment (diet 3). In summary, phytochemical blends that have anti-obesity effects appear to not cause adverse events in the liver. Such compounds may not only help with weight management, but may also be effective in preventing downstream hepatic lipotoxicity in those with NAFLD.

 

Nothing to Disclose: CNM, JYY, TA, SA, NMH, DLH, ERE, MAD, SR, CAB

14765 10.0000 MON-0847 A Efficacy of a Dietary Phytochemical Blend on Preventing Lipid-Induced Hepatotoxicity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0838-0849 4792 1:00:00 PM Lipid Biology and Disease- Basic and Translational Aspects Poster

Keita Tatsushima*1, Masatoshi Nomura1, Miki Hiasa2, Nobuyuki Sudo1, Yoshinori Moriyama2 and Ryoichi Takayanagi1
1Kyushu University, Fukuoka, Japan, 2Okayama University, Okayama, Japan

 

While nucleotides are well known for their important role in intracellular energy metabolism, it is now established that they also play a role as extracellular signaling molecules to promote a purinergic signaling response. Therefore, extracellular nucleotide levels, mainly controlled by cellular secretion, are important to maintain cellular homeostasis. Recently we have identified SLC17A9 as a vesicular nucleotide transporter (VNUT) with an essential role for exocytosis in regulated release of ATP. Chronic hyperglycemia in insulin resistance in known to increase the risk of cardiovascular disease and to be associated with dyslipidemia. High blood glucose is also known to stimulate the release of ATP into the extracellular space from several cell types such as endothelial cell, mesangial cells, macrophages and pancreatic beta cells. However, whether hepatocytes release ATP in response to glucose and extracellular ATP affect hepatic lipid metabolism in the liver is poorly understood. In this study, we therefore investigated the role of VNUT in the liver with the mice deficient for VNUT (VNUT-/- mice). Re-feeding after 18 h fasting resulted in dramatic increase of the serum triglyceride level in control mice, while no increase was found in VNUT-/- mice. Triglyceride level after tyloxapol, an inhibitor for lipoprotein lipase, injection was also suppressed in VNUT-/- mice, indicating that VNUT is required for postprandial secretion of triglyceride by the liver. Consequently, the hepatic content of triglyceride in VNUT-/- mice was higher than that in control mice after re-feeding. It is noted that ATP release was observed in primary cultured hepatocytes from control mice after glucose stimulation, while this ATP release was completely cancelled by the lack of VNUT in hepatocytes. Interestingly, histological analysis revealed that hepatic inflammation assessed by F4/80 staining was less severe in VNUT-/- mice. Our results suggest that hepatocyte VNUT-dependent ATP exocytosis is an indispensable process that control postprandial TG secretion and thus lipid homeostasis.

 

Nothing to Disclose: KT, MN, MH, NS, YM, RT

15546 11.0000 MON-0848 A Vesicular Nucleotide Transporter (VNUT) Is Crucial for Lipid Secretion and Metabolism in the Liver Though Exocytosis of ATP 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0838-0849 4792 1:00:00 PM Lipid Biology and Disease- Basic and Translational Aspects Poster

Ram Prakash Narayanan*1, Adrian H Heald2, William ER Ollier3 and J Martin Gibson2
1University of Liverpool, Liverpool, United Kingdom, 2The University of Manchester, Salford, United Kingdom, 3Centre for Integrated Genomic Medical Research, Manchester, United Kingdom

 

High IGF-II and IGFBP-2 have been associated with longitudinal increases in HDL cholesterol in a type 2 diabetes population. We wished to study associations of genes coding for IGF-I, IGF-II and four IGF binding protein genes (IGFBP1, IGFBP2, IGFBP3 and IGFBP5) with longitudinal HDL cholesterol trends in 991 Caucasian subjects from Salford with type 2 diabetes.

Sixteen IGF1, fifteen IGF2, nine IGFBP1, four IGFBP2, ten IGFBP3 and eight IGFBP5  SNPs were successfully genotyped. Longitudinal HDL cholesterol data for the years 2002 to 2009 was obtained from integrated primary care and hospital electronic medical records. Mixed effects regression analyses were used to study SNPs as predictors of HDL cholesterol in models adjusted for age, gender, time duration and prescription of statins or fibrates.

IGF1 rs6214, IGF2 rs7924316 and IGFBP1 rs2471550 were associated with longitudinal increases in HDL cholesterol, while IGFBP1 rs12702181, IGFBP5 rs1978345 and IGFBP5 rs2241193 were associated with decreases in HDL cholesterol over the study duration. When all the significantly associated proteins were taken together in a stepwise regression model along with age, gender and the earlier medications as covariates, associations for four SNPs – IGFBP1 rs2471550 (β 0.014, 95% CI 0.010 to 0.018, p<0.001), IGFBP5 (β -0.007, 95% CI -0.011 to -0.003, p<0.001), IGFBP1 (β 0.006, 95% CI 0.003 to 0.01, p<0.001) and IGFBP5 (β -0.007, 95% CI -0.012 to -0.001, p=0.008) retained significance.Results will need replication in an independent cohort with type 2 diabetes.

Variants in genes encoding IGF binding proteins appear to influence HDL cholesterol measurements. Levels of IGF binding proteins play an important role in determining bioavailability and tissue action of IGF-I and IGF-II, and uncovering the pathophysiology of these IGF binding proteins in the vasculature may assist our understanding and management of individual cardiovascular risk.

 

Nothing to Disclose: RPN, AHH, WEO, JMG

12261 12.0000 MON-0849 A Genes Encoding IGF Binding Proteins Influence Longitudinal Trends in HDL Cholesterol in Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0838-0849 4792 1:00:00 PM Lipid Biology and Disease- Basic and Translational Aspects Poster

Kazutaka Nanba* and William E. Rainey
University of Michigan, Ann Arbor, MI

 

Context: There is growing evidence that chronic inappropriate elevations in circulating aldosterone cause renal, cardiovascular, and other pathologic complications. Adrenal production of aldosterone relies acutely on increased expression of steroidogenic acute regulator protein (StAR) while the overall capacity to produce aldosterone relies on aldosterone synthase (CYP11B2). In normal physiology, both StAR and CYP11B2 are tightly regulated by circulating K+ and the renin-angiotensin II (Ang II) system. Both Ang II and K+ share calcium signaling as a key regulator of aldosterone production. Despite the important role of calcium signaling, there have been no studies to date that investigate the role played by Ca2+/calmodulin-dependent protein kinase kinase (CaMKK) in adrenal cells.

Objective: In this study we investigated the role of CaMKK in adrenal cell aldosterone production.

Methods: To determine the role of CaMKK, we used a CaMKK inhibitor (STO-609) in the HAC15 human adrenal cell line. Cells were treated with aldosterone agonists (Ang II 10nM and K+ 18mM). We then evaluated expression of StAR (mRNA/protein) and CYP11B2 (mRNA/protein) as well as aldosterone production using quantitative RT-PCR, western blotting, and radioimmunoassay, respectively. Several time points were used for mRNA/protein experiments (6h for StAR mRNA, 8h for StAR protein, 24h for CYP11B2 mRNA/protein) and aldosterone assay (24h).

Results: Ang II and K+ significantly increased mRNA levels for StAR and CYP11B2 as well as aldosterone (p<0.001 versus basal). Both Ang II and K+ also increased protein levels for StAR and CYP11B2 in western analysis. STO-609 inhibited aldosterone production in cells treated with Ang II in dose-dependent manner (inhibitory rate; 7-83% at 0.3-30µM). There was no cell toxicity found for inhibitors at these concentrations. STO-609 (20μM) also significantly inhibited StAR [inhibition rate; 36% versus Ang II (p<0.001), 32% versus K+ (p<0.001)] and CYP11B2 [inhibition rate; 64% versus AngII (p<0.001) and 42% versus K+ (p<0.001)] induction in mRNA as well as aldosterone [inhibition rate; 63% versus Ang II (p<0.001); 42% versus K+ (p<0.001)]. STO-609 also inhibited protein levels for StAR and CYP11B2.

Conclusion: In the present study, blockade of CaMKK inhibited Ang II and K+ stimulation of StAR, CYP11B2, and aldosterone production, suggesting that CaMKK plays a pivotal role in the calcium signaling cascade regulating acute and chronic production of aldosterone.

 

Nothing to Disclose: KN, WER

12909 1.0000 MON-0850 A Role of Ca2+/Calmodulin-Dependent Protein Kinase Kinase (CaMKK) in Acute and Chronic Aldosterone Production 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Junhua Zhou*1, Elena AB Azizan1, Sudeshna G Neogi2, Ian McFarlane2, Lalarukh Haris Shaikh1, Ada ED Teo1, Cheryl A. Brighton1, Carmela Maniero1, Matthew H. Brandorff1 and Morris Jonathan Brown1
1University of Cambridge, Cambridge, United Kingdom, 2Genomics CoreLab, Cambridge National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), Cambridge, United Kingdom

 

Common somatic mutations in CACNAID and ATP1A1 may define a sub-group of smaller, zona glomerulosa (ZG)-like aldosterone producing adenomas (APAs).1 We have therefore sought signature ‘ZG-genes’ which may provide insight to the frequency and pathogenesis of ZG-like APAs. A microarray was performed of 14 trios of ZF, ZG and APAs, and 7 pairs of ZF and ZG adjacent to phaeochromocytoma. RNA was extracted by laser capture microdissection. Validation by qPCR and immunohistochemistry (IHC) was performed of the genes most up-regulated in ZG vs ZF.  Their exome sequence was examined in germline and APAs of 10 patients, and mutated genes were selected for further study. Their regulation of aldosterone production and apoptosis was assessed in H295R cells using ON-TARGETplus siRNA, overexpression, and TUNEL assay. Three genes (LGR5, VSNL1, ANO4) were >20-fold more abundant in ZG than ZF (P<10-23), and four >10-fold (NEFM, VCAN, DACH1, NR4A2). All have been confirmed as highly ZG-selective by qPCR and IHC, whether adjacent to an APA or phaeo. By contrast, CYP11B2 expression was reduced next to APAs, and patchy or absent in all ZGs on IHC. DACH1, a cell fate determination factor, was the only up-regulated gene to have a common, germline variant – a 5’ glycine-repeat deletion – not reported on the NIH server of 8000 exomes. Its expression was 14.4 fold higher in ZG than ZF (P=1.4×10-21) and 3.0 higher in ZG than APA (P=2.2×10-7); on qPCR the fold-changes were 30.3 and 4.1, respectively. On IHC, there was dense nuclear staining of ZG in all 13 adrenals, which was weak or absent in APAs. Western blot supported IHC. Knockdown of DACH1 RNA and protein in Si-DACH1 cells was associated with a 1.5-fold increase in aldosterone secretion compared to Si-non-targeting cells (P=1.0x10-9). Reversely, DACH1 overexpression reduced secretion by 2.4-fold (P=4.2x10-6); this was partially attributable to a 5.9-fold increase in apoptotic cells (P=0.008, background corrected data). In conclusion, several unexpected genes are markedly over-expressed in human ZG. Interestingly, there was no overlap between our top 50 ZG-genes and those in rodent ZG.2 We postulate that [i] inhibition of aldosterone secretion by DACH1, and patchy expression of CYP11B2, reflects human over-exposure to salt; [ii] increased cell-turnover or migration gives selective advantage to somatic mutations which restore constitutive aldosterone synthesis; [iii] a pro-apoptotic role of up-regulated human ZG-genes contributes to the small size of ZG-like APAs.

 

Nothing to Disclose: JZ, EAA, SGN, IM, LH, AET, CAB, CM, MHB, MJB

13282 2.0000 MON-0851 A Microarray and Exome Sequencing Reveals Dach1 As an Inhibitor of Aldosterone Production in Humans: Do Inhibitory up-Regulated Zona Glomerulosa Genes Contribute to the Frequency of Aldosterone Producing Adenomas? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Louise Diver1, Scott MacKenzie1, Frances McManus1, E. Marie Freel1, Elaine Friel1, Samantha Alvarez-Madrazo1, Robert Fraser1, Neil Anthony Hanley2, John Muir Connell3 and Eleanor Davies*1
1University of Glasgow, Glasgow, United Kingdom, 2Univ of Manchester, Manchester, United Kingdom, 3University of Dundee, Dundee, United Kingdom

 

Recent genome-wide association studies (GWAS) implicate the CYP17A1 locus in human blood pressure regulation. This gene is important to steroidogenesis, regulating both glucocorticoid and androgen synthesis through catalysis of 17α-hydroxylation and 17,20 lyase reactions. We hypothesised that functional polymorphisms exist at this locus, influencing blood pressure. The aims of this study were to screen the entire CYP17A1 locus by direct sequencing, identify possible functional variants by in vitro analysis and genotype associations with intermediate corticosteroid phenotype in a hypertensive cohort. 

A detailed examination of variation across the CYP17A1 locus was completed in a normotensive cohort of 62 subjects, establishing patterns of linkage disequilibrium and the corresponding haplotypes. Variants located in the 5′ regulatory region were prioritised for further investigation. Bioinformatic analysis coupled with in vitroreporter gene assays confirmed that single base changes at three polymorphic sites each altered transcriptional activity. These data provide strong evidence that common variation at this locus is of functional significance. 

The association between genotype and intermediate corticosteroid phenotype was explored using 24–hour urinary metabolite excretion data from a cohort of 232 hypertensive subjects. Production of corticosterone, cortisol and androgens was not significantly altered in the population when stratified by genotype for each polymorphism. However, following stratification by gender, increased cortisol excretion rates were found to associate with the minor allele at rs248658 in males (p=0.05) and at rs2150927 in females (p=0.04). Furthermore, ratios of selected corticosteroid intermediate metabolites (e.g. THDOC:THS) were significantly reduced in the presence of the rs2150927 minor allele, in a manner indicative of increased 17α-hydroxylase efficiency (p=0.02). Aldosterone excretion was significantly elevated in individuals with CC genotype at rs138009835 (p=0.05); we propose an indirect genotype-dependent effect. 

In conclusion, this study identifies CYP17A1 polymorphisms that are co-inherited alongside one previously reported by GWAS as being associated with a significant rise in systolic blood pressure. Furthermore, it provides evidence that these variants alter transcriptional activity at this locus and that they associate with corticosteroid intermediate phenotypes in a hypertensive population. This implies functional effect and a mechanism for the development of hypertension. Further studies will investigate whether the observed changes in transcriptional activity result from altered transcription factor binding at polymorphic sites. 

We gratefully acknowledge the contribution of the BRIGHT investigators.

 

Nothing to Disclose: LD, SM, FM, EMF, EF, SA, RF, NAH, JMC, ED

14807 3.0000 MON-0852 A The CYP17A1 Gene in Hypertension: Linking GWAS to Function 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Koshiro Nishimoto*1, Tsugio Seki2, Kazutaka Nanba3 and William E. Rainey3
1University of Michigan, MI, 2Georgia Regents University, Augusta, GA, 3University of Michigan, Ann Arbor, MI

 

Aldosterone controls sodium homeostasis, and its physiological production in the adrenal zona glomerulosa (zG) is tightly controlled by the renin-angiotensin-aldosterone-system. However, in ~8% of hypertensive patients, aldosterone is autonomously produced due to idiopathic hyperaldosteronism or aldosterone-producing adenoma (APA). There is considerable evidence that calcium signaling in zG cells play a key role in aldosterone regulation and that its defects are a major cause of hyperaldosteronism. Hence, we hypothesized that Ca2+ channel genes selectively expressed in the zG are regulators of aldosterone synthesis. To identify the zG-dominant Ca2+ channel genes, we laser-captured zG and zona fasciculata (zF) cells from 5 normal human adrenal glands, and the RNA from each zone was analyzed with microarray. Among the number of genes up-regulated in the zG, CACNB2 was the highest up-regulated Ca2+ channel gene (zG/zF 5.5-fold, p<0.001). CACNB2 qPCR using laser-captured RNA (n=4 each) showed 8.0 [5.8–11.1] (mean [± SE range]) -fold higher expression in the zG than zF (p<0.001). Immunohistochemical (IHC) analysis of CACNB2 revealed its zG-specific expression in human adrenal cortex. Intriguingly, IHC analyses also showed strong CACNB2 staining in APA. In order to study CACNB2 function, a lentiviral shRNA that decreased CACNB2 mRNA expression by 70.4 % [70.2-70.5] (mean [±SEM]) was utilized in HAC15 adrenal cells. Under the basal condition, 24h-cumulative aldosterone production was 59% lower in the CACNB2 knockdown (KD) cells than those with scrambled (Scr) shRNA (157.3 ± 30.6 vs. 385.1 ± 42.4 pM, p<0.01). Under angiotensin II (AngII) stimulation, the aldosterone production was 41% lower in the KD cells than the Scr cells (3205.2 ± 106.8 vs. 5407.4 ± 565.9 pM, p<0.05). Interestingly, under potassium stimulation, aldosterone production was notably inhibited (79%) in the KD cells (593.4±36.3 pM vs. 2793.7±363.6, p<0.001). Under these conditions, a preliminary qPCR study showed attenuation of aldosterone synthase (CYP11B2) expression in the KD cells: 23% lower compared to the Scr cells in basal condition (p=0.21), 34% lower in AngII (p<0.01), and 74% lower in K+ (p<0.0001). These results suggest that CACNB2 plays an important role in aldosterone production, especially under K+ stimulation, and that CACNB2 may be a new target for the excess aldosterone synthesis in APA.

 

Nothing to Disclose: KN, TS, KN, WER

16312 4.0000 MON-0853 A The β2 Voltage-Dependent Calcium Channel (CACNB2): Its Potential Function in Aldosterone Production 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Mutsa Patience Seremwe and Wendy B Bollag*
Charlie Norwood VA Medical Center, Augusta, GA

 

Aberrant production of aldosterone, a steroid hormone important in the regulation of blood pressure, results in the development and/or progression of diseases such as hypertension and congestive heart failure. Angiotensin II (AngII) regulates aldosterone production, in part through its ability to increase intracellular calcium levels. Calcium can activate calpains, proteases classified as typical or atypical based on the presence or absence of penta-EF-hands. Calpains are involved in various cellular responses including cytoskeletal rearrangement and AngII signaling through the AngII type 1 receptor. We hypothesized that calpain plays a role in AngII-stimulated aldosterone production in a zona glomerulosa model, adrenocortical carcinoma (HAC15) cells. Our previous results showed that AngII induced calpain activation in HAC15 cells; in addition, the pan-calpain inhibitors, calpeptin and MDL 28170, inhibited AngII-induced aldosterone production and CYP11B2 expression in these cells. To further investigate the role of calpain in AngII-induced aldosterone production, HAC15 cells were treated with additional inhibitors in the presence and absence of AngII or were transduced with calpain-expressing adenovirus. Aldosterone secretion into the media was then monitored by radioimmunoassay and steroidogenic enzyme expression by quantitative RT-PCR. The typical (classical) calpain inhibitors PD-150606 and calpastatin peptide had no effect on AngII-elicited aldosterone production, suggesting a lack of involvement of a classical calpain in this process. The atypical calpains expressed by HAC15 cells include calpain 5, 7, 10 and 15. Indeed, the calpain-10 inhibitor, CYGAK inhibited both AngII-induced aldosterone production and CYP11B2 expression. Consistent with this result, overexpression of calpain 10 induced an increase in aldosterone production in the presence and absence of AngII.  Our results suggest that AngII-induced activation of calpain 10 in HAC15 cells underlies, at least in part, aldosterone production. Our results identify calpain 10 as a potential target for the development of drug therapies to inhibit aldosterone production for the treatment of hypertension.

 

Nothing to Disclose: MPS, WBB

16474 5.0000 MON-0854 A The Atypical Calpain, Calpain 10 Underlies Angiotensin II-Induced Aldosterone Production in an Adrenal Glomerulosa Cell Model 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Michaela Kuhn*1, Franziska Werner2, Heike Oberwinkler2, Baktybek Kojonazarov3, Ralph Schermuly3, Birgit Gaßner2 and Katharina Völker2
1University of Würzburg, Würzburg, Germany, 2Physiology, University of Würzburg, Würzburg, Germany, 32Department of Internal Medicine, University of Gießen and Marburg Lung Center (UGMLC), Gießen, Germany

 

Rationale. Atrial natriuretic peptide (ANP) modulates arterial blood pressure by activation of the receptor guanylyl cyclase-A (GC-A) and intracellular cGMP formation. In mice, global deletion of the GC-A gene provokes marked pulmonary hypertension (PH), emphasizing that ANP has a critical role not only in the systemic but also in the pulmonary circulation.

Objectives. To dissect the vascular cell type(s) mediating the protective effects of ANP in the pulmonary circulation, we studied genetic mouse models with conditional, selective deletion of GC-A either in vascular smooth muscle cells or in endothelia. The pathophysiological relevance of GC-A dysfunction in idiopathic PAH was elucidated by studying lung GC-A responses to ANP in patient biopsies.

Methods. Cardiovascular studies in genetic mouse models were combined with functional and biochemical experiments in cultured lung endothelial cells and human lung tissues.

Measurements and main results. Remarkably, smooth muscle deletion of GC-A completely abolished the pulmonary vasodilating effects of ANP but did not cause PH. In contrast, endothelial GC-A deletion preserved ANP pulmonary vasodilatation but provoked chronic PH, with enhanced muscularization of small arteries, arteriolar rarefaction and mild perivascular inflammation. This was associated with right ventricular hypertrophy and dysfunction. In vitro, ANP/GC-A activated proangiogenic pathways and regeneration of murine microvascular lung EC. Of note, pulmonary GC-A/cGMP responsiveness to ANP was attenuated in PAH patients.

Conclusions. ANP, via GC-A/cGMP signaling, modulates the proliferation of pulmonary endothelial cells and their crosstalk with smooth muscle and inflammatory cells. Endothelial ANP/cGMP dysfunction may have a critical role in the pathogenesis of PAH.

 

Nothing to Disclose: MK, FW, HO, BK, RS, BG, KV

16928 6.0000 MON-0855 A Role of Natriuretic Peptides in Pulmonary Hypertension 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Ada ED Teo*1, Elena AB Azizan1, Lalarukh Haris Shaikh1, Junhua Zhou1, Diane Walters2, Sudeshna G Neogi3, Ian McFarlane3 and Morris J Brown1
1University of Cambridge, Cambridge, United Kingdom, 2Tissue Bank, Cambridge, United Kingdom, 3Genomics CoreLab, Cambridge National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), Cambridge, United Kingdom

 

Adrenal zona glomerulosa (ZG) is the principal site of physiological aldoster­one production, but most classical aldosterone-producing adenomas (APA) paradoxically resemble cells of the cortisol-secreting zona fasciculata (ZF). Our finding of common gain-of-function mutations in a distinct group of smaller APAs resembling small ZG cells (1) prompted the questions whether these tumors originate from normal adrenal ZG, and the process of tumorigenesis differs between ZG- and ZF-like APAs. In order to define ZG-specific genes, we undertook microarray analysis comparing normal adrenocortical ZG with ZF using laser capture microdissection. This showed several putative ZG genes, upregulated many-fold in ZG vs. ZF. A second microarray was therefore performed comparing 5 ZG-like APAs with mutations in CACNA1D or ATP1A1, to 8 ZF-like APAs with mutations in KCNJ5. For proof of concept that the genes upregulated in ZG–like APAs indicate a ZG origin, gene expression was validated by quantitative PCR (qPCR) and immunohistochemistry. Microarray analysis identified 43 genes differentially expressed in ZG-like APAs, with >2-fold greater expression than ZF-like APAs, and false discovery rate <0.5%. The top gene was Nephronectin (NPNT) (x12.2 on microarray, p= 2.97E-08), a secreted matrix protein, recently reported to regulate cell migration and invasion in malignant melanoma (2). Microarray results also showed NPNT to be almost entirely down-regulated in the ZG of adrenals adjacent to an APA. qPCR confirmed that NPNT was 25.3-fold more highly expressed in normal ZG vs ZF (P=0.0001) and 29.9-fold upregulated in ZG-like vs ZF-like APAs (P=0.00034). It was also highly expressed by H295R cells from an adrenocortical carcinoma cell-line. At protein level, immunohistochemistry showed highly selective staining of ZG, and confirmed that NPNT was more abundant in ZG-like than ZF-like tumors. NPNT staining outlined the glomerular ‘rotundules’ in all cases. Phenotypically and genotypically-distinct from ZF-like APAs, small NPNT-rich APAs probably resolve the paradox of the ‘missing’ APAs of ZG-origin. It appears that NPNT staining differentiates ZG-from ZF-like APAs. Its striking peri-glomerular distribution, and high H295R expression, point to an extracellular protein secreted by glandular cells, whose role may be to facilitate clustering of these cells into functional units for aldosterone secretion. When aldosterone is not required (e.g. in the negative feedback from an APA), we postulate that switch-off of NPNT accelerates centripetal cell migration from ZG to ZF as a mechanism for reducing aldosterone production.

 

Nothing to Disclose: AET, EAA, LH, JZ, DW, SGN, IM, MJB

13461 7.0000 MON-0856 A Highly Selective Expression of Nephronectin (NPNT) Delineates a Common Subtype of Aldosterone-Producing Adenomas of Zona Glomerulosa Origin, and a Putative Role in Aldosterone Production 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Gabi Shefer*1, Yonit Marcus2, Ester Knoll3, Rona Limor3, Stav Brown4, Pazit Zadicario5 and Naftali Stern6
1Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel, 2Tel Aviv Medical Center, Tal Aviv, Israel, 3Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, 4Tel-Aviv University, Israel, 5Tel Aviv University, Tel Aviv, Israel, 6Tel Aviv Medical Center, Tel Aviv, Israel

 

Background: Angiotensin 1-7 (Ang1-7) antagonized many of the cardiovascular effects of Angiotensin II (AngII). We recently reported that Ang1-7 attenuates the increase in circulating renin and aldosterone induced in a rat model of metabolic-syndrome. Whether or not the reduction in aldosterone was indirect, operating through a decrease in renin remained unclear.

Objective: To study the effect of Ang1-7 administration in-vivo on the renin and aldosterone response to salt restriction in rats.

Methods: Rats were fed on either normal chow or low salt diet (Teklad Rat Diet 7034 Harlan) for one week, during which either vehicle or Ang1-7 was continuously infused through Alzet pumps (576 µg/kg/day, s.c.; n=6-7/group). Blood was drawn for plasma renin concentration and aldosterone prior to the subdivision to dietary intervention and by the end of the experiment, following which animals were then euthanized to harvest the kidneys. Renal slices were prepared to assess ex-vivo renin release. Since rodents have low circulating angiotensinogen, all renin assays were carried in media enriched with plasma from 24h nepherctomized rats.

Results:  In rats fed on regular chow, Ang1-7 infusion had no effect on either plasma aldosterone or plasma renin activity (PRA). In rats fed on a low salt diet, aldosterone increased from 10±5 to 27±8ng/dl (p<0.002), but this increase was attenuated by Ang1-7 infusion (16±4.7ng/dl; p=0.02). PRA rose by 50-70% in salt restricted rats, which was not modified by Ang1-7 infusion. Renin secretion was higher in renal slices prepared from salt-deprived rats compared with rats fed on normal chow (p=0.003) and was increased in renal slices from Ang1-7 treated rats (p<0.012). Finally, Mas, Ang1-7 receptor, was expressed in the adrenal cortex but not in the medulla, and Ang1-7 reduced the aldosterone response to AngII in zona-glomerulosa cells from normal rats.

Conclusion: This is the first report showing that Ang1-7 is a negative modulator of the aldosterone response to salt deprivation, acting independent of the renin. Rather, this effect is apparently exerted via Mas receptors expressed in the adrenal cortex, through which Ang1-7 reduces the stimulatory effect of AngII on aldosterone secretion.

 

Nothing to Disclose: GS, YM, EK, RL, SB, PZ, NS

13342 8.0000 MON-0857 A Angiotensin 1-7 Is a Novel Regulator of Aldostertone Secretion and a Modulator of the Aldosterone Response to Salt Restriction 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Cristian A Carvajal*1, Alejandra Tapia1, Araceli Vidal1, Carolina Valdivia1, Carmen Campino1, Carlos F Lagos1, Andrea Vecchiola1, Cristobal A Fuentes1, Alejandro Martínez-Aguayo1, Marlene Aglony2, Hernan Garcia Bruce2, Simonetta Friso3, Oliviero Olivieri4 and Carlos E Fardella1
1Pontificia Universidad Catolica de Chile, Santiago, Chile, 2Pontificia Universidad Católica de Chile, Santiago, Chile, 3University of Verona School of Medicine, Verona, Italy, 4University of Verona, Verona, Italy

 

The expression and activity of 11beta-hydroxysteroid-dehydrogenase type 2 (11BHSD2) can be affected by mutations, polymorphisms (SNPs) (1) and epigenetic modifications. SNPs in HSD11B2 promoter may impair its normal activity in vivo, which could be estimated by serum or urinary cortisol to cortisone ratio (F/E). 

Aim: To study the presence of SNPs in HSD11B2 promoter and its impact in HSD11B2 RNA expression and functional activity in vivo.

Subjects and Methods: We studied 105 subjects, 50 children (<16 years-old) and 55 adults (16-65 years old). We excluded patients with primary aldosteronism and pBMI >99. We measured plasma renin activity (PRA), serum aldosterone and urinary F and E. We obtained RNA and DNA from peripheral blood mononuclear cells  (PBMC) and amplified the HSD11B2 proximal promoter (NG_016549). To identify polymorphisms (SNP) we did PCR-HRM and either Pyro- or Sanger-sequencing. We analyzed eleven SNPs in HSD11B2 proximal promoter (rs72649084, rs72649085, rs72649086, rs7264908, rs72649088, rs72649089, rs72649090, rs45622839, rs72649091, rs45598932 (G-209A), rs56057545 (G-126A)). Moreover, in a subset of patients (n=22, 16 WT and 6 SNP) we assayed the HSD11B2 and U6 mRNA expression in PBMC by RT-qPCR. Data are expressed as median[Q1-Q3]  and analyzed by Mann-Whitney in Prism v5.0.

Results:We successfully amplified and sequenced eleven SNPs in HSD11B2 proximal promoter. Only heterozygous alterations were observed in two SNPs: rs45598932 (G-209A) and rs56057545 (G-126A). We identified these SNPs in 9/105 subjects:  G-209A (4/105, 3.8%) and G-126A (5/105, 4.7%). No alternative homozygous subjects were detected. The HSD11B2 RNA expression analyses showed a lower expression in subjects carrying the SNPs than native (0.37[0.14-1.08] vs. 1.26[1.0-5.4] AU, p 0.04).  The overall comparison between subjects with and without SNPs did not shown differences in biochemical parameters studied. However, in pediatric subjects carrying the SNPs (n=5/50), we found a trend to higher urinary F/E ratio (0.41[0.32-0.57] vs. 0.30[0.23-0.43], p 0.08). In adults carrying the SNPs (n=4/55) this trend was not observed.

Conclusions: The HSD11B2 promoter polymorphisms, G-209A and G-126A, showed a minor allele frequency (MAF) of 3.8% and 4.7%, respectively. Their MAF were similar to the already reported in NCBI (2.4% and 4.8%). Subjects carrying these SNPs showed a lower mRNA expression of HSD11B2 promoter than those with native promoter, which could affect the activity of 11BHSD2 in vivo, especially in pediatric subjects.

 

Nothing to Disclose: CAC, AT, AV, CV, CC, CFL, AV, CAF, AM, MA, HG, SF, OO, CEF

14523 9.0000 MON-0858 A 11Beta-Hydroxysteroid Dehydrogenase Type2 Promoter Polymorphisms Determines a Decreased HSD11B2 Expression in Vivo 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Elena AB Azizan*1, Ada ED Teo1, Catherine B Xie1, Lalarukh Haris Shaikh1, Junhua Zhou1, Sumedha Garg1, Wanfeng Zhou2, Soosung Kang3, Richard B Silverman3 and Morris Jonathan Brown1
1University of Cambridge, Cambridge, United Kingdom, 2Human Research Tissue Bank, Cambridge, United Kingdom, 3Northwestern University, Illinois

 

Aldosterone-producing adenomas (APAs) vary in clinical presentation and genotype. We found that zona glomerulosa (ZG)-like APAs frequently have gain-of-function mutations of an L-type calcium channel (LTCC) CaV1.3 (1). We have now determined whether CaV1.3 is a ZG-selective LTCC, and investigated the role of CaV1.3 on steroidogenesis. We used a novel, >600-fold selective antagonist of CaV1.3, Compound 8 (C8) (2), which we compared to the antihypertensive drug nifedipine, a dihydropyridine (DHP) with 4.5 selectivity for the vascular LTCC, CaV1.2. Localization of CaV1.3 in human adrenals was determined using immunohistochemistry (IHC). Drug effects were tested in the human adrenocortical cell line, H295R, and both tumor and adjacent normal adrenal cells from 4 patients with APAs. These were treated for 24h with C8, nifedipine or pregabalin (an antagonist of the auxiliary α2δ subunit of all LTCCs). Concentration of corticosteroids and expression of steroidogenic genes were measured. IHC identified CaV1.3 in APAs and in ZG (aldosterone-producing) cells of normal adrenal. In primary normal adrenal cells, only C8 inhibited steroid production: aldosterone to 79+4 and 58+4 % of basal, at 10 and 100 uM; cortisol to 72+1 and 50+4 % of basal, p<0.05. Nifedipine 1 uM increased aldosterone by 25+4% (p=0.00003) and decreased aldosterone only to 91+4 % at 100 uM, p=0.04, nifedipine 10 uM increased cortisol by 17+6%, p=0.02. By contrast, in APA cells, both C8 and nifedipine, 1-100 uM, decreased aldosterone to a max of 53+3 and 58+8 %, respectively, p<0.005. Similarly, in H295R cells, both C8 and nifedipine, 1-100 uM, decreased aldosterone secretion (p<0.05). The reductions in secretion were not due to reduced transcription of CYP11B1 or CYP11B2. Pregabalin 1-1000 nM did not affect aldosterone or cortisol secretion from normal adrenal, but at 1 and 100 nM increased aldosterone secretion from H295R cells by 41+5 and 38+8 % respectively (p<0.01). This study shows that selective CaV1.3 blockade, by C8, consistently decreased steroid secretion from both normal and tumor-derived adrenal cells, whereas blockade of other LTCC subunits has no effect on, or increases, secretion from normal adrenal. Activation or mutation of CaV1.3 in tumor cells may increase its sensitivity to nifedipine. Selective CaV1.3 blockade may offer a novel way of treating primary hyperaldosteronism, which avoids the common CaV1.2-mediated ankle-edema of non-selective DHP calcium blockers.

 

Nothing to Disclose: EAA, AET, CBX, LH, JZ, SG, WZ, SK, RBS, MJB

11316 10.0000 MON-0859 A Common Somatic Mutations in CaV1.3, Adrenal Immunohistochemistry, and Inhibition of Aldosterone Secretion By CaV1.3 Blockade, Indicate a Zona Glomerulosa-like Subset of Aldosterone-Producing Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Andrea Vecchiola*1, Mariana Cifuentes2, Cristobal A Fuentes1, Carlos F Lagos1, Carolina P Valdivia1, Alejandra Tapia1, Carmen Campino1, Fidel Allende1, Sandra Solari1, Carmen A Carrasco1, Alejandro Martínez-Aguayo1, Clarita Ferrada3, Carolina Mendoza3, Hernan Garcia Bruce3, Cristian A Carvajal1, Alexis Kalergis3 and Carlos E Fardella1
1Pontificia Universidad Catolica de Chile, Santiago, Chile, 2Universidad de Chile, Santiago, Chile, 3Pontificia Universidad Católica de Chile, Santiago, Chile

 

The mineralocorticoid receptor (MR) plays a crucial role in the regulation of Na(+) balance and blood pressure. Unliganded MR is located in the cytosol as a multiprotein complex including heat shock protein 90 (Hsp90) and 70 (Hsp70). Recent evidence supports a role of inflammation and immunity in hypertension development. Molecules suggested to elicit immune responses include oxidized LDL and HSPs, which are endogenous ligands of Toll-like receptors (TLRs). Hsp70 has various immunogenic epitopes that induce T cells with anti-inflammatory properties. However, the precise role of heat shock proteins in hypertension remains to be defined.

AIM:To assess if mineralocorticoid markers of hypertension are associated to Hsp70, Hsp90, TLR-2, TLR-4 and CD-14 mRNA expression in humans.

METHODS: We studied 239 subjects (9-67 years, BMI 26.8 ± 5.1 kg/m2, 61% female). Aldosterone (ng/dL), plasma renin activity (PRA, ng/mL*h), cortisol (ug/dL), high-sensitivity C-reactive protein (hsCRP, mg/L), creatinine (mg/dL), total cholesterol (CHOL-T), CHOL-HDL(mg/dL), CHOL-LDL(mg/dL) were measured in blood samples. We isolated RNA from peripheral blood mononuclear cells (PBMC) and evaluated Hsp70, Hsp90, TLR-2, TLR-4 and CD-14 mRNA expression by q-RT-PCR. Aldosterone-plasma renin activity ratio (ARR) was calculated. Data were analyzed by Spearman correlations.

RESULTS: Hsp70 mRNA was associated to PRA (r=0.1607, p 0.0256), and inversely with ARR (r=-0.1692, p=0.0187), CHOL-LDL (r=-0.1618, p=0.0246); Hsp90 correlated inversely with CHOL-LDL (r=-0.1654, p=0.0348) and show a tendency with PRA (r=0.1473, p 0.06); TLR-4 correlated inversely with ARR (r=-0.2096, p=0.0023), CHOL-T (r=-0.1872, p=0.0066) and CHOL-LDL (r=-0.208, p=0.0025); TLR-2 correlated inversely with CHOL-LDL (r=-0.166, p=0.0365) and CD-14, correlated inversely with creatininemia (r=-0.1451, p=0.0494) and showed a negative tendency with ARR (r=-0.1269, p 0.0835). Aldosterone, cortisol and hsCRP did not correlates with these molecules.

CONCLUSIONS: Hsp70, TLR-4 and CD-14 mRNA expression correlated with plasma mineralocorticoid variables and its expression could contribute in hypertensive condition.

 

Nothing to Disclose: AV, MC, CAF, CFL, CPV, AT, CC, FA, SS, CAC, AM, CF, CM, HG, CAC, AK, CEF

15537 11.0000 MON-0860 A Mineralocorticoid Markers of Hypertension Are Associated with Immune Signaling Molecules 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Yoshiyu Takeda*1, Takashi Yoneda2, Masashi Demura2, Shigehiro Karashima2, Mitsuhiro Kometani2, Fen Wang2, Yuan Cheng2 and Masashi Ohe2
1Kanazawa Univ Sch of Med, Ishikawa, Japan, 2Kanazawa University, Kanazawa, Japan

 

Objective: DNA methylation is a fundamental epigenetic silencing mechanism. 11Beta-hydroxysteroid dehydrogenase 1 (11beta-HSD1) is the key enzyme of metabolic syndrome. The epigenetic control of 11beta-HSD1 is not unclear. We examined the 11beta-HSD1 mRNA levels and the methylation status of 11beta-HSD1 gene promoter region in the adipose tissue of Cushing’s syndrome.

Methods: Five adipose tissues of Cushing’s syndrome (Cu), 7 ones of aldosterone-producing adenomas (APAs) and 5 of non-functioning adrenal adenomas (NFA) were used. Cushing’s syndrome and APA were diagnosed according to the guideline of Japanese Endocrine Society. The expression levels of 11beta-HSD1 mRNA were quantified using a real time PCR. Isolated DNA was treated with bisulfite and amplified using primers specific for the human 11beta-HSD1 promoter region.

Results: 11Beta-HSD1 mRNA levels were significantly increased in the adipose tissues of Cu compared with those of APA or NFA (p<0.05). The methylation status was lower in Cu compared with APA or NFA.

Conclusion:  These results may suggest that 11beta-HSD1 gene expression is controlled by the epigenetic mechanism in human tissues. The pathophysiological significance of epigenetic control of 11beta-HSD1 gene in the adipose tissue should be further studied.

 

Nothing to Disclose: YT, TY, MD, SK, MK, FW, YC, MO

15968 12.0000 MON-0861 A Epigenetic Control of 11beta-Hydroxysteroid Dehydrogenase 1 in the Adipose Tissue of Cushing's Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Alejandra Tapia*1, Cristian A Carvajal1, Carmen Campino1, Caroline Hill2, Andrea Vecchiola1, Carmen A Carrasco1, Cristobal A Fuentes1, Rodrigo Bancalari1, Carolina Valdivia1, Carlos F Lagos1, Alejandro Martínez-Aguayo1, Hernan Garcia Bruce3, Marlene Aglony3 and Carlos E Fardella1
1Pontificia Universidad Catolica de Chile, Santiago, Chile, 2Pontificia Universidad Catolica de Chile, 3Pontificia Universidad Católica de Chile, Santiago, Chile

 

The responsiveness of blood pressure to sodium (Na) intake differs among individuals and are classified as salt-sensitive (SS) and salt-resistant (SR). Recently, the Rac1 GTPase has been implicated in SS-hypertension as modulator of the mineralocorticoid receptor (MR) activity [1]. Rac1 could affect expression markers of oxidative stress such as hemoxigenase-1 (HO-1) or NFKB, and regulate the release of cytokine dependent MR as NGAL, which have been shown in patients with renal failure.

Aim: To evaluate salt sensitive based in RAC1 expression in adults subjects, assessing the effect of high salt intake on the RNA expression of RAC1, RAC1b (constitutively active isoform), MR, NGAL, HO-1 and NFKB beside to associations with biochemical parameters.

Subjects and methods: We studied 146 subjects (16-60 years-old). A food survey was conducted to determine the intake of Na/day with a cutoff <5g salt/day, according WHO 2013 recommendation. RNA was isolated from peripheral leukocytes. The gene expression was quantified by RT-qPCR and expressed in relative units (RU). We determined an upper cutoff for RAC1 expression based in normotensive subjects with low salt intake. We identified 20 subjects with low Na intake and 126 subjects with high Na intake. In this group, 18 subjects have high RAC1 expression and 108 have low RAC1 expression, which were defined SS and SR subjects respectively. We measured aldosterone, plasma renin activity (PRA), urinary sodium excretion. Data were expressed as median [Q1-Q3] and compared with Mann Whitney test.

Results: The expression analysis in SS vs SR subjects showed increase in MR (5.5[2.3-13.2] vs 0.8[0.1-3.0] RU; p 0.02), NGAL (19.1[5.3-29.4] vs 2.2[0.7-8.2] RU; p<0.0001), HO1 (17.1[4.9-25.9] vs 1.0[0.3-2.8] RU; p<0.0001) and NFKB (16.7[10.6-23.1] vs 2.1[0.6-5.1] RU; p<0.0001). Furthermore, the PRA was lower in SR compared to SS-subjects (1.2[0.6- 1.7] vs 1.7[0.9- 2.7] ng/ml*hr; p 0.02). RAC1b expression was inversely associated to urinary sodium excretion (mEq/24h) (r -0.3; p 0.006) in SR-subjects.

 

Conclusions: The RAC1 expression is a useful tool to identify SS-subjects. The SS subjects showed a high expression of mineralocorticoid related genes and oxidative stress. Our results suggest that in SS subjects, the salt beside to induce hypertension may lead endothelial damage and oxidative stress through activation of MR.

 

Nothing to Disclose: AT, CAC, CC, CH, AV, CAC, CAF, RB, CV, CFL, AM, HG, MA, CEF

14661 13.0000 MON-0862 A RAC1 Expression a Possible New Biomarker of Salt-Sensitive Hypertension 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Carolina P Valdivia*1, Cristian A Carvajal1, Fidel Allende1, Carmen Campino1, Andrea Vecchiola1, Carlos F Lagos1, Cristobal A Fuentes1, Alejandra Tapia1, Carmen A Carrasco1, Sandra Solari1, Marlene Aglony2, Alejandro Martínez-Aguayo1, Rene Baudrand1, Clarita Ferrada2, Carolina A Loureiro1, Araceli Vidal1, Carolina Mendoza2, Rodrigo Bancalari1, Alexis Kalergis2, Gareth Ivor Owen1 and Carlos E Fardella1
1Pontificia Universidad Catolica de Chile, Santiago, Chile, 2Pontificia Universidad Católica de Chile, Santiago, Chile

 

Endocrine hypertension can be caused by a deficit in the cortisol (F) to cortisone (E) converting enzyme (11β-HSD2). In vitro studies have demonstrated that the RNA in exosomes is proportional to the RNA content of the producing cell (1). Exosomes are nanovesicles (40-100 nm), formed by an invagination of the cell membrane and subsequent exocytosis (2). Urinary exosomes are secreted into the urine by all cell types in contact with the urinary space (3,4), making them a potential tool for noninvasive diagnosis. Currently there no reports of HSD11B2 mRNA in exosomes from human urine.

Objective: Determine if HSD11B2 mRNA is present in urine exosomes, and to evaluate whether F/E ratio in urine correlates with the levels of HSD11B2 mRNA in human urinary exosomes. 

Method: Total 24-hour urine samples and morning urinary voiding (UV) (7am-9am) was collected. Both samples were obtained from the same 5 adult subjects. F and E were measured by HPLC-MS/MS and F/E ratio calculated. Urinary exosomes were obtained from: total 24-hour sample and from morning UV by ultracentrifugation (26ml of each sample) with a protocol previously validate by observation of urinary exosomes in electron microscopy. Total RNA was extracted by phenol-chloroform protocol, cDNA was prepared from total RNA and quantified by qPCR (SyberGreen). The expression of HSD11B2 gene was evaluated by delta-CT formula respect to 18S gene. The data were expressed as median[Q1-Q3] and analyzed by Spearman correlation.

Results: mRNA of HSD11B2 was detected and quantified from human urinary exosomes (24h and morning UV). Levels of HSDS11B2 mRNA from 24-hour urine isolated exosomes were 1568[526.3-7433] and from morning UV exosomes were 5759[4389-7536]. 24H Urinary F/E ratio was similar to morning F/E ratio 0.69[0.48-0.79] and 0.77[0.54-1.19], respectively. No correlation was found between mRNA HSD11B2 exosome levels and the F/E ratio, in urine 24h r: -0.700, p=0.233, n=5 nor in morning UV r: 0.300, p=0.683, n=5. However, we detected a potential difference between gender: 2 men presented higher levels of RNA-HSD11B2 than women but similar F/E ratio in morning UV samples.

Conclusions: We detected mRNA-HSD11B2 from urine exosomes in human samples. However, in our cohort of 5 subjects, we found no correlation between RNA-exosome levels and F/E ratio. A larger cohort is necessary to determine if a correlation between RNA-HSD11B2 levels and F/E in urine samples exists.

 

Nothing to Disclose: CPV, CAC, FA, CC, AV, CFL, CAF, AT, CAC, SS, MA, AM, RB, CF, CAL, AV, CM, RB, AK, GIO, CEF

15112 14.0000 MON-0863 A Detection of HSD11B2 mRNA from Human Urinary Exosomes and Its Potencial Association with the Enzyme Activity Indicator in Vivo 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Naotaka Kogure1, Ken Matsuda2, Akira Uruno3, Kaori Sugawara1, Ikuko Sato1, Kyoko Shimizu1, Rehana Parvin1, Takeo Yoshikawa3, Masataka Kudo2, Akiko Saito-Hakoda1, Ryo Ito1, Atsushi Yokoyama1, Sadayoshi Ito2 and Akira Sugawara*1
1Tohoku Univ Grad School of Med, Sendai, Japan, 2Tohoku University Hospital, Sendai, Japan, 3Tohoku Univ Grad School of Med

 

Purpose: Aldosterone synthase gene (CYP11B2) is the key enzyme of adrenal aldosterone production. We here examined the effects of high-glucose on CYP11B2 expression using human adrenal H295R cells and a stable H295R cell line expressing CYP11B25’-flanking region/luciferase cDNA chimeric construct (1).

Methods: H295R cells were incubated with several concentrations of D-glucose. The cellular osmolarity was adjusted by L-glucose. mRNA expression of CYP11B2 and transcription factors was determined by real-time PCR. Aldosterone secretion to the media was measured by EIA. Intracellular Ca2+concentration was measured using Calcium Kit-Fluo4.

Results: D-glucose dose- and time-dependently stimulated CYP11B2 transcription. High concentrations of D-glucose also stimulated CYP11B2 mRNA expression, aldosterone secretion, and intracellular Ca2+ concentration. Moreover, high-glucose stimulated the expression of transcription factors NGFIB and NURR1. Transient transfection experiments using CYP11B2 5’-flanking region deletion mutants revealed the possible involvement of NBRE-1 element that is transactivated by NGFIB and NURR1. The high-glucose stimulated CYP11B2 transcription was not affected by angiotensin II receptor blockers treatment, but was abrogated by treatment with KN-93, a Ca2+/calmodulin-dependent kinase (CaMK) inhibitor. The high-glucose stimulated CYP11B2 transcription was also suppressed by T/L-type Ca2+ channel blockers treatment. Interestingly, high-glucose stimulated the mRNA expression of T-type Ca2+ channel subunits.

Conclusions: High-glucose was demonstrated to stimulate CYP11B2 transcription possibly via the T-type Ca2+ channel-mediated CaMK-dependent NBRE-1 element activation. Our observation may give us the clue for the elucidation of the link between hypertension and diabetes mellitus.

 

Nothing to Disclose: NK, KM, AU, KS, IS, KS, RP, TY, MK, AS, RI, AY, SI, AS

16731 15.0000 MON-0864 A High-Glucose Stimulates Aldosterone Synthase Gene (CYP11B2) Expression Via the Induction of T-Type Calcium Channels in H295R Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Chris J Charles*, David L Jardine, Miriam T Rademaker and A Mark Richards
University of Otago, Christchurch, New Zealand

 

In cardiovascular disease, circulating and tissue levels of angiotensin II (Ang II) are increased, which, either via peripheral actions and/or actions on circumventricular organs, may increase sympathetic outflow. It is well established that stimulation of AT1 receptors in the brain has potent actions on the sympathetic nervous system. Less clear is whether peripheral Ang II can directly stimulate sympathetic nerve activity (SNA). In addition, to date there is little information on the effects of Ang II on sympathetic traffic directed specifically to the heart, namely cardiac SNA (CSNA). Thus, we have examined the effect of systemic administration of Ang II on CSNA hypothesising that infusion of Ang II at physiologically relevant doses will raise sympathetic traffic directed to the heart. Eight conscious sheep previously implanted with nerve recording electrodes in post-ganglionic cardiac nerves received incremental doses of intravenous Ang II (3, 6, 12, 24 and 48 ng/kg/min each for 30 min) whilst recording hemodynamics and CSNA. Ang II infusions induced a dose dependent increase in plasma Ang II levels (p<0.001) to be 50pmol/L above control levels during the highest dose. There was no significant change in plasma catecholamines. Ang II induced the expected dose dependent increments in MAP (p<0.001) with subtle (but significant) increases at lowest doses with MAP eventually raised 20-25 mmHg above control levels at the highest dose. Heart rate (p<0.001) and cardiac output (p=0.001) fell significantly in response to higher doses of Ang II. At no dose did Ang II increase any CSNA parameters measured. By contrast, there was a fall in both CSNA burst frequency (p<0.001), burst incidence (p=0.002) and burst area (p=0.004) with CSNA being significantly below time-matched control during the 3 highest doses of Ang II. In conclusion, Ang II infused at physiologically relevant, incremental doses induced the expected increase in MAP but no significant activation of CSNA. By contrast, medium-high doses of Ang II resulted in falls in CSNA burst frequency and burst area, presumably via a baroreceptor mediated pathway. This study provides no evidence for systemic Ang II stimulating sympathetic traffic directed to the heart, at least in normal conscious sheep.

 

Nothing to Disclose: CJC, DLJ, MTR, AMR

13541 16.0000 MON-0865 A Systemic Angiotensin II Does Not Increase Cardiac Sympathetic Nerve Activity in Conscious Sheep 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Javad Habibi*1, Adam T Whaley-Connell2, Ravi Nistala1, Mona Garro1, Brittany Dodd3, Melvin R Hayden4, Carlos Ferrario5 and James R. Sowers6
1University of Missouri, Columbia, MO, 2Harry S Truman Memorial Veterans Hospital, Columbia, MO, 3University of Missouri, 4Univ of Missouri Columbia, Camdenton, MO, 5Wake Forrest University, 6Harry S Truman VA Hospital and University of Missouri, Columbia, MO

 

Objective: It is increasingly recognized there is sexual dimorphism in kidney disease progression; however, this disparity is lost in the presence of diabetes where women progress at a  similar rate to men.  The renin-angiotensin-aldosterone system (RAAS) is known to regulate diabetes-induced kidney injury and recent literature would suggest there exist gender differences in RAAS-dependent responses in the kidney.  In this regard, these gender differences may be overcome by salt.  Thereby, we hypothesized that salt would promote proteinuria in transgenic female rats under conditions of excess tissue angiotensin (Ang) II and circulating aldosterone.  Materials/Methods: We utilized young female transgenic (mRen2)27 (Ren2) and Sprague-Dawley (SD) littermates exposed to a high (4%) salt diet over three weeks.  Results: Compared to SD and Ren2 controls, female Ren2 rats fed a high salt diet displayed increases in proteinuria, peri-arterial and interstitial fibrosis as well as ultra-structural evidence of basement membrane thickening loss of mitochondrial elongation, mitochondrial fragmentation and attenuation of basilar canilicular infoldings.  These findings occurred temporally with increases in transforming growth factor (TGF)-β but no indices of oxidant stress.  Conclusions: Our current data suggest that a diet high in salt promotes progressive kidney injury as measured by proteinuria through TGF- β-induced increases in fibrosis under conditions of excess tissue Ang II and circulating aldosterone.

 

 

Nothing to Disclose: JH, ATW, RN, MG, BD, MRH, CF, JRS

14064 17.0000 MON-0866 A Salt Loading Promotes Kidney Injury Via Fibrosis of Young Female Ren2 Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Amina Saniyyah Wofford*1, Alexis White2, Cynthia Ann Jackson2, Chastity Bradford2 and Gerald Dion Griffin3
1Tuskegee University, Auburn, AL, 2Tuskegee University, AL, 3Tuskegee University, Tuskegee, AL

 

Herpes Simplex Virus type I (HSV-1) is a double-stranded DNA virus belonging to the Herpesviridae family. Approximately 60% of the United States population is infected with HSV-1, and it is a leading infectious cause of corneal blindness and encephalitis. After infecting epithelial cells, HSV-1 virions travel to sensory ganglia neurons where they form a latent infection and remain until reactivation. Several antiviral agents exist, yet viral reactivation continues to persist and cause significant clinical problems. Thus, there is a need for more effective therapies. In addition to the well-known functions of angiotensin peptides and receptor antagonists in blood pressure regulation, they also have characterized anti-viral effects. We hypothesized that Captopril, an angiotensin-converting enzyme (ACE) inhibitor, attenuates cytopathic effects of HSV-1 in SH-SY5Y neuroblastoma cells. Immunocytochemistry and Western Blot analysis revealed that ACE is located in the membrane of SH-SY5Y cells. Captopril inhibited HSV-1 mediated cell death by 20% as evidenced by a trypan blue cell viability assay.  More specifically, Captopril treatment increased the percentage of living neuroblastoma cells from 63.9% to 84.7% (SH-SY5Y infected with the F strain of HSV-1 alone; F-value=2.85; df=8). Utilizing a quantitative method of cell proliferation, the 3-[4,5-dimethylthiazol-2-yl]-2,5 diphenyl tetrazolium bromide (MTT) assay, preliminary data suggests that 1nM of Captopril (cell viability index; 3.62) is the most effective concentration to reduce HSV-1 cytotoxicity compared to five other concentrations: 0(Control), 1mM(2.84), 10nM(3.57), 100nM(3.28), and 1pM(3.22). Current studies are testing the role of Captopril on HSV-1 replication. The current data demonstrates that Captopril decreases the amount of cytotoxicity induced by HSV-1.  These results augment a growing work of studies detailing antiviral properties of components of the Renin Angiotensin System.  Altogether, the current data indicates that Captopril is a worthy therapeutic target to help ameliorate the multiple pathologies associated with HSV-1 infection and reactivation.

 

Nothing to Disclose: ASW, AW, CAJ, CB, GDG

16176 18.0000 MON-0867 A Captopril Reduces Cytopathic Effects in Herpes Simplex Virus 1 (HSV-1) Infected SH-SY5Y Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Naoki Hiroi*, Aya Yoshihara, Mariko Sue, Kenzaburo Oda, Yasuyo Ando and Mayumi Yoshida-Hiroi
Toho University School of Medicine, Tokyo, Japan

 

[Introduction] The renin-angiotensin (RA) system is understood to be an exacerbation factor promoting high blood pressure and an organ disorder by angiotensin-converting enzyme (ACE)/ angiotensin (Ang)II/ATI receptor axis. On the other hand, it is reported that the activation of the ACE2/Ang-(1-7)/Mas receptor axis participates in organ protection, however, to our knowledge there are no report of the examination in human. We examined the effects of olmesartan to the ACE2/Ang-(1-7)/Mas receptor axis on essential hypertension patients for  

[Subjects and Methods] We prospectively studied 8 essential hypertensive patients who do not achieve depression target. All patients were treated with 20 mg/day  of olmesartan for 3 months. Blood pressure (BP), ACE2, Ang-(1-7) and plasma aldosterone concentration (PAC) were measured before and at 1 and 3 months of treatment.

[Results] Levels of ACE2 and Ang-(1-7) before treatment were 7.21±4.91 ng/mL and 3.90±0.92 ng/mL, respectively, and were 10.64±14.08 ng/mL and 4.54±1.88 ng/mL 3 months after treatment, respectively. The tendency to increase was seen, however there was not the significant difference in ACE2 and Ang-(1-7). No change was seen in PAC in before and 3 months after treatment (before and after treatment were 109.2±49.6 pg/mL and 100.4±32.7 pg/mL, respectively).

[Discussion] There are many reports that olmesartan activated ACE2 and, as a result, Ang-(1-7) increased. In this examination, levels of ACE2 and Ang-(1-7) before and after treatment of olmesartan in essential hypertension patients were increase tendencies. To clarify, it will seem that the accumulation of the case is necessary in future.

 

Nothing to Disclose: NH, AY, MS, KO, YA, MY

14342 19.0000 MON-0868 A Effects of Olmesartan to the ACE2/Ang-(1-7)/Mas Receptor Axis on Essential Hypertension Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Ryo Ito1, Ken Matsuda2, Akira Uruno3, Atsushi Yokoyama1 and Akira Sugawara*1
1Tohoku Univ Grad School of Med, Sendai, Japan, 2Tohoku University Hospital, Sendai, Japan, 3Tohoku Univ Grad School of Med

 

Hypertension is known as one of the most important risk factors for the progression of atherosclerosis. Among hypertensive patients, approximately 20~30% are estimated as “resistant hypertension” who are above their target blood pressure even in the simultaneous use of three different class anti-hypertensive drugs. Recently, aldosterone is recognized as one of the main causes of the etiology of “resistant hypertension.” Therefore, it is important to discover novel drugs that inhibit the synthesis and secretion of aldosterone. We recently generated a stable H295R cell line expressing aldosterone synthase gene (CYP11B2) promoter/luciferase chimeric reporter construct (1). The cell line is highly sensitive to angiotensin II (AII) and potassium, and its activity is completely suppressed by AII receptor blockers (1). We therefore established a high-throughput screening (HTS) system for the discovery of novel anti-hypertensive drugs that inhibit CYP11B2 expression using the cell line. In order to examine validation of the system, the cells plated on 384-well plates were incubated either with or without AII for 6 hours. Their luciferase activities were thereafter measured, and their Z’-factor, which is the indicator for the efficacy of HTS system, was calculated. Since the score was approximately 0.496, the system was acceptable for HTS. We are now screening drugs using Core-9600 and off-patent libraries obtained from Open Innovation Center for Drug Discovery of The University of Tokyo.

 

Nothing to Disclose: RI, KM, AU, AY, AS

14419 20.0000 MON-0869 A The Innovation of a Novel Drug Screening System for the Inhibitors of Aldosterone Synthase Gene (CYP11B2) Expression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Cardiovascular Endocrinology Monday, June 23rd 3:00:00 PM MON 0850-0869 4794 1:00:00 PM Renin-Angiotensin-Aldosterone System/Endocrine Hypertension-B Poster

Hye Soo Chung*1 and Moon-Kyu Lee2
1MyongJi Hospital, Goyang-si, 2Samsung Medical Center, Sungkyunkwan University, Seoul, Korea, Republic of (South)

 

Background/Aim: Activated pancreatic stellate cells (PSCs) have been suggested to have an
important role in β-cell dysfunction, a hypothesis supported by both in vitro and in animal
experiment. The aim of this study was to investigate the relationship between activated PSCs
and pancreatic islet fibrosis in type 2 diabetes mellitus patients for the first time.
Methods: We retrospectively reviewed the prevalence of activated PSCs in groups of
diabetic and non-diabetic patients, all of whom underwent surgical resection of intraductal
papillary mucinous neoplasms (IPMNs). Out of a total of 38 surgically-resected IPMNs
included in this study, 12 were from diabetic patients and 26 were from non-diabetic patients.
Activated PSCs were identified through α-smooth muscle actin (α-SMA) immunostaining;
fibrosis was semi-quantitatively graded in the pancreatic islets. We analyzed the associations
among activated PSCs, pancreatic islet fibrosis, and other clinicopathologic parameters.
Results: In diabetic patients, the numbers of α-SMA-positive activated PSCs and the degrees
of fibrosis in the islet cells were significantly increased compared with those of non-diabetic
patients [exact logistic regression analysis; odds ratio (95% confidence interval), p-value;
number of α-SMA-positive activated PSCs: 3.90 (1.73, 14.30), <0.01; degree of fibrosis in
islet cells: 22.07 (2.05, >999), <0.01]. Furthermore, the number of α-SMA-positive
activated PSCs was positively associated with the mean glycemic control (correlation
coefficient of Spearman’s rho, 0.66; p-value=0.04).
Conclusions: Activated PSCs and islet fibrosis were increased in type 2 diabetic patients.
These data support a key role for activated PSCs in islet dysfunction and the pathogenesis of
type 2 diabetes mellitus.

 

Nothing to Disclose: HSC, MKL

12740 1.0000 MON-0947 A Activated Pancreatic Stellate Cells Are Increased in the Pancreas of Type 2 Diabetic 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Mary Angelynne Esquivel*1, Mia Williams2, James Bena1, Simon Lam1, Deborah Rathz1 and M. Cecilia Lansang1
1Cleveland Clinic Foundation, Cleveland, OH, 2University of California San Francisco, San Fancisco, CA

 

Guidelines recommend transitioning stable ICU patients on intravenous insulin infusion (IVII) to scheduled subcutaneous (SQ) insulin before IVII discontinuation. Adoption of these guidelines has not been fully explored. Our study aimed to: 1) determine the frequency of transitioning to SQ insulin in the medical ICU (MICU), and 2) compare glycemic control, MICU length of stay (LOS) and hospital LOS amongst groups of patients based upon receipt of SQ basal insulin. A retrospective chart review was done on MICU admissions to a single tertiary care center June-Aug 2013 who received IVII. Patients were classified as follows: NB (did not receive basal insulin), IB (incorrect basal insulin defined as basal insulin given after IVII discontinuation, or greater than 12 hours (hrs) before IVII discontinuation without a 2nd dose of basal insulin afterwards) and CB(correct basal insulin defined as basal insulin given 1-12 hrs prior to IVII discontinuation time). Blood glucose (BG) levels were assessed at 1, 4, 8, 12, 24 and 48 hrs after IVII cessation. Target BG was 70-180 mg/dL. Comparison of the groups was performed using Kruskal-Wallis and Pearson chi-square tests. Data are in medians [interquartile ranges].

A total of 151 patients were included (79 males, median age 62 yrs, median weight 88 kg). There were 80 (53%) in NB, 55 (36%) in IB, and 16 (11%) in CB. All those with DM type 1 (n=15) were given SQ basal insulin, 53% of whom received it correctly. For DM type 2 (n=73), 62% received SQ basal insulin, but only 10% received it correctly. Of all patients on insulin at home (n=63), 21% received SQ basal insulin correctly. Fourteen patients had DM-related diagnoses on admission and all received SQ basal insulin. The average SQ basal insulin dose/kg given around the time of IVII discontinuation for all groups combined was 0.13 [0.09,0.25] units per kg, and 0.19 [0.13,0.37] for CB. CB had the shortest MICU LOS (2.0 days [1.00,4.5], p<0.001) and hospital LOS (5.5 days [3.2,20.5], p<0.002).

Known DM was present in 49% of NB, 93% of IB, and 100% of CB. NB had lower BGs than IB for BG 8, 12 and 24 (140 vs 186 mg/dL; 134.5 vs 198 mg/dL; and 141.0 vs 219.5 mg/dL, respectively). NB had lower BGs for the 1st 24 hrs after MICU discharge (144.2 mg/dL) compared to IB and CB (218 and 188.3 mg/dL, respectively). CB had lower BGs than IB for all time points except BG 1, with average BG within the 1st 24 hr 157.0 [138.2,258.5] vs 194.3 mg/dL [144.4,241.3], but none of these reached statistical significance, likely owing to the small sample size. CB had higher frequency of reaching target BG compared to IB (69% vs 40%, p 0.042).

For known DM, the practice of transitioning to SQ insulin is less than optimal. Our institution is piloting a new order set to assist in this. Most patients with no known DM do not need transitioning. CB had higher frequency of achieving target BG than IB. CB was associated with shorter MICU and hospital LOS, but further analysis of the variables is needed.

 

Disclosure: MCL: Consultant, Sanofi. Nothing to Disclose: MAE, MW, JB, SL, DR

13486 2.0000 MON-0948 A Intravenous Insulin Infusion Transition to Subcutaneous Insulin in the Medical ICU 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Sun Hee Lee*1 and Jae Hyun Kim2
1Graduate School of Medicine, Gacheon University of Medicine and Science, Gil Medical Center, Incheon, Korea, Republic of (South), 2Inje University College of Medicine, Ilsan Paik Hospital, Goyang-si, Korea, Republic of (South)

 

Introduction: The incidence of type 1 diabetes mellitus (T1DM) in children and adolescents has increased gradually worldwide. However, the epidemiology of T1DM among youth in Korea has not been reported since 2000. The aim of this study is to investigate the incidence and prevalence of T1DM in Korean children and adolescents in 2012.

Materials and Methods: T1DM cases in children <15 years of age were obtained through the nationwide registry of the National Health Insurance Service (NHIS) in 2012. Inclusion criteria were as follows: insulin treatment and one or more findings such as fasting serum c-peptide ≤0.6 ng/mL, stimulated serum c- peptide ≤1.8 ng/mL, 24 hour urine c-peptide ≤ 30 μg, diabetic ketoacidosis at diagnosis, and autoantibody positivity (e.g. anti-GAD antibody, insulin antibody, islet cell antibody). The incidence rate and prevalence were calculated per 100,000 population.

Results: A total of 217 patients with T1DM <15 years of age were registered in NHIS. The age-adjusted incidence rate was 2.87/100,000 per year [95% Confidence interval (CI) 2.50-3.28]. The overall incidence by age group in 2012 was 1.21 (95% CI 0.80–1.74) in children 0-4 years old, 2.89 (95% CI 2.23-3.68) in children 5–9 years old, and 4.16 (95% CI 3.46-4.97) in youth 10–14 years old. There was a slightly higher overall incidence among girls. Incidence rate of T1DM was 2.63 (95% CI 2.14-3.19) in boys and 3.13 (95% CI 2.59-3.77) in girls. However incidence of children aged 0-4 and 10-14 years showed slightly higher among boys, although incidence in 5-9 years showed marked female predominance. The incidence rate of T1DM among youth in 2012 was higher than in 1995-2000, which was 1.36/100,000 (95% CI% 1.23-1.48).

The prevalence of T1DM in children <15 years in 2012 was 28.9/100,000 (95% CI 27.5-30.0). The overall prevalence by age group in 2012 was 17.5 (95% CI 15.8-19.3) in children 0-4 years old, 31.2 (95% CI 28.9-33.5) in children 5-9 years old, and 36.1 (95% CI 34.0-38.3) in youth 10-14 years old. The prevalence was 24.7 (95% CI 23.2-26.3) in boys and 33.4 (95% CI 31.5-35.3) in girls.

Conclusion: There was an increase in T1DM incidence among children <15 years old in Korea. The incidence rate had doubled since late 1990s, which was higher than other countries. The prevalence of T1DM in Korean youth was first described in this study. Ongoing investigation to evaluate the long-term trend of the epidemiology in T1DM should be performed.

 

Nothing to Disclose: SHL, JHK

13309 3.0000 MON-0949 A Increasing Incidence of Type 1 Diabetes Mellitus Among Korean Children and Adolescents in 2012: Analysis of Data from the Nationwide Registry of Korea 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Brian J Ulmer*1, Areeba Kara2 and Cary N Mariash3
1Indiana University Health Physicians, Indianapolis, IN, 2Indiana University Health Physicians, 3Methodist Research Institute and Indiana University, Indianapolis, IN

 

Hyperglycemia with or without a history of diabetes is common in hospitalized patients and is associated with increased morbidity and mortality.  The treatment of hyperglycemia with insulin or oral agents involves the risk of hypoglycemia, which may be associated with poor clinical outcomes, and efforts should be made to minimize the risk of hypoglycemia during hospitalization.  Previous studies have suggested a temporal pattern to hypoglycemia, and we reviewed audit data of hypoglycemia (blood glucose (BG)<50 mg/dL) in adult patients at two academic health centers from July, 2012 to June, 2013 to study the temporal occurrence and recurrence of hypoglycemia during hospitalization.  During the audit period, 274 index hypoglycemic episodes were identified.  The mean age of the patients was 53.8 years with roughly equal gender distribution (male 47%, female 53%).  46% of the index hypoglycemic events occurred in the intensive care unit (ICU) while the remainder occurred on the general medical/surgical floor or progressive care unit.  A recurrence of hypoglycemia (repeat BG <50 mg/dL between 1 and 24 hours following the index hypoglycemic event) occurred in 47 cases, with 12 cases of 3 or greater distinct hypoglycemic episodes separated by at least 1 hour during the 24 hour period.  No patients on intravenous (IV) insulin experienced a recurrence of hypoglycemia while 80% of the patients who experienced a recurrence of hypoglycemia on subcutaneous insulin received basal insulin (glargine, detemir, NPH, or continuous subcutaneous insulin infusion).  197 hypoglycemic events were associated with the use of insulin or oral hypoglycemia agents, while 77 hypoglycemic episodes were found in patients without documentation of insulin or oral agents.  Among the patients who received anti-hyperglycemic therapy, 84% received subcutaneous insulin, 15% received IV insulin, and 0.5% were on an oral agent alone.  Of the patients who received subcutaneous insulin, 72% received basal insulin within twenty-four hours of the index hypoglycemic episode.  To determine the temporal distribution of hypoglycemia, we compared the frequency of events that occurred in 6-hour intervals.  Among patients receiving insulin or oral agents, 92 episodes occurred between midnight (MN) and 6AM, 43 episodes between 6AM and noon,  27 episodes between noon and 6PM, and 35 episodes between 6PM and MN.  To control for the frequency of glycemic testing, we divided the total number of hypoglycemic events by the total number of BG readings for that time period and determined that hypoglycemia occurred more frequently between MN and 6AM and less frequently between noon and 6PM (p<0.05) among patients receiving subcutaneous insulin.  There was, however, no discernable diurnal pattern among patient receiving IV insulin.  Hypoglycemia may occur more frequently overnight and nocturnal glycemic testing should be considered during hospitalization.

 

Nothing to Disclose: BJU, AK, CNM

14030 4.0000 MON-0950 A Temporal Occurrence and Recurrence Patterns of Hypoglycemia during Hospitalization 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Metib Alotaibi*1, On behalf of the Residents, Department of Medicine2 and Ali Saeed Alzahrani3
1King Faisal specialist Hospital and research centre, Riyadh, Saudi Arabia, 2King Faisal Specialist Hospital & research center, Riyadh, Saudi Arabia, 3King Faisal Specialist Hospital, Riyadh, Saudi Arabia

 

Uncontrolled Diabetes Mellitus (DM) is associated with a signficant risk of complications and mortality.  Major trials have shown a clear benefit of tight DM control in the outpatient setting.  Recently, a major focus has been directed towards inpatient hyperglycemia.  Although many studies from North America and Europe have shown a major impact of hyperglycemia on the outcome and a signficant benefit from good control of hyperglycemia in hospitalized patients, there are no data on the prevalence, management and outcome of DM and in-hospital hyperglycemia (IHH) in Saudi Arabia and Gulf countries.   For this reason, we undertook a study to assess the prevalence of IHH, the management approaches used, the level of BS control, the rate of hypoglycemia and the impact of IHH on the outcome.

Patients and Methods

This is a cross-sectional observational study over a 4-week period in which all non-ICU hospitalized adult patients (≥14 years) admitted during one month (within 2 weeks before and 2 weeks after the start of the study) were included.  Those with known diabetes or who develop hyperglycemia while in the hospital were the study group.  The rest of the patients (Non-hyperglycemic) served as control (observation group). 

Results

A total of 399 patients (177 males, 222 females, Median age 46.6, range 14-94 years) were admitted during the 4-week study period.  One hundred seven (27%), were known diabetics (52 on insulin and 57 on oral medications) before admission while 30 cases (7.5%) developed hyperglycemia during hospitalization.  So the total cases of inpatient hyperglycemia were 137 cases (34.5%) and 262 cases (65.5%) were non diabetic and remained euglycemic.   The inhospital management of hyperglycemia consisted of modified home regimen in 39 cases, sliding scale only in 10 cases, Insulin BID in addition to sliding scale in 26 cases, no treatment in 17 cases and OHA in 20 cases.  In the study group, the median highest BS was 11.80 (range 4-32) and the median lowest BS was 4.9 mmol/l (range 3-19).  The mean ± SD BS was 8.3±3.6 mmol/L.  The median percentage of time in which BS >10 mmol/L was 36.4% (range 8-100) and >15 mmol/l 18% of the time (range 4-100%).   

Comparing the outcome of patients with those without hyperglycemia, the risk of infection was much higher (38% vs. 18%, p <0.0001).  Although mortality was not statistically significant, probably due to low number of deaths, there was a trend towards more mortality with 4 cases (2.9%) with hyperglycemia died during their hospitalization vs.  2 cases (0.8%) in those without hyperglycemia (p 0.18)

Conclusions:

More than one third of hospitalized patients have preexisting diabetes or develop inpatient hyperglycemia.  Blood sugar control is not satisfactory in at least 50% of the cases and this is likely a significant contributor to higher risk of infectious complications and a trend towards increased mortality in those patients compared to patients with euglycemia.

 

Nothing to Disclose: MA, OBOTRD, ASA

14896 6.0000 MON-0952 A In-Hospital Hyperglycemia Prevalence, Management, Level of Control and Associated Complications and Mortality 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Susannah Macdonald Becker*1, Kwame Osei1 and Kathleen M Dungan2
1Ohio State Univ Med Ctr, Columbus, OH, 2The Ohio State University, Columbus, OH

 

Acutely ill hospitalized patients with or without a history of diabetes often have elevated and fluctuating blood sugar influenced by a variety of factors.  It has become common practice to treat hyperglycemia in the hospitalized patient with subcutaneous insulin regardless of the etiology or history of diabetes.  However, it is often difficult to predict the correct amount of basal insulin to use in a hospitalized patient, as this can differ markedly from home basal insulin dose.

To study the change in basal insulin requirement during hospitalization and the factors affecting it, we analyzed 100 non-ICU hospitalized patients with type 2 diabetes (T2D) who were enrolled in an insulin dosing study for 72 hours after admission.  The basal, prandial, and correction insulin doses were titrated daily by the study PI using a predetermined titration algorithm.  We compared basal dose, total daily dose, % basal insulin (basal dose insulin/total dose insulin) on day 0 and day 2, and change in %basal using paired t-test or nonparametric testing as appropriate.  We also analyzed for univariable predictors of %basal day 2  and the change in %basal from day 0 to day 2.  Of 100 patients, the median HbA1c was 8.75 +/-2.3%, median duration of T2D was 11 (IQR 6-18) years, 80% took insulin prior to admission (median basal dose 34 [IQR 14-64] units), and 30% had renal insufficiency.  Patients required less total insulin over time (68.5 [IQR 35.5-100] vs 57.9 [IQR 47.4-68.3] units, N=94, p=0.0002).  The %basal insulin increased from 50.81% on D0 to 58.83% on D2, after exclusion of patients who were NPO (p=0.04). Diabetes duration, insulin naïve status, and renal failure were important predictors of %basal on day 2.  Patients with longer (log transformed) duration of diabetes had a smaller % basal day 2 (estimate -0.055, p=0.04).  Finally, % basal day 2 was 58% for crt<1.5 and 47% for crt>1.5 (p=0.04).  The change in percent basal was significant for insulin naïve patients (increased 7%, p=0.002) but not patients taking insulin on admission (increased 3%, p=0.15).        

Overall the data suggests that the commonly recommended starting dose of insulin is too aggressive in this population (non-critically ill patients with long-standing T2D).  The data are contrary to commonly held beliefs that insulin requirements increase during acute illness, which might only be true in critically ill patients or only for brief periods of time.  Secondly, the proportion of basal insulin is not always 50%, but is dependent upon pre-admission insulin exposure, diabetes duration, and renal insufficiency.

 

Disclosure: KMD: Advisory Group Member, Eli Lilly & Company, Investigator, Novo Nordisk, Advisory Group Member, Sanofi. Nothing to Disclose: SMB, KO

15889 8.0000 MON-0954 A Predictors of Basal Insulin Dosing in Hospitalized Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Indu Mathew*1, Michael C. Grimes1, R Harsha Rao2, Candace Ann Cunningham2, Robert Muder3 and Peter L Perreiah2
1VA Pittsburgh Health System, Pittsburgh, PA, 2VA Pittsburgh Healthcare System, Pittsburgh, PA, 3VA Pittsburgh Health System

 

Hyperglycemia is a major risk factor for wound infections in patients with diabetes undergoing surgery.  Early indications of its importance in cardiac surgery, in particular, evident in the Portland Project1, were validated by the Leuven study, a randomized controlled trial in which a majority of patients had undergone cardiac surgery.  It established unequivocally that aggressive glycemic management (BG <110mg/dl) reduces the risk of sepsis-related mortality by 46%2, although the study did not specifically detail the impact of aggressive control on the risk or the severity of postoperative sternal wound infections (SWI).

The VA Pittsburgh has been engaged in a 13 year project aimed at reducing hyperglycemia-related mortality with an intravenous insulin infusion to maintain blood glucose (BG) <140mg/dl during intensive care in patients undergoing cardiac surgery.  A standard formula-based program used in the first 8 years (Formula, n=1264) was replaced by a complex automated software program called Glycemic Expert system for Nurse Implemented Euglycemia (GENIE®, n=870), in order to achieve tight glycemic control (TGC) without provoking the severe hypoglycemia (BG<40mg/dl) that inevitably occurs with TGC in all studies to date.

Despite similar BG targets, glycemic control was significantly better in the GENIE cohort (Mean Time-Averaged Glucose: GENIE 134±0.7mg/dl versus Formula 152±1.0, p<0.001), with many more patients maintaining Mean BG≤140mg/dl (GENIE ~83%, Formula ~57%, p<0.001), and fewer patients with Mean BG>200mg/dl (GENIE ~1 in 500, Formula ~1 in 12, p<0.001).  Even though glycemic control was much more aggressive with GENIE, the incidence of severe hypoglycemia was substantially decreased (BG<40mg/dl, GENIE ~1 in 100 versus Formula ~1 in 40, p=0.02) and less repetitive (~1 fewer episode/patient, p=0.006) or prolonged (Dwell Time BG<70mg/dl shorter by ~1.3h, p=0.002). 

The incidence of all wound infections after cardiac surgery did not change significantly (Formula 3.2% vs GENIE 2.5%, p=NS).  The incidence of deep sternal wound infections (DSWI) declined but did not reach statistical significance (Formula 2.1% vs GENIE 1.35%, p=0.07).  A preliminary analysis revealed that the introduction of GENIE eliminated deaths associated with DSWI (6 deaths on Formula versus none on GENIE).   The reduction in mortality could be attributed to the improvement in glycemic management, and not to any changes in infection control procedures, because the overall incidence of wound infections in surgical procedures other than cardiac surgery did not change significantly across the study period (during the Formula years, versus during the GENIE years). 

We conclude that the elimination of fatal mediastinitis is a major benefit from TGC and, although it does not change the incidence of SWI, TGC may protect patients with deep organ space infection after cardiac surgery from death.

 

Nothing to Disclose: IM, MCG, RHR, CAC, RM, PLP

16271 10.0000 MON-0956 A Eliminating Deaths from Mediastinitis after Cardiac Surgery Using Aggressive Glycemic Intervention to Maintain Blood Glucose 80-140mg/Dl: The VA Pittsburgh Experience 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Leslie Anne Eiland*1, Whitney S Goldner1, Andjela T Drincic1 and Jiangtao Luo2
1University of Nebraska Medical Center, Omaha, NE, 2Univeristy of Nebraska Medical Center, Omaha, NE

 

Little is known about hospital readmission rates in patients with diabetes or hyperglycemia.  Since hyperglycemia has been associated with worse outcomes, we sought to characterize readmission rates in inpatients with diabetes and hyperglycemia and determine factors associated with readmission. 

We analyzed two sets of data.  The first was hospital data from fiscal years 2011-2013 respectively (FY 2011-2013) using ICD-9 codes for diabetes.  The second was data on inpatients in the same time period who received point of care (POC) monitoring.  Readmission was defined as an inpatient admission within 30 days of discharge.  Variables analyzed included gender, age and mean, minimum and maximum glucose.  All statistical analyses were performed using SAS®9.3. Chi-square tests were used for categorical data (gender) and t-tests were used for continuous data (age and glucose).

For FY 2011-2013, there were 66,518 discharges from our institution. The percent of patients with diabetes who were admitted to our hospital was 26.8, 29.4, and 29.2% in FY 2011-2013.  During these years 35,246 patients (53%) received POC monitoring during their admission, and 52% were female. 

Overall readmission rates for the hospital were 14.6, 14.1, and 12.8% for FY 2011-2013.  Using ICD-9 codes, readmission rates for patients with diabetes were higher than those without diabetes at 20.1, 19.0, and 17.1% for FY 2011-2013. Of all readmitted patients, 36.8, 39.6, and 39.9% had a diagnosis of diabetes during FY 2011-2013.  Using POC data which includes diabetes and hyperglycemia, readmission rates were 21.8, 19.9, and 20.0% for FY 2011-2013.  

Analyzing all POC data from January 2010-June 2013, 53% of the readmitted and 52% of the non-readmitted population were female.  Mean glucose values were 156 ± 62 mg/dL for the non-readmitted group and 161 ± 67 mg/dL for the readmitted group, which was statistically different (p<0.0001).  Average age was 58.5 ±17 in the non-readmitted group and 58.2 ±16 in the readmitted group, which was not significantly different. 

Obtaining accurate readmission rates depends on an accurate definition of diabetes and hyperglycemia in the inpatient setting.  POC glucose monitoring captures more patients being monitored and treated for hyperglycemia than ICD-9 code for diabetes alone which is dependent on accurate provider coding.  Our data shows that 53% of inpatients are being monitored for hyperglycemia.  Overall, we found that patients with diabetes identified by ICD-9 code and inpatients being monitored for hyperglycemia by POC have increased 30-day readmission rates compared to the general population.  The high rate of patients receiving POC testing suggests that roughly half of the inpatient population may have either diabetes or hyperglycemia.  Mean glucose was statistically associated with readmission, but the clinical significance of these findings is unclear.

 

Nothing to Disclose: LAE, WSG, ATD, JL

11083 11.0000 MON-0959 A Readmission Rates in Inpatients with Diabetes and Hyperglycemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Adrienne M. Fleckman1, Mahmoud M. Hassan*2 and David J. Lucido2
1Beth Israel Med Center, a Member of the Mount Sinai Health System, New York, NY, 2Beth Israel Medical Center, a Member of the Mount Sinai Health System, New York, NY

 

Introduction:  The Affordable Care Act promotes meaningful use of the electronic medical record. Diabetes mellitus is increasingly prevalent, with one in 8 people in the population that we serve estimated to have diabetes mellitus (1). Major morbidities are preventable with interventions directed to accessible objective data. Published studies have not addressed the impact of Medicaid insurance per se on diabetic control.

Objective: To utilize an electronic medical record to determine if patients insured by Medicaid as a proxy for socioeconomic status have a different level of diabetes control from other insured patients as assessed by HbA1c.

Methods: We performed a retrospective review of the ambulatory electronic medical records in a single inner city urban hospital for calendar years 2012 and 2013. Patients ≥ 18 years old were identified by all ICD-9 codes for “diabetes mellitus” (DM). Among this population with DM, we identified patients insured by Medicaid, Medicare, self-pay and commercial insurance. We extracted the first recorded hemoglobin A1c (A1c), additional A1c values and the mean A1c levels for each patient and compared these between the group with Medicaid and those with commercial insurance.

 Results: The electronic medical record for 2012 and 2013 contained 17,292 patients with a diagnosis of DM.   Of those, 6770 patients were Medicaid-insured or covered by Medicaid managed care, 3826 Medicare insured, 154 self-pay and 6542 commercially insured.  A1c levels were available for 84% of the patients, with 84% of these having more than one value.  The mean A1c at presentation for Medicaid-insured patients as a group was 8.40% (95% CI 8.09% to 8.72%) and was 7.37% (95% CI  7.16% to 7.57%) for commercially insured patients (p<0.001). The mean A1c for all available time points for Medicaid-insured patients was 8.43% (95% CI  8.15% to 8.72%) compared to 7.28% (95% CI  7.13% to 7.43%) for commercially insured patients (p<0.001).

Conclusions:  The hemoglobin A1c in our Medicaid-insured patients was significantly higher than those with commercial insurance both at presentation and overall. Achieving glucose goals in patients with diabetes can significantly reduce microvascular complications including chronic kidney disease, and may favorably impact macrovascular disease with long-term follow up (2).  The 1% higher A1c in our Medicaid-insured patients is of proven clinical importance for increased microvascular events (3). This pilot study underscores the necessity to determine further associations and potential causes for poor control in the Medicaid group. A mandate for further intervention directed to these patients to improve diabetes control will require careful assessment of HbA1c response to increased visit frequency, intensive monitoring, team approach to care, enrollment in the medical home and development of other innovative approaches.


 

Nothing to Disclose: AMF, MMH, DJL

11826 12.0000 MON-0960 A Control of Diabetes Is Less Successful in Medicaid-Insured Patients Compared to Those Who Are Commercially Insured 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Alexandria Ajoa Atuahene*1, Susan Lee2 and Tracy Lynn Breen3
1North Shore Long Island Jewish Health System, Manhasset, NY, 2North Shore Long Island Jewish Health System, Manhasset, 3North Shore LIJ Health System, New Hyde Park, NY

 

To assess the rates of inpatient hypoglycemia in older patients with Diabetes Mellitus (DM) receiving Sulfonylureas (SU) for glycemic control.

We reviewed hospital records of patients with DM admitted to two tertiary academic hospitals between 6/2012-6/2013. In this time there were 12,077 admissions (6547 at NSUH, 5530 at LIJMC) of patients with DM ages 65 and older. These patients were divided into two groups (outpatient SU use vs no outpatient SU use), and were further categorized by: continued inpatient use of SU, discontinuation of SU during hospitalization, newly started SU during hospitalization, and overall rates of hypoglycemia (capillary blood glucose <70 mg/dl).

Of these 12,077 admissions, 8206 patients were admitted at least once during the time period. 2279 (27.8%, 95% CI: 26.8%, 28.7%) were treated with SU at home, and 5927 had no history of SU use prior to admission.  Of the 2279 patients admitted on SU, 1205 (52.9%, 95% CI: 50.8%, 54.9%) were continued upon admission and 1074 were discontinued. Of the 5927 without previous SU use, 284 patients were started during hospitalization, resulting in a total of 1489 (18.1%) patients using SU during hospitalization.  Data analysis revealed a significant difference in rates of hypoglycemia.  24.2% (360/1489)(p<0.0001) of patients on SU during hospitalization had one or more episodes of hypoglycemia, while 19.2% (1293/6717) of patients not on SU during hospitalization had one or more episodes.

This data highlights concerning areas surrounding SU use in elderly patients with DM.  27.7% of elderly patients admitted to our hospital were receiving SU prior to admission, and 52.9% of these patients were continued on these medications as an inpatient.  Current guidelines suggest that these agents should be avoided in this age group in the outpatient setting, and that oral antidiabetic agents should be discontinued in all inpatients. Although not standard of care, 4.8% of elderly patients not admitted on SU were newly started during their hospitalization.  SU use in the elderly is associated with adverse events, particularly, hypoglycemia, and this is clearly illustrated by our data.  In the group of patients receiving SU during hospitalization, the rate of hypoglycemia was significantly higher than in the group not receiving SU.

It is known that hypoglycemia is common in inpatients with DM, and this leads to increased LOS and increased mortality (1). Geriatric patients receiving SU during hospitalization are at even higher risk. SU have been identified as one of the most common agents used in the elderly associated with poor patient outcomes (2). It is concerning that these agents are still being used as an outpatient at such high rates, and despite the abovementioned information, these agents are frequently being continued upon admission. This data has led to substantial changes in our inpatient formulary and new patient safety initiatives have been implemented.

 

Nothing to Disclose: AAA, SL, TLB

17015 12.0000 MON-0958 A Inpatient Sulfonylurea Use in Older Patients: Continuation of a High Risk Outpatient Regimen Associated with Increased Harm during Hospitalization 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Samir Malkani*1, Sarika Rao2, George Asdourian3, Joseph Cohen4 and David Marshall Harlan5
1UMass Memorial, Worcester, MA, 2University of Massachusetts Medical School, Worcester, MA, 3UMassMemorial, 4Colgate University, 5UMass Memorial Medical Center, Northborough, MA

 

Diabetes remains a leading cause of blindness in adults, which can often be prevented by early detection of eye problems by periodic eye exams. Many individuals, however, do not get these exams. A systematic review of the literature shows that digital retinal photography with remote analysis (telemedicine) has the potential to deliver cost effective screening for underserved and hard to reach populations. However, there is limited data on its role in well-served populations with easy access to eye care. Hence, we decided to assess the utility of digital retinal photography within a specialty diabetes practice serving an almost fully insured population with ample access to community-based ophthalmologic services. All patients who attended the diabetes clinic during a 3 month period were surveyed to ascertain if they had seen an eye specialist in the preceding year, and if not, were administered a non-mydriatic retinal photograph to each eye on a Topcon TRC-NW8 (Topcon Medical Systems, Oakland, NJ) camera by clinic personnel trained by our ophthalmologist. The photos were read by a  retinal specialist as either being normal, showing evidence of diabetic retinopathy, showing evidence of an ocular condition other than diabetic retinopathy or unsuitable for interpretation. Individuals whose photographs fell in any category other than normal, were advised to see an ophthalmologist. 6 months later, we followed up with those instructed to see an ophthalmologist, to assess their compliance with our request. A total of 827 patients were surveyed and 147 (18%) qualified for and had retinal photographs. 78 (53%) had normal photographs, 30 (21%) had diabetic retinopathy, 5 (3%) had other abnormalities, and 34 (23%) were unsuitable for interpretation. Only 22/35 (63%) patients with abnormal retinal photos, and only 17/34 (50%) with non-interpretable photographs followed up with an ophthalmologist. Our results suggest that even among those with health insurance and easy access to eye care, a fifth of those with diabetes  do not get recommended eye exams. Nonmydriatic retinal photography offered at point of care has a high yield of detecting retinopathy, and is a worthwhile service to offer.  One drawback was the significant percentage of photographs unsuitable for interpretation due to small pupils, cataracts, or poor visualization of the macula. Of note, the proportion of unsatisfactory photographs in our study is in keeping with prior studies.  Our study also showed the importance of pursuing those with abnormal photographs with reminders and focused efforts, as 40% of these individuals had not sought eye care 6 months after becoming aware of their result. The only expense to provide this service was the purchase of a retinal camera and training of our regular clinic staff. The ophthalmologist’s effort in reading the photos was felt to be compensated by referrals generated to their service by the abnormal photographs.

 

Nothing to Disclose: SM, SR, GA, JC, DMH

11846 13.0000 MON-0961 A Incorporating Retinal Photography into Diabetes Clinic Visits Improves Early Detection of Retinopathy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Nosariemen LILIAN Okonyia*1, Sandra Omozehio Iwuala2, Oluwarotimi Bolaji Olopade3, Opeyemi BUKOLA Salako1, Oyinkansola Ogundimu1, Ernest Ogbonnaya1 and Augustine E Ohwovoriole4
1LAGOS UNIVERSITY TEACHING HOSPITAL, LUTH., LAGOS, Nigeria, 2Lagos Univ Teaching Hosp, Lagos, Nigeria, 3Lagos Univ Teaching Hosp, Surulere, Nigeria, 4University of Lagos, Yaba Lagos, Nigeria

 

MEDICAL AUDIT IN NIGERIA: THE DIABETES IN-PATIENT PERSPECTIVE.

 

Okonyia N.L, Iwuala S.O, Olopade O.B, Ogundimu O.M, Salako O.B, Ogbonnanya E.E,  Ohwovoriole A.E.

 

Endocrinology, Diabetes and Metabolism Division, Department of medicine, Lagos University Teaching Hospital(LUTH), Idi-Araba, Lagos, Nigeria.

                             

Background: Medical Audit is a retrospective review of the quality of medical care. It evaluates the structure, process and outcome of care of patients. The purpose is to improve quality of care by establishing set standards. Till date, no report on medical audit on diabetes care in Nigeria is available.

Objectives: To describe the diagnosis, duration of hospital stay, the structure and outcome of care of DM in-patients.

Method: The study was a retrospective review of hospital records of all diabetic patients admitted into the Adult medical wards of the Lagos University Hospital over two years. We also reviewed the existent manpower and facilities available for the management and care of diabetic in-patients. Our results were based on standards set by International bodies.  Data extracted included sex, age, diagnosis, the duration of hospital stay and outcome of admission. Data were analyzed using SPSS version 22. Results were expressed as mean(SD) and percentages.

Results: Of the 3,276 patients admitted during the period under review, 341(10.4%) were diabetic with 196(55.2%) being females and 145(44.8%) males. The mean age at admission was 58.3(14.3) years for males and 59.09(13.8) years for females. Hyperglycemic emergency was the most common presentation. This was closely followed by Diabetes mellitus foot syndrome (DMFS). The average length of hospital stay was 21.1(31.2) days for males and 22.3(39.6) days for females. A total of 71(24.7%) of the diabetic patients admitted died. 191(68.7%)patients were discharged, while about 6% discharged against medical advice. The mortality rates for DMFS and hyperglycemic crisis were 33.8% and 25.4% respectively.

Regarding structure, there are fifteen bed-spaces available to the endocrine unit, which consist of four consultants, nine senior-registrars, two registrars and three house-officers. Occasionally, diabetes in-patients are admitted into other wards when the medical wards are full to capacity. Other staffs such as nurses, and podiatrists are inadequate. Laboratory support is often delayed or not within reach. Admitted patients have access to blood glucose monitoring but Insulin pumps are not available.

Conclusion: Hyperglycemic emergencies and DMFS are common causes of hospitalization in diabetes in-patients in Nigeria and are associated with long periods of hospitalization and high mortality. Inadequate manpower and structure contribute to the poor outcome. Improved facilities and staffing, well structured and regular medical audit will go a long way in reducing both morbidity and mortality.

 

Nothing to Disclose: NLO, SOI, OBO, OBS, OO, EO, AEO

14785 14.0000 MON-0962 A Medical Audit in Nigeria: The Diabetes in-Patient Perspective 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Clement Lo*1, Helena J. Teede2, Dragan Ilic3, Kerry Murphy2, Martin Gallagher4, Greg Ronald Fulcher5, Peter Kerr6, Kevan Polkinghorne6, Rowan Walker7 and Sophia Zoungas8
1Monash University, Clayton, VIC, Australia, 2Monash University, Melbourne, Australia, 3Monash University, Australia, 4The George Institute for Global Health, University of Sydney, Sydney, NSW, Australia, 5Royal North Shore Hosp, St Leonards NSW, Australia, 6Monash Health, Clayton, VIC, Australia, 7Alfred Health, Melbourne, Australia, 8Monash University, Clayton VIC, Australia

 

Diabetes is the most common cause of chronic kidney disease (CKD) globally [1].  When combined, both conditions substantively increase cardiovascular morbidity and mortality [2].  Despite this, the health-care of patients with diabetes and CKD is often sub-optimal, with widely differing care, inconsistent and fragmented health care approaches, poor communication and evidence-practice gaps.  The purpose of this qualitative study was to understand how the health-care of patients with diabetes and CKD can be improved by examining key processes in the management of these patients. Given the key role of health professionals in the health systems utilised by these patients, their views and opinions were sought.  Health professionals from four major metropolitan hospitals in two of Australia’s largest states were purposively sampled. Thirty-six participants were recruited into six focus groups.   Maximal variation sampling ensured representation of endocrine, renal and allied health professionals. Focus groups were led by the same facilitators and performed until a point of data saturation was reached.  Focus group discussions were transcribed verbatim and analysed independently by two researchers using a thematic analysis approach.  The following key themes emerged concerning the management of diabetes and CKD: 1) Patient self-management; 2) Access to health-care; 3) Communication between various health care providers, and between health care providers and their patients; 4) Coordination and integration of care between health professionals, and between primary and tertiary health care; and 5) Prevention and early intervention.  The findings of this study of hospital-based health professionals indicate that improvements in the health-care of patients with diabetes and CKD may be achievable by addressing barriers to patient self-management, improving access to hospital and community health-care, improving communication with patients and between health professionals, and improving coordination and integration of care across hospital and community sectors.  Additionally, a preventive approach to health-care, with a focus on community management, could be adopted.   An ideal model of care for diabetes and CKD is likely to centre on a combination of hospital health-care, community health-care and patient self-management.

 

Nothing to Disclose: CL, HJT, DI, KM, MG, GRF, PK, KP, RW, SZ

12439 15.0000 MON-0963 A Improving the Health-Care and Management of Patients with Diabetes and Chronic Kidney Disease: Hospital-Based Health Professionals' Perspectives 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Paula Freitas*1, Eva Lau1, Joana Isabel Oliveira2, Mariana Lobo3, Tiago Silva Costa4, Alberto Freitas4 and Davide Carvalho5
1Centro Hospitalar São João; Faculty of Medicine, Porto University, Portugal, 2Centro Hospitalar São João, Faculty of Medicine, Porto University, Porto, Portugal, 3Center for Research in Health Technologies and Information Systems, 4Center for Research in Health Technologies and Information Systems, Faculty of Medicine of University of Porto, 5Centro Hospitalar São João, Faculty of Medicine, University of Porto, Portugal

 

Introduction: Diabetes (DM) has been associated with an increased risk of pancreatitis. Several risk factors, including alcohol consumption, gallbladder stones, obesity, hypertriglyceridemia, and some drugs have been evoked as both risk factors as complications of diabetes and pancreatitis.

Aims: To evaluate: 1) the prevalence of hospitalizations for pancreatitis in: a) DM vs general population, b) in type 1 diabetes (DM1) vs type 2 (DM2), 2) mortality due to pancreatitis in DM vs general population; 3) prevalence of dyslipidemia, alcohol, obesity and hypertension in patients with pancreatitis (DM vs general population).

Methods: Retrospective analysis of patients admitted to a tertiary hospital between 1988 and 2012.  Cohorts were defined based on the primary and/or secondary diagnosis of pancreatitis and/or diabetes, coded according to the ICD-9-CM. The prevalence of hospitalizations is expressed in percentages and χ2 test was used for inferential analysis, with a significance level to α = 0.05.

Results: The prevalence of pancreatitis was higher in diabetic patients [1.06% (1098/104007)] vs general population [0.65% (5876/897645), p <0.001]. Since 2001, the prevalence of pancreatitis was consecutively higher in diabetic patients compared to the general population. According to the type of DM (DM1 vs DM2), no differences in the prevalence of pancreatitis were found. Pancreatitis associated mortality was non-significantly different in diabetic vs general population. In patients with pancreatitis, prevalence of dyslipidemia (22.68% vs 7.56%, p< 0.001), hypertension (43.26% vs 17.46%, p <0.001) and obesity (7.19 vs 3.15%; p<0.001) were significantly higher in diabetic versus the general population. However, no differences were found in alcohol consume.

Conclusion: The prevalence of hospitalizations for pancreatitis was higher in diabetics compared to the general population, having significantly increased  in the last 12 years. Diabetic patients hospitalized for pancreatitis have higher frequency of obesity, hypertension and dyslipidemia.

 

Nothing to Disclose: PF, EL, JIO, ML, TSC, AF, DC

15709 16.0000 MON-0964 A Hospitalization and Mortality for Pancreatitis and Diabetes: A Cohort from a Terciary Hospital 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Mariana Marin*1, Colby Ayers2 and Naim M Maalouf1
1UT Southwestern Medical Center, Dallas, TX, 2UT Southwestern Medical Center

 

Hyperuricemia is associated with insulin resistance and the development of type 2 Diabetes (T2D), although it remains unclear if this association is causal or simply coincidental. Recent epidemiologic studies have suggested that the impact of serum uric acid (SUA) on metabolic risk factors may be more significant in younger compared to older individuals. The goal of the present study was to investigate the effect of age on the association between hyperuricemia and the risk of developing T2D in a multiethnic, population-based cohort. 2,486 participants enrolled in the Dallas Heart Study between 2000 and 2002 returned for a follow-up visit between 2007 and 2009. Subjects were well-characterized with detailed questionnaires and measurement of anthropometric and laboratory studies. Incident T2D between baseline and follow-up visits was defined as development of fasting serum glucose ≥126 mg/dl, random serum glucose ≥200 mg/dl, hemoglobin A1c ≥6.5%, or interval initiation of anti-diabetes medications. The association between baseline SUA and incident T2D was examined in multivariable models, and we tested for interaction between age and SUA in these models. Results: In the subgroup of 1,877 participants without T2D at baseline, 165 subjects developed incident T2D during a median 7.0 (6.6-7.6) years of follow up. Compared to those without incident T2D, these 165 subjects were more likely to be older (age 46 ±8 vs. 43±10 years, p=0.0003), have a higher BMI (31.7 ±6.8 vs. 28.8±6.7Kg/m2 p<.0001), and a higher SUA (5.9±1.5 vs. 5.3± 1.4mg/dl, p<.0001) at baseline. Baseline SUA was independently associated with development of T2D (OR 1.22; 95% CI, 1.05-1.42 per 1 mg/dl increase in SUA) in a multivariate model adjusting for age, gender, race, BMI, hypertension, hypercholesterolemia, estimated GFR, smoking, diuretic use, and menopausal status. A significant interaction was noted between age and SUA on incident T2D (p=0.025). The multivariate adjusted Odds Ratio (95% CI) for incident T2D with each 1 mg/dl increase in baseline SUA was 1.56 (1.18-2.07) in individuals age < 40 years, 1.14 (0.89-1.46) in individuals age 40-50, and 1.13 (0.88-1.45) in individuals over age 50 years. In conclusion, higher SUA is independently associated with development of T2D. This association is stronger in younger adults. The mechanisms underlying these findings need to be further clarified. Age is an important factor to be considered in future studies targeted at lowering SUA.

 

Disclosure: NMM: Principal Investigator, Takeda. Nothing to Disclose: MM, CA

11038 17.0000 MON-0965 A Age Is an Important Modifier of the Association Between Hyperuricemia and the Risk of Incident Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Kevin M Pantalone*1, Todd M Hobbs2, Brian J Wells1, Sheldon X Kong2, Michael W Kattan1, Jonathan R Bouchard3, Changhong Yu1, Brian Sakurada2, Alex Milinovich1, Wayne Weng4 and Robert S Zimmerman1
1Cleveland Clinic, Cleveland, OH, 2Novo Nordisk, Plainsboro, NJ, 3Novo Nordisk, Inc., Plainsboro, NJ, 4Novo Nordisk Inc., Plainsboro, NJ

 

Introduction:There is limited real-world data describing the treatment patterns and glycemic control of patients with type 2 diabetes mellitus (T2D).  Previous research has reported that only 57% of patients with T2D have a glycosylated hemoglobin (A1C) <7% (1). The objective of this research was to assess the clinical characteristics and treatment patterns of patients with T2D in a large integrated health system.  

Methods:An enterprise-wide electronic health record system (EHR) at a U.S. academic center was used to conduct a cross-sectional analysis of 94,600 patients with T2D with a baseline A1C value available on or before July 1, 2013.  Patients with T2D were identified using ICD-9 codes and were required to have received at least one prescription for an oral hypoglycemic agent at some point in the past. The population was divided into four groups based on the index A1C level: <7%, 7–7.9%, 8–8.9%, and ≥9%.

Results:The number of patients in the defined A1C categories were 53,383 (56.4%), 20,278 (21.4%), 9137 (9.7%), and 11,802 (12.5%), respectively. The population had a mean age of 66.8 years, was 48.7% female, and 72.7% White. The mean ages (years) for patients across the A1C categories were 68.1, 68.0, 65.5, and 59.6, respectively (p <0.01). The percentages of Black and non-Black patients with an A1C ≥9% were 18.1 and 11.1%, respectively (p<0.01).

On the index date, 52.7% were receiving oral medications only, 10% insulin only, 15.5% insulin in combination with oral agent(s), and 18.2% were on no anti-diabetic medications.  Of the patients receiving oral agents, 62.6% had an A1C <7% while 8.4% had an A1C ≥9%.  Among those who received insulin and orals in combination, 33.2% of patients had an A1C <7% and 25.0% had an A1C ≥9%.  Among insulin only users, 39.5% had an A1C <7% whereas 22% had an A1C ≥9%.  The percentage of patients receiving specific medications were as follows: 51.4% metformin, 31.5% sulfonylurea, 10.5% dipeptidyl peptidase-4 inhibitor, 8.7% thiazolidinedione, 26.9% insulin, and 3.7% glucagon-like peptide-1 agonist.  Among those patients receiving oral medications only, 63.7% received one class of medication, 28.6% received two classes of medication, and 7.8% received > two classes of medications.  

Conclusion: While greater than half of the population demonstrated effective glycemic control, 43.6% of patients had an A1C ≥7%. These results reflect the challenge for patients with T2D and their clinical team in effectively managing glycemia with currently available treatment options.  In unadjusted analyses, patients with poorly controlled diabetes (A1C ≥ 9%) tended to be younger and were more likely to be Black.

 

Disclosure: KMP: Researcher, Novo Nordisk, Medical Advisory Board Member, Novo Nordisk, Medical Advisory Board Member, Sanofi, Medical Advisory Board Member, Eli Lilly & Company, Speaker Bureau Member, Bristol-Myers Squibb, Speaker Bureau Member, Eli Lilly & Company. TMH: Employee, Novo Nordisk. BJW: Researcher, Novo Nordisk. SXK: Employee, Novo Nordisk. MWK: Researcher, Novo Nordisk, Consultant, GlaxoSmithKline, Consultant, Merck & Co.. JRB: Employee, Novo Nordisk. BS: Employee, Novo Nordisk. WW: Employee, Novo Nordisk. RSZ: Speaker Bureau Member, Santarus, Speaker Bureau Member, Johnson &Johnson, Speaker Bureau Member, Merck & Co., Speaker Bureau Member, Jansen Pharmaceuticals, Speaker Bureau Member, Novo Nordisk, Researcher, Novo Nordisk. Nothing to Disclose: CY, AM

12494 18.0000 MON-0966 A Clinical Characteristics and Treatment Patterns in Patients with Type 2 Diabetes Mellitus in a Large Integrated Health System 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Jean Huang*1, Horng-Yih Ou2, Rudruidee Karnchanasorn3, Raynald Samoa1, Wei Feng1, Lee-Ming Chuang4 and Ken C Chiu1
1City of Hope National Medical Center, Duarte, CA, 2National Cheng-Kung University Medical College and Hospital, Tainan, Taiwan, 3The University of Kansas Medical, Kansas City, KS, 4Natl Taiwan Univ, Taipei

 

Obesity is a well-known major risk factor for diabetes. Currently HbA1c is the preferred diagnostic tool for diabetes. However, there is no information about the relationship of HbA1c and obesity in non-diabetic subjects. When reviewing the relationship of the trend of obesity and prevalence of diabetes, ethnic disparities have been long recognized especially in ethnic minorities. Thus, we hypothesized that there was a correlation of HbA1c and BMI in non-diabetic subjects as well as a different rate change of HbA1c per BMI among ethnic groups.

Adults subjects (age ≥ 18 years old) with HbA1c and BMI measured from NHANES 2005-2010 were included in this study.  Subjects with previous diagnosis of diabetes or HgbA1c ≥ 6.5% were excluded. The relationship of HbA1c and BMI was examined with consideration of co-variants including age, gender, family history of diabetes, current alcohol consumption, current smoking status, education, physical activity level, and poverty level. The rate of change for HbA1c per BMI was compared among different ethnic groups. Per NHANES survey, ethnic groups were divided into Mexican American (MA), other Hispanics (OH), Non-Hispanic White (NHW), Non-Hispanic Black (NHB) and others.  Given the small sample size, we excluded the other racial ethnic group.

There were 2,700 MA, 1,178 OH, 6,923 NHW, and 2,692 NHB included in our analysis. When adjusted for all co-variants, the relationship of HbA1c and BMI was highly significant among all ethnic groups (P < 0.000001). A significantly faster rate change of HbA1c per BMI was observed in both MA (0.0153 %/Kg/m2, 95% CI: 0.0129 – 0.0178 %/Kg/m2, P = 0.002) and OH (0.0158 %/Kg/m2, 95% CI: 0.0123-0.0193 %/Kg/m2, P = 0.01) when compared to NHW (0.0109 %/Kg/m2, 95% CI: 0.0097 - 0.0123 %/Kg/m2). No difference was seen between NHB (0.0115 %/Kg/m2, 95% CI: 0.093 - 0.0138 %/Kg/m2, P = 0.67) and NHW.

In all ethnic groups, we saw a progressively increased HbA1c along with BMI in non-diabetic subjects which could explain an increased prevalence of diabetes in obese patients. When comparing different ethnic groups, our findings demonstrated that MA and OH were more sensitive to BMI changes with a faster change of HbA1c than the NHW.  This fast rate change of HbA1c per BMI among MA and OH could contribute to a higher prevalence of diabetes that we have seen in Hispanic communities. On the other hand, with the same reduction of BMI, we could possibly achieve a more drastic reduction of HbA1c in MA and OH compared to NHW. Thus, MA and OH could benefit more from weight loss in diabetes prevention and management than NHW.

 

Nothing to Disclose: JH, HYO, RK, RS, WF, LMC, KCC

12549 19.0000 MON-0967 A Racial and Ethnic Differences in the Rate of HbA1c Changes per BMI in Non-Diabetic Subjects 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Linda Truong*1, Pritisheel Banga1, Jacob Cohen1, Maria Arambulo1, Ambar Rahman1, Tiffney Colon1, Dori Louie-Kai2, Patricia Calderon2, Steven Stoltz1 and Soe Naing1
1University of California, San Francisco, Fresno Medical Education Program, Fresno, CA, 2Community Diabetes Care Center, Fresno, CA

 

OBJECTIVE: To determine the effect of a nurse-led Diabetes Medication Management Clinic (DMMC) on glycemic control in diabetic patients

METHOD: This retrospective cohort study was conducted at a community outpatient clinic. The study period was from 10/2010 to 9/2011 for one year. Non-pregnant adult diabetic patients who attended DMMC at least twice and had at least 2 A1c results were included in the study.  Their mean A1c result was compared with that of diabetic patients who did not attend DMMC.

RESULTS:59 DMMC patients (mean age-51 years; men-52.5%; Hispanics-76.2%; mean baseline A1c-10.6%; interval between 2 A1c tests-10.4 weeks) were included in the study. 88 diabetic patients from medical outpatient clinics, who were matched for age, gender, ethnicity, baseline A1c and interval between 2 A1c tests, were selected for the control group. Mean A1c level significantly decreased from 10.6% to 8.9% (P<0.0001) in the DMMC group whereas there was a modest decrease in A1c from 10.59% to 10.03% in the control group. Of 59 patients in DMMC group, 45 patients received simultaneous Diabetes Self-Management Training (DSMT) in Diabetes Care Center and 14 attended DMMC only for insulin dose titration. Mean A1c decreased significantly (-1.92%, P < 0.0001) in those with simultaneous DSMT whereas mean A1c reduction was not significant (-0.73%, P = 0.1632) in those who did not receive DSMT.

DISCUSSION: The DMMC was set up in a community outpatient clinic historically associated with lengthy delays in obtaining physician appointments, as a resource to provide timely and improved diabetic care for those with poorly-controlled diabetes mellitus.  Traditionally, Certified Diabetic Nurse Educators (CDEs) provide DSMT only.  In DMMC, CDEs initiate and adjust the insulin dose under supervision of the internists over a maximum period of 3 months. DSMT provided by CDEs has been shown to improve the glycemic control in several studies. However, the impact of a nurse-led medication clinic on glycemic control was previously unknown. In our study, there was an average of 1.7% decrease in A1c level from baseline in DMMC group whereas the decrease was only 0.56% in control group. Therefore DMMC may be an effective resource to help improve glycemic control at least in short term.

CONCLUSION: Nurse-led medication management clinic significantly improved short-term glycemic control. The reduction of HbA1c was 2.5 times greater in the patients who received simultaneous DSMT than those who did not. All patients in the medication management clinic should therefore undergo simultaneous DSMT to get the maximum benefit of the clinic.

 

Nothing to Disclose: LT, PB, JC, MA, AR, TC, DL, PC, SS, SN

12748 20.0000 MON-0968 A Nurse-Led Diabetes Medication Management Clinic: An Effective Resource to Improve Glycemic Control 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Lynn Kessler*1, Fabiana Araujo2, Keiki Hinami2 and Leon Fogelfeld3
1Stroger Hospital of Cook County, Chicago, IL, 2Stroger Hospital of Cook County, 3Stoger Hospital of Cook County, Chicago, IL

 

Background: At our large urban, safety-net hospital, the diabetes clinic (DC) offers regular visits with endocrinologists, access to dieticians, diabetes educators (CDEs), psychotherapists, a dedicated social worker, and a series of diabetes education classes. Despite these interventions, a subset of the population of our patients remain in poor glycemic control .

Objective:  To improve diabetes control in patients where standard interventions have not demonstrated success.

Description:

Eligibility: Type 2, diabetic (T2DM) patients on multiple daily insulin injections become eligible for the Last Chance Clinic (LCC) when their hemoglobin A1C levels are greater than 10% or, in special cases per physician discretion, between 9-10% after at least 1 year in the DC.

Clinic Structure and Intervention:

The clinic is comprised of a dedicated endocrinologist, a CDE/dietitian, social worker, and psychotherapist. During each visit, all four clinic providers sit jointly with the patient.

At the initial visit, a verbal contract is made with the patient ensuring their active participation in their care in exchange for continued access to the intensive intervention. The initial visit lasts approximately 1 hour; return visits average 45 minutes.  Initially, visits are scheduled every 2-4 weeks.  They are eventually spaced out to 6-8 weeks.

We use a patient centered model with an emphasis on eliciting the patient’s perspective (including identifying obstacles to care, baseline diabetes self-care practices and daily routines), demonstration of empathy, shared decision making, and providing intensive diabetes education. `Insulin management is focused on simplifying regimens whenever possible to fewer daily shots, including the initiation of U500 in several cases. 

Patients are discharged back to the general diabetes clinic when they:  have a relative reduction in A1C greater than 2%,  a final absolute A1C value less than 8.5%, or are determined, by consensus agreement among the 4 providers, to no longer benefit from the interventions offered.

Results:  Forty four patients have been enrolled in the LCC. The mean (SD) A1c upon referral was 11.1% (1.5) and mean final A1c is 9.2% (1.3) for an average decrease of 1.9% (p<0.0001). Twenty-one out of 44 patients(48%) reached the goals of our clinic (A1C  reduction >2% and/or final A1c < 8.5%). These improvements were made without any significant difference in the mean total insulin daily dosage (mean initial = 171 units; mean final dose = 162 units; mean D = -9.7 units, p=ns).

Summary:  This multidisciplinary intensive intervention significantly improved glycemic control in a difficult-to-treat population without increasing mean insulin dosage.  We speculate that this observed effect was the result of improved adherence, diabetes knowledge, and motivation.

 

Nothing to Disclose: LK, FA, KH, LF

13056 21.0000 MON-0969 A The Last Chance Clinic: A Multidisciplinary Intensive Intervention for Poorly Controlled Type 2 Diabetes (T2DM) Patients Unresponsive to Usual Care 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Paula K Polzer* and Xiao Ni
Eli Lilly and Company, Indianapolis, IN

 

Male hypogonadism is defined by low serum testosterone (T) levels and associated clinical symptoms, and is observed at elevated prevalence among men with type 2 diabetes mellitus (T2DM). Thus, further characterization of T levels in T2DM is needed. This post hoc analysis examined baseline associations between low T levels and demographic and disease characteristics in diabetic men previously treated with insulin who were entering a phase 3 trial of the once weekly GLP-1 receptor agonist dulaglutide.

Patients were ≥18 years of age with T2DM duration ≥3 months, had screening HbA1c between 7.0% and 11.0%, inclusive, and had received insulin (≤2 doses/day) alone or with oral antihyperglycemic medications (OAMs). Low T was defined as total T (TT) <300 ng/dL or free T (FT) <65 pg/nL (calculated using the Vermeulen equation). A two-sample t-test and Fisher’s exact test were used to compare between testosterone subgroups for continuous and categorical variables, respectively. Men receiving T replacement (n=11) were not analyzed.

At baseline, 33.9% of men (n=151) had low TT and 66.1% had normal TT (n=294); mean age was 60.3 and 59.3 years (p=.59), and HbA1c was 8.6% and 8.4% (p=.31), respectively. Significant differences were observed between low-TT versus normal-TT men for mean BMI (33.9 vs. 31.0 kg/m2, p<.001), weight (103.8 vs. 93.7 kg, p<.001), proportion with HbA1c >9.5% (21.2 vs. 12.9%, p=.028), and proportion using a phosphodiesterase 5 inhibitor (9.3 vs. 3.4%, p=.014).

Men with low versus normal FT (26.4% [n=117] vs. 73.7% [n=327]) were older (63.4 vs. 58.3 years, p<.001) and had higher BMI (34.0 vs. 31.3 kg/m2, p<.001), weight (103.1 vs. 95.0 kg, p<.001), and proportion with a history of cardiovascular disease (40.2% vs. 22.9%, p<.001). Mean HbA1c (8.5% vs. 8.4%, p=.95) and proportion with HbA1c >9.5% (17.1% vs. 15.3%, p=.66) were similar between men with low versus normal FT.

In a population of men with T2DM previously treated with insulin ±OAM, >1/3 (n=151) had untreated low TT; 11 additional men were receiving T replacement therapy. Men with untreated low-TT were of similar age but had greater BMI and weight versus men with normal TT, and more low-TT men had HbA1c >9.5%. The approximately 1/4 of men with low FT had greater age, BMI, and weight, but similar HbA1c versus normal-FT men. These data support Endocrine Society Guidelines for measuring testosterone levels in men with T2DM, and highlight the need for further study of T replacement in T2DM.

 

Disclosure: PKP: Clinical Researcher, Eli Lilly & Company. XN: Employee, Eli Lilly & Company.

13059 22.0000 MON-0970 A Characteristics Associated with Low Testosterone Levels in Men with Type 2 Diabetes Mellitus Previously Treated with Insulin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Paula K Polzer* and Xiao Ni
Eli Lilly and Company, Indianapolis, IN

 

Male hypogonadism is defined by low serum testosterone (T) levels and associated clinical symptoms, and is observed at elevated prevalence among men with type 2 diabetes mellitus (T2DM). Thus, further characterization of T levels in T2DM is needed. This post hoc study assessed the association of low T levels with baseline characteristics of diabetic men in a phase 3 randomized clinical trial of the once weekly GLP-1 receptor agonist dulaglutide versus metformin.

Patients were at least 18 years of age with T2DM (duration ≥3 months and ≤5 years), were treatment naïve or on 1 oral antihyperglycemic medication (OAM) at ≤50% of the recommended maximum daily dose, and had screening HbA1c between 6.5% and 9.5%, inclusive. Low total T (TT) was defined as <300 ng/dL. Free T (FT) was calculated using the Vermeulen equation. A two-sample t-test and Fisher’s exact test were used to compare testosterone subgroups for continuous and categorical variables, respectively. Pearson’s correlation coefficients were calculated between T and continuous variables. Men receiving T replacement (n=3) were excluded from analysis.

At baseline, 101 men (32.4%) had low TT and 211 (67.6%) had normal TT; mean age was 56.7 and 56.0 years, respectively (p=.82), and HbA1c was 7.6% in both groups (p=1.0). Men with low (vs. normal) TT had higher BMI (34.6 vs. 30.8 kg/m2, p<.001), higher weight (107.1 vs. 92.7 kg, p<.001), and lower insulin sensitivity (HOMA2-%S, 40.8 vs. 52.8, p=.008). Among men reporting a lack of energy, mean energy levels were lower among men with low versus normal TT (p=.044). Use of statins was significantly more prevalent among men with low (vs. normal) TT (52.5% vs. 28.0%; p<.001) and a history of cardiovascular disease was numerically more prevalent in men with low TT (17.8% vs. 10.9%; p=.107). Both TT and FT correlated negatively with BMI, weight, and lack of energy, and positively with HOMA2-%S (all p<0.05)

In a population of men with T2DM naïve to injectable therapy, approximately one-third of men (n=101) had untreated low TT, with only 3 additional men receiving T replacement. Men with low TT were of similar age and had comparable HbA1c relative to men with normal TT, but had higher BMI and weight, and reduced insulin sensitivity. Low T correlated with patient-reported lack of energy. These data support Endocrine Society Guidelines for measuring testosterone levels in men with T2DM. Further study is needed to evaluate the role of T replacement in T2DM.

 

Disclosure: PKP: Clinical Researcher, Eli Lilly & Company. XN: Employee, Eli Lilly & Company.

13070 23.0000 MON-0971 A Prevalence and Characteristics of Low Serum Testosterone Levels in Men with Type 2 Diabetes Mellitus Naïve to Injectable Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Roberto Emilio Izquierdo*1, Ruth S Weinstock2, Dongliang Wang1, Danning Huang3 and Walter Palmas4
1SUNY Upstate Medical University, Syracuse, NY, 2SUNY Upstate Med Univ/Syracuse, Syracuse, NY, 3SUNY Upstate Medical Center, Syracuse, NY, 4Columbia University Medical Center, New York, NY

 

Telemedicine can be used to improve health care delivery to underserved populations with chronic diseases such as diabetes. The Informatics for Diabetes Education and Telemedicine (IDEATel) demonstration project was a randomized trial comparing a telemedicine intervention with usual care in Medicare beneficiaries with diabetes residing in medically underserved areas of NYS. In the intervention group nurse or dietitian educators videoconference with patients monthly to download and review glucose and blood pressure readings, diabetes related issues, and lab data. The visit results were reviewed with an endocrinologist and recommendations to change therapy were made to the primary care providers (PCPs). As previously reported, intention–to-treat mixed models showed that telemedicine intervention reduced A1c, LDL-chol, and blood pressure (p<0.001) over a follow up period of 5 yrs. The focus of the current study was the interaction between the PCP and the telemedicine intervention team.  We evaluated factors that affected the PCPs’ decision on whether or not to follow the telemedicine team’s therapeutic recommendations.

At annual visits, in addition to obtaining labs (A1c, lipids), participants completed the DSC-Type 2 Symptom Severity Score and Impact of Telemedicine surveys. Data were obtained from PCPs (n=178) and their practices in Upstate New York.  Over half of the PCPs were aged 45-54 yrs, 73% male, and 85% White. Their practices contained 3299 (mean) patients. Most PCPs were physicians unaffiliated with the diabetes center conducting the intervention; approximately half were in solo practice and worked a mean of 48.3 hrs/wk.

A likelihood-based, Generalized Linear Mixed Model showed that the acceptance rate of IDEATel recommendations by PCPs increase over time (p=0.0052). Compared to stopping a medication, PCPs were more likely to change medication doses (p<0.0001), and more likely to adjust an oral anti-diabetes medication or insulin dose than hypertensive or anti-lipid medications (p<0.0001).  They were also more likely to accept a recommendation if the total DSC-Type 2 symptom severity score was higher (p=0.045). The higher the number of glucose readings submitted by patients the greater the odds of an IDEATel recommendation being accepted (p=0.014). The odds of a PCP accepting a recommendation from the diabetes case management team was greater if the PCP was female (p=0.097) and White (p=0.0028). The greater the impact of telemedicine on patients’ knowledge, adherence, and satisfaction, the greater the odds of an IDEATel recommendation being accepted (p=0.0023).

In conclusion, we identified factors associated with PCP acceptance of the telemedicine diabetes team recommendations, with changes in glycemic control medications being well-accepted and with greater acceptance over time. This suggests that telemedicine can be a helpful to PCPs in providing diabetes care.

 

Disclosure: RSW: Investigator, Medtronic Minimed, Investigator, Eli Lilly & Company, Investigator, Sanofi, Investigator, Novo Nordisk, Investigator, Intarcia, Investigator, Biodel. Nothing to Disclose: REI, DW, DH, WP

13502 24.0000 MON-0972 A An Interactive Diabetes Case Management Model with Primary Care Providers and a Diabetes Team Using Telemedicine in the Upstate Cohort of Ideatel 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Pham Thu Ha*1, Nguyen Khoa Dieu Van1, Gunjan Yogendra Gandhi2 and Geoffrey Steven Gates3
1Bach Mai Hospital, Hanoi, Vietnam, 2Mayo Clinic, Jacksonville, FL, 3Mayo Clinic Emeritus, Duluth, MN

 

The etiology of diabetes requiring the use of scarce hospital resources has implications for healthcare policy in Vietnam, where the prevalence of diabetes is increasing. Outpatient surveys in Vietnam found a positive association between diabetes and increasing age, sex, waist-hip ratio (WHR) and body mass index (BMI). We conducted a descriptive study of adult Vietnamese patents with newly diagnosed diabetes requiring hospital admission, as there is currently no available data in this population. We recruited 53 patients with a new diagnosis of diabetes presenting with symptomatic hyperglycemia with or without ketoacidosis who were admitted to Bach Mai Hospital, a large public hospital in Hanoi.  Measures of beta cell function, insulin resistance and autoimmunity were obtained when patients were stable. The group comprised 31 males and 22 females. Age ranged from 20 to 73 years with a median of 46 years. Only 3 patients were overweight. BMI and WHR were 19.8±2.8 kg/m2 and 0.84±0.07 for study males and 21.0±2.6 kg/m2 and 0.86±0.06 for females respectively. BMI and WHR in the study were less than for outpatient diabetes and comparable to the general population. Only 2 patients had a family history of diabetes. All but one patient reported weight loss. Five male patients met full ADA criteria for diabetic ketoacidosis. All patients had ketonuria and 26 had mild acidosis. Plasma glucose on hospital admission ranged from 258 to 1186 mg/dl with a median of 371 mg/dl. HbA1c was 11.9% ±3.0. We used the HOMA2 calculator for 46 patients just prior to discharge whose insulin values fit within the allowable range. Results included %B 46.2±33.5, %S 76.1±25.9 and IR 1.5±0.5. Glucose and C-peptide were measured 30 minutes before and after a 75 gram glucose drink. For 35 patients, C-peptide after an OGTT increased ≤ 0.20 nmol/L, indicating a severe loss of beta cell function. Only two patients had a C-peptide stimulated by hyperglycemia that was above the normal range for fasting. No patient had a positive screen for autoimmunity with GAD65ab. Most of the patients who were admitted to a public hospital in Vietnam with newly diagnosed diabetes had significant loss of beta cell function without significant insulin resistance. Autoimmunity as a cause for diabetes, even with ketoacidosis, could not be demonstrated by testing for GAD65ab. The etiology for the profound loss of beta cell function in this subset of lean adults remains to be determined.

 

Nothing to Disclose: PTH, NKD, GYG, GSG

14231 25.0000 MON-0973 A New Onset Diabetes in Vietnam Requiring Hospital Admission Is Caused By Beta Cell Dysfunction, Not Insulin Resistance 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Amy Anicete Lopez*1, Erick Sta. Rosa Mendoza2, Valerie Ann Uy Valdez1 and Leilani Basa Mercado-Asis3
1University of Santo Tomas, Manila, Philippines, 2University of Santo Tomas, Manila City, Philippines, 3Univ of Santo Tomas, Quezon, Philippines

 

Attainment of HbA1c goal results in decreased microvascular and macrovascular complications of diabetes mellitus.To demonstrate the successful attainment of HbA1c goal (<7% for age <60 years and  < 7.5% for age ≥ 60 years or with chronic kidney/liver disease) our group utilized a  stepwise algorithm of insulin combination therapy. This is a descriptive review of records of  109 patients seen at an Endocrinology referral clinic using such an algorithm consisting of the following: regimen A - oral (metformin/glitazone with SU and/or DPP IV inhibitors) ; regimen B - basal + oral; regimen C - basal + premeal bolus ± oral; regimen D - premix 70/30 TID premeal or premix 70/30 BID + prelunch bolus ± oral; regimen E - premix 70/30 BID  + premeal bolus ± oral; regimen F- premix 70/30 BID  + premeal bolus + basal ± oral. All received automatic snacking 2 hours after main meals, a regimen proven to prevent hypoglycemia. Patients’ profile were: mean age 59± 12 years, diabetic for 9 ± 6 years; and 65% obese. Co-morbidities included hypertension (52%), chronic kidney disease (33%), dyslipidemia (20%), ischemic heart disease (8%), and chronic liver disease (3%). Mean baseline HbA1c was 10 ± 2%.  All regimens were able to reduce HbA1c, those that were able to attain goal HbA1c in >50% of patients were regimens A,C and D,  the greatest HbA1c reduction was by  regimen F, by 2.6%. A total of 8 patients reported hypoglycemia, majority using regimen F (62%). Mean weight gain was 2 ±5 kg.

Conclusion: Individualized approach in attaining HbA1c goal is achieved through stepwise algorithm of combination insulin therapy.

 

Nothing to Disclose: AAL, ESRM, VAUV, LBM

14512 26.0000 MON-0974 A Attainment of HbA1c Target through Stepwise Algorithm of Insulin Combinations in Type 2 Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Kalpana Dash*1 and Chiranjit ROY2
1Apollo Hospital, Bilaspur, India, 2Apollo Hospitals Bilaspur, Bilaspur, India

 

Diabetes mellitus (DM) is emerging as a major health-care challenge for India. According to the World Health Organization (WHO) estimates, India had 32 million diabetic subjects in the year 2000 and this number is predicted to increase to 80 million by the year 2030[1]. There are different types of diabetes; most common form is type 2 diabetes mellitus (90%). Commonly we classify diabetes as Type 2 diabetes mellitus, type 1 diabetes mellitus and GDM[2]. However, we also see other types of diabetes like GDM, MODY, NIDDY and secondary diabetes in our OPD. We analyzed 3581 diabetic patients in a tertiary care center, Endocrine clinic based at central India.  We found that majority (95.89%, n=3434) of our patients were type 2 diabetes mellitus, 103 (2.87%) were type 1 diabetes mellitus and others were 44 (12%). Out of total 3581 patients, 162 (4.52%) patients are less then 30 years of age, 2815 (78.60%) patients were between 30-60 years of age and 604 patients were more then 60 (16.86%) years of age. Hence there was clustering of diabetes between ages of 30 – 60 years. Mean age 51.34 years. Among 3434 type 2 diabetic patients, maximum no of patients were 2769 (80.63%) belonging to the age group of 30-60 years. Among all type 1 diabetes patients (103), mean age was 21.81 Years. 86 (83.49%) belonged to age less than 30 years, 15 (14.56%) patients were between 30-60 years and only 2 (1.94%) cases were more than 60 years. We found, very few numbers of other types of diabetic patients. Among them are, 17 MODY (0.47%), 13 NIDDY (0.36%), 7 GDM (0.19%) and only 5 cases secondary diabetes (0. We conclude that our diabetic population consists of, mostly type 2 diabetes. Next common types of diabetes were type 1 diabetes and very few belonged to other types of diabetes.  Among all diabetic patients, secondary diabetes patients were very few.

 

Nothing to Disclose: KD, CR

14518 27.0000 MON-0975 A Spectrum of Diabetes Mellitus in Central India 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Rachel Coleman-Pierron*1, Carrie Caruthers1, Catherine Hebert1, Betty Lo1, Robert Richards2, Lydia Melendez2, Yong Yi3, Jorge Martinez1, Lee Engel1, William T Cefalu2 and Karen Friday2
1LSUHSC-New Orleans, New Olreans, LA, 2LSUHSC-New Orleans, New Orleans, LA, 3LSUHSC-New Orleans

 

Most Internal Medicine (IM) Residency programs integrate diabetes care into regularly scheduled continuity clinics. LSUHSC–New Orleans IM Residency program created Diabetes (DM) Continuity Clinics attended by residents monthly, and staffed by Endocrinologists. Patients in DM clinics and General IM Residency clinics with diabetes between 2008-2011 were identified. Labs and vitals were analyzed at baseline and follow-up. Categorical residents (CR) who participate in the DM Continuity Clinics and Medicine-Pediatric residents (MP) who do not participate were anonymously surveyed about their experience treating diabetes.

1,255 patients with diabetes were identified–1,010 in the General IM clinics (control group) and 245 in dedicated DM Continuity clinics (test group). Gender and age distribution were similar. Baseline hemoglobin A1C (A1C) for the control group was 7.88% with follow-up 7.83% while test group had baseline A1C of 9.54% with follow-up 8.53%, statistically significant between the groups (p<0.01). There was no significant difference for the Low-Density Lipoprotein value between the two groups at baseline; yet, both groups decreased from baseline to follow-up. There was a statistically significant difference in change of total cholesterol for these groups (p<0.01), control group decreased by 9.8 mg/dL compared to test group by 30.7 mg/dL. Thirty-Three percent of control group had blood pressure goal of 140/80 initially with improvement to 40% at follow-up, while 45% of test group were at goal with improvement to 59% at follow-up. Both groups had significant decreases (p<0.01), but magnitudes of decreases were not significant.

Although not statistically significant, 37.04% of CR felt very competent treating diabetes compared to 15.79% of MP. Forty-four percent of CR felt very comfortable initiating or modifying a medication regimen for patients with uncontrolled diabetes compared to 10.53% of MP (p 0.014).  Seventy percent of CR felt participating in the monthly DM continuity Clinic was beneficial to them as residents, but there was no difference between the DM continuity and the General IM clinics when comparing satisfaction in treating diabetes.

Dedicated DM Continuity Clinics demonstrate improvement in patient outcomes in diabetes patients with regards to A1C and total cholesterol compared to patients with diabetes treated in the General IM clinics. Residents reported higher rates of confidence in changing diabetes medicines after participating in continuity clinics staffed by endocrinologists.  Extending this novel concept to other IM Residency programs could potentially strengthen the training of Internists to better treat and manage patients with diabetes.

 

Nothing to Disclose: RC, CC, CH, BL, RR, LM, YY, JM, LE, WTC, KF

15120 28.0000 MON-0976 A Diabetes Clinic Benefits Patients and Residents 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Douglas Weed*1 and Michelle Althuis2
1DLW Consulting Services LLC, Salt Lake City, UT, 2EpiContext, Washington, DC

 

Evaluating Confounding Bias When Designing Meta-analyses of Dietary Risk Factors with Weak Associations: a Systematic Review of Risk Factors for Type 2 Diabetes.

Douglas L. Weed, MD, PhD,1 Michelle Althuis, PhD.2

1 DLW Consulting Services, Salt Lake City, UT

2 EpiContext, Washington DC

Planning meta-analyses of weakly associated dietary factors is complicated by the fact that epidemiological studies often measure diet only at baseline and have limited capacities to control for known confounders in studies of long duration.  Because weak associations are sensitive to uncontrolled confounding, we present a systematic method for identifying and rank ordering potential confounders of dietary risk factors and type 2 diabetes (T2D) prior to meta-analysis.  A systematic review of meta-analyses of prospective studies of T2D identified the strength of association (including dose-response relationships) and usual practices for modeling risk factors in the primary studies.   45 risk factors for T2D were identified from 47 published meta-analyses. Body size was the strongest risk factor (RR pooled of obesity = 7.3 and RR pooled of overweight = 2.9). In addition to body size, meta-analyses adjusted for lifestyle covariates with established dose-response relationships: e.g. smoking (RR pooled=1.5-1.6), physical inactivity (RR pooled =1.4-1.5), and moderate alcohol consumption (RR~0.60-0.87).   Dietary risks of T2D were the focus of 28 meta-analyses revealing weak associations with RRs < 1.5, including diets high in processed meats (RR pooled =1.2-1.5) and eggs (RR pooled =1.42).  All meta-analyses of diet and T2D combined risk estimates from studies that adjusted for body size (including macronutrients fructose, sucrose and dietary sugars) except for a meta-analysis of sugar-sweetened beverages (RR pooled  = 1.26).  Because T2D risk is associated with many dietary factors that are considerably weaker than lifestyle factors, the relative strength of known confounders should be documented prior to summarization.  Current practice does not include this critically important step.  As a result, risk estimates from current meta-analyses may provide a precise estimate of average confounded effects rather than accurate estimates of effect.

 

Disclosure: DW: Consultant, The Coca Cola Company. MA: Consultant, The Coca Cola Company.

14859 29.0000 MON-0977 A Evaluating Confounding Bias When Designing Meta-Analyses of Dietary Risk Factors with Weak Associations: A Systematic Review of Risk Factors for Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Okpara Ukandu Igwe*1, Anthony Chinedu Anyanwu2, Oluwarotimi Bolaji Olopade3, Ope-Oluwas Fasanmade1, Nosariemen LILIAN Okonyia4, Toluwalope Adenike Adedugbe1, Olufemi Adetola Fasanmade1, Sandra Omozehio Iwuala5, Ifedayo Odeniyi1 and Augustine E Ohwovoriole6
1Lagos University Teaching Hospital, Lagos, Nigeria, 2Division of EDM, Dept of Medicine, Lagos University Teaching Hospital, Lagos, Nigeria, 3Lagos Univ Teaching Hosp, Surulere, Nigeria, 4LAGOS UNIVERSITY TEACHING HOSPITAL, LUTH., LAGOS, Nigeria, 5Lagos Univ Teaching Hosp, Lagos, Nigeria, 6University of Lagos, Yaba Lagos, Nigeria

 

Title: Audit of intermediate glycaemic outcomes among patients with type 2 diabetes in Lagos, Nigeria

Authors: Igwe OU*, Anyanwu AC*, Olopade OB*, Okonyia NL*, Adedugbe TA*, Fasanmade OO*, Fasanmade OA*, Odeniyi IA*, Iwuala SO*, Ohwovoriole AE*

*Endocrinology, Diabetes and Metabolism (EDM) Division, Department of Medicine, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria.

Contact: ukanduigwe@yahoo.co.uk

Key words: Diabetes, glycaemia, HbA1c, audit, outcome.

Background: Diabetes mellitus (DM) is associated with long term complications. Tight glycaemic control has been shown to reduce the risk of the microvascular, and to some extent, macrovascular, complications, among patients with type 2 DM. A medical audit assesses the adequacy of care with respect to the structure, the process and the outcome, with the aim of improving the standard of care. Glycaemic control can be assessed using the glycosylated haemoglobin (HbA1c), with a levels < 7% defining good glycaemia, according to the American Diabetes Association. HbA1c can be used to predict intermediate outcomes of DM. The number of people achieving target glycaemia is quite low in most centres. Glycaemic control can be a good tool to assess adequacy of care for patients with DM. There is a lack of Nigerian audit and clinical practice guidelines.

Objectives: In this study, we set to determine to what degree the care of our out-patients meet international standards in diabetes care using HbA1c as a measure of glycaemic control.

Methods: We analyzed the records of patients attending Diabetes Clinic over 1 year. Information sought included: age, sex, type of diabetes, weight, height, fasting and postpandrial blood glucose and HbA1c. Adequacy of glycaemic control was assessed using ADA standards to determine the proportion of our patients who meet these targets.

Results: Most of the patients were female (~62%). The age range was 23-95 years, with a mean of 59.0 (±11.8) and a mean body-mass index of 27.6kg/m2 (±5.5). Most of the study population (51.7%) were in the age range ≥60, while <6.4% were <40 years of age. The mean HbA1C in the study group was 8.0% (±2.4), with no significant difference between males (mean = 8.0%) and females (mean = 7.8%). Mean fasting blood glucose was 162.9mg/dl (±81.5), and mean 2h postpandrial blood glucose was 211.8mg/dl (±96.9). Thirty-eight percent of the population had an HbA1C <7%, 44.3% had 7-10%, while it was >10% in 18.6%.

Conclusion: The findings from the study were consistent with those reported in some other centres describing a lower proportion of the patients achieving target glycaemia, although our study population was a little aged and overweight. Improvement in care for the patients would likely lead to an improvement in their level of glycaemia.

 

Nothing to Disclose: OUI, ACA, OBO, OOF, NLO, TAA, OAF, SOI, IO, AEO

15335 30.0000 MON-0978 A Audit of Intermediate Glycaemic Outcomes Among Patients with Type 2 Diabetes in Lagos, Nigeria 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Nanwei Tong*1, Lizhi Tang1, Yuzhen Tong2 and Qiu Yang1
1West China Hospital, Sichuan University, China, 2Department of Clinical Medicine, West China School of Medicine, Sichuan University, China

 

Polymorphism of rs2293855 in gene MTMR9 has been associated with obesity and metabolic syndrome. Given that obesity and metabolic syndrome are characterized by insulin resistance, and both of them are key risk factors for prediabetes and T2DM, we hypothesize that rs2293855 in MTMR9 could also be associated with T2DM intermediate phenotypes. To analyze the association between rs2293855 with phenotypes of insulin secretion and insulin sensitivity derived from fasting and OGTT measures, the polymorphism of 838 individuals was genotyped by using Matrix-Assisted Laser Desorption/Ionization Time of Flight Mass Spectrometry (MALDI-TOF MS); all participants underwent a 75 g oral glucose tolerance test; associations between the polymorphism and glucose tolerance, indices of insulin secretion and indices of insulin sensitivity were comprehensively analyzed. We found that the GG homozygous presented higher fasting plasma glucose (FPG, P=0.009), higher 2h plasma glucose (P=0.024) and higher glucose AUC (P=0.01). Moreover, the G allele of rs2293855 was found to be associated with all measures of glucose tolerance (increased FPG, β=0.114, P=0.012; increased glucose AUC, β=0.3, P=0.006; increased 2-h glucose, β=0.323, P=0.024), it was also associated with decreased indices of insulin sensitivity (fasting insulin, β=0.048, P=0.043; Matsuda, β= ‒0.064, P=0.009; HOMA-IR, β=0.07, P=0.008) and decreased indices of insulin secretion (HOMA-B, β= ‒0.054, P=0.028; insulinogenic index, β= ‒0.116, P=0.003). In addition, we observed that the allele G was nominally associated with increased HbA1c (β=0.048, P=0.087). Furthermore, we found the G allele was significantly associated with increased risk of prediabetes (OR=1.463, 95%CI: 1.066‒2.009, P=0.018), indicating a 1.4-fold higher risk of prediabetes in carriers of the G allele than in AA homozygous. To conclude, our study showed the polymorphism of rs2293855 in MTMR9 was associated with measures of glucose tolerance, indices of insulin secretion and indices of insulin sensitivity. We speculate that allele G increase the risk of prediabetes by influencing both insulin secretion and insulin sensitivity.

 

Nothing to Disclose: NT, LT, YT, QY

12028 31.0000 MON-0979 A MTMR9 rs2293855 Polymorphism Is Associated with Glucose Tolerance, Insulin Secretion, Insulin Sensitivity and Prediabetes in a Chinese Population 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Justin Yoon*1, Meredith Akerman2, Ann Marie Hasse3 and Alyson K. Myers4
1Hofstra University - School of Medicine/ NS-LIJ Health System, Manhasset, NY, 2North Shore LIJ Health System, Manhasset, NY, 3North Shore University Hospital, Manhasset, NY, 4Northwell Health, Manhasset, NY

 

Background: Diabetes is one of the most common chronic conditions among Americans, affecting 11.3% of adults older than 20 years old.1   The chronicity of diabetes and end-organ complications of the disease add to the complexity of a patient’s ability to manage their diabetes.

Hypothesis: Provision of inpatient diabetes education classes for patients with diabetes will encourage them to have more confidence in goal setting upon discharge.

Methods: Group diabetes education classes, focusing on survival skills, were provided for hospitalized patients with diabetes at our institution. At the end of each session, a questionnaire about the improvement in the patient’s understanding of diabetes, goal setting, barriers to goal setting, and acknowledgment of their support system was distributed. Over a period of six months, forty six individuals filled out the questionnaire and the results were analyzed using the Fisher’s exact test to compare different demographic groups for each of the categorical variables. The data were grouped by gender, age (<60, 60+), ethnicity (Caucasian, African-American, other), length of having diabetes (<5 years, 5-10 years, 10+ years), or diabetes treatment (oral agent, insulin, combination/other/no treatment). 

Results/Conclusions: Majority of patients (n=22) had never attended a diabetes class, were male (n=24), over age 40 (n=38) and had diabetes for over one year (n=31). All agreed or strongly agreed that after attending the class they can set one goal for their diabetes care and create a plan to do so. Overall, patients noted confidence in diabetes care goal setting after a group class. Furthermore, there was no difference in confidence of patients across age, gender, duration of diabetes or diabetes treatment among the participants of the diabetes education session. Therefore, the group inpatient diabetes education may be beneficial for goal setting of diabetes care in adults of any gender, age, or treatment type.

 

Nothing to Disclose: JY, MA, AMH, AKM

15437 32.0000 MON-0980 A Patient Confidence in Diabetes Care Goal Setting after a Group Inpatient Diabetes Class 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Maximilian von Eynatten*1, Michael Lehrke2, Nikolaus Marx2, Sanjay Patel3, Thomas Seck4, Susanne Crowe4 and Odd Erik Johansen5
1Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, 2University Hospital Aachen, Aachen, Germany, 3Boehringer Ingelheim Ltd., Bracknell, United Kingdom, 4Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany, 5Boehringer Ingelheim Norway KS, Asker, Norway

 

Patients with type 2 diabetes mellitus (T2DM) are at an increased risk of serious complications such as cardiovascular disease and chronic kidney disease, and are often on multiple therapies. Thus, establishing the safety of T2DM agents is critical. This study evaluated the safety of the dipeptidyl peptidase-4 inhibitor linagliptin in patients with T2DM. Safety data were pooled from a multinational clinical development program of all available randomized, double-blind, placebo-controlled linagliptin trials lasting up to 102 weeks. Incidences of predefined adverse events (AE) were calculated with descriptive statistics; results were summarized by treatment group (linagliptin, placebo) overall and by estimated (Modification of Diet in Renal Disease formula) GFR category (< 60 [moderate, severe or end stage renal disease], 60 – <90 [mild renal disease], ≥ 90 mL/min/1.73 m2 [normal renal function]). Hypoglycemia was assessed descriptively and with an exploratory analysis based on the risk ratio, the respective 95% confidence interval (CI), and Fisher’s exact test. In total, 22 trials were included in the analysis involving 7400 patients (eGFR< 90: 60.8%) of whom 4810 received linagliptin 5 mg total daily and 2590 received placebo. The overall incidence of AEs or serious AEs (SAE) by various system organ classes including cardiac disorders, vascular disorders, infections and infestations, and gastrointestinal disorders (including pancreatitis) with linagliptin was similar to placebo (AE 57.3% vs. 61.8%; SAEs 4.8% vs. 6.4%, respectively). As expected, declining renal function was associated with a numerical increase in the incidence of AEs, but the incidences for linagliptin compared with placebo remained similar. A low risk of investigator-defined hypoglycemia was observed; the overall incidence rate was 11.5% for linagliptin as compared with 14.0% for placebo (risk ratio 0.82 [95% CI: 0.73 – 0.93; P=0.0021]). This pooled comprehensive safety analysis supports previous evidence that linagliptin is well tolerated overall and irrespective of renal function, with a low incidence of hypoglycemic events. Ongoing large outcome trials will provide further insights into the long-term safety profile of linagliptin.

 

Disclosure: MV: Employee, Boehringer-Ingelheim. ML: Speaker, Novo Nordisk, Speaker, Merck & Co., Speaker, Boehringer-Ingelheim, Speaker, Roche Pharmaceuticals, Speaker, Sanofi Aventis, Advisory Group Member, Astra Zeneca, Speaker, Bristol-Myers Squibb, Speaker, Astra Zeneca, Advisory Group Member, Bristol-Myers Squibb, Advisory Group Member, Roche Pharmaceuticals, Advisory Group Member, GlaxoSmithKline, Researcher, Merck & Co., Researcher, Boehringer-Ingelheim. NM: Speaker, Berlin Chemie, Speaker, Bristol-Myers Squibb, Speaker, Novo Nordisk, Speaker and Advisor, Merck & Co., Speaker, Boehringer-Ingelheim, Speaker, GlaxoSmithKline, Speaker and Advisor, Roche Pharmaceuticals, Speaker, Astra Zeneca, Advisory Group Member, GlaxoSmithKline, Advisory Group Member, Merck & Co., Advisory Group Member, Boehringer Ingelheim, Advisory Group Member, Bristol-Myers Squibb, Advisory Group Member, Novo Nordisk, Advisory Group Member, Astra Zeneca. SP: Employee, Boehringer-Ingelheim. TS: Employee, Boehringer-Ingelheim. SC: Employee, Boehringer-Ingelheim. OEJ: Employee, Boehringer-Ingelheim.

12997 33.0000 MON-0981 A Comprehensive Analysis of Safety Data Pooled from 22 Randomized Controlled Trials of Linagliptin in Patients with Type 2 Diabetes Mellitus with or without Renal Impairment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Shimon Harary*1, Tanganyika Barnes2, Adrian Padkowsky2, Ruchi Kumari2 and Steven Keller2
1Vanderbilt University Medical Center, Nashville, TN, 2University of Medicine and Dentisry-NJ Medical School

 

Background: Diabetes Mellitus (DM) is a chronic metabolic condition characterized by either the failure to produce insulin (Type 1 DM) or by insulin resistance leading to inability to appropriately utilize insulin (Type 2 DM).  According to the WHO approximately 346 million people are affected worldwide and it is projected that the number of diabetes-related deaths will double by the year 2030.  Given the prevalence of the disease, as well as the systemic complications associated with inadequate glycemic control, DM remains a major health burden and economic burden on the global community.  The aim of this community-based study was to determine how closely the resident physicians at UMDCare, the resident-run Internal Medicine clinic, adhere to national guidelines set forth by the American Diabetes Association (ADA).

Methods: Patients with DM being treated at the UMDCare Clinic were selected at random (n = 113).  A thorough chart review of the electronic medical record was subsequently performed to evaluate that the standards of care as delineated by the ADA were being followed.  These standards of care included routine HbA1c monitoring with established goals, LDL goals and annual ophthalmology and podiatry examinations or referrals.

Results: The mean age of the patient population for this study was 56.75 years and the sex distribution was fairly even with 48.6% females and 50% males.  Residents were found to perform routine monitoring of HbA1c 78.76% of the time with the mean HbA1c value of the study being 8.39.  The mean LDL was 95.3 however the percentage of patients at goal LDL was only 59%.  Referrals to ophthalmology and podiatry were 82% and 73%, respectively however documentation of the aforementioned referrals occurred in only 0% and 22% of the charts, respectively.

Conclusion: Routine monitoring of HbA1c values occurred in only 78% of patients indicating a need for more aggressive monitoring to ensure reduction of systemic complications associated with DM.  Although the mean LDL of the study was at goal with a value of 95.3, only 59% of patients were at goal indicating the need for more aggressive counseling on lifestyle modifications, introduction of lipid-lowering agents and ensuring appropriate dosing of lipid-lowering agents.  The study revealed that only 22% of patients had documented foot exams suggesting that residents need to remain cognizant of performing annual foot exams.  Despite a referral rate of greater than 80% to ophthalmology, none of the patients in the study had any documentation of the ophthalmology visit indicating the need for unification of the electronic medical record to allow the various medical specialties access to patient records in their entirety.

 

Nothing to Disclose: SH, TB, AP, RK, SK

15492 34.0000 MON-0982 A Evaluation of Physician Compliance with Guidelines for Management of Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Jamal Ahmad*, Mohammad Zubair, Km Neelofar, Zephy D and Alok Raghav
Aligarh Muslim University, Aligarh, India

 

Although optimizing glycemic and non-glycemic targets reduced micro- and macrovascular complications in type 2 diabetes, multiple barriers hinder turning evidence into practice. Mounting evidence suggests that those with onset of disease in early or mid-adult life, compared with those with onset at an older age, may have a more severe disease course and worse glycemic control. In this study, we tested the hypothesis that those diagnosed at younger age would have worse glycemic control, even after adjustment for duration of diabetes, higher BMI and other known risk factors for worse glycemic control. A cross-sectional analysis of 560 type 2 diabetic subjects from North Indian populace in the year 1999-2012 who reported to endocrine clinic was performed. Sixty patients did not report in the successive year and final data analysis were done in 500 patients attending clinic regularly over a period of 10 years for evaluation of glycemic and non-glycemic targets. None of the patients were insured. They were paying the cost of investigations and purchasing medicine on their own.  They were followed up at 3 monthly intervals with all patients undergoing anthropometric measurement (BMI= weight in kg/height in m2), diet and lifestyle advice by a diabetic educator and consultation by endocrinologist. Fasting and postprandial plasma glucose, A1c (3 monthly), besides evaluation of SMBG (in 50 % of these patients regularly) was performed. Fasting lipids, S.creatinine and microalbuminuria were assessed annually and blood pressure recoding was done at each visit. The treatment was modified as per the investigation reports. We classified age at diabetes diagnosis as younger (<60 yrs) vs older (≥60 yrs). The primary outcome of interest was HbA1c ≥9%. Secondary outcomes were HbA1c ≥8%--<9% and HbA1c ≥7%--<8%. After adjustment for sex, duration of diabetes, hyperglycaemic medications, BMI, co-morbid conditions, age <60 years at diagnosis remains significantly associated with greater odds of HbA1c ≥9% [OR 0.95(0.84-1.07)], HbA1c ≥8%--<9% [OR 1.04(0.93-1.15)] and HbA1c ≥7%--<8% [OR 1.05(0.85-1.17)] for female sex. Seventy two (72.7%) of patients <60 years achieved BP <140/90 mmHg (p<0.001) as compared to 62.3% of patients ≥60 years who achieved BP <150/90 mmHg (p<0.001) and LDL-cholesterol <100mg/dl in 33.7% patients and 39.1% respectively (p<0.002). it is concluded that younger age (<60 years) at type 2 diabetes diagnosis is significantly associated with worse subsequent glycemic control and lipid control , as younger patients at diagnosis have fewer competing co-morbidities and complications. As patient-centredness is a priority in type 2 diabetes care, safe, aggressive  and individualized treatment could benefit this higher- risk group.

 

Nothing to Disclose: JA, MZ, KN, ZD, AR

13702 35.0000 MON-0983 A Glycemic and Non-Glycemic Targets in Younger and Older North Indian Subjects with Type 2 Diabetes in a Tertiary Care Hospital: A 10 Years Retrospective Data Analysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Smita Jha*1, Gopakumar Nair2, Jaymin Patel3, Ashmeet Bhatia3, Shant A Parseghian4 and Stewart Gary Albert5
1National Institute of Health, Bethesda, 2Brockton Hospital, 3North Shore Medical Center, 4NSPG, Winchester, MA, 5St Louis Univ Sch of Med, Saint Louis, MO

 

Introduction

Diabetic ketoacidosis is a common complication of Diabetes Mellitus with over 120,000 hospital discharges in 2005.1 However; most endocrinologists have an office-based practice and may not be able to evaluate patients with ketoacidosis admitted to a hospital on an urgent basis. The purpose of this study is to determine if evaluation by an endocrinologist within twenty-four hours of a patient’s presentation improves outcomes in a protocol-based management of diabetic ketoacidosis in a community hospital.

Methods and Materials

 

Hypothesis

There is NO difference in outcome between patients with diabetic ketoacidosis evaluated by endocrinologists within twenty-four hours of presentation to the ER and those evaluated later or not evaluated in a community hospital setting with a protocol based management approach.

Retrospective cohort study with data collected primarily through chart reviews.

Inclusion criteria for subject selection was all adults aged > 18 years admitted in 2010 and 2011 with the diagnosis of DKA. Patients admitted for surgical services and those aged <18 years were excluded from the study. Also, patients transferred to outside hospitals, discharges against medical advice/ patients that expired in < 24 hours were excluded.

Length of hospital stay was our primary outcome while time to correction of anion gap (<12 meq/L), time to reach blood sugar < 250 mg/dl, incidence of hypoglycemia, hypokalemia and hypophosphatemia and time to reach bicarbonate > 20 mg/dl were regarded as secondary outcomes. T-test, multiple regression analyses and MANOVA was used to analyze continuous variables and to correct for baseline difference in demographics while Chi-square test was used to analyze categorical variables.

Results

Length of hospital stay

There were no statistical or clinically relevant differences between the two groups.

There were 90 with type 1 and 15 with type 2. Those with type 2 had a longer length of hospitalization 7.9 ± 9.1 days vs type 1 with 5.3 ± 3.5 days (p=0.03). The length of hospitalization in those with type 2 was 4.6 ±1.9 days in the 9 who received consultations and 12.2 ± 13.2 days in the 6 who did not (p=0.004) suggesting a benefit of Endocrinology consultation in Type 2 diabetics with ketoacidosis. There was no benefit of performing consultations in those with type 1.

There was a difference in the length of hospitalization depending upon the severity of the DKA. Interestingly, those with mild DKA had more prolonged hospitalization. (mild: 7.7 ±8.5 days, moderate: 5.2 ±2.3 days, severe: 4.9 ±2.1 days, p = 0.046).  This difference was not noted in patients with only DKA and no other secondary illness. (mild 4.5 ±1.9 days, moderate 4.8 ±2.1 days, severe 4.7 ±2.0 days, p=not significant)

No statistically significant difference was noted in any of the measures of secondary outcome.

We suggest no benefit of urgent Endocrinology consult for diabetic ketoacidosis.

 

 

 

Nothing to Disclose: SJ, GN, JP, AB, SAP, SGA

15527 36.0000 MON-0984 A Exploring the Benefits of Early Endocrinology Consultation for Diabetic Ketoacidosis in a Community Hospital Setting 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Timothy Reid1, Ling Gao2, Jasvinder Gill3, Andreas Stuhr*3, Louise Traylor3, Aleksandra Vlajnic3 and Andrew Rhinehart4
1Mercy Diabetes Center, Janesville, WI, 2Analysta Inc., Somerset, NJ, 3Sanofi US, Inc., Bridgewater, NJ, 4Johnston Memorial Diabetes Care Center, Abingdon, VA

 

Current treatment guidelines suggest that treatment of prandial glucose excursions should be considered if daily doses of basal insulin (INS) exceed 0.5 IU/kg.

We pooled patient-level data from 15 treat-to-target (FPG < 100 mg/dL) RCTs of insulin glargine in T2DM patients to investigate the characteristics and outcomes in patients on high INS doses.

During 24 weeks of treatment 1,075, 453, and 111 patients exceeded INS doses of > 0.5, > 0.7, and > 1 IU/kg, respectively. Those exceeding doses of > 0.5, > 0.7, and > 1 IU/kg were younger (55.6 vs 59.0 years, 54.6 vs 58.3 years, and 52.8 vs 57.9 years, respectively; all P < 0.05), had shorter T2DM duration (8.2 vs 9.5 years, 8.1 vs 9.2 years, and 7.6 vs 9.1 years; all P < 0.05), higher baseline A1C (9.0 vs 8.6 %, 9.2 vs 8.7%, and 9.2 vs 8.8%; all P < 0.05), and tended to have higher baseline weight (88.2 vs 85.6 kg, 89.2 vs 86.1 kg [both P < 0.05], and 89.8 vs 86.5 kg [P > 0.05]). A1C reductions from baseline to Week 24 were also lower and weight gain higher vs patients not exceeding dose cutoffs (A1C: −1.49 vs −1.61%, −1.43 vs −1.59%, and −1.26 vs −1.57%; all P < 0.05; weight: +2.41 vs +1.38 kg, +2.38 vs +1.67 kg [both P < 0.05], and +2.32 vs +1.77 kg [P > 0.05); those with INS dose > 1 IU/kg were less likely to reach A1C < 7.0% at Week 24 (33.0% vs 45.8%; P < 0.05). During the treatment period, hypoglycemic event rates (modeled considering baseline characteristics) were consistently lower in patients exceeding dose cutoffs compared with those who never reach the high dose cutoff. Foroverall hypoglycemia (with blood glucose < 70 mg/dL and including events requiring third party assistance), event rates per patient-year in patients exceeding vs not exceeding > 0.5, > 0.7, and > 1 IU/kg were: 3.40 vs 4.70, 2.67 vs 4.49, and 1.87 vs 4.28, respectively; all P < 0.05. For nocturnal hypoglycemia with blood glucose < 70 mg/dL, event rates per patient-year were 0.60 vs .0.85, 0.39 vs 0.82, and 0.34 vs 0.76, respectively all P < 0.05. In those exceeding the dose cutoffs, the hypoglycemic event rate prior to exceeding the cutoff was lower than after exceeding the cutoff. For overall hypoglycemia, event rates per patient-year prior to and after exceeding > 0.5, > 0.7, and > 1 IU/kg were 1.55 vs 4.49, 1.12 vs 3.90, and 0.71 vs 2.85, respectively. For nocturnal hypoglycemia, event rates per patient-year were 0.27 vs 0.85, 0.12 vs 0.59, and 0.11 vs 0.46, respectively. Event rates also decreased as the dose cutoff level increased.

In certain patients, low hypoglycemia rates permit continued titration of INS > 0.5 IU/kg, but this does not further improve glycemic control and leads to weight gain. In such patients, supportive of current guidelines, prandial therapy may be required.

 

Disclosure: TR: Speaker/Consultant/Advisory Board Member, Eli Lilly & Company, Speaker/Consultant, Boerhinger Ingelheim/Lilly, Speaker/Consultant/Advisory Board Member, Janssen, Speaker/Consultant/Advisory Board Member, Sanofi, Speaker/Consultant, Novo Nordisk, Speaker/Consultant/Advisory Board Member, BMS/AstraZeneca. LG: Consultant, Sanofi. JG: Employee, Sanofi, Employee, Sanofi. AS: Stock ownership, Roche Pharmaceuticals, Employee, Sanofi, Employee, Sanofi. LT: Employee, Sanofi, Employee, Sanofi, Spouse employee, Bristol-Myers Squibb. AV: Employee, Sanofi, Employee, Sanofi. AR: Speaker Bureau Member, Sanofi, Speaker Bureau Member, Eli Lilly & Company/Boerhinger Ingelheim, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Janssen, Speaker Bureau Member, Forest, Speaker Bureau Member, Bristol-Myers Squibb, Ad Hoc Consultant, Sanofi, Advisory Group Member, Sanofi, Advisory Group Member, Boerhinger Ingelheim, Advisory Group Member, Janssen, Advisory Group Member, Amylin Pharmaceuticals.

15812 37.0000 MON-0985 A How Much Is Too Much? Outcomes in Patients Using High-Dose Insulin Glargine 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Patrick OJO Adunbiola*1, Anthony Chinedu Anyanwu2, Olufemi Adetola Fasanmade3, Fabian Puepet4, Esther Ofoegbu5, Bilikisu Mubi6, Okeoghene Anthonia Ogbera7, Ahanuwa Eregie8, Felicia Anumah9, Rosemary T Ikem10, Abdullahi Adamu11 and Augustine E Ohwovoriole12
1IRRUA TEACHING HOSPITAL, EKPOMA, Nigeria, 2Division of EDM, Dept of Medicine, Lagos University Teaching Hospital, Lagos, Nigeria, 3Lagos University Teaching Hospital, Lagos, Nigeria, 4University of Jos, Nigeria, 5UNIVERSITY OF NIGERIA TEACHING HOSPITAL, 6UNIVERSITY OF MAIDUGURI TEACHING HOSPITAL, 7c/o Dr FO Ogbera, Lagos, Nigeria, 8university of benin teaching hospital, 9AHAMADU BELLO UNIVERSITY ZARIA, 10Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria, 11university of ilorin teaching hospital, 12University of Lagos, Yaba Lagos, Nigeria

 

DISCORDANCE IN   ANTHROPOMETRIC INDICES OF TYPE 2 DIABETES MELLITUS MALE AND FEMALE PATIENTS IN NIGERIA.

BACKGROUND

Anthropometric indices are   important in the management and surveillance of various medical conditions. The impact   of sex on the analysis of anthropometric values in Nigerians with type 2 diabetes mellitus (T2DM) has not been adequately addressed nationally

OBJECTIVE/HYPOTHESIS

 The study  sought  to determine and compare the values of anthropometric measurement and indices in male and female Nigerians with type 2 DM.We hypothesizedthat there were  no sex differences in the anthropometric  values s ofNigerians with Type 2 diabetes mellitus

METHODOLOGY

  We pooled clinical and anthropometric data from charts of type 2 DM patients from eight centres across the health zones Nigeria. Data   included age, sex, type of diabetes mellitus, height (cm), weight (kg ),  waist and hip circumferences ( cm). The body mass index (BMI), waist - hip ratio and waist - height ratio were derived from the anthropometric measurements. The patients’ data were entered into Microsoft Excel spreadsheet, cleaned and transferred to  SPSSversion 20 for statistical analysis.Average values were expressed as mean (SD).  Group means were compared using student t test. Relationship between variables were determined using Pearson correlation coefficient. A p value of < 0.05 was considered statistically significant.

RESULTS

Atotal of 2480 DM patients (1069 male and 1141 female) patients   from eight centres across the six health zones of Nigeria had adequate data for analysis. The means of their age, weight, height, waist circumference, hip circumference, body mass index (BMI) and waist –hip ratio (WHR)were 53 years, 72kg, 1.6m, 91cm, 97cm, 26.50kg/m2  and 0.94cm respectively. About 2%, 39%,  39%,  and 20% were  respectively underweight,normal weight, overweight and obese. The male patients had higher weight, height and waist – hip ratio. The female patients had higher HC hip , BMI and waist – height ratio.Obesity was more prevalent in the female than male patients (29% V 14%). BMI  correlate best with waist circumference. Age correlated poorly with BMI, but moderately with  WC

CONCLUSION

Thereare statistically significant differences in the  valuesofweight, BMI , WHR , WHtR waist hip ratio and waist circumference . Obesity is much commoner in female than male Nigerian DM patients. Sex difference in  WC  is unclear from this study. More work is needed  to clarify    the  relationship of WC  to sex  as well as anthropometrics of  non-diabetic Nigerians

 

Nothing to Disclose: POA, ACA, OAF, FP, EO, BM, OAO, AE, FA, RTI, AA, AEO

16782 38.0000 MON-0986 A Discordance in Anthropometric Indices of Type 2 Diabetes Melliyus Male and Female Patients in Nigeria 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Selorm Adzaku* and Francesco De Luca
St. Christopher's Hospital for Children, Philadelphia, PA

 

The incidence of type 2 diabetes in children and adolescents has steadily risen over the past two to three decades.  Current treatment modalities to achieve glycemic control in this population include metformin and insulin.  A retrospective chart review of children and adolescents diagnosed with T2DM (diabetes mellitus in obese children with negative type 1 diabetes autoantibodies) at St. Christopher’s Hospital for Children between January 1st 2007 and December 31st2011 was performed. Data collected included age, BMI, blood glucose and HgbA1c at diagnosis and 1 year after diagnosis.

After excluding all the subjects with incomplete clinical data, 25 patients were identified. In 21 of these 25 subjects, there was a consistency of treatment between diagnosis and follow-up: on metformin alone at diagnosis and at 1 year (metformin group; n=8); and on insulin, with or without metformin, at diagnosis and at 1 year (insulin group; n=17).

At diagnosis, HgbA1c and blood glucose were significantly greater in the insulin group (insulin group vs. metformin group. HgbA1C: 10.84 ± 2.14 vs. 7.91 ± 1.4 %, p= 0.013. Blood glucose: 374.8 ± 152.8 vs. 175 ±52.9 mg/dl, p=0.0005). In contrast, there was no difference regarding mean age and BMI. 1 year after diagnosis, the metformin group experienced a modest decrease in HgbA1c, which did not reach statistical significance (-1.41 %; p= 0.051). Interestingly, the 3 subjects in this group with HgbA1C > 8 % at diagnosis did experience a significant HgbA1C decrease 1 year later. At 1 year, the insulin group’s HgbA1c was markedly and significantly lower compared to diagnosis (-3.16 %; p= 0.0003). No significant change of BMI between diagnosis and 1 year was found in neither group; however, at 1 year, BMI of the metformin group was significantly lower than that of the insulin group (28.7 ±4.6 vs. 36.4 ± 10.2, metformin group vs. insulin group; p= 0.029). Next, we grouped the patients treated with insulin at diagnosis as follows: those who were still on insulin at 1 year (n= 17) and those who were only on metformin by 1 year after diagnosis (n =4). At diagnosis, we found no difference between the 2 groups in terms of age, BMI, blood glucose, or HgbA1c. After 1 year, both groups experienced a similar and significant decrease of HgbA1c (-4.42 %, p= 0.024 in the insulin-to-metformin group; -3.16, p=0.0003 in the insulin group), with no difference of HgbA1C, blood glucose, or BMI between the 2 groups.

In conclusion, our findings suggest that metformin may help maintaining an adequate glycemic control in type 2 diabetes children 1 year after diagnosis, especially (but not only) in those with moderate hyperglycemia at diagnosis.

 

Nothing to Disclose: SA, FD

15838 39.0000 MON-0987 A Achieving Glycemic Control in Children with Type 2 Diabetes Mellitus 1 Year after Diagnosis: Efficacy of Different Treatment Regimens 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Ope-Oluwa Olufunmilayo Fasanmade*1, Oluwarotimi Bolaji Olopade2, Okpara Ukandu Igwe1, Olufemi Adetola Fasanmade1 and Augustine E Ohwovoriole3
1Lagos University Teaching Hospital, Lagos, Nigeria, 2Lagos Univ Teaching Hosp, surulere, lagos, Nigeria, 3University of Lagos, Yaba Lagos, Nigeria

 

Background:The prevalence of Diabetes Mellitus (DM) is increasing globally. This has been attributed to increase in the prevalence of obesity, sedentary lifestyle and westernization of our community. The mean age at diagnosis of Type 2 diabetes mellitus (T2DM) has been reported to be decreasing and this change may be attributed to an earlier onset of T2DM or earlier detection or a combination of both. There is also concern that T2DM may be occurring at a greater frequency in adolescents and in younger adults.  In Nigeria, there’s is scant data on the trend of the age at diagnosis of our T2DM patients.

Research question:What is the mean age at diagnosis of T2DM and what is the trend of the age at diagnosis of T2DM in Nigeria?

Methodology: It was a cross sectional study and the data was from the Diabetes Clinic Register of patients attending the Lagos University Teaching Hospital, Lagos, Nigeria. Information such as; date of Birth, sex, year of diagnosis, BMI (Body Mass Index), waist circumference were extracted. Data collected was analyzed using SPSS version 17. 

Results:Data of 396 subjects were analyzed. Of these, 243 (61.4%) were females, 153 (38.6%) males. Mean age of the subjects was 59.95±12.02 years. Mean age at diagnosis of the subjects was 50.84±12.09 years. Minimum age at diagnosis was 17years, maximum age was 82years. Mean age at diagnosis for females was 50.69 ± 12.05 years, while that of males was 51 ± 12.16 years(p= 0.762). 78 (19.7%) subjects were diagnosed at the age of ≤ 40years. Mean age at diagnosis gradually decreased from 72.33±12.08 years in subjects born in the 1920s to 26.20±5.26 years in subjects born in the 1980s. There was a weak inverse relationship between age at diagnosis and BMI(r = - 0.019, p = 0.709)). There was a similar though stronger inverse relationship between age at diagnosis and waist circumference (r = -0.1, p = 0.047). Over half (57.4%) of the subjects were diagnosed between 2001 to 2010.

Conclusion: Age at diagnosis of T2DM is reducing in Nigeria especially in the last 2 decades. These findings may be due to increasing westernization in the last 2 decades, increasing obesity or increased screening of the population which may be attributed to increased awareness of the disease by both healthcare professionals and patients. Waist circumference seems to strongly predict earlier age at DM diagnosis than the BMI.

 

Nothing to Disclose: OOOF, OBO, OUI, OAF, AEO

16812 40.0000 MON-0988 A Decade of Birth and Waist Circumference Influence Age at Diagnosis of Type 2 Diabetes Mellitus in Nigeria 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Aiqun Liu*1, Kim A Carmichael2, Martha Jean Riley3, Marilyn E Schallom1 and W Dean Klinkenberg1
1Barnes-Jewish Hospital, St. Louis, MO, 2Washington University School of Medicine, St. Louis, MO, 3Barnes Jewish Hospital, St. Louis, MO

 

Background: Diabetes Mellitus (DM) and prediabetes (PD) contribute significantly to the risk of stroke. Commonly found in the stroke population, unrecognized DM and PD, as well as undertreated hyperglycemia, increase not only the rates of stroke recurrence but also poor post-stroke outcomes. Identifying stroke patients with DM or PD and providing an appropriate anti-diabetic regimen during and after hospitalization are theoretically instrumental to the improvement of clinical outcomes. The purposes of this study are 1) to identify patients with elevated glycosylated hemoglobin (HbA1c) but with no history of DM and PD and 2) to evaluate the current practice in utilizing HbA1c measurement for diabetic screening and subsequent treatment among stroke patients in an acute care hospital setting. Methods: A total of 1095 adult patients who were hospitalized in 2012 with a principal diagnosis of stroke (ICD-9 codes) and a HbA1c charge code were identified. 200 patients were randomly selected for this retrospective chart review to evaluate the incidence of previously undiagnosed DM or PD, and the recommendations of diabetes treatment and follow-up care based on current ADA guidelines per HbA1c. Results: Among the 200 patients, 86 (43%) patients had previously known DM and 1 patient had PD. Among 113 patients with no previous history of DM or PD, 70 patients (61.9%) had HbA1c level in PD range (5.7%-6.4%) and 10 patients (8.8%) were in DM range (≥6.5%). Of the 10 newly diagnosed DM patients, 4 had DM acknowledged and received diabetes education, one received an endocrine consult. Six of the 10 were on in-patient insulin, 3 were prescribed diabetes medications post-discharge and 2 were recommended for diabetes follow-up care. No patients with PD were recognized to have this diagnosis. Three of the 45 patients (6.7%) with known DM and HbA1c ≥ 7% received a recommendation for diabetes follow-up care and 59% had adjustments in DM therapy before discharge. Patients with HbA1c > 6.5% were more likely to be readmitted for any reason within 1 year (33.3%) than patients with HbA1c between 5.7% and 6.5% (16.5%; χ2 = 6.61; p <.05). Conclusions: The majority of acutely admitted stroke patients without a history of DM or PD had HbA1c >5.7%. Newly diagnosed DM and PD patients received inadequate follow-up care per ADA guidelines. These findings provide significant opportunities for improvement in the management of patients with acute stroke.

 

Disclosure: KAC: Clinician, Merck & Co., Clinician, Jansen Pharmaceuticals. Nothing to Disclose: AL, MJR, MES, WDK

12673 41.0000 MON-0989 A Detecting and Managing Diabetes Mellitus and Prediabetes with HbA1c Measurement in Patients with Acute Stroke 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Syed Imran Ali*
Sindh Institute of Urology and Transplantation, KARACHI, Pakistan

 

Aims:
Insulin remains the mainstay of treatment for people with Type 1 diabetes and also in Type 2 diabetes when in cases of secondary drug failure it has to be given alone or in combination with oral antidiabetic agents. The use of this drug is limited by many barriers both from the patients as well as doctors. This study was done to assess the perceptions of patients about insulin and the phobias associated with its use amongst people with Type 2 diabetes from different socioeconomic backgrounds in Karachi. 

Methods:
Total 426 patients with Type 2 Diabetes who required insulin (as assessed by their physician) were administered a structured questionnaire. The study was conducted in three different areas of Karachi and patients were categorized on the basis of income into high, middle or low socioeconomic groups.

Results:
The age of the participants varied from 30 – 54 years with a male to female ratio of 1.13:1.0. 4.9% of participants had postgraduate education, 13.8% were graduates, 42.25% had attended secondary school and 38.9% were uneducated. All the subjects were from urban background with 28%, 42% and 30% belonging to high, middle or low socioeconomic groups respectively. The questionnaire assessed knowledge about benefits of insulin and the phobias prevalent in the community about it's use.

Only 29.8% of participants agreed that use of insulin can help them achieve good glycemic control and can prevent complications in the long term. As high as 85.6% said that they would be uncomfortable if prescribed insulin.

The phobias associated with use of insulin were prevalent. 70% of the patients said that the use of insulin means 'The beginning of the end' and stressed that it should be avoided at all costs. 21.3% went to extreme and labeled it a cause of early death. 36.8% attributed it to blindness, 45.5% calling it a cause of foot amputation and 52.5% said that it causes renal failure and eventually makes a person dependant on haemodialysis. The insulin phobia was found amongst people of all socioeconomic groups irrespective of their educational background.

Conclusion:
It is evident from this study that myths associated with use of insulin are prevalent in the Pakistani community and because the physicians do not give time to detailed education, the people gather information from non professional sources. It the need of the hour to start structured 'Diabetes Education Programmes' that can help reduce the negative perceptions of insulin, thereby improving quality of life and care for people with diabetes.

 

Nothing to Disclose: SIA

16120 42.0000 MON-0990 A Perceptions about Insulin Therapy Amongst People with Type 2 Diabetes in a Developing Country.a Study from Karachi, Pakistan 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Spyridoula Maraka*, Yogish C Kudva, Todd Andrew Kellogg, Maria L Collazo-Clavell and Manpreet Mundi
Mayo Clinic, Rochester, MN

 

Background: Bariatric surgery has been shown to significantly improve obesity related co-morbidities such as type 2 diabetes, hypertension, and hyperlipidemia.  Congruent to the overall increase in prevalence of obesity, increasingly patients with type 1 diabetes (DM1) are obese and experience weight related co-morbidities and insulin resistance.  Data is limited regarding differences in the impact of bariatric surgery on metabolic outcomes in patients with DM1 versus insulin requiring type 2 diabetes (IRDM2).  

Methods: Bariatric surgery database was analyzed for subjects with insulin requiring diabetes undergoing primary bariatric surgery after 2008 with additional information obtained from review of medical records.  Subjects with DM1 were compared with IRDM2 at baseline and 1 year post-surgery for: anthropometric measures, obesity related co-morbidities; HbA1c, daily insulin requirements, and number of medications (diabetes, anti-hypertensive, lipid lowering).

Results: Ten subjects with DM1 and 99 subjects with IRDM2 underwent primary bariatric surgery.  At the time of surgery, there was no difference between DM1 and IRDM2 groups in age (50.6 ± 8.8 vs. 54.7 ± 10.3 yr), BMI (44.3 ± 8.0 vs. 46.5 ± 9.1 kg/m2), and HbA1c (8.2 ± 1.6 vs. 7.8 ± 1.3 %) respectively.  Subjects with DM1 had longer duration of diabetes (20.6 ± 11.4 vs. 12.4 ± 7.5 yr), required less insulin (68.0 ± 37.4 vs. 122.8 ± 83.60 units), and used less diabetes medications (1.6 ± 0.5 vs. 2.5 ± 0.8) than IRDM2 subjects respectively.  Both DM1 and IRDM2 groups lost similar amount of weight 1 year after bariatric surgery (37.4 ± 12.0 vs. 37.4 ± 18.4 kg).  IRDM2 subjects had significant decrease in insulin use (pre- 122.8 ± 83.6 vs. post- 11.6 ± 26.7 units p-value <0.0001), diabetes medications (2.5 ± 0.8 vs. 0.7 ± 0.8 p-value <0.0001), anti-hypertensive medications (2.2 ± 1.3 vs. 1.2 ± 1.1 p-value <0.0001), lipid lowering medications (1.1 ± 0.8 vs. 0.6 ± 0.6 p-value <0.0001) and had a significant improvement in their HbA1c (7.8 ± 1.3 vs.6.6 ± 1.3 % p-value <0.0001). DM1 subjects had lower insulin requirements (68.0 ± 37.4 vs. 35.7 ± 14.4 units p-value 0.03), but did not show improvement in the number of medications used for diabetes (1.6 ± 0.5 vs. 1.8 ± 0.7) or HbA1c (8.2 ± 1.6 vs. 8.3 ± 1.3 %). Their use of lipid lowering medications improved (1.0 ± 0.5 vs. 0.6 ± 0.7 p-value 0.04) but there was no change in number of anti-hypertensive medications (2.1 ± 1.4 vs. 2.2 ± 1.6).

Conclusion: To our knowledge, this is the largest cohort reporting metabolic outcomes of patients with DM1 who have undergone bariatric surgery.  Our study found a decrease in insulin requirements, however no benefit in glycemic control as determined by HbA1c.  The only decrease observed in medications used was in lipid lowering medications.  Additional investigation is warranted; however improved glycemic control may not be an expected outcome when considering bariatric surgery in patients with DM1.

 

Nothing to Disclose: SM, YCK, TAK, MLC, MM

12825 43.0000 MON-0991 A Bariatric Surgery and Diabetes: Implications of Type 1 Versus Insulin Requiring Type 2 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Agnes Wahrenberg*1, Johan Hoffstedt2 and Hans Wahrenberg3
1Karolinska Institute, Stockholm, Sweden, 2Karolinska Institute, Stockholm, Sweden, 3Karplinska Institute, Stockholm, Sweden

 

Obesity is a major factor to poor glycaemic control in type 2 diabetes, contributing to micro and macro vascular complications. Sustained weight loss and improved glycaemic control has been achieved with bariatric surgery. However, surgery is not suited for all patients and the availability is limited. Thus, there is a need for more effective medical treatment programs for obese DM type 2 patients. We report the effects on weight and glycaemic control after 1 year of follow-up of a combined Very Low Calorie Diet (LCD) and a cognitive behavioural therapy program in a clinical setting. Obese type 2 diabetic patients with a BMI > 30 kg/m2 were voluntarily recruited from the referrals for poor glycaemic control after a motivating stay in the diabetic day-care unit at Karolinska university hospital. The intervention program consisted of 5 weeks LCD (~900 Kcal/day), followed by a 2 week transition to a normal diet. The participants met regularly in groups for psychological intervention (cognitive behavioural therapy, problem solving and coping activities) during 12 months. The diabetic group consisted of 91 subjects, 40 females and 51 men, with a mean age of 55±9 yrs, BMI 38±5 kg/m2 and HbA1c 67±8 mmol/mol (IFCC standard). There was no gender difference in the above parameters. Forty-four patients were on oral anti diabetic medication alone and 47 patients were on oral agents and supplemented insulin treatment. The mean weight loss (±SD) after LCD was 10 ± 3 kg (n=40) and after 12 months 11 ±7 kg (n= 30) in the female group. In men the mean weight loss after LCD was 13 ±4 kg (n=51) and 11 ±7 kg (n= 42) after 12 months. In females HbA1c fell from 69±4 to 58±4 (p<0,001) after LCD and remained at 56±12 at 12 months. In males HbA1c fell from 66±7 to 53±6 (p<0,001) after LCD and slightly increased to 58±8 at 12 months. The mean reduction of HbA1c at 12 months was 11 and 8 mmol/mol in females and males, respectively. Insulin sensitivity estimated by HOMA-IR improved by 50% in the female group but only 26 % in the male group. Of the 47 insulin treated patients, 20 could stop taking insulin and the mean insulin dose was reduced from 75±44 to 22±29 IU at the 12 month follow up. Nineteen patient dropouts occurred before the 12 month follow up due to various reasons. In conclusion, seventy-two patients followed through the 12 month program with a sustained mean weight loss of 10-11 kg corresponding to 10 % of initial body weight. This resulted in a mean reduction of HbA1c of about 10 mmol/mol which is in the same magnitude as the effect of the oral anti diabetic agents currently on the market. One of the drawbacks with insulin supplement in obese insulin resistant type 2 diabetes is that it promotes a vicious weight gain. In our program, 43% of the patients on supplemented insulin therapy could stop taking insulin and still achieve better glycaemic control, revealing the power of weight controlling programs in general diabetic care.

Nothing to disclose: AW,JH,HW

 

Nothing to Disclose: AW, JH, HW

16205 44.0000 MON-0992 A A Combined LCD and Psychological Intervention Program Effectively Prevents Weight Gain and Markedly Improves Glycaemic Control in Obese Type 2 Diabetics 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Olubunmi Anibaba, Tochukwu Igwe and Rhonda Kay Trousdale*
Harlem Hospital, New York, NY

 

 

 Background:  25.6 million adults in the US (11.3%) have diabetes mellitus (DM)1.  The prevalence of DM is higher in minority populations: 18.7% amongst blacks and 13.2% amongst Latinos2.  Interestingly, estimates of the prevalence of pre-diabetes (PDM) are similar at 35% for whites, blacks, and Hispanics1. 

Harlem Hospital has a predominant minority population with 48% blacks, 35% Latino and 17% other.  A Diabetes Clinic manages difficult diabetics.  Endocrine Clinic is for non-diabetic diseases (thyroid, adrenal, pituitary, and bone).  In July 2012, the Endocrine Clinic did not routinely screen for DM; screening was performed primarily by a general internist.  In August 2012, the Endocrine Clinic initiated an effort to increase screening for DM regardless of the referral diagnosis. 

Study Purpose:  Determine the rate of diabetes screening and prevalence of PDM/DM in patients referred to the Endocrine Clinic at Harlem Hospital before and after the clinic policy change on DM screening.

Methods: A retrospective chart review of all patients seen in Endocrine Clinic in July 2012 and July 2013 was performed. Criteria for diabetes risk were based on a limited version of standard American Diabetes Association (ADA) screening recommendations: 1) All patients age ≥ 45; 2) age <45 with a BMI ≥25 from high-risk race (Black, Latino or Asian).  PDM was defined as A1C 5.7-6.4 measured in prior 12 months; DM A1C ≥ 6.5.  Patients with a known diagnosis of DM were included in the screened category.  Screening rates and prevalence were calculated for each year.

Results: A total of 326 charts were reviewed: 182 from July 2012, 144 from July 2013. A total of 315 patients (96.6%) were identified as at-risk or known DM.  Only 33.5% were screened 12 months prior to July 2012.  Screening rose significantly to 83% for patients seen in July 2013 (p<0.001).  The prevalence rate of DM amongst screened patients was similar in 2012 (26%) and 2013 (27%).  The increased number of patients identified as having DM lead to a dramatic rise in the the calculated prevalence of DM in the Endocrine Clinic from 9% in 2012 (17/182) to 20% (30/144) in 2013. Prevalence of PDM also increased from 16% (30/182) in 2012 to 36% (52/144) in 2013.  The clinic prevalence rates for PDM and DM was notably lower than national average in 2012; improved screening in 2013 brought the prevalence rates at Harlem Hospital clinic in-line with the CDC estimates for minority patients.

Conclusion:  Harlem Hospital is an inner city hospital with a predominately minority population at high risk for diabetes.  In the non-diabetic general endocrine clinic, 96.6% of patients met ADA criteria for DM screening.  With a 2.5-fold increase in screening rates from 2012 to 2013, the number of patients identified with PDM was double and DM also was double.  Vigilant screening for diabetes and pre-diabetes is necessary for improving early diagnosis so intervention can be initiated promptly in a high risk population.

 

Nothing to Disclose: OA, TI, RKT

13444 45.0000 MON-0993 A Diabetes Screening in a High Risk Population at an Inner City Hospital 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Buthaina Almahmeed*1, Nashwah Taha2, Shelley Pallan3, Jeannette M Goguen4 and Geetha Mukerji1
1University of Toronto, Toronto, ON, Canada, 2University of Toronto, 3University of Toronto, Brampton, ON, Canada, 4St Michaels Univ Hosp, Toronto, ON, Canada

 

Title: Enhancing knowledge of hypoglycemia and driving guideline recommendations among patients with diabetes: a quality improvement project

Background: Hypoglycemia is commonly seen in patients with diabetes who take insulin or insulin secretagogues. Up to 60% of patients do not check their blood sugar before driving1. Many patients do not receive adequate physician counseling on hypoglycemia and driving.

Objectives: To assess and improve physician counselling rates, and improve patients’ knowledge of hypoglycaemia and driving guideline recommendations at the Diabetes clinic at St. Michael’s Hospital in Toronto using the Model of Improvement Quality improvement framework.

Methods: Eligible patients were a) patients with diabetes on insulin and/or an insulin secretagogue, and b) who were driving a private or commercial vehicle or had a valid driver’s license. Baseline chart review of patients between June 2013 – January 2013 was done to determine rates of physician counselling. Baseline patient knowledge was assessed between November 2013-January 2014 with a patient questionnaire. Adequate knowledge was deemed adequate if 3 out of 4key components of the driving points were recalled by patients: 1) keep a glucometer in the car, 2) keep simple carbohydrates in the car, 3) check blood glucose at least 15 minutes before driving and 4) check blood glucose every 4 hours during long drives.2 A patient educational pamphlet was designed via Plan-Do-Study-Act (PDSA) cycles as an intervention to improve patient’s knowledge, and outcomes will be assessed post-intervention.

Results: Preliminary results show that 77% (n=26) of new patients received counselling between June 2013-January 2013, whereas only 40% (n=278) of follow up patients received counselling. Of the new and follow up patients surveyed between November 2013 and January 2014, 31% and 33%, respectively, recalled 3/4 counselling points. Further data will be analyzed to determine if introducing a patient education pamphlet for both new and follow-up patients improves rates of physician counselling and patients’ retention of knowledge.

Conclusion: Preliminary data suggest that while most physicians are documenting counselling, this is not translating into increased patient knowledge. Therefore, a patient educational pamphlet will be implemented to enhance patients’ long-term knowledge.

 

Nothing to Disclose: BA, NT, SP, JMG, GM

16717 46.0000 MON-0994 A Enhancing Knowledge of Hypoglycemia and Driving Guideline Recommendations Among Patients with Diabetes: A Quality Improvement Project 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Chikezie Hart Onwukwe*1, Ukamaka Odife2, Okpara Ukandu Igwe3, Olufemi Adetola Fasanmade3 and Augustine E Ohwovoriole4
1Nnamdi Azikiwe University Teaching Hospital, Nnewi,Anambra State,Nigeria, 2Lagos University Teaching Hospital,Idi-Araba,Lagos State, 3Lagos University Teaching Hospital, Lagos, Nigeria, 4University of Lagos, Yaba Lagos, Nigeria

 

Correlation between Blood Glucose and Glycated Haemoglobin tests in Nigerians with Type 2 Diabetes Mellitus.

Authors: Hart Onwukwe1, Ukamaka Odife2, Ukandu Igwe2, Olufemi Fasanmade2, Augustine Ohwovoriole2.

  1. Endocrinology and Diabetes Unit, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra, Nigeria.
  2. Endocrinology, Diabetes and Metabolism Division, Lagos University Teaching Hospital (LUTH), Idi-Araba, Lagos, Nigeria.

Background: Good glycaemia in DM patients is associated with a reduction in long term complications based on findings from several intervention studies. Glycated haemoglobin and blood glucose tests are commonly used methods of monitoring glycaemia in patients with DM. The glycated haemoglobin assay test is the most acceptable measure of chronic glycaemia, though affordability of this test still limits its use in Nigeria where the cheaper blood glucose tests are used more. Studies done outside Nigeria have shown varying relationships between blood glucose and HbA1c assay tests. Data on such relationships are scanty in Nigeria.

Research question: Is there a significant relationship between blood glucose tests and HbA1c in Nigerians with type 2 diabetes mellitus?

Methodology: This is a chart review of type 2 DM patients seen in the Lagos University Teaching Hospital (LUTH) diabetes clinic over a two year period. Variables were extracted from the LUTH diabetes clinic register and include age, fasting blood glucose (FBG), two-hour post-prandial blood glucose (2hPP) and HbA1c at first presentation. Data were entered, cleaned and statistical analysis done with Microsoft Office Excel 2007. Data were expressed as mean + standard deviation and percentages. The two-tailed unpaired student’s t-test was used to compare means while Pearson’s correlation coefficient was used to test the association between blood glucose (FBG and 2hPP) and glycated haemoglobin. Statistical significance was set at p<0.05.

Results: The records of 712 type 2 DM patients [247 males (34.7%) and 465 females (65.3%)] were extracted. After data verification and cleaning, 222 of the patients [83 males (37.4%) and 139 females (62.6%)] with complete data were used for this study. Their overall mean age was 59.8 + 11.6 years (58.5 + 10.4 and 60.5 + 12.2 years for males and females respectively). Using IDF glycaemic targets, the proportion of patients with poor glycaemic control were 71.6%, 77.5% and 69.4% using FBG, 2hPP and HbA1c tests respectively. The females were older than males (p=0.21) while males had higher FBG, 2hPP and HbA1c (p=1.43, 4.68 and 1.33 respectively) than females.  The 2hPP test correlated better with HbA1c (r=0.37, p=9.59) than the FBG test (r=0.30, p=5.7).

Conclusion: The two-hour post glucose test correlated better with HbA1c than fasting blood glucose from this study. Hence two-hour post glucose test may be a surrogate for HbA1c in Nigerian patients with type 2 diabetes mellitus.

 

Nothing to Disclose: CHO, UO, OUI, OAF, AEO

15467 47.0000 MON-0995 A Correlation Between Blood Glucose and Glycated Haemoglobin Tests in Nigerians with Type 2 Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Hassan A-R Ibrahim*
Erbil (Layla Qasim) Diabetes Center,, Erbil, Iraq

 

Poor Awareness of the Right Injection Techniques Deteriorates Glycemic Control Among Insulin Treated Diabetic Patients 


Background:

Insufficient knowledge of injection technique contributes to errors in insulin use that may cause poor control and adverse patient outcomes. Knowledge of injection technique of insulin therapy among the insulin-treated diabetic patients has been poorly studied.


Objective:

To assess the knowledge of injection technique principles and to evaluate its association with sociodemographic and clinical characteristics of insulin treated diabetic patients. To investigate the impact of injection technique on diabetes control.


Methods

A 12-item, structured Injection Technique Knowledge (ITK) Questionnaire was used for data collection. The questionnaire was developed depending on Forum of Injection Technique recommendations (1). The participants (n=216) were categorised as having poor or acceptable scores if total percentage scores were ≤50 or >50, respectively.


Results

The mean percentage of ITK score was 47.5 ±19.5%, and only 31% (n=67) of the participants had acceptable score.  There was no significant association between place of residency, gender or age of the patients or duration of having diabetes and the ITK score. However, participants with higher level of education had significantly higher scores than those with lower levels (P < 0.005). Chi square test of associations also showed significant association between ITK scores category and type of diabetes, insulin regimen, insulin devices, glycemic control, prior training on the correct injection technique and previous lump formation at the site of injection.The results of logistic regression analysis showed that high school education (OR=4.56, 95% CI, P=0.027), prior training on the correct injection technique (OR=10.14, P=<0.001) and no previous lump formation at the site of injections (OR=3.9, P=<0.01) were predictors of acceptable scores on ITK. 51% of participants with poor ITK scores had poor glycemic control (HbA1c >9%) compared to 28.4% of the participants with acceptable ITK scores (P=0.005).


Conclusion:

This study showed that the majority of insulin-treated diabetic patients had knowledge deficit of the right injection practice. Delivering education about injection techniques among diabetics can result in better glycaemic control and outcome among insulin treated patients.


Reference:

1-   Forum for Injection Technique (FIT) (2010) The First UK Injection Technique Recommendations. Available at: http://bit.ly/woChLF

 

Nothing to Disclose: HARI

16724 48.0000 MON-0996 A Poor Awareness of the Right Injection Techniques Deteriorates Glycemic Control Among Insulin Treated Diabetic Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Naoya Emoto*1 and Rei Goto2
1NMS Chiba-Hokusoh Hosp, Chiba-ken, Japan, 2Kyoto University, Kyoto, Japan

 

The basic treatment for type 2 diabetes is dietary therapy and appropriate exercise, but improvement in these lifestyle habits is often difficult. To search for new solutions to problems in the treatment of type 2 diabetes, we focused on behavioral economic analysis and analyzed trends in patients with diabetes that have poor glycemic control from a neuroeconomic perspective.  We conducted a behavioral economic survey in 219 outpatients: 66 with type 1 diabetes and 153 with type 2 diabetes. Some of the survey questions are listed below.

QA: Suppose that there were a lottery worth 2000 yen (USD 20) with a 50% chance of winning. What is the most that you would pay for a lottery ticket?  I would pay up to    yen.

QB: Suppose that there were a lottery worth 100,000 yen (USD 1000) with a 1% chance of winning. What is the most that you would pay for a lottery ticket? I would pay up to    yen.

The survey response rate in patients with type 2 diabetes (71.9%) was significantly lower than in those with type 1 diabetes (87.9%) (p<0.05). QA and QB are standard questions that ask certainty equivalents for uncertain benefits. The mathematical expectation in both situations is 1000 yen (USD 10). These questions relate to willpower and the ability (quantitative literacy proficiency) to accurately understand the question and seriously respond with a quantitatively appropriate amount. If those who responded ≤1000 yen (USD 10) to both QA and QB are called “quantitative respondents”, in the age-45-to-under-65 group, the percentage of quantitative respondents was significantly lower in patients with type 2 diabetes (14%) than those with type 1 diabetes (42%) (p<0.05). In the under-age-45 (Type 1; 52%, Type 2; 50%) and the age-65-and-older groups (Type 1; 33%, Type 2; 30%), there were no significant differences between patients with type 1 and type 2 diabetes. Levels of HbA1c did not significantly differ between patients with type 1 and type 2 diabetes in any of the age groups.  Our survey from a behavioral economic perspective suggests that type 1 and type 2 diabetes are basically different diseases. In middle-aged patients with type 2 diabetes, quantitative literacy proficiency was lower. The low survey response rate may also be related to awareness of this low proficiency.  This lower literacy proficiency may play a role in the onset of type 2 diabetes, and with the additional factor of procrastination, this can lead to a worsening condition and progression of complications.

 

Nothing to Disclose: NE, RG

13316 49.0000 MON-0997 A Low Quantitative Literacy Proficiency in Middle-Aged Patients with Type 2 Diabetes Relative to Patients with Type 1 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Manmohan Kamal Kamboj*1, Jeff Lewis1, Belinda Seimer2, Linda Mount1, Bethany King3, Tracie Rohal1, Heather Yardley1, Setenay Kara1 and David Roy Repaske4
1Nationwide Children's Hospital, Columbus, OH, 2Nationwide Childrens Hospital, Columbus, OH, 3Nationwide Children's Hospital, Columbus, 4ED431, Nationwide Children's Hospital, Columbus, OH

 

Background: The health care environment is undergoing an immense change. Reduction in acute care utilization is the key to achieving optimal financial feasibility in this challenging health care environment along with promoting wellness and overall quality of life in the setting of chronic illness.  Patients and families with Type 1 diabetes mellitus (T1DM) face multiple challenges. Comprehensive management strategies may improve diabetes care and management, decrease acute hospital care, and improve quality of life (QOL). We were able to reduce the emergency room visits by implementing several interventions directed at improved communication and improvement in the diabetes care and knowledge.

Objective: A multidisciplinary “Intensity Clinic” offering comprehensive diabetes management to patients with high acute medical care visits was established with the primary aim of decreasing the number of acute care hospital visits and secondary outcomes of projected reduction in health care costs and overall improvement of QOL, over 1 year.

Design/Methods: 4 patients with high acute care visits were recruited to participate in this clinic. Clinic structure explained and permission obtained from families. The “Intensity Clinic” was held once a month in a half day clinic setting. At each visit: Each patient was seen by all team members in rotation, over about a 2 hour period. The multiple providers included: MD/APN, CDE, MSW, psychologist, and a RD. All patients/families had a phone follow-up from one of the providers, initially at least twice a week and then 1-2 times/week over the year based on individual needs. The clinic was run from 01/2013 to 12/2013. Acute care visits for all these patients were tracked on a monthly basis.

Results:

Pre-intervention:

Acute care visits (03/2012 - 10/2012) = 12

Projected healthcare expenditure = $ 89,593

Post-intervention:

Acute care visits (03/2013 - 12/2013) = 4

Projected healthcare expenditure = $ 3,942

QOL questionnaire reveals high level of satisfaction.

Significant decrease in DM related missed school days

Increased overall comfort and confidence in diabetes management and dealing with illness. Improved family dynamics and interactions were also reported. 

15.8% reduction in emergency room visits for patients with type I DM followed at Nationwide Children’s from 6.76 visits per 1,000 patients  in the initial baseline period of Jan 1st 2010 to Feburary 29th 2012, to  5.69 visits per 1,000 patients from March 1st 2012 to December 31st 2013.

Conclusion and projections: The expansion of the “Intensity Clinic” concept to a greater proportion of our T1DM patients in the “high utilizer of acute care “category” has the potential for a greater reduction in the acute care utilization, reduction in health care dollars, and a significant improvement in quality of life of these patients and families.

 

Nothing to Disclose: MKK, JL, BS, LM, BK, TR, HY, SK, DRR

16898 50.0000 MON-0998 A Reduction in Acute Care Visits for Patients with Type 1 Diabetes Mellitus through Comprehensive Management Strategies 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Volha Vasilkova*1, Arkadij Silin2, Victor Martinkov2, Elena Naumenko2, Margarita Zshmailik2, Kulyash Zekenova2 and Tatiana Mokhort3
1Gomel State Medical University, Gomel, Belarus, 2The Republican Research Centre for Radiation Medicine and Human Ecology, Gomel, Belarus, 3Belarusian State Medical University, Minsk, Belarus

 

Polymorphisms in angiotensin-converting enzyme (ACE) gene and angiotensin II type 1 receptor (AGTR1) gene have been assessed in previously multiple studies for association with diabetic nephropathy (DN), but results are still controversial. The aim of our study was to find out the role of ACE (I/D) and AGTR1 (A1166C) in genetic susceptibility of diabetic nephropathy in Belarusian population. The present case-control study investigated the association of the I/D polymorphism in the ACE gene and A1166C polymorphism in the AGTR1 gene with DN. The study included 101 patients with type 1 and type 2 diabetes (67 subjects with DN) and 100 normal controls. DNA was isolated from peripheral blood leucocytes, and genotyped using allele specific PCR (ACE ID) or PCR (AGTR1) methods. Genotype frequencies of the ACE (I/D) and AGTR1 (A1166C) polymorphisms were in accordance with the Hardy-Weinberg equilibrium. In subjects with DN, the frequencies of the DD, ID and II genotypes (ACE) were 0.409; 0.227 and 0.364 respectively. The frequencies of the AA, AC and CC genotypes (AGTR1) were 0.554; 0.355 and 0.091 respectively. We found no significant association of the ACE I/D polymorphism with DN in genotype, allele, dominant, and recessive models. Homozygosity for the A allele, of the AGTR1 (A1166C) polymorphism, was associated with increased risk of DN (OR=3.06; 99%CI=1.02-9.08), independently of the other associated variables: age, duration of diabetes, sex and HbA1c. Our data did not reveal significant association of the ACE I/D polymorphism with diabetic nephropathy. The risk of having diabetic nephropathy was increased in patients homozygous for the A1166 allele AGTR1 gene. However, more investigations are required to further this association.

 

Nothing to Disclose: VV, AS, VM, EN, MZ, KZ, TM

12808 51.0000 MON-0999 A Association of Angiotensin-Converting Enzyme (ACE) Gene Polymorphism and Angiotensin II Type 1 Receptor (AGTR1) Gene Polymorphism and Diabetic Nephropathy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Marisela Noorhasan*1, Irl B Hirsch2 and Dace Lilliana Trence3
1University of Washington, Seattle, WA, 2Univ of Washington Med Ctr, Seattle, WA, 3Univ of WA Medical Ctr, Seattle, WA

 

Objective:Evaluate glycemic control, measured by A1C and self-monitoring blood glucose (SMBG) and costs of glycemic control, when a transition from glargine to neutral protamine Hagedorn (NPH) insulin is made in obese, insulin resistant patients with Type 2 diabetes (T2DM) and Type 1 diabetes (T1DM).

Methods: Retrospective chart analysis from the University of Washington, of patients in whom a change in basal insulin from glargine to NPH could be documented from institutional pharmaceutical records within the past 7 years. Additional inclusion criteria included BMI greater than 30kg/m², average glargine dose >1.0U/kg, transition from glargine to NPH for at least 3 months, and availability of glucose meter downloads. Any other glycemic lowering drug additions or changes excluded those subjects. Validity of average glucose required SMBG three times daily over the course of one month. A1C and mean glucose ± SD data were collected. 

Results:Ten out of 184 subjects met inclusion criteria. Demographics: 3 T1DM, 7 T2DM, 4 M, 6 F.  BMI was 43±7kg/m², age 51±15 years. Insulin glargine, average total dose (TD)/Kilogram (Kg) was 0.68±0.31U/kg.  After switch to NPH, average NPH TD/Kg was 0.78±0.55U/kg, p = 0.31. Average A1C on glargine was 9.3±1.5 %, A1C on NPH 8.3±0.9%, p =0.041.  Average meter download SMBG was 209 ± 62 mg/dL on glargine while on NPH 188±56 mg/dl; p=0.123.  Cost analysis, as obtained from goodrx.com, based on averaged insulin cost from local regional pharmacies, showed glargine per person annually as $5994, NPH as $3325, P<0.0001.

Conclusions: Basal NPH insulin was more effective than glargine in lowering A1C values in these obese, relatively insulin resistant patients.  There was no difference between daily doses or meter download data for insulin glargine with NPH insulin.  This is likely due to the limitation of point in time fingerstick glucoses obtained, being typically limited to pre-meal determinations and bedtime. Of critical importance in an era of skyrocketing insulin costs, a significant cost savings can be seen in transition from glargine to NPH insulin.  At 2014 insulin costs, an estimated cost savings of $2669/ year/ person, in the setting of improved glycemic control, can be achieved. We conclude there is a large number of insulin resistant patients in whom NPH insulin should be strongly considered to be the basal insulin utilized, larger numbers of patients in prospective trials utilizing these larger insulin doses should be considered.

 

Disclosure: IBH: Study Investigator, Sanofi, Study Investigator, Halozyme, Consultant, Roche Pharmaceuticals, Consultant, Abbott Laboratories. DLT: stock holder, Sanofi, Investigator, Lilly USA, LLC. Nothing to Disclose: MN

12929 52.0000 MON-1000 A With Diabetes: Turn to the Past for Both Efficacy and Cost 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Yael Tobi Harris*1, Claudia M Elera2, Taylor B Gibbons3 and Nina Kohn4
1Hofstra NSLIJ School of Medicine, Great Neck, NY, 2North Shore-LIJ Health System, Manhasset, NY, 3Binghamton University, Binghamton, NY, 4Feinstein Institute for Medical Research, Manhasset, NY

 

Background: Diabetes Mellitus Type 2 (T2DM) affects over 25 million Americans, can lead to blindness, kidney failure and heart disease, and results in $176 billion in direct medical costs annually. Glycemic control, which improves patient outcomes, is often suboptimal in T2DM due to poor medication adherence. Although in chronic diseases a variety of barriers contribute to medication non-adherence, it remains unclear whether psychological factors contribute to the medication non-adherence seen in T2DM. Understanding these obstacles could lead to interventions improving patient care.

Methods: We performed a descriptive cohort study in an academic general endocrine practice. Patients were >/= 18 years, with T2DM, prescribed diabetes medication for at least 3 months. Survey questions addressed demographics, medical history, medication adherence (with the Morisky Medication Adherence Scale 8, a validated self-report measure), and barriers to adherence (using tools designed to reveal ambivalence about taking medication, cognitive distortions, socioeconomic barriers, co-morbid depression, and deficits in memory/cognition). Glycemic control was measured by HbA1c.

Results: 142 patients were recruited, with a mean HbA1c of 7.9% (+/- 1.9). The mean age was 57.4 (+/- 11.7) years. 50% of patients were male, 53% Caucasian, 18% black, 14% Hispanic/Latino, and 15% other. 47% of patients were employed, 28% retired, 25% unemployed/on disability. 87% of patients had at least one co-morbid condition and 56% had been prescribed 5 or more medications per day.  36% of patients reported high adherence to their diabetes medication, 36% moderate and 28% low adherence. Low adherence was associated with elevated HbA1c (Spearman correlation, r=-0.25, p<0.01).  Barriers associated with low adherence included high levels of concern about taking medications (r=-0.41, p<0.0001), and beliefs that medications are overused (r=-0.24, p<0.01), harmful (r=-0.21, p<0.02), and reduce patient control (r=0.34, p<0.0002) and self-image (r=0.33, p<0.0003). Notably, increased levels of cognitive distortions were correlated with lower adherence (r=-0.58, p<0.0001). Additional barriers were not getting refills on time (r=0.26, p<0.004), experiencing side effects (r=0.22, p<0.016) and financial factors (r=0.28, p<0.002).

Conclusion: Medication adherence is suboptimal among patients with T2DM.  Psychological barriers to adherence exist in this population that may be amenable to psychotherapeutic intervention.

 

Nothing to Disclose: YTH, CME, TBG, NK

12945 53.0000 MON-1001 A Barriers to Medication Adherence in Adult Patients with Type 2 Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Marcio Garrison Dytz1, Julia Mendes Melo2, Isabel Silva Santos2, Melanie Rodacki2, Flavia Lucia Conceicao2 and Tania Maria Ortiga-Carvalho*2
1Universidade Federal do Rio de Janeiro, Rio de Janerio, Brazil, 2Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil

 

Hereditary pancreatitis (HP) is an autosomal dominant condition, which results in recurrent attacks of acute pancreatitis, progressing to chronic pancreatitis often at a young age. It is believed that inappropiate intrapancreatic activation of zymogens by trypsin leads to autodigestion and pancreatitis (1). Mutations of the cationic trypsinogen (PRSS1), secretory pancreatic trypsin inhibitor 1 (SPINK1) and the cystic fibrosis transmembrane conductance regulator (CFTR) were described as resulting in hereditary pancreatitis (2). In patients with autossomal dominant traits the mutations N29I and R122H of PRSS1 are prevalent (3). We enrolled a family with hereditary pancreatitis with 16 members (7 HP patients and 9 unaffected relatives) and 15 healthy subjects served as controls. Informed consent was obtained. Clinical information was obtained from all subjects. DNA was extracted from whole blood samples and the exons 2 and 3 of the cationic trypsinogen gene and the exon 3 of the SPINK1 gene were amplified by polymerase chain reaction (PCR). The PCR products were purified with QIAquick PCR Purification Kit - Qiagen, and then the direct sequencing of the double-stranded PCR fragments was carried out with DNA ABI 3100 sequencer.We identified a mutation within the exon 2 of the cationic trypsinogen gene. That is a heterozygous A to C transition mutation at position 131945 (according to accession number U66061) which resulted in an N29T amino acid substitution. Ten members from HP family carried a cationic trypisinogen mutation, asparagine to threonine substitution at position 29 (N29T). All the seven symptomatic patients and three unaffected relatives had N29T mutation in heterozygosity.One reported neutral polymorphism in intron 2 of the SPINK1 gene (c.88-352A>G) was observed in all members of PH family (13 in homozygosity and 3 in heterozygosity) as well as in majority of controls (4 normals, 4 in homozygosity and 4 in heterozygosity). No alterations were found in exon 3 of cationic trypsinogen in our study.

To the best of our knowledge, that is the first description of cationic trypisinogen mutation leading hereditary pancreatitis in a brazilian kindred. The N29T mutation is very rare, but may have significant role in the pathogenesis of pancreatitis as the N29I mutation. In accordance with the literature, the brazilian kindred has high penetrance that is 70%. This study contributes to the epidemiological characterization of hereditary pancreatitis in Brazil and in the world.

 

Nothing to Disclose: MGD, JMM, ISS, MR, FLC, TMO

14627 54.0000 MON-1002 A Hereditary Pancreatitis with N29T Mutation of Cationic Trypsinogen in a Brazilian Family 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Meera Shah*1, Heidi A Apsey2, Joshua D Stearns2, Richard T Schlinkert2, Karen M Seifert2 and Curtiss Bela Cook3
1Mayo Clinic Rochester, Rochester, MN, 2Mayo Clinic, Scottsdale, AZ, 3Mayo Clinic Scottsdale, Scottsdale, AZ

 

Background: Preoperative, intraoperative, and postoperative hyperglycemia are all associated with poorer patient outcomes. Successful management of hyperglycemia during the continuum of surgical care improves the chances of successfully and safely transitioning a patient through the different segments of the perioperative period.

Objective: To assess impact on perioperative care of the implementation of practice guidelines for patients with diabetes mellitus.

Methods: A multidisciplinary group developed guidelines for patients with diabetes undergoing elective surgical procedures. The primary goal of the team was to establish a framework for the development of processes and protocols to measure and maintain a random blood glucose level of <180 mg/dL without increasing rates of hypoglycemia in patients with known diabetes. In order to meet the goal of keeping glucose below 180 mg/dL, the threshold to treat hyperglycemia was set at 140 mg/dL. Guidelines were implemented between January and March 2013. The impact of the guidelines on perioperative care between April and June 2013 was determined and compared with a historical cohort.

Results: There were 303 patients in the post–guidelines implementation cohort who had a total of 326 surgeries compared to 241 patients with 254 procedures in the historical cohort. Hemoglobin A1c measurements were obtained in 80% (260/326) of the cases after guidelines implementation compared with 47% (120/254) in the historical cohort (P<.01). Preoperative glucose monitoring was 95% (311/326) after guidelines implementation vs 88% (223/254) in the historical cohort (P<.01). Intraoperative glucose monitoring was 67% (186/278) after guidelines implementation vs 29% (71/247) historically (P<.01), whereas no change was found in postanesthesia care unit data (P=.11). After introduction of the guidelines, the frequency of insulin use increased in all phases of perioperative care (P<.04). Mean preoperative glucose was 130 mg/dL in the post–guidelines implementation cohort vs 141 mg/dL in the historical cohort (P<.01). In the postanesthesia care unit, mean values were 152 mg/dL in the post-guidelines implementation group versus 162 mg/dL in the historical group (P=.01).

Conclusion: A multidisciplinary approach geared toward developing standards of care for patients with diabetes can improve perioperative glucose monitoring, insulin use, and possibly glucose control. Ongoing assessment will determine whether practice patterns can be improved further and sustained. Also of interest will be assessing the impact of these guidelines on clinical outcomes in these patients.

 

Nothing to Disclose: MS, HAA, JDS, RTS, KMS, CBC

13864 55.0000 MON-1003 A Implementation of Multispecialty Guidelines to Improve Perioperative Management of Diabetes Mellitus- an Example of a Successful Quality Initiative 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Lorena Alarcon-Casas Wright*, Sumangala Vasudevan, Peter Huynh, Rhea Coquia Smith and Irl B Hirsch
University of Washington Medical Center, Seattle, WA

 

Real time continuous glucose monitoring systems (CGM) have shown to improve long-term glycemic control in patients with type 1 diabetes. Limited data is available regarding the benefit of short-term blinded professional CGM (PCGM); furthermore, results have been conflicting with regards to benefits in A1C. No studies have evaluated self-monitoring of blood glucose (SMBG) frequency and data before and after PCGM.

We aimed to assess the most common indications for PCGM and its effect on glycemic control in insulin-treated patients with diabetes in our academic practice. During a routine PCGM session, patients are advised to keep logs of their food, exercise, medications, and asked to perform SMBG ≥4x /day. Using the PCGM information and logs by the patients, they are educated on glucose trends, effects of food, insulin, exercise, etc., to help tailor their medication management, avoid hypo/hyperglycemia and control glucose fluctuations. We hypothesized that a PCGM intervention results in better glycemic control when assessed by A1C and data from SMBG in our clinic. We performed a retrospective review of insulin-treated patients, age 42.2±15.4 years, who underwent PCGM at the University of Washington, Diabetes Care Center, from November 2011 to June 2013. We included patients with A1C levels within a period of 6 months before and after PCGM and who performed SMBG ≥2x/day within a period of 6 months for 30 days before and after PCGM. Indications, episodes of nocturnal or severe hypoglycemia, and A1C before and after PCGM were extracted from the patient’s records. Number of readings and mean capillary glucose measurements were obtained from the patients’ meter downloads. Sixty-six patients met inclusion criteria.

Indications for PCGM were classified within 6 categories: 1) glycemic variability, 39.2%; 2) hyperglycemia, 25.7%; 3) hypoglycemia, 20.3%; 4) to match food/prandial insulin, 8.1%; 5) evaluation of insulin treatment, 4.1%; 6) unspecified, 2.7%. Normally distributed data are means±SD (t-test); not-normally distributed data are medians [interquartile ranges] (Wilcoxon Signed rank test). Number of readings and mean capillary glucose by SMBG did not change after PCGM: p=0.3 and 0.9, respectively. There was no difference in self-reported hypoglycemia or severe hypoglycemia after PCGM. A1C (%) decreased from 8.1±1.0 to 7.8±1.0, p=0.05. When including patients who performed at least SMBG ≥3x/day (n= 55), results for mean capillary glucose by SMBG did not change, but the difference in A1C (%) became more significant: 8.0±1.0 vs. 7.7±1.0, p=0.02.

PCGM improved glycemic control when assessed by A1C without a significant change in frequency or mean glucose by SMBG.

PCGM should be considered a valuable tool to improve glycemic control in insulin-requiring patients; further studies are needed to evaluate its impact in overall glycemic control, including hypoglycemia and glycemic variability.

 

Disclosure: IBH: Study Investigator, Sanofi, Study Investigator, Halozyme, Consultant, Roche Pharmaceuticals, Consultant, Abbott Laboratories. Nothing to Disclose: LACW, SV, PH, RCS

14676 56.0000 MON-1004 A Professional Continuous Glucose Monitoring Improves Hemoglobin A1C in Insulin-Requiring Diabetic Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Anna L. Ross*1, Gillian S. Boyd-Woschinko1, David L. Kaiser1, Adham M. Alifarag1, D'Arcy King2, Michael Diefenbach1 and Ronald Tamler1
1Icahn School of Medicine at Mount Sinai, New York, NY, 2New School for Social Research

 

Objective:  To determine the prevalence of smartphone use among patients with diabetes and to establish the most important elements of a smartphone application (app) for diabetes self-management through a patient survey.

Background:  Diabetes is a chronic and, in many aspects, self-managed condition.  Studies investigating mobile phone technology in diabetes management have shown that there is benefit in offering education, support, and clinical feedback to patients with diabetes to enhance glycemic control.1, 2 However, little is known about prevalence of app usage in this population.

Methods:  English-speaking adults in the waiting rooms of the diabetes Medicare/Medicaid practice and the diabetes faculty practice at the Mount Sinai Medical Center were asked to complete a survey with demographic background and information about their phone and app preferences.  Exclusion criteria included pregnancy and end-stage renal disease. 

Results:  Of the 125 patients surveyed, 69 (55.2%) were in the Medicare / Medicaid clinic, and of 120 patients (96%) with a cell phone, 81 patients (67.5%) owned a smartphone. Android OS (40.7%) and iOS (47%) were most prevalent. Smartphone ownership was higher among faculty practice patients than clinic patients (87.9% vs 45.5%, p<0.01), graduate degree holders vs. subjects who never attended college (100% vs. 45.8%, p<0.01) and Caucasians compared to minorities (96% vs. 56%, p<0.01). Only 36% of African Americans reported smart phone ownership. Among smartphone owners, 1 patient was using an app for diabetes self-management, but 70 subjects (86.4%) said they would be interested in downloading a diabetes self-management app. 45 of the patients with smartphones (55.6%) felt they had significant or excellent control over their diabetes.  Subjects ranked the following properties as most important for a diabetes self-management app: ease of use, legibility, functionality for tracking blood glucose, weight, blood pressure and food intake, recording medication administration, and reminders about medications and doctor appointments.

Conclusions:  To our knowledge, this is the first survey of smartphone use in patients with diabetes, and surveys in larger populations need to follow.  The data presented will help to build more targeted smartphone apps.

 

Disclosure: DK: Marketing, Merck & Co.. Nothing to Disclose: ALR, GSB, DLK, AMA, MD, RT

14792 57.0000 MON-1005 A Smartphone Use By Patients with Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Anna L. Ross*1, Gillian S. Boyd-Woschinko1, David L. Kaiser1, Adham M. Alifarag1, D'Arcy King2, Michael Diefenbach1 and Ronald Tamler1
1Icahn School of Medicine at Mount Sinai, New York, NY, 2New School for Social Research

 

Objective:  To survey providers about their patients’ use of and interest in a smart phone application (app) for diabetes self-management and to establish the most important elements of a smart phone app for this purpose.

Background:  Self-monitored blood glucose (SMBG) provides valuable information to health care providers and has been shown to improve glycemic control in patients with type 2 diabetes.1 However, only a minority of patients with diabetes make this information available to their provider.2Smartphone apps for diabetes self-management can help patients to log and manage SMBG results, though little is known about the prevalence of app use among patients with diabetes and provider attitudes towards this technology.

Methods:  Health care providers attending a diabetes continuing medical education event completed a survey with demographic background and information about their phone and app preferences.  A Pearson Chi-Square test was used to analyze cross-tabulated survey data.

Results:  Of the 70 participants, (31.4% physicians, 45.8% nurses and physician assistants, 15% dieticians and pharmacists), 69 providers (98.6%) owned a cell phone themselves, and 58 (82.9%) owned a smartphone.  49 providers (70%) estimated that less than half of their patients owned a smartphone; 11 (15.7%) believed that those patients who did own a smartphone would use an app for diabetes self-management.  32 providers (45.7%) said that at least half of their patients have diabetes.  Only 11 providers (15.7%) thought that at least half of their patients consistently bring a glucose meter or log to their visits though 69 providers (98.6%) thought this information would improve their treatment.  16 providers (22.9%) currently recommend an app to their patients and 23 providers (32.8%) thought it would be at least moderately influential on their patients’ participation towards their diabetes care.  The majority of providers (75.7%) said they would like to incorporate a smartphone app into the care of their diabetic patients.

Conclusions:  To our knowledge, this is the first survey of health care providers regarding smart phone use in patients with diabetes, and surveys in larger populations need to follow.  The data presented will help to build more targeted smart phone apps.

 

Disclosure: DK: Marketing, Merck & Co.. Nothing to Disclose: ALR, GSB, DLK, AMA, MD, RT

15091 58.0000 MON-1006 A Provider Attitudes Toward Smartphone Use By Patients with Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Sanjeev N. Mehta*1, Monika A. Niewczas1, William J. McMullen1, Alf H. Gruener2 and Alessandro Doria1
1Joslin Diabetes Center, Boston, MA, 2Sanofi, Bridgewater, NJ

 

Incretin-based therapies (i.e., glucagon-like peptide-1 agonists [GLP-1a] and dipeptidyl peptidase-4 inhibitors [DPP-4i]) are second-line therapies for adults with T2D. We evaluated new incretin-based prescriptions at a diabetes center to assess factors associated with initiating GLP-1a rather than DPP-4i. Among 19,839 eligible patients, 20% (47% female) initiated an incretin-based therapy (58% GLP-1a) from 2005-2011. Due to increased availability and rapid uptake of incretin-based therapies following first-in-class FDA approvals (2005-2006), we limited analyses to 2008-2011 (n=2,046). Hemoglobin A1c (reference range 4-6%) defined glycemic control. In bivariate analyses, factors associated with a greater odds of initiating a GLP-1a rather than DPP-4i included younger age (≤60 years), shorter T2D duration (<15 years), BMI>30 kg/m2, A1c>8.5%, higher diastolic BP (≥75 mmHg), and private insurance. In a multivariate logistic model, the odds of initiating GLP-1a remained associated with A1c>8.5%, BMI>30 kg/m2, younger age, and private insurance (p<.05 for all). The effects of elevated A1c and BMI were additive in relation to the odds of initiating GLP-1a rather than DPP-4i. Using patients with A1c≤8.5% and BMI≤30 kg/m2 as the referent group, the odds of initiating GLP-1a rather than DPP-4i were 2.0 (95%CI 1.2-3.2) for patients with A1c>8.5% and BMI≤30 kg/m2, 6.1 (95%CI 4.6-8.4) for patients with A1c≤8.5% and BMI>30 kg/m2, and 10.6 (95%CI 7.7-14.5) for patients with A1c>8.5% and BMI>30 kg/m2(p<.05 for all ORs). Incretin-based therapies were prescribed to 1 in 5 adults with T2D at a multidisciplinary diabetes center. Providers were more likely to initiate a GLP-1a rather than a DPP-4i in adults with T2D who were obese especially in the setting of suboptimal glycemic control.

 

Disclosure: AHG: Employee, Sanofi. Nothing to Disclose: SNM, MAN, WJM, AD

15235 59.0000 MON-1007 A Factors Associated with Choice of Incretin-Based Medication Class in Adults with Type 2 Diabetes (T2D) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Rocio DeLaTorre1, Gabriela Delgado*1, Nancy Rodriguez2 and Hong Lee2
1MacNeal Hospital, berwyn, IL, 2MacNeal Hospital, Berwyn, IL

 

Objective: To show the benefits of plant based diet in the Latino diabetic population as a way to motivate Latino patients to implement these dietary changes to better control their diabetes and subsequently slow down the progression of complications. The hypothesis of the study is that Plant Based dietary changes lead to steeper declines in A1C in Latino patients compared to those who recevied traditional diabetic dietary advices.

Methods: A retrospective analysis of the dietary impact on A1C levels.  100 diabetic patients with latino heritage were enrolled in this study.  They were referred by their primary doctors to the MacNeal Diabetes Center for diabetes education and diet counselling.  The experimental group consisted of 23 patients whose diets consisted of at least 70 percent daily intake of whole, plant-based foods under the care and supervision of a Certified Diabetic Nurse Educator. The control group consisted of 67 patients of the Family Medicine Center who adhered to the Standard American Diet (SAD).  Participants were between 30 and 80 years of age and of Latino heritage, males and females at 2 to 1 ratio.  All of them are oral diabetic medications and/or insulin for at least 6 months and most recent A1C >6.5%.  Exclusion Criteria: patients <30 and >80 years of age were excluded, pregnant women, patients with A1C <6.5, and those who failed to follow-up after 3 months of diagnosis.  Three health professionals retrospectively analyzed their health outcomes over the first year they participated in the dietary program.

Results: Men in the Plant Based Diet seemed to respond faster (avg of 3 months) for the most drastic change in A1C than women in the Plant Based Diet group. The average time to see a change in A1C was 4 months and the change was 3.28%(95% CI 0.6406 to 2.14, P:0.0371). All 23 patients were on diabetes medications at the beginning of the study but 7 (30%) had their medications reduced or were taken off all diabetes medications.

Patients in the Standard American diet group had an average change in A1C of 1.11% and the average time was 5 months. Most patients remained on the same medications they started with, some increased the number or the dosage of their diabetic medications (95%CI: 0.51 to 186.32, P:0.1031).

Discussion: Latino patients enrolled in the plant based group had 3-fold greater A1c reduction compared to the Standard American Diet group. This difference may be attributed to the fact that Latino food staples are based in low density carbs and starch such as corn, rice, bread, tortilla. Nearly twice the number of men were able to adhere to the plant based diet (13M:7F) which could be attributed to metabolic differences between men and women. It may also have a large part in cultural gender roles.

Conclusion: Latino diabetic patients who adopted plant based diet had 3-fold greater A1c reduction than patients on Standard American Diet.  Plant base group also helped them to require less diabetic medications.

 

Nothing to Disclose: RD, GD, NR, HL

15571 60.0000 MON-1008 A The Effect of Plant Based Diet in A1C Lowering in Latino Diabetic Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Gloria Wu*1, Kimberly D. Pham2, Vinna Nam3, Byongdo Kim4 and Stephanie Tang5
1Stanford Hospital & Clinics, San Jose, CA, 2University of California, Berkeley, Berkeley, CA, 3University of California, Berkeley, San Jose, CA, 4University of California, Berkeley, 5Stanford University

 

Diabetes affects 26 million Americans: one third do not know that they have the disease.  79 million Americans may have pre-diabetes.  Of Type 2 Diabetics, 80-90% are thought to have weight issues.  Diet plays a role in the mamnagement of Type 2 diabetes. $110 Billion is spent on fast food in US.  To this end, we wanted to reach out to diabetic patients who eat fast food by creating an Android application, accessible and free for patient use via their smartphones.

Purpose: To create a diet app for diabetic patients

Methods:  Choice of menus: fast food take out menus. Google search engine was used to find the 100 most common foods in American fast food and Asian fast food.  Java was the programming language used.  For the "Diabetes and Fast Food" app, we used the average serving size available for the top searched fast food, eg,  McDonalds, Burger King, Wendy's etc. For pizzas, we used Pizza Hut, Papa Johns or most commonly searched on the web.  The serving size and calorie count was was averaged.  Glycemic Index was determined using Google search engine data. Body Mass Index was calculated when users upload height and weight.   No paid advertising was used. 

Results: "Diabetes and Fast Food,"  an andorid smartphone app was created.  It was uploaded on Google Play using a gmail account and password.  Uploaded August 20, 2013, the app generated increasing numbers with each month.  Google analytics show that a total of 230 downloads were generated in 4 months: US: 69.43% , United Kingdom 4.78%, Australia 3.48%, India 3.48%, Germany 3.04%. This is in contrast to the number of visitors on health and fitness apps: US 16.96%,  South Korea 5.10%, Japan 4.73%,  Germany 3.83%, United Kingdom 2.88%.

Discussion: While Android apps are not easily searchable as are iPhone apps, Android smartphones are now the most commonly purchased smartphone worldwide. Despite this disadvantage, there is a utility to the free app such that increasing numbers are installing the app over its 4 month lifespan on the internet.  Android's Java programming language is taught in high school whereas the Apple's  iOs platform software language requires college level or graduate school computer science skills.   Apps may be useful as an outreach tool patient education in the future.  We  hope to use this poster session to demonstrate the usefulness of the app for diabetic patients and their physicians. We will demonstrate how to download this app onto smart phones or tablet devices. To our knowledge, this is the only smartphone Android app for evaluating fast food targeting diabetic patients.

 

Nothing to Disclose: GW, KDP, VN, BK, ST

15616 61.0000 MON-1009 A Creation of New Android App for Diabetes Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Ayse Kubat Uzum*1, Selda Celik2, Nurdan Gul3, Gulsah Yenidunya Yalin1, Cemile Idiz4, Elif Temel4, Emine topaloglu Topaloglu4, Nevin Dinccag5, Kubilay Karsidag5 and Ilhan Satman5
1Istanbul University, Istanbul Medical Faculty, Istanbul, Turkey, 2Istanbul University Istanbul Medical Faculty, Istanbul, Turkey, 3Istanbul Faculty of Medicine, Istanbul, Turkey, 4Istanbul University, Istanbul Medical Faculty, istanbul, Turkey, 5Istanbul University, Istanbul Faculty of Medicine, Istanbul, Turkey

 

We evaluated outpatient charts of 8,903 type 2 diabetes patients seen between 2001 and 2008. Factors leading to treatment change and predicting future insulin requirement were investigated.

Patients under insulin treatment or those who were started on insulin during follow-up, and seen for at least three consecutive years were included (median ± SEM follow-up: 6.9 ± 2.5, range: 2 - 17 yrs). Data of treatment modalities, body weight, BMI, and HbA1c at 1st, 3rd, 5th, and 7th year of follow-up were retrospectively analyzed.

Three hundred and fifty two patients (54.5% women, mean ± SD; age: 54.2 ± 9.6 yrs, and BMI: 29.9 ± 5.9 kg/m2) with a duration of diabetes 7.7 ± 7.5 (median 6.0) yrs were included. Two hundred patients (56.8%) were under oral antidiabetic drugs (OADs), 84 (23.9%) patients under insulin regimen, and 51 (19.8%) patients were treatment-naive. Eighty one (42%) patients on OADs were shifted to another treatment regimen by the end of the first year (metformin alone: 2.5%, any combination of OADS: 28.4%, basal insulin plus metformin: 11.1%, basal insulin plus other OADs: 13.6%, premixed insulin only: 22.2%, premixed insulin plus metformin: 11.1%, and basal-bolus insulin: 11.1%). Mean duration to insulin treatment was found 3.4 ± 2.2 (range: 1-10) yrs (sulphonlyureas/glinides: 3.1 ± 1.9 yrs and metformin: 4.0 ± 1.9 yrs). At baseline, 84 patients (23.9%) were under one of the insulin regimens (basal: 21.4%, OAD plus basal: 5.9%, premixed: 50.5% and basal-bolus: 21.4%). By the end of the first year, 184 patients (52.3%) switched to one of the insulin regimens (basal: 14.2%, basal plus OAD: 21.8%, premixed: 31.5% and basal-bolus: 32.5%). The mean duration of diabetes in those who started insulin at first year of follow-up was 9.4 ± 8.1 yrs. At the end of the 7th yr, basal-bolus insulin regimen was predominantly chosen (42.1%) (basal plus OAD: 26.7%, premixed: 14.2%, OAD: 12.6% and basal: 4.4% ). Mean values of BMI, HbA1c, C-peptide were 29.9 ± 5.9 kg/m2, 8.8 ± 0.3% and 3.3 ± 1.2 ng/mL. Patients on insulin increased exponentially during follow-up (3rd yr; 59.6%, 5th yr: 86.2% and 7th yr: 90.8%). Mean daily insulin requirement increased from 0.44 ± 0.16 to 0.79 ± 0.29 IU/kg body weight. Mean HbA1c decreased to 7.9 ± 1.8% at the end of the 1st year but this trend could not be maintained.

To search baseline determinants of need for insulin at 7th yr we set a multiple logistic regression model; duration of diabetes, BMI, HbA1c levels at baseline were identified as risk factors to predict insulin treatment. One year increase in diabetes duration, one unit increase above the mean BMI and 1% increase above the mean HbA1c was associated with 6% (p<0.001), 62% (p<0.001) and 9% (p=0.01) increase in insulin therapy at 7th year, respectively.

We conclude that subjects with longer diabetes duration, higher BMI and higher HbA1c need a close follow-up to commence insulin early in order to prevent long-term complications.

 

Nothing to Disclose: AKU, SC, NG, GYY, CI, ET, ETT, ND, KK, IS

17036 62.0000 MON-1010 A Natural Course of Type 2 Diabetes Treatment in Turkey: Predictors of Insulin Initiation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 0947-1010 4800 1:00:00 PM Diabetes Clinical Care; Genetics & Epidemiology Poster

Niralee Vaishnav* and Patrick M Moriarty
University of Kansas Medical Center, Kansas City, KS

 

Background:  Elevated levels of serum uric acid (SUA) may adversely affect coronary arteries through pro-inflammation, endothelial cell dysfunction, inhibition of nitric oxide release, free radical generation, and insulin resistance.  Animal studies have shown increased xanthine oxidase activity during ischemia and use of allopurinol has been shown to limit infarction size.  Although hyperuricemia is an independent risk factor for cardiovascular disease (CVD), it remains debated if lowering SUA levels can improve CVD.

Clinical Case:  A 62 year old male with history of familial hypercholesterolemia, CVD (myocardial infarction at the age of 52) and Metabolic Syndrome presented with recalcitrant chronic angina.  Cardiac catheterization showed hemodynamically non-significant coronary atherosclerosis and he was started on anti-anginal drug therapy.  Despite maximization of his anti-anginal medication regimen and medical optimization of risk factors, he continued to have chronic angina.  During this time, he was noted to have persistently elevated SUA levels (7.2-9.4 mg/dL, n=2.5-7.0 mg/dL) and allopurinol was initiated.  Although the patient had asymptomatic hyperuricemia, allopurinol use resulted in symptomatic improvement of his angina.  While on allopurinol, SUA levels decreased (5.2-6.4 mg/dL) and the patient experienced a 6 month pain free period. Accidental discontinuation of allopurinol resulted in return of his angina.  Re-initiation of allopurinol resulted in subsequent improvement of his cardiac symptoms.

Conclusion:  Through its effect on cardiovascular risk factors such as hypertension and hyperlipidemia, elevated SUA levels may facilitate coronary artery inflammation resulting in chronic angina.  Prognostically, hyperuricemia often precedes the development of MI and Metabolic Syndrome and patients with higher SUA levels tend to have higher rates of cardiovascular mortality.  Detecting hyperuricemia may enable earlier identification of individuals at greatest risk for CVD and treatment of asymptomatic hyperuricemia may limit coronary artery perfusion abnormalities and reverse cardiovascular risk factors.

 

Nothing to Disclose: NV, PMM

14909 5.0000 MON-1047 A Utility of Detecting and Treating Hyperuricemia in High Risk Patients with Unexplained CHEST PAIN 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Tae Hyuk Kim*1, Yul Hwangbo1, Kyong Yeun Jung1, Ye An Kim1, Jung Hee Kim1, Jae Hoon Moon2, Kyung Won Kim3, Do Joon Park1 and Young Joo Park1
1Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 2Seoul National University College of Medicine, Korea, Republic of (South), 3Seoul National University Colledge, Seoul, Korea, Republic of (South)

 

Objective: To determine whether serum thyroid stimulating hormone (TSH) levels improve the prediction of cardiovascular risk in addition to common clinical risk scores, given the association between subclinical hypothyroidism (SCH) and cardiovascular disease.

Design: Prospective cohort study.

Setting: A representative rural community.

Participants: A total of 344 SCH and 2624 euthyroid participants aged over 40 years.

Main outcome Measures: We measured thyroid function and traditional risk factors at baseline and estimated the 10-year cumulative incidence of cardiovascular disease.

Results: There were 251 new cases of cardiovascular events during 10 years of follow-up. The hazard ratio for cardiovascular disease was 1.11 (95% CI, 1.01-1.23) per 1-SD increase in TSH levels. However, in the National Cholesterol Education Program (NCEP) - Adult Treatment Panel (ATP)-III or the Reynolds Risk Score (RRS) model, the addition of serum TSH levels had no effect on model discrimination as measured by the area under the curve (0.631 to 0.641; P = 0.69 in the ATP-III, 0.667 to 0.672; P = 0.83 in the RRS). Adding serum TSH did not improve the Net Reclassification Improvement (-2.2%; P = 0.39 in the ATP-III, 0.7%; P = 0.75 in the RRS) and only mildly affected the Integrated Discrimination Improvement (0.25%; P = 0.014 in the ATP-III, 0.16%; P = 0.065 in the RRS).

Conclusion: Serum TSH elevation predicted new cases of cardiovascular disease in the community but did not improve the predictability of common risk scoring models.

 

Nothing to Disclose: THK, YH, KYJ, YAK, JHK, JHM, KWK, DJP, YJP

11374 6.0000 MON-1048 A Subclinical Hypothyroidism in Addition to Common Risk Scores for Prediction of Cardiovascular Disease: A 10-Year Community-Based Cohort Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Anas Ahmad Sabir*1, Jimoh Abdulgafar2, Umar Aminu Kaoje3, Yusuf Saidu2 and Simeon Isezuo3
1Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria, 2Usmanu Danfodiyo University, 3Usmanu Danfodiyo University Teaching Hospital

 

PREVALENCE OF METABOLIC SYNDROME IN SOKOTO METROPOLIS

BACKGROUND: Metabolic syndrome is a cluster of metabolically related cardiovascular risk factors. The core components comprise of central obesity, insulin resistance, dyslipidaemia and hypertension. The presence of the metabolic syndrome predicts the risk of cardiovascular disease in patients with type 2 diabetes mellitus as well as in those without diabetes mellitus.

AIM: The aim of this study was to investigate the prevalence of metabolic syndrome in Sokoto metropolis of Nigeria.

METHODS: A cross-sectional epidemiologic study was carried out. Four hundred and ten subjects (201 males and 209 females) were recruited for the study using a multi-stage sampling technique.  Demographic and the life style data was obtained from the participants. Evaluation of anthropometric variables, fasting blood sugar, lipid profiles, insulin resistance and blood pressure was performed. The classification of metabolic syndrome was based on the NCEP ATP III guidelines Data was analysed using Epi Info version 3.3.4.

RESULTS: The mean (SD) age of the sample population was 39.6 (14.4) years. The mean (SD) age of the male subjects was 38.4(14.9) years and that of the females was 40.8(13.9) years (p> 0.05). The prevalence of metabolic syndrome was 23.6%. The prevalence was significantly higher in the female subjects (31.6%) than the male subjects (14.4%) p= 0.04.  The most important metabolic syndrome parameters in the study subjects were low HDL (65.7%), hypertension (53.9%), central obesity (increased waist circumference 32.5%) ,elevated triglycerides (15.7%),  and hyperglycemia in (33.7%). Most of the women had low HDL (67.4%) and central obesity elevated (54.6%)

The mean (SD) waist circumference was 86.2 (13.7) with the female subjects having significantly higher waist circumference [90.8+12.6 vs. 80.9+13.1 cm (p=0.001)] and had higher BMI [23.6+5.9 vs. 22.6+4.9 kg/m2 (p=0.197)] than the male subjects. The mean fasting plasma glucose levels were higher in the female [5.38(1.82)] than the male [4.85(0.97)] subjects (p=0.17). The mean serum HDL-C was higher in the males [48.0 (17.9) mg/dl] than in female subjects [47.01 (21.7) mg/dl] but not statistically significant (p=0.84).  The mean serum Triglycerides was 122.3 (64.6) mg/dl with no significant difference between males and females [121.8 vs. 122.8 mg/dl  (p=0.92)]. The mean systolic blood pressure was 138.5(26.6) mmHg higher in the males than the females [138.6 +19.2 vs. 138.4 +31.6 mmHg (p=0.97)]. The mean diastolic blood pressure was 79.3 (16.4) mmHg higher in males than in females [79.9 +15.1 vs. 78.8 +17.5 mmHg (p=0.65)

 

CONCLUSION:

Metabolic syndrome is relatively common in residents of Northwestern Nigeria, commoner in the females than males. Risk factors for metabolic syndrome should be detected in normal individuals for implementing effective preventive measures.

 

Nothing to Disclose: AAS, JA, UAK, YS, SI

13243 7.0000 MON-1049 A Prevalence of Metabolic Syndrome in Sokoto Metropolis Nigeria 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Suhad Bahijri*1, Ghada Ajabnoor1, Anwar Borai2, Altaf Abdulkhaliq3, Jumana AL-Aama4 and George Chrousos5
1Faculty of Medicine-King Abdulaziz University, Saudi Arabia, 2King Saud Bin Abdulaziz for Health Sciences University, Saudi Arabia, 3Faculty of Medicine- Umm Al-Qura University, Saudi Arabia, 4Faculty of Medicine- King Abdulaziz University, Saudi Arabia, 5King Fahd Medical Research Center - King Abdulaziz University, Saudi Arabia

 

Background: intermittent fasting improves risk factors for coronary artery disease. However, Muslims in Saudi Arabia experience severe disturbance in their sleeping patterns during the fasting month of Ramadan and cortisol, a hormone that controls the expression of many hormones and inflammatory markers,  loses its circadian rhythm during this month.  This might have deleterious effects on metabolic homeostasis, increasing the risk of chronic cardiometabolic disorders.

Objectives: to investigate the change during Ramadan in the pattern of secretion of: 1- high sensitivity C-reactive protein (hsCRP), an inflammatory marker associated with increased cardiovascular risk and regulated by cortisol and 2-the adipokines leptin and adiponectin and related changes in insulin resistance. 

Subjects and methods: Twenty-three young, apparently healthy subjects were evaluated before and two weeks into Ramadan. Blood samples were collected at 9.00 am and 9.00 pm for measurements of glucose, insulin, leptin, adiponectin and hsCRP.

Results: During Ramadan, the concentratios of hsCRP were lower compared to regular living conditions, while glucose homeostasis was maintained by increases in the secretion of insulin without a change in its circadian pattern, indicating an increase in insulin resistance, as also measured by HOMA- IR. Furthermore, leptin and adiponectin secretion were significantly changed to a pattern favoring insulin resistance. Mean morning concentrations of leptin were significantly higher than pre-Ramadan values (p = 0.001), in contrast to those of adiponectin, which were significantly lower (p < 0.001).

Conclusions: In Saudi Arabia, the beneficial effects of fasting on hsCRP during Ramadan is offset by disturbed sleeping and eating patterns leading to alterations in leptin and adiponectin secretion, associated with decreased insulin sensitivity. These changes  might contribute to the high prevalence of obesity, metabolic syndrome and diabetes mellitus type 2, and their cardiovascular sequelae, in this population.

 

Nothing to Disclose: SB, GA, AB, AA, JA, GC

16944 8.0000 MON-1050 A Beneficial Effects of Ramadan Fasting in Saudi Arabia Might be Offset By Changes in Secretion Pattern of Adipokines and Increased Insulin Resistance 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Wan Aizad Wan Mahmood*1, Thomas King1, Tommy Kyaw Tun1, Seamus Sreenan1 and John H McDermott2
1Connolly Hospital, Dublin, Ireland, 2Connolly Hospital, Dublin 15, Ireland

 

Endothelial Progenitor Cells (EPCs) are circulating bone-marrow derived cells which promote post-natal vasculogenesis. EPCs play a central role in cardiovascular repair and studies have demonstrated a link between EPC number and function and future cardiovascular risk[1]. Interventions which modify cardiovascular risk have early effects on EPC number and function [2]. Recently there has been increased appreciation of the need to evaluate cardiovascular safety of new anti-diabetic agents, but long-term post-marketing trials are often required before an adverse cardiovascular signal is seen. DPP-4 inhibitors are effective glucose-lowering agents, but their long-term cardiovascular safety has not been extensively tested. We aimed to evaluate the long-term cardiovascular safety of Saxagliptin (SAX, a DPP-4 inhibitor) versus Gliclazide Modified Release (GLC) using EPC number and function as surrogate markers of cardiovascular risk. 18 patients with T2DM on Metformin monotherapy requiring diabetes treatment intensification were randomized to SAX (n=7) or GLC (n=11) in an open-label fashion.  EPC number and adhesion capacity were measured, using methods as previously described [3], before and 6 months after treatment. At baseline, there were no significant differences between the groups in gender, age, BMI, diabetes duration, total cholesterol or LDL cholesterol.  Mean baseline HbA1c was higher in GLC group (62.2 ± 8.8 vs 53.1 ± 4.4mmol/mol, p=0.02) while mean serum creatinine was higher in SAX (88.9 ± 15.2 vs 63.5 ± 14.5mmol/L, p=0.003). There was no difference in median EPC number (35 (21 – 54) vs 25 (22 – 46) cells per high power field (HPF), p=0.6) or adhesion capacity (0.22 (0.17 – 0.85) vs 0.27 (0.1 – 0.67 fluorescence units, p=0.8) at baseline between SAX and GLC groups respectively. At 6 months, weight had increased in the GLC group compared to baseline (87.9 ± 14.9 vs 86 ± 14.7 kg, p=0.008) with no change in the SAX group (84.5 ± 9.6 vs 84.2 ± 10 kg, p=0.8). There was no statistically significant change in mean HbA1c after 6 months treatment with either SAX (50.4 ± 6.6 vs 53.1 ± 4.4mmol/mol, p=0.33) or GLC (58 ± 8.3 vs 62.9 ± 9 mmol/mol, p=0.13) compared to baseline, or in total or LDL cholesterol. Compared to baseline there was no change in median EPC number [SAX: 35 (28-38) vs 35 (21-54) cells/HPF, p=0.5 and GLC:39 (28-46) vs 25 (22-46) cells/ HPF, p=0.24] or adhesion capacity [SAX: 0.3 (0.17 – 0.65) vs 0.2(0.17 – 0.86), p=1.0, GLC: 0.32 (0.14 – 0.84) vs 0.27 (0.1 – 0.67) fluorescence units, p=0.9] after 6 months treatment in either group. In summary, we found no difference in EPC number or function in patients treated with SAX versus GLC for 6 months. These results may suggest a similar cardiovascular safety profile of SAX to GLC, a well-established treatment for T2DM.

 

Nothing to Disclose: WAW, TK, TK, SS, JHM

13957 9.0000 MON-1051 A Cardiovascular Safety of DPP-4 Inhibition in Patients with Type 2 Diabetes Mellitus: Endothelial Progenitor Cells As an Early Marker of Long-Term Cardiovascular Risk 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Yasuhiro Ohno*1, Yoichi Tanaka2, Mika Fujimoto2 and Yasunori Maruyama2
1Sakai Hospital, Kinki University Faculty of Medcine, Osaka, Japan, 2Sakai Hospital, Kinki University Faculty of Medicine, Sakai, Japan

 

Backgroud: It has been known that an incretin, GLP-1 has a variety of functions on many organs other than increasing insulin secretion. Therefore, DPP-4 inhibitors also may exert other clinical effects than lowering blood glucose, by enhancing endogenous GLP-1. Especially, beneficial effects of DPP-4 inhibitors on the cardiovascular system are expected.

Aim: To elucidate effects of a DPP-4 inhibitor, sitagliptin on cardiovascular system in patients with type 2 diabetes.

Subjects and Methods: Seventy patients with type 2 diabetes were subjected and divided into two groups, one treated with a DPP-4 inhibitor, sitagliptin, alogliptin or vildagliptin (D group) and the other without DPP-4 inhibitors (C group). D group and C group consisted of 56 (mean age 61.7 y.o) and 54 (mean age 63.7 y.o.)  patients, respectively. Patients with overt cardiac failure were excluded. Effects of sitagliptin on cardiovascular function were evaluated with left ventricular ejection fraction (EF), blood pressure (BP) and BNP levels 6 months after the start of this study

Result: Six months after the start of the study, there was significant reduction in HbA1c levels in D group (7.6% vs 7.0%, p<0.01), while there was no significant change in HbA1c levels in the C group.There was significant reduction in both systolic and diastolic BP in S group (SBP/DBP: 136/77 vs 127/73 mmHg, p<0.05), while there was significant reduction only in systolic BP in C group. In addition, there was significant reduction in BNP levels in D group (13.6 vs 10.6 pg/ml, p<0.05), while there was no significant change in C group. No change was observed in EF in both S and C groups. It is known that DPP-4 degrades BNP1-32 to BNP3-32 at its N-terminal end and does not influence NT-proBNP metabolism. However, there was no difference in BNP to NT-proBNP ratio between before and 6 months after DPP-4 treatment. 

Conclusion: The results suggest that DPP-4 inhibitors may have cardioprotective effect.

 

Nothing to Disclose: YO, YT, MF, YM

16744 10.0000 MON-1052 A Effects of DPP-4 Inhibitors on Cardiovascular System in Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Orebowale ADEBIMPE Olugbemide*1, Oluwarotimi Bolaji Olopade2, Anthony Chinedu Anyanwu3, Ukamaka Odife4, Nasiru Sanni5, Sandra Omozehio Iwuala6, Ifedayo Odeniyi7, Olufemi Adetola Fasanmade7 and Augustine E Ohwovoriole8
1Irrua Specialist Teaching Hospital, Irrua , Edo State, Irrua, Esan Central, Nigeria, 2Lagos Univ Teaching Hosp, Surulere, Nigeria, 3Division of EDM, Dept of Medicine, Lagos University Teaching Hospital, Lagos, Nigeria, 4Lagos University Teaching Hospital,Idi-Araba,Lagos State, 5university of ilorin teaching hospital, kwara state, Nigeria, 6Lagos Univ Teaching Hosp, Lagos, Nigeria, 7Lagos University Teaching Hospital, Lagos, Nigeria, 8University of Lagos, Yaba Lagos, Nigeria

 

PREDICTION OF METABOLIC SYNDROME:  WAIST-TO-HEIGHT RATIO OUT PERFORMS WAIST CIRCUMFERENCE AND WAIST-TO-HIP RATIO.

BACKGROUND                

The metabolic syndrome (MS) is a cluster of cardiovascular risk factors.Diagnosis of MS is made using clinical, anthropometric and biochemical variables. Anthropometric indices are cost effective and accessible surrogate makers of MS. Recent reports suggest that waist-to- height ratio (WHtR) may be a more sensitive correlate of metabolic syndrome than waist circumference (WC) and waist-to-hip ratio.

Research Question/ Objective

Is the waist-to-height ratio a better predictor of MS than WC in Nigerians with Type 2 diabetes mellitus (T2DM)?                                                                                                                                                                To determine the relationship between WHtR and WC against components of the MS in Nigerians with T2DM.

Methodology

This was a cross-sectional study involving 509 participants made up of 434 (171males and 263 females) T2DM patients with MS and 75 (34 males and 41females) apparently normal subjects. Measurements obtained included:body weight in kg, height in cm, hip circumference (HC) in cm, WC in cm, serum triglyceride (TG) in mg/dl, HDL-C in mg/dl and FPG in mg/dl using standard techniques. Diagnosis of MS was made using the World Health Organisation criteria. We derived a metabolic syndrome score (MSS) with 0 being the least and 9 the maximum score using the components of MS as the weight points and the cut off set at 4 points.                       Results were expressed as means (SD) and percentages. Comparisons of means were done using student t-test. The performance of WC and WHtR in making a diagnosis of MS was done using correlation analysis (Pearson’s) and tests of accuracy. P-value < 0.05 was considered statistically significance.  

Results

The mean (SD) age of the participants was 56.3(10.9)years. The mean (SD) body weight, WC waist-hip ratio, WHtR and BMI were 77.5(15.2) kg, 97.5(11.9)cm, 0.93 (0.09), 0.56 ( 0.11), 29.3(5.5)kg/m2respectively. The mean WC and WHtR were significantly higher in participants with MS compared to those without . There was a significant correlation between  WHtR, WC, waist-to-hip ratio and metabolic syndrome score ( r =0.804; 0.591 and 0.389 respectively).  Using WHtR as a diagnostic tool, the sensitivity (Sn), specificity (Sp) and positive predictive value (PPV) were Sn93.2% ; Sp54%; PPV 86% for female and Sn93.6%;Sp42%;90% for male participants. Using a cut-off value of 80cm for females and 94cm for males, the Sn, Sp, and PPV of WC for the females were 91%, 62% and 92%;  and for males Sn64.3 %;Sp82.4% ; PPV 95% respectively. Diagnotic accurancy for waist-to-hip ratio, WC and WHtR were 78.2%, 79%  and 81% respectively.                                       

Conclusion

From the study, both WHtR and WC comparably performed as diagnotic tools for metabolic syndrome. Waist-to-height ratio correlated better than WC and waist-to-hip ratio. Waist-to-height ratio appears to be a more sensitivity predictor of metabolic syndrome.

 

Nothing to Disclose: OAO, OBO, ACA, UO, NS, SOI, IO, OAF, AEO

14965 11.0000 MON-1053 A Prediction of Metabolic Syndrome: Waist-to-Height Ratio out Performs Waist Circumference and Waist-to-Hip Ratio 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Hye Jin Yoo1, Ja Young Ryu*1, Ho Cheol Hong1, Kyoung-Mook Choi2, Sei Hyun Baik1, Sin Gon Kim1, Nam Hoon Kim1, Hee Young Kim1, Nan Hee Kim1 and Dong Seop Choi1
1College of Medicine, Korea University, Seoul, Korea, Republic of (South), 2Korea Guro Univ Hosp, Seoul, Korea, Republic of (South)

 

Objective: Despite recent interest in differential impact of body size phenotypes on cardiovascular outcomes and mortality, studies evaluating the association between body size phenotypes and indicators of atherosclerosis are limited. This study investigated the relationship of metabolically abnormal but normal weight (MANW) and metabolically healthy but obese (MHO) individuals with arterial stiffness and carotid atherosclerosis in Korean adults without cardiovascular disease.

Methods: A total of 1,012 participants (575 men and 437 women, mean age 50.8 years), who underwent a health examination between April 2012 and May 2013 were prospectively enrolled based on inclusion and exclusion criteria. Study subjects were classified according to body mass index (BMI) and the presence/absence of metabolic syndrome.

Results: The prevalence of metabolically healthy normal weight (MHNW), MANW, MHO, and metabolically abnormal obese (MAO) were 54.8%, 6.4%, 22.8%, and 15.9%, respectively. Individuals with MANW had significantly higher brachial ankle pulse wave velocity and maximal carotid intima-media thickness values than those with MHO, after adjusting for age and gender (P = 0.026 and P = 0.018, respectively). The odds ratio (OR) of arterial stiffness and carotid atherosclerosis in the MANW group were significantly higher than in the MHNW group in unadjusted models. Furthermore, multivariable models showed that increased OR of carotid atherosclerosis in the MANW group persisted even after adjusting for confounding factors (OR = 2.98, 95% CI = [1.54, 5.73], P = 0.011).

Conclusions: Compared to MHNW or MHO subjects, Korean men and women with the MANW phenotype exhibited increased arterial stiffness and carotid atherosclerosis

 

Nothing to Disclose: HJY, JYR, HCH, KMC, SHB, SGK, NHK, HYK, NHK, DSC

15806 12.0000 MON-1054 A Association of Metabolically Abnormal but Normal Weight (MANW) and Metabolically Healthy but Obese (MHO) Individuals with Arterial Stiffness and Carotid Atherosclerosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Rajit Aziz Gilhotra*1, Beverly Terezinha Rodrigues1, Usman H Malabu2, Venkat Vanagaveti1, George Kan2 and Kunwarjit Singh Sangla2
1James Cook University, Douglas, Australia, 2The Townsville Hospital, Douglas, Australia

 

Hemodialysis has recently been identified as a risk factor for lower limb amputations (1,2). In spite of this no study has been published that analyses the magnitude and risk factors for amputation amongst hemodialysis patients in rural and remote communities and Indigenous Australian residents of the Tropical Northern region where diabetes and kidney disease are quite common (3). The objectives of this study were to document trends in prevalence and identify risk factors of non-traumatic lower limb amputations in diabetes subjects treated with hemodialysis in the region. 155 current haemodialysis patients attending the Townsville Dialysis Centre were included in the study. Odds ratio and χ2 tests were performed to identify variables most strongly associated with amputation. We identified a 13.6% prevalence of lower limb amputation in 155 subjects on hemodialysis at our centre. The major risk factors of amputations in the cohort were history of ulceration (RR 24.74 [95%CI 6.02-101.76] p<0.0001) and the presence of diabetes (RR 23.19 [95%CI 1.43-375.49] p=0.027). Other variables tested but fell short of statistical significance included: Indigenous background, smoking history, gender and type of ulceration. Thus, patients with end stage renal failure on hemodialysis who have a past history of ulceration and have diabetes mellitus are at higher risk of having lower limb amputation. Primary prevention of diabetes in the sub-population may help in reducing the limb loss. In-depth analysis of the data will be presented at the conference.

 

Nothing to Disclose: RAG, BTR, UHM, VV, GK, KSS

15811 13.0000 MON-1055 A High Rates of Lower Limb Amputation in Patients with Diabetes End Stage Renal Failure on Hemodialysis: Is There a Causal Factor? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Irina Ciubotaru*1, Arfana Akbar2, Karthik Cherukupally2, Hassan Zaidi2, Subhash C Kukreja1 and Elena Barengolts3
1UIC Section of Endocrinology, Chicago, IL, 2Jesse Brown VAMC, Chicago, IL, 3University of Illinois at Chicago, Chicago, IL

 

The role of gut microbiota in obesity and insulin resistance has been recently under scrutiny. A high fat and low fiber diet may impact the microbiota and damage the intestinal epithelium, leading to a leaky gut and release of bacterial products (i.e., LPS) in circulation. Inflammatory effects of LPS are mediated by LPS binding protein (LBP) and cell-bound CD14. It has been suggested that shedding of CD14 in circulation as soluble CD14 (sCD14), as well as an increase in anti-LPS core antibodies (Abs) may have anti-inflammatory effects. Zonulin has emerged as a marker of intestinal permeability. Little is known about the effect of vitamin D on the gut of the metabolically impaired individuals. Twenty African-American males, with vitamin D insufficiency, pre-diabetes, and obesity from an inner-city VA center were  supplemented with weekly 50,000 U vitamin D for 12 mo. Serum was collected at baseline and 12 mo for vitamin D, sCD14, LBP, LPS Abs, and zonulin. Dietary information were collected using 24-h dietary recalls. The effects of vitamin D on HbA1c, BMI, and inflammatory markers were analyzed as differences from baseline using a paired t-test and correlations using Pearson coefficient. Mean baseline characteristics were age 60 yo, BMI 32.7, HbA1c 6.2%, and vitamin D 11.7ng/dl. Average 24h intake was 2070kcals, fat 80g, saturated fat 25g, carbohydrate 264g, protein 73g, and fiber 15g. Baseline sCD14 was 1428 ng/ml, LBP 18519 ng/ml, LPS Abs 237 GMU/ml, and zonulin 6 ng/ml. At 12 mo, BMI was 32.6 (p=0.92), HbA1c 6.4% (p=0.18), and vitamin D 56 ng/dl (p<0.000). After 12 mo of supplementation, vitamin D significantly increased sCD14 (P< 0.003) and LPS Abs (p< 0.037), decreased zonulin (p< 0.01), but did not significantly change LBP. Changes in all four markers had strong inverse correlations to changes in HbA1c and BMI (r=-0.4 to -0.6). Changes in all four markers had strong positive intercorrelations (r= 0.6 to 0.9). The strongest correlation was between sCD14/ zonulin (r=0.9) and sCD14/ LPS Abs (r=0.85). There were moderate to strong correlations between changes in all four markers and total caloric intake (kcals, r=0.32-0.41), as well as carbohydrate and fiber intake (g, r=0.37-0.45). The change in LBP had a moderate correlation to fat (g, r=36) and a weak correlation to saturated fat intake (g, r=21). Vitamin D supplementation resulted in changes of inflammatory markers associated with gut derived endoxemia: 1. it decreased zonulin suggesting a protective effect on the intestinal barrier. 2. it increased sCD14 and LPS Abs suggesting an anti-inflammatory effect by preventing LPS triggered inflammation. BMI and HbA1c may impede these effects, as they inversely correlated with changes in these markers. Our data suggest that vitamin D as well as changes in calorie, carbohydrate, and fiber intakes may modulate gut permeability and hence prevent low grade inflammation associated with obesity and insulin resistance.

 

Nothing to Disclose: IC, AA, KC, HZ, SCK, EB

16531 14.0000 MON-1056 A The Role of Vitamin D in Preventing Leaky GUT-Induced Endotoxemia in African American Veterans at Risk for Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Pablo Rodrigues Costa-Alves1, Erika Cesar de Oliveira Naliato*2, Margarete Domingues Ribeiro1, Filipe Augusto Carvalho Paula1, Ana Cristina Moreira Jorge Ghazali1, Mariana Tayt-Sohn Martuchelli Moço1 and Maria de Fatima Moreira Silva Jorge1
1UNIFESO (Serra dos Orgaos University Center), 2UNIFESO (Serra dos Orgaos University Center), Teresopolis, Brazil

 

The introduction of antiretroviral therapy (ART) resulted in a mortality reduction in patients with HIV/AIDS. However, both HIV and ART have been shown to cause adverse metabolic alterations that increase cardiovascular risk. This prospective interventional study was based on data collection of 50% of the adult HIV/AIDS patients on Highly Active Antiretroviral Therapy (HAART) for at least one year, registered in the Program of STD/AIDS of Teresópolis/Brazil (n = 129) and aimed to analyze the prevalence of the Metabolic Syndrome (MS) at study entry and the effects of a 2-year intervention with dietary counseling, physical activity implementation, cessation of smoking, and treatment of dyslipidemia, hypertension, and Diabetes (DM). At study entry, the prevalence of MS corresponded to 21%, while 3% of patients had DM (only 1% previously diagnosed) and 11%, impaired fasting glucose (IFG). Metformin was prescribed to all patients with DM and those in which IFG was associated with obesity. Hypertension affected 24.4% and dyslipidemia 68.9% of the patients, 59.5% were overweight/obese, and 41.8% had increased abdominal circumference. Most patients were medicated with captopril for the hypertension. Other anti-hypertensive drugs prescribed to the patients were atenolol, losartan, and hydrochlorothiazide. Simvastatin was prescribed to the patients with a high cardiovascular risk (5.7% of the present sample) and those with triglycerides levels ≥ 500 mg/dL (3.7%). The prevalence of smoking was 29.6% and 34% were sedentary. At the 2-year follow-up evaluation, 23% of patients had MS, 8% DM, 7% IFG, 28.7% hypertension, 68.9% dyslipidemia, 57.7% were overweight or obese, and 41.8% had increased abdominal circumference. At that point, there were statistically significant reductions in serum glucose levels (p = 0.008) and blood pressure (p = 0.0100) and non-significant reductions in total cholesterol and triglycerides levels. However, the elevation of HDL was statistically significant (p = 0.0100). The prevalence of smokers dropped to 27% (p = 0.0400) and sedentary lifestyle, to 30% (p = 0.0200). In our series, there was a reduction in cardiovascular risk from 6.0 ± 0.7%, at study entry, to 5.0 ± 0.6%, after the 2-year intervention period (p = 0.0400). Our results point out the high prevalence and the importance of controlling the metabolic abnormalities of HIV infection and HAART in Brazilian patients in order to reduce their cardiovascular risk.

 

Nothing to Disclose: PRC, ECDON, MDR, FACP, ACMJG, MTSMM, MDFMSJ

13303 15.0000 MON-1057 A Managing the Metabolic Syndrome in Brazilian HIV Patients Treated with Highly Active Antiretroviral Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Catarina Castelo Branco1, Eva Lau*2, Joana Isabel Oliveira3, Ana Cristina Santos4, Rosário Serrão5, António Sarmento6, Davide Carvalho7 and Paula Freitas2
1Faculty of Medicine, University of Porto, Portugal, 2Centro Hospitalar São João; Faculty of Medicine, Porto University, Portugal, 3Centro Hospitalar São João, Faculty of Medicine, Porto University, Porto, Portugal, 4Faculty of Medicine, Porto University, Porto, Portugal, 5Centro Hospitalar São João, Portugal, 6Centro Hospitalar São João, Faculty of Medicine, Porto University, Portugal, 7Centro Hospitalar São João, Faculty of Medicine, University of Porto, Portugal

 

Introduction: Liver stiffness (LS) by transient elastography seems to be correlated with fibrosis grade according to Metavir score. Objectives:To evaluate and compare clinical and metabolic parameters in patients with HIV/HCV co-infection, according to fibrosis grade determined by transient elastography. Methods: Retrospective cohort study of HIV/HCV co-infected patients. 4 groups were defined according to the presence of fibrosis determined by LS: 1) absence of significant fibrosis, if LS≤6 kPa; 2) undetermined fibrosis, if 6<LS<9 kPa; 3) significant fibrosis, if LS≥9 kPa; 4) cirrhosis, if LS≥14.6 kPA. Results: 69 patients were evaluated, of whom 31.9% did not present significant fibrosis, 34.8% presented undetermined fibrosis, 21.7% significant fibrosis and 11.6% cirrhosis, differences which were non-significant. The prevalence of patients under non nucleoside reverse-transcriptase inhibitor (NNRTI) therapy was different between groups (50% in the absence of significant fibrosis vs 29.2% in those with undetermined fibrosis vs 20% in those with significant fibrosis; p=0.043). Genotype 1 was the most common in all 4 groups (p=0.019). Increasing fibrosis was associated with lower levels of total cholesterol (p=0.02) and higher levels of AST (p=0.011). Those with fibrosis presented lowers levels of albumin. No differences were found in gender, age, risk behaviours, HIV infection and antiretroviral therapy duration, CD4 cells count, viral load, alcohol use, BMI, waist perimeter, blood pressure, C-LDL, c-HDL, triglycerides, ALT, GGT, alkaline phosphatase, total bilirubin or prothrombin time. No differences were found in the median value, neither a correlation with HOMA-IR, glucose, insulin or HgA1c between fibrosis groups. Conclusion: Fibrosis grade, defined by Liver Stiffness, was associated with differences in the prevalence of patients under NNRTI therapy and HCV genotype. Increasing fibrosis was associated with lower levels of total cholesterol and higher levels of AST.

 

Nothing to Disclose: CCB, EL, JIO, ACS, RS, AS, DC, PF

16639 16.0000 MON-1058 A Non-Invasive Evaluation of Hepatic Fibrosis By Transient Elastography: Clinical and Metabolic Parameters in HIV and HIV/HCV Co-Infection 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Catarina Castelo Branco1, Eva Lau*2, Joana Isabel Oliveira3, Ana Cristina Santos4, Rosário Serrão5, António Sarmento6, Davide Carvalho7 and Paula Freitas2
1Faculty of Medicine, University of Porto, Portugal, 2Centro Hospitalar São João; Faculty of Medicine, Porto University, Portugal, 3Centro Hospitalar São João, Faculty of Medicine, Porto University, Porto, Portugal, 4Faculty of Medicine, Porto University, Porto, Portugal, 5Centro Hospitalar São João, Portugal, 6Centro Hospitalar São João, Faculty of Medicine, Porto University, Portugal, 7Centro Hospitalar São João, Faculty of Medicine, University of Porto, Portugal

 

Introduction: Hepatitis C (HCV) seems to worsen insulin resistance, a common disturbance in HIV-1 infected patients. The mechanisms behind this association are still not fully understood. Objectives: To evaluate insulin resistance and other clinical and metabolic parameters in HIV infected vs HIV/HCV co-infected patients. Methods: Retrospective cohort study of patients with VIH and VIH/VHC infection, under combined antiretroviral therapy (cART). Insulin resistance was determined by HOMA-IR. Results: 285 (80.5%) HIV infected and 69 (19.5%) HIV/HCV co-infected patients were evaluated. Co-infection was more common among men (89.9%). No differences were found in HOMA-IR, QUICKI, insulin and A1c, age, viral load, protease inhibitors use, HDL cholesterol level and alcohol use between HIV and HIV/HCV infected patients. Co-infected patients presented longer HIV infection duration [13 (7.5) vs 8.0 (5.0) years] and cART [9 (23) vs 6.0 (6.50) years], and higher AST, ALT, GGT and alkaline phosphatase levels. They had lower CD4 cell count, use of non-nuceotide reverse-transcriptase inhibitors (NNRTI) and nucleotide reverse-transcriptase inhibitors (NRTI), BMI, waist perimeter, hypertension, total cholesterol, C-LDL, triglycerides and fasting glucose. Conclusion: No differences were found in insulin-resistance parameters. However, patients with HIV/HCV co-infection had a different lipid and hepatic profile comparing to those with HIV mono-infection.

 

Nothing to Disclose: CCB, EL, JIO, ACS, RS, AS, DC, PF

16654 17.0000 MON-1059 A HIV/HCV Co-Infection Is Associated with Different Lipid and Hepatic Profile Comparing to Mono-Infected By HIV Infection 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Joana Isabel Oliveira*1, Eva Lau2, Ana Cristina Santos3, Rosário Serrão4, António Sarmento5, Davide Carvalho6 and Paula Freitas2
1Centro Hospitalar São João, Faculty of Medicine, Porto University, Porto, Portugal, 2Centro Hospitalar São João; Faculty of Medicine, Porto University, Portugal, 3Faculty of Medicine, Porto University, Porto, Portugal, 4Centro Hospitalar São João, Portugal, 5Centro Hospitalar São João, Faculty of Medicine, Porto University, Portugal, 6Centro Hospitalar São João, Faculty of Medicine, University of Porto, Portugal

 

Introduction: Premature cardiovascular (CV) disease, and particularly coronary heart disease, is an emerging area of concern in HIV infected people. The early development of CV disease can be explained by the accelerated atherosclerosis process due to HIV infection per se and/or by the premature exposure to conventional CV risk factors.

Objectives: 1) Assess the CV risk categories calculated by the Framingham risk score and SCORE: a) in the total sample, b) in patients with and without clinical lipodystrophy (CL), 2) Evaluate the agreement between SCORE and Framingham risk score in categorization of CV risk in a) and b), 3) Characterize the discordant population between the two risk scores.

Patients and Methods: Cross-sectional observational study of 123 patients with HIV-1 infection treated with combination antiretroviral therapy (cART). We evaluated and categorized CV risk by Framingham score and SCORE.

Results: Patients with CL (61.8%) were 76.3% male and had a higher frequency of moderately high and high risk categories calculated by Framingham score risk and moderate, high and very high risk categories by SCORE. We found a moderate agreement (K=0.442, p<0.001) between the Framingham score and SCORE in total population, regardless of the presence of lipodystrophy [without CL (K=0.412, p< 0.001), with CL (K=0.439; p <0.001)]. In patients whose risk assessment is not concordant, 75.5% were male, 57.1% of smokers, 44.9% were hypertensive, and mostly presented the categories of moderate (38.8%) and moderately high risk (32.7%) calculated by Framingham score and low (49%) and moderate risk (44.9%) when used SCORE.

Discussion/Conclusion: Patients with CL were classified into categories of high risk for both equations, despite the agreement between them being only moderate. The fact that these equations do not include emerging risk factors such as inflammation, immune activation, coagulation disorders, kidney disease, HIV infection per se and antiretroviral therapy, associated with atherosclerosis in patients with HIV infection, may underestimate the real cardiovascular risk of these patients.

 

Nothing to Disclose: JIO, EL, ACS, RS, AS, DC, PF

16685 18.0000 MON-1060 A Cardiovascular Risk Assessment in HIV Infected Patients: Framingham or Score? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Paula Freitas1, Joana Isabel Oliveira*2, Eva Lau1, Mariana Lobo3, Tiago Silva Costa4, Alberto Freitas4 and Davide Carvalho5
1Centro Hospitalar São João; Faculty of Medicine, Porto University, Portugal, 2Centro Hospitalar São João, Faculty of Medicine, Porto University, Porto, Portugal, 3Center for Research in Health Technologies and Information Systems, 4Center for Research in Health Technologies and Information Systems, Faculty of Medicine of University of Porto, 5Centro Hospitalar São João, Faculty of Medicine, University of Porto, Portugal

 

Introduction: Diabetes Mellitus (DM) is associated with an increase in cardiovascular complications, namely coronary heart disease and heart failure (HF).

Objectives: To assess 1) the prevalence of HF hospitalizations: a) in DM vs. general population, b) in type 1 DM vs. Type 2 DM, 2) HF mortality in DM vs. general population, 3) the prevalence of obesity (BMI≥30kg/m2) or overweight (BMI≥25kg/m2) in patients with HF (DM vs. general population).

Methods: Cross-sectional analysis of patients admitted to our hospital between 1988 and 2012. Cohort was defined according to primary and/or secondary diagnosis of heart failure and/or diabetes, coded according to the ICD-9-CM. The prevalence of hospitalizations is expressed in percentages and chi-squared test was used for inferential analysis, with a significance level to α = 0.05.

Results: The prevalence of HF was higher in diabetic patients [15.50% (16153)] vs. general population [3.90% (35143)], p< 0.001]. In diabetic patients, the prevalence was higher in women, with no differences regarding gender in the general population. When evaluated each year, we noticed that the prevalence of HF increased in diabetic vs. general population since 2003. Those diabetic patients with HF, the majority had type 2 DM [95.69% (15457) vs. 4.31% (696), p< 0.001]. The prevalence of HF was higher in women regardless of the type of DM. The HF mortality was higher in DM vs. general population [(0.30% vs. 0.10%), p<0.001)], and it was higher in women in both groups. We found that in patients with HF, the prevalence of obesity was higher in diabetic [19.70% (3189), p<0.001] vs. general population [7.70% (2717), p<0.001]. In both groups, the population was mainly composed of individuals with grade 1 and 2 obesity.

Conclusion: The prevalence of HF hospitalizations and mortality was higher in diabetic patients than in general population. There was an increase in HF hospitalizations in the last 10 years.

 

Nothing to Disclose: PF, JIO, EL, ML, TSC, AF, DC

16708 19.0000 MON-1061 A Hospitalizations and Mortality for Heart Failure Are Higher in Diabetic Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Joana Isabel Oliveira*1, Eva Lau2, Ana Cristina Santos3, Rosário Serrão4, Flora Correia5, António Sarmento6, Davide Carvalho7 and Paula Freitas2
1Centro Hospitalar São João, Faculty of Medicine, Porto University, Porto, Portugal, 2Centro Hospitalar São João; Faculty of Medicine, Porto University, Portugal, 3Faculty of Medicine, Porto University, Porto, Portugal, 4Centro Hospitalar São João, Portugal, 5University of Porto, 6Centro Hospitalar São João, Faculty of Medicine, Porto University, Portugal, 7Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João. Faculty of Medicine, Porto University. Portugal, Porto, Portugal

 

Introduction:Human immunodeficiency virus (HIV) infected patients under combination antiretroviral therapy (cART) may develop complications related to premature aging, including decreased lean mass, namely sarcopenia when severe. Sarcopenia increases the risk of functional decline, comorbidities and mortality.

Objectives:To evaluate the presence of sarcopenia in a population of HIV-1 infected patients under cART.

Patients and methods: Retrospective observational study of 163 HIV-1 infected patients under cART. Sarcopenia was defined as non-fat mass index [non-fat mass (kg)/height2(m)] by electrical bioimpedance <17.4kg/m2 (in men) and <15.0 kg/m2(in women).

Results:We evaluated 103 (63.2%) men and 60 (36.8 %) women, with a mean age of 47.4 (SD 11.3) years, disease duration of 8.0 (SD 3.9) years, duration of cART 6.8 (SD 3.9) years, BMI 24.8 (SD 4.1) kg/m2, waist circumference 90.8 (SD 11.0) cm. Regarding smoking habits, 71 (43.8 %) were non-smokers, 63 (38.9%) smokers and 28 (17.3%) ex-smokers. Sarcopenia was present in only 1 (0.6 %) patient. 

Discussion: The prevalence of sarcopenia was less than that found in other studies, which may be related to the younger age of cohort, which indirectly allows greater mobility. Physical activity is a parameter to evaluate in future studies. Another possible explanation is the use of an equation that considers only the total non-fat mass over the square of height and not appendicular lean body mass. Furthermore, current definitions of sarcopenia include notions of muscle strength and function, which was not reported, constituting a limitation.

 

Nothing to Disclose: JIO, EL, ACS, RS, FC, AS, DC, PF

16822 20.0000 MON-1062 A Sarcopenia: A Reality in HIV-1-Infected Patients Under Antiretroviral Combination Therapy in the XXI Century? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Mette Nygaard Andersen*1, Anne-Marie Schjerning Olsen1, Jesper Clausager Madsen2, Jens Faber3, Christian Torp-Pedersen1, Gunnar Hilmar Gislason1 and Christian Selmer3
1Gentofte University Hospital, Hellerup, Denmark, 2Copenhagen General Practitioners Laboratory, Copenhagen, Denmark, 3Herlev University Hospital, Herlev, Denmark

 

Background: Subclinical hypothyroidism is associated with a number of cardiovascular risk factors such as hypertension, hypercholesterolemia and diastolic dysfunction, but only limited data exist on long-term outcome of levothyroxine substitution therapy.

Objectives: To examine effects of levothyroxine substitution treatment on mortality in patients with subclinical hypothyroidism.

Study design:Historical cohort study.

Methods: Patients > 18 years consulting their general practitioner from 2000–2009 in Copenhagen, Denmark, who underwent thyroid blood tests, were identified by individual-level linkage of nationwide registries. Only patients with subclinical hypothyroidism at baseline were included (defined as elevated TSH with normal free T4). History of thyroid disease, related medication or treatment with lithium, amiodarone and glucocorticoids were excluded. Levothyroxine treatment was only considered if initiated within 6 months from baseline. Incidence Rate Ratios (IRR) of all-cause mortality were analyzed using Poisson regression models. 

Results: The total cohort comprised 628,953 patients of whom 12,212 (1.9%) had subclinical hypothyroidism (mean age 55.2 [SD ± 18.8] years; 79.8% female). Within the first 6 months, 2,452 patients (20.1%) claimed prescription of levothyroxine. The remaining 9,760 patients (79.9%) either initiated levothyroxine therapy later than 6 months after their initial blood test, or did not receive any substitution treatment. During a mean follow-up of 5.0 (SD ± 2.6) years 1,566 patients died. Overall mortality rate was 26/1000 person-years (py) and 21/1000 (py) among untreated and levothyroxine treated, respectively. No influence on all-cause mortality was found in patients substituted with levothyroxine (IRR 1.02 [95% CI: 0.88–1.17]).

Conclusions: In patients with subclinical hypothyroidism substitution with levothyroxine does not affect all-cause mortality.

 

Nothing to Disclose: MNA, AMSO, JCM, JF, CT, GHG, CS

13963 21.0000 MON-1063 A Levothyroxine Substitution in Subclinical Hypothyroidism Does Not Affect All-Cause Mortality 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Somlak Chuengsamarn*1, Suthee Rattanamongkolgul2 and Siwanon Jirawatnotai3
1Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, Nakornnayok, Thailand, 2Faculty of Medicine, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot University, Nakornnayok, Thailand, Nakornnayok,, Thailand, 3Siriraj Medical School, Mahidol University, Bangkok, Thailand

 

Aims: To determine the correlation between of an inflammatory cytokine hs-CRP and metabolic control/ chronic vascular complications in type 2 diabetes.

Methods: The cross-sectional study was randomly enrolled with 608 patients with type 2 diabetes.  All subjects were examined, and basic information was recorded. We measured parameters of basic chemical laboratory (fasting plasma glucose, HbA1c, triglyceride, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and serum hs-CRP) at baseline and after follow up of 1 year. The related chronic vascular complications in type 2 diabetes were monitored and recorded. 

Results: Logistic regressions of odds ratios between hs-CRP and chronic vascular complications (cerebrovascular disease, coronary arterial disease, diabetic nephropathy, diabetic retinopathy, and diabetic peripheral neuropathy) showed a significant correlation, [2.0 (0.71-5.60), 5.30(2.64-6.19), 36.88(12.28-110.79), 2.08(0.70-6.18), 4.18(6.03-6.19)]. This is with an exception of cerebrovascular disease complications. Linear regressions of the changes of hs-CRP were significantly correlated with HbA1c (r =0.40), fasting plasma glucose (r =0.36), triglyceride (r =0.20), low-density lipoprotein cholesterol (r =0.12), and high-density lipoprotein cholesterol (r = -0.12), but not the total cholesterol (r =0.06).

Conclusions: Our data suggested that all of chronic diabetic vascular, except cerebrovascular complications, were associated with a systemic inflammatory response (hs-CRP) in patients with type 2 diabetes. The strong correlations also suggested that control of these metabolic components in diabetic patients may help lowering the inflammatory cytokine (hs-CRP). 

 

Nothing to Disclose: SC, SR, SJ

11201 22.0000 MON-1064 A Association of Serum High-Sensitivity C - Reactive Protein to Metabolic Control and Chronic Vascular Complications in Patients with Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Saswati Das*
Maulana Azad Medical College, Delhi, India

 

Background: Lipoprotein-associated phospholipase A2 (LpPLA2) enzyme, mainly associated with LDL, hydrolyzes its phospholipids producing proinflammatory compounds like lysophosphatidylcholine and oxidized non-esterified fatty acids. Lp-PLA2 is an emerging marker of coronary artery disease (CAD). However its role and levels have not been documented clearly in diabetic patients with CAD  in  an Indian population. The aim of this study was to compare  the levels of  LpPLA2 levels between diabetic and non-diabetic patients with CAD and observe its correlation with the severity of CAD in both groups.

METHODS:

Sixty individuals  with  angiographically proven CAD and 30 healthy individuals matched for age & sex were studied. CAD patients were divided into two groups based on presence (n=30) [Group I] and absence (n=30) [group II] of type 2 diabetes mellitus (DM). The serum levels of LpPLA2 were measured by ELISA and routine lipid profile was measured by automated analyzer . Angiographic clinical vessel scoring was also done for all the patients. Data is presented as mean±SD and relationships were determined by Pearson correlations.

RESULTS:

Both groups of CAD with and without DM had significantly higher levels of  LpPLA2  (Group I- 408.48 +/- 38.96 ng/ml, Group II-272.88 +/- 34.21ng/ml  respectively) when compared with healthy control subjects (LpPLA2 =200.82 +/- 20.97ng/ml) [p<0.01]. The difference in LpPLA2  levels between the two CAD groups was highly significant(p<0.01), levels  being  maximum for CAD with type 2 diabetes (Group I) which could be due an increase in its substrate sLDL and oxidised LDL in DM. Angiographic clinical vessel score of CAD severity was also higher in patients of DM with CAD. LpPLA2 levels correlated strongly with the angiographic clinical vessel score in diabetes with CAD patients (r=0.763,p<0.01) than without diabetes(r=0.399, p<0.05).

CONCLUSION:

The LpPLA2 levels is markedly increased in patients of  type 2 diabetes mellitus with CAD as compared to only CAD patients. Measurement of  LpPLA2  may be considered as a marker for better prediction of cardiovascular risk in diabetes patients.

 

Nothing to Disclose: SD

11559 23.0000 MON-1065 A A Comparison of Lipoprotein Associated Phospholipase A2 Levels Between Diabetic and Non-Diabetic Patients with Coronary Artery Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Irina Dzherieva*1, Natalya Volkova2, Maria Antonenko3, Igor Reshetnikov4, Ilia Davidenko5 and Maria Komurdzhyants6
1Rostov State Medical University, Rostov on Don, Russia, 2The Rostov State Medical University, Rostov-on-Don, Russia, 3Rostov State Medical University, Rostov-on-don, Russia, 4Rostov State Medical University, Rostov-on-Don, Russia, 5Rostov State Medical University, 6Medical center, Rostov on Don, Russia

 

Nocturnal hypertension is an important risk factor of stroke and acute myocardial infarction. Blood pressure has circadian regulation. Melatonin (M) represents the main hormonal output of the pineal gland and it is considered to be important modulator of circadian rhythms. Melatonin is secreted during the day in various amount, but the secretion at 3 a.m. is the most important for cardiovascular regulation. The changing of melatonin level might be one of the causes which destroy a nocturnal pattern of blood pressure, but yet it is unknown whether the changing of melatonin level is dependence between the degree of melatonin decreasing and the variation of nocturnal blood pressure.

To study the role of changing melatonin level at 4 a.m. in «night-picker» and «non-dipper» patients with arterial hypertension (AH) and metabolic syndrome (MetS)  blood pressure had been monitored for 24 hours and at the same time melatonin secretion had been determined according to excretion 6-sulfatoxymelatonin (MT6S) in urine at 4 a.m. This issue corresponds to maximum melatonin secretion at 3 a.m. 35 patient with AH and MetS and 21 practically health men took part in this research. The mean age of the patients was 47 years (min 38; max 52). The level of MT6S excretion in hypertensive patients was less than in control group (25.3 95% CI: 17.8-32.8 ng/ml vs 38.6 95% CI: 32.3.8-45.1 ng/ml, p=0.04). When the peak of MT6S excretion decreases, the risk of insufficient night blood pressure decreasing rose (OR 1.6, 95% CI: 0.8-3.4; p<0.05). But there was not the significant difference in MT6S excretion between «night-picker» and «non-dipper» patients with AH and MetS (27.1 95% CI: 25.8-33.6 ng/ml vs 28.6 95% CI: 24.3-36.1 ng/ml, p>0.05). Thus we showed that M secretion deceased in patients with AH and MetS but it did not define its structure.

 

Nothing to Disclose: ID, NV, MA, IR, ID, MK

14814 24.0000 MON-1066 A Changing Melatonin Level Did Not Define the Pattern of Nocturnal Hypertension 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Ma. Etzabel Villegas-Rodriguez*1, Sergio Solorio-Meza2, Martha Eugenia Fajardo3, Juan M Malacara4, Kazimierz Wrobel5 and Ma Eugenia Garay-Sevilla6
1University of Guanajuato, León, Mexico, 2Instituto Mexicanao del Seguro Social, León, Mexico, 3Universidad de Guanajuato, Leon GTO, Mexico, 4Univ de Guanajuato, Leon Gto, Mexico, 5University of Guanajuato., Guanajuato, Mexico, 6Univ de Guanajuato, Leon GTO, Mexico

 

Diabetes is associated with a greatly increased risk of cardiovascular disease and the advanced glycation end products (AGEs) have an important role in atherosclerosis, a systemic arterial disease that permits the progression to diabetic complications.

Objective: To study the association of skin autofluorescence AGEs and the interaction of cardiovascular risk factors, in obese and normal weight patients of recent diagnosis type 2 diabetes mellitus.

Material and methods: We conducted a cross-sectional study in 35 to 65 years old subject with type 2 diabetes mellitus of recent diagnosis, by means of a glucose tolerance test according to the ADA criteria. We studied two groups, one with obesity (n=28) and the other of normal weight (n=29). We measured somatometric variables, SBP, DBP, glucose, HbA1c, lipid profile. We also made the ultrasound measurement of the carotid intima-media thickness (CIMT), flow-mediated dilation (FMD) and ankle-brachial index. AGEs were measured by skin autofluorescence with the AGE reader.

Result: We studied 57 patients with 49±7.1 years of age and with HbA1c 6.45±1.03.

Comparing obese and non-obese patients, CIMT was larger (p<0.03), stiffness lower (p<0.02) and FMD lower (p<0.02) in normal weight patients.

CIMT was associated with AGEs in the total group (p<0.002) and with LDL-C (p<0.02) and in normal weight patients with LDL-C (p<0.03). FMD was associated with AGEs both in normal weight (p<0.00007) and obese (p<0.01) subjects. FMD was also associated in normal weight patients with LDL-C (p<0.004), BMI (p<0.02) and SBP (p<0.04) and in obese patient with LDL-C (p<0.005) and with ankle- brachial index (p<0.01).

Conclusion: The results show the strongly association of CIMT and FMD with skin autofluorescence AGEs and LDL-C.

 

Nothing to Disclose: MEV, SS, MEF, JMM, KW, MEG

14979 25.0000 MON-1067 A Skin Autofluorescence Ages Are Associated with Ultrasound Alterations of the Carotid in Subjects of Recent Diagnosis of Type 2 Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Martin Gaksch*1, Andreas Meinitzer2, Bríain ó Hartaigh3, Katharina Kienreich1, Nicolas Verheyen1, Martin R Grübler1, Jana Grogorenz1, Astrid Fahrleitner-Pammer4, Winfried März5, Andreas Tomaschitz2 and Stefan Pilz1
1Medical University of Graz, Graz, Austria, 2Medical University of Graz, Austria, 3Yale School of Medicine, New Haven, 4Med Univ, Graz, Austria, 5Ruprecht Karls University Heidelberg, Mannheim, Germany

 

Low levels of homoarginine have been associated with a decline in kidney function, adverse cardiovascular events and death due to heart failure (1,2). Prior genome-wide association studies further documented low concentrations of homoarginine were linked to the AGXT2 locus, which may promote autonomic nervous system dysregulation, as well as impaired cardiac function (3). To further disentangle the relationship, we examined homoarginine and its association with night-time heart rate variability (HRV) in patients with diabetes mellitus (DM).

Patients were derived from a tertiary care center at the Medical University of Graz. DM was diagnosed according to the 2010 ADA guidelines. Ambulatory blood pressure monitoring (ABPM) was recorded using a Spacelabs 90207 monitor. Night-time HRV was defined as the standard deviation (SD) of mean night-time heart rate between the hours of 01:00-06:00 a.m., based on the British Hypertension Society recommendations. Homoarginine was uniformly measured using reverse phase high-performance liquid chromatography method (4).

We included sixty-one patients (n=41% female, 76% type 2 DM), the median age (interquartile range [IQR]) of the study participants was 62.5 (53.5-71.1). Mean (±SD or IQR) night-time systolic and diastolic blood pressure (BP), heart rate, HRV, and homoarginine were 122±17 mmHg, 68±10 mmHg, 67±10 beats/min, 4.34 (2.69-7.01) beats/min, and 1.63 (1.28-2.45) µmol/L, respectively. There was a positive and significant correlation (rho=0.30; P=0.02) between homoarginine levels and night-time HRV. Following log-transformation, the association remained significant (β=0.29; P=0.05) in linear regression analysis even after adjusting for numerous covariates.

In this cross-sectional investigation, we observed a positive and significant relationship between homoarginine and night-time HRV. These data suggest an important role for homoarginine in the maintenance of autonomic nervous system regulation and cardiac function, particularly among diabetic patients.

 

Nothing to Disclose: MG, AM, BÓH, KK, NV, MRG, JG, AF, WM, AT, SP

15941 26.0000 MON-1068 A Higher Concentrations of Homoarginine Are Associated with Improved Night-Time Heart Rate Variability Among Patients with Diabetes Mellitus: Cross-Sectional Findings from the Styrian Hypertension Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Sait Demirkol*1, Mustafa Cakar2, Sevket Balta3, Cengiz Ozturk4, Hakan Sarlak4, Ali Kilinc4, Turgay Celik5 and Atila Iyisoy1
1Gulhane Medical Faculty, ANKARA, Turkey, 2Eskisehir Military Hospital, Eskisehir, Turkey, 3Eskişehir Military Hospital, Eskişehir, 4Gulhane Medical Faculty, 5Gulhane Medical Faculty, ANKARA

 

Background: Diabetes mellitus(DM)  is an independent predictor for mortality in coronary artery disease. Endothelial dysfunction is widely regarded as being the initial lesion in the development of atherosclerosis. Carotid intima media thickness (cIMT) is widely used to assess endothelial dysfunction(1). Endocan is a novel human endothelial cell specific molecule. Previous studies have showed that endocan may be a surrogate endothelial dysfunction marker and may predict the cardiovascular diseases (2-4).

Objectives: To investigate the relationship between serum levels of endocan and cardiovascular risk in patients with psoriasis vulgaris.

Methods: A total of 28 patients with newly diagnosed DM without any disorders and medication and 33 control subjects were enrolled in present study. Endocan, cIMT were measured in all subjects. Human endothelial-cell specific molecule-1 was measured by an enzyme-linked immunosorbent assay (ELISA) according to the manufacturer's protocol (Aviscera Bioscience Inc., Santa Clara, CA, USA). cIMT were evaluated by high-resolution ultrasound using the Philips IE 33 6.0 equipped with a L 11-3 broadband linear array transducer .

 Results: Serum endocan levels were higher in patients with DM compare with controls. Also, cIMT measurements were also increased in DM patients (p< 0.001). In patients with DM, serum endocan levels moderate correlated with cIMT.

Conclusion: Circulating endocan may represent a new marker that correlates with cardiovascular risk in patients with DM. Endocan may be a surrogate endothelial dysfunction marker and may have a functional role in endothelium-dependent pathological disorders.

 

Nothing to Disclose: SD, MC, SB, CO, HS, AK, TC, AI

16230 27.0000 MON-1069 A Serum Endocan Levels As a Novel Inflammatory Indicator in Newly Diagnosed Diabetes Mellitus Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Sevket Balta*1, Sait Demirkol2, Mustafa Cakar3, Cengiz Ozturk4, Turgay Celik5, Atila Iyisoy2, Muharrem Akhan4 and Omer Kurt4
1Eskişehir Military Hospital, Eskişehir, 2Gulhane Medical Faculty, ANKARA, Turkey, 3Eskisehir Military Hospital, Eskisehir, Turkey, 4Gulhane Medical Faculty, 5Gulhane Medical Faculty, ANKARA

 

Background:Although diabetes increases the risk of cardiovascular disease and mortality, however, whether other glucose abnormalities are associated with death risk in cardiovascular disease patients is unclear. Endothelial dysfunction is widely regarded as being the initial lesion in the development of atherosclerosis. Endothelial dysfunction is the critical early step in the process of atherogenesis, and it is commonly investigated by measuring arterial stiffness(1). Human endothelial-cell specific molecule-1(endocan) is also a novel human endothelial cell specific molecule(2-4). We investigated the relationship between serum levels of endocan and arterial stiffness parameters (ASPs) as a cardiovascular risk in patients with impaired fasting glucose(IFG).

Methods: A total of 28 patients with IFG without any conditions and 37 control subjects were included in the study. Endocan, ASPs were measured in all subjects. Human endothelial-cell specific molecule-1 was measured by an enzyme-linked immunosorbent assay (ELISA) according to the manufacturer's protocol (Aviscera Bioscience Inc., Santa Clara, CA, USA).

Results:Age, body mass index, blood pressure, lipid profiles, smoking rates were not different between the 2 groups except for fasting levels of glucose. Serum endocan levels were significantly different between the two groups (p< 0.01). In all study individuals, serum endocan levels correlated with ASPs.

Conclusion: Circulating endocan may represent a new marker that correlates with ASPs as a cardiovascular risk in patients with IFG.

 

Nothing to Disclose: SB, SD, MC, CO, TC, AI, MA, OK

16332 28.0000 MON-1070 A The Relation Between Serum Endocan Levels and Aortic Arterial Stiffness in Patients with Impaired Fasting Glucose 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Ye Eun Kang*1, Ju Hee Lee2, Ji Min Kim2, Koon Soon Kim3, Hyun Jin Kim2 and Bon Jeong Ku2
1Chungnam National University Hos, Dae Jeon, Korea, Republic of (South), 2Chungnam National University Hospital, Daejeon, Korea, Republic of (South), 3Chungnam National University College of Medicine, Daejeon, Korea, Republic of (South)

 

Chronic low-grade inflammation caused by activation of the innate immune system plays an essential role in the pathogenesis of type 2 diabetes and its major complications. Emerging evidence suggests that activation of the nucleotide binding and oligomerization domain-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome leads to the maturation and secretion of interleukin (IL)-1β and is involved in the pathogenic mechanisms of obesity-induced inflammation, insulin resistance, and type 2 diabetes development. In our previous study, NLRP3 inflammasome activation is elevated in myeloid cells from drug-naïve, newly diagnosed type 2 diabetic patients and antidiabetic treatment with metformin contributes to modulation of inflammasome activation. These previous reports prompted us to explore the association of cardiovascular risk and the inflammasome activation in type 2 diabetes. Therefore, we performed a sub-analysis to evaluate the association of the Framingham score with the NLRP3 inflammasome activation. Framingham score was associated neither relative mRNA expression of NLRP3, apoptosis-associated speck-like protein containing a CARD nor production of proinflammatory cytokines regardless of stimulation with lipopolysaccharide in monocyte-derived macrophages(MDMs) from the type 2 diabetic patients. Framingham score was not correlated with IL-1β secretion in MDMs after stimulation with various danger molecules such as ATP, monosodium uric acid crystals, islet amyloid polypeptides, free fatty acids, too. The type 2 diabetic patients with intermediate to high risk did not show the increase of either IL-1β or IL-18 in serum compared to the patients with low risk (23.3±11.5 vs 21.3±16.7 pg/ml; P=0.651, 34.6±14.3 vs 31.2±16.5 pg/ml; P=0.530). In conclusion, the NLRP3 inflammasome activation is not associated the cardiovascular risk in the newly diagnosed type 2 diabetes.

 

Nothing to Disclose: YEK, JHL, JMK, KSK, HJK, BJK

16506 29.0000 MON-1071 A Association of NLRP3 Inflammasome Activation and Cardiovascular Risk in Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Esra Tutal*1, Melia Karakose2, Mustafa Sahin3, Mustafa Caliskan4, Bekir Ucan1, Taner Demirci1, Gulfer Ozturk5, Erman Cakal1, Mustafa Ozbek1 and Tuncay Delibasi1
1Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey, 2Diskapi Yildirim Beyazit Teaching and Research Hospital, Ankara, Turkey, 3Ankara University School of Medicine, Ankara, Turkey, 4Diskapi Training and Research Hospital, Ankara, Turkey, 5Diskapi Yildirim Beyazit Training and Research Hospital, Turkey

 

OBJECTIVE:

Pre-diabetes is a leading risk factor for type 2 diabetes. It also carries important risk for microvascular and macrovascular diseases. Accumulating evidence demonstrated that osteoprotegerin (OPG) is associated with cardiovascular risk in patients with diabetes.  We investigated OPG levels and its relationship with cardiovascular risk factors in patients with prediabetes.

MATERIALS  and METHODS:

We analyzed age and sex compatible 47 patients (19 with impaired fasting glucose (IFG), 6 with impaired glucose tolerance (IGT), 22 with both IFG and IGT) and 58 healthy controls.  IR was determined using the homeostasis model assessment of insulin resistance (HOMA-IR).  OPG and receptor activator of nuclear factor κB ligand (RANKL) levels measured by ELISA We compared OPG and RANKKL levels with control group. Also we evaluated the relationship OPG and RANKL levels with fasting glucose, insulin resistance, glycosylated hemoglobin, high sensitivity C-reactive protein (hs-CRP) and carotid intima media thickness (CIMT).

RESULTS:

Fasting glucose, fasting insulin, HOMA-IR and triglyceride levels were found significantly higher in patients with prediabetes than controls (p<0.05). Compatible with these results body mass index (BMI) and waist circumference (WC) were found significantly higher in patients (p<0.05). However, no differences were observed in OPG and serum RANKL levels. We found higher CIMT and hs-CRP in patients with prediabetes than controls (p<0.05). Furthermore, we found a significant correlation between CIMT and fasting glucose, fasting insulin, WC, BMI, triglyceride,  hs-CRP (respectively, r= 0.394, p< 0.05, r=0.314, p<0.05, r=0.621, p<0.05, r=0.604, p<0.05, r=0.287, p<0.05, r=0,358, p<0.05). However, we could not find any correlation between OPG, RANKL and other variables.

CONCLUSIONS:

Prediabetes is associated with high cardiovascular disease risk. However, OPG/RANKL is not a valuable cardiovascular marker for these patients.

 

Nothing to Disclose: ET, MK, MS, MC, BU, TD, GO, EC, MO, TD

16727 30.0000 MON-1072 A Circulating Receptor Activator of Nuclear Factor κB Ligand and Osteoprotegerin in Prediabetes: Relationships to Cardiovascular Risk 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1043-1072 4803 1:00:00 PM Obesity, Diabetes, and Cardiovascular Risk Poster

Sanford R Sampson*1, Sigalit Boura-Halfon2, Roi Isaac2, Yaron Vinik2 and Yehiel Zick2
1Weizmann Inst of Science, Rehovot, Israel, 2Weizmann Institute of Science, Rehovot, Israel

 

     Infiltration of pancreatic islets by cells of the immune system (insulitis) is the initial event leading to the ultimate destruction of pancreatic β cells in Type 1 Diabetes. However, knowledge of the early processes involved in this autoimmune process is incomplete. In recent years, the ligand/receptor duo, TWEAK (TNF-like weak inducer of apoptosis) and its receptor Fn14 (fibroblast growth factor-inducible molecule 14), along with their downstream signaling pathways, have been gaining growing interest in diverse medical conditions, in particular chronic autoimmune diseases such as Lupus Erythematosus, Rheumatoid Arthritis, and experimental autoimmune encephalomyelitis. The biological effects of TWEAK include induction of cytokine release, modulation of the immune response, and stimulation of cell death mechanisms. Surprisingly, however, studies on TWEAK/Fn14 in autoimmune destruction of pancreatic beta (β) cells have not been reported. In this study we examined the possibility that the TWEAK-Fn14 system may be involved in the initiation and promulgation of the autoimmune process in pancreatic β cells. We first studied Fn14 RNA and protein expression by Real Time PCR and Western blotting in both MIN6 cells and human pancreatic islets and found it to be readily detectable in both preparations. Moreover, we could show that cytokine treatment up-regulated Fn14 RNA expression in MIN6 cells, and this effect was abrogated entirely in cells expressing sRNAiFn14. Cytokine up regulation of the NFκB target MCP1 was also reduced in cells expressing sRNAiFn14. Recombinant human TWEAK increased RNA expression of NFκB targets MCP-1 and IP10 in human islets and in MIN6 cells, and increased Caspase 3/7 activity; these effects were strongly reduced in cells expressing sRNAiFn14. These findings suggest that the "TWEAK/Fn14 axis", acting through NF-κB signaling, may play an important role in the interface between the immune system and pancreatic β-cells and may offer new prospects for therapeutic interventions in type 1 diabetes and its complications.

 

Nothing to Disclose: SRS, SB, RI, YV, YZ

11172 1.0000 MON-1011 A The "Tweak-Fn14 Axis"-a New Player in Autoimmune Destruction of Pancreatic Beta Cells? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Abdussalam E Elsenousi*, Edward F Hollinger, Sameh A Fayek, Edie Y Chan, Martin Hertl, Stephen C Jensik and Oyedolamu K Olaitan
Rush University Medical Center, Chicago, IL

 

Kidney Transplantation in Diabetics: Results from a Single Center

Section of Transplantation, Department of General Surgery, Rush University Medical Center, Chicago, IL.

 

Aim

Few studies have looked specifically at the results of renal transplantation in patients with diabetes mellitus (DM).  We analyzed the results of kidney transplantation in diabetics at a single center and compared the results with those of non-diabetic patients that received renal transplants during the same period.

Materials & Method

We performed a retrospective chart review of 392 patients who received kidney transplants from July 2008 to June 2012. Patients with at least one year of post-transplant follow-up were included. Three multi-organ transplant recipients (liver-kidney, N=2; heart-kidney, N=1) were excluded from the data analysis; recipients of simultaneous pancreas kidney transplant (SPK) were included.  We examined donor and recipient demographics and characteristics of the transplant procedure and performed Kaplan-Meier analysis of patient and graft survival.

Results

Three hundred and eighty nine recipients were examined, of which 180 (46%) had diabetes at the time of transplant.  For diabetic patients, 15 (8.3%) received SPK and 165 (91.7%) received a kidney transplant alone (KTA). Donor and recipient characteristics as well as characteristics of equivalent surgical procedures were similar between the groups.   One-year survivals are similar for diabetic (patient=98%, graft=90%) and non-diabetic (patient=99%, graft=93.8%) patients.  However, 5-year survivals are significantly worse for patients with diabetes (patient=83.3%, graft=80.6%) than those without DM (patient=94.9%, graft=89.5%), p=0.001 and p=0.029.  Patients with DM who receive an SPK have better 1-year survival (patient=100%, graft=94%) than those who receive a KTA (patient=98%, graft=89%).  At five years, however, differences between SPK (patient=93%, graft=86.7%) and KTA (patient=82%, graft=80%) are more apparent.

Conclusions

Patient and graft survival were comparable between diabetics and non-diabetics at 1 year, however, results are significantly better for non-diabetics at 5 years. The poorer long term outcomes are, however, only seen in diabetic patients that receive KTA, whereas results for patients receiving SPK transplants approach those of patients who are not diabetic and receive a KTA.  These results suggest that SPK should be strongly considered in all insulin dependent diabetics being evaluated for kidney transplantation if they meet the listing criteria for both organs.

 

Nothing to Disclose: AEE, EFH, SAF, EYC, MH, SCJ, OKO

14971 2.0000 MON-1012 A Renal Transplantation in Patients with Diabetes: Results from a Single Center 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Abdussalam E Elsenousi*, Edward F Hollinger, Sameh A Fayek, Edie Y Chan, Martin Hertl, Stephen C Jensik and Oyedolamu K Olaitan
Rush University Medical Center, Chicago, IL

 

Aim

Patient compliance with immunosuppressive therapy after transplantation has a major impact on graft and patient outcomes.  Prior studies have used HbA1C level as a marker for measuring compliance with insulin regimens for diabetic patients. We use HbA1C in conjunction with other parameters including missed clinic visits and compliance with dialysis as a screening tool to help predict a patient’s ability to maintain a complicated post–transplant medication regimen, including immunosuppression.  For diabetic end stage renal disease (ESRD) patients being evaluated for kidney or pancreas transplantation, we have used a HbA1C level of >10% as a flag that the patient may be at risk for non-compliance and that more-aggressive psychosocial screening is needed prior to transplant.

Materials & Method

We performed a retrospective chart review of 392 patients who received kidney transplant at Rush University Medical Center from January 2008 to June 2012.  We included only patients with at least one year of post-transplant follow up. Data collected included patient demographics, graft outcomes, HbA1c before transplant, target and measured immunosuppressant levels after transplant, and acute rejection episodes.

Results

A total of 392 charts were analyzed.  183 patients (46.7%) were diabetic; 23 (13%) type 1, 137 (74%) type 2, and 23 (13%) unclassified (missing C-Peptide). Grafts failed in 36 (19.7%) of the diabetic kidney graft recipients and at least one rejection episode occurred in 24 (13%) of them. The mean HbA1c for all patients was 6.5%. There was no significant difference between mean HbA1c level for patients whose grafts had failed and those with functioning grafts (6.7% and 6.5%, respectively, p=0.19) nor was there any significant difference between HbA1c levels for patients who had rejection episodes and those who did not (6.5% and 6.5%, respectively, p=0.8). There was also no significant difference between HbA1c level for patients who were documented to be non-compliant with their medications compared with those with no documentation of poor compliance (6.6% and 6.4%, respectively, p=0.6).

Conclusion

In diabetic patients with HbA1C values below 10% selected for transplant, elevated pre-transplant HbA1c levels are not predictive of poor post-transplant medication compliance.  Further studies are needed to determine if pre-transplant HbA1c levels above 10% are predictive of worse post-transplant compliance and outcomes.

 

Nothing to Disclose: AEE, EFH, SAF, EYC, MH, SCJ, OKO

16913 3.0000 MON-1013 A Glycosylated Hemoglobin (HbA1C) As a Tool for Assessing Post-Transplant Compliance in the Evaluation of Diabetic End Stage Renal Disease Patients for Transplantation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Kyung-Soo Kim*1, Hye Yun Jeong1, Yoo-Lee Kim2, Won-Keun Park2, Seok Won Park1, Yong-Wook Cho1 and Soo-Kyung Kim1
1CHA Bundang Medical Center, CHA University, Seongnam, Korea, Republic of (South), 2CHA Gangnam Medical Center, CHA University, Seoul, Korea, Republic of (South)

 

Background and aims: The prevalence and incidence of chronic kidney disease (CKD) in patients with type 2 diabetes have increased over the last two decades. Nevertheless, there are still limited data on the prevalence of CKD and risk factors related to its progression in elderly patients with type 2 diabetes. The aim of this study was to evaluate prevalence and progression rate of CKD in elderly patients with type 2 diabetes after 6 years of follow-up.

Methods: A cohort of elderly patients (65 years or older) with type 2 diabetes participated in an examination during 2005 (n = 208), a 6-years follow-up examination during 2011 (n = 136). Of the 136 patients who participated in the 2011 examination, 98 patients completed study and 38 patients excluded because end-point events occurred. The estimated glomerular filtration rate (eGFR) was calculated using the modification of diet in renal disease equation. The CKD was defined as eGFR < 60 mL/min/1.73m2.

Results: Among the 208 elderly patients with type 2 diabetes, 95 patients (45.7%) had CKD at baseline. After 6 years, the prevalence of CKD was increased up to 67.3% (66/98) and renal function was aggravated in one third of patients (37.8%, 37/98). Furthermore, in elderly patients with normal renal function, progression rate to CKD was 50.9% (27/53). Higher baseline HbA1c, higher blood pressure, higher albumin creatinine ratio, and history of hypoglycemia and coronary artery occlusive disease were associated with decreasing eGFR.

Conclusions: In conclusion, CKD and its progression were commonly accompanied in elderly patients with type 2 diabetes. Consequently, it is important to identify and manage CKD as early as possible in elderly patients with type 2 diabetes.

 

Nothing to Disclose: KSK, HYJ, YLK, WKP, SWP, YWC, SKK

15323 4.0000 MON-1014 A Higher Prevalence and Progression Rate of Chronic Kidney Disease after 6 Years of Follow-up Study in Elderly Patients with Type 2 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Atsushi Aoki*
Jichi Medical University Saitama Medical Center, Saitama, Japan

 

Sclerostin is produced by osteocytes, and is a soluble inhibitor of  canonical wnt signaling. Sclerostin plays a crucial role in bone homeostasis. The present study was undertaken to determine whether serum sclerostin levels are associated with atherosclerosis and diabetic nephropathy in type2 diabetic subjects. 121 type 2 diabetic subjects were enrolled. They were 73 males and 48 females, with the ages of 60.4±12.9 years. Serum levels of sclerostin and fibroblast growth factor (FGF) 23 were measured by ELISA. Vascular calcification and intima-media thickness in cervical artery, and flow-mediated dilation (FMD) were determined by ultrasound sonogram. Serum sclerostin levels were gradually elevated according to clinical stages of nephropathy (stage1: 34.7±1.9, stge2: 38.1±2.3, stage3: 50.7±3.9, and stage 4: 81.5±10.0 pmol/l, p=0.001). Similar results were obtained with serum FGF23 (p=0.001). Simple regression analysis showed that serum sclerostin levels had significantly positive correlations with serum creatinine levels (r=0.61, p=0.001) and serum FGF23 levels (r=0.23, p=0.01), and significantly negative correlation with eGFR (r= -0.53, p=0.001). Serum sclerostin did not correlate with FMD. The subjects were divided into 3 tertiles dependent upon serum sclerostin levels, and there was no difference in vascular calcification among the tertiles. These findings indicate that serum sclerostin levels are associated with the progression of renal impairment, but not with atherosclerotic change, in the type 2 diabetic subjects.

 

Nothing to Disclose: AA

13579 5.0000 MON-1015 A Serum Sclerostin Levels Are Increased According to the Progression of Nephropathy in Type 2 Diabetes Subjects 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Miguel Angel Gomez-Samano*1, Paloma Almeda-Valdes1, Daniel Cuevas-Ramos1, Roopa Pravin Mehta2, Iliana Manjarrez3, Griselda Brito4, Ana López4, Mariana Cárdenas-Vera4, Eira Huerta4, Ana Sarmiento4, Lineth Sigala4, Yessica Ávila4, Carlos Sánchez-Jaimes4, Víctor Enríquez4, Manuel Alejandro López4 and Francisco Javier Gomez-Perez1
1Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico, 2INCMNSZ, Mexico City DF, Mexico, 3Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubrian, 4Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán

 

Fructose is a monosaccharide present in in fruit, honey, sucrose, and corn syrup. Unlike glucose, which is phosphorylated by hexokinase, fructose is phosphorylated by the ketohexocinase and enters glycolisis in an unregulated manner, causing hepatic ATP depletion, decreased protein synthesis, inflammatory, and pro-oxidant changes. Fructose can also form acetyl-CoA, which can be used for fatty acid synthesis. Chronic use of fructose increases the activity of lipogenic enzymes, causing increased hepatic production of triglycerides and very low density lipoproteins (VLDL). Other deleterious effects of fructose include increase ER stress, activation of the n-terminal kinase Jun, mitochondrial dysfunction and increased apoptosis. In rodent models high fructose diet accelerates progression of renal damage, causes glomerular sclerosis, tubular atrophy, tubular dilatation and cellular infiltration.

To evaluate the association between fructose consumption and albuminuria, glycemic control, and dyslipidemia in patients with type 2 diabetes (DM2) we performed a cross-sectional and comparative study. The correlation between the consumption of fructose, albuminuria, glycemic control, and lipid profile in patients selected from the Diabetes Clinic at the INCMNSZ were evaluated. Clinical and laboratory assessment was performed and a prospective food record of 24 hours 3 days a week was applied to calculate the daily consumption of fructose using the tables of the Australian government (Nuttab 2010) and the Department of Agriculture of the United USA.

We evaluated 28 patients with a mean age of 58.0±10.8 years, 45.2% male, with time since DM2 diagnosis of 16.0±8.8 and mean BMI of 29.3±4.3 kg/m2, mean A1c was 9.1±1.8. The median and interquartile range for albuminuria and fructose consumption were 127.8 (20.9-376.8) mg/day and 12.5 (6.7-22.4) g/day, respectively. We found a strong positive correlation between fructose consumption and levels of serum creatinine and albuminuria (r=0.42, p=0.02, and r=0.60, p=0.001 respectively). After adjusting for weight, waist circumference, and duration of DM2 we found a strong correlation between fructose consumption and albuminuria r=0.64, p=0.003.

A strong positive association between fructose consumption and albuminuria in patients with DM2 was found. More prospective studies are required to assess the effect of a low fructose diet on albuminuria and prevent further deterioration of renal function in these patients.

 

Nothing to Disclose: MAG, PA, DC, RPM, IM, GB, AL, MC, EH, AS, LS, YÁ, CS, VE, MAL, FJG

14907 6.0000 MON-1016 A Positive Association Between Fructose Consumption and Albuminuria in Patients with Type 2 Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Maria Javaid*1, Jennifer Giordano2, Robert J Tanenberg1, Hassan Alhosaini3 and Caroline M Houston1
1East Carolina University, Greenville, NC, 2East Carolina University/Brody School of Medicine, Greenville, NC, 3East Carolina Univerity

 

Background: Decline in renal function has previously been reported in patients with type 2 Diabetes Mellitus receiving canagliflozin who have underlying stage III CKD. Our case demonstrates an abrupt decline in renal function with the initiation of canagliflozin in a patient with stage II CKD and compensated stage C, NYHA class II heart failure.

Clinical Case: A 38-year old woman with type 2 Diabetes Mellitus for 4 years, who had no diabetic complications, had recently been started on canagliflozin 100 mg daily. Her past medical history was significant for non-ischemic cardiomyopathy with ACC Stage C, stable NYHA class II heart failure. She was on stable doses of nebivolol 20 mg bid, lisinopril 20 mg bid, digoxin 125-mcg daily, bumetanide 2 mg daily and spironolactone 25 mg daily. She was taking Lantus twice a day and Novolog three times a day for glycemic control. When last seen in our diabetes clinic, her hemoglobin A1c had worsened from 6.9 to 7.7% despite compliance with medical therapy and lifestyle modifications.  The addition of a non-insulin agent was considered, and given the limitations imposed by her underlying heart failure and stage II CKD, she was started on canagliflozin 100 mg daily.

Five days after starting canagliflozin, she presented to heart failure clinic with symptoms of dizziness, diarrhea, and fatigue; these symptoms had developed shortly after starting canagliflozin.  Her vital signs included blood pressure 110/52 mm, pulse 90/min, and weight 391 lbs (baseline 392 lbs). No signs of decompensated heart failure were found on physical examination.  Laboratory evaluation revealed acute-on-chronic renal failure: her BUN had increased to 56 mg/dl from a baseline of 20 (normal 7-20), creatinine had increased to 2.9 mg/dl from a baseline of 1.2 (normal 0.6-1.3), and eGFR had increased to 24 ml/min from a baseline of 59. 

Canagliflozin was immediately discontinued; lisinopril, bumetanide, and digoxin were temporarily held; and her dietary fluid intake was liberalized.  Two days later her renal function began to improve and her symptoms abated.  Her cardiac medications were slowly reintroduced.  Her renal function continued to improved and after two months had returned to baseline.  

 

Nothing to Disclose: MJ, JG, RJT, HA, CMH

17028 7.0000 MON-1017 A Canagliflozin Associated Acute Renal Failure in a Patient with Stage II CKD and Compensated Heart Failure 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Bo-Yeon Kim*1, Kyu-jin Kim1, Chan-Hee Jung1, Jioh Mok1, Chul-Hee Kim2 and Sung-koo Kang2
1Soonchunhyang University School of Medicine, Bucheon hospital, Bucheon, Korea, Republic of (South), 2Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon city, Gyeonggi-do, Korea, Republic of (South)

 

Aims/Introduction: The associations between non-alcoholic fatty liver disease (NAFLD) and chronic vascular complications of type 2 diabetes remain uncertain. We assessed the relationships between NAFLD and chronic vascular complications in patients with type 2 diabetes.

Subjects and Methods: Patients with type 2 diabetes (n = 929) attending a diabetes clinic of a university hospital were studied retrospectively. Patients who have any clinical evidence of cirrhosis or other causes of chronic liver disease were excluded. Prevalences of chronic microvascular and macrovascular complications were assessed. NAFLD was ascertained by ultrasonography.
Results: The prevalence of NAFLD in patients with type 2 diabetes was 63.3%. The prevalences of diabetic retinopathy and nephropathy were significantly lower in patients with NAFLD than those without NAFLD (33.0% vs. 70.2%, P < 0.001, 29.3% vs. 37.1%, P = 0.007, retrospectively), whereas no difference was found in the prevalence of diabetic neuropathy. The prevalence of diabetic macrovacular complication was lower in type 2 diabetic patients with NAFLD than those without NAFLD (9.2% vs.14.7%, P = 0.008). After adjustment for confounding factors, such as age, sex, HbA1c, fasting serum C-peptide, diabetic duration, BMI, and hypertension, NAFLD remained significantly associated with lower odds ratio (OR) of diabetic retinopathy (OR 0.440 [0.255-0.757], P = 0.003) and nephropathy, (OR 0.541 [0.358-0.817), P = 0.003). In contrast, NAFLD was not significantly associated with macrovacular complications after adjustment for confounding factors.
Conclusions: These results suggest that NAFLD is inversely associated with prevalences of diabetic retinopathy and nephropathy in Korean patients with type 2 diabetes.

 

Nothing to Disclose: BYK, KJK, CHJ, JM, CHK, SKK

15449 8.0000 MON-1018 A The Prevalences of Diabetic Retinopathy and Nephropathy Are Lower in Type 2 Diabetes with Non-Alcoholic Fatty Liver Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Seong Su Moon*1 and Young-Sil Lee2
1Dongguk University College of Medicine, Gyeongju, Korea, Republic of (South), 2Dongguk University College of Medicine

 

Title:

Prevalence and clinical characteristics of diabetic patients with blepharoptosis
in the general Korean population

Rationale: Third cranial nerve palsy is known to be a rare diabetic neuropathic complication. Third nerve palsy is one of the causes of blepharoptosis(Ptosis).

Objective: We investigated the prevalence of ptosis and clinical characteristics of diabetic patients with ptosis in the general Korean population.

Methodology: This cross-sectional study is based on data from the fourth and fifth Korea National Health and Nutritional Examination Surveys (KNHNES), which were conducted in 2009 and 2010 among members of the Korean population. Participants included 5811 males and 7650 females 20 years of age or older, who were selected from all of the 16 administrative districts of South Korea. Ptosis was defined as the marginal reflex distance 1 (MRD1) of < 2mm. Homeostatic model assessment of insulin resistance (HOMA-IR) was calculated in participants without diabetes. HbA1c was measured and diabetic retinopathy was defined in participants with diabetes by ophthamologic examination.

Findings: The prevalence of subjects with ptosis was 20.8% and 9.4 % among diabetic (n=1379) and non-diabetic participants (n=12082), respectively. Multiple regression analyses of the correlation between ptosis and the study variables showed diabetes was the significant determinants in the general population. The diabetic patients with ptosis had longer duration of diabetes (7.49±0.51 vs. 6.19±0.23 years, P= 0.012), higher serum creatinine level (0.91±0.02 vs. 0.87±0.01 mg/dL, P=0.009), higher prevalence of hypertension (60.3% vs. 47.9%, P<0.001), and were older (67.0±0.6 vs. 60.5±0.4 years, P<0.001) in comparison with diabetic subjects without ptosis.

Conclusion: Diabetic subjects have remarkably higher prevalence of ptosis than those without diabetes. Diabetes is an independent risk factor for ptosis in the general Korean population. Diabetic patients with longer duration, higher serum creatinine, hypertension and old age warrant screening for ptosis.

 

Nothing to Disclose: SSM, YSL

12066 9.0000 MON-1019 A Prevalence and Clinical Characteristics of Diabetic Patients with Blepharoptosis in the General Korean Population 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Omoluyi E.A. Adesanya*1, Mark Bolinger2 and David .A. Antonetti2
1The University of Chicago, Chicago, IL, 2The University of Michigan, Ann Arbor, MI

 

Diabetic retinopathy and age-related macular edema are leading causes of visual loss, both characterized by increased vascular permeability and subsequent intraretinal fluid accumulation. Occludin is a key transmembrane protein that, through phosphorylation, regulates formation of cell-cell tight junctions. Using a human adult retinal pigmented epithelial cell line (ARPE-19), we aim to assess the role of occludin phosphorylation in the maintenance of the blood-retinal barrier to thus prevent pathologic leakage. To these ends, we have created phosphoinhibitory (Ser471Ala) and phosphomimetic (Ser471Asp) occludin mutations. Through delivery of these genes to ARPE-19 cells, we can evaluate cellular permeability compared with non-mutated occludin control. To date, we have established that transfection via electroporation results in optimal gene delivery with occludin localizing, as expected, to ARPE-19 cell borders. Permeability assays have shown that phosphoinhibitory occludin mutation results in increased cell permeability compared to cells with phosphomimetic and control occludin. Having now confirmed that a human retinal cell line can be genetically modified to study cell-cell tight junctions, we look to further evaluate the role of compromised occludin phosphorylation in blood-retinal barrier breakdown. We anticipate that our studies will greatly contribute to understandings of the blood-retinal barrier, providing novel therapeutic insights to control and prevent retinovascular disease.

 

Nothing to Disclose: OEAA, MB, DAA

11672 10.0000 MON-1020 A Blood-Retinal Barrier Breakdown and Tight Junction Regulation in Human Arpe-19 Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Esra Hatipoglu*1, Ahmet Ozkok2, Mutlu Niyazoglu3, Nevbahar Tamcelik2, Nahid Memmedov4, Eray Atalay4 and Ahmet Sadi Gundogdu2
1Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey, 2Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey, 3Istanbul Teaching and Research Hospital, Istanbul, Turkey, 4Department of Ophthalmology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey

 

Introduction: The corneal epithelium has a barrier function, so the integrity of the epithelial layer is crucial for the corneal protection. Diabetic keratopathy, disturbance of both epithelial functions and morphology in cornea, is one of the ocular complications in diabetes mellitus (DM). Herein we aimed to define the possible role of Optical coherence tomography (OCT), commonly used for posterior segment imaging,  in evaluation of diabetic keratopathy.

Methods:  A total of 47 patients with type 2 DM (F/M: 26/21) and 42 age and gender-matched non-diabetic healthy subjects (HS) (F/M: 23/19) were included in the study. Topcon 3D OCT (Topcon, Tokyo, Japan) was used for corneal imaging and Central corneal thickness (CCT)  measurements.   IMAGEJ program was used to calculate central corneal epithelial thickness  (CCET)  values from OCT images. We involved the measurements obtained from the right eyes of each subject for comparison of the two groups. Additionally in cases with DM relationship of the disease duration, laboratory values, bodymass index and corneal measurements were evaluated.

Results: The mean age of the cases with DM and HS was 60.1 ± 8.03 and 55.9±17.4 years, respectively (p=0.2). The mean duration of DM was 9.9±6.9 years. The mean CCT in cases with DM was 575.04±29.8 μ and in HS was 570.4±36.5 μ (p=0.8). The mean CCET in DM and HS was 51.9±4.9 μ and 54.9±4.6 μ, respectively (p=0.006). In cases with DM there was a tendency towards a negative correlation between CCET and fasting blood glucose (r=-0.3, p=0.08). CCET was negatively correlated with duration of DM (r=-0.3, p=0.04) and triglyceride levels in diabetic cases (r=-0.4, p=0.009). Mode of treatment and presence of macro/micro vascular complications did not cause a change in CCT or CCET of the diabetic cases.

Conclusion: We found decreased CCET in cases with DM compared to HS group. Although there was no correlation between micro/macro-vascular complications and CCET; there was a negative correlation between CCET and both duration of DM, and triglyceride level. Corneal optical coherence tomography imaging including epithelial thickness analysis may open a new anatomical examination window in evaluation of diabetic keratopathy.

 

Nothing to Disclose: EH, AO, MN, NT, NM, EA, ASG

12275 11.0000 MON-1021 A Evaluation of Corneal Epithelial Thickness in Cases with Type 2 Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Erika Cesar de Oliveira Naliato*1, Aline Pacheco Moura Silva1, Georgia Marielle Soares Chagas2, Ramon Gabriel Souza Oliveira2, Victor Luiz Sepúlveda Rey2, Jackson da Silva2, Augusto Righetti Vieira Ferreira Araujo2, Caio Sulino Matias2, Daniel Pinheiro Hernandez2, Matheus Guideroli Dela Marta2 and Jose Alberto Telles Falcão3
1UNIFESO (Serra dos Orgaos University Center), Teresopolis, Brazil, 2UNIFESO (Serra dos Orgaos University Center), 3Medclinica do Centro de Teresópolis

 

A relationship between Diabetes Mellitus (DM) and a higher incidence of cancer has been reported in the literature.  In addition, the presence of micronucleus in epithelial cells is suggestive of DNA damage. To compare the concentration of micronucleated buccal cells (MN) in diabetics and healthy controls, this cross-sectional study analyzed clinical history, anthropometric measures (waist circumference, body mass index), serum HBA1c, and exfoliated buccal cells in 60 diabetics and 20 controls. For each subject, a total of 2000 exfoliated buccal cells were evaluated and MN concentration was reported as MN/1000 cells. Diabetics were older than controls (63.6 ± 15.4 vs 39.0 ± 10.6 years, respectively; p <0.0001) and had a higher waist circumference (99.3 ± 12.9 vs 88.5 ± 10.9 cm, respectively; p = 0.0006). However, there was no difference in body mass index between the two groups (27.9 ± 4.7 vs 26.8 ± 4.1 kg/m², respectively; p = 0.3458). The mean time elapsed since the diagnosis of DM was 11.7 ± 8.0 years. The mean HBA1c of patients with DM corresponded to 7.1 ± 1.8%; 33 patients (55%) had HbA1c values above 6.5% and 26 (43.3%), above 7%. The mean value of HbA1c calculated for the period correspondent to the previous 12 months reached 7.1 ± 1.8%. Diabetics had a higher concentration of micronucleated buccal cells than controls (5.1 ± 6.9 vs. 0.1 ± 0.3 MN/1000 cells; p <0.0001). In order to investigate factors that could account for this difference, we assessed the relationships between MN concentration and age, waist circumference, body mass index, time elapsed since the diagnosis of DM, and HbA1c, but failed to find any statistically significant correlation (respectively, p = 0.6206, 0.3414, 0.333, 0.7147, and 0.4954). We speculate that a prospective study might be successful in determining the factors responsible for the increased concentration of MN in diabetics, since the group had more than 10 years of diagnosis and DM is characterized by multiple pathophysiological processes, which begin many years before the diagnosis itself and vary along the disease timeframe. Nevertheless, the present study corroborates the literature regarding the increased levels of DNA damage and cancer risk in diabetics.

 

Nothing to Disclose: ECDON, APMS, GMSC, RGSO, VLSR, JDS, ARVFA, CSM, DPH, MGD, JATF

12122 12.0000 MON-1022 A Diabetics Have a Higher Concentration of Micronucleated Buccal Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Carlo Prades*1, Janice L Gilden2, Cheryl Xiang1, Bennett Smith3, Shalini Paturi2, Boby G Theckedath4, Janine Stoll5 and Rosemary Trotta6
1Rosalind Franklin University of Medicine and Science/Chicago Medical School, North Chicago, IL, 2Rosalind Franklin University of Medicine and Science/Chicago Medical School and Captain James A Lovell Federal Health Care Center, North Chicago, IL, 3Captain James A. Lovell Federal Health Care Center, North Chiago, IL, 4Capt James A Lovell Federal Health Care Ctr, North Chicago, IL, 5Capt James A Lovell FHCC, North Chicago, IL, 6Capt. James A Lovell Federal Health Care Center, North Chicago, IL

 

Previous studies have established the use of QT intervals (time between start of the Q wave and end of the t wave, which represents electrical depolarization and repolarization of the ventricles) corrected for heart rate intervals (QTc) on Electrocardiograms, as a surrogate marker for progressive autonomic neuropathy over time in diabetic patients (1).  However, similar studies evaluating the utility of this measurement in patients with other etiologies for autonomic dysfunction with neurogenic orthostatic hypotension (NOH) (decrease in blood pressure with inadequate heart rate response upon upright posture and symptoms of dizziness, lightheadedness, visual disturbances, presyncope, or even syncope) have not been well established. The objective of this study was to determine if QTc interval prolongation occurs over time and can demonstrate progressive autonomic dysfunction. Therefore, a retrospective chart survey of 75 subjects (mean age for all subjects=65 ± 15.5 yrs) (mean duration of follow-up = 7.6 yrs): [(47 diabetics (7 Type 1: 40 Type 2 ) (glycosylated hemoglobin = 7.3  ± 1.8%.; BMI= 30.5 ± 5.8 mm2/kg) (mean duration of diabetes mellitus (DM) = 17 yrs (1 - 42)): 28 NOH of various etiologies (mean duration of NOH = 4 yrs)] was performed.  QTc values were determined using Bazett’s formula (2). Results demonstrated that although in the diabetic group, the mean baseline QTc was 434 ± 28 ms, there was no significant mean change over time.  However, individual subjects did have a significant increase in QTc of  0.53 mm (p < 0.05), indicating a greater degree of autonomic dysfunction. In the NOH group, there was a significant QTc prolongation over time (mean baseline: 430 ± 34 ms to 440 ± 28 ms; p = 0.001), as well as a significant worsening of autonomic function over time (mean change of QTc from baseline = 22.0 ms; p = 0.001).  Although there were no significant differences in QTc between the two groups at baseline, both DM and NOH demonstrated a significant worsening of autonomic function over time. When compared to the DM group, NOH showed a more rapid increase in QTc over a shorter period of time, indicating more progressive autonomic failure.  In conclusion, although progressive worsening of autonomic function occurs over time in both well-controlled DM and NOH, there is a greater and faster decline in those patients with other etiologies for autonomic failure than that which occurs in patients with diabetes mellitus.

 

Disclosure: JLG: Principal Investigator, Shire. Nothing to Disclose: CP, CX, BS, SP, BGT, JS, RT

14319 13.0000 MON-1023 A Progression of Cardiac Autonomic Neuropathy in Patients with Diabetes Mellitus Compared to Other Etiologies of Autonomic Dysfunction 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Anne E Bunner*, Joseph Gonzalez, Ulka Agarwal, Francesca Valente and Neal D Barnard
Physicians Committee for Responsible Medicine, Washington, DC

 

Diabetic peripheral neuropathy occurs in 60-70% of diabetes patients. Symptoms include pain, loss of sensation, and autonomic symptoms, with pain occurring in 15-30% of cases. Dietary interventions appear to have been helpful for diabetic neuropathy pain in investigations carried out by several research teams. We performed a pilot study evaluating the role of a low-fat plant-based dietary intervention for diabetic neuropathy pain. In this 20-week study, 15 individuals with type 2 diabetes and painful diabetic neuropathy were randomly assigned to a diet-plus-supplement group or a supplement-only group. The supplement taken by both groups was vitamin B12, which is needed for healthy nerve tissues. The diet group was asked to consume only plant-based foods and to limit oils, nuts, and other fatty foods. The diet group was also asked to attend weekly nutrition classes which provided education and support for following the prescribed diet. At baseline, midpoint, and 20 weeks, clinical, laboratory, and questionnaire data were collected. After 20 weeks, change scores for body weight, LDL cholesterol, McGill pain questionnaire, Michigan neuropathy screening instrument patient questionnaire, and several other pain and symptom scales showed significantly (p<0.05) more improvement in the diet group. In addition, improvements in HbA1c, visual analog pain scale, Norfolk quality of life score, and neuropathy total symptoms score were significant (p<0.05) within the diet group, although the between-group differences did not reach statistical significance. This study demonstrates the potential of diet interventions for treating diabetic neuropathy pain and lays the groundwork for a larger study.

 

Nothing to Disclose: AEB, JG, UA, FV, NDB

13873 14.0000 MON-1025 A Nutrition Intervention for Diabetic Neuropathy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Elizabeth Blanchard*1, Nicole Kochan2, John D Crawford3, Simone Reppermund4, Melissa J Slavin4, Lesley V Campbell5, Henry Brodaty4, Perminder Sachdev3, Katherine Samaras6 and Julian N Trollor7
1Garvan Institute of Medical Research, Darlinghurst, NSW, Australia, 2Prince of Wales Hospital, Randwick, Australia, 3University of New South Wales, Randwick, Australia, 4University of New South Wales, Kensington, Australia, 5Garan Institute of Medical Research, Darlinghurst, Australia, 6Garvan Institute of Medical Research, Sydney NSW, Australia, 7Centre for Healthy Brain and Ageing, UNSW, Randwick

 

The impact of glucose and its regulation on brain structure and function is under intense investigation, particularly as the number of people reaching advanced age is increasing globally. Diabetes is associated with accelerated cognitive decline and greater dementia risk. Consequently the role of insulin and insulin deficiency in brain health and decline is under scrutiny. Insulin has protective neurotrophic effects on the brain. Higher serum insulin levels have been associated in some observational studies with less cognitive decline, but this remains controversial. Trials are investigating whether inhaled insulin assists memory and cognition in Alzheimer’s disease and mild cognitive impairment. Whether serum insulin levels have a protective effect on brain volume in the elderly is not known.

We hypothesized that lower insulin concentrations are associated with greater cognitive decline and loss of brain volume, independent of important covariates. In a large cohort of non-demented, community-dwelling elderly, this study examined the effects of insulin concentration on cognition and brain volume over 2 years.

Methods: Participants from the Sydney Memory and Aging Study, a longitudinal population-derived cohort (70-90 years at baseline), were assessed at baseline and at 2-years.1Global cognition was measured by neuropsychological testing in 5 domains (memory, processing speed, language, visuospatial and executive function), used to form a composite score (normalized Z-score). Participants with diabetes, fasting glucose ≥7.0 mmol/L or on anti-diabetic medications were excluded. Data on 682 participants were analyzed. A subset of 259 underwent magnetic resonance imaging at both times to measure total grey and white matter brain volume (TBV) and regional brain volumes. Data were analyzed by repeated measure ANCOVA (covariates: age sex, education, BP, BP- and lipid-lowering drugs, smoking, apoEe4 genotype).

Results:

   Baseline mean ± SD age was 78.2 ± 4.6 y, BMI 26.8 ± 4.8 kg/m2, fasting glucose 5.6 ± 0.6 mmol/L and insulin 14.67 ± 5.89 uU/mL. In tertile analyses, the decline in global cognition with low insulin was similar to that in high (-0.20 ± 0.05 v -0.26 ± 0.04, p=0.15). Analyses of domain-specific function showed no differences in cognitive decline over time between the groups.

   Decline in TBV was similar between the lowest and highest insulin tertiles (-27.1 ±3.9 v 31.7 ±4.6 cm3, respectively, p=0.39), as for other regional brain volumes.

   When restricted to include only subjects with FGL<5.5mmol/L, changes in cognition and TBV were also similar between high and low insulin tertiles.

Conclusion: In this cohort of community-dwelling elderly without diabetes, lower insulin levels were not associated with any greater decline in global cognition at 2 years. Lower insulin levels were not associated with any greater decline in total brain volume.

 

Nothing to Disclose: EB, NK, JDC, SR, MJS, LVC, HB, PS, KS, JNT

14280 15.0000 MON-1026 A Serum Insulin and Two-Year Changes in Global Cognition, Memory and Total Brain Volume in the Elderly: The Sydney Memory and Ageing Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Mariia Vladimirova Novoselova*1, Julia Samoylova2 and Natalia Zhukova2
1Siberian State Medical University, Tromsk, Russia, 2Siberian State Medical University, Tomsk, Russia

 

Aim: To identify neurospecific proteins in diagnosis of cognitive dysfunction in patients with diabetes mellitus type1.

Materials and methods: we examined 58 patients with diabetes mellitus type 1 aged 16-30 years, the control group consisted of 29 healthy young adults, matched by sex and age. Complex survey included clinical metabolic and psychological testing. Screening for cognitive impairment used Montreal scale (MoCa test). All patients were advised by a neurologist. To identify early markers of the development of cognitive dysfunction were identified neurospecific protein - protein S100, glial fibrillary acidic protein (GFAP), myelin basic protein (MBP). Statistical data processing was carried out by methods of variation statistics using software packages «Microsoft Excel», «SPSS» Version 8.

Results: Analysis of the parameters of carbohydrate metabolism showed that the average level of HbA1c in patients with diabetes mellitus type 1 was 8,84±1,833%, fasting glucose corresponded 11,52 ± 4,957 mmol/l , so patients had unsatisfactory metabolic control, 50 % of adolescents and 100 % of adults do not reach target values of carbohydrate metabolism. The study found an increased level of all neurospecific proteins - S100 (121,65 ± 66,39 ng / l) , myelin basic protein (0,13 ± 0,043 ng / ml) and glial fibrillary acidic protein (0,11 ± 0,041 ng / ml) in patients with diabetes mellitus type 1 compared with the control group (p <0,001), which is correlated with indicators of carbohydrate metabolism and cognitive deficits ( MoCa test less than 26 points). Analysis of the results showed that patients with diabetes mellitus type 1 had cognitive impairment (total score of 25 points) to 72.2% while in the control group cognitive functions were normal in 100% (total score of 30 points). When evaluating MoCa test recorded a statistically significant reduction of parameters that assess short-term memory and attention in patients with diabetes mellitus type 1 compared with the control group Conclusions: The data suggest that for patients with diabetes mellitus type 1 are characterized by significantly elevated levels of all surveyed neurospecific proteins. S100 protein in patients with should be considered as a possible measure of cognitive deficits, in particular, can serve as an indicator of memory decline. As a consequence, we recommend wider use in practical public health definition neurospecific proteins in patients with diabetes mellitus type 1 who have not achieved the target values of carbohydrate metabolism, for early detection of possible development of cognitive dysfunction.

 

Nothing to Disclose: MVN, JS, NZ

16609 16.0000 MON-1027 A Neurospecific Proteins in Diagnosis of Cognitive Dysfunction in Patients with Diabetes Mellitus Type 1 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Ozan Kocakaya*1 and Dilek Gogas Yavuz2
1Marmara University Medical School, Istanbul, 2Marmara University Medical School, Istanbul, Turkey

 

Diabetic polyneuropathy is a major source of morbidity in patients with diabetes. Effective, easy to use and objective diagnostic methods are necessary to diagnose the condition. Quantitative determination of vibration perception threshold (VPT) by a neurothesiometer is more reliable because the device minimizes the subjectivity of the examiner.

In this study we aimed to determine VPTs by a neurothesiometer in our  type 2 diabetic patients in order to evaluate effects of anti diabetic therapy.

494 type 2 diabetic patients ( F/M:258/236, age 53.3±12.9yrs ) diagnosed diabetes at least 1 year included in the study While 200 (F/M: 108/92, age 55.3±9.9yrs) of them were treated with OAD alone 294 patients  (F/M,161/133, age 51.9±14.3yrs) received insulin either as a basal treatment, premix or in a basal-bolus regimen. All VPT examinations are performed by a single examiner who is blinded to the patients' treatments by the same neurothesiometer.

Duration of diabetes was 12.3±7.6 yrs in the insulin treated group and 10.3±7.7 yrs in the OAD group (p = 0.0002) and mean Hemoglobin A1C level of  8.28±2.0% was significantly higher in the insulin group while 7.45±1.9% in the OAD group (p < 0.0002) VPT were significantly higher in insulin treated patients (12.1±0,76 V) than OAD treated patients (8.79±0.56 V, p=0.01)

Linear regression analysis was performed to determine the predictors of VPT. Among age, hemoglobn A1C, disease duration, carotis intima media thickness, BMI and serum kreatinine levels that were included in the linear regression only hemoglobin A1C levels were found to be significantly and independently affecting VPT  (r2 of the model = 6.94%; p= 0.02).

Our study showed that patients requiring insulin treatment meanwhile develop a peripheral sensory neuropathy which is easily diagnosed with neurothesiometer studies and the extend of this involvement can be quantified objectively by using this device. We found that VPT measurements and the disease durations of the of the patients treated with insulin are significantly higher.  When interpreted as a peripheral neuropathy sign higher VPT measurements are observed in type 2 diabetic patients treated with insulin and there is a delay in insulin treatment initiation.

 

Nothing to Disclose: OK, DG

13618 17.0000 MON-1028 A Neurothesiometer Measured Vibration Perception Thresholds in Patients Receiving Insulin or Oral Antidiabetics Alone 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Katherine Samaras*1, Helen Lucia Lutgers2, Lesley V Campbell3, Bernhard Baune4, Ora Lux5, Henry Brodaty6, Julian N Trollor7 and Perminder Sachdev5
1Garvan Institute of Medical Research, Sydney NSW, Australia, 2Garvan Institute of Medical Research, Darlinghurst, 3Garan Institute of Medical Research, Darlinghurst, Australia, 4University of Adelaide, Adelaide, 5Prince of Wales Hospital, Randwick, 6University of New South Wales, Kensington, Australia, 7Centre for Healthy Brain and Ageing, UNSW, Randwick

 

Objective: Impaired fasting glucose (IFG) is highly prevalent in the elderly, yet its relationship to health and outcomes is unclear in this age group. This study examined whether IFG in the elderly was associated with a greater prevalence of metabolic and inflammatory abnormalities and disease and greater 2-year mortality and incident disease.

Research design and methods: A prospective observational study of a population-derived, community-dwelling cohort (n=945, mean age 78.6±4.7), recruited from the electoral roll, described elsewhere.1 Disease ascertainment was by standardized questionnaire at baseline and at 2-years. Fasting blood was collected and glucose, metabolic and inflammatory markers measured at baseline. Disease prevalence, cardiovascular risk, markers of inflammation and oxidative metabolism, 2-year mortality rate and 2-year incident disease were compared in IFG vs. normal fasting glucose (NFG), adjusting for covariates of age, sex, smoking, hypertension and body mass index.

Results: IFG prevalence was 41%. Rates of heart disease, stroke, kidney disease or any cancer were similar between IFG and NFG. IFG was associated with higher levels of  inflammatory markers and end-products of oxidative metabolism, including interleukin-8 (21.8 vs. 18.6 pg/ml, p<0.01), interleukin-12p70 (3.64 vs 3.40 pg/ml, p<0.05) urate (0.35 vs. 0.32 mmol/l, p<0.001) and malondialdehyde (13.4 vs. 12.8 umol/l, p<0.001), compared to NFG.

At 2-years, incident rates of cardiac disease, stroke and cancers were similar in IFG compared to NFG, as was 2-year all-cause mortality.

Conclusions IFG in the elderly was accompanied by increased metabolic and inflammatory markers, but not associated with increased 2-year incident disease burden or 2-year mortality. Longer term prospective studies will further clarify whether IFG-associated abnormalities in the elderly portend greater eventual morbidity and mortality.

 

Nothing to Disclose: KS, HLL, LVC, BB, OL, HB, JNT, PS

14300 18.0000 MON-1029 A Impaired Fasting Glucose in the Elderly: Metabolic and Disease Burden and 2-Year Incident Heart Disease, Cancer and Mortality 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Hyun-Ae Seo*1 and Eui-Hyun Kim2
1Deagu Fatima Hospital, Daegu, Korea, Republic of (South), 2Daegu Fatima Hospital, Daegu, Korea, Republic of (South)

 

Aims: Coronary artery disease is the major cause of morbidity and mortality in patients with type 2 diabetes. The coronary artery calcium score infers the presence of coronary atherosclerosis and has been known to predict the risk for cardiovascular disease. Albuminuria is also associated with cardiovascular disease. However, the relationship among albuminuria and coronary artery calcification has not been widely studied. Thus, we examined the association between urinary albumin to creatinine ratio (uACR) and coronary calcification score in type 2 diabetes patients.

Method: We calculated coronary calcium scores of 504 subjects with type 2 diabetes (234 males and 270 females) via multi-detector row computed tomography (MDCT). Height, body weight, blood pressure, biochemical markers including uACR were assessed concurrently.

Result: Coronary artery calcifications were identified in 310 patients (64.5%). Mean coronary calcium score was 227.93 ± 671.26. Microalbuminuria was shown in 132 (26.19%) patients and 46 (9.12%) subjects had overt albuminuria. Coronary calcium score and uACR were significantly correlated in type 2 diabetic patients (r = 0.212, P < 0.001). This significant association was retained in multivariate analysis adjusted for age, BMI, systolic blood pressure, blood urea nitrogen, high density lipoprotein and use of lipid lowering drugs (beta coefficient = 0.189, P < 0.001). We performed subgroup analysis. In patients with microalbuminuria, there was no significant difference in the prevalence of coronary calcification (OR 1.109, 95% CI 0.732-1.678, P = 0.626). In patients with overt proteinuria, the presence of coronary calcification was significantly greater than no calcification (OR 3.446, 95% CI 1.561-7.607, P = 0.002).

Conclusion: In the present study, we found that uACR is a useful independent indicator of coronary artery calcification in patients with type 2 diabetes. Type 2 diabetic patients with overt proteinuria need more careful examination and management for cardiovascular disease.

 

Nothing to Disclose: HAS, EHK

13583 19.0000 MON-1030 A The Association Between Urinary Albumin to Creatinine Ratio and Coronary Artery Calcium Score in Type 2 Diabetic Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Erika Brutsaert*1, Vishnu Oruganti2 and Ulrich K Schubart3
1Albert Einstein College of Medicine, New York, NY, 2Jacobi Medical Center, Bronx, NY, 3Albert Einstein Coll of Med, New York, NY

 

Background:

Glycogenic hepatopathy is a rare cause of liver dysfunction that occurs in patients with poorly controlled diabetes mellitus.  It is characterized by the development of significant transaminitis and marked hepatomegaly.  On liver pathology, there is an abundance of glycogen deposition, which is not associated with inflammation or fibrosis.  Patients with glycogenic hepatopathy have flares that occur during times of poor glycemic control, but can have resolution of liver dysfunction when glycemia improves. 

Case presentation:

We describe a 23 year old homeless male with poorly controlled type I diabetes mellitus, who presented to our institution with recurrent DKA.  During recent admissions for DKA, he also had significant transaminitis with peak AST 2339 U/L (1-40 U/L), ALT 919 U/L (1-40 U/L).  Hepatomegaly was discovered on exam and confirmed with imaging.  During each hospitalization, transaminitis improved with glycemic control. Liver biopsy revealed increased accumulation of intranuclear and intracytoplasmic glycogen in hepatocytes, consistent with glycogen accumulation associated with diabetes mellitus.  

Conclusion: 

Non-alcoholic fatty liver disease, a common cause of transaminitis in diabetes mellitus, can cause inflammation, fibrosis and eventually even cirrhosis. In contrast, glycogenic hepatopathy, a reversible cause of transaminitis that occurs in poorly controlled diabetes mellitus, is not associated with inflammation or cirrhosis.  Mauriac initially described transaminitis, hepatomegaly, and pathologic hepatocellular glycogenosis in children with poorly controlled type 1 diabetes as part of a syndrome that also included growth retardation, delayed puberty, and cushingoid habitus.  It is now clear that adults can have the characteristic liver dysfunction of the Mauriac Syndrome, but without the other features.   Although glycogenic hepatopathy is rare, it is probably more common than we realize, but not recognized or reported. The pathogenesis is not understood, but reports suggest that both high blood levels of glucose and exogenous insulin are necessary for the development of this condition.   As in the case we describe, treatment of dysglycemia results in improvement and/or resolution of hepatomegaly and transaminitis.  In patients with poorly controlled diabetes with hepatic dysfunction, glycogenic hepatopathy must be considered as part of the differential diagnosis, especially if marked transaminitis and hepatomegaly are present.

 

Nothing to Disclose: EB, VO, UKS

12651 20.0000 MON-1031 A Glycogenic Hepatopathy: A Rare Complication of Uncontrolled Diabetes Mellitus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Nauman Arif Jadoon*1, Zeeshan Butt2, Kamran Mushtaq3, Osman N Salaria2 and Ahmed Shehzad4
1Ittefaq Hospital, Lahore, Pakistan, 2Mayo Hospital, Lahore, Pakistan, 3Services Hospital, Lahore, Pakistan, 4Nishtar Medical College Hospital, Multan, Pakistan

 

Background:

Diabetes leads to increased gastric transit and orocecal time, increased glutamase activity and intestinal bacterial overgrowth which may increase intestinal ammonia production. Thus, we speculated that diabetes mellitus (DM) may predispose cirrhotic patients to development and/or exacerbation of hepatic encephalopathy (HE).

Objective:

To analyze the effect of DM on frequency and severity of HE in patients with liver cirrhosis.

Methods:

352 patients with liver cirrhosis were prospectively assessed for severity of liver disease and presence of DM in a multicenter study. The presence and severity of HE was determined using West Haven criteria. Kolmogorov-Smirnov Goodness-of-Fit Test was used to check normality of continuous variables. Modified Child Pugh score and Model for End Stage Liver Disease scores (MELD) were calculated. Chi-square test for independence was used for categorical data while chi-squares test for trend was employed for ordered categorical variables. T-test and Mann-Whitney U test were used for continuous normal and continuous non-parametric data respectively.

Results:

Hepatic encephalopathy (HE) was present in 50.3% of patients at time of admission and 33.5% of patients were diabetic. Chronic hepatitis C was the most common causes of cirrhosis (71.6%). Hepatic encephalopathy at admission was present in 58.5% of diabetics and 42.6% of non-diabetics (p value 0.03). Severity of hepatic encephalopathy was higher in patients with diabetes than those without diabetes (p value for trend 0.01). Chronic Hepatitis C, ascites, esophageal varices, modified Child-pugh class and MELD score were not different in diabetics as compared to non-diabetics. Trend for increasing serum creatinine was significant for diabetics while trend for increasing AST levels and serum bilirubin was significant for non-diabetics (p values 0.04, 0.03, 0.04 respectively). When stratified by age, more patients with diabetes presented with HE as compared to patients without diabetes (74.4% vs. 53.2%, p value 0.02) albeit in the older age group only. Among gender subgroup analysis, only males with diabetes had increased HE prevalence (p value 0.03). In the multivariate model with age, gender, and diabetes as predictors and HE as dependent variable, both diabetes and older age were independently associated with HE (p values 0.03 and 0.006 respectively) while gender remained insignificant.

Conclusion:

Cirrhotic patients with type 2 diabetes are more likely to present with hepatic encephalopathy than cirrhotic patients without type 2 diabetes. Moreover diabetes and age interact to cause increased prevalence of hepatic encephalopathy in decompensated cirrhosis.

 

Nothing to Disclose: NAJ, ZB, KM, ONS, AS

16980 21.0000 MON-1032 A Diabetes Mellitus Is Associated with Increase in Frequency and Severity of Hepatic Encephalopathy in Liver Cirrhosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Mehmet Sercan Marangoz* and Raman Mehrzad
Steward Carney Hospital, Boston, MA

 

BACKGROUND:

Gangrenous cholecystitis (GC) is a dangerous complication of acute cholecystitis. Although clinical signs of peritonitis can be absent, patients with GC usually present with; abdominal pain, fever, jaundice or vomiting. Diabetic neuropathy, one of the most important complications of Diabetes mellitus (DM) can silence symptoms of many diseases. We present an 83 year-old gentleman with a past medical history of type 2 diabetes mellitus (DM) with complaints of nausea and vomiting for 10 days, who presented with a complete benign physical exam, and was found to have a GC.

CASE REPORT:

An 83 year old male with history of DM, hypertension hyperlipidemia presented to his primary care physician’s office with complaints of nausea, vomiting and diarrhea for 10 days. The patient’s finger stick blood sugar was found higher than 600mg/dl and he was transferred to the emergency department (ED) at our hospital. He mentioned eating a beef sandwich at a restaurant four days prior to his symptoms started. He had not been able to take his anti-diabetic medication which consisted of glyburide 1.25mg daily during that time. His vital signs in the ED showed a temperature of 98.2 F, pulse 89/min, respiratory rate 18/min, and a blood pressure 147/79mmHg. Laboratory results were significant for a white blood count of 16.5 mcL, Sodium 132 Mmol/L, Glucose 598 mg/dl, AST 49 U/L, Alkaline Phosphatase (ALP) 196 U/L. Urinalysis was negative for ketones.

Physical examination was unremarkable; his abdominal exam, specifically, was soft, non-tender, non-distended, with normal bowel sounds, and no organomegaly could be palpated.

The patient was admitted to the hospital and his hyperglycemia was managed. Due to an elevated ALP, an abdominal ultrasound was ordered to rule out liver and gall bladder pathologies. The ultrasound showed hepatomegaly, thickening of the gallbladder wall, gallbladder wall edema and pericholecystic fluid. Findings were consistent with acute cholecystitis.

The patient was consulted by general surgery, and an emergent laparoscopic cholecystectomy was performed with the findings of a severe gangrenous gallbladder, copious purulent drainage from gallbladder with subhepatic abscesses, and cholelithiasis. There were no peri- or postoperative complications.

CONCLUSION:

This case depicts the tricky nature of identifying underlying diseases in patients with DM who presents with atypical or no symptoms. GC can be fatal if untreated and this is the 4th case ever reported of asymptomatic GC in patients with DM. Similar to diabetic patients who present with “silent” acute coronary syndrome, the neuropathy in these patients can not only mask typical symptoms of GC but be misleading. In conclusion, we stress that asymptomatic patients with leukocytosis and/or abnormal liver function tests with a history of DM should be considered for further work up to avoid serious complications of cholecystitis.

 

Nothing to Disclose: MSM, RM

13402 22.0000 MON-1033 A Gangrenous Cholecystitis: A Silent but Potential Fatal Disease in Patients with Diabetic Neuropathy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Tripti Joshi*1, Judy Luu2 and Emmanuel D'Almeida3
1John Hunter Hospital, New Lambton, Australia, 2John Hunter Hospital, Coal Point, Australia, 3John Hunter Hospital, New Lambton

 

Background:  Diabetes myonecroisis is a rare complication associated with poorly controlled diabetes. Its knowledge is important to avoid undue treatment.

Clinical case: A 59-year-old diabetic male presented with severe pain in his left thigh, gradually progressive over 2-3 weeks. He had no fever, rash nor arthralgia. His past medical history was significant for poorly controlled type 2 diabetes mellitus managed with oral hypoglycemic agents for the past 2 years complicated by proliferative retinopathy, chronic kidney disease and erectile dysfunction.

Physical examination revealed a locally swollen, tender distal lateral left thigh and presence of bilateral pedal pulses.  Left thigh movements were restricted in flexion; however, there was no knee or hip joint effusion.

Ultrasound of the thigh revealed diffuse subcutaneous edema.  MRI scan revealed extensive swelling and edema in the left vastus medialis, intermedius and lateralis muscles with sparing of rectus femoris, suggestive of myositis or myonecrosis.

Investigations revealed an elevated creatinine kinase of 788 U/L (RR 1-185) and ESR of 64mm/hr. The hemoglobin was 98 g/L. with a white cell count of 7.3 × 109 /L. Vasculitic and autoimmune screen were negative. His renal function was stable with serum urea of 22.2mmol/L (RR 3.6-8.4), creatinine 540umol/L (RR 60-120) and eGFR of 9mL/min. Liver function tests were normal. Glycemic control was poor with an HbA1c of 74mmol/mol (8.9%).

He was treated empirically with parenteral steroids with minimal response.

Subsequent muscle biopsy confirmed myofibre necrosis with evidence of regeneration of the quadriceps muscle, indicating chronic ischemia. There was no evidence of vasculitis and blood vessels were normal.

Ultrasound duplex showed normal flow in proximal iliac, femoral, and popliteal arteries with only minimal plaque formation.

Over the course of the next few months, there was significant improvement in muscle strength, decreased swelling, and function of the left thigh.  Repeat MRI 3 months later showed resolution of edema and swelling with minor residual signal changes in vastus lateralis and medialis.

Conclusion: This is a rare complication of poorly controlled diabetes with only few reported cases. It is usually associated with other microvascular complications. The exact pathogenesis remains unknown, but possible mechanisms include: hypoxia–reperfusion injury, arteriosclerosis, atheroembolism, and vasculitis with thrombosis, hypercoagulability, and association with anti-phospholipid syndrome (1) (2). It most commonly affects the quadriceps muscle and is a self-limited condition.  Treatment is conservative. Muscle biopsy is not routinely indicated but appropriate in cases of atypical presentation or progression. The short-term prognosis is good but long-term prognosis is poor with recurrence rates up to 47.2% (1).

 

Nothing to Disclose: TJ, JL, ED

15672 23.0000 MON-1034 A Diabetes Myonecrosis: A Rare Complication 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Anna A Gusova*1, Maria G Pavlova2, Galina A Melnichenko3 and Gennadiy M. Kavalersky3
1Scientific Research Institute of Neurosurgery n.a. N.N. Burdenko, Moscow, Russia, 2Sechenov First Moscow State Medical University, Moscow, Russia, 3First Moscow State Medical University n.a. I.M. Sechenov, Moscow

 

Low-trauma fractures and diabetes mellitus are common conditions in elder people. The majority of studies showed that both type 1 and type 2 diabetes are associated with a higher risk of fractures. To define the group of high fracture risk in diabetic population, we examined the association between possible risk factors and incidence of any fracture in diabetic population. We analyzed local trauma clinic data for 3 sequential years from 2 662 diabetic persons who were entered The National Register of diabetes mellitus patients (NRDM), 149 random patients with T2DM from the NRDM were interviewed via telephone about lifestyle, medical history, fall risk and detailed  gynecologic history (women). Fracture incidence was higher in T1DM people compared to T2DM ones (RR=1.67, 95% CI: 1.22-3.40). We haven’t found in T2DM population any significant influence on fracture risk for gender, age, body mass index, diabetes duration and use of any antidiabetic drugs. Presence of any vascular complication was associated with two-fold higher risk of all fractures while diabetic neuropathy was not (RR=1.77; 95% CI: 0.96-3.25). Among 149 interviewed T2DM patients fracture risk was increased in current smokers (RR=3.1; 95% CI: 1.08-8.88) and daily coffee drinkers (>7 cups a week: RR=10.9; 95% CI: 1.18-101.13), compared to moderate or non-drinkers (<1 cup a week). Alcohol consumption, calcium intake and physical activity appeared not to change fracture risk in both sexes.   There was a slight correlation between fracture rate in elderly (>50 years) and female sex (r=0.169) and fall risk factor’s score(r=0,202). The correlations between hip fracture and severe diabetic nephropathy (r=0.291), proximal humerus fracture with alcohol drinking (r=0,206) and current smoking (r=225), forearm fracture and coffee consumption were also observed (r=0,185). We did not find any elevation in fracture incidence along with duration of postmenopause. The only significant risk factor for women was short period of breastfeeding (up to 5 month: RR=3.06; 95% CI: 1.02-9.16), this risk was getting lower as duration of breastfeeding increased.  Insignificant fracture risk reduction was observed in women with 2 or more parities (RR=0.28; 95% CI: 0.06-1.26) and pregnancies (RR=0.25; 95% CI: 0.06-1.11). Duration of  fertile period less than 35 years leaded to slight fracture risk elevation (RR=1.89; 95% CI: 0.62-5.79).  Thus, though the main fracture risk factors in this population were diabetic complications, influence of lifestyle factors are also significant and should be taken into account in defining the vulnerable population.  Fracture prevention strategy should be considered in the diabetes management strategies for this people.

 

Nothing to Disclose: AAG, MGP, GAM, GMK

16222 24.0000 MON-1035 A Lifestyle Factors and the Risk of Fracture in Diabetic Population 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Mohammad Zubair* and Jamal Ahmad
Aligarh Muslim University, Aligarh, India

 

HSPs has been proposed to have a role in the wound healing process, supported by finding that its expression is rapidly induced after skin is wounded in animal models. Circulating levels of HSP 70 and HSP 47, were measured in diabetic patients with an ulcer (n=30), without ulcer (n=30) and healthy subjects (n=30). Of the patients, 83.3% had type 2 diabetes. Subjects with diabetic foot ulcer showed higher median plasma level of HSP70 [3229.01(1984.5-4137.1) vs 1625.7(1435.1-2253.5) vs 1025.7(835.1-1653.5)]µg/ml and HSP47 [2.33(2.118-2.58) vs 0.98(0.83-1.07) vs 0.58(0.42-0.68)µg/ml] of the diabetic foot, diabetic control and healthy subjects.  A probability of risk(OR) and association of risk (RR) factors for DFU after age adjusted were  BMI (>25kg/mt2) [OR 1.78(1.35-3.30), RR 1.35(1.14-1.81)], HbA1c >7% [OR 3.37(2.33-8.19), RR1.76(1.46-2.15)], Neuropathy [OR 5.79(3.86-10.9), RR3.13(2.10-4.67)], retinopathy[OR 3.44(2.17-5.78), RR 1.82(1.44-2.55)], hypertension [OR 1.54(1.15-2.74), RR 1.18(1.02-1.59)], and smoking cessation [OR 4.53(2.77-7.42),RR 2.09(1.68-3.31). A positive correlation was also found between age, grades of ulcer, BMI, A1c, HDL-C, TSP, retinopathy, smoking cessation, amputation and neuropathy assessment by ABI-index and TcpO2for HSP 70. This study demonstrates that diabetic subjects with various co-morbid conditions show a higher plasma HSPs (70 & 47) levels in comparison with diabetes without foot ulcer and healthy subjects independent of the concomitant infections. It would be interesting to find out whether ahigh HSPs precedes the delay in wound healing and whether HSPs will have relationship with the infection, and type therapies for infection in improving the outcome in such patients.

 

Nothing to Disclose: MZ, JA

13725 25.0000 MON-1036 A Heat Shock Protein (HSP) 70 & 47 Plasma Levels in Subjects with Diabetic Foot and Its Possible Correlation with Clinical Variables in a North Indian Tertiary Care Hospital 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Seohui Lee*1, Chul Woo Ahn2, Shinae Kang2, Jong Suk Park1, Sehee Jo3, Chanhee Kyung2, Sohee Kim2, Jiwoon Kim1, Jisun Nam4, Haeri Back3 and Jaeyoung Cheon4
1College of Medicine, Yonsei University, Gangnam Severance Hospital, Seoul, Korea, Republic of (South), 2Gangnam Severance Hospital, Seoul, Korea, Republic of (South), 3College of Medicine, Yonsei University, Gangnam Severance Hospital, Korea, Republic of (South), 4College of Medicine, Yonsei University, Gangnam Severance Hospital

 

Background: Hemorheological parameters, such as erythrocyte deformability, erythrocyte aggregation are altered in patients with diabetes mellitus. These changes of erythrocyte in turn make whole blood more viscous and may play an important role on the pathogenesis of vascular complications of diabetes mellitus.

Methods: 190 subjects were divided by five groups according to their past history and test results as follows: Healthy control (n=28), prediabetes (pre-DM, n=14), diabetes without vascular complications (DM-no Cx, n=89), diabetes with microvascular complications (DM-microCx, n=43) and diabetes with macrovascular complications (DM-macroCx, n=15).

Results: A significant reduction of erythrocyte deformability was observed in DM-no Cx and DM-microCx group compared with healthy control (0.318 & 0.314 vs. 0.347 p<0.05). Whereas, AI does not show significant tendency (p<0.05).  And critical shear stress shows significant difference between DM-no Cx and DM-microCx group (273.41 vs 339.47 p<0.05). SS1/2/EImax shows significant reduction in DM-no Cx and DM-microCx group compared with healthy control (0.245 & 0.242 vs. 0.271 p<0.05). CSS/EI at 3Pa shows significant difference between DM-no Cx and DM-microCx group (861.01 vs 1094.11 p<0.05)

Conclusion: EI is a sensitive parameter to detect impairment of erythrocyte in diabetic process. And critical shear stress is also a useful parameter to detect diabetic microangiopathic complications early. Through analyzing tendency of these hemorheologic factors, discovering the new hemorheologic parameter and making the equation or scoring system to detect diabetic microcomplications is very important task

 

Nothing to Disclose: SL, CWA, SK, JSP, SJ, CK, SK, JK, JN, HB, JC

14279 26.0000 MON-1037 A Hemorheological Approach for Early Detection of Diabetic Microangiopathy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Luciene de Carvalho Cardoso Cardoso Weide*1, Dario Barreto Reino Almeida1, Andrea Claudia Freitas Ferreira2, Denise Pires Carvalho3, Kleber Luiz Araujo Souza4 and Giselle Fernandes Taboada1
1Universidade Federal Fluminense, Rio de Janeiro, Brazil, 2Federal University of Rio de Janeiro, 3Federal University of Rio de Janeiro, Brazil, 4Univ Federal do Rio de Janeiro

 

In type 2 diabetes (T2DM), the decrease in both antioxidant capacity and nitric oxide levels might be associated with the severity of micro and macrovascular complications. The oxidative stress due to excessive reactive oxygen species (ROS) production and low antioxidant capacity are related to the decrease in insulin secretion and to pancreatic islet cells dysfunction and death. Superoxide dismutase (SOD) and glutathione peroxidase (GPx) are members of the antioxidant cellular system responsible for the fine control of ROS levels. Moreover, the low production of NO by endothelial cells might be related to the development of vascular complications, the leading cause of mortality and co-morbidities in T2DM. In order to study the role of NO and oxidative stress in the development of TDM2 complications, we have evaluated the correlation between NO and the activities of antioxidant enzymes with glycated hemoglobin A1c (HbA1c) levels – a serum biomarker of diabetes complications in 15 TDM2 patients. Patients (59.4±2.28 years old) were distributed according to their HbA1c levels in 3 groups: well controlled diabetes (HbA1c <7%), poorly controlled diabetes (7≤HbA1c ≥9%) and uncontrolled diabetes (HbA1c > 9%). NO serum levels were evaluated through fluorimetric assay while SOD and GPx activities were assessed by colorimetric assays. In HbA1c <7% patients, NO serum levels were 20.1 ± 3.27 pmol/µl,  SOD and GPx activities, 11.35± 3.37U/ml and 71.82±11.22 nmol/h/ml, respectively. In 7≤HbA1c ≥9%, NO serum concentration was 20.8± 2.99 pmol/µl, SOD activity 7.72±3.10 U/ml and GPx activity 68.51±4.20 nmol/h/ml. In HbA1c > 9% group, we have found a significant reduction in NO concentration (9.67±1.88), when compared to the other 2 groups, while SOD and GPx activities were not statistically different from the other groups (SOD = 9.87±2.13 U/ml and GPx = 61.17±6.68 nmol/h/ml). In conclusion, since NO is normally produced by the endothelium as a physiological vasodilator, the lower levels of NO found in HbA1c > 9% patients might be associated with a worse prognosis and should be correlated to the development of vascular complications of the T2DM. However, comparative studies with normoglicemic individuals should be done in order to confirm the deleterious effect of NO reduction.

 

Nothing to Disclose: LDCCC, DBRA, ACFF, DPC, KLAS, GFT

14810 27.0000 MON-1038 A Correlation Between Glycated Hemoglobin Levels of Type 2 Diabetetic Patients, Antioxidant Enzyme Activities and Serum Nitric Oxide 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Abdulhameed Y. Alsaheel*1, Eileen A. Báez1, Dania Felipe1, John Maynard2 and Stuart Alan Chalew3
1LSUHSC, New Orleans, LA, 2Veralight, 3LSU Health Sciences Center and Children's Hospital of New Orleans, New Orleans, LA

 

Background:  Tissue accumulation of AGEs is implicated in the development and progression of diabetes complications. Longitudinal evaluation of change in tissue AGE levels has not been previously performed in children due to the need for repeat biopsy.  Skin AGEs can now be estimated quickly and noninvasively by measurement of skin intrinsic fluorescence (SIF).  In this study we assessed the accumulation of skin AGEs over time in youth with T1DM in comparison with a reference population of youth without T1D.  

Methods: SIF (420nm excitation with intrinsic correction coefficients kx=0.5, km=0.5) was measured with a Scout DS (VeraLight, Albuquerque, NM) as an estimate of skin AGEs in youth with and without T1D. SIF is reported in arbitrary units. Repeat SIF measurement was performed in youth with T1D at least 6 months after first measurement, a subgroup of patients had initial SIF measurement performed within one week of T1D diagnosis (NewT1D, n=14). For T1D patients, rate of SIF change over time was calculated as the difference in SIF divided by the difference in elapsed time between first and second SIF exams.  For youth without diabetes, rate of SIF change was the slope of the linear regression fitted to cross-sectional SIF data by age for children less than 10 yrs of age and separately for children 10 years and older.

Results:  In individuals without T1D, rate of SIF increase in children under 10 years (n=55) was 0.029 units/year and 0.056 for youth 10 years of age and older (n=58).  In children with T1D (n=59), the age at first SIF measurement was 11.9±3.6 years, duration of T1D 3.9±3.7 years, interval between SIF measurements was 2.24±0.93 years, rate of SIF increase was 0.157±0.29 units/year overall.  Rate of SIF rise increased with older chronologic age (r=0.27, p= 0.0373) and duration of diabetes (r=0.35, p=0.0079). Thus rate of SIF increase was higher in the established patients compared to NewT1D group.  There was no influence of initial HbA1c or gender on rate of SIF change. 

Conclusions: Most T1D patients show marked acceleration in estimated skin AGE accumulation several fold higher than would be expected from typical rate of increase in children without diabetes.  Rate of increase does not appear to be linked to preceding HbA1c.  Patients with highest rate of AGE increase will need to be closely observed as they may potentially be at higher risk of diabetes complications.

 

Nothing to Disclose: AYA, EAB, DF, JM, SAC

16216 28.0000 MON-1039 A Accelerated Accumulation of Tissue Advanced Glycation Endproducts (AGE) in Youth with Type 1 Diabetes (T1D): Preliminary Results from a Longitudinal Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Kathryn CB Tan*, Alan CH Lee, Joanne KY Lam, Sammy WM Shiu and Ying Wong
University of Hong Kong, Hong Kong

 

The receptor for advanced glycation end products (RAGE) plays an important role in the pathogenesis of diabetic complications and atherosclerosis. Soluble forms of the receptor (sRAGE) can act as decoy for RAGE ligands and counteract the detrimental action of the full-length receptor. Soluble RAGE is produced by alternative splicing [endogenous secretory RAGE (esRAGE)] and/or by proteolytic cleavage of the membrane-bound form of RAGE. It has been suggested that ectodomain shedding is one of the mechanisms for regulating the function of RAGE. A Disintegrin And Metalloproteinase (ADAM) is a major proteinase family that mediates ectodomain shedding of cell surface proteins. Our in vitro experiments showed that the RAGE shedding (both constitutive and insulin-induced) was significantly reduced after inhibition of the sheddase ADAM10 in macrophages. We further examined whether there was any relationship between ADAM10 and total sRAGE and esRAGE levels in type 1 diabetes. 102 type 1 diabetic patients and age- and sex-matched controls were recruited. Serum ADAM10 was measured by in-house competitive ELISA using a monoclonal anti-human ADAM10 antibody (Millipore, CA). Serum total sRAGE and esRAGE were assayed by commercial ELISA kits (Quantikine, R&D systems, MN, USA, and B-Bridge International Inc., CA, USA respectively). The difference between total sRAGE and esRAGE gave an estimated measure of soluble forms of RAGE formed by cleavage (cRAGE). Type 1 diabetic patients have higher serum total sRAGE [1038 (749-1217) pg/ml vs 802 (532-1129), median (interquartile range), p<0.01], esRAGE [367 (269-476) pg/ml vs 291 (214-389), p<0.01] and cRAGE [594 (447-812) pg/ml vs 484 (283-796), p<0.01] than controls. Serum ADAM10 was also increased in patients with type 1 diabetes [324 (179-433) ng/ml vs 156 (112-278), p<0.01]. Serum ADAM10 level correlated with serum cRAGE in type 1 diabetes (r=0.40, p<0.01) and in controls (r=0.31. p<0.01) but no correlations were seen with esRAGE. The association remained significant after adjusting for age, gender, body mass index and smoking status. In conclusion, our data suggested that ADAM10 contributed to the shedding of RAGE and ADAM10 level was significantly associated with serum cRAGE in type 1 diabetes and non-diabetic control.

 

Nothing to Disclose: KCT, ACL, JKL, SWS, YW

11734 29.0000 MON-1040 A Association Between Soluble Receptor for Advanced Glycation End Products and a Disintegrin and Metalloproteinase 10 in Type 1 Diabetes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Yong Joo Hong*1, Hyung Jin Choi2, Myoung Jin Ji1, Taekeun Oh1, Sung-Soo Koong1 and Hyun Jeong Jeon1
1Chungbuk National University College of Medicine, Cheongju, Korea, Republic of (South), 2Seoul National University College of Medicine, Seoul, Korea, Republic of (South)

 

Type 2 diabetes is one of the most common disease in with devastating complications. However, genetic susceptibility of diabetic complications has not been clarified. The vitamin D endocrine system is related with calcification and lipolysis, insulin secretion, and may be associated with many complicated disease including diabetes and cardiovascular disease. Recent studies reported that single nucleotide polymorphisms (SNP) of vitamin D receptor (VDR) gene were associated with diabetic complications. In present study, we evaluated the association of VDR SNPs (BsmI and ApaI) with diabetic complications in Korean diabetes patients. Total of 537 type 2 diabetic subjects from the Endocrinology clinic of Chungbuk National University Hospital were investigated. PCR-restriction fragment length polymorphism was used to test the genotype and allele frequency of BsmI (rs1544410; BB, Bb, bb) and ApaI (rs7975232; AA, Aa, aa) polymorphisms. Mean age was 62.5±11.0 years and mean disease duration was 13.4±7.7 years. Patients with B allele (BB or Bb) was significantly associated with lower risk of severe retinopathy (severe nonproliferative diabetic retinopathy or proliferative retinopathy) (7.4%; 5/68) compared with patients without B allele (bb) (17.3%; 81/ 469) (Odds Ratio=2,63, P=0.037). This association was significant after adjusting for age, sex and BMI (P=0.044) in logistic regression analysis. In Kaplan-Meier survival analysis, there was a trend of lower risk of severe retinopathy among patients with B allele (BB or Bb) compared with patients without B allele (bb) (P=0.091). Regarding coronary artery disease, patients with B allele (BB or Bb) had significantly higher risk of developing myocardiac infarction compared with patients without B allele (bb) (P=0.049). No significant association was observed regarding ApaI SNP. Our findings suggest that BsmI SNP in VDR gene is associated with lower risk of severe retinopathy and higher risk of coronary artery disease in type 2 diabetic patients. BsmI genotype could be used as a susceptibility marker to predict the risk of diabetes complications.

 

Nothing to Disclose: YJH, HJC, MJJ, TO, SSK, HJJ

15320 30.0000 MON-1041 A The Association Between Bsm1/Apa1 Polymorphisms in Vitamin D Receptor Gene and Complications of Type 2 Diabetes in Korean Population 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Chinedum Ogbonnaya Eleazu*1, Kate Eleazu2, Sonia Chukwuma1, Chinyere Ironkwe1, Mercy Iroaganachi3 and Uche Emenike2
1National Root Crops Research Institute, Umudike, Nigeria, 2Michael Okpara University of Agriculture, Umudike, Nigeria, 3Abia State Polytechnic, Aba, Abia State, Nigeria

 

In many countries of the world, much attention has been paid to find novel types of natural anti-diabetic drugs from various medicinal plants due to their effectiveness, limited side effects and relatively low costs. This search for novel plants that could be useful in the management of diabetic complications led to the study of the effect of livingstonepotato on diabetes and its complications in Streptozotocin diabetic rats which lasted for four weeks. The blood glucose of the rats was measured with a glucometer, the protein, glucose and specific gravity in the urine samples of the rats were measured using urine assay strips and urinometer respectively. The liver and kidney function parameters in the serum of the rats were determined using Biosystems Assay Kits. The diabetic rats administered livingstonepotato incorporated feeds (19.55% incorporation), had 129.7% decrease in their hyperglycemia with corresponding amelioration of their (elevated urinary protein, sugars, specific gravity), renal and liver growths well as 15.64% decrease in  body weights compared with the non-diabetic rats that had 5.54% decrease in blood glucose and 20.39% increase in body weight unlike the diabetic control rats that had 18.34% decrease in blood glucose and 52.68%  decrease in body weight. There were significant differences (P<0.05) in the relative liver, pancreas and kidney weights of the diabetic rats administered livingstonepotato feeds compared with the diabetic control while there were no significant differences (P>0.05) in the relative heart weights of all the rats in the 3 groups. In terms of liver and kidney function parameters, values obtained for the diabetic rats administered livingstonepotato incorporated feeds were not significantly different from that of the non-diabetic rats except for total bilurubin, aspartate transaminase and creatinine  (P<0.05) while they were significantly different from the values obtained for the diabetic control rats (P<0.05). In addition, the serum amylase of the diabetic rats administered livingstonepotato incorporated feeds were not significantly different (P>0.05) from that of the non-diabetic rats while the serum lipase activities of the diabetic rats administered livingstonepotato incorporated feeds were significantly lower (P<0.05) than that of the diabetic control rats. Results show the ameliorating potentials of livingstonepotato on pancreatic dysfunction and its usefulness in the management of dyslipidemia which is one of the leading causes of diabetic complications and we speculate that the anti-diabetic potentials of this plant result from a synergy between its crude fibre and phenolic-phytochemicals.

 

Nothing to Disclose: COE, KE, SC, CI, MI, UE

12248 31.0000 MON-1042 A Effect of Livingstonepotato (Plectranthus esculenthus N.E.Br) on Diabetes and Its Complications in Streptozotocin Induced Diabetes in Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Monday, June 23rd 3:00:00 PM MON 1011-1042 4809 1:00:00 PM Immunology & Transplantation; Insulin Signaling; Islet Biology; Pathophysiology/Complications Poster

Elaine Mary Richards*1, Andrew Antolic1, Charles E Wood1 and Maureen Keller-Wood2
1University of Florida, Gainesville, FL, 2Univ of FL Coll Pharmacy, Gainesville, FL

 

During the development of the ovine fetal heart, the increase in cortisol at the end of gestation acts with thyroid hormone to mature the heart in preparation for extra-uterine life. The changes include muscle cell structural maturation (with a switch from a proliferative to terminally differentiated phenotype), changes in calcium signaling and cellular energetics (especially of mitochondria) and remodeling of the ventricles. We used transcriptomic analyses to model these changes in septa from sheep fetuses by comparing 130 day gestation (n=6) and term fetuses (n=8), term is ~145 days, using one color labeling of RNA with Agilent reagents and methods, the Agilent ovine 8X15K microarray, Jmp Genomics 6.0 and Webgestalt. We hypothesized that the processes of maturation could be successfully modeled and that prediction of the transcription factors involved would implicate glucocorticoid (GR) and thyroid hormone receptors (T3R).

Webgestalt gene ontology (GO) analysis of the differentially regulated genes supported our hypothesis that the maturation could be modeled by predicting (for example) the biological processes cellular metabolic process (923 genes p=6.15e-30) including protein metabolism (368 genes p=6.24e-13) and carboxylic acid metabolism (272 genes p=9.05e-14); apoptosis (431 genes p= 3.78e-12); protein targeting (174 genes p=1.04e-14); the molecular functions structural components of muscle cells (22 genes, p=7e-4) and of ribosomes (82 genes p= 4.17e-17), hydrogen ion transmembrane transporter activity (44 genes p=4.3e-6) in the cellular components mitochondrion (536 genes p=2.88e-53) ribosome (104 genes p=4.45e-24) and nucleus (771 genes p=4.59e-19) effectively modeling all the expected processes except calcium signaling. However transcription target analysis did not predict the classic glucocorticoid response element as a major effector (25 genes p= 2.36e-5), ranking below T3R (58 genes p= 5.36e-13). Instead, estrogen-related receptor, ESRRA, the orphan nuclear receptor that has been shown to be highly expressed in the heart and other tissues with high energy demand, and to interact with other nuclear receptors including T3R and GR and the nuclear coactivator, PGC1-a, was suggested as a more important factor (265 genes, p=2.43e-65). Since ESRRA effects mitochondrial biogenesis (1), an important process occurring in the maturation of the late gestation fetal heart, these analyses suggest that ESRRA should be evaluated as an important modulator of maturation of the fetal heart.

 

Nothing to Disclose: EMR, AA, CEW, MK

15244 1.0000 MON-0375 A Transcriptomic Analyses of the Late Gestation Sheep Heart Suggest That Estrogen-Related Receptor May Influence Maturation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Houda Benlhabib*1, Wei Guo2 and Carole R Mendelson3
1UTSouthwestern Medical center, Dallas, TX, 2University of Texas Southwestern Med Ctr, Dallas, TX, 3UT Southwestern Med Ctr, Dallas, TX

 

Surfactant protein A, the major lung surfactant protein, is developmentally upregulated in fetal lung upon type II cell differentiation and is important for innate immunity within the lung alveolus. SP-A expression in cultured midgestation human fetal lung (HFL) is induced by cAMP and inhibited by transforming growth factor β (TGF-β) and hypoxia. SP-A transcription is controlled by epigenetic changes that are temporally and hormonally regulated. Importantly, the human (h) SP-A gene is upregulated by cAMP-induced phosphorylation, activation and binding of thyroid transcription factor 1 (TTF-1/Nkx2.1) to the hSP-A promoter. We observed that TGF-β inhibition of hSP-A expression in cultured HFL epithelial cells was associated with increased expression of the TGF-β-induced transcriptional repressor, ZEB1. ZEB1 and TGF-β exist in a positive feedforward loop that is upregulated in lung cancer and serves a prominent role in promoting epithelial-mesenchymal transition (EMT) and tumor metastasis. Notably, both TGF-β and ZEB1 exhibited a pronounced decline in cultured HFL during cAMP-induced type II cell differentiation. Conversely, we observed that TGF-β treatment inhibited binding of endogenous TTF-1 to the hSP-A promoter and reduced SP-A expression in cultured HFL type II cells. Moreover, shRNA-mediated ZEB1 knockdown enhanced cAMP stimulation and prevented TGF-β inhibition of SP-A expression. These findings strongly suggest that TGF-β inhibits hSP-A expression in HFL epithelial cells through upregulation of ZEB1 and that endogenous ZEB1 plays a suppressive role in SP-A expression in HFL. The finding that LY364947, a selective ATP competitive inhibitor of TGF-β receptor I (TGF-βRI) kinase, blocked TGF-β induction of ZEB1 and inhibition of hSP-A expression, further suggests that TGF-β/TGF-βRI inhibits SP-A expression via ZEB1. Collectively, these findings suggest that the cAMP-induced decline in TGF-β/ZEB signaling in developing fetal lung promotes differentiation of alveolar epithelial cells to surfactant-producing type II cells. By contrast, we speculate that an increase in TGF-β/ZEB1 signaling in lung alveolar epithelium can enhance mesenchymal properties leading to lung carcinogenesis and metastasis.

 

Nothing to Disclose: HB, WG, CRM

13164 2.0000 MON-0376 A Mechanisms Underlying TGF-β Inhibition of Surfactant Protein-a (SP-A) Expression in Human Fetal Lung: Implications for Development and Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Rachel Morissette*1, Wuyan Chen2, Zhi Xu3, Jennifer L. Dreiling4, Martha M Quezado4, Nazli B. McDonnell5 and Deborah P. Merke1
1National Institutes of Health, Bethesda, MD, 2PreventionGenetics, Marshfield, WI, 3The University of Hong Kong, Pokfulam, Hong Kong, 4National Cancer Institute, Bethesda, MD, 5Eastern Colorado Health System, Colorado Springs, CO

 

Background:

Mutations in CYP21A2 result in congenital adrenal hyperplasia (CAH) due to 21-hydoxylase deficiency.  Flanking CYP21A2 is TNXB, the gene encoding tenascin-X (TNX), an extracellular matrix glycoprotein that is highly expressed in connective tissue and regulates collagen fibrillogenesis and matrix maturation. TNX deficiency is a known cause of Ehlers Danlos syndrome (EDS), a connective tissue dysplasia. We previously reported that approximately 7% of CAH patients have haploinsufficiency for a contiguous deletion of CYP21A2 and TNXB resulting in CAH-X syndrome with characteristic clinical features of a connective tissue dysplasia, such as joint laxity, cardiac valvular abnormalities, and bifid uvula. In 10 of 330 patients, evidence of a CAH-X phenotype was found; however, a TNXB deletion was not identified. Therefore, we sought to determine the cause of the CAH-X phenotype in these CAH patients. 

Methods:

Dermal fibroblasts and direct tissue from patients and controls were used for biochemical experiments. Sanger sequencing, western blotting, and immunohistochemistry are being used to investigate potential defects in TNX. Immunohistochemical analysis of elastin, fibrillin, and overall extracellular matrix organization in dermal tissue from patients and controls is ongoing.

Results:

We identified a potentially pathogenic variant c.12174C>G (p.Cys4058Trp) in TNXB in five CAH patients with an EDS phenotype. p.Cys4058Trp is in the fibrinogen, alpha/beta/gamma chain, and C-terminal globular domain of TNX. This variant currently is not found in the 1000 Genomes Project or dbSNP database. PolyPhen-2 software predicted that the variant is probably damaging. Software modeling showed that mutating this highly conserved cysteine disrupts a disulfide bond and likely results in protein misfolding. Western blot analysis in fibroblasts showed that this missense variant does not alter TNX expression compared to controls as expected. Immunohistochemical analysis is underway.

Conclusion:

A novel variant of a highly conserved cysteine in TNX is likely responsible for at least some of the connective tissue phenotypes found in patients with CAH. Patients with CAH due to 21-hydroxylase deficiency are at risk for also having a connective tissue dysplasia due to TNX deficiency. In addition to the known contiguous gene deletion, other types of TNXB genetic mutations may commonly occur in CAH patients.

 

Disclosure: WC: Employee, PreventionGenetics, Inc.. DPM: Investigator, Diurnal. Nothing to Disclose: RM, ZX, JLD, MMQ, NBM

14608 3.0000 MON-0377 A A Novel Variant in Tenascin-X May be Associated with an Ehlers Danlos Phenotype in Patients with Congenital Adrenal Hyperplasia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Grace Jones*1, Davy Jones1, Peter Teal2, Agnes Sapa3, Iwona Bil-Lula3, Mietek Wozniak3, Rebecca Spokony4, Steve Jadczak1 and John Fagel1
1University of Kentucky, Lexington, KY, 2USDA/ARS, Gainesville, FL, 3Wroclaw Medical University, Wroclaw, Poland, 4Baruch College, CUNY, New York

 

An effective model of endocrine regulation of epidermal morphogenesis is the transformation of the soft, transparent Drosophilalarval cuticle to a hardened, darkened puparium at metamorpohosis. Our recent studies have evidenced that signaling by sesquiterpene hormone methyl farnesoate (MF) through Drosophila RXR ("ultraspiracle", USP) is necessary for accomplishment of this morphogenetic event (1, 2).  The genetic targets of this ligand-receptor axis have not yet been established.

The null phenotype for Drosophilahomolog of the nuclear hormone receptor ROR (="DHR3") includes misformation of the larval puparium (3), raising the possibility of DHR3 as a target of MF-USP signaling.  When we disrupted the MF-USP axis by mutating the USP ligand pocket for reduced binding to methyl farnesoate, the larval epidermis failed to form a puparium, although the remainder of the body exhibited continued metamorphic progression. Chromatin immunoprecipitation studies detected USP binding at the DHR3 gene at the time of normal puparium formation.  qPCR analysis showed that expression of DHR3 in epidermis became prematurely accelerated prior to the normal time of puparium formation in null-USP larvae that are transgenically expressing the ligand pocket-mutated USP. 

We used a binary genetic system to functionally test whether DHR3 participates in puparium formation in the target epidermal cells, where an epidermal specific driver (A58) forced expression of a DHR3-RNAi (44399) specifically in the larval epidermis.  The animals exhibited distinct misformation of the puparium, including a softer cuticle than normal.  The results support a hypothesis that DHR3 is a target of a ligand-RXR(USP) axis in regulation of a morphogenetic event of larval epidermis.  In vertebrates, ROR has also been implicated in embryonic appendage formation (4).  This Drosophila model system may then provide insight on DHR3/ROR-dependent morphogenetic mechanisms in both vertebrates and invertebrates.

 

Nothing to Disclose: GJ, DJ, PT, AS, IB, MW, RS, SJ, JF

15563 4.0000 MON-0378 A Participation of the Drosophila Homolog of ROR in RXR-Mediated Epidermal Morphogenesis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Karen Featherstone*1, Kirsty Hey2, Hiroshi Momiji2, Anne Victoria McNamara1, Amanda Louise Patist1, David Spiller1, Helen C Christian3, Alan S McNeilly4, John Mullins5, Barbel Finkenstadt2, David Rand2, Michael R White1 and Julian Richard Davis1
1University of Manchester, Manchester, United Kingdom, 2University of Warwick, 3University of Oxford, Oxford, United Kingdom, 4Queen's Medical Research Institute, Edinburgh, United Kingdom, 5The University of Edinburgh, Edinburgh, United Kingdom

 

Transcription of numerous mammalian genes has been shown to display pulsatile dynamics with bursts of expression occurring with variable duration and frequency. This transcriptional pulsatility is partly stochastic in nature and unco-ordinated between individual isolated cells. Regulatory influences on DNA such as chromatin remodelling and transcription factor recruitment and activation clearly influence transcription dynamics and contribute to this stochastic behaviour. To date, studies of transcriptional dynamics have been limited to isolated cellular systems, such as mammalian cell lines, and therefore have been unable to characterise transcription dynamics in cells maintained in a native tissue environment.

Using the human prolactin gene as a model of tissue-specific gene regulation (reviewed in (1)), we have performed spatio-temporal analyses of prolactin gene transcription dynamics in pituitary tissue, using transgenic BAC-reporter rats in which the firefly luciferase or d2EGFP reporter gene is expressed under the control of the human prolactin locus. In adult pituitary tissue, temporal patterns of transcription activity from individual cells showed increased correlation over short (30µm, or 1-2 cell) distances. Furthermore distant cells that appeared connected by a contiguous network showed greater correlation in transcription activity than unconnected cells. Consistent with a signalling influence on transcription, limited trypsin digestion, which maintained cells in a tissue structure whilst degrading cell junctions, abolished the correlation of transcription between cells. We also used developing, neonatal (P1.5) pituitary tissue as a second model system where cell communication is not fully established and lactotroph cell density is reduced. Electron microscopy showed that cell junctions at this developmental stage were immature with cadherin positive sites showing no thickening of the cell membrane, which is characteristic of established cell junctions. We found that correlation of transcription activity was lower in neonatal pituitary tissue than in adult tissue and indistinguishable from randomised control data. These data suggest that local signalling between lactotroph cells, potentially enabled by intercellular junctions, facilitate the spatiotemporal co-ordination of transcriptional behaviour between cells. Such co-ordination of cellular behaviour may be important for determining tissue-level responses to physiological demand in vivo.

 

Nothing to Disclose: KF, KH, HM, AVM, ALP, DS, HCC, ASM, JM, BF, DR, MRW, JRD

15882 5.0000 MON-0379 A Spatial Organisation of Lactotroph Cells in Pituitary Tissue Facilitates Co-Ordination of Prolactin Gene Transcription Dynamics 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Tetsuya Mizutani*1, Yoshitaka Imamichi1, Shinya Kawabe1, Shin Ishikane1, Tsukasa Osaki2, Naoto Minamino2 and Kaoru Miyamoto1
1Univ of Fukui, Japan, 2Natl Cerebral & Cardiovascular C, Osaka, Japan

 

Steroidogenic factor 1 (SF-1, also known as Ad4BP) is a nuclear orphan receptor and plays a pivotal role in the regulation of reproductive and endocrine functions, including expression of steroidogenesis-related genes. Recently, it was found that SF-1 transduction in human mesenchymal stem cells (MSCs) induces cell differentiation into steroidogenic cell lineages. To elucidate the molecular mechanisms of SF-1-mediated functions, we attempted to identify protein components of the SF-1 nuclear protein complex in differentiated cells. SF-1 immunoaffinity chromatography followed by tandem mass spectrometry analysis was performed, and 24 proteins were identified. Among these proteins, we focused on CCAAT/enhancer-binding protein β (C/EBPβ), because C/EBPβ is known as a critical factor for ovulation, luteinization and steroidogenesis in the ovary, but little is known about the molecular mechanisms by which it regulates gene transcription in cooperation with SF-1.

To investigate whether C/EBPβ is involved in 8-Br-cAMP-induced steroidogenesis, progesterone production assays and gene expression analysis were performed. Knockdown of C/EBPβ dramatically attenuated the 8-Br-cAMP-induced progesterone production in granulosa tumor-derived KGN cells. Furthermore, the 8-Br-cAMP-induced STAR, CYP11A1 and HSD3B2 expressions were attenuated. EMSA and ChIP assays revealed C/EBPβ binding sites in the upstream regions of the STAR, CYP11A1 and HSD3B2 genes. These interactions were enhanced by cAMP stimulation. Interestingly, each C/EBPβ binding site is close to the SF-1 binding sites of these genes. Luciferase assay showed that C/EBPβ is involved in the cAMP-induced transcriptional activity of these genes together with SF-1. These results indicate that C/EBPβ is an important mediator of progesterone production by working together with SF-1, especially under tropic hormone-stimulated condition.

 

Nothing to Disclose: TM, YI, SK, SI, TO, NM, KM

16450 6.0000 MON-0380 A Steroidogenic Factor 1 (SF-1) and CCAAT/Enhancer-Binding Protein b (C/EBPb) Cooperatively Regulate Progesterone Production 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Thomas Thomou*1, Marcelo A Mori2 and C. Ronald Kahn3
1Joslin Diabetes Center, Harvard Medical School, Boston, MA, 2Federal University of Sao Paulo, Sao Paulo, Brazil, 3Joslin Diabetes Center, Boston, MA

 

We have previously shown that microRNAs (miRNAs), i.e., small non-coding RNAs, are differentially expressed in different fat depots, regulated in obesity, and undergo a broad down-regulation in adipose tissue with aging. The latter is due to a reduction in the levels of the miRNA-processing enzyme Dicer in adipocytes. To better understand the role of changing miRNAs in fat we created mice with a fat-specific knockout of Dicer using Dicer lox/lox and Adiponectin-Cre mice. These AdipoDicer KO mice developed a form of partial lipodystrophy with loss of intra-abdominal and subcutaneous fat, increase and whitening of brown fat, insulin resistance and dyslipidemia. miRNAs are also found in the circulation, primarily in exosomes. To determine if adipose tissue contributes to the circulating miRNA pool and if changes in circulating miRNAs originating from fat tissue might have systemic effects by altering mRNA translation in other organs and tissues, thus impacting on function of tissues at a distance, we isolated circulating exosomal miRNAs from serum of AdipoDicerKO and control mice by differential ultra-centrifugation. The recovered exosomes were between 50 and 100 nm in diameter and stained strongly positive for the exosomal markers CD63 and CD9 on immuno-electron microscopy. Profiling of exosomal miRNAs content by qPCR of all known miRNAs revealed a marked reduction in circulating miRNAs in the serum of AdipoDicer KO mice, suggesting that adipose tissue might be a major source of exosomal circulating miRNAs. To test if these exosomal miRNAs could influence gene expression in secondary target cells, we developed an in vitro exosome transfer assay.  To this end, exosomes were isolated from murine preadipocytes which had been transfected with a human-specific miRNA Hsa-miR-10b. These exosomes were then incubated with cultured murine C2C12 myoblasts which had been transfected with reporter construct for the human 3'-UTR miR-10b response element. We found that the exosomes containing the human miRNA from adipocytes could specifically bind to and active its reporter in muscle cells. By contrast, culture medium devoid of exosomes failed to have an effect on the reporter in the myoblasts. Taken together these findings support the notion that adipose tissue constitutes a major contributor of circulating miRNAs, and that these miRNAs may exhibit specific mRNA-regulatory effects on other cells and organs.

 

Disclosure: CRK: Principal Investigator, Sanofi, Scientific Board Member, Ember Therapeutics, Scientific Board Member, Catabasis, Scientific Board Member, CohBar, Scientific Board Member, FivePrime Therapeutics. Nothing to Disclose: TT, MAM

16904 7.0000 MON-0381 A Adipose Tissue Micrornas Account for a Major Fraction of Circulating Exosomal microRNAs and Regulate mRNA Expression in Other Tissues 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Frank A. Claessens*, Thomas Van Den Broeck, Liesbeth Clinckemalie and Steven Joniau
KU Leuven, Leuven, Belgium

 

The androgen, progesterone, mineralocorticoid and glucocorticoid receptors (AR, PR, MR and GR) share very similar DNA-binding domains (DBD) and bind to very similar DNA elements in the genome. In fact, their consensus sequences are nearly identical. And yet, the AR has a more relaxed DNA sequence-specificity which correlates with a stronger dimerization interface in the second zinc finger of the DBD. Of course, AR, PR, MR and GR have different target genes, so other mechanisms besides DNA selectivity must lead to the specificity of the hormone responses.

While approximately half of all prostate cancers harbor a genomic reorganization which puts the expression of ERG under control of the androgen-regulated and prostate-specific TMPRSS2 promoter, the exact consequences of the ERG overexpression remains obscure. The androgen-dependency of prostate cancer is its Achilles’ heel: AR antagonists have been successfully used to prolong life, even of patients with metastatic, castration-resistant forms. Therefore, here we studied the androgen regulation of the TMPRSS2 gene.

We performed DNaseI footprinting, electrophoretic mobility shift assays (EMSA), transfection assays and mutation analyses of plasmid constructs and bacterial artificial chromosomes (BAC). These all pointed at a crucial androgen-dependent enhancer at -13 kb upstream of the TMPRSS2 transcription start site. This enhancer encompasses a high affinity binding site for the AR, three adjacent binding sites for GATA-2 and one overlapping binding site for Oct1 at the site where others have clearly shown AR binding by chromatin immunoprecipitation (Wang Q et al. Mol Cell 2007). The ARE was called TMPRSS2-ARE2 to distinguish it from the in silico predicted ARE which was not active in our analyses.

Not surprisingly, the AR- and GR-DBD bind the TMPRSS2-ARE2 with similar affinities. Moreover, a Single Nucleotide Polymorphism (SNP) resides in this ARE, affecting AR binding and transactivation as measured in EMSA and BAC constructs. We found this SNP in approximately 10% of prostate cancer patients and will now determine its effect on ERG expression in fusion positive prostate cancers.

 

Nothing to Disclose: FAC, TV, LC, SJ

14394 8.0000 MON-0382 A The Androgen Regulation of the Prostate-Specific TMPRSS2 Gene Is Subject to Genetic Variation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Fulden Zeliha Sarac*1, Sefa Sarac2, Sumru Savas1 and Fehmi Akcicek3
1School of Medicine, Ege University, Izmir, Turkey, 2Atatürk Training and Research Hospital, Izmir, Turkey, 3Ege University Medical Faculty, Izmir, Turkey

 

Introduction: Metabolic syndrome (MetS) can be associated with endocrinal and nonendocrinal disorders and has widespread consequences. The aims of the study were 1.  To compare the thyroid function tests, and 2. to evaluate the relationships between  insulin receptor substrat-1 (IRS-1) and insulin receptor substrat-2 (IRS-2) gene polymorphisms and thyroid function tests such as TSH, free (F) T3, and free (F) T4  in patients with MetS and without MetS.

Subjects and Methods: The study population included 100 patients with MetS and 30 patients without MetS as control group. All entire coding exons of IRS-1 and IRS- 2 gene were amplified by polymerase chain reaction (PCR). Insulin resistance (IR) was estimated using the homeostasis model assessment (HOMA-IR).

Results: In patients with MetS, 34 (34%) patients had G972R gene polymorphism and 66 (66%) had no nucleotide substitution at IRS-1 gene (p<0.0001). And also, in IRS-2 gene, 44 (44%) had no nucleotide substitution, 18 (18%) had G1057D heterozygous, 11 (11.0%) had G1057D homozygous, 2 (2%) had P1031P heterozygous/P1033PG1057 heterozygous, 17 (17.0%) had P1033P heterozygous, 3 (3.0%) had P1033P homozygous and 5 (5%) had P1033P heterozygous/G 1067D heterozygous polymorphisms in MetS. Mean levels of TSH, FT3, and fT4 were found to be 2.7±0.9 μIU/ml, 3.2±0.5 pg/ml and 1.2±0.2 ng/dl, respectively, in patients with MetS. In patients without MetS, mean levels of TSH, FT3, and FT4 were found to be 2.2±0.7 μIU/ml, 3.1±0.2 pg/ml and 1.2±0.2 ng/dl, respectively. Mean levels of TSH were statistically significantly higher in patients with MetS than that of patients without MetS (p=0.02) but not FT3, and fT4 levels (p=0.76), (p=0.26), respectively. In patients with MetS, mean levels of TSH were positively correlated with HOMA-IR levels (r=0.850, p=0.001). Mean levels of TSH were positively correlated with G972R gene polymorphism at IRS-1 gene (r= 0.400, p=0.03) in patients with MetS. However, mean levels of FT3 were positively correlated with G1057D homozygous gene polymorphism at IRS-2 gene in patients with MetS.

Conclusion: Mean levels of TSH were positively correlated with G972R gene polymorphism at IRS-1 gene in patients with MetS. And also, mean levels of FT3 were positively correlated with G1057D homozygous gene polymorphism at IRS-2 gene in patients with MetS.

 

Nothing to Disclose: FZS, SS, SS, FA

11375 9.0000 MON-0383 A The Relationships Between Thyroid Function Tests and Insulin Receptor Substrate Gene Polymorphisms in Patients with Metabolic Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Zhong Zheng*1, Sang Hwan Hyun1, Yong-Xun Jin2, Chang-Kyu Lee3 and Nam-Hyung KIM2
1Chungbuk National University, Cheongju, Korea, Republic of (South), 2Chungbuk National University, 3Seoul National University, Seoul, Korea, Republic of (South)

 

Pigs provide outstanding models of human genetic diseases due to the striking similarities to human anatomy, physiology and genetics. Genetically modified pigs have been produced using genetically modified somatic cells and nuclear transfer but with low efficiency. Pig induced pluripotent stem cells (piPSCs) have been generated for several years but the cloning efficiency using unsynchronized piPSCs was not satisfactory. Here, we reported a method to produce cloned embryos from piPSCs which were synchronized to metaphase. The piPSCs cell line was established using a drug-inducible system and exhibit similar morphology and markers expression to mouse ESCs with normal karyotype. These cells were synchronized to metaphase by a 2-step block method with Aphidicolinand Nocodazole. Round cells at metaphase were then selected and used for nuclear transfer. After activation, the reconstructed embryos started to extrude one pseudo-polar bodies (pPB) from 1 hours post activation (hpa) and reached more than 80% pPB extrusion rate at 4 hpa. The immunofluorescent results confirmed that half chromatids were extruded into the pPB. The effect of different activation methods on the in vitropre-implantation development of these embryos was compared and the result showed that, delayed activation method yield significant higher blastocyst rate than immediately activation method (32.6% VS. 24.5%, P<0.05). Karyotyping of these blastocysts indicated that they have normal karyotype. This study demonstrated anew efficient way to produce cloned embryos from piPSCs, which may lead to an opportunity to generate transgenic pigs from piPSCs more efficiently.

 

Nothing to Disclose: ZZ, SHH, YXJ, CKL, NHK

14309 10.0000 MON-0384 A Producing of Cloned Embryos from Porcine Induced Pluripotent Stem Cells Synchronized to Metaphase 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Leonardo Domingues Araújo*1, Silvia Ruiz Roa2, Fernanda Borchers Coeli-Lacchini1, Ayrton C. Moreira1, Jose Antunes-Rodrigues1, Lucila Elias1, Paula C. L. Elias1 and Margaret De Castro1
1Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil, 2Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil

 

Introduction: Food access restriction is associated to changes in gene expression of the circadian biological clock system. The core circadian clock consists in an autoregulatory transcriptional/translation feedback loops. One of these involves Rev-erbα and Rorα genes that modulate Bmal1 gene transcription. There are few studies regarding non-photic synchronizers, as food entrainment, in the expression of auxiliary loop clock genes. Objective: To evaluate the expression of Rev-erbα and Rorα genes in SCN, PVN and ARC hypothalamic nuclei, brown adipose tissue (BAT), and adrenal glands in rats submitted to different restrictive dietary patterns. Methods and results: Rats (n=5-7) were divided into three groups: Control (CG; food ad libitum), Food Restriction (FR; food from ZT [Zeitgeber time] 12-14), and Food Shift (FS; food from ZT3-5) for 21 days with light/dark cycle (lights on 0600h–ZT0) and were  decapitated at ZT3 and ZT11. Blood was collected for corticosterone (B). Expression of Rev-erbα and Rorα genes were determined by qPCR (2-ΔΔCT). Significance was considered at P<0.05. CG showed greater weight (g) compared to FR and FS (385.4±55.4 vs 245.5±32.0 vs 227.9±40.9; respectively, P<0.0001). Lower B levels (µg/dL) were observed at ZT3 than ZT11 in CG (1.0±0.6 vs 14.1±8.1) and FR (3.6±2.6 vs 20.7±7.6), with opposite finding in FS (22.7±6.2 vs 10.6±5.7). There was no significant difference in Rev-erbα and Rorα gene expressions between ZT3 and ZT11 in SCN, PVN, and ARC nuclei in any experimental group. In BAT of CG group, Rev-erbα expression was lower at ZT3 than at ZT11 (1.0±0.3 vs 2.2±0.5; P=0.002). This pattern of expression was lost in FR and FS groups (0.9±0.4 vs 0.4±0.1 and 1.4±0.8 vs 0.7±0.4, respectively). In adrenal gland of CG, Rev-erbα expression was not different between ZT3 and ZT11. However, it was higher at ZT3 than at ZT11 in FR (1.6±1.1 vs 0.5±0.3; P=0.02) and FS (1.3±1.0 vs 0.1±0.1; P=0.001) groups. No differences in Rorα expression was observed in BAT and adrenal gland. Conclusions: Our data show that dietary restriction patterns have no effect on Rev-erbα and Rorα gene expression in central oscillators; probably by the fact that light/dark cycle is the main regulator of SNC clock oscillators. Conversely, Rev-erbα gene expression was modulated by food restriction in BAT and adrenal gland; suggesting that in peripheral oscillators other cues, such as food availability, might be involved in the control of the auxiliary loop of clock system.

 

Nothing to Disclose: LDA, SRR, FBC, ACM, JA, LE, PCLE, MD

14731 11.0000 MON-0385 A The Expression of Genes Related to the Auxiliary Loop of Circadian Clock System in Central and Peripheral Oscillators on Restricted Feeding Patterns 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Brian M Shewchuk*1 and Patti R Shaver2
1East Carolina University School of Medicine, Greenville, NC, 2East Carolina University School of Medicine

 

Obesity is a risk factor for developing the characteristics of metabolic syndrome (MetS), which include insulin resistance, hyperglycemia, hypertension, dyslipidemia and inflammation, and is associated in part with a diet rich in saturated fats.  In contrast, evidence suggests that a diet rich in n-3 polyunsaturated fatty acids (n-3 PUFA) may prevent some of the comorbidities of MetS. Some features of MetS are due to altered function in peripheral tissues, but CNS effects such as insensitivity to peripheral metabolic signals or changes in hypothalamic and pituitary peptides are also thought to contribute. We hypothesize that these central effects may include broadly altered gene expression in the hypothalamus and pituitary, which has the potential to impinge on a range of physiological functions that may contribute to the pathophysiology of MetS. In the present study, we addressed the potential for high fat diet and n-3 PUFAs to affect the expression of selected hypothalamic and pituitary hormone and hormone receptor genes in a mouse model of diet-induced obesity. Six-week-old male C57BL/6 mice were fed either a low fat control diet, or diets high in saturated fat alone or supplemented with fish oil as a crude source of long chain PUFAs, or purified ethyl esters of the n-3 PUFAs docosahexaenoic acid (22:6n-3, DHA) or eicosapentaenoic acid (20:5n-3, EPA). By 5 weeks of feeding, mice fed a high fat diet had significantly increased body mass compared to low fat diet controls that was independent of the specific lipid composition.  This effect was magnified by 10 weeks, when pituitary and hypothalamic RNA was purified for analysis by qRT-PCR. The high fat diet resulted in significantly altered levels of multiple pituitary and hypothalamic transcripts compared to the low fat diet controls, with both positive and negative effects observed. The effects were dependent on the lipid composition, with fish oil, DHA, and EPA significantly modifying the effects of the high fat diet. These preliminary findings suggest that a lipid-responsive mechanism can directly or indirectly affect gene transcription in the hypothalamus and pituitary, and appears to be sensitive to the specific lipid composition of the diet. These effects have the potential to alter the function of the hypothalamic-pituitary axis in the context of diet-induced obesity, and may represent a significant component of the progression of metabolic syndrome and the protective effects of n-3 PUFAs.

 

Nothing to Disclose: BMS, PRS

14732 12.0000 MON-0386 A Differential Effects of Dietary Lipid Content and Composition on Gene Expression in the Hypothalamus and Pituitary 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Silvia Ruiz Roa*1, Rogério Lenotti Zuliani2, Paula C. L. Elias2, Margaret De Castro2, Lucila Elias2, Jose Antunes-Rodrigues2 and Ayrton C. Moreira2
1Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Brazil, 2Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil

 

Introduction: The circadian rhythm of hypothalamic-pituitary-adrenal (HPA) axis depends on clock genes expressed in the hypothalamic suprachiasmatic nucleus (SCN) and also in peripheral oscillators. The circadian rhythm of plasma corticosterone (B) levels is established at post natal day 16 (P16) in rats. However, the ontogeny of diurnal variation of adrenal clock genes and steroidogenesis related genes is still unknown. Objectives: The aim of this study was to compare the ontogeny of diurnal variation of adrenal clock genes and Star and Mc2r expression and the rhythm of B secretion. Material and Methods: We studied neonate male Wistar rats born to mothers kept under a 12h light; 12h dark cycle (lights on at 0700h, zeitgeber time-ZT0). Litters were decapitated every 4h over a 24h period on days P6, P16 and P24. Trunk blood was collected for B measurement by RIA. Right adrenals were stored until RNA extraction. The expression levels of the mRNA of Clock, Bmal1, Per1, Per2, Per3, Cry1, Cry2, Rev-Erbα, Rorα, Star and Mc2r were measured by RT-PCR and analyzed by Mann-Whitney test. The significance level was set at α=0.05. All procedures were approved by the Animal Bioethics Committee. Results: The ZT0- ZT12 mean plasma B levels (µg/dL) were 0.57±0.0- 0.57±0.0, (P=1.0); 1.24±0.71- 3.74±0.94, (P<0.01); 0.67±0.14- 10.2±3.42, (P<0.01) at P6, P16 and P24 respectively. Plasma B levels at ZT12 were higher than ZT0 from 16 days of age. There were no changes in the adrenal gene expression of Clock and Rorα between ZT0 and ZT12 in all groups. At ZT12 in P6, Bmal1 and Mc2r gene expression were higher (P<0.01) and Per2 and Per3 (P<0.01) were lower than ZT0. In P16 at ZT12 there was a lower expression of Mc2r (P<0.01). At ZT12 in P16 and P24, Per1, Per2, Per3, Cry1 and Star gene expression were higher than ZT0 (P<0.05). In contrast, Bmal1 had a lower expression at ZT12 in P16 and P24 (P<0.01). In P24 at ZT12 there was a higher expression of Cry2 and Rev-Erbα (P<0.01) than at ZT0. Conclusion: These results indicate that diurnal variation of Bmal1, Per1, Per2, Per3, Cry1, Cry2, Rev-Erbα, Star and Mc2r genes is detectable in the adrenal gland of neonatal rats. In addition, daily expression of Per1,2,3, Cry1 and Star in the adrenal is parallel to plasma B rhythm from P16 on. The mechanisms underlying the progressive maturation of the HPA axis and its predominant vespertine activity in rats involve besides a neurohumoral circuitry also an intrinsic adrenal molecular components.

 

Nothing to Disclose: SRR, RLZ, PCLE, MD, LE, JA, ACM

14766 13.0000 MON-0387 A Ontogeny of Diurnal Variation of Adrenal Clock Genes and the Expression of Star and Mc2r and Its Relationship with Plasma Corticosterone Rhythm in Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Chiung-Min Wang1 and Wei-Hsiung Yang*2
1Mercer University School of Medicine, Savannah, GA, 2Mercer University School of Medi, Savannah, GA

 

AP-1 is a heterodimeric protein and mainly consists of proteins belonging to c-Jun, c-Fos, activating transcription factor (ATF), and Jun dimerization protein (JDP) family. In addition to AP-1 site, JDP2 also binds to cAMP responsive element (CRE) site in numerous cis-elements of the target genes. In biological and cellular functions, JDP2 has been shown to be involved in cancer development and cell-cycle regulation, suppression of adipocyte differentiation, controlling replicative senescence, promoting skeletal muscle differentiation, mediating osteoclast differentiation, mediating atrial dilatation and atrial fibrillation, interacting with and regulating progesterone receptor, and controlling bone homeostasis and antibacterial immunity. Though JDP2 is widely expressed in mammalian tissues, its function in regulation of steroidogenesis and adrenal development is largely unknown. Herein, we first find that JDP2 is expressed in mouse adrenal gland tissues. Notably, Mc2r promoter activity is activated by JDP2 in a dose-dependent manner. Similarly, overexpression of JDP2 in Y1 mouse adrenocortical cancer cells increases the level of MC2R protein. By mapping the Mc2r promoter, we provide evidence that distal cAMP response elements (-1320 and -720) are mainly required for Mc2r activation by JDP2. Furthermore, we demonstrate that de-phosphorylation of JDP2 results in attenuated transcriptional activity of Mc2r. Taken together, we show for the time that JDP2 acts as a transcriptional activator of the mouse Mc2r gene. Our results suggest that JDP2 functions as a novel player in MC2R-mediated cell signaling as well as steroidogenesis in adrenal glands.

 

Nothing to Disclose: CMW, WHY

14793 14.0000 MON-0388 A JDP2 Enhances Activation of the Mouse Mc2r Promoter 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Tae-Hwa Chun*1, Masakuni Tokunaga2, Mayumi Inoue1 and Yibin Jiang3
1Univ of Michigan, Ann Arbor, MI, 2University of Michigan, 3Universityof Michigan

 

Fat depot-specific regulation of adipocyte function adds a layer of complexity to the disease mechanism by which obesity induces insulin resistance. Stem Cell Antigen-1 (Sca1 or Ly6A) is a cell surface marker that is widely expressed by mesenchymal stem cells, including adipose-derived stem cells (ASCs). We hypothesized that the fat depot-specific gene signature of Sca1High ASCs may play the major role in defining depot-specific adipose ECM remodeling and function. Herein we aimed to characterize the unique gene signature and ECM remodeling of Sca1High ASCs in subcutaneous (inguinal) and visceral (epididymal) adipose tissues. Sca1High ASCs are found in the adventitia and perivascular areas of adipose tissues. Sca1High ASCs enriched by magnetic-activated cell sorting (MACS) demonstrate the higher expression of chemokines (Il6, Cxcl1) and lower expression of the insulin-independent glucose transporter (Glut1) relative to Sca1Low cells. Subcutaneous and visceral fat-derived Sca1High ASCs differ in the expression of extracellular matrix proteins in parallel with the depot-specific expression of transcription factors (Tbx15 versus Tcf21). While the expression of the major membrane-type collagenase (MMP14) is comparable between Sca1High and Sca1Low cells, the expressions of pro-inflammatory soluble collagenases (MMP8 and MMP13) are significantly higher in visceral Sca1High ASCs. Consistently, MMP-dependent focal collagenolysis was observed preferentially with subcutaneous Sca1High ASCs, whereas acute and bulk collagenolysis was observed with visceral Sca1High ASCs in vitro and in vivo. These results suggest that the distinct gene signatures of ASCs may contribute to the depot-specific ECM remodeling and function of adipose tissues. Our findings may help us understand the depot-specific regulation of adipose tissue function and ECM remodeling during development and obesity progression.

 

Nothing to Disclose: THC, MT, MI, YJ

15256 15.0000 MON-0389 A Depot-Specific ECM Remodeling and Gene Signature of Adipose Stem Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Joseph Riley Knoedler*1 and Robert J Denver2
1University of Michigan, Ann Arbor, MI, 2Univ of MI, Ann Arbor, MI

 

Krüppel-like factor 9 (KLF9) is a DNA-binding transcription factor that is expressed in the mammalian brain, most prominently in the hippocampus and cerebellum. In rodents its expression is low at birth but rises postnatally in parallel with rising plasma T3 titers. KLF9 is a direct target of glucocorticoid and thyroid hormone receptors, and it may mediate actions of T3 on maturation, morphogenesis and survival of neurons and oligodendrocytes. However, its transcriptional targets and genomic binding sites in the brain are unknown. We used the immortalized mouse hippocampal cell line HT22 as a model system to discover KLF9-regulated genes in differentiated neurons. We generated stably transfected HT22 cells to allow for tetracycline (TET)-inducible KLF9 expression by co-transfecting cells with a plasmid expressing the TET repressor and a TET-responsive expression plasmid encoding KLF9.  We selected one stable clone for analysis that had low basal KLF9 expression that was increased ~5-fold after TET induction (similar to that achievable with hormone treatment). Forced expression of KLF9 reduced cell proliferation measured by MTT cell viability assay, and reduced neurite outgrowth. We conducted RNA-sequencing on the parent cell line and the stable TET-inducible line treated +/- 0.5 mg/ml TET for 8 hr (3 replicates/treatment). Data analysis using the Tuxedo suite (Bowtie, Cuffdiff and CummeRbund) identified ~550 downregulated and ~120 upregulated genes, suggesting that KLF9 functions predominantly as a repressor of gene transcription in these cells. We validated the relative expression levels of 18 genes by RT-qPCR in independent TET-treated samples and transiently transfected HT22 cells. Gene ontology (GO) analysis by the DAVID pipeline (http://david.abcc.ncifcrf.gov/) showed that among the most enriched functional categories of repressed genes were cytoskeletal and actin-binding proteins and cell adhesion molecules, suggesting a physiological basis for the reduction in neuritogenesis following forced KLF9 expression. Other strongly enriched categories included kinase signaling and regulation of transcription, suggesting that KLF9 may influence many downstream physiological and gene-regulatory processes. Promoter analysis using the PAINT motif discovery web tool (http://www.dbi.tju.edu/dbi/tools/paint/) found overrepresentation of Sp1-sites (GC-boxes that can be bound by KLFs) in the proximal promoters of KLF9-repressed genes, compared to their frequency in the promoters of mouse genes as a whole. This is consistent with direct repression of these genes by KLF9 binding to their promoters. Our results are the first to identify regulatory targets of KLF9 in neurons to explain its role in neuronal development and nuclear receptor signaling. 

 

Nothing to Disclose: JRK, RJD

15259 16.0000 MON-0390 A Identification of Transcriptional Targets of Krüppel-like Factor 9 in Mouse Hippocampal Neurons 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Ester Saraiva Brust*, Cristine Barbosa Beltrao and Suemi Marui
Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil

 

The iodide organification is one of the main stages of thyroid hormonogenesis and requires adequate amounts of hydrogen peroxide, generated by DUOX/DUOXA system. DUOX2 and DUOXA2 are substantially expressed in thyroid tissue and have higher efficiency in the peroxide production. Patients with congenital hypothyroidism due to mutations in DUOXA2 and DUOX2 genes may present partial or total iodide organification defect.

Objective: Search for mutations in DUOX2 and DUOXA2 genes in patients with congenital hypothyroidism by partial and total iodide organification defects.

Methods: Seven patients were diagnosed with congenital hypothyroidism by iodide organification defect. All presented ectopic thyroid, elevated serum thyroglobulin, increased 131I uptake, positive perchlorate test and normal hearing. The coding region and exon/intron boundaries of DUOX2 and DUOXA2 genes (from peripheral leukocytes DNA) were amplified and automatically sequenced, and results were compared with normal sequences of each gene (GenBank).

Results: In DUOXA2 gene we identified 5 previously described polymorphisms. In DUOX2 gene we identified 20 polymorphisms already described in the literature and an unprecedented change. The new change in DUOX2 gene (p.A1087V) was identified in heterozygosity in one patient and also on his father (without thyroid disease, but not submitted to perchlorate test), 200 normal controls did not show the change. We have not identified any other changes in this patient. Among the polymorphisms identified in DUOX2 gene, p.H678R is described as functional, probably depending on the action of other changes present in DUOX2 or other proteins participants of hormonogenesis for its pathogenicity. The polymorphism was identified in 3 patients who also have important alterations in TPO gene, but their interaction could not be evaluated yet.

Conclusion: We have not identified mutations in the studied regions of DUOX2 and DUOXA2 genes. We identified previously described polymorphisms, including a functional polymorphism in DUOX2 gene. We also observed a change not described in DUOX2 gene (p.A1087V), only enzymatic studies may define the action of this change in the cause of congenital hypothyroidism in the patient.

 

Nothing to Disclose: ESB, CBB, SM

16945 17.0000 MON-0391 A Study of DUOX2 and DUOXA2 Genes in Patients with Iodide Organification Defects 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Herve Lefebvre*1, Mireille Castanet2, Estelle Louiset3, Alexandre Naccache4 and Céline Duparc5
1INSERM U982, Institute for Research and Innovation in Biomedicine, Rouen, France, 2INSERM U982, Institute for Biomedical Research and Innovation, University of Rouen, Mont Saint Aignan, France, 3Normandie University, UNIROUEN, INSERM U982, Laboratoire Différenciation et Communication Neuronale et Neuroendocrine, ROUEN, France, 4INSERM U982, Institute for Biomedical Research and Innovation, UNiversity of Rouen, Mont Saint Aignan, France, 5Normandie University, UNIROUEN, INSERM U982, ROUEN, France

 

We previously found that mast cells are present in the human adult adrenal gland with a possible role in the regulation of aldosterone secretion  in both physiological conditions and aldosterone-producing adrenocortical adenomas responsible for primary hyperaldosteronism. In order to investigate the presence of mast cells in the human developing adrenal gland, immunochemistochemical studies were performed on paraffin- embedded adrenal glands from 16 weeks of gestation (WG) to the term.

Immunopositive cells for the mast cell marker tryptase were firstly detected at 20 WG with a peak of density at 28-31 WG. Double immunostaining with antibodies against the steroidogenic enzymes 3βHSD, characterizing the definitive and transition zones, and 17 α-hydroxylase (17-OH; CYP17), characterizing the transition and foetal zones, revealed that mast cells are mainly located in the vicinity of steroidogenic cells in the subcapsular definitive zone. There was no correlation, in term of timing of expression, with either 17-OH, which was present at all studied stages, or 3βHSD firstly detected quite earlier at 18 GW.

In conclusion, we demonstrated for the first time, that mast cells are present in the human fetal adrenal gland from the second trimester of pregnancy. However, no clear evidence of relationship was found with the kinetics of steroidogenic enzymes expression. Further studies need to be performed, such as investigation of CYP11B2 expression, to assess an eventual role of mast cells in aldosterone production and to better understand the role of these intra-adrenal mast cells in the fetal development.

 

Nothing to Disclose: HL, MC, EL, AN, CD

16107 18.0000 MON-0392 A Mast Cells in Human Adrenal Gland during Fetal Development 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Pamela Monahan*, Ishwar Radhakrishnan and Kelly E Mayo
Northwestern University, Evanston, IL

 

Ovarian folliculogenesis is regulated by changes in gene expression that are coordinated in part by levels of the pituitary gonadotropins follicle stimulating hormone (FSH) and luteinizing hormone (LH). The inhibin-α subunit gene (Inha) is positively regulated by FSH, is maximally expressed in granulosa cells during the periovulatory period, and is subsequently repressed by the LH surge. The proper expression of inhibin has been shown to be important for reproductive function and knockout or overexpression of inhibin-α results in severe reproductive deficiencies in mouse models. Previous studies demonstrate that the cyclic AMP (cAMP) response binding element protein (CREB) participates in transcriptional regulation of Inha. CREB binding occurs at a non-consensus cAMP response element (CRE) located in the proximal promoter region of Inha.  Recent studies have highlighted the role of CREB-regulated transcription co-activators (CRTCs) in CREB mediated transcriptional regulation. Although, all three CRTC mRNAs are detected in mouse primary granulosa cells in culture and in immortalized mouse granulosa cells (GRMO2) the wealth of biochemical data supporting a role for CRTC2 in cAMP-mediated transcriptional regulation has led us to characterize its significance in regulating Inha expression. To elucidate the role of CRTC2 in Inha transcription we co-transfected a luciferase reporter construct containing -547bp of the proximal promoter region of Inha and a CRTC2 expression construct into GRMO2 cells in culture. Upon forskolin induction, CRTC2 transfected cells had increased promoter activity compared to the empty vector and reporter construct alone. Additionally, siRNA knockdown of Crtc2 in GRMO2 cells reduced endogenous Inha mRNA expression as analyzed by qRT-PCR. Together, these studies indicate a role for CRTC’s in cAMP-mediated transcriptional activation of Inha.

 

Nothing to Disclose: PM, IR, KEM

16117 19.0000 MON-0393 A The Transcriptional Co-Activator CRTC2 Augments Cyclic AMP-Mediated Regulation of the Inhibin-α Subunit Gene in Ovarian Granulosa Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Jonathan A Young*, Adam Jara and John J Kopchick
Ohio University, Athens, OH

 

Reverse transcription quantitative PCR (RT-qPCR) is a powerful method to quantify specific RNA transcripts in biological samples. However, the power of this technique relies on relative quantification of the target RNA compared to stably expressed ‘reference’ genes in the tissue of interest. The amount and stability of reference gene expression can vary from tissue to tissue. Therefore, when performing a RT-qPCR experiment, it is imperative to find stably expressed reference genes for each tissue being studied. Many published sets of reference genes do not include all of the information suggested in the MIQE (Minimum information for the publication of qPCR experiments) guidelines;[1] thus they have limited use. When no set of reference genes of sufficient quality are found, it becomes necessary to determine stable reference genes using specific experimental conditions. The purpose of this experiment was to determine stable reference genes in mouse intestinal tissue. This was accomplished using whole intestine from male C57BL/6 mice. The tissue was removed, rinsed, and flash frozen.  RNA extraction, RNA integrity analysis, and cDNA synthesis were performed on the dissected tissue. The resulting cDNA was used in qPCR experiments to determine the stability of commonly used reference genes (EEF2, RPL38, EIF3F, HPRT, ACTB, B2M, RPS3, PPIB). The primers used in this experiment were designed to be specific to the mRNA target, and additional analyses such as primer efficiency curves and melting temperature optimization were performed, as required by MIQE guidelines. Analysis of reference gene stability was performed using geNorm, a rank-based algorithm for the determination of the most stable reference genes in a given experiment. The most stable reference genes in mouse intestinal tissue were found to be PPIB and HPRT. These reference genes will be used when comparing RNA Levels of Growth Hormone Receptor, IGF-1 Receptor, and Insulin Receptor in mouse strains that possess elevated or depressed levels of GH action. Results of these experiments will be presented.

 

Nothing to Disclose: JAY, AJ, JJK

15366 20.0000 MON-0394 A Selection of Stable Reference Genes for RT-qPCR in Mouse Intestinal Tissue 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Tadashi Yoshida*, Maho Yamashita and Matsuhiko Hayashi
Keio University School of Medicine, Tokyo, Japan

 

Cardiac hypertrophy, an increase in the size of individual cardiomyocytes, is an adaptive response of the heart to exogenous stress, and often leads to fatal heart failure.  Atrial natriuretic factor (ANF) is one of the most sensitive markers for cardiac hypertrophy, and it has been shown to be regulated by multiple transcriptional mechanisms including two CArG cis-elements, their trans-binding factor, SRF, and an SRF co-factor, myocardin.  Because a putative binding site for Krüppel-like factor 4 (KLF4) was found between two CArG elements within the ANF promoter, we examined whether: (1) KLF4 regulated expression of ANF in cultured H9c2 cardiac cells and (2) KLF4 regulated cardiac hypertrophy in mice in vivo.  Results showed that over-expression of KLF4 inhibited serum-induced ANF expression, whereas siRNA-mediated knockdown of Klf4 augmented serum-induced activation of ANF in cultured H9c2 cells.  Transfection/luciferase assays showed that transcriptional activity of the ANF gene was induced by myocardin, and KLF4 inhibited myocardin-induced ANF activation in H9c2 cells.  Site-directed mutagenesis revealed that the inhibitory effect of KLF4 was mediated by the consensus KLF4 binding site between CArG elements within the ANF promoter.  Moreover, electrophoretic mobility shift assays and chromatin immunoprecipitation assays showed that KLF4 bound to the ANF promoter.  We then generated cardiomyocyte-specific Klf4 knockout mice by breeding Myh6-Cre mice and Klf4 floxed mice, and examined effects of Klf4 deletion on cardiac hypertrophy induced by chronic infusion of β-adrenoceptor agonist, isoproterenol.  Of interest, isoproterenol-induced cardiac hypertrophy was accelerated in cardiac Klf4 knockout mice, as determined by the heart weight to body weight ratio (control: 5.4 ± 0.3 mg/g versus knockout: 6.4 ± 0.3 mg/g) as well as the assessment of individual cardiomyocyte size (control 203 ± 9 μm2 versus knockout 253 ± 5 μm2).  These results provide novel evidence that KLF4 is a critical factor regulating ANF expression as well as cardiac hypertrophy.

 

Nothing to Disclose: TY, MY, MH

12958 21.0000 MON-0395 A Krüppel-like Factor 4 Regulates Atrial Natriuretic Factor Expression and Isoproterenol-Induced Cardiac Hypertrophy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Shinobu Takayasu*1, Jacques Drouin2 and Aurelio Balsalobre2
1Hirosaki Univ Schl of Med, Hirosaki-Shi, Japan, 2Institut de Recherches Cliniques de Montreal, Montreal, QC, Canada

 

The Mediator was purified as a protein complex that facilitates transcription of signal-dependent genes. Mediator is recruited through transcription factor interactions at enhancers and it acts as bridge with core promoters and pre-initiation complexes; loops between enhancers and promoters. It has not clarified which genes use Mediator for transcription, and what is the specific role of Mediator for control of transcription. The signal-dependent recruitment of Mediator Regulatory kinase Cdk8 was observed at hormone-activated promoters where Cdk8 occupancy was correlated with levels of RNA polymerase II phosphorylated at Serine 5 of the C-terminal domain and transcription in highly-differentiated mouse hormone-responsive cells. In contrast, promoter recruitment of Cdk7, the purported Ser5 kinase, was not correlated with transcription. Pituitary POMC gene transcription is regulated by a variety of signals, including activation by the hypothalamic CRH and repression by glucocorticoids that regulate transcription through the GR. POMC gene further indicated that hormonal regulation, both activation and repression, is not reflected in the strength of looping interactions between enhancer and promoter as revealed by chromosome conformation capture but that recruitment of Mediator at enhancers and of Cdk8 at promoter was correlated with activated transcription. In summary, the present work supports a model where the Mediator complex serves a primary role in controlling transcription through activation and delivery of Mediator rather than the strength of interactions between enhancer and promoter.

 

Nothing to Disclose: ST, JD, AB

16780 22.0000 MON-0396 A A Role for Mediator in Pomc Transcriptional Activation By RNA Polymerase II 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Kristen R. Davis*1, Sarah L. Giesy1, Qiaoming Long1, Kevin J. Harvatine2, Laurie H. Glimcher3 and Yves R. Boisclair1
1Cornell University, Ithaca, NY, 2The Pennsylvania State, University Park, PA, 3Weill Cornell Medical College, New York, NY

 

Lactation represents a metabolically demanding phase of mammalian life.  Over the course of lactation, the mouse mammary gland synthesizes over 30 grams of triglycerides and 12 grams of proteins.  The assembly and secretion of milk triglycerides and proteins involve the endoplasmic reticulum (ER), an organelle regulated in part by the transcription factor XBP1.  Recent work showed that adipose tissue XBP1 is essential for full activity of the lactating gland and that the lactogenic hormone prolactin induces the formation of its transcriptionally active form (spliced XBP1 or sXBP1).   To address the direct role of XBP1 in lactation, we obtained mice harboring a null XBP1 mutation in mammary epithelial cells (ΔXPB1MEC) by crossing floxed XBP1 mice with mice carrying the Cre recombinase gene under the control of the ovine beta lactoglobulin promoter.  When bred, ΔXPB1MEC females had normal pregnancies and gave birth to the same number of pups as WT mice.  On lactation day 5 (L5), however, XBP1 expression was reduced by over 90% in MEC isolated from ΔXPB1MEC females.  To study lactation, litters were equalized to 9 pups and weighed daily from L1 to L14, and milk was collected at L14.  ΔXPB1MEC litters suffered a growth deficit as early as L3 and exhibited a 74% reduction in weight gain by L14.  The protein content of ΔXPB1MEC milk was reduced by 21%, whereas the profile of fatty acids synthesized in MEC or contributed by either diet or adipose tissue was unaffected.   Whole mount analysis of L14 mammary gland, however, revealed a substantially smaller MEC compartment in ΔXPB1MEC mice.   To identify the timing of this effect, whole mount analysis was performed at pregnancy day 14 (P14), P18, L1 and L5 on a second cohort of WT and ΔXPB1MEC mice.  The MEC compartment was similar in both genotypes at P14, P18 and L1 but obviously smaller at L5 in ΔXPB1MEC mice.  To understand why the epithelial compartment failed to expand at L5, indices of proliferation and apoptosis were obtained using Ki67 and Tunnel immunohistochemistry assays, respectively.  Proliferation at L5 was lower, whereas apoptosis was higher in ΔXPB1MEC than WT mice.  Quantitative real time RT-PCR was performed on total RNA isolated from MEC of both genotypes at L5.  Absence of XBP1 had no effect on the expression of genes involved in lipid or protein synthesis (e.g., Fasn, Scd1 and Csn) but caused increased expression of markers of ER stress (e.g., Ddit3 and Hspa5).  By electron microscopy, both morphology and abundance of the ER compartment were substantially disrupted at L5 in MEC of ΔXPB1MEC mice.   Collectively, these results show that ablation of XBP1 in mammary epithelial cells impairs lactation.  This impairment relates to a failure to develop a normal ER compartment in early lactation and to an imbalance of proliferative and apoptotic signals such that expansion and activity of the secretory epithelium is reduced.

 

Nothing to Disclose: KRD, SLG, QL, KJH, LHG, YRB

16926 23.0000 MON-0397 A XBP1 Is Required for Expansion of the Mammary Epithelial Compartment in Early Lactation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Monday, June 23rd 3:00:00 PM MON 0375-0397 4814 1:00:00 PM Gene Regulation & Developmental Expression Poster

Claudia Veiga Chang*1, Ricardo Viera Araujo2, Cinthya Santos Cirqueira3, Agata Parfieniuk3, Mariana F Guzzo4, Anna Flavia F Benedetti3, Ibere C Soares5, Maria Ines Perez-Millan6, Sally A Camper6 and Luciani R S Carvalho7
1Hospital das Clinicas University of Sao Paulo, São Paulo, Brazil, 2University of Sao Paulo, Sao Paulo, Brazil, 3University of Sao Paulo, 4HC FMUSP, Sao Paulo, Brazil, 5Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, 6University of Michigan, Ann Arbor, MI, 7University of São Paulo, Hospital das Clinicas, São Paulo, Brazil

 

Pituitary stem cells have the capacity for proliferation, self-renewal, and differentiation, yet little is known about the functional properties of stem cells in cases of congential hypopituitarism. We aimed to analyze the pattern of expression of SOX2, a critical stem cell marker, by immunohistochemistry, and to quantify expression of several genes by RT-qPCR, including transcription factors, markers for stem and progenitor cells, and factors characteristic of apoptosis and cell proliferation, in mouse models of  hypopituitarism. Three mouse strains with different causes of hypopituitarism were selected.  Two dwarf strains exhibit defective differentiation of TSH, GH and PRL producing cells: Prop1  and Pou1f1.  The, hypopituitary Cga  or αGSU knockout strain, cannot secrete any of the glycoprotein hormones, fails to produce normal levels of GH or PRL, and ultimately develops thyrotroph adenomas.  Pituitaries were collected at four time points spanning birth (P0) to adulthood (8W), including P7 and 4W.  Each strain was analyzed for SOX2 immunostaining and RT-qPCR of stem/progenitor cell markers (Sox2, Nanog, Nestin, Cd44 and Oct4), early transcription factors (Hesx1, Otx2 and Hes1), cell proliferation (Ki67), cell differentiation factors (S100β and Sox9) and apoptosis (caspases 3 and 7) markers. SOX2 immunostaining was normally observed in the niche surrounding Rathke’s cleft (marginal layer), as well as in diffuse sites throughout the glandular tissue.  The αGSU mutant strain exhibited reduced expression of Nanog, Oct4 and Hesx1 at 4W, and  Nestin at 8W.  The Pou1f1 mutants exhibited increased expression of Sox2, Nanog, Cd44, Hesx1, Hes1, Otx2, S100β and Sox9 at 4W and increased Sox2, Cd44, Hesx1, Otx2 and Sox9 at 8W.  The proliferation marker Ki67 was reduced at 4W and 8W.  The Prop1 mutants had increased expression of Sox2, Nanog, Cd44, Hesx1, Hes1, Otx2, S100β and Sox9 at 4W and 8W; and Ki67 was reduced at 4W.  Caspases 3 and 7 were unchanged. The elevated expression of stem and progenitor cell markers in Prop1 and Pou1f1 dwarves suggest that the absence of these early transcription factors arrests cell differentiation and causes stem cell accumulation.  In contrast, the αGSU knockout mice appear to be expending stem cells. These studies shed light on the regulation of stem and progenitor cell expansion and differentiation in genetic causes of hypopituitarism characterized by arrested and expanded differentiation.

 

Nothing to Disclose: CVC, RVA, CSC, AP, MFG, AFFB, ICS, MIP, SAC, LRSC

PP33-4 15125 2.0000 MON-0697 A Congenital Hypopituitarism: Stem Cell Accumulation in Mutants with Developmental Arrest and Depletion in Mutants with Hyperplasia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0696-0702 4817 1:00:00 PM Pituitary Development and Function Poster

Jyoti Kapali*
Southern Illinois University Carbondale, Carbondale, IL

 

Various mouse models have identified several transcription factors that are necessary for pituitary development. Lesions in transcription factor genes result in pituitary hormone deficiency. Pituitary hormone deficiencies have been found to occur in approximately one in 4000 live births. Pituitary hormone deficiency may occur due to loss of a single hormone causing isolated hormone deficiency (IPHD) or several hormones that leads to combined pituitary hormone deficiency (CPHD). Defects in genes such as LHX3, LHX4, RPX, PROP1, and PIT1 are known to contribute to CPHD in humans. We are investigating FOXO1, which is a subclass of the forkhead family of transcriptional regulators. FOXO1 is expressed in muscle, adipose tissue, liver, vascular epithelial cells, ovary, brain, heart. It is essential for metabolism, maintenance of hematopoietic stem cells, vascular development, regulating cell cycle progression and promoting apoptosis. Previous studies in mice have shown that FOXO1 is expressed in most of the somatotrope cells in mice at embryonic day 18.5 (e18.5) and in adulthood. In order to determine if FOXO1 is affecting pituitary development and/or function and determine the mechanism behind it, we are studying mouse embryos in which Foxo1 has been deleted in the pituitary gland (Foxo1Δpit mice). We find that the number of growth hormone (GH) positive cells is reduced at e16.5 and e18.5 in the absence of FOXO1. Our hypothesis is that FOXO1 drives the expression of Gh1 or upstream regulators that control somatotrope differentiation, proliferation and/or function presumably by binding to Gh1 promoter regions or promoter regions of upstream regulators. Pitx2 and Pit1 defects lead to loss of Gh1 production. Neurod4 is initially expressed at e13.5 shortly before differentiation of somatotropes and is required for normal Gh1 expression. To determine if any of these transcription factors are altered in Foxo1Δpit mice, we performed qRT-PCR to measure their expression in Foxo1Δpit mice and wildtype (WT) littermates. We found a significant decrease (p<0.05) in the expression of Neurod4 in Foxo1Δpit embryos as compared to the WT littermates. Despite the significant reduction in the number of somatotropes expressing GH during embryonic development, Foxo1Δpit mice do not exhibit any phenotypic changes related to Gh1 deficiency in adulthood. Therefore, we plan to continue examining at what stage Gh1 expression recovers. The data from these studies provide us with a greater understanding of pituitary organogenesis and expand the molecular diagnosis for congenital hypopituitarism.

 

Nothing to Disclose: JK

15020 5.0000 MON-0700 A Conditional Deletion of Gene for Forkhead Transcription Factor FOXO1 Affects Anterior Pituitary Function 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0696-0702 4817 1:00:00 PM Pituitary Development and Function Poster

Ken Fujiwara*, Rita Maliza, Alimuddin Tofrizal, Motoshi Kikuchi and Takashi Yashiro
Jichi Medical University School of Medicine

 

Midkine and pleiotrophin are a newly described family of heparin-binding growth factors that regulate neurite outgrowth, enhance cell proliferation and migration. We recently reported the expression of midkine in both anterior and posterior pituitary glands of adult rat (ENDO2013). Midkine was produced in the folliculostellate cell in the anterior pituitary gland and it may act locally on hormone-producing cells. However, little is known of the characteristics of the cells that express midkine and pleiotrophin in the developing pituitary gland. In the present study, we performed non-radioactive in situ hybridization to detect midkine and pleiotrophin mRNAs in the pituitary gland of fetal Wistar rats. At embryonic day 12.5 (E12.5), midkine mRNA was strongly expressed in the epithelium of Rathke’s pouch and in the neurohypophyseal primordium. From E12.5 to E19.5 midkine mRNA was expressed in the developing neurohypophysis, and expression gradually decreased in the developing adenohypophysis. To characterize cells that expressed midkine, we performed double staining of midkine mRNA and anterior pituitary hormones. At E19.5, no midkine-expressing cells were stained with any hormone. In contrast, pleiotrophin was expressed only in the neurohypophysis primordium at all embryonic stages. In situ hybridization clearly showed that midkine was expressed in primitive (immature/undifferentiated) adenohypophyseal cells and neurohypophyseal cells, while pleiotrophin was expressed only in neurohypophyseal cells. These findings suggest that midkine/pleiotrophin family has role as novel signaling molecule in pituitary development.

 

Nothing to Disclose: KF, RM, AT, MK, TY

15682 6.0000 MON-0701 A Expression of Midkine/Pleiotrophin Family in the Developing Pituitary Gland of Rat 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0696-0702 4817 1:00:00 PM Pituitary Development and Function Poster

Takehiro Tsukada*, Morio Azuma, Dini Ramadhani, Khongorzul Batchuluun and Takashi Yashiro
Jichi Medical University School of Medicine

 

Laminin is a major basement membrane component and plays important roles in structural support of tissues. In addition, laminin is known to play as a ligand to regulate cell function. In rat anterior pituitary gland, we recently determined that gonadotrophs and capillary endothelial cells produce laminin. We also found that laminin promotes proliferation and migration of folliculostellate (FS) cells, which are non-granular cells of anterior pituitary. Although it is reported that FS cells contact with basement membrane in in vivo anterior pituitary gland, it has not been determined whether there is an interaction between FS cells and laminin-producing cells in the gland. The aim of this study is to investigate the effect of FS cells on laminin-producing cells in rat anterior pituitary. We utilized 3-dimensional cell culture of anterior pituitary cells from S100b-GFP transgenic rats, which express GFP specifically in FS cells. Anterior pituitary cells were cultured in the presence/absence of FS cells and cell aggregates were analyzed by immunocytochemical approach. Cell aggregates containing FS cells displayed round-shape, while aggregates were amorphous in the absence of FS cells. We next performed immunocytochemistry using pan-laminin antibody and found that laminin deposition was observed in extracellular space when cultured with FS cells. In the absence of FS cells, on the other hands, laminin-positive cells appeared instead of extracellular laminin deposition. We identified laminin-positive cells by double-immunostaining with antibodies for adenohypophyseal hormones, and found that laminin-positive cells were only co-stained with LHbeta. To determine whether humoral factor secreted from FS cells induce laminin release from gonadotrophs, we cultured FS cell-deficient cell aggregates in medium supplemented with FS cell-conditioned medium. The result showed that the number of laminin-positive gonadotorphs was significantly decreased compared to that cultured in control medium. The above data suggest that humoral factor(s) from FS cells is required for release of laminin from gonadotrophs.

 

Nothing to Disclose: TT, MA, DR, KB, TY

15690 7.0000 MON-0702 A Folliculostellate Cells Are Required for Laminin Release from Gonadotrophs in Rat Anterior Pituitary Gland 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0696-0702 4817 1:00:00 PM Pituitary Development and Function Poster

Emmanuel Somm*1, Cheng Xu1, Hichem Miraoui1, Tarja Kinnunen2, Nadia Preitner1, Andrew Dwyer1, Gerasimos Sykiotis1, Richard Quinton3, William F Crowley Jr.4, Michael Hauschild1, Franziska Phan-Hug1, Yisrael Sidis1, Moosa Mohammadi5 and Nelly Pitteloud1
1Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland, 2University of Huddersfield, Huddersfield, United Kingdom, 3University of Newcastle-on-Tyne, Newcastle Upon Tyne, United Kingdom, 4Massachusetts General Hospital, Boston, MA, 5New York University School of Medicine, New York, NY

 

Background: Loss-of-function (LOF) mutations in FGFR1 are a frequent cause of congenital hypogonadotropic hypogonadism (CHH), a severe form of gonadotropin-releasing hormone (GnRH) deficiency, in males and females. They also predispose females to hypothalamic amenorrhea (HA), a milder and reversible form of GnRH deficiency associated with stress and/or energy deficits. FGF21 is an important metabolic regulator, which signals through a complex of FGFR1c with its co-receptor ß-Klotho. Several lines of evidence support the hypothesis that mutations in KLB, which encodes ß-Klotho, could also underlie CHH by compromising FGF21 signalling: 1) female Fgf21 transgenic (Tg) mice are resistant to high-fat diet and exhibit HH and infertility; 2) a CHH patient, obese with severe insulin-resistance carries a FGFR1 L342S mutation (1) that impairs FGF21 signalling in vitro.

Methods: We screened 295 CHH patients for mutations in KLB and FGF21. The functionality of identified mutations were evaluated in vitro using cell-based reporter gene assays and expression assays, as well as in vivo using rescue experiments in C.elegans deficient of both worm KLB homologues. Klb deficient mice (Klb-/-) were evaluated for reproductive and metabolic phenotypes.

Results: No mutations were identified in FGF21. We identified 9 heterozygous KLB mutations among 13/295 unrelated CHH patients (4%, 9 males and 4 females).  Five patients harbor an identical KLB deletion (p.Phe777del) while the other mutations are missense. All mutations have a MAF<1% in EVS and 1000 genome database and are LOF in vitro and/or in vivo. Additional gene defects in CHH-associated genes were identified in 6/13 patients; these including 3 heterozygous FGFR1 mutations, consistent with an oligogenic model of inheritance. Notably, 10/13 subjects also exhibited metabolic defects, such as obesity, impaired fasting glucose, and/or severe dyslipidemia. Klb-/- mice are smaller in size than wild-type littermates. Female Klb-/- exhibit delayed sexual maturation and irregular estrous cycles, with reduced  time spent in estrous. Further reproductive and metabolic phenotyping of the Klb-/-mice is underway.

Conclusion: Loss-of-function KLB mutations underlie congenital GnRH deficiency. The delayed puberty phenotype of Klb-/- mice supports a role for KLB in reproduction. These findings highlight FGF21 as a probable important link between metabolism and reproduction.

 

Nothing to Disclose: ES, CX, HM, TK, NP, AD, GS, RQ, WFC Jr., MH, FP, YS, MM, NP

PP30-1 13731 1.0000 MON-0602 A Klb, Encoding the Co-Receptor for FGF21, Is Mutated in Congenital GnRH Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Marcela Vargas*1, Bruna Kalil2, Suresh Ramaswamy3, Gloria E Hoffman4 and Tony M. Plant5
1Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, 2University of Sao Paulo, Ribeirão Preto, Brazil, 3University of Pittsburgh School of Medicine and Magee Womens Research Institute, Pittsburgh, PA, 4Morgan State University, Baltimore, MD, 5University of Pittsburgh School of Medicine, and Magee-Womens Research Institute, Pittsburgh, PA

 

While kisspeptin (KP) neurons in the pre-optic area (POA) play a critical role in the neural control of ovulation in rodents, the role of this hypothalamic region in governing the preovulatory LH surge in primates is controversial. Therefore, we examined KP immunopositive neurons in the POA of ovarian intact monkeys in 1) the follicular phase (FP) or ovulatory phase (OP) of the menstrual cycle, and 2) the early FP after treatment with E2 to induce a premature LH surge.

Two groups of rhesus monkeys were evaluated; 6 hysterectomized (Hys) adults in the FP or OP, and 4 in the early FP implanted for 36 h with either E2-containing Silastic capsules to produce circulating E2 levels of 200-300 pg/ml or empty capsules (N=2/group). In the Hys monkeys, E2, progesterone, LH and FSH were measured on the day of perfusion. E2 and LH were measured every 12 h during implantation of the Silastic capsule. The brains were perfused with 4% paraformaldehyde and hypothalami serially sectioned at 25 µm. Standard nickel-diaminobenzidine (NiDAB) immunostaining was performed with the sheep anti-human KP-54 antibody (GQ2) at 1:60,000. KP-54 was used to preadsorb GQ2 for control purposes.

KP neurons were seen in the POA of intact females in the FP and OP. Cell bodies were adjacent to the third ventricle, an area that corresponded to the anteroventral periventricular nucleus and the medial pre-optic area (MPOA) (1). In most sections, a few KP cell bodies were seen in the subventricular nucleus (SVN) found beneath the base of the third ventricle and above the optic chiasm at the level of the MPOA.  KP fibers were visualized in all of these locations and in some sections fibers were also seen in the lateral POA and the bed nucleus of the stria terminals. E2 implantation in the early FP induced a -premature LH surge that was associated with up-regulation of KP in cell bodies and fibers in the POA.

Although KP immunopositive neurons have been described in the POA of the human female (2), we present the first description of these cells in this hypothalamic region in the female monkey.  Their location in the female monkey generally matches that reported earlier for neurons expressing the KP gene (KISS1) (3). However, to our knowledge, neither KP nor KISS1 expressing neurons have been reported in the SVN in any species, although in rodents this does not appear to be a well-established structure. Our data support the view of Smith et al (3) that KP neurons in the POA of the monkey could be a site for the positive feedback action of E2 that is required for the pre-ovulatory LH surge, although classical studies by Knobil argue that such sites of E2 feedback are non essential for ovulation in primates (4).  Moreover, in the human, Hall and colleagues provide evidence, albeit indirect, that the spontaneous pre-ovulatory LH surge in women is triggered in the absence of a GnRH surge – see (5).  Clearly the neurobiology underlying ovulation in primates requires further study.

 

Nothing to Disclose: MV, BK, SR, GEH, TMP

15899 2.0000 MON-0603 A Kisspeptin Neurons in the Pre-Optic Area of the Rhesus Monkey (Macaca mulatta) Revealed By Immunohistochemistry 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

An K Dang*1, Dilyara Murtazina1, Christianne Magee1, Amy Marie Navratil2, Colin M Clay1 and Greg Amberg1
1Colorado State University, Fort Collins, CO, 2University of Wyoming, Laramie, WY

 

The binding of hypothalamic neuropeptide gonadotropin-releasing hormone (GnRH) to its receptor on gonadotrope cells in the anterior pituitary initiates signaling cascades that result in the activation of extracellular signal regulated kinase (ERK) and subsequently enhanced luteinizing hormone (LH) biosynthesis. Previous work suggested that Ca2+ influx through L-type Ca2+ channels is necessary for ERK phosphorylation. More recently, we have used a combination of TIRF microscopy and electrophysiology to directly visualize GnRH induced Ca2+ influx (“Ca2+ sparklets”) mediated by L-type Ca2+ channels with high temporal and spatial resolution. Thus, for the first time we are able to directly address the molecular events that reside between activation of the GnRHR and opening of L-type Ca2+ channels in the plasma membrane. In this regard, we and others have shown that Jasplakinolide (Jas, a pharmacological inhibitor of actin remodeling), leads to a loss of ERK activation in response to GnRH. Herein we sought to test the hypothesis that the Jas mediated lesion between GnRH binding and ERK phosphorylation reflects a loss of subplasmalemmal Ca2+ influx via L-type Ca2+ channels. To test this hypothesis, we used our TIRF based approach to image and quantitate subplasmalemmal Ca2+ influx in the gonadotrope derived alphaT3-1 cell line. Pretreatment of alphaT3-1 cells with Jas (100nM) decreased Ca2+ influx at GnRH (3nM) induced Ca2+ sparklets sites (sparklet activity), but did not change the number of sites on the plasma membrane (sparklet density). Thus, Jas does not affect the distribution of the L-type Ca2+ channels on the cell surface, but rather the Ca2+ influx at individual sites. Consistent with previous work, ERK phosphorylation in response to GnRH was lost in the presence of Jas. In contrast, Jas had no effect on Ca2+ sparklet activity, sparklet density, or ERK phosphorylation induced by either the PKC agonist phorbol 12, 13-dibutyrate (50 nM) or L-type Ca2+ channel agonist FPL64176 (500 nM) suggesting that the Jas induced lesion may reside upstream of PKC. Thus, disrupting actin dynamics with Jas interrupts GnRH activation of ERK by uncoupling the GnRH signal to Ca2+ influx through L-type Ca2+ channels rather than a signaling event(s) that resides downstream of the subplasmalemmal Ca2+ influx. In summary, these data support our hypothesis that actin disruption uncouples GnRH activation of ERK via the loss of localized Ca2+ influx through subplasmalemmal microdomains of L-type Ca2+ channels.

 

Nothing to Disclose: AKD, DM, CM, AMN, CMC, GA

PP30-3 12913 4.0000 MON-0605 A Actin Cytoskeleton Modulates Local L-Type Calcium Channel Signaling and ERK Activation in Gonadotropes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Richard B. McCosh*1, Katrina L Porter2, Donal C Skinner3 and Robert L. Goodman1
1West Virginia University School of Medicine, Morgantown, WV, 2Cornell University, Ithaca, NY, 3Univ of Wyoming, Laramie, WY

 

Neurokinin B (NKB) is a potent stimulator of GnRH/LH in primates and sheep and senktide (an NK3R agonist) administered into either the retrochiasmatic area (RCh) or preoptic area (POA) induces surge-like LH secretion in ewes. Senktide administered to the RCh results in activation of kisspeptin cells based on increased expression of Fos (Porter et al., SFN, 2013), but no increase in Fos expression in kisspeptin neurons was observed with senktide treatment into POA. Because somatostatin (SST) has also been suggested to have a role in the regulation of the GnRH/LH surge of sheep and rodents, we sought to determine whether senktide administered to the RCh or to POA alters the proportion of SST immunoreactive cells that also contain Fos. Four groups of ovary-intact ewes received either bilateral senktide containing micro-implants (n=4) or empty microimplants (n=4) into RCh, or bilateral senktide containing micro-implants (n=3) or empty microimplants (n=4) into POA. Jugular blood samples were collected at 12 minute intervals for 3 hrs after microimplants were inserted, and hypothalamic tissue was then collected and processed for dual label immunocytochemistry. Ewes that received senktide into POA had a lower (P=0.016) percentage of SST cells that contained Fos in the ventral lateral hypothalamic area (9.2 ± 2.1%) than control ewes (40.5 ± 7.2%). There was no difference in the percentage of SST cells that contained FOS between senktide and control treatments into the RCh. Ewes that received senktide containing microimplants into either RCh or POA had higher (RCh, P=0.03; POA, P=0.06) mean LH concentrations (RCh, 5.48 ± 2.74 ng/mL; POA, 6.06 ± 2.00 ng/mL) than ewes that received empty microimplants (RCh, 1.56 ± 0.54 ng/mL; POA, 1.18 ± 0.39 ng/mL). Because there is a concomitant growth hormone (GH) surge with the LH surge, we examined the possibility of a change in GH concentrations in response to senktide administration. There was no difference (P>0.1) in mean GH concentrations during the 3 hrs prior to tissue collection between ewes that received senktide or empty microimplants, into either the RCh (senktide, 7.99 ± 2.35 ng/mL; control, 9.23 ± 3.41 ng/mL ) or POA (senktide, 11.45 ± 3.38 ng/mL; control, 18.33 ± 3.76 ng/mL). The inhibition of Fos expression in SST cells produced by senktide in the POA raises the possibility that the stimulatory effect of senktide on LH in this area is mediated by a reduction in the activity of inhibitory SST containing cells.

 

Nothing to Disclose: RBM, KLP, DCS, RLG

15875 5.0000 MON-0606 A Activation of NK3R in the Ovine Preoptic Area Increases LH Secretion and Inhibits Activity of Somatostatin Containing Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Tova Berg*1, Margaret B Allison2, Martin Grosvenor Myers Jr.3 and Suzanne M Moenter1
1University of Michigan, Ann Arbor, MI, 2University of Michigan, 3Univ of Michigan, Ann Arbor, MI

 

GnRH neurons act as the final common pathway for the central regulation of fertility. Many cues known to affect fertility at the level of the central nervous system act via a network of presynaptic inputs to influence GnRH neuronal activity. Despite the importance of this presynaptic network to the regulation of reproduction, it is still poorly understood. The circuitry of GnRH neurons has been difficult to trace due to the diffuse distribution and relatively scarcity of these cells. Here, a new method was used to identify neurons directly upstream of GnRH neurons (i.e., primary afferents). This method takes advantage of mice expressing Cre-recombinase (Cre) in GnRH neurons(1). Two viruses were sequentially stereotaxically injected into one hemisphere of the preoptic area (POA). The first is an adeno associated virus (AAV) carrying a floxed gene payload of TVA, the receptor for a modified rabies virus, and G, a critical gene for integration and retrograde spread of rabies virus. One week later, a modified rabies virus was delivered to the same location. This virus is missing G and has been modified to require TVA for infection; it also expresses mCherry. Because the complete rabies virus including G can only assemble in Cre-expressing cells, this system allows for retrograde tracing exclusively from those neurons and limits the tracing to the direct (monosynaptic) inputs. In our studies, Cre was driven by the GnRH promoter, which is expressed in lateral septal neurons during development(2). We thus first tested if ectopic Cre expression persisted in adults by delivering an AAV containing floxed GFP into the POA and the lateral septum (n=2 mice). GFP was detected only in GnRH neurons therefore the gene payload was delivered only to neurons currently expressing Cre, regardless of developmental Cre expression. Viral injections were performed in 3 adult male mice; 1wk after the second injection, mice were perfused with 10% formalin and 30µm coronal sections were examined from 3mm rostral to Bregma thru Bregma. GnRH neurons and their presynaptic inputs were identified by dual immunofluroescence for GnRH and mCherry. In these mice, 30-40 GnRH neurons coexpressed mCherry. In addition, between 32 and 80 presumptive afferents expressing only mCherry were identified. Preliminary observations indicate that GnRH afferents can be identified as distally as the olfactory bulb (2.5mm rostral of Bregma) and were seen through 0.2mm rostral to Bregma. Specific regions with high proportions of afferents included the anterior olfactory nucleus, medial preoptic area, and anteroventral periventricular area. Interestingly, no mCherry-positive cell bodies were seen contralateral to the injection site, perhaps suggesting that afferent input to the GnRH system may be lateralized to one hemisphere. These preliminary data demonstrate the power of this method to provide interesting insights into the GnRH neuronal circuitry.

 

Nothing to Disclose: TB, MBA, MGM Jr., SMM

14109 6.0000 MON-0607 A Monosynaptic Retrograde Tracing of Gonadotropin-Releasing Hormone (GnRH) Neuron Circuitry 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Kimberly H Cox*, Luciana Mattos Barros Oliveira, Lacey C Plummer, Ravikumar Balasubramanian and William F Crowley Jr.
Massachusetts General Hospital, Boston, MA

 

Background:  Mutations in PROKR2, which encodes Prokineticin Receptor 2, cause Isolated GnRH Deficiency (IGD) in humans.  In contrast to other autosomal recessive genes causing IGD, >90% of PROKR2 “mutations” are heterozygous; they are also typically missense, increasingly present in normative databases, and segregate incompletely within pedigrees.  These facts raise the question of whether these are truly causal “mutations” and, if so, how they contribute to IGD.  One IGD-associated PROKR2 mutation has been shown to have dominant negative (DN) activity in vitro, offering a potential explanation for how other heterozygous rare sequence variants (RSVs) may cause disease; however, it is unclear how widespread this phenomenon is.  The purpose of this study was two-fold: 1) to assess the functional effects of all known RSVs in PROKR2 in a comprehensive fashion, and 2) to model heterozygosity seen in IGD by examining effects of mutant PROKR2 co-expressed with wild-type (WT). 

Methods:  Sixty RSVs (<1% minor allele frequency) were studied:  14 found in IGD patients, 31 reported in control populations, and 15 seen in both.  Mutant and WT PROKR2 were either transfected alone or co-transfected together into HEK293 cells at fixed ratios.  PROKR2 signaling via the mitogen-activated protein kinase (MAPK) pathway was assessed using an Egr1-luciferase reporter assay. 

Results:  When transfected alone, 43 mutants showed LOF with 33 having <50% WT maximal activity.  With WT co-transfection, 6 mutants (including the previously described R80C) exerted a DN effect.  Of note, 4 of these DN mutations were seen only in IGD patients, while the other 2 were found in both IGD and controls.  Surprisingly, the function of the remaining mutants was rescued (i.e. signaling activity restored to WT levels) when co-expressed with WT. 

Conclusions:  By conducting a comprehensive functional analysis to accurately model the heterozygous context of RSVs in PROKR2, we conclude that:

1)     The vast majority of PROKR2 RSVs do not cause a reduction in MAPK signaling, suggesting that they are not sufficient to cause IGD and may represent false positive associations.

2)    A minority of PROKR2 RSVs exhibit dominant negative activity, yet they are always associated with IGD, which suggests that these variants represent true causal “mutations.”

Further studies using this same methodology to investigate alternative signaling pathways are required to fully assess the contribution of PROKR2 variants to IGD.

 

Nothing to Disclose: KHC, LMBO, LCP, RB, WFC Jr.

15010 8.0000 MON-0609 A Heterozygous PROKR2 Mutations in Isolated GnRH Deficiency: False Positives or Dominant Negatives? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Brittany R Jenkins*1, Roger J Davis2 and Amy Marie Navratil1
1University of Wyoming, Laramie, WY, 2HHMI/UMASS Med Schl, Worcester, MA

 

Gonadotropin releasing hormone (GnRH) activation of gonadotrope cells initiates an intricate network of signaling pathways that results in the synthesis and secretion of gonadotropins, luteinizing hormone (LH) and follicle stimulating hormone (FSH), from the anterior pituitary. Previous work has highlighted an important role for the c-Jun N-terminal kinase (JNK) signaling cascade in regulating both GnRH receptor (GnRHR) expression levels and pulsatile secretion of LH; events that are essential for reproductive viability. What awaits systematic clarification are the in vivo requirements of JNK in the regulation of fertility at the level of the pituitary. To specifically address this, we utilized cre/lox technology to selectively knockout JNK 1 and JNK 2 (JNK 1/2) in the anterior pituitary (pitJNK KO). Conditional knockout of transgenic C57BL/6 mice with floxed JNK 1/2  alleles was accomplished using the previously described αGSU-CRE mouse, in which expression of Cre recombinase is regulated by a 4.6 kb fragment of the murine αGSU promoter. Previous reports indicate that CRE expression under the control of this promoter is restricted to cells of the anterior pituitary that express the endogenous αGSU subunit (thyrotropes and gonadotropes). Estrous stage cycling revealed that pitJNK KO females had irregular cycles most notably marked by prolonged diestrus and an abnormal cycle length that ranged upwards of 9 days. Consistent with abnormal cyclicity, our initial breeding experiments showed that pitJNK KO females paired with a control CRE-negative male had significantly reduced litters averaging 3 pups/litter compared to 7 pups/litter from control animals. Litter sizes were similarly reduced when control CRE-negative females were paired with pitJNK KO males suggesting reproductive deficits may also occur at the level of the male. Finally, pitJNK KO females mated to pitJNK KO males resulted in an even greater reduction in litter size with an average of 1 pup/litter. Collectively, our results reveal that ablation of JNK1/2 expression impairs the timing of ovulation, and functional JNK activity is important for fertility in both females and males.

 

Nothing to Disclose: BRJ, RJD, AMN

16959 9.0000 MON-0610 A Pituitary-Specific Ablation of JNK 1/2 Leads to Impaired Fertility 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Laura L Burger*1, Katarzyna M Glanowska2 and Suzanne M Moenter1
1University of Michigan, Ann Arbor, MI, 2University of Virginia, Charlottesville, VA

 

Our ongoing studies indicate that in brain slices from male mice, pulsatile GnRH release in the median eminence is observed well before the onset of puberty. Further, the frequency of GnRH release is greater in 1wk-old mice (~5 release events/h) than in adults (~1event/2-3h). This finding raised the question of how prepubertal pituitary gonadotropes respond to high-frequency spontaneous GnRH release. Here we investigated LH and FSH release and transcriptional regulation of several pituitary gonadotrope genes in control mice and after a single GnRH injection. Male mice aged 7, 14, 21 and 90-94d were treated with either GnRH (150ng/kg; ip) or saline (n=5-8 mice/group). Trunk blood and pituitaries were collected 15 min later. Pituitary RNA was extracted and reverse transcribed, cDNA (30ng) was linearly preamplified for selected transcripts and qPCR performed (1). Serum LH and FSH were measured using the Milliplex rat pituitary panel. Serum LH in saline-treated mice of all ages was at or near the limits of detection (0.25 ng/ml). GnRH increased LH levels 8-10 fold, but only in mice ≥14d of age; 7d-old mice did not respond. FSH was low (~15ng/ml) on days 7-14 and increased from d21 (51±8ng/ml) to adulthood (117±12ng/ml); unlike LH, serum FSH was not altered by one GnRH pulse at any age. The lack of serum LH induction by GnRH in d7 mice may be due to low steady-state LHβ and FSHβ mRNA levels, which were 10% that of adults. An adult-like serum LH response to GnRH was observed in d14 mice even though LHβ mRNA was only 28% of adult values. A single GnRH pulse did not alter either steady-state LHβ or FSHβ mRNA at any age, but did increase LHβ primary transcript in adults. Low levels of β-subunit mRNAs during postnatal development are not due to lack of GnRH receptor expression; Gnrhr mRNA was 25% of adults by d7 and increased with age, but did not reach adult levels until d21. Similarly Egr1 mRNA, critical for LHβ expression, was 25% of adult levels at d7 and increased to 50% by d21. Interestingly, transcripts for two proteins implicated in the respective suppression of LHβ and FSHβ gene expression, GnIH receptor (Npffr1, aka GPR147) and Follistatin (Fst), are markedly elevated in early postnatal life. Specifically, Npffr1 mRNA is 5-fold greater on d7 than in adults, then decreases and is not different from adults by d14, while Fst mRNA is 6-fold greater than adults on d7 and decreases until it is no different from adults by d21. Pituitary Fst and Npffr1 have both been reported to be upregulated by GnRH. These data indicate normal LH secretory response to GnRH can be achieved when steady-state levels of several critical transcripts are lower than in adults. These observations further raise the possibility that in early postnatal development the pituitary shields the downstream reproductive system from the effects of high frequency GnRH by increased expression of transcripts that suppress LHβ and FSHβ subunit gene expression.

 

Nothing to Disclose: LLB, KMG, SMM

14617 10.0000 MON-0611 A Does High-Frequency GnRH Postnatal Release Actively Suppress Pituitary Function? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Liat Rahamim-Ben Navi*1 and Zvi Naor2
1Tel Aviv University, 2Tel Aviv Univ

 

We have recently described a preformed multi protein complex (signalosome) associated with the GnRH receptor (GnRHR) in pituitary gonadotrope cells. This signalosome included c-Src, focal adhesion kinase (FAK), paxillin, vinculin, tubulin, caveolin-1, protein kinase C (PKC) δ, PKCε, PKCα, Ras, kinase suppressor of Ras-1 (KSR), MAPK kinase (MEK) 1/2, ERK1/2 and the GnRHR. Incubation of LβT2 gonadotrope cells with GnRH resulted in a rapid phosphorylation of caveolin-1, FAK, vinculin, and paxillin on Tyr residues by the GnRH-activated c-Src. Then, GnRH activated ERK1/2 in the complex in a c-Src-dependent manner, and the activated ERK1/2 subsequently phosphorylated FAK and paxillin. Addition of GnRH to LβT2 cells transfected with GnRHR-mCherry and ERK-GFP resulted in bleb formation, ERK accumulation in the blebs and apparent cell migration. Also, addition of GnRH to LβT2 gonadotrope cells transfected with GnRHR-mCherry and paxillin-GFP resulted in enrichment of paxillin in focal adhesions in the newly formed blebs. Moreover, caveolin-1 and vinculin, which are members of the signalosome, accumulated in the blebs. Treatment whit U0126, a MEK inhibitor, caused a decreased in bleb formation. Addition of EGF to LβT2 cell resulted in minimal bleb formation, suggesting that the bleb formation is mediated via the GnRHR. We therefore propose that the role of the signalosome is to sequester a cytosolic pool of activated ERK1/2 to phosphorylate FAK and paxillin at focal adhesions apparently to mediate gonadotropes migration

 

Nothing to Disclose: LR, ZN

14996 11.0000 MON-0612 A ERK Phosphorylates FAK and Paxillin in GnRH-Stimulated Signalosome: Possible Role in Gonadotropes Migration 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Joshua George Pemberton*, James Lee Stafford and John Philip Chang
University of Alberta, Edmonton, AB, Canada

 

In goldfish (Carassius auratus), two endogenous GnRH isoforms, GnRH2 ([His5,Trp7,Tyr8]GnRH) and GnRH3 ([Trp7,Leu8]GnRH), are released at the pituitary. Although both GnRHs stimulate LH and GH release via the same population of G protein-coupled receptors (GnRHRs)(1), GnRH isoform-selective signal transduction mechanisms mediate the differential control of hormone release from goldfish gonadotropes and somatotropes. We have previously shown that broad-spectrum inhibitors of  phosphoinositide 3-kinases (PI3K) reduced GnRH2- and GnRH3-elicited Ca2+-signaling as well as LH and GH release(2). Of the three known classes of PI3Ks, class I PI3Ks are the best characterized and consist of four 110 kDa catalytic isoforms (p110α, p110β, p110δ and p110γ) that form heterodimers with subclass-specific regulatory subunits. Among these isoforms, p110γ and p110β catalytic activity is stimulated by binding to the Gβγ subunits of heterotrimeric G proteins(3); suggesting that direct coupling of class I PI3K signaling downstream of GnRHR activation is possible. In the present study, we examined the effects of selective small molecule inhibitors of p110α, p110β, p110δ, and p110γ on GnRH2- and GnRH3-stimulated LH and GH release from primary cultures of dispersed goldfish pituitary cells in column perifusion. Results indicated that p110α catalytic activity was not involved in GnRH actions on hormone release, but p110β and p110γ both participated in GnRH2- and GnRH3-stimulated GH release; whereas GnRH2-induced LH release responses involved p110β while GnRH3 selectively utilized p110γ. GnRH2 and GnRH3 actions on LH release, and GnRH3 stimulation of GH release, also required the p110δ catalytic isoform that is activated by tyrosine-phosphorylated proteins or Ras superfamily GTPases(3). These results constitute the first evidence for the differential involvement of PI3K catalytic subunits in GnRH actions, and suggests that GnRH2 and GnRH3 binding to GnRHRs can bias the activation of class I PI3K signaling in two distinct goldfish pituitary cell-types. The involvement of p110β and p110γ catalytic activity also implicates Gβγ-dependent signal transduction downstream of GnRHR activation. Overall, by studying naturally biased GnRH isoforms in a lower vertebrate model, our findings will help to elucidate how functional selectivity in ligand-receptor signal transduction systems has evolved and how this phenomenon ultimately impacts the neuroendocrine control of growth and reproduction.

 

Nothing to Disclose: JGP, JLS, JPC

13069 12.0000 MON-0613 A Selective Signal Transduction By Two Endogenous GnRH Isoforms in Gonadotropes and Somatotropes: Differential Activation of Class I Phosphoinositide 3-Kinase Catalytic Subunits 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Changchuan Xie1 and Djurdjica Coss*2
1Xiamen University, Fujian, China, 2University of California, Riverside, Riverside, CA

 

Although c-Fos was one of the first transcription factors recognized as induced by a variety of stimuli in various cell types, its role in reproduction and specificity of regulation in endocrine tissues has not yet been determined. In pituitary gonadotropes, GnRH induces c‑Fos and through it FSHβ. We determined that while GnRH rapidly induces both Egr1, the key intermediate gene for LHβ induction, and c‑Fos, which activates transcription of FSHβ through its AP1 site, it specifically decreases the rate of c-Fos protein degradation. c‑Fos is normally rapidly degraded, however GnRH stimulated c-Fos phosphorylation through ERK1/2 extends its half-life. Confirming the role of phosphorylation in promoting increased protein activity, we showed that a c‑Fos mutant that cannot be phosphorylated by GnRH induces expression of the FSHβ promoter less effectively than wild-type c-Fos. Our studies expand upon the role of GnRH in the regulation of gonadotropin gene expression by highlighting the role of c‑Fos post-translational modification that may cause higher levels of FSH during the time of low GnRH pulse frequency to stimulate follicular growth. To investigate the role of c-Fos in reproduction in vivo, we obtained c‑Fos deficient mice and determined that they develop normally in utero, are born at a Mendelian frequency, but tend to die at 2 months of age, and are infertile. c‑Fos-deficient females lack corpora lutea and males have incomplete spermatogenesis. In addition, the female mice fail to advance to puberty as indicated by the lack of vaginal opening. Ovarian histology shows secondary follicles but a lack of antral follicles, and granulosa cells do not increase cAMP in response to FSH stimulation. c‑Fos deficient mice have lower expression of FSHβ and LHβ in the pituitary, but similar levels of TSHβ and POMC genes showing specificity in regulation of pituitary gene expression. Surprisingly, these animals have the same number of GnRH neurons as their wild-type littermates and their axons reach median eminence. Conversely, females, but not males, have fewer kisspeptin expressing neurons, and lower expression of kisspeptin gene specifically in AVPV neurons. Thus, c‑Fos plays a role in reproduction at multiple levels of the hypothalamic-pituitary-gonadal axis.

 

Nothing to Disclose: CX, DC

13155 13.0000 MON-0614 A Reproductive Anomalies in the c-Fos-Deficient Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Marco Bonomi*1, Valeria Vezzoli2, Ivan Bassi2, Domenico Vladimiro Libri2, Gunnar Kleinau3, Manuela Simoni4, Flavia Prodam5, Paola Razzore6, Csilla Krausz7 and Luca Persani8
1Istituto Auxologico Italiano IRCCS, Cusano Milanino, Italy, 2IRCCS Istituto Auxologico Italiano, Cusano Milanino, Italy, 3Charité - Universitätsmedizin Berlin Campus Virchow, Berlin, Germany, 4Università di Modena e Reggio Emilia, Modena, Italy, 5Università del Piemonte Orientale, Novara, Italy, 6AO Ordine Mauriziano, Torino, Italy, 7Università di Firenze, Firenze, Italy, 8Università di Milano, IRCCS Istituto Auxologico Italiano, Milano, Italy

 

Recent studies have described that defects of prokineticin pathway affect the neuroendocrine control of reproduction, but their role in the pathogenesis of idiopathic hypogonadotropic hypogonadism (IHH) remains undefined and the functional impact of missense PROKR2 variants has been incompletely characterized. The functional study on nine PROKR2 germline variants opened new perspectives by demonstrating their differential modulation of distinct intracellular pathways (1). Here we present the new findings in a large series of IHH patients (n = 394) where we found PROKR2 germline variants in 8% of patients. Four mutations are novel (p.G70S, p.D99N, p.C208S, p.M278K) and 3 already known but lacking extensive functional studies so far (p.M64V, p.R85H, p.P290S). All variants demonstrate a general impairment of their targeting to the cell membrane on FACS analysis, which was more evident for the variant p.G70S, p.C208S, p.M278K and p.P290S. Immunofluorescence experiments confirmed the intracellular retention of these variants. Interestingly, western blot analysis revealed that, despite a similar efficient translation, the allelic variant pG70S and p.C208S showed an impaired receptor dimerization. Except for variant p.M64V, all the mutants showed consistent remarkable changes in cAMP accumulation while the IP3 signalling appeared strongly affected only for p.G70S, p.C208S, p.M278K and p.P290S variants. In conclusion these studies support the importance to study either the Gs and Gq-dependent intracellular signal pathway in case of PROKR2 variants. The integrity of both pathways appears necessary for the normal development and function of GnRH-secreting neurons. Furthermore PROKR2 allelic variants can interfere with the dimerization process and have a negative impact on parameters like ligand binding, surface expression or the intracellular signal stimulation. These studies open interesting perspectives for the understanding of the structure-function relationships of this class of GPCRs.

 

Nothing to Disclose: MB, VV, IB, DVL, GK, MS, FP, PR, CK, LP

15954 14.0000 MON-0615 A PROKR2 Loss-of-Function Missense Variations Can Affect Surface Expression, Intracellular Pathways and Dimerization Process 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Leman Damla Kotan*1, Alejandro Lomniczi2, Doris Kretzschmar3, Gregory A Dissen4, Craig Alexander McArdle5, Filiz Koc1, Ben C Hamel6, Meitn Guclu7, Esra D. Papatya7, Erdal Eren7, Eda Mengen1, Fatih Gurbuz1, Mandy Cook3, Juan Manuel Castellano8, M Burcu Kekil1, Neslihan Mungan1, Bilgin Yuksel9, Sergio R Ojeda8 and A. Kemal Topaloglu10
1Cukurova University, 2Oregon Health & Science University/Oregon National Primate Research Center (OHSU/ONPRC), Beaverton, OR, 3Oregon Health and Science University, 4OR Natl Primate Res Ctr/OHSU, Beaverton, OR, 5University of Bristol, Bristol, United Kingdom, 6Radboud University, 7Uludag University, 8Oregon National Primate Research Center/Oregon Health and Science University (ONPRC/OHSU), Beaverton, OR, 9Cukurova Univ Med Faclty, Istanbul, Turkey, 10Cukurova University Faculty, Adana, Turkey

 

Background:Gordon Holmes syndrome (GHS) (MIM 212840) is characterized by cerebellar ataxia/atrophy and normosmic hypogonadotropic hypogonadism (nHH). The neurological phenotype of this syndrome, characterized by progressive neurodegeneration, becomes gradually established typically during the second or third decade of life.  Recently, inactivating mutations in ubiquitination related genes were reported to be the cause of the syndrome in some cases. Nevertheless, the underlying pathophysiology of combined neurodegeneration and nHH remains unknown.

Methods:We studied a group of multiplex families with GHS through autozygosity mapping and whole exome sequencing to identify causative gene mutations. We performed complementary studies to shed light on the disease mechanism.

Results: We identified three unrelated families carrying loss-of-function mutations in PNPLA6, which encodes neuropathy target esterase (NTE), a lysophospholipase that maintains intracellular phospholipid homeostasis by converting lysophosphatidylcholine (LPC) to glycerophosphocholine. Wild-type PNPLA6, but not PNPLA6bearing these mutations, rescued the Drosophila neurodegenerative phenotype caused by the absence of sws, the fly ortholog of mammalian PNPLA6.   Inhibition of NTE activity in the LβT2 gonadotrope cell line diminished GnRH-stimulated exocytosis and reduced the LH response to GnRH, without affecting GnRH receptor signaling or LHβ synthesis. 

Conclusions: Thus NTE-dependent alteration of lipid homeostasis in GHS causes both neurodegeneration and nHH, the latter is due to impaired LH release from pituitary gonadotropes.

 

Nothing to Disclose: LDK, AL, DK, GAD, CAM, FK, BCH, MG, EDP, EE, EM, FG, MC, JMC, MBK, NM, BY, SRO, AKT

15887 15.0000 MON-0616 A Loss of Function Mutations in PNPLA6 Encoding Neuropathy Target Esterase Cause Pubertal Failure and Cerebellar Ataxia (Gordon Holmes Syndrome) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Varykina G. Thackray*1, Chung H Park2, David J Arriola2 and Danalea V. Skarra1
1University of California, San Diego, La Jolla, CA, 2University of California, San Diego

 

Synthesis of luteinizing hormone (LH) and follicle stimulating hormone (FSH) is tightly controlled by a complex network of hormonal signaling pathways that may be regulated by metabolic cues, such as insulin. One group of candidate genes that may act as metabolic sensors in pituitary gonadotrope cells is the FOXO subfamily of forkhead transcription factors. We have demonstrated previously that FOXO1 is expressed in murine pituitary gonadotropes and that insulin signaling regulated FOXO1 phosphorylation and cellular localization in LβT2 cells. We also showed that FOXO1 inhibited basal and GnRH-induced Lhb transcription. Although we did not detect FOXO1 binding to the Lhb promoter, the FOXO1 DNA-binding domain (DBD) was necessary for suppression and the suppression mapped to the proximal Lhb promoter, suggesting that FOXO1 exerts its effect through protein-protein interactions with transcription factors required for Lhb gene expression such as SF1, PITX1 or EGR1. In addition to Lhb, we have previously investigated the mechanisms of FOXO1 suppression of basal and GnRH Fshb transcription. Similar to its action on the Lhb promoter, FOXO1 repression of basal and GnRH-induced Fshb synthesis mapped to the Fshb proximal promoter containing a PITX1 binding element and required the FOXO1 DBD although there was no evidence that FOXO1 bound to the proximal Fshb promoter. Additional results indicating that the mechanism of FOXO1 repression of Fshb transcription involves PITX1 include an interaction between FOXO1 and PITX1 as well as FOXO1 repression of PITX1 induction of the Fshb promoter in CV-1 cells. GnRH induction of an Fshb promoter containing a deletion at ‑50/‑41 or ‑30/‑21 was not repressed by FOXO1, suggesting that these two regions, one of which overlaps the PITX1 binding element, may be involved in FOXO1 suppression of GnRH-induced Fshb synthesis. In the current study, we investigated the effect of FOXO1 on activin induction of Fshb gene expression. In contrast to its effect on basal and GnRH-induced Fshb transcription, FOXO1 suppression of activin induction mapped to the ‑304/-95 region of the Fshb promoter containing multiple activin response elements. FOXO1 suppression of activin-induced Fshb transcription also required the FOXO1 DBD, indicating that protein-protein interactions between FOXO1 and SMAD proteins may lead to FOXO1 suppression. Further supporting evidence comes from an interaction between FOXO1 and SMAD3/4 and FOXO1 suppression of SMAD3/4 induction of the Fshb promoter. In summary, our studies demonstrate that FOXO1 represses basal, GnRH and activin-dependent Fshb transcription through distinct mechanisms, likely involving interactions between FOXO1 and transcription factors such as PITX1 and SMAD3/4. Our studies also suggest that FOXO1 may play an important role in controlling FSH levels in response to metabolic cues.

 

Nothing to Disclose: VGT, CHP, DJA, DVS

14120 16.0000 MON-0617 A Mechanisms of FOXO1 Down Regulation of Follicle-Stimulating Hormone Beta Gene Expression in Pituitary Gonadotrope Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Michael J Woller*
Univ of Wisconsin - Whitewater, Whitewater, WI

 

Pulsatile release of GnRH drives pituitary release of gonadotropins in a wide range of animal species.   The vast majority of evolution of GnRH isoforms has occurred in fishes, specifically in salmonids.  We have collected Silver Salmon in the wild during their spawning migration, documented the physical condition of the fish as an indicator of development prior to spawning, and collected brain tissue explants to measure the release of both sGnRH and chGnRH-II isoforms over a 5-hour period in a tissue perifusion apparatus.  With this model, we have viewed developmental change in different stages of migration into freshwater as well as the morphological changes the fish undergo during migration.  Further, we are able to measure pulsatile release of both sGnRH and chGnRH-II from brain explants in culture.  Our preliminary results indicate that: 1) There are clear differences in the pulsatile release of sGnRH in fish harvested early in migration (prior to morphological change associated with migration into freshwater) compared with fish that have undergone morphological change and are ready to spawn.  2) Changes in release parameters for chGhRH-II are less dramatic during the migration of the fish.  3) Release of both sGnRH and chGnRH-II are clearly pulsatile in fish at all developmental stages. 4) Pulsatile release of these two isoforms of GnRH are independent of each other in that there is a very low level of correlation between pulses of sGnRH and pulses of chGnRH-II from the same brain explants.

 

Nothing to Disclose: MJW

17102 17.0000 MON-0618 A Measurement of Sgnrh and Chgnrh-II Release from Brain Explants Isolated from Silver Salmon Harvested in Alaska during Spawning 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Ali Abbara*1, Channa N Jayasena2, Alexander N Comninos1, Gurjinder M Nijher3, Georgios Christopoulos4, Shakunthala Narayanaswamy2, Chioma Izzi-Engbeaya2, Mathini Sridharan5, Alexina Mason5, Jane Warwick5, Deborah Ashby2, Mohammad A Ghatei2, Stephen R Bloom3, Anna Carby6, Geoffray Howard Trew7 and Waljit S Dhillo1
1Imperial College NHS Healthcare Trust, London, United Kingdom, 2Imperial College London, London, United Kingdom, 3Imperial College London, United Kingdom, 4Hammersmith Hospital, London, United Kingdom, 5Imperial College London, 6Imperial College NHS Trust, london, United Kingdom, 7IVF Unit Hammersmith Hospital, London, United Kingdom

 

Introduction: In vitro fertilisation (IVF) treatment is an effective treatment for infertility, but can be associated with the potentially life-threatening complication known as the ovarian hyperstimulation syndrome (OHSS)1. The major cause of OHSS is the pharmacological use of human chorionic gonadotrophin (hCG) to initiate oocyte maturation during IVF therapy. Developing a more physiological stimulus for oocyte maturation may avoid this dangerous side effect and thereby improve the safety of IVF treatment. Kisspeptin is a recently identified hypothalamic hormone, which acutely and potently increases endogenous LH secretion in a GnRH-dependent manner. We previously demonstrated that kisspeptin stimulates LH release most potently when administered to healthy women immediately prior to ovulation3. The effects of kisspeptin on oocyte maturation have not been investigated previously.

Aim: To determine if kisspeptin can effectively induce oocyte maturation in women undergoing IVF treatment.

Study design: Fifty-three women underwent a modified FSH/GnRH antagonist IVF protocol using kisspeptin in place of hCG to trigger oocyte maturation. Subcutaneous daily injections of FSH (Gonal F 150iu) were started from menstrual day 2, and GnRH antagonist (Cetrotide 0.25mg) was used to prevent a premature LH surge. A subcutaneous bolus of kisspeptin-54 (Dose: 1.6-3.2 (n=5), 6.4 (n=24) or 12.8nmol/kg (n=24) was administered 24hrs after the last GnRH antagonist injection. Oocytes were retrieved 36hrs after kisspeptin injection. Following intracytoplasmic sperm injection (ICSI), 1 or 2 embryos were transferred to the uterine cavity.

Primary outcome: number of mature oocytes (oocytes in metaphase II; MII).

Results: Serum LH was increased 9.0-fold at 12 hours following kisspeptin injection, when compared with serum LH immediately prior to kisspeptin injection. Oocyte maturation (defined as at least one mature oocyte) was observed at all doses of kisspeptin: 96% (51/53) of patients, with a mean of 7.9±3.9 MII oocytes/cycle. Fertilisation occurred in 92% (49/53) of cases, with a mean of 5.6±3.5 zygotes/cycle. Biochemical and clinical pregnancy rates were 40% (21/53) and 23% (12/53), respectively. Eight women have already given birth to healthy babies including two sets of twins.

Conclusion:  We show for the first time that kisspeptin can effectively induce oocyte maturation in IVF treatment. Kisspeptin may therefore offer an entirely novel therapeutic option for fertility treatment.

 

Nothing to Disclose: AA, CNJ, ANC, GMN, GC, SN, CI, MS, AM, JW, DA, MAG, SRB, AC, GHT, WSD

14666 18.0000 MON-0619 A Kisspeptin – a Novel Physiological Trigger for Oocyte Maturation in IVF Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Aki Oride*1, Tselmeg Mijiddorj2, Unurjargal Sukhbaatar3 and Haruhiko Kanasaki4
1Shimane University, Izumo, Japan, 2Shimane University School of Med, Izumo Shi, Japan, 3Shimane University School of Medicine, Izumo, Japan, 4Shimane Univ Sch of Med, Izumo, Japan

 

Trichostatin A (TSA) is a selective inhibitor of mammalian histone deacetylase. TSA can be used to alter gene expression by interfering with removal of acetyl groups from histones and altering the ability of DNA transcription factors to bind the DNA molecules inside chromatin. In the present study, TSA was found to selectively increase gene expression of the pituitary gonadotropin β-subunit of follicle-stimulating hormone (FSH). Stimulation of mouse pituitary gonadotroph cell lines, LβT2, with TSA for 24 h resulted in no change in mRNA expression of the a- and LHb-subunit. On the other hand, FSHβ-subunit mRNA expression was significantly increased by TSA in a dose-dependent fashion. Similarly, specific induction of FSHb-subunit gene by TSA stimulation was observed in the primary cultures of rat pituitary cell. Histone acetylation in whole cells lysates of LβT2 cells was significantly increased after TSA treatment, but not after GnRH treatment. Effect of TSA on FSHβ  mRNA expression was prominent compared to that of gonadotropin-releasing hormone (GnRH); however, TSA-stimulated FSHβ mRNA expression was significantly reduced with combined TSA and GnRH treatment. TSA slightly increased extracellular signal-regulated kinase (ERK) phosphorylation, while GnRH-increased ERK phosphorylation was potentiated in the presence of TSA. In addition, TSA, but not GnRH significantly stimulated the gene expression of retinaldehyde dehydrogenase 1 (RALDH1), a retinoic acid (RA) synthesing enzyme which is involved in the cell differentiation.Present study demonstrates that TSA specifically increases FSHβ subunit gene expression with a concomitant increase in whole cell histone acetylation. Although GnRH is a stimulator of FSHβ gene expression, it interfered with the stimulatory effect of TSA on FSHβ mRNA expression without modification of TSA-increased whole cell histone acetylation. These findings suggest that the mechanisms of TSA and GnRH-induced gonadotropin subunit gene expression are entirely distinct.

 

Nothing to Disclose: AO, TM, US, HK

13662 19.0000 MON-0620 A Specific Expression of Gonadntropin Fshb By Trichostatin a in Mouse Gonadotroph LbT2 Cell 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Noelia Paula Di Giorgio1, Paula V López1, Nadia Bourguignon1, Sheila J Semaan2, Bernhard Bettler3, Alexander S Kauffman2, Carlos Libertun1 and Victoria A Lux-Lantos*1
1Instituto de Biologia y Medicina Experimental-CONICET, Buenos Aires, Argentina, 2University of California, San Diego, La Jolla, CA, 3Univ. of Basel, Basel, Switzerland

 

Adult GABAB1KO (KO) female mice, which lack functional GABAB receptors, have altered cyclicity, increased GnRH pulsatility and infertility. Moreover, Gnrh1 and Gad1 (enzyme that synthesizes GABA) mRNA expressions are altered in KO hypothalami (H), especially in anterior H (AH) and this is not due to serum estrogen levels. We also showed that Kiss1 mRNA in anteroventral/periventricular (AVPV/PeN) and arcuate (ARC) nuclei is similar to adult WT females (1,2).

Here we evaluated the role of brain estrogens in these effects, in WT and KO adult female mice (in estrus) and, comparatively, in males. We also evaluated GnRH pulsatility in the presence of Kiss1r agonist and/or antagonist in E2-treated ovariectomized adult mice.

We determined aromatase (Cyp19a1) and alpha estrogen receptor (Er1) mRNA expressions in AH and medial basal H (MBH) and progesterone receptor (Pgr) mRNA expression in micropunches of AVPV/PeN and ARC by qPCR in WT and KO mice.

 For in vitro GnRH pulsatility studies, adult WT and KO females were ovariectomized and treated immediately with a single dose of estradiol valerate (sc, 10µg/kg). Seven days post-ovariectomy, they were sacrificed. H were collected and incubated in 250 µl of Krebs-Ringer bicarbonate buffer-4.5 mg/ml glucose-16 mM HEPES at 37°C for 7.5h. Treatments: control (CT), Kiss-10 (agonist, 1.10-7M), Kiss-234 (antagonist, 1.10-7M) and Kiss-10+Kiss-234 (1.10-7M each). Media were collected at 9-min intervals and replaced with fresh medium with/without stimuli. Secreted GnRH was measured by RIA.

Cyp19a1 was higher in males vs females (p<0.01) in AH and MBH. Er1 was higher in females vs males (p<0.01) and higher in KO mice vs WTs (p<0.05) in AH and MBH. In AVPV/PeN, Pgr was higher in males vs females (p<0.05), but this difference was lost in KO mice. In ARC, Pgr was lower in KO mice vs WTs (p<0.05), without sex differences. Pulsatility studies revealed that H of WT females have decreased amplitude of GnRH pulses in all treated groups vs CT (p<0.05). However, Kiss-10 induced higher GnRH pulse amplitude in H of KO females compared to WT females (p<0.05).

In conclusion, KO H may have a different sensitivity to estrogens due to the higher Er1 expression. Moreover the H of KO females show a different response to Kiss-10 compared to WTs, probably due to different expression levels, desensitization mechanisms and/or signalling of the Kiss1r in these animals.

 

Nothing to Disclose: NPD, PVL, NB, SJS, BB, ASK, CL, VAL

13932 20.0000 MON-0621 A Infertility in GABAB1KO Female Mice: Possible Role of Brain Estrogens and Hypothalamic Response to Kisspeptin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0602-0621 4819 1:00:00 PM GnRH & Gonadotrope Biology & Signaling Poster

Mika Habu*1, Kazunori Arita1, Shingo Fujio1, Hiroshi Tokimura1, Atushi Tominaga2 and Yasuyuki Kinoshita2
1Graduate School of Medical and Dental Sciences Kagoshima University, Kagoshima, Japan, 2Graduate School of Biomedical Science, Hiroshima University, Hiroshima, Japan

 

Introduction:   In most cases of non-functioning pituitary adenomas (NFoma), normal pituitary glands were compressed by adenomas and surrounding the tumors. In rare cases, although the tumors were large, pituitary glands were neither disfigured nor thinned and the adenoma mainly grew out of pituitary gland (exophytic adenoma).  We assessed between characteristic form and endocrinological function in these cases.

Materials and Methods: 

In 2005-2013, 76 patients (32 men and 44 women) with NFoma were evaluated with pituitary provocation tests including insulin tolerance test (ITT). Among them, the subjects were 14 patients, 4 men and 10 women with large adenoma predominantly showed exophytic growth. 17 patients, 11 men and 6 women matched for subject group with the tumor size were selected for control. We assessed pre- and postoperative pituitary function of these cases.

Results:

Mean age of all patients was 49.3±15 (mean±SD) ranged from 19 to 73 years. Mean maximum tumor diameter was 29±10mm (range:23-46). In subjects, mean age was 47.2±14.7 years (range:19-73) and mean maximum diameter was 35.6±6.3mm (range:30-46).  Compared with  non-exphytic group consisted of 62 patients except members of subject group, subjects were significantly larger (mean maximum diameter of non-exphytic group was 27.7±10 mm). (p<0.05)  In control, mean age was 51.8±13.9 years (range: 28-66) and mean maximum diameter was 36±5.3mm (range:30-46).

There were inversely relations between the size of NFoma and GH secretion. There were 38 patients with GH deficiency (GHD). Mean maximum diameter of 29 patients with severe GHD was 31.9mm, of 9 patients with GHD was 27.7mm and of non-GHD patients was 19.6mm. The peak values of the hormones with non-exphytic group in the preoperative stimulation tests were as follows: GH6 μg/L, TSH 45μU/ml, CORT 21 μg/dl, and PRL 78ng/ml. There were 38 patients with GH deficiency (GHD). In subjects group, peak GH 13.8±5.5 μg/L, peak CORT 22.9±4.1 μg/dl, peak TSH 16.4±10.11μU/ml and peak PRL 48.9±37ng. There was no patients with GHD. In controls, the peak values of the hormones were as follows: GH 1 μg/L, CORT 15 μg/dl, TSH 19±14.8μU/ml and PRL 47±37ng.  All patients in this group were severe GHD. The secretory function of GH and CORT in subject group were significantly preserved compared to patients in control group. (p<0.05)

In subject group, we assessed pre-and post-operative pituitary functions. Secretion of GH, CORT and TSH were maintained after operation.

 

Conclusions: In some non-functioning pituitary adenomas, pituitary gland were not thinly compressed and had their normal configuration despite the large tumor sizes.  In these cases, the tumors showed mainly exophytic growth from the pituitary gland.  Good preservation of secretory function of pituitary hormones including GH was outstanding characteristics of this subset of NFomas.

 

Nothing to Disclose: MH, KA, SF, HT, AT, YK

13795 2.0000 MON-0623 A Endocrinological Function in Nonfunctioning Pituitary Adenomas with Predominantly Exophytic Growth 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Serafino Lio*1 and Gianluca Occhi2
1ASL No 9, Motta Di Livenza TV, Italy, 2Division of Endocrinology, Padova, Italy

 

Pituitary macroadenoma occurs in sporadic or familiar manner (5% about), this last one concerned in the setting of MEN 1, Carney complex or isolated form. The Familiar Isolated Pituitary Adenomas (FIPA) may exhibit (20% about) germline mutation in aryl hydrocarbon receptor-interacting protein (AIP); patients with AIP mutation are characterized by young-onset and usually associated with somatotropinomas and prolactinomas. A minority of cases other functional adenoma and non-secreting adenoma (NFA) can also occur and cohort is equally divided in homogeneous or heterogeneous tumor types.

We report two patients, father and son, with homogeneous FIPA by non-secreting macroadenoma shown in a different periods of life.

Case 1: a 67-years old man began with visual loss with bitemporal haemianopsia in patient with hypertension, diabetes mellitus type 2. MRI revealed pituitary macroadenoma (cm 4x3) with extra- and suprasellar extension and invasion of cavernous sinus; endocrine evaluation displays non functional adenoma with hypogonadotropic hypogonadism; functional screening for MEN is negative. Transphenoidal endoscopic excision was performed; microscopical examination showed that it was an adenoma and immunocytochemical analysis showed diffuse immunoreactive for FSH and focal immunoractivity for ACTH and GH; Ki67 < 1%. The AIP sequencing shows a variant missens of AIP (R304Q), previous reported in GH, PRL or ACTH hypersecretion.

Case 2: after six years also the son of 34-years old showed visual disturbance with bitemporal haemianopsia without personal history of other diseases. MRI revealed pituitary macroadenoma (cm 3.2x2) with extra- and suprasellar extension and compression of third ventricle; endocrine studies reveal non functional abnormality with only slightly elevation of FSH-LH and testosterone serum levels; functional screening for MEN is negative; abdominal and testis US were normal. Transphenoidal endoscopic excision was performed; microscopical examination showed an pituitary adenoma and immunocytochemical analysis a focal immunoreactivty for FSH-LH, negative for other pituitary hormones; Ki67=1%.

In conclusion: the FIPA may begin in different period of life; the AIP R304Q variant is possible also in NFA; if NFA macroadenoma with AIP mutation is clinically presented after the age of 60 years-old in isolated form the clinical, functional and morphologic control in parents is indicated .

(1). Beckers,A., Aaltonen, LA., Daly, AF., Karhu, A. Familial isolated pituitary adenomas (FIPA) and the adenoma predisposition due to mutation in the aryl hydrocarbon receptor protein (AIP) gene. Endocr. Rev. 2013; 34; 239-277

 

Nothing to Disclose: SL, GO

13890 3.0000 MON-0624 A Non-Functioning Pituitary Adenoma (NFA) in Familial Isolated Pituitary Adenona (FIPA): AIP Variant 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Jennie Luna*1, Ila Khanna1, Fiona J Cook2, Eric M Martin1 and Regis G Hoppenot1
1Brody School of Medicine, East Carolina University, Greenville, NC, 2Brody School of Medicine, Greenville, NC

 

Background

Spontaneous intracranial hypotension (SIH) is a relatively rare condition caused by a spontaneous cerebral spinal fluid (CSF) leakage which often presents as new onset orthostatic headaches. This uncommon entity came to light in 1991 when meningeal gadolinium enhancement in intracranial hypotension was first reported in the medical literature.  MRI, the diagnostic study of choice, demonstrates distinct features in SIH, including pachymeningeal enhancement, subdural fluid collection, engorgement of venous structures, pituitary hyperemia and lowering of the brainstem and cerbellar tonsils, hence the term “sagging brain”.  Not all of these features are detected in every patient. Pachymeningeal enhancement is the most common.  Associated risk factors include mechanical stress, meningeal diverticula and connective tissue disorders.  Enlargement of the pituitary gland can be seen in this condition due to engorgement of the epidural venous plexus.

Clinical Case

A 55 year old woman with a diagnosis of non-functioning pituitary macroadenoma underwent transphenoidal resection due to orthostatic headache and visual field deficits found with formal opthalmological testing. MRI showed interval enlargement of a pituitary mass, increasing in superior to inferior dimension from 0.9 cm to 1.3 cm in 6 months, with mass effect on the optic chiasm. Surgical pathology showed no features of adenoma. Additional findings on brain MRI included features characteristic of SIH: pachymeningeal gadolinium thickening and enhancement, flattening of the pons, and lowering of the brainstem and cerebellar tonsils.  Post-operatively headaches ultimately improved and MRI done 6 months after surgery showed improvement in the findings described. To date the etiology for this patient’s intracranial hypotension is not known.

Conclusion

SIH is a rare cause for persistent headaches and is therefore often misdiagnosed.  To date, there is no definitive etiology for this entity, however CSF leak due to trivial trauma and meningeal weakness are two causes commonly entertained. Enlargement of the pituitary may occur due to engorgement of the dural and epidural venous sinuses and can be mistaken for a macroadenoma. Increasing awareness may avoid misdiagnosis and unnecessary procedures. To our knowledge, this is the first reported case of SIH which has resulted in visual field deficit due to optic chiasm compression.

 

Nothing to Disclose: JL, IK, FJC, EMM, RGH

13955 4.0000 MON-0625 A Sagging Brain Masquerading As a Pituitary Macroadenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Timothy Patrick Moran*1, Lane Frey2, Andrew Parent3, Scott Stringer3, Johnathen Fratkin3 and Christian A. Koch4
1Univ. of Mississippi Med Center, Ridgeland, MS, 2University of Mississippi Medical Center, Jackson, MS, 3UMMC, 4Univ of Mississippi Med Ctr, Jackson, MS

 

Non-functioning pituitary adenomas (NFPA) generally are treated surgically and with radiation (XRT) depending on their location and surrounding structures.  Residual pituitary adenomas (PA) after treatment may exhibit growth with slow extension into surrounding structures which can take years to occur. Ectopic PA  are rare and are mostly located in the sphenoid sinus.  Predicting aggressive or malignant behavior in PA remains challenging.
 
A 55-yo AA man with a PMH of a NFPA resected in 2001 and treated with gamma knife radiation to residual tissue,  had anterior hypopituitarism, and presented to the ED with left sided headaches worsening over 4 days. Sinus CT scan revealed a new mass extending from the left maxillary sinus into the sella turcica. He had been followed by Endocrinology and Neurosurgery for his thus far stable residual tumor in the left sphenoid sinus as well as hormone requirements. His most recent MRI 2 y before his ED presentation showed the size of the residual tumor at that time being smaller than on prior MRIs.  In the ED, neurosurgery  colleagues evaluated him and recommended a biopsy of the sinus mass which was performed by Otolaryngology along with a left maxillary sinusotomy, anterior ethmoidectomy, and sphenoidotomy with tissue removal. The bx revealed a recurrence of the NFPA with tumor cells on pathology staining positive for Ki-67 (> 3%) and for p53, suggesting it was more aggressive.  The patient’s sx improved and he continued hormone replacement therapy with close f/u.
 
This case illustrates the need for longterm follow-up of patients with NFPA, especially after treatment with any form of radiation (1). It further underscores the lack of biomarkers that could reliably assist in predicting which tumors are more likely to recur or become more aggressive including invasion (2). CT and MRI features of sphenoid sinus ectopic PA are well described (3,4). Misdiagnosis (such as olfactory neuroblastoma, neuroendocrine carcinoma, sinonasal undifferentiated carcinoma, paraganglioma, melanoma) of patients with a sinus mass and/or a history of PA should be avoided (5). Surgical removal of residual tumors remains the mainstay of therapy, if feasible. Nonsurgical therapy options are less standardized (1). PA that stain positive for Ki-67 or P53 are more likely to be aggressive than those that do not.  Aggressive PA and pituitary carcinomas often require more novel treatments when traditional surgery and XRT fail (6,7). 

 

Nothing to Disclose: TPM, LF, AP, SS, JF, CAK

14824 5.0000 MON-0626 A Headache and Sinus Mass As Presenting Features of an Aggressive Nonfunctional Pituitary Adenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Mae Whelan* and Sarah E Mayson
Hallett Center-Brown University, East Providence, RI

 

Background: Primary central nervous system germinomas are rare neoplasms, accounting for approximately 0.3-3.4% of intracranial tumors. Nearly one-third of tumors occur in the neurohypophysis. CNS germinomas most commonly present in children. Because germinomas are extremely radiosensitive, correctly diagnosing these tumors is critically important to provide optimal care for the patient. Here we present an unusual case of an adult male with a suprasellar germinoma.

Clinical Case:  A 24-year-old male presented to the hospital after visual field testing revealed a left homonymous hemianopsia. He described an eight-month history of blurred vision as well as approximately four years of polyuria and polydipsia. He also reported long-standing low energy, low libido and cold intolerance.  Brain MRI revealed a 4.3 x 2.3 x 3.1 cm heterogeneously enhancing sellar mass. The mass demonstrated extension into the suprasellar and interpeduncular cisterns and exerted mass effect on the optic chiasm and midbrain. Pre-operatively this was thought to be most consistent with a pituitary macroadenoma or craniopharyngioma.  Prolactin was measured and was found to be 36 ng/mL (2-17). The patient underwent transcranial biopsy, but because the pathology on frozen section was consistent with a typical germinoma, surgery was aborted. Hormonal evaluation post-operatively revealed panhypopituitarism with free T4 0.59 ng/dL (0.8-1.8), FSH 0.19 mIU/mL (2.0-9.2), LH 0.01 mIU/mL (1.5-9.0), and 8AM total testosterone <2.5 ng/dL (348-1197). He was started on dexamethasone peri-operatively for presumed adrenal insufficiency. A post-operative cosyntropin stimulation test (cosyntropin 250 ug IV) confirmed chronic secondary adrenal insufficiency (serum cortisol 0.3, 7.4, and 8.1 ug/dL (5.5-20) at baseline, 30, and 60 minutes). He was treated with prednisone for adrenal insufficiency and levothyroxine for thyroid hormone replacement. Based on post-operative serum sodium of 152 meq/L (135-145), urine output of 600-900 cc/hr, urine specific gravity of 1.005 (1.010-1.030), he was diagnosed with diabetes insipidus and treatment was initiated with desmopression 0.1 mg twice daily. Serum AFP and b-HCG were measured and were within normal limits. The patient subsequently underwent fractionated Intensity-Modulated Radiation Therapy (IMRT) and received a total cumulative dose of 48 Gy over five weeks. Repeat Brain MRI after completing IMRT showed no residual mass, but was notable for absent posterior pituitary bright spot. Repeat visual field testing following IMRT showed improvement in visual acuity and visual field defect.

Conclusion:  Unlike most patients with pituitary macroadenomas, patients with suprasellar germinomas commonly present with diabetes insipidus. In young patients presenting with diabetes insipidus and a suprasellar mass, germinoma should remain high on the differential.

 

Disclosure: MW: Coinvestigator, Novartis Pharmaceuticals. SEM: Study Investigator, Novartis Pharmaceuticals.

15310 6.0000 MON-0627 A Suprasellar Germinoma in an Adult Patient Presenting with Vision Loss and Diabetes Insipidus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Alice Azzalin*1, Christina Appin1, Rachel Peter Puttnam2, James Ritchie1, Daniel Brat1, Nelson M Oyesiku1 and Adriana Gabriela Ioachimescu1
1Emory University School of Medicine, Atlanta, GA, 2Kaiser Permanente, Johns Creek, GA

 

Background: TSH secreting pituitary adenomas (TSH-omas) are extremely rare. We present 3 cases of plurihormonal TSH-omas seen at a single pituitary center.

Clinical Cases:

1. A 46 year old man presented with paroxysmal atrial fibrillation and tremor for a year. Laboratory data was remarkable for TSH of 3.57 (0.5-4.78 mcIU/mL), Free T4 of 2.8 (0.7-1.8 ng/dL), Free T3 of 11.9 (2.4-4.2 pg/mL), and glycoprotein hormone alpha-subunit (GSU)/TSH molar ratio of 3.6 (<1). MRI showed a 1x1 cm pituitary mass. He received octreotide followed by TSA and was euthyroid postoperatively, with follow up 15 months.  Immunochemistry was strongly positive for TSH, with scattered cells positive for GH and PRL.

 2. A 57 year old man was found to have a pituitary mass (3.6x3.0 cm) during staging for lung adenocarcinoma. IGF-1 was elevated 861 (68-245ng/mL), GH 11.7 (<3 ng/mL) with nadir 1.3 ng/mL during OGTT, TSH 1.77 mcIU/mL, FT4 1.7 ng/dL and GSU/TSH molar ratio 6.21. Prolactin was normal. He was started on lanreotide with improvement of IGF-1. A year later, thyroid hormones became elevated (FT4 1.9 ng/dL, FT3 7.2 pg/mL) with TSH 2.37 mcIU/mL. He underwent TSA and became euthyroid post-op, follow up 2 months. Immunohistochemistry was strongly and diffusely positive for TSH, PRL and GH.

3. A 49 year old man presented with dizziness and sweating. TSH was 6.40 mcIU/mL, FT4 2.1 pg/mL and GSU/TSH molar ratio 14.53. He underwent TSA for a 1.9x1.5 cm pituitary mass. He remained hyperthyroid and received octreotide for 3 months, then methimazole. He presented 4 years later with progression of the residual tumor. Labs off methimazole showed TSH 7.11 mcIU/mL, FT4 1.7 ng/dL, FT3 6.0 pg/mL, GSU/TSH molar ratio 6.19 and normal PRL, LH, FSH and testosterone. He underwent repeat TSA and became euthyroid postoperatively, follow up 2 months.  Immunochemistry was strongly and diffusely positive for TSH with scattered cell positive for PRL, LH and FSH. 

All 3 adenomas had diffuse and moderate immunoreactivity for the pituitary transcription factor 1 (Pit-1).

Conclusion: Few plurihormonal TSH-omas have been reported. The later development of hyperthyroidism in a patient with acromegaly (case 2) is exceptionally rare. Our cases illustrate possible mechanisms involved in TSH-oma tumorigenesis, including Pit-1 overexpression, dedifferentiation between somatotroph and thyrotroph cell lines and development from precursor stem cells. Long-term surveillance is important as clinical and biochemical phenotype may change.

 

Nothing to Disclose: AA, CA, RPP, JR, DB, NMO, AGI

13843 8.0000 MON-0629 A Pleiotropic Manifestations of TSH-Secreting Pituitary Adenomas: Emory University Case Series 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Milad Abusag*
University of Chicago, Chicago, IL

 

Introduction:

Pituitary enlargement secondary to primary hypothyroidism was first recognized in 1851. Even with advanced neuroimaging studies, it is still difficult to distinguish pituitary hyperplasia for pituitary adenoma based on pituitary MRI.  

Clinical Case:

A 49-year-old female, with several years history of primary hypothyroidism on Synthroid 100 mcg daily presented to her PCP with one year history of generalized headache, associated with blurry vision, worsening fatigue and weight gain. She gained about 40 pounds over the past year. On physical examination, BP 125/67 mmHg, pulse rate 72 bpm, Wt 146.8 kg (BMI 52) and non-palpable thyroid gland. Rest of the physical examination was unremarkable apart from Supraclavicular fullness and light silvery striae. She was initially seen by ophthalmologist and complete ophthalmological examination revealed normal visual acuity and normal fundal examination. Visual field examination showed right eye with arcuate defect and left eye with inferior and nasal defect. Giving visual field defect and persistent headache cranial and pituitary MRI done and showed an intra-sellar and supra-sellar pituitary mass, extended on the suprasellar cistern with indentation on the optic chiasm. The pituitary stalk was dislocated.

She was referred to our clinic for endocrine evaluation before any surgical intervention. Endocrine work up showed TSH 146.8 mcu/ml, Free T4 0.39 ng/dl, T3 ng/dl), Alpha subunit 0.4 ng/ml. Random cortisol 5.5 mcg/dl, ACTH 11 ng/ml, Prolactin 13.16 ng/ml, 24 hrs urine free cortisol normal x3 (29, 14 and 18 mcg/24hrs), E2 7 pg/ml, FSH 8.9 mIU/ml, LH 15.3 mIU/ml, IGF-1 80 ng/ml.    

Clinical course; Synthroid dose was increased from 100 mcg/day to 200 mcg/day. Two months later repeated TFT showed TSH 3.84 mcU/ml, free T4 1.34 ng/dl, T3 118 ng/dl, and repeated pituitary MRI showed completely normal pituitary gland with no evidence of micro or macroadenoma. Repeated visual field exam was completely normal.  

Discussion:

Primary hypothyroidism should be considered in the differential diagnosis of solid mass lesions of the pituitary gland. Thyrotroph hyperplasia can be explained by the classical negative feedback loop in which reduced levels of thyroid hormone result in overstimulation of thyrotrophs by TRH. It is not possible to distinguish between TSH-producing macroadenoma and hyperplasia of pituitary thyrotroph cells on CT and MR scans. Assessment of thyroid function is very important in the evaluation of any patient with an enlarged pituitary gland in order to avoid errors in diagnosis, which can result in complex, unnecessary, and even harmful therapeutic interventions.

 

 

Nothing to Disclose: MA

16417 9.0000 MON-0630 A Pituitary Hyperplasia Secondary to Long-Standing Primary Hypothyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Wojciech Zgliczynski*1, Izabella Katarzyna Czajka-Oraniec2, Maria Stelmachowska-Banas3, Piotr Zdunowski4 and Magdalena Kochman3
1The Medical Centre of Postgraduate Education, Warsaw, Poland, 2Med Ctr Postgrad Edu, Warsaw, Poland, 3Medical Center of Postgraduate Education, Warsaw, Poland, 4Bielanski Hospital, Warsaw, Poland

 

Efficacy and Safety of Somatostatin Analogues (SSA) in the Treatment of Hyperthyroidism Due to Thyrotropin-Secreting Pituitary Adenomas (TSH-oma) before Transphenoidal Adenomectomy.

 Introduction

Thyrotropin-secreting pituitary adenomas (TSH-omas) account for <1% of pituitary adenomas with the incidence estimated at about 0.2/mln/year. Due to somatostatin receptors expression on tumor cells somatostatin analogs (SSA) are potent treatment option. The data on preoperative SSA effectiveness are scant.

 Aim

We aimed to characterize the group of patients with newly diagnosed hyperthyroidism due to TSH-oma who had been treated with SSA before transsphenoidal tumor resection.

 Material and Methods

We analyzed data of 15 patients (9 women and 6 men) diagnosed with TSH-oma, treated and followed-up between 1997 and 2013 in one academic center.

 Results

Patients’ mean age was 42.8±14.7 years and median time to diagnosis TSH-oma was 2 years (range: 0.5-20 years). It was longer (median 7 years) in patients misdiagnosed with primary hyperthyroidism and hence treated with antithyroid drugs (n=6), radioiodine (n=1) and/or thyroidectomy (n=1). All patients but 1 had moderate or severe symptoms of hyperthyroidism. MR imaging revealed 13 macroadenomas (mean tumor maximal diameter TMD 18.9± 9.1 mm) and two microadenomas (<5 mm). A mean thyroid gland volume was 27.4±14.3 mL and goiter was present in 9/15 (60%) cases. Radioiodine uptake was increased in all patients (mean 68±15.7%). Initially, all patients had elevated fT4 (mean: 35.7±10.3 pmol/L) and 80% of them had increased fT3 (mean: 5.6±2.2 pg/mL) levels with high unsuppressed TSH (mean 6.4±5.7 mIU/L, above upper limit in 73.3% patients). No response (Δ-TSH<1 mIU/L) in TRH stimulation test was present in 14/15 (93.3%) cases. All patients were preoperatively treated with SSA (long-acting octreotide or lanreotide) for median 3 months (range: 2-8). All patients on SSA treatment had biochemical and clinical improvement and 13 of them achieved euthyreosis before operation (mean TSH 1.9±1.9 mIU/L, fT4 17.1±5.6 pmol/L, fT3 2.6±1.7 pg/mL). In 9 patients thyroid ultrasound repeated before neurosurgery showed decrease in thyroid volume by mean 6.6±4.0 mL. One patient underwent thyroidectomy due to papillary carcinoma before transsphenoidal operation. In 10/14 (71.4%) patients there was a decrease in pituitary adenoma size (median difference in TMD: 3.0 mm, range: 0-10 mm). No side-effects of SSA treatment were noted apart from mild diarrhea and stomach ache.

 Conclusion

In patients with hyperthyroidism due to TSH-oma a preoperative SSA therapy appears to be highly efficacious and safe in achieving euthyreosis, thyroid gland volume reduction and pituitary tumor shrinkage, proving their role in the preoperative treatment and durable follow-up.

 

Nothing to Disclose: WZ, IKC, MS, PZ, MK

16686 10.0000 MON-0631 A Efficacy and Safety of Somatostatin Analogues (SSA) in the Treatment of Hyperthyroidism Due to Thyrotropin-Secreting Pituitary Adenomas (TSH-oma) before Transphenoidal Adenomectomy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Carly E Kelley*1, Anna Beth Barton1, Manal Abdelmalek2, Ann Julia Brown3 and Tracy Lynn Setji1
1Duke University Medical Center, Durham, NC, 2Duke University Medical Center, 3Duke Univ Med Ctr, Durham, NC

 

Background:  Nonalcoholic fatty liver disease (NAFLD), the leading cause of liver disease in the Western world, may progress from hepatic steatosis to steatohepatitis and cirrhosis. We report a rare case of NAFLD cirrhosis secondary to panhypopituitarism following craniopharyngioma (CP) resection. 

Case: A 23-year old African-American man with a history of CP resection at age 7 presented with five days of encephalopathy, nausea, vomiting,  abdominal pain, and weight loss. Long-term medications included physiologic replacement of hydrocortisone, levothyroxine, growth hormone (GH), testosterone, and DDAVP.   History at age 17 included nonadherence to testosterone and GH therapies with symptoms of fatigue, depressed mood, gynecomastia, a BMI of 44 kg/m2, muscle wasting, hyperinsulinemia, a low IGF-1, low testosterone, and elevated liver enzymes.  He denied alcohol use and had no family history of liver disease.

At presentation, examination noted a BMI of 38 kg/m2, acanthosis nigricans, cognitive delay, asterixis, gynecomastia, hepatosplenomegaly, and abdominal tenderness.  Laboratory studies noted an AST 156 U/L (range 15-41 U/L), ALT 60 U/L (range 17-63 U/L), total bilirubin 6.9 mg/dL (range 0.4-1.5 mg/dL), INR 2.0 (range 0.8-1.1), platelet count/L 76 x 10^9 (range 150-450 x 10^9), and venous ammonia 57 umol/L (range 16-50 umol/L).  Serum albumin, creatinine, thyroid function, lipid panel and glycosylated hemoglobin were normal.  Calculated MELD score was 21.  Imaging studies revealed normal hepatic vasculature, diffuse hepatic steatosis, hepatosplenomegaly, and no ascites, biliary obstruction or pituitary mass.  EGD was normal.  A serologic evaluation for alternative causes of chronic liver disease was unrevealing.  Liver biopsy confirmed NAFLD with cirrhosis, “spidery” pericellular fibrosis, chronic inflammation and severe macrovesicular steatosis.  Due to increased MELD score and recurrent hepatic encephalopathy, he was listed for liver transplantation.

Conclusion: CPs are associated with increased morbidity, mortality and complications including visual loss, neurological /behavioral deficits, endocrinopathies, cerebral vascular disease, hypothalamic dysfunction and/or NAFLD.  While physiologic corticosteroid replacement is not known to cause cirrhosis, GH deficiency, insulin- and leptin resistance are associated with fibrosis progression.  The metabolic complications of CP must be managed aggressively to avoid cirrhosis from NAFLD and its complications.

 

Nothing to Disclose: CEK, ABB, MA, AJB, TLS

15226 11.0000 MON-0632 A Liver Cirrhosis Secondary to Nonalcoholic Fatty Liver Disease in a Patient with Hypopituitarism after Craniopharyngioma Resection 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Clarissa Groberio Borba*1, Rafael Loch Batista2, Ana Elisa Evangelista Alcantara3, Vanielle Carvalho Machado1, Malebranche Cunha Neto1 and Nina de Castro Musolino4
1Hospital das Clínicas, FMUSP, 2Hospital das Clinicas, FMUSP, Brazil, 3Hospital Das Clinicas FMUSP, Brazil, 4Hospital das Clínicas, FMUSP, São Paulo, Brazil

 

Introduction: Although the literature suggests no difference in frequency of recurrence between GH-treated and non-GH-treated craniopharyngiomas patients1,2, there are some patients where a relation between GH treatment and recurrence can be suspected3. 

Case Report: We describe a patient who presented recurrence twice on GH replacement. Female patient, with complain of headache, was diagnosed with craniopharyngioma after sella imaging followed by transphenoidal surgery in 1995 when she was six year old. She was submitted to radiotherapy in 1996 for residual tumor. Anterior total hypopituitarism was confirmed and she was treated with glucocorticoid and levothyroxine previously to surgery.  In 1999, she started GH replacement. After 18 months, a tumor re-growing was observed, GH was withdrawn and a transcranial surgery was performed due to visual worsening.  No residual tumor was observed on the MRI after surgery. When the patient was 22 year old (2011), due to metabolic and neuropsychological disturbances, such as memory problems and humor depressed, GH replacement was restarted at 0.33 mg daily, after a confirmation of no residual tumor on MRI. She noticed improvement of her symptoms besides normalization of IGF-1 levels, from < 25 ng/mL to 147 ng/mL (normal range:122-384 ng/mL). The GH was withdrawn one year later when MRI depicted a cystic lesion. Eight months followed by the GH discontinuation, a new MRI showed no growth of the cystic mass. Indeed, a discrete reduction was observed. 

Comments: The recurrences of tumor during the two different occasions on the GH replacement: the first a short period after radiotherapy, and the second after a long follow up period free of recurrence, suggest the relation between GH treatment and tumor recurrence in this patient. This case reinforces the indication of imaging follow up in patients with craniopharyngioma during GH replacement even in a long follow up.

 

Nothing to Disclose: CGB, RLB, AEEA, VCM, MC, NDCM

15286 12.0000 MON-0633 A Recurrence of Craniopharyngioma Twice in Pacient Under Growth Hormone (GH) Replacement 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Thomas Graillon*1, Celine Defilles2, Amira Mohamed3, Christophe Lisbonis3, Anne-Laure Germanetti4, Olivier Chinot5, Dominique Figarella-Branger6, Philippe Metellus6, Pierre-Hugues Roche7, Tarek Adetchessi6, Stephane Fuentes6, Henry Dufour8, Alain Enjalbert9 and Anne Barlier9
1CHU Timone, Marseilles, France, 2CRN2M Faculté de Médecine Nord, Marseilles, France, 3CRN2M, Marseilles, France, 4Biochimy department, Marseille, 5Neurooncology, marseilles, France, 6Hopital La Timone, Marseilles, France, 7Hopital Nord, Marseilles, France, 8Aix Marseille University, Marseille, France, 9Aix-Marseille University, Marseille, France

 

Additive effect of sst2 somatostatin receptor agonist and mTOR inhibitor remain a key point in the perspective of neuroendocrine tumor treatment. But considering different in vitro, in vivo experimental model and clinically in humans, additive effect was demonstrated only in rare tumoral cells.

Meningioma cells were extracted from fresh tumors. SST2 receptor is strongly express in meningiomas. SST1 receptor is significantly expressed in 40% of tested meningiomas. mTOR pathway was demonstrated to be hyperactivated in meningiomas.

Combination of octreotide and everolimus provided an additive inhibitor effect on cell proliferation compared to each drug alone. Using BrdU incorporation, the mean inhibitory effect was -30 ± 6% under everolimus alone, -43 ± 4% under octreotide alone, and -70 ± 3% under the combination of both drugs. Everolimus was demonstrated to increase Akt phosphorylation, limiting inhibitor efficiency. Western blot studies were performed, demonstrated additive effect on different Pi3K-Akt-mTOR pathway stages (S6K, 4E-BP1, P27Kip1). Octreotide reversed Akt phosphorylation induced by everolimus, explaining, at least partially, this additive effect.

Interestingly pasireotide provided a slight but significant better inhibitor dose-effect than octreotide. Moreover, combination of pasireotide-everolimus provided a significant better inhibitor effect than combination of octreotide-everolimus. Pasireotide inhibitor effect was significantly higher than octreotide at low doses in the group with significant SST1 receptor expression.

In conclusion, primary meningioma cells offer an interesting model to further molecular investigations about combination of somatostatin agonists and mTOR inhibitors. These results establish the basement of clinical trial in aggressive meningiomas.

 

Disclosure: TG: Clinical Researcher, Novartis Pharmaceuticals. CD: Researcher, Novartis Pharmaceuticals. AM: Researcher, Novartis Pharmaceuticals. CL: Researcher, Novartis Pharmaceuticals. Nothing to Disclose: ALG, OC, DF, PM, PHR, TA, SF, HD, AE, AB

16588 13.0000 MON-0634 A Additive Effect of the Combinations Octreotide/Everolimus and Pasireotide/Everolimus on Cell Proliferation and Intracellular Pathways on a Model of Short-Term Meningioma Primary Cell Culture 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Saad Sakkal*
Pikeville Medical Center, Pikeville, KY

 

Introduction: The Hypothalamus is the master control for hormonal balance through the pituitary. In addition its nuclei control all metabolic functions coordinating many central nuclei with cortical, midbrain, thalamic, limbic and full arrays of neuroendocrine pathways effecting most  vital functions: Energy/macronutrient metabolism, Temperature, appetite/ weight, sleep/diurnal rhythm, Mood/ well-being, Reproduction/libido, Pain and muscle tone, and visceral sympathetic/parasympathetic balance. The symptoms related to these hypothalamic functions are the most common complaints in practice, yet, there are no studies documenting how common is the diagnosis of Hypothalamic Dysfunction is in the endocrine clinic?

Methods: we prospectively tabulated the complaints of the first 120 consecutive patients referred for evaluation of thyroid, parathyroid, pituitary, adrenal , other endocrine and metabolic diagnosis. Complaints were extracted from the patient review of symptoms sheet used for intake in the EHR. The prevalence of the seven groups of symptoms described above was quantified as a percentage of the total patient number. The diagnosis of hypothalamic dysfunction was considered likely if symptoms from 3 different systems were present, definite if present from four or more,according to our definition in previous well described studies published in abstracts in the Endocrine society  meetings since 2007. Details of physical and laboratory findings are reported separately.

Results: patients demographics:  female were 78(% 65), age (18-86)with the majority between 40-70.Education, occupation, smoking ,caffeine ,ETOH, recreational and prescription drug use  data were tabulated but not presented here for lack of space.

Reasons for referral  were often proven not be present : Thyroid 50 (proven 20:%17),Metabolic including diabetes 30 (proven 30:%25),Adrenal 12 (proven 6: %5),parathyroid 14 (proven 2:%1.6) , others 16 (proven 6:%5). All combined proven reasons for referral were 64/120(%53.3); the rest were hypothalamic.

Frequency of symptoms groups: 1) Energy, fatigue, tiredness 74/120 (% 62); 2) Temperature dysregulation 58/120 (%48); 3) Appetite and weight changes 67/120 (% 59); 4)sleep and diurnal changes 33/120 (% 27.5 );Pain, muscle spasm, fibrositis , fibromyalgia syndromes 69/120 (% 57.5); Mood disorders 87/120(%72.5); Libido and Reproduction 32/120 (%26.6); sympathetic/ parasympathetic symptoms 98/120 (%81.6 ).

 Frequency of Hypothalamic Dysfunction diagnosis: 1) Likely (3 systems) 25/120 (% 21); 2) definite (4 or more systems) 65/120 (%54).

Conclusion: Hypothalamic dysfunction is the most common disease in the endocrine clinic (%54) exceeding other disorders and often associated with them , but often forgotten.

 

Nothing to Disclose: SS

13408 14.0000 MON-0635 A The Most Common Endocrine Disease in the Clinic Is Often Forgotten 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Anika Hoffmann1, Monika Warmuth-Metz2, Ursel Gebhardt3, Torsten Pietsch4, Fabian Pohl5, Rolf-Dieter Kortmann6, Gabriele Calaminus7 and Hermann Lothar Muller*8
1Klinikum Oldenburg AöR, Medical Campus University Oldenburg, Oldenburg, Germany, 2University Hospital Würzburg, Würzburg, Germany, 3Klinikum Oldenburg, Medical Campus University Oldenburg, Oldenburg, Germany, 4University Hospital Bonn, Germany, 5University Hospital Regensburg, Regensburg, Germany, 6University Hospital Leipzig, Germany, 7University Hospital of Münster, Münster, Germany, 8Klinikum Oldenburg, Oldenburg, Germany

 

Background: Despite high survival rates in childhood craniopharyngioma, prognosis is frequently impaired due to sequelae. Radical surgery was the treatment of choice for several decades. However, even at experienced surgical facilities radical surgery can result in hypothalamic disorders such as severe obesity.

Objective: We analyzed, whether treatment strategies for childhood craniopharyngioma patients recruited in German studies (KRANIOPHARYNGEOM 2000/2007) have changed during the last 12 years.

Materials and methods: We compared the grade of pre-surgical hypothalamic involvement, the treatment, degree of resection and grade of surgical hypothalamic lesions between patients recruited in KRANIOPHARYNGEOM 2000 (n=120; 2001-2007) and KRANIOPHARYNGEOM 2007 (n=106; 2007-2012).

Results: The grade of initial hypothalamic involvement was similar in patients treated 2001-2007 and 2007-2012. The intention-to-treat was more radical (p=0.01) in patients recruited 2001-2007 (38%) when compared with patients treated 2007 to 2012 (18%). In patients with pre-surgical involvement of anterior/posterior hypothalamic areas, the rate of hypothalamus-sparing operations resulting in no (further) hypothalamic lesions was higher (p=0.005) in patients treated 2007 to 2012 (35%) in comparison with the 2001-2007 cohort (13%). Event-free-survival rates were similar in both cohorts.

Conclusions: A trend towards less radical surgical approaches is observed, which was accompanied by a reduced rate of severe hypothalamic lesions. Event-free survival was not compromised by this development. Radical surgery is not an appropriate treatment strategy in patients with hypothalamic involvement. Despite previous recommendations to centralize treatment at specialized centers, a trend towards further decentralization was seen. Treatment should be confined to experienced multidisciplinary teams.

 

Nothing to Disclose: AH, MW, UG, TP, FP, RDK, GC, HLM

11752 15.0000 MON-0636 A Childhood Craniopharyngioma – Changes of Treatment Strategies in the Multinational Prospective Trials Kraniopharyngeom 2000 / 2007 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Maria Belen Menucci*1, Dennis Daniel Taub2, John D. Sorkin3, Charles Hesdorffer2, Sherman Mitchell Harman4 and Marc R. Blackman5
1Division of Endocrinology, Department of Medicine, Medstar Washington Hospital Center/Georgetown University Hospital, Washington, DC, 2Center for Translational Hematology and Immunology Studies, Medical Services, Hematology Section, Veterans Affairs Medical Center, Washington, DC., 3Baltimore VA Geriatrics Research, Education and Clinical Center, Baltimore MD; University of Maryland Claude D. Pepper Older Americans Independence Center, Baltimore MD; Univ. of Maryland North Atlantic Nutrition, Obesity, Research Center, Baltimore, MD, 4Kronos Longevity Research Institute, Phoenix, AZ, 5Research Service, Veterans Affairs Medical Center, Washington, DC, Department of Medicine, Georgetown University School of Medicine, Washington, DC, and Department of Medicine, George Washington University School of Medicine, Washington, DC

 

Background: Thymosin β4 (Tβ4) is an actin-sequestering peptide, originally isolated from the thymus and now shown to be ubiquitous, that participates in cell migration and proliferation. Thymulin (Thy) is a nonapeptide exclusively produced by the thymus. Both peptides exhibit anti-inflammatory effects, promote T cell maturation and have been associated with multiple other immunomodulatory actions. They decline with age and are known to cross-communicate with the neuroendocrine system even in early prenatal stages of development. Growth Hormone (GH), through insulin-like growth factor-I, stimulates the production of these peptides, whereas Sex Steroids (SS) have more variable effects.

Objectives: We examined the effects of GH and SS administration on Tβ4 and Thy serum concentrations in 104 older (age 65-88 years, mean=71) men (n=56) and women (n=48) with age-related declines in IGF-I (≤ 230 ng/ml) and SS (men with Serum Total Testosterone < 16.3 nmol/l and postmenopausal women), and a mean BMI at baseline of 26.5 kg/m2.

Methods: Using a double-masked, placebo-controlled, randomized study design, the participants were divided into 8 groups (Men: GH, n=12; SS, n=16; SS+GH, n=14; double placebo, n=14. Women: GH, n=9; SS, n=12; SS+GH, n=14; double placebo, n=13) where GH was human recombinant GH 20 µg/kg SQ three times/week; and SS for men was testosterone enanthate IM 100 mg biweekly, and for women, estradiol patch 100 μg/day plus oral medroxyprogesterone acetate 2.5 mg 10 days/month, all administered for a period of 26 weeks. Serum Tβ4 and Thy concentrations were measured by ELISA at baseline and at week 26.

Results: Serum Tβ4 concentrations increased from baseline to week 26 in all treatment groups, as compared with placebo (p<0.001), both in men and women. A stronger stimulatory effect occurred in the groups that received GH alone (mean increase = 23.57 ng/ml) versus SS alone (12.45 ng/ml), GH+SS (18.78 ng/ml), or placebo (1.4 ng/ml), p<0.001. Compared with men, women had lower serum Thy concentrations and lower Thy responses to GH (p=0.005).  In men, GH alone demonstrated a greater trend towards increasing Thy concentrations (mean increase = 9.8 ng/ml) than did other study interventions (SS alone= -2.35 ng/ml, GH+SS=6.76 ng/ml, placebo=0.31), p=0.068. GH + SS increased Thy concentrations more than did SS alone in both men and women, p<0.05.

Conclusion: Administration of GH to healthy older men and women increases serum concentrations of Tβ4, a peptide known to reduce sterile inflammation and to exhibit putative cardiac healing effects, among other immunomodulatory actions. GH also enhanced serum concentrations of Thy; however, the physiological implications are less clear. SS administration appeared to blunt GH effects on both peptides, in agreement with previous in vitro and in vivo animal studies.

 

Nothing to Disclose: MBM, DDT, JDS, CH, SMH, MRB

14920 16.0000 MON-0637 A Differential Effects of Growth Hormone and Sex Steroid Administration on Serum Concentrations of Thymosin β4 and Thymulin in Healthy Older Men and Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Frank Peter Postma1, Anika Hoffmann2, Ursel Gebhardt3 and Hermann Lothar Muller*1
1Klinikum Oldenburg, Oldenburg, Germany, 2Klinikum Oldenburg AöR, Medical Campus University Oldenburg, Oldenburg, Germany, 3Klinikum Oldenburg, Medical Campus University Oldenburg, Oldenburg, Germany

 

Background: Due to hypothalamic tumour involvement and/or treatment related hypothalamic damage, up to 75% of childhood craniopharyngioma patients (CP) develop hypothalamic obesity.

Methods: In this case-control study, eating behaviour and psychological assessment of weight problems in 102 CP patients, recruited between 1980 and 2001 in the HIT Endo trial, were analysed as well as a gender-, age- and BMI-matched healthy control group (n=61). Assessment of eating behaviour was performed by the “Inventory for Eating Behaviour and Weight Problems (IEG)” questionnaire.

Results: CP patients were divided into a normal weight group (BMI<+3SDS; n=49) and an obese group (BMI>+3SD; n=53). Obese CP showed less pathological eating behaviour for the IEG domains “food intake on special occasions” (p=,008), “eating as a means of coping with emotional stress” (p=,049), “eating style” (p=,000), “pressure to eat during childhood” (p=,007), “bulimia” (p=,024), “feelings of constraint whilst eating out” (p=,001), and “interpersonal seclusion” (p=,006) when compared to 37 BMI-matched obese controls. Only for the domain ‘restrains due to being overweight’ obese CP scored worse then matched overweight controls (p=,001). Obese and normal weight CP answered the IEG quite similar. The comparison of 49 normal weight CP with 24 normal weight matched controls showed similar results except for the domains “eating style” (p=,018), “pressure to eat during childhood” (p=,041) and “perfectionism and achievement of goals (,015), for which CP scored higher e.g. had less pathological findings.

Conclusion: Obese CP patients score better or non-different to obese controls on 22 of 23 IEG domains. We conclude that there is no disease-specific disturbance of eating behaviour in CP. We hypothesize, that severe obesity in CP might be the result of hypothalamic involvement/damage but not of disease-specific alterations in eating behaviour.

 

Nothing to Disclose: FPP, AH, UG, HLM

11750 17.0000 MON-0638 A Eating Behaviour and Weight Problems in Long-Term Survivors of Childhood Craniopharyngioma – Results of the HIT Endo Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Istvan Merchenthaler*1, May E Montasser1, Ayelet Ziv-Gal2, Jessica P Brown1 and Jodi A Flaws2
1University of Maryland Baltimore, Baltimore, MD, 2University of Illinois, Urbana, IL

 

Background: Hot flashes (HFs) are the most common symptoms of the peri-menopause and menopause and  negatively impact the lives of millions of women. Although estrogens efficiently alleviate HFs, studies from the Women’s Health Initiative raised some concerns about the use estrogen therapy. Therefore, there is a recent increase in using alternative therapies, including selective serotonin reuptake inhibitors and/or serotonin-norepinephrine reuptake inhibitors (SSRIs/SNRIs) to relieve HFs, even though they are less efficient than estrogen therapy and the response to them is heterogeneous. We hypothesized that this heterogeneity might be partially due to single nucleotide polymorphisms (SNPs) in the genes encoding the serotonin and/or norepinephrine transporters resulting in alteration in their structure and/or function. As a first step in testing the role of genetic variants in response to SSRIs/SNRIs, we first examined the association between HFs and genetic variants within a norepinephrine transporter gene (SLC6A2) and a serotonin transporter gene (SLC6A4) in European American and African American peri-menopausal women.

Methods: We tested 29 haplotype tag SNPs within SLC6A4 and SLC6A2 for their association with HFs separately in European American (EA; 396 cases, 392 controls) and African American (AA; 125 cases, 81 controls) peri-menopausal women. Case control analysis with 10000 permutations was performed to calculate the empirical p values using an additive genetic model, and logistic regression was used to calculate the odds ratio of the significant SNPs, adjusted for age, smoking status, and BMI.

Results: After adjusting for multiple testing, we found that the minor allele of rs11080121 in SLC6A4 was protective against HFs (OR=0.75, 95%CI=0.61-0.93) only in EA. Bioinformatics analyses indicated that rs11080121 is highly correlated with 21 SNPs including rs1042173 in the 3’UTR of SLC6A4.  The minor allele of rs1042173 seems to disrupt a conserved binding site for hsa-miR-590-3p microRNA.

Discussion: Disrupting a microRNA binding site should lead to higher expression of SLC6A4, which might look like a contradiction since SSRIs/SNRIs work by inhibiting the production of SLC6A4. However, higher SLC6A4 will lead to depleted serotonin from the synaptic cleft, and that will trigger the presynaptic autoreceptor feedback mechanism to produce more serotonin. Therefore, a woman who has a life-time exposure to a variant that increases the production of SLC6A4 will be protected from HF in the adulthood, which is consistent with our results.

Conclusion: This is the first study to test the association between HFs in both EA and AA peri-menopausal women and genetic variants in two neurotransmitter transporter genes: SLC6A2 and SLC6A4. This result may assist in the design of non-hormonal, tailored pharmaceutical treatments, a step forward on the road to personalized clinical medicine.

 

Nothing to Disclose: IM, MEM, AZ, JPB, JAF

12029 18.0000 MON-0639 A A Potentially Functional Variant in the Serotonin Transporter Gene (SLC6A4) Is Associated with Peri-Menopausal Hot Flashes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Margaret Flynn Lippincott*, Yee-Ming Chan and Stephanie Beth Seminara
Massachusetts General Hospital, Boston, MA

 

Introduction: When administered as an IV bolus, kisspeptin-10 can be a potent stimulus for GnRH-induced LH secretion. We previously administered continuous kisspeptin-10 to healthy men resulting in a robust rise in LH, followed by a modest decline in LH from peak values, consistent with stimulation then partial desensitization of the kisspeptin receptor. To explore the impact of sex steroids on kisspeptin responsiveness, continuous kisspeptin-10 was administered to postmenopausal women ± physiologic estradiol replacement.

Methods: Three post-menopausal woman received kisspeptin 12.5 mcg/kg/h IV x 24 h; one woman repeated the protocol on physiologic estradiol replacement. Blood sampling was performed q10-60 min beginning 6 h before the infusion and continuing for 6 h after the infusion was stopped. Mean LH levels during 5 time windows were compared using one-way ANOVA: 1) PRE infusion 2) START infusion (first 3 h), 3) NADIR (lowest 3 h) 4) PEAK (highest 3 h) and 5) END infusion.

Results: PRE infusion, the 3 postmenopausal women (no estradiol replacement) had elevated LH levels (average 12 to 32 mIU/mL), consistent with their hypogonadal state.  In sharp contrast to what had been observed in healthy men, LH did not rise at the start of the kisspeptin infusion in postmenopausal women (Subj. 1: PRE 24±2 - START 21±2, p <0.05; Subj. 2: PRE 32±2 - START 28±3, p <0.05; Subj. 3: PRE 13±1 - START 12±1 mIU/mL, p = NS).  Rather, LH levels fell moderately in each woman, reaching their NADIR values 10-13 hr after the start of the infusion (Subj. 1: PRE 24±2 - NADIR 18±1, p <0.05; Subj. 2: PRE 32±2 - NADIR 20±1, p <0.05; Subj. 3: PRE 13±1 - NADIR 10±1 mIU/mL, p <0.05). Approximately 15hr after the start of the infusion, LH levels began to return to baseline (Subj. 1: PRE 24±2 - END 24±3, p = NS; Subj. 2: PRE 32±2 - END 28±2, <0.05; Subj. 3: PRE 13±1 - END 11±1 mIU/mL, p <0.05). Subject 1 returned on estradiol and, unlike subjects’ 1-3 initial studies, there was a slight, non-significant rise in LH levels then a return to baseline (PRE 16±2 - START 20±1 - NADIR 16±1 mIU/mL, p=NS). Later in the infusion, LH levels climbed (START 20±1 - PEAK 26±3 mIU/mL, p<0.05) and remained significantly elevated (START 20±1 - END 25±2 mIU/mL, p<0.05).

Conclusions: The administration of continuous kisspeptin to postmenopausal women (± physiologic estradiol replacement) does not result in an initial stimulation of LH release as it does in men. Instead, in the postmenopausal women a moderate suppression of LH was seen, suggesting partial desensitization of the kisspeptin receptor. Preliminary data suggests that this suppression is sex-steroid dependent, as it was not seen in one woman after administration of estradiol. Full desensitization of the kisspeptin receptor with kisspeptin-10 may require a higher rate or longer duration of infusion. These data highlight the role of sex steroids, and possibly sex, in shaping hypothalamic kisspeptin signaling.

 

Nothing to Disclose: MFL, YMC, SBS

16345 19.0000 MON-0640 A Responses to Continuous Kisspeptin-10 Infusions: Influences of Sex and Sex Steroids 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Alescia Linda Azzola*1, Kristin K Clemens2, Hala H Mosli3, Alan Dennis4, Walter Kocha5 and Stan Van Uum6
1Schulich School of Medicine and Dentistry, Western University, London, ON, Canada, 2University of Western Ontario, London, ON, Canada, 3King AbdulAziz University, Jeddah, Saudi Arabia, 4London Laboratory Services Group, London, ON, Canada, 5London Health Sciences Centre, London, ON, Canada, 6Department of Medicine, Western University, London, ON, Canada

 

Background: The accurate measurement and interpretation of Chromogranin A (CGA) is of utmost importance for the care of patients with neuroendocrine neoplasms (NEN). Information on the reference ranges of several commercially available CGA assays as well as the effect of collection mediums is limited. The aims of this study were to determine the reference range of CGA across assays, and to compare the serum vs. plasma CGA levels. Moreover, we assessed utility of these assays for NEN patients with both active and inactive disease.

Methods: In a cross-sectional study, we collected serum and plasma samples in 61 healthy subjects and one hundred and sixteen NEN patients, of which 57 had active disease. Patients were recruited from a referral clinic for diagnosis and treatment of NEN. All samples were analyzed in a single laboratory using CGA ELISA assays from CisBio (serum & plasma), Alpco (serum & plasma), Dako (plasma only), RIA from CisBio (plasma only) and a chemiluminescent method from Invitron (plasma only). Reference ranges were determined using a bootstrap non-parametric procedure, and Passing-Bablok non-parametric regression. Paired T tests were used to compare results across assays and plasma vs. serum values. Unpaired T tests were used to compare results across disease states and controls.  Test accuracy was analyzed via ROC curves.

Results:The reference ranges were calculated for CGA values specified by assay and medium. There was considerable variation across assays both for plasma and serum, with serum ranges often significantly lower than plasma. Furthermore, for several assays, reference ranges that we established varied significantly from those provided in package inserts.

Also, CGA levels were significantly higher in NEN patients compared with healthy controls throughout assays (P<0.001). Within NEN patients, CGAs were significantly higher in active disease states than non-active disease states in six of seven assays (P<0.05). ROC curve analysis did not reveal strong cut off points for active disease throughout assays (Sensitivity 41-68%, specificity 50-72%). DAKO was superior when differentiating healthy subjects vs. NEN and active vs. non-active disease (AUC 0.823 & 0.641).  PPI use did not result in a significant CGA variation within NEN patients.

Conclusions: Reference ranges for CGA in healthy subjects may considerably differ from package insert references. Reference ranges need to be established separately for serum and plasma. This information is critical for correct interpretation of CGA results in the care of patients with NEN’s. Furthermore, high levels of CGA are a characteristic feature of patients with NENs and CGA levels vary to some extent with disease activity. However, no strong cut off values for the diagnosis of active disease were identified, suggesting its utility as a prognostic marker within individual patients rather than as a screening tool.

 

Nothing to Disclose: ALA, KKC, HHM, AD, WK, SV

12724 20.0000 MON-0641 A Comparison of Five Methods for Chromogranin Α Measurement in Healthy Subjects and in Patients with Neuroendocrine Neoplasms 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Suhalia Bakerywala*1, Jennifer Poste2 and Harriette Rosen Mogul3
1New York Medical College, Valhalla, NY, 2Westchester Medical Center, Valhalla, NY, 3New York Med Coll, Valhalla, NY

 

Introduction Prader Willi syndrome (PWS) is a complex genetic disorder caused by lack of expression of genes on the paternally inherited portion of chromosome 15q11-q13, characterized by obesity, excessive and unusual eating habits, growth hormone deficiency (GHD), and cognitive impairment.  This can occur through various genetic mechanisms, including 1) deletion of the q11-q13 region on the paternal chromosome (70%); 2) uniparental disomy for chromosome 15 (30%); or 3) imprinting center mutation (1-2 %).1 We present a patient with classic PWS phenotype and multiple genetic defects, none of which had been previously associated with PWS. HPI: The patient presented at age 22 with past history of GHD, obesity, mild mental retardation,  hypogonadotropic hypogonadism, primary hypothyroidism, osteoporosis, and metabolic syndrome. Family history was negative for genetic abnormalities, except for ichthyosis in a brother. He had been followed at an academic center, with thyroid and growth hormone replacement. SNRPN gene expression for PWS, at age 17, was normal excluding most common PWS etiologies: no additional testing. Social history: longstanding hyperphagia. PE: obese white male, BMI 32.6 kg/m2, BP 140/90, ichthyosis trunk, extremities, abdominal striae, small hands. Labs Abnormalities: HDL 30 mg/dl, triglycerides 275mg/dl, FSH 5.5 miu/ml, LH 5.7, testosterone 324ng/dL. Subsequent labs confirmed GHD, normal OGTT, marked hyperinsulinemia. Whole blood whole genome microarray test showed 3 pathologic imbalances, includiing: 1) Interstitial deletion of 1.7Mb at XP22.31 which included 5 genes, including steroid sulfatase gene, known to cause  X-linked ichthyosis  and steroid sulfatase deficiency;2 2) A deletion of 3.0 Mb on chromosome 2q37.3 which includes 37 genes; and 3) A gain of copy of 218kb at chromosome 16p13.3, which includes 11 genes. This suggests an unbalanced translocation between chromosome 2q and 16 p, which is not associated with any phenotype. Conclusion: Advancements in molecular genetics has made it possible to pinpoint specific mutation sequences in various diseases, leading to carrier detection, prenatal diagnosis, and revision of earlier diagnosis. Our case demonstrates the utility of whole genome microarray analysis, a gene expression profile generated by DNA microarray, to detect genomic imbalances and smaller changes than routine karyotypes.  The need for a correct diagnosis is important to address issues of prognostic and genetic counseling.

 

Nothing to Disclose: SB, JP, HRM

16494 21.0000 MON-0642 A Prader Willi Syndrome Revisited: A Case Report of a Phenotype of PWS with Multiple Genetic Defects Detected by Microarray Analysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Natascia Di Iorgi*1, Roberta Biancheri2, Annalisa Calcagno2, Isabella Ceccherini2, Yael Hacohen3, Leslie Jacobson3, Lang Bethan3, Angela Vincent3 and Mohamad Maghnie4
1Istituto G. Gaslini, University of Genova, Genova, Italy, 2Istituto G. Gaslini, Genova, Italy, 3John Radcliffe Hospital, Oxford, United Kingdom, 4Istituto G. Gaslini, University of Genova, Genova, Italy

 

Objectives: To evaluate a possible role of autoimmunity in rapid-onset obesity with hypothalamic dysfunction, hypoventilation and autonomic dysregulation (ROHHAD) syndrome. This disorder affects previously-normal children at 2 to 4 years of age.  In spite of a high suspicion for genetic etiology, disease-associated genetic variations have not been identified as yet. On the other hand, a paraneoplastic/autoimmune etiology has been suggested mainly because of the association with neural crest tumors.

Materials and methods: Six patients with ROHHAD underwent clinical, neurophysiological and neuroradiologic studies; serum antibodies to neuronal antigens (NMDAR, LGI1, CASPR2, dopamine receptor, AMPAR, Ganglionic AChR (autonomic), VGKC and VGCC), often found in association with tumours, were assessed.

Results:  All patients (2M,4F) had normal birth size and no symptoms until 2-4 years, when they developed rapid weight gain (mean BMI Z-score +3.5SDS), hyperprolactinemia, water/salt balance disruption and behavioral problems or EEG alterations (4 patients). Central apnoeas were diagnosed at age 2-6.5 in 4 patients and non-invasive ventilation was started. Central adrenal insufficiency was found in 2 patients. 4 patients had growth hormone deficiency, 2 had central precocious puberty and 5 had central hypothyroidism. Brain MRI was normal or not significant in all patients. A retroperitoneal mass was found in 3 patients. None of their sera were positive for any of the neuronal antibodies tested.

Conclusions:  The possible autoimmune etiology of ROHHAD is based on the frequent association with neural crest tumors, the extensive infiltrates of lymphocytes and histiocytes in the hypothalamus of some patients, and a partial response to intravenous immunoglobulin, rituximab and cyclophosphamide. We investigated the sera for most of the known autoantibodies associated with different forms of immune-mediated encephalitis, but all results were negative.  Additional studies to look for novel autoantibodies are needed.

 

Nothing to Disclose: ND, RB, AC, IC, YH, LJ, LB, AV, MM

13438 22.0000 MON-0643 A Immunological Studies in Rapid-Onset Obesity with Hypothalamic Dysfunction, Hypoventilation, and Autonomic Dysregulation (ROHHAD) Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Suelem Izumi*1, Fernando Flexa Ribeiro-Filho1, Glaucia Carneiro1, Sonia Togeiro2, Sergio Tufik2 and Maria Tereza Zanella1
1Federal Univ of Sao Paulo, Sao Paulo, Brazil, 2Federal Univ of Sao Paulo

 

Previous studies have shown conflicting results concerning the secretory patterns of cortisol and growth hormones in patients with obstructive sleep apnea syndrome (OSAS). To further evaluate the impact of OSAS on hypothalamic-pituitary-adrenal (HPA) and somatotropic axes activities we studied forty-two men who were referred to a sleep clinic for suspected OSAS. They were submitted to polysomnography (PSG) and classified according to their apnea-hypopnea index (AHI) in two groups. Group 1 (G1) included individuals without or mild OSAS, showing AHI < 15 events/h (n=16), while group 2 (G2) included individuals with moderate to severe OSAS (n=26), with AHI ≥ 15. Body mass index (BMI) and glycated hemoglobin (HbA1c) were determined and all subjects underwent an oral glucose tolerance test (OGTT) with HOMA-IR calculation for assessment of insulin resistance. The urinary free cortisol (UFC) 24h was chosen for assessment of the hypothalamic-pituitary-adrenal (HPA) axis and IGF-1 for somatotropic axis.

No differences between groups were found for age (48.3± 7.5 vs 44.1± 7.6 ys; p=0,09), BMI ( 33.2 ± 3.2 vs 32.6 ± 4.6 kg/m²; p=0.625) , waist circumference ( 110.3 ± 8.8 vs 107.5 ± 9.7 cm; p=0.343), fasting glucose ( 5.4 ± 0.7 vs 5.2 ± 0.3 mmol/L ; p=0.341), 2h-glucose ( 6.8 ± 2.4 vs 6.4 ± 1.6 mmol/L; p=0.549), HbA1c ( 5.9 ± 0.4 vs 5.7 ± 0.4 %; p=0.097) and HOMA-IR ( 3.5 ± 1.6 vs 3.2 ± 1.9; p=0.658) were observed.

In G2, the IGF-1 levels were lower (151.9 ± 53.3 vs 206.8 ± 73.5 ng/ml ; p=0.008) and UFC higher (170.2 ± 79.6 vs 122.3 ± 51.4 μ/24 h; p=0.038) compared with G1. UFC was negatively correlated with minimum oxygen (O2) saturation (r=-0.472; p=0.002) and no significant correlations were found with age or BMI. IGF-I levels were negatively correlated with BMI (r=-0.337; p=0.029), AHI (r=-0.330; p=0.033) and O2 desaturation time <90% (r=-0.316, p=0.045) and positively correlated with average O2 saturation (r=0.356; p=0.021) and minimum O2 saturation (r=0.444; p=0.033). Multiple linear regression analysis using IGF-1 as a dependent variable revealed that minimum O2 saturation (r²=0.253; p=0.01) , but not BMI , was independently associated with IGF-1.  Our data support the hypothesis that an hypoxic state induced by OSAS is a stressfull condition that may impair GH/IGF-I axis activity and increase HPA axis activity.

 

Nothing to Disclose: SI, FFR, GC, ST, ST, MTZ

16257 23.0000 MON-0644 A High Urinary Free Cortisol and Low Insulin-like Growth Factor I Levels Are Associated with Sleep Apnea Syndrome in Non- Diabetic Men 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Gustavo Arantes R Maciel*1, Claudia M.A.F. Ferrer2, Jose de Sa1, Milena Gurgel Teles3, Maria Izabel Chiamolera1, Rosa Paula Mello Biscolla4 and Jose Gilberto Vieira5
1Fleury Medicina e Saude, São Paulo, Brazil, 2Grupo Fleury, São Paulo, Brazil, 3Fleury Medicina e Saúde, São Paulo, Brazil, 4Fleury Medicina e Saude, São Paulo, 5Fleury Medicina e Saude, Sao Paulo, Brazil

 

Introduction: Low levels of HCG in non-pregnant women detected by most of HCG assays are source of doubts and clinical questions. It is known that the pituitary gland produces small amounts of HCG in women in post-menopausal years or in menopausal transition. Depending on the sensitivity of the assay, a considerable number of false positive pregnant tests may occur.  Objectives: The aim of this work is to examine two different assays of HCG detection and to evaluate potential effects on clinical decision.  Methods:  A total of 95,210 laboratory samples of HCG from female subjects were analyzed.  Two different assays were used: HCG STAT (cobas e 411) and HCG+β (MODULAR ANALYTICS E170)(both by Roche Diagnostics).  In the HCG STAT, monoclonal antibodies recognize the holo‑hormone. In the HCG+ β assay, specific monoclonal antibodies recognize the holo‑hormone, “nicked” forms of hCG, the β‑core fragment and the free β‑subunit.   Undetectable results (<2 UI/l) were excluded and only those with concomitant FSH were included in the analysis. It was considered as false positive for pregnancy the samples with HCG from 2 to 15 UI/L and FSH > 30 UI/L. Results: Mean age (±SD)  of the subjects was 48 ±9,1.  Nearly 65% of the test were performed using HCG STAT (n=61,322) and 35%, the HCG+β assay (n=33,888).  From the positive tests, 518 had an available FSH assessment.  HCG STAT presented 3.1% of positive test (9/287), whereas HCG+ β showed 9.6% (22/230). Conclusion:  The potential finding of HCG between 2 and 15 UI/L in non-pregnant women is a relatively rare event that can be influenced by the range of molecular detection and the analytical specificity of the assay.

 

Nothing to Disclose: GARM, CMAFF, JDS, MGT, MIC, RPMB, JGV

17054 24.0000 MON-0645 A Low Levels of HCG in Non-Pregnant Women 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Cecilia Albala*1, Barbara Angel2, Lydia Lera2, Hugo Sanchez2 and Carlos Marquez2
1INTA University of Chile, Santiago, Chile, 2INTA, University of Chile

 

Recent studies have shown that obesity, besides it well known association with excess of mortality and chronic diseases, increase the risk of dementia. The relationship between obesity and dementia is complex, considering that both obesity and aging are associated with pathophysiological changes through which it can cause brain damage. They include insulin resistance, glucose intolerance, low-grade inflammation, dyslipidemia and changes in the secretion of adipokines that lead to vascular damage, with consequent deterioration of the cerebral microcirculation and neurodegeneration, mainly through IR and diabetes. Recent studies have involved adipose tissue in this association through the action of adipokines in certain brain regions. To study the contribution of obesity and adipokines for developing dementia we designed a nested case and control study from the follow up of ALEXANDROS cohorts, designed to study disability associated with obesity in Chilean older people. From the oldest cohort (people born before 1940) 886 subjects were free of dementia at baseline. Available participant in 2010 were 554 (70,2% women), 100 were died and 234 were lost to follow up. Obesity at baseline was associated with incidence pof dementia in women but not in men. Among the 554 participants evaluated in 2010, 183 had frozen baseline blood samples available. Among the later, 29 (69% women) incident cases of dementia were identified. We randomly selected 87 controls (67% women) for measuring leptin, soluble leptin receptor (sOB-R) and adiponectin. Free leptin index (FLI) was calculated as the ratio of leptin over sOB-R. Dementia was defined with a test validated for Chile consisting in MMSE score<22 and a score >5 in the Pffefer activities questionnaire. At baseline similar proportion of cases and controls had IMC ≥30Kg/m2 (25% vs 32%, P=0.8). Leptin was similar in cases and controls (15.9 vs 17.1ng/mL respectively, p=0.8); sOB-R was  higher in demented than in non-demented (49.0 vs 38.5 ng/mL, p=0.04) . Similar association was observed for adiponectin (cases 13.5 vs 10.9 ng/mL, p=0.01). FLI was lower in cases (0.41) than controls  0.77), p=0.02 . After logistic regression analysis the sex, age and BMI adjusted RR of having dementia increased with higher log adiponectin (RR=5.00; 95%CI 1.43-17.5, p=0.012) and the lower the log FLI (OR=0.57, 95%CI 0.303-1.057, p=0.07). Our results do not confirm obesity as risk factor for  dementia but show lower availability of free leptin in the cases than in the controls indicating a role of leptin in cognition. In opposition higher adiponectin is a strong independent risk factor for dementia. Further studies are needed to clarify the mechanisms involved.

 

Nothing to Disclose: CA, BA, LL, HS, CM

16541 25.0000 MON-0646 A High Adiponectin and Low Free Leptin Index Are Risk Factors for Dementia in Chilean Older People 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Matthew LaClair*, Jeemin Chang and Agnes Lacreuse
University of Massachusetts, Amherst

 

Aging in men is associated with decreases in both serum and free testosterone (T) and a decline in cognitive abilities. Studies of the effects of exogenous T in men have provided mixed results, with some showing positive effects on cognition, but many others finding no effects.  We sought to clarify the relationship between T, aging and cognition by using the common marmoset (callithrix jacchus), which has been shown to be a useful model of human aging.  Ten castrated male marmosets (ages 3-8) were given weekly injections of either T cypionate dissolved in cottonseed oil (T, n = 5) or cottonseed oil alone (controls, n = 5). The marmosets completed two tasks, the object reversals (OR) and the delayed response (DR) and are currently completing a third task, the delayed Matching-to -Position (DMP). Marmoset behavior was recorded twice daily using a modified frequency scoring system in which the occurrence of 20 target behaviors was measured in 15-s intervals over a 5-min session. In OR, a task of the orbitofrontal cortex/striatum, the monkey had to discriminate between two tokens, one of which was always rewarded.  When the animal had learned to choose the rewarded token on 90% of trials over two test periods, a reversal was introduced, where the monkey learn that the previously unrewarded token now indicated the location of reinforcement. The number of trials and errors to reach the 90% learning criterion was measured. The DR task, which relies on the function of the dorsolateral prefrontal cortex, consisted of the marmoset watching a reward being hidden under one of two identical tokens and remembering its location after a delay of 0, 1, 3, 6 or 10 s randomly presented in one session. We analyzed the percent of correct responses for each delay. For the OR task, no effect of group (F (1,8) = .51, p = .50), reversal (F (3,24) = .527, p = .67), or group x reversal interactions (F (3,24) = .640, p = .60) was found in the number of correct trials.  Although there was a main effect of delay (F (4,32) = 8.779, p < .001) on the DR task, there was no effect of treatment (F (1,8) = .65, p = .81) or an interaction treatment x delay (F (4,32) = .445, p = .76) on the percentage of correct responses.  The data for the DMP are currently being collected.  No significant difference between the groups was found on any of the behaviors measured, however, the T-treated marmosets tended to spend more time eating than the controls (t (8) = 2.239, p = .056). Overall, the lack of effect for T treatment on these cognitive tasks is consistent with previous studies in macaques and men and suggest that T does not facilitate prefrontal cortex-mediated cognition in male marmosets.

 

Nothing to Disclose: ML, JC, AL

17063 26.0000 MON-0647 A Testosterone Treatment Does Not Facilitate Prefrontal Cortex Mediated Cognition in Male Marmosets (callithrix jacchus) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Madhusmita Misra*1, Maria de Lourdes Eguiguren1, Vibha Singhal2, Kathryn E Ackerman1, Hannah Clarke1, Meghan Slattery3 and Kamryn T. Eddy2
1Massachusetts General Hospital and Harvard Medical School, Boston, MA, 2Massachusetts General Hospital/Harvard Medical School, Boston, MA, 3Massachusetts General Hospital, Boston, MA

 

Background: Cognitive eating restraint (CER) is conscious restriction of eating to control weight, while drive for thinness (DT) is an excessive concern or preoccupation with dieting, weight, and fat phobia. Higher CER and DT scores have been associated with low energy states, higher cortisol, and lower bone mineral density (BMD). However, associations with bone microarchitecture parameters have not been assessed in adolescent and young adult female athletes and non-athletes.

Objectives: To compare CER and DT scores in amenorrheic athletes (AA), eumenorrheic athletes (EA) and nonathletes (NA), and determine associations with cortisol levels, BMD and bone microarchitecture parameters.

Methods: We enrolled 139 subjects (74 AA, 35 EA and 30 NA) 14-25 y in this cross-sectional study. Participants completed the Three Factor Eating Questionnaire and the Eating Disorders Inventory-2 for assessment of CER and DT respectively, and were grouped into “low” or “high” CER and DT groups based on median scores. We used DXA to assess body composition and BMD at the spine and hip, and high-resolution peripheral quantitative CT to assess distal radius microarchitecture. We measured integrated cortisol levels overnight (frequent sampling q 20’, 11 PM to 8 AM) and bone formation (P1NP) and resorption (CTX) markers in a subset.

Results: AA had the highest CER (14.2±4.2 vs. 12.4±3.7 in EA and 12.7±3.4 in NA, p=0.04) and DT scores (3.7±5.3 vs. 1.45±2.4 in EA and 2.2±3.9 in NA, p=0.03). Higher CER and DT scores were associated with higher total (r=0.35, p=0.008; r=0.49, p=0.0001) and pulsatile (r=0.38, p=0.004; r=0.50, p=<0.0001) cortisol secretion. CER score was also associated with age (r=0.24, p=0.003) and amenorrhea duration (r=0.25, p=0.004). CER and DT scores were not associated with BMI. Subjects from the high CER group were older and had lower lumbar BMD Z-scores (p=0.05), cortical perimeter (p=0.005), trabecular area (p=0.02), and percent trabecular area (p=0.01), but greater percent cortical area (p=0.009), cortical density (p=0.003), and percent trunk fat (p=0.08).  CER score was negatively associated with P1NP (r=-0.35, p=0.01) and CTX (r=-0.28, p=0.04). After controlling for age, BMI and athletic status, CER score was associated with percent trunk fat (β estimate 0.002, p=0.03), and lumbar BMD Z-scores (β estimate -0.056, p=0.04); however, associations with microarchitecture were lost. When cortisol AUC was added to the multivariate model, associations with percent trunk fat were lost, but those with lumbar BMD Z-scores persisted (β estimate -0.08, p=0.04). DT scores were not associated with BMD or microarchitecture.

Conclusion: AA have increased CER and DT, which are associated positively with integrated measures of cortisol secretion and trunk fat, and inversely with lumbar BMD. Higher cortisol in AA may explain in part the association of higher CER with higher percent trunk fat.

 

Nothing to Disclose: MM, MDLE, VS, KEA, HC, MS, KTE

14817 27.0000 MON-0648 A Increased Cognitive Restraint in Amenorrheic Adolescent and Young Adults Athletes Is Associated with Higher Cortisol Secretion and Trunk Fat and Lower Bone Density 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0622-0648 4823 1:00:00 PM Hypothalamic and Pituitary Masses & Translational Neuroendocrinology Poster

Du Soon Swee*1, Jun Hui Eberta Tan2, Jen Min Ng3 and Tunn Lin Tay3
1Changi General Hospital, Endocrinology, Singapore, Singapore, Singapore, 2Changi General Hosp, Singapore, Singapore, 3Changi General Hospital, Singapore, Singapore

 

Title: Prevalence of hypopituitarism in hospitalized patients with euvolemic hyponatremia    

Introduction:

Hyponatremia is commonly encountered in hospitalized patients and has been associated with adverse clinical outcomes. In euvolemic patients, it is important to exclude hypocortisolism. Hypothalamic-Pituitary-Adrenal axis suppression due to prior exogenous glucocorticoid use is the commonest cause. However, frequency of hypopituitarism is little known.  We aimed to investigate the prevalence of adrenal insufficiency and hypopituitarism in this group of patients.   

Methodology:

This was a retrospective single centre study of all adult patients with hyponatremia who were investigated for hypocortisolism over the period October 2002 to December 2010 inclusive. Hyponatremia was defined as plasma sodium of less than 135 mmol/L. Short synacthen test (SST) using either 1 or 250 micrograms was performed for evaluation of adrenal function. Peak cortisol response of less than 550 nmol/L was considered to be inadequate. 

Results:

Of a total of 1204 subjects, 111 (9.2%) had inadequate response to SST. Of these, Twenty five were found to have hypopituitarism, of which 15 were males, with a median age of 58. Fourteen subjects (56%) had sellar/ parasellar mass.The diagnoses included pituitary macroadenoma, Rathke cleft cyst, cystic pituitary lesion, metastasis, diffuse large B cell lymphoma and granulomatous infiltration. The rest were due to head and neck irradiation (n=8, 32%), empty sella (n=2, 8%) and idiopathic (n=1, 4%).

Conclusion:

In the appropriate clinical context, clinicians need to be alert to hypocortisolism as a potential cause of hyponatremia, which was found to be present in close to one-tenth of patients in this study. Among them, 22.5% (n=25) were subsequently diagnosed with hypopituitarism, of which sellar mass accounts for majority of cases, followed by post radiation therapy effect.

 

Nothing to Disclose: DSS, JHET, JMN, TLT

12564 1.0000 MON-0672 A Prevalence of Hypopituitarism in Hospitalized Patients with Euvolemic Hyponatremia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Viral P Chikani*1, Ross Collin Cuneo1, Ingrid Hickman1 and Ken Ho2
1Princess Alexandra Hospital, Brisbane, QLD, Australia, 2Princess Alexandra Hospital, Brisbane QLD, Australia

 

Background GH improves sprinting in recreational athletes, a performance measure dependent on anaerobic glycolysis (1). This observation suggests that GH regulates anaerobic energy generation in skeletal muscle. The pathophysiological and functional relevance of GH on the anaerobic energy system is unknown.

Aims To (i) investigate whether anaerobic capacity is impaired in adults with GH deficiency (GHD) and (ii) assess the functional significance of anaerobic capacity

Method 12 adults with GHD and 12 age-, gender- and BMI-matched normal subjects were studied. Anaerobic capacity (watts) was assessed by the Wingate test and aerobic capacity by the VO2max (L/min) test. The functional significance was assessed by the stair-climb test, chair-stand test and 7-day pedometry. The mean CVs from 6 subjects were: anaerobic power 3%, VO2max 4%, stair-climb test 4%, chair-stand test 11% and 7-day pedometry 6%. Lean body mass (LBM) and fat mass were quantified by DEXA. Group differences were determined by the t-test and relationships between performance and functional tests analyzed by linear regression.

Results LBM was lower in GHD but the difference was not statistically significant. The mean anaerobic power (250±23.4 vs. 323±14.8 watts, p=0.02) and VO2max (1.6±0.1 vs. 2.1±0.1 L/min, p=0.002) were significantly lower in the GH deficient group. The mean duration for the stair-climb test was longer (18.9±0.6 vs. 16.1±0.6 seconds, p=0.002) in the GH deficient group and correlated negatively (R2= 0.6, p=0.0001) with the anaerobic power. The number of chair-stand repetitions and daily step counts were lower in the GH deficient group (P<0.05). In a multivariate analysis correcting for age and gender, LBM but not GH status was a significant determinant of anaerobic power. Anaerobic power but not VO2max was significantly (p=0.004) associated with stair-climb performance. Neither anaerobic power nor VO2max significantly correlated with chair-stand performance or daily step counts.

Summary Anaerobic power, VO2max and physical function were reduced in GHD. LBM accounted for group difference in anaerobic power which was associated with stair climb performance but not daily walking activity.

Conclusion Anaerobic capacity is impaired in GHD from reduced LBM. Subnormal anaerobic capacity impairs some functional activities of daily living such as climbing stairs.

 

Nothing to Disclose: VPC, RCC, IH, KH

12973 2.0000 MON-0673 A Impairment of Anaerobic Capacity in Adults with Growth Hormone Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Alexander Terence Faje*1, Ryan Sullivan2, Donald Lawrence2, Nicholas A Tritos1, Anne Klibanski1 and Lisa B Nachtigall1
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Massachusetts General Hospital

 

Ipilimumab (ipi) is a monoclonal antibody approved for the treatment of unresectable or metastatic melanoma.  Ongoing studies are evaluating ipi and other new immunotherapeutic agents to treat various malignancies.  Relatively little is known about ipilimumab-induced hypophysitis (IH), an important treatment complication.

Objective: To (1) examine the incidence of IH, (2) characterize the clinical course and treatment outcomes in patients with IH, (3) identify risk factors for the development of IH, and (4) determine optimal strategies for the management of IH.

Design and Methods: 154 patients with metastatic melanoma were evaluated at the Massachusetts General Hospital and treated with ipi between 3/2008 and 12/2013.  The medical records of these patients, including provider encounters, laboratory results, medication records, and radiologic images were analyzed.

Results: IH was diagnosed in 17 patients (11% of the cohort).  Male gender and age were risk factors for the development of IH (IH prevalence in males 15.5% vs 3.6% in females, p=0.02; mean age 68.2 ± 2.4 vs 59.9±1.0 years, p=0.005 in IH vs patients without IH).  The incidence of IH was not related to the cumulative dose of ipi (mean number of ipi cycles 3.06±0.18 vs 3.72±0.23, p=0.27 in IH vs patients without IH).  All patients with IH had anterior hypopituitarism; none had diabetes insipidus.  Most patients (14/17) had multiple pituitary hormone deficiencies.  Diffuse pituitary enlargement was observed in all cases of IH and, upon retrospective review of MRI’s, this finding preceded the diagnosis of hypophysitis in 8 patients.  The degree of pituitary enlargement was mild; optic chiasm compression did not occur in any patient.  Pituitary enlargement was not observed in patients without IH.  The majority of patients (81%) with IH had persistent hypopituitarism.  Recovery of adrenal function was demonstrated in one patient, thyroid recovery occurred in one patient, and gonadal function normalized in two patients.  Radiographic resolution of pituitary enlargement was observed in all patients with IH, and it occurred rapidly (resolution was observed in 7/7 patients within 40 days of the diagnosis of IH).  The median length of survival in patients with IH was 19.4 vs 8.8 months in the remainder of the cohort.  The difference in survival between the two groups was borderline significant (p=0.05).

Conclusions: Patients treated with ipilimumab have a substantial risk of hypophysitis which is higher in men and older patients.  Pituitary enlargement appears to be pathognomonic for ipilimumab-induced hypophysitis, can precede the clinical diagnosis, and resolves rapidly.  Recovery of anterior pituitary function is rare.  The incidence of hypophysitis may be a positive predictor for survival in melanoma patients treated with ipilimumab.

 

Nothing to Disclose: ATF, RS, DL, NAT, AK, LBN

16817 3.0000 MON-0674 A Ipilimumab-Induced Hypophysitis: A Detailed Longitudinal Analysis in a Large Cohort of Patients with Metastatic Melanoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Le Min*1, F. Stephen Hodi2, Rona S. Carroll3 and Ursula B Kaiser3
1Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 2Dana-Farber Cancer Institute, Boston, MA, 3Brigham and Women's Hospital/Harvard Med School, Boston, MA

 

Ipilimumab, a monoclonal antibody against cytotoxic T-lymphocyte-associated antigen 4 (CTLA4), has shown promising therapeutic effects for the treatment of metastatic melanoma and other malignancies. Compared with conventional chemotherapy, the adverse effects are unique. Ipilimumab-related endocrinopathies have been reported in clinical trials and case reports. Hypophysitis is the most common endocrinopathy associated with anti-CTLA4 therapy. The incidence, time of onset after initiation of ipilimumab, and the reversal of the hypophysitis with or without high dose glucocorticoid treatment have not been well defined. We characterized 26 patients with metastatic melanoma who received ipilimumab treatment and developed immunotherapy-related hypophysitis. Hypophysitis was diagnosed by biochemical evidence of anterior pituitary hormone deficiency. Two-thirds of the patients (18/26) who developed ipilimumab-related hypophysitis were male. Fifty-eight percent (15/26) of the patients had MRI evidence of pituitary enlargement. Hyponatremia was identified in 54% (14/26) of patients.  The median time of onset of hypophysitis was 9 weeks after initiation of ipilimumab therapy (range: 5-36 weeks). The rates of remission of pituitary enlargement, secondary adrenal insufficiency, secondary hypothyroidism, male hypogonadotropic hypogonadism (the majority of female patients were menopausal), and hyponatremia were 73%, 0%, 61%, 47%, and 93% respectively. The median times for resolution of pituitary enlargement, secondary hypothyroidism, male hypogonadotropic hypogonadism, and hyponatremia were 16, 11, 27.5, and 3.5 weeks, respectively.   High dose glucocorticoid treatment did not increase the rate of resolution but appeared to shorten the time to resolution in male hypogonadotropic hypogonadism and secondary hypothyroidism. In conclusion, in this large case analysis, we have found that the time to onset is typically several weeks after initiation of therapy. Notably, hyponatremia is common among these patients. Although remission may occur in many of the immunotherapy-associated anterior pituitary hormone deficiency, secondary adrenal insufficiency did not remit in any cases. High dose glucocorticoid treatment did not alter the outcome of ipilimumab–associated hypophysitis.

 

Disclosure: LM: Advisory Group Member, Merck & Co.. FSH: Investigator, Bristol-Myers Squibb. Nothing to Disclose: RSC, UBK

16481 4.0000 MON-0675 A Hypophysitis Associated with Ipilimumab, a Novel Immunotherapy for Metastatic Melanoma: Analysis of 26 Cases 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Jamil bawerjan Alkhaddo*1, Ameer Khowaja2, Asad Saeed3 and Lynn A Burmeister1
1University of Minnesota, Minneapolis, MN, 2Hennepin County Medical Center, Minneapolis, MN, 3Univ of Minnesota, Minneapolis, MN

 

Introducion

Ipilimumab, a monoclonal antibody directed against CTLA-4 receptors, enhances host immune response against tumor cells and has been used to treat metastatic malignant melanoma. Its use has been associated with immune-related adverse events including hypophysitis and other  hormone abnormalities.  The drug package inserts recommends to monitor thyroid function tests before each dose during ipilimumab therapy.  We present a case of a 53 y/o woman treated with Ipilimumab who presented with hyponatremia in association with adrenal insufficiency and hypothyroidism.  The onset of central hypothyroidism correlated with low TSH, but was not diagnosed until hyponatremia presented and low free T4 was measured. 

Case

A 53 year old woman was  diagnosed in 2000 with a melanoma on the plantar foot. CT chest in 2012, incidentally discovered right sided pulmonary nodules, later proven to be metastatic malignant melanoma. She underwent six cycles of interleukin-2 treatment followed by radiation therapy.  Follow up imaging showed disease progression. Therapy was changed to Ipilimumab 3 mg/kg every 3 weeks for a total of 4 cycles.

Less than 7 weeks after the last dose of ipilimumab, she presented with 2-3 weeks of fatigue, dizziness, cold intolerance, dry skin, memory impairment and headaches.  Labs showed hyponatremia (Na 118 mM (133-144), Urine osm 431 mmol/kg, urine Na 87 mM) and other labs were consistent with hypopituitarism: Cortisol 0.7 ug/dL (4-22), free T4 0.45 ng/dL (0.7-1.85), TSH 1.49 mU/L  (0.4-5), IGF1 44 ng/ml (83-242), FSH 5.4 IU/L (23-116) LH 0.7 IU/L (16-54).

Central hypothyroidism and hypoadrenalism due to presumed hypophysitis was treated with  levothyroxine and high doses of methylprednisolone and later prednisone.  Pituitary MRI 3 days after hyponatremia presentation was normal.  Hyponatremia improved with intravenous normal saline infusion and the above therapy. Follow up labs, 2 months later, showed improvement of thyroid function, but not of the pituitary-adrenal function.

Serial TSH measurements during ipilipumab therapy had not resulted in  identification of central hypothyroidism prior to the presentation with hyponatremia: TSH 5.85 (before ipilimumab); TSH on ipilimumab 3.24 (day 1 ), 3.47 (day 22), 5.55 (day 43, with free T4 0.98), 4.01 (day 60).   One week prior to presentation with hyponatremia the TSH was 0.13 mU/L and brain MRI suggested a change in the pituitary gland (now convex upward upper border, identified in retrospect) compared to one year earlier. 

 Conclusion

This case illustrates how even with a high index of suspicion, the diagnosis of hypophysitis with ipilimumab therapy can be missed at earliest presentation, especially if thyroid function testing is incomplete. Free T4 should be added to TSH for hypothyroid screening in patients getting ipilimumab, and more specific guidelines for oncologists should be emphasized.

 

Nothing to Disclose: JBA, AK, AS, LAB

15220 5.0000 MON-0676 A Serial TSH Levels during Treatment and Onset of Ipilimumab-Induced Hypophysitis. Failure of TSH Alone to Make the Diagnosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Kajalben Buddhdev*1 and Bhuvin Mukesh Buddhdev2
1University of Nebraska Medical Center, Omaha, NE, 2Abington Memorial Hospital, Abington, PA

 

Introduction

Ipilimumab is a human monoclonal antibody directed against cytotoxic T-lymphocyte antigen-4 (CTLA-4) recently approved for the treatment of metastatic melanoma; however a host of new side effects related to the mechanism of action of these drugs has appeared. Ipilimumab related adverse reactions are mainly autoimmune and occur in 61% of patients, of which 7.6% involve endocrinopathies like hypo and hyperthyroidism secondary to thyroiditis, primary adrenal insufficiency and isolated hypogonadism. We present an interesting case of Ipilimumab associated hypophysitis, which occurs in about 1.5% patients receiving this medication.

Case report

68 year old Caucasian male presented to the emergency room with weakness, nausea, vomiting, diarrhea and headache since 1 week. His past medical history was significant for Stage IV spindle cell melanoma and hepatitis B. He was enrolled in an ipilimumab study and received 10 mg/kg dose for 3 cycles. Laboratory studies on admission were significant for sodium 124 mmol/L, serum free AM Cortisol 0.25 ug/dL, ACTH 1.0 pg/mL, TSH 0.24 uIU/mL and thyroxine 4.34 ug/dL. Magnetic resonance imaging of brain revealed no evidence of metastatic disease but instead showed enlargement of the pituitary gland of 12 mm in craniocaudal length and thickening of infundibulum with diffuse enhancement consistent with lymphocytic hypophysitis. Ipilimumab was stopped and he was started on tapering doses of prednisone 60 mg daily as well as levothyroxine 75 mcg daily. In contrast to the most patients who usually shows improvement within 1-2 weeks following discontinuation of ipilimumab, his symptoms recurred when steroids were tapered and required him to be on long term replacement therapy.

Discussion

Endocrinologists need to be aware of this new immuno-modulating agent used in cancer treatment as it causes a variety of autoimmune complications which could be life threatening if unrecognized. Pituitary hypophysitis is usually is associated with ipilimumab dose of 10mg/kg and after its third administration. Only MRI can make the diagnosis in some patients without clinical and/or biological signs. Disease is usually reversible after stopping the drug and may require hormonal supplementation.

 

Nothing to Disclose: KB, BMB

16441 6.0000 MON-0677 A A Rare Case of Ipilimumab Induced Pituitary Hypophysitis: An Evolving Clinical Entity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Moebar Mahzari1 and Heather Anne Lochnan*2
1University of Ottawa, 2Ottawa Hospital Research Institute, Ottawa, ON, Canada

 

 Background: Inflammatory hypophysisits is described as predominantly autoimmune mediated with a gender ratio of ~6:1 in women and typically occurring in premenopausal women. Immune checkpoint inhibitors such as ipilimumab, that block CTLA4 and activate the immune system, are now used widely for treatment of metastatic melanoma.  Hypophysitis is a recognized side effect with varied presentation and exceedingly rare in women compared to men. Endocrinologists must be cognizant of the varied presentations of this previously rare disorder and work with their oncology colleagues to ensure rapid diagnosis and treatment.

 Clinical cases: The first patient diagnosed with ipilimumab associated hypophysitis at our centre is a 79 year old male treated for metastatic melanoma who had delayed diagnosis of hypophysitis despite presenting with sodium of 114 that did not resolve over 1 week. Development of headache prompted an MRI which showed pituitary enlargement and hypophysitis was confirmed with very low level of ACTH and cortisol, Prolactin, FSH, LH and testosterone, TSH and free T4. He responded quickly to high dose steroids with resolution of pituitary enlargement within only 24 hours though months later he continues to require glucocorticoid replacement.

Despite the male predominance of ipilumumab associated hypophysitis, one female patient has presented at our centre. Headache was her presenting symptom. Pituitary gland was enlarged on MRI which improved quickly with steroid therapy and withdrawal from ipilimumab.  She also requires continuing glucocorticoid replacement but her thyroid levels have normalized.

Conclusion:  Ipilimumab is associated with many autoimmune adverse effects but the pituitary seems to be the most common for reasons that are not clear. The higher, almost exclusive incidence in males cannot be explained. Local inflammation due to metastases has not been implicated and no putative pituitary antigens have been identified. The persistence of secondary hypoadrenalism could be in part due to the exposure to high dose steroids but is not likely the entire explanation.

Immune check point therapy will likely expand to include treatment of more common cancers which will increase the prevalence of hypophysitis. Markers to identify patients at risk of this life threatening side effect are still to be explored.

 

Nothing to Disclose: MM, HAL

14091 7.0000 MON-0678 A Immune Check Point Inhibitor Therapy and the New Presentation of Hypophysitis: Time to Update the Textbooks 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Bert M. Bieler*1, Alan R. Turtz2 and Farah Hena Morgan3
1Cooper University Hospital, Camden, NJ, 2Cooper University Health Care, Camden, NJ, 3Cooper University Hospital, Cherry Hill, NJ

 

Background: Hypophysitis is a rare inflammatory disorder in which the pituitary becomes infiltrated by lymphocytes and plasma cells with resultant destruction of the parenchyma. Classification of hypophysitis is based on histologic diagnosis. Lymphocytic adenohypophysitis is the most common histopathologic type. It is associated with autoimmune disease and is most frequently seen in the peripartum and postpartum periods.

Clinical Case: We report a case of a 64 year old female, with a past history of hypertension, hyperlipidemia, stroke, and idiopathic recurrent deep venous thrombosis, who presented to the ER with complaints of fatigue, headaches and weakness.  A CT head demonstrated a 1.7 cm pituitary mass and a follow-up MRI demonstrated a pituitary macroadenoma measuring 1.8 cm and abutting the optic chiasm. Endocrine evaluation revealed a cortisol level of 6.1 mcg/dl (5.0-23.0 mcg/dl), FT4 0.56 ng/dl (0.8-1.8ng/dl), TSH 1.16 uIU/ml (0.27-4.20uIU/ml) and prolactin 7.2 ng/ml ( 2-20ng/ml). She was started on physiologic replacement with hydrocortisone (20mg/day in divided doses). Two months later, at presentation for surgery, preoperative MRI revealed resolution of the mass. Cortisol and FT4 normalized (21 mcg/dl and 0.9  ng/dl respectively) and hydrocortisone was discontinued.  Three months after discontinuation of hydrocortisone, the patient again developed weakness, anorexia and visual loss. Visual fields demonstrated bitemporal visual field deficits in the superior quadrants.  MRI showed return of a 1.8 cm pituitary mass, with chiasmal compression, and labs revealed cortisol 0.8 mcg/dl and FT4 0.6 ng/dl. She was treated during admission with 2 days of prednisone 60mg for a presumed diagnosis of hypophysitis and discharged on physiologic hydrocortisone (20mg/day) and levothyroxine. One day after discharge, visual fields were normal. Follow up MRI was normal at 1 month and 3 month intervals. No recurrence has occurred while on hydrocortisone over a 6 month follow up period.

Conclusion: We present a case of hypophysitis with the classic triad of headaches, visual field deficit and anterior pituitary dysfunction with predominant ACTH deficiency. This case demonstrates a rare case of recurrent hypophysitis with exquisite sensitivity to glucocorticoid treatment. Maintaining patients on physiologic hydrocortisone treatment, despite normalization of endogenous cortisol levels during remission, may be important in preventing recurrence of hypophysitis.

 

Nothing to Disclose: BMB, ART, FHM

12944 8.0000 MON-0679 A Hypophysitis - a Case of Exquisite Steroid Sensitivity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Rafael Loch Batista*1, Clarissa Groberio Borba2, Vanielle Carvalho Machado2, Ana Elisa Evangelista Alcantara3, Luciano Silva Ramos4 and Malebranche Cunha Neto2
1Hospital das Clinicas, FMUSP, Brazil, 2Hospital das Clínicas, FMUSP, 3Hospital Das Clinicas FMUSP, Brazil, 4hospital do servidor publico municipal de sao paulo

 

Introdution: IgG4 -Related hypophysitis was first reported in 2004 [1]. Since then 30 cases have been reported in published articles [2]. Almost all cases showed an enlargement of the anterior pituitary gland and/or stalk on magnetic resonance imaging (MRI), presenting various degrees of hypopituitarism and diabetes insipidus [3].

Clinical case: A 40 year-old male patient, with diagnosis of central diabetes insipidus since 2001, using oral desmopressin 0.3 mg/day, complained frontal headache, sexual and libido disturbances. Endocrine assessment in 2003 revealed low levels of testosterone, gonadotropins and IGF-1. The patient was treated with replacement of testosterone decanoate 250mg injections every 21 days and noticed improvement of sexual performance. In 2005 a MRI revealed a pituitary stalk 6mm lesion with focal nodular thickening at lower portion characterized by iso-intensity on T1, hypo-intensity on T2 with a intense heterogeneous enhancement after gadolinium. There was also a presence of heterogeneous materials inside the sphenoidal sinus. On the following MRI no changes were observed. In 2012, due to reports on medical literature about the occurrence of pituitary lymphocytic infiltration in patients with IgG4-related disease, a diagnosis of autoimmune hypophysitis mediated by IgG4 was suspected. Search for autoimmune diseases and tumor markers were negative.In 2013 there was a worsening of gonoadotropins, IGF-1 and total testosterone levels. Laboratory results revealed the following: serum IgG, 1644 mg/dL (reference range 952-1538 mg/dL) and serum IgG4, 2040 mg/dL (reference range 84–888 mg/dL). IgG4 was titled in two different analysis.

Results: The patient’s test results strongly favored a diagnosis of IgG4-related hypophysitis. Discussion about the need of biopsy to confirm the suspicion or a therapeutic approach without surgery should be decided together to the patient.

 

Nothing to Disclose: RLB, CGB, VCM, AEEA, LSR, MC

16152 9.0000 MON-0680 A IgG4-Related Hypophysitis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Hironori Bando*, Genzo Iguchi, Hidenori Fukuoka, Ryusaku Matsumoto, Kentaro Suda, Hitoshi Nishizawa, Michiko Takahashi and Yutaka Takahashi
Kobe University Graduate School of Medicine, Kobe, Japan

 

[Background] Autoimmune hypophysitis (Lymphocytic hypophysitis) is classified into 3 subtypes based on the affected anatomical region: lymphocytic adenohypophysitis (LAH), lymphocytic infundibuloneurohypophysitis (LINH), and lymphocytic panhypophysitis (LPH). Recently, IgG4-related hypophysitis (IgG4-RH) has emerged as a new clinical entity. IgG4-RH is characterized by a onset in middle-aged to elderly and presenting with hypopituitarism(HP)and diabetes insipidus (DI). Previously, we have reported that IgG4-RH was noted in 30% of all hypophysitis (1). In this study, we aimed to outline the clinical characteristics of IgG4-RH in comparison with autoimmune hypophysitis (AH).

[Subjects] We screened 170 consecutive outpatients with HP and DI at Kobe University Hospital according to the criteria of IgG4-RH and AH (1, 2, 3).

[Results] We diagnosed 7 patients with IgG4-RH and 15 patients with AH. AH consists of 5 (33%) LAH, 7 (47%) LINH, and 3 (20%) LPH. In contrast, IgG4-RH consists of 1 (14%) IgG4-R-adenohypophysitis, 2 (28%) IgG4-R-infundibuloneurohypophysitis, and 4 (42%) IgG4-R-panhypophysitis (PH), suggesting an increased prevalence of PH in IgG4-RH. Ages of the onset of LAH, LINH, and LPH were 58.2±14.2, 58.6±12.6, and 50.7±10.7 (year-old, mean±SD), respectively. In contrast, that in IgG4HP was 61.6 ± 8.2, suggesting that the age of onset is higher in IgG4HP. There were no differences in the affected anterior pituitary hormones between IgG4-RH and AH. In AH, no other organ involvement was observed. Interestingly, 4 cases of IgG4RH exhibited other organ involvement such as autoimmune pancreatitis, pseudo-orbital tumor, and Mikulicz’s disease, and all those cases developed DI.

 [Conclusion] Although the number of the patients is limited, these results suggest that age of the onset of IgG4-RH is higher than AH. An increased prevalence of panhypophysitis in IgG4-RH may reflect the non-specific infiltrate of IgG4+ plasma cells. Involvement of other organs warrants a suspicion of IgG4RH.

 

Nothing to Disclose: HB, GI, HF, RM, KS, HN, MT, YT

14333 10.0000 MON-0681 A The Characteristics of IgG4-Related Hypophysitis; A Comparison with Autoimmune Hypophysitis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Nemanja D Stojanovic*1, Kirun Gunganah2, Sanjiv Chawda3, Abhijit Chaudhuri4 and Jonathan Pollock5
1Barking, Havering & Redbridge University Hospitals NHS Trust, United Kingdom, 2Queens Hospital, Romford UK, Essex, United Kingdom, 3Queen's Hospital, London, 4Barking, Havering and Redbridge University Hospitals NHS Trust, London, 5Barking, Havering and Redbridge University Hospitals NHS Trust, Romford, United Kingdom

 

Background:

Tuberculosis (TB) is a rare cause of pituitary pathology nowadays. We present a case of partial anterior pituitary failure due to a likely tuberculous sellar granuloma.

 

Case:

 

A 41-year-old woman previously fit and well, presented with one-month history of headache, confusion, diplopia and pyrexia. She had associated partial right VI nerve palsy. Initial CT head was normal. Subsequent lumbar puncture result was in keeping with TB meningitis.

However, no organisms were isolated on CSF PCR or culture. Primary TB focus was not found. She was empirically treated for bacterial meningitis and quadruple antituberculous therapy and steroids were added. An MRI head with contrast, at the time of diagnosis, showed multiple parenchymal granulomas. A diagnosis of neurotuberculosis was made on clinical, biochemical and radiological findings despite no microbiological confirmation. Steroids were stopped within six months. She improved clinically.

The patient developed amenorrhoea 14 months after onset of illness, and on subsequent MRI scan a suprasellar granuloma was noted. However, this has reduced in size with treatment for multidrug resistant TB. The patient’s LH and FSH remain suppressed but she had normal prolactin, cortisol and thyroid function tests.

Discussion:

This patient presented with a clinical picture of tuberculous meningitis and  hypophysitis. Imaging and CSF findings were in keeping with TB hypophysitis, so the patient was treated empirically with a prolonged course of antibiotics and responded to treatment well.

TB hypophysitis is a difficult diagnosis to make, as both CSF cultures and tissue biopsies may turn out to be inconclusive. 30% of patients will not have a primary focus of infection identified. TB hypophysitis may lead to various degree of pituitary failure.

After differential diagnosis have been ruled out, the course of anti TB treatment should be administered where TB hypophysitis is strongly suspected on clinical grounds, even when histological and microbiological tests are inconclusive.

 

Nothing to Disclose: NDS, KG, SC, AC, JP

16315 11.0000 MON-0682 A Tuberculous Hypophysitis: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Maria Batool*1, Alyssa Larish2 and Sidney A Jones3
1University of Minnesota Medical Center, Minneapolis, MN, 2University of Minnesota Medical Center, 3Ridgeview Medical Center, Chaska, MN

 

INTRODUCTION:

Diabetes insipidus in the postpartum period can be caused by Sheehan's syndrome or lymphocytic hypophysitis and usually occurs in combination with anterior pituitary hormone deficiencies. We present the case of a 24 year old female in whom the diagnosis of diabetes insipidus in the postpartum period led to the discovery of a rare intracranial neoplasm.

CLINICAL CASE:

A 24 year old female was seen in consultation for a twelve month history of polydipsia and polyuria, beginning in the immediate postpartum period. She also had progressive symptoms of visual changes, headache and vertigo. Past history was significant for uncomplicated labor and delivery and six months of successful breastfeeding. The patient endorsed amenorrhea dating back to the placement of a levonorgestrel IUD at the time of breastfeeding cessation. Physical examination was unremarkable for any neurological findings. Laboratory investigation revealed: Serum Osmolality 298 mOsm/kg (275-295); Urine Osmolality 77 mOsm/kg (50-1400);  Sodium 147 mmol/L (136-145);  Prolactin 41.2 ng/mL (3.0-18.6); FSH 3.8 IU/L (1.38-23.40); LH 1.9 IU/L (0.83-96.90); 5 pm cortisol 4.85 mcg/dL (1.7-14.1); TSH 1.25 mIU/L (0.47-4.68); Total T3 98 ng/dL (80-190); Total T4 8.4 mcg/dL (5.0-12.5); and IGF-1 164 ng/mL (84-323).

Brain MRI showed a multicystic, heterogeneously enhancing mass in the corpus callosum extending into the septum pellucidum, hypothalamus, pituitary infundibulum, and the third and fourth ventricles. Lumbar puncture revealed CSF  B-hCG 16 IU/ml (nml 0-3) though it was negative for alpha-feto protein. Serum B-hCG  was negative. A brain biopsy was undertaken with pathology identifying atypical cells with rare placental alkaline phosphatase (PLAP) immunoreactivity, suspicious for a germinoma. The patient began chemotherapy with carboplatin/etoposide for treatment of disseminated germinoma.

CONCLUSION:

Primary cerebral germ cell tumors are a rare cause of diabetes insipidus. These tumors comprise about 1% of all primary brain tumors in adults. 90% of intracranial germ cell tumors occur in patients before the age of 20 years. In females, 75% of germ cell brain tumors are suprasellar. Patients often present with pituitary dysfunction, including diabetes insipidus (3). Localized germinomas are treated with radiation therapy and exhibit a relatively good prognosis. Chemotherapy is reserved for disseminated germinomas.


 

Nothing to Disclose: MB, AL, SAJ

15078 12.0000 MON-0683 A Intracranial Germ Cell Tumor Presenting As Diabetes Insipidus in a Postpartum Female 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Colin P Carracher* and Sona Sharma
University of Cincinnati Academic Health Center, Cincinnati, OH

 

Background:
Hydrocephalus is a known cause of SIADH but a less common cause of Diabetes Insipidus (DI) (1-2). Ventriculostomy of the third ventricle is also a rare cause of DI (3-4).

Clinical Case:
A 46 year old white male with a several month history of worsening Whipple’s encephalitis and obstructive hydrocephalus s/p ventriculoperitoneal shunt was admitted with altered mental status. He received an external ventricular drain (EVD) that required manual drainage. On hospital day #23 he underwent endoscopic 3rdventriculostomy and the EVD was clamped. Within hours he developed DI, with a Serum Na (S. Na) of 149 mmol/L (up from 140 mmol/L five hours prior; normal 135-146), a Urine Output (UOP) ranging from 350-500 cc/hr (up from an average 40 cc/hr right before the ventriculostomy) and a UOsm of 133 mOsm/kg (down from last available reading of 495 mOsm/kg five days prior; normal 50-1200). He was treated with an oral dose of 0.1mg DDAVP and fluids, resulting in a transient improvement in UOP and S. Na.

On hospital day #25 the EVD was removed. His UOP stayed in the range of 150-350 cc/hr. By day #26 his mental status declined. His S. Na reached 178 mmol/L (up from 155 mmol/L one day prior) with a UOsm of 139 mOsm/kg (down from 244 mOsm/kg one day prior). Head CT showed marked interval enlargement of the ventricles so a new EVD was placed resulting in a decrease in ventricular size. A single subcutaneous dose of 2mcg DDAVP along with fluid management lead to improvement in S. Na, UOP and UOsm.

He continued to improve until hospital day #29, when his EVD ceased draining again. The recurrent obstruction in EVD flow was attributed to progressive encephalitis. His S. Na reached 156 mmol/L (up from 149 mmol/L twelve hours prior), UOP was 345 cc/hr (up from 90 cc/hr three hours prior) and UOsm was 224 mOsm/kg (down from 303 mOsm/kg four hours prior).  The EVD was replaced with a drop in UOP to 100 cc/hr and a rise in UOsm to 433 mOsm/kg withoutthe use of DDAVP. Unfortunately, the new EVD also failed and hospice care was initiated.

Conclusion:
This patient’s clinical course suggests a causal relationship between obstructive hydrocephalus and the development of DI. Improvement in UOP and UOsm with attempts to improve CSF drainage further supports this relationship. It also demonstrates the development of DI as a complication of 3rd ventriculostomy. Understanding the relationship between third ventricular disorders and hypothalamic-pituitary function is clinically relevant and directly applicable.

 

Nothing to Disclose: CPC, SS

16791 13.0000 MON-0684 A Central Diabetes Insipidus Secondary to Obstructive Hydrocephalus and Ventriculostomy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Nicole Nigro*1, Bettina Winzeler1, Isabelle Suter-Widmer1, Philipp Schuetz2, Birsen Arici1, Martina Bally2, Claudine Angela Blum1, Christian Nickel1, Roland Bingisser1, Andreas Bock3, Andreas Huber2, Beat Mueller2 and Mirjam Christ-Crain1
1University Hospital Basel, Basel, Switzerland, 2Kantonsspital Aarau, Aarau, Switzerland, 3Kantonsspital Aarau, Aarau

 

Background: Hyponatremia is common in hospitalized patients and its differential diagnosis and therapy is challenging. An important mechanism leading to hyponatremia is suppressed or adequately or inadequately secreted plasma arginine vasopressin (AVP). Therefore, AVP levels may help in the differential diagnosis and in therapy management. Copeptin is secreted in an equimolar ratio to AVP and is easier and more reliable to measure.

Design and Setting: Prospective multicentre observational study in two tertiary referral centers in Switzerland.

Methods: 298 consecutive patients admitted to the emergency department with severe hypoosmolar hyponatremia (Na<125mmol/L) were included. After a standardized diagnostic evaluation, patients were treated according to a diagnostic algorithm with fluid restriction or physiologic saline administration, respectively. Copeptin levels were compared between different aetiologies of hyponatremia and for prediction of therapeutic management.

Results: We found 24 patients (8%) with primary polydipsia, 72 patients (24%) had diuretic induced hyponatremia, 106 (36%) patients SIAD, 4 (1%) patients cortisol deficiency, 33 patients (11%) hypervolemic hyponatremia and 59 patients (20%) hypovolemic hyponatremia. Overall Copeptin levels discriminated between various aetiologies of severe hyponatremia (p <0.0001). Copeptin levels were higher in patients requiring saline infusion (n=139) as compared to patients requiring fluid restriction (n=159) (21.40 [8.00-65.60 pmol/L] vs. 12.16 [IQR 5.13-28.15] pmol/L, p=0.0003). A copeptin level >56.8 pmol/L allowed a diagnosis of hypovolemic or diuretic induced hypovolemia requiring saline infusion with a specificity of 86%. Conversely, a copeptin level <4.4pmol/L identified patients with need of fluid restriction with a specificity of 91%. In multivariate analysis copeptin, fractional uric acid excretion (FEuric acid) and volume status were independently associated with therapy management. The combination of these three factors showed a high prognostic accuracy for therapy management (area under the combined receiver operating characteristics curve: 0.77 (95% 0.71-0.83).  

Conclusion: Copeptin levels identify a subset of patients with a need of saline infusion or fluid restriction and may be a helpful new tool for therapeutic management in about one third (n=74) of patients. The best prediction of therapeutic management is achieved when combining copeptin, volume status and FEuric acid. Copeptin measurement in patients with severe hyponatremia may therefore allow early treatment decisions.

 

Disclosure: PS: Speaker, Thermo Fisher AG. BM: Speaker, Thermo Fisher AG. MC: Speaker, Thermo Fisher AG. Nothing to Disclose: NN, BW, IS, BA, MB, CAB, CN, RB, AB, AH

PP35-1 12971 14.0000 MON-0685 A Copeptin for the Differential Diagnosis and Therapy Management of Hyponatremia in Hospitalized Patients ''the Co-MED-Study'' 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Bettina Winzeler*1, Nicole Nigro1, Christian Zweifel2, Birsen Arici1, Martina Bally3, Philipp Schuetz3, Claudine Angela Blum1, Christopher Kelly1, Luigi Mariani1, Hans Landolt3, Andreas Huber3, Beat Mueller3 and Mirjam Christ-Crain1
1University Hospital Basel, Basel, Switzerland, 2University Hospital of Basel, Basel, Switzerland, 3Kantonsspital Aarau, Aarau, Switzerland

 

Introduction:

Postoperative diabetes insipidus (DI) remains a common complication after pituitary surgery. AVP measurement might contribute to a straightforward diagnosis, though, its measurement is cumbersome. Copeptin, the stable C-terminal glycopeptide of the AVP prohormone, is a reliable surrogate of AVP.

We aimed to elucidate whether copeptin is a helpful marker in the diagnostic approach of postoperative DI.

Design and Setting:

Prospective observational study in three tertiary referral centres in Switzerland and Canada.

Material and Methods:

Patients undergoing pituitary surgery were daily monitored for clinical items (i.e. balance of fluids) and routine laboratory parameters. Copeptin levels were measured pre- and daily postoperatively until discharge. We also recorded tumour specific features and intraoperative manipulation of the neurohypophysis.

Results:

Of the 205 patients included (mean age 53 years, 55.6% female) 50 (24.4%) developed postoperative DI, 155 patients had an uneventful postoperative course or developed SIADH (5,4%). 

Overall, the median copeptin levels measured preoperatively were 3.6 pM (IQR 2.4, 5.7) and increased more than two-fold to 8.4 pM (IQR 3.9, 22.6) after surgery. Copeptin levels of patients developing DI did not increase during surgery-induced stress and were lower postoperatively compared to patients without DI (median (IQR) 2.9 pM (1.9, 7.9) vs 10.8 pM (5.2, 30.4), p<0.001). This was most pronounced in a subset of 157 patients with early (< 12 hours) postoperative copeptin measurement  (median (IQR) 2.9 pM (1.8, 10.3) vs 17.0 pM (7.6, 39.1), p<0.001).

In patients with postoperative copeptin values <2.5 pM the positive predictive value for development of DI was 81%  (specificity 97%). Conversely, if copeptin increased to levels >20 pM or >30 pM, negative predictive values and sensitivities were 93%/95% and 95%/98%.

Conclusion:

Low postoperative copeptin levels despite surgery-induced stress indicate later DI. Copeptin may become a novel tool in the management of patients after pituitary surgery.

 

Disclosure: PS: Speaker, Thermo Fisher Scientific BRAHMS GmbH. BM: Speaker, Thermo Fisher AG. MC: Speaker, Thermo Fisher AG. Nothing to Disclose: BW, NN, CZ, BA, MB, CAB, CK, LM, HL, AH

16610 15.0000 MON-0686 A Copeptin Levels Measured after Pituitary Surgery Predict Later Development of Diabetes Insipidus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Pranav Ghody*1, Ronak S Chaudhari2, Patricia Park3 and Elizabeth Sedlis-Singer4
1SUNY Downstate Medical Center, Brooklyn, NY, 2SUNY Downstate Med Ctr, Brooklyn, NY, 3Maimonides Medical Center, Brooklyn, NY, 4Maimonides Medical Center

 

Introduction:

Coincident development of Diabetes Mellitus (DM) and Diabetes Insipidus (DI) in adults has rarely been reported.

Clinical case:

A 54 year old obese white male with no known past medical history was admitted to the hospital with 2 day history of slurred speech, weakness and 1 week history of polyuria. At the time of presentation, he was found to be in Hyperosmolar Hyperglycemic state [Blood Glucose 792 mg/dl, Anion Gap 23, HCO3: 20mEq/L , ABG pH:7.35, Serum Osmolality: 395mOsm/kg, Serum Sodium: 149 mEq/L]  which was treated with insulin infusion and iv fluids and transitioned in 10 hours to subq basal-bolus insulin regimen. 

However, his polyuria [urine output 4-5 L/day] persisted and serum sodium (Na+) rose to 152mEq/L over the next 3 days despite aggressive free water replacement and adequate control of DM. In view of polyuria and Hypernatremia, a diagnosis of DI was considered. This was supported by the finding of hypo-osmolar urine [Urine Osmolality: 214mOsm/kg] with hyperosmolar serum [Serum Osmolality: 321mOsm/kg].  Thyroid function and serum cortisol were normal.  He was given a dose of Desmopressin acetate 1 microgram nasal spray with decrease in urine output and 300% increase in Urine Osmolality [from 214 to 671 mOsm/kg] over the next 8 hours. He was diagnosed with Central Diabetes Insipidus (CDI) and Desmopressin was continued with normalization of the serum Na: 138 mEq/L and Serum Osmolality: 295 mOsm/kg. Imaging of the brain did not show pituitary stalk thickening or absence of bright spot. Pt was discharged on Desmopressin, Insulin and Sitagliptin-Metformin. On a follow up outpatient visit, his DDAVP dose was titrated down and DM remained well controlled.

Discussion:

Co-existence of DM and DI has been reported in pediatric population as a genetic disorder known as Wolfram syndrome characterized by DIDMOAD [Diabetes Insipidus; Diabetes Mellitus; Optic Atrophy and Deafness].  In the adult population, combination of DM and Lithium associated Nephrogenic DI has been reported more frequently(1). But less than 10 cases have been reported worldwide to have co-existent DM and CDI,all of who had been diagnosed with DM for 2-15 years before developing CDI.  An exception was the 1st case reported with simultaneous development of DM and CDI(2).  The simultaneous occurrence of these 2 diseases may have an underlying common mechanism similar to the one reported in patients with Wolfram syndrome which warrants investigation.

Conclusion:

This is only the second reported case of a patient with coincident DM and CDI in adults.

 

Nothing to Disclose: PG, RSC, PP, ES

16496 16.0000 MON-0687 A Polyuria- Diabetes Mellitus or Diabetes Insipidus or Both 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Pranav Ghody*1 and Jocelyne Georges Karam2
1SUNY Downstate Medical Center, Brooklyn, NY, 2Maimonides Medical Center, Brooklyn, NY

 

Introduction:

We describe for the first time a case of Syndrome of Inappropriate Secretion of ADH (SIADH) in the prodromic phase of Herpes Zoster Infection.

 

Clinical Case:

 81 year old female with a medical history of coronary artery disease, scleroderma, thyroid cancer in remission and Diabetes was noted to have hyponatremia (Serum sodium: 128 mEq/L) on routine office follow-up labs. On further history, the patient reported recurrent lower abdominal pain over the previous few weeks, associated with nausea and not related to meals. Patient was admitted to the hospital and was noted to have normal vitals, mild lower quadrant abdominal tenderness and a normal skin examination. Patient was clinically in a euvolemic status. Laboratory results confirmed hyponatremia (Na+ down to 123 mEq/L) with a normal renal function (BUN: 18 mg/dl; Creatinine: 0.8 mg/dl), normal morning Cortisol (16.9 ug/dl), and normal thyroid function (TSH: 1.59 mIU/L; free T4: 0.92 ng/dl). SIADH was thought to be causing the hyponatremia, given the coexistence of hypoosmolar serum (Serum Osmolality: 268 mOsm/kg) with an inappropriately high urine osmolality (525 mOsm/kg), high urine Na level (40 mEq/L), low plasma uric acid: (3.1 mg/dl), and the absence of other clear etiologies of hyponatremia.  She was placed on 1200 ml fluid restriction with minimal improvement of hyponatremia. On Day 3 of hospitalization, she was noted to have a new vesicular rash on the groin consistent with Herpes Zoster (HZ) infection of T12-L1 dermatome. Interestingly, her hyponatremia improved on Day 4 with a Na plasma level of 132mEq/L .The serum sodium levels returned to normal (136mEq/L) on repeat labs done at 10 days post discharge.

Discussion:

The association with localized HZ has been rarely documented, with most case reports involving HZ Opthalmicus. The postulated mechanism has been a possible involvement of Varicella Zoster virus infection in the regulatory pathway of ADH secretion(1). The patient that we have described is among the very few reported cases of non ophthalmic HZ association with SIADH and the first case involving T12-L1 dermatomes. Unlike all the other reports, our patient was diagnosed with SIADH in the prodromic phase, three days prior to the visible rash eruption, compared to several days after the rash in other reported cases(1,2). Hence, it is important for providers to be aware of this association, although rare, when evaluating a patient with hyponatremia, especially in context of an acute neuritis that could confuse the initial clinical picture.  Furthermore, the diagnosis of hyponatremia in our patient was incidental on routine outpatient testing, raising the possibility of underestimation of such an association in patients who present with HZ infection and whose clinical course could be affected by this electrolyte abnormality.

 Conclusion:

New onset hyponatremia secondary to SIADH might be a prodromic feature of HZ infection.

 

 

Nothing to Disclose: PG, JGK

16435 17.0000 MON-0688 A Syndrome of Inappropriate Secretion of Anti Diuretic Hormone and Localized Abdominal Herpes Zoster Infection 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Leslie Anne Eiland*1, Andjela T Drincic1, Whitney S Goldner1, Jay Rajni Patel2 and Chhaya Makhija1
1University of Nebraska Medical Center, Omaha, NE, 2Sentara, Virginia Beach, VA

 

Background: Central Diabetes Insipidus (CDI) has been reported in association with acute myelogenous leukemia (AML).   Resolution of DI has been reported in 36-40% of patients with AML and CDI, however, it is unclear if resolution is as a result of specific treatment modalities or remission of the AML itself.    We present two patients with CDI associated with AML who experienced resolution of CDI after individualized therapy of different types of AML.

Case 1: A 33 year old male who presented with a one month history of polyuria and polydipsia was diagnosed with AML when he was evaluated for fever.  A water deprivation test confirmed CDI (serum sodium 147 mmol/L (136-145 mmol/L), serum osmolality of 303 mmol/L (275-295 mmol/L), urine osmolality of 178 mOsm/Kg (50-1000 mOsm/Kg)) and oral desmopressin (DES) was initiated.  Pituitary magnetic resonance imaging (MRI) showed a normal pituitary gland but thickened pituitary stalk at 3.2 mm. Bone marrow biopsy revealed hypercellular bone marrow (>95%) with AML with t(3;3)(q21;q26.2) abnormalities. Cytogenetic analysis demonstrated the presence of monosomy 7 (AML-M7).  He was treated with cytarabine and idarubicin.  His AML and CDI persisted requiring treatment with DES.  An allogenic hemotopoietic stem cell (HSC) transplant was performed 3 months later with immunosuppressant therapy fludarabine, busulfan, and anti – thymocyte globulin.  His CDI resolved 45 days after HSC transplant.  10 months after transplant, there has been no recurrence of CDI and no evidence of AML relapse.  A repeat pituitary MRI showed a decrease in stalk thickness, now measuring 2.7 mm in size.

 Case 2: A 52 year old female was diagnosed with AML (AML-M2) and CDI (serum sodium 171 mmol/L, serum osmolality 325 mmol/L, urine osmolality 228 mOsm/Kg) when she was admitted with sagittal sinus thrombosis requiring embolectomy and thrombolysis.  MRI identified a hemorrhage in the left frontoparietal region but a normal pituitary.  Bone marrow biopsy revealed findings consistent with persistent AML.  She was treated with decitabine and DES and her CDI resolved 2 weeks after starting therapy with decitabine.  After 8 cycles of decitabine, there has been no recurrence of CDI. 

Conclusion: Concurrent CDI and AML have been reported, and resolution of CDI can occur in a minority of patients.  However, mechanisms for resolution of CDI are unclear.  Based on the MRI changes in the first patient, it is possible that treating the AML results in decreased leukemic infiltration of the pituitary stalk, decreased stalk thickness and resolution of the CDI.  We present two different cases of CDI associated with different types of AML (AML-M7 and AML-M2) and resolution from different modalities:  HSC transplant and decitabine chemotherapy, respectively.  This supports treatment of AML as the mechanism for resolution of CDI, rather than a result of a specific treatment modality.

 

Nothing to Disclose: LAE, ATD, WSG, JRP, CM

11099 18.0000 MON-0689 A Two Cases of Resolution of Acute Myelogenous Leukemia Associated Central Diabetes Insipidus after Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Pui Lin Chong*, Malik Humayun, Partha Kar, Michael Cummings, Darryl Meeking and Iain Cranston
Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom

 

Background:

We previously published data for short term outcomes in patients with SIADH related hyponatraemia unresponsive to fluid restriction and treated with Tolvaptan. In light of concerns over longer term side effects we have revisited the topic and extended both group size and follow-up period to determine longer term safety and treatment implications.

Aims/Methods:

We report ongoing treatment outcomes (case-note review) of 25 patients (age 71±5 years, 60% females) consecutively treated with Tolvaptan as an inpatient for confirmed SIADH with persistent hyponatraemia (Na <125mmol/L) despite removal of reversible causes and 48hr fluid restriction, and include longer term outcome data (re-treatment/readmission/mortality) for 2 years follow-up.

Results:

Concordance with locally agreed criteria for Tolvaptan use remains high; short term outcomes remain good; 92% achieve target of treatment (Na >125mmol/L with clinical improvement) after a mean of 3.4±2.6 days treatment; and 8% with partial response (rise in Na>5mmol/L but not achieving 125mmol/L with initial therapy). No patient experience a Na rise greater than 12mEq/24hr, hypernatraemia, drug-associated liver injury or CNS myelinosis.

Longer term outcomes were less good, mortality rates in this population was 40% within 3 months and 56% over the follow-up period. Underlying causes of SIADH were found to be malignancy related in 60% (of whom 90% were undiagnosed at presentation). Mortality in those with malignancy was 46% at 3 months and 75% over the follow-up period. 24% of patients required re-treatment for recurrent hyponatraemia after Tolvaptan discontinuation (100% of whom has relapsed within a week and had underlying malignancy).

Conclusions:

Tolvaptan use remains safe and effective as an inpatient short term therapy option in the group we have identified and our data merit investigation for its wider use. Na level one week after discontinuation is a good indicator of re-treatment/longer term therapy needs, nearly all of whom have malignancy. Thus, the criteria we have set locally to indicate Tolvaptan use also identifies a group who should receive urgent investigation for underlying malignancy.

 

Nothing to Disclose: PLC, MH, PK, MC, DM, IC

16147 19.0000 MON-0690 A Long Term Follow up of Patients with Resistant Hyponatraemia Treated with Tolvaptan 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Juan Pablo Perdomo Rodriguez, Juan Pablo Perdomo Rodriguez* and Cara Ruggeri
St Luke's University Hospital, Bethlehem, PA

 

Introduction:

We present a challenging case of concomitant Nephrogenic Diabetes Insipidus (NDI) and Psychogenic Polydipsia.

Clinical case:

A 42 year-old male, with bipolar disorder, was found unresponsive at home. Lithium and carbamazepine levels, drawn at admission were within normal therapeutic ranges as was his serum sodium at 140 mmol/L. He was noted to be oliguric and in acute kidney failure and admitted to the ICU. Lithium was discontinued. Due to his persistent encephalopathy, an EEG was performed but despite being inconclusive, anti-seizure prophylaxis with levetiracetam was initiated. Eventually, kidney function returned to normal with IV hydration. On hospital day 4, the patient began to develop polyuria. His urine output reached a maximum of 22.6 L/day and his sodium peaked at 170 mmol/L. Serum and urine osmolality were 353 and 267 mmol/kg respectively. Urine sodium was 24 mmol/L. Serum sodium levels and urine output did not change after the administration of desmopressin. Serum sodium normalized on a treatment regimen of amiloride, ibuprofen and hydrochlorothiazide. On hospital day 9, BMP showed a trend towards hyponatremia (lowest sodium 127 mmol/L) and refractory hypokalemia (2.5-3 mmol/L). The patient demonstrated excessive thirst and polyuria despite intakes and outputs which approximated each other. Discontinuation of hydrochlorothiazide, carbamazepine, fluid restriction to 2 L/day and salt tablets were necessary to normalize sodium levels. All water supplies to his room were shut off including the toilet.

Water reabsorption and urine-concentrating ability is a complex phenomenon. A hypertonic medulla is generated by active NaCl reabsorption from the thick ascending loop of Henle and dilute tubular fluid is delivered to the distal nephron where water is reabsorbed through aquaporins, a process facilitated by vasopressin and inhibited by lithium. Protein malnutrition, hypercalcemia and hypokalemia also cause NDI. NDI is diagnosed in the setting of hypo-osmolar urine relative to serum osmolality that does not improve after water deprivation testing and desmopressin. The mainstay of therapy of NDI is adequate hydration to prevent hypernatremia. Alternatively, psychogenic polydipsia can lead to severe hyponatremia due to water intoxication. Psychogenic polydipsia ranges between 6-17% amongst psychiatric patients and causes hyponatremia in up to 36% of the cases. 18% of deaths in schizophrenic patients, under the age of 53, may be related to water intoxication.

Conclusion:

Diabetes insipidus and psychogenic polydipsia should be suspected in the setting of polyuria. Our case represents two conflicting diagnoses that pose a unique challenge to the clinician and nursing staff. Concomitant psychogenic polydipsia and nephrogenic diabetes insipidus can produce rapid pertubations in sodium levels which can precipitate seizures and even death.

 

Nothing to Disclose: JPP, JPP, CR

16497 20.0000 MON-0691 A To Drink or NOT to Drink: That Is the Question 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Mauro Antonio Czepielewski*1, Themis Zelmanovitz2, Nelson Pires Ferreira3, Eduardo Yunes Filho4 and Rafael Machry5
1Faculdade de Medicina UFRGS, Porto Alegre, Brazil, 2Hospital de Clinicas POA, Porto Alegre, Brazil, 3Irmandade da Santa Casa de Misericórdia, Porto Alegre, Porto Alegre, Brazil, 4Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil, 5Hospital de Clínicas de Porto Alegre, UFRGS, Porto Alegre, Brazil

 

Background: Primary intracranial GCT is a rare central nervous system tumor (<2% brain tumors), that typically arises in midline structures (pineal and neurohypophyseal region) of adolescents or young adults. These tumors are highly radiosensitive and have an excellent prognosis with overall survival of 90% at 10 years. Here we present a case of young man with diabetes insipidus (DI) and hypopituitarism associated to suprasellar tumor treated only by radiotherapy (RT).

Case report: A 18-year-old male patient presented polyuria, polydipsia and fatigue associated with pulsatile headache without visual disturbance. Physical and neurological examination revealed no abnormality, except the testes (12 cm³). The bone age was in the chronological age. Biochemical evaluation was normal except hypernatremia (Na=148 mEq/L;NR:136-145). Hormonal evaluation showed hypogonadotropic hypogonadism (LH < 0.1 mIU/mL, NR1,5-9,3; FSH 0.36 mIU/mL, NR:1,4-18,1; total testosterone 0.13 ng/mL, NR:2,41-8,27), hyperprolactinemia (81.6 ng/mL N:2,1-17,7), low IGF-1 (90 ng/mL NR:197-956). Cortisol and free thyroxine was normal. Central DI was diagnosed based on clinical presentation and response to desmopressin. Magnetic resonance imaging (MRI) showed diffuse thickening of the pituitary stalk (4 mm) and a lesion of 1.2x1.2 cm involving the infundibulum, mammillary bodies, hypothalamus and third ventricle floor with isosignal in T1 and isosignal to the cerebral cortex in T2. Additional biochemical evaluation showed normal serum calcium, phosphorus and hypercalciuria (403 mg/24h;6,2 mg/kg/24h), and undetectable PTH (<2.5 pg/mL). Granulomatous disease was suggest, but the serum 1,25-dihydroxycholecalciferol was normal (29 pg/ml;NR=18-78) and 25-hydroxycholecalciferol was 20.4 ng/mL (NR>30 ng/mL). Spinal angiotensin-converting enzyme (ACE) and PPD test excluded sarcoidosis and tuberculosis. Skeletal X-rays and cintigraphy rule out histiocytosis. Additional exams was normal (chest and abdomen CT, Galium Cintigraphy, rheumatologic and infections serology proofs). Serum and spinal cerebral fluid (CSF) tumor markers (alpha-fetoprotein and β-HCG) were negative. Excluded other causes, the MRI images was suggestive of GCT.  So, due to the difficulty to access and, in generally, the excellent response to RT, we decided to do a initial dose of 20 Gy in fractionated ten sections and repeat the images. The posterior MRI showed significative reduction of the mass. Then, we completed the treatment with 30 Gy in fractionated fifteen sections in Linear Accelerator (total dose 50 Gy).

Conclusion: we describe a patient with DI and hypopituitarism associated a pituitary-hypothalamic lesion suggestive of GCT, with extense negative investigation, who was treated only by RT and excellent evolution.  This approach should be recommended in similar cases avoiding hazardous surgical procedures.

 

Nothing to Disclose: MAC, TZ, NPF, EY, RM

14230 21.0000 MON-0692 A Diabetes Insipidus and Hypopituitarism Associated with Suprasellar Tumor: Dramatic Response to Radiotherapy Suggest Germ Cells Tumor (GCT) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Isao Kurihara*, Kazutoshi Miyashita, Sakiko Kobayashi, Kenichi Yokota, Ayano Murai-Takeda, Yuko Mitsuishi, Toshifumi Nakamura, Mitsuha Morisaki, Hirobumi Tokuyama and Hiroshi Itoh
School of Medicine, Keio University, Tokyo, Japan

 

Case presentation: A case is 55-year-old male. At the age of 48-year-old, he was attacked by acute subarachnoid hemorrhage and treated with clipping surgery on anterior communicating (acom) aneurysm. Serum Na level was gradually increasing and reached 166 mEq/L on postoperative day 4. Fluid therapy reversed electrolyte balance to normal range and etiological assessment was not performed at that time. 5 years later he visited psychiatrist for short memory disorder and personality change. Laboratory data indicated severe hypernatremia (Na 168 mEq/L) and renal dysfunction (Cr 2.20 mg/dL). He had ulcerative lesion on his foot, which was proved as gout by identifying uric acid crystals. Plasma antidiuretic hormone (ADH) level was 1.6 pg/ml, which was very low and unmatched with high plasma osmolarity (327 mOsm/L). Urine volume was 1000mL/day because he was lacking in sense of thirst. We diagnosed this case as “adipsic diabetes incipidus (DI)” and started treatment with desmopressin. Adipsic DI has been reported as associated with acom aneurysm surgery and usually well-responsive to demopressin treatment. This case, however, resulted in sustained hypernatremia even though we were titrating up dose of demopressin. We suspected it was combined with nephrogenic DI and performed kidney biopsy to examine if tubulointerstitial lesions were observed. Most glomeruli were grossly normal and active inflammation was not shown in tubulointerstitial areas.

Discussion: The present case showed severe hypernatremia, which was due to adipsic DI. Although hypernatremia in adipsic DI is easily alleviated by desmopressin treatment, we failed to normalize serum Na level by administration of desmopressin. Urea transporter expression is known to be important to give gradient of osmolarity in renal medulla and help ADH concentrating urine. It’s been also reported that ADH is required to keep urea transporter expression. We speculated chronic ADH deficiency secondarily induced downregulation of urea transporter expression in renal medulla and impaired response to ADH, leading to hypernatremia refractory to desmopressin treatment. We started long-term treatment of desmopressin to verify our hypothesis.

 

Nothing to Disclose: IK, KM, SK, KY, AM, YM, TN, MM, HT, HI

16139 22.0000 MON-0693 A A Case of Adipsic Dabetes Incipidus with Impaired Response to Desmopressin Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Elie Klam*, Creighton Mitchell and Amnon Schlegel
University of Utah, Salt Lake City, UT

 

INTROCUCTION:

Pituitary adenomas are uncommon causes of the Syndrome of Inappropriate Antidiuresis (SIAD). We here report a case of prolactinoma- induced SIAD in which Cabergoline was shown to be effective in restoring water metabolism.

CASE REPORT:

A twenty-nine year-old woman presented to an Emergency Department complaining of bilateral foot swelling, dizziness, nausea, vomiting and diarrhea. She was afebrile and had normal heart rate, and blood pressure. She was not taking any medications. Serum sodium was 117 mmol/L; creatinine was 0.72 mg/dl, and serum osmolality was 252 mosm/kg. Thyroid Stimulating Hormone was 4.12, and free thyroxine was 1.02.  The cortisol was 22.3 mcg/dL at 8 a.m. She received fluid resuscitation, anti-emetic therapy, and salt tablets. The sodium increased to 138 mEq/L. Salt tablets were discontinued. Three weeks later she presented to the Emergency Department with the same symptoms. She was clinically euvolemic. Serum sodium was 123 mmol/L; serum osmolality was 271 mosm/kg; urine osmolality was 639 mosm/kg, and urinary sodium was 245 mosm/kg. Chest X-ray was normal. Syndrome of inappropriate antidiuresis (SIAD) was diagnosed, and a 1 liter daily fluid restriction was implemented. Total brain MRI was obtained due to previous head trauma. It revealed an anterior pituitary mass measuring 11 mm craniocaudally by 6 mm transversely by 10 mm anteroposteriorly. Normal posterior pituitary enhancement was seen in the sagittal T1-weighted images, although the mass posteriorly displaced the neurohypophysis. The serum prolactin was 193.7 ng/mL. Other pituitary axes were normal. The patient received 0.25 mg of Cabergoline twice weekly. The serum sodium rose from 121 mmol/L to 133 mmol/L within 12 hours after the first dose, and remained over 135 mmol/L. Four months after, serum sodium was 139 mmol/L, and serum prolactin decreased to 8.4 ng/mL.

CONCLUSION:

Acquired SIAD due to pituitary tumors is exceedingly rare, with four of the previously reported five cases being non-functioning macroadenomas (1-4), and the other being a macroprolactinoma (5). The mechanism of inappropriate antidiuresis in prolactinoma is likely due to a lowering of the osmotic threshold for arginine vasopressin secretion (6). To our knowledge, this case is the first case to show that dopamine agonists can achieve rapid restoration of normal water metabolism in patients with prolactinoma-induced SIAD.

 

Nothing to Disclose: EK, CM, AS

12443 23.0000 MON-0694 A Restoration of Normal Water Metabolism with Cabergoline in Prolactinoma-Induced Syndrome of Inappropriate Antidiuresis (SIAD) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0672-0695 4828 1:00:00 PM Neuroendocrinology: Hypophysitis; Diabetes Insipidus; Melatonin Poster

Fusun Salgur1, Pelin Tutuncuoglu*2, Mithat Bahceci1, Ahmet Gorgel1, Hüsnü Yilmaz3 and Gonca Oruk1
1Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey, 2Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey, 3Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey

 

Objective: Long acting somatostatin analogues are used in  acromegaly therapy, enable reduction in size of the pituitary mass as well as an effective decrease in growth hormone and IGF-1 concentrations. We aimed to analyze alterations in growth hormone and IGF-1 concentrations and pituitary adenoma sizes retrospectively in patients with acromegaly treated with somatostatin analogues.

Subjects and Methods: Acromegalic patients treated with octreotide LAR (n:61, mean age: 49.2±13.6yr) or somatuline autogel (n:10, mean age: 47±7.1) were evaluated retrospectively. Information about the status of the patients (age, gender, presence of comorbid diseases, GH and IGF-1 concentrations and pituitary mass size) were collected from medical records of our hospital data processing system and were evaluated.

Statistical analysis: All values were expresses as mean±standard deviation and values p<0.05 accepted as meaningful. It was used for statistical analyses Fisher’s Exact test to compare categorical variables between groups, Mann-Whitney U to compare continuous data between the two groups, Kruskal Wallis H to compare continuous data between more than two groups. Alterations before and after one year was analysed via Wilcoxon Signed Rank. P values <0.05 was considered statistically significant.

Results : We determined a significant decrements in  IGF-1 ( from 437,7 to 337,7 µg/L and 12,5±59,2%) and growth hormone ( from 3 to 2.4 µg/L and 12,7%) after 12 months therapy with octreotide (p<0,05). In the same patient group a reduction in tumor size was also determined (from 7,7mm to 5.96 mm, 19.1%, p<0,05). Same decrements were determined in Lanreotid group (IGF-1:from 397,6 to 356,3 and 11.4%, GH: from 3.7 to 2.8 and 10.8%, tumor size from 11,2 mm to 9.1 and 23%).

Conclusions: Both octreotide and lanreotide have same significant effectiveness in GH, IGF-1 and reduction in tumor size.

 

Nothing to Disclose: FS, PT, MB, AG, HY, GO

14380 1.0000 MON-0703 A Evaluation of the Effetcs of Octreoide and Lanreotide on Growth Hormone and Adenoma Size in Acromegalic Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Christopher D'Sylva*1, Tayyab Khan1, Lisa-Ann Fraser2 and Stan Van Uum3
1Western University, London, ON, Canada, 2Division of Endocrinology and Metabolism, Department of Medicine, Western University, London, Canada, 3Department of Medicine, Western University, London, ON, Canada

 

Hyperprolactinemia has been associated with increased bone resorption and low bone mineral density.  This has been attributed to prolactin induced hypogonadism; however, recent studies have identified an increased fracture rate in patients with hyperprolactinemia, independent of gonadal function.  To further assess the impact of hyperprolactinemia on bone health, we performed a systematic review to identify studies assessing fracture risk in patients with untreated hyperprolactinemia compared to similar patients treated with dopamine agonists. We searched MedLine, EMBASE, Cochrane (EBMR on Ovid), Web of Science and BIOSIS Previews from their inception to December 2013 for observational studies with fracture as an outcome.  Two authors independently performed title and abstract searches, full-text searches, data abstraction, and quality assessment using the Newcastle-Ottawa Scale. A summary odds ratio (OR) was calculated using a random effects model. A total of 197 articles were identified. Only 2 studies met the full inclusion criteria and were included in the final analysis.  Both were high quality cross-sectional studies examining cabergoline use (or non-use) in patients with known prolactin-secreting adenomas, with prevalent morphometric vertebral fractures as the primary outcome.  The studies were very similar in methodology as they were performed by the same group of researchers, just in different genders. For women, vertebral compression fractures were identified in 46% of untreated patients with hyperprolactinemia, vs. 20% of patients on cabergoline (OR: 0.29, 95% CI: 0.1-0.78). The majority (22 of 25) of women with fractures were post-menopausal. For men, the results were 67% in untreated, vs. 26% in cabergoline treated patients (OR: 0.18, 95% CI: 0.03-0.94), with no difference between eugonadal and hypogonadal men (p = 0.8).  Combining studies gave a summary measure odds ratio of 0.25 (CI: 0.11-0.59), I2 = 0%.  Literature examining fracture risk in patients with hyperprolactinemia, and the effects of intervention with a dopamine agonist, is sparse.  In the small number of studies available, fracture prevalence was increased in patients with untreated hyperprolactinemia compared to those on a dopamine agonist, independent of gonadal hormone status. Further studies need to clarify if post-menopausal women, or high-risk men, with no other indication for treatment with a dopamine agonist, should be on dopamine-agonists to decrease fracture risk.

 

Nothing to Disclose: CD, TK, LAF, SV

15466 2.0000 MON-0704 A Osteoporotic Fractures in Patients with Untreated Hyperprolactinemia Vs. Those Taking Dopamine Agonists: A Systematic Review and Meta-Analysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Elahu Gosney Sustarsic*1, Riia Karoliina Sustarsic1, James Herpy2, Martin Bidlingmaier3 and John J Kopchick4
1Medizinische Klinik und Poliklinik IV, Munich, Germany, 2Ohio University, 3Klinikum der Universität München, Medizinische Klinik und Poliklinik IV, Munich, Germany, 4Ohio University, Athens, OH

 

Metastatic melanoma is an aggressive disease that has been increasing in incidence in recent years. Advances in the understanding of the biomolecular profile of melanoma have delineated specific sub-types that may be vulnerable to treatment with targeted therapeutics. We have previously reported a universally high GHRmRNA expression in melanoma cell lines of the National Cancer Institute’s panel of 60 cancer cell lines (NCI60). Furthermore, a high dose of GH increased proliferation in three of these melanoma cell lines. GH is known to activate a variety of signal transduction pathways known to be involved in the processes of carcinogenesis, most notably the JAK2/STAT5 pathway. MAPK and PI3K-Akt signaling also have been shown to be activated by GH and their constitutive activation is often observed in human melanomas.

Here, we examined the effect of low-dose of GH (0.05 nM) on cell proliferation and signal transduction pathways in several NCI60 melanoma lines. There is considerable variation in the response to GH treatment across cell lines. A low GH dose significantly decreases proliferation in SK-MEL-5 and MDA-MB-435 cell lines, although the effect is modest. In MDA-MB-435, we observe a biphasic effect of GH, with a reduction in proliferation at low GH doses and an increase in proliferation at a high dose (100 nM). Low-dose GH treatment alters cell signaling pathways, including the phosphorylation status of Akt, STAT3 and STAT5.

Although GH does not induce dramatic changes in the growth of melanoma lines under our experimental conditions, our results show that melanoma cells possess GH receptors that are capable of modulating multiple signaling pathways in a complex manner. The biphasic response was not easily explained by the effect of treatment on cell signaling pathways. Further investigations will result in a better understanding of the role of GH in cancer and may reveal novel relationships that could one day be exploited in the diagnosis and treatment of metastatic melanoma.

 

Nothing to Disclose: EGS, RKS, JH, MB, JJK

16846 3.0000 MON-0705 A A Low Dose of GH Alters Cell Signaling and Growth in Human Metastatic Melanoma Cell Lines 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Mussa H Almalki*1, Naji J Aljohani1, Saad H Alzahrani1, Safia M Sherbeeni2, Badurudeen M Buhary2 and Ghada Alhowsawi1
1King Saud bin Abdul-Aziz university, Riyadh, Saudi Arabia, 2King Fahad Medical City, Riyadh, Saudi Arabia

 

Background: Although dopamine agonists remain the first-line treatment, as they have been shown to effectively normalize prolactin levels and reduce tumor volume, but the management of giant prolactinoma is still a major challenge.

Objective:The aim of this study is to characterise therapeutic aspects and outcome of giant prolactinomas at single tertiary center in Riyadh.

Methods: This study involved retrospective data collection from 16 patients diagnosed with giant prolactinoma at the pituitary clinic in King Fahad Medical City between January 2006 and July 2012.

Result:16 patients, (10 male) were included in the analysis with age at diagnosis 21-55 years (mean, 34.9 years). Most common presenting features included headache, visual defect and sexual dysfunction. The most common co-morbidities were hypopituitarism, gonadal dysfunction and GH deficiency.The baseline mean serum prolactin level was extremely high at 114129.5 nmol/l (reference range, 100-390 nmol/l) and the mean tumor volume was 48.7 cm 3. Following treatment, serum prolactin concentrations entirely normalized in 6 patients and decreased in 5 patients to a level 3 to 5 times that of normal. Tumor volume was decreased on average by 88.3%

Conclusion: These findings indicate that cabergoline provides dramatic clinical improvement with excellent safety profile. Therefore, cabergoline should be consider as the primary therapy for giant prolactinoma.

 

Nothing to Disclose: MHA, NJA, SHA, SMS, BMB, GA

11562 4.0000 MON-0706 A Giant Prolactinomas: Clinical Manifestations and Outcomes of 16 Arab Cases 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Christine G Yedinak*1, Shirley McCartney1, Alp Ozpinar2, Justin S Cetas1, Aclan Dogan1 and Maria Fleseriu1
1Oregon Health & Science University, Portland, OR, 2Oregon Health & Science University, OR

 

CONTEXT: We compare hypopituitarism prevalence in prolactinoma (P) before/after dopamine agonist (DA) vs non-functioning pituitary adenoma (NFA) pts pre and post transsphenoidal surgery (TSS) and investigate the relationship to prolactin (PRL) level & tumor size.

METHODS: Review of P (104) and NFA (98) pts in a prospective database. Pts with follow up < 52w and XRT were excluded. P were divided into 2 groups: Gr1 naïve to DA and Gr2 DA prior to presentation. Gr3 included NFA pts matched to Gr1 for tumor size & gender. DAs used were cabergoline and bromocriptine. Uniform biochemical evaluation included: PRL, cortisol, ACTH, Cortrosyn stimulation test, thyroid, gonadal axis & IGF1 pre/post DA and TSS, at 6, 12 & 52 weeks. Descriptive analysis with PASW18: ANOVA, Bonferroni post hoc analysis, independent & paired T tests.

RESULTS: Gr1: (30M/27F; 27 micro (Mi:7M/20F) & 30 macro (Ma:23M/7F). Gr2: (7M/18F: Ma 17, Mi 12, & 2 no tumor). Gr3: 27 Mi (7M/20F) & 30 Ma (23M/7F). There was no significant (NS) difference between groups for age, gender or mean max tumor dimension (Gr1: 1.47cm, Gr2: 0.92cm and Gr3: 1.36cm). At baseline, prevalence of adrenal insuf (AI) & low IGF1 was similar between groups; hypogonadism was more significant in Gr1 (p=0.017). PRL was higher for Ma (p=0.05) in Gr1.

PRL decreased after 52 wks of DA in Gr1 (Mi 91.3 ng/ml, Ma 1771.5 ng/ml) by 83.6% and 98.1%, respectively.

Baseline AI in Gr1 36.8% (Mi 24.5%/Ma 46.6%), Gr2 16% & Gr3 29.8% (Mi 29.6%/Ma 30%) recovered significantly at 52 wks after DA in Gr1 (p=0.028) & Gr2 (p=0.05).

Hypogonadism significantly recovered at 52 wks in Gr1 90% to 13% (p=0.017) vs Gr2 57% to 28% (p=0.34) & Gr3 53.3% to 46.6% (p=0.57). Over all groups, males were older, had larger tumors (p=0.000), higher PRL levels (0.006) & higher prevalence of AI and low IGF1 (P<0.001).

Low IGF1 over all groups significantly recovered at 52 wks (p=0.030), but resolution within each group was NS. Hypothyroidism recovery was also NS within each group.

DISCUSSION: Some authors suggest that hypopituitarism in P is irreversible, while others suggest improvement on DA. In our study, AI significantly recovered in pts naïve to DA (independent of tumor size or PRL) at similar rates with NFA after TSS. As expected, hypogonadism also recovered in P after PRL normalization vs NFA at 52 wks.

CONCLUSION: In one of  the largest study to date of pts with P systematically assessed at specific intervals and naive to any therapy, we show that AI significantly recovered after DA treatment independent of tumor size. Reversibility of hypogonadism is expected after PRL normalization. Moreover, the potential for HPA axis recovery approaches half of pre-treatment rates for either P or NFA. We recommend short and long-term pituitary function evaluation to avoid lifelong unnecessary replacement therapies. Further research is needed to better identify the characteristics of pts more likely to have reversible hypopituitarism.

 

Nothing to Disclose: CGY, SM, AO, JSC, AD, MF

12879 5.0000 MON-0707 A Reversibility of Hypopituitarism after Dopamine Agonist Therapy in Prolactin-Secreting Pituitary Adenomas Versus Non-Functioning Pituitary Adenomas after Transphenoidal Surgery – a Large Single Center Experience 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Carolina Ballarino*1, Sabrina Diez2, Susana Mallea Gil1, Mariana Salazar2 and Graciela Stalldecker2
1Hospital Militar Central, Buenos Aires, Argentina, 2Hospital Pirovano, Buenos Aires, Argentina

 

Dopamine agonists (DA) are first-line drugs for patients with prolactinomas. The Endocrine Society states that it is possible to discontinue DA in patients treated for at least 2 years, if they have normoprolactinemia and no evidence of tumor remnant on MRI. Our objective was to assess recurrence of hyperprolactinemia following DA withdrawal in patients with prolactinomas after 2 years or more of treatment. Patients with prolactin (PRL) levels above the upper reference range after therapy withdrawal were considered to be recurrent. Retrospective study: 26 patients (20 premenopausal women and 6 male) who discontinued DA because they fulfilled criteria for withdrawal. Initial tumor size was: 20 microprolactinoma (MI), 5 macropolactinoma (MA) and 1 giant macroprolactinoma (GM). Under treatment, all patients reached normal PRL levels and had favorable MRI response. At the time of withdrawal, DA doses were: cabergoline ≤ 1mg/week (25 patients) and bromocriptine ≤ 5mg/d (1 patient). Follow-up was done for at least 6 months (range 6–132). The mean length on DA therapy was 70 months for MI, 141 months for MA and 90 months for GM, respectively. At the time of withdrawal, MRI was normal in 13/20 MI. In patients with MA and GM, tumor shrinkage during treatment was >50% (3 had empty sella). After DA withdrawal 10/20 (50%) MI, 2/5 (40 %) MA and 1/1 GM recurred. Overall recurrence was 50% (13/26). Patients who recurred had less time of normoprolactinemia under treatment compared to those who remitted (45 months vs. 80 months in MI group and 95 vs. 168 in MA group, respectively). In 90% of patients who recurred, PRL levels after DA withdrawal were lower than pre-treatment levels. Twelve of 13 patients recurred during the first year. Only 5 patients who recurred (4 MI and 1 GM) had to restart therapy. The remaining patients had mild asymptomatic hyperprolactinemia and there were no changes in MRI during the follow-up. In 2 patients of the MI group, a successful second attempt to withdraw AD was made after an additional year of therapy. In conclusion, 50% of our patients recurred after DA withdrawal. A minority of these patients had to restart therapy because of clinical recurrence. It is important to do a close follow-up during the first year of DA discontinuation. Longer time of normoprolactinemia under treatment was associated with a better outcome. A second attempt to withdraw DA after additional years of therapy seems to be possible.

 

Nothing to Disclose: CB, SD, SM, MS, GS

14128 6.0000 MON-0708 A Recurrence of Hyperprolactinemia after Discontinuation of Dopamine Agonist Therapy in Patients with Prolactinomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Alice Helena Violante*1, Adilson Lamounier Jr.2, Erika Cesar de Oliveira Naliato3, Fernanda Dias Carneiro Carneiro4 and Renan Moritz Almeida5
1Fed Univ of Rio de Janeiro, Niteroi Rio de Janeiro, Brazil, 2Federal University of Espirito Santo, Vila Velha - Espirito Santo, Brazil, 3UNIFESO - Serra dos Orgaos University Center, Teresopolis, Brazil, 4Federal University of Rio de Janeiro, Niteroi Rio de Janeiro, Brazil, 5COPPE (Posgraduate Engineering Program Coordenation) - UFRJ, Niteroi Rio de Janeiro, Brazil

 

Prolactinoma is the most common pituitary adenoma in women. Greater or equal to 1 cm are called macroprolactinomas (MAC). These can lead to symptoms of intracranial hypertension besides other co-morbidities of the disease, and these as well as microprolactinoma have medical treatment with dopamine agonists (DA) and excellent result. The pituitary gland increases physiologically 120% of  volume during pregnancy. This leads to great concern in the presence of pregnancy and MAC since there is consensus in the attempt to remove the AD during pregnancy. However tumor growth during the pregnancies of these women may occur and require some type of medical intervention, which leads to concern with keeping or not the AD, the possible side effects of this, follow-up and complications of pregnancy and the fetus. Objective: Show the evolution of pregnancy in patients with MAC. .Patients and methods: Retrospective study of 8 patients and 11 pregnancies  which were observed: evolution of the size of adenoma, diagnosis data, disease and pregnancy evolution, use of dopamine agonists (DA), and breast feeding. Results: 8 women with macroprolactinoma who had 11 gestations were evaluated (two patients had 2 gestations each) with ages varying between 22 to 35 years (average = 26, 4 years) at the moment of the prolactinoma diagnosis. The age of the patients when pregnancy was acknowledged varied between 24 to 39 years (average = 30, 2 years). The period between the diagnosis of the prolactinoma and the gestation varied between 6 months to 16 years (average = 3, 8 years) and the pre-pregnancy confirmation PRL values were located in the interval between 18, 5 and 122 ng/ml (average = 57, 4 ng/mL).The level of pre-gestation PRL was obtained by the simple average of the last three PRL levels, except for two patients, already aware of the pregnancy. And another that got pregnant after 4 weeks of AD.  Seven patients, 87, 5 % had pregnancy diagnosis while using DA. Two patients continued to use AD through the whole period of gestation. Regarding the intercurrences during gestation and lactation: intense headache episode and focal hemiplegia, which regressed without medication; intense headache and visual alteration with diplopia.  Patient with tumor of 2.5 cm, without drug treatment during her 1st gestation, gave birth to a stillborn. From the eleven gestations with live babies, eight were breast fed. In the patients with macroprolactinoma, the PRL at the last evaluation reached an average of 42.9 ng/mL (range of values 13.4 – 83.0 ng/mL). In these patients there was a significant reduction (p = 0.003) of the tumoral size, from 1.8 cm (pre) to 1.3 cm (post-gestation).Conclusion: Pregnancy is viable for patients with prolactinoma, independently of the tumor's size. AD is safer to use even throughout pregnancy. However, there is a necessity of follow-up of these patients during pre, per, and post-pregnancy in order to assure the success of pregnancy.

 

 

Nothing to Disclose: AHV, AL Jr., ECDON, FDCC, RMA

14934 7.0000 MON-0709 A Prolactinoma in Pregnancy – Macroprolactinomas, Always a Surprise? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Dilek Yazici*1, Murat Sunbul2, Mehmet Yasar1, Oguzhan Deyneli3 and Dilek Yavuz4
1Section of Endocrinology and Metabolism, Marmara Univ Medical School, Istanbul, Turkey, 2Marmara University Medical School, Department of Cardiology, 3Section of Endocrinology and Metabolism, Marmara Univ Medical School, Istanbul, Turkey, Istanbul, Turkey, 4Section of Endocrinology and Metabolism, Marmara Univ. Medical School, Istanbul, Turkey, Istanbul, Turkey

 

Aim: Epicardial fat thickness (EAT) is considered to be a surrogate for visceral fat and it is considered to be a novel cardiovascular risk indicator. Hyperprolactinemia has been shown to be associated with cardiovascular risk markers, like endothelial dysfunction and carotid stiffness. The aim of the study was to determine EAT in patients with prolactinoma.

Materials and Methods: Patients followed with the diagnosis of prolactinoma were included. The control group consisted of healthy age and gender matched individuals with normal prolactin levels. Fasting blood glucose (FBG), alanine transaminase (ALT), HbA1c and lipid levels of the study groups were determined.  EAT was measured using echocardiography.

Results: Sixty eight patients with prolactinoma ( 43.7±9.1, F/M:50/18) were evaluated with 45 controls (41.6±8.1, F/M:34/11). Sixteen patients had macroadenomas and the rest had microadenomas. FBG (87.5 ± 8.2 vs 83.0 ± 15.6) and HbA1c of the patients were comparable ( 5.2±0.5% vs 5.0±0.5%). ALT levels were comparable to controls (18.9±9.6mg/dL vs 20.9±6.6mg/dL). Total cholesterol  (184.0±44.2 mg/dL vs 186.0±32.2 mg/dL), triglycerides (118.7±61.9 mg/dL vs 81.4 ± 16.6 mg/dL), HDL (55.0 ± 19.6 mg/dL vs 51.5 ± 8.5 mg/dL) and LDL cholesterol  (107.6 ± 28.5 vs 108.8 ± 32.4) of the patients were similar to controls. Epicardial fat thickness was increased in the patient group (3.0 ± 0.5mm)  compared to controls (2.6 ± 0.4mm, p<0.0001). EAT was correlated with ALT (r=0.28, p=0.03, triglycerides (r=0.31, p=0.03) and HbA1c (r=0.31, p=0.04) but not with prolactin, total, LDL or HDL cholesterol. Multivariate association showed only HbA1c to be related to EAT (r2=0.20, p=0.04).

Conclusion: EAT was increased in patients with prolactinoma. It was related to levels of HbA1c, which was found to be in normal ranges. EAT may be an early sign predicting cardiovascular risk in patients with prolactinoma and it seems to be related to subtle changes in the glycation status.

 

Nothing to Disclose: DY, MS, MY, OD, DY

15156 8.0000 MON-0710 A Epicardial Adipose Tissue Thickness in Patients with Prolactinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Alin Abreu*1 and Jose Arturo Hernandez Yero2
1Centro Medico Imbanaco, Cali, Valle Delcauca, Colombia, 2Instituto Nacional de Endocrinología, La Habana, Cuba

 

Objective: to describe a series of 30 male subjects with invasive macroprolactinomas and their response to pharmacologic treatment.

Methods: Retrospective analysis of 30 male subjects attending to hypophysis clinics at Instituto Nacional de Endocrinología in Habana, Cuba (21 subjects), and Centro Médico Imbanaco, Cali, Colombia (9 subjects) between 2002-2012. Clinical charts were retrieved and analyzed for demographic characteristics, treatments, hormonal tests and tumor size variation before and after treatment with dopamine agonists.  Tumor size variation was assessed by two independent evaluators  using a standardized imagenologic  measurement technique (Syngo e Imagic). Differences were determined using Chi square test o Fisher exact test (SPSS 17.0). Significance levels was p<0.05.

Results: 30 subjects with a mean age 44,2   years were included. The mean BMI was 28,1±3,7kg/m2. Basal hormonal test showed variable degrees of hypopituitarism and hyperprolactinemia. 18 patients were operated without achieving cure, and received further medical therapy with dopamine agonists. 12 patients received medical treatment only, being cabergoline the most frequently used drug. After 6 and 12 months of treatment the prolactin levels and tumor size decreased significantly (p<0,05).

Conclusions: Primary medical therapy or after unsuccessful surgery with dopamine agonist in male subjects with invasive macroprolactinomas may be an effective and well tolerated therapeutical option.

 

Nothing to Disclose: AA, JAH

15379 9.0000 MON-0711 A Invasive Macroprolactinomas and Treatment Response in Male Subjects: A Case Series Analysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Eva Lau*1, Joana Isabel Oliveira2, Ana Isabel Oliveira2, Paula Freitas1, Eduardo Vinha3 and Davide Carvalho4
1Centro Hospitalar São João; Faculty of Medicine, Porto University, Portugal, 2Centro Hospitalar São João, Faculty of Medicine, Porto University, Porto, Portugal, 3Centro Hospitalar São João, Porto, Portugal, 4Centro Hospitalar São João, Faculty of Medicine, University of Porto, Portugal

 

Introduction: Dopamine agonists (DA) are the treatment of choice for prolactinomas and idiopatic hyperprolactinemia. However, the best treatment strategy, including the optimal point of suspension is not consensual, by the difficulty of predicting hyperprolactinemia recurrence. Objectives: To study the determinants of hiperprolactimenia recurrence after discontinuation of DA in patients with prolactinomas and idiopatic hyperprolactinemia. Methods: Observational, retrospective study of patients with prolactinomas or idiopatic hyperprolactinemia who discontinued DA treatment, followed in Endocrinology consultation of a tertiary hospital. Descriptive analysis and univariate logistic regression of potential determinants of recurrent hyperprolactinemia. Results: We identified 21 patients from a total of XX, who discontinued therapy, median age at diagnosis was 31 years, 19 were female. The initial median prolactin was 117.8 ng/ml (82.0 to 155.5) and prolactin levels during treatment, including basal, 41.7 ng/mL (7.5 to 67.3). There was recurrence of hyperprolactinemia in 8 patients (38.1%). Patients with recurrence had a mean prolactin during treatment significantly higher than those who did not recur (85.0 vs 20.8, p=0.002). Mean prolactin>60 ng/mL during treatment predicts recurrence with a sensitivity and specificity of 1 and 0.85, respectively (ROC curve with AUC of 0.9). Cabergoline was the initial therapy in a patient. The remaining (n = 20) started bromocriptine, in 75% in a initial dose ≥ 5mg. Patients with relapse initiated bromocriptine at a significantly lower dose than those patients without recurrence (p=0.03). The median treatment time was 8 years; patients with recurrence had a significantly lower treatment time, than patients without recurrence (4 vs 12, p=0.01). Conclusion: In patients with prolactinomas, the mean prolactin during treatment, its duration and respective initial dose of bromocriptine are determinants of recurrence of hyperprolactinemia after treatment suspension. An average prolactin <60 ng / mL during follow-up treatment seems to be an excellent cutoff point for considering the suspension of treatment.

 

Nothing to Disclose: EL, JIO, AIO, PF, EV, DC

15765 10.0000 MON-0712 A Determinants of Recurrent Hyperprolactinemia in Prolactinomas and Idiopatic Hyperprolactinemia after Dopamine Agonists Suspension 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Arpeta Gupta*1, Michael D. Richter1, Faisal Kamal1, Kalmon D. Post2 and Eliza B. Geer2
1Icahn School of Medicine at Mount Sinai, New York City, NY, 2Icahn School of Medicine at Mount Sinai, New York, NY

 

BACKGROUND: Prolactinoma is the most common type of hormone-secreting pituitary adenoma, with a prevalence of approximately 35 cases per 10,000 people. While prolactinomas are more common in women, some data suggest that prolactinomas are larger and more aggressive in men. However, the presentation, natural history, and treatment outcomes in men are incompletely understood.

AIM: To determine gender-based differences in the presentation, treatment patterns, and outcomes of patients with prolactinomas.

METHODS: A retrospective chart review identified 261 prolactinoma patients treated either medically or surgically at the Mount Sinai Medical Center. Patients with a prolactin concentration >200 ng/ml regardless of MRI findings and those with a concentration >50 ng/ml with MRI evidence of a pituitary tumor were included in the study.

RESULTS: Of the 261 patients, 184 (70.5%) were female with a mean age of 28.5±10.3 years as compared to 77 (29.5%) males with a mean age of 43.9±15.4 years (p<0.001 for age). Mean basal prolactin concentrations (2613.7±4983.4 ng/ml in men vs. 377.6±1075.5 ng/ml in women) and mean tumor size (23.5±13.8 mm in men vs. 11.2±7.7 mm in women) were higher in men as compared to women (p<0.001 for both). Men predominately presented with macroadenomas (69.2%) and giant prolactinomas (12.3%) as compared to women (47.7% and 1.3%, p=0.004 and <0.001, respectively). The most common presenting symptoms in men were decreased libido (74.0%), visual disturbances (42.8%), headaches (41.5%) and weight gain (27.2%). Women presented with galactorrhea (60.8%), amenorrhea (52.2%), irregular periods (32.0%), headaches (42.9%), weight gain (25%), and visual disturbances (17.9%). Approximately 50% of all patients underwent surgery (n=37/77 males and n=93/184 females). Women treated surgically had larger tumors (14.6±8.6 mm vs. 7.5±4.3 mm, p<0.001) and higher prolactin concentrations (622.5±1504.5 ng/ml vs. 137.5±194.2 ng/ml, p<0.003) compared to those treated medically, whereas for men tumor size and prolactin concentration did not differ based on treatment type (25.9±1 mm vs. 21.5±13.5 mm, p=0.23; and 3077.0±6352.7 ng/ml vs. 2203.2±3395.0 ng/ml, p=0.47). The main indications for surgery in men and women were medication intolerance (21.6% vs. 35.4%), persistently elevated prolactin on dopamine-agonist therapy (27.0% vs. 36.5%), apoplexy (10.8% vs. 4.3%) and patient choice (5.4% vs. 9.6%).

CONCLUSIONS: Gender has a significant impact on presentation and natural history of prolactinomas. Male gender increases the age of presentation, tumor size, and prolactin concentration. Gender also affects treatment patterns: females with larger tumors are more likely to be treated surgically vs. medically, whereas surgical and medical treatments were equally distributed among tumor size in males. These data impact the monitoring and treatment of patients with prolactinomas.

 

Nothing to Disclose: AG, MDR, FK, KDP, EBG

16585 11.0000 MON-0713 A Characterization of Presentation and Treatment Patterns of Prolactinomas in Male and Female Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Rafael Loch Batista*1, Nina de Castro Musolino2, Clarissa Groberio Borba3, Valter Angelo Sperling Cescato4 and Malebranche Cunha Neto3
1Hospital das Clinicas, FMUSP, Brazil, 2Hospital das Clínicas, FMUSP, São Paulo, Brazil, 3Hospital das Clínicas, FMUSP, 4HC FMUSP, Sao Paulo, Brazil

 

INTRODUCTION : clinically nonfunctioning pituitary adenomas are benign tumors whose diagnosis tends to be delayed . The current treatment options include surgery and radiotherapy . However , there is scientific evidence pointing to a clinical benefit with the use of dopamine agonists , especially cabergoline . However , response rates tend to be modest and little is known about predictors of response to cabergoline . Identifying these factors helps in the possibility of screening which may be patients who respond to this treatment.

METHODS: We evaluated the immunohistochemical profile ( ACTH , GH , LH , FSH , prolactin and TSH ) of 78 patients with clinically nonfunctioning pituitary adenomas , which were operated on with the rest of tumor 6 months after surgery to verify whether there were differences among the group who used cabergoline ( 3.5 mg per week) for 12 months ( N = 42 ) with another group that did not cabergoline this same period ( N = 36 ) , with the aim of assessing whether immunohistochemistry might be predictive of clinical response to use of cabergoline . These groups (with and without cabergoline ) were divided into 3 groups according to the change in tumor volume observed : Group A - stable rest tumor; Group B - > 15% decrease in tumor volume and group C - growth of tumor rest .

RESULTS : In group A ( stable tumor rest , n = 55 ) among those who used cabergoline , 58.62 % of adenomas classified as Null Cell , 13.79 % expressed gonadotropins ( LH and FSH ), 17,24% were plurihormonals and 10.34 % showed expression for isolated hormones without clinical secretion (ACTH , GH , TSH) . Among those who did not use cabergoline saw 50% Null Cell , LH and FSH 11.53 % , 26.92 % of plurihormonais and 11,53% other expressions . There was not statistical difference between the groups ( p 0.11) . In group B ( reduction of tumor Moreover, n = 12) , the group using cabergoline was 60% of tumors Null Cell, 10% LH and FSH and 30% plurihormonais . The group that did not cabergoline had 50% Null Cell and 50% plurihormonals ( p 0.423 ) . In group C, (tumor growth, n = 11 ) , the group that used cabergoline showed Null Cell in 66.6 % and FSH /LH in 33.3 % . The group that did not cabergoline had 87.5 % of Null Cell and 12.5 % of plurihormonal expression ( p 0.7 ) .

CONCLUSIONS : The immunohistochemical expression in nonfunctioning pituitary adenomas was not predictive of clinical response to cabergoline .

 

Nothing to Disclose: RLB, NDCM, CGB, VASC, MC

16753 12.0000 MON-0714 A Immunohistochemistry Is NOT Predictive of Response to Cabergoline in Clinically Nonfunctioning Pituitary Adenomas 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Maria Fleseriu*1, Rosario Pivonello2, Alberto M Pedroncelli3, Heather Patino4, Moncy Ye4, Mounir Aout3 and Richard A. Feelders5
1Oregon Health & Science University, Portland, OR, 2Federico II University of Naples, Naples, Italy, 3Novartis Pharma AG, Basel, Switzerland, 4Novartis Pharmaceuticals Corporation, East Hanover, NJ, 5Erasmus Medical Center, Rotterdam, Netherlands

 

Background: Most corticotroph pituitary adenomas simultaneously express dopamine and somatostatin receptors. Combining medical treatment modalities can be considered in order to improve outcome of patients with Cushing’s disease (CD). Data indicate synergistic effects between pasireotide and cabergoline in improving biochemical control rates and clinical features in patients with CD. This study was designed to evaluate safety and efficacy of pasireotide alone or in combination with cabergoline in patients with CD.

Methods: This Phase II, multicenter, prospective, international, open-label, non-comparative study will enroll adults with confirmed diagnosis of CD (persistent/recurrent/de novo not considered candidates for pituitary surgery). Group1: pasireotide-naïve patients or who had discontinued pasireotide earlier for lack of efficacy; Group2: patients currently receiving maximal tolerated dose (MTD) of pasireotide monotherapy for ≥8wks, but biochemically uncontrolled (mean urinary free cortisol [mUFC]>ULN; mean of 3 samples with 2/3>ULN). Target enrolment is 128 patients (Group1=68; Group2=60).

Group1 will receive pasireotide s.c. 600μg bid for 8wks; if uncontrolled, dose increased to 900μg bid for 8wks; if still uncontrolled, pasireotide s.c. 900μg bid + cabergoline 0.5mg qd for 8wks (if intolerant of pasireotide 900μg bid, 600μg bid allowed); if still uncontrolled, cabergoline dose increased to 1mg qd for 8wks. Group2 will receive MTD of pasireotide (300/600/900μg bid) s.c. + cabergoline 0.5mg qd for 8wks; if uncontrolled, cabergoline dose increased to 1mg qd for 8wks. For both groups, dose modifications for cabergoline due to safety are allowed.

Primary endpoint for Group1: proportion of responders (mUFC≤1.0XULN) with pasireotide alone or with cabergoline at wk35. Primary endpoint for Group2: proportion of responders with pasireotide + cabergoline at wk17. Secondary endpoints: actual and percentage change in mUFC from baseline to study end; proportion of patients attaining mUFC≤1.0xULN at each scheduled visit; proportion of UFC responders or patients having ≥50% reduction from baseline in mUFC at each scheduled visit; shift from baseline in clinical signs.

No formal hypothesis testing planned. Proportion of patients (95%CI) attaining primary endpoint will be reported.

Conclusions: This study will assess safety and efficacy of pasireotide s.c. in combination with cabergoline as a stepwise approach in the treatment of CD.

 

Disclosure: MF: Principal Investigator, Corcept, Ad Hoc Consultant, Genentech, Inc., Principal Investigator, Ipsen, Ad Hoc Consultant, Ipsen, Ad Hoc Consultant, Novartis Pharmaceuticals, Principal Investigator, Novartis Pharmaceuticals, Consultant, Novartis Pharmaceuticals. RP: Principal Investigator, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals, Ad Hoc Consultant, Novartis Pharmaceuticals, Ad Hoc Consultant, Ipsen, Investigator, Pfizer, Inc., Investigator, Viropharma, Ad Hoc Consultant, Viropharma, Investigator, Institut Biochimique SA, Ad Hoc Consultant, Italfarmaco. AMP: Employee, Novartis Pharmaceuticals. HP: Employee, Novartis Pharmaceuticals. MY: Employee, Novartis Pharmaceuticals. MA: Employee, Novartis Pharmaceuticals. RAF: Investigator, Novartis Pharmaceuticals, Speaker, Novartis Pharmaceuticals.

12067 13.0000 MON-0715 A Study Design of a Phase II Trial of Subcutaneous Pasireotide Alone or Combined with Cabergoline in Patients with Cushing's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Kar Mun Eu*, Cherng Jye Seow and Gerard Daoming Lim
Tan Tock Seng Hospital, Singapore, Singapore

 

BACKGROUND:

Acromegaly is a chronic disease with far reaching impact in patients. Biochemical control of this disease is now far more easily achieved with advancements in various treatment modalities – surgical, medical and radiological. However, biochemical control improvement of the disease may not necessarily correlate with patients’ improved perception of their quality of life.  Quality of life (QOL) following treatment for acromegaly has been well studied in overseas populations, but has not been studied locally before.  This study correlated the QOL of local patients with acromegaly following treatment.


SUBJECTS AND METHODS:

21 patients with acromegaly on follow up with Tan Tock Seng Hospital were invited to participate in this study and 13 patients responded (response rate 61.9%). The assessment was carried out using the Acromegaly quality of life (AcroQOL) questionnaire score, a tool which measures outcomes in terms of physical appearance, psychological well-being and personal relations.


RESULTS:

Treatment resulted in significant improvement in global AcroQOL (before: 65.8217, after: 75.2622, p-value = 0.05) and physical appearance score (before: 24.4615, after: 27.0769, p-value = 0.033) in our surveyed patients. Spearman correlation was used to assess correlation between current IGF and current QOL score, with moderate negative correlation found between IGF and global score (rho=-0.655, p=0.021). There was no significant improvement in scores for the psychological domains of well-being and personal relations after treatment.


DISCUSSION:

Patients with treated disease had improvement in global AcroQOL further supporting the effect of treatment in QOL. Treatment of disease, as evidenced by decreased IGF, has a negative correlation with QOL scores. Hence, we believe that AcroQOL should be used along side biochemical markers to monitor improvement in patient’s quality of life as part of the holistic management of patients. Our data also suggested that local patients with acromegaly did not have improvement in their psychological wellbeing despite treatment. We recommend that other forms of therapy e.g. counselling, psychologist evaluation be considered in the holistic treatment of acromegaly.

 

Nothing to Disclose: KME, CJS, GDL

12243 14.0000 MON-0716 A Quality of Life and Disease Perception of Patients with Acromegaly in an Institution in Singapore 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Noriaki Fukuhara*1, Hiroshi Nishioka2 and Shozo Yamada1
1Toranomon Hosp, Tokyo, Japan, 2Toranomon Hospital, Tokyo, Japan

 

Context: A GH and TSH co-secreting pituitary adenoma (GTA) which clinically causes acromegaly and SITSH at the same time, is a very rare tumor. Clinical features of this tumor have been rarely reported.

Objective: Aim of this study is clarifying clinical features of GTA.

Patients and Methods: We experienced 15 patients with GTAs among 1043 with acromegaly and 89 with TSH secreting pituitary adenomas (TSHomas) those were operated on at Toranomon Hospital between 1988 and 2013. Clinical features including symptoms, hormonal activity, tumor size, Knosp grading, reactivity to octreotide, tumor consistency and surgical outcome were retrospectively reviewed.

Results: GTAs accounted for 1.4% of patients with acromegaly and 16.9% of patients with TSHoma. One of 15 GTAs also co-secreted PRL. The patients included 10 men and 5 women with a mean age of 45 years (range, 25-63 years). Initial diagnosis was acromegaly in 8, hyperthyroidism in 3, galactorrea in one, and incidentally found in 3.  The median serum GH level was 3.9 (range, 0.3-808.9) ng/ml, the median serum IGF-1 level was 615 (range, 326-1230) ng/ml (median SD score was 6.9, [range, 3.1-12.7]), the median serum TSH level was 1.79 (range, 1.04-4.26) mIU/l, the median free-T3 level was 5.10 (range, 3.79-10.49) ng/ml, and the median free-T4 level was 1.81 (range, 1.53-3.63) ng/dl. The mean maximum tumor diameter was 24.1 (range, 9-57) mm. Ten of them were Knosp grade 0-2 tumor, and five were grade 3-4 tumor. Of 12 patients who received once or twice preoperative octreotide LAR administration, normalization of IGF-1 was attained in 2 (17%), and normalization of free-T4 was attained in 8 (67%). Similarly, >20% tumor volume reduction was seen in six of 10 GTAs (60%) whose MRIs before and after octreotide treatment were available. Ten of 15 GTAs (67%) were fibrous hard like as thyrotropinoma. All GTAs were performed transsphenoidal tumor resection. Ten of 15 GTAs (67%) were totally removed. Of five partially removed GTAs, one achieved endocrinological remission. Another four attained thyroid hormones normalization but needed adjuvant therapy for high IGF-1.

Conclusion: Although GTAs were more common in thyrotropinoma than acromegaly, they were more often diagnosed as acromegaly. Effects of octreotide treatment in hormonal control were limited in short-term administration. Surgical cure rate remained to be two thirds of all GTAs due to predominance of large, invasive, and fibrous tumors. GH hypersecretion but hyperthyroidism mattered in non-cured GTAs.

 

Nothing to Disclose: NF, HN, SY

12271 15.0000 MON-0717 A Clinical Features of GH and TSH Co-Secreting Pituitary Adenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Carlos Rafael Figueroa*1, Jose Hernan Martinez2, Monica Santiago3, Coromoto Palermo2, Michelle M Mangual4, Rafael Trinidad2, Madeleine Gutierrez2, Alfredo Sanchez5, Maria de Lourdes Miranda2 and Eva Gonzalez3
1San Juan City Hospital, Caguas, PR, 2San Juan City Hospital, San Juan, PR, 3San Juan Hospital, San Juan, PR, 4San Juan City Hospital, 5San Juan City Hospital, PR

 

Thirty-two years old female G2P1A0 seen at our endocrinology clinic nine years ago complaining of persistent menstrual irregularities associated to elevated prolactin values. MRI done revealed a pituitary microadenoma. However, she refused treatment for microprolactinoma. Four years afterwards, patient return complaining of recurrent episodes of headache. Repeated MRI showed a Pituitary Macroadenoma, so start on cabergoline treatment.

Once more, patient was lost to follow up and on 2012 she visited our clinic at 24th weeks of gestation with history of progressive hands and feet enlargement. On physical examination marked prognathism, hands and feet enlargement, acanthosis nigricans and hirsutism were found, so acromegaly was suspected. Elevations of prolactin and IGF-1 levels were found during whole pregnancy.

After six months post-partum, laboratories were repeated and basal and 2hr insulin showed marked elevation, increased HOMA index, and normal IGF-1 and GH values. Thus, the diagnosis of Insulin Mediated Pseudoacromegaly was confirmed.

 

Nothing to Disclose: CRF, JHM, MS, CP, MMM, RT, MG, AS, MDLM, EG

12611 16.0000 MON-0719 A Young Female with Acromegaloid Features, Pituitary Macroadenoma and an Uncomplicated Pregnancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Aysegul Atmaca*, Elif Kilic Kan, Gokhan Sarisoy, Feyzi Gokosmanoglu and Gulcin Cengiz Ecemis
Ondokuz Mayis University School of Medicine, Samsun, Turkey

 

Pituitary lesions, with both hormonal deficiency and excess,  interfere with prefrontal cortex and limbic structures leading to changes in personality.  Little is known about the personality changes in acromegalic patients. In this cross-sectional study, we aimed to compare the personality changes of acromegalic patients with those of patients with non-functioning pituitary adenomas and a healthy control group. We used Cloninger’s Temperament and Character Inventory (TCI) to assess personality. Novelty seeking, harm avoidance, reward dependence, persistance, self-directedness, cooperativeness and self-transcendence are the scales of TCI. We also compared depression,  anxiety and self-esteem with Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI)and Rosenberg Self-Esteem Scale (RSES), respectively. Fifty-eight acromegalic patients, 45 patients with non-functioning adenoma and 40 healthy subjects were enrolled in the study. All three groups were age and gender matched. Depression and anxiety scores were higher in patients with acromegaly and non-functioning adenoma than healthy controls (p<0.001 for depression and p=0.004 for anxiety). RSES scores were similar among the three groups. Regarding the scales of TCI, only novelty seeking was significantly reduced in acromegalic patients and patients with non-functioning adenoma than the control group (p = 0.022). Pairwise comparisons revealed that the difference was due to the difference between acromegalic patients and controls (p = 0.019). Scales of TCI were correlated with depression and anxiety in patients with acromegaly and non-functioning adenoma but not in healthy controls. In conclusion, novelty seeking was reduced in patients with acromegaly. Reduced novelty seeking is related with the reduction in dopamin levels. However, we do not know much about changes in dopamin levels in acromegalic patients. More studies need to be done about personality changes in acromegaly and other pituitary diseases.

 

Nothing to Disclose: AA, EKK, GS, FG, GCE

13076 17.0000 MON-0720 A Personality Traits in Acromegalic Patients: Comparison with Patients with Non-Functioning Adenomas and Healthy Controls 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Izumi Fukuda*, Naomi Hizuka, Toko Muraoka and Atsuhiro Ichihara
Tokyo Women's Medical University, Tokyo, Japan

 

Background: Since 2000, post-surgical remission of acromegaly had been defined as nadir GH during OGTT was <1 μg/L and normal IGF-I.  However, in 2009, it was proposed that nadir GH of less than 0.4 μg/L would be consistent with remission using sensitive assays.

Objective: In this study, we investigated time-course of post-surgical IGF-I, which is a sensitive and practical biochemical marker of GH excess, in patients with acromegaly whose post-surgical nadir GH during OGTT was <1 μg/L.  The patients were divided into two groups according to nadir GH during post-surgical OGTT (group C: complete remission; nadir GH<0.4 μg/L and group I: inadequately controlled; nadir GH from 0.4 to <1 μg/L).  We compared normalization rate of IGF-I between these groups.

Patients and Methods: We studied 54 patients with naïve acromegaly (M/F 20/34, age range: 21-72) who underwent transsphenoidal surgery (TSS).  75g OGTT was performed within one month (median 13 days, 6-28 days) and serum IGF-I was measured 3 month (3M) and 12 months (12M) after TSS.

Results: Serum IGF-I normalized in 89% (48/54) patients in 3M after TSS.  Sixty percent of them (29/48) were in group C (nadir GH during OGTT <0.4 μg/L).  Serum IGF-I levels (3M) were high (2.41-3.81 SD) in 6 patients (11%).  Four of them were in group C.  Serum IGF-I normalized in 94% (51/54) patients in 12 M after TSS.  Sixty-one percent of them (31/51) were in group C.  Serum IGF-I levels (12M) were high (2.1-3.61 SD) in 3 patients remaining (6%).  Two of them were in group C (nadir GH 0.16,0.19), and one was in group I ((nadir GH 0.97).

Conclusion: The remission rate of acromegaly decreased when early post-surgical nadir GH during OGTT of <0.4 μg/L was applied.  However, patients’ clinical response to surgery might be various and the remission rate might be affected by the timing when post-operative OGTT was performed.  On the other hand, not a few patients in group I had persistent normal IGF-I levels at least 12M post-surgically, and were observed without any adjunctive therapy in a clinical practice.  Serum IGF-I levels and nadir GH were discordant in a few patients.  They had elevated IGF-I levels in spite of low nadir GH levels.  Longer follow up period might be required to establish the ideal management of these patients with “discordance”.

 

Disclosure: NH: Chairman, Pfizer, Inc., Consultant, Novo Nordisk, Speaker, Eli Lilly & Company, Speaker, JCR. Nothing to Disclose: IF, TM, AI

13397 18.0000 MON-0721 A The Evaluation of Remission in Patients with Post-Surgical Acromegaly Applying Previous and Newly Proposed Criteria 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Tomris Erbas*1, Nese Cinar2, Selcuk Dagdelen1, Arzu Gedik2, Hikmet Yorgun2, Ugur Canpolat2 and Giray Kabakci2
1Hacettepe University Medical School, 2Hacettepe University Medical School, Ankara, Turkey

 

Acromegaly is associated with increased cardiovascular morbidity. The role of renin-angiotensin-aldosterone system in this morbidity is unknown. We aimed to determine the effect of angiotensin converting enzyme (ACE) gene and angiotensinogen (AGT) gene polymorphisms on the development of cardiovascular and metabolic disorders in acromegalic patients.

Design:Cross-sectional study

Patients: One hundred and seventeen acromegalic patients (62 F/55 M, age: 50.2±12.3 yrs) and 106 healthy controls (92 F/14 M, age: 41.4±11.3 yrs) were enrolled in the study.

Measurements: The prevalence of ACE and AGT genotype was evaluated by PCR.

Results: The distribution of DD, ID and II genotypes in acromegalic patients was 41.0% (n: 48), 44.4% (n: 52) and 14.5% (n: 17), respectively. The frequencies of the ACE polymorphism in the control group were significantly different with prevalences of 48.1% (n: 51) for DD, 25.5% (n: 27) for ID and 26.4% (n: 28) for II genotype. One hundred and four acromegalic patients (88.9%) had AGT- MT genotype for AGT polymorphism, the rest had MM and TT genotype (9.4% MM genotype, 1.7 % TT genotype), with similar distribution in the controls (80.2% MT genotype, 15.1% MM genotype and 4.7% TT genotype). Anthropometric measures, blood pressure values and baseline GH and IGF-1 levels were similar among the groups in ACE genotype; whereas, the AGT-MM+TT group had significantly higher systolic blood pressure values [130 (126-150) vs. 122.5 (117-140) mmHg] and GH levels [40 (16-48) vs. 12 (5-34) µg/L] as compared to AGT-MT carriers. ACE- II group had significantly higher HDL-C levels than ACE-D allele carriers [59.8 (52.5-66.1) vs. 49 (39.0-56.0) mg/dL for ACE-DD group and 59.8 (52.5-66.1) vs. 44.7 (39.2-56.0) mg/dL for ACE-ID group, p<0.05 for all] with similar fasting plasma glucose levels. There was no significant difference in metabolic parameters among AGT genotypes in acromegalic patients. The prevalence of coronary artery disease, hypertension, hyperlipidemia and Type 2 diabetes mellitus did not differ among the groups in both genotypes. Regarding echocardiographic parameters, the patients showed similar systolic and diastolic function in both genotypes except significantly higher mitral inflow Apeak values in ACE-ID group compared to others [0.84±0.29 vs. 0.69±0.19 for ACE-DD group; 0.84±0.29 vs. 0.65±0.12 for ACE-II group, p<0.05 for all]. The ACE or AGT genotype had no significant effect on LV mass index values in acromegalic patients. 

Conclusion: Serum lipid levels are affected from the ACE genotype in acromegaly and ACE- D allele may predispose the development of diastolic dysfunction in acromegalic patients. AGT homozygous M and T allele genotype may have a role in the development of systolic hypertension in acromegaly.

 

Nothing to Disclose: TE, NC, SD, AG, HY, UC, GK

13427 19.0000 MON-0722 A Association Between ACE and AGT Polymorphism and Cardiovascular Risk in Acromegalic Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Henry Dufour*1, Thierry Brue2, Frederic Castinetti3, Isabelle Morange4, Frederique Albarel5 and Thomas Graillon6
1Aix Marseille University, Marseille, France, 2Hopital de la Conception, Marseille, France, 3La Timone Hospital, Marseille, France, 4CHU Timone, Marseille - CDX 05, France, 5CHU Timone Marseille, MArseilles, France, 6CHU Timone, Marseilles, France

 

Context: Following the recent evolution in therapeutic strategies for GH-secreting pituitary adenomas, determining optimal individualized patient management is now crucial.

Objective: To determine whether pre-surgical medical treatment (PSMT) in patients with acromegaly improves surgical outcome and to specify thresholds for such a strategy.

Methods and design: This retrospective study included 110 newly diagnosed acromegalic patients operated on between 1997 and 2007 at Timone Hospital, Marseille, France. The mean long-term follow-up period was 52 ± 36.6 months (median 41 months). Sixty-four patients (58.4%) received PSMT (long acting Somatostatin Analogs) during 2 to 18 months (mean 6.4 months) and all patients underwent pituitary surgery. Remission was based on updated criteria, associating GH nadir after oral glucose tolerance test <0.4 µg/L and normal IGF-1 for age, sex and gender at early (3 months) evaluation or at the end of follow-up (n=95).

Results:  In multivariate analysis, PSMT was significantly linked to early remission (45.3% patients in remission with PSMT vs 26.1% without; p=0.01) and to long-term remission (61.1% with PSMT vs 36.6% without; p<0.01). Duration of PSMT was not significantly different in cured or non-cured patients, at both evaluations. At 3 months and at long-term evaluation, pre-treated and non pre-treated groups were comparable for the main confounding factors except for IGF-1 at diagnosis which was higher in patients with PSMT. PSMT was more beneficial for patients with somatotroph adenoma larger than 15 mm. Noteworthy, no patient with a more than 18 mm adenoma or a mean GH exceeding 35 ng/ml at diagnosis was cured by surgery without PSMT.

Conclusions: Pre-surgical medical treatment significantly improved short and long-term remission in acromegalic patients, independently of its duration and main confounding factors, and seemed to be especially interesting in adenomas larger than 15 mm.

 

Disclosure: TB: Clinical Researcher, Pfizer, Inc., Clinical Researcher, Novo Nordisk, Clinical Researcher, Novartis Pharmaceuticals, Clinical Researcher, Ipsen, Clinical Researcher, Serono, Clinical Researcher, Sandoz. Nothing to Disclose: HD, FC, IM, FA, TG

13447 20.0000 MON-0723 A Pre-Surgical Medical Treatment Improve the Remission Rate in Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Shingo Fujio*1, Yuki Kasamo2, Mika Habu1, Syunji Yunoue3, Hirofumi Hirano4, Hiroshi Tokimura1, Hiroshi Arimura3, Yoshihiko Nishio1 and Kazunori Arita1
1Graduate School of Medical and Dental Sciences Kagoshima University, Kagoshima, Japan, 2Graduate School of Medical and Dental Sciences, Kagoshima University, Kaghosima, Japan, 3Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan, 4Graduate School of Medical and Dental Sciences Kagoshima University, kagoshima, Japan

 

Introduction

Remission criteria for acromegaly have been in the middle of spirited discussion, but since GH and IGF-1 would be influenced by age, physical shape, and nutrition status, the consensus has not yet been reached whether the unified remission criteria should be applied to all patients. We compared young and elderly patients, and then examined their pathologic characteristics by generation.

Subjects and methods

The study consisted of 59 patients who underwent surgery for primary acromegaly at our hospital. We classified them into Y group with age under 50 years (24 patients; 10 male and 14 female) and O group with age over 50 years (35 patients; 13 male  and 22 female), then compared/examined their clinical features and pathological findings. The age range for Y group was 18-49 years (Mean±SD: 33.0±8.1 years) while the age range for O group was 50-75 years (60.5±7.4 years)

Results

Y group had significantly larger tumor size (23.1±10.1 vs 15.8±6.0 mm, p<0.01) and high GH level (33.5±39.7 vs 16.0±14.6 ng/ml, p=0.02) before operation. Although the preoperative IGF-1 level was higher for Y group (809.7±325.9 vs 541.5±164.4 ng/ml, p<0.01), there was no difference between the two groups when calculated in SD score. The postoperative remission rate was 54.2% (13/24) for Y group and 97.1% (34/35) for O group. When they were classified into dot pattern, perinuclear pattern, and mixed pattern with cytokeratin staining, the results were 36.4%, 45.5%, and 18.1% for Y group and 20.6%, 55.9%, and 23.5% for O group respectively; therefore, more dot patterns were present in Y group.

Conclusion

There was a large difference between young group and elderly group in preoperative tumor size, GH level, and remission rate. Histological type of GH producing adenoma indicated a different possibility with generation and age would be considered to be one of the important factors for treatment strategy.

 

Nothing to Disclose: SF, YK, MH, SY, HH, HT, HA, YN, KA

14284 21.0000 MON-0724 A Characteristics of Acromegalic Patients By Generation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Ignacio Bernabeu*1, Eva Venegas2, Tomás Lucas3, Cristina Alvarez -Escola4, Juan Antonio Garcia-Arnés5, Mónica Marazuela6, Peter J. Jonsson7, Nuria Mir8, Roy Gomez9, Spanish Acrostudy Group10 and Antonio Pico11
1Complejo Hospitalario Universitario de Santiago de Compostela, Universidad de Santiago de Compostela, Santiago de Compostela, Spain, 2Instituto de Biomedicina de Sevilla (IBiS), Consejo Superior de Investigaciones Científicas, Endocrinology Unit of Virgen del Rocío University Hospital, University of Seville, Sevilla, Spain, 3Hospital Universitario Puerta de Hierro, Majadahonda, Spain, 4Hospital Universitario La Paz, Madrid. Spain, 5Hospital Carlos Haya, Malaga, Spain, 6Hospital Universitario de La Princesa, Instituto de Investigacion Princesa. Universidad Autonoma, Madrid, Spain, 7Endocrine Care, Pfizer Health AB, Sollentuna, Sweden, 8Pfizer Medical Affairs, Madrid, Spain, 9Pfizer Medical Affairs Europe, 10Acrostudy centers Spain, Spain, 11Hospital General Universitario de Alicante, Alicante, Spain

 

ACROSTUDY is a global non-interventional safety surveillance study designed to evaluate long-term safety and treatment outcomes of pegvisomant (PEG) treatment.

Objective: Evaluate long-term safety of PEG in the Spanish cohort of ACROSTUDY.

Methods: 199 Spanish patients have been included in ACROSTUDY as of July 2013. All patients were observed for safety, 99% of patients for biochemical and 92.5% for local MRI evaluations.

Results: 199 patients included, 57% were female. 48.2% received PEG monotherapy. The mean age at start of PEG treatment was 49.6±14.3 years. The mean daily dose was 15.5 ±7.5 mg.The mean follow up was 6.7±2 years and the mean time since inclusion in ACROSTUDY was 4.9±1 years. 195 adverse events (AE) were reported in 88 patients (44.2%), among which 34 AEs in 23 patients (11.6%) were considered related to PEG treatment. Serious AEs (SAEs) were described in 31 patients (15.6%), and in 3 cases (1.5%) the SAEs were considered related to treatment, including pituitary tumour recurrence (1), lipohypertrophy (1) and a no therapeutic response (1).PEG was discontinued due to an SAE in 16 cases (8%), only 2 (1%) were related to treatment (no therapeutic response and pituitary tumor recurrence). 10 patient deaths were unrelated to PEG. Injection site reactions were observed in 5 patients (2.5%) and abnormal liver tests (ALT or AST >3 ULN).were reported in 3 (1.5%) patients. There were no cases of transaminases >10 ULN, liver failure or permanent liver damage. At baseline, diabetes mellitus (DM) was documented in 61 patients. In the DM group, mean change in glucose levels from baseline at year 1 and 4, were statistically significant (-24.6mg/dL and -25.9mg/dl, respectively; p=0.04). The DM group showed no changes in Hb1Ac during the course of treatment. Changes in tumor size were locally reported in 61 cases (33.5%). An increase was observed in 11 cases (6%), a decrease in 45 cases (24.7%) and both increase and decrease in 5 cases (2.7%). These changes were not confirmed by a central MRI reading. Among the 45 cases with a tumor decrease, 25 had been previously irradiated.  

Conclusion:  This analysis showed that long-term treatment with PEG (6.7±2 years) is not associated with an increased frequency safety findings such as liver dysfunction or pituitary tumor size increase.  In patients with DM on PEG treatment a decrease in serum glucose values were reported.

 

Disclosure: IB: Clinician, Ipsen, Clinician, Pfizer, Inc., Clinician, Novartis Pharmaceuticals, Clinician, Pfizer, Inc.. MM: Principal Investigator, Pfizer, Inc.. PJJ: Employee, Pfizer, Inc.. NM: Employee, Pfizer, Inc.. RG: Employee, Pfizer, Inc.. AP: Investigator, Pfizer, Inc.. Nothing to Disclose: EV, TL, CA, JAG, SAG

14397 22.0000 MON-0725 A Safety of Long-Term (up to six years) Treatment with Pegvisomant: Analysis of Spanish Patients Included in Global Acrostudy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Aida Glamocak*1, Ghulam Warsi2, Luz Zimmermann2 and William H Ludlam2
1Novartis Pharmaceuticals, East Hanover, NJ, 2Novartis Pharmaceuticals Corporation, East Hanover, NJ

 

Background:Pasireotide is a novel somatostatin analogue (SSA) with a broader binding profile to somatostatin receptors than the 2 SSAs currently approved for treatment of acromegaly, octreotide and lanreotide. In a phase 3 trial in patients with active acromegaly, pasireotide long-acting release (LAR) demonstrated superior efficacy versus octreotide LAR, with rapid and sustained reductions in levels of growth hormone (GH) and insulin-like growth factor 1 (IGF-1). ACCESS (NCT01995734) is an open-label, uncontrolled, single-arm, multicenter, expanded treatment protocol study designed to provide acromegalic patients for whom medical therapy is appropriate with access to pasireotide LAR while regulatory approval is sought.

Objective and Design:The primary objective of the ACCESS study is to document the safety of pasireotide LAR in patients with acromegaly. Patients aged ≥18 years with a confirmed diagnosis of active acromegaly caused by a GH-producing pituitary tumor, lack of disease control by pituitary surgery or ineligibility for surgery, and Karnofsky performance status >60 are included. Eligible patients must have demonstrated elevated (>1.3 x upper limit of normal [ULN]) circulating IGF-1 concentrations (age- and sex-adjusted) and random GH concentration >1 μg/L within 28 (± 2) days before screening.

After screening, which includes a washout period for prior acromegaly medications of at least 8 weeks, patients (estimated enrollment, n=40) will receive pasireotide LAR 40 mg administered intramuscularly every 28 days. IGF-1 and GH will be monitored every 3 months. Pasireotide LAR dose may be increased to 60 mg for patients with age- and sex-adjusted IGF-1 levels > ULN after a third injection with pasireotide LAR 40 mg.

The primary endpoint of the study is the proportion of patients who experience a treatment-emergent grade 3 or 4 adverse event (AE) or a serious AE. Secondary endpoints are incidence of AEs plus laboratory, vital sign, and electrocardiographic abnormalities.

Results: The trial is ongoing, and results are not currently available. Patients will be treated until pasireotide LAR becomes commercially available and reimbursed, or until December 31, 2015, whichever occurs first.

Conclusion: The ACCESS study will provide important information regarding the safety and tolerability of pasireotide LAR in patients with acromegaly.

 

Disclosure: AG: Employee, Novartis Pharmaceuticals. GW: Employee, Novartis Pharmaceuticals. LZ: Employee, Novartis Pharmaceuticals. WHL: Employee, Novartis Pharmaceuticals.

14600 23.0000 MON-0726 A An Acromegaly, Open-Label, Multi-Center, Safety Monitoring Program for Treating Patients with SOM230 (pasireotide) LAR Who Have Need to Receive Medical Therapy (ACCESS) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Tanya Burton*1, Laura Becker2, Elisabeth LeNestour3, Maureen P Neary4 and William H Ludlam4
1Optum, Waltham, MA, 2OptumInsight, 3inVentiv Health Clinical, France, 4Novartis Pharmaceuticals Corporation, East Hanover, NJ

 

OBJECTIVE: To describe the treatment journey of acromegaly patients in a large US managed care health plan.

METHODS: A retrospective cohort study design was used to analyze administrative claims data of commercial health plan enrollees with evidence of acromegaly between 1/2000-6/2012. Children and adults with 2+ acromegaly diagnosis codes (ICD-9: 253.0x) or an acromegaly diagnosis code in combination with a pituitary tumor or procedure were observed for at least 6 months after their first acromegaly-related claim. Use of acromegaly-related surgery (hypophysectomy), medical (octreotide, lanreotide, pegvisomant, bromocriptine, cabergoline) and/or radiation therapy was reported descriptively.

RESULTS: Of the 1,031 acromegaly patients identified, 350 (34%) had some evidence of an acromegaly-related treatment.  Those with and without treatment had similar distributions of sex (~50%) and death (4%), while those treated were on average older than those without treatment (45 years vs. 40 years, p<0.001). Enrollment with acromegaly between 2000-2011 was steady and ranged between 4-10% each year. (Enrollment for January – June 2012 was 4%.) Yet the trend for treatment shifted about midway, with a higher proportion receiving treatment  each year starting in 2008. Among the 350 with treatment, the first therapy received was medical for 94 (27%), surgical for 252 (72%), and radiation for 4 (1%). Second and third lines of therapy were observed for 116 and 49 patients, respectively. Use of medical and radiation therapy increased while surgery decreased during the second and third lines of therapy (2nd line: medical – 89 [77%], surgery – 19 [16%], and radiation – 8 [7%]; 3rd line: medical – 29 [59%], surgery – 14 [29%], and radiation – 6 [12%]).

CONCLUSION: Little is known about the treatment journey of patients with acromegaly in the US. This study provided an opportunity to describe in detail the treatment patterns of acromegaly patients in a large managed care health plan over a 12-year time period. This analysis examined the type and nature of first, second, and third lines of treatment for patients with this rare disease. Future evaluations will include estimating treatment durations and transition intervals between each line of therapy.

 

Disclosure: TB: Researcher, Novartis Pharmaceuticals. LB: Researcher, Novartis Pharmaceuticals. MPN: Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals, Employee, Novartis Pharmaceuticals. WHL: Employee, Novartis Pharmaceuticals. Nothing to Disclose: EL

14602 24.0000 MON-0727 A Acromegaly Treatment Patterns in a Large US Managed Care Health Plan 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Andrea Giustina*1, John S Bevan2, Marcello D Bronstein3, Felipe F Casanueva4, Philippe Chanson5, Stephan Petersenn6, Xuan-Mai Truong Thanh7, Christine Massien7, Carla Dias-Barbosa8, Isabelle Guillemin8, Benoit Arnould8 and Shlomo Melmed9
1University of Brescia, Brescia, Italy, 2Aberdeen Royal Infirmary, Aberdeen, Scotland, United Kingdom, 3Hosp das Clin/Univ Sao Paulo, Sao Paulo SP, Brazil, 4Santiago de Compostela, Santiago Compostela, Spain, 5Univ Paris-Sud, UMR-S693, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France, 6ENDOC Center for Endocrine Tumors, Hamburg, Germany, 7Ipsen Pharma, Boulogne Billancourt, France, 8Mapi, Lyon, France, 9Cedars-Sinai Medical Center, Los Angeles, CA

 

Introduction: Acromegaly is a rare, chronic, disorder caused by excessive growth hormone (GH) and insulin-like growth factor 1 (IGF-1) production resulting predominantly from a pituitary adenoma. The objective was to test the acceptability to endocrinologists of a newly developed SAGIT tool in clinical practice.

Methods: SAGIT (Signs and symptoms - Associated comorbidities - GH concentration level – IGF-1 – Tumor) is a Clinician-Reported Outcomes (ClinROs) tool developed by international acromegaly experts; it allows patients to be classified and described in a standardized manner. The tool was pre-tested for acceptability, understanding, and ease of use with practicing endocrinologists in France, Germany, United Kingdom, Spain, Italy, and Brazil (n=2 per country) using the PRAgmatic Content and face validity Test (PRAC-Test). Endocrinologists completed the SAGIT tool prior to and following an intervention (therapeutic or surgery) for three patients each (n=36). Once completed, a 1-hour phone interview was conducted with each endocrinologist to collect feedback on the utility of the tool.

Results: The tool was well accepted and deemed concise (11/12, 92%) and informative (10/12, 83%). Several illustrations of usefulness in clinical practice included: removal of subjectivity when assessing disease severity, opportunity for rapid evaluation of control/progression of acromegaly or of a treatment response, and the achievement of standardization across countries. Key recommendations for improvements included: 1) instructions to facilitate understanding and use of the tool; 2) definitions of rules and recommendations for patient management; and 3) addition of other signs and symptoms and further details about tumor size to better reflect clinical situations.

Conclusions: SAGIT is a useful tool for endocrinologists to accurately stage and classify acromegaly patients in clinical practice, and is currently undergoing a cross-sectional study. Validation of scoring rules will confirm the utility of the tool to improve patient management.

 

Disclosure: AG: Consultant, Ipsen, Consultant, Novartis Pharmaceuticals, Consultant, Pfizer, Inc.. JSB: Consultant, Ipsen, Study Investigator, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, ViroPharma. MDB: Advisory Group Member, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Pfizer, Inc., Advisory Group Member, Chiasma, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Principal Investigator, Ipsen, Principal Investigator, Novartis Nutrition, Inc.. PC: Researcher, Ipsen, Researcher, Novartis Pharmaceuticals, Researcher, Novo Nordisk, Researcher, Pfizer, Inc., Advisory Group Member, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Viropharma, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Speaker, Pfizer, Inc.. SP: Speaker, Pfizer, Inc., Speaker, Novartis Pharmaceuticals, Speaker, Ipsen, Advisory Group Member, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Pfizer, Inc.. XMT: Employee, Ipsen. CM: Employee, Ipsen. CD: Consultant, Ipsen. IG: Consultant, Ipsen. BA: Consultant, Ipsen. SM: Principal Investigator, Ad Hoc Consultant, Ad Hoc Consultant, Genentech, Inc., Principal Investigator, Pfizer, Inc., Planning Group Member, Ipsen. Nothing to Disclose: FFC

14835 25.0000 MON-0728 A Sagit©: A Novel Comprehensive Clinical Practice Tool for Managing Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Alessandra Casagrande*1, Debora Maria Nazato2, Marcello D Bronstein3, Raquel S Jallad4, Mônica Gadelha5, Nelma Veronica Marques6, Aline Barbosa Moraes7, Mauro Antonio Czepielewski8, Artur Boschi8, Lucio Vilar9, Paula C. L. Elias10, Margaret De Castro11, Antonio Ribeiro Oliveira Junior12, Junia Schweizer13, Estela Muszkat Jatene14, Miriam da Costa Oliveira15, Carolina G.S. Leaes16, Cesar Luiz Boguszewski17, Jose Italo Soares Mota18, Paulo Augusto Miranda19 and Julio Abucham20
1Unifesp-Endocrinologia, Sao Paulo/SP, Brazil, 2Universidade Federal de São Paulo, Vila Clementino-Sao Paulo, Brazil, 3University of São Paulo Medical School, São Paulo, Brazil, 4Hosp das Clinicas Univ of Sao Paulo Medical School, Sao Paulo SP, Brazil, 5Federal University of Rio de Janeiro, Rio de Janeiro, Brazil, 6Universidade Federal do Rio de Janeiro, 7UFRJ, Rio De Janeiro, Brazil, 8Faculdade de Medicina UFRGS, Porto Alegre, Brazil, 9Federal Univ of Pernambuco, Recife (Pernambuco), Brazil, 10Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil, 11Sch of Med of Ribeirao Preto-U, Ribeirao Preto SP, Brazil, 12UFMG, Brazil, 13Universidade Federal de Minas Gerais (UFMG), 14H Clinicas UF Goias, Goiania, Brazil, 15Univ Fed Ciencias Saude, Porto Alegre RS, Brazil, 16Complexo de Santa Casa, Porto Alegre, Brazil, 17Sempr Fed Univ Parana, Curitiba, Brazil, 18Hosp Geral de Fortaleza, Fortaleza Ceara, Brazil, 19Santa Casa de Belo Horizante, Belo Horizonte MG, Brazil, 20UNIFESP/ Escola Paulista de Me, Sao Paulo, Brazil

 

Introduction: Remission of acromegaly after drug treatment withdrawal has been recently reported in a considerable proportion of patients in a few studies with relatively small number of patients. 

Aim: To evaluate short and long term biochemical control (remission), predictive factors, and tumor growth following drug treatment withdrawal in acromegaly.

Inclusion criteria: Adult patients with acromegaly receiving octreotide LAR and/or cabergoline for at least 24 months, on stable doses and dose frequency in the previous year, with mean IGF-1 levels over the last two years within the normal range for age. Exclusion criteria: pituitary tumor near the optic chiasm (<5mm), pregnancy, pituitary radiotherapy in the last ten years, and current treatment with pegvisomant.

Study protocol: Patients were clinically and biochemically evaluated before and at 8, 16, 24, 36, 48, 60, 72, 84, 96, and 108 weeks after octreotide or cabergoline withdrawal. A quality of life questionnaire (AcroQol) was applied at each visit; GH levels during oGTT and sellar MRI scans were performed before and at 48 and 96 weeks. All patients with recurrence (IGF- 1>1.2 ULN) were returned to previous treatment. Once IGF-1 levels returned to the normal range, octreotide injection interval was increased (+2 weeks) or cabergoline dose was  reduced by 50% in patients who had recurred at or after 16 weeks.

Methods: Serum IGF-1 was measured by Immulite® and expressed as the ratio between IGF-1 concentration and the upper limit of the normal range for age (ULN). Statistical analysis were performed by Graph Pad Prism; significance was set at P<0.05.

Results: Seventy-two patients (49 F; mean age: 41 y) from 12 centers were included from January/2013 to January/2014; inclusion period will end in April/2014; longest follow up: 48 weeks. Previous treatment: only surgery (66); surgery and radiotherapy (13). Drug treatment was octreotide (66), cabergoline (4), or both (2). Twenty-six patients had no visible tumor at pituitary MRI. Number of patients already seen on follow up visits until January/2014: 29 (8w); 13 (16w); 5 (24w); 4 (36w) and 4 (48w).

Partial analysis of data shows that IGF-1 levels remained normal in 18 (62%) and recurred in 11 (38%) patients at 8w. Early recurrence (8w) was significantly associated with the presence of a tumor remnant at MRI (P=0.018, Fisher´s exact test), but not with age, sex, previous treatment, drug dose, AcroQol score, GH, Prolactin, and IGF-1 levels before drug suspension. At 16 weeks, IGF-1 levels remained normal in 10 (77%) and recurred in 3 (23%). The number of patients reaching 24-48 weeks of follow up in our next report (June/2014) should be adequate for statistical analysis and is expected to provide meaningful information on the remission and recurrence rates as well as on predictive factors for those outcomes following treatment  withdrawal  in patients with acromegaly.

 

Disclosure: AC: Employee, Novartis Pharmaceuticals. MG: Medical Advisory Board Member, Novartis Pharmaceuticals, Collaborator, Novartis Pharmaceuticals, Collaborator, Ipsen, Collaborator, Pfizer, Inc., Principal Investigator, Novartis Pharmaceuticals, Researcher, Novartis Pharmaceuticals, Researcher, Pfizer, Inc.. NVM: Consultant, Novartis Pharmaceuticals. ABM: Consultant, Novartis Pharmaceuticals. CLB: Speaker, Novartis Pharmaceuticals, Participant, Novartis Pharmaceuticals. JA: Consultant, Novartis Pharmaceuticals, Consultant, Ipsen, Consultant, Pfizer, Inc.. Nothing to Disclose: DMN, MDB, RSJ, MAC, AB, LV, PCLE, MD, AROJ, JS, EMJ, MDCO, CGSL, JISM, PAM

15072 26.0000 MON-0729 A Biochemical Remission of Acromegaly after Withdrawal of Drug Treatment: Preliminary Data from a Large Prospective Multicentric Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Selcuk Dagdelen*1, Safak Akin1, Levent Kilic2, Ali Akdogan2 and Tomris Erbas1
1Hacettepe University Medical School, 2Hacettepe University Medical School, Ankara, Turkey

 

Background and aim: Acromegaly is characterized by an increased risk of cardiovascular disease. While macrovascular changes are widely investigated, microvascular involvement is not a known entity in acromegaly. Nailfold videocapillaroscopy is one of the best non-invasive imaging techniques to evaluate microcirculation. Here we aimed to investigate the microvascular changes in acromegaly with nailfold videocapillaroscopy.

Methods: Twenty-five patients ( 13 males and 12 females; aged 17-71 yr) with acromegaly, 17 patients had controlled disease activity (IGF-I: 197.8 ± 82.0 ng/mL; GH: 2.7 ± 3.6 ng/mL) and 8 patients had active disease (IGF-I: 675.5 ± 213.6 ng/mL; GH: 31.4 ± 5.1 ng/mL) were evaluated with nailfold videocapillaroscopy (video capnet DS medica-Milano) with the following parameters: tortuous and enlarged loops; presence of capillary loss, haemorrhage, and giant capillary.

Results: Morphological alterations at microcirculation was observed in 52 % of our patients (13/25). Abnormal nailfold videocapillaroscopy findings were as follows: haemorrhage (n= 5, 20 %), enlarged loops (n=5, 20%) and tortuous loops (n=6, 24%). None of the patients had capillary loss and/or giant capillary. No significant correlation was found between microvascular changes and disease activity and/or gender.

Conclusions: Our study shows that, microvascular involvement is underestimated in acromegaly, and it can be easily documented by videocapillaroscopy.

 

Nothing to Disclose: SD, SA, LK, AA, TE

15195 27.0000 MON-0730 A Assessment of the Microcirculation in Vivo with Nailfold Videocapillaroscopy in Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Alexander V Dreval*, Yulia G Pokramovich, Olga Nechaeva, Tatyana Shestakova, Irina V Trigolosova and Irena A Ilovayskaya
Moscow Regional Research & Clinical Institute, Moscow, Russia

 

ACRO-registry in Moscow Region included 180 patients with acromegaly (80% women, 20% men), age 22-77 y.o. (median 55 y.o.). Median age at diagnosis was 49 y.o., median period from the onset of first acromegaly symptoms to diagnosis of acromegaly was 6 (2-25) years. Patients had macroadenoma in 77.8%, microadenoma – in 23.2% of cases.

We have analyzed clinical symptoms and signs in patients with active acromegaly. One of the most frequent complaints (89.9% of cases) was sweating: it was slightly increased in 15.6%, moderate in 25.6% and severe in 48.7% of patients. Headache was observed in 87.4% of patients: periodic in 34.4%, moderate with good effect of analgetics in 40% and permanent without effect of analgesics in 13.0% of patients. Muscle weakness and decreased exercise tolerance identified in 87.2% of cases: with slight disturbance in 30.0%, moderate in 33%, and severe in 24.2% of patients. Swelling of the face and limbs was observed in 84.1 % of patients: mild in 20.1%, moderate in 21.4%, and serious in 42.6% of patients. Diastema was revealed in 60.0% of patients, prognathism – 45.7%, skin papillomas – 61.4%. Arthralgia was noted in 72% of patients: periodic in 27.1%, moderate in 18.8 %, and severe with moving restrictions in 26.1% of cases. Hypertension was observed in 64.7% of cases (1-2-3 stage of hypertension in 53.5 - 32.1 - 14.2% of patients, respectively). Significant sleep breathing disorders were found in 80% of patients: moderate in 46% and severe in 34% of cases. Severity of SBD was associated with patients’ age, IGF-1 levels, acromegaly duration and gravity of hypertension. Glucose metabolism disorders were found in 75.4% of patients: prediabetes in 25.8% and overt diabetes in 52.6%. In women of reproductive age menstrual and/or reproductive disturbances were observed in 89% of cases: amenorrhea (34%), opsomenorrhea (34%), menorrhagies (14.9%), acyclic bleeding (6.4%), infertility (26.7%); it was one of the first symptoms of acromegaly in 36.2% of women. Thyroid disorders were found in 78% of patients and included nodular goiter (46.7%), diffuse goiter (14.3%), thyroid cancer (9.5%). Hyperprolactinemia presented in 55% of cases (mostly – due to pituitary stalk compression).

Thus, high rate of comorbidities was found in our cohort of patients with active acromegaly so observation of the acromegalic patients should be dynamic and multimodal.

 

Nothing to Disclose: AVD, YGP, ON, TS, IVT, IAI

15724 28.0000 MON-0731 A Symptoms and Sign of Active Acromegaly in Patients from Moscow Region 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Felipe HG Duarte*1, Raquel S Jallad2 and Marcello D Bronstein3
1Hospital das Clinicas, University of São Paulo Medical School, São Paulo, Sao Paulo, Brazil, 2Hosp das Clinicas Univ of Sao Paulo Medical School, Sao Paulo SP, Brazil, 3University of São Paulo Medical School, São Paulo, Brazil

 

Background. Surgery and medical therapy (somatostatin analogs and cabergoline) are the mainstay of acromegaly treatment. Although surgical technique and drugs have improved along the years the rate of cure/control do not encompass all patients. In the last decade the use of the GH receptor antagonist pegvisomant led to improvement of these rates but it is not available in all medical centers.  Few studies have looked for other drug options for uncontrolled patients. Estrogen and selective estrogen receptor modulators (SERM) have shown to impair IGF-1 generation in GH-deficient patients under GH replacement. Concerning acromegaly, few studies have shown slight reduction of IGF-1 levels under tamoxifen or raloxifen. Clomiphene citrate (CC) is a SERM that can increase LH and FSH secretion improving hypogonadism and fertility outcomes. No studies looked at the impact of CC on IGF-1 and testosterone levels as seen with other SERMs.

Objective. To assess the impact of CC on IGF-1 and testosterone levels in non-controlled patients by surgery, radiotherapy and/or medical treatment (octreotide LAR and/or cabergoline) at our institution.

Patients and method. Sixteen male patients (median age: 52.5 years, range 34-79 years) met the following criteria: one or more years of continuous acromegaly treatment, IGF-1 above the upper limit of normal range (ULNR) for at least one year despite the use of all available medical therapies (Octreotide LAR and/or cabergoline). Testosterone was assessed in 13 patients who were not on testosterone replacement. CC (50 mg/day) was added to their previous treatment for 3 months in an open label, non-controlled prospective study that was approved by local ethical committee.

Results. During CC treatment, serum IGF-1 levels decreased by 40±14% (mean±SD)  (412±101 to 246±82 ng/mL, P=0.0004) leading 56% of patients (9/16) to normalize IGF-1 levels. In addition, testosterone levels increased by 209±233% (mean±SD) (282±210 to 497±310 ng/dL, P= 0.020) normalizing in 71% (5/7) of patients with previous low hormonal level. No side effects were reported during treatment.

Conclusion. The addition of CC should be considered as an option in male acromegalic patients non-controlled by conventional medical therapy, particularly in those with central hypogonadism. Further studies are needed in order to assess the efficacy and safety of such treatment in the long term, as well as the role as monotherapy.

The authors declare no conflict of interests.

 

Nothing to Disclose: FHD, RSJ, MDB

15783 29.0000 MON-0732 A Impact of Clomiphene Citrate on IGF-1 and Testosterone Levels in Acromegalic Patients Non Controlled By Conventional Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Philippe Caron*1, Stephan Petersenn2, Daniel Flanagan3, Antoine Tabarin4, Gaetan Prevost5, Pascal Maisonobe6, Caroline Sert6 and John S Bevan7
1CHU Larrey, TOULOUSE, France, 2ENDOC Center for Endocrine Tumors, Hamburg, Germany, 3Derriford Hospital, Plymouth, United Kingdom, 4Universite de Bordeaux II/Hopital Haut Leveque, Pessac, France, 5CHU de Rouen, Bois-Guillaume, France, 6Ipsen Pharma, Boulogne-Billancourt, France, 7Aberdeen Royal Infirmary, Aberdeen, Scotland, United Kingdom

 

Introduction: The PRIMARYS study showed that primary therapy with lanreotide Autogel 120 mg is associated with tumor volume reduction (TVR) in treatment-naïve acromegalic patients. In fact, 63% of patients in the study achieved TVR ≥20% at week 48. Here, we present post hoc analyses conducted on the PRIMARYS dataset to further characterize tumor responses over time. In particular, we investigate whether baseline TV and TVRs at 12 and 24 weeks are correlated with TVRs at 48 weeks, and may therefore be predictors of a tumor response at 48 weeks. 

Methods: PRIMARYS was an international multicenter open-label single-arm study of 90 treatment-naïve acromegalic patients with pituitary macroadenomas receiving primary therapy with lanreotide Autogel 120 mg every 28 days for 48 weeks (NCT00690898). TVR was measured at 12, 24, and 48 weeks using central assessments of MRI scans. The primary endpoint was the proportion of patients with ≥20% TVR from baseline at week 48/last post-baseline value available (LVA). Post hoc correlation analyses have been performed for each of baseline TV and TVRs at 12 and 24 weeks vs TVR at 48 weeks; descriptive statistics have also been generated for shifts in TVR rates at various timepoints and for TVR over time stratified by TVR subgroups.

Results: There was a strong and statistically significant correlation between TVR at 12 and 24 vs 48 weeks (correlation coefficients, 0.79 and 0.76, respectively; p<0.0001 for both); there was no correlation between baseline TV and TVR at 48 weeks. Of 46 patients with a tumor response at 12 weeks, 43 (93%) maintained the response at 48 weeks; of 39 without a 12-week response, 11 (28%) had a response at 48 weeks. Maintenance of a response was also high between weeks 24 and 48 (42/45 [93%]); of 35 patients without a 24-week tumor response, 11 (31%) had a response at 48 weeks.

Conclusions: These post hoc analyses in acromegalic patients with macroadenomas suggest an early assessment of tumor responses to primary treatment with lanreotide Autogel 120 mg is, for the most part, predictive of a continuing response over subsequent months. The predictive value of the 12-week tumor response with lanreotide Autogel may be helpful for clinicians appraising the treatment options for individual patients.

 

Disclosure: PC: Advisory Group Member, Ipsen, Speaker, Novartis Pharmaceuticals, Speaker, Ipsen, Consultant, Novartis Pharmaceuticals, Consultant, Ipsen. SP: Advisory Group Member, Ipsen, Advisory Group Member, Novartis Pharmaceuticals, Advisory Group Member, Pfizer Global R&D, Speaker, Pfizer, Inc., Speaker, Novartis Pharmaceuticals, Speaker, Ipsen. DF: Consultant, Novartis Pharmaceuticals, Researcher, Ipsen, Speaker, Ipsen. AT: Speaker, HRA Pharma, Speaker, Novartis Pharmaceuticals, Consultant, HRA Pharma, Consultant, Novartis Pharmaceuticals, Consultant, Ipsen. PM: Employee, Ipsen. CS: Employee, Ipsen. JSB: Advisory Group Member, ViroPharma, Advisory Group Member, Novartis Pharmaceuticals, Study Investigator, Ipsen, Consultant, Ipsen. Nothing to Disclose: GP

15830 30.0000 MON-0733 A Tumor Responses to Lanreotide Autogel/Depot 120 Mg after 12 and 24 Weeks Are Correlated with Tumor Responses after 48 Weeks in Treatment-Naïve Acromegalic Patients: Post Hoc Analyses of the Primarys Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Natasa Rajicic1, Judith Hey-Hadavi2, Nina Camacho-Hubner2, Nicky Kelepouris3, Roy Gomez4, Joseph F. Heissler2 and Jose Francisco Cara*5
1Pfizer, Inc., New York, NY, 2Pfizer Inc, New York, NY, 3Pfizer, Collegeville, PA, 4Pfizer UK, Brussels, Belgium, 5Pfizer Global Pharmaceuticals, New York, NY

 

Background: Additional safety data (SD) have become available since initial regulatory approval of PEGV for treatment of acromegaly in 2003. Purpose: To integrate, analyze and evaluate all reported SD from subjects with acromegaly enrolled in PEGV interventional clinical trials (CTs). Methods: Data from 15 PEGV CTs (2 placebo-controlled) were combined to create an ICTSD.  SD were analyzed to identify the most commonly reported treatment-emergent adverse events (AEs), new AEs and assess the overall safety profile of PEGV. Results: The ICTSD included 550 unique (non-duplicate) subjects (56% males) who received at least one dose PEGV and 47 unique placebo subjects. Ages ranged from 20 to 84 years (mean 46.8 ± 12.9 years). Median treatment duration (TD) was 283.5 days and total TD was 188,550 patient-days. Incidence of AEs was 83.3% in the PEGV group and 76.6% in the placebo group. Common AEs reported by >10% of PEGV subjects included headache, nasopharyngitis, arthralgia, diarrhea, and back pain. In the PEGV group, uncommon AEs known to be associated with PEGV were (n[%]): alanine aminotransferase (ALT) increased (14 [2.5%]), hepatic enzymes increased (12 [2.2%]), transaminases increased (11 [2.0%]), liver function test (LFT) abnormal (9 [1.6%]), and aspartate aminotransferase (AST) increased (8 [1.5%]). Eight deaths were reported among the 550 subjects (1.5%) but none were treatment related. Serious AEs (SAEs) were reported in 15.5% of PEGV and 6.4% of placebo subjects. SAEs reported in more than one PEGV subject (n) included chest pain (8), cholelithiasis (5), pneumonia (4), colonoscopy (4), myocardial infarction, cerebrovascular accident (3 each), cholecystectomy, and osteoarthritis (2 each). AEs leading to treatment withdrawal in more than 2 PEGV subjects (n) included headache (12), increased hepatic enzymes (8), ALT increased, AST increased (4), increased transaminases, cerebrovascular accident, abdominal pain, constipation, fatigue, and arthralgia (3 each). PEGV treated females had more than twice the incidence of abdominal discomfort, nausea, lower abdominal pain, urinary tract infection, and depression than males, as well as over twice the incidence of other uncommon AEs including LFT abnormalities, ALT increased, AST increased and hepatic enzymes increased. Conclusions: These data provide further evidence of the safety of pegvisomant therapy in subjects with acromegaly and support the positive benefit – risk of PEGV in this patient population.

 

Disclosure: NR: Employee, Pfizer, Inc.. JH: Employee, Pfizer, Inc.. NC: Employee, Pfizer, Inc.. NK: Employee, Pfizer, Inc.. RG: Employee, Pfizer, Inc.. JFH: Employee, Pfizer, Inc.. JFC: Employee, Pfizer, Inc..

15885 31.0000 MON-0734 A Pegvisomant (PEGV; Somavert®) Safety in Acromegaly: Analysis of Data from the Pegv Integrated Clinical Trial Safety Database (ICTSD) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Kim M.J.A. Claessen*1, Paul W de Bruin2, Willemien Visser2, Badelog JE de Lange-Brokaar2, Alberto M. Pereira3, Herman Kroon4, Margreet Kloppenburg2 and Nienke R. Biermasz1
1Leiden University Medical Center, Netherlands, 2Leiden University Medical Center, 3Leiden University Medical Center, Leiden, Netherlands, 4Leiden University Medical Center, Leiden, The Netherlands

 

Background

Arthropathy is a prevalent and invalidating complication of acromegaly with a characteristic radiographic phenotype. We aimed to further characterize cartilage and bone abnormalities associated with acromegalic arthropathy using Magnetic Resonance Imaging (MRI). MRI may give additional information to plain films. MRI directly visualizes joint cartilage, enabling assessment of cartilage defects, thickness and quality, but also other structural subchondral bone abnormalities, such as osteophytes, cysts and bone marrow edema.

Methods

Twenty-six patients (23% women, mean age 56.8±13.4yr), with active (N=10) and controlled acromegaly (N=16) underwent a 3.0T MRI of the right knee. Osteophytes, cartilage defects, bone marrow laesions, and subchondral cysts were assessed by KOSS (Knee Osteoarthritis Scoring System). Cartilage thickness and cartilage T2 relaxation times, reflecting biochemical composition of cartilage, were measured. Controls with primary knee OA were included for comparison.

Results

In active acromegaly, structural OA defects were already highly prevalent. Active acromegaly patients had thicker cartilage (p=0.008) and higher cartilage T2 relaxation times than controlled patients, indicating also differences in cartilage quality. Structural abnormalities according to KOSS were not related to self-reported joint complaints. When compared to primary OA subjects, acromegaly patients seemed to have less cysts, but comparable prevalence of osteophytosis, cartilage defects and bone marrow laesions. Acromegalic patients had thicker joint cartilage with higher cartilage T2 relaxation times than primary OA subjects.

Conclusions

Patients with active acromegaly already have high prevalence of structural OA abnormalities as observed by MRI scanning.  Joint cartilage is thickened, with increased water content, as reflected by increased T2 relaxation times. Distribution of structural abnormalities on MRI differs from that observed in subjects with primary OA, predominantly due to differences in joint cartilage.

 

Nothing to Disclose: KMJAC, PWD, WV, BJD, AMP, HK, MK, NRB

16204 32.0000 MON-0735 A Acromegalic Arthropathy Assessed By 3.0 Tesla Magnetic Resonance Imaging (MRI): A Case-Control Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Maria Vittoria Davi'*1, Francesca Dal Molin2, Luigi Fondrieschi3, Mattia Cominacini2, Simone Romano3, Cinzia Castellani2, Marcello Ferrari2, Luca Dalle Carbonare2 and Giuseppe Francia2
1Medicina Generale e Malattie Aterotrombotiche, University of Verona, Verona, Italy, 2Internal Medicine sect D, University of Verona, Verona, Italy, 3Internal Medicine sect C, University of Verona

 

Background: obstructive sleep apnoea syndrome (OSAS) is a common disease in acromegaly and contributes to the increased cardiovascular (CV) risk and mortality rate in acromegalic patients. In the general population the relationship between OSAS and CV disorders is not fully understood and is likely due to the sympathetic hyperactivity secondary to the hypoxia and sleep fragmentation secondary to the apnoeas. Uptodate no data on autonomic function in acromegalic patients with OSAS are available.

Patients  and methods: 30 acromegalic patients (mean age 59 ±10,6 yrs, 13 female, 17 male, 11 with active disease and 19 in remission), 18 with OSAS (apnoea/hypopnoea Index AHI 26,7 ± 21/h), 12 without OSAS (AHI <5/h) and 15 normal subjects were studied. Cardiac autonomic function was assessed by power spectral analysis of heart rate variability (HRV) during head up tilt test that identifies peaks of power: high frequency (HF), which expresses vagal activity, low frequency (LF) sympathetic activity and LF/HF sympathovagal balance. Echocardiographic parameters were also measured.

Results LF/HF in ortostatism (o) was significantly reduced in OSAS patients vs controls  (2,2 vs 8 p<0,05) and non OSAS patients (6,8 n.s.). HFo was significantly higher in OSAS patients vs controls  (51,2% vs 22,2% p<0,001) and non OSAS patients (37,1% n.s). Left ventricular mass index (LVMi) was significantly higher in OSAS patients vs non OSAS (101,6 ±29,6 vs 65 ± 16 g/m2, p<0,001) as well as inter-ventricular septum thickness (IVST) (11,6 ±2 vs 9±1,2 mm   p<0,001) and left atrial dimension (LAD) (23,3 ±6,2  vs 18,2 ±2,2 cm2 ) .

Conclusions: vagal hypertone persists in acromegalic patients despite OSAS. This finding needs to  be confirmed in a larger series and its clinical meaning to be clarified. Cardiac alterations are more pronounced in OSAS than in non OSAS acromegalic patients.

 Nothing to disclose

 

Nothing to Disclose: MVD, FD, LF, MC, SR, CC, MF, LD, GF

16628 33.0000 MON-0736 A Autonomic Disfunction and Cardiac Alterations in Acromegalic Patients with Obstructive Sleep Apnoea Syndrome: Preliminary Data 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Steinunn Arnardottir*1, Pia Burman2, Per Dahlqvist3, Bertil Ekman4, Charlotte Höybye5, Jacob Järås6, Thord P Rosen7 and Britt Eden Engström1
1Uppsala University Hospital, Uppsala, Sweden, 2University Hospital, Malmö, Sweden, 3Umeå University Hospital, Umeå, Sweden, 4Linköping University, Linköping, Sweden, 5Karolinska University Hospital, Stockholm, Sweden, 6RCC stocckholm/Gotland, 7Sahlgrenska Univ Hosp, Goteborg, Sweden

 

Acromegaly is a rare disease associated with considerably increased mortality and morbidity. Large studies regarding epidemiology, cure rate/biochemical control and complications are sparse. Patients with newly diagnosed pituitary tumours are since 1991 reported in the Swedish National Pituitary Registry. Age of diagnosis and data about MRI findings, pituitary function and visual symptoms before treatment were registered. Adenoma invasiveness was reported according to the SIPAP classification system, i.e. directions of tumour extension in relation to the sella turcica: Superior, Inferior, Parasellar, Anterior and Posterior, indicating the impact on adjacent structures.  Surgery, radiotherapy and medical treatment were registered.  The report is a prospective study of 698 patients with acromegaly, diagnosed 1991-2011.  Sex distribution was equal.  Mean age was 51 years. The incidence was 3.64/million/year.  Most patients, 62%, had macroadenoma at diagnosis.  SIPAP was reported for 78%.   18% had visual field defect and 74% had no pituitary hormone deficiency.  572 patients (82%) had pituitary surgery during the study period.  Radiation therapy was reported for 10% of the patients and medical therapy for 30%.  About one third of the patients received combination therapy during the study period.  94 patients had more than one surgery. One year follow up was reported for 533 patients (80 %), five years for 467 patients (75 %) and ten years for 296 patients (68 %).  Among all patients IGF-1 levels were normalized in 48% one year after diagnosis, in 60% at five years and in 57% at ten years. Of the operated patients, those with microadenoma had normalized IGF-1 in 62%, 71% and 69% after one, five and ten years, respectively.  Corresponding figures for macroadenoma were 50%, 59% and 51%.  SIPAP data indicated that largest extensions supra-, infra- and parasellar appeared to have worse outcome, potentially important as a prognostic tool before surgery.   In conclusion, we find an incidence of acromegaly in Sweden similar to previous reports, assuming that most of Swedish acromegaly patients are reported in the Registry. Furthermore,  the percentage of patients achieving biochemical control (normalized IGF-1) after treatment is similar to previous studies.  Finally, the percentage of patients participating in  long term follow up seems to be higher than reported in other studies (1,2).  The long term outcome indicates a need for improvement of the management for this patientgroup

 

Disclosure: CH: Committee Member, Sandoz. Nothing to Disclose: SA, PB, PD, BE, JJ, TPR, BE

16742 34.0000 MON-0737 A Acromegaly in Sweden 1991-2011: Prospective Study Based on the Swedish Pituitary Registry 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Sanne Franck*1, Aart J. van der Lely2, Richard A. Feelders3, Joseph A M J L Janssen4, Jens Otto Jorgensen5 and Sebastian J.C.M.M. Neggers4
1erasmus university medical center rotterdam, Rotterdan, Netherlands, 2Erasmus University Medical Center, Rotterdam, Netherlands, 3Erasmus Medical Center, Rotterdam, Netherlands, 4Erasmus MC, Rotterdam, Netherlands, 5Aarhus Univ Hospital, Arhus C, Denmark

 

Introduction: The required doses of pegvisomant (PEGV) to normalize the insulin-like growth factor 1 (IGF1) vary a lot between acromegaly patients. The influence of growth hormone receptor deletion of exon 3 (GHRD3) on the outcome in patients using long-acting somatostatin receptor ligands (LA-SRIFs) and PEGV differ in the literature (1-3).

Aim of the study: 1) Assess the influence of GHRD3 on the outcome in the largest single center cohort of acromegaly patients using LA-SRIFs and PEGV with follow up for up to 9 years and 2) determine GHR polymorphismin this cohort.

Materials and methods: Data were collected at our Pituitary Center between 2004–2013. Acromegaly patients (n=112) were selected with elevated IGF1 levels (>1.2 upper limit of normal (ULN)) who were treated for at least 6 months with high-dose LA-SRIF treatment (30 mg Sandostatin LAR or Lanreotide Autogel 120 mg per 28 days). All patients continued their LA-SRIFs, while PEG-V was added by a weekly injection. In 104 out of the 112 patients, genomic DNA could be extracted from peripheral blood leukocytes by standard procedures. Analysis of the GHRD3 polymorphism was carried out using quantitative PCR (Q-PCR) as previously described (2).

Results: The GHR genotype was assessed in 104 (93.0%) of the 112 patients. The GHRD3  was observed in 51 (49.0%) of the patients, 41.3% heterozygous and 7.7% homozygous. The median duration of the combination treatment was 4.9 years (min-max: 0.5–9.2). Normalization in IGF1 within the age adjusted normal limits, is defined as the lowest IGF1 during treatment. This was observed in 97.3% of the subjects. Two patients with full length GHR genotype and one heterozygous GHRD3 genotype patient showed no normalization. All homozygous genotype patients showed normalization. Median PEGV doses to achieve these lowest IGF1 levels were 80 mg (IQR; 60-115) in patients with a normal full length GHR genotype, 80 mg (IQR; 60-160) in the heterozygous GHRD3 genotype and 100 mg (IQR; 65-160) in the homozygous GHRD3 genotype. No significant association between GHRD3 and PEGV dose was found in patients with heterozygous (P=0.277) or homozygous polymorphism (P=0.306).

Conclusion: Growth hormone receptor genotype does not predict a better outcome in acromegaly patients using a combination of long-acting somatostatin analogues and pegvisomant. No significant difference in pegvisomant dose was found between the GHRD3 and the full length GHR.

 

Nothing to Disclose: SF, AJV, RAF, JAMJLJ, JOJ, SJCMMN

13405 35.0000 MON-0738 A Growth Hormone Receptor Deletion of Exon 3 and the Outcome of Long-Acting Somatostatin Analogues in Combination with Pegvisomant in 104 Acromegaly Patients, with Follow up for up to 9 Years 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Filip Gabalec*1, Monika Drastikova1, David Netuka2, Vaclav Masopust2, Tomas Cesak1, Josef Machac3, Josef Marek4, Martin Beranek1 and Jan Cap1
1Charles University Hospital and Faculty of Medicine, Hradec Kralove, Czech Republic, 2Charles University in Prague, Central Military Hospital, Prague, Czech Republic, 3University Hospital Olomouc, 4Charles Univ/ Medical Sch, Prague 2, Czech Republic

 

The background: Commercially available somatostatin analogues (SSA) are effective in control of acromegaly in 48-67%. In contrast SSA are effective only in 12% of clinically non-functioning adenomas (CNFAs). Dopamine agonists are effective approximately in one third of patients with acromegaly and CNFAs. As these analogues act on somatostatin (SSTR1-5) and dopamine 2 receptors (D2R), the aim of our study was to analyze the SSTR1-5, D2R, and estrogen receptors (ER) expressions in these types of adenomas.

Methods:  198 clinically non-functioning adenomas and 45 patients with acromegaly were analyzed using quantitative real-time PCR.

Results: Median of relative mRNA expression was 2.9 and 2.3 for SSTR1, 48.7 and 8.2 for SSTR2, 4.5 and 11.5 for SSTR3, 0.01 and 0.003 for SSTR4, 6.6 and 0.03 for SSTR5, 107.3 and 212.2 for D2R and 9.1 and 30.9 for ER1 in acromegaly and CNFAs, respectively. SSTR2 and SSTR5 were significantly more expressed in acromegaly, SSTR3 and ER1 were more expressed in CNFAs. A slightly but not significantly higher median of relative expression was observed for D2R.

Conclusion: These differences in the receptor expression profile add another evidence why available somatostatin and dopamine analogues are differently and insufficiently effective in acromegaly and CNFAs.

 

Nothing to Disclose: FG, MD, DN, VM, TC, JM, JM, MB, JC

14505 36.0000 MON-0739 A Significant Differences in Estrogen, Dopamine 2 and Somatostatin Receptors Expression Profile Between Clinically Non-Functioning Adenomas and Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Sonia Cheng-Oviedo*1, Karen Gomez-Hernandez2, Omar Serri3, Constance L Chik4 and Shereen Z Ezzat2
1University of Alberta, Edmonton, AB, Canada, 2University Health Network, University of Toronto, Toronto, ON, Canada, 3Notre Dame Hosp, Montreal, QC, Canada, 4Univ of Alberta, Edmonton, AB, Canada

 

Introduction: The risk and mortality due to cancer in patients with acromegaly have been extensively investigated.  The association of GH/IGF-1 excess gives a pathophysiological explanation for this association. Nonetheless, the conclusions in clinical studies have been so far contradictory.  We postulate that other pathways, aside from the somatotrophic axis, can be involved in the development and increased incidence of neoplasms in this group of patients.

Patients and methods: All patients treated for acromegaly in three Canadian referral centers (Toronto, Montreal, Edmonton) were included. Using all available medical records, their clinical information was recorded including: age, initial and average IGF-1 levels, co-morbidities and other neoplasms (benign and malignant). Genotyping for FGFR4 Arg388Gly was performed in the Toronto subset of cases.

Preliminary results: 408 cases, 184 cases from Toronto, 107 from Montreal and 117 from Edmonton were assessed. 185 were women (45.3%) and 223 men (54.7%). Of these, 126 (30.9%) developed extra-pituitary neoplasms, 55 malignant and 71 benign.  The most frequent anatomic site was the gastrointestinal tract (46 [11.3%]), followed by head and neck (36 [8.8%]) and multiple locations (14 [3.4%]).  106 (26.0%) cases had a diagnosis of diabetes. Initial IGF-1 was significantly higher in cases with benign tumors vs. those without tumors (941.6 vs. 829.3 ug/L, p = 0.034), more specifically in cases younger than 50 (1128.5 vs. 914, p = 0.019). Average IGF-1 during follow-up was significantly lower in women above 50 years with extra-pituitary neoplasms vs. those without them (209.2 vs. 282.6, p = 0.041). Both initial (1093.0 vs. 812.9, p = 0.045) and average IGF-1 (571.3 vs. 305, p = 0.021) were significantly higher in pre-menopausal diabetic women compared with those without diabetes. Other IGF-1 differences were consistent with age stratification.

48/106 (45.3%) of cases with diabetes developed extra-pituitary neoplasms vs. 71/292 (24.3%) without diabetes (p = 0.001, OR: 2.576 95%CI 1.615-4.108). 24/106 (22.6%) of cases with diabetes developed malignant tumors vs. 27/292 (9.2%, p < 0.001, OR 2.873, 95%CI 1.572-5.250).

In the FGFR4 genotyped subgroup (N = 104), 8/19 WT (42.1%) vs. 1/8 HET (12.5%) vs. 2/4 HOZ (50%) presented with other tumors while having metabolic syndrome (p = 0.014 OR 1.465, 95%CI 1.283-9.355).

Discussion: These results suggest that acromegalic patients with diabetes are more likely to develop extra-pituitary neoplasms. Initial IGF-1 level appears to have a stronger association to their development than IGF-1 level during follow-up, particularly in pre-menopausal women. Further, the FGFR4 trans-membrane polymorphism appears to represent an additional, hormone-independent risk for extra-pituitary neoplasms.

 

Nothing to Disclose: SC, KG, OS, CLC, SZE

16064 37.0000 MON-0740 A Serum IGF-1 and FGFR4 Genetic Status in the Risk of Benign and Malignant Neoplasms in Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0703-0740 4832 1:00:00 PM Prolactinoma and Acromegaly 2 Poster

Yathindar Satya Rao*1, Cody Lee Shults2, Natasha Mott3, Elena Pinceti2 and Toni R Pak4
1Loyola University Chicago, Forest Park, IL, 2Loyola University Chicago, Maywood, IL, 3Loyola Univ Med Cntr, Lombard, IL, 4Loyola Univ Stritch Schl Med, Maywood, IL

 

Menopause is characterized by the rapid age-related decline in circulating 17β-estradiol (E2) levels, which can result in cognitive disorders such as impaired memory and increased anxiety. Hormone therapy (HT), such as E2 supplementation, is widely used as a treatment for the adverse effects associated with menopause. However, data from the Women’s Health Initiative (WHI) showed that HT failed to provide any benefit for women who were 10 years post menopause. Previous data from our lab have shown that E2treatment can regulate microRNA (miRNA) expression in the hypothalamus of ovariectomized (OVX) rats in an age dependent manner (1). miRNAs are a class of small RNAs that regulate gene expression at the post-transcriptional level by binding to the 3’ untranslated region (UTR) of an mRNA target and inducing its degradation. miRNAs are transcribed from the genome in a RNA polymerase II dependent manner to produce a long primary miRNA (pri-miRNA), which is sequentially cleaved to form the small (~22 nucleotides) mature miRNA.

            We hypothesized that E2 treatment after a period of extended ovarian hormone deprivation differentially regulates mature miRNA expression. Fischer 344 female rats were OVX and then received 3 consecutive days of E2 treatment (s.c. 2.5μ/kg) at either 1, 4, 8, or 12 weeks post-OVX. 24 hours after their last treatment, animals were sacrificed and the hypothalamus from the right side of the brain was removed for RNA extraction. Our qRT-PCR results showed that E2 treatment significantly increased let-7i, miR-9, and miR-7a after 8 weeks of ovarian hormone deprivation. Interestingly the expression of the pri-miRNA forms did not correspond to the mature miRNA expression, suggesting that E2 might regulate miRNA processing.  E2 has two intracellular mediators: estrogen receptor (ER) α and β. To understand how E2 regulates miRNAs we analyzed the expression levels of ERα and ERβ by qRT-PCR. Our results showed that ovarian hormone deprivation did not alter ERα mRNA expression in the hypothalamus; however 8 weeks of deprivation significantly increased ERβ expression. We also showed that E2 and ovarian hormone deprivation had no effect on mRNA expression levels of miRNA processing enzymes, drosha and dicer, and did not alter argonaute 2. Finally we examined mRNA expression levels of two potential gene targets of miR-9 and miR-7a; sirtuin1 (SIRT1) and glucocorticoid receptor (GR). We observed that GR expression significantly decreased after 8 weeks of ovarian hormone deprivation, corresponding to increased miR-9 and miR-7a expression. Together our data demonstrate that prolonged periods of ovarian hormone deprivation, as occurs following menopause, alters E2-mediated regulation of miRNA expression profiles, which could result in altered gene expression. These results support the possibility that miRNAs might contribute to the observed differential age-related effects of HT.

 

Nothing to Disclose: YSR, CLS, NM, EP, TRP

16191 3.0000 MON-0407 A Prolonged Ovarian Hormone Deprivation Alters the Effects of 17β-Estradiol on Mature Microrna Expression in the Aged Female Rat Hypothalamus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Tamara Escajadillo*1, James H. Segars2 and Marion B Sewer3
1Cal State Univ Dominguez Hills, Carson, CA, 2Natl Inst of Hlth, Potomac, MD, 3Univ California San Diego, La Jolla, CA

 

By virtue of their expression in distinct subcellular locations, members of the A-Kinase anchoring protein (AKAP) family play a role in the spatiotemporal coordination of cell signaling, particularly the cAMP-dependent protein kinase (PKA) signaling pathway. Mitochondrial AKAP121 facilitates the activation of steroidogenic acute regulatory protein (StAR) phosphorylation and steroidogenesis in MA10 murine Leydig cells and the localization of AKAP79 at mitochondria in human placental cells has been implicated in targeting PKA activity to this organelle. Moreover, we have previously identified AKAP13 as a component of a protein complex containing RhoA, diaphanous 1 (DIAPH1), tubulin, and other proteins that may facilitate glucocorticoid production in the human adrenocortical cells. Consistent with our findings, AKAP13 (also called AKAP-Lbc) was originally identified as an effector protein that integrates PKA and Rho signaling. AKAP13 also coordinates the functions of protein kinase D (PKD), extracellular-signal regulated kinase, and phosphodiesterases (PDE). Based on these data, we hypothesized that AKAP13 regulates cortisol production by integrating RhoA and PKA signaling and that disruption of AKAP13 expression leads to mislocalized cAMP signaling. We show that silencing AKAP13 in H295R human adrenocortical cells abrogates the phosphorylation of RhoA, DIAPH1, PKD, and cAMP response element binding protein family members. Microarray analysis identified 82 genes that were up-regulated and 141 genes that were down-regulated when compared to wild type H295R cells.  Silencing AKAP13 led to aberrant the expression of multiple proteins, including PDE11A, melanocortin 2 receptor (Mc2R), Mc2R accessory protein, CYP11B2, CYP21A2, and 3beta-hydroxysteroid dehydrogenase type 2.  Analysis of steroid hormone levels in the serum of mice heterozygous for AKAP13 support a role for AKAP13 in steroidogenesis.  In summary, we conclude that AKAP13 plays a critical role in spatially relaying cAMP signaling in response to trophic hormone stimulation, thereby ensuring optimal steroidogenic capacity.

 

Nothing to Disclose: TE, JHS, MBS

17022 6.0000 MON-0410 A Silencing a-Kinase Anchoring Protein Impairs cAMP Signaling and Steroid Hormone Biosynthesis in the Adrenal Cortex 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Can Jin*, Yama A Abassi, Xiaobo Wang and Xiao Xu
ACEA Biosciences, Inc, San Diego, CA

 

Cell based assays for detection of androgen receptor (AR) modulators were developed using real time impedance technology. Two androgen responsive human prostate cancer cell lines 22Rv1 and LNCaP, were used for the study. Stimulation of these cells with androgen agonists such as R1881 and dihydrotestosterone (DHT), lead to alterations in cell number and cell adhesion, which can be detected by gold microelectrodes embedded in the bottom of the well of specialized microelectronic plates. The time-dependant cellular kinetic response profiles were different in 22Rv1 and LNCaP cells, indicating distinctive endogenous androgen signaling pathways in these two cell lines. Both cell types exhibited EC50 values in the picomolar range, indicating high sensitivity to androgen receptor stimulation.  The specificity of the assay for AR activity was established using “pure” AR antagonists, such as bicalutamide and nilutamide, and chemicals known with anti-androgen side effect, such as vinclozolin. More interestingly, when LNCaP cells were starved, the kinetic response profile to AR agonist was changed, reflecting altered native androgen response pathways in response to  changes in growth condition. In addition, under this condition, nilutamide and vinclozolin displayed AR agonist rather than AR antagonist effects in the real time cellular assay, consistent with reported effect of the T877A mutation in LNCaP AR.  The data suggests that the impedance based real time cellular assay system has the capacity to sensitively, selectively and quantitatively detect endogenous AR responses. The information can be useful to understand endogenous AR signaling pathways, and to develop new AR modulators for therapeutic applications.

 

Disclosure: CJ: Employee, ACEA Biosciences, Inc. YAA: Management Position, ACEA Biosciences, Inc. XW: Management Position, ACEA Biosciences, Inc. XX: Chairman, ACEA Biosciences, Inc.

13163 7.0000 MON-0411 A Establishment of Sensitive, Quantitative and Real-Time Cellular Assays for Assessment and Screening of Modulators of Endogenous Androgen Receptor Signaling Pathways 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Ping Gong*1, Zeynep Madak-Erdogan1, John A Katzenellenbogen1, Jodi A Flaws2 and Benita S Katzenellenbogen1
1University of Illinois at Urbana-Champaign, Urbana, IL, 2Univ of Illinois, Urbana, IL

 

Many postmenopausal women take botanical estrogen dietary supplements for relief of menopausal symptoms with the expectation that these supplements are safe and effective in substituting for the loss of endogenous estrogens at menopause. We have compared the effects of botanical estrogens versus estradiol (E2) to determine if their actions on estrogen target cells are similar or different. Our work and that of others has revealed that there is considerable cross-talk and cross-regulation between estrogen receptors (ERs) and the aryl hydrocarbon receptor (AhR). Therefore, we compared gene regulatory effects of four of the most widely used botanical estrogen dietary supplements, namely genistein, daidzein, and S-equol from soy and liquiritigenin from licorice root versus estradiol (E2). The four botanical estrogens bind to ER alpha and ER beta with affinities 20-10,000 times lower than that of E2, but at high concentrations, similar to those obtained in women consuming dietary supplements, they stimulated MCF-7 breast cancer cell proliferation and regulated many of the same genes as E2 in MCF-7 cells and mouse hepatocytes, and this cell regulation was reversed by the antiestrogen ICI 182,780. By contrast, the AhR agonist TCDD/dioxin decreased MCF-7 cell proliferation and had little effect on most ER target genes such as PgR or pS2. The botanical estrogens also regulated many AhR target genes, including CYP1A1 and CYP1B1, but in contrast to E2 which decreased the level of expression of these genes, the botanical estrogens all acted like TCDD in up-regulating expression of these genes. Regulation of these genes by botanical estrogens and E2 was reversed by the AhR antagonist CH 233191, but not by ER antagonists, indicating mediation by AhR. Likewise, the regulation of AhR target genes by botanical estrogens in primary mouse hepatocytes was eliminated in hepatocytes derived from AhR knockout mice, further indicating the requirement for AhR. Hence, the botanical estrogens exert effects opposite to that of E2 on some AhR target genes, implying that they might have an opposite impact on metabolism of drugs and polyaromatic hydrocarbons by these AhR regulated enzymes.

 

Nothing to Disclose: PG, ZM, JAK, JAF, BSK

12873 8.0000 MON-0412 A Cross-Talk Between the Aryl Hydrocarbon Receptor and Estrogen Receptor Mediates the Effects of Botanical Estrogens on Gene Expression, Cell Metabolism, and Behavior of Target Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Man-Sau Wong*, Quangui Gao, Vien Lee and Wing Yin Man
The Hong Kong Polytechnic University, Hong Kong, China

 

Ginsenoside Rg1, an abundant active ingredient in Panax Ginseng, is a unique class of phytoestrogens that can activate estrogen-like activities without direct interaction with the ER [1]. Our previous study revealed that Rg1 could activate ER ligand-independently via the activation of mitogen-activated protein kinase (MAPK) pathways in ER(+) cells [2]. However, the mechanism by which Rg1 activated MAPK was yet to be determined.  We hypothesized that the activation of MAPK and ER by Rg1 involved the formation of a complex containing signal proteins (signalosome) in ER (+) cells. The present study aimed to determine if shc, IGFR,EGFR, MNAR and c-Src were involved in mediating the actions of Rg1. Human breast cancer (MCF-7) cells were treated with Rg1 (10-12M), 17-b-estradiol (10-12M) or its vehicle. To determine if IGFR and Shc were involved in its actions, siRNA directed against IGFR and Shc were transfected to MCF-7 cells. The results showed that ERK and MEK phosphorylation induced by Rg1 were suppressed by the knockdown of IGFR and shc in MCF-7 cells. Immunoprecipitation studies indicated that Rg1 increased the binding between ERa, shc as well as IGFR in MCF-7 cells within 10 min of incubation, suggesting that shc facilitated the cross talk between IGFR and ER pathway in response to Rg1 treatment. To determine if EGFR was involved in the action of Rg1, MCF-7 cells were pretreated with selective ERFR inhibitor, AG 1478. The results showed that AG1478 suppressed MEK phosphorylation induced by Rg1, supporting the role of EGFR in mediating its action. MNAR was known to be required for estrogen induced ERa activation of c-src and downstream MAPK pathway [3]. To determine if MNAR and c-src were involved in its action, siRNA directed against MNAR and c-src were transfected to MCF-7 cells. The results showed that the knockdown of MNAR and c-src suppressed Rg1-induced phosphorylation of MEK and ERK in MCF-7 cells. Pre-treatment of MCF-7 cells with Src kinase inhibitor PP2 abolished MEK phosphorylation induced by Rg1, confirming the role of c-src in mediating the actions of Rg1. Immunoprecipitation studies showed that Rg1 increased the binding between MNAR, ERa and c-src in MCF-7 cells within 10 min of incubation. Our results indicated that shc, IGFR, EGFR, MNAR and c-src were involved in mediating the stimulatory actions of Rg1 on MAPK pathways and that Rg1 rapidly induced the formation of ER containing signalosome within 10 min of incubation in MCF-7 cells.

 

Nothing to Disclose: MSW, QG, VL, WYM

14401 9.0000 MON-0413 A Ginsenoside Rg1 Exerted Estrogenic Actions By Rapidly Inducing the Formation of Estrogen Receptor (ER) Containing Signalosome in Human Breast Cancer MCF-7 Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Elisabeth M Walczak*1, Isabella Finco1, Natacha Bohin2 and Gary D Hammer1
1University of Michigan, Ann Arbor, MI, 2University of Michigan

 

Wnt/Beta-catenin (βcat) signaling is critical for adrenal homeostasis. To elucidate how Wnt/βcat signaling elicits homeostatic maintenance of the adrenal cortex, we have characterized the identity of the adrenocortical Wnt-responsive population. We find that Wnt-responsive cells consist of Shh+ adrenocortical progenitors, as well as differentiated, steroidogenic cells of the zona glomerulosa, yet are infrequently proliferating. To determine the effects of βcat signaling on adrenocortical steroidogenesis, we have utilized the Wnt-responsive mouse ATCL7 adrenocortical cell line. Stimulation of βcat signaling caused decreased steroid release due to reduced transcription of steroidogenic genes Cyp11a1, Cyp11b1, Star and Mc2r. Decreased steroidogenic gene expression was correlated with diminished Steroidogenic factor 1 (Sf1) expression and occupancy on steroidogenic promoters. Additionally, βcat signaling suppressed the ability of Sf1 to transactivate steroidogenic promoters independent of changes in Sf1 expression level. To investigate the Sf1-independent mechanisms of the effects of βcat on steroidogenesis, we utilized Affymetrix gene expression profiling of Wnt-responsive cells in vivo and in vitro. One candidate gene identified, Ccdc80, encodes a secreted protein with unknown signaling mechanisms. We report that Ccdc80 is a novel Wnt/βcatenin-regulated gene in adrenocortical cells. Treatment of adrenocortical cells with media containing secreted Ccdc80 partially phenocopies bCat-induced suppression of steroidogenesis, albeit through an Sf1-independent mechanism. This study reveals multiple mechanisms of βcat-mediated suppression of steroidogenesis and suggests Wnt/βcat signaling regulates adrenal homeostasis by promoting the undifferentiated state of progenitor cells.

 

Nothing to Disclose: EMW, IF, NB, GDH

13898 10.0000 MON-0414 A Multiple Mechanisms of Wnt/βcat-Mediated Inhibition of Adrenocortical Steroidogenesis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Congcong Chen*, Jason Dienhart and Eric Christopher Bolton
University of Illinois at Urbana-Champaign, Urbana, IL

 

The androgen receptor (AR) is a ligand-activated transcriptional regulator that mediates the developmental, physiologic and pathologic effects of androgens such as 5-dihydrotestosterone (DHT). Although it plays a pivotal role in prostate development, function and neoplasia, the mechanisms through which AR regulates epithelial cell survival/death are not well understood.

Here, we report that androgen sensitizes HPr-1AR human prostate epithelial cells to apoptotic cell death. Treatment of HPr-1AR cells with DHT itself inhibits cell proliferation but does not trigger apoptosis or other types of cell death. However, co-treatment of HPr-1AR cells with DHT and an apoptosis inducer, such as staurosporine or AT101, synergistically increases apoptotic cell death in comparison to treatment with apoptosis inducer by itself. AR antagonist, 2-hydroxyflutamide, suppressed DHT-stimulated apoptosis, indicating that AR function is required for synergy. Importantly, the proapoptotic effect of androgen is distinct from the antiproliferative action of androgen on cyclinD-CDK4/6 complexes that we have described previously.

Our current hypothesis is that DHT induces the expressions of UNC-51 like autophagy activating kinase 1 (ULK1) and autophagy-related gene 12 (ATG12). Transient overexpression of ULK1 indeed decreases HPr-1AR proliferation, possibly through inhibition of the mTOR signaling pathway. Induction of ATG12 by DHT is correlated with increased levels of free ATG12 and ATG12-ATG3 conjugation. Remarkably, both forms of ATG12 have been implicated in the initiation of mitochondrial apoptosis. As the conversion of LC3-I to LC3-II, which is a hallmark of autophagy, is not increased by DHT, the proapoptotic effect of DHT appears to be distinct from the 'autophagy' function of ULK1 and ATG12. Taken together, DHT sensitizes HPr-1AR cells to mitochondrial apoptosis, which might be mediated by 'apoptotic' functions of ULK1 and ATG12. Notably, human prostate cancer cell lines, including LNCaP and PC3-AR, have altered regulation of cell survival/death in response to androgen. Our study provides insight into AR-mediated epithelial survival and the role of autophagy-related genes in apoptosis.

 

Nothing to Disclose: CC, JD, ECB

16042 11.0000 MON-0415 A Androgen Sensitizes Human Prostate Epithelial Cells to Apoptotic Cell Death 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Cheri Peyton Goodall1, Ian Heller2, Jodi Schwarz3, Virginia M Weis4, Deborah Lutterschmidt5 and Patrick Everett Chappell*6
1Oregon State University, College of Veterinary Medicine, Corvallis, OR, 2Vassar College, NY, 3Vassar College, Poughkeepsie, NY, 4Oregon State University, Corvallis, OR, 5Portland State University, Portland, OR, 6Oregon State University College of Veterinary Medicine, Corvallis, OR

 

Scleractinian corals exhibit diverse reproductive patterns, ranging from synchronized mass spawning to discrete temporal reproductive isolation. While previous efforts described the ecology of coral reproduction, considerably less attention is given to underlying physiological regulatory processes. In a time of rapid environmental change, understanding these mechanisms is critical to identify variables contributing to disruption of coral reproductive cycles. Although data exist suggesting hormones play a role in the timing of coral reproduction, we have at present only glimpses of a regulatory system. We quantified levels of estradiol in tissue from P. damicornis throughout reproductive cycles via radioimmunoassay, finding marked changes in estradiol synthesis correlated with peak planulae release over the lunar cycle. While other labs detected estradiol-like molecules, and found aromatization of androgen precursors in coral lysates, genomic exploration yields no sequence homology to mammalian aromatase, suggesting that the estradiol-like steroid in corals is synthesized using enzymes distinct from mammalian aromatase. Since localization of steroidogenic sites is critical for determining cell types involved in reproduction, we designed a “click-chemistry”-based fluoroprobe to detect aromatase-like cytochrome p450 enzyme activity in situ, which revealed activity in mesenteric cells proximal to gonadal cells in the anemone Aiptasia pallida. To explore if upstream regulators of steroid biosynthesis are conserved, we used bioinformatics to identify two homologs of gonadotropin-like hormone receptors (LGRA1/LGRA2) in Aiptasia. We cloned LGRA2 and stably transfected this receptor into heterologous cells (HEK293), confirmed by His-tagging. Treatment of stably-expressing cells with LH and FSH significantly increased intracellular cAMP and CREB phosphorylation in comparison to vehicle. These results suggest that the anemone LGRA2 receptor can activate appropriate downstream signaling pathways upon exposure to mammalian gonadotropins. Ongoing studies are assessing whether mammalian gonadotropins can also induce signaling in corals/anemones, and if observed signaling changes affect aromatase-like enzyme activity or levels of the estrogen-like molecule found in reproducing corals. We are also assessing localization and expression patterns of anemone LGRA2 using in situ hybridization and gene expression profiling through the reproductive cycle in Aiptasia cells isolated by laser-capture microdissection. Elucidation of reproductive hormones in coral will provide insight into the evolution of reproductive mechanisms in animals, as well as contribute to understanding how these timed reproductive processes will be affected as the planet warms.

 

Nothing to Disclose: CPG, IH, JS, VMW, DL, PEC

16593 12.0000 MON-0416 A Characterization of Reproductive Hormonal Pathways in Cnidarians 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Jonathan W Mueller*1, Jan Idkowiak1, Philip J House1, Joanne Christine McNelis1, Ian T Rose1, Johannes van den Boom2, Florian Schlereth1, Vivek Dhir1 and Wiebke Arlt1
1University of Birmingham, Birmingham, United Kingdom, 2University of Duisburg-Essen, Essen, Germany

 

Human sulfation depends on provision of the universal sulfate donor PAPS by the two PAPS synthase isoforms PAPSS1 and PAPSS2. Mutations in PAPSS2 have been identified as a monogenic cause of androgen excess presenting with premature adrenarche and polycystic ovary syndrome, due to decreased sulfation of the androgen precursor DHEA by DHEA sulfotransferase (SULT2A1) and hence increased conversion of DHEA to active androgens. Here, we examined why ubiquitously expressed PAPSS1 cannot compensate for the impact of PAPSS2 deficiency on DHEA sulfation.  First, we carried out siRNA-mediated knockdown of PAPSS1/2 in the adrenal cell line NCI-H295R1, selected for equal expression of both isoforms. Realtime PCR confirmed >90% knockdown and the impact at protein level was assessed by Western blot and SULT2A1 activity assays. Efficient knockdown of PAPSS2 reduced DHEA sulfation to 30±5%. Strikingly, PAPSS1 knockdown did not impact on DHEA sulfation, providing the first in vitro evidence for non-overlapping functionality of the two PAPSS isoforms. To further dissect these isoform-specific differences, we characterised the two distinct activities of PAPSS1/2 by assessing the activities of sulfurylase (converting ATP to APS) and APS kinase (converting APS to PAPS) coupled to NADPH production and NADH consumption, respectively. In addition, we determined the APS-binding affinity of PAPSS1/2 using fluorescent APS. All three assays revealed remarkable similarity of both PAPSS isoforms. To test whether changing subcellular localisation would impact on isoform-specific capacity to support DHEA sulfation, we used HEK293 cells to co-express SULT2A1 with either wild-type PAPSS1/2 or PAPSS1/2 variants shown to result in exclusive nuclear or cytoplasmic expression.  While wild-type and nuclear PAPSS1/S2 equally supported DHEA sulfation, SULT2A1 activity with exclusively cytoplasmic PAPSS2 was 1.6fold higher than with cytoplasmic PAPSS1. Finally, we conducted a proteomics screen for PAPSS2-interaction partners in HEK293-FlpIn cells expressing PAPSS2-Strep-HA followed by pull-down and LC-MS/MS analysis. Proteasomal subunits were significantly enriched in our dataset. Treatment with the proteasome inhibitor MG-132 revealed that PAPSS2, but not PAPSS1, was subject to proteasomal degradation. Taken together, we provide a growing number of molecular differences between PAPS synthase isoforms that may explain their different functionality, both in vitro and in vivo.

 

Nothing to Disclose: JWM, JI, PJH, JCM, ITR, JV, FS, VD, WA

15665 13.0000 MON-0417 A Differential Impact of PAPS Synthase Isoforms on DHEA Sulfation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Dalia Somjen*1, Esther Knoll2, Orli Sharon3, Arie Many2 and Naftali Stern3
1Tel Aviv Med Ctr, Tel Aviv, Israel, 2Tel-Aviv med ctr, Tel-Aviv, Israel, 3Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel

 

Estrogen receptors (ERα and ERβ) and lipoxygenases (12LO and 15LO) as well as vitamin D receptors (VDR) and 25 hydroxyy vitamin D 1- hydroxylase (1OHase) mRNA are expressed in human cultured vascular smooth muscle cells (VSMC). In these cells, estrogen ( E2) affects  cell proliferation as measured by DNA synthesis (DNA) in a dose-dependent manner (Hypertension. 1998 ;32:39). A unique effect of E2 is that it stimulates growth at low concentrations, but inhibits proliferation at high concentrations. Here we set out to assess whether this yin-yen effect involves alternate activation of ERα/β. First, the ERβ agonist DPN inhibited cell proliferation whereas the ERα agonist, PPT, stimulated VSMC growth. Concordantly, the ERα antagonist, MPP, inhibited PPT's–induced stimulation of VSMC proliferation whereas ERβ antagonist PTHPP inhibited DPN-induced inhibition of cell growth. E2 and the ERβ agonist DPN stimulated ERα mRNA, whereas both DPN and PPT inhibited ERβ mRNA. Neither of the ER antagonists ( MPP and PTHPP) affected the increase in  ERα mRNA induced by E2, and both had no effect on ERβ mRNA expression. Only E2 stimulated 12 and 15LO mRNA whereas both ERα and ERβ agonists alone inhibited 12LOmRNA while DPN (ERβ agonist) stimulated 15LO mRNA. Both ERα and ERβ antagonists MPP and PTHPP inhibited 12 and 15LO mRNA stimulation by E2. E2 and the specific ER agonists also stimulated the production of 12 and 15 hydroxyeicosatetraenoic acid (HETE), the respective products of 12-and 15LO, which was unaffected by the ER-specific antagonists MPP and PTHPP. E2 and the ER specific agonists stimulated VDR and 1OHase mRNA and only the ERβ antagonist PTHPP inhibited these stimulatory effects. In conclusion, the bimodal concentration dependent effect of E2 on VSMC growth can be explained based on alternate ERα/β activation. Further, the induction of VDR expression and LO expression and LO-derived products, which exert inhibitory and stimulatory (respectively) effects on VSMC growth suggest complex control of E2-dependent growth modulation. Finally, because some E2 effects cannot be reversed by ERα/β antagonists, participation of non-ERα/non-ERβ mediated effects (e.g. incease in LO products) must be assumed.   How these results can be utilized for better understanding of the overall estrogenic effects in the vasculature is subject to ongoing work.

 

Nothing to Disclose: DS, EK, OS, AM, NS

14590 14.0000 MON-0418 A Estrogenic Compounds Modulate the Expression of Estrogen Receptors, the Vitamin D Receptor and 25 Hydroxyy- Vitamin D 1-Alpha Hydroxylase in Human Vascular Smooth Muscle Cells: Relation to Effects on Growth 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Yuefeng Sun*, Ravi Kasiappan, Jinfu Tang, Panida Lungchukiet, Waise Quarni, Xiaohong Mary Zhang and Wenlong Bai
USF Morsani College of Medicine and H. Lee Moffitt Cancer Center, Tampa, FL

 

Fe65 is a multidomain adaptor with established functions in neuronal cells and neuro-degeneration diseases. It binds to the carboxyl terminus of the Abeta amyloid precursor protein (and is involved in regulating gene transcription. The present studies show that Fe65 is expressed in breast cancer cells and acts as an Estrogen receptor alpha (ERα) coactivator that is recruited by 17β-estradiol to the promoters of estrogen target genes. Deletion analyses mapped the ERα binding domain to the phosphotyrosine binding domain 2 (PTB2). Ectopic Fe65 increased the transcriptional activity of the ERα in a PTB2-dependent manner in reporter assays. Fe65 knockdown decreased, whereas its stable expression increased, the transcriptional activity of endogenous ERα in breast cancer cells as well as estrogen stimulation of target gene expression, the recruitment of ERα and coactivators to target gene promoters and cell growth. Furthermore, Fe65 expression decreased the antagonistic activity of tamoxifen, suggesting a role for Fe65 in tamoxifen resistance. Overall, the studies define a novel role for the neuronal adaptor in estrogen actions in breast cancer cells.

 

Nothing to Disclose: YS, RK, JT, PL, WQ, XMZ, WB

15993 15.0000 MON-0419 A Identification of the Fe65 Neuronal Adaptor As a Novel Estrogen Receptor Alpha Coactivator in Breast Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Daniel Marcus Kelly*1, Patrick s Harrison2, Samia Akhtar1 and Thomas Hugh Jones3
1University of Sheffield, Sheffield, United Kingdom, 2Sheffield Hallam University, Sheffield, United Kingdom, 3Barnsley Hospital NHS Foundation Trust, Barnsley, United Kingdom

 

Background  Low testosterone levels in men increases the risk of developing type-2 diabetes (T2D). Physiologically restoring testosterone through replacement therapy (TRT) improves insulin resistance and glycaemic control in hypogonadal men with T2D. The cellular mechanisms underlying these actions remain unknown, but may be due in part to an effect on the liver as a major metabolic organ involved in glucose regulation. Our previous work has shown in testicular feminized mice, which have low testosterone levels and a non-functional androgen receptor, that hepatic expression of glucose regulatory targets (Hexokinase 4, HK4; Phosphofructokinase, PFK; Mitogen-activated protein kinase kinase, MAP2K) were significantly reduced and that TRT increased HK4 expression. Here we investigate the hypothesis that testosterone increases hepatic glucose uptake and metabolism in human liver cells as a mechanism to improve glucose homeostasis and T2D. Methods  Glucose uptake was assessed using 2-NBDG, a fluorescent glucose analogue, in HepG2 cells treated with either testosterone (1-100nM) or vehicle control for 24h. Metformin was used as a positive control (5mM, 10mM). XF metabolic assays (Seahorse Bioscience) were performed to further assess cellular bioenergetics and mitochondrial function. Cells were analysed for mRNA and protein expression of targets of glucose regulation; HK4, PFK and liver X receptor (LXR), by qPCR and western blotting. Results  Glucose uptake was increased in testosterone treated cells at 10nM (117±3.8% of control, P<0.05) and 100nM (117±4.3%, P<0.05) concentrations compared to control. This increase was similar to that of Metformin 5mM (113±3.5, P>0.9) and 10mM (122±4.8, P>0.9).  Extracellular acidification rate as an indicator of changes in the rate of glycolysis were marginally increased in testosterone treated cells. Similarly, oxygen consumption rate as a function of mitochondrial respiration was slightly but not significantly increased in testosterone treated cells. HK4 protein expression was increased in 10nM testosterone treated cells versus vehicle control (0.56±0.04 Vs 0.24±0.11 arbitrary densitometry units (ADU), P=0.08), and significantly at 100nM concentrations (0.68±0.25 Vs 0.24±0.11 ADU. P<0.05). No difference was observed between treated and untreated cells for PFK and LXR protein expression and for mRNA expression of all targets. Conclusion  Testosterone increases the metabolic activity of HepG2 cells by increasing glucose uptake as a mechanism to potentially improve hepatic glucose control and T2D in men. This action may be via increased hepatic glycolysis involving the upregulation of HK4 expression, a key regulatory enzyme in glycolysis.

 

Nothing to Disclose: DMK, PSH, SA, THJ

15792 16.0000 MON-0420 A Testosterone Increases Glucose Uptake and Glycolysis in HepG2 Human Liver Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Ming Xian HO, Sisi Cao* and Man-Sau Wong
The Hong Kong Polytechnic University, Hong Kong, China

 

Genistein, naringin and icariin are flavonoids reported to promote bone anabolic functions by exerting estrogen-like effects on osteoblasts. While genistein was reported to bind estrogen receptors (ERs) directly to activate estrogenic signaling, naringin and icariin [1,2] were shown not to activate classical ER signaling to initiate ERE transcription in UMR106 cells but rather to exert their effects through ligand-independent activation of ERα. The present study investigated the role of rapid ERK signaling in mediating the actions of genistein, naringin and icariin in UMR106 cells. To study if flavonoids administration stimulated the rapid ERK signaling, UMR106 cells were treated with each compound for 5, 10, 30 and 60 min. Their effects on ERK phosphorylation were examined by measuring the ratio of phospho-ERK (pERK) to total ERK via western blotting. Our results demonstrated that treatment with genistein, naringin and icariin stimulated ERK phosphorylation as early as 5 min and the signals were sustained for at least 60 min. Exposure to genistein, naringin and icariin for 10 min increased pERK/ERK ratio in UMR 106 cells by 5.5-fold, 2.8-fold and 3.5-fold, respectively (vs control, P<0.05). The results indicated that these compounds triggered ERK signaling in UMR106 cells. To investigate the correlation of rapid ERK signaling with the activation of ERα, the effects of flavonoids on ERα phosphorylation at Ser 118 site, a phosphorylation site in response to MAPK signaling, were investigated. In consistent with ERK phosphorylation, treatment of UMR 106 cells with genistein, naringin and icariin significantly increased ERα phosphorylation by 2.46-fold, 1.45-fold and 2.48-fold, respectively (vs control, P<0.05). Pre-treatment with specific inhibitor of ERK U0126 completely abolished ERα phosphorylation at Ser 118 induced by the flavonoids in UMR106 cells, suggesting that ERα phosphorylation stimulated by flavonoids required the activation of ERK signaling. Moreover, pre-treatment with U0126 dramatically attenuated the stimulatory effects of flavonoids on UMR106 cell proliferation to levels even lower than control. Together, these results suggested that ERK signaling plays a significant role in mediating the estrogenic responses induced by flavonoids in UMR106 cells.

 

Nothing to Disclose: MXH, SC, MSW

13516 17.0000 MON-0421 A Molecular Actions of Flavonoids in Osteoblast-like UMR106 Cells Involve Estrogen Receptor Activation Via ERK Signaling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Elena Pinceti*1, Cody Lee Shults1, Yathindar Satya Rao2 and Toni R Pak3
1Loyola University Chicago, Maywood, IL, 2Loyola University Chicago, Forest Park, IL, 3Loyola Univ Stritch Schl Med, Maywood, IL

 

The loss of circulating estrogen at menopause leads to an increased risk of stroke, neurodegenerative disease, cognitive decline, mood disorders as well as coronary heart disease, atherosclerosis and hypertension. Clinical studies show that hormone therapy (HT) can be beneficial depending on how soon it is initiated following the perimenopausal transition. Importantly, the molecular mechanisms regulating this age-related switch in estrogen action are unknown.

            One possibility is that increased kinase activity associated with aging and estrogen levels results in increased phosphorylation of estrogen receptor β (ERβ), which is known to mediate both neuroprotective and cardioprotective functions of estrogens. Indeed the cellular stress associated with aging activates the Mitogen Activated Protein Kinases (MAPK) p38 and ERK known to target ERβ. Phosphorylation of steroid receptors of the same family as ERβ affects nearly every aspect of their signaling, including its interactions with the coregulatory proteins. Using promoter assays I previously demonstrated that phosphorylation of ERβ indeed alters ERE and AP-1 transcriptional regulation.  Our hypothesis is that age and estrogen deprivation following menopause alters the levels of expression and activation of p38 and ERK kinases in the brain and heart.

            In order to analyze the effects of age and duration of endogenous estrogen deprivation prior to estrogen treatment, we designed the following in vivo paradigm: surgically induced menopause was established in 18 mo. old rats through bilateral ovariectomy (OVX) and an acute dose of 17β-estradiol (E2; 2.5μg/Kg once/day x 3 days) or vehicle then administered at varying time points post-OVX (1 week, 4 weeks, 8 weeks, or 12 weeks). Using qRT-PCR and Western Blot I determined the expression and activation levels of p38 and ERK kinase in the hypothalamus, hippocampus and heart. The results showed an overall age and estrogen dependent increase in expression of these kinases, supporting our hypothesis.

Overall it is well understood that MAPKs signaling plays an integral role in aging, and their aberrant regulation might be involved in age-related disorders. Clinical studies show benefits of HT during early menopause but detrimental effects later, which might be reflective of changes in kinase expression and activation status.

 

Nothing to Disclose: EP, CLS, YSR, TRP

16041 18.0000 MON-0422 A Loss of Circulating Estrogen Results in Altered Kinase Activity in Hearts and Brains of Aged Female Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Yasumasa Iwasaki*1, Mitsuru Nishiyama2, Takafumi Taguchi2, Makoto Tsugita2, Mizuho Okazaki2, Shuichi Nakayama2 and Kazuo Kawamura3
1Health Care Center, Kochi University, Kochi, Japan, 2Kochi Medical School, Nankoku, Japan, 3Kochi University, Kochi, Japan

 

The expression of CYP11B2, a key enzyme in aldosterone synthesis, is regulated by angiotensin II (AII), potassium (K), and ACTH, and the rise in intracellular calcium (Ca) plays an important role.  However, the molecular mechanism of the transcriptional regulation of CYP11B2 gene is not fully clarified.  In this study, we tried to identify the transcription factor(s) involved in CYP11B2 gene expression.  Human adrenocortical cell line H295R cells were transfected with human CYP11B2 gene promoter (2 kb)-luciferase fusion gene, and then stimulated with AII (10 nM), forslolin (10 µM), and KCl (15 mM). 　We found that all the treatments elicited rapid and robust rises in the transcriptional activity of CYP11B2 gene (starting within 2 hr and max >20-fold increase).  Regarding the effect of AII, PLC inhibitor (YM254890), PKA inhibitor (H89) and calcineurin/NFAT inhibitor (Cyclosporin A) completely abolished the stimulatory effects, whereas PKC, MAPKs (p42/44 and p38), and CaMK inhibitors had no effect.  Finally, co-expression of NFATc markedly induced the promoter activity of CYP11B2, whereas that of Nurr1 or CaMKII/IV showed minimal effects. Since NFAT as well as CREB is already present within the cells and can be responsible for the rapid induction of target genes, the current results suggest that Ca-dependent activation of NFAT may play an important role in the transcriptional regulation of CYP11B2 gene by AII.

 

Nothing to Disclose: YI, MN, TT, MT, MO, SN, KK

15032 19.0000 MON-0423 A Calcium-Responsive Transcription Factor NFAT Is Involved in Angiotensin II-Induced CYP11B2 Gene Expression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Lisandra (Lisa) L Martin*1, Slavica Praporski2, C. Jo Corbin3, Daphne Wong4, Dario Mizrachi5, Raymond J Rodgers6 and Alan James Conley3
1Monash University, Clayton, Australia, 2Monash University, Australia, 3University of California, Davis, CA, 4The University of Adelaide, Adelaide, Australia, 5Cornell University, Ithaca, NY, 6University of Adelaide, Adelaide, Australia

 

Estrogen is an essential mammalian hormone with major roles in reproduction, menopause, osteoporosis and hormone-dependent cancers.  It is therefore critical to understand the molecular mechanism of estrogen synthesis. The biosynthesis of estrogens from androgens involves multiple hydroxylations of androgens.  This is catalyzed by cytochrome P450 aromatase (P450arom) bound to the endoplasmic reticulum. Despite its importance, the X-ray crystal structure of P450arom was only obtained in 2009 (1) and its molecular mechanism still remains very poorly understood.

We have used a combination of biological, chemical and biophysical approaches to discover the molecular basis that is critical for the regulation of P450arom activity. We directly compared the human and porcine gonadal P450arom, as porcine gonadal P450arom has very low catalytic efficiency, with a ten-fold higher affinity (Km) for a substrate (androstenedione) and ten-fold reduction in turn over (Vmax) than the human P450arom (2). We recombinantly expressed these proteins and compared their interactions with lipid membrane and also with the electron donor protein cytochrome P450 oxidoreductase (3).  We identifed that human and not the porcine gonadal isoform acts as a homo-dimer. Using in silico analysis of the X-ray crystal structure we identified the site of homo-dimerization in human P450arom and showed that these critical amino acids were substantially differnt in the porcine gonadal aromatase, rendering it capable of acting only as a monomer.

We conclude that the lower affinity and higher activity with reduced release of intermediate metabolites by the human isoform is as a consequence of its ability to form homo-dimers.

 

Nothing to Disclose: LLM, SP, CJC, DW, DM, RJR, AJC

16502 20.0000 MON-0424 A Evolutionary Comparisons Predict That Dimerization of Cytochrome P450 Aromatase Increases Its Enzymatic Activity and Efficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Kathleen M Eyster*1, Michelle Booze2, Donis D. Drappeau3, Olga Klinkova4 and Connie Mark-Kappeler5
1Univ of South Dakota, Vermillion, SD, 2Sanford Research, Sioux Falls, SD, 3University of South Dakota, Vermillion, SD, 4University of Buffalo, Buffalo, NY, 5Wil Research Laboratories, Ashland, OH

 

The role of estrogen in the cardiovascular system remains controversial.  Premenopausal women have a lower incidence of many cardiovascular diseases than age-matched men; however, this cardiovascular advantage is lost at the menopause, and estrogen replacement after a time delay can result in deleterious cardiovascular effects.  Aside from the controversies, a well-documented adverse reaction to the administration of pharmaceutical estrogens in both pre- and postmenopausal women is the development of blood clots.  The selective estrogen receptor modulators (SERMs), tamoxifen (Tam) and raloxifene (Ral), mimic the effects of estrogen in some tissues but act as antagonists of estrogen in others; both Tam and Ral increase the incidence of blood clot formation similar to the effect of estrogen.  This project was undertaken to test the hypothesis that estrogen, Tam, and Ral regulate the gene expression in the liver, including genes related to blood clot formation.  Ovariectomized Sprague-Dawley rats were treated with vehicle (2-hydroxypropyl-beta-cyclodextrin), estrogen (0.15 mg/kg), Tam (3 mg/kg), or Ral (3 mg/kg) by gavage for 2 days.  Total RNA was extracted from the liver and gene expression signatures were analyzed by DNA microarray.  Real time RT-PCR was used to confirm differential expression of selected genes.  127 genes were differentially expressed (p<0.05) with 2-fold or greater difference from control in response to the treatments.  The largest category of differentially expressed genes was that of ligands, receptors, and signal transduction with 35 genes.  Of the 22 genes in the category of steroid/lipid metabolism, 17 were down-regulated and 5 were up-regulated.  Two differentially expressed genes were directly associated with blood clotting:  coagulation factor X (F10) and complement component 3 (C3).  The down-regulation of both of these genes was confirmed by real time RT-PCR.  Up-regulation of the acute phase gene, alpha 1-acid glycoprotein (alias orosomucoid), and down-regulation of oxidative stress-induced growth inhibitor 1 were also confirmed by real time RT-PCR.  In general, the effects of Tam were more similar to those of estrogen than were the effects of Ral.  In summary, estrogen, Tam, and Ral modified gene expression in the liver; however, the direct effects on blood clotting genes were minimal.

 

Nothing to Disclose: KME, MB, DDD, OK, CM

16425 21.0000 MON-0425 A Estrogen and Selective Estrogen Receptor Modulators Regulate Gene Expression in the Liver 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Himangshu S Bose1 and Jasmeet Kaur*2
1Mercer Univ Schl of Med, Savannah, GA, 2Mercer University, Savannah, GA

 

Signal anchors, composed of a hydrophobic N-terminal transmembrane segment, function as both an ucleavable signal sequence and a stop-transfer sequence to halt translocation. Once such signal anchor is signal anchor type-I (SA-I), commonly found in microsomal cytochrome P450 proteins   To better understand the function of SA-Is, we evaluated translocation of the P450 protein aromatase, which has a hydrophilic region upstream of its signal anchor. Using cell-free synthesized aromatase and microsomal membranes in a membrane integration assay, we found that the aromatase SA-I mediated both the translocation of a short N-terminal domain to the ER lumen where it underwent glycosylation, and the integration of a portion of the protein into the membrane, with the remainder residing in the cytosol. The first 40 amino acids of aromatase were sufficient to target passenger cytosolic and mitochondrial proteins to the ER. We also showed that the lack of a signal peptidase cleavage site was not responsible for the stop-transfer function of SA-I. Moreover, microsomal SA-Is did not block the translocation of a full-length microsomal secretory protein and were cleaved as part of the downstream signal sequence. We propose that interaction between the translocon and the region following the signal anchor plays a critical role in directing the topology of the protein by SA-Is.

 

Nothing to Disclose: HSB, JK

13732 22.0000 MON-0426 A Mechanism of Action of Aromatase in the Endoplasmic Reticulum 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Yuki Kawashima*1, Yoshiki Okayama1, Masanobu Fujimoto2, Naoki Miyahara1, Rei Nishimura1, Keiichi Hanaki3, Takeshi Usui4 and Susumu Kanzaki1
1Tottori University Faculty of Medicine, Yonago, Japan, 2Tottori University Faculty of Medicine, Yanago, Japan, 3Tottori Univ Fac of Med, Yonago, Japan, 4National Hospital Organization Kyoto Medical Center, Kyoto, Japan

 

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is caused by mutations in the CYP21 gene encoding the steroid 21-hydroxylase enzyme, and has a broad spectrum of clinical forms, ranging from classical form to non-classical form (NCCAH). More than 90% of these mutations result from intergenic recombination between CYP21 and the closely linked CYP21P pseudogene. On the other hand, rare point mutations that arise independently of the pseudogene have been described to date. We report a CAH patient, who showed atypical clinical form, and was eventually identified novel compound heterozygous mutations (IVS2-13 A/C>G and p.E431K).

The patient was a 1-year-old Japanese boy, the first child of his parents. At 16 days old, he was referred to our hospital because of the elevated serum 17-OH-progesterone (17-OHP) levels (16.6 ng/ml) in neonatal screening.  He didn’t have significant physical findings (virilization, pigmentation, and salt-wasting), and his body weight gain was well. The findings of urine steroid hormone profile (pregnanetriolone: 3.632 mg/g cr, 11β-hydroxyandrosterone: 0.589 mg/g cr) at 28 days old stronglysuspected as 21-hydroxylase deficiency.  As the compound heterozygous mutations (IVS2-13 A/C>G and p.E431K) in CYP21 gene were identified at 2 months old, we diagnosed as NCCAH. However, his body weight decreased, and his serum 17 OHP level elevated (99.5 ng/ml) at 3 months old.  We started steroid replacement therapy since 3 months old.  The steroid therapy improved his general condition, and normalized serum 17 OHP level.

IVS 2-13 A/C>G mutation is known as a common mutation for classical form of CAH and result in no CYP21 enzyme activity. On the other hand, p.E431K is known as a rare point mutation, the residual enzyme activity might result in the atypical clinical form on our case. We are currently under investigation for the enzyme activity. Urine steroid hormone profile and gene analysis were important tools for a diagnosis on atypical CAH.

 

Nothing to Disclose: YK, YO, MF, NM, RN, KH, TU, SK

12270 23.0000 MON-0427 A Congenital Adrenal Hyperplasia Due to 21-Hydroxylase Deficiency Derived from Novel Compound Heterozygous Mutations (IVS2-13 A/C>G and p.E431K) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Ilka Nemere*1 and Tremaine LeBlanc2
1Utah State University, Logan, UT, 2Utah State University, Logan

 

Using MRI on mice bearing a targeted knockout of the 1,25D3-MARRS receptor/PDIA3/ERp57 we found that they had decreased body fat relative to their littermate controls, a condition associated with increased lifespan. Others have found that this is correlated with decreased lipid droplets in intestinal cells that appears to be mediated by a factor secreted by germ cells (possibly estradiol). We first tested whether estradiol could compete for binding to the 1,25D3-MARRS receptor by radioassay. In the presence of a reducing environment estradiol effectively competed for binding. We subsequently found that a functional consequence of this was that estradiol could stimulate calcium uptake in intestinal cells isolated from littermate mice. We then cultured intestinal cells from littermate mice in a timecourse study to establish optimal increases in lipid droplets. Lipid droplets increased in response to 1 nM estradiol from 1-5 D of culture, relative to corresponding controls, while at 6 and 7 D the steroid slightly decreased lipid droplets. We then incubated isolated intestinal cells from littermates or knockouts with estradiol for 1-4D and found the hormone increased lipid droplets, relative to controls at each of those timepoints. Using the 4D culture period, we then performed a dose response analysis and found that 1 and 10 nM estradiol significantly increased the number of lipid droplets in cells from littermate mice, compared to equivalent conditions in knockout mice. In exploring potential signal transduction pathways, no differences in phosphor-mTORC1 were found between cells from littermate mice treated with vehicle, 1,25D3, or estradiol, nor were there differences in phosph-S6K (although cells from chicks did exhibit a hormone-mediated difference). We did however, find an increase in phosphor-AkT levels in mouse cells in response to hormone. Finally, the remaining mice (which had stopped reproducing) were allowed to die naturally and lifespan recorded. Littermate mice lived 687 + 77 D (without an outlying value) while knockout mice lived 740 D + 80 D. These data suggest the 1,25D3-MARRS receptor may contribute to the length of lifespan in mammals.

 

Nothing to Disclose: IN, TL

11143 24.0000 MON-0428 A Actin and Keratin Are Binding Partners of the 1,25D3-Marrs Receptor/PDIA3/ERp57 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Sameer Udhane*1, Gaby Hofer1, Primus E Mullis1 and Christa E Flueck2
1University Children's Hospital Bern, Bern, Switzerland, 2Pediatric Endocrinology and Diabetology, Bern, Switzerland

 

Introduction:

The human adrenal cortex produces mineralocorticoids, glucocorticoids and androgens but the underlying regulation is not fully understood. Most molecular studies of adrenal steroidogenesis use human adrenocortical NCI-H295R cells as a model because appropriate animal models do not exist. Previously, we demonstrated that the steroid profile of NCI-R cells is altered under starvation growth conditions showing a significant increase in androgen production due to an upregulation of CYP17A1-17,20 lyase activity and a decrease of HSD3B2 expression and activity. As this profile resembles the events seen in the human adrenal during adrenarche, we have been using the starved NCI-R cell model successfully for our studies of androgen regulation. The objective of this study was to compare gene expression patterns of NCI-R cells grown in normal growth and in low serum medium (starved condition) in order to find cellular networks of genes, which might play a role in the regulation of androgen biosynthesis.

Methods:

Total RNA was isolated from NCI-R cells grown under different growth condition. Then gene expression profiling was performed using Affymetrix Microarray. Differential expression of identified genes was confirmed by quantitative real-time PCR (qRT-PCR). Functional analysis of data was performed by GeneGo Metacore software.

Results:

By microarray studies, we identified 14 genes with a significantly altered (+/-2-fold) expression profile when comparing starved with control NCI-R cells. Overall, 13 genes were down-regulated and one gene was up-regulated under starvation conditions. We were able to confirm this profile by qRT-PCR for most of the significantly changed genes. By enrichment analysis of the chip data, we found interesting genes that are involved in different signaling and metabolic pathways such as genes for androstenedione and testosterone biosynthesis and metabolism (HSD3B2, HSD3B1), fat and energy metabolism, adrenal development, nuclear transcription factors, phosphatases and kinases.

Conclusion:

Gene microarray studies of starved (‘hyperandrogenic’) and control NCI-R cells identified a small number of differentially expressed genes. Some of them are known to play a role in steroid and energy metabolism, others are involved in signaling. Further studies of these new genes/networks will enhance our knowledge on how androgen biosynthesis is regulated.

 

Nothing to Disclose: SU, GH, PEM, CEF

12969 25.0000 MON-0429 A Gene Expression Profiling of Human Steroidogenic NCI-H295R Cells Under Different Growth Condition:on the Search for Androgen Regulators 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Ju-Yeon Moon*, Hyun-Hwa Son, Bong Chul Chung and Man-Ho Choi
KIST, Seoul, Korea, Republic of (South)

 

Although ionizing radiation is commonly used in medical diagnostic imaging procedures, it may modulate steroidogenesis and disrupt endocrine functions. However, there has not been a short- and long-term effect of a single exposure to gamma radiation on steroid metabolism to date. A comprehensive assessment of dose- and time-related changes in the levels of serum steroids was performed in mice. Gas chromatography-mass spectrometry-based quantitative steroid signatures were introduced to 6-week-old C57BL/6 female mice (n = 5, each group) exposed to different dose (0, 1 and 4 Gy) with total body irradiation (TBI). Following TBI, serum samples were collected at 1, 3, 6, and 9 months. TBI in C57BL/6 female mice resulted in a slight decrease of the levels of androgens and progestins. Among progestins, progesterone, 5β-dihydroprogesterone (DHP), 5α-DHP, and 20α-DHP showed a significant down-regulation following short-term exposure to 4 Gy, with the exception of 20α-DHP, which was notably decreased at each of the time points measured and this may occur by the disruption of 20α-HSD activity, as observed in young mouse ovaries due to be sensitive to irradiation injury. In addition, TBI led to increase in certain corticoids and sterols. The corticosteroids 5α-tetrahydrodeoxycorticosterone and 5α-dihydrocorticosterone were significantly elevated at each of the time points measured after exposure to either 1 or 4 Gy, which may be associated with stress. Among the sterols, 24S-OH-cholestoerol, which has been shown to possess potent cytotoxicity and induce neuronal cell death, showed a dose-related elevation after irradiation that reached significance in the high dose group at the 6- and 9-month time points. To our knowledge, this is the first long-term study focusing on the effect of a single, low-dose exposure of gamma irradiation on serum steroid levels and steroid metabolism. These biomarkers could be used as tools to provide evidence in the case of a suspected radiation exposure.

 

Nothing to Disclose: JYM, HHS, BCC, MHC

13393 26.0000 MON-0430 A Metabolic Changes in Serum Steroids Induced By Total-Body Irradiation of Female C57B/6 Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Loren W Kline*1 and Edward Karpinski2
1Univ of AB/Fac of Med & Dentist, Edmonton, AB, Canada, 2University of Alberta, Edmonton, AB, Canada

 

Both estrogen and progesterone (P) have inhibitory effects on the contractility of gastrointestinal smooth muscle, including the gallbladder.  This study investigated whether17b-estradiol (E2) and P exerted their effects using the same second messenger system(s) in female guinea pig gallbladder strips.  E2 relaxed cholecystokinin octapeptide (CCK) induced tension in a concentration-dependent manner.  Fulvestrant significantly (p<0.001) reduced the amount of relaxation induced by 50 mM E2 (56.6+2.4 vs. 43.5+2.3%).  This suggested that an estrogen receptor was present on the gallbladder smooth muscle cells.   P also relaxed CCK-induced tension in a concentration-dependent manner.  E2 and P had a similar effect on KCl-induced tension.  The PKA inhibitor 14-22 amide mystrolated  (PKA-IM) had no significant effect on E2-induced relaxation or CCK-induced tension, but significantly (p<0.01) decreased the amount of P-induced relaxation of CCK-induced tension.  Treatment of the strips with 2-APB, an inhibitor of IP3-induced Ca2+ release significantly (p<0.001) increased the amount of E2-induced relaxation of both CCK- or KCl-induced relaxation, but had no significant effect on P-induced relaxation.  A similar pattern was observed when PKC inhibitors were used.  When either E2  or P were added to the chambers 3 min prior to either CCK or KCl, a significant (p<0.001) decrease in the amount of tension generated was observed.  When both E2 and P were added to the chambers after the CCK-induced tension had reached a steady level, the amount of relaxation observed was significantly (p<0.001) greater than when either was used alone.  The P-induced relaxation is mediated by the PKA/cAMP and PKC second messenger systems and the inhibition of extracellular Ca2+ entry.  The E2-induced relaxation is mediated by estrogen receptors on the smooth muscle membranes and the inhibition of extracellular Ca2+ entry.  In addition, E2 and P, when used together, have an additive effect on the amount of CCK-induced relaxation as expected if E2 and P are using different second messenger pathways to exert their effects.

 

Nothing to Disclose: LWK, EK

11034 27.0000 MON-0431 A Cholecystokinin- and KCl-Induced Tension Is Relaxed By Sex Steroids in Female Guinea Pig Gallbladder Strips 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Douglas C. Leder1, Kumud Joshi2 and Pandurangan Ramaraj*3
1A.T.Still Univeersity, Kirksville, MO, 2KCOM, Kirksville, MO, 3KCOM, A T Still University, Kirskville, MO

 

Forty-eight hours of progesterone treatment of human melanoma (BLM) cells not only decreased cell growth (1), but also resulted in lot of floating cells. Addition of 2 mM of 3-methyl adenine (3-MA) partially rescued cell growth (2). Partial rescue in cell growth with 3-MA led us to check adhesion and migration functions as well because of floating cells. Partial rescue in cell growth also prompted us to check for recovery of those in-vitro functions after removing progesterone and 3-MA. Hence, the aim of the study was to compare in-vitro functions of progesterone treated, 3-MA rescued and recovered human melanoma cells. MTT proliferation assay, crystal violet adhesion assay and scratch migration assay were used to assess respectively in-vitro cell growth, adhesion and migration functions of melanoma cells.

Fifty μM of Progesterone treatment resulted in 42% cell growth compared to 100% growth in untreated control. But, 3-MA addition partially rescued cell growth to 46.7%. When both treated and rescued cells were allowed to recover initially for 48 hrs, P-50 μM treated cells showed improvement in cell growth to 50%, whereas 3-MA rescued cells showed 57.5% growth. Again, when both cells were allowed to recover for second 48 hrs, rescued cells showed a cell growth of 87%, whereas treated cells maintained at 52.9%, the previous level of growth. So rescued cells recovered cell growth better than treated cells. Partial recovery of cell growth in rescued cells prompted us to check adhesion function. P-50 μM treatment resulted in 71.8% adhesion compared to 100% in untreated control. But, 3-MA partially rescued adhesion to 76.9%. When both treated and rescued cells were allowed to recover for first 48 hrs, rescued cells showed improved adhesion (86.5%) than treated cells (71%). Again, when both cells were allowed to recover for second 48 hrs, rescued and treated cells showed almost equal recovery in adhesion 91.2% and 87.9% respectively. Following adhesion, migration function was checked. P-50 μM treatment decreased migration to 23% compared to 100% in untreated control. But 3-MA partially rescued migration to 45%. However, initial 48 hrs recovery did not improve migration function in both treated and rescued cells.

In conclusion, progesterone treatment decreased in-vitro cell growth, adhesion and migration functions of BLM cells. But 3-MA partially rescued cell growth, adhesion and migration functions. 3-MA rescued cells showed better recovery of in-vitro functions than progesterone treated cells.

 

Nothing to Disclose: DCL, KJ, PR

15322 28.0000 MON-0432 A Rescued and Recovered Ιn-Vitro Functions of Progesterone Treated Human Melanoma (BLM) Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Mark Douglas Aupperlee*, Kim T Nguyen, Jaya Gupta, Jianwei Xie and Sandra Z Haslam
Michigan State University, East Lansing, MI

 

Progesterone and synthetic progestins are implicated in the etiology and progression of breast cancer. Increased proliferation and breast cancer risk have been observed in postmenopausal women receiving estrogen (E) + progestin hormone replacement therapy (HRT).  Progesterone action is mediated through the progesterone receptor (PR) that exists as two isoforms, PRA and PRB, which have unique transcriptional activity and function. Though co-expressed at similar levels within the normal premenopausal breast, altered PR isoform expression has been observed in the progression of breast cancer.  However, progestin action and PR isoform regulation in the normal human breast remains poorly understood.  Archival benign breast biopsies from 31 postmenopausal women were analyzed with cyclin E and p27 antibodies by immunofluorescence to examine potential mediators of proliferation. PRA and PRB-specific antibodies were used for immunofluorescence to measure relative PR isoform localization and regulation. The women were characterized as users of: 1) E alone (n=12); 2) E + medroxyprogesterone acetate (MPA) (n=13); or 3) no HRT (n=16). Compared with no HRT, nuclear p27 was significantly decreased 1.6-fold and nuclear cyclin E was significantly increased 2.2 fold in breast epithelium of women who had received E alone HRT.  Treatment with E+MPA further decreased nuclear p27 2-fold more than E alone, but did not significantly alter nuclear cyclin E compared to E alone. PRA and PRB expression was maintained, but decreased, in the breast epithelium of postmenopausal women who received no HRT compared to premenopausal women.  Both PRA and PRB expression were increased by treatment with E alone or E+MPA; the addition of MPA had no effect on PRA or PRB expression.  Across all treatments, PRA and PRB were generally co-expressed within the same cells in the breast epithelium at comparable amounts; a small percentage of cells expressed either only PRA or only PRB.  The present results suggest that both cyclin E and p27 mediate hormone-induced proliferation, while p27 may be a more important mediator of progestin-induced proliferation in the normal about the human breast.  These findings are consistent with the increased proliferation reported with E+MPA and increased incidence of breast cancer in postmenopausal women receiving E+MPA hormonal therapy.

 

Nothing to Disclose: MDA, KTN, JG, JX, SZH

12487 29.0000 MON-0433 A Progestin Action in the Normal Postmenopausal Human Breast 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Kentaro Hayashi*1 and Craig S Atwood2
1Univerdsity of Wisconsin-Madison, Madison, WI, 2Univ of Wisconsin, Madison, WI

 

The focus of our studies has centered on pathways that regulate steroidogenesis, since it is postulated that the endocrine dyscrasia associated with menopause, and andropause in men, is central to senescent changes leading to age-related diseases. Indeed, the incidence of a range of age-related diseases in both genders is elevated in those with lower circulating concentrations of sex steroids. Therefore, identifying the underlying genetic factors that regulate basal circulating sex steroid concentrations is of scientific, prognostic and diagnostic importance. To address which genetic factors regulate basal circulating sex steroid concentrations, we obtained 132 matched serum and DNA samples from age-matched women (n = 64; age = 76.6 ± 7.04) and men (n = 68; age = 76.6 ± 7.04). These samples were analyzed for 17b-estradiol (E2) and follicle-stimulating hormone (FSH) concentrations and 115 single nucleotide polymorphisms in genes that regulate sex steroid synthesis, catabolism, inactivation and elimination. Our data indicate a wide variation in the concentration of circulating sex steroids, including E2, in both post-menopausal women (range: 12-42 pg/mL) and age-matched men (range: 12-70 pg/mL). Moreover, age-matched males had significantly higher circulating concentrations of E2 than post-menopausal females (mean = 37.9 ± 12.1 pg/mL vs. 21.7 ± 8.4 pg/mL; p<0.0001). Recursive partitioning analyses of these results stratified by splitting the sample into either high or low circulating E2 revealed that males (n = 33 high, 35 low) containing 1 or 2 T alleles in an FSHR exonic polymorphism (rs6165) and who also were T allele homozygous in an HSD17B1 intronic polymorphism (rs12602084) had lower circulating E2 concentrations 100% of the time (n = 11). Importantly, these results makes biological sense since a change in FSHR signaling induced by this missense mutation (Ala ® Thr, position 281) and the intronic-induced changes in 17b-HSD expression, which converts E1 and androstenedione/testosterone into E2, would be anticipated to modulate E2 concentration. In females (n = 32 high, 32 low), those heterozygous (G/C) for an intronic SNP in LHR (rs4073366) were 82% likely to have lower circulating E2 concentrations. These results support the utility of identifying gene-gene interactions in identifying complex human traits such as circulating sex steroid concentration.

 

Nothing to Disclose: KH, CSA

16031 30.0000 MON-0434 A Identification of Gene-Gene Interactions in the Steroid Metabolic Pathway That Predict Circulating Sex Hormone Concentrations 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Monday, June 23rd 3:00:00 PM MON 0405-0434 4837 1:00:00 PM Novel Pathways in Steroid Hormones Action Poster

Oleg Varlamov*1, Michael P Chu2, Anda Cornea3 and Charles T Roberts Jr.3
1Oregon National Primate Research Center, Beaverton, OR, 2Oregon Health & Science University, Portland, OR, 3Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR

 

White adipose tissue (WAT) mediates the insulin-stimulated postprandial adsorption of free fatty acids (FFA) and glucose, which serve as the precursors for triglyceride synthesis and subsequent storage in lipid droplets (LDs).  Mature WAT adipocytes are typically unilocular in nature, with a central LD (cLD) occupying the main volume of the cell.  WAT hypertrophy, principally a function of cLD volume, is linked to the pathophysiology of obesity and insulin resistance.  The spatial and temporal dynamics of FFA uptake and cLD formation in authentic mature adipocytes are unknown.  Here we employed a single-cell, fluorescence-imaging assay to resolve the pathway of basal and insulin-stimulated FFA uptake in primary omental WAT explants from non-human primates.  The fluorescent FFA analogue BODIPY-C12 is rapidly taken up by mature adipocytes to enter the reticular network of the endoplasmic reticulum (ER).  The adipocyte ER engulfs the surface of the cLD in the series of discrete reticular patches and tubules.  Each ER patch harbors a series of closely spaced spherical cavities approximately 0.5-1 microns in diameter.  BODIPY-C12 immediately fills these spherical cavities, which appear as micro-lipid droplets (mLDs).  Fluorescent immunohistochemistry revealed that mLDs are ER-associated, covered with perilipin A, and are closely associated with hormone-sensitive lipase.  The number of mLDs per adipocyte was increased by insulin stimulation.  Both the cLD and mLD compartments exhibited insulin-stimulated FFA uptake; however, mLDs were more insulin-sensitive than cLDs.  FFA transport and incorporation into mLDs was decreased by the lipolytic agent isoproterenol.  Following rapid translocation into mLDs, BODIPY-C12 enters the cLD in an insulin-dependent manner, suggesting the existence of an insulin-dependent pore or transporter that carries newly synthesized triglycerides from mLDs to the cLD.  In conclusion, we have identified an intermediate mLD compartment that is the initial intracellular reservoir of FFAs following insulin stimulation.  Because of their intimate association with the ER, perilipin, and hormone-sensitive lipase, we propose that mLDs are the insulin-responsive triglyceride synthesis and hydrolysis sites in WAT.  Due to their high surface-to-volume ratio and close proximity to lipolytic enzymes and other cytoplasmic components, mLDs may represent flexible organelles that mediate rapid metabolic response in healthy WAT.

 

Nothing to Disclose: OV, MPC, AC, CTR Jr.

12383 1.0000 MON-0875 A Fluorescence Imaging of Fatty Acid Transport in White Adipose Tissue Reveals a Novel Insulin-Responsive Compartment in Adipocytes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Oleg Varlamov*1, Michael P Chu2, Anda Cornea3 and Charles T Roberts Jr.3
1Oregon National Primate Research Center, Beaverton, OR, 2Oregon Health & Science University, Portland, OR, 3Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR

 

Current concepts of the heterogeneity of adipocyte structure and function include the distinctions between white, brown, and beige/brite adipocytes, the existence of different white adipose tissue depots such as subcutaneous, visceral, etc., and preliminary evidence for differences in gene expression profiles between adipocytes of different sizes.  To date, however, there has been little information available on the potential specialization of adipocytes of the same type in a given depot.  We employed a sensitive single-cell fluorescence imaging approach to evaluate the differential behavior of white adipose tissue adipocytes with respect to basal and insulin-stimulated lipid metabolism.  Free fatty acids (FFA) and glucose are the two principal substrates used by adipose tissue for triglyceride synthesis.  We used a BODIPY-C12 fluorescent FFA reporter to explore FFA uptake in adipose tissue explants of non-human primates. BODIPY-C12 is transported into mature adipocytes in an insulin-dependent manner.  Surprisingly, adipose tissue displayed a striking mosaic pattern with respect to BODIPY-C12 uptake, in that some adipocytes residing in the same explant were less efficient than adjacent adipocytes in FFA transport, despite the presence of typical central lipid droplets.  Mosaicism was apparent both under basal and insulin-stimulated conditions, although insulin treatment enhanced cellular fluorescence.  This mosaic pattern was observed in various fat depots of non-human primates, humans, and in mice, and was independent of age and gender.  Furthermore, in vitro-differentiated human adipocytes were also mosaic with respect to BODIPY-C12 uptake; specifically, adipocytes growing on the same dish varied significantly in their apparent level in insulin-stimulated FFA uptake, even though all were viable as assessed by cell viability markers such as calcein.  This mosaic pattern was inhibited by pretreatment with the lipolytic agent isoproterenol, which also inhibited insulin-stimulated FFA uptake.  In vitro incubation of adipose tissue explants for 24 hours did not alter the mosaic pattern of FFA uptake, suggesting that active and inactive adipocytes represent stable subpopulations of cells.  Adipose tissue from obese animals, containing large insulin-resistant adipocytes, lacked the mosaic pattern of FFA uptake, in that every adipocyte exhibited a similar level of BODIPY-C12 fluorescence.  In conclusion, we have identified a new level of intrinsic heterogeneity in the level of FFA uptake in healthy adipose tissue, which is altered in obesity.  We propose that white adipose tissue harbors different subpopulations of adipocytes that mediate differential uptake of FFA.

 

Nothing to Disclose: OV, MPC, AC, CTR Jr.

12513 2.0000 MON-0876 A Mosaic Pattern of Fatty Acid Uptake in Adipocytes of White Adipose Tissue Revealed By Single-Cell Fluorescence Imaging 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Eric R Hugo*1, Randall R Sakai2, Eric J Phillips1, Sejal R Fox1, Vidjaya LV Premkumar1 and Nira Ben-Jonathan1
1University of Cincinnati, Cincinnati, OH, 2Univ of Cincinnati, Cincinnati, OH

 

Background: Second generation antipsychotics (SGA) are prescribed to millions of patients with neuropsychiatric disorders. Although SGAs can ameliorate mental dysfunctions, they have serious metabolic side-effects such as weight gain, the metabolic syndrome, and increased risk of diabetes and cardiovascular disease. The primary therapeutic targets of SGAs are dopamine (DAR) and serotonin (5-HTR) receptors. The current dogma is that metabolic side effects of SGAs are attributed to their action on the brain. We recently discovered expression of functional DAR and 5-HTR subtypes in human and rodent adipocytes and speculated that these receptors are targeted by SGA.

Hypothesis: Direct effects of SGA on selected adipocyte functions contribute to weight gain and metabolic dysregulation. 

Methods: in vitro model: Subcutaneous (sc) adipose explants and mature adipocytes were harvested from patients undergoing abdominoplasty. Both sc and periovarian (visceral) explants were obtained from female Sprague-Dawley rats. Samples were incubated with 1-100 nM olanzapine or ziprasidone for 72 h and analyzed for lipolysis by glycerol release and for a panel of metabolic-related genes by qRT-PCR.  In vivo model: Rats were treated with olanzapine or ziprasidone in cookie dough for 3 or 7 days. Food intake, body weight, and fat accumulation (by NMR) were determined. Periovarian and sc adipose explants were analyzed by qRT-PCR for the gene panel as above. Serum leptin and adiponectin were determined by ELISA.

Results: Olanzapine, and to a lesser extent ziprasidone, caused marked suppression of leptin and adiponectin, and modest suppression of basal and isoproterenol-stimulated lipolysis from human sc adipose explants and mature adipocytes, respectively. Treatment of rats with SGA rapidly increased food intake and body weight and a delayed increase in fat accumulation.  In sc fat, SGA caused over 5-fold suppression of key lipases, leptin, adiponectin, and PPARg, but a significant stimulation of SREBP.    

Conclusion:  SGA-induced metabolic dysregulation is caused, in part, by their direct action on adipose tissue, presumably via the local DAR and/or 5-HTR subtypes. We suggest that adipocytes should be integrated into the screening paradigm of candidate new antipsychotics to identify undesirable metabolic characteristics prior to costly animal studies and clinical trials. The long term goal is to provide safer drugs to patients requiring treatment with these medications.

 

Nothing to Disclose: ERH, RRS, EJP, SRF, VLP, NB

14640 3.0000 MON-0877 A Direct Effects of Weight-Inducing Antipsychotics on Adipose Tissue from Humans and Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Purificación Ros*1, Pilar Argente-Arizón2, Francisca Diaz3, Vicente Barrios4, Miguel Angel Sanchez-Garrido5, Manuel Tena-Sempere6, Jesús Argente7 and Julie Ann Chowen4
1Hospital Universitario Puerto de Hierro, Madrid, Spain, 2Hospital Infantil Universitario Niño Jesús, Instituto de Investigación la Princesa, Universidad Autónoma de Madrid, CIBERobn Instituto Carlos III, Madrid, Spain, 3Hospital Infantil Universitario Niño Jesús. CIBERobn Instituto Carlos III, Madrid, Spain, 4Hospital Infantil Universitario Niño Jesús. Universidad Autónoma de Madrid. CIBERobn, Instituto de Salud Carlos III, Madrid, Spain, 5University of Cordoba, Cordoba, Spain, 6University of Cordoba, Instituto Maimonides de Investigacion Biomedica de Cordoba (IMIBIC/HURS), CIBERobn Instituto Carlos III, Cordoba, Spain, 7Hospital Infantil Universitario Niño Jesus, Universidad Autonoma de Madrid, CIBERobn Instituto Carlos III, Madrid, Spain

 

There is a clear sexual dimorphism not only in the distribution of adipose tissue, but also in its gene expression profile and functionality, as well as in adipocyte morphology. These differences can affect an individual’s risk for metabolic disease. Post-pubertal sex steroids are clearly involved in determining some of these differences; however, the neonatal hormonal environment also has effects on long-term metabolic control. We hypothesized that exposure of female rats to excess androgens during early development modifies both the expression pattern of adipokines and adipocyte morphology in adulthood, thus changing their propensity to metabolic dysfunction. On postnatal day (PND) 1 female rats were injected with testosterone (208 mg/Kg; AF) or vehicle (F) and killed with male littermates (M) on PND 90. Body weight, fat pads, circulating cytokines (by multiplex assays) and mRNA levels (by RT-PCR) of leptin, adiponectin, IL6, IL1β and TNF-α and adipocyte morphology were measured in visceral adipose tissue (VAT). We found that AF (206.4±7.5 g) weighed more than F (189.6±3.1 g), but less than M (323.4±6.2 g; p<0.0001). Mean VAT weight was higher in M (4.7±0.7 g) compared to F (1.8±0.3 g), but not to AF (2.0±0.5 g; p<0.0001). There were no differences in serum adiponectin levels (M: 58.8± 6.2; F: 66.0±4.3; AF: 65.7±4.8 ng/ml), but serum leptin (M: 1.9±0.1, F: 0.9±0.2, AF 1.5±0.1 pg/ml; p<0.0001) and IL1β (M: 25.1±3.4, F 9.1±1.8, AF: 21.5±4.7 pg/ml; P<0.005) levels were lower in F than M and significantly increased in AF compared to F. These changes paralleled modifications in leptin (M: 100±2, F: 50.4±4.2, AF: 86.6±7.5 % M; p<0.005) and IL1β (M: 100±19.6, F: 85.1±19.6, AF: 158.8±32.5 % M; p<0.05) mRNA levels in VAT.  IL6 mRNA levels (M: 100±18.9, F: 24.8±6.3, AF: 20.8±4 % M; p<0.0001) were lower in both F and AF compared to M. In contrast, TNFα mRNA levels in VAT (M: 100±17.3, F: 133.3±10, AF: 51.6±5.4 %M; p<0.02) were higher in F than M, with AF having lower levels than both M and F. We found no difference in VAT adiponectin gene expression (M: 100.0± 19.6; F: 68.7±11.7; AF: 114.7±18.8 % M). VAT adipocytes were larger in M than in F, with neonatal androgens having no effect on this parameter (M: 86.6±5.3, F: 53.7±4.1, AF: 53.5±3.2 µm2; p<0.01).

Conclusion: Exposure to increased androgens during development modifies adipokine expression, but not adipocyte morphology, in VAT of adult female rats. This could affect, and possibly worsen, their response to metabolic insults.

 

Nothing to Disclose: PR, PA, FD, VB, MAS, MT, JA, JAC

15958 4.0000 MON-0878 A Changes in Serum Adipokine Levels and Visceral Adipose Adipokine Expression in Female Rats after Exposure to Increased Androgens during Early Development 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Florencia Martin1, Juan P Fariña1, Daniel Castrogiovanni2, Andres Giovambattista2, Juan Jose Gagliardino1 and Eduardo Spinedi*3
1CENEXA (CONICET-UNLP), La Plata, Argentina, 2IMBICE (CONICET-CICPBA), La Plata, 3CENEXA (UNLP -CONICET - FCM), La Plata, Argentina

 

Background and Aim: Dieudonne et al (1). earlier suggested that androgens and estrogen behave as antiadipogenic and proadipogenic hormones, respectively, on rat pre-adipocytes; and that these are receptor-mediated effects. We presently aimed to assess whether the in vitro adipogenic capacity of stromal-vascular fraction cells (SVFs) isolated from rat white adipose tissue (WAT), is modulated by the endogenous sex steroid milieu in male (M) and female (F) Wistar rats. Design & Measurements: Pre-pubertal (25 day-old) rats were either bilaterally gonadectomized (ODX, OVX) or sham operated (controls: CM and CF); 40-50 days later, animals were sacrificed in non fasting condition and trunk blood was collected to measure total testosterone (TT) and estradiol (E2) plasma concentrations. Epididymal and parametrial WATs pads (EAT and PAT, respectively) were then aseptically dissected, weighed and processed for SVFs isolation. A similar number of SVFs (15,000 cells approximately) from all groups was seed and cultured 6-7 days to reach 60-70 % confluence and re-counted (proliferation capacity). Thereafter, cells were induced to differentiate (with a classic cocktail) in a 10 day-culture system. At the end of this period intracellular lipid content was assessed by Oil Red O (ORO) staining and thereafter, the ORO was extracted and its concentration quantified (OD: 490 ORO/260 DNA nm) and expressed in AU as color/DNA. Results: Pre-pubertal gonadectomy drastically reduced the peripheral levels of the homologous sex steroid (TT: 0.72 ± 0.11 and 0.39 ± 0.02 ng/mL in CM and ODX, respectively; E2: 83.86 ± 16.29 and 38.98 ± 10.43 pg/mL in CF and OVX, respectively; P < 0.05). Processed WAT rendered more SVFs in CF-PAT than in CM-EAT pads (498.12 ± 47.17 vs. 346.57 ± 39.86 cells/mg WAT, respectively; P < 0.05). The number of isolated cells was significantly reduced  in OVX-PAT (323.94 ± 50.28 cells/mg WAT) compared to CF-PAT (P < 0.05). Accordingly to cell number at confluence, the proliferative capacity of SVFs was slightly, albeit significant, greater in females than in males (CF = OVX > CM = ODX; P = 0.049). Finally, the capacity of SVFs to accumulate lipid at the end of the differentiation period followed a decreasing trend: 27.43 ± 3.14, 16.22 ± 0.77, 15.31 ± 0.69 and 10.89 ± 0.84 AU in CF, OVX, ODX and CM cells, respectively (P < 0.05). Conclusions: Our data suggest that gender-dependent differences in the distribution and expansion processes of the SVFs from epididymal and parametrial WAT pads seem to be related to the impact of the endogenous sex steroid-rich milieu on local (EAT/PAT) precursor cells. Nevertheless, it remains to be determined the SVF cell, post-steroid receptor mediators involved in these events.

 

Nothing to Disclose: FM, JPF, DC, AG, JJG, ES

12210 5.0000 MON-0879 A Endogenous Sex Steroid-Dependent in Vitro Rat Adipogenesis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Aldo Grefhorst*, Johanna C. van den Beukel, Jacobie Steenbergen, Jenny A. Visser and Axel P.N. Themmen
Erasmus MC, Rotterdam, Netherlands

 

Mammals have two distinct types of adipose tissue. White adipose tissue (WAT) stores fat and brown adipose tissue (BAT) dissipates fat to produce heat. The latter process requires the presence of uncoupling protein-1 (UCP1). WAT can gain characteristics of BAT and this so-called browning is thought to significantly contribute to energy expenditure. Thus, both activation of BAT and browning of WAT are considered beneficial in combating obesity. Human and animal studies showed that females have more active BAT, but the differences in browning of WAT between the sexes, in particular the role of the gonads have hardly been studied. In this study we investigated the modulating effects of gonadectomy and cold-treatment on BAT activity and browning of WAT.

Male and female mice were gonadectomized or received a sham operation and were exposed 24 hours to 23 °C or 4 °C 45 days later to activate BAT and to induce browning of WAT. In addition, to test the role of estrogens in BAT activity and browning of WAT, male mice were injected with diethylstilbesterol (DES) for 1 week.

Upon gonadectomy, male mice gained 14.1 ± 1.9 % bodyweight while sham operated males gained 26.2 ± 1.5% bodyweight. For the female mice, these numbers were 16.0 ± 1.0 % for the sham and 34.0 ± 2.9% for gonadectomized mice. Unexpectedly, expression of Ucp1 and other classical markers such as Ppargc1a did not differ between the sexes and were not affected by gonadectomy. Histological examinations revealed that female BAT was denser than male BAT, suggestive for more active BAT. In male mice, gonadectomy increased BAT density while gonadectomy of female mice caused a reduction. This indicates that the presence of ovaries is associated with more active BAT while the presence of testes is associated with reduced BAT activity. Similar results were found for inguinal WAT. In contrast to males, inguinal WAT of females showed the appearance of small, brown like adipocytes, although WAT Ucp1 expression did not differ between the sexes and upon gonadectomy. Treatment of male mice with DES did not enhance BAT density and browning of inguinal WAT, suggesting that other ovarian factors are involved in activation of BAT and browning of WAT.

In conclusion, in mice, ovaries stimulate BAT activity and browning of WAT but this is not (solely) due to the ovarian hormone estrogen. Presence of testis reduces BAT activity and browning of WAT. Since Ucp1 gene expression does not differ between male and female mice, other markers of BAT activity and/or browning of WAT need to be explored.

 

Nothing to Disclose: AG, JCV, JS, JAV, APNT

16263 6.0000 MON-0880 A Ovaries Stimulate While Testes Reduce Brown Adipose Tissue Activity and Browning of White Adipose Tissue in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Kathleen V. Abadie, Sean Michael Hartig*, Pradip K Saha, Massoud Motamed, Mandeep Bajaj, David D Moore, Lawrence C Chan and Sean E McGuire
Baylor College of Medicine, Houston, TX

 

Chronic positive imbalance between energy intake and energy expenditure in fat cells promotes lipid deposition in non-adipose tissues, accelerating pathologies including cardiovascular disease, hyperlipidemia, insulin resistance, and type 2 diabetes mellitus (T2DM). We identified miR-30a as a non-coding RNA that promotes insulin sensitivity, fat storage and mitochondrial biogenesis in subcutaneous adipocytes.  miR-30a expression is decreased in white fat from diabetic mice and humans but is specifically enriched in brown adipose tissue. miR-30a overexpression in human subcutaneous adipocytes in vitro promotes fatty acid storage, induces a gene expression profile associated with increased energy expenditure, and increases oxygen consumption.  Thus, miR-30a overexpression drives a white fat to beige fat transition, commonly referred to as ‘browning’ of white adipose tissue.  miR-30a expression is regulated by thiazolidinediones, suggesting that promoting miR-30a expression may offer the benefits of thiazolidinediones without negative side effects.  To test the hypothesis that restoration of miR-30a expression in white adipose tissue would improve peripheral insulin insensitivity, we injected adenovirus (Adv) expressing either miR-30a or GFP directly into the inguinal fat pad of mice.  This unilateral Adv-miR-30a overexpression did not change body weight but was sufficient to modestly improve whole body glucose tolerance and markedly enhance peripheral insulin sensitivity as assessed by insulin tolerance.  Serum analysis showed reduced levels of insulin, free fatty acids, and triglycerides.  In agreement with our in vitro findings, gene expression analysis showed increased expression of brown adipocyte genes in Adv-miR-30a infected WAT compared to Adv-GFP controls.  We conclude that miR-30a drives white to brown fat conversion, leading to improved insulin sensitivity. Increasing miR-30a action represents a novel therapeutic avenue for treating metabolic syndrome.

 

Nothing to Disclose: KVA, SMH, PKS, MM, MB, DDM, LCC, SEM

16318 7.0000 MON-0881 A Mir-30a Improves Peripheral Insulin Sensitivity By Browning White Adipose Tissue 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Nalini Santanam*1 and Carla Cook2
1Marshall University School of Medicine, Huntington, WV, 2Marshall University School of Medicine

 

Adipose tissue is an endocrine organ that plays an important physiological role in lipid and glucose homeostasis. Increased adiposity and altered adipose function leads to obesity and increased risk to cardiovascular disease and diabetes. Consumption of high fat containing diet and sedentary lifestyle are major risk factors for obesity. Our laboratory is interested in studying the interactions between diet and environmental factors on adipose function. Preadipocytes or adipose derived stem cells (ASCs) are tiny niche cells that respond to their microenvironment and have the ability to differentiate into adipocytes or other cellular lineages. MicroRNAs (miRNA or miR) are endogenously expressed non-coding RNAs (22 nt) which regulate gene transcription and translation. We recently showed that micRNA regulated preadipocytes function. Simulated Microgravity (SMG) has been shown to alter cellular function. SMG also can modulate the ability of ASCs to differentiate into other lineages such as lymphocytes or osteocytes. In the present study we investigated the effect of dietary omega-3 and 6 lipids on adipokine and miRNA profile in human pre and post adipocytes cultured in normal or simulated microgravity in the presence or absence of 25 μM of docosahexaenoic acid or linoleic acid. Human whole genome miRNome miScript miRNA PCR array (v16.0) on isolated miRNA and adipokine multiplex array on conditioned media was performed.  DHA effects were opposite to LA effects in relation to adipocyte differentiation (DHA induced, LA inhibited) in cells grown in SMG.  This effect correlated with the levels of miRs that increased adipogenesis (mR-143, miR-204) which was upregulated by DHA but downregulated by LA. The reverse was true with miRs that inhibited adipogenesis (miR-133 and miR-130). There was also differential expression of transcription factors that regulated adipogenesis (PPAR, CEBP and SREBP). Our data provides evidence that diet and environment modulate epigenetic changes in adipose tissue and its significance in space travel will be explored in future studies.

 

Nothing to Disclose: NS, CC

16716 8.0000 MON-0882 A Omega-3 and 6 Fatty Acids Modulates Mirna Profile in Microgravity Cultured Adipocytes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Laura Louise Gathercole*1, Aparajita Bhattacharya1, Jonathan Mark Hazlehurst1, Paul M Stewart2, Gareth Geoffrey Lavery1 and Jeremy W Tomlinson1
1University of Birmingham, Birmingham, United Kingdom, 2University of Leeds, Leeds, United Kingdom

 

Patients with glucocorticoid (GC) excess develop insulin resistance and central obesity however the underpinning molecular mechanisms remain poorly understood. Over the last decade small non-coding RNAs (microRNAs) controlling protein expression have been identified, representing an additional regulatory layer to the control of metabolism through the altered expression of enzymes, transcription factors and signalling components. We hypothesise that GCs regulate the expression of microRNAs that impact insulin action and metabolic homeostasis.

In order to identify GC and insulin regulated microRNAs blood was extracted from 10 healthy volunteers under four treatment conditions. Volunteers were fasted for 12h and infused with either saline or hydrocortisone (0.2mg/kg/h) this was followed by 4h of insulin infusion (100mU/m2.min). Samples were taken after fasting (+/- hydrocortisone) and after insulin infusion (+/- hydrocortisone). RNA was extracted and used in microRNA array analysis, providing full coverage of mirBASE17. microRNAs that potentially target metabolic mRNAs and pathways were identified in silico using the target prediction software, targetscan and WEB-based Gene SeT AnaLysis Toolkit, WebGstalt. Expression of these metabolic microRNAs was measured across differentiation and in response to insulin and hydrocortisone in the human subcutaneous cell line, SGBS.

Of the 68 microRNAs significantly altered by insulin 49 were no longer regulated in the presence of hydrocortisone, including mir-642b, which is predicted to regulate adipogenesis. In vitro mir-642b expression increased across pre-adipocyte differentiation, but was not regulated in response to insulin or hydrocortisone in either pre-adipocytes or adipocytes. A further 8 microRNAs were regulated by insulin only in the presence of hydrocortisone. These included mir-223, mir-143 and mir-145 which are predicted to regulate insulin signalling and adipogenic pathways. In vitro mir-223, expression decreased across pre-adipocyte differentiation, mir-143 and mir-145 were not altered. In SGBS pre-adipocytes mir-143 expression was increased by insulin, both in the presence and absence of insulin. Mir-145 and mir-223 were not regulated by insulin or hydrocortisone in vitro.

This study has profiled serum microRNAs in response to GC and insulin treatment, and identified microRNAs associated with pre-adipocyte differentiation that may be crucial in regulating the increased fat mass associated with GC excess.

 

Nothing to Disclose: LLG, AB, JMH, PMS, GGL, JWT

16694 9.0000 MON-0883 A Serum microRNA Profile Highlights a Novel Mechanistic Link Between Glucocorticoid Excess and Human Adipocyte Differentiation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Lara A Householder*, Katie Troike, Ellen R Lubbers, Silvana Duran-Ortiz, Adam Jara, Edward O List, John J Kopchick and Darlene E Berryman
Ohio University, Athens, OH

 

White adipose tissue (WAT) fibrosis is now a recognized hallmark of obesity. This overabundance of extracellular matrix fibers, primarily collagens, has been linked with a number of other WAT dysfunctions associated with the obese state, namely, impaired glucose and lipid metabolism and inflammation. Interestingly, WAT fibrosis is thought to limit the expansion of adipocytes as increased fibrosis is associated with smaller adipocytes. Though these dysfunctions are associated with obesity, it is also possible they are a hallmark of unhealthy adipose tissue independent of adiposity. GH-altered transgenic mice provide a unique paradigm through which to examine this idea. Important to this project, bovine GH transgenic (bGH) mice have high serum levels of GH, insulin-like growth factor 1 (IGF-1), and insulin resulting in a giant, lean phenotype. Counterintuitively, they are also unhealthy, suffering from altered metabolism, increased rates of cancer development, and a shortened lifespan. Notably, GH has been shown to promote fibrosis in others tissues such as the kidneys. For this study, a cohort of six month-old male bGH mice and their WT controls were examined to determine whether excess GH promoted fibrosis in WAT. Weight and body composition were measured prior to sacrifice and then four different WAT depots were gathered: subcutaneous, epididymal, retroperitoneal, and mesenteric. Histological samples were sliced and stained with picosirus red, which stains for all collagen types. Samples were then analyzed to quantify the amount of staining. Results revealed drastically higher amounts of collagen in the bGH WAT, particularly in the subcutaneous depot. Adipocyte size followed the expected trend with significantly smaller adipocytes appearing in the bGH subcutaneous depot. However, when collagen gene expression was measured by RNASeq, differences in some collagens and matrix degradation enzymes were detected, but significance was only found between depots, not between genotypes. Thus, our results clearly demonstrate that GH has a depot-dependent effect on WAT fibrosis; however, the mechanism for this effect is still unclear. Further research will be required to determine how GH fosters these effects. Additionally, our results have shown that fibrosis may actually work to promote the lean phenotype in bGH mice by limiting the lipid storage capacity of adipocytes.

 

Nothing to Disclose: LAH, KT, ERL, SD, AJ, EOL, JJK, DEB

13904 10.0000 MON-0884 A Excess Growth Hormone Promotes White Adipose Tissue Fibrosis in a Depot-Dependent Manner in GH Transgenic Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Genlai Li1, Wen Yao1 and Honglin Jiang*2
1Nanjing Agricultural University, Nanjing, China, 2Virginia Tech, Blacksburg, VA

 

Short-chain fatty acids (SCFAs) are the main products of microbial fermentation in the gastrointestinal tract and have recently been proposed to mediate the effect of gut microbiota on obesity. However, little is known about how SCFAs might contribute to obesity. In this study we determined the effect of acetate, propionate, and butyrate, the main SCFAs in the gut, on adipocyte differentiation. We used the stromal vascular fraction (SVF) of porcine subcutaneous fat as the preadipocyte cell model. Adding acetate, propionate, or butyrate to the differentiation medium enhanced the differentiation of porcine SVF into adipocytes, as evidenced by increased number of Oil Red O-stained cells and/or increased mRNA expression of PPARG, CEBPA, FABP4, and LEP (leptin), which are adipocyte markers. Based on the expression levels of adipocyte markers, the adipogenic effect of propionate and butyrate was greater than that of acetate. We also found that propionate and butyrate, but not acetate, could acutely increase the expression of CEBPA and/or PPARG mRNA in porcine SVF. Because PPARG and CEBPA are two redundant master regulators of adipocyte differentiation, acute upregulation of their expression by propionate and butyrate suggests that propionate and butyrate stimulate adipocyte differentiation through increased expression of PPARG and/or CEBPA. The SCFAs can affect the physiology of a cell through binding to G protein-coupled receptors 41 (GPR41) and GPR43, activation of GPR41- and GPR43-independent cAMP-PKA-CREB signaling, inhibition of AMPK, or inhibition of histone deacetylases (HDACs). However, we found that GPR41 and GPR43 mRNAs were not detectable in differentiated or undifferentiated porcine SVF. This suggests that the stimulatory effect of SCFAs on porcine adipocyte differentiation is unlikely mediated through GPR41 or GPR43. Rp-cAMPS, a cell-permeable cAMP analogue, had no effect on basal or propionate- or butyrate-induced expression of PPARG and CEBPA mRNAs in porcine SVF. This suggests that SCFAs do not stimulate adipocyte differentiation through the cAMP-PKA-CREB pathway. Adding AICAR, a cell-permeable activator of AMPK, to the SVF culture increased both basal and propionate- or butyrate-induced expression of PPARG and CEBPA mRNAs. This result rules out the possibility that SCFAs stimulate porcine adipocyte differentiation through inhibition of AMPK. Trichostatin A, a specific inhibitor of HDACs, increased the basal but not propionate- or butyrate-induced expression of PPARG and CEBPA mRNAs in porcine SVF. This result supports the possibility that SCFAs stimulate adipocyte differentiation through inhibition of HDACs. Overall, these results demonstrate that SCFAs, in particular, propionate and butyrate, stimulate porcine adipocyte differentiation in vitro and suggest that this stimulation may be mediated through inhibition of HDACs.

 

Nothing to Disclose: GL, WY, HJ

16339 11.0000 MON-0885 A Short-Chain Fatty Acids Stimulate Porcine Adipocyte Differentiation Probably through Inhibition of Histone Deacetylases 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Akira Aoki*, Hisamitsu Nagase and Tsuyoshi Nakanishi
Gifu Pharmaceutical University, Gifu-Shi, Japan

 

Major Urinary Protein (MUP) 1 is a member of lipocalin family synthesized in several organs and carries small hydrophobic ligands such as pheromones. In addition, MUP1 suppresses gluconeogesis and lipogenesis in the liver and increases mitochondrial function in skeletal muscle in obese/diabetic condition. Although the expression level of MUP1 changed along with nutritional status, it remains unclear that the physiological function of MUP1 in non-obese/ diabetic condition. Here, to investigate the role of MUP1 in normal states, we generated the transgenic (TG) mice that overexpress MUP1 under the control of cytomegalovirus early enhancer/chicken b-actin promoter (MUP1-TG). Expression of MUP1 was very high in various tissues, including adipose tissue, of MUP1-TG mice compared to those of wild-type mice. The mRNA expressions of gluconeogenic and lipogenic genes were not different between wild-type and MUP1-TG mice under standard chow diet. However, overexpression of MUP1 protected short-term high-fat diet (HFD)-induced lipidemia and body weight gain with increasing adipose tissue mass. In vitro model of adipocyte differentiation using mouse embryonic fibroblasts, overexpression of MUP1 suppressed the mRNA levels of adipocyte-related genes in the early stage, and prevent lipid droplet accumulation. Furthermore, the protection of HFD-induced lipidemia and body weight gain in MUP1-TG mice was attenuated by heterozygous peroxisome proliferator-activated receptor γ knockouts. Our findings suggest a novel role of MUP1 which may maintain metabolic homeostasis by regulation of adipocyte differentiation in the early stage.

 

Nothing to Disclose: AA, HN, TN

12333 12.0000 MON-0886 A The Roles of Major Urinary Protein 1 As a Regulator for Adipocyte Differentiation in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Emmanuelle Kuhn*1, Say Viengchareun2, Bruno Feve3 and Marc Lombes2
1INSERM, Le Kremlin Bicêtre, France, 2INSERM U693, Le Kremlin Bicêtre, France, 3INSERM, PARIS, France

 

Brown Adipose Tissue (BAT) re-emerges as a pivotal metabolic player in humans regulating energy homeostasis and thermogenesis. Understanding how regulatory factors control brown adipocyte commitment and function is thus a critical challenge. Among essential transcription factors involved, the mineralocorticoid receptor (MR), besides its role in controlling hydroelectrolytic homeostasis, acts as a pro-adipogenic and anti-thermogenic factor that inhibits mitochondrial uncoupling protein-1 (UCP1) expression. To investigate the involvement of MR in energy expenditure, we used the transgenic mouse model with global MR overexpression that presented with a paradoxical resistance to high fat diet-induced obesity (1). We show that BAT mass was not different between wild type and transgenic mice which does not exclude a contribution of altered UCP1 expression and function. To gain more insights into the mechanisms by which MR through interaction with unknown molecular partners participates to these metabolic regulations, we analyzed the expression profile of various MR coregulators in the brown adipocyte T37i cells during differentiation. Along with the incremental induction ofmRNA levels of specific adipogenic markers (PPARγ2, leptin), we show that corticosteroid receptors (MR and glucocorticoid receptor), as well as UCP1 expression drastically increased as a function of brown adipocyte differentiation. We also demonstrate that transcript levels of some MR coactivators (PGC-1α, PRC, ELL, SRC3) and MR corepressors (PIAS 1,2,3 and RIP140) significantly increased by approximately 2-fold at day 3 of differentiation, considered as the commitment of adipogenesis. Such transient and simultaneous peak of coregulator expression is consistent with a concerted cooperation of physiological significance that occurs during brown adipocyte fate. Given that UCP1 expression is inversely controlled by catecholamines and corticosteroids, we are investigating the mechanisms of MR-inhibitory effect on UCP1 transcription in T37i cells. Identification of MR transcriptional complexes is currently under investigation by chromatin immunoprecipitation experiments enabling us to comfort the major role played by MR during brown adipocyte development. Our studies demonstrate that MR exerts a pivotal metabolic role by controlling energy expenditure, and should provide useful information for the identification of coregulators involved in MR-regulated brown adipocyte function.

 

Nothing to Disclose: EK, SV, BF, ML

14392 13.0000 MON-0887 A Brown Adipocyte Differentiation and Function Are Regulated By Mineralocorticoid Receptor through Coregulator-Mediated Transcriptional Control of Uncoupling Protein-1 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Yu-Ting Chiang, Yu-Chun Lin and Juu-Chin Lu*
Chang Gung University, Tao-yuan, Taiwan

 

The adipose tissue is now recognized as an endocrine organ due to its active secretion of cytokines and hormones, collectively named adipokines (for adipocyte-secreted cytokines), which regulate many physiological functions. Among these adipokines, leptin is secreted primarily by adipocytes and stimulated by insulin to regulate energy balance and food intake. Adipocytes also secrete chemokines such as monocyte chemoattractant protein-1 (MCP-1), which can also be secreted by immune cells and is up-regulated by proinflammatory stimuli such as tumor necrosis factor a (TNFa) in obesity. While leptin is required for negative feedback control of adiposity against obesity, elevated MCP-1 secretion in obesity leads to local inflammation, which has been linked to pathogenesis of obesity-associated diseases such as insulin resistance and type II diabetes. Although the function and physiological importance of adipokines has been well documented, the secretory mechanism and regulation in adipocytes remain largely unknown. Lipid rafts are membrane structures enriched in cholesterol. They play an important role in endocytosis, secretion and signaling in many cell models. In macrophages, lipid rafts mediate the secretion of TNFa. In adipocytes, the proteins involved in exocytosis of glucose transporter 4 are localized in lipid rafts. However, whether lipid rafts play a role in adipokine secretion remains to be determined. We applied methyl-beta-cyclodextrin (MbCD), a drug with high affinity for cholesterol, on differentiated 3T3-L1 adipocytes to deplete membrane cholesterol and disrupt the function of lipid rafts. We found that MbCD treatment reduced basal and insulin-stimulated secretion of leptin. MbCD treatment also reduced insulin-stimulated Akt phosphorylation, suggesting the effects on insulin signaling. In contrast, MbCD treatment increased basal secretion of MCP-1 without affecting MCP-1 secretion stimulated by TNFa. MbCD treatment also increased the mRNA and protein levels of MCP-1, suggesting a role in biosynthesis of MCP-1 in adipocytes. Moreover, MbCD treatment increased phosphorylation of extracellular signal-regulated kinases, which are known to be involved in TNFa signaling and MCP-1 biosynthesis. Taking together, reducing membrane cholesterol by MbCD treatment, which disrupts the structure and function of lipid rafts, may alter adipokine secretion in adipocytes. Further experiments will be required to elucidate the mechanism.

 

Nothing to Disclose: YTC, YCL, JCL

12461 14.0000 MON-0888 A Depletion of Membrane Cholesterol Alters Adipokine Secretion in 3T3-L1 Adipocytes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Silvana Duran-Ortiz*, Adam Jara, Nicole E Brooks, Ellen R Lubbers, Edward O List, John J Kopchick and Darlene E Berryman
Ohio University, Athens, OH

 

Adipose Tissue (AT) is a very complex tissue comprised of various cell types, an extracellular matrix, and an intricate vasculature. AT is recognized as an active endocrine organ with discrete depots that are functionally, compositionally, and metabolically distinct. AT’s unique characteristic is its plasticity, which refers to its ability to undergo expansion and regression throughout life. AT expansion is intimately related with appropriate vascularization and angiogenesis. Growth hormone (GH) has an impact on AT plasticity with disruption of GH action increasing AT mass while increasing GH action decreases AT mass in a depot-specific manner. GH has been implicated in angiogenesis in several tissues; however, to date, no one has investigated the effect of GH on angiogenesis in AT. Therefore, we compared the expression levels of angiogenic factors in inguinal (subcutaneous) and epididymal (visceral) AT depots from 6-month-old male mice that overexpress bovine GH (bGH) to wild type (WT) littermate controls. Using RNA sequencing technology, we performed Ingenuity Pathway Analysis (IPA) as well as specifically examined the levels of thirty-four genes associated with angiogenesis. Eight of the 34 genes showed a significant depot difference between bGH and control mice. Compared to the inguinal AT depot, the epididymal depot expressed significantly higher levels of several pro-angiogenic factors, including angiogenin (Ang), fibroblast growth factor 1 (Fgf1), c-Fos induced growth factor (Figf), leptin (Lep), and vascular endothelial growth factor B (Vegfb). Regarding genotype differences, while there were no noteworthy differences in gene expression within the epididymal depot between genotypes, in the inguinal depot there were significant changes in four genes. That is, the expression levels of Fgf1, Lep, Vegfa and Vegfb were significantly higher in the WT inguinal depot than in the bGH inguinal depot. The higher expression level of pro-angiogenic genes in the epididymal depot compared to the inguinal depot support the notion that visceral AT is more vascularized than subcutaneous AT. Furthermore, the genotype comparison suggests that GH could have a negative impact on AT vascularization in the subcutaneous depot. Future studies will confirm the depot and genotype differences in angiogenic capacity by assessing protein expression of the endothelial cell marker CD34 in the epididymal and inguinal depot of WT and bGH mice.

 

Nothing to Disclose: SD, AJ, NEB, ERL, EOL, JJK, DEB

14073 15.0000 MON-0889 A Impact of Growth Hormone on the Expression of Angiogenic Growth Factors in Subcutaneous and Visceral Adipose Tissue 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Shizhan Ma*1, Fei Jing2, Dongqing Jiang3, Xinli Zhou1, Qingbo Guan4, Ling Gao4 and Jiajun Zhao4
1Shandong Provincial Hospital Affiliated to Shandong University, 2Shandong Provincial Hospital affiliated to Shandong University, Department of Endocrinology and Metabolism, China ;, 3The Second Hospital of ShanDong University, 4Shandong Provincial Hospital affiliated to Shandong University, Jinan, China

 

Background:

Obesity is considered as a hypertrophic disease resulted from an increase in the number or size of 

individual adipocytes. Epidemiological evidence indicated the severity of obesity in patients with 

subclinical hypothyroidism (SCH) was obviously higher than that in patients with euthyroid. Our 

previous study showed that TSH could increase the number of adipocytes by promoting 

preadipocytes differentiate into mature adipocytes. It is known that triglyceride (TG) plays an 

important role in storage of energy and excessive of TG accumulation is one reason of adipocyte

 hypertrophy. However, the role of TSH on regulating TG synthesis in differentiated adipocytes is 

less established. Our purpose here was to detect the possible effects of TSH on the regulation of 

GPAT3, the rate-limiting enzyme of TG synthesis in mature adipocytes. 

Methods: 

After a 15-day induction of differentiation, 3T3-L1 adipocytes presented the character of mature 

adipocytes, and then were used in the following experiments. Firstly, TSH (1 or 2μM) treatment for 

24 or 48 hours, intracellular TG and lipid droplet contents were confirmed by triglyceride assay kit 

and Oil Red O staining, respectively. Expression of GPAT3 and its upstream regulator, PPARγ were 

evaluated by RT-PCR, western blotting and immunofluorescence. Then cells were transfected with 

TSHR siRNA or PPARγ siRNA, respectively, and the expression of PPARγ and GPAT3 and intracellaular 

TG contents were evaluated after TSH stimulation for 24h, respectviely.

Results:

(1) TSH treatment significantly increased the TG contents in a dose- and time-dependent manners, 

TSH (2μM, 48h) increased TG contents significantly compared with the control (5.55±1.43 vs.2.58±0.2 

mmol/g protein; p <0.05). These results are consistent with the increase in lipid droplet contents in 

TSH treated adipocytes.

 (2) In a panel of genes which are known to play a critical role in adipogenesis were changed at mRNA

 levels, GPAT3 and PPARγ was increased by about 8- and 2.5 times than the control, respectively after 

TSH (1μM,48h) treatment (p < 0.05 for both). Similarly, compared with the control, TSH increased the 

protein expression of GPAT3 and PPARγ in a dose- and time-dependent manners.

 (3) After transfected with TSHR siRNA, the function of TSH on GPAT3 , PPARγ and intracellular TG contents

were disappeared .

(4) Consistently, when transfected with PPARγ siRNA,  the function of TSH on PPARγ  activity, adipogenesis

and GPAT3 expression were suppressed.

Conclusion:

Our results demonstrated that TSH, by acting on the TSHR in differentiated 3T3-L1 adipocytes, could enhance

TG synthesis by up-regulating the expression of GPAT3 through activating PPARγtranscriptional program.

These results revealed a potential effect of TSH on TG synthesis in mature adipocytes, and we speculate that

elevated adipose tissue content in SCH patients were at least in part due to TSHR-mediated PPARγ/GPAT3 pathway.

 

Nothing to Disclose: SM, FJ, DJ, XZ, QG, LG, JZ

14396 16.0000 MON-0890 A TSH Mediates Triglyceride Synthesis through GPAT3 in the Differentiated 3T3-L1 Adipocytes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Mohit Harsh*1, Zeid Khitan2, Hayden Ansinelli2, Komal Sodhi2, Luca Vanella2, Jordan Hilgefort2, George E Banks V2, Joseph I Shapiro2 and Nader G Abraham2
1Marshall University Joan C. Edwards School of Medicine, Huntinton, WV, 2Marshall University Joan C. Edwards School of Medicine, Huntington, WV

 

Adiponectin is an important hormone secreted into the bloodstream from healthy, functional small adipocytes, and is essential for protecting against cardiovascular disease. Adiponectin release is inhibited during adipocyte remodeling as a result of an increase in large, inflamed adipocytes.  Fructose-mediated obesity is due to an increase in adipogenesis and suppression of adiponectin release. Fructose metabolism is reported to increase levels of intracellular uric acid via ATP depletion; blood uric acid levels are shown to have a positive correlation with obesity.  Our hypothesis is that inhibition of adiponectin release from adipocytes in fructose and uric acid treated cells is in part due to an increase in adipocyte dysfunction. Methods: Adipogenesis was induced by treatment of human mesenchymal stem cells (MSCs) derived adipocyte stem cells or 3T3-L1 cell line with various concentrations of fructose or uric acid and adiponectin levels were measured.  Fructose and uric acid significantly increased (p<0.04) adipogenesis and diminished the secretion of adiponectin (p<0.02).  MSCs treated with apocynin, an NADPH oxidase inhibitor, or allopurinol, a xanthine oxidase inhibitor, resulted in decreases in adipogenesis levels and increases in adiponectin levels (p<0.05 and p<0.04, respectively).  Conclusion: We have shown for the first time that fructose treatment on MSCs has an inhibitory mechanism on adiponectin levels, which may help explain obesity associated with vascular dysfunction.

 

Nothing to Disclose: MH, ZK, HA, KS, LV, JH, GEB V, JIS, NGA

16085 17.0000 MON-0891 A Adiponectin Production Diminishes By Fructose or Uric Acid during Adipocyte Proliferation and Differentiation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Anthony Chukunweike Okolo*
Imperial College London, London, United Kingdom

 

Brown and white adipose tissues have the capacity to be dynamic in nature with respect to temperature changes, and recent studies have shown that appreciable deposits of brown adipose tissue (BAT) exist in the adult humans. There is therefore a potential for a manipulative control of energy homeostasis via the induction of specific genes to enhance BAT levels. We carried out a micro-array analysis to determine the genes that are regulated in this temperature-dependent manner.  Nrg4 was found to be more highly expressed in brown adipose tissue compared to white adipose tissue and this expression was upregulated upon cold exposure in the white fat. In determining the role of Nrg4 in BAT, an immortalized brown fat cell (IMBAT) culture system was developed. Nrg4 was significantly induced following adipocyte differentiation and this induction was increased upon treatment with a β3-Adrenergic Receptor (β3-AR) agonist.  Conditioned medium from the IMBAT cells contained secreted NRG4, detected, by ELISA, promoted neurite outgrowth in PC12 cells stably expressing HER4 receptor. Nrg4 could represent an important signalling gene in BAT, for promoting differentiation and brown adipose tissue innervation in response to cold and sympathetic stimuli. Therefore, targeting Nrg4 could have a therapeutic potential in obesity, insulin resistance and type 2 diabetes.

 

Nothing to Disclose: ACO

16759 18.0000 MON-0892 A Neuregulin-4 (Nrg4) Is a Novel Cold-Induced Adipokine Secreted By Brown Adipocytes That Promotes Neurite Outgrowth 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Vanesa Daniela Ramseyer* and James G. Granneman
Wayne State University, School of Medicine

 

Vacuolar protein sorting-associated protein 13C (VPS13C) is present in many tissues including the adipose tissue. Certain human VPS13C allelic variants are associated with changes in fasting glucose and glucose tolerance; however, VPS13C function remains largely unknown. Proteins that belong to the VPS13 family are involved in trafficking of membrane proteins between trans-Golgi and pre-vacuolar compartments, in phagosome formation and in yeast prospore membrane morphogenesis. However, the subcellular localization of VPS13C and its role in adipose tissues has never been studied before. We hypothesized that VPS13C is present in brown adipocyte lipid droplets, its subcellular localization is affected by activation of protein kinase A (PKA) and that VPS13C regulates lipolysis in these cells. Western blot analysis of protein lysates from mouse brown adipose tissue and brown adipocyte cell cultures showed the presence of a 420 KDa band corresponding to VPS13C. VPS13C mRNA levels increased 2.4 ± 0.4 fold by day 2 after induction of brown adipocyte differentiation (p<0.05 vs non-differentiated) whereas VPS13C protein levels increased to greater than 6 fold by days 4 and 6 after induction of brown adipocyte differentiation (p< 0.002 and p< 0.02 vs non-differentiated respectively). Proteomic analysis of brown adipose tissue cell fractions revealed that VPS13C concentrates on lipid droplets suggesting that VPS13C could be an important player in lipid droplet biology. Similar results were found in cell fractions from both, brown adipose tissue and brown adipocyte cell cultures by Western blot. Interestingly, immunofluorescence experiments showed that VPS13C localizes to some but not all lipid droplets in brown adipocytes. Next, we studied whether activation of PKA affects VPS13C localization using a brown adipocyte cell line that expresses a doxycycline-inducible constitutively-active Gsα. Activation of PKA for 2 days decreased VPS13C protein levels in lipid droplets by 54 ± 3% (p<0.03) with no significant changes in cytoplasm or total levels. Finally, we examined the effect of VPS13C knockdown on brown adipocyte lipolysis using lentiviruses expressing VPS13C shRNA. ShRNA reduced VPS13C protein by more than 96%. Knockdown of VPS13C increased basal lipolysis by 170% (p<0.001), increased maximal lipolysis by 35% (p<0.02) and decreased the EC50 for isoproterenol by about 3 times (from 1.00 ± 0.2 to 0.36 ± 0.05 nM, p<0.05). In conclusion, our results show that VPS13C is a novel lipid droplet protein that is increased during brown adipocyte differentiation and that is regulated by PKA activation. Our data also suggest that VPS13C may be a negative regulator of basal and β-adrenergic stimulated lipolysis.

 

Nothing to Disclose: VDR, JGG

13766 19.0000 MON-0893 A Vacuolar Protein Sorting-Associated Protein 13C: A Novel Player in Brown Adipocyte Lipid Metabolism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Geetanjali Sharma*1, Natalie C Fredette1, Roger A Vaughan2, Chelin Hu1, Kristina A Trujillo1 and Eric R Prossnitz1
1University of New Mexico, 2Univeristy of New Mexico

 

Estrogen (E2) regulates adipose content by directly modulating adipogenesis or indirectly affecting multiple aspects of metabolism. Increased adipose can result in obesity, which is associated with metabolic syndrome that increases the risk of diabetes and cardiovascular disease. E2 can exert its effects via multiple receptors such as Estrogen Receptor α and β as well as G protein-coupled estrogen receptor (GPER/GPR30). The role of GPER in adipogenesis remains unclear. Our study focused on examining the effect of GPER on adipogenesis. Since E2 binds non-selectively to all three receptors, we utilized selective approaches including GPER-specific ligands and GPER KO mice. Treatment of mouse 3T3-L1 and primary human preadipocytes with the GPER-selective agonist G-1 inhibited adipogenesis in a dose-dependent manner.  Exploration of the mechanism of G-1-induced inhibition of adipogenesis in 3T3-L1 cells revealed an increase in the activation of 5' AMP-activated protein kinase with a concomitant downregulation of key genes involved in adipogenesis, such as Peroxisome proliferator-activated receptor gamma, CCAAT-enhancer-binding protein and adipocyte Protein 2. Furthermore, mitochondrial biogenesis, which is an important event in the remodeling of preadipocytes prior to conversion into adipocytes, was inhibited upon G-1 treatment. Conversely, GPER KO mice exhibited increased body weights, larger fat depots throughout the body and increased adipocyte cell area in perigonadal fat. Additionally, our preliminary results reveal that in ovariectomized mice, G-1 treatment attenuated the increase in perigonadal fat content. In conclusion, our results show for the first time that GPER is involved in modulating key events involved in adipogenesis.

 

Nothing to Disclose: GS, NCF, RAV, CH, KAT, ERP

15278 20.0000 MON-0894 A G-Protein Coupled Estrogen Receptor (GPER/GPR30) Inhibits Adipogenesis in Mouse and Human Preadipocytes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Konstantinos N Manolopoulos*1, Iwona Bujalska2, Paul M Stewart3 and Jeremy W Tomlinson4
1University of Birmingham, Birmingham, United Kingdom, 2University of Birmingham, United Kingdom, 3University of Leeds, Leeds, United Kingdom, 4Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and Experimental Medicine, University of Birmingham, United Kingdom

 

Background: Aging is characterized by a chronic inflammatory state and profound changes in adipose tissue distribution and mass, alongside an increased risk for cardiovascular and metabolic disease. Adipose tissue dysfunction could be a potential driving factor behind the cardiometabolic risk associated with aging. The aim of this study was to investigate the expression of gene clusters controlling various areas of adipose tissue function across age in humans.

Methods: Paired subcutaneous and omental adipose tissue biopsies were obtained from patients (n=63, age range 27-83 years, BMI range 20.8-39.1 kg/m2) undergoing elective open abdominal surgery. Using a custom-design microfluidic chip, high-throughput gene expression analysis of 93 genes of importance in adipose tissue biology was performed, followed by statistical analysis using multiple linear regression and bootstrap with models to include age, sex and BMI. Gene clusters were revealed by hierarchical clustering and dendrogram analysis.

Results: 25.8% of genes were differentially expressed between subcutaneous and omental adipose tissue (Wilcoxon p<0.05), with ACSL1, AR, CCND1, CD36, CIDEC, DGAT2, HOXA10, HOXC9, LEP, MGLL, PLIN4, TWIST1 being more highly expressed in subcutaneous, and C3, CEBPD, IL6, KRT19, MSLN, NAMPT, PPARGC1A, RARRES1, TCF21, TNFAIP3, WNT5A, XBP1 more in omental adipose tissue. Across all models, age was a significant determinant (p<0.05) of expression of gene clusters associated with adipose tissue differentiation and fibrosis (CCND1, LOXL2), lipid sequestration (CIDEA, SREBF1), local glucocorticoid modulation (HSD11B1), ER stress (XBP1) and insulin signalling (GSK3B, MAPK1, MAPK3). Interestingly, these associations were significant only in subcutaneous and not omental adipose tissue samples, while there was no relationship to BMI or sex.

Conclusion: Aging is a determinant of several subcutaneous adipose tissue genes involved in functions expected to be important in a local environment of chronic inflammation. As these relationships were confined to the subcutaneous depot only, it implies that subcutaneous adipose tissue function could be an important determinant of healthy aging. Structural and functional derangement could lead to ectopic fatty acid deposition which is known to be associated with increased cardiovascular and metabolic risk.

 

Nothing to Disclose: KNM, IB, PMS, JWT

16829 21.0000 MON-0895 A Aging Determines the Expression of Key Regulatory Gene Clusters in Human Adipose Tissue 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Jacob Couturier*1, David J Luke2, Ashok Balasubramanyam3 and Dorothy E Lewis1
1University of Texas Health Science Center at Houston, Houston, TX, 2Baylor College of Medicine, Houston, TX, 3Baylor Coll of Med, Houston, TX

 

HIV associated lipodystrophy is characterized by abnormal immune-metabolic interactions resulting in adipose infiltration by immune cells, defective adipose function increased circulating proinflammatory cytokines, dyslipidemia and insulin resistance.  The well-characterized adipose infiltration and dysregulation of immune cell function include increased memory CD4 T cell and macrophage activation and proliferation, cytokine production, and subset polarization.  Memory CD4 T cells and macrophages are the main hosts and reservoirs for HIV, raising the possibility that the adipose milieu could play a role in HIV pathogenesis.  We hypothesized that adipocytes may interact with HIV-infected memory CD4 T cells to influence HIV infection, and studied the interactions in vitro and in vivo. 

First, primary human adipocytes were cocultured with purified memory CD4 T cells (pre-infected with HIV in vitro) in transwells for ~1 week, and T cell activation (CD69) and HIV production (p24) were measured by flow cytometry and ELISA.  Adipocyte-secreted IL6 and an integrin ligand, VLA-1, increased memory CD4 T cell activation and HIV production ~2-fold.  These activities were dependent on the presence of common gamma-chain cytokines such as IL2, IL7, or IL15.  Increased T cell activation and HIV production did not result in increased T cell proliferation, however T cell viability improved.

Next, we examined adipose tissue stromal-vascular fraction cells (AT-SVF) isolated from visceral or subcutaneous adipose tissue of uninfected (n=5) and HAART-treated HIV-infected (n=2) donors.  Phenotypic and functional characterization of CD4 and CD8 T cells by flow cytometry showed that the majority of AT-SVF T cells in both controls and HIV infected fat are activated (>50% CD69) memory CD4 and memory CD8 T cells, and capable of producing IL2 and IFNγ.  However, AT-SVF of HIV-infected donors contained more memory CD8 T cells compared to uninfected donors.  Sensitive nested PCR of DNA extracted from AT-SVF of the HIV patients demonstrated HIV provirus in both donors.  Thus, within adipose tissue, or in other compartments associated with abundant fat such as lymph nodes and bone marrow, adipose cells and adipose-derived gamma-chain cytokines may promote the persistence of HIV in memory CD4 T cells, challenging efforts to eradicate the virus. 

 

Nothing to Disclose: JC, DJL, AB, DEL

16861 22.0000 MON-0896 A Human Adipose Tissue As a Reservoir for HIV-Infected Memory CD4 T Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Rachana Shah*
Childrens Hosp of Philadelphia, Philadelphia, PA

 

Storage of fat into lipid droplets is the key step in adipogenesis. Impaired lipid droplet formation after omega 3 fatty acid exposure has been reported in mouse adipocytes but effects in primary human cells has not been shown.

We treated human primary pre-adipocytes with eicosapentaenoic acid (EPA; C20:5n-3), docosahexaenoic acid (DHA; C22:6n-3), or a combination of the EPA/DHA at 50 uM during the 7-day differentiation period. Lipid droplet morphology and size was assessed using Oil Red O staining. RNA was extracted and cDNA created for RT-PCR analysis of lipogenic and lipolytic genes. 

Compared to controls, we found decreased lipid droplet size and number with both EPA and DHA, and an enhanced effect when both were used together. Percent lipid accumulation by colorimetric assay of Oil Red O staining quantified this finding (control 100%, EPA 75%, DHA 60%, both 45%; p<0.05 for all groups vs. control and for both vs. EPA alone). Expression of the lipogenic genes perilipin A and caveolin-1 were suppressed in omega 3-treated cells (perilipin A, relative expression 0.22; Caveolin-1, relative expression 0.15; p<0.001). Lipolytic gene expression was increased with omega 3 treatments for both LPL (relative expression 4.25, p<0.05) and ATGL (relative expression 6.52, p<0.05). 

Omega 3 fatty acids, both DHA and EPA, suppress lipid droplet formation in primary human adipocytes in vitro.

 

Nothing to Disclose: RS

14948 23.0000 MON-0897 A Omega 3 Fatty Acids Suppress Lipid Droplet Formation in Human Adipocytes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Julio César Sanchez* and Diego Fernando López-Zapata
Universidad Tecnológica de Pereira, Pereira, Colombia

 

NCX plays a key role in Ca2+ homeostasis and calcium transport in many cells, but its function in adipocytes has not been adequately explored. Ca2+ regulation is critical to adipocyte since affects the synthesis of a number of chemical mediators, which influence systemic metabolism. Furthermore, adipocytes from obese and diabetes mellitus type 2 patients exhibited higher levels of intracellular Ca2+ concentration ([Ca2+]i ) and a number of hormones and regulators may use this mechanism to affect adipocyte homeostasis (1), driving to insulin resistance. In this study, using whole cell mode patch clamp technique on human cultured adipocytes, a Ni2+-sensitive current, which exhibited outward rectification, was elicited by a voltage ramp protocol. The current was attenuated by benzamil and KBR7943, known inhibitors of NCX. This current was modulated by changes in both intracellular and extracellular calcium in a manner characteristic of NCX. Measured values of reversal potentials (Er) were consistent with those expected at ion concentrations employed. A significant increase was observed for both inward current (at -80 mV 94 ± 10.5%, n = 10, p < 0.01) and outward current (at +80 mV 67.4 ± 8.7%, n = 10, p < 0.01) following the addition of insulin (1µM), but the effect was more pronounced on inward currents. Insulin did not alter significantly the Er. This effect was mediated by protein kinase C (PKC) activation, which is suggested by the inhibition produced by chelerythrine.  

Leptin (100 ng/mL) also produced a significant increase of both inward (at -80 mV 44.5 ± 10.5%, n = 8, p < 0.01) and outward currents (at +80 mV 31.2 ± 7.3%, n = 10, p < 0.01), although the effect was lower than the insulin effect and was not mediated by

PKA, MAPK, NOS, PI3K or PKC, given that it was not affected by the respective inhibitors of these enzymes. These results confirm that NCX in human adipocytes is regulated by insulin and leptin, two hormones which have been involved in the metabolic impairment in obesity and the metabolic syndrome. The mechanism by which these hormones regulate NCX need further study, but these findings may help to better understand the adipocyte Ca2+ homeostasis process.

 

Nothing to Disclose: JCS, DFL

17018 24.0000 MON-0898 A Na+-Ca2+ Exchanger (NCX) in Human Adipocytes Is Regulated By Insulin and Leptin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0875-0898 4839 1:00:00 PM Adipocyte Biology-Basic and Translational Aspects Poster

Katya B. Rubinow*1, Shari Wang1, Laura den Hartigh1, Savitha Subramanian1, Gregory J. Morton1, Bill Buaas2, Robert E. Braun2 and Stephanie T. Page3
1University of Washington, Seattle, WA, 2The Jackson Laboratory, Bar Harbor, ME, 3University of Washington and Harborview Medical Center, Seattle, WA

 

Background: Men with low circulating androgen levels have increases in body fat mass, but the mechanisms by which testosterone suppresses fat deposition have not been elucidated fully.  Adipose tissue macrophages (ATMs) express the androgen receptor (AR) and regulate adipose tissue remodeling through the secretion of paracrine mediators.  Thus, testosterone signaling in ATMs could alter the paracrine function of these cells and thereby contribute to the metabolic effects of androgens in men.  We hypothesized that the loss of AR signaling in hematopoietic cells would result in greater accumulation of adipose tissue in male mice fed a high fat diet. 

Methods: C57Bl6/J male mice (ages 12-14 weeks) underwent bone marrow transplant from either wild-type (WT) or androgen receptor knockout (ARKO) donors (n=11-13 per group).  After a recovery period, mice were initiated on a high fat diet (60% fat).  Body weights and food intake were measured weekly for a 16-week feeding period.  At baseline, 8 weeks, and 16 weeks, glucose and insulin tolerance tests were performed, and body composition was analyzed through fat-water imaging by MRI.   After 16 weeks, animals were sacrificed and tissues were harvested.

Results: No differences in body weight or food intake were observed between the mice transplanted with WT (WT-WT) or ARKO (WT-ARKO) bone marrow, either at baseline or subsequent to high-fat feeding.  However, after 8 weeks of the high fat diet, WT-ARKO mice exhibited significantly more visceral (14,741±287 v. 12,541±265 mm3; p<0.001) and total (29,776±652 v. 25,342±1072 mm3; p=0.02) fat mass than WT-WT animals.  Despite having more visceral fat, WT-ARKO mice exhibited no impairments in either glucose tolerance or insulin sensitivity compared with WT-WT mice.  At sacrifice, livers from the WT-ARKO mice had higher triglyceride (82.1±3 v. 71.0±2 mg/gm liver weight; p<0.01) and cholesterol (26.7±1 v. 19.6±1 mg/gm liver weight; p<0.001) content relative to those from the WT-WT mice.  WT-ARKO mice also had higher levels of plasma triglycerides (41.2±2 v. 32.7±2 mg/dL; p=0.02) and adiponectin (25.1±10 v. 17.6±5 µg/mL).  No differences were observed in plasma concentrations of insulin, glucose, leptin, or cholesterol.

Conclusions: AR signaling in hematopoietic cells regulates body fat distribution in male mice, and the absence of hematopoietic AR plays a permissive role in visceral and hepatic fat accumulation.  The relative contributions of AR signaling in macrophages and other marrow-derived cells require further investigation.  Notably, despite greater visceral fat, WT-ARKO mice did not exhibit impairments in glucose homeostasis, indicating the possible dissociation between visceral fat content and insulin resistance.  These findings demonstrate a novel metabolic role for AR signaling in marrow-derived cells and suggest a new mechanism by which androgen deficiency in men might promote increased adiposity.   

 

Nothing to Disclose: KBR, SW, LD, SS, GJM, BB, REB, STP

14165 1.0000 MON-0899 A Hematopoietic Androgen Receptor Deficiency Promotes Visceral Fat Deposition in Male Mice without Impairing Glucose Homeostasis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0899-0914 4845 1:00:00 PM Adipose Tissue and the Adipocyte Poster

Richard B Meagher*, Elizabeth Cohen McKinney, Ping Yu and Clifton A Baile
University of Georgia, Athens, GA

 

Obesity appears to epigenetically reprogram specific neurons in the hippocampus and hypothalamus and other parts of the brain that control eating behavior, hunger, and satiety. Further, reprogramming of adipocytes in visceral and subcutaneous adipose tissues (VAT, SAT) likely controls the inappropriate secretion of adipokines that impact these behaviors. Recent evidence suggests adult mature neurons and adipocytes are more hyperplasic than once thought, and frequently give rise to neural and adipocyte progenitor cells (NPCs, APCs). Our working hypothesis is that obesity epigenetically reprograms and physically damages adult-cell derived NPC and APC populations. However, the cell-type-specific analysis and epigenetic reprogramming of neuronal and adipocyte cell populations derived from mature tissues are poorly explored due to the technical difficulty of isolating intact mature neurons and adipocytes. Adult neurons are too highly interdigitated (e.g., axons, dendrites) within brain tissues to be physically separated from one another and adult adipocytes are so large and fragile that they are difficult to isolate in large numbers and sort into subpopulations. For the cell type specific analyses of neurons and adipocytes, we characterized cellular nuclei from brain, VAT, and SAT. Nuclei were relatively easy to isolate from fresh, frozen, or formalin fixed tissues. Fluorescence Nuclear Cytometry (FNC) and Fluorescence Activated Nuclear Sorting (FANS) provided an initial characterization of populations of nuclei derived from mouse brain and porcine VAT. We identified a surprisingly large population of NPC derived nuclei (i.e., 20% of total young mouse brain nuclei), based on the following. First, these nuclei had several times the volume of normal 2N mammalian nuclei. Decondensed chromatin is typical of transcriptionally and epigenetically potentiated, multipotential cells. Second, based on immunofluorescence and qRT-PCR analysis, these large neuronal nuclei highly overexpressed machinery for chromatin remodeling (e.g., SIRT1, HDAC1, HDAC2, KAT2B, KAT3B) and makers of the cell cycle (e.g., PCNA, SHH, SOX2, DNMT1) and stem cell potentiation (e.g., OCT4, KLF4, cMYC) relative to normal sized neuronal nuclei. Preliminary data on porcine VAT suggest we have identified a similarly large population of nuclei from highly potentiated APCs. FNC and FANS have enabled the rapid cell-type specific analyses of fragile neuronal and adipocyte cell types and gives novel access to progenitor cell types.

 

Nothing to Disclose: RBM, ECM, PY, CAB

14445 2.0000 MON-0900 A Nuclear Cytometry Identifies Large Numbers of Neuronal and Adipocyte Progenitor Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0899-0914 4845 1:00:00 PM Adipose Tissue and the Adipocyte Poster

Yong-Qi Li*1, Min Chen2, Oksana Gavrilova1 and Lee S. Weinstein2
1NIDDK, NIH, Bethesda, MD, 2NIH/NIDDK, Bethesda, MD

 

Gsα, the G protein which mediates receptor-stimulated cAMP generation, has been implicated as a modulator of various adipose tissue functions, such as sympathetic nervous system (SNS) - stimulated lipolysis, browning of white adipose tissue (WAT) and brown adipose tissue (BAT) thermogenesis.  These processes have been thought to be major targets for treating obesity and diabetes.  In this study, we generated a mouse line with adipose tissue-specific Gsα deficiency (Adipoq-GsKO: adiponectin-cre+, Gsα flox/flox). Adipoq-GsKO mice had impaired BAT function, as they were unable to maintain body temperature or induce the expression of Ucp1 during cold exposure and had reduced oxygen consumption after treatment with a β3-adrenergic-receptor agonist, CL-316,243. They also lost the ability of browning their WAT. However, adipose tissue specific Gsα deficiency caused neither hyperphagia nor obesity in mice fed on either a standard chow or a high-fat diet. Both lipolysis and de novo lipogenesis in Adipoq-GsKO mice were attenuated, which was accompanied by an improvement of glucose metabolism, increase of insulin-stimulated glucose uptake in skeletal and cardiac muscles, and enhancement of insulin sensitivity. While leptin, RBP4 and FGF21 levels remained relatively unchanged, levels of circulating aP2, a newly identified adipokine markedly elevated in obese/diabetic patients, was significantly reduced in Adipoq-GsKO mice. Altogether, specific inhibition of Gsα signaling in adipose tissue might be a plausible strategy in the treatment of obesity-related insulin resistance and diabetes without disturbance in body weight.

 

Nothing to Disclose: YQL, MC, OG, LSW

14671 3.0000 MON-0901 A Gsα Deficiency in Fat Tissues Leads to Improved Glucose Metabolism and Insulin Sensitivity without Effects on Body Weight 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0899-0914 4845 1:00:00 PM Adipose Tissue and the Adipocyte Poster

Elaine Vieira1, Elena Ruano1, Gloria Aranda2, Ana Lucia Figueroa3, Francesc Carmona2, Dulce Momblan4, Ramon Gomis2, Josep Vidal2 and Felicia Alexandra Hanzu*2
1CIBERDEM/IDIBAPS, Barcelona, Spain, 2HCB/IDIBAPS/CIBERDEM, Barcelona, Spain, 3CIBDERDEM/IDIBAPS, Spain, 4HCB, Barcelona, Spain

 

Peripheral alterations of clock genes oscilation is implicated in the etiology of obesity and diabetes. Altough visceral adipose tissue present an endogenous clock gene rythm,  previous studies in subcutaneous adipose tissue find no differences between the clock genes expression  of obese and lean individuals.

This work was designed to study and compare the expression of clock genes between lean and obese subjects in visceral adipose tissue (VAT), as well as its clinical implications. Therefore, we comparatively studied in healthy lean and morbidly obese women the endogenous 24h expression of clock genes in isolated adipocytes, their expression in VAT and stromal cells and its association with metabolic syndrome (MS) components.

Human VAT was obtained from lean non-obese (BMI 21-25 kg/m2; n=21) and morbidly obese women (BMI >40 kg/m2; n=28). Stromal cells and adipocytes were isolated using a collagenase method. The 24h pattern of clock genes was analyzed every 6 hours using RT-PCR. Correlation with the clinical data was studied by Spearman analysis.

Among the clock genes studied there was an upregulation of Cry2 and Rev-erb alpha in VAT, adipocytes and stromal cells from obese women. The 24h pattern of clock genes showed that obesity alters the pattern of Clock, Bmal1, Per1, Cry2 and Rev-erb alpha in adipocytes. A positive correlation was observed for Rev-erb alpha gene expression with BMI (r=0.552; p=0.008) and waist circumference (r=0.526; p=0.012). Expression of Ror alpha was correlated with HDL levels (r=0.450; p=0.047) and Clock with LDL (r=0.422; p=0.04). Obese subjects with metabolic syndrome exhibited positive correlation in the Per2 gene with LDL cholesterol, whereas Rev-erb alpha was correlated with waist circumference (r=0.50; p=0.049).

Therefore, our data demonstrated for the first time that morbid obesity alters the circadian expression of clock genes in VAT and identified Rev-erb alpha as an important gene associated with MS.

 

Nothing to Disclose: EV, ER, GA, ALF, FC, DM, RG, JV, FAH

15344 4.0000 MON-0902 A The Circadian Pattern of Clock Genes Expression Is Altered in the Obese Visceral Adipose Tissue and Is Associated with Metabolic Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0899-0914 4845 1:00:00 PM Adipose Tissue and the Adipocyte Poster

Guillermina María Luque*1, Maria Ines Perez-Millan1, Maria Cecilia Ramirez1, Felicitas Lopez-Vicchi1, Ana Ornstein1, Marcelo Rubinstein2 and Damasia Becu-Villalobos3
1IBYME-CONICET, Buenos Aires, Argentina, 2INGEBI, CONICET, Buenos Aires, Argentina, 3Instituto de Biologia y Medicina Experimental CONICET, Buenos Aires, Argentina

 

Prolactin, a pleiotropic hormone secreted by lactotropes, participates in metabolic processes and acts by binding to its receptor (PRLR). In mice, one long (PRLR-L) and three short receptor forms (PRLR-S1, PRLR-S2, and PRLR-S3) have been identified. We previously found conditional mutant mice that selectively lack D2Rs from pituitary lactotropes (lacDrd2KO) present chronically elevated prolactin levels, increased food intake, adipose tissue accretion, and produced glucose intolerance. We now evaluated the role of elevated prolactin levels on adipose tissue and liver gene expression. LacDrd2KO female mice exhibited chronic hyperprolactinemia, preserved GH axis, increased body weight, and a marked increment in adipocyte size and liver weight. We found that Prlr-l mRNA expression in adipose tissue of female lacDrd2KO mice was similar to that in controls, while the short forms were below the detection limit in this tissue. A decrease in lipolytic enzymes (Atgl and Hsl) was observed in female lacDrd2KO adipose tissue, while GH (Ghr) and glucocorticoid receptor (Gr) mRNA expression showed no change.

On the other hand, the liver of lacDrd2KO female mice had increased lipid content as indicated by oil red staining, in accordance with increased triglyceride content. A different Prlr mRNA expression pattern was found in this tissue: Prlr expression level was increased (P<0.01) in the liver of female lacDrd2KO mice compared to controls, and all four mRNAs Prlr isoforms were detected; in particular, the Prlr-s3 isoform was significantly increased. The liver has a central role in glucose homeostasis which may be modulated by serum prolactin; we found that glucokinase mRNA expression was significantly increased (P<0.02) in female lacDrd2KO, while sterol regulatory element binding transcription factor 1 (Srebf1), glycogen synthase 2 (Gys2) and carbohydrate response element binding protein (Chrebp) gene expression were similar to that observed in controls. These results suggest that high prolactin levels may modulate lipid and glucose metabolism. In the liver prolactin upregulates its own receptor and glucokinase expression, while in the adipose tissue it increases lipogenesis by decreasing lipolytic enzymes with no change in Prlr , Ghr or Gr expression.

 

Nothing to Disclose: GML, MIP, MCR, FL, AO, MR, DB

13809 5.0000 MON-0903 A Liver and White Adipose Tissue Gene Expression in Hyperprolactinemic Lactotrope-Drd2KO Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0899-0914 4845 1:00:00 PM Adipose Tissue and the Adipocyte Poster

Sana Hasan*1, Ronda L Simpson1, Frederick G Hamel2, Cyrus V Desouza3 and Robert G. Bennett4
1University of Nebraska Medical Center, Omaha, NE, 2Omaha VA Med Ctr, Omaha, NE, 3Univ of Nebraska Med Center, Omaha, NE, 4VA Nebraska-Western Iowa Health Care System, Omaha, NE

 

The current pandemic of type 2 diabetes is closely associated with obesity and insulin resistance, which play an important role in the development of hepatic steatosis.  All-trans retinoic acid (ATRA), a potent derivative of Vitamin A, regulates lipid homeostasis and insulin resistance through regulation of nuclear receptors, including the peroxisome proliferator-activated receptors(PPAR).

We previously showed that treatment (tx) of db/db mice with ATRA decreased random and fasting blood glucose, promoted weight loss, and improved glucose tolerance. The objectives of this study were to determine whether the effects of ATRA were reversible after treatment cessation, and to identify possible mechanisms for its effects. Obese 3 month old db/dbmice (10 per group) were treated with vehicle (corn oil) or ATRA at 0.6 mg/day, 5 days/week for 12 weeks by voluntary oral feeding, then a subset of mice was monitored for 8 weeks after ATRA withdrawal (post tx).

ATRA led to a significant reduction in body weight and the mice continued to maintain lower body weight post tx (44.7±1.7 g initial vs 36.2±3.8 g ATRA vs post tx 38.9±5 g).  The non-fasting glucose reduced significantly with ATRA, and the lower glucose levels were maintained after tx cessation (273.5± 17.3 mg/dL initial vs 89±18.6 mg/dL ATRA vs 106.2±9 mg/dL post tx, p<0.001).  Glucose tolerance improved dramatically with ATRA; furthermore, this effect was sustained after tx cessation. ATRA did not have a significant effect on fasting insulin, but fasting glucose was significantly lower in the ATRA-treated group, which was evident as early as week 6 of tx. This led to a significant reduction in HOMA-IR after 6 weeks (21.2±1.2 control vs 14.3±3.0, ATRA, p<0.05), and 12 weeks (20.8±2.3 control vs 8.5±2.2 ATRA, p<0.05).  

The db/db mice developed hepatic steatosis, which was markedly reduced with ATRA, and maintained post tx, which was reflected histologically and in the liver triglyceride content (48.9±6.1 ug/mg control vs 23.4±3.2 1 ug/mg ATRA vs 13.9±2.51 ug/mg post tx, p<0.05).

Obesity is accompanied by downregulation of adipose PPARδ expression and activity, leading to weight gain and insulin resistance. ATRA increased PPARδ gene expression in visceral white adipose which was statistically significant (1.1±0.1 control vs 6.7±3.4 ATRA vs 16.5±7.4 post tx, p<0.001).  This likely contributed to ATRA′s regulation of body weight and insulin sensitivity.

In summary, we have shown that ATRA improves glucose tolerance and insulin sensitivity, increases PPARδ expression and reduces hepatic steatosis by regulating lipid homeostasis. Furthermore, these effects were sustained after ATRA tx cessation.  Upregulation of PPARδ provides a possible mechanism for the effect of ATRA. The results from our study have potential implications for the design of therapies for patients with obesity and diabetes.

 

Disclosure: CVD: Consultant, Takeda, Consultant, Novo Nordisk. Nothing to Disclose: SH, RLS, FGH, RGB

13871 6.0000 MON-0904 A Sustained Effects of All-Trans Retinoic Acid on Weight, Glucose Regulation and Hepatic Steatosis in an Obese Type 2 Diabetes Model 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0899-0914 4845 1:00:00 PM Adipose Tissue and the Adipocyte Poster

Michella Soares Coelho*1, Caroline Lourenço Lima2, Carine Royer1, Ivan da Rocha Pitta3, Francisco de Assis Rocha Neves1 and Angelica Amorim Amato1
1University of Brasilia, Brasilia, Brazil, 2University of Brasilia, Brasilia-DF, Brazil, 3Federal University of Pernambuco, Pernambuco-PE, Brazil

 

Thiazolidinediones (TZDs) are used for the treatment of type 2 diabetes (T2DM), and their therapeutic actions are mediated via activation of peroxisome proliferator-activated receptor γ (PPARγ). Despite their efficacy, their use is limited by side effects such as weight gain, edema, bone loss, and visceral adiposity, in addition to increased risk of cardiac mortality with rosiglitazone (RSG). This has prompted the search for novel PPARγ agonists with reduced side effects. We have previously identified a novel PPARγ ligand (QG-16) with similar anti-diabetic efficacy as RSG, yet in the absence of weight gain in obese and insulin-resistant mice treated with 20 mg/kg/d of GQ-16. The aim of this study was to evaluate the effects of different doses of GQ-16 on adiposity and expression of PPARγ-dependent genes in mice with obesity and insulin resistance induced by high fat diet (HFD). Mice were fed a normal-fat diet (NFD, 10% kcal fat) or HFD (60% kcal fat - Harlan Teklad) since weaning. At the age of 16 wk, they were randomly assigned into six groups and received GQ-16 (5, 10 or 20mg/kg/d), RSG (4mg/kg/d) or vehicle by gavage daily for two weeks. Body weight (BW) gain, food and water intake, energy intake, metabolic efficiency, and fasting blood glucose were measured daily or weekly. White adipose tissue (WAT) fat pads were excised and weighed for determination of adiposity. Two different white adipose depots (subcutaneous and visceral) and interscapular brown adipose tissue (BAT) were harvested for determination of gene expression by quantitative real-time PCR. Results (P<0.05, ~ 4 mice/group): As expected, BW, BW gain, WAT fat mass content and blood glucose were greater in the HFD group (BW: 67.4±2.2 g) compared to the NFD group (BW: 51.8±2.6 g). In HFD-treated mice, weight gain was reduced by treatment with 5, 10 and 20 mg/kg/d of GQ-16 (2.2±2 g, -8.6±3.1 g, -9.5±1.9 g, respectively), but increased by RSG (15.02±1.7 g). In addition, GQ-16 treatment (20 mg/kg/d) reduced visceral WAT pads, whereas RSG treatment increased them (NFD: 2.09±0.3 g, HFD: 3.5±0.21 g, HFD+RSG: 4.41±0.9 g, HFD+GQ-16: 1.35±0.1 g). Brown fat-selective genes were upregulated in WAT in response to different doses of GQ-16. Additionally, the two highest doses of GQ-16, 10 and 20 mg/kg/d, decreased blood glucose levels (91.3±1.4 and 85±5.5 mg/dL, respectively), similarly to RSG (78.25±3.04 mg/dL), when compared to the HFD group (123±6.4 mg/dL). In conclusion lower doses of GQ-16 decreased blood glucose and visceral adiposity in mice with obesity and insulin resistance induced by HFD. This latter finding might possibly reflect increased thermogenesis, since GQ-16 induced the expression of thermogenesis-related genes, and reinforces the potential of GQ-16 as a new strategy to treat obese patients with T2DM.

 

Nothing to Disclose: MSC, CLL, CR, IDRP, FDARN, AAA

15851 7.0000 MON-0905 A GQ-16, a Partial Ppargamma Agonist, Decreases Visceral Adiposity and Induces the Expression of Thermogenesis-Related Genes in Obese and Diabetic Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0899-0914 4845 1:00:00 PM Adipose Tissue and the Adipocyte Poster

Marika Charalambous*1, Simao da Rocha2, Elizabeth J Radford2 and Anne C Ferguson-Smith3
1Queen Mary University of London, London, United Kingdom, 2University of Cambridge, 3University of Cambridge, Cambridge, United Kingdom

 

Non-alcoholic fatty liver disease (NAFLD) is associated with insulin resistance and obesity, as well as progressive liver dysfunction[1].  Recent animal studies have underscored the importance of hepatic GH signalling in the development of NAFLD[2-5].  The imprinted Delta-like homologue 1 (Dlk1) gene encodes a complex protein that can produce circulating and membrane-tethered isoforms[6].  The expression dosage of Dlk1 is functionally important, since even modest elevation during embryogenesis causes lethality[7], and modulation of expression in a stem cell niche profoundly alters the self-renewal properties of cells[8].  DLK1 is upregulated during embryogenesis[9], suckling[10, 11] and in the mother during pregnancy[10].  We investigated the normal role for elevated DLK1 dosage by overexpressing Dlk1 from endogenous control elements.  This led to improved glucose tolerance with no primary defect in adipose tissue expansion even under extreme metabolic stress.  Rather, Dlk1 overexpression caused pituitary IGF1 resistance and a defect in feedback regulation of GH.  Increased circulatory GH culminated in a switch in whole body fuel metabolism with a consequent reduction in hepatic steatosis. We propose that the function of DLK1 is to shift the metabolic mode of the organism toward peripheral lipid oxidation and away from lipid storage, thus mediating important physiological adaptations associated with early life.

 

Nothing to Disclose: MC, SD, EJR, ACF

13791 8.0000 MON-0906 A DLK1/PREF1 Regulates Nutrient Metabolism and Protects from Steatosis By Elevating Pituitary Growth Hormone Secretion 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0899-0914 4845 1:00:00 PM Adipose Tissue and the Adipocyte Poster

María Guillermina Zubiría*1, Eduardo Spinedi2 and Andres Giovambattista3
1IMBICE (CONICET-CICPBA), La Plata, Argentina, 2CENEXA (UNLP -CONICET - FCM), La Plata, Argentina, 3IMBICE (CONICET-CICPBA-UNLP), La Plata, Argentina

 

Adipose tissue (AT) overexpansion is one of the main features of obesity. This could result from either AT hyperplasia, adipocyte hypertrophy or both. Hypertrophic adipocytes have been proposed to have a prevalent contribution in advanced obesity states. We studied several features indicative for AT mass expansion in both, L-monosodium glutamate (MSG)-treated (neonatally) and normal littermate (CTR) male rats over development (pre-pubertal and adult ages). Retroperitoneal AT (RPAT) pads were aseptically dissected, weighted and, thereafter, mature adipocytes and Stromal Vascular Fraction (SVF) cells were isolated. RPAT adipocyte diameter was determined (image analyses) and adipocyte size frequency histograms were built. Adipose precursor cells (APC) number was counted by the flow cytometry immuno-staining strategy (CD34+/CD31-/CD45-). Specific adipocyte determination (PPAR-γ2 and Zfp 423) and, pro- (MR, GR) and anti- (Pref-1, Wnt10b) adipogenic gene markers were quantified in SVF cells (qPCR Real Time). MSG rats showed increased RPAT mass and circulating levels of corticosterone and leptin (P < 0.05 vs. CTR values) at both ages examined. Data indicated that RPAT pads from 30 day-old MSG rats displayed only one population of large adipocytes after comparison with cells from CTR littermates. Conversely, RPAT pads from adult 60 day-old MSG rats showed two (vs. one adipocyte population in CTR) different populations of adipocytes: one small, presumably  new, and the other enlarged (P < 0.05). APC number in SVF cells was similar in both groups, regardless of the age examined.  Zfp423 and PPARγ2 mRNA levels were higher (vs. CTR; P < 0.05) in SVF cells from pre-pubertal MSG rats; however, at adult age these markers were lower in MSG than CTR SVF cells. Finally, 30 day-old MSG SVF cells displayed increased pro-adipogenic (MR) and decreased anti-adipogenic (Pref-1/ Wnt10b) mRNAs levels (P < 0.05 vs. CTR); conversely, SVF cells from adult MSG rats showed a completely opposite expression pattern of these genes. Our data demonstrate that while MSG RPAT mass expansion in pre-pubertal rats is due to cell hypertrophy, in adult rats results from both AT hyperplasia and cell enlargement. This study suggests that an active adipogenic process takes place on different ages in MSG rats over development. The degree of commitment in MSG RPAT SVF cells from rats on different ages could be, at least in part, responsible for the different pattern of AT mass expansion.

 

Nothing to Disclose: MGZ, ES, AG

14745 9.0000 MON-0907 A Association Between Precursor Cells Commitment and Adipose Tissue Mass Expansion in Hypercorticosteronemic Obese Rats over Development 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0899-0914 4845 1:00:00 PM Adipose Tissue and the Adipocyte Poster

Iwona Bujalska1, Danielle RG Foucault*1, Elizabeth H Rabbitt1, Jeremy W Tomlinson2 and Paul M Stewart3
1University of Birmingham, United Kingdom, 2University of Birmingham, Birmingham, United Kingdom, 3University of Leeds, Leeds, United Kingdom

 

The detrimental effect of obesity on insulin resistance is well established and the Wnt signaling pathway has been reported to regulate the expansion of adipose tissue (AT), in terms of both preadipocyte commitment and adipogenesis. Recent studies have identified Secreted Frizzled Related Protein 2 (sFRP2) as a novel factor stimulating adipogenesis via the inhibition of the canonical Wnt pathway. Expression of sFRP2 and Wnt receptor mRNA has been reported in preadipocytes, and Wnt signaling is also known to be involved in pancreatic β-cell insulin production and secretion. The aim of this study was to validate sFRP2 secretion from various depots of human AT and elucidate any deleterious cross-talk mechanisms between expanding AT and pancreatic β-cells. We first confirmed sFRP2 mRNA expression; PCR revealed sFRP2 mRNA expression in mouse subcutaneous (SC) and gonadal fat (GF) which was absent in pancreas, liver and mouse pancreatic β- and α-cell lines, MIN6 and TC1.9 respectively. Next, we quantified the response to sFRP2 via measurement of cell proliferation rates and insulin secretion. Recombinant mouse sFRP2 decreased proliferation rates of MIN6 cells; 100ng/ml: 83.6% (p<0.01), 200ng/ml: 72.2% and 400ng/ml: 73.8% (p<0.001) vs 100% control, n=4. There was no significant difference in proliferation rates in TC1.9 or in the human preadipocyte cell line ChubS7. We observed significantly decreased insulin secretion from MIN6 cells treated with recombinant mouse sFRP2; control: 3.88µg/L+/-0.53, 200ng/ml: 2.95µg/L+/-0.11, p<0.05, 400ng/ml: 2.02µg/L+/-0.57, p<0.01, n=3. We then compared sFRP2 mRNA expression as well as insulin secretion into media between various human AT explants. Conventional PCR showed higher mRNA expression of sFRP2 from human omental (OM) AT depots compared to SC AT, adipocytes, and adipose stromal cells (ASC). sFRP2 mRNA was absent in human hepatocytes. Real-Time PCR showed that sFRP2 mRNA expression was 6.9-fold higher in paired OM than SC AT depots (SC ΔCt=15.62 vs OM ΔCt=12.82, p<0.01, n=4). In cells isolated from human paired SC and OM AT, sFRP2 mRNA was 4.2-fold higher in OM than SC adipocytes (SC ΔCt=19.11+/-0.97 vs OM ΔCt=17.04+/-1.8; p=0.016, n=5). Similarly, OM ASC sFRP2 mRNA expression was 4.3-fold higher than in SC ASC (SC ΔCt=16.85+/-2.47 vs OM ΔCt=14.76+/-2.60, p=0.018, n=8). Western blot analysis for sFRP2 protein secretion into media revealed OM AT explants secreted 63% more sFRP2 than SC explants during 48h culture, p=0.008, n=5. Finally, serum sFRP2 protein levels were significantly higher in obese diabetic female patients (7.47ng/ml +/-3.1) vs non-diabetic (3.04ng/ml +/-1.16), p<0.05, n=6. From these findings, we postulate that the systemic ‘spill-over’ of sFRP2 in obesity could have a detrimental effect on pancreatic β-cell function and contribute to the pathogenesis of insulin resistance and/or diabetes in human obesity.

 

Nothing to Disclose: IB, DRF, EHR, JWT, PMS

12525 10.0000 MON-0908 A The Systemic ‘Spill-over' of sFRP2 in Obesity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0899-0914 4845 1:00:00 PM Adipose Tissue and the Adipocyte Poster

Kristy L Townsend*1, Wenjie Chen2, TianLian Huang3, Sarah Lessard4, Laurie Goodyear5, Jodie Babitt2, Herb Lin2 and Yu-Hua Tseng3
1Harvard Medical School, Joslin Diabetes Center, Boston, MA, 2Massachusetts General Hospital, 3Joslin Diabetes Center, Harvard Medical School, Boston, MA, 4Harvard Medical School, Joslin Diabetes Center, 5Harvard Medical School, Boston, MA

 

One promising obesity therapeutic option is to increase the amount and activity of brown adipocytes in the body.  Brown adipose tissue (BAT) differs from white adipose tissue (WAT) in its ability to burn fuel instead of solely storing it, conferred by densely packed mitochondria with the unique expression of uncoupling protein 1 (UCP1).  This allows for BAT thermogenesis to increase whole body energy expenditure.  We have previously shown that the growth factor bone morphogenetic protein (BMP)7, is capable of committing precursor cells to develop into the brown fat lineage.  Hemojuvelin (HJV) is a member of the repulsive guidance molecule (RGM) family of BMP co-receptors, and has a well-described role in the regulation of iron homeostasis, by augmenting BMP6 signaling in the liver.  HJV is normally membrane bound, where it assists in BMP receptor binding, but it can also be cleaved to generate a soluble/secreted form that is thought to sequester BMP ligand and prevent signal transduction.  HJV is highly expressed in BAT of mice, and is increased in WAT of obese humans; however, the role of HJV in the differentiation and function of brown adipose tissues has not been explored until now.  In this study, we uncovered a novel role for HJV in brown adipocytes.  Mice lacking HJV (knock-out, or KO) displayed a striking pattern of ‘browning’ of WAT, with increased presence of recruitable, UCP1-positive brown adipocytes in WAT, reduced fat pad size and lower body weight.  This WAT phenotype was also observed in heterozygous mice which lacked the characteristic tissue iron-overload phenotype of the KO mice, indicating it was a phenotype independent of HJV’s role in iron-homeostasis.  Immortalized brown preadipocyte cell lines created from HJV KO mice displayed a propensity to differentiate into mature brown adipocytes in vitro, versus similar cells created from WT mice.  These KO preadipocytes were also able to spontaneously differentiate into brown adipocytes in the absence of normally required induction cocktail.  Even at the preadipocyte stage, the HJV KO cells had a marked increase in BMP signaling, including increased phosphorylation of SMAD1/5/8.  The KO preadipocytes also displayed higher mitochondrial activity, as measured by oxygen consumption rate in a respirometer.  Pre-treatment with a pharmacological inhibitor of BMP signaling prevented the accelerated differentiation phenotype of these cells.  Together, these data suggest a new role for HJV in brown adipogenesis: cleavage of HJV generates a soluble form that likely acts to inhibit BMP signaling and brown adipocyte differentiation.  Deletion of HJV leads to increased BMP signaling, increased mitochondrial activity, and accelerated brown adipogenesis.  Targeting HJV by preventing its cleavage may be a potential new treatment to increase the presence of brown adipocytes in the body.

 

Disclosure: LG: Exercise-related drug targets, Jansen Pharmaceuticals, Exercise-related drug targets, Jansen Pharmaceuticals, Brown adipose tissue transplantation, Energesis Pharmaceuticals, Speaker, Pfizer, Inc.. Nothing to Disclose: KLT, WC, TH, SL, JB, HL, YHT

11512 11.0000 MON-0909 A Loss of BMP Co-Receptor Hemojuvelin Leads to Increased Brown Adipogenesis in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0899-0914 4845 1:00:00 PM Adipose Tissue and the Adipocyte Poster

Xarubet Ruiz-Herrera*1, Maria Lemini1, Fernando López-Barrera1, Edith Arnold1, Gonzalo Martinez de la Escalera2, Carmen Clapp2 and Yazmin Macotela1
1National University of Mexico (UNAM), Querétaro, Mexico, 2National University of Mexico (UNAM), Queretaro, Mexico

 

Excessive accumulation of body fat stores or obesity is an important risk factor for the development of type 2 diabetes, cardiovascular disease, cancer and other pathologies. Understanding how adipose tissue expansion alters metabolic homeostasis is essential to develop effective therapies against obesity and its comorbidities. Prolactin (PRL) is one factor that may regulate adipose tissue function and metabolic homeostasis. Recently, reduced prolactin serum levels have been associated with obesity, glucose intolerance and type 2 diabetes in humans. In the present study, we tested whether obese rats show reduced PRL serum levels, as occurs in humans, and if increasing PRL serum levels in these animals has any impact on metabolic dysfunction. Male Wistar rats were fed with either a control diet (CD) or a high fat diet (HFD) and 4 weeks later, both groups were divided in half to form groups: CD, CD+PRL, HFD and HFD+PRL. PRL serum levels were increased by placing subcutaneous osmotic pumps releasing the hormone for 4 weeks, and PRL circulating levels were evaluated by radioimmunoassay and by the Nb2 bioassay. An insulin tolerance test was performed after 3 weeks of PRL treatment, and adipose tissues and serum were collected at the end of the 4th week. We observed that PRL serum levels were decreased in animals on a HFD compared to their chow diet fed counterparts, and that PRL treatment significantly reduced obesity-induced insulin resistance. Interestingly, PRL treatment also resulted in larger visceral and subcutaneous fat depots in the HFD-fed animals. However, this was the result of increased adipocyte number in both subcutaneous and visceral fat depots but reduced adipocyte size specifically in visceral adipose tissue. PRL treatment had no effect on insulin sensitivity and adipose tissue expansion in CD-fed rats, or on food intake or body weight in rats under either diet. PRL treatment also resulted in increased adiponectin serum levels and in decreased interleukin-1 beta expression in visceral fat in animals under both dietary regimens. In conclusion, PRL treatment exerts beneficial metabolic effects by modulating adipocyte growth and proliferation, and adipokine production in obesity.

 

Nothing to Disclose: XR, ML, FL, EA, GM, CC, YM

14918 12.0000 MON-0910 A Increasing Prolactin Serum Levels in Obese Rats Reduces Insulin Resistance, Prevents Visceral Adipocyte Hyperthrophy and Modulates Adipokine Production 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0899-0914 4845 1:00:00 PM Adipose Tissue and the Adipocyte Poster

Mariano Ruiz-Gayo*1, Francisco Hernández-Nuño1, Danila Del Rio1, Adrián Plaza1, Giorgia Parisella1, Victoria Cano1, Julie Ann Chowen2 and Beatriz Merino1
1Universidad CEU-San Pablo, Madrid, Spain, 2Hospital Infantil Universitario Niño Jesús. Universidad Autónoma de Madrid. CIBERobn, Instituto de Salud Carlos III, Madrid, Spain

 

The aim of this study was to investigate the role of CCK in regulating dietary lipid storage in adipose tissue. We have characterized the effect of the sulfated C-terminal octapeptide of CCK (CCK-8) on mechanisms regulating the uptake of dietary triglycerides (TGs) by white adipose tissue. We administered CCK-8 to both control and diet-induced obese rats and observed that CCK-8 indiscriminately decreased both food intake and body weight in all rats, but it increased the size and total lipid content of white adipose tissue in obese rats, suggesting that CCK drives dietary TGs towards adipose tissue in obese animals. CCK-8 also enhanced lipoproteinlipase (LPL) activity and concomitantly decreased expression of the LPL-modulator angiopoietin-like protein 4 (Angptl-4) in the adipose tissue of these animals. The increase in adipose pads is unlikely due to de novo fatty acid synthesis since the amount of active (phosphorylated) protein kinase B (pAkt) and AMP-dependent protein kinase (pAMPK) was not affected by CCK-8. Taken together, our results show that CCK has an adipotropic effect as it facilitates postprandial TG uptake after high-fat meals and suggest that this hormone might act coordinately with insulin to drive nutrients toward energy deposits. The effect of CCK-8 was only observed in obese individuals, suggesting that CCK might promote lipid storage in adipose tissues and account for obesity in obesity-prone individuals.

 

Nothing to Disclose: MR, FH, DD, AP, GP, VC, JAC, BM

12766 13.0000 MON-0911 A Cholecystokinin (CCK-8) Drives the Activity of the Angptl-4-Lipoproteinlipase Pathway in Adipose Tissue of Obese Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0899-0914 4845 1:00:00 PM Adipose Tissue and the Adipocyte Poster

Elizabeth A Jensen*, Edward O List, Darlene E Berryman, Ellen R Lubbers, Adam Jara, Ross Comisford, Wenjuan Zhang and John J Kopchick
Ohio University, Athens, OH

 

Obesity is a growing worldwide concern as it increases the incidence of many other diseases, including heart disease, type 2 diabetes, and some cancers.  The overall decline in health and longevity associated with obesity suggests that obesity itself may accelerate aging. Several studies suggest that cellular senescence may be an underlying mechanism responsible for aging.  That is, with advancing age, accumulation of senescent cells in various tissues, such as adipose tissue, leads to chronic inflammation, which is thought to hasten the aging process.  Here, we analyze the effects of diet-induced obesity (DIO) on the accumulation of senescent cells in subcutaneous and visceral white adipose tissue (WAT) to better understand the role of senescence on aging during an obese state.  

Male C57BL/6J mice were placed on standard chow (n=10) or a high-fat (HF) diet (n=10) from weaning until 15 months of age. Body composition was measured using a desktop NMR.  Mice were sacrificed at 15 months of age, at which time mesenteric (visceral) and inguinal (subcutaneous) WAT depots were collected.  Senescence-associated beta-galactosidase assays were performed on a portion of each depot while another portion was used for mRNA isolation and real-time quantitative PCR analysis.

As expected, mice on the HF diet became obese with a significant and progressive increase in body fat.  Fasting blood glucose and insulin levels were also increased in HF fed mice.  Senescence-associated beta-galactosidase assays revealed a significant increase the number of senescent cells per nuclei in both WAT depots in the HF fed mice compared to controls.  Moreover, the HF diet resulted in a greater increase in senescence in visceral WAT (5.5 fold increase) and subcutaneous WAT (3.6 fold increase) compared to controls.

Based on the current findings, DIO increases cellular senescence in WAT.  Since obesity is known to accelerate aging and decrease lifespan in humans and mice, understanding the molecular mechanisms involved are critical.  Our findings suggest that increased cellular senescence in WAT may be one such mechanism and that visceral adipose tissue is affected to a greater extent by cellular senescence than subcutaneous adipose tissue.  We are currently verifying these results using RTqPCR.

 

Nothing to Disclose: EAJ, EOL, DEB, ERL, AJ, RC, WZ, JJK

14854 14.0000 MON-0912 A Diet-Induced Obesity Increases Cellular Senescence in Multiple White Adipose Tissue Depots: Investigating Accelerated Aging with Obesity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0899-0914 4845 1:00:00 PM Adipose Tissue and the Adipocyte Poster

Rong Yuan*1, Moammir Aziz1, Jared Osland1 and Leslie Goodwin2
1Southern Illinois University, Springfield, IL, 2The Jackson laboratory, Bar Harbor

 

Nuclear receptor interacting protein 1, Nrip1, a regulator of nuclear receptors that have broad functions in regulating cell growth, cell death and metabolism, is expressed at a high level in liver, brain, fat and muscle. Globally knocking out Nrip1 (Nrip1-/-) results in resistance to high fat diet-induced obesity and some physiological characteristics that are found in diet restricted mice, including lower body fat percentage, increased glucose tolerance and insulin sensitivity. The potential underlying mechanisms include increased mitochondria function, reduced oxidative stress, reduced pro-inflammatory and increased anti-inflammatory cytokines. Importantly, knocking out Nrip1 increases mitochondrial biogenesis by activating peroxisome proliferator-activated receptor gamma coactivator 1α (PGC-1α), a key molecular mechanism of improving metabolism and extending longevity in diet restriction.

However, globally knocking out Nrip1 significantly delays development and reduces reproduction capability. White-fat depots recently have been recognized as an endocrine organ that has profound effects on metabolism. It has been shown that reducing visceral white-fat could improve metabolism. Nrip1-/-mice have 70% reduction of fat compared to wild-type controls.

Using the cre-lox technique, we have successfully generated the mouse model, in which the Nrip1 is specifically and significantly suppressed in the white-fat tissue. Glucose and insulin tolerance tests suggested improved insulin sensitivity. Ongoing study focuses on investigating the effects of suppressing Nrip1 in white-fat on metabolism in aging process.

 

Nothing to Disclose: RY, MA, JO, LG

15031 15.0000 MON-0913 A Improving Metabolism By Suppressing Nrip1 Expression in White-Fat Tissue 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0899-0914 4845 1:00:00 PM Adipose Tissue and the Adipocyte Poster

Cheryl Cero* and Alessandro Bartolomucci
University of Minnesota, Minneapolis, MN

 

beta-Adrenergic Receptors-Activation is Required for the Pro-Lipolytic and Anti-Obesity Effect of the VGF-Derived Peptide TLQP-21

Cheryl Cero1, Maria Razzoli1, Jake McCallum1, Allison Gurney1, Bradford B. Lowell2, Alessandro Bartolomucci1

1Dept. of Integrative Biology and Physiology, University of Minnesota, MN, USA

2Dept. of Medicine, Division of Endocrinology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA. 

The Vgf gene encodes for a pro-peptide processed to yield several bioactive peptides, one of which is the C-terminal internal fragment TLQP-21 [1]. In mice, TLQP-21 is expressed in the central nervous system and in sympathetic nerve terminals innervating the white adipose tissue (WAT) [2]. Complement 3a receptor 1 (C3aR1), a GPCR, has recently been identified as the target for TLQP-21 [3]. Chronic TLQP-21 peripheral treatment decreases adipocyte diameter without causing adverse cardiovascular effects [2]. Moreover, TLQP-21 acts as an enhancer of beta-adrenergic receptor (beta-ARs)-activation induced lipolysis in adipocytes via phosphorylation of hormone sensitive lipase (HSL) [2]. The exact mechanism of TLQP-21 induced lipolytic effects has yet to be identified. We hypothesize that functional beta-ARs are required for the pro-lipolytic and anti-obesity effects of TLQP-21. To test our hypothesis we conducted in vivo experiments with wild type and beta1- 2 and 3-ARs knockout mice (beta-less) that develop sever obesity under a high fat diet regime [4]. We injected diet-induced obese wt and b-less mice with TLQP-21 (or saline) for 4 weeks. Results showed that TLQP-21 treatment significantly decreased body weight and fat mass in wild type mice without affecting lean mass, caloric intake or energy expenditure. On the contrary, beta-less mice were fully resistant to the anti-obesity effect of TLQP-21. Finally, adipocytes from wt and beta-less mice were treated in vitro with TLQP-21 in presence or absence of isoproterenol (ISO) and glycerol release was used as an index of lipolysis. As previously established, TLQP-21 potentiated ISO-induced lipolysis in wt adipocytes while beta-less adipocytes were unresposive to both the beta-agonist ISO as well as to TLQP-21 treatments. In conclusion, these data demonstrate that TLQP-21 enhances beta-ARs-activation induced lipolysis and opposes obesity in mice. Furthermore we demonstrated that despite TLQP-21 binding the C3aR1, its pro-lipolytic effect requires priming via activation of beta-ARs. Further ongoing studies will determine the downstream target and clarify the cell signaling cascade activated by TLQP-21/C3aR1 activation.

 

Nothing to Disclose: CC, AB

15109 16.0000 MON-0914 A Beta-Adrenergic Receptors-Activation Is Required for the Pro-Lipolytic and Anti-Obesity Effect of the Vgf-Derived Peptide Tlqp-21 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0899-0914 4845 1:00:00 PM Adipose Tissue and the Adipocyte Poster

Antje Horsch*1, Anaelle Boichat2, Susi Kriemler3, Simone Munsch4, Bertrand Crottet1, Pedro Marques-Vidal2, Ayala Borghini1, Ulrike Ehlert5 and Jardena J Puder1
1University Hospital Lausanne, Lausanne, Switzerland, 2University of Lausanne, Lausanne, Switzerland, 3University of Zürich, Zürich, Switzerland, 4University of Fribourg, Fribourg, Switzerland, 5University of Zuerich

 

Stress elicits physiological stress responses in the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal (HPA) axis. Stress exposure is a risk factor in the development of childhood obesity. In obese adults, acute stress reactivity is altered, but data in children are scarce. Physical activity may protect from negative stress effects but studies in children are lacking.

We investigated the role of physical activity in modulating acute stress reactivity of the HPA and ANS systems after acute social stress exposure in overweight/obese (OW/OB) and normal weight (NW) children. We hypothesised that acute physical activity in both NW and OW/OB children modulates HPA and ANS stress responses following acute stress exposure and that stress reactivity following acute stress exposure differs between OW/OB and NW children.

Twenty-four prepubertal OW (n=5)/OB and 26 NW children (7-11 years) were randomly assigned to either a moderate physical or a sedentary activity for 30 min followed by a standardised social stressor (Trier Social Stress Test for Children, TSST-C). Salivary cortisol (HPA), systolic, diastolic blood pressure, and heart rate (ANS) were measured at seven time points before and after the stress exposure.

Following stress exposure, salivary cortisol levels increased significantly for all children (p=0.04), but the cortisol response curve to stress was completely flat in the obese sedentary group (p=0.6). A significant interaction effect between the randomization arms and weight status for salivary cortisol after stress exposure was found, i.e. physical activity increased cortisol levels in the OW/OB, while it decreased it in the NW children (interaction: 2.2 nmol/l (0.2-4.2), p=0.035). There was no interaction between randomization arms and weight status regarding and measures of the ANS. BP changes after the TSST- C did not differ according to randomization arms, but HR after stress exposure was significantly higher in the physical activity arm compared to the sedentary control arm (14.6 beats per minute (9.8-19.5), p<0.001). Following stress exposure, only systolic BP differed between OW/OB and NW children, with values being higher in the OW/OB (6.0 mmHg (2.2 to 9.8), p=0.002).

Results indicate that physical activity increases stress reactivity in OW/OB children, while it decreases this reactivity in NW children, possibly rendering the HPA reactivity more adaptive to stress in both groups. It may thus have a protective role in the development of obesity by modulating responses to social stress.

 

Nothing to Disclose: AH, AB, SK, SM, BC, PM, AB, UE, JJP

14448 1.0000 MON-0915 A Impact of Physical Activity on Stress Reactivity in Obese and Normal Weight Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Rafael Alfonso Cristancho*1, Sara Beck1, Sean D Sullivan1, Lou Garrison1, David Arterburn2, Steve Bock2, David R Flum1, Mette Hammer3 and Jakob Langer3
1University of Washington, Seattle, WA, 2Group Health Research Institute, Seattle, WA, 3Novo Nordisk, Inc., Plainsboro, NJ

 

Severe obesity, defined as BMI ≥40 kg/m2 or BMI ≥35 kg/m2 with obesity-related comorbidities, has a negative impact on individual’s health, life expectancy and quality of life. Bariatric surgery is recommended for weight loss in people with severe obesity. Yet, only a minority of eligible individuals undergoes surgery as a means of weight loss. Our aim was to investigate differences in clinical and demographic characteristics between people with severe obesity who underwent bariatric surgery and eligible people who did not undergo bariatric surgery. Group Health Cooperative members in Washington State from 2004 to 2010 were assessed. Surgery subjects were identified by ICD-9 and CPT codes. Non-surgery subjects were included if they had a BMI ≥40 kg/m2 or BMI ≥35 kg/m2 and relevant comorbidities identified by ICD-9 codes. People with contraindications for bariatric surgery were excluded. Baseline clinical and demographic characteristics were assessed using electronic medical records. Specific comorbidities and diabetic/pre-diabetic status were identified following ADA criteria during a baseline period of 90 days prior to surgery and 1 year after identification of eligibility for surgery, for surgery and non-surgery individuals, respectively. Differences in baseline characteristics between surgery and non-surgery people were analyzed using Chi2 test for categorical variables and Student’s T tests for continuous variables. In total, 1,434 people were included in the bariatric surgery group, and 39,711 people in the non-surgery group. The majority of the surgery subjects underwent open Roux-en-Y gastric bypass (RYGBP) (46.7%) or laparoscopic RYGBP (46.7%). Compared to non-surgery individuals, surgery people were slightly younger (mean age 47.6 vs. 48.6 years, p<0.001), with a higher proportion of females (82.2 vs. 68.6%, p<0.0001), and a higher mean baseline BMI (49.0 vs. 41.0 kg/m2, p<0.0001). More than half of the surgery cohort had BMI >45 kg/m2, whereas more than half of the non-surgical subjects belonged to the BMI category 35-40 kg/m2. Diabetes and pre-diabetes were more prevalent among surgery individuals compared to non-surgical individuals (36.7% vs. 19.1% for diabetes and 8.6% vs. 6.2% for pre-diabetes). All other chronic comorbidities were more frequent among people undergoing surgery compared to those who did not: hypertension, dyslipidemia, sleep apnea, osteoarthritis, metabolic syndrome, depression, fatty liver disease (all p<0.0001). Among people with severe obesity eligible for bariatric surgery, those who undergo bariatric surgery are significantly different from those not undergoing surgery. The group of people undergoing surgery had a higher proportion of females, a higher baseline BMI, a higher prevalence of comorbidities, including diabetes and pre-diabetes, as compared to non-surgery individuals.

 

Disclosure: RA: Researcher, Novo Nordisk. SDS: Researcher, Novo Nordisk. LG: Researcher, Novo Nordisk. MH: Employee, Novo Nordisk, Employee, Novo Nordisk. JL: Employee, Novo Nordisk, Employee, Novo Nordisk. Nothing to Disclose: SB, DA, SB, DRF

14722 2.0000 MON-0916 A Differences in Characteristics Between People with Severe Obesity Undergoing and Not Undergoing Bariatric Surgery 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Ray Morris Joe*1, Laura Pearce2, Hsiao-Wen Su1, Michael Doche1, Lawrence Stanton Argetsinger3, Joel M Cline1, I Sadaf Farooqi4 and Christin Carter-Su5
1University of Michigan, Ann Arbor, MI, 2University of Cambridge Metabolic Research Laboratories and NIHR Cambridge Biomedical Research Centre, Cambridge, United Kingdom, 3Univ of Michigan Medical School, Ann Arbor, MI, 4Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom, 5Univ of Michigan, Ann Arbor, MI

 

SH2B1 is a scaffolding protein for the receptors of multiple hormones, neurotrophins, and cytokines, including GH, leptin, insulin, brain-derived neurotrophic factor (BDNF), and nerve growth factor (NGF).  SH2B1 is alternatively spliced, resulting in 4 isoforms that differ only at the C-terminus.  SH2B1β and γ are ubiquitously expressed in human tissues whereas SH2B1α  and δ are expressed primarily in the brain. SH2B1β and γ have been implicated in NGF- and/or BDNF-induced neurite outgrowth. SH2B1 isoforms have also been shown to enhance insulin and leptin stimulation of tyrosyl phosphorylation of IRS proteins as well as GH-dependent changes in the actin cytoskeleton and macrophage migration.  We recently reported 4 variants (P90H, T175N, P322S, F344Lfs*20) in SH2B1 in  individuals from the Genetics of Obesity Study (GOOS) cohort.  These individuals exhibit severe early onset childhood obesity, greater than expected insulin resistance, and maladaptive behavior. Here we characterize a new variant, T546A, that lies in the SH2 domain of SH2B1, a region shared amongst all SH2B1 isoforms.  The T546A proband exhibited early onset childhood obesity, insulin resistance, hyperphagia, and mild developmental delay.  Introduction of T546A into human SH2B1α did not impair the ability of ectopically expressed SH2B1 to enhance leptin or insulin-stimulated tyrosyl-phosphorylation of IRS2 or JAK2 activity.  However, introduction of the T546A mutation into SH2B1α  blocked the ability of SH2B1α  to enhance GH-induced migration of RAW macrophages. Introduction of the T546A mutation into SH2B1β  also impaired the ability of SH2B1β  to enhance NGF-induced neurite outgrowth of PC12 cells.  In contrast, the common coding SNP, A484T, which has been associated with serum leptin and body fat, had no impact on SH2B1 enhancement of macrophage motility or neurite outgrowth.  These results identify a new human variant in SH2B1 associated with obesity.  They provide additional support that multiple regions within the shared N-terminal region of SH2B1 isoforms are critical for the cellular functions of SH2B1 leading to obesity.  Finally, these results raise the question of whether impaired neurite projections and/or motility of neurons, macrophages and/or other cells during development play a critical role in the phenotype of these individuals.

 

Nothing to Disclose: RMJ, LP, HWS, MD, LSA, JMC, ISF, CC

16855 3.0000 MON-0917 A A Novel SH2B1 Variant Associated with Human Obesity That Impairs GH-Dependent Cellular Migration and Neurite Outgrowth 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Anne Kurrat*1, Tina Blei1, Sabine Kulling2, Dennis Mueller1, Sebastian Soukup2, Carmen Weigt1 and Patrick Rene Diel1
1German Sports University Cologne, Cologne, Germany, 2Max Rubner Institut (MRI), Karlsruhe, Germany

 

Obesity has rapidly increased in western countries over the last decades. It is linked to chronic diseases, including diabetes, arteriosclerosis and certain forms of cancer such as breast cancer. Asian countries have a lower risk in developing these diseases and it is assumed that this is linked to the soy consumption and health benefits of its content isoflavones (ISO) belonging to the group of phytoestrogens.

In this study, we investigated whether dietary exposure of female rats to ISO modulates the susceptibility to develop obesity. Lifelong and acute exposure scenarios were compared.

Female Wistar rats were bred and raised on standard ISO depleted diet (IDD: 3,5 mg/kg) or ISO rich diet enriched with a commercial extract (IRD: 507 mg/kg). Some of the animals were ovariectomized (OVX) at postnatal day (PND) 80. Starting PND 83, all animals were fed a high calorie diet in the presence and absence of ISO for 12 weeks to induce obesity. A special diet switch group (IRD switch) raised on IDD and switched to high calorie IRD after ovariectomy mimics the acute exposure to ISO in postmenopausal western women. From ablactation until the end of the experiment body weight and food consumption were determined continuously.

After 12 weeks high calorie exposure animals were sacrificed and body weight, visceral fat mass and soleus muscle weight were measured and blood samples were taken.

Intact rats showed reduced increase of body weight and lower visceral fat mass compared to OVX groups. OVX and intact rats fed IRD lifelong showed lower increase of body weight and lower visceral fat mass compared to the respective IDD animals. Lowest triglyceride levels were detected in OVX animals fed IRD. Development of obesity could not be prevented in the IRD switch group. In IDD animals soleus muscle weight was significantly decreased in OVX animals compared to intact animals. Interestingly, in IRD OVX animals soleus muscle weight was as high as observed in intact IDD animals.

To investigate underlying molecular mechanisms of the observed effects on fat and muscle, endocrine feedback (TSH, leptin, irisin, IGF-1), histological analysis and tissue specific gene expression (GLUT 4, PPARs, FAS) are under investigation.

In conclusion we assume that in rats A: lifelong but not acute ISO intake may result in a reduced risk to develop obesity and B: lifelong and acute ISO exposure may antagonize loss of skeletal muscle mass induced by ovariectomy.

 

Nothing to Disclose: AK, TB, SK, DM, SS, CW, PRD

14592 4.0000 MON-0918 A Effects of Lifelong Dietary Phytoestrogen Exposure on the Susceptibility to Develop Obesity - a Study in Ovariectomized and Intact Female Wistar Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Susan J. Melhorn1, Mario Kratz2, Kathryn Elizabeth Berkseth1, Vidhi Tyagi1, Mary Webb1, Sonya Mehta1, Carolyn J. Noonan1, Dedra S. Buchwald1 and Ellen A. Schur*1
1University of Washington, Seattle, WA, 2Fred Hutchinson Cancer Research Center, Seattle, WA

 

Background: Considerable individual variability exists in circulating concentrations of appetite-regulating hormones, particularly ghrelin. This study hypothesized that inherited factors would influence plasma levels of ghrelin, leptin, and insulin, thereby modulating food intake.

Methods: Healthy monozygotic twin pairs (N=21 pairs, 11 male (M), 10 female (F); mean age 27±8 yr) were recruited through the University of Washington Twin Registry. After an overnight fast and blood draw, participants ate a standardized breakfast and, 3.5 h later, a standardized preload meal followed 1 h later by an ad libitumbuffet. Total caloric intake at the buffet was assessed. Visual analog scale (VAS) ratings of hunger and fullness (0-100 mm) as well as blood draws for plasma glucose, insulin, and ghrelin concentrations were performed serially. Total body fat mass was measured by dual x-ray absorptiometry. Intraclass correlations (ICC) were used to compare within-pair to between-pair variance. If the between-pair variance was larger, then twins were presumed to respond more similarly because of inherited factors. Generalized estimating equations were used to test associations between hormones and eating behavior, accounting for twin relatedness.

Results: Mean BMI was 27±6 kg/m2. Body weight (M ICC=0.96, P<0.0001; F ICC=0.97, P<0.0001), BMI (M ICC=0.94, P<0.0001; F ICC=0.97, P<0.0001), and total fat mass (M ICC=0.92, P<0.0001; F ICC=0.97, P<0.0001) showed very strong inherited influences. VAS appetite ratings and caloric intake at the buffet showed consistent genetic influence (VAS ICC 0.39-0.61, P<0.05; buffet ICC=0.49, P=0.01). Fasting ghrelin (ICC=0.87, P<0.0001), leptin (ICC=0.90, P<0.0001) and insulin (ICC=0.81, P<0.0001) concentrations were also significantly more similar within twin pairs. These findings persisted after statistical correction for total fat mass, VAS hunger, and VAS fullness. ICCs remained significant when males and females were analyzed separately. Total AUC for ghrelin and insulin (ICC=0.37, P<0.05; ICC=0.63, P=0.001) and pre-meal peaks (ICC=0.60, P=0.002; ICC=0.74, P<0.0001) were also correlated within twin pairs, but the change in plasma hormones induced by the standardized meal was only significant for insulin (ICC=0.46, P<0.05). Plasma hormone concentrations did not predict food intake at the buffet. However, pre-buffet VAS appetite (P<0.05) and anxiety ratings (P<0.05) were associated with the amount consumed.

Conclusions: Independent of sex and adiposity, circulating concentrations of ghrelin, insulin, and leptin were strongly influenced by inherited factors. Hormone concentrations did not, however, predict ad libitum caloric intake, suggesting that cognitive factors such as anxiety may be more influential on eating behavior after a preload than physiologic signals.

 

Nothing to Disclose: SJM, MK, KEB, VT, MW, SM, CJN, DSB, EAS

15173 5.0000 MON-0919 A Inherited Factors Influence Plasma Concentrations of Appetite-Regulating Hormones 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Elizabeth A. Lawson*1, Pouneh K. Fazeli2, Dean A. Marengi3, Ela Cross1, Alexander Terence Faje1, Clifford J Rosen4, Anne C Breggia5, Karen K. Miller1 and Anne Klibanski1
1Massachusetts General Hospital/Harvard Medical School, Boston, MA, 2Neuroendocrine Unit, Massachusetts General Hospital/Harvard Medical School, Boston, MA, 3Massachusetts General Hospital, Boston, MA, 4Maine Medical Center Research Institute, Scarborough, ME, 5Maine Medical Center Rsrch Inst, Scarborough, ME

 

Anorexia nervosa (AN) is a psychiatric disorder characterized by self-induced starvation and consequently, decreased resting energy expenditure. Irisin is a novel myokine involved in energy metabolism, driving energy expenditure via “browning” of white adipocytes and thermogenesis. Irisin levels are not well characterized in AN, and the relationship between irisin and reduced energy expenditure in AN has not been studied. We hypothesized that low irisin mediates reduced energy expenditure in AN. We studied 45 females with AN and 44 healthy controls (HC), mean±SEM age 26.9±0.6 yrs. We assessed serum irisin levels (ELISA, Adipogen), body composition (Hologic DXA), and in 16 AN and 19 HC, fasting resting energy expenditure (REE; indirect calorimetry). Mean %IBW (79.5±1.0 vs. 99.8±0.9, p<0.0001), body fat (9.2±0.4 vs. 17.7±0.5 kg, p<0.0001), lean body mass (3.9±0.7 vs. 4.3±0.7, p<0.0001) were lower in AN than HC. Mean REE (933±40 vs. 1169±31 cal, p<0.0001) was lower in AN than HC, even after controlling for lean body mass (p=0.006). Irisin levels were higher in AN than HC (2.6±0.1 vs. 2.1±0.1 ug/mL, p<0.003). In AN, irisin was negatively associated with BMI (R=-0.44, p=0.003) and lean mass (R= -0.46, p=0.002), but not fat mass (R=-0.15, p=0.33). Irisin was also negatively associated with REE in AN (R=-0.63, p=0.009). There were no significant relationships between irisin and body composition parameters or REE in HC. High irisin levels in AN may represent a response to the starvation-induced slowing of the metabolic rate. Irisin may be ineffective at increasing energy expenditure in AN due to redundant endocrine pathways that promote conservation of energy in the starved state.  It is also possible that AN is an irisin resistant state, perhaps due to insufficient white adipose tissue substrate for conversion to beige fat.

 

Nothing to Disclose: EAL, PKF, DAM, EC, ATF, CJR, ACB, KKM, AK

13933 6.0000 MON-0920 A Irisin Levels Are High in Anorexia Nervosa and Inversely Associated with Resting Energy Expenditure 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Paul Kievit*1, Lynley Pound1, Theodore Hobbs1, Drew Martin1, Chris Johnson1, Alex Escalona2, Lindsay Bader1, Jeanette Valleau1, Joel Keith Elmquist3, Randy Seeley4, Lee M. Kaplan5 and Kevin L. Grove1
1Oregon National Primate Research Center, Beaverton, OR, 2Massachusetts General Hospital, Boston, MA, 3UT Southwestern Medical Center, Dallas, TX, 4Univ of Cincinnati, Cincinnati, OH, 5Massachusetts General Hospital/Harvard Medical School, Boston, MA

 

Roux-en-Y gastric bypass (RYGB) surgery in humans has proven to be an effective and durable treatment for obesity, resulting in significant weight loss and improvements in diabetes. This study establishes a unique model of RYGB in diet-induced obese Rhesus Macaques to further characterize the cellular and molecular mechanisms underlying the impressive effects of Roux-en-Y gastric bypass (RYGB) that may not be representative in rodent models or achievable from human clinical studies.  Twenty diet induced obese adult animals were selected, of which 13 were insulin resistant and 7 were classified as diabetic and requiring insulin treatment to manage diabetes. Initially, animals were calorically restricted over 12 weeks to achieve 50% of normal food intake to determine the metabolic effects of dieting. This dieting regime reduced body weight by 12% (p<0.0001) and resulted in significant improvements in glucose tolerance (p<0.0001) and insulin resistance (insulin sensitivity index; p<0.001). Energy expenditure, measured by indirect calorimetry, was proportionally reduced in response to the weight loss. After regaining body weight, animals were divided into groups receiving either the RYGB or a sham surgery and pair fed to the RYGB group (SHAM/PF). Food intake was reduced to 20% of normal in the first 2 weeks, but returned to pre-surgery levels at week 12.  Similar to the caloric restriction, Sham/PF animals lost 13%  (p<0.0001) of their body weight, compared to 24% in the RYGB group (p<0.0001).  In male animals, energy expenditure was increased after RYGB (p<0.05, pre versus post RYGB) but not in SHAM/PF, suggesting that the additional weight loss was partly driven by increased metabolic rate.  Glucose homeostasis was greatly improved in both groups with no additional improvement as a result of the RYGB compared to SHAM/PF. Using food preference testing, no differences in fat or sucrose preference were observed between RYGB of SHAM/PF animals. Molecular and immunohistological analysis of the pancreas demonstrated no differences between the RYGB and SHAM/PF group.  Changes in mRNA transcripts, using RNA-SEQ, was performed on liver biopsies collected before and after the RYGB or SHAM/PF. Interestingly, although there was a large number of gene expression changes before and after RYGB or SHAM/PF, there was little difference in the expression pattern between SHAM/PF and RYGB animals.  These results support that many, but not all initial metabolic improvements of RYGB can be attributed to drastically reduced caloric intake in the early stages following surgery.

 

Disclosure: RS: Consultant, Johnson &Johnson, Investigator, Johnson &Johnson. Nothing to Disclose: PK, LP, TH, DM, CJ, AE, LB, JV, JKE, LMK, KLG

15577 7.0000 MON-0921 A Caloric Intake Reduction Following Roux-En-Y Gastric Bypass Surgery Drives Rapid Improvements in Glucose Homeostasis and Beta Cell Function in Obese Rhesus Macaques 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Saranyapin Potikanond*1, Pinyada Rattanachote2, Panan Suntornsaratoon3, Narattaphol Charoenphandhu3, Nipon Chattipakorn4 and Siriporn C Chattipakorn4
1Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand, 2Faculty of Medicine, Chiang Mai University, 3Mahidol University, Bangkok, Thailand, 4Chiang Mai University, Chiang Mai, Thailand

 

We previously demonstrated that an obese-insulin resistant condition induced by long-term high-fat diet (HFD) consumption markedly impaired osteoblastic insulin signaling and osteoblast proliferation, and decreased osteoblast survival, leading to osteoporosis in the jaw bone (1).  Previous study also showed that testosterone deprivation led to the development of osteoporosis (2).  However, the effects of combined testosterone deprivation and obesity on osteoblastic insulin signaling and osteoblast survival have not been investigated.  In the present study, we hypothesized that testosterone deprivation impairs osteoblastic insulin signaling, decreases osteoblast survival, reduces bone density, and that obesity aggravates those deleterious effects in testosterone-deprived animals.  Twenty four male rats were divided into sham-operated and orchiectomized groups (n=12/group).  A week after the surgery, rats in each group were divided into 2 subgroups and fed with either normal diet (ND) or HFD for 12 weeks.  At the end of week 12, blood samples were collected from all rats (sham-operated ND rats (NDS), orchiectomized ND rats (NDO), sham-operated HFD rats (HFS) and orchiectomized HFD rats (HFO)) to determine the levels of glucose, insulin, cholesterol, testosterone and HOMA index.  The tibias were extracted to determine bone mass using microcomputed tomography.  Furthermore, osteoblasts were isolated from rats’ tibia in each subgroup, and were used for determination of (1) osteoblastic insulin signaling by measuring insulin-mediated insulin receptor phosphorylation (IR-p) and Akt phosphorylation (Akt-p), (2) cell proliferation using Alamarblue cell viability assay, and (3) cellular apoptosis using Bax/Bcl2 expression.  We found that only HFS and HFO groups developed peripheral insulin resistance as indicated by increased HOMA index (26.6 + 3.0, 25.2 + 4.1, respectively), compared to that of NDS and NDO groups, (14.6+ 1.7, 17.2 + 3.2, respectively).  However, the testosterone levels of NDO, HFS and HFO groups were significantly decreased compared to that of NDS group.  Similar to testosterone levels, the impairment of osteoblastic insulin signaling isolated from NDO, HFS and HFO groups was demonstrated as indicated by the decreased IR-p and Akt-p.  NDO, HFS and HFO osteoblasts also demonstrated the decreased cell proliferation and increased Bax/Bcl-2 ratio expression.  The trabecular bone density was significantly decreased in NDO, HFS and HFO groups (126.9 + 11.1, 140.9 + 15.3, 155.8 +10 mg/cm3, respectively), compared to that in the NDS group (203.4 + 14.4 mg/cm3).  No differences were found among NDO, HFS and HFO rats.  These findings indicate that either testosterone deprivation or obesity alone can impair osteoblastic insulin signaling, leading to the development of osteoporosis.  However, obesity does not aggravate those deleterious effects in the testosterone-deprived rats.

 

Nothing to Disclose: SP, PR, PS, NC, NC, SCC

11978 8.0000 MON-0922 A Obesity Does Not Aggravate the Impairment of Osteoblastic Insulin Signaling and the Reduction of Bone Density in Testosterone Deprived Models 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Alev Cagla Ozdemir*, Grace M Wynn and Katharine M Rudd
Emory University, Atlanta, GA

 

Recently we described a chromosomal duplication of the Guanine nucleotide-binding protein beta subunit 3 (GNB3) gene in an early-onset obesity syndrome. Children with an unbalanced translocation including GNB3 are obese with BMI values above the 95th percentile. Genome-wide association studies have also implicated a cytosine to thymine (C825T) polymorphism in GNB3 as a risk factor for hypertension and obesity. To model GNB3 overexpression we created BAC transgenic mice with extra copies of human GNB3-T or GNB3-C alleles and characterized weight gain, fat deposition, food intake, and circulating hormone profiles at 5 and 20 weeks. Transgenic GNB3 is highly expressed in the brain, at levels greater than endogenous Gnb3. Mice that overexpress GNB3-T weigh significantly more than wild-type littermates from age 6-7 weeks onwards (p=0.002), and by 20 weeks have greater subcutaneous and visceral white adipose tissue and brown adipose tissue percent, larger white adipocytes, and larger livers. Though GNB3-T mice have elevated weight gain and adiposity, they consume similar amounts of food at 5, 10, 15 and 20 weeks as compared to wild-type littermates. GNB3-T mice also have significantly greater fasting plasma leptin, glucose, insulin and C-peptide at 20 weeks, suggesting insulin resistance. In addition, GNB3-T mice have elevated fasting plasma triglycerides, total cholesterol and phospholipids at 20 weeks compared to wild-type littermates. These findings are consistent with metabolic syndrome. Together, these data suggest a new role for GNB3-T overexpression in obesity. Future experiments will elucidate whether GNB3-T overexpression impairs heat production and brown fat function.

 

Nothing to Disclose: ACO, GMW, KMR

14000 9.0000 MON-0923 A Obesity and Metabolic Syndrome in a Mouse Model of GNB3 Overexpression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Jung Han Kim*1, David Neff2, James Denvir3, Donald Primerano3, Jun Fan3, Xia Mao1 and Kristy Dillon1
1Marshall University School of Medicine, Huntington, WV, 2Marshall University, 3Marshall University School of Medicine

 

Background: We previously mapped an obesity susceptibility locus on chromosome 6 in a backcross from the obese and type 2 diabetic TALLYHO/Jng (TH) and C57BL/6 (B6) mouse strains.  Introgression of a TH-derived chromosome 6 genomic interval containing the locus into a B6 background resulted in a congenic mouse with obesity.  Using sub-congenic mice, we narrowed the obesity susceptibility locus to a 45-Mb interval, named tabw2a.  The objective of this study was to identify candidate genes within the tabw2ainterval. 

Methods: We performed whole genome sequencing of TH mice in two paired end read strategies using an Illumina HiSeq1000 next generation sequencer.  COS-1 cells were cultured in DMEM supplemented with 10% fetal bovine serum, 100 U/ml penicillin and 100 U/ml streptomycin.  Murine pAcGFP1-Cidec was created by cloning Cidec cDNA upstream and in-frame with the AcGFP1 sequence in pAcGFP1-N1.  The entire Cideccoding region was included except for the stop codon.  Site-directed mutagenesis was used to introduce the missense polymorphism R46S.  Plasmids were transiently transfected into COS-1 cells using Lipofectamine LTX&PLUS.  After transfection, the cells were cultured for 40 h, fixed, and strained with Nile-Red.  Where indicated, the cell culture medium was supplemented with 400mM BSA-complexed oleic acid. Morphometric analysis of lipid droplet was undertaken using confocal microscopy.  

Results: Whole genome sequencing of TH generated total usable yield of 134,281 Mbases with 64.8X coverage.  We compared the TH genome to the B6 genome using CASAVA (Illumina) and identified 5,520,947 SNPs genome-wide.  To search a positional candidate gene for tabw2a, SNPs that map to the interval of tabw2a were viewed through the IGV.  Non-synonymous substitutions were found in 57 genes, and 5 of them were classified as “predicted to affect protein function” by SIFT program and include Lmod3 (S93N), Ppp4r2 (D417H), Cidec (R46S), Irak2 (L81V), and Ret (T351I).  Cell death-inducing DNA fragmentation factor-alpha (DFFA)-like effector c (Cidec/Fsp27) protein is localized to lipid droplets in adipocytes and hepatocytes and involved in the regulation of lipid droplet size and lipid storage during lipid metabolism.  Acknowledging the critical role of CIDEC in lipid metabolism, we further examined the function of the CidecR46S polymorphism.  COS-1 cells transfected with S46 variant exhibited an increase in lipid accumulation compared to the wild type R46 variant, P<0.05.  It was also the case when the cells were cultured in the media supplemented with oleic acid.

Conclusion: Mouse Cidec S46 may be a gain-of-function variant.  The missense polymorphism R46S in Cidec may influence the development of obesity mediated by tabw2a locus.

 

Nothing to Disclose: JHK, DN, JD, DP, JF, XM, KD

16025 10.0000 MON-0924 A The Missense Polymorphism R46S in Cell Death-Inducing DNA Fragmentation Factor-Alpha (DFFA)-like Effector c (Cidec/Fsp27) May Influence the Obesity Mediated By Mouse Locus tabw2a 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Moahad Saeed Dar1 and Lindsey Aber Finnegan*2
1Brody School of Medicine, Greenville, NC, 2Brody School of Medicine, Greenville

 

Background

Granuloma annulare (GA) is a benign, self-limited cutaneous condition manifested by papular annular eruptions that affects children and adults and has been associated with diabetes mellitus, hyperlipidemia, and internal malignancy.1 Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed bariatric procedures in the world and is effective in achieving weight loss and disease remission. Despite its many benefits, there is a 2.7 fold higher risk for hypoglycemia which develops ~ 6 months or more after RYGB.2 We herein report a case of post-RYGB hypoglycemia associated with granuloma annulare.

Clinical Case

A 50-year-old white female developed hypoglycemia nine months after RYGB and was referred to the ECU endocrine clinic for further management. RYGB was felt to be the most likely explanation for hypoglycemia after clinical testing ruled out hypothyroidism [TSH 2.3 uIu/mL (ref 0.35-5.50 uIu/mL) , Free T4 0.89 ng/dL (reference 0.82-1.77 ng/dL )], primary adrenal insufficiency [ baseline cortisol 6.6 µg/dL ►60 minute cortisol 25.7 µg/dL (ref  > 18 µg/dL)], insulin autoantibodies [< 2 µU/mL (ref < 5 µU/mL)], insulinoma (negative 72 hour fast), and tumor related hypoglycemia [IGF-II 519 ng/mL (ref 288-736 ng/mL)]. Interestingly, the patient reported skin eruptions on hands, elbows, and upper arms that were associated with episodes of hypoglycemia.  The patient was referred to dermatology and underwent a skin biopsy. Final pathology of the biopsy showed granuloma annulare. The patient had type 2 diabetes prior to undergoing RYGB but denied any prior history of GA. She experienced complete remission of diabetes after RYGB and was on no medications. The GA skin lesions persisted as the patient’s hypoglycemia failed to improve on a diet of decreased refined carbohydrates, smaller more frequent meals and increased protein intake.  After failing acarbose and octreotide, the patient showed clinical improvement of hypoglycemia (i.e. decreased frequency and severity) after diazoxide was started and most of the GA skin lesions also receded. The patient remains on diazoxide and   rarely experiences hypoglycemia but when she does that GA skin lesions recur.   

Conclusion

This is the first reported association between granuloma annulare and post-RYGB hypoglycemia that we are aware of. Eruptions of GA appeared to mirror the clinical course of post-RYGB hypoglycemia which suggests that the underlying mechanism(s) responsible for this condition may also contribute to GA. Since increased insulin and glucagon-like-peptide-1 secretion after meals has been reported in post-RYGB hypoglycemia, it is interesting to speculate on whether these hormones also play a contributory role in GA.

 

Nothing to Disclose: MSD, LAF

16342 11.0000 MON-0925 A Granuloma Annulare Associated with Hypoglycemia after Roux-En-Y Gastric Bypass 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Ebru Selin Selen*1, Zainab Bolendnazar2, Marco Tonelli3, Warren P Porter2 and Fariba Assadi-Porter4
1University of Wisconsin-Madison, MAdison, WI, 2University of Wisconsin- Madison, Madison, WI, 3University of Wisconsin Madison, 4Texas Tech University, Lubbock, TX

 

Polycystic ovary syndrome (PCOS) is a complex metabolic disorder affecting 10-20% of adult women, which is associated with weight gain and insulin resistance. Etiology and onset of PCOS is still unknown, hence it is only diagnosed after puberty and by exclusion criteria. Our recent metabolic studies in PCOS women [1] and in PCOS-like mouse model [2] indicated increased rates of carbohydrate to lipid synthesis and decreased lipid utilization as common metabolic dysfunctions in PCOS. The goal of this study was to examine effects of chronic treatment of PCOS mice with a pharmacological dose of 3-iodotyramine (T1AM), as a possible treatment regime. T1AM is an endogenous thyroid hormone analog that induces lipid oxidation and weight loss [3]. We hypothesized that T1AM reverses lipid dysfunction and normalizes metabolic syndromes in PCOS. We used one-dimensional proton nuclear magnetic resonance (NMR)-metabolomics approach to screen plasma and tissue specific metabolic changes in control PCOS and PCOS mice treated with 25mg/Kg T1AM. We investigated changes in gene expression of associated metabolic pathways by quantitative PCR analysis. Statistical analysis revealed that T1AM treatment results in significant changes in biomarkers associated with lipid metabolism (e.g.: increased lipid oxidation: 3-Hydroxybutyrate (p=0.03), acetone (p=0.03), and reduced lipid synthesis: glycerol (p=0.002)), increased gluconeogenesis (e.g.: glucose (p=0.007), pyruvate (p=0.003)) and increased antioxidant activity (e.g.: glutathione (p=0.008), 2-Hydroxybutyrate (p=0.05)), in a tissue specific manner. Gene expression studies supported metabolic changes in lipid and glucose metabolism. This is the first metabolic treatment regime in PCOS by nutrigenomics study that may open a new avenue for future interventions for PCOS metabolic syndrome in women.

 

Nothing to Disclose: ESS, ZB, MT, WPP, FA

16921 12.0000 MON-0926 A Pharmacological Treatment with 3-Iodotyramine (T1AM) Normalizes Metabolic Syndrome in Polycystic Ovary Syndrome in a Mouse Model 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Joshua Lowndes*, Stephanie Sinnett and James Marshall Rippe
Rippe Lifestyle Institution, Celebration, FL

 

Fructose has long been known to elicit a blunted glycemic response compared to other sugars.  Accordingly, fructose elicits a blunted stimulus from the hormonal pathways involved in energy regulation. While this may explain how pure fructose could promote weight-gain, such studies used experimental models that do not reflect how fructose is typically consumed, either in the type of sugar consumed or the amount, and so should be interpreted with caution.  The purpose of the present study was to examine the effect on glucose and energy regulating hormones of fructose consumed at the 50th percentile level of American consumption (9% of calories) when consumed as part of a mixed nutrient diet either as pure fructose or, as is typically consumed, in combination with glucose (e.g. HFCS or sucrose).

76 weight-stable (weight change <3% in previous 30 days) individuals aged 20-60 years old drank sugar-sweetened low fat milk every day for 10 weeks as part of their usual diet.  The amount of milk consumed was individualized for each participant based on the estimated number of calories required to maintain body weight (Mifflin St Jeor equation) and random group assignment: Groups 1 and 2 – 9% estimated caloric intake from fructose or glucose respectively added to milk.  Groups 3 and 4 – 18% of estimated caloric intake from HFCS or sucrose respectively added to the milk.  Participants stayed in a metabolic ward for 24 hours at the beginning and end of the study during which standardized meals were provided and blood samples obtained at fasting and every 30 minutes thereafter.  AUC for the entire day was calculated using the trapezoidal method. 

AUC for the 24 hour duration for all sweetened milk drinkers was unchanged for glucose (pre 2148 ± 160 vs post 2161 ± 145 hr*mg/dL, p > 0.05) and insulin (pre 555 ± 246 vs post 578 ± 325 hr*µIU/mL, p>0.05).  There was a reduction in active ghrelin (pre 2526 ±1817 vs post 2123 ± 1604 hr*pg/mL, p<0.001) and an increase in leptin (pre 272 ± 238 vs 307 ± post 266 hr*ng/mL, p<0.001).  The type of sugar did not affect any of the observed responses (interaction p>0.05).

These data support the conclusion that chronic consumption of sugar of any form may alter the metabolic pathways that regulate appetite.  The implications of this warrant further investigation.  However, these data also show that when consumed at levels typical of the US diet the source of sugar is not important.

 

Nothing to Disclose: JL, SS, JMR

11161 13.0000 MON-0927 A The Effects of Consumption Levels of Fructose and Fructose Containing Sugars on Circulating Glucose, Insulin, Leptin, and Active Ghrelin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Mikyung Kim*1, Hye Soon Kim2, Nam kyeong Kim3 and Inwook Song4
1Keimyung Univ Dongsan Med Ctr, Daegu, Korea, Republic of (South), 2Keimyung University Dongsan Medical Center, Daegu, Korea, Republic of (South), 3Keimyung University Dongsan Medical Center, Daegy, Korea, Republic of (South), 4Keimyung University DongSan Medical Center, Daegu, Korea, Republic of (South)

 

Dipeptidyl peptidase-4 (DPP-4) is a glycoprotein which inhibits the enzymatic degradation of glucagon-like peptide-1, glucose-dependent insulinotropics polypeptides, neuropeptides and various chemokines. DPP-4 is highly expressed in macrophage and dendritic cells of adipose tissue, and considered to play a role in the accumulation of visceral adipose tissue. Recent reports have shown that serum DPP-4 is correlated with the clinical parameters of obesity, however, this type of study had never been conducted in Korea. Therefore, we investigated the relationship between serum DPP-4 activity and the clinical parameters of obesity in Korean people. Between January and March 2013, visitors who received a routine health examination at the Health Promotion Center in Keimyung University Dongsan Medical Center and agreed to participate in the study were enrolled. We investigated the parameters of obesity and serum DPP-4 using an ELISA kit and analyzed them. Among the total 585 subjects, males accounted for 253 subjects, or 37.3%. The median age was 44.63 ± 10.48 yr, and the median body mass index (BMI) was 23.46 ± 3.11 kg/m2. The BMI displayed a positive correlation with age, body fat rate, visceral fat ratio, blood pressure, total cholesterol, triglyceride, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol, fasting glucose, insulin, HOMA-IR, plasma DPP-4 activity and was statistically significant, but had a negative correlation with HDL cholesterol. Serum DPP-4 activity showed a positive correlation with age, BMI, visceral fat ratio, systolic blood pressure, diastolic blood pressure, total cholesterol, triglyceride, LDL cholesterol, fasting glucose and was statistically significant. To investigate the relationship between serum DPP-4 and obesity, we divided participants into three groups; normal (BMI<23 kg/m2), overweight (23 kg/m2 ≤ BMI < 25 kg/m2) and obesity (BMI > 25 kg/m2) and analyzed the relationship of each. The results showed the level of visceral fat ratio, systolic blood pressure, diastolic blood pressure, total cholesterol, triglyceride, LDL cholesterol, and fasting blood glucose were elevated and statistically significant. Serum DPP-4 activity also increased according to the BMI. In conclusion, this study showed that BMI and serum DPP-4 were significantly correlated, and that serum DPP-4 activity increased when age, blood pressure, total cholesterol, triglyceride, LDL cholesterol and fasting glucose in the participants was higher.

 

Nothing to Disclose: MK, HSK, NKK, IS

13595 14.0000 MON-0928 A Association Between Serum Dipeptidyl Peptidase-4 Activity and Obesity-Related Factor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Daniela P Reyes-Capo*1, Jan D Marshall2, Jürgen K Naggert2, Joy C Bryant1, Melanie D Hicks1, Meera M Kattapuram1, Theo Heller1, Chia-Ying Liu1, Evrim Turkbey1, Jennifer G Myles1, Shanna B Bernstein1, James C Reynolds1, Robert D Shamburek1, William A Gahl1, Meral Gunay-Aygun1 and Joan C Han1
1National Institutes of Health, Bethesda, MD, 2The Jackson Laboratory, Bar Harbor, ME

 

Background: Alström syndrome (AS), a ciliopathy caused by ALMS1 mutations, is associated with cardiomyopathy, hearing loss, retinal dystrophy, and obesity. Our objective was to characterize further the endocrine and metabolic abnormalities associated with AS.

Methods: 24 patients with biallelic ALMS1 mutations were evaluated at the NIH Clinical Research Center with fasting venous blood draws, mixed-meal tolerance tests, dual-energy X-ray absorptiometry, MRI/MR spectroscopy, and indirect calorimetry. For metabolic studies, patients with AS were matched 1:2 with 48 control subjects by age (mean ± SD, AS vs. controls: 16.2 ± 10.8 vs. 15.2 ± 9.0 yr, p=0.70), sex (% male: 46% vs. 48%, p=0.87), race (% African American: 13% vs. 23%, p=0.46), BMI (28.5 ± 10.0 vs. 27.9 ± 7.5 kg/m2, p=0.80), and BMI-Z (1.90 ± 1.03 vs. 1.77 ± 1.06, p=0.61). Groups were compared using T or U tests, Fisher’s exact or chi-square tests, and ANCOVAs (adjusting for age, sex, race, and body composition).

Results: In the AS group, endocrine abnormalities included obesity (71%), type 2 diabetes (42%), hypothyroidism (26%), short stature (17%), hypogo­­­­­­­nadism (13%), and adrenal insufficiency (4%). Abnormalities in males with AS included microphallus (55%), undescended testes (18%), hypospadias (9%), small testes in adulthood (100%), and low testosterone in adulthood (29%). Post-pubertal females with AS frequently had oligomenorrhea (70%) and hyperandrogenism (50%). AS patients and controls were similar for total percentage body fat (p=0.47), abdominal visceral/subcutaneous fat ratio (p=0.94), basal metabolic rate (p=0.70), systolic BP-Z (p=0.34), diastolic BP-Z (p=0.30), and waist circumference-Z (p=0.91). However, AS had lower HDL (adjusted mean [95%CI], AS vs. controls: 32 [27-37] vs. 44 [40-49], p=0.001), and higher rate of metabolic syndrome (58 [37-78] vs. 5 [1-17]%, p<0.001), liver fat percentage (11 [8-14] vs. 6 [4-8], p=0.01), serum alanine aminotransferase (45 [37-54] vs. 29 [25-33] U/L, p<0.001), respiratory quotient (0.93 [0.89-0.96] vs. 0.86 [0.81-0.91], p=0.02), triglycerides (175 [130-235] vs. 83 [67-102], p<0.001), HOMA-IR (6.5 [4.1-10.2] vs. 1.8 [1.3-2.4], p<0.001), and mixed meal glucose AUC (p=0.003) and insulin AUC (p<0.001).

Conclusions: Endocrine abnormalities are frequent in AS, and metabolic complications are higher than expected for degree of adiposity, which may be attributable, in part, to the higher frequency of fatty liver disease in AS.

 

Nothing to Disclose: DPR, JDM, JKN, JCB, MDH, MMK, TH, CYL, ET, JGM, SBB, JCR, RDS, WAG, MG, JCH

14746 15.0000 MON-0929 A Endocrine and Metabolic Characterization of Alström Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

George William Moll Jr.*
University of Mississippi Medical Center, Jackson, MS

 

Background:  An obesity epidemic originating in childhood remains a National health concern. The 2007-2008 National Health and Nutrition Survey (NHANES) estimated 16.9% of children 2-19 years of age to be obese by Body Mass Index (BMI) criteria. Center for Disease Control (CDC) recognized overweight children more likely to become severely obese adults with corresponding health and economic burdens. Comparing weight control programs among States is made difficult by the diversity of adolescent populations, but uniformity of 9th through 12th grade Public High School (PHS) adolescent male football players makes this sport useful for comparisons concerning weight control.

Objective:  National Health Statistics averaged over 2007-2009 identified a leanest State at 19.1% obese and a fattest State at 33.8% obese. We hypothesized participants in organized PHS football programs in these respective States would not reflect such a BMI gap but have statistically similar BMI overall and at comparable football player positions.

Design/Methods:  PHS vital statistics with many PHS football program team rosters displaying individual football player positions played, height and weight are available for free public access on the internet. We selected four PHS with similar vital statistics for each of the leanest and fattest State Capital areas. Individual player’s BMI’s were calculated and averaged +/- SD for Leanest (LS) and Fattest (FS) States and compared overall and for several football player positions (Quarterback (Q), Backfield (B), Line (L)).

Results:  LS PHS had 705 +/- 51(SD) males of whom 5.7 +/- 0.5(SD) % participated in organized football. FS PHS had 580 +/- 111(SD) males of whom 14.2 +/- 3.8% participated in organized football. Insignificant mean differences were noted for Overall, Q, B, L comparisons:

LS Overall BMI 26.6 +/- 5.3(SD)    vs     FS Overall BMI 26.8 +/- 5.6(SD)

LS         Q BMI 24.5 +/- 2.4           vs     FS        Q BMI  23.9 +/- 2.4

LS          B BMI 23.7 +/- 4.0          vs     FS         B BMI  24.0 +/- 3.1

LS          L BMI 29.9 +/- 4.7           vs     FS         L BMI  31.6 +/- 5.7

               Within LS & FS mean differences were significant (p<0.01) for Q or B vs L:

LS         Q BMI 24.5 +/- 2.4 (SD)    vs     LS         B BMI 23.7 +/- 4.0 (SD)

LS         Q BMI 24.5 +/- 2.4            vs     LS         L BMI 29.9 +/- 4.7  *

LS         B BMI 23.7 +/- 4.0             vs     LS         L BMI 29.9 +/- 4.7   *

FS         Q BMI 23.9 +/- 2.4 (SD)     vs     FS         B BMI 24.0 +/- 3.1 (SD)

FS         Q BMI 24.5 +/- 2.4             vs     FS         L BMI 31.6 +/- 5.7   *

FS          B BMI 24.0 +/- 3.1            vs     FS         L BMI  31.6 +/- 5.7   *

Conclusions:  Participants in PHS football whether in lean or fat States have similar BMI that may appear overweight due to athelete muscle over fat weight for height (kg/M^2). Mean BMI’s for Overall and specific player positions were not significantly different though Line player BMI’s trend upward as might be anticipated for the tasks required of them. Mean BMI’s were significantly higher (*p<0.01) for L players when compared with those of Q & B players. Our results favor organized sports with attention to safety first rotation of player positions to achieve healthy adolescent weight control.

 

Nothing to Disclose: GWM Jr.

16476 16.0000 MON-0930 A Body Mass Index (BMI)'s of Public High School Football Players Are Similar in Lean and Fat States 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Moahad Saeed Dar*1, Jennie Luna2, Almond Jerkins Drake III3, John R Pender1 and William Chapman1
1Brody School of Medicine, Greenville, NC, 2Brody School of Medicine, East Carolina University, Greenville, NC, 3ECU Brody School of Medicine, Greenville, NC

 

Background

The obesity epidemic is associated with co-morbid conditions like type 2 diabetes, hypertension and sleep apnea. Diet and medications are tried by many but rarely sustain weight loss. Patients are increasingly turning to more extreme measures like bariatric surgery. Roux-en-Y gastric bypass (RYGB) is a commonly performed bariatric procedures and has demonstrated decreased mortality, effective weight loss and disease remission.1 These desirable outcomes are tempered by post-surgical complications. Hypoglycemia is 2.7 times more likely to occur after RYGB and develops ~6 months or more post-RYGB.2Current dietary and medical therapies are not uniformly effective. Diazoxide has been described in some case reports to improve hypoglycemia but its long-term effectiveness and safety are not known. We report our long-term experience with diazoxide in 2 patients with persistent post-RYGB hypoglycemia.

Clinical cases

Two Caucasian females (mean age 52 ±4.2 yr, mean BMI 28.5 ±.7 kg/m2) presented to the ECU endocrine clinic with complaints of post-prandial hypoglycemia which developed 9-72 months post-RYGB.  Hypoglycemia was defined as a value < 60 mg/dl on two separate occasions using a glucometer based on the glucose oxidase method.  None of the patients reported hypoglycemia prior to RYGB nor were they on medications after RYGB. After initial consultation, patients were referred to a registered dietician and counseled on a diet of decreased refined carbohydrates, small frequent meals and increased protein consumption. Patients were re-evaluated after 6 weeks and reported no improvement in frequency and/or severity of hypoglycemia. The patients were subsequently started on diazoxide. Prior to diazoxide treatment, the mean number of hypoglycemic episodes per month was 8.5± 2.1.  After diazoxide treatment, mean number of hypoglycemic episodes per month decreased to 1±1.4. Doses ranged from 25 mg to 100 mg per day.  Length of diazoxide use ranged from 4-15 months. During diazoxide treatment, A1C increased modestly (0.5 % ± 0.28) and mild peripheral edema developed in one patient but did not require diuretics. Liver function studies remained stable during diazoxide treatment.

Conclusion

Post-RYGB hypoglycemia is rare but providers will likely see more patients with this complication due to increased number of RYGB procedures being performed to treat the obesity epidemic. We found diazoxide to be safe and effective in decreasing the severity and frequency of hypoglycemia in patients refractory to dietary interventions. Patients strongly preferred to continue therapy because they felt an improvement in their overall quality of life. Although monitoring of glycemic status (A1C), liver function (CMP) and fluid status (peripheral edema) is necessary, diazoxide should be considered in patients with moderate to severe post-RYGB hypoglycemia who have failed dietary interventions.

 

Nothing to Disclose: MSD, JL, AJD III, JRP, WC

14290 17.0000 MON-0931 A Hypoglycemia after Roux-En-Y Gastric Bypass: Is Diazoxide a Safe and Effective Long-Term Treatment? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Matthew T Flowers*, Nicholas A Sanek and Jon E Levine
University of Wisconsin-Madison, Madison, WI

 

It is well established that estrogen (17-β-estradiol; E2) signaling through estrogen receptor alpha (Esr1; ERα) is critical for energy homeostasis, the prevention of metabolic disease and proper neuroendocrine control of the reproductive axis. In addition to its classical role in the nucleus of mediating transcription by directly binding to estrogen response elements (EREs) in the DNA of target genes, ERα also has both non-classical genotropic (independent of ERE) and non-classical, non-genotropic cellular roles (i.e. rapid membrane signaling). We have previously reported that in C57BL/6 mice expressing a knock-in mutation of ERα that abolishes classical ERα signaling but retains non-classical ERα signaling (E207A/G208A; Esr1-/AA; NERKI), the obesity and metabolic dysfunction observed in Esr1-/- mice (ERαKO) are normalized (1). These previous body weight and metabolic observations in NERKI mice were made in mice bred and maintained on soy- and alfalfa-containing diets. Plant-derived phytoestrogens from soy and alfalfa meal have been shown to increase energy expenditure, decrease adiposity and improve various facets of lipid and glucose metabolism in rodents. However, the cellular receptor(s), signaling mechanisms, and tissue-specific effects that mediate the metabolic actions of phytoestrogens have yet to be determined. In this study, we report that NERKI mice bred and maintained lifelong on a soy- and alfalfa-free diet (2019 Teklad; Harlan Laboratories) do not exhibit a lean phenotype, as previously reported; both NERKI and ERαKO mice on the low-phytoestrogen 2019 diet become obese and glucose intolerant relative to controls. Exposure of offspring to the low-phytoestrogen 2019 diet only during gestation and lactation, but subsequently switching to a high-phytoestrogen diet (7912 Teklad; Harlan Laboratories) at weaning, also results in obesity and glucose intolerance in both NERKI and ERαKO mice. However, we find that the lean NERKI phenotype is completely restored in offspring fed the high-phytoestrogen 7912 diet lifelong and born from parents re-introduced to the 7912 diet pre-pubertally, and partially restored if parents commenced 7912 feeding as older adults. These data suggest that the non-classical actions of ERα on energy metabolism depend on maternal exposure to dietary phytoestrogens.

 

Nothing to Disclose: MTF, NAS, JEL

15289 18.0000 MON-0932 A Maternal Phytoestrogen Consumption Programs Body Weight Regulation By Non-Classical Estrogen Receptor Alpha Signaling in Female Offspring 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Oren Hershkovitz*, Ahuva Bar Ilan, Lital Israeli-Yagev, Dina Raichlin, Vered Lev, Eyal Fima and Gili Hart
Prolor Biotech, Nes Ziona, Israel

 

Prolor Biotech is developing long acting oxyntomodulin (OXM; dual GLP-1/Glucagon agonist), utilizing reversible PEGylation technology for treatment of type 2 diabetes and obesity. The technology enables a slow release of the intact OXM, enabling a prolonged exposure of the peptide.  The PEG moiety is linked via spacer to the N-terminus of OXM generating a reversible PEGylated OXM (MOD-6031).

The objectives were to characterize the hydrolysis rate and in vitro binding of MOD-6031, to verify the protection of MOD-6031 from DPPIV cleavage and to assess the involvement of OXM as mediator in glucose-dependent insulin secretion.

The hydrolysis rate of MOD-6031 in different matrices and conditions was assessed using LC-MS/MS based method. MOD-6031 in vitro binding was characterized by measuring the binding affinity of MOD-6031 to GLP-1 receptor (GLP-1) and glucagon receptor (GCGR) using two stably transfected cell-lines highly expressing these receptors. Upon ligand binding the cells secreted cAMP at a dose dependent manner, EC50 values were calculated and compared to the in vitro binding of other incretins.  The protection from DPPIV cleavage was evaluated by HPLC analysis following incubation of MOD-6031with DPPIV enzyme. Finally, the ability of OXM to induce glucose-dependent insulin secretion was evaluated using primary perifused pancreatic rat islets cells at different glucose and OXM concentrations.

MOD-6031 had shown comparable hydrolysis rates in different matrices and 10 fold reduction of binding affinities compared to OXM in both cell-lines, while following hydrolysis the OXM shown full binding affinity restored. Following incubation of MOD-6031 with DPPIV, the conjugated OXM was not cleaved, suggesting that PEG conjugation gives high protection from DPPIV digestion while circulating intact. OXM was shown to induce glucose dependent insulin secretion at a dose dependent manner.

 

Nothing to Disclose: OH, AB, LI, DR, VL, EF, GH

14357 19.0000 MON-0933 A A Novel Reversible Pegylation Dual GLP-1/Glucagon Agonist ( MOD-6031) -Comprehensive in Vitro Characterization 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Mohammed AlQambar*1, Wadei Elhakimi1, Mohammed Elsammak1, Abdulaziz Alwosaibi1, Osama Alsaif1, Jamal Alsaeed2 and Hisham Musleh1
1King Fahad Specialist Hospital, Dammam, Saudi Arabia, 2King Fahad Specialist Hospital, Saudi Arabia

 

Introduction: Hypoglycemia is a known complication of bariatric surgery and it is attributed to several mechanisms one of them is islet cell hyperplasia (1). To our knowledge there are just few reported cases in the literature of confirmed insulinoma discovered after bariatric surgery (2).

Clinical case:  A 42 year old man morbidly obese underwent biliopancreatic diversion, four months later and after losing twenty kilograms of his weight he started to have repeated episodes of sever hypoglycemia almost always induced by fasting with confirmed low blood sugar level as low as 1.6 mmol/liter with history of loss of consciousness several times in two months period. Two weeks before he undergoes the ultimate management his hypoglycemia was persistent and he needed to be admitted and kept on contentious intravenous infusion of D10 % to maintain his blood sugar just above 4 mmol/liter. His physical examination was unremarkable apart from obesity with BMI of 51 kg/m2. His laboratory workup after stopping intravenous dextrose for five minutes was consistent with endogenous insulin induced hypoglycemia :  blood sugar 2mmol/liter (n 3.9-6.1), insulin 157 pmol/liter (n 43-193), C-Peptide 2521 pm/liter (n 260-1390), proinsulin 1100 pmol/liter (n 3-20), screening for serum sulfonylurea and meglitinides were negative. The rest of

his blood works include: Am cortisol 282 nmol/liter (n 138-635), kidney and liver functions were normal. CT scan of abdomen showed 2x1.6 cm tumor at the body of the pancreas which was resected laproscopically and patient blood sugar normalized within minutes intra-operatively. The Histopathology examination confirmed that the mass was insulinoma. The patient remains free of symptoms after one year of follow up.        

Conclusion:  We report a very rare case of insulinoma that was unmasked by biliopancreatic diversion and we believe such an etiology should be considered in workup of post bariatric hypoglycemia.

 

Nothing to Disclose: MA, WE, ME, AA, OA, JA, HM

12768 20.0000 MON-0934 A Insulinoma Unmasked By Bariatric Surgery 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Ediz Yesilkaya*1, Ömer Günes2, Erkan Sari3, Ahmet Tas2, Muhittin Serdar2, Turker Turker4, Emre Tascilar2, Oguzhan Babacan3, Mehmet Saldir3, Abdulbaki Karaoglu2 and Okan Ozcan2
1Gülhane Military Medical Academy, ANKARA, Turkey, 2GATA, 3Gulhane Military Medical Academy, 4Gulhane Military Medical Academy School of Medicine, Ankara, Turkey

 

Childhood obesity is an increasing public health problem in our country as well as developed and developing countries. The insulin resistance, which is at the center of the metabolic complications of obesity, has come to be observed in children and adolescents. Genetic and environmental factors play an important role in childhood obesity. Excessive calorie and fat intake due to unhealthy eating are the leading environmental factors so they should be documented by eating habit records and measurement of erythrocyte membrane fatty acid level. In this study it was aimed to document the food consumption and investigate the relationship between erythrocyte membrane fatty acid levels and insulin resistance. The study was planned as a cross-sectional and case-control study. Ninety five obese adolescents between 8-18 years old, and 40 healthy adolescents with similar age and gender were included in the study. Study and control groups were compared according to demographic features, anthropometrical measurements, biochemical parameters and erythrocyte membrane fatty acid levels. Duration of breastfeeding and the timing of transition to complementary nutrition were shorter in the study group than control group. The BMI levels of parents in the study group were higher. In the obese group monthly income and the time spent on TV and computer was significantly higher among obese group. The anthropometrical measurements of BMI standard deviation, waist and hip circumference, waist/hip ratio, body fat ratio and metabolic syndrome components of LDL cholesterol, fasting insulin levels, HOMA-IR, systolic and diastolic blood pressure levels were higher and HDL levels were lower in obese group than the control group. Eating record parameters were not different between obese and control groups. Among the SFA group fatty acids, the levels of PDA, AiA, LSA and PAO levels in MUFA fatty acid group were higher, EPA levels in ω-3 fatty acid group were lower in obese group than control group. PDA and POA levels were higher and EPA levels were lower in the obese group with insulin and resistance than control group. Finally new methods should be improved to measure fat intake in adolescents and SFA group fatty acid intake should be decreased because of its role in the development of obesity and insulin resistance and ω-3 group fatty acid intake should be increased. Large-scale studies about the effect of erythrocyte membrane fat acid on obesity and insulin resistance in obese adolescent patients are needed.

 

Nothing to Disclose: EY, ÖG, ES, AT, MS, TT, ET, OB, MS, AK, OO

11958 21.0000 MON-0935 A Investigation of Relation Between Nutrition and Insulin Resistance with Erythrocyte Membrane Fatty Acid Levels in Obese Adolescents 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Gbadebo O.D. Ajani*1, Rosemary T Ikem2, Babatope A Kolawole2, Michael Olawale Ajala3 and Atinuke Arinola Ajani2
1Federal Medical Centre, Ido Ekiti, Ekiti State, Nigeria, 2Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria, 3General Hospital, Lagos, Nigeria

 

Obesity is associated with high circulating levels of leptin, a hormone that inhibits energy intake, increases energy expenditure and also regulates glucose metabolism. Since obesity is a significant risk factor for type 2 diabetes mellitus (T2DM) therefore, leptin may be a link between obesity and T2DM . We determined and compared the levels of serum leptin in obese and non-obese females with T2DM with levels in obese non diabetic females in a cross sectional hospital based study involving 60 obese T2DM females, 60 non-obese T2DM females and 60 obese non-diabetic female adults at OAUTHC in Ile-Ife, Nigeria. Anthropometric parameters were measured and fasting venous blood samples were used for determination of plasma glucose, serum leptin, HbA1C and HOMA-IR. Serum leptin levels in Obese T2DM , Obese non-diabetic and Non-obese T2DM subjects were (20.61 ± 15), (20.94 ± 17.64) and (7.59 ± 3.39) ng/ml respectively with a significantly higher levels among the obese subjects than Non-obese T2DM subjects (p= 0.0001). There was no significant difference in serum leptin levels in Obese T2DM and Obese non-diabetic females (p = 0.999). However,serum leptin levels in obese diabetic subjects with good glycaemic control (25.81 ± 21.00 ng/ml) were found to be higher than the serum leptin levels ( 16.90 ± 7.26 ng/ml) in those with poor glycaemic control (p = 0.051). In conclusion, serum leptin levels were similar in obese diabetic and Obese non-diabetic female Nigerian but they were significantly higher than the levels in non-obese subjects. The higher serum leptin levels seen in obese subjects with controlled diabetes may suggest that leptin has a therapeutic role to play in glycaemic control of obese diabetic subjects.

 

Nothing to Disclose: GODA, RTI, BAK, MOA, AAA

16662 22.0000 MON-0936 A Role of Leptin in Obese Type 2 Diabetic Female Nigerians 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Monday, June 23rd 3:00:00 PM MON 0915-0936 4846 1:00:00 PM Obesity: Basic Biology to Clinical Cases Poster

Adam Stevens1, Jerome Wojcik2, John Raelson3, Maria Slootweg4, Pierre Chatelain5 and Peter Clayton*6
1University of Manchester and Royal Manchester Children’s Hospital, Manchester, United Kingdom, 2Quartz Bio, Geneva, Switzerland, 3PGx Services, Montreal, Canada, 4Merck Serono, Darmstadt, Germany, 5Université Claude Bernard, Lyon, France, 6Royal Manchester Children's Hospital, Manchester, United Kingdom

 

Background: Genetic markers associated with the response to r-hGH treatment have been identified in GH-naïve, pre-pubertal children with GHD in the PREDICT Long-Term Follow-Up (LTFU) prospective study (NCT00699855) (1). A validation (VAL) study (NCT01419249) was conducted to confirm association of these markers in an independent study group.

Patients and Methods:  Inclusion and exclusion criteria for children with GHD (including peak GH <10 µg/L, pre-pubertal at start of r-hGH treatment) were identical in the LTFU and VAL studies. Children in the VAL study had already completed 1 r-hGH treatment year. Twenty-two single nucleotide polymorphisms (SNPs) previously associated with GHD were tested with the study powered to validate at least one marker. A total of 318 patients with GHD were recruited from 29 sites in 9 countries; 293 were included in the full analysis set. SNPs identified as associated with growth response in the LTFU study were genotyped in the VAL cohort. For both studies, growth response (either centimetres grown [cm], or change in height [Ht] standard deviation score [SDS] or Ht velocity SDS, over 1 year of treatment with r-hGH) was used as the dependent variable in a regression analysis for each SNP, with gender, age, GH peak during provocative test, GH dose (1st year average daily dose by body weight), distance to target Ht SDS, and mid-parental Ht SDS as covariates. The models with the best interaction term p-value (p<0.05) were selected.

Results: There were no differences in gender distribution and SNP allele frequencies between LTFU and VAL, but age, distance to target Ht SDS and GH dose were lowest (p<1.7x10-8), and GH peak, mid-parental Ht SDS (both p<6x10-5) and 1st year growth responses highest, in VAL. No genetic associations were replicated in a direct analysis of growth response versus genotype. However, using regression modelling to control for differences between the studies and to investigate for interactions with covariates, we found SOS1 (rs2888586) associated with change in Ht SDS in an interaction with GH peak as covariate (p=0.0036 VAL; p=0.0009 LTFU), and INNPL1 (rs2276048) associated with growth in cm in an interaction with distance to target Ht (p=0.0057 VAL; p=0.0144 LTFU).

Conclusions: The PREDICT VAL study confirmed in an independent cohort the association of genetic markers with growth response to r-hGH treatment in pre-pubertal children with GHD, when controlling for covariates.

 

Disclosure: AS: Speaker, Merck Serono. JW: Consultant, Merck Serono. JR: Consultant, Merck Serono. MS: Employee, Merck Serono. PC: Investigator, Merck Serono, Consultant, Merck Serono, Speaker, Merck Serono. PC: Coinvestigator, Merck Serono (PREDICT programme), Investigator, Merck Serono, Speaker, Merck Serono.

12161 1.0000 MON-0156 A Genetic Markers of Response to Recombinant Human Growth Hormone (r-hGH) in Children with Growth Hormone Deficiency (GHD): Results from the Predict Validation Study, on Behalf of the Study Team 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Adam Stevens*1, Jerome Wojcik2, John Raelson3, Maria Slootweg4, Pierre Chatelain5 and Peter Clayton6
1University of Manchester and Royal Manchester Children’s Hospital, Manchester, United Kingdom, 2Quartz Bio, Geneva, Switzerland, 3PGx Services, Montreal, Canada, 4Merck Serono, Darmstadt, Germany, 5Université Claude Bernard, Lyon, France, 6Royal Manchester Children's Hospital, Manchester, United Kingdom

 

Background: Genetic markers associated with the response to r-hGH treatment have been identified in GH-naïve, pre-pubertal children with TS in the PREDICT Long-Term Follow-Up (LTFU) prospective study (NCT00699855) (1). A validation (VAL) study (NCT01419249) was conducted to confirm the association of these markers in an independent study group.

Patients and Methods:  Inclusion and exclusion criteria for children with TS (pre-pubertal at start of r-hGH treatment) were identical in the LTFU and VAL studies. Children in the VAL study had already completed one r-hGH treatment year (i.e. retrospective). Twenty-six single nucleotide polymorphisms (SNPs) previously associated with TS were tested and the study was powered to validate at least one marker. A total of 140 TS patients were recruited from 29 sites in 9 countries; 132 were included in the full analysis set. SNPs identified as associated with growth response in the LTFU study were genotyped in the VAL cohort. For both studies, growth response (either centimetres grown, or change in height [Ht] standard deviation score [SDS] or Ht velocity SDS, over 1 year of treatment with r-hGH) was used as the dependent variable in a regression analysis for each SNP, with age, GH dose (1st year average daily dose by body weight), distance to target Ht SDS, and mid-parental Ht SDS as covariates. For each SNP the model with the best interaction term p-value (p<0.05) was selected.

Results: There were no differences in SNP allele frequencies between LTFU and VAL, but age, distance to target Ht SDS and GH dose were lowest (p<1.2x10-5), and mid-parental Ht SDS (p<2.1x10-8) and 1st year growth response highest, in VAL. No genetic associations were replicated in a direct analysis of growth response versus genotype. However, using regression modelling to control for differences between the studies and to investigate for interactions with covariates, we found ESR1 SNP rs2347867 associated with Ht velocity SDS in both VAL (p=0.0304) and LTFU (p=4.3x10-5), and PTPN1 (rs2038526) associated with change in Ht SDS in an interaction with mid-parental Ht SDS (p=0.0113 VAL; p=0.0055 LTFU).

Conclusions: The PREDICT VAL study confirmed in an independent cohort the association of genetic markers with growth response to r-hGH treatment in pre-pubertal children with TS, when controlling for covariates.

 

Disclosure: AS: Speaker, Merck Serono. JW: Consultant, Merck Serono. JR: Consultant, Merck Serono. MS: Employee, Merck Serono. PC: Investigator, Merck Serono, Consultant, Merck Serono, Speaker, Merck Serono. PC: Coinvestigator, Merck Serono (PREDICT programme), Investigator, Merck Serono, Speaker, Merck Serono.

12162 2.0000 MON-0157 A Genetic Markers of Response to Recombinant Human Growth Hormone (r-hGH) in Children with Turner Syndrome (TS): Results from the Predict Validation Study, on Behalf of the Study Team 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Adam Stevens*1, Chris Knight2, Chiara De Leonibus3, Neil Swainston4, Philip Murray2 and Peter Clayton5
1University of Manchester, Manchester, United Kingdom, 2University of Manchester, 3Manchester Academic Health Sciences Centre, Royal Manchester Children's Hospital, Manchester, United Kingdom, 4Manchester Institute of Biotechnology, 5Royal Manchester Childrns Hosp, Manchester, United Kingdom

 

Background: Evolutionarily conserved networks of genes are associated with the phases of childhood growth in multiple tissues1, implying the existence of an underlying genetic program of transcriptional regulation. Previous investigation of this phenomenon utilised statistical interpretation based on age group, we now use an unsupervised approach to assess patterns of gene expression over childhood.

Samples and Methods:  We conducted gene expression (GE) analysis on cells of lymphoid origin using a dataset from normal children and young adults with age annotation (n=87, 43 males and 44 females, average 7.7 years of age (yrs), range 0.2 to 29 yrs1). Firstly we applied multidimensional scaling (MDS) visualised with Isomap2 (Qlucore Omics Explorer 3.0) using all gene probe sets [GP-sets] (n=44592) to define groups based on their pattern of GE. Those genes whose expression was significantly different between the groups were identified by ANOVA with a false discovery rate modified p-value of q<0.001, and then organised into hierarchical clusters. Causal networks associated with GE profiles were identified algorithmically (Ingenuity Pathway Analysis).

Results: Five groups of gene expression profiles were identified in both sexes. The average age of each group (yrs) was different, between 5.0 and 12.1yrs in males and 3.7 and 11.3yrs in females. 487 GP-sets were different between the groups in males and 3302 in females with 145 of these represented in both sexes. Hierarchical clustering showed two underlying oscillations of gene expression the first with peaks at 5.0, 7.2 & 12.1yrs (99 GP-sets) and the second with peaks at 5.6, 10.2yrs (388 GP-sets) in males; similar oscillations were seen in females with peaks at 5.0, 7.0 & 11.3yrs (1221 GP-sets) and 3.7 & 7.0yrs (2081 GP-sets). Causal network analysis on these oscillation-related GE profiles in both sexes implicated epigenetic control of gene transcription (p<4.9x10-3), metabolic process (p<1.3x10-3) and cell growth (p<1.7x10-4) as key functions. The overlap in GE between the sexes was associated with growth (p<1.3x10-5) causally linked to growth hormone (GH) and IGF-I action.

Conclusions: We have identified specific sets of genes whose expression oscillates through childhood to adulthood. The overall function of these genes are similar between the sexes and implicates not only cell growth and the GH-IGF-I axis but also epigenetic and metabolic functions.

 

Nothing to Disclose: AS, CK, CD, NS, PM, PC

14468 3.0000 MON-0158 A Oscillations in Gene Expression Occur in Both Sexes Across Childhood Related to Epigenetic, Metabolic and Growth Functions 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Paula A. Scaglia1, Lucia Martucci2, Liliana Karabatas2, Ana C. Keselman1, Angela Maria Spinola-Castro3, Débora Braslavsky1, María Gabriela Ballerini1, María Gabriela Ropelato1, Alicia S. Martínez2, Sonia V. Bengolea4, Viviana Pipman5, Sabina Domené2, Ignacio Bergadá1, Rodolfo Alberto Rey6, Horacio M. Domene2 and Héctor G. Jasper*2
1Hospital de Niños Dr. Ricardo Gutiérrez, Buenos Aires, Argentina, 2Hospital de Niños "Ricardo Gutiérrez", Buenos Aires, Argentina, 3Universidad Federal de Sao Paulo, Sao Paulo, Brazil, 4Hospital Fernández, Buenos Aires, Argentina, 5Hospital Tornú, Buenos Aires, Argentina, 6Hospital de Niños, Buenos Aires, Argentina

 

Background: First degree relatives of complete ALS deficient patients (ALS-D), heterozygous carriers (HC) for IGFALS mutations present height 1.0 SD lower than wild type (WT) relatives (1), associated with IGF-I, IGFBP-3 and ALS levels intermediate between ALS-D (2 alleles affected) and WT relatives. In addition, children with idiopathic short stature (ISS) HC carriers for IGFALS mutations present reduced levels of IGF-I, IGFBP-3 and ALS (2). These findings are suggestive of a gene-dosage effect of IGFALS mutations on both height and components of the circulating IGF system.

Aim: To test whether there is a gene-dosage effect by exploring the impact of IGFALS mutations on height and the IGF system within families of ALS-D patients.

Subjects and Methods: We recruited 9 ALS-D (ages 2.8 to 19.6 years), 18 HC (8 siblings and 10 parents; 5.2 to 48.0 years) and 8 WT relatives (6 siblings and 2 parents; 4.4 to 42.0 years). IGF-I and IGFBP-3 serum levels were determined by CLIA, and ALS by ELISA. IGFBPs were evaluated by Western ligand-blot (WLB). All subjects were genotyped for the IGFALS gene by sequencing PCR amplified fragments. SDS for IGF-I, IGFBP-3 and ALS serum levels in children were calculated from local age-matched control groups (3).  Wilcoxon signed rank and Kruskal-Wallis tests were used for statistical analysis.

Results: When compared to the normal population, median SDS for height and levels of IGF-I, IGFBP-3 and ALS were significantly lower for both ALS-D and HC, while WT relatives did not differ from normal, as evaluated by Wilcoxon signed rank test. Results are expressed as median SDS (interquartile range), p-value. Height: ALS-D -1.91 (-2.59 to -1.46), p=0.0020, HC -0.80 (-1.51 to 0.11), p=0.0161, WT 0.08 (-0.53 to 0.87), p=0.2734. IGF-I: ALS-D -5.68 (-7.00 to –5.46), p=0.0020, HC -0.55 (-0.92 to -0.19), p=0.0013, WT 0.08 (-0.41 to 0.35), p=0.4727. IGFBP-3: ALS-D -7.00 (all -7.00 except one -5.30), p=0.0020, HC -1.84 (-2.09 to -1.30), p=0.0002, WT -0.62 (-1.33 to 0.99), p=0.3711. ALS: ALS-D -7.00 (all -7.00 except one -3.57), p=0.0020, HC -2.16 (-2.96 to -1.80), p=0.0001, WT 0.64 (-0.47 to 1.16), p=0.2305. Kruskal-Wallis analysis showed significant differences among the 3 groups (p=0.0011 for height, p<0.0001 for IGF-I, IGFBP-3 and ALS levels). In ALS-D patients, all parameters were significantly lower than WT (p<0.001) and HC (height p<0.05, IGF-I and IGFBP-3 p<0.001, ALS p<0.01) but in HC only ALS levels were significantly lower than WT relatives (p<0.05). WLB results showed a generalized reduction of all IGFBPs in ALS-D patients and variable levels of IGFBPs in HC children.

Conclusions: A significant gene dosage-effect was observed for ALS levels among ALS-D, HC and WT subjects, while the effect on height and IGF-I and IGFBP-3 levels was less evident.

 

Nothing to Disclose: PAS, LM, LK, ACK, AMS, DB, MGB, MGR, ASM, SVB, VP, SD, IB, RAR, HMD, HGJ

12165 4.0000 MON-0159 A Gene-Dosage Effect of Igfals Gene Mutations on the IGF System 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Alejandro Martínez-Aguayo*1, Alejandra Vera2, Helena Poggi3, Carolina Avalos4, Cecilia Mellado5, Mariana Aracena5 and Marcela Lagos3
1Pontificia Universidad Catolica de Chile, Santiago, Chile, 2Pontificia Universidad Catolica de Chile, 3Pontificia Universidad Católica de Chile, Santiago de Chile, Chile, 4Pontificia Universidad Católica de Chile, Santiago, Chile, 5Pontificia Universidad Catolica de Chile, Santiago de Chile, Chile

 

Background: Heterozygous SHOX (short stature homeobox-containing gene) defects are present in ~ 60% of patients with Léri-Weill dyschondrosteosis (LWD), and are also the main monogenic cause of short stature (2-5%) presenting with highly variable clinical severity. Most of them are deletions, encompassing the gene, and upstream and downstream sequences. Point mutations are also found but less frequently.

Research question: What type of SHOX gene mutations can be found in Chilean patients?

Setting: School of Medicine, Pontificia Universidad Catolica de Chile (2010-2013).

Design: Cross-sectional study.

Methods: Twenty three unrelated patients presenting SHOX gene defects were included in the study. They had either point mutations detected by sequencing of the entire coding region, or deletions as analyzed by MLPA (P018-F1 probemix), which includes probes covering the SHOX gene, upstream regions and downstream regulatory elements from the pseudoautosomal region 1 of both sex chromosomes.

Results: All, but one patient with Langer mesomelic dysplasia (LMD), presented mesomelic short stature with various radiological findings consistent with LWD and suggestive of SHOX deficiency. Of the 23 patients, 3 had point mutations and 21 deletions. In 8 patients, a deletion of more than 800 kb was found, spanning from PPP2R3B gene upstream the SHOX promoter and 12 of 13 SHOX downstream regulatory areas as covered by the probes used. Likewise, another 5 patients had a deletion of over 350 kb which extended from the promoter region down to SHOX gene intron 6. The remaining 8 patients had individual deletions ranging from 77 kb to more than 2,000 kb. The patient with LMD presented a deletion and a novel point mutation.

Conclusion: Deletions were the most frequent genetic defects. Regardless of the extent of the deletion, LWD was observed in all patients, thus deletion size seems to have little or no effect on the phenotype. Two deletions are responsible for more than half of the mutations found in Chilean patients with LWD; none of them have been reported previously as frequent in any other population, therefore these observed frequencies could be either the result of a founder effect, or be endogenous to our population, which is predominantly the result of an unequal admixture between Amerindians of Asian origin, and Caucasian Europeans. In order to determine whether they share a common origin, breakpoint and haplotype analysis should be performed.

 

Nothing to Disclose: AM, AV, HP, CA, CM, MA, ML

15403 5.0000 MON-0160 A Two Types of Deletions Are Responsible for the Majority of Shox Gene Defects in Chilean Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Renata C Scalco*1, Mariana F A Funari2, Rosana Midori Aracava3, Carlos André Tonelli4 and Alexander Augusto Lima Jorge5
1Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo - SP, Brazil, 2Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo - SP, Brazil, 3Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 4Faculdade de Medicina da Universidade do Extremo Sul de Santa Catarina (UNESC), Criciuma, Brazil, 5Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil

 

Background: STAT5b is a protein involved in the signaling pathway of GH and interleukins. Homozygous inactivating mutations in STAT5B gene cause GH insensitivity with chronic pulmonary disease and/or other immune dysfunctions. Since the first case report in 2003 (1), ten patients homozygous for seven different mutations in STAT5B were described, including two brothers homozygous for c.424_427del mutation (2). These brothers were born from non-consanguineous parents heterozygous for the same mutation at Criciúma, a city in the south of Brazil. Moreover, their parents reported that an unrelated family in the same city had two kids with similar clinical findings, deceased as a consequence of respiratory failure. These facts led us to study the prevalence of c.424_427del STAT5B mutation at Criciúma and the possible existence of a founder effect explaining these cases.

Objectives: To confirm the presence of c.424_427del STAT5B mutation in a second affected family, to assess the prevalence of this mutation at the city of Criciúma and to analyze the existence of a founder effect of this mutation.

Subjects and Methods: We evaluated the presence of c.424_427del mutation in four relatives from the second family and in 457 controls descendants from individuals born in Criciúma using DNA fragment analysis technique. We also genotyped two polymorphic markers (D17S932 and D17S1801) around this mutation (<1cM) in the two homozygous patients, 19 heterozygous individuals from four families harboring the same STAT5B mutation and 32 randomly assigned wild type controls from the region.

Results: Both the parents from the second family, who are first cousins, are heterozygous for c.424_427del STAT5B mutation, while the two evaluated daughters are non-carriers. Additionally, four control individuals from the general population were identified as carriers of the same STAT5B mutation. Two of them were later found to be relatives of the originally described family, however the other two are from apparently unrelated families. Considering only these last two controls, the minor allelic frequency of c.424_427del mutation at Criciúma is 2/914 or 0.22%. Furthermore, the analysis of the markers around STAT5B showed that the two homozygous patients have the haplotype D17S932 196/196, D17S1801 242/242. The same haplotype was identified in all heterozygous individuals (n=19), but in only 3 of 32 controls (9.4%, p<0.001).

Discussion and Conclusions: Criciúma was founded in 1880 with the arrival of 22 families of Italian immigrants from the Veneto region and we speculated that maybe one or more of these immigrants harbored the c.424_427del STAT5B mutation. Considering the allelic frequency found and the birth rate at Criciúma, it is possible to estimate the incidence of new homozygous cases in 0.01 per year. Our present findings suggest that the increased prevalence of this mutation in Criciúma may be due to a founder effect.

 

Nothing to Disclose: RCS, MFAF, RMA, CAT, AALJ

14133 6.0000 MON-0161 A Evidence for a Founder Effect of C.424_427del STAT5B Mutation Causing Growth Hormone Insensitivity in the South of Brazil 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Cuixia Tian1, Brenda Wong1, Lindsey Hornung2, Jane Khoury2, Lauren Miller1, Jean Bange1, Irina Rybalsky1 and Meilan Marianne Rutter*1
1Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, OH, 2Cincinnati Children's Hospital Medical Center, Cincinnati, OH

 

Background: Osteoporosis is an important problem in patients with Duchenne Muscular Dystrophy (DMD). Long term glucocorticoid (GC) therapy delays motor decline and death, but impairs bone health, frequently resulting in spine and long bone fractures. Accurate detection and early intervention of osteoporosis will help preserve motor function and improve quality of life in DMD. Currently, there is neither age-specific prevalence data of osteoporosis in DMD, nor consensus regarding optimal measurement and treatment of GC-induced osteoporosis in pediatric patients with DMD and other disorders.

Aim: To determine the age-specific prevalence of osteoporosis and frequency of poor bone health indices in pediatric patients with DMD.

Methods: We retrospectively examined age-specific prevalence of osteoporosis and poor bone health indices in GC-treated DMD patients seen between January 2005 and July 2012 at the Cincinnati Children’s Hospital Neuromuscular Comprehensive Care Center. Outcomes of interest were fractures (total, vertebral and long bone), and low age- and height-adjusted z-scores (< -2) of total body (TB) and lumbar spine (LS) bone mineral density (BMD) and bone mineral content (BMC) by DXA.

Results: We studied 408 patients with 1415 clinical visits (median 3 visits per patient). Age ranged from 3.0 to 19.3 years (mean 10.6 ± 3.7 years) at last follow up visit. By the last visit: 85 (20.8%) were on bisphosphonates, 293 (71.8%) were ambulatory, 339 (83.1%) were prepubertal, and mean duration of daily GC therapy was 4.4 ± 2.8 years.

DMD patients acquired vertebral and long bone fractures at a young age. Fracture prevalence increased progressively with age, along with worsening motor function. Prevalence of total fractures was 16.5%, 37.4% and 83.3% at ages 5, 10 and 18 years respectively. Prevalence of vertebral compression fractures was 4.4%, 19.1% and 58.3% at the same ages. Frequency of low BMD and BMC z-scores also increased progressively with age, and varied with site of measurement.

Conclusions: Osteoporosis is a major problem in DMD patients, starting at a young age. Our study is the first to examine the age-specific prevalence of osteoporosis and frequency of poor bone health indices throughout the pediatric age span in a large DMD cohort. These data also highlight the complexity of bone health measures in DMD patients, and the urgent need to improve detection, prevention and treatment of osteoporosis in these young patients.

 

Nothing to Disclose: CT, BW, LH, JK, LM, JB, IR, MMR

16807 7.0000 MON-0162 A Age-Specific Prevalence of Osteoporosis and Frequency of Poor Bone Health Indices in Duchenne Muscular Dystrophy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Tania Andrea Condarco*1, Jennifer R. McDuffie1, Sheila M Brady2, Mopelola Adetola Adeyemo3, Rubi Maricela Garcia3, James Reynolds4, Van S Hubbard5, Karim Anton Calis4 and Jack A Yanovski3
1NICHD/NIH, Bethesda, MD, 2Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 3NIH, Bethesda, MD, 4CC-NIH, Bethesda, MD, 5National Institute of Diabetes and Digestive and Kidney Diseases/NIH, Bethesda, MD

 

Background: Orlistat is the only FDA-approved drug for obesity in adolescents. Differences in bone markers in African American (AA) and Caucasian (CAU) adolescents are recognized (1); however, the effects of orlistat on bone turnover in these groups are unknown. 

Methods: We conducted a single-center, randomized, double-blind, placebo-controlled trial in 200 obese African-American (AA) and Caucasian (CAU) adolescents (mean age 14.6 yrs; mean BMI 41.6±9.0 kg/m2; 65% female; median breast Tanner stage V (range II-V) in girls and testicular volume 12.7±7.0 ccs in boys). Subjects were randomized to orlistat 120 mg TID (n=100) or placebo TID (n=100) for 6 months; all received a daily multivitamin and participated in a weight-loss program. Measurements included: 25-(OH)-vitamin D (vitD), osteocalcin (OCA), and deoxypyridinoline (DPY). Dual energy X-ray absorptiometry (DXA) measures of fat mass, bone mineral content and density (BMD) in total body, pelvis, lumbar and thoracic spine (TS) were performed.

All measures were analyzed accounting for missing data by multiple imputation followed by pre-specified ANCOVAs adjusted for age, sex, baseline weight, race, and pubertal and socioeconomic status.

Results: At baseline, AA (n=123) were heavier (118.2 ±24.8 kg) than CAU (107.8±24.5 kg) but did not differ significantly in fat mass (P=0.87). At the end of six months, the orlistat group had a significant decrease in BMIz score compared to the placebo group (Mean±SEM orlistat-placebo difference: -0.02±0.01, P=0.002). When comparing the effects of orlistat across racial groups, the influence of orlistat on BMI (AA-CAU difference: +0.31±0.14 kg/m2, P=0.03) and fat mass (AA-CAU difference: +2.12±0.87 kg, P=0.01) was less in AA compared to CAU. Changes during the study in bone turnover and bone density were associated with race and sex, but not orlistat treatment (all P>0.14). AA had greater decreases in DPY (-1.5±0.6 mmol/mmol Cr, P=0.01), VitD (-4.7±1.2 ng/mL, P<0.001) and OCA (-7.7±2.7 ng/mL, P<0.01) compared to CAU. AA had greater increases in TS BMD (0.02±0.01 gm/cm2, P=0.02) compared to CAU, although there were no significant differences in change of total body BMD (0.02±0.01 g/cm², P=0.31).  When adjusting for change in fat mass, the change in DPY (P=0.47) in AA vs. CAU was no longer significant, while VitD and OCA remained unchanged.

Conclusion: Among obese adolescents, orlistat treatment induced only a small weight loss and did not change bone turnover markers or BMD compared to placebo. AA had a greater increase in trabecular bone density and bone formation markers compared to CAU during the study, a finding consistent with the greater bone mineral deposition of AA observed in prior studies.

 

Nothing to Disclose: TAC, JRM, SMB, MAA, RMG, JR, VSH, KAC, JAY

11472 8.0000 MON-0163 A Differences in Bone Turnover Markers and Bone Mineral Density in African-American and Caucasian Adolescents Taking Orlistat 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Stacy Rustico*1, Andrew Charles Calabria2, Andrea Kelly3 and Heather Monk1
1The Children's Hospital of Philadelphia, Philadelphia, PA, 2The Children's Hosp of Philade, Philadelphia, PA, 3Childrens Hosp of Philadelphia, Philadelphia, PA

 

Background

Metabolic bone disease (MBD) is common in preterm, low-birth weight, and chronically ill infants, and can lead to fractures, compromise pulmonary status, and contribute to poor growth. Primary phosphorus (P) deficiency underlies much MBD, and P, vitamin D, and calcium (Ca) supplementation are traditional treatment strategies.  In a subset of children, Ca deficiency cannot be addressed with Ca repletion due to severe GI issues and leads to excessive parathyroid hormone (PTH) secretion and subsequent urinary P wasting and excessive bone resorption. In such cases, active vitamin D (calcitriol) therapy may enhance gastrointestinal calcium absorption, directly suppress PTH secretion, and ultimately reverse PTH mediated urinary P wasting to promote bone mineralization.

Objective

To describe the change in serum PTH and other biochemical markers of bone disease in response to calcitriol treatment in premature infants with elevated PTH (>100 pg/mL).

Design/Methods

This retrospective chart review examined the change in intact PTH, serum Ca, P, and alkaline phosphatase,  urine Ca/creatinine, and tubular phosphate reabsorption (TRP) in 32 infants median age 91 days (min/max: 47/141) gestational age 25 weeks (23/33) treated with calcitriol (starting dose: 0.05mcg/kg/day (0.02/0.1) daily IV/enteral).

Results

Following calcitriol treatment, PTH decreased 24 (3/259) vs. 220 (115/593) pg/ml, p<0.001; albumin-corrected Ca increased 10.4 (9.7/11.4) vs. 9.9 (8.9/10.7) mg/dl, p<0.001; P increased 5.5 (2.7/7.4) vs. 4.3 (2.9/6.4) mg/dl, p=0.0012; and TRP increased 91.5 (78/98) vs. 81.4 (59/ 98)%, p=0.04; but  alkaline phosphatase did not differ 489 (196/1229) vs. 598 (209/1193) U/L, p=0.12; compared to pretreatment values. Median time to PTH nadir was 61 days.

Hyperphosphatasia persisted in 10 of 28 subjects: 5 with significant liver disease and one with acute fracture. Hypercalciuria was found in 2/10 subjects; one treated with furosemide in whom hypercalcemia was absent and one whose serum and urinary calcium normalized with calcitriol dose reduction. No nephrocalcinosis was reported.

Conclusion:

Overall improvements in MBD markers and lack of adverse effects suggest calcitriol may be a viable treatment modality in infants with secondary hyperparathyroidism, in particular when other treatment options are not available.

 

Nothing to Disclose: SR, ACC, AK, HM

12664 9.0000 MON-0164 A Reduction of Parathyroid Hormone with Calcitriol in Metabolic Bone Disease of Prematurity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Carole Fournier*, Rene Rizzoli and Patrick Ammann
Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland

 

Low Protein diet (LPD) impairs body growth, decreases serum IGF-I and increases serum FGF21, two hepatokines influencing bone growth. Low Calcium-Phosphate diet (LCaPiD) increases serum calcitriol. We hypothesized that LPD effects on bone growth may differ according to calcium and phosphate intakes through the hormonal modulation of calcitriol, IGF-I and FGF21. One-month old rats were fed isocaloric diets containing 10 or 5% casein (10Prot, 5Prot), with 1.0% calcium and 0.8% phosphorus (normal; NCaPi) or 0.2% calcium and 0.16% phosphorus (low; LCaPi) for 8 weeks. Tibia bone microarchitecture was analyzed by microCT, BMC by DXA, tibia midshaft and proximal strength by flexion and compression tests, respectively, and cortical tissue hardness by nanoindentation. Independently of CaPi intakes, LPD led to body growth retardation. In NCaPi, LPD decreased bone strength and altered microstructure in association with higher serum FGF21 (+466%, p<0.01), lower serum IGF-I (-24% p<0.05) and reduced hepatic GH receptor (GHR) gene expression (-48% p<0.01). In LCaPi, LPD-related effects were attenuated in association with a lower decrease in serum IGF-I (-11%, vs. 10ProtLCaPi, p=0.14) and hepatic GHR mRNA levels (-30% vs. 10ProtLCaPi, p<0.01). The latter was however higher than 5ProtNCaPi (+48% vs. 5ProtNCaPi, p<0.05). In LCaPi, LPD still maintained high serum FGF21. Cortical tissue hardness was not affected in 5ProtNCaPiD, while it was lower in 5ProtLCaPiD (-15% vs. 10ProtLCaPi; p<0.01). Positive correlations were observed between serum IGF-I and midshaft Ct.BV (r=0.73, p<0.01) and proximal BV/TV (r=0.52, p<0.01). In LCaPi groups, normocalcemia and normophosphatemia were maintained together with increased serum calcitriol. In conclusion, LCaPiD attenuated the LPD-related alteration of bone growth by reducing hepatic GH resistance, however at the expense of cortical tissue hardness. Our results suggest that a factor induced by LCaPiD could act at the liver level to attenuate the LPD effects.

 

Disclosure: CF: Investigator, Nestlé. PA: Investigator, Servier. Nothing to Disclose: RR

15948 10.0000 MON-0165 A Low Calcium-Phosphate Diet Attenuates Dietary Protein Deficiency-Mediated Impairment of Bone Growth By Blunting the Decrease in Serum IGF-I and in Hepatic GH Receptor Gene Expression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Philippe Backeljauw*1, Ali S Calikoglu2, Vinnie G Duncan3, Sandra L Blethen4, Joyce Elaine Kuntze5, James W Frane6, Kathleen Graham Lomax7 and Steven D. Chernausek8
1Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 2Univ of North Carolina, Chapel Hill, NC, 3University of North Carolina, NC, 4consultant, 5JK Consulting, Burfordville, MO, 6Self-employed Statistical Consultant, Santa Monica, CA, 7Ipsen Biopharmaceuticals, Inc, Basking Ridge, NJ, 8University of Oklahoma Health Sciences Center, Oklahoma City, OK

 

Introduction: rhIGF-1 (mecasermin; Increlex) is indicated for the treatment of growth failure in children with severe primary IGF-1 deficiency (PIGFD) or with growth hormone gene deletion who have developed growth-attenuating antibodies.  The objective of the study was to examine the long-term efficacy and safety of rhIGF-1 therapy in severe PIGFD.  This report summarizes the data after nearly two decades of follow-up.

Methods: Children were treated under a predominantly open-label design in several separate studies that merged into a single, open label, long-term study. The study was sponsored sequentially by Genentech, Tercica, and Ipsen Biopharmaceuticals, Inc.  Demographics, efficacy data, and adverse events (AE) were collected. The primary endpoint was height velocity (HV) in patients naïve to rhIGF-1 treatment.

Results: 92 children in 24 countries were enrolled between 1991-2011 and received rhIGF-1 subcutaneously in doses between 60-160 mg/kg/dose given twice daily (BID). At baseline, 58% were male,  86% were prepubertal, mean age was 7.6 yr, mean height SD score was -6.7, mean IGF-1 SD score was -4.2, and mean pre-treatment HV was 2.6 cm/yr.  During year 1 of therapy, the mean HV was 8.0 ±2.3 cm/yr. HV SD for years 1-15 remained above baseline. The dose effect during year 1 was highly significant (p=0.0008), comparing doses of about <60 μg/kg BID with approximately 120 μg/kg BID. The statistical significance of this dose effect continued into year 2 (p = 0.0157). Beginning with year 3, there were few subjects treated at <80 μg/kg BID making it further difficult to establish a dose-related effect of treatment. The patient group had cumulative 516 years of drug exposure. 76 (83%) had >1 one AE, 18 had a serious AE, there were no deaths and no discontinuations due to AEs.  43 (47%) had >1 episodes of hypoglycemia; of these, 20 had a history of hypoglycemia before treatment.  No new safety signals were seen with prolonged treatment exposure, compared to prior reports.

Conclusions: The safety and efficacy of rhIGF-1 was evaluated over 19 years in 92 subjects

with severe primary IGFD. A dose‑response effect for doses of 60‑120 μg/kg given BID was demonstrated. The dose of 120 μg/kg BID was generally associated with the greatest growth responses. rhIGF-1 appears to be safe for the patient population treated, and demonstrates beneficial and durable effects on statural growth with long-term replacement therapy in children with short stature due to SPIGFD.

 

Disclosure: ASC: Investigator, Ipsen. SLB: Employee, Ipsen. JEK: Employee, Ipsen. JWF: Consultant, Ipsen. KGL: Employee, Ipsen. SDC: Investigator, Ipsen. Nothing to Disclose: PB, VGD

14596 11.0000 MON-0166 A Efficacy of Recombinant Human IGF-1 (rhIGF-1) in Patients with Severe Primary IGF-1 Deficiency (IGFD): Nearly Two Decades of Follow-up from the Pivotal Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Ian Paul Hughes*1, Philip Terrill2, Mark Harris3 and Andrew M Cotterill4
1Mater Health Services, South Brisbane, QLD, Australia, 2The University of Queensland, St Lucia, QLD, Australia, 3Mater Children's Hosp, South Brisbane, Australia, 4Mater Children's Hosp, S Brisbane QLD, Australia

 

Introduction

The Australian paediatric GH database, OZGROW, contains a complete treatment and response history of every patient to have received GH. This rich resource presents a unique opportunity to analyse growth response to GH, with the goal of response prediction and individualized treatment.  Ranke’s group have published most in this area and have developed prediction models and a “data-driven” approach to treatment of GH deficiency (GHD), Turner Syndrome (TS), and Idiopathic Short Stature (ISS) for up to the first four years [1-4].  Ranke’s studies utilize a fixed mg/kg/week protocol which differs from the incremental mg/m2/week protocol used in Australia. In addition, a diagnostic group denoted as short stature and slow growing (SSSG), while similar to ISS, is unique to Australia.

We present a novel approach to response analysis and prediction whereby individual patient growth response curves are plotted and compared to representative curves generated from the OZGROW database.  

Methods

Patients were stratified by diagnosis, gender (M/F), and commencement age. 53 M and 28 F GHD, 65 TS, and 123 M and 65 F SSSG patients were sampled at starting ages of 8 and 9 years. The median and 1st and 3rd quartiles for height SDS were calculated and plotted for the first five years of treatment at 0.1 year intervals. Individual growth response curves, with dose increments annotated, were then plotted against the relevant median and quartile curves. 

Results

Median curves showed a linear component followed by a plateau and then, for SSSG and TS, a drop. Other distinct differences were noted between the morphologies of median curves of different diagnoses, genders, and starting ages. The median curve shape closely represented a vertical translation of the majority of individual curves. Six individual growth response curve "phenotypes" were identified that deviated markedly from median curves.

  1. Flat – Non-responder.

  2. Late Plateau – Prolonged linear component at similar slope to median curves.

  3. Slow Linear – Slope of linear component less than that of median curves. 

    1. plateau occurs at normal time,

    2. late plateau (most).

  4. Early Plateau – Normal slope of linear component but plateau occurs 1-2 years early.

  5. Precipitous Drop – Normal linear component and timing of plateau but drops suddenly rather than plateauing.

  6. Growth Failure – Initial and ongoing Height SDS decrease.

Conclusions

Representative growth response curves exist for specific diagnosis-gender-commencement age combinations. Five curve phenotypes deviating from these norms were identified. If growth response curve phenotypes are correlated with baseline or demographic values, they may be predicted leading to the possibility of individualized GH treatment and optimized response outcome.

 

Nothing to Disclose: IPH, PT, MH, AMC

16582 12.0000 MON-0167 A Analysis of Growth-Response Curves Reveal Standard and Novel Response “Phenotypes” to Growth Hormone (GH) Treatment in Australian Children: Implications for Individualized Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Lawrence A. Silverman*1, E. Kirk Neely2, Gad B. Kletter3, Surya Chitra4 and Oksana Terleckyj4
1Goryeb Children's Hospital, Morristown, NJ, 2Stanford University, Stanford, CA, 3Swedish Medical Center, Seattle, WA, 4Endo Pharmaceuticals Inc, Malvern, PA

 

Background: Once-yearly histrelin implant has proven to be an effective method of delivering gonadotropin-releasing hormone analog (GnRHa) therapy to children with central precocious puberty (CPP), yet there are little data available regarding hormonal suppression and auxologic changes during an extended course of therapy. Objective: To report on auxologic outcomes from a 6-year, phase 3, long-term extension study of histrelin therapy. Methods: Patients who received 1 to 6 once-yearly histrelin implants were included. Auxologic outcomes including bone age/chronological age ratio and height were assessed periodically for up to 6 years of treatment and up to 12 months of follow-up. Results: Thirty-six children (33 girls; mean age at baseline [time of first implant] 7.9 years [range, 4.5 – 11.6 years]) were enrolled; 16 had received prior GnRHa therapy. The mean bone age/chronological age ratio significantly decreased (P < .05) from baseline (1.38) to month 12 (1.30), month 24 (1.24), month 36 (1.19), and month 48 (1.16). Bayley-Pinneau–predicted adult height (in cm) was significantly higher (P < .05) compared with baseline (153.42) at month 12 (157.14), month 24 (157.48), month 36 (158.45), month 48 (157.36), through 60 months of therapy (167.50). Improvements in bone age/chronological age ratio and predicted adult height were maintained in the post-explant follow-up period. Bone age/chronological age ratio remained significantly lower compared with baseline at 12 months post-explant (P = .0012). There was a strong correlation between predicted adult height at the end of treatment with actual height 12 months after explant (R2 = 0.98). Mean height standard deviation score (SDS) corrected for bone age increased from the 9th% at baseline to the 75th% at month 60 in treatment-naive patients, and increased from the 23th% at baseline to the 56th% at month 60 among previously treated patients. Body mass index SDS corrected for bone age trended toward a small increase with treatment duration, especially among previously treated patients. The most frequently occurring treatment-emergent adverse events were implant site reactions (ie, pain or discomfort), occurring in 19 (52.8%) patients over 72 months. Conclusion: Up to 6 years of continuous histrelin implant therapy is effective in improving auxologic outcomes in patients with CPP.

 

Disclosure: LAS: Investigator, AbbVie, Investigator, Endo Pharmaceuticals, Consultant, AbbVie, Consultant, Endo Pharmaceuticals. EKN: Investigator, Endo Pharmaceuticals, Investigator, Abbott Laboratories, Consultant, Endo Pharmaceuticals, Consultant, Abbott Laboratories. GBK: Investigator, Endo Pharmaceuticals, Investigator, Eli Lilly & Company, Consultant, Endo Pharmaceuticals, Speaker Bureau Member, Endo Pharmaceuticals, Speaker Bureau Member, AbbVie. SC: Employee, Endo Pharmaceuticals. OT: Employee, Endo Pharmaceuticals.

13863 13.0000 MON-0168 A Auxologic Outcomes of up to 6 Years of Therapy with Once-Yearly Histrelin Subcutaneous Implants in Children with Central Precocious Puberty 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Young Ah Lee*1, Hwa Young Kim2, Hae Woon Jung3, Kyung Min Lee2, Choong Ho Shin2 and Sei Won Yang4
1Seoul Ntl Univ Childrens Hospita, Seol, Korea, Republic of (South), 2Seoul Natl Univ College of Med, Seoul, Korea, Republic of (South), 3Seoul National University Children's Hospital, 4Seoul National University Children's Hospital, Seoul, Korea, Republic of (South)

 

Introduction: The reasons why Turner syndrome (TS) patients are predisposed to autoimmune disease remain unclear. Haploinsufficiency for forkhead box P3 (FOXP3) related to regulatory T cells (Tregs) may play a role in the pathogenesis. Thus, the phenotypical and functional characteristics of CD4+Tregs were investigated in TS patients compared with age-matched controls.

Methods: Fifty-three participants aged 17.4 to 35.7 years (24 TS patients and 29 controls) with a similar proportion of patients having thyroid autoimmunity. Peripheral blood mononuclear cells were stained with several surface and intracellular markers that represent phenotype and function of Tregs and effector T cell subsets. CD4+CD25bright Tregs and autologous CD4+CD25–target cells were mixed at ratios of Tregs to target cells of 0:1, 0.1:1, 0.25:1, 0.5:1 and 1:1 and incubated for 6 days with anti-CD3 and soluble anti-CD28 antibodies. The suppressive function of Tregs was expressed by the inhibitory index (%) for cell proliferation and cytokine production.

Results: Despite a lower percentage of lymphocytes that were CD4+ T cells (31.4% vs. 39.9%, P < 0.001) in TS patients compared to controls, a higher percentage of lymphocytes were CD4+FOXP3+ cells in TS patients than in controls (mean 2.06% vs. 1.52%, P = 0.005). The percentage of CD4+ cells that were FOXP3+ (mean 7.44% vs. 4.19%, P < 0.001) or FOXP3+CD127lo (mean 7.93% vs. 4.51%, P < 0.001) was also significantly higher in TS patients than in controls. TS patients also had a higher frequency than controls of central memory (mean 24.5% vs. 19.3%, P = 0.001) and effector memory (mean 35.9% vs. 25.9%, P = 0.002) CD4+ T cell subsets, especially those producing IFN-g (mean 10.9% vs. 7.2%, P = 0.011) and/or IL-17, (mean 0.17% vs. 0.12%, P = 0.045), but a lower frequency of naïve CD4+ T cells (mean 34.9% vs. 48.7%, P < 0.001). While TS patients showed an increased expression of CTLA-4 (mean 214.1 vs. 184.6, P = 0.003), TS patients had similar frequencies of CD4+FOXP3+ Tregs that were GITR+, CXCR3+, and CCR4+CCR6+ than cotrols. The Tregs of TS patients and controls showed comparable ability to inhibit inflammatory cytokine production by effector CD4+ T cells. However, their ability to suppress the in vitro proliferation of autologous CD4+CD25– T cells was defective in TS patients compared with controls (P < 0.05 at 0.1:1, P< 0.01 at 0.25:1, 0.5:1, and 1:1 ratios of Tregs to target cells).

Conclusions: Tregs of TS patients may be less able than control Tregs to suppress efficiently effector T cell proliferation, despite the abundance of Tregs in the peripheral circulation. Although FOXP3 itself may not be a haploinsufficient gene, other X-linked genetic factors may contribute either to defective function of Tregs or to the provocation of an autoimmune response. The mechanism of the defective ability of Tregs in TS patients to suppress autologous effector T cells needs to be elucidated in a further study.

 

Nothing to Disclose: YAL, HYK, HWJ, KML, CHS, SWY

11839 14.0000 MON-0169 A Phenotypic and Functional Delineation of CD4+ FOXP3+ Regulatory T Cells in Patients with Turner Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Ayanna M Butler-Cephas*1, K. Alaine Broadaway2, Michael P. Epstein1, Erica L. Ditkoff3 and Judith L. Fridovich-Keil4
1Emory University School of Medicine, 2Emory University Graduate School, 3Emory College, 4Emory University School of Medicine, Atlanta, GA

 

Classic galactosemia (CG) is a potentially lethal genetic disorder caused by profound loss of the enzyme galactose-1-phosphate uridylyltransferase (GALT). Affected infants are unable to metabolize galactose, a sugar abundant in milk and dairy products. Current treatment for classic galactosemia involves immediate and life-long dietary restriction of galactose. Previous studies have demonstrated that children with CG have normal weight at birth but decreased height and weight velocities postnatally. A majority of girls with classic galactosemia have hypergonadotrophic hypogonadism, which may result in delayed puberty. Two large studies have also reported delayed puberty in 5% of boys. Given that many of the volunteers in earlier studies were diagnosed following the onset of acute symptoms, we wanted to test whether a population of subjects identified predominantly by pre-symptomatic newborn screening would show patterns of growth and development similar to those reported earlier. Further, we wanted to determine whether delayed growth and development of children with CG would show any relationship with available genetic or biochemical markers, or with other parameters of long-term outcome.  To address these points, we collected height and puberty data in a cross-sectional sample of 180 volunteers with CG. We also determined anti-Müllerian Hormone (AMH) and galactose-1-phosphate levels, scholastic achievement, and predicted residual GALT activity for many of these volunteers. Additionally, we ascertained longitudinal growth data for a subset of our participants. We excluded anyone on a medication believed to affect growth or with a concurrent chronic illness known to affect growth. We found that many of the children had poor linear growth compared to controls, though BMI was not atypical. Overall, both young men and women with CG did reach normal adult heights as predicted from mid-parental heights. Unlike previous studies of scholastic outcome and ovarian function in CG, growth of children with CG was not a function of the predicted presence of residual GALT activity. Growth also did not correlate with scholastic achievement or AMH level, a marker of ovarian function. Finally, whether a girl with CG achieved spontaneous menarche also did not correlate with linear growth. In our study cohort, 73% of young women achieved spontaneous menarche and 61% used hormone replacement therapy (HRT) to complete puberty or regulate menses. 31% of young men also reported experiencing delayed puberty. Our results suggest that newborn screening is not sufficient to prevent the decreased prepubertal growth previously described for children with CG, and the factors that modify this growth phenotype may be independent of those that modify scholastic or ovarian outcomes. Finally, our data suggest that boys with CG may have a higher rate of delayed puberty than previously reported.

 

Nothing to Disclose: AMB, KAB, MPE, ELD, JLF

13287 15.0000 MON-0170 A Growth and Development of Children and Young Adults with Classic Galactosemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Akiko Yamamoto*1, Yasuhiro Naiki2 and Reiko Horikawa3
1National Center for Child Health and Development, Tokyo, Japan, 2Natl Ctr for Child Hlth & Dev, Tokyo, Japan, 3Natl Cntr Child Health & Dev, Tokyo, Japan

 

Background: It is known that maternal VD insufficiency causes cord blood VD insufficiency in their children. Recent data suggest VD affects on glucose metabolism and possibly on infant growth.

Objective: To assess the VD status of mothers during pregnancy and infants at birth and one year of age in Japan, and to assess the effect of VD levels on growth, development, and metabolic outcome.

Methods: 236 pairs of children and mothers who participate in the prospective birth cohort study of our institute from December 2010 to April 2013 were enrolled in this study. Blood samples were obtained from mothers at second trimester of pregnancy (16 weeks to 27 weeks gestational age), at birth from cord blood, and from children at 1 year of age. Serum 25OHVD levels, IGF-I, Leptin, Adiponectin, and other biochemical markers were measured. We assessed children’s growth and development, evaluated nutrition and environmental factors by questionnaire, and investigate the relationship of these factors and VD levels.

Results: Median 25OHVD levels of maternal blood, cord blood, and blood at 1 year were 18.65ng/ml (range:8.3-39.8),　12.05ng/ml (4.1-28) , 23.5ng/ml (8.0-52.3), respectively. 25OHVD of cord blood has significant positive relationship with mother’s and 1 year’s samples (r=0.44, ＜0.001, r=0.20, p=0.002, respectively). 25OHVD levels at 1 year also show siginificantly positive relationship with maternal levels (r=0.24, p=0.0002). Maternal gestational diabetes mellitus has no significant effect on cord blood 25OHVD levels. Short exposure time to sunlight at 1 year showed tendency to reduce 25OHVD levels, but not significant (<30 minutes/day; 9.95ng/ml, 30 min~ 2hrs; 23.65ng/ml, >2hrs group;24.4ng/ml, p=0.0692). Breast-fed infants showed significantly lower 25OHVD levels than formula-fed or mixed-fed infants (19.25ng/ml, 26.2ng/ml, 27.8ng/ml, p<0.001), irrespective of intake of solid food. Motor and neurological development assessed by questionnaire show no significant difference according to cord blood 25OHD levels. There was no significant correlation of 25OHVD and other biochemical makers, nor children’s growth.

Conclusions: Maternal vitamin D insufficiency influences 25OHVD levels in children at 1 year of age. Breast feeding and short exposure time to sunlight affects 25OHVD in children in Japan, suggesting necessity of some prevention program. To assess the effect of low VD levels for growth and development, further and long-term observation is needed.

 

Nothing to Disclose: AY, YN, RH

12428 16.0000 MON-0171 A The Effect of Vitamin D (VD) Insufficiency in Mothers during Pregnancy on VD Status and Growth, Development, and Metabolic Outcome in Their Infants at One Year of Age 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Maria Isabel Hernandez*1, Patricio Ibañez2, German Iniguez3, Alejandra Rebeca Avila4, Carolina Sanchez5 and Eduardo Chavez5
1University of Chile, Santiago, Chile, 2Catholic University of Chile, 3Univ of Chile Schl of Med, Santiago, Chile, 4Hospital San Borja Arriaran, Santiago, Chile, 5Hospital Clinico San Borja Arriaran

 

Introduction: Inflammatory Bowel Disease ( IBD) is a chronic disease which causes inflammation of the digestive tract. The estimated  incidence in the pediatric population is 5.2 / 100,000 below 16 years of age.In this group of children the average age at diagnosis is 11.9 years . Poor control of the disease has been associated with poor growth. Objective: To evaluate the impact of IBD on growth and development of pediatric patients , and their relation to biomarkers of growth axis, inflammation and disease activity . Methods: We recruited patients diagnosed with IBD (Ulcerative colitis (UC) or Crohn's disease ( CD)) younger than 18 years  in our center . Registered data included: age at diagnosis , treatments  , complete anthropometrics and  pubertal development staging , bone age (BA ) and pelvic ultrasound (in girls)  (U.S. ) . Circulating IGF-1,LH , FSH , testosterone , TSH , FT4 , cortisol , 25OHVitD , biomarkers of inflammation (CRP and fecal calprotectin ), hematocrit , platelets count and albumin were measured. In addition a Clonidine stimulation test for GH was performed in patients with a BA <14 years in girls and <16 in boys. Results: A total of 17 patients were included ,52% male, with a mean age of 15. 4 ± 3.9 with the diagnosis of  CU in 70.5 % and CD in 29.4 %.  .Mean age at  onset was 10.9 years. A 70.5 %  was within normal in mean BMI-SDS, at  risk of malnutrition 5.8 % and malnourished 5.8 %. Pubertal staging distribution was :Tanner I 11.7 % , II- III 5.8%, IV- V 82.2 %. Mean age at menarche  was 12.5 ± 1.64 years . Receiving Mesalazine and / or azathioprine 88%,  and 12% with a monoclonal antibody History of treatment with steroids 12 ( mean  time 72 days). According to the PUCAI and PCDAI score for UC and CD: were in remission 58.8 % and  with a mild disease 7. Only one patient  had IGF1( < -2 SDS)  and stimulated GH  in a deficient  range , but had  a  normal height (SDS). In 47% of the patients , 25OHVitamin D  was < 20ng/ml . Calprotectin levels :  < 15ug/gr = 4 ,  15-60 = 8 and  > 60 = 4 . Subjects with calprotectin > 60ug/gr had a lower height-SDS compared with their target size, compared with those patients with a calprotectin <60 (p = 0.004). There was an inverse correlation between height-SDS  and  CRP (p = 0.02). No differences between patients with UC and CD . Conclusions: In our group of patients, who mostly were in remission we found no significant alteration of the somatotropic axis , or hormonal parameters . Fecal calprotectin and CRP are highly sensitive markers of active disease and its elevation correlates withheight SDS. Good control of IBD preserves the normal growth of patients presenting in childhood.

 

Nothing to Disclose: MIH, PI, GI, ARA, CS, EC

16841 17.0000 MON-0172 A Somatotrophic AXIS in Pediatric Patients with Inflamatory Bowel Disease: Relation to Inflammation and Disease Activity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Yoriko Hatta*1, Tomoko Ando2, Takashi Kamijo3, Masamichi Ogawa4 and Kazumichi Onigata5
1Japan Red Cross Nagoya Daiichi Hospital, Nagoya, Japan, 2Japan Red Cross Nagoya Daiichi Hospital, 3Nagoyaka Children's Clinic, Nagoya, Japan, 4Ogawa Clinic, Nagoya, Japan, 5Shimane Univ Sch of Med, Shimane, Japan

 

The final height of forty seven Turner females in Japan

YORIKO HATTA   , TOMOKO ANDO          Japan Red Cross Nagoya Daiichi Hospital

TAKASHI KAMIJO                                     Nagoyaka Children’s Clinic

MASAMICHI OGAWA                                 Ogawa Clinic

KAZUMICHI ONIGATA                             Shimane University Hospital

BACKGROUND

Short stature and gonadal dysfunction are the most prominent feature of Turner females. In Japan, growth hormone (GH) treatment was approved in 1991, but the dose of GH was limited to 0.5 IU/kg/week. From 1999, GH treatment for Turner girls without GH deficiency was approved. The final height of untreated Turner females without spontaneous pubertal development and GH treated females are 139.6±3.5cm and 146.9±4.2cm, respectively. It has been reported that estrogen replacement therapy (ERT) might improve the final height in other countries. The most effective strategy including starting time and dose of ERT is still unclear in Japan.

 OBJECTIVE

To search for appropriate starting time of ERT, we determined the effect of GH and estrogen on the final height of Turner females.

 METHODS

Final height was reviewed in the medical records of 50 Turner females, regularly followed up at one hospital and two clinics. Three girls who had pubertal development spontaneously were excluded. Forty seven females were classified to group A (ERT start during GH), group B (after GH), and group C (ERT only). Their bone age and height at started ERT, their parents’ height, and the period of GH treatment were extracted.

 RESULTS

The number of patients of Group A, B, and C are 12, 23, and 12, respectively. Mean final height of group A, B, and C were 148.2 ± 4.1 (mean±SD), 145.8 ± 5.0, 146.8 ± 6.5 cm, respectively. The mean age of the three groups were 26.7 ± 5.7, 29.0 ± 8.2, and 39.3±12.3 years old. The period of GH treatment of group A and B were 9.8 ± 4.3 years and 6.7 ± 3.2 years old. The mean age at start of ERT were 16.0 ± 1.5, 18.0 ± 2.8, and 20.9 ± 4.6 years old. The mean height at start of ERT in group A and B were 139.3 ± 6.1 and 144.7  ± 4.7 cm, respectively. With assessment of the bone age of 10 women in group B, their bone ages at the start of ERT were 11 (n=2), 12 (n=3), 12.5 (n=1), 13 (n=2) and 13.5 (n=2). And their height gain after ERT were 4.1 cm, 2.7 cm, 2.7 cm, 0.3 cm, 0.3 cm, respectively.

 DISCUSSIONS

The height at the start of ERT in group A was shorter than in group B. On the other hand, the final height in group A was taller than in group B. This indicated the start of ERT during GH treatment was better than after GH treatment. In the patients whose bone age was over 13 years at the start of ERT, their final height were not improved. The final height in group C was taller than in group B. The growth in group C might explain they had the potential with higher final height than in group B.

 CONCLUSION

The ERT during GH therapy could improve the final height of Turner female. We propose the starting time of ERT is at their bone age of 12~12.5 years old.

 

Nothing to Disclose: YH, TA, TK, MO, KO

15871 18.0000 MON-0173 A The Final Height of Forty Seven Turner Females in Japan 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Vaman Khadilkar*1, Anuradha Khadilkar2, Lavanya Parthasarathy3, Shashi Chiplonkar1, Veena Ekbote3, Supriya Phanse-Gupte3 and Neha Kajale4
1Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India, 2Hirabai Cowasji Jehangir Medical Research Institute, Pune, Maharashtra, India, 3Hirabai Cowasji Jehangir Medical Research Institute,Jehangir Hospital, Pune, India, 4Hirabai Cowasji Jehangir Medical Research Institute,, Pune, India

 

Cross sectional growth data when used for an individual child to follow longitudinal growth may lead to misleading assessments, especially during the growth spurt. Growth velocity is affected by environmental and genetic factors, and very little longitudinally measured height velocity data is available for Asian Indian children. Thus, aim of our study was to longitudinally assess height velocity in 5-16 year old apparently healthy Indian children. We hypothesized that peak height velocities would be lower in Indian children than seen in Caucasian counterparts.

From 2007, 1600 apparently healthy children (data on 450 is presented here, 287 boys) from a middle class school in Pune (Western India) were followed till 2013. Measurements were made yearly , standing height and weight were measured by standard techniques; BMI was computed and height, weight and BMI were converted to Z score (Khadilkar et al, 2009). Yearly height velocities were calculated for each subject by dividing the difference between the annual distance measurements by the age increment. Mixed longitudinal growth data were used for analysis, i.e.  yearly observations were recorded  on each individual, data were then combined to assess growth over the total age range of all individuals.

In all, 1785 height velocity measurements were available (1090 measurements on boys); mean ht of boys and girls at the time of first measurement was close to zero (-0.4± 1.1, girls -0.3± 1.1), indicating they were apparently healthy. Mean ht velocities from 5-16 yrs for boys and girls were computed.  Height velocity for boys and girls was higher at 5 years (7.7 cms/yr) and then was 6, 5.8, 5.7, 5.7, 5.3, 5.7, 6.9, 7.5, 7.0, 6.9 and 4.1 in boys from 6-16 years.  Height velocity was 7.1, 5.8, 5.5, 5.7, 5.8, 6.5, 6.3, 4.3, 2.4, 1.2, 0.9 and 0.3 in girls. In boys, a maximum height velocity of 7.4±2.1 years was achieved at 13 years, while in girls, the peak velocity of 6.5±1.5 cms during puberty was achieved at 10years. Though data for comparison with a similar study design is scarce, when comparison was made with published data (Tanner, 1976, design longitudinal)1, Indian boys and girls had more variability and a smaller spurt. However, this needs to be confirmed on longitudinal data analysis.

Longitudinal height velocities have been described in Asian Indian children.  Preliminary data suggest that Indian boys have a peak height velocity at 13 years and girls at 10 years.

 

Nothing to Disclose: VK, AK, LP, SC, VE, SP, NK

15574 19.0000 MON-0174 A Height Velocities in 5-16 Year Old Apparently Healthy Indian Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Nozomi Matsuda*1, Atsumi Tuji2, Keisuke Nakajima2, Kei Takasawa3, Chikako Morioka2, Atsuko Taki2, Yoshihiro Minosaki4, Kikuko Oku4 and Kenichi Kashimada3
1Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), tokyo, Japan, 2Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), 3Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan, 4Neonatal Intensive Care Unit (NICU), Kawaguchi municipal medical center1

 

【Background】

Factors affecting growth and development in ELBWIs born SGA have not been precisely elucidated. In order to identify the perinatal factors, we carried out a retrospective analysis of ELBWIs born SGA who were treated in NICU of Kawaguchi municipal medical center, Saitama, Japan. Our analysis is based on a single institute and might eliminate bias caused by multi-institutional research.

【Subjects】

The number of ELBWIs born from 2003 to 2010 was 244. We defined SGA as a weight and a height below the 10th percentile for the gestational age. Among 38 ELBWI SGAs, we excluded 15 patients due to death, severe developmental retardation, congenital anomalies, or dropping out from our following up system before the age of three years. Twenty three patients were continuously followed up at least for three years and were eligible for our study. We evaluated body sizes and development of the patients at the age of three, and analysed association with factors during fetal period (maternal age, placental weight), at birth (gestational age, Apgar score, body sizes at birth) and after birth (durations of mechanical ventilation, durations of oxygen administration, gastrointestinal problems, persistent hypoglycemia that required high glucose infusion rate, glucagon and/or glucocorticoid).

【Results】

At the age of three years, the heights of 19 patients (83%) and the weights of 18 patients (78%) were more than -2SD. Lower Apgar score less than 7pts at 5 min correlated to lower body heights and body weights.

The average scores of DQ were 101 in posture and motor control, 84 in cognitive ability, 89 in language and social development, and 89 in full scale. Lower Apgar score (<7) at 5 min and episodes of persistent hypoglycemia were significantly associated with full scale IQ.

【Conclusion】

Growth and development at three years of life were associated with perinatal asphyxia and persistent hypoglycemia in ELBWIs born SGA.

 

Nothing to Disclose: NM, AT, KN, KT, CM, AT, YM, KO, KK

14533 20.0000 MON-0175 A Growth and Development at Three Years of Life Were Associated with Perinatal Asphyxia and Persistent Hypoglycemia in Extremely Low Birth Weight Infants (ELBWIs) Born Small for Gestational Age (SGA) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Aline Hamati Rosa Batista*1, Marina Gagliardi de Assumpção1, Cristiane Kochi2, Flavio Richeti1, Carla Sant'Anna Corrêa1, Carlos Alberto Longui3 and Mylene Neves Rocha1
1Faculdade de Ciências Médicas da Santa Casa de São Paulo, 2Santa Casa SP School of Medical Sciences, Sao Paulo, Brazil, 3Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo, Sao Paulo, Brazil

 

Evaluation of Second Sexual Chromosome Presence in Turner Syndrome 45,X on Different Embryonic Origins Tissues

Background: Turner Syndrome (TS) is one of the most frequent chromosome abnormalities and  recognition of the disease is very important. 45, X monosomy is usually detected in 50% of patients with TS, and mosaicism and X anomaly are detected in the other half. Despite this frequency, many authors have suggested that 45, X monosomy is lethal and that most surviving 45, X individuals are actually mosaicisms undetected by cytogenetic tests.

Aim: To evaluate the possibility of a mosaicism in two tissues of different embryonic origins in 45,X patients.

Patients and Methods: 14 patients with 45,X monosomy detected by karyotype were included. DNA samples were obtained from peripheral blood and 10 hair follicles with hair bulb. The analyzed genes were SRY (by Real-Time PCR method) and androgen receptor (analyzed employing GeneScan software which is able to determine the relative size of the amplified fragment, where the latter variable depends on the number of CAG repeats present in the exon 1 of the AR gene. Using this method, the patients could be divided in two different groups: homozigote and heterozigote, depending on the presence of one or two alleles respectively).

Results: 13/14 patients had negative results for both in peripheral blood and in hair samples and one patient had SRY positive in both samples. The GeneScan results showed that only one patient 45,X were homozigote and heterozigote in blood and in hair bulb respectively, suggesting a possible mosaicism.

We conclude that, on the genotyping technique, one patient presented distinct results for both samples, suggesting the presence of a second sexual chromosome in hair bulb cells and a possible mosaicism between tissues.  By evidence of genotyping and the evidence from the literature, we believe that a larger number of samples, as well as the inclusion of other genes targeted to the X and Y chromosomes to investigate our hypothesis would be necessary.

 

Nothing to Disclose: AHRB, MGDA, CK, FR, CSC, CAL, MNR

15422 21.0000 MON-0176 A Evaluation of Second Sexual Chromosome Presence in Turner Syndrome 45,X on Different Embryonic Origins Tissues 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Mika Habu*, Tatsuki Oyoshi, Hirofumi Hirano, Kazunori Arita, Shingo Fujio and Hiroshi Tokimura
Graduate School of Medical and Dental Sciences Kagoshima University, Kagoshima, Japan

 

Introduction:  Childhood craniopharyngioma, a rare embryogenic tumorous malformation of the sellar region those survival rates ranging from 91 to 98%. Quality of survival is impaired due to proximity to optical, pituitary, and hypothalamic structures. Long-term equelae substantially reduce the quality of life of approximately due to extreme obesity owing to hypothalamic involvement and/or surgical- or radiation-induced lesions. We assessed the current treatment outcome of childhood craniopharyngioma.

Materials and Methods: 

In 2003-2013, 47 patients with craniopharyngioma underwent surgical treatment in our department.

Among them, 8 patient were evaluated, 4 men and 4 women. We assessed symptoms, treatment options, pre- and postoperative physical, cognitive and endcrinological function of these cases.

Results:

Mean age of the patients at surgery was 6.3 years ranging from 2 to 10 years. Mean follow-up time was 47 months ranging 11-74 months. 4 patients had huge tumor which maximum tumor diameter was over 40mm. Major symptoms at diagnosis was consciousness disturbance in 2 cases, mental retardation in 2cases, headache in 2 cases, short stature in 2 cases, and nystagmus in only 1cases. Except patients with impaired consciousness, 6 patients referred to pediatrician at first. As treatment, all patients underwent surgery and 3 patients had the tumor completely removed and 50% (4/8) had radiation with stereotactic modality.  The most frequent complications with surgery was diabetes insipidus (DI) developed in 75 %( 6/8). Incidence of complications with surgery survival time was hypopituitarism: 25% (2/8), electrolyte imbalance: 25 %( 2/8). After operation, all patients needs hormone replacement therapy; 6 patients have vasopressin, 4 patients have hydrocortisone, 2 patients have thyroid hormone and 2 patients have growth hormone.

　The pre-operative IGF-1 score was less than -2SD in 3 patients (37.5%), postoperative IGF-1 score was less than -2SD in 6 patients (75%).   The preoperative BMI was less than 18 in all patients and BMI raised to 22 in only 2 cases after operation. There is no morbid patients. But most of them minded the eating habits and made an effort not to gain weight.        

 There is no patients with disorder of cognitive function and visual performance after operation.

Conclusion:

The morbid obesity is one of the serious problem which reduce the quality of life for children with craniopharyngioma.  There is no obese patients in our cases. Furthermore, long-term observation is necessary.

 

Nothing to Disclose: MH, TO, HH, KA, SF, HT

15407 22.0000 MON-0177 A Outcome of Craniopharyngioma Surgery in Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0156-0177 4849 1:00:00 PM Growth and its Disorders: Genetic and Clinical Poster

Seon-ung Hwang* and Sang Hwan Hyun
Chungbuk National University, Cheongju, Korea, Republic of (South)

 

Ganglioside is acidic glycosphingolipid with sialic acids residues. The roles of ganglioside are cell differentiation, adhesion, regulating growth and signal transduction. Most of all, b-series ganglioside GT1b was reported that suppressing damage of mtDNA by reactive oxygen species (ROS) in mouse brain. The purpose of this study is to investigate the effect of exogenous addition of ganglioside GT1b on in vitro maturation (IVM) of porcine oocytes and to confirm the related bradykinin 2 receptors (B2R). Ganglioside GT1b were treated on IVM that concentration was 0 (control), 5, 10 and 20nM. Data were analyzed by ANOVA followed by Duncan using SPSS (Statistical Package for Social Science) mean ± SEM. First, we evaluated nuclear maturation [Germinal Vesicle (GV), Metaphase I (MI), Anaphase & Telophase I (Ana & Telo) and Metaphase II (MII)]. As a result, MII rates were statistically different (P<0.05) between 0nM group (78.9±1.3%) and 5nM group (86.6±1.1%). But the other groups did not differ significantly from control (82.9±0.7 and 80.0±2.5% in the 10 and 20nM group, respectively; P<0.05). The other stages (GV, MI, Ana & Telo) rates did not differ significantly (P<0.05). Second, we evaluated intracellular glutathione (GSH) levels and ROS levels. Intracellular GSH levels in oocytes matured with 5nM and 20nM GT1b decreased significantly (P<0.05) compared with those in the other groups. The 10nM and 20nM groups showed a significant (P<0.05) decrease in intracellular ROS levels compared with control group. Third, we examined after development (parthenogenesis, in vitro fertilization) using oocytes matured with Gt1b in IVM stage. However, there were no significant (P<0.05) developmental difference in the two experiments. Forth, to confirm the mechanism of GT1b effect on IVM, we identified the existence of B2R known to increase calcium concentration stimulated by GT1b. As a result, we identified the expression of B2R in cumulus cell but not in oocyte. In conclusion, these results indicated that ganglioside GT1b play an important role in increasing the nuclear maturation rate and decreasing the intracellular ROS levels during IVM. But it did not effect on after development. To identify the effect of GT1b, further studies are needed to experiment with mRNA expression of apoptosis-associated genes (Bax, BCl2, Caspase-3) and CaMKII in matured cumulus cells and oocytes. We also will be identified embryo development with addition of GT1b only in IVC (In Vitro Culture) stage.

 

Nothing to Disclose: SUH, SHH

14377 3.0000 MON-0024 A Ganglioside GT1b Play an Important Role in Nuclear Maturation and Decreasing the Intracellular ROS Levels during in Vitro Maturation of Porcine Oocytes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Jessica Elizabeth Hornick*, Francesca Duncan and Teresa K Woodruff
Northwestern University, Chicago, IL

 

Radiation, surgery, and chemotherapy, as treatment for cancer or other conditions, can compromise nearly all aspects of the female reproductive axis resulting in infertility, subfertility, or premature menopause. Fortunately for females, the ovary has the potential for diverse fertility preservation and endocrine function restoring options ranging from standard (i.e. IVF, ICSI, embryo banking) to investigational (ovarian tissue cryopreservation, ovarian transplant). In vitro follicle growth (IVFG) is another emerging technology that has tremendous promise for a subset of individuals who cannot undergo standard options. Tremendous success has been achieved in performing IVFG in the mouse, including live births using gametes derived from nearly all methods attempted to date. Translation of this technology to large mammalian species, however, has not been trivial due to significant differences in factors such as follicle size, development, metabolic requirements, and physical niche. While our lab and others have made significant progress with in vitro culture of human ovarian follicles, a reliable and reproducible method to produce healthy human gametes from cultured follicles has not been achieved. Human ovarian tissue for research purposes is rare and thus, large scale studies to define culture conditions have been limited. The cow, however, is an excellent model for studying reproductive biology due to unique similarities shared with human ovarian structure, folliculogenesis, and hormonal profiles, however, tissue is readily available in large quantities.  In addition, cow and human eggs are similar in terms of diameter, morphology, spindle size and position. While many aspects of bovine reproduction are well-defined, the details of meiosis and meiotic progression have not been fully described, as they have for the mouse model.  Such knowledge is required to fully understand which in vitro follicle culture conditions generate the highest quality eggs. Here, we have determined the time line of key events in meiosis that occur during in vitro maturation (IVM) of bovine oocytes and the progression of spindle assembly. Bovine oocytes undergo germinal vesicle breakdown (GVBD) by 6-8 hours and reach metaphase of meiosis I by 14-16 hours. Progression through anaphase I occurs and oocytes reach meiosis II by 20-22 hours post-IVM. With a combination of fixed-cell and live-cell imaging, we have determined the pathway of spindle assembly in bovine oocytes. Additionally, we have begun to describe the effects of culture conditions on oocyte quality, including time in culture. Bovine oocytes show evidence of post-ovulatory aging by 40 hours post-IVM. These studies now provide the platform to fully evaluate the gametes that are generated from in vitro bovine follicle culture and will allow for advances to be made in translating new technologies to human follicles.

 

Nothing to Disclose: JEH, FD, TKW

15192 4.0000 MON-0025 A Establishment of in Vitro Maturation of Bovine Oocytes As a Model for Meiosis in Large Mono-Ovulatory Mammalian Species 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Shuo Xiao*1, Francesca Duncan2, Jessica Elizabeth Hornick2 and Teresa K Woodruff2
1Feinberg School of Medicine, Northwestern University, Chicago, IL, 2Northwestern University, Chicago, IL

 

In vitro follicle growth (IVFG) may provide new fertility preservation options to young cancer patients. We developed a three-dimensional alginate-based encapsulated IVFG system that recapitulates the key events of mammalian folliculogenesis and oogenesis, and produces meiotically and developmentally competent eggs capable of giving rise to live offspring in mice. Follicles are typically isolated and cultured for a defined period and then analyzed as a cohort. However, follicle growth is not synchronous and oocyte quality depends on the initial follicle size and quality. Moreover, human follicles mature for greater than 30 days in culture and the somatic cells preclude evaluation of oocyte size as a marker of development. Thus, methods that can serve as proxy for the best timing of IVFG that correlates with oocyte meiotic competence was investigated, including follicle diameter and hormone production with oocyte transcriptional status. Multilayer secondary follicles (150 μm) were isolated from day 16 CD-1 mice and encapsulated in 0.25% alginate, and cultured individually for up to 8 days. The transition of the oocyte from a transcriptionally active state (meiotically incompetent) to a quiescent state (meiotically competent) occurred on day 4, with 95% of oocytes being transcriptionally quiescent on day 6 (follicle diameters: approximately 270 μm). This suggested that maintaining oocytes in a prolonged state of transcriptional arrest until day 8 of in vitro culture may compromise gamete quality. We then evaluated follicle diameter and estradiol production as predictors of oocyte quality. Follicles were cultured individually for specific time periods or to different diameters followed by in vitro maturation (IVM). The metaphase II (MII) rate on day 6 was 78%, which was significantly higher than that on days 2, 4, and 8. However, follicles with diameters of 300±25 μm had a 93% MII rate, significantly higher than the MII rate on day 6, when follicle diameters were approximately 270 μm. Perhaps not surprisingly, follicles that produced MII eggs showed significantly higher estradiol secretion levels than follicles that produced GV and GVBD oocytes after IVM. Our findings that (1) oocytes reach transcriptional quiescence when follicles reach a diameter of 270 μm, but (2) oocyte meiotic competence peaks when follicles reach a diameter of 300 μm, suggest that oocyte maturation requires post-transcriptional events that occur after day 6 but before day 8 of culture. Taken together these findings suggest that the follicle diameter and estradiol secretion profiles rather than absolute culture time, are potential markers of follicle maturity and oocyte quality in vitro. These studies will be extended to examine embryo quality of oocytes individually cultured to these endpoints to assess whether a ‘personalized follicle’ approach is superior to the currently accepted ‘days in culture’ method.

 

Nothing to Disclose: SX, FD, JEH, TKW

16027 5.0000 MON-0026 A Markers That Predict Oocyte Meiotic Competence during in Vitro Follicle Growth 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Katti Pancharatna*1 and Prasad A Deshpande2
1Karnatak University, DHARWAD, India, 2Karnatak University, Dharwad, India

 

Involvement of insulin/IGF1 signaling mechanism if any, in the release of meiotic arrest in  zebrafish (Danio rerio) oocytes was studied by examining the effects of galactose, insulin and insulin like growth factor (IGF1) individually and in combination, in the induction of germinal vesicle break  down (GVBD) in vitro.  Fully grown preovulatory oocytes mechanically isolated from the ovaries of gravid females were exposed to galactose (1 ng/ml), insulin (1 ng/ml), insulin like growth factor 1(IGF1) (1 ng/ml) individually and in combination.  All the chemicals were dissolved in zebrafish ringer solution (ZRS). Oocytes exposed to ZRS alone and Diethylstilbestrol (DES 2µM/ml ZRS) served as controls and positive controls respectively (experiment 1). In another experiment, oocytes  were exposed to graded (0.1, 1.0, 5.0, 10 ng/ml) concentrations of IGF1 alone (experiment 2). Experiments were   conducted at 26 ± 1º C temperature under aseptic conditions and each treatment group comprised 30 oocytes. Rate of GVBD was scored from 0 - 6 hours which was further confirmed by (i) treating oocytes with clearing solution and (ii) staining them in acridine orange. Highest percentage of GVBD was elicited in oocytes exposed to DES (73 %), followed by the combination of galactose + Insulin + IGF 1 (70 ± 11 %). Oocytes exposed to galactose alone recorded lowest GVBD. In second experiment, maximal GVBD (83 ± 3%) was observed in 10 ng/ml IGF1, followed by DES (73 ± 7 %), 5.0, 1.0, 0.1 ng/ml concentrations of IGF1 respectively. In 5.0 ng and 10 ng/ml IGF1 treated oocytes GVBD was significantly (P < 0.05) higher compared to controls. These results suggest that insulin is a potential inducer of GVBD in zebrafish oocytes and IGF1 may mediate the process of oocyte maturation in this fish.

 

Nothing to Disclose: KP, PAD

16630 6.0000 MON-0027 A Resumption of Meiosis in Zebrafish (Danio rerio) Oocytes in Response to Exposure to Insulin and Insulin like Growth Factor 1 (IGF1) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Eunhye Kim* and Sang Hwan Hyun
Chungbuk National University, Cheongju, Korea, Republic of (South)

 

The carboxyethylgermaniumsesquioxide (Ge-132) is an organogermanium compound known to have biological activities such as antioxidant and anticancer effect. In this study, we examined the effect of Ge-132 on in vitro maturation (IVM) of porcine oocytes analyzing nuclear maturation, intracellular glutathione (GSH) and reactive oxygen species (ROS) levels and subsequent embryonic development after in vitro fertilization (IVF) and  parthenogenetic activation (PA). After 40 h of IVM, no significant difference was observed in maturation of the 50-, 100- and 200 μg/ml Ge-132 treated groups (89.9%, 91.3% and 90.4%, respectively) compared with the control (89.0%). Intracellular GSH levels in oocytes treated with 200 μg/ml Ge-132 increased significantly (P< 0.05) compared with those in the control. The 200- and 400 μg/ml Ge-132 treated groups showed a significant (P< 0.05) decrease in intracellular ROS levels compared with the control. Oocytes matured with 200 μg/ml Ge-132 during IVM had no significantly higher blastocyst formation rates (31.6% vs. 36.7%) but had higher total cell numbers after IVF (71.5 vs. 101.3) than the control group. Furthermore, oocytes matured with 200- and 400 μg/ml Ge-132 during IVM had significantly higher cleavage rates (78.7% and 82.7%, respectively vs. 67.5%) and the 200 μg/ml Ge-132 treated group had higher blastocyst formation rates and total cell numbers after PA (59.5% and 38.2 vs. 67.8 and 55.3, respectively) than the control group. These findings suggest that 200μg/ml Ge-132 supplementation during IVM enhanced the developmental competence of IVF and PA porcine embryos by increasing the intracellular GSH levels and decreasing ROS levels during oocyte maturation.

 

Nothing to Disclose: EK, SHH

14378 7.0000 MON-0028 A The Effect of Carboxyethylgermaniumsesquioxide (Ge-132) on in Vitro Maturation of Porcine Oocytes and Subsequent Embryonic Development after in Vitro Fertilization 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Yubyeol Jeon*, Junchul David Yoon, Lian Cai, Seon-ung Hwang, Eunhye Kim, Zhong Zheng and Sang Hwan Hyun
Chungbuk National University, Cheongju, Korea, Republic of (South)

 

Zinc (Zn) is required for fetal growth and development. Zn deficiency results in fetal teratogenesis, prolonged gestation, difficult labor, and weak offspring. In this study, we investigated the effects of Zn deficiency during porcine in vitro maturation (IVM). Zn deficiency was induced by administering the membrane-permeable Zn chelator N,N,N′,N′-tetrakis-(2-pyridylmethyl)-ethylendiamine (TPEN). In experiment 1, we compared nuclear maturation, cytoskeletal component organization, and subsequent embryonic development among three groups of oocytes to investigate the effects of Zn deficiency during IVM: 1) treatment without TPEN (control); 2) treatment with 10 μM TPEN for 22 h during IVM; and 3) treatment with 10 μM TPEN + 10 μM Zn for 22 h during IVM. The oocyte maturation rates and subsequent embryonic developmental competence of the TPEN + Zn-treated oocytes were similar to those of the control oocytes (metaphase II [MII] rate: 93.0 ± 1.2 and 92.7 ± 1.8%, blastocyst [BL] formation rate: 42.0 ± 6.7 and 40.0 ± 7.5% for TPEN + Zn-treated oocytes and the control, respectively). These results are significantly different from those obtained for the TPEN-treated oocytes (MII rate: 0.61 ± 0.61%, BL formation rate: 0%). Although the TPEN-treated oocytes were arrested at metaphase I (MI), the distribution of microtubules was normal. However, microfilament formation was abnormal in the TPEN-treated oocytes. In experiment 2, we investigated the effect of a temporary Zn deficiency during IVM on oocyte maturation and subsequent embryonic development after parthenogenetic activation. TPEN (10 μM) was added to the IVM medium for 0, 7, 15, or 22 h. After TPEN treatment, 10 μM Zn was added to the IVM medium except in the 0 h group. Reductions in the nuclear maturation rate were dependent on the duration of TPEN treatment. The 0 h-treated oocytes showed an 83.9 ± 3.9% MII rate. The 7 h-treated oocytes had a significantly lower MII rate (44.8 ± 3.0%) than the 0 h-treated oocytes. Most of the 15 and 22 h-treated oocytes were arrested at MI (MI rate: 98.0 ± 1.0 and 97.2 ± 1.7%, MII rate: 0 and 0%, respectively). Similar results were obtained for embryonic developmental competence. Reductions in the rates of cleavage and BL formation were dependent on the TPEN treatment duration (cleavage rate: 65.3 ± 1.4, 42.6 ± 4.8, 2.6 ± 0.1, and 3.0 ± 1.6%, BL formation rate: 29.3 ± 2.8, 9.2 ± 1.5, 0, and 0% after 0, 7, 15, and 22 h). The total cell number in the BL in the 0 h-treated group (51.4 ± 4.5) was significantly higher than that in the 7 h-treated group (23.2 ± 1.6). In conclusion, Zn is an essential element for successful oocyte maturation and embryonic development in pigs. Zn deficiency for more than 7 h caused a meiotic block and had lasting effects on early embryonic development.

 

Nothing to Disclose: YJ, JDY, LC, SUH, EK, ZZ, SHH

14395 8.0000 MON-0029 A Zinc Deficiency during Porcine Oocytes in Vitro Maturation Caused Meiotic Block and Developmental Failure 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Yubyeol Jeon*, Junchul David Yoon, Lian Cai, Seon-ung Hwang, Eunhye Kim, Zhong Zheng and Sang Hwan Hyun
Chungbuk National University, Cheongju, Korea, Republic of (South)

 

We investigated the effects of zinc (Zn) supplementation during the in vitro maturation (IVM) of porcine oocytes. We investigated nuclear maturation, intracellular glutathione (GSH) and reactive oxygen species (ROS) levels, subsequent embryonic development, and gene expression. Prior to the experiment, Zn concentrations in IVM medium and body fluids were measured and treatment concentrations were determined. Zn concentrations in porcine plasma and follicular fluid were 0.82 ± 0.02 and 0.84 ± 0.01 μg/mL, respectively. Zn was not detected in IVM medium. Nuclear maturation was evaluated in 541 cumulus–oocyte complexes matured in TCM 199 medium supplemented with various Zn concentrations (0.0, 0.4, 0.8, 1.2, and 1.6 µg/mL). After 44 h, no significant difference in IVM was observed among groups (85.7%, 88.7%, 90.4%, 90.3%, and 87.2%, respectively). The effects of different Zn concentrations on porcine oocyte intracellular GSH and ROS levels were examined in 100 mature oocytes. Intracellular GSH levels were significantly higher in the 0.8-, 1.2-, and 1.6-µg/mL groups (1.45, 1.67, and 1.78, respectively) than in the control and 0.4-µg/mL groups (1.00 and 1.08, respectively; p < 0.05). Intracellular ROS levels of oocytes matured with 0.8, 1.2, and 1.6 µg/mL Zn (0.82, 0.68, and 0.55, respectively) were reduced significantly (p < 0.05) compared with the control and 0.4-µg/mL groups (1.00 and 1.03, respectively). The developmental competence of oocytes matured with different Zn concentrations was evaluated after parthenogenetic activation (PA) and in vitro fertilization (IVF). Oocytes treated with Zn during IVM showed no significant difference in cleavage rate after PA. Oocytes treated with 0.8 and 1.2 µg/mL Zn during IVM had significantly higher blastocyst formation rates after PA (41.5% and 41.1%, respectively) than the control (27.2%). IVF embryos showed similar results. The blastocyst formation rate was significantly higher (28.2%) in the 0.8-µg/mL group. TNFAIP2 and Bax were decreased in Zn-treated cumulus cells. Increased POU5F1 and decreased Bax transcript levels were observed in Zn-treated oocytes. POU5F1 and Bcl-2 transcript levels were significantly higher in Zn-treated IVF blastocysts. These results indicate that treatment with Zn concentrations similar to or slightly higher than physiological levels during IVM improved the developmental potential of PA and IVF in porcine embryos by increasing the intracellular GSH concentration and reducing the ROS level.

 

Nothing to Disclose: YJ, JDY, LC, SUH, EK, ZZ, SHH

14402 9.0000 MON-0030 A Effects of Zinc on Porcine Oocyte Maturation in Vitro and Subsequent Embryonic Development 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Yubyeol Jeon*, Junchul David Yoon, Lian Cai, Seon-ung Hwang, Eunhye Kim, Zhong Zheng and Sang Hwan Hyun
Chungbuk National University, Cheongju, Korea, Republic of (South)

 

Transgenic (TG) pigs have been used as large-animal model in many biomedical researches. However, the production efficiency of TG pig is very low. The lower TG pig production efficiency has been an obstacle to the application of TG pig for biomedical research. Zinc supplementation (0.8 µg/ml) on in vitro maturation (IVM) medium significantly enhances oocyte’s quality and in vitro development of the parthenogenetically activated and in vitro-fertilized embryos. And, a somatic cell nuclear transfer (SCNT) method in which somatic cells derived from TG pig are used as the nuclear donor (recloning method) is an effective technique for TG pig production. In this study, we compared the in vitro and in vivo developmental rate of TG SCNT embryos between control (conventional IVM) and zinc-supplemented IVM group. And the other hand, TG efficiency of recloning method was confirmed. A total of 485 TG SCNT embryos were produced to compare the in vitro developmental rate. There were no significant differences in the cleavage rate (80.6% vs. 75.3%) or blastocyst formation (22.9% vs. 23.7%) between the control and zinc-supplemented group. A total of 1206 and 890 TG SCNT embryos were produced using control and zinc-supplemented oocytes, and then transferred to 11 and 8 recipients. Five recipients in the control group and three recipients in the zinc-supplemented group became pregnant. The pregnancy rate was not significantly different (45.5% vs. 37.5%). Two live piglets and eight mummies were born from two recipients in the control group and ten live piglets and six stillborn piglets were born from three recipients in the zinc-supplemented group. Zinc supplementation during IVM tended (P=0.09) to affect pregnancy status (abortion: 27.3% vs. 0%, parturition 18.2% vs. 37.5%, control vs. zinc-supplemented group). The production efficiency was significantly increased in the zinc-supplemented group (0.33% vs. 3.02%, control vs. zinc-supplemented group). Using the recloning method, 1237 recloned embryos were produced from zinc-supplemented oocytes and then transferred to 11 recipients. Seven teen live and six stillborn piglets were born from four recipients. All of the seven teen recloned piglets showed target gene integration. But, of twelve direct-cloned piglets, target gene integration was confirmed in seven piglets. TG efficiency efficiency was significantly increased in recloning group (58.3% vs. 100.0%, direct cloning vs. recloning). This report indicates that zinc supplementation on IVM medium improved the production efficiency of TG pigs, and the TG efficiency was improved by recloning.

 

Nothing to Disclose: YJ, JDY, LC, SUH, EK, ZZ, SHH

14413 10.0000 MON-0031 A Efficient Production of Transgenic Pigs By Zinc Supplementation during in Vitro Maturation and Recloning 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Valérie Bernard*1, Justine Bouilly2, Nadège Carré1, Martin Schlumberger3, Jenny A. Visser4, Jacques Young5 and Nadine Binart1
1Unité Inserm 693, Le Kremlin-Bicêtre, France, 2Unité Inserm 1185, Le Kremlin-Bicêtre, France, 3Institut Gustave Roussy, Villejuif, France, 4Erasmus MC, Rotterdam, Netherlands, 5University Paris Sud, Department of Endocrinology, Bicetre Hospital, INSERM U693, Le Kremlin-Bicêtre, Fance, Le Kremlin Bicêtre, France

 

During the last decade, sunitinib, an oral multitargeted tyrosine kinase inhibitor (TKI), proved its efficacy in different types of cancer in both adults and children. Prolonged administration of this product, as well as other TKIs, is known to cause endocrine-related side effects such as hypothyroidism and diabetes, but data regarding its effects on gonadal function and subsequent fertility are lacking. The aim of this study was to evaluate, in a preclinical setting, the effects of sunitinib on ovarian function and follicular reserve using a mouse model. Six-week-old female mice were randomized into 2 groups: mice received [orally, once daily (5d/wk)] either vehicle (n=12) or sunitinib (n=19) (50 mg/kg/d) during 5 weeks. Cyclicity, ovulation rate, Amh transcripts and circulating AMH levels were evaluated at the end of the treatment in both groups. Sunitinib exposition significantly reduced (i) corpora lutea number per ovary (1.1 ± 0.38 in sunitinib group versus 4 ± 0.79 in control group, p<0.01) and (ii) serum AMH levels in sunitinib treated mice (12.01 ± 1.16 ng/ml) compared to control mice (14.33 ± 0.87 ng/ml, p< 0.05). Sunitinib dramatically altered the ovarian ovulation process in mice suggesting a deleterious fertility effect. The decrease in ovarian Amh transcripts and serum AMH levels suggests that sunitinib could also impact ovarian reserve in rodents. Its effect should absolutely be evaluated in women, since it is already being administered to children and young adults. Thus, sunitinib, as well as other TKIs, could be suspected to induce premature ovarian insufficiency. Therefore, fertility preservation methods should be discussed before initiation of the treatment in girls and young women.

 

Nothing to Disclose: VB, JB, NC, MS, JAV, JY, NB

12618 11.0000 MON-0032 A Sunitinib Affects Ovarian Function in Mouse: A Pre-Clinical Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

James Robert McFarlane*, Suresh K.A Palanisamy and Muren Herrid
University of New England, Armidale NSW, Australia

 

Leptin was first identified as a peripheral satiety signal made by adipose tissue which crosses the blood brain barrier and signals to the hypothalamus regulating energy expenditure and appetite. Although it was originally thought to be derived predominantly from adipose tissue, leptin actually appears to be almost ubiquitously expressed in many tissues and has a multitude of possible functions including a direct role in reproduction.  The complete absence of leptin is not developmentally lethal and in mice results in early onset obesity, stunted skeletal and brain growth, extreme insulin resistance, hyperphagia, a compromised immune system and infertility. Fertility can be restored in both female and male ob/ob mice by the exogenous provision of leptin, which is characterized by an increase in basal LH and FSH. However, fertility of ob/ob mice is not reversed simply by food restriction, indicating an effect of leptin per se on reproductive function. We have previously demonstrated that leptin neutralizing antibodies increases ovarian weight in response to gonadotropins compared to gonadotropin treatment alone. In this study we examine the effects on ovulation and mRNA expression profiles of leptin, its receptors and anti mullerian hormone (amh) and aromatase in the ovary.

Immature mice (3 weeks old) were divided into four groups (n=3) and given subcutaneous  injections of the following treatments on day 1 and day 3 (i) saline; (ii) anti-leptin antibody (50 µg); (iii) eCG (0.1 IU); (iv) eCG (0.1 IU) + anti-leptin antibody (50 µg). Animals were sacrificed by CO2 asphyxiation 24 hours after the last injection. Ovaries and uteri were dissected out, weighed and samples were collected for RNA extraction. The numbers of eggs in the oviduct were counted. The experiment was then repeated. The mRNA expression for leptin, leptin receptors and amh in the ovary were determined by qPCR.

There was no difference in ovarian and uterus weights between experimental groups except for the eCG + anti-leptin group ovaries which was significantly heavier than the control ovaries. A higher number of eggs were collected from the eCG + anti-leptin (16.1 ± 1.8) group compared to control (1.12 ± 0.02), eCG (0.8 ± 0.03) anti-leptin group (2.8 ± 0.09). Leptin mRNA  was increased in the eCG and eCG + anti leptin groups. There were differential responses of the leptin receptor isoforms to the treatments. Anti-leptin treatment in combination with eCG increased the expression of aromatase, amhand its receptor in comparison the other experimental groups.

In summary, reducing peripheral leptin increases the sensitivity of the ovary to gonadotropins and increases the expression of aromatase, amh and its receptor suggesting leptin antagonizes follicular development.

 

Nothing to Disclose: JRM, SKAP, MH

14324 12.0000 MON-0033 A Passive Immunization Against the Hormone Leptin Improves Ovarian Sensitivity to Gonadotropins 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Yuan Cheng*1, Kazuhiro Kawamura2, Masashi Deguchi1, Yorino Sato2, Yi Feng1 and Aaron J W Hsueh1
1Stanford University, 2St. Mariana University

 

Hippo signaling pathway is conserved from flies to mammals and is important in maintaining optimal organ sizes. Hippo signaling consists of several negative growth regulators acting in a serine/threonine kinase cascade that ultimately phosphorylate and inactivate Hippo signaling effector YAP (Yes-associated protein). Our recent study demonstrated that fragmentation of murine ovaries increases actin polymerization and decreases phospho-YAP (pYAP) levels, leading to increases nuclear localization of YAP  in follicle cells. YAP, in turn, induces downstream CCN growth factors to promote follicle growth (1). For patients with the polycystic ovarian syndrome (PCOS) showing follicle growth arrest, wedge resection and laser drilling of ovaries promote follicle growth. Because these damaging procedures, similar to ovarian fragmentation in animal models, likely involve actin polymerization, actin polymerization-promoting drugs could be effective as PCOS therapies.  Here, we demonstrated that treatment of intact ovaries from mice at day 10 of age with either Jasplakinolide (JASP), an actin polymerization-promoting cyclic peptide, or sphingosine-1-phosphate (S1P), a follicular fluid constituent known to promote actin polymerization, increased the conversion of globular (G)-actin to the filamentous (F-) form after drug exposure, and decreased pYAP levels based on immunoblotting analyses (P<0.05; n=6). Immunohistochemical analyses further showed that treatment with either JASP or S1P increased YAP nuclear localization in follicular cells.  By using real-time PCR and immunoblotting, we found increased  expression of downstream growth factor CCN2 following JASP or S1P treatment (P<0.05; n=8). JASP and S1P treatment increased immunoreactive CCN2 by 2.0 and 1.8-fold, respectively. Furthermore, short-term treatments with either JASP or S1P (10 uM JASP for 30 min.; 12 uM S1P for 18h), followed by ovarian grafting into FSH-treated adult hosts for 5 days, promoted ovarian weight gain and follicle growth (p<0.05; n=10). Our studies demonstrated the role of actin polymerization in the disruption of Hippo signaling, leading to nuclear YAP localization in ovarian follicles to promote follicle growth.  Both JASP and S1P are potential therapeutic agents for treating the prevalent PCOS and other ovarian diseases.

 

Nothing to Disclose: YC, KK, MD, YS, YF, AJWH

13285 13.0000 MON-0034 A Polymerization of Actin Promotes Ovarian Follicle Growth Mediated By the Hippo Signaling Effector YAP 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Nisan M Hubbard*, Dallas A Vanorny and Kelly E Mayo
Northwestern University, Evanston, IL

 

In response to the pituitary gonadotropins, Follicle-Stimulating Hormone (FSH) and Luteinizing Hormone (LH), ovarian follicles undergo growth and maturation that results in the ovulation of a meiotically competent oocyte and transformation of the remaining somatic cells into a corpus luteum that will produce hormones necessary to sustain a pregnancy. There is substantial information regarding the role of steroid nuclear receptors, such as the progesterone, estrogen, and androgen receptors, in ovarian function, but there is a lack of information on the regulation and function of many of the other nuclear receptors in the ovary. Using high-throughput techniques, we profiled the expression of all 49 nuclear receptors in the ovaries of mice treated with exogenous gonadotropins to facilitate ovulation and luteinization of follicles. Post-natal day 21 female CD1 mice were treated with vehicle or with Pregnant Mare’s Serum Gonadotropin (PMSG) for 48 hours, or with PMSG followed by injection with human Chorionic Gonadotropin (hCG) for 1, 4, 12, or 24 hours. We found more than 30 nuclear receptor mRNAs to be expressed in the ovary under these conditions and observed multiple nuclear receptors to be regulated following the hormone treatments. In unstimulated ovaries, Liver Receptor Homolog-1 (Lrh1), Chicken Ovalbumin Upstream Promoter Transcription Factor II (COUP-TFII), Steroidogenic Factor I (Sf1), Estrogen Receptor beta (Esr2), and Thyroid Receptor alpha (Thra) were the most abundantly expressed mRNAs. Some of the most dynamically expressed transcripts following PMSG and hCG stimulation were Progesterone Receptor (Pgr), Liver Receptor Homolog-1 (LRH-1), the Nerve Growth Factor IB-Like Receptors (Nur77, Nurr1, and Nor1), COUP-TFII, and Rev-Erb Beta (Nr1d2). Mutations in several of these dynamically expressed genes have known reproductive phenotypes; however, their specific roles in follicular growth, ovulation, and differentiation remain unknown. These expression data suggest several nuclear receptors as potential candidates for further study to enhance understanding of gonadotropin-mediated signaling events in the mammalian ovary.

 

Nothing to Disclose: NMH, DAV, KEM

16343 14.0000 MON-0035 A Dynamic Expression and Regulation of Nuclear Receptor Superfamily mRNAs in the Mouse Ovary Following Gonadotropin Stimulation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Yuanming Xu*1, Robin Michelle Skory2, Jie Zhu1, Francesca Duncan1, Min Xu3, Lonnie D Shea3, Mary Ellen Pavone1, Julie Kim1, Joanna Elizabeth Burdette4 and Teresa K Woodruff5
1Northwestern University, Chicago, IL, 2Northwestern Univ, Chicago, IL, 3Northwestern Univ, Evanston, IL, 4University of Illinois at Chicago, Chicago, IL, 5Feinberg School of Medicine, Northwestern University, Chicago, IL

 

Studies of the human ovary and follicle function are limited by the availability of human tissue and the lack of good in vitro models. We developed an encapsulated, three-dimensional in vitro follicle growth (eIVFG) system to create a physical environment that supports complete human and rodent follicle development through luteinization. When grown in this artificial ovary, human follicles secrete steroid and peptide hormones that recapitulate the patterns of serum hormones seen during the natural 28-day menstrual cycle. We were also able to mimic the complete human cycle using follicles isolated from mice, thereby providing a surrogate tissue source for human follicle research. The eIVFG culture system reliably phenocopies in vivo follicle hormone production and provides a new tool to study human follicle biology and the influence of cycling female hormones on other tissue systems in vitro, with additional applications in preclinical toxicity testing and sex-based research to improve women’s health.

 

Nothing to Disclose: YX, RMS, JZ, FD, MX, LDS, MEP, JK, JEB, TKW

12620 15.0000 MON-0036 A Engineering the Ovarian Cycle Using in Vitro Follicle Culture – a New Tool for Preclinical Reproductive Research 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Kate Hardy*1, Mark Fenwick2, Jossie Mora3 and Stephen Franks1
1Imperial College London, London, United Kingdom, 2University of Sheffield, Sheffield, United Kingdom, 3Imperial College London, United Kingdom

 

The obligatory role of follicle stimulating hormone (FSH) in normal development and function of antral follicles in the mammalian ovary is well recognized but its function in preantral growth is unclear. Granulosa cells of preantral follicles express FSH receptors but there has been no systematic assessment of the response to FSH in preantral follicles. The specific objective of this study was to investigate the response, in culture, to FSH of mouse preantral follicles of increasing size, focusing particularly on rate of growth and gene expression.

Preantral follicles were mechanically isolated, using acupuncture needles from ovaries of C57BL/6 mice aged between 12-16 days post partum and single follicles were cultured for up to 96h in individual wells containing 100μl MEM-α supplemented medium alone (n=511) or with rhFSH 10ng/ml (n=546). Follicle area was measured at 24-hour intervals, using ImageJ. Images of follicles at consecutive time points, as well as diameters, were imported into a custom-made database (FileMaker Pro 11.0v2; http://www.filemaker.com) to enable easy inspection and analysis of follicles during development. Data were grouped according to intial follicle size in 6 strata of follicle diameter ranging from <100 to >140 μm.

All follicles grew significantly during 96h in culture in the absence of FSH (p<0.001, ANOVA) but the relative change in area was greatest in the smallest follicles. Follicles at all sizes grew at a significantly faster rate (p<0.0001) in the presence of 10 ng/ml FSH but here the larger follicles showed the greatest change in response to FSH. In terms of gene expression, even the smallest follicles expressed FSH receptor mRNA, in the absence of FSH stimulation. In response to FSH, FSH receptor mRNA (measured by qPCR) was significantly reduced (p<0.01) as was Amh (p<0.01) whereas gene expression of StAR (p<0.0001) and the steroidogenic enzymes Cyp11a1 (p<0.01) and Cyp19 (p<0.0001) was increased.

These results confirm that preantral ovarian follicles are responsive to FSH but show a heterogeneous response according to initial follicle size, smaller follicles being less FSH-dependent for growth than larger preantral follicles. In conclusion, although follicle development to the late preantral stage can progress in the absence of FSH, our data confirm the notion of FSH responsiveness in prentral follicles and strongly suggest that FSH has a physiological role in normal preantral follicle growth and function.

 

Nothing to Disclose: KH, MF, JM, SF

13714 16.0000 MON-0037 A FSH Regulation of Preantral Follicle Growth and Gene Expression in the Mouse Ovary 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Shruti Kmath, Michael Demczuk* and Jingjing Kipp
DePaul University, Chicago, IL

 

Retinoic acid (RA), an active derivative of vitamin A, is involved in tissue organization, patterning and growth. Although RA has been shown to regulate male reproduction, information on its roles in ovary development is very limited. We have demonstrated that RA stimulates the growth of ovarian granulosa cells and follicles in vitro, and RA deficiency results in reduced follicle/corpus luteum numbers, increased follicle atresia and ovarian cyst formation in vivo. To further investigate RA function in the ovary, we examined its regulation of early ovarian follicle formation and development using whole ovary cultures. Newborn mouse ovaries were cultured for 4 days in the presence of vehicle control, RA, or RA Metabolism Blocking Agents (RAMBAs) including R115688 and liarozole. The cultured ovaries were then collected for morphological examination, follicle counting, and immunohistological studies. The ovaries appeared to be larger in the liarozole treated group than in other groups. Follicle counting showed a decrease in oocyte nests and increase in secondary follicles in RA, R115866 or Liarozole treated groups as compared to the control. In addition, RA or Liarozole treated ovaries showed a decrease in primordial follicles. Atretic follicles were also observed in ovaries treated with liarozole but not in other groups. The ovaries treated with RA or liarozole also showed an increase in the total number of follicles as compared to the control. Immunohistological studies showed that RA, R115866, or liarozole all induced the expression of CYP26B1, a key enzyme that degrades RA, consistent with reports by others. TUNEL assays showed no obvious difference in cell apoptosis in all treatment groups, suggesting that the effects of RA or RAMBAs in neonatal ovaries were mediated through other pathways, which we are currently examining. Overall, our studies suggest that RA is critical for early ovarian follicle formation and development.

 

Nothing to Disclose: SK, MD, JK

15664 19.0000 MON-0040 A Retinoic Acid Regulation of Early Ovarian Follicle Formation and Development 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Justine Bouilly*1, Reiner Veitia2 and Nadine Binart3
1Unité Inserm 1185, Le Kremlin-Bicêtre, France, 2Institut Jacques Monod, Paris, France, 3Unité Inserm 693, Le Kremlin-Bicêtre, France

 

Several transcription factors involved in ovary development and folliculogenesis are mutated in reproductive disorders. We have recently shown a high prevalence (>6 %) of Primary Ovarian Insufficiency (POI) cases harboring mutations in the Newborn oogenesis homeobox (NOBOX) gene, which encodes a homeodomain-containing transcription factor expressed preferentially in oocyte (1). This prevalence is currently validated on another large cohort. NOBOX plays an important role in oogenesis and ovarian development, it is a critical transcription factor during the transition from primordial to primary follicles, and it continues to be expressed throughout folliculogenesis and its absence leads to sterility. We showed that NOBOX was also expressed in follicular granulosa cells (FGCs), those surrounding the germ cell. Since NOBOX and FOXL2, a master regulator of FGC development (belonging to forkhead family) (2), are co-expressed in FGCs, we have hypothesized their potential interaction. By immunoprecipitation and double-hybrid assays using HEK 293T cells, we demonstrated that NOBOX and FOXL2 indeed physically did interact. Moreover, we showed that the FOXL2 and NOBOX interaction lead to down-regulation of their transactivation capacity. The molecular targets are being currently characterized. The post-translational modifications of NOBOX could play a role in this interaction and are under investigation. Interestingly, a naturally occurring truncating human mutation of NOBOX abolished its repressive activity on FOXL2. Altogether, these observations highlighted a novel role for NOBOX in interaction with FOXL2, and suggested that they may be antagonistic transcription regulators. The high prevalence of NOBOX mutations in women with POI and its interaction with FOXL2 is of particular interest to understand basic pathophysiological principles of ovarian gene regulation.

 

Nothing to Disclose: JB, RV, NB

12772 20.0000 MON-0041 A Nobox a Master Regulator of Folliculogenesis: Relevance to Primary Ovarian Insufficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Marilia Cordeiro*1, So-Youn Kim1, Katy Ebbert1, Francesca Duncan1, João Ramalho-Santos2 and Teresa K Woodruff3
1Northwestern University, Chicago, IL, 2University of Coimbra, Center of Neuroscience and Cell Biology, Coimbra, Portugal, 3Feinberg School of Medicine, Northwestern University, Chicago, IL

 

Folliculogenesis is a complex process in which primordial follicles are selectively activated to grow and ultimately produce a female gamete capable of being ovulated and fertilized. To date, there is no robust method to track follicles/oocytes during the course of development in vivo. In this study, we generated a triple transgenic mouse in which oocyte-specific promoters (VASA, GDF-9 and ZP3), active at distinct stages of oocyte and follicle development, drive the expression of genes encoding exogenous fluorescent proteins (EGFP, mCherry and AmCyan, respectively). The mice were generated by pronuclear microinjection 1:1:1 ratio of the three independent DNA constructs (injections performed by NU Transgenic Core). The co-injection resulted in random insertion of exogenous DNA into the mouse genome and 9 independent transgenic lines were generated – 1 double and 8 triple transgenic founders. We then selected a line (#5570) in which the 3 transgenes segregated together after 4 generations and that had relatively robust expression for all three transgenes. We examined the expression pattern of the promoter-driven fluorescent proteins in ovaries from different age mice and found a follicle-class dependent pattern consistent with prior studies using VASA, GDF9, and ZP3 promoters. We examined the expression intensity of the oocytes and found that levels differed even within follicle classes, suggesting an underlying activity or intrinsic stratification of function not previously appreciated. Finally, we used the mouse line to examine the location of the first wave of follicle activation in the postnatal mouse. The first activated/growing follicles appear on the dorsal side of the ovary in a relatively posterior location (on the ovarian side nearest the rete ovarii). In conclusion, our triple transgenic mice represent the first oocyte specific reporter lineage in which the signal of fluorescent proteins can be use to follow oocyte gene activity and follicle activation. This transgenic mouse line will be an important tool for expanding our basic understanding of the mechanisms controlling follicle selection, oocyte quality and ovarian developmental dynamics. Similar utility may be found in the male offspring.

 

Nothing to Disclose: MC, SYK, KE, FD, JR, TKW

13506 21.0000 MON-0042 A Gene Reporter Profile of Oocytes and Spatial Mapping of Follicle Activation Using a VASA/GDF-9/ZP3 Triple Transgenic Reporter Line 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Yogeshwar Makanji*1, Duaa Al-Muhana2, Jared Mamrot3, Peter Temple-Smith2, Craig Anthony Harrison1, David Walker3 and Hayley Dickinson3
1MIMR-PHI Institute of Medical Research, Clayton, Australia, 2Monash University, Clayton, Australia, 3MIMR-PHI Institute, Clayton, Australia

 

Spiny mice are precocial and exhibit advanced ovarian maturity compared to altricial species like C57BL/6 F1 mice. In addition, the germ-cell nest breakdown in the ovary and establishment of ovarian reserve in spiny mice occurs in utero, similar to humans. The typical estrous cycle and gestation period in the spiny mouse is longer than in F1 mice (~11 days vs. 4-5 days and ~39 days vs. 20 days, respectively). The aims of this study were to establish a three-dimensional culture model for spiny mouse follicles and compare with F1 follicle development, in vitro. In this study, secondary (130-150 μm) follicles were mechanically isolated from F1 and spiny mouse ovaries and encapsulated in alginate hydrogels. Individual encapsulated follicles were cultured in defined culture medium for up to 18 days at 5% CO2, 37°C. Medium was refreshed every other day and follicles were imaged. Cultured medium was stored at -80C for hormone analysis. Follicles were imaged every other day and diameter was measured using NIH ImageJ software. Pre-ovulatory follicles (~500 μm) were removed from alginate hydrogel and incubated overnight in medium containing hCG/EGF. Following maturation, oocyte meiotic competence was assessed under the microscope. Spiny mouse and F1 follicles grew at similar rates, 26 and 24 μm/day, respectively. Interestingly, on day 8 of culture, survival of spiny mouse follicles was higher (86±19%), whilst F1 follicles had poor survival (51±17%, P<0.05). Antrum formation in F1 follicles occurred around day 8, however, in spiny mouse follicles antrum formation was delayed by an average of 4 days (~day 12) In addition, during the first 12 days of culture, spiny mouse follicles had a prominent thick theca-like layer of cells surrounding the entire follicle. The theca-like layer became less prominent with antrum formation. In comparison, F1 follicles had a less prominent theca-like layer throughout the culture. Similar MII rates (~50%) were observed for spiny mouse and F1 follicles. In conclusion, three-dimensional in vitro culture of spiny mouse follicles provides insights into folliculogenesis of a unique species. Despite growing at similar rates to F1 follicles, spiny mouse follicles have increased survival and delayed antrum formation. In addition, the transient theca-like layer diminishes with antrum formation but may underpin improved survival of spiny mouse follicles in culture. The underlying mechanisms of increased survival and transient theca-like layer are currently being explored.

 

Nothing to Disclose: YM, DA, JM, PT, CAH, DW, HD

16641 22.0000 MON-0043 A Characterisation of Spiny Mouse (Acomys cahirinus) Folliculogenesis Using a Three-Dimensional in Vitro Culture Model 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Mhairi Laird*1, Jenny A. Visser2, E. Leonie A.F. van Houten2, Kate Hardy3, Elena Georgiou3 and Stephen Franks4
1University of Reading, Reading, United Kingdom, 2Erasmus MC, Rotterdam, Netherlands, 3Imperial College London, London, United Kingdom, 4Imperial College London, United Kingdom

 

Polycystic ovary syndrome (PCOS) is the commonest cause of reproductive and metabolic disorders in women of reproductive age. Prepubertal mice subjected to chronic exposure of DHT develop both metabolic and reproductive disorders that are similar to those seen in women with PCOS (1). Our aim was to examine the effects of DHT on stromal/theca morphology and on protein expression of SMADS (key signaling molecules for growth factors of the TGFb superfamily) in granulosa cells of follicles at various stages of development.

Female C57BL/6 mice were implanted subcutaneously with either a 90-day continuous release DHT (daily dose of 27.5µg) or placebo pellet (control). At the end of treatment, mice were sacrificed and the ovaries collected and prepared for immunohistochemical localization of androgen receptor (AR), granulosa specific ligands, SMAD2/3, SMAD1/5/8, and known vascular markers of both the ovarian stroma and theca layer, α-smooth muscle actin (SMA) and pecam (endothelial cell marker). Image analysis was performed to quantify differences in abundance of staining in DHT-exposed ovaries compared to control.

DHT-treated animals showed a significant increase in the abundance of SMA, throughout the ovary, compared to controls (P<0.0001). Furthermore, the pattern of SMA staining surrounding growing follicles was noticeably different from normal ovarian tissue, with multiple thickened layers of SMA observed in DHT-treated ovaries. Endothelial cell localization also appeared to be dysregulated. In placebo-treated animals pecam staining was limited, as expected, to the ovarian vasculature. However, in DHT-treated animals it appeared that not only were there increased numbers of endothelial cells but these were spread randomly throughout the stroma. Within the granulosa compartments an increase in SMAD1/5/8 intensity was observed in large growing follicles of DHT-treated animals compared to control. However, differences observed with SMAD2/3 were more variable. AR expression was similar in granulosa cells of both DHT- and placebo-treated animals, but there was an increase in the number of AR positive cells within the stroma of androgenized animals.

In conclusion, treatment with DHT during puberty results in extensive changes in stromal expression of factors thought to be involved in vascularization and theca formation, suggesting that exposure to excess androgen induce changes to stroma that are reminiscent of abnormal ovarian morphology in human polycystic ovaries.

 

Nothing to Disclose: ML, JAV, ELAFV, KH, EG, SF

15849 23.0000 MON-0044 A Ovarian Abnormalities in Androgenized Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Takeshi Hosoya*, Fumio Otsuka, Eri Nakamura, Tomohiro Terasaka, Naoko Tsukamoto-Yamauchi, Kishio Toma, Kanako Ogura-Ochi, Takayuki Hara, Kenichi Inagaki and Hirofumi Makino
Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan

 

BMP-9 (GDF-2) is mainly expressed in the liver, showing hematopoietic, hepatogenic and osteo-chondrogenic activities.  BMP-9 also acts as a metabolic regulator for glucose, lipid and iron as well as a neuronal differentiation factor.  BMP-9 exists in human serum and plasma, in which the circulating concentration was found to be higher at the order of ng/mL compared with the other BMPs.  Recently, it was reported that BMP-9 is associated with cancer cell proliferation, apoptosis and differentiation in the ovary, prostate, breast and thyroid tissues.  These findings implicate a possible involvement of BMP-9 in the regulation of endocrine functions.  In the ovary, various BMPs expressed in the ovary differentially regulate steroidogenesis by granulosa cells.  For instance, oocyte BMP-15 attenuates FSH actions by suppressing FSHR expression in granulosa cells.  BMP-6 inhibits FSH-induced progesterone level by suppressing adenylate-cyclase in granulosa cells.  BMP-2 in granulosa and BMP-4 and BMP-7 in theca increase FSH-induced estradiol but suppress progesterone production.  However, the effects of BMP-9 on the ovarian steroidogensis and folliculogensis have yet to be elucidated.  In the present study, we investigated the effects of BMP-9 on steroidogenesis by rat primary granulosa cells.  BMP-9 had no specific effects on basal estradiol or progesterone level by rat granulosa cells.  FSH-induced estradiol production was not significantly altered by BMP-9, whereas BMP-9 potently suppressed FSH-induced progesterone production in a concentration-dependent manner.  The effects of BMP-9 on FSH-induced steroidogenesis were not influenced by the presence of oocytes.  To know the mechanism by which BMP-9 suppresses FSH-induced progesterone production in granulosa cells, cAMP synthesis and the expression levels of steroidogenic enzymes were examined.  As a result, FSH-induced cAMP synthesis was inhibited by BMP-9.  FSH-induced mRNA levels of StAR, P450scc, 3bHSD2 and FSHR were suppressed by BMP-9, while that of aromatase was not significantly changed by BMP-9.  Although BMP-9 is the physiological ligand for ALK-1, the functional receptors for BMP-9 have not been well characterized.  Here, we confirmed that BMP-9 activated Smad1/5/8 phosphorylation and Id-1 transcription as shown in the cases treated with BMP-4, -6 and 7 by rat granulosa cells.  Furthermore, the functional receptors for BMP-9 in granulosa cells were revealed to be ALK-1 and BMPRII based on the results using extracellular domains of BMP receptors.  These findings suggest that BMP-9 functionally contributes to the progesterone reduction as a new luteinizing inhibitor in the process of ovarian folliculogenesis.

 

Nothing to Disclose: TH, FO, EN, TT, NT, KT, KO, TH, KI, HM

13554 24.0000 MON-0045 A Effects of BMP-9, a Circulating BMP, on Steroidogenesis By Rat Granulosa Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Hiromi Koso Nishimoto*1, Juilee Rege1, Bruce R Carr2, Raymond J Rodgers3 and William E. Rainey1
1University of Michigan, Ann Arbor, MI, 2Univ Texas SW Med Sch, Dallas, TX, 3University of Adelaide, Adelaide, Australia

 

Background: Bone morphogenetic proteins (BMPs) are members of the transforming growth factor-β (TGF-β) superfamily that play a critical role in the regulation of gonadal stem cells and their steroidogenic progeny. We have previously shown that BMP4 inhibits androstenedione (A4) production and CYP17 expression in a human ovarian theca-like tumor (HOTT) cell culture model. Similar effects of BMP4, 6 and 7 have been shown for bovine theca cells (Endocrinol 146:1883, PNAS 110:1426).  In this study, we tested the hypothesis that BMP4 has broad effects on theca cell gene expression, including key genes involved in differentiated function. We previously demonstrated the utility of the HOTT cell model (JCEM 81:257, JCEM 85:3331). HOTT cells retain many of the characteristics of normal theca cells and respond to protein kinase A agonists, including dibutyryl cAMP (dbc) by increasing production of A4 and expression of steroidogenic enzymes.

Methods: HOTT cells were incubated in the absence (basal) or presence of dbc (1.5mM) and/or BMP4 (10ng/ml).  A4 production was measured by immunoassay and 17-alpha-hydroxylase (CYP17), R-spondin 3 (RSPO3), insulin-like 3 (INSL3) and inhibitor of DNA binding 1, dominant negative helix-loop-helix protein (ID1) were measured by quantitative RT-RTPCR.  

Results: HOTT cell production of A4 (17.2±0.3 nmol/well at 48h) was inhibited by treatment with BMP4 (by 33%). BMP4 also significantly inhibited several transcripts associated with theca cell differentiation, including INSL3 (0.4-fold) and CYP17 (0.1-fold). In contrast, BMP4 increased transcript levels for RSPO3 (4.2-fold) and ID1 (4.9-fold). Treatment with dbc (48h) increased A4 production (6-fold vs basal) and transcript levels of INSL3 (4.8-fold), RSPO3 (2.3-fold) and CYP17 (20-fold). In contrast, dbc decreased ID1 expression (0.3-fold). Co-treatment with BMP4 and dbc (48h) inhibited A4 production by 50% (vs. dbc alone). In addition, BMP4 inhibited dbc-induced expression of CYP17 (60% inhibition). Dbc also caused a surprising augmentation of BMP4-induced theca cell ID1 transcript levels at both 24h (22.6-fold vs. basal) and 48h (10.8-fold vs. basal).

Conclusions: BMP4 caused dramatic effects on HOTT cell expression of key markers of differentiation and inhibited androgen production. Definition of the molecular mechanism causing BMP dependent androgen synthesis is currently underway.

 

Nothing to Disclose: HKN, JR, BRC, RJR, WER

16725 25.0000 MON-0046 A Bone Morphogenetic Protein 4 (BMP4) Regulation of Theca Cell Gene Expression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Saúl Lira*1, Leticia González1, Rocio García-Becerra1, David Ordaz-Rosado1, Marta Durand2 and Fernando Larrea3
1National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico, 2Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, Mexico, 3National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico DF, Mexico

 

Hormonal contraceptives have been used to prevent unwanted pregnancies for more than four decades. One of these compounds, levonorgestrel, a 19-nor-testosterone-derived progestin, has recently been evaluated as emergency contraceptive by our research group. In these studies, levonorgestrel, when given before ovulation in healthy ovulatory women, decreased serum concentrations of LH, estradiol, and estrone in the periovulatory phase (1). Therefore, we hypothesized that levonorgestrel prevents ovulation by also interfering with estradiol biosynthesis in ovarian follicular granulosa cells.  We assessed the effects of levonorgestrel on FSH-induced aromatase in primary rat ovarian granulosa cell cultures. Cells were coincubated in the presence of FSH (EC50%) with or without levonorgestrel during 48 h. As expected, levonorgestrel inhibited both FSH-induced aromatization of androstenedione to estradiol and Cyp19a1 mRNA expression in a dose-dependent manner. These results support previous information on progesterone effects upon endometrial aromatase. In conclusion, we identified a dose-dependent inhibitory effect of levonorgestrel on aromatization and Cyp19a1 mRNA expression in primary rat ovarian granulosa cell cultures.  Our findings give further additional information on the mechanism of action of this progestin as emergency contraceptive.

 

Nothing to Disclose: SL, LG, RG, DO, MD, FL

17087 26.0000 MON-0047 A Levonorgestrel Inhibits Cyp19a1 Expression in Primary Rat Ovarian Granulosa Cell Cultures 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Fumiya Ojima*1, Yuka Saito1, Yukiko Tsuchiya1, Kenichi Inagaki2, Eri Nakamura2, Fumio Otsuka2, Maho Ogoshi1, Sakae Takeuchi1 and Sumio Takahashi1
1Okayama University, Graduate School of Natural Science and Technology, Okayama, Japan, 2Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan

 

Runx3 is a transcription factor that belongs to the Runx family. We recently reported that female Runx3 knockout (Runx3-/-) mouse was anovulatory and infertile. In the present study, we examined the mechanism of anovulation in the Runx3-/- mouse in relation to the function of granulosa cells. Runx3 mRNA expression was detected in the granulosa cells of ovarian follicles, but not in corpora lutea. At the age of 2 weeks, all four types of follicles including primordial follicles were found in the ovary and their numbers did not differ between wt and Runx3-/- mice. At the ages of 3 weeks, the numbers of primary and antral follicles per an ovary were significantly fewer in Runx3-/- mice than those in wt mice, while the number of secondary follicles per an ovary was more in Runx3-/- mice than that in wt mice. At the age of 8 - 9 weeks, the number of antral follicles was smaller in the Runx3-/- ovaries than wild type (wt) ones, although the number of primordial follicles was similar in both of them, indicating loss of Runx3 affects the process of maturation of follicles. Runx3 continued to express in granulosa cells during most of stages of folliculogenesis, while FSH receptors start to express in the preantral stages. Hence, these findings suggest that Runx3 expression was regulated by intraovarian systems, but not by FSH. Ovarian transplantation experiment showed that wt mice with Runx3-/- ovarian grafts exhibited regular estrous cycle, whereas Runx3-/- mice with wt ovarian grafts exhibited irregular estrous cycles. Ovarian grafts from Runx3-/- mice contained corpora lutea when transplanted into wt mice, but not into Runx3-/- mice. These results suggest that lack of ovulation in Runx3-/- mice was caused by alteration of gonadotropin secretion in Runx3-/- mice. We then examined the function of granulosa cells in the Runx3-/- mice. At 3 weeks of age, mRNA expression levels of steroidogeneic enzymes, including Cyp11a1, Hsd3b1 and Cyp19a1 were less in Runx3-/- mouse ovaries than in wt ones, and at 8-9 weeks of age Cyp11a1 mRNA expression was less in Runx3-/- mouse ovaries than in wt ones. Cultured granulosa cells from 3 week-old mouse ovaries, the basal Cyp19a1 mRNA levels were lower than that in wt mice. FSH treatment increased Cyp19a1 mRNA levels in both wt and Runx3-/- granulosa cells, but the increase in Runx3-/- granulosa cells was less and the basal expression of aromatase Cyp19a1 mRNA was lower in Runx3-/- mice compared with wt mice, indicating that granulosa cells could not function fully in the absence of Runx3. These findings suggest that Runx3 plays a key role in female reproduction through (1) regulation of folliculogenesis and (2) regulation of steroidogenesis by granulosa cells.

 

Nothing to Disclose: FO, YS, YT, KI, EN, FO, MO, ST, ST

14322 27.0000 MON-0048 A Runx3 Regulates Ovulation and Steroidogenesis in Granulosa Cells in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Bindu Menon*1, Thippeswamy Gulappa1 and Jairam K M Menon2
1University of Michigan, Ann Arbor, MI, 2Univ of Michigan, Ann Arbor, MI

 

Using yeast two hybrid screening, we have previously demonstrated that eukaryotic initiation factor 5A (eIF5A) interacts with the LH receptor mRNA binding protein (LRBP) during downregulation of the receptor in response to preovulatory LH surge (1). Recent studies have shown that eIF5A participates in RNA metabolism including translation and RNA degradation. Furthermore, eIF5A undergoes hypusination by transferring hypusine (4-amino butyl moiety) from polyamine to ε-amino group of lysine to convert eIF5A to the active form which is essential for its function. The present study examined the role of the hypusination of eIF5A in the ligand-mediated downregulation of functional LH receptors in the ovary. Superovulated rats on day 5 were treated with a single dose of hCG (50 IU) or saline to downregulate LH receptor. A second group of superovulated rats on day 5 were treated with GC7, a competitive inhibitor of hypusination, at a dose of 16 mg/Kg b.w. by i.p. injection, 2 hours prior to hCG treatment. Ovaries were then harvested 8 or 12 h post hCG/saline treatment and homogenized for the isolation of plasma membrane fraction. A second set of ovaries were processed for RNA isolation. The expression of functional LH receptors was analyzed in the membrane fractions using 125I-hCG binding assay. The results showed that, as expected, the specific binding of 125I-hCG to LH receptors in the hCG treated groups was reduced 50% and 75% by 8h and 12h respectively, compared to the controls. Inhibition of eIF5A hypusination by pretreatment with GC7 prior to hCG treatment showed significant reversal of the hCG-induced downregulation of LH receptor. Reversal of downregulation by GC7 treatment was also seen in the expression of LH receptor mRNA as measured by real time PCR analysis since treatment with hCG produced 80 percent inhibition compared to the control (p<0.05), but pretreatment with GC7 produced only 40 percent inhibition (p<0.05 vs. hCG). These results provide evidence that eIF5A and its activation through hypusination play a crucial role in the downregulation of LH receptor in response to preovulatory LH surge.

1.         L. Wang, T. Gulappa, K.M.J. Menon, Identification and characterization of proteins that selectively interact with the LHR mRNA binding protein (LRBP) in rat ovaries, Biochim Biophys Acta 1803 (2010) 591-597.

 

Nothing to Disclose: BM, TG, JKMM

15113 28.0000 MON-0049 A Evidence for the Regulation of Functional Luteinizing Hormone (LH) Receptor Expression in the Ovary By Eukaryotic Initiation Factor 5A (eIF5A) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Thippeswamy Gulappa*1, Bindu Menon1 and Jairam K M Menon2
1University of Michigan, Ann Arbor, MI, 2Univ of Michigan, Ann Arbor, MI

 

Extracellular signal-regulated kinase (ERK)1/2, is activated by RAS-RAF-MEK1 in response to Luteinizing hormone (LH) in the ovary. Our previous studies have implicated that ERK1/2 mediated signaling is involved in hCG-induced LH receptor (LHR) mRNA downregulation. It has been shown recently that inhibition of eukaryotic initiation factor 5A (eIF5A) inhibit phosphorylation and activity of ERK1/2 and overexpression of eIF5A activates ERK1/2 kinase implicating a role for eIF5A in ERK1/2-mediated signaling (1, 2). Our previous studies have shown that eIF5A interacts with LHR mRNA binding protein (LRBP) and selectively inhibits LHR mRNA expression in the ovary.  eIF5A undergoes hypusination, a unique posttranslational modification, which is essential for its function. The present study investigated the mechanism by which eIF5A and its hypusination regulate LRBP-mediated LHR downregulation in rat ovaries.  Superovulation was induced in 23 day old rats by the established PMSG-hCG regimen. On day 5 of superovulation, the rats were injected with hCG (50 IU) and the controls received saline. One group of rats were injected with eIF5A hypusination inhibitor, N1-Guanyl-1, 7-diaminoheptane (GC7) (i.p., 16mg/kg body weight), 2h prior to hCG treatment for downregulation. Ovaries were then harvested at different time intervals of hCG treatment. Western blot analyses of the ovary lysates showed that eIF5A was upregulated 2-3 fold during the time course of hCG-induced downregulation of LHR. Using isoelectric focusing and western blotting, we showed that the expression of hypusinated eIF5A increased by 2 fold after 1h and sustained up to 6h after hCG treatment. By contrast, this hCG-induced eIF5A hypusination was completely inhibited by GC7 treatment. We further sought to examine if inhibition of eIF5A hypusination had any effect on hCG-induced phosphorylation of ERK1/2 and subsequent induction of LRBP and LHR mRNA downregulation. Our results showed that GC7 treatment significantly (50-60%) inhibited phosphorylation of ERK1/2 without affecting the expression of total ERK1/2. Furthermore, GC7 treatment also significantly inhibited hCG-induced LRBP expression and LHR mRNA downregulation. Taken together, our data provide strong in vivo evidence that eIF5A play an important role in hCG-induced ERK1/2 mediated signaling that leads to LHR downregulation. This work is supported by NIH grant HD06656-37.

(1)   Taylor et al., Mol Ther, 2012, Jul; 20(7): 1305-14.  (2)  Taylor et al., Molecular Cancer, 2013, May 2; 12(35): 1-11.

 

Nothing to Disclose: TG, BM, JKMM

15194 29.0000 MON-0050 A Extracellular Signal-Regulated Kinase 1/2- Mediated Regulation of Luteinizing Hormone Receptor Expression in Response to Preovulatory LH Surge Is Controlled By Eukaryotic Initiation Factor 5A (eIF5A) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Rexxi D Prasasya* and Kelly E Mayo
Northwestern University, Evanston, IL

 

In mammals, growth and ovulation of the ovarian follicle requires integration of endocrine and paracrine signaling. Follicle stimulating hormone (FSH) and luteinizing hormone (LH) secreted by the anterior pituitary serve as predominant endocrine cues, while within the ovary, numerous paracrine signalings participate in folliculogenesis. Among these local factors, the juxtacrine signaling system Notch is emerging as an integral means of intra-follicular cell communication. Using conditional knockout mouse models, our group has shown that chronic disruption of Notch signaling in the ovary resulted in abnormal follicular development and impaired fertility. Given the key role of gonadotropins in regulating folliculogenesis, we hypothesized that FSH and LH might regulate or cooperate with Notch signaling during follicle development. To test this concept, we treated prepubertal mice with pregnant mare serum gonadotropin (PMSG) to activate FSH receptors followed by human chorionic gonadotropin (hCG) to activate LH receptors and measured mRNAs expression of select Notch receptors, ligands, and target genes using qRT-PCR. We also conducted this experiment in Transgenic Notch Reporter (TNR) mice, in which an EGFP reporter is expressed in Notch active cells, in order to obtain an overall view of gonadotropin effects on ovarian Notch signaling. While PMSG treatment resulted only in a modest increase in expression of the Notch target gene Hey2, hCG treatment resulted in significant increases in the expression of multiple Notch ligands (Jag1, Dll1, Dll3, and Dll4) and receptors (Notch1, Notch2, Notch3, and Notch4). This was associated with increased expression of the Notch target gene Hes1, as well as the eGFP Notch reporter in the TNR ovaries. The temporal patterns and extent of regulation of Notch pathway genes by hCG stimulation varied, with most changes occurring in the periovulatory and early luteinization periods. These findings suggest a broad regulation of local ovarian Notch signaling in response to hCG initiation of the ovulatory cascade. Current efforts are focused on examining protein expression and localization of Notch signaling molecules in the ovary following gonadotropin stimulation and investigating the potential role of Notch signaling during ovulation and luteinization.

 

Nothing to Disclose: RDP, KEM

16122 30.0000 MON-0051 A Notch Pathway Genes and Activity Are Regulated By Gonadotropins in the Mouse Ovary 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Osamu Suzuki*
Natl Inst of Biomed Innovation, Ibaraki, Japan

 

[Aim] Strain/individual differences in superovulation efficiency with gonadotropins constitute a serious problem in mouse reproduction (Ref. 1). To solve this problem, I focused on the primordial follicle activation, which is negatively controlled by the Phosphatase and Tensin Homolog Deleted from Chromosome 10 (PTEN). In the previous ENDO 2013 meeting, I reported that a PTEN inhibitor would be a possible enhancer for superovulation in A/J mouse strain. In this study, this enhancer effect was compared between A/J and two additional mouse strains (C57BL/6N and DBA/2). In addition, ovarian PTEN contents were also compared between three strains. [Method] I used three mouse strains: A/J, C57BL/6N, and DBA/2. In Experiment 1, 0 (control) or 30 µg of dipotassium bisperoxo (picolinato) oxovanadate (V) (bpV(pic), Enzo) dissolved in Ringer’s solution was injected to 28-day-old females with eCG. About 48 h later, hCG was injected to the females. About 16 h later, the numbers of ovulated oocytes per female were examined. In Experiment 2, ovarian PTEN protein contents in 4-week-old females of three mouse strains were measured by quantitative Western blots with GAPDH as an internal control (Ref. 2) using whole ovary homogenates. [Results and Discussion] In Experiment 1, the average numbers of oocytes collected were 12.6±3.7 vs. 21.2±2.0 (control vs. bpV(pic), mean±SEM, n=5), 23.0±8.4 vs. 30.8±6.0, and 10.8±3.4 vs. 9.6±1.7 in A/J, C57BL/6N, and DBA/2, respectively. No significant difference between control and bpV(pic) groups in each strain was found on analysis of variance, but more oocytes tended to be collected in the bpV(pic) groups in A/J and C57BL/6N. In Experiment 2, ovarian PTEN protein contents were 2.0±0.1 (arbitrary unit, mean±SEM, n=4), 1.3±0.1, and 1.1±0.2 in A/J, C57BL/6N, and DBA/2, respectively. No significant difference was found on analysis of variance, but A/J tended to contain more ovarian PTEN proteins than the other strains. Thus, my new method using both PTEN inhibitors and gonadotropins is a promising method for improving superovulation in mice, although the strain difference in the effect of bpV(pic) is not negligible. This strain difference might be correlated with ovarian PTEN protein contents.

 

Nothing to Disclose: OS

13570 31.0000 MON-0052 A Strain Difference in Superovulation with a PTEN Inhibitor in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Julie Rizwana Islam*1, Donna L T Seto-Young2, Martin Lesser3, Zev Rosenwaks4 and Leonid Poretsky1
1Mount Sinai Beth Israel, New York, NY, 2Beth Israel Med Ctr, New York, NY, 3Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, 4Weill Med Coll of Cornell Univ, New York, NY

 

Irisin is a recently discovered hormone secreted by muscle and adipose tissue which plays a role in fat and energy metabolism. Because energy metabolism is closely linked to reproduction, we hypothesized that irisin may have effects in the reproductive system.  In this study we examined the effects of irisin on luteinizing hormone (LH) secretion in murine pituitary cells and on estradiol (E2) secretion in human granulosa cells.

Methods:  The adult mouse pituitary cell lines (mPitA12 and mPitA19, CELLutions Biosystems Inc. and UCLA at San Diego, respectively) were incubated with or without increasing concentrations of irisin (0-250ng/mL) and GnRH (0-50nM). 

Human granulosa cells from in-vitro fertilization were cultured with and without irisin (0-275ng/mL) and insulin (0-10,000ng/mL).

ELISA was used to measure LH or E2 concentrations in the conditioned culture medium. Two-way analysis of variance (ANOVA) was used to compare mean LH or E2 for various combinations of GnRH and irisin or insulin and irisin.

Results:   In the pituitary cell experiments, GnRH alone (without irisin) stimulated LH secretion in a dose-dependent manner  (ρ<0.0005), thus validating the assay.  Irisin alone (without GnRH) did not show a clear pattern of either stimulation or inhibition of LH. When irisin and GnRH were used together, there was significant GnRH/irisin interaction (ρ<0.0019), with the pattern of LH still depending on GnRH concentration. 

 In the granulosa cell experiments, E2 concentration in the medium increased as insulin concentration increased (ρ<0.0494), thus validating the assay. Irisin alone (without insulin) showed no clear trend for E2 as a function of irisin at any concentration.With both irisin and insulin in the system, there was significant irisin/insulin interaction (ρ=0.0049) at insulin concentrations of 0 and 50 ng/ml.  Additional experiments are in progress.

Conclusions:  In these preliminary in-vitro experiments, irisin appears to interfere with the effects of GnRH in the pituitary cells and with the effects of insulin in granulosa cells.  To understand the mechanisms of these interactions, if confirmed, will require  further study.

 

Nothing to Disclose: JRI, DLTS, ML, ZR, LP

14781 32.0000 MON-0053 A Does Irisin Have an Effect on Female Reproductive Function? Initial in-Vitro Studies 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Misung Jo*, Birendra Mishra and Jiyeon Park
University of Kentucky, Lexington, KY

 

Core binding factor (CBF) is a small family of heterodimeric transcription factors comprised of a non-DNA binding subunit (CBFβ) and a DNA-binding subunit (one of three Runx proteins; Runx1, Runx2, and Runx3). CBFβ enhances DNA binding and stability of RUNX proteins. We previously demonstrated the spatiotemporally regulated expression of Runx1 and Runx2 in rat and human periovulatory ovaries. Our In vitro studies further demonstrated that RUNX1 and RUNX2 regulate the expression of several key genes in luteinizing granulosa cells, suggesting the role of CBFs in normal ovarian function. Mice deficient in Runx1, Runx2, and CBFβ die in the uterus or at birth, posing a challenge in demonstrating the physiological importance of CBFs in vivo. To determine the functional significance of CBFs in the ovary, we generated ovarian cell specific CBFβ knockout mice by crossbreeding CBFβ flox and Cyp19 cre mice.  Female mice of CBFβ flox * Cyp19 cre (mutant) exhibited compromised fertility; during 5 months of breeding, one female delivered 1 pup, while 3 other females did not produce any pups. To assess the impact of CBFβ in follicular development and ovulation, mutant mice (25 days old) were injected with PMSG to stimulate follicular development and then with hCG to initiate the ovulatory process.  Real-time PCR data indicated incomplete removal of CBFβ expression (~60% reduction) in periovulatory granulosa cells of mutant mice.  Histological analysis further confirmed the expression of CBFβ, Runx1, and Runx2 in periovulatory follicles of the mutant mouse ovary, although CBFβ expression was slightly lower compared to that in wildtype mice. However, a striking difference for the expression of CBFs was observed in adult mice: ovaries of 6 month old mutant mice showed negligible expression of CBFβ, Runx1, and Runx2 in corpus lutea (CL), whereas the expression of CBFβ, RUNX1, and RUNX2 was strong in the CL of wildtype mice. The levels of progesterone were very low in mutant mice compared to that of wild type mice. Histological analyses revealed abundant lipid droplet accumulation in all of the CLs of the mutant mouse ovary, whereas no visible lipid droplets in the CL of wildtype mice. Further analysis of proteins involved in steroidogenesis indicated that StAR expression was drastically reduced, but Cyp11a1 and 3βHSD expression were slightly higher in the CL of mutant mice compared to that of wildtype mice.  In conclusion, this study provides the first evidence that CBFs are highly expressed in the CL and play a critical role in progesterone production by regulating the expression of steroidogenic enzymes.  The infertility of ovarian cell specific CBFβ knockout mice is likely due to an inability to produce sufficient progesterone, a critical hormone for luteal function and establishment and maintenance of pregnancy.

 

Nothing to Disclose: MJ, BM, JP

16130 33.0000 MON-0054 A Core Binding Factor Beta Is Essential for Female Fertility in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Miranda L. Bernhardt* and Carmen J Williams
NIH / NIEHS, Research Triangle Park, NC

 

Mammalian fertilization is marked by oscillatory rises in intracellular calcium that drive the events of egg activation. These oscillations are the result of IP3-mediated release of endoplasmic reticulum (ER) calcium. In many cell types, store operated calcium entry (SOCE) is a critical source of cellular calcium for refilling the ER following calcium release. SOCE depends on interaction between STIM (stromal-interacting molecule) proteins that sense ER Ca2+ levels and Orai proteins, which act as pore-forming subunits of the store-operated channel. In mouse germinal vesicle stage oocytes, calcium entry occurs in response to reduced ER stores, but this influx is reduced in metaphase-II (MII) arrested eggs. Previous studies in mouse and porcine oocytes suggest that STIM1 may play a role in mediating calcium entry at fertilization. To determine whether there is an absolute requirement for STIM1 in regulating calcium dynamics at fertilization, we generated oocyte-specific Stim1 knockout mice (Stim1 cKO) by crossing Stim1-flox mice with a Zp3-cre transgenic line. Stim1 cKO females are fertile, and resulting offspring are heterozygous for the excised allele. These findings indicate that oocyte STIM1 is not required for fertilization and early embryo development and that excision of the floxed exon of Stim1 in cKO oocytes is efficient.  To determine whether loss of Stim1 subtly impacts calcium homeostasis, calcium changes during in vitro fertilization were compared for eggs from Stim1 cKO and Stim1-flox control mice by performing ratiometric calcium imaging. Calcium oscillation frequency, first oscillation length, and persistence did not differ significantly between the two groups. In addition, ER calcium stores, as measured by calcium release following treatment with thapsigargin, were similar for Stim1 cKO and control oocytes and eggs. In preliminary experiments, similar levels of calcium influx were observed following store depletion with thapsigargin for control and Stim1 cKO oocytes; however, additional experiments are needed to determine conclusively whether STIM1 is involved in SOCE in mouse oocytes, and further studies are underway to confirm loss of STIM1 protein in conditional knockout oocytes. Overall, these data lead us to conclude that STIM1 is not required for normal calcium dynamics at fertilization in mouse eggs and that other mechanisms of regulating calcium uptake must be active instead.

 

Nothing to Disclose: MLB, CJW

15122 34.0000 MON-0055 A Normal Fertilization Is Observed in Oocyte-Specific Stim1 Knockout Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Pavine Lee Lefevre*1, Robert Berger1, Sheila Rose Ernest1, Mike Wade2, Bernard Robaire3 and Barbara Hales4
1McGill University, MONTREAL, QC, Canada, 2Health Canada, Ottawa, ON, Canada, 3McGill Univ, Montreal, QC, Canada, 4McGill University

 

Chronic exposure to toxic chemicals in the environment is hypothesized to contribute to the significant increase over the past decades in infertility in North America. Brominated flame retardants (BFRs) may act as endocrine disrupters; BFRs in consumer products leach out to the environment and are absorbed. Pregnancy failure has been associated with BFRs in human follicular fluid, raising serious questions regarding their impact on female reproductive health. Our goal is to assess the effects of exposure to an environmentally relevant BFR mixture on female reproductive health using a rat model. A BFR mixture formulated to mimic the relative congener levels in house dust, the major source of human exposure in North America, was composed of three commercial brominated diphenyl ethers (BDEs) (52.1% DE-71, 0.4% DE-79, 44.2% decaBDE-209) and hexabromocyclododecane (all 3 isomers, 3.3%). Adult female Sprague-Dawley rats received this BFR mixture in the diet (0, 0.06, 20 or 60 mg/kg/day; n=16, 21, 17 and 18, respectively) from 2-3 weeks before mating until gestation day (GD) 20. Estrous cyclicity was monitored during the premating period. Reproductive parameters, such as mating, fertility indices and litter size, were analysed. Levels of estradiol (E2), follicle-stimulating hormone (FSH), luteinizing hormone (LH) and anti Mullerian hormone (AMH) were measured in serum collected at GD20 by radioimmunoassay (E2 and AMH) and multiplex assay (FSH and LH). Morphometric analysis was done on ovarian sections to evaluate folliculogenesis by counting primordial, primary, secondary and antral follicles and, measuring follicle diameters and areas in five ovaries per experimental group. Quantification of ovarian gene expression was done by real-time PCR. BFR exposure had no significant effect on estrous cyclicity, reproductive success, or serum hormones in the dams. Although the proportion of follicles found at each stage was similar in ovaries collected from exposed and control dams, BFR exposure induced a significant dose-dependent increase in the numbers of primary (r=0.462; p=0.0456) and antral follicles (r=0.501; p=0.0243). At the low and high doses of the BFR mixture, antral follicles were enlarged, as reflected by a significant increase in both diameter (p=0.002) and area (p=0.01). Expression of Insulin-like growth factor 3 (Insl3) and Estrogen receptor 1 (Esr1) was significantly downregulated at the highest dose (p=0.01 and p=0.02, respectively), while 17α-hydroxylase (Cyp17a1) gene expression was reduced at the lowest (p=0.04) and highest (p=0.01) dose of the BFR mixture. Exposure to an environmentally relevant BFR mixture disrupts ovarian steroidogenic gene expression and affects folliculogenesis in the rat. BFRs may interfere with the growth of the antral follicles and affects steroidogenesis. Supported by CIHR grant RHF100625, FRQS (PL), REDIH (PL) and RQR- CREATE (RB).

 

Nothing to Disclose: PLL, RB, SRE, MW, BR, BH

16081 35.0000 MON-0056 A Ovarian Functions Are Impaired after Exposure to Brominated Flame Retardants in Sprague-Dawley Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0022-0056 4854 1:00:00 PM Female Reproduction: Regulation of Follicle Growth Poster

Ramon Bossardi Ramos*1, Vitor Costa Fabris2, Leticia de Almeida Brondani3 and Poli Mara Spritzer4
1Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil, 2Universidade Federal Rio Grande do Sul, 3Hospital de Clinicas de Porto Al, Porto Alegre, Brazil, 4Hospital de Clínicas de Porto Alegre and Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

 

Genetic susceptibility and environmental exposures may play a role on pathogenesis of PCOS and on its clinical presentation. Single nucleotide polymorphism (SNP) rs7903146 in the gene encoding the transcription factor 7-like 2 (TCF7L2) was identified as one of the few genetic polymorphisms with powerful effects on the risk of type T2D. Given the genetic overlap between PCOS and T2D our study aims to perform a systematic review and meta-analysis from case-control trials to examining the association between rs7903146 polymorphism and PCOS. The study was registered at PROSPERO CRD 42013005930. MEDLINE (accessed by PubMed), Cochrane Central Register of Controlled Trials (Cochrane CENTRAL accessed by Wiley Science), EMBASE and LILACS databases were searched through September 2013 and were not limited by language. Data extraction and quality control assessment was made independently by two investigators (R.B.R and V.C.F) and any inconsistencies between these two reviewers were settled by the third reviewer (PMS) until a consensus was reached. Six case-control trials fulfilled the eligibility criteria and were included in meta-analysis: 2 studies included Asian descendents and the remaining were done with European descendents totalizing 1773 women with PCOS, diagnosed according to Rotterdam criteria, and 2545 controls. Quality of studies was estimated by the Newcastle-Ottawa Scale (NOS). Mean age of PCOS patients ranged from 22.8 to 32.0 years, and from 25.2 to 29.9 years for the controls, while BMI means range from 22.2 to 30.2 kg/m2 in PCOS and 20.0 to 27.0 kg/m² in controls. Gene-disease associations were measured for the following genetic inheritance models: allele contrast, additive, recessive and dominant. All the genetic inheritance models were performed stratifying trials by ethnicity (Asian and non-Asian). No association was found between the polymorphism and PCOS for non-Asian, OR 1.06 (0.94 – 1.20) and Asian, OR 1.00 (0.74 – 1.35). There was no significant heterogeneity (Q test p >0.10 and I2 <50%) between studies when assuming any inheritance model. In conclusion, our study showed no significant association between the rs7903146 T allele and the risk for PCOS in non-Asian or Asian populations. Further studies are needed with other different populations in order to extend and universalize these conclusions.

 

Nothing to Disclose: RBR, VCF, LDAB, PMS

14114 1.0000 MON-0057 A Polycystic Ovary Syndrome Is Not Associated with rs7903146 Polymorphism of TCF7L2 Gene: A Systematic Review and Meta-Analysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Do Kyeong Song*, Hyejin Lee, Jee-Young Oh, Young Sun Hong and Yeon-Ah Sung
Ewha Womans University School of Medicine, Seoul, Korea, Republic of (South)

 

Polycystic ovary syndrome (PCOS) is a highly complex endocrine disorder in reproductive age women. Although many genetic approaches have been taken to understand the etiology of PCOS, only two genome-wide association studies (GWAS) were reported. The objective of this study was to identify additional risk regions for PCOS through GWAS.

We conducted a two-stage GWAS. At discovery stage, we recruited 1,000 women with PCOS and 1,000 unrelated controls. The genomic DNA was extracted from individual’s peripheral blood and genotyped using the HumanOmni1-Quad v1 array. At second stage, we replicated the most promising 21 signals in an independent set of 249 cases and 778 controls.

We identified one genome-wide significant novel locus and 7 moderately associated loci. The strongest association was on chromosome 8q24.2 (rs10505648, OR=1.93, P=5.46x10-8), and other association signals located at 4q35.2, 16p13.3, 4p12, 3q26.33, 9q21.32, 11p13, and 1p22 (P=5.72x10-6 ~6.43x10-5).

This study identified novel genetic loci and several candidate genes related to fetal implantation, dyslipidemia, endometriosis, insulin resistance, and steroidogenesis. Our findings provide new insight into the genetics and biologic pathways of PCOS, and further local and international collaborative study is essential to confirm our genetic variants.

 

Nothing to Disclose: DKS, HL, JYO, YSH, YAS

13683 2.0000 MON-0058 A Genome-Wide Association Study Identify the New Susceptibility Loci for Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Emily Daviau*1, Priyathama Vellanki1, Laura Torchen2, Ryan Sisk3, Brian Werstein1, Richard S Legro4, Margrit Urbanek3, M. Geoffrey Hayes1 and Andrea Dunaif3
1Northwestern University, Feinberg School of Medicine, Chicago, IL, 2Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, 3Northwestern University Feinberg School of Medicine, Chicago, IL, 4Penn State University, Hershey, PA

 

PCOS is a highly heritable non-Mendelian disorder. As in other complex genetic diseases, common susceptibility variants mapped by genome-wide association studies do not account for all of the observed heritability. Uncommon (MAF<5%) or rare (MAF<1%) variants with larger biological effects may account for this “missing heritability”. This hypothesis is testable using next generation sequencing technologies. We present a workflow for identifying deleterious variants through two complementary approaches: case-control and family-based.

Whole genome sequencing at a depth of 40x was performed on 77 PCOS probands diagnosed by NIH criteria and their parents (69 fathers, 71 mothers), affected sisters (13 PCOS, 4 elevated androgens with regular menses) and unaffected sisters (UA, 77). The case-control analysis included 77 probands and 62 UA sisters with highest BMIs. Using bioinformatics tools from Complete Genomics Incorporated (Mountain View, CA), 20,297,703 high quality variants were identified in the study subjects.

In the case-control analysis, 396,833 exonic (+/-5bp) variants (Galaxy, Penn State University and Johns Hopkins University) were annotated with ANNOVAR (Biobase, Wolfenbüttel, DE). After removal of 52,048 synonymous variants, 66,077 non-synonymous single nucleotide variants, 4,385 frame-shift substitutions, 1,756 frame-shift deletions, 12,894 non-frame-shift insertions, 1,150 non-frame-shift deletions and 1,138 stop-codon mutations remained. Assessment of the damaging potential of these mutations, excluding frame-shifts, using bioinformatic tools (SIFT and Provean [J. Craig Venter Institute, San Diego, CA]; PolyPhen2 [Harvard University, Cambridge, MA]) identified 1,432 deleterious variants mapping to 1,268 genes.

In the analysis of 10 multiplex PCOS families (≥2 affected and ≥1 UA sister), 1,166 variants from 979 genes were identified. Of these variants, 1,149 were also found in the case-control data, 48 of which were deleterious. There were 153 variants from 126 genes found in 2 or more families. Ten of these variants (localized to 9 genes) were identified as damaging by all three tools (implemented using Golden Helix SNP & Variation Suite v7.x; Bozeman, MT).  

Genes identified in the case-control and family-based analyses will be re-sequenced by Sanger sequencing to confirm putative deleterious mutations. The biologic impact of the confirmed mutations will be investigated in appropriate cell systems or transgenic animal models. Any mutations thus identified will provide considerable insight into the etiology of PCOS since they are predicted to be physiologically relevant.

 

Nothing to Disclose: ED, PV, LT, RS, BW, RSL, MU, MGH, AD

16112 3.0000 MON-0059 A Mapping Missing Heritability in PCOS: Developing Interpretive and Validation Methodology for Identifying the Contribution of Rare Variants to PCOS 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Mariana Di Pietro1, Fernanda Parborell1, Griselda Irusta1, Paula Accialini2, Marta Tesone1 and Dalhia Abramovich*1
1Instituto de Biología y Medicina Experimental. IByME-CONICET, Buenos Aires, Argentina, 2Instituto de Biología y Medicina Experimental. IByME-CONICET,, Buenos Aires, Argentina

 

PCOS is the most common endocrine disorder among women of reproductive age. The main features of PCOS are anovulation, oligo- or amenorrhea, hyperandrogenism and polycystic ovaries. It is also associated with obesity and insulin resistance.

PCOS women have elevated levels of serum and follicular fluid VEGF, leading to an increase in ovarian blood flow. Increased VEFG levels may be involved in the high risk of developing OHSS when PCOS patients are stimulated with gonadotropins.

In a previous work, we have demonstrated that in a PCOS rat model developed by administration of dehydroepiandrosterone (DHEA), both VEGF and Angiopoietin1 (ANGPT1) levels were increased.

Metformin is an insulin sensitizer used in type 2 diabetes. This drug is being used in PCOS women to target not only insulin resistance but also other aspects of the pathology, including reproductive alterations. In addition, metformin is able to reduce VEGF levels in different types of cancer, regulating tumour angiogenesis.

The use of metformin in PCOS patients has been associated with an increase in menstrual cycles and ovulation rates, and with the decrease in circulating androgens and first-trimester spontaneous abortions. However, these observations are controversial and the mechanisms of action of metformin in the ovary remain unknown.

Our hypothesis was that metformin acts in the ovary at least in part by regulating angiogenic factor levels. This would improve ovarian angiogenesis leading to an enhancement in follicular development, a decrease in cyst formation and an increase in ovulation rates.

We used a rat PCOS model developed by DHEA administration (6mg/ 100g weight) to 21 days old rats for 15 days. Control rats received vehicle. One PCOS group of rats received metformin (300 mg/ Kg) diluted in drink water during the 15 days of treatment. At day 16 rats were killed and the ovaries extracted.

Metformin administration decreased the ovarian VEGF (PCOS: 81.8±12.2; PCOS + met: 28.6±5.8 pg/mg protein; p<0.01) and ANGPT1 levels (PCOS: 0.47±0.04; PCOS + met: 0.33±0.02 arbitrary units; p<0.05) in PCOS rats. Moreover, metformin reversed the increase in periendothelial cell area observed in the PCOS rat ovaries (PCOS: 7.7±0.3%; PCOS + met: 5.6±0.4%; p<0.05). Regarding follicular development, metformin decreased the % of primary and atretic follicles (PCOS: 36.8±4.0%; PCOS + met: 19.5±3.1%; p<0.01) while increased the % of antral follicles (PCOS: 46.7±2.7%; PCOS + met: 62.5±5.0%; p<0.01). Interestingly, metformin decreased the % of cysts (PCOS: 4.6±0.5%; PCOS + met: 2.9±0.5%; p<0.05) and increased the % of corpora lutea (PCOS: 0.1±0.1%; PCOS + met: 1.5±1.0%; p<0.05).

These results suggest that the treatment with metformin to the PCOS rats decreases VEGF and ANGPT1 ovarian levels, improving follicular angiogenesis. This may contribute to a better follicular development, with an increase in ovulation and a decrease in cyst formation.

 

Nothing to Disclose: MD, FP, GI, PA, MT, DA

12123 4.0000 MON-0060 A Metformin Treatment Decreases Ovarian VEGF and Angiopoietin1 Levels, Improves Follicular Development and Decreases Cyst Formation in a Rat Model of Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Dalhia Abramovich*1, Leopoldina Scotti1, Griselda Irusta1, Camila Pazos Maidana1, Ignacio de Zúñiga2, Claudio Bisioli2, Fernanda Parborell1 and Marta Tesone1
1Instituto de Biología y Medicina Experimental. IByME-CONICET, Buenos Aires, Argentina, 2Centro Médico PREGNA Medicina Reproductiva, Buenos Aires, Argentina

 

Polycystic Ovary Syndrome (PCOS) is the most common endocrinological pathology among women of reproductive age. Among other diverse features, PCOS is characterized by abnormalities in ovarian angiogenesis. While VEGF is the main angiogenic factor that promotes endothelial cell migration and proliferation, there are other angiogenic factor families involved in angiogenic process. Among these families are the Angiopoietin (ANGPT) and PDGF families, both involved in vessel stabilization and vascular permeability. It is known that follicular fluid (FF) levels and ovarian expression of VEGF are increased in PCOS patients. However, there are no studies analyzing other angiogenic factors in ovaries from PCOS women. Our hypothesis was that besides VEGF, other angiogenic factors are dysregulated in the ovaries from these patients, leading to altered angiogenesis and vascular permeability. Therefore, in this study we examined the levels of ANGPT1, ANGPT2, their soluble receptor TIE2 (sTIE2), PDGFBB and PDGFDD proteins in FF from PCOS (n=19) and control (n=27) patients undergoing assisted reproductive techniques. In addition, we analyzed the effect of FF from these patients on endothelial adherens and tight junction protein expression. We found a significant increase in the levels of ANGPT1 in PCOS patients (control: 201.1±23.1 pg/ml; PCOS: 516.4±81.8 pg/ml; p<0.0001) with no changes in the levels of the two soluble antagonists ANGPT2 and sTIE2. PDGFBB and PDGFDD were decreased in PCOS patients (PDGFBB: control: 1.29±0.15; PCOS: 0.81±0.05 arbitrary units; p<0.01) (PDGFDD: control: 2.37±0.14; PCOS: 1.94±0.07 arbitrary units; p<0.05). The levels of claudin 5 were significantly increased in endothelial cells incubated for 24h with PCOS follicular fluids compared to control FF (control: 2.05±0.13; PCOS: 3.50±0.52 arbitrary units; p<0.05). The levels of p-VE-cadherin, p-beta-catenin and ZO1 were no different in cells incubated with control and PCOS FF at any time point analyzed. These results suggest that the alterations observed in the ANGPTs and PDGFs levels may prevent VEGF-induced vascular leakage in the ovary at least in part by regulating endothelial cell junction proteins. Restoration of the levels of angiogenic factors may provide new insights to PCOS treatment and OHSS prevention in PCOS women.

 

Nothing to Disclose: DA, LS, GI, CP, ID, CB, FP, MT

12090 5.0000 MON-0061 A Platelet-Derived Growth Factor BB and DD and Angiopoietin1 Are Altered in Follicular Fluid from Polycystic Ovary Syndrome Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Natalya Volkova*1, Tatiana Dimitriadi2, Maria Antonenko3, Ilia Davidenko4, Igor Reshetnikov5 and Irina Dzherieva6
1Rostov state medical university, Rostov on Don, 2Regional Diagnostic Centre, Rostov on Don, Russia, 3Rostov State Med Univ, Rostov-on-don, Russia, 4Rostov State Medical University, Rostov-on-Don, Russia, 5Rostov State Medical University, Rostov-on-Don, Russia, 6Rostov State Medical University, Rostov on Don, Russia

 

Female hyperandrogenism (HA) is a clinical syndrome that is often overdiagnosed. On the one hand, it consists a lot of widespread multiform clinical signs. On the other, these signs are non specific and exceedingly subjective. Nowadays, there are no algorithms that could allow the doctor to make objective prognoses of presence of HA resting on clinical symptoms. The aim of the study was to make a ranking of clinical signs conditionally on its diagnostic importance, and on the basis of their integrated assessment to develop a clinical predicative scale of HA. There was performed a retrospective analysis of 396 patients with definitive diagnosis of HA and assessed the prevalence of acne, hirsutism, abdominal obesity, alopecia, oligomenorrhea, and amenorrhea. Using Bayes statistics, which allows to determine the probability of the disease in the presence of certain signs, there was possible to make a ranking of clinical signs. Conditionally on diagnostic importance, there were received next results: waist circumflex more than 80cm – 1 score; hirsutism 8-15 (Ferriman-Gallwey score) - 4 scores; hirsutism more than 15 (Ferriman-Gallwey score) – 6 score; acne, which is resistant to dermatologic therapy, – 4 scores, oligomenorrhea – 5 scores, amenorrhea – 8 scores, androgenic alopecia – 15 scores. Based on these data, there was developed the clinical predicative scale with next thresholds: less 8 scores is consistent with low possibility, 9-11 – moderate possibility, 12-13 – high possibility, and 14-17 – very high possibility. Futher, the developed scale was approved in clinical practice. There were examined 104 young women with reproductive disturbances. Clinical signs of all women were assessed with developed clinical scale. Twenty patients of 104 had score less than 8, forty four - moderate grade, thirty five – high grade, five – very high grade. In order to prove effectiveness of developed scale, there was assessed concentration of total testosterone of all 104 women. Laboratory HA was diagnosed at 0% of women, who had been classified with low possibility, 57% of women with moderate possibility, 66% of women with high possibility, and 100% of woman with very high possibility. It is important to note that no one woman with HA was missed. Thus, the developed clinical predicative scale of HA might allow the doctor to make objective prognoses of presence of HA resting on clinical symptoms. Taking into account that laboratory diagnostic of HA is characterized with objective difficulties, careful clinical judgment is of prime importance.

 

Nothing to Disclose: NV, TD, MA, ID, IR, ID

16800 6.0000 MON-0062 A Clinical Predicative Scale of Female Hyperandrogenism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Jung Min Ahn*1, Ah Reum Kwon2, Yejin Kim3, Hyun-wook Chae4, Duk-Hee Kim5 and Ho-Seong Kim6
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Severance Hospital, Seoul, Korea, Republic of (South), 3Severance Hosp, Seoul, Korea, Republic of (South), 4Gangnam Severance Hospital, Seoul, Korea, Republic of (South), 5Yonsei Univ Coll of Med, Seoul, Korea, Republic of (South), 6Severance Children's Hospital, Seoul, Korea, Republic of (South)

 

Purpose: The purpose of this study was to investigate the clinical, ultrasonographic, biochemical and metabolic manifestations in adolescents with polycystic ovary syndrome (PCOS).

Methods: Retrospective observational study was conducted in adolescents aged 12 to 21 years diagnosed with PCOS according to the Rotterdam Consensus. All patients either with dysmenorrhea or excess androgen activity were confirmed with ultrasonographic polycystic ovary findings. Forty three PCOS adolescents from January 2008 to August 2013 were enrolled from Severance Hospital. Anthropometric, hormonal and metabolic parameters were investigated. The homeostatic model for insulin resistance (HOMA-IR) was calculated by glucose (mg/dl) x insulin (mU/ml)/405. Free androgen index was calculated as total T/SHBG x 100. Metabolic syndrome was defined according to the recommendations of the International Diabetes Federation, such as body mass index (BMI) >90th percentile, fasting glucose >100 mg/dL, triglycerides >150 mg/dL, HDL <40 mg/dL, and blood pressure >Hg 130/85 mm.

Results: Mean age was 17.0 ± 2.3 years. The menstrual irregularity most frequently observed was amenorrhea (90.6%, 39/43); hirsutism was observed in 14.0% (6/43) and acne in 7.0% (3/43). Biochemical hyperandrogenemia (FAI>5.63) was diagnosed in 11.6% (5/43). Mean BMI was 22.1±4.0 kg/m2. According to BMI, 9.3% of adolescents were obese, 9.3% were overweight and 81.4% had a normal weight. Rate of HOMA-IR higher than 2.5 is 39.5% (17/43), and that of HOMA-IR lower than 1.6 is 20.9% (9/43), suggesting that about 2/3 of adolescents with PCOS have no insulin resistance (HOMA-IR>2.5). Increased cholesterol and triglycerides were observed in 16.3% (7/43) and 4.6% (2/43), and increased blood pressure and impaired fasting glucose were found in 9.3% (4/43) and 4.6% (2/43) of cases, respectively. But there was no case which met the diagnostic criteria of metabolic syndrome.

Conclusion:According to anthropometric, hormonal and metabolic parameters, Korean adolescents with PCOS showed lower rates of hirsutism, hyperandrogenemia, obesity and insulin resistance compared with PCOS women. Diagnosis should be made cautiously because PCOS in adolescents shows different symptoms and features from in adults.

Key words: Polycystic ovarian syndrome, Adolescents, Clinical manifestations

 

Nothing to Disclose: JMA, ARK, YK, HWC, DHK, HSK

14326 7.0000 MON-0063 A Clinical and Biochemical Manifestations in Adolescents with Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Asma Javed*, Aida N Lteif, Seema Kumar, Patricia Simmons and Alice Y Chang
Mayo Clinic, Rochester, MN

 

Polycystic Ovary Syndrome (PCOS) is a condition of androgen excess, oligoanovulation and/or polycystic ovarian morphology (PCOM) and can be diagnosed as early as adolescence. High prevalence of irregular menses and PCOM in adolescents without PCOS makes diagnosis challenging. Adolescents are more likely to present for evaluation of primary and secondary amenorrhea. We sought to evaluate whether increasing menstrual irregularity was associated with greater phenotypic and metabolic features of PCOS in adolescents. Secondarily, we evaluated influence of body mass index (BMI) across the same phenotypic and metabolic features.

METHODS:

This was a retrospective study of 366 adolescents with PCOS seen at Mayo Clinic Rochester, MN, from 1996 to 2013. Participants included for analysis were 265 adolescent girls, 13 to 18 years old, newly diagnosed with PCOS and treatment naïve. The cohort was divided into those who presented with primary amenorrhea (PA), secondary amenorrhea (SA) and oligomenorrhea (OM) (< 9 menstrual cycles/year). Clinical, metabolic and sonographic characteristics were compared among groups using general linear models and Chi square tests.

RESULTS:

Out of 265 adolescents with PCOS, PA =17, SA =30 and OM=218. Age at diagnosis (years) for PA was younger than OM (15.2 ± 1.45 vs. 16.3 ± 1.45 P < 0.01) but not different from SA. Mean BMI (kg/m2) at diagnosis was not different between the groups (PA: 34.5 ± 1.95 vs SA 32.3 ± 10.2, OM 31.1 ± 7.64 P= 0.09). Mean age at menarche (years) [induced in PA] was older for PA than SA and OM (15.2 ± 1.3 vs 12.3 ± 1.64 vs 11.9 ± 1.54 P <0.01).

Mean fasting glucose (mg/dl) was higher in PA than OM (94.4 ± 9.54 vs 90.1 ±10.2 p=0.048) but not different from SA (P=0.08). Insulin concentrations were higher in PA than SA and OM (P=0.02 for each). PA had higher prevalence of acanthosis nigricans at diagnosis (64.7%) vs. SA (20%) and OM (34.4%)        (P< 0.01).

Lipid profiles were available in 145 subjects (PA: 10/17, SA 15/30, OM 120/218). Mean serum triglyceride concentrations (mg/dl) were higher in PA (199.9 ± 90.5) vs SA (112.2 ± 44.7) and OM (120.4 ± 64.5) (p < 0.001 for each). HDL and LDL levels and prevalence of hypertension did not differ.

Although prevalence of hirsutism did not differ between groups, total testosterone concentrations (ng/dl) were higher in PA (70 ± 42.4) vs. SA (50.1 ± 27.1) vs OM (51.5 ± 23.2) (P < 0.01 for each).

Ultrasound was performed in 155 subjects (PA 15/17, SA 21/30, OM 119/218) with PCOM found in 111/155 subjects and no difference among groups.

Across BMI categories, lean PCOS (BMI < 85th percentile) had lower triglycerides, insulin and total testosterone vs. overweight and obese PCOS (BMI > 85thpercentile).

CONCLUSIONS:

In context of other features of PCOS, primary amenorrhea in adolescent PCOS is associated with greater evidence for insulin resistance, including acanthosis, higher fasting glucose, insulin, triglyceride and total testosterone concentrations.

 

Nothing to Disclose: AJ, ANL, SK, PS, AYC

16368 8.0000 MON-0064 A Phenotypic Characterization of Polycystic Ovary Syndrome in Adolescents Based on Menstrual Irregularity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Christine M. Burt Solorzano* and Christopher R. McCartney
University of Virginia, Charlottesville, VA

 

Many investigators have advocated the routine use of mass spectrometry (MS)-based assays when assessing sex steroid concentrations. The Journal of Clinical Endocrinology and Metabolism recently announced an upcoming requirement that MS-based assays be used for manuscripts reporting sex steroids as important endpoints (JCEM 2013; 98: 3971-3). Cited reasons included insufficient sensitivity and specificity of direct immunoassays, especially at low concentrations (e.g., those observed in adolescent girls). In recent years, we have routinely and prospectively obtained pooled serum samples for total testosterone assessment by both (a) direct radioimmunoassay (Center for Research in Reproduction [CRR] Assay Core Laboratory, University of Virginia) and (b) liquid chromatography-tandem mass spectrometry assay (Mayo Clinic Laboratories), primarily to evaluate the accuracy of the CRR’s direct radioimmunoassay.  

Reported sensitivities for the CRR and Mayo assays are 10 and 7 ng/dl, respectively; values below assay sensitivity were assigned the value of assay sensitivity. Correlation between the two assays was assessed using Spearman rank correlation, a non-parametric test based on ranks of observations and requiring no assumptions about underlying data distribution. Pearson (parametric) correlation was performed as well. 

To date, we have collected pooled samples from 27 admissions in 22 peripubertal girls, all with total testosterone values < 60 ng/dl. Subject characteristics include age (mean ± SD [range]) 12.9 ± 2.5 (8-16) years and Tanner breast stage 3.8 ± 1.6 (1-5). Seventeen of the 22 subjects were obese. 

Mean ± SD (median, range) testosterone was 21.5 ± 10.4 (20.6, 10.0-47.1) and 21.6 ± 12.6 (21, 7-55) ng/dl for CRR and Mayo assays, respectively. Spearman rank correlation between the two estimates of total testosterone concentration was very high (r = 0.91, p < 0.0001). Similar results were obtained by Pearson correlation (r = 0.91, p < 0.0001). 

These data indicate that, when performed with careful attention to quality control, direct radioimmunoassay can provide estimates of testosterone concentrations comparable to those of MS-based assay systems, even in the low ranges typical of peripubertal girls. We therefore suggest that direct immunoassays can have an important role in the future of high-quality clinical research, particularly since the current research-related costs of direct radioimmunoassay are substantially less than those of MS-based assay.

 

Nothing to Disclose: CMB, CRM

15043 9.0000 MON-0065 A Estimating Testosterone Concentrations in Adolescent Girls: A Comparison Between Direct Radioimmunoassay and Liquid Chromatography-Tandem Mass Spectrometry Assay 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Susan Sam*1, Ruth Gordillo2, Sudha K Yalamanchi3, Philipp E Scherer2 and Theodore Mazzone4
1University of Chicago, Chicago, IL, 2University of Texas Southwestern Medical Center, Dallas, TX, 3University of Illinois Medical Center, Chicago, IL, 4NorthShore University, Evanston, IL

 

Insulin resistance is a common feature of polycystic ovary syndrome (PCOS) independent of body weight.  Non-obese women with PCOS have the same degree of insulin resistance as obese control women. The mechanisms for insulin resistance in PCOS are not well characterized.  Accumulation of ceramide and related species in tissues especially skeletal muscle mediates insulin resistance.1,2,3 Ceramides are increased in plasma of obese, type 2 diabetic mice and humans and may directly induce insulin resistance in skeletal muscle.4 Adiponectin may regulate ceramide catabolism.5 Dihydroceramides (DHC) are generated de novo from free fatty acids (FFA) and higher levels indicate higher FFA or reduced FFA suppression due to adipose tissue (AT) insulin resistance.6 Previously we had shown that non-obese women with PCOS have increased abdominal fat, reduced expression of adiponectin in gluteal AT and lower systemic insulin sensitivity compared to non-obese control women of similar ethnicity, age and BMI.7

We obtained fasting ceramide and DHC levels from 14 non-obese women with PCOS and 14 non-obese control women of comparable ethnicity, age and BMI.  Levels were quantified by liquid chromatography tandem mass spectrometry.  Continuous data are presented as mean ± STD if normal or median (25, 75 interquartile range) if not normally distributed.

Women with PCOS were similar to controls in age 26 ± 5 vs. 27 ± 6 yrs (P=0.73) and BMI 27.2 ± 4.1 vs. 25.5 ± 3.9 kg/m2 (P=0.28).  Women with PCOS had higher visceral (VAT) and subcutaneous abdominal fat (SAT) compared to controls:  450 (312, 895) vs. 230 (157, 333) cm3 for VAT (P=0.009) and 3,020 (2,609, 3,218) vs. 1,772 (1,589, 2,229) cm3for SAT (P=0.005).  Women with PCOS had lower insulin sensitivity based on insulin sensitivity index (SI) from an intravenous glucose tolerance test 7 ± 4 vs. 15 ± 10 (P=0.008).  Adiponectin expression in gluteal AT was lower in PCOS 2.60 (1.37, 3.63) vs. 3.97 (1.72, 5.55) (P=0.02).  The following ceramide (C) and DHC species were increased in PCOS by non-parametric Mann-Whitney U test: DHC24:1 [45 (32, 51) vs. 27 (18, 43) ng/ml; P=0.04]; DHC18:0 [11 (8, 13) vs. 7 (6, 8) ng/ml, P=0.009]; C18:0 [51 (40, 58) vs. 40 (32, 50) ng/ml, P=0.08]; and C18:1 [17 (14, 20) vs. 14 (11, 16) ng/ml, P=0.02]. There were negative correlations between SI and DHC 24:1 (rho=-0.58, P=0.005) and DHC18:0 (rho=-0.47, P=0.03) and borderline negative correlation between AT adiponectin expression and DHC 24:1 (rho=-0.431, P=0.05) and DHC18:0 (rho=-0.41, P=0.07).  There were positive correlations between DHC24:1 and VAT (rho=0.62, P=0.006), DHC24:1 and SAT (rho=0.43, P=0.08), DHC18:0 and VAT (rho=0.72, P=0.001) and DHC18:0 and SAT (rho=0.61, P=0.007).

We conclude that PCOS independent of obesity is associated with higher ceramide and DHC levels that maybe mediating reduced insulin sensitivity. The increase in DHC maybe related to higher abdominal fat and lower AT adiponectin expression.

 

Nothing to Disclose: SS, RG, SKY, PES, TM

14949 10.0000 MON-0066 A Plasma Ceramide and Dihydroceramide Levels Are Increased in Non-Obese Women with PCOS 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Kevin Maas*1, Sandy Shuai-Ju Chuan1, Kevin Phung2, Jingwen Hou2, Antoni J Duleba2 and R Jeffrey Chang2
1Univeristy of California, San Diego, La Jolla, CA, 2University of California, San Diego, La Jolla, CA

 

Objective:  Women with PCOS have heterogeneous ovarian steroid production following treatment with GnRH agonist or recombinant human HCG (r-HCG), with approximately 50% demonstrating exaggerated 17-hydroxyprogesterone (17-OHP) responses (high responder PCOS, HR-PCOS), while the remainder exhibit responses equivalent to normal women (normal responder PCOS, NR-PCOS). While this distinct response has been demonstrated previously, prior studies have not examined indices of ovarian follicle morphology in these two subpopulations. To address this issue the relationships of serum anti-Mullerian hormone (AMH), inhibin-B (Inh B), and total antral follicle count (AFC) to 17-OHP responses following r-hCG stimulation were assessed in normal control, NR-PCOS, and HR-PCOS women.

Design:  Prospective study in an academic center.

Materials and Methods:  Women with PCOS (age, 19-34 yr; n= 18) and normal controls (age, 19-35 yr; n=15) were enrolled in the study. All subjects underwent transvaginal ultrasonography to determine the number of antral follicles in each ovary. Blood samples were obtained during the mid-follicular phase for measurement of 17-OHP and androgen levels before and 24 hours after stimulation with iv r-HCG. Serum AMH and Inh B levels were assessed in baseline samples. Student's t-test or ANOVA followed by post-hoc analysis with the Tukey-Kramer test were used to establish statistical significance between control, NR-PCOS, and HR-PCOS groups.  All results are reported as mean ± standard error.

Results:  Serum 17-OHP responses to hCG in 8 PCOS women were greater than 2 SD above the mean for normal controls (HR-PCOS). By comparison, 10 PCOS women had 17-OHP responses that were similar to normal controls (NR-PCOS). Ultrasound revealed that the mean total AFC (both ovaries) in HR-PCOS (53.9 ± 7.3) and NR-PCOS (48.3 ± 6.5) were significantly higher (p=0.02) than that of the control group (30 ± 1.96). AFCs were not statistically different between PCOS subgroups. Baseline serum AMH levels were substantially elevated in NR-PCOS (15.97 ± 1.54 ng/mL) compared to both control individuals (5.34 ± 1.02 ng/mL) and HR-PCOS women (6.7 ± 1.5 ng/mL). Similarly, Inh B levels were significantly greater in NR-PCOS (172.9 ± 18.8 pg/mL) that that of control (109.54 ± 11.21 pg/mL) and HR-PCOS (76.1 ± 11.1 pg/mL).

Conclusions:  Similar AFCs were observed in HR-PCOS and NR-PCOS women. Unexpectedly, serum AMH was markedly lower in HR-PCOS compared to NR-PCOS patients. Consistent with reduced AMH, Inh B levels were also significantly decreased in HR-PCOS compared to the NR-PCOS individuals. These findings suggest that functionally distinct groups of PCOS patients exhibit either differences in granulosa cell function or have differences in the distribution of pre-antral or small antral follicles.

 

Nothing to Disclose: KM, SSJC, KP, JH, AJD, RJC

15487 11.0000 MON-0067 A Relationship of Ovarian Markers to Androgen Production in Women with Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

E. Leonie A.F. van Houten1, Marlies E. Kevenaar1, Yvonne V. Louwers1, Wendy van Dorp2, Axel P.N. Themmen1, Joop S.E. Laven1 and Jenny A. Visser*1
1Erasmus MC, Rotterdam, Netherlands, 2Erasmus MC University Medical Center, Rotterdam, Netherlands

 

Polycystic ovary syndrome (PCOS) is associated with an increased risk for the metabolic syndrome (MetS). Serum anti-Müllerian hormone (AMH) levels are increased in women with PCOS and correlate with the severity of PCOS. However, conflicting results have been reported regarding the relationship between serum AMH levels and metabolic parameters. In this study we determined whether serum AMH levels correlated with MetS risk factors and the presence of MetS.

A total of 522 Caucasian women with PCOS, diagnosed by the Rotterdam criteria, for which data on all MetS risk factors (waist circumference, fasting glucose, triglycerides, HDL-C, and blood pressure) were available, were included. We analyzed the contribution of serum AMH in the prediction of the levels of individual MetS risk factors and the overall number of MetS risk factors using multiple linear regression analysis with HOMA-IR, FAI, age and AFC as additional covariants.

In our cohort, 15% of the women with PCOS were diagnosed with the metabolic syndrome (n=77). Median serum AMH levels were significantly lower in PCOS women with MetS compared to those without MetS (7.5 ng/ml vs 9.0 ng/ml, respectively, P=0.003). Furthermore, serum AMH levels were negatively correlated with HOMA-IR (r=-0.119, P=0.007) and BMI (r=-0.219, P<0.001). Serum AMH was an independent negative predictor of waist circumference (β=-2.175, P<0.001), triglycerides (β=-0.054, P=0.029), and systolic (β=-1.410, P=0.002) and diastolic (β= -1.695, P=0.002) blood pressure, while AFC was not a significant factor. Likewise, serum AMH contributed in the prediction of the number of MetS risk factors present (β=-0.161, P=0.002). However, serum AMH did not remain an independent predictor of the presence of MetS. Furthermore, the observed associations between serum AMH and MetS risk factors were attenuated when BMI was included as a covariant in the prediction model.

In conclusion, serum AMH contributes in the prediction of the number of MetS risk factors, independently of AFC. This suggests that serum AMH is inversely correlated with the severity of the metabolic phenotype in PCOS, although this effect is largely driven by BMI. Our results therefore indicate that serum AMH levels should be interpreted with caution in overweight and obese women.

 

Disclosure: APNT: Consultant, Ansh Labs. JSEL: Clinical Researcher, Ferring Pharmaceuticals, Clinical Researcher, Merck & Co., Clinical Researcher, Merck BV, Clinical Researcher, Organon Laboratories, Clinical Researcher, Serono. Nothing to Disclose: ELAFV, MEK, YVL, WV, JAV

13720 12.0000 MON-0068 A Serum Anti-Müllerian Hormone Levels Are Negatively Associated with Risk Factors of the Metabolic Syndrome in Women with Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Nabila Roohi*
Department of Zoology (Endocrinology), University of the Punjab, Lahore, Pakistan

 

Background and aims: Incidence of polycystic ovary syndrome (PCOS), in young women, is considerably rising. Women with PCOS are at increased risk of developing low grade inflammation and insulin resistance (IR) progressing towards type 2 diabetes mellitus (T2DM) and associated complications. Identification of risk predictors associated with susceptibility to T2DM and comorbidities, in PCOS women, therefore, becomes increasingly important.

Subjects and Methods: Participants were women with PCOS (n=73; aged 18-39 years) approached at infertility clinics of Lahore. These were compared with age and sex matched controls (n=60) selected randomly from the same localities. Fasting blood glucose, fasting insulin, glycated hemoglobin (HbA1C), lipid profile, apolipoproteins (Apo) and inflammatory markers were measured by enzyme linked immunosorbent assay (ELISA) and automated clinical chemistry analyzer. Insulin sensitivity was determined by homeostatic model assessment insulin resistance index (HOMA-IR). Body mass index (BMI) and waist to hip ratio (WHR) were also evaluated to study their correlation with IR. Data was analyzed statistically using Graph Pad Prism (version 5.00).

Results: Total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), triglycerides (TG), ApoA-IV, ApoE, leptin, C-reactive protein (CRP) and tumor necrosis factor-a (TNF-a) were significantly elevated (P<0.05) and positively correlated with HOMA-IR, BMI and WHR, whereas, high density lipoprotein cholesterol (HDL-C) and ApoA-I were signifinatly reduced (P<0.05) in women with PCOS compared to healthy women. The results of our study clearly suggest the possible contribution of dyslipidemia and raised inflammatory markers towards IR and T2DM progression in PCOS women.

Conclusions: The altered lipid profile, apolipoproteins and inflammatory responses predict that women with PCOS are at a higher risk of future progression towards insulin resistance, T2DM and cardiovascular disorders. Identifying the women at higher risk, at an earlier stage, and appropriate measures to increase insulin sensitivity may reduce or prevent the manifestation of comorbidities in these women.

 

Nothing to Disclose: NR

16210 13.0000 MON-0069 A Insulin Resistance and Type 2 Diabetes Mellitus Risk in Women with Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Mihail Gr Coculescu*1, Madalina Aura Vintila1, Redha Attaoua2, Nicoleta Baculescu3, Monica Gheorghiu4 and Florin Grigorescu2
1National Institute of Endocrinology, Bucharest, Romania, 2Institute of Clinical Research (IURC), Montpellier, France, 3"C.I Parhon" National Institute of Endocrinology, Bucharest, Romania, 4National Institute of Endocrinology, CI Parhon, Bucharest, Romania

 

Polycystic ovary syndrome (PCOS) represents an excellent population model to identify genetic determinants of insulin resistance (IR) and metabolic syndrome (MetS). Both abnormalities are associated with a chronic low-grade inflammatory state, partially reflected by C-reactive protein (CRP). In the aim of MEDIGENE European program (FP7-279171) to find influential genes for MetS we investigated 17 genes in PCOS women following Rotterdam criteria (n = 401) versus controls (n = 143) from Romania. PCOS women displayed 40% obesity (BMI 35.1±0.3 kg/m2), 20% MetS by ATPIII criteria and were by 61% IR (mean HOMA of 4.7±0.2). Among prioritized genes from HuGe-database of GWAS results, including LHCGR, THADA, FSHR, KLF14, DENND1A, YAP1, RAB5B, AVPR1A, HMGA2, ZNF664, TOX3, CILP2, SUMO1P1, FTO, INSR, DUSP9 and CRP genes, leader SNPs showed association particularly with DUSP9 gene. Previous studies strongly reinforced the association by exploring DUSP9 proxy SNP, haplotype association with additional SNPs at the locus as well as by replications in other ethnic populations. FTO gene was also influential but neither DUSP9 nor FTO completely explained the IR by the HOMA values. The CRP gene was studied by its leader SNP rs3091244 (A/G) using KaspAr method and interactions with other genes were investigated by ANOVA. In non-complicated PCOS (absence of MetS), SNP homozygous variant (AA) of CRP was associated with IR with P < 0.015, OR 2.4 95% CI [1.18 – 5.1]. In ANOVA this variant explained variations of HOMA from 4.53 ± 0.3 (n=252) to 6.3 ± 1.1 (n=53) with P < 0.036, interaction factor alpha of 0.5 in all PCOS patients. The effect was even more evident in non-complicated PCOS (data not-shown). Among all tested interactions, the strongest was found between FTO gene (CC homozygous at SNP rs145089) and CRP (rs3091244) with P < 0.01, alpha factor 0.75, although the FTO alone remained a strong determinant of IR (P < 0.006). The interaction CRP – FTO displayed a gene dosage, the highest effect being between AA of CRP and CC variant of FTO (HOMA 7.2±0.9). Interactions among other genes were much lower and did not correlate with IR measured by HOMA. These data indicated that CRP, FTO and DUSP9 are influential genes in PCOS and that IR is essentially related with CRP (Chr 1q23.2) and FTO (Chr 16q12.2) interaction. We conclude that genes positively associated with PCOS manifest effects on various components in PCOS pathogenesis (e.g LH surge, hyperandrogenism, IR) and that further sub-classification of populations may considerably improve GWAS results along with locus refining by dense mapping.

 

Nothing to Disclose: MGC, MAV, RA, NB, MG, FG

16909 14.0000 MON-0070 A Interaction Between C-Reactive Protein (CRP) and Fat Mass and Obesity (FTO) Genes Better Explains Insulin Resistance in Polycystic Ovary Syndrome in Romanian Population 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Priyathama Vellanki*1, Darko Stefanovski2, Richard N Bergman3 and Andrea Dunaif4
1Northwestern University, Feinberg School of Medicine, Chicago, IL, 2Cedars-Sinai Medical Center, West Hollywood, CA, 3Cedars-Sinai Medical Center, CA, 4Northwestern University Feinberg School of Medicine, Chicago, IL

 

PCOS is associated with major defects in insulin action and secretion conferring substantially increased risk for type 2 diabetes (T2D) in affected women.  Obesity has a synergistic deleterious effect on insulin action in PCOS resulting in changes in hepatic glucose homeostasis.  Variants in key regulatory genes of hepatic glucose metabolism, glucokinase (GCK) and glucokinase regulatory protein (GCKR), are associated with increased risk for T2D.We applied our novel model of lactate kinetics during frequently sampled intravenous (FSIGT) and oral glucose tolerance tests (OGTT) to further characterize hepatic glucose homeostasis in PCOS.

PCOS (43) and  control (C, 49) women of comparable ethnicity, age, BMI with normal glucose tolerance had 75-g OGTTs with every 30 min blood samples for 180 min.  Sixteen PCOS women had insulin-modified FSIGTs with 30 blood samples for 180 min.  Both tests were performed in 10 PCOS women.  Lactate, glucose and insulin levels were measured in all blood samples.  Insulin sensitivity (Si) and acute insulin response to glucose (AIRg) were determined by minimal model analysis of FSIGT glucose and insulin data; the disposition index (DI) was calculated (AIRg x Si).  A linear, 2-compartment model of glucose and lactate kinetics during the FSIGT and the OGTT estimated liver GCK (HGK) activity (KGK), glycolysis (K12) and whole body fractional lactate clearance (K01). Data are reported as mean ±SD

Fasting lactate (P=0.04) and insulin levels (P=0.01) were increased in PCOS.  HGK activity was decreased in PCOS (KGK: PCOS 0.010524 ± 0.0089  vs C 0.018058 ±0.020421/min, P=0.02), while glycolysis and lactate clearance did not differ.  Fasting lactate (r=0.58, P=0.02) and insulin (r=0.57, P=0.02) were significantly correlated with lactate clearance but not with other hepatic glucose metabolism parameters in PCOS.  AIRg, Si and fasting glucose did not correlate with any parameters of hepatic glucose homeostasis.  Lactate clearance (p=0.03) were higher during OGTTs than FSIGTs in the same subjects while lactate appearance did not differ. 

Obese women with PCOS had significantly decreased HGK activity, independent of dysglycemia.  Whether this finding reflects the established deleterious effect of obesity on hepatic glucose metabolism in PCOS or variation in genes regulating hepatic insulin- independent glucose metabolism requires further investigation.  Lactate clearance was increased in association with evidence for insulin resistance in PCOS, e.g. increased insulin levels, as it is in other populations.  An incretin effect may account for higher lactate parameters during oral compared to iv glucose tolerance tests.

 

Nothing to Disclose: PV, DS, RNB, AD

13815 15.0000 MON-0071 A Obese Women with PCOS Have Reduced Liver Glucokinase Activity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Frank González*1, Marguerite K Shepard1, Neal S Rote2 and Judi Minium2
1Indiana University School of Medicine, Indianapolis, IN, 2Case Western Reserve University School of Medicine, Cleveland, OH

 

In Polycystic Ovary Syndrome (PCOS), the circulating mononuclear cell (MNC) has been shown to play a unique role in chronic low-grade inflammation that is separate from the contribution of excess adiposity.  We evaluated the status of plasma interleukin-6 (IL-6) and glucose-stimulated IL-6 release from MNC of women with PCOS of varying adiposity compared with body composition-matched controls in relation to insulin sensitivity and circulating androgens.  We studied 23 women with PCOS (7 NW normal abdominal adiposity [AA], 8 NW excess AA, 8 obese) between ages 18-40 years who were diagnosed on the basis of oligo- or amenorrhea and hyperandrogenemia, and 24 ovulatory controls (8 NW normal AA, 8 NW excess AA, 8 obese) of similar age.  Excess AA was defined as the percent ratio of truncal fat to total body fat (% TF/TBF) measured by DEXA that was 2 SD above the mean of NW normal AA controls.  Insulin sensitivity was derived by ISOGTT.  All subjects underwent a 2-hour 75-gm oral glucose tolerance test.  MNC were isolated from blood samples obtained at 0 and 2 hours.  IL-6 was measured by ELISA in fasting plasma and MNC culture supernatants.  ISOGTT was lower (p<0.02) in both obese groups (PCOS: 2.9±0.4; controls, 4.4±1.1) and both NW PCOS groups (excess AA: 4.6±0.6; normal AA: 5.1±0.4) compared with either NW control group (excess AA: 8.5±1.0; normal AA: 11.3±1.3).  Plasma IL-6 (pg/ml) was higher (p<0.04) in obese women with PCOS (3.0±0.6), obese controls (2.6±0.7) and NW women with PCOS with excess AA (2.1±0.2) compared with NW women with PCOS with normal AA (0.8±0.1) and both NW control groups (excess AA: 0.9±0.1; normal AA: 0.8±0.1).  In response to glucose ingestion, the absolute change in IL-6 release (pg/ml) from MNC increased in both obese groups (PCOS: 18.5±9.3; controls, 15.1±7.9) and both NW PCOS groups (excess AA: 10.1±7.9; normal AA: 4.9±1.7) and was significantly different (p<0.05) compared with either NW control group which decreased (excess AA: -15.2±5.7; normal AA: -16.9±5.7).  For the combined groups, % TF/TBF was positively correlated with plasma IL-6 (r=0.56, p<0.0002).  The absolute change in IL-6 release was negatively correlated with ISOGTT (r=-0.39, p<0.009), and positively correlated with testosterone (r=0.35 p<0.02) and androstenedione (r=0.40, p<0.007).  These data suggest that in PCOS, increased IL-6 release from MNC following glucose ingestion is independent of excess AA and/or frank obesity.  In contrast, circulating IL-6 is of adipose tissue origin.  Thus, MNC and excess adiposity may work in concert to promote hyperandrogenism and insulin resistance in this disorder.

 

Nothing to Disclose: FG, MKS, NSR, JM

11248 16.0000 MON-0072 A The Proinflammatory Mononuclear Cell Interleuken-6 Response to Glucose Ingestion Is Independent of Excess Adiposity in Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Hiroshi Ishikawa*1, Tatsuya Kobayashi1, Yoshimasa Kawarai1, Tomoya Segawa2, Shokichi Teramoto2 and Makio Shozu1
1Chiba University, Chiba, Japan, 2Shinbashi YUME Clinic, Tokyo, Japan

 

Objective: Polycystic ovary syndrome (PCOS) is a heterogenous endocrine disorder, affecting approximately 4%–10% women of reproductive age. Clinical observations suggest metabolic disturbance in patients with PCOS because they often exhibit complications such as obesity, insulin resistance, and dyslipidemia. However, little is known regarding metabolic pathways in women with PCOS. In this study, we performed a non-targeted metabolomic approach using capillary electrophoresis time-of-flight mass spectrometry (CE-TOFMS) to identify abnormal metabolites in the plasma of obese Japanese women with PCOS.

Materials and Methods: All participants provided written informed consent. Obese patients with PCOS (n = 5, BMI ≥ 27 kg/m2) exhibited hyperandrogenemia, multicysts in their ovaries (more than 12 follicles per ovary), and irregular menstruation, whereas age and BMI-matched controls (n = 5) had regular menstrual cycles. Plasma samples were collected from patients with PCOS regardless of the menstrual cycle and controls on day 3 of their menstruation. The samples containing internal standards (H3304-1002, Human Metabolome Technologies, Inc., Tsuruoka, Japan) were mixed and centrifugally filtered to remove proteins and macromolecules and subsequently prepared for CE-TOFMS. Principal component analysis (PCA) was performed using the software SampleStat. Detected metabolites were plotted on metabolic pathway maps using visualization and analysis of networks containing experimental data (VANTED) software.

Results: Women with PCOS have higher luteinizing hormone/follicular stimulating hormone (LH/FSH) ratios and homeostatic model assessment-IR (HOMA-IR) than controls. PCA analysis revealed that metabolites associated with glycolysis and the tricarboxylic acid (TCA) cycle were clearly distinct in women with PCOS compared with those in controls. Out of 113 detectable metabolites, concentrations of 11 metabolites were significantly higher in women with PCOS (P < 0.05, Mann–Whitney U test). These metabolites were amino acids (valine, leucine, proline, alanine, and phenylalanine), TCA cycle-related metabolites (isocitric acid and cis-aconic acid), and others (creatine, choline, carnitine, and ornithine). The concentration of total branched-chain amino acids (BCAA) was also significantly higher in women with PCOS; and it was positively correlated with HOMA-IR.

Conclusion: Metabolomic analysis revealed metabolic abnormality in obese Japanese women with PCOS. Insulin resistance may play a crucial role for the abnormal BCAA metabolism in this population.

 

Nothing to Disclose: HI, TK, YK, TS, ST, MS

11267 17.0000 MON-0073 A Metabolomic Profile of Obese Japanese Women with Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Alice Y Chang*1, Tumpa Dutta1, Xuan-Mai T Persson1, G Charles Ford2, Surendra Dasari2, Richard J. Auchus3 and K Sreekumaran Nair1
1Mayo Clinic, Rochester, MN, 2Mayo Clinic, 3University of Michigan, Ann Arbor, MI

 

Polycystic Ovary Syndrome (PCOS) is a condition of androgen excess and impaired insulin sensitivity that is frequently associated with obesity. The heterogeneity of PCOS in clinical presentation, pathophysiologic mechanisms and response to therapies presents a challenge for future research. We sought to determine if a metabolomics approach could identify specific metabolic pathways that distinguish PCOS from obese controls with the traditional metabolic syndrome.

METHODS: Twenty obese untreated women diagnosed with PCOS demonstrating androgen excess and oligomenorrhea were compared to 18 women without PCOS who met criteria for the metabolic syndrome (MetS) as defined by the NHLBI. Plasma samples were obtained fasting at baseline during an frequently sampled intravenous glucose tolerance test. We utilized a liquid chromatography/mass spectrometry (Agilent Technologies 6220 time-of-flight mass spectrometer)-based non-targeted metabolomics approach to identify metabolites most frequently observed and different between groups. Metabolites detected in at least 50% of the samples in both groups with thresholds of 1.5 fold difference between groups with a level of significance less than 0.05 and false discovery rate less than 5% were further evaluated by principal component analysis and followed by pathway enrichment analysis.

RESULTS: Principal component analysis and heat map supported the grouping of PCOS and controls with minimal overlap between groups. A total of 385 significantly different metabolites were detected, of which 22% were identified by high-resolution mass analysis. The identified metabolites characterized 18 significantly altered canonical pathways between PCOS and MetS controls. This included metabolites involved in networks for lipid, steroid, amino acid, carbohydrate and vitamin metabolism. Among the significantly altered pathways included vitamin D2, N-acylethanolamines N-acyltransferase, prostaglandin H2 biosynthesis and metabolism, regulation of CFTR gating, and branched chain amino acid metabolism.

CONCLUSIONS: PCOS is associated with significant metabolic alterations not explained alone by androgen-related pathways and even when compared to obese women with the metabolic syndrome. Large-scale metabolomics analysis demonstrated that PCOS has unique metabolic characteristics offering potential opportunity for more focused research on its pathophysiology and therapeutic targets.

 

Nothing to Disclose: AYC, TD, XMTP, GCF, SD, RJA, KSN

16616 18.0000 MON-0074 A Significant Alterations in Metabolomic Pathways in Women with PCOS Compared to Obese Women with the Metabolic Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Maria Valeria Premrou*, Malena Alvarellos, Ana Iris Paizal, Carolina Pelegrin, Diana Pezzutti, Ana Maria Talarico, Eugenia Segura and Laura Elena Maffei
Centro Médico Dra Laura Maffei, Buenos Aires, Argentina

 

Introduction: Polycystic ovary syndrome (PCOS) is defined by the presence of 2 diagnostic criteria: hyperandrogenism, compatible ultrasound PCOS, and chronic oligo/anovulation. According to the different association of them, different phenotypes can be formed. PCOS is associated with increased risk of obesity, metabolic syndrome, cardiovascular disease and diabetes. Objective: The aim of this work was to study in our PCOs patient-population the prevalence of different phenotypes and their correlation with metabolic syndrome, with their components and insulin resistance. And the correlation between the body mass index (BMI) was also analyzed. Material and methods: It was a retrospective descriptive study. Included PCOS patients with basal lipid profile, glucose and insulin values. All had hyperandrogenism. They were divided according to the phenotype of clinical presentation and BMI. Were included until phenotype I (American Society of androgen excess). Study metabolic syndrome parameters: high density lipoprotein (HDLc) < 40 mg/dl, triglycerides (TG) ≥150 mg/dl, glucose (glu) ≥100 mg/dl, TG/HDL ≥1,65, HOMA ≥3. Obesity definition for BMI ≥ 30.  Results: 190 patients were included. The most frequent phenotype (PH) was A: 49 patients 25,8%, 55 in B PH (55%), 24 in C PH (12,6%). No significant difference was observed related to TG, glu, HDLc, HOMA and TG/HDLc levels between different phenotype groups. 15,8% patients had  BMI≥30. When analyze BMI was observed with an increase of the mean BMI was lower HDL, and higher glu, TG, HOMA and ratio of TG / HDL. Differences between groups were statistically significant in all cases (p= 0.001 for HDL, TG p < 0.001, for glu p 0.016, HOMA p <0,001, TG / HDLc p < 0.001 (ANOVA). In the groups with BMI ≥30 altered variables results were significantly elevated (for HDLc p 0,015, for TG p <0,001, for glu p <0,001), also found a higher percentage of women with pathological values of each of the variables studied. The differences were also statistically significant (for HDLc p 0,015, for TG p <0,0001, for glu p <0,0001) chi square test. Conclusions: PCOs are associated with an increased risk of metabolic syndrome and diabetes. An association with the phenotypes of clinical presentation was not observed in this work. We observe a relationship with the increase of BMI, so overweight and obesity would be one of the major risk factors in PCOS of metabolic syndrome and insulin resistance in this population.

 

 

Nothing to Disclose: MVP, MA, AIP, CP, DP, AMT, ES, LEM

16167 19.0000 MON-0075 A Prevalence of Different Types of Polycystic Ovary Syndrome and the Relationship with Metabolic Syndrome and Insulin Resistance 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Bachir Antoun Abi Salloum*1, Almudena Veiga-Lopez2, Tanu Soni1, Charles F Burant1 and Vasantha Padmanabhan1
1University of Michigan, Ann Arbor, MI, 2Univ of Michigan Med Schl, Ann Arbor, MI

 

Prenatal exposure of female sheep to excess of testosterone (PT) advances placental differentiation, reduces maternal progesterone (P4) levels, and causes intrauterine growth restriction (IUGR). Placental changes mediated by androgenic actions of testosterone (T) may compromise the flow of metabolites [free fatty acids (FFA) and amino acids (AA)] between maternal and fetal compartments contributing to the IUGR. We hypothesized that T by its androgenic action disrupts FFA / AA distribution in the maternal and fetal compartments and that these changes are facilitated indirectly via changes in maternal P4. The study included three treatment groups (n=10-12/group): control (C), PT (T, twice weekly i.m. injections of 100 mg of T propionate from gestational day (D) 30 to 90), T + an androgen antagonist, flutamide (15 mg/kg/day orally; TF). On D90, maternal and fetal cord levels of FFA and AA were measured by gas chromatography (GC) and GC-MS respectively, and related to changes in maternal P4 concentrations. Analysis of variance using pairwise comparisons adjusted for false discovery rate was used to compare treatment groups with the control. Spearman correlation was used to assess association of P4 with FFA and AA. PT had no effect on maternal or fetal levels of FFA and AA. A positive correlation existed between P4 with total FFA (P<0.05) and linoleic acid (P<0.05) at the maternal level in the C group but not in the PT group. Co-treatment with androgen antagonist restored these positive associations. Maternal P4 was also positively correlated with fetal stearic acid in the PT, but not C group with the androgen antagonist co-treatment eliminating this positive association. P4 was positively correlated with glutamic acid (P<0.05) and negatively with ornithine (P<0.05) at the maternal level in C females, with both associations lost in PT females. Androgen antagonist cotreatment did not reverse T effect. In contrast, the positive correlation of P4 with histidine (P<0.05) in PT, but not C females was lost when cotreated with the androgen antagonist. Maternal P4 was positively correlated with fetal aspargine levels (P<0.05) in C, but not the PT group, with androgen antagonist having no impact. In summary PT, via androgenic or estrogenic action, disrupts the association between maternal P4, the key steroid in pregnancy maintenance, and the metabolites in the maternal / fetal compartments indicating that P4 mediates the maternal-fetal FFA/AA balance during pregnancy.

 

Nothing to Disclose: BAA, AV, TS, CFB, VP

15051 20.0000 MON-0076 A Development Programming: Prenatal Testosterone Excess Disrupts Free Fatty Acid and Amino Acid Distribution Across the Placental Barrier 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Arpita Kalla Vyas*1, Vanessa Hoang2 and Vasantha Padmanabhan3
1Michigan State university, East Lansing, MI, 2Michigan State University, East Lansing, MI, 3Univ of Michigan, Ann Arbor, MI

 

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder amongst reproductive age women with increased risk not only of infertility but also peripheral insulin resistance, type 2 diabetes and cardiovascular dysfunction. It is now well known that hypertension is associated with PCOS but emerging data is suggestive of cardiac dysfunction (Diastolic dysfunction and increased left ventricular mass) in even young women with PCOS after controlling for BMI. Endothelial dysfunction and diastolic dysfunction have been associated with both androgen excess and insulin resistance but the exact mechanisms leading to cardiovascular disorders are not clear. Animal models provide unique resources to address the developmental origin of cardiac pathologies in PCOS. We hypothesize that peripheral insulin resistance and hyperinsulinemia lead to altered cardiac insulin signaling, which in turn leads to cardiac dysfunction in PCOS. To determine if peripheral insulin resistance disrupts cardiac insulin signaling contributing to the cardiovascular abnormalities seen in PCOS, we used a well established animal model of PCOS that develops insulin resistance and hypertension in response to prenatal exposure to excess testosterone (T). Offspring of Suffolk sheep exposed to testosterone in utero (days 30-90 of gestation, term: 147 days) develop PCOS and cardiometabolic disturbances by 2 yrs of age. Left ventricle tissue was harvested from the 2 yr old control (n=8) and prenatal T-treated (n=8) female offspring. Changes in expression of cardiac genes  related to insulin signaling were quantified by RT-PCR and the data was analyzed by Student’s t test. Prenatal T excess increased expression level of insulin inducible glucose transporter 4 (GLUT 4) by 2.6 fold (p=0.02), IRS-1 by 5.9 fold (p= 0.02), PPAR gamma 2.3 fold (p=0.02) and AKT 27.1 fold (p=0.04) in the left ventricle over control. There was also a 4-fold increase in left ventricular expression of BNP (p=0.009) in the prenatal T treated offspring. Accentuated insulin signaling at the mRNA level in cardiac tissue may be related to chronic systemic hyperinsulinemia. Elevated IRS-1 and AKT mRNA may lead to cardiac hypertrophy through the mitogenic pathway, a feature also considered in diabetic cardiomyopathy. Alternatively, these effects may be compensatory changes.  Increased BNP expression in the left ventricle is suggestive of left ventricular dysfunction. Further studies are needed to investigate the mitogenic pathway and cardiac function and relate these to the metabolic perturbations seen in PCOS.

 

Nothing to Disclose: AKV, VH, VP

15219 21.0000 MON-0077 A Altered Cardiac Insulin Signaling in a Sheep Model of Polycystic Ovarian Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Ronald C Ma*, Kin Hung Liu, Tiffany Yau, Guozhi Jiang, Andrea O Luk, Po Mui Lam, Michael H Chan, Chung Shun Ho, Wai Kei Lam, Alice Pik-shan Kong, Wing Yee So, Juliana CN Chan, Lai Ping Cheung, Winnie Chu, Francis CC Chow and Wing Hung Tam
The Chinese University of Hong Kong

 

Background:

Subjects with polycystic ovary syndrome are associated with increased metabolic risk and diabetes. Visceral adiposity is known to be associated with fatty liver and increased metabolic risk, though the role of visceral adiposity in the pathogenesis of metabolic abnormalities in PCOS is not clear. We have utilized sonographic measurements of intra-abdominal fat depots to quantify visceral adiposity, and validated it against visceral adipose tissue measured using magnetic resonance imaging. We previously identified mesenteric fat thickness to be strongly associated with metabolic risk and early atherosclerosis. In this study, we evaluated the relationship between sonographic measurements of visceral adiposity and metabolic abnormalities in Chinese women with and without PCOS.

Methods:

We recruited 123 women with PCOS diagnosed according to the Rotterdam criteria. Control subjects were 557 healthy women with normal glucose tolerance from a mother-offspring cohort. All subjects underwent detailed assessment, including anthropometric measurements, biochemical evaluation, oral glucose tolerance test, and sonographic assessment with measurement of mesenteric, preperitoneal and subcutaneous fat thickness, carotid intima-media thickness and presence of fatty liver.

Results:

The mean age of PCOS subjects and controls were 28.6 ± 6.5 and 37.6 ± 4.6 years respectively (p<0.001). PCOS subjects had higher BMI (24.4 ± 5.4 kg/m2 vs 22.6 ± 3.3kg/m2, p<0.001), waist circumference, waist-hip ratio and systolic blood pressure (all p<0.01). PCOS subjects had higher fasting insulin, fasting glucose and 2 hour glucose, and had significantly higher triglyceride and ALT (p<0.01). Subjects with PCOS had significantly increased mesenteric, preperitoneal and subcutaneous fat thickness, and these remain significantly higher in subjects with PCOS after adjustment for age and BMI.  Prevalence of fatty liver was significantly higher among women with PCOS. On multiple linear regression, age (beta 0.114), increasing BMI (beta 0.318), increasing waist circumference (beta 0.491) and a diagnosis of PCOS (beta 0.068) were identified to be independent predictors of mesenteric fat thickness.

Conclusions:

We identified increased visceral adiposity as reflected by mesenteric fat thickness among subjects with PCOS. Increased visceral adiposity may partly explain the increased metabolic risk observed in subjects with PCOS.

 

Nothing to Disclose: RCM, KHL, TY, GJ, AOL, PML, MHC, CSH, WKL, APSK, WYS, JCC, LPC, WC, FCC, WHT

15782 22.0000 MON-0078 A Increased Mesenteric Fat Thickness and Visceral Adiposity in Chinese Women with Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Charikleia Stefanaki*1, Dario Boschiero2, Flora Bacopoulou1, Evanthia Diamanti-Kandarakis3 and George P. Chrousos4
1University of Athens Medical School, Athens, Greece, 2Biotekna, Venice, Italy, 3Athens University Medical School, Athens, Greece, Athens, Greece, 4University of Athens School of Medicine, Athens, Greece

 

Limited data are available on the body composition of Polycystic Ovary Syndrome (PCOS) patients. In this case-control study, we aimed to elucidate the body composition differences between PCOS patients and their age- and weight- matched controls using Bio-Impedance (BIA) and BIA spectroscopy measures. Seventeen (17), lean PCOS patients and seventeen (17) healthy age- and weight- matched controls were studied. All underwent BIA and BIA spectroscopy analysis, using two advanced medical devices (BIA-ACC & TomEEx, Biotekna Co, Venice, Italy). The PCOS group demonstrated class I sarcopenia (x2 = 3414.167; df = 33; p=0.001), and low muscle mass, expressed as percentage of fat-free mass (Median = 31.1; U test = 28; p=0.001;, r = 0.7). Glycogen mass was also decreased in the PCOS group (PCOS: Median = 0.331, Control group: Mdn = 0.4, U test = 60; p=0.004;,r = 0.5). Fat mass did not differ statistically between the two groups (PCOS: Median = 13, Control: Mdn = 17.9; ns; U test = 133; r = 0.063) nor did the abdominal fat mass (PCOS: Mdn = 191.2, Control: Mdn = 273.88; ns; U test = 134; r = 0.06). Bone minerals and bone mass were decreased when compared to the control group results (PCOS: Mdn = 1.64, Control: Mdn =1.91; U test = 78; p = 0.02; r = 0.4/ PCOS: Mdn = 3, Control: Mdn = 3.53; U test = 74; p = 0.02;, r = 0.41). PCOS patients were dehydrated in terms of total body water volume and intracellular body water (PCOS: Median=53, Control: Mdn =57.487; U test = 10, p = 0.001, r = 0.799/ PCOS: Mdn = 14.9, Control:Median = 18; U test = 57; p = 0.002;, r = 0.52, respectively). Extracellular body water measured as percentage of total body water was increased in the PCOS group (PCOS: Median = 47, Control: Median = 42.51, U test = 10; p = 0.001; r = -0.8). Potassium was also decreased (PCOS: Median = 90, Control: Median = 108.841; U test = 59; p = 0.003; r = 0.507). TomEEx (BIA spectroscopy device) detected increased conductance in the anatomical areas of inferior abdomen (PCOS:Median = 27.60, Control: Median =0; U test =0; p =0.001; r =-0.91), superior abdomen (PCOS:Median = 6.7, Control: Median = 0; U test = 42.5; p = 0.000; r =-0.7) and lumbar area (PCOS:Median = 6.4, Control: Median = 0; U test=51; p = 0.000; r =-0.7). Our results demonstrate major differences in body composition between PCOS patients and healthy controls with decreased lean body mass in the former. They also imply that chronic low-grade inflammation is present in PCOS patients, which is consistent with the decreased muscle, glycogen and bone mass despite hyperandrogenemia. Skeletal muscle mitochondrial respiration is not impaired in PCOS; thus, their insulin resistance might be attributed to their decreased lean body mass. Lastly, bio-impedance spectroscopy revealed increased electrical conductance in the abdomen and lumbar area of PCOS patients. The significance of these findings and the utility of BIA spectroscopy as a potential screening tool for PCOS remain to be proved with further studies.

 

Disclosure: DB: Chief Scientific Officer, BIOTEKNA. Nothing to Disclose: CS, FB, ED, GPC

14611 23.0000 MON-0079 A Decreased Muscle Mass and Bone Minerals and Increased Abdominal “Inflammation” Were Revealed in Body Composition and Spectroscopy Analysis of Lean PCOS Patients – a Case-Control Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Liudmila Ivanova*1, Olga Rostovtseva2 and Anastasiya Pachomova2
1Kuban State Medical University, Krasnodar, Russia, 2Kuban State Medical University

 

Aim of our study was evaluate the effect of alpha-lipoic (Thioctic) acid on hyperinsulinemia, insulin resistance, menstrual function, ovarian volume in patients with polycystic ovary syndrome (PCOS). 25 women with PCOS (average age 25,4 ± 2,5 years) who formed the experimental group. After the initial survey patients of the experimental group received thioctic acid: 1 tablet 30 minutes before breakfast for 3 months. The control group consisted of 20 women with PCOS (average age 23,7±2,2 years), who kept to a triple high-protein diet and total elimination of dietary carbohydrate. The groups were matched by age, the incidence of pre-obese and obesity, carbohydrate and lipid metabolism disorder. Hyperinsulinemia was detected on the basis of an oral glucose tolerance test with 75 g of pure glucose (OGTT). The presence of insulin resistance (IR) was judged by the index HOMA (fasting glucose (mmol/l) x fasting IRI (mU/L)/22.5. Impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) was diagnosed according to WHO recommendations, 2001. Statistical data processing was performed by Statistica for Windows version 6.0.  The reliable values were p<0,05. As a result of treatment with thioctic acid 600 mg/day for 3 months there was a significant decrease in average basal insulin 104.7 pmol/L (67 %, p = 0.023 ) and a decrease in average postprandial insulin 499.6 pmol/L (54.4 %, p = 0.015). In the control group, the levels of the average values, in both basal and postprandial insulin were practically unchanged (p=0.761). Taking of thioctic acid at a dose of 600 mg per day resulted in a significant decrease in the average index of insulin resistance after 3 months of treatment (p=0.038) compared with the original data. Among patients, treated with high-protein diet only, the average index of insulin resistance remained practically unchanged (p = 0.83). Thioctic acid treatment at a dose of 600 mg/day improved menstrual function and favorably affected the average ovarian volume after 3 months of treatment. Among patients, treated with thioctic acid, in 20 (80%) the duration and frequency of ovarian-menstrual cycle was normalized. Every third patient with amenorrhea were induced menstruation, two patients had dominant follicle. Normalization of the average ovarian volume after 3 months of treatment occurred in 16 (64%) patients of the experimental group. In the control group, similar positive results after 3 months of treatment were absent. The results of our study showed that taking of thioctic acid at a dose of 600 mg per day resulted in a significant decrease in basal and/or glucose-stimulated hyperinsulinemia, as well as a decrease in insulin resistance index in women with PCOS compared with the high-protein diet. Thioctic acid at a dose of 600 mg / day significantly reduces the average volume of the ovaries and has a positive effect on menstrual function in women with PCOS after 3 months of treatment.

 

Nothing to Disclose: LI, OR, AP

14914 24.0000 MON-0080 A Influence of Thioctic Acid on Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Hassan Kahal*1, Eric S Kilpatrick2, Anne-Marie Coady2 and Stephen L Atkin3
1Hull York Medical School, Hull, United Kingdom, 2Hull and East Yorkshire NHS Trust, Hull, United Kingdom, 3Hull York Medical School, E Yorkshire, United Kingdom

 

Background: Polycystic ovary syndrome (PCOS) is associated with conditions that may have a negative impact on quality of life (QoL) including hirsutism, oligomenorrhoea, obesity and sub-fertility. Obesity is seen in up to 78% of women with PCOS and is associated with reduced Qol. In this study our aim was to assess the effects of six months treatment with liraglutide 1.8mg od on obesity, depression and QoL in young obese women with PCOS and matched controls.

Methods: Interventional case-control study. PCOS was diagnosed according to the Rotterdam criteria; none of the women wanted fertility. Depression was measured using the Centre for Epidemiologic Studies Depression Scale (CES-D). An average score of ≥16 on this scale suggests a high risk for depression. QoL was measured using the short version of the World Health Organization QOL questionnaire (WHOQOL-BREF) that includes four subscales (physical, psychological, social and environment). Scores are given out of a hundred and higher scores are better. Data presented as mean ±SD.

Results: Thirty six women were recruited (19 PCOS, 17 controls), age 33.9 ±6.7 vs. 33.5 ±7.1yr, and weight 102.1 ±17.1 vs. 100.4 ±15.1kg, respectively (all P >0.05). The PCOS group, as expected, had higher testosterone, free androgen index, insulin, and HOMA-IR. Baseline scores on the CES-D and WHOQOL-BREF did not differ between the two groups.

Twenty five women, 69%, completed the study (13 PCOS, and 12 controls). Following six months treatment with liraglutide weight was reduced by 3.0 ±4.2kg (P=0.01) in the PCOS group and 3.8 ±3.4kg (P=0.001) in controls. At six months, there was no significant change after treatment in CES-D scores, compared to baseline, in either group. However, there was improvement on the WHOQOL-BREF questionnaire scores in psychological health 59.1 ±9.7 vs. 65.6 ±13.3 (P=0.02) and social health,73.7 ±12.5 vs. 78.3 ±12.6 (P=0.06), for the PCOS group, while changes in the control group were not significant.

Conclusions: Six months treatment with liraglutide resulted in a significant reduction in weight and improvement in QoL in young obese women with PCOS compared to weight matched controls.

 

Nothing to Disclose: HK, ESK, AMC, SLA

16385 25.0000 MON-0081 A The Effects of Treatment with Liraglutide on Quality of Life and Depression in Young Obese Women with PCOS and Controls 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Hiba Al-Zubeidi*1 and Karen Oerter Klein2
1University Of California San Diego, 2Rady Children's hospital San Diego, San Diego, CA

 

Polycystic ovarian syndrome (PCOS) is characterized by irregular menses, elevated androgens and insulin resistance . It is the most common cause of infertility in women in the reproductive age. Despite consensus recommendations, little is known about the management of adolescents with PCOS. The aim of this study is to evaluate the effect of metformin versus Oral contraceptive pills( OCP) in the treatment of PCOS . Twenty adolescents between 12-18 years of age were randomized to one of the two treatments arms for six months.  The outcome variables included Body mass index (BMI), free Testosterone (FT) level, and quality of life (QOL) measured at baseline and six months. All patients had a significant decrease in BMI, from 34.8 to 31.8 kg/m2 in the metformin group, and 36.9 to 35.6 in the OCP group, (P=0.005), but no significant difference in the degree of change between the two groups. Both groups had  decreased FT levels ( OCP: 9.4 ng/dl to 5.6 ng/dl; Metformin 9.6 ng/dl to 7.7 ng/dl) but that was not statistically significant within or between the two  groups. There was an improvement in QOL in both groups at six months and trended towards significance in the metformin group( P=0.08). Ten patients were followed for 3 months post treatment; Seven had an increase in both BMI and FT levels, and 3 maintained improved BMI and FT. We conclude that in adolescents with PCOS treated with metformin and OCP experienced similar beneficial outcomes including reduction in BMI and FT and improvement in the QOL while on treatment making both feasible treatment options.

 

Nothing to Disclose: HA, KOK

13574 26.0000 MON-0083 A Randomized Clinical Trial Evaluating Metformin Versus Oral Contraceptive Pills in the Treatment of Adolescents with Polycystic Ovarian Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Samta Jain*, Georgiana Alina Dobri, Lu Wang, James Bena and Marwan Hamaty
Cleveland Clinic Foundation, Cleveland, OH

 

Background

Hormonal contraception therapy (HCT) remains the mainstay of therapy for PCOS. High estrogen HCT is associated with higher risk for hypertension (HTN). Low estrogen HCT showed no increased risk for hypertension in the general female population. Effects of low estrogen HCT on blood pressure (BP) among women with PCOS, who are at higher risk for HTN, have not been adequately evaluated.

Aims

To investigate the effect of low dose estrogen HCT (≤35 mcg) on blood pressure among women with PCOS

Methods

Retrospective chart review of women 18-40 years of age with the diagnosis of PCOS treated in Cleveland Clinic between 2008 and 2013. Women with PCOS on low dose HCT for at least 3 months were designated as treatment group and women with PCOS without HCT were selected as control group. Women with premature menopause, hysterectomy, HCT use < 3 months, and high dose estrogen HCT were excluded. BP measurements during pregnancy and post delivery period were also excluded. The systolic and diastolic BPs were obtained at baseline, during treatment and at the end of observation.  This report focuses on comparisons between BP levels in HCT and control groups after adjusting for age, ethnicity, BMI, smoking status, alcohol use, duration of observation, number of BP measurements, use of antihypertensive meds and use of other medications (for diabetes and hyperlipidemia). Statistical analysis used t-test and Wilcoxon rank sum test for continuous variables, and Pearson’s chi-square test for categorical variables. Linear regression was used to compare outcomes after adjustments for covariates.

Results

Out of the 5131 women included in the study, 49.6% were taking low estrogen dose contraceptives (HCT group). These were younger (Median age 29 vs. 33 years) and had lower BMI than the control group (33±9 vs. 36±9 kg/m²).  There were fewer women of Hispanic ethnicity in HCT group (2.5% vs. 3.7%). Tobacco use in this group was less prevalent (30% vs. 40%) while alcohol use was slightly greater (44% vs. 42%). Further, they were less likely to use medications (e.g. 18% vs. 28% for antihypertensive medications). Unadjusted analyses showed lower blood pressure among HCT users (Systolic 119±14 vs. 122±11 mmHg, P < 0.001; Diastolic 75±10 vs. 76±7 mmHg, P < 0.001). There was no difference in pulse rate. After adjusting for confounding factors, no differences in blood pressure were found (Systolic 122±1.5 vs. 122±1.4 mmHg, P = 0.23; Diastolic 78±1 vs. 77±1 mmHg, P = 0.17).

Conclusion

Therapy with hormonal contraceptives low in estrogen showed no increased risk for developing hypertension among women with PCOS, who are at higher risk for developing hypertension.

 

Nothing to Disclose: SJ, GAD, LW, JB, MH

13529 27.0000 MON-0084 A Effects of Low Dose Estrogen Contraceptives on Blood Pressure in Women with Polycystic Ovarian Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Tone Loevvik1, Nathalie Roos2, Olof Stephansson3, Anna-Karin Wikstrøm4, Martin Neovius5 and Eszter Vanky*1
1Norwegian University of Science and Technology, Trondheim, Norway, 2Karolinska Institute, Stockholm, Sweden, 3Karolinska University Hospital, Stockholm, Sweden, 4Karolinska Institutet (KI), Department of Medicine, Solna (MedS), K2,, Stockholm, Sweden, 5Enheten för klClinical Epidemiology Unit (T2), Karolinska Institutet, Stockholm, Sweden

 

Objective: To investigate pregnancy- and perinatal outcomes in twin births among women with and without polycystic ovary syndrome (PCOS) diagnosis.

Methods:  A total of 20,965 women with twin births were identified in the Swedish Medical Birth Register between 1995 and 2009. Through linkage with the Swedish National Patient Register we identified 226 women diagnosed with PCOS. Using logistic regression analysis, we calculated odds ratios (OR) with 95% confidence intervals (CI) for preterm birth, caesarean section, low birth weight, preeclampsia, Apgar score < 7 at 5 minutes and perinatal mortality, in women with twin pregnancies and PCOS diagnosis. Women without PCOS diagnosis were used as reference.

Results:

Having a PCOS diagnosis in twin pregnancy was associated with increased risk of preterm delivery (51.3% vs 42.9%, adjusted OR (95% CI:1.0-1.9, P=0.02)), particularly spontaneous preterm delivery (36.9% vs 27.8%; adjusted OR 1.5 (95% CI:1.1-2.1, P=0.02)). The risk for Cesarean section was increased in the PCOS group (58.9% vs 49.7%, adjusted OR 1.3;(95% CI: 1.0-1.9, P=0.05)). Twins born to mothers with PCOS had more often low birth weight (47.7% vs 39.3%, adjusted OR 1.4 (95% CI:1.1-1.8, P=0.003)). This difference disappeared when adjusting for gestational length at birth. No difference in risk was found between the groups for preeclampsia, Apgar score or perinatal death.

Conclusions: The increased risk of preterm delivery and Cesarean section in twin pregnancies is further increased by having PCOS diagnosis. This should be considered in the risk estimation and follow-up of twin pregnancies in mothers with PCOS diagnosis.

 

Nothing to Disclose: TL, NR, OS, AKW, MN, EV

11588 28.0000 MON-0085 A Pregnancy and Perinatal Outcomes in Women with Polycystic Ovary Syndrome and Twin Births - a Population Based Cohort Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Fabio Vasconcellos Comim*1, Rafaela V Copês2, José Antônio Mainardi de Carvalho2, Lucas Venturini Zottele2, Luciana Leiria de Almeida2, Adhan Rizzi de Vieira1 and Melissa Orlandin Premaor2
1Federal University of Santa Maria, Santa Maria, Brazil, 2Federal University of Santa Maria, Brazil

 

PCOS is the most common reproductive disorder in menacme.   Although limitations for the   diagnosis of PCOS in postmenopausal women exist, some abnormalities frequently observed  may influence positively or negatively bone loss and the development of fractures. Therefore, the objective of this study was to explore the presence of hirsutism and oligomenorrhea  and their  impact in the history of fractures in postmenopausal women.

We conducted a cross-sectional study in the city of Santa Maria, parallel 29°, Southern Brazil, from 1st March to 31 August 2013. In this survey, post-menopausal women aged 55 years or over who attended to a General Practice Surgery (GP) were selected. Women with cognitive impairment, communication disabilities or still having periods were excluded. Data were collected using a standardized questionnaire that covered domains about patients characteristics, fracture history, risk factors for fractures and medication use. This questionnaire also inquired about reproductive history including past events of oligo-amenorrhea, hirsutism, miscarriage, and the diagnosis or treatment for hypothyroidism, hyperprolactinemia or infertility.

 Overall, 1,057 subjects were eligible for analysis.  BMI was assessed in 973 women, in which  39.6% had a BMI of 30 kg/m2 or more.  A history of fracture after age 45 was present in 17.0%.  The prevalence of hirsutism  was 12.7%;  oligomenorrhea  was  10.6%  and  both (hirsutism or  oligomenorrhea) 21.8%.

The report of hirsutism or oligomenorrhea was associated to a higher chance of any   bone fracture, even after correction for age, with an OR (CI 95%) of 1.4 (1.003, 2.2) (p=0.048). Similarly, an increase in specific fracture sites (corrected for age) was observed in lower leg with an OR 2.88 (1.06-7.84)(p=0.038), and  humerus with OR  2.8 (1.4-5.9).    Bone fractures of wrist, hip, rib, clavicle, clinical vertebral, anklewere not related to these features.

Our results indicated that characteristics of oligomenorrhea or hirsutism, self-reported by women after 55 years of age were linked to the total number of fractures, and particular sites for fractures such as the humerus or lower leg which persisted even after correction for age and BMI.

To sum up, evidence from this study suggests that common features associated to PCOS may affect negatively the bone health, predisposing postmenopausal women with these characteristics to an increased risk of fractures.

 

Nothing to Disclose: FVC, RVC, JAMD, LVZ, LLD, ARD, MOP

14164 29.0000 MON-0086 A The Impact of Self-Reported Symptoms of Oligomenorrhea or Hirsutism on Bone Fractures in Women Aged +55 Years 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Evgenia Gourgari*1, Maya Beth Lodish2, Margaret Farmar Keil3, Ninet Sinai4, Evrim Turkbey2, Charalampos Lyssikatos5, Divya Khurana6, Chris Crutchfield7, Maria V Nesterova8, Maria De La Luz Sierra8, Paraskevi Xekouki8, Peter Backlund9, Al Yergey10, Svetlana B Ten11, Adrian Sandra Dobs12 and Constantine A Stratakis8
1Georgetown University Hospital, Washington, DC, 2National Institutes of Health, Bethesda, MD, 3Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH)., Bethesda, MD, 4NICHD, Bethesda, MD, 5NIH, 6MMC, Hicksville, NY, 7Johns Hopkins Medical Institutions, Baltimore, 8National Institutes of Health (NIH), Bethesda, MD, 9NICHD, Bethesda, 10NICHD/NIH, 11Maimonides Med Ctr, Brooklyn, NY, 12Johns Hopkins School of Medicine

 

Introduction: Androgen excess in women with polycystic ovarian syndrome (PCOS) may be adrenal and/or ovarian in origin; we hypothesized that a subgroup of patients with PCOS has abnormal adrenocortical function or even bilateral adrenal hyperplasia (BAH). We examined steroid hormone secretion in young women with PCOS and age-matched healthy controls; the function of their hypothalamic pituitary adrenal axis (HPAA) was examined by a number of tests including an oral low- and high-dose dexamethasone (DEX)-suppression test (Liddle’s test).

Methods: 38 women with PCOS (androgen excess criteria) and 20 healthy volunteers (HV) aged 16-29 yrs were studied. All medications were discontinued one month prior to participation. Patients with non-classic adrenal hyperplasia, severe insulin resistance-acanthosis nigricans syndrome, thyroid dysfunction, and hyperprolactinemia were excluded. We obtained BMI, Ferriman Gallaway scores (FGS), OGTT, and measured urinary free cortisol (UFC) and 17OH steroids (17OHS), and blood levels of steroid hormones. C/T of the adrenals was done in certain patients with PCOS and volume of adrenals was calculated. Data were analyzed by mixed modeling for repeated measures, Pearson’s correlation, and two-sample t-tests.

Results: 24hr urinary 17OHS and UFC were measured during day 1 to day 8 of the Liddle’s test. Baseline values for UFC were not statistically significantly different between PCOS and HV; however, baseline urinary 17OHS were higher in the women with PCOS vs HV (5.7±1.6 vs 4.4±2.4 mg/gr creatinine/day, p=0.0173). On the last day of high dose dexamethasone (day 8 of the Liddle’s test), UFC was higher in the PCOS group (2.0±0.7 mcg/m2/day) than the HV group (1.5±0.5) (p=0.0378). On day 7, 17OHS and UFC were negatively correlated with adrenal volumes (r=-0.5 for each, p=0.011 and p=0.002, respectively). PCOS patients above the 75th quartile for UFC or 17OHS after high dose dexamethasone ( n=15) had a significantly smaller total adrenal volume when compared to the remaining PCOS patients (n=22) (6.9±1.9 vs 9.2±1.8 cc. p=0.0025).

Conclusion: These data indicate that, indeed, in a subset of young women with PCOS we detected a pattern of glucocorticoid secretion that suggests the presence of micronodular adrenocortical hyperplasia: smaller adrenal volumes, overall, with some nodularity, and in association with higher steroid hormone secretion after dexamethasone than controls.

 

Nothing to Disclose: EG, MBL, MFK, NS, ET, CL, DK, CC, MVN, MDLLS, PX, PB, AY, SBT, ASD, CAS

11927 30.0000 MON-0087 A Micronodular Adrenal Hyperplasia: A New Mechanism for Hyperandrogenism in Women with Polycystic Ovarian Syndrome (PCOS) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Thang S Han1, Gerard S Conway2, Debbie S Willis3, Nils P. Krone4, Aled Rees5, Roland H Stimson6, Wiebke Arlt4, Brian R Walker6 and Richard J Ross*7
1Royal Holloway University of London (ICR2UL) and Ashford and St Peter's NHS Foundation Trust, Surrey, United Kingdom, 2University College London, London, United Kingdom, 3British Endocrine Society, Bristol, United Kingdom, 4University of Birmingham, Birmingham, United Kingdom, 5Cardiff University, Cardiff, United Kingdom, 6University of Edinburgh, Edinburgh, United Kingdom, 7University of Sheffield, United Kingdom

 

Context: Treatment of congenital adrenal hyperplasia (CAH) in childhood focuses on growth and development and adult final height (FH) is a measure of effective treatment. We examined the relationship between FH and health outcomes in a cohort of adult patients.

Methods: Cross-sectional analysis of 199 adults with CAH. FH and QoL were expressed as z-scores adjusted for mid-parental target height (FHTH) or UK population (FHUK).

Results: FH correlated inversely with age (men r = -0.38; women r = -0.26, P <0.01). Men and women had FHTH z-scores -2 and -1 respectively, and both groups had FHUK z-scores -1 below the UK population (P <0.01). In women, FH was shorter in non-SW than SW classic CAH (P <0.05) and in moderately affected genotype group B women than either more severely affected groups Null and A (P <0.01) or mildest group C (P <0.001). Classic CAH patients diagnosed late were shorter than those diagnosed in the first year of life (P <0.05). The shortest CAH patients were 3.4 times (95% CI: 1.4 to 8.0, P = 0.006) more likely to have hypertension than the tallest. FH did not associate with insulin sensitivity, lipid profile, adiposity and QoL.

Conclusions: Adult CAH patients remain shorter than predicted although height prognosis improved over time suggesting better management in childhood. Patients diagnosed late with moderate severity CAH are shorter as adults, and short stature was associated with adult hypertension. We hypothesise that patients with a reduced FH are those exposed to high androgens and/or excessive glucocorticoid in childhood with potential programming of hypertension.

 

Disclosure: RJR: Other activities, please specify:, Asterion Ltd, Director, Diurnal Ltd. Nothing to Disclose: TSH, GSC, DSW, NPK, AR, RHS, WA, BRW

13229 31.0000 MON-0088 A Final Height in Relation to Health Outcomes in Adults with Congenital Adrenal Hyperplasia: United Kingdom Congenital Adrenal Hyperplasia Adult Study Executive (CaHASE) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Eunice Marumudi*, Bindu Kulshreshtha, Arundhati Sharma, Rajesh Khadgawat, Madan L Khurana and Ariachery C Ammini
All India Institute of Medical Sciences, New Delhi, India

 

Congenital adrenal hyperplasia (CAH) is a group of recessively inherited diseases and is one of the most common forms of autosomal recessively inherited inborn errors of metabolism in which cortisol secretion from the adrenal cortex is impaired leading to a compensatory hypersecretion of androgens. As a result, genetic female (46, XX)    fetuses masculinize in utero. Whereas males develop precocious puberty and later present with adrenal rests. Both male and female patients are equally at risk if not diagnosed/treated. This disorder can present with different clinical manifestations according to the degree of enzyme activity and the CYP21A2gene mutational status Though CAH is an autosomal recessively inherited disorder, but our study showed the dominant pattern of disease penetrance with female preponderance.  Hence in this present study, we planned to see the inheritance from our large CAH cohort and to identify the genotype of the parents/ siblings of   CAH patients.

The data presented is taken from the CAH study cohort of hundred and nineteen patients. This is an ongoing study, approved by Institute’s ethics committee. We had taken the detailed medical history including genital appearance, hirsutism status and three generational family pedigrees. Informed consent was taken from the patients’/parents/siblings before collecting the blood samples for molecular analysis. Genotyping was done by PCR and RFLP method to find out the underlying mutations of CYP21A2 gene (1).

There were fifteen families who had one or more affected siblings with CAH. These fifteen parents gave birth to fifty eight children. Among these 58 children, 19 were males and 39 were females. Among them, 10 males and 3 females died at infancy due to diarrhoea and vomiting from 7 families. In two families, 8 pregnancies were medically terminated. Even if these were considered as males, yet females  outnumbered. In the remaining 45 children, 25 siblings were affected with classic CAH. Out of these 25 siblings, 19 were females and 6 were males. Out of these 25 siblings, 20 (80%) were found to have CYP21A2 gene mutations. Among them 14 had compound heterozygous mutations.In2 mutation was found to be high (70%) followed by P30L (50%), Q318X (45%), R356W (15%), I172N (15%) and del 8bp (10%).

Female predominance was observed. As per our present experience this trend was due to male infant deaths before the diagnosis. Most of the females were diagnosed early because they had exhibited genital ambiguity and adrenal crisis. These six boys were diagnosed in infancy because they presented with adrenal crisis and also because of the family history.  We observed that  more girls were  born and  neonatal deaths were  more in boys.The most predominant mutation was found in In2.

 

Nothing to Disclose: EM, BK, AS, RK, MLK, ACA

16721 32.0000 MON-0089 A Gender Disparity Among Children Born in Families with Congenital Adrenal Hyperplasia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Monica Patricia Recabarren1, Albert Carrasco1, Karina Morales1, Pedro Pablo Rojas-Garcia1, Teresa Sir-Petermann2 and Sergio E Recabarren*1
1University of Concepcion, Chillan, Chile, 2University of Chile, Santiago, Chile

 

The etiology of the Polycystic Ovary Syndrome (PCOS) is partially known. It has been proposed that elevated testosterone (T) levels observed in pregnant PCOS women could provide an anomalous intrauterine environment to the developing fetus, perpetuating the metabolic disturbances observed in PCOS women. Experimental studies in monkeys and sheep have given support to this hypothesis. In sheep, we have shown that females born to mothers exposed to T during gestation, exhibit insulin resistance (IR), manifested at early age and that persists into adulthood. IR could even become worse if the adult females are obese (1). However, the role of fetal exposure to T as a programming insult in the presentation of IR during postnatal development and adulthood is controversial, given that the metabolic environment of the mother in gestation, could also contribute as a reprogramming stimulus. One question arising from these controversial effects of T on insulin sensitivity (IS) is whether the effect of T is a consequence of the T hyperstimulation over the pancreas or it is programmed by T excess during fetal development.  The prenatally T exposed sheep as a model system of PCOS brings the possibility to evaluate the effects of acute administration of T, as a challenge for insulin (I) secretion and IS and if the experimental administration of T will aggravate the IR derived of the effect of the prenatal T exposure. In order to isolate the effect of T, independent of other gonadal steroids, we used ovariectomized sheep without (C-ovx females) and with prenatal exposure to T (T-ovx females) to assess the acute effect of T on IS. Plasma levels of T and I were measured during pregnancy in mothers of these female offspring. In both groups of sheep (n = 6/Group), the intravenous glucose tolerance test (IVGTT) was used in order to evaluate the insulin sensitivity index (ISI-C), before and again 48 hrs post T (40 mg T Propionate im). Plasma I levels were comparable in pregnant sheep. Plasma levels of T in both groups of ovx females were undetectable before T administration, and increased to 1.71 ±0.22 and 1.72 ±0.27 ng/mL respectively 48 hrs post T. The secretion of I during the IVGTT was greater in C-ovx females than in T-ovx females in both experimental sessions (P < 0.05). The secretion of I post T in C-ovx females was greater than before T (P < 0.05). Plasma glucose concentrations during the IVGTT were similar between C-ovx and T-ovx females. In T-ovx females, there was lower secretion of I after T than before T. ISI-C in C-ovx females (P < 0.05) diminished after T; but in T-ovx females remained unchanged. The acute effect of T was discernible in C-ovx females with a clear decrease in IS. T-ovx females, because of the low I secretion, suggest that these females had a pancreatic beta cell failure but the ISI-C was greater than in C-ovx females. These differences may partly explain the various phenotypes of the IR in PCOS women

 

Nothing to Disclose: MPR, AC, KM, PPR, TS, SER

12610 33.0000 MON-0090 A Acute Testosterone Administration Aggravates the Insulin Resistance of Ovariectomized Sheep Prenatally Exposed to Excess Testosterone 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0057-0090 4862 1:00:00 PM Hyperandrogenic Disorders Poster

Mary Rebecca Moreci*1, Jennifer Catherine Condon2 and Jeyasuria Pancharatnam1
1University of Pittsburgh, Pittsburgh, PA, 2Univ of Pittsburgh, Pittsburgh, PA

 

Steroidogenic factor 1 is known to play a critical role in male sexual development and spermatogenesis. Global ablation of SF-1 results in gonadal and adrenal agenesis; compromised gonadotrope expression and a failure to develop the VMH. To study post developmental SF-1 function in the testes we had previously used the Anti-Müllerian hormone type 2-receptor promoter driven Cre (AMHr2-Cre) to specifically knock SF-1 out in the developing testis. This transgene expressed Cre recombinase in the Leydig cells as well as partially in the Sertoli cells. The phenotype in this animal was complex due to the loss of SF-1 in the early developing Leydig cells and thus the loss of testosterone (T) production, which caused a cryptorchid phenotype. This study focuses on SF-1 function specifically in Sertoli cells. We ablated SF-1 starting at E15 in the developing testis using the AMH-Cre transgenic mouse. SF-1 homozygous loxed males were crossed with AMHCre/SF-1 homozygous floxed females resulting in the conditional Sertoli cell specific SF-1 knockout (SCADKO) male offspring having markedly hypoplastic testes when compared with AMH-Cre negative, homozygous loxed littermates (wildtype). Testes descent was normal in knockouts and seminal vesicle and epididymal size was similar in 3-week and 6-week animals. Histological examination revealed the hypoplastic phenotype could in part be explained by loss of Sertoli cell proliferation and the loss of germ cells. The SCADKO testes display cord regression from E17.5 to E18.5. Immunohistochemical examination of these testes using the vasa antibody shows a loss of germ cells probably due to the loss of Sertoli cells surrounding germ cells. However, by 11 weeks there was a reduction in the size of these organs, suggesting a drop in testosterone production. Gross histological examination of testes (6 and 11 weeks) showed signs of crenation of the tunica albuginea due to loss of testicular mass. Sertoli cells that escape ablation continue to proliferate and produce cords at PD1 and minimal spermatogenesis is seen in postnatal testes. Some testicular cords form seminiferous tubules that are Sertoli cell-only while others trap some germ cells and continue spermatogenesis. The incomplete ablation produces a severe hypomorhic phenotype and we are currently undertaking a cross that utilizes the SF1null/+ males with AMHCre/SF-1 homozygous floxed female. We believe that the ablation of SF-1 at E15 causes developmental changes that block the expansion of the Sertoli cell pool. We also believe that the loss of Sertoli cells causes germ cell loss. BRDU studies confirm the loss of proliferation of Sertoli cells at E17.5 and E18.5.

 

Nothing to Disclose: MRM, JCC, JP

17021 1.0000 MON-0091 A A Conditional Ablation of SF-1 in Sertoli Cells Implicates SF-1 As Essential in Sertoli Cell Proliferation and Function 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Nooshin Mirkheshti*1, Bandana Chatterjee2 and Chung Seog Song3
1Univ of Texas Health Science Cen, San Antonio, TX, 2South Texas Veterans Health Care System, San Antonio, TX, 3Univ of Texas Hlth Science Ctr, San Antonio, TX

 

In addition to the reactivated androgen receptor (AR), which is a major contributor to the recurrence of prostate cancer and its transition to castration resistance, the oncogenic activation of the PI3K/AKT/mTOR axis also frequently fuels prostate cancer progression. The mTOR axis inhibitors like rapamycin and BEZ-235 (a PI3K/mTORC1 dual inhibitor) are ineffective against advanced prostate cancer since they activate AR by inducing HER kinases, which phosphorylate and enhance AR activity. Reciprocally, inhibition of AR leads to AKT activation due, in part, to reduced expression of the AKT phosphatase PHLPP, which is encoded by an AR target gene (1, 2). We earlier showed that the antibiotic salinomycin, used widely on farm animals to prevent coccidiosis, inhibits proliferation of prostate cancer cells without imposing inhibition on non-malignant RWPE-1 prostate cells. Here we report that both androgen-dependent LNCaP and castration-resistant C4-2B prostate cancer cells are inhibited by salinomycin.  Salinomycin not only reduced mTORC1 activity, as evident from reduced phosphorylation of S6 kinase and its downstream target, i.e. the ribosomal protein S6 (RPS), it also decreased AR mRNA and protein levels in these cells. Importantly, serine-81 phosphorylation of AR, a metric for the nuclear AR activity, was markedly reduced in salinomycin-treated cells.  Reduction of Ser-81 phosphorylation was detected at a very low salinomycin concentration when AR protein levels were minimally reduced.  RWPE-1 cells did not show these changes. Preliminary data suggest that mTORC1 was targeted by salinomycin as a result of decreased expression of the forskolin-binding protein FKBP-12, which is a regulator of mTORC1 activity.  Kinetic analysis shows that salinomycin-mediated inhibition of mTORC1 activity is an early event when none of the known upstream components of the mTOR axis are affected. These results contrast the effect of rapamycin, which increased AR protein levels and Ser-81 phosphorylation of AR in LNCaP and C4-2B cells while markedly reducing mTORC1 activity. In ongoing study with xenograft tumor models, we are exploring the anti-neoplastic activity of salinomycin against prostate tumor and its efficacy in the intratumoral targeting of two pivotal oncogenic axis involving AR and mTORC1 activities.  Our results suggest that salinomycin (or its analogs) holds the potential for serving as a clinically useful drug against metastatic, castration-resistant prostate cancer.

 

Nothing to Disclose: NM, BC, CSS

13536 2.0000 MON-0092 A Dual Targeting of Androgen Receptor and PI3K/AKT/mTOR Pathways in Prostate Cancer By Salinomycin: A Contrast to Rapamycin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Yasaman Aghazadeh*1, Vassilios Papadopoulos2, Martine G Culty3, Daniel Benjamin Martinez-Arguelles4 and Jinjiang Fan5
1McGill University, Montreal, QC, Canada, 2McGill University Health Centre, Montreal, QC, Canada, 3Rsrch Inst of MUHC, Montreal, QC, Canada, 4The Research Institute of the McGill University Health Centre, Montreal, Canada, 5The Research Institute of the McGill University Health Centre, Montreal, QC, Canada

 

Induction of androgen formation in the male by a peptide blocking 14-3-3ε protein adaptor and mitochondrial VDAC1 interactions

Yasaman Aghazadeh, Daniel B. Martinez-Arguelles Jinjiang Fan, Martine Culty, and Vassilios Papadopoulos

The Research Institute of the McGill University Health Centre and the Department of Medicine, McGill University, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada

Low testosterone (T) is a major cause of male hypogonadism and infertility and is linked to mood changes, fatigue, osteoporosis, reduced bone-mass index, and aging. The treatment of choice, T-replacement therapy, is linked with increased risk for prostate cancer and luteinizing hormone (LH) suppression, and shown to lead to reduced fertility, cardiovascular diseases and higher mortality rates. In search of the mechanisms regulating T synthesis in the testes, we identified the 14-3-3ε protein as a negative regulator of steroidogenesis. 14-3-3ε interacts with the outer mitochondrial membrane voltage-dependent anion channel (VDAC1) protein and translocator protein (TSPO), forming a scaffold that limits the availability of cholesterol for steroidogenesis. Peptides were developed using a sequence of HIV transcription factor I conjugated to 14-3-3 motif containing S167 on VDAC1. These peptides compete with endogenous VDAC1 and blocked 14-3-3ε-VDAC1 interactions in vitro and in vivo, leading to increased serum and intratesticular T levels in adult male rats. These peptides also rescued intratesticular and serum T formation in adult male rats treated with GnRH antagonist, which dampened LH and T production.  These results not only unveiled a novel mechanism regulating androgen biosynthesis but also suggest that the identified peptide is a new tool and potential therapy for treating primary hypogonadism and for maintaining physiological T levels during situations, such as aging, without requiring exogenous administration of T.

 

Nothing to Disclose: YA, VP, MGC, DBM, JF

12420 3.0000 MON-0093 A Induction of Androgen Formation in the Male By a Peptide Blocking 14-3-3Epsilon Protein Adaptor and Mitochondrial VDAC1 Interactions 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Grete Lottrup*1, John Erik Nielsen1, Lisa Leth Maroun2, Lars Michael Alling Møller3, Mohammed Yassin1, Henrik Leffers1, Niels Erik Skakkebaek4 and Ewa Rajpert-De Meyts1
1Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark, 2Copenhagen University Hospital (Rigshospitalet), 3Copenhagen University Hospital (Gentofte Hospital), 4University of Copenhagen, Faculty of Health and Medical Sciences, Rigshospitalet, Denmark, Copenhagen, Denmark

 

Normal Leydig cell (LC) function, in particular hormone secretion, is essential for male development and reproduction. Signs of LC failure, including clustering in large micronodules, are often observed in patients with reproductive disorders, such as subfertility, testicular germ cell cancer, cryptorchidism, and Klinefelter syndrome. While LC differentiation has been well described in rodents, little is known about maturation of LCs during human development and in testis pathology. The aim of this study was to investigate differentiation stages of human LCs during development and in adult disorders associated with testicular dysgenesis syndrome (TDS), especially within LC micronodules. To that end we investigated retrospectively a panel of markers and factors linked to the development and differentiation of LCs in a series of testis tissue samples, including early fetal material and samples from patients with various TDS disorders and Klinefelter syndrome. The expression patterns of DLK1, INSL3, COUP-TFII, CYP11A1 and SMA were investigated by immunohistochemistry and qRT-PCR.

CYP11A1 was expressed in the majority of LCs regardless of age and pathology. In contrast DLK1, INSL3 and COUP-TFII expression changed during development or between pathologies. During development DLK1 was expressed in all fetal LCs, but only in spindle-shaped progenitor LCs and in a small subset of polygonal LCs in the adult testis. In contrast INSL3 was expressed in a subset of fetal LCs and in the majority of adult LCs, but rarely in the DLK1-positive LCs. COUP-TFII was expressed in peritubular and mesenchymal stromal cells at all ages, in differentiating fetal LCs early in gestation and in a subset of adult LCs. In testes with dysgenesis DLK1-positive interstitial cells increased in numbers and DLK1 expression was also observed in peritubular cells. The proportion of LCs expressing DLK1 increased with total LC numbers (p<0.01) from 5-20% in normal testes to >60% in some testes with LC hyperplasia and atrophy of the seminiferous tubules. The proportion of DLK1-positive LCs also correlated with serum gonadotropin levels (p<0.01), and with DLK1 expression in peritubular cells (p<0.01), which was highly associated with the enlargement of the peritubular compartment (p<0.001). INSL3 expression was absent in some LC micronodules and was mutually exclusive with DLK1 expression in samples with large LC micronodules.

In conclusion, the LC and peritubular cell populations in testes with dysgenesis are heterogeneous and contain an increased proportion of undifferentiated cells when compared to control samples, as demonstrated by increased DLK1 expression and decreased INSL3. DLK1 and INSL3 are useful markers of human LC differentiation and maturation.

 

Nothing to Disclose: GL, JEN, LLM, LMAM, MY, HL, NES, ER

15772 4.0000 MON-0094 A Developmental Expression Pattern of DLK1 and INSL3 Identifies Stages of Leydig Cell Differentiation in Development and in Disorders Associated with Testicular Dysgenesis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Pedro Pablo Rojas-Garcia1, Daniel Sandoval1, Maria Ester Chaucon2, Albert Carrasco1, Teresa Sir-Petermann3 and Sergio E Recabarren*1
1University of Concepcion, Chillan, Chile, 2School of Medicine, University of Chile, Santiago, Chile, 3University of Chile, Santiago, Chile

 

A number of experimental and clinical evidence show that prenatal exposure to excess testosterone (T) induces reproductive and metabolic disturbances in females. However, despite significant advances in understanding the adverse effects in females, few studies have addressed the same in males. Males born to PCOS mothers manifest metabolic disarrangements beginning at birth. In an experimental ovine model of PCOS we have shown that adult male sheep exposed to excess T during prenatal life exhibit significant reduction in sperm count, sperm motility and increased number of Sertoli cells. The increase in Sertoli cell number and the decrease number of germ cell was observed from infancy to adulthood. Apoptosis as well as proliferation of germ cells and Sertoli cells could explain the discrepancy between both types of cells. To further evaluate the ontogeny of this difference, in the present study, we compared proliferation, using Ki-67 nuclear antigen and apoptosis by means of TUNEL assay, of germ cells and Sertoli cells respectively in male fetus of 120 days and in prepubertal males of 24 weeks of age. In parallel, the protein expression of molecules involved in the regulation of the blood-testis barrier was assessed by WB and immunohistochemestry. Males were born to mothers treated with either T propionate (T-males, 30 mg twice daily from day 30 to 90 of gestation and 40 mg twice weekly from 90 to 120 days of gestation) or the vehicle (C-males). Immunoreaction positive for Ki-67 was observed in germ cells and Sertoli cells in fetal and prepubertal testis, without difference between both groups at both ages. There was no difference in the apoptotic index of germ cells and Sertoli cells in fetal testis, however, the apoptotic index of germ cells was greater in prepubertal T-males than in C-males (P<0.04) , with no difference in Sertoli cells. N-cadherin protein expression was similar in T-and C-males fetuses, but lower in prepubertal T-males. Protein expression of connexin 43 was similar in fetuses, but higher in prepubertal T-males compared to C-males (P<0.05). Additionally, the immunoreaction for claudin-11 was higher in T-males in the apical part of the adluminal compartment. These findings suggest that the altered relationship between sperm cells and Sertoli cells observed in adult males because of prenatal exposure to excess T, is observed at the prepubertal stage, with an abnormal molecular and cellular environment associated to spermatogenesis and progression of germ cells within the seminiferous tubule. Taking into account differences between humans and animal models of PCOS, males born to PCOS mothers may be at risk in terms of fertility

 

Nothing to Disclose: PPR, DS, MEC, AC, TS, SER

15361 5.0000 MON-0095 A Abnormal Programming of Germ Cells and Sertoli Cells in Prepubertal Male Sheep By Excess Prenatal Exposure to Testosterone 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Yue Jia*1, Jennifer Kuang Wei Yee2, Christina Wang3, Liana Nikolaenko4, Samuel French5, Peter Y Liu6, Maruja Diaz-Arjonilla3, Yan-He Lue3, Wai-Nang Paul Lee2 and Ronald S. Swerdloff3
1LABioMed at Harbor-UCLA Medical Center, Torrance, CA, 2Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA, 3Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA, 4Harbor-UCLA Medical Center, Torrance, CA, 5Harbor-UCLA Medical Center and Los Angeles Biomedical Research Center, Torrance, 6Harbor-UCLA Medical Center and Los Angeles Biomedical Research Institute, Torrance, CA

 

Objective: Testosterone (T) deficiency is associated with obesity, metabolic syndrome and type 2 diabetes risk factors for NAFLD. We developed a model of NAFLD without insulin resistance induced by high fat, low carbohydrate diet (HFD) in castrated male rats to investigate the effects of T on the pathogenesis of hepatic steatosis/steatohepatitis. Our prior studies showed T replacement in castrated rats decreased HFD induced hepatic steatosis independent of insulin action. To understand the mechanism of T action in hepatic steatosis, we studied de novo fatty acid synthesis, and expression of genes/proteins regulating: triglyceride synthesis (SCD1 and DGAT1); fatty acid β-oxidation (CPT1a); and hepatic lipoprotein assembling (ApoB and MTP) in HFD induced hepatic steatosis.

Materials and Methods: Adult male rats were randomized to 4 groups and fed for 15 weeks: intact rats on regular chow diet (RCD), intact rats on HFD (I+HFD), castrated rats on HFD (C+HFD), and castrated rats on HFD+T replacement (C+HFD+T). The HFD provided 71% and 11% whereas RCD provided 16% and 56% of energy from fat and carbohydrates respectively. Fatty acid de novo synthesis was measured by deuterium enrichment and analysis by gas chromatography/mass spectrometry. Quantitative real time PCR detected changes of mRNA expression of SCD-1, DGAT1, CPT-1a, and ApoB. Western blotting determined the change in protein levels of ApoB and MTP. 

Results: T replacement attenuated hepatic steatosis in C+HFD rats. De novo fatty acids synthesis rates did not reflect the fat accumulation in castrated rats on HFD or protective effect of T replacement. Compared to I+RCD, SCD-1 was suppressed in I+HFD, and was further suppressed in C+HFD, but not changed by T replacement. No changes were detected in CPT-1a and DGAT1 in any group. ApoB gene expression was suppressed in I+HFD and C+HFD compared to I+RCD which was attenuated with T replacement. Western blot confirmed suppression of ApoB100 and MTP protein levels in C+HFD which was restored by T replacement.

Conclusions: In castrated rats HFD induced insulin-independent NAFLD. Low ApoB100 and MTP levels lead to defective triglyceride export from the liver as VLDL. Low serum T is associated with increased risk of hepatic stetosis/steatohepatitis; T treatment reverses this damage through maintenance of hepatic lipid export via VLDL. Insulin resistance is not required for the action of T on hepatic steatosis.

 

Disclosure: CW: Investigator, Clarus, Speaker, Lilly USA, LLC, Investigator, Besins Health Care, Investigator, Lipocine. RSS: Consultant, Clarus, Investigator, Novartis Pharmaceuticals, Consultant, Endo Pharmaceuticals, Investigator, Abbott Laboratories. Nothing to Disclose: YJ, JKWY, LN, SF, PYL, MD, YHL, WNPL

14094 6.0000 MON-0096 A Testosterone Ameliorates Non-Alcoholic Fatty Liver Disease (NAFLD) in Castrated Male Rats through Effects on Liver Fat Export 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Sander van den Driesche*, Diane Rebourcet, Karen Kilcoyne and Richard Michael Sharpe
MRC, Edinburgh, United Kingdom

 

From human epidemiological and related studies, there is strong (indirect) evidence that common male reproductive disorders that manifest at birth (cryptorchidism, hypospadias) or in adulthood (low sperm count, low testosterone, testicular germ cell cancer) may have a common origin in fetal life due to impaired androgen (testosterone) production/action; the so-called testicular dysgenesis syndrome (TDS) hypothesis. We have developed an animal model of TDS based on fetal exposure to the environmental chemical dibutyl phthalate (DBP), which causes impairment of fetal testosterone production in males. The degree of testosterone impairment can be monitored after birth by measuring anogenital distance (AGD). Reduction in AGD correlates closely with risk of TDS disorders and with adult size of all male reproductive organs. Similar AGD relationships have been shown recently for man. The purpose of this study was to establish the relationship between fetal age-specific suppression of fetal testis testosterone and/or induction of focal dysgenesis via DBP on the occurrence of TDS disorders, testicular dysgenesis/morphology and the relationship with AGD in adulthood. Adult female Wistar rats were treated with either vehicle (control) or dibutyl phthalate (DBP; 750 mg/kg/day) from embryonic day (e)15.5-e18.5 (masculinization programming window; MPW), e19.5-e21.5 (late window) or from e13.5-e21.5 (full window). Resulting male offspring were examined for the appearance of hypospadias and cryptorchidism, AGD, penis length and penis, testis and prostate weights in adulthood as well as the plasma levels of testosterone and LH. All DBP treatments suppressed fetal testosterone but only when this included the MPW did it result in adverse reproductive changes, namely significant reduction in adult AGD, penis length, penis, testis and prostate weights and induction of cryptorchidism and hypospadias. Similarly, only animals exposed in utero to DBP during the MPW exhibited compensated LC failure (high LH + low/normal testosterone) in adulthood. Regression analysis demonstrated strong positive correlations between AGD and testis, penis and prostate weights and penis length. AGD was negatively correlated with the LH:Testosterone ratio (ie compensated LC failure). We conclude that DBP-induced fetal androgen suppression during the MPW, but not later in gestation, results in life-long reduction in AGD, and a significant increase in adult male reproductive disorders. Similarly, only DBP exposure in the MPW is associated with the induction of focal testicular dysgenesis, which in turn is associated with reduced AGD. Our findings demonstrate that androgen exposure during the MPW is critical in programming the structure and functionality of the adult testis.

 

Nothing to Disclose: SV, DR, KK, RMS

14539 7.0000 MON-0097 A Fetal Androgen Suppression in the Masculinisation Programming Window (MPW) Determines Adult Reproductive Disorders in the Rat 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Eui-ju Hong*1, Young-Kwon Choi2 and Eui-Bae Jeung3
1Chungbuk National Univ, Cheongju, Korea, Republic of (South), 2Chungbuk National University, Cheongju Chungbuk, Korea, Republic of (South), 3Biochemistry and molecular biology of veterinary medicine college, Chungbuk National Univ, Cheongju, Korea, Republic of (South)

 

Introduction: Calcium homeostasis is the balanced regulation of uptake, storage, and expenditure in body. Calcium level is also regulated in response to endogenous signal and physiological needs. Impairment of calcium uptake or reabsorption over a long period of time could contribute to the etiology of many diseases such as osteoporosis and cardiovascular disease. Imbalance in calcium homeostasis may originate from sex steroid hormone deprivation or vitamin D disorder, as well as from gradual loss of efficiency in reabsorption in kidney during aging process. Methods: To examine whether the expression of calcium-related genes in kidney is due to androgen-dependent effect, the progesterone receptor or various calcium related transcripts were monitored in kidney of orchiectomied mouse after treatment with dihydrotestosterone (DHT), with/without androgen receptor (AR) antagonist, bicalutamide. Results: When androgen responsive PR mRNA is dramatically increased in orchiectomy, DHT treatment decreased to base line levels of PR expression, and restored its level by AR antagonist. The results imply that renal PR expression levels are decreased by androgen. Moreover, the DHT-induced PR expression is involved with renal physiology, such as calcium reabsorption or mineral homeostasis. Thus, the various ions related proteins are observed in kidney with/without androgen, and also showed their expression alterations under condition of PR induction. Conclusion: We suggests that androgen may be involved in ions reabsorption via progesterone receptor, and that this may be especially important under condition where the supply of androgen is limited.

 

Nothing to Disclose: EJH, YKC, EBJ

12317 8.0000 MON-0098 A Androgen-Regulated Progesterone Receptor Regulates Renal Calcium-Related Proteins 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

María Noel Galardo*, Mariana Regueira, María Fernanda Riera, Eliana Herminia Pellizzari, Selva Beatriz Cigorraga and Silvina Beatriz Meroni
Centro de Investigaciones Endocrinológicas, Dr César Bergadá-CONICET-División de Endocrinología-FEI, Ciudad Autónoma de Buenos Aires, Argentina

 

Sertoli cells (SC) provide the structural and nutritional support for germ cell development. Studies on SC glucose metabolism have shown that this cell type actively metabolizes glucose and converts it to lactate, which is the major source of energy for germ cells. On the other hand, the transcription factor HIF-1 plays a central role in the regulation of glycolytic metabolism. Active HIF-1 is a heterodimer consisting of an oxygen-dependent α subunit and a constitutively expressed β subunit. Under normoxic conditions, α subunit is rapidly degraded via a mechanism that involves hydroxylation by oxygen-dependent prolyl-hydroxylases. Prolyl-hydroxylases inhibition —by low oxygen tension or transition metals like cobalt— leads to HIF-1α subunit stabilization, which enables HIF-1 α and β subunits to associate and form active HIF-1. The aim of this work was to evaluate HIF-1 participation in the regulation of molecular mechanisms involved in lactate production in SC. In order to augment HIF-1 levels, 20-day-old rat SC cultures were incubated for different periods of time in the presence of cobalt chloride (CoCl2 300μM). HIF-1α protein levels, lactate production and different mechanisms involved in its production such as: glucose uptake, LDH activity and the expression of GLUT1, MCT4, LDHA and PDK1 were analyzed. As expected, Western blot analysis showed that CoCl2 increased HIF-1α (CoCl2: 5.4±0.5*, *p<0.05 vs. Basal (B)). Concomitantly, CoCl2 led to an increase in: glucose uptake (B:524±92, CoCl2:1874±55*dpm/μgDNA), LDH activity (B:22.6±0.6, CoCl2:30.2±0.2*mUI/μgDNA) and lactate production (B:6.7±0.3, CoCl2:22.8±2.9*μg/μgDNA) (X±SD, n=3, *p<0.05 vs B). In addition, by RQ-PCR it was shown that CoCl2 increased mRNA levels of: GLUT1 (4.0±0.2*), MCT4 (1.7±0.1*), LDHA (3.0±0.5*) and PDK1 (2.7±0.3*), fold variation vs. B, *p<0.05 vs. B. Taking into account that FSH regulates lactate production and the expression of the above-mentioned genes in SC, the possibility that the hormone could regulate HIF-1α expression was explored. It was observed that under normoxic conditions, FSH increased HIF-1α mRNA and HIF-1α protein levels (2.3±0.4*and 4.6±0.5*, fold variation vs. B respectively, *p<0.05 vs. B). These results suggest on the one hand, that HIF-1 regulates several mechanisms involved in lactate production in SC and on the other hand, that HIF-1 might be participating in the mechanism of action utilized by FSH to regulate lactate production under normoxic conditions.

 

Nothing to Disclose: MNG, MR, MFR, EHP, SBC, SBM

12106 9.0000 MON-0099 A Hypoxia-Inducible Factor-1 (HIF-1) Regulates Sertoli Cell Lactate Production 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Ruifeng Yang*1, Chon-Hwa Tsai-Morris2 and Maria L Dufau3
1National Institutes of Health, Bethesda, MD, 2National Institutes of Health, 3NIH-NICHD, Bethesda, MD

 

Gonadotropin regulated testicular RNA helicase (GRTH) is a testis specific member of the DEAD-box family of RNA helicases present in Leydig and germ cells of the testis. It is developmental regulated and essential for post-transcriptional regulation of spermatogenesis (1). Male mice lacking GRTH are sterile due to lack of mature germ cells (2). Failure expression of chromatin remodelers Transition protein 2 (Tp2) and Protamine 2 (Prm2), essential for spermatid elongation and completion of spermatogenesis, with preservation of their mRNA expression was observed in GRTH null mice. As component of messenger ribonuclear protein, GRTH transports target mRNAs from the nucleus to cytoplasmic sites for storage in Chromatoid Bodies of round spermatids (equivalent to somatic P-Bodies), and to polyribosomes for translation (3,4). To determine the RNA binding motif(s)/regions within GRTH protein required for interaction with germ cells specific 3’UTR of Tp2 mRNA transcripts, expressing plasmids of GRTH full length, and sequential deletions, which included specific conserved RNA helicase motifs, were constructed in mammalian expressing pcDNA3.1-v5 for in vitro TnT expression. RNA-EMSA study showed that biotin labeled in vitro transcript of 130 bp 3’ UTR of Tp2 RNA was retarded in the presence of full length GRTH protein.  The immediate 50 bp sequence downstream of termination codon (TGA) of Tp2 (T1) is essential for the binding to GRTH. Further downstream sequence from 50/130 bp of TP2 3’UTR is not required for the binding to GRTH.  Sequential deletion in GRTH revealed region(s) corresponding to two of the four RNA binding motifs of the RNA helicase family (Ia & V) that are essential for GRTH binding to the Tp2 mRNA. T1 associated retarded complexes were supershifted by V5 antibody confirming the specificity of GRTH/Tp2 association. Our studies provide insights for the regulation of Tp2 expression via binding to the conserved RNA binding motifs of GRTH protein which associates at the polysomal sites. These studies offer basis for understanding the manner in which GRTH contributes to the regulation of the expression of genes that are essential for germ cell elongation and completion of spermatogenesis.

 

Nothing to Disclose: RY, CHT, MLD

12220 10.0000 MON-0100 A Elucidation of RNA Binding Regions of Gonadotropin Regulated Testicular RNA Helicase (GRTH/DDX25) Protein to Transcripts of a Chromatin Remodeling Protein Essential for Spermatogenesis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Cortney Christian, Shakira J O'Neil, William H. Walker and Sandra Ann Murray*
University of Pittsburgh, Pittsburgh, PA

 

Gap junction plaque endocytosis is thought to be essential for a number of physiological events. In the testes, altered distribution of gap junctions has been suggested to be involved in abnormal conditions including neoplastic transformation and infertility. In the absence of gap junctions between testicular Sertoli cells, the blood-testes barrier is impaired and germ cells fail to develop.  Elucidating the molecular machinery involved in gap junction plaque internalization is critical to our understanding of a broad range of cellular phenomena in the normal and the diseased state. Such information could impact our capacity to target gap junctions to correct diseased conditions.  To test the hypothesis that Src kinase signaling regulates internalization of gap junction plaques or plaque fragments into the cytoplasm of Sertoli cells, immunocytochemistry, immunoblotting, and confocal microscopy strategies were used to detect the gap junction protein (Cx43) in cultured rat primary Sertoli cells. Gap junction plaque formation was confirmed with western blot and immunofluorescence. Testosterone treatment (10-250 nM for 60 minutes), which activates Src kinase in Sertoli cells caused the number and size of gap junction plaques at the cell surface to decrease, while increasing the number of cytoplasmic annular gap junctions. However, if the cells were pre-treated with a specific Src kinase inhibitor, PP2 (4-amino-5-(4-hlorophenyl)-7-(dimethylethyl) pyrazolo[3,4-d]pyrimidine), these changes in gap junctions were diminished.  We suggest, based on these findings, that Src kinase activation contributes to the loss of gap junction plaques from the Sertoli cell surface.  Information regarding gap junction protein trafficking and internalization could  lead to development of new techniques for influencing and controlling Sertoli cell behavior and will be critical for our understanding of a broad range of cellular phenomena in the normal and the diseased state, including the responses to environmental toxins.

 

Nothing to Disclose: CC, SJO, WHW, SAM

16182 11.0000 MON-0101 A Regulation of Gap Junction Expression in Sertoli Cells By Src Kinase 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Pedro Pablo Rojas-Garcia*1, Daniel Sandoval1, Monica Patricia Recabarren1, Albert Carrasco1, Teresa Sir-Petermann2 and Sergio E Recabarren1
1University of Concepcion, Chillan, Chile, 2University of Chile, Santiago, Chile

 

In contrast to the clear establishment of reproductive compromises in female sheep by prenatal exposure to excess testosterone (T), little attention has been given to consequences in the male. We have found that rams exposed during their fetal life to excess testosterone (T-males) are characterized by a higher number of Sertoli cells in the seminiferous tubules but reduced number of germ cells, resulting in low sperm count and motility (1). However, it is unknown the mechanism implicated in the reduction of sperm account. The aim of the present work was to evaluate the testicular morphology and the expression of key regulator factors involved in the spermatogenesis in prepubertal male sheep exposed prenatally to an excess of T. Pregnant Suffolk sheep were administered either 30 mg T propionate (from day 30 to 90 of pregnancy) followed by 40 mg (from day 90 to 120 of pregnancy) i.m. twice weekly (term is ~147 days) or vehicle. At 24 weeks of age the testis was removed, histological parameters were measured using light microscopy, the mRNA and protein expression were measured using real time PCR and western blotting, respectively. The testis of T-males displayed an increased number of Sertoli cells per tubule, which completely obliterated the tubular lumen, a reduced number of spermatocytes (16.03 ± 4.38 in T-males and 31.02 ± 3.49 in C-males), and spermatids (16.31 ± 7.35 in T-males and 41.80 ± 8.11 in C-males). Furthermore, seminiferous tubules of T-males were characterized by reduced diameter, area and epithelium height of tubules. Additionally, the mRNA expression of SOX9 and AMH was higher in T-males, but the expression of LH receptor was lower. Moreover, the protein expression of AR was lower in T-males in compared to C-males. These findings provide evidence that the deleterious effects on spermatogenesis are observed around puberty, with an altered testicular cell population associated to a disruption in the endocrine receptor expression.

 

Nothing to Disclose: PPR, DS, MPR, AC, TS, SER

15904 12.0000 MON-0102 A Prenatal Testosterone Excess Alters the Number of Sertoli and Germ Cells Associated to a Higher Expression of SOX9, AMH and a Lower Expression of Lhr and AR in Prepubertal Male Sheep 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Eric Christopher Bolton* and Hyun-Jung Park
University of Illinois at Urbana-Champaign, Urbana, IL

 

The prostate gland is formed late in embryonic development when androgen produced by the testis induces urogenital sinus (UGS) epithelial invasion into the UGS mesenchyme. However, much interest in the prostate stems from its high propensity for hyperproliferative disorders, including benign prostatic hyperplasia and prostate cancer. Thus, elucidating the etiology of prostatic hyperproliferative disorders is of significant interest to public health.

A fundamental question is how hormonal signals regulate nearly all aspects of prostate development and growth. To fill this important gap, we have identified the morphogenic genes GDNF and GFRα1 as androgen-responsive genes in the embryonic UGS of mice through mRNA expression analyses. Glial cell line derived neurotrophic factor (GDNF) is a member of the TGFβ protein super-family, and GDNF signals through RET receptor tyrosine kinase and cell surface co-receptor, GFRα1. GDNF signaling plays crucial roles in urogenital processes ranging from cell fate decisions in germline progenitors to ureteric bud outgrowth and renal branching morphogenesis. Gene ablation studies in mice have revealed essential roles for GDNF signaling in urogenital development, although its role in the developing prostate is unclear.

Our objective was to examine the functional role of GDNF signaling in the developing mouse prostate. We observed expression of GDNF and GFRα1 in the urogenital sinus (UGS) prior to and during prostate development. GDNF shows time-specific and cell-specific expression during prostate development and growth in vivo. Using a well-established UGS organ culture system, we provide compelling evidence that exogenous GDNF increases proliferation of mesenchymal and epithelial cells in the UGS, altering prostate development. With regard to mechanism, the inhibition of RET kinase activity or ERK kinases (MEK1/2) suppressed GDNF-induced proliferation of the UGS mesenchyme. In addition, GDNF treatment dramatically increased Ret mRNA and protein expression in the UGS mesenchyme, and GDNF also increased phosphorylation of ERK1/2 in the UGS mesenchyme. Taken together, these findings suggest that GDNF signaling influences cellular proliferation in the UGS and developing prostate. Furthermore, we propose that GDNF signaling in the UGS mesenchyme is mediated by RET receptor tyrosine kinase and involves activation of the MEK-ERK pathway, thus implicating GDNF-RET-MEK-ERK signaling in prostate development and growth.

 

Nothing to Disclose: ECB, HJP

16105 13.0000 MON-0103 A GDNF Signaling Stimulates Cell Division and Hyperplasia in the Developing Prostate 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Beatriz de Carvalho Borges*, Sanseray da Silveira Cruz-Machado, Jun Ding, Gary D Smith and Carol F Elias
University of Michigan, Ann Arbor, MI

 

Declines in male reproduction around the world may be a consequence of the increased prevalence of obesity. Studies have shown that obesity decreases the activity of the hypothalamic-pituitary-testicular (HPT) axis, reducing testosterone levels and sperm count, which may have deleterious outcome on male reproductive function. To evaluate the effects of obesity on male fertility mice were fed with high fat diet (HFD) for 12 weeks. All males were initially tested for fertility (3 females/male, T0) and assigned into 2 groups: those on chow (n = 6) and those on HFD (n = 7). Twelve weeks later (T12), fertility test was performed (4 females/male) to assess their reproductive capacity. Mice fed with HFD showed increased (p<0.05) body weight (54.4 ± 1.9g) compared with chow fed mice (41.2 ± 1.2g). The number of copulatory plugs was similar between groups, both at T0 (chow: 79.3%; HFD: 84.2%) and T12 (chow: 79.1%; HFD: 82.1%). The percentage of females impregnated by males in chow and the number of offspring per male were similar at T0 (pregnant females: 50.0 ± 7.4%; number of offspring: 9.3 ± 2.1, from the average of 2 pregnant females) and T12 (pregnant females: 45.8 ± 10.0%; number of offspring: 12.1 ± 3.6, from the average of 2 pregnant females). However, the percentage of females impregnated by males under HFD at T12 (21.4 ± 8.5%) and the number of offspring per male (6.4 ± 2.4, from 1 pregnant female) were significantly lower (p<0.05) compared to T0 (pregnant females: 80.9 ± 6.7%; number of offspring: 18.7 ± 1.8, from the average of 3 pregnant females). Remarkably, mice fed with HFD showed reduced (p<0.05) sperm motility (55.4±2.3%) compared with chow group (69.8 ± 2.5%), with no difference in testes and epididymis weight. In conclusion, diet induced obesity does not seem to affect the copulatory behavior in male mice. Nevertheless, declines in male fertility induced by high fat feeding and increased body weight are likely due to impairment in sperm motility.

 

Nothing to Disclose: BDCB, SD, JD, GDS, CFE

16149 14.0000 MON-0104 A Effects of Obesity in Male MOUSE Fertility 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Hamed A Benghuzzi*1 and Michelle Tucci2
1Univ of MS Med Ctr, Jackson, MS, 2Univ of Mississippi Med Ctr, Jackson, MS

 

The overall goal of this project was to evaluate the cellular alteration in the cuboidal epithelium of ventral prostate during the exposure to sustained delivery of testosterone (TE) and estrogen (ES) or in combination.  It was hypothesized that understanding the alterations of prostate tissue changes at cellular level may provide the literature with more insights regarding prevention or treatment of classical medical conditions such as benign prostatic hyperplasia (PBH). To accomplish this, Sprague Dawley (BW: 250-300 gm) rats were randomly divided into four equal groups (n =80 rats/20 per group).  Three treatment groups were each implanted (S/C) with tricalcium phosphate lysine (TCPL) ceramic drug delivery devices designed to deliver continuous physiologic doses of TE (5 ng/ml), ES (20 pg/ml), or TE+ES (5ng/ml +20 pg/ml). The control group was left unimplanted (sham).  At the end of 1, 3, 6 and 9 months, 5 animals from each group were sacrificed and the ventral prostate glands were collected by following approved laboratory techniques. The tissues were fixed, processed, embedded, sectioned and stained (H&E) for histopathological evaluation. At the end of 3, 6 and 9 months, the results revealed a morphometric analysis (Image Pro Software) of cuboidal epithelial cells lining the tubules of the ventral prostate similar to pre-clinical manifestation as seen at the cellular level during early development of BPH.  This study demonstrated that the number of cells counted (10 views/animal) was not significantly different between the treatment and control groups.  The TE and ES treated groups showed larger nuclear area than the control and TE+ES groups.  All animals treated with TE showed a larger n/c ratio (48%) compered to ES (8%), TE+ES  (19%) and control groups (p<0.05).  It was interesting to note that, at the end of 9 months of treatment,  control and TE+ES treated animals showed a larger cell area and cell length than the TE and ES treated animals. In conclusion, results of this study suggest that the changes occurring at the cellular level of the prostate during early development of BPH could be directly related to major adaptive responses such as hyperplasia in conjunction with hypertrophy.  These observations suggest that sustained delivery of TE+ES can be used effectively to regulate the functional capacity of the prostate tissues in a rat model.

 

Nothing to Disclose: HAB, MT

15627 15.0000 MON-0105 A Pathophysiological Changes in Ventral Prostate during the Exposure to Sustained Delivery of Testosterone and Estrogen in a Rat Model 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Bei Yang1, Ting Zhong1, Teng Zhong1, Yan Lin2, Min Ren1, Xiaochun Yu1 and Haibin Kuang*1
1Department of Physiology, School of Medicine, Nanchang University, China, 2Department of Obstetrics and Gynecology, Hospital of Jixi Province People, China

 

Research data showed that proto-oncogenes were present in vertebrate testis and involved in cellular growth, differentiation, spermatogenesis and endocrine. C-Fos and c-Jun have been detected during the annual reproductive cycle in the frog testis and cultured pig Leydig cells. However, the effect of c-Fos on testosterone production of Leydig cells remains unknown. The present study was conducted to investigate the effect of antisense c-Fos oligodeoxynucleotides (ODN) on hCG-induced testosterone production in isolated Sprague Dawley rats Leydig cells. To suppress intracellular c-Fos activity, dispersed rat leydig cells were incubated with antisense c-Fos ODN. Testosterone concentration in the supermedium were measured by radioimmunoassay.The results showed that hCG significantly increased the secretion of testosterone compared to control (P<0.01, n=6 per group); Antisense c-Fos ODN inhibited hCG-induced testosterone secretion in a dose-dependent manner, whereas treatment with nonsense tat ODN caused no significant change on testosterone secretion(P>0.05, n=6 per group). Further experiments showed that dbcAMP(10-4mol/L) could reverse the inhibitory effects of antisense c-Fos ODN for hCG-induced testosterone secretion. However, Verapamil (10-6mol/L), a Ca2+ channel antagonist, had no significant effect on hCG-induced testosterone secretion. In conclusion, it is suggested that c-Fos was closely correlated with hCG-induced testosterone secretion, and the mechanism is possible to enhance the expression of c-Fos proto-oncogene by cAMP-dependent pathway.

Bei Yang, Ting Zhong, Teng Zong contributed equally to this work.

 

Nothing to Disclose: BY, TZ, TZ, YL, MR, XY, HK

12433 16.0000 MON-0106 A Suppression of c-Fos By Antisense Oligodeoxynucleotides Causes Inhibition of Hcg-Induced Testosterone Production By Rat Leydig Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Samuel Sang*1, Barkha Singhal2, Arpita Talapatra2, Dibyendu Dutta1, In Park2 and Nathaniel C Mills3
1Texas Woman's University, Denton, TX, 2Texas Womans' University, Denton, TX, 3Texas Woman's Univ, Denton, TX

 

Testosterone (T) acting through the androgen receptor (AR) is needed for maintenance of spermatogenesis. T regulates genes that are needed for male fertility and virility and is thought to act in the Sertoli and /or peritubular cells to create an enabling environment for normal progression of germ cells during spermatogenesis.  Sertoli cell tight junctions (TJ) are an essential component of blood testes barrier (BTB) that regulates movement of substances into and out of the seminiferous epithelium. This study investigated the effect of T loss and short term replacement on TJ function and TJ proteins expression.  Using ethylene dimethane sulfonate (EDS) we selectively destroy Leydig cells - the source of androgen in adult rat testis.  EDS treatments significantly reduced testicular weights and serum and testicular androgens.  Several days post-EDS, we examined the changes in gene expression of TJ proteins with and without testosterone replacement. TJ protein expressions were assessed by real-time PCR and immunohistochemistry whereas TJ integrity was assessed with a biotin permeation tracer. Using RT-qPCR, we examined the tissue mRNA levels for tricellulin (Marvld2, Tric), claudin 3 (Cldn3), claudin 11 (Cldn11) and aquaporin-9 (Aqp9), major anchoring junction (AJ) and TJ proteins.  We also examined tissue mRNA levels for testin (Testin), a protein associated with ectoplasmic specialization – a testis specific anchoring junction. A decreased expression of  Marvld2 and Cldn3 and an increased expression of testin and Aqp9 occurred in the absence of testosterone.  With EDS treatment plus T replacement, expression values for these genes returned to near control levels.  In contrast to controls, EDS induced seminiferous tubule - BTB permeability to biotin and loss of tubule lumen whereas EDS plus maintenance of T via exogenous testosterone replacement retained the BTB integrity.  This suggests that testosterone may control paracellular movement of water, electrolytes, nutrients, and biomolecules by maintaining the BTB.  As well, genes that modulate transcellular water, glycerol, electrolytes and other small solutes appear to be regulated by T.  These parameters may be important for Sertoli cells to maintain the environment of the adluminal compartment and providing needed components and stability to the developing germ cells in seminiferous tubules.

 

Nothing to Disclose: SS, BS, AT, DD, IP, NCM

15521 17.0000 MON-0107 A Androgens MAY Indirectly Regulate Spermatogenesis By Directly Regulating Proteins of the Blood-Testis Barrier Tight Junctional-Complex 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Estefania Maria Alejandra Massa*1, Carlos Zumoffen2 and Sergio Ghersevich3
1School of Biochemistry and Pharm, Rosario, Argentina, 2School of biochemical and pharmaceutical sciences, 3National Univ of Rosario, Rosario, Argentina

 

A protein isolated from human oviductal cells in vitro secretion that can bind to spermatozoa was identified as S100 A9. The aim of this study was to detect S100 A9 binding sites on spermatozoa under different conditions. Human motile sperm were obtained from semen samples (n=9) of normozoospermic donors (WHO, 2010). Sperm were incubated in the presence (10.0 µg/ml) or the absence of human recombinant S100 A9, under capacitating conditions (Ham´s F10 medium, 5 mg/ml BSA, 37ºC, 5% pCO2) for 1 h or 6 h. Sperm acrosome reaction was induced with progesterone 20 μM (30 min, 37ºC, 5% pCO2) after 6 h incubation and detected with Pisum sativum agglutinin coupled with fluorescein isothiocyanate. Detection of bound S100 A9 was performed by anti-S100 A9 rabbit antibody, followed by Cy3 conjugated anti-rabbit IgG antibody. Staining patterns were observed in spermatozoa in the following conditions: 1) non capacitated, 2) after 6 h under capacitating conditions, 3) intact acrosome and 4) acrosome reacted sperm. Two hundred cells were examined in each group in a fluorescence microscope and the percentage of each staining pattern was calculated. In all experimental conditions mean sperm viability, assessed by eosin Y staining, was 93.3±1.8 %. Staining patterns observed were: AS (absence of staining), HT (staining in post acrosomal region, midpiece and sperm tail), and W (staining in whole sperm). The difference between patterns from groups 1 and 2 and from groups 3 and 4 was analyzed by Student’s t test (results were expressed as mean ± standard error). Detection of S100 A9 staining tended to be lower in group 1 (8.9±1.0 %) than in group 2 (14.6±2.7 %; p=0.06). No significant differences between the respective staining patterns from groups 1 and 2 were observed. However, the percentage of sperm showing W pattern was significantly lower in group 3 cells (0.8±0.5%) than in those from group 4 (7.2±1.8%; p<0.05). The frequency of AS pattern from group 3 sperm (91.2±2.8%) tended to be higher than that from group 4 cells (73.2±9.5%; p=0.08). S100 A9 could bind to a subpopulation of human sperm showing different binding patterns. Despite total S100 A9 binding tended to increase after 6 h incubation under capacitating conditions, each type of binding patterns remained similar to that before incubation. S100 A9 binding sites expression could be related to the acrosome status, since protein binding to the whole sperm increased when they underwent the acrosome reaction.

 

Nothing to Disclose: EMAM, CZ, SG

15222 18.0000 MON-0108 A Detection of S100 A9 Binding Sites on Human Spermatozoa 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Ademola ayodele Oremosu*1, Olajumoke Gloria Daramola2 and Oladapo adenrele Ashiru2
1College of Medicine, University of Lagos, Idi Araba, Nigeria, 2Medical ART Centre, Lagos, Nigeria

 

 Male factor infertility has been on the increase, due to several factors including cryptorchidism has been associated with increased apoptosis, degeneration of spermatogenic cells resulting in increased free radical production. This research was carried out to determine the effects of nutritional supplements such as L- Carnithine, Biotin, Vitamin D administered alone and co-administration on the semen quality, testicular histology and oxidative stress markers and on sex determination of offspring.  25 male Wistar rats weighing 170-200g were randomly divided into 5 groups (A-E). The animals in each group were surgically made unilaterally right sided cryptorchid. Group A control received distilled water for 8-weeks while groups B-D received 0.3mls of L- Carnithine, Biotin and Vitamin D respectively. Group E received a combination of the supplements for the same duration. There were decreased  testosterone levels in all the groups. There was improved sperm count and motility in groups B-E when compared with control. Activity of superoxide dismutase and catalase increased in the treatment groups while MDA and GSH levels reduced significantly in the treatment groups (p>0.05). There was diffuse atrophy of the seminiferous tubular cytoarchitecture being least prominent in group E that showed amelioration of the effects of cryptorchidism. There was increase male sex outcomes from the groups C and E mated with rats of proven fertility.  Our findings indicate that the administration of supplements of L-Carnithine, Biotin and Vitamin D improved the fertility parameters and outcomes in experimental cryptorchidism in the rat. In combination, the supplements improved the chances of a male outcome in sex determination

 

Nothing to Disclose: AAO, OGD, OAA

15997 19.0000 MON-0109 A The Effects of Administration of Antioxidant Nutritiional Suppliments on the Crytorchid Testes and Sex Selection Fertility Outcomes in Wistar Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Sung-Ho Lee*
Sangmyung University, Seoul-City, Korea, Republic of (South)

 

Circadian rhythmicity (e.g. secretory pattern of hormones) plays an important role in the control of reproductive function. We hypothesized that the alteration of feeding pattern via meal time shift/restriction might disrupt circadian rhythms in energy balance, and induce changes in reproductive activities. To test this hypothesis, we employed simple animal model that not allowing ad libitum feeding but daytime only feeding. The animals of ad libitum feeding group (Control) have free access to food for 4 weeks. The day feeding (=reverse feeding, RF) animals (RF group) have restricted access to food during daytime (0900-1800) for 4 weeks. After completing the feeding schedules, body weights, testis and epididymis weights of animals from both group were not significantly different. However, the weights of seminal vesicle (control : RF group = 0.233 ± 0.014 g : 0.188±0.009 g, p<0.01) and prostate (control : RF group = 0.358 ± 0.015 g : 0.259 ± 0.015 g, p<0.001) were significantly lower in RF group animals. The mRNA levels of pituitary common alpha subunit (Cα control : RF group = 1.0 ± 0.0699 AU : 0.1923 ± 0.0270 AU, p<0.001) and FSHβ (control : RF group = 1.0 ± 0.1489 AU : 0.5237 ± 0.1088 AU, p<0.05) were significantly decreased in RF group. The mRNA levels of ACTH were not significantly different. We were unable to find any prominent difference in the microstructures of epididymis, and there were slight alterations in those of seminal vesicles after 4 weeks of reversed feeding when compared to control samples. The present study demonstrates that the shift and/or restriction of feeding time could alter the pituitary gonadotropin expression and the weights of seminal vesicle and prostate in rats. These data suggest the lowered gonadotropin inputs may decrease androgen secretion form testis, and consequently results in poor response of androgen-dependent tissues such as seminal vesicle and prostate.

 

Nothing to Disclose: SHL

16517 20.0000 MON-0110 A Effect of Feeding Time Shift on the Reproductive System in Male Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0091-0110 4863 1:00:00 PM Testicular Cells, Fertility and Prostate Poster

Lisa L Morselli*, Karla A Temple, Florian Chapotot, Rachel Leproult, David A Ehrmann, Eve Van Cauter and Babak Mokhlesi
University of Chicago, Chicago, IL

 

Slow-wave activity (SWA) is a marker of sleep depth and a stable within-subject characteristic that has been implicated in the control of glucose homeostasis and blood pressure. Studies exploring the predictors of the large inter-individual differences in SWA have been performed mainly in lean individuals. As 75% of men are now overweight or obese in the United States, the aim of this study was to identify predictors of SWA in overweight and obese men.

Forty-four overweight and obese men aged 20-50 years (mean±SE: 35±1 years) were recruited from the community and underwent an overnight in-laboratory polysomnogram. SWA was computed as the average absolute spectral EEG power in the frequency band 0.75-4.5 Hz during non rapid eye movement (NREM) sleep, in the first 6 hours of sleep. Obstructive sleep apnea (OSA) was defined by an apnea-hypopnea index (AHI) ≥5. Total plasma testosterone was measured on the morning following the polysomnogram. Multivariate regression models were run to explore the predictors of SWA.

Obstructive sleep apnea was present in 66% of the men, and the median AHI was 16 (interquartile range 9-26) events/hour. In a model including only demographic characteristics, NREM SWA was negatively predicted by African-American race (β=-0.25, p<0.0001) and age (β=-0.03, p=0.004), but not BMI. When total testosterone was added, it improved the percentage of variance accounted for by the model and was independently and strongly associated with SWA (β=-0.75, p=0.005). In order to maintain statistical power, BMI was dropped from the last model, which examined the simultaneous contribution of AHI and total testosterone levels.  In this model, the negative association of total testosterone (β=-0.56, p=0.02) and race (β=-0.26, p<0.0001) with NREM SWA persisted, whereas AHI (β=-0.11, p=0.08) and age (β=-0.02, p=0.08) only weakly predicted SWA.

In conclusion, in overweight and obese men under 50 years old, NREM SWA is negatively predicted by total circulating testosterone levels, in addition to race, age and AHI. These results have potential clinical implications as exogenous testosterone is being increasingly prescribed to middle-aged men.

 

Nothing to Disclose: LLM, KAT, FC, RL, DAE, EV, BM

15326 5.0000 MON-0005 A High Testosterone Levels Predict More Shallow Sleep in Overweight and Obese Men, Independently of Obstructive Sleep Apnea 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0001-0021 4865 1:00:00 PM Effects of Regulating Sex Hormone Levels in Men Poster

Alper Sonmez*1, Cem Haymana1, Aydogan Aydogdu2, Serkan Tapan2, Yalcin Basaran1, Coskun Meric2, Kamil Baskoy3, Mustafa Dinc2, Mahmut Yazici2, Abdullah Taslipinar2 and Omer Azal2
1Gulhane Military Medical Academy School of Medicine, Ankara, Turkey, 2Gulhane School of Medicine, Ankara, Turkey, 3GATA Haydarpasha Training Hospital, Istanbul, Turkey

 

 

Objective: Patients with hypogonadism have poor cardiovascular and metabolic outcomes. Testosterone replacement therapy (TRT) significantly improves symptoms of testosterone deprivation such as mood, libido or musculoscelatal power. However, the data is not clear about the improvement of cardiac and metabolic risks of these subjects. Recent reports have shown that TRT may cause adverse cardiovascular events in the elderly hypogonadal population. In order to clarify the controversy, we searched for the presence of inflammation, insulin resistance and endothelial dysfunction in an unconfounded population of  congenital hypogonadotrophic hypogonadism (CHH) and the effect of TRT on these subjects.

 

Design: Prospective study, performed in the outpatient units of Gulhane Medical School.

 

Methods: Treatment naive young male patients with CHH (n=60, mean age 21.82 ± 2.2yrs) and age matched healthy control subjects (n=70, mean age 21.32±1.1yrs) were enrolled. Patients were treated with testosterone esters (250mg/3weeks IM) for a mean follow-up period of 5.56 ± 2.04 months. The demographic parameters, fasting glucose, lipids, insulin, Asymmetric dimethylarginine (ADMA), TNF-like weak inducer of apoptosis (TWEAK), high sensitive C reactive protein (hs-CRP) levels were measured in patients and controls. Insulin sensitivity was estimated by homeostatic model assessment (HOMA-IR) formula. The measurements were repeated in patients after the treatment period.

 

Results: The Waist Circumferences (p=0.009), Diastolic Blood Pressures (p=0.02), Triglycerides (p=0.03), ADMA, insulin and HOMA-IR levels (p<0.001 for all) were significantly higher, and the TWEAK levels were significantly lower (p<0.001) in patients with CHH, when compared to the healthy controls . After the six months of follow up, the patients had significantly elevated systolic blood pressures (p=0.01), body mass indexes and waist circumferences (p<0.001 and p=0.001 respectively) and the decrease in total and HDL cholesterol levels (p=0.032 and p<0.001 respectively).  ADMA levels significantly increased (p=0.003), while the alterations in TWEAK, hsCRP and HOMA-IR were not significant

 

Conclusions: The results of the present study show that  endothelial dysfunction, inflammation and insulin resistance are present even in very young subjects with CHH, who have no metabolic or cardiac problems at present. This increased cardiometabolic risk however, do not improve but even get worse after the six months of TRT. These findings support our previous reports and are likely to increase the scepticism on the cardiometabolic effects of TRT. Long term, randomized prospective cohorts with different methods of testosterone supplementation are warranted in order to see whether these short term unfavorable results will cause negative cardiometabolic outcomes in these patients.

 

Nothing to Disclose: AS, CH, AA, ST, YB, CM, KB, MD, MY, AT, OA

15193 6.0000 MON-0006 A Endothelial Dysfunction, Insulin Resistance and Inflammation Are Present in Young Patients with Congenital Hypogonadism and Do Not Improve after the Testosterone Replacement Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0001-0021 4865 1:00:00 PM Effects of Regulating Sex Hormone Levels in Men Poster

Jiaxiu He*1, Kevin Edward Yarasheski2, Shalender Bhasin3, Carmen Castaneda-Sceppa4, Ellen F. Binder5, E Todd Schroeder6, Stanley P. Azen7 and Fred R Sattler8
1Northwestern Unversity, Evanston, IL, 2Washington University in St. Louis, Saint Louis, MO, 3Brigham and Women's Hospital - Harvard Medical School, Boston, MA, 4Northwestern Unversity, Boston, MA, 5Washington University School of Medicine, St. Louis, MO, 6Univ of Southern CA, South Pasadena, CA, 7University of Southern California, Los Angeles, CA, 8Univ of Southern CA, Los Angeles, CA

 

Background.  Uncertainty exists regarding the actions of testosterone (T) and human growth hormone (hGH) on the kinetic rates of human muscle protein synthesis and proteolysis. We hypothesized that abrupt withdrawal of T + hGH after a 16 weeks of exposure would reduce muscle protein synthesis (MPS) and increase muscle proteolysis rates (MPx) in older men. Methods. T gel (5 or 10 g/day) under Leydig cell clamp conditions (Lupron 7.5mg IM at weeks 0, 4, 8, 12) and subq rhGH (0 or 3 or 5 µg/kg/day) were administered to 112 men (65-90 years old) enrolled in a 16 week double-blind, randomized trial. Serum T and IGF1 levels were measured at baseline, weeks 16 and 17 (one week after discontinuing hormone exposure). Measurements made at baseline and week 17 included: in vivo 13C2-leu incorporation into mixed muscle proteins (MPS), whole body proteolysis (Leu Ra), and muscle proteasome-specific enzyme activities (trypsin, chymotrypsin,peptidyl glutamyl peptide hydrolase  [PGPH]) as MPx markers. Linear regressions, ANOVA, and t-tests were used to analyze data. Mean ± SD are reported. Results. Between week 16 and 17, serum T declined (812±462 to 288±150ηg/dL), and serum IGF1 declined (184±66 to 127±35ηg/mL). Some men (n=52) experienced very large T decrements (~850ηg/dL), while some (n=53) experienced smaller T decrements (~150ηg/dL). Between baseline and week 17, MPS was unchanged (0.002 ± 0.028 %/hr; p=0.43), but whole body proteolysis rate and all proteasome enzyme activities increased (Leu Ra +0.56±1.85 µmol/kg/hr p=0.002; trypsin +0.89±3.43 p=0.009, chymotrypsin +5.17±16.78 p=0.002, PGPH +0.92±3.84 U/g p=0.01). Similarly, large serum T reductions were associated with increased whole body proteolysis rates (p=0.0002), and both small and large T decrements tended to be associated with increased MPx markers (p=0.03-0.07) with no association with MPS changes (p>0.05). Treatment with rhGH vs rhGH placebo, as well as whether there were large or small declines in IGF-1, did not affect the impact of large T declines on MPS or MPx markers.  Conclusion.  Abrupt reductions in serum testosterone (as occurs during androgen deprivation therapy, GnRH antagonist for prostate hypertrophy or cancer) appear to increase muscle proteolysis without reducing muscle protein synthesis rates. At least in older men, this suggests that testosterone exposure affects muscle proteolytic pathways more than muscle protein synthetic pathways.

 

Disclosure: SB: Principal Investigator, Abbott Laboratories, Principal Investigator, Eli Lilly & Company. Nothing to Disclose: JH, KEY, CC, EFB, ETS, SPA, FRS

15266 7.0000 MON-0007 A Effects of Acute Androgen Deprivation on Skeletal Muscle Protein Synthesis and Breakdown 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0001-0021 4865 1:00:00 PM Effects of Regulating Sex Hormone Levels in Men Poster

Richard V Clark*1, Melissa C Rhodes2, Ann C Walker3, Allen Wolstenholme4, Jeffrey a Wald5, Tara l Dimino6, Philip s Turnbull2, Anita Kapur2 and Ronald Goldwater7
1Muscle Metabolism DPU, GlaxoSmithKline R&D, Research Triangle Park, NC, 2GlaxoSmithKline R&D, Research Triangle Park, NC, 3GlaxoSmithKline R&D, Collegeville, PA, 4GlaxoSmithKline R&D, Upper Merion, PA, 5GlaxoSmithKline R&D, Reserach Triangle Park, NC, 6GlaxoSmithKline, Upper Providence, PA, 7Parexel Int'l, Baltimore, MD

 

Clinical studies with novel compounds are supported by progressively longer non-clinical toxicology studies, as a compound progresses through short, early studies to longer, mid-stage studies.  With progression, clinical safety experience supplants the non-clinical safety data for late stage studies.

 We initiated a First Time in Human (FTIH) study with a potent SARM, GSK2849466.  The safety support for this study was based on thorough non-clinical toxicology evaluation, including 2 week studies in both rat and dog which provided appropriate exposure cover for clinical dosing up to 14 days at anticipated exposures, per FDA guidelines for FTIH studies.  The opening clinical study was a single dose escalation, beginning at a low dose approximating a minimal biologic effect level, 0.01mg, advancing to 0.03, 0.05, and 0.1mg in first cohort of healthy male subjects (8), and 0.1, 0.2, 0.35, and 1.0mg in second cohort (9).  Dosing was done on a weekly interval, allowing for review of safety parameters (vital signs, clinical lab studies, ECGs and cardiac telemetry) and pharmacokinetic (PK) interpretation.  All subjects (17) had unremarkable safety evaluations during study with no observations considered clinically meaningful.   Adverse events (4) were reported in 2 subjects, and these resolved.  Two subjects did not complete the study:  one withdrew consent, and the other had a significantly elevated lab parameter, CPK, prior to his second dosing period.  PK analyses following single dose administration of GSK2849466 showed rapid absorption with median tmax of 0.75-1.25 hr at all dose levels.  At highest dose of GSK2849466 studied, 1mg, geometric mean for AUC(0-t) was 80.8 ng.h /mL, and Cmax was 10.8ng/mL.  These values were 20-fold and 104-fold below the AUC and Cmaxsafety coverage from non-clinical toxicology studies.

As the second cohort completed, the ongoing 13 week toxicology study reported cardiac necrosis in rats.  This finding led to immediate termination of further clinical exposure and a diligent safety review.   Residual plasma samples from PK sample time points at 4, 8, 12, and 24 hr after dose, were assayed for cardiac troponin (cTn1) levels in all subjects.  These showed no evidence of cardiac injury.  Follow-up visits were done at 2 and 5 months after the last dose, and included echocardiography and additional troponin evaluation; 16 of the 17 subjects attended at least one visit.  These studies showed no evidence of injury from the compound. 

The accelerated timing and rapid review of the 13 week toxicology findings resulted in prompt study termination.  Drug exposure to subjects was limited to 3 single doses of active compound given at once weekly intervals.  The study was terminated prior to repeat dose studies, avoiding any further exposure to subjects.  Our experience with SARMs suggests considering longer toxicology studies before clinical exposure in this class of compounds.  (NCT01696604-ARM116715)

 

Disclosure: RVC: Clinical Researcher, GlaxoSmithKline. MCR: Employee, GlaxoSmithKline. ACW: Employee, GlaxoSmithKline. AW: Employee, GlaxoSmithKline. JAW: Employee, GlaxoSmithKline. TLD: Clinician, GlaxoSmithKline. PST: Employee, GlaxoSmithKline. AK: Employee, GlaxoSmithKline. RG: Principal Investigator, GlaxoSmithKline.

12412 8.0000 MON-0008 A Use of Non-Clinical Toxicology Findings to Rapidly Terminate Early Clinical Progression of a Selective Androgen Receptor Modulator (SARM) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0001-0021 4865 1:00:00 PM Effects of Regulating Sex Hormone Levels in Men Poster

Keith B. Marschke*1, Robert A Moller2, Eric G. Vajda1, Lin Zhi1 and Greg CG Wei3
1Ligand Pharmaceuticals Incorporated, La Jolla, CA, 2Pfizer Inc, Groton, CT, 3SynteractHCR, Carlsbad, CA

 

Lasofoxifene (laso) is a next-generation selective estrogen receptor modulator (SERM) that at a daily dose of 0.5 mg has been shown to reduce the risk of nonvertebral and vertebral fractures, ER-positive breast cancer, coronary heart disease, and stroke in postmenopausal women, but with an increased risk of venous thromboembolic events(1). The effects of laso in males are unknown. Certain SERMs have been shown to stimulate endogenous testosterone (T) production in men via perturbation of the gonadal axis(2). Here we report the potent and prolonged effect of a single dose of laso to increase circulating T levels in young healthy men. The study was an investigator-blind, randomized, placebo-controlled, parallel group, single ascending dose study of laso or placebo in 36 healthy male volunteers age 18-41, consisting of 5 fasted dose groups (1, 3, 10, 30 and 100 mg) and 1 fed dose group (100 mg) where each group has 4 subjects receiving laso and 2 receiving placebo. Pharmacokinetic parameters, luteinizing hormone (LH), and total T in plasma samples were measured out to 28 days postdose. Following oral administration of single doses of laso, Cmax and AUC(0-∞) increased in a dose proportional fashion with overall mean T1/2 of 116 ± 44 hours (group mean Tmax of 6.0-9.5 hours). At the 100 mg dose, food appeared to have little effect on the absorption of laso and only delayed Tmax 2.5 hours to the parallel group. Changes in LH were detected with the higher doses of laso (10, 30, and 100 mg) with a transient and relative small early decrease in LH (19-39% drop from baseline) within 24 hours, followed by a large rebound increase of 200-500% from baseline during days 3-7. LH levels remained elevated relative to baseline to day 28, the last data point collected, except for the 10 mg group in which LH levels gradually returned to the placebo level. The pooled placebo group also had a 25 ± 28% drop in LH at 12 hours. T levels followed the pattern of change in LH. At 12 hours, T levels were reduced relative to baseline by -31 ± 8% (placebo), -60 ± 0% (30 mg), -48 ± 20% (100 mg), and -48 ± 15% (100 mg fed). At day 7, T levels were increased +22 ± 23% (placebo), +36 ± 0% (30 mg), +82 ± 20% (100 mg), and +90 ± 50% (100 mg fed). T changes appeared to be more sensitive than LH whereas the 1 mg group had 46 ± 34% increase from baseline at day 3 versus 5 ± 14% for placebo. The changes in T were long lasting and at day 28 the increases were 15 ± 28% (placebo), 24 ± 81% (1 mg), 57 ± 38% (3 mg), 28 ± 18% (10 mg), 81 ± 49% (30 mg), 109 ± 42% (100 mg), and 92 ± 38% (100 mg fed). Group mean T levels appeared to plateau at 30-40 nmol/L 7-14 days postdose regardless of laso dose or LH level. For example, at day 21 T levels were 25.5 (3 mg), 35.2 (10 mg), 32.7 (30 mg), 39.3 (100 mg), and 33.2 (100 mg fed) nmol/L. The pharmacodynamic effects of laso on the gonadal axis are quite different from other SERMs and warrant further study for potential clinical benefits of laso treatment in men.

 

Disclosure: KBM: Employee, Ligand Pharmaceuticals Incorporated. RAM: Employee, Pfizer, Inc.. EGV: Employee, Ligand Pharmaceuticals Incorporated. LZ: Employee, Ligand Pharmaceuticals Incorporated. Nothing to Disclose: GCW

13945 9.0000 MON-0009 A Single Doses of the SERM Lasofoxifene Increases Testosterone Levels for over 28 Days in Healthy Men 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0001-0021 4865 1:00:00 PM Effects of Regulating Sex Hormone Levels in Men Poster

Ramona Bhatia*1, Adam B Murphy1, Chad Achenbach1 and On behalf of the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems2
1Northwestern University, 2CNICS

 

Background:Testosterone supplementation in US men is increasing, often without proper indications and monitoring. HIV predisposes to hypogonadism, yet testosterone supplementation practices in HIV-infected (HIV+) men are largely unknown.

Methods:We conducted a cohort study of adult HIV+ men engaged in care at 7 sites within the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) from 1996-2011, excluding men on testosterone at cohort entry. We used total and free testosterone data. We calculated testosterone supplementation incidence as number of events per follow-up time (person-years, py) from entry to initial supplementation, loss to follow-up, or death. We assessed factors associated with testosterone supplementation using chi-square and Cox regression.

Results:We studied 14,454 men with 75,173py of follow-up. Mean age was 38y (±9.4), 50% were White, 69% were men who have sex with men (MSM), and 4% ever had AIDS wasting. 70% were on antiretroviral therapy (ART), with mean viral load of 4392 copies/ml and nadir CD4+ T-lymphocyte cell count (CD4) of 286 cells/µl at entry. 1482 (10%) initiated testosterone supplementation at mean age of 45y (±9.0) and rate of 20/1,000py. In bivariable comparisons, testosterone supplementation was significantly associated with age ≥ 50y, MSM, AIDS wasting, nadir CD4<200cells/µl, ART, and White race (all p<0.01). In multivariable analyses, testosterone supplementation was independently associated with age (per decade; HR 1.29, 95% CL1.21-1.38; p<0.01), AIDS wasting (HR 2.13, 95% CL 1.69-2.67; p<0.01), nadir CD4 (per 100 cells/µl; HR 0.96, 95% CL 0.94-0.99; p<0.01), ART (HR 1.21, 95% CL 1.05-1.40; p<0.01), and White race (HR 1.69, 95% CL 1.48-1.92; p<0.01). Pre-supplementation serum testosterone level was measured in 67%(992/1482), and there was deficiency (total testosterone ≤300 ng/dl) in 36%(360/992). Testosterone levels were measured within 6 months of initiating supplementation in 25%(377/1482). Of men over 40y who initiated testosterone, 33% had a pre-supplementation prostate specific antigen (PSA) test, and 12% had a PSA test 6 months after initiation.

Conclusions:In a large, geographically diverse cohort of HIV+ men, we observed a higher testosterone supplementation rate than that reported in a 2011 general US male population (7.57/1,000py). Pre-supplementation testosterone deficiency and post-supplementation monitoring occurred in only 36% and 25%, respectively, suggesting providers do not commonly follow Endocrine Society Clinical Practice Guidelines in HIV+ men.

 

Nothing to Disclose: RB, ABM, CA, OBOTCFA

16881 10.0000 MON-0010 A Testosterone Supplementation and Monitoring Practices in HIV-Infected Men in a Large Multi-Center US Cohort: Results from CNICS 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0001-0021 4865 1:00:00 PM Effects of Regulating Sex Hormone Levels in Men Poster

Leticia Ribeiro Oliveira1, Alexsandra C Malaquias*1, Cristiane Kochi2, Thais Kataoka Homma1, Renata Santos Batista Woloszynek3, Vinicius N. Brito4 and Carlos Alberto Longui1
1Faculdade de Ciencias Medicas da Santa Casa de Sao Paulo, Sao Paulo, Brazil, 2Santa Casa SP School of Medical Sciences, Sao Paulo, Brazil, 3Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 4Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil

 

Background: Cryptorchidism is the failure of one or both testes to descend into the scrotum and is the most frequent congenital birth defect in male children (2–4% in full-term male births). Cryptorchidism can occur as an isolated disorder or may be associated with other congenital anomalies such as hypogonadotropic hypogonadism, androgen insensitivity syndrome and inactivating mutations in the LH receptor gene. Testosterone response to hCG stimulation test has been used to evaluate gonadal function in prepubertal children. Currently, hCG extracted from urine (uhCG) of pregnant women is not available in many countries, requiring standardization of a new recombinant hCG (rhCG; Ovidrel®) stimulation test. Objectives: To determine testosterone response to rhCG stimulation test in prepubertal boys and to verify the correlation between basal AMH and rhCG-stimulated testosterone levels 7 days after injection. Patients and Methods: We evaluated 31 prepubertal boys (age: 0.75-9.0 yr) with unilateral (n=24) or bilateral (n=7) cryptorchidism. None of the boys had previously received hormonal treatment and patients with other genital abnormalities were excluded. Serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), total testosterone, 17-hydroxyprogesterone (17OHP), anti-mullerian hormone (AMH), inhibin B and dihydrotestosterone (DHT) concentrations were determined at baseline and seven days after rhCG stimulation (250 mcg subcutaneously; single dose). Results: There was no significant difference between hormone levels when unilateral was compared with bilateral cryptorchidism. All basal hormone concentrations were within the normal ranges for age. Serum concentrations of the following hormones increased 7 days after rhCG injection:  testosterone (from 10.0 ± 0.0 to 247.8 ± 135.8 ng/dL), DHT (from 4.56 ± 0.77 to 32.3 ± 17.1 ng/dL) and T/DHT ratio (from 2.19 to 7.7). rhCG-stimulated testosterone higher than 100 ng/dL indicates normal testicular function, based on the 10th percentile values for this cohort. Basal AMH was positively correlated with rhCG-stimulated testosterone levels (r=0.55; p=0.001). Conclusions:  We demonstrated that a single 7-days rhCG-stimulated testosterone levels is useful to assess testicular function and is correlated with basal AMH in this cohort. Although all patients had no impairment of testicular function, long-term follow-up of patients with mild cryptorchidism is recommended. This work was partially supported by FAPESP 2011/21297-6 to VNB.

 

Nothing to Disclose: LRO, ACM, CK, TKH, RSBW, VNB, CAL

15395 11.0000 MON-0011 A Standardization of a New Protocol with Recombinant Human Chorionic Gonadotropin (rhCG) in the Assessment of Testicular Function 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0001-0021 4865 1:00:00 PM Effects of Regulating Sex Hormone Levels in Men Poster

Laura Fink DeFina*1, Nina Butwell Radford2, David Leonard3, Larry W Gibbons4, Tyler C Cooper2, Rick Wilson2, S Michael Clark2 and Ugis Gruntmanis5
1The Cooper Institute, Dallas, TX, 2Cooper Clinic, 3The Cooper Institute, 4The Cooper Clinic, 5UT Southwestern Med Ctr, Dallas, TX

 

Background:  Presently it is unknown how much of testosterone decline associated with aging is actually due to aging per se, and how much is related to weight gain, decreased activity, and other age-related factors.  Understanding the modifiable factors associated with low testosterone, such as obesity or possibly cardiorespiratory fitness (fitness), is critical given the increasing use of testosterone replacement as well as the evidence that this replacement may have significant risks including cardiovascular events.  The purpose of this study was to determine if testosterone level in relatively healthy males is associated with age, weight and/or fitness. 

Methods:  The cross-sectional study included 1653 men, ≥50 and <80 years of age, seen between January 2012 and December 2012 for a preventive medical examination and underwent BMI, total testosterone, and fitness measurements as part of routine screening.  Exclusion criteria included persons using any form of androgens and 5 alpha reductase inhibitors (n=189) resulting in a group of 1464.   All participants underwent morning (7-9 am) total testosterone measurement using the standard Chemiluminescence method. Thresholds were categorized into low (<250 ng/dL), low normal (250-<400 ng/dL), and normal (≥400 ng/dL).  Traditional sample statistics were used to summarize characteristics of the sample within ordered categories of age and BMI.  Multiple logistic regression models were used to test associations of low testosterone and age, BMI and fitness.

Results:  Mean testosterone levels in all age groups were in the normal range (50-59 years, testosterone mean=479.0 (SD=175.4); 60-69 years, testosterone mean=457.2 (SD=204.1); 70-79 years, testosterone mean=464.6 (SD=176.7); trend p value=0.05) although the trend was statistically different between groups. The prevalence of low testosterone did not significantly change across the decades (<250 ng/dL=7.6% to 9.3% to 8.7%; trend test p=0.17) but did change with increasing BMI, (<250 ng/dL=3.4% to 6.8% to 17.8%; trend test p<0.001).  Finally, fitness was positively correlated with total testosterone levels (p<0.001) and this correlation persisted after adjustment for age and BMI.    

Conclusion:  In this group of generally healthy men, there was no decrease in the mean total testosterone level with increasing age, yet we found statistically and clinically negative correlation between testosterone and BMI and positive correlation between testosterone and fitness.

 

Nothing to Disclose: LFD, NBR, DL, LWG, TCC, RW, SMC, UG

15902 12.0000 MON-0012 A Testosterone Level in Men Is Lower with Increasing BMI and Decreasing Cardiorespiratory Fitness but Is Not Related to Age 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0001-0021 4865 1:00:00 PM Effects of Regulating Sex Hormone Levels in Men Poster

Tomas Ahern*1, Aftab Khattak2, Roland Reece1, Mark Kilbane1, Thomas P Smith1, Ciannait Lehane1, Malachi J McKenna1, Donal O'Shea1 and Frances J Hayes3
1St Vincent's University Hospital, Dublin 4, Ireland, 2Cork University Hospital, Cork, Ireland, 3Massachusetts General Hospital, Boston, MA

 

Introduction

Men with severe obesity (BMI>40kg/m2) and/or low testosterone (T) levels have elevated mortality and cardiovascular disease (CVD) incidence and elevated C-reactive protein (CRP) concentrations may be contributory. In men with severe obesity and low T, aromatase inhibition (AI) normalises both T and oestradiol (E2) levels whereas T therapy may increase already elevated E2 levels. Elevating E2 levels in men raises CRP. We hypothesised that AI decreases CRP concentrations more than T therapy in severely obese men with low T.

Methods

Thirty-seven severely obese men with low T (<8.5nmol/L) were assigned randomly to letrozole (LET) 1mg once weekly (n=19), or to testosterone undecanoate (TU) 1g every 6 weeks (n=18). The primary efficacy measure was the 12 week change in serum CRP concentrations. The co-primary safety measures were the changes in markers of bone formation (procollagen type-1 N-terminal propeptide (P1NP)), and bone resorption (collagen cross-linked C-telopeptide type-1 (CTX-1)). Secondary outcome measures included changes in concentrations of fasting glucose (FG), glycated haemoglobin (HbA1c), alanine transferase (ALT), prostate specific antigen (PSA) and haemoglobin (Hb). Data are presented as mean ± standard deviation, if parametric, and as median (interquartile range) if non-parametric.

Results

Mean age was 48.5±11.2 years and mean BMI was 54.0±9.2 kg/m2. At baseline the LET and TU groups had similar T (6.8±1.8 vs 6.2±2.1 nmol/L, p=0.359, ref range 8.6-31.3) and E2 levels (173±77 vs 145±64 pmol/L, p=0.249, ref range 50-170). After 12 weeks T levels were restored to the normal range in both groups but were higher with LET than TU (17.1±4.5 vs 13.1±3.2 nmol/L, p=0.005). In contrast, E2 levels were suppressed to 64±42 pmol/L with LET and elevated to 257±103 pmol/L with TU (p<0.001).

LET effected opposing changes to TU on:

  • CRP (+0.4mg/L [-1.1- +2.8] vs -1.7mg/L [-3.8- -0.3], p=0.010);
  • CTX-1 (+16.0±25.1% vs -13.2±13.5%, p<0.001);
  • FG (-0.3mmol/L [-0.5- +0.1] vs +0.2mmol/L [-0.1- +0.6], p=0.014); and
  • ALT (+3.5IU/L [-2.3- +3.5] vs -4.0IU/L [-8.5- +0.3], p=0.011).

LET and TU did not result in different changes in:

  • P1NP (+17.5±22.2% vs +29.8±30.3%, p=0.217);
  • HbA1c (-0.1% [-0.3- +0.2] vs -0.1% [-0.3- +0.1], p=0.962);
  • PSA (+0.16ng/ml [+0.09- +0.41] vs +0.13ng/ml [+0.05- +0.42], p=0.638); or
  • Hb (+0.5±0.6g/dl vs +0.6±0.9g/dl, p=0.672).

Conclusions

Short-term aromatase inhibition, despite normalising T and E2 levels, had unfavourable effects on CRP and bone turnover. In contrast, T therapy, despite effecting supra-physiological E2 levels, decreased CRP and improved bone turnover.

 

Nothing to Disclose: TA, AK, RR, MK, TPS, CL, MJM, DO, FJH

11356 13.0000 MON-0013 A Contrasting Effects of Aromatase Inhibition and Testosterone Therapy in Men with Severe Obesity: A Randomised Clinical Trial 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0001-0021 4865 1:00:00 PM Effects of Regulating Sex Hormone Levels in Men Poster

Christian Høst*1, Anders Bojesen2, Kristian A. Groth3, Kurt Kristensen4, Niels Holtum Birkebæk5, Anne Grethe Jurik6, Jens Sandahl Christiansen7 and Claus H. Gravholt1
1Aarhus University Hospital, Aarhus University, Institute of Clinical Medicine, Aarhus C, Denmark, 2Lillebaelt Hospital, Vejle, Denmark, 3Aarhus University Hospital, Aarhus N, Denmark, 4Aarhus University Hospital, Skejby, Århus N, Denmark, 5Aarhus University Hospital, Århus N, Denmark, 6Aarhus University Hospital, Aarhus, Denmark, 7Aarhus University Hospital, Aarhus C, Denmark

 

Context:Patients with Klinefelter syndrome (KS) are hypogonadal and have a high incidence of metabolic disease, and epidemiological studies report an increased mortality due to diabetes and cardiovascular disease. Testosterone treatment of other hypogonadal patients with type 2 diabetes primarily improves insulin sensitivity in obese patients, which indicates that improvements in insulin sensitivity may largely depend on the amount of “modifiable fat.” Whether such observations can be extrapolated to KS patients is presently unknown, since no formal studies are at hand.

Objective: To investigate the effect of testosterone treatment on glucose metabolism and body composition in KS patients.

Design, setting, and participants: In a randomized, double-blind, placebo-controlled, cross-over study, 13 KS patients (age: 34.8 (22-56) yrs); BMI: 26.7±8.8 (kg/m2)) received Andriol® 160 mg per day or placebo treatment for 6 month. Thirteen age (age: 34.8(21-53) yrs) and BMI (27.0±6.9 (kg/m2)) matched healthy controls were recruited. DEXA scan, abdominal CT scan and a 3-h hyperinsulinemic euglycemic clamp were performed after each period of treatment and once in controls.

Results: Testosterone naïve KS were comparable to controls with respect to total lean (61.0±12.1 vs. 64.0±12.9 (kg), P=0.37) and body fat mass (26.8±16.8 vs. 21.3±15.2 (kg), P=0.14)), whereas visceral fat mass was increased (3.5± 2.4 vs.2.3±1.9 (kg), P=0.05), as was both total abdominal and intra-abdominal fat by CT scan (both p<0.01). Testosterone treatment decreased total body fat (26.8±16.8 vs. 24.6±15.3 (kg), P=0.01) and abdominal fat by CT (533±408 vs. 495±366 (cm3), P=0.04) There was no change in lean body mass or VO2max during 6 month treatment. Total glucose disposal was similar between T naïve KS and controls (8.9±1.1 vs. 10.3±0.6 (µmol/kg/min), P=0.28), and there was no effect of T on total glucose disposal in KS (8.9±1.1 vs. 8.6±1.0 (µmol/kg/min), P=0.82).

Conclusion: The first randomized study of testosterone supplementation in Klinefelter syndrome shows that testosterone treatment for 6 month leads to favorable changes in body composition with reductions in fat mass, including abdominal fat mass, but not to changes in glucose homeostasis. We speculate that longer term treatment would lead to greater changes in body composition and eventually to an increase in insulin sensitivity.

 

Disclosure: JSC: Research Funding, Novo Nordisk, Board Member, Novo Nordisk, Board Member, The name is Merck Serono, lectures, Novo Nordisk, lectures, Pfizer, Inc., fees, Eli Lilly & Company. Nothing to Disclose: CH, AB, KAG, KK, NHB, AGJ, CHG

15945 14.0000 MON-0014 A Effects of 6 Month Testosterone Treatment on Body Composition and Glucose Metabolism in Klinefelter Syndrome Patients. a Randomized, Double-Blind, Placebo-Controlled, Cross-over Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0001-0021 4865 1:00:00 PM Effects of Regulating Sex Hormone Levels in Men Poster

Saad Sakkal*1 and Mohamed loutfy Sakkal2
1Metabolic Care Center, Mason, OH, 2Metabolic care center, Mason, OH

 

Introduction: Recent medical and public publications have given an immense emphasis on “Traumatic Brain Injuries “related executive and neurologic manifestations in football players who were exposed to repetitive trauma. However a careful screen of the literature failed to document the Hypothalamic Dysfunction, a vulnerable delicate system, which may be associated with these injuries. We prospectively tabulated head injury data in our young patients who were referred for Hypogonadism and fatigue.

Methods:10 consecutive patients referred for fatigue and Hypogonadism below the age of 40 were routinely screened for: prior head injury during contact sport ,Testosterone , FSH ,LH ,Prolactin, PSA ,Vitamin D,T4,TSH , cortisol ,GH, and other metabolic disorders based on clinical history. Their screen for review of symptoms taken from the office intake sheet were also tabulated for hypothalamic symptoms of chang in energy, temperature, weight, sleep, mood, Libido/ED, sympathetic/parasympathetic balance and memory/concentration. We present here the hpogonadism/Vit D data since space does not allow more details. Hypothalamic Dysfunction is diagnosed when 4 or more systems involved, Vit D deficiency defined as symptomatic level below 30 ng/dl.

Results: Frequency of symptoms groups: 1) Energy, fatigue, tiredness 9/10 (% 90); 2) Temperature dysregulation;.7/10 (%70); 3) Appetite and weight changes 7/10 (%70); 4)sleep and diurnal changes 7/10 (% 70);Pain, muscle spasm, fibrositis , fibromyalgia syndromes 8/10 (% 80); Mood disorders 8/10(%80);Libido/ED and Reproduction 8/10 (%80); sympathetic/ parasympathetic symptoms 9/10 (%90 ). Fibromyalgia pain trigger points were documented in %80 with average of 17/18 points(range 14-20).

Frequency of Hypothalamic Dysfunction diagnosis: 1) Likely (3 systems or less) 1 /10 (% 10); 2) definite (4 or more systems) 9/10 (%90).

Frequency of Laboratory abnormalities: Low testosterone was found in all patients since the group was referred for this diagnosis  with average Free Testosterone 5.2(range :3.4-8.9) ; non elevated LH in%66 with average 4.1(range 3.2-5.2);FSH in %63 with average of 4.5 (range 1.5-7.8);Prolactin in %42 with average of 15.7(range5.5-27);Low PSA below 1 ng/dl in %80 with average of 0.9 (range 0.2-1.2); Vit D deficiency found in %70 with average of 24.7 (range 8-35).

Conclusion : Hypothalamic Dysfunction is the most common disease in football players with prior head injury,Hypogonadism and fatigue  (%90) exceeding other all disorders including TBI associated with them , but often forgotten.

 

Nothing to Disclose: SS, MLS

16745 15.0000 MON-0015 A Hypothalamic Dysfunction with Hypogonadism in Football Players with Head Injury 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0001-0021 4865 1:00:00 PM Effects of Regulating Sex Hormone Levels in Men Poster

Michael Zitzmann*1 and Farid Saad2
1University Clinics Muenster, Muenster, Germany, 2Bayer Schering Pharma AG, Berlin, Germany

 

Background

It is still largely unclear to what extent testosterone substitution has age-related effects. Especially outcome in regard to blood pressure or elevation of hematocrit might be different in older men compared to younger men.

Methods

The IPASS study is an international study of testosterone substitution using intramuscular injections of testosterone undecanoate 1000mg in hypogonadal men involving 1438 men (1240 men aged younger than 65 years, range 15 to 64 years, mean 46±12 years, and 198 men aged at least 65 years (range 65 to 94 years, mean 69±4 years). Substitution was monitored for 1 year.

Results

Baseline systolic was was significantly different between groups (128±14 mmHg in younger men and 136±15 mmHg in older men, p<0.0001). Also baseline waist circumference was significantly lower in younger men (99±15 cm in younger men and 102±16 years in older men, p=0.009). Significant changes during treatment were observed in lowering body weight and waist circumference, indendent from age, but depending on pre-treatment status with other androgens. Effects of lowering systolic and diastolic blood pressure were largely seen in younger men, while a decrement in HbA1c was much more pronounced in the older group. Elevation of hematocrit was rather differential depending on pre-treatment and not on age. Changes in lipid values, PSA and psychological estimates were largely similar.

Conclusions

The effects of testosterone substitution using intramuscular testosterone undecanoate in hypogonadal men are partially different in younger vs older men. Older men seem to benefit more from decrement of insulin resistance while younger men have a more pronounced effect in lowering blood pressure. Other parameters seem to be independent from age.

 

Disclosure: FS: Employee, Bayer Schering Pharma. Nothing to Disclose: MZ

16692 16.0000 MON-0016 A Age-Related Effects of Testosterone Substitution in a Very Large International Cohort of 1438 Men: The Ipass-Experience 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0001-0021 4865 1:00:00 PM Effects of Regulating Sex Hormone Levels in Men Poster

Mirjana Pavlic*1 and Richard Arthur Bebb2
1University of British Columbia, Vancouver, BC, Canada, 2Univ of British Columbia, Vancouver, BC, Canada

 

The anabolic androgenic steroids (AAS) have been used by competitive athletes since1950s, to increase performance, gain muscle and lose body fat. Furthermore, testosterone (T) has been increasingly studied as a potential, reversible male contraceptive agent. Regardless of the reason of exogenous steroid use the consequences are the same and lead to suppression of the hypothalamic-pituitary-gonadal (HPG) axis with all of its negative effects, including decrease in spermatogenesis and testosterone production lasting for several months to years following T exposure. Long-term adverse effects including loss of muscle and increased fat, loss of libido, energy and concentration with impaired quality of life pose a significant problem. More importantly, low testosterone states have been associated with increased mortality. Recommendations for treatment of endogenous testosterone suppression caused by AAS use are not available.

Clomiphene citrate (CC) is a weak estrogen receptor antagonist that competes with estradiol feedback at the pituitary and hypothalamic levels, leading to an increase in LH and FSH, improving steroidogenesis and spermatogenesis in men. There is only a limited amount of evidence to suggest benefit of CC in treatment of AAS induced HPG suppression. Several case reports have been reported, but to date, no larger retrospective studies have been performed.

We preformed a retrospective chart review aiming to assess the effect of CC on HPA axis in AAS users by analyzing T, LH and FSH levels prior and after CC use. Charts at the Men’s Health Initiative in Vancouver dating from 1998 to 2013 were searched using keywords including CC, hypogonadism and AAS use. Charts meeting criteria were reviewed and serum T, LH, FSH levels were analyzed at baseline as well as at different time points after initiating therapy to assess for efficacy and duration needed for restoration of HPG axis.

Our hypothesis was that Clomiphene significantly reduces the amount of time needed for HPA recovery in AAS users with specific aims to assess the effect of Clomiphene on HPA axis by analyzing information on testosterone, LH and FSH levels in AAS users prior and after Clomiphene use.

Our results support this as demonstrated by an increase in all three hormones following Clomiphene therapy. There was a 62.9%, 46.7% and 42.2% increase from baseline at 2 months in testosterone, LH and FSH levels respectively, and this was maintained at 57.8%, 46.6% and 43.9% at the 4 month mark (N=6). This reached statistical significance for testosterone levels with p<0.05 at both time points.

This is the first larger retrospective case series to demonstrate clear benefit of clomiphene in restoring HPG axis in AAS users.

 

Nothing to Disclose: MP, RAB

11684 17.0000 MON-0017 A Clomiphene Citrate in Anabolic Steroid Users: A Retrospective Review 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0001-0021 4865 1:00:00 PM Effects of Regulating Sex Hormone Levels in Men Poster

Ahmad Haider*1, Aksam A Yassin2, Gheorghe Doros3, Abdulmaged M Traish4 and Farid Saad5
1Private Urology Practice, Bremerhaven, Germany, 2Institute of Urology and Andrology, Norderstedt, Germany, 3Boston University School of Public Health, Boston, MA, 4Boston University School of Medicine, Boston, MA, 5Bayer Pharma AG, Berlin, Germany

 

Objective: Hypogonadism is a risk factor for a host of diseases. This study analysed effects of testosterone replacement therapy (TRT) in hypogonadal men on urinary and sexual functions and QoL. 

Material and Methods: Two pooled, prospective, cumulative registry studies in 561 men (age: 58.55 ± 7.59 years) with T levels below 12.1 nmol/L.  450 men were aged ≤ 65 years (Group Y), 111 were > 65 years (Group O). They received parenteral TU 1000 mg/12 weeks following an initial 6-week interval for up to six years. The International Prostate Symptom Score (IPPS), International Index of Erectile Function-Erectile Function Domain (IIEF-EF, maximum score: 30) and Aging Males’ Symptoms Scale (AMS) were assessed at every visit. Post-void residual urine volume (PVR) as well as prostate volume were measured by ultrasonography. 

Results: Prostate volume increased in Group Y from 26.77±9.4 to 31.58±10.9 ml (p<0.0001), in Group O from 33.85±8.66 to 39.95±7.6 ml (p<0.0001). 

IPSS improved in Group Y 7.74±5 to 3.89±3.12 (p<0.0001), in Group O from 10.7±4.07 to 4.63±2.63 (p<0.0001). These changes were statistically significant vs. previous year for all six years in Group Y and the first five years in Group O and were then maintained throughout the observation period. 

PVR declined in Group Y from 34.87±23.12 to 16.72±6.74 ml (p<0.0001), in Group O from 41.46±23.48 to 18.84±5.75 ml (p<0.0001). 

IIEF improved in Group Y from 14.94±7.34 to 24.21±4.39 (p<0.0001), in Group O from 11.87±7.58 to 22.12±6. 41 (p<0.0001). These changes were statistically significant vs. previous year for the first four years in Group Y and the first two years in Group O and were then maintained throughout the observation period. 

AMS improved in Group Y 53.53±9.47 to 21.68±6.88 (p<0.0001), in Group O from 54.99±9.02 to 23.45±7.91. These changes were statistically significant vs. previous year for the first three years in both groups and were then maintained throughout the observation period.

C-reactive protein (CRP) as a marker of inflammation dropped in Group Y from 4.04±6.34 to 0.75±1.06 (p<0.0001), in Group O from 2.65±3.75 to 0.71±0.51 mg/dl.  

Conclusions: Despite an expected increase in prostate volume, TRT in both younger and older hypogonadal men produced sustainable improvements in urinary function with parallel improvements in sexual function and QoL. These effects are closely interrelated and may be partly mediated through anti-inflammatory effects of T.

 

 

Disclosure: AH: Speaker, Bayer Schering Pharma, Speaker, Takeda. AAY: Speaker, Bayer Schering Pharma, Speaker, Ferring Pharmaceuticals. GD: Coinvestigator, Bayer Schering Pharma. FS: Employee, Bayer Schering Pharma. Nothing to Disclose: AMT

13214 18.0000 MON-0019 A Long-Term Treatment with Testosterone Undecanoate (TU) Injections Improves Urinary and Sexual Functions and Quality of Life (QoL) Independent of Age 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0001-0021 4865 1:00:00 PM Effects of Regulating Sex Hormone Levels in Men Poster

George Mskhalaya*1, Yuliya Tishova2, Daria Gusakova3 and Svetlana Kalinchenko4
1Center for Reproductive Medicine MAMA, Moscow, Russia, 2People`s Friendship University, Moscow, Russia, 3Research Institute of Urology, Moscow, Russia, 4People's Friendship University of Russia, Moscow, Russia

 

The number of reproductive–age patients with hypogonadism is increasing. Prescription of intramuscular testosterone injections may be the cause of decreased sperm production, because of supraphysiological peak concentrations of testosterone. Testosterone formulation that is not suppressing pituitary LH and FSH production and thus not leading to spermatogenesis impairment may be used.

The aim was to study the influence of testosterone gel treatment (Androgel), taken 50 mg daily, on the parameters of spermatogenesis.

Materials and methods: We studied 18 men with confirmed eugonadotropic hypogonadism, who received treatment with Androgel 50 mg daily for 3 months. All men had history of previous fatherhood. Serum testosterone, SHBG levels were assessed before and after 3 months of testosterone treatment. Spermatogenesis parameters, such as sperm volume, sperm count, motility (a+b), percent of normal forms and vitality, were assessed before and after 3 months of Androgel treatment. Data is presented as a median and quartile range. Statistical analysis was made using Wilcoxon test.

Results: Median age of the patients was 35 [30;44] years. Normalization of testosterone levels was achieved in all patients: from 8.4 [7.6;11.2] to 16.3 [15.3;18.0] nmol/l, p<0.001. There was a significant increase in sperm volume from 2.05 [1.6;4.0] to 2.6 [1.8;4.4] ml, p<0.001.  No significant difference was found in sperm count (from 19.0 [15.0;37.0] to 23.0 [15.0;47.0] million in 1 ml, p=0.24.) sperm motility (a+b) (from 42.6 [18.0;47.0] to 42.0 [25.0;51.0] %, p=0.69), percent of normal forms (from 24.0[14.0;32.0] to 15.0 [13.0;22.0] %, p=0.06) and vitality of spermatozoa (from 76.0[65.0;86.0] to 77.0 [58.0;81.0] %, p=0.5).

Conclusion: Androgel treatment during 3 months doesn’t lead to decrease in sperm count and volume without any change in sperm vitality, motility (a+b) or percent of normal forms. More studies are needed to evaluate the long-term effect of Androgel treatment on spermatogenesis.

 

Nothing to Disclose: GM, YT, DG, SK

15723 19.0000 MON-0020 A The Influence of Testosterone Gel Treatment on Spermatogenesis: A Pilot Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0001-0021 4865 1:00:00 PM Effects of Regulating Sex Hormone Levels in Men Poster

David Muram*1, Alvin M. Matsumoto2, Xiang Zhang3 and Zhanglin Lin Cui3
1Eli Lilly and Company, 2VA Puget Sound Hlth Care Syste, Seattle, WA, 3Eli Lilly and Company, Indianapolis, IN

 

Introduction: The Endocrine Society guidelines on testosterone therapy in androgen deficient men published in 2010 were based on the best scientific evidence available.  However, little is known about application of the guidelines in clinical practice. The purpose of this study was to evaluate application of the 2010 Endocrine Society guidelines related to the use of serum testosterone for the diagnosis of hypogonadism and monitoring of testosterone therapy.

Materials and Methods: Using the Truven MarketScan® Database, which includes US claim data on over 180 million commercial, Medicare, and Medicaid insurance plans, we identified men 18 years or older who received transdermal testosterone therapy in 2011 and had a diagnostic code for hypogonadism.  Patients who received testosterone treatment within 6 months prior to the index date (initial testosterone prescription) were excluded. Patients were required to have continuous pharmacy and medical benefit enrollment for 1 year prior to and 6 months after the index date. 27,758 men met criteria for analysis.

Main Outcome Measures: Determination of serum testosterone levels within 1 year prior to initiation of therapy (to diagnose hypogonadism) and during the 6 months following index date (follow-up monitoring and as guide for dose adjustment).

Results: Out of the 27,758 men, 18-95 (mean 52.8 ± 10.8) years with a hypogonadism diagnosis and who were treated with testosterone, 22,107 (79.6%) had at least 1 serum testosterone measurement performed in the year prior to initiation of therapy; 8091 (29.1%) had 1 and 14,016 (50.5%) had 2 or more testosterone determinations. During the 6 months following testosterone treatment, 11,742 (42.3%) had no follow up testosterone measurements performed; 6176 (22.2%) had 1 testosterone measurement and 9840 (35.4%) had 2 or more.  2572 (9.3%) patients had dose adjustment within 6 months, 1921 (6.9%) and 651 (2.4%) men had a dose escalation and reduction, respectively. Follow-up testosterone levels were not measured in 1282 (49.8%) men who had a dose adjustment.

Summary and Conclusions: The 2010 Endocrine Society recommendation to measure 2 or more testosterone levels for diagnosis of hypogonadism was followed in about 50% of patients. The recommendation to monitor testosterone measurements in patients on testosterone therapy was followed in only about 60% of men within 6 months after initiation of transdermal testosterone therapy. In the patients who had their dose of transdermal testosterone adjusted, about half had serum testosterone determinations following adjustment. Only 40-50% of practitioners who prescribe testosterone adhere to evidence-based guidelines for use of testosterone levels in the diagnosis of hypogonadism and monitoring of testosterone therapy, suggesting a need for further investigation into reasons for non-adherence to guidelines and for practitioner-based educational efforts.

 

Disclosure: DM: Employee, Eli Lilly & Company. AMM: Principal Investigator, Abbott Laboratories, Principal Investigator, GlaxoSmithKline, Consultant, Endo Pharmaceuticals, Consultant, Lilly USA, LLC, Consultant, GTx, Consultant, Forendo. XZ: Employee, Eli Lilly & Company. ZLC: Employee, Eli Lilly & Company.

11216 20.0000 MON-0021 A Application of the Endocrine Society Clinical Guidelines on Testosterone Therapy in Men with Androgen Deficiency Syndromes in Clinical Practice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Monday, June 23rd 3:00:00 PM MON 0001-0021 4865 1:00:00 PM Effects of Regulating Sex Hormone Levels in Men Poster

Shuchie Jaggi Jain*1 and Maya P Raghuwanshi2
1Temple Hospital, Philadelphia, PA, 2UMDNJ-NJ Med Sch, Newark, NJ

 

Introduction:  Tumors metastatic to the mandible are infrequent and exceedingly rare if it they are of thyroid origin. Recognition of papillary carcinoma is crucial for early treatment. We present a rare case of metastatic papillary carcinoma to the mandible with no detected primary cancer in the thyroid.

Case: 44 year old female with no significant past medical history who presented with an increasing right sided mandibular mass. Patient underwent biopsy of the mandibular mass and a right sided enlarged neck node. Biopsy of the mandible showed metastatic carcinoma consistent with a thyroid origin. Tumor invasion through the bone with involvement of the adjacent skeletal muscle was noted after resection of the mass. The morphology of the tumor was consistent with papillary carcinoma of the thyroid. Immuno-histochemical staining revealed positive staining for thyroglobulin which thus supported the above diagnosis. Benign salivary gland tissue was obtained from a fine needle aspiration of the right parotid.  Patient underwent fine needle biopsy for the search of the primary cancer which revealed scant groups of follicular cells in rosette like clusters suggestive of a follicular lesion. Total thyroidectomy was conducted 2 months after diagnosis of the metastatic lesion with a high suspicion of primary cancer in the thyroid gland. However, pathology of the thyroid and para-tracheal lymph node resection were negative for neoplasm. Thyroid gland only showed nodular hyperplasia in the right and left lobe. Radioactive iodine uptake was also performed on the patient after the total thyroidectomy which showed increased uptake in the zygomatic region.  Patient underwent a second radioactive iodine ablation 2 years later. Patient has been cancer free for greater than 10 years.

Discussion: Most papillary thyroid cancers present with a palpable thyroid abnormality. In this case, the primary presentation was mandibular bone metastases with no overt thyroid anomaly.  Metastases are uncommon beyond the neck in this cancer type. Only 25 percent of those patients with metastases beyond the neck have skeletal involvement.  This case is especially rare given that there was no primary cancer found in the thyroid gland. Though metastases of papillary carcinoma to the orofacial region are rare it should be considered when a patient presents with a suspicious lesion. Early detection and treatment may decrease mortality in this patient population.

 

Nothing to Disclose: SJJ, MPR

11102 1.0000 MON-0463 A A Case of Thyroid Cancer Where Its Least Expected 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Yoko Miyoshi*1, Kie Nakao1, Makiko Tachibana1, Yuki Miyahara1, Hiroki Kondou1, Noriyuki Namba1, Kazunori Miki2, Yukiko Nakata1, Toru Takano1 and Keiichi Ozono1
1Osaka University Graduate School of Medicine, Suita Osaka, Japan, 2Itami Municipal Hospital, Itami Hyogo, Japan

 

Antithyroid drugs (methimazole: MMI or propylthiouracil: PTU) have been employed as treatment in pediatric Graves' disease (GD) patients in Japan and radioiodine is not recommended. PTU has been avoided as first-line therapy due to the risk of severe hepatotoxicity among pediatric GD patients in accordance with revised 2011 Japanese guidelines. The aim of this study is to clarify the side effects of the antithyroid drugs in Japanese pediatric patients with GD. We retrospectively reviewed the clinical course and side effects of antithyroid drugs in 52 pediatric GD patients (≤15 years at the initial diagnosis) who received regular outpatient management at our institute (Department of Pediatrics, Osaka University Hospital) from 1979 to 2013. The 52 patients (10 male, 42 female) were aged 2-15 years (median 11 years ) at first visit and 12 were followed for underlying diseases. Patients were diagnosed from goiter (n=27), signs of hyperthyroidism (n=18), orbitopathy (n=6), and by chance (n=1). Serum free T4 level at the first visit was <5 ng/dL (n=24), 5-7 ng/dL (n=15), >7 ng/dL in 12, and unknown (n=1). Antithyroid drugs were selected for initial treatment in all patients: MMI (n=48) and PTU (n=4). The initial dose of MMI was low (<0.7 mg/kg/day) in 16 patients, high (≥0.7 mg/kg/day and/or 30mg/day) in 31 patients, and unknown in one patient. The dose of PTU was 150-300 mg/day. Side effects of antithyroid drug therapy were observed in 21 cases (40%) and occurred within 1 month of treatment initiation in 14 of these cases (67%). A switch from MMI to PTU was selected in 13 cases (27%). Side effects of MMI were: rash (n=11), arthralgia (n=6), neutropenia (n=5), mild or moderate liver dysfunction (n=2), and high serum creatine kinase (n=1). Side effects were observed in 25% of patients (n=4) with low-dose MMI and in 52% of patients (n=16) with high-dose MMI. Side effects of PTU were observed in four patients: rash (n=1), moderate liver dysfunction (n=1), and nephritis and vasculitis with antineutrophil cytoplasmic antibody positivity (n=2). These four patients had first received MMI and were switched to PTU due to side effects. With respect to prognosis, 17 patients were in drug-free remission and 38 attended the Internal Medicine Department at the time of their last medical examination. Thyroidectomy was selected in five patients due to the side effects of PTU (n=2), patient request (n=2), and resistance to antithyroid drug therapy (n=1). No pediatric patients selected isotope therapy. In conclusion, side effects of the antithyroid drugs were observed in 40% of pediatric GD patients in our retrospective series. It is expected that the frequency of side effects will decrease in the future now that modified guidelines recommend low-dose methimazole.

 

Nothing to Disclose: YM, KN, MT, YM, HK, NN, KM, YN, TT, KO

12274 3.0000 MON-0465 A Side Effects of Antithyroid Drugs in 52 Japanese Pediatric Patients with Graves' Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Tanawan Riangwiwat*1, Jutarat Sangtian1 and Chutintorn Sriphrapradang2
1Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, 2Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

 

Introduction: Steroid-responsive encephalopathy associated with autoimmune thyroiditis, often termed Hashimoto encephalopathy (HE), is a rare neurocognitive syndrome characterized by elevated thyroid autoantibodies, even if thyroid function tests (TFTs) were normal, the absence of infection or structural abnormalities in the central nervous system and a remarkable responsiveness to steroids. We described a patient who developed HE and manifested simultaneously with Hashitoxicosis. This is an unusual manifestation because most were reported in either euthyroid or hypothyroid state.

Clinical case: A 26-year-old man was diagnosed with HE based on the presence of subacute behavior changes without localizing signs, a lack of cerebrospinal fluid evidence of infection, and absence of abnormal immunologic serology except a high serum titer of anti-TPO 520 IU/mL (reference range, 0-34) and anti-thyroglobulin 1,822 IU/mL (reference range, 0-115). TFTs were within normal limit. MRI demonstrated no abnormalities. EEG showed low amplitude, slow waves and theta waves at both frontal areas. The patient was treated with high dose intravenous glucocorticoid followed by an oral taper. His condition improved dramatically. Thyroid autoantibodies levels and EEG returned to normal. After 2 years of relapsing-remitting course, a new episode occurred. He experienced behavioral changes. Thyroid gland was not enlarged. He was in euthyroid state except heart rate of 100/min. There was abrupt change of thyroid hormones within 5 days: FT4 from 1.52 to 1.53 ng/mL (reference range, 0.70-1.48), FT3 3.25 to >30 pg/mL (reference range, 1.71-3.71) and TSH 5.080 to 0.782 mIU/L (reference range, 0.35-4.94). Repeated TFTs in the following day found FT4 2.58, FT3 14.67, and TSH 0.042. High anti-TPO 1,700 IU/mL and anti-thyroglobulin 421 IU/mL were noted. TSH receptor antibody was negative. Thyroid uptake found a decrease in thyroid uptake compatible with thyroiditis. He was diagnosed HE and Hashitoxicosis. Treatment of high dose glucocorticoid and beta-blockers were initiated. The symptoms gradually improved and thyroid function normalized within 2 weeks.

Conclusions: In the presence of unexplained encephalopathy, the search should include evaluation of TFTs and thyroid autoantibodies. Previous studies revealed majority of cases presented with hypothyroidism or euthyroidism. However, the demonstrated patient showed thyrotoxicosis at the time of the active disease. Endocrinologists should be aware of this rare syndrome.

 

Nothing to Disclose: TR, JS, CS

12747 5.0000 MON-0467 A Steroid-Responsive Encephalopathy: An Under Recognized Aspect of Hashimoto's Thyroiditis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Jutarat Sangtian*1, Tanawan Riangwiwat1, Siripich Triamchaisri1, Wasana Kanoksil1 and Chutintorn Sriphrapradang2
1Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, 2Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

 

Introduction: Langerhans cell histiocytosis (LCH) can present as either solitary or multisystem disease. LCH of the thyroid gland is a rare presentation. We report on a case of LCH presenting as a goiter.

Clinical case: A 54-year-old woman presented with progressive thyroid enlargement for 1 year with compressive symptoms. Ultrasonography of the thyroid gland showed multinodular enlargement with a prominent 8x6 cm isoehoic mass on the right lobe and a 6x5 cm hyperechoic mass on the left lobe. TSH was 5.391 mIU/L (reference range, 0.35-4.94) and FT4 was 0.48 µg/dl (reference range, 0.70-1.48). Secondary hypothyroidism was diagnosed. Fine-needle aspiration biopsy (FNAB) was performed. The cytology was reported as suggestive of LCH. Careful systemic history taking revealed that patient experienced polyuria, polydipsia and fatigue. She had menopause at 46 years old. Further investigations revealed FSH 3.92 IU/L (reference range, 26.72-133.41), LH 0.14 IU/L (reference range, 10.39-64.57), IGF-1 55 ng/mL (reference range, 87-238), prolactin 139.17 ng/mL (reference range, 5.18-26.53), and morning cortisol 2.5 µg/dL. Urinalysis showed urine specific gravity of 1.002. There was a few small osteolytic lesion at the frontal bone on skull x-ray. Magnetic resonance imaging of the pituitary gland showed a homogenous enhancing well-defined lesion involving tuber cinereum, the superior aspect of pituitary stalk, extending to floor of the hypothalamus, measured about 1.2x0.8x1.0 cm. Computed tomographic scan of the chest and whole abdomen found diffused enlargement of thyroid gland and no other evidence of LCH. The diagnosis of LCH is confirmed by immunohistochemical study, the histiocytes were positive for S-100 protein and CD1a. The final diagnosis was multisystem LCH (hypopituitarism, central diabetes insipidus, thyroid goiter, and skull involvement). The patient was administered chemotherapy of vinblastine and prednisolone, and levothyroxine. On the follow-up, the thyroid gland had decreased in size. The symptoms of polyuria and polydipsia were improved. 

Conclusions: Diagnosing LCH as a cause of thyroid goiter can be challenging because of its rarity. A goiter with symptoms of pituitary dysfunction should raise the suspicion of LCH. FNAB can be useful in establishing a diagnosis with immunohistochemical staining. Further investigations are necessary to determine multisystem involvement which will help to decide the choice of treatment.

 

Nothing to Disclose: JS, TR, ST, WK, CS

12750 7.0000 MON-0469 A Langerhans Cell Histiocytosis Presenting As a Thyroid Goiter 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Beniko Mutsuo*1, Ikawa Hiroyuki2, Mori Takayuki1 and Mashio Yasuo3
1Sapporo-Kosei General Hospital, Sapporo, Japan, 2Sapporo-Kosei General Hospital, Sapporo, 3Sapporo-Kosei Kyosai Clinic, Sapporo, Japan

 

INTRODUCTION. According to the guideline for medical treatment of Graves’ disease by the Japan Thyroid Association in 2011, discontinuation of antithyroid drug is recommended when normal thyroid functions have been maintained for a certain period (>6 months) after treatment with a minimum maintenance dose. We prospectively studied the remission rates on this therapy protocol in the patients with Graves’ disease. Patients and METHODS. The subjects were 108 patients with Graves’ disease, who were newly diagnosed from 2003 to 2008 (mean age, 46.2±13.2 years old, 22 men and 86 women). They were treated with methimazole (MMI) at the initial dose of 15mg/day. MMI doses were gradually decreased to minimum maintenance dose (5mg every other day).In this study, the duration of minimum maintenance dose was defined as 12 months. We finally discontinued MMI when their serum FT4 and TSH had been kept within normal range for 12 months. After discontinuation of MMI, they were followed every 6 months to confirm continuous remission. Follow-up periods were 33±22 months RESULTS. 1) In 86 patients, MMI had reached a minimum maintenance dose. The percentage of patients who reached a minimum maintenance dose was 46% at 1 year, 68% at 2 years and 78% at 3 years. 2) In 55 patients(mean age, 48.2±11.5 years old, 9 men and 46 women, smokers 19 and non-smokers 36 patients), in whom MMI was stopped after therapy for 23±8 months contained minimum maintenance dose periods, remission rates were 82.7% at 1 year, 76.0% at 2 years and 70.6% at 3 years after MMI discontinuation(Kaplan-Meier method). 3) The titers of TRAb (TRAb-CT) and the rate of positive TRAb(>15%) at the time of MMI cessation were 13.9±13.5% and 23% in 37 cases of remission group keeped for 2 years. In 17 cases of relapse group within 2 years, those were 11.0±8.8% and 44%, respectively. The averege titers of TRAb was no difference in the two groups, but the rate of  positive TRAb was significantly higher in relapse group(p<0.01, χ2 test). CONCLUSION. The present study indicates that a minimum maintenance dose therapy to keep euthyroid state for 12 months is a useful and practical procedure for treatment of Graves’ disease. It was suggested that the patients with positive TRAb tended to relapse Graves’ disease.

 

Nothing to Disclose: BM, IH, MT, MY

13338 9.0000 MON-0471 A Remission Rate in the Patients with Graves' Disease after Treatment with a Minimum Maintenance Dose of Methimazole for 12 Months 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Shanshan Shao*1, Yongfeng Song2, Qingbo Guan3, Chao Xu4, Ling Gao3 and Jiajun Zhao3
1Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan, Shandong, 2Shandong Provincial Hospital, Endo, Jinan, Shandong Province, 3Shandong Provincial Hospital affiliated to Shandong University, Jinan, China, 4Shandong Provincial Hospital affiliated to Shandong University, Department of Endocrinology and Metabolism, China ;, Jinan, Shandong

 

It is known that long term excess saturated fat intake could induce lipotoxicity towards target organs such as pancreas and liver, and leading to metabolic disorders such as diabetes and non-alcoholic fatty liver disease. However, it has been unknown whether fat intake can act on thyroid gland. Our aim here was to observe the effects of saturated fat intake on thyroid function. Sixty six-week-old male Sprague Dawley rats were taken randomly into two groups: the normal diet group was fed standard rodent chow (3.49 kcal/g) and the saturated high-fat diet group received 85% standard rodent chow supplemented with 15% lard (4.14 kcal/g). Body weights of the animals were monitored weekly. Fasting blood samples were collected by subclavian vein puncture at the end of 12th, 18th and 24th week, respectively. Serum lipid profile was detected using enzymatic methods, while serum concentrations of free thyroxine (FT4) and thyrotropin (TSH) were measured by radioimmunoassays, respectively. At the end of the high-fat diet for 24th week, high-frequency ultrasound scanning of thyroid gland and indirect calorimetry were carried out, and then, all rats were sacrificed. Their thyroid gland tissues were properly collected for morphology observation using light microscopy and transmission electron microscopy (TEM), respectively. Compared with the rats in the normal diet group, those rats in the saturated high-fat diet group were tested a significant increase in body weights from the 18th week, and an elevation of serum triglyceride levels (0.93 ± 0.08 mmol/L vs. 0.52 ± 0.12 mmol/L, P=0.002) at the 24th week. As serum triglyceride levels elevated, FT4 and TSH concentrations altered correspondingly. Excess saturated fat intake decreased the levels of serum FT4 accompanied by increased the levels of TSH at the 18th (FT4: 10.04 ± 1.38 pmol/L vs. 14.28 ± 3.02 pmol/L, P=0.022; TSH: 0.53 ± 0.12 µIU/ml vs. 0.30 ±0.15µIU/ml, P=0.002) and 24th week (FT4: 7.86 ± 1.59 pmol/L vs. 10.53 ± 1.91 pmol/L, P=0.014; TSH: 1.04 ± 0.20 µIU/ml vs. 0.84 ±0.16µIU/ml, P=0.025). Consistently, compared with the control rats, the saturated high-fat rats with lower serum FT4 levels also showed evidences of hypometabolism assessed by indirect calorimetry measurements, and the thyroid tissues exhibited the increased volumes with rough echo and relatively heterogeneous feature under ultrasonic imaging. Simultaneously, the enlarged follicle cavities and flattened follicular epithelial cells were observed under light microscopy, while twisted nucleus, dilated RER cisternae, fewer microvilli and secretory vesicles were clearly found under TEM in thyroid tissues of these rats fed saturated high-fat diet. We speculate that excess saturated fat intake may be a significant risk factor for thyroid dysfunction.

 

Nothing to Disclose: SS, YS, QG, CX, LG, JZ

14411 10.0000 MON-0472 A Excess Saturated Fat Intake Induces Rat Thyroid Dysfunction 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Feyza Yener Ozturk*, Hande Mefkure Ozkaya and Yuksel Altuntas
Sisli Etfal Training and Research Hospital, Istanbul, Turkey

 

Background: Pre-existing autoimmunity as indicated by the presence of thyroid peroxidase antibodies (TPO Ab),  anti-thyroglobulin antibodies (Anti-Tg Ab), or thyroid receptor antibodies (TRAb) may result in Graves’ disease and more rarely thyroid associated ophtalmopathy following radioiodine therapy for toxic multinodular goiter.

Aim: By presenting our case, we aimed to underline the risk of development of Graves’ Disease and thyroid ophtalmopathy following radioiodine therapy for toxic nodular goiter in patients with autoimmunity.

Case report: A 43 year old female with toxic multi-nodular goiter presented with symptoms of hyperthyroidism. Thyroid function test results revealed elevated free T3 (5,13 pg/ml, reference range:1,64-4,42), supressed TSH (<0,005 uIU/ml, reference range:0,27-4,20) and normal free T4 levels.  Anti-thyroglobulin antibodies (Anti-Tg Ab)  was slightly elevated (46,8IU/ml, reference range:0-35), but TPO Ab and TRAb were negative. Thyroid ultrasonography showed multipl heterogeneous isoechoic nodules with the largest one located in the right lobe inferoposteriorly, sized 26x16mm in diameter and in the left lob inferoposteriorly, sized 17x11.5 mm in diameter. Scintigraphic evaluation demonstrated hyperactive nodule in the inferior pole of right thyroid lobe and hypoactive nodules in the remaining gland.  Hypoactive nodules were diagnosed as benign with fine-needle aspiration biopsy. Anti-thyroid therapy with metimazole 10 mg/day was given for a short period. When euthyroidism was established, 12 mci radioiodine ablation therapy was performed. Four months after radioablation, she was presented with signs and symptoms of hyperthyroidism and thyroid ophtalmopathy. Biochemical analysis was surprising with TSH:0,01 uIU/ml, fT4:3,75 ng/dl, fT3:16,47IU/ml, TRAb:45 U/L, Anti-Tg Ab:403 IU/ml. She was complaining of puffy eyelids and blurred vision. Her scintigraphic evalution demonstrated bilateral hyperplasia and increased diffuse uptake in both lobes. Her ophtalmologic examination revealed periorbital edema, mild propitosis with Hertel measurements of 22 (right) and 23 (left), positive Kocher and Dalrymple sign.  Her ocular movements were normal. She had no decrease in visual acuity. Orbita MRI didn’t show any extra-ocular muscle hypertrophy. Anti-thyroid therapy with metimazole was re-started. As clinical activity score was <4, it is not decided to start steroid therapy for ophtalmopathy. 

Conclusion: The incidence of Graves’ hyperthyroidism and thyroid associated ophtalmopathy following radioiodine treatment for toxic nodular goiter is reported to be 1-5% and 0,07-0,7%, respectively. It is thought that release of thyroid antigens from destroyed follicular cells in susceptible individuals with pre-existing immunity, mounting an immune responce to these antigens (1-3).

 

Nothing to Disclose: FY, HMO, YA

13379 11.0000 MON-0473 A Graves' Disease and Thyroid Ophtalmopathy Following Radioiodine Therapy in Toxic Multinodular Goiter 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Syed Ali Imran*1, Utkarshini Anand2 and Remigius Agu2
1Dalhousie University, Halifax, NS, Canada, 2Dalhousie University

 

Background: Most cases of hypothyrioidism require lifelong thyroxine replacement therapy. Currently available forms of therapy i.e., oral and parenteral preparations face several limitations including pathophysiological (such as absorption defects); pharmacological (drug-drug/drug-food interaction) and patient-related (cost and painful injections) which can lead to therapeutic failure. Transdermal route is a non-invasive alternative that can be explored for delivery of thyroid replacement therapy; however, the availability of in-vitro skin models and associated costs is a challenge.  Strat-M® is a synthetic transdermal membrane that mimics properties of stratum corneum, a major barrier for transdermal absorption of drugs. Objectives: To test human skin substitute (Strat-M®) as an alternative to enable development of non-invasive transdermal delivery systems for T4. Method: Strat-M® (Millipore, Billerica, MA, USA) was used to analyze T4 transdermal permeation studies. Validation of Strat-M® was performed as per OECD Guideline 428 using caffeine as a reference test compound in NaviCyte® horizontal diffusion chambers (Warner Instruments, Hamden, CT, USA). Studies were conducted with and without transdermal absorption enhancers (PEG 600, polypropylene glycol, vitamin-E TPGS) over a 24h period to assess transdermal permeation of T4. Results: The maximal absorption rate (6.58 ± 0.86 μg/cm2-h; p<0.0001; n=6 ) and time to maximal rate (2.06 ± 0.92 h; n=6) for permeation of caffeine across Strat-M® was in line with values obtained in rat and human skin models. T4 permeation across Strat-M® was not observed over a 24h period (n=6). Experiments with various concentrations of absorption enhancers (30% PEG 600, 30% polypropylene glycol and 15% Vitamin E-TPGS) also resulted in no T4 transport across Strat-M® (n=6).  This was expected considering high molecular weight, lipophilicity and net negative charge of levothyroxine. Conclusion: In-house validation data obtained suggested Strat-M® as a viable alternative to human and animal skin models for transdermal permeation studies. Considering the properties of T4 at physiological pH, successful transport of the compound across the skin requires strategies that physically and reversibly compromise the stratum corneum (e.g. iontophoresis, sonophoresis, electroporation, microneedles) or help bypass the stratum corneum (e.g. subcutaneous thyroxine pellets).

 

Nothing to Disclose: SAI, UA, RA

15301 12.0000 MON-0474 A Human Skin Substitute (Strat-M®) As an Alternative for Testing Transdermal Delivery of Levothyroxine (T4) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Xiaomei Liu*1, Wei Qiang1, Xingjun Liu1, Lianye Liu1, Shu Liu1, Aibo Gao1, Shan Gao2 and Bingyin Shi3
1First Affiliated Hospital of Xi’an Jiaotong University Health Science Center, China, 2Shaanxi Provincial People's Hospital, China, 3The First Affiliated Hospital of Xi’an Jiaotong University School of Medicine, Xi'an, China

 

Background: A major problem with antithyroid drug (ATD) therapy in Graves’ disease (GD) is the high recurrence rate and lack of strong index for predicting remission. The objective of this study is to compare the effect of different discontinuation doses of methimazole (MMI) for predicting permanent remission. Methods: 311 patients with GD were prospectively enrolled in this study and prescribed MMI therapy until the doses were reduced to 5 mg qd. Then they were divided into 3 groups and group 1 was discontinued with 5 mg qd after about 5 months. On the basis drug therapy of group 1, group 2 was continuously reduced to 2.5 mg qd (5 mg qd→2.5 mg qd) and discontinued with 2.5 mg qd after about 5 months. Group 3 was continuously reduced to 2.5 mg qod on the basis therapy of group 2 (5 mg qd→2.5 mg qd→2.5 mg qod) and discontinued with 2.5 mg qod after about 5 months. The enrolled patients were followed for 18-96 months after drug withdrawal. TSH and other factors associated with recurrence were analyzed. Results: The remission rate of 2.5 mg qod group is significantly higher than that of the other two groups (2.5 mg qod vs 2.5 mg qd, p=0.001; 2.5 mg qod vs 5 mg qd, p=0.032). Cox regression shows that the hazard ratio for recurrence of TSH≤2.0μIU/mL is 2.784 times greater than group of TSH>2.0μIU/mL. Conclusion: The discontinuation drug dose of 2.5 mg qod can bring a more favorable long-term remission in patients with GD, and a high or high normal TSH level at drug withdrawal is another favorable index for predicting permanent remission.

 

Nothing to Disclose: XL, WQ, XL, LL, SL, AG, SG, BS

12084 13.0000 MON-0475 A Minimum Dosage of Methimazole at Discontinuation Is a Strong Index for Predicting Remission of Graves' Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Aya Yoshihara*, Kenzaburo Oda, Yasuyo Ando, Mariko Sue, Sinji Ujiie, Hiroyoshi Ohsuka, Toshisuke Morita and Naoki Hiroi
Toho University School of Medicine, Tokyo, Japan

 

Introduction: Measurements of TSH and free thyroxine(FT4) and triiodothyronine(FT3) are widely used evaluation of thyroid function. Chemiluminescent immunoassay methods are often used measurements of these hormones. However, some serum samples will exhibit any specific or nonspecific binding with assay reagents that interfere with the measurement of these hormones. The presence of such interferences results in abnormal concentrations of these hormones inconsistent with the patient’s thyroid state. Circulating thyroid hormone autoantibodies are an important class of interference factor and can bind to hormone tracers used in various immunoassays.    

Clinical Case: Our patient, a 65-year-old male, was followed up for latent hypothyroidism. When serum TSH levels were elevated to more than 10 μU/ml, he started to take levothyroxine 50 μg per day. Serum TSH levels were consistently within the reference ranges for few years. Serum TSH levels were markedly elevated (63.62 μIU/ml, n<4.12 μIU/ml) three years after levothyroxine administration, whereas FT3 and FT4 levels weren’t changed and he didn’t have any symptoms. Thereafter, TSH levels were persistently high (110-180μIU/ml) inconsistent with clinical state of the patient. We considered that abnormality of TSH levels could be the problem of assays. Serum TSH was usually determined with ECLIA in our hospital. Then, serum concentrations of TSH were determined by other chemiluminescent immunoassay methods, CLEIA and EIA. Serum TSH levels were 111 μIU/ml by ECLIA, but 5.04 μIU/ml by CLEIA and 43.09 μIU/ml by EIA. When serum immunoglobulins were removed by precipitation with PEG, recovery rates of  serum TSH from control was 51% but sample from the patient was 11%. These data suggested that polymer protein interferences were generated in serum of the patient. Heterophile antibodies are known to interfere in a wide spectrum of immunoassays. We identified that human anti-mouse antibodies (HAMA) which is best-known heterophile antibody was not exist in serum of the patient. Then, Gel filtration experiments indicated autoantibody against TSH bind to TSH in the serum of the patient.       

Conclusion: It has not been exactly known whether the autoantibodies against TSH to interfere in thyroid function test exist or not. We introduce some speculations about antibody interference in thyroid assays.

 

Nothing to Disclose: AY, KO, YA, MS, SU, HO, TM, NH

13384 14.0000 MON-0476 A The Case with Abnormally Elevation of TSH Levels Due to Autoantibody to the TSH 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Xiaomei Liu*1, Wei Qiang1, Xingjun Liu1, Lianye Liu1, Shu Liu1, Aibo Gao1, Shan Gao2 and Bingyin Shi3
1First Affiliated Hospital of Xi’an Jiaotong University Health Science Center, China, 2Shaanxi Provincial People's Hospital, China, 3The First Affiliated Hospital of Xi’an Jiaotong University School of Medicine, Xi'an, China

 

Background: Antithyroid drug (ATD) therapy for recurrent Graves' disease (GD) was largely replaced by radioiodine and surgery, due to the belief that they were more effective than ATD therapy which may cause recurrence again, while nearly no clinical studies on ATD for recurrent GD have explored or determined this drawback. The objective of this study was to investigate the efficiency and long-term prognosis of methimazole (MMI) treatment on patients with recurrent GD who relapsed after a regular ATD therapy. Methods: 128 recurrent GD patients who had finished a first regular ATD therapy were prospectively enrolled in this study, and they were prescribed MMI treatment with titration regimen. The patients were randomly divided into two groups when the drug doses were reduced to 2.5 mg qd with normal thyroid functions. Group 1 was discontinued with 2.5 mg qd after about 5 months. Group 2 was continuously reduced to 2.5 mg qod after 5 months and then discontinued with 2.5 mg qod after about further 5 months. The patients were followed for 48 months after drug withdrawal. Results: Of the enrolled 128 patients, 97 cases (75.78%) achieved permanent remission at the end of follow-up, with the recurrence of 31 cases (24.22%). The remission rate of group 2 was significantly higher than that of group 1 (p=0.024). Cox regression showed that the hazard ratio for recurrence was decreased with a high or high normal TSH level at drug withdrawal. Conclusion: A second course of ATD therapy can bring about an unexpected satisfying long-term remission with GD who relapsed after a first regular ATD therapy. The drug dose of 2.5mg qod and a high or high normal TSH level at drug withdrawal may increase the likelihood of permanent remission.

 

Nothing to Disclose: XL, WQ, XL, LL, SL, AG, SG, BS

12095 15.0000 MON-0477 A Antithyroid Drug Therapy Holds Good for Recurrent Graves' Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Enrico Papini*1, Teresa Rago2, Giovanni Gambelunghe3, Roberto Valcavi4, Giancarlo Bizzarri1, Paolo Vitti5, Pierpaolo De Feo6, Irene Misischi1, Enrico Di Stasio7 and Caludio Maurizio Pacella8
1Regina Apostolorum Hospital, Albano Laziale, Italy, 2University of Pisa, Italy, 3University of Perugia, Perugia, 4Arcispedale S Maria Nuova, Reggio Emilia, Italy, 5University of Pisa, Pisa, Italy, 6IMISEM, Perugia, Italy, 7Catholic University of Sacred Hearth, Rome, 8Regina Apostolorum Hospital, Albano Laziale

 

Background. Thermal ablation techniques are reported to significantly decrease thyroid nodule volume in several single-center short-term series. The present trial on ultrasound (US)-guided laser ablation (LAT) of solid thyroid nodules is addressed to assess long-term clinical efficacy, side-effects and variability of outcomes in different centers operating with the same LAT procedure.

Patients. Two hundred and one consecutive patients were randomly assigned to a single LAT session (Group 1) or follow-up (Group 2) at four thyroid referral centers. Entry criteria were: solid thyroid nodule with volume > 5 and < 18 ml, repeat benign cytological findings, normal thyroid function, no autoimmunity, no thyroid gland treatment.

Methods. Group 1: LAT was performed in a single session with two optical fibers, a 1.064 nm neodymium yttrium-aluminum garnet laser source, and an output power of 3 watts. Energy delivery was 3600 joules for nodules up to 13 ml and 7200 Joules for nodules larger than 13 ml. Volume and local symptoms changes were evaluated 1, 6, 12, 24 and 36 months after LAT. Side effects and tolerability of treatment were registered. Group 2: follow-up with no treatment.

Results. Group 1: Volume decrease after LAT was -49±32,7%, -59±41,7%, -60±51,1%, and -58±54,1% at 6, 12, 24 and 36 months, respectively (p <0.001 vs baseline).  LAT resulted in a nodule reduction > 50% in 67,3% of cases (p<0.001). Pressure symptoms decreased from 31% to 5% of cases (p=0.002) and cosmetic signs from 74% to 12% of cases. The procedure was well tolerated in most (92%) of cases. One case of vocal cord paresis self-resolved in 2 weeks. No changes in thyroid function were observed. In Group 2 nodule volume increased at 36 months (25 +/-42 %; p = 0. 04) and local symptoms worsened not significantly.

Discussion. A single LAT treatment of solid thyroid nodules results in a significant volume reduction with improvement of local symptoms and signs. These effects are persistent on the long-term in absence of relevant side-effects or thyroid function changes.

 

Nothing to Disclose: EP, TR, GG, RV, GB, PV, PD, IM, ED, CMP

13387 16.0000 MON-0478 A Outcomes of Laser Treatment of Solid Thyroid Nodules Are Consistent in Different Centers and Independent from the Baseline Ultrasound Features 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Linette Rivera*1, Anthony Morrison2 and Sindhu Basavaiah Igala3
1USF, TAMPA, FL, 2USF Coll of Med, Tampa, FL, 3USF, Tampa, FL

 

Exogenous hyperthyroidism is the term used to describe ingestion of excessive amounts of thyroid hormone. When exogenous hyperthyroidism is due to surreptitious ingestion, it is termed thyrotoxicosis factitia. The symptoms in patients taking too much hormone are: weight loss, palpitations, anxiety, heat intolerance or tremors. The diagnosis of exogenous hyperthyroidism is based upon clinical manifestations, laboratory findings, and 24–hour radioiodine uptake. Usual laboratory findings are: Decreased TSH, decreased thyroglobulin, elevated free T4 and/or elevated total T3. Discontinuation or reduction in the dose of thyroid hormone is usually the only treatment needed. Thyrotoxicosis factitia has been seen in patients taking thyroid hormone to promote weight loss.

62 y.o. man, accompanied by his wife, presented to the Emergency Department (ED) with complaints of altered mental status, 101° fevers, tachycardia and malaise for the prior 2 days. Per his wife, he had been in his usual state of health and only has a history of hypertension. Denied illicit drug use. Physical exam was unremarkable except for altered mental status, tachycardia and hypotension. EKG showed sinus tachycardia; chest x–ray, MRI and CT of the head where unremarkable. Lumbar puncture was negative. Labs: CBC/CMP where unremarkable, Cortisol 16.8 UG/DL, TSH 0.099 UIU/ML, FT4 0.99 NG/DL, FT3 20.45 PG/ML, TT4 6.94 UG/DL, TT3 5.99 NG/ML, thyroglobulin 1.34 NG/ML and antibody of q3.0 IU/ML. In the ED, he was treated with aggressive IV fluids and antibiotics and he was also started on Hydrocortisone, Esmolol drip and PTU. Patient was seen by endocrinology and PTU switched to Methimazole. After 2 days, the patient became oriented and confirmed he had been taking thyroid hormone in an effort to lose weight. He had been taking a “thyroid booster” called Thyroid PX for approximately 4 months. Repeat labs prior to discharge: TFTs: TSH 0.07 UIU/ML, FT3 3.15 PG/ML and FT4 0.66 NG/DL. Patient improved, fever and hypotension had resolved. Methimazole and antibiotics where stopped, steroids quickly tapered and he was asked to follow up with endocrinology. The patient was diagnosed with Thyrotoxicosis factitia caused by taking too much thyroid medication.

Thyroid PX is a dietary supplement for "thyroid support" which has Iodine and 3,5–Diiodotyrosine in each capsule. 3,5–Diiodotyrosine is a precursor of thyroid hormone which increases conversion of T4 to T3. It also contains Selenium, a cofactor for 5’–deiodinase, the enzyme that converts T4 to T3. Thyroid hormone should not be used to speed weight loss in patients who do not have a thyroid condition since it may cause serious life–threatening side effects. There are multiple dietary supplements available that claim to benefit thyroid levels but we recommend caution and to talk to your doctor or specialist before starting any new medications which could interfere with your current ones.

 

Nothing to Disclose: LR, AM, SBI

13457 17.0000 MON-0479 A Dangerous Weight Loss: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Duan Lian*
Department of Endocrinology, The Second Affiliated Hospital, Third Military Medical University,Chongqing,China, Chongqing, China

 

Background: Glucocorticoids are administered in moderate and severe cases of subacute thyroiditis (SAT),providing markedly relief from fever and pain. To our knowlage, there have been no reports regarding the efficiency using short-term prednisone course to treat SAT. In our study, we used 30mg/d of prednisone as the initial dosage only one week and NSAIDs following up next week.We assessed the efficiency and safety of this treatment protocol.

Methods: This is a prospective, randomized, controlled, single-blind study.

(ClinicalTrials.gov ID：NCT01837433).We examined 28 patients with moderate and severe SAT who visited our thyroid clinic between August 2013 and January 2014. They were randomly divided into two groups. In experimental group, we used prednisone 30mg/d as the initial dosage one week and celecoxib 400mg in first day, and then 200mg bid in the remaining next week, total 2 weeks. In control group, the dosage of  prednisone was 30mg/d, and then tapered it by 5mg every one week from the second week, total 6 weeks. The primary outcome was efficiency of experimental group comparing with control group during 2 weeks. The secondary outcomes we observed were recurrence rate, hypothyroidism, adrenal insufficiency, glucose, blood pressure, bone metabolism, lipids and other side effects of prednisone. The relapse was defined as pain in their neck , high erythrocyte sedimentation rate(ESR) or C-reactive protein (CRP). After relapse, we used 20mg prednisone to treat it.

Results: According to preliminary datas,We observed change of ESR from>20mm/h to normal, and CRP<8mg/l, pain and goiter disappear after 2 weeks in experimental group. The recurrence rates were 21.4 %(3/14) and 14.3 %(2/14) in experimental group and control group, respectively. After six months, just a case of hypothyroidism was observed in experimental group. Adrenal crisis were not found in both groups. The change of glucose, blood pressure, bone metabolism, lipids and other side effects will be statistics in the future.

Conclusions: Our treatment protocol indicates efficiency and safety of moderate and severe SAT, preliminarily. Less adverse reactions will be observed, comparing with the guidelines recommend in the future.We speculate the recurrence rate, adrenal insufficiency, temporary and permanent hypothyroidism should not be significant difference in both groups.

 

Nothing to Disclose: DL

15836 18.0000 MON-0480 A An Efficiency and Safety of Short-Term Prednisone Treating to Moderate and Severe Subacute Thyroiditis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Joel R L Ehrenkranz*1, Charles H Emerson2, Theodure Espiritu3, Randall Polson3 and Salvatore Benvenga4
1Intermountain Healthcare, Murray, UT, 2Univ of MA Med Sch, Sanibel, FL, 3University of Utah, Salt Lake City, UT, 4University of Messina, Messina, Italy

 

Thyroid disease is very common and TSH measurement is the initial and key test for diagnosing and monitoring thyroid dysfunction.  Clinical TSH assays currently available use sophisticated and expensive instrumentation that limits access to laboratory testing for thyroid disease.   Additionally, the analysis of thyroid function tests can be complex and erroneous results interpretation is not uncommon.  Consequently the correct diagnosis and management of thyroid disease is often not performed in resource-limited environments.

   We have developed a disposable quantitative self-performing immunochromatographic TSH assay and inexpensive smartphone-based point-of-care assay reader.  This technology uses 30 microliters of capillary blood, can be performed at the point of care, and has a turn-around time from specimen collection to results reporting of 16 minutes.  Each individual TSH assay incorporates a two-point calibration curve, has an analytic sensitivity of 0.1 mIU/L, and can measure TSH in the range of 0.1< to >30.0 mIU/L

   We have also developed a rules-based decision support algorithm for interpreting TSH test results.  This algorithm uses patient data, including age, weight, thyroid disease history, symptoms, and reproductive and cardiac status, to interpret TSH test results and provide diagnostic and treatment recommendations.  The algorithm can be programmed as an application (“app”) on a smartphone.  By interfacing the smartphone-based point-of-care TSH immunoassay with the TSH decision support algorithm app, a smartphone can provide comprehensive point-of-care thyroid disease management

   Smartphone-based point-of-care thyroid disease management is able to screen for congenital hypothyroidism, provide an indirect index of a population’s iodine intake, diagnose primary hypothyroidism, identify patients with suppressed TSH levels, and monitor the treatment of thyroid disease.   This low-cost and easy to use mobile technology increases the efficiency of diagnosing and treating thyroid disorders and provides thyroid diagnostic testing and disease management for patients and populations lacking access  to clinical laboratory services or endocrine expertise.

 

Nothing to Disclose: JRLE, CHE, TE, RP, SB

11884 19.0000 MON-0481 A Smartphone-Based Thyroid Disease Management 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Cherng Jye Seow*, Pei Shan Yeo, Wen Yang Benjamin Ho, Kok Seng Melvin Lee, Dao Ming Gerard Lim, Kar Mun Eu and Seng Kiong Tan
Tan Tock Seng Hospital, Singapore, Singapore

 

Introduction: Medullary thyroid cancer (MTC), when metastatic, has a very poor prognosis. Multikinase inhibitors have shown great promise in increasing progress free survival compared to placebo. We report a patient with metastatic MTC whose disease remained stable 9 months after initiation of sorafenib.

Case Report: A 53 years old Chinese lady with no significant history of note presented with a thyroid nodule of 2 weeks duration. There was no family history of thyroid malignancies or any previous head and neck irradiation. Clinically she was euthyroid. Physical examination: a hard, irregularly shaped and non tender left thyroid nodule with cervical lymphadenopathy. Ultrasound of the thyroid gland: 2.1x1.3x1.5cm solid nodule with coarse calcifications and multiple enlarged lymph nodes with irregular margins. Fine needle aspiration cytology of the thyroid nodule: malignant epithelial cells in discohesive clusters staining positive for calcitonin, pCEA, chromogranin, synaptophysin and TTF-1. Imaging of the thorax: multiple pulmonary nodules suspicious for metastases. Further tests: adjusted calcium 2.49 mmol/L (RI: 2.15-2.58); PTH 5.3 pmol/L (RI: 0.8-6.8); serum calcitonin 669.8 ng/L (RI: 0-10); CEA 759 ug/L (RI: 0-5); 24 hour urinary metanephrines and catecholamines: normal; RET mutation screen: negative. She had total thyroidectomy and radical neck dissection. Post operatively, calcitonin reduced to 193.7 ng/L but doubled to 366.9 ng/L in less than 6 months. Imaging studies showed recurrence of cervical lymphadenopathy, increase in pulmonary metastases and malignant infiltration of the greater omentum and transverse mesocolon. Sorafenib 200mg twice daily was started with rapid reduction of calcitonin levels to 150 ng/L within 1 month. Imaging studies 2 months later showed significant regression of lymphadenopathy and lung metastases. It is 9 months post initiation of sorafenib and calcitonin and CEA levels remained stable at 150ng/L and 50 ug/L respectively. However, she developed complications of hypertension and maculopapular rash. Other adverse events including electrolyte abnormalities and gastrointestinal complications were fortunately not experienced.

Discussion: Mutations in the RET proto-oncogene and vascular endothelial growth factor receptor (VEGFR) activity are critical in the pathogenesis of MTC. Sorafenib, a multikinase inhibitor targeting RET and VEGFR, has been investigated in phase II trials with moderate response rates, but have not advanced into phase III trials. Results on this patient have been promising thus far. Hypertension is a known association and postulated to be secondary to impaired angiogenesis leading to a decrease in the density of microvessels and endothelial dysfunction with a decrease in nitric oxide production and an increase in oxidative stress. Patients should be instructed to monitor their blood pressure regularly.

 

Nothing to Disclose: CJS, PSY, WYBH, KSML, DMGL, KME, SKT

13514 20.0000 MON-0482 A Sorafenib in the Management of Metastatic Medullary Thyroid Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Lara Paraskos*1, Violet Lagari2 and Brian Won-Sik Kim3
1University of Miami, Coral Gables, FL, 2University of Miami School of Medicine, 3University of Miami, Miami, FL

 

Graves Orbitopathy is a result of stimulation of the thyrotropin receptors located in the retro-orbital fibroblast and adipose tissue by thyrotropin receptor antibodies (TRAb) leading to muscle swelling and increased orbital pressure.  Administration of radioactive iodine to patients with a thyroid transiently increases TRAb levels, with or without Graves’ disease.  Therefore, iodine may not always be appropriate in Grave’s patients with orbitopathy depending on severity and smoking status.  However, in patients post thyroidectomy for Graves’, treatment with I-131 has been shown to be safe an effective and resulting in a significant reduction of TRAb levels over time. 

A 39 year old female was referred for hyperthyroidism. After complaining of weight loss and irregular, labs confirmed a low TSH of <0.01 µIU/mL (0.5 - 4.70 µIU/mL) with an elevated Free T4 of 4.41 ng/L (0.8-1.8 ng/L). She also had a TPO antibody of IU/mL units (<9 IU/mL) and thyroid stimulating immunoglobulins of 210% (<122%).  She denied any recent URI, neck pain or eye symptoms. Nuclear Medicine Iodine Uptake and Scan showed a 79% uptake at 24 hours and a photopenic area in the right thyroid.  This confirmed a diagnosis of Grave’s Disease without evidence on history or physical of orbitopathy.  The patient was started on methimazole 20 mg daily with improvement in symptoms and TSH.  Thyroid ultrasound described two nodules, 1.1x1.6x1.4cm and 1.6x2x1cm.  Fine Needle Aspiration of the thyroid nodules was performed and pathology was Bethesda VI.  Total thyroidectomy confirmed a 2 cm papillary thyroid cancer, diffuse sclerosing variant with follicular and tall cell features, extrathyroidal extension and extensive lymphovascualar invasion.  Two subcentimeter satellite lesions were present.  Thyroglobulin post-surgery was 2.59 ng/mL (</= 60ng/mL) with negative antibodies.  She received 199mCi of I-131 after withdrawal from thyroid hormone andher thyroglobulin became undetectable. Twomonths after  iodine therapy, she complained of excessive tearing, pain, redness and bulging of her eyes bilaterally.  On physical exam, she exhibited severe conjunctival injection without visual disturbances.    The patient was referred to ophthalmology, ruling out lacrimal duct obstruction and confirming a diagnosis of Graves’ Orbitopathy.  She is being treated with selenium with minimal improvement.

Few case reports describe the development of thyroid eye disease after total thyroidectomy and I-131 for thyroid cancer.  Our patient who had Grave’s disease with no clinical or subjective evidence of orbitopathy prior to surgery and I-131, developing fulminant Grave’s oribitopathy following I-131 ablation  The proposed mechanism is remnant thyroid tissue was present after surgery as evidenced by an elevated thyroglobulin. Following administration of 199 mCiI-131, a transient increase in TRAb levels led to the development of eye disease.

 

Nothing to Disclose: LP, VL, BWSK

13787 21.0000 MON-0483 A An Interesting Case of Graves' Orbitopathy after Total Thyroidectomy and I-131 for Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Deepthi Rao*1, Bhavini Bhavsar2, George Hebdon3, Saleh Aldasouqi4, George Abela5 and Ved V Gossain6
1Michigan State University, Okemos, MI, 2Michigan State University, Portland, OR, 3Michigan State University, Haslette, MI, 4Michigan State University, East lansing, MI, 5Michigan State University, 6Michigan State Univ, East Lansing, MI

 

Introduction:

Subclinical hyperthyroidism (SCH), defined as a low TSH with normal free T4 and free T3, is a common condition with an estimated prevalence of about 1%. The course of SCH is variable and there is considerable variation in guidelines and practice patterns. We sought to determine the course and management of patients with SCH in an academic practice and to evaluate the effect of treatment vs. no treatment on left ventricular function.

Methods:

All patients with a diagnosis of SCH from 2003 to 2013 were identified from electronic medical records at Michigan State University. Data regarding demographics, co-morbid conditions, treatment modality were collected and the patients were followed longitudinally. The decision to treat or not treat SCH was made by individual physicians.

Results:

One hundred and six patients with SCH were identified of which 30 were men and 76 women. Mean age was 56.99 years (SD ±16.45). Mean follow up was 53.62 months (SD ±33.42). Twenty three (22%) patients were treated and 83 (78%) were not treated. Atrial Fibrillation (AF) was present on diagnosis in 10 patients of which 5 were untreated. Osteoporosis was present by history in 10 patients (8 untreated).

Of the 83 untreated patients, SCH resolved spontaneously in 42 (50.6%), remained persistent in 38 (45.8%) while 3 (3.6%) developed overt hyperthyroidism. None of the untreated patients developed AF on follow up. Of the 23 treated patients, 18 were treated with thionamide drugs and 5 underwent surgery.

Echocardiograms were obtained in 8 treated patients of which 3 demonstrated diastolic dysfunction and the rest were normal. Seventeen untreated patients had echocardiograms with systolic dysfunction in 2 and diastolic dysfunction in 2. Three of the 4 untreated patients with ventricular dysfunction had hypertension. There was no difference in the presence of diastolic (p=0.28) or systolic (p=1.0) dysfunction between the treated and untreated groups.

Discussion:

Only 3.6% of the untreated patients in our study developed overt hyperthyroidism. None of the untreated patients developed AF during the follow up period. Our study, although limited by small sample size suggests that most patients with SCH either revert to normal or remain persistently in SCH and demonstrates no difference in ventricular function between treated and untreated groups.

 

Nothing to Disclose: DR, BB, GH, SA, GA, VVG

16989 22.0000 MON-0484 A Course of Subclinical Hyperthyroidism in an Academic Center and Effect on Ventricular Function 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Yotsapon Thewjitcharoen*, Sirinate Krittiyawong, Siriwan Butadej, Soontaree Nakasatien and Thep Himathongkam
Theptarin Hospital, Bangkok, Thailand

 

Clinical Features and Outcome of Subacute Thyroiditis in Thai patients

Abstract

Background: Subacute thyroiditis (SAT) is a relatively rare condition which associated with pain and systemic symptoms. A few large studies have been reported to the clinical features and outcomes of SAT in Thai populations.

Objective: To evaluate the clinical characteristics and outcome of SAT patients who visited our thyroid clinic at Theptarin Hospital from 2007 through 2013.

Study Design: Descriptive retrospective study

Material and Methods: A retrospective review was conducted on medical records of SAT in Theptarin Hospital from January 2007 through December 2013. Clinical characteristics, laboratory findings, modes of treatment, and complications were retrieved.

Results: From January 2007 through December 2013, subacute thyroiditis had been diagnosed in 149 patients with peak occurrence of SAT in October and November.  Of the 115 patients who had complete follow-up data, the mean age was 43.8 ±10.8 years, 88.7% were women, and SAT had been preceded by upper respiratory tract infection in 68.7% of cases. Anti-thyroid peroxidase (Anti-TPO) antibodies were measured in 69 patients and results were positive in 16% of cases. Oral prednisolone with the initial dose of 10-60 mg/day (median daily starting dose at 30 mg/day) was given in 83 cases (72.2%) and was continued for a median duration of 49 days (range 6-194 days). Recurrence of SAT during tapering of oral prednisolone was observed in 12% of patients and late recurrence of SAT resulted in steroid readministration in 13% of patients. Transient and permanent hypothyroidism developed in 6.1% and 8.7% of patients respectively. Interestingly, we observed the appearance of overt autoimmune thyroid disease (AITD) following SAT in 3 cases: one case of Graves’ disease occurring 2 months after the onset of SAT and 2 cases of Hashimoto’s thyroiditis following SAT at 2 months and 3 months.

Conclusions: Subacute thyroiditis in Thai patients showed a significant seasonal cluster in October and November months and recurrence of SAT were common in the course of steroid treatment. Furthermore, the development of AITD following SAT could occur in some patients after the resolution of SAT. Therefore, attentive follow-up of SAT patients is required during treatment and long-term surveillance to detect thyroid dysfunction.

 

Nothing to Disclose: YT, SK, SB, SN, TH

11478 23.0000 MON-0485 A Clinical Features and Outcome of Subacute Thyroiditis in Thai Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Lorinne Rutkowski*1, Stephen G Rosen1 and Paul Kinniry2
1Pennsylvania Hospital, Philadelphia, PA, 2Pennsylvania Hospial, Philadelphia, PA

 

Amiodarone-induced thyrotoxicosis (AIT) rarely presents as thyroid storm.   A 60-year-old man presented with a history of hypertension, atrial fibrillation, and congestive heart failure that were treated with aspirin, amiodarone, lisinopril, and furosemide.  He was admitted with a two-day history of worsening dyspnea on exertion after furosemide discontinuation.  He reported a 15-pound weight loss with decreased appetite, tachycardia, palpitations, and nausea.  Physical examination was significant for an irregular heart rate of 117 beats/min, blood pressure of 120/74 mm Hg, and fever to 101.6°F in addition to bibasilar rales, elevated jugular venous pressure, and altered mental status.  Initial laboratory testing showed elevated serum troponin and NT-proBNP levels.  After admission, he rapidly decompensated into atrial fibrillation with rapid ventricular response as well as hypercapnic respiratory insufficiency requiring non-invasive ventilation.  He was placed on a heparin drip for a non-ST segment elevated myocardial infarction.  His serum levels of total T4, free T4, total T3 and TSH were >24.8 mcg/dL (normal range 4.5-11.7 mcg/dL), >7.76 ng/dL (normal range 0.93-1.70 ng/dL), 2.2 ng/mL (normal range 0.8-2.0 ng/mL) and <0.01 mU/L (normal range 0.27-4.20 mU/L), respectively.  Based on Burch and Wartofsky’s scoring criteria, he was “highly likely” to have thyroid storm (1).  He was started on dexamethasone and propylthiouracil; his dose of propranolol was increased. A Tc-99 thyroid scan revealed no radiotracer uptake in the thyroid bed, consistent with AIT type 2.  Thyroid receptor antibodies were negative.  Within one day of treatment, bipap was tapered; he spontaneously converted back into normal sinus rhythm.  Amiodarone was discontinued.  Four days after initiation of treatment, his serum free T4 concentration decreased to 5.21 ng/dL and his serum T3 level returned into the normal range.  He underwent cardiac catheterization with stent placement.  He was discharged on methimazole, dexamethasone, and propranolol in good condition.  Whereas amiodarone is an effective treatment for atrial fibrillation, AIT can cause cardiac decompensation.   Measurement of serum thyroid hormone and TSH levels on a regular basis is crucial to prevent atrial fibrillation with rapid ventricular response and pulmonary edema during amiodarone treatment.

 

Nothing to Disclose: LR, SGR, PK

13834 24.0000 MON-0486 A Amiodarone-Induced Thyroid Storm Presenting As Congestive Heart Failure 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Yasuo Mashio*1, Noriko Senshu1, Hiroyuki Ikawa2, Mutsuo Beniko2 and Akemi Ikota3
1Kyosai Clinic, Sapporo Kosei Hospital, Sapporo, Japan, 2Sapporo Kosei Hospital, 3Kin-ikyo Chuo Hospital, Sapporo, Japan

 

Introduction: In many areas of the world, patients with Graves’ hyperthyroidism are initially treated with methimazole (MMI), however, MMI has many adverse effects and some are occasionally critical. We compared the two regimens, potassium iodide (KI) or MMI, for the initial control of thyrotoxicosis in the patients with Graves’ hyperthyroidism, who have mild thyrotoxicosis. Moreover, the long term prognosis in the patients treated with KI was investigated.  Patients and methods: Forty-five Japanese patients with newly diagnosed Graves’ hyperthyroidism, who had mild thyrotoxicosis, were treated with 50-100 mg of KI (group I), and 56 patients were treated with 15mg of MMI (group M). Serum FT4 levels before treatment were 2.9 ± 1.0 ng/dl in group I, and 3.4 ± 0.8 ng/dl in group M. TRAb(CT) levels were 37.1 ± 20.5 % in group I and 38.8 ± 22.5 % in group M, respectively. There were no differences in the initial data between the two groups.  Results: 1) After 3, 6, and 12 weeks of treatment, normal FT4 was observed in 40%, 76%, and 84% of patients in group I, and in 16%, 57%, and 91% of patients in group M, respectively. The mean time required to become euthyroid was 3.9 ± 2.3 weeks in group I, and 6.2 ± 3.0 weeks in group M. The difference was statistically significant (p<0.001). 2) After 2-7 months, serum FT4 increased again in 9 cases in group I, these patients were added 5-15mg of MMI, but other 36 cases (80%) remained euthyroid after 31 ± 12 months. 3) KI doses was gradually reduced and stopped in 21 patients after 18±8 months. In 18 cases of these patients, euthyroid condition was maintained over 1 year (23 ± 9 months), recurrence was observed in only 3 cases. 4) Most patients with their serum FT4 below 3.5 ng/dl before treatment could controlled by KI alone. 5) The TRAb positive ratios in 36 patients who remained euthyroid with KI alone in group I, were 94% before treatment, 78% after 1 year, and 64% after 2 years. In group M, those were 92%, 72%, and 66%, respectively.  Conclusions: 1) In the patients with mild thyrotoxicosis, KI therapy normalized their thyroid function more rapidly than MMI therapy. 2) Complete remission or longstanding euthyroid state was obtained with KI alone in many patients with mild Graves’ disease. 3) Considering the adverse effects of MMI, KI therapy may become one of the treatment methods in the patients with Graves’ hyperthyroidism.

 

Nothing to Disclose: YM, NS, HI, MB, AI

12545 25.0000 MON-0487 A Treatment with Potassium Iodide for Graves' Hyperthyroidism; Comparison with Methimazole Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Xiaochun Teng*1, Ting Jin1, Gregory A Brent2, An-hua Wu3, Weiping Teng4 and Zhongyan Shan5
1Institute of Endocrinology, Shenyang, China, 2Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, Tarzana, CA, 3Department of Neurosurgery, Shenyang, China, 4The Endocrine Institute, Shenyang, China, 5Institute of Endocrinology, China

 

The classic form of Resistance to thyroid hormone (RTH) is due to the mutations in the β-isoform of the thyroid hormone receptor (TRβ). RTH patients display inappropriate secretion of thyrotropin (TSH) from the anterior pituitary, despite elevated levels of thyroxine and triiodothyronine[1]. Thyrotropin-secreting adenomas (TSHomas) are presumed to represent a clonal expansion of a mutated cell that overexpresses TSH[2]. Although it has been demonstrated that mice with an RTH-associated TRβ gene knock-in mutation spontaneously develop TSHomas[3], no patient as yet has been reported to have both a TSHoma and RTH.

A 12-year-old girl who presented with goiter, tachycardia and inappropriately elevatedTSH levels was referred for evaluation. She was previously diagnosed as hyperthyroidism and treated with thiamazole. On admission, her laboratory studies included: TSH 21.12 mIU/L (nl 0.35-4.94 mIU/L); FT3 14.25 pmol/L (nl 2.63-5.7 pmol/L); FT4 11.55 pmol/L (nl 9.01-19.05); serum α-SU 0.32 ng/ml (nl 0.22-0.39 ng/ml) and α/TSH molar ratio 0.015. Thyroid 123I uptake was 52.5% at 2h and 94.4% at 24h. Thyroid scintigram by 99mTcO4 showed diffuse distribution of radioactive iodine uptake. The thyroid gland was diffusely enlarged by thyroid ultrasound, with the size of 3.9 x 2.4 x 5.5 cm in the left lobe and 3.6 x 2.7 x 5.5 cm in the right lobe. A T3 suppression test, as established by Dr. Refetoff, was performed and showed TSH was suppressed from baseline 16.5 mIU/L to1.73 mIU/L (50ug T3) ; 0.74 mIU/L (100ug T3); 0.24 mIU/L (200ug T3), compared with the control from baseline 3.05 mIU/L to 0.08 mIU/L(50ug T3); 0.019 mIU/L(100ug T3); 0.017(200ug T3), supporting the diagnosis of RTH. A number of serum markers of thyroid hormone action, serum cholesterol, sex hormone binding globulin, creatine kinase, and ferritin, were tested and the results were consistent with peripheral resistance to thyroid hormone. Sequencing of the TRβ gene confirmed a mutation in the TRβ gene with a predicted P453T substitution in the patient, but not in her parents or sister. Pituitary magnetic resonance image revealed there was an adenoma (6 mm x 5 mm) in the left side of the pituitary, which did not enhance. The patient underwent exploratory transsphenoidal microsurgery with the findings of an adenoma with a capsule and softer density than the surrounding tissue. Considering her age and the risk of hypopituitarism, a tissue sample was obtained for pathological analysis instead of removing the tumor completely. Histologically, the tumor showed positivity for TSH (+`++), ACTH (+`++),GH (++`+++),PRL (++`+++) and alpha- subunit negative. Although staining for multiple pituitary hormones suggests hyperplasia, only excess secretion of TSH was shown, at a level significantly higher than usually seen in RTH.

Conclusion: This patient, with confirmed RTH, has a pituitary adenoma and evidence for excess TSH secretion, consistent with a TSHoma.

 

Nothing to Disclose: XT, TJ, GAB, AHW, WT, ZS

14186 26.0000 MON-0488 A A Girl with Resistance to Thyroid Hormone (P453T) and a Suspected Thyrotropin-Secreting Pituitary Microadenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Imali Sirisena* and Hamdee Yousef Attallah
Philadelphia VAMC, Philadelphia, PA

 

Background: Resistance to thyroid hormone (RTH) is a condition characterized by a decreased pituitary and tissue response to thyroid hormone. This results in high T4 and T3 levels with a normal TSH level.  Patients can manifest clinical symptoms of both hypo and hyperthyroidism, and it is often associated with tachycardia.  Although it is generally thought to be a benign condition, we report a case of a patient with thyroid hormone resistance and difficult to control re-entrant atrial flutter.

 Clinical case: A 55 year old male initially presented to our clinic with multinodular goiter and abnormal thyroid function tests. He had a long history of atrial fibrillation and cardiomyopathy since the age of 42. Of note, he also had hearing loss since childhood. He had markedly elevated T4 of 23.2 ug/dL and T3 of 2.39 ng/mL with a TSH of 1.46 mIU/L. Free T4 measurements were repeated with equilibrium dialysis and still found to be elevated at 5.9 ng/dL (0.8-1.7 ng/dl). Measurements of alpha subunit were normal at 0.72 ng/ml (0.09-0.76) and testing for human antimouse antibodies (HAMA) were negative. He had a 24 hour RAI uptake and scan which showed increased uptake of 56% with multiple cold nodules. Subsequent ultrasound showed multinodular goiter. He had an FNA of a 2 cm thyroid nodule that was benign.  He had genetic testing which showed heterozygous mutation in the TH receptor beta gene, c.1353dupT. No further thyroid treatment was initiated. Patient remained clinically euthyroid except for palpitations and episodes of atrial fibrillation and flutter. He has had two ablation procedures and is being treated with sotalol and coumadin. Despite this, he still gets episodes of re-entrant atrial flutter necessitating frequent ER visits. Furthermore, he has recently developed hematuria on Coumadin.

Conclusion: Thyroid hormone resistance has been associated with a slight increased risk of atrial fibrillation (1). While our patient initially had atrial fibrillation he went on to develop difficult to control re-entrant atrial flutter despite two ablative procedures and multiple medications. Our hypothesis is that his arrhythmias are secondary to over activation of the alpha-receptors in cardiac tissue. This implies that cardiac tissue is not as resistant to the effects of high levels of thyroid hormone as other tissues in the body. While thyroid hormone resistance is often considered a benign condition, this case illustrates that this condition can be associated with significant morbidity.

 

Nothing to Disclose: IS, HYA

14857 27.0000 MON-0489 A Thyroid Hormone Resistance Associated with Difficult to Control Atrial Arrhythmias 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Maria Inez Caser Franca*1, Ana Luiza Resende Galrão2, Rosalinda Yossie Asato Camargo3 and Eduardo K Tomimori4
1Dr. Dório Silva Public Hospital, Vitoria - E. Santo, Brazil, 2Federal University of São Paulo, 3Univeristy of Sao Paulo, Sao Paulo, Brazil, 4Medical Sciences University of Santa Casa of São Paulo, Brazil

 

Hashimoto’s thyroiditis (HT) is the most prevalent autoimmune thyroid disorder. The clinical disease may present with a variety of different manifestations ranging from a simple presence of thyroid autoantibodies to severe thyroid dysfunction. Regional lymph nodes may be involved in the pathogenesis of HT. The extensive use of more refined ultrasound equipment has made it possible to describe the sonographic pattern of cervical lymph node in HT, and to differentiate neck lateral lymph node metastasis from hyperplastic lymph nodes. However, the presence of central compartment lymph node is a cause for concern regarding the risk of lymph node metastases. This study aims to identify the prevalence and clinical characteristics of reactional lymph nodes of HT in the central compartment. We studied 125 consecutive patients with HT (114 females and 11 males) with a median age of 42 years (range 20-80). The control group with no clinical, biochemical, and ultrasonographic evidence of thyroid desease consisted of 50 subjects (45 females and 5 males) with a median age of 40 years (range 20-80). We performed laboratory tests (TSH, antithyroperoxidase antibodies, antithyroglobulin antibodies) in order to evaluate the thyroid function, and presence of autoimmunity. All patients underwent ultrasound examination to evaluate thyroid volume, parenchymal echogenicity, and the number, morphology and topographic distribution of central compartment lymph nodes. The frequency of lymph nodes identified in the central compartment was significantly higher in the HT group (68%, 85/125) than in the control group (10%, 5/50) (p<0.001). The number of central compartment lymph node was also higher in the HT group than in the control group with median of the 2 per patient (0-6) versus 0 per patient (0-3), respectively (p<0,001), with significantly increased differences in left paratracheal region when compared to right paratracheal and prelaryngeal region,68% versus 6.4%, respectively ( p<0.001). In the HT group, the high number of central compartment lymph nodes was found in patients with increased thyroid volume (mean ± standard deviation: 2.83±1.85 mL lymph nodes/patient) as compared with patients with normal thyroid volume (1.77±1.39 mL lymph nodes/patient) (p<0.05). Furthermore, the central compartment lymph nodes was associated with positive antithyroperoxidase antibodies and markedly hypoechoic parenchyma (p<0.05). The frequency and number of lymph nodes per patient were similar when considering the age and sex of patients. An increased number of central compartment lymph nodes, especially in the left paratracheal region appears to be another characteristic sonographic finding of HT, and is associated with high levels of antithyroperoxidase antibodies, increased thyroid volume and markedly hypoechoic parenchyma.

 

Nothing to Disclose: MICF, ALRG, RYAC, EKT

15429 28.0000 MON-0490 A Prevalence and Clinical Characteristics of Central Compartment Lymph Nodes in Hashimoto's Thyroiditis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Maria Mercedes Pineyro*, Jimena Pereda, Pamela Schou, Karina De los Santos and Raul Pisabarro
Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay

 

Mature cystic teratoma (MCT) accounts for approximately 20% of ovarian tumors. Malignant transformation is uncommon with an estimated risk of 0.17–2%. When malignant transformation occurs, 80% of times a squamous cell carcinoma is found. Less common malignancies include adenocarcinomas, carcinoid tumors and thyroid carcinomas. Struma ovarii is a monodermal ovarian teratoma, diagnosed when thyroid tissue constitutes more than 50% of specimen. Struma ovarii represents 2% of MTC. Histological characteristics of thyroid carcinoma are found in approximately 5-35% of struma ovarii. There have been few reported cases of papillary thyroid microcarcinoma (PMC) in struma ovarii. Differentiated thyroid carcinoma (DTC) arising from a MCT is even more exceptional, with an estimated incidence of 0.1-0.2%. We present the case of a patient with a PMC arising within a mature cystic ovarian teratoma.

Clinical Case: A 34-year-old female presented with abdominal pain and a left pelvic mass. Family history is positive for mother diagnosed with DTC. Ultrasonography revealed a cystic ovarian mass measuring 99x72 mm. During laparotomy left annessectomy was performed, and a right ovarian cyst was discovered and excised. Histopathology study of the left ovary revealed an 80x55x50 mm-MCT, as well as a 4-mm single papillary thyroid carcinoma. Moreover, a 55x44x35 mm-MCT in the right ovary was found. Thyroid function tests were normal. Thyroid ultrasound showed a 4x4x5 mm-right hypoechoic nodule, with irregular margins, microcalcifications and peripheral vascularity. Fine needle aspiration (FNA) yielded insufficient material. Repeat FNA is pending.

Discussion: DTC have been reported arising within struma ovarii.  After surgical resection, subsequent therapy depends on extent of primary lesion and disease stratification.  Metastases can happen in approximately 20% of patients.  Further therapy may include total thyroidectomy and radioiodine ablation. This allows for thyroglobulin monitoring, as well as radioiodine treatment if needed. PMC have been seldom reported arising within sruma ovarii. In these cases, after surgical resection of ovarian tumor no further therapy involving the thyroid was done.  PMC arising from the thyroid and confined to it have an almost 100% survival rate at 30 years, with current guidelines favoring partial thyroidectomy without further radioiodine ablation. To our knowledge, this is the first reported case of PMC arising from mature ovarian teratoma, without struma ovarii. There is scant information on the natural history or prognosis of PMC arising within ovarian tumors. Consequently, there is no consensus on surgical approach and postoperative management of this entity.

In conclusion, PMC can also arise within mature ovarian teratomas. Although a favorable prognosis is anticipated, there is limited information about the history or prognosis of PMC within the ovary.

 

Nothing to Disclose: MMP, JP, PS, KD, RP

14877 29.0000 MON-0491 A Papillary Thyroid Microcarcinoma Arising within a Mature Ovarian Teratoma: Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Anna Ansaloni1, Chiara Diazzi1, Daniele Santi1, Giulia Brigante1, Francesa Ferrara2, Cesare Carani1, Antonello Pietrangelo2, Manuela Simoni1 and Vincenzo Rochira*1
1Chair and Unit of Endocrinology & Metabolism, Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy, 2“Mario Coppo” Liver Research Center, University Hospital of Modena, Modena, Italy

 

Background: Thyroid function is commonly impaired in beta-thalassemic patients with an estimated prevalence of hypothyroidism of 9-11%. According to literature, iron overload is the main cause of tissue damage involving both thyroid and pituitary gland, thus leading to primary or secondary hypothyroidism, respectively. However, thyroid morphology has been rarely investigated in adults. The aim of this study is to evaluate thyroid volume (TV) and thyroid morphology in beta-thalassemic adult patients compared to healthy controls.

Subjects and Methods: We performed a cross-sectional, controlled study in 19 beta-thalassemic adult patients (8 males, 11 females) (36.36+4.26 years) and 120 healthy volunteers (28 males, 92 females) (38.1+4.9 years). All subjects underwent thyroid ultrasonography performed by the same operator. TV was calculated as the sum of the volume of the two lobes, each estimated by standardized formula: length x width x depth x 0.479. Ultrasound evaluation included the presence/absence of hypoechogenicity and echotexture heterogeneity, and the presence/absence of nodules.

Results: TV was significantly lower in beta-thalassemic patients (5.37+1.35 mL) than in the control group (8.45+2.81 mL) (p<0.001) independently from their thyroid function (euthyroidism or hypothyroidism). The prevalence of diffuse echotexture heterogeneity and hypoechogenicity of the thyroid was significantly higher in thalassemic patients (92.5%) than in the control group (42.4%) (p<0.001). Thyroid antibodies were negative in all thalaseemic patients. Thyroid nodules were found in 6 thalassemic patients (31.5%) and in 44 volunteers (36.7%) (p=0.674).

Discussion and Conclusion: In adult beta-thalassemic patients TV was smaller than in healthy subjects even when patients with a normal thyroid function were considered. Moreover the prevalence of hypoechogenicity and echotexture heterogeneity, without a confirmed diagnosis of autoimmune thyroiditis, was greater in beta-thalassemic patients than in controls. These results suggest that thyroid is hypoplasic in patients with thalassemia probably due to a primary thyroid damage and tissue alterations caused by iron infiltrates. Moreover, iron infiltrates confers to the thyroid gland an US pattern which is similar to that of autoimmune chronic thyroiditis. Finally, the risk of developing thyroid nodules seems not to be increased in beta-thalassemic patients with respect to controls.

 

Nothing to Disclose: AA, CD, DS, GB, FF, CC, AP, MS, VR

16632 30.0000 MON-0492 A Thyroid Volume in Adult Beta-Thalassemic Patients Is Smaller THAN in Controls 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Eider Pascual1, Gala Gutierrez1, Francisco Guillén-Grima1, Belén Perez Pevida1, Patricia Andrada1, Javier Larrache1, Javier Escalada2, Javier Salvador3 and Juan C Galofre*1
1Clínica Universidad de Navarra, University of Navarra, Pamplona, Spain, 2Clínica Universidad de Navarra. Navarra Institute for Health Research (IdiSNA)., Pamplona, Spain, 3Clínica Universitaria de Navarra. Universidad de Navarra, Pamplona, Spain

 

The relationship between metformin, thyroid function, and thyroid volume has been of interest to many investigators. A number of studies have consistently reported a TSH-lowering effect of metformin in hypothyroid patients. In addition, some previous reports found that metformin, alone or in combination with levothyroxine, shrank thyroid nodules in diabetic individuals with insulin resistance. Furthermore, other authors showed an anti-goitrogenic effect of metformin on subjects with type 2 diabetes (T2DM). Unfortunately, literature on the association between T2DM and thyroid volume is sparse.

We designed a two-group retrospective study with euthyroid T2DM patients treated with metformin (Group A) or with other anti-diabetes agents (Group B). Examined were basal TSH (mU/mL), HbA1c (%), BMI (kg/m2), and thyroid nodule size (mm) assessed by sonography. The same examinations were repeated one year later. Exclusion criteria included the following conditions: type 1 diabetes, thyroid dysfunction, levothyroxine or antithyroid treatment, and corticoid therapy. Results from Groups A and B were compared using the Student’s t and the Mann-Whitney U tests.

A total of 63 nodules were analyzed. Group A included 31 nodules from 18 patients. Group B included 32 nodules from 15 patients. Groups A and B pre-TSH levels were 1.62± 1.19 and 2.06± 1.28, respectively; we found no statistically significant differences between them (p=0.164). Groups A and B post-TSH levels were 1.34± 0.87 and 1.99± 1.33, respectively; we observed a statistically significant difference between them (p=0.003). Groups A and B basal nodules mean size were 17.31± 9.97 and 12.45± 8.12, respectively. After one year of treatment, Groups A and B nodules mean size were 17.97± 10.31 and 12.90±7.92, respectively; we did not observe a statistically significant difference between them (p=0.961). We observed no statistically significant difference between Groups A and B in pre- and post-BMI, HbA1c, T2DM duration (data not shown). No patient in Group B was treated with glitazones.

Conclusions: Thyroid nodule size in euthyroid patients with T2DM diabetes remained unchanged following treatment with metformin for one year despite changes in TSH levels.

 

Nothing to Disclose: EP, GG, FG, BP, PA, JL, JE, JS, JCG

13611 31.0000 MON-0493 A Metformin Has No Shrinkage Effect on Euthyroid Nodules 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Elys M Perez*, Tanya Weston, Gary Greene and Stephen G Rosen
Pennsylvania Hospital, Philadelphia, PA

 

Radioactive Iodine Excretion from the Lactating Breast.  Elys M. Perez, Tanya Weston, Gary Greene, and Stephen G. Rosen.  Pennsylvania Hospital and the University of Pennsylvania Health System. Philadelphia, PA 19107.

Lactating breast tissue absorbs large amounts of radioactive iodine via the increased expression of the sodium symporter. The American Thyroid Association recommends that breastfeeding mothers initiating 131I treatment for thyroid cancer wait at least six weeks for lactation to cease to minimize the radiation exposure to the breast and to eliminate infant exposure to radioactive iodine. However, it is not clear when to resume breastfeeding in women receiving diagnostic 123I whole body imaging after thyroidectomy.  A 31-year-old woman presented with hyperthyroidism that was diagnosed during the first trimester of pregnancy. She had clinical features of thyroid ophthalmopathy.  Thyroid ultrasound showed a top-normal sized thyroid gland with indeterminate nodularity in the right lower pole. A diagnosis of Graves’ disease was based on her physical examination plus elevated serum TSH receptor antibody concentration.  She was treated with PTU during the first trimester and methimazole during the second and third trimesters.  She was clinically euthyroid; serum levels of free T4 and free T3 were at the upper limit of normal.  She delivered a healthy boy at 39 weeks of gestation. After birth, she began breastfeeding while continuing methimazole.  One year later, she elected for total thyroidectomy to eliminate the potential fetal side effects from antithyroid medications.  Pathological examination revealed papillary thyroid microcarcinoma, tall cell variant, 1cm in size, with 2-3 foci of intra-lymphatic tumor on the right lobe all of which were confined to the thyroid gland. In addition, there was also a focus of papillary microcarcinoma, follicular variant, 2mm in size, confined to the thyroid gland.  A whole body 123I scan was ordered.  She stopped breastfeeding, but continued to pump milk to clear 123I.  Whole body scanning revealed uptake in the thyroid bed and both breasts.  Breast milk was positive for radioactivity until Day 4 after 123I administration.  Although the physical half-life of 123I is 13.13 hours, this radioisotope may persist for days despite breast pumping.  This case highlights the importance of proper counseling in the breastfeeding patient who requires diagnostic nuclear thyroid imaging.  We propose that breastfeeding be stopped prior to diagnostic imaging.  Women who wish to continue breastfeeding should be advised to pump milk for one week prior to resumption to eliminate any potential risk to the infant.

 

Nothing to Disclose: EMP, TW, GG, SGR

14961 32.0000 MON-0494 A Radioactive Iodine Excretion from the Lactating Breast 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Yeon Jin Jeon*, In Ah Jung, Shin Hee Kim, Won-Kyoung Cho, Jae-Wook Lee, Kyoung Soon Cho, So Hyun Park, Nak-Gyun Chung, Bin Cho and Byung-Kyu Suh
College of Medicine, The Catholic University of Korea, Seoul, Korea, Republic of (South)

 

Background: We evaluated 12months follow-up of thyroid function in patients who underwent hematopoietic stem cell transplantation (HSCT) during childhood and adolescents.

Methods: We studied 83 hematologic-malignancy patients (46 boys and 37 girls, acute lymphoblastic leukemia=25, acute myeloid leukemia=51, chronic myelogenous leukemia=7) who underwent HSCT between January 2006 and December 2011.

The mean age at HSCT was 9.78 ± 4.42 years. Thyroid function of the patients was evaluated before and 1, 3, 6, 9, 12 months after HSCT. The incidence and risk factors of overt hypothyroidism, subclinical hypothyroidism (SH) and euthyroid sick syndrome (ESS) were studied. The effect of conditioning regimen, graft-versus-host disease, use of steroid hormone or other clinical factors on thyroid dysfunction was investigated.

Results: forty-four patients (53.0%) had thyroid dysfunction during 12 months after HSCT.

Thyroid dysfunction developed in 14 (17.3%), 10 (12.0%), 14 (17.3%) and 21 (24.1%) patients at 1, 3, 6, 9 and 12 months after HSCT. The incidence according to duration increased significantly (P for trend 0.035). ESS developed in 8(9.9%), 5(6.9%), 3(3.7%), 3(3.7%) and 2(2.4%) patients at 1, 3, 6, 9 and 12 months after HSCT. The incidence according to duration increased significantly (P for trend 0.00015). SH developed in 2(2.5%), 2(2.4%), 13(16.0%), 13(15.9%) and 12(14.5%) patients at 1, 3, 6, 9 and 12 months after HSCT. The incidence according to duration increased significantly (P for trend 0.031). A total of 11 patients (13.3%) needed thyroid hormone replacement; 10 out of them had SH and one overt hypothyroidism. In univariate analysis, there was no significant risk factor of thyroid dysfunction at 12 months after HSCT. 

Conclusion: After HSCT during childhood and adolescence, a significant number of patients experience thyroid dysfunction including ESS and SH. Short-term and continuous follow-up for thyroid function after HSCT is important to provide timely and appropriate treatment.

 

Nothing to Disclose: YJJ, IAJ, SHK, WKC, JWL, KSC, SHP, NGC, BC, BKS

14492 33.0000 MON-0495 A Thyroid Dysfunction in Children after Hematopoietic Stell Cell Transplatation : Short Term Follow-up for 12 Months 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Yang Shen* and Dorothy Santos Martinez
UCLA, Los Angeles, CA

 

Background:

Psychosis can be a presenting symptom of thyrotoxicosis and in severe cases requires urgent admission to psychiatric ward. Rapid reduction of thyroid hormone is needed for patient in acute psychosis and hyperthyroidism. Iopanoic acid (IA) is an iodinated cholecystographic agent that inhibits deiodinase activity and reduces the conversion of T4 to T31. It has been demonstrated that IA rapidly reduces the T4 and T3 levels and therefore, iopanoic acid has been used as a pre-operative treatment of hyperthyroidism, or treatment for acute thyroid poisoning, thyrotoxicosis, amiodarone-induced hyperthyroidism or TSH-secretion tumors 2-6. 

Clinical Cases: we report three patients who were admitted to the UCLA Neuropsychiatric Hospital with suicidal or homicidal ideation. All three patients had suppressed TSH (TSH: < 0.02, normal range 0.3-4.7 mcIU/mL), elevated free T4 (1.8 – >7.0, normal range 0.8-1.6 ng/dL) and free T3 (746 – 1469, normal range 222-383 pg/dL) at the time of admission. Two of the three patients were found to have Graves’ disease and the other patient’s etiology was consistent with thyroiditis. One of the patients was treated with PTU for 3 months prior to the admission however did not adhere to the therapy; the remaining two patients had newly-diagnosed hyperthyroidism and had not yet been started with anti-thyroid medication. Iopanoic acid 500mg twice daily treatment was administrated, in addition to psychiatric treatment. Two of the patients were concurrently treated with thionamides (one with PTU, another with MMI). All patients had resolution of psychiatric crisis and reduction of thyroid hormone levels. After the treatment of iopanoic acid, all patients were treated with thionamides until they reached euthyroid state. No adverse events associated with Iopanoic acid were found.

Conclusion: Iopanoic acid is an effective and safe treatment option for patient in psychotic crisis with hyperthyroidism. Although IA is not widely available in the US, it can be obtained through compounding pharmacies.

 

Nothing to Disclose: YS, DSM

14985 34.0000 MON-0496 A Treating Psychiatric Crisis in Patients of Hyperthyroidism with Iopanoic Acid 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Helena Oosthuizen*1, Elsabe de de Kock2, Jaco J Jurgens3, Rudy Onia4, Hermanus Schoeman5 and Phillip Smuts4
1Pretoria East Hosp, Gauteng, Pretoria, South Africa, 2Retrasol, Pretoria, South Africa, 3Jürgens and Botha Inc, Krugersdorp, South Africa, 4Merck (Pty) Ltd South Africa, Johannesburg, South Africa, 5ClinStat, Pretoria, South Africa

 

Background: It can be seen from international literature that a significant amount of patients, fail to reach target TSH levels.  International guidelines exist on the management of hypothyroidism but this is not always adhered to.

Objectives: This observational study aimed to measure the efficacy of individually titrated doses of levothyroxine to achieve a euthyroid state.  The average daily dosage /kg body weight was a secondary objective of this study.

Methods: Patients with hypothyroidism, treatment naïve and insufficiently controlled, confirmed with a laboratory TSH value, were included in the study  Patients were followed-up every seven weeks until target TSH values were achieved. Total study duration was 28 weeks, patients reaching target before that, were regarded as end of study target achieved. TSH levels, levothyroxine absolute dose and  changes, compliance, concomitant medication used, weight and changes in typical disease symptoms were assessed at each visit.

Results: 290 evaluable patients were enrolled. Overall 221(76.2%) patients reached TSH target levels during the study.  The mean daily dosage per kg/body weight for all patients achieving a euthyroid state was 1.12 ug/kg (SD 0.54) and the different values for treatment naïve patients and pre-treated patients were 0.86 and 1.12 ug/kg respectively. The mean daily dosage was 88.8 ug/day (SD 43.2), the median daily dosage was 1.09 ug/day and 0.63 ug/day for naïve patients and 1.25 ug/day for pre-treated patients. The most frequently used dosages in treatment naïve patients were 50 and 100 ug, whilst in pre-treated patients it were 75 and 100 ug.  The 25 ug thyroxin dosage was used in 46.4 % of patients and the 12.5 ug dosage in 8.2 % of patients.  The mean daily dosage in female patients was 91.4 ug/day, compared to 99.0 ug/day in male patients. At the study end a total of 11.7% of patients were over-titrated. In this study 135 (46.6%) of patients reached control after 7 weeks of treatment initiation.

Conclusions: This study demonstrated a lower mean daily dosage/ kg bodyweight than what is recommended in current guidelines.  This study highlights that a high proportion (50%) of patients required the 25ug and 12.5 ug dosages for optimal titration.  The lower mean dosage may explain the lower % of patients that was over-titrated in our study compared to other studies.  A structured treatment plan not exceeding 7-week intervals can assist in reaching target TSH early on in treatment

 

Disclosure: HO: Speaker, Astra Zeneca, Principal Investigator, Merck & Co., Board Member, Novartis Pharmaceuticals, Speaker, Novo Nordisk, Investigator, Sanofi, Speaker, Abbott Laboratories. RO: Employee, Serono. PS: Employee, EMD Serono. Nothing to Disclose: EDD, JJJ, HS

15022 35.0000 MON-0497 A Structured Levothyroxine Dose Titration to Achieve Euthyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Hideyuki Iwayama*1, Laura C Sillers2, Alexandra M Dumitrescu3, Samuel Refetoff3 and José J. Alfaro Martínez4
1the University of Chicato, Chicago, IL, 2the University of Chicago, Chicago, IL, 3The University of Chicago, Chicago, IL, 4Complejo Hospitalario Universitario de Albacete, Albacete, Spain

 

Background: The significant elevation of TSH is usually diagnosed as hypothyroidism, but may appear in more rare entities such as TSH-producing pituitary tumors, resistance to thyroid hormone, resistance to TSH, or TSH falsely elevated due to heterophile antibodies. In addition, macromolecules formed between TSH and Immunoglobulin (Macro-TSH) can be the cause of isolated TSH elevation in clinical euthyroid patients.

Case: A 36-year-old woman showed high serum level of TSH 284mU/L (normal range: 0.4 – 3.6) but normal free T4 of 1.1 ng/dl (0.7–2.4) and T3 of 339 pg/dl (230–420) during pregnancy. Treatment with 100 μg L-T4 daily reduced her TSH to 53 mU/L. Her mother and sister had subclinical hypothyroidism. Her daughter and her recently born son were diagnosed as having neonatal hypothyroidism at 7 days of age based on TSH values of 78, and >100, respectively. The patient was asymptomatic and had no goiter. Three months postpartum and off L-T4, her TSH remained elevated at 218 mU/L. Total serum iodothyronine concentrations were within the normal range T4 8.7 μg/dl (5–12), T3 135 ng/dl (90–180), rT3 22.2 ng/dl (16–36), as was the free T4 index of 10.1 (6.0 – 10.5). Thyroperoxidase and thyroglobulin antibodies were borderline positive. No mutations were identified in the TSH receptor, THRB and DIO2 genes. Given these results, we searched for possible interference in the immunometric assay of TSH. Serial dilutions showed a good linear TSH recovery. However, the bioactivity of TSH measured by cAMP generated by CHO cells expressing the human TSH receptor, showed a 15 fold lower activity than authentic TSH. Gel filtration chromatography demonstrated a TSH peak fraction consistent with the molecular size of IgG. Gel filtration following acidification of the serum, moved the TSH fraction to its normal position, indicating the presence of TSH-IgG complex. Gel filtration chromatography and Protein A affinity chromatography with dot blotting analysis using specific antibodies to immunoglobulins indicated that TSH was associated mainly with IgG4. Serum TSH concentration was normal in the children following discontinuation of levothyroxine replacement at 3 years and 6 months of age, respectively, indicating that the IgG was transferred from the mother.

Conclusions: We report a case of macro-TSH, a rare entity that should be included in the differential diagnosis of elevated TSH without hypothyroidism. In such instances, the demonstration of Macro-TSH should be sought.

 

Nothing to Disclose: HI, LCS, AMD, SR, JJA

15064 36.0000 MON-0498 A Hyperthyrotropinemia in a Mother and Her Two Newborn Children Due to Macro-TSH 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Ezequiel Ohana1, Rosane Ness-Abramof*1, Dan A Nabriski1, Pnina Rotman-Pikielny2, Meir Nyska3, Brian Fredman4 and Jeffrey Sachs1
1"Meir" Medical Center, Kfar Saba, Israel, 2MEIR MED CTR, Kfar-Saba, Israel, 3"Meir" Medical Center, 4"Meir" Medical Center, Kfar Saba

 

Introduction:

Thyroid dysfunction is a common endocrinopathy, affecting  4.3% of the population, particularly women and older patients.  Hypothyroidism may depress myocardial function, decrease ventilation, cause anemia and impair hepatic drug metabolism. Thyroid dysfunction may be particularly challenging in the management of the surgical patient.

Aim of the study: To evaluate the effect of uncontrolled  hypothyroidism on surgical outcome of patients with hip fractures having emergent surgery.

Methods: A retrospective study of patients that had emergent hip surgery at Meir Medical Center during 1/2010 and 07/2011. Data collected from charts included demographic data, previous medical history, laboratory tests, surgical procedure, perioperative morbidity and mortality and long term mortality.  A TSH > 4 mU/L  was defined as hypothyroidism. A matched controlled group of euthyroid patients was chosen.

Results: A total of 640 records of patients that underwent surgery due to hip fracture were reviewed. A total of 45 patients with a TSH > 4 mU/L in the perioperative period were found . The mean age was 83.7y ± 9.3 and 83.7 ± 9 (P=0.99)  in the hypothyroid and control group respectively. Mean TSH was 11.2 mU/L ± 20.1 in hypothyroid patients and 1.8 mU/L  ± 0.7 in the control group (P=0.016) and mean FT4 was 13.7  nmol/L ± 4.5  in hypothyroid patients and 14.4 nmol/L ± 2.8 in the control group.  In the hypothyroid group, 95% had a diagnosis of hypothyroidism. A preoperative diagnosis of anemia and arrythmia was more common in hypothyroid patients (24.4% vs 8.9%,P=0.048 for anemia and  33.3% vs 13.3%, P=0.025 for arrythmia). Hypothyroid patients had more episodes of hypotension compared to the control group (64.4% vs 33.3%, P=0.003) and needed more blood transfusions (1.8 units vs 1.3 units, P=0.044) during surgery. The length of hospitalization, the complication rate of  ileus, need for mechanical ventilation, arrythmia, cardiovascular complications,  infection rate and mortality  was similar between groups.  

Conclusion:  Hypothyroid patients that underwent emergent surgery due to hip fractures had a higher rate of  intraoperative hypotension and needed more blood transfusions compared to euthyroid patients.

 

Nothing to Disclose: EO, RN, DAN, PR, MN, BF, JS

15040 37.0000 MON-0499 A The Effect of Hypothyroidism on the Surgical Outcome of Patients with Hip Fractures 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Mario Amilcar Valdes*1 and Heather Anne Lochnan2
1The University of Ottawa, Ottawa, ON, Canada, 2Ottawa Hospital Research Institute, Ottawa, ON, Canada

 

Background: Only two percent of patients under chronic amiodarone therapy may develop thyrotoxicosis in areas with high iodine intake whereas 13 percent will develop hypothyroidism. The effect of the antiarrhythmic in previously hypothyroid patients has never been described. We report the first case of Amiodarone induced hyperthyroidism in a patient who had an elevated TSH prior to starting amiodarone.

Clinical Case: A 54 year old woman with congestive heart failure, primary ICD therapy and untreated hypothyroidism was started on amiodarone due to recurrent episodes of monomorphic ventricular tachycardia. Two years after starting Amiodarone she developed fatigue, TSH was 10.97 mU/L and FT4 16.1 pmol/L. She was started on levothyroxine 0.025 mg daily. Three months later the hormone was stopped as she developed asymptomatic hyperthyroidism (TSH 0.05 mU/L, FT4 62.1 pmol/L, FT3 9.2 pmol/L). She was started on Methimazole 10 mg PO BID and later increased to 15 mg PO BID, and prednisone 40 mg PO OD. A thyroid ultrasound reported a diffusely enlarged gland without any dominant nodules. RAIU reported decreased uptake as expected. Her comorbidities included HTN, liver cirrhosis, two previous myocardial infarctions and a recently diagnosed breast cancer. She unfortunately developed febrile neutropenia while on Methimazole and renal failure requiring dialysis. Then TSH was <0.05 mU/L, FT4 70.3 pmol/L and FT3 7.2 pmol/L without significant symptoms. She underwent thyroidectomy and was started on levothyroxine. She unfortunately died of heart failure six months after surgery. CFDS and thyroid stimulating antibodies were not available, pathology showed dffuse hyperplasia with macrofollicles.

Discussion: Discerning the type of AIT was very difficult. She had an underlying thyroid disease since she was hypothyroid before starting amiodarone therapy. She had a diffuse but small goiter and RAIU was low. T4/T3 ratio was 6.75 at the beginning of the hyperthyroid phase. She received treatment for mixed type AIT, but it was complicated by methimazole severe side effects.

Conclusion: While it is known that a normal thyroid gland can develop amiodarone induced hyperthyroidism, the mechanisms behind Amiodarone induced hyperthyroidism in a previously hypothyroid patient are not clear.  Previous hypothyroidism does not exclude the risk of hyperthyroidism.

 

Nothing to Disclose: MAV, HAL

15431 38.0000 MON-0500 A Amiodarone Induced Hyperthyroidism in a Previously Hypothyroid Patient 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Tulsi Sharma*1 and Barbara L Mols-Kowalczewski2
1SUNY Upstate Univeristy, Syracuse, NY, 2Suny Upstate Medical University, Syracuse, NY

 

Introduction: Resistance to thyroid hormone (RTH) and central hyperthyroidism (TSH-oma) are rare conditions associated with elevated TSH, FT4 and T3 levels.  Differentiating between them is a clinical challenge. The presence of preexisting autoimmune thyroid disease and a pituitary lesion further complicate this case.

Clinical Case:

A 33-year-old female was referred for difficult to manage post-surgical hypothyroidism.  She was diagnosed with Graves’s disease in the past.  Thyroid pathology (status post subtotal thyroidectomy in 2004) showed diffuse hyperplasia. She was on levothyroxine therapy; her dose was adjusted based on TSH levels. Over the past 6 yrs, she reported fatigue, a 30lb weight gain and occasional palpitations at rest. Ultrasound (2011) revealed small thyroid remnants bilaterally. She had elevated TSH at 16 (0.2-4.2 mIU/L), elevated FT4 at 2.7(0.9-1.7 ng/dL), elevated FT3 at 4.67(2-4.4 pg/mL) and elevated RT3 at 380 (90-350 pg/mL).

TPO antibodies were positive but TSI and TSH receptor antibodies were negative. Central hyperthyroidism was suspected. MRI scan (2011) revealed a 2 mm enhancing defect in the pituitary with slight leftward infundibular stalk deviation. Lesion was stable on repeat MRI (2012). Other pituitary hormone levels were normal.

The differential diagnosis, given this hormone profile, is a TSH-oma or RTH. Neurological signs and symptoms if present suggest a TSH-oma. Elevated α-subunit and high α-subunit/TSH molar ratio are suggestive of TSH-oma. SHBG and the carboxyterminaltelopeptide of type I collagen are in the hyperthyroid range in TSH-oma, and in the normal or low range in RTH.

Our patient had a normal SHBG and α-subunit making the diagnosis of RTH more likely than TSH-oma (despite the abnormal pituitary imaging). The genetic marker for RTH (p.Pro453 Ser mutation of the thyroid receptor β) was found, confirming our suspicion for RTH.

Based on the above evaluation the dose of levothyroxine was reduced, which helped improve her clinical symptoms. She was able to have a successful pregnancy and unwanted (and unnecessary) pituitary surgery was avoided. RTH is associated with increased risk for autoimmune conditions. There are also some reports of TSH producing pituitary tumors in the RTH syndrome; hence our patient will need to be carefully monitored.

Conclusion: When there are persistent elevations of T3 and T4 with non-suppressed TSH, RTH and TSH-oma are suspected. There is a paucity of clinical manifestations specific to each disorder and when present, manifestations are variable from one patient to another. As a consequence, clinical and laboratory evidence of thyroid hormone deficiency and excess often coexist as did in our patient. In addition, the presence of a pituitary lesion cannot, in and of itself, be considered evidence of a TSH-oma. Results of genetic testing for RTH were critical in making the correct diagnosis and avoiding pituitary surgery.

 

Nothing to Disclose: TS, BLM

15493 39.0000 MON-0501 A Resistance to Thyroid Hormone Versus Central Hyperthyroidism: A Diagnostic Dilemma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Danilo Villagelin*1, Valeria Bahdur Chueire2, Roberto Bernando Santos2, Ana Carolina Castelli2, Rafael Ribeiro2, Karina Magalhães Brasio2 and Joao Hamilton Romaldini3
1Pontificia Universidade Catolica de Campinas and University Campinas Laboratory of Cancer Molecular Genetics, Brazil, 2Pontificia Universidade Catolica de Campinas, Brazil, 3PUC-CAMPINAS and HSPE-IAMSPE, Sao Paulo, Brazil

 

The evidence that hypothyroid patients present impairment in attention, and memory are scarce. The aim of this study was to evaluate the concentrated attention (CA-test) and pictorial of visual memory (PVM-test) tests in subclinical hypothyroidism (SCH) and overt hypothyroidism (OH) patients at baseline (B) and four months after reaching biochemical euthyroidism (EU) following levothyroxine (LT4) replacement.

We studied 21 patients with SCH, 19 patients with OH compared with 19 control subjects (C) evaluated on two occasions (B and EU). The CA-test is the result of stimuli that the individual should mark and scored, subtracted errors plus omissions. The instrument has 500 stimuli in 25 columns, 180 are target stimuli, and each column contains 9 targets and 16 distracters stimuli.  The PVM-test assess the individual's ability to recover a figure with several drawings and details for one minute and write them in response to the test sheet in two minutes.

RESULTS: The groups did not differ in age (43.4+3.8 years) gender (79% of female) and education. The concentration of serum TSH was increased in OH (33+46.8 mU/L) than in SCH (8.0+2.5 mU/L, p <0.0001) which differ from group C (2.1+0.9 mU/L, p < 0.0001). FT4 values in OH (0.6+0.3 ng/dL) were lower (p<0.0001) than in SCH (1.2+0.1 ng/dL) and C (1.2+0.2 ng/dL). Following treatment with LT4 (25 to 150 mg/day) after four to six months, TSH values in EU were 1.8+1.2 mU/L (SCH) and 1.7+1.1mU/L (OH). FT4 were 1.1+1.6 ng/dL (SCH) and 1.4+0.2 ng/dL (OH). All these values were similar to group C. The number of points of CA-test (hits, errors and omissions ) in patients SCH (38.8+28.9) and OH (31.1+36.4) were lower than C (70.8+10; p< 0.001). During the EU period there was an increase in the total of CA-test points in SCH (58.6+25.0, p<0.02) but not in OH (45.8+33.7) patients, and both groups were lower than second assess in C group (79.6+26.5, p< 0.01). The PVM-test score was significantly lower in SCH (10.1+5.1) and OH (9.4+3.6) compared to C group (15+7.0, p<0.003).Both groups improved with LT4 replacement (SCH: 11.4 ± 5.2; OH: 11.6+5, p< 0:02), but the scores were lower than C (16+6.1, p< 0.004). The concentration of TSH was negatively correlated with CA-test and the PVM-test (p< 0.002).
These data suggest that SCH and OH patients showed inability to access the concentration attention and pictorial visual memory, which had a small improvement after LT4 treatment but not enough to entirely restore these cognitive signs

 

Nothing to Disclose: DV, VBC, RBS, ACC, RR, KMB, JHR

16436 40.0000 MON-0502 A Hypothyroidism Associated with Disabilities of Concentrated Attention and Pictorial Visual Memory: Lack of Improvement Following Levothyroxine Replacement 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Shervin Yousefian*, Todd Beyer and Vibhavasu Sharma
Albany Medical College, Albany, NY

 

Background: Papillary Thyroid Carcinoma (PTC) is the most common thyroid malignancy. However, its presentation at an early age especially with metastasis is uncommon in patients with Graves’ disease. 

Clinical Case: A 15 year old girl was diagnosed with hyperthyroidism by the primary care physician, and was referred to an endocrinologist. Ultrasound showed multinodular goiter with the prominent nodule of 2.9 cm in the isthmus. Patient’s thyroid scan showed a large nodule with increased uptake with a central area of decreased uptake. Patient was started on Methimazole for Graves’ disease with a plan for regular surveillance ultrasound as FNA had shown a colloid nodule.

After 1 year repeat ultrasound showed persistence of the nodule. Patient was referred to an endocrine surgeon and had total thyroidectomy 6 months later. Pathology was multi focal papillary thyroid carcinoma with 1 out of 2 lymph nodes positive, consistent with stage I disease (T3 N1 Mx).  She underwent radioactive Iodine ablation after surgery. She was kept on Synthroid 125 mcg per day with TSH in the range of 0.22 µIU/ml-0.55 µIU/ml (n 0.45-4.50 µIU/ml). Whole body scan was consistent with remnant disease in thyroid bed. Three months after thyroidectomy Thyroglobulin (TG) was 0.2 ng/ml (n <35 ng/ml) and raised concern for remnant disease. Three months later the second TG level rose to 5.44 ng/ml. Thyroglobulin antibodies were negative. Ultrasound of neck at follow up visit at surgical clinic showed 2-3 confluent lymph nodes. Resection of these lymph nodes was discussed with the patient and her parents.

Patient obtained a second opinion. A repeat ultrasound and FNA confirmed recurrent malignant disease in the cervical lymph nodes. She had complete central compartment clean out one year after her total thyroidectomy. Four out of 8 lymph nodes were positive. One month later, her lab test showed Thyroglobulin antibody (TG Ab) of 54.8 IU/ml (n <4), which made measurement of TG impossible. At her last office visit she appeared well with a reassuring neck ultrasound. Her blood test showed TSH 0.03 µIU/ml, T4 15.6 ng/dl (n 0.60-1.30 ng/dl), and TG Ab of 21.6 IU/ml. 

Conclusion: This case demonstrates the possibility of PTC with metastasis   in a young patient whose care was complicated by recurrent disease 1 year after adequate therapy. It also is an example of TG Ab appearance several months after thyroidectomy in a patient diagnosed with Graves’ disease.

 

Nothing to Disclose: SY, TB, VS

15509 41.0000 MON-0503 A Metastatic Papillary Thyroid Carcinoma in a 15-Year Old Patient with Graves' Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Ravi Kant*1, Hillary Barnes Loper2, David Lawrence Levitt2, Rana Malek2, Casey Lynnette Overby2 and Kashif M. Munir2
1AnMed Health and Medical University of South Carolina, 2University of Maryland School of Medicine, Baltimore, MD

 

Levothyroxine (LT4) is the most commonly prescribed medication to treat hypothyroidism. Thyroid hormone replacement has a narrow therapeutic index and both under- or over-replacement may cause adverse effects. Although LT4 dose is adjusted based on highly sensitive TSH levels, several studies have shown that 30-40% of patients on thyroid replacement have abnormal TSH. Traditionally, LT4 maintenance dose is estimated using actual total body weight (TBW), with a recommended range of 1.6–1.7 mcg/kg/day. We hypothesized that several factors other than weight determine daily thyroid hormone requirements and purely weight based formulas would fail to estimate LT4 maintenance dose.

Eighty charts of primary hypothyroid patients, ≥ 18 years old, seen at University of Maryland outpatient clinics from 2010-2011 were retrospectively reviewed. Forty patients (36 female and 4 male; 11 new hypothyroidism and 29 chronic hypothyroidism) met the inclusion criteria (TSH values within reference range on LT4); others were excluded from final analysis predominantly due to incomplete data, unable to achieve euthyroidism, medication non-adherence and diagnosis of central hypothyroidism or thyroid cancer. Twenty-seven patients had non-surgical etiology (10 autoimmune, 8 post radioactive iodine therapy, 1 post radiation therapy, 8 idiopathic) while 5 were hypothyroid due to thyroidectomy (3 total thyroidectomy, 2 partial thyroidectomy). Etiology could not be determined in 8 patients based on chart review. Patients with a new diagnosis of hypothyroidism required 1-8 (median=2) TSH checks, 1-3 (median=1) clinic visits and 1-12 (median=4) months to achieve euthyroidism after the initial diagnosis. The mean TBW-based (1.6 x TBW) and IBW-based (1.6 x IBW) calculated LT4 doses were 31.7 ± 5.25 mcg higher and 14.1 ± 2.2 mcg lower than the patient’s LT4 dose required to achieve euthyroidism (103.5 ± 6.4), respectively. Interestingly, the difference was significant only for the IBW-based calculated LT4 dose (z = 4.422, p = 0.00). When assessing if there was a difference between IBW-based calculated dose and TBW-based calculated dose in terms of accuracy (within ± 20% of calculated dose), we found IBW-based doses were accurate for 55% of patients and TBW-based calculations were accurate for 40% of patients. This difference, however, is not statistically significant.

Traditional weight-based formulas are widely used by clinicians to estimate LT4 maintenance dose. Unfortunately, our study demonstrated that purely weight based dosing fails to accurately and efficiently predict thyroid hormone replacement and IBW is no better a predictor of LT4 requirement than TBW alone.  Further studies are needed to determine which factors affect daily LT4 requirements in hypothyroid patients and develop a simple and effective algorithm utilizing these factors to estimate therapeutic doses of LT4.

 

Nothing to Disclose: RK, HBL, DLL, RM, CLO, KMM

16859 42.0000 MON-0504 A Weight Based Levothyroxine Dosing Fails to Predict Thyroid Hormone Replacement in Primary Hypothyroid Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Lakshmi Kannan*1 and Arthur Chernoff2
1Einstein Medical Center, Philadelphia, PA, 2EINSTEIN MEDICAL CENTER, Philadelphia, PA

 

HYPOTHYROIDISM AND ATHEROSCLEROTIC CARDIOVASCULAR DISEASE

Thyroid function regulates a wide array of metabolic parameters thus influencing overall Atherosclerotic Cardiovascular disease (ASCVD) risk. Previously we have shown that hypothyroidism is associated with 2 to 5 times increased odds of metabolic syndrome1. We now report results of a retrospective case control analysis to study the relation between thyroid status and ASCVD, namely coronary artery disease(CAD), ischemic cerebrovascular accident(CVA) and peripheral vascular disease(PVD).  

METHODS We conducted a retrospective case control study to compare the prevalence of ASCVD between euthyroid and hypothyroid subjects. We analyzed 149 subjects in total, 39 euthyroid and 110 hypothyroid subjects. All data were collected through chart review. Statistical analysis was performed by the Chi-square test and logistic regression analysis.

RESULTS Euthyroid and hypothyroid groups were found to be similar in terms of demographic variables including age, gender, smoking status, alcohol consumption.  We found that 23% of the euthyroid and 42% of hypothyroid subjects had CAD. Pearsons chi square test revealed a P-Value of 0.03. Regression analysis was conducted to stratify the thyroid groups based on metabolic syndrome.  Among those without the metabolic syndrome, 21% of euthyroid and 37% of hypothyroid subjects had CAD. Among those with MS,  27% of euthyroid and 46% of hypothyroid subjects had CAD. After adjusting for metabolic syndrome the difference in the prevalence of CAD among the different thyroid groups lost statistical significance. No significant difference was found in the prevalence of CVA and PVD.

CONCLUSION Our study suggests that hypothyroid subjects are at increased risk of coronary artery disease as compared to euthyroid individuals, and this increased risk appears to be due to the association of hypothyroidism with metabolic syndrome. The present study serves as proof of concept that hypothyroid patients are at increased risk of CAD and future prospective studies could further define the link between hypothyroidism and CAD, including the role of MS in this association. 

 

Nothing to Disclose: LK, AC

12088 43.0000 MON-0505 A Hypothyroidism and Atherosclerotic Cardiovascular Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Erwyn Chua Ong*, Halis Sonmez and Agustin Busta
Mount Sinai Beth Israel, New York, NY

 

Introduction: The simultaneous occurrence of various types of thyroid carcinoma in a single patient is unusual.  Here we report a case of this rare event in a patient presenting initially with subacute thyroiditis.

Case: A 54-year-old female presented with two-month history of neck pain after a bout of systemic viral infection.  She had no prior history of radiation exposure, and no known family history of thyroid cancer. On examination, the thyroid gland was palpated (left more than the right) with irregular surface, tenderness, and induration.  Work up: FT4 3.5 (0.7-1.7 ng/dL), TSH 0.03 (0.38-5.5 mU/L), anti-TPO/anti-thyroglobulin autoantibodies negative, I123 uptake scan 1% (10-30%), consistent with subacute thyroiditis.  Thyroid ultrasound showed  a 7 mm irregular hypoechoic nodule with central microcalcification in the mid left lobe.  Fine needle aspiration biopsy (FNAB) revealed benign nodule initially. Follow-up thyroid ultrasound showed suspicious sonographic features, thus repeat FNAB showed result suspicious for follicular neoplasm.  Work-up for multiple endocrine neoplasia (MEN) showed no RET proto-oncogene mutation detected.  Calcitonin, carcinoembryonic antigen (CEA), and plasma catecholamines were normal.  Patient underwent left thyroid lobectomy, with three foci of disease: (1) Papillary thyroid carcinoma (PTC), follicular variant measuring 0.8 cm; (2) Papillary microcarcinoma less than 1 mm; (3) Medullary thyroid carcinoma (MTC) 1 mm in size, reactive for chromogranin, synaptophysin, calcitonin and thyroid transcription factor 1, but negative for thyroglobulin.  Patient then underwent completion thyroidectomy with bilateral central compartment lymph node dissection, with no complication. Pathologic staging was T1aN0Mx.

Discussion: The simultaneous occurrence of PTC and MTC in the same thyroid is rare. A retrospective study by Kim et al (2010) suggest that the occurrence of concurrent MTC/PTC in the same thyroid should be considered coincidental.  The pathogenesis of these peculiar cases of thyroid malignancy remains unknown, but an underlying common genetic drive has been hypothesized.  Genetic analysis of RET oncogene in cases of concurrent PTC and MTC had provided conflicting results, and genetic alterations in the papillary carcinoma component of these mixed cases have not been found.  In a study by Rossi et al (2005), MTC and PTC were found to be associated with RET and BRAF somatic mutations respectively.  The foundation of treatment of this lesion is total thyroidectomy with central compartment lymph node dissection.  In our patient, RET proto-oncogene mutation was not detected.  It is important for clinicians: (1) to recognize that simultaneous PTC and MTC can occur in the same thyroid, and know the management based on this finding; and (2) to have a low threshold for repeat FNAB if there is strong clinical and sonographic suspicion for thyroid malignancy.

 

Nothing to Disclose: ECO, HS, AB

15557 44.0000 MON-0506 A Synchronous Occurrence of Differentiated Thyroid Carcinoma and Medullary Thyroid Carcinoma in a Patient Presenting with Subacute Thyroiditis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Jerome M Hershman*1, Llanyee Liwanpo2, Cynthia Ro2 and Muhammd Salman ul Haq3
1VA Greater LA Healthcare System, Los Angeles, CA, 2VA Greater Los Angeles, Los Angeles, CA, 3Sansum Clinic, Santa Barbara, CA

 

Background. Sunitinib (Sutent) is used for treatment of renal cell cancer and gastrointestinal stromal tumor. Fatigue, often observed in cancer patients taking sunitinib, is sometimes due to hypothyroidism, but is most likely multifactorial in nature. Nine prospective studies showed that sunitinib caused hypothyroidism in a median of 33.4%. The mechanism by which sunitinib induces hypothyroidism is unclear. Our previous work in vitro showed that sunitinib inhibited peroxidase activity, and we hypothesized that this is a possible cause of the hypothyroidism. To test this hypothesis, we performed tests of peroxidase activity in patients taking sunitinib for metastatic renal cell cancer.

Methods. Perchlorate discharge tests were performed to test thyroid peroxidase activity. Studies were carried out at the end of the 2-week rest period off drug and at the end of the 4-week period on sunitinib. Patients had thyroid function tests consisting of serum TSH, free T4 and total T3 measurement at each time. Patients received a 200 microCi dose of 123I with 0.5 mg iodide as KI; thyroid uptake was measured at 3-hr. Then the patient received 1000 mg perchlorate to displace 123I that had been taken up but not organified, and thyroid uptake was remeasured at 4-hr. A positive test is reduction of thyroid uptake by at least 15% at 4-hr compared with the value at 3-hr. The study was approved by the VA IRB, and each patient gave informed consent.

Results.Studies were completed in 8 patients. Each patient had been taking sunitinib for at least 2 cycles of 4 weeks each before the study tests. Three patients had serum TSH >20 mU/L during the sunitinib therapy, but none of these three hypothyroid patients had a positive perchlorate discharge test. Only one of the 8 patients had a positive perchlorate discharge test of -18.9% when his TSH was 11 mU/L and free T4 was 0.92 ng/dl on sunitinib, but his very low uptake of 1.5% at 3-hr reduced the reliability of the test. The 3-hr thyroid radioiodine uptakes on sunitinib (mean 2.9±1.7%) were all lower than those during the rest period off drug (5.8±2.6%, p<0.02).  

Discussion. Based on clinical studies of thyroid radioiodine uptake in patients taking sunitinib, Mannavola et al proposed that hypothyroidism was due to inhibition of iodide transport, but our in vitrostudies with rat thyroid cells showed that cells incubated with sunitinib had no impairment of iodide transport or down-regulation of the sodium/iodide symporter.  Sunitinib inhibits vascular endothelial growth factor receptors as a principal mechanism of its action on tumors. Vasoconstriction of thyroid capillaries could reduce uptake of radioiodine and impair thyroid function.

Conclusion.Studies in 8 patients taking sunitinib showed no significant reduction of thyroid peroxidase based on perchlorate discharge tests and make it unlikely that peroxidase inhibition is responsible for sunitinib-induced hypothyroidism.

 

Nothing to Disclose: JMH, LL, CR, MSUH

12425 45.0000 MON-0507 A Sunitinib Does Not Inhibit Thyroid Peroxidase in Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Jiao Fu*1, Xiao-Hui Liao2, Maria Belen Menucci3, Alexandra M Dumitrescu2 and Roy E Weiss2
1The First Affiliated Hospital of Xi’an Jiaotong University School of Medicine, Xi'an, China, 2The University of Chicago, Chicago, IL, 3Division of Endocrinology, Department of Medicine, Medstar Washington Hospital Center/Georgetown University Hospital, Washington, DC

 

Background: Selenoproteins contain the rare aminoacid Selenocystein (Sec). The biosynthesis of the 25 known selenoproteins requires multiple factors, among which an mRNA stem loop structure (Sec insertion sequence, SECIS) and SECIS-binding protein 2 (SBP2). The selenoenzymes iodothyronine deiodinases (Ds) are responsible for the intracellular metabolism of thyroid hormones (TH), providing a mechanism for local regulation of TH supply. To date, only 8 families with inherited TH metabolism defect caused by mutations in SBP2 gene were reported.

Clinical case: The proband is a 5 5/12y girl from Argentina, the 2nd child born to unrelated parents after a normal pregnancy and uncomplicated delivery. At 6 months of age, she presented with failure to thrive and thyroid function tests (TFTs) revealed elevated serum T4 and low T3 with normal TSH levels. No other thyroid-related symptoms were present and no goiter was noted. Neonatal screening was normal. She started to sit without support at 9 months and walked at 18 months. At the chronological age of 5yr 2 months, her bone age was 2 yr. Circulating GH and IGF-1 levels were normal. The abnormal TFTs persisted, with recent total T4 of 15.9 μg/dL (5-12), total T3 of 94 ng/dL (115-200), reverse T3 of 85.5 ng/dL (1-36), FT4I 19.9 (6.0-10.5), and TSH of 2.1 μU/mL (0.4-3.6) with no antibodies against TG or TPO. Nutritional support was given but no treatment with thyroid hormone. Her parents and 2 siblings had normal TFTs. Sequencing of the SBP2 gene identified heterozygous mutations in the proposita. She inherited from her mother a nonsense mutation in exon 5 of the SBP2gene, R197X, and from her father a missense mutation in exon 14 leading to an amino acid substitution in codon 679 changing glutamic acid to aspartic acid (E679D).

 The carboxy-terminal half of SBP2 contains an RNA-binding domain encompassing amino acids 517-777. The missense mutation E679D is predicted to be damaging by the PolyPhen-2 algorithm with a maximal score of 0.998, and may result in impaired mRNA-binding activity and defective selenoprotein biosynthesis. Regarding the premature termination R197X, our previous work(1)has shown that smaller functional isoforms of SBP2 might be synthesized from the two downstream ATGs. This could explain the relatively mild phenotype observed in this patient.

 Conclusion: We report a patient with TH metabolism defect caused by novel compound heterozygous mutations R197X/E679D in the SBP2 gene. Genetic testing for this defect should be considered in patients with growth delay and the characteristic TFTs phenotype showing high T4, low T3, high rT3 and normal or slightly elevated serum TSH.

 

Nothing to Disclose: JF, XHL, MBM, AMD, REW

15587 46.0000 MON-0508 A Thyroid Hormone Metabolism Defect Caused By Novel Compound Heterozygous Mutations in the SBP2 Gene 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Alessandro Antonelli*, Silvia Martina Ferrari, Ilaria Ruffilli, Marta Mosca and Poupak Fallahi
University of Pisa, Pisa, Italy

 

To our knowledge, no study has evaluated the incidence of new cases of thryoid disorders in systemic lupus erythematosus patients (SLE). The study aimed to evaluate the incidence of new cases of clinical and subclinical thyroid dysfunctions in women with SLE.

Transversal study: Thyroid disorders were evaluated in 211 women with SLE, in comparison with 211 gender- and age-matched controls. Longitudinal study: SLE patients with thyroid dysfunctions (n=47) at the initial evaluation were excluded, then the appearance of new cases of thyroid disorders was evaluated in 164 SLE and in 164 matched controls, with similar iodine intake (median follow-up 85 months in SLE, vs 91 in controls).

We demonstrate that:

Transversal study: In women with SLE mean TSH value, the titre and prevalence of thyroid peroxidase antibodies (AbTPO), the percentage of a thyroid hypoechoic pattern and a small thyroid volume were significantly (p<0.05) higher than in controls.

Longitudinal study: We have shown a high incidence of new cases of hypothyroidism, thyroid dysfunctions, AbTPO positivity, and appearance of a hypoechoic thyroid pattern in SLE (17, 23, 12, 15/ 1000 female SLE per year; respectively) in comparison with the control group, despite a significantly longer observational period in the control group. A logistic regression analysis showed that in female SLE the appearance of hypothyroidism was related to a border line high initial TSH, AbTPO positivity, a hypoechoic pattern, and a small thyroid volume.

In conclusion, we first show a high incidence of new cases of hypothyroidism, thyroid dysfunctions, AbTPO positivity, and appearance of a hypoechoic thyroid pattern in female with SLE in comparison with the control group. Female SLE patients, who are at high risk [high (even if in the normal range) TSH, positive AbTPO, hypoechoic and small thyroid] should have periodically thyroid follow-up.

 

Nothing to Disclose: AA, SMF, IR, MM, PF

12612 47.0000 MON-0509 A Incidence of Thyroid Disorders in Systemic Lupus Erythematosus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Tomohiko Yoshida*, Akitoshi Nakayama, Eri Komai, Akina Shiga, Takashi Kouno, Tomoko Takiguchi, Seiichirou Higuchi, Ikki Sakuma, Hidekazu Nagano, Naoko Hashimoto, Sawako Suzuki, Hisashi Koide, Koutaro Yokote and Tomoaki Tanaka
Chiba University Graduate School of Medicine, Chiba, Japan

 

Introduction: The average dose of synthetic thyroid hormone for hypothyroidism treatment ranges normally from 1.6 to 1.8 μg/kg. However, some patients require higher doses of levothyroxine for normalization of their TSH. The leading causes are poor compliance or consumption of levothyroxine tablets with food or drugs interfering with thyroxine absorption. Some other reasons are malabsorption disorders such as celiac disease or short bowel from prior small bowel bypass or resection (1). In addition to these, there are a few cases of intestinal absorption of drugs impaired possibly due to aberrant drug transporters, but the mechanism remains uncertain. Here, we describe a case of Hashimoto’s hypothyroidism complicated by impaired intestinal absorption of multiple drugs including levothyroxine. In vitro study for cellular membrane transport indicated levothyroxine incorporation was seriously impaired in lymphocytes of the patient by flow cytometry analysis.

Clinical case and in vitro study: An 80-year-old woman was referred to our division because she expressed symptoms compatible with hypothyroidism, and her TSH level remained elevated despite treatment with 600 μg/day (15 μg/kg/day) of levothyroxine. Her Hashimoto’s hypothyroidism was diagnosed with high TPO antibody (229 IU/ml, normal = <16 IU/ml) and hypothyroidism (TSH = 81.425 μU/ml, normal = 0.350-4.940 μU/ml; Free T4 = 0.44 ng/dL, normal = 0.70-1.48 ng/dL, with 600 μg/day of levothyroxine), and it was complicated with refractory hypertension, and immune thrombocytopenia, which was poorly responded after Helicobacter pyroli eradication, splenectomy and treatment with prednisolone tablets. Although she was forced to take levothyroxine on an empty stomach under close scrutiny and avoid taking other medications or food for 30-60 min afterwards, her TSH levels remained unchanged. She didn’t have any noticeable symptoms of malabsorption. When she was treated with 300-500 μg of intravenous levothyroxine once a fortnight and 15 mg of parenteral prednisolone 3 times a week, her thyroid function and platelet count have normalized. Then, we were interested in determining whether her cellular membrane transport in lymphocytes was impaired. To address this question, we performed fluorescence- activated cell sorting (FACS) analysis by using FITC-conjugated levothyroxine. Results suggest 58% of the patient’s lymphocytes showed the same ability of levothyroxine incorporation as normal control, but 42% of them showed reduced ability to incorporate levothyroxine determined by fluorescence intensity.

Conclusion: In a patient with Hashimoto’s hypothyroidism and reduced intestinal absorption of levothyroxine, it is suggested that the cellular membrane transport is critically impaired in lymphocytes, possibly due to aberrant membrane transporters.

 

Nothing to Disclose: TY, AN, EK, AS, TK, TT, SH, IS, HN, NH, SS, HK, KY, TT

15671 48.0000 MON-0510 A Reduced Cellular Membrane Transport for Levothroxine in a Patient with Hashimoto's Hypothyroidism and Impaired Intestinal Drug Absorption 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Hernando Vargas-Uricoechea*1, Beatriz Bastidas-Sánchez2, Martha Cecilia Perdomo-Cabrera3 and Claudia Orozco-Chamorro2
1Universidad del Cauca, Popayán-Colombia, Popayán-Cauca, Colombia, 2Universidad del Cauca, Popayán-Cauca, Colombia, 3Specialized Clinical Laboratory, Popayán-Cauca, Colombia

 

Background: Iodine Deficiency Disorders (IDD) are a serious public health issue across the world, with more than 2 billion people at risk. In Latin America, endemic goiter is a health problem in 17 countries.  Clinical manifestations of IDD include goiter, hypothyroidism, mental retardation, and high neonatal and infant mortality rates, among others. The systematic use of iodized salt is proposed as a strategy to revert those consequences. However, surveillance programs for IDD in Colombia and the impact of supplementation with iodized salt in Colombia are deficient and unknown. 

 Methods: Cross-sectional study. School children in fifth grade with no history of thyroid disorders were included (n=140).

The following parameters were measured: TSH, TPOAb, TgAb, TRAb, Tg and urine iodine.  Palpation was used to measure goiter frequency. 

 Results: Median urine iodine was 513,5 µg/L. Goiter prevalence was 37,4%. Of the study population, 98,6% reported intake of adequately iodized salt; 9,4% had a TSH level  >4,0 mUI/L; 46,4% had positive TPOAb; 6,5% had positive TgAb; and 100% had negative TRAb.

 Conclusions: Our findings demonstrate an extremely high level of urine iodine, associated with excess daily intake of iodine. This finding may be associated with the high frequency of thyroid autoimmunity (expressed in the presence of TPOAb) and a future risk of autoimmune thyroid dysfunction, and the high rate of goiter on palpation.

 

Nothing to Disclose: HV, BB, MCP, CO

14187 49.0000 MON-0511 A Iodine Intake-Associated Disorders in a School-Age Population in Popayán, Cauca-Colombia (Cauca-Iodine Study) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Sang Youl Rhee*1, Min A Park2, Jong Kyu Byun2, Yu Jin Kim1, Soo Min Hong1, So Young Park1, Sang Ouk Chin3, Chi Hoon Maeng2, Young Gyu Eun2, Bong Jin Park2, Youn Wha Kim2, Tae-Hyung Kim4, Hyung Jin Choi5, Joo Young Kim6, Seungjoon Oh1, Sung-Woon Kim7, Jeong-taek Woo1 and Young Seol Kim8
1Kyung Hee University School of Medicine, Seoul, Korea, Republic of (South), 2Kyung Hee University School of Medicine, 3Jeju National University Hospital, Jeju, Korea, Republic of (South), 4Theragen BiO Institute, TheragenEtex, Suwon, Korea, Republic of (South), 5Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 6Dongsuwon General Hospital, Suwon, Korea, Republic of (South), 7Kyung Hee Univ Sch of Med, Seoul, Korea, Republic of (South), 8Kyung Hee Univ, Seoul, Korea, Republic of (South)

 

We report an anaplastic thyroid cancer patient with somatic mutation of epidermal growth factor receptor (EGFR). A sixty-two-year-old woman was admitted to our hospital with a palpable neck mass. She was healthy and had no important medical history except for dyslipidemia. The neck mass was discovered by the patient only 1 week before admission, and was estimated by ultrasonography to be 2.8×2.0×3.5 cm. Anaplastic cancer was confirmed by aspiration cytology. Because the patient had a good performance status and a limited metastatic region, as determined by further evaluation, we planned radical thyroidectomy and postoperative chemo- and radiotherapy. However, brain hemorrhage occurred 10 days after surgery, and the patient’s general condition rapidly deteriorated. To identify an alternative treatment strategy, we performed mutational analysis of the tumor using novel sequencing technology. With this method, we found deletion of exon 19 in the EGFR gene within 5 days, and judged that gefitinib might be an effective treatment. However, because off-label use of anti-cancer medications had been prohibited by the national healthcare system in Korea, we could not use gefitinib, and the patient died 38 days after surgery.

 

Nothing to Disclose: SYR, MAP, JKB, YJK, SMH, SYP, SOC, CHM, YGE, BJP, YWK, THK, HJC, JYK, SO, SWK, JTW, YSK

15720 50.0000 MON-0512 A A Case of Anaplastic Cancer with Somatic Mutation of Epidermal Growth Factor Receptor 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Jung Ah Lim*1, Min Joo Kim2, Ji Young Park1, Jin Taek Kim1, Sung Kee Ryu1, Hong Kyu Lee1 and Hyo Jeong Kim1
1School of Medicine, Eulji University, Seoul, Korea, Republic of (South), 2Korea Cancer Center Hospital, Seoul, Korea, Republic of (South)

 

Background: Endothelial and myocardial dysfunction as well as abnormal thyroid hormone levels may be responsible for increased cardiovascular risk in Graves’ disease (GD). Myocardial fibrosis is a major determinant of myocardial  dysfunction and LV hypertrophy with stiff myocardium. Metalloproteinase (MMPs) and tissue inhibitor of matrix metalloproteinase (TIMPs), representing cardiac extracellular matrix turnover, has provided useful information on myocardial fibrosis. The aim of this study was to assess the changes in serum MMPs and TIMPs levels during the treatment and to investigate the relationship among those markers and thyroid hormones in newly diagnosed Graves’ patients.

Methods: Thirty-two patients with GD (GD group) and 8 age-matched euthyroid subjects (control group) were evaluated prospectively for 6 months. All patients in GD group were treated by methimazole or carbimazole. We performed 2-dimensional, M-mode, and Doppler echocardiography for each subjects. Serum MMP-1, MMP-9 and TIMP-1 were measured by ELISA methods.

Results: Before treatment, serum TIMP was significantly higher, while serum MMP-9 and the ratio of MMP-9:TIMP-1 were significanty lower in GD group than control group. The echography data showed that septal a’ and right ventricular pressure (RVP) were significantly higher in GD group. After treatment, there was a significant decrease in serum TIMP (16640±769 to 16355±970pg/ml, p<0.001) in GD group. There were also significant decreases in left ventricular EF (67.6±4.8 to 64.9±3.7%, p=0.044), septal a’ (0.09±0.02 to 0.08±0.02m/s, p=0.009) and RVP (32.3±8.2 to 23.8±6.1mmHg, p=0.007). Serum TIMP-1 was positively associated with MMP-1 (r=0.355, p=0.050) and free thyroxine (r=0.365, p=0.040), respectively, in pre-treated GD group.

Conclusion: In conclusion, serum MMP-9 and TIMP-1 might be one of determinants of myocardial dysfunction in Graves’ patients.

 

Nothing to Disclose: JAL, MJK, JYP, JTK, SKR, HKL, HJK

14328 51.0000 MON-0513 A Changes of Serum Concentrations of Matrix Metalloproteinase (MMPs) and Tissue Inhibitor of Matrix Metalloproteinase (TIMPs) during the Treatment of Patients in Newly Diagnosed Graves' Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Vinay Maudar*
VAMC, Murfreesboro, TN

 

Background: Leflunomide is a disease modifying agent used in treatment of Rheumatoid arthritis (RA). The author reports a case of leflunomide induced thyroditis.

Clinical case: 76 yr white male with history of RA was on treatment with methotrexate (MTX) & prednisone with adequate control of his RA symptoms. His MTX was replaced with leflunomide because of side effects to MTX. After starting leflunomide he was noted to be clinically thyrotoxic. His thyroid function test showed suppressed TSH and normal Free T3 & T4. His radioactive iodine uptake scan (RAIU Scan) findings suggested thyroditis. Patient was managed conservatively with symptomatic treatment. On follow up he was clinically & biochemically euthyroid.

Thyroid function tests (TFT): Before starting leflunomide- TSH-1.64 uIU/ml (0.465-4.68); after starting leflunomide TSH- 0.048 uIU/ml, Free T4- 1.16 ng/dl (0.78-2.19), Free T3- 3.34 pg/ml (2.77-5.27), TPO Ab <6 IU/ml(0-34); at appro. 2 months TSH- 0.37 uIU/ml, Free T4- 1.3 ng/dl, Free T3- 3.3 pg/ml; at appro. 4 months TSH- 0.625 uIU/ml, Free T4- 1.2 ng/dl, Free T3- 3.46 pg/ml

Radioactive Iodine uptake scan (RAIU Scan): The 6 hour uptake was reduced at 1.5% (normal 4-10%), and the 24 hour uptake was reduced at 3.4% (normal 10-25%).

Conclusion: Patient’s started on treatment with leflunomide should have their TFT checked at baseline and then monitored periodically while on treatment

 

Nothing to Disclose: VM

15897 52.0000 MON-0514 A Leflunomide Induced Thyroditis: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Takeshi Takayanagi*1, Izumi Hiratsuka1, Yoshiteru Maeda2, Megumi Shibata1, Hiroyuki Hirai3, Sahoko Ueda1, Masaki Makino3, Nobuki Hayakawa3, Atsushi Suzuki1 and Mitsuyasu Itoh4
1Fujita Health University, School of Medicine, Toyoake, Japan, 2Fujita health university, Toyoake city, Japan, 3Fujita Health University, Toyoake city, Japan, 4Fujita Health Univ Sch of Med, Aichi, Japan

 

Background: In recent years, the combination therapy of Pegylated interferon, Ribavirin, and Telaprevir therapy has been known to render HCV infection to remission. However, several adverse effects were noted, which relate to the disruption of thyroid function. Method: The medical records have been retrospectively reviewed in 483 cases with HCV infection who were treated with Pegylated interferon, Ribavirin, and Telaprevir from January 2006 to June 2013. Result: Fourteen cases (2.9%) had suffered from thyrotoxicosis, of which 7 were diagnosed as Graves' disease and the remaining showed transient thyrotoxicosis. The latent periods were 5 months in 3 cases,and other cases were 4,8,10, and 13 months respectively. Four cases of 7 Graves’ disease were ameliorated with anti-thyroid drugs, while 3 cases with mild elevation of thyroid hormone were followed-up without these drugs. One case was complicated with Graves' ophthalmopathy. On the contrary,7 cases (1.4%) showed hypothyroidism. Three of them showed temporal hyperthyroidism followed by gradual decline of thyroid hormone. The dysfunction in 2 cases subsided without thyroxine supplementation after completion of concomitant interferon therapy.Forty three cases were treated with the combination of Talaprevir, of which 11 showed subclinical thyroid dysfunctions. Conclusion: The Pegylated interferon, Ribavirin, and Telaprevir therapy for HCV infection causes a variety of thyroid dysfunction. Graves' disease related to interferon therapy has been considered as a rare side effect, but in our survey the prevalence ranged up to 1.4%. They presented mild elevation of thyroid hormone, which returned to the normal value in relatively short periods. This means that a careful observation of the thyroid function during the therapy must be needed.

 

Nothing to Disclose: TT, IH, YM, MS, HH, SU, MM, NH, AS, MI

15054 53.0000 MON-0515 A Clinical Picture of Thyroid Diseases Related to the Pegylated Interferon, Ribavirin, and Telaprevir Therapy for HCV Infection 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Richa Tikaria*1, Deepthi Takkalapelli2 and Saleh Aldasouqi3
1MSU, MI, 2MSU, 3Michigan State University, East lansing, MI

 

Introduction:

Fine needle aspiration (FNA) is the diagnostic test of choice for the evaluation of thyroid nodules.. It is relatively safe, simple, and cost effective diagnostic procedure. However FNA still has a false negative rate of 5-10%. We report a case of 4 cm thyroid nodule in which FNA was mostly benign (4/5 passes) but final pathology was consistent with follicular variant of papillary carcinoma.

Case:

A 35 yr old female with no family history of thyroid cancer was first diagnosed with Graves’ disease in 2002 and went into remission after treatmetn with antithyroid medications. In 2007 she had an ultrasound of the thyroid that demonstrated a 2.3 cm nodule and FNA showed hyperplasia without malignancy. In July of 2013 she was found to be clinically and biochemically hyperthyroid and Methimazole was restarted. Thyroid ultrasound in September 2013 showed a large complex mass with solid and cystic components of the size 4.3 cm x 3.1 cm x 2.3 cm. Because of the significant increase in size, FNA was repeated with pathology showing benign cytology 4/5 passes while 1 showed atypical cells. She underwent total thyroidectomy and final surgical pathology revealed follicular variant of papillary cancer. Post surgical treatment is being planned currently.

Conclusion:

Although FNA of the thyroid has relatively low  false negative rates; this rate can be particularly high in large nodules. Our patient had a nodule which did not have suspicious features for malignancy except the size. Although several  passes are usually done during FNA of thyroid nodules, our case emphasizes the need for more passes accessing different areas of the nodule in order to increase the reliability of FNA.

 

Nothing to Disclose: RT, DT, SA

15919 54.0000 MON-0516 A Large Thyroid Nodules and FNA 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Katarina Topchyan*1, Richard J Santen2, David Shonka1, Philip Smith1 and Sugoto Mukherjee3
1University of Virginia Health System, 2University of Virginia, Charlottesville, VA, 3University of Virginia Health System.

 

Background:Riedel’s thyroiditis is a rare, IgG4-related fibrotic condition, resulting in thyroid destruction, infiltration of surrounding tissues, and tracheal and esophageal compression. Because of invasive fibrosis, surgery is usually limited to isthmusectomy to relieve constrictive pressure. The high risk of hypoparathyroidism and recurrent laryngeal nerve damage makes aggressive surgical intervention problematic. Recommended medical therapies have included high dose Prednisone, Tamoxifen, Raloxifene, and Cellcept. A recent case report suggested Rituximab use for Riedel’s thyroiditis, due to its efficacy in patients with IgG4-related systemic disease.

Case description: A 40-year-old female presenting with a rapidly enlarging goiter, hypothyroidism, severe dysphagia, orthopnea and dyspnea underwent open biopsy and partial resection of the isthmus with a pathologic diagnosis of Riedel’s thyroiditis with IgG4 presence. Postoperatively, she had minimal symptomatic improvement.  She underwent sequential treatments with Prednisone, Tamoxifen, high dose Cellcept, and Raloxifene over 18 months, with no significant changes in thyroid volume as measured by serial CT scans. Based on a case report in JCEM, she was started on Rituximab. Nonetheless, her respiratory distress worsened over the next 4 months. Pulmonary consultation recommended operative tracheostomy because of marked flattening of the inspiratory flow loop limb and progressive focal tracheal narrowing from 2.65 to 1.56 mm (p<0.001) at the most compromised site. Discussion with the surgeon raised the possibility of thyroid resection if tissue planes were amenable. Right hemi-thyroidectomy and isthmusectomy were performed with intraoperative identification of the recurrent laryngeal nerve. While the nerve was encased in fibrotic tissue and extensive dissection was required, a plane was developed that allowed complete removal of the thyroid lobe and preservation of the nerve with intact electrical stimulation. Post-operatively, calcium levels were normal and flexible laryngoscopy demonstrated normal vocal cord function. Comparison of the histology between the initial biopsy and the hemithyroidectomy specimen revealed no significant changes in histologic appearance. Two weeks later, the patient noted that she could sleep flat for the first time in years and her stridor and dyspnea had resolved.

Conclusion: In a patient with increasing stridor and airway obstruction due to Riedel's thyroiditis, hemithyroidectomy with recurrent laryngeal nerve preservation was successfully completed, possibly facilitated by the anti-inflammatory effects of multiple agents.

 

Nothing to Disclose: KT, RJS, DS, PS, SM

16050 55.0000 MON-0517 A Impact of Medical Therapy on Successful Hemithyroidectomy in Riedel's Thyroiditis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Esra Akkaymak*1, Mustafa Ozbek1, Müyesser Sayki Arslan2, Melia Karakose3, Bekir Ucan1, Mustafa Caliskan4, Taner Demirci5, Erman Cakal4 and Tuncay Delibasi1
1Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey, 2Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey., 3Diskapi Yildirim Beyazit Teaching and Research Hospital, Ankara, Turkey, 4Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey., Ankara, Turkey, 5Diskapi Training and Research Hospital, Ankara, Turkey

 

Objective: Subacute thyroiditis (SAT) is a self limited condition of thyroid that assumed to be virally triggered generally after an upper respiratory tract infection. Graves’ disease is an autoimmune thyroid disease characterized by hyperthyroidism. Although SAT and Graves’ diseases have different etiology and necessiteate different management, these two diseases may share similar clinical, biochemical and ultrasonographic features during the thyrotoxic period and may cause difficulties in the differential diagnosis. The purpose of this study is to determine whether there are differences between SAT and Graves’ disease in terms of elastosonographic images during the initial phase of the diseases, as well as to assess the applicability of the method in these two forms of thyroiditis.

Materials and methods:  A total of 47 age and sex matched newly diagnosed patients (30 patients with SAT and 17 with Graves’ disease) were recruited to the study. All patients underwent physical examination, routine laboratory tests, conventional grayscale ultrasonography (US) and elastosonographic examination. We used characteristics of the hypoechoic areas on elastosonography in 5 patterns ( i.e. elasticity scores (ES) 1-5). Highly elastic tissues (soft) appear in red  (ES considered 1) and hard tissues appear in dark blue (ES considered as 5).

Results: Fourteen of 30 SAT parenchyma had an ES of 4, twelve had an ES of 3, 2 had ES of 2, 1 had ES of 1 and 1 had ES of 5. Eleven of 17 Graves’ disease had an ES of 1, 5 had ES of 2 and 1 had an ES 3. There were no correlation between ES and erytocyte sedimantation rate, C-reactive protein, thyroid stimulating hormone, free T3, free T4, levels in each groups.

Conclusion: SAT is related with increased stiffness of the thyroid tissue whereas Graves’ disease is related with only a slightly increase in the stiffness of thyroid tissue. Elastosonography may be used as an adjunctive method to support the differential diagnosis of SAT.

 

Nothing to Disclose: EA, MO, MSA, MK, BU, MC, TD, EC, TD

16700 56.0000 MON-0518 A The Role of Elastosonography in the Diagnosis of Subacute Thyroiditis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Sridevi Paladugu*1 and Rakesh Kumar Sahay2
1Apollo Hyderguda, Hyderabad, India, 2Osmania General Hospital, Hyderabad, India

 

Auditory evoked potentials (AEPs) are a subclass of Event related potentials (ERPs) used to study information processing in CNS objectively.Most of the studies on cognitive function in hypothyroidism were subjective .The P300 wave is an AEP which is used to assess cognitive function, it is recorded as positive deflection in voltage at latency of roughly 300milliseconds(ms) at 2 points on scalp at Cz(Cz :On the midline of the head at the vertex)and Pz (Pz: On the midline of the head between vertex and occipital protruberence).This study was undertaken to evaluate ,the effect of hypothyroidism on cognitive function using  latencies of P300.P300latency suggests that shorter latency times are related to better cognitive performance.P300 latencies were also done after thyroxine replacement to see the effect of treatment on cognitive function.Biochemically proven new onset cases with hypothyroidism were enrolled into study. After detailed history & physical examination P300 potentials were recorded at 2 points -Cz and Pz using a Nicolet Viking Select neuro-diagnostic system version 10.0. Study was done in electrophysiology lab in Osmania Medical College. Results: Patient characteristics (i.e age, sex, BMI) of both cases and controls were comparable.Cases consisted of 2 groups, overt hypothyroid cases −24, mean TSH values in them was 94.1,subclinical cases−21 in whom mean TSH value was 12.3.Mean P300 latencies of all cases at Cz was 342.42±29.5ms,and at Pz was 345.4±30ms.Mean P300 latencies of controls at Cz was 296.4±34ms and at Pz was 297.9±33ms.Difference between cases and controls was highly significant p value <0.001.Mean P300 values in overt cases was 362.6±32.9ms at Cz, and at Pz it was 362.5±33.9ms.Mean P300 values in subclinical cases was 319.3+/30.9ms at Cz, and at Pz it was 316.4±27.9ms.P300 values in overt cases was highly significant compared to controls.Whereas p300 values in subclinical cases vs controls was just significant.There was statistically significant difference in p300 values (at Cz and Pz) before and after treatment in overt (P value<0.001)as well as subclinical cases (P value<0.009).P300 latency prolongation in both clinical and subclinical hypothyroid cases shows that cognitive function is affected adversely in hypothyroidism including the subclinical hypothyroid cases. Larger studies evaluating the effect of subclinical hypothyroidism on cognitive function are needed with objective means such as the  auditory evoked potentials p300.

 

Nothing to Disclose: SP, RKS

13592 57.0000 MON-0519 A Evaluation of Cognitive Function Using p300 Evoked Potentials in Hypothyroid Patients before and after Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Alejandro Velez-Hoyos*1, Carlos Simon Duque2, Karen Lorena Palacios-Bayona3, Carolina Aguilar-Londoño3 and Natalia Aristizabal-Henao4
1Dinamica IPS, Medellin, Colombia, 2Hospital Pablo Tobon Uribe, 3Universidad de Antioquia, Medellin, Colombia, 4Universidad Pontificia Bolivariana, Medellin, Colombia

 

ABSTRACT

 

Background: Thyroid metastases are not rare, and should always be considered a possible diagnosis in presence or absence of primary neoplasm; they represent approximately 1.4 to 3% of all the thyroid malignancies, but autopsies reveal that the incidence could be up to 24%. The primary tumors that most frequently produce metastases to the thyroid are renal (22%) and lung (22%) followed by head and neck tumors (12%). But, there are also reports that related with breast cancer, gastrointestinal tumors, melanoma, sarcoma, hematologic neoplasm and urinary tract tumors. The diagnosis can be made in a precise way with the fine needle aspiration citology (FNAC) of the suspicious thyroid nodule, but sometimes, only the pathology after surgery is the reveals the diagnosis. 

Clinical Case: We present three cases of malignant melanoma and one patient with renal cell carcinoma that had thyroid metastases, characterized for presenting years after the primary tumor had been identified and treated, the diagnosis could be made with FNAC of the thyroid, just one patient was taken to surgery considering the prognosis and management expectations. The patients died rapidly after identified the metastases in the cases of malignant melanoma and thyroidectomy did not show improvement in outcomes.

Conclusion: The presence of thyroid metastases confers poor prognosis and up to date it is not clear the role of thyroidectomy as a modifier of the survival, although some patient may benefit from surgery.

 

Nothing to Disclose: AV, CSD, KLP, CA, NA

16098 58.0000 MON-0520 A Thyroid Metastases Confers Poor Prognosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Hernando Vargas-Uricoechea*1, Ivonne Meza-Cabrera2, Alfredo Romero-Rojas3 and Hernando David Vargas-Sierra4
1Universidad del Cauca, Popayán-Colombia, Popayán-Cauca, Colombia, 2Hospital Universitario San José, Popayán-Cauca, Colombia, 3Instituto Nacional de Cancerología, Bogotá, DC, Colombia, 4Corporación Universitaria Rafael Núñez, Cartagena-Bol, Colombia

 

Background: Thyroid nodules (TN) have become a common clinical problem. The minority of them are harmful, hence the need for correct diagnosis in order to avoid unnecessary surgical procedures. Considering the high frequency of TN in the population, it is not cost effective to assess structure and function in all nodules found; indeed, up to 38% of palpable nodules shrink spontaneously. However, the agreement between TN ultrasound findings and BACAF is not clear.  Consequently, establishing an agreement standard (or concordance) between the two diagnostic procedures might result in lower healthcare costs and reductions in unnecessary procedures in a population at risk. 

 Methods: This study determined the agreement of Ultrasound (reported with TIRADS criteria) and Fine Needle Aspiration Biopsy –FNA- (reported with BETHESDA criteria) used for the assessment of the non-hyper functional TN. A total of 180 subjects 18 years old or older underwent the two diagnostic tests and their results were compared using weighted and stratified kappa index. 

 Results: Participants were mostly women (78,3%) with an average age of 57 years, and with a family history of thyroid cancer (33,9%). Paralysis of vocal cords was present in 27,8%, while nodule size was >4cm in 39,4%. The observed agreement was 87,2% with a linear weighted kappa of 0,69 (95% CI: 0,59-0,79).

 Conclusions: In our target population the results from this study show that thyroid ultrasound imaging recorded under TIRADS criteria are in good agreement with the cytological findings (BETHESDA) obtained by means of punch biopsy. In all likelihood, malignant findings on ultrasound will be consistent with the results from the cytology.

 

Nothing to Disclose: HV, IM, AR, HDV

14212 59.0000 MON-0521 A Agreement Between Ultrasound Criteria-Tirads- and -Bethesda- Cytological Criteria in the Non-Hyperfunctional Thyroid Nodule 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Ishita Prakash*1 and Sabyasachi Sen2
1GW University Hospital, Washington, DC, 2The George Washington University, Washington, DC

 

Title: Use of Lithium as an alternative therapeutic option in management of Graves Thyrotoxicosis

Ishita Prakash, MD, Fellow, Endocrinology Fellowship Program, GW University

Sabyasachi Sen, MD, PhD, FACP, FACE, Associate Professor, Endocrinology, GW University (ENDO full member # 212740)

Case History:  A 67 year old woman was admitted with signs and symptoms of Graves thyrotoxicosis. Biochemistry: TSH undectable; FT4 >6.99 ng/dL (0.7-1.8); FT3 18 pg/mL (3-5); TSI 658% (0-139). Thyroid Uptake and Scan showed diffusely increased tracer uptake in the thyroid gland. The patient was started on Methimazole 40 mg BID but her LFTs elevated precipitously with features of fulminant hepatitis. Methimazole was determined to be the cause, and was stopped.

After weighing pros and cons Lithium was initiated to treat her persistent thyrotoxicosis. Lithium 300 mg daily was given daily with a goal to maintain between 0.4-0.6. High dose Hydrocortisone and propranolol were also administered concomitantly.

Free thyroid hormone levels decreased and the patient reached a biochemically euthyroid state in about 8 days. Though definitive RAI was planned the patient has been maintained on Lithium for more than a month to control her hyperthyroidism. Trial removal of Lithium results in re-emergence of thyrotoxicosis within 24 hours. Thus far, there has been no development of Lithium toxicity and the patient remains clinically and biochemically euthyroid.

Conclusion: Lithium has a unique physiologic profile and can be used to treat thyrotoxicosis when thionamides cannot be used while awaiting elective radio-ablation. Lithium levels must be closely monitored to prevent development of toxicity.

 

Nothing to Disclose: IP, SS

16142 60.0000 MON-0522 A Use of Lithium As an Alternative Therapeutic Option in Management of Graves Thyrotoxicosis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Hiroki Shimura*1, Asako Miyazaki2, Katsumi Taki3, Fumihiko Furuya4, Kazuyasu Ohta4, Masato Ikeda5, Kazutaka Haraguchi6, Toyoshi Endo4, Masahiro Takusagawa2, Yukio Ozaki4, Shinichi Suzuki7, Nobuhiro Fukunari8, Masashi Kitaoka9 and Tetsuro Kobayashi4
1Fukushima Medical University, Fukushima-shi, Japan, 2Isawa Hot Spring Hospital, 3Fujiyoshida Municipal Hospital, 4University of Yamanashi, 5Yamanashi Hospital of Social Insurance, 6Haraguchi Naika Jin Clinic, 7Fukushima Medical University, Fukushima, Japan, 8Showa University School of Medicine, 9Showa General Hospital

 

Accumulating evidence revealed that subclinical hypothyroidism increases various clinical risks such as cardiovascular diseases.  In addition, association of subclinical hyperthyroidism and morbidity and mortality of cardiovascular diseases  Recent advances permitting high-resolution ultrasonography has raised importance of ultrasonographic examination in management of autoimmune thyroid diseases and consequent thyroid dysfunction.  Previously, we performed a multi-center study in which all of participants with thyroid autoantibody-positive thyroid dysfunction were found out from general population by B-mode ultrasonographic examination.  We also observed that 50% and 20% of autoantibody-positive and antibody-negative euthyroid subjects showed abnormal ultrasonographic findings suggesting diffuse thyroid diseases, respectively.  In this study, we prospectively analyzed the spontaneous course of thyroid function in the subjects with or without ultrasonographic findings in the thyroid, and investigated whether ultrasonographic diagnosis can be a predictor  in the development of thyroid dysfunction.

Participants with normal thyroid function in our previous study were enrolled in this study.  We performed thyroid function tests 2 to 7 years after the initial study.  The participants in this study were classified into 4 groups.

Group A: thyroid autoantibody-negative, ultrasonographically normal.

Group B: thyroid autoantibody-negative, ultrasonographically abnormal.

Group C: thyroid autoantibody-positive, ultrasonographically normal.

Group D: thyroid autoantibody-positive, ultrasonographically abnormal.

Between 2005 and 2012, 778 participants were enrolled in this study.  In Group A, B, C, and D, hypothyroidism, including subclinical and overt disorder, was appeared in 3.0%, 4.0%, 6.0%, and 9.0% of participants, respectively.   The rate of onset in Group D was significantly higher than that in Group A.  Hyperthyroidism, including subclinical and overt disorder, was developed in 3.0%, 4.0%, 1.3%, and 5.1% in Group A, B, C, and D, respectively.  The rate of onset in Group D was highest, but there was, nevertheless, no significant difference.  To analyze the susceptibilities to risks of hypothyroidism and hyperthyroidism simultaneously, we calculated absolute values of Δlog(TSH) and ΔFT4.  These values in Group D exhibited significant differences compared with those in Group A.

These results suggest that B-mode ultrasonographic examination of thyroid gland is useful in prediction of progression to thyroid function disorder in autoantibody-positive euthyroid individuals.

 

Nothing to Disclose: HS, AM, KT, FF, KO, MI, KH, TE, MT, YO, SS, NF, MK, TK

14516 61.0000 MON-0523 A B-Mode Ultrasonography Is a Predictor of Progression to Thyroid Dysfunction: A Prospective Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Tiago Lopes Nunes da Silva*, Henrique Vara Luiz, Bernardo Dias Pereira, Ana Catarina Matos, Isabel Manita and Jorge Ralha Portugal
Garcia de Orta Hospital, Almada, Portugal

 

Introduction

Acute suporative thyroiditis is a rare and potentially life threatening infection of the thyroid gland. In healthy individuals it has been associated with a left side persistent fistula of the pyriform sinus or from a fistulous tract caused by fine-needle aspiration cytology (FNAC) . In an immunocompromised host it is usually caused by hematogenous spread. Due to its rarity it may present difficulties in the differential diagnosis with sub acute thyroiditis.

  • Clinical Case

We report the case of a 41 year-old otherwise healthy woman who presented with right neck pain and goiter for 3 months. The initial investigation showed a euthyroid state and a 15 mm right lobe thyroid nodule. As symptoms progressed, she was evaluated by an endocrinologist who diagnosed a sub acute thyroiditis and treated her with prednisolone and aceclofnac. Twenty days latter, she was admitted to an endocrinology unit with a tender goiter with cutaneous inflammatory signs, increased inflammatory parameters, euthyroidism and without fever. The patient was started on flucloxacilin. Ultrasonography showed an abscess in the right thyroid lobe with 4,7*1,8*5,7 cm with anterior extension to another 14 mm abscess.  Cervical CT confirmed the thyroid abscess and showed cartilaginous, muscular and vocal cord involvement. Ultrasound guided FNAC sampled a purulent fluid collection with positive culture for a penicillin sensitive Streptococcus milleri. The patient was switched to penicillin G with normalization of the inflammatory parameters and spontaneous drainage of the fluid collection. At the 12th treatment day she developed a prurigenous rash which worsened with each penicillin infusion. In order to continue her treatment she underwent a successful desensitization protocol. The etiologic study showed no risk factors for the thyroid infection: negative auto-immunity, no HIV or hepatitis viral infection and no fistular tract  (negative oral esophagogram and transnasal flexible fiberoptic laryngoscopy).  At the 45th day of therapy the patient was discharged, clinically asymptomatic, with a subclinical hypothyroidism and with neck imaging showing a resolution of the thyroid abscess and a marked improvement in the muscular and cartilaginous infiltration.

  • Conclusion.

The authors present a patient with an acute thyroiditis for which there was no clearly identifiable risk factor. This case illustrates the importance of considering this rare and potential life threatening disease in the differential diagnosis of a tender thyroid gland since the patient already showed laryngeal involvement at the time of diagnosis. Another important teaching point was the need to do a desensitization protocol in order to maintain the best etiological treatment and prevent further infection spread and vocal cord and cartilage destruction.

 

Nothing to Disclose: TLN, HVL, BDP, ACM, IM, JRP

16146 62.0000 MON-0524 A Acute Bacterial Thyroiditis with No Risk Factors and a Difficult Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Kazuhiko Matsuzawa*1, Shoichiro Izawa1, Hiroko Ohkura1, Risa Nakanishi1, Keisuke Sumi1, Hideki Shiochi1, Youhei Fujioka1, Naoya Yamamoto1, Tsuyoshi Ohkura1, Akio Yoshida2, Chiaki Shigemasa3, Masahiko Kato1, Kazuhiro Yamamoto1 and Shin-ichi Taniguchi1
1Tottori University Faculty of Medicine, Yonago, Japan, 2Tottori University Graduate School of Medicine, Yonago, Japan, 3Tottori Municipal Hospital, Tottori, Japan

 

[Back ground] Graves’ ophthalmopathy (GO) is considered that typical cases have bilateral eye disorder. However, it is not rare to experience the cases which signs and symptoms were shown only unilateral eye. So, we analyzed the difference of treatment response to intravenous glucocorticoid therapy (ivGC) between bilateral GO and unilateral GO.

[Method] Thirty-nine patients with GO who were received ivGC at Tottori University Hospital were studied. We found the ratio that calculates thickness of most enlargement extraocular muscle / diameter of the optic nerve, as ‘GO-MRI index’. Finally, we found the ratio between ‘GO-MRI index’ of right and left, which named ‘Bilateral index’. We divided those patients into two groups, one of which was over 1.4 Bilateral index (patients of unilateral, named group U) and the other was less than 1.4 Bilateral index (patients of bilateral, named group B). The response to ivGC was evaluate by clinical activity score (CAS), diplopia, proptosis, GO-MRI index and Bilateral index in both groups.

[Results] Group U consisted of 13 patients and group B consisted of 26 patients. Before ivGC, following parameters, age, TSH, TSAb, duration from the onset GO, CAS, diplopia, proptosis and GO-MRI ratio of both groups were not shown significantly difference. Mean Bilateral ratio was 1.6 in group U and 1.1 in group B. Mean decrease of CAS after ivGC was 2.4 points in group U, 2.5 points in group B (not significance). Number of patients who got improvement of diplopia after ivGC were 4 cases (30.7%) in group U, 18 cases (69.2%) in group B (p<0.05). Mean decrease of proptosis was 0.5mm in group U, 0.6mm in group B (not significance). Mean GO-MRI index after ivGC was 1.5 in group B, 1.4 in group U (not significance). Mean Bilateral ratio was 1.3 in group U, 1.0 in group B (p<0.05).

[Discussion] There was almost same response to ivGC for CAS, proptosis and GO-MRI index in both groups, however there was poor therapeutic response for diplopia and Bilateral index in group B. It was difficult to improve Bilateral index by ivGC, and this is one of reasons for remain of diplopia after ivGC. This study suggests that GO patients of unilateral eye disorder have a tendency to remain diplopia.

 

Nothing to Disclose: KM, SI, HO, RN, KS, HS, YF, NY, TO, AY, CS, MK, KY, SIT

13668 63.0000 MON-0525 A Differential Therapeutic Response to Intravenous Glucocorticoid Therapy for Graves' Ophthalmopathy Patients with Bilateral Eye Disorder and Unilateral Eye Disorder 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Mehmet muhittin Yalcin, Goksun Ayvaz, Ozlem Gulbahar, Fusun Toruner*, Cigdem Ozkan, Alev E. Altinova, Mujde Akturk and Metin Arslan
Gazi University Faculty of Medicine, Ankara, Turkey

 

A 31 year-old female was admitted to our hospital with inconsistent TSH results while using

levothyroxine treatment despite dose adjustment.

She had a history of total thyroidectomy for multinodular goiter two years ago. The pathology was

benign. After the operation levothyroxine replacement therapy (LRT) was started. While she

was taking 150 µg/d Levothyroxin therapy regularly, euthyroid state could not be achieved. Her

laboratory analysis showed spuriously high TSH levels with low free (f) T3 and fT4, despite she

was complaining for only mild fatique.

She had no other medical problems and was not taking any other drugs. Her TSH level was 650

µIU/ml (reference interval: 0.35-4.94 µIU/ml) with low levels of fT4 and fT3. The anti-thyroglobulin

and anti- thyroid peroxidase antibodies were negative.

Although TSH analysis were repeated in different platforms ( Abbott Architect, Siemens Advia Centaur XP, Beckman Dxi, Roche Cobas) and serial dilution analysis did not show any laboratory interference, Her rheumatoid factor was negative. Heterophile blocking and non specific antibodies were negative. Polyethylene glycol (PEG) precipitation analysis revealed a recovery of 14.1% (pre-PEG TSH:210.5 µIU/ml, post-PEG TSH: 29.8µIU/ml).

Test results suggested she had macro-TSH. Since the TSH analysis with the PEG precipitation

may not be accurate, we decided to follow-up the patient with free T4 and free T3 levels

Macro TSH should be considered in patients with inconsistent TSH results without symptoms

which are expected in patients with hypothyroidism.

 

Nothing to Disclose: MMY, GA, OG, FT, CO, AEA, MA, MA

16250 64.0000 MON-0526 A A Rare Cause of Discordant TSH: Macro-TSH 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Kevser Onbasi*1, Lezan Keskin2 and Serdar Ucgun3
1Dumlupinar University, Kutahya, Turkey, 2Malatya State Hospital, Malatya, Turkey, 3Dumlupınar University, Kutahya, Turkey

 

Introduction: Thyrotoxicosis is a frequent disease occurring in approximately 2% of women and 0.2% of men. Thyrotoxicosis can have many causes; such as Graves’ disease, and toxic nodular goiter. Autoimmune forms of thyrotoxicosis are more prevalent among smokers. Toxic nodular goiter is common in regions where dietary iodine is insufficient. Anti- thyroid therapy during thyrotoxicosis can affect the platelet count due to bone marrow suppression but also thyrotoxicosis itself can be associated with thrombocytopenia. For a better understanding of the pathogenesis of thrombocytopenia we evaluated thyrotoxicosis patients before and after drug therapy. Methods: We retrospectively analyzed the clinical records of 91 patients diagnosed to have thyrotoxicosis. The platelet counts during the hyperthyroid phase and after the treatment were evaluated. Therapy duration was depending on achieving the euthyroid status.  Statistical analyses for comparison of the mean values were done with the Student’s t-test. p< 0,05 was considered as significant.  Results: 26 male and 65 female patients were evaluated. The mean age of male patients were 48, 46±16, 4/year and 54, 41±19, 49/year for female patients. The platelet count before therapy 219,04±79,43 /x103 ul  and 248,49±72,47/x103 ul after therapy ( p value was <0,001) . The MPV (mean platelet volume) was 8, 73±1, 07 fl before therapy and 8, 68±1, 15 fl (p value was <0,001) when the patient became euthyroid.  TSH levels and FT4 levels were 0,056±0, 1 mIU/L (normal 0.30–4.00) and 2,22± 1, 46 ng/dL (normal 1.00-1.60), respectively before therapy and  TSH levels were 2, 87±8, 38 and FT4 levels were 1, 17±0, 5 after therapy (p values were <0,001). Discussion: The thyrotoxic state can affect the platelet numbers, but the effect of therapy on platelet numbers is controversial. Anti-thyroid drugs may have some suppressive effects on bone marrow and also normalization of the thyrotoxic status may lead to normalization of the thrombocytopenia. In our study the mean value of the platelet count was lower during the hyperthyroid status, which may depend on the increased turnover of the platelets.  The platelet numbers in our study group increased after resolution of the thyrotoxic state suggesting the theory that elevation of thyroid hormones can diminish platelet numbers which seems to be reversible with appropriate therapy. Improvement in thyroid function with drugs may lead to the spontaneous recovery of the platelet count.

 

Nothing to Disclose: KO, LK, SU

14509 65.0000 MON-0527 A May Thyrotoxicosis Trigger Thrombocytopenia? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Miriam Thomas*1 and Hilary Whitlatch2
1Brown University, Providence, RI, 2Alpert Medical School of Brown University/Rhode Island Hospital, East Providence, RI

 

Introduction: The thyroid is not susceptible to bacterial infections, given it is encapsulated with a rich blood supply, lymphatic drainage system and  high iodide content. When such infections occur, the most common pathogens are Staphylococcus aureus and Streptococcus pyogenes. The most commonly affected patients are immunocompromised or have pre-existing thyroid disease. Treatment consists of broad spectrum parenteral antibiotics with surgical intervention if there is evidence of intraglandular abscess or gas. Although the prevalence of methicillin-resistant S. aureus (MRSA) infection is increasing, there are few reports of acute suppurative MRSA thyroiditis.

Clinical Case:  A 37 year old man with ongoing intravenous drug use, hepatitis C and no known history of thyroid disease presented with 3 days of progressive throat swelling, pain and fever. He noted intermittent sweats, but denied palpitations, tremor, change in weight, or diarrhea. A CT scan suggested suppurative thyroiditis without discrete abscess, and he was transferred to our tertiary medical facility. On admission, temperature was 100.1oF, heart rate 118 and oxygen saturation 78% on room air. Physical exam revealed a tender, boggy thyroid 3 times normal size with overlying cellulitis. Laboratory studies included a white blood cell count  6.4 (3.5-11 x 109/L) with 22% bands, TSH 0.018 (0.35-5.5 uIU/ml), free T4 1.68 (0.8-1.8 ng/dl), and free T3 428.5 (230-420 pg/dl). An ultrasound showed an enlarged, heterogeneous thyroid with decreased perfusion. A chest CT  showed multifocal pneumonia consistent with septic emboli.

He was intubated for airway protection and treated with vancomycin and cefepime. Blood cultures were positive for MRSA.  A transesophageal echocardiogram was without evidence of endocarditis.  After 2 weeks of antibiotics, thyroid fluctuance was noted. A C-spine MRI showed a cystic, multispatial mass extending from the base of the tongue to the thoracic inlet.  A thyroid fine needle aspiration revealed frank pus, prompting surgical drainage of a large volume of purulent fluid, the cultures of which grew MRSA. HIV testing was negative.

By his third week of treatment, thyroid function tests had normalized. Three weeks later, TSH 24.96,  Free T4 0.27, and Free T3 118, and he was started on levothyroxine. He developed fevers and neutropenia attributed to vancomycin, prompting transition to daptomycin and cefepime. Over time, his thyroid decreased substantially in size. Ultimately, he was unwilling to complete 6 weeks of IV antibiotics in-house and signed out against medical advice on oral double strength Bactrim to complete his last week of therapy. TSH 8 months after discharge was 79, suggesting permanent hypothyroidism.

Conclusion: Acute suppurative MRSA thyroiditis is rare and can present as a rapid and progressive infection requiring prompt antibiotic therapy and surgical evaluation.

 

Disclosure: HW: Coinvestigator, Takeda, Coinvestigator, Novo Nordisk. Nothing to Disclose: MT

16283 66.0000 MON-0528 A A Case of Acute Suppurative MRSA Thyroiditis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Farhan Sheikh*, Monica Y Plazarte and Ali Iranmanesh
VA Medical Center, Salem, VA

 

Background: Association of malignant thyroid nodules with hyperthyroidism is variably reported as decreased, unchanged, or increased when compared to the euthyroid cohorts. We present the case of a patient with Graves’ disease with metastatic anaplastic thyroid cancer.

Clinical Case:  49 year old male was first seen in Endocrine Clinic in early 2012. Past medical history was significant for a goiter claimed by the patient to be unchanged in size for a number of years. He was diagnosed with hyperthyroidism in late 2011, and was started on methimazole (stopped 6 days prior to Clinic visit) and propranolol by his primary care provider. PE was remarkable for lid lag, markedly enlarged multinodular goiter, particularly on the left side, and no palpable cervical lymph nodes. Laboratory findings:  Free T4 >8 ng/dL (n: 0.76-1.46), free T3 > 30 pg/mL (n: 2.5-3.9), TSH <0.005 µIU/mL (n: 0.48-3.94), thyroid peroxidase 1339 IU/mL (n: 0-34), ThyRAb 540 IU/L (n: 0-1.75); 123I uptake: 2 hr 56% (n: 3-8), 6 hr 64% (n: 3-17); scan: enlarged thyroid gland with large cold area in the left lobe; thyroid US: large multinodular goiter with dominant nodule in the left lobe. At this point, patient declined 131I treatment or surgical intervention and elected to continue treatment with methimazole under the care of his primary care provider. In mid 2013, patient sought medical care for further enlargement in the thyroid gland over a 3-4 week period, and development of multiple scattered nodules. PE at his time was significant for markedly enlarged thyroid gland, right clavicle/manubrium sterni mass, right groin mass, right deltoid mass, and right axillary lymphadenopathy. Imaging studies revealed large necrotic thyroid mass, bilateral pulmonary nodules, upper sternal lesion, and C4-C5 paraspinal filling defect.  Pathological assessment performed by FNB was diagnostic of follicular cancer of thyroid and anaplastic cancer of sternal mass.

Conclusion: Considering the clinical course, it is presumed that the development of Graves’ disease with markedly elevated TSH receptor immunoglobulin provoked further growth of an underlying follicular carcinoma, leading to local/distant metastases, and eventual anaplastic transformation. With this in mind, a more aggressive approach to the work-up and management of thyroid nodules in a setting of Graves’ disease may be warranted, particularly when the disease is associated with high level of TSH receptor immunoglobulins.

 

Nothing to Disclose: FS, MYP, AI

16411 67.0000 MON-0529 A Association of Metastatic Anaplastic Thyroid Cancer with Graves' Disease: Potential Role of TSH-Receptor Immunoglobulin in the Anaplastic Transformation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Jenna L. Sarvaideo*1, Eisha Wali2, Ying Zhou3, Tricia A Moo-Young4, Alexandra E Reiher4 and Mihir K. Bhayani3
1Medical College of Wisconsin, Milwaukee, WI, 2Case Western Medical School, 3Northshore University Health System, Evanston, IL, 4NorthShore University Health System, Evanston, IL

 

Introduction:

Obstructive sleep apnea (OSA) is a disorder characterized by recurrent, partial or complete episodes of apnea due to upper airway obstruction during sleep. The presence of external thyroid compression may be one of many causes for obstruction. Several small series have found that thyroid surgery can improve compressive symptoms of OSA both subjectively and objectively. The purpose of our study was to determine if undergoing thyroid surgery improved the degree of obstructive sleep apnea post-operatively when evaluated by polysomnogram (PSG), regardless of whether or not the indication for surgery was compressive symptoms. 

Methods:

A retrospective chart review was performed using diagnostic codes for patients who had undergone both thyroid surgery and PSG between 2003 and 2012. Patients who had both a pre-operative and post-operative PSG were included. Primary outcome measure was change in apnea-hypopnea index (AHI). Secondary outcome measures were body mass index (BMI) and thyroid gland weight.

Results:

We identified 97 patients who had both a thyroidectomy and PSG. Of these, only seven patients had both pre- and post-operative PSG evaluation. All seven patients had OSA confirmed by nocturnal PSG prior to thyroidectomy.

Two patients were male and five female. Average age at time of thyroidectomy was 52.7 years (range 40-73). Six patients underwent a total thyroidectomy; one patient had a left hemithyroidectomy. Indications for surgery were: thyroid cancer (N=4), indeterminate cytology (N=1), thyroid nodule >4cm (N=1) and Graves’ disease (N=1).

Average thyroid gland weight was 42.2 grams (12-100 g, SD=30.9). Average right thyroid lobe volume was 24.4 cm3 and average left thyroid lobe volume was 17.4 cm3.

Mean pre-thyroidectomy BMI was 41.1 kg/m2 (27.4-58.7 kg/m2). Mean post-thyroidectomy BMI was 41.8 kg/m2 (29.4-62.6 kg/m2). The BMI increased from pre to post-thyroidectomy, but the change was not statistically significant (p=0.5625). Mean pre-thyroidectomy AHI was 19.44. Mean post-thyroidectomy AHI was 29.18. The mean AHI increased from pre- to post-thyroidectomy, but change was not statistically significant (p=0.3906).

The change of AHI was positively correlated with change of BMI (correlation coefficient=0.36, p=0.43), i.e. the larger the change of BMI from pre-thyroidectomy, the larger the change of AHI from pre-thyroidectomy.

Conclusions:

This pilot study found no significant improvement in sleep apnea after thyroidectomy. While it is known that thyroidectomy can relieve symptoms of OSA in patients with large goiters, substernal goiters, and symptoms of compression; few studies have assessed for changes in objective measures of sleep apnea before and after thyroid surgery in patients without such indications. This study suggests thyroidectomy is unlikely to benefit patients with OSA who do not have compressive symptoms prior to surgery. 

 

Nothing to Disclose: JLS, EW, YZ, TAM, AER, MKB

16501 68.0000 MON-0530 A A Retrospective Study Reveals No Change in Sleep Apnea Symptoms after Routine Thyroidectomy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Roberto Vita*1, Giovanna Saraceno1, Francesco Trimarchi1 and Salvatore Benvenga2
1University of Messina, Messina, Italy, 2University of Messina Policlinico G. Martino; University of Messina School of Medicine;University Hospital Policlinico G. Martino, Messina, Italy

 

Background and hypothesis. Among drugs that impair tablet levothyroxine (LT4) intestinal absorption, calcium salts (CaS) and iron salts (FeS) act by sequestrating LT4 into insoluble complexes, thus hindering LT4 permeation through the intestinal epithelium. In our country, a novel formulation available is LT4 as oral solution (OS) (Tirosint®soluzione orale, IBSA Italia s.r.l.). Unlike the tablet, OS LT4 does not need a dissolution phase prior to its absorption in the upper intestine. Therefore, we hypothesized that, in patients with tablet LT4 malabsorption induced by CaS or FeS, switching to the OS would minimize the T4 malabsorption.  

Methodology. Upon informed consent, we recruited 11 patients with tablet LT4 malabsorption due to CaS (8 patients), or FeS (2 patients), or both CaS and FeS (1 patient). All the 11 patients used to take LT4 120 to 180 minutes prior to either CaS or FeS. Of the 11 patients, 9 took LT4 for replacement (REP group), while 2 patients did so for TSH-suppression (SUP group). While maintaining the same daily dose, we switched the 11 patients from the tablet to OS LT4. TSH (mU/L) was assayed at least twice in each patient, starting from two months after the switch. Data are mean±SD [and median]. Statistics is based on Wilcoxon test and Fisher’s exact test.

Results. In the REP group, serum TSH decreased significantly at least two months after the beginning of tablet LT4 therapy (pre-therapy 33.1±20.0 [27.6] vs. 9.7±7.6 [7.2], P= 0.002), but remained far above the target of ≤2.5 mU/L. After the switch to the OS, serum TSH decreased substantially (9.7±7.6 [7.2] vs. 2.2±1.3 [2.4], P< 0.0001). Under the OS, 11/21 (52.4%) determinations of TSH fell within the target level, while only 2/20 (10%) (P= 0.006) did so under the tablet. Using a TSH target level of ≤4.12 mU/L [1] the proportion became 20/21 (95.2%) under the OS and 4/20 (20.0%) under the tablet (P< 0.0001). In the SUP group, TSH was significantly lower under the OS than under the tablet (0.2±0.2 [0.07] vs.1.0±0.6 [1.1], P= 0.005). Of the 7 TSH determinations under the tablet, none was ≤0.10 mU/L, in contrast with 4/5 (80%) under the OS (P= 0.01).

Conclusions.We conclude that LT4 contained in the OS is protected from the sequestration by CaS or FeS. Patients who fail to reach target serum TSH levels because they take CaS and/or FeS, may benefit from switching to the OS without increasing LT4 daily dose. Alternatively, these patients should take OS from the beginning.

[1] Garber JR et al. Thyroid. 2012;22:1200-35.

 

Nothing to Disclose: RV, GS, FT, SB

11907 69.0000 MON-0531 A Levothyroxine Oral Solution Solves the Problem of Impaired Absorption Due to Calcium and Iron Salts 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Vaishnavi Amit Parnerkar*1, Jamil Alkhadoo2 and Tasma Harindhanavudhi3
1University of Minnesota, MN, 2University of Minnesota, 3Univ of Minnesota, Minneapolis, MN

 

INTRODUCTION:Medullary thyroid cancer (MTC) arises from parafollicular C cells of the thyroid and represents ~3% of thyroid cancer. Although it is rare, early detection may reduce adverse consequence. Elevation of serum calcitonin (Ct) is associated with MTC. However, the routine measurement of Ct in incidentally discovered thyroid nodule is controversial.


CASE:A 55 year old woman with SLE, seizure, cardiac arrhythmia status post pacemaker presented for an evaluation of incidental thyroid nodules noted on CT scan of the neck. She had complained of right-sided neck pain without dysphagia for 8-9 months. Her grandmother had thyroid cancer and adrenal cancer although the details were unknown. She denied personal history of cancer or radiation exposure. Thyroid ultrasound revealed a 1.6 x 1.4 x 1.4 cm solid hypoechoic isthmic nodule, 1.4 x 0.9 x 0.9 cm hypoechoic nodule with internal calcification and 0.9 x 0.5 x 0.6 cm hypo echoic nodule on the left lobe. Serum Ct was screened given a family history of thyroid cancer and was elevated at 207 pg/ml (normal <10 pg/ml). The patient was not on any medications interfering with Ct level. FNA of all nodules was performed. The left inferior nodule was positive for malignancy with Hurthle’s cell predominance and the isthmic and left superior nodule showed follicular neoplasm with Hurthle's cell feature. She underwent total thyroidectomy. Pathology revealed multifocal 1.1 cm MTC without lymphovascular invasion and lymph node involvement and was staged as T1bN0Mx. Post-operative Ct level normalized.


CONCLUSION: The diagnostic accuracy of FNA in detecting MTC varied widely based on a cytology series with the sensitivity ranging from 63 to 80%. Ct measurement represents the most sensitive test for an early diagnosis of MTC. It has improved the histologic assessment and has resulted in an increased incidence of MTC. Other diagnostic approaches include pentagastrin stimulated Ct measurement, FNA and Ct measurement on FNA washout. The routine screening of Ct in the patient with incidental thyroid nodules is still not a standard practice in the USA.  Area of uncertainty is mainly from the difficulty assigning the cut-off value, lack of pentagastrin in the USA and unproved cost-effectiveness. Elevated basal Ct level is also present in other conditions including medications, smoking status, autoimmune thyroiditis, hyperparathyroidism, hypergastrinemia, renal insufficiency and neuroendocrine tumor, although, the value greater than 100 pg/ml is highly suggestive of MTC. Also, men and women differ in thyroidal C-cell mass and Ct secretion. Our case reinforces the Ct screening in the patient with incidentally discovered thyroid nodules and increased risk of MTC based on history. Significant basal Ct elevation should prompt further intervention. Whether routine screening should become available and recommended in the USA, yet to be further determined its utility.

 

Nothing to Disclose: VAP, JA, TH

16430 70.0000 MON-0532 A Calcitonin Measurement in Incidental Thyroid Nodule: An Importance of Diagnostic Screening 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Aileen Grace Malazarte Salalima - Dela Paz* and Christy Sy Yao
The Medical City, Pasig City, Philippines

 

 

Introduction

The clinical spectrum of Posterior Reversible Encephalopathy Syndrome (PRES) is rarely reported in the presence of autoimmune thyroid disease.  In this article, we report a case of uncontrolled Graves’ disease in thyroid storm, with characteristic radiologic findings and neurologic manifestations consistent with PRES.

 

Clinical Case

A 33-year-old Filipino woman, with Graves’ disease for 7 years, presented with sudden complete loss of vision and signs and symptoms of thyroid storm (Burch and Wartofsky score of 80).  Cranial MRI showed multiple cortical/subcortical foci of T2/FLAIR prolongation in the occipital lobes and the parasagittal regions of the parietal and frontal lobes which were bilateral and fairly symmetric in distribution.  Baseline thyroid function tests showed a TSH of 0 (0.35 – 4.94 uIU/mL), elevated FT3 and FT4 levels at 6.11 (1.71 – 3.71 pg/mL) and 2.29 (0.70 – 1.48 ng/dL) respectively. She was given Propanolol and Propylthiouracil, which was later shifted to Methimazole.

Spontaneous improvement in vision was noted a few hours after onset of symptoms.  On the 5thhospital day, the patient had sudden onset of difficulty of breathing and went into cardiopulmonary arrest. The patient was resuscitated after nine minutes and underwent therapeutic hypothermia.  Intravenous antibiotics for possible aspiration pneumonia and vasopressors were given.  The patient developed acute renal failure with multiple electrolyte imbalance for which renal replacement therapy was started. 

Cardiology referral was made due to multiple arrhythmias with findings of diastolic failure secondary to hyperthyroidism, ventricular diastolic dysfunction and hypertension. 

The patient’s sensorium gradually improved and she was discharged with complete recovery of vision with no neurologic deficits after more than a month of hospital stay.  Repeat cranial MRI done as outpatient showed near total resolution of previous neuroimaging findings.  Autoimmune work-up (ANA) was negative.  The patient underwent RAI therapy 3 months after admission and is presently clinically and biochemically euthyroid.

 

Conclusion

PRES can lead to significant morbidity and mortality.  Early determination of its underlying etiology, as seen in this case - Graves’ disease in thyroid storm, is necessary for opportune management.

 

 

 

 

Nothing to Disclose: AGMS, CSY

16507 71.0000 MON-0533 A Atypical Presentation of Uncontrolled Graves' Disease - Posterior Reversible Encephalopathy Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Bekir Ucan*1, Mustafa Sahin2, Müyesser Sayki Arslan3, Nujen Colak Bozkurt4, Mustafa Caliskan5, Esra Tutal6, Taner Demirci7, Güleser Saylam1 and Tuncay Delibasi3
1Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey, 2Ankara University School of Medicine, Ankara, Turkey, 3Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey., 4Ankara Training and Research Hospital, Ankara, Turkey, 5Diskapi Yildirim Beyazit Teaching and Research Hospital, Ankara, Turkey, 6Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey., Ankara, Turkey, 7Diskapi Training and Research Hospital, Ankara, Turkey

 

It has been discussing whether total thyroidectomy or lobectomy as best suitable treatment option for patients with follicular neoplasm cytology. We have evaluated retrospectively our patients data subjected to thyroidectomy because of follicular neoplasm according to Bethesda classification system. A total of 74 patients with follicular neoplasm cytology by fine-needle aspiration cytology (FNAC) then consequently underwent surgery.  

A total of 74 patients, 64 (83.7%) were female, 10 (16.3%) were males. Average age was 46.3 ± 12.2 years.  In cytologic examination malignancy rate was 31/74 (% 41.9 ) in these patients. Among the patients with malignancy most common cancer were (20/31) papillary thyroid carcinomas (PTC).  Only 8 were diagnosed with follicular thyroid carcinoma, 2 were diagnosed with hurthle cell carcinoma and one of them was diagnosed as neoplasm of uncertain malignant potential. Among subtype of PTCs;  eleven were classical PTC; five were follicular variant of PTC; 2 were oncocytic variant of PTC, one was diffuse sclerosing variant, one was a columnar cell variant, PTC.

It is known that most of papillary cancer has multifocal features and metastases to central lymph nodes in the time of diagnosed. Since most of the follicular neoplasm cytology has been diagnosed as papillary cancer pathologically, and some of papillary cancer subtype has been unfavorably pathology, total thyroidectomy should be best suitable treatment option in this group.  In conclusion; lobectomy is not suitable for our patients with follicular neoplasm or hurthle cell neoplasm in cytology by fine needle aspiration biopsy.

 

Nothing to Disclose: BU, MS, MSA, NCB, MC, ET, TD, GS, TD

16614 72.0000 MON-0534 A Lobectomy May Not be Suitable for Patients with Follicular Neoplasm Cytology 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Alicia Lynn Warnock* and Henry B Burch
Walter Reed National Military Medical Center, Bethesda, MD

 

The most important determinants of survival in life-threatening thyrotoxicosis are early recognition and institution of appropriate therapy.  Yet, diagnostic efforts have been frustrated on multiple levels.  Laboratory parameters have little value in distinguishing uncomplicated thyrotoxicosis from thyroid storm.  In addition, diagnostic criteria for thyroid storm have historically been far from uniform.  Based on these difficulties, a diagnostic point scale was proposed by Burch and Wartofsky in 1993 for distinguishing uncomplicated thyrotoxicosis from impending or established thyroid storm (1).  The Burch-Wartofsky Point Scale (BWPS) is an empirically-derived system taking into account three principal observations in patients with thyroid storm, including: 1) the continuum of end organ dysfunction; 2) the high variability of individual patient presentation; and 3) the high mortality associated with a missed diagnosis. 

               In 2012, Akamizu and colleagues reported on 356 patients with definite or possible thyroid storm over a 5-year period (2).  The authors empirically-derived diagnostic criteria for thyroid storm, based on literature review; the final criteria were referred to as the Japanese Thyroid Association (JTA) criteria for thyroid storm.  The authors provided data that allows a comparison of the JTA criteria to the BWPS for the selection of patients for treatment of impending or established thyroid storm.  Assuming patients with a diagnosis of thyroid storm or impending/possible thyroid storm will receive aggressive therapy, among 406 patients the authors considered for a diagnosis of thyroid storm, 354 would receive therapy using both systems, 41 would receive therapy using the BWPS but not the JTA system, 2 would receive therapy based on JTA criteria but not the BWPS, and 9 would not receive therapy by either system.  Hence, although there is overall agreement between these two diagnostic systems, the BWPS appears to select a higher percentage of patients for aggressive therapy than the JTA system. 

It is important to note that inappropriate application of either system can lead to misdiagnosis.  Exemplary cases can be applied to the systems and reveal the diagnostic variability (and consequent management strategies) in a simplistic manner.  Based on the data previously mentioned (obtained from Ref 2, authors’ Table 6) and these cases, we illustrate the importance of clinical judgment in assessing each individual patient.

 

Nothing to Disclose: ALW, HBB

11385 73.0000 MON-0535 A Diagnosing Thyroid STORM: A Comparison of the Japanese Thyroid Association Criteria to the Burch-Wartofsky POINT Scale 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Swaytha Yalamanchi*1 and Douglas Wilmot Ball2
1John Hopkins University School of Medicine, Baltimore, MD, 2Johns Hopkins Univ Sch of Med, Baltimore, MD

 

Papillary Thyroid Carcinoma Arising from Suspected Parotid Gland Teratoma

Swaytha Yalamanchi, Douglas Ball

Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD 21287

Background: Malignant transformation of parotid teratoma tissue to papillary thyroid cancer has not been previously described.

Clinical case: A 23-year old woman s/p parotid resection at the age of 3 due to teratoma presented with a parotid mass. Subsequent imaging revealed a multifocal tumor within the parotid bed with extension into the parapharyngeal space and up to the skull base with cytopathology from FNA showing scant tissue fragments including muscle, adipose tissue and sebaceous glands.  She underwent a revision left total parotidectomy with pathology demonstrating a 1.6 cm focus of papillary thyroid carcinoma involving fibroadipose tissue and skeletal muscle with extension to margins of surgical sample. Microscopic foci of residual parotid were identified, and 19/19 lymph nodes were negative for tumor. Given background of histologically benign-appearing thyroid follicles and focal ciliated ductal structures, it was felt to be possible that the carcinoma arose from ectopic thyroid tissue in residual parotid teratoma, though metastatic disease could not be excluded.

Subsequent thyroid and neck ultrasound were negative. The patient underwent a total thyroidectomy to exclude the possibility of metastatic disease. Pathology showed mild lymphocytic thyroiditis without evidence of PTC. She was started on levothyroxine post-operatively with outpatient thyroid function tests demonstrating TSH of 0.23 mcIU/ml (0.50-4.50), free T4 1.6 ng/dl, (0.8-2.0) and thyroglobulin of 0.5 ng/ml (1.1-35.0) with undetectable thyroglobulin antibody levels. Diagnostic I-123 scan showed evidence of iodine-avid tissue in the thyroid bed without evidence of distant metastases, including at site of parotid gland resection. Patient was treated with 30.2 mCi of 131-I with unremarkable post-treatment scan.

Conclusion: Papillary thyroid cancer can develop in teratomas arising at several anatomic sites, most prominently the ovary. To our knowledge, this is the first reported case of papillary thyroid cancer arising in a parotid teratoma

 

Nothing to Disclose: SY, DWB

16586 74.0000 MON-0536 A Papillary Thyroid Carcinoma Arising from Suspected Parathyroid Gland Teratoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Saad Sakkal*
Pikeville Medical Center, Pikeville, KY

 

Introduction:Every Endocrinologist sees many referred patients who have “thyroid symptoms” with normal thyroid tests. Another large number of patients, receiving adequate thyroxin Rx, continue to be dissatisfied with persistent symptoms. Patients’ wellbeing does not correlate with “biochemical wellbeing” .These symptoms could be related to hypothalamic function. The Hypothalamus is the master control for hormonal balance. In addition its nuclei control all metabolic functions coordinating many neuroendocrine pathways effecting vital functions: Energy/metabolism, Temperature, weight, diurnal cycle, well-being, Reproduction, Pain, muscle tone, and sympathetic/ parasympath balance. These hypothalamic symptoms are the most common complaints in practice, yet, there are no studies documenting how common is the diagnosis of Hypothalamic Dysfunction is in patients referred for thyroid disease?

Methods: we prospectively tabulated the complaints of 50 consecutive patients referred for evaluation of thyroid diagnosis. Complaints were extracted from the patient review of symptoms sheet used for intake in the EHR. The prevalence of the symptoms described above was quantified. The diagnosis of hypothalamic dysfunction was considered "likely" if symptoms from 3 different systems were present, "definite" if present from four or more, according to our definition in studies published in abstracts in Endo meetings since 2007. Thyroid disease was diagnosed by standards thyroid tests.

Results: patients demographics:  female were 38(%76), age (18-72) , the majority between 40-60. Other data and all thyroid tests were tabulated but not presented here for lack of space.

Reasons for referral  were often proven not to be present : of  50 patients referred for suspected thyroid diagnosis 20 were proven to have thyroid disorder ,of which 8 had subclinical thyrotoxicosis (%16),10 subclinical Hashimoto’s Thyroiditis (%20),5 simple or familial goiter(%10) and one Papillary thyroid carcinoma(%0.5); the rest 30/50(%60),had normal thyroid tests and evidence of  Hypothalamic Dysfunction: idiopathic 24/30 (%80) or associated with other diseases :6 diabetes,1 parathyroid ,and 2 others (total more than 30 because of co-morbidity).

Frequency of symptoms groups: 1) Energy, fatigue 21/30 (% 70); 2) Temperature dysregu. 20/30 (%66); 3) Appetite, weight 18/30 ( % 60 ); 4)sleep, diurnal 15/30(%50); 5)Pain,  fibromyalgia 19/30 (% 63); 6) Mood dis. 17/30(%56.5 ); 7)Libido/Reproduction 9/30 (%30 ); sympathetic/ parasymp. symptoms 18/30 (%60 ).

 Frequency of Hypothalamic Dysfunction diagnosis in  the total 50 referred population 1) Likely (3 systems) 11/50 (% 22); 2) definite (4 or more systems) 30/50 (%60).

Conclusion: Hypothalamic Dysfunction is the most common disease in the endocrine clinic (%60) documented in patients who are referred for" thyroid symptoms" with normal thyroid tests.

 

Nothing to Disclose: SS

13422 75.0000 MON-0537 A The Persistent Unexplained Thyroid Symptoms with Normal Thyroid Tests : Etiology and Prevalence in Endocrine Practice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Zahily Sardinas*1, Mansi Mehta2, Mitchel Karten3, Lester Freedman4, Salini Chellappan Kumar5 and Kenneth H Hupart5
1Nassau Univ, East Meadow, NY, 2North Shore LIJ Health System, East Meadow, NY, 3Nassau University Medical center, 4Nassau University Medical Center, 5Nassau Univ Med Ctr, East Meadow, NY

 

Background: Consensus guidelines recommend EBRT as palliative treatment for bone metastases (BM) from Differentiated Thyroid Cancer (DTC).  However, when an isolated BM is present can EBRT be used with a curative intent?

Case Report: 76 year old male with a 7.5 cm right thyroid nodule was diagnosed with Hurthle Cell neoplasm by fine needle aspiration cytology. Total thyroidectomy revealed HCC prompting therapy with 96.7mCi 131I in 2007. Serum thyroglobulin (Tg) remained positive but 131I Whole Body Scan (WBS) did detect disease. In 2010, FDG-PET/CT scan revealed a focus of hypermetabolic activity in the right middle lung lobe which increased in size on serial CTs. Right middle lobe lung resection confirmed a thyroid metastasis. WBS remained negative and Tg was undetectable with TSH suppression. In January 2012, WBS showed no evidence of metastasis but stimulated Tg was positive; 147 mCi 131I was administered. Post treatment WBS identified foci of uptake in the neck and superior mediastinum. Despite treatment, Tg remained positive. PET/CT scan showed a 4.5 cm area of uptake in the skull, but WBS was negative. Biopsy of skull mass showed HCC. Patient was not a candidate for surgical excision due to its proximity to the sagittal sinus. Given the absence of iodine avidity, EBRT was performed. Post treatment FDG-PET/CT scan showed no evidence of uptake. Six months later Tg remains negative with TSH suppression.

Discussion: HCC has the highest incidence (≈30%) of metastases among DTC. BM from DTC decrease the 10 year survival rate by 50%. Management of patients with BM involves a multidisciplinary approach, comprising surgery, 131I I therapy for iodine avid lesions, and other therapies including EBRT, intra-arterial embolization, radiofrequency ablation and bisphosphonates.

EBRT is used for palliation when pain, pathological fractures, or neurological complications are present [1]. However, the relevant literature reveals the presence of cases where BM from DTC were eradicated with EBRT [2, 3].

Our patient had a single skull metastasis not amenable to surgical resection due to a bleeding risk; it was also non-131I avid. EBRT was administered because of the location of this metastasis. FDG PET/CT after EBRT showed resolution of the previous hypermetabolic uptake, and Tg during TSH suppression is undetectable 6 months after treatment. Theses surrogates of disease activity indicate an optimistic short term response to EBRT raising the possibility that EBRT may confer an advantage greater than just palliation. Research regarding factors which may predict thyroid cancer BM responses to EBRT is warranted.

References:

  1. Cooper et al. Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2009 Nov. 19 (11):1-48.
  2. Schlumberger M et al. J Nucl Med. 1996 Apr;37(4):598-605.
  3. Durante C et al. J Nucl Med. 1996 Apr;37(4):598-605.

 

Nothing to Disclose: ZS, MM, MK, LF, SCK, KHH

16860 76.0000 MON-0538 A Hurthle Cell Thyroid Cancer (HCC) with Skull Metastases - Good Short Term Response to External Beam Radiation Therapy (EBRT) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Rajshree M Patel*1, Daniel Alberto Cadena1 and Ramona Granda-Rodriguez2
1Ochsner Clinic Foundation, New Orleans, LA, 2Ochsner Clinic Foundation, Gretna, LA

 

The presence of concomitant thyroid conditions such as Hashimoto’s thyroiditis, non-medulllary thyroid cancer, multinodular goiter and Grave’s disease in patients with hyperparathyroidism has been described in multiple publications. Different factors such as age, lithium consumption and neck irradiation could be attributed as causality for this to occur. The diagnosis of thyroid cancer in patient with Grave’s disease has been rarely reported, but most of these cases are attributed to radio ablation exposure. We are presenting a case of a patient with history of Grave’s disease presenting with right sided parathyroid adenoma and left sided papillary thyroid cancer.

43 year-old female with history of Grave’s disease since age 24, presented with a newly developed large left thyroid nodule and hypercalcemia. She did not have any symptoms of neck compression, and had never received radio ablation therapy. She was taking methimazole since diagnosis and was receiving a stable dose of 2.5 mg daily since 2011.  During our evaluation she was clinically and biochemically euthyroid and her thyroid stimulating immunoglobulin antibodies (TSI) were negative since remission.  The patient did not have a history of neck irradiation or family history of thyroid cancer. Her neck ultrasound showed a 3.2 cm left thyroid nodule with calcifications and a 3.3 cm mass posterior to the right thyroid lobe. Fine needle aspiration (FNA) of the left thyroid nodule showed benign follicular epithelial cells with scant colloid.  The laboratory tests revealed high serum calcium, high parathyroid hormone (PTH) and low serum phosphorus raising the suspicion of hyperparathyroidism. A 24 hour urinary calcium collection and a sestamibi scan confirmed the diagnosis of right sided parathyroid adenoma.  The patient underwent total thyroidectomy with right parathyroidectomy. The pathology report indicated  benign parathyroid adenoma and papillary thyroid cancer follicular variant.

Since multiple thyroid and parathyroid pathologies can co-exist, the current protocols for adequate pre-surgical evaluation are heading towards a complete anatomical evaluation including both sestamibi and neck ultrasound. This case supports the need of ultrasound and sestamibi scan before parathyroidectomy even in patients with previous diagnosis of Grave’s disease.

 

Nothing to Disclose: RMP, DAC, RG

16887 77.0000 MON-0539 A Interesting Case of Concomitant Graves's Disease, Thyroid Cancer and Parathyroid Adenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Shawn Peavie*1 and Jenny Tong2
1University of Cinncinnati, Cincinnati, OH, 2Univ of Cincinnati, Cincinnati, OH

 

Background:
Cutis verticis gyrata (CVG) is a superficial skin thickening that leads to visible folds, ridges, or creases on the surface of the top of the scalp. [1] This dermatologic condition is rare (1/100,000 in males and 0.026/100,000 in females) and has no known etiology or cure. Primary CVG typically presents early in life and is sometimes associated with neuropsychiatric disorders and congenital syndromes. Secondary CVG is acquired and has been associated with a number of diseases and drugs such as acromegaly, amyloidosis, and connective tissue disorders. There is one reported case of CVG associated with Grave’s disease (GD).

Clinical Case:
A 59 year old female presented to her internist with a complaint of enlarging “lumps” on her scalp that started five years ago. She was referred to Dermatology and subsequently diagnosed with secondary CVG. An extensive workup for possible secondary causes of CVG was negative except for a diagnosis of GD 40 years previous.  The GD was difficult to control and she was treated with radioactive iodine ablation twice and subsequently required total thyroidectomy to normalize her thyroid function. She was treated with levothyroxine therapy for post-ablative hypothyroidism. Notable physical exam findings included multiple elevated soft skin folds running anterior-posterior on her scalp and severe clinically active Grave’s ophthalmopathy (GO). Relevant laboratory results included an elevated thyrotropin receptor antibody (TRAb) at 61.60 IU/L (0.00-1.75 IU/L) and normal thyroid function tests with total T3 of 1.44 ng/mL (0.96-1.69 ng/mL), free T4 of 1.39 ng/dL (0.61-1.76 ng/dL), and TSH of 1.49 mIU/L (0.45-4.50 mIU/L) while on 150 mcg of levothyroxine per day. An orbital CT scan revealed GO with marked proptosis and mild expansion of the bilateral inferior, medial, and superior rectus muscles with increased intraorbital fat.

Conclusion:
This is the second reported case of CVG associated with GD to our knowledge. The relationship of active ophthalmopathy with a skin disease having similarities to cutaneous myxedema raises the possibility that these are related. It is interesting that this patient has such active ophthalmopathy and elevated TRAb levels 40 years after treatment of her GD. Medical treatment for ophthalmopathy may also benefit her CVG. Rituximab, an immunomodulator, has been tested for the treatment of GD-related conditions and has been shown to be superior to steroid therapy in some studies. [2]. This patient is currently on Rituximab for treatment of both her GO and CVG.

 

Nothing to Disclose: SP, JT

17005 78.0000 MON-0540 A Cutis Verticis Gyrata As an Alternative Presentation of Cutaneous Myxedema in Grave's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Poonam Sood*1, Hussain Mahmud2 and Shane Otto LeBeau3
1University of Pittsburgh Medical Center, 2University of Pittsburgh, Pittsburgh, PA, 3Univ of Pittsburgh Med Ctr, Pittsburgh, PA

 

Introduction: Iodine is critical for thyroid hormone synthesis, and the recommended dietary allowance is 150 mcg daily. Iodine deficiency may result in goiter formation, hypothyroidism and impaired intelligence. It has been speculated that raising iodine levels may decrease the risk of endometrial, ovarian and prostate cancer. Individuals with underlying thyroid disorders such as iodine deficiency goiter, underlying autoimmune thyroid disease, or autonomous nodules are at a high risk of developing thyroid dysfunction, when exposed to excess exogenous iodine. We describe iodine-induced hyperthyroidism (IIH) from oral iodine supplements in a patient with no underlying thyroid dysfunction.

Case:  A 64-year-old male presented for evaluation of hyperthyroidism with fatigue, tremor, insomnia, heat intolerance, anxiety, muscle loss, weight loss, and severe weakness. He reported no recent illness, eye symptoms, exposure to contrast media and no family history of thyroid disease. He had been taking 12.5 mg of potassium iodide (Iodoral) daily for prostate cancer prevention. Examination revealed no thyromegaly, palpable nodules, or ocular findings, +fine tremor, +brisk reflexes, and warm skin. On presentation, TSH was <0.01 (0.3-5.0 uIU/mL), FT4 4.6 (0.8-1.8 ng/dl), total T3 273 (76-18 ng/dl), TPO Ab <10 (negative <60 IU/mL), TSI 30 (negative <140 %) and urinary iodine 1297 (34-523 mcg/L). Sonography revealed normal sized thyroid without nodules or hypervascularity. Iodoral was stopped and propranolol and methimazole 20 mg initiated and titrated to 60 mg without improvement. Patient was also switched to propylthiouracil for a short time and had a poor response. FT4 increased to 8.0, so prednisone 40 mg and hydrochlorothiazide 50 mg daily were started. One month later, FT4 was 3.8, total T3 179, and urinary iodine 365 at which time patient’s symptoms improved. I-123 uptake scan demonstrated 0.4% uptake at 24 hrs. Methimazole was stopped one month later and steroids were tapered off over 3 months. Patient is currently off all medications and remains euthyroid.

Discussion: This is an unusual case of IIH as our patient had a prolonged course and had no history of underlying thyroid dysfunction. The thyroid gland has intrinsic mechanisms to maintain normal thyroid function even when additional iodine is available. However, within two to four weeks of continuous exposure to excess iodide, iodide organification and thyroid hormone biosynthesis resume in a normal fashion and escape the normal intrinsic protective processes. IIH tends to resolve on its own; however beta-blockers and thionamides may also be required. In severe cases, steroids may have to be initiated to reduce the destructive thyroiditis1 and hydrochlorothiazide to increase urinary iodine clearance2. Our patient was unable to tolerate the excess exogenous iodine and therefore these iodine supplements were clearly too much for him.

 

Nothing to Disclose: PS, HM, SOL

14277 79.0000 MON-0541 A Iodine: Too Much of a Good Thing? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Dinesh Edem1, Esther Irina Krug*2, Rahul Gosain3 and Amitoj Gill3
1Sinai Hospital of Baltimore, Baltimore, MD, 2Johns Hopkins University/ Sinai Hosp of Baltimore, Baltimore, MD, 3Johns Hopkins University/Sinai Hospital of Baltimore, Baltimore, MD

 

Introduction:  Hyperthyroidism (HT) associated with Graves’ disease leads to a hypermetabolic state with sympathetic activation. Gastrointestinal symptoms of HT usually include weight loss despite good appetite and diarrhea or increased frequency of bowel movements. Persistent intermittent vomiting is rare and potentially misleading presentation of hyperthyroidism. It may lead to delay in diagnosis or misdiagnosis and inappropriate treatment, causing significant morbidity and distress to the patient.

Case: A 25 year old man with a 10 year history of Type1 Diabetes Mellitus (DM1) and hypertension diagnosed 6 months ago was admitted with intractable vomiting and a 4 kg weight loss. Patient had multiple previous admissions for similar complaints of recurrent vomiting over the past 2 years. Vomiting episodes tended to start in the morning prior to meals. Vomitus content was clear liquid. Once vomiting episode started the patient was unable to retain any fluids or food. He would typically present with significant hyperglycemia since he was afraid to administer insulin in the absence of meaningful food intake. In the interim his blood glucose was well controlled. Home medications also included glargine, aspart, pantoprazole. Physical Exam revealed a thin man in moderate distress vomiting clear liquids that he had swallowed just a few minutes ago. He had heart rate of 115-120 beats per minute. There was no lid lag, stare or proptosis. Thyroid was easily palpable but not overtly enlarged. There was no tremor noted. Initial labs revealed TSH of <0.009 uIU/mL (0.5 - 5.0), elevated free T4 - 2.13 ng/dL (0.8-1.8), Free T3 - 4.7pg/mL (1.8 - 4.2), TSI titer 566% (n < 130). HbA1c was 8.7%. Ultrasound revealed a diffusely heterogenous thyroid with increased Doppler flow, EGD revealed severe reflux esophagitis and gastric emptying study showed no significant gastroparesis. Patient was started on methimazole 10 mg BID, and propranolol 40mg Q12H which led to cessation of nausea and vomiting within 24 hours. In follow-up the patient has remained symptom free off pro-kinetic agents, with good glycemic control and improved thyroid function on methimazole.

Conclusion: This case illustrates severe recurrent vomiting as a highly unusual presenting symptom of relatively mild hyperthyroidism. Pre-existing DM1 made the correct diagnosis especially challenging. Absence of response to pro-kinetic agents and lack of severe gastroparesis may provide a diagnostic clue. Etiology of thyrotoxic vomiting is not well understood. Proposed mechanisms include increase in β-adrenergic activity, delayed gastric emptying or direct activity of thyroid hormones on the chemical trigger zone. Treatment includes administration of antithyroid agents and β-blockers.

 

Nothing to Disclose: DE, EIK, RG, AG

16424 80.0000 MON-0542 A A Case of Intractable Recurrent Vomiting in a Young Patient with Type 1 Diabetes. an Unusual Presentation of Graves' Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Shimon Harary*1, Wasim Samara2 and Shichun Bao1
1Vanderbilt University Medical Center, Nashville, TN, 2University of Jordan School of Medicine

 

Introduction:

Lenalidomide (Revlimid), an immunomodulatory drug, is a structural analogue of thalidomide with similar antiangiogenic and anticancer properties, approved in the United States for treatment of multiple myeloma and myelodysplastic syndromes. We report a case of thyroiditis with hyper- and hypothyroidism in a patient receiving lenalidomide in a clinical trial for diffuse large B-cell lymphoma.

Case Presentation:

A 62-year-old male with diffuse large B-cell lymphoma but no history of thyroid disease received 25 mg oral lenalidomide daily for one week. He developed hyperthyroidism, with TSH of 0.04 mcU/mL decreasing from a normal baseline of 0.93 mcU/mL two months prior.  Lenalidomide was then held due to thrombocytopenia. There were no interim medication changes or recent contrast CT, viral illness, amiodarone or interferon treatment. Patient denied overt hyperthyroid symptoms, with stable vital signs and unremarkable physical exam (no exophthalmos, thyromegaly or palpable thyroid nodules, normal reflexes).  After six weeks, the patient’s TSH spontaneously normalized to 1.34 mcU/mL, and lenalidomide was restarted at 20 mg daily. Two weeks later, TSH fell again to 0.05 mcU/mL, with elevated FT4 of 2.02 ng/dL. Further work-up showed normal thyrostimulating immunoglobulin, thyroperoxidase and thyroglobulin antibodies but high thyroglobulin of 679 ng/mL. Thyroid ultrasound showed a heterogeneous gland with some sub-centimeter nodules. Thyroid pertechnetate scan showed minimal uptake, suggesting Lenalidomide-induced thyroiditis. His hyperthyroidism again spontaneously resolved, but three months later he developed hypothyroidism, with TSH of 16.4 mcU/mL, FT4 0.29 ng/dL, and levothyroxine treatment was initiated. Lenalidomide was later stopped, and his thyroglobulin normalized, but patient continued requiring  levothyroxine 112 mcg daily for hypothyroidism, even one year after initial thyroid changes. 

Conclusion

Lenalidomide is increasingly used in the treatment of myelodysplastic syndromes and other pathologies. Treating physicians must be aware of potential thyroid dysfunction associated with lenalidomide treatment. Checking thyroid function before starting the treatment and throughout the course is recommended.

 

Nothing to Disclose: SH, WS, SB

12301 81.0000 MON-0543 A Lenalidomide-Induced Hyper- and Hypothyroidism during Treatment for Diffuse Large B-Cell Lymphoma: A Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0463-0543 4870 1:00:00 PM Non-Neoplastic Thyroid Disorders-Clinical and Case Reports Poster

Yuqian Luo*1, Yuko Ishido1, Kazuko Yamazaki2, Makoto Kammori2, Yoshiyuki Sugishita2, Emiko Yamada2, Tetsu Yamada2, Donald Francis Sellitti3 and Koichi Suzuki1
1Natl Inst of Infectious Diseas, Tokyo, Japan, 2Institute, Kanaji Thyroid Hospital, 3Uniformed Serv Univ Hlth Sci, Bethesda, MD

 

Background: We have demonstrated in cultured rat thyroid FRTL-5 cells and rat thyroid in vivo, that thyroglobulin (Tg) exerts a negative feedback effect on follicular function by suppressing thyroid-specific genes essential for thyroid hormone (TH) production and iodide transport. However, the role of Tg in the regulation of cells derived from normal and diseased thyroid in the human remains undetermined.

Objective:To demonstrate the effect of Tg on thyroid-specific gene expression in normal and of diseased thyroids.

Methods: Primary cultures were established from normal human thyroid, Graves’ thyroid, adenomatous goiter, follicular adenoma and papillary carcinoma obtained at surgery. Cells were treated with Tg, or with BSA (control) for different times and over a range of Tg concentrations. The expression of thyroid-specific genes essential for follicular function was then evaluated using real-time RT-PCR and Western blotting for mRNA and protein, respectively.

Results: In normal thyroid cells, Tg decreased the mRNA expression of genes involved in TH synthesis, including TG, TPO, SLC5A5 (NIS), SLC26A4 (Pendrin), DUOXA2, NKX2-1 (TTF-1), FOXE1 (TTF-2), and PAX8, whereas DUOX1, DUOXA1 and ACTB(β-actin) expression were not affected by Tg treatment. Treatment with BSA, in contrast, had no affect on any of these genes. Protein levels of TG, TPO, NIS, and pendrin were also strongly suppressed by Tg, but not BSA, in a dose-dependent manner. Graves’ thyroid cells, like normal thyroid cells, responded to Tg with a concentration-dependent decrease in the expression of TH-synthetic genes. Primary cultures of adenomatous goiter, follicular adenoma and papillary carcinoma did not however, respond to Tg at any concentration. The contrasting responses of normal and neoplastic thyroid (papillary carcinoma) to Tg were observed even when cultures were obtained from adjacent areas of the same thyroid.

Conclusion: The present study confirms that the suppression of thyroid-specific genes observed in rat thyroid cells also occurs in normal human thyroid cells, suggesting that negative feedback of thyroid function by Tg is a clinically important phenomenon. Furthermore, we show that the feedback effect of Tg remains intact in Graves’ thyroid, but is lost from adenomatous goiter, follicular adenoma and papillary carcinoma cells. Although the loss of a response to Tg is likely a consequence of, rather than a cause of neoplastic transformation, further research into thyroid autoregulation by Tg may help shed light on some of the unanswered questions of the etiology and progression of thyroid neoplasia and hyperplasia.

 

Nothing to Disclose: YL, YI, KY, MK, YS, EY, TY, DFS, KS

11130 4.0000 MON-0547 A ‘Escape' from Thyroglobulin (Tg) Regulation in Hyperplastic and Neoplastic Thyroid Cells, but Not in Graves' Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Eun Kyung Lee*1, Seog Yun Park1, Min Ji Park1, Daeyoon Park1, You Jin Lee1, Junsun Ryu1, Yuh-Seog Jung1, Seok-ki Kim1, Tae Sung Kim1, Tae Hyun Kim1, Chang Yoon Lee1, Chang Hwan Ryu1, Young Joo Park2 and Do Joon Park2
1National Cancer Center, Goyang, Korea, Republic of (South), 2Seoul National University College of Medicine, Seoul, Korea, Republic of (South)

 

Background: About 5~10% of thyroid cancer patients does not respond to radioactive iodine(RAI) therapy, since the expression or membrane trafficking of sodium iodine symporter(NIS) was ameliorated. The dysfunction of NIS may be related to de-differentiation of cancer cells, so many researchers had been eager to develop new strategy to re-differentiate thyroid cancer cell. We investigated whether iodine uptake was regulated by the balance of SUMOylation in thyroid cancer.

Methods: We analyzed the expression of NIS mRNA in fresh frozen tissues of papillary thyroid cancer. After overexpression of desumoylating enzyme SENP2 in human anaplastic thyroid cancer cell line (FRO) and silencing SENP2 in human NIS-overexpressed HeLa cell line (HeLa-hNIS), we evaluated the expression of NIS mRNA and iodine uptake. We selected 30 patients of different expression level of SENP2 (low and normal SENP2) and constructed tissue microarray for immunohistochemistry stain. And the patients’ clinicopathologic features were reviewed using medical records.

Results: Twenty six percent of papillary thyroid cancer tissue showed reduced expression of SENP2 and NIS mRNA. Silencing SENP2 in HeLa-hNIS, NIS mRNA and iodine uptake was reduced. By co-immunoprecipitation, the interaction between SUMO2/3 and C/EBPβ was detected. After overexpression of SENP2, NIS mRNA and iodine uptake was restored. By comparison of response of RAI among two group, reduction of serum thyroglobulin level after RAI was blunted in the group of low SENP2, compared to that in the group of normal SENP2.

Conclusion: In summary, overexpression of SENP2 can induce NIS expression and iodine uptake. This may be a novel therapeutic target for RAI-refractory thyroid cancer patients.

 

Nothing to Disclose: EKL, SYP, MJP, DP, YJL, JR, YSJ, SKK, TSK, THK, CYL, CHR, YJP, DJP

11702 5.0000 MON-0548 A Regulation of Iodine Uptake By SENP2 in Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Takao Kunori*
Iwaki-Kyoritsu Hosp, Fukushima, Japan

 

Background: Introduction of fine needle aspiration biopsy (FNAB), in 1982, dramatically changed the operative indication of nodular goiter (ND). The method is sufficiently accurate with very low misdiagnosis rate. In this paper our experience as regards diagnostic problem and NOD related laboratory data are discussed.

Subjects and methods: A total of 794 (2007-2013) FNAB from 121 patients, 59 years old (mean, 15-93, female 85%), were analyzed. FNAB was performed with ultrasonogram (US) by assistance of cytology technicians. The results were reported to doctors by classification of malignancy; 0 (no cell), 1 -2 (benign), 3 (difficult to judge), 4 (suspicious) and 5 (malignant) with, in some cases, pathological diagnosis. Surgery was generally performed if ND had suspicious malignancy, cosmetic problem or severe trachea deformity.

Results: 1. FNAB: Single exam was 465 (79%), twice 74 (13%), 3 times 27 (4.6%), 4 times 8 (1.4%) and over 5 times 12 (2%).  2. Classification: Class 0, 82 (11%); class 1. 119 (16%); class 2, 452 (60%); class 3, 38 (5%); class 4, 20 (2.7%); class 5, 38 (5.1%). 3. Comparison with surgical diagnosis (accuracy): Malignancy was confirmed by surgical specimens; 3/9 (33%) in class 2, 4/11 (36%) in class 3, 5/11 in class 4, 2/5 in class 5 (40%), “papillary carcinoma” 59/59 (0%), “follicular carcinoma” 1/1 (100%), “adenomatous goiter” 7/7 (0%) and “follicular adenoma” 16/16 (0%). False positive, 3/45 (6.6%); false negative 3/74 (4%). 4. Relation with serum thyroglobulin (Tg) data: Concomitant exam of Tg on the same day was not affected by FNAB.Increased Tg was observed in class 3-5. Tg per nodule’s volume (Tg/Vol) was highest in class 3.  

Conclusions: FNAB is a most powerful diagnostic procedure in thyroid surgery. Though the diagnosis is very accurate, some needs repeated assay because of altered cytology during observation period. Significance of increased Tg/Vol is not known yet.

 

Nothing to Disclose: TK

11791 6.0000 MON-0549 A Experience of Fine Needle Aspiration Biopsy in Japanese City Hospital and Laboratory Analysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Seok-Man Son*, Hye Ju Yeo, Hye Won Lee, Dongwon Yi and Yang Ho Kang
Pusan National University School of Medicine, Yangsan, Korea, Republic of (South)

 

Many patients with differentiated thyroid cancer (DTC) experience short-term hypothyroidism due to thyroxine withdrawal for radioiodine (RI) therapy. The relationship between short-term hypothyroidism and risk of cardiovascular disease is not clear. Previous studies addressing the influence of thyroid hormones on serum levels of cardiovascular markers yielded conflicting results. In this study, we evaluated the impact of short-term overt hypothyroidism on lipid profiles and cardiovascular parameters in patients with DTC for RI therapy. We included the 195 patients who underwent total thyroidectomy due to DTC and treated with RI from March 1, 2008 to February 1, 2012. We studied subjects at two time points: on the last day on levothyroxine (LT4) at their usual thyroid-stimulating hormone (TSH)-suppressive doses (P1) and at the end of the LT4 withdrawal protocol (P2). All subjects attained hypothyroid states (P2), TSH was 102.8±47.6 uIU/ml and total cholesterol (TC) level (P2) was significantly increased (262.1±56.7 mg/dL, p<0.005). After adjustment for multiple factors such as age, sex, BMI, hypertension and DM, the relationship between TSH and TC remained significant (p=0.04). After thyroxine withdrawal (P2), serum mean levels of TC , homocysteine (15.4±7.1), low density lipoprotein-cholesterol (LDL-C, 169.7±50.3), triglycerides (TG, 212.0±128.1) were increased. And serum levels of high density lipoprotein-cholesterol (HDL-C), cystatin C, C-reactive protein (CRP), apolipoprotein B (ApoB), apolipoprotein A1 (Apo A1), lipoprotein (a) (Lp(a)), aspartate transaminase (AST), alanine aminotransferase (ALT), total bilirubin, uric acid remained within normal range. Splitting the whole cohort into the three different age groups, serum Apo B, Lp(a) levels and BMI increased with increasing age (p<0.05). And splitting into three different TSH level groups, all values did not have a statistical significant meaning except Apo A1. In spite of increased TC levels, other cardiovascular markers did not increase during short-term hypothyroidism. It means that there is no direct relationship between risk of cardiovascular disease and short-term hypothyroidism. The withdrawal of thyroxine would be  safely used to patients with low cardiovascular risk.

 

Nothing to Disclose: SMS, HJY, HWL, DY, YHK

11946 7.0000 MON-0550 A Effect of Thyroxine Withdrawal for Radioiodine Therapy in Differentiated Thyroid Cancers on Lipid Profile and Cardiovascular Markers 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Carolina C. P. S. Janovsky*1, Danielle M Andreoni2, Rosalia de Prado Padovani3, Claudia Cristina Doimo Nakabashi4, Cleber Pinto Camacho4, Eduardo Zadrozny Malouf5, Elza Setsuko Ikejiri6, Jairo Wagner7, Rui M. B. Maciel8 and Rosa Paula Mello Biscolla9
1Federal Univesity of São Paulo, São Paulo, SP, Brazil, 2UNIFESP, 3UNIFESP, Sao Paulo, Brazil, 4UNIFESP, Brazil, 5UNIFESP, Campinas SP, Brazil, 6UNIFESP, 000 Sao Paulo, Brazil, 7Hospital Israelita Albert Einstein, Brazil, 8Universidade Federal de Sao Paul, Sao Paulo, SP, Brazil, 9UNIFESP, São Paulo, Brazil

 

INTRODUCTION: Nowadays there is a tendency against the use of radioiodine remnant ablation after total thyroidectomy in low-risk differentiated thyroid cancer patients, because of its low recurrence rate and low cancer specific mortality1. However there are still weak evidences concerning the follow up of those patients.

OBJECTIVE: To evaluate the outcome of low-risk thyroid cancer patients treated with total thyroidectomy, who did not undergo radioiodine remnant ablation (RRA), determining which test  best predicts a disease-free follow-up: basal sensitive thyroglobulin (Tg), stimulated Tg, neck ultrasonography or whole body scan (WBS) .

PATIENTS AND METHODS: We evaluated 60 patients with papillary thyroid carcinoma, classified as low risk (T1/T2N0, with non-aggressive histology) who underwent total thyroidectomy 2. Soon after surgery, serum sensitive thyroglobulin and neck ultrasonography (US) were performed with suppressed TSH. These patients were submitted to a stimulated Tg and WBS after recombinant human TSH (rhTSH) 3-12 months after surgery. After 18-24 months of surgery, the patients were evaluated with US and another measurement of serum sensitive thyroglobulin under TSH 0.5-2.0mcUI/mL.

RESULTS: After total thyroidectomy, the mean basal thyroglobulin with suppressive L-T4 therapy was 0.73 ng/dL (<0.1-16.2). rhTSH WBS showed thyroid bed uptake (0.1-6.4%) and the mean stimulated thyroglobulin was 3.29 ng/dL (<0.1-10.1). After 18-24 months of surgery, the mean sensitive thyroglobulin was 0.24 ng/dL (<0.1-2.1) and the neck US was negative.

These patients were followed-up by a period of 12 to 66 months, without any sign of recurrence (negative neck US and stable or descending Tg levels).

CONCLUSION: After 1-year follow-up, all patients presented an excellent response to initial surgical therapy with negative neck ultrasonography and stable or descending Tg levels.

Our data suggest that in patients not submitted to RRA, the "Tg trend" associated with neck ultrasonography is a good and reliable disease marker to predict a free-disease follow-up.

 

Nothing to Disclose: CCPSJ, DMA, RDPP, CCDN, CPC, EZM, ESI, JW, RMBM, RPMB

12296 8.0000 MON-0552 A Follow-up of Low-Risk Thyroid Cancer Patients Not Submitted to Radioiodine Ablation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Misa Imaizumi*1, Waka Ohishi2, Eiji Nakashima1, Nobuko Sera1, Kazuo Neriishi1, Michiko Yamada1, Yoshimi Tatsukawa2, Ikuno Takahashi2, Saeko Fujiwara3, Takao Ando4, Toshiro Usa4, Atsushi Kawakami4, Masazumi Akahoshi1 and Ayumi Hida1
1Radiation Effects Research Foundation, 2Radiation Effects Research Foundation, Hiroshima, Japan, 3Hiroshima Atomic Bomb Casualty Council, 4Nagasaki University Graduate School of Biomedical Sciences

 

There are few studies evaluating radiation effects on thyroid nodules among adults who were exposed in their childhood. In order to evaluate radiation-dose responses for the prevalence of thyroid nodules in atomic-bomb survivors exposed in their childhood, we conducted a survey study comprising 3,087 of Hiroshima and Nagasaki atomic-bomb survivors who were younger than 10 years old at exposure. We performed thyroid examinations including thyroid ultrasonography between October 2007 and October 2011. The analyses were performed for 2,668 participants (mean age 68.2 years, 1,213 men and 1,455 women) with known atomic-bomb thyroid radiation doses (mean dose 0.182 Gy, median dose 0.018 Gy, and  dose range 0-4.040 Gy). The prevalence of all nodules (10mm or more in diameter, 17.6%), solid nodules (16.0%), malignant tumors (1.8%), benign nodules (7.0%) and cysts (1.8%) were significantly associated with thyroid radiation dose. Excess odds ratios (95% confidence intervals) were 1.65 (0.89, 2.64) for  all nodules, 1.72 (0.93, 2.75) for solid nodules, 4.40 (1.75, 9.97) for malignant tumors, 2.07 (1.16, 3.39) for benign nodules, and 1.11 (0.15, 3.1) for cysts. The interaction of age at exposure with dose was significant for the prevalence of all nodules and solid nodules, indicating that the dose effects were significantly higher in early childhood exposure. There was no interaction of sex, family history of thyroid diseases, anti-thyroid antibodies, or seaweed intake. No dose-response was observed for small thyroid nodules < 10 mm in diameter. In conclusion, radiation effects on thyroid nodules, but not on small thyroid nodules, were observed in atomic-bomb survivors after six decades from exposure in childhood.

 

Nothing to Disclose: MI, WO, EN, NS, KN, MY, YT, IT, SF, TA, TU, AK, MA, AH

12314 9.0000 MON-0553 A Thyroid Study in Hiroshima and Nagasaki Atomic-Bomb Survivors Exposed in Childhood: Radiation Dose-Response Relationships for Thyroid Nodules (2007-2011) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Alessandro Antonelli*1, Paolo Miccoli1, Andrea Ferrari2, Maura Massimino2, Alessandro Inserra3, Gianni Bisogno4, Giovanni Cecchetto4, Silvia Martina Ferrari1, Poupak Fallahi1 and Claudio Spinelli1
1University of Pisa, Pisa, Italy, 2Istituto Tumori, Milano, Italy, 3Bambino Gesù Pediatric Hospital, Rome, Italy, 4University of Padova, Padova, Italy

 

A great attention and debate are direct to the extension of thyroid surgery in (non medullary) differentiated thyroid cancer (DTC) in pediatric age. The total thyroidectomy, with or without central neck dissection, and laterocervical lymphadenectomy in case of clinical evidence of nodal involvement is the most common treatment. After operation, radioiodine therapy and lifelong hormone replacement therapy were performed. Substantial decrease of DTC recurrences but a higher percentage of postsurgical complications were associated with the radical surgical approach. In specific cases, some specialists prefer the most conservative approach. In this work, we report the results of a multicentric Italian study in 180 patients (TREP Project; Tumori Rari in Età Pediatrica). We have reviewed the data of 180 DTC patients (median age 13 years, range 4-18 years) who underwent surgery from January 2001 to December 2011. One hundred and fifty-four patients underwent total thyroidectomy (TT) associated in 74 cases with a cervical lymphadenectomy (CL); 26 patients considered low-risk DTC with carefully preoperative staging underwent hemithyroidectomy (HT). The median follow-up was 5.6 years (range 1-11 years).
 We recorded 22% cases of postoperative complications that included hypoparathyroidism (76% transient and 24% permanent) and recurrent laryngeal nerve injury in 2.4% (1.6% unilateral and 0.8% bilateral) in the group that underwent TT. In the TT group, we observed clinical persistent disease (presence of neoplastic tissue uptaking radioiodine) in 3 patients with lymphnode metastases, 2 cases of local recurrence and 4 cases of lung metastases. Recurrences occurred in 17  patients in the TT group; 11 cases of lymphnode metastases, 4 cases of lung metastases, and 2 cases of local recurrence (between the 6th and 24th months after surgery). No complications and local recurrences occurred in the HT group. In conclusion, a careful preoperative staging of DTCs in children is necessary to identify low-risk cases that can be treated with a conservative surgery.

 

Nothing to Disclose: AA, PM, AF, MM, AI, GB, GC, SMF, PF, CS

12622 11.0000 MON-0555 A Results of a Multicentric Study on Radical Vs Conservative Surgical Management in Children with (non medullary) Differentiated Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Hwa Young Ahn*1, Yun Jae Chung1, Ka Hee Yi2, Young Joo Park2, Min Suk Kim3 and Min Joo Kim4
1Chung-Ang University Hospital, Seoul, Korea, Republic of (South), 2Seoul National University College of Medicine, Seoul, Korea, Republic of (South), 3Dongnam Institute of Radiological & Medical Sciences, 4Korea Cancer Center Hospital, Seoul, Korea, Republic of (South)

 

Objectives: We investigated the expression of estrogen receptors (ERs) in papillary thyroid cancers (PTCs) and evaluated their prognostic role.

Methods: We enrolled 81 female patients who underwent thyroid surgery and had a confirmed diagnosis of PTC between January 1, 1995 and December 31, 1996. Data on clinicopathologic parameters were obtained from patients’ medical records. Tissue paraffin blocks of these 81 patients were collected for immunohistochemistry for ERα and ERβ.

Results: ERα expression was observed in only 8 patients (9.9%). In contrast, ERβ expression was positive in 36 (44.4%) patients. Total thyroidectomy (84.4% vs. 61.1%, P = 0.017) and cervical lymph node metastasis (62.2% vs. 22.2%, P = 0.000) were more frequent in the ERβ-negative group than in the ERβ-positive group. Among younger female patients (<45 years), the ERβ-negative group showed a tendency towards more frequent recurrent or persistent disease than the ERβ-positive group (42.3% vs. 13.6%, P = 0.029). In contrast, the ERα-positive group showed more recurrent or persistent disease than the ERα-negative group in female patients aged between 45 to 54 years old (100% vs. 18.2%, P = 0.024). In multivariate analysis, ERβ negativity, extrathyroidal invasion and radioactive iodine treatment were risk factors for recurrence.

Conclusion: Loss of ERβ expression was associated with poor prognosis in female PTC patients. This finding suggests that estrogen might play a protective role in the progression of PTC via ERβ, especially in young female patients.

 

Nothing to Disclose: HYA, YJC, KHY, YJP, MSK, MJK

13231 12.0000 MON-0556 A Loss of ER Beta Expression in Papillary Thyroid Carcinoma Is Associated with Poor Prognosis in Young Female 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Maria Belen Albuja-Cruz*1, Patel Nayana2, Christopher D Raeburn1, John I Lew3, Bryan R Haugen4, Joshua Paul Klopper5, Punam P Parikh6 and Robert C McIntyre Jr.2
1University of Colorado School of Medicine, Aurora, CO, 2University of Colorado School of Medicine, 3Univ of Miami Miller Schl of Med, Miami, FL, 4Univ of CO Denver, Schl of Medic, Aurora, CO, 5Univ of Colorado School of Medic, Aurora, CO, 6University of Miami School of Medicine

 

Clinical and Ultrasonographic Predictors of Malignancy for Indeterminate Thyroid Nodules with Suspicious Molecular Testing

Background:   Despite improved risk stratification of indeterminate (Bethesda III/IV) thyroid nodules by molecular testing, surgical resection for nodules suspicious by gene-expression classifier (GEC) testing remains a clinical dilemma since >50% will be benign on final histopathology. Conventionally, these nodules are treated at minimum with thyroid lobectomy for definitive diagnosis. This study examines whether clinical and/or ultrasonographic features might be useful in further distinguishing benign from malignant thyroid nodules that are indeterminate by cytopathology and suspicious by GEC testing. 

 Methods: A retrospective review from two tertiary care centers, 101 patients with Bethesda III/IV thyroid nodules and a suspicious result on GEC testing (Afirma) were identified. Patient demographics (age and gender), clinical characteristics (compressive symptoms, hyper or hypothyroidism), history of radiation exposure, family history of thyroid cancer, preoperative TSH levels, Bethesda classification and ultrasound features (nodule size, echogenicity, structure, texture, borders, calcifications, vascular flow, shape and presence of halo) of the index thyroid nodule were correlated with benign and malignant final histopathology. 

Results: Of 101 patients with indeterminate thyroid nodules by cytology and suspicious on GEC testing, 85 (84%) underwent surgical resection, while the other 14 declined surgery or had prohibitive comorbidities. Of those who had thyroid surgery for diagnosis, final histopathology of the index nodule was malignant in 45% (38/85). On univariate analysis, only nodule size (p=<.0001) and irregular borders on ultrasound (p=0.0024) were significantly different between patients with bening vs. malignant histopathology. On multivariate analysis, irregular borders on ultrasound was the only independent variable predictive of malignancy (OR= 5.720). Risk of malignancy was 76% in indeterminate nodules with suspicious GEC and irregular borders detected by ultrasound. There were no clinical or ultrasonographic features that predicted benignity.

Conclusions: In this study, >50% of cytologically indeterminate, GEC suspicious thyroid nodules had benign final histopathology. Irregular borders on ultrasound were associated with a 6-fold increase risk of malignancy; thus, this variable may be useful in determining the need of surgical resection for definitive diagnosis. The results of this study suggest that ultrasonographic features (size and irregular borders) may be a useful adjunct to further improve risk stratification provided by GEC testing in the management of indeterminate thyroid nodules.

 

Disclosure: BRH: Research Funding, Veracyte, Inc.. JPK: Consultant, Veracyte, Inc.. Nothing to Disclose: MBA, PN, CDR, JIL, PPP, RCM Jr.

16013 13.0000 MON-0557 A Clinical and Ultrasonographic Predictors of Malignancy for Indeterminate Thyroid Nodules with Suspicious Molecular Testing 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Alaa Al Nofal*, Michael R. Gionfriddo, Asma Javed, Juan Pablo Brito, Qusay Haydour, Siobhan T Pittock and Mohammad Murad
Mayo Clinic, Rochester, MN

 

Introduction:  Thyroid ultrasound (US) is a widely accepted tool for evaluating thyroid nodules in children; but the accuracy of the US features in detecting thyroid cancer in this population is not determined.    

Objective: To conduct a systematic review to assess the diagnostic accuracy of different thyroid ultrasound features in detecting thyroid cancer in pediatric patients.

Methods:  We utilized multiple online databases for all different types of original studies that enrolled pediatric patients (Age <21 years) with thyroid nodules and evaluated the diagnostic features of thyroid sonography.  A total of 11 relevant ultrasound features were analyzed. Histo-pathological diagnosis after thyroidectomy was considered the gold standard for diagnosing thyroid cancer. A constellation of multiple tests were considered reference tests for defining benign nodules; these tests were histo-pathology after surgery, two consistent FANs, and one FNA with a follow up US after a minimum period of 6 months. The quality of the studies was assessed using the quality assessment tool for studies of diagnostic accuracy (QUADAS).

Results: The search strategy yielded 1199 potentially relevant abstracts and 11 articles (years 1995-2013) met our predefined inclusion criteria.  The number of nodules studied was 674 (Female to male ratio was 5:1). The frequency of thyroid cancer was 28.3% (34.5% in patients with history of radiation exposure and 26.1% in patients without history of exposure to radiation). The most common cancer was papillary thyroid cancer (85.8%).  The presence of internal calcifications was the US feature with the highest likelihood ratio (4.19, 95%CI 1.65-10.63) and diagnostic odds ratio (7.56, 95%CI 2.51-22.83) for thyroid cancer. On the other hand, the feature with highest likelihood ratio for benign nodules was “cystic nodule” (1.28, 95%CI 1.14-1.44).

Discussion: Many thyroid ultrasound findings are considered “suspicious” for malignancy in children. However, there is no single thyroid US feature that, if present, is pathognomonic for thyroid cancer. “Internal calcifications” has the highest likelihood ratio for thyroid cancer in children with thyroid nodules. Although the presence of cystic nodule is suggestive of benign etiology, its presence is not sufficient to rule out malignancy.

Conclusion: The current available evidence is of Low quality but suggests that US features are not accurate predictors of benign or malignant etiology of thyroid nodules in children.

 

Nothing to Disclose: AA, MRG, AJ, JPB, QH, STP, MM

16366 14.0000 MON-0558 A The Accuracy of Thyroid Ultrasound in Detecting Thyroid Cancer in Pediatric Patients with Thyroid Nodules: Systematic Review and Meta-Analysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Eman A Humudh1, Hindi Al-Hindi1, Mai Almohanna2 and Ali Saeed Alzahrani*3
1King Faisal Specialist Hospital & research center, Riyadh, Saudi Arabia, 2King Faisal Specialist Hospital & research center, 3King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia

 

The mTOR is an important downstream mediator in the PI3K/AKT pathway.  It interacts with multiple pathways and is widely involved in cellular growth and metabolism.  Although frequently up-regulated in many types of cancers, gene mutations have been only described at low frequencies.  To our knowledge, no previous study described mTOR mutations in thyroid cancer.  In this study, we screened for mTORmutations in benign and malignant follicular cell-derived thyroid tumors

Patients and Methods

We initially screened 63 cases of thyroid neoplasms including 10 benign nodular goiters and 53 differentiated thyroid cancer {41 classical papillary thyroid cancer (PTC), 7 follicular variant PTC, 1 tall cell variant, 1 hurthle cell cancer, 1 columnar cell variant PTC, and 2 poorly differentiated thyroid cancer}.  The histopathological specimens were carefully examined by an endocrine pathologist and tumor tissue was carefully dissected from formalin fixed Paraffin embeded tissue.  DNA was extracted using the Puregene DNA extraction kit according to the manfacturer’s instruction.  We used polyemrase chain reaction (PCR) and direct sequencing to screen for mutations in mTOR.  The primers were designed to encompass the exons and the exon-intron boundaries.  The PCR conditions were as follows: Initial denaturation at 95C for 5 minutes followed by 35-40 cycles of denaturation at 95C for 1 minute, anealing at 55-62C (diffeent exons have different anealing temperature) for 45 seconds, extension at 72C for 45 seconds.  This was followed by a final extension step at 72C for 7 minutes.  Since the mTOR gene is large with 58 exons, we choose exons that were previously described to be frequently mutated (exons 1, 3, 6, 12, 16, 21, 25, 29, 38, 42, 46, 52, 55).  To increase the chance of finding mutations, we then extended our search for mutations to 21 selected high grade tumors (large tumors with extrathyroidal extension and lymph node metastases and/or distant metastases, poorly differentiated or anaplastic  thyroid cancer) and limited our search to the most frequently previously described mutated exons (1, 3, 21, 38, 42, 46, 55).

 Results

Neither the initial screening of 63 thyroid tumors revealed mutations in exons 1, 3, 6, 12, 16, 21, 25, 29, 38, 42, 46, 52 and 55 nor the further search in 21 highly malignant and poorly differentiated thyroid cancers revealed mutations in exons 1, 3, 21, 38, 42, 46 and 55.

Conclusions

Despite the importance of mTOR in the AKT/PI3K pathway, mTOR mutations do not seem to be an important mechanism of thyroid tumorogenesis.

 

Nothing to Disclose: EAH, HA, MA, ASA

13446 15.0000 MON-0559 A Absence of the Most Frequently Reported mTOR Mutations in Thyroid Neoplasms 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Dania M Alkhafaji1, Ali AlMaqbali1, Ahmed S Qaitoon1, Reem F Alamawi1, Mahmoud Tuli1, Ahmed S Almuhaideb1 and Ali Saeed Alzahrani*2
1King Faisal Specialist Hospital & research center, Riyadh, Saudi Arabia, 2King Faisal Specialist Hospital & research center

 

Although recombinant human thyrotropin (TSH) is frequently used for thyroid remnant ablation, its cost and availability restrict its common use in many countries.  Worldwide, thyroid hormone withdrawal continues to be the most commonly used preparation method for radioactive iodine (RAI) remnant ablation.  The conventional approach is to hold L-thyroxine therapy for 4-5 weeks to allow serum TSH to rise above 25-30 mU/l, a level widely accepted as adequate for stimulation of thyroid tissue to take up RAI.  In this study, we questioned the duration needed to reach this TSH level.  Our objective was to determine the thyroid hormone withdrawl time needed for serum TSH to reach 30 mU/l. 

 Patients and Methods

We studied 14 patients (10 Females and 4 Males) with papillary thyroid cancer who were scheduled to have radioactive remnant ablation for the time needed for TSH to exceed the conventional target TSH of 30 mU/l.  All patients had total thyroidectomy ± lymph node dissection and were TNM stage I or II.  None of them had distant metastases, unusual histopathology or evidence of significant residual tissue.  The median age was 27.5 years (range 18-56).  Apart from PTC, there was no history of chronic medical problems and no history of pituitary disease.  Patients were withdrawn form thyroid hormones and serum TSH level was measured every 5-7 days.  When the patient TSH exceeded 30 mU/l, he/she was treated with RAI.

Results

The median baseline TSH and FT4 were 2.91 mU/l (0.036-4.3) and 18 pmol/l (range, 15.6-27.3, normal range in our laboratory is 12-22 pmol/l), respectively.  The median time needed for TSH to exceed the target TSH of 30 mU/l was 12.4 days (range, 7-18).  In fact, TSH rose too quickly that most patients had TSH much higher than the target TSH (30 mU/L).  The median TSH achieved was 68.4 mU/l (range 36-162).  The corresponding FT4 values decreased to a median of 4.95 pmol/l (range, 1.6-9).   It is clear that the target TSH would have been reached much earlier if the patients had more frequent measurements of TSH but for practical reasons, we could not measure it more frequently than every 5-7 days. 

Conclusions

The conventional withdrawal time of 4-5 weeks for RAI remnant ablation is not needed in almost all patients.  This long period of thyroid hormone withdrawal is associated with significant morbidity.  The average time needed to reach the conventional target TSH of 30 mU/l is about 12 days and is likely to be associated with much better quality of life than the standard protocol.

 

Nothing to Disclose: DMA, AA, ASQ, RFA, MT, ASA, ASA

14938 16.0000 MON-0560 A Thyroid Hormone Withdrawal Time Needed for TSH to Reach 30 Mu/l for Radioactive Iodine (RAI) Remnant Ablation in Differentiated Thyroid Cancer Is Much Shorter Than the Conventional 4-5 Weeks 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Ali Saeed Alzahrani*1, Ebtesam Qasem1, Hindi Al-Hindi2, Mai Almohanna3, Yufei Shi4 and Abeer S Alomair2
1King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia, 2King Faisal Specialist Hospital & research center, Riyadh, Saudi Arabia, 3King Faisal Specialist Hospital & research center, 4King Faisal Specialist Hospital, Riyadh, Saudi Arabia

 

Background

The Telemorase Reverse Transcriptase (TERT) promotor mutations C288T and C250T have recently been described in follicular cell-derived thyroid cancer from North America (1, 2).  They are associated with more aggressive tumors and with high rate of BRAFV600E mutation. Their prevalence and significance in differentiated thyroid cancer (DTC) has not been reported from other ethnic groups.  In this study, we report the prevalence and prognostic value of TERT mutations in a series of patients with DTC from the Middle East.

Patients and Methods

We studied tumors from 149 non-selected patients with thyroid neoplasms (132 DTC and 17 cases of benign multinodular goiter). The DTC included 84 conventional papillary thyroid cancers (CPTC), 29 follicular variant PTC (FVPTC), 1 tall cell PTC (TC-PTC), 2 hurthle cell cancer, 1 follicular thyroid cancer (FTC), 7 poorly differentiated thyroid cancer (PDTC) and 8 mixed types of DTC.  The tumor tissue was carefully dissected from formalin fixed Paraffin embedded tissue.  DNA was extracted using the Puregene DNA extraction kit according to the manufacturer’s instruction.  We used PCR and direct sequencing to screen for TERTpromotor mutations using primers and PCR conditions as previously described (2). Data were extracted from the medical charts of the patients.  The Fisher Exact and multivariate logistic regression analysis were used to analyze the data.

Results

None of the 17 benign MNG carried TERT mutations.  Overall, C250T or C228T mutations were found in 18 out of 132 cases of thyroid cancer (13.6%).  C250T mutation was present in only 3 cases (2.2%); 2/29 FVPTC (6.9%) and 1/8 (12.5%) mixed tumor FVPTC/CPTC.   C288T mutation was present in a total of 15/132 cases (11.4%); 7/84 CPTC (8.3%), 6/29 FVPTC (20.7%), and 1/6 PDTC (16.7%).  Similar to previous reports, these two mutations were mutually exclusive.  TERT mutations were more common in older (≥45 yrs) than young patients {13/18 (72.2%) vs. 5/18 (27.8%), P 0.006}.  TERT mutations were associated with larger tumor size (4.9±2.9 cm vs. 3.46±2.4 cm, P 0.025), vascular invasion (66.7% vs. 28.6%, P 0.004) and more likelihood of persistent disease at 6-12 months after RAI remnant ablation (83.3% vs. 38.6%, P 0.001).  BRAFV600E mutation was more common in patients with than those without TERT mutations (66.7% vs. 34.2, P 0.018).  In a multivariate analysis model that included age, tumor size, extrathyroidal invasion, multifocality, lymph node metastases, distant metastases and BRAFV600E mutation, TERT mutations remained an independent predictor of vascular invasion ( P 0.022, odd ratio 5.04 (95 CI 1.26-20.2) and persistent disease at 6-12 months after RAI remnant ablation {P 0.0001, Odd ratio 66.4 (95% CI, 7.0-631)}

Conclusion

TERT C288T and C250T mutations are relatively common in DTC.  They are associated with more aggressive features of DTC, higher rate of BRAFV600E mutation and higher risk of persistent disease.

 

Nothing to Disclose: ASA, EQ, HA, MA, YS, ASA

15090 17.0000 MON-0561 A TERT Promoter Mutations in Follicular-Cell-Derived Thyroid Cancer: Their Frequency and Association with BRAF Mutation, Histopathological Features and Short-Term Outcome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Aayushi Garg*, Saurav Chopra, Sanjana Ballal and C S Bal
All India Institute of Medical Sciences, New Delhi, India

 

The incidence of differentiated thyroid cancer (DTC) is increasing all over the world. Traditionally, AJCC staging system stratifies the risk in thyroid cancer patients according to the age less than or greater than 45 years. Patient age >45 years has consistently been recognised as a poor prognostic factor by various reports (2). However, recent literature suggests that among the patients >45 years, particularly poorer prognosis is associated with age >60 yrs (3). Published literature on elderly DTC patients is scarce. This retrospective study from a large tertiary care academic institution sought to identify the prognostic factors in DTC patients >60 years of age. The institute thyroid cancer database had 4370 DTC patients, of which 447(10%) were aged >60. However, 9 patients were excluded due to follow-up less than 1 year.  Among the 438 patients, 311(71%) had only loco-regional disease (M0) and 127(29%) had distant metastases (M1) at the time of initial presentation. Male gender, tumor size (>4cm), follicular histology and extra-thyroidal extension were host factors associated with distant metastases. Among Mo patients, 195 (63%) achieved complete remission while only 12 (9%) M1 patients did so. Average number of 131I doses administered to achieve complete remission were 2.3 (range,1-6) and mean cumulative dose was 92 mCi (range,25-1250 mCi). In multivariate logistic regression among Mo patients, follicular histology, nodal metastases and surgical treatment lesser than total/near-total thyroidectomy and among M1 patients, tumor size (>4cm) and site of distant metastases (skeletal and multiple sites) were independent factors predicting non remission. Among the patients (both M0 and M1) who achieved remission, factors associated with disease recurrence were analysed using multivariate Cox proportional hazard model. Among the 207 patients who achieved remission, 28(14%) patients developed recurrence during the mean follow-up of 67 months (range,12–216 mo).  Disease free survival of the patients at 5 and 10 years were 80% and 73%, respectively. The recurrence sites were lymph nodes in 17(61%), lungs in 7(25%) and bones in 4(14%) patients. Tumor size (>4cm), nodal metastases, pulmonary metastases and non remission after first dose of radioactive iodine were associated with greater chances of disease relapse. This study highlights that DTC in elderly behaves more aggressively than in adults, and successfully identifies several prognostic factors for remission and subsequent relapse.

 

Nothing to Disclose: AG, SC, SB, CSB

13202 18.0000 MON-0562 A Differentiated Thyroid Cancer in Patients over 60 Years of Age at Presentation: A Retrospective Study of 438 Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Saurav Chopra*, Aayushi Garg, Sanjana Ballal and C S Bal
All India Institute of Medical Sciences, New Delhi, India

 

Differentiated thyroid cancer (DTC) is the most common endocrine malignancy. Unlike other cancers, DTC has favourable prognosis with high 10-year survival rates. Distant metastases, though rare, account for maximum disease related mortality (1). Lungs and bones are the most frequent sites of metastases. We sought to identify the prognostic factors in adult DTC patients presenting with pulmonary metastases at initial diagnosis. Among the 3889 DTC patients with age>21, 200(5%) patients with pulmonary metastases at diagnosis were included in this retrospective study. The sites of metastases were lungs alone in 133(67%) patients and additional sites in remaining 67(33%) patients were: bones in 59, liver in 4, brain in 2 and both bone and liver in 2 patients. Multivariate logistic regression was performed to assess the prognostic factors predicting remission during the radioactive iodine (RAI) treatment course. Among the patients who achieved remission, factors pertaining recurrence were analysed using multivariate Cox proportional hazard model. Seventy-six patients (38% became disease free with average number of 131I administrations of 3.2 (range, 1-8) and mean cumulative dose of 424 mCi (range, 40-1075 mCi). During the mean follow-up of 61 months (range, 12-312 months), 121(60.5%) patients had biochemically and/or structurally persistent disease and 3 patients showed disease progression. Among patients who achieved complete remission, the disease-free survival at 5 and 10 years were 73% and 61%, respectively. Multivariate analysis revealed macro-nodular (chest x-ray positive) pulmonary metastases and presence of concomitant skeletal metastases as independent factors decreasing the likelihood of remission. Of the 76 patients with remission, 16 (21%) developed subsequent recurrence. The recurrence sites were lymph nodes in 8, lungs in 4 and bones in 4 patients. Patient age >45 years and follicular histopathology were independently associated with greater hazards of developing recurrence in multivariate analysis.  To conclude, this study suggests that aggressive management strategy should be adopted in patients with macro-nodular lung metastases and/or with concomitant skeletal metastases. Moreover, significant number of patients recur even after complete remission with RAI treatment, hence strict surveillance is recommended especially in patients with age >45 years and/or with follicular histology of DTC.

 

Nothing to Disclose: SC, AG, SB, CSB

13208 19.0000 MON-0563 A Lung Metastases from Differentiated Thyroid Carcinoma in 200 Patients: Prognostic Factors Related to Remission and Disease Free Survival 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Carolina Ballarino*1, Marta Kura2, Marta Aparicio1, Florencia Rodriguez1, Francisco Tamagnone2, Silvina Sankowics1, Bruno Peressotti2, Alejandro Vega2, José Gomez Escalante2, Susana Mallea Gil1 and Karina Bertini1
1Hospital Militar Central, Buenos Aires, Argentina, 2Hospital Militar Central

 

Ultrasonography (US) and Power Doppler (PD) are the usual techniques in the evaluation of thyroid nodules. Ultrasound elastography (USE) is a new tool that uses ultrasound to evaluate tissue stiffness by the degree of distortion; it has been applied to study hardness/elasticity of nodules to differentiate malignant from benign lesions with a higher prediction of malignancy. Our objective was to assess the combined use of these methodologies in the diagnosis of thyroid nodules and its correlation with fine needle aspiration (FNA) and histological diagnosis of the operated patients. Prospective and observational study: 246 thyroid nodules in 221 patients. We used US and PD to evaluate size, echogenicity, borders sharpness, presence of halo, blood flow and its pattern; and USE with measurement of the strain ratio between the lesion and the normal tissue and micropure technique. FNA was performed with sonographic guideline; cytology was done using The Bethesda system. Toshiba Aplio 400 was used; all studies were performed by the same operator. Statistical analysis was handled by IBM SPSS statistic 20. We excluded 5 cases with category I and 27 with category III-IV. Of 214 cases included the mean age was 57±17 years, 81% were women. We compared patients with Bethesda II (group 1:195 cases) vs Bethesda V-VI (group 2:19). In the  uni and multivariated statistical analysis we only found significant statistical difference for sharpness of borders 11% vs 35%; incomplete halo 25% vs 60%; positive micropure 9% vs 40% (P:0,001) and average strain ratio was 1.80±1.8 vs 5±4.4 (P:0,004). The cut-off of the elastography strain ratio of ≤ 2  (148 out of 214 nodules) had a sensibility of 70% and specificity of 72% to predict Bethesda associated with benign pathology with a Negative Predictive Value (NPV) of 96% and a Positive Predictive Value of 21%. In group 2 pathology reports were available in 14/19; there were 13 carcinomas, the average strain ratio was 6.42± 4.66. Conclusions: USE strain ratio ≤ 2 allowed us to rule out malignant nodules with NPV of 96%. The increase of the elastography strain ratio was associated with higher probability of malignancy; however, we could not state a cut-off because of the few cases with Bethesda V-VI. We found a good correlation between USE and the definitive diagnosis. The evaluation of thyroid nodules by US and USE together with micropure technique performed by an experienced operator may improve the selection of patients for FNA.

 

Nothing to Disclose: CB, MK, MA, FR, FT, SS, BP, AV, JG, SM, KB

14088 20.0000 MON-0564 A Usefulness of Ultrasound Elastography in the Diagnosis of Thyroid Nodules and in the Prediction of Malignancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Sharleen Sidhu1, Vallikantha Nelliaippan1, Aditi Gupta1, Veena Iyer1, Preethi Sridhar2, Boby G Theckedath1 and Charles P Barsano*1
1Capt James A Lovell Federal Health Care Ctr, North Chicago, IL, 2Endocrinology Physicians Group, Mountain View, CA

 

Monitoring thyroid nodule growth ultrasonographically is commonly employed. The reported changes in diameters of nodules from one USG to the next reflect both technical variations and actual nodular changes. This study was performed to determine the minimum reported nodular diameter increase or decrease that may confidently be regarded as an actual change in nodule size. The longest dimensions of 80 ultrasonographic images of predominantly solid nodules were independently drawn and measured by pairs of observers using the ImpaxTM image viewer (Agfa). Observers were not aware of the measurements determined by other observers. For each nodule, one of the paired observers was randomly assigned to provide the initial measurement while the other member was assigned to provide the follow-up measurement, thus simulating the monitoring of a nodule that had not changed. The mean difference between initial and follow-up measurements was 0.0 mm. The sd of the differences was 1.8 mm. This exercise indicated that the probability that a truly unchanging nodule would be reported as unchanging (i.e. change in longest diameter being < ± 1 mm) would only be ~60%. The probabilities of a reported change of ≥ 1 mm but < 2 mm, or ≥ -1 mm but < -2 mm, would each be ~10%. The probabilities of a reported change of ≥ 2 mm but < 3 mm, or ≥ -2 mm but < -3 mm, would each be ~5%. The probabilities of a reported change of ≥ 3 mm, or ≥ -3 mm, would each be ~5%.

  These probabilities were applied to 215 reported changes between successive USGs drawn from 66 predominantly solid benign nodules to estimate the true fractions of growing, shrinking and stable nodules. Nodules were regarded as enlarging [or decreasing] if their reported longest diameters changed by ≥ +3 mm [or ≥ -3 mm]. The probabilitiesof a reported increase or decrease occuring by reading error alone would therefore be ~5% for each.

  Of the 215 reported changes in longest diameters, 13.0% were increases of ≥ 3 mm and 12.1% were decreases of ≥ 3 mm. The remaining 74.9% of reported changes were < ± 3mm and therefore not confidently regarded as true changes in diameter. Had the attribution of "growing" or  "shrinking" been based on reported changes of ≥ 1 mm or ≥ -1 mm, respectively, the fractions of "growing," "shrinking" and "stable" nodules would have been very different: 39.5%, 31.2% and 29.3%, respectively. Using the ≥ ± 3 mm criteria for change, the relative proportions of "enlarging," "shrinking" and "stable" benign nodules did not appear to differ significantly on the basis of histological cell types. Too few malignant nodules had serial USGs to permit a comparative analysis.

  This study demonstrates that the attribution of growth or shrinkage to nodules on the basis of reported changes of ≥ ± 1 mm on consecutive USG’s could be very misleading. Attributing actual nodular growth or shrinkage to changes no less than ± 3 mm in longest diameter should substantially minimize over-interpretation of USG reports.

 

Nothing to Disclose: SS, VN, AG, VI, PS, BGT, CPB

11413 21.0000 MON-0565 A The Significance of Reported Changes in the Size of Benign Thyroid Nodules on Consecutive Ultrasonograms (USGs) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Vallikantha Nelliaippan1, Sharleen Sidhu1, Aditi Gupta1, Veena Iyer1, Preethi Sridhar2, Boby G Theckedath1 and Charles P Barsano*1
1Capt James A Lovell Federal Health Care Ctr, North Chicago, IL, 2Endocrinology Physicians Group, Mountain View, CA

 

This study was performed to test previously published data indicating (1) that nodules whose Anterior-Posterior (AP) diameters were greater than their Left-Right (LR) diameters (“taller than wide” on the transverse views of ultrasonograms) were more likely to be malignant, and (2) that nodules whose Aspect Ratios (expressed as the ratio of Longest Diameter/Shortest Diameter) were greater than 2.5 were rarely malignant. We reviewed the LR, AP and SI (Superior-Inferior) diameters of 115 predominantly solid, non-isthmus, benign and malignant nodules on thyroid ultrasonograms.

  Although we found that too few nodules had AP/LR ratios > 1 [29 of 115 (25.2%), 23 of which were benign] or Aspect Ratios > 2.5 [2 of 115 (1.7%), both benign] to be very helpful, we found that malignant nodules exhibited a strong predilection [19 of 21 malignancies (90.5%)] to have bothAP/LR ratios ≥ 0.750 and Aspect Ratios ≤ 1.750 (together referred to as “Quadrant 1” dimensional ratios). Benign nodules did not exhibit a strong predilection for Quadrant 1 ratios: 53 of 94 benign nodules (56.4%) exhibited Quadrant 1 ratios; the other 41 benign nodules (43.6%) did not exhibit one or both Quadrant 1 ratios). This difference in dimensional ratio distributions between benign and malignant nodules was statistically significantly different (p<0.01).

  Quadrant 1 characteristics did not have a high Positive Predictive Value for identifying malignancy since approximately half of benign nodules also exhibited Quadrant 1 ratios. Nodules that did not exhibit Quadrant 1 ratios, however, had a very high Negative Predictive Value for malignancy since many benign nodules but relatively few malignant nodules exhibited non-Quadrant 1 ratios. If the observed differences in the distributions of dimensional ratios among benign and malignant nodules were projected to the usually encountered population of thyroid nodules (~7% malignant; ~93% benign), the Negative Predictive Value (probability of a non-Quadrant 1 nodule being benign) would be 98%. If there were no dimensional ratio differences between benign and malignant nodules, the Negative Predictive Value of non-Quadrant 1 nodules in the projected population would equal the overall prevalence of benign nodules, i.e. ~93%.

  When categorized by cytological or surgical diagnosis, no type of benign nodule exhibited such a strong predilection for Quadrant 1 dimensional ratios. Of the malignant nodules, 17 of the 21 were Papillary, 3 were Follicular and 1 Medullary. One Papillary and 1 Follicular carcinoma exhibited non-Quadrant 1 dimensional ratios.

  Though not a substitute for thyroid biopsy, consideration of the AP/LR Ratios and Aspect Ratios of predominantly solid, non-isthmus thyroid nodules with non-Quadrant 1 dimensional ratios (AP/LR ratio < 0.750 and/or Aspect Ratio > 1.750) should serve as a useful predictor of benignity.

 

Nothing to Disclose: VN, SS, AG, VI, PS, BGT, CPB

12705 22.0000 MON-0566 A The Predictive Value of Ultrasonographically Determined Dimensional Ratios of Benign and Malignant Thyroid Nodules 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Carlos Benbassat*1, Eyal Robenshtok2, Gideon Bachar3, Diana Braslavski3 and Dania Hirsch1
1Rabin Medical Center and Sackler School of Medicine, Tel-Aviv University, Petah-Tiqva, Israel, 2Rabin Medical Center, Petah-Tiqva, Israel, 3Rabin Medical Center, Petah Tikva, Israel

 

Introduction: The new Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) was developed in 2009 to standardize the terminology for thyroid FNA results. Objective: To investigate the impact of the TBSRTC on the number of indeterminate nodules excised and its correlation with the final pathologic diagnosis. Methods: All thyroid FNAs performed at Rabin Medical Center in 2011-2012 were revised. The clinical and pathologic data on nodules categorized as Bethesda3-Bethesda4 were collected from the electronic records. Results were compared to our published data from 1999-2000. Results:  Of the 3927 nodules aspirated at our center during the study period (twice the number than in 1999-2000), 575 (14.6%) were categorized as B3-B4. Medical records were available for 322 (56%). Thyroidectomy was performed in 122/322 cases (38%): 65/250 (26%) B3, 57/72 (79%)  B4. Differentiated thyroid cancer was found in 66/122 (54%): 30/65 (46%) B3, 36/57 (63%)  B4, with a trend-level difference between B3 and B4 nodules (p=0.089). Comparison of patients operated/not operated for B3 disease yielded no differences in age and sex, but the non-operated group had more benign repeated  cytologic results (63% vs 30%, p<0.001) and smaller nodules (22.2±10 vs 27.2±13 mm, p=0.014).  Compared to 1999-2000, the number of FNAs for indeterminate nodules increased from 6% (111/1854) to 14.5%, but the surgery rate decreased from 55% (58/111) to 38%, and the diagnostic accuracy of malignancy increased from 26% (15/58) to 54%. Conclusion: Application of the Bethesda classification significantly improves diagnostic accuracy for indeterminate thyroid nodules, leading to higher malignancy detection despite lower thyroidectomy rates.

 

Nothing to Disclose: CB, ER, GB, DB, DH

13242 23.0000 MON-0567 A Does the Bethesda Classification for Thyroid Cytology Improve the Preoperative Probability of Malignancy in Suspicious Nodules? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Carlos Benbassat*1, Adi Guy2, Eyal Robenshtok3, Gideon Bachar2 and Dania Hirsch1
1Rabin Medical Center and Sackler School of Medicine, Tel-Aviv University, Petah-Tiqva, Israel, 2Rabin Medical Center, Petah Tikva, Israel, 3Rabin Medical Center, Petah-Tiqva, Israel

 

Introduction: The presence of cervical LN metastases is a strong predictor for persistent disease in DCT patients. Aims: To investigate predictive factors that correlates with improved outcome in patients with DTC and LN metastases. Methods: From the Rabin Medical Center Thyroid Cancer Registry we identified 183 patients with N1 disease out of 800 operated since 1995 having sufficient data for analysis. All patients were treated with total thyroidectomy and RAI. Lateral ND was performed in 52%, central ND in 27% and no formal ND in 21%. Partial thyroidectomy, distant metastases and poor differentiation were exclusion criteria. Follow-up period was 8 years. Results: Mean age at diagnosis was 46.5±15, 70% were females, 93% were PTC/PTCFV, T1-2 was documented in 60%  and extra-thyroid extension (ETE) in 42%. Median number of LN affected/excised 4/12. Less than 3 LN were excised in 24%. Median size of largest LN was 15 mm. By inclusion criteria all patients were N1 (N1a 48% and N1b 52%). Mean RAI first dose was 142+32 mCi. At 1 year post-treatment, 82/183 (45%) patients had persistent disease (23 biochemically only). Factors associated with persistency were gender, primary size, focality, ETE, N1b, LN yield, LN size and postOp stTg. At last follow-up 25/79 patients had NED and this was associated with the size of the primary tumor, postOp and 1-yr stTg and the cumulative I-131 dose. Conclusion: Extension of disease, stTg levels and cumulative I-131 dose (but not first dose) were associated with persistency in patients with lymph node involvement

 

Nothing to Disclose: CB, AG, ER, GB, DH

13249 24.0000 MON-0568 A Short and Long-Term Outcome of Differentiated Thyroid Cancer in Patients with Lymph Nodes Involvement 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Chiaw Ling Chng* and Adoree Yi Ying Lim
Singapore General Hospital, Singapore, Singapore

 

Title: A 3 year study of ultrasound guided fine needle aspiration biopsy of thyroid nodules in a tertiary institution in Singapore

Introduction

Ultrasound guided fine needle aspiration biopsy (USGFNA) is currently the most sensitive diagnostic procedure available for thyroid nodules. A dedicated thyroid USGFNA service was set up in our institution since 2009 and we aim to audit the biopsies performed and compare our results with the current accepted standards.

Methods

An audit was conducted for all thyroid USGFNA performed between January 2010 and December 2012. Information such as patient gender, age, cytology results and postoperative histopathology results (for patients who underwent thyroidectomy) was collected via written and electronic medical records. Data entry and statistical analyses were performed with SPSS Software 21.0.

Results

A total of 694 thyroid USGFNA were performed between 2010 and 2012. Majority of the patients were female and average age of the patients was 52.9 years old.  5.2% of the cytology results were non-diagnostic, 5.6% cystic, 76.2% benign, 9.1% indeterminate, 2.2% suspicious for malignancy and 1.7% were malignant. 11/15 patients with cytology results that were suspicious for malignancy underwent surgery and final histology showed malignancy in 7 of them. 30/63 patients with indeterminate cytology results underwent surgery and final histology showed malignancy in 12 of them. 10/36 patients with initial non diagnostic cytology results had a repeat USGFNA and an adequate yield was achieved at the second attempt in 7 of them (all benign).

Conclusions

Our non-diagnostic rate is comparable to current accepted standards. Repeating the USGFNA for an initial non-diagnostic cytology result increases the diagnostic yield and should be considered at the first instance. The risk of malignancy from a cytology result that is suspicious for malignancy is similar to previously reported but the risk of malignancy from a cytology result that is indeterminate appears to be higher in our cohort. 

 

Nothing to Disclose: CLC, AYYL

12493 25.0000 MON-0569 A A 3 Year Study of Ultrasound Guided Fine Needle Aspiration Biopsy of Thyroid Nodules in a Tertiary Institution in Singapore 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Chiaw Ling Chng*1, Grant Stewart1, Mark Patrick Vanderpump2, Bernard Chong Eu Khoo3, Pierre-Marc Gilles Bouloux2, Dora Afful1 and Salim Janmohamed2
1Royal Free Hospital, 2Royal Free Hospital, London, United Kingdom, 3Royal Free Campus, UCL, London, United Kingdom

 

Title: A study on the management of differentiated thyroid cancer at a large UK teaching hospital


Aim: Thyroid cancer is the most common endocrine malignancy, although some aspects of its management remain controversial. The aim of the study was to audit existing clinical practice in a large UK teaching hospital and compare them with the current standards of care based on the British Thyroid Association 2007 guidelines.

Method: A retrospective case record review of cases of differentiated thyroid cancer (DTC) diagnosed between 2008 and 2012 was performed. Available information such as baseline demographics, initial cytological diagnosis, stage of cancer, type of surgery, radioiodine therapy and follow up thyroglobulin (Tg) levels were collected and analysed.

Results: A total of 54 patients were diagnosed with DTC between 2008 and 2012 of whom 78% were women. Average age at diagnosis was 49.9 + 15.4 years. 85% were papillary thyroid cancer, and 71% were stage 1 disease. 20% had treatment within 31 days from diagnosis. All patients with tumours > 1cm had total thyroidectomy or completion thyroidectomy after initial hemithyroidectomy. Neck dissection was performed in 58% of cases and a third of these cases had confirmed nodal disease on histology. Remnant RAI ablation (3GBq) and post ablation scan was performed in 93%. 79% of patients with an undetectable serum TSH-stimulated Tg at the time of remnant ablation had a positive post ablation scan. 82% had serum TSH suppressed to <0.1mIU/L (>50% measured in 1st 2 yrs). Average Tg monitoring interval was 3.6 + 0.9 months, with minimum detection limit of the Tg assay at 5ug/L. Thyroglobulin antibodies (TgAb) measurement was performed in 30% cases. 74% of cases who had remnant ablation had a second ablation (5GBq), and of these 66% had an undetectable serum TSH stimulated Tg at time of second ablation.

Conclusions: There was general adherence to the current standards of care. However, a Tg assay with a lower detection limit (<1ug/L) and greater reinforcement to the simultaneous measurement of TgAb and Tg are recommended. Further research and audits are required to explore the reasons for the high rate of surgical neck dissections and a second radioiodine ablation. This audit will facilitate the development of locally agreed protocols to improve the current practice.

 

Nothing to Disclose: CLC, GS, MPV, BCEK, PMGB, DA, SJ

13297 26.0000 MON-0570 A A Study on the Management of Differentiated Thyroid Cancer at a Large UK Teaching Hospital 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Bo Cui*
The First Affiliated Hospital of Xi’an Jiaotong University School of Medicine, xi'an, China

 

Abstract

Context: EZH2, a core component of polycomb repressive complex 2 (PRC2), is frequently overexpressed in human cancers. DZNep (3-deazaneplanocin A) depletes EZH2 and exhibits promising anti-tumor activity. Its cellular responsiveness is determined by certain genetic factors.

Objectives: Our aims were: 1) to test therapeutic potential of DZNep and explore genetic determinants affecting DZNep response in thyroid cancer cells; and 2) to test combined therapeutic effect of DZNep and PRIMA-1, a mutant p53 reactivator, in thyroid cancer.

Experimental design: We evaluated the phenotypic effects of DZNep in thyroid cancer cells, and examined the effects of DZNep alone or in combination with PRIMA-1 on cell proliferation, cell cycle, apoptosis and xenograft tumor growth.

Results: DZNep induced EZH2 depletion and H3K27me3 histone mark reduction in all thyroid cancer cells, however, only TP53 wild-type cells exhibited growth inhibition upon DZNep treatment. In these cells, DZNep caused p53 protein accumulation through upregulating USP10 expression, resulting in activation of p53 pathway, contributing to inhibition of cell growth. Conversely, TP53 mutant-type cells were resistant to DZNep. Strikingly, combination of DZNep with PRIMA-1 restored sensitivity of TP53 mutant-type cells to DZNep. Similar anti-tumor effect of DZNep and PRIMA-1 alone or in combination was also seen in xenograft tumor models.

Conclusion: Our data demonstrated that DZNep responsiveness was strongly associated with TP53 genomic status in thyroid cancer cells. Reactivation of p53 restored the sensitivity of TP53 mutant-type cells to DZNep. Thus, a combined therapeutic strategy may be effective in treating thyroid cancer cells/patients harboring mutant p53.

 

Nothing to Disclose: BC

13615 27.0000 MON-0571 A Combined Treatment of DZNep and PRIMA-1 in Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Debora Lucia Seguro Danilovic*1, Evandro S Mello2, Eliana ST Frazzato1, Andrea GF Silva1, Erika Urbano Lima1, Amanda Shinzato1, Lenine Garcia Brandao3, Alexander Augusto Lima Jorge4, Ana Oliveira Hoff5 and Suemi Marui4
1Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 2Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil, 3Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Brazil, 4Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil, 5Instituto do Câncer do Estado de São Paulo, Sao Paulo, Brazil

 

Oxidative stress is a dynamic condition characterized by imbalance between oxidants and antioxidants. Reactive oxygen species (ROS) promote DNA damage and tumor initiation. On the other hand, antioxidants agents activate cytoprotector genes which may favor survival of cancerigenous cells and, consequently, tumor promotion. Nuclear factor erythroid 2-like 2 (NFE2L2) encodes a transcrition factor, Nrf2, which binds to antioxidant response element DNA sequences and activates transcrition of downstream genes. Under basal conditions, the inhibitor Keap1-Cul3 ubiquitin E3 ligase complex binds to Nrf2 in the cytoplasm and promotes its degradation. In the presence of ROS, the inhibitor complex is disrupted and releases Nrf2 resulting in its nuclear translocation. Mutations in NFE2L2 and KEAP1 genes favoring constitutive Nrf2 activation were described in several human cancers. Immunohistochemical study in papillary thyroid carcinomas (PTC) revealed increased Nrf2 staining of tumor cells, and promoter hypermethylation has been described as an inactivating mechanism affecting Keap1 in thyroid carcinomas. This study aims to evaluate the presence of mutations in NFE2L2 and KEAP1 genes and the expression of NFE2L2 mRNA in PTC. Methods: we sequenced exon 2 of NFE2L2 and exons 2-6 of KEAP1 in 156 archived surgical specimens of PTC, formalin-fixed and paraffin-embedded. Gene expression was determined by qRT-PCR (Taqman) in 8 PTC samples conserved in liquid nitrogen paired to their respective normal thyroid tissues. Quantification was done by ΔΔCt (cycle threshold) method normalized to reference gene. Results: In all but one sample, NFE2L2 was underexpressed in PTC compared to respective normal thyroid tissue (ΔCt for tumors 6.9±1.9 vs. ΔCt for normal tissues 5.5±1.9, p=0.011), with mean relative fold change of 0.52. We identified new mutations in KEAP1, p.Trp252stop and p.Arg261Trp. No mutation in NFE2L2 was found. Conclusions: Underexpression of NFE2L2 in PTC reinforces the presence of other mechanisms increasing Nrf2 activity. Mutations in KEAP1 may disrupt the inhibitory interaction Nrf2-Keap1, favoring increased Nrf2 activity.

 

Nothing to Disclose: DLSD, ESM, ESF, AGS, EUL, AS, LGB, AALJ, AOH, SM

12986 28.0000 MON-0572 A Oncogenic Mutations Disturbing Inhibitory Nrf2-Keap1 Interaction and the Antioxidant NRF2 Expression in Thyroid Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Monday, June 23rd 3:00:00 PM MON 0544-0572 4879 1:00:00 PM Thyroid Neoplasia Poster

Mariana Bonjiorno Martins*1, Marjory Alana Marcello2, Fernando de Assis Batista1, Karina Colombera Peres1, Murilo Meneghetti1, Mirela Andrea Latham Ward1, Ligia Vera Montalli Assumpção3 and Laura Sterian Ward4
1University of Campinas (Unicamp), Campinas, Brazil, 2University of Campinas, Campinas, Brazil, 3University of Campinas, Brazil, 4University of Campinas, Campinas,SP, Brazil

 

Thyroid tumor cells produce considerable amounts of interleukins (ILs), cytokines that participate in immune/inflammatory reactions and are able to modulate cell proliferation, thus, influencing the risk and progression of carcinomas, including differentiated thyroid cancers (DTC). IL-4 and IL-10 have been reported as having a stimulating effect on DTC cell growth.

In order to investigate the clinical utility of IL-4 and IL-10 as diagnostic and prognostic markers for DTC, we studied 200 patients with malignant tumors; 60 patients with benign tumors and 100 healthy controls. Patients were treated and followed according to a standard protocol for 86.25±74 months. Serum IL-4 and IL-10 levels were measured by ELISA.

IL-4 levels differentiated benign (0.27±0.04pg/mL) from malignant nodules (0.24±0.20pg/mL, p=0.0240). However, it did not differentiate controls (0.27±0.19pg/mL) from malignant (0.27±0.20pg/mL, p=0.3780) or follicular (0.17±0.14pg/mL) from papillary carcinomas (0.24±0.20pg/mL, p=0.1581). IL-4 levels did not correlate with tumor size, presence of multifocality, invasion, and metastasis at diagnosis or during follow-up. However, patients without distant metastasis (0.24±0.20pg/mL) produced higher levels of IL-4 than patients with distant metastasis (0.12±0.15pg/mL, p=0.0290). Likewise patients with thyroiditis (0.28±0.17pg/mL) had higher IL-4 levels than patients without thyroiditis (0.11±0.11pg/mL, p=0.0005). A ROC curve with a cutoff ≤0.2pg/mL, showed a sensitivity of 42.5%, specificity 98.3%, positive predictive value (PPV) of 98.8% and negative predictive value (NPV) of 33.9% of IL-4 in the diagnosis of malignant nodules.

IL-10 distinguished malignant (1.00±3.61pg/mL) from controls (0.51±0.39pg/mL, p=0.0304) but did not differentiate benign (0.58±2.84pg/mL) from malignant nodules (1.00±3.61pg/mL, p=0.1752). IL-10 levels were not correlated with tumor size, presence of multifocality, invasion, and metastasis at the diagnosis or during follow-up. A ROC curve with a cutoff ≤0.33pg/mL showed a sensitivity of 74%, specificity 77%, PPV of 85.6% and NPV of 61.7% of IL-10 for the diagnosis of malignant nodules.

In conclusion, serum IL-4 and IL-10 levels may help diagnose malignancy but do not appear to be useful in the definition of DTC patients outcome.

 

Nothing to Disclose: MBM, MAM, FDAB, KCP, MM, MALW, LVMA, LSW

14741 1.0000 MON-0279 A Investigation on SERUM Interleukin-4 (IL-4) and Interleukin-10 (IL-10) Utility As Clinical Markers for Differentiated Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0279-0288 4884 1:00:00 PM Biomarkers; Endocrine Neoplasia Poster

Marjory Alana Marcello*1, Antonio Ramos Calixto2, Jacqueline Fatima Martins Almeida3, Lucas Leite Cunha3, Bruno Geloneze2, Ligia Vera Montalli Assumpção3 and Laura Sterian Ward4
1University of Campinas, Campinas, Brazil, 2State University of Campinas - UNICAMP, Campinas, Brazil, 3University of Campinas, Brazil, 4University of Campinas, Campinas,SP, Brazil

 

Obesity and differentiated thyroid carcinomas (DTC) have been presenting increasing incidence in the last decades. Our group and others have been demonstrating that both conditions are associated with the serum concentrations of some cytokines produced by the adipose tissue, such as leptin. This adipokine is encoded by LEP gene and requires its receptor (LEPR) to exert its functions. Two polymorphisms in LEP (rs7799039 and rs2167270) and two in LEPR gene (rs1137101 and rs1137100) could modify leptin serum concentrations. To study these polymorphisms’ role in DTC, we genotyped 142 DTC patients matched to 142 healthy subjects using TaqMan® SNP Genotyping assays, and serum leptin levels were measured by ELISA. Clinical pathological data were reviewed in patients’ charts and used for staging. LEPR polymorphisms were not correlated with serum concentrations of leptin. In contrast, patients who presented AA genotype of rs7799039 in LEP gene had higher serum levels of leptin (9.22±0.98 ng/ml) than those with AG genotype (10.07±0.60 ng/ml; p=0.005). Individuals with the AG genotype of SNP rs2167270 also produced higher serum leptin levels (10.05±0.59 ng/ml) than subjects of GG genotype (9.52±0.79 ng/ml; p<0.05). Multivariate logistic regression adjusted for sex, age, ethnicity, smoking, and BMI showed that the inheritance of the AG genotype of LEP rs7799039 was an independent risk for DTC (OR=11.689, p= 0.0183, 95%CI=1.516 to 90.119). Similarly, genotypes AG and GG of LEPR rs1137101 increased the susceptibility to DTC (OR=3.747, p=0.027, 95% CI=1.161 to 12.092 and OR=5.437, p=0.013, 95% CI=1.426 to 20.729, respectively). No association was found between genotypes and parameters of isolated tumor aggressiveness, but the GG genotype of LEP rs2167270 was more frequent among patients with less advanced stage (I and II, 46.2 % of patients) than in stages III and IV (22.7%, p=0.043). Disease-free survival analysis showed no association between genotypes or serum leptin levels. We conclude that the two polymorphisms of the LEP gene may alter the serum concentration of leptin in patients with DTC. Moreover, the inheritance of LEP rs779903 and LEPR rs1137101 may increase the risk of development of DTC, but do not appear to correlate with tumor aggressiveness.

Financial support: FAPESP and CNPq

 

Nothing to Disclose: MAM, ARC, JFMA, LLC, BG, LVMA, LSW

14581 2.0000 MON-0280 A The Inheritance of Leptin and Leptin Receptor Polymorphisms MAY Increase Differentiated Thyroid Cancer Risk 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0279-0288 4884 1:00:00 PM Biomarkers; Endocrine Neoplasia Poster

Fernando de Assis Batista*1, Marjory Alana Marcello2, Mariana Bonjiorno Martins1, Murilo Meneghetti1, Ligia Vera Montalli Assumpção3, Marcio José Silva4 and Laura Sterian Ward5
1University of Campinas (Unicamp), Campinas, Brazil, 2University of Campinas, Campinas, Brazil, 3University of Campinas, Brazil, 4University of Campinas, 5University of Campinas, Campinas,SP, Brazil

 

Benign and malignant thyroid nodules have been increasing in frequency, leading to the search for markers that could help diagnose malignancy and predict prognosis, saving the majority of individuals from unnecessary, aggressive treatments. The maintenance of the thyroid differentiated phenotype depends on thyroid-specific transcription factors, such as Forkhead Box E1 (FOXE1). Abnormal FOXE1 expression might disturb the thyrocyte metabolism and differentiation, thus, playing an important role in thyroid oncogenesis.  In order to investigate the clinical utility of FOXE1 mRNA expression as a marker of diagnosis and prognosis in thyroid nodules, we performed a RT-PCR followed by relative quantification through qPCR technique. We investigated 49 thyroid nodules: 6 Follicular adenomas (FA), 12 colloid goiters (G), 15 classic papillary thyroid carcinomas (PTC) and 16 follicular variants of PTC (FVPTC). Patients were managed and followed for 47.2±29.5 months according to ATA/LATS/SBEM recommendations. We found a higher expression of FOXE1 in benign (0.75±0.60 AU) than in malignant thyroid nodules (0.41±0.30 AU) (p=0.0085). FOXE1 was able to diagnose malignancy in thyroid nodules with 80% sensitivity, 62% specificity, 76.9% Positive Predictive Value (PPV) and 66.7% Negative Predictive Value (NPV). FOXE1 expression also helped distinguish follicular-patterned differentiating FVPTC from FA with a sensitivity of 85%, specificity=83.3%, PPV=94.4% and NPV=62.5 %. No correlation between FOXE1 expression values and clinical, pathological data or outcome was found. In conclusion, FOXE1 not only distinguishes benign and malignant nodules, but also helps in the differentiation of follicular lesions, the current major challenge in thyroid nodules diagnosis.

 

Nothing to Disclose: FDAB, MAM, MBM, MM, LVMA, MJS, LSW

15019 3.0000 MON-0281 A FOXE1 Expression Might Help the Diagnosis of Thyroid Nodules Malignancy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0279-0288 4884 1:00:00 PM Biomarkers; Endocrine Neoplasia Poster

Carles Villabona*1, Rocío García-Carbonero2, Jaume Capdevila3, Paula Jiménez-Fonseca4, Guillermo Crespo5, Concepción Blanco6, Mª Carmen González-Garcia7, José Ángel Díaz Pérez8, Cristina Álvarez-Escolá9, Mónica Marazuela10, Javier Aller11, Isabel Sevilla12, Justo P Castano13 and Antonio Jesus Martínez-Fuentes14
1Hospital Universitario Bellvitge, L'Hospitalet de Llobregat, Spain, 2Hospital Universitario Virgen del Rocío, Sevilla, Spain, 3Hospital Universitario Vall d'Hebron, Barcelona, Spain, 4Hospital Universitario Central de Asturias, Oviedo, Spain, 5Hospital Universitario de Burgos, Burgos, Spain, 6Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Spain, 7Hospital Universitario Ramón y Cajal, Madrid, Spain, 8Hospital Clínico Universitario San Carlos. Madrid.Spain, Madrid, Spain, 9La Paz University Hospital, Madrid, Spain, 10Hospital Universitario de La Princesa, Instituto de Investigacion Princesa. Universidad Autonoma, Madrid, Spain, 11Hospital Universitario Puerta de Hierro, Madrid, Spain, 12Hospital Clínico Virgen de la Victoria, Malaga, Spain, 13Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofia, CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn) and ceiA3, Córdoba, Spain, 14University of Córdoba, Reina Sofía University Hospital, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC); CIBER Fisiopatología de la Obesidad y Nutrición (CIBERobn), Cordoba, Spain

 

Introduction:

Distinctive biological features of GEP-NETs, such as somatostatin receptor expression, high vascularization and altered signal transduction activation, are currently being used as therapeutic management tools. Our preliminary data showed that the somatostatin receptor transcriptional profile in GEP-NETs may substantially differ according to primary tumor, functionality or stage of disease (1).

Aims:

To characterize the tumor expression of 36 genes in patients with well-differentiated GEP-NETs and to correlate with the patients’ clinical characteristics as well as tumor behavior.

Materials and methods:

Fresh-frozen GEP-NET tumor mRNA expression (copy number) of the following genes was analyzed by quantitative PCR: somatostatin receptors (sst1, sst2, sst3, sst4, sst5), dopamine receptors (DR2-total, DR2-long), epidermal growth factor receptor (EGFR), death-domain associated protein (DAXX), transcriptional regulator ATP-dependent helicase (ATRX), multiple endocrine neoplasia (MEN1), platelet derived growth factor (PDGF), vascular endothelial growth factor receptor (VEGFR), angiopoietin (Ang)1, Ang2, Tie2, b-catenin, E-cadherin, hypoxia inducible factors (HIF1A, HIF1B), thrombospondin (THBS)1, adrenomedullin (AM), CD34, phosphatase and tensin homolog (PTEN), Notch and mamalian target of rapamycin (mTOR).

Results:

40 tumor samples of Grade (G)1-2 GINETs (n=20) and pNETs (n=20) have been collected from 12 Spanish centers. Median patient age was 57 yrs, there were 21 (53%) males, 26 (65%) G2 NETs, 21 (53%) stage IV at diagnosis and 8 (20%) functioning tumors. The main somatostatin receptor expressed in GEP-NETs was sst2, followed by sst1, sst5, sst3 and sst4. In GINET samples there was significantly higher median expression of MEN1 (614 vs 407; p<0.02), DAXX (84180 vs 23182; p<0.045) sst4 (745 vs 106; p<0.04), and RET transcripts (3460 vs 749; p<0.05) than in pNETs. Median expression of Ang1 (513 vs 158; p<0.03), Tie2 (320 vs 145; p<0.02), and ATRX (3692 vs 1424; p<0.05) transcripts was significantly higher in G1 than G2 tumors. Functioning tumors expressed more CD34 (2635 vs 910; p<0.003) and less AM (528 vs 1623; p<0.04) or sst1 (224 vs 305; p<0.032) than non-functioning tumors. Significant associations were observed between CgA levels and HIF1A expression (r=0.54; p<0.03), sst4 and RET (r=0.38; p<0.01), sst4 and Notch (r=0.66; p<0.001), sst4 and AM (r=0.53; p<0.001), MEN1 and DAXX (r=0.79; p<0.001), ATRX and DAXX (r=0.69; p<0.001), Tie2 and DR2-total (r=0.58; p<0.001) or DR2-long (r=0.53; p<0.002), and HIF1A and DR2-total expression (r=0.47; p<0.009).

Conclusions:

Transcriptional profile in GEP-NETs may substantially differ according to primary tumor type, grade, and functionality of disease. Our results may help identify molecular targets with potential prognostic and/or therapeutic value for patients with well-differentiated GEP-NETs.

 

Disclosure: IS: Advisory Group Member, Ipsen. Nothing to Disclose: CV, RG, JC, PJ, GC, CB, MCG, JÁD, CÁ, MM, JA, JPC, AJM

12786 4.0000 MON-0282 A Characterization of Gene Expression in Gastroenteropancreatic Neuroendocrine Tumors (GEP-NETS: Gastrointestinal and Pancreatic NETs [GINETs and pNETs]) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0279-0288 4884 1:00:00 PM Biomarkers; Endocrine Neoplasia Poster

Robert Y Osamura*1, Chie Inomoto2, Hiroshi Kajiwara2 and Midori Matsuda3
1Intl Univ of Health and Welfare, Tokyo, Japan, 2Tokai University School of Medicine, Isehara, Japan, 3International University of Health and Welfare, Tokyo, Japan

 

Background:WHO classification of gastroentero-pancreatic(GEP) neuroendocrine neoplasm(NEN) includes neuroendocrine tumors(NET) grade 1(G1), NET G2 and neuroendocrine carcinomas(NEC) which are subgrouped according to the proliferative activities of tumor cells. Somatostatin receptor(SSTR)2a has  been studies extensively in GEPNENs, but the integrative studies with SSTR5 and mTOR have not been extensive.This study is aimed at to elucidate the incidence of SSTR5, p-mTOR in addition to SSTR2a in GEPNENs.

Matrials and methods Total 84 cases, 74 cases, 64 referred cases were subjected to immunohistochemical studies for SSTR2a, SSTR5 and mTOR respectively using formalin-fixed paraffin embedded sections from multiple institutions and the following antibodies;anti-SSTR2a(Epitomics Inc.), anti-SSTR5(Epitomics Inc.) and anti-p-mTOR(Phospho-mTOR (Ser2448)Cell Signaling Co) antibodies. The staining for SSTR2a and SSTR5 was scored according to Volane et al(2007). SSTR2a and 5 were interpreted as positive if Volante score is 3 or 2. P-mTOR was interpreted as positive if the tumor cells were stained positive in the cytoplasm.

Results and comments:In primary gastroenteric(GE) and pancreatic(P) NENs, positive rates for SSTR2a were 62.2% and 63.2% respectively. In the metastatic GE and P NENs, positive rates for SSTR2a were 81.8% and76.5% respectively. Although SSTR2a-positive rate in is high in PNET G1 and G2, SSTR2a in GENENs was high in G3. For STR5, positive rates for primary tumors was 42.3%(GE) and 50%(P) respectively. For GE and P metastatic NENs, the SSTR5-positive rate for GE and P were 29.4% and 18.2%, respectively. SSTR5-positive cases were apparently more frequent in G1 and G2 in both primary GE and P NENs. For p-mTOR, positive rate for primary GE and P NENs was 35.7% and 31.3% respectively. Metastatic GE and P NENs showed the psotive p-mTOR rate of 42.9% and 36.4% respectively. For both primary and metastatic tumor,  positive cases of p-mTOR were evenly distributed among G1,G2 and NEC.

Conclusions:Although SSTR2a was positive with high incidence in both primary and metastatic GEPNEN, certain proportion of them were positive for SSTR5 and p-mTOR. Our results suggest that the primary and metastatic GEPNENs should be clinically evaluated as the candidates for targeted therapy, SOM230 and Everolimus, in SSTR2a-negative or resistant cases.  

 

Nothing to Disclose: RYO, CI, HK, MM

16459 5.0000 MON-0283 A Immunohistochemical Analysis of SSTR2a SSTR5 and p-mTOR for Therapeutic Application in Primary and Metastatic Gastroenteric and Pancreatic(GEP) Neuroendocrine Neoplasm(NEN) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0279-0288 4884 1:00:00 PM Biomarkers; Endocrine Neoplasia Poster

Qing Li*1, George Zogopoulos2, Xianyong Gui3, Zu-hua Gao1 and Jun-Li Liu1
1McGill University Health Centre, Montreal, QC, Canada, 2McGill University Health Center, Montreal, QC, Canada, 3Foothills Medical Centre, Calgary, Canada

 

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive cancer types, with a 5-year survival rate <5% [1]. Tumor specific biomarkers that can aid in early detection and treatment monitoring are needed in order to improve the outcome of these patients. Currently there is not a single biomarker that can be used universally for cancer diagnosis; neither carbohydrate antigen 19-9 (CA19-9) nor carcinoembryonic antigen (CEA) is specific or reliable [2]. Reg family proteins (Reg1A, Reg1B, Reg3A/G, Reg4 in human) are a group of proteins that are normally expressed in the pancreas, intestines and hepatocytes and have been shown to promote cell growth and inflammatory response in pancreatic islets, intestine and liver. In the meantime, pancreatic cancer cells have been reported to express Reg1A and Reg4 [3-5]; in vivo treatment of recombinant Reg4 protein accelerated tumor growth in mice [6]. In this study, we evaluated the immunohistochemical expression of the five isoforms on the tissues of 30 pancreatic cancer patients. Antibodies against Reg1A, Reg1B, INGAP (mouse) and Reg4 exhibited positive staining in cancer glandular epithelium. Patchy expression of Reg1A, Reg3A/G, INGAP and Reg4 was observed in some duct-like structures in the adjacent non-neoplastic pancreatic acini morphologically, consistent to the phenomenon of acinar-to-ductal metaplasia (ADM). In tumor-free endocrine portion, Reg1A, 1B and INGAP were highly expressed in specific cell populations while Reg3A/G and Reg4 were not. In conclusion, Reg1A and Reg1B are clearly overexpressed in ductal epithelial cells, significantly higher than Reg4 as previously reported [5], and the unique staining pattern of INGAP suggests a novel isoform not yet characterized in human. The study of pancreatic cell-specific and isoform-specific expression of Reg proteins in PDAC may improve diagnostic accuracy and help reveal novel mechanisms of cancer development.

 

Nothing to Disclose: QL, GZ, XG, ZHG, JLL

12089 6.0000 MON-0284 A Specific Overexpression of Reg Proteins 1A and 1B in Human Pancreatic Ductal Adenocarcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0279-0288 4884 1:00:00 PM Biomarkers; Endocrine Neoplasia Poster

Munira Siddiqua Abbasi*1, Valerie L Reeves2, Jules Aljammal1, Bret Goodpaster3, John Dube2 and Erin Elizabeth Kershaw2
1UPMC, Pittsburgh, PA, 2Universtiy of Pittsburgh, Pittsburgh, PA, 3Sanford Burnham Medical Research Institute,, Orlando, FL

 

Background: Obesity and the metabolic syndrome are major public health problems. Adipokines serve as both pathogenic factors and potential therapeutic targets for these disorders. One of the most abundant adipokines in human serum is pigment epithelium-derived factor (PEDF/serpinf1). PEDF is a multi-functional member of the non-inhibitory serpin family with neurotrophic, anti-angiogenic, anti-adipogenic, pro-lipolytic, anti-oxidative, and anti-inflammatory functions. Serum PEDF levels are increased in humans with metabolic syndrome and cardiovascular disease. However, whether PEDF can serve as a biomarker for early insulin resistance and metabolic disease remains unknown.

 Objective: The goal of the current study was to determine the relationship between PEDF and early features of metabolic syndrome in older obese human subjects.

 Experimental Design: To achieve this goal, 46 human subjects (19 Male, 27 Female) age 60-74 years with BMI of 24-37 were phenotyped for features of the metabolic syndrome. Phenotypic evaluation included the following: body mass index, body composition (fat mass, lean mass), waist circumference blood pressure, fasting serum lipids (total cholesterol, LDL, HDL, triglycerides), fasting glucose and insulin, serum glucose response to an oral glucose tolerance test, HbA1c, and insulin sensitivity by glucose infusion rate (GIR) during an hyperinsulinemic euglycemic clamp. Serum PEDF was then determined by ELISA (Bioproducts of Maryland).

 Results: Serum PEDF was higher in subjects with metabolic syndrome (p=0.02). PEDF was positively correlated with body mass index (r=0.38, p=0.008), triglycerides (r=0.12, p=0.018), VLDL (r=0.09, p=0.047) and HbA1c (r=0.13, p=0.01). PEDF was also increased in patients with impaired glucose tolerance and overt type 2 diabetes as compared to patient with normal glucose tolerance (r=0.17, p=0.003). PEDF did not correlate with other features of metabolic syndrome including systolic blood pressure or waist circumference. Interestingly, PEDF did not correlate with GIR, the gold standard for quantifying insulin sensitivity.

 Conclusion: In conclusion, serum PEDF levels correlated with early features of the metabolic syndrome in older obese human subjects. Additional studies will be done to understand the correlation between PEDF and insulin resistance following interventions designed to improve insulin sensitivity.

 

Nothing to Disclose: MSA, VLR, JA, BG, JD, EEK

12793 7.0000 MON-0285 A Serum Pigment Epithelium Derived Factor (PEDF/serpinf1) Levels Correlate with Early Features of the Metabolic Syndrome and Decreases after Weight Loss Intervention 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0279-0288 4884 1:00:00 PM Biomarkers; Endocrine Neoplasia Poster

Carolina Panico*1, Sonia Q Doi2, Eric S Nylen1 and Kenneth L Becker1
1Veterans Affairs Medical Center, Washington, DC, 2Uniformed Services University, Bethesda, MD

 

INTRODUCTION.   Procalcitonin (ProCT) and its 1-57 aminoterminus peptide, nProCT, are associated with sepsis and organ failure.  On a molar basis, nProCT is the dominant peptide in health and disease.  Moreover, immunoneutralization studies using nProCT-specific Ab effectively improved experimental septic outcomes.  We have previously shown that ProCT has direct toxic effects in mouse mesangial cells (MMC) in vitro via up-regulation of several proinflammatory cytokines. 

OBJECTIVE. In the present study we tested the hypothesis that nProCT has a direct proinflammatory in vitro action.  

METHODS. Normal Human Mesangial Cells (NHMC) culture system was developed from human biopsy specimens (Lonza Inc).  At the time of study, the cells were at 70% confluency (passage #4).  Cells were exposed to a range of concentrations of nProCT (Bachem) (10-9M to 10-3M) for 6 hours.  IL-6 mRNA levels were measured by real time RT-PCR (ABI 5700 System) and normalized to the expression levels of GAPDH.

RESULTS.  The mRNA transcript levels of IL-6 were significantly increased in NHMC incubated for 6 h with nProCT compared to cells incubated with vehicle (10-fold increase; p<0.001).  Moreover, that response reached a plateau at 10-6M concentration. 

CONCLUSION. This study demonstrated for the first time that the aminoterminus peptide of ProCT directly induces a proinflammatory effect in cultured NHMC, suggesting that this small peptide can elicit a systemic inflammatory response, independent of the intact ProCT.

 

Nothing to Disclose: CP, SQD, ESN, KLB

15947 8.0000 MON-0286 A Aminoprocalcitonin (nProCT) Has Proinflammatory Bioactivity in Vitro 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0279-0288 4884 1:00:00 PM Biomarkers; Endocrine Neoplasia Poster

Yvonne S Ziegler*1, James Moresco2, Patricia Tu2, John R Yates III2 and Ann M Nardulli1
1University of Illinois at Urbana-Champaign, Urbana, IL, 2The Scripps Research Institute, La Jolla, CA

 

The use of broad spectrum chemotherapeutic agents to treat cancer results in substantial and debilitating side effects, necessitating the development of targeted therapies to limit tumor proliferation and prevent metastasis.  In recent years, the list of approved targeted therapies has expanded, and it includes both monoclonal antibodies and small molecule inhibitors that interfere with key proteins involved in the uncontrolled growth of cancer cells.  The targeting of plasma membrane proteins has been most successful to date, and this is reflected in the large representation of these proteins as targets of newer therapies. In view of this fact, experiments were designed to investigate the plasma membrane proteome of a variety of breast cancer cell lines, representing hormone responsive, HER2 over expressing, and triple negative cell types, as well as a benign control.  Plasma membranes were isolated using an aqueous two phase system, and the resulting proteins were subjected to mass spectrometry. The resulting data set was biologically validated by selecting candidate proteins for Western blot, RT-PCR, and immunofluorescent analysis.  After validation, the data was further examined for patterns of expression and to search for current as well as novel targets. Interestingly, a number of tyrosine kinases were up-regulated, some of which are targeted by therapies already in use to treat very different types of cancer. Overall, the data set provides a very rich and complex picture of plasma membrane proteins on breast cancer cells, and the sorting and categorizing of this data is providing interesting insights into the biology, classification, and potential treatment of this prevalent yet debilitating disease. 

 

Nothing to Disclose: YSZ, JM, PT, JRY III, AMN

12818 9.0000 MON-0287 A Plasma Membrane Proteomics Identifies Potential Targets for Breast Cancer Diagnosis and Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0279-0288 4884 1:00:00 PM Biomarkers; Endocrine Neoplasia Poster

Jane Schmidt*, Richard Fuerstenberg, Michael Anderson, James David, Matthew Schwartz and Isabel O'Brien
R&D Systems, Inc., Minneapolis, MN

 

Cancer is a complex disease involving changes in metabolic pathways related to cell growth and proliferation, invasion, metastasis, adhesion, angiogenesis, apoptosis, and others. Multiple biomarkers in serum have been identified that are indicative of the presence of breast cancer as well as the stage, metastatic potential, therapeutic susceptibility, and prognosis. Efforts to quantify changes in these biomarkers will enhance our understanding of the disease. While measurement of a single biomarker can have limited utility in such a complex disease as cancer, multiplex profiling can help elucidate patterns of biomarkers. As a result, simultaneous measurement of multiple biomarkers can lead to a better understanding of cancer biology and the interactions of the many pathways it involves.

Human Luminex Screening Assays are highly flexible bead-based multiplex immunoassays. They allow up to 100 biomarkers, selected from a total of 200 analytes, to be simultaneously profiled in cell culture supernates, serum or plasma samples. Assay ranges and sensitivities are appropriate for measurement of each analyte, and inter-assay variation typically is <20%. We used Luminex Screening Assays to measure a total of 200 analytes in cell culture supernates from a variety of breast cancer cell lines and in serum samples from individuals diagnosed with breast cancer or apparently healthy individuals. The biomarkers tested included cancer antigens, cytokines, chemokines, growth factors, adhesion molecules, MMPs, and protease inhibitors, as well as endocrine factors. Starting with less than 200 µL of each sample, we obtained quantitative results for biomarkers of cancer growth and metastasis, angiogenesis, matrix remodeling, cell adhesion, metabolic function, and cell death. This allowed comparisons among cell lines, and between cell lines and serum/plasma samples. Customizable multiplex immunoassays offer the ability to probe many cell processes at once and thus can be an important tool in identifying potential biomarkers for further investigation.

 

Nothing to Disclose: JS, RF, MA, JD, MS, IO

14813 10.0000 MON-0288 A Multiplex Analysis of 200 Biomarkers in Breast Cancer Cell Culture Supernates and Serum or Plasma Using the Human Luminex® Screening Assay 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0279-0288 4884 1:00:00 PM Biomarkers; Endocrine Neoplasia Poster

Lamiaa El-Shennawy*1 and Jonna Frasor2
1Univ of IL - Chicago, Chicago, IL, 2University of Illinois at Chicago, Chicago, IL

 

Estrogen receptor (ER) is expressed in ~75% of breast tumors and is generally a biomarker for good prognosis. Women with ER+ tumors will receive endocrine therapy, but ~50% of these women will experience a relapse, often with more aggressive, drug-resistant, and metastatic tumors. One proposed driver of this more aggressive phenotype is an inflammatory tumor microenvironment. A growing body of evidence indicates that infiltration of macrophages, production of inflammatory cytokines, and activation of the canonical arm of the NFκB pathway is highly associated with progression of ER+ tumors to more aggressive, endocrine and chemoresistant stages. Despite this association, it is not known whether the canonical NFκB pathway is sufficient to drive a more aggressive ER+ breast cancer phenotype. In order to study this, we developed DOX-inducible, constitutively active IκBα kinase β (CA-IKKβ) expressing MCF-7 and T47D breast cancer cell lines. The canonical arm is activated via IKKβ, consequently, DOX treatment induced CA-IKKβ expression and led to p65 phosphorylation, nuclear translocation, and transcriptional activity, but had no effect on other cytokine-activated signaling pathways. In these cell lines, DOX-induced CA-IKKβ did not affect the basal proliferation; however, it significantly inhibited 17β-estradiol (E2)-dependent proliferation. Intriguingly, although these cell lines have a non-migratory or invasive nature, the combination of CA-IKKβ and E2 induced a highly migratory phenotype compared to either CA-IKKβ or E2 alone, as demonstrated by wound healing and transwell migration assays. CA-IKKβ induced morphological changes in the cells where they became fibroblastic and elongated, suggestive of epithelial mesenchymal transition (EMT). Detecting EMT markers revealed that the combination of CA-IKKβ and E2 decreased E-cadherin and up-regulated ZEB1 expression. The migratory phenotype coincided with significantly lower ER and progesterone receptor expression, a condition similar to that observed in aggressive, Luminal B, ER+ breast tumors. However, ER was still transcriptionally active since the combination of CA-IKKβ and E2 recapitulated the regulation of genes from an ER-NFκB crosstalk signature that we have previously reported as associated with Luminal B breast cancers. Thus, activation of the canonical arm of the NFκB pathway results in a switch in the phenotype of ER+ breast cancer cells from proliferative to migratory, suggesting that this pathway may be a driver of ER+ breast cancer progression to a more aggressive phenotype. Since the most deadly aspect of breast cancer is metastasis, and approximately 70% of metastatic breast tumors are ER+, understanding the effect of the canonical arm of the  NFκB  pathway in ER+ tumors can help define new specific drug targets and therapeutic strategies for the treatment of ER+  breast cancers.

 

Nothing to Disclose: LE, JF

15209 2.0000 MON-0290 A Constitutive Activation of the Canonical NFκB Pathway Switches the Phenotype of Estrogen Receptor Positive Breast Cancer Cells from Estrogen–Induced Proliferation to Estrogen-Induced Migration 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

Xuyi Wang*1, Maria M Docanto1, Hironobu Sasano2, Evan R Simpson3 and Kristy A Brown3
1MIMR-PHI Institute of Medical Research, Clayton, Australia, 2Tohoku University Graduate School of Medicine, Sendai, Japan, 3MIMR-PHI Institute of Medical Research, Clayton VIC, Australia

 

Estrogen-dependent postmenopausal breast cancer is associated with the increased expression of aromatase in breast adipose stromal cells (ASCs). Androgens are converted into estrogens by aromatase and tumor-derived factors such as prostaglandin E2 (PGE2) stimulate aromatase expression via the activation of the proximal promoter II (PII). As a tumour suppressor, p53 is often mutated in breast cancer. However, mutations in p53 in ASCs are infrequent. This study aimed to determine the effect of PGE2 on p53 and to examine the role of p53 in regulating aromatase expression in human breast ASCs in the context of postmenopausal breast cancer.

Primary human breast ASCs were isolated from breast tissue following breast reduction surgery. ASCs were treated with 1µM PGE2 or the PGE2 mimetic forskolin(FSK; 25µM)/phorbol ester (PMA; 4nM), and/or RITA (1µM; to stabilize p53). The effect of PGE2 on p53 expression, subcellular localization and activity was examined by real-time PCR, Western blotting, immunofluorescence (IF) and reporter assays. Results demonstrate that p53 transcript and nuclear protein expression are significantly decreased in ASCs in response to PGE2. Moreover, PGE2 also reduces p53 phosphorylation (Ser15) and acetylation (Lys382), as well as p53 activity. The effect of p53 on aromatase transcript and activity was examined in RITA-treated ASCs by real-time PCR, and tritiated-water release assays. RITA significantly decreased the PGE2-mediated mRNA expression and activity of aromatase. ChIP and reporter assays were also performed to examine p53 binding and regulation of aromatase PII. ChIP results demonstrate that p53 binds to a region on PII 438-418bp upstream of the transcription start site and that this interaction is significantly decreased in the presence of PGE2. Reporter assays demonstrate that RITA also significantly decreases the PGE2-stimulated activity of aromatase PII. IF performed on clinical samples of breast tissue from cancer-free women and women with breast cancer demonstrates that nuclear and total p53 expression are significantly decreased in ASCs in the presence of a tumor. A positive correlation between perinuclear (inactive) p53 and aromatase was also observed.

In conclusion, our findings demonstrate that p53 inhibits aromatase expression via direct effects on PII, and that this inhibition is alleviated in the presence of PGE2. This study therefore reveals an unconventional role for p53 as a tumor suppressor in breast cancer.

 

Nothing to Disclose: XW, MMD, HS, ERS, KAB

16419 3.0000 MON-0291 A Regulation of Aromatase: An Unconventional Function for Tumor Suppressor p53 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

Diana Hatoum*1 and Eileen Mary McGowan2
1University of Technology Sydney, Sydney, NSW, Australia, 2University of Technology Sydney, Sydney NSW, Australia

 

The activation of the tumor suppressor p14ARF-p53 pathway does not always induce premature senescence or cell death; rather it changes the metabolism of cancer cells (1). Our laboratory was the first to show that ER positive breast cancer cell division was abrogated within hours of p14ARF-p53 expression, followed by an increase in cell size and altered cell respiration, evidenced by an increase in functional mitochondria (1, 2). SILAC MS/MS analysis and MaxQuant software were employed to study the proteomic changes associated with p14ARF-p53 24h and 72h post-activation. MS/MS spectra data were further analysed with the MASCOT search engine against the decoy IPI-human database. Over 1270 differentially regulated proteins were identified with a protein false discovery rate (FDR) of 0.01. Cytoscape 3 software program were used to analyse global protein function and interactions. Specific protein changes were explored in two cell lines in which p14ARF could be induced (MCF-7 and U2OS) by Western blot analysis. The top 50 upregulated protein were involved in functions including mitochondrial fusion, organelle fusion, monocarboxylic acid catabolic process, sequestering of actin monomers and anti-apoptosis. Noticeably, the annexin family and associated S100 binding proteins were differentially expressed post p14ARF-p53 activation. Annexins A1, A2, A4, A6 and A9, and annexin binding proteins S100A10 and S100A11 were all among the top 50 upregulated whereas A5, A7, A11 showed little or no change in expression. Western blot analysis verified the upregulation of annexin A1 and A2 in MCF-7 cells. Interestingly, high basal levels of A1 and A2 were observed in U2OS cells with no change in expression post p14ARF activation. Taken together, these results suggest the annexin family and associated binding S100 proteins play key roles in fundamental biological activities, including calcium metabolism, growth and differentiation. Upregulation of A1 and A2 have been shown to be important in lactogenic/pre-secretory differentiation function whereas A5, a protein involved in the induction of apoptosis, remained unchanged. These observations are consistent with our previous published data (1,2), whereby p14ARF-p53 activation in ER positive breast cancer cells did not induce cell death but induced a viable differentiated cell.  The lack of annexin A1 and A2 regulation by p14ARF/p53 in U2OS cells suggested annexin regulation was cell-type and content specific. Thus, the relative expression of different proteins within a cell at a given time is important for function and these experiments highlight the importance of a holistic approach to protein analysis to determine normal cell function and tumour progression.

 

Nothing to Disclose: DH, EMM

16599 4.0000 MON-0292 A Activation of the p14ARF-p53 Pathway: A Role for p14ARF-p53 in the Differential Regulation of the Annexin Family and S100-Associated Proteins 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

Susanne U Miedlich*1, Ismary O De Castro2, Suzan Saber3 and Stephen R Hammes4
1University of Rochester Medical Center, Rochester, NY, 2Memorial Health University Physicians, Savannah, GA, 3Unity Health System, Rochester, NY, 4University of Rochester, Rochester, NY

 

Breast cancer is the most common malignancy among women in the United States. Despite major advances in therapy, breast cancer remains the second most common cause of cancer death. Estrogen and growth factor-mediated signaling cascades are recognized as major driving forces for the propagation of breast cancer growth and metastasis. One important regulator of proliferation in steroid-dependent breast, as well as prostate, cancers is the rapid, nongenomic transactivation of receptor tyrosine kinases such as the EGF receptor in response to estradiol and androgen, respectively. Our laboratory has shown that, in prostate cancer, the versatile scaffold protein paxillin is an essential regulator of both androgen- and growth factor-mediated growth, functioning first in the cytoplasm to promote Erk1/2 signaling, and then in the nucleus as phosphoserine-paxillin to regulate transcription of androgen- and Erk-mediated proliferative genes. Based on similarities between androgen- and estrogen signaling, we hypothesized that paxillin might also be an important regulator of estradiol- and growth factor-mediated signaling and proliferation in breast cancer cells. We found that, in estrogen-sensitive breast cancer cell lines MCF7 and T47D, paxillin is highly expressed and estrogen-dependent proliferation is significantly reduced by paxillin knockdown, suggesting a role of paxillin for estrogen-dependent breast cancer growth. Contrary to androgen receptors in prostate cancer, estrogen receptors in breast cancer cells are primarily located in the nucleus both in the presence and absence of estradiol, and this nuclear localization is unaltered by paxillin knockdown. Furthermore, in MCF7 cells, classic estrogen-dependent signaling through EREs is unaffected by paxillin knockdown. However, EGF-dependent Erk phosphorylation is significantly reduced by paxillin knockdown. We therefore speculate that paxillin may affect Erk- but not ERE-dependent gene expression in response to estrogen and/or growth factors thus mediating breast cancer growth. Studies are currently underway to assess endogenous estrogen- and Erk-dependent gene expression in the presence of paxillin knockdown. Understanding the mechanisms of how paxillin regulates estrogen- and growth factor-dependent breast cancer growth and invasion will enable us to identify new potential targets for cancer staging as well as intervention strategies.

 

 

Nothing to Disclose: SUM, IOD, SS, SRH

14019 5.0000 MON-0293 A Role of Paxillin for Estrogen- and Growth Factor-Dependent Breast Cancer Growth in Vitro 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

Yingfeng Zheng*1, Chrissie Bruce2 and Leigh Campbell Murphy3
1University of Manitoba, Winnipeg, MB, Canada, 2CancerCare Manitoba, Winnipeg, MB, Canada, 3Univ of Manitoba, Winnipeg, MB, Canada

 

Estrogen Receptor α is present in a Complex with mTOR in MCF7 Human Breast Cancer Cells.  

Yingfeng Zheng, M Chrissie Bruce, Leigh C Murphy. Department of Biochemistry and Medical Genetics and the Manitoba Institute of Cell Biology, University of Manitoba and CancerCare Manitoba, 675 McDermot Ave, Winnipeg, Manitoba, Canada. R3E 0V9

Over 70% of primary breast cancers express estrogen receptor α (ERα), which is the ‘gold-standard’ predictor of response to endocrine therapy.  Previously, we established a phosphorylation score (P7-score) for ERa by measuring  phosphorylation at 7 different  sites on  ERα in breast tumors [1]. Our data suggested that P7-score is a more accurate prognostic marker than ERα alone [1]. We predict that cell signaling pathways are altered between high and low P7-score tumors. Our preliminary data, based on a high through-put antibody array screen (Kinexus; www.kinexus.ca) using extracts from high and low P7 tumors and immunohistochemistry, confirmed that differential expression/activation of kinases was correlated with P7-score in ER+ breast tumors.   Here we focus on one of the kinases identified, mechanistic target of rapamycin (mTOR). We previously reported that pS2448mTOR was inversely correlated with the P7-score and estrogen in part could regulate expression of pS2448mTOR in MCF7 cells (2). As well kinase substrate motif analysis suggested that several serine residues in ERa were potential FRAP/mTOR substrates (3). Using an in vitro kinase assay and mass spectrometry, we previously found that recombinant mTOR could phosphorylate ERa at multiple serines (3), suggesting that mTOR might directly interact with and phosphorylate ERa.

            To investigate further we determined if mTOR could interact with ERα in intact cells. Co-immunoprecipitation assays (co-IP)  and in situ proximity ligation assays (PLA) were performed using MCF7 ER+ human breast cancer cells. We were able to detect ERa within immunoprecipitates when specific antibodies to endogenous mTOR were used, with and without DSP cross-linking.  Interestingly, this interaction could be seen without estrogen treatment although estrogen treatment appeared to enhance the ERa/mTOR interaction. We also carried out PLA to investigate the endogenous interactions in situ of ERα with mTOR as well as its downstream target p70S6Kinase (S6K1), previously known to interact with and phosphorylate ERα (4), in intact cells, and to gain insight into where these interactions may be occurring. PLA results support protein-protein interactions between ERα and mTOR or S6K1. In addition PLA demonstrated both nuclear associated and cytoplasmic complexes. In conclusion two distinct methodologies support the idea that endogenously expressed mTOR can interact with ERα in intact ER+ breast cancer cells. These data support the novel hypothesis that ERα is a substrate of mTOR in addition to S6K1 in ER+ breast cancer cells.

 

Nothing to Disclose: YZ, CB, LCM

15232 6.0000 MON-0294 A Estrogen Receptor Alpha Is Present in a Complex with mTOR in MCF7 Human Breast Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

Rosalia Ines Cordo Russo*1, Wendy Béguelin2, Maria Celeste Diaz Flaque2, Violeta Alicia Chiauzzi3, Leandro Venturutti2, Natalia M Galigniana2, Cecilia Jazmín Proietti1, Eduardo Hernán Charreau1, Roxana Schillaci2 and Patricia Virginia Elizalde1
1Instituto de Biología y Medicina Experimental (IBYME-CONICET), Buenos Aires, Argentina, 2Instituto de Biología y Medicina Experimental, CONICET, Buenos Aires, Argentina, 3Laboratory of Molecular Mechanisms of Carcinogenesis, Instituto de Biología y Medicina Experimental (IBYME-CONICET), Buenos Aires, Argentina, Buenos Aires, Argentina

 

ErbB-2, a member of the ErbB family of membrane receptor tyrosine kinases, is a major player in the breast cancer (BC) scenario. ErbB-2 overexpression is associated with poor prognosis and is therapeutically targeted by trastuzumab (TZ). The dogma of ErbB-2 mechanism of action has been challenged by the demonstration that membrane ErbB-2 (MErbB-2) migrates to the nucleus (NErbB-2) of BC cells where it acts as a transcription factor or, according to our previous findings, as a transcriptional coactivator. We have recently demonstrated that NErbB-2 function is absolutely necessary for in vitro and in vivo growth of MErbB-2-positive BC cells both sensitive (BT-474) and resistant (JIMT-1) to TZ (1). Besides, we revealed that blockade of NErbB-2 localization constitutes a novel therapeutic strategy in TZ-resistant BC (1). Here, we explored the molecular mechanisms underlying NErbB-2 promotion of growth. Our findings demonstrated that heregulin (HRGβ1), a ligand of ErbB-3 and ErbB-4 which recognizes ErbB-2 as co-receptor, stimulates ErbB-2 and ErbB-3 nuclear (NErbB-3) translocation and their colocalization with signal transducer and activator of transcription 3 (Stat3) in human T47D BC cells devoid of basal NErbB-2 and NErbB-3. HRGβ1 also enhanced formation of nuclear ErbB-2/ErbB-3 heterodimers in BT-474 and JIMT-1 cells, which express basal levels of NErbB-2 and NErbB-3. To block NErbB-2 presence, we used a human ErbB-2 nuclear localization domain mutant (hErbB-2ΔNLS), unable to translocate to the nucleus, and which we have previously showed acts as a dominant negative inhibitor of endogenous NErbB-2 migration (2). Interestingly, we found that hErbB-2ΔNLS colocalized with ErbB-3 at the cytoplasm and abrogated basal and HRGβ1-induced ErbB-3 nuclear migration in BT-474 and JIMT-1 cells. Our recent findings revealed that progestin regulates cyclin D1 expression, a cancer-related gene that contains Stat3 binding sites (GAS sites) but lacks ErbB-2 response elements (HAS sites) in its proximal promoter, via the assembly of a transcriptional complex in which ErbB-2 acts as coactivator of Stat3 (2). Here, we found that HRGβ1 induces in vivo binding of Stat3, ErbB-2, and ErbB-3 to the GAS sites of the cyclin D1 promoter in T47D, BT-474, and JIMT-1 cells. Transfection of JIMT-1 cells with hErbB-2ΔNLS abolished both basal and HRGβ1-induced recruitment of ErbB-2 and ErbB-3 to the cyclin D1 promoter as well as HRGβ1-induced up-regulation of cyclin D1 protein and mRNA levels, indicating that the hErbB-2ΔNLS growth inhibitory effects on TZ-resistant cells lies in the disruption of the Stat3/ErbB-2/ErbB-3 nuclear complex driving cyclin D1 expression. These findings for the first time reveal the nuclear interaction and function of ErbB-2/ErbB-3 heterodimers and highlight the importance of targeting NErbB-2 function as a novel therapeutic strategy in TZ-resistant BC.

 

Nothing to Disclose: RIC, WB, MCD, VAC, LV, NMG, CJP, EHC, RS, PVE

PP32-4 11466 7.0000 MON-0295 A Nuclear Function of ErbB-2/ErbB-3 Heterodimers in Trastuzumab-Resistant Breast Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

Natalia M Galigniana*1, Maria Celeste Diaz Flaque2, Leandro Venturutti3, María Florencia Mercogliano1, Mara De Martino3, Franco Izzo4, Cecilia Jazmín Proietti4 and Patricia Virginia Elizalde4
1Instituto de Biología y Medicina Experimental, CONICET, Buenos Aires, Argentina, 2Instituto de Investigaciones Biomedicas, UCA-CONICET, Buenos Aires, Argentina, 3Instituto de Biología y Medicina Experimental (IBYME) CONICET, Buenos Aires, Argentina, 4Instituto de Biología y Medicina Experimental (IBYME-CONICET), Buenos Aires, Argentina

 

The progesterone receptor (PR) is known to participate in breast cancer cell proliferation and to cross-talk with the oestrogen receptor alpha (ERα), yet its roles in resistance to anti-oestrogen therapies are not fully understood. In the present work, we studied the effects of the synthetic progestin medroxyprogesterone acetate (MPA) alone or in combination with tamoxifen (Tam), a commonly used selective ER modulator, in Tam-sensitive and -resistant breast cancer cell lines. We used Tam at a concentration (1 μM) in which it acts as an antagonist of ERα-mediated effects and therefore mimics its expected role in patients. We found that Tam inhibited MPA-induced activation of the c-Src/ERK1/2 signaling pathway in BT474-HR cells, which are sensitive to the antiproliferative effects of Tam. As a result, two synergic downstream effector mechanisms were disrupted. On the one hand, Western blot and chromatin immunoprecipitation assays revealed that MPA-induced c-Src/ERK1/2 phosphorylation and recruitment of the transcription factor AP-1 to the cyclin D1 promoter, along with ERα and PR itself, were inhibited by co-treating BT474-HR cells with MPA+Tam. This prevented MPA from inducing cyclin D1 transcription and cell proliferation. Interestingly, Tam failed to block MPA-activation of c-Src/ERK1/2 and assembly of the said complex in the Tam-resistant cell line BT474 (1). On the other hand, we found that PR-dependent activation of c-Src/ERK1/2 leads to the activation of c-Myc and subsequent down-regulation of miR-16, a microRNA we have previously shown acts as a tumor suppressor in progestin-induced breast cancer growth (2). This decrease in miR-16 levels resulted in increased expression of its target, the anti-apoptotic protein Bcl-2. Co-treatment of BT474-HR cells with MPA+Tam disrupted MPA activation of c-Src/ERK1/2, restoring miR-16 levels to control levels and keeping Bcl-2 expression repressed. Such inhibitory effects of Tam were not evidenced in BT474 cells. Together, these results suggest that Tam effects on PR-dependent c-Src/ERK1/2 signaling can inhibit cell proliferation by regulating the formation of transcription factor complexes whilst inducing apoptosis through control of microRNA levels only in Tam-sensitive cells. Our results provide insight into complex synergic mechanisms underlying Tam resistance involving the PR, a receptor not classically studied in the context of ER-targeted therapies shown here to be a possible therapeutic target to prevent its unrestrained functions in Tam-resistant cells.

 

Nothing to Disclose: NMG, MCD, LV, MFM, MD, FI, CJP, PVE

11720 8.0000 MON-0296 A PR Rapid and Genomic Effects Participate in the Response of Breast Cancer Cells to Tamoxifen 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

Kevin Christopher Knower*1, Sarah Quynh Giao To1, Vanessa Cheung2, Kyren Aloysious Lazarus1 and Colin D Clyne1
1MIMR-PHI Institute of Medical Research, Melbourne, Australia, 2MIMR-PHI Institute of Medical Research

 

TNFα plays a critical role in estrogen receptor positive (ER+) breast cancer pathology. Importantly, it serves as an anti-adipogenic factor, responsible for maintaining cancer-associated fibroblasts in an undifferentiated state resulting in the increased transcription and activity of key estrogen-producing enzymes such as aromatase. High levels of TNFα are detected within the tumour microenvironment, and though infiltrating immune cells are thought to contribute a significant amount of TNFα, the relative role of the ER+ tumour epithelial cells in producing this cytokine as a tumour-derived paracrine signalling factor has not been examined. The aim of this study was to determine the relative contribution of tumour epithelial cells to TNFα production and how this is regulated.

Relative mRNA expression of TNFα was measured in a number of ER- and ER+ breast cancer cell lines. High levels of TNFα mRNA was seen in the ER+ breast cancer cell lines MCF7, T47D and ZR-75. These findings correlated with high levels of secreted protein in conditioned media as measured by ELISA. Treatment of ER+ cell lines with estradiol (10 nM) significantly increased TNFα mRNA (2.5-fold), translating into elevated TNFα protein assayed by western blot and ELISA. Inhibition of ERα action through the use of Tamoxifen, a commonly used endocrine therapy drug, and the compound ICI-182780 significantly inhibited TNFα mRNA and protein secretion in ER+ breast cell lines. Investigation of the TNFα promoter revealed a number of ERα response elements through which estrogen regulation may be mediated.

These results demonstrate a novel way in which endocrine therapy assists in combating disease, by reducing levels of estrogen-stimulating cytokines within the ER+ breast cancer microenvironment. Through inhibition of TNFα, the capacity of tumors to maintain a surrounding dense layer of undifferentiated fibroblasts is reduced, subsequently resulting in a loss of sustained estrogen production. TNFα has many roles in breast cancer pathology, and breaking the positive cycle of its production and action within an ER+ breast tumour microenvironment is critical for successful clinical outcomes.

 

Nothing to Disclose: KCK, SQGT, VC, KAL, CDC

16569 9.0000 MON-0297 A Origins and Actions of TNF-Alpha in the Breast Tumor Microenvironment: A Novel Model of Targeted Inhibition through Endocrine Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

Sheng-Xiang Lin*
Laboratory of Molecular Endocrinology and Oncology, Centre Hospitalier Universitaire (CHU) de Quebec Research Center (CHUL) and Laval University

 

Reductive 17beta-hydroxysteroid dehydrogenases, for example 17beta-HSD1, catalyze simultaneously the activation of estrogen and the inactivation of androgen (Aka et al. & Lin, 2010, Mol Endocrinol. 24:832; Lin et al. 2010, Nat. Rev. Endocrinol. 6:485), their knockdown and inhibition result in sex-hormone modulation, cell cycle arrest and proliferation reduction in breast cancer cells. The synergistic roles of these enzymes can be used for improving breast cancer treatment.

Here we introduce our latest results in this domain, proposing novel compounds highly potential for the  treatment of this  most incidental cancer in western women.    Efficient targeting of sex-hormones may bring a new generation of drugs in hormone-dependent breast cancer therapy after the two milestone treatments selective estrogen receptor modulator and aromatase inhibitors.

 

Nothing to Disclose: SXL

16866 11.0000 MON-0299 A Reductive 17beta-Hydroxysteroid Dehydrogenases in Hormone-Dependent Breast Cancer Cells: Novel Targets for Estrogen-Dependent Breast Cancer Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

Lucila Sackmann Sala*1, Aurélie Chiche1, Nerea Mosquera-Garrote1, Florence Boutillon2, Ivan Pourmir1, Luz Pascual-Mathey1, Karima Kessal1, Natascha Pigat1, Philippe Camparo1 and Vincent Goffin3
1Inserm U1151 - Institut Necker Enfants Malades (INEM), Faculté de Médecine, Université Paris Descartes, Paris, France, 2Inserm U1151 - Institut Necker Enfants Malades (INEM), Paris, France, 3Faculté de Médecine, Université Paris Descartes, Paris cedex 14, France

 

Mounting evidence suggests that prolactin (PRL)/Stat5 signaling could represent an alternative target for prostate cancer treatment to circumvent the failure of androgen-ablation. Levels of PRL or activated Stat5 correlate with disease progression and recurrence (1,2). However, mechanistic data are scarce. Transgenic mice expressing PRL in the prostate epithelium (Pb-PRL mice) develop prostate tumors that show an amplification of epithelial basal/stem cells (3). Given the proposed role of these cells in cancer initiation and recurrence, we looked further into the amplification of basal/stem cells in Pb-PRL mice. Our data showed that the activation of Stat5 signaling correlated with the occurrence of abnormal basal/stem cell clusters in prostate tumors. Immunohistological analysis of these basal/stem cell clusters and immediately adjacent luminal cells demonstrated higher proliferation, Stat5 signaling, and expression of the stem/progenitor cell marker Sca-1 (stem cell antigen 1) compared to occasional basal cell clusters detected in wild-type prostates. These results suggest that basal cell clusters in Pb-PRL mice are more numerous and also display different differentiation status. In addition, FACS analysis of isolated prostate cells revealed the existence of a new subpopulation of Sca-1-positive luminal cells that was also amplified in Pb-PRL compared to wild-type prostates. These cells might represent luminal progenitors originating from the amplified basal/stem cell compartment and could be relevant for the initial steps of PRL-induced prostate tumorigenesis. The present results provide further understanding of the tumorigenic process induced by PRL to help determine if this hormone or its downstream targets could be useful as alternative therapy for prostate cancer.

 

Nothing to Disclose: LS, AC, NM, FB, IP, LP, KK, NP, PC, VG

12199 12.0000 MON-0300 A Prolactin-Induced Prostate Tumorigenesis Associates Stat5 Signaling with the Amplification of Basal/Stem Cells and the Emergence of Putative Luminal Progenitors 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

Ashlee K Clark*1, Michelle Richards1, Mitchell G Lawrence1, Roxanne Toivanen1, Mark Frydenberg1, John Pedersen2, Renea A Taylor1 and Gail P Risbridger1
1Monash University, Melbourne, Australia, 2Tissupath Pathology Services, Melbourne, Australia

 

Prostate cancer is a heterogeneous disease and it is proposed that the sub-population of cancer cells that survive androgen deprivation possess a lethal phenotype. Identifying the unique biological characteristics of these cells that reside in the primary cancer lesion is essential to determine their role in tumour progression and susceptibility to novel therapeutic agents. We recently identified a population of castrate-tolerant cancer cells that ‘pre-exist’ in prostate cancer specimens using patient-derived xenografts (PDX) (1). We hypothesised that the castrate-tolerant cells represent a select clone that evades treatment without the need to evolve under this selective pressure. To test this, we established PDX of human primary specimens from 3 men with localised (Gleason 7) prostate cancer.  For each patient, we performed a series of grafts to compare the role of castrate-tolerant cells in regenerating tumours following testosterone (T) replacement.  Similar to previous studies, the castrate-tolerant cancer cells from all patients expressed stem cell markers including Oct-4, Sox2, NANOG and ALDH1, and possessed regenerative potential based on their ability to repopulate tumours with re-administration of testosterone. Using immunohistochemistry, we showed that the localisation and expression of PTEN, FoxA1, ERG and p21 were similar in T-restored grafts compared to intact controls, indicating that the castrate-tolerant stem cells faithfully repopulate the original tumour.  We are now using laser capture microdissection to subject the same tumours to expression profiling by RNA-seq analysis to determine whether the same molecular phenotype can be detected in intact and T-restored tumours. Collectively, these data will provide evidence that castrate-tolerant cells are a lethal clone in localised tumours.  Whilst this cell clone is likely to attain further alterations after prolonged or additional therapies, new targeted therapies that eliminate the castrate-tolerant cells before this occurs may prevent or delay disease progression.

 

Disclosure: GPR: Speaker, Takeda. Nothing to Disclose: AKC, MR, MGL, RT, MF, JP, RAT

14312 13.0000 MON-0301 A Clonal Selection of Castrate-Tolerant Stem Cells Leads to Regeneration of Phenotypically Similar Prostate Cancer Tumours 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

Aritro Sen*1, Soumya Mitra2 and Stephen R Hammes1
1University of Rochester, Rochester, NY, 2University of Rochester Medical Center, Rochester, NY

 

Chronic inflammation is now regarded as an enabling factor for human cancer, and several lines of evidence suggest a potential role of inflammation in prostatic carcinogenesis and tumor progression. However, how chronic inflammation influences prostate cancer (PCa) progression is poorly understood. Recently, we reported (1,2) that a scaffold protein called paxillin is a critical regulator of androgen- and epidermal growth factor (EGF)-induced signaling both in the cytoplasm (nongenomic) and within the nucleus (genomic). In fact, we found that paxillin is essential for PCa growth both in vitro and in vivo, and that paxillin expression and signaling were up-regulated in human PCa biopsy samples. Intriguingly, we find that inflammatory cytokines promote paxillin expression or activity in PCa cells. For example, TGFβ1 induces the expression of paxillin, while TNFα and IFNγ activate paxillin without altering expression. Additionally, we have uncovered that Neutrophil Elastase (NE), a serine protease secreted by neutrophils and macrophages during inflammation, activates the proliferative paxillin-regulated signaling pathway and promotes PCa cell proliferation through transactivation of the EGF receptor. Interestingly, a FDA-approved inhibitor of NE, called Sivelestat blocks all of these effects in PCa cells. To better study the relationship between inflammation, NE and PCa, we developed a xenograft mouse model of inflammation and PCa. In this model, intra-peritoneal or intra-tumor injection of lipopolysaccharide (LPS) induces systemic or local chronic inflammation, respectively. These LPS injections remarkably increase tumor growth (20 fold vs initial volume) compared to controls (7.4 fold vs initial volume) and in some cases even promote metastasis. Utilizing this model and an activatable optical biomarker probe specific to NE, we have non-invasively monitored NE activity in live animals with PCa xenografts. Our results show that NE activity is significantly elevated in PC3 xenograft tumors and the metastatic lesions compared to controls. Furthermore, we have used fluorescence molecular tomography to image tumor volume depth and quantification of NE activity in 3-D. Finally, we used granulocyte differentiation antigen (Gr1) that is expressed predominantly on neutrophils to correlate the in vivo NE activity with the extent of inflammation-induced neutrophil infiltration into these tumors. Confocal imaging of excised tumors shows about 60% more neutrophil infiltration in the LPS-treated tumors than those in the control tumors. Based on these results, we propose that chronic inflammation through induction of paxillin expression and NE actions augments androgen and EGF signaling, thereby facilitating growth of prostatic carcinoma. Moreover, we propose that NE may be a potential therapeutic target and/or biomarker for PCa.

 

Nothing to Disclose: AS, SM, SRH

13078 14.0000 MON-0302 A Inflammation Promotes Prostate Cancer Development and Progression By Enhancing Androgen- and EGF-Mediated Signaling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

Florian Handle*1, Holger H.H. Erb2, Frederic R Santer3 and Zoran Culig3
1Innsbruck Medical University, Innsbruck, Austria, 2Innsbruck Medical University, 3Innsbruck Med Univ, Innsbruck, Austria

 

The pro-inflammatory cytokine Interleukin-6 (IL-6) has been shown to play an important role in prostate cancer and high IL-6 levels are associated with bad prognosis. Suppressor of cytokine signaling 3 (SOCS-3) is an IL-6 induced negative feedback regulator of the JAK/STAT signaling pathway. Epigenetic silencing of SOCS-3 by promoter hypermethylation was reported in prostate cancer and may explain the pleiotropic role of IL-6 in this type of cancer. Previously, our group has shown that SOCS-3 is essential in cell lines which have an IL-6 autocrine loop. Under androgen deprivation conditions IL-6 is also able to activate the androgen receptor (AR) but this interaction of the androgen and IL-6 pathway is not well understood yet. Therefore, we speculated that SOCS-3 may influence the cross-talk between the IL-6 and the AR pathways and may play a role in progression to castration resistance. In IL-6 negative cell lines the role of SOCS-3 was not studied so far because of the very low basal mRNA expression. In this study we could show that treatment with physiological levels of IL-6 (10ng/ml) highly induced SOCS-3 mRNA (up to 100 fold) in four AR positive cell lines lacking the IL-6 autocrine loop. Additionally, lentiviral overexpression of SOCS-3 diminished phosphorylation of STAT-3 in response to IL-6 treatment in LNCaP. Surprisingly we found that androgen treatment down-regulates SOCS-3 mRNA levels in a dose dependent manner (0.001-1nM R1881) in LNCaP cells (negative correlation to PSA mRNA: R²=0.908, **p=0.003). This down regulation could be confirmed in two additional AR-positive cell lines and it was also present in cells in which SOCS-3 was overexpressed. This promoter-independent effect on mRNA level would suggest a miRNA based regulation mechanism. These findings demonstrate that SOCS-3 is not only present in AR-positive cells but is also functionally relevant. Therefore, we suggest that androgen ablation may protect the cells from the negative effects of IL-6 signaling by up-regulation of SOCS-3. This would imply that there is a bidirectional interaction between the androgen and IL-6 pathways.

 

Nothing to Disclose: FH, HHHE, FRS, ZC

13608 15.0000 MON-0303 A The Role of SOCS-3 in the Cross-Talk of Androgen and IL-6 Signaling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

Mitchell G Lawrence*1, Itsuhiro Takizawa1, Helen Pearson2, John Pedersen3, Normand Pouliot2, Australian Prostate Cancer Bioresource1, Patrick Humbert2, Luc Furic1 and Gail P Risbridger1
1Monash University, Melbourne, Australia, 2Peter MacCallum Cancer Centre, Melbourne, Australia, 3Tissupath Pathology Services, Melbourne, Australia

 

Prostate cancer is a hormone-dependent disease of aging men that coincides with the relative increase in the ratio of estrogen to testosterone levels. There is growing evidence that estrogens contribute to cancer progression, an effect that is attributed to the activity of the estrogen receptor α (ERα). However, the expression profile of ERα in prostate cancer is controversial and a paucity of suitable models means that the precise autocrine role of ERα in prostate cancer is still poorly understood. In this study we observed increased ERα expression in three different models of prostate cancer. In human prostate cancer, all low grade Gleason Score 6 specimens lacked ERα (0/15), whereas 48% (10/21) of high grade Gleason 9 tumors expressed ERα. Similarly, ERα was highly expressed in tumors from two different mouse models of prostate cancer, Hi-Myc and PTEN null mice, compared to benign prostate tissue from control mice. Within the prostate of PTEN null mice, there was a consistent pattern of ERα expression: low in benign glands, moderate in tumors within the dorsal, lateral and ventral lobes, and high in tumors within the anterior prostate. Systematic counting of ERα staining revealed that the pattern significantly correlated with the levels of the proliferative marker Ki67. There was also a significant correlation between ERα and Ki67 within individual malignant glands in the anterior prostate. We further showed that ERα directly regulates the proliferation of prostate cancer cells. There was a significant decrease in the in vitro proliferation of cells derived from a PTEN null tumor when they were treated with TPSF, a non-competitive ERα antagonist. Stable transduction of an ERα-specific shRNA also attenuated the proliferation of the PTEN null cells in 2D and 3D assays. The proliferative effect of ERα was due to downstream regulation of the PI3K and MAPK pathways. Knockdown of ERα decreased the phosphorylation of erk1/2, S6 kinase and other factors. Significantly, this effect was reversed in rescue experiments with an expression construct encoding full length ERα, capable of both genomic and non-genomic signaling. Collectively, these results demonstrate that the increased levels of ERα in prostate cancer promote proliferation through classical survival signaling.

 

Disclosure: GPR: Speaker, Takeda. Nothing to Disclose: MGL, IT, HP, JP, NP, APCB, PH, LF

15624 16.0000 MON-0304 A Estrogen Receptor Alpha Drives Proliferation of Prostate Cancer through PI3K and MAPK Signaling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

David A Bader*, Cristian Coarfa, Sean Michael Hartig, Arun Sreekumar, Bert W O'Malley and Sean E McGuire
Baylor College of Medicine, Houston, TX

 

Prostate cancer (PCa) is driven by the hormonally responsive transcription factor androgen receptor (AR) and the disease is frequently managed with therapies to prevent synthesis or action of androgens. Resistance mechanisms to androgen deprivation therapy often involve reactivation of AR in the castrate setting by a variety of mechanisms including AR amplification, constitutively active AR splice variants, AR mutations that enable ligand promiscuity, conversion of adrenal androgen precursors, and de novo intratumoral androgen synthesis.  Metabolic perturbation is an emerging hallmark of cancer and AR regulates many metabolic genes to mediate PCa growth and survival. Therefore, while disruption of AR signaling may not currently be feasible in castrate resistant tumors, downstream inhibition of metabolic AR target genes represents a rational approach to therapy. Accordingly, our lab performed a comprehensive bioinformatic analysis to identify androgen-responsive metabolic target genes and nominated a recently-identified subunit of the mitochondrial pyruvate carrier complex, MPC2, as a putative oncogene in PCa. MPC2 imports cytosolic pyruvate into the mitochondrion for incorporation into the citric acid cycle (TCA). However, the TCA in PCa is often repurposed to support de novo lipid biosynthesis (lipogenesis) which is metabolically advantageous to the cancer cell. Therefore, we hypothesize that increased expression of MPC2 in PCa increases pyruvate flux through the inner mitochondrial membrane to support the lipogenic phenotype common to the disease.  In line with our hypothesis, expression profiles of PCa cell lines in the Cancer Cell Line Encyclopedia indicate MPC2 expression is significantly increased in PCa cells compared to benign prostate tissue and treatment of LNCaP cells with metribolone results in a significant and rapid increase in MPC2 mRNA and protein. Further, MPC2 expression is increased across several clinical PCa data sets including the Cancer Genome Atlas and alterations in MPC2 expression predict decreased disease free survival, suggesting clinical relevance of MPC2.Ongoing experiments aim to determine the effect of MPC2 manipulation on pyruvate flux, glycolysis, and lipogenesis. Given the critical importance of MPC2 to cellular energy and biosynthetic processes, therapeutic targeting of this gene may hold significant promise in the treatment of castration sensitive and resistant PCa.

 

Nothing to Disclose: DAB, CC, SMH, AS, BWO, SEM

16981 17.0000 MON-0305 A Investigation of the Mitochondrial Pyruvate Carrier Complex in Prostate Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

John J Evans*, Muthana Majid, Kenny Chitcholtan and Peter H Sykes
University of Otago, Christchurch, Christchurch, New Zealand

 

Adiposity is recognised as a risk factor in cancer development. There are, however, substantial gaps in our understanding of the details of the effects of adipokines. It has been reported that high levels of leptin and low levels of adiponectin are associated with endometrial cancer development. In this study we investigated the effects of leptin and adiponectin, which are both products of adipose tissue, on cells of an endometrial adenocarcinoma cell line (Ishikawa) in in vitro culture.

In our cultures leptin at a concentration of 20 ng/ml stimulated proliferation of Ishikawa cells and further increased proliferation at 50 ng/ml. There was a small decline at 50–100 ng/ml. On the other hand when exposed to adiponectin, the cancer cells exhibited an n-shaped response curve. Proliferation increased when the cells were incubated in the presence of 20 ng/ml adiponectin compared to untreated control cells. In contrast there was a modest decrease in proliferation with 100 ng/ml adiponectin compared to control cells. When adiponectin (100 ng/ml) was added to leptin (50 ng/ml) the stimulatory effect of leptin was absent and proliferation was at control levels. When a low concentration of adiponectin (20 ng/ml) was added to leptin (50 ng/ml) the level of proliferation was higher than control and similar to that induced by adiponectin alone. The effects of the two adipokines on a second parameter, secretion of vascular endothelial growth factor (VEGF), were determined. Ishikawa cells in the presence of leptin (100 ng/ml) secreted less VEGF than in control incubations. In contrast VEGF secretion was increased by adiponectin (20 ng/ml). VEGF secretion was further increased by more concentrated adiponectin (100 ng/ml). A mixed solution of leptin (50 ng/ml) and adiponectin (100 ng/ml) secreted levels of VEGF similar to control cells. The VEGF secretory response profiles were thus different from that induced by leptin and adiponectin on proliferation.

We demonstrated a range of interactive effects of the two adipokines. The results suggest that their activities in cancer should be investigated in a relevant milieu.

 

Nothing to Disclose: JJE, MM, KC, PHS

15068 18.0000 MON-0306 A Responses of Proliferation and VEGF Secretion By Ishikawa Cells Are Not Parallel When Exposed to Leptin and Adiponectin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

Simon Chu*1, Maria Alexiadis2 and Peter J Fuller3
1Hudson Institute of Medical Research and Monash University, Melbourne Vic, Australia, 2Hudson Institute of Medical Research, Clayton, Australia, 3MIMR-PHI Institute and Monash University, Clayton VIC, Australia

 

Adult ovarian granulosa cell tumors (GCT) are hormonally-active neoplasms characterized by a mutation in the FOXL2 gene (C134W). They exhibit an indolent course with unexplained propensity for late recurrence. Approximately 80% of patients with aggressive or recurrent tumors die from their disease; aside from surgery the therapeutic options are very limited. In order to address the key questions of pathogenesis and targeted therapeutics, our strategy has been to use whole transcriptome analysis of molecularly defined (FOXL2 C134W mutation positive) adult GCT to identify genes that are differentially expressed between early (stage 1) and advanced/recurrent GCT. We have established transcriptome profiles for early (n=6), advanced (n=7) adult GCT and for two GCT-derived cell lines (KGN and COV434), using the Agilent Human Gene 4x44K Expression Microarrays. Our preliminary analysis using Agilent GeneSpring GX software, identified 21 genes whose expression is >3-fold (p < 0.001) differential expression between early and advanced GCT. Several features emerge from our preliminary analysis: (1) clearly discriminant patterns of expression suggest that the clinicopathological-derived distinction of the tumor stage appears robust; (2) confirmation of the relative homogeneity of expression for many genes across the cohort; (3) several genes associated with differentiated granulosa cell function are highly significantly down-regulated in GCT and the GCT-derived cell lines, including INSL3 (insulin-like 3; >60-fold, p <0.001); and desmin (>7-fold, p <0.001), while genes with known roles in advanced malignancy including HOXA7 (>4-fold, p <0.005); FOXD1 (22-fold, p <0.001) and MFAP5 (>26-fold, p<0.001) are up-regulated in advanced GCT. In KGN cells, HOXA7 and FOXD1 were also observed to be over-expressed. We have validated these changes in gene expression in an independent cohort by Taqman RT-PCR. An interesting finding was the observation that FAP (fibroblast activating protein) had abundant gene expression in both early and advanced GCT. FAP is a membrane serine protease, and its overexpression is potentially significant for GCT, as FAP is an established target for therapeutic development. We are currently using Pathway Analysis and Hierarchical Clustering to further interrogate this unique data set. These studies will validate the functional significance of the differential expression of the identified genes which in turn may identify specific targets and/or pathways of relevance to the treatment of advanced GCT.

 

Nothing to Disclose: SC, MA, PJF

16779 20.0000 MON-0308 A Identifying Potential Therapeutic Targets through Whole Transcriptome Analysis of Early and Advanced Stage Granulosa Cell Tumors of the Ovary 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0289-0308 4886 1:00:00 PM Hormone Dependent Tumors Poster

Matthew T Cook*1, Yayun Liang2, Benford Mafuvadze2, Cynthia Besch-Williford3 and Salman M Hyder2
1Univ of Missouri, Columbia, MO, 2University of Missouri, Columbia, MO, 3IDEXX BioResearch

 

Clinical and epidemiological evidence show that combined estrogen (E) and progestin (P) hormone replacement therapy (HRT) increases the risk of breast cancer in postmenopausal women.  Tumor progression is dependent on angiogenesis, which provides nutrients vital to the developing cancer. We have shown that physiological levels of P (10 nM), including medroxyprogesterone acetate (MPA), which is widely used in HRT, increases the production of the potently angiogenic vascular endothelial growth factor (VEGF), in human breast cancer cells both in vitro and in vivo. The anti-progestin RU-486 blocks this effect, suggesting the involvement of progesterone receptors in the process (Int J Cancer, 2001, 92:469). Evidence from our laboratory using in vivo breast cancer models suggests that P accelerates the development of tumors from latent tumorigenic cells, leading to the development of palpable tumors (Cancer Res., 2007, 67:9929; Clin Can Res, 2006, 12:4062), a process that may be attributed to increased production of VEGF.  RU-486 blocks P-dependent VEGF production and thereby reduces tumor growth; however, the anti-progestin has severe side-effects and therefore cannot be used in the long-term. Recently, we have been studying less toxic naturally-occurring compounds for their ability to antagonize P-dependent VEGF induction and block tumor progression.  We tested the effects of the flavonoid luteolin, which is commonly found in fruits and vegetables, on the proliferation of BT-474 and T47-D breast cancer cells and their production of VEGF.  Luteolin treatment (25-100 μM) for 24 h reduced in vitro tumor cell viability. Interestingly, treatment with a lower concentration of luteolin (10 μM) blocked the production of P-dependent VEGF, indicating that VEGF suppression precedes luteolin-mediated loss of cell viability.  Furthermore, luteolin (20 mg/kg, i.p.) suppressed growth of MPA-dependent BT-474 human xenograft tumors in nude mice. Immunohistochemical analysis showed that luteolin reduced both VEGF and PR in tumor cells, and induced apoptosis, which was measured using the TUNEL assay (p<0.05).  Our findings strongly suggest that disruption of tumor progression by luteolin occurs as a consequence of the flavonoid blocking P-dependent VEGF production and consequent angiogenesis and tumor cell proliferation (Endocrinology, 2005, 146:3632).  We contend therefore that luteolin is a compound with valuable therapeutic properties against P-dependent human breast cancer.

 

Nothing to Disclose: MTC, YL, BM, CB, SMH

PP38-1 11825 1.0000 MON-0327 A The Nutraceutical Luteolin Inhibits Progestin-Dependent VEGF Induction in Breast Cancer Cells and Blocks Tumor Progression in a Xenograft Model 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0327-0339 4888 1:00:00 PM Therapies for Cancer Poster

Arunkumar Arumugam*1, Ramadevi Subramani2, Sushmita B Nandy1, Rebecca Lopez3, Thiyagarajan Boopalan4 and Rajkumar Lakshmanaswamy5
1Texas Tech University Health Sci, El Paso, TX, 2Texas Tech University Health Sciences Center, El Paso, TX, 3Texas Tech University Health Sciences, El Paso, TX, 4Texas Tech Univ, El Paso, TX, 5Texas Tech Univ Health Sci Ctr, El Paso, TX

 

Breast cancer is the common and frequently diagnosed cancer in women. Chemotherapy is a main choice for the treatment of aggressive breast cancers. Although the tumors respond initially, large numbers of patients develop recurrence due to chemoresistance. Growth hormone receptor (GHR) is a class I cytokine receptor, which plays vital role in the development of chemoresistance. Studies have shown that silencing of GHR sensitizes breast cancer cells to chemotherapeutic drugs. The aim of this study was to identify the impact of GHR knockdown in aggressive forms of breast cancer cells and investigate the possible mechanisms implicated in GHR silencing induced sensitization in breast cancer cells. GHR was silenced using small interfering RNAs in metastatic breast cancer cells MDA MB 231 and BT 20. Molecular analyses were performed to determine apoptosis, cytotoxicity, colony formation, invasion and migration in GHR knockdown cells. Expression of multi drug resistance protein 1 (MDR1) and breast cancer resistance protein (BCRP) were also evaluated. Silencing of GHR induced cytotoxic effects and apoptosis in breast cancer cells. Moreover, epithelial to mesenchymal transition markers were significantly down regulated by GHR silencing. GHR targeted cells responded well to docetaxel treatment in the culture. Inhibition of GHR also inhibited the expression of MDR1 and BCRP, which are frequently corroborated for chemoresistance in breast cancer cells. Further, the flowcytometric determination of drug efflux showed that GHR knockdown reduced the number of drug effluxing cells and sensitizes the cells to chemotherapy. Further, treatment of GH induced the overexpression of drug transporter proteins involved in chemoresistance. Inhibition of GHR in breast cancer cells reverted the expression of these proteins and sensitized the cells to chemotherapy. These findings support the hypothesis that targeting GHR could have a potential new therapeutic approach to overcome chemoresistance, especially in aggressive breast cancers.

 

Nothing to Disclose: AA, RS, SBN, RL, TB, RL

16972 4.0000 MON-0330 A Growth Hormone Receptor Silencing Enhances the Sensitivity of Breast Cancer Cells to Chemotherapy By Inhibiting MDR1 and BCRP 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0327-0339 4888 1:00:00 PM Therapies for Cancer Poster

Sean W Fanning1, David J Hosfield*1, Madison Taylor2 and Geoffrey L Greene3
1University of Chicago, Chicago, IL, 2University of Chicago, 3Univ of Chicago, Chicago, IL

 

Current therapies used to treat hormone-associated cancers generally rely upon drugs targeting nuclear hormone receptors (NHRs).  Unfortunately, many patients do not respond to these treatments and for those patients that do, therapy is often hindered due to the development of drug resistance.  This limitation has led to interest in developing new classes of modulators with alternate mechanisms of action.  Small molecules that prevent the correct assembly of NHR-containing complexes at sites of active transcription thus represent a novel approach to targeting oncogenic signaling pathways needed for cell growth and metastases.    We are combing medium-throughput chemical screening with biophysical studies, cell biology and structure-based design to identify these new classes of small molecules.   For the Estrogen receptor (ER) we found that the clinically relevant Y537S and D538G mutations confer receptor activation in the absence of estradiol and crystal structures of these mutant receptors with SERMS are SERDS have been determined to understand the molecular basis of this aberrant activation.  For the Androgen receptor (AR) we have identified an activating F876L mutation that confers resistance to the next generation prostate cancer drug Enzalutamide™.  Using a structure based approach we synthesized and tested next-generation anti-androgens that are effective against the mutated receptor.   In parallel we are targeting the AR and ER co-activators ATAD2 and TRIM24 by identifying small molecules that bind to functional domains involved in catalysis and chromatin localization.  To facilitate these studies we have cloned, expressed, and purified various functional domains for both proteins and have used Fluorescence Polarization Spectroscopy (FP) and Differential Scanning Fluorimetry (DSF) to identify small molecule chemical leads that target each protein.  Results from these studies will be described in the presentation.

 

Disclosure: GLG: Advisory Group Member, Pfizer, Inc.. Nothing to Disclose: SWF, DJH, MT

16060 5.0000 MON-0331 A Chemical Biology Approaches Applied to the Discovery of Inhibitors and Probes for Hormone Associated Cancers 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0327-0339 4888 1:00:00 PM Therapies for Cancer Poster

Maria Theresa E Montales*1, Adam R Brown2, Rosalia CM Simmen1 and Frank A Simmen1
1University of Arkansas for Medical Sciences, Little Rock, AR, 2University of Arkansas Medical Sciences, Little Rock, AR

 

Colon cancer is the third leading cause of cancer-related deaths worldwide. Obesity and diabetes, due in part to high-caloric diet and sedentary lifestyles, underlie increased colon cancer risk. Epidemiological studies suggest that the biguanide metformin (Met), commonly used as a first-line treatment for Type 2 diabetes, may exhibit anti-cancer activity by reducing blood glucose and hence insulin levels that fuel growth of cancer cells and by activating the AMPK pathway that regulates their metabolic state. While Met has been evaluated for its ability to inhibit the malignant potential of colon cancer cells, studies addressing the effects of dietary factors with health benefits and their combined effects with Met have not been reported. Herein we performed in vitro studies to evaluate whether Met and the soy bioactive components genistein (GEN) and Lunasin (LUN) alone and in combination inhibit the tumor potential of the metastatic human colon cancer line HCT116. The abundance of the CD133+CD44+epithelial sub-population of HCT116 cells, that form non-adherent colonies (termed colonospheres) under anchorage-independent conditions, is an in vitro measure of tumor formation. Met (5 μg/ml) decreased cell viability, induced cell apoptosis, decreased the frequency of sphere formation, promoted tumor suppressor PTEN expression and inhibited pro-tumorigenic FASN transcript levels in HCT116 cells. Similar to Met, GEN (2μM) and the soy peptide LUN (2 μM) reduced cell viability (GEN>LUN>Met), inhibited colonosphere formation (Met>GEN>LUN), and enhanced PTEN mRNA expression. The effects of Met on colonosphere formation were enhanced by GEN but not by LUN; co-addition of all three eliminated colonospheres. In previous work, we showed that colon tumor formation in vivo was promoted by null mutation of the transcription factor Krüppel-like Factor 9 (KLF9) in the ApcMin/+ mouse. To evaluate if Met limits colonosphere formation partly through KLF9, Met-treated cells were evaluated for KLF9 mRNA expression, and siKLF9-targeted HCT116 cells were assessed for proliferation. Met reduced KLF9 and FASN gene expression by 2h and 6h, respectively, suggesting a temporal relationship, and siKLF9 targeting decreased proliferation. Results suggest that Met, when used in conjunction with dietary bioactives, may limit the expansion of colon tumor-initiating cells. The intriguing possibility of mechanistic linkages among Met, KLF9 and FASN in colon tumorigenesis warrants further study.

 

Nothing to Disclose: MTEM, ARB, RCS, FAS

15071 6.0000 MON-0332 A Metformin and Soy Bioactives Limit the Frequency of the CD133+CD44+ Epithelial Sub-Population in Human Colon Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0327-0339 4888 1:00:00 PM Therapies for Cancer Poster

Kerstin Knoop1, Kathrin A Schmohl2, Nathalie Schwenk1, Andrea Maria Mueller1, Guido Böning2, Janette Carlsen2, Burkhard Göke2, Ernst Wagner3, Peter J Nelson2 and Christine Spitzweg*4
1University Hospital of Munich, Germany, 2University Hospital of Munich, Munich, Germany, 3Ludwigs-Maximilians-University, Munich, Germany, 4University Hospital of Munich, LMU Munich, Munich, Germany

 

The tumor-homing property of mesenchymal stem cells (MSC) has lead to their use as delivery vehicles for therapeutic genes. The application of the sodium iodide symporter (NIS) as theranostic gene allows non-invasive imaging of MSC biodistribution and functional transgene expression by 123I-scintigraphy or PET-imaging, as well as therapeutic application of 131I or 188Re. Based on the critical role of the chemokine RANTES/CCL5 secreted by MSCs in the course of tumor stroma recruitment and differentiation into cancer associated fibroblasts, use of the RANTES/CCL5 promoter should allow tumor stroma-targeted expression of NIS after MSC-mediated delivery.

We stably transfected human MSCs with NIS driven by the CCL5 promoter (RANTES-NIS-MSC). Human hepatocellular cancer (HCC) cells Huh7 were injected directly into the right liver lobe of nude mice resulting in induction of a primary liver tumor after 4 weeks. We investigated distribution and recruitment of RANTES-NIS-MSCs by 123I-scintigraphy and 124I-PET imaging and ex vivo analyses after systemic injections of RANTES-NIS-MSCs.

123I-scintigraphy and ex vivo radioiodine biodistribution studies as well as 124I-PET imaging revealed active MSC recruitment and CCL5 promoter activation in the intrahepatic xenograft tumors as shown by tumor-selective iodide accumulation. Immunofluorescence analysis confirmed selective MSC recruitment and RANTES/CCL5-promoter activation, while healthy liver tissue and non-target organs did not show MSC recruitment. To examine the therapeutic effect of NIS-mediated radioiodine therapy, 55.5 MBq 131I was administered 48 h after three MSC-applications (in 2-day intervals). After two of these treatment cycles followed by a last MSC injection with a final 131I application 48 h later, mice with intrahepatic Huh7 xenografts showed significantly improved survival as compared to the control groups (RANTES-NIS-MSC + saline; WT-MSC + 131I; saline only). In addition, immunfluorescence analysis showed markedly reduced proliferation and decreased blood vessel density of RANTES-NIS-MSC/131I treated tumors in contrast to control tumors.

Our results convincingly demonstrate selective recruitment of MSCs stably expressing NIS driven by the RANTES/CCL5-promoter into orthotopic liver tumors resulting in induction of tumor-specific iodide accumulation and a therapeutic effect of 131I, opening the exciting prospect of NIS-mediated radionuclide cancer therapy after systemicMSC-mediated NIS gene delivery.

 

Nothing to Disclose: KK, KAS, NS, AMM, GB, JC, BG, EW, PJN, CS

16962 7.0000 MON-0333 A Mesenchymal Stem Cell-Mediated Sodium Iodide Symporter (NIS) Imaging and Therapy in an Orthotopic Liver Cancer Mouse Model 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0327-0339 4888 1:00:00 PM Therapies for Cancer Poster

Ramadevi Subramani*1, Rebecca Lopez2, Thiyagarajan Boopalan3, Arunkumar Arumugam4, Sushmita B Nandy4 and Rajkumar Lakshmanaswamy5
1Texas Tech University Health Sciences Center, El Paso, TX, 2Texas Tech University Health Sciences, El Paso, TX, 3Texas Tech Univ, El Paso, TX, 4Texas Tech University Health Sci, El Paso, TX, 5Texas Tech Univ Health Sci Ctr, El Paso, TX

 

Pancreatic cancer is the only major cancer with a single digit survival rate (1%) and is the 4th leading cause of cancer related death. This is largely due to a lack of detectable symptoms in the early stages of the disease. Pancreatic cancer incidence and mortality rates continue increasing because we still lack sufficient knowledge to effectively detect and manage the disease. Hyperactivated growth hormone receptor (GHR) levels have been shown to increase the risk of cancer in general and this pathway is a master regulator of key cellular functions like proliferation, apoptosis, differentiation, metastasis, etc. However, to date there is no available data on how GHR promotes pancreatic cancer pathogenesis. Here, we used an RNA interference approach targeted to GHR to determine whether targeting GHR is an effective method for controlling pancreatic cancer growth and metastasis.  For this, we used an in vitro model system consisting of HPAC and PANC-1 pancreatic cancer cells lines.   We found that GHR is upregulated in both of these cell lines and silencing GHR significantly reduced cell proliferation and viability. Inhibition of GHR also reduced the metastatic potential of pancreatic cancer cells, which was aided through decreased colony forming ability and reduced matrigel invasion and would healing capacity. Flow cytometric and western blot analyses revealed the induction of apoptosis in GHR silenced cells. Key pathways affected by GHR silencing included PI3K/AKT, MEK/ERK, JAK/STAT, and mTOR signaling, as well as, epithelial to mesenchymal transition.  Interestingly, silencing GHR also suppressed the expression of insulin receptor β and COX-2. All together, the inhibitory effect of GHR silencing on each of these pathways significantly controls the growth and metastasis of pancreatic cancer and reveals the importance of this pathway in pancreatic cancer pathogenesis.

 

Nothing to Disclose: RS, RL, TB, AA, SBN, RL

17061 8.0000 MON-0334 A Growth Hormone Receptor: An Oncotarget for Pancreatic Ductal Adenocarcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0327-0339 4888 1:00:00 PM Therapies for Cancer Poster

Traci R Tuttle*1, Keith A. Casper2, Michelle L. Mierzwa2 and Nira Ben-Jonathan2
1Univ of Cincinnati, Cincinnati, OH, 2University of Cincinnati, Cincinnati, OH

 

Background:Head and neck squamous cell carcinomas (HNSCC) originate from the mucosal lining of the oral and nasal cavities, paranasal sinuses, pharynx and larynx. These cancers are more common in men than women, are associated with tobacco and alcohol use, and human papillomavirus (HPV) infection. The worldwide incidence of HNSCC exceeds 500,000 cases annually. The most common treatments are surgery, radiotherapy and cytotoxic chemotherapy, all of which result in many adverse side effects and a decrease in the quality of life. Treatment failure or relapse are common. Therefore, there is an urgent need for novel prognostic and therapeutic applications for these cancers. Dopamine (DA) acts as a neurotransmitter within the brain and as a hormone in the periphery. DA binds to five receptors, classified by structure and function into D1-like (D1R and D5R) and D2-like (D2R, D3R and D4R). D1R couples to stimulatory G proteins that increase intracellular cyclic AMP (cAMP) and/or cGMP.  The latter is rapidly broken down by phosphodiesterase 5 (PDE5). Previous studies in our laboratory found D1R expression in breast cancer cells and primary ductal carcinomas. D1R activation by selective agonists resulted in apoptosis and increased chemosensitivity in breast cancer cells.  The objective of this investigation was to determine whether: 1) D1R is also expressed in HNSCC, and 2) activation of D1R or its downstream signaling pathway results in cell death.

Methods:D1R expression was determined in HNSCC cell lines, primary tumors and normal H&N mucosa by real-time PCR, Western blotting and/or immunohistochemistry. The effects of D1R agonists and pathway modulators on the viability of HNSCC cell lines were determined by the MTT assay.

Results:D1R was expressed in many primary tumors and HNSCC cell lines. Several D1R agonists, including Fenoldopam, an FDA-approved, high affinity peripheral D1R agonist, markedly decreased the viability of HNSCC cell lines, as did the PDE5 inhibitor Tadalafil (Cialis). The combination of the two drugs was more effective in suppressing cell viability than either alone.

Conclusions: Detection of D1R in tumor biopsies could serve as a prognostic biomarker for identifying subpopulations of patients who are most likely to respond to D1R-targeted therapy. Both Fenoldopam and Tadalafil are FDA-approved for the treatment of other conditions and have only minimal side effects.  Thus, a combination treatment has the potential to become a novel treatment for head and neck cancers.

 

Nothing to Disclose: TRT, KAC, MLM, NB

13074 9.0000 MON-0335 A Expression and Therapeutic Applications of Dopamine Receptors in Head and Neck Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0327-0339 4888 1:00:00 PM Therapies for Cancer Poster

Maria Chiara Zatelli*1, Giulia Zuolo2, Erica Gentilin3, Teresa Gagliano3, Federico Tagliati4 and Ettore Ciro degli Uberti5
1Univ. of Ferrara, Ferrara, Italy, 2Section of Endocrinology, University of Ferrara, Ferrara, Italy, 3University of Ferrara, Ferrara, Italy, 4Section of University of Ferrara, Ferrara, Italy, 5Section of Endocrinology, University of Ferrara, Italy

 

The only therapeutic option for relapsing advanced endometrial cancer is chemotherapy, which may fail due to the development of chemoresistance. It has been previously demonstrated that GH enhances chemoresistance in breast cancer cells and that endometrial cancer cells secrete GH, stimulating their own growth in an autocrine fashion. The aim of this study is to evaluate whether GH may reduce the sensitivity of HEC1A and AN3CA endometrial cancer cell lines to Doxorubicin (D) and Cisplatin (C) in terms of cell proliferation reduction, evaluating the implicated mechanisms. To this aim, cell viability, caspase activation and protein expression were evaluated in two endometrial cancer cell lines (HEC-1A cell line, expressing the estrogen receptor (ER), and the AN3CA cell line, which does not express ER), undergoing treatment with GH and D or C, in the presence or in the absence of the GH receptor (GHR) antagonist, Pegvisomant. We found that in endometrial cancer cells GH confers resistance to D- and C-induced apoptosis. In addition, GH reduced D- and C-induced ERK 1/2 phosphorylation and PKCδ expression, both involved in chemotherapic-dependent apoptosis. These effects were reduced by Pegvisomant, suggesting a GHR-mediated mechanism. These data indicate that GH promotes resistance to apoptosis induced by chemotherapic agents modulating the apoptotic pathway, possibly inhibiting ERK1/2 phosphorylation and PKCδ expression. These findings support the hypothesis that GHR blockade may be represent a potential new therapeutic approach to overcome chemoresistance in endometrial cancer.

 

Disclosure: ECD: Principal Investigator, Pfizer, Inc.. Nothing to Disclose: MCZ, GZ, EG, TG, FT

13920 10.0000 MON-0336 A Growth Hormone Modulates Chemoresistance in Human Endometrial Cancer Cell Lines 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0327-0339 4888 1:00:00 PM Therapies for Cancer Poster

John A Katzenellenbogen*1, Julie A. Pollock1, Alexander A Parent1, Suzanne Elizabeth Wardell2, Donald P McDonnell2 and John D Norris3
1University of Illinois at Urbana-Champaign, Urbana, IL, 2Duke University School of Medicine, Durham, NC, 3Duke University, Durham, NC

 

After an initial favorable response of prostate cancer (PC) to antiandrogens and other androgen deprivation therapies, resistance frequently develops, leading to a more aggressive state termed castration-resistant prostate cancer (CRPC). While resistance undoubtedly derives from several mechanisms, CRPC is nearly always still dependent on signaling from the androgen receptor (AR), which persists in some cases due to point mutations that confer resistance to specific antiandrogens: The LNCaP mutation (AR T877A) is resistant to hydroxyflutamide, and the AR mutants W741C and F876L show marked resistance to casodex (bicalutamide) and enzalutamide (MDV3100), respectively. Thus, there is a continuing need for the development of novel antiandrogens that retain inhibitory activity on these resistant AR mutants, as well as on other resistant mutants that are likely to develop in the future, as new agents are added to the clinic. In addition, AR ligands that block the activity of mutant ARs in a selective fashion (i.e., without substantially inhibiting wild type AR (WT-AR)) would be particularly useful because they might provide effective therapy for certain forms of CRPC without the deleterious side effects (e.g., loss of muscle strength and libido, bone loss) associated with an overall blockade of AR signaling in non-tumor androgen target tissues.

Using a high throughput screen for inhibitors of AR signaling, based on conformational sensing, we have identified a number of structurally novel AR ligands, both competitive and non-competitive, that are potent inhibitors of androgen-stimulated proliferation and regulation of reporter and endogenous genes in various PC cell lines, including those overexpressing WT-AR and expressing mutant ARs that are models of CRPC. A number of these have low to submicromolar potency and low cell toxicity. We have expanded a unique class of small molecule cyclobutanes (CBs) that selectively target all major antiandrogen-resistant AR mutants, and we have obtained CBs that have up to 350-fold potency selectivity on mutant vs. WT-AR. One of the CBs tested was shown to significantly inhibit the growth of LNCaP cells (AR T877A) propagated as xenografts in mice. Because these molecules are able to distinguish between WT and mutant ARs, they may have therapeutic potential as drugs that are effective against aggressive CRPC yet provide improved patient quality of life by not compromising normal androgen function.

 

Nothing to Disclose: JAK, JAP, AAP, SEW, DPM, JDN

PP38-3 13136 11.0000 MON-0337 A Structurally Novel Antagonists of Androgen Receptors with Elevated Potency for Antiandrogen-Resistant Receptor Mutants in Prostate Cancer: Tetra-Aryl-Substituted Cyclobutanes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0327-0339 4888 1:00:00 PM Therapies for Cancer Poster

Gnanasekar Munirathinam*1 and Kavanya Gray2
1Univesity of Illinois, Rockford, IL, 2Ripon College

 

Prostate cancer is the most frequently diagnosed cancer in men next to skin cancer and second only to lung cancer as the leading cause of male cancer-related deaths in the United States. Androgen ablation therapy is the gold standard for treating prostate cancer patients. However, there is no effective treatment available for patients who have progressed to androgen independent disease status or castration-resistant prostate cancer (CRPC). Thus, there is an urgent need to develop effective and non-toxic alternative treatments for CRPC. Certain natural compounds such as curcumin, genistein, resveratrol and lycopene derived from dietary products have been shown to possess anti-cancer properties with minimal toxicity. A promising natural compound, cinnamaldehyde (CA), which is abundantly present in Cinnamomum zeylanicum bark has proven effective in inhibiting proliferation of many types of cancer such as melanoma, leukemia, and hepatoma. However, its therapeutic effects against prostate cancer are untested. Therefore, the focus of this study is to evaluate whether CA targets prostate cancer cells in a pre-clinical study. The anti-cancer effects of CA were first screened using a panel of prostate cancer cell lines in a cell viability assay. Results of this screening study showed that CA was particularly effective in inhibiting cell proliferation of PC-3, DU145 (androgen independent), and LNCaP (androgen dependent) prostate cancer cell lines. Specifically, we found that CA inhibits up to 67% of DU145 cells from proliferating as well as up to 57% of LNCaP cells and up to 75% of PC-3 cells. PC-3 cells treated with CA were further subjected to flow cytometry analyses to determine the type of cell death occurring in these cells. This study revealed that CA induced programmed cell death (apoptosis) of PC-3 prostate cancer cells. In addition to inducing apoptosis, CA treatment also significantly decreased the migration ability of PC-3 cells as determined in a Transwell migration assay implicating that CA may reduce the metastatic properties of CRPC cells. Subsequent studies revealed that CA substantially increased homotypic adhesion in PC-3 cells which may be partly responsible for motility inhibition in these cells. Interestingly, our additional studies showed that CA can inhibit androgen receptor activity in LNCaP cells resulting in the down regulation of prostate specific antigen expression. These results suggest that CA may also function as an androgen receptor antagonist. Taken together, our pre-clinical studies for the first time infer that CA is a promising natural product which can be developed to effectively manage both hormone-dependent and hormone-independent prostate cancer.

 

Nothing to Disclose: GM, KG

16915 12.0000 MON-0338 A Cinnamaldehye, a Dietary Flavoring Agent Derived from Cinnamon Targets Prostate Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0327-0339 4888 1:00:00 PM Therapies for Cancer Poster

Cheryl S Watson*1 and Luke Y Koong2
1Univ of TX Med Branch, Galveston, TX, 2UTMB, Galveston, TX

 

Diethylstilbesterol (DES) and other pharmaceutical estrogens at ≥µM concentrations have been used in the past to treat patients with advanced prostate tumors, with 17% success primarily attributed to negative feedback on androgen production via the hypothalamic-pituitary-testicular axis. However, estrogens also reduce prostate tumor cell numbers directly, though the mechanisms are not well understood. We examined multiple rapid signaling pathways that could explain this effect. Androgen-dependent LAPC-4 prostate cancer cells and androgen-independent PC-3 cells were used to model early vs. advanced tumors, respectively. MTT assays showed that estradiol (E2) was much more effective and potent at reducing viable cell numbers than DES, and that LAPC-4 cells were more responsive to estrogen treatments than PC-3 cells; 0.1nM E2 or 1µM DES were optimal, and physiologically/clinically relevant. Traditionally, activation of the kinase ERK is associated with cell proliferation, and JNK is associated with apoptosis. However, in our studies, E2, but not DES, rapidly increased phosphorylation of ERK, and JNK was not activated, except in E2-treated PC-3 cells. Caspase 3 was activated by E2 and DES treatment in LAPC-4 cells, but not in PC-3 cells. Alternatively, sustained activation of ERK can increase levels of reactive oxygen species (ROS), which then induce cell death. We found that E2, but not DES, increased ROS in both cell lines after 15 min. The cell cycle inhibitor protein p16INK4A disrupts the formation of the cyclin D1-CDK4/6 complex required for cell cycle progression from M to G1; we observed that p16INK4A was rapidly phosphorylated in both cell lines by both 0.1 nM E2 and 1µM DES, though to lower levels in DES-treated PC-3 cells. Cyclin D1 phosphorylation at Thr-286 by p38 kinase tags the protein for degradation. Though both estrogens activated p38 in both cell types, cyclin D1 was rapidly phosphorylated by E2 and DES in LAPC-4 cells, and only by E2 in PC-3 cells. DES instead caused cyclin D1 de-phosphorylation in PC-3 cells. Correspondingly, subsequent degradation of total cyclin D1 levels was seen in all cases except DES-treated PC-3 cells. The activation of these direct estrogenic mechanisms by very low dose E2 could be the basis of treatment strategies to dramatically improve current outcomes for both early- and late-stage prostate cancers, while likely reducing unwanted side effects caused by the typically high dose treatments with DES.

 

Nothing to Disclose: CSW, LYK

15008 13.0000 MON-0339 A Direct and Rapid Estrogenic Signaling Mechanisms That Reduce Cell Numbers in Early- Vs. Late-Stage Prostate Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0327-0339 4888 1:00:00 PM Therapies for Cancer Poster

Kathleen Glymph*1 and Aidar R Gosmanov2
1Univ of Tennessee Health Science Center, Memphis, TN, 2University of Tennessee Health Science Center, Memphis, TN

 

Introduction: Dopamine-secreting tumors are rare with only 135 cases reported in the literature since 1980. These tumors are generally extraadrenal paragangliomas. Diagnosis of these tumors is delayed due to low prevalence of hypertension or classic symptoms of typical catecholamine-producing tumors.

Case: A 66 year-old African American man presented to our Endocrinology clinic for evaluation of an adrenal mass that was incidentally detected during computed tomography (CT) of chest ordered for assessment of a pulmonary nodule. The adrenal mass was 2.7 cm x 2.6 cm in size with characteristics suggesting possible pheochromocytoma. A fluorodeoxyglucose (FDG) positron emission tomography (PET)-CT was ordered and showed intense signal accumulation in the left adrenal mass with no other sites of activity. Outside plasma and urine laboratory data revealed mild elevation of normetanephrine, normal metanephrine, and mild elevation of dopamine levels.  Presumed diagnosis of pheochromocytoma was made. On our evaluation, the patient reported a 1-year history of unexplained anxiety, headaches, unintentional weight loss, and palpitations. His blood pressure was well-controlled on amlodipine 10 mg daily. Follow up studies ordered in our office showed free plasma normetanephrine of 1,409 (82-500pg/ml), metanephrine of 315 (45-290pg/ml), norepinephrine of 1295 (0-874 pg/ml), epinephrine of 12 (0-62 pg/ml), and dopamine of 74 (0-48 pg/ml). Fractionated 24-hr urine total catecholamines revealed norepinephrine of 149 (0-135 µg/24h), epinephrine of 9 (0-20 µg/24h), and markedly elevated dopamine of 1,753 (0-510 µg/24h). He underwent surgical resection of the left adrenal tumor. Pathology showed left pheochromocytoma measuring 3.2 cm x 2.8 cm confined to the adrenal. The tumor stained positive for synaptophysin and chromogranin A. Of note, postsurgical laboratory done 2, 6, and 11 months after resection, demonstrated normal plasma epinephrine and persistent mild elevation of norepinephrine (820 to 1464 pg/ml) and dopamine (49 to 133 pg/ml). However, PET-CT done 6 months after surgery showed no abnormal FDG accumulation in any parts of the body. Despite these increases in catecholamine levels post-operatively, the patient is clinically stable, has well-controlled hypertension and no new symptoms.

Conclusion: Even though dopamine-secreting tumors are rare, they tend to have an atypical clinical presentation, absence of hemodynamic abnormalities, increased potential for malignancy and recurrence, and need to be included in the differential diagnosis of all patients with suspicion of neuroendocrine tumors or pheochromocytoma. Typical treatment options with alpha or beta blockade may not be advised in purely dopamine-secreting tumors due to possibility of hemodynamic collapse, which also highlights the importance of measuring dopamine level in those with suspected pheochromocytoma.

 

Nothing to Disclose: KG, ARG

16416 1.0000 MON-0309 A A Man with Persistent Elevation of Dopamine after Resection of Intaadrenal Pheochromocytoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

LeeAnn King* and Aime T Franco
University of Arkansas for Medical Sciences, Little Rock, AR

 

Thyroid cancer is the most common endocrine malignancy, and its incidence has doubled over the last 30 years. Genetic alterations leading to the activation of the MAPK signaling pathway are crucial for the initiation and progression of thyroid cancer, as evidenced by the high frequency of activating mutations in BRAF, HRAS, NRAS, RET and TRK. Interestingly, mutations in BRAF are observed in ~45% of papillary thyroid cancers (PTCs), while follicular thyroid cancer (FTC) is often associated with mutations of RAS family members. Similarly, we have shown that thyroid specific expression of HrasG12V and Pten inactivation leads to the development of FTCs and poorly differentiated thyroid cancer (PDTC) in HrasG12V/Ptenhom/TPO-cre mice while thyroid specific expression of BrafV600E and loss of Pten leads to the rapid development of PTC and PDTC in BrafV600E/Ptenhom/TPO-cre mice with completely lethality by weaning.  Recent evidence suggests that oncogenic mutations have the capacity to modulate the tumor microenvironment by regulating the expression of various tumor extracellular matrix (ECM) proteins. In order to understand whether activation of Braf versus Hras differentially impacts the tumor microenvironment, we derived stable cell lines from HrasG12V/Ptenhom/TPO-cre and BrafV600E/Ptenhom/TPO-cre tumors. Pathway profiling indicated a significant increase of Col1a1 mRNA in HrasG12V/Ptenhom   cells in comparison to BrafV600E/Ptenhom cells (p<0.0001) and wild type primary thyrocytes (p=0.0004). We confirmed these results via western blot and immunofluorescence analyses, which revealed increased expression of type I collagen (Col1) in both whole cell lysate and ECM derived from HrasG12V/Ptenhom cells. We sought to determine whether tumor derived ECM altered the behavior of tumor cells in culture. We observed increased filopodial formation and cytoskeletal rearrangements in BrafV600E/Ptenhom cells plated on ECM derived from HrasG12V/Ptenhom cells, suggesting that a Col1 enriched ECM may play a role in modulating cell motility. We hypothesize that tumor versus stromal derived Col1 has differential effects on tumor pathophysiology. Further, we hypothesize that Col1 is primarily tumor cell derived in FTC and stromal derived in PTC and that this contributes to the different pathophysiology of these tumor sub-types. We aim to translate these findings to the discovery of novel therapeutic strategies for thyroid cancer targeted against the modified tumor microenvironment.

 

Nothing to Disclose: LK, ATF

13051 2.0000 MON-0310 A Type I Collagen Is Differentially Regulated in Mouse Models of Follicular Vs. Papillary Thyroid Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Wei Qiang*1, Yuan Zhao2, Qi Yang1, Wei Liu1, Haixia Guan3, Si Qing Lv1, Meiju Ji1, Bingyin Shi1 and Peng Hou1
1The First Affiliated Hospital of Xi’an Jiaotong University School of Medicine, Xi'an, China, 2Shaanxi Provincial People's Hospital, Xi'an, China, 31st Affiliated Hosp of China Med, Shenyang Liaoning

 

As a zinc finger transcription factor, ZIC1 is involved in vital development processes. Recently, its dichotomous role in tumorigenesis has also been revealed. ZIC1 has been reported to be overexpressed and play an oncogenic role in some brain tumors, whereas inactivated by promoter hypermethylation and act as a tumor suppressor in gastric and colorectal cancers. The aim of this study is to explore the biological functions and related molecular mechanism of ZIC1 in thyroid carcinogenesis. Using quantitive RT-PCR and methylation-specific PCR, we first found that ZIC1 was frequently down-regulated by promoter hypermethylation in both primary thyroid cancer tissues and thyroid cancer cell lines. Moreover, the association of ZIC1 hypermethylation with clinicopathologic characteristics was analyzed in 178 papillary thyroid cancer (PTC)s and ZIC1 hypermethylation was found significantly associated with lymph node metastasis in PTC patients (p=0.026). The functions of ectopic ZIC1 expression in thyroid cancer cells were further studied. Restoration of ZIC1 expression in thyroid cancer cells inhibited cell proliferation, colony formation, migration and invasion, and induced G0/G1 cell cycle arrest as well as apoptosis. To explore the underlying mechanisms, major signaling pathways of thyroid cancer were assessed. We found that ZIC1 acted as a tumor suppressor through blocking the activities of the phosphatidylinositol-3-kinase (PI3K)/Akt and RAS/RAF/MEK/ERK (MAPK) pathways.We also found ZIC1 exert its tumor suppressing function partially via enhancing the transcriptional activity of FOXO3a and transcriptionally regulating its cell cycle-related targets including p19, p21, p130 and cyclin D1, as well as its apoptosis-related targets Bim and TRAIL.Our data demonstrated that ZIC1 was frequently inactivated by promoter hypermethyaltion and functions as a tumor suppressor in thyroid cancer through modulating PI3K/Akt and MAPK signaling pathways and transcription factor FOXO3a.

 

Nothing to Disclose: WQ, YZ, QY, WL, HG, SQL, MJ, BS, PH

15398 3.0000 MON-0311 A ZIC1 Is a Putative Tumor Suppressor in Thyroid Cancer By Modulating Major Signaling Pathways and FOXO3a 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Justyna Kulpa*1, Radia Ouelaa Benslama2, David Laperrière1, Christine Tibolla2 and Sylvie Mader1
1Universite de Montreal, Montreal, QC, Canada, 2Institute for Research in Immunology and Cancer (IRIC), Montreal, QC, Canada

 

The process of human mammary epithelial cell (HMEC) immortalization is still poorly understood, but likely involves the cooperation of several events affecting key tumor suppressor/oncogenic pathways. Two immortalized cell lines (184A1, 184B5) were previously derived from a single culture of normal breast epithelial mammary cells by treatment with the mutagenic polycyclic aromatic hydrocarbon Benzo(a)Pyrene (B(a)P). In this study, next-generation exome and transcriptome sequencing (Illumina HiSeq2000) of 184A1 and 184B5 cell lines was performed to identify mutations that may have contributed to the immortalized phenotype. CNV and SNV analysis confirmed the reported pseudo-diploïd nature and clonal origin of each cell line. We identified 97 mutations unique to 184A1 and 77 mutations present only in 184B5 cells, and thus likely not present in the normal parental tissue. A predominance of G-T transversions, characteristic of the B(a)P mutational signature, supported the hypothesis that these mutations were introduced during the mutagenesis step. While most mutations were heterozygous, a few homozygous non-synonymous mutations also found in the transcriptome were characterized, affecting 2 genes (CUL3, DYNC2H1) in 184B5 and 6 genes (ARHGAP32, CDKN2A, HCAR2, NFKBIE, PRPF19, USP28) in 184A1. A homozygous missense mutation (G283V) in the ubiquitin protein ligase cullin-3 correlated with higher levels of the protein in 184B5 cells and increased ubiquitination of its target antioxidant response transcription factor Nrf2, which participates in cytoprotective responses to B(a)P. In 184A1 cells, a stop-gain mutation of the deubiquitinase USP28 (E331X), which plays a role in the DNA-damage response, correlated with absence of the protein product. Stable suppression of USP28 expression in HMEC cells by shRNA prolonged survival of these cells past the senescence crisis, suggesting that this mutation contributed to cell immortalization. Systematic sequencing of carcinogen-immortalized or transformed cells is expected to yield novel insights into the signaling pathways that contribute to cancer initiation.

 

Nothing to Disclose: JK, RO, DL, CT, SM

13111 4.0000 MON-0312 A Next-Generation Exome and Transcriptome Sequencing Identifies Possible Mechanisms of Human Mammary Epithelial Cell Immortalization 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Akitoshi Nakayama*1, Sawako Suzuki1, Hidekazu Nagano1, Naoko Hashimoto1, Masanori Fujimoto1, Eri Komai1, Akina Shiga1, Yutaka Suzuki2, Sumio Sugano2, Koutaro Yokote1 and Tomoaki Tanaka1
1Chiba University Graduate School of Medicine, Chiba, Japan, 2Graduate School of Frontier Sciences, The University of Tokyo, Tokyo, Japan

 

Tumor suppressor p53, implicated in the pathogenesis of a wide variety of tumors including endocrine neoplasm as well as hormone sensitive tumors such as breast cancer, receives multiple forms and diverse range of stress signals such as DNA damage, oxidative or metabolic stress, and then initiates different cellular outcomes including cell-cycle arrest, apoptosis or metabolic functions through transactivation of target genes. In addition, p53 has also been shown to exert the repressive function for oncogenic signals, angiogenesis and cancer invasion. While how p53 achieves the transactivation is well characterized, the mechanism underlying transcriptional repression is still unclear. To identify transcriptional repression genes regulated by p53 and elucidate its mechanism we performed RNA-seq, AcH3 ChIP-seq and ChIP assay analysis using HCT116 p53+/+ and -/- cells and examined the effect of p53 silencing as well as Trichostatin A (TSA), a HDAC inhibitor. RNA-seq analysis displayed that 280 of p53-depdent repression genes were identified under non-stressed conditions, 1218 after daunorubicin treatment in HCT116 cells. Among them, we intriguingly found SLC19A1 and MT1F as repressive targets, possibly through p53-dependent regulation of histone acethylation.  SLC19A1 is known as a reduced folate carrier (RFC) for main cellular transport systems of reduced folate in the cellular membrane. SLC19A1 also actively transports antifolate chemotherapeutic agents such as methotrexate (MTX) into cells. MT1F is a kind of the metallothioneins (MT). MT plays an important role in the regulation of transcription factor and its dysfunction or abnormal expression, which in turn, may lead to malignant transformation of cells.　Consistently, p53 knockdown by siRNA and TSA treatment restored the repression of SLC19A1 and MT1F expression in accordance with reasonable changes in acethylation of H3 on their locus, while some genes are repressed in AcH3 independent manner. Moreover, GEO database analysis showed that these genes are significantly upregulated in breast cancer patients with mutant-p53 and patients groups with high expression of these genes exhibit shortening cumulative survival in Kaplan-Meier analysis. Taken together, our data suggest that we have identified several p53-dependent repression genes, involved in prognosis in breast cancer patients and p53 exerts repressive function through multiple mechanisms including HDAC-dependent or independent pathways.

 

Nothing to Disclose: AN, SS, HN, NH, MF, EK, AS, YS, SS, KY, TT

16656 5.0000 MON-0313 A Repressive Function of Tumor Suppressor p53 and Its Concerns in Prognosis of Breast Cancer Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Rebecca Lopez*1, Rene Roberts2, Sushmita B Nandy3, Ramadevi Subramani Reddy2, Arunkumar Arumugam3, Thiyagarajan Boopalan4 and Rajkumar Lakshmanaswamy5
1Texas Tech University Health Sciences, El Paso, TX, 2Texas Tech University Health Sciences Center, El Paso, TX, 3Texas Tech University Health Sci, El Paso, TX, 4Texas Tech Univ, El Paso, TX, 5Texas Tech Univ Health Sci Ctr, El Paso, TX

 

Introduction:  Diabetes and obesity rates have skyrocketed worldwide and are both associated with increased risk and progression of many other fatal diseases, including breast cancer.  Today, breast cancer is the most common cancer affecting women and global breast cancer incidence is increasing at an alarming rate with a 20% increase already noted between 2008 and 2013 alone.  Thus, it is imperative to understand how diabetes/obesity increase the risk and progression of breast cancer.  In this regard, microRNAs (miRNAs) are increasingly recognized for their role in regulating a majority of signaling pathways implicated in disease pathology.

Methods:  We previously demonstrated that hyperglycemia alone induces leptin signaling and enhances cell growth in both non-tumorigenic and malignant breast epithelial cells.  To further elucidate the specific role of leptin under hyperglycemic conditions, non-tumorigenic MCF10A and malignant MDA-231 breast epithelial cells were treated with distinct glucose concentrations to mimic physiologically normal (5.5mM) and diabetic (10mM) levels of glucose in the presence and absence of leptin receptor inhibitor peptides. The effects of these treatments on miRNA expression profiles were assessed using SA Biosciences pathway focused breast cancer miRNA arrays.  Expression profiles of key miRNAs were further confirmed using RT-PCR.  In addition, the effect of high glucose on stem cell number was assessed via CD44/CD24 flow cytometric analysis.

Results: Within 72hr, diabetic glucose levels led to upregulation of various oncogenic miRNAs and downregulation of certain tumor suppressor miRNAs in both MCF10A and MDA-231 cells.  Concurrent treatment with leptin inhibitors significantly reversed these effects, implicating leptin signaling in the perturbation of miRNA expression profiles under hyperglycemia.  Intriguingly, in MDA-231 cells miRNA pathways involved in cell proliferation, migration, and invasion were primarily affected (miR1, miR10a/b, miR100, miR29b, miR129, miR18a).  In MCF10A cells both pathways involved in cell proliferation/migration/invasion and pathways involved in stem cell self-renewal were affected (miR10a/b, miR100, miR129, miR141, miR18a).  Moreover, diabetic glucose levels appear to increase the percentage of stem cells in both MCF10A and MDA-231 populations.

Conclusion: To our knowledge, we show for the first time that diabetic glucose levels alone contribute to breast cancer risk and progression through leptin-mediated:  1) downregulation of tumor suppressor miRNAs, 2) upregulation of oncogenic miRNAs, 3) differential regulation of miRNAs involved in stem cell self-renewal, and 4) enrichment of the stem cell population in both normal and malignant cells.

 

Nothing to Disclose: RL, RR, SBN, RSR, AA, TB, RL

16956 6.0000 MON-0314 A Hyperglycemia-Induced Leptin Signaling Enhances Expression of Oncogenic microRNAs and microRNAs Governing Stem Cell Self-Renewal in Normal and Malignant Breast Epithelial Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

John J Evans*1, Li Hui Tan1, Peter H Sykes1 and Maan M Alkaisi2
1University of Otago, Christchurch, Christchurch, New Zealand, 2University of Canterbury, Christchurch, New Zealand

 

The limitations in our ability to control cancer constitute a long-standing frustration. It has led to two USA presidents (R Nixon in 1971 and B Obama in 2009) to decree that substantial government resources be provided to the endeavour. It has been suggested that a major reason for the failure of medicine to prevail over oncogenic processes is that factors, other than genetic mutations, might be unrecognised. In this study, in which an endometrial adenocarcinoma cell line (Ishikawa) was investigated, we documented the effects on cell behaviour of a physical topography with cell-associated features in the microenvironment. We used in vitro methods in which culture substrates were polystyrene moulds of Ishikawa cells formed by a soft lithography technique for producing a polymeric replica of the cells with nano-scale resolution. Imprints of both negative (concave) and positive (convex) forms of the cells in an initial culture were manufactured. These imprinted replicas and flat polystyrene surfaces were used as platforms for cultures of Ishikawa cells. The behaviour of the cells were determined and compared on at least five independent occasions for relevant parameters. Relative to cells on flat surfaces, cells on positive-imprinted surfaces had higher expression of integrin (p<0.05), focal adhesion kinase (p<0.01), actin (p<0.05), and cytokeratin-18 (p<0.05), smaller cell size (p<0.01), and slower proliferation (p<0.05). Similar trends were observed on negative imprints but to a lesser extent.

The results demonstrated that cancer cells in an environment with features similar to their own exhibit modified activities compared to cells on flat surfaces without features.  Our method that incorporates genuine cell shapes is a notable advance on other technologies that have used lithographically generated geometric patterns as substrates. Further it isolates physical parameters from those involving chemical patterning of extracellular matrix. The observations are consistent with the physical microenvironment being important to tumour development. Therefore a future strategy in drug development may be profitably targeted at directly modifying the physical features of a tumour cell’s neighbourhood or, alternatively, indirectly interrupting the associated signalling pathways.

Our investigation reports effects on cancer cells of topographical, cell-associated features in the microenvironment, independent of biochemical factors.

 

Nothing to Disclose: JJE, LHT, PHS, MMA

13518 7.0000 MON-0315 A Topography of the Microenvironment Determines Cancer Cell Behaviour 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Lisa K Mullany*1, Yi Ren2, David C. Marciano3, Kwong-Kwok Wong4, Erin R King-Crane5, Panagiotis Katsonis2, Zhilin Liu6, Olivier Lichtarge2 and JoAnne S Richards7
1Baylor College of Medicine, MCB, Houston, TX, 2Baylor College of Medicine, Houston, TX, 3Baylor College of Medicine, Houston, 4The University of Texas MD Anderson Cancer Center, Houston, TX, 5The University of Texas at MD Anderson Cancer Center, Houston, TX, 6Baylor College of Med, Houston, TX, 7Baylor Coll of Med, Houston, TX

 

Analysis of the Cancer Genome Atlas (TCGA) data has revealed that TP53 is mutated in the vast majority (>90%) of high-grade ovarian cancers and thus is a determinant of at least some ovarian cancer subtypes. One sub-group, known as gain-of-function (GOF) mutants, occurs frequently (~13%) and, with other mutants, is over-represented (~23%) in ovarian cancer.  Because GOF mutants lack wild type TP53 activity and have gained oncogenic functions, they are highly resistant to existing cancer therapies, explaining the poor clinical outcomes. The functional activity of many other mutations remains unknown. Unexpectedly, and contrary to existing dogma, most (56-72%) of the human ovarian cancer cells that express these GOF, and other mutants, also express one wild type TP53 allele. This provocative evidence provides a new paradigm: the functions of TP53 mutants need to be tested not only in the absence, but also in the presence, of the wild type allele. Many ovarian cancers also express estrogen receptor alpha (ESR1) and/or the progesterone receptor (PGR), and TP53 regulates their expression and function. Strong evidence shows that steroids can impact the incidence and metastatic potential of ovarian cancer cells, but the functional relation between TP53 status and steroids remains vague.  To address these issues, we investigated the impact of different TP53 mutants using in vitro and in vivo approaches to 1) understand the biology of each TP53 mutant in the same genetic background and 2) determine the response of each mutant to specific anti-cancer drugs that target TP53, steroid receptors or oncogenic pathways.  Preliminary data indicate that several mutants that are over-represented in high-grade ovarian cancer retain TRP53 activity and are also sensitive to nutlin-3a when expressed in the mouse Pten/Kras Trp53 null cells.  Thus, nutlin-3a (or a similar small molecule) provides an exciting alternative treatment for human ovarian cancers that express mutants that retain TP53 activity. Conversely, Trp53 mutants that lack TRP53 activity (R172H, R248Q, R248W, R273H and Y220C) and are expressed in our Trp53 null cells are resistant to nutlin-3a. Moreover, cells that express one R172H allele and one wild type allele are also resistant to nutlin-3a indicating that one mutant allele is sufficient to block the effects of wild type TRP53 in this context. Additionally, estrogen-activity is elevated in cells depleted of TRP53 compared to cells expressing wild type or mutant TRP53 suggesting that TRP53 status may be a determinant of metastatic potential. Therefore, some high-grade ovarian cancers may be selectively responsive to anti-estrogen therapy.

 

Nothing to Disclose: LKM, YR, DCM, KKW, ERK, PK, ZL, OL, JSR

15965 8.0000 MON-0316 A Mutant P53 Is a Key Determinant of Ovarian Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Megan Emilie Patton*1, Sherwin Kelekar2 and Sayeepriyadarshini Anakk3
1University of Illinois at Urbana- Champaign, IL, 2University of Illinois at Urbana- Champaign, 3University of Illinois, Urbana, IL

 

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-associated mortality, affecting nearly twice as many men as women. Yes-associated protein (Yap) activation has been recently linked to the development of high risk, high mortality hepatocellular carcinoma in clinics. Yap, a transcriptional co-activator, controls genes involved in cell proliferation, including cyclin-D1, survivin, gli2, and ctgf.  We identified bile acids as upstream activators of Yap and have shown that excessive bile acid accumulation in mice resulted in spontaneous development of aggressive liver tumorigenesis that mimicked the gender-biased incidence observed clinically.

            Interleukin 6 and Foxa2, the known modulators of this gender-biased incidence were not altered in these mice. Also, this mouse model showed comparable Yap mRNA expression in both males and females. On the other hand, we observed a 50% decrease in serum bile acid levels in female mice implying that a reduction in Yap activation could possibly prevent these mice from developing liver cancer.

            Cyclin-D1, a Yap target, when overexpressed has been shown to stimulate estrogen receptor alpha (ERα) transcriptional activity and to increase serum estradiol levels. Consistent with this finding, ERα targets are induced in these mice, which exhibit excessive bile acid levels, Yap activation, and concomitant Cyclin D1 induction. In addition, these mice also exhibit decreased expression of Hsd3b5 and Srd51 similar to those observed in Cyclin D1 transgenic mice, indicating an alteration in sex steroid levels. Based on these findings we postulate that a Bile Acid-Yap-Cyclin D1-ERa axis may coordinate gender differences in HCC incidence.

 

Nothing to Disclose: MEP, SK, SA

16305 9.0000 MON-0317 A Bile Acids Contribute to Gender-Biased Occurrence of Hepatocellular Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Antongiulio Faggiano*1, Salvatore Tafuto2, Ferdinando Riccardi3, Lucia Tozzi4 and Annamaria Colao5
1University, Napoli, Italy, 2National Cancer Institute Fondazione G. Pascale of Naples, 3Cardarelli Hospital, Naples, 4Casa Sollievo della Sofferenza Hospital, San Giovanni Rotondo, 5University, Naples, Italy

 

Introduction: Somatostatin analogues (SSAs) have been demonstrated to have antiproliferative effects in ileal neuroendocrine tumours (NETs). The 2010 WHO NET classification provides a grading score which can be helpful to predict tumour response to SSA.

Objective: To evaluate the efficacy of long-acting SSA in NET pts according to Ki-67 score. Materials and Methods: An observational Italian multicentric study has been designed to collect data on NET pts under treatment with SSA. The observational data have been collected through an e-CRF and stored in a centralized computer database. Both retrospective data of pts in treatment with SSA from 2005 and prospective data of pts treated with SSA from March 2012 to November 2012 were included. Study population included 280 pts who have had a histological diagnosis of NET (77 thoracic, 80 pancreatic, 83 gastro-intestinal, 40 unknown primary tumors). Among these, 134 have been treated with octreotide LAR or lanreotide autogel. These form the basis of the statistical analysis. Ki-67 score was immunohistochemically evaluated in tumour samples and gradued according to WHO classification of NETs (G1= ki-67 score 0-2%, G2= ki-67 score 3-20%, G3= ki-67 score >20%).

Results: An objective tumour response was observed in 13%, stability in 53% and progression in 34%. Objective tumor response was significantly higher in G1 - G2 than G3 NETs (p<0.01), while not significantly different between G1 and G2. However, clinical benefit (including both objective response and stability) was significantly higher in G1 than G2 (p<0.05), as well as in GEP than in either thoracic or unknown primary NETs (p<0.05).

Conclusion: Therapy with SSAs is a remarkable antiproliferative therapeutic option in well differentiated low/intermediate-proliferating NETs, not only G1 but also in G2 type.

 

Nothing to Disclose: AF, ST, FR, LT, AC

15697 10.0000 MON-0318 A Anti-Tumor Efficacy of Somatostatin Analogues (SSAs) in Patients with Neuroendocrine Tumours (NETs) According to Ki-67 Score: A Multicentric Study from Elios (Educational Learning Investigational Observational Study) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Philippe Ruszniewski1, Martyn E Caplin2, Juan Valle3, Catherine Lombard-Bohas4, Graeme Poston5, Petros Perros6, Luboš Holubec7, Gianfranco Delle Fave8, Denis Smith9, Patricia Niccoli10, Pascal Maisonobe11 and Christine Massien*12
1Beaujon Hospital, Clichy, France, 2Royal Free Hospital, London, United Kingdom, 3Christie Hospital NHS Foundation Trust, 4Edouard-Herriot Hospital, Lyon, France, 5University Hospital Aintree, Liverpool, United Kingdom, 6Newcastle upon Tyne NHS Hospitals Trust, Newcastle Upon Tyne, United Kingdom, 7Teaching Hospital Plzen, Plzen–Bory, Czech Republic, 8Ospedale Sant’ Andrea, Rome, Italy, 9University Hospital of Bordeaux, Bordeaux, France, 10CHU Timone, Marseille, France, 11Ipsen Pharma, Boulogne-Billancourt, France, 12Ipsen Pharma, Boulogne Billancourt, France

 

Introduction:Clinical trials show somatostatin analogs (SSAs) improve CS symptoms. SSA impact on patients’ treatment satisfaction and its possible predictors in real-world settings, however, needs further study.

Methods: SymNET was a non-interventional, cross-sectional and retrospective study of patient-reported outcomes (PRO) after >3 months’ LAN for CS-related diarrhea in 273 NET patients (NCT01234168). At a routine clinic visit (=assessment visit, AV), patients reported their satisfaction with diarrhea control (primary endpoint) and flushing control, changes in diarrhea symptoms and their impact on daily activities. Potential predictors for satisfaction with diarrhea control were explored using data physicians provided from chart reviews.

Results: 58% (157/273) of patients were >60 years, mean (SD) time since diagnosis was 4.4 (4.5) years, 66% (176/267) had small-bowel primary tumors, and 80% (217/271) had liver metastases. Of 66% (179/271) who had undergone surgery for carcinoid tumors, 17% had had surgery on both primary tumor and liver metastases. At the AV, median LAN treatment duration was 11 months, 57% of patients were receiving ≥120 mg/month, and 64% had not had a LAN dose change during treatment. 76% [203/268] reported being “completely” or “rather satisfied” with diarrhea control (primary endpoint) and, of 54% [147/271] with flushing previously, 73% were satisfied with control. Among patients satisfied with diarrhea control, physicians reported improved daily stool frequency in 78% (150/193) and fewer stool urgency feelings in 63% (116/185). 79% (34/43) of these satisfied patients who had baseline stool leakage reported reduced stool leakage and 78% (54/70) reported reduced abdominal pain. Similar satisfaction rates were observed in patients who had surgery on both primary tumor and liver metastases (77% [24/31]) vs no surgery (79% [71/90]), and also for liver tumor load >25% (72% [36/50]) vs ≤25% (78% [80/102]). Rates of satisfaction with diarrhea control differed according to AV BMI: 63% (12/19) with <18.5 kg/m2 vs 89% (24/27) with ≥30 kg/m2. Potential predictors of satisfaction were initial stool leakage (odds ratio (OR)=0.31 p=0.03) and primary localization outside the small bowel (OR=2.10 p=0.04).

Conclusions: Patient satisfaction, based on PROs, with LAN for control of CS-related diarrhea is high and consistent with physician assessments. Factors such as stool leakage and primary tumor localization may be potential predictors of PRO.

 

Disclosure: PR: Speaker, Novartis Pharmaceuticals, Speaker, Ipsen, Researcher, Novartis Pharmaceuticals, Researcher, Ipsen, Consultant, Ipsen, My spouse is an employee, Ipsen. MEC: Consultant, Ipsen. JV: Consultant, Ipsen, Speaker, Ipsen. GP: Advisory Group Member, Ipsen. PP: Researcher, Ipsen. GD: Investigator, Novartis Pharmaceuticals, Researcher, Novartis Pharmaceuticals. PM: Employee, Ipsen. CM: Employee, Ipsen. Nothing to Disclose: CL, LH, DS, PN

15934 11.0000 MON-0319 A Patient-Reported Satisfaction with Diarrhea Control Associated with Lanreotide Autogel/Depot (LAN) Treatment for Carcinoid Syndrome (CS) Is High in Gastroenteropancreatic Neuroendocrine Tumor (NET) Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Martyn E Caplin1, Philippe Ruszniewski2, Marianne Ellen Pavel3, Jaroslaw B Cwikla4, Alexandria T Phan5, Markus Raderer6, Eva Sedlackova7, Guillaume Cadiot8, Lucy Wall9, Guido Rindi10, Alison Langley11 and Joelle Blumberg*12
1Royal Free Hospital, London, United Kingdom, 2Beaujon Hospital, Clichy, France, 3Charité University Medicine Berlin, Berlin, Germany, 4University of Warmia and Mazury, The Faculty of Medical Sciences, Olsztyn, Poland, 5University of Texas MD Anderson Cancer Center, Houston, TX, 6University Hospital, Vienna, Austria, 7First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic, 8Robert-Debré Hospital, Reims, France, 9Western General Hospital, Edinburgh, United Kingdom, 10Università Cattolica del Sacro Cuore, Rome, Italy, 11Ipsen, Les Ulis, France, 12Ipsen Innovation, Les Ulis, France

 

Introduction: The CLARINET core study showed that the long-acting somatostatin analog (SSA) lanreotide Autogel 120 mg significantly prolonged progression-free survival (PFS) vs placebo in patients with metastatic enteropancreatic neuroendocrine tumors (NETs) (p=0.0002). Median PFS was not reached with lanreotide vs 18.0 months with placebo. This study was the first randomized placebo-controlled trial investigating PFS with an SSA in a population that included patients with pancreatic NETs and those with grade G2 tumors (Ki-67 <10%). Here, we report PFS data and safety findings from the open-label extension to CLARINET.

Methods: Patients enrolled in CLARINET had: well/moderately differentiated non-functioning enteropancreatic NETs with Ki-67 <10%; no prior SSAs, or other medical therapies in last 6 months; documented disease progression status; metastatic disease. In CLARINET, patients were randomized to lanreotide Autogel 120 mg (n=101) or placebo (n=103) every 28 days for 96 weeks or until death/disease progression (according to RECIST 1.0). Lanreotide patients without progression and placebo patients with/without progression could then enter the single-arm (lanreotide Autogel) extension (NCT00842348). The primary objective of the extension study was safety and the main efficacy endpoint was PFS, defined as time from randomization (in core study) to death/disease progression.

Results: A total of 88 patients from the CLARINET core study (41 from lanreotide arm; 47 from placebo arm) participated in the extension. At core study enrollment, 96% of the extension-study patients did not have tumour progression; 38% had pancreatic primary tumors, 39% had midgut, and 8% hindgut. The median PFS for lanreotide, 32.8 months, was reached during the extension study. For the patients who had disease progression while on placebo in the CLARINET core study, median time to further progression with lanreotide in the extension was 14.0 months. During the extension, 27% who continued lanreotide vs 40% who switched to lanreotide had treatment-related adverse events (TRAE). The most frequent TRAE was diarrhea. No new safety concerns were identified in the extension.

Conclusions: CLARINET extension data suggest there were antitumor effects with lanreotide Autogel in enteropancreatic NET patients with progressive disease. Long-term safety/tolerability of lanreotide in the extension was consistent with its known profile.

 

Disclosure: MEC: Consultant, Ipsen. PR: My spouse is an employee, Ipsen, Consultant, Ipsen, Researcher, Ipsen, Researcher, Novartis Pharmaceuticals, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals. MEP: Consultant, Ipsen, Consultant, Pfizer, Inc., Consultant, Novartis Pharmaceuticals, Consultant, Lexicon Pharmaceuticals, Inc., Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Speaker, Pfizer, Inc., Speaker, Lexicon Pharmaceuticals, Inc., Researcher, Novartis Pharmaceuticals. JBC: Researcher, Ipsen. ATP: Principal Investigator, Ipsen. MR: Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Speaker, Roche Pharmaceuticals, Speaker, Pfizer, Inc., Speaker, Bayer, Inc., Speaker, Celgene. GC: Consultant, Ipsen, Consultant, Novartis Pharmaceuticals, Consultant, Keocyt, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Speaker, Keocyt. GR: Consultant, Ipsen, Consultant, Novartis Pharmaceuticals, Consultant, Pfizer, Inc., Consultant, Advanced Accelerator Applications, Speaker, Ipsen, Speaker, Novartis Pharmaceuticals, Speaker, Pfizer, Inc.. AL: Consultant, Ipsen. JB: Employee, Ipsen. Nothing to Disclose: ES, LW

16840 12.0000 MON-0320 A Lanreotide Autogel/Depot Shows Antitumor Effects in Patients with Metastatic Enteropancreatic NETs: Results of the Clarinet Extension Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Giampaolo Trivellin*1, Fabio R Faucz2, Anelia Dafinova Horvath1, Isaac Levy1, Beata Bak3, Paraskevi Xekouki1, Eva Szarek1, Evgenia Gourgari1, Allison D Manning2, Rodrigo Bertollo de Alexandre1, Emmanouil Saloustros1, Yu Sun4, Maria V Nesterova1, Jan M. Wit4, Daniel J. Bernard3 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2National Institutes of Health, Bethesda, MD, 3McGill University, Montreal, QC, Canada, 4Leiden University Medical Center, Leiden, Netherlands

 

Background: The immunoglobulin superfamily, member 1 (IGSF1) is a well-conserved gene, located at Xq26.2, which encodes a plasma membrane glycoprotein. IGSF1 is expressed at high levels in Rathke’s pouch and the adult anterior pituitary gland. IGSF1 mutations were observed in humans with congenital central hypothyroidism and testicular enlargement (1). Igsf1 knockout mice were similarly centrally hypothyroid, perhaps secondary to reduced pituitary TRH receptor expression, and exhibited increased body mass.

Aim of the study: To investigate if IGSF1 has a causative role in gigantism/acromegaly in humans.

Patients and methods: We sequenced for IGSF1 germline mutations in 19 patients with gigantism and in 92 healthy controls. The impact of an identified variant on protein expression was then studied by in silico analyses, immunohistochemistry, transient transfection of GH3 cells followed by GH ELISA, pulse-chase, and trafficking analyses in HEK293 cells.

Results: We identified the p.N604T (c.1811A>C) variant in one male patient. This variant, which was previously reported in a family presenting with central hypothyroidism and testicular enlargement, is predicted to be damaging by in silico analyses. The same variant, however, was also observed in two controls. Increased IGSF1 immunostaining was observed in the GH-secreting tumor of the patient harboring the variant compared to both a mutation-negative somatotropinoma and a normal pituitary. Overexpression of p.N604T in GH3 cells did not significantly increase GH secretion compared to wild-type IGSF1. Both wild-type and mutant IGSF1 proteins exhibited the same pattern of maturation, stability, and membrane expression levels in HEK293 cells.

Conclusions: Our results do not support a causative role for IGSF1 in pituitary tumor development but the increased expression of mutant IGSF1 may indicate that IGSF1 works as a modifier gene during oncogenesis.

 

Nothing to Disclose: GT, FRF, ADH, IL, BB, PX, ES, EG, ADM, RBD, ES, YS, MVN, JMW, DJB, CAS

13310 13.0000 MON-0321 A IGSF1 As a New Modifier Gene Involved in Pituitary Adenoma Formation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Renata Costa Camargo*, Clarissa Silva Martins, Fabiano Pinto Saggioro, Luciano Neder, Helio Rubens Machado, Ayrton C. Moreira and Margaret De Castro
Ribeirao Preto Medical School - University of Sao Paulo, Ribeirao Preto, Brazil

 

Introduction: Genes involved in proliferation and apoptosis regulated by ribosomal proteins (RPs), which have been linked to tumorigenesis, might be involved in the pathogenesis of pituitary tumors.

Objective: To evaluate in somatotropinomas the expression of genes encoding RPs (RPS3 and RPL11) and cell cycle regulators (BTG2, MDM2, RB1, TP53, E2F, CDK2, CDK4/6, CCNE1, and CCND1) and their association to clinical findings.

Methods: We studied human normal pituitaries (n=7) and GH-secreting pituitary tumors (n=18). Clinical data was collected. In addition, cell cultures were performed using normal rat anterior pituitary cells and rat somatotroph tumoral lineage (GH3). RNA was isolated by TRIzol and gene expression assessed by qPCR. Mann-Whitney or Kruskal-Wallis test was used for continuous variables and Fisher Exact test for categorical data.

Results:  We observed no differential expression of RPS3, RB1, TP53, MDM2, CDK6 CCND1, and E2F1 in somatotropinomas compared to normal pituitaries. We observed underexpression of BTG2 (p=0.001), CDK4 (p=0.008), and RPL11 (p=0.02) in somatotropinomas. The CCND1 gene tended to be underexpressed in GH-secreting pituitary adenomas compared to normal pituitaries (p=0.08). In somatotropinomas, BTG2 underexpression was associated with lower IGF-1 levels (p=0.04) and E2F1 underexpression with higher IGF-1 levels (p=0.04). CDK6 underexpression was associated with lower basal GH levels (p=0.02) and tended to correlate to lower post-oGTT GH levels (p=0.06) and smaller tumor size (p=0.06). BTG2, RB1, CCND1, CDK4, CDK6, RSP3 and RPL11 genes, which were differentially expressed in vivo, were also analyzed in vitro using GH3 tumor cell line. There was no differential expression of RPS3, RPL11, and BTG2 either among four passages of GH3 lineage culture or 24 hours normal anterior pituitary primary culture. RB1, CDK2, CDK4, and CCNE1 were overexpressed in three passages of GH3 lineage compared to primary culture (p<0.01). CDK6 was underexpressed in the first two passages of GH3 lineage culture compared to primary culture (p<0.05). CCND1 gene was expressed in primary culture but not in GH3 lineage cells. Conclusion: Our data suggest differential gene expression in somatotropinomas, which was not reproduced by the GH3 lineage, probably due to molecular disruption caused by culture immortalization. Data on somatotropinomas suggest a deregulation of genes involved in cell cycle regulation, which might contribute to their pathogenesis. However, the mechanism seems not to be dependent of RPS3, CCND1 or P53 pathway as the main regulators.

 

Nothing to Disclose: RCC, CSM, FPS, LN, HRM, ACM, MD

15159 14.0000 MON-0322 A Assessment of Genes Involved in Controlling CELL Proliferation and Apoptosis in the Molecular Pathogenesis of GH-Secreting Pituitary Adenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Joanne Adaway*1, Rebecca Dobson2, Jennifer S Walsh3, Phillip Monaghan4, Neil Devlin5, Daniel Cuthbertson6, Juan Valle4 and Brian G. Keevil7
1University Hospital of South Manchester, Manchester, United Kingdom, 2Aintree University Hospital NHS Foundation Trust, 3University of Sheffield and Sheffield Teaching Hospitals NHS Foundation Trust, 4Christie Hospital NHS Foundation Trust, 5University of Manchester, 6University of Liverpool, Liverpool, United Kingdom, 7Univ Hospital of South Manchester, Manchester, United Kingdom

 

Background:  5-hydroxyindole acetic acid (5-HIAA) (a metabolite of serotonin) is used as a marker for patients with serotonin-secreting neuroendocrine tumours.  Currently, most laboratories measure 24 hour 5-HIAA excretion in urine samples.  Urine collections are cumbersome for the patient and impact on their daily activities; they are consequently often poorly performed, leading to over- or under-collection of urine and inaccurate 5-HIAA excretion results.  Furthermore, large volumes of urine present a health and safety challenge to processing laboratories, especially as hydrochloric acid is added to the urine bottles to act as a preservative. We compared urinary and serum 5-HIAA using previously published LC-MS/MS methods to assess whether serum 5-HIAA could replace urinary 5-HIAA estimation in the diagnosis and monitoring of neuroendocrine tumours.

Methods:  We measured 5-HIAA in 233 paired serum and urine samples from 26 healthy volunteers and 151 patients with known neuroendocrine tumours. 

Results:  The results were expressed as a percentage of the reference range and linear regression showed a correlation coefficient of 0.64 with a Passing Bablock regression equation of Serum 5-HIAA = 1.41 x urine 5-HIAA-25.8  Bland Altman analysis showed a proportional positive bias in the serum 5-HIAA results, with the bias increasing with the 5-HIAA concentration.  We also looked at the clinical sensitivity and specificity of the test in this population, excluding 20 patients diagnosed with non-functioning neuroendocrine tumours.  The sensitivity of urine 5-HIAA in this population was 75.8%, with a specificity of 96.2%.  The sensitivity of serum 5-HIAA was superior to this at 80.3%, and the test had a specificity of 100%. 

Conclusion:  We have demonstrated a strong correlation between serum and urine 5-HIAA results.  In patients with 5-HIAA concentrations above the reference range, the increase in serum 5-HIAA is greater than that of urinary 5-HIAA, indicating that serum 5-HIAA may be preferable in the diagnosis and monitoring of neuroendocrine tumours.  The clinical sensitivity of serum 5-HIAA is superior to that of urine 5-HIAA, as is the specificity.  Furthermore serum 5-HIAA measurement offers greater patient convenience, as 5-HIAA is stable in blood for 24 hours so samples can be easily taken in the community and sent to the lab for analysis.  This data supports the assertion that serum 5-HIAA is a better test than urine 5-HIAA for the diagnosis and monitoring of neuroendocrine tumours.

 

Nothing to Disclose: JA, RD, JSW, PM, ND, DC, JV, BGK

13760 15.0000 MON-0323 A Serum 5-Hiaa - a Better Marker of Neuroendocrine Tumour Than Urine 5-Hiaa 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Joanne Adaway*1, Miguel Debono2, John Newell-Price3 and Brian G. Keevil4
1University Hospital of South Manchester, Manchester, United Kingdom, 2University of Sheffield, Sheffield, United Kingdom, 3Univ of Sheffield, Sheffield, United Kingdom, 4Univ Hospital of South Manchester, Manchester, United Kingdom

 

Background: Plasma 5-hydroxyindole acetic acid (5-HIAA) measurement is used in the diagnosis and management of patients with serotonin-secreting neuroendocrine tumours.  In order to calculate the reference change value of an assay, i.e. the amount by which a result must change to be significant when monitoring the efficacy of treatment of these patients, it is important to know the biological variability of the analyte, so we carried out a study to determine this.

Methods: Plasma was collected from 37 post-menopausal women beyond the age of 50 whose last menstruation was more than one year prior to study start. Subjects attended the Clinical Research Facility in the Centre for Biomedical Research, Sheffield Teaching Hospitals NHS Foundation Trust between 0800h and 0930h after having fasted overnight. Eight samples were collected over 4 to 8 weeks with a day interval of 6 days (IQR 4 – 7days). Their mean (SD) age was 69.2 (6.8) years, 71.7 (12.1) kg and BMI 27.7 (4.2kg/m2).

Subjects diagnosed with or being treated for malignancy in the last 5 years, on oestrogen replacement or glucocorticoids in the last 6 months, chronic alcoholism (> 21 units of alcohol/week), chronic renal disease (eGFR <30ml/min/1.73m2), diabetes and on-going inflammatory diseases were excluded.

Plasma samples were centrifuged at 3000rpm for 15 minutes at 4oC within 30 minutes of sampling. They were stored at a temperature of -80oC prior to analysis by LC-MS/MS.

Results: The analytical CV of the assay used was 4.9%.  The mean inter-individual CV was 29.47%, the mean intra-individual CV was 13.46%, giving an overall variance of 32.77%.  The reference change interval for plasma 5-HIAA is 23.8 nmol/L.

 

Conclusions:  Determination of the biological variation in plasma 5-HIAA has enabled us to calculate that the minimum significant change in this assay is 23.8 nmol/L.  This will be of use when monitoring the treatment of patients with serotonin secreting neuroendocrine tumours.

 

Nothing to Disclose: JA, MD, JN, BGK

13887 16.0000 MON-0324 A Biological Variability of Plasma 5-Hiaa 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Tania Pilli*, Maria G Castagna, Fabio Maino, Carla Fioravanti, Fausta Sestini, Letizia Pasqui, Carlo Scapellato, Renato Scarinci, Gabriele Cevenini, Alice Cannoni and Furio Pacini
University of Siena, Siena, Italy

 

Introduction: MEN2 children carrying germline RET mutation are candidate to prophylactic thyroidectomy, whose timing is based on the mutation associated risk status and on the calcitonin (CT) levels. However the reference range for serum CT in children and adolescent is not clearly defined. Objectives: Aim of this study was to establish the reference range for serum CT in newborn, children and adolescents up to 16 years. Patients and Methods: Serum samples were available in a total of 776 children (407 girls and 369 boys) equally distributed in each age-years. Samples were collected in the out-patient paediatric clinic in children undergoing blood testing for any medical condition not affecting serum CT levels. We also evaluated 32 cord blood samples. Serum CT levels were measured by a commercially available two-site chemiluminescence immunometric assay (analytic sensitivity 2.0 pg/ml). Reference ranges were calculated using the Gole and Green LMS methods. Results: A negative correlation between CT values and age was observed in both sex (females: r = 0.39, p < 0.0001; males: r = 0.33 p <0.0001). The age related reduction of CT was more significant before 3 years of age: at one year CT values ranged from <2.0 pg/ml (-2SD) to 12.82 pg ml (+2SD), at 2 years of age CT values ranged from <2.0 pg/ml (-2SD) to 9.84 pg/ml (+2SD) and at 3 years of age CT values ranged from <2.0 pg/ml (-2SD) to 7.56 pg/ml (+2SD). After 3 years of age the progressive fall in the levels of CT was less significant and at 16 years CT values ranged from <2.0 pg/ ml (-2SD) to 4.68 pg / ml (+2SD). The same trend was observed when we evaluated males and females, separately. CT levels in cord blood samples were similar to the first year-levels (6.3±4.7 pg/ml and 5.1±5.9 pg/ml, respectively, p=0.06). Conclusions: In conclusion, the evidence of the age related CT levels suggests the need to use specific reference ranges for serum CT measurement in children and adolescents (0-16 years). These data may be used to interpret the results of serum CT in children at risk of MEN 2 pedigree.

 

Nothing to Disclose: TP, MGC, FM, CF, FS, LP, CS, RS, GC, AC, FP

15769 17.0000 MON-0325 A Reference Range of Serum Calcitonin in Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Bingfang Yue*, Tiedong Guo and Loan Nguyen
NMS Labs

 

Catecholamines (dopamine, norepinephrine/noradrenaline and epinephrine/ adrenaline) act as neurotransmitters or hormones in both neuronal (central and peripheral) and non-neuronal tissues. The involvement of catecholamines in multiple regulatory systems and metabolic processes supports their use as biomarkers for the clinical diagnosis, therapy and prognosis of several neuroendocrine and cardiovascular disorders. Catecholamines exist in biological samples at extremely low concentrations and are chemically unstable, prone to spontaneous oxidation and decompose easily at high pH. The quantification of catecholamines demands specific and very sensitive bioanalytical methods. The current standard method of choice is HPLC with electrochemical (EC) detection, despite time consuming sample preparation, long chromatographic runtime and low sensitivity severely limiting its use in biomedical research and clinical diagnosis. We intended to develop a simple, fast and sensitive 2D-LC-MS/MS method to measure three catecholamines in routine clinical laboratory setting.

Heparin plasma was cleaned up with double liquid-liquid extraction before the extract was derivatized and injected without further cleanup post derivatization. An API-5000 triple-quadrupole mass spectrometer (AB Sciex) is coupled to a Shimadzu HPLC system of two sets of binary pumps for 2D-LC-MS/MS. The API 5000 is operated in positive electrospray and multiple reaction monitoring (MRM) mode with two MRMs monitored for each analyte or internal standard.

The lower limit of quantitation (LLOQ) was validated at 5 pg/mL for each catecholamine with accuracy >89.3% and %CV < 10.43%, while the upper limit of quantitation (ULOQ) was validated at 1000 pg/mL for each catecholamine with accuracy >91.7% and %CV < 6.72%. Within-run CVs for three analyte were < 8.61% for three levels of QC samples while between-run CVs were <8.89%. The extraction recovery was ~60% and matrix effect was not observed. The correlations compared with a HPLC-EC method (EP Evaluator, Deming Regression, 99% confidence interval to exclude outliers) are as follows: norepinephrine, YLC-MS/MS = 1.023 * X HPLC-EC + 11.76, r =0.9967, n=32; Epinephrine, YLC-MS/MS = 1.036 * X HPLC-EC + 9.281, r =0.9957, n=36; dopamine, YLC-MS/MS = 0.961 * X HPLC-EC + 19.859, r =0.9738, n=31;

We developed and validated a simple and sensitive method to accurately quantify all three individual catecholamines in heparin plasma by 2D-LC-MS/MS, with a LLOQ of 5 pg/mL and a chromatographic run time of 5 min. This method is the most sensitive and the highest throughput to our knowledge, suitable for routine laboratory use.

 

Nothing to Disclose: BY, TG, LN

16369 18.0000 MON-0326 A Plasma Catecholamines - Sensitive Measurement By 2D-LC-MS/MS 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Monday, June 23rd 3:00:00 PM MON 0309-0326 4890 1:00:00 PM Neoplasia of Endocrine Tissues Poster

Pamela A. Cousounis*1, Kenneth R. Ginsburg1, Terri H. Lipman2, Andrew J. Cucchiara3 and Adda Grimberg4
1Children's Hospital of Philadelphia, Philadelphia, PA, 2Univ of Pennsylvania, Philadelphia, PA, 3Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, 4Children's Hosp Philadelphia, Philadelphia, PA

 

Background:Parental concerns play an integral role in deciding who receives growth evaluation and treatment. 

Objective:To examine parental concerns about growth in children and their impact on medical decision-making related to height using a four phase mixed qualitative-quantitative approach.

Methods:Parents of randomly selected children of any height, age 9-14 years, from nine primary care pediatric offices were recruited. In Phases 1 and 2, thirteen open focus groups with 71 parents (40 black, 31 white) and ten nominal group technique sessions with 63 parents (24 black, 39 white) were held to gather information about parental beliefs and attitudes regarding short stature and its medical treatment. Growth concerns expressed by the parent groups were incorporated into a quantitative survey. In Phase 3, a survey, available in English or Spanish, was completed anonymously during the summer of 2012 by parents of other children evaluated at four primary care pediatric offices (2 urban and 2 non-urban) affiliated with a tertiary care pediatric hospital. Recruitment was conducted without regard to height and age of the children.  In Phase 4, parents recruited from the same population used for the first two phases participated in twelve explanatory focus groups (39 black, 38 white parents) to explore the meanings and ramifications of the survey results.  

Results:  Parent groups expressed 22 distinct concerns that could influence a parent’s decision to seek medical care for a short child. 1820 surveys were completed (83% response rate; 1587 female, 231 male). Using a 5-point Likert scale, parents scored degree of impact that each concern would have on their decision to pursue evaluation or treatment if their child was short.   Research team consensus and factor analysis of parent responses led to organization of the 22 concerns into seven categories.  The mean Likert score of the individual concerns for each category was calculated as the summary score for that category.  The category rated as having the greatest effect on parental decision-making was treatment characteristics (including questions about prior research and results, and possible side effects), followed by, in descending order, categories of: health (physical pain or discomfort, clinician concern, and health issues are causing/caused by child’s short height), psychosocial functioning, physical appearance and adult success.  Comparison (child’s height relative to the growth chart or to their peers) and cultural/demographic features (family’s religious beliefs, child’s gender and race/ethnicity) had the least influence.

Conclusions: While psychosocial issues can influence decisions about short stature evaluation and treatment, parental concerns about medical treatment and the physical health of their children have the greatest impact on their decision-making.

 

Nothing to Disclose: PAC, KRG, THL, AJC, AG

12822 1.0000 MON-0136 A Parental Concerns about Growth in Children and Their Impact on Seeking Medical Evaluation and Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Chiara Guzzetti*1, Anastasia Ibba1, Sabrina Pilia1, Nadia Beltrami2, Natascia Di Iorgi3, Alessandra Rollo4, Giorgio Radetti2, Stefano Zucchini4, Mohamad Maghnie3, Marco Cappa5 and Sandro Loche1
1Ospedale Microcitemico, Cagliari, Italy, 2Ospedale Generale Regionale Bo, Bolzano, Italy, 3Univ of Genova/IRCCS Giannina, Genova, Italy, 4Univ Bologna, Bologna, Italy, 5Bambino Gesu Children's Hosp, Rome, Italy

 

Background:The diagnosis of GH deficiency (GHD) in children and adolescents is classically established when GH concentrations fail to reach a cut-off level (usually between 7-10 µg/L) after at least two provocative tests. These limits are arbitrary and do not take into account the type of test, nor the type of assay used to measure GH. 

Objective: The aim of this study was to define the optimal GH cut-offs to different provocative tests in children and adolescents with short stature.

Patients and methods: This was a retrospective study in 333 subjects who underwent GH secretion studies for short stature, after exclusion of other causes for their shortness. GH and IGF-I were measured by the same chemiluminescence assay in all samples (Immulite, Siemens). The patient group consisted of 115 patients (72 boys, 43 girls, aged 11.8±3.5) with an established diagnosis of GHD: 113 organic or genetic GHD and 2 with idiopathic GHD (age <10 years, with peak GH <8.0 µg/L in two provocative tests, H-SDS <-3 SDS and IGF-I SDS <-2 SDS). The control group consisted of 218 prepubertal children (120 boys, 98 girls, age <10 y) with a GH response to at least one provocative test >10 µg/L. The provocative tests used were Arginine (132 controls, 84 patients; Arginine was administered i.v. (0.5 g/kg, max 30 g) in 30 min and blood samples were collected every 30 min for 2h), Insulin Tolerance Test (ITT; 68 controls, 84 patients; Insulin was administered i.v. (0.1-0.15 U/kg) and blood samples were collected every 30 min for 2h), Clonidine (93 controls, 15 patients; Clonidine was administered orally (0.15mg/m2) and blood samples were collected every 30 min for 2h) and evaluation of Spontaneous nocturnal GH Secretion (SS; 64 controls, 24 patients; assessed with blood samples taken every 30 min for 12h; 20.00-08.00). All provocative tests were performed between 8.00 and 9.00 am after fasting overnight. Receiver operating characteristic (ROC) analysis and Likelihood Ratio (LR) were used to evaluate the optimal GH cut-offs and the diagnostic accuracy of the provocative tests.

Results: ROC analysis showed that optimal GH cut-off for Arginine test is 6.9 µg/l (Sensibility=75%, Specificity=81.1%, LR=3.96), for ITT is 5.1 µg/l (Sensibility=75%, Specificity=82.4%, LR=4.25), for Clonidine test is 8.6 µg/l (Sensitivity=80%, Specificity=93.6%, LR=12.4) and for SS is 11.7 µg/l (Sensitivity=83.3%, Specificity=79.7%, LR=4.1). IGF-I SDS has low accuracy in the diagnosis of GHD (AUC=0.68).  

Conclusions: The results of ROC analysis showed that the cut-offs limits which discriminate between normal and GHD differ according to the provocative tests. IGF-I is characterized by low diagnostic accuracy.

 

Nothing to Disclose: CG, AI, SP, NB, ND, AR, GR, SZ, MM, MC, SL

12642 2.0000 MON-0137 A A Reappraisal of the Cut-off Limits of the Peak GH Response to Stimulation Tests for the Diagnosis of GH Deficiency in Children and Adolescents 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Loyal Keating Coshway*1, Justin A Indyk2 and Sasigarn Arunchaiya Bowden1
1Nationwide Children's Hospital/The Ohio State University, Columbus, OH, 2Nationwide Children's Hospital, Columbus, OH

 

Background: Low dose ACTH stimulation test has been the test of choice to evaluate adrenocortical function in neonates with suspected ACTH deficiency. There is limited data about its sensitivity in diagnosing central adrenal insufficiency in this age group.

Clinical Cases: Case 1: A term female infant was evaluated at age 9 days for hypernatremia and diagnosed with diabetes insipidus and septo-optic dysplasia. Pituitary testing showed normal thyroid function (free T4 1.1 ng/dL [0.9-2.1], TSH 2.52 µIU/mL [1-12]) and normal peak cortisol of 36.2 µg/dL [defined normal >18] on a low dose ACTH stimulation test.  She was admitted at age 2 months for jaundice and hypoglycemia. Repeat ACTH stimulation test showed baseline cortisol <1 µg/dL, with peak cortisol of 8.6 µg/dL.  Repeat thyroid tests showed borderline low free T4 of 0.7 ng/dL [normal 0.7-1.8] with TSH 3.4 µIU/mL [0.8-8], and growth hormone 5.8 ng/mL at the time of hypoglycemia [defined normal >7.5 ng/mL].  She was then started on hydrocortisone, levothyroxine, and growth hormone.

Case 2: A term female infant was evaluated at age 10 days for persistent hypoglycemia.  A low dose ACTH stimulation test revealed a baseline cortisol at 10.9 µg/dL, with peak cortisol of 29.6 µg/dL. Thyroid function testing at age 16 days showed low free T4 0.7 ng/dL [0.9-2.1] and normal TSH 2.43 µIU/mL [0.9-10].  Growth hormone level was low at 2.8 ng/mL at time of hypoglycemia.  Both levothyroxine and growth hormone replacement were started.  A brain MRI revealed pituitary hypoplasia. A morning cortisol level drawn at age 21 days was 1.1 µg/dL.  Repeat ACTH stimulation test performed at age 22 days showed a baseline cortisol of 2.5 µg/dL and low peak cortisol of 11 µg/dL. The patient was then started on hydrocortisone.

Conclusions: In these 2 cases, a robust cortisol response on initial ACTH stimulation test obtained on 9-10 days of life provided a falsely reassuring assessment of the hypothalamic-pituitary-adrenal axis.  Repeat testing showed an inadequate response, necessitating adrenal replacement therapy. These cases raise awareness of false negative adrenal function test and the importance of repeating ACTH stimulation testing in infants with congenital hypopituitarism for timely diagnosis of ACTH deficiency.  Adrenal reserve provided by upregulation of fetal steroidogenic enzymes by placental CRH and pro-opiomelanocortin is a possible mechanism for a high cortisol response on initial testing.  Studies have shown that CRH directly induces transcription of fetal adrenal steroidogenic enzymes and cortisol production.  As CRH and pro-opiomelanocortin are produced by the placenta, normal fetal adrenal maturation may occur even in infants with pituitary dysfunction. We hypothesize that withdrawal of placental stimulation leads to adrenal atrophy and eventual failure of the low dose ACTH stimulation test in the neonatal period.

 

Nothing to Disclose: LKC, JAI, SAB

13953 3.0000 MON-0138 A Repeating ACTH Stimulation Test Is Necessary to Diagnose ACTH Deficiency in Neonatal Hypopituitarism with Initial False Negative Result 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Mirta Beatriz Miras*1, Laura Castro2, Silvia Edith Martin2, Constanza Pelliza2, Adriana Rebeca Boyanovsky3, Graciela Testa2, Liliana Muñoz3, Gabriela Sobrero1 and Liliana Silvano3
1Hospital de Niños de la Santisima Trinidad, Cordoba, Argentina, 2Hospital de Niños de la Santísima Trinidad. Córdoba, Argentina, 3Hospital de Niños de la Santísima Trinidad. Córdoba, Córdoba, Argentina

 

Background: Congenital Hypopituitarism (CHP) comprises a heterogeneous group of patients with isolated GH Deficiencies (IGHD) or combined with other pituitary hormone deficits (MPHD); their reported incidence is of 1/53.000 newborns. Clinical presentation is variable in severity and time. Early diagnosis can prevent damage to cognitive function or others resulting from associated deficiencies.

Objectives: To evaluate clinical signs and symptoms present at early life stages and analyze their relationships with hormone laboratory tests and diagnostic imaging in children with CHP.

Patients and methods: Forty nine patients were evaluated retrospectively: 27 females and 22 males that consulted before 3 years of age between 1999 and 2013.  

Results: The 49 patients with congenital GHD were divided into two categories: MPHD (33/49) and IGHD (16/49). The perinatal history revealed symptoms  such as hypoglycemia in 67% of MPHD. Of these, 59% had history of seizures; 53% of micropenis ; 39% of jaundice and 21% of cholestasis.  At diagnosis, patients with  multiple and isolated deficiencies showed -3.48 and -4.2 height SDS, respectively. All patients had GH deficiency,100% of  MPHD patients showed TSH deficiency, 51% ACTH deficiency, 36% Gonadotropins deficiency and 0.99% ADH deficiency. Brain MRI of patients with MPHD presented that 63% had hypoplastic adenohypophysis, absence of stalk and ectopic neurohypophysis versus 28.5% of patients with isolated somatotrophic deficiencies. Four patients showed dysgenesis of the corpus callosum and five optic nerve hypoplasia.

Conclusions: An early CHP diagnosis can be obtained with high accuracy based on a high clinical suspicion index.  

Characterization of GH- deficient patients by presence and type of hypothalamic- pituitary imaging abnormality provides valuable information for both physicians and families, regarding the likely severity of phenotype and potential for developing additional hormonal deficits.  Precise definition of different MRI phenotypes will become even more important as whole genome studies seek to identify additional causative genes for IGHD and MPHD.

Our results show that delayed diagnosis of an underlying endocrine disease predisposes these patients to higher morbimortality risk due to the combination of recurrent hypoglycemia, acute adrenal insufficiency, and secondary hypothyroidism.

 

Nothing to Disclose: MBM, LC, SEM, CP, ARB, GT, LM, GS, LS

16211 4.0000 MON-0139 A Congenital Hypopituitarism: Clinical, Biochemical and Neuroradiological Relationships 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Thais Kataoka Homma1, Rafael Estevão de Angelis1, Cristiane Kochi1, Eduarda Tebet Ajeje1, Marco Bonini Filho1, Davi Chen Wu1 and Carlos Alberto Longui*2
1Santa Casa SP, Sao Paulo, Brazil, 2Santa Casa SP School of Medical Sciences, Sao Paulo, Brazil

 

BACKGROUND: Headache is a common complaint in children, and its onset or worsening can occur during GH treatment, requiring differential diagnosis with idiopathic intracranial hypertension (IIH) (1). Complete ophthalmologic examination, angiography, SNCMRI and cerebrospinal fluid pressure measurement have been used to confirm the diagnosis. The availability of third-generation equipments and reference values for children (2), allowed the use of optical coherence tomography (OCT) as tool to identify IIH (3). AIM: To determine the retinal nerve fiber layer (RNFL) thickness measured by OCT in patients treated with GH. PATIENTS AND METHODS: 43 patients aged between 5.6 and 19.7 years, 24 boys and 19 girls, with no ocular disease, receiving GH for 1.83 (0.25-7.4) years. Clinically relevant headache was present in only 2 girls. Papilledema was detected by direct ophthalmoscopy in 18/43 patients (9M:9F). RNFL thickness were determined by using the OCT device TOPCON 3D OCT 1000, Japan. The RNFL results were corrected according to the reference values for age and expressed as SDS scores (2). RESULTS: Average RNFL: -0.67(±1.40); Superior RNFL: -0.87(±1.14); Temporal RNFL: -0.24(±1.3); Nasal RNFL 0.72(±1.8); Inferior RNFL 1.14(±1.1). There was no correlation of RNFL thickness with BMI, height, duration of GH therapy, GH peak or IGF1 values. Comparing patients with and without papilledema we found significant differences between the two groups, with higher values of average RNFL thickness (-0.17 vs 1.13; t test, p:0.016); nasal RNFL (1.5 vs 0.26; t test, p:0.029) and superior RNFL (-0.5 vs -1.27; t test, p:0.027) in the papilledema group. There was no correlation between clinical features and the presence of papilledema. The broad dispersion of RNFL thickness did not allow the definition of a cut off value to identify papilledema risk, although the majority of patients with papilledema had RNFL nasal values higher than zero SDS. Prospective studies comparing OCT RNFL values before and after GH therapy should discriminate better those patients under risk of relevant clinical papilledema. We concluded that OCT is a noninvasive method that can be used to identify incipient IIH in pediatric patients under GH therapy, allowing the selection of those who need invasive CSF measurement.

 

Nothing to Disclose: TKH, RED, CK, ETA, MB, DCW, CAL

13707 5.0000 MON-0140 A Optical Coherence Tomography (OCT) As a Tool to Identify Idiopathic Intracranial Hypertension in Pediatric Patients Under GH Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Tatiana Y. Tselovalnikova*, Alla E. Yudina, Maria G Pavlova and Alexey V. Zilov
Sechenov First Moscow State Medical University, Moscow, Russia

 

Aim: Medulloblastoma is curable in approximately 70 % of patients. Over the last few decades, progress in improving survival using conventional therapies has stalled, resulting in reduced quality of life due to treatment-related side effects. The aim of this study was to determine the prevalence of growth hormone (GH) deficiency (GHD) in adult survivors of medulloblastoma.

Methods: 31 medulloblastoma survivors (13 women, 18 men) were included.  All patients received craniospinal irradiation (CSI) up to 36 Gy and boost to the tumor up to 55 Gy and chemotherapy. The median age was 20 [18;22], age at the time of treatment – 12 [9;15], follow-up period was 5 years [2;10]. We measured insulin-like growth factor-1 (IGF-1), basal GH. Insulin tolerance test (ITT) were performed in 15 patients. Severe GHD was diagnosed if the value of peak GH in ITT< 3 ng/ml.
Results: Median of target height was 174 [166;177.5]. 14/30 patients were attained target height. 3 patients had been previously diagnosed with GHD, one of them received GH-replacement therapy for 6 years, but in spite of therapy his final growth was 157 cm and his target height was 185 cm +/-10 cm. Basal GH 0,34 ng/ml [0,151; 0,464], IGF-1 155 ng/ml [135; 219]. In 14 patients there were no significant peaks of GH in ITT - median level - 1.2 ng/ml [0,289; 2,26], which was rated as severe GHD.

Conclusions: The prevalence of GHD after complex treatment for medulloblastoma in childhood is extremely high more than 90%. This group of patients requires ITT after treatment for deciding on the timely appointment of replacement therapy.

 

Nothing to Disclose: TYT, AEY, MGP, AVZ

17026 6.0000 MON-0141 A Endocrine Outcomes in Patients after Complex Treatment for Medulloblastoma in Childhood: Growth Hormone Deficiency in Young Adults 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Henrik Thybo Christesen1, Birgitte Tønnes Pedersen2, Effie Pournara*3 and Pétur Benedikt Juliusson4
1Odense Univ Hosp, Odense, Denmark, 2Novo Nordisk A/S, Søborg, Denmark, 3Novo Nordisk Health Care AG, Zurich, Switzerland, 4University of Bergen, Bergen, Norway

 

The performance of the unifying multi-ethnic WHO growth standard for children below 5 years of age or of the WHO growth reference for older children has not been thoroughly tested in clinical practice.

To assess the impact of growth evaluation based on WHO vs. national growth charts in children with short stature, we analyzed height standard deviation scores (SDS) at baseline for children with growth hormone deficiency (GHD), born small for gestational age (SGA), or with Turner syndrome (TS) enrolled in the NordiNet® IOS according to both growth charts. Data were analyzed from 5440 children (GHD, n=3230; SGA, n=1460; TS, n=750; 21.4% <5 years old) from Czech Republic, Denmark, France, Germany, Netherlands, Norway, Sweden, Switzerland, and UK. The proportions of children below the clinical cut off values in height; -2 SDS for GHD and TS, and -2.5 SDS for SGA, were calculated using WHO vs. national growth charts. The equality of the proportions was evaluated by the Pearson chi-square test.

In most countries (7/9), fewer children across indications had height SDS below the cut off values with WHO vs. national growth charts. For children with GHD, the largest differences in the proportion of children with height <-2 SDS were observed in Norway and Sweden [WHO vs. national: 64% vs. 87% (p=0.007); and 72% vs. 95% (p<0.0001), respectively]; and a non-significant difference was observed in the UK (74% vs. 73%). In France, percentages of children with height <-2 SDS were higher using WHO vs. national growth charts (81% vs. 67%; p<0.0001).

For children born SGA, the largest difference in the percentage of children with height <-2.5 SDS calculated using WHO and national growth charts was seen in the Netherlands (WHO, 58%; national, 100%; p<0.0002), while in France, percentages of children with height <-2.5 SDS were higher using WHO vs. national growth charts (81% vs. 74%; p=0.027).

Similar trends across countries were observed in patients with TS.

Significant differences were shown in the percentage of those with height <-2 SDS in GHD or TS, and <-2.5 SDS in children born SGA, using WHO growth charts vs. national European growth charts. As height SDS values are used in the diagnosis and clinical decision making for initiating growth hormone treatment, the use of WHO growth charts may lead to a significant misclassification compared with the use of updated national growth charts in Europe.

 

Disclosure: HTC: Consultant, Novo Nordisk. BT: Employee, Novo Nordisk. EP: Employee, Novo Nordisk. PBJ: Consultant, Novo Nordisk, Speaker, Merck Serono.

11215 7.0000 MON-0142 A Differences in Height Standard Deviation Scores of Children Enrolled in Nordinet® IOS with Growth Hormone Deficiency, Born Small for Gestational Age, or with Turner Syndrome Using National Growth Charts Vs. WHO Growth Charts 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Pinchas Cohen*1, Debra Counts2, M. Jennifer Abuzzahab3, Ricardo Maamari4 and John Germak4
1University of Southern California, Los Angeles, CA, 2University of Maryland Medical Center, Baltimore, MD, 3Children’s Hospitals and Clinics of Minnesota, St. Paul, MN, 4Novo Nordisk Inc., Plainsboro, NJ

 

Prader-Willi syndrome (PWS) is a rare genetic disorder that causes prenatal growth retardation and short stature after birth. Additional characteristics commonly observed in PWS patients include obesity, low levels of serum insulin-like growth factor 1 (IGF-1), muscular hypotonia and hypogonadism. Childhood treatment of PWS patients with growth hormone (GH) has been approved by the FDA to improve growth failure observed in these patients. To assess the growth and auxological outcome of pediatric patients with PWS receiving GH treatment, this study analyzed data collected over 5 years in patients who were prescribed Norditropin® (somatropin [rDNA origin] injection, Novo Nordisk A/S, Denmark) at the discretion of their physicians. Collected data were entered by participating physicians into the American Norditropin Studies: Web-enabled Research (ANSWER) Program®, an observational study using the enhanced research Web-based platform, NovoNet®. Key baseline demographics from 124 pediatric GH-naïve patients with PWS were collected (53 males, 71 females, mean ± SD age 6.1 ± 4.7 years). These included height standard deviation score (HSDS), serum IGF-1 levels, BMI SDS and GH dose (mcg/kg/day). Cross-sectional data were analyzed for these characteristics over 5 years, with a visit window ± 3-month for each year. Longitudinal data were also evaluated for the changes in HSDS from baseline to 3 years. Both data sets showed a similar trend for HSDS in patients treated with growth hormone. Cross-sectional data showed a change in HSDS (-1.0 ± 1.3, n=124) to Year 5 (-0.2 ± 1.2, n=23). Longitudinal data demonstrated a distinct increase in HSDS (-1.7 ± 1.1, n=16) to Year 3 (-0.4 ± 1.1, n=16, p<0.001). Analysis of the cross-sectional data also showed fluctuations in mean BMI SDS, from baseline (1.8 ± 1.1) to Year 2 (1.5 ± 1.0), a return to baseline by Year 4 (1.7 ± 0.7), and then a downward shift at Year 5 (1.5 ± 0.9). There was a slight change in mean GH dose (mcg/kg/day), from baseline to Year 5 (from 33.1 ± 11.3 to 27.2 ± 11.9). In addition, the mean serum concentration of IGF-1 increased from 132.5 ± 172.2 ng/mL at baseline to 327.3 ± 164.6 ng/mL in patients treated for 18 to 30 months (p<0.001). The results from this observational study suggest that pediatric patients with PWS respond positively to growth hormone treatment with increases in mean HSDS and serum IGF-1 concentrations, and mild changes in BMI SDS. These findings were observed at mean GH doses within the FDA-approved range for PWS, and thus support the use of growth hormone in the treatment of children with PWS.

 

Disclosure: PC: Consultant, Novo Nordisk. RM: Employee, Novo Nordisk. JG: Employee, Novo Nordisk. Nothing to Disclose: DC, MJA

13657 8.0000 MON-0143 A A Positive Response to Growth Hormone Treatment By Pediatric Patients with Prader-Willi Syndrome: Five-Year Data from the Answer Program® 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Robert Rapaport*1, Peter A. Lee2, Judith L. Ross3, Paul Saenger4, Ricardo Maamari5 and John Germak5
1Pediatric Endocrinology and Diabetes, Icahn School of Medicine at Mount Sinai, New York, NY, New York, NY, 2Penn State College of Medicine, The Milton S. Hershey Medical Center, Hershey, PA, 3Thomas Jefferson University/duPont Hospital for Children, Philadelphia, PA, 4Winthrop University Hospital, Mineola, NY, 5Novo Nordisk Inc., Plainsboro, NJ

 

The ANSWER Program® is a non-interventional study of the clinical response of patients to Norditropin® treatment (somatropin [rDNA origin] injection, Novo Nordisk A/S, Denmark) as prescribed by their physicians in a real-world practice setting. Patients were enrolled at the discretion of their physicians after informed consent was obtained. The objective was to assess 2-year treatment outcomes among GHD and ISS patients who fulfilled birth weight (BW) and/or body length (BL) <-2 SD criteria for SGA defined in the 2007 consensus statement (1). 2850, 666 and 481 patients were diagnosed as GHD, ISS or SGA, respectively, by physician investigators. Patients were classified as to whether or not they also fulfilled SGA consensus criteria for SGA (+SGA or -SGA, respectively). BW and BL SD scores (BWSDS; BLSDS) were calculated based on sex and gestational age using the Usher-McLean method. Change in height SDS (ΔHSDS) was analyzed descriptively, as well as GH dose over 2 years. All data are presented as mean values.

14.7% (420) of GHD patients, 17.1% (114) of ISS patients and 84.4% (406) of SGA patients fulfilled the SGA criteria. The age at initiation of treatment was: 8.2 yr (SGA), 9.9 yr (GHD+SGA), 11.0 yr (GHD-SGA), 10.4 yr (ISS+SGA) and 11.2 yr (ISS-SGA). Of the patients who met the SGA criteria, 82% (GHD), 84% (ISS) and 85% (SGA) had BLSDS <-2, while 37% (GHD), 29% (ISS) and 76% (SGA) had BWSDS <-2. Both SGA criteria (BLSDS and BWSDS <-2) were met in 20% (GHD), 13% (ISS) and 61% (SGA) of patients classified as +SGA. BMISDS at enrollment for SGA patients was -0.8, compared with -0.1 for GHD+SGA and -0.2 for ISS+SGA. Baseline mean HSDS was -2.5 for SGA, -2.3 for GHD+SGA, -2.0 for GHD-SGA, -2.4 for ISS+SGA and -2.2 for ISS-SGA. ΔHSDS at Year 2 was 1.02 for SGA, 1.01 for GHD+SGA and 0.84 for ISS+SGA. Within each diagnostic group, ΔHSDS was similar between +SGA and -SGA patients: 1.01 for GHD+SGA and 1.05 for GHD-SGA; 0.84 for both ISS+SGA and ISS-SGA. The GH doses (mg/kg/day) at baseline and Year 2 were 0.053 and 0.052 for SGA, 0.047 and 0.052 for GHD, and 0.053 and 0.050 for ISS. For both GHD and ISS groups, GH doses at baseline and Year 2 were similar between +SGA and -SGA patients. Growth hormone treatment outcomes for GHD and ISS patients who were also born SGA (+SGA), were similar to that of the general GHD and ISS populations. ISS+SGA patients were older than SGA patients at the start of GHT. Recognition of SGA status in ISS patients may result in earlier diagnosis of SGA, younger age at GHT start and possibly better growth outcome. A birth history of SGA may also prompt further investigation into genetic or syndromic etiologies for short stature.

 

Disclosure: RR: Consultant, Novo Nordisk. PAL: Consultant, AbbVie, Speaker Bureau Member, AbbVie, Medical Advisory Board Member, Novo Nordisk, Consultant, Novo Nordisk. PS: Speaker, Novo Nordisk. RM: Employee, Novo Nordisk. JG: Employee, Novo Nordisk. Nothing to Disclose: JLR

13665 9.0000 MON-0144 A Growth Hormone Treatment in Pediatric Patients Diagnosed with Growth Hormone Deficiency (GHD) or Idiopathic Short Stature (ISS) Fulfilling Criteria for Small for Gestational Age (SGA): Results from the Answer Program® 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Bradley Miller*1, Peter A. Lee2, Judith L. Ross3, Susan R Rose4, Pinchas Cohen5, Ricardo Maamari6 and John Germak6
1University of Minnesota Amplatz Children's Hospital, Minneapolis, MN, 2Penn State College of Medicine, The Milton S. Hershey Medical Center, Hershey, PA, 3Thomas Jefferson University/duPont Hospital for Children, Philadelphia, PA, 4Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 5University of Southern California, Los Angeles, CA, 6Novo Nordisk Inc., Plainsboro, NJ

 

The ANSWER Program® is a non-interventional study of Norditropin® treatment (somatropin [rDNA origin] injection, Novo Nordisk A/S, Denmark) for US patients enrolled at the discretion of treating physicians after informed consent was obtained. The objective was to assess the impact of diagnosis and age at initiation of treatment on response to GHT in children with IGHD or ISS. 4818 IGHD (peak GH <10 ng/mL) and 885 ISS (peak GH ≥10 ng/mL) treatment-naïve children were categorized as “younger” (≤10 yrs for girls, ≤11 yrs for boys) and “older” (>10 yrs for girls, >11 yrs for boys) at treatment initiation. Cross-sectional data for height SD score (HSDS), insulin-like growth factor (IGF-I) SDS and GH dose of younger vs older patients at baseline and Years 1 and 2 were analyzed. Change in HSDS (DHSDS) was analyzed at Years 1 and 2. Comparisons for younger vs older patients were performed using t-test and presented as mean (±SD). At baseline, IGHD vs ISS patients had similar age (yrs) (11.1 vs 11.3, P=0.16), lower peak GH (ng/mL) (5.9 vs 17.3, P<0.001), but higher BMI SDS (-0.1 vs -0.4, P<0.001), HSDS (-2.0 vs -2.3, P<0.001) and target HSDS (-0.4 vs -0.7, P<0.001). Younger patients had greater baseline IGF-I SDS vs older patients with IGHD (-1.5±1.4 vs -2.0±1.6) and ISS (-1.2±1.5 vs -1.7±1.6) (P<0.001). The starting GH dose was lower in IGHD vs ISS patients (P<0.001). This difference was smaller and not significant at Years 1 and 2 (P>0.05). GH dose (mcg/kg/day) was lower for younger vs older IGHD patients at baseline (45.4±12.4 vs 47.4±11.5), Year 1 (43.6±17.5 vs 48.2±20.0) and Year 2 (42.4±20.7 vs 47.7±22.9) (P<0.001). GH dose was similar for younger vs older ISS patients at baseline (50.8±13.3 vs 50.3±10.6, P=0.55), significantly lower in younger ISS patients at Year 1 (44.5±18.6 vs 48.4±20.9, P=0.03) but not statistically different at Year 2 (45.4±22.0 vs 49.6±22.0, P=0.08). Younger patients had lower baseline HSDS vs older patients in IGHD (-2.2±1.0 vs -1.9±0.9, P<0.001) and ISS (-2.4±0.7 vs -2.2±0.7, P<0.001). HSDS for younger vs older patients at Years 1 and 2 were as follows for IGHD: -1.5±0.9 vs. -1.5±0.9 (Year 1) and -1.1±0.9 vs. -1.1±0.9 (Year 2), and as follows for ISS: -1.7±0.7 vs -1.8±0.7 (Year 1) and -1.5±0.7 vs. -1.5±0.7 (Year 2). Greater DHSDS was observed for younger vs older IGHD patients at Year 1 (0.8±0.5 vs 0.5±0.04) and Year 2 (1.2±0.6 vs 0.9±0.6) (P<0.001). Greater DHSDS was observed in younger vs older ISS patients at Year 1 (0.6±0.4 vs 0.4±0.3) and Year 2 (1.0±0.5 vs 0.8±0.5) (P<0.001). Lower HSDS at baseline but greater DHSDS at Years 1 and 2 were observed in younger vs older IGHD and ISS patients. The observation that IGHD patients had greater DHSDS than ISS patients is consistent with a degree of GH insensitivity in some ISS patients that potentially could be addressed by younger age at diagnosis and GHT start, as well as individual dose optimization up to FDA-approved doses for this indication.

 

Disclosure: BM: Principal Investigator, Novo Nordisk, Consultant, Novo Nordisk, Consultant, Genentech, Inc., Principal Investigator, Sandoz, Consultant, Sandoz, Principal Investigator, Versartis. PAL: Consultant, AbbVie, Speaker Bureau Member, AbbVie, Medical Advisory Board Member, Novo Nordisk, Consultant, Novo Nordisk. PC: Consultant, Novo Nordisk. RM: Employee, Novo Nordisk. JG: Employee, Novo Nordisk. Nothing to Disclose: JLR, SRR

13675 10.0000 MON-0145 A Impact of Diagnosis and Age at Initiation of Treatment on Response to Growth Hormone Therapy (GHT) in Children with Idiopathic Growth Hormone Deficiency (IGHD) and Idiopathic Short Stature (ISS) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Richard A Noto1 and Nathan Alan Lee*2
1New York Medical College, Valhalla, NY, 2New York Medical College

 

Background:

Diminished adherence to growth hormone replacement (GHR) has been shown to be a cause of poor response to GH treatment. The Easypod System (EPS) has been shown to be an easy reliable tool to track GH adherence. In this study we used the EPS to see if poor response to GHR was caused by poor adherence.

Methods:

To determine if unexplained PGR to GHR was caused by poor adherence we routinely switched patients GHR to the EPS where adherence to dose, date and number of injections can be easily tracked on a daily basis. For this study we reviewed our Saizen roster for patients switched to the ESP to determine adherence to GHR. Multiple parameters for each patient were recorded and tabulated.

Results:

12 patients, 10 males and 2 females, were found with complete data for an analysis. Their ages ranged from 10.3 to 17.0 years with a mean of 15.6+/- 1.9 yrs. and a median of 16.4 yrs. The age that they started GH ranges from 7 to 15 yrs. with a mean of 10.9 +/- 3.3 yrs. and a median of 11.25 yrs. The years on GH treatment range from 1.5 to 9 yrs with a mean of 4.5+/- 2.7 yrs. and a median of 3.75 yrs. Initial height percentile prior to starting GH range from the 1st to the 10th % with a mean percentile of 3.6+/- 2.45 with a median of 3.   Initial height percentile prior to starting EPS ranged from the 1st to 25th %. with a mean percentile of 10.1+/- 8.0 and a median of 10.  Ten patients had MRI studies of which 2 were read as normal 7 with small pituitary glands and 1 with a pituitary cyst.

Only one of the 12 patients acknowledged poor adherence prior to starting the EPS however, it turned out that 10 of the 12 patients were non adherent for the cause of poor growth. At the first visit the EPS demonstrated that 5 patients were not adherent to GHR. After confronting the non-adherent patients about compliance then only one patient remained non-adherent to GHR. 

The growth rate prior to starting EPS ranged from 0 to 6.8 cm/yr with a mean of 2.5+/- 2.4 cm/yr and a median of 2.5cm/yr. The growth rate on Saizen when patients were found adherent including the one continued non-adherent patient demonstrated a growth rate ranging from 0 cm/yr to 11.4 cm/yr. with a mean of 6.3+/- 3.6cm/yr and a median of 6.5cm/yr. This growth rate was significantly greater than the pre-Saizen value P<0.00.  The growth rates prior to becoming adherent for the four non adherent patients who eventually became adherent on Saizen ranged from 2.4 cm/yr to 4.4 cm/yr with a mean of 3.4+/-0.7 cm/yr and a median of 3.3 cm/yr with these growth rates not significantly greater from their pre-Saizen values P=0.29.  The one patient who was non adherent throughout the study period, as well as two poorly growing adherent patients discontinued GH.  GH and IGF-1 was not helpful in determining adherence.

Conclusions:

Adolescents with an unexplained poor growth response to GH treatment show a low rate of adherence to explain their poor growth.

 

Disclosure: RAN: Consultant, EMD Serono. Nothing to Disclose: NAL

13271 11.0000 MON-0146 A Unmasking Adherence As a Cause of Unexplained Poor Growth Response (PGR) in Adolescents Treated with Growth Hormone (GH) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

George M Bright*1, Wayne V Moore2, H. Q. Nguyen3, Gad B. Kletter4, Bradley Miller5, Douglas G. Rogers6, Eric Humphriss7 and Jeffrey L Cleland8
1Versartis, Inc., Redwood City, CA, 2Children's Mercy Hospital, Kansas City, MO, 3Sierra Medical Research, Clovis, CA, 4Swedish Physician Division, Seattle, WA, 5Univ of Minnesota Amplatz Childr, Minneapolis, MN, 6Cleveland Clin Fndn, Cleveland, OH, 7Versartis, Inc, Menlo Park, CA, 8Versartis Inc., Menlo Park, CA

 

Background: VRS-317 is a novel fusion protein (M.W. 119 kDa) consisting of rhGH with amino acid sequences (XTEN) attached at the N- and C-termini. In Phase 1 studies in GHD adults and children, VRS-317 concentrations, IGF-I and IGFBP-3 responses were proportional to dose, with drug concentrations and increases in IGF-I and IGFBP-3 still present 30 days after a single subcutaneous injection. Single dose VRS-317 administration has been safe and well tolerated, with minimal injection site discomfort; no new safety signals compared to daily rhGH products have emerged.

Objectives: Conduct a repeat dosing study to determine the safety, tolerability, height velocity, IGF-I and IGFBP-3 responses after 6 months of VRS-317 treatment.

Methods: The primary endpoint is mean 6-month height velocity.  Subjects were all pre-pubertal and naïve to rhGH treatment. GHD was diagnosed by short stature (HT-SDS < -2), delayed bone age, paired GH stimulation tests (GHmax ≤ 10 ng/mL), a low IGF-I (IGF-I SDS < -1) and absence of other conditions to cause poor growth. Initially, 48 subjects (8/dose cohort) received single doses at one of six VRS-317 dose levels (0.8 to 6.0 mg/kg; equivalent to 4.9 to 37 µg rhGH/kg/d taken for 30 d). Based on observed PK/PD results, 64 subjects were randomized into three dosing arms to evaluate 5.0 mg/kg monthly, 2.5 mg/kg semimonthly or 1.15 mg/kg weekly (cumulative dose of 30 mg/kg/6m for all). At the start of repeat dosing, the subjects (37M/27F) had a mean (SD) age of 7.8 (2.4) yrs, HT-SDS of -2.5 (0.5) and IGF-I SDS of -1.7 (0.8).

Results: With more than 465 injections administered to date, discomfort at injection sites has been mild (Grade 1), transient (generally < 30 min) and reported in only 22% of subjects. No nodule formation or lipoatrophy were noted at injection sites. There have been no related serious adverse events (SAEs) or unexpected AE. Other related AE have been mild and transient and of the type expected when rhGH is initiated in children naïve to rhGH treatment (e.g., musculoskeletal pain in 5 subjects, headache in 1 subject).  Peak IGF-I SDS levels are greatest with monthly dosing but not > 3 and in only 2 cases transiently exceeded 2 (2.01 and 2.12). Mean trough IGF-I SDS levels remain above baseline at Day 30 in all dosing groups.  After 2 months of dosing, peak IGF-I levels are generally higher than after the first dose, suggesting that repeat VRS-317 dosing may augment IGF-I responses.

Conclusion:  At doses equivalent  in rhGH mass to approximately 30 µg rhGH/kg/d,  repeat dosing with VRS-317 were found to be safe and well tolerated in pre-pubertal GHD children and maintains mean IGF-I increases over baseline without IGF-I overexposure when given at weekly, semimonthly and monthly intervals.  Repeat VRS-317 dosing may augment the IGF-I response seen with initial dosing.  The mean 6 month height velocities and updated safety and PK/PD from each cohort in the study will be presented at the meeting.

 

Disclosure: GMB: Vice President, Versartis, Inc.. WVM: Investigator, Versartis, Inc. HQN: Investigator, Versartis, Inc.. GBK: Investigator, VErsartis, Inc. BM: Consultant, Sandoz, Principal Investigator, Sandoz, Consultant, Genentech, Inc., Consultant, Novo Nordisk, Principal Investigator, Novo Nordisk, Principal Investigator, Versartis. DGR: Investigator, Versartis, Inc. EH: Vice President, Versartis, Inc.. JLC: Chief Executive Officer, Versartis, Inc..

13170 12.0000 MON-0147 A Safety and Efficacy Results of a 6 Month, Randomized, Multi-Center Trial of a Novel Long-Acting Rhgh (VRS-317) in Naïve to Treatment, Pre-Pubertal Children with Growth Hormone Deficiency (GHD) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Oren Hershkovitz*1, Laura Moschcovich2, Rachel Guy3, Yana Felikman3, Ahuva Bar Ilan4, Ron G Rosenfeld5, Vivian Hwa6 and Eyal Fima1
1Prolor Biotech, Nes Ziona, Israel, 2Prolor Biotech, Nes-Ziona, Israel, 3OPKO Biologics, Nes Ziona, Israel, 4PROLOR BIOTECH, Nes Ziona, 5Oregon Health and Science University, Portland, OR, 6Oregon Hlth Sci Univ, Portland, OR

 

Background: 

Prolor Biotech Inc. is a clinical stage public company developing long acting therapeutic proteins utilizing a technology called CTP. The technology involves fusion of the C terminus peptide of hCG, which is a highly O-glycosylated peptide, to the target protein. CTP enabled the production of a long-acting hGH (MOD-4023), which supports a single weekly injection in growth hormone deficient patients. MOD-4023 is manufactured as a non-viscous liquid formulation.

Aims:

Characterization of MOD-4023 drug substance and drug product with respect to the protein quality attributes process reproducibility

Methods:

MOD-4023 characterization was carried out by applying various acceptable analytical methods including glycosylation profiling and serine site occupancy, Capillary Zone Electrophoresis (CZE) and peptide mapping.  The pharmacological characteristics of MOD-4023 have been analyzed in vitro utilizing stable GH receptor expressing cells while the binding affinity of MOD-4023 to the Growth Hormone Receptor (GHR) was assessed by BIAcore analysis.

Results:

Glycoprofyling analysis of different batches shows that the major O-glycan structure in MOD-4023 is mono-sialylated core 1 with comparable site occupancy of the O-glycans in MOD-4023 between different batches. The high glycosylation levels contributes to the significant increased hydrodynamic volume of MOD-4023 as compared to recombinant hGH, which results in the elongated circulating time of MOD-4023. Similar peptide map profiles of MOD-4023 batches are obtained supporting the consistency of the drug substance primary structure in each batch. Comparable results for different batches were also obtained using on CZE analysis. MOD-4023 potency was assessed in vitro, utilizing cells stably expressing the human growth hormone receptor. MOD-4023 was shown to bind and activate the human GHR. MOD-4023 drug product has a low viscosity and consequently can be easily delivered using 31G needle.

Conclusion:

MOD-4023 manufacturing process is robust, producing a highly reproducible O-glycosylated product .Based on these findings and combined with its excellent safety profile and significant prolonged GH activity MOD-4023 has the potential to replace the daily injections of hGH now required for the treatment of GH deficiency with a weekly regimen.

 

Disclosure: RGR: Consultant, Prolor. Nothing to Disclose: OH, LM, RG, YF, AB, VH, EF

13691 13.0000 MON-0148 A Production and Characterization of Mod-4023, a LONG Acting Growth Hormone Supporting Clinical and Commercial Drug Product Supply 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Gili Hart*1, Zvi Zadik2, Klaudziya Radziuk3, Nataliya Zelinska,4, Oleg Malievsky5, Violeta Iotova6, Julia Skorodok7, Ronit Koren8, Leanne Amitzi9 and Eyal Fima1
1Prolor Biotech, Nes Ziona, Israel, 2Kaplan Medical Center, Rehovot, Israel, 32nd Children City Clinic, Minsk, Belarus, 4Ukrainian Children Specialized Clinical Hospital, Kyev, Ukraine, 5Bashkir State Medical University, Ufa, Russia, 6UMHAT, Varna, Bulgaria, 7St. Petersburg State Pediatric Medical Academy, St. Petersburg, Russia, 8Prolor, Nes Ziona, Israel, 9OPKO Biologics, Nes Ziona, Israel

 

Objective: Growth Hormone (GH) replacement therapy currently requires daily injections, which may cause poor compliance, inconvenience and distress for patients. CTP-modified hGH (MOD-4023) is being developed for once-weekly administration in Growth Hormone Deficient (GHD) adults and children. In the present study the pharmacokinetics (PK) and pharmacodynamics (PD) profile of MOD-4023 in GHD naïve children was assessed.

Design and methods:  A randomized, comparator-controlled Phase 2 study was conducted in up to 56 pre-pubertal, naïve GHD children receiving one of three MOD-4023 doses as once-weekly regimen (0.25, 0.48, 0.66mg/Kg per week) or daily hGH (34µg/Kg/day) as comparator arm in subcutaneous injections. In order to introduce naïve patients to the allocated MOD-4023 dose in a gradual manner, a stepwise dose increase approach was implemented. All patients randomized to receive one of the three MOD-4023 doses started treatment for 2 weeks with the low MOD-4023 dose and based on the patient's dose allocation, followed by a dose increase to the next dose level every two weeks until the final allocated dose was reached. Subsequently to the second dose administration of the targeted dose MOD-4023, GH, IGF-1 and IGF-BP3 concentrations were measured and PK-PD analysis was conducted utilizing a population based approach.

 

Results: MOD-4023 administration to GHD children further confirmed its long acting properties and superior properties compared to daily hGH as reflected by extended half-life, increased exposure and reduced clearance. In addition, MOD-4023 Cmax, and AUC were increased at a clear dose proportional manner, while pre-dose and trough levels indicated no accumulation of circulating MOD-4023. IGF-1 and IGF-1 SDS following MOD-4023 administration also increased at a dose proportional manner with no indication for excessive levels at the higher doses and were shown to be normalized and maintained within the normal range up to 168 hrs. As anticipated, IGF-BP3 levels increased reaching the normal range but as anticipated, not at a dose sensitive manner.

Conclusions: MOD-4023 once-weekly treatment at three different doses demonstrated an excellent PK and PD profile supporting once weekly injection in pediatric GHD population and therefore can potentially promote proper growth. In addition, the changes observed in IGF-1 and IGF-BP3 demonstrate adequate stimulation of the GH-IGF-1 axes which were shown to be comparable to that observed with daily hGH treatment.

 

Nothing to Disclose: GH, ZZ, KR, NZ, OM, VI, JS, RK, LA, EF

13640 14.0000 MON-0149 A Pharmacokinetics and Pharmacodynamics Profile of Once-Weekly, CTP-Modified Human Growth Hormone (MOD-4023): Phase 2 Dose Finding Study in Children with Ghd Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Mahmoud Ameri*, Miryam Kadkhodayan, Joe Nguyen, Joseph A Bravo, Rebeca Su, Kenneth Chan, Ahmad Samiee and Peter E Daddona
Zosano Pharma, Fremont, CA

 

There is a major unmet need for safe, convenient, and cost effective alternatives to conventional injectable forms of biopharmaceuticals. Recombinant human growth hormone (rhGH) is currently administered by daily subcutaneous (SC) injection for the treatment of pediatric patients with short stature due to hGH deficiency.  Treatment requires years of good compliance to attain its therapeutic effect, thus a patient-friendly and needle-free delivery would be a desirable alternative. We describe the development of a novel rhGH transdermal microneedle patch demonstrating 6 months at 40 oC packaged storage stability and a simple, one step press-and-apply application. Preclinical in vivo delivery and pharmacokinetic compared the rhGH microneedle patch to Norditropin® at 0.5 and 1mg doses in a hairless guinea pig model. Patch wear time was 1 hour. Results showed that the rhGH microneedle patch delivered with high efficiency (70 % of the patch loaded dose) with a linear dose response and  tmax of 30 minutes. The bioavailability of the rhGH microneedle patch was similar to the comparable subcutaneous injected dose. These results suggest that transdermal microneedle patch delivery of rhGH is feasible and warrants further development as a patient-friendly alternative to current subcutaneous injection.

 

Nothing to Disclose: MA, MK, JN, JAB, RS, KC, AS, PED

15028 15.0000 MON-0150 A Efficient Recombinant Human Growth Hormone Delivery with a Transdermal Microneedle Patch System: Patch Stability, Efficient Delivery and Dose Dependent Delivery Comparable to SC Injection 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Anne-Marie Kappelgaard*1, Richard F Pollock2, Lisa Seitz3 and Chioma Smith4
1Novo Nordisk A/S, Søborg, Denmark, 2Ossian Health Economics and Communications GmbH, Basel, Switzerland, 3Novo Nordisk Pharma GmbH, Mainz, Germany, 4Novo Nordisk Inc., Plainsboro, NJ

 

GH is the standard treatment for short stature linked to conditions such as GH deficiency (GHD) and Turner syndrome (TS), and for children born small for gestational age (SGA). Injections are required daily, over many years, and carry substantial costs for the healthcare payer. GH injection devices differ in design and the dose increments patients use to set their target dose. The size of the dose increments influences the proximity to the target dose that patients can achieve. This study modeled variation in excess dosing arising from differences in dose increment granularity among the Norditropin® injection devices, FlexPro®, NordiFlex®, NordiPen® (Novo Nordisk A/S, Denmark), and the Genotropin® injection device, MiniQuick® (Pfizer Inc., USA). A cohort simulation model estimated the mean annual GH dose and excess GH used per patient in hypothetical cohorts of pediatric patients with GHD, TS or SGA in Europe and the USA. Mean (SD) bodyweight was assumed to be 30(4) kg in Europe and 35(5) kg in the USA. GH doses used were 0.035, 0.067, and 0.035 mg/kg/day in the European cohort and 0.048, 0.067, and 0.067 mg/kg/day in the US cohort for GHD, TS, and SGA, respectively, in line with the relevant package inserts. The model generated a patient cohort normally distributed by bodyweight and calculated the proportion of the cohort in each kilogram interval. The nearest dose that could be set for each device above the target dose was used to calculate the excess GH, reported as an absolute value (mg) and as a percentage of the annual target dose. Devices with the smallest dose increments had the lowest excess dosing; in the US cohort, over 1 year, FlexPro® 5 mg pen administered 4.7 mg (0.6%) GH above the target dose for TS and SGA, and 4.6 mg (0.8%) GH above the target dose for GHD. FlexPro®/NordiFlex® 30 mg pen administered 20.0 mg (2.4%) GH above the target dose for TS and SGA, and 16.6 mg (2.7%) GH above the target dose for GHD. For MiniQuick®, which had the largest dose increments, these values were 44.4 mg (5.2%) and 34.8 mg (5.7%) GH. European cohort results were similar to the US results, but with slightly greater relative and absolute wastage; for Norditropin® devices, across all tested indications, wastage ranged from 4.9 mg (0.7%) GH with FlexPro® 5 mg pen to 20.7 mg (2.8%) GH with FlexPro® 15/NordiFlex® 15/NordiPen® 10 and 15 mg pens, compared with 36.5 mg (9.5%) GH to 45.1mg (6.1%) GH with MiniQuick®. A smaller dose increment in GH injection devices results in less excess GH being given to patients with GHD, TS or SGA. Use of Norditropin® injection devices with fine dose increments results in less product wastage and may reduce the annual cost of GH treatment.

 

Disclosure: AMK: Employee, Novo Nordisk. RFP: Employee, Ossian Health Economics and Communications GmbH. LS: Employee, Novo Nordisk. CS: Employee, Novo Nordisk.

13019 16.0000 MON-0151 A Small Dose Increments Allow for Accurate Dosing and Reduce Growth Hormone (GH) Wastage in GH Injection Devices 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Hwal Rim Jeong*1, Young Seok Shim2, Hae Sang Lee1 and Jin Soon Hwang3
1Ajou University School of Medicine, Suwon, Korea, Republic of (South), 2Ajou University Hospital, Suwon, Korea, Republic of (South), 3Ajou Univ School of Med, Suwon City, Korea, Republic of (South)

 

Background: Idiopathic short stature (ISS) is short stature due to unknown causes. In 2003, the FDA approved the use of recombinant human growth hormone (GH) for ISS. Several studies have evaluated the effect of GH in children with ISS, where it has been shown to improve growth velocity and height standard deviation score (SDS). However, much remains unresolved. There is still no universal definition of ISS as a condition, its etiology is uncertain, growth hormone secretion in these children is non-deficient, the cost of GH treatment is high, and height improvement varies with ethnicity.

Objective: To evaluate effects of GH therapy in ISS and to analyze clinical factors associated with growth velocity.

Method: This study was conducted retrospectively. Subjects diagnosed with ISS at Ajou University Hospital were divided into two groups, an ISS with GH-treatment group (n = 34) and an ISS control group (n = 36). All children were prepubertal, and aged less than 10 years. We reviewed their auxological data, laboratory findings, and bone age.

Results: Growth velocity of the GH-treatment group exceeded that of controls by 3.37 cm/yr (95% CI, 2.78–3.95). At baseline, the mean standard deviation score (SDS) for height in the treatment and control groups were equivalent (-2.25 ± 0.29 and -2.22 ± 0.31 respectively). However, after 1 yr, the height of the GH-treated group exceeded that of the control group by 0.73 SDS (95% CI, 0.57–0.88). A negative correlation was found between age and growth velocity in the GH-treatment group.

Conclusion: GH treatment increases short-term growth velocity and height SDS of Korean children with ISS. Age is the single most important factor correlated with growth velocity in GH therapy.

 

Nothing to Disclose: HRJ, YSS, HSL, JSH

11640 17.0000 MON-0152 A The Effect of Growth Hormone Treatment on Height in Children with Idiopathic Short Stature 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Michael Liang1, Chioma Smith*1, Wayne Weng1 and John Germak2
1Novo Nordisk Inc., Plainsboro, NJ, 2Novo Nordisk Inc, Plainsboro, NJ

 

Introduction: There are 7 rhGH brands in the U.S., each containing the same active substance, somatropin(1-7). Brands differ by device type, dosing increments and attributes that may influence device usability. No known studies describe patient users of rhGH using an administrative claims database. The objective of this research  is to assess types of patients using rhGH and how patient characteristics impact product utilization. Methods: Retrospective analysis (2008-2012) using Truven Health Marketscan® databases.  Pediatric and adult patients with growth hormone (GH) deficiency and other GH-related disorders were included based on evidence of clinically validated ICD9 codes and use of Genotropin®, Humatrope®, Norditropin®, Nutropin®, Omnitrope®, Saizen® or Tev-Tropin®. Patients were naïve to and persistent with therapy (no fills of rhGH 1 year prior to diagnosis, last fill ≥1 year after first fill, no other rhGH used), with continuous enrollment ≥ 1 year before first diagnosis and after rhGH fill. Results: 1,144 patients met study criteria, 63% male. Majority of patients (77.7%) were diagnosed with GH deficiency, followed by idiopathic short stature (12.0%). Most patients were pediatric (≤18 yo; 81.4%) and across all rhGH, highest proportions of patients were of pubertal age (10-18 yo female; 11-18 yo male). Overall mean (SD)/median age was 17.9 yo (15.2)/13.0 yo. Mean (SD)/median pediatric age was 11.2 yo (3.3)/12.0 yo. Mean (SD)/median adult age was 47.5 yo (11.2)/49.0 yo. With exceptions of Genotropin® and Humatrope®, between 2009 and 2011, the highest proportions of initiators of rhGH were of pubertal age (PA), followed by child and adult. Adults represented the largest group of initiators for Genotropin® and Humatrope®. Total number of rhGH product initiators increased between 2009 and 2010 (228 vs. 482); the largest increase among PA initiators (106 to 261). Total initiators fell slightly in 2011 (434). From 2010 to 2011, number of adult initiators dropped by almost half (103 vs. 54, respectively). Conclusions: Findings support current, well-established knowledge in GH therapeutic area; most treated patients are male, ≤18 yo, diagnosed with GH deficiency. Further insight into changes in product initiators by year may reflect formulary changes and increasingly stringent policies on access and appropriate use, particularly for adults. Though the focus of this analysis was descriptive, future analyses including assessment of rhGH utilization patterns could further inform treatment practices in the GH disease area. Patient age group differences with product use (e.g., Genotropin®, Humatrope®) may play a role in product utilization, though further research is warranted.

 

Disclosure: ML: Employee, Novo Nordisk. CS: Researcher, Novo Nordisk. WW: Director, Medical Data Analytics, Novo Nordisk. JG: Senior Medical Director, Novo Nordisk.

13886 18.0000 MON-0153 A A Descriptive Analysis of Patients Using Recombinant Human Growth Hormone (rhGH)—an Administrative Claims Database Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Emily C Walvoord*, Ariana H Greene, Jennifer M Katzenstein and Brenna C McDonald
Indiana University School of Medicine, Indianapolis, IN

 

Substantial debate persists around the idea that using growth hormone (GH) to increase height will correlate with improved psychological adaptation. Additionally, early data suggest that the subtle cognitive problems seen in adults with GH deficiency (GHD) might also occur in children with GHD and improve with treatment. We evaluated cognitive and behavioral status following GH therapy or observation alone in children with GHD and idiopathic short stature (ISS).

Methods: Subjects were 6-16 years old with heights ≤ 3rd percentile for age. GHD was defined as a peak GH level <5 ng/mL. All subjects underwent a targeted neuropsychological test battery at baseline and following 9-12 months of GH therapy. Parents completed the Behavior Assessment System for Children-Second Edition (BASC-2) to assess emotional and behavioral functioning. ANOVA, dependent and independent samples t-tests and chi square tests were used for between and within-group comparisons, as appropriate to the results outlined (SPSS20). GHD subjects treated with GH (N=19) were compared to ISS subjects who were treated (ISS-T, N=9) and not-treated with GH (ISS-NT, N=13). At baseline, GHD subjects were compared to all ISS subjects. Longitudinal analyses compared all three groups (GHD, ISS-T, ISS-NT), and treated vs. untreated subjects (GHD+ISS-T vs. ISS-NT).

Results: Forty-one children (25 boys) had baseline testing; 28 children have completed follow-up testing (19 boys). Mean age at baseline was 11.0 years, (SD = 2.4), with no between-group differences in age, sex, or height SDS. GH-treated children showed a significant improvement in height SDS over time. No clinically meaningful cognitive differences were found between GHD and ISS children at baseline, or between any groups longitudinally. At baseline, no differences were apparent between GHD and ISS subjects on BASC-2 scales. However, longitudinal analyses showed that treated subjects were rated to have worsening depression and withdrawal symptoms over time, while untreated subjects showed lessening of symptoms. Both groups were rated as less anxious at follow-up. When the three groups were compared separately, improvement in anxiety scores was seen for all groups. Both treated groups showed worsening of withdrawal symptoms over time, while the ISS-NT group showed less withdrawal symptoms.

Discussion: GHD and ISS children treated with GH had worsening emotional symptoms over time when compared to children of the same age and height who were not treated with GH. Medical intervention with daily injections, frequent clinic visits and repeated discussions about height might exacerbate instead of improve psychosocial concerns for short, otherwise healthy children. This novel longitudinal study of both the cognitive and emotional effects of GH therapy in GHD and ISS children raises concerns that psychosocial benefits may not be achieved despite improvements in height.

 

Disclosure: ECW: Principal Investigator, Eli Lilly & Company. Nothing to Disclose: AHG, JMK, BCM

13515 19.0000 MON-0154 A Psychological Changes in Children Following Growth Hormone Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Jonathan Christian Howell*1, Sarita Joshi2, Lindsey Hornung1, Jane Khoury1, Richard Harris3 and Susan R Rose1
1Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 2Nationwide Children's Hospital, 3Cincinnati Children's Hospital Medical Center

 

Diamond-Blackfan anemia (DBA) is an inherited hypoplastic anemia syndrome with risk for development of bone marrow failure, MDS/leukemia, and other malignancies.  Most children with DBA have short stature.  Steroid therapy, which can further contribute to poor linear growth, is a mainstay of treatment.  Isolated cases of children with DBA have demonstrated improved growth on growth hormone (GH) therapy, but no population-based clinical studies have been performed.  We hypothesized that treatment with GH would improve linear growth in children with DBA who have very short stature.  GH treatment data were obtained from 6 children with DBA and short stature at our site and from 13 similar children with DBA in the Genentech National Cooperative Growth Study database.  Control data from 44 non-GH treated children with DBA were obtained from the National DBA Registry and were used to construct DBA-specific male and female height-for-age growth charts for non-GH treated patients.  Annual growth velocity (GV) and height-for-age Z-scores (HAZ) were compared between the groups and over time for up to four years.   GH-treated patients had significantly lower HAZ immediately prior to treatment initiation (baseline) compared to non-treated, control patients.  Among GH-treated patients, each child demonstrated an increase in GV in the first year, and average annual GV significantly improved in the first two years relative to pre-treatment GV.  In addition, HAZ significantly improved in each of the four years of GH therapy compared to baseline.  After two years of therapy, HAZ for GH-treated patients were not significantly different from controls, demonstrating successful catch up growth to DBA patients without GH treatment.  In conclusion, GH treatment in children with DBA improves both GV and HAZ during treatment sustained for up to four years. Very short children with DBA can be treated successfully with GH to restore stature to levels comparable to less affected patients.  DBA height charts are useful tools for assessing age-specific growth in this typically short population.  Careful assessment of individualized benefit versus risk when considering GH treatment is important in view of long-term underlying ~5% malignancy risk in DBA.

 

Nothing to Disclose: JCH, SJ, LH, JK, RH, SRR

11845 20.0000 MON-0155 A Growth Hormone Improves Short Stature in Children with Diamond-Blackfan Anemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0136-0155 4968 1:00:00 PM Growth and GH: Diagnostic Issues and Treatment Poster

Odelia Cooper*1, Vivien Shelley Bonert2, Franklin Moser1, James Mirocha1 and Shlomo Melmed2
1Cedars-Sinai Medical Center, Los Angeles, CA, 2Cedars-Sinai Med Ctr, Los Angeles, CA

 

Lifetime prevalence of posttraumatic stress disorder (PTSD) is estimated at 8%. Traumatic events increase risk of poor physical health, and chronic PTSD often leads to disability. The pathophysiology of PTSD is unclear, and improved treatment modalities for this debilitating disorder are required. We postulated that an altered stress axis in PTSD includes pituitary changes. We tested the hypothesis that patients with PTSD exhibit enhanced negative feedback on pituitary corticotrophs leading to smaller pituitary volume. 

Methods: We designed a prospective study to investigate structural and functional changes in the hypothalamic-pituitary-adrenal axis in patients with PTSD.  We recruited 10 subjects with PTSD and eight age, gender, BMI matched controls.  Primary outcome was pituitary volume and secondary outcomes were ACTH area under the curve (AUC), 24 hour urine free cortisol (UFC), and time of peak ACTH on dexamethasone/CRH test. Numerical variables were summarized by median (range).  Spearman correlation coefficients were calculated and Wilcoxon signed rank test used to determine differences in matched pairs. 

Results: Median pituitary volume in PTSD was 696 (403-1025) compared to 906 (466-1379) mm3 in controls (1-sided p = 0.03). Median UFC was 28 mcg (8-47) in PTSD compared to 16 (10-34) in controls (normal <50 mcg), and ACTH AUC was 229 pg/mL (120-495) in PTSD compared to 234 (120-563) in controls. Median ACTH levels were higher at 15 minutes in controls compared to PTSD subjects (5.5, 3.3, respectively, p = 0.057). In controls, pituitary volume and ACTH AUC were positively correlated (Spearman correlation 0.64, p= 0.016) compared to a nonsignificant correlation in PTSD subjects (Spearman correlation 0.09, p = 0.41). UFC levels negatively correlated with age in PTSD (Spearman correlation -0.66, p = 0.04) and basal ACTH levels in controls (Spearman correlation -0.75, p = 0.03). 

Conclusions: These results indicated a downregulated and dysregulated HPA axis in PTSD, as demonstrated by smaller pituitary volumes and discordant corticotroph function and pituitary size. In healthy controls, HPA axis function was intact, confirmed by an intact feedback mechanism as well as correlation of pituitary size with ACTH levels and escape of ACTH from dexamethasone suppression, findings not observed in PTSD subjects. The results suggest a link between pituitary structure and function in PTSD, which may lead to novel endocrine targeted therapeutic approaches for the disorder.

 

Nothing to Disclose: OC, VSB, FM, JM, SM

13439 1.0000 MON-0649 A Altered Pituitary Gland Structure-Function in Posttraumatic Stress Disorder 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Martine Pollack-Zollman*, Madeline Candelario, Jennifer Hui and Carla Maria Romero
Beth Israel Medical Center, New York, NY

 

Background:

Most patients with chronic autoimmune thyroiditis do not develop adrenal insufficiency (AI). However, concurrent AI, unmasked after starting thyroid hormone replacement, can be fatal if missed.

Case:

A 31 year old woman with hypothyroidism presented to the emergency room with acute weakness and fatigue for 1 week, associated with abdominal pain, nausea, and vomiting. For the past 6 months, she had malaise, a 10 lb weight loss, and a tan in the absence of sun exposure. She was diagnosed with primary hypothyroidism 6 weeks prior with a TSH of 110 mIU/mL (nl 0.55-4.78 mIU/mL) and was started on thyroxine replacement.  At that time, her sodium and potassium were 133 mmol/L (nl 136-146 mmol/L) and 5.2 mmol/L (nl 3.5-5.1 mmol/L), respectively. She takes no other medications and has no other medical issues. Her mother has hypothyroidism. Exam was significant for a euvolemic afebrile patient, mentating well with diffusely tan skin and BP 96/61, HR 77. Initially, sodium was 110 mmol/L and she was admitted to the ICU. Normal saline improved her sodium to 121 mmol/L, followed by a regular diet and fluid restriction. The following labs were obtained: urine sodium 149 mmol/L, urine osmolality 514 mOsm/kg, serum osmolality 229 mOsm/kg (nl 280-296 mOsm/kg), TSH 0.75 mIU/mL, T4 10.1 ug/dL (nl 5.7-11.4 ug/dL), TPO antibody 805 IU/mL (nl 0-35 IU/mL), aldosterone 2 ng/dL (nl 3-16 ng/dL), and plasma renin activity 19.14 ng/mL/h (nl 0.25-5.82 ng/mL/h). A cosyntropin test showed cortisol <1 µg/dL at 0, 30, and 60 minutes; baseline ACTH was 1458 pg/mL (nl 6-50 pg/mL). CT abdomen showed atrophied adrenal glands. She was started on glucocorticoid and mineralocorticoid replacement therapy with good response and discharged with close follow up for management of adrenal insufficiency.

Clinical Lesson:

We report a patient with newly diagnosed Hashimoto’s thyroiditis presenting with adrenal crisis, most likely due to the initiation of thyroxine therapy without close follow-up, in the setting of autoimmune polyglandular syndrome (APS). Although most patients with autoimmune hypothyroidism do not have concurrent AI, 50-65% of patients with AI have autoimmune involvement in another organ, most commonly the thyroid or pancreas. This is known as APS type II. Clinicians, when diagnosing hypothyroidism, should pay close attention to the patient’s signs, symptoms, and laboratory values for the possibility of coexisting AI. Clinicians must also be aware that starting thyroxine replacement therapy can precipitate an adrenal crisis due to the increased clearance of cortisol and need to follow their patients closely for any subtle changes in symptoms.

 

Nothing to Disclose: MP, MC, JH, CMR

14883 2.0000 MON-0650 A A Case of Thyroid Replacement Precipitating an Adrenal Crisis - a Missed Opportunity for an Earlier Diagnosis of Autoimmune Polyglandular Syndrome Type II 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Zain Al-Safi*1, Justin Chosich2, Lauren W Roth3, Leslie Palacios-Helgeson4, Andrew P Bradford2, Alex J. Polotsky5 and Nanette Santoro6
1University of Colorado, 2University of Colorado School of Medicine, Aurora, CO, 3University of Colorado, Aurora, CO, 4University of Colorado School of Medicine, 5University of Colorado-Denver, Aurora, CO, 6University of Colorado School of, Aurora, CO

 

Introduction:  Hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis may play a role in the pathogenesis of comorbidities encountered in obesity, including the reproductive deficit that we and others have observed.  To examine this hypothesis, we investigated serum cortisol profiles throughout the day and evening in a sample of obese and normal weight women.

Methods: A luteal phase frequent blood sampling study was undertaken in regularly menstruating obese (n=12) and normal (n=10) weight women. The study included 16 hours of frequent blood sampling (8AM-midnight). To control for ambient sex steroids, all women were sampled after ovulation. Blood sampling was done every 20 minutes and cortisol was measured by a direct chemiluminescent assay (Advia Centaur; Siemens).  Mean and area under the curve (AUC) cortisol was compared between obese and normal weight women for the entire study and for selected time intervals using t test or Mann-Whitney as appropriate. Data presented as median (interquartile range).

Results: Cortisol levels were significantly higher in the obese compared to normal weight women (6.2 (4.3, 6.6) vs 4.7 (3.7, 5.5) ug/dl, p=0.04). Over the two-hour post-prandial period, obese women displayed a significantly higher (7.2 (6.5, 8.6) ug/dl) rise in cortisol than that of normal weight controls (4.4 (3.7, 6.2) ug/dl, p=0.007).  In addition, obese women had a sustained rise in evening cortisol compared to normal weight women who displayed the typical decline in cortisol (3.2 (2.3, 4) vs 2 (1.5, 3.2) ug/dl, p=0.05). Mean cortisol was correlated with the body mass index (p=0.05) and waist-hip ratio (p=0.03), as was higher evening cortisol (p=0.007).

Conclusions: We observed higher cortisol in obese women, which appeared to be coincident with increases in endogenous cortisol response to meals.  The diurnal rhythm of cortisol was also disrupted in obese women, with a failure to demonstrate a steep late afternoon-evening decline. Changes in the HPA axis in the setting of obesity may be related to risk of obesity-associated metabolic comorbidities. The causality and directionality of these findings require further investigation to put into clinical perspective.

 

Disclosure: NS: Advisory Group Member, Menogenix, Principal Investigator, Bayer, Inc.. Nothing to Disclose: ZA, JC, LWR, LP, APB, AJP

16095 3.0000 MON-0651 A Obesity and Cortisol Rhythm in Women: Food for Thought 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Ragini C Bhake*1, Jack Leendertz2, Astrid CE Linthorst2 and Stafford L Lightman3
1university of bristol, Bristol, United Kingdom, 2University of Bristol, United Kingdom, 3University of Bristol, Bristol, United Kingdom

 

Total cortisol level measured in blood routinely under normal circumstances includes approximately 90% hormone bound to carrier proteins and up to 5% unbound, free cortisol. Total hormone levels may not accurately estimate the levels of hormone found in extracellular space surrounding tissues and their receptors, where the predominant moiety is free cortisol. The technique of microdialysis allows direct measurement of free cortisol in man and free corticosterone in rats (Linthorst et al.,Endocrinology, 1994). Saliva sampling is becoming widely accepted for clinical and research purposes, but samples cannot be obtained during sleep (circadian nadir) and interpretation of the results obtained is not straightforward (Perogamvros et al., JCEM, 2010). 

The glucocorticoid cortisol has a circadian and an ultradian rhythm. To understand the significance of these rhythms in man, both in health and disease, it is essential to be able to obtain multiple samples over extended periods, especially when an individual is asleep. The Human Automated Blood Sampling (HABS) system reported by Henley et al. (Henley et al., JMET, 2009) can achieve stress-free venous sampling, but is only safe in the setting of a clinical investigation unit, which is its major drawback. In a recent publication we have described the portable sampling system developed by us and its ability to collect multiple samples continuously and automatically over 24 hours without the need for venous access, without waking the individual. For many diagnostic and scientific questions, the most meaningful physiological setting to look at profiles of homeostatically important hormones like cortisol is an individual’s home setting. The combination of our device with microdialysis presents the unique opportunity to realise this objective. Here we describe validation of the microdialysis method for the measurement of free cortisol in healthy men. 

Acknowledgements: This work was carried out with financial support from the European Union – FP7 grant to OPTIMI

 

Nothing to Disclose: RCB, JL, ACL, SLL

12775 4.0000 MON-0652 A Free Cortisol Profiles in Healthy Men 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Jitske Tiemensma*1, Cornelie D. Andela2, Adrian A Kaptein3, Johannes A. Romijn4, Roos C. van der Mast2, Nienke R. Biermasz2 and Alberto M. Pereira3
1University of California Merced, 2Leiden University Medical Center, Netherlands, 3Leiden University Medical Center, Leiden, Netherlands, 4Academic Medical Center, Amsterdam, Netherlands

 

Context: A high prevalence of psychological morbidity and maladaptive personality as well as impaired quality of life (QoL) is observed in patients with and without hydrocortisone dependency following (cured) Cushing's syndrome. However, it is currently unclear whether a similar pattern is present in patients with chronic glucocorticoid replacement for primary adrenal insufficiency (PAI).

Objective: To evaluate psychological functioning, personality traits, and QoL in patients with PAI.

Design and subjects:  A cross-sectional study including 54 patients with stable treatment for PAI and 54 healthy matched controls. Both patients and controls completed questionnaires on psychological functioning (Apathy Scale, Irritability Scale, Mood and Anxiety Symptoms Questionnaire short-form, and Hospital Anxiety and Depression Scale), personality traits (Dimensional Assessment of Personality Pathology short-form), and QoL (Multidimensional Fatigue Inventory, Short-Form 36, EuroQoL-5D, Nottingham Health Profile, and Physical Symptom Checklist).

Results: Patients with PAI suffered from more psychological morbidity (i.e. irritability and somatic arousal) and QoL impairments compared with controls (all P<0.01). There were no differences regarding maladaptive personality traits between patients and controls. However, there was a strong and consistent positive association between the daily hydrocortisone dose and prevalence of maladaptive personality traits (i.e. identity problems, cognitive distortion, compulsivity, restricted expression, callousness, oppositionality, rejection, conduct problems, social avoidance, narcissism, and insecure attachment, all P<0.05). There was also a strong relation between the mean daily hydrocortisone dose and both psychological morbidity (i.e. depression, P<0.05) and QoL impairments (i.e. general health perception, several measures of physical functioning, and vitality, all P<0.05).

Conclusion: Patients with stable glucocorticoid replacement therapy for PAI report psychological morbidity and impaired QoL. Psychological morbidity, impaired QoL, and maladaptive personality traits were all associated with higher hydrocortisone dosages.

 

Nothing to Disclose: JT, CDA, AAK, JAR, RCV, NRB, AMP

13490 5.0000 MON-0653 A Psychological Morbidity and Impaired Quality of Life in Patients with Stable Treatment for Primary Adrenal Insufficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Jitske Tiemensma*1, Cornelie D. Andela2, Alberto M. Pereira3, Johannes A. Romijn4, Nienke R. Biermasz2 and Adrian A Kaptein3
1University of California Merced, 2Leiden University Medical Center, Netherlands, 3Leiden University Medical Center, Leiden, Netherlands, 4Academic Medical Center, Amsterdam, Netherlands

 

Introduction: Patients with adrenal insufficiency (AI) require a daily intake of hydrocortisone (HC). Previous studies demonstrated that medication beliefs are associated with illness perceptions. The spectrum of medication beliefs in patients with AI is currently unknown.

Method:  Cross-sectional evaluation of illness perceptions and medication beliefs in 107 patients with primary (n=49) or secondary AI following Cushing’s syndrome (n=29) or non-functioning pituitary adenoma (n=29). The Illness Perception Questionnaire-Revised and the Beliefs about Medicines Questionnaire were used.

Results: Stronger beliefs about the necessity of HC and stronger concerns about the adverse effects of HC were related to attributing more symptoms to AI, to perceiving AI being more cyclical, to perceiving more negative consequences of AI, and to having stronger emotional representations (all P<0.05). Furthermore, stronger beliefs about the necessity of hydrocortisone were associated with feelings of less personal control over AI (P<0.05). Stronger concerns about the adverse effects of hydrocortisone were associated with lower perceived treatment control and lower illness coherence (both P<0.05). In addition, patients with Cushing’s syndrome reported stronger beliefs regarding the necessity of taking hydrocortisone, compared with patients with Addison’s disease (P=0.039) or NFA (P<0.001).

Conclusion: Specific beliefs about the necessity of hydrocortisone and concerns about its adverse effects were strongly associated with more negative illness perceptions. Patients with adrenal insufficiency due to different etiologies demonstrate differences in beliefs about the necessity of HC intake. These results need to be taken into account when developing psychosocial education / self-management programs aiming at improving QoL.

 

Nothing to Disclose: JT, CDA, AMP, JAR, NRB, AAK

13483 6.0000 MON-0654 A Patients with Adrenal Insufficiency Hate Their Medication: The Relation Between Medication Beliefs and Illness Perceptions 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Katia El Sibai*1, Ribal Al Aridi2, Laure Sayyed Kassem2, Joumana T Chaiban1, Nadine El Asmar3, Warren Selman4 and Baha M Arafah5
1University Hospitals Case Medical Center, Cleveland, OH, 2University Hospitals,Case Medical Center, Cleveland, OH, 3UH Case Medical Center/ Case Western Reserve University, Cleveland, 4UH Case Medical Center, Cleveland, OH, 5Case Western Reserve Univ, Cleveland, OH

 

Background: Postop activation of HPA function is heralded by sharp rise in ACTH secretion shortly after surgery. While the rise in ACTH is known to result in increased cortisol production, its impact on secretion of other ACTH-dependant adrenal steroids (DHEA and DHEA-S) is unknown. The aim of the study is to assess the dynamics of HPA responses to TSS in patients with normal (NL) HPA and to identify predictors of postop recovery of function in those with preop adrenal insufficiency (AI).

Methods: Blood samples were obtained before and at 2-4, 6-8, 12-18, 24, 36 and 48 hrs after TSS from patients with macroadenomas (excluding ACTH or PRL-secreting) who had NL preop HPA function (NL-HPA; n=105) and in others who had preop AI (n=64). Samples were assayed for ACTH, Cortisol, DHEA and DHEA-S measurements. Patients with NL- HPA were not given any GC before, during or after surgery and had NL function postop. Patients with AI were given one oral dose of GC few hours before surgery and were classified as having recovered HPA (AI-Rec; n=33) if they have multiple postop cortisol levels ≥15 mcg/dL. Those with lower cortisol levels were classified as AI No-Rec (n=31). All groups had similar age and gender distribution.

Results: In patients with NL-HPA, ACTH increased to a peak of 242±235 ng/L at 2-4hr (p<0.05) and decreased gradually to baseline at 12-18hrs. This was followed by a parallel rise in cortisol and DHEA levels that peaked at 6-8hrs (38±14.3mcg/dL;7.8±8 ng/ml, respectively) and returned to baseline values at 36 and 24hrs respectively.The Cortisol/DHEA molar ratio remained constant during the first 12-18hrs suggesting equimolar response to ACTH. DHEA-S levels increased 2-4hr postop to peak at 12-18hr and back to baseline at 36hrs. Patients with AI-Rec had a similar dynamic pattern of HPA response and although their baseline ACTH was lower (13.9±8.6ng/L), levels at 2-4hr and onward were similar to those of NL-HPA. Recovering patients had dramatic increases in cortisol reaching values similar to those of the NL-HPA 12-18hrs and onward. Although DHEA and DHEA-S levels increased in recovering patients, their levels were lower than those of NL-HPA at all times. The rise in ACTH at 2-4hr in patients with AI-NoRec was <50(44.2±43.6)ng/L, with subsequent suboptimal cortisol, DHEA or DHEA-S levels at all times(p<0.05).

Conclusion: The normal response to TSS is characterized by a peak rise in ACTH at 2-4hr with subsequent parallel increases in cortisol and DHEA levels peaking at 6-8hr and indicating equimolar secretion of the two steroids. However, DHEA levels decreased to NL earlier than those of cortisol, likely due to its shorter half life. A sharp rise in ACTH levels at 2-4hr postop is an early marker of HPA recovery in patients with preop AI. This is  followed by a rise in cortisol and DHEA at 6-8hrs. However, the rise in serum DHEA is lower than that observed in patients with NL-HPA suggesting that recovery of GC precedes that of DHEA.

 

Nothing to Disclose: KE, RA, LS, JTC, NE, WS, BMA

14215 7.0000 MON-0655 A Dynamics of the Alerations in ACTH, Cortisol, Dehydroepiandrosterone (DHEA) and Dehydroepiandrosterone-Sulfate (DHEA-S) Levels in the Perioperative Period: Parallel and Equimolar Increase in Glucocorticoid (GC) and Adrenal Androgens Following Transsphenoidal Pituitary Surgery (TSS) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Charikleia Stefanaki*1, Sarantis Livadas2, Anna Kandaraki3, Flora Bacopoulou1, Athanasios Karachalios4, Evanthia Diamanti-Kandarakis3 and George P. Chrousos5
1University of Athens Medical School, Athens, Greece, 2Unit of Endocrinology, Metabolism and Diabetes, Athina, Greece, 3Athens University Medical School, Athens, Greece, Athens, Greece, 4Athens University Medical School, Athens, Greece, 5University of Athens School of Medicine, Athens, Greece

 

Polycystic Ovary Syndrome (PCOS) is one of the most common endocrine disorders in women, with a prevalence of about 7%. PCOS is associated with high incidence of anxiety and depressive symptomatology, which indicates stress system dysfunction in these patients. This reduces their quality of life and accelerates the development of chronic non-communicable disorders, such as obesity, cardiometabolic diseases and cancer. Mindfulness-based Stress Reduction (MBSR) programs promote stress alleviation by producing a relaxation response. In this single-masked, randomized, controlled trial, we used an 8-wk MBSR program, accompanied by a weekly 30-min session with the principal investigator. Twenty-three PCOS patients of reproductive age and fifteen controls were randomly allocated and administered the DASS21, PSS-14, PCOSQ, Daily Life and General Life Satisfaction Questionnaires both before and after the intervention. At the same time points they also provided three serial samples for salivary cortisol measurements. Patients in the intervention group were also given the Credibility/Expectancy Questionnaire at the day of enrollment, to look for a possible placebo effect in the outcome measures and to evaluate expectancy for change and treatment credibility. Post-intervention between group results revealed statistically significant differences in depressive symptoms (p = 0.011) and stress levels (p = 0.025). There were statistically significant reductions in stress-associated (95% C.I.: 4.38 – 9.7, p = 0.000), anxiety (95% C.I.: 1.74 – 5.91, p = 0.001) and depressive (95% C.I.: 1.66 – 6.33, p = 0.002) symptoms, along with a significant increase in Life Satisfaction and Quality of Life scores in the intervention group only. Lastly, cortisol AUCg in the intervention group, demonstrated a statistically significant reduction (p = 0.037). According to our results, there was no impact of the study on the credibility and/or expectancy, and, hence, no placebo effect. The data suggest that MBSR in PCOS patients leads to significant reductions in stress-associated, anxiety and depressive symptoms, as well as salivary cortisol, and ameliorates their quality of life. These findings also imply that relaxation techniques might be useful alternative therapies for other non-PCOS hyperandrogenic disorders.

 

Nothing to Disclose: CS, SL, AK, FB, AK, ED, GPC

14534 8.0000 MON-0656 A Impact of a Mindfulness-Based Stress Reduction Program on Depressive and Anxiety Symptomatology, Stress and Cortisol Levels and the Quality of Life in Premenopausal Patients with Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Maria Antonenko*1, Natalya Volkova2, Lilia Ganenko3, Aida Gulmagomedova3, Ilia Davidenko4, Igor Reshetnikov5 and Irina Dzherieva3
1Rostov State Med Univ, Rostov-on-don, Russia, 2Rostov state medical university, Rostov on Don, 3Rostov State Medical University, Rostov on Don, Russia, 4Rostov State Medical University, Rostov-on-Don, Russia, 5Rostov State Medical University, Rostov-on-Don, Russia

 

Diagnostics of mild, or occult (1), CS is complicated since the screen tests cut off, sensitivity (Sen) and specificity (Sp) were calculated on results of patients with overt CS. The aim was to estimate diagnostic characteristics of established screen test thresholds in case of mild CS. There were studied 23 patients with obesity who didn't have any CS specific signs, but did have abnormal test result of 1-mg DST (cut off 50 nmol/l). In order to precise the diagnosis there were measured midnight plasma cortisol (MPC) (cut off 207 nmol/l), UFC (40-180mcg/day) and calculated the coefficient of cortisol circadian rhythm secretion (CCCRS) (2). If all three-test results were normal, CS was excluded. The diagnosis was established in case of at least one abnormal result. There were measured morning plasma ACTH (5-46 pg/ml), performed 8-mg DST and imaging to determine the type of CS. After having been established final diagnosis, there were calculated Sen, Sp, likelihood ratio of positive result (LR+), likelihood ratio of negative result (LR-), diagnostic odd ratio (DOR) of three screen tests. Among 23 patients, 6 had normal results of all three tests, and rested 17 exhibited at least one abnormal result. According to the next evaluation, there were diagnosed 4 cases of Cushing disease and 2 cases of corticosteroma. All patients were examined in tertiary centres, where CS was confirmed. Rested 11 patients had ambiguous results, since 3 of them had adrenal nodular hyperplasia without ACTH suppression and pituitary abnormality, and 8 patients didn't have any adrenal or pituitary abnormality. All 11 patients were evaluated in 3, 6 and 12 months, and CS was not confirmed. Thus, there were compared results of 6 patients with CS and results of 11 patients without CS. Next diagnostic characteristics were received: MPC – Sen 83,33% (95%CI 35,88-99,58), Sp 63,64% (95%CI 30,79–89,07), LR+ 2,29, LR- 0,26, DOR 8,75 (95%CI 0,73-103,82), UFC -  83,33% (95%CI 35,88-99,58), Sp 18,18% (95%CI 2,28-51,78), LR+ 1,02, LR- 0,92, DOR 1,11 (95%CI 0,07-15,53), CCCRS - Sen 66,67 (95%CI 22,28-95,67), Sp 63,64% (95%CI 30,79-89,07), LR+ 1,83, LR- 0,52, DOR 3,50 (95%CI 0,43-28,45). Moreover, no any combination of the studied tests was effective to confirm CS, since 95% CI for DOR contained 1. Thus, well-known established thresholds of screen tests are not valid for diagnostics of mild CS. Since the prevalence of mild CS is about 1%, it is absolutely necessary to study the test cut off for mild CS diagnostics.

 

Nothing to Disclose: MA, NV, LG, AG, ID, IR, ID

16810 9.0000 MON-0657 A Overt and Mild Cushing Syndrome: Are Test Threshold Values Equal? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Mihail Zilbermint*1, Aaron Hodes2, Maya Beth Lodish1, Ninet Sinaii3, Elena Belyavskaya4, Charalampos Lyssikatos5, Kendra Rosenberg6, Jerrold Meyer6 and Constantine A Stratakis1
1National Institutes of Health (NIH), Bethesda, MD, 2Drexel University College of Medicine, Philadelphia, PA, 3National Institutes of Health, Bethesda, MD, 4Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH)., Bethesda, MD, 5Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD, 6University of Massachusetts, Amherst, MA

 

Context: Hair cortisol has been recently studied to determine evidence of hypercortisolemia in humans. This test may be useful in estimating cortisol levels, particularly in patients with cyclical Cushing’s syndrome (CS).

Objective: To determine correlations with biochemical evidence of CS, and to compare hair cortisol measurements in a small sample of patients with CS to normative data.

Methods: Hair samples from five female patients with CS (mean age 18.2 ±17.3 years) were collected. Among these patients, four patients had pathologically confirmed ACTH-producing pituitary tumors, and one had an ACTH-secreting pulmonary carcinoid. Hair samples were processed and analyzed for cortisol according to the methods described in Meyer et al., 2014. Three hair cortisol measurements were obtained from each patient. Diurnal serum cortisol measurements, plasma ACTH levels, 24 hr urinary free cortisol (UFC) and 17-hydroxysteroids (17OHS) were assessed prior to surgery. 17OHS was corrected by urine creatinine (17OHS/Cr), per day per gram creatinine, while UFC was corrected by body surface area (UFC/BSA). Average hair cortisol data were log transformed to achieve normality. Data were analyzed using Pearson’s correlations and the t-test.  The comparison of hair cortisol concentrations in our sample was to the reported normal data in healthy adults as measured using identical methodology in the same laboratory.  

Results: The average hair cortisol in the study sample was 74.0 ±96.9 pg/mg (median: 23.5 pg/mg; range: 18.0–243.7 pg/mg). Average hair cortisol was positively correlated with UFC/BSA (r=0.89, p=0.04), 17OHS/Cr (r=0.97, p=0.008), and morning serum cortisol (r=0.90, p=0.04). However, mean cortisol in patients with CS was not statistically significantly different from the mean level of 36.0 ±110 pg/mg in previously reported normal patients (p=0.47).

Conclusions: We found that hair cortisol levels positively correlated with some biochemical evidence of CS; however, there was no difference in hair cortisol levels between our cohort and published normative data. We speculate that small sample size and a lack of normative data in children limited our results. More research is needed for certification of the diagnostic value of hair cortisol in the workup of patients with CS.

 

Nothing to Disclose: MZ, AH, MBL, NS, EB, CL, KR, JM, CAS

12407 10.0000 MON-0658 A Hair Cortisol Measurement in the Evaluation of Cushing's Syndrome: A Pilot Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Etty Osher*1, Yael Sofer2, Rona Limor3, Gabi Shefer4, Karen Michele Tordjman5, Yona Greenman6 and Naftali Stern3
1Tel Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel, 2Tel Aviv Sourasky Medical Center, 3Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel, 4Tel Aviv Sourasky Medical Center, Tel Aviv, 5Tel Aviv Sourasky Medical Center, Tel Aviv, Israel, 6Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel

 

Objective

The effect of gender on the hypothalamic-pituitary-adrenal axis (HPA) has not received much attention. Only recently several studies have emerged pointing to the fact that women exhibit lower hair cortisol than men. Accordingly our aim was to elucidate the gender differences in serum free cortisol in the basal and ACTH-stimulated state.

Methods

Low-dose 1-μg ACTH test was performed in 87 subjects, 62 females, 25 males. Serum total cortisol (TC) was determined by an ECL method, and serum free cortisol (FC) was measured by the same method following equilibrium dialysis.

 

Results:

Basal TC levels and post-ACTH stimulation did not differ between males and females. In contrast, basal serum FC levels was ~65% higher in men than in women (0.87±0.61 vs. 0.52±0.32 µg/dl; mean+/-SD; P=0.0009, adjusted for age). The FC fraction (% free cortisol, out of total cortisol) was concordantly higher in men (7.9 ±2.8% vs. 6.3 ±2.4%; p=0.015).  Likewise, peak ACTH- stimulated FC levels were significantly higher in men compared to women (1.95±0.8, 1.57±0.72, µg/dl P=0.025) as was the area under the response curve, (73.6±33.9 vs. 53±25.3 µg Xmin; P=0.004).

Conclusion

Gender is a formerly unknown determinant of serum free cortisol in humans. This may be related to the well-known up regulation of cortisol binding globulin by estradiol, leaving less cortisol in the free circulating pool. Since cortisol tends to induce central fat deposition, we speculate that higher circulating free cortisol in men may contribute to gender-related fat distribution (android vs. gynecoid). Studies are underway to test these hypotheses.

 

 

Nothing to Disclose: EO, YS, RL, GS, KMT, YG, NS

13344 11.0000 MON-0659 A Is Android Fat Deposition in Men Induced By Higher Circulating Serum Free Cortisol in Men Vs. Women? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Richard A. Feelders*1, Susmeeta T. Sharma2, Reham Elgarf3, Ronald Ouwerkerk4, Ahmed M. Gharib4, Khaled Z. Abd-Elmoniem3 and Lynnette K. Nieman3
1Erasmus Medical Center, Rotterdam, Netherlands, 2Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 3National Institutes of Health, Bethesda, MD, 4NIH, Bethesda, MD

 

Background. Cushing’s syndrome (CS) is associated with increased cardiovascular morbidity and mortality. Time-Resolved Phase-Sensitive Dual Inversion Recovery (TRAPD) technique at 3T magnetic resonance (MR) imaging is a recently developed noninvasive tool to examine vessel wall thickness (VWT) of coronary arteries. We assessed coronary atherosclerosis using this method in patients (pts) with active CS and risk-matched controls (HV). We also examined whether hepatic fat fraction (HFF), measured with 1H MR spectroscopy, is associated with atherosclerotic disease in CS.

Methods. 15 untreated CS pts (9 pituitary adenoma [CD], 6 ectopic ACTH syndrome [EAS]) and 15 age, gender, BMI and Framingham score-matched HV underwent 3T-MRI with TRAPD technique. VW circumferential irregularities, indicated by standard deviation of circumferential VWT, and eccentricity, indicated by the difference between minimum and maximum circumferential VWT, were also assessed. 18 CS pts (12 CD, 4 EAS, 2 occult EAS) and 18 age, gender and BMI-matched HV underwent hepatic 1H MR spectroscopy. Data are shown as mean ± SD. Between-group differences were analyzed using paired Student’s t-test.

Results. Age (CS: 47.8±16.2, HV: 47.1±18.8 years), BMI (CS: 26.4±5.6, HV: 28.1±5.8 kg/m2), gender (12/15 females) and Framingham score (CS: 14.7±14.1, HV: 7.3±8.3%) were not significantly different in the 2 Cardiac MRI groups. Mean VWT was similar in CS pts and HV (1.34±0.22 vs. 1.26±0.19 mm). However, CS pts had significantly higher VWT standard deviation (0.20±0.08 vs. 0.14±0.04, p<0.02) and VWT eccentricity (0.72±0.27 vs. 0.54±0.18 mm, p<0.05).  The Framingham score was correlated with VWT irregularities (r=0.47, p<0.01) and VWT eccentricity (r=0.51, p<0.005). HFF was similar in CS pts and controls. In the 10 CS pts who underwent both cardiac MRI and MR spectroscopy liver, HFF showed no significant correlation with parameters of coronary VWT.

Conclusion. Chronic glucocorticoid exposure in CS is associated with increased eccentric vessel wall thickness indicating accelerated coronary atherosclerosis as assessed noninvasively with TRAPD technique MRI. The more advanced atherosclerotic disease seen in CS compared to risk-matched controls suggests that hypercortisolism per se may directly or indirectly promote atherosclerotic plaque formation. In addition to control of hypercortisolism, cardiovascular risk factors should be adequately treated in CS pts to reduce morbidity and mortality.   

 

Nothing to Disclose: RAF, STS, RE, RO, AMG, KZA, LKN

14638 12.0000 MON-0660 A Noninvasive Assessment of the Coronary Artery Vessel Wall in Cushing's Syndrome Using 3-T Magnetic Resonance Imaging: Evidence for Increased Atherosclerosis Compared to Risk-Matched Controls 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Ikuko Ueki*1, Takao Ando2, Ai Haraguchi2, Aya Nozaki2, Haruko Takashima1, Toshiyuki Ikeoka1, Junichi Yasui1, Ichiro Horie2, Misa Imaizumi2, Toshiro Usa2 and Atsushi Kawakami2
1Nagasaki University Graduate School of Biomedical Sciences, Japan, 2Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan

 

Background and Methods: It is well known that Cushing syndrome is one of the important causes of obesity. Here we reviewed the medical charts of 29 patients with Cushing syndrome who were referred to our endocrinology department from 2005 to 2013, especially focusing on body mass index (BMI) at the time of the first presentation.

Results: Among 29 patients, 2 patients with subclinical Cushing syndrome with adrenal tumor and a patient who was diagnosed with Cushing syndrome during steroid treatment to underlying autoimmune disease were excluded. In the remaining 26 patients, 10 were with Cushing disease with ACTH-producing pituitary adenoma, one with ectopic CRH or ACTH producing tumor, and 15 with cortisol-producing adrenal tumor. Mean age was 59.8±13.8 years and 80.7% were female. The mean weight and BMI were 61.9±14.9kg and 25.8±5.0kg/m2, respectively. We found that 46.15% of our patients with Cushing syndrome were with their BMI being less than 25kg/m2 and also found that only 19.23% of them were with BMI being higher than 30kg/m2 and thus apparently obese. There was no statistical difference in frequency of patients with BMI lower than 25 kg/m2 between patients with ACTH-producing pituitary tumor (40%) and those with cortisol-producing adrenal tumor (46.7%).

Conclusions:It has been recently shown that about 95-97% of patients with Cushing syndrome were obese (BMI>30kg/m2) and/or with a history of weight gain among Caucasian. This contrasts with our findings in the present study. Interestingly, average BMI of female adults(40-69years old) in our prefecture in Japan is 23.6kg/m2 which is very similar to our patients with Cushing syndrome. Our data may suggest that patients with Cushing syndrome might not be necessarily obese in Japan.

 

Nothing to Disclose: IU, TA, AH, AN, HT, TI, JY, IH, MI, TU, AK

13773 13.0000 MON-0661 A Patient with Cushing Syndrome Might Not be Obese in Japan 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Curie Kim*1, Cheol Ryong Ku1, Sun Ho Kim1 and Eun Jig Lee2
1Yonsei University College of Medicine, Seoul, Korea, Republic of (South), 2Yonsei University College of Medicine, Korea, Republic of (South)

 

Cushing’s disease (CD) is a Cushing syndrome, caused by increased secretion of adrenocorticotropic hormone (ACTH) from pituitary adenoma. The overproduction of ACTH from pituitary adenoma leads to chronic stimulation of adrenal glands. So far there had been rare report on pathologic changes of adrenal glands. We evaluated the changes of adrenal glands of the patients with CD using Computed Tomography (CT) scan. 

 Sixty five CD patients (12 men, 53 women; mean age 37.6±12.74 years, range 17-68 years) were included. The diagnosis of CD had been confirmed by histologically after trans-sphenoidal surgery of pituitary adenoma. Radiologic findings of the adrenal glands were categorized by normal, hyperplasia, nodular hyperplasia, and adenoma. The duration of clinical symptoms was 26 ± 30.57 months (1-180 months), including weight gain, moon face, central obesity, abdominal striae, and disorders of menstruation. Forty (61.5%) of 65 patients had normally shaped adrenal glands proven by CT scan. Thirteen patients (20.0%) had hyperplasia (bilateral 8, left 5) of the adrenal glands, seven patients (10.8%) had nodular hyperplasia (bilateral 2, left 5), and five patients (7.7%) had adrenal adenoma (bilateral 1, left 4). There were no differences in sex ratio, age, Hardy classification, preoperative ACTH and cortisol level, and preoperative basal 24 hour urine cortisol among patients with each adrenal lesion on CT scan. Our study revealed variable changes of adrenal gland in CD patients.

 

Nothing to Disclose: CK, CRK, SHK, EJL

15625 14.0000 MON-0662 A Changes of Adrenal Gland in Patients with Cushing's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Henry G Fein*
Sinai Hospital and Johns Hopkins School of Medicine, Baltimore, MD

 

Persistent Weight Loss in Patients Treated with Mifepristone (MIFE) for Cushing's Syndrome: Results from the SEISMIC & Long Term Extension Studies

Henry G. Fein1, T. Brooks Vaughan III2, Coleman Gross3, Dat Nguyen3

1Sinai Hospital and Johns Hopkins School of Medicine, Baltimore, MD; 2The University of Alabama at Birmingham School of Medicine, Birmingham, AL; 3Corcept Therapeutics, Menlo Park, CA.

Background: Weight (WT) gain is common in Cushing’s syndrome (CS) and is associated with adverse metabolic consequences of the disease including increased cardiovascular risk and poor quality of life. SEISMIC, a multicenter open label study of MIFE (300-1200 mg qd) in CS patients (n=50), demonstrated significant WT loss over 24 weeks (wks) that was associated with decreases in total body and abdominal fat. Here we present WT loss data on those patients continuing in the long term extension (LTE) study who received MIFE for up to 3.5 years.

Methods: After the 24 wks of SEISMIC, and then 6 wks off (drug safety evaluation period), 30 patients were enrolled in the LTE. We analyzed change in body WT at baseline (BL), and wk 24 of SEISMIC and at Entry, month (mo) 6, 12, 18 and 24 and/or Endpoint (last measure) in LTE. Evaluable WT data was available in 29 patients. 

Results: Twenty women and 9 men, mean age 45.4±11.24yr received MIFE for a median of 29.3mo (8.4–42.0).  At BL mean WT was 105.4±34.3kg (n=29) and decreased to 97.2±30.8kg (n=29) at wk 24.  At entry into LTE mean WT was 98.6±30.5kg (n=28). In the LTE, mean WT was 95.2±32.2kg (n=27), 96.3±31.2kg (n=26), 96.6±34.7kg (n=25), 98.8±37.1kg (n=16) at mo6, 12, 18, 24, respectively. At endpoint, mean WT was 95.0±33.5kg, a 9.5% decrease from BL(p = 0.007); a -1.9% change from week 24 (p=ns) in SEISMIC. Of the 18/29 patients who experienced ≥5% WT loss at the end of the SEISMIC, 58.8%, 50.0%, 66.7% maintained at least that degree of WT loss at mo 6, 12, and Endpoint, respectively, in LTE. At Endpoint, WT loss was maintained in 7/10 patients who had ≥10% WT loss in SEISMIC.

Conclusion: MIFE treatment in CS produces significant WT loss that is sustained in most patients during long term treatment. This sustained WT loss may translate into positive metabolic and other health outcomes in this population.

 

Disclosure: HGF: Speaker Bureau Member, Corcept.

12682 15.0000 MON-0663 A Persistent Weight Loss in Patients Treated with Mifepristone (MIFE) for Cushing's Syndrome: Results from the Seismic & Long Term Extension Studies 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Aikaterini A. Nella*1, Ashwini Mallappa2, Verena Gounden1, Lori-Ann Daley1, Adam Gonzalez3, Peter C. Hindmarsh4, Steven J. Soldin5 and Deborah P. Merke1
1National Institutes of Health, Bethesda, MD, 2National Institutes of Health Clinical Center, Bethesda, MD, 3National Institutes of Health, Clinical Center, Bethesda, MD, 4Univ College London, London, United Kingdom, 5Georgetown University, Bethesda, MD

 

Background: Classic congenital adrenal hyperplasia (CAH) treatment focuses on cortisol and aldosterone replacement, and prevention of ACTH-driven androgen excess. Conventional cortisol replacement with oral glucocorticoids is suboptimal and often fails to effectively suppress adrenal androgen overproduction without supraphysiologic doses. Continuous subcutaneous hydrocortisone infusion (CSHI) has been suggested to mimic physiologic cortisol secretion, leading to improved CAH control at doses similar or lower than conventional treatment, but no clinical trials have been performed to date to systematically investigate this hypothesis.

Methods: We are conducting a phase I-II clinical trial assessing the safety and tolerability of 6-month CSHI in CAH, and hypothesized that near-physiologic cortisol replacement via CSHI will improve CAH control in difficult-to-treat patients as compared to conventional oral glucocorticoid therapy. To date, 4 adults (2 men, 2 women) with difficult-to-treat classic CAH due to 21-hydroxylase deficiency have been recruited. Difficult-to-treat classic CAH was defined as the coexistence of hyperandrogenism (8 am 17-OHP >1200 ng/dL or androstenedione >210 ng/dL), hypercortisolism (treatment with supraphysiologic glucocorticoid doses), and one or more glucocorticoid-related comorbidities.  Patients were admitted to the National Institutes of Health Clinical Research Center. Informed consent was obtained. Patients had serial hormonal sampling on conventional therapy prior CSHI initiation, and at 2 month intervals while on CSHI to permit infusion rate adjustments. Primary endpoint was the percent of patients with 17-OHP≤1,200 ng/dL at 8 am. Secondary endpoints included changes in androstenedione, ACTH, fasting insulin and glucose, HOMA-IR, weight, blood pressure (BP), AST, ALT, fatigue and quality of life.

Results: All patients tolerated CSHI well and only minimal local skin reaction was reported. At 2 months, all patients had achieved 8 am 17-OHP ≤1,200 ng/dL. Glucocorticoid dose via CSHI was similar or lower than conventional therapy in all but one patient, who had high cortisol clearance. Reductions in androstenedione and ACTH concentrations were noted, but they did not reach statistical significance. Despite a mild increase in the patients’ weight, fasting insulin and HOMA-IR improved (p-values 0.014 and 0.015, respectively), whereas fasting blood glucose remained unchanged. BP, AST and ALT concentrations did not significantly change. Quality of life, fatigue and symptoms of adrenal insufficiency are being evaluated.

Conclusions: CSHI is a safe and well-tolerated therapy in classic CAH patients. CSHI appears to effectively suppress adrenal androgens in difficult-to-treat classic CAH patients at doses similar or lower than the conventional regimen. Long-term outcomes need to be determined.

 

Disclosure: AAN: Coinvestigator, Medtronic Minimed. DPM: Principal Investigator, Diurnal, Principal Investigator, Medtronic Minimed. Nothing to Disclose: AM, VG, LAD, AG, PCH, SJS

12871 16.0000 MON-0664 A A Pilot Study Assessing the Use of Continuous Subcutaneous Hydrocortisone Infusion in the Treatment of Congenital Adrenal Hyperplasia: Preliminary Data 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Alejandro Martínez-Aguayo*1, Francisca Grob2, Carolina Mendoza2, Marcela Lagos3, Eliana Romero4, Alejandra Vera4 and Helena Poggi3
1Pontificia Universidad Catolica de Chile, Santiago, Chile, 2Pontificia Universidad Católica de Chile, Santiago, Chile, 3Pontificia Universidad Católica de Chile, Santiago de Chile, Chile, 4Pontificia Universidad Catolica de Chile

 

Background: Non Classical Congenital Adrenal Hyperplasia (NCAH) due to 21-hydroxylase deficiency is caused by mutations in the CYP21A2 gene, and diagnosed based on 17OHP levels. Individuals with NCAH may show baseline17-OHP (b17-OHP) within the normal range; therefore ACTH stimulation test is performed (p17-OHP). In some cases it is difficult to differentiate between unaffected individuals (UI), heterozygotes (carriers, C), and affected individuals (AI) based on 17OHP levels. Research question: How accurate do 17-OHP levels correlate with the number of affected alleles in the CYP21A2 gene? Setting: School of Medicine, Pontificia Universidad Catolica de Chile (2010-2013). Design: Cross-sectional study. Methods: Fifty subjects with hyperandrogenic signs were studied. 17-OHP was measured by RIA (Coat-A-Count, Siemens), and the CYP21A2 gene was analyzed using large fragment PCR, multiplex ligation probe amplification (MLPA, MRC-Holland), and sequencing. Individuals with b17-OHP < 7 ng/mL, and p17-OHP > 10 and > 15 ng/mL, were grouped according to the number of affected alleles: UI (0 allele), C (1 allele) and AI (both alleles). Also median 17OHP and range were obtained for each group; statistical differences were analyzed with Kruskal-Wallis Test. Results: Among the 36 subjects with b17-OHP < 7 ng/mL, 33 were UI or C, and 3 were AI with a known mutation on one allele and a novel mutation on the other; each of them being different and non severe. Ten out of 24 individuals with p17-OHP > 10 ng/mL and 4/18 with 17OHP > 15 ng/mL were C. Median b17-OHP and p17-OHP in UI (n=14) were 2.4 ng/ml [0.3-6.0] and 6.9 ng/ml [2.0-9.3]; in C (n=22) 2.0 ng/ml [0.5-9.5] and 9.5 ng/ml [3.5-23.4], and in AI (n=14) 9.5 [3.1-40.0] ng/ml and 54.6 [15.4-176.0] ng/ml. The median values were higher in AI compared to UI and to C (P <0.0001). Conclusion: When p17OHP cut-off values of 10 and 15 ng/mL are used, a significant number of individuals had only one mutated allele in the CYP21A2 gene. This could be explained by a mutation in another gene (not studied) that affects 17OHP levels, and the lack of a cut-off value established locally according to the genotype. In cases with 17OHP values near the cut-off, genetic analysis confirms the diagnosis by distinguishing carriers from affected individuals (mutations on both alleles). This has the additional benefit of offering appropriate genetic counseling, especially for individuals with a severe mutation in the CYP21A2 gene.

 

Nothing to Disclose: AM, FG, CM, ML, ER, AV, HP

13037 17.0000 MON-0665 A Diagnosis of Non Classical Congenital Adrenal Hyperplasia: Basal and Stimulated 17-Hydroxyprogesterone Levels or CYP21A2 Genotyping? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Anna Tolli*
Karolinska Institutet, Stockholm, Sweden

 

The effect of moderate-severe traumatic brain injury and subarachnoid haemorrhage on cortisol response to ACTH-stimulation

 

Anna Tölli 1, Jörgen Borg 1, Bo-Michael Bellander 3, Charlotte Höybye 2

1Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden

2Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden

3Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden

A potential complication to Traumatic Brain Injury (TBI) and Subarachnoid Hemorrhage (SAH) is pituitary dysfunction, which has received increased interest. Multiple factors in addition to the primary injury and the ubiquitous stress response to critical illness, may play a role for the development of pituitary deficiencies. We performed a prospective study in patients with a moderate to severe TBI or an aneurysmal SAH with the purpose to explore the response to ACTH stimulation 10 days after TBI or SAH.

Patients, aged ≥18 year, treated in the Neuro-intensive care unit (NICU) after moderate or severe TBI or aneurysmal SAH (GCS 3-13) were included. Ten days post injury/illness or if earlier at discharge from NICU, an ACTH stimulation test (Synacthene) was performed. A normal response was defined as S-cortisol >550 nmol/L. at 30 minutes. Of 84 patients with TBI, 65 were men, 19 women, 63 with a severe and 21 had a moderate TBI. Of 46 patients with SAH, 8 were men and 38 women, 31 had a severe and 15 had a moderate SAH.

Data was obtained in 77 patients with TBI and 43 patients with SAH. Nine patients (12%)with TBI and 6 patients (14%) with SAH responded with an insufficient increase (S-cortisol <550 nmol/l). In contrast 27 patients (32%) with TBI and 23 patients (50%) with SAH had an exaggerated response (S-cortisol 1000-2000 nmol/L). No correlations between S-cortisol response and GCS and peak S100B were found.

In conclusion SAH elicited more frequently an exaggerated response to ACTH-stimulation but the response was not related to indices of severity of brain damage.  The clinical consequences during follow-up need to be further explored.

 

Nothing to Disclose: AT

15207 18.0000 MON-0666 A The Effect of Moderate-Severe Traumatic Brain Injury and Subarachnoid Haemorrhage on Cortisol Response to ACTH-Stimulation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Shira Harel*, Brenden E Hursh, Edmond S. Chan, Vishal Avinashi and Constadina Panagiotopoulos
BC Children's Hospital, Vancouver, BC, Canada

 

Eosinophic esophagitis (EoE) is an allergic inflammatory condition of the esophagus with increasing prevalence in children and adults. Oral viscous budesonide (OVB) is one of the topical corticosteroids considered first-line treatment due to its low systemic bioavailability. Adrenal suppression (AS) has not been previously reported with OVB treatment. Recent evidence suggests that active EoE is associated with reduced elimination of budesonide. Our aim was to determine the prevalence of and associated risk factors for AS in children with EoE treated with OVB for at least 3 months. We retrospectively reviewed a quality assurance initiative that took place in BC Children’s Hospital between June 1, 2012 and November 30, 2013. Consensus was reached between the Endocrinology and Gastroenterology departments that all children with EoE, who were being treated with OVB for at least 3 months, needed to be referred for an Endocrine assessment, including a 1 µg ACTH stimulation test. We reviewed demographic and anthropometric data, medical problems and medication history, symptoms suggestive of AS and recent endoscopic inflammatory findings. Thirteen children (age range 3-17 years) have been assessed. Doses of OVB ranged from 0.5 to 2 mg/day and mean duration of treatment was 18.9 months (range 4-52 months). Five patients (38%) had suboptimal stimulated cortisol [range 343-497 nmol/L; mean (± SD) 426.8 nmol/L (± 58.3); normal ≥500 nmol/L], consistent with AS. We found no significant association between suboptimal cortisol levels and duration of treatment with OVB, ratio of dose to body surface area, dosing regimen (once versus twice daily) or use of concomitant inhaled/nasal/topical corticosteroids. There was also no association with symptoms suggestive of AS or with disease activity on endoscopy. In conclusion, this study suggests that children with EoE treated with OVB for at least 3 months duration are at high risk for AS. These data highlight the need for clinicians to provide families with anticipatory counseling, ensure assessment for AS, and have a low threshold to provide stress dosing for endoscopies and intercurrent illness in these patients. The results of this study may also have clinical applicability for other inflammatory conditions that use topical preparations of budesonide.

 

Nothing to Disclose: SH, BEH, ESC, VA, CP

16587 19.0000 MON-0667 A Adrenal Suppression in Children Treated with Oral Viscous Budesonide for Eosinophilic Esophagitis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Francisco Nieves-Rivera*, Neyda Henriquez-Marrero, Evelyn Cruz-Tirado and Lilliam Gonzalez-Pijem
University of PR, Medical Sciences Campus, San Juan, PR

 

Congenital adrenal hyperplasia (CAH) refers to a group of genetic enzyme deficiencies that impair normal steroid synthesis by the adrenal cortex. The most common form is 21 hydroxylase deficiency, accounting for more than 90% of the cases.  Screening studies indicate that the worldwide incidence of CAH classical type is 1:15,000 live births, of which approximately 75% are salt wasters.  The highest prevalence of CAH classical type has been identified in Yupik Eskimos in Alaska (1:300),and the lowest in New Zealand newborns (1:23,000).    Intermediate prevalence has been reported in Saudi Arabia (1:5,000) and Japan (1:21,000).  In 2004 CAH testing was incorporated to the Puerto Rico Neonatal Screening Program (PRNSP): AutoDELFIA Neonatal 1 7α-OH-progesterone (17-OHP) kit to quantify 17OHP in blood specimens dried on filter paper as an aid in screening newborns for CAH using the 1235 AutoDELFIA automatic immunoassay system (cost ~3 USD/test).

A retrospective review of all screening cases between January 2004 and June 2013 was done to identify newborns with a positive screening test that were later confirmed with the disease.

A total of 20 confirmed cases were identified from a total of 404,656 samples collected for a ratio of 1:20,233 during the period revised.  These positive screening tests prevented these newborns from having a major serious event such as adrenal crisis or demise.

The number of newborns affected with CAH in Puerto Rico was low compared to other populations.  However, it is worth to continue including the screening for CAH since half of the births, males, would fail to be diagnosed early enough as to prevent them from falling into a potentially fatal adrenal crisis.

 

Nothing to Disclose: FN, NH, EC, LG

14453 20.0000 MON-0668 A Ten Years of Neonatal Screening for Congenital Adrenal Hyperplasia in PR: If Investment Really Worth? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Edwin Chng*, Stanley Lam, Robert Hawkins and Shaikh Abdul Kader Kamaldeen Shakoor
Tan Tock Seng Hospital, Singapore, Singapore

 

Introduction:

Intermittent traditional Chinese medicine (TCM) use is highly prevalent in Singapore and many other Asian countries. They often contain steroids, and the effect of its chronic usage leading to adrenal insufficiency has not been well documented. Furthermore, the clinical presentation of adrenal insufficiency is highly variable, ranging from florid presentation to more insidious and vague symptoms. Hence, the diagnosis is challenging, and often depends on a high index of clinical suspicion. A short synacthen test (SST) is often used to diagnose adrenal insufficiency. The aim of this study is to explore the signs and symptoms of patients on chronic TCM use, and the usefulness of SST use in diagnosing adrenal insufficiency in this group of patients.

Method:

The data of 124 patients in our tertiary hospital who underwent SST in the last 2 years was collected prospectively by interview and clinical notes. Of which 46 had chronic TCM usage.

Results and discussion:

46 (37.1%) patients had history of TCM use. 15 (32.6%) patients failed SST: 60min cortisol <20µg/dl (550nmol/L). 5 (10.9%) patients had borderline failed SST: 60min cortisol 14-20µg/dl (400-550nmol/L). The clinical features in those who failed SST are as follows: cushingoid features (66.7%), fatigue (66.7%), giddiness (66.7%), weight loss (53.3%), anorexia (46.7%), myalgia/arthralgia (40.0%), nausea and vomiting (26.7%). Of all the clinical features that we studied, only cushingoid signs were predictive: positive predictive value for failed SST is 60%, and the negative predictive value is 75%. 

All the patients that failed SST were started on hydrocortisone replacement, of which 7 (46.7%) patients came off treatment after an average of 1.04 years (range 0.56 - 1.52 years, median 1.25 years). 8 (53.3%) patients showed minimal improvement in SST levels, and remained on hydrocortisone replacement until now.

All patients on TCM with either a random or 8am cortisol ≥14.5µg/dl (400nmol/L), eventually passed SST, suggesting that these patients (8.7%) could have avoided an SST.

We noticed an under utilisation of ACTH measurements in our clinical practice, and hence we were unable to draw any conclusion of its usefulness from our limited data. However, the combination of both cortisol and ACTH done at 8am could be very helpful in diagnosing adrenal insufficiency in patients on TCM. Moreover, patients without cushingoid features had a low chance of a failed SST.  These findings might serve as a guide in reducing the frequency of using SST in patients with TCM usage.

 

Nothing to Disclose: EC, SL, RH, SAKKS

15613 21.0000 MON-0669 A The Use of Short Synacthen Test in Patients on Exogenous Steroids Use in Diagnosing Adrenal Insufficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Andri Snaer Olafsson1 and Helga Agusta Sigurjonsdottir*2
1University of Iceland, Reykjavík, Iceland, 2Landspitali University Hospital, Reykjavik, Iceland

 

Context: Primary adrenal insufficiency (PAI) is a life-threatening endocrine disease unless properly treated. However, only few publications are found on the prevalence and concomitances of the disease. Latest reports indicate an increase in the incidence of PAI. (1,2)

Objective: The main objective of the study was to find the prevalence of PAI in Iceland. Additional objectives were to study the most common concomitant diseases in patients with PAI, as well as the mode of glucocorticoid (GC) replacement therapies.

Design: The medical records of all patients in Iceland who had received the ICD-10 diagnosis code E27 were evaluated for true PAI. Additionally, these records were evaluated for mode of GC replacement therapy and for concomitant diseases.

Setting: The study covered Iceland as a whole, the records being retrieved from large hospitals and clinics, and every practicing specialist in endocrinology.

Results: PAI was found in 53 individuals, 26 female and 27 male, yielding a prevalence of 22.1 per 100.000. Most of them receive GC replacement with short-acting GCs, and hypothyroidism is by far the most common concomitant disease.

Conclusions: The prevalence of PAI in Iceland is higher than in older publications and in line with latest reports. Treatment is according to latest protocols with short-acting GCs, and comorbidities seem to be the same as previously published in the Western world.

 

Nothing to Disclose: ASO, HAS

16099 22.0000 MON-0670 A Prevalence of Mb.Addison in Iceland 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Josiane Festti1, Cintia M. C. Grion1, Luciana Festti2, Tania L Mazzuco3, Helena Panteliou Lima Valassi4, Vinicius N. Brito5, Decio Sabbatini Barbosa1 and Alexandre Jose Faria Carrilho*6
1Londrina State University, Londrina, Brazil, 2Federal University of Paraná, Curitiba, Brazil, 3Univ Estadual de Londrina-UEL, Londrina PR, Brazil, 4Hospital das Clinicas, Sao Paulo, Brazil, 5Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil, 6Univ de Estadual de Londrina, Londrina, Brazil

 

Relative adrenal insufficiency in sepsis has been extensively debated; however, accurate diagnosis and therapeutic intervention remain controversial. Objectives: To evaluate adrenocorticotropic hormone (ACTH), salivary cortisol, total cortisol and estimated plasma-free cortisol (EFC), cholesterol and lipoproteins as predictors of adrenal insufficiency in patients within 24 h of septic shock diagnosis. Methods: This prospective study evaluated all hospitalized patients aged >18 years, who developed septic shock and were using vasoactive drugs, within 24 h of diagnosis. Blood and saliva samples were drawn at baseline and 60 min (T60) after 250 µg tetracosactide intravenous injection. Patients were divided into two groups: responders (Δ [T60 minus baseline] total cortisol >9 µg/dL; and non-responders (Δ total cortisol ≤9 µg/dL or baseline total cortisol <10 µg/dL). The latter group was considered to have adrenal insufficiency. Results: 7324 hospitalized patients were monitored and 34 subjects with septic shock were included in the analysis. Adrenal insufficiency was found in 32.4%. Total cholesterol, high-density lipoprotein cholesterol, triglycerides and salivary cortisol did not differ between groups. EFC was not better than total plasma cortisol in estimating adrenal function. Baseline endogenous ACTH was higher in non-responders than responders (55.5 pg/mL vs 18.3 pg/mL, respectively, P <0.01). The cutoff ACTH value that discriminated patients with adrenal insufficiency was 31.5 pg/mL. Conclusion: Endogenous ACTH measured within 24 h of septic shock diagnosis could predict adrenal response to tetracosactide.

 

Nothing to Disclose: JF, CMCG, LF, TLM, HPLV, VNB, DSB, AJFC

13441 23.0000 MON-0671 A ACTH but Not HDL-Cholesterol or Salivary Cortisol Was a Predictor of Adrenal Insufficiency in Patients with Septic Shock 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0649-0671 5055 1:00:00 PM Hypothalamic-Pituitary-Adrenal Axis - CAH, AI & Cushing's Poster

Masako Hatano*1, Yuriko Kuwabara2, Emi Suwa2, Kenta Imai2, Takujiro Iuchi2, Shigemitsu Yasuda1, Akinobu MInagawa2, Yuichi Noguchi1, Takuya Awata2 and Shigehiro Katayama3
1Saitama Medical University, Saitama, Japan, 2Saitama Medical University, 3Saitama Med Univ, Saitama, Japan

 

Feminizing adrenal tumors are rare and sometimes highly malignant. Although these tumors were reported to be associated with estrogen production and/or aromatase activity, we herein describe a case with testosterone production which was pathologically proven in a feminizing adrenal tumor.  The patient was a 60-year-old man who had begun to experience pain in the right hypochondrium around in 2009. Abdominal CT at another hospital in January 2012 showed a 16-cm tumor in the right adrenal gland and the patient was referred to our hospital. He had developed gynecomastia without any evidence of Cushing’s sign. Blood examinations showed increased DHEA-S and estradiol , and decreased testosterone, with suppressed levels in LH and FSH. The urinary steroid profile showed a normal range of cortisol and the aldosterone metabolites and a marked elevation in DHEA, pregnenolone, 17OH-pregnenolone, estrogen and the 11-deoxycortisol and androstenedione  metabolite. Abdominal MRI also demonstrated  a tumor in the right adrenal gland, the intensity of which was high on T2- and T1-weighted images, suggesting bleeding and necrosis. Based on the diagnosis of an adrenocortical carcinoma, he underwent right adrenalectomy. The extirpated adrenal gland was pathologically examined. SF-1 was positive, the tumor met seven Weiss criteria, and the Ki67/MIB-1 index was 18% (hot spot), confirming the suspected diagnosis of adrenocortical carcinoma. Immunohistochemical analysis of enzymes involved in steroidgenesis revealed disorganized pattern. There were few enzymes involved in sex steroid metabolism, such as aromatase, 17β-HSD1, ST and 5α-reductase 1. Some of the tumor cells expressed 5α-reductase 2, while 17β-HSD5 was diffusely expressed in all tumor cells. Based on these histological findings, testosterone synthesis was predominant. After surgery, eleveated steroid metabolites as described above were decreased. However, since the patient had local recurrence and lymph node involvement, mitotane therapy was started.   These results suggest that, in the present case, feminization was initially considered to be caused by excessive estrogen which was converted through peripheral aromatization of testosterone synthesized in the tumor. However, RT-PCR of the adrenal tumor revealed promoterⅡgene expression, indicating aromatization of testosterone to estrogen within the adrenal tumor. Discrepancies between clinical and pathological findings may be explained by the amount of estrogen production by the tumor.

 

Nothing to Disclose: MH, YK, ES, KI, TI, SY, AM, YN, TA, SK

11152 1.0000 MON-0747 A A Case of Feminizing Adrenal Cancer with Pathologically Confirmed Testosterone Production 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Carolina Mendoza*1, Carolina A Loureiro1, Carmen Campino2, Cristian A Carvajal2, Carlos E Fardella2, Hana Rumie3 and Alejandro Martinez4
1Pontificia Universidad Católica de Chile, Santiago, Chile, 2Pontificia Universidad Catolica de Chile, Santiago, Chile, 3Complejo Asistencial Hospital Dr Sótero del Río, Santiago, Chile, 4Pontificia Universidad Catolica de Chile, Santiago

 

Background: Familial hyperaldosteronism type I (FH-I, OMIM #103900) is often characterized by severe hypertension, variable hyperaldosteronism, low plasma renin activity (PRA) and normal or decreased serum potassium due to unequal crossing over of the genes that encode the steroid 11ß-hydroxylase (CYP11B1) and aldosterone synthase (CYP11B1) enzymes, which results in a chimeric CYP11B1/CYP11B2 gene (CG) with aldosterone synthase activity regulated by plasma ACTH. An early diagnosis and treatment is important, not only to manage hypertension but also to avoid possible deleterious effects of aldosterone on the endothelium and cardiovascular diseases.

Clinical case: a 3 months old boy was referred for evaluation because his mother, grandfather and uncle have FH-I confirmed by presence of chimeric CYP11B1/CYP11B2 gene. He was born at 36 weeks gestation, cesarean delivery due to intrauterine growth restriction, birth weight 2365 g. (<p10th), birth length 44 cm (<p10th), he was admitted to the hospital during one week with the diagnosis of transient tachypnea; without electrolytes or blood pressure disturbances during hospitalization. At initial evaluation his was normotensive (75/54 mmHg, reference < 106/62 mmHg) and his physical exam was unremarkable. Laboratory tests were consistent with hyperaldosteronism: elevated serum aldosterone (SA) (> 120 ng/dL, reference: 5-90 ng/dL), suppressed PRA (0.39 ng/ml*h-1, reference: 2.35-37 ng/ml*h-1), elevated aldosterone/renin ratio (ARR) (307, reference: 10 in childhood[1], not validated in new-born), genetic study was performed by XL-PCR and confirmed chimeric CYP11B1/CYP11B2 gene.

The patient began treatment with cortisol (10 mg /m2 /d) showing favorable response. After 8 months of therapy his laboratory tests have normalized: SA (77.8 ng/dL, n: 5-90 ng/dL), PRA (5.2 ng/ml*h-1), ARR (14.9), normal echocardiography, normal fundoscopic exam, normal hs-CRP (0.35 mg/L, reference: <3 mg/L . He has remained normotensive and has shown catch up growth without Cushingoid side effects.

Conclusion: patients with FH-I usually show a rapid response to the institution of glucocorticoid therapy. Clinical and experimental data suggests that aldosterone excess can induce adverse cardiovascular, cerebrovascular, metabolic and renal sequels independently of its effects on blood pressure, this put emphasis on high suspiction diagnosis, confirmatory genetic test and early treatment.


 

Nothing to Disclose: CM, CAL, CC, CAC, CEF, HR, AM

15905 2.0000 MON-0748 A Familial Hyperaldosteronism Type I, Early Diagnosis and Treatment: Avoiding Future Complications 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Jay Karlou I Piedad Sanchez*, Tze ping Loh, Lip Min Soh and Shih Ling Kao
National University Hospital Singapore, Singapore, Singapore

 

Background: The main treatment goals for primary aldosteronism are normalization of blood pressure (BP) and serum potassium. This is achieved through adrenalectomy or medical therapy with mineralocorticoid receptor antagonist. We describe a case of resolution of hypertension and hypokalemia in a patient with untreated primary aldosteronism and end-stage renal failure following initiation of hemodialysis.

Clinical Case: A 34 year-old lady with end-stage renal failure awaiting dialysis was referred for uncontrolled hypertension and severe persistent hypokalemia (K 2.2 – 3.4 mmol/L). She was treated with nifedipine LA 30mg OM, metoprolol 100mg BD and potassium chloride 1.2g OM. Plasma aldosterone was elevated at 9817 pmol/L (reference: 110-860 pmol/L) with suppressed renin activity (< 0.02ng/ml/hr) [reference: 1.35-3.95ng/ml/hr], consistent with the diagnosis of primary aldosteronism.  Non-contrast CT scan showed a hypodense nodule measuring 26 x 16mm in the right adrenal gland. Nifedipine LA was increased to 90mg OM, and prazosin 0.5mg BD and indapamide SR 1.5mg OM were added for BP control. Serum potassium was maintained between 3.3 – 4.9 mmol/L on spironolactone 25mg OM and potassium chloride 1.2g OM. Six months later, the patient was initiated on hemodialysis with subsequent improvement of her BP and potassium levels. She required only metoprolol 12.5 mg BD on non-dialysis days, and potassium supplements were discontinued as she remained normokalemic.

The mechanism underlying this dramatic clinical improvement was investigated. Plasma aldosterone levels were re-measured and was persistently elevated at 5796 pmol/L, with a suppressed renin activity of 0.52 ng/ml/hr. This excluded tumor infarction as an underlying cause. We hypothesized that aldosterone, being 55% unbound, could potentially be removed during hemodialysis. Aldosterone levels were measured in plasma and dialysate before, during and after hemodialysis. Plasma aldosterone level was noted to increase 3-fold post-dialysis, and dialysate:plasma aldosterone ratio was 0.05, suggesting that aldosterone was not significantly dialyzed. Repeat trans-thoracic echocardiogram showed normal cardiac function, excluding a cardiogenic cause for the reduction in BP.

Conclusion: Aldosterone acts on the distal nephron to increase sodium reabsorption and potassium secretion, which manifest as hypertension and hypokalemia. The improvement in hypokalemia in this patient is likely due to progression of end-stage renal failure with impaired potassium excretion, and absence of functioning collecting tubules for aldosterone action. The improvement in hypertension is likely secondary to fluid removal via hemodialysis. Circulating aldosterone remained high despite hemodialysis, and the patient underwent laparascopic right adrenalectomy to eliminate the detrimental extra-renal effects of hyperaldosteronism.

 

Nothing to Disclose: JKIPS, TPL, LMS, SLK

16627 3.0000 MON-0749 A Amelioration of Hypertension and Hypokalemia in a Patient with Untreated Primary Aldosteronism and End-Stage Renal Failure after Initiation of Hemodialysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Rami Fikri*1, Jeannie Todd2, Fausto Palazzo1, Stephen Robinson3, Jeremy Philip Cox1, James Jackson1 and Karim Meeran4
1Imperial College Healthcare NHS Trust, London, United Kingdom, 2Imperial College Healthcare NHS Trust, London, 3Imperial Colllege Healthcare NHS Trust, London, 4Imperial College NHS Healthcare Trust, London, United Kingdom

 

Background:

Conn’s is a syndrome of autonomous aldosterone oversecretion presenting with hypokalaemic hypertension. It is a heterogeneous group of disorders that includes adrenal adenoma, bilateral adrenal hyperplasia, adrenocortical carcinoma & inherited familial hyperaldosteronism (1-4). Subclinical Cushing's syndrome is present in up to 20% of adrenal incidentalomas. It is defined as a mild subclinical ACTH-independent hypercortisolemic state that may eventually cause complications. Co-secreting adenomas are rare.

Case report:

We present a series of 6 patients who had hypokalaemic hypertension. They were all initially diagnosed with primary hyperaldosteronism then later with subclinical Cushing’s syndrome. The mean age at diagnosis was 51.8 yrs. All patients needed at least 2 antihypertensives & continuous oral potassium supplements except for 1 patient who needed it intermittently. Plasma renin activity was suppressed in all patients with aldosterone levels between 390 and 1000 pmol/L and a ratio between 2000 and 4750. Aldosterone failed to suppress on saline loading test in all patients  There was concordance between the cross sectional and adrenal vein sampling results in all patients. 5 patients were later diagnosed with subclinical Cushing’s syndrome after failing the Low dose Dexamethasone suppression test (LDDS). The 6thpatient with bilateral adrenal hyperplasia was diagnosed post retroperitoneoscopic adrenalectomy that was done for an enlarging adenoma. 4 patients had a Conn’s adenoma confirmed on histopathology and 2 had nodular adrenal hyperplasia. All patients failed short synacthen test (SST). The 2 patients with bilateral adrenal hyperplasia had surgery because 1 was misdiagnosed and the other for an enlarging 3.2 cm adenoma.

All patients required steroid replacement postadrenalectomy. Follow up with repeat SST showed a slow adrenal axis recovery in only 2 patients with a reduction in the hydrocortisone dose.

Conclusion:

The Endocrine Society guidelines suggest an initial Conn's screening then confirmation followed by subtype testing (5). There are controversial diagnostic issues due to the variability in diagnostic algorithms, workup & testing for co-secretion (6-8).

We suggest that all patients who are diagnosed with Conn’s hyperaldosteronism should be screened for possible cortisol co-secretion. There has to be a consensus on the best test to assess hypercortisolism in these patients and we recommend the LDDS.

Although most co-secreting adenomas present with subclinical Cushing’s syndrome, this is usually enough to suppress the adrenal axis which slowly recovers because of the  prolonged exposure to a low burden of autonomous cortisol oversecretion. Patients with subclinical Cushing’s syndrome need further workup to manage the metabolic, cardiovascular and skeletal complications that may last for years after cure.

 

Nothing to Disclose: RF, JT, FP, SR, JPC, JJ, KM

11782 4.0000 MON-0750 A The Lost Subtype of Conn's Syndrome. Case Series of Aldosterone & Cortisol Co-Secreting Adenomas Complicated By Post Retroperitoneal Adrenalectomy Hypoadrenalism Requiring Glucocorticoid Replacement 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Paola Luca*1, Eileen Pyra1, Richard P Lifton2 and David K Stephure1
1Alberta Children's Hospital, Calgary, AB, Canada, 2Yale Univ Schl of Med, New Haven, CT

 

Introduction: Familial hyperaldosteronism type 1 (FH-1) is the most common monogenic cause of hypertension and presents with early onset moderate to severe hypertension. FH-1 is an autosomal dominant condition caused by a hybrid gene consisting of 11 B-hydroxylase and aldosterone synthase, resulting in ACTH-driven production of aldosterone in the zona fasciculata of the adrenal gland.

Clinical Case:  Four patients with FH-1 presented between the ages of 0.2-4.7 years, and have been followed for an average of 4.2 years (range 3-5.7 years). The oldest patient was initially referred due to hypertension and a family history of FH-1 in her mother, maternal uncle and maternal grandfather. Her maternal great-grandmother passed away of a brain hemorrhage at age 77 years. Her two younger siblings and maternal cousin were subsequently referred due to the family history. At presentation, 3/4 patients had systolic and diastolic blood pressures >99th and >95th percentile for age, gender and height respectively. Potassium levels were normal in all patients (3.5-4.7 mmol/L, reference range 3.3-5.1 mmol/L), renin was <0.01 ng/mL/hr in 3/4 patients and aldosterone levels ranged from <70 to 851 pmol/L (reference range 111-860 pmol/L). The diagnosis of FH-1 was confirmed by direct screening for the chimeric gene duplication at the Yale Center for Mendelian Genomics by PCR and Southern blotting, where 2000 referrals for FH-1 have been analyzed. Three patients started treatment with spironolactone (initial dosage 1 mg/kg/day) at an average age of 2.7 years (range 1.2-5.2 years). One patient does not yet require treatment. All three patients demonstrated a response to spironolactone with BP maintained <90th percentile for age, gender and height, after dose adjustments. Potassium levels have remained normal with treatment. The oldest patient switched to eplerenone at the onset of puberty and underwent MRI brain angiography, which was normal.

Clinical Lessons: The diagnosis of FH-1 should be considered in all children with hypertension, especially those with a suppressed plasma renin to aldosterone ratio, a family history of early onset severe hypertension, or a family history of early cerebrovascular events. Direct genetic testing is available for children with features suggestive of FH-1. In children with FH-1, initial treatment with mineralocorticoid receptor antagonists such as spironolactone may be safe and effective thereby avoiding the potential risks of glucocorticoid treatment including symptoms or signs of glucocorticoid excess and iatrogenic glucocorticoid deficiency during intercurrent illness.

 

Nothing to Disclose: PL, EP, RPL, DKS

11493 5.0000 MON-0751 A Familial Hyperaldosteronism Type I: Presentation and Clinical Course in a Family with Four Affected Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Eriko Kabata*1, Mitsuhiro Kometani2, Masashi Oe2, Shigehiro Karashima2, Masashi Demura2, Takashi Yoneda2 and Yoshiyu Takeda2
1Kanazawa Univercity, Kanazawa, Japan, 2Kanazawa University, Kanazawa, Japan

 

A 27-year-old Japanese female was diagnosed with hypertension 2 years ago. She was referred to our hospital for hypokalemia (serum potassium 2.8mEq/L). Her blood pressure was 158/98mmHg. Plasma renin activity was 0.5ng/mL/h and plasma aldosterone concentration was 300pg/mL.  Primary aldosteronism was confirmed by a furosemide and upright test, a captopril challenge test and a saline infusion test. There were no clinical and laboratory data of suggesting Cushing’s syndrome or other secondary hypertension. Computed tomography imaging showed no finding of tumor in both adrenal glands. Adrenal venous sampling showed overproduction of aldosterone from right adrenal gland. Laparoscopic right adrenalectomy was done and her blood pressure was normalized and hypokalemia was improved. Pathological findings demonstrated 10 multiple aldosterone-producing microadenomas which diameter were less than 6mm. Adrenocortical tissues and adenomas were histologically evaluated and immunohistochemical analyses for the steroidogenic enzymes, including 3beta-HSD and CYP17 indicated aldosterone-producing adenomas. DNAs were extracted form 4 different microadenomas and were analyzed by Sanger DNA sequence for KCNJ5 gene. One microadenoma showed G151R mutation and 2 microadenomas had T158A mutation. No genomic mutations were detected in this patient. Further studies are necessary to clarify the somatic mutagenesis in microadenoma of aldosterone.

 

Nothing to Disclose: EK, MK, MO, SK, MD, TY, YT

14538 6.0000 MON-0752 A A Case of Multiple Aldosterone-Producing Microadenomas with Different Mutations in KCNJ5 Gene 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Akiyo Tanabe*1, Motohiko Aiba2, Kazunari Tanabe1 and Atsuhiro Ichihara1
1Tokyo Women's Medical University, Tokyo, Japan, 2Tokyo Women's Medical University Medical Center East, Tokyo, Japan

 

Introduction: In the setting of end-stage renal disease (ESRD), plasma aldosterone concentration (PAC) and plasma renin activity (PRA) may be increased and hypokalemia may be masked in patients with primary aldosteronism (PA). Herein we describe a patient with PA and ESRD treated with hemodialysis (HD), the later associated with secondary hyperaldosteronism.

Clinical case: A 40-year-old Japanese woman with an incidentally discovered right adrenal mass had been treated with HD for 20 years for ESRD caused by chronic nephritis. She was normotensive and normoglycemic. Computed tomography (CT) demonstrated a 55 x 34 x 45 mm bilobed right adrenal mass, which consisted of 2 nodules (30 mm and 20 mm in diameter). The adrenal nodules were low density on CT and enhanced inhomogeneously with contrast administration. Magnetic resonance imaging showed low intensity right adrenal nodules on T1-weighted images and inhomogeneous high intensity nodules on T2-weighted images. Her serum potassium (s-K) levels averaged 4.8 mEq/L before HD and 3.2 mEq/L at the end of each episode of HD. ACTH (18 pg/mL, Ref; 10-60), serum cortisol (7.1 μg/dL, Ref; 5-18), DHEA-S (31 μg/dL, Ref; 9-231), plasma catecholamines levels were normal. PAC levels (1480 ng/dL, Ref; 0.4-15) were extremely high and PRA levels (2.8 ng/mL/h, Ref; 0.5-3.0) were normal; however, the aldosterone to renin ratio was increased at 529 (Ref <20). 131-I-MIBG did not accumulate in the adrenal mass. After laparoscopic right adrenalectomy, s-K levels, PAC and PRA before HD were 4.6 mEq/L, 231 ng/dL and 1.7 ng/mL/hr, respectively. s-K levels at the end of HD averaged 5.0 mEq/L. On pathology, 2 cortical tumors were confirmed in the right adrenal gland. The sectioned surfaces of the tumors were mixed with white, yellow, and brown areas; in addition, there were areas of necrosis. Microscopically, the tumor tissue predominantly consisted of compact type cells and some clear type cells. There was fibrotic capsule and atrophic adrenocortical tissue between the two tumors. Because the Weiss diagnostic criteria showed only a single parameter of predominant cell composition, the tumors were determined to be adenomas. The adenoma cells were positive on immunohistochemical staining for P450aldo (aldosterone synthase) and negative for P45011β (11β-hydroxylase) — findings compatible to aldosterone producing adenoma (APA). In adjacent cortical tissue, zona glomerulosa showed positive staining for 3β-hydroxysteroid dehydrogenase and P450aldo — findings suggestive of chronic activation of the renin-angiotensin-aldosterone system and possibly due to chronic hyperkalemia.

Conclusion: Concurrent secondary hyperaldosteronism may confound the diagnosis of PA and APA in patients with ESRD on HD. An important clue to underlying PA in the patient with an adrenal incidentaloma and ESRD is the finding of hypokalemia the end of HD.

 

Nothing to Disclose: AT, MA, KT, AI

12153 7.0000 MON-0753 A Primary and Concurrent Secondary Hyperaldosteronism in the Clinical Setting of End-Stage Renal Disease and Hemodialysis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Kohkichi Morimoto*, Kazutoshi Miyashita, Toshifumi Nakamura, Isao Kurihara and Hiroshi Itoh
School of Medicine, Keio University, Tokyo, Japan

 

BACKGROUND: Primary aldosteronism (PA) is one of the most common diseases inducing secondary hypertension. Patients with polycystic kidney disease (PKD), a relatively rare cause (about 3.5% in Japan) of end-stage renal disease (ESRD), are often accompanied by hypertension, although there have been only twelve case reports of PKD with PA available in PubMed. Massive renal cysts and deteriorated renal function would make it difficult to diagnose adrenal masses with conventional imaging investigations, and more powerful diagnostic modalities have been desired to be established.

CLINICAL CASE: 41-year-old female presented hypertension since she was 22-year-old, proteinuria since 24-year-old, and chronic kidney disease (serum creatinine level of 1.2 mg/dl at the beginning of its course) since 30-year-old. Abdominal computed tomography (CT) revealed PKD when she was 34-year-old. The deterioration of her renal function had been progressive, and she initiated peritoneal dialysis when she was 41-year-old (serum creatinine level of 6.37 mg/dl). Her hypertension had been still therapeutics-resistant after the introduction of dialysis, and finally, investigations for secondary hypertension were performed.

Endocrinological evaluations indicated hyperaldosteronemia with high aldosterone to renin ratio and high 24-hour urinary aldosterone excretion (plasma aldosterone concentration (PAC) 958 pg/ml, active renin concentration (ARC) <2.0 pg/ml, 24-hour urinary aldosterone 8.8 mg). Clinical work-up indicated no other endocrinological abnormalities. Abdominal magnetic resonance imaging (MRI) with chemical shift imaging clarified left adrenal adenoma (27 x 14 mm), although abdominal CT without contrast agent failed to reveal the adrenal lesion because of multiple massive renal cysts with calcification and intracystic hemorrhage. Adrenal vein sampling showed left unilateral production of aldosterone, and laparoscopic left adrenalectomy was performed. After the operation, her PAC level and blood pressure normalized.

CONCLUSION: We present a case of PA that arised in a patient with PKD and ESRD. Imaging diagnosis of adrenal masses would be rather difficult in such patients, although conventional imaging studies including abdominal CT have been recommended for localization diagnosis of PA. MRI, especially chemical shift imaging, would be one of more sophisticated means for detection of adrenal adenoma.

 

Nothing to Disclose: KM, KM, TN, IK, HI

13780 8.0000 MON-0754 A A Case of Polycystic Kidney Disease with End-Stage Renal Disease Presenting Persistent Hypertension Caused By Primary Aldosteronism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Takashi Yoneda*1, Mitsuhiro Kometani1, Masashi Demura1, Shigehiro Karashima1, Masashi Oe1, Toshitaka Sawamura1, Mitsugu Yoneda2, Masakazu Yamagishi1 and Yoshiyu Takeda1
1Kanazawa University, Kanazawa, Japan, 2Kanazawa University

 

Context: Adrenal vein sampling (AVS) is the most reliable procedure for identifying surgically-curable primary aldosteronism (PA). Adrenocorticotropic hormone (ACTH) is used widely during AVS to increase the success rate, but sometimes causes confusing results.

Objective: The aim of this paper was to report a case of surgically-curable PA with two aldosterone producing adenomas (APA) associated with somatic mutations in the KCNJ5 gene in single adrenal gland and demonstrated diagnostic discrepancy between basal and ACTH-stimulated AVS.

Results: A 49-year-old Japanese woman was admitted to our hospital with resistant hypertension and cerebral apoplexy. After treatment of cerebral hemorrhage, her blood pressure was 148/84mmHg on slow-release nifedipine 80mg daily and doxazosin 2mg daily. The diagnosis of PA was confirmed by the captopril- challenge and saline-loading tests. PRA was 0.4 ng/mL/h and PAC was 94pg/mL, with an ARR of 235 after the captopril-challenge test. PAC after the saline-loading test was not suppressed (92pg/mL). An abdominal CT scan revealed a 10 mm right-sided adrenal tumor, and adosterolscintigraphy demonstrated uptake into the right adrenal mass. AVS was performed and subtype diagnosis was made based on the international criteria and the Japan Endocrine Society’s criteria Basal AVS indicated overproduction of aldosterone from the right adrenal gland, while the ACTH-stimulated AVS indicated overproduction of aldosterone from both adrenal glands. The aldosterone level in the contralateral adrenal side was increased by ACTH stimulation from 1100 to 14000pg/mL.Based on comprehensive judging of the combined findings and the agreement of the patient for surgery, a right adrenalectomy was performed. The pathological examination demonstrated a 0.8×1.2 cm nodule and small nodules (2-3 mm in diameter) consisting of clear cells with abundant cytoplasm and polygonal nuclei. Somatic mutations (L168R) in the KCNJ 5 gene were confirmed in a large nodule and one of small nodules by genetic analysis. After the right adrenalectomy, blood pressure decreased to normal levels without an antihypertensive agent, although treatment with amlodipine 5mg daily was continued because of a history of apoplexy. The ARR remained <200. Two years later, blood pressure remained in the normal range two weeks after cessation of amlodipine for endocrinological reevaluation. PRA was 1.2 ng/mL/h and PAC was 83 pg/mL with an ARR of 69. A captopril-challenge test and a saline-loading test were both negative.

Conclusion: Some surgically-curable PAs show diagnostic discrepancy between the results of AVS with or without ACTH stimulation, which implies the existence of micro lesions in the contralateral gland. This case might be an intermediate subtype between unilateral and bilateral PA. Two types of AVSs are required to identify such a case.

 

Nothing to Disclose: TY, MK, MD, SK, MO, TS, MY, MY, YT

14645 9.0000 MON-0755 A Diagnostic Discrepancy Between Adrenal Vein Sampling with and without ACTH Stimulation in Surgically-Curable Primary Aldosteronism Associated with KCNJ5 Somatic Mutation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Gabriel Ikponmosa Uwaifo*1 and Christian A. Koch2
1Louisiana State University Health Sciences Center, New Orleans, LA, 2Univ of Mississippi Med Ctr, Jackson, MS

 

HAIR-AN; HyperAndrogenism (HA), Insulin Resistance (IR)  and Acanthosis Nigricans (AN) is a syndrome found in 5-10% of women with HA. It is presumed to be a subtype of polycystic ovarian syndrome (PCOS). HAIR-AN onset is often in early adolescence. Management is directed at the IR and HA. HAIR-AN, however, can have other causes. We present 2 women with HAIR-AN, secondary hypertension (htn) and primary hyperaldosteronism (PH) that raise the possibility of idiopathic adrenocortical hyperplasia (IAH) as another cause of HAIR-AN.

Case 1: A 32 yo woman seen for longstanding non progressive hirsutism (HR) with onset soon after menarche. She is HIV+ve with undetectable viral load. Longstanding menstrual irregularities and htn with intermittent hypokalemia were present for at least 10y. Examination showed Ferriman Gallwey score of 12, android physique and voice, and extensive AN. PH confirmed with serum aldosterone (AL) of 31-42 ng/dl (0-21) and 24 hr urine AL 26 mcg (3-20) without change after oral salt loading. Adrenal CT: no anomalies; pelvic ultrasound (US): marginally enlarged ovaries with a single 1.7 cm left sided cyst. Serum androgens: elevated testosterone, DHEA-S, and androstenedione with normal 17 OH progesterone (17 OHP), ACTH and DHEA.  ACTH stimulation test showed no abnormal 17OHP increase and overnight 1mg Dex suppression showed normal  suppressed cortisol and unchanged AL. She also had impaired glucose tolerance (HBA1c 5.8%) and fasting hyperinsulinemia ; 33mu/ml (5-13). She was managed with metformin, aldactone and shaving creams which resulted in improved BP, glycemia and IR but no significant change in HA still requiring cosmetic management.

Case 2: A 44 yo woman seen for glycemic control of type2 diabetes (DM) of 7y duration. She also has htn, hyperlipidemia and long standing HR that started after menarche. She had no virilizing symptoms and her periods are erratic with two pregnancies and one life birth. She had a strong family history of htn, DM and HR. Examination showed excess facial hair but no virilization; nuchal AN but no facial acne or skin tags. PH confirmed with a plasma AL of 26-34 ng/dl and 24 hr urine AL 28 mcg without change after oral salt loading. Serum androgens: elevated testosterone, DHEA-S and normal 17 OH progesterone. She had HBA1c of 8.7 which improved to 6.9 with treatment, baseline hyperinsulinemia  (57mu/ml) and  ACTH of 12.4pg/ml (10-60). Adrenal CT scan and pelvic US were normal.  She was managed with metformin, OCPs and aldactone. This resulted in improvement in glycemia, normal BP but minimal change in HR which continued to be managed cosmetically.

HAIR-AN syndrome is a clinical syndrome of multiple potential etiologies. While variants of PCOS are most common, in women with associated htn, a possible adrenal etiology needs to be considered (1-7). A distinct form of IAH presenting with PH, htn and HAIR-AN should be included in the clinical spectrum for this presentation.

 

Nothing to Disclose: GIU, CAK

14629 10.0000 MON-0756 A Hair-an Syndrome and Primary Hyperaldosteronism: Distinct Syndrome or Random Association ? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Matthew Allum*1, Sophie Barnes1, James Jackson1, Tricia Tan2 and Karim Meeran3
1Imperial College Healthcare NHS Trust, London, United Kingdom, 2Imperial College London, London, United Kingdom, 3Charing Cross Hospital, London, United Kingdom

 

Adrenal vein sampling (AVS) is the gold standard test for distinguishing unilateral hypersecretion from bilateral hyperplasia in primary hyperaldosteronism.  The aldosterone cortisol ratio (ACR) is used to correct for variable dilution between samples.  Published guidelines vary on the interpretation of ACR ratios.  AVS results should be interpreted with caution, especially if near borderline or in the context of discordant imaging.

A 45 year old woman with longstanding hypertension and hypokalaemia was investigated for possible Conn’s Syndrome.  Aldosterone renin ratio was consistently raised and subsequent saline suppression test confirmed primary hyperaldosteronism.  CT scan showed right-sided 9mm adrenal nodule and the left adrenal gland was reported as normal.  AVS without cosyntropin infusion was then performed.   Cortisol levels confirmed appropriate cannulation.  ACR for the left adrenal vein was 15.9, compared to 3.0 on the right adrenal vein and 3.2 for the IVC.  According to Endocrine Society guidelines this could be interpreted as supporting unilateral hypersecretion from the left, as ACR left/ACR IVC >2.5 and ACR right/ACR IVC <1 (1,2).  However, according to our experience and local guidelines, we apply a stricter ratio of ACR right/ACR IVC <0.5 to confirm unilateral hypersecretion.  As the ACR right /ACR IVC was 0.94 and given the discordant imaging suggesting an adenoma on the right, we remained cautious and the patient was managed with continued medical therapy.

Three years later the patient was reinvestigated due to difficulty in tolerating spironolactone.  Repeat AVS showed ACR of 14.4 in the left compared to 18.5 in the right and 3.5 in the IVC.  This now clearly demonstrated bilateral secretion of aldosterone.

This prismatic case suggests that a stricter criterion for suppression of the ACR in the contralateral adrenal should be considered.  We also conclude that AVS results can change over time, as they did here with evolving bilateral adrenal hyperplasia, and that repeat AVS is justified in cases where diagnosis is not clear-cut.

 

Nothing to Disclose: MA, SB, JJ, TT, KM

14821 11.0000 MON-0757 A Repeat Adrenal Vein Sampling Demonstrating Bilateral Aldosterone Secretion after Initial Discordant Results in the Investigation of Conn's Syndrome, a Case Report 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Masashi Oe*, Mitsuhiro Kometani, Shigehiro Karashima, Masashi Demura, Takashi Yoneda and Yoshiyu Takeda
Kanazawa University, Kanazawa, Japan

 

A 55-year-old Japanese female was diagnosed with hypertension one year ago. She was referred to our organization for high blood pressure (140-150/90-100mmHg) before the operation of cochlear implantation. Her blood pressure was 152/92mmHg. Plasma renin activity was 0.1ng/mL/h and plasma aldosterone concentration was 191pg/mL. Primary aldosteronism was confirmed by a captopril challenge test and a furosemide and upright test. Computed tomography imaging showed no findings of tumor in both adrenal glands. Adrenal venous sampling showed overproduction of left adrenal gland. Laparoscopic left adrenalectomy was done and her blood pressure was normalized. Pathological findings showed a microadenoma which diameter was 2mm. DNA was extracted from a microadenoma and was analyzed by Sanger DNA sequence for KCNJ5 gene. The microadenoma had G151R mutation. However, the microadenoma was not immunohistochemically stained using the antibody of CYP11B2. No genomic mutation was detected in this patient. The clinical significance of gene analysis and immunohistochemical staining of CYP11B2 antibody in the tumor should be further investigated.

 

Nothing to Disclose: MO, MK, SK, MD, TY, YT

15944 12.0000 MON-0758 A A Case of Aldosterone-Producing Microadenoma with KCNJ5 Mutation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Ya-Hui Hu*1, Yao-Chou Tsai2, Shi Wen Kuo3 and Shiou-Chi Cherng4
1Taipei Tzuchi Hospital, The Buddhist Tzuchi Medical Foundation, Taiwan, New Taipei City, 2Taipei Tzuchi Hospital, The Buddhist Tzuchi Medical Foundation, Taiwan., 3Taipei Tzuchi Hospital, The Buddhist Tzuchi Medical Foundation, Taiwan, New Taipei City, Taiwan, 4Taipei Tzuchi Hospital, The Buddhist Tzuchi Medical Foundation, Taiwan

 

There are two major subtypes of primary aldosteronism (PA) one is aldosterone-producing adenoma (APA) and the other is idiopathic adrenal hyperplasia(IAH). The adrenal venous sampling (AVS) is golden standard to differentiate APA and IAH. The proficient technique of AVS can increase the accuracy and decrease the complications. The examination of AVS is unavailable in some hospital. We retrospectively reviewed 12 PA cases with adrenal tumor by computed tomography (CT) scan in our hospital. They planned to do adrenalectomy. These 12 PA cases received the 131I-6b-iodomethyl-19-norcholesterol (NP-59) adrenal scintigraphy to find out tumor is functional or non-functional tumor before adrenalectomy.  There are two cases was non-functional tumors who confirmed by AVS. They didn’t accept adrenalectomy. The 50% of patients are cured hypertension and almost patients improved blood pressure after adrenalectomy. The NP-59 adrenal scintigraphy is done first because it is non-invasive examination in our hospital. The AVS is only performed in the cases that have inconsistent reports between CT and NP-59.

 

Nothing to Disclose: YHH, YCT, SWK, SCC

16615 13.0000 MON-0759 A 131I-6b-Iodomethyl-19-Norcholesterol (NP-59) Adrenal Scintigraphy Is Greatly Helpful to Detect Functional Adenoma in Primary Aldosteronism before Operation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Alicia Christine Weeks* and Dawn Belt Davis
University of Wisconsin, Madison, WI

 

Background

24-hour urine fractionated catecholamines and metanephrines are diagnostic tests with high sensitivity and specificity in the workup for pheochromocytoma, especially when levels are dramatically elevated. However, two previous reports have demonstrated marked elevations of catecholamines and their metabolites in the setting of uncontrolled obstructive sleep apnea (OSA)1,2.   OSA can also result in hypertension and headache, two of the classic symptoms of pheochromocytoma.  In a patient with uncontrolled or undiagnosed OSA, misinterpretation of the biochemical tests can result in unnecessary testing or procedures.

Clinical Case

A 56 year-old woman presented with a several year history of paroxysmal hypertension, tachycardia, and diaphoresis.  Abdominal/Pelvic CT performed during hospitalization for an unrelated issue revealed a 2.0 cm left-sided adrenal nodule quantified as 37 Hounsfield units.  Post-hospitalization, 24-hour urine metanephrine levels revealed a markedly elevated normetanephrine level of 2340 mcg/24 hr (n 52-310 mcg/24 hours).  24-hour urine metanephrines were remeasured 2 weeks later with continued, albeit lesser, elevation of normetanephrine at 900 mcg/24 hours. There were also mild elevations in 24-hour urine norepinephrine and plasma metanephrines. Thyroid function tests, a.m. cortisol, aldosterone, and plasma renin activity were all normal.  The patient was referred to surgery and ultimately underwent a laparoscopic adrenalectomy with final pathology revealing an adrenal adenoma.   Paroxysms continued in the post-operative state and a similar elevation in 24-hour urine normetanephrine levels (1142 mcg/24 hr, n 52-310 mcg/24 hours) was seen after adrenalectomy.  A search for an alternative underlying cause ensued.  As the patient had a history of OSA, a temporal correlation between symptom onset and lack of continuous positive airway pressure (CPAP) compliance was investigated.  The patient indeed confirmed that the progression of symptoms occurred as CPAP use waned and ultimately was discontinued entirely.  She restarted CPAP therapy and after several weeks of compliance had documented reduction in her pulse and blood pressure, even with the discontinuation of metoprolol.

Conclusion

OSA affects 42 million American adults and the prevalence in those with drug-resistant hypertension is 82%.  It is estimated that 75% of cases of severe OSA remain undiagnosed. Given the high prevelance of OSA and the very low prevelance of pheochromocytoma, one can predict that the false positive rate of 24 hr urine metanephrines is actually much higher in the general population than the reported values of 2%. Importantly, there can also be significant overlap in the symptoms of these disorders. Uncontrolled or undiagnosed OSA is an important reversible cause of catecholamine elevation that should be excluded prior to making a diagnosis of pheochromocytoma.

 

Nothing to Disclose: ACW, DBD

13137 14.0000 MON-0760 A Obstructive Sleep Apnea Mimicking Pheochromocytoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Chhaya Makhija*, Whitney S Goldner and Andjela T Drincic
University of Nebraska Medical Center, Omaha, NE

 

Background: Pheochromocytoma crisis is a rare life-threatening endocrine emergency. We present 2 cases of pheochromocytoma/paraganglioma (pheo/para) crisis precipitated by oral prednisone and intra-articular triamcinolone, the latter being the first case reported to induce a delayed catecholamine crisis.   

Case 1:  45 year old healthy, athletic female presented with chest pain after receiving 60mg of oral prednisone for laryngitis. Cardiac catheterization revealed normal coronary arteries with severely reduced ejection fraction. Within 3 hours, she had a cardiac arrest complicated by multiorgan failure.  Ultrasound identified an incidental right adrenal mass measuring 4.7cm x 3.9cm x 4.7cm.  Subsequently, she stabilized but became hemodynamically unstable again after receiving 100mg intravenous hydrocortisone.  Plasma metanephrines and normetanephrines were markedly elevated, 11nmol/L (<0.50nmol/L) and 12 nmol/L (<0.90nmol/L) respectively.  She was treated with alpha blockade and calcium channel blockade and underwent successful right adrenalectomy confirming pheochromocytoma. 

Case 2:  77 year old physically active, asymptomatic male with long standing hypertension and remote coronary artery disease presented with chest pain 2 weeks after receiving intra-articular triamcinolone injection.  Cardiac catheterization revealed patent stent and no evidence of new ischemia. He had extremely labile blood pressures treated with IV fluids, alpha blockade and beta-blockade.  He was found to have an abdominal paraganglioma measuring 9cm x 7.5cm with markedly elevated plasma metanephrines and normetanephrines at 17nmol/L and 108nmol/L respectively and underwent successful paraganglioma resection.   

Conclusion:  We describe two patients with pheo/para crisis precipitated by steroid exposure.  Both were previously asymptomatic and presented with chest pain as their initial crisis manifestation.  One presented within 24 hours of oral prednisone exposure consistent with existing literature and the second is a novel presentation of crisis following an intraarticular triamcinolone injection.  Based on pharmacokinetics, intraarticular triamcionolone raises serum cortisol in 2-3 weeks.  Postulated mechanisms are inhibition of Catecholo-O-methyltransfearse activity and induction of catecholamine synthesis by steroids.  These cases illustrate the risks of exogenous glucocorticoids in a patient with a catecholamine secreting tumor.  Although there are rare reports of steroid induced pheochromocytoma crisis, we are unaware of any reports of intraarticular steroids resulting in crisis. Hence this is a novel risk factor for pheochromocytoma crisis that clinicians should be aware of.  Furthermore, presence of catecholamine secreting tumor should be considered in patients presenting with significant hemodynamic instability following exposure to steroids.

 

Nothing to Disclose: CM, WSG, ATD

11469 15.0000 MON-0761 A Pheochromocytoma/Paraganglioma Crisis Precipitated By Oral and Intra-Articular Steroid Exposure 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Yusef Hazimeh*1, Vibhavasu Sharma2, Mary Koeppe Luidens3 and Mary Ellen Ehlers4
1Albany Med College, Albany, NY, 2albany medical college, Beavercreek, OH, 3Albany Medical Center, Albany, NY, 4Albany Medical Center, Loudonville, NY

 

Background: 

Pheochromocytoma may have multiple clinical manifestations including paroxysmal hypertension, tachycardia, sweating, nausea, and headache.  Migraine has some of the manifestations seen with pheochromocytoma. We describe a patient who had a history of migraine headaches since childhood and was found to have pheochromocytoma and subsequently Multiple Endocrine Neoplasia. 

Clinical case:

A 20 year-old female, with a history of migraine since the age of seven, presented to the emergency department with headache, abdominal pain, nausea and vomiting. She has been on topiramate, cycloheptadine, fioricet, oxycodone, and sumatriptan for migraine headaches for the previous six years. Her blood pressure was 130/80, heart rate 112 BPM. Her abdomen was slightly tender to palpation without any palpable masse. CAT scan of abdomen  revealed a heterogeneous 6.0 cm right adrenal mass. The second day, she had an elevated blood pressure of 210/100 mmHg. 24-hour urine collection showed:  cortisol  78 mcg/24hr (<50),  metanephrine 1,195mcg/24hr (24-290), normetanephrine 6,680 mcg/24hr ( 82-500), dopamine 244mcg/24hr (65-400), epinephrine 50 mcg/24hr ( 0-20), and normetanephrine 815mcg/24hr ( 0-135) with creatinine level indicating adequate collection. Serum aldosterone was 2.6 ng/dl (1-16) and renin 49 ng/dl/hr (20-160). Her serum electrolytes were normal. Her blood pressure was treated adequately with phenoxybenzamine followed by metoprolol. One week later she underwent right adrenalectomy. Pathology was consistent with pheochromocytoma. After subsequent follow up, her migraine attacks become less frequent and she stopped three of her headache medications. Serum calcitonin level checked in follow up visit was 30.1 pg/ml (<15). Her calcium and parathyroid hormone levels were in the normal range. Genetic testing came back positive for RET germline mutation involving codon 634; the mutation that is associated with Multiple Endocrine Neoplasia type 2A. She was referred for thyroidectomy due to high risk of medullary thyroid cancer.   Family members were contacted for genetic counselling.  

Conclusion:

Headache is a highly prevalent symptom of pheochromocytoma.  Children and adolescents with long term headache, requiring multiple medications, may need to be screened for a missed pheochromocytoma. A diagnosis of pheochromocytoma can result in an earlier and successful treatment of headaches. In addition, subsequent testing and diagnosis of MEN-2 and thyroidectomy can be completed. Importantly, family members can be counseled and their risk assessment done in a timely manner.

 

Nothing to Disclose: YH, VS, MKL, MEE

12898 16.0000 MON-0762 A From Childhood Migraine Headache to Pheochromocytoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Mohammed Ahmed*1, Nora Al Kahtani1, Ali Al Reesi1 and Bader Mansour Alsughyer2
1King Faisal Specialists Hospital & Research Centre, Riyadh, Saudi Arabia, 2King Khalid University Hospital, Riyadh, Saudi Arabia

 

Background Information:

 Neurofibromatosis type 1  (NF I) is an autosomal dominant genetic disorder. About one-half cases are familial; the remainder are new mutations. NF1 gene is a large gene , spanning over 350 kb containing 60 exons  and is mapped to ch 17q11.2  Gene mutations result in a loss of functional protein Neurofibrin, a tumor suppressor gene and account for a wide a highly variable phenotypic expression. The hallmarks of NF1 are the multiple cafe’-au-lait spots (CALS),  and cutaneous neurofibromas. The diagnostic criteria developed by the NIH Consensus Conference are highly specific and sensitive. According to these criteria, at least two of seven features must be evident for the diagnosis. Skeletal lesions appear early in life. Optic gliomas are frequent brain tumors. Vascular lesions causing renovascular HTN are frequent . Renovascular lesions can be detected in patients who are still normotensive. Pheochromocytoma is  a much less cause of HTN.  We have reported previously at 2010 Endocrine Society meetings NF1in association with renovascular HTN. We now report a case of NF1 associated with pheochromocytoma.

Objective: To highlight HTN is a frequent findings, its presence is considered essential in most cases of NF1. It is important to determine the etiology of HTN. 

Case Summary:

A 56-yr old man with NF1 and HTN was  investigated to uncover the cause of HTN. Of his 9 children 4 have had skin lesions of NF1. O/E; he had multiple café-au-lait spots, subcutaneous neurofibromas, and diffuse freckling. Slit lamp examination of the eyes revealed Lisch nodules(pigmented  iris hamartomas; relatively specific finding for NF1 and do not affect  the vision. Investigations: he had a large 5.8x 4.5 cm left adrenal lesion on CT, abnormal  urine metanephrine : 24 umol/day (RR: 0-1.49), and normetanephrine 21 umol/d (RR: 0-3.43). Additional findings detected on CT/PET-CT included a soft tissue lesion measuring 7.7 cm in lower sacral region extending  within vertebral neural foramin, highly suggestive of a neurogenic tumor, MRI brain detected no intracranial lesions including no optic neuroma. Whole body bone scan yielded negative findings.

Conclusions:

Diagnosis of NF 1 is based on the presence of characteristic clinical findings. Genetic testing is not necessary for diagnosis. NF1 is characterized by complete penetrance with highly variable clinical expression. Accordingly, patients should be investigated thoroughly to define phenotypic features. HTN is considered essential feature, its etiology must be investigated. Renovascular HTN is frequent and pheochromocytoma is a much less cause of HTN.

 

Nothing to Disclose: MA, NA, AA, BMA

11321 17.0000 MON-0763 A Neurocutaneous Genetic Disorder (Neurofibromatosis Type 1; von Recklinghausen's disease) Associated with a Correctable Cause of Hypertension 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Alex Manzano*1, Mario Andres Bustos2 and Atil Yilmaz Kargi1
1University of Miami Miller School of Medicine, Miami, FL, 2Military University, Colombia

 

Introduction

The term “silent” or “nonfunctional” pheochromocytoma has been used to describe adrenal masses that lack the classic clinical symptomatology and no detectable biochemical markers to confirm the diagnosis of pheochromocytoma. We present two cases of adrenal incidentalomas that had complete negative biochemical evaluation but pathologic findings consistent with pheochromocytomas.

 Case 1: 43-year old male with unintentional 20lbs weight loss associated with abnormal liver function test and CT scan of the abdomen showing a 12 x 11 x 14 cm cystic and solid mass without clear identification of primary site. Abdominal MRI showed a 15 cm right adrenal mass. No history of hypertension, panic attacks, palpitations or skin changes. 24 hours urinary vanilmandelic acid (VMA) 2.7mg/day (range, 6-90 mg/day, fractionated norepinephrine 60 mcg (range, 15-100 mcg/d), epinephrine 8 mcg (range, 2-24 mcg/d), dopamine 348 mcg (range, 52-400 mcg/d), total cathecholamines 68 mcg (range, 26-121 mcg/d), normetanephrine 462 mcg (44-546 mcg/d), metanephrine 111 mcg (range, 80-230 mcg/d) total metanephrines 573 mcg (range, 90-690 mcg/d). He underwent right adrenalectomy without documentation of hypertension or arrhythmias. Histopathologic studies confirmed the final diagnosis: malignant nonfunctional pheochromocytoma.

 Case 2: 47-year old male with an incidental left adrenal mass discovered on a routine abdominal CT for evaluation of abdominal pain. The left adrenal mass was heterogeneous, measured 2.1 cm and 59 Hounsfield units (HU) on unenhanced images. Biochemical evaluation to exclude functional adrenal mass showed: serum cortisol level 1.1 mcg/dL (after 1 mg DST), plasma aldosterone 4 ng/dL, 24 hours urine normetanephrine 186 mcg/d (44-546 mcg/d), urine metanephrine 185 mcg/d (range, 80-230 mcg/d), total urine metanephrines 537 mcg/d (range, 35-460 mcg/d), serum normetanephrine 295pg/mL (range, 80-520 pg/mL), epinephrine 60 pg/mL (range 20-100 pg/mL), serum dopamine <10 pg/mL, plasma normetanephrines 124 pg/mL (0-145 pg/mL), plasma metanephrines  67 pg/mL (0-62 pg/mL)  DHEAS 280 mcg/dL (range, 44-331 mcg/dL). Laparoscopic left adrenalectomy was performed without  evidence of hypertensive crisis or arrhythmias. Final pathologic report revealed a 3 cm left adrenal tumor composed by 30 % pheochromocytoma and 70% ganglioneuroma, no immature elements or neuroblastic component.

Conclusion:

Although clinically silent, we recommend a complete pre-operative evaluation since the risk of perioperative hemodynamic instability and adrenergic crisis can be prevented with alpha-blockade. In our series, one case was a malignant pheochromocytoma despite being nonfunctional; the other showed minimal biochemical activity after three years of the initial diagnosis. Future research should focus on novel markers that could assist in early detection of silent pheochromocytomas.

 

Nothing to Disclose: AM, MAB, AYK

12681 18.0000 MON-0764 A Silent Pheochromocytomas: When a Known Disease Goes Undercover 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Gustavo Rocha Dissenha*1, Letícia Alarcão Maxta1, Lívia Grimaldi Abud Fujita1, Thaís Helena Monteiro de Oliveira1, Larissa Araújo Nogueira2, Ricardo A Guerra1 and Evandro S Portes1
1Hospital do Servidor Público Estadual, São Paulo, Brazil, 2Hospital do Servidor Público Estadual, São Paulo, São Paulo, Brazil

 

Backgroung

Pheochromocytomas and paragangliomas are rare neoplasms in children and adolescents. Compared to adults, children have higher incidence of bilateral, extraadrenal and multiple tumors. They are also at greater risk of malignant disease. Familial type is more common in this age span and genetic causes more often manifest as bilateral tumors.

Hypercalcemia is an uncommon feature of pheochromocytoma. Causes include: hyperparathyroidism in MEN 2A and MEN 2B, tumor production of PTHrP and distant metastasis.

Clinical case

A 17-year-old boy admitted in the pediatric emergency room with an episode of dizziness, blurry vision and tingling in his upper limbs. He was asymptomatic at admission. His physical exam was normal except for elevated blood pressure (BP : 160/100) and tachycardia (HR: 110 bpm). Abnormal blood pressure levels were already detected in previous routine medical exams six months earlier but no specific therapy or investigation was proposed. He had been complaining of excessive nocturnal sweating in the last eight months.  He had otherwise no history of cardiovascular, renal or endocrine diseases, as well as drug or alcohol abuse.

Investigation for secondary hypertension was initiated. Lab results revealed altered fasting blood glucose levels (106 mg/dl, n: 75-99 mg/dl), mild hypercalemia (total calcium: 10,6 mg/dl, n: 8,8 – 10,6) (ionized calcium: 1,33 mmol/L, n: 1,13 - 1 ,32 mmol/L) with suppressed levels of PTH (<3,00 pg/ml, n: 12 – 72 pg/ml).

Urinary catecholamines were normal but urinary total metanephrines were elevated (8562  mcg/24h, n < 1000 mcg/24h) suggesting the diagnosis of pheochromocytoma. Abdominal MRI showed bilateral adrenal masses with T2 weighted enhancement, reinforcing the diagnosis.  MIBG scintigraphy showed uptake on the right adrenal mass only, with no evidence of extraadrenal disease.

The patient had no family historoy of pheochromocytoma or known genetic disorders.

He was started on an alpha adrenergic blocker (Prazosin) which was titrated up to 6 mg a day until blood pressure levels stabilized around 120/80 mmHg. His heart rate normalized after the prescription of a low dose beta blocker. 

The patient underwent bilateral laparoscopic adrenalectomy successfully. He has been supplemented with 5 mg of prednisone and 0.1 mg of fludrocortisone daily.

Serum calcium levels dropped to normal values soon after surgery (total calcium 8,9 mg/dl, n: 8,8-10,6 ng/dL) and PTH levels also normalized (21,5 pg/ml, n: 12-72 pg/ml).  PTHrP dosage prior to the surgical procedure yielded normal values (19 pg/ml, n: 14 – 27 pg/ml).

Conclusion

We present a case of bilateral pheochromocytoma diagnosed at a young age with no evidence of malignancy. Genetic investigation is recommended. Hypercalcemia was not a consequence of MEN 2, tumor production of PTHrP or distant metastasis.

 

Nothing to Disclose: GRD, LAM, LGAF, THMDO, LAN, RAG, ESP

15608 19.0000 MON-0765 A Bilateral Pheochromocytoma with Hypercalcemia in a Young Patient 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Fareeda Tabassum*1, Khurram Khan2, Edel Casey3, Tomasz Kurzawinski4, Frederick Nkonge2, Belayet Hossain5, Eltayab Marouf2, Khash Nikookam2, Stuart Jones2, Antony Pithankal2 and Nemanja D Stojanovic6
1Barking, Havering and Redbridge University Hospitals NHS Trust, 2Barking, Havering & Redbridge University Hospitals NHS Trust, 3Barking, Havering, & Redbridge University Hospitals NHS Trust, 4UCLH, London, United Kingdom, 5Barking, Havering & Redbridge University Hospitals NHS Trust, Ilford, Essex, United Kingdom, 6Barking, Havering & Redbridge University Hospitals NHS Trust, United Kingdom

 

Background:  Pheochromocytomas are rare tumors with annual incidence of two patients per million population but the autopsy studies suggest a higher incidence with 61% of pheochromocytomas discovered in patients who had hypertension and 91% in those who had nonclassical symptoms during life. This indicates that the great majority of pheochromocytomas remain undiagnosed during life and appropriate screening is important to detect these cases. 

Aims:To review the presentation and results of screening tests used for diagnosis of  asymptomatic and nonclassical pheochromocytomas. 

Methods: Retrospective case note review of cases screened and treated for pheochromocytoma and subsequent confirmation of diagnosis on histology. 

Results: The results showed that out of 12 pheochromocytoma cases, 58% ( 6/12 ) were detected incidentally in asymptomatic patients who had the imaging for some other reasons, 25% ( 4/12 ) presented with nonclassical symptoms of bloating, loin pain and constipation and only 17% ( 2/12 ) of patients presented with classical symptoms of headache, palpitations and anxiety. Hypertension remains the commonest feature present in 75% ( 9/12 ) of patients but not as the presenting complaint. 25%( 3/12 ) patients had other concurrent malignancy and pheochromocytomas were detected as incidentalomas. 24 hour urine metanephrines were significantly raised in 42% ( 5/12 ) of the total cases with 24 hour urine metadrenaline and normetadrenaline raised in 33% ( 4/12 ) cases. 58% ( 7/12 ) of cases had significantly raised 24 hour urine noradrenaline and catecholamines.  The 24hour urine dopamine and 3-methoxytyramine were raised in 8% (1/12 ) cases only. CT imaging showed the presence of adrenal lesions in 100% ( 12/12 ) cases out of which 58% ( 6/12 ) were an incidental finding and 25% ( 3/12 ) had concurrent malignancy. MIBG scan was positive in 92% ( 11/12 ) cases. 58% ( 7/12 ) tumours were located on left side and the size of tumours was variable between 1.7cm – 6.4cm with a median size of about 3.5cm. 

Conclusion: Pheochromocytomas display protean manifestation and majority remain asymptomatic and undiagnosed. Careful biochemical evaluation must be undertaken for patients with asymptomatic incidental adrenal lesion. In patients with metastatic malignancies and adrenal mass, pheochromocytoma must be ruled out prior to eventual biopsies.

 

Nothing to Disclose: FT, KK, EC, TK, FN, BH, EM, KN, SJ, AP, NDS

15167 20.0000 MON-0766 A Pheochromocytoma, Presentation Analysis of Twelve Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Monday, June 23rd 3:00:00 PM MON 0747-0766 5057 1:00:00 PM Adrenal Case Reports - Cushing's, Conn's, Pheo Poster

Sasigarn Arunchaiya Bowden*1, Cindy Young2 and Lawrence Allen Wetterau3
1Nationwide Children's Hospital/The Ohio State University, Columbus, OH, 2Nationwide Children's Hospital, Columbus, OH, 3Kaiser Permanente, Baldwin Park, CA

 

Introduction

McCune-Albright syndrome (MAS) is classically characterized by the triad of peripheral precocious puberty (PP), fibrous dysplasia, and café-au-lait (CAL) spots.  Some patients may have atypical presentation with an incomplete triad.  Also, molecular testing by peripheral leukocyte may not yield diagnosis.  Treatment for PP is challenging.  Reports on the use of aromatase inhibition or partial estrogen receptor blockade have shown inadequate efficacy and some of these agents have been associated with increased ovarian size.  We report an atypical case of a 9 year-old female with MAS and enlarging autonomous ovarian cyst that required cystectomy.

Clinical Case

A female patient presented at age 15 months with one-week history of vaginal bleeding.  She had Tanner stage 3 breast development, but no CAL, and a left ovarian cyst of 4.5 cm in diameter on her pelvic ultrasound.  Her estradiol was elevated at 67 ng/dl (n <1.5).  Pelvic MRI scan performed a month later showed a smaller cyst measuring 1.5 cm in diameter.  Repeat FSH, LH and estradiol levels at that time were normal, therefore, no interventions were given.  Her PP was waxing and waning with elevation of estradiol on 2 occasions (33 and 35 ng/dL, n <1.5) at age 2 years and recurrent vaginal bleeding.  At age 5.6 years, she had progressive breast development and the ovarian cyst enlarged from a diameter of 5.7 cm to 8.1 cm (174 mL in volume) in 3 months.  Her estradiol was markedly elevated at 1860 pg/mL (n <15) with suppressed FSH and LH.  Due to concern for ovarian torsion, cystectomy was performed.  An Arg201Cys mutation was detected in exon 8 of the GNAS1 gene from her cyst tissues, confirming MAS.  Bone radiograph was initially read to be normal, but did show a subtle area of ground glass appearance in the same area noted by bone scan. Bone scan showed abnormal uptake in the right superior acetabulum.  She had done well with prepubertal FSH, LH, and estradiol levels for 3 years after cystectomy.  Her height had been normal following along the 97th%, with normal bone age and normal endocrine studies throughout the course of follow up.  However, at last follow up at age 9 years, she had recurrent left ovarian cyst of 6.1 cm in diameter.

Conclusions

Cystectomy appears to be beneficial in the treatment of PP in this patient who had significantly enlarged autonomous ovarian cyst.  This treatment approach resulted in remission of her PP for 3 years with normal growth and bone age without the use of medical therapy.  This case also illustrates the usefulness of ovarian tissue molecular diagnosis of MAS as well as the importance of long term follow up and close monitoring of the clinical course in a patient presenting with gonadotropin independent precocious puberty.

 

Nothing to Disclose: SAB, CY, LAW

15296 1.0000 MON-0121 A An Atypical Case of a 9 Year Old Female with Mccune-Albright Syndrome with Normal Growth and Skeletal Maturation after Cystectomy for Precocious Puberty 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0121-0135 5058 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Masanobu Fujimoto*1, Yuki Kawashima2, Takashi Hamajima3, Yoshiki Okayama2, Naoki Miyahara2, Rei Nishimura2, Keiichi Hanaki4 and Susumu Kanzaki2
1Tottori University Faculty of Medicine, Yanago, Japan, 2Tottori University Faculty of Medicine, Yonago, Japan, 3Aichi Children's Health and Medical Center, Obu, Aichi, Japan, 4Tottori Univ Fac of Med, Yonago, Japan

 

Introduction: The insulin-like growth factor (IGF)-I receptor (IGF1R) is widely expressed in various tissues. The IGF plays key roles in fetal and postnatal growth through the IGF1R. Heterozygous IGF1R mutations presenting with intrauterine and postnatal growth retardation have been reported in over 10 families. Last year, we reported that a heterozygous nonsense mutation (p.Q1220X) led to decrease IGF1R protein expression through endoplasmic-reticulum-associated protein degradation (ERAD) mechanism, resulted in growth failure. Recently, we identified another case with SGA short stature bearing a novel heterozygous nonsense mutation (p.W1219X) in the IGF1R gene.

Case: Patient was a 3-year-old Japanese girl, who was born at 40 weeks of gestation, with a birth weight of 2,110 g (-3.0 SD), birth height of 44.3 cm (-2.8 SD), and head circumference of 30.0 cm (-2.1 SD). She had no family history of short stature. Although she presented with slightly motor developmental delay under the age of 1 year, it has improved. At the age of 2 years and 5months, her basal serum GH level was high (10.5 ng/ml), but IGF-1 level showed normal [185 ng/ml (normal range: 32-213)]. The GH stimulation test had not been performed yet. At the age of 3 years, she presented with missing catch-up growth; her height was 82.9 cm (-3.1 SD); head circumference, 46.0cm (-1.6 SD). Her karyotype was normal (46, XX). We performed the gene analysis of IGF1R gene by direct sequencing and multiplex ligation-dependent probe amplification (MLPA). We identified a novel heterozygous nonsense mutation (p.W1219X) in the IGF1R gene.

Discussion and conclusion: This mutation causes premature stop codon within exon 21 of the IGF1R gene, and is considered to results in the absence of the carboxyl terminal fragment of IGF1R after the mutation site. We consider that ERAD, which is one of the major protein quality control systems, might cause a reduced IGF1R protein on cells with the mutated IGF1R. We are going to test whether this mutation results in the degradation of the mutant IGF1R protein through ERAD. Our results provide important new information on the IGF1R mutation in SGA short stature.

 

Nothing to Disclose: MF, YK, TH, YO, NM, RN, KH, SK

15635 2.0000 MON-0122 A SGA Short Stature Bearing with a Novel Nonsense Mutation (p.W1219X) in the IGF1R Gene 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0121-0135 5058 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Mohammad Saeed Alkhatib* and Anzar Haider
Cleveland Clinic Childrens Hospital, Cleveland, OH

 

Duane syndrome (DS) is a congenital eye movement disorder characterized by abnormal sixth cranial nerve development resulting in limited eye abduction or adduction and narrowing of the palpebral fissure with retraction of the globe on attempted adduction.  Both genetic and environmental factors are implicated in the pathogenesis. In 70% of the cases, DS is present as isolated cases while 30% may present in association with other malformations including skeletal, cardiac, ears, renal, and nervous system.  Pituitary gland abnormality in DS is not well characterized.   We report an adolescent with DS associated with pituitary gland hypoplasia.                                                                                                                            

Case Report:  A 14 5/12 year old male adolescent presented to our endocrine clinic for evaluation of growth failure. He was diagnosed at age 6 year  with DS based on restricted abduction of both eyes  past midline with horizontal gaze. He also had mild developmental delay and learning difficulties.  A review of his growth chart indicated that his growth percentile started drifting downward from 45th% at age 10 year to 8th% by age 14 5/12 year.  Family history was negative for growth failure or DS. Mid parental height was  5’9”.  His height was 154.7 cm (8%) and weight was 37.1 kg ( 3%)with a BMI of 15.5. He had subtle dysmorphic features (left  ear pits, long face, mild hypertelorism,)  His testes measured 6 mls bilaterally. Laboratory studies demonstrated a normal CBC and chemistry profile. His IGF-1 level measured low,  107 ng/ml ( reference 143-996 ). Other hormones  cortisol, T4 and TSH, LH , FSH and testosterone level were normal for pubertal status.  Bone age was consistent with 13 year at a chronological age of 14 5/12 year .  A growth hormone (GH) stimulation study demonstrated a peak GH level of 8.6 ng/ml on 2 secretagouges.  MRI of the brain revealed hypoplastic anterior pituitary gland. Chromosomal analysis revealed a duplication of of proximal 22q11.1 (Cat Eye Locus) through and including DiGeorge syndrome 1 region 22q11.22. This has been previously identified in patients with developmental delay. Growth hormone therapy was started at age 14 ½ year. His growth velocity increased from a pretreatment value of 3 cm/ year to an annualized growth velocity of 8.2 cm/year. Three years after starting growth hormone, his height advanced to  75% on growth chart.

 Conclusion:  GH deficiency with pituitary hypoplasia may be an additional association in patients with Duane syndrome. GH deficiency should be investigated in patients with DS with growth failure and treatment instituted if found deficient.

 

Nothing to Disclose: MSA, AH

15680 3.0000 MON-0123 A Duane Syndrome Associated with Pituitary Hypoplasia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0121-0135 5058 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Aurelia Holland*, Kupper Anthony Wintergerst, Michael Foster, Suzanne Erinn Kingery and Adetokunbo Omoruyi
University of Louisville, Louisville, KY

 

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is characterized by agenesis or underdevelopment of the Müllerian structures in females with 46, XX karyotype. This is mainly characterized by lack of a uterus, malformations of the upper third of the vagina and in some variants uterovaginal hypoplasia or aplasia thereby, causing anomalies in the lower third of the vagina. The syndrome has also been associated with skeletal and kidney abnormalities, androgen excess, and rarely, with other endocrine abnormalities. MRKH is usually detected in the teenage years when patients present with primary amenorrhea.

We report a case of a chronologically 6 6/12 year-old female with MRKH, premature adrenarche and then later progression to precocious puberty. The patient was referred to endocrinology for evaluation of premature adrenarche where she was noted to have Tanner 3 pubic hair, a bone age of 8 8/12years and absent vaginal introitus was observed. Pelvic ultrasound and MRI of the abdomen and pelvis revealed presence of ovaries bilaterally, but absence of the uterus and upper two-thirds of the vagina. She had a 46, XX karyotype, negative FISH for SRY, normal baseline adrenal screen and response to ACTH stimulation test. At chronologic age of 7 years, Tanner stage 2 breast development was noted. Leuprolide stimulation test was consistent with central precocious puberty. MRI of the pituitary was unremarkable. Despite the inability to menstruate, therapy with an implanted gonadotropin releasing hormone agonist, Histrelin acetate, was initiated because of potential for compromise of final adult height and progression of secondary sexual characteristics. Pubertal progression has declined since beginning treatment. 

Even though androgen excess has been associated with MRKH, this, to our knowledge is the first reported case of a child with MRKH developing central precocious puberty. This case emphasizes the importance of thorough genital examination in all children undergoing evaluation for premature adrenarche, and also the need to monitor for development of precocious puberty in established cases of MRKH with virilization.

 

Nothing to Disclose: AH, KAW, MF, SEK, AO

15770 4.0000 MON-0124 A A Case of Mayer-Rokitansky-Küster-Hauser Syndrome in a 6 Year-Old Female with Precocious Puberty 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0121-0135 5058 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Filippina Filia Dimitriadi*1, Francesco De Luca2 and Rita Ann Kubicky1
1St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, 2St. Christopher's Hospital for Children, Philadelphia, PA

 

Background:  Triple X syndrome occurs in about 1 in 1,000 newborn girls, and can be associated with congenital hypothyroidism, autoimmune thyroid disorders, and premature ovarian failure.

Clinical Case: A.R. is a 13 3/12 female with Triple X syndrome, who presented to St. Christopher’s Hospital for Children with abnormal weight gain (30-40 lbs in 1 year) and fatigue. Past medical history included seizure disorder, hypotonia, speech and motor delay, ADHD, and hydrocephalus. Review of systems was negative for polyuria, polydipsia, nocturia, changes in bowel habits, heat/cold intolerance, headaches or abdominal pain.

Initial physical examination was remarkable for obesity and mild acne on her forehead.  She did not have skin or buccal hyperpigmentation, acanthosis nigricans, hirsutism or striae. Her weight was >97th percentile, height 50-75th percentile, and BMI >97th percentile.  Vitals were within normal limits.

Laboratory evaluation obtained by her PMD 2 years prior showed normal TSH of 2.92 mIU/L (0.5-4.3) and low FT4 of 0.7 ng/dL (0.9-1.4). Repeat labs after the visit showed normal TSH of 3.33 mIU/L with persistently low FT4 of 0.7 ng/dL, and negative TPO and TG antibodies (16 IU/mL and <20 IU/mL, respectively).

 Due to concerns for possible pituitary hormone deficiencies, laboratory evaluation was performed: IGFBP3 4.8 mg/L (2.4-8.4), IGF-1 345 ng/mL (152-593), AM cortisol 11.2 mcg/dL, serum ACTH of 39 pg/mL, LH 7.29 mIU/mL (0.04-10.8), FSH 2.99 mIU/mL (0.4-6.5), estradiol 23 pg/mL (<142), prolactin 12.6 ng/mL (2.6-18).  A low-dose (1 µg) ACTH stimulation test revealed a suboptimal peak cortisol of 13.1 mcg/dL, followed by standard dose (250 µg) ACTH stimulation test revealing a normal peak cortisol of 19.9 mcg/dL.

MRI of brain and pituitary gland was normal.

Since the diagnosis of central hypothyroidism, A.R. has been managed with levothyroxine (started at 50 µg QD, gradually increased to 200 µg QD). In 21 months of treatment, she has gained ≈8 kg. She had menarche at age 12 and her menses have been regular. She has not developed any symptoms/signs of other pituitary hormone deficiencies, and is being monitored for co-morbidities associated with obesity in our Center for the Metabolic Syndrome.

Conclusion: Although the association between Triple X syndrome and congenital hypothyroidism or autoimmune thyroid disorders has been previously reported, to our knowledge, this is the first reported case of central hypothyroidism in a patient with Triple X syndrome.

 

Nothing to Disclose: FFD, FD, RAK

15819 5.0000 MON-0125 A Triple X Syndrome Associated with Central Hypothyroidism 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0121-0135 5058 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Bach-Mai Katherine Vu*1, Roshanak Mansouri1, Jennifer E Dietrich1, Sheila K Gunn1, Lefkothea P Karaviti1 and Laurence McCullough2
1Baylor College of Medicine, Texas Children's Hospital, Houston, TX, 2Baylor College of Medicine, Houston, TX

 

Introduction:  In patients with complete androgen insensitivity syndrome (CAIS), optimum timing of gonadectomy remains controversial.  The patients presented here illustrate the medical and ethical dilemmas which render challenging the development of standardized management for CAIS. 

Clinical Cases:  First we present a healthy newborn girl with XY karyotype on amniocentesis.  Sequencing detected a novel mutation (c.2004R>A, p.Y668X) in the androgen receptor (AR) gene.  MRI revealed bilateral inguinal gonads.  Gonadectomy initially was deferred.  She returned at 3 years of age with an inguinal hernia and underwent ipsilateral gonadectomy; her parents opted to retain the contralateral gonad to allow natural puberty.  We also describe a healthy 16-year-old girl with primary amenorrhea, Tanner V breasts, male-range testosterone, and XY karyotype, a presentation consistent with CAIS.  MRI showed bilateral intra-abdominal gonads.  Her parents have not consented to surgery.

We searched Cochrane and PubMed for evidence to support or refute early gonadectomy.  Risk for gonadal malignancy in CAIS is low before puberty but approaches 33% by 50 years of age.  In patients with retained gonads, no data exist on methods of monitoring for malignancy.  Approximately 80-90% of girls with CAIS develop inguinal hernia; case reports of incarceration further support the argument for early gonadectomy.  However, deferring surgery avoids the challenge of ensuring compliance in the medical induction of puberty and allows patient participation (informed consent or pediatric assent) in the decision for surgery.  Evidence suggests that timing of surgery should not be influenced by considerations of adult height, bone density, or surgical technique.

Clinical Lessons:  In addition to describing a novel AR mutation in one case, our study highlights the low quality of evidence on optimal timing of gonadectomy.  We advocate an individualized approach that considers malignancy risk and the ethics of early versus delayed intervention.  Patients diagnosed before puberty should receive nondirective counseling; those diagnosed after puberty, directive counseling that includes the patient to undergo gonadectomy.  Future studies must assess the quality of pubertal development achieved via hormone replacement in CAIS and the psychosocial impact of early versus delayed surgery.  Uniform, multicenter guidelines are needed to enable large-scale data collection on long-term outcomes in this rare disorder.

 

Nothing to Disclose: BMKV, RM, JED, SKG, LPK, LM

15992 6.0000 MON-0126 A Complete Androgen Insensitivity: Medical and Ethical Considerations in Timing of Gonadectomy, and a Novel Mutation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0121-0135 5058 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Philippe Klee*, Sabrina Anderson de la Llana, Jean-Louis Blouin, Federico Santoni, Jeremy Bevillard, Riccardo Pfister and Valerie M Schwitzgebel
University Hospitals of Geneva, Geneva, Switzerland

 

Background

Diabetes diagnosed within the first 6 months of life and commonly referred to as neonatal diabetes (ND) represents a rare entity that affects approximately 1:100’000 – 260’000 live births and can be either transient or permanent. The origin of the disease is rarely related to auto-immunity but rather to single gene mutations. Mutations in Hepatocyte nuclear factor 4 alpha (HNF4A) are classically associated to permanent diabetes developing by the age of 25 years and commonly referred to as Maturity Onset Diabetes of the Young (MODY) 1. To our knowledge, no case of ND related to a HNF4A mutation was described so far, but about half of the carriers of mutations in this transcription factor were macrosomic at birth and some of them presented with transient neonatal hypoglycemia.

Clinical Case

We present the case of a girl born prematurely at 28 weeks postmenstrual age with a birth weight of 1030g (10th – 50th percentile) due to placental abruption. After an uneventful early adaptation, a short period of hyperglycemia occurred on day 2 and was considered glucose intolerance of extreme prematurity. After 9 hours of intravenous insulin, blood glucose levels normalized. On day 16, she presented with asymptomatic hyperglycemia between 15 and 20 mmol/l, without ketosis. The girl was treated with subcutaneous insulin via an insulin pump at an initial maximal rate of 0.76U/kg/day without significant side effects. The treatment could progressively be reduced after 18 days and was finally stopped after 32 days. At 13 months, the infant was developing normally, blood glucose levels have remained normal without treatment and HbA1C was 5.1% [Normal range: 3-6%].

Methods

Genetic analysis was performed by targeted exome sequencing on a selection of genes using high throughput sequencer (NGS). The P190L (p.Pro190Leu) HNF4A mutation identified by NGS was confirmed by Sanger sequencing and is located in the dimerization domain of the transcription factor.

Conclusion

We describe a HNF4A mutation associated with transient ND in a premature infant born at 28 weeks of gestation. We hypothesize that the neonatal phenotype previously described in carriers of HNF4A mutations might have been modified by prematurity and / or by complications related to preterm birth. Indeed, due to respiratory distress, the child needed mechanical ventilation between day 1 and 5 and continuous positive airway pressure (CPAP) between day 5 and day 43, which could have increased insulin needs during this period. Alternatively, prematurity could have unmasked a period during which beta cells carrying a HNF4A mutation are functionally less mature than their non-mutated counterparts.

 

Nothing to Disclose: PK, SA, JLB, FS, JB, RP, VMS

16049 7.0000 MON-0127 A Transient Neonatal Diabetes in a Preterm Infant, Due to a HNF4A Mutation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0121-0135 5058 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Hironori Shibata*1, Tomohiro Ishii1, Midori Awazu1, Takumi Kuramae1, Kazunari Yoshida1, Mari Satoh2 and Tomonobu Hasegawa1
1School of Medicine, Keio University, Tokyo, Japan, 2Toho University Omori Medical Center, Tokyo, Japan

 

Introduction: Cerebral salt wasting syndrome (CSWS) is characterized by hypovolemic hyponatremia due to natriuresis seen in cerebral disease. The mechanism of natriuresis remains unexplained. Maesaka reported increased FEurate and occasional FEphosphate in cases with CSWS without cerebral disease. He proposed that the natriuresis is mainly caused by defective solute transport in the proximal tubule (1).

Clinical Case: An 11-yr-old boy presented with decreased growth velocity. He was diagnosed as having growth hormone deficiency due to craniopharyngioma and underwent tumor resection. Hydrocortisone had been administered before operation. He exhibited polyuria, hypernatremia (154.2 mEq/L) and weight loss during operation, and was diagnosed as having central diabetes insipidus. Intravenous injection of pitressin was started, and hypertonic dehydration was improved in the morning of postoperative day 1. In the afternoon, from decreased serum sodium level (136.3 mEq/L) and, increased sodium and water loss, he was diagnosed as having CSWS. We started sodium and water replacement. Increased urinary excretion of sodium (FENa 2.1%), urate (FEurate 14.3%), calcium (Urine Ca/Cr 0.62), phosphate (FEphospate 19.8%), and glucose (Urine glucose 32 mg/dL) were present. On postoperative day 4, he complained of abdominal pain. White sludge was observed in urine. Urinalysis revealed alkaline urine and microscopic hematuria. The diagnosis of left ureteral calculus was made on computerized tomography. By postoperative day 9, increased excretion of sodium, urate, calcium, phosphate, and glucose were resolved. On postoperative day 10, the stone passed spontaneously. Stone analysis showed that the calculus was composed of 97% calcium phosphate.

Conclusion: Increased urinary excretion of sodium, urate, calcium, phosphate, and glucose on postoperative day 1, indicates proximal tubular dysfunction in this patient with CSWS. This finding supports the hypothesis that natriuresis in CSWS is caused by defective solute transport in the proximal tubule. Increased urinary excretion of calcium and phosphate in alkaline urine probably have caused ureteral calculus.

 

Nothing to Disclose: HS, TI, MA, TK, KY, MS, TH

16390 8.0000 MON-0128 A Renal Proximal Tubular Dysfunction and Ureteral Calculus in a Boy with Cerebral Salt Wasting Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0121-0135 5058 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Kajal Gandhi*1, Ioanna D Athanassaki2, Lefkothea P Karaviti3 and Deepa Suresh4
1Baylor College of Medicine/Texas Children's Hospital, Houston, TX, 2Texas Children's Hospital, Baylor College of Medicine, Houston, TX, 3Baylor College of Medicine, Texas Children's Hospital, Houston, TX, 4Texas Children's Hospital, Houston, TX

 

Background: Lithium induced hyperparathyroidism is a rare entity causing hypercalcemia due to an alteration of the set point of calcium triggered PTH secretion by antagonizing the Calcium Sensing Receptor (CASR). There are no known case reports studying the effectiveness of treatment with Cinacalcet in the pediatric population for lithium induced hyperparathyroidism.

Case: The patient is a 17 year old female with bipolar disorder previously on Lithium therapy. She presented with abdominal pain, vomiting, elevated serum calcium of 12.3 mg/dL (8.9-10.7 mg/dL) and elevated PTH level of 153.8 pg/ml (16-60.4 pg/ml) despite discontinuation of Lithium 6 days prior to admission. She had a normal sestamibi scan with no evidence of parathyroid adenoma and no osteodystrophy or nephrocalcinosis. The case presented many challenges, as she did not respond to initial treatment with IV fluids and furosemide, followed by calcitonin and zoledronic acid. As repeat treatments with bisphosphonates may increase CASR dysregulation and further decrease CASR sensitivity, she was subsequently started on Cinacalcet. On outpatient follow up she continues on Cinacalcet with no symptoms.

Conclusion: The case is unique because of patient’s age at diagnosis, relatively shorter duration of Lithium therapy, severity of disease and the value of importing an innovative treatment from limited adult protocols to pediatrics. Lithium induced hyperparathyroidism remains a challenge with respect to management as long term lithium treatment increases circulating bioactive PTH by acting on CASR to alter the set point of PTH secretion and causes hypercalcemia resistant to routine medical management and persists even after discontinuation. Despite reports that chronic Lithium therapy induces parathyroid adenoma or multi-glandular parathyroid disease, there was no radiographic evidence of adenoma in our case. Calcimimetics like Cinacalcet mimic the action of calcium by allosteric stimulation of CASR, to re-establish the set point of PTH and suppress PTH secretion. If this is unsuccessful, surgical options include focused or complete parathyroidectomy. Although the case only has short term follow up data, the clinical lesson is that Cinacalcet is a promising option for management of patients with persistent hypercalcemia or on chronic Lithium therapy when it cannot be weaned. The case has implications for future management of patients with this condition as it could potentially avoid parathyroid surgery.

 

Nothing to Disclose: KG, IDA, LPK, DS

16533 9.0000 MON-0129 A Calcimimetics in a Pediatric Case of Lithium Induced Hyperparathyroidism: New Application of an Old Drug in Pediatrics 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0121-0135 5058 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Heather D Wadams*, Ravinder J. Singh, Seema Kumar, Hemamalini Ketha, Kara Pozehl and Aida N Lteif
Mayo Clinic, Rochester, MN

 

Background:Hypervitaminosis D in infants typically presents with nonspecific signs and symptoms of hypercalcemia such as irritability, anorexia, vomiting, constipation, hypotonia, and polyuria. Serum phosphorus is either high or normal. Vitamin D supplementation is recommended to all breastfed infants. Over-the-counter supplements are not regulated by the FDA to the same stringent criteria as prescription medication and these are often being used by parents without clear understanding of the significant variation in the concentration of available supplements.  We herein report a case of severe hypercalcemia with hypophosphatemia due to inadvertent extra intake of Vitamin D in an infant. 

Case: A four month old infant, exclusively breast fed, presented with a three day history of emesis with every feed and diarrhea. She was noted to be lethargic, dehydrated and weighing less than her 2-month well child visit weight. A preliminary evaluation of electrolytes was remarkable for a serum calcium level of 18.7 mg/dL (9.0-11 mg/dL). The infant was hospitalized and rehydrated overnight. Electrolytes following 15 hours of IV hydration were remarkable for a repeat total calcium of 15.5 mg/dL, and phosphorus of 1.9 mg/dL (4.3-5.4 mg/dL). Other studies included PTH of 2 pg/mL (15-65 pg/mL), alkaline phosphatase 161 U/L, TSH 3.67 mIU/L (0.27-4.2 mIU/L), ionized calcium 9.1 mg/dL (5.1-5.9 mg/dL), and total 25-hydroxy vitamin D of 294 ng/mL (20-50 ng/mL). Due to the hypophosphatemia, bisphosphonate therapy was not initiated and instead calcitonin was administered subcutaneously at a dose of 22 units. Calcium levels progressively decreased.  Upon further questioning, it was noted that infant had been receiving a non-infant supplement of Vitamin D3 amounting to 28,000 IU daily since two months of age.

Conclusion:  Recommendations regarding the preparation and dose of vitamin D supplementation need to be clearly outlined by physicians. There is need for greater regulation of over the counter vitamin supplements due to their potential for use without specific prescription. Hypophosphatemia has not been reported previously in hypervitaminosis D. A low phosphorus may not rule out the diagnosis of vitamin D excess.

 

Nothing to Disclose: HDW, RJS, SK, HK, KP, ANL

16688 10.0000 MON-0130 A A Case of Hypercalcemia with Low Phosphorus Due to Vitamin D Toxicity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0121-0135 5058 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Larisa Anatolievna Rusyn*1, Kristen Thomas1, Howard Ginsburg1, Cristina Hajdu1 and Brenda Kohn2
1NYU Langone Medical Center, New York, NY, 2NYU Medical Center, New York, NY

 

Background:

PNETs (Pancreatic Neuroendocrine tumors) are infrequent in the context of tuberous sclerosis complex (TSC) in children. There is marked disease heterogeneity, challenging clinical presentation and a limited knowledge of underlying molecular mechanisms. Inactivating mutations in the two genes TSC1 and TSC2, which correspondingly encode for hamartin and tuberin, are pathognomonic for the disease. The upregulation of the phosphoinositide 3-kinase (PI3K)/AKT (protein kinase B) with cascade activation of mitogen-activated protein kinase (MAPK) and the mammalian target of rapamycin (mTOR) leads to uncontrolled cell proliferation and tumorigenesis. The association of TSC and PNET is not clearly defined.

We describe a case of PNET in a toddler with TSC1.

Case presentation:

An asymptomatic male aged 3 years 10 months with a TSC1 was identified with a pancreatic mass. Clinical sequence of events: diagnosed at 3 months with epilepsy and 3 hypomelanotic lesions on trunk; delayed speech development; at 3 years:  kidney angiomyolipomas/left cortical cyst; at 3 years 7 months: multiple small rhabdomyomas in the right/left ventricles, at 3 years 9 months: a subependymal giant cell astrocytoma (SGCA)/excision and at 4 years of age open enucleation of 1 cm pancreatic mass located near junction of body and tail.

Endocrine study:                                                

Test Name                                      Value              Reference Range

Gastrin, pg/mL                                83                    Fasting 3-4 hrs: 2-168

Neuron-Specific Enolase (NSE),

Serum, ng/mL                                  8.9                   0.0-12.5

Chromogranin A, nmol/L                   2                      0-5  

Glucose, plasma, mg/dL                   81                    65-99

Insulin, ulU/mL                                 4                      2.6-24.9

IGF-1, ng/mL                                   59                    20-141

IGFBP3, ng/mL                               1960                972-4123

Diagnostic study: Molecular study: exon 10 of the TSC1 gene has a heterozygous base-change mutation (c.989dupT, an abnormal TSC1 protein, hamartin – p.Ser331fs).

Brain MRI: SGCA (2.3 cm).

Histology: Grade I, single mitoses, immunostains (+) for GFAP (glial fibrillary acidic protein) and synaptophysin (neuroendocrine marker), increased MIB-1 proliferation index (10%) indicative of high activity of cell proliferation. SGCA in the setting of TSC1 is able to express GFAP.

MRI abdomen with contrast: pancreatic body lesion 1.1 cm in diameter (interval change from 4 mm in 5 months).

Pathology:  1.0 x 0.8 x 0.6 cm; pale tan-pink tumor.

Histology: PNET, grade 2; 2 mitotic figures/10 hpf, the Ki-67 proliferation index is about 20%; diffuse positivity with chromogranin, synaptophysin and CD56 (membranous).

Conclusions:

Our case demonstrates that patients with TSC1 may develop SGCA and pancreatic nonsecretory tumor at an early age along with the typical clinical stigmata of this entity. PNETs express neuroendocrine markers, which are useful to differentiate functional vs nonfunctional tumors. Semi-annual/annual evaluation with abdominal MRI will be beneficial for identification of PNETs. Some evidence exists to support that PNETs are an associated feature of TSC and require further investigation.

 

Nothing to Disclose: LAR, KT, HG, CH, BK

17002 11.0000 MON-0131 A Tuberous Sclerosis (TSC1): Subependymal Giant Cell Astrocytoma (SGCA) and Pancreatic Neuroendocrine Tumor (PNET) in a Toddler 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0121-0135 5058 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Roxana L Aguirre Castaneda*1 and Josue Flores2
1University of Illinois, Chicago, IL, 2Children's Hospital of Illinois, Peoria, IL

 

Background:Pseudohypoaldosteronism (PHA) is a heterogeneous group of disorders characterized by resistance to the action of aldosterone. The classic form, PHA-1 manifests early in life usually with failure to thrive. PHA-1 autosomal dominant form or renal form has a better prognosis since patients can outgrow it during early childhood and do not require high doses of sodium supplementation.

Clinical Case: A 3 week old Caucasian female patient presented to the local ER for evaluation of poor weight gain and frequent episodes of emesis since the first week of life. Her initial tests showed hyponatremia  (122mMol/L) with normal potassium levels. She was born full term and pregnancy was uneventful. Family history was unremarkable. The physical exam showed weight loss of 1.3 Kg since birth and normal female genitalia. Newborn screening was normal. She received IV fluids with improvement of sodium to 131 mMol/L after 3 days of therapy. She was referred to our institution for further evaluations which included random cortisol at 9mcg/dl, 17 hydroxyprogesterone < 40 ng/dl (<100 ng/dl), Aldosterone 735 ng/dl (17-154), renin activity 120 ng/ml/hr (1.4-7.8), normal urinalysis, normal renal ultrasound, and normal voiding cystourethrogram. All these results suggested Pseudohypoaldosteronism (PHA). She was started on sodium chloride supplementation requiring up 84 mEq/day to normalize sodium levels. Sweat chloride tests was normal suggesting PHA-1. Genetic studies of the mineral corticoid receptor gene (NR3C2) revealed a novel mutation reported as c.2321A>G (p.Asn774Ser). At the time of discharge patient gained 540 gm, emesis resolved with normalization of sodium.

Conclusion: Hyponatremia associated to failure to thrive can be the manifestation of multiple endocrine disorders. We report a case of PHA-1, autosomal dominant form, manifested with failure thrive, hyponatremia, and normokalemia, who required high doses of sodium supplementation to normalize levels. Sequencing analysis of the NR3C2 gene identified a novel mutation causing an amino acid substitution in the position p.Asn774Ser with in silico analyses predicted to be pathogenic.

 

Nothing to Disclose: RLA, JF

17093 12.0000 MON-0132 A Pseudohypoaldosterinism Tipe 1 and Failure to Thrive: Description of a Novel Mutation in the NR3C2 Gene 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0121-0135 5058 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Lindsey Waldman*1, Molly Oliver Regelmann2, Bradley Delman3, Marina Goldis2, Evan Graber2, Ahmed Khattab2, Dennis Jay Chia4, Michelle Klein4, Elizabeth Wallach1 and Robert Rapaport1
1Pediatric Endocrinology and Diabetes, Icahn School of Medicine at Mount Sinai, New York, NY, New York, NY, 2Icahn School of Medicine at Mount Sinai, New York, NY, 3Mount Sinai Hospital, New York, NY, 4Ichan School of Medicine at Mount Sinai, New York, NY

 

Introduction

Previous reports have suggested that ectopic posterior pituitary (EPP) is associated with a more severe presentation, commonly with multiple pituitary hormone deficiencies (MPHD) (1).

Aim

To characterize presenting symptoms and pituitary hormone deficiencies (PHD) in children with EPP on MRI.

Methods

A retrospective chart review of MRI reports from 2000-13. Details regarding age of presentation, presenting symptoms and for hormonal deficiencies were obtained from charts of patients with EPP.

Results

Of the 853 patients with MRI reports reviewed, 20 patients had an EPP. Data on 2 were unavailable. Of the remaining 18 patients, 8 presented prior to 3 mo, 2 shortly after 1 yr, 5 between 4-10 yr and 3 between 11-17 yr. 

Of the 8 presenting as newborns, 7 had hypoglycemia. 4 infants had hyperbilirubinemia. 4 out of the 6 males presenting as newborns had micropenis. All had MPHD; 8 had TSH and ACTH deficiencies, 4 had LH/FSH deficiency, 2 seemed likely to have LH/FSH deficiency due to micropenis.  Growth hormone deficiency (GHD) was confirmed in 3.

10 patients presented with GF and 5 had isolated GHD after follow up of 4.1±1.1 yr. Of the patients presenting after the newborn period, 4 had TSH deficiency (all diagnosed prior to GHD) and 2 have a partial ACTH deficiency evolve after more than a year of monitoring (normal baseline cortisol level with failure to respond to glucagon stimulation). Only 1 patient presenting outside of the newborn period, a 17.8 yr female, had LH/FSH deficiency; her presenting complaints were primary amenorrhea and short stature. Frank diabetes insipidus (DI) was not present in any of the patients.

Conclusion

Contrary to previous reports, our data support that the presentation of EPP can vary greatly. In the newborn period, there seems to be a greater risk of MPHD with a predominance of ACTH and TSH deficiencies.  In older children, GHD predominates. 60% of those presenting outside of the newborn period with EPP had isolated GHD and 1 out of the 6 evolved to have partial ACTH deficiency. Given the risks for evolving PHD in those with EPP, this serves as an additional clinical indication for MRI in the setting of isolated GHD.  Genotyping of these patients may potentially shed some light on the presenting phenotypes.

 

Nothing to Disclose: LW, MOR, BD, MG, EG, AK, DJC, MK, EW, RR

14603 13.0000 MON-0133 A Variable Presentation of Ectopic Posterior Pituitary 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0121-0135 5058 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

David Werny*1, Clinton Elfers2 and Christian Ludwig Roth1
1Seattle Children's Hospital, Seattle, WA, 2Seattle Children's Research Institute, Seattle, WA

 

Central Diabetes Insipidus (CDI) is a potentially life-threatening disorder of osmoregulation with many underlying causes. Previous groups have reported a high prevalence of idiopathic CDI (30-50%), but these have been limited by small sample sizes outside of the United States. CDI is often difficult to manage. Providers must adequately treat the hypernatremic dehydration that results from dilute urine losses, while balancing potential complications of DDAVP including hyponatremic seizures.  With this analysis we aim to identify the causes of CDI and the risk-factors for hyponatremia in our population.

We are analyzing all charts and sodium values for patients seen at SCH with a diagnosis of CDI.  Causes of CDI were grouped: (1) Anatomic: septo-optic dysplasia, holoprosencephaly, ectopic posterior pituitary, encephalocele; (2) Infiltrative/Tumor: Langerhan’s Cell Histiocytosis, germinoma, craniopharyngioma, infectious, benign mass; (3) Genetic/Idiopathic.  Hyponatremia was defined as sodium < 135.  Episodes of hyponatremia < 130 were abstracted and relevant clinical factors identified from notes, input/output measurements, and the medication record.

As of December 2013 we have identified 109 patients with CDI.  Etiologies include anatomic malformations (28%), infiltrative/tumor (55%), genetic/familial (6%), and idiopathic (10%).  52% of patients had documented hyponatremia.  The most common factor associated with hyponatremia was IV fluid use (52%), with many having fluids at more than maintenance rate (23%).  DDAVP was given while sodium was < 135 in 26% of cases.  Home management may play a role as 20% of episodes documented hyponatremia on admission.  A subset of 65 patients with available surgical history showed that those with pituitary surgery had more episodes of hyponatremia (2.7 vs. 0.6; p < 0.05).

Our population of patients with CDI features a lower percentage of idiopathic diagnoses and a higher prevalence of anatomic malformations than previously described.  This is likely related to differences in referral patterns, availability of diagnostic tools, and prevalence of brain malformations.  Hyponatremia is common and associated with IV fluid use as well as dosing of DDAVP with sodium < 135.  Preventing hyponatremia may be accomplished with care plans that minimize IV fluid use and emphasize proper timing of DDAVP administration.  In particular, patients with pituitary surgery are a high-risk group for hyponatremia and warrant close monitoring.

 

Nothing to Disclose: DW, CE, CLR

12265 14.0000 MON-0134 A Description of Safety Factors for Hyponatremia and Causes of Diabetes Insipidus at Seattle Children's Hospital 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0121-0135 5058 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Shruti A. Fadia* and Francesco De Luca
St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA

 

Background: Klinefelter syndrome (KS) is a common cause of hypergonadotropic hypogonadism, occurring in approximately 1:600 males. Although the disorder is highly prevalent, it is often underdiagnosed; only about 25% of adult males with KS are diagnosed, and fewer than 10% of cases are diagnosed prior to puberty. Small testes, low inhibin B, and high LH and FSH are typical findings in pubertal males with KS. Onset of puberty usually occurs at a normal age, however slow progression or lack of completion of puberty is a common feature of this disorder. There have been rare case reports in the literature of subjects with KS with testicular failure associated with hypogonadotropic hypogonadism.

Case: M.M. presented at age 13 11/12 for evaluation of micropenis. On physical exam, his height was 167.5 cm (50th-75th percentile), weight 77.7 kg (>97th percentile), and BMI 27.7 (>95th percentile). Physical exam identified sparse axillary hair and pubic hair at Tanner stage II. He had undescended testes approximately 1 ml in volume, his penile length was 6.4 cm, and he had no gynecomastia. Ultrasound confirmed the presence of both testes in the inguinal canals. A laboratory workup showed pre-pubertal LH (<0.02 mIU/mL, nl 0.23-4.41 mIU/mL), FSH (0.18 mIU/mL, nl 0.3-4.0 mIU/mL), and testosterone (3 ng/dL, nl ≤167 ng/dL) levels with an adrenarchal DHEAS (115 mcg/dL, nl ≤138 mcg/dL) level. On his most recent follow-up visit at age 15 6/12, he had scant axillary and facial hair. His testes, measuring 1 ml in volume, were palpable in the scrotum, and his pubic hair was still at Tanner stage II. Repeat gonadotropin levels were slightly higher (but still not elevated), with a LH level of 0.58 mIU/mL (nl 0.2-4.9 mIU/mL) and FSH level of 2.8 mIU/mL (nl 1.8-3.2 mIU/mL), while testosterone level remained low at 7 ng/dl (nl 18-150 ng/dL). Penile length had increased to 7.5 cm. Given the lack of progression in testicular volume, chromosomal analysis was pursued. Karyotype was found to be 47, XXY, consistent with KS.

Conclusion: In this adolescent male with KS, the lack of hypergonadotropinemia (despite his long-standing clinical and biochemical hypogonadism) could be due to either an extreme delay in the maturation of the hypothalamic-pituitary-gonadal axis or due to hypogonadotropic hypogonadism. Such a case suggests the need of including chromosomal analysis in the diagnostic work-up of an adolescent/young adult with delayed or slow-progressing puberty, despite the absence of elevated gonadotropins.

 

Nothing to Disclose: SAF, FD

16939 15.0000 MON-0135 A Lack of Hypergonadotropinemia in a Hypogonadal Adolescent with Klinefelter Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Monday, June 23rd 3:00:00 PM MON 0121-0135 5058 1:00:00 PM Case Reports: Pediatric Endocrinology Poster

Ronald Wayne Matheny Jr.*
US Army Research Institute of Environmental Medicine, Natick, MA

 

Phosphoinositide 3-OH kinase (PI3K) regulates a number of physiologic, metabolic, and genetic processes in skeletal muscle.  However, little is known with respect to the role of the 110 kDa catalytic subunit β (p110β) of PI3K in skeletal muscle, particularly in vivo.  To address this, we generated male mice that lacked p110β specifically in skeletal muscle (p110β-mKO), as well as control mice (p110β-flox), using the cre-lox system under the control of the Myf5 promoter.  Mice were born in expected Mendelian ratios with no apparent gross abnormalities.  While there were no differences in bodyweights between p110β-mKO and control mice at 10 weeks of age, p110β-mKO mice possessed ~15% greater bodyfat (10.53 ± 0.38 vs. 12.12 ± 0.50; P<0.02) and ~2% less lean mass than control littermates (88.59 ± 0.34 vs. 86.93 ± 0.53; P<0.02).  To determine the degree to which reduced skeletal muscle mass may contribute to loss of lean body mass, we next examined the quadriceps muscles of p110β-mKO and control mice.  Quadriceps muscle mass was reduced by ~12% in p110β-mKO mice as compared to control mice when normalized to body mass (P<0.05), and histological examination revealed that the mean cross-sectional area of p110β-mKO quadriceps muscle fibers was ~13% less than control (P<0.05).  In a grip strength test, mean tension as a function of body mass exhibited by p110β-mKO mice was ~15% less than that of control mice (P<0.05).  Despite these reductions in skeletal muscle mass and strength, we observed no differences in food intake, VO2, respiratory exchange ratio, or ambulatory activity over a 48 hour period in p110β-mKO mice as compared to control mice.  Furthermore, we observed no differences in fasted blood glucose concentrations between control and p110β-mKO mice, and no differences in response to a glucose bolus challenge (2g/kg) over a 120 minute period.  Finally, there were no detectable differences in blood glucose concentrations in response to intraperitoneal injection of insulin (1 U/kg) between control mice and p110β-mKO mice at time points up to 60 minutes following injection.  In summary, these data suggest that while p110β is necessary for full development of skeletal muscle mass and strength in vivo, skeletal muscle p110β appears to be dispensable with regard to whole-body physiologic and metabolic homeostasis.

 

Nothing to Disclose: RWM Jr.

14567 1.0000 MON-0345 A Skeletal Muscle-Specific Deletion of p110beta Reduces Skeletal Muscle Mass and Strength in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Taek-Jeong Nam1, Jung-wook Choi*1, Young-Min Kim1, Su-Jin Park1, JinA Ryu1, In-Hye Kim2 and Youn-Hee Choi1
1Pukyong National University, Busan, Korea, Republic of (South), 2Pukyong Natl University, Busan, Korea, Republic of (South)

 

As liver disease has become a common health problem, d-galactosamine (GaIN) treatment can be used to generate well-known in vivo and in vitro hepatic injury models by inhibiting RNA and protein synthesis. In addition, GaIN-induced oxidative stress generates reactive hydroxyl radicals, which damage the cell membrane by stimulating lipid peroxidation. Nuclear factor erythroid 2-related factor 2(Nrf2) is a transcription factor that targets genes including NAD(P)H quinine oxidoreductase 1(Nqo1), GSH synthesis, and GSH conjugation (Gsts), with many protective effects against oxidative stress. During oxidative stress, Nrf2 is translocated to the nucleus from the cytosol, and as a result, antioxidant enzymes are upregulated and oxidative stress damage decreases. We explored whether Nrf2 protected against GaIN-induced cell death in Hepa-1c1c7 cells and characterized the protective mechanism. Based on MTS and LDH release assays, GaIN induced cell death in a dose-dependent manner, and pretreatment with Porphyra yezoensis glycoprotein (PYGP) counteracted this effect. Based on Western blot analysis, pretreatment with PYGP increased the phosphorylation of Akt and Nrf2. Phosphorylated Akt activated the Nrf2 signaling pathway and increased Ho-1, Nqo1, and GST levels, while GaIN upregulated the MAPK signaling pathway that regulates ERK, JNK, and p38. However, pretreatment with PYGP inhibited the MAPK signaling pathway. We also observed that GaIN induced oxidative stress based on the TBARS assay, while SOD, CAT, and GST activated by PYGP prevented this oxidative damage. Therefore, we suggest that PYGP has protective effects against GaIN-induced cytotoxicity. PYGP was extracted from P. yezoensis, a red alga distributed on the coast of Korea, China, and Japan.

 

Nothing to Disclose: TJN, JWC, YMK, SJP, JR, IHK, YHC

14610 2.0000 MON-0346 A Protective Effect of Porphyra Yezoensis Glycoprotein on D-Galactosamin-Induced Cytotoxicity in Hepa 1c1c-7 Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Taek-Jeong Nam1, Min-Kyeong Lee*1, Mi-Hye Kang1, Jung-wook Choi1, Young-Min Kim1, Su-Jin Park1, JinA Ryu1, In-Hye Kim2 and Youn-Hee Choi1
1Pukyong National University, Busan, Korea, Republic of (South), 2Pukyong Natl University, Busan, Korea, Republic of (South)

 

Porphyra yezoensis is an important global ocean resource with many biological properties, such as antiulcer, anti-inflammatory, antioxidant, and antitumor activities. In the present study, we examined signaling pathways related to the proliferation effects of the P. yezoensis peptide (PY-PE) in rat intestinal epithelial cells (IEC-6).

   Epidermal growth factor (EGF) is a canonical member of the peptide growth factor family that acts as a ligand for the epidermal growth factor receptor (EGFR), which is widely expressed in mammalian epithelial tissues; binding of EGF affects cell growth, survival, and proliferation. PY-PE increased the expression of EGFR, Grb2, and SOS1, while EGFR induced activation of the Ras signaling pathway through Raf, MEK, and ERK phosphorylation.

   We also performed cell cycle and expression analysis of cell cycle-related proteins. Cell proliferation analysis revealed an increased number of cells in G1 phase and increased expression of cyclin D, cyclin E, Cdk2, Cdk4, and Cdk6, as well as a decrease in the protein levels of p21 and p27.

   AP-1 regulates cell proliferation and survival responses. The present study examined the effects of PY-PE on the AP-1 signaling pathway. AP-1 protein and mRNA levels in the nuclear fraction increased after PY-PE treatment. These findings suggest that PY-PE stimulates the proliferation of rat intestinal epithelial cells (IEC-6). Therefore, PY-PE could be a potential biofunctional food with a cell proliferation effect.

 

Nothing to Disclose: TJN, MKL, MHK, JWC, YMK, SJP, JR, IHK, YHC

14650 3.0000 MON-0347 A Porphyra Yezoensis Peptide Regulates Proliferation through the Epidermal Growth Factor Receptor Signaling Pathway in IEC-6 Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Taek-Jeong Nam, Mi-Hye Kang*, Su-Jin Park, JinA Ryu, Min-Kyeong Lee, Jung-wook Choi, Young-Min Kim, In-Hye Kim and Youn-Hee Choi
Pukyong National University, Busan, Korea, Republic of (South)

 

Phloroglucinol is a polyphenol that has free radical scavenging and anti-inflammatory activities, in addition to anti-tumor effects on cancer cells. This study investigated the role of insulin-like growth factor 1R (IGF-1R) signaling pathways in the anti-cancer effects of phloroglucinol in human colon cancer HT-29 cells. Cell proliferation was confirmed using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTS) assay; the expression of related proteins and mRNA were determined using Western blotting and RT-PCR, respectively. Apoptosis was examined using confocal microscopy with 4',6-diamidino-2-phenylindole (DAPI) staining. A caspase inhibitor affected the expression of IGF-1R signaling-related proteins.

These results showed the potential inhibitory effect of phloroglucinol on the growth of human colon cancer HT-29 cells. This might be associated with the induction of apoptosis via IGF-1R signaling pathways. The results demonstrate that IGF-1R activates two main downstream signaling pathways involving PI3K, Akt, Ras, Raf, MEK, and ERK. Phloroglucinol treatment significantly inhibited the expression levels of Raf, MEK, ERK phosphorylation, PI3K, and Akt in HT-29 cells. In addition, the levels of mTOR, a critical regulator of cellular growth, the downstream effector p70S6K, and the translation initiation factors eIF4B and RPS6 decreased. DAPI staining clearly showed cell shrinkage and condensed nuclei. The caspase inhibitor treatment resulted in the recruitment of PI3K and Akt. Therefore, the insulin-like growth factor 1R pathway is involved in phloroglucinol-induced apoptosis.

These results have important implications for understanding the roles of cell growth pathways in colon cancer tumorigenesis. Although further studies are required to understand the multiple mechanisms involved, these findings suggest that phloroglucinol inhibits the proliferation of human colon cancer HT-29 cells. Therefore, phloroglucinol has therapeutic potential in the pathogenesis of colon cancer in humans.

 

Nothing to Disclose: TJN, MHK, SJP, JR, MKL, JWC, YMK, IHK, YHC

14684 4.0000 MON-0348 A Induction of Apoptosis By Phloroglucinol Via IGF-1R Signaling Pathways in Human Colon Cancer HT-29 Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Allyson M Agostini-Dreyer*, Amanda E Jetzt and Wendie S Cohick
Rutgers, The State University of NJ, New Brunswick, NJ

 

While IGFBP-3 localizes to the nucleus during apoptosis, its nuclear function remains unclear.  We previously reported that in non-transformed bovine mammary epithelial cells (MECs) the intrinsic apoptosis inducer anisomycin (ANS) activates production and nuclear localization of IGFBP-3, and that IGFBP-3 knockdown attenuates ANS-induced apoptosis.  Exogenous IGFBP-3 has been shown to induce apoptosis by facilitating nuclear export of the orphan receptor Nur77 in prostate cancer cells.  Therefore the goal of the present work was to determine if Nur77 plays an IGFBP-3-dependent role in intrinsic apoptosis.  Knockdown of Nur77 with siRNA decreased ANS-induced cleavage of caspases 3 & 7 and their downstream target PARP, indicating a role for Nur77 in ANS-induced apoptosis.  Cellular fractionation and immunofluorescence showed that ANS induced phosphorylation and nuclear export of Nur77.  These effects were attenuated by knockdown of IGFBP-3.  However, knockdown of IGFBP-3 did not completely reduce phosphorylation of Nur77; therefore Jun-N-terminal kinase (JNK) involvement was examined.  JNK siRNA also reduced ANS-induced Nur77 phosphorylation.  Together, these data indicate that activation of nuclear Nur77 is mediated by both IGFBP-3 and JNK.

 

Nothing to Disclose: AMA, AEJ, WSC

14733 5.0000 MON-0349 A IGFBP-3 Mediates Intrinsic Apoptosis through Phosphorylation and Nuclear Export of Nur77 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Gang Xi*1, Christine Wai2, Morris F White3 and David R Clemmons2
1University of North Carolina at Chapel Hill, Cary, NC, 2University of North Carolina at Chapel Hill, Chapel Hill, NC, 3Children's Hospital, Boston, MA

 

Our previous in vitro studies have shown that IRS-1 is an important regulator for maintaining vascular smooth muscle cells (VSMCs) in the non-proliferative state and that its down-regulation under hyperglycemic conditions allows enhanced VSMC  responsiveness to IGF-I.  Using Sm22α-derived Cre mice and IRS-1 or IRS-2 floxed mice, we specifically knocked out IRS-1 or IRS-2 in the mouse smooth muscle. Unlike global knockout of IRS-1 or IRS-2, VSMC specific knockout of IRS-1 or IRS-2 did not result in any significant change of mouse body weight. In addition, there were no differences in the kidney, heart and liver weight between knockout mice and their wild type littermates. However, either knockout reduced significantly the weight of the aorta. For example, IRS-1 knockout resulted in 28 ± 5% (P<0.001) reduction and IRS-2 knockout resulted in 15 ± 5% reduction in aortic weight, compared to wild type littermates. Since our in vitro studies have shown that down-regulation of IRS-1 under hyperglycemic conditions is required for IGF-I to stimulate SHPS-1 phosphorylation and activation of its downstream signaling, we hypothesized that knockout of IRS-1 in smooth muscle would allow activation of the IGF-I-stimulated SHPS-1-mediated signaling pathway activation under normoglycemic conditions in VSMCs, thereby leading to enhanced responsiveness to IGF-I and VSMC remodeling. The results showed that, like diabetic, wild type littermates, IGF-I stimulated the phosphorylation of SHPS-1 in non-diabetic mice when IRS-1 was specifically knocked out in smooth muscle. However, IGF-I could not stimulate SHPS-1 phosphorylation when IRS-2 was knocked out under normoglycemic conditions. Consistently, when downstream signaling was examined, IGF-I-stimulated AKT and MAP kinase activation were detected in non-diabetic IRS-1 knockout mice but not in non-diabetic IRS-2 knockout mice.

Kruppel-like factor 4 (KLF4) has been shown to stimulate VSMC dedifferentiation. KLF4 is not expressed in VSMCs under normal conditions but is increased in response to injury or stress. Myocardin is a downstream gene of KLF4 and a co-activator of SMC differentiation markers, such as SM22α, therefore it is an indicator of VSCMs differentiation status. Our current study showed that hyperglycemia induced the expression of KLF4 in aorta in wild type mice and a similar level of KLF4 expression was also detected in non-diabetic mice when IRS-1 but not IRS-2 was knocked out in smooth muscle. Consistently, myocardin expression was detected in non-diabetic wild type mice but not in diabetic wild type mice or non-diabetic IRS-1 knockout mice. These results demonstrate that IRS-1 plays a critical role in regulating IGF-I signaling and VSMCs remodeling by maintaining VSMC in their differentiated, contractile phenotypic state.

 

Nothing to Disclose: GX, CW, MFW, DRC

15004 6.0000 MON-0350 A Tissue Specific Knockout Reveals That IRS-1 but Not IRS-2 Plays an Important Role in Regulating Vascular Smooth Muscle Cell Remodeling 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Weiping Qin*1, Jianping Pan2, William A Bauman2 and Christopher Pratt Cardozo1
1James J. Peters Veteran Affairs Medical Center, Bronx, NY, 2James J. Peters VA Medical Center, Bronx, NY

 

The calcium-regulated calcineurin-nuclear factor of activated T cells (NFAT) pathway modulates a wide variety of biological responses, including those of lymphocyte activation, neuronal and muscle development and neurite outgrowth. Upon activation, calcineurin dephosphorylates NFAT family transcription factors, triggering their nuclear entry and activation or repression of target genes [1,2]. mTORC1 is a master regulator of growth and protein synthesis through the regulation of S6K1 and 4E-BP1, and thus plays vital roles in apopotosis, cancer, and longevity [3,4]. We have recently reported that calcineurin is involved in the androgen-induced hypertrophy of myotubes and increase in size of skeletal muscle fibers, and that in differentiated L6 myoblast cells, this androgen-induced hypertrophy was inhibited by rapamycin, an inhibitor of mTOR [5]. Taken together, this evidence suggests the possibility that a regulatory interaction may be present between calcineurin and mTOR. Here, we demonstrate that the activation of mTORC1 activity in TSC2 -/- rat embryonic fibroblasts significantly enhances calcineurin phosphatase activity, NFAT reporter gene luciferase activity, and NFATc4 nuclear levels, while the inactivation of mTORC1 activity by Raptor siRNA in C2C12 cells reduces NFAT luciferase activity and NFATc4 nuclear levels. These data indicate that the stimulation of mTORC1 activity results in increased calcineurin activity. On the other hand, inhibition of calcineurin by cyclosporin A reduced mTOR activity, which was assessed by phosphorylation of p70S6 kinase at Thr389 and protein synthesis, whereas overexpression of calcineurin A by an adenovirus vector increased mTOR activity, as reflected by the increased phosphorylation of p70S6 kinase at Thr389 and 4E-BP1 at Thr30/47, which suggests that promotion of calcineurin activity results in enhanced mTOR activity. Our findings provide the first evidence to demonstrate reciprocal regulatory interaction between calcineurin and mTORC1, two important cellular signaling pathways. This complex molecular network appears to plays distinct, yet common and mutually favorable roles in regulation of cell growth.

 

Nothing to Disclose: WQ, JP, WAB, CPC

15189 7.0000 MON-0351 A Molecular Crosstalk Between Calcineurin and mTORC1 Signaling Pathways 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Yoko Fujita-Yamaguchi*1, Astufumi Nakazawa2 and Noriyuki Yuasa2
1Beckman Research Institute of City of Hope, Duarte, CA, 2Tokai University School of Engineering, Hiratsuka, Japan

 

Insulin-like growth factor I receptor (IGF-ΙR) plays an essential role in cancer growth, progression, and metastasis. IGF-IR is overexpressed in a variety of malignant tumors and also plays a role in hormone-independent growth of breast and prostate cancers. IGF-IR is therefore considered to be a good target molecule for cancer therapy. Recombinant single chain antibodies (scFvs), derived from anti-IGF-IR monoclonal antibody 1H7, was previously expressed in E. coli cells (Kusada et al. J. Biochem. 143, 9-19, 2008). Expression of 1H7 scFv proteins in E. coli, however, did not yield significant quantities.  To achieve better yields, we used a Drosophila S2 cell expression system. In addition, 1H7 scFv-human IgG1 Fc conjugates (1H7 scFv-Fc) was expressed in Drosophila S2 and CHO cells. Both 1H7 scFv and 1H7 scFv-Fc expressed in Drosophila S2 cells as well as 1H7 scFv-Fc expressed in CHO cells were purified from respective stable clones to compare their yields and specific binding activities to IGF-IR. CHO cells were transfected with an 1H7 scFv-Fc/pCI-neo expression vector, from which stable clones were selected by limiting dilution method as previously described (Zhang et al. Biochemistry 46, 263-270, 2007). The 1H7 scFv or scFv-Fc gene cloned into a pMT/BiP/V5-His expression vector was co-transfected with a pCoHygro selection vector into S2 cells. Stable S2 cell clones expressing either 1H7 scFv or scFv-Fc proteins were selected by limiting dilution method in the presence of feeder S2 cells. After 2-weeks culture in the presence of 0.3 mg/ml hygromycin B, stable S2 cell clones were treated with 0.5 mM CuSO4 to induce scFv or scFv-Fc protein expression. From culture supernatants, 1H7 scFv proteins were purified by Ni2+-Sepharose chromatography. The 1H7 scFv-Fc proteins were purified from supernatants of CHO and S2 cell stable clones by Protein A-Sepharose chromatography. Both 1H7 scFv and 1H7 scFv-Fc proteins were successfully expressed in culture supernatants of stable clones, and purified to homogeneity. IGF-IR binding activity measured using SPR and ELISA revealed production of active 1H7 scFv and scFv-Fc proteins. Specific binding activity of S2 cell-produced1H7 scFv-Fc was ~2-fold higher than that of CHO cell-produced 1H7 scFv-Fc. These results thus suggested that an insect cell expression system producing soluble and active scFv and scFv-Fc proteins is not only cost- and time-effective but also the best available system to produce 1H7 scFv and scFv-Fc proteins in the laboratory settings.

 

Nothing to Disclose: YF, AN, NY

15582 8.0000 MON-0352 A Expression and Purification of Anti-IGF-I Receptor 1H7 Constructs in Drosophila S2 Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Amy Shah Dhesi*, Andrea Wojtczuk, Gerson Weiss and Laura T Goldsmith
Rutgers - New Jersey Medical School, Newark, NJ

 

Interleukin-8 (IL-8), a proinflammatory cytokine that promotes chemotaxis and angiogeneisis, is an important maternal factor involved in human implantation. IL-8 is produced by the endometrium with increased expression occurring with decidualization. We have previously demonstrated that in endometrial cells IL-8 is regulated in a cAMP dependent manner which is MAPKinase dependent and PKA independent. However, regulation of IL-8 in decidualized endometrium remains uncharacterized. We tested the hypothesis that decidualized endometrial cells have increased IL-8 expression, which is mediated by MAPKinase.

A well characterized line of telomerase-immortalized human endometrial stromal cells (HESC-T), which undergo the characteristic decidualization response to increased intracellular cAMP, was used as an in vitro model. Replicate wells of cells were incubated in phenol red-free media without or with 0.5mM 8-br-cAMP for 9 days to induce decidualization. To determine the role of MAPKinase, cells were also incubated with 8-br-cAMP in the presence of a specific MEK inhibitor (UO126). Conditioned media were collected and replaced every 48 hours and cell morphology was assessed under phase contrast microscopy. Four independent experiments, each in triplicate, were performed. IL-8 concentrations were determined in medium from each well using a human IL-8 specific enzyme immunoassay. Data were assessed for normality using the Kolmogorov-Smirnov test and differences between groups were assessed using nonparametric Mann Whitney tests.

Decidualization of endometrial stromal cells significantly increased IL-8 expression to levels 14 fold greater than those of nondecidualized endometrial stromal cells (p< 0.0001). Inhibition of MAPKinase during the 9-day decidualization protocol decreased IL-8 expression to 22±5% [M±SE, n=4 experiments, each in triplicate] of that of control, untreated decidual cells (p< 0.0001). In these experiments, inhibition of MAPKinase in nondecidualized endometrial stromal cells (performed as a positive control) decreased IL-8 expression to 20±2% of that of control, untreated nondecidualized cells (p< 0.0001).

Decidualization of endometrial stromal cells significantly stimulates IL-8 expression in preparation for implantation and this occurs in a MAPKinase dependent manner.  These data indicate a significant role for the MAPKinase pathway in endometrial and decidual function heretofore unrecognized.

 

Nothing to Disclose: ASD, AW, GW, LTG

15907 9.0000 MON-0353 A Decidualization of Human Endometrial Stromal Cells Stimulates Interleukin-8 Expression: Mediation By Mitogen-Activated Protein Kinase 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Brian D Fink1, Liping Yu2 and William I Sivitz*3
1Iowa City VAMC, Iowa City, IA, 2University of Iowa, Iowa City, IA, 3Univ of Iowa and the Iowa City VAMC, Iowa City, IA

 

Mitochondrial ROS production is highly dependent on the type of fuel (substrate) used for energy. It is well known that respiration on the complex II substrate, succinate, generates large amounts of matrix superoxide via reverse electron transport and that the process is dependent on membrane potential (ΔΨ). The respiratory state, as it changes from state 4 (no ATP production) to state 3 (maximal ATP production), as well as mitochondrial calcium entry, both markedly affect ΔΨ. Here, we examined ROS production on different energy substrates upon exposure to different magnitudes of calcium concentration at an intermediate, but clamped, respiratory state. To do this we used a 2-deoxyglucose (2DOG) energy clamp which also enabled simultaneous detection of ATP production via measurement of the amount of 2DOG-phosphate (2DOGP) formed. We also assessed ROS during reverse electron transport in both state 4 and clamped state 3 respiration. As expected, ROS production in muscle mitochondria respiring on succinate in state 4 was very high and far greater than in mitochondria respiring on complex I substrates. However, this was reversed in the presence of ongoing clamped ATP production. This was the case at all levels of added calcium.  Low concentrations of calcium enhanced ΔΨ and ATP production on complex I and combined complex I and II substrates, but not on succinate alone. We also observed that even though ROS production on succinate alone (in the presence of ATP production) was low, succinate markedly increased ROS when added to complex I substrates. In summary: 1) reverse electron transport and associated ROS decrease markedly during active ATP synthesis; 2) low (Ca++) enhances ΔΨ and ATP production in parallel while higher calcium concentrations inhibit these parameters, likely due to opening of the mitochondrial permeability transition pore; 3) Succinate potentiates state 3 ROS production on complex I substrates by an, as yet, unclear mechanism.

 

Nothing to Disclose: BDF, LY, WIS

15994 10.0000 MON-0354 A Calcium-Mediated Mitochondrial ATP Production and Reactive Oxygen: Substrate Dependence: 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Doaa Abdulkalig Aboalola*1 and Victor Khin Han2
1Children's Health Research Institute- UWO, London, ON, Canada, 2Children's Hlth Rsrch Inst, London, ON, Canada

 

BACKGROUND: Insulin-like growth factors are major components of the stem cell niche, as they regulate proliferation and differentiation of many tissues including skeletal muscle. Insulin-like growth factor binding protein-6 (IGFBP-6) is expressed in developing muscle cells and is the main regulator of IGF-II (fetal IGF). To date, no previous studies have been reported relating placental mesenchymal stem cells (PMSCs), muscle differentiation, and IGFBP-6. In this study, we hypothesized that IGFBP-6 regulates the maintenance of pluripotency of PMSCs and promotes their differentiation into muscle via intracellular and extracellular interactions. OBJECTIVES: 1) to investigate the capacity of PMSCs to differentiate into skeletal muscle cells; and 2) to evaluate the intracellular and extracellular actions of IGFBP-6 on PMSCs muscle differentiation. METHODS: Chorionic villi were collected from preterm placenta (12-20 weeks) and cells were extracted by mechanical and enzymatic digestion. Following cell expansion, stem cell identity was verified. Then, cells were differentiated into muscle lineage for 14 days and the impact of IGFBP-6 on this differentiation process was investigated over time by either adding IGFBP-6 or silencing it using siRNA. RESULTS: Isolated cells differentiated into muscle cells, forming multi-nucleated fibers that express muscle markers Pax3/7, MyoD, MyoG, and MHC using immunoblotting with increased protein levels of IGFBP-6 and decreasing levels of OCT4. Additionally, extracellular addition of IGFBP-6 significantly increased protein levels of muscle commitment maker Pax3/7 overtime, with an increase at the earlier time points for muscle markers MyoD and MyoG that goes down by time. Interestingly, both SOX2 and OCT4 protein levels correlate with the levels of IGFBP-6. On the other hand, intracellular silencing of IGFBP-6 using siRNA, significantly decreased MyoD and MyoG at the earlier time points which goes up by day 5 after differentiation, with a significant increase in muscle commitment marker Pax3/7 protein levels as early as day 1 after differentiation. Moreover, silencing IGFBP-6 also decreased OCT4 levels significantly over time. CONCLUSION: IGFBP-6 regulates PMSC differentiation into muscle, with more prominent effects at the beginning of the differentiation process, when PMSCs commit to muscle formation and dependent on intracellular or extracellular location. RELEVANCE: Testing if myogenesis can be manipulated through IGFBP-6 expression will help us improve muscle regeneration therapies using stem cells.

 

Nothing to Disclose: DAA, VKH

16132 11.0000 MON-0355 A The Role of Insulin-like Growth Factor Binding Protein-6 in the Differentiation of Placental Mesenchymal Stem Cells into Skeletal Muscle 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Isabella Finco*1 and Gary D Hammer2
1University of Michigan, Ann Arbor, MI, 2Univ of Michigan, Ann Arbor, MI

 

Clinical adrenocortical suppression following the chronic administration of supra-physiologic glucocorticoids is a frequent health problem due to iatrogenic adrenocortical atrophy. The Hedgehog (Hh) signaling pathway has been implicated in the tissue patterning, homeostasis and regeneration mediated by organ-specific stem and progenitor cells in multiple systems. The adrenal stem/progenitor cell niche in the peripheral cortex is not well characterized, and the mechanism of regrowth following adrenal atrophy remains elusive.  However, Sonic hedgehog (Shh), the predominant Hh ligand in the adrenal, is restricted to this progenitor cell population.  Prior work has catalogued hypoplastic adrenal glands in mice with adrenal-specific knockout of Shh. Lineage tracing studies have demonstrated that Shh-responsive cells that express the obligate Gli transcription factors are restricted to the adrenal capsule but migrate centripetally to give rise to differentiated cells of the cortex.

To determine the contribution of capsular (Shh responsive) and peripheral cortical (Shh producing) cells to physiologic adrenocortical regeneration, we have established a murine model of dexamethasone (DEX)-mediated atrophy and regrowth of the adrenal cortex. In the peripheral cortex of these mice during and directly following DEX, we observed an increase in Shh expression and in the number of cells responsive to the canonical Wnt pathway – a signaling pathway shown to be pivotal for adrenal homeostasis. Moreover, Gli1 lineage tracing revealed a marked increase in the number of Gli1 descendants contributing to the regenerating cortex.

To assess the contribution of Shh signaling to the regenerative process, we have generated an inducible mouse line in which constitutively active Smoothened, the Hh signal transducer, is expressed in Gli1+ cells. The adrenals of these mice displayed an increased expression of Wnt ligands and a decreased expression of Wnt pathway inhibitors at baseline.  After DEX, the adrenals exhibited a marked increase in cortical proliferation, concomitant with more rapid regeneration compared to wild type adrenals. A further robust increase in β-catenin expression in the peripheral cortex is consistent with an active role of the canonical Wnt pathway in the repair process.

To further explore the relationship between the Shh and Wnt pathways in the regeneration process, an inhibitor of the Hh pathway was administered to DEX-treated mice. Besides the expected decreased in Hh pathway activation, the mice exhibited a diminished expression of Wnt pathway target genes. These results suggest that Shh plays an active role in adrenal regeneration by promoting 1) the egress and differentiation of Shh-responsive Gli1+ capsular cells into the regenerating cortex and 2) the activation of canonical Wnt pathway through the differential regulation of peripheral Wnt ligand and inhibitor expression.

 

Nothing to Disclose: IF, GDH

16277 12.0000 MON-0356 A Sonic Hedgehog in Adrenal Regeneration 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Annika Burleigh*1, Katherine A Staines1, Joelle R Kahlani1, Blandine Poulet2, Andrew A Pitsillides1 and Abir Mukherjee1
1Royal Veterinary College, London, United Kingdom, 2University College London, United Kingdom

 

The TGFβ ligand superfamily is important in the development and maintenance of bone and cartilage. We have previously shown that mice deficient in the activin/TGFβ ligand signalling antagonist, Follistatin-like 3 (FSTL3 KO), develop spontaneous osteoarthritis (OA) with age, and exhibit premature growth plate closure. Here we examine the hypothesis that FSTL3 KO mice have an altered endochondral growth phenotype that reflects their predisposition to developing OA. To this end, 4 and 8 week old male FSTL3 KO and age-matched wildtype (WT) mice were culled after treating for 1 week with BrdU. The endochondral growth phenotype of these mice was assessed by standard histology and immunohistochemical labelling of growth plate structure. Metatarsal rudiments dissected from e14.5 embryos were cultured for up to 10 days. Mineralisation zone and metatarsal length was measured during culture. At 4weeks FSTL3 KO mice displayed widened growth plates, corresponding to an increase in the size of the hypertrophic zone of chondrocytes, compared to age-matched WT mice. No striking differences were seen in the growth plate measurements at 8 weeks. FSTL3 KO mice showed decreased SafraninO staining in the hypertrophic zone at both 4 and 8 weeks of age, indicating an alteration in the composition of sulphated proteoglycans, and disordered columnar organisation of growth plate chondrocytes. There was also an increase in the intensity and number of BrdU positive labelling in 8, but not in 4 week old, FSTL3 KO mice when compared to WT mice. Immunolabelling for markers of chondrocyte hypertrophy at 4 weeks of age revealed increases in MMP13 expression in FSTL3 KO growth plates, but a decreased expression of Col10a1, which supports an alteration of the chondrocyte phentoype. pSMAD2 expression was located predominantly in the hypertrophic zone and was increased in FSTL3 KO mice at 4 but not 8 weeks.  No alteration in caspase 3 or TUNEL staining was observed. Deletion of FSTL3 resulted in accelerated mineralisation and increased longitudinal growth in e14.5 embryonic metatarsal organ cultures. Our initial data suggest, therefore, that FSTL3 KO mice display an accelerated bone and endochondral growth phenotype. This most likely contributes to the development of OA directly or points to a fundamental chondrocyte deficit that underpins osteoarthritic initiation. We are currently addressing these possibilities to elucidate the molecular mechanisms responsible for initiating OA in mice.

 

Nothing to Disclose: AB, KAS, JRK, BP, AAP, AM

16795 13.0000 MON-0357 A Follistatin-like 3 (FSTL3): A Novel Regulator of Growth Plate Dynamics 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Memoona Rehman, Caroline Wheeler-Jones and Abir Mukherjee*
Royal Veterinary College, London, United Kingdom

 

Follistatin-like 3 (FSTL3) is a secreted and nuclear glycoprotein which inhibits the action of activin and related TGFβ ligands. We have shown in the FSTL3 deletion mouse (FSTL3 KO) that concomitant with increased activin signalling there is hyperplasia in tissues where FSTL3 is normally expressed. We hypothesise that increased activin-dependent signalling in the absence of FSTL3 can promote cell proliferation. To test this, mouse embryonic fibroblasts (MEFs) were cultured from FSTL3 KO and wildtype (WT) embryos and the effects of FSTL3 deletion on signalling pathways and cell proliferation were investigated. FSTL3 deletion led to increased MEF cell numbers compared to WT both in the presence and absence of serum. Addition of exogenous FSTL3 did not affect proliferation of FSTL3 KO cells. Flow cytometric analyses of MEFs following released from nocodazole-induced G2/M arrest show that, compared to WT, numbers of FSTL3 KO cells are increased in the S phase, reduced at the G0/G1 boundary and there is no alteration in the proportion of cells in the M phase. These results suggest that the rate of cellular proliferation is increased in the absence of FSTL3. To identify cellular proliferation-associated signalling pathways altered in an activin-dependent manner, HEK 293 were treated with activin in the presence or absence of ALK inhibitor SB431542 (SB), PI3K inhibitor LY294002 (LY) and MEK inhibitor U0126 (U0). We found SMAD2, AKT and ERK phosphorylation was significantly increased in the presence of exogenous activin, an effect which was reversed following treatment with SB, LY and U0, respectively. This suggests that there is cross talk between activin-initiated ALK activation and PI3K/AKT and ERK pathways. Also, KO cell proliferation is increased in the presence of exogenous activin and this effect is reversed in the presence of SB or LY but not U0. Activation of caspases 3/7 is also significantly increased in FSTL3 KO MEFs suggesting increased apoptosis in the fibroblasts in the absence of FSTL3. Our findings suggest, therefore, that deletion of FSTL3 increases cellular proliferation, by increasing the rate of cell division, as well as apoptosis, leading perhaps, to increased cellular turnover. While SMAD2, AKT and ERK pathways appear to be linked to activin stimulation and cellular proliferation, exogenous FSTL3 does not affect increased proliferation of FSTL3 KO cell, perhaps suggesting that FSTL3 action is cell autonomous and not paracrine/endocrine.

 

Nothing to Disclose: MR, CW, AM

16849 14.0000 MON-0358 A FSTL3: A Tgfβ Ligand Inhibitor Regulates Cell Proliferation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Rachel D Robertson1, Memoona Rehman1, Waheed Mahmood1, Gurtej K Dhoot1, Imelda Mary McGonnell2 and Abir Mukherjee*1
1Royal Veterinary College, London, United Kingdom, 2The Royal Veterinary College, London, United Kingdom

 

Follistatin-like 3 (FSTL3) is an endogenous glycoprotein inhibitor of transforming growth factor-β (TGFβ) ligands such as activin. We have identified a group of activin-responsive genes that have an expression pattern closely aligned to that of FSTL3 and our expression analyses support the likelihood that FSTL3 action is important in circulation and placental function. In addition, FSTL3 is strongly induced in preeclamptic placenta. To test the hypothesis that FSTL3 is a regulator of placental function we studied the placenta in FSTL3 gene deleted mice (FSTL3 KO). We found striking defects in the FSTL3 KO placenta when compared to WT. There is a significant increase in placental size at 16.5 and 18.5 dpc compared to WT. While gross morphology is altered from flat to domed in shape, histology reveals morphological differences in placental junctional zones in FSTL3 KO placenta compared to WT. Morphometric analyses show that the proportion of the labyrinth is reduced significantly in the FSTL3 KO placenta. As a measure of increased activin action we found increased SMAD2/3 phosphorylation in FSTL3 KO placentae, and this activation is more pronounced in the labyrinth compared to the trophoblast layer. Most strikingly, the FSTL3 KO placenta has significantly reduced red blood cell amount in the labyrinth, supportive of a role for FSTL3 in regulating placental circulation. Immunohistochemical analyses reveal that the expression of von Willebrand factor, a marker of blood vessel endothelial cells, is reduced while phosphohistone, an indicator of cellular division, is reciprocally induced in FSTL3 KO placenta. These findings suggest that a balance between cellular proliferation and differentiation might be altered in the absence of FSTL3. Activin-responsive FSTL3-synexpression genes are upregulated in FSTL3 KO placenta. Of these, EPHB4 protein is strongly induced in the placenta along with its ligand EphrinB2. This suggests that there might be reduced EphrinB2-EPHB4 signaling leading to EphrinB2 ligand accumulation. Since EPHB4 signaling is strongly implicated in capillary network formation it is likely that along with increased proliferation and reduced differentiation of blood vessels, a reduction of EPHB4 signaling contributes to the diminished circulation phenotype seen in the placenta of FSTL3 KO mice. Thus we conclude that FSTL3 function, and hence regulation of activin action, is necessary for normal placental development.

 

Nothing to Disclose: RDR, MR, WM, GKD, IMM, AM

16886 15.0000 MON-0359 A Follistatin-like 3 (FSTL3), a Transforming Growth Factor β (TGFβ) Ligand Inhibitor, Is Essential for Placental Development in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Alissa N Blackler, Mariana R Haedo* and Louise M Bilezikjian
Salk Institute for Biol Studies, La Jolla, CA

 

FoxL2 plays an important role in gonadotrope signaling by facilitating activin actions on cell-type specific expression of target genes including follistatin (Fst) and Fshb. FoxL2 also controls ovarian function and fertility through actions on granulosa cell maturation and steroidogenic genes. In humans, inactivating mutations of FOXL2 are associated with BPES, with a subset of patients suffering premature ovarian failure. A somatic point mutant, FOXL2(C134W), is associated with adult type granulosa cell tumors. Studies with αT3-1 and LβT2 cells have established that FoxL2 partners with Smad3 to facilitate activin effects on Fst, Fshb and Gnrhr transcription. Whether FoxL2 and the activin pathway interact to regulate other aspects of gonadotrope function is not known. To address this question, we developed inducible LβT2 lines by transduction with lentiviral vectors that permit doxycycline (dox)-inducible expression of FoxL2, inhibin-βA, FoxL2+inhibin-βA or only GFP (vector provided by Drs. Wahl and Spike, Salk Institute). Immunoblot analysis confirmed dox-inducible FoxL2 expression in lysates of LβT2-FoxL2 or LβT2-FoxL2/βA cells. Activation of a Smad2/FoxH1-luc reporter by conditioned media demonstrated dox-inducible production of bioactive activin-A by LβT2-bA or LβT2-FoxL2/βA. Immunoblot analysis following heparin enrichment verified presence of βA subunit. Given that activin signaling and FoxL2 are both implicated in the control of cell proliferation, we measured the growth patterns of the inducible lines in vitro (using CyQuant) and in vivo, following injections into the flanks of J:NU nude mice. Dox-treatment of LβT2-FoxL2 cells did not significantly alter their growth rate in vivo or in vitro, and tumor weight/volume in mice fed dox-diet was not significantly different from those fed regular chow or tumors of LβT2-GFP cells. By contrast, dox treatment of LβT2-βA caused a statistically significant reduction in growth rate in vitro. Similarly, LβT2-βA tumors grew substantially slower and tumor size was significantly smaller in mice fed dox-diet. Interestingly and in contrast to LβT2-βA cells, the growth rate of LβT2-FoxL2/βA cells was higher in general and not suppressed by dox treatment, similar to LβT2-FoxL2 cells, suggestive of an interaction of the pathways in the modulation of cell growth.

 

Nothing to Disclose: ANB, MRH, LMB

15275 16.0000 MON-0360 A Establishment of Doxycycline-Inducible LßT2 Cells to Evaluate Activin and FoxL2 Actions in Pituitary Gonadotropes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Yining Li*1, Jérôme Fortin1, Ulrich Boehm2, Herbert Y Lin3 and Daniel J. Bernard1
1McGill University, Montreal, QC, Canada, 2University of Saarland School of Medicine, Homburg, Germany, 3Massachusetts General Hospital and Harvard Medical School, Boston, MA

 

FSH is an essential regulator of ovarian follicle development and fertility in females and of quantitatively normal spermatogenesis in males. FSH synthesis is stimulated by intra-pituitary activins and is suppressed by gonadal inhibins. Activins stimulate transcription of the FSH β subunit gene (Fshb) in gonadotrope cells. Inhibins, in contrast, impair FSH production via competitive antagonism of activin signaling. That is, inhibins bind the activin type II receptor, ACVR2, with picomolar affinity in the presence of the co-receptor TGFBR3 (also known as betaglycan), blocking autocrine/paracrine activin signaling. The current model of inhibin action via TGFBR3 is based on in vitro observations. Tgfbr3-deficient mice die during embryonic development, precluding their use for in vivo assessment of TGFBR3 function.  We therefore employed a conditional knockout approach (Cre/lox) to investigate the necessity for TGFBR3 in inhibin action and FSH synthesis in gonadotropes in vivo. First, we generated a conditional (floxed) Tgfbr3 allele by gene targeting in murine embryonic stem cells. Cre-mediated recombination deletes exon 2, generating a loss of function allele. Indeed, mice homozygous for the globally recombined Tgfbr3 allele died during embryonic development. Next, we assessed TGFBR3’s role in inhibin action in primary pituitary cultures of Tgfbr3flox/flox mice. Inhibin A potently and dose-dependently inhibited FSH secretion and Fshb mRNA expression in cultures transduced with a control (GFP-expressing) adenovirus.  In contrast, inhibin A action was abrogated in cells transduced with a Cre-expressing adenovirus. Finally, we selectively ablated Tgfbr3 in gonadotropes by crossing Tgfbr3flox/flox and GnrhrIRES-Cre (GRIC) mice (hereafter, T3cKO). We confirmed the selective reduction of TGFBR3 protein expression in gonadotropes of T3cKO mice by immunofluorescence. Whereas T3cKO males had normal reproductive organ weights and serum FSH, their pituitary Fshb mRNA levels were significantly increased. T3cKO females were super-fertile, producing approximately two more pups per litter than controls (7.5±0.5 vs. 9.6±0.5) over a 6 month breeding trial. T3cKO ovaries contained a greater number of corpora lutea than controls (4.7±0.5 vs. 6.6±0.9 per ovary). We are currently investigating FSH levels and antral follicle numbers in females. Collectively, these data suggest that inhibins act via TGFBR3 in gonadotropes to suppress FSH synthesis in vivo.

 

Nothing to Disclose: YL, JF, UB, HYL, DJB

14943 17.0000 MON-0361 A Enhanced Fertility and FSH Synthesis in Mice Lacking the Inhibin Co-Receptor TGFBR3 (betaglycan) in Pituitary Gonadotropes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Growth Factor/Tyrosine Kinase/G Protein-Coupled Receptor/Intracelluar Signaling & Biology Monday, June 23rd 3:00:00 PM MON 0345-0361 5062 1:00:00 PM Growth Factor/Tyrosine Kinase Signaling, Inhibin/Activin Superfamily, Cell Regulation Poster

Milica Medic-Stojanoska*1, Nikola Curic2, Natasa Milic3, Bojan Vukovic2, Ivana Bajkin2, Tijana Icin2, Jovanka Novakovic-Paro2, Andrijana Milankov2 and Branka Kovacev-Zavisic2
1Clinical Center of Vojvodina, Medical Faculty University of Novi Sad, Novi Sad, Serbia, 2Clinical Center of Vojvodina, Medical Faculty, University of Novi Sad, Novi Sad, Serbia, 3Medical Faculty, University of Novi Sad, Novi Sad, Serbia

 

Introduction. Phthalates are widely used chemicals as personal care and consumer products.  In recent years experimental and human epidemiological and observational studies confirm that phthalates have thyroid disrupting properties. The exact mechanism of this action is not elucidated. The aim of this study was to exam association between diethyl phthalate (DEP) and di-2-ethylhexyl phthalate (DEHP) through the levels of their urinary metabolites and thyroid function.

Material and methods. Study group included 182 persons (96 healthy non-obese and 86 obese), mean age 37,10±8,18, 93 males and 89 females, without thyroid disease. Phthalate monoester metabolites, monoethyl phthalate (MEP) originated from DEP and mono-2-ethylhexyl phthalate (MEHP) originated from DEHP, were measured in single urine sample by mass spectrometry. Free thyroxin (FT4), free triiodothyronine (FT3) and thyroid stimulating hormone (TSH) were measured from blood sample. According to presence of urinary phthalate metabolites, examinees were devided in groups:  MEP positive, MEP negative, MEHP positive and MEHP negative. According to BMI (body mass index) MEP positive and MEHP positive groups were divided into MEP non-obese and MEP obese subgroups and MEHP non-obese and MEHP obese subgroups.

Results. MEP was positive in urine of 30,77% examinees with mean level  143,55±219,45ng/ml. There was no difference in age, body mass index (BMI) and FT3 between MEP positive and negative group. FT4 and TSH were normal, significantly increased  in MEP positive than negative group (FT4 14,0±1,43 vs 13,41±1,84pmol/l, p< 0,024; TSH 2,18±1,02 vs. 1,85±1,01mIU/l, p< 0,047). There was no significant correlation between MEP and thyroid hormones and TSH. MEHP was positive in 25,82% examinees with mean value of 93,08±91,91ng/ml. MEHP positive group had similar age and TSH as negative group. BMI was significantly higher in MEHP positive than negative group (30,52±7,16 vs. 27,83±7,68kg/m2, p<0,44). Levels of F4 and FT3 were normal but lower in MEHP positive than negative group, with border significance (FT4 13,13±2,43 vs 13,73±1,47pmol/l, p< 0,046; FT3 4,58±0,66 vs 4,80±0,67pmol/l, p<0,059). There were not any significant correlation of MEHP with FT4, FT3 and TSH. But, in MEP non obese subgroup (n=26) we found significant negative correlation between MEP and FT4 (p<0,0045)  MEP and FT3 (< 0,0288) and significant positive correlation between MEP and TSH (p < 0,0046). In MEHP non obese subgroup (n=17) we found significant positive correlation between MEHP and TSH (p<0,0236). In obese subgroups only in MEP obese subgroup (n=30) we found significant positive correlation between MEP and TSH (p< 0,0349).

Conclusion. According to literature data and our results, despite small number of examinees, the association between DEP and DEHP and thyroid function is possible. Future studies have to confirm and elucidate this association.

 

Nothing to Disclose: MM, NC, NM, BV, IB, TI, JN, AM, BK

16133 1.0000 MON-0362 A Do Diethyl Phthalate and Di-2-Ethylhexyl Phthalat Have Influence on Thyroid Function? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Monday, June 23rd 3:00:00 PM MON 0362-0374 5065 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Lee A Meserve*1, Hannah Duffy2 and Howard C. Cromwell3
1Bowling Green State Univ, Bowling Green, OH, 2Bowling Green State University, 3Bowling Green State University, Bowling Green, OH

 

Commercial manufacturing and widespread use of polychlorinated biphenyl (PCB) in the

United States left lasting negative effects on the environment. These persistent contaminants continue to bioaccumulate in the food web because of their stable structure resulting in long half-life, and high lipophilicity. Adding PCB into the diet of Sprague-Dawley rats during pregnancy and lactation alters the thyroid status of offspring, as well as behavior of the dams and the pups. To examine the hypothesis that there is a critical period or “window” of development with the greatest impact of PCB exposure of females on offspring fitness, female Sprague-Dawley rats were mated and fed PCB diet (25 ppm PCB 47 and PCB 77 congeners combined in standard rat chow) during either one of five, two week “development windows” (prenatal weeks 1 and 2, 2 and 3, prenatal week 3 and postnatal week 1, postnatal weeks 1 and 2, or postnatal weeks 2 and 3), or one of three, one week “developmental windows” (prenatal week 1, 2, or 3). Ultrasonic vocalizations (USVs) were recorded on pup postnatal day (PND) 3, 7, 14, 21, and 22. Grooming (PND 14), open field (PND 21), and play behaviors (PND 22) were also observed in pups. Blood serum was collected on PND 3, 7, 14, 21, and 22 for thyroid hormone analysis. Given the brief exposure to PCB, alteration of thyroid hormone concentrations in pups were subtle but significant, especially with regard to thyroxine.  There was a significant increase in the number of USVs emitted by pups across all treatment groups between developmental days PND 3 and 7 (p < 0.01), and also among the window groups (p < 0.001), with pups from dams given PCB diet from the first day of pregnancy to early lactation emitting USV isolation calls at a significantly greater rate than those exposed later in development. This increased rate of vocalization could be analogous to that seen in human developmental disorders. Other behavioral measures were less obviously altered by these brief exposures to PCB, however the “window” for influencing rate of ultrasonic vocalization appears to be early in gestation.

 

Nothing to Disclose: LAM, HD, HCC

14798 2.0000 MON-0363 A Characterization of Developmental Endocrine Disruption By PCB As Monitored By Ultrasonic Vocalization 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Monday, June 23rd 3:00:00 PM MON 0362-0374 5065 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Mathilde Munier*1, Julie Grouleff2, Louis Gourdin1, Regis Coutant3, Birgit Schiott2, Marie Chabbert1 and Patrice Rodien4
1INSERM, Angers, France, 2Aarhus University, Aarhus C, Denmark, 3CHRU Hotel-Dieu, Angers, France, 4CHU Angers - Centre Hospitalier Universitaire, Angers, France

 

In humans, exposure to p,p’DDT, an organochloride insecticide defined as endocrine disruptor (ED), is frequently associated with reproductive diseases (genital malformation and precocious puberty). p,p’DDT accumulates in the environment. Thus, while banned in most countries, it is a major pollutant. The FSH receptor (FSHR) is involved in gonadal function especially and gametogenesis. This receptor is preferentially coupled to Gs thus to the production of cAMP. Given the importance of this GPCR in reproductive function, we aimed at investigating the impact of p,p’DDT on FSHR activity. We have used a stably transfected CHO cell lines overexpressing the human FSHR and assessed the effect of p,p’DDT by measuring the production of cAMP using biosensor kit. Our data show that p,p’DDT has a dose-dependent potentiating effect on FSH-stimulated cAMP accumulation. It increases the maximal response of FSHR 1.3-fold without changing FSH sensitivity or basal activity. Interestingly, we show a 1.4-fold rise of forskolin (an AC activator)-induced cAMP accumulation with p,p’DDT in CHO-FSHR cells compared with CHO cells where no effect is observed, indicating that the p,p’DDT effect on cAMP is FSHR-dependent. In addition, p,p'DDT has no effect on the endogenous calcitonin receptor function. Finally, to establish which domain of the FSHR (ectodomain or transmembrane domain) may interact with p,p’DDT, we developed and used structural models of FSHR for molecular docking of p,p’DDT. Preliminary results reveal preferential binding sites in the internal cavity of FSHR. The sensitivity of FSHR to a low molecular weight agonist, binding to the internal cavity of transmembrane domain (1), increases 10-fold in presence of p,p'DDT, making likely the presence of different binding sites. In order to validate the putative binding sites of p,p’DDT, FSHR mutants in the transmembrane helices 3 and 7 have been engineered and are currently under investigation. In summary, p,p’DDT seems to behave as a positive allosteric modulator of FSH receptor. Moreover, this work suggests that beyond their effects on nuclear receptors, ED could also modify the GPCR activity and contributes to a better understanding of mechanisms of action of ED.

(1) Wrobel et al, Bioorgan Med Chem, 2006

 

Nothing to Disclose: MM, JG, LG, RC, BS, MC, PR

12582 3.0000 MON-0364 A Impact of p,P'dichlorodiphenyltrichloroethane (p,p'DDT) on the FSH Receptor Activity 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Monday, June 23rd 3:00:00 PM MON 0362-0374 5065 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Christopher D Kassotis*1, Chung-Ho Lin2, Donald Tillitt3 and Susan Carol Nagel4
1Univ of Missouri, Columbia, MO, 2University of Missouri, Columbia, MO, 3United States Geological Survey, Columbia, MO, 4Univ of MO-Columbia, Columbia, MO

 

There has been a rapid rise in the use of hydraulic fracturing to produce natural gas and oil. Over 750 chemicals are used in this process and many are known toxicants, carcinogens, and/or endocrine disrupting chemicals (EDCs). Spills of wastewater associated with this process are common and can contaminate surface and ground water. We have previously found an association between hydraulic fracturing spills and endocrine disrupting activity in surface and ground water. Water samples collected from sites with documented natural gas drilling contamination exhibited the highest levels of activity, samples collected from the Colorado River had intermediate levels of activity, and reference sites in areas away from natural gas drilling exhibited the lowest levels.

We previously found that eleven of twelve chemicals used in hydraulic fracturing exhibited significant anti-estrogenic activity and nine exhibited significant anti-androgenic activity. Based on this small subset of chemicals and the vast number of chemicals used, we hypothesized that a wider analysis of chemicals would reveal other hormonally active chemicals. Initial work focused exclusively on the estrogen and androgen receptor, while this study extends the analysis to include agonist and antagonist activities of the estrogen, androgen, progesterone, glucocorticoid, and thyroid receptors for 24 individual chemicals used in the fracturing process. To date, we have identified 19, 16, 7, 7, and 5 chemicals that exhibit antagonist activities for the estrogen, androgen, progesterone, glucocorticoid, and thyroid receptors, respectively.

Previous work has reported additivity of EDCs with the same mechanism of action. With hundreds of chemicals used, it is essential to begin to assess in vitro and in vivo effects of complex mixtures of the EDCs used throughout the natural gas drilling process. Chemical mixtures will be made at equimolar concentrations for 1) all 24 EDCs analyzed, 2) 9 EDCs that we have analytically measured in hydraulic fracturing wastewater, and at equipotent concentrations for 3) chemicals interacting with each of the five receptors individually. These mixtures will all be tested in an in vitro system, and the smaller mixture of analytically identified EDCs will also be tested in an in vivo model. Briefly, timing of puberty and other estrogen, androgen, and thyroid-related endpoints will be assessed in mice following peripubertal exposure to four concentrations of the mixture, provided via drinking water. Overall, we have shown that many chemicals used in hydraulic fracturing are EDCs. Completion of the in vivo studies will substantially increase our knowledge associated with exposure to complex mixtures of EDCs used in hydraulic fracturing and increase our understanding of the potential health risks.

 

Nothing to Disclose: CDK, CHL, DT, SCN

16236 4.0000 MON-0365 A Endocrine Disrupting Activity of Hydraulic Fracturing Chemicals and in Vivo Adverse Health Outcomes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Monday, June 23rd 3:00:00 PM MON 0362-0374 5065 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Mayah Rose Brand*1, Emily Milford2, Katie Pelch3, John Bromfield1 and Susan Carol Nagel4
1University of Missouri-Columbia, Columbia, MO, 2Univerity of Missouri-Columbia, Columbia, MO, 3National Institute of Environmental Health Sciences, Research Triangle Park, NC, 4Univ of MO-Columbia, Columbia, MO

 

Introduction: Endocrine disrupting chemicals (EDCs) are compounds in our environment that mimic hormones and can cause irreversible developmental programming resulting in adult disease. Estrogen-mimicking EDCs are called xenoestrogens, and include diethylstilbestrol (DES), bisphenol-A (BPA), and ethinyl-estradiol (EE2). These have been linked to increased risk for breast cancer in humans and/or laboratory animals. BPA is found in plastics, DES was used as an anti-abortive therapy, and EE2 is a component of oral contraceptives.

Hypothesis: Perinatal exposure to xenoestrogens at environmentally relevant levels causes permanent changes to adult mammary gland histoarchitecture.

Methods: Fetal mice were exposed to xenoestrogens or vehicle control via miniosmotic pump implanted in the dam. In adulthood, mammary glands were removed, whole mounted on slides, fixed, stained with carmine alum, and stored in pouches containing methyl salicylate.  Mammary gland morphology was assessed to determine longitudinal, lateral length of mammary duct, and the amount and type of epithelial structures. They were qualitatively scored using a 1-5 developmental scale. Mammary gland pathology was assessed by identifying structures using a grid-analysis.

Results: Perinatal exposure to BPA and DES resulted in increased ductal density at 2 and 3 months of age, suggesting structural changes to the mammary gland at an early age. This is an ongoing project and the effects of EE2 will be analyzed to determine if similar developmental programming of adult histoarchitecture occurs. These data will help us elucidate possible mechanisms linking the development of breast cancer to perinatal xenoestrogen exposure.

 

Nothing to Disclose: MRB, EM, KP, JB, SCN

16948 5.0000 MON-0366 A Perinatal Exposure to Xenoestrogens Alters Adult Mammary Gland Histoarchitecture in the Mouse 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Monday, June 23rd 3:00:00 PM MON 0362-0374 5065 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Daniel Benjamin Martinez-Arguelles*1 and Vassilios Papadopoulos2
1The Research Institute of the McGill University Health Centre, Montreal, Canada, 2McGill University Health Centre, Montreal, QC, Canada

 

Di-(2-ethylhexyl) phthalate (DEHP) is an endocrine disruptor used as a plasticizer in the industry to modify the properties of polyvinyl chloride for the manufacture of consumer products. DEHP is ubiquitously found in the environment and DEHP and its metabolites are readily detected in various human bodily fluids. We used an animal model where pregnant Sprague-Dawley dams were gavaged from gestational day 14 until birth with oil or 300 mg DEHP/kg/day. This fetal exposure results in reduced testosterone and aldosterone levels in the adult male offspring. DEHP is rapidly cleared, within 72 hrs, and not stored in the body, suggesting that an epigenetic mechanism is mediating the long-term effects of DEHP. We used reduced representation bisulfite sequencing to measure DNA methylation levels of the adrenal gland at postnatal day (PND) 60 in the male offspring. We identified 972 differentially methylated CpGs (dmCGs) clustering in hotspots. The dmCGs were found in CpG islands (37%), shore/shelf regions (30%), and repetitive elements (6%). We did not find significant dmCGs in promoter regions or within the body of genes with altered expression suggesting that dmCGs could be altering regional gene expression. Transcriptomic data from adrenal and non-adrenal tissues collected at PND21 or PND60 showed that dmCG hotspots correlate with regional gene expression changes in chromosomes 2, 5, 7, 12 and 20. We identified the major histocompatibility complex (RT1) in chr20q12 to be one of the main targets of DEHP. RT1 plays a critical role in controlling immune responsiveness, susceptibility to certain diseases and histo-incompatibility. Taken together these results suggest that in utero exposure to DEHP results in long-term epigenomic changes affecting areas regulating tissue-specific and regional gene expression.

 

Nothing to Disclose: DBM, VP

16033 6.0000 MON-0367 A In Utero Exposure to the Endocrine Disruptor Plasticizer Di-(2-ethylhexyl) Phthalate Induces Hot Spots of DNA Methylation Correlated with Regional Gene Expression Changes in the Adult Male Offspring 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Monday, June 23rd 3:00:00 PM MON 0362-0374 5065 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Anneline Pinson*1, Elise Naveau1, Arlette Gerard2, Jean-Pierre J Bourguignon3 and Anne-Simone M Parent2
1University of liege, giga neurosciences, Liège, Belgium, 2Developmental Neuroendocrinology Unit, GIGA Neurosciences, University of Liège, Liège, Belgium, 3Univ of Liège, Liège, Belgium

 

Perinatal exposure to Polychlorinated biphenyls (PCBs) is associated with disruption of thyroid function as well as learning and memory deficits in children and rodents. Neurogenesis in the dentate gyrus (DG) of the hippocampus plays a fundamental role in learning and memory throughout life. This neurogenesis is regulated by thyroid hormones and is highly influenced by local environment.

We hypothesized that perinatal exposure to PCBs could decrease serum thyroid hormone levels and impair neurogenesis in the granule layer of the DG. We aimed at studying the effect of perinatal exposure to A1254, from gestational day 6 (E6) to postnatal day 21 (P21), on hippocampal neurogenesis and serum thyroxin in C57BL/6J mice.

Perinatal exposure to Aroclor 1254 (6 mg/kg/d; orally) led to an accumulation of PCBs in the brain at P21 (3988.3± 931.5 vs 87.7 ± 4.9 ng/g of wet tissue; control vs exposed). In young adult (P56) there was still 168.73 ± 43.00 ng/g of wet tissue in exposed mice and only 18.63 ± 2.22 ng/g of wet tissue in control. We showed a 35% decrease of circulating total thyroxin at P19 after Aroclor 1254 exposure. Total thyroxin in serum was normalized in young adults (P56). At P8, Aroclor 1254 did not affect the volume of the dentate gyrus (0.047 ± 0.002 vs 0.046 ± 0.002 mm3; control vs exposed). At the same age, no effect of Aroclor 1254 exposure on the number of proliferating neurons labelled by bromodeoxyuridine (BrdU) was observed in the sub-granular zone of the DG (43421 ± 2739 vs 48951 ± 3952 cells/mm3; control vs exposed).

We show here that prenatal and lactational exposure to a commercial mixture of PCBs leads to an accumulation of PCBs in the brain and a decrease of total thyroxin serum levels in mice at weaning. In adults, PCBs levels in the brain are still 9 times higher than in control but serum thyroxin is normalized. The early decrease in serum thyroxin is not accompanied by decreased proliferation of neurons in the dentate gyrus. Based on PCB persistence in the adult brain, the next step is to study whether thyroxin-independent delayed alteration of proliferation due to perinatal exposure could substantiate a possible mechanism of learning deficit in young adults.

 

Nothing to Disclose: AP, EN, AG, JPJB, ASMP

14368 7.0000 MON-0368 A Effects of Prenatal and Lactational Exposure to Polychlorinated Biphenyls on Serum Thyroxin Levels and Neurogenesis in Mouse Dentate Gyrus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Monday, June 23rd 3:00:00 PM MON 0362-0374 5065 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Kathryn L Gruchalla*1 and Turk Rhen2
1University of North Dakota, Grand Forks, ND, 2Univ of North Dakota, Grand Forks, ND

 

Atrazine, a widely-used herbicide in the United States, has been identified as a possible endocrine disrupting chemical (EDC).  Evidence suggests atrazine has a demasculinizing effect on male reproductive development in several species including amphibians, reptiles, birds, and mammals.  While atrazine’s effects appear to mimic those of estrogens, the mechanism of action has yet to be determined. The hypothalamus contains sexually dimorphic regions that regulate a range of targets via the pituitary gland including the liver, kidneys, thyroid gland, adrenal glands, and gonads. Sex differences in the vertebrate hypothalamus-pituitary axis (HP) are programmed by steroids during critical periods of development; implicating the HP as an especially sensitive target of EDCs.  Disruptions during development could lead to life-long effects including abnormal reproductive behavior and infertility. We determined the sex-specific effects of embryonic exposure to ecologically relevant levels of atrazine on gene expression within the developing HP in the common snapping turtle, Chelydra serpentina; a species with temperature-dependent sex determination (TSD).  We used estradiol-17β as a positive control.  We conducted an RNA-seq study to characterize the normal pattern of HP development in turtle embryos and hatchlings from male-and female-producing temperatures.  Analysis of gene expression profiles suggests a role for estrogens, temperature, and epigenetic modification in neuroendocrine development, and these observations are consistent with our understanding of the role of steroidogenic enzymes in TSD.  We treated embryos with estradiol-17β, 2 ppb atrazine, or 40 ppb atrazine after gonadal sex had been determined.  Total RNA was collected from the hypothalamus and pituitary glands 24-hours following treatment, at hatch, and six-months post-hatch.  Gene expression was analyzed using RT-qPCR.  Genes were selected a priori based on the literature or findings from our RNA-seq analysis.  Cyp19A1, AR, and ERα expression was analyzed in embryos collected 24-hours following treatment.  Treatment and incubation temperature did not influence expression of ERα mRNA. However, there was a significant interaction between treatment and incubation temperature for expression of Cyp19 (p=0.046) and AR (p=0.017).  In both cases, estradiol and high atrazine treatment decreased gene expression at the female-producing temperature, while having no effect at the male-producing temperature.  These results are contrary to effects seen in gonads of other species. This study supports atrazine’s status as an EDC, adds the common snapping turtle to the list of vertebrates showing susceptibility to endocrine disruption by atrazine, and raises questions about potential sex-specific effects in other species including humans.

 

Nothing to Disclose: KLG, TR

15970 8.0000 MON-0369 A Effects of Atrazine on Gene Expression within the Hypothalamus and Pituitary Gland 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Monday, June 23rd 3:00:00 PM MON 0362-0374 5065 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Kayla Quinnies*1, Timothy Doyle2, Kwan Hee Kim3 and Emilie F Rissman4
1University of Virginia, 2Washington State University, 3Washington State Univ, Pullman, WA, 4Univ of Virginia Schl of Med, Charlottesville, VA

 

Di-(2ethylhexyl) phthalate (DEHP) is a man made endocrine disrupting compound (EDC) used in production of flexible plastics. The mechanism of action for this EDC is complex acting on both steroid receptors and steroidogenic enzymes. Much of the work on this compound has focused on the effects that high doses have on androgen-target tissues. However, in addition to gonadal hormones, behavioral effects of DEHP may be caused by its actions on lipid and cholesterol, the hypothalamic-pituitary-adrenal axis, and/or retinoic acid. Epidemiological studies have demonstrated correlations between metabolites in urine and a variety of behaviors in children, including higher urinary levels of DEHP in autistic as compared with control children. Transgenerational effects of DEHP on testes and sperm have recently been documented in mice, and here we ask if the same dose that yields these effects affect behaviors. Pregnant mice were given DEHP via oral gavage at a dose of 200mg/kg body weight/day during days mid-pregnancy. The offspring from these dams (F1) were bred for two additional generations to the third generation (F3) removed from DEHP exposure. Juvenile F3 male and female mice from the control and DEHP lineages were tested for social and anxiety behaviors. In addition, blood was collected from mice following restraint stress to evaluate stress-responsivity as indicated by serum corticosterone levels. A number of other assays to examine the stress hormone axis and anxiety-related behaviors in these mice are in progress. Preliminary data indicates that F3 male offspring from a DEHP exposed lineage spend more time alone, and self-grooming in a juvenile interaction task. Furthermore, F3 female offspring from a DEHP exposed lineage have lower levels of baseline corticosterone and in response to stress, and are less active on the elevated plus maze than control females. These data indicate for the first time that DEHP has heritable transgenerational effects on social and anxiety related behavior. Furthermore, assessing heritable outcomes using animal models is necessary for understanding the long term impact of human exposure to EDCs.

 

Nothing to Disclose: KQ, TD, KHK, EFR

15977 9.0000 MON-0370 A Transgenerational Effects of Endocrine Disrupting Chemical DEHP 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Monday, June 23rd 3:00:00 PM MON 0362-0374 5065 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Byung-Ho Kang*1, Ja Hyang Cho2, Won Seok Lee2, Mun Suk Park2 and Kye Shik Shim2
1Kyung Hee University College of Medicine, Seoul, Korea, Republic of (South), 2Kyung Hee University Hospital, Seoul, Korea, Republic of (South)

 

Bedding types affect pubertal progression in rats.

Background

Recently, many experimental animal studies have demonstrated several adverse effects of endocrine disrupting agent, such as reduced reproductive behavior, altered estrous cycle, and decreased slow-wave sleep.

The purpose of this study was to compare the pubertal progression in wild type female rats according to different bedding types.

  

Method

Twenty wild type female Sprague Dawley rat (SD rat) were randomly divided into two groups according to their bedding types. The 1st group was raised in wood shaving bedding as a control and 2nd one was in corncob bedding as an endocrine disrupting agent.

 Each group was checked daily for the first day of vaginal opening, and their vaginal smears were collected to determine estrous cyclicity after vaginal opening. The interval between vaginal opening and the first normal estrous cycle was recorded for determining sexual maturation.

The phases of normal estrous cycles were as follows, proestrus, estrus, metestrus and diestrus.

We compared the proportion of normal estrous cycles in each group.

Result

Vaginal opening was shown early in corncob bedding, but there was no significant difference in the day of the first estrous cycle between 2 groups. Therefore, the periods between vaginal opening and the first estrous cycle were prolonged in that. 

The proportion of normal estrous cycles was 80% in 1st and 60% in 2nd group.

In corncob bedding, the number of proestrus and estrus phases was significantly decreased and that of diestrus phases was increased.

Conclusion

The onset of vaginal opening was earlier, and the irregularity of estrous cycles was increased in corncob bedding groups.

Endocrine disrupting agents in corncob bedding were considered to be associated with early vaginal opening and the irregularity of estrous cycles.

Therefore, the bedding type can be an affecting factor in pubertal progression in rodents.

 

Nothing to Disclose: BHK, JHC, WSL, MSP, KSS

15372 10.0000 MON-0371 A Bedding Types Affect Pubertal Progression in Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Monday, June 23rd 3:00:00 PM MON 0362-0374 5065 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Chanel Griggs*1, Maryam Gilpatrick1, Rebecca Justiniano1, Vineela Kadiyala1 and Catharine Lynn Smith2
1University of Arizona, 2Univ of Arizona, Tucson, AZ

 

Most organisms operate on 24-hour light/dark cycle, known as circadian rhythm. Specific genes in the brain create an internal rhythmicity under the influence of light/dark information and physical activities. Disruption of circadian rhythms, such as experienced by shift workers, has been linked to metabolic syndrome. Activation of the glucocorticoid receptor (GR) through administration of glucocorticoids (GC) led to restoration of rhythmicity in mice, whose rhythmic liver gene expression was partially lost, suggesting an important role of GC release in the regulation of peripheral genomic oscillation. GCs induce circadian rhythm through activation of several transcription factors (Per1/2, and Cry 1/2). The circadian rhythm system operates through interacting feedback loops. Evidence indicates that lysine deacetylases (KDACs, also known as HDACs) are involved in these feedback loops.

            Our lab is interested in the role of Class I KDACs in GR-mediated transactivation. Valproic acid (VPA) is a KDAC inhibitor used to treat bipolar and seizure disorders. Up to 50% of patients taking VPA experience side effects similar to those involved in metabolic syndrome. Expression profiling experiments in a hepatic cell culture model showed that GCs and VPA treatment rapidly up-regulate the Per1 gene. Further investigation revealed that VPA simultaneously up-regulates several other circadian transcription factors, including Per2, Cry2, and Bmal1 within 5 h treatment. In an undisturbed circadian rhythm, Bmal1 and Per/Cry are not found up-regulated at the same time; their expression oscillates in opposite fashion during the 24 h cycle. A time course analysis showed that the simultaneous activation of Bmal1 and Per/Cry is sustained for 24 h of VPA treatment, but is reversible if VPA is removed. The aberrant regulation of circadian transcription factors by VPA could provide an explanation for the metabolic effects in VPA users. Since GCs are reported to establish circadian cycles of Per/Cry and Bmal1 expression in cultured cell models, we hypothesize that simultaneous treatment with VPA will disrupt the cyclic expression of these transcription factors. Using low dose dexamethasone, a synthetic GC, we can induce circadian oscillation in cultured cells. Ongoing studies in the lab will address the impact VPA has on our peripheral clock system. We expect the dexamethasone-induced oscillations of Per/Cry and Bmal1 expression to be disrupted when exposed to VPA.

 

Nothing to Disclose: CG, MG, RJ, VK, CLS

15280 11.0000 MON-0372 A Misregulation of Circadian Transcription Factors By the Histone Deacetylase Inhibitor Valproic Acid 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Monday, June 23rd 3:00:00 PM MON 0362-0374 5065 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Zhengui Zheng*
SIU School of Medicine, Carbondale, IL

 

Congenital penile anomalies (CPAs) are birth defects of the penis that include hypospadias, epispadias, chordee, micropenis, ambiguous genitalia and other penile malformations.  CPAs are very common malformations; a nationwide inpatient sample survey reported that 1/125 male newborns have CPA, and the frequency of CPA has increased in recent decades[1]. It is well known that androgen signaling through the androgen receptor (AR) masculinizes external genitalia, inducing and maintaining male genital development, and that estrogen signaling through estrogen receptors (ER) controls normal female external genitalia development. The mechanisms of when, where and how androgen and estrogen control sexually dimorphic development of external genitalia are not understood, and little is known about the interaction between androgen and estrogen signaling during genital development. In this study, we show that masculinization of male external genitalia involves two important steps in mice, prenatal formation of a closed urethra tube and neonatal differentiation and growth of penile structures. The prenatal phase is controlled by androgen acting through AR during a narrow time window; disruption of androgen signaling during this period results hypospadias and chordee.  Inactivation of AR before this time window results in ambiguous genitalia and even external genital sex reversal, while deletion of AR after the window leads to micropenis.  The neonatal phase of penile differentiation and growth is controlled by a balance of androgen to estrogen signaling; inhibition of androgen signaling and/or augmentation of estrogen signaling during this period results in micropenis. Next we asked how these sex steroid hormones interact with locally-acting gene networks to control sexual differentiation. Pathway-specific quantiative PCR array analysis revealed that androgen and estrogen differentially regulate Hedgehog, Fgf, Bmp, and Wnt signaling. Prenatal androgen promotes apoptosis of urethral epithelium and proliferation and migration of mesenchymal cells to form a closed urethral tube in males. Neonatal androgen stimulates cell proliferation in developing penis, whereas neonatal estrogen inhibits cell proliferation in developing clitoris. These studies uncover the temporal roles of androgen and estrogen signaling in sexual differentiation of the external genitalia, and provide experimental evidence that the timing of endocrine disruption determines the class of congenital penile anomaly, including hypospadias, chordee, micropenis and ambiguous genitalia.

 

Nothing to Disclose: ZZ

17062 12.0000 MON-0373 A Timing of Androgen Receptor Disruption Underlies the Spectrum of Congenital Penile Anomalies 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Monday, June 23rd 3:00:00 PM MON 0362-0374 5065 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Nadia Bourguignon*1, Marianne Bizzozzero Hiriart2, Victoria A Lux-Lantos1 and Carlos Libertun1
1Instituto de Biologia y Medicina Experimental-CONICET, Buenos Aires, Argentina, 2Instituto de Biología y Medicina Experimental, CONICET, Buenos Aires, Argentina

 

Inorganic arsenic (A) is a soil and ground water contaminant with worldwide distribution. It is highly toxic and a proved carcinogenic in humans. It has also been described as an endocrine disruptor impacting the reproductive axis. In this study we evaluated the effects of A exposure in drinking water in pregnant rats on fertility and hormones related to reproduction.

Young, previously virgin, pregnant Sprague-Dawley rats were treated with sodium arsenite in drinking water: 5 (A5) or 50 (A50) ppm in distilled water or distilled water as control (C), from gestation day 1 (GD1, determined by the presence of vaginal sperm plug) to sacrifice (GD18). Standard chow was given ad libitum. Studies were performed according to protocols for animal use approved by the Institutional Animal Care and Use Committee, which follow NIH guidelines.

On GD18, BW of dams were recorded and sacrificed by quick decapitation. Truncal blood was collected for hormone determinations (LH, FSH, PRL, T, E2 and P4 by RIA). The ovaries were dissected, weighted and the numbers of corpora lutea (CLs) were counted. Resorprtion and implantation sites were identified. Results are expressed as means ± S.E.M (n). Differences between means were analyzed by one-way ANOVA. P<0.05 was considered statistically significant.

BW was reduced at 18 days of pregnancy in A50 (g: C=341.7±8.3 (10); A5=347±12.7 (9); A50=291.4±21.7 (9), p< 0.05, A50 vs. C). OW was similar among groups; thus, the ratio OW/ BW was higher in A50 (mg/g: C=0.18±0.01 (10); A5=0.20±0.01 (9); A50=0.23±0.01 (9), p< 0.05, A50 vs. C). Basal serum levels of LH, FSH, PRL and P4 were unchanged after any treatment. E2 and T levels were elevated in A50 (pg/ml; E2: C=16.03±4.12 (13); A5=10.81±2.17 (8); A50=30.10±6.58 (10), p<0.05 A50 vs. C, A5; T: C=357.2±50.6 (13); A5=358.6±114.2 (8); A50=785.9±113 (10), p<0.05 A50 vs. C, A5 ). No effects were found in the numbers of CLs, resorption or implantation sites.

Exposure to A in drinking water during pregnancy decrease BW in dams (A50) and increased serum E2 and T. Further studies are needed to clarify the impact of hormonal alterations on the development of the fetuses.

 

Nothing to Disclose: NB, MB, VAL, CL

13792 13.0000 MON-0374 A Exposure to Inorganic Arsenic during Pregnancy: Effects on the Reproductive Axis and Fertility 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Disruptors Monday, June 23rd 3:00:00 PM MON 0362-0374 5065 1:00:00 PM Impacts of Endocrine Disrupting Chemicals on Physiological Functions Poster

Mohammed Ahmed*1 and Fahad Al Hajri2
1King Faisal Specialists Hospital & Research Centre, Riyadh, Saudi Arabia, 2King Fasail Specialists Hospital & Research Centre, Riyadh, Saudi Arabia

 

Background:

Although pituitary surgery remains the  treatment of choice in most patients, there has been a resurgence of interest in medical management of Cushing’s disease (CD). This is related to a lower true remission and sizeable number of patients with persistent or recurrent adenoma (up to 25%) following surgery. Recent reports of frequent co-expression of dopamine receptor subtype 2 (D2) and sst5 receptor in corticotroph adenomas have drawn attention as potential targets for tumor-directed medical therapy either alone or in combination with steroidogenic enzyme blockers. We report herein an impressive remission of CD within weeks of use of combination of metyrapone and carbergoline in a patient with long-standing persistent disease who had been previously treated using transsphenoidal surgey and stereotactic radiosurgery.

Objective:

Sequential treatment consisting of metapirone followed by carbergoline can induce a prompt clinical and biochemical remission in a short period in a  patient with long-standing persistent CD that failed TSS and pituitary stereotactic radiosurgery without adverse effects.

Case Summary:

 A 40-yrs old female presented with persistent  Cushing’s disease. Fifteen years earlier she underwent transsphenoidal  pituitary surgery at an outside hospital  and had also received stereotactic radiotherapy to residual tumor. Our evaluation: MRI and PET pituitary showed right sellar hypermetabolic  lesion. Lab results and the impact of medical therapy are shown below:

Metapirone was initiated at 250 mg Q6hx 3 days, then increased to 500 mg Q6h x 3 days. This resulted in a decline of serum AM cortisol from 633 to 198 (Ref. Range 170-356 nmol/l), and a decrease in 24-hour free cortisol from 1,222 to 172 (Ref. Range 100-379 nmol/l), in 6 days with little change in serum ACTH (changing from 71 to only 67; Ref. Range 5-60 ng/l) during this short period . Subsequently, Carbergoloine 0.5 mg x3 weekly was added resulting in a further decline in Serum AM  cortisol from 198 to 95 and 24-hour urine cortisol declined from 172 to 30, with the serum ACTH decreasing from 67 to 42 in one week.

Conclusion:

Medical management using combination therapy directed at steroidogenic enzyme blockers and pituitary- directed dopamine receptor subtype 2 (D2) can achieve a rapid remission in chronic persistent CD that failed previous TSS and pituitary stereotactic radiosurgery without adverse effects. Pituitary corticophobe adenoma remnant following previous TSS and radiotherapy is capable of responding to dopamine agonist via the modulation of dopamine receptor subtype 2 (D2).

 

Nothing to Disclose: MA, FA

11393 1.0000 MON-0589 A Combination Medical Therapy for Long-Standing Persistent Cushing's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0589-0601 5067 1:00:00 PM Cushing's Disease and Syndrome; Diagnosis and Management Poster

Gulsah Elbuken*1, Zuleyha Karaca2, Fatih Tanriverdi2, Kursad Unluhizarci2 and Fahrettin Kelestimur2
1Namik Kemal University, Faculty of Medicine, Tekirdag, Turkey, 2Erciyes University Medical School, Kayseri, Turkey

 

Aim: The synthesis of cortisol binding globulin (CBG) and albumin is reduced in critical illness leading to decreased measured serum cortisol (C) levels. The aim of the present study was to compare C and salivary cortisol (sC) levels in the diagnosis of adrenal insufficiency in patients with severe sepsis (SS).

Materials and methods: Thirty-one patients with SS (16 men, and 15 women), were included in the study. Low dose (1 µg) ACTH stimulation test was performed on the first day of diagnosis of SS. C and sC levels were measured during ACTH stimulation test. Data were compared with 19 healthy controls. Calculated free cortisol (cFC) levels were estimated from Coolens’ equation.

Results: Patients were categorized as having adrenal insufficiency or not according to basal C cut-off level of 10 µg/dl. Basal C was higher in patients with SS who had normal HPA axis than in healthy controls. Peak C after ACTH stimulation was found to be lower in patients with SS with adrenal insufficiency. sC levels at baseline and after ACTH stimulation were found to be higher in patients with SS with normal HPA axis than in healthy control, but sC levels were not different from healthy control in patients with SS who had adrenal insufficiency. CBG levels were found to be lower in patients with SS than in the control group, but not different in SS subgroups. cFC levels were found to be similar to healthy control group in patients with SS who had normal HPA axis. However  cFC levels were found to be lower in patients with SS who had adrenal insufficiency.

Conclusion: Basal C and basal sC or peak sC response to low dose ACTH were found to be higher in patients with SS with normal HPA axis functions. So higher cut-off levels for both C and sC should be used for the diagnosis of adrenal insufficiency.

 

Nothing to Disclose: GE, ZK, FT, KU, FK

13224 3.0000 MON-0591 A Comparison of Serum, Salivary and Calculated Free Cortisol Levels in Patients with Severe Sepsis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0589-0601 5067 1:00:00 PM Cushing's Disease and Syndrome; Diagnosis and Management Poster

Howard A Brand*1, Kimberly Calcagno2 and Michele Lamerson3
1Sound Endo PLLC, Stony Brook, NY, 2Sound Endocrinology, Stony Brook, NY, 3Corcept Therapeutics, Greenlawn, NY

 

Background: Persistent hypercortisolism can lead to increased morbidity and mortality.  In refractory Cushing’s disease (CD), multimodal therapy may be required. Clinical Case:  A 37 y/o woman presents to the ER in 1/04 with sudden onset of headache and visual defect. There was a one year h/o weight gain and chin hair growth. Initial UFC was 28 µg/24h.  MRI revealed a macroadenoma extending to the optic chiasm and into the R cavernous sinus. Visual fields suggested bitemporal hemianopsia.  Pituitary apoplexy was suspected and a TS hypophysectomy was performed.  Visual symptoms and headache improved post-operatively.  AM cortisol was 19.5 µg/dl.  Post-op MRI revealed a large residual tumor with stalk deviation and invasion to the R cavernous sinus. Immunochemistry of surgical specimen stained + for ACTH further suggesting persistent CD.  After dexamethasone was tapered, UFC was elevated 100 µg/24h.   Major symptoms that continued were:  central weight gain, ↑ hirsutism, and muscle weakness.  She developed severe anxiety leading to a diagnosis of panic disorder and agrophobia.  Ketoconazole was initiated and the patient could not tolerate more than 400-600 mg daily.  24 hour UFC ranged from 52 µg/24h to 126 µg/24h.  In 2006, the patient had gamma knife radiation with no change in MRI findings and UFC remained elevated 100 µg/24 h.  Her neuropsychiatric condition worsened and she became progressively homebound. Impaired fasting glucose progressed to Type 2 Diabetes in 2011 which became more treatment resistant with maximum dose metformin and sitagliptin.  She developed the first response to gamma knife; secondary hypogonadism and hypothyroidism.  Since patient’s cortisol activity was not optimally controlled, ketoconazole was discontinued and mifepristone, a glucocorticoid receptor antagonist, was initiated in 4/13 at 300 mg and titrated gradually to 1200 mg.  Significant improvement in clinical symptoms including lessened anxiety and agrophobia, improved glycemic control with decrease in HbA1C to 5.8% and discontinuation of anti-diabetic meds, improved Cushingoid appearance, weight loss of  6% body weight with decrease in 3 dress sizes, and increase in muscle strength were observed.  No change in BP initially but an increase in BP was noted with mifepristone 900 mg.  Serum K+ decreased from 5.2 to 3.7meq/L .  Spironolactone was initiated and BP and K+ returned to baseline. This can be an expected adverse event since mifepristone can indirectly lead to activation of the mineralocorticoid receptor. Conclusion: In a patient with persistent CD despite surgery, radiation and cortisol lowering agents, mifepristone demonstrates a marked improvement in psychiatric symptoms, glycemic control, metabolic profile, and Cushingoid signs and symptoms.

 

Disclosure: ML: Employee, Corcept. Nothing to Disclose: HAB, KC

13503 4.0000 MON-0592 A A Case Report of a 37 y/o Woman Diagnosed with Cushing's Disease Presenting As Pituitary Apoplexy after Multiple Treatment Failures Effectively Responds to Mifepristone 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0589-0601 5067 1:00:00 PM Cushing's Disease and Syndrome; Diagnosis and Management Poster

Anu Verma*1, Nitesh D Kuhadiya2, Antoine Makdissi3, Ajay Chaudhuri4, Anshu Alok5 and Manav Batra2
1State University of New York -Buffalo, University at Buffalo, Williamsville, NY, 2University at Buffalo, Buffalo, NY, 3State Univ of New York at Buffal, Buffalo, NY, 4Diabetes and Endocrinology Center of Western New York, Buffalo, NY, 5State University of New York- Buffalo, University at Buffalo

 

Introduction: We are reporting a case of pituitary ACTH secreting adenoma incidentally discovered on Sestamibi scan of parathyroids, done for the workup of normocalcemic primary hyperparathyroidism (pHPT).

Clinical Case: 49 year old Caucasian lady with no significant medical history was referred for evaluation of pHPT. She reported increased thirst, urination and weight gain of 10 lbs in one year. Paired corrected calcium/albumin/ Intact PTH levels on two separate days 3 months apart were 9.82 mg/dl/ 4.6g/dl/ 63.9 pg/ml and 10.0 mg/dl/ 5.0g/dl/ 58.9 pg/ml (N:8.6-10.2 mg/dl/ 3.5-5.2g/dl/ <65 pg/ml respectively). Vitamin D-25 OH level was 31ng/dl. 24 hour urinary calcium and phosphate levels were 400mg/24h(N<250)/1169mg/24hr(N:170-1200) respectively. Urinary calcium/creatinine ratio: 299mg/g creat (N<275). Sestamibi scan did not reveal parathyroid adenoma but there was radio-ligand uptake in the midline at the skull base, in a location consistent with pituitary adenoma. Serum cortisol levels(7:15 am):17.4 mcg/dl and 24hr urinary free cortisol(UFC) levels on two occasions were found to be elevated at 150 mcg/24hr and 135.8mcg/24hr(N<50). Cortisol level was not suppressed after 1mg overnight dexamethasone suppression test (DST) (pre-suppression: 18.3,post-suppresion: 6.3mcg/dl). Baseline ACTH was 30pg/ml. 11 PM salivary cortisol levels on two separate days were elevated at 0.35 mcg/dl(N<0.09) and 0.14 mcg/dl(N<0.09). A 24hr UFC with 2mg DST was 14.7mcg/24hr (pre-test 135.8mcg/24hr). Serum cortisol post 2mg DST was elevated at 5.8mcg/dl. With the high dose overnight 8mg DST the cortisol levels were suppressed to 1.2mcg/dl from 15.9mcg/dl. Baseline ACTH was 24 pg/ml suggesting ACTH dependent Cushing’s syndrome and contrast enhanced CT scan of chest, abdomen and pelvis not showing an ectopic source of ACTH. MRI of pituitary done on 2 separate occasions 3 months apart was normal. Inferior Petrosal Sinus Sampling(IPSS) showed a central to peripheral ACTH ratio of > 3.0, with a lateralization to the right. Trans-sphenoidal resection of the 40% of the pituitary gland revealed an ACTH producing corticotroph adenoma.

Conclusion: Tiktinski et al. have reported pituitary incidentalomas on sestamibi scan done for evaluation of parathyroids, however their secretory nature, was not studied. Further investigations are needed to clarify the role of Sestamibi scan in the diagnosis of imaging negative clinical and subclinical pituitary Cushing’s disease and other secretory pituitary tumors.
We hereby report a subclinical case of pituitary ACTH secreting adenoma not visualized on MRI but incidentally discovered on a Sestamibi scan done for parathyroid evaluation

 

Nothing to Disclose: AV, NDK, AM, AC, AA, MB

15324 5.0000 MON-0593 A Incidentally Discovered ACTH Secreting Pituitary Adenoma on a Sestamibi Scan in a Patient with Hypercalcemia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0589-0601 5067 1:00:00 PM Cushing's Disease and Syndrome; Diagnosis and Management Poster

Sadia Moinuddin*1 and Laura Arlene Knecht2
1St. Joseph's Hospital and Medical Center, Phoenix, AZ, 2St Joseph's Med Center, Cave Creek, AZ

 

Background

Cushing’s disease (CD) is caused by pituitary corticotrophin (ACTH) secreting tumors leading to elevated cortisol levels. Treatment of choice for CD is transsphenoidal surgery (TSS). Currently, medical therapy for CD serves as an adjunctive role after unsuccessful TSS, waiting for radiation therapy to be effective, and/or if patient is not a surgical candidate. Mifepristone is the first in class glucocorticoid receptor antagonist approved by FDA in 2012 for use in Cushing’s syndrome. It is proven to be effective at controlling hypertension and hyperglycemia associated with hypercortisolism. Most common adverse events secondary to mifepristone reported in literature are hypokalemia, adrenal insufficiency, and endometrial thickening. There have not been any reported cases in literature of gout as a side effect of mifepristone.

Clinical Case 

A 64 year old man presented with a six month history of double vision and left eye droop. Workup revealed CNIII palsy and a pituitary macroadenoma. Patient endorsed symptoms of Cushing’s disease. Laboratory workup revealed elevated urinary free cortisol 1525 µg/24h (3.5-45) and ACTH of 135 pg/ml (6-50). After evaluation by neurosurgery, he underwent a transsphenoidal resection of the pituitary macroadenoma. Pathology revealed pituitary adenoma with ACTH staining. He subsequently underwent cyber knife radiosurgery after postoperative MRI identified residual tumor and he continued to exhibit symptoms. Following the radiation therapy, his salivary cortisol remained elevated with persistent symptoms. While waiting for radiation therapy to be effective, he was started on mifepristone 300 mg po daily. A short time after starting mifepristone, he had significant weight loss, decreased waist circumference, adrenal insufficiency as well as severe elbow joint pain. On physical exam, he had swelling and redness with limited range of motion. X-ray of elbow showed abnormal posterior fat pad consistent with joint effusion.  He was found to have elevated serum uric level of 16.1 mg/dL (3.5 - 8.0) and left elbow synovial fluid showed numerous needle shaped MSU crystals consistent with gout. He was initially treated with antibiotics by orthopedic surgeon; however he only had improved swelling and pain after starting Medrol when he was found to have elevated uric acid and synovial fluid consistent with gout. After starting colchicine and allopurinol, his arthritis improved and serum uric acid decreased from 8.6 mg/dL (3.5 - 8.0) to 5.9 mg/dL (3.5 – 8.0).

Conclusion

This is the first case reporting gout as a side effect of mifepristone, the first FDA approved glucocorticoid antagonist for medical treatment of Cushing’s disease. In our patient, gout may have been exacerbated with adrenal insufficiency from mifepristone. Discontinuation of mifepristone with the addition of steroids was effective in treating both the gout and adrenal insufficiency.

 

Nothing to Disclose: SM, LAK

15362 6.0000 MON-0594 A Gout: Potential Side Effect of Mifepristone When Used for Cushing's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0589-0601 5067 1:00:00 PM Cushing's Disease and Syndrome; Diagnosis and Management Poster

Kevin C.J. Yuen*1 and Harold I Magazine2
1Oregon Health and Science University, Portland, OR, 2Corcept Therapeutics, Inc., Menlo Park, CA

 

Introduction

Mifepristone (MIFE, Korlym®) is an FDA-approved glucocorticoid receptor (GR2) antagonist used to treat adults with Cushing’s syndrome with concurrent hyperglycemia who have failed surgery, or are not surgical candidates. In addition to improvement in glucose metabolism, MIFE has been shown to decrease body weight and improve quality of life. We report a patient with Cushing’s disease (CD) with poorly controlled diabetes, obesity and hypertension treated with MIFE. After 20 months of therapy, her antidiabetic and antihypertensive medications were discontinued, and improvements in her clinical features were noted.

Case report

A 48 year-old female presented with an 18-month history of Cushingoid features, worsening diabetes (HbA1c 8.3%, FPG 168 mg/dL), hypertension (BP 182/91 mmHg) and weight gain of 75 lbs. The patient also reported headaches, nausea, vomiting, and lack of energy. Due to her poorly-controlled glycemia, she was started on insulin therapy (NPH and Novolin R).

After biochemical confirmation of CD, she underwent transsphenoidal surgery. Two months post-surgery, due to worsening of her glycemia, the doses of her insulin therapy had to be increased and Metformin was introduced.

However, due to persistent hypercortisolism after surgery, she was started on MIFE and Spironolactone. MIFE was started at 300 mg/day, her dose was then titrated upwards to 900mg/day, and eventually maintained at 600 mg/day. Over 20 months of therapy, due to frequent hypoglycemic episodes, Metformin was discontinued and her insulin dosing was tapered, and eventually discontinued. In the last 3 months of therapy, orthostatic hypotension was noted and all of her antihypertensive medications were also discontinued.  On her current MIFE dose of 600 mg/day, her HbA1c is 5.7%, FPG is 104 mg/dL and BP is 132/85 mm Hg.  She now reports decreased headaches, no nausea or vomiting, weight loss of 75 lbs since starting therapy, and has increased energy.

Conclusion

MIFE therapy can significantly improve glycemic and BP control potentially allowing the discontinuation of insulin, oral antidiabetic and antihypertensive medications. Clinicians managing patients on MIFE therapy should be aware of these changes so that careful monitoring and adjustment of antidiabetic and antihypertensive medications are made to avoid hypoglycemia and hypotension.

 

Disclosure: HIM: Employee, Corcept. Nothing to Disclose: KCJY

13542 7.0000 MON-0595 A Discontinuation of Insulin, Oral Antidiabetic and Antihypertensive Medications in a Patient with Cushing's Disease Following Mifepristone (MIFE) Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0589-0601 5067 1:00:00 PM Cushing's Disease and Syndrome; Diagnosis and Management Poster

Rifat Emral1, Berna Imge Aydogan2, Ali Riza Uysal3 and Demet Corapcioglu*3
1Ankara University School of Medicine, Ankara, Turkey, 2Ankara University Faculty of Medicine, 3Ankara University School of Medicine

 

Objective : The management of invasive pituitary macroadenomas is difficult  because of  their tendency for recurrence, aggressive behavior and incomplete resections.

Case Report:  A 29-year old male patient admitted to Endocrinology clinic with mild visual  loss, proximal muscle weakness,  facial plethora and  abdominal purple striae. Hormonal evaluation showed elevated urinary free cortisol levels (138 mcg/24 hr- normal: 10-80 mcg/24 hr) . No cortisol supression was assessed after overnight  1 mg and  subsequent 2 mg (classical two days) dexamethasone tests. Plasma ACTH level was normal (32 pg/ml) .  These results  indicated ACTH-dependent Cushing’s Disease. Magnetic-resonance imaging of the hypophysis  revealed a 24 mm macroadenoma with invasion to cavernous sinus and  internal carotid artery, located in the left side of hypophysis.  He underwent a TN/TS  adenomectomy procedure.  The Ki67 proliferation index was 10% on histopathology. Postsurgical  MRI showed a residual mass. During the follow-up, left eyelid ptosis occurred  and regressed after five courses of Cyber-knife radiotherapy.  Pasireotide treatment was given but at the first month of therapy, right eyelid ptosis occured. Pituitary MRI revealed that residual mass at the left side was totally disappeared and there was a new macroadenoma  located in the right side of hypophysis. The patient underwent the second TN/TS adenomectomy  and Ki67 proliferation index was 15%  .  Laboratory results and clinical signs were consistent with residual disease although no mass was observed on pituitary MRI. Subsequently, temozolomide treatment was given for a cycle.  The response to treatment will be assessed at the third month of therapy.

Conclusion:   We report an invasive and recurrent case of ACTH-producing pituitary macroadenoma. This case represents the challenging problems in management of aggressive pituitary adenomas. Further investigations will exhibit the  response to temozolomide treatment.

 

Nothing to Disclose: RE, BIA, ARU, DC

16702 8.0000 MON-0596 A Invasive and Recurrent ACTH-Producing Pituitary Macroadenoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0589-0601 5067 1:00:00 PM Cushing's Disease and Syndrome; Diagnosis and Management Poster

Mauro Antonio Czepielewski*1, Ticiana Costa Rodrigues2, Fabiola Costenaro3 and Paula Borges Lima4
1Faculdade de Medicina UFRGS, Porto Alegre, Brazil, 2Hospital de Clínicas de Porto Alegre, UFRGS, Porto Alegre, Brazil, 3Hospital de Clinicas de Porto Alegre, Porto Alegre - RS, Brazil, 4Faculdade de Medicina, UFRGS, Porto Alegre, Brazil

 

Ketoconazole (Ktc) has been successfully used as an adjuvant in Cushing's syndrome treatment. However, it is not recommended in pregnancy because of its teratogenic potential mainly because of its antiandrogen effects. In this paper we report a case of a Cushing's disease patient who became pregnant on Ktc therapy .Case report: A 34-year-old woman with CD attended in a tertiary center of Endocrinology in Brazil. She had undergone two unsuccessful pituitary transsphenoidal surgeries and external radiotherapy at the same year of the surgeries. To control CD activity, Ktc was started soon after surgery (200-400mg/day) and maintained for eight years when struck in proper control of the disease and was stopped. After 6 months of drug withdrawal the patient started with hypertension, weight gain and cortisol 1mg overnight of 17 µg/dl. Ktc was reintroduced (200mg twice/day) and antihypertensive agents were initiated. Seven months on Ktc there was hypercortisolism control. Ten months after Ktc reintroduction, the pregnancy was diagnosed and the antihypertensive drugs were replaced by methyldopa and acetylsalicylic acid 100mg/day was initiated. At 7weeks of gestation Ktc was suspended. At 16weeks of gestation the urinary free cortisoluria 24 hours (UFC) was 299µg/24h and 456µg/24h (37-136µg/24h). At that moment Ktc (400mg/day) was restarted, considering that at 16 weeks of gestational age the risk of hypercortisolism was larger than the use of Ktc. After 1week on Ktc, the UFC was 181µg/24h. Gestational diabetes mellitus was diagnosed and controlled by diet. At 20weeks of gestational age the fetal ultrasound showed adequate fetal growth .At 31weeks of gestation a premature labor was suspected. The patient was hospitalized, received the first dose of dexamethasone for fetal maturation. Ktc was suspended for a month, and then again reintroduced and maintained out of the labor. Vaginal delivery at 36weeks of gestation of female newborn, weighing 2770g, 48cm in length, no congenital abnormalities, and normal female genitalia. Patient could not breastfeed. Diabetes was resolved. She remained without ketoconazole for 5 months after delivery, then it was restarted (200mgtwice/ day) by increased levels of UFC. After 2 months on ktc, the UFC normalized. The case progressed satisfactorily, with adequate hypercortisolism, and metabolic control. This report shows that the ktc can be a safe alternative in cases of pregnancy on CD, since a close medical follow-up be done.

 

Nothing to Disclose: MAC, TCR, FC, PBL

15432 9.0000 MON-0597 A Successful Pregnancy in Cushing's Disease on Ketoconazole Treatment 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0589-0601 5067 1:00:00 PM Cushing's Disease and Syndrome; Diagnosis and Management Poster

Audrey Elisabeth Arzamendi* and Alison Marie Semrad
UC Davis Medical Center, Sacramento, CA

 

Background: 

Mifepristone (MIFE, Korlym®) was FDA-approved in 2012 for treatment of Cushing’s-associated hyperglycemia. Its competitive glucocorticoid receptor antagonism increases serum cortisol and ACTH levels, leading to mineralocorticoid receptor cross activation that can potentially induce HTN, hypokalemia, and metabolic alkalosis even in patients with MIFE-induced functional adrenal insufficiency (AI).

Clinical Case:

A 50-year-old male with HTN, CKD, and baseline hyperkalemia developed signs and symptoms of Cushing’s syndrome (CS). ACTH, 24-hour urine cortisol, low-dose dexamethasone suppression, and salivary cortisol were consistent with ACTH-dependent CS; HbA1c revealed pre-diabetes. Imaging and petrosal sinus sampling were unrevealing.

The patient underwent transsphenoidal pituitary resection and gamma knife radiosurgery, but remained symptomatic with elevated ACTH and cortisol levels. MIFE 300mg po daily was initiated, and the patient’s strength and energy rapidly improved. His MIFE was increased to 600mg daily, after which his serum potassium fell to 3.3mEq/L (3.3-5.0mEq/L), requiring oral supplementation. Metabolic panels were assessed every 1-3 weeks, and necessitated upward titration of potassium every 6-12 weeks as the patient’s weight continued to decline.

Surgical exodontia was scheduled to address extensive dental abscesses. MIFE was withheld for two days prior to the procedure in hopes of allowing an effective steroid “stress dose” and minimizing the risk of perioperative AI. The surgery was well tolerated, however over the following months the patient’s HTN and hypokalemia worsened despite additional antihypertensives and potassium chloride SR 80mEq po BID supplementation. MIFE was reduced to 300mg daily, with improvement.

The patient today is clinically improved on MIFE 300mg po daily. His blood pressure is controlled, and his HbA1c and potassium, normalized. His central weight loss has stabilized after 83lb, and his strength has returned to his pre-CS baseline.

 

Conclusion:

MIFE is an effective treatment for CS, but requires close follow up and monitoring. Despite standard non-weight-based dosing recommendations, MIFE dosing needs may fall as central obesity improves. Prescribing physicians should monitor for MIFE-induced functional AI, and recognize the unconventional findings (elevated ACTH and cortisol, HTN, hypokalemia, and metabolic alkalosis) this might entail. Serum potassium should be followed at least weekly after MIFE dosing changes, and may require frequent monitoring even after several weeks of stable dosing needs, in the setting of weight loss.  MIFE dose reduction may be indicated for patients with refractory HTN or hypokalemia, and withdrawal perioperatively may minimize the risk of AI in patients undergoing surgical procedures.

 

Nothing to Disclose: AEA, AMS

16624 10.0000 MON-0598 A Mifepristone for Refractory Cushing's Syndrome in a Patient with CKD Hyperkalemia Undergoing Surgical Exodontia and Weight Loss: Recommendations for Clinical/Biochemical Monitoring and Perioperative Dosing 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0589-0601 5067 1:00:00 PM Cushing's Disease and Syndrome; Diagnosis and Management Poster

Xiaorui Zhao*, Wei Qiang, Juan Liu, Xiaoli Yao and Bingyin Shi
The First Affiliated Hospital of Xi’an Jiaotong University School of Medicine, Xi'an, China

 

Background: Cushing's disease (CD) is a severe endocrine condition caused by an adrenocorticotropin (ACTH)-producing pituitary adenoma and with potentially serious complications if not or inadequately treated. The diagnosis of CD frequently involves a stepwise approach including clinical, laboratory, neuroimaging, often mandating multidisciplinary collaboration from numerous specialty practitioners.

Clinical case: A 51 year old female presented with gradually increased central obesity for 16 year, refractory hypertension for 5 year, right limb venous thromboembolism and diabetes for 2 year, irritability for 6 month. Due to the dissatisfacted controlled hyperglycemia with the Intensive insulin therapy, she came to our hospital. Physical Examination showed overweight with centripetal fat distribution, moon face, buffalo hump, arterial hypertension, thin skin with no scarce purple striae and muscular hypotrophia, Visual field exam was normal. Laboratory examination showed: low-normal potassium, elevated plasma cortisol; elevated plasma ACTH 149.0pg/ml(5-60pg/ml); 24h urine showed elevated 17-ketosteroids and 17-OH-corticosteroids, Abdominal CT showed a right adrenal mass consistent with adrenal adenoma; The standard low dose dexamethasone suppression test revealed no suppression, Cushing's syndrome was confirmed. Does it is ACTH-dependent CS? OR it is a adrenal incidentalomaHThen we search for the real reason: 24h urine metanephrines was normal, plasma aldosterone was normal; Does adrenal adenoma is the real Etiology cause the CS? The standard 8 mg dexamethasone suppression test revealed suppression, but Plain and enhanced pituitary CT scan showed no obvious abnormalities. Because there is a metal filter in her right limb venous , so she can’t do the MRI examination. It is difficult to do the differential diagnosis of CS , Then diagnosis was confirmed with inferior petrosal sinus sampling, The basal ratio of ACTH concentration between inferior petrosal sinus and peripheral veins was >2, and the adenoma which lie in the middle of pituitary fossa was successfully removed by transsphenoidal surgery.1 month after surgery. She was tapered off antihypertensive agent and insulin, most of her symptoms was resolved, patient is in remission state. This indicates her hypercortisolism originated from the CD and the adrenal adenoma was an adrenal incidentaloma.

Conclusion: The diagnosis and differential diagnosis of CS is one of the most challenging algorithms in endocrinology.  In this case we raise that IPSS Was carried out for the diagnosis of ACTH-dependent Cushing’s syndrome who had not been identified of diagnosis after a series of dexamethasone suppression tests and Imaging negative; the importance of early recognition and adequate treatment is well established. Surgery with resection of a pituitary adenoma is the first line therapy.

 

Nothing to Disclose: XZ, WQ, JL, XY, BS

13692 11.0000 MON-0599 A Diagnosis and Management of Cushing's Disease in Patient with Adrenal Incidentaloma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0589-0601 5067 1:00:00 PM Cushing's Disease and Syndrome; Diagnosis and Management Poster

Cornelie D. Andela*1, Steven J.A. van der Werff1, J. Nienke Pannekoek1, Onno C. Meijer1, Mark A. Buchem1, Serge A.R.B. Rombouts1, Roos C. van der Mast1, Nienke R. Biermasz1, Alberto M. Pereira2 and Nic J.A. van der Wee1
1Leiden University Medical Center, Netherlands, 2Leiden University Medical Center, Leiden, Netherlands

 

Background: Hypercortisolism leads to various physical, psychological and cognitive symptoms, which may partly persist after treatment of Cushing's disease. The aim of the present study was to investigate abnormalities in white matter integrity in patients with long-term remission of Cushing's disease, and their relation with psychological symptoms, cognitive impairment and clinical characteristics.

Methods: In patients with long-term remission of Cushing's disease (n=22) and matched healthy controls (n=22) we examined fractional anisotropy (FA) values of white matter in a region-of-interest  (ROI; bilateral cingulate cingulum, bilateral hippocampal cingulum, bilateral uncinate fasciculus and corpus callosum) and the whole brain, using 3T diffusion tensor imaging (DTI) and a tract-based spatial statistics (TBSS) approach. Psychological and cognitive functioning were assessed with validated questionnaires and clinical severity was assessed using the Cushing's syndrome Severity Index.

Results: The ROI analysis showed FA reductions in all of the hypothesized regions, with the exception of the bilateral hippocampal cingulum, in patients when compared to controls. The exploratory whole brain analysis showed multiple regions with lower FA values throughout the brain. Patients reported more apathy (p = .003) and more depressive symptoms (p < .001), whereas depression symptom severity in the patient group was negatively associated with FA in the left uncinate fasciculus (p <0.05). Post-hoc analyses showed increased radial and mean diffusivity in the patient group.

Conclusion: Patients with a history of endogenous hypercortisolism in present remission show widespread changes of white matter integrity in the brain, with abnormalities in the integrity of the uncinate fasciculus being related to severity of depressive symptoms, suggesting persistent structural effects of hypercortisolism.

 

Nothing to Disclose: CDA, SJAV, JNP, OCM, MAB, SARBR, RCV, NRB, AMP, NJAV

13655 12.0000 MON-0600 A Widespread Reductions of White Matter Integrity in Patients with Long-Term Remission of Cushing's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0589-0601 5067 1:00:00 PM Cushing's Disease and Syndrome; Diagnosis and Management Poster

Pooja Raghavan*1, Gautam Mehta2, Susmeeta T. Sharma3, Prashant Chittiboina4, Edward Hudson Oldfield5 and Lynnette K. Nieman2
1National Institutes of Health, North Bethesda, MD, 2National Institutes of Health, Bethesda, MD, 3Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 4National Institute of Neurological Diseases and Stroke (NINDS), National Institutes of Health, Bethesda, MD, 5Univ of Virginia, Charlottesville, VA

 

Introduction: Presence of multiple clinically evident pituitary adenomas, though rare, can complicate surgical management of Cushing’s disease (CD) (1). We present a case of CD with two distinct pituitary adenomas.

Case: A 42 year-old female presented with a 2-year history of 50lb weight gain, amenorrhea, hirsutism, fatigue, depression and short-term memory loss. Laboratory testing revealed ACTH-dependent Cushing’s syndrome with an elevated 24-hr urinary free cortisol (122.3 mcg/day, normal (N) 3.5-45), loss of diurnal rhythm (midnight serum cortisol = 20.3 mcg/dl), and elevated plasma ACTH level (61.3 pg/ml, N <46). Calcium and prolactin levels were normal and there was no personal or family history suggestive of multiple endocrine neoplasia. The 8 mg overnight dexamethasone suppression and CRH stimulation tests were both suggestive of a pituitary source of ACTH. MRI of the pituitary gland revealed a 5mm left hypoenhancing area suggestive of a microadenoma.  Inferior petrosal sinus sampling showed a clear central to peripheral gradient (peak post-CRH petrosal-to-peripheral ACTH ratio = 22).  The patient underwent transsphenoidal surgery (TSS) with resection of the microadenoma at the left pituitary margin.  Since this corresponded with the pre-operative MRI, no further exploration of the pituitary gland was performed.  Post-operatively, cortisol and ACTH levels remained elevated.  Pathology revealed a tumor with a pseudocapsular plane, reticulin breakdown, and Crooke’s hyaline changes but immunohistochemical stains for ACTH, LH, FSH, TSH, GH and prolactin were negative.  On repeat TSS and exploration of the remaining pituitary gland, performed a week after initial TSS, a 10mm tumor was visualized adjacent to the previous tumor resection cavity, which was not as apparent on pre-operative MRI.  Resection of the second tumor led to undetectable plasma cortisol and ACTH levels consistent with remission. Pathology revealed an ACTH-staining pituitary adenoma.

Conclusion: Although uncommon, multiple pituitary tumors can pose a clinical challenge in the management of CD.  In the setting of a single lesion on MRI and obvious tumor intra-operatively, further exploration of the pituitary gland is not indicated given risk of hypopituitarism (1).  However, if hypercortisolemia persists and pathology reveals lack of ACTH staining, repeat TSS with exploration of the pituitary gland is indicated for definitive cure.

 

Nothing to Disclose: PR, GM, STS, PC, EHO, LKN

16220 13.0000 MON-0601 A Multiple Pituitary Adenomas in Cushing's Disease: A Clinical Dilemma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Monday, June 23rd 3:00:00 PM MON 0589-0601 5067 1:00:00 PM Cushing's Disease and Syndrome; Diagnosis and Management Poster

Daphne T Adelman1 and Simone M Howell*2
1Northwestern University, Chicago, IL, 2Corcept Therapeutics, Dallas, TX

 

BACKGROUND: Hypertension (HTN), glucose intolerance, obesity, hypokalemia, depression and impaired quality of life (QoL) are frequent manifestations of Cushing’s disease (CD).  Mifepristone (MIFE), a glucocorticoid receptor antagonist FDA approved for patients with endogenous Cushing's syndrome, has known endometrial effects as it is also a progesterone receptor (PR) antagonist. This case highlights 4 years of MIFE therapy in a premenopausal female (PT) who was previously unable to work or care for her family due to uncontrolled CD.

CASE:  Medical history includes obesity, type 2 diabetes, hyperlipidemia, HTN, hypothyroidism, acanthosis nigricans, polycystic ovaries, ovarian cyst, anovulation and amenorrhea. CD was diagnosed in 2006. PT underwent transsphenoidal surgery followed by gamma knife irradiation a year later due to persistent tumor on MRI.  ACTH and cortisol levels remained elevated.  Central obesity, rounded face, HTN, diabetes, depression and reduced QoL persisted.

In 2008, PT entered SEISMIC, a 24 week open label MIFE study.  PT was followed 2 years in an extension phase and continues on MIFE post FDA approval.  MIFE dose started at 300mg/d and then escalated to 1200mg/d. Dose later reduced to 600mg due to nausea/vomiting. At Week 24 PT experienced vaginal spotting with increased endometrium and decreased HCT 29.9 % (35-46%).  PT referred to Gynecologist and D&C performed but bleeding continued despite stopping therapy for 5 weeks. Ultimately, PT decided to have a hysterectomy to continue the beneficial effects she experienced while eliminating the menorrhagia.  PT continues on 600mg MIFE and concomitant TX for HTN and Hypokalemia.

Baseline to current visit changes include:  Weight: -16 Kg; BMI -5.7 kg/m2; waist circumference - 10 cm; diabetes  HbA1c 8.4% down to 5.0% and 370 units of insulin daily decreased to no diabetes medications; Beck Depression Inventory (BDI – II) improved from mild levels of depression and anxiety to normal mood. CushingQoL scores 124% better with improvement in all areas of QoL. 

LESSONS LEARNED:  CD induced diabetes was eradicated during long term MIFE treatments and significant improvements in glucose tolerance, weight, mood and QoL were seen.  Hypokalemia and HTN may need monitoring and intervention due to mineralocorticoid receptor activation. Endometrial changes may occur which require gynecologic evaluation. PT returned to a normal, active life with capability to care for her family and maintain a full time job.

 

Disclosure: SMH: Employee, Corcept. Nothing to Disclose: DTA

13980 1.0000 MON-0439 A Improved Activities of Daily Living, Normal Mood and Quality of Life: 4 Years of Treatment Data in a Premenopausal Women with Cushing's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Monday, June 23rd 3:00:00 PM MON 0439-0440 5254 1:00:00 PM Endocrine Nursing Poster

Michelle H. Gurel*1, Yi Han2, Aaron Furtado3 and Kathleen Graham Lomax3
1Massachusetts General Neuroendocrine Center, Boston, MA, 2WG Consulting, New York, NY, 3Ipsen Biopharmaceuticals, Inc, Basking Ridge, NJ

 

Introduction: Many patients with acromegaly require medical treatment including with somatostatin analogs (SSAs).   Better treatment outcomes should be achieved when patients follow their prescribed medication regimens.  This analysis using insurance data explored compliance and persistence with the common injectable medications used to treat acromegaly.

Methods: This was a retrospective analysis using the MarketScan™ database which links paid claims and encounter data for over 100 payers and over 500 million claims in the United States. The database includes commercial claims and encounters (CCAE) from employer-sponsored plans.  The period between 2007 through June 2012 was studied for patients with acromegaly using either of 2 SSAs (lanreotide depot [LD] or octreotide long-acting release [O-LAR]).  Compliance was assessed for each patient via determining the medication possession ratio (MPR), injection count, and treatment time.  MPR was calculated as follows: (total injection number-1)*30/Treatment Duration.  The Index Date is the first date an acromegaly diagnostic code is given. Injection Count is the total number of injections observed in the database post index date. Treatment Time is the total observed treatment time between index date and last injection date. Persistence was determined via Kaplan-Meier (KM) analyses and Cox proportional hazards modeling.  KM survival analyses were performed to compare cumulative incidence of non-persistence. A Cox proportional hazards model was conducted to model the hazard ratio of non-persistence. A washout period (where patients had no prescription activity in the database 180 days before the index date) was used in order to focus on likely treatment-naïve acromegaly patients and was determined by the following formula: Index date minus First Reporting Date (when a patient first appears in the claims database).

Results: 1632 patients with acromegaly were found in the database.  Compliance data demonstrated an  average MPR of 89% for O-LAR and 87% for LD.  Median number of days on therapy for O-LAR was 169 (95% CI 135-232) and for LD was 400 (95% CI 232-532). The point estimate of the Cox proportional hazard ratio for stopping treatment was 1.385 for O-LAR vs LD (95% CI 1.079-1.777).

Conclusions: Compliance was similarly good for both injectable SSA treatments studied, at 87% or greater.  Persistence was better for LD than O-LAR.  The risk of discontinuing therapy was also lower with LD than O-LAR.

 

Disclosure: MHG: Consultant, Ipsen. YH: Consultant, Ipsen. AF: Employee, Ipsen. KGL: Employee, Ipsen.

14217 2.0000 MON-0440 A Compliance and Persistence to Somatostatin Analog Therapy for the Treatment of Acromegaly 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Endocrine Healthcare Delivery and Education Monday, June 23rd 3:00:00 PM MON 0439-0440 5254 1:00:00 PM Endocrine Nursing Poster

Stuart Andrew Morgan*1, Emma Louise McCabe1, Laura Louise Gathercole1, Zaki K Hassan-Smith1, Dean Paul Larner1, Iwona Bujalska1, Paul M Stewart2, Jeremy W Tomlinson1 and Gareth Geoffrey Lavery1
1University of Birmingham, Birmingham, United Kingdom, 2University of Leeds, Leeds, United Kingdom

 

Glucocorticoids are widely prescribed for their anti-inflammatory properties, but have a significant adverse effect profile, leading to a Cushingoid phenotype. In the present study, we test the hypothesis that reactivation of glucocorticoids, in peripheral tissues by 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1), is a major determinant of exogenous Cushing’s syndrome. Wildtype (WT), global 11β-HSD1 knockout (GKO), liver-specific 11β-HSD1 knockout (LKO) and fat-specific 11β-HSD1 knockout (FKO) mice were treated with corticosterone (100μg/mL) or vehicle via drinking water for 5 weeks. Corticosterone treated WT and global GKO mice had grossly elevated serum corticosterone levels.  However, GKO mice were protected from Cushingoid features, as indicated by reversal of glucose intolerance, hyperinsulinaemia, systolic hypertension, increased adiposity, myoatrophy and dermal atrophy. Corticosterone increased expression of the lipolytic enzymes: hormone sensitive lipase (HSL) and adipose triglyceride lipase (ATGL) in adipose tissue of WT mice, paralleled by increased serum free fatty acids (FFAs) and hepatic steatosis, whilst GKO mice were completely protected from the hepatic manifestations of corticosterone treatment. Similarly, in corticosterone-treated FKO mice, reversal of increased ATGL and HSL in adipose tissue, increased serum FFAs and hepatic steatosis was demonstrated, but no protection from the impact of corticosterone was observed in LKO mice. These data demonstrate that glucocorticoids, reactivated by 11β-HSD1 in peripheral tissues, are a major determinant of Cushingoid features in corticosteroid treated mice. Furthermore, local glucocorticoid regeneration in adipose tissue, and not liver, is central in driving the hepatic manifestations of glucocorticoid excess. 11β-HSD1 is an exciting therapeutic target for patients with Cushing’s syndrome.

 

Nothing to Disclose: SAM, ELM, LLG, ZKH, DPL, IB, PMS, JWT, GGL

OR49-1 14543 1.0000 A 11β-HSD1 Is the Major Regulator of the Tissue-Specific Effects of Circulating Glucocorticoid Excess 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Tuesday, June 24th 11:00:00 AM OR49 4718 9:30:00 AM Novel Mechanism of Glucocorticoid Metabolism and Action Oral

Vincent L. Wester*1, Jan W. Koper2, Erica L.T. van den Akker1, Salome Scholtens3, Ronald P. Stolk3 and Elisabeth F.C. van Rossum2
1Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands, 2Erasmus MC, Rotterdam, Netherlands, 3University Medical Center Groningen, Groningen, Netherlands

 

Background: An excess of glucocorticoids (e.g. Cushing’s syndrome) often presents with features of metabolic syndrome. Sensitivity to glucocorticoids is partly determined by polymorphisms in the glucocorticoid receptor (GR). These polymorphisms may therefore affect the risk for metabolic syndrome. We examined the association between functional GR polymorphisms and presence of metabolic syndrome.

Subjects and methods: In 13.386 adult Dutch individuals from the LifeLines Cohort study (58.2% female; median age 47, IQR 40 – 55), functional GR polymorphisms (BclI, N363S, ER22/23EK, GR-9beta and TthIIII) were genotyped using GWAS imputation with 1000 Genomes as a reference set. Using PHASE, GR haplotypes were constructed. Using logistic regression with a stepwise backwards elimination approach, the association between metabolic syndrome (ATPIII criteria) and each GR haplotype was tested, with age, sex, education level and smoking status as covariates.

Results: Six GR haplotypes accounted for 99.7% of all haplotypes found, with frequencies similar to those in our previous studies. We found a significant contribution of GR haplotype 5 (P<0.001), which contained polymorphism N363S (rs56149945), on the presence of metabolic syndrome in interaction with age, sex and education status. Stratification for education status showed that haplotype 5 increased the risk of metabolic syndrome in people with low (OR 1.47, 95% CI 1.08 – 2.01) but not in people with middle or high education status (OR 0.84, 95% CI 0.64 – 1.09 and OR 0.84, 95%CI 0.55 – 1.31, respectively). The influence of haplotype 5 declined with increasing age (OR per year increase 0.97, 95%CI 0.96 – 0.99).

Conclusion: a GR haplotype that is known to be related with increased glucocorticoid sensitivity was associated with increased risk of metabolic syndrome in interaction with education level. Our results indicate a significant gene-environment interaction, in which a genetic constitution predisposing for metabolic syndrome (a hypersensitive GR) is predominantly expressed in the presence of low education status.

 

Nothing to Disclose: VLW, JWK, ELTV, SS, RPS, EFCV

OR49-2 14432 2.0000 A A Glucocorticoid Receptor Haplotype That Enhances Glucocorticoid Sensitivity Is Associated with Increased Risk of Metabolic Syndrome: The Lifelines Cohort Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Tuesday, June 24th 11:00:00 AM OR49 4718 9:30:00 AM Novel Mechanism of Glucocorticoid Metabolism and Action Oral

Rowan Samuel Hardy*1, Mark Pierson1, Craig L Doig2, Janet M Lord3, Paul M Stewart4, Gareth Geoffrey Lavery2, Mark Stuart Cooper5 and Karim Raza2
1The University of Birmingham, Birmingham, United Kingdom, 2University of Birmingham, Birmingham, United Kingdom, 3MRC ARUK Centre for Musculoskeletal Ageing, School of Immunity and Infection, University of Birmingham, Birmingham, UK, Birmingham, United Kingdom, 4University of Leeds, Leeds, United Kingdom, 5Univ of Sydney, Sydney, United Kingdom

 

Muscle wasting remains a significant complication in patients with inflammatory disease where it contributes to disability, risk of falls and early mortality. Interestingly, muscle wasting in patients with glucocorticoid excess mirrors that observed in patients with inflammatory disease. We have previously reported that the glucocorticoid activating enzyme 11β-Hydroxysteroid dehydrogenase type 1 (11β-HSD1) is potently up-regulated within mesenchymal derived cell populations in response to pro-inflammatory stimuli.

Consequently, we hypothesise that muscle wasting in patients with inflammatory disease is driven by elevated glucocorticoid activation in mesenchymal derived myocytes. In this study we have collected biopsies of quadriceps from 14 patients with osteoarthritis. 11β-HSD1 expression and activity in muscle was examined by Real-Time RT PCR, immunohistochemistry and tritiated steroid conversion assays. In vitro regulation of 11β-HSD1 by the pro-inflammatory cytokines TNFα and IL-1β (10ng/ml) was assessed in primary myocyte culture.

Positive 11β-HSD1 mRNA expression was identified in muscle (Avg ΔCt = 16.6 + 0.75), with enzyme expression observed ubiquitously throughout the tissue. This was supported by significant oxoreductase activity (14 + 5 fmol/mg tissue/hr). In primary cultures of myocytes, 11β-HSD1 was potently up-regulated at 24 hr by the cytokines TNFα and IL-1β (7.8 + 0.9 & 18.2 + 2.1 fold respectively; p<0.05). This effect was abrogated by the NFκ-B inhibitor parthenolide (1mM). 11β-HSD1 mRNA expression in muscle was shown to positively correlate with markers of inflammation (IL-6, R2 = 0.62; p<0.05) and atrophy (FOXO-1, R2 = 0.36; p<0.05).

These findings demonstrate that 11β-HSD1 is actively expressed within human muscle and primary myocytes, where it is positively regulated by pro-inflammatory cytokines and correlates with markers of muscle inflammation and atrophy. Consequently, these data support a role for glucocorticoid activation by 11β-HSD1 in driving inflammatory muscle wasting

 

Nothing to Disclose: RSH, MP, CLD, JML, PMS, GGL, MSC, KR

OR49-3 14578 3.0000 A Glucocorticoid Activation in Muscle By 11 ß-Hydroxysteroid Dehydrogenase Type 1: Contributions to Inflammatory Muscle Wasting 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Tuesday, June 24th 11:00:00 AM OR49 4718 9:30:00 AM Novel Mechanism of Glucocorticoid Metabolism and Action Oral

Sivapriya Ramamoorthy*1, Robert H Oakley2, Julie F Foley3 and John A Cidlowski4
1NIEHS, Research Triangle Park, NC, 2National Institute of Environmental Health Sciences, Research Triangle Park, NC, 3National Institute of Environmental Health Sciences, RTP, NC, 4NIEHS/NIH, Research Triangle Pk, NC

 

Glucocorticoids are essential for life and have an important role in the regulation of metabolism, immune functions and response to physical and psychological stress. The biological responses to glucocorticoids are determined by glucocorticoid sensitivity, which is influenced by multiple factors and varies considerably among tissues. We have reported that multiple glucocorticoid receptor (GR) isoforms are generated from the single GR gene by alternative translation initiation. These translational isoforms of GR have distinct tissue distribution patterns and unique gene targets, thus the unique GR isoforms composition within a cell or tissue could determine the cell-specific response to glucocorticoids. The C3 isoform of GR has enhanced transcriptional activity compared to the other GR isoforms and the D3 isoform of GR is transcriptionally compromised. To determine the physiological consequence of the GR isoform-specific gene regulation in vivo, we have generated knock-in mice that exclusively express only the C3-GR isoform or the D3-GR isoform. Knock-in of C3-GR and D3-GR leads to post-natal lethality due to respiratory distress within hours after birth and genotyping at 21 days of age revealed that the number of total knock-in mice failed to meet the expected Mendalian ratio (25%). However, we demonstrate that C3-GR isoform alone is sufficient to support mouse postnatal development after embryonic rescue with maternal administration of dexamethasone on embryonic day 15.5 and 16.5. In contrast the D3-GR isoform alone cannot yield viable adult mice after comparable glucocorticoid administration. Genome-wide microarray analysis of glucocorticoid-regulated genes in Mouse Embryonic Fibroblasts (MEFs) derived from WT and GR-C3 knock-in mouse reveals profound differences in their transcriptomes. The GR-C3 isoform selectively regulates genes involved in several canonical pathways including Integrin-linked kinase signaling, cardiac hypertrophy signaling, circadian rhythm signaling and inflammation. These findings suggest that, GR isoform composition within cells can determine the glucocorticoid transcriptional regulatory profile, which in turn contribute to tissue specific physiological action of glucocorticoids.

 

Nothing to Disclose: SR, RHO, JFF, JAC

OR49-4 13872 4.0000 A Glucocorticoid Receptor Isoform Knock-in Mice Have Unique Responses to Glucocorticoids 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Tuesday, June 24th 11:00:00 AM OR49 4718 9:30:00 AM Novel Mechanism of Glucocorticoid Metabolism and Action Oral

John R Pooley*1, Diego M Presman1, Sundar Ganesan2, Rodney L Schiltz1, Ashwini Sheshasayee1, Valeria Levi3, Ozlem Keskin4, Stafford L Lightman5 and Gordon L Hager1
1National Cancer Institute, Bethesda, MD, 2National Institute of Allergy and Infectious Diseases, Bethesda, MD, 3Universidad de Buenos Aires, Buenos Aires, Argentina, 4Koc University, Istanbul, Turkey, 5University of Bristol, Bristol, United Kingdom

 

Limited 11beta-hydroxysteroid dehydrogenase 2 in brain allows glucocorticoid actions to be mediated by two nuclear hormone receptors, the glucocorticoid receptor (GR) and the mineralocorticoid receptor (MR). MR and GR bind endogenously circulating glucocorticoids, share a hormone response element, and are co-expressed in the same neurons in several brain areas involved in HPA axis and stress regulation (e.g. hippocampus, PVN). This arrangement opens the possibility for MR/GR cooperation in the regulation of gene expression, a prospect first reported two decades ago when MR-GR interaction was observed in vitro. We have expanded on this work utilizing microscopy in conjunction with a unique cell line (3617ChMR) to study MR-GR interactions in vivo. 3617ChMR expresses GFP-tagged GR and mCherry-MR under tetracycline regulation and includes a tandem array of the MMTV long terminal repeat driving Ras expression. Accumulation of fluorescent MR/GR at the chromatinized, stably integrated array structure (800-1200 GREs) is observable microscopically. The fluorescence lifetime (FLIM) approach to Forster resonance energy transfer (FRET) and fluctuation analysis by cross-correlation number and brightness assay (ccN&B) were used to assess MR-GR interactions in living cells. Initially confirming an interaction of MR-GR biochemically by co-immunoprecipitation, we show MR-GR interactions occur in the nucleus of living cells (FLIM-FRET, ccN&B) but crucially also at a chromatinized DNA template (ccN&B). This result strongly supports the expectation that the interacting complex plays a transcriptional role in co-expressing cells. We compared the patterns of array-associated Ras and endogenous gene expression between MR+GR (interacting) and GR only (non-interacting) conditions by RT-qPCR. Results indicate that the MR-GR interaction confers a different pattern of gene induction compared to that mediated by GR alone under a physiologically relevant hormone presentation (ultradian pulse). Curiously, examination of the stoichiometry of the complex formed in the nucleoplasm (N&B method) indicated the MR-GR interaction in the living cell may not be the anticipated heterodimer. We conclude that an interaction of MR and GR within the living cell participates in transcriptional regulation in response to endogenous glucocorticoids. More work is required to determine how hormone signals carried through the MR-GR complex differ in output from those carried by MR or GR alone.

 

Nothing to Disclose: JRP, DMP, SG, RLS, AS, VL, OK, SLL, GLH

OR49-5 13900 5.0000 A The Interaction of MR and GR in the Nucleus and at DNA: Transcriptional Implications for the Glucocorticoid Response of Stress-Associated Brain Regions 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Tuesday, June 24th 11:00:00 AM OR49 4718 9:30:00 AM Novel Mechanism of Glucocorticoid Metabolism and Action Oral

Emma Louise McCabe*, Craig L Doig, Stuart Andrew Morgan, Agnieszka Ewa Zielinska, Dean Paul Larner, Jeremy W Tomlinson, Paul M Stewart and Gareth Geoffrey Lavery
University of Birmingham, Birmingham, United Kingdom

 

Brown adipose tissue (BAT) in mice generates heat through the uncoupling of mitochondrial oxidative phosphorylation during non-shivering thermogenesis. Recent evidence suggests that humans have significant depots of metabolically active BAT, leading to the notion that improving BAT function could be beneficial in preventing weight gain by augmenting whole body energy expenditure. A decline in BAT function has been linked to age related accumulation of body fat. Glucocorticoids (GC) have a negative effect upon BAT function by inhibiting uncoupling protein 1 (UCP1) expression and interfering with catecholamine potentiation of BAT function; an important consideration for adults taking therapeutic GC, as interfering with BAT function could compound the side-effects. In this study we test the hypothesis that 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1), which generates active GC in BAT, contributes to BAT decline during ageing. We analysed BAT tissue from young (15-weeks, n=7) and aged (100 weeks, n=8) global 11β-HSD1KO (GKO) and control (CON) mice maintained in standard animal-house conditions. 11β-HSD1 mRNA and protein was significantly increased during ageing in BAT (40-fold and 5-fold respectively). BAT mass and markers of differentiation and function were marginally enhanced in young GKO compared to CON mice. However, aged GKO mice had a significant increase in BAT mass vs CON (by 20%, p<0.02). Though histologically indistinguishable, GKO mice also had significantly enhanced mRNA expression of UCP1 (p<0.05), PGC1a (p<0.01), PPARg (p<0.01), cox8b (p<0.005), and cox7a1 (p<0.005), and at the protein level UCP1 expression was enhanced 4-fold (p<0.01). Further to this, GKO mice had a significantly increased mitochondrial copy number and blotting for electron transport chain complexes 1-5 identified an approximately 2-fold increase in the levels of NADH dehydrogenase 1 beta subcomplex subunit 8 and Succinate dehydrogenase iron-sulfur subunit compared to CON. These data demonstrate that abrogation of age-associated 11β-HSD1 up-regulation alleviates GC induced suppression of BAT function by maintaining mitochondrial capacity. These will have relevance for patients taking GC therapy as a decrease in BAT activity could contribute to the commonly seen side-effect of weight gain. We believe that 11β-HSD1 and GC activity in BAT should be considered a legitimate target for improving BAT function in age associated metabolic disease.

 

Nothing to Disclose: ELM, CLD, SAM, AEZ, DPL, JWT, PMS, GGL

OR49-6 16809 6.0000 A 11â-HSD1 Mediated Glucocorticoid Generation Impairs Brown Adipose Tissue Function in Ageing Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Adrenal HPA Axis Tuesday, June 24th 11:00:00 AM OR49 4718 9:30:00 AM Novel Mechanism of Glucocorticoid Metabolism and Action Oral

Erik Allen Imel*1, Xiaoping Zhang2, Mary Denise Ruppe3, Thomas Joseph Weber4, Mark Klausner5, Takahiro Ito6, Maria Vergeire6, Jeffrey Humphrey6, Francis H Glorieux7, Anthony A Portale8, Karl Insogna9, Munro Peacock10 and Thomas O Carpenter11
1Indiana University School of Medicine, Indianapolis, IN, 2Kyowa Hakko Kirin Pharma Inc, Princeton, NJ, 3Univ of TX at Houston, Houston, TX, 4Duke Univ, Durham, NC, 5Kyowa-hakko Kirin Pharma Inc., Princeton, NJ, 6Kyowa Hakko Kirin Pharma Inc., Princeton, NJ, 7Shriners Hosp for Children, Montreal, QC, Canada, 8Univ of CA - San Francisco, San Francisco, CA, 9Yale University School of Medicine, New Haven, CT, 10Indiana Univ Sch Med/Univ Hosp, Indianapolis, IN, 11Yale Univ Schl of Med, New Haven, CT

 

Background:  In XLH, abnormally elevated serum FGF23 results in low renal maximum threshold for phosphate reabsorption (TmP/GFR), low serum phosphorus (inorganic, Pi), and inappropriately normal 1,25- dihydroxyvitamin D [1,25(OH)2D] with subsequent development of rachitic deformities (1,2). In a previous study in adults with XLH, a single subcutaneous (SC) or intravenous dose of KRN23 increased TmP/GFR, serum Pi, and 1,25(OH)2D (3). Methods: Up to four SC doses of KRN23 were given every 28 days to 28 adults with XLH. Pre-dose serum Pi guided the KRN23 dose in a stepwise dose-escalation algorithm: 0.05, 0.1, 0.3 and 0.6 mg/kg. The primary outcome was the proportion of subjects with post-dose serum Pi of:  ≤ 2.5, 2.5 to ≤ 3.5, 3.5 to ≤ 4.5 and > 4.5 mg/dL. Secondary outcomes included changes in TmP/GFR, 1,25(OH)2D and other biochemical variables. Results: At baseline 96.3% of subjects had serum Pi <2.5 mg/dL. Mean (±SD) KRN23 dose administered were: 0.05, 0.10 ± 0.01, 0.28 ± 0.06, and 0.48 ± 0.16 mg/kg. Serum Pi and TmP/GFR increased from baseline at all subsequent samplings except the first-dose trough (p < 0.05). Serum 1,25(OH)2D increased from baseline except for first and second-dose troughs (p < 0.05). Mean serum Pi peaked around day 7 and declined before the next dose. The peak serum Pi increased from 2.21 ± 0.33 mg/dL after Dose 1 to 3.03 ± 0.42 mg/dL after Dose 4. The predose serum Pi increased from 1.89 ± 0.33 at baseline to 2.55 ± 0.37 mg/dL after 4 doses. Peak serum Pi increased to 2.5 to ≤ 3.5 mg/dL on Day 7 in 14.8% of subjects after the first dose, and in 37.0%, 74.1%, and 70.4% after the 2nd, 3rd, and 4th dose, respectively. Serum Pi reached 3.5 to ≤ 4.5 mg/dL only after the 4th dose, occurring in 14.8% of subjects. Serum Pi did not exceed 4.5 mg/dL in any subject. TmP/GFR also reached peak values 7 days post-dose, while serum 1,25(OH)2D peaked 3 to 7 days post-dose. There were no clinically significant changes in parathyroid hormone, serum calcium or urinary calcium excretion. One patient discontinued KRN23 due to injection site urticaria. The most common adverse events were nasopharyngitis and arthralgia. There were no serious adverse events, deaths, development of anti‑KRN23 antibodies or significant changes in electrocardiograms, or renal or cardiac tissue calcification. Conclusions: Monthly injections of KRN23 blocked the pharmacodynamic effects of excessive FGF23 in adults with XLH, increasing serum Pi, TmP/GFR, and serum 1,25(OH)2D. KRN23 was safe and well tolerated.

 

Disclosure: EAI: Coinvestigator, Kyowa Hakko Kirin, Investigator, Merck & Co.. XZ: Employee, Kyowa Hakko Kirin Pharma Inc.. MDR: Investigator, Kyowa Hakko Kirin Pharma Inc.. TJW: Investigator, Kyowa Hakko Kirin Pharma Inc.. MK: Employee, Kyowa Hakko Kirin Pharma Inc.. TI: Researcher, Kyowa Hakko Kirin Pharma Inc.. MV: Employee, Kyowa Hakko Kirin Pharma Inc.. JH: Employee, Kyowa Hakko Kirin Pharma Inc.. FHG: Investigator, Kyowa Hakko Kirin Pharma Inc.. AAP: Consultant, Sanofi, Consultant, Abbvie. KI: Investigator, Kyowa Hakko Kirin Inc. MP: Investigator, Amgen, Investigator, NPS, Investigator, Lilly USA, LLC. TOC: Ad Hoc Consultant, Kyowa Hakko Kirin, Investigator, Kyowa Hakko Kirin , Data Safety and Monitoring, Alexion.

OR43-1 12597 1.0000 A The First Multi-Dose Trial of a Human Anti-FGF23 (Fibroblast Growth Factor 23) Antibody (KRN23) in Adults with X-Linked Hypophosphatemia (XLH) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Tuesday, June 24th 11:00:00 AM OR43 4722 9:30:00 AM FGF23 & Phosphate Disorders; Osteoporosis risk factors Oral

Diala El-Maouche*1, Martin Kaufmann2, Rachel I Gafni3, Glenville Jones2 and Michael T. Collins4
1National Institutes of Health, Bethesda, MD, 2Queen's University, Kingston, ON, Canada, 3National Institute of Dental and Craniofacial Research/NIH, Bethesda, MD, 4National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD

 

Background: Fibroblast growth factor-23 (FGF23) is a phosphaturic hormone produced by osteocytes and osteoblasts that regulates and is regulated by phosphorus and vitamin D. Tumor-induced osteomalacia (TIO) is caused by phosphaturic mesenchymal tumors that secrete FGF23, resulting in phosphaturia, hypophosphatemia, and low 1,25-(OH)2D levels. In mouse models, FGF23 has been shown to simultaneously inhibit the expression of 1α-hydroxylase (CYP27B1) and increase the expression of 24-hydroxylase (CYP24A1), thereby decreasing 1,25-(OH)2D and increasing 24,25-(OH)2D levels. We have previously shown that surgical removal of TIO tumors resulted in a rapid and marked increase in 1,25-(OH)2D  in response to the decrease in FGF231.  However, the changes in 24,25-(OH)2D after TIO tumor removal have not been reported.  To better understand the FGF23 effects on vitamin D metabolism in humans, we assessed 24,25-(OH)2D3 levels before and after TIO tumor removal.

 Subjects/Methods: Eight patients with TIO were studied.  Serial measurements of phosphorus, FGF23, 1,25-(OH)2D3, 25-OH-D3, 24,25-(OH)2D3 were performed at baseline and daily for 8 days post-operatively following tumor removal . 24,25-(OH)2D3was measured by LC-MS/MS.

Results: Surgical resection was curative in all subjects; FGF23 decreased to undetectable levels immediately with normalization of serum phosphorus by day 5.   Prior to surgery, 1,25-(OH)2D3 levels were undetectable or inappropriately low for the degree of hypophosphatemia.  After surgery, 1,25-(OH)2D3 increased dramatically to as much as 10 times the upper limit of normal, peaking on post-operative day 7.  In contrast, the 24,25-(OH)2D3 levels were not elevated prior to surgery (2.06 ng/mL, 95% CI 1.81-2.31, upper limit of normal approximately 3.75 ng/mL).  Post-operatively, there was a significant decrease in 24,25-(OH)2D3 levels, and an increase in the 25–OH-D3/24,25-(OH)2D3 ratio.  The maximum effect on both was approximately 60% by day 8 (p<0.0001 for both). PTH and calcium levels did not change significantly post-operatively.

Conclusion: Following curative surgery for TIO, 24,25-(OH)2D3 levels decreased as expected with a concurrent rise in 1,25-(OH)2D3 and decrease in FGF23 levels.  Although baseline 24,25-(OH)2D3  levels were not frankly elevated, the subsequent decrease seen after surgery suggests that reduction of circulating FGF23 results in downregulation of 24-hydroxylase.  Similar studies in hyp mice (model of FGF23 excess) treated with anti-FGF23 antibodies showed suppressed expression of 24-hydroxylase. As 24-hydroxylation is the first step in the degradation of both 1,25-(OH)2D and 25-OH-D,  24-hydoxylase is an important regulator of vitamin D metabolism.  Our study supports the existing evidence that FGF23, along with inhibiting 1α-hydroxylase, also activates 24-hydroxylase.

 

Nothing to Disclose: DE, MK, RIG, GJ, MTC

OR43-2 15442 2.0000 A FGF23-Mediated Vitamin D Metabolism in Tumor-Induced Osteomalacia 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Tuesday, June 24th 11:00:00 AM OR43 4722 9:30:00 AM FGF23 & Phosphate Disorders; Osteoporosis risk factors Oral

Deborah M Mitchell*1, Harald W Jueppner2 and Sherri-Ann M Burnett-Bowie1
1Massachusetts General Hospital, Boston, MA, 2Massachusetts General Hospital and Harvard Medical School, Boston, MA

 

Background: Fibroblast growth factor 23 (FGF23), a hormone produced by osteocytes, regulates urinary phosphate (PO4) excretion and production of 1,25 dihydroxyvitamin D (1,25(OH)2D). The regulation of FGF23 production in humans remains poorly understood. In particular, children have higher levels of serum PO4 than adults, and a role for FGF23 in either regulating or responding to these altered levels has not been explored.

Design and methods: We performed a cross-sectional study in 90 healthy girls aged 9-18 years. We measured intact FGF23 (Kainos, Japan); additional serum parameters including calcium (Ca), PO4, creatinine (Cr), 25OHD, 1,25(OH)2D, and PTH; and urinary Ca, PO4, and Cr. TMP/GFR was calculated. All labs were drawn in the early morning in the fasting state. Total body bone mineral content (BMC) was measured by DXA.

Results: As expected, both serum PO4 and TMP/GFR decreased with age (R=-0.49, p<0.001 and R=-0.48 p<0.001 respectively). FGF23 did not vary with age, and there was no association of FGF23 with serum PO4 or TMP/GFR. In univariate analyses, FGF23 was associated positively with 25OHD (R=0.29, p=0.005) and negatively with 1,25(OH)2D (R=-0.32, p=0.003). There was no association of FGF23 with PTH and no association with total body BMC either with or without adjustment for height. FGF23 was not associated with Cr in univariate analysis but was positively associated with Cr after adjusting for age (p=0.03). Unexpectedly, FGF23 correlated positively with serum Ca (R=0.39, p<0.001) and negatively with the urine Ca/Cr ratio (R=-0.27, p=0.01). In a multivariate model including all factors significantly associated with FGF23 in univariate analyses plus age, serum Cr, and serum PO4, significant predictors of FGF23 levels were serum Ca, urine Ca/Cr, and 1,25(OH)2D (p=0.001, p=0.01, and p=0.001 respectively) with a borderline significance for 25OHD (p=0.06) (adjusted R2 for model=0.32).

Conclusions: Our data suggest that the decrease in serum PO4 observed during childhood growth, which is driven by a change in TMP/GFR, is not a result of changes in circulating FGF23 levels, at least cross-sectionally. The mechanism underlying the physiologic decrease in TMP/GFR thus remains unclear. The association of FGF23 levels with lower urinary Ca excretion and higher serum Ca was surprising. These results add to emerging data from animal models which suggest that circulating FGF23 levels are affected by multiple different regulators of mineral ion homeostasis, and that the plasma concentrations of these regulators are in turn influenced by FGF23.

 

Nothing to Disclose: DMM, HWJ, SAMB

OR43-3 16279 3.0000 A Fibroblast Growth Factor 23 Is Not Associated with Age-Related Changes in Phosphate Handling in Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Tuesday, June 24th 11:00:00 AM OR43 4722 9:30:00 AM FGF23 & Phosphate Disorders; Osteoporosis risk factors Oral

Sogol Mostoufi-Moab*1, Wenli Sun2, Elizabeth Isaacoff3, Jill P Ginsberg3, Felix Wehrli2 and Mary B Leonard4
1Children's Hosp of PA, Philadelphia, PA, 2University of Pennsylvania, Perelman School of Medicine, 3The Children's Hospital of Philadelphia, 4Children's Hosp, Philadelphia, PA

 

Background:We previously reported that long-term survivors of hematologic malignancies requiring allogeneic hematopoietic stem-cell transplantation (alloHSCT) have significant bone and lean mass deficits and excess adiposity.  Marrow adipocytes share common mesenchymal stem cells (MSC) with bone-forming osteoblasts, with an inverse relation between MSC differentiation into osteoblasts or adipocytes.  The impact of alloHSCT and total body irradiation (TBI) on marrow adipose tissue (MAT), trabecular bone microarchitecture (TBA), and whole body adiposity has not been addressed. 

Methods:Twenty-five alloHSCT survivors, ages 12-24 years, were enrolled, a median of 11 years (range 5-19) after alloHSCT and TBI, and compared with age-, sex- and race-matched healthy controls. Magnetic resonance spectroscopy (MRS) and micro-MRI were used to quantify vertebral MAT and distal tibia TBA on a 1.5 Tesla magnet, respectively.  Whole body lean mass (LM) and fat mass (FM) were measured with DXA and converted to Z-scores relative to age and adjusted for height Z-score. Fasting HOMA-IR was obtained in the alloHSCT survivors.

Results: Compared with controls, alloHSCT survivors had lower mean (± SD) height Z-scores (-1.34 ± 0.97 vs. 0.25 ± 0.93; p < 0.001), lower LM Z-scores (-0.88 ± 1.28 vs. -0.01 ± 0.74; p < 0.001) and greater FM Z-scores (0.72 ± 1.06 vs. 0.02 ± 0.95; p < 0.001) while BMI Z-scores did not differ.  Overall, greater MAT was associated with lower bone volume fraction (BVF), R = -0.57, p < 0.001. AlloHSCT survivors had greater vertebral fat fraction (59.0 ± 11.3 vs. 29.3 ± 9.9; p < 0.001) and trabecular deficits including lower bone volume fraction (β -0.01; 95% CI -0.12, -0.00; p = 0.02) and evidence of abnormal microarchitecture [greater erosion (p = 0.01) with a more rod like structure (p = 0.02)], vs. controls. Growth hormone deficiency was not associated with MAT or bone deficits.  HOMA-IR was associated with FM Z-score (R = 0.50, p = 0.01) but was not associated with MAT.  FM Z-score and MAT were modestly correlated (R = 0.29, p= 0.06).

Conclusion: Survivors of childhood alloHSCT after TBI demonstrate marked increases in vertebral MAT combined with abnormal trabecular microarchitecture. Future studies are needed to determine the metabolic effects and fracture implications of excess MAT, and to identify therapies for improved bone accrual following childhood alloHSCT.

 

Nothing to Disclose: SM, WS, EI, JPG, FW, MBL

OR43-4 15085 4.0000 A Increased Vertebral Marrow Adiposity in Long-Term Survivors of Pediatric Allogeneic Hematopoietic Stem Cell Transplant Is Associated with Deficits in Trabecular Microarchitecture 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Tuesday, June 24th 11:00:00 AM OR43 4722 9:30:00 AM FGF23 & Phosphate Disorders; Osteoporosis risk factors Oral

Karolina Lundstam*1, Mikael Hellström2, Ansgar Heck3, Kristin Godang3, Marek Baranowski4, Jan Erik Varhaug5, Charlotte L Mollerup6, Thord P Rosen7, Jörgen Nordenström8, Svante Jansson9 and Jens Bollerslev3
1Sahlgrenska University Hospital, Gothenburg, Sweden, 2Sahlgrenska University Hospital and Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden, 3Oslo University Hospital, Oslo, Norway, 4St Olav's Hospital, University of Trondheim, Trondheim, Norway, 5University of Bergen, Bergen, Norway, 6Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark, 7Sahlgrenska Univ Hosp, Goteborg, Sweden, 8the Karolinska Institute, Stockholm, Sweden, 9Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden

 

Introduction

Cohort studies using surrogate endpoints suggest decreased fracture risk after parathyroidectomy in patients with asymptomatic primary hyperparathyroidism (PHPT), but long-term prospective studies are lacking. Here we report 5 year data on bone mineral density (BMD) and vertebral fracture (VF) incidence from the SIPH study¹, where patients with PHPT were randomized to either parathyroidectomy (PTX) or observation (OBS).

Methods

Data were available from 130 patients (OBS n= 67, PTX n= 63) 5 years after randomization (mean age at inclusion 62 years, 9 men in each group). Baseline biochemistry (total Calcium (Ca), Parathyroid hormone (PTH), Creatinine) and BMD Z-scores by DXA (Z) for lumbar spine (LS) and femoral neck (FN) were similar in the two groups. Lateral radiographs of the thoraco-lumbar spine were obtained at baseline, and after 2 and 5 years. Two radiologists, blinded to randomization and clinical data, evaluated the radiographs in consensus, using the semiquantitative method of Genant² (including also L5).

Results

Basic biochemistry was stable in the OBS group, and normalized after parathyroidectomy (P< 0.001 for Ca and PTH).

For the OBS group, baseline BMD Z in LS was -0.3 (IQR: -1.25 to +1.0) and in FN -0.2 (IQR: -0.9 to +0.5). After 5 years BMD Z in LS was -0.2 (IQR: -1.2 to +0.6) and in FN -0.6 (IQR: -1.0 to +0.1); not significant for both sites.
For the PTX group, baseline BMD Z in LS was -0.2 (IQR: -1.0 to +1.0) and in FN -0.3 (IQR: -1.0 to +0.3). After 5 years BMD Z in LS increased to +0.4 (IQR: -0.7 to +1.2) and in FN to -0.2 (IQR: -0.7 to +0.4); P< 0.01 for both sites.
The change in Z-scores (LS; FN) was different between OBS and PTX (P=0.04; P=0.013).

At 5 years, X-rays were available for 110 patients (15 men) with baseline radiographs and at least one follow-up radiograph. Fifty-six patients were randomized to OBS (6 men) and 54 to PTX (9 men). Total follow-up time was 267.9 years (mean 4.8 years) in the OBS group and 271.5 years (mean 5.0 years) in the PTX group. There were 12 VFs in 10 patients (all women; 9.1% of all patients) at baseline (4 OBS patients with 6 VFs, 6 PTX patients with 6 VFs). During follow-up, 5 new VFs occurred in 5 patients (women), exclusively in the OBS group. Thus, 8.9% of the patients randomized to OBS, and none in the PTX group (P= 0.029), developed a new VF. Four of the new VFs occurred in patients with no VFs at baseline. All new VFs were of mild to moderate degree, and none had symptoms that could be related to the VF.

Conclusion

Five years after randomization, biochemistry and BMD Z-scores were stable with observation. Following parathyroidectomy biochemistry normalized and BMD Z-scores increased. New non-symptomatic vertebral fractures developed in 5 females in the observation group, a significantly higher risk for fractures than following surgery.

 

Nothing to Disclose: KL, MH, AH, KG, MB, JEV, CLM, TPR, JN, SJ, JB

OR43-5 12804 5.0000 A Increased Risk for Vertebral Fractures with Long-Term Observation in Mild Primary Hyperparathyroidism: Five Year Data from the Scandinavian Investigation of Primary Hyperparathyroidism (SIPH) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Tuesday, June 24th 11:00:00 AM OR43 4722 9:30:00 AM FGF23 & Phosphate Disorders; Osteoporosis risk factors Oral

John D. Christensen*1, Andreea O. Lungu2, Elaine Cochran3, Michael T. Collins4, Rachel I Gafni5, James C Reynolds6, Phillip Gorden3 and Rebecca J. Brown7
1NIDDK, National Institutes of Health, Bethesda, MD, 2Joslin Diabetes Center, Brookline, MA, 3NIH, Bethesda, MD, 4NIDCR, National Institutes of Health, Bethesda, MD, 5National Institute of Dental and Craniofacial Research/NIH, Bethesda, MD, 6National Institutes of Health, Bethesda, MD, 7National Institute of Health, Bethesda, MD

 

Rodent models have suggested a role of the adipokine leptin in bone metabolism. In the leptin-deficient state, ob/ob mice have increased trabecular bone and decreased cortical bone in the vertebrae, and decreased cortical bone in the limbs, resulting in low total-body bone mineral content; this is reversed by leptin gene therapy (1). However, these effects have not been verified in humans. Congenital generalized lipodystrophy (CGL), in which there is deficiency of adipose tissue (and hence, adipokines such as leptin), represents an excellent model for understanding the actions of leptin in a state of deficiency and replacement. To determine leptin effects on bone metabolism in humans, we studied 32 subjects with CGL (age 4.5 to 46.7 years) enrolled in an open-label, nonrandomized study at the National Institutes of Health that was designed to investigate the effects of recombinant human methionyl leptin (metreleptin) replacement on metabolic derangements in subjects with lipodystrophy. Bone mineral content (BMC) and density (BMD) and lean body mass were assessed by dual-energy X-ray absorptiometry (DXA). Standard deviation scores (SDS) for BMC, BMD, and lean body mass per height-squared (lean mass index, LMI) were calculated based on age, sex, race, and height using population normative data. At baseline, subjects had increased lean mass (LMI SDS 1.5±0.8, p<0.001), tall stature (height SDS 1.2±1.3, p<0.0001), and total body less head (TBLH) BMC (SDS 1.8±0.7, p<0.0001) compared to population norms. No significant change in TBLH BMC SDS was seen with metreleptin (mixed model). To examine differences in cortical versus trabecular bone, site-specific BMD of the AP Spine, Total Hip, and 1/3 Radius was measured in 9 subjects. At baseline, BMD SDS was significantly increased in the AP Spine (2.2±1.4, p=0.01) and Total Hip (2.1±0.9, p=0.0004), but not in the 1/3 Radius (0.9±1.8). No changes were observed in site-specific BMD SDS with metreleptin. In conclusion, patients with CGL have high bone mass in the spine, hip, and total body in the leptin-deficient state, which does not change with leptin replacement.  With the exception of high vertebral bone mass in leptin deficiency, these human data are not consistent with rodent findings on leptin’s role in bone metabolism, and raise questions about the clinical relevance of rodent models to study leptin-bone interactions.

 

Nothing to Disclose: JDC, AOL, EC, MTC, RIG, JCR, PG, RJB

OR43-6 12587 6.0000 A Increased Bone Mineral Content in Patients with Congenital Generalized Lipodystrophy Is Unaffected By Metreleptin Replacement Therapy 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Bone, Calciotropic Hormones & Vitamin D Tuesday, June 24th 11:00:00 AM OR43 4722 9:30:00 AM FGF23 & Phosphate Disorders; Osteoporosis risk factors Oral

Pritisheel Banga*, Elizabeth Parra Garnica, Jacki Deguzman, Norman Orr, Paul Mills, Vijay Balasubramanian and Soe Naing
University of California, San Francisco, Fresno Medical Education Program, Fresno, CA

 

Background:Several studies have shown that Intensive Insulin Therapy (IIT) with intravenous insulin infusion targeting to achieve blood glucose (BG) range of 80 to 110 mg/dL conferred no overall mortality benefit among critically ill patients in Medical ICU (MICU) setting. Therefore less stringent glycemic control with BG target of 140 to 180 mg/dL has been recommended for MICU patients. However, such a higher and more permissive BG target range may result in less frequent use of insulin infusion and potentially poor glycemic control with undesirable outcomes.

Aim of the study:Our study was to determine effect of less stringent glycemic targets on the frequency of use of insulin infusion, glycemic control and clinical outcomes in MICU patients. 

Study design:IIT with intravenous insulin infusion targeting to achieve BG range of 80 to 110 mg/dL was used in 2008 in the MICU at a community-based teaching hospital. However, less stringent glycemic control with BG target of 140 to 180 mg/dL has been adopted since 2010-2011. Data of diabetes management and outcome of all diabetic patients who were admitted to the same MICU during the first 3 months in 2008 and 2012 were collected and compared.

Results and discussion:170 and 272 diabetic patients were admitted to MICU during first 3 months in 2008 and 2012 respectively. There was no significant difference in age, gender, BMI, baseline A1c, APACHE II score, serum creatinine, WCC, hematocrit, lipids profile on admission between stringent group (2008) and less stringent group (2012). The frequency of use of insulin infusion was significantly less in 2012 than in 2008 (73.5% vs 52.2%; p<0.0001). As expected, both mean FBG (135.7 mg/dL vs 156.1 mg/dL: p<0.001) and mean all BG levels (141.5 vs 157.1 mg/dL: p<0.0001) significantly increased in less stringent group but they remained within target and desirable ranges. There was no significant difference in hospital mortality (24.7% vs 25%: p=1.0), MICU length of stay (LOS) (8.5 vs 6.9 days: p=0.13), total hospital LOS (18.3 vs 17.7 days: p=0.77), rate of hospital acquired infection (20% vs 22%: p=0.63) and duration on ventilators (9.0 vs 7.1 days: p=0.21) between 2 groups (2008 vs 2012). Risk of both severe (17.1 vs 5.5%: p=0.0001) and mild/moderate (57.1 vs 28.4%: p<0.0001) hypoglycemic episodes were significantly lower in less stringent group.

Conclusion: The less stringent glycemic targets resulted in less frequent need and use for intravenous infusion in MICU. However, this approach did not result in poor glycemic control. Risk of hypoglycemia was significantly lower in less stringent group. There was no significant difference in clinical outcomes between stringent (2008) and less stringent (2012) glycemic control groups.

 

Nothing to Disclose: PB, EP, JD, NO, PM, VB, SN

OR54-1 12368 1.0000 A Less Stringent Blood Glucose Target in Medical ICU Patients: Effect on the Frequency of Use of Insulin Infusion, Glycemic Control and Clinical Outcomes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Tuesday, June 24th 11:00:00 AM OR54 4730 9:30:00 AM Type 2 Diabetes: Glycemic Outcomes Oral

Mary Tilak*1, Melanie E Mabrey2, Mark Mamros3, John Stewart4, Terry Dex4 and Mehul Dalal4
1TAWL, Schererville, IN, 2Duke Univ, Durham, NC, 3Kenneth J. Yablonski Health Center, Washington, PA, 4Sanofi US, Inc., Bridgewater, NJ

 

T2DM is mainly managed by primary care providers. The increase in oral and injectable treatment options and understanding of the T2DM process and metabolic defects have empowered but also complicated disease management for physicians and their patients. In this study, we assessed real-world differences between T2DM patients on OADs and on injectable drugs.

Diabetes FORWARD is a large practice-based study to assess practice patterns, patient experiences, and outcomes in the management of T2DM in the US, using data from electronic medical records and surveys. The results of this research platform may suggest future directions for the management of T2DM.

Of 10,000 anticipated patients, 2,195 (enrolled from March 2012 - November 2013) were included: 1,576 on OADs only and 619 on injectables. Of 780 patients with data on medication, 379 patients were on basal insulin alone and 156 on GLP-1 agents. Surprisingly, 13 GLP-1 patients were also on DPP-4 inhibitors and, of 485 patients on any type of insulin, 125 (25.8%) were on sulfonylureas. Overall, the most commonly used OAD was metformin (88% vs. 80.5% in the OADs and injectables groups, respectively), with the sulfonylureas (51.9% vs. 41.7%) and DPP-4 inhibitors (31% vs. 21.7%) also widely prescribed.

Patients in the OADs group had a lower baseline A1C (7.1% vs. 8.0%; P < 0.0001) and a shorter duration of disease (9.9 years vs. 14 years; P = 0.0015) than patients on injectables. They also tended to be older (60.5±11.6 years vs. 57.4±12.1; P = 0.06), be white (80.2% vs. 70.4% were white, 11.6% vs. 20.9% African American; P < 0.0001), have a lower BMI (34±7.3 vs. 36.1±8.5 kg/m2; P = 0.045), and be married (11.3% vs. 16.7% were single, 66.5% vs. 56.3% married/partnered, 12.3% vs. 17.3% divorced/separated, and 10% vs. 9.7% windowed; P < 0.0001). There was also a trend towards more education in the OADs group: 14.1% (vs. 11.6%) had a bachelor’s degree and 12.5% (vs. 8.4%) had undertaken a postgraduate degree. There was no difference in gender or Charlson Comorbidity index. Patients taking OADs alone tended to be more satisfied with their treatment (71.9% vs. 69.8%; P = 0.0142), particularly when rating their medication for convenience (78.5% vs. 70.6%; P < 0.0001). They also reported less side-effects (16.8% vs. 20.9%; P = 0.0025) and rated their medication as more effective (18.4% vs. 17.8%; P = 0.024).In both groups there were a large number of patients on multiple OADs. Within the injectables group, more than half of patients (65.4%) were also taking one or more OAD. For the OADs group, 32.2% were on 1 OAD, 52% were on 2, 14.3% on 3, and 1.5% on more than 3.

The high numbers of patients on multiple OADs suggests an overutilization of OADs and a possible underutilization of injectables, which may be related to provider factors and to some extent patient convenience, suggesting an opportunity for future education and improvement in existing therapies.

 

Disclosure: MT: Consultant, Sanofi. MEM: Speaker Bureau Member, Sanofi, Consultant, Glytec, LLC, Consultant, Sanofi. MM: Consultant, Sanofi, Speaker Bureau Member, Sanofi. JS: Employee, Sanofi, Employee, Sanofi. TD: Employee, Sanofi, Stock ownership, Merck & Co., Stock ownership, Proctor & Gamble, Stock ownership, Pfizer, Inc., Employee, Sanofi. MD: Employee, Sanofi, Employee, Sanofi.

OR54-2 15701 2.0000 A Real-World Use of Oads and Injectable Drugs in Patients with T2DM: The Diabetes Forward Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Tuesday, June 24th 11:00:00 AM OR54 4730 9:30:00 AM Type 2 Diabetes: Glycemic Outcomes Oral

Edward Shahady1, Jodi Strong*2, Terry Dex3, Mehul Dalal3, Jeffrey Frimpter3, Wei Zhou4 and John Stewart4
1Florida Academy of Family Physicians, Fernandina Beach, FL, 2Ministry Medical Group, Stevens Point, WI, 3Sanofi US, Inc., Bridgewater, NJ, 4Sanofi Canada, Laval, QC, Canada

 

Achieving glycated hemoglobin A1C (A1C), blood pressure (BP), and low-density lipoprotein cholesterol (LDL-C; ABC) goals at the same time is crucial for cardiovascular health due to the effect of all these factors on inflammation and endothelial dysfunction.

We descriptively compared data from Diabetes FORWARD (DF), a large practice-based research network (PBRN) focused on patients with type 2 diabetes mellitus (T2DM) and their providers across the US (September 2012–December 2013); the Diabetes Master Clinician Program (DMCP) a large PBRN primarily based in Florida (November 2013–December 2013); and the National Health and Nutrition Examination Survey (NHANES; 2007–2010). Eligible patients were ≥ 18 years (≥ 20 years in NHANES), with a diagnosis of T2DM (self-reported diabetes in NHANES).

Data from 1,968, 22,438, and 4,926 patients from DF, DMCP, and NHANES, respectively, were compared. Mean A1C, BP, and LDL-C were: 7.3% and 7.2%, 130/77 mmHg and 131/76 mmHg, and 91 mg/dL and 93 mg/dL in DF and DMCP, respectively. More patients in the DMCP cohort achieved A1C goal (56.0%) than in the DF or NHANES cohorts (49.0% and 52.5%, respectively). More patients in the DMCP cohort achieved BP goal (57.0%) than in the DF or NHANES cohorts (47.3% and 51.1%, respectively). While more patients in the DF (65.7%) and DMCP (62.0%) cohorts achieved LDL-C goals than in the NHANES cohort (56.2%). Attainment of all three goals at the same time was low in all cohorts; but highest in the DMCP (23.0%) cohort compared with the DF (15.9%) or NHANES (18.8%) cohorts.

Attainment of individual healthcare goals was close to or greater than 50% in all 3 real-world cohorts investigated. However, attainment of all 3 goals simultaneously was low in all cohorts. In order to improve cardiovascular outcomes the focus of T2DM treatment in primary care should be broadened to focus on all 3 ABC goals and not A1C alone.

 

Disclosure: ES: Advisory Group Member, Lilly/Boehringer Ingelheim, Advisory Group Member, Jansen Pharmaceuticals, Advisory Group Member, Novo Nordisk, Speaker Bureau Member, Merck & Co.. JS: Speaker Bureau Member, Sanofi, Speaker Bureau Member, Novo Nordisk, Speaker Bureau Member, Jansen Pharmaceuticals. TD: Stock ownership, Proctor & Gamble, Stock ownership, Merck & Co., Employee, Sanofi, Employee, Sanofi, Stock ownership, Pfizer, Inc.. MD: Employee, Sanofi, Employee, Sanofi. JF: Employee, Sanofi, Employee, Sanofi. WZ: Employee, Sanofi. JS: Employee, Sanofi, Employee, Sanofi.

OR54-3 15756 3.0000 A ABC Goal Attainment in Patients with Type 2 Diabetes Mellitus in US Primary Care 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Tuesday, June 24th 11:00:00 AM OR54 4730 9:30:00 AM Type 2 Diabetes: Glycemic Outcomes Oral

Eric Harman1, John Stewart2, Wei Zhou3, Jeffrey Frimpter2, Aleksandra Vlajnic2, Robert M Cuddihy4 and Terry Dex*2
1Mountain Region Family Medicine, Kingsport, TN, 2Sanofi US, Inc., Bridgewater, NJ, 3Sanofi Canada, Laval, QC, Canada, 4Sanofi-Aventis U.S., Bridgewater, NJ

 

T2DM is managed most often by primary care providers (PCP), who typically aim for A1C ≤ 7%. Real-world data on why patients do or do not meet target A1C is lacking. We assessed real-world differences between characteristics of patients who did or did not meet A1C goals.

Diabetes FORWARD is a longitudinal, practice-based study to assess practice patterns, patient experiences, and outcomes in the management of T2DM in the US. Data are derived from electronic medical records and surveys. The results of this research platform may suggest future directions for the management of T2DM. Patients were stratified based on their A1C at time of enrollment.

Of 2,195 enrolled patients, 686 of were eligible for this analysis. When compared with patients with A1C ≤ 7%, those with A1C > 7% at 6 month follow-up visit were somewhat younger (58.8±11.4 vs 61.4±11.6 years; P = 0.003) and more often tended to be non-whites (African American: 18.4% vs 12.2; white: 75.5% vs 82.1%; other: 17.1% vs 5.7%; P = 0.089), have a higher BMI (35.5±8.5 vs 34.1±8.1; P = 0.031), have a higher baseline A1C (8.0±1.4 vs 6.7±1.1; P < 0.001), be more likely to have a personal A1C goal (53.7% vs 43.3%; P = 0.007), use ≥ 3 OADs (17.1% vs 11.0%), be less educated (11.7% vs 13.3% had a bachelor’s degree and 9.9% vs 14.4% had undertaken a postgraduate degree), have a lower opinion of their health (9.3% vs 5.1% thought that their health was poor whereas 15.9% vs 28.9% thought that their healt was very good), use more sulfonylureas (52.3% vs 42.5%; P = 0.011) and basal insulins (28.2% vs 8.8%; P< 0.001), and believe that nocturnal hypoglycemia is significantly impacting their diabetes (10.4% vs 4.4%).

These real-world data in the PCP setting suggest that US T2DM patients might benefit from better disease education and improved weight management skills. Among those not achieving A1C goals, low percentages of patients were on injectable therapy, suggesting that attention to treatment progression is of importance for this group.

 

Disclosure: EH: Clinical Researcher, Jansen Pharmaceuticals, Clinical Researcher, Boehringer-Ingelheim. JS: Employee, Sanofi, Employee, Sanofi. WZ: Employee, Sanofi. JF: Employee, Sanofi, Employee, Sanofi. AV: Employee, Sanofi, Employee, Sanofi. RMC: Employee, Sanofi, Employee, Sanofi. Nothing to Disclose: TD

OR54-4 15861 4.0000 A Real-World Characteristics of Patients at A1C Goal (≤ 7%) Compared with Patients Not at Goal (> 7%): The Diabetes Forward Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Tuesday, June 24th 11:00:00 AM OR54 4730 9:30:00 AM Type 2 Diabetes: Glycemic Outcomes Oral

Roselyn Mateo*1, Suruchi Gupta2, Cristina Garcia3, Amisha Wallia1, Kathleen Schmidt4, Diana Johnson Oakes4, Grazia Aleppo1, Adin-Cristian Andrei5, Kathleen Grady5, Edwin McGee5, Jane Wilcox6 and Mark E Molitch1
1Northwestern University Feinberg School of Medicine, Chicago, IL, 2Northwestern University Feinberg School of Medicine, 3Family Health Centers of San Diego, 4Northwestern Medical Faculty Foundation, 5Northwestern Memorial Hospital, 6Northwestern University Feinberg School of medicine

 

Hyperglycemia has been shown to have deleterious effects on rejection and infection  following kidney and liver transplants. Prior studies have shown that presence of diabetes mellitus (DM) pre heart transplant (HT) and new onset DM after HT are associated with a borderline increased risk of HT rejection. Little is known about the effects of immediate post-operative hyperglycemia and glucose control on HT rejection. 

We analyzed data of 92 consecutive patients who underwent HT between 6/2005-9/2009 at Northwestern Memorial Hospital and had a Glucose Management Service/Endocrine consult. We evaluated fasting blood glucose levels immediately preoperatively [Pre-Op Glucose], glucose control during the entire inpatient stay [Inpatient Glucose Mean], and development of rejection after HT. Rejection was defined as ≥ grade 2 rejection (International Society of Heart and Lung Transplantation grading system) on routine heart biopsies performed in the first year following HT and that required increased immunosuppressive therapy.  Glucose levels were compared between those who had rejection ([R], n=28) and those who did not ([nonR], n=64).  Data are reported as mean ± SD.

There were no significant differences between the two groups for either the Pre-Op Glucose (R, 100.4 ± 19.9 mg/dL, n=28; nonR, 109.2 ± 31.8 mg/dL, n=62; p=NS), or the Inpatient Glucose Mean (R, 138.2 ± 14.5 mg/dL, n=28; NonR, 141.3 ± 14.3 mg/dL, n=64; p=NS).  A pretransplant diagnosis of DM did not influence the rejection rate (DM, n=26, 26.9% with rejection; nonDM, n=66, 31.8% with rejection; p=NS).

Unlike kidney and liver transplant, our data do not show significant associations of preoperative diagnosis of DM, preoperative glucose levels, or early postoperative glucose levels with rejection within the first year after HT.  However, mean glucose levels were <150 mg/dL in both groups, and we cannot exclude the possibility that much higher glucose levels may influence rejection rates.

 

Disclosure: AW: Advisory Group Member, Jansen Pharmaceuticals, Investigator, Merck & Co.. MEM: Ad Hoc Consultant, Abbott Laboratories, Advisory Group Member, Astra Zeneca, Advisory Group Member, Bristol-Myers Squibb, Advisory Group Member, Jansen Pharmaceuticals, Investigator, Novartis Pharmaceuticals, Advisory Group Member, Novo Nordisk, Investigator, Bayer, Inc., Ad Hoc Consultant, Eli Lilly & Company, Ad Hoc Consultant, Merck & Co.. Nothing to Disclose: RM, SG, CG, KS, DJ, GA, ACA, KG, EM, JW

OR54-5 15910 5.0000 A Glucose Levels Pre and Post Heart Transplant: Are They Related to Risk of Subsequent Rejection? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Tuesday, June 24th 11:00:00 AM OR54 4730 9:30:00 AM Type 2 Diabetes: Glycemic Outcomes Oral

Michael C. Grimes*1, Indu Mathew1, Archana Bandi2, Emily Martin3, Ronald Codario4 and R Harsha Rao5
1VA Pittsburgh Health System, Pittsburgh, PA, 2VAPHS/Oakland, Wexford, PA, 3VA Pittsburgh Healthcare System, Munhall, PA, 4University of Pittsburgh Med Ctr, Pittsburgh, PA, 5VA Pittsburgh Healthcare System, Pittsburgh, PA

 

Extreme insulin resistance associated with morbid obesity is increasingly prevalent in Type 2 diabetes, posing a major therapeutic challenge in a growing subset of patients with diabetes mellitus in whom the total daily dose (TDD) of insulin exceeds 200u/day.  In such patients, the only viable option for glycemic control is U-500 insulin, the use of which increased 137% from 2007 to 2009.  However, the cost-versus-benefit of using U-500 insulin in patients with extreme insulin resistance is unknown, because the true incidence of hypoglycemia remains undetermined.  Hypoglycemia is particularly worrisome when using five-fold concentrated insulin, but objective data on hypoglycemia with U-500 insulin are lacking, with most published studies relying on subjective reporting of hypoglycemic symptoms, rather than blood glucose (BG) readings.

The increasing prevalence of extreme insulin resistance is reflected in the increasing use of U-500 insulin at our institution, as reported elsewhere.  However, the uniquely comprehensive VA database provides access to all recorded home BGs, through either the Home Telehealth Program or the patient call-in program, in addition to laboratory and mortality data.  This afforded us the unique opportunity to evaluate the cost (hypoglycemia and mortality) versus benefit (glycemic improvement) of U-500 therapy, in a cohort of 41 unique patients with type 2 diabetes and extreme insulin resistance (TDD >200 units) followed for 18±14.74 months (Mean±SD, Range 3-62 months).

The initiation of U-500 resulted in a substantive reduction in mean A1c (9.8±1.7% at baseline to 8.2±1.7%, at last follow up, mean difference=1.6%, p=0.0001), which was both immediate (1.6% at 3 months, p=0.0001) and sustained (1.46% at 6 months, 1.8% at 12 months, both p=0.0001), and not accompanied by significant changes in either TDD (baseline 270±62 vs 296±99 units, p=0.07) or weight (baseline 292±59 vs 295±62lbs, p=0.3).   The frequency of hypoglycemia (BG <70mg/dl) was 2.96% (369 out of 12,483 outpatient BG values), with each patient experiencing a mean of 9±11.84 episodes of hypoglycemia over the duration of follow up.  Despite the low frequency of severe hypoglycemia, U-500 usage was also associated with surprisingly high mortality (9.8% [4/41] at 1 year, 19.5% [8/41] at 3.3 years).

We conclude that U-500 insulin is effective in achieving a rapid and sustained improvement in glycemic control in patients with extreme insulin resistance, without a significant increase in either TDD of insulin or weight.  Hypoglycemia is relatively infrequent, but it remains unclear whether the surprisingly high mortality is attributable to U-500 usage itself, or to the underlying poor prognosis associated with the morbid obesity and extreme insulin resistance that necessitate its use.  If the latter, it may imply that the need for U-500 insulin is in itself a bad prognostic indicator in patients with diabetes.

 

Nothing to Disclose: MCG, IM, AB, EM, RC, RHR

OR54-6 16871 6.0000 A Impact of U-500 Insulin on Glycemic Control, Risk of Hypoglycemia, and Mortality in Patients with Extreme Insulin Resistance: The VA Pittsburgh Experience 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Diabetes & Glucose Metabolism Tuesday, June 24th 11:00:00 AM OR54 4730 9:30:00 AM Type 2 Diabetes: Glycemic Outcomes Oral

Wassim Eid*1, Lennart Opitz2 and Anna Lauber-Biason3
1University of Fribourg, Switzerland, 2University of Zurich, Switzerland, 3University of Fribourg, Fribourg, Switzerland

 

The process of sexual differentiation is central for reproduction of almost all metazoan. Sex development includes both the determination of the gonads from the bipontential precursor and the subsequent differentiation of reproductive organs. Generally speaking, factors influencing sex determination are transcriptional regulators, whereas factors important for sex differentiation are secreted hormones and their receptors. Recently, our group identified CBX2.1 as an essential transactivator for human male gonadal development. M33/CBX2 (Chromobox homolog protein 2) is a regulator of chromatin structure and chromosome architecture at its target loci. Two splicing variants of CBX2 are known: CBX2.1 and CBX2.2. Yet the exact position of CBX2 in sex development cascade is still unknown, moreover very little is known about the role of second isoform CBX2.2 in human sex development.

To rank more precisely CBX2 in the sex development cascade we set to identify DNA sequences that are target for CBX2 binding. To that end, we adapted a method for mapping chromatin regulators that uses a fusion enzyme and does not rely on crosslinking and antibodies such as chromatin immunoprecipitation (ChIP). We used the DNA adenine methyltransferase identification (DamID) to identify target genes of CBX2 in the genome of the human Sertoli-like cells NT2-D1. We generated CBX2-Dam constructs for both isoforms of CBX2; constructs were delivered into cells by viral transduction. Using immunofluorescence microscopy we confirmed that the fusion proteins are correctly targeted to the nucleus. The genomic targets of CBX2.1 and CBX2.2 were mapped by sequencing specific Dam-methylated DNA sequences. Using next-generation sequencing we were able to identify 2066 and 1901 sequence of CBX2.1 and CBX2.2 respectively. In order to validate our findings, NT2-D1 cells were transiently transfected with either CBX2 or small interference RNA (siRNA) against CBX2 and qRT-PCR was used to detect the expression levels of the candidates.

Examination of relative expression levels of selected candidate genes (e.g. SOX9, SOX3, EXO1, NR5A1) revealed that their expression levels were significantly upregulated upon exogenously expressing CBX2 and were downregulated upon knocking-down CBX2 using siRNA.

Taken together, using a novel approach we were able to identify targets of CBX2 in the human sex development cascade, which could help to elucidate the molecular basis of differences of sex development to better define phenotypes of these complex diseases.

 

Nothing to Disclose: WE, LO, AL

OR44-1 14483 1.0000 A CBX2 in Sex Development: Identifying CBX2 Binding Targets in the Human Genome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Tuesday, June 24th 11:00:00 AM OR44 4736 9:30:00 AM Gene Regulation & Developmental Expression Oral

Tulip Sunil Nandu*1, Rui LI1, Shrikanth Gadad2, Miao Sun2, Minho Chae2 and W Lee Kraus2
1University of Texas Southwestern Medical Center, Dallas, TX, 2UT Southwestern Medical Center, Dallas, TX

 

Transcriptome profiling studies suggest that greater than 70% of the human genome is transcribed, with about 20% of transcribed regions exhibiting antisense transcription from the opposite DNA strand.  Antisense transcription generates antisense RNAs (asRNAs), which are complimentary to their cognate sense RNAs, including messenger RNAs (mRNAs) and long non-coding RNAs (lncRNAs).  Previous studies suggest that sense/antisense transcript ratios are globally altered in breast cancers and specific asRNAs, including H19 and TFPI-2, are overexpressed in breast cancers.  We are interested in characterizing the antisense transcriptome in breast cancer cells.  To that end, we used genomic approaches, including global run-on sequencing (GRO-Seq), which provides the location of actively transcribing RNA polymerases across the genome, and RNA-seq, which indicates the steady-state levels of transcripts genome-wide, to generate comprehensive lists of antisense transcription units and asRNAs in MCF-7 human breast cancer cells.  From these lists, we are assessing the roles of antisense transcription, which may generate transcriptional interference, and asRNAs, which may cause RNA interference, in estrogen-regulated transcriptional responses.  We found that antisense transcription through the promoters of estrogen-regulated genes is associated with enhanced estrogen-dependent transcription relative to those promoters that do not have antisense transcription.  These studies are revealing new facets of the estrogen-regulated transcriptome and suggest that antisense transcription and/or asRNAs may play a role in estrogen-dependent signaling outcomes.

 

Nothing to Disclose: TSN, RL, SG, MS, MC, WLK

OR44-2 15331 2.0000 A Identification, Regulation, and Function of Antisense Transcription in the Estrogen Response in Breast Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Tuesday, June 24th 11:00:00 AM OR44 4736 9:30:00 AM Gene Regulation & Developmental Expression Oral

Yu-Cheng Tsai*1, Stephen A Liebhaber2 and Nancy E Cooke3
1University of Pennsylvania, 2Univ of PA - Clinical Res Bldg, Philadelphia, PA, 3Univ of PA Schl of Med, Philadelphia, PA

 

The five genes within the Human Growth Hormone (hGH) gene cluster are specifically expressed in either the anterior pituitary (hGH-N) or in the placental villi (hCS-L, hCS-A, hGH-V and hCS-B). These genes are under the control of a multi-component Locus Control Region (LCR), corresponding to a set of DNase I hypersensitive sites (HSs) located -14.5 to -32 kb 5’ to the cluster. HSI, II, III, and V are assembled at the hGH locus in pituitary somatotrope chromatin. A partially overlapping set of HSIII, IV, and V are assembled in chromatin of the placental villous syncytiotrophoblast cells. Functional studies reveal that the pituitary-specific HSI,II are necessary and sufficient to activate robust transcription of hGH-N. This activation pathway is linked to ‘looping’ of HSI,II to the hGH-N gene promoter in the pituitary somatotrope. The corresponding basis for placenta-specific activation of hCS expression from the hGH cluster, and the role of the HSIII-V LCR or the placenta-specific HSIV in this process, remain undefined. Here we generate a series of hGH/BAC transgenes specifically modified to identify structural features of the hGH locus required for placental expression. We find that an isolated hCS gene with its full set of contiguous proximal control elements (promoter, P-element, and 3’ enhancer) lacks sufficient determinants for appropriately activated in the mouse placenta, even when linked to the HSIII-V segment. In contrast, hCS gene expression is appropriately maintained when the HSIII-V LCR and the structure of the multigene cluster are both maintained intact, regardless of the spacing reduction between them. Importantly, site-specific deletion of HSIII-V from an otherwise intact hGH/BAC transgene triggers a major relaxation of the tissue-specific and copy-number dependent expression of the hCS genes. This apparent ‘insulator’ activity of the HSIII-V region is paralleled by placenta-specific occupancy of the chromatin architectural protein, CTCF, at HSIV. Finally, 3C analyses of the hGH/BAC locus in the mouse placenta and a parallel set of studies of the native hGH locus in primary human syncytiotrophoblast nuclei reveal that the hGH chromatin locus is assembled into a higher-order configuration that juxtaposes the HSIII-V region with multiple sites within the hGH cluster. These data support a model in which robust placenta-specific expression of hCS from the hGH/CS gene cluster reflects the complex multigene structure of the locus, placenta-specific insulator functions, and a set of long-distance interactions of the cluster with its placental LCR determinants. When combined with our preceding studies of the hGH cluster in the anterior pituitary, these findings establish a chromatin-based pathway for the respective and mutually exclusive expressions of hGH and hCS genes in the human pituitary and placenta.

 

Nothing to Disclose: YCT, SAL, NEC

OR44-3 14048 3.0000 A Long-Range Chromatin Interactions Establish an Activated Placental Hgh Locus 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Tuesday, June 24th 11:00:00 AM OR44 4736 9:30:00 AM Gene Regulation & Developmental Expression Oral

Juan Manuel Castellano*1, Hollis Wright2, Sergio R Ojeda1 and Alejandro Lomniczi2
1Oregon National Primate Research Center/Oregon Health and Science University (ONPRC/OHSU), Beaverton, OR, 2Oregon Health & Science University/Oregon National Primate Research Center (OHSU/ONPRC), Beaverton, OR

 

The importance of the Kiss1 gene in the control of reproductive development is well documented.  However, much less is known about the transcriptional regulation of Kiss1 expression in the hypothalamus.  Critical for these studies is an accurate identification of the site(s) where Kiss1 transcription is initiated.  Employing 5’-RACE PCR we detected a transcription start site (TSS1) used by the hypothalamus of rats, mice, nonhuman primates and humans to initiate Kiss1 transcription.  In rodents, an exon 1 encoding 5’-untranslated sequences is followed by an alternatively spliced second exon, which encodes 5’-untranslated regions of two different lengths and contains the translation initiation codon (ATG).  In nonhuman primates and humans exon 2 is not alternatively spliced.  Surprisingly, in rat mediobasal hypothalamus (MBH), but not preoptic region (POA), an additional TSS (TSS2) located upstream from TSS1 generates an exon 1 longer (377 bp) than the TSS1-derived exon 1 (98 bp).  The content of TSS1-derived transcripts increased at puberty in the POA and MBH of female rats. It also increased in the MBH after ovariectomy, and this change was prevented by estrogen.  In contrast, no such changes in TSS2-derived transcript abundance were detected.  Promoter assays showed that the proximal TSS1 promoter is much more active than the putative TSS2 promoter, and that only the TSS1 promoter is regulated by estrogen.  These differences appear to be related to the presence of a TATA box and binding sites for transcription factors activating transcription and interacting with estrogen receptor alpha (ERα) in the TSS1, but not TSS2, promoter.

 

Nothing to Disclose: JMC, HW, SRO, AL

OR44-4 13084 4.0000 A An Alternative Transcription Start Site Yields Estrogen Unresponsive Kiss1 mRNA Transcripts in the Hypothalamus of Prepubertal Female Rats 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Tuesday, June 24th 11:00:00 AM OR44 4736 9:30:00 AM Gene Regulation & Developmental Expression Oral

Wei Guo*1, Houda Benlhabib1 and Carole R Mendelson2
1University of Texas Southwestern Med Ctr, Dallas, TX, 2Univ Texas Southwestern Med Ctr, Dallas, TX

 

Type II cells are highly specialized epithelial cells of the lung alveoli that uniquely synthesize pulmonary surfactant, a developmentally-regulated, surface-active lipoprotein that is essential for breathing. Inadequate surfactant production by the lungs of prematurely born infants can result in respiratory distress syndrome, a major cause of neonatal morbidity and mortality. Surfactant protein A (SP-A), the major surfactant protein, is a well-established marker of type II cell differentiation. To define the mechanisms controlling type II cell differentiation, we investigated the role of microRNAs (miRNA, miR), ~22 nt non-coding RNAs that are potent posttranscriptional inhibitors of gene expression. We conducted miRNA microarray of epithelial cells isolated from mid-gestation human fetal lung (HFL) explants before and after 48 and 96 h of culture ± cAMP, which enhances type II cell differentiation and SP-A expression. Interestingly, we found that expression of all members of the miR-29 family increased during type II cell differentiation and was induced by cAMP. In parallel studies in mice, we also observed developmental upregulation of miR-29 family members in epithelial cells isolated from mouse fetal lung between E15.5 and E18.5 gestation, in concert with type II cell differentiation and induction of SP-A expression. To determine the functional role of miR-29 family members during type II cell differentiation, we transfected LNA miR-29 family inhibitor (anti-miR-29) into cultured HFL type II cells. Upon highly efficient knockdown of all miR-29 family members, we observed a dramatic loss of SP-A expression and decrease in lamellar body accumulation, indicating that miR-29 is required for type II cell differentiation and function. Known targets of miR-29 include DNMT3a/b, KLF4, HDAC4 and TGF-β, a recognized inhibitor of type II cell differentiation and SP-A expression. Notably, knockdown of miR-29 resulted in increased expression of TGF-β2 and downstream mediators, including phospho-Smad2 and the transcriptional silencer, ZEB1. Co-treatment of the cells with TGF-β inhibitor restored the induction of SP-A and lamellar body accumulation. Altogether, our findings suggest that upregulation of miR-29 expression in developing fetal lung serves a crucial role in type II cell differentiation and function by targeting the inhibitory TGF-β signaling pathway and its downstream mediators.

 

Nothing to Disclose: WG, HB, CRM

OR44-5 13145 5.0000 A The miRNA-29 Family Serves a Key Role in Type II Cell Differentiation in Developing Fetal Lung 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Tuesday, June 24th 11:00:00 AM OR44 4736 9:30:00 AM Gene Regulation & Developmental Expression Oral

Henriette Undeutsch*1, Christoffer Löf2, Matti Poutanen3 and Jukka Kero4
1Univ of Turku, Turku, Finland, 2Univ. of turku, 3University of Turku, Turku, Finland, 4Univ. of Turku, Turku, Finland

 

MicroRNAs are small non-coding RNAs that post-transcriptionally regulate gene expression. Tissue-specific silencing of Dicer1, a key enzyme functioning the microRNA processing, provides a tool to study the influence of RNA interference in the tissue development and function. So far, little is known about miRNA in the development, growth and function of the thyroid gland, but miRNA are described to play an oncogenic role thyroid tumor development.

To understand the role of Dicer1 in thyroid in vivo, we have generated a constitutive, thyrocyte-specific Dicer1 knockout mouse line (cTgKO) by crossing Dicer1 fl/fl mice with Tg-Cre mice expressing the Cre recombinase under the thyroglobulin promoter. To be able to study the role of Dicer1 in adult thyroid we have created an inducible thyrocyte-specific Dicer1 KO model (iTgKO) by using a mouse line expressing a tamoxifen-inducible Cre under the thyroglobulin promoter.
Both mouse lines are lacking Dicer1 in thyrocytes. As a consequence, cTgKO mice showed an altered histology of the thyroid gland with disorganized follicles. Similar histological changes were observed in iTgKO mice 4 weeks after the tamoxifen induction. Furthermore, the cTgKO mice developed mild hypothyroidism with increased serum thyroid stimulating hormone (TSH) bioactivity and decreased free thyroxine (fT4) serum levels compared to the wild-type mice. Interestingly, neither cTgKO nor iTgKO mice respond to goiter-inducing drug treatment. While the control mice showed a 4-fold increased weight of the thyroid gland, there was no significant change in thyroid size or weight of cTgKO and iTgKO mice after.

In summary, these data indicate that Dicer1 plays a crucial role in thyroid function and goiter development. Further characterization and comparison of the constitutive and inducible Tg-Cre Dicer1 KO mice will provide novel information about the role of Dicer1 in the development, function and growth of the thyroid gland.

 

Nothing to Disclose: HU, CL, MP, JK

OR44-6 16798 6.0000 A Dicer1 Plays an Important Role in Goiter Development in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Gene Regulation & Development Tuesday, June 24th 11:00:00 AM OR44 4736 9:30:00 AM Gene Regulation & Developmental Expression Oral

Georgina M Russell*1, Claire Durant2, Alia Ataya2, Chrysoula Papastathi3, Ragini Bhake4, Karin Jane Bradley5, Wolfram Woltersdorf6 and Stafford Louis Lightman7
1Univ of Bristol, Bristol, United Kingdom, 2university of bristol, bristol, 3University Hospitals of Bristol NHS Foundation Trust, bristol, 4university of bristol, Bristol, United Kingdom, 5University Hospitals of Bristol NHS Foundation Trust, Bristol, United Kingdom, 6University Hospital of Bristol NHS Foundation Trust, Bristol, United Kingdom, 7University of Bristol, Bristol, United Kingdom

 

Glucocorticoid hormones secreted by the adrenal cortex are critical for life. Before steroid therapy was available patients lacking endogenous glucocorticoids did not survive. Despite the fact we have oral preparations of glucocorticoids and administer in a pattern aimed to mimic the normal circadian rhythm, our patients still have double the normal age related mortality (risk akin to smoking) and have major morbidity from mental and physical fatigue[1].

Underlying the classical circadian rhythm is a dynamic ultradian pulsatile pattern of cortisol secretion. This pattern is found in all mammalian species including man and is critical for normal gene regulation, cognitive and metabolic function. It is now clear optimal regulation of glucocorticoid responsive genes has an absolute requirement for pulsatile presentation of glucocorticoids[2]. As we currently treat patients with constant as opposed to episodic receptor activation, we are inducing unphysiological regulation of both trans-activated and trans-repressed genes, which is likely to contribute to the increased morbidity and mortality of our patients. Here we describe the development of a novel pulsed subcutaneous hydrocortisone therapy via a portable infusion pump, to more accurately mimic normal circadian and ultradian release.

22 healthy volunteers underwent dexamethasone suppression (total daily dose 2 mg). Subjects received hydrocortisone subcutaneously as two individual pulses of secretion as a high, medium or low sized dose via a portable subcutaneous infusion pump (Cane Crono P infusion pump). Blood samples for cortisol were taken every 10 minutes and hourly for ACTH (to confirm adequate endogenous adrenal suppression) via a human automated blood sampling system (HABS)[3] for 7 hours. Dose size and frequency was adjusted to obtain physiological blood levels of cortisol.

In a further pilot study we administered dexamethasone (total daily dose 4mg) to inhibit endogenous HPA activity and infused hydrocortisone subcutaneously via the infusion pump at a total daily dose of 20mg; 8 pulses (3 high, 3 medium and 2 low). Blood samples for cortisol were taken every 10 minutes and hourly for ACTH via the HABS for 24 hours. This resulted in a circadian cortisol peak of ≥500nmol/L and trough of ≤100nmol/L with a definitive “on/off” period between individual pulses of secretion.

These data show it is possible to provide physiological circadian and ultradian cortisol replacement in man via a simple subcutaneous regimen.

 

Nothing to Disclose: GMR, CD, AA, CP, RB, KJB, WW, SLL

OR48-1 11251 1.0000 A Pulsed Glucocorticoid Replacement Therapy – a Novel Treatment Modality 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Tuesday, June 24th 11:00:00 AM OR48 4744 9:30:00 AM Novel Aspects of the HPA Axis: Bench to Smartphone Oral

Joel R L Ehrenkranz*1, Randall Polson2 and Theodure Espiritu2
1Intermountain Healthcare, Murray, UT, 2University of Utah, Salt Lake City, UT

 

Measuring salivary cortisol by laboratory immunoassay or mass spectroscopy requires instrumentation and technical personnel and is unable to deliver timely results. We have developed a smartphone-based quantitative salivary cortisol immunoassay that provides results in 5 minutes and can be performed at the point of care.

Disposable cortisol immunoassay strips consisted of nitrocellulose membranes to which cortisol-BSA conjugate (test line) and goat anti-mouse IgG antibody (control line) were attached.  A glass fiber element containing colloidal gold labeled murine anti-cortisol antibodies and a saliva collection pad were inserted at the proximal end of the nitrocellulose membrane and a wicking sump placed at the membrane’s distal end. These tests, read by a spectrophotometer, were able to detect cortisol in PBS in 0.1 mcg/ml increments between 0.1-30 mcg/ml.  Samples of artificial saliva containing cortisol in concentrations between 0.012 and 3.0 mcg/dl were deposited on the strip’s saliva collection pad.  The assay strip was then inserted into a reader that aligned a collimating lens and light diffuser with a smartphone’s camera and flash and the strip was imaged 5 minutes after specimen addition. Because gold nanoparticles with a diameter of 70-100 nm have a plasmon surface resonance peak around 600 nm, a smartphone flash can illuminate and camera image the color generated by colloidal gold labeled anti-cortisol antibodies.  A smartphone image analysis app identified the control and test lines on the assay strip and quantified the pixel density of the green color channel of the test line image.  An algorithm derived by fitting an exponential curve to a graph of observed versus reference salivary cortisol values converted the pixel density of the green color channel of the test line image to a cortisol value. The R value of this curve was 0.996 for salivary cortisol in the range of 0.012-3.0 mcg/dl.

This smartphone-based immunochromatographic quantitative salivary cortisol technology can measure cortisol with a detection limit and dynamic range sufficient to diagnose adrenal insufficiency, hypercortisolism, and monitor physiologic variations in cortisol concentration.  Measuring salivary cortisol at the point-of-care in 5 minutes using an inexpensive immunochromatographic assay, reader, and smartphone may obviate the need to presumptively treat patients for adrenal insufficiency and makes cortisol assays available to regions of the world which currently lack access to this diagnostic test.

 

Nothing to Disclose: JRLE, RP, TE

OR48-2 11289 2.0000 A Point-of-Care Salivary Cortisol Immunoassay Using a Smartphone 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Tuesday, June 24th 11:00:00 AM OR48 4744 9:30:00 AM Novel Aspects of the HPA Axis: Bench to Smartphone Oral

Anna Papadopoulou1, Thomas Siamatras*1, Raul Delgado-Morales2, Niranjana D. Amin3, Varsha Shukla3, Harish C. Pant3, Osborne F X Almeida2 and Tomoshige Kino4
1Program in Reproductive and Adult Endocrinology, NICHD/NIH, Bethesda, MD, 2Max Planck Institute of Psychiatry, Munich, Germany, 3National Institute of Neurological Disorders and Stroke, Bethesda, MD, 4NICHD/NIH, Bethesda, MD

 

Glucocorticoids have major actions in the brain, affecting cognition, mood, behavior and memory through the glucocorticoid receptor (GR), and play significant roles in pathophysiology of major depression. We previously reported that the neuronal cyclin-dependent kinase 5 (CDK5), essential for nervous system development, function, survival and pathogenesis of neurodegenerative disorders, modulates GR-induced transcriptional activity by phosphorylating multiple serine residues located in the N-terminal domain of this receptor (Kino T et al. Mol Endocrinol 21: 1552, 2007). To examine potential contribution of CDK5, GR and their interactions to stress response and pathophysiology of major depression, we measured enzymatic activity and protein expression of CDK5, phosphorylation of GR [at serine 211 (human) and 220 (mouse)] and mRNA expression of glucocorticoid-responsive and/or stress response-related genes in the prefrontal cortex (PFC) and hippocampus (Hippo) of female mice after intraperitoneal injection of corticosterone (20 mg/kg, n=3, at 1, 3 and 24 hours after injection), acute (restraint stress for 15 min, n=3, at 1, 3 and 24 hours after exposure) or chronic unpredictable (maternal separation for 30 days, n=3) stress, and those with veihcle injection or no stress exposure. We also measured these parameters in postmortem brain hippocampi from patients with major depression or control subjects (n=4, for each group). CDK5 activity and protein expression were reduced by 20% and 80% respectively, in PFC from 1hr-stressed mice, while they were upregulated by 30%, and 800% respectively, in Hippo of 3hr-stressed mice. Similar changes were observed in mice injected with corticosterone, suggesting that the activated glucocorticoid signaling system by acute stress is responsible for the observed changes in these CDK5 parameters. Levels of GR phosphorylation increased both in PFC (by 300%) and in Hippo (210%) after 1 hr-exposure of animals with acute stress or corticosterone injection, suggesting that other unknown kinase(s) distinct from CDK5 phosphorylated GR in response to these stimuli. Chronically stressed mice showed increaed CDK5 activity in PFC (by 80%) and Hippo (45%) and elevated protein levels in these brain regions (by 360% and 245%, respectively), indicating involvement of additional mechanism(s) compared to acute stress and corticosterone injection. These two CDK5 parameters were upregulated (by 16 and 1,050%, respectively) in Hippo of patients with major depression compared to control subjects, while levels of GR phosphorylation were similar in both groups. Taken together, these results suggest that acute and chronic stress differentially regulate the CDK5 activity/expression in a brain region-specific fashion, which may further contribute to pathophysiology of major depression.

 

Nothing to Disclose: AP, TS, RD, NDA, VS, HCP, OFXA, TK

OR48-3 12645 3.0000 A Acute and Chronic Stress Differentially Regulate Enzymatic Activity and Protein Expression of the Cyclin-Dependent Kinase 5 (CDK5) in Mouse Brain Partly through Modulation of the Glucocorticoid Signaling Pathway: Implication to Major Depression 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Tuesday, June 24th 11:00:00 AM OR48 4744 9:30:00 AM Novel Aspects of the HPA Axis: Bench to Smartphone Oral

Maria Elisa Mercau*1, Esteban Martin Repetto2, Matías Nicolás Perez3, Camila Martinez Calejman3, Rocio Sanchez3, Juan Manuel Olejarczyk3, Carla V Finkielstein4 and Cora Beatriz Cymeryng1
1Universidad de Buenos Aires, Facultad de Medicina; CEFYBO-CONICET, Buenos Aires, Argentina, 2Universidad de Buenos Aires; CEFYBO-CONICET, Buenos Aires, Argentina, 3School of Medicine, University of Buenos Aires; CEFYBO-CONICET, 4School of Sciences, Virginia Polytechnic Institute and State University, Blacksburg, VA

 

The goal of this study was to evaluate the alterations caused by a sucrose rich diet (SRD) on the hypothalamic-pituitary-adrenal (HPA) axis of male Wistar rats, and the therapeutic effect of a moderate exercise (E) protocol in animals with an insulin-resistant (IR) phenotype. The protocol was implemented at different stages of the treatment, in order to analyze whether the effect of the SRD could be prevented and/or reversed by E. Rats were randomized into 6 groups (n=5): Control and SRD-fed sedentary rats (C-S, SRD-S), C and SRD-fed rats that exercised daily since week 1 (C-E, SRD-E), C and SRD-fed animals that exercised daily since IR was confirmed (C-R, SRD-R). The treatments were carried out for 15 weeks. On week 7, Insulin Tolerance Test (ITT) was performed to confirm the IR state of SRD fed animals. Statistical significance was analyzed by ANOVA followed by Tukey's post hoc test.

First, we analyzed the effect of the SRD in the sedentary group. Serum metabolites such as fasting glucose (p<0.01), triglycerides (p<0.01) and total cholesterol levels (p<0.05), as well as the weight of the retroperitoneal fat depot (p<0.01), were increased in SRD-S animals by the end of the 15th week of treatment, as compared to C-S animals. Interestingly, only the increase in total cholesterol levels was prevented in the SRD-E group, and was reversed in the SRD-R group.

The DRS-S group showed significantly lower levels of plasma ACTH (p<0.05), decreased expression of POMC mRNA (p<0.05) in the pituitary, and lower serum corticosterone levels (p<0.01) vs.the C-S group. Analysis of the pituitary expression of antioxidant enzymes (e.g. heme-oxygenase 1 and catalase), ER stress markers (e.g. GRP78 mRNA) and autophagy markers (e.g. p62 and LC-3 II), suggest an activation of these cellular pathways in the SRD-S group. Interestingly, autophagy in  does not appear to be activated in the pituitary gland of SRD-E and SRD-R groups.

In summary, the administration of a sucrose-rich diet has a significant impact on pituitary function and ACTH production. Our results showed increase in antioxidant enzymes expression, and ER stress and autophagy markers in the pituitary gland. Given that exercise restores the functionality of the gland, and also the activation of these cellular pathways, we propose a role for autophagy and ER stress in the sucrose-induced pituitary dysfunction.

 

Nothing to Disclose: MEM, EMR, MNP, CM, RS, JMO, CVF, CBC

OR48-4 16148 4.0000 A Endoplasmic Reticulum Stress and Autophagy Contribute to the Functional Remodeling of the Anterior Pituitary Gland in Diet-Induced Insulin Resistance 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Tuesday, June 24th 11:00:00 AM OR48 4744 9:30:00 AM Novel Aspects of the HPA Axis: Bench to Smartphone Oral

Heather A Halem*1, Maria Ufret2, Nicholas Prairie1, Jeremy Beech2, Lauren Clive2, Yeelana Shen2, Richard Nelson1, Sonia Bernetiere2 and Michael D Culler1
1Ipsen, Milford, MA, 2Ipsen Bioscience, Inc., Cambridge, MA

 

Cushing’s disease (CD) is caused by chronically elevated circulating levels of cortisol due to over-stimulation of the adrenal gland by excess adrenocorticotropin (ACTH) secreted from a pituitary corticotroph tumor. The high level of cortisol produces significant changes in both the appearance and the physiology of these patients, leading to significant morbidity, and, potentially, mortality. CD is primarily treated by transsphenoidal surgery; however, in a significant number of cases, surgery is unsuccessful, or the condition reoccurs. As a result, there remains a significant need for safe and effective medical therapies to normalize cortisol in CD patients. One approach is to block the receptor mediating the ACTH stimulation of cortisol secretion, the melanocortin-2 (MC2) receptor. We have discovered several peptides that act as antagonists of ACTH at the hMC2 receptor. These peptides are able to inhibit binding of 125I-ACTH 1-24 to the MC2 receptor in a competitive, dose-related manner with IC50s ranging from 10-30nM.  In HEK293 cells co-expressing both hMC2 and the melanocortin 2 receptor accessory protein (MRAP), these antagonist peptides are able to inhibit ACTH (1nM)-stimulated  cAMP production in a dose-related manner with IC50s ranging from 15-40nM. Because of the high degree of variability in corticosterone secretion in vivo due to circadian rhythm, stress, and glycemic status, normal rats are difficult to use as a model system for studying antagonism of MC2. We have, therefore, adopted a model in which ACTH-containing osmotic minipumps are implanted in hypophysectomised rats to induce and maintain a constant level of circulating corticosterone. This protocol allows us to examine the efficacy of our antagonists in preventing ACTH from activating the MC2 receptor in vivo, and to observe the resultant reduction in circulating corticosterone levels. Using this model we are able to observe significant dose and time-related reductions in circulating corticosterone after treatment with our MC2 antagonists.  In summary, we have produced peptidic compounds that prevent ACTH from binding to and activating the MC2 receptor, and that can suppress ACTH-stimulated corticosterone levels in vivo.  These novel peptide antagonists of the MC2 receptor may potentially lead to useful therapies for normalizing cortisol secretion in CD patients.

 

Disclosure: HAH: Employee, Ipsen. MU: Employee, Ipsen. NP: Employee, Ipsen. JB: Employee, Ipsen. LC: Employee, Ipsen. YS: Employee, Ipsen. RN: Employee, Ipsen. SB: Employee, Ipsen. MDC: Employee, Ipsen.

OR48-5 16262 5.0000 A Novel, Selective, Peptide MC2 Receptor Antagonists As a Potential Treatment for Cushing's Disease 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Tuesday, June 24th 11:00:00 AM OR48 4744 9:30:00 AM Novel Aspects of the HPA Axis: Bench to Smartphone Oral

Qiong Deng* and Greti Aguilera
National Institute of Child Health and Human Development, Bethesda, MD

 

A major target of glucocorticoid feedback for HPA axis activity is inhibition of pituitary ACTH secretion proopiomelanocortin (POMC) transcription. While transcriptional repression is mediated by genomic actions of glucocorticoid receptors (GR), rapid inhibition of ACTH secretion may involve non-genomic effects. This hypothesis was tested in rat anterior pituitary cells cultured in microcarrier beads under continuous perifusion with corticotrophin releasing hormone (CRH), at concentrations in the range of basal levels in pituitary portal circulation, and 30min pulses of the natural glucocorticoid, corticosterone.  ACTH immunoassay in 5-min fractions showed rapid and sustained increases in ACTH secretion under continuous exposure to low concentrations of CRH (30pM).  Corticosterone pulses (30min) inhibited ACTH secretion depending on the duration of glucocorticoid deprivation preceding the experiment and pulse-dose.  After 2h preincubation in serum/glucocorticoid-free medium, stress corticosterone levels (1µM) but not lower concentrations caused prolonged inhibition of CRH-stimulated ACTH secretion with a 20 min lag period.  In contrast, after glucocorticoid deprivation for 6h, low corticosterone pulses (10nM) inhibited CRH-stimulated ACTH secretion within 5 min, returning to stimulated levels 10min after corticosterone pulse termination.  In contrast to POMC transcriptional responses, rapid inhibition of ACTH secretion by corticosterone was unaffected by actinomycin D.  In the hypothalamic cell line 4B, western blots showed a ligand-dependent association of GR to membrane fractions, which was evident with nM but not stress corticosterone levels.  CRH caused rapid phosphorylation of Src, an effect which was prevented by 10 nM corticosterone. Consistent with a role of Src mediating rapid glucocorticoid effects on ACTH secretion, Src inhibitors decreased CRH-stimulated ACTH secretion, without affecting POMC transcription. The data suggest that membrane association of the classical GR mediates rapid pituitary glucocorticoid feedback through mechanisms involving inhibition of CRH-induced Src phosphorylation. The high sensitivity and rapid responsiveness of ACTH secretion to glucocorticoid inhibition supports the hypothesis that rapid glucocorticoid feedback at the pituitary corticotroph is part of the mechanism of ultradian pulse generation.

 

Nothing to Disclose: QD, GA

OR48-6 16834 6.0000 A Rapid Glucocorticoid Feedback Inhibition of ACTH Secretion Involves Ligand-Dependent Membrane Association of Glucocorticoid Receptors and Inhibition of Src Phosphorylation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Neuroendocrinology and Pituitary Tuesday, June 24th 11:00:00 AM OR48 4744 9:30:00 AM Novel Aspects of the HPA Axis: Bench to Smartphone Oral

Wen Yang Hu*1, Shyama Majumdar1, Dan Ping Hu1, Guang Bin Shi1, Timothy Gauntner1, Susan Kasper2 and Gail S. Prins1
1University of Illinois at Chicago, Chicago, IL, 2University of Cincinnati, Cincinnati, OH

 

The roles of ERα and ERβ in prostate development and carcinogenesis are not well delineated. We previously demonstrated that human prostate epithelial stem-progenitor cells express ERα and ERβ and that estradiol-17β (E2) augments their numbers, implicating them as direct estrogen targets1. The present studies sought to elucidate specific roles for ERα and ERβ in the human prostate stem-progenitor cell populations. Primary prostate epithelial cells (PrEC) of young, disease-free donors were utilized and stem-progenitor cells isolated using FACS and 3-D prostasphere (PS) culture. Triple channel-FACS (TROP2+/CD49fhi/ERα or ERβ) of PS cells and western blots confirmed stem and progenitor cells as both ERα+ and ERβ+. Further, BrdU labeling documented that E2 significantly (P<0.001) increased their proliferation.  While PrEC culture in 10 nM E2 for 72 hr doubled (P<0.05) the FACS stem-like cell side population, E2+MPP (ERα antagonist) reduced stem-like cell numbers 4-fold (P<0.01) whereas E2+PHTPP (ERβ antagonist) increased them 8-fold (P<0.05).  Similarly, siRNA for ERα in PrEC cells decreased E2-stimulated FACS stem-like cells 4-fold (P<0.05) and inhibited PS formation in 3-D culture whereas ERβ siRNA in PrEC doubled (P<0.05) E2 stimulated stem-like cells. Together these findings suggest that ERα stimulates whereas ERβ reduces stem-like cell self-renew. Although ERβ siRNA did not influence ERα mRNA levels, ERα siRNA doubled (P<0.01) ERβ expression in the stem-like cells in a ligand-independent manner suggesting a suppressive role of ERα on ERβ action. To assess an ER-selective role in stem cell apoptosis, PS were exposed to E2 or 8 separate ER selective agonists or antagonists followed by FACS analysis with Annexin V-PI labeling. No evidence was found for ER-mediated early or late apoptosis of stem-progenitor cells, a result confirmed by TUNEL. Using the PS assay, continued culture in basal medium for up to 30 days showed a direct correlation between increased ERβ expression and induction of luminal cell gene expression. To further evaluate a role for ERβ in stem cell differentiation, a spontaneously immortalized human prostate cancer stem-like cell line, HuSLC, identified as ERα-/ERβ+, was cultured +/- 1nM  E2 for 1-24 hr. A rapid decline in stem cell genes (NANOG, SOX2, OCT 4) was initiated by E2 with maximal suppression at 6 hr followed by induction of differentiation-associated genes (NKX3.1, SOX9) at 12-24 hr. In total, the present findings identify distinct roles for ERs in human prostate stem-like cells with ERα driving self-renewal and ERβ promoting entry into a differentiation pathway. We propose that a delicate balance between ERα and ERβ contributes to prostate stem cell niche homeostasis and that their dysregulation may play a role in prostate carcinogenesis and progression.

 

Nothing to Disclose: WYH, SM, DPH, GBS, TG, SK, GSP

OR51-1 13274 1.0000 A Distinct Actions of ERα and ERβ in Human Prostate Stem and Progenitor Cell Self-Renewal and Differentiation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Tuesday, June 24th 11:00:00 AM OR51 4746 9:30:00 AM Nuclear Receptors and Prostate Cancer Oral

Sari Toropainen*1, Marjo Malinen1, Tiina Jääskeläinen1, Sanna Kaikkonen1, Miia M Rytinki1, Biswajyoti Sahu2, Olli Jänne2, Merja Heinäniemi1 and Jorma Juhani Palvimo1
1University of Eastern Finland, Kuopio, Finland, 2University of Helsinki, Helsinki, Finland

 

Androgen receptor (AR) is a ligand-activated transcription factor that plays a central role in both normal prostate physiology and the development and growth of prostate carcinoma. AR activity is also regulated by post-translational modifications, such as SUMOylation (small ubiquitin-like modifier modification). SUMOylation has an impact on the AR's stability, intranuclear mobility, chromatin interactions and its target gene expression. PIAS1 is a SUMO E3 ligase that interacts with the AR and influences receptor activity in reporter gene assays, showing coregulator activity. In VCaP prostate cancer cells, PIAS1 is the major PIAS family member, and its expression is interestingly up-regulated by androgens. However, there is scarce information on the role PIAS1 in the regulation of endogenous AR target genes in prostate cancer cells. To study the importance of PIAS1 for the androgen-regulated transcriptome of VCaP prostate cancer cells, we silenced its expression by RNAi. Illumina BeadChip analyses of the transcriptomes from PIAS1-depleted cells vs. control cells revealed that ~10% of the AR-regulated genes are significantly influenced, either activated or repressed, by PIAS1 depletion. Furthermore, silencing of PIAS1 exposed a completely new set of genes to androgen regulation in VCaP cells, suggesting that PIAS1 can mask genes from AR access. Ingenuity Pathway Analysis (IPA) of the gene expression data further suggests that PIAS1 plays a role in the regulation of cellular growth and proliferation. In keeping with the role of PIAS1 in this cellular process, decreased PIAS1 levels attenuated VCaP cell proliferation. The IPA also predicted that the genes masked from androgen regulation by PIAS1 are linked to gene expression and protein synthesis functions. Genome-wide ChIP-seq analyses of VCaP cells showed that PIAS1 interacts with the AR also on chromatin; androgen exposure increased the number of PIAS1-occupying chromatin sites by four-fold, resulting in >95% overlap with AR chromatin binding events. Interestingly, >90% of the PIAS1 cistrome also overlapped with that of FOXA1. Taken together, these results strongly suggest that PIAS1 functions as a genuine and chromatin-bound coregulator of AR in prostate cancer cells.

 

Nothing to Disclose: ST, MM, TJ, SK, MMR, BS, OJ, MH, JJP

OR51-2 13759 2.0000 A PIAS1 Functions As a Target Gene and Pathway Selective Androgen Receptor Coregulator in Prostate Cancer Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Tuesday, June 24th 11:00:00 AM OR51 4746 9:30:00 AM Nuclear Receptors and Prostate Cancer Oral

Shih-Chieh Lin, PhD*1, Sophia Y Tsai2 and Ming-Jer Tsai3
1Baylor College of Medicine, Houston, 2Baylor College of Medicine, Houston, TX, 3Baylor Coll of Med, Houston, TX

 

Prostate cancer is the most common male malignancy in the United States. Although early detection and treatment of localized prostate cancer (PCa) improve outcomes, many men still die because of metastatic PCa. Previously, we have found that COUP transcription factor II (COUP-TFII) is overexpressed in the primary prostate cancer specimens. The increased expression of COUP-TFII enhances the tumor growth. Moreover, we also found that COUP-TFII levels increased even further in the metastatic PCa. This further increase enables the indolent tumor to break the TGF-ƒ"1-induced growth barrier enacted in the early development of prostate cancer. However, the role of COUP-TFII in the tumor growth and the underlying mechanism causing COUP-TFII overexpression remain largely undefined. Here, we found that several microRNAs can target to COUP-TFII 3’ untranslated region (3’UTR) through bioinformatics analysis. Interestingly, the levels of those microRNAs including miR-101, miR-27a, miR-27b and miR-365 were decreased in the prostate cancer specimens and further decreased in the metastatic PCa. We showed these microRNAs negatively regulate COUP-TFII protein expression. Functional analysis demonstrated that inhibition of miR-101-induced prostate cancer cell migration and invasion were mediated by COUP-TFII. Finally, we also identified that COUP-TFII positively regulated the levels of miR-21, a critical oncomiR overexpressed in prostate cancer. In conclusion, our data demonstrates that microRNA and COUP-TFII play an indispensable role in the development of metastatic PCa.

 

Nothing to Disclose: SCL, SYT, MJT

OR51-3 14330 3.0000 A A Reciprocal Regulation of microRNA and Coup-Tfii Promotes Prostate Cancer Growth and Metastasis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Tuesday, June 24th 11:00:00 AM OR51 4746 9:30:00 AM Nuclear Receptors and Prostate Cancer Oral

Thomas Ullrich1, Sanjita Sasmal2, Chetan Pandit2, Sven Weiler1, Sujatha Rajagopalan2, Dhanya Shashikumar2, Shekar Chelur2, Chikwendu Ibebunjo3, Paulo G Santos4, Bharat Lagu3, Mark Perrone3, Mark Bock3 and Hansjoerg Keller*1
1Novartis Institutes for BioMedical Research (NIBR), Basel, Switzerland, 2Aurigene Discovery Technologies Ltd., Bangalore, India, 3NIBR, Cambridge, MA, 4Novartis Pharma, Basel, Switzerland

 

Drug discovery efforts have identified selective androgen receptor modulators (SARMs) that, similar to steroidal androgens, exert strong anabolic effects on skeletal muscle and bone, but with minimal androgenic effects in tissues such as prostate. To date, only oral SARMs have been developed whose efficacies in the clinic are critically limited by adverse events including induction of liver enzymes such as alanine aminotransferase (ALT) and lowering of high density lipoprotein (HDL). To overcome these drawbacks we developed SARMs for transdermal administration as mostly used in testosterone (T) therapy. A 3-alkoxy-pyrrolo[1,2-b]pyrazoline compound termed AUSRM-057 was identified that bound to human androgen receptor (AR) with a Ki of 0.45 nM with great selectivity over other nuclear receptors such as progesterone, glucocorticoid and estrogen receptor alpha. AUSRM-057 potently activated AR in a C2C12 muscle cell reporter gene assay with an EC50 of 0.5 nM and induced hypertrophy in human myotubes with a comparable EC50 of 0.2 nM. AUSRM-057 showed good aqueous solubility of 1.3 g/L at pH7.4 and in silico predictions as well as a skin parallel artificial membrane permeability assay (PAMPA) indicated good skin penetration. Indeed, when measuring human skin permeation in vitro an excellent flux of 2.8 µg/cm2/h was determined without any permeation enhancers. In a short single subcutaneous (s.c.) injection 24h biomarker in vivo assay in castrated rats, it reduced more potently the atrophy marker gene MAFbx and induced more potently the hypertrophy marker gene IGF1 in levator ani (LA) muscle than T. Furthermore, it only partially induced the prostate marker gene probasin compared to T. In a two week Hershberger assay using castrated rats AUSRM-057 showed dose-dependent effects fully restoring LA weight at 0.3 mg/kg/day s.c. with high selectivity over prostate stimulation. Next, AUSRM-057 was assessed in young growing pubertal rats where two week treatment selectively stimulated LA over prostate at 1 mg/kg/day. Finally, AUSRM-057 restored LA muscle weight and significantly increased triceps brachii and quadriceps muscle weights compared to vehicle treated animals without significant stimulation of prostate weight in voluntary running adult castrated mice following 2 week s.c. administration of 1 mg/kg/day. In conclusion, we have identified a novel highly potent SARM AUSRM-057 that exerts selective anabolic action on skeletal muscle tissues over androgenic prostate tissues and easily penetrates human skin. Thus, AUSRM-057 holds promise as a novel transdermal SARM for the treatment of various muscle wasting disorders avoiding important limitations of oral SARMs.

 

Disclosure: TU: Employee, Novartis Pharmaceuticals. SS: Employee, Aurigene. CP: Employee, Aurigene. SW: Employee, Novartis Pharmaceuticals. SR: Employee, Aurigene. DS: Employee, Aurigene. SC: Employee, Aurigene. CI: Employee, Novartis Pharmaceuticals. PGS: Employee, Novartis Pharmaceuticals. BL: Employee, Novartis Pharmaceuticals. MP: Employee, Novartis Pharmaceuticals. MB: Employee, Novartis Pharmaceuticals. HK: Employee, Novartis Pharmaceuticals.

OR51-4 14626 4.0000 A Ausrm-057 - a Novel Selective Androgen Receptor Modulator (SARM) for Transdermal Administration 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Tuesday, June 24th 11:00:00 AM OR51 4746 9:30:00 AM Nuclear Receptors and Prostate Cancer Oral

Mary Szatkowski Ozers*, Matthew J Rodesch and Christopher L Warren
Proteovista LLC, Madison, WI

 

A critical unmet need in implementing personalized medicine is the ability to sort through the millions of single nucleotide polymorphisms (SNPs) present in the human genome and to pinpoint which of these DNA variations are causative in disease. A key under-studied function of SNPs is their ability to generate or disrupt genomic binding sites for transcription factors involved in cancer. Toward this goal, we developed the SNP-SNAP (Specificity and Affinity for Proteins) microarray as a prototype high-throughput device to evaluate SNP function in prostate cancer. Each probe on the SNP-SNAP array was displayed as double-stranded DNA matching a 25 base pair (bp) region of the genome containing a SNP allele. The SNP-SNAP arrays contained approximately 400,000 DNA probes representing over 175,000 SNPs from genomic regions that were identified from genome wide association studies (GWAS) of prostate cancer and spanned 2.5 Mbp of the genome. The SNPs on the array included allelic variations that demonstrated a strong statistical association with prostate cancer and/or were predicted to affect the binding site for key transcription factors involved in prostate cancer. We evaluated the binding of p53, NFKB, ERG, and androgen receptor (AR) to the SNPs on the array and detected several SNPs that modulated the binding affinity and specificity of these transcription factors. These SNPs were analyzed to identify nearby genes, minor allele frequencies (MAFs), distance to and linkage disequilibrium with their corresponding GWAS SNPs, localization within peaks defined by previously published ChIP-Seq data, and other parameters. The high content data from the SNP-SNAP arrays was displayed using SNP-Sequence Specificity Landscapes, creating a prostate cancer “molecular signature” that relates transcription factor binding, SNP preferences, and chromosomal position of the nearest genes. Functional SNPs which differentially bound transcription factors on the SNP-SNAP array are being analyzed in an independent patient population for statistical association with prostate cancer incidence.

 

Disclosure: MSO: Founder, Proteovista LLC. MJR: Employee, Proteovista LLC. CLW: Founder, Proteovista LLC.

OR51-5 15306 5.0000 A SNP-SNAP Binding Arrays Reveal SNPs That Modulate Transcription Factor Interactions in Prostate Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Tuesday, June 24th 11:00:00 AM OR51 4746 9:30:00 AM Nuclear Receptors and Prostate Cancer Oral

Huy Q Ta*1, Melissa L Ivey1, Henry F Frierson, Jr2, Mark R Conaway2, Jaroslaw Dziegielewski2, James M Larner2 and Daniel Gioeli3
1University of Virginia, Charlottesville, VA, 2University of Virginia, 3Univeristy of Virginia, Charlottesville, VA

 

Prostate cancer (PCa) is the second leading cause of cancer deaths in American men. While almost all patients with disseminated PCa initially respond to androgen deprivation therapy (ADT), virtually every patient will relapse due to the development of metastatic and incurable castration-resistant prostate cancer (CRPC). A high-throughput RNAi screen to identify signaling pathways that regulate PCa cell growth led to our discovery that Checkpoint Kinase 2 (CHK2) knockdown dramatically increased PCa growth and hypersensitized cells to low levels of androgen. These effects of CHK2 knockdown were dependent on the downstream signaling proteins CDC25C and CDK1. Immunohistochemistry analysis of CHK2 expression in patient samples demonstrated a decrease in high-grade tumors indicative of the clinical relevance of CHK2 in PCa. Moreover, CHK2 expression is lower in castration-resistant C4-2 and CWR22Rv1 cells compared to androgen-sensitive LNCaP cells suggesting that CHK2 expression is lost during progression to castration-resistance. CHK2 depletion increased androgen receptor (AR) transcriptional activity on both androgen-activated and androgen-repressed genes, providing evidence that CHK2 affects PCa proliferation, at least in part, through the AR. Interestingly, we found that CHK2 is a novel AR-repressed gene indicating that the AR and CHK2 are part of a negative feedback loop. We show that (1) CHK2 associates with the AR by co-immunoprecipitation; (2) this association increases with DNA damage; and (3) the absence of CHK2 prolongs H2AX phosphorylation induced by ionizing radiation under androgen starvation. Based on these data, we suggest that CHK2 is a negative regulator of androgen sensitivity and PCa growth. Moreover, our data raise the intriguing possibility that CHK2 may collaborate with the AR in responding to DNA damage. Thus, perturbation of CHK2 signaling may sensitize CRPC to ADT and radiation.

 

Nothing to Disclose: HQT, MLI, HFF, MRC, JD, JML, DG

OR51-6 17052 6.0000 A Checkpoint Kinase 2 (CHK2) Is a Novel Regulator of Prostate Cancer Cell Growth 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Nuclear Receptors and Steroid Hormone Action Tuesday, June 24th 11:00:00 AM OR51 4746 9:30:00 AM Nuclear Receptors and Prostate Cancer Oral

Liora S Katz*1, Elizabeth Geras-Raaka1 and Marvin C Gershengorn2
1NIH/NIDDK, Bethesda, MD, 2NIDDK NIH, Bethesda, MD

 

Individual cells from freshly isolated white adipose tissue (WAT) exhibit variable levels of fat accumulation.  To explore causative factors of this variation, primary WATs from adult mice were labeled with BODIPY lipid probe, a marker for fat accumulation in live cells, and sorted by a fluorescence-activated cell-sorter into two populations according to BODIPY content. After at least 7 weeks of proliferation as de-differentiated cells in culture in growth media and numerous passages, cells were induced to re-differentiate into adipocytes. We show that the cells that were initially sorted to have low or high BODIPY contents maintained a similar phenotype after re-differentiation. TSH receptor expression on the cell surface correlated with BODIPY staining in all states. mRNA levels of Pparγ, key regulator of adipogenesis, leptin and Tshr, known to increase when preadipocytes are differentiated, correlated with the levels of fat accumulation.  To elucidate the molecular details of heritability and show that these findings were not unique to primary WATs, we studied the mouse 3T3-L1 cell-line of pre-adipocytes. BODIPY staining and mRNA levels for adipogenic markers were similarly inherited.  3T3-L1 cells infected with a Pparγ expressing lentivirus accumulated more fat. Chromatin immunoprecipitation of histone H3 acetylation on the Pparγ promoter reveals more acetylation in preadipocytes and adipocytes in the high than in the low BODIPY-derived populations. We conclude that epigenetic modification on the Pparγ promoter accounts partially for the heritability of WAT fat accumulation.

 

Nothing to Disclose: LSK, EG, MCG

OR46-1 11812 1.0000 A Heritability of Fat Accumulation in White Adipocytes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Tuesday, June 24th 11:00:00 AM OR46 4748 9:30:00 AM Intrinsic and Extrinsic Variations in Adipose Tissue Function Oral

Simon Nitter Dankel*1, Alfred Ramirez1, Ruidan Xue1, Kevin Yu-sun Lee1, Thomas Thomou1, Simon Kasif2, Yu-Hua Tseng1 and C. Kahn3
1Joslin Diabetes Center, Harvard Medical School, Boston, MA, 2Boston University, 3Section on Integrative Physiology and Metabolism, Joslin Diabetes Center and Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA

 

Adipocytes play a crucial role in the regulation of energy homeostasis, and altered adipocyte function contributes to development of diseases such as type 2 diabetes. Visceral adiposity associates with increased risk of metabolic disease, whereas preferential fat storage in subcutaneous depots may be protective. While some of these depot-specific effects may arise from mixtures of brown/beige adipocytes in white fat depots, we hypothesized that the depot-specific effects may be the results of different “types” of white adipocytes within each depot.  To  explore the potential heterogeneity of white adipocytes, we isolated single cell preadipocyte clones from subcutaneous fat of four human subjects, and prepared hTERT-immortalized clonal cell lines for functional characterization (n=12 per subject, total = 48 clones). These clones showed a broad range of differentiation potentials measured by PPARG2 mRNA and metabolic activity measured by oxygen consumption rates, consistent with heterogeneity of this population. To identify distinct preadipocyte subtypes, we compared gene expression profiles by RNA-seq. Principal component analysis (PCA) revealed a clustering of clones in at least two subgroups. Comparison of differential gene expression showed an enrichment of genes related to proteolysis in one group and oxidative phosphorylation in another. Moreover, to explore if preadipocyte gene expression can predict adipogenic potential, we correlated the RNA-seq gene expression data with PPARG2 mRNA levels in fully differentiated adipocytes. Positively correlated genes were related to carbohydrate metabolic processes, and negatively correlated genes to angiogenesis and cell adhesion. In summary, we could distinguish between preadipocyte subtypes in white adipose tissue based on gene expression profiling. These subtypes show different adipogenic potentials and may give rise to adipocytes with different metabolic functions. Our data provide new molecular insight into the heterogeneity of white preadipocytes and adipocytes.

 

Nothing to Disclose: SND, AR, RX, KYSL, TT, SK, YHT, CK

OR46-2 17067 2.0000 A Preadipocyte and Adipocyte Heterogeneity within a Single White Fat Depot in Humans 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Tuesday, June 24th 11:00:00 AM OR46 4748 9:30:00 AM Intrinsic and Extrinsic Variations in Adipose Tissue Function Oral

Vincenzo Marzolla*1, Andrea Armani1, Alessandra Feraco1, Francesca Cinti2, Carmelo Quarta3, Uberto Pagotto4, Saverio Cinti2, Giuseppe Rosano1, Andrea Fabbri5, Morag Jennifer Young6 and Massimiliano Caprio1
1IRCCS San Raffaele Pisana, Rome, Italy, 2University of Ancona, 3University of Bologna, Bologna, Italy, 4Alma Mater University of Bologna S.Orsola Hospital, Bologna, Italy, 5University Tor Vergata, Rome, Italy, 6Hudson Instittue of Medical Research, Clayton VIC, Australia

 

The mineralocorticoid receptor (MR) plays a key role in adipocyte differentiation and function. We studied the effects of MR antagonists (spironolactone and drospirenone, 10-5M) in C57BL/6 mice fed a high fat diet (HFD) for 90 days. MR antagonism induced a marked up-regulation of brown adipocyte marker transcripts PRDM16, CIDEA, ADRB3, UCP1 and increased UCP1 protein levels in subcutaneous and abdomino-pelvic adipose depots. Also, MR antagonists induced “browning” of white fat depots, as demonstrated by histological analysis, UCP1 immunohistochemistry, and the marked increase in water content, which was detected by Magnetic Resonance Spectroscopy analysis. Moreover, PET/CT studies showed an increase in glucose uptake in fat depots where browning occurred. Importantly, MR antagonists curbed HFD-induced impairment in glucose tolerance, and prevented body weight gain and white fat expansion, which can be explained by the observed increase in thermogenic adipocytes in white adipose tissue (WAT). Autophagy is a key remodeling process in adipocyte differentiation. Murine models with adipose-specific deletion of genes involved in autophagy show resistance to HFD, demonstrating its potential role in this process in vivo. For such reason we studied the effects of MR antagonists on adipose tissue autophagy. MR blockade was able to reduce autophagic flux with a parallel increase of UCP1 protein levels in cultured primary inguinal preadipocytes. Accordingly, we found a marked decrease in autophagic rate with a parallel increase in UCP1 protein levels in WAT depots of mice treated with MR antagonists. Treatment of primary murine preadipocytes with an autophagy inhibitor (bafilomycin A1, 10-8M) led to a significant increase of UCP1 protein to levels equivalent to those detected for MR antagonists. Finally, we showed that treatment with everolimus (10-7M), an activator of autophagy, markedly reduced brown-like differentiation of primary inguinal preadipocytes, blunting the effects of MR antagonists on UCP-1 protein up-regulation. In conclusion, these findings indicate that pharmacological MR antagonism prevents the adverse metabolic consequences of HFD through a reduction of autophagy, which in turn promotes browning of WAT.

 

Nothing to Disclose: VM, AA, AF, FC, CQ, UP, SC, GR, AF, MJY, MC

OR46-3 13905 3.0000 A Mineralocorticoid Receptor Antagonism Promotes Brown-like Remodeling of Murine White Adipose Tissue Via Reduction of Autophagic Flux in Adipocytes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Tuesday, June 24th 11:00:00 AM OR46 4748 9:30:00 AM Intrinsic and Extrinsic Variations in Adipose Tissue Function Oral

Steven W Yau*, Vincenzo C Russo, George A Werther and Matthew A Sabin
Murdoch Childrens Research Institute, Parkville, Vic, Australia

 

Introduction: Subcutaneous (sc) and visceral (vis) adipocytes have molecular and functional differences, with increased vis adiposity predisposing to the metabolic syndrome(1). Insulin-like growth factor binding protein-2 (IGFBP-2) is the principal IGFBP produced by white adipocytes during adipogenesis. Circulating levels are reduced in obesity and, as overexpression of IGFBP-2 in transgenic mice prevents obesity(2), it may be integrally involved in the regulation of adipo/lipogenesis. Depot-specific effects of IGFBP-2 on adipo/lipogenesis are unknown. Furthermore, mechanisms by which IGFBP-2 influences adipo/lipogenesis are unclear but may involve IGF-independent metabolic actions via the Heparin Binding Domain (HBD)(3) and/or integrin binding domain.

Hypothesis/Aims: IGFBP-2 has depot-specific effects on adipo/lipogenesis. To investigate whether IGFBP-2 differentially affects adipo/lipogenesis in human sc and vis adipocytes and the mechanisms involved.

Methods: Human sc and vis preadipocytes were differentiated in vitro (without exogenous IGF-I) and treated as follows: A) IGFBP-2 (100ng/ml) introduced at day 0 of differentiation until days 4, 7 or 10; B) IGFBP-2 siRNA for 24h following differentiation, with ‘add-back’ of IGFBP-2 for a further 24h; C) Echistatin (disintegrin, 100nM) for 24h following differentiation, with subsequent IGFBP-2 treatment (24h); D) Wild-type (WT) or HBD-mutant IGFBP-2 (HBDmut: 100ng/ml) at day 0 of differentiation until day 7. Outcomes (n=4) included lipid staining (LipidTOX neutral red), gene expression of lipogenic markers by qPCR, phosphorylation of Focal Adhesion Kinase(y397) (pFAK) and PTEN protein level in cell lysates by Western immunoblotting.

Results: A) IGFBP-2 reduced final lipid content by 58% (p<0.01), 62% and 72% (p<0.001) in vis adipocytes at day 4, 7 and 10 respectively. No effect was seen in sc adipocytes. IGFBP-2 down-regulated PPARγ by 72%, C/EBPα by 48% and adiponectin expression by 91% (p<0.001) at day 10 in vis (but not sc) adipocytes. B) Silencing IGFBP-2 increased SREBP1c by 38% and FAS expression by 25% (p<0.05) and enhanced lipid content by 40% (p<0.01) in vis adipocytes only. Subsequent add-back of IGFBP-2 reduced SREBP1c and FAS expression (p<0.01), and reduced lipid content (p<0.05) in vis adipocytes. C) IGFBP-2 increased pFAK and decreased PTEN levels (p<0.01), an effect negated by prior Echistatin treatment. D) HBDmut increased pFAK (p<0.05) and reduced PTEN levels, adiponectin, SREBP1c and FAS expression (p<0.001), and lipid content (p<0.05), but with significantly reduced potency compared with WT IGFBP-2 (eg. lipid content 20% vs. 62% reduction, p<0.01).

Conclusion: IGFBP-2 inhibits adipo/lipogenesis in vis, but not sc, adipocytes. This appears to involve cell-surface association and activation of integrins. Specific domains of IGFBP-2 may therefore be novel targets for obesity prevention.

 

Nothing to Disclose: SWY, VCR, GAW, MAS

OR46-4 16544 4.0000 A Inhibition of Adipogenesis and Lipogenesis By IGFBP-2: A Depot-Specific Effect in Visceral Adipocytes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Tuesday, June 24th 11:00:00 AM OR46 4748 9:30:00 AM Intrinsic and Extrinsic Variations in Adipose Tissue Function Oral

Casey R Doucette*1, Erica L Scheller2, Mark C Horowitz3 and Clifford J Rosen1
1Maine Medical Center Research Institute, Scarborough, ME, 2Washington University, 3Yale University School of Medicine, New Haven, CT

 

C3H/HeJ (C3H) is an inbred mouse strain that evolved in a distinct lineage from the more common C57BL/6J (B6) strain. One of its unique features is very high bone mass relative to other inbred strains such as B6, despite similar body sizes. Recently, we noted that male C3H mice also have very high quantities of marrow adipose tissue (MAT) and have hypothesized that this MAT may play a role in regulating other cells within the marrow microenvironment. To test this hypothesis, we utilized methods of nutritional and environmental stress to determine whether MAT is an inert or dynamic tissue. First, 3-week-old B6 and C3H male mice were fed a 30% calorie restricted (CR) or control diet for 12 weeks. As a separate model of environmental stress and sympathetic nervous system (SNS) activation, male B6 and C3H mice were exposed to 4ºC or 22ºC for a period of 6 hours (acute) or 3 weeks (long-term). In our nutritional model, 30% CR led to significant decreases in BV/TV in both strains at 15 weeks of age (p<0.05), while marrow adiposity was markedly increased in B6 (p<0.05). Control C3H mice displayed significantly higher levels of Ucp-1 and Cidea gene expression in the marrow as compared to B6 (50- and 20-fold, respectively; p<0.05). Our environmental stress model demonstrated that acute cold exposure resulted in increased Ucp-1 and Pgc1α expression levels in the marrow compartment of C3H mice (p<0.05). These mice also showed increased RANKL and FGF-21 serum concentrations (p<0.05), indicating a negative effect of SNS activation on bone. In contrast, we found that long-term cold exposure had no effect on bone mass when compared to 22°C controls. In C3H mice, core body temperature (CBT) was significantly elevated after two days at 4ºC (p<0.05). After two weeks of cold exposure, CBT returned to baseline levels, suggesting that adaptive mechanisms could be affecting the regulation of temperature and may also counter the acute effects of SNS activation on bone. C3H mice exposed to long-term cold displayed markedly decreased MAT volume by osmium staining (p<0.05), while B6 MAT was increased. Along with their elevated Ucp-1 levels, these results suggest that C3H mice may be utilizing marrow fat as a source of thermogenesis. We conclude that: 1) MAT is dynamic and changes with environmental and nutritional stress 2) C3H has a genetic predisposition for brown-like adipogenesis in the bone marrow 3) in response to long-term cold, decreased MAT may indicate active thermogenesis within the marrow. Activation of SNS activity by acute cold exposure appears to have a negative effect on bone, but adaptive responses during long-term cold exposure, including activation of thermogenesis in the marrow, may prevent bone loss. While the optimal temperature for marrow is not currently known, the capacity of marrow adipocytes to generate heat may be a critical compensatory mechanism to ensure adequate function and bone remodeling within the marrow.

 

Disclosure: MCH: Collaborator, Merck & Co., Speaker, Amgen, Speaker Bureau Member, Ember Theraputics. Nothing to Disclose: CRD, ELS, CJR

OR46-5 16316 5.0000 A Marrow Fat Is a Dynamic Adipose Depot Responsive to Environmental and Nutritional Stress 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Tuesday, June 24th 11:00:00 AM OR46 4748 9:30:00 AM Intrinsic and Extrinsic Variations in Adipose Tissue Function Oral

Kathrin Landgraf1, Denise Rockstroh1, Isabel Wagner1, Sebastian Weise1, Julian Tristan Schwartze1, Magdalena Wojan2, Holger Till2, Wieland Kiess1, Matthias Blüher2 and Antje Körner*1
1University of Leipzig, Dept. of Women´s & Child Health, Leipzig, Germany, 2University of Leipzig, Leipzig, Germany

 

Accumulation of fat mass in the development of obesity may result from hypertrophy and/or hyperplasia and is associated with adipose tissue dysfunction. Considering the early onset of obesity at childhood age, we aimed to investigate alterations in adipose tissue biology with normal development and with obesity in children. For this, we performed a comprehensive experimental characterization of 171 adipose tissue samples from children and adolescents (aged 0 to 19 years) and assessed composition, function, lipolysis, and inflammation.

In normal lean children, the size (r=0.62) as well as the number (r=0.76) of adipocytes gradually increased with age. Beginning in early childhood, obese children had significantly enlarged adipocytes (by 17%) compared to lean children and adipocyte number was 2.6-fold increased. The proliferation rate of stromal vascular cells of obese children was enhanced, whereas the differentiation potential was not statistically significantly altered compared to lean children. These alterations in adipose tissue composition were accompanied by a significant decrease in basal lipolytic activity to about 60% in obese children. Furthermore, obese children had an increased degree of macrophage infiltration and formation of crown-like structures in adipose tissue, which correlated with age (r=0.23), BMI (r=0.35), and adipocyte size (r=0.41) in univariate analyses, but was largely determined by adipocyte size in multivariate analyses (R2=0.13).

In summary, we show adipocyte hypertrophy as well as hyperplasia, functional impairment and increased inflammation in adipose tissue in obese children and thereby provide evidence that obesity-associated adipose tissue dysfunction develops early in life.

 

Nothing to Disclose: KL, DR, IW, SW, JTS, MW, HT, WK, MB, AK

OR46-6 15735 6.0000 A Obesity in Children Is Associated with Early Alterations in Adipose Tissue Biology 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Tuesday, June 24th 11:00:00 AM OR46 4748 9:30:00 AM Intrinsic and Extrinsic Variations in Adipose Tissue Function Oral

Cristina García-Cáceres*1, Jae Geun Kim2, Yuanqing Gao1, Hong Wang3, Esther Fuente-Martin1, Beata Legutko1, Carola Meyer1, Paul T. Pfluger1, C. Kahn4, Christophe Magnan5, Serge Luquet5, Robert H. Eckel3, Flora M. Vaccarino6, Marya Shanabrough2, Chun-Xia Yi1, Tamas L. Horvath2 and Matthias H. Tschöp1
1Helmholtz Diabetes Center, Helmholtz Zentrum München & Division of Metabolic Diseases, Technische Universität München, Munich, Germany, 2Program in Integrative Cell Signaling and Neurobiology of Metabolism, Section of Comparative Medicine, Yale University School of Medicine, New Haven, CT 06520, USA, 3Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA, 4Section on Integrative Physiology and Metabolism, Joslin Diabetes Center and Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA, 5Unité Biologie fonctionnelle et adaptative, Université Paris Diderot-Paris 7, CNRS EAC 4413, 4, Rue Marie-Andrée-Lagroua-Weill-Hallé, bâtiment Buffon, case courrier 7126, 75205 Paris cedex 13, France, 6Child Study Center, Department of Neurobiology, and Kavli Institute for Neuroscience, Yale University, New Haven, CT 06520, USA

 

Neuronal circuits respond to afferent hormones such as leptin or insulin in order to maintain systemic energy homeostasis as well as balanced glucose- and lipid metabolism. The astrocyte as the predominant cell type of the brain, however, has been assumed to be less relevant for neuroendocrine regulation of body weight and blood sugar. Intrigued by the recent discovery(1) that high fat diet induced obesity causes hypothalamic astrogliosis, we investigated if afferent endocrine signaling through metabolically relevant hormones such as leptin or insulin may also target astrocytes to modulate systemic metabolism. We therefore crossed LepR-flox and InsR-flox mice with GFAP-creERT2 mice to generate inducible, and astrocyte specific, loss of function models for leptin- or insulin signals. Both conditional loss of function models exhibited defects in their systemic response to endocrine signals controlling energy homeostasis and metabolism. Mice lacking leptin receptors in astrocytes exhibited diminished suppression of feeding following leptin treatment when compared to control mice (p<0.05, all mice on standard chow diet). Postnatal ablation of leptin signaling specifically in astrocytes also caused exaggerated fasting-induced or ghrelin-triggered overfeeding (p<0.01). Such metabolic phenotypes could result from decreased astrocytic coverage of POMC-neurons, which we observed in the hypothalamus of these mice. Postnatal astrocyte specific deletion of the insulin receptor in mice on standard chow diet resulted in impaired systemic metabolic responses to glucose challenges or insulin injections (p<0.03 and p<0.02, respectively), in spite of a modestly reduced fat mass/bw (wt: 9.6% ± 0.6 vs KO: 5.3% ± 0.3; p<0.05, all mice on chow diet). Finally, we deleted lipoprotein lipase postnatally in astrocytes by crossing LPL-flox with GFAP-creERT2 mice. The resulting impaired lipid uptake into CNS astrocytes also triggered a systemic metabolic phenotype, which included accelerated weight gain on high fat diet (p<0.001) and impaired glucose tolerance (p<0.05) when compared to controls. Our findings uncover a previously unknown role of astrocytes in the CNS control of energy homeostasis and glucose metabolism, where they seem to serve as functional targets of afferent hormone action and participate in nutrient sensing.

 

Nothing to Disclose: CG, JGK, YG, HW, EF, BL, CM, PTP, CK, CM, SL, RHE, FMV, MS, CXY, TLH, MHT

OR45-1 16738 1.0000 A Astrocytes Co-Regulate Systemic Metabolism in Response to Hormones and Nutrients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Tuesday, June 24th 11:00:00 AM OR45 4752 9:30:00 AM Hormone and Nutrient Regulation of Body Weight: Basic Mechanisms Oral

Amin Alamshah*1, Elly Spreckley1, Anne K. McGavigan1, Wan Cheong1, Mohammad A Ghatei1, Stephen R Bloom2 and Kevin G. Murphy1
1Imperial College London, London, United Kingdom, 2Imperial College London, United Kingdom

 

L-arginine promotes gut hormone release and reduces appetite in rodents.

Obesity is an increasing health problem. Current drug treatments have limited efficacy and significant side effects. Lifestyle and dietary modifications remain the most effective treatment strategy. High protein diets promote weight loss and subsequent weight maintenance, but are difficult to adhere to. The mechanism by which high protein diets exert their effects is not fully understood. However, the amino acids produced by protein digestion may play a role in appetite regulation and satiety. We tested the effect of various amino acids on gut hormone release in a mouse primary colonic L-cell model. L-arginine dose dependently stimulated the release of glucagon-like peptide 1 (GLP-1) and peptide tyrosine tyrosine (PYY) from these cells. Oral and intraperitoneal administration of L-arginine dose-dependently reduced food intake in both mice and rats. This reduction in food intake did not appear to be secondary to abnormal behavioural side effects. L-arginine had no significant effect on energy expenditure in mice as assessed by measuring oxygen consumption (VO2) using the Comprehensive Lab Animal Monitoring System. Plasma GLP-1 and PYY levels were significantly elevated following oral administration of L-arginine in rats. Central administration of L-arginine had no effect on food intake in rats, suggesting the effect is peripherally mediated. L-arginine may therefore contribute towards protein-induced satiety, and the L-arginine sensing system may represent a possible target for anti-obesity agents.

 

Nothing to Disclose: AA, ES, AKM, WC, MAG, SRB, KGM

OR45-2 14173 2.0000 A L-Arginine Promotes Gut Hormone Release and Reduces Appetite in Rodents 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Tuesday, June 24th 11:00:00 AM OR45 4752 9:30:00 AM Hormone and Nutrient Regulation of Body Weight: Basic Mechanisms Oral

Margaret B Allison*1, Christa M Patterson1, Michael Krashes2, Bradford Barr Lowell3, David P Olson4 and Martin Grosvenor Myers Jr.5
1University of Michigan, 2NIDDK/NIH, Bethesda, MD, 3Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 4University of Michigan, Ann Arbor, MI, 5Univ of Michigan, Ann Arbor, MI

 

Two thirds of American adults are overweight or obese, predisposing them to Type 2 diabetes and cardiovascular disease. Adipose tissue produces the hormone, leptin, which signals the repletion of energy stores to the brain, where it acts to modulate feeding, energy expenditure, and glucose homeostasis.  Leptin mediates these effects by activating its receptor (LepRb), which promotes crucial STAT3-dependent transcriptional signals in specialized hypothalamic LepRb neurons. While LepRb neurons and their complement of leptin-regulated genes thus represent potential therapeutic targets for the prevention and treatment of metabolic disease, little is known about gene expression in LepRb cells.  To define the LepRb neuron transcriptome and elucidate its regulation by leptin, we generated LeprcreRosa26L10-eGFP mice, in which LepRb neurons express an eGFP-tagged ribosomal subunit.  This permits the isolation of LepRb neuron-derived mRNA by anti-eGFP Translating Ribosome Affinity Purification (TRAP).  We subjected hypothalamic LepRb neuron-derived TRAP RNA (and TRAP-depleted hypothalamic RNA) from vehicle or 3-hour leptin-treated LeprcreRosa26L10-eGFP mice to deep sequencing.  This analysis revealed ~1300 genes whose expression was significantly enriched in hypothalamic LepRb neurons.  In addition to the mRNA species previously associated with LepRb neurons (e.g., Pomc, Agrp, Npy, Socs3), this list included many genes not previously known to be expressed specifically in LepRb cells (e.g., Pdyn, Atg7).  Acute, 3-hour leptin treatment increased the expression of ~25 genes in LepRb neurons.  Most of these genes represent known STAT3 targets, many of which encode transcriptional regulators or SOCS proteins.  In contrast, 3-hour leptin treatment failed to alter many LepRb neuron-expressed genes that are known to be regulated by leptin in the long term (e.g., Pomc, Agrp, Npy).  Thus, 3-hour leptin treatment promotes the expression of first-order STAT3-dependent transcripts, but prolonged leptin action may be required to mount the full transcriptional response to leptin.  This finding suggests that STAT3 may mediate crucial long-term transcriptional responses to leptin indirectly, by the expression and action of STAT3-regulated transcription factors.

 

Nothing to Disclose: MBA, CMP, MK, BBL, DPO, MGM Jr.

OR45-3 15964 3.0000 A Translational Profiling Reveals the Transcriptome of Hypothalamic Leptin Receptor Neurons and Its Regulation By Leptin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Tuesday, June 24th 11:00:00 AM OR45 4752 9:30:00 AM Hormone and Nutrient Regulation of Body Weight: Basic Mechanisms Oral

David R Powell*1, Jason P Gay2, Nathaniel Wilganowski2, Zhi-Ming Ding2, Brian Zambrowicz1 and Urvi Desai2
1Lexicon Pharmaceuticals, The Woodlands, TX, 2Lexicon Pharmaceuticals, Inc., The Woodlands, TX

 

Shared phenotypes between mouse knockouts (KOs) of protein-encoding genes suggest that those proteins may interact closely within the same physiologic pathways. We found, among the >4500 KO lines generated at Lexicon Pharmaceuticals, that cannabinoid receptor 1 (Cnr1) KO mice had the same lean phenotype published by others. We asked if Lexicon gene-trap KOs of the enzymes DAG Lipase-Alpha or -Beta (Dagla or Daglb), involved in synthesizing the endocannabinoid (EC) 2-Arachidonoylglycerol (2-AG), or N-acyl-phosphatidylethanolamine-hydrolyzing phospholipase D (Nape-pld), which synthesizes neuroactive N-acylethanolamines, shared any or all of the components of the metabolic phenotype observed in Cnr1 KO mice.

During phenotypic screening of our KO lines, Dagla KO and Cnr1 KO mice, but not Daglb KO or Nape-pld KO mice, had % body fat values relative to wild type (WT) littermates that were among the lowest of 3653 chow-fed KO lines screened by DEXA, and among the lowest of 2476 high-fat diet (HFD)-fed KO lines screened by quantitative magnetic resonance (QMR). In confirmatory studies, chow- or HFD-fed weanling or adult Dagla KO mice were leaner than wild type (WT) littermates; when data from multiple cohorts of 16 wk-old mice were normalized (WT mice of the same gender from each cohort were assigned a mean value of 100%) and combined, Dagla KO (n=131) values were significantly less (p<0.001 for each) than WT (n=169) for body weight (BW; 79±10% vs 100±13%), body fat by QMR (53±21% vs100±35%) and LBM by QMR (89±9% vs 100±10%), similar to data from Cnr1 KO mice. In contrast, neither HFD-fed Daglb nor Napepld KO mice were lean at 15 wks of age, and Dagla/Daglb double KO mice had the same lean phenotype as Dagla KO littermates. Food consumption of weanling Dagla KO mice was 17% and 14% lower than WT mice in 2 studies (p < 0.001 for each); also, Dagla KO mice had comparable BW to pair-fed WT mice, comparable activity and V02 levels to ad lib-fed WT mice, and no evidence of malabsorption, similar to data from Cnr1 KO mice. Dagla KO mice also had significantly lower fasting triglyceride (TG) levels, and during oral glucose tolerance tests (2 g/kg glucose challenge) they showed modest lowering of glucose excursions but significant lowering of baseline and 30 minute insulin levels; all of these findings were observed in our Cnr1 KO mice.

These data suggest: 1) the lean phenotype of Dagla KO mice is mainly due to hypophagia, similar to what is observed with Cnr1 KO mice; 2) in neural pathways where ECs signal through Cnr1 to regulate appetite and possibly other aspects of the metabolic phenotype observed in Cnr1 KO mice, Dagla alone provides the 2-AG that serves as the endogenous EC signal; and 3) small molecule Dagla inhibitors with a pharmacokinetic profile similar to that of Cnr1 inhibitors may mirror the ability of Cnr1 inhibitors to decrease body weight, appetite and TGs while improving glycemic control in diabetic patients.

 

Disclosure: DRP: Employee, Lexicon Pharmaceuticals, Inc., Employee, Lexicon Pharmaceuticals, Inc., Employee, Lexicon Pharmaceuticals, Inc.. ZMD: Employee, Lexicon Pharmaceuticals, Inc., Employee, Lexicon Pharmaceuticals, Inc., Employee, Lexicon Pharmaceuticals, Inc.. BZ: Employee, Lexicon Pharmaceuticals, Inc., Employee, Lexicon Pharmaceuticals, Inc., Employee, Lexicon Pharmaceuticals, Inc.. UD: Employee, Lexicon Pharmaceuticals, Inc., Employee, Lexicon Pharmaceuticals, Inc.. Nothing to Disclose: JPG, NW

OR45-4 13263 4.0000 A Diacylglycerol Lipase Alpha Knockout Mice Reproduce the Metabolic Phenotype of Cannabinoid Receptor 1 Knockout Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Tuesday, June 24th 11:00:00 AM OR45 4752 9:30:00 AM Hormone and Nutrient Regulation of Body Weight: Basic Mechanisms Oral

Raluca Bugescu*, Juliette Anne Brown, Thomas Mayer, Hillary Lauren Woodworth and Gina Marie Leinninger
Michigan State University, East Lansing, MI

 

Circulating hormones act via neurons in the lateral hypothalamic area (LHA) to adaptively modify feeding and locomotor behaviors thus aiming to resolve energy imbalance.  LHA neurons that express the neuropeptide Hypocretin/Orexin (OX) are activated by ghrelin to increase food intake and reverse energy deficit.  Separate LHA neurons express the neuropeptide neurotensin (Nts), and many of these co-express the long form of the leptin receptor (LepRb) and are activated by the hormone leptin: we refer to these as NtsLepRb neurons.  We previously showed that NtsLepRb neurons synaptically regulate OX neurons and are required for the anorectic response to leptin.  We therefore hypothesized that disruption of the NtsLepRb neuronal circuit would derange both NtsLepRb neurons and OX neurons from responding appropriately to their respective hormonal cues, leptin and ghrelin, and thus could disturb adaptive energy balance.  To examine this hypothesis we studied the response of leptin or ghrelin in mice with intact action via the NtsLepRb neuronal circuit (Control mice) and mice lacking LepRb specifically in NtsLepRb neurons (KO mice), which have a disrupted NtsLepRb neuronal circuit.  Leptin treatment activates NtsLepRb neurons in control, but not KO mice, consistent with their loss of LepRb.  Ghrelin treatment activates OX neurons in control mice but not in KO mice, suggesting loss of action via the LHA NtsLepRb neuronal circuit “silences” the ability of OX neurons to respond to ghrelin. To determine whether loss of hormonal regulation via the NtsLepRb neuronal circuit compromised adaptive energy balance, we examined the sucrose preference of control and KO mice in response to leptin or ghrelin.  Leptin suppressed the sucrose intake of control mice, but did not attenuate intake in KO animals.  In contrast, ghrelin increased sucrose intake in control animals but not in KO animals.  Collectively these data suggest that developmental loss of action via the NtsLepRb neuronal circuit blunts the functional response of NtsLepRb neurons and postsynaptic OX neurons, to leptin and ghrelin, respectively.  Intact regulation of NtsLepRb neurons is therefore essential for the coordination of hormonal cues and appropriate adaptive behaviors to regulate feeding and energy balance.

 

Nothing to Disclose: RB, JAB, TM, HLW, GML

OR45-5 14912 5.0000 A Loss of Leprb Expression in Lateral Hypothalamic Neurotensin Neurons Disrupts Adaptive Behavioral Responses to Leptin and Ghrelin 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Tuesday, June 24th 11:00:00 AM OR45 4752 9:30:00 AM Hormone and Nutrient Regulation of Body Weight: Basic Mechanisms Oral

David M Golding, Jennifer R Davies, Anthony R Isles and Timothy Wells*
Cardiff University, Cardiff, United Kingdom

 

Prader–Willi syndrome (PWS) is a neurodevelopmental disorder caused by a lack of paternal gene expression from 15q11–q13 and is characterized by a failure to thrive in infancy, followed by impaired skeletal growth, hyperghrelinemia, reduced satiety responses, hyperphagia and obesity.  We have shown that many of these characteristics are replicated in a mouse model for this condition in which the imprinting center of the homologous PWS interval has been deleted (PWS-IC mice).  However, despite hyperghrelinemia, proportionate hyperphagia and exaggerated food hoarding behavior, these animals remain remarkably lean, abdominal white adipose tissue (WAT) depots being reduced by 70-80% (1).  Since circulating lipids are regulated in rodents by the activity of brown adipose tissue (BAT) (2), we have now investigated whether leanness in PWS-IC mice arises from dysregulated thermogenesis.

When maintained in standard housing conditions, interscapular BAT weight in PWS-IC mice was 48% lower than in wild-type (WT) mice (p<0.01), brown adipocytes showing reduced lipid storage.   Since this suggested increased lipid utilization, we used thermal imaging to reveal that the surface temperature of PWS-IC mice was increased by 1.4 and 2.0°C in the head and interscapular regions (p<0.05), while lumbar and tail root temperatures were unaffected.  In order to determine whether this elevated thermogenesis could be corrected by maintaining PWS-IC mice in thermoneutral conditions, 6 month-old WT and PWS-IC mice were maintained at room temperature (RT; 20-22°C) or thermoneutrality (TN; 30°C) for 9 weeks.   In WT mice daily food intake was unaffected at TN, with mean terminal body weight and proportionate inguinal, retroperitoneal and omental WAT mass being 150, 115, 139 and 175% of that in RT-maintained mice.   Proportionate interscapular BAT mass in WT mice at TN was 119% of that in RT-maintained mice, with clear evidence of lipid engorgement in brown adipocytes.   In contrast, daily food intake was reduced by 38% in TN-maintained PWS-IC mice (p<0.01), with body weight gain reversed from 0.86±0.30g (RT) to -1.80±1.30g (p<0.05) in TN-maintained mice.   In addition, the proportionate mass of the inguinal, retroperitoneal and omental depots in TN-maintained PWS-IC mice was 82, 94 and 131% of that in RT-maintained PWS mice.   Although proportionate BAT mass was unaltered in TN-maintained PWS-IC mice, lipid storage appeared increased.

Thus, although overactive BAT and excess thermogenesis may contribute to the development of abdominal leanness in PWS-IC mice, the effect of suppressing BAT function on WAT mass is obscured by reduced food intake.  Given the sporadic reports of hyperthermia in human PWS infants (3,4), it is now important to establish the relationship between BAT activity, food intake and WAT mass in children with this condition and determine whether activation of BAT could ameliorate the obesity usually seen in PWS.

 

Nothing to Disclose: DMG, JRD, ARI, TW

OR45-6 13823 6.0000 A Abdominal Leanness in the Imprinting Center-Deletion Mouse Model for Prader-Willi Syndrome May Result from Excess Thermogenesis 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Obesity, Adipocyte Biology and Appetite Tuesday, June 24th 11:00:00 AM OR45 4752 9:30:00 AM Hormone and Nutrient Regulation of Body Weight: Basic Mechanisms Oral

Laetitia Martinerie1, Eric Pussard2, Nadya Yousef2, Claudine Cosson2, Ingrid Lema3, Sebastien Mur4, Pascal Boileau5 and Marc Lombes*6
1INSERM U693, Le Kremlin Bicetre, France, 2Hopital Bicetre, APHP, Le Kremlin Bicetre, France, 3INSERM U693, Le Kremlin Bicêtre, France, 4CHRU Lille, Lille, France, 5CHU Poissy, Poissy, France, 6Inserm U1185, Le Kremlin-Bicêtre, France

 

The neonatal period is characterized in humans by a tubular immaturity responsible for sodium wasting, notably in preterm neonates. We have previously demonstrated a partial renal aldosterone resistance coincident with low tubular expression of the mineralocorticoid receptor in term newborns (1, 2).

The objective of our clinical trial (NCT01176162) was to assess aldosterone resistance in neonates according to gestational age and during a one-year postnatal follow-up period, by measuring urinary aldosterone concentration (UAC) and its correlation to the urinary Na/K ratio as an index of renal aldosterone sensitivity.

One hundred and seventy newborns were enrolled prospectively, classified into 3 gestational age groups: <33 GW (gestational weeks) (52 patients), 33-36 GW (69 patients), >37 GW (49 patients).

Plasma aldosterone levels measured from umbilical cord blood samples were very high in the >37 GW group (1001±98 pg/ml). However, these levels significantly decreased with gestational age (583±48 and 380±55 pg/ml in the 33-36 and <33 GW groups, respectively, p<0.0001). This was associated with an increase in renin levels (from 81±10 pg/ml in the >37 GW group to 135±22 pg/ml in the <33 GW group) suggesting an aldosterone biosynthesis/secretion defect in preterms. UAC followed a similar pattern (from 20.2±3.2 mg/mmol urinary creatinine in term neonates to 8.8±1.2 in preterms, p<0.0001), significantly correlated with plasma aldosterone levels in all groups (p<0.0001), demonstrating its reliability as an accurate and non-invasive index of aldosterone secretion. Renal aldosterone resistance was demonstrated in newborns given the lack of correlation between UAC and the urinary Na/K ratio in all groups, and high sodium wasting at birth in very preterm infants (Na/creatinine urinary ratio: 75.7, 46.0 and 10.7 in the <33 GW, 33-36 GW and >37 GW group, respectively). During follow-up, UAC progressively decreased to reach adult levels at one year of age in term infants, while in the <33 GW group, UAC increased till one month reaching values of term newborns at birth, with a delayed diminution afterwards. Renal aldosterone responsiveness appears in term infants at one month of age (p=0.02) while renal aldosterone insensitivity persists in the preterm groups beyond 3 months of follow-up.

These results uncover the mechanism of sodium wasting in preterm neonates and underscore new potential therapeutic management of sodium homeostasis based on UAC measurement.

 

Nothing to Disclose: LM, EP, NY, CC, IL, SM, PB, ML

OR53-1 14436 1.0000 A Defects in Aldosterone Signaling Exacerbate Sodium Loss at Birth in Preterm Infants: Prime Results from the Premaldo Study 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Tuesday, June 24th 11:00:00 AM OR53 4755 9:30:00 AM Translational Research in Pediatric Endocrinology Oral

Jack A Yanovski*1, Bong Gi Lee1, JaShin Koo1, Oksana Gavrilova2, Dezmond Taylor-Douglas3, Robin Roberson3 and Dimitri Koutzoumis3
1NIH, Bethesda, MD, 2NIDDK, NIH, Bethesda, MD, 3Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD

 

We have previously reported that children who are homozygous for a pair of missense MC3R variants (Thr6Lys+Val81Ile) that decrease MC3R signaling (1) have significantly greater BMI and fat mass (1) and, even after adjusting for body composition, consume significantly more energy at a laboratory buffet meal than children with wild type MC3R (2). To validate this human association and characterize the effects of these mutations in mice, we created two novel knock-in mouse models replacing the murine Mc3r with either wild type human MC3R (hWT) or Thr6Lys+Val81Ile human MC3R (hMU). Homozygous hMU mice (hMU/hMU) had significantly greater body weight and body fat mass (p<0.01) and significantly lower fat-free mass (p<0.05) compared to homozygous hWT (hWT/hWT) or mice with 2 murine MC3R alleles. hMU/hMU had increased energy intake and increased feeding efficiency on both chow and high fat diets (p’s<0.02), but, after adjustment for body composition, no consistent differences in energy expenditure at 24 or 30C. During matched pair-feeding studies, hMU/hMU and hWT/hWT showed no significant differences in body weight, indicating energy intake plays a role in the increased body weight of hMT/hMU mice. However, pair-fed hMU/hMU still had significantly greater adiposity than hWT/hWT (p<0.01), suggesting redistribution of body composition towards adipose tissue. Energy intake decreased after leptin administration (1 μg/g b.w.) equally in hMU/hMU and hWT/hWT, indicating that altered leptin sensitivity does not explain the greater energy intake of hMU/hMU. Surprisingly, despite the greater fat mass of hMU/hMU mice, metabolic parameters were not impaired: serum adiponectin was significantly increased (fed state: 24.7±1.0 vs. 13.3±0.7 μg/mL, p<0.0001; fasted state: 34.5±0.8 vs. 24.5±2.8 μg/mL, p=0.0022), insulin sensitivity was not decreased, serum lipids were not different, and white adipose tissue infiltration with macrophages and neutrophils was not increased. We therefore measured human samples for adiponectin concentrations, finding significantly greater adiponectin in 14 children with hMU/hMU than 14 children with hWT/hWT genotype (67.1±5.8 vs. 45.4±5.6 ug/mL, p=0.017), even after adjustment for body fat and age. These data suggest that homozygosity for the human MC3R sequence variant Thr6Lys+Val81Ile alters energy homeostasis in mice at least partially by increasing food intake; however, additional, undetermined factors appear to promote adipogenesis in hMU/hMU and offer protection from some of the complications of excess adiposity. Studies examining how such mutations affect peripheral tissue metabolism may further reveal the mechanisms through which MC3R mutations affect energy homeostasis, body composition, and metabolism and may lead to pediatric obesity.

 

Nothing to Disclose: JAY, BGL, JK, OG, DT, RR, DK

OR53-2 11047 2.0000 A Studies of Mechanisms for Pediatric Obesity Due to Melanocortin 3 Receptor (MC3R) Insufficiency Using Knock-in Mice Expressing Human Wild Type MC3R or Thr6Lys+Val81Ile Human Variant MC3R 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Tuesday, June 24th 11:00:00 AM OR53 4755 9:30:00 AM Translational Research in Pediatric Endocrinology Oral

Yasuhiro Naiki*1, Noriyuki Katsumata2, Masashi Onodera3 and Maki Fukami4
1Natl Ctr for Child Hlth & Dev, Tokyo, Japan, 2Natl Res Inst for Child Hlth & Dev, Tokyo, Japan, 3National Center for Child Health and Development, Tokyo, Japan, 4National Research Institute for, Tokyo, Japan

 

Congenital adrenal hyperplasia (CAH) is caused by defects of steroidgenic enzymes resulting in adrenal cortex dysfunction and abnormal sex steroids production founded in 1 in 18000 births. Most common form is caused by defect of 21-hydorxylase (21OH) which is encorded by CYP21A2 and resulted in underproduction of both glucocorticoid and mineral corticoid and over production of androgens causing ambiguous genitalia in female. Patients need life-long steroid supplementation and extra steroid cover in stress period otherwise adrenal crisis may lead patient’s death. Tajima et al. succeeded Cyp21a cDNA introduction into adrenal grand of Cyp21a deficient (21OHD) mice by adenovirus vector but introducing into adrenal grand may have some risk in clinical practice. Our hypothesis is introduction of Cyp21a gene into extra adrenal tissue may recover 21OH activity and improve steroid production in in 21OHD mouse. Method 21OHD mice were made by breeding with heterozygous of H-2aw18 haplotype mice and treated with subcutaneous corticosteroid injection until 3 weeks of age. Retrovirus vector, pDN-IREhuKO-Cyp21 containing mouse Cyp21a cDNA (RV-Cyp21a) was constructed and transmitted to fibroblasts cultured from 21OHD mice. Cyp21a expression in fibroblasts was detected by RT-PCR and 21-hydroxylase activity was confirmed by measuring deoxycorticosteron (DOC) concentration in medium after 24hr incubation with progesterone (P4) containing medium. Cyp21a-induced fibroblasts were transplanted into 21OHD mice intraperitoneally and measured serum progesterone and DOC concentrations before and after injection. Adenoassociated virus vector containing Cyp21a cDNA (AAV-Cyp21a) was constructed with pAAV-CMV-shuttle and injected into limbs muscles of 21OHD mice. Serum P4 and DOC concentrations were also measured before and after injection. P4 and DOC concentrations were measured by LC-MS/MS. Results Serum P4/DOC ratio were 0.22±0.08 in wild type and 2223±2534 in 21OHD, respectively. Diminished DOC production and accumulation of P4 that is precursor of DOC were observed in 21OHD mice. Transgenic 21OHD fibroblasts by RV-Cyp21a showed Cyp21a gene expression and 21OH activity was detected. Transplantation of the fibroblasts into 21OHD mice showed slight change serum P4/DOC ratio, 2515±2133 to 1435±769. Transgenic 21OHD mice with AAV-Cyp21a showed increase DOC production (0.029 ng/ml to 1.81 ng/ml, ex.3.02±1.75ng/ml in wild type ) and decreased P4/DOC ratio (1223 to 39.2) at 4weeks after injection. Conclusion We succeeded recovering 21OH activity steroid production in in 21OHD mouse by introducing Cyp21a gene into muscle with adenoassociated virus vectors for 4 weeks. Longer period observation is needed.

 

Nothing to Disclose: YN, NK, MO, MF

OR53-3 12446 3.0000 A Extra-Adrenal Expression of Cyp21a for GENE Therapy of CAH 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Tuesday, June 24th 11:00:00 AM OR53 4755 9:30:00 AM Translational Research in Pediatric Endocrinology Oral

David Zangen*1, Abdulsalam Abulibdeh1, Ariella weinberg-Shukron2, Sharon Zeligson3, Fouad Zhadeh4, Liran Carmel4, Paul Renbaum5 and Efrat Levy-Lahad2
1Hadassah Hebrew University Medical Center, Jerusalem, Israel, 2Shaare Zedek Medical Center, Jerusalem, Israel, 3Shaare Zedek Medical Center, 4Hebrew University of Jerusalem, 5Shaare Zedek Medical Center, Israel

 

Background: NNT (Nicotinamide Nucleotide Transhydrogenase) gene mutations have been recently shown to cause familial glucocorticoid deficiency (FGD), by decreasing reactive oxygen species (ROS) detoxification in adrenocortical cells. Affected infants present within the first few months of life with isolated glucocorticoid  deficiency. We report a novel NNT gene mutation, in two Palestinian kindreds presenting uniquely with neonatal addisonian crisis (both mineralo and glucocorticoid deficiency) in 4 cases.

Clinical data: Palestinian male infant with normal external genitalia born to consanguineous parents, presented neonatally with Na: 118, K:6 mmol/l, decreased basal and ACTH stimulated Cortisol and 17-hydroxyprogesterone, normal infantile Testosterone, and elevated Plasma Renin Activity (>15ng/ml/hr). Two female cousins and another unrelated female neonate from consanguineous kindred presented with normal female external genitalia but with similar solute and hormonal manifestations.

Results: Whole exom sequencing in two affected cousins revealed a G200S homozygous mutation in NNT gene.  The homozygous variant found segregated with the disease in both unrelated families, and all four pairs of parents were heterozygous. . Haplotype analysis revealed a founder effect and the mutation was not found in 100 alleles from ethnically matched controls.  Expression studies of the ROS detoxification capacity in fibroblasts are underway.

Conclusion: The founder and novel G200S mutation in the very recently described NNT gene causes uniquely early-infantile-severe mineralo and glucocorticoid deficiency. NNT mutations should be added to the differential diagnosis of neonatal addissonian crisis. Given the ubiquitous nature of NNT, further studies of various mutations are required to elucidate the specific target organs prone to develop pathologies in relation to their impaired antioxidant defense.

 

Nothing to Disclose: DZ, AA, AW, SZ, FZ, LC, PR, EL

OR53-4 14143 4.0000 A Mineralo and Glucocorticoid Deficiency in Early Infancy Are Caused By a Founder Novel Mutation in the Nicotineamid Nucleotide Transhydrogenase Gene 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Tuesday, June 24th 11:00:00 AM OR53 4755 9:30:00 AM Translational Research in Pediatric Endocrinology Oral

Robert C. Olney*1, Parisa Salehi2, Timothy CR Prickett3, John Lima1, Eric A. Espiner4, Kaitlin Sikes1 and Mitchell E. Geffner5
1Nemours Children's Clinic, Jacksonville, FL, 2Seattle Children's Hospital, Seattle, WA, 3University of Otago, Christchurch, New Zealand, 4University of Otago, Christchurch, Christchurch, New Zealand, 5Children's Hospital Los Angeles, The Saban Research Institute, Los Angeles, CA

 

Background:  There are no effective biomarkers to predict the efficacy of rhGH treatment in children with short stature.  C-type natriuretic peptide (CNP) is a small peptide produced by growth plate chondrocytes that plays an essential role in growth plate expansion and hence linear growth.  Plasma levels of its amino terminal propeptide (NTproCNP) correlate with height velocity (HV) in both healthy children(1) and in those treated with rhGH(2), and is a potential biomarker of rhGH responsiveness.  The objective of this study was to describe the pharmacokinetics of rhGH and pharmacodynamic response of plasma NTproCNP in short children commencing rhGH therapy.

Methods:  Twenty prepubertal children were enrolled (8 girls, 12 boys) and 18 completed the study.  Nine had GH deficiency (peak GH <7 ng/mL, GHD) and 11 had idiopathic short stature (ISS).  Subjects were treated with rhGH (Norditropin, Novo Nordisk, Princeton NJ) at 0.05 mg/kg, administered at 9pm nightly.  Blood sampling (9am) was done at baseline (the day of the first injection), 2, 4, 7, 14, and 28 days and 3, 6, and 12 months.  Blood levels of GH, IGF-I, CNP, NTproCNP, leptin, and bone-specific alkaline phosphatase were determined.

Results:  Baseline height SD scores were -2.8 (-3.2, -2.4) [median (25th, 75th percentile)].  Baseline HV was 4.8 cm/y (3.8, 6.1 cm/y) and rose to 9.9 cm/y (8.7, 10.8 cm/y) after one year of treatment.  Responses in GHD and ISS groups did not differ so the data were combined.  Following initiation of rhGH treatment, plasma GH levels rose rapidly to a peak of 5.9 ng/dL (4.3, 7.0 ng/dL) at 4 days (2, 7 days) then fell by 37% (27, 60%) to more stable levels thereafter.  GH levels on day 2 correlated strongly with HV at one year (r=0.71, n=18, p<0.001).  In contrast, IGF-I rose progressively to reach a plateau at 250 days (219, 328 days) which was 161% (124, 205%) above baseline.  The dynamic response of NTproCNP differed from IGF-I; peak levels occurred at 14 days (14, 28 days), 48%(31, 65%) above baseline, after which values fell before stabilizing.  NTproCNP levels at 14 days were weakly associated with HV at one year (r=0.45, n=18, p=0.06).  Leptin levels closely followed the pattern of GH levels whereas bone-specific alkaline phosphatase decreased in the initial two weeks before rising to elevated levels at three-months.  Neither analyte, nor IGF-I, correlated at any time with HV at one year.

Conclusion:  In short, prepubertal children, the dynamic responses of GH, IGF-I, and NTproCNP to rhGH differ markedly.  In contrast to GH and IGF-I, responses of NTproCNP reflect increased growth plate activity, which diminishes after four weeks of sustained treatment.  Whether plasma NTproCNP at 14-21 days provides a clinically useful index of subsequent response in HV during rhGH treatment now requires a study of larger groups of children.

 

Nothing to Disclose: RCO, PS, TCP, JL, EAE, KS, MEG

OR53-5 16062 5.0000 A Pharmacokinetics of Recombinant Human Growth Hormone (rhGH) and Dynamic Response of Amino-Terminal Pro C-Type Natriuretic Peptide (NTproCNP) in Short Children 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Tuesday, June 24th 11:00:00 AM OR53 4755 9:30:00 AM Translational Research in Pediatric Endocrinology Oral

Andrew Dauber*1, Yan Meng2, Laura Audí3, Antonio Carrascosa4, Michael B Ranke5, Michael Paul Wajnrajch6, Kerstin Albertsson-Wikland7, Natasa Rajicic8, Anders Lindberg9, Nina Camacho-Hubner10 and Joel N Hirschhorn11
1Boston Children's Hospital, Boston, MA, 2Boston Children's Hospital and Program in Medical and Population Genetics, Broad Institute, Boston, MA, 3Vall d'Hebron Research Institute, Barcelona, Spain, 4Hospital Universitari Vall d'Hebrón, Barcelona, Spain, 5Univ Klinikum Tübingen, Tübingen, Germany, 6Pfizer Global Pharmaceuticals, New York, NY, 7Univ of Gothenburg/Dept of Ped, Molndal, Sweden, 8Pfizer, Inc., New York, NY, 9Pfizer Health AB, Sollentuna, Sweden, 10Pfizer Inc, New York, NY, 11Division of Endocrinology, Boston Children's Hospital and Program in Medical and Population Genetics, Broad Institute, Harvard Medical School, Boston, MA

 

Background: Individual patients vary in their response to growth hormone (GH). Prediction models using demographic and clinical variables partially capture this variability, but the models do not include specific genetic factors. No large scale genomewide studies have been performed to look for genetic predictors of GH responsiveness.

Objective and hypothesis: To identify genetic variants associated with GH responsiveness.

Population and/or methods: Using Illumina platforms, we genotyped 677 individuals receiving GH from 5 short stature cohorts. After removing samples that failed quality control filters (e.g., genotyping success rate, outliers for heterozygosity or ancestry), 633 prepubertal subjects remained: 304 with idiopathic short stature, 276 with isolated GH deficiency, and 65 born small for gestational age (12 of whom also had GH deficiency).  Association of >2 million variants with GH responsiveness was tested using linear regression, adjusting for estimated genetic ancestry. The primary analysis tested individual SNP association with change in height SDS over the 1st year of treatment (not adjusting for clinical variables). A secondary analysis tested the association of a polygenic score calculated from 697 genomewide significant height SNPs with change in 1st year height SDS.

Results: No common variant (minor allele frequency >5%) associations met strict criteria for genomewide significance (p<5X10-8) in the primary analysis of all subjects. However, we observed an enrichment of p-values approaching significance in some regions, suggesting the presence of true associations that require additional samples for validation. There was no association between the polygenic height SNP score and 1st year change in height SDS. Analyses of diagnostic subgroups and accounting for clinical covariates are ongoing as are analyses of rarer variants.

Precise conclusions: We performed the largest genomewide association study of GH responsiveness to date. Our analysis suggests that it is unlikely for a common genetic variant to have a large effect on growth hormone responsiveness. Our results are consistent with a polygenic component to growth hormone responsiveness, possibly distinct from the genetic regulators of adult height.

 

Disclosure: MBR: Speaker, Eli Lilly & Company, Speaker, Novo Nordisk, Speaker, Pfizer, Inc., Speaker, Ipsen. MPW: Employee, Pfizer, Inc.. NR: Employee, Pfizer, Inc.. AL: Employee, Pfizer, Inc.. NC: Employee, Pfizer, Inc.. JNH: Principal Investigator, Pfizer, Inc.. Nothing to Disclose: AD, YM, LA, AC, KA

OR53-6 15027 6.0000 A Genomewide Association Study of Growth Hormone Responsiveness 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Pediatric Endocrinology Tuesday, June 24th 11:00:00 AM OR53 4755 9:30:00 AM Translational Research in Pediatric Endocrinology Oral

Allison Light* and Stephen R Hammes
University of Rochester, Rochester, NY

 

G Protein-Coupled Receptor (GPCR)/Epidermal Growth Factor Receptor (EGFR) crosstalk is a key event in the gonads (i.e., ovaries and testes) and adrenals for the production of steroid in response to LH or ACTH, respectively. While trans-activation of the EGFR occurs in a ligand-independent fashion in the testes and adrenals, the ovary uniquely employs an extracellular, ligand-dependent mechanism of crosstalk that requires matrix metalloproteinases (MMPs). Specifically, others and we have demonstrated that LH-mediated activation of its GPCR on theca and mural granulosa cells triggers MMPs to cleave and release membrane bound EGFR ligands (i.e., amphiregulin and epiregulin).  These ligands in turn trans-activate the EGFR to promote steroidogenesis in the ovarian follicle. Notably, our laboratory has shown that this GPCR/MMP/EGFR pathway is essential for normal LH-mediated steroid production.  We find that LH-induced progesterone production is significantly reduced in freshly isolated mouse ovarian follicles using EGFR inhibitors as well as three different MMP inhibitors, Galardin, MMP2/9 inhibitor and Doxycycline.  Administration of doxycycline to female mice similarly reduced LH-triggered steroidogenesis by approximately 50% in-vivo. With these data, we proposed that LH was either up-regulating MMP expression/activity (thus promoting the enzyme), or was up-regulating amphiregulin and/or epiregulin expression (thus promoting the substrate).  Using freshly isolated mouse granulosa cells (GC) from PMSG-primed mice, we found that mRNA levels of the MMPs targeted by Galardin, MMP2/9 inhibitor, and Doxycycline (MMP2 and MMP9) were unchanged in response to LH treatment.  Additionally, using zymography, we were unable to detect changes in gelatinase activity in response to LH.  In contrast, amphiregulin and epiregulin mRNA expression was quite low in freshly isolated primary mouse GCs, but increased markedly in the presence of LH.  Given these observations, we propose that substrate availability rather than changes in MMP expression/activity, directs MMP-mediated amphiregulin and epiregulin release during LH-induced steroidogenesis in the ovary. Using this model, siRNA-mediated knockdown of MMP2 and MMP9, as well as prevention of amphiregulin and epiregulin mRNA induction, is currently underway to confirm and further characterize this pathway.  These studies will help unravel how MMPs and EGFR ligands influence LH-induced steroidogenesis in the ovary, and could provide insight into new treatment avenues for disorders of hormone excess, such as Polycystic Ovary Syndrome (PCOS).

 

Nothing to Disclose: AL, SRH

OR47-1 13114 1.0000 A LH Upregulates Amphiregulin and Epiregulin Transcription to Direct MMP-Mediated Ovarian Steroid Production 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR47 4758 9:30:00 AM New Insights into the Pathophysiology of PCOS Oral

Samuel Leblanc*, Marie Claude Battista and Jean-Patrice Baillargeon
Université de Sherbrooke, Sherbrooke, QC, Canada

 

BACKGROUND: Polycystic ovary syndrome (PCOS) is characterized by androgen excess and chronic anovulation. PCOS women also frequently display insulin resistance and compensatory hyperinsulinemia. Our group and others previously showed that in vivo exposure to non-esterified fatty acids (NEFA) could lead to insulin resistance and androgen excess in humans. We also reported that in vitro exposure of bovine adrenal fasciculata cells to palmitate, a saturated NEFA, promotes androgen secretion. Therefore, insulin and NEFA metabolism are likely to be key factors in PCOS pathogenesis. We thus hypothesize that overexposure of theca cells to NEFA triggers insulin stimulation of androgen secretion, under LH activation. The main aim of this study was thus to determine in vitroeffects of NEFA and insulin on theca cells androgen secretion.

METHODS: Bovine theca cells were isolated and proliferated for five days, which leads to a 95% pure theca cells culture (based on P450c17 immunofluorescence). Then cells were exposed for 48 hrs to: palmitate (saturated fatty acid, 25 μM twice a day), oleate (unsaturated fatty acid, 50 μM twice a day), a mixture of both or vehicle (BSA); in the absence or presence of insulin (0 to 10,000 ng/ml daily); and without or with forskolin (Fsk; 10 μM once; which activates LH pathway). After 48h, the androgen androstenedione (A4; ELISA) and an oxidative stress marker, 8-isoprostane (ELISA), were measured in cell culture media. Results were compared between conditions using Mann-Withney tests, based on 4 different experiments.

RESULTS: In this model, Fsk increased theca cells A4 production 3 folds, as compared to control cells, regardless of insulin dose (all Ps<0.05). In the presence of Fsk, cell exposure to the palmitate/oleate mixture increased A4 production in response to insulin stimulation (insulin doses ranging from 100-1,000 ng/mL), as compared to unexposed cells, without affecting cell viability. In cells exposed to the palmitate/oleate mixture, Fsk plus insulin 500 ng/mL (optimal dose) increased A4 production by 43±17% over Fsk alone (P=0.03), as compared to no effect in unexposed cells (+4±18%, P=NS). Palmitate alone did not affect A4 production, but decreased cell viability, and oleate alone was not as effective as the NEFA mixture. Moreover, NEFA did not increase Fsk-stimulated A4 production in the absence of insulin, and vice-versa. Under Fsk treatment, palmitate alone increased 8-isoprostane production by 123±58% (P=0.03), in comparison to unexposed cells, but this oxidative stress was not induced using the palmitate/oleate mixture (+4±15% over Fsk alone; P=NS).

CONCLUSION: This study found that overexposure of theca cells to NEFA induces a significant stimulation of androgen production by insulin, under LH pathway activation. These results thus support a role of lipotoxicity and insulin in ovarian androgen overproduction, the main characteristic of PCOS.

 

Nothing to Disclose: SL, MCB, JPB

OR47-2 13266 2.0000 A Non-Esterified Fatty Acids Induce Insulin Stimulation of Androgen Production in Bovine Theca Cells 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR47 4758 9:30:00 AM New Insights into the Pathophysiology of PCOS Oral

Lori D Homa*1 and Suzanne M Moenter2
1University of Michigan, Ann Arbor, 2University of Michigan, Ann Arbor, MI

 

PCOS conservatively affects 8% of women and is the most common cause of infertility. PCOS also predisposes women to metabolic syndrome. Lifestyle management with diet and exercise are key components in the treatment of PCOS. Prenatal androgen (PNA) exposure in several species produces phenotypes that recapitulate many aspects of PCOS, allowing studies of underlying mechanisms and early preclinical studies of interventions. Here, we investigated the effects of PNA on voluntary exercise and estrous cyclicity in mice. Metformin can restore estrous cycles in PNA mice (1). We hypothesized that voluntary exercise, which can activate similar metabolic pathways, would improve estrous cycles in these mice. PNA mice were generated by injecting dams with dihydrotestosterone (225µg sc) on d16-18 of gestation (d1, morning of copulatory plug). Four groups of 9 mice each were housed individually at 8wk of age. Two groups, one PNA and one control (CON, vehicle injected dams), were given running wheels at 10wk of age to allow voluntary exercise. Running wheel activity and estrous cycles (by vaginal lavage) were monitored daily; food intake and body mass were monitored weekly. Data (presented as mean±SEM) were analyzed using 2-way ANOVA. Unexpectedly, PNA mice ran 30% less distance than CON mice (7.7±0.5 km/day PNA, 11.0±0.6 km/day CON, p=0.006), a difference sustained over 8wk. Food intake did not differ between non-running PNA and CON mice, but was higher in both groups of running compared to non-running mice, and further increased (p<0.01) in CON running mice (Kcal/wk: PNA 72.5±1.9 vs PNA running 79.7±1.2, p=0.048; CON 69.1± 0.9 vs CON running 88.8±1.6, p<0.0001). Likewise, body mass was not different between non-running CON and PNA mice (PNA 20.2±0.2 g, control 20.9±3 g), but was greater in CON than PNA running mice (PNA 20.9±0.3 g, CON 21.9±0.4 g, p=0.04). Running did not affect estrous cyclicity in CON mice (16% of days in proestrus, 42% in diestrus, 42% in estrus). Estrous cycles were markedly disrupted in PNA mice and were not improved by the first 8wk of running; PNA groups spent more time in diestrus (89%) and less in proestrus (2%) and estrus (9%) (p<0.0001). Of note, metformin treatment required 10wk to restore estrous cycles in PNA mice. This finding of decreased voluntary running in the PNA mice may have implications for women with PCOS. The lower food intake and body mass in running PNA vs CON mice corresponded with their lower running activity. Possible explanations include altered fuel utilization (reduced metabolic rate), lower reward value of food, or lower reward value of voluntary exercise in PNA mice. These are initial observations in a mouse model, thus must be conservatively interpreted with regard to humans. Exercise is important for management of PCOS symptoms, however, and if women with PCOS are inherently less inclined to exercise, this is an obstacle that will need to be addressed in their care.

 

Nothing to Disclose: LDH, SMM

OR47-3 16202 3.0000 A Prenatal Androgenization Programs Reduced Voluntary Exercise: Possible Implications for Polycystic Ovary Syndrome (PCOS) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR47 4758 9:30:00 AM New Insights into the Pathophysiology of PCOS Oral

Melanie Cree-Green*1, Lindsey Newnes2, Amy West2, Samantha Bacon3, Bryan C Bergman3, Ann Scherzinger4 and Kristen J Nadeau5
1University of Colorado School of Medicine, Aurora, CO, 2Children's Hospital Colorado, Aurora, CO, 3University of Colorado, Aurora, CO, 4University of Colorado, 5Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO

 

The prevalence of both fatty liver disease and type 2 diabetes are increased in women with polycystic ovarian syndrome (PCOS), a hyperandrogenic state. However, the prevalence of fatty liver disease has not been measured in adolescents with PCOS, and the etiology of fatty liver disease in PCOS is unclear. We hypothesized that liver fat in girls with PCOS would be related to increased whole body and liver insulin resistance (IR) and free androgen index (FAI). Thirty obese girls with PCOS (OBPCOS; age 14.9±1.5, BMI% 98.5±0.9, FAI 11.6±7.2) and thirteen obese girls without PCOS (OB; age 14.5±0.3, BMI% 96.4±0.1, FAI 4.2±2.5) were enrolled. Percent liver fat and the proportion of subcutaneous and visceral fat were assessed with MRI.  Fasted serum measures included AST, ALT, testosterone, SHBG, triglycerides, total free fatty acids (FFA) and FFA specific to hepatic de novo lipogenesis:16:1n7 and 18:1n7. A 3-stage hyperinsulinemic euglycemic clamp with stable isotope glucose and glycerol tracers was performed to assess adipose, liver and whole body IR.  47% of OBPCOS had hepatic steatosis, defined as >5% fat (mean 6.1±7.2%), compared to 8% of OB (mean 2.3±2.4%), and OBPCOS had higher serum n7 FFA (45±15 nmol/g OBPCOS vs 29±12 OB; P=0.009) despite similar AST and ALT concentrations. Glucose disappearance during hyperinsulinemia (80mU/m2/min) was significantly lower in PCOS (10.1±4.1 mg/kg lean/min OBPCOS vs. 16.5±6.5 OB; p<0.001) and the insulin concentration required to suppress 50% of endogenous glucose production was greater in PCOS (99±38 IU/ml OBPCOS vs. 52±24 OB; p=0.006), indicating muscle and hepatic IR, respectively. However, glycerol data failed to show adipose IR. Percent liver fat correlated with total serum n7 concentration (R=0.53, P=0.004) and visceral fat content (R=0.56, P<0.001), but not FAI, muscle IR, hepatic IR, or BMI. Muscle IR was closely related to FAI (R=-0.684, P<0.001) and BMI. Girls with PCOS have higher rates of hepatic steatosis, which is related to visceral fat depots and serum markers of hepatic de novo lipogenesis, but not IR or androgens. The mechanism for the increased liver fat in PCOS needs to be further explored, so that preventive therapies can be initiated.

 

Nothing to Disclose: MC, LN, AW, SB, BCB, AS, KJN

OR47-4 11401 4.0000 A Insulin Resistance, but Not Excess Liver Fat, Is Related to Hyperandrogenism in Adolescent PCOS 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR47 4758 9:30:00 AM New Insights into the Pathophysiology of PCOS Oral

Cindy Ta Pau*1, Thushiga Kasippillai2, Candace Keefe1 and Corrine K. Welt3
1Massachusetts General Hospital, Boston, MA, 2VU University Medical Center, Amsterdam, Netherlands, 3The University of Utah, Salt Lake City, UT

 

Background: Metformin is widely used in polycystic ovary syndrome (PCOS) with variable clinical response. Genetic variants in membrane transporters are important determinants of metformin pharmacokinetics. These and other genes associated with metformin action may explain the variable clinical response.

Methods: Women with PCOS diagnosed according to the NIH criteria (18-40 yrs) were studied. DNA samples were obtained from the subgroups of women treated with metformin in the Reproductive Medicine Network study PPCOSI (n=131), a randomized trial of clomiphene citrate, metformin and the combination, for treatment of infertility. Subjects were treated for 30 weeks, 6 cycles or until they became pregnant, with fasting glucose and insulin, testosterone levels, and ovulation recorded before treatment and at the final visit. Results were replicated in a 12 week, open-label, interventional treatment study of metformin for PCOS (n=38). Glucose and insulin parameters at baseline and during an IVGTT, testosterone levels, and ovulatory response were recorded before and after treatment. The effect of missense variants in SLC22A1 (OCT1), which decreases metformin transport into cells and missense and promoter variants in SLC22A2 (OCT2) and SLC47A1(MATE1), which decrease metformin efflux out of cells, were genotyped. In addition, a variant in linkage disequilibrium with ATM (rs11212617-C), the ataxia-telangiectasia gene, which mediates metformin-induced AMPK phosphorylation and is associated with metformin treatment success in a type 2 diabetes genome-wide association study, was genotyped in the subjects participating in the open-label study (n=38). Associations between allele frequency and response to metformin were analyzed using Haploview.

Results: PPCOSI subjects who failed to demonstrate a lowered glucose level after metformin treatment were more likely to carry the L160F variant in SLC22A1 (Χ2 4.05; p<0.05). Similarly, those subjects who failed to demonstrate a decreased insulin level after metformin treatment were more likely to carry missense variants in SLC22A1 (R61C Χ2 4.92; p<0.05; L160F Χ2 8.10; p<0.01; Χ2 12.62; p<0.001). These findings were not replicated in subjects participating in the interventional study. The ATM rs11212617-C allele was more common in subjects who demonstrated increased glucose-mediated glucose disposal after metformin treatment (Χ2 3.98; p<0.05), but genotypes were not available for replication from subjects participating in the PPCOSI study. There was no relationship between any of the variants and ovulation or changes in testosterone levels.

Conclusions: Variants known to affect metformin transport do not reproducibly predict response to metformin in women with PCOS. However, preliminary data suggest an association between a variant near ATM and metformin treatment success. Additional data will be obtained for confirmation.

 

Disclosure: CKW: Ad Hoc Consultant, Up To Date, Consultant, Astra Zeneca. Nothing to Disclose: CTP, TK, CK

OR47-5 16890 5.0000 A Response to Metformin in Women with PCOS: The Role of Variants Regulating Metformin Transport and Action 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR47 4758 9:30:00 AM New Insights into the Pathophysiology of PCOS Oral

Wassim Y Almawi*1, Bayan Hubail1, Dana Z Arekat2, Entissar S. Al-Zaman3 and Fabiola Lisa Saldanha1
1Arabian Gulf University, Manama, Bahrain, 2ARABIAN GULF UNIVERSITY, Manama, Bahrain, 3Salmaniya Medical Complex, Manama, Bahrain

 

CONTEXT.   Previous genome-wide association study identified chromosome 2p16.3 region encoding the follicle-stimulating hormone receptor (FSHR) and leutinizing hormone/choriogonadotropin receptor (LHCGR) genes as reproducible polycystic ovary syndrome (PCOS) susceptibility loci.

OBJECTIVE. The present study aims to examine the influence of genetic variants of the FSHR and LHCGR gene on the susceptibility to PCOS in Bahraini Arab women.

SUBJECTS and METHODS. : This was a case-control study, conducted at outpatient endocrinology and OB/GYN clinics. Participants in the study included 182 women with PCOS diagnosed by Rotterdam criteria, and 197 control women. FSHR and LHCGR genotyping was done by allelic exclusion method on real-time PCR.

RESULTS. There were no differences in the risk for PCOS noted with the FSHR rs 46166, rs1007541, rs11692782, rs2055571, and rs1394205 variants, since the minor allele frequencies (MAF) of the five tested variants were comparable between patients and control women, irrespective of the status of obesity., and None of the tested FSHR SNPs were associated with PCOS under any of the additive, dominant, and recessive genetic models tested. Haploview analysis revealed low linkage disequilibrium between the FSHR variants tested, and no 5-locus FSHR haplotypes were identified. In contrast, among the six LHCGR tested (rs2293275, rs7371084, rs4953616, rs4597581, rs13405728, rs4073366), we found strong evidence for an association of PCOS with rs7371084 (P = 0.004), and rs4953616 (P = 0.002).  The association of rs7371084 genotypes with PCOS was seen under the additive (P = 0.008), and dominant (P = 0.004) models, while the association of rs4953616 genotypes was seen only under the additive model (P = 0.008). Six-locus haplotype analysis identified 111121 [OR (5% CI) = 4.54(1.03 – 19.93)] and 211121 [OR (5% CI) = 5.91 (1.21 – 28.79)] to be associated with increased risk of PCOS.

CONCLUSION.   Of the LHCGR variants tested (rs2293275, rs7371084, rs4953616, rs4597581, rs13405728, rs4073366), both rs7371084 and rs4953616 were shown to be independent susceptibility loci for PCOS, while none of the five tested FSHR variants were linked with altered PCOS susceptibility.  This suggests that LHCGR might play a role in the genetic susceptibility to PCOS.

 

Nothing to Disclose: WYA, BH, DZA, ESA, FLS

OR47-6 16775 6.0000 A Leutinizing Hormone/Choriogonadotropin Receptor and Follicle Stimulating Hormone Receptor Gene Variants in Polycystic Ovary Syndrome 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR47 4758 9:30:00 AM New Insights into the Pathophysiology of PCOS Oral

Channa N Jayasena*1, Ali Abbara2, Alexander N Comninos3, Risheka Ratnasabapathy3, Julianne Mogford3, Zainab Malik3, Joanne Calley3, Mohammad A Ghatei3, Stephen R Bloom1 and Waljit S Dhillo2
1Imperial College London, United Kingdom, 2Imperial College NHS Healthcare Trust, London, United Kingdom, 3Imperial College London, London, United Kingdom

 

BACKGROUND: Existing fertility therapies bypass the natural hypothalamic mechanism driving reproduction. Kisspeptin peptides are potential novel fertility therapies sharing a common decapeptide motif, which potently stimulate endogenous gonadotrophin releasing hormone (GnRH). Kisspeptin-10 (KP10) and kisspeptin-54 (KP54) are, by far, the two most investigated kisspeptin isoforms. However it is not known how potently KP10 and KP54 stimulate gonadotrophin secretion (through endogenous GnRH release) when compared with exogenous GnRH, using an identical dosing regimen in humans.

METHODS: Following ethical approval, a single blinded placebo controlled study was performed.  Ten different 3h intravenous continuous infusions were administered to healthy men: vehicle; 0.1, 0.3 or 1.0nmol/kg/h KP10; 0.1, 0.3 or 1.0nmol/kg/h KP54; 0.1, 0.3 or 1.0nmol/kg/h GnRH (n=4-5/group). The effects of each dose were investigated in the same men for all peptides. Serum was analysed for luteinising hormone (LH) and follicle stimulating hormone (FSH), and plasma was analysed for kisspeptin immunoreactivity (kiss-IR).

RESULTS: Kiss-IR was low during vehicle or GnRH, and increased dose-dependently during KP54, and to a lesser extent, during KP10 (mean plasma kisspeptin IR during 1.0nmol/kg/h infusion in pmol/L: 38±5.9, vehicle; 48±3.6, GnRH; 179±24, KP10, 6648±397, KP54, P=<0.001 vs. vehicle, GnRH or KP10). For all peptides, the smallest LH response was observed during the 0.1nmol/kg/h dose (mean LH increase in iU/L: 1.2±0.3, vehicle; 8.4±1.9, KP10; 12.1±1.6, KP54, P=<0.05 vs. vehicle; 19.6±3.2, GnRH, P<0.001 vs. vehicle, P<0.01 vs. KP10). For all peptides, the greatest LH response was observed during the 0.3nmol/kg/h dose (mean LH increase in iU/L: 1.2±0.3, vehicle; 12.5±1.5, KP10; 20.6±4.4, KP54; 36.9±9.6, GnRH, P<0.01 vs. vehicle, P<0.05 vs. KP10). All peptides stimulated LH more potently when compared with FSH at all doses (mean ratio of LH increase to FSH increase 7.2 to 9.8 for all treatment groups excluding vehicle).

CONCLUSIONS: For the first time, we have quantified the gonadotrophin secretion during equimolar administration of KP10 or KP54 (stimulating endogenous GnRH) and exogenous GnRH in healthy men. At the doses tested, pituitary stimulation (with GnRH) increases gonadotrophins more potently when compared with hypothalamic stimulation (with KP10 or KP54). This data has potentially important therapeutic implications, since it suggests that kisspeptin may stimulate a more physiological level of gonadotrophin secretion when compared with direct pituitary stimulation.

 

Nothing to Disclose: CNJ, AA, ANC, RR, JM, ZM, JC, MAG, SRB, WSD

OR41-1 16584 1.0000 A Comparing the Effects of Pituitary Versus Hypothalamic Stimulation of the Human Reproductive Axis Using Equimolar Intravenous Infusions of Kisspeptin-10, Kisspeptin-54 and Gonadotrophin Releasing Hormone (GnRH) in Healthy Men 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR41 4760 9:30:00 AM Clinical Male Reproduction: Genetic and Endocrine Aspects Oral

Alberto Ferlin*, Cinzia Vinanzi, Francesco Ganz, Manuel Pengo, Massimo Menegazzo and Carlo Foresta
University of Padova, Padova, Italy

 

Introduction Recent studies also from our group evidenced that polymorphisms in FSH receptor gene (FSHR) and FSH beta subunit (FSHB) gene could modulate FSH plasma levels and could represent valid genetic markers for a pharmacogenetic approach to male infertility treatment. Polymorphisms rs6166 (c.2039 A>G, Asn680Ser) and rs1394205 (c.-29 G>A) in FSHR have been better characterized in women, whereas rs10835638 (-211 G>T) in FSHB seems to have a determinant role mainly in the male. However, no studies have been performed analyzing the combined effect of these three polymorphisms.

Materials and methods We studied 365 consecutive males: 39 with azoospermia, 177 with oligozoospermia, and 149 with normozoospermia. Main parameters examined were: seminal analysis, FSH, LH, and testosterone levels, testicular volume, rs6166, rs1394205 and rs10835638 (through RFLP and direct sequencing).

Results The polymorphism -211 G>T in FSHB is significantly associated with FSH plasma levels (9.3±8.2, 7.4±7.2 and 3.0±2.5 IU/L respectively for subjects GG homozygotes, GT heterozygotes, and TT homozygotes, P<0.001). Polymorphisms -29 G>A and Asn680Ser in FSHR considered separately were not associated with different FSH levels. Combined analysis of the three polymorphisms underlined better that the major determinant of FSH plasma levels is polymorphism -211 G>T, but the effect is modulated by the -29 G>A polymorphism, so that subjects with the -211 GG/-29 GG genotype had the highest levels of FSH. No effect was evident for LH and testosterone, whereas, in agreement with these findings, the total sperm count and testicular volume are modulated by the genotype. Subjects TT homozygotes for polymorphism -211 in FSHB are invariably azoo-oligozoospermic with low testicular volume and FSH always <8 IU/L. The combined effect of Asn680Ser polymorphism is marginal.

Conclusions This is the first study analyzing the combined contribution of the most interesting polymorphisms in FSHR and FSHB gene to male reproductive function. We showed that the -211 G>T polymorphism in FSHB has a determinant role, slightly modulated by polymorphisms in FSHR, in FSH plasma levels, sperm count and testicular volume. This polymorphism influences the transcriptional activity of the FSHB gene, causing isolated deficiency of FSH and azoo-oligozoospermia, therefore representing the ideal marker for a pharmacogenetic approach to treatment with FSH.

 

Nothing to Disclose: AF, CV, FG, MP, MM, CF

OR41-2 16635 2.0000 A Male Reproductive Function Is Genetically Determined By Polymorphisms in Fshb and FSHR Genes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR41 4760 9:30:00 AM Clinical Male Reproduction: Genetic and Endocrine Aspects Oral

Carolina J Jorgez*, Nathan Wilken, Larry L Lipshultz and Dolores J Lamb
Baylor College of Medicine, Houston, TX

 

Introduction: There are many recognized causes of infertility including cryptorchidism, karyotype abnormalities, Y-chromosome microdeletions, and gene mutations1. This study focuses on E2F transcription factor-1 (E2F1), a gene encompassed by a copy-number-variation (CNV) identified in an infertile cryptorchid man using array comparative genomic hybridization (aCGH). E2F1 CNVs were common in men with idiopathic non-obstructive azoospermia (9.8%, n=8/81). E2F1 is a key player in cell cycle regulation and carcinogenesis. In mice, E2f1 targeted deletion or overexpression by transgenesis results in spermatogenic failure2-4. Given E2f1’s role in the cell cycle and apoptosis, we sought to further define the role of E2F1 in testicular development and function.

Methods: Wild-type and E2f1-null males were mated to control females to define their relative fertility over seven months. Over time the mice were sacrificed, testis location noted during dissection and organ weights recorded. RNA was extracted from one testis to determine gene expression measured by qPCR. The contralateral testis was used for histology. Sperm isolated from the cauda epididymis were used to define density and motility. Circulating hormone levels were defined by radioimmunoassay using the Ligand Core at University of Virginia.

Results: Our data and review of the literature revealed five cryptorochid boys with E2F1 microduplications5,6. Like the human phenotype, 95% of E2f1-null mice were cryptorchid. The cryptorchidism was associated with a significant misregulation of genes involved in testicular descent and steroidogenisis. Testicular histology of E2f1-null mice revealed a progressive depletion of germs cells leading to a Sertoli cell only phenotype (SCO) and Leydig cell hyperplasia. Not surprisingly, there was a significant elevation of FSH and a decrease in litter size, litters per month, testicular weight, sperm density, and motility associated with the testicular failure. Misregulation of the expression of genes involved in cell cycle, cell junctional complexes and Wnt signaling pathways occurred with E2f1-deficiency. Notably, E2f1-null mice exhibited a 20-fold upregulation of testicular Wnt4 gene expression.

Conclusions: Gene-dosage changes of E2F1 represent a previously unrecognized cause of infertility and cryptorchidism. Results suggest that E2F1 deficiency affecting testicular descent and spermatogenesis may result in an inappropriate up-regulation of Wnt4.

 

Nothing to Disclose: CJJ, NW, LLL, DJL

OR41-3 11498 3.0000 A E2F1 an Important Regulator of Testicular Descent and Fertility 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR41 4760 9:30:00 AM Clinical Male Reproduction: Genetic and Endocrine Aspects Oral

Shilpi Relan*1, Luis Zamora Siliezar1, Lester Freedman2, Eric Vilain3 and Renee Bargman1
1Nassau University Medical Center, East Meadow, NY, 2Nassau University Medical Center, 3UCLA Schl of Med/Gonda Ctr, Los Angeles, CA

 

Background:  Despite the advances made in animal models and mutation studies in human patients, up to 50% of cases with 46 XY DSD and almost all cases of non-syndromic ovotesticular DSD remain unexplained. This is the first case demonstrating a MAP3K1 mutation causing ovotestes in 46XY DSD.

Clinical Case: The case is a baby born with incompletely fused scrotum, hypospadias, curved micropenis, bilateral cryptorchidism and underdeveloped left scrotal sac. The chromosomal analysis revealed 46 XY Karyotype. An ultrasound confirmed absence of a uterus and an empty scrotal sac so male sex was assigned. He has two maternal aunts, each with one child born with ambiguous genitalia. His maternal uncle had similar problems but was able to reproduce without any interventions.

The hormonal evaluation had revealed normal testosterone, AMH, deoxycorticosterone, androstenedione, DHEA, 17-OH progesterone, 17-OH pregnenolone, LH and FSH levels.  An hCG stimulation test showed normal testosterone and no estrogen production. Surgical exploration revealed an undescended right testis, and a left ovotestis with remnants of fallopian tube, uterus and vaginal tissue, confirmed by pathology results. During surgery, the right testis was brought down and the ovotestis was removed along with mullerian remnants. Microarray did not reveal any genomic imbalance. On experimental genomic sequencing, MAP3K1 mutation was found and then confirmed commercially (Heterozygous for MAP3K1 variant c.1846G>A(p.Gly616Arg)).

Conclusion: MAP3K1 is a putative testicular determining gene on the long arm of chromosome 5.  MAP3K1 mutation has been implicated in both 46 XY complete and gonadal dysgenesis. It has an autosomal dominant, sex limited inheritance with 46 XY being the penetrant genotype (1).  This is the first case report of a MAP3K1 variant c.1846G>A mutation resulting in a phenotype of 46 XY ovotesticular DSD that impacted the differentiation of one gonad. It illustrates autosomal dominant, sex limited inheritance. We suggest that MAP3K1 mutation should be considered in an individual with 46 XY ovotesticular DSD especially with a positive family history.

 

Nothing to Disclose: SR, LZS, LF, EV, RB

OR41-4 15976 4.0000 A MAP3K1 Mutation in a Patient with 46 XY Ovotesticular DSD 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR41 4760 9:30:00 AM Clinical Male Reproduction: Genetic and Endocrine Aspects Oral

María Cecilia Lardone*1, Felipe Argandoña1, Marcel Lorca1, Mauricio Ebensperger2, Alexis Parada-Bustamante1, Antonio Piottante3 and María Andrea Castro1
1Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile, 2San Borja Arriaran Clinical Hospital, Santiago, Chile, 3School of Medicine, Andrés Bello University, Santiago, Chile

 

Severe spermatogenic failure is often associated with dysfunction of the Leydig cell (LC), characterized by decreased serum Testosterone to LH ratio (T/LH) and Leydig cell hyperplasia (LCH). Testicular CYP11A1 and CYP17A1 are key enzymes of the T biosynthetic pathway. INSL3 is exclusively expressed and secreted by LC. Although its physiological function in the adult testis is not yet elucidated, it has been suggested as a marker of differentiation and function of adult LC. We aimed to determine if the expression of steroidogenic enzymes is decreased in subjects with spermatogenic failure and signs of LC dysfunction. We studied 33 cases (27 Sertoli cell-only syndrome and 6 mixed atrophy) with signs of LC dysfunction (LCH and/or T/LH< percentile 2.5 of controls), and 22 controls with preserved spermatogenesis (obstructive azoospermia). LCH, defined as >11 LC/cluster (>percentile 97.5 of controls), correlated with the LC area (aLC) measured in testicular sections (Spearman r=0.693, P<0.0001). Patients with hypogonadotropic hypogonadism and Y chromosome microdeletions were excluded. Tissue samples were obtained for histological analysis, CYP11A1, CYP17A1 and INSL3 mRNA quantification, CYP17A1 protein expression and intratesticular testosterone (ITT) measurement. Transcriptional expression was quantified by SYBR-Green qPCR with standard curve. Transcript copy number was normalized by GAPDH mRNA and corrected by aLC. Immunofluorescence of CYP17A1 in testicular sections was quantified using the parameter IOD (Integrated Optical Density) from Image ProPlus software version 6.2. ITT was extracted with diethyl ether and measured by RIA. CYP11A1, CYP17A1 and INSL3 mRNA expression was higher in cases compared to controls (P<0.0001, Mann Whitney test), and correlated with aLC (r=0.575; r=0.366 and r=0.497; P≤0.003). After correcting by aLC, CYP11A1 and CYP17A1 transcript levels were decreased (P=0.001 and P=0.029), whereas INSL3 expression was similar compared to controls. The mean fluorescence intensity of CYP17A1 corrected by aLC (mean IOD/mean aCL) was lower in cases (n=6) compared to controls (n=6) (P=0.01). In agreement with the low steroidogenic enzyme expression, the ratio ITT/aLC was decreased in cases (n=26) compared to controls (n=10) (P=0.03). Our results suggest that LC dysfunction of subjects with severe, idiopathic spermatogenic failure is associated with lower expression of key steroidogenic enzymes, but not to abnormal Leydig cell differentiation.

 

Nothing to Disclose: MCL, FA, ML, ME, AP, AP, MAC

OR41-5 14846 5.0000 A CYP11A1 and CYP17A1 Expression Is Decreased in Testicular Tissue of Subjects with Spermatogenic Failure and Signs of Leydig Cell Dysfunction 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR41 4760 9:30:00 AM Clinical Male Reproduction: Genetic and Endocrine Aspects Oral

Emma L. Carter1, Joseph D. Finn2, Stephen R. Pye2, Terence W. O'Neill1, Gyorgy Bartfai3, Felipe F Casanueva4, Gianni Forti5, Aleksander Giwercman6, Thang S Han7, Ilpo T. Huhtaniemi8, Krzysztof Kula9, Michael E. J. Lean10, Neil Pendleton2, Margus Punab11, Dirk M Vanderschueren12 and Frederick C Wu*1
1The University of Manchester, Manchester, United Kingdom, 2University of Manchester, Manchester, United Kingdom, 3Albert Szent-György Medical University, Szeged, Hungary, 4Universidad de Santiago de Compostela, Santiago de Compostela, Spain, 5University of Florence, Florence, Italy, 6Malmo University Hospital, Malmo, Sweden, 7University College London, London, United Kingdom, 8Imperial College London, London, United Kingdom, 9Medical University of Łódź, Łódź, Poland, 10University of Glasgow, Glasgow, United Kingdom, 11Tartu University Hospital, Tartu, Estonia, 12KULeuven, Leuven, Belgium

 

Elevated Luteinising Hormone (LH) with normal testosterone (T) is commonly encountered in ageing men as an early indicator of dysregulation in the hypothalamic-pituitary-testicular (HPT) axis. This can be regarded as a transitional state of compensatory hypogonadism which portents the subsequent development of  primary hypogonadism, when the testicular reserve eventually fails, and T falls into the hypogonadal range. Better definition of this unfolding sequence will improve understanding of the natural history and clinical significance of the ageing-related decline in T in men.  Our objective was to identify predictive factors which predispose eugonadal men (T≥10.5 nmol/l, LH≤9.4 U/l) to the development of compensated hypogonadism (T≥10.5 nmol/l, LH>9.4 U/l) and to seek evidence for deficiency in various androgen-dependent characteristics in these new ‘cases’ of compensated hypogonadism.

The European Male Aging Study (EMAS) is a multicentre prospective observational cohort survey of 3,369 community-dwelling men aged 40-79 yr at baseline followed up for 4.3 years in 8 European countries.  Participants were classified into 1) incident (eugonadal at baseline but hypogonadal at follow-up, n = 99), 2) persistent (same at baseline and follow up, n = 131) compensated hypogonadism or 3) persistent eugonadism (referent group, n =1773).  Relationships between potential risk factors for incident compensated hypogonadism and comparison of putative androgen-dependent characteristics amongst the three defined gonadal status were investigated by multiple linear and logistic regression models compared to eugondism.

Risk factors which predisposed men to the development of compensated hypogonadism included age (OR 1.9 (CI 1.5-2.4), p<0.001), per decade), smoking (OR 1.7 (CI 1.0-2.9), p<0.05)), poor or fair health (OR 1.6 (CI 1.0-2.5), p<0.05)) and chronic pain (OR 2.1 (CI 1.2-3.9), p<0.05)). Higher LH and FSH and lower free T at baseline also predicted the development of compensated hypogonadism, which was associated with only minimal evidence of androgen deficiency after adjustments, e.g. lower haemoglobin (144.1±13.6 vs. 150.7±10.9 g/litre, p<0.001). If compensated hypogonadism persists for several years, when free T falls further, clear evidence of impaired physical and psychological functions emerged e.g. limited walking (OR 2.1 (CI 1.2-3.8), p<0.05), decreased physical activity (OR 2.0 (CI 1.3-3.0) p<0.01) and unable to bend (OR 2.5 (CI 1.3-4.7) p<0.01).  These nascent changes in the HPT axis provide better understand of the aetiology and clinical significance of hypogonadism associated with advancing age and enable the early identification of a minority (1% per annum) of men at risk. Elevated LH may be regarded as a highly sensitive biomarker not only of testicular dysfunction but also general health, providing evidence for a subclinical state with evolving androgen deficiency.

 

Disclosure: FCW: Speaker, Bayer Schering Pharma, Clinical Researcher, Eli Lilly & Company, Speaker, Besins Healthcare. Nothing to Disclose: ELC, JDF, SRP, TWO, GB, FFC, GF, AG, TSH, ITH, KK, MEJL, NP, MP, DMV

OR41-6 12497 6.0000 A Natural History of the Development Compensated Hypogonadism in Eugonadal Ageing Men: Predisposing Factors, and Potential Clinical Significance - Longitudinal Data from the European Male Ageing Study (EMAS) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR41 4760 9:30:00 AM Clinical Male Reproduction: Genetic and Endocrine Aspects Oral

Matthew C Leinung*
Albany Med College, Albany, NY

 

Objective:  Multiple therapeutic options for male to female (MTF) patients are available and the optimal regimen is unknown. The goal of this study was to characterize the hormonal response to oral estradiol (E2), with and without anti-androgens.

Methods:  Data was analyzed from a prospectively collected database of patients seen in the transgender clinic at our institution.  All MTF seen from 2008 through 2013 were included. The therapeutic approach is to titrate patients up to 4 or 6 mg E2.  Medroxyprogesterone (MP), 2.5 to 10 mg, is added if testosterone (T) levels are not well suppressed.  Spironolactone or finasteride are added primarily to lessen body hair, without regard to T levels. 

Results:  A total of 162 patients were seen. Of these, 36 were just initiating therapy or did not wish to take full dose eE2; 25 had gender reassignment surgery and lacked valid pre-surgical T levels ; and 19 were on Premarin.  This left 82 who had hormone levels measured on E2 doses meant to provide full feminization.  While on 4 mg, 7 of 21 (33%) T levels in 14 patients were suppressed (<100 ng/dL: normal male > 300).  Of the 9 patients not suppressed, 6 went to 6mg but only 2 achieved suppression.  On 6 mg E2, 54 of 112 (48%) testosterone levels in 64 patients were suppressed.  Of 31 patients not suppressed, ten were increased to 8 mg E2.  On this dose, 5 of 16 (31%) T levels were suppressed.   MP was used in 32 patients to help suppress T.  In 1 of 4 (25%) patients on 4mg E2, in 7 of 22 (32%) on 6mg E2, and in 2 of 6 (33%) on 8mg E2 it lead to T suppression.  Measured 17E2 levels (in pg/mL, normal male <44) trended up with increasing doses (means of 111±39, 130±52, and 153±92 on 4, 6, and 8 of E2 respectively) but did not correlate with T suppression.  Overall, 41 of 82 (50%) had suppressed T at their last visit on 4-8 mg E2 with or without MP.  Use of spironolactone (n=25) did not lower T and in fact there was a trend towards higher levels (130± 102 vs 108± 114). Finasteride use (n=45) was associated with higher T levels while on E2 (mean T 178 ±130 vs 107±113).

Conclusions:  Estradiol in doses of 4-8mg daily is able to increase E2 levels significantly but is incompletely effective in suppressing testosterone levels in MTF. The addition of medroxyprogesterone  can bring further suppression, but many patients remain incompletely suppressed. The use of spironolactone and finasteride do not help with T suppression.

 

Nothing to Disclose: MCL

OR42-1 14134 1.0000 A Variable Response to Oral Estradiol Therapy in Male to Female Transgender Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR42 4761 9:30:00 AM Disorders of Sex Development and Transgender Medicine Oral

Lindsey v. Spratt*1, Erin Reardon1, Jerrold S. Olshan2 and Toni Eimicke2
1Maine Medical Center, Portland, ME, 2The Barbara Bush Children's Hospital @ Maine Medical Center, Portland, ME

 

Although both the Endocrine Society guidelines and the World Professional Association for Transgender Health agree that suppression of endogenous gonadal function is an important goal of transsexual hormonal therapy, neither endorse specific regimens of hormonal therapy for female-to-male (FTM) or male-to-female (MTF) patients. Both guidelines cite a lack of evidence.  How often a GnRH agonist or progestin is necessary for effective suppression of endogenous gonadal activity has not been reported. We evaluated gonadal suppression with T or E2 alone in 31 adult transsexual patients from our clinic (21 FTM and 10 MTF).  Inclusion criteria were:  1) age 18-40 for FTM and age 18-50 for MTF, 2) normal reproductive function prior to therapy, 3) normal renal and hepatic function, 4) serum free T within the normal adult male range in FTM (at least 10% above lower and 10% below upper limits of normal) and serum E2 100-200 pg/mL in MTF while on therapy and 5) no concurrent therapy with a progestin or GnRH agonist. FTM patients received intramuscular (IM) or subcutaneous ( SC) T cypionate injections and MTF patients received oral E2.  Consistent with Endocrine Society guidelines, effective suppression of ovarian function in FTM patients was assessed by absence of menses and serum E2 <50 pg/mL and testicular suppression in MTF patient was assessed by serum free T within the adult female normal range (1.1-6.3 pg/mL). Serum free T (equilibrium dialysis following determination of total T by tandem mass spectrometry), E2 and LH (MTF) or FSH (FTM) were measured in all patients. All FTM patients were amenorrheic and 18/21 had serum E2 <50 pg/mL (mean 30.0±2.1 SE pg/mL) with T therapy alone. 7/10 MTF patients had serum free T within the normal adult female range (2.3±1.6 SE pg/mL). LH and FSH demonstrated variable degrees of suppression. These results suggest that most transgender patients may not need GnRH agonist or progestin treatment in addition to T or E2 therapy suppress endogenous gonadal activity. Thus, suppression on T or E2 therapy alone should be assessed before adding additional endocrine therapies to suppress ovarian or testicular activity to avoid unnecessary expense or side effects.

 

Nothing to Disclose: LVS, ER, JSO, TE

OR42-2 15498 2.0000 A Efficacy of Testosterone (T) or Estradiol (E2) Therapy without a GnRH Agonist or Progestin to Suppress Endogenous Gonadal Activity in Transsexual Patients 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR42 4761 9:30:00 AM Disorders of Sex Development and Transgender Medicine Oral

Henk Asscheman*1, Guy G. T'Sjoen2 and Louis J Gooren3
1HAJAP, Amsterdam, Netherlands, 2Univ Hospital Ghent, Gent, Belgium, 3Andro-Consult, Chiangmai, Thailand

 

Morbidity in cross-sex hormone-treated transgender people

A multisite retrospective cohort study (6 US & 9 European centers).

We studied retrospectively the data on health of trangender subjects (N >2000)  followed for at least 1 year when starting with or already on cross-sex hormone treatment.

Results:Our data  show a large co-morbidity at the start of hormone treatment: in particular > 20% depression and thyroid disease in 2%. Other comorbidity is very variable and appears not different from data on morbidity with simular age. Few deaths were reported. HIV positivity was observed in 3% as expected in Men having Sex with Men (MSM)

Hormone treatment varied in male-to-female transgender persons (MtF): various estrogen preparationa in different ways of administration: patch, gel, oral and intramuscular. Cyproterone acetate (CPA) in Europe and spirolonactone (ALD) were used as anti-androgens. In FtM: testosterone intramuscular short- and longacting and gel, were prescribed in > 90%. Very few side effects were reported. The main serious side effect, venous thrombo-embolism (VTE) was observed in 1% and related to estrogen use. In FtM: acne, muscle problems and weight increase were the main side effects.

Conclusion: Our data show a very reassuring picture of side effects with cross-sex hormone treatment. Our observations are biased because we have no data on those who were lost after few visits (lost to follow up) and those who went to other clinics ("shoppers"). Nevertheless our data confirm the reassuring data from studies with smaller numbers published in the last 10 years.

 

Disclosure: GGT: Clinical Researcher, Bayer Schering Pharma, Principal Investigator, Pfizer, Inc., Clinician, Ipsen. Nothing to Disclose: HA, LJG

OR42-3 14354 3.0000 A Morbidity in a Multisite Retrospective Study of Cross-Sex Hormone-Treated Transgender Persons 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR42 4761 9:30:00 AM Disorders of Sex Development and Transgender Medicine Oral

Jill D. Jacobson*1, Julie L. Strickland1, Laurie Smith1, Anna M. Egan2, Laurel K. Willig3, Emily G Farrow1, Carol J. Saunders1, Stephen F. Kingsmore1, Terri L. Luetjen1 and John M. Gatti1
1Children's Mercy Hospital, Kansas City, MO, 2Children's Mercy Hospital, Kansas City, 3Children's Mercy Hospitals and Clinics, Kansas City, MO

 

The 2006 Endocrine Society Consensus Statement for Disorders of Sexual Development (DSD) states that only 50% of undervirilized males receive definitive diagnoses, and only about 20% of patients receive molecular diagnoses (1). We established a multidisciplinary DSD clinic (termed GUIDE clinic) at our institution in 2008. One of our objectives was to increase our molecular diagnosis rate.  From 2008 to 2013, we saw 88 patients with DSD in our clinic. We utilized a detailed testing algorithm designed to maximize our molecular diagnosis rate, with a focus on undervirilized males. Upon IRB approval, we identified 36 undervirilized males, 42 overvirilized females, and 10 patients with sex chromosome mosaicism. Eight undervirilized males did not have DNA available. We identified a molecular diagnosis in 18 of 28 (64%) undervirilized males for whom DNA was available. One patient was identified with Klinefelter syndrome by a routine karyotype.  Targeted genetic analysis based on clinical suspicion yielded the following 10 mutations/diagnoses: androgen receptor gene (n=3), NR5A1 (n=2) SOX9 (n=2), Beckwith Wiedeman syndrome (n=1), SRD5A2 (n=1) and a congenital dyserythroblastic anemia gene(n=1). Microarray and/or custom array analysis were performed on the remaining 17 genetic males, resulting in 7 additional diagnoses. Microarray analysis demonstrated duplications or deletions suspected to be associated with genital ambiguity in 4 patients.  Targeted gene panel testing by next generation sequencing (TaGSCAN) identified causative mutations in 3 patients, one in OPHN1, and 2 in NR5A1.  An additional patient was found to have a heterozygous mutation in GNRHR, which is not known to be causative.  The remaining 9 undervirilized males who had DNA available and who had not received molecular diagnoses were offered whole exome sequencing (WES).  Only one undervirilized male has undergone all tests, including WES without receiving a diagnosis.  With respect to virilized females, 25 of 42 (60%) received molecular diagnoses.  Of these, one patient was diagnosed with Down syndrome by a routine karyotype.  Targeted gene analysis yielded the following 23 diagnoses: CAH (n=20), Beckwith Wiedeman syndrome (n=1), Smith Magenis syndrome (n=2). Altogether, including the patients with sex chromosome mosaicism, we achieved a molecular diagnosis rate of 61%.   We conclude that a combination of routine karyotyping, targeted genetic testing, microarray testing, and targeted genome sequencing can provide definitive diagnoses in more than half of patients with DSD.  Whole exome sequencing may be important for undervirilized males who receive no molecular diagnosis despite extensive testing. We anticipate that a higher diagnosis rate can be achieved in DSDs using all currently available genetic tools.  There may remain novel genetic and epigenetic causes for DSD that will be identifiable using emerging tests.

 

Disclosure: JLS: Teacher, Merck & Co.. Nothing to Disclose: JDJ, LS, AME, LKW, EGF, CJS, SFK, TLL, JMG

OR42-4 12517 4.0000 A Increasing the Diagnosis Rate in Patients with Disorders of Sex Development (DSD) 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR42 4761 9:30:00 AM Disorders of Sex Development and Transgender Medicine Oral

Esperanza Beatriz Berensztein*1, Paula Aliberti1, Roxana Marino1, Pablo Ramirez2, Natalia Perez Garrido2, Mercedes Maceiras1, Alberto J. Solari3, Roberta Sciurano4, Roberto Ponzio4, Mariana Costanzo1, Diana M. Warman2, Gabriela Guercio2, Silvia Gil1, Elisa Vaiani1, Marcela Bailez2, Marco A. Rivarola1 and Alicia Belgorosky1
1Garrahan Pediatric Hospital, Buenos Aires, Argentina, 2Hospital de Pediatria Garrahan, Buenos Aires, Argentina, 3School of Medicine,, Buenos Aires, Argentina, 4School of Medicine, University of Buenos Aires, Buenos Aires, Argentina

 

Certain disoders of sex development (DSD), as androgen insensitivity syndrome (AIS), are prone to develop germ cell cancer (GCC). This risk is related to the expression of OCT3/4, and the presence of TSPY (1). It has been reported that in AIS the high risk is associated with the onset of puberty and that this is higher in parcial (PAIS) than in complete (CAIS) AIS (2).  OCT 3/4 is also expressed in normal fetal gonocytes (3). Our aim was to study the incidence of GCC risk in a pediatric population of AIS patients. We have studied 19 gonads of 11 prepubertal (PP): median age 3.36, range 1.25-8.8 y, or pubertal (Pu) patients,  age 16.0, 10.3-19.0 y (CAIS: n=8, PAIS: n=3), belonging to 9 families. Three PP and 5 Pu patients were CAIS, while 3 PP patients were PAIS. The presence of Leydig cells and the value of serum testosterone were used as criteria to define a Pu patient. Three/6 PAIS gonads had inguinal location, 1 was abdominal, and 2 were scrotal. Nine/13 CAIS gonads had inguinal location and 4 were abdominal. Diagnosis of AIS was based on phenotypic features, hormonal studies, and AR gene loss-of-function mutations in all cases. Histological description, as well as immunoexpression of OCT3/4 and TSPY was performed. A positive sample was defined as > 5% positive GC with nuclear OCT3/4 and cytoplasmic  TSPY. Sixteen gonads of patients without endocrine or metabolic disorders were used as controls (C). Signs of testicular dysgenesis, such as cord forming rings, presence of calcifications, fibrotic interstitium and GC with clumps of heterochromatin, were found in the 19 testes. Positive samples were found in GC of 3 inguinal testes corresponding to 2 PP CAIS (1.8 and 4.4 years old) and in the 2 abdominal testes of 1 Pu CAIS (19 years-old). In a 10.3-year-old Pu CAIS, one gonad with inguinal location showed GC with OCT3/4 expression while the scrotal gonad, was OCT 3/4 negative. The persistence of gonocytes near the basal membrane was assessed by electron microscopy in the 1.8-year-old CAIS patient. Gonocyte presence and OCT 3/4 positive expression are not normal at this age. No expression of OCT3/4 and TSPY was found in PP Cs. In summary, presence of markers of risk of GCC, and abnormally immature GCs in inguinal testes of PP patients with CAIS were found, suggesting that careful follow-up of these patients at this age should be recommended. The concept that PP is a period of life with lesser risk of GCC development must be reconsidered.

 

Nothing to Disclose: EBB, PA, RM, PR, NP, MM, AJS, RS, RP, MC, DMW, GG, SG, EV, MB, MAR, AB

OR42-5 13972 5.0000 A Androgen Insensitivity Syndrome and Risk of Germ Cell Tumor Development before Puberty 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR42 4761 9:30:00 AM Disorders of Sex Development and Transgender Medicine Oral

Iram Shabir*1, Angela Ann Joseph2, Marumudi Eunice3, Madan L Khurana3, Manju Mehta2, Nandita Gupta4 and Ariachery C Ammini5
1All India Institute of Medical Sciences, New Delhi., India, 2All India Institute of Medical Sciences, New Delhi, 3All India Institute of Medical Sciences, 4All India Insititute of Medical Sciences, New Delhi, 5All India Institute of Medical Sciences, New Delhi, India

 

5α reductase 2 deficiency (5α RD) is a rare autosomal recessive disorder in which conversion of Testosterone (T) to DHT is impaired. Here, we describe the Phenotype – Genotype correlation and gender identity of pubertal and post pubertal patients with 5α RD.

Records of patients attending the endocrine clinic of our tertiary care hospital and new patients with diagnosis of 5α RD were compiled. All patients had detailed history, physical examination, chromosomal analysis and hormonal studies done. Chromosomal analysis was carried out on G-banded metaphases obtained from 72-h cultures from peripheral blood. The genotype of the patients was analysed for Srd5A2 gene mutations. LH, FSH, T were estimated by Electrochemiluminiscence using commercially available kits from Roche, Germany. DHT and androstenedione (A) were extracted from plasma by diethyl ether and separated from other androgens by Celite-chromatography and estimated by radioimmunoassay (Immunotech, DSL9600i, Czech Republic, Prague). DNA was isolated from the blood samples, quantified and subjected to PCR amplification using specific primers for Srd5A2 gene.

Clinical diagnosis of 5α RD was established in 24 patients. Out of these, 12 patients presented in pubertal and post-pubertal age group (10 to 20 yrs). The mean age of presentation was 13.5 ± 2.0 yrs and the present age of the patients was 16.9 ± 4.3 yrs. Seven patients (58%) sought medical attention with the complaint of primary amenorrhoea and were initially reared as females. Gender (re) assignment was done in 6 patients and one patient 14 yrs old (under evaluation) wishes to continue as female. Four patients reared as males had complaint of ambiguous genitalia and one patient reared as male had B/L gonadectomy done in childhood without establishing a definitive diagnosis. All patients had normal 46, XY karyotype. Mean LH was 4.3± 2.2 mIU/ml, FSH was 8.4± 5.9 mIU/ml, Testo was 3.2± 1.3 ng/ml, DHT was 112.7± 85.2 pg/ml, T/DHT was 45.1± 33.9, A was 0.59± 0.28 ng/ml and T/A was 6.2± 3.7. Molecular analysis of SRD5A2 gene revealed that 4 patient harboured homozygous mutation of R246Q and one patient had compound homozygous R246Q and heterozygous A12T mutation. Two patients had compound homozygous mutation of V89L on exon 5 and T > C intronic (1-2) transition. One patient had compound homozygous mutation of V89L and Ins A (frameshift mutation) in exon 1. One patient had insertion of TA nucleotides at c.188_189 resulting in premature termination of the protein due to stop codon at amino acid position 7. Diagnosis of 5α RD was established in one patient who had undergone gonadectomy prior to diagnosis and endocrine (hormonal profile) evaluation could not be used to make a definitive diagnosis. He had a novel mutation of p.57 Glutamic acid to stop codon. Ten out of 12 patients with 5α RD had mutations in SRD5A2 gene. Eleven patients had male gender identity and 6 patients reared as females opted male gender.

 

Nothing to Disclose: IS, AAJ, ME, MLK, MM, NG, ACA

OR42-6 16728 6.0000 A Phenotype, Genotype and Gender Identity in Pubertal and Post-Pubertal Patients with 5 Alpha Reductase 2 Deficiency 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Reproductive Endocrinology Tuesday, June 24th 11:00:00 AM OR42 4761 9:30:00 AM Disorders of Sex Development and Transgender Medicine Oral

Dania M Alkhafaji1, Mahmoud Tuli1 and Ali Saeed Alzahrani*2
1King Faisal Specialist Hospital & research center, Riyadh, Saudi Arabia, 2King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia

 

Age represents a major prognostic factor in differentiated thyroid cancer (DTC).  Patients  ≥ 45 years usually have a higher risk for recurrence and mortality from DTC than those  < 45 years .  However, it is not clear if this favorable outcome in patients < 45 years is consistent across all age groups.  In several case series, DTC in pediatric and adolescents (<20 years, referred to thereafter as pediatric DTC) seems to have a different clinicopathological profile and outcome.   However, none of the previous studies have compared DTC in patients >20-<45 years with DTC in the pediatric age group (≤ 20 years).   In this study, we compared a large series of pediatric DTC (age ≤ 20) with another large series of DTC patients in the age range >20 to <45 years.  Both groups were managed by the same team at a single institution.

Patients and methods:

Due to the rare occurrence of DTC in children and adolescents, we studied all cases of pediatric DTC seen during the period 1998-2011.  To avoid selection bias, we compared this group with a large sample of 213 consecutive adult patients in the age group >20<45 years seen during the years 1998-1999. Demographic, histopathological features, management and outcome data were extracted from the medical records, entered in a database and analyzed. T test and Wilcoxon rank sum test were used to compare continuous variables and Chi-Square test for categorical parameters.  Kaplan Meier analysis was used to compare persistent/recurrent disease over time.

Results:

A total of 310 DTC were studied including 97 cases of pediatric DTC {Median age 17 years (range, 8-20)} and 213 {Median age 33 years (range, 20.5-44.9)} of young adults DTC.  Comparing pediatric with young adult DTC, there was no difference in gender distribution (F:M 79:18 vs. 174:39, P 0.96) , tumor subtypes (P 0.15), size (2.9±1.7 cm vs. 2.7±1.7 cm, P 0.30), extrathyroidal extension/invasion {26/59 (44.1%) vs. 81/196 (41.3%), P 0.08}  and multifocality {26/59 (44.1%) vs. 73/186 (39.2%), P 0.61} but there was a significantly higher rate of lymph node {78/94 (83%) vs. 102/183 (55.7%), P <0.0001} and distant metastases {16/96 (16.7%) vs. 8/207(3.9%), P <0.0001}.  Kaplan Meier analysis showed a higher risk of persistent/recurrent disease in the pediatric age group than adults (Log-rank test 0.01)

Conclusions

Pediatric DTC seems to be distinct from DTC in the young adults (age >20<45).  It is characterized by a higher rate of lymph node and distant metastases and a higher risk of persistent/recurrent DTC.  This difference might be due to a difference in the molecular basis of DTC in these two different age groups and we are currently characterizing the genetic mutations in these two groups.

 

Nothing to Disclose: DMA, MT, ASA

OR52-1 16896 1.0000 A Comparison of Differentiated Thyroid Cancer in Pediatric and Adolescents with Young Age Group 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Tuesday, June 24th 11:00:00 AM OR52 4766 9:30:00 AM Thyroid Neoplasia Oral

Yoon Young Cho*, Ji Young Joung, Na Kyung Kim, Seo Young Sohn, Jae Hoon Chung and Sun Wook Kim
Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, Republic of (South)

 

Context: Radioiodine (RAI) therapy is one of multifactorial treatments for differentiated thyroid carcinoma. Rate of RAI use has been increasing however, recent studies reported secondary malignancies as a serious adverse effect of RAI. Hematopoietic system is known as radiosensitive organ and few studies indicated that the risk of developing leukemia was elevated after RAI treatment. However, the study regarding leukemia and cumulative dose of RAI is scarce.

Objective: We aim to investigate the incidence of leukemia as second primary malignancy in Korean patients with primary thyroid cancer and whether higher dose of RAI treatment increases the risk of developing leukemia using National Health Insurance (NHI) database.

Design, Setting, and Participants: Our cohort included 170,091 claimants with thyroid cancer from the NHI database between 2008 and 2012.

Main Outcome Measures: Standardized incidence ratios (SIRs) for leukemia were calculated. To calculate the risk of RAI treatment on leukemia, Cox proportional hazards methods were used.

Results: Among 170,091 subjects, 46 patients (0.03%) were diagnosed with leukemia after thyroid cancer. The risk for developing leukemia was significantly elevated (SIR 2.28, 95% CI: 1.76–2.92, P-value<0.001), especially in subjects receiving RAI treatment (SIR 2.81, 95% CI: 2.01–3.83, P<0.001) compared to patients without RAI (SIR 1.72, 95% CI: 1.09–2.59, P=0.024). When calculating Hazards ratio compared to patients without RAI treatment, 0.78 (95% CI: 0.32–1.88, P-value=0.58) in group with cumulative dose of RAI equal or less than 120 mCi and 2.48 (95% CI: 1.31–4.83, P-value<0.01) in group with RAI more than 120 mCi, respectively.

Conclusions: This is the largest, population-based study using nationwide data from the entire Korean population. Although leukemia is a rare malignancy after thyroid cancer, physicians need to be cautious using higher dose of RAI therapy.

 

Nothing to Disclose: YYC, JYJ, NKK, SYS, JHC, SWK

OR52-2 14314 2.0000 A The Risk of Leukemia Is Elevated after Higher Dose of Radioactive Iodine Therapy in Patients with Thyroid Cancer: A Nationwide, Population-Based Study in Korea 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Tuesday, June 24th 11:00:00 AM OR52 4766 9:30:00 AM Thyroid Neoplasia Oral

Monika Kolanowska, Anna Wojcicka, Anna Kubiak, Michal Swierniak, Monika Maciag and Krystian Jazdzewski*
Medical University of Warsaw, Warsaw, Poland

 

Introduction: Papillary Thyroid Carcinoma (PTC) is accompanied by disturbed expression of genes that are essential for physiology of the thyroid gland, such as thyroglobulin, key factor in synthesis and storage of thyroid hormones. Moreover, most PTC cases exhibit constitutive activation of MAPK (Mitogen-activated protein kinases) signaling pathway leading to uncontrolled cellular division and growth. A search for factors implicated in thyroid tumorigenesis led to conclusion that disturbances in MAPK signaling may in part result from deregulation of microRNAs. MicroRNAs (miRs) are short, non coding RNAs that inhibit expression of protein-coding genes, and aberrant expression of miRs in cancer leads to severe deregulation of the cellular transcriptome. Genes coding for miRs are very often localized within other, usually protein coding-genes and expression of such miR is linked with expression of its host gene. The role of numerous microRNAs remains to be elucidated and many miRs are yet to be identified.

Employing next-generation sequencing (NGS), we revealed comprehensive miRNA profiles of normal thyroid and PTC, and identified putative novel microRNA genes.

Aim: The aim of this study was to analyze the role of a newly identified microRNA in physiology and neoplastic transformation of the thyroid gland.

Methods and results: NGS analysis performed in 14 PTC and control samples resulted in identification of a novel microRNA encoded within the thyroglobulin gene (TG). Cloning into the expression vector, cell line transfection and Taqman quantification revealed that the microRNA gene was processed towards mature microRNA. SQ-PCR analysis in 33 PTC and matched non-tumorous tissue samples showed that the levels of miR-TG and thyroglobulin were decreased in tumor by 30% (p=0.001) and 16% (p=0.04), respectively. Levels of both transcripts were positively correlated (r=0.48, p=0.005). In silico analysis revealed that genes putatively regulated by novel microRNA included MAPK and Pi3K/Akt pathway proteins: DUSP6 and MAP4K4. SQ-PCR showed a 12-fold upregulation of DUSP6 (p=0.00001) and a 2.5-fold upregulation of MAP4K4 (p=0.002) in PTC compared to control tissue. Moreover, expression of both genes negatively correlated with expression of novel microRNA: r=-0,44 for DUSP6 (p=0.01) and r=-0.48 for MAP4K4 (p=0.005). Direct binding of studied microRNA to 3’UTRs of MAP4K4 and DUSP6 was confirmed in luciferase assay, leading to reduced luciferase activity by 10% (p=0.0006) and 17% (p=0.0008), respectively.

Conclusion: We propose that in normal thyroid the newly identified miRNA plays a fine tuning effect on the maintenance of MAPK pathway, inhibiting the expression of its targets: MAP4K4 and DUSP6. This regulation is disturbed in cancer due to severe downregulation of microRNA, therefore the altered expression of the novel miR-TG can be one of the risk factors for PTC.

 

Nothing to Disclose: MK, AW, AK, MS, MM, KJ

OR52-3 15768 3.0000 A Next-Generation Sequencing Reveals a Novel, Thyroglobulin-Embedded microRNA Gene Deregulated in Papillary Thyroid Carcinoma 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Tuesday, June 24th 11:00:00 AM OR52 4766 9:30:00 AM Thyroid Neoplasia Oral

Ramona Dadu*1, Komal Shah2, Roland L Bassett Jr3, Naifa L Busaidy1, Steven G Waguespack1, Steven I Sherman1, Mouhammed Amir Habra1, Camilo Jimenez1, Mimi I-Nan Hu1, Anita K Ying1 and Maria E Cabanillas1
1The University of Texas MD Anderson Cancer Center, Houston, TX, 2The University Of Texas MD Anderson Cancer Center, 3The University of Texas MD Anderson Cancer Center

 

Background: Sorafenib (SOR), a VEGFR and weak BRAF inhibitor, is the first FDA-approved oral targeted agent for differentiated thyroid cancer. SOR benefit is likely due to its antiangiogenic properties. In the subgroup of patients with advanced PTC harboring the BRAFV600Emutation, selective BRAF inhibition has been of interest. Vemurafenib (VEM), a selective and potent BRAF inhibitor, has shown promising clinical activity for these patients. A comparison between SOR and VEM in patients with BRAF-positive PTC has not been performed yet.

Methods: This is a retrospective analysis of BRAFV600E-positive PTC patients treated with either VEM or SOR outside of a clinical trial. All patients had BRAFV600E mutation by DNA testing. Best response was evaluated using RECIST v1.1. All images were reviewed by a single radiologist.

Results: We identified 34 patients who were treated with SOR (n=17) or VEM (n=17) for advanced BRAFV600E-positive PTC. Thirty patients were evaluable for best response (15 VEM and 15 SOR); 3 patients stopped drug due to adverse events (AEs) before restaging (2 VEM and 1 SOR) and 1 SOR patient had missing radiographic data. The 2 groups were well balanced. In VEM vs. SOR: median age of diagnosis was 65 vs. 63 years (p=0.23); 56% male in both groups (p=1.0); conventional PTC 53% vs. 73% (p=0.45); stage IV at diagnosis 73% vs. 60% (p=0.68); prior surgery 87% vs. 93% (p=1.0); RAI 73% vs. 87% (p=0.65); XRT 40% vs. 27% (p=0.70); prior to drug start, neck disease was present in 100% vs. 73% (p=0.10); sites of distant metastases were lung in 67% vs. 100% (p=0.04) and bone in 27% vs. 20% (p=1.0). All SOR patients were treatment naive vs. 11/15 VEM patients. Best response with VEM: partial response (PR) in 7/15 (47%), stable disease (SD) in 8/15 (53%) patients. In the cohort of patients treated with first line VEM, best response: PR in 5/11 (45%), SD in 6/11 (55%). Best response with first line SOR: PR in 1/15 (7%), SD in 12/15 (80%), progressive disease (PD) in 2 (13%) patients. Median percent change in sum of target lesions was 25% decrease in VEM group and 8% decrease in SOR group (p=0.049). Median progression free survival was not reached in VEM and was 8.8 months in SOR group (p=0.01). To date, the median time on treatment with VEM was 10 months (range: 1-16). Drug was discontinued in 5/15 (33%) of VEM patients (3 PD, 2 AEs) and in 14/15 (93%) of SOR patients (12 PD, 1 AEs, 1 unrelated malignancy). In VEM and SOR group, drug hold was needed in 73% and 60% (p=0.7) and dose reduction in 60% and 40% (p=0.2), respectively. In the entire population (n=34), drug discontinuation due to AEs was needed in 4/17 VEM patients (3 skin toxicities, 1 atrial fibrillation) and 2/17 SOR patients (1 diverticulitis, 1 mucositis).

Conclusions: VEM has shown benefit and represents a valuable alternative strategy for patients with advanced PTC harboring the BRAFV600E mutation. Further prospective studies to compare first line SOR and VEM are warranted.

 

Disclosure: NLB: Investigator, GlaxoSmithKline, Investigator, Bayer, Inc., Consultant, Novartis Pharmaceuticals. SIS: Consultant, Bayer, Inc.. MAH: Investigator, Eisai. MEC: Researcher, Genentech, Inc., Researcher, Eisai, Researcher, Exelixis, Inc., Consultant, Eisai, Consultant, Exelixis, Inc., Researcher, Roche Pharmaceuticals. Nothing to Disclose: RD, KS, RLB, SGW, CJ, MINH, AKY

OR52-4 12932 4.0000 A Is There an Alternative Treatment Option for Patients with Advanced Papillary Thyroid Cancer (PTC) Harboring the BRAFV600E Mutation? 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Tuesday, June 24th 11:00:00 AM OR52 4766 9:30:00 AM Thyroid Neoplasia Oral

Amit Mehta*1, Lisa Zhang1, Myriem Boufraqech1, Dhaval Patel1, Naris Nilubol1, Sean R Davis2, Yaqin Zhang3, Zhuyin Li3, Min Shen3 and Electron Kebebew1
1National Cancer Institute, NIH, Bethesda, MD, 2Center for Cancer Research, National Cancer Institute, Bethesda, MD, 3National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD

 

Anaplastic thyroid cancer (ATC) is one of the most aggressive human malignancies, with a median survival of 5 months and currently with no effective therapeutic approaches. The aim of the present study was to use a global approach by integrating genome wide expression data with high throughput drug library screening to identify novel therapeutic agents for the treatment of ATC. We performed quantitative high-throughput screening (qHTS) in ATC cell lines (SW1736, 8505c and C643), using a compound library with 3,282 clinically approved drugs. Integrated genome-wide gene expression analysis was performed in ATC vs. papillary thyroid cancer (PTC) and normal thyroid tissue. Follow up validation in vitro experiments were then conducted to determine the anticancer effect in ATC cell lines, and the mechanism of action. qHTS identified 170 compounds that were active in all three cell lines. Enrichment analysis selected the Survivin inhibitor, YM155, as one of the most active inhibitory drugs (>90% efficacy) in three ATC cell lines: 8505C, SW1736, C643. Genome-wide expression analysis showed over-expression of the anti-apoptotic protein, Survivin, in ATC samples compared to PTC (p<0.01) and normal thyroid tissue (p=0.01). Survivin was highly expressed in all ATC cell lines, confirmed by Western blot. Treatment of ATC cells with YM155 (0.0nM – 9.4nM) induced a significant dose and time-dependent growth inhibition, as well as, caspase-dependent apoptosis. Furthermore, sensitivity to YM155 in the ATC cells was associated with the level of Survivin expression. Our data shows that YM155 is a promising anti-cancer agent for the treatment of ATC and that its target is overexpressed in ATC. Further investigation into the potential of YM155 as a new therapeutic agent for anaplastic thyroid cancer is warranted.

 

Nothing to Disclose: AM, LZ, MB, DP, NN, SRD, YZ, ZL, MS, EK

OR52-5 14057 5.0000 A Integrated Genome-Wide Expression Analysis and High Throughput Drug Screening in Anaplastic Thyroid Cancer Identifies YM155, a Survivin Inhibitor, As a Novel Therapeutic Agent 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Tuesday, June 24th 11:00:00 AM OR52 4766 9:30:00 AM Thyroid Neoplasia Oral

Hung-Chih Lin1, Ching-Ping Tseng2, Szu-Tah Chen3, Miaw-Jene Liou4 and Jen-der Lin*5
1College of Medicine, Chang Gung University, Taoyuan, Taiwan, 2College of Medicine, Chang Gung University, Taiwan, 3Chang Gung Memorial Hospital, Kweishan, Taiwan, 4Chang Gung Memorial Hospital, Taiwan, 5Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University

 

Metastasis of papillary thyroid cancer (PTC) is a multistep and complex process that requires cancer cells to dislocate from the primary thyroid tumor, survive in the blood stream or lymphatic system, and then establish a new tumor at a distant site. Circulating tumor cells (CTCs) are tumor cells that have acquired the ability to enter the circulation, and are ultimately responsible for the development of metastases in distant organs. This study aimed to utilize the negative selection based CTC isolation which removes the normal blood cells in the peripheral whole blood samples for detecting CTCs.

Subjects and methods

The efficiency of PowerMag in leukocyte depletion and recovery of CTCs was evaluated. Cell populations in leukocyte-depleted cell filtrates were characterized by immunofluorescence staining using anti-epithelial cell adhesion molecule (EpCAM) and anti-thyroid stimulating hormone receptor (TSHR) antibodies. For the study, patients were divided into the following groups.

Group I (control): This group included patients negative for any thyroid disorder and other systemic diseases.

Group II: This group included PTC patients with a disease-free status (DF) confirmed by histopathology, serum thyroglobulin levels (Tg, less than 0.1 ng/mL), negative anti-Tg antibody test result, and radioactive iodine (131I) whole body scan (WBS).

Group III: This group included PTC patients with distant metastases. Distant metastases were confirmed by 131I WBS or other imaging methods and by elevated Tg levels (>10 ng/mL). Patients positive for anti-Tg antibodies before and after the blood tests were excluded.

Statistical analysis was performed using SPSS for Windows (version 18, SPSS, Chicago, IL). All data were expressed as mean ± standard error of the mean.

Results

Thirty patients were enrolled in this preliminary study, including 14 patients in group I, 8 patients in group II, and 8 patients in group III. Patients in group III had metastases to the lung and mediastinum (4 cases), to the bones (3 cases), and to the lung and kidney (1 case). The mean accumulated radioactive iodide in group III was 300 mCi. Two patients in group III had a history of local neck external radiotherapy. The mean ± SD values of EpCAM- and TSHR-positive cells were 3.0 ± 2.76 and 9.97 ± 9.22 cells/mL in group I, 11.24 ± 8.88 and 19.17 ± 9.77 cells/mL in group II, and 100.06 ± 73.34 and 141.60 ± 82.08 cells/mL in group III. The number of EpCAM- and TSHR-positive cells in group III was significantly higher than those in groups I and II (p < 0.001).

Conclusions:

This preliminary study revealed higher levels of CTCs in PTC patients with distant metastases than that in patients with a DF status and healthy control subjects. Additional implications of CTCs in the diagnosis and treatment of thyroid cancer need to be further investigated.

 

Nothing to Disclose: HCL, CPT, STC, MJL, JDL

OR52-6 11040 6.0000 A Discrepancy of Epithelial Cell Adhesion Molecule-Positive Circulating Tumor Cells in Health Control and Papillary Thyroid Cancer Patients with Disease-Free Status 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Thyroid/HPT Axis Tuesday, June 24th 11:00:00 AM OR52 4766 9:30:00 AM Thyroid Neoplasia Oral

Sita D Modali*1, Shruti S Desai2, Vaishali I Parekh3, Electron Kebebew4 and Sunita K Agarwal2
1National Institute of Diabetes and Digestive and Kidney Diseases,NIH, Bethesda, MD, 2National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD, 3National Institutes of Health, NIDDK, Bethesda, MD, 4National Cancer Institute, NIH, Bethesda, MD

 

Insulinomas are a class of functioning pancreatic neuroendocrine tumors (PNETs) derived from pancreatic islet β-cells that produce and secrete excess insulin. Understanding the molecular basis of insulinoma pathogenesis will not only provide insights into the pathways and therapeutic targets associated with tumorigenesis but it will also impact research about conditions that require β-cell replacement such as diabetes. Insulinomas mostly occur sporadically or they occur in the multiple endocrine neoplasia type 1 (MEN1) syndrome. MEN1 is characterized by the co-occurrence of tumors in multiple endocrine glands, mainly the parathyroids, pituitary and pancreas. In MEN1 patients, a germline-inactivating mutation in MEN1 (1st hit) and subsequent somatic loss of the second copy of MEN1 (2nd hit) leads to tumor development. Interestingly, somatic MEN1 mutations are observed in 30-40% of sporadic parathyroid tumors and PNETs, but not in sporadic pituitary tumors. However, non-functioning sporadic pituitary tumors lack MEG3 expression. MEG3 is a maternally expressed long non-coding RNA that acts through the p53 and Rb pathways to suppress cell proliferation. We recently reported that MEG3 is a downstream target of menin (encoded by MEN1), because menin-null mouse embryonic stem cells showed loss of H3K4me3 at the Meg3 locus, and reduced expression of Meg3 mRNA. In order to determine the role of MEG3 in insulinomas, we examined the level of MEG3 mRNA in 23 human sporadic insulinomas and in 6 normal islet samples by RT-PCR, and studied the consequence of MEG3 mRNA overexpression in a mouse insulinoma cell line (MIN6-4N). Insulin staining, assessed by immunohistochemistry, was positive in all tumor sections. MEG3 mRNA was significantly reduced in the insulinomas (p<0.005) suggesting a tumor suppressor role of MEG3 in insulinomas. Whether the reduced MEG3 expression is due to MEN1 mutations (menin loss) in a sub-set of these tumors remains to be determined. Stable overexpression of MEG3 mRNA in MIN6-4N cells decreased cell proliferation, and delayed cell cycle progression with increased number of cells in the S-phase. Overall, our results show that MEG3 is silenced in sporadic insulinomas supporting a tumor suppressor role of MEG3 in β-cells, and warrants further studies to explore the targets and mechanism of action of MEG3 in normal and pathologic β-cell proliferation, and the possible therapeutic option of restoring MEG3 expression for the management of insulinomas.

 

Nothing to Disclose: SDM, SSD, VIP, EK, SKA

OR50-1 13682 1.0000 A Tumor Suppressor Role of the Long Non-Coding RNA MEG3 in Insulinomas and in Insulinoma Cell Proliferation 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Tuesday, June 24th 11:00:00 AM OR50 4770 9:30:00 AM Novel Players in the Development and Progression of Endocrine-Related Cancers Oral

Christian Argueta*1, Di Wu2, Di Hu2, Michael Smith2, Celestine He2 and Yujiang Shi1
1Brigham and Women's Hospital/Harvard Medical School, Boston, MA, 2Brigham and Women's Hospital, Boston, MA

 

Recent epidemiologic evidence indicates that patients with type-2 diabetes have a greater risk of developing cancer.  Although several factors likely contribute to the increased cancer incidence in diabetics, the renewed interest in the Warburg hypothesis has emphasized the importance of deregulated glucose metabolism as a major contributor.  We found that diabetic patients exhibit a loss of global 5-hydroxymethylcytosine (5hmC) levels, which is a well-established hallmark of cancer progression.  The ten-eleven translocation family of proteins (TET1/2/3) is known to dynamically regulate 5hmC levels by oxidizing methylated cytosine (5mC) to 5hmC.  To examine the effect elevated glucose concentrations have on global 5hmC levels, we cultured TET2 expressing cells with normal and high glucose concentrations for several days and extracted their genomic DNA.  We found that high glucose levels negatively regulate 5hmC.  In cancer cells, the loss of TET2 and TET1, but not TET3, has been found to promote a more invasive phenotype, although TET1 expression is generally very low.  The nutrient-sensing O-linked N-acetylglucosamine (GlcNAc) transferase (OGT) is a major binding partner of TET2 and is greatly affected by environmental changes that result from the excessive glucose uptake and prolonged hyperglycemia attributed to cancer and diabetes, respectively.  OGT responds to cellular levels of the glucose metabolite UDP-GlcNAc by dynamically modifying an extensive range of proteins; however, in the presence of high concentrations of glucose an overactive OGT can hyper-O-GlyNAcylate its substrates and compromise their activity.  To determine whether the loss of 5hmC in the presence of high glucose is due to OGT, we cultured cells in the presence of GlcNAc. We found that the addition of GlcNAc resulted in the loss of 5hmC, suggesting that hyper-O-GlcNAcylation results in the loss of 5hmC.  Additionally, in vitro incubation of purified OGT and TET2 revealed that OGT repeatedly modifies TET2 and inhibits the oxidation of 5mC.  Strikingly, we found that hyper-O-GlcNAcylation of TET2 significantly affects its stability and results in proteolysis.  Altogether, our findings suggest that OGT posttranslationally modifies TET2 and thereby regulates 5hmC levels in response to glucose concentrations.  We hypothesize that the hyperglycemic conditions present in patients with type-2 diabetes may contribute to carcinogenesis in part through the inactivation of TET2.

 

Nothing to Disclose: CA, DW, DH, MS, CH, YS

OR50-2 16151 2.0000 A Posttranslational Regulation of TET2 Links Hyperglycemia and Diabetes to Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Tuesday, June 24th 11:00:00 AM OR50 4770 9:30:00 AM Novel Players in the Development and Progression of Endocrine-Related Cancers Oral

Angela Yang*1, Jonathan Zhao1, Longtao Wu1, Jung A Kim1, Will Fong1, Hongjian Jin1, Chunxiao Song2, Chuan He2 and Jindan Yu1
1Northwestern University, Chicago, IL, 2University of Chicago

 

The recent breakthrough findings of TET1 and its catalytic product, 5hmC, in embryonic stem cells have substantiated the importance of epigenetic events in the process of development. In light of TET1's functions in reversing DNA methylation, which is a phenomenon frequently altered in various cancer types, including prostate cancer, it is now imperative to investigate what roles TET1 may play during carcinogenesis.

Here, utilizing the model of prostate cancer, we found that TET1 plays a crucial role in enhancing the transcription factor FOXA1’s ability to bind to DNA and conduct transcriptional regulation. FOXA1 has long been established as a critical contributor to prostate cancer development and progression. We have demonstrated through bioinformatic analyses that, FOXA1 binding sites exhibit a distinct epigenetic profile which includes a significant enrichment of 5hmC marks paralleled by a diminished enrichment of 5mC marks. Moreover, upon TET1 knockdown in prostate cancer LNCaP cells, we observe extensive changes in FOXA1’s genomic binding patterns, where a majority of FOXA1 occupied sites have lower binding intensity, suggesting that TET1 is required for FOXA1 to bind efficiently to its recognized sequences. Supporting our hypothesis that FOXA1 binding is modulated by TET1, co-immunoprecipitation experiments confirm that there exists physical interaction between the two proteins, which further indicates a mechanistic model whereby TET1 could be recruited by FOXA1 to demethylate surrounding DNA and facilitate the latter in transcriptional signaling.

With these results, it is anticipated that TET1’s function in DNA demethylation could play a significant role in prostate cancer, through its ability to modulate chromatin accessibility for FOXA1. Therefore, understanding the exact mechanisms underlying TET1’s involvement in prostate cancer could provide new insights into disease development and progression, and offer novel opportunities for therapeutic targeting.

 

Nothing to Disclose: AY, JZ, LW, JAK, WF, HJ, CS, CH, JY

OR50-3 16950 3.0000 A TET1-Mediated DNA Demethylation and Epigenomic Regulation in Prostate Cancer 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Tuesday, June 24th 11:00:00 AM OR50 4770 9:30:00 AM Novel Players in the Development and Progression of Endocrine-Related Cancers Oral

Maria Theresa E Montales*, Stepan B Melnyk, Frank A Simmen and Rosalia CM Simmen
University of Arkansas for Medical Sciences, Little Rock, AR

 

Chronic diseases might be programmed during early life by maternal diet. Potential mechanisms by which maternal high fat diet (HFD) influences offspring’s phenotype may include systemic changes in inflammatory cytokines, nutrients (glucose), free radicals, and hormones (insulin). We evaluated herein the consequences of maternal HFD on offspring’s metabolic profile and mammary tumor risk using the MMTV-Wnt-1 transgenic (Tg) mouse model of human breast cancer. Female Tg mice were exposed to high fat (HFD, 45% kcal from fat) or control (CD, 17% kcal from fat) diet during gestation and lactation through their dams and weaned to CD at postnatal day (PND) 21. Relative to the CD group, offspring exposed to maternal HFD had higher body, abdominal fat and mammary tissue weights; impaired glucose tolerance (elevated blood sugar and insulin); and higher serum leptin and lower adiponectin levels. By six months of age, mammary tumor incidence was higher (42.9% vs. 26.1%) and tumor latency lower (3.76 ± 0.42 vs. 5.22 ± 0.28 months) in HFD-exposed offspring than in those exposed to CD. HFD-exposed offspring showed higher serum oxidative stress biomarker levels (Cystine/Cysteine) and lower serum methylation status (Methionine/Homocysteine) than CD offspring. Mammary expression of tumor suppressors PTEN and p53 were lower in pre-neoplastic tissues and tumors of offspring exposed to maternal HFD. To determine if systemic changes noted with maternal HFD underlie the more aggressive tumor outcome in Tg offspring, sera from PND30 CD and HFD offspring were evaluated for ability to influence the proliferation (cell numbers), self-renewal capacity (sphere formation in non-adherent conditions), and pro-(IL-6) and anti-(PTEN, p53, BCL2) tumorigenic gene expression, when added to human MCF-7 breast cancer cells. Addition of sera (2.5% v/v final dose) from maternal HFD-exposed offspring increased MCF-7 cell viability and frequency of mammosphere formation, and recapitulated the attenuated PTEN, p53, and BCL2 and conversely, the enhanced IL-6, expression seen in mammary preneoplastic tissues and tumors, when compared to those of CD-sera treated cells. Post-lactating HFD-fed dams showed increased adiposity and higher serum TNFα and oxidative stress (GSSG/GSH) levels than counterparts fed CD. Our results suggest that early metabolic history maybe a key factor for increased breast cancer risk as adults and that a major strategy to eradicate this disease may start from the maternal womb.

 

Nothing to Disclose: MTEM, SBM, FAS, RCS

OR50-4 15179 4.0000 A Maternal High Fat Diet Promotes Wnt-1-Induced Mammary Tumor Formation in Female Offspring Via Long-Term Effects on Mammary and Metabolic Phenotypes 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Tuesday, June 24th 11:00:00 AM OR50 4770 9:30:00 AM Novel Players in the Development and Progression of Endocrine-Related Cancers Oral

Manuel D. Gahete*1, Alicia Villa-Osaba1, Jose Cordoba-Chacon2, Luis de Lecea3, Francisco Gracia-Navarro1, Elena Gonzalez-Rey4, Raul M. Luque5 and Justo P Castano5
1University of Córdoba; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofia, and CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn), Córdoba, Spain, 2University of Córdoba; Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC); Hospital Universitario Reina Sofia, and CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn) / University of Illinois at Chicago, Córdoba, Spain, 3Stanford University School of Medicine, Stanford, CA, 4Institute of Parasitology and Biomedicine “López-Neyra”, Granada, Spain, 5Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Universitario Reina Sofia, CIBER de la Fisiopatología de la Obesidad y Nutrición (CIBERobn) and ceiA3, Córdoba, Spain

 

Somatostatin (SST) and cortistatin (CORT) are two highly structurally and functionally related peptides that share a family of receptors (sst1-5) to exert common biological actions, including their ability to suppress cell proliferation in different tumor cell models. In fact, various sst receptors are known to be widely and abundantly expressed in normal mammary gland (MG) tissues and MG tumors, thereby offering a potential therapeutic target. However, attempts to apply SST analogs in breast cancer have been unsuccessful hitherto, and the specific role of SST and/or CORT in MG tumorigenesis remains uncertain. Here, we studied the influence of endogenous SST and CORT on carcinogen-induced mammary gland tumor development and progression, by treating female SST- and CORT-knockout (KO) mice and their respective littermate controls (n=9-16/group; FVN/B background; 22-wk-old) with 7,12-dimethyl-benza-anthracene (DMBA; 0.5mg/10g BW; once/wk for 3 wk) and MG tumorigenesis was followed for 24 wk. Surprisingly, lack of SST did not impact DMBA-induced MG tumor incidence [1/13 (8%) and 2/16 (13%) mice developed MG tumors in SST-KO and littermate control mice, respectively]. Conversely, lack of endogenous CORT profoundly aggravated DMBA-induced MG tumorigenesis, as 8 out of 14 (57%) CORT-KO mice developed MG tumors compared to 1 out of 9 (11%) littermate controls. In addition, tumor latency was reduced while tumor multiplicity increased in CORT-KO mice compared with littermate controls. These results were further supported by MG whole mount analyses, which revealed higher incidence of neoplastic or preneoplastic lesions in CORT-KO mice compared with controls [6/14 (43%) and 3/9 (33%), respectively]. Of note, lack of endogenous SST or CORT did not significantly alter local expression of SST/CORT receptors in MG of these animals, neither the expression of the main components of the GH/IGF-I system, which play relevant roles in MG tumorigenesis and are regulated by SST/CORT in other tissues. Altogether, our data demonstrate that endogenous SST and CORT contribute quite distinctly to the control of DMBA-induced MG tumorigenesis, and thereby suggest that CORT, rather than SST, might act as a key inhibitor factor of MG tumorigenesis in mice. Future studies should aim at elucidating this issue as well as to identify the receptors and signaling mechanisms involved.

 

Nothing to Disclose: MDG, AV, JC, LD, FG, EG, RML, JPC

OR50-5 15678 5.0000 A Lack of Endogenous Cortistatin but Not Somatostatin Exacerbates Carcinogen-Induced Mammary Gland Tumorigenesis in Mice 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Tuesday, June 24th 11:00:00 AM OR50 4770 9:30:00 AM Novel Players in the Development and Progression of Endocrine-Related Cancers Oral

Niketa A. Patel*1, Amanda Morris2, Gay Carter1, Rekha Patel3, Michel M. Murr4 and Denise R. Cooper5
1J.A. Haley VA Hospital, Tampa, FL, 2Saint Leo University, St Leo, FL, 3University of South Florida, Tampa, FL, 4University of South Florida, 5James A. Haley VA Hospital, Tampa, FL

 

Ovarian cancer remains the most common cause of death from gynecologic malignancy in the United States. One factor that is known to be associated with abdominal cancers and potentially ovarian cancer is the health disparity of obesity (BMI>40). However, little is known about what factors obesity imparts to the cancer niche that account for the relationship.  Abdominal white adipose tissue (WAT) surrounds the ovaries and contains a stromal vascular fraction where mesenchymal stem cells reside. We have isolated and differentiated adipose derived stem cells (ADSC) into adipocytes and showed that ADSC derived from lean and obese patients have distinct differences in gene expression. All ADSC release exosomes, small nanovesicles, into conditioned media (CM). Exosomes contain factors that perform extracellular functions involving interactions with the cellular microenvironment such as transfer of genetic material. We evaluated the possibility that the secretome of obese ADSC could have paracrine effects on ovarian cells promoting growth and development of cancer cells. Our finding shows that ADSC exosomes contain long noncoding RNA (lncRNA) NEAT1. NEAT1 levels secreted by ADSC from morbidly obese patients (ADSCmo) were considerably higher than from normal ADSC. We evaluated cisplatin-resistant ovarian cells (TOV-112D) and found that tumor cell migration increased with ADSCmo-CM. Our data indicate that TOV-112D cells had 5–fold higher expression of the survival protein Bcl2, and 10-fold higher PKCδVIII, a signaling kinase which upregulates expression of Bcl2 compared to normal ovarian cells and cisplatin-sensitive ovarian cancer cells. Further, NEAT1 secreted from ADSCmo increases Bcl2 and PKCδVIII expression. When ADSC NEAT1 was silenced using antisense oligonucleotides, tumor cell migration decreased. These results suggest that the secretion of NEAT1 is accentuated in the setting of obesity to intensify the tumor niche.

 

Nothing to Disclose: NAP, AM, GC, RP, MMM, DRC

OR50-6 15921 6.0000 A Lncrna NEAT1 Secreted By Obese ADSC Increases Ovarian Cancer Survival Via PKCδviii and Bcl2 2014-06-24 Chicago 2014-06-17 16th International Congress of Endocrinology & the Endocrine Society’s 96th Annual Meeting & Expo Tumor Biology Tuesday, June 24th 11:00:00 AM OR50 4770 9:30:00 AM Novel Players in the Development and Progression of Endocrine-Related Cancers Oral 98ff87660e38aa34f1ac1c734c6f30cf